Medicamentos hormonales, supresores (que actúan en las ...

Advantage by Sunshine State Health Plan (HMO SNP)
Formulario Completo de 2013
(Lista de Medicamentos Cubiertos)
Aprobado el 11/09/2012
Vigente a partir del 1 de enero de 2013
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
NOTA PARA LOS MIEMBROS EXISTENTES: Este formulario ha cambiado desde el año pasado.
Sírvase revisarlo para asegurarse de que todavía contenga los medicamentos que usted recibe.
Los beneficiarios deben usar farmacias de la red para acceder a su beneficio de medicamentos recetados.
Los beneficios, el formulario, la red de farmacias, las primas y/o copagos/coseguros pueden cambiar el 1 de
enero de 2014.
Advantage by Sunshine State Health Plan es un plan de Atención médica coordinada que tiene un
contrato con Medicare Advantage y un contrato con el programa de Medicaid de Florida.
Esta información está disponible de manera gratuita en otros idiomas. Comuníquese con el Departamento
de Servicios para los Miembros llamando al 1-866-796-0530 para obtener información adicional. Los
usuarios de TTY/TTD deben llamar al 1-800-955-8770. El horario de atención es de 8:00 a. m. a 8:00 p. m.,
los 7 días de la semana.
H5190_RX013_001_CMSApproved_11/09/2012

¿Qué es el Formulario de Advantage by Sunshine
State Health Plan?
Un formulario es una lista de medicamentos
cubiertos seleccionados por Advantage by Sunshine
State Health Plan (HMO SNP) (Sunshine Health) en
consulta con un equipo de proveedores de atención
médica, que representa las terapias recetadas que se
cree son una parte necesaria de un programa de
tratamiento de calidad. Sunshine Health
generalmente cubrirá los medicamentos que aparecen
en nuestro formulario siempre y cuando el
medicamento sea necesario desde el punto de vista
médico, la receta se surta en una farmacia de la red de
Sunshine Health y se sigan otras reglas del plan.
Para obtener más información sobre cómo surtir sus
recetas, revise su Evidencia de cobertura.
¿Puede cambiar el Formulario?
Generalmente, si usted recibe un medicamento de
nuestro formulario del 2013 que estaba cubierto al
comienzo del año, no discontinuaremos ni
reduciremos la cobertura del medicamento durante
el año de cobertura 2013 excepto cuando un
medicamento genérico nuevo y más barato se
encuentre disponible o cuando se publique nueva
información adversa sobre la seguridad o eficacia
de un medicamento. Otros tipos de cambios en el
formulario, como retirar un medicamento de
nuestro formulario, no afectarán a los miembros
que reciben actualmente el medicamento.
Permanecerá disponible al mismo costo compartido
para los miembros que lo reciben, por lo que queda
del año de cobertura. Creemos que es importante
que tenga acceso continuo por lo que queda del año
de cobertura a los medicamentos del formulario
que estaban disponibles cuando usted eligió
nuestro plan, excepto por casos en los que puede
ahorrar dinero adicional o nosotros podemos
garantizar su seguridad.
Si retiramos medicamentos de nuestro formulario,
añadimos autorización previa, límites de cantidad,
y/o restricciones de terapia escalonada para un
medicamento o movemos un medicamento a un
nivel de costo compartido más alto, debemos
notificar a los miembros afectados sobre el cambio
al menos 60 días antes de que el cambio entre en
efecto, o en el momento en que el miembro solicite
una renovación de la receta, momento en el cual el
miembro recibirá un suministro de 60 días del
medicamento. Si la Administración de Alimentos y
Medicamentos considera que un medicamento de
nuestro formulario no es seguro o el fabricante del
i
medicamento retira el medicamento del mercado,
nosotros lo retiraremos inmediatamente de nuestro
formulario e informaremos a los miembros que lo
reciben. El formulario adjunto está actualizado a
partir del 1 de enero de 2013.
Para obtener información actualizada sobre los
medicamentos cubiertos por Sunshine Health
visite nuestro sitio Web en
o llame
al Departamento de Servicios para los Miembros
al 1-866-796-0530, de 8:00 a. m. a 8 p. m., los
siete días de la semana. Los usuarios de
TTY/TDD deben llamar al 1-800-955-8770.
Sunshine Health comunicará a los miembros
cambios de mitad de año que no son de
mantenimiento del formulario en la Explicación de
beneficios mensual de la Parte D. La Explicación de
beneficios incluirá instrucciones para la presentación
de apelaciones o reclamos relacionados con cambios
del formulario.
¿Cómo uso el Formulario?
Hay dos maneras de encontrar su medicamento
dentro del formulario:
Por enfermedad
El formulario comienza en la página 1. Los
medicamentos de este formulario están
agrupados en categorías dependiendo del tipo de
enfermedad para las que se usan. Por ejemplo,
los medicamentos usados para tratar una
enfermedad cardiaca aparecen bajo la categoría,
Agentes cardiovasculares.
Si usted sabe para qué se usa su medicamento,
busque el nombre de la categoría en la lista que
comienza en la página 1. Luego busque su
medicamento bajo el nombre de la categoría.
Lista Alfabética
Si no está seguro(a) de bajo qué categoría buscar,
debe buscar su medicamento en el Índice que
comienza en la página 80. El Índice presenta una
lista alfabética de todos los medicamentos que
incluye este documento. En el Índice aparecen tanto
medicamentos de marca como genéricos. Busque en
el Índice y encuentre su medicamento. Junto a su
medicamento, usted verá el número de página en el
que puede encontrar información sobre la cobertura.
Pase a la página que aparece en el Índice y
encuentre el nombre de su medicamento en la
primera columna de la lista.

¿Qué son los medicamentos genéricos?
Sunshine Health cubre tanto medicamentos de
marca como medicamentos genéricos. Un
medicamento genérico tiene la aprobación de la
FDA como uno que tiene el mismo ingrediente
activo que el medicamento de marca.
Generalmente, los medicamentos genéricos cuestan
menos que los medicamentos de marca.
¿Tiene restricciones mi cobertura?
Algunos medicamentos cubiertos pueden tener
requisitos o límites adicionales en la cobertura.
Estos requisitos y límites pueden incluir:
Autorización Previa: Sunshine Health requiere
que usted [o su médico] obtenga autorización
previa para ciertos medicamentos. Esto significa
que usted necesitará obtener aprobación de
Sunshine Health antes de surtir sus recetas. Si no
obtiene aprobación, es posible que Sunshine
Health no cubra el medicamento.
Límites de Cantidad: Para ciertos medicamentos,
Sunshine Health limita la cantidad de medicamento
que Sunshine Health cubrirá. Por ejemplo, Sunshine
Health proporciona 30 pastillas por receta para
Januvia. Esto puede ser en adición a un suministro
estándar de un mes o tres meses.
Usted puede determinar si su medicamento tiene
requisitos o límites adicionales buscando en el
formulario que comienza en la página 1. Además
puede obtener más información sobre las
restricciones aplicadas a medicamentos específicos
cubiertos visitando nuestro sitio Web en
.
Puede pedir a Sunshine Health que haga una
excepción a estas restricciones o límites. Consulte la
sección, “¿Cómo solicito una excepción al formulario
de Sunshine Health?” en esta página para obtener
información sobre cómo solicitar una excepción.
ii
¿Qué son medicamentos de venta sin receta (OTC,
siglas en inglés)?
Los medicamentos OTC son medicamentos que
no necesitan receta, que normalmente no están
cubiertos por un plan de medicamentos recetados
de Medicare. Sunshine Health paga por ciertos
medicamentos de venta sin receta. Sunshine
Health le proporcionará estos medicamentos de
venta sin receta sin costo para usted. El costo de
Sunshine Health para estos medicamentos de
venta sin receta no contará para sus costos totales
de medicamentos. La lista de medicamentos de
venta sin receta (OTC) y las instrucciones para el
pedido están disponibles en el sitio web de
Sunshine Health y además están disponibles en
copia impresa en el paquete de bienvenida para
miembros nuevos y el Aviso anual de cambios.
¿Qué pasa si mi medicamento no está en el
Formulario?
Si su medicamento no está incluido en este
formulario, debe comunicarse primero con el
Departamento de Servicios para los Miembros y
confirmar si su medicamento no está cubierto. Si se
entera que Sunshine Health no cubre su
medicamento, usted tiene dos opciones:
• Puede pedir al Departamento de Servicios para
los Miembros una lista de medicamentos
similares que están cubiertos por Sunshine
Health. Cuando usted reciba la lista,
muéstrela a su médico y pídale que prescriba
un medicamento similar que esté cubierto por
Sunshine Health.
• Puede pedir a Sunshine Health que haga una
excepción y cubra su medicamento. Consulte
abajo para obtener información sobre cómo
solicitar una excepción.
¿Cómo solicito una excepción al Formulario de
Sunshine Health?
Puede pedir a Sunshine Health que haga una
excepción a las reglas de cobertura. Hay varios tipos
de excepciones que nos puede pedir que hagamos.
• Nos puede pedir que cubramos su medicamento
incluso si no está en nuestro formulario.

• Nos puede pedir que exoneremos restricciones o
límites en la cobertura para su medicamento. Por
ejemplo, para ciertos medicamentos, Sunshine
Health limita la cantidad de medicamento que
cubriremos. Si su medicamento tiene un límite de
cantidad, nos puede pedir que exoneremos el
límite y cubramos más.
• Puede pedirnos que proporcionemos un nivel más
alto de cobertura para su medicamento. Si su
medicamento está en nuestro nivel no
preferido/más alto sujeto al proceso de
excepciones de los niveles, puede pedirnos que
más bien lo cubramos a la cantidad de costo
compartido que se aplica a los medicamentos en el
nivel preferido/más bajo sujeto al proceso de
excepciones de los niveles. Esto disminuiría la
cantidad que usted debe pagar por su
medicamento. Sírvase notar, si otorgamos su
solicitud de cubrir un medicamento que no está en
nuestro formulario, no nos puede pedir que
proporcionemos un nivel más alto de cobertura
para el medicamento.
Generalmente, Sunshine Health sólo aprobará su
solicitud para una excepción si los medicamentos
alternativos incluidos en el formulario del plan, el
medicamento del nivel más bajo o las restricciones
adicionales en la utilización no serían tan eficaces en el
tratamiento de su enfermedad y/o causarían que usted
tuviera efectos médicos adversos.
Debe comunicarse con nosotros para solicitarnos una
decisión inicial de cobertura para una excepción al
formulario, los niveles o de restricción de la
utilización. Cuando usted solicita una excepción al
formulario, de los niveles o de la restricción de la
utilización debe presentar una declaración de su
médico respaldando su solicitud. Generalmente,
debemos tomar nuestra decisión dentro de un plazo de
72 horas de obtener la declaración de respaldo del
médico que le recetó. Usted puede solicitar una
excepción acelerada (rápida) si usted o su médico
considera que su salud podría ser gravemente dañada
si esperara hasta 72 horas por una decisión. Si se
acepta su solicitud de acelerar, debemos darle una
decisión a más tardar 24 horas después de que
obtengamos la declaración de respaldo del médico que
le recetó.
3
¿Qué hago antes de que pueda hablar con mi
médico sobre cambiar mis medicamentos o
solicitar una excepción?
Como miembro nuevo o continuo en nuestro plan,
puede que usted tome medicamentos que no están en
nuestro formulario. O, es posible que esté recibiendo
un medicamento que está en nuestro formulario pero
su capacidad de obtenerlo es limitada. Por ejemplo,
usted puede necesitar nuestra autorización previa
antes de que pueda surtir su receta. Debe consultar
con su médico para decidir si debe cambiar a un
medicamento apropiado que cubrimos o solicitar una
excepción al formulario para que cubramos el
medicamento que recibe. Mientras usted consulta
con su médico para determinar el curso correcto de
acción para usted, podemos cubrir su medicamento
en ciertos casos durante los primeros 90 días que sea
miembro de nuestro plan.
Para cada uno de sus medicamentos que no esté en
nuestro formulario o si su capacidad de obtener sus
medicamentos es limitada, cubriremos un suministro
temporal de 30 días (a menos que su receta sea por
menos días) cuando vaya a una farmacia de la red.
Después de su primer suministro de 30 días, no
pagaremos por estos medicamentos, aun si ha sido
miembro del plan por menos de 90 días.
Si es residente de una instalación de atención
médica a largo plazo, le permitiremos renovar su
receta hasta que le hayamos proporcionado un
suministro de transición de 91 días, de acuerdo con
el aumento de surtido, (a menos que tenga una
receta para menos días). Cubriremos más de una
renovación de estos medicamentos durante los
primeros 90 días que es miembro de nuestro plan. Si
necesita un medicamento que no está en nuestro
formulario o si su capacidad de obtener sus
medicamentos es limitada, pero usted ha pasado los
primeros 90 días de su afiliación a nuestro plan,
cubriremos un suministro de emergencia de 31 días
de ese medicamento (a menos que tenga una receta
por menos días) mientras busca una excepción al
formulario.

Para obtener más información
Para obtener información más detallada sobre su
cobertura de medicamentos recetados de
Sunshine Health, revise su Evidencia de
cobertura y otros materiales del plan.
Si tiene preguntas sobre Sunshine Health, llame al
Departamento de Servicios para los Miembros al
1-866-796-0530, de 8 a. m. a 8 p. m., los 7 días de
la semana. Los usuarios de TTY/TDD deben
llamar al 1-800-955-8770. O visite nuestro sitio
Web en
.
Si tiene preguntas generales sobre la cobertura de
medicamentos recetados de Medicare, llame a
Medicare al 1-800-MEDICARE (1-800-633-
4227) las 24 horas del día, los 7 días de la
semana. Los usuarios de TTY/TDD deben llamar
al 1-877-486-2048 o visitar
http://www.medicare.gov.
Formulario de Sunshine Health
El formulario que comienza en la página 1
presenta información de cobertura acerca de
algunos de los medicamentos cubiertos por
Sunshine Health. Si tiene problemas para
encontrar su medicamento en la lista, pase al
Índice que comienza en la página 80.
La primera columna de la tabla muestra el
nombre del medicamento. Los medicamentos de
marca están en mayúsculas (por ejemplo,
BRANDIN) y los medicamentos genéricos
aparecen en minúsculas y cursiva (por ejemplo,
metformin).
La información de la columna de Requisitos
/Límites le dice si Sunshine Health tiene
requisitos especiales para la cobertura de su
medicamento.
Lista de abreviaturas
B/D: Este medicamento recetado tiene un
requisito administrativo de autorización previa de
la Parte B contra D. Este medicamento puede
estar cubierto bajo la Parte B o D de Medicare
dependiendo de las circunstancias. Puede ser
necesario presentar información que describa el
uso y entorno del medicamento para hacer la
determinación.
4
LA: Disponibilidad limitada. Esta receta puede
estar disponible solo en ciertas farmacias. Para
obtener más información consulte su Directorio de
farmacias o llame al Departamento de Servicios
para los Miembros al 1-866-796-0530, de 8:00 a.
m. a 8:00 p. m., los 7 días de la semana. Los
usuarios de TTY/TDD deben llamar al 1-800-955-
8770.
PA: Autorización previa. Sunshine Health
requiere que usted [o su médico] obtenga
autorización previa para ciertos medicamentos.
Esto significa que será necesario que reciba
aprobación de Sunshine Health antes de surtir
sus recetas. Si no recibe aprobación, puede
que Sunshine Health no cubra el medicamento.
QL: Límites de cantidad. Para ciertos
medicamentos, Sunshine Health limita la cantidad
del medicamento que Sunshine Health cubrirá. Por
ejemplo, Sunshine Health > provee 30
comprimidos por receta para Januvia. Esto puede
ser además de un suministro estándar de un mes o
tres meses.
Niveles y copagos de medicamentos
Nivel del
Medicamento
Descripción del
nivel
1 Genéricos $0
2 De marca
preferidos
3 De marca no
preferidos
Copago
$0, $3.50, ó
$6.60
$0, $3.50, ó
$6.60
4 Inyectables $0, $3.50, ó
$6.60
(si es
genérico,
aplicaría $0
de copago )

Analgésicos
Medicamentos antinflamatorios no esteroideos
Nombre del Medicamento
1
Nivel del
Medicamento
naproxen 1
naproxen sodium 1
piroxicam 1
Analgésicos opioides de acción prolongada
Nombre del Medicamento
Nivel del
Medicamento
ASTRAMORPH 4
DURAMORPH 4
fentanyl 1
levorphanol tartrate 1
METHADONE HCL INJECTION 4
methadone hcl concentrate, oral solution, tablet 1
methadose 1
morphine sulfate er tablet extended release 12 hour 15mg,
200mg, 30mg, 60mg
Requisitos/Límites
Requisitos/Límites
1 QL (120 cada vez para 30 días)
morphine sulfate er tablet extended release 12 hour 100mg 1 QL (180 cada vez para 30 días)
morphine sulfate tablet 1
morphine sulfate solution 10mg/5ml, 20mg/5ml 1
Analgésicos opioides de acción corta
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
acetaminophen/codeine #3 1 QL (390 cada vez para 30 días)
acetaminophen/codeine tablet 1 QL (390 cada vez para 30 días)
ascomp/codeine 1
BUTORPHANOL TARTRATE INJECTION 4
butorphanol tartrate nasal solution 1
DEMEROL INJECTION 4
endocet tablet 650mg; 10mg 1 QL (180 cada vez para 30 días)
endocet tablet 500mg; 7.5mg 1 QL (240 cada vez para 30 días)
endocet tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 1 QL (360 cada vez para 30 días)

Nombre del Medicamento
2
Nivel del
Medicamento
fentanyl citrate oral transmucosal 1
Requisitos/Límites
hydrocodone bitartrate/acetaminophen tablet 750mg; 10mg 1 QL (150 cada vez para 30 días)
hydrocodone/acetaminophen tablet 650mg; 10mg 1
hydrocodone/acetaminophen tablet 750mg; 7.5mg 1 QL (150 cada vez para 30 días)
hydrocodone/acetaminophen tablet 650mg; 7.5mg, 660mg;
10mg
hydrocodone/acetaminophen tablet 500mg; 10mg, 500mg;
2.5mg, 500mg; 5mg, 500mg; 7.5mg
hydrocodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg,
325mg; 7.5mg
HYDROMORPHONE HCL INJECTION 4
hydromorphone hcl tablet 1
meperidine hcl oral solution, tablet 1
MEPERIDINE HCL INJECTION 25MG/ML, 50MG/ML 4
meperidine hcl injection 100mg/ml 4
NALBUPHINE HCL 4
oxycodone hcl tablet 1
1 QL (180 cada vez para 30 días)
1 QL (240 cada vez para 30 días)
1 QL (360 cada vez para 30 días)
oxycodone/acetaminophen tablet 500mg; 7.5mg 1 QL (240 cada vez para 30 días)
oxycodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg,
325mg; 7.5mg
1 QL (360 cada vez para 30 días)
stagesic 1 QL (240 cada vez para 30 días)
TALWIN 4
tramadol hcl 1 QL (240 cada vez para 30 días)
tramadol hydrochloride/acetaminophen 1 QL (240 cada vez para 30 días)

Anestésicos
Anestésicos locales
Nombre del Medicamento
3
Nivel del
Medicamento
lidocaine 1
lidocaine hcl jelly 1
LIDOCAINE HCL INJECTION 4
lidocaine hcl external solution 1
lidocaine/prilocaine 1
Requisitos/Límites
LIDODERM 3 PA (Anestésicos)
XYLOCAINE INJECTION 4
Antiadicción/medicamentos para tratar el abuso de sustancias químicas
Con efecto disuasivo/contra el ansia del alcohol
Nombre del Medicamento
Nivel del
Medicamento
CAMPRAL 2
disulfiram 1
naltrexone hcl 1
Antagonistas opioides
Nombre del Medicamento
Nivel del
Medicamento
BUPRENORPHINE HCL INJECTION 4
buprenorphine hcl tablet sublingual 1
NALOXONE HCL 4
SUBOXONE TABLET SUBLINGUAL 2
Medicamentos para dejar de fumar
Nombre del Medicamento
Nivel del
Medicamento
buproban 1
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites
CHANTIX 2 QL (56 cada vez para 28 días)
CHANTIX STARTING MONTH PAK 2
NICOTROL NS 2

Medicamentos antinflamatorios
Medicamentos antinflamatorios no esteroideos
Nombre del Medicamento
4
Nivel del
Medicamento
diclofenac potassium 1
diclofenac sodium dr 1
diclofenac sodium er 1
diflunisal 1
etodolac 1
etodolac er 1
fenoprofen calcium 1
flurbiprofen 1
ibuprofen 1
indomethacin 1
indomethacin er 1
ketoprofen 1
Requisitos/Límites
ketoprofen er 1 QL (30 cada vez para 30 días)
KETOROLAC TROMETHAMINE INJECTION 4
ketorolac tromethamine tablet 1 QL (30 cada vez para 30 días)
meclofenamate sodium 1
meloxicam suspension 1
meloxicam tablet 1 QL (30 cada vez para 30 días)
nabumetone 1
naproxen 1
naproxen dr 1
oxaprozin 1
piroxicam 1
sulindac 1
tolmetin sodium 1

Antibióticos
Aminoglucósidos
Nombre del Medicamento
5
Nivel del
Medicamento
AMIKACIN SULFATE 4
gentak 1
GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE 4
GENTAMICIN SULFATE/SODIUM CHLORIDE 4
GENTAMICIN SULFATE INJECTION 4
gentamicin sulfate cream, ointment, ophthalmic solution 1
ISOTONIC GENTAMICIN 4
KANAMYCIN SULFATE 4
neomycin sulfate 1
NEOMYCIN/POLYMYXIN B SULFATES 4
paromomycin sulfate 1
STREPTOMYCIN SULFATE 4
TOBI 2
TOBRAMYCIN SULFATE/SODIUM CHLORIDE 4
TOBRAMYCIN SULFATE INJECTION 4
tobramycin sulfate ophthalmic solution 1
Otros antibióticos
Nombre del Medicamento
Nivel del
Medicamento
alcohol preps 1
BACIIM 4
bacitracin/polymyxin b 1
BACITRACIN INJECTION 4
CHLORAMPHENICOL SODIUM SUCCINATE 4
CLEOCIN GALAXY 4
CLEOCIN IN D5W 4
clindamycin hcl 1
clindamycin phosphate 1
CLINDAMYCIN PHOSPHATE ADD-VANTAGE 4
COLISTIMETHATE SODIUM 4
Requisitos/Límites
Requisitos/Límites

Nombre del Medicamento
6
Nivel del
Medicamento
CUBICIN 4
LINCOCIN 4
methenamine hippurate 1
METRONIDAZOLE IN NACL 0.79% 4
metronidazole vaginal 1
metronidazole cream, gel, lotion, tablet 1
mupirocin 1
neomycin/bacitracin/polymyxin 1
neomycin/polymyxin/bacitracin/hydrocortisone 1
neomycin/polymyxin/gramicidin 1
nitrofurantoin macrocrystalline 1
nitrofurantoin monohydrate 1
POLYMYXIN B SULFATE 4
PRIMSOL 2
silver sulfadiazine 1
ssd 1
SYNERCID 4
thermazene 1
trimethoprim 1
trimethoprim sulfate/polymyxin b sulfate 1
TYGACIL 2
VANCOCIN HCL 2
VANCOMYCIN HCL INJECTION 4
vandazole 1
XIFAXAN TABLET 200MG 2
Requisitos/Límites
ZYVOX TABLET 2 QL (20 cada vez para 10 días)
ZYVOX SUSPENSION RECONSTITUTED 2 QL (600 ml para 10 días)
ZYVOX INJECTION 4

Betalactámicos, Cefalosporinas
Nombre del Medicamento
7
Nivel del
Medicamento
cefaclor 1
cefaclor er 1
cefadroxil 1
CEFAZOLIN SODIUM 4
cefdinir 1
cefepime 4
CEFOTAXIME SODIUM 4
CEFOXITIN SODIUM INJECTION 10GM, 1GM, 2GM 4
cefpodoxime proxetil tablet 1
cefprozil 1
ceftazidime 4
CEFTRIAXONE SODIUM 4
cefuroxime axetil 1
CEFUROXIME SODIUM 4
cephalexin 1
CLAFORAN 4
FORTAZ INJECTION 1GM/50ML; 5%, 2GM/50ML; 5% 4
ZINACEF IN ISO-OSMOTIC DEXTROSE 4
ZINACEF IN ISO-OSMOTIC DILUENT 4
Otros Betalactámicos
Nombre del Medicamento
Nivel del
Medicamento
AZACTAM 4
AZACTAM IN ISO-OSMOTIC DEXTROSE 4
aztreonam 4
imipenem/cilastatin 4
INVANZ 4
meropenem 4
Requisitos/Límites
Requisitos/Límites

Betalactámicos, Penicilinas
Nombre del Medicamento
8
Nivel del
Medicamento
amoxicillin 1
amoxicillin/clavulanate potassium 1
amoxicillin/clavulanate potassium er 1
amoxicillin/potassium clavulanate 1
ampicillin 1
AMPICILLIN SODIUM 4
AMPICILLIN-SULBACTAM 4
BACTOCILL IN DEXTROSE 4
BICILLIN C-R 4
BICILLIN L-A 4
dicloxacillin sodium 1
NAFCILLIN SODIUM 4
NALLPEN/DEXTROSE 4
OXACILLIN SODIUM 4
PENICILLIN G POTASSIUM 4
PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE 4
PENICILLIN G PROCAINE 4
PENICILLIN G SODIUM 4
penicillin v potassium 1
PFIZERPEN-G 4
piperacillin sodium/tazobactam sodium injection 4gm; 0.5gm 4
TIMENTIN 4
ZOSYN 4
Requisitos/Límites

Macrólidos
Nombre del Medicamento
9
Nivel del
Medicamento
AZITHROMYCIN INJECTION 4
Requisitos/Límites
azithromycin suspension reconstituted 100mg/5ml 1 QL (15 ml para 5 días)
azithromycin suspension reconstituted 200mg/5ml 1 QL (22.5 ml para 5 días)
azithromycin tablet 500mg 1 QL (3 cada vez para 3 días)
azithromycin tablet 250mg 1 QL (6 cada vez para 5 días)
azithromycin tablet 600mg 1 QL (8 cada vez para 28 días)
clarithromycin er 1
clarithromycin suspension reconstituted 1
clarithromycin tablet 250mg 1 QL (28 cada vez para 14 días)
clarithromycin tablet 500mg 1 QL (42 cada vez para 21 días)
e.e.s. 400 1
e.e.s. granules 1
ERY-TAB 2
ERYPED 400 2
ERYTHROCIN LACTOBIONATE 4
erythrocin stearate 1
erythromycin base 1
erythromycin ointment, solution 1
KETEK TABLET 300MG 2
KETEK TABLET 400MG 2 QL (20 cada vez para 10 días)
ZMAX 2

Quinolonas
Nombre del Medicamento
10
Nivel del
Medicamento
AVELOX INJECTION 4
CIPRO I.V.-IN D5W 4
ciprofloxacin 1
ciprofloxacin hcl 1
LEVAQUIN INJECTION 4
levofloxacin in d5w 4
levofloxacin oral solution 1
levofloxacin injection 4
Requisitos/Límites
levofloxacin tablet 250mg 1 QL (10 cada vez para 10 días)
levofloxacin tablet 500mg, 750mg 1 QL (14 cada vez para 14 días)
ofloxacin 1
Sulfamidas
Nombre del Medicamento
Nivel del
Medicamento
sodium sulfacetamide 1
sulfadiazine 1
sulfamethoxazole/trimethoprim ds 1
SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 4
sulfamethoxazole/trimethoprim suspension, tablet 1
Tetraciclinas
Nombre del Medicamento
Nivel del
Medicamento
demeclocycline hcl 1
doxycycline hyclate capsule, tablet 1
doxycycline hyclate injection 4
minocycline hcl capsule 1
tetracycline hcl 1
Requisitos/Límites
Requisitos/Límites

Anticonvulsivos
Otros anticonvulsivos
Nombre del Medicamento
11
Nivel del
Medicamento
levetiracetam oral solution 1
levetiracetam injection 4
levetiracetam tablet 250mg 1
Requisitos/Límites
levetiracetam tablet 750mg 1 QL (120 cada vez para 30 días)
levetiracetam tablet 500mg 1 QL (180 cada vez para 30 días)
levetiracetam tablet 1000mg 1 QL (90 cada vez para 30 días)
POTIGA 2
Medicamentos antagonistas del calcio
Nombre del Medicamento
Nivel del
Medicamento
CELONTIN 2
ethosuximide 1
Requisitos/Límites
LYRICA CAPSULE 150MG, 200MG, 225MG, 300MG 2 QL (60 cada vez para 30 días)
LYRICA CAPSULE 100MG, 25MG, 50MG, 75MG 2 QL (90 cada vez para 30 días)
zonisamide 1

Medicamentos que aumentan el ácido gamma aminobutírico (GABA)
Nombre del Medicamento
12
Nivel del
Medicamento
clonazepam 1
clonazepam odt 1
Requisitos/Límites
clorazepate dipotassium 1 QL (90 cada vez para 30 días)
diazepam gel 1
divalproex sodium 1
divalproex sodium dr 1
divalproex sodium er 1
gabapentin 1
GABITRIL TABLET 4MG 2
GABITRIL TABLET 12MG, 16MG, 2MG 2 QL (90 cada vez para 30 días)
ONFI 2
primidone 1
SABRIL 2 QL (360 cada vez para 30 días)
VALPROATE SODIUM 4
valproic acid 1
Medicamentos reductores de glutamato
Nombre del Medicamento
Nivel del
Medicamento
felbamate 1
lamotrigine 1
topiramate 1
Requisitos/Límites

Medicamentos bloqueadores de los canales de sodio
Nombre del Medicamento
13
Nivel del
Medicamento
BANZEL SUSPENSION 2
Requisitos/Límites
BANZEL TABLET 2 QL (240 cada vez para 30 días)
carbamazepine 1
carbamazepine er 1
CARBATROL 2
DILANTIN 2
DILANTIN INFATABS 2
epitol 1
fosphenytoin sodium 4
oxcarbazepine 1
PEGANONE 2
PHENYTEK 2
phenytoin 1
PHENYTOIN SODIUM 4
phenytoin sodium extended 1
TEGRETOL 2
TEGRETOL-XR 2
TRILEPTAL SUSPENSION 2
VIMPAT ORAL SOLUTION 2
VIMPAT INJECTION 4
VIMPAT TABLET 100MG, 50MG 2
VIMPAT TABLET 150MG, 200MG 2 QL (60 cada vez para 30 días)

Medicamentos antidemencia
Inhibidores de la colinesterasa
Nombre del Medicamento
14
Nivel del
Medicamento
Requisitos/Límites
donepezil hcl 1 QL (30 cada vez para 30 días)
galantamine hydrobromide solution 1
galantamine hydrobromide capsule extended release 24 hour 1 QL (30 cada vez para 30 días)
galantamine hydrobromide tablet 4mg 1 QL (180 cada vez para 30 días)
galantamine hydrobromide tablet 12mg 1 QL (60 cada vez para 30 días)
galantamine hydrobromide tablet 8mg 1 QL (90 cada vez para 30 días)
rivastigmine tartrate 1 QL (60 cada vez para 30 días)
Antagonistas de los receptores N-metil-D-aspartato (NMDA)
Nombre del Medicamento
Nivel del
Medicamento
NAMENDA TITRATION PAK 2
Requisitos/Límites
NAMENDA SOLUTION 2 QL (360 ml para 30 días)
NAMENDA TABLET 2 QL (60 cada vez para 30 días)
Antidepresivos
Otros antidepresivos
Nombre del Medicamento
Nivel del
Medicamento
budeprion sr 1
budeprion xl tablet extended release 24 hour 300mg 1
Requisitos/Límites
budeprion xl tablet extended release 24 hour 150mg 1 QL (30 cada vez para 30 días)
bupropion hcl 1
bupropion hcl sr 1
maprotiline hcl 1
mirtazapine 1
mirtazapine odt 1
nefazodone hcl 1
trazodone hcl 1

Inhibidores de la monoamino oxidasa
Nombre del Medicamento
15
Nivel del
Medicamento
EMSAM 2
MARPLAN 2
phenelzine sulfate 1
selegiline hcl 1
tranylcypromine sulfate 1
ZELAPAR 2
Inhibidores de recaptación de serotonina/norepinefrina
Nombre del Medicamento
Nivel del
Medicamento
citalopram hydrobromide 1
CYMBALTA 2
escitalopram oxalate solution 1
Requisitos/Límites
Requisitos/Límites
escitalopram oxalate tablet 1 QL (30 cada vez para 30 días)
fluoxetine hcl capsule, solution 1
fluvoxamine maleate 1
paroxetine hcl 1
paroxetine hcl er tablet extended release 24 hour 37.5mg 1
PAXIL SUSPENSION 2
PRISTIQ 2 QL (30 cada vez para 30 días)
sertraline hcl 1
venlafaxine hcl 1 QL (90 cada vez para 30 días)
venlafaxine hcl er 1 QL (30 cada vez para 30 días)
VIIBRYD 2

Tricíclicos
Nombre del Medicamento
16
Nivel del
Medicamento
amitriptyline hcl 1
amoxapine 1
clomipramine hcl 1
desipramine hcl 1
doxepin hcl capsule 100mg, 10mg, 25mg, 50mg, 75mg 1
doxepin hcl concentrate 1
imipramine hcl 1
imipramine pamoate 1
nortriptyline hcl 1
perphenazine/amitriptyline 1
protriptyline hcl 1
trimipramine maleate 1
Antieméticos
Otros antieméticos
Nombre del Medicamento
Nivel del
Medicamento
meclizine hcl 1
trimethobenzamide hcl 1
Terapia emetogénica complementaria
Nombre del Medicamento
Nivel del
Medicamento
dronabinol 1
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites
EMEND CAPSULE 40MG 2 QL (1 cada vez para 14 días)
EMEND CAPSULE 0 2 QL (3 cada vez para 14 días)
granisetron hcl injection 4
ondansetron hcl oral solution 1
ondansetron hcl injection 4
ondansetron hcl tablet 24mg 1 QL (1 cada vez para 15 días)
ondansetron hcl tablet 4mg, 8mg 1 QL (90 cada vez para 30 días)
ondansetron odt 1 QL (90 cada vez para 30 días)

Antifúngicos
Antifúngicos
Nombre del Medicamento
17
Nivel del
Medicamento
ABELCET 4
AMBISOME 4
AMPHOTEC 4
AMPHOTERICIN B 4
CANCIDAS 4
ciclopirox olamine 1
ciclopirox suspension 1
clotrimazole 1
clotrimazole/betamethasone dipropionate 1
econazole nitrate 1
FLUCONAZOLE IN DEXTROSE 4
fluconazole suspension reconstituted 1
fluconazole tablet 100mg, 200mg, 50mg 1
Requisitos/Límites
fluconazole tablet 150mg 1 QL (1 cada vez para 10 días)
flucytosine 1
GRIS-PEG 2
itraconazole 1
ketoconazole cream, shampoo, tablet 1
miconazole 3 1 QL (12 cada vez para 30 días)
MYCAMINE 4
NAFTIN CREAM 2
NATACYN 2
nyamyc 1
nystatin 1
nystatin/triamcinolone 1
nystop 1
pedi-dri 1
SPORANOX SOLUTION 2
terbinafine hcl 1

Nombre del Medicamento
18
Nivel del
Medicamento
Requisitos/Límites
terconazole suppository 1 QL (3 cada vez para 30 días)
terconazole cream 1 QL (90 gramos para 30 días)
zazole cream 0.8% 1
Medicamentos antigotosos
Medicamentos antigotosos
Nombre del Medicamento
Nivel del
Medicamento
allopurinol 1
ALLOPURINOL SODIUM 4
ALOPRIM 4
COLCRYS 2
probenecid 1
probenecid/colchicine 1
Medicamentos antimigraña
Alcaloides del cornezuelo
Nombre del Medicamento
Nivel del
Medicamento
DIHYDROERGOTAMINE MESYLATE 4
ergotamine tartrate/caffeine 1
migergot 1
Agonistas de los receptores de serotonina (5-HT) 1b/1d
Nombre del Medicamento
Nivel del
Medicamento
IMITREX STATDOSE REFILL 4
IMITREX SOLUTION 2
MAXALT 2
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites
MAXALT-MLT 2 QL (12 cada vez para 30 días)
naratriptan hcl 1
sumatriptan succinate tablet 1
sumatriptan succinate injection 6mg/0.5ml 1

Medicamentos antimiasténicos
Parasimpaticomiméticos
Nombre del Medicamento
19
Nivel del
Medicamento
MESTINON TIMESPAN 2
MESTINON SYRUP 2
pyridostigmine bromide 1
REGONOL 4
Antimicobacterianos
Otros antimicobacterianos
Nombre del Medicamento
Nivel del
Medicamento
DAPSONE 2
MYCOBUTIN 2
Medicamentos antituberculosos
Nombre del Medicamento
Nivel del
Medicamento
CAPASTAT SULFATE 4
ethambutol hcl 1
ISONIAZID INJECTION 4
isoniazid syrup, tablet 1
PASER 2
PRIFTIN 2
RIFAMPIN INJECTION 4
rifampin capsule 1
RIFATER 2
SEROMYCIN 2
TRECATOR 2
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites

Antineoplásicos
Medicamentos alquilantes
Nombre del Medicamento
20
Nivel del
Medicamento
ALKERAN 4
BICNU 4
BUSULFEX 4
CEENU 2
cyclophosphamide 1
DACARBAZINE 4
HEXALEN 2
IFEX 4
IFOSFAMIDE 4
LEUKERAN 2
MATULANE 2
melphalan hydrochloride 4
MUSTARGEN 4
THIOTEPA 4
TREANDA 4
ZANOSAR 4
Medicamentos antiangiogénicos
Nombre del Medicamento
Nivel del
Medicamento
CAPRELSA 2
REVLIMID 2 LA
THALOMID 2
Antiestrógenos/Modificadores
Nombre del Medicamento
Nivel del
Medicamento
EMCYT 2
FARESTON 2
FASLODEX 4
tamoxifen citrate 1
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites

Antimetabolitos
Nombre del Medicamento
21
Nivel del
Medicamento
CLADRIBINE 4
CLOLAR 4
CYTARABINE 4
CYTARABINE AQUEOUS INJECTION 100MG/ML 4
cytarabine aqueous injection 20mg/ml 4
DROXIA 2
ELITEK 4
fluorouracil 4
FOLOTYN 4
gemcitabine hcl 4
hydroxyurea 1
mercaptopurine 1
pentostatin 4
TABLOID 2
Otros medicamentos antineoplásicos
Nombre del Medicamento
Nivel del
Medicamento
ABRAXANE 4
ADRIAMYCIN 4
ALIMTA 4
amifostine 4
ARRANON 4
BLEOMYCIN SULFATE 4
CAMPTOSAR 4
carboplatin 4
CERUBIDINE 2
CISPLATIN 4
COSMEGEN 2
DACOGEN 4
DAUNORUBICIN HCL 2
DEXRAZOXANE 4
Requisitos/Límites
Requisitos/Límites

Nombre del Medicamento
22
Nivel del
Medicamento
DOCEFREZ 4
docetaxel 4
DOXIL 2
DOXORUBICIN HCL 4
ELLENCE 4
ELSPAR 4
epirubicin hcl 4
ERIVEDGE 2
FLUDARABINE PHOSPHATE 4
FUSILEV 4
HALAVEN 4
IDAMYCIN PFS 4
IDARUBICIN HCL 4
irinotecan 4
ISTODAX 4
IXEMPRA KIT 4
JAKAFI 2
JEVTANA 4
LEUCOVORIN CALCIUM INJECTION 4
leucovorin calcium tablet 1
MENEST 2
MESNA 4
MESNEX 4
MITOMYCIN 4
MITOXANTRONE HCL 4
ONTAK 4
oxaliplatin 4
PACLITAXEL 4
PICATO 2
PROLEUKIN 4
SYLATRON 4
TRISENOX 4
Requisitos/Límites

Nombre del Medicamento
23
Nivel del
Medicamento
VELCADE 4
VIDAZA 2
VINBLASTINE SULFATE 4
vincristine sulfate 1
VINORELBINE TARTRATE 4
ZINECARD 4
ZOLINZA 2
ZYTIGA 2
Inhibidores de la aromatasa de tercera generación
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
Requisitos/Límites
anastrozole 1 QL (30 cada vez para 30 días)
exemestane 1
letrozole 1
Inhibidores enzimáticos
Nombre del Medicamento
Nivel del
Medicamento
ETOPOPHOS 2
ETOPOSIDE 4
TOPOSAR 4
topotecan hcl 4
Requisitos/Límites

Inhibidores de objetivos moleculares
Nombre del Medicamento
24
Nivel del
Medicamento
AFINITOR 2
GLEEVEC 2
INLYTA 2
NEXAVAR 2
SPRYCEL 2
SUTENT 2
TARCEVA 2
TASIGNA 2
TYKERB 2
Requisitos/Límites
VOTRIENT 2 QL (120 cada vez para 30 días)
XALKORI 2
ZELBORAF 2
Anticuerpos monoclonales
Nombre del Medicamento
Nivel del
Medicamento
ARZERRA 4
AVASTIN 4
CAMPATH 4
ERBITUX 4
HERCEPTIN 4
RITUXAN 4
VECTIBIX 4
YERVOY 4
Retinoides
Nombre del Medicamento
Nivel del
Medicamento
PANRETIN 2
TARGRETIN 2
tretinoin 1
Requisitos/Límites
Requisitos/Límites

Antiparasitarios
Antihelmínticos
Nombre del Medicamento
25
Nivel del
Medicamento
ALBENZA 2
STROMECTOL 2
Antiprotozoicos
Nombre del Medicamento
Nivel del
Medicamento
ALINIA 2
atovaquone/proguanil hcl 1
chloroquine phosphate 1
COARTEM 2
DARAPRIM 2
hydroxychloroquine sulfate 1
MALARONE TABLET 62.5MG; 25MG 2
mefloquine hcl 1
MEPRON 2
NEBUPENT 2
PENTAM 300 4
PRIMAQUINE PHOSPHATE 2
Medicamentos pediculisidas/escabisidas
Nombre del Medicamento
Nivel del
Medicamento
lindane lotion 1
malathion 1
permethrin 1
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites

Medicamentos antiparkinson
Anticolinérgicos
Nombre del Medicamento
26
Nivel del
Medicamento
benztropine mesylate tablet 1
benztropine mesylate injection 4
trihexyphenidyl hcl 1
Otros medicamentos antiparkinson
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
Requisitos/Límites
COMTAN 2 QL (240 cada vez para 30 días)
TASMAR 2
Agonistas de la dopamina
Nombre del Medicamento
Nivel del
Medicamento
APOKYN 4
bromocriptine mesylate 1
pramipexole dihydrochloride 1
ropinirole hcl 1
Precursores de dopamina/Inhibidores de L-aminoácido decarboxilasa
Nombre del Medicamento
Nivel del
Medicamento
carbidopa/levodopa 1
carbidopa/levodopa er 1
carbidopa/levodopa odt 1
STALEVO 100 2
STALEVO 125 2
STALEVO 150 2
STALEVO 200 2
STALEVO 50 2
STALEVO 75 2
Requisitos/Límites
Requisitos/Límites

Inhibidores de la monoaminooxidasa B (MAO-B)
Nombre del Medicamento
27
Nivel del
Medicamento
Requisitos/Límites
AZILECT 2 QL (30 cada vez para 30 días)
Antipsicóticos
Primera generación/Típicos
Nombre del Medicamento
Nivel del
Medicamento
CHLORPROMAZINE HCL INJECTION 4
chlorpromazine hcl tablet 1
compro 1
FLUPHENAZINE DECANOATE 4
FLUPHENAZINE HCL INJECTION 4
fluphenazine hcl concentrate, elixir, tablet 1
haloperidol 1
HALOPERIDOL DECANOATE 4
HALOPERIDOL LACTATE 4
loxapine succinate 1
ORAP 2
perphenazine 1
PROCHLORPERAZINE EDISYLATE 4
prochlorperazine maleate 1
thioridazine hcl 1
thiothixene 1
trifluoperazine hcl 1
Requisitos/Límites

Segunda generación/Atípicos
Nombre del Medicamento
28
Nivel del
Medicamento
ABILIFY DISCMELT 2
ABILIFY ORAL SOLUTION 2
Requisitos/Límites
ABILIFY TABLET 2 QL (30 cada vez para 30 días)
ABILIFY INJECTION 4
FANAPT 2 QL (60 cada vez para 30 días)
FANAPT TITRATION PACK 2
GEODON INJECTION 4
INVEGA SUSTENNA 4
INVEGA TABLET EXTENDED RELEASE 24 HOUR 1.5MG,
3MG, 9MG
2 QL (30 cada vez para 30 días)
INVEGA TABLET EXTENDED RELEASE 24 HOUR 6MG 2 QL (60 cada vez para 30 días)
LATUDA 2
olanzapine odt 1
olanzapine tablet 1
olanzapine injection 4
quetiapine fumarate 1
RISPERDAL CONSTA 4
risperidone 1
risperidone odt 1
SAPHRIS 2
ziprasidone hcl 1
Resistencia al tratamiento
Nombre del Medicamento
Nivel del
Medicamento
clozapine 1
FAZACLO 2
Requisitos/Límites

Medicamentos antiespasticidad
Medicamentos antiespasticidad
Nombre del Medicamento
29
Nivel del
Medicamento
baclofen 1
dantrolene sodium 1
tizanidine hcl tablet 1
Antivíricos
Medicamentos anticitomegalovirus (CMV)
Nombre del Medicamento
Nivel del
Medicamento
FOSCARNET SODIUM 4
ganciclovir capsule 1
VALCYTE 2
VISTIDE 4
Requisitos/Límites
Requisitos/Límites
Medicamentos anti VIH, inhibidores de la transcriptasa reversa no nucleósida
Nombre del Medicamento
Nivel del
Medicamento
ATRIPLA 2
COMPLERA 2
EDURANT 2
INTELENCE 2
nevirapine 1
RESCRIPTOR 2
SUSTIVA 2
VIRAMUNE XR 2
VIRAMUNE SUSPENSION 2
Requisitos/Límites

Medicamentos anti VIH, inhibidores de la transcriptasa reversa nucleósida y nucleótida
Nombre del Medicamento
30
Nivel del
Medicamento
didanosine 1
EMTRIVA 2
EPIVIR HBV 2
EPIVIR SOLUTION 2
EPZICOM 2
lamivudine 1
lamivudine/zidovudine 1
RETROVIR IV INFUSION 4
stavudine 1
TRIZIVIR 2
TRUVADA 2
VIDEX PEDIATRIC 2
VIREAD 2
ZERIT SOLUTION RECONSTITUTED 2
ZIAGEN 2
zidovudine 1
Otros medicamentos anti VIH
Nombre del Medicamento
Nivel del
Medicamento
FUZEON 2
ISENTRESS 2
SELZENTRY 2
Requisitos/Límites
Requisitos/Límites

Medicamentos anti VIH, inhibidores de la proteasa
Nombre del Medicamento
31
Nivel del
Medicamento
APTIVUS 2
CRIXIVAN 2
INVIRASE 2
KALETRA 2
LEXIVA 2
NORVIR 2
PREZISTA 2
REYATAZ 2
VIRACEPT 2
Medicamentos antigripales
Nombre del Medicamento
Nivel del
Medicamento
amantadine hcl 1
Requisitos/Límites
Requisitos/Límites
RELENZA DISKHALER 2 QL (56 cada vez para 180 días)
rimantadine hcl 1
TAMIFLU SUSPENSION RECONSTITUTED 2
TAMIFLU CAPSULE 30MG, 45MG 2
TAMIFLU CAPSULE 75MG 2 QL (28 cada vez para 180 días)

Medicamentos antihepatitis
Nombre del Medicamento
32
Nivel del
Medicamento
BARACLUDE 2
HEPSERA 2
INCIVEK 2
Requisitos/Límites
INFERGEN 3 PA (Medicamentos inmunitarios -
Infergen)
INTRON-A 4
INTRON-A W/DILUENT 4
PEG-INTRON 3 PA (Medicamentos inmunitarios -
Peg-Intron, Pegasys)
PEG-INTRON REDIPEN 3 PA (Medicamentos inmunitarios -
Peg-Intron, Pegasys)
PEGASYS 3 PA (Medicamentos inmunitarios -
Peg-Intron, Pegasys)
PEGASYS PROCLICK 3 PA (Medicamentos inmunitarios -
Peg-Intron, Pegasys)
REBETOL SOLUTION 2
ribapak 1
ribasphere tablet 1
ribavirin 1
TYZEKA 2
VICTRELIS 2
Medicamentos antiherpéticos
Nombre del Medicamento
Nivel del
Medicamento
acyclovir 1
ACYCLOVIR SODIUM 4
DENAVIR 2
Requisitos/Límites
famciclovir 1 QL (60 cada vez para 30 días)
trifluridine 1
valacyclovir hcl 1 QL (30 cada vez para 30 días)
ZOVIRAX CREAM, OINTMENT 2 QL (30 gramos para 30 días)

Ansiolíticos
Otros ansiolíticos
Nombre del Medicamento
33
Nivel del
Medicamento
alprazolam intensol 4
Requisitos/Límites
alprazolam tablet 0.25mg 1 QL (120 cada vez para 30 días)
alprazolam tablet 0.5mg, 1mg, 2mg 1 QL (150 cada vez para 30 días)
buspirone hcl 1
chlordiazepoxide/amitriptyline 1
diazepam intensol 4
diazepam tablet 1 QL (120 cada vez para 30 días)
lorazepam intensol 4
lorazepam tablet 0.5mg 1 QL (120 cada vez para 30 días)
lorazepam tablet 1mg, 2mg 1 QL (150 cada vez para 30 días)
meprobamate 1
Medicamentos contra trastornos bipolares
Estabilizadores del estado de ánimo
Nombre del Medicamento
Nivel del
Medicamento
lithium carbonate 1
lithium carbonate er 1
lithium citrate 1
LITHOBID 2
Requisitos/Límites

Medicamentos reguladores de la glucosa sanguínea
Medicamentos antidiabéticos
Nombre del Medicamento
34
Nivel del
Medicamento
Requisitos/Límites
acarbose 1 QL (90 cada vez para 30 días)
ACTOPLUS MET 2 QL (90 cada vez para 30 días)
ACTOS 2 QL (30 cada vez para 30 días)
AVANDAMET TABLET 500MG; 2MG 2 QL (120 cada vez para 30 días)
AVANDAMET TABLET 1000MG; 2MG, 1000MG; 4MG,
500MG; 4MG
2 QL (60 cada vez para 30 días)
AVANDARYL 2 QL (30 cada vez para 30 días)
AVANDIA TABLET 8MG 2 QL (30 cada vez para 30 días)
AVANDIA TABLET 2MG, 4MG 2 QL (60 cada vez para 30 días)
BYETTA INJECTION 5MCG/0.02ML 3 PA (Reguladores de la glucosa
sanguínea)
BYETTA INJECTION 10MCG/0.04ML 3 QL (2.4 ml para 30 días) PA
(Reguladores de la glucosa
sanguínea)
chlorpropamide 1
CYCLOSET 2
DUETACT 2 QL (30 cada vez para 30 días)
glimepiride tablet 1mg, 2mg 1 QL (30 cada vez para 30 días)
glimepiride tablet 4mg 1 QL (60 cada vez para 30 días)
glipizide er tablet extended release 24 hour 2.5mg, 5mg 1 QL (30 cada vez para 30 días)
glipizide er tablet extended release 24 hour 10mg 1 QL (60 cada vez para 30 días)
glipizide/metformin hcl 1 QL (120 cada vez para 30 días)
glipizide tablet 10mg 1 QL (120 cada vez para 30 días)
glipizide tablet 5mg 1 QL (90 cada vez para 30 días)
glyburide micronized tablet 1.5mg, 3mg 1 QL (30 cada vez para 30 días)
glyburide micronized tablet 6mg 1 QL (60 cada vez para 30 días)
glyburide/metformin hcl 1 QL (120 cada vez para 30 días)
glyburide tablet 5mg 1
glyburide tablet 1.25mg, 2.5mg 1 QL (30 cada vez para 30 días)
GLYSET 2 QL (90 cada vez para 30 días)
JANUVIA 2 QL (30 cada vez para 30 días)
KOMBIGLYZE XR 2
metformin hcl er tablet extended release 24 hour 500mg 1 QL (120 cada vez para 30 días)

Nombre del Medicamento
35
Nivel del
Medicamento
Requisitos/Límites
metformin hcl er tablet extended release 24 hour 750mg 1 QL (90 cada vez para 30 días)
metformin hcl tablet 500mg 1 QL (120 cada vez para 30 días)
metformin hcl tablet 1000mg 1 QL (60 cada vez para 30 días)
metformin hcl tablet 850mg 1 QL (90 cada vez para 30 días)
nateglinide 1 QL (90 cada vez para 30 días)
ONGLYZA 2
PRANDIN 2
SYMLINPEN 120 3 PA (Reguladores de la glucosa
sanguínea- amilinomiméticos)
SYMLINPEN 60 3 PA (Reguladores de la glucosa
sanguínea- amilinomiméticos)
tolbutamide 1
TRADJENTA 2
Medicamentos para estabilizar la glucemia
Nombre del Medicamento
Nivel del
Medicamento
CLINIMIX 4.25%/DEXTROSE 20% 4
CLINIMIX 5%/DEXTROSE 15% 4
CLINIMIX 5%/DEXTROSE 20% 4
CLINIMIX E 2.75%/DEXTROSE 10% 4
CLINIMIX E 2.75%/DEXTROSE 5% 4
CLINIMIX E 4.25%/DEXTROSE 25% 4
CLINIMIX E 4.25%/DEXTROSE 5% 4
CLINIMIX E 5%/DEXTROSE 15% 4
CLINIMIX E 5%/DEXTROSE 25% 4
DEXTROSE 10%/NACL 0.45% 4
DEXTROSE 10% FLEX CONTAINER 4
DEXTROSE 10%/NACL 0.2% 4
DEXTROSE 2.5%/SODIUM CHLORIDE 0.45% 4
DEXTROSE 5% 4
DEXTROSE 5%/NACL 0.2% 4
DEXTROSE 5%/NACL 0.225% 4
Requisitos/Límites

Nombre del Medicamento
36
Nivel del
Medicamento
DEXTROSE 5%/NACL 0.33% 4
DEXTROSE 5%/NACL 0.45% 4
DEXTROSE 5%/NACL 0.9% 4
GLUCAGEN HYPOKIT 4
GLUCAGON EMERGENCY KIT 4
IONOSOL-B/DEXTROSE 5% 4
IONOSOL-MB/DEXTROSE 5% 4
KCL 0.075%/D5W/NACL 0.45% 4
KCL 0.15%/D5W/LR 4
KCL 0.15%/D5W/NACL 0.2% 4
KCL 0.15%/D5W/NACL 0.225% 4
KCL 0.15%/D5W/NACL 0.9% 4
KCL 0.3%/D5W/NACL 0.45% 4
KCL 0.3%/D5W/NACL 0.9% 4
NORMOSOL-R IN D5W 4
POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% 4
POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45%
VIAFLEX
POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% 4
PROGLYCEM 2
4
Requisitos/Límites

Insulinas
Nombre del Medicamento
37
Nivel del
Medicamento
Requisitos/Límites
HUMALOG 2 QL (40 ml para 30 días)
HUMALOG KWIKPEN 2 QL (40 ml para 30 días)
HUMALOG MIX 50/50 2 QL (40 ml para 30 días)
HUMALOG MIX 50/50 KWIKPEN 2 QL (40 ml para 30 días)
HUMALOG MIX 75/25 2 QL (40 ml para 30 días)
HUMALOG MIX 75/25 KWIKPEN 2 QL (40 ml para 30 días)
HUMULIN 70/30 2 QL (40 ml para 30 días)
HUMULIN 70/30 PEN 2 QL (40 ml para 30 días)
HUMULIN N 2 QL (40 ml para 30 días)
HUMULIN N U-100 PEN 2 QL (40 ml para 30 días)
HUMULIN R 2 QL (40 ml para 30 días)
HUMULIN R U-500 (CONCENTRATED) 2
LANTUS 2 QL (30 ml para 30 días)
LEVEMIR 2 QL (30 ml para 30 días)
NOVOLIN 70/30 2 QL (40 ml para 30 días)
NOVOLIN N 2 QL (40 ml para 30 días)
NOVOLIN R 2 QL (40 ml para 30 días)
NOVOLOG 2 QL (40 ml para 30 días)
NOVOLOG FLEXPEN 2 QL (40 ml para 30 días)
NOVOLOG MIX 70/30 2 QL (40 ml para 30 días)
NOVOLOG MIX 70/30 PREFILLED FLEXPEN 2 QL (40 ml para 30 días)

Productos de la sangre/Modificadores/Expansores de volumen
Anticoagulantes
Nombre del Medicamento
38
Nivel del
Medicamento
ARIXTRA 4
COUMADIN TABLET 2
COUMADIN INJECTION 4
enoxaparin sodium 4
fondaparinux sodium 4
FRAGMIN INJECTION 10000UNIT/ML, 25000UNIT/ML,
2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML
HEPARIN SODIUM 4
HEPARIN SODIUM/D5W 4
HEPARIN SODIUM/NACL 0.45% 4
HEPARIN SODIUM/SODIUM CHLORIDE 0.9% PREMIX 4
jantoven 1
LOVENOX 4
PRADAXA 2
warfarin sodium 1
XARELTO 2
4
Requisitos/Límites

Modificadores de la formación de sangre
Nombre del Medicamento
39
Nivel del
Medicamento
anagrelide hydrochloride 1
ARANESP ALBUMIN FREE INJECTION 100MCG/ML,
150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML,
25MCG/0.42ML, 25MCG/ML, 300MCG/ML, 40MCG/0.4ML,
40MCG/ML, 500MCG/ML, 60MCG/ML
Requisitos/Límites
3 PA (Productos de la
sangre/Modificadores/
Expansores de volumen)
EPOGEN 3 PA (Productos de la
sangre/Modificadores/
Expansores de volumen)
LEUKINE 4
NEULASTA 4
NEUMEGA 4
NEUPOGEN 4
PROCRIT 3 PA (Productos de la
sangre/Modificadores/
Expansores de volumen)
PROMACTA TABLET 50MG 3 QL (30 Cada vez para 30 días)
PA (Productos de la sangre
/Modificadores/ Expansores de
volumen - Promacta)
PROMACTA TABLET 25MG 3 QL (90 Cada vez para 30 días)
PA (Productos de la sangre
/Modificadores/ Expansores de
volumen - Promacta)
Coagulantes
Nombre del Medicamento
Nivel del
Medicamento
tranexamic acid 4
Medicamentos modificadores de plaquetas
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
Requisitos/Límites
AGGRENOX 2 QL (60 cada vez para 30 días)
cilostazol 1
clopidogrel tablet 300mg 1
clopidogrel tablet 75mg 1 QL (30 cada vez para 30 días)
dipyridamole 1
EFFIENT 2 QL (30 cada vez para 30 días)
ticlopidine hcl 1 QL (60 cada vez para 30 días)

Medicamentos cardiovasculares
Agonistas alfa adrenérgicos
Nombre del Medicamento
40
Nivel del
Medicamento
clonidine hcl tablet 1
guanfacine hcl 1
methyldopa 1
methyldopa/hydrochlorothiazide 1
METHYLDOPATE HCL 4
midodrine hcl 1
Medicamentos bloqueantes alfa adrenérgicos
Nombre del Medicamento
Nivel del
Medicamento
prazosin hcl 1
reserpine tablet 0.25mg 1
Antagonistas de los receptores de angiotensina II
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites
DIOVAN 2 QL (30 cada vez para 30 días)
DIOVAN HCT 2 QL (30 cada vez para 30 días)
losartan potassium 1 QL (30 cada vez para 30 días)
losartan potassium/hydrochlorothiazide 1 QL (30 cada vez para 30 días)

Inhibidores de la enzima convertidora de angiotensina (ECA)
Nombre del Medicamento
41
Nivel del
Medicamento
benazepril hcl/hydrochlorothiazide 1
Requisitos/Límites
benazepril hcl tablet 10mg, 20mg, 5mg 1 QL (30 cada vez para 30 días)
benazepril hcl tablet 40mg 1 QL (60 cada vez para 30 días)
captopril 1
captopril/hydrochlorothiazide 1
enalapril maleate 1
enalapril maleate/hydrochlorothiazide 1
fosinopril sodium 1
fosinopril sodium/hydrochlorothiazide 1
lisinopril 1 QL (30 cada vez para 30 días)
lisinopril/hydrochlorothiazide 1
quinapril hcl 1 QL (60 cada vez para 30 días)
quinapril/hydrochlorothiazide 1 QL (30 cada vez para 30 días)
ramipril 1 QL (60 cada vez para 30 días)
trandolapril tablet 1mg, 2mg 1 QL (30 cada vez para 30 días)
trandolapril tablet 4mg 1 QL (60 cada vez para 30 días)

Antiarrítmicos
Nombre del Medicamento
42
Nivel del
Medicamento
AMIODARONE HCL INJECTION 4
amiodarone hcl tablet 1
disopyramide phosphate 1
flecainide acetate 1
mexiletine hcl 1
MULTAQ 2
PACERONE TABLET 100MG, 400MG 2
pacerone tablet 200mg 1
PROCAINAMIDE HCL 4
propafenone hcl 1
QUINIDINE GLUCONATE 4
quinidine gluconate er 1
quinidine sulfate 1
quinidine sulfate er 1
sorine 1
sotalol hcl 1
Requisitos/Límites
TIKOSYN 2 QL (60 cada vez para 30 días)

Medicamentos beta bloqueantes adrenérgicos
Nombre del Medicamento
43
Nivel del
Medicamento
acebutolol hcl 1
atenolol 1
atenolol/chlorthalidone 1
betaxolol hcl 1
bisoprolol fumarate 1
bisoprolol fumarate/hydrochlorothiazide 1
Requisitos/Límites
carvedilol 1 QL (60 cada vez para 30 días)
LABETALOL HCL INJECTION 4
labetalol hcl tablet 1
metoprolol succinate er 1
metoprolol tartrate tablet 1
metoprolol tartrate injection 4
metoprolol/hydrochlorothiazide 1
nadolol 1
nadolol/bendroflumethiazide 1
pindolol 1
propranolol hcl er 1
PROPRANOLOL HCL INJECTION 4
propranolol hcl oral solution, tablet 1
propranolol/hydrochlorothiazide 1
timolol maleate 1

Medicamentos bloqueadores de los canales de calcio
Nombre del Medicamento
44
Nivel del
Medicamento
Requisitos/Límites
afeditab cr 1 QL (30 cada vez para 30 días)
amlodipine besylate 1 QL (30 cada vez para 30 días)
amlodipine besylate/benazepril hcl 1 QL (30 cada vez para 30 días)
amlodipine besylate/benazepril hydrochloride 1 QL (30 cada vez para 30 días)
cartia xt 1 QL (30 cada vez para 30 días)
dilt-cd 1 QL (30 cada vez para 30 días)
dilt-xr 1 QL (30 cada vez para 30 días)
diltiazem cd 1 QL (30 cada vez para 30 días)
diltiazem hcl er capsule extended release 24 hour 180mg 1
diltiazem hcl er capsule extended release 24 hour 360mg 1 QL (30 cada vez para 30 días)
diltiazem hcl er capsule extended release 12 hour 1
DILTIAZEM HCL INJECTION 4
diltiazem hcl tablet 1
felodipine er 1 QL (30 cada vez para 30 días)
matzim la 1 QL (30 cada vez para 30 días)
nicardipine hcl capsule 1
nifediac cc 1 QL (30 cada vez para 30 días)
nifedical xl 1 QL (30 cada vez para 30 días)
nifedipine 1
nifedipine er 1 QL (30 cada vez para 30 días)
taztia xt 1 QL (30 cada vez para 30 días)
verapamil hcl er tablet extended release 1
verapamil hcl er capsule extended release 24 hour 1 QL (30 cada vez para 30 días)
VERAPAMIL HCL INJECTION 4
verapamil hcl tablet 1

Otros medicamentos cardiovasculares
Nombre del Medicamento
45
Nivel del
Medicamento
DEMSER 2
DIGOXIN INJECTION 4
digoxin oral solution, tablet 1
LANOXIN TABLET 2
LANOXIN INJECTION 4
pentoxifylline er 1
RANEXA TABLET EXTENDED RELEASE 12 HOUR
500MG
Requisitos/Límites
3 QL (120 cada vez para 30
días) PA (medicamentos
cardiovasculares)
TEKTURNA 2 QL (30 cada vez para 30 días)
TEKTURNA HCT 2 QL (30 cada vez para 30 días)
Diuréticos, inhibidores de la anhidrasa carbónica
Nombre del Medicamento
Nivel del
Medicamento
ACETAZOLAMIDE SODIUM 4
Diuréticos de asa
Nombre del Medicamento
Nivel del
Medicamento
BUMETANIDE INJECTION 4
bumetanide tablet 1
FUROSEMIDE INJECTION 4
furosemide oral solution, tablet 1
torsemide tablet 1
torsemide injection 4
Requisitos/Límites
Requisitos/Límites

Diuréticos ahorradores de potasio
Nombre del Medicamento
46
Nivel del
Medicamento
amiloride hcl 1
amiloride/hydrochlorothiazide 1
eplerenone 1
spironolactone 1
spironolactone/hydrochlorothiazide 1
triamterene/hydrochlorothiazide 1
Diuréticos tiazídicos
Nombre del Medicamento
Nivel del
Medicamento
chlorothiazide 1
chlorothiazide sodium 4
chlorthalidone 1
hydrochlorothiazide 1
indapamide 1
methyclothiazide 1
metolazone 1
THALITONE 2
Dislipidémicos, derivados del ácido fíbrico
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites
fenofibrate 1 QL (30 cada vez para 30 días)
fenofibrate micronized 1 QL (30 cada vez para 30 días)
gemfibrozil 1 QL (60 cada vez para 30 días)

Dislipidémicos, inhibidores de la HMG CoA reductasa
Nombre del Medicamento
47
Nivel del
Medicamento
Requisitos/Límites
atorvastatin calcium 1 QL (30 cada vez para 30 días)
lovastatin tablet 10mg, 20mg 1 QL (30 cada vez para 30 días)
lovastatin tablet 40mg 1 QL (60 cada vez para 30 días)
pravastatin sodium 1 QL (30 cada vez para 30 días)
simvastatin 1 QL (30 cada vez para 30 días)
Otros dislipidémicos
Nombre del Medicamento
Nivel del
Medicamento
cholestyramine light 1
colestipol hcl 1
LOVAZA 2
NIASPAN 2
prevalite 1
Requisitos/Límites
ZETIA 2 QL (30 cada vez para 30 días)
Vasodilatadores, que actúan directamente en venas/arterias
Nombre del Medicamento
Nivel del
Medicamento
isosorbide dinitrate 1
isosorbide dinitrate er 1
isosorbide mononitrate 1
isosorbide mononitrate er 1
nitroglycerin transdermal 1
NITROGLYCERIN INJECTION 4
nitroglycerin patch 24 hour 1
NITROSTAT 2
Requisitos/Límites

Vasodilatadores, que actúan directamente en arterias
Nombre del Medicamento
48
Nivel del
Medicamento
HYDRALAZINE HCL INJECTION 4
hydralazine hcl tablet 1
minoxidil 1
Requisitos/Límites
Medicamentos que actúan en el sistema nervioso central
Anfetaminas, medicamentos contra el trastorno de hiperactividad y déficit de atención
Nombre del Medicamento
amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg; 5mg,
7.5mg; 7.5mg; 7.5mg; 7.5mg
amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg;
1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg;
2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg,
3.75mg; 3.75mg; 3.75mg; 3.75mg
Nivel del
Medicamento
dextroamphetamine sulfate 1
Requisitos/Límites
1 QL (60 cada vez para 30 días)
1 QL (90 cada vez para 30 días)
Medicamentos no anfetaminas contra el trastorno de hiperactividad y déficit de atención,
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
INTUNIV 2 QL (30 cada vez para 30 días)
METADATE CD 2 QL (30 cada vez para 30 días)
methylphenidate hcl 1 QL (90 cada vez para 30 días)
methylphenidate hcl er tablet extended release 1 QL (90 cada vez para 30 días)
STRATTERA 2 QL (60 cada vez para 30 días)
Otros medicamentos que actúan en el sistema nervioso central
Nombre del Medicamento
Nivel del
Medicamento
butalbital/acetaminophen/caffeine/codeine 1
RILUTEK 2
Requisitos/Límites
XENAZINE 3 PA (medicamentos terapéuticos
misceláneos - Xenazine)

Medicamentos contra la esclerosis múltiple
Nombre del Medicamento
49
Nivel del
Medicamento
COPAXONE 4
GILENYA 2
Medicamentos dentales y orales
Medicamentos dentales y orales
Nombre del Medicamento
Nivel del
Medicamento
chlorhexidine gluconate oral rinse 1
KEPIVANCE 4
periogard 1
pilocarpine hcl 1
pilocarpine hydrochloride 1
triamcinolone in orabase 1
Medicamentos dermatológicos
Medicamentos dermatológicos
Nombre del Medicamento
Nivel del
Medicamento
adapalene 1
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites
AMEVIVE 3 PA (Medicamentos
dermatológicos – IV contra la
psoriasis
ammonium lactate 1
calcipotriene solution 1 QL (60 ml para 30 días)
claravis 1
clindamycin phosphate gel, lotion, solution, swab 1
clindamycin/benzoyl peroxide 1
curity gauze pads 2”x2” 1 QL (204 cada vez para 30 días)
DOVONEX 2 QL (200 gramos para 30 días)
ELIDEL 3 QL (60 gramos para 30 días)
PA (Medicamentos
dermatológicos)
erythromycin/benzoyl peroxide 1
fluorouracil 1
imiquimod 1 QL (24 cada vez para 30 días)

Nombre del Medicamento
50
Nivel del
Medicamento
laclotion 1
OXSORALEN 2
OXSORALEN ULTRA 2
podofilox 1
Requisitos/Límites
PROTOPIC 3 QL (60 gramos para 30 días)
PA (Medicamentos
dermatológicos)
REGRANEX 3 QL (15 gramos para 30 días)
PA (Medicamentos
dermatológicos - Regranex)
SANTYL 2
selenium sulfide 1
sulfacetamide sodium 1
TAZORAC 2
tretinoin cream 1
tretinoin gel 1 QL (90 gramos para 30 días)
UVADEX 4
VEREGEN 2 QL (15 gramos para 30 días)
VOLTAREN 2
ZONALON 2

Medicamentos modificadores/de reemplazo enzimático
Medicamentos modificadores/de reemplazo enzimático
Nombre del Medicamento
51
Nivel del
Medicamento
ADAGEN 4
ALDURAZYME 4
BUPHENYL 2
CEREZYME 4
CREON CAPSULE DELAYED RELEASE PARTICLES
120000UNIT; 24000UNIT; 76000UNIT, 30000UNIT;
6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT
CYSTADANE 2
CYSTAGON 2
ELAPRASE 4
FABRAZYME 4
2
Requisitos/Límites
KUVAN 3 PA (Medicamentos
modificadores/de reemplazo
enzimático - Kuvan)
NAGLAZYME 4
ORFADIN 2
PANCREAZE 2
SUCRAID 2
VPRIV 4
ZAVESCA 2
ZENPEP 2
Medicamentos gastrointestinales
Antiespasmódicos, gastrointestinales
Nombre del Medicamento
Nivel del
Medicamento
ATROPINE SULFATE 4
dicyclomine hcl 1
GLYCOPYRROLATE INJECTION 4
glycopyrrolate tablet 1
methscopolamine bromide tablet 2.5mg 1
Requisitos/Límites

Otros medicamentos gastrointestinales
Nombre del Medicamento
52
Nivel del
Medicamento
cromolyn sodium 1
diphenoxylate/atropine tablet 1
GASTROCROM 2
loperamide hcl 1
METOCLOPRAMIDE HCL INJECTION 4
metoclopramide hcl oral solution, tablet 1
RELISTOR 4
ursodiol 1
Antagonistas de los receptores de la histamina tipo 2 (H2)
Nombre del Medicamento
Nivel del
Medicamento
cimetidine 1
CIMETIDINE HCL INJECTION 4
cimetidine hcl oral solution 1
FAMOTIDINE PREMIXED 4
FAMOTIDINE INJECTION 4
famotidine tablet 1
RANITIDINE HCL INJECTION 4
ranitidine hcl capsule, syrup, tablet 1
ZANTAC INJECTION 4
Medicamentos contra el síndrome de colon irritable
Nombre del Medicamento
Nivel del
Medicamento
AMITIZA 2
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites
LOTRONEX 3 QL (60 cada vez para 30
días) PA (Medicamentos
contra el síndrome de colon
irritable)

Laxantes
Nombre del Medicamento
53
Nivel del
Medicamento
enulose 1
gavilyte-c 1
gavilyte-g 1
gavilyte-n/flavor pack 1
lactulose 1
NULYTELY/FLAVOR PACKS 2
polyethylene glycol 3350 1
trilyte 1
Medicamentos protectores
Nombre del Medicamento
Nivel del
Medicamento
misoprostol 1
sucralfate 1
Inhibidores de la bomba de protones
Nombre del Medicamento
Nivel del
Medicamento
NEXIUM I.V. 4
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites
omeprazole capsule delayed release 10mg 1 QL (30 cada vez para 30 días)
omeprazole capsule delayed release 20mg, 40mg 1 QL (90 cada vez para 30 días)
pantoprazole sodium tablet delayed release 40mg 1
pantoprazole sodium tablet delayed release 20mg 1 QL (30 cada vez para 30 días)
PROTONIX INJECTION 4

Medicamentos para problemas genitourinarios
Antiespasmódicos urinarios
Nombre del Medicamento
54
Nivel del
Medicamento
Requisitos/Límites
DETROL 2 QL (60 cada vez para 30 días)
DETROL LA 2 QL (30 cada vez para 30 días)
flavoxate hcl 1
oxybutynin chloride er 1
oxybutynin chloride tablet 1
Medicamentos contra la hipertrofia prostática benigna
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
alfuzosin hcl er 1 QL (30 cada vez para 30 días)
AVODART 2 QL (30 cada vez para 30 días)
doxazosin mesylate 1
finasteride 1 QL (30 cada vez para 30 días)
tamsulosin hcl 1 QL (60 cada vez para 30 días)
terazosin hcl 1
Otros medicamentos para problemas genitourinarios
Nombre del Medicamento
Nivel del
Medicamento
bethanechol chloride 1
ELMIRON 2
Medicamentos fijadores de fosfato
Nombre del Medicamento
Nivel del
Medicamento
FOSRENOL 2
RENAGEL 2
RENVELA TABLET 2
Requisitos/Límites
Requisitos/Límites

Medicamentos hormonales, estimulantes/de reemplazo/modificadores (que
actúan en las glándulas adrenales)
Glucocorticoides/mineralocorticoides
Nombre del Medicamento
55
Nivel del
Medicamento
a-hydrocort 4
alclometasone dipropionate 1
amcinonide 1
augmented betamethasone dipropionate 1
betamethasone dipropionate 1
betamethasone valerate 1
clobetasol propionate e 1
clobetasol propionate gel, ointment, solution 1
cortisone acetate 1
DEPO-MEDROL INJECTION 20MG/ML 4
desonide 1
desoximetasone 1
dexamethasone 1
DEXAMETHASONE SODIUM PHOSPHATE 4
fludrocortisone acetate 1
fluocinolone acetonide 1
fluocinonide 1
fluocinonide-e 1
fluticasone propionate cream, ointment 1
halobetasol propionate 1
hydrocortisone 1
hydrocortisone valerate 1
methylprednisolone 1
METHYLPREDNISOLONE ACETATE 4
methylprednisolone dose pack 1
METHYLPREDNISOLONE SODIUMSUCCINATE 4
mometasone furoate cream, ointment 1
mometasone furoate solution 0.1% 1
prednicarbate cream 1
prednisolone sodium phosphate 1
Requisitos/Límites

Nombre del Medicamento
56
Nivel del
Medicamento
prednisone 1
proctocream hc 1
SOLU-CORTEF 4
SOLU-MEDROL 4
triamcinolone acetonide 1
triderm 1
u-cort 1
Requisitos/Límites

Medicamentos hormonales, estimulantes/de reemplazo/modificadores (que actúan en la
glándula pituitaria)
Medicamentos hormonales, estimulantes/de reemplazo/modificadores (que actúan en la glándula pituitaria)
Nombre del Medicamento
57
Nivel del
Medicamento
chorionic gonadotropin 4
desmopressin acetate tablet 1
desmopressin acetate injection 4
Requisitos/Límites
EGRIFTA 3 PA (Medicamentos hormonales,
estimulantes/de reemplazo
/modificadores (que actúan en la
glándula pituitaria) - Egrifta)
INCRELEX 4
NORDITROPIN FLEXPRO INJECTION 15MG/1.5ML,
5MG/1.5ML
3
PA (Medicamentos hormonales,
estimulantes/de reemplazo
/modificadores (que actúan en la
glándula pituitaria))
NUTROPIN 3 QL (28 cada vez para 28 días)
PA (Medicamentos hormonales,
estimulantes/de reemplazo
/modificadores (que actúan en la
glándula pituitaria))
NUTROPIN AQ PEN INJECTION 10MG/2ML 3 QL (28 cada vez para 28 días)
PA (Medicamentos hormonales,
estimulantes/de reemplazo
/modificadores (que actúan en la
glándula pituitaria))
PREGNYL W/DILUENT BENZYL ALCOHOL/NACL 4
SAIZEN 3 PA (Medicamentos hormonales,
estimulantes/de reemplazo
/modificadores (que actúan en la
glándula pituitaria))
SAIZEN CLICK.EASY 3 PA (Medicamentos hormonales,
estimulantes/de reemplazo
/modificadores (que actúan en la
glándula pituitaria))
SEROSTIM 3 QL (28 cada vez para 28 días)
PA (Medicamentos hormonales,
estimulantes/de reemplazo
/modificadores (que actúan en la
glándula pituitaria)) - Serostim)
STIMATE 2
TEV-TROPIN 3 QL (28 cada vez para 28 días)
PA (Medicamentos hormonales,
estimulantes/de reemplazo
/modificadores (que actúan en la
glándula pituitaria))
ZORBTIVE 3 PA (Medicamentos hormonales,
estimulantes/de reemplazo
/modificadores (que actúan en la
glándula pituitaria) - Zorbtive)

Medicamentos hormonales, estimulantes/de reemplazo/modificadores
(hormonas sexuales/modificadores)
Esteroides anabólicos
Nombre del Medicamento
58
Nivel del
Medicamento
oxandrolone 1
Andrógenos
Nombre del Medicamento
Nivel del
Medicamento
ANDROXY 2
danazol 1
METHITEST 2
TESTOSTERONE CYPIONATE INJECTION 100MG/ML 4
testosterone cypionate injection 200mg/ml 4
TESTOSTERONE ENANTHATE 4
Estrógenos
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites
ALORA 2 QL (8 cada vez para 28 días)
apri 1 QL (28 cada vez para 28 días)
aranelle 1
aviane 1
balziva 1
CLIMARA PRO 2 QL (4 cada vez para 28 días)
cryselle-28 1
DEPO-ESTRADIOL 4
enpresse-28 1
ESTRACE CREAM 2
estradiol valerate 4
estradiol tablet 1
estradiol patch weekly 1 QL (4 Cada vez para28 días)
estropipate 1
junel 1.5/30 1

Nombre del Medicamento
59
Nivel del
Medicamento
junel 1/20 1
junel fe 1.5/30 1
junel fe 1/20 1
kariva 1
kelnor 1/35 1
leena 1
lessina-28 1
levora 0.15/30-28 1
Requisitos/Límites
loestrin 24 fe 1 QL (28 cada vez para 28 días)
low-ogestrel 1 QL (28 cada vez para 28 días)
lutera 1
microgestin 1.5/30 1 QL (21 cada vez para 21 días)
microgestin 1/20 1 QL (21 cada vez para 21 días)
microgestin fe 1
microgestin fe 1.5/30 1
mononessa 1
necon 0.5/35-28 1 QL (28 cada vez para 28 días)
necon 1/35-28 1 QL (28 cada vez para 28 días)
necon 10/11-28 1 QL (28 cada vez para 28 días)
necon 7/7/7 1 QL (28 cada vez para 28 días)
nortrel 0.5/35 (28) 1 QL (28 cada vez para 28 días)
nortrel 1/35 (21) 1 QL (28 cada vez para 28 días)
nortrel 1/35 (28) 1 QL (28 cada vez para 28 días)
nortrel 7/7/7 1 QL (28 cada vez para 28 días)
OGESTREL 2
ORTHO EVRA 2 QL (3 cada vez para 28 días)
portia-28 1 QL (28 cada vez para 28 días)
PREMARIN CREAM 2
PREMARIN INJECTION 4
PREMARIN TABLET 0.3MG, 0.625MG 2
PREMARIN TABLET 0.45MG, 0.9MG, 1.25MG 2 QL (30 cada vez para 30 días)
PREMPHASE 2

Nombre del Medicamento
60
Nivel del
Medicamento
Requisitos/Límites
PREMPRO 2 QL (30 cada vez para 30 días)
previfem 1
quasense 1 QL (91 cada vez para 91 días)
sprintec 28 1
sronyx 1
tri-previfem 1 QL (28 cada vez para 28 días)
tri-sprintec 1 QL (28 cada vez para 28 días)
trinessa 1 QL (28 cada vez para 28 días)
trivora-28 1
velivet 1
VIVELLE-DOT PATCH BIWEEKLY 0.0375MG/24HR 2
zovia 1/35e 1
zovia 1/50e 1 QL (28 cada vez para 28 días)
Progesterona
Nombre del Medicamento
Nivel del
Medicamento
camila 1
DEPO-SUBQ PROVERA 104 4
errin 1
jolivette 1
MEDROXYPROGESTERONE ACETATE INJECTION 4
medroxyprogesterone acetate tablet 1
megestrol acetate 1
nora-be 1
norethindrone acetate 1
progesterone 1
Medicamentos modificadores selectivos de los receptores de estrógenos
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
Requisitos/Límites
EVISTA 2 QL (30 cada vez para 30 días)

Medicamentos hormonales, estimulantes/modificadores (que actúan en la
glándula tiroides)
Medicamentos hormonales, estimulantes/modificadores (que actúan en la glándula tiroides)
Nombre del Medicamento
61
Nivel del
Medicamento
CYTOMEL 2
levothroid 1
levothyroxine sodium 1
levoxyl 1
LIOTHYRONINE SODIUM INJECTION 4
liothyronine sodium tablet 1
SYNTHROID 2
unithroid 1
Requisitos/Límites
Medicamentos hormonales, supresores (que actúan en las glándulas adrenales)
Medicamentos hormonales, supresores (que actúan en las glándulas adrenales)
Nombre del Medicamento
Nivel del
Medicamento
LYSODREN 2
Requisitos/Límites
Medicamentos hormonales, supresores (que actúan en las glándulas
paratiroides)
Medicamentos hormonales, supresores (que actúan en las glándulas paratiroides)
Nombre del Medicamento
Nivel del
Medicamento
SENSIPAR 2
Requisitos/Límites

Medicamentos hormonales, supresores (que actúan en la glándula pituitaria)
Medicamentos hormonales, supresores (que actúan en la glándula pituitaria)
Nombre del Medicamento
62
Nivel del
Medicamento
cabergoline 1
ELIGARD 4
FIRMAGON 4
LEUPROLIDE ACETATE 4
LUPRON DEPOT-PED 4
LUPRON DEPOT INJECTION 22.5MG, 3.75MG, 30MG,
7.5MG
OCTREOTIDE ACETATE INJECTION 200MCG/ML 4
octreotide acetate injection 1000mcg/ml, 100mcg/ml,
500mcg/ml, 50mcg/ml
SANDOSTATIN LAR DEPOT 4
SOMATULINE DEPOT INJECTION 120MG/0.5ML,
90MG/0.3ML
4
4
4
Requisitos/Límites
SOMAVERT 3 PA (Medicamentos hormonales,
supresores (que actúan en la
glándula pituitaria) - Somavert)
SYNAREL 2
TRELSTAR DEPOT MIXJECT 4
TRELSTAR LA MIXJECT 4
Medicamentos hormonales, supresores (hormonas sexuales/modificadores)
Antiandrógenos
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
bicalutamide 1 QL (30 cada vez para 30 días)
flutamide 1
NILANDRON 2 QL (60 cada vez para 30 días)

Medicamentos hormonales, supresores (que actúan en la glándula tiroides)
Medicamentos antitiroideos
Nombre del Medicamento
63
Nivel del
Medicamento
methimazole 1
propylthiouracil 1
Medicamentos inmunitarios
Inmunodepresores
Nombre del Medicamento
Nivel del
Medicamento
azathioprine 1
AZATHIOPRINE SODIUM 4
CELLCEPT INTRAVENOUS 4 B/D
CELLCEPT SUSPENSION RECONSTITUTED 2 B/D
cyclosporine modified 1 B/D
CYCLOSPORINE INJECTION 4 B/D
cyclosporine capsule 1 B/D
Requisitos/Límites
Requisitos/Límites
ENBREL 3 PA (Medicamentos inmunitarios)
gengraf 1 B/D
HUMIRA 3 PA (Medicamentos inmunitarios)
HUMIRA PEN-CROHNS DISEASESTARTER 3 PA (Medicamentos inmunitarios)
KINERET 3 QL (28 ml para 28 días) PA
(Medicamentos inmunitarios)
methotrexate 1
METHOTREXATE SODIUM 4
mycophenolate mofetil 1 B/D
NULOJIX 4 B/D
ORENCIA 3 PA (Medicamentos inmunitarios)
PROGRAF CAPSULE 2 B/D
PROGRAF INJECTION 4 B/D
RAPAMUNE 2 B/D
REMICADE 3 PA (Medicamentos inmunitarios)

Nombre del Medicamento
64
Nivel del
Medicamento
tacrolimus 1 B/D
TORISEL 4
ZORTRESS 2 B/D
Medicamentos para inmunización pasiva
Nombre del Medicamento
Nivel del
Medicamento
CARIMUNE NANOFILTERED 4
GAMMAGARD LIQUID 4
GAMUNEX-C 2
THYMOGLOBULIN 4 B/D
Inmunomoduladores
Nombre del Medicamento
Nivel del
Medicamento
ACTIMMUNE 4
ARCALYST 4
AVONEX 4
BETASERON 4
Requisitos/Límites
Requisitos/Límites
Requisitos/Límites
leflunomide 1 QL (30 cada vez para 30 días)
REBIF 4
REBIF TITRATION PACK 4
SIMULECT 4 B/D

Vacunas
Nombre del Medicamento
65
Nivel del
Medicamento
ACTHIB 4
ADACEL 4
BOOSTRIX 4
CERVARIX 4
COMVAX 4
DAPTACEL 4
DECAVAC 4
ENGERIX-B 4
GARDASIL 4
HAVRIX 4
INFANRIX 4
IPOL INACTIVATED IPV 4
IXIARO 4
M-M-R II W/DILUENT 10 DOSE 4
MENACTRA 4
MENOMUNE-A/C/Y/W-135 4
MENVEO 4
PEDVAX HIB 4
PROQUAD 4
RABAVERT 4
RECOMBIVAX HB 4
ROTATEQ 2
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT 4
TWINRIX 4
TYPHIM VI 4
VAQTA 4
VARIVAX 4
YF-VAX 4
ZOSTAVAX 4
Requisitos/Límites

Medicamentos contra la enfermedad intestinal inflamatoria
Aminosalicilatos
Nombre del Medicamento
66
Nivel del
Medicamento
Requisitos/Límites
ASACOL 2 QL (180 cada vez para 30 días)
balsalazide disodium 1
mesalamine 1
Glucocorticoides
Nombre del Medicamento
Nivel del
Medicamento
budesonide 1
hydrocortisone 1
methylprednisolone 1
Sulfamidas
Nombre del Medicamento
Nivel del
Medicamento
sulfasalazine 1
sulfazine ec 1
Requisitos/Límites
Requisitos/Límites

Medicamentos contra enfermedades óseas metabólicas
Medicamentos contra enfermedades óseas metabólicas
Nombre del Medicamento
67
Nivel del
Medicamento
Requisitos/Límites
ACTONEL TABLET 30MG, 5MG 2 QL (30 cada vez para 30 días)
ACTONEL TABLET 35MG 2 QL (4 cada vez para 28 días)
alendronate sodium tablet 10mg, 40mg, 5mg 1 QL (30 cada vez para 30 días)
alendronate sodium tablet 35mg, 70mg 1 QL (4 cada vez para 28 días)
calcitonin-salmon 1 QL (4 ml para 30 días)
CALCITRIOL INJECTION 4
calcitriol capsule, oral solution 1
etidronate disodium tablet 400mg 1
FORTEO 3 PA (Medicamentos contra
enfermedades óseas metabólicas
- IV osteoporosis)
fortical 1 QL (4 ml para 30 días)
HECTOROL INJECTION 4
HECTOROL CAPSULE 0.5MCG, 2.5MCG 2
MIACALCIN INJECTION 4
PAMIDRONATE DISODIUM 4
RECLAST 4
ZOMETA 4

Medicamentos terapéuticos misceláneos
Medicamentos terapéuticos misceláneos
Nombre del Medicamento
68
Nivel del
Medicamento
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2” 2
Requisitos/Límites
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16” 2 QL (200 cada vez para 30 días)
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2” 2 QL (200 cada vez para 30 días)
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16” 2 QL (200 cada vez para 30 días)
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM 2 QL (200 cada vez para 30 días)
BOTOX 3 PA (Medicamentos terapéuticos
misceláneos - Botox)
INTRALIPID 4
lactated ringers irrigation 1
LEVOCARNITINE INJECTION 4
levocarnitine oral solution, tablet 1
methylergonovine maleate 1
physiolyte 1
physiosol irrigation 1
ringers irrigation 1
sodium chloride 0.9% 1
sterile water irrigation 1
Medicamentos oftálmicos
Prostaglandina oftálmica y análogos de la prostamida
Nombre del Medicamento
Nivel del
Medicamento
latanoprost 1
LUMIGAN SOLUTION 0.03% 2
Otros medicamentos oftálmicos
Nombre del Medicamento
Nivel del
Medicamento
ak-con 1
Requisitos/Límites
Requisitos/Límites
RESTASIS 3 PA (Medicamentos
oftálmicos - Restasis)
tropicamide 1

Medicamentos oftálmicos anti-alergia
Nombre del Medicamento
69
Nivel del
Medicamento
cromolyn sodium 1
PATANOL 2
Antinflamatorios oftálmicos
Nombre del Medicamento
Nivel del
Medicamento
CIPRODEX 2
dexamethasone sodium phosphate 1
diclofenac sodium 1
flurbiprofen sodium 1
Requisitos/Límites
Requisitos/Límites
ketorolac tromethamine 1 QL (5 ml para 15 días)
LOTEMAX SUSPENSION 2
neomycin/polymyxin/dexamethasone 1
PRED-G 2
PRED-G S.O.P. 2
prednisolone acetate 1
prednisolone sodium phosphate 1
sulfacetamide sodium/prednisolone sodium phosphate 1
TOBRADEX OINTMENT 2
tobramycin/dexamethasone 1

Medicamentos oftálmicos antiglaucoma
Nombre del Medicamento
70
Nivel del
Medicamento
acetazolamide 1
acetazolamide er 1
ALPHAGAN P SOLUTION 0.1% 2
betaxolol hcl 1
brimonidine tartrate 1
carteolol hcl 1
COMBIGAN 2
Requisitos/Límites
dorzolamide hcl 1 QL (20 ml para 30 días)
dorzolamide hcl/timolol maleate 1 QL (20 ml para 30 días)
levobunolol hcl 1
methazolamide 1
metipranolol 1
PHOSPHOLINE IODIDE 2
PILOPINE HS 2
timolol maleate 1
timolol maleate ophthalmic gel forming 1
Medicamentos óticos
Medicamentos óticos
Nombre del Medicamento
Nivel del
Medicamento
acetasol hc 1
acetic acid 1
DERMOTIC 2
hydrocortisone/acetic acid 1
neomycin/polymyxin/hc 1
neomycin/polymyxin/hydrocortisone 1
Requisitos/Límites

Medicamentos para tratar enfermedades del tracto respiratorio
Corticosteroides inhalados, antinflamatorios
Nombre del Medicamento
71
Nivel del
Medicamento
Requisitos/Límites
ADVAIR DISKUS 2 QL (60 cada vez para 30 días)
ADVAIR HFA AEROSOL 115MCG/ACT; 21MCG/ACT,
45MCG/ACT; 21MCG/ACT
ADVAIR HFA AEROSOL 230MCG/ACT; 21MCG/ACT 2 QL (12 gramos para 30 días)
ASMANEX 120 METERED DOSES 2
ASMANEX 14 METERED DOSES 2
ASMANEX 30 METERED DOSES 2
ASMANEX 60 METERED DOSES 2
FLOVENT DISKUS 2
FLOVENT HFA AEROSOL 44MCG/ACT 2 QL (21.2 gramos para 30 días)
FLOVENT HFA AEROSOL 110MCG/ACT, 220MCG/ACT 2 QL (24 gramos para 30 días)
flunisolide 1 QL (50 ml para 30 días)
fluticasone propionate 1 QL (32 gramos para 30 días)
RHINOCORT AQUA 2
2

Antihistamínicos
Nombre del Medicamento
72
Nivel del
Medicamento
Requisitos/Límites
azelastine hcl 1 QL (30 ml para 30 días)
carbinoxamine maleate liquid 1
clemastine fumarate 1
cyproheptadine hcl 1
DIPHENHYDRAMINE HCL INJECTION 4
diphenhydramine hcl capsule 1
HYDROXYZINE HCL INJECTION 4
hydroxyzine hcl syrup, tablet 1
hydroxyzine pamoate 1
levocetirizine dihydrochloride solution 1
levocetirizine dihydrochloride tablet 1 QL (30 cada vez para 30 días)
phenadoz 1
PROMETHAZINE HCL INJECTION 4
promethazine hcl suppository, syrup, tablet 1
promethazine vc 1
promethegan 1
Antileucotrienos
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
SINGULAIR 2 QL (30 cada vez para 30 días)
zafirlukast 1 QL (60 cada vez para 30 días)
ZYFLO CR 2 QL (120 cada vez para 30 días)

Broncodilatadores, anticolinérgicos
Nombre del Medicamento
73
Nivel del
Medicamento
Requisitos/Límites
ATROVENT HFA 2 QL (39 gramos para 30 días)
COMBIVENT 2 QL (45 gramos para 30 días)
ipratropium bromide/albuterol sulfate 1 QL (540 ml para 30 días) B/D
ipratropium bromide inhalation solution 1 QL (300 ml para 30 días) B/D
ipratropium bromide nasal solution 0.06% 1 QL (15 ml para 30 días)
ipratropium bromide nasal solution 0.03% 1 QL (30 ml para 30 días)
SPIRIVA HANDIHALER 2 QL (30 cada vez para 30 días)
Broncodilatadores, inhibidores de la fosfodiesterasa (xantinas)
Nombre del Medicamento
Nivel del
Medicamento
AMINOPHYLLINE 4
ELIXOPHYLLIN 2
LUFYLLIN 2
theophylline cr 1
theophylline er 1
Requisitos/Límites

Broncodilatadores, simpaticomiméticos
Nombre del Medicamento
74
Nivel del
Medicamento
albuterol sulfate er 1
albuterol sulfate syrup, tablet 1
Requisitos/Límites
albuterol sulfate nebulization solution 0.083% 1 QL (1170 ml para 30 días) B/D
albuterol sulfate nebulization solution 0.63mg/3ml, 1.25mg/3ml 1 QL (1200 ml para 30 días) B/D
albuterol sulfate nebulization solution 0.5% 1 QL (200 ml para 30 días) B/D
EPINEPHRINE HCL 4
EPIPEN 2-PAK 4 QL (2 cada vez para 10 días)
EPIPEN-JR 2-PAK 4 QL (2 cada vez para 10 días)
metaproterenol sulfate 1
PROAIR HFA 2 QL (36 gramos para 30 días)
SEREVENT DISKUS 2 QL (60 cada vez para 30 días)
TERBUTALINE SULFATE INJECTION 4
terbutaline sulfate tablet 1
VENTOLIN HFA 2 QL (36 gramos para 30 días)
XOPENEX 2 QL (450 ml para 30 días) B/D
XOPENEX HFA 2 QL (45 gramos para 30 días)
Estabilizadores de los mastocitos
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
cromolyn sodium 1 QL (305 ml para 30 días) B/D
Antihipertensores pulmonares
Nombre del Medicamento
Nivel del
Medicamento
LETAIRIS 2
REMODULIN 4
Requisitos/Límites
REVATIO TABLET 2 QL (90 cada vez para 30 días)
TRACLEER 2 QL (60 cada vez para 30 días) LA
VENTAVIS 4

Otros medicamentos para tratar enfermedades del tracto respiratorio
Nombre del Medicamento
75
Nivel del
Medicamento
acetylcysteine 1
ARALAST NP 4
PROLASTIN-C 4
PULMOZYME 4
TYZINE 2
TYZINE PEDIATRIC NASAL DROPS 2
Requisitos/Límites
XOLAIR 3 PA (Medicamentos para tratar
enfermedades del tracto
respiratorio)
ZEMAIRA 4
Relajantes musculoesqueléticos
Relajantes musculoesqueléticos
Nombre del Medicamento
Nivel del
Medicamento
chlorzoxazone 1
Requisitos/Límites
cyclobenzaprine hcl tablet 10mg, 5mg 1 QL (90 cada vez para 30 días)
methocarbamol 1
ORPHENADRINE CITRATE 4
orphenadrine citrate er 1
Medicamentos para tratar problemas del sueño
Moduladores de los receptores GABA
Nombre del Medicamento
Nivel del
Medicamento
Requisitos/Límites
flurazepam hcl 1 QL (30 cada vez para 30 días)
temazepam capsule 15mg, 30mg 1 QL (30 cada vez para 30 días)
zaleplon 1 QL (30 cada vez para 30 días)
zolpidem tartrate 1 QL (30 cada vez para 30 días)
zolpidem tartrate er 1 QL (30 cada vez para 30 días)

Otros medicamentos para tratar trastornos del sueño
Nombre del Medicamento
76
Nivel del
Medicamento
phenobarbital 1
Requisitos/Límites
PROVIGIL TABLET 200MG 3 QL (30 cada vez para 30
días) PA (Medicamentos
que actúan en el sistema
nervioso central)
PROVIGIL TABLET 100MG 3 QL (60 cada vez para 30
días) PA (Medicamentos
que actúan en el sistema
nervioso central)
XYREM 2 QL (540 ml para 30 días) LA
Sustancias nutritivas terapéuticas/minerales/electrolitos
Electrolitos/modificadores minerales
Nombre del Medicamento
Nivel del
Medicamento
AMMONIUM CHLORIDE 4
CHEMET 2
DEPEN TITRATABS 2
EXJADE 2
kionex 1
SODIUM LACTATE 4
sodium polystyrene sulfonate 1
SYPRINE 2
Requisitos/Límites

Reemplazo de electrolitos/minerales
Nombre del Medicamento
77
Nivel del
Medicamento
AMINOSYN 8.5%/ELECTROLYTES 4
AMINOSYN II 4
AMINOSYN II 8.5%/ELECTROLYTES 4
AMINOSYN M 4
AMINOSYN-HBC 4
AMINOSYN-PF 4
AMINOSYN-PF 7% 4
calcium acetate 1
CLINIMIX 2.75%/DEXTROSE 5% 4
CLINIMIX 4.25%/DEXTROSE 10% 4
CLINIMIX 4.25%/DEXTROSE 25% 4
CLINIMIX 4.25%/DEXTROSE 5% 4
CLINIMIX 5%/DEXTROSE 25% 4
CLINIMIX E 5%/DEXTROSE 20% 4
DEXTROSE 5%/LACTATED RINGERS 4
DEXTROSE 5%/POTASSIUM CHLORIDE 0.15% 4
ELIPHOS 2
FREAMINE III 4
FREAMINE III 3% 4
HEPATAMINE 4
ISOLYTE-H/DEXTROSE 5% 4
ISOLYTE-M/DEXTROSE 5% 4
ISOLYTE-P/DEXTROSE 5% 4
ISOLYTE-S 4
ISOLYTE-S/DEXTROSE 5% 4
klor-con 10 1
klor-con 8 1
klor-con m15 1
klor-con m20 1
lactated ringers 4
MAGNESIUM SULFATE 4
Requisitos/Límites

Nombre del Medicamento
78
Nivel del
Medicamento
NEPHRAMINE 4
NORMOSOL-M IN D5W 4
NORMOSOL-R 4
PLASMA-LYTE A 4
PLASMA-LYTE-148 4
PLASMA-LYTE-56/D5W 4
POTASSIUM CHLORIDE 4
POTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX 4
POTASSIUM CHLORIDE 0.15% NACL 0.9% 4
POTASSIUM CHLORIDE 0.224%/DEXTROSE 5% VIAFLEX 4
POTASSIUM CHLORIDE 0.3%/ NACL 0.9% 4
POTASSIUM CHLORIDE 0.3%/D5W/VIAFLEX 4
potassium chloride er 1
PREMASOL 4
PROCALAMINE 4
PROSOL 4
RINGERS INJECTION 4
SODIUM CHLORIDE 4
SODIUM CHLORIDE 0.45% VIAFLEX 4
sodium fluoride 1
TPN ELECTROLYTES 4
TRAVASOL 4
TROPHAMINE 4
Vitaminas
Nombre del Medicamento
Nivel del
Medicamento
niacor 1
PRENATABS OBN 2
Requisitos/Límites
Requisitos/Límites

Productos de venta sin receta (OTC, siglas en inglés)
Medicamentos terapéuticos misceláneos
Medicamentos terapéuticos misceláneos
Nombre del Medicamento
79
Nivel del
Medicamento
1st choice pen needles 31gx8mm 1
bd insulin syringe ultrafine/1ml/30g x 1/2” 1
bd insulin syringe/detachable needle/u-100/1ml/25g x 5/8” 1
bd pen needle/mini/ultrafine/31g x 3/16” 1
bd pen needle/short/ultrafine/31g x 5/16” 1
bd pen needles short/ultrafine/31g x 5/16” 1
easy touch pen needles 31gx5/16” 1
easy touch pen needles/31g x 3/16” 1
exel insulin pen needles 31gx1/3” 1
insupen ultrafin 31gx8mm 1
lite touch pen needles/31g x 3/16” 1
monoject insulin syringe/softpack/1ml/25g x 58” 1
novofine 32gx6mm 1
prodigy insulin mini pen needles/31g x 3/16” 1
prodigy insulin short penneedles/31g x 5/16” 1
sure-fine pen needles 31gx3/16” 5mm 1
sure-fine pen needles 31gx5/16” 8mm 1
ulticare short pen needles 31gx8mm 1
ulticare short pen needles ulti-fine iv 1
Requisitos/Límites

Índice
#
1st choice pen needles 31gx8mm ..........................................................................................................................79
A
a-hydrocort .............................................................................................................................................................55
abelcet ....................................................................................................................................................................17
abilify discmelt.......................................................................................................................................................28
abilify injection ......................................................................................................................................................28
abilify oral solution ................................................................................................................................................28
abilify tablet ...........................................................................................................................................................28
abraxane .................................................................................................................................................................21
acarbose..................................................................................................................................................................34
acebutolol hcl .........................................................................................................................................................43
acetaminophen/codeine #3.......................................................................................................................................1
acetaminophen/codeine tablet ..................................................................................................................................1
acetasol hc ..............................................................................................................................................................70
acetazolamide.........................................................................................................................................................70
acetazolamide er.....................................................................................................................................................70
acetazolamide sodium ............................................................................................................................................45
acetic acid...............................................................................................................................................................70
acetylcysteine .........................................................................................................................................................75
acthib......................................................................................................................................................................65
actimmune..............................................................................................................................................................64
actonel tablet 30mg, 5mg .......................................................................................................................................67
actonel tablet 35mg ................................................................................................................................................67
actoplus met ...........................................................................................................................................................34
actos .......................................................................................................................................................................34
acyclovir.................................................................................................................................................................32
acyclovir sodium ....................................................................................................................................................32
adacel .....................................................................................................................................................................65
adagen ....................................................................................................................................................................51
adapalene................................................................................................................................................................49
adriamycin..............................................................................................................................................................21
advair diskus ..........................................................................................................................................................71
advair hfa aerosol 115mcg/act; 21mcg/act, 45mcg/act; 21mcg/act .......................................................................71
advair hfa aerosol 230mcg/act; 21mcg/act ............................................................................................................71
afeditab cr...............................................................................................................................................................44
afinitor....................................................................................................................................................................24
aggrenox.................................................................................................................................................................39
ak-con.....................................................................................................................................................................68
albenza ...................................................................................................................................................................25
albuterol sulfate er..................................................................................................................................................74
albuterol sulfate nebulization solution 0.083%......................................................................................................74
albuterol sulfate nebulization solution 0.5%..........................................................................................................74
albuterol sulfate nebulization solution 0.63mg/3ml, 1.25mg/3ml .........................................................................74
albuterol sulfate syrup, tablet .................................................................................................................................74
alclometasone dipropionate ...................................................................................................................................55
80

alcohol preps ............................................................................................................................................................5
aldurazyme .............................................................................................................................................................51
alendronate sodium tablet 10mg, 40mg, 5mg ........................................................................................................67
alendronate sodium tablet 35mg, 70mg .................................................................................................................67
alfuzosin hcl er .......................................................................................................................................................54
alimta......................................................................................................................................................................21
alinia.......................................................................................................................................................................25
alkeran ....................................................................................................................................................................20
allopurinol ..............................................................................................................................................................18
allopurinol sodium .................................................................................................................................................18
aloprim ...................................................................................................................................................................18
alora........................................................................................................................................................................58
alphagan p solution 0.1% .......................................................................................................................................70
alprazolam intensol ................................................................................................................................................33
alprazolam tablet 0.25mg.......................................................................................................................................33
alprazolam tablet 0.5mg, 1mg, 2mg.......................................................................................................................33
amantadine hcl .......................................................................................................................................................31
ambisome ...............................................................................................................................................................17
amcinonide .............................................................................................................................................................55
amevive ..................................................................................................................................................................49
amifostine...............................................................................................................................................................21
amikacin sulfate .......................................................................................................................................................5
amiloride hcl ..........................................................................................................................................................46
amiloride/hydrochlorothiazide ...............................................................................................................................46
aminophylline ........................................................................................................................................................73
aminosyn 8.5%/electrolytes ...................................................................................................................................77
aminosyn ii.............................................................................................................................................................77
aminosyn ii 8.5%/electrolytes ................................................................................................................................77
aminosyn m ............................................................................................................................................................77
aminosyn-hbc .........................................................................................................................................................77
aminosyn-pf ...........................................................................................................................................................77
aminosyn-pf 7% .....................................................................................................................................................77
amiodarone hcl injection........................................................................................................................................42
amiodarone hcl tablet .............................................................................................................................................42
amitiza....................................................................................................................................................................52
amitriptyline hcl .....................................................................................................................................................16
amlodipine besylate ...............................................................................................................................................44
amlodipine besylate/benazepril hcl........................................................................................................................44
amlodipine besylate/benazepril hydrochloride ......................................................................................................44
ammonium chloride ...............................................................................................................................................76
ammonium lactate ..................................................................................................................................................49
amoxapine ..............................................................................................................................................................16
amoxicillin ...............................................................................................................................................................8
amoxicillin/clavulanate potassium...........................................................................................................................8
amoxicillin/clavulanate potassium er.......................................................................................................................8
amoxicillin/potassium clavulanate ...........................................................................................................................8
amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg;
1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg,
3.75mg; 3.75mg; 3.75mg; 3.75mg ....................................................................................................................48
amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg...........................48
81

amphotec ................................................................................................................................................................17
amphotericin b .......................................................................................................................................................17
ampicillin .................................................................................................................................................................8
ampicillin sodium.....................................................................................................................................................8
ampicillin-sulbactam................................................................................................................................................8
anagrelide hydrochloride .......................................................................................................................................39
anastrozole .............................................................................................................................................................23
androxy ..................................................................................................................................................................58
apokyn ....................................................................................................................................................................26
apri .........................................................................................................................................................................58
aptivus ....................................................................................................................................................................31
aralast np ................................................................................................................................................................75
aranelle ...................................................................................................................................................................58
aranesp albumin free injection 100mcg/ml, 150mcg/0.3ml, 200mcg/0.4ml, 200mcg/ml,
25mcg/0.42ml, 25mcg/ml, 300mcg/ml, 40mcg/0.4ml, 40mcg/ml, 500mcg/ml, 60mcg/ml .............................39
arcalyst ...................................................................................................................................................................64
arixtra .....................................................................................................................................................................38
arranon ...................................................................................................................................................................21
arzerra ....................................................................................................................................................................24
asacol......................................................................................................................................................................66
ascomp/codeine ........................................................................................................................................................1
asmanex 120 metered doses...................................................................................................................................71
asmanex 14 metered doses.....................................................................................................................................71
asmanex 30 metered doses.....................................................................................................................................71
asmanex 60 metered doses.....................................................................................................................................71
astramorph................................................................................................................................................................1
atenolol...................................................................................................................................................................43
atenolol/chlorthalidone ..........................................................................................................................................43
atorvastatin calcium ...............................................................................................................................................47
atovaquone/proguanil hcl .......................................................................................................................................25
atripla .....................................................................................................................................................................29
atropine sulfate .......................................................................................................................................................51
atrovent hfa ............................................................................................................................................................73
augmented betamethasone dipropionate ................................................................................................................55
avandamet tablet 1000mg; 2mg, 1000mg; 4mg, 500mg; 4mg ..............................................................................34
avandamet tablet 500mg; 2mg ...............................................................................................................................34
avandaryl ................................................................................................................................................................34
avandia tablet 2mg, 4mg ........................................................................................................................................34
avandia tablet 8mg .................................................................................................................................................34
avastin ....................................................................................................................................................................24
avelox injection ......................................................................................................................................................10
aviane .....................................................................................................................................................................58
avodart....................................................................................................................................................................54
avonex ....................................................................................................................................................................64
azactam ....................................................................................................................................................................7
azactam in iso-osmotic dextrose ..............................................................................................................................7
azathioprine............................................................................................................................................................63
azathioprine sodium ...............................................................................................................................................63
azelastine hcl ..........................................................................................................................................................72
azilect .....................................................................................................................................................................27
82

azithromycin injection .............................................................................................................................................9
azithromycin suspension reconstituted 100mg/5ml.................................................................................................9
azithromycin suspension reconstituted 200mg/5ml.................................................................................................9
azithromycin tablet 250mg ......................................................................................................................................9
azithromycin tablet 500mg ......................................................................................................................................9
azithromycin tablet 600mg ......................................................................................................................................9
aztreonam .................................................................................................................................................................7
B
baciim.......................................................................................................................................................................5
bacitracin injection...................................................................................................................................................5
bacitracin/polymyxin b ............................................................................................................................................5
baclofen ..................................................................................................................................................................29
bactocill in dextrose .................................................................................................................................................8
balsalazide disodium ..............................................................................................................................................66
balziva ....................................................................................................................................................................58
banzel suspension...................................................................................................................................................13
banzel tablet ...........................................................................................................................................................13
baraclude ................................................................................................................................................................32
bd insulin syringe safetyglide/1ml/29g x 1/2 ........................................................................................................68
bd insulin syringe ultrafine/0.3ml/31g x 5/16........................................................................................................68
bd insulin syringe ultrafine/0.5ml/30g x 1/2..........................................................................................................68
bd insulin syringe ultrafine/1ml/30g x 1/2.............................................................................................................79
bd insulin syringe ultrafine/1ml/31g x 5/16...........................................................................................................68
bd insulin syringe/detachable needle/u-100/1ml/25g x 5/8 ...................................................................................79
bd pen needle/mini/ultrafine/31g x 3/16 ................................................................................................................79
bd pen needle/short/ultrafine/31g x 5/16 ...............................................................................................................79
bd pen needle/ultrafine/29g x 12.7mm ..................................................................................................................68
bd pen needles short/ultrafine/31g x 5/16 ..............................................................................................................79
benazepril hcl tablet 10mg, 20mg, 5mg.................................................................................................................41
benazepril hcl tablet 40mg .....................................................................................................................................41
benazepril hcl/hydrochlorothiazide........................................................................................................................41
benztropine mesylate injection ..............................................................................................................................26
benztropine mesylate tablet....................................................................................................................................26
betamethasone dipropionate...................................................................................................................................55
betamethasone valerate ..........................................................................................................................................55
betaseron ................................................................................................................................................................64
betaxolol hcl.....................................................................................................................................................43, 70
bethanechol chloride ..............................................................................................................................................54
bicalutamide ...........................................................................................................................................................62
bicillin c-r.................................................................................................................................................................8
bicillin l-a .................................................................................................................................................................8
bicnu.......................................................................................................................................................................20
bisoprolol fumarate ................................................................................................................................................43
bisoprolol fumarate/hydrochlorothiazide...............................................................................................................43
bleomycin sulfate ...................................................................................................................................................21
boostrix ..................................................................................................................................................................65
botox ......................................................................................................................................................................68
brimonidine tartrate................................................................................................................................................70
bromocriptine mesylate..........................................................................................................................................26
83

udeprion sr ...........................................................................................................................................................14
budeprion xl tablet extended release 24 hour 150mg ............................................................................................14
budeprion xl tablet extended release 24 hour 300mg ............................................................................................14
budesonide .............................................................................................................................................................66
bumetanide injection ..............................................................................................................................................45
bumetanide tablet ...................................................................................................................................................45
buphenyl.................................................................................................................................................................51
buprenorphine hcl injection .....................................................................................................................................3
buprenorphine hcl tablet sublingual.........................................................................................................................3
buproban ..................................................................................................................................................................3
bupropion hcl .........................................................................................................................................................14
bupropion hcl sr .....................................................................................................................................................14
buspirone hcl ..........................................................................................................................................................33
busulfex..................................................................................................................................................................20
butalbital/acetaminophen/caffeine/codeine............................................................................................................48
butorphanol tartrate injection ...................................................................................................................................1
butorphanol tartrate nasal solution...........................................................................................................................1
byetta injection 10mcg/0.04ml...............................................................................................................................34
byetta injection 5mcg/0.02ml.................................................................................................................................34
C
cabergoline .............................................................................................................................................................62
calcipotriene solution .............................................................................................................................................49
calcitonin-salmon ...................................................................................................................................................67
calcitriol capsule, oral solution ..............................................................................................................................67
calcitriol injection ..................................................................................................................................................67
calcium acetate .......................................................................................................................................................77
camila .....................................................................................................................................................................60
campath ..................................................................................................................................................................24
campral.....................................................................................................................................................................3
camptosar ...............................................................................................................................................................21
cancidas ..................................................................................................................................................................17
capastat sulfate .......................................................................................................................................................19
caprelsa ..................................................................................................................................................................20
captopril .................................................................................................................................................................41
captopril/hydrochlorothiazide ................................................................................................................................41
carbamazepine........................................................................................................................................................13
carbamazepine er ...................................................................................................................................................13
carbatrol .................................................................................................................................................................13
carbidopa/levodopa ................................................................................................................................................26
carbidopa/levodopa er ............................................................................................................................................26
carbidopa/levodopa odt ..........................................................................................................................................26
carbinoxamine maleate liquid ................................................................................................................................72
carboplatin..............................................................................................................................................................21
carimune nanofiltered ............................................................................................................................................64
carteolol hcl............................................................................................................................................................70
cartia xt...................................................................................................................................................................44
carvedilol................................................................................................................................................................43
ceenu ......................................................................................................................................................................20
cefaclor.....................................................................................................................................................................7
84

cefaclor er.................................................................................................................................................................7
cefadroxil .................................................................................................................................................................7
cefazolin sodium ......................................................................................................................................................7
cefdinir .....................................................................................................................................................................7
cefepime ...................................................................................................................................................................7
cefotaxime sodium ...................................................................................................................................................7
cefoxitin sodium injection 10gm, 1gm, 2gm ...........................................................................................................7
cefpodoxime proxetil tablet .....................................................................................................................................7
cefprozil ...................................................................................................................................................................7
ceftazidime ...............................................................................................................................................................7
ceftriaxone sodium...................................................................................................................................................7
cefuroxime axetil .....................................................................................................................................................7
cefuroxime sodium...................................................................................................................................................7
cellcept intravenous ...............................................................................................................................................63
cellcept suspension reconstituted ...........................................................................................................................63
celontin...................................................................................................................................................................11
cephalexin ................................................................................................................................................................7
cerezyme ................................................................................................................................................................51
cerubidine...............................................................................................................................................................21
cervarix ..................................................................................................................................................................65
chantix......................................................................................................................................................................3
chantix starting month pak.......................................................................................................................................3
chemet ....................................................................................................................................................................76
chloramphenicol sodium succinate ..........................................................................................................................5
chlordiazepoxide/amitriptyline ..............................................................................................................................33
chlorhexidine gluconate oral rinse .........................................................................................................................49
chloroquine phosphate ...........................................................................................................................................25
chlorothiazide.........................................................................................................................................................46
chlorothiazide sodium ............................................................................................................................................46
chlorpromazine hcl injection..................................................................................................................................27
chlorpromazine hcl tablet.......................................................................................................................................27
chlorpropamide ......................................................................................................................................................34
chlorthalidone ........................................................................................................................................................46
chlorzoxazone ........................................................................................................................................................75
cholestyramine light...............................................................................................................................................47
chorionic gonadotropin ..........................................................................................................................................57
ciclopirox olamine .................................................................................................................................................17
ciclopirox suspension.............................................................................................................................................17
cilostazol ................................................................................................................................................................39
cimetidine...............................................................................................................................................................52
cimetidine hcl injection..........................................................................................................................................52
cimetidine hcl oral solution....................................................................................................................................52
cipro i.v.-in d5w .....................................................................................................................................................10
ciprodex..................................................................................................................................................................69
ciprofloxacin ..........................................................................................................................................................10
ciprofloxacin hcl ....................................................................................................................................................10
cisplatin ..................................................................................................................................................................21
citalopram hydrobromide .......................................................................................................................................15
cladribine................................................................................................................................................................21
claforan ....................................................................................................................................................................7
85

claravis ...................................................................................................................................................................49
clarithromycin er ......................................................................................................................................................9
clarithromycin suspension reconstituted..................................................................................................................9
clarithromycin tablet 250mg ....................................................................................................................................9
clarithromycin tablet 500mg ....................................................................................................................................9
clemastine fumarate ...............................................................................................................................................72
cleocin galaxy ..........................................................................................................................................................5
cleocin in d5w ..........................................................................................................................................................5
climara pro .............................................................................................................................................................58
clindamycin hcl ........................................................................................................................................................5
clindamycin phosphate.............................................................................................................................................5
clindamycin phosphate add-vantage ........................................................................................................................5
clindamycin phosphate gel, lotion, solution, swab ................................................................................................49
clindamycin/benzoyl peroxide ...............................................................................................................................49
clinimix 2.75%/dextrose 5% ..................................................................................................................................77
clinimix 4.25%/dextrose 10% ................................................................................................................................77
clinimix 4.25%/dextrose 20% ................................................................................................................................35
clinimix 4.25%/dextrose 25% ................................................................................................................................77
clinimix 4.25%/dextrose 5% ..................................................................................................................................77
clinimix 5%/dextrose 15% .....................................................................................................................................35
clinimix 5%/dextrose 20% .....................................................................................................................................35
clinimix 5%/dextrose 25% .....................................................................................................................................77
clinimix e 2.75%/dextrose 10% .............................................................................................................................35
clinimix e 2.75%/dextrose 5% ...............................................................................................................................35
clinimix e 4.25%/dextrose 25% .............................................................................................................................35
clinimix e 4.25%/dextrose 5% ...............................................................................................................................35
clinimix e 5%/dextrose 15% ..................................................................................................................................35
clinimix e 5%/dextrose 20% ..................................................................................................................................77
clinimix e 5%/dextrose 25% ..................................................................................................................................35
clobetasol propionate e ..........................................................................................................................................55
clobetasol propionate gel, ointment, solution ........................................................................................................55
clolar ......................................................................................................................................................................21
clomipramine hcl ...................................................................................................................................................16
clonazepam ............................................................................................................................................................12
clonazepam odt ......................................................................................................................................................12
clonidine hcl tablet .................................................................................................................................................40
clopidogrel tablet 300mg .......................................................................................................................................39
clopidogrel tablet 75mg .........................................................................................................................................39
clorazepate dipotassium .........................................................................................................................................12
clotrimazole............................................................................................................................................................17
clotrimazole/betamethasone dipropionate .............................................................................................................17
clozapine ................................................................................................................................................................28
coartem...................................................................................................................................................................25
colcrys ....................................................................................................................................................................18
colestipol hcl ..........................................................................................................................................................47
colistimethate sodium ..............................................................................................................................................5
combigan ................................................................................................................................................................70
combivent...............................................................................................................................................................73
complera.................................................................................................................................................................29
compro ...................................................................................................................................................................27
86

comtan....................................................................................................................................................................26
comvax ...................................................................................................................................................................65
copaxone ................................................................................................................................................................49
cortisone acetate .....................................................................................................................................................55
cosmegen................................................................................................................................................................21
coumadin injection.................................................................................................................................................38
coumadin tablet ......................................................................................................................................................38
creon capsule delayed release particles 120000unit; 24000unit; 76000unit, 30000unit; 6000unit;
19000unit, 60000unit; 12000unit; 38000unit ....................................................................................................51
crixivan ..................................................................................................................................................................31
cromolyn sodium .......................................................................................................................................52, 69, 74
cryselle-28 ..............................................................................................................................................................58
cubicin......................................................................................................................................................................6
curity gauze pads 2x2.............................................................................................................................................49
cyclobenzaprine hcl tablet 10mg, 5mg ..................................................................................................................75
cyclophosphamide..................................................................................................................................................20
cycloset ..................................................................................................................................................................34
cyclosporine capsule ..............................................................................................................................................63
cyclosporine injection ............................................................................................................................................63
cyclosporine modified............................................................................................................................................63
cymbalta .................................................................................................................................................................15
cyproheptadine hcl .................................................................................................................................................72
cystadane ................................................................................................................................................................51
cystagon .................................................................................................................................................................51
cytarabine ...............................................................................................................................................................21
cytarabine aqueous injection 100mg/ml ................................................................................................................21
cytarabine aqueous injection 20mg/ml ..................................................................................................................21
cytomel...................................................................................................................................................................61
D
dacarbazine ............................................................................................................................................................20
dacogen ..................................................................................................................................................................21
danazol ...................................................................................................................................................................58
dantrolene sodium ..................................................................................................................................................29
dapsone ..................................................................................................................................................................19
daptacel ..................................................................................................................................................................65
daraprim .................................................................................................................................................................25
daunorubicin hcl.....................................................................................................................................................21
decavac...................................................................................................................................................................65
demeclocycline hcl.................................................................................................................................................10
demerol injection .....................................................................................................................................................1
demser ....................................................................................................................................................................45
denavir....................................................................................................................................................................32
depen titratabs ........................................................................................................................................................76
depo-estradiol.........................................................................................................................................................58
depo-medrol injection 20mg/ml.............................................................................................................................55
depo-subq provera 104...........................................................................................................................................60
dermotic .................................................................................................................................................................70
desipramine hcl ......................................................................................................................................................16
desmopressin acetate injection...............................................................................................................................57
87

desmopressin acetate tablet....................................................................................................................................57
desonide .................................................................................................................................................................55
desoximetasone ......................................................................................................................................................55
detrol ......................................................................................................................................................................54
detrol la ..................................................................................................................................................................54
dexamethasone .......................................................................................................................................................55
dexamethasone sodium phosphate ...................................................................................................................55, 69
dexrazoxane ...........................................................................................................................................................21
dextroamphetamine sulfate ....................................................................................................................................48
dextrose 10% flex container...................................................................................................................................35
dextrose 10%/nacl 0.2%.........................................................................................................................................35
dextrose 10%/nacl 0.45%.......................................................................................................................................35
dextrose 2.5%/sodium chloride 0.45% ..................................................................................................................35
dextrose 5%............................................................................................................................................................35
dextrose 5%/lactated ringers ..................................................................................................................................77
dextrose 5%/nacl 0.2%...........................................................................................................................................35
dextrose 5%/nacl 0.225%.......................................................................................................................................35
dextrose 5%/nacl 0.33%.........................................................................................................................................36
dextrose 5%/nacl 0.45%.........................................................................................................................................36
dextrose 5%/nacl 0.9%...........................................................................................................................................36
dextrose 5%/potassium chloride 0.15% .................................................................................................................77
diazepam gel ..........................................................................................................................................................12
diazepam intensol...................................................................................................................................................33
diazepam tablet ......................................................................................................................................................33
diclofenac potassium................................................................................................................................................4
diclofenac sodium ..................................................................................................................................................69
diclofenac sodium dr ................................................................................................................................................4
diclofenac sodium er ................................................................................................................................................4
dicloxacillin sodium.................................................................................................................................................8
dicyclomine hcl ......................................................................................................................................................51
didanosine ..............................................................................................................................................................30
diflunisal ..................................................................................................................................................................4
digoxin injection ....................................................................................................................................................45
digoxin oral solution, tablet ...................................................................................................................................45
dihydroergotamine mesylate ..................................................................................................................................18
dilantin ...................................................................................................................................................................13
dilantin infatabs......................................................................................................................................................13
dilt-cd .....................................................................................................................................................................44
dilt-xr......................................................................................................................................................................44
diltiazem cd ............................................................................................................................................................44
diltiazem hcl er capsule extended release 12 hour .................................................................................................44
diltiazem hcl er capsule extended release 24 hour 180mg.....................................................................................44
diltiazem hcl er capsule extended release 24 hour 360mg.....................................................................................44
diltiazem hcl injection............................................................................................................................................44
diltiazem hcl tablet .................................................................................................................................................44
diovan.....................................................................................................................................................................40
diovan hct...............................................................................................................................................................40
diphenhydramine hcl capsule.................................................................................................................................72
diphenhydramine hcl injection...............................................................................................................................72
diphenoxylate/atropine tablet.................................................................................................................................52
88

dipyridamole ..........................................................................................................................................................39
disopyramide phosphate.........................................................................................................................................42
disulfiram .................................................................................................................................................................3
divalproex sodium..................................................................................................................................................12
divalproex sodium dr .............................................................................................................................................12
divalproex sodium er..............................................................................................................................................12
docefrez ..................................................................................................................................................................22
docetaxel ................................................................................................................................................................22
donepezil hcl ..........................................................................................................................................................14
dorzolamide hcl......................................................................................................................................................70
dorzolamide hcl/timolol maleate............................................................................................................................70
dovonex..................................................................................................................................................................49
doxazosin mesylate ................................................................................................................................................54
doxepin hcl capsule 100mg, 10mg, 25mg, 50mg, 75mg .......................................................................................16
doxepin hcl concentrate .........................................................................................................................................16
doxil .......................................................................................................................................................................22
doxorubicin hcl ......................................................................................................................................................22
doxycycline hyclate capsule, tablet........................................................................................................................10
doxycycline hyclate injection ................................................................................................................................10
dronabinol ..............................................................................................................................................................16
droxia .....................................................................................................................................................................21
duetact ....................................................................................................................................................................34
duramorph ................................................................................................................................................................1
E
e.e.s. 400 ..................................................................................................................................................................9
e.e.s. granules ...........................................................................................................................................................9
easy touch pen needles 31gx5/16...........................................................................................................................79
easy touch pen needles/31g x 3/16.........................................................................................................................79
econazole nitrate ....................................................................................................................................................17
edurant....................................................................................................................................................................29
effient .....................................................................................................................................................................39
egrifta .....................................................................................................................................................................57
elaprase ..................................................................................................................................................................51
elidel.......................................................................................................................................................................49
eligard ....................................................................................................................................................................62
eliphos ....................................................................................................................................................................77
elitek.......................................................................................................................................................................21
elixophyllin ............................................................................................................................................................73
ellence ....................................................................................................................................................................22
elmiron ...................................................................................................................................................................54
elspar ......................................................................................................................................................................22
emcyt ......................................................................................................................................................................20
emend capsule 0 .....................................................................................................................................................16
emend capsule 40mg..............................................................................................................................................16
emsam ....................................................................................................................................................................15
emtriva ...................................................................................................................................................................30
enalapril maleate ....................................................................................................................................................41
enalapril maleate/hydrochlorothiazide...................................................................................................................41
enbrel......................................................................................................................................................................63
89

endocet tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg ....................................................................................1
endocet tablet 500mg; 7.5mg ...................................................................................................................................1
endocet tablet 650mg; 10mg ....................................................................................................................................1
engerix-b ................................................................................................................................................................65
enoxaparin sodium .................................................................................................................................................38
enpresse-28 ............................................................................................................................................................58
enulose ...................................................................................................................................................................53
epinephrine hcl .......................................................................................................................................................74
epipen 2-pak ...........................................................................................................................................................74
epipen-jr 2-pak .......................................................................................................................................................74
epirubicin hcl .........................................................................................................................................................22
epitol ......................................................................................................................................................................13
epivir hbv ...............................................................................................................................................................30
epivir solution ........................................................................................................................................................30
eplerenone ..............................................................................................................................................................46
epogen ....................................................................................................................................................................39
epzicom ..................................................................................................................................................................30
erbitux ....................................................................................................................................................................24
ergotamine tartrate/caffeine ...................................................................................................................................18
erivedge ..................................................................................................................................................................22
errin ........................................................................................................................................................................60
ery-tab ......................................................................................................................................................................9
eryped 400................................................................................................................................................................9
erythrocin lactobionate.............................................................................................................................................9
erythrocin stearate ....................................................................................................................................................9
erythromycin base ....................................................................................................................................................9
erythromycin ointment, solution ..............................................................................................................................9
erythromycin/benzoyl peroxide .............................................................................................................................49
escitalopram oxalate solution.................................................................................................................................15
escitalopram oxalate tablet.....................................................................................................................................15
estrace cream..........................................................................................................................................................58
estradiol patch weekly............................................................................................................................................58
estradiol tablet ........................................................................................................................................................58
estradiol valerate ....................................................................................................................................................58
estropipate ..............................................................................................................................................................58
ethambutol hcl........................................................................................................................................................19
ethosuximide ..........................................................................................................................................................11
etidronate disodium tablet 400mg..........................................................................................................................67
etodolac ....................................................................................................................................................................4
etodolac er ................................................................................................................................................................4
etopophos ...............................................................................................................................................................23
etoposide ................................................................................................................................................................23
evista ......................................................................................................................................................................60
exel insulin pen needles 31gx1/3 ...........................................................................................................................79
exemestane .............................................................................................................................................................23
exjade .....................................................................................................................................................................76
90

F
fabrazyme...............................................................................................................................................................51
famciclovir .............................................................................................................................................................32
famotidine injection ...............................................................................................................................................52
famotidine premixed ..............................................................................................................................................52
famotidine tablet ....................................................................................................................................................52
fanapt......................................................................................................................................................................28
fanapt titration pack ...............................................................................................................................................28
fareston...................................................................................................................................................................20
faslodex ..................................................................................................................................................................20
fazaclo ....................................................................................................................................................................28
felbamate ................................................................................................................................................................12
felodipine er ...........................................................................................................................................................44
fenofibrate ..............................................................................................................................................................46
fenofibrate micronized ...........................................................................................................................................46
fenoprofen calcium ..................................................................................................................................................4
fentanyl ....................................................................................................................................................................1
fentanyl citrate oral transmucosal ............................................................................................................................2
finasteride...............................................................................................................................................................54
firmagon .................................................................................................................................................................62
flavoxate hcl...........................................................................................................................................................54
flecainide acetate....................................................................................................................................................42
flovent diskus .........................................................................................................................................................71
flovent hfa aerosol 110mcg/act, 220mcg/act .........................................................................................................71
flovent hfa aerosol 44mcg/act ................................................................................................................................71
fluconazole in dextrose ..........................................................................................................................................17
fluconazole suspension reconstituted.....................................................................................................................17
fluconazole tablet 100mg, 200mg, 50mg...............................................................................................................17
fluconazole tablet 150mg .......................................................................................................................................17
flucytosine ..............................................................................................................................................................17
fludarabine phosphate ............................................................................................................................................22
fludrocortisone acetate ...........................................................................................................................................55
flunisolide ..............................................................................................................................................................71
fluocinolone acetonide ...........................................................................................................................................55
fluocinonide ...........................................................................................................................................................55
fluocinonide-e ........................................................................................................................................................55
fluorouracil.......................................................................................................................................................21, 49
fluoxetine hcl capsule, solution..............................................................................................................................15
fluphenazine decanoate ..........................................................................................................................................27
fluphenazine hcl concentrate, elixir, tablet ............................................................................................................27
fluphenazine hcl injection ......................................................................................................................................27
flurazepam hcl........................................................................................................................................................75
flurbiprofen ..............................................................................................................................................................4
flurbiprofen sodium ...............................................................................................................................................69
flutamide ................................................................................................................................................................62
fluticasone propionate ............................................................................................................................................71
fluticasone propionate cream, ointment .................................................................................................................55
fluvoxamine maleate ..............................................................................................................................................15
folotyn ....................................................................................................................................................................21
91

fondaparinux sodium .............................................................................................................................................38
fortaz injection 1gm/50ml; 5%, 2gm/50ml; 5% ......................................................................................................7
forteo ......................................................................................................................................................................67
fortical ....................................................................................................................................................................67
foscarnet sodium ....................................................................................................................................................29
fosinopril sodium ...................................................................................................................................................41
fosinopril sodium/hydrochlorothiazide ..................................................................................................................41
fosphenytoin sodium ..............................................................................................................................................13
fosrenol ..................................................................................................................................................................54
fragmin injection 10000unit/ml, 25000unit/ml, 2500unit/0.2ml, 5000unit/0.2ml, 7500unit/0.3ml ......................38
freamine iii .............................................................................................................................................................77
freamine iii 3%.......................................................................................................................................................77
furosemide injection...............................................................................................................................................45
furosemide oral solution, tablet..............................................................................................................................45
fusilev.....................................................................................................................................................................22
fuzeon.....................................................................................................................................................................30
G
gabapentin ..............................................................................................................................................................12
gabitril tablet 12mg, 16mg, 2mg............................................................................................................................12
gabitril tablet 4mg ..................................................................................................................................................12
galantamine hydrobromide capsule extended release 24 hour ..............................................................................14
galantamine hydrobromide solution ......................................................................................................................14
galantamine hydrobromide tablet 12mg ................................................................................................................14
galantamine hydrobromide tablet 4mg ..................................................................................................................14
galantamine hydrobromide tablet 8mg ..................................................................................................................14
gammagard liquid ..................................................................................................................................................64
gamunex-c..............................................................................................................................................................64
ganciclovir capsule.................................................................................................................................................29
gardasil ...................................................................................................................................................................65
gastrocrom..............................................................................................................................................................52
gavilyte-c................................................................................................................................................................53
gavilyte-g ...............................................................................................................................................................53
gavilyte-n/flavor pack ............................................................................................................................................53
gemcitabine hcl ......................................................................................................................................................21
gemfibrozil .............................................................................................................................................................46
gengraf ...................................................................................................................................................................63
gentak .......................................................................................................................................................................5
gentamicin sulfate cream, ointment, ophthalmic solution .......................................................................................5
gentamicin sulfate injection .....................................................................................................................................5
gentamicin sulfate/0.9% sodium chloride................................................................................................................5
gentamicin sulfate/sodium chloride .........................................................................................................................5
geodon injection.....................................................................................................................................................28
gilenya ....................................................................................................................................................................49
gleevec ...................................................................................................................................................................24
glimepiride tablet 1mg, 2mg ..................................................................................................................................34
glimepiride tablet 4mg ...........................................................................................................................................34
glipizide er tablet extended release 24 hour 10mg.................................................................................................34
glipizide er tablet extended release 24 hour 2.5mg, 5mg ......................................................................................34
glipizide tablet 10mg..............................................................................................................................................34
92

glipizide tablet 5mg................................................................................................................................................34
glipizide/metformin hcl..........................................................................................................................................34
glucagen hypokit ....................................................................................................................................................36
glucagon emergency kit .........................................................................................................................................36
glyburide micronized tablet 1.5mg, 3mg ...............................................................................................................34
glyburide micronized tablet 6mg ...........................................................................................................................34
glyburide tablet 1.25mg, 2.5mg .............................................................................................................................34
glyburide tablet 5mg ..............................................................................................................................................34
glyburide/metformin hcl ........................................................................................................................................34
glycopyrrolate injection .........................................................................................................................................51
glycopyrrolate tablet ..............................................................................................................................................51
glyset ......................................................................................................................................................................34
granisetron hcl injection.........................................................................................................................................16
gris-peg ..................................................................................................................................................................17
guanfacine hcl ........................................................................................................................................................40
H
halaven ...................................................................................................................................................................22
halobetasol propionate ...........................................................................................................................................55
haloperidol .............................................................................................................................................................27
haloperidol decanoate ............................................................................................................................................27
haloperidol lactate ..................................................................................................................................................27
havrix .....................................................................................................................................................................65
hectorol capsule 0.5mcg, 2.5mcg...........................................................................................................................67
hectorol injection ...................................................................................................................................................67
heparin sodium.......................................................................................................................................................38
heparin sodium/d5w...............................................................................................................................................38
heparin sodium/nacl 0.45%....................................................................................................................................38
heparin sodium/sodium chloride 0.9% premix ......................................................................................................38
hepatamine .............................................................................................................................................................77
hepsera ...................................................................................................................................................................32
herceptin.................................................................................................................................................................24
hexalen ...................................................................................................................................................................20
humalog..................................................................................................................................................................37
humalog kwikpen ...................................................................................................................................................37
humalog mix 50/50 ................................................................................................................................................37
humalog mix 50/50 kwikpen .................................................................................................................................37
humalog mix 75/25 ................................................................................................................................................37
humalog mix 75/25 kwikpen .................................................................................................................................37
humira ....................................................................................................................................................................63
humira pen-crohns diseasestarter ...........................................................................................................................63
humulin 70/30 ........................................................................................................................................................37
humulin 70/30 pen .................................................................................................................................................37
humulin n ...............................................................................................................................................................37
humulin n u-100 pen ..............................................................................................................................................37
humulin r ................................................................................................................................................................37
humulin r u-500 (concentrated) .............................................................................................................................37
hydralazine hcl injection ........................................................................................................................................48
hydralazine hcl tablet .............................................................................................................................................48
hydrochlorothiazide ...............................................................................................................................................46
93

hydrocodone bitartrate/acetaminophen tablet 750mg; 10mg...................................................................................2
hydrocodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg ..................................................2
hydrocodone/acetaminophen tablet 500mg; 10mg, 500mg; 2.5mg, 500mg; 5mg, 500mg; 7.5mg .........................2
hydrocodone/acetaminophen tablet 650mg; 10mg ..................................................................................................2
hydrocodone/acetaminophen tablet 650mg; 7.5mg, 660mg; 10mg.........................................................................2
hydrocodone/acetaminophen tablet 750mg; 7.5mg .................................................................................................2
hydrocortisone..................................................................................................................................................55, 66
hydrocortisone valerate ..........................................................................................................................................55
hydrocortisone/acetic acid .....................................................................................................................................70
hydromorphone hcl injection ...................................................................................................................................2
hydromorphone hcl tablet ........................................................................................................................................2
hydroxychloroquine sulfate ...................................................................................................................................25
hydroxyurea ...........................................................................................................................................................21
hydroxyzine hcl injection.......................................................................................................................................72
hydroxyzine hcl syrup, tablet .................................................................................................................................72
hydroxyzine pamoate .............................................................................................................................................72
I
ibuprofen ..................................................................................................................................................................4
idamycin pfs ...........................................................................................................................................................22
idarubicin hcl .........................................................................................................................................................22
ifex .........................................................................................................................................................................20
ifosfamide ..............................................................................................................................................................20
imipenem/cilastatin ..................................................................................................................................................7
imipramine hcl .......................................................................................................................................................16
imipramine pamoate...............................................................................................................................................16
imiquimod ..............................................................................................................................................................49
imitrex solution ......................................................................................................................................................18
imitrex statdose refill .............................................................................................................................................18
incivek....................................................................................................................................................................32
increlex...................................................................................................................................................................57
indapamide .............................................................................................................................................................46
indomethacin............................................................................................................................................................4
indomethacin er........................................................................................................................................................4
infanrix ...................................................................................................................................................................65
infergen ..................................................................................................................................................................32
inlyta ......................................................................................................................................................................24
insupen ultrafin 31gx8mm .....................................................................................................................................79
intelence .................................................................................................................................................................29
intralipid .................................................................................................................................................................68
intron-a ...................................................................................................................................................................32
intron-a w/diluent...................................................................................................................................................32
intuniv ....................................................................................................................................................................48
invanz .......................................................................................................................................................................7
invega sustenna ......................................................................................................................................................28
invega tablet extended release 24 hour 1.5mg, 3mg, 9mg.....................................................................................28
invega tablet extended release 24 hour 6mg ..........................................................................................................28
invirase ...................................................................................................................................................................31
ionosol-b/dextrose 5% ...........................................................................................................................................36
ionosol-mb/dextrose 5% ........................................................................................................................................36
94

ipol inactivated ipv.................................................................................................................................................65
ipratropium bromide inhalation solution ...............................................................................................................73
ipratropium bromide nasal solution 0.03% ............................................................................................................73
ipratropium bromide nasal solution 0.06% ............................................................................................................73
ipratropium bromide/albuterol sulfate ...................................................................................................................73
irinotecan................................................................................................................................................................22
isentress..................................................................................................................................................................30
isolyte-h/dextrose 5%.............................................................................................................................................77
isolyte-m/dextrose 5% ...........................................................................................................................................77
isolyte-p/dextrose 5%.............................................................................................................................................77
isolyte-s ..................................................................................................................................................................77
isolyte-s/dextrose 5% .............................................................................................................................................77
isoniazid injection ..................................................................................................................................................19
isoniazid syrup, tablet ............................................................................................................................................19
isosorbide dinitrate.................................................................................................................................................47
isosorbide dinitrate er.............................................................................................................................................47
isosorbide mononitrate...........................................................................................................................................47
isosorbide mononitrate er.......................................................................................................................................47
isotonic gentamicin ..................................................................................................................................................5
istodax ....................................................................................................................................................................22
itraconazole ............................................................................................................................................................17
ixempra kit .............................................................................................................................................................22
ixiaro ......................................................................................................................................................................65
J
jakafi ......................................................................................................................................................................22
jantoven..................................................................................................................................................................38
januvia....................................................................................................................................................................34
jevtana ....................................................................................................................................................................22
jolivette ..................................................................................................................................................................60
junel 1.5/30 ............................................................................................................................................................58
junel 1/20 ...............................................................................................................................................................59
junel fe 1.5/30 ........................................................................................................................................................59
junel fe 1/20 ...........................................................................................................................................................59
K
kaletra.....................................................................................................................................................................31
kanamycin sulfate ....................................................................................................................................................5
kariva......................................................................................................................................................................59
kcl 0.075%/d5w/nacl 0.45% ..................................................................................................................................36
kcl 0.15%/d5w/lr....................................................................................................................................................36
kcl 0.15%/d5w/nacl 0.2% ......................................................................................................................................36
kcl 0.15%/d5w/nacl 0.225% ..................................................................................................................................36
kcl 0.15%/d5w/nacl 0.9% ......................................................................................................................................36
kcl 0.3%/d5w/nacl 0.45% ......................................................................................................................................36
kcl 0.3%/d5w/nacl 0.9% ........................................................................................................................................36
kelnor 1/35 .............................................................................................................................................................59
kepivance ...............................................................................................................................................................49
ketek tablet 300mg ...................................................................................................................................................9
95

ketek tablet 400mg ...................................................................................................................................................9
ketoconazole cream, shampoo, tablet ....................................................................................................................17
ketoprofen ................................................................................................................................................................4
ketoprofen er ............................................................................................................................................................4
ketorolac tromethamine .........................................................................................................................................69
ketorolac tromethamine injection ............................................................................................................................4
ketorolac tromethamine tablet..................................................................................................................................4
kineret ....................................................................................................................................................................63
kionex.....................................................................................................................................................................76
klor-con 10 .............................................................................................................................................................77
klor-con 8 ...............................................................................................................................................................77
klor-con m15 ..........................................................................................................................................................77
klor-con m20 ..........................................................................................................................................................77
kombiglyze xr ........................................................................................................................................................34
kuvan......................................................................................................................................................................51
L
labetalol hcl injection .............................................................................................................................................43
labetalol hcl tablet ..................................................................................................................................................43
laclotion..................................................................................................................................................................50
lactated ringers .......................................................................................................................................................77
lactated ringers irrigation .......................................................................................................................................68
lactulose .................................................................................................................................................................53
lamivudine..............................................................................................................................................................30
lamivudine/zidovudine...........................................................................................................................................30
lamotrigine .............................................................................................................................................................12
lanoxin injection.....................................................................................................................................................45
lanoxin tablet..........................................................................................................................................................45
lantus ......................................................................................................................................................................37
latanoprost..............................................................................................................................................................68
latuda......................................................................................................................................................................28
leena .......................................................................................................................................................................59
leflunomide ............................................................................................................................................................64
lessina-28 ...............................................................................................................................................................59
letairis.....................................................................................................................................................................74
letrozole..................................................................................................................................................................23
leucovorin calcium injection..................................................................................................................................22
leucovorin calcium tablet .......................................................................................................................................22
leukeran ..................................................................................................................................................................20
leukine....................................................................................................................................................................39
leuprolide acetate ...................................................................................................................................................62
levaquin injection...................................................................................................................................................10
levemir ...................................................................................................................................................................37
levetiracetam injection ...........................................................................................................................................11
levetiracetam oral solution .....................................................................................................................................11
levetiracetam tablet 1000mg ..................................................................................................................................11
levetiracetam tablet 250mg ....................................................................................................................................11
levetiracetam tablet 500mg ....................................................................................................................................11
levetiracetam tablet 750mg ....................................................................................................................................11
levobunolol hcl.......................................................................................................................................................70
96

levocarnitine injection............................................................................................................................................68
levocarnitine oral solution, tablet...........................................................................................................................68
levocetirizine dihydrochloride solution .................................................................................................................72
levocetirizine dihydrochloride tablet .....................................................................................................................72
levofloxacin in d5w................................................................................................................................................10
levofloxacin injection.............................................................................................................................................10
levofloxacin oral solution ......................................................................................................................................10
levofloxacin tablet 250mg......................................................................................................................................10
levofloxacin tablet 500mg, 750mg ........................................................................................................................10
levora 0.15/30-28 ...................................................................................................................................................59
levorphanol tartrate ..................................................................................................................................................1
levothroid ...............................................................................................................................................................61
levothyroxine sodium.............................................................................................................................................61
levoxyl....................................................................................................................................................................61
lexiva......................................................................................................................................................................31
lidocaine ...................................................................................................................................................................3
lidocaine hcl external solution .................................................................................................................................3
lidocaine hcl injection ..............................................................................................................................................3
lidocaine hcl jelly .....................................................................................................................................................3
lidocaine/prilocaine ..................................................................................................................................................3
lidoderm ...................................................................................................................................................................3
lincocin.....................................................................................................................................................................6
lindane lotion .........................................................................................................................................................25
liothyronine sodium injection ................................................................................................................................61
liothyronine sodium tablet .....................................................................................................................................61
lisinopril .................................................................................................................................................................41
lisinopril/hydrochlorothiazide................................................................................................................................41
lite touch pen needles/31g x 3/16...........................................................................................................................79
lithium carbonate ...................................................................................................................................................33
lithium carbonate er ...............................................................................................................................................33
lithium citrate .........................................................................................................................................................33
lithobid ...................................................................................................................................................................33
loestrin 24 fe ..........................................................................................................................................................59
loperamide hcl........................................................................................................................................................52
lorazepam intensol .................................................................................................................................................33
lorazepam tablet 0.5mg ..........................................................................................................................................33
lorazepam tablet 1mg, 2mg....................................................................................................................................33
losartan potassium..................................................................................................................................................40
losartan potassium/hydrochlorothiazide ................................................................................................................40
lotemax suspension ................................................................................................................................................69
lotronex ..................................................................................................................................................................52
lovastatin tablet 10mg, 20mg .................................................................................................................................47
lovastatin tablet 40mg ............................................................................................................................................47
lovaza .....................................................................................................................................................................47
lovenox...................................................................................................................................................................38
low-ogestrel............................................................................................................................................................59
loxapine succinate ..................................................................................................................................................27
lufyllin....................................................................................................................................................................73
lumigan solution 0.03% .........................................................................................................................................68
lupron depot injection 22.5mg, 3.75mg, 30mg, 7.5mg..........................................................................................62
97

lupron depot-ped ....................................................................................................................................................62
lutera ......................................................................................................................................................................59
lyrica capsule 100mg, 25mg, 50mg, 75mg ............................................................................................................11
lyrica capsule 150mg, 200mg, 225mg, 300mg ......................................................................................................11
lysodren ..................................................................................................................................................................61
M
m-m-r ii w/diluent 10 dose.....................................................................................................................................65
magnesium sulfate .................................................................................................................................................77
malarone tablet 62.5mg; 25mg ..............................................................................................................................25
malathion................................................................................................................................................................25
maprotiline hcl .......................................................................................................................................................14
marplan ..................................................................................................................................................................15
matulane .................................................................................................................................................................20
matzim la................................................................................................................................................................44
maxalt.....................................................................................................................................................................18
maxalt-mlt ..............................................................................................................................................................18
meclizine hcl ..........................................................................................................................................................16
meclofenamate sodium ............................................................................................................................................4
medroxyprogesterone acetate injection..................................................................................................................60
medroxyprogesterone acetate tablet.......................................................................................................................60
mefloquine hcl .......................................................................................................................................................25
megestrol acetate....................................................................................................................................................60
meloxicam suspension .............................................................................................................................................4
meloxicam tablet ......................................................................................................................................................4
melphalan hydrochloride .......................................................................................................................................20
menactra .................................................................................................................................................................65
menest ....................................................................................................................................................................22
menomune-a/c/y/w-135 .........................................................................................................................................65
menveo ...................................................................................................................................................................65
meperidine hcl injection 100mg/ml .........................................................................................................................2
meperidine hcl injection 25mg/ml, 50mg/ml...........................................................................................................2
meperidine hcl oral solution, tablet..........................................................................................................................2
meprobamate ..........................................................................................................................................................33
mepron ...................................................................................................................................................................25
mercaptopurine ......................................................................................................................................................21
meropenem...............................................................................................................................................................7
mesalamine ............................................................................................................................................................66
mesna .....................................................................................................................................................................22
mesnex ...................................................................................................................................................................22
mestinon syrup .......................................................................................................................................................19
mestinon timespan .................................................................................................................................................19
metadate cd ............................................................................................................................................................48
metaproterenol sulfate............................................................................................................................................74
metformin hcl er tablet extended release 24 hour 500mg......................................................................................34
metformin hcl er tablet extended release 24 hour 750mg......................................................................................35
metformin hcl tablet 1000mg.................................................................................................................................35
metformin hcl tablet 500mg...................................................................................................................................35
metformin hcl tablet 850mg...................................................................................................................................35
methadone hcl concentrate, oral solution, tablet......................................................................................................1
98

methadone hcl injection ...........................................................................................................................................1
methadose ................................................................................................................................................................1
methazolamide .......................................................................................................................................................70
methenamine hippurate ............................................................................................................................................6
methimazole ...........................................................................................................................................................63
methitest .................................................................................................................................................................58
methocarbamol.......................................................................................................................................................75
methotrexate...........................................................................................................................................................63
methotrexate sodium ..............................................................................................................................................63
methscopolamine bromide tablet 2.5mg ................................................................................................................51
methyclothiazide ....................................................................................................................................................46
methyldopa.............................................................................................................................................................40
methyldopa/hydrochlorothiazide ...........................................................................................................................40
methyldopate hcl ....................................................................................................................................................40
methylergonovine maleate .....................................................................................................................................68
methylphenidate hcl ...............................................................................................................................................48
methylphenidate hcl er tablet extended release .....................................................................................................48
methylprednisolone ..........................................................................................................................................55, 66
methylprednisolone acetate....................................................................................................................................55
methylprednisolone dose pack ...............................................................................................................................55
methylprednisolone sodiumsuccinate ....................................................................................................................55
metipranolol ...........................................................................................................................................................70
metoclopramide hcl injection.................................................................................................................................52
metoclopramide hcl oral solution, tablet................................................................................................................52
metolazone .............................................................................................................................................................46
metoprolol succinate er ..........................................................................................................................................43
metoprolol tartrate injection...................................................................................................................................43
metoprolol tartrate tablet ........................................................................................................................................43
metoprolol/hydrochlorothiazide.............................................................................................................................43
metronidazole cream, gel, lotion, tablet...................................................................................................................6
metronidazole in nacl 0.79%....................................................................................................................................6
metronidazole vaginal ..............................................................................................................................................6
mexiletine hcl.........................................................................................................................................................42
miacalcin injection .................................................................................................................................................67
miconazole 3 ..........................................................................................................................................................17
microgestin 1.5/30..................................................................................................................................................59
microgestin 1/20.....................................................................................................................................................59
microgestin fe.........................................................................................................................................................59
microgestin fe 1.5/30 .............................................................................................................................................59
midodrine hcl .........................................................................................................................................................40
migergot .................................................................................................................................................................18
minocycline hcl capsule .........................................................................................................................................10
minoxidil ................................................................................................................................................................48
mirtazapine.............................................................................................................................................................14
mirtazapine odt.......................................................................................................................................................14
misoprostol.............................................................................................................................................................53
mitomycin ..............................................................................................................................................................22
mitoxantrone hcl ....................................................................................................................................................22
mometasone furoate cream, ointment ....................................................................................................................55
mometasone furoate solution 0.1%........................................................................................................................55
99

monoject insulin syringe/softpack/1ml/25g x 58 ...................................................................................................79
mononessa..............................................................................................................................................................59
morphine sulfate er tablet extended release 12 hour 100mg....................................................................................1
morphine sulfate er tablet extended release 12 hour 15mg, 200mg, 30mg, 60mg ..................................................1
morphine sulfate solution 10mg/5ml, 20mg/5ml.....................................................................................................1
morphine sulfate tablet.............................................................................................................................................1
multaq ....................................................................................................................................................................42
mupirocin .................................................................................................................................................................6
mustargen ...............................................................................................................................................................20
mycamine ...............................................................................................................................................................17
mycobutin ..............................................................................................................................................................19
mycophenolate mofetil...........................................................................................................................................63
N
nabumetone ..............................................................................................................................................................4
nadolol....................................................................................................................................................................43
nadolol/bendroflumethiazide .................................................................................................................................43
nafcillin sodium .......................................................................................................................................................8
naftin cream ...........................................................................................................................................................17
naglazyme ..............................................................................................................................................................51
nalbuphine hcl ..........................................................................................................................................................2
nallpen/dextrose .......................................................................................................................................................8
naloxone hcl .............................................................................................................................................................3
naltrexone hcl...........................................................................................................................................................3
namenda solution ...................................................................................................................................................14
namenda tablet .......................................................................................................................................................14
namenda titration pak.............................................................................................................................................14
naproxen...............................................................................................................................................................1, 4
naproxen dr ..............................................................................................................................................................4
naproxen sodium ......................................................................................................................................................1
naratriptan hcl ........................................................................................................................................................18
natacyn ...................................................................................................................................................................17
nateglinide..............................................................................................................................................................35
nebupent .................................................................................................................................................................25
necon 0.5/35-28......................................................................................................................................................59
necon 1/35-28.........................................................................................................................................................59
necon 10/11-28.......................................................................................................................................................59
necon 7/7/7.............................................................................................................................................................59
nefazodone hcl .......................................................................................................................................................14
neomycin sulfate ......................................................................................................................................................5
neomycin/bacitracin/polymyxin ..............................................................................................................................6
neomycin/polymyxin b sulfates ...............................................................................................................................5
neomycin/polymyxin/bacitracin/hydrocortisone .....................................................................................................6
neomycin/polymyxin/dexamethasone....................................................................................................................69
neomycin/polymyxin/gramicidin .............................................................................................................................6
neomycin/polymyxin/hc ........................................................................................................................................70
neomycin/polymyxin/hydrocortisone ....................................................................................................................70
nephramine.............................................................................................................................................................77
neulasta ..................................................................................................................................................................39
neumega .................................................................................................................................................................39
100

neupogen ................................................................................................................................................................39
nevirapine...............................................................................................................................................................29
nexavar ...................................................................................................................................................................24
nexium i.v. .............................................................................................................................................................53
niacor......................................................................................................................................................................77
niaspan ...................................................................................................................................................................47
nicardipine hcl capsule...........................................................................................................................................44
nicotrol ns.................................................................................................................................................................3
nifediac cc ..............................................................................................................................................................44
nifedical xl .............................................................................................................................................................44
nifedipine ...............................................................................................................................................................44
nifedipine er ...........................................................................................................................................................44
nilandron ................................................................................................................................................................62
nitrofurantoin macrocrystalline................................................................................................................................6
nitrofurantoin monohydrate .....................................................................................................................................6
nitroglycerin injection ............................................................................................................................................47
nitroglycerin patch 24 hour ....................................................................................................................................47
nitroglycerin transdermal .......................................................................................................................................47
nitrostat ..................................................................................................................................................................47
nora-be ...................................................................................................................................................................60
norditropin flexpro injection 15mg/1.5ml, 5mg/1.5ml ..........................................................................................57
norethindrone acetate .............................................................................................................................................60
normosol-m in d5w ................................................................................................................................................77
normosol-r..............................................................................................................................................................77
normosol-r in d5w..................................................................................................................................................36
nortrel 0.5/35 (28) ..................................................................................................................................................59
nortrel 1/35 (21) .....................................................................................................................................................59
nortrel 1/35 (28) .....................................................................................................................................................59
nortrel 7/7/7............................................................................................................................................................59
nortriptyline hcl......................................................................................................................................................16
norvir......................................................................................................................................................................31
novofine 32gx6mm ................................................................................................................................................79
novolin 70/30 .........................................................................................................................................................37
novolin n ................................................................................................................................................................37
novolin r .................................................................................................................................................................37
novolog ..................................................................................................................................................................37
novolog flexpen .....................................................................................................................................................37
novolog mix 70/30 .................................................................................................................................................37
novolog mix 70/30 prefilled flexpen......................................................................................................................37
nulojix ....................................................................................................................................................................63
nulytely/flavor packs..............................................................................................................................................53
nutropin ..................................................................................................................................................................57
nutropin aq pen injection 10mg/2ml ......................................................................................................................57
nyamyc ...................................................................................................................................................................17
nystatin ...................................................................................................................................................................17
nystatin/triamcinolone............................................................................................................................................17
nystop .....................................................................................................................................................................17
101

O
octreotide acetate injection 1000mcg/ml, 100mcg/ml, 500mcg/ml, 50mcg/ml.....................................................62
octreotide acetate injection 200mcg/ml .................................................................................................................62
ofloxacin ................................................................................................................................................................10
ogestrel ...................................................................................................................................................................59
olanzapine injection ...............................................................................................................................................28
olanzapine odt ........................................................................................................................................................28
olanzapine tablet ....................................................................................................................................................28
omeprazole capsule delayed release 10mg ............................................................................................................53
omeprazole capsule delayed release 20mg, 40mg .................................................................................................53
ondansetron hcl injection .......................................................................................................................................16
ondansetron hcl oral solution .................................................................................................................................16
ondansetron hcl tablet 24mg ..................................................................................................................................16
ondansetron hcl tablet 4mg, 8mg ...........................................................................................................................16
ondansetron odt ......................................................................................................................................................16
onfi .........................................................................................................................................................................12
onglyza ...................................................................................................................................................................35
ontak.......................................................................................................................................................................22
orap ........................................................................................................................................................................27
orencia ....................................................................................................................................................................63
orfadin ....................................................................................................................................................................51
orphenadrine citrate ...............................................................................................................................................75
orphenadrine citrate er ...........................................................................................................................................75
ortho evra ...............................................................................................................................................................59
oxacillin sodium.......................................................................................................................................................8
oxaliplatin ..............................................................................................................................................................22
oxandrolone............................................................................................................................................................58
oxaprozin..................................................................................................................................................................4
oxcarbazepine ........................................................................................................................................................13
oxsoralen ................................................................................................................................................................50
oxsoralen ultra........................................................................................................................................................50
oxybutynin chloride er ...........................................................................................................................................54
oxybutynin chloride tablet .....................................................................................................................................54
oxycodone hcl tablet ................................................................................................................................................2
oxycodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg......................................................2
oxycodone/acetaminophen tablet 500mg; 7.5mg ....................................................................................................2
P
pacerone tablet 100mg, 400mg ..............................................................................................................................42
pacerone tablet 200mg ...........................................................................................................................................42
paclitaxel ................................................................................................................................................................22
pamidronate disodium............................................................................................................................................67
pancreaze................................................................................................................................................................51
panretin ..................................................................................................................................................................24
pantoprazole sodium tablet delayed release 20mg.................................................................................................53
pantoprazole sodium tablet delayed release 40mg.................................................................................................53
paromomycin sulfate................................................................................................................................................5
paroxetine hcl.........................................................................................................................................................15
paroxetine hcl er tablet extended release 24 hour 37.5mg .....................................................................................15
102

paser .......................................................................................................................................................................19
patanol....................................................................................................................................................................69
paxil suspension .....................................................................................................................................................15
pedi-dri ...................................................................................................................................................................17
pedvax hib ..............................................................................................................................................................65
peg-intron ...............................................................................................................................................................32
peg-intron redipen ..................................................................................................................................................32
peganone ................................................................................................................................................................13
pegasys ...................................................................................................................................................................32
pegasys proclick .....................................................................................................................................................32
penicillin g potassium ..............................................................................................................................................8
penicillin g potassium in iso-osmotic dextrose ........................................................................................................8
penicillin g procaine.................................................................................................................................................8
penicillin g sodium...................................................................................................................................................8
penicillin v potassium ..............................................................................................................................................8
pentam 300.............................................................................................................................................................25
pentostatin ..............................................................................................................................................................21
pentoxifylline er .....................................................................................................................................................45
periogard ................................................................................................................................................................49
permethrin ..............................................................................................................................................................25
perphenazine ..........................................................................................................................................................27
perphenazine/amitriptyline ....................................................................................................................................16
pfizerpen-g ...............................................................................................................................................................8
phenadoz ................................................................................................................................................................72
phenelzine sulfate...................................................................................................................................................15
phenobarbital..........................................................................................................................................................76
phenytek .................................................................................................................................................................13
phenytoin................................................................................................................................................................13
phenytoin sodium...................................................................................................................................................13
phenytoin sodium extended ...................................................................................................................................13
phospholine iodide .................................................................................................................................................70
physiolyte ...............................................................................................................................................................68
physiosol irrigation ................................................................................................................................................68
picato......................................................................................................................................................................22
pilocarpine hcl........................................................................................................................................................49
pilocarpine hydrochloride ......................................................................................................................................49
pilopine hs ..............................................................................................................................................................70
pindolol ..................................................................................................................................................................43
piperacillin sodium/tazobactam sodium injection 4gm; 0.5gm ...............................................................................8
piroxicam .............................................................................................................................................................1, 4
plasma-lyte a ..........................................................................................................................................................77
plasma-lyte-148......................................................................................................................................................77
plasma-lyte-56/d5w................................................................................................................................................77
podofilox ................................................................................................................................................................50
polyethylene glycol 3350 .......................................................................................................................................53
polymyxin b sulfate..................................................................................................................................................6
portia-28 .................................................................................................................................................................59
potassium chloride .................................................................................................................................................77
potassium chloride 0.15% /nacl 0.45% viaflex......................................................................................................77
potassium chloride 0.15% d5w/nacl 0.33% ...........................................................................................................36
103

potassium chloride 0.15% d5w/nacl 0.45% viaflex...............................................................................................36
potassium chloride 0.15% nacl 0.9% .....................................................................................................................77
potassium chloride 0.22% d5w/nacl 0.45% ...........................................................................................................36
potassium chloride 0.224%/dextrose 5% viaflex ...................................................................................................77
potassium chloride 0.3%/ nacl 0.9% ......................................................................................................................77
potassium chloride 0.3%/d5w/viaflex....................................................................................................................77
potassium chloride er .............................................................................................................................................77
potiga......................................................................................................................................................................11
pradaxa ...................................................................................................................................................................38
pramipexole dihydrochloride .................................................................................................................................26
prandin ...................................................................................................................................................................35
pravastatin sodium .................................................................................................................................................47
prazosin hcl ............................................................................................................................................................40
pred-g .....................................................................................................................................................................69
pred-g s.o.p.............................................................................................................................................................69
prednicarbate cream ...............................................................................................................................................55
prednisolone acetate ...............................................................................................................................................69
prednisolone sodium phosphate .......................................................................................................................55, 69
prednisone ..............................................................................................................................................................56
pregnyl w/diluent benzyl alcohol/nacl ...................................................................................................................57
premarin cream ......................................................................................................................................................59
premarin injection ..................................................................................................................................................59
premarin tablet 0.3mg, 0.625mg ............................................................................................................................59
premarin tablet 0.45mg, 0.9mg, 1.25mg ................................................................................................................59
premasol .................................................................................................................................................................77
premphase ..............................................................................................................................................................59
prempro ..................................................................................................................................................................60
prenatabs obn .........................................................................................................................................................77
prevalite..................................................................................................................................................................47
previfem .................................................................................................................................................................60
prezista ...................................................................................................................................................................31
priftin......................................................................................................................................................................19
primaquine phosphate ............................................................................................................................................25
primidone ...............................................................................................................................................................12
primsol .....................................................................................................................................................................6
pristiq .....................................................................................................................................................................15
proair hfa ................................................................................................................................................................74
probenecid ..............................................................................................................................................................18
probenecid/colchicine ............................................................................................................................................18
procainamide hcl ....................................................................................................................................................42
procalamine ............................................................................................................................................................77
prochlorperazine edisylate .....................................................................................................................................27
prochlorperazine maleate .......................................................................................................................................27
procrit .....................................................................................................................................................................39
proctocream hc .......................................................................................................................................................56
prodigy insulin mini pen needles/31g x 3/16 .........................................................................................................79
prodigy insulin short penneedles/31g x 5/16 .........................................................................................................79
progesterone ...........................................................................................................................................................60
proglycem ..............................................................................................................................................................36
prograf capsule .......................................................................................................................................................63
104

prograf injection.....................................................................................................................................................63
prolastin-c ..............................................................................................................................................................75
proleukin ................................................................................................................................................................22
promacta tablet 25mg.............................................................................................................................................39
promacta tablet 50mg.............................................................................................................................................39
promethazine hcl injection .....................................................................................................................................72
promethazine hcl suppository, syrup, tablet ..........................................................................................................72
promethazine vc .....................................................................................................................................................72
promethegan...........................................................................................................................................................72
propafenone hcl......................................................................................................................................................42
propranolol hcl er ...................................................................................................................................................43
propranolol hcl injection ........................................................................................................................................43
propranolol hcl oral solution, tablet .......................................................................................................................43
propranolol/hydrochlorothiazide............................................................................................................................43
propylthiouracil......................................................................................................................................................63
proquad ..................................................................................................................................................................65
prosol......................................................................................................................................................................77
protonix injection ...................................................................................................................................................53
protopic ..................................................................................................................................................................50
protriptyline hcl......................................................................................................................................................16
provigil tablet 100mg .............................................................................................................................................76
provigil tablet 200mg .............................................................................................................................................76
pulmozyme.............................................................................................................................................................75
pyridostigmine bromide .........................................................................................................................................19
Q
quasense .................................................................................................................................................................60
quetiapine fumarate................................................................................................................................................28
quinapril hcl ...........................................................................................................................................................41
quinapril/hydrochlorothiazide................................................................................................................................41
quinidine gluconate ................................................................................................................................................42
quinidine gluconate er ............................................................................................................................................42
quinidine sulfate.....................................................................................................................................................42
quinidine sulfate er.................................................................................................................................................42
R
rabavert ..................................................................................................................................................................65
ramipril...................................................................................................................................................................41
ranexa tablet extended release 12 hour 500mg ......................................................................................................45
ranitidine hcl capsule, syrup, tablet........................................................................................................................52
ranitidine hcl injection ...........................................................................................................................................52
rapamune ................................................................................................................................................................63
rebetol solution.......................................................................................................................................................32
rebif ........................................................................................................................................................................64
rebif titration pack ..................................................................................................................................................64
reclast .....................................................................................................................................................................67
recombivax hb........................................................................................................................................................65
regonol ...................................................................................................................................................................19
regranex..................................................................................................................................................................50
105

elenza diskhaler ....................................................................................................................................................31
relistor ....................................................................................................................................................................52
remicade .................................................................................................................................................................63
remodulin ...............................................................................................................................................................74
renagel ....................................................................................................................................................................54
renvela tablet ..........................................................................................................................................................54
rescriptor ................................................................................................................................................................29
reserpine tablet 0.25mg ..........................................................................................................................................40
restasis....................................................................................................................................................................68
retrovir iv infusion .................................................................................................................................................30
revatio tablet...........................................................................................................................................................74
revlimid ..................................................................................................................................................................20
reyataz ....................................................................................................................................................................31
rhinocort aqua ........................................................................................................................................................71
ribapak....................................................................................................................................................................32
ribasphere tablet .....................................................................................................................................................32
ribavirin..................................................................................................................................................................32
rifampin capsule .....................................................................................................................................................19
rifampin injection...................................................................................................................................................19
rifater ......................................................................................................................................................................19
rilutek .....................................................................................................................................................................48
rimantadine hcl.......................................................................................................................................................31
ringers injection .....................................................................................................................................................77
ringers irrigation.....................................................................................................................................................68
risperdal consta ......................................................................................................................................................28
risperidone..............................................................................................................................................................28
risperidone odt .......................................................................................................................................................28
rituxan ....................................................................................................................................................................24
rivastigmine tartrate ...............................................................................................................................................14
ropinirole hcl ..........................................................................................................................................................26
rotateq ....................................................................................................................................................................65
S
sabril.......................................................................................................................................................................12
saizen......................................................................................................................................................................57
saizen click.easy.....................................................................................................................................................57
sandostatin lar depot ..............................................................................................................................................62
santyl ......................................................................................................................................................................50
saphris ....................................................................................................................................................................28
selegiline hcl ..........................................................................................................................................................15
selenium sulfide .....................................................................................................................................................50
selzentry .................................................................................................................................................................30
sensipar ..................................................................................................................................................................61
serevent diskus .......................................................................................................................................................74
seromycin ...............................................................................................................................................................19
serostim ..................................................................................................................................................................57
sertraline hcl ...........................................................................................................................................................15
silver sulfadiazine ....................................................................................................................................................6
simulect ..................................................................................................................................................................64
simvastatin .............................................................................................................................................................47
106

singulair..................................................................................................................................................................72
sodium chloride......................................................................................................................................................77
sodium chloride 0.45% viaflex ..............................................................................................................................77
sodium chloride 0.9% ............................................................................................................................................68
sodium fluoride ......................................................................................................................................................77
sodium lactate ........................................................................................................................................................76
sodium polystyrene sulfonate ................................................................................................................................76
sodium sulfacetamide.............................................................................................................................................10
solu-cortef ..............................................................................................................................................................56
solu-medrol ............................................................................................................................................................56
somatuline depot injection 120mg/0.5ml, 90mg/0.3ml .........................................................................................62
somavert .................................................................................................................................................................62
sorine......................................................................................................................................................................42
sotalol hcl ...............................................................................................................................................................42
spiriva handihaler ...................................................................................................................................................73
spironolactone ........................................................................................................................................................46
spironolactone/hydrochlorothiazide.......................................................................................................................46
sporanox solution ...................................................................................................................................................17
sprintec 28 ..............................................................................................................................................................60
sprycel ....................................................................................................................................................................24
sronyx.....................................................................................................................................................................60
ssd ............................................................................................................................................................................6
stagesic .....................................................................................................................................................................2
stalevo 100 .............................................................................................................................................................26
stalevo 125 .............................................................................................................................................................26
stalevo 150 .............................................................................................................................................................26
stalevo 200 .............................................................................................................................................................26
stalevo 50 ...............................................................................................................................................................26
stalevo 75 ...............................................................................................................................................................26
stavudine ................................................................................................................................................................30
sterile water irrigation ............................................................................................................................................68
stimate ....................................................................................................................................................................57
strattera...................................................................................................................................................................48
streptomycin sulfate .................................................................................................................................................5
stromectol...............................................................................................................................................................25
suboxone tablet sublingual.......................................................................................................................................3
sucraid ....................................................................................................................................................................51
sucralfate ................................................................................................................................................................53
sulfacetamide sodium.............................................................................................................................................50
sulfacetamide sodium/prednisolone sodium phosphate.........................................................................................69
sulfadiazine ............................................................................................................................................................10
sulfamethoxazole/trimethoprim ds.........................................................................................................................10
sulfamethoxazole/trimethoprim injection ..............................................................................................................10
sulfamethoxazole/trimethoprim suspension, tablet................................................................................................10
sulfasalazine ...........................................................................................................................................................66
sulfazine ec.............................................................................................................................................................66
sulindac ....................................................................................................................................................................4
sumatriptan succinate injection 6mg/0.5ml ...........................................................................................................18
sumatriptan succinate tablet ...................................................................................................................................18
sure-fine pen needles 31gx3/16 5mm ....................................................................................................................79
107

sure-fine pen needles 31gx5/16 8mm ....................................................................................................................79
sustiva ....................................................................................................................................................................29
sutent ......................................................................................................................................................................24
sylatron...................................................................................................................................................................22
symlinpen 120 ........................................................................................................................................................35
symlinpen 60 ..........................................................................................................................................................35
synarel ....................................................................................................................................................................62
synercid ....................................................................................................................................................................6
synthroid ................................................................................................................................................................61
syprine ....................................................................................................................................................................76
T
tabloid ....................................................................................................................................................................21
tacrolimus...............................................................................................................................................................64
talwin........................................................................................................................................................................2
tamiflu capsule 30mg, 45mg..................................................................................................................................31
tamiflu capsule 75mg .............................................................................................................................................31
tamiflu suspension reconstituted............................................................................................................................31
tamoxifen citrate ....................................................................................................................................................20
tamsulosin hcl ........................................................................................................................................................54
tarceva ....................................................................................................................................................................24
targretin ..................................................................................................................................................................24
tasigna ....................................................................................................................................................................24
tasmar .....................................................................................................................................................................26
tazorac ....................................................................................................................................................................50
taztia xt...................................................................................................................................................................44
tegretol ...................................................................................................................................................................13
tegretol-xr...............................................................................................................................................................13
tekturna ..................................................................................................................................................................45
tekturna hct.............................................................................................................................................................45
temazepam capsule 15mg, 30mg ...........................................................................................................................75
terazosin hcl ...........................................................................................................................................................54
terbinafine hcl ........................................................................................................................................................17
terbutaline sulfate injection....................................................................................................................................74
terbutaline sulfate tablet .........................................................................................................................................74
terconazole cream ..................................................................................................................................................18
terconazole suppository .........................................................................................................................................18
testosterone cypionate injection 100mg/ml ...........................................................................................................58
testosterone cypionate injection 200mg/ml ...........................................................................................................58
testosterone enanthate ............................................................................................................................................58
tetanus/diphtheria toxoids-adsorbed adult .............................................................................................................65
tetracycline hcl .......................................................................................................................................................10
tev-tropin................................................................................................................................................................57
thalitone..................................................................................................................................................................46
thalomid .................................................................................................................................................................20
theophylline cr .......................................................................................................................................................73
theophylline er .......................................................................................................................................................73
thermazene ...............................................................................................................................................................6
thioridazine hcl.......................................................................................................................................................27
thiotepa...................................................................................................................................................................20
108

thiothixene..............................................................................................................................................................27
thymoglobulin ........................................................................................................................................................64
ticlopidine hcl.........................................................................................................................................................39
tikosyn....................................................................................................................................................................42
timentin ....................................................................................................................................................................8
timolol maleate.................................................................................................................................................43, 70
timolol maleate ophthalmic gel forming................................................................................................................70
tizanidine hcl tablet ................................................................................................................................................29
tobi ...........................................................................................................................................................................5
tobradex ointment ..................................................................................................................................................69
tobramycin sulfate injection.....................................................................................................................................5
tobramycin sulfate ophthalmic solution...................................................................................................................5
tobramycin sulfate/sodium chloride.........................................................................................................................5
tobramycin/dexamethasone....................................................................................................................................69
tolbutamide ............................................................................................................................................................35
tolmetin sodium .......................................................................................................................................................4
topiramate ..............................................................................................................................................................12
toposar....................................................................................................................................................................23
topotecan hcl ..........................................................................................................................................................23
torisel......................................................................................................................................................................64
torsemide injection.................................................................................................................................................45
torsemide tablet ......................................................................................................................................................45
tpn electrolytes .......................................................................................................................................................77
tracleer....................................................................................................................................................................74
tradjenta..................................................................................................................................................................35
tramadol hcl .............................................................................................................................................................2
tramadol hydrochloride/acetaminophen...................................................................................................................2
trandolapril tablet 1mg, 2mg..................................................................................................................................41
trandolapril tablet 4mg ...........................................................................................................................................41
tranexamic acid ......................................................................................................................................................39
tranylcypromine sulfate .........................................................................................................................................15
travasol ...................................................................................................................................................................77
trazodone hcl ..........................................................................................................................................................14
treanda ....................................................................................................................................................................20
trecator ...................................................................................................................................................................19
trelstar depot mixject..............................................................................................................................................62
trelstar la mixject....................................................................................................................................................62
tretinoin ..................................................................................................................................................................24
tretinoin cream .......................................................................................................................................................50
tretinoin gel ............................................................................................................................................................50
tri-previfem ............................................................................................................................................................60
tri-sprintec ..............................................................................................................................................................60
triamcinolone acetonide .........................................................................................................................................56
triamcinolone in orabase ........................................................................................................................................49
triamterene/hydrochlorothiazide ............................................................................................................................46
triderm....................................................................................................................................................................56
trifluoperazine hcl ..................................................................................................................................................27
trifluridine ..............................................................................................................................................................32
trihexyphenidyl hcl ................................................................................................................................................26
trileptal suspension.................................................................................................................................................13
109

trilyte ......................................................................................................................................................................53
trimethobenzamide hcl...........................................................................................................................................16
trimethoprim ............................................................................................................................................................6
trimethoprim sulfate/polymyxin b sulfate................................................................................................................6
trimipramine maleate .............................................................................................................................................16
trinessa ...................................................................................................................................................................60
trisenox...................................................................................................................................................................22
trivora-28................................................................................................................................................................60
trizivir.....................................................................................................................................................................30
trophamine .............................................................................................................................................................77
tropicamide ............................................................................................................................................................68
truvada....................................................................................................................................................................30
twinrix ....................................................................................................................................................................65
tygacil.......................................................................................................................................................................6
tykerb .....................................................................................................................................................................24
typhim vi ................................................................................................................................................................65
tyzeka .....................................................................................................................................................................32
tyzine ......................................................................................................................................................................75
tyzine pediatric nasal drops....................................................................................................................................75
U
u-cort ......................................................................................................................................................................56
ulticare short pen needles 31gx8mm......................................................................................................................79
ulticare short pen needles ulti-fine iv.....................................................................................................................79
unithroid .................................................................................................................................................................61
ursodiol ..................................................................................................................................................................52
uvadex ....................................................................................................................................................................50
V
valacyclovir hcl ......................................................................................................................................................32
valcyte ....................................................................................................................................................................29
valproate sodium ....................................................................................................................................................12
valproic acid ...........................................................................................................................................................12
vancocin hcl .............................................................................................................................................................6
vancomycin hcl injection .........................................................................................................................................6
vandazole .................................................................................................................................................................6
vaqta .......................................................................................................................................................................65
varivax....................................................................................................................................................................65
vectibix...................................................................................................................................................................24
velcade ...................................................................................................................................................................23
velivet.....................................................................................................................................................................60
venlafaxine hcl .......................................................................................................................................................15
venlafaxine hcl er ...................................................................................................................................................15
ventavis ..................................................................................................................................................................74
ventolin hfa ............................................................................................................................................................74
verapamil hcl er capsule extended release 24 hour................................................................................................44
verapamil hcl er tablet extended release ................................................................................................................44
verapamil hcl injection...........................................................................................................................................44
verapamil hcl tablet ................................................................................................................................................44
110

veregen ...................................................................................................................................................................50
victrelis...................................................................................................................................................................32
vidaza .....................................................................................................................................................................23
videx pediatric........................................................................................................................................................30
viibryd ....................................................................................................................................................................15
vimpat injection .....................................................................................................................................................13
vimpat oral solution ...............................................................................................................................................13
vimpat tablet 100mg, 50mg ...................................................................................................................................13
vimpat tablet 150mg, 200mg .................................................................................................................................13
vinblastine sulfate ..................................................................................................................................................23
vincristine sulfate ...................................................................................................................................................23
vinorelbine tartrate .................................................................................................................................................23
viracept...................................................................................................................................................................31
viramune suspension ..............................................................................................................................................29
viramune xr ............................................................................................................................................................29
viread......................................................................................................................................................................30
vistide .....................................................................................................................................................................29
vivelle-dot patch biweekly 0.0375mg/24hr ...........................................................................................................60
voltaren ..................................................................................................................................................................50
votrient ...................................................................................................................................................................24
vpriv .......................................................................................................................................................................51
W
warfarin sodium .....................................................................................................................................................38
X
xalkori ....................................................................................................................................................................24
xarelto ....................................................................................................................................................................38
xenazine .................................................................................................................................................................48
xifaxan tablet 200mg................................................................................................................................................6
xolair ......................................................................................................................................................................75
xopenex ..................................................................................................................................................................74
xopenex hfa ............................................................................................................................................................74
xylocaine injection ...................................................................................................................................................3
xyrem .....................................................................................................................................................................76
Y
yervoy ....................................................................................................................................................................24
yf-vax .....................................................................................................................................................................65
Z
zafirlukast...............................................................................................................................................................72
zaleplon ..................................................................................................................................................................75
zanosar ...................................................................................................................................................................20
zantac injection ......................................................................................................................................................52
zavesca ...................................................................................................................................................................51
zazole cream 0.8% .................................................................................................................................................18
zelapar ....................................................................................................................................................................15
zelboraf ..................................................................................................................................................................24
111

zemaira ...................................................................................................................................................................75
zenpep ....................................................................................................................................................................51
zerit solution reconstituted .....................................................................................................................................30
zetia ........................................................................................................................................................................47
ziagen .....................................................................................................................................................................30
zidovudine..............................................................................................................................................................30
zinacef in iso-osmotic dextrose................................................................................................................................7
zinacef in iso-osmotic diluent ..................................................................................................................................7
zinecard ..................................................................................................................................................................23
ziprasidone hcl .......................................................................................................................................................28
zmax .........................................................................................................................................................................9
zolinza ....................................................................................................................................................................23
zolpidem tartrate ....................................................................................................................................................75
zolpidem tartrate er ................................................................................................................................................75
zometa ....................................................................................................................................................................67
zonalon ...................................................................................................................................................................50
zonisamide .............................................................................................................................................................11
zorbtive ..................................................................................................................................................................57
zortress ...................................................................................................................................................................64
zostavax..................................................................................................................................................................65
zosyn ........................................................................................................................................................................8
zovia 1/35e .............................................................................................................................................................60
zovia 1/50e .............................................................................................................................................................60
zovirax cream, ointment.........................................................................................................................................32
zyflo cr ...................................................................................................................................................................72
zytiga ......................................................................................................................................................................23
zyvox injection.........................................................................................................................................................6
zyvox suspension reconstituted................................................................................................................................6
zyvox tablet ..............................................................................................................................................................6
112