Elite Extra - MMM

¿Cómo utilizo el Formulario?Hay dos maneras de encontrar su medicamento en el formulario:Condición médicaEl formulario comienza en la página 9. En este formulario, los medicamentos están agrupados por categoríasegún el tipo de condición médica que tratan. Por ejemplo, los medicamentos que se utilizan para tratar unacondición cardíaca aparecen listados bajo la categoría “Cardiovasculares, Hipertensión / Lípidos”. Si ustedsabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza más adelante.Luego, busque el nombre del medicamento dentro de esa categoría.Listado alfabéticoSi no está seguro de la categoría en la que debe realizar su búsqueda, busque su medicamento en el índice quecomienza en la página 133. El índice ofrece una lista alfabética de todos los medicamentos incluidos en estedocumento. En el índice se enumeran, tanto los medicamentos de marca, como los medicamentos genéricos.Vea el índice y busque su medicamento. Junto al medicamento verá el número de la página en la que podráencontrar información sobre la cubierta. Vaya a la página que se indica en el índice y busque el nombre de sumedicamento en la primera columna de la lista.¿Qué son los medicamentos genéricos?MMM ofrece cubierta para medicamentos de marca y medicamentos genéricos. Un medicamento genérico estáaprobado por la FDA como que tiene el mismo ingrediente activo que el medicamento de marca. Losmedicamentos genéricos usualmente cuestan menos que los medicamentos de marca.¿Existe alguna restricción en mi cubierta?Es posible que algunos medicamentos cubiertos tengan requisitos o límites adicionales para la cubierta. Estosrequisitos y límites pueden incluir:• Preautorización: MMM exige que el afiliado obtenga preautorización para ciertos medicamentos. Estosignifica que necesitará la aprobación de MMM antes de adquirir la receta. Si no obtiene la aprobacióndel plan, es posible que MMM no cubra el medicamento.• Límites de cantidad: Para ciertos medicamentos, MMM limita la cantidad del medicamento cubiertopor MMM. Por ejemplo, MMM establece la cantidad de 30 tabletas por receta para irbesartan. Estopuede ser adicional a un suplido regular para un (1) mes o tres (3) meses.Usted puede verificar si su medicamento tiene algún requisito o límite adicional, consultando el formularioque empieza en la página 9. También puede obtener información adicional sobre las restricciones que seaplican a medicamentos específicos cubiertos en su formulario, visitando nuestra página de Internet. Nuestrainformación de contacto, al igual que la fecha en que este formulario fue actualizado, aparece en la portada ycontraportada.Página 3 de 150

Formulario de MMMEl formulario a continuación ofrece información sobre la cubierta de algunos de los medicamentos cubiertospor MMM. Si tiene dificultad para localizar un medicamento en la lista, consulte el índice que comienza en lapágina 133.La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca aparecenen letra mayúscula (por ejemplo, LANOXIN) y los medicamentos genéricos aparecen en letra cursiva (itálica)minúscula (por ejemplo, digoxin).La información que aparece en la columna de Requisitos/Límites indica si MMM establece algún requisitoespecial para la cubierta del medicamento.Estructura de nivelesAntes de que el costo total anual de medicamentos (pagados tanto por usted, como por MMM alcance los$2,850.00, usted pagará lo siguiente por medicamentos recetados:Elite Extra(HMO POS)Nivel Medicamento Copago porcantidad aldetal(30 días)Copago porcantidad aldetal(90 días)Copago pororden porcorreo (90días)1 Genérico Preferido $2.00 $6.00 $4.002 Genérico No Preferido $5.00 $15.00 $10.003 Marca Preferida $25.00 $75.00 $50.004 Marca No Preferida $50.00 $150.00 $100.005 Especialidad 30% 30% 30%Luego de que su costo total anual de medicamentos alcance $2,850.00 usted recibe cobertura limitada por elplan en ciertos medicamentos. También recibe un descuento en medicamentos de marca y, por lo general, nopaga más de 47.5% del costo del plan por medicamentos de marca y 72% del costo del plan por medicamentosgenéricos hasta que su costo de bolsillo anual por medicamentos alcance $4,550.00.El plan ofrece cubierta adicional durante la brecha para los siguientes niveles:Elite Extra(HMO POS)Nivel Medicamento Copago porcantidad aldetal(30 días)Copago porcantidad aldetal(90 días)Copago pororden porcorreo (90días)1 Genérico Preferido $2.00 $6.00 $4.002 Genérico No $5.00 $15.00 $10.00PreferidoLuego de que los gastos de su bolsillo alcancen los $4,550.00 en el año, usted pagará la cantidad mayor entre:• 5% de coaseguro, o• $2.55 por medicamentos genéricos (incluyendo medicamentos de marca tratados como genéricos) y$6.35 por todos los demás medicamentos.Página 6 de 150

Tabla de ContenidoAnti-infectivos ....................................................................................................................................................... 9Cardiovasculares, Hipertensión / Lípidos ............................................................................................................ 27Dermatológicos / Tratamiento Tópico ................................................................................................................. 41Diagnósticos /Agentes Misceláneos..................................................................................................................... 50Gastroenterología ................................................................................................................................................. 53Inmunología, Vacunas / Medicamentos Biotecnológicos ................................................................................... 58Medicamentos Antineoplásicos e Inmunosupresores .......................................................................................... 64Medicamentos Autonómicos y del Sistema Nervioso Central ............................................................................. 72Medicamentos Endocrinos / Medicamentos para la Diabetes ............................................................................. 94Medicamentos Musculoesqueletales / Medicamentos Reumatológicos ............................................................ 105Medicamentos Obstétricos / Ginecología .......................................................................................................... 108Medicamentos para Oído, Nariz y Garganta ...................................................................................................... 115Medicamentos Respiratorios yAlergias ............................................................................................................. 117Oftalmología ...................................................................................................................................................... 123Urológicos .......................................................................................................................................................... 128Vitaminas, Hemáticos / Electrolitos................................................................................................................... 130Indice de Medicamentos .................................................................................................................................... 133Página 8 de 150

MedicamentoAnti-infectivosAgentes AntifungalesABELCET INTRAVENOUS SUSPENSION(amphotericin b lipid)5 MG/MLAMBISOME INTRAVENOUS SUSPENSIONRECONSTITUTED(amphotericin b liposome)50 MGamphotericin b injection solution reconstituted 50MGCANCIDAS INTRAVENOUS SOLUTIONRECONSTITUTED(caspofungin acetate)50 MG, 70 MGReferencia deMarcaNivel Requisitos /Límites5 PA5 PAAMPHOCIN 2 PAclotrimazole mouth/throat troche 10 MG MYCELEX 2ERAXIS INTRAVENOUS SOLUTIONRECONSTITUTED(anidulafungin)100 MGfluconazole oral suspension reconstituted 10MG/ML, 40 MG/MLDIFLUCAN 2fluconazole oral tablet 100 MG, 200 MG, 50 MG DIFLUCAN 15 PA3 PAfluconazole oral tablet 150 MG DIFLUCAN 2 QL (2 / 7 día(s))fluconazole in dextrose intravenous solution 400MG/200MLDIFLUCAN 2 PAflucytosine oral capsule 250 MG, 500 MG ANCOBON 5griseofulvin microsize oral suspension 125MG/5MLgriseofulvin ultramicrosize oral tablet 125 MG,250 MGGRIFULVIN 1GRIS-PEG 2itraconazole oral capsule 100 MG SPORANOX 2 QL (120 / 30 día(s))ketoconazole oral tablet 200 MG NIZORAL 1LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 9 de 150

MedicamentoMYCAMINE INTRAVENOUS SOLUTIONRECONSTITUTED(micafungin sodium)50 MGMYCAMINE INTRAVENOUS SOLUTIONRECONSTITUTED(micafungin sodium)100 MGNOXAFIL ORAL SUSPENSION(posaconazole)40 MG/MLnystatin mouth/throat suspension 100000UNIT/MLReferencia deMarcaMYCOSTATIN 2nystatin oral tablet 500000 UNIT MYCOSTATIN 1terbinafine hcl oral tablet 250 MG LAMISIL 1VFEND ORAL SUSPENSIONRECONSTITUTED(voriconazole)40 MG/MLvoriconazole intravenous solution reconstituted200 MGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 10 de 150Nivel Requisitos /Límites3 PA5 PA55VFEND 2voriconazole oral tablet 200 MG, 50 MG VFEND 5Agentes del Tracto Urinariomethenamine hippurate oral tablet 1 GM HIPREX 2MONUROL ORAL PACKET(fosfomycin tromethamine)3 GMPRIMSOL ORAL SOLUTION(trimethoprim hcl)50 MG/5MLtrimethoprim oral tablet 100 MG PROLOPRIM 1Antiviralesabacavir sulfate oral tablet 300 MG ZIAGEN 2 MT; CGacyclovir oral capsule 200 MG ZOVIRAX 2acyclovir oral suspension 200 MG/5ML ZOVIRAX 244

MedicamentoReferencia deMarcaacyclovir oral tablet 400 MG ZOVIRAX 2acyclovir oral tablet 800 MG ZOVIRAX 1acyclovir sodium intravenous solutionreconstituted 500 MGZOVIRAX 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 11 de 150Nivel Requisitos /Límitesamantadine hcl oral capsule 100 MG SYMMETREL 2 MTamantadine hcl oral syrup 50 MG/5ML SYMMETREL 2 MTamantadine hcl oral tablet 100 MG SYMMETREL 2 MTAPTIVUS ORAL CAPSULE(tipranavir)250 MGAPTIVUS ORAL SOLUTION(tipranavir)100 MG/MLATRIPLA ORAL TABLET(efavirenz-emtricitab-tenofovir)600-200-300 MGBARACLUDE ORAL SOLUTION(entecavir)0.05 MG/MLBARACLUDE ORAL TABLET(entecavir)0.5 MG, 1 MGCOMPLERA ORAL TABLET(emtricitab-rilpivir-tenofovir)200-25-300 MGCRIXIVAN ORAL CAPSULE(indinavir sulfate)200 MG, 400 MGdidanosine oral capsule delayed release 125 MG,200 MG, 250 MG, 400 MGEDURANT ORAL TABLET(rilpivirine hcl)25 MGEMTRIVA ORAL CAPSULE(emtricitabine)200 MG5 MT5 MT5 MT3 PA; MT5 PA; MT5 MT3 MTVIDEX EC 2 MT; CG5 MT3 MT

MedicamentoEMTRIVA ORAL SOLUTION(emtricitabine)10 MG/MLEPIVIR ORAL SOLUTION(lamivudine)10 MG/MLEPIVIR HBV ORAL SOLUTION(lamivudine)5 MG/MLEPIVIR HBV ORAL TABLET(lamivudine)100 MGEPZICOM ORAL TABLET(abacavir sulfate-lamivudine)600-300 MGReferencia deMarcaNivel Requisitos /Límites3 MT3 MT3 MT3 MT5 MTfamciclovir oral tablet 125 MG, 500 MG FAMVIR 2 QL (21 / 7 día(s))famciclovir oral tablet 250 MG FAMVIR 2 QL (60 / 30 día(s))foscarnet sodium intravenous solution 24 MG/ML FOSCAVIR 2FUZEON SUBCUTANEOUS SOLUTIONRECONSTITUTED(enfuvirtide)90 MGganciclovir sodium intravenous solutionreconstituted 500 MGHEPSERA ORAL TABLET(adefovir dipivoxil)10 MGINCIVEK ORAL TABLET(telaprevir)375 MGINTELENCE ORAL TABLET(etravirine)100 MG, 200 MGINVIRASE ORAL CAPSULE(saquinavir mesylate)200 MG5 MTCYTOVENE 2 PA5 PA; MT5 QL (168 / 28 día(s))5 MT3 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 12 de 150

MedicamentoINVIRASE ORAL TABLET(saquinavir mesylate)500 MGISENTRESS ORAL TABLET(raltegravir potassium)400 MGISENTRESS ORAL TABLET CHEWABLE(raltegravir potassium)100 MG, 25 MGKALETRA ORAL TABLET(lopinavir-ritonavir)100-25 MGKALETRA ORAL SOLUTION(lopinavir-ritonavir)400-100 MG/5MLKALETRA ORAL TABLET(lopinavir-ritonavir)200-50 MGReferencia deMarcaNivel Requisitos /Límites5 MT5 MT5 MT3 MT5 MT5 MTlamivudine oral tablet 150 MG, 300 MG EPIVIR 2 MT; CGlamivudine-zidovudine oral tablet 150-300 MG COMBIVIR 2 MT; CGLEXIVA ORAL SUSPENSION(fosamprenavir calcium)50 MG/MLLEXIVA ORAL TABLET(fosamprenavir calcium)700 MG3 MT5 MTnevirapine oral tablet 200 MG VIRAMUNE 2 MT; CGNORVIR ORAL CAPSULE(ritonavir)100 MGNORVIR ORAL SOLUTION(ritonavir)80 MG/MLNORVIR ORAL TABLET(ritonavir)100 MG3 MT3 MT3 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 13 de 150

MedicamentoPREZISTA ORAL SUSPENSION(darunavir ethanolate)100 MG/MLPREZISTA ORAL TABLET(darunavir ethanolate)150 MG, 75 MGPREZISTA ORAL TABLET(darunavir ethanolate)400 MG, 600 MG, 800 MGRELENZA DISKHALER INHALATIONAEROSOL POWDER, BREATH ACTIVATED(zanamivir)5 MG/BLISTERRESCRIPTOR ORAL TABLET(delavirdine mesylate)100 MG, 200 MGRETROVIR INTRAVENOUS SOLUTION(zidovudine)10 MG/MLREYATAZ ORAL CAPSULE(atazanavir sulfate)100 MGREYATAZ ORAL CAPSULE(atazanavir sulfate)150 MG, 200 MG, 300 MGRIBAPAK ORAL TABLET(ribavirin)400 & 600 MG, 400 MG, 600 MGribasphere oral capsule(ribavirin)200 MGribasphere oral tablet(ribavirin)200 MGribasphere oral tablet(ribavirin)400 MGReferencia deMarcaNivel Requisitos /Límites3 MT3 MT5 MT4 QL (60 / 180 día(s))3 MT33 MT5 MT5 PAREBETOL 2 PACOPEGUS 2 PARIBATAB 2 PALA - Esta receta puede estar sólo disponible en algunas farmacias.Página 14 de 150

Medicamentoribasphere oral tablet(ribavirin)600 MGReferencia deMarcaNivel Requisitos /LímitesRIBATAB 5 PArimantadine hcl oral tablet 100 MG FLUMADINE 2SELZENTRY ORAL TABLET(maraviroc)150 MG, 300 MGstavudine oral capsule 15 MG, 20 MG, 30 MG,40 MG5 MTZERIT 2 MT; CGstavudine oral solution reconstituted 1 MG/ML 2 MT; CGSTRIBILD ORAL TABLET(elviteg-cobicis-emtricit-tenof)150-150-200-300 MGSUSTIVA ORAL CAPSULE(efavirenz)200 MG, 50 MGSUSTIVA ORAL TABLET(efavirenz)600 MGTAMIFLU ORAL CAPSULE(oseltamivir phosphate)45 MGTAMIFLU ORAL CAPSULE(oseltamivir phosphate)75 MGTAMIFLU ORAL SUSPENSIONRECONSTITUTED(oseltamivir phosphate)6 MG/MLTAMIFLU ORAL CAPSULE(oseltamivir phosphate)30 MGTRIZIVIR ORAL TABLET(abacavir-lamivudine-zidovudine)300-150-300 MG5 MT3 MT3 MT3 QL (42 / 180 día(s))3 QL (56 / 365 día(s))3 QL (600 ML / 180día(s))3 QL (84 / 180 día(s))5 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 15 de 150

MedicamentoTRUVADA ORAL TABLET(emtricitabine-tenofovir)200-300 MGTYZEKA ORAL TABLET(telbivudine)600 MGReferencia deMarcaNivel Requisitos /Límites5 MT5 PA; MTvalacyclovir hcl oral tablet 1 GM, 500 MG VALTREX 2 QL (30 / 30 día(s))VALCYTE ORAL SOLUTIONRECONSTITUTED(valganciclovir hcl)50 MG/MLVALCYTE ORAL TABLET(valganciclovir hcl)450 MGVICTRELIS ORAL CAPSULE(boceprevir)200 MGVIDEX ORAL SOLUTION RECONSTITUTED(didanosine)2 GMVIRACEPT ORAL TABLET(nelfinavir mesylate)250 MG, 625 MGVIRAMUNE ORAL SUSPENSION(nevirapine)50 MG/5MLVIRAMUNE XR ORAL TABLET EXTENDEDRELEASE 24 HR(nevirapine er)100 MG, 400 MGVIREAD ORAL POWDER(tenofovir disoproxil fumarate)40 MG/GMVIREAD ORAL TABLET(tenofovir disoproxil fumarate)150 MG, 200 MG, 250 MG, 300 MG5553 MT5 MT3 MT3 MT5 MT5 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 16 de 150

MedicamentoZERIT ORAL SOLUTION RECONSTITUTED(stavudine)1 MG/MLZIAGEN ORAL SOLUTION(abacavir sulfate)20 MG/MLReferencia deMarcaNivel Requisitos /Límites3 MT3 MTzidovudine oral capsule 100 MG RETROVIR 2 MT; CGzidovudine oral syrup 50 MG/5ML RETROVIR 2 MT; CGzidovudine oral tablet 300 MG RETROVIR 2 MT; CGCefalosporinasCEDAX ORAL CAPSULE(ceftibuten)400 MGcefaclor oral capsule 250 MG, 500 MG CECLOR 2cefaclor er oral tablet extended release 12 hr 500MG4CECLOR CD 2cefadroxil oral capsule 500 MG DURICEF 1cefadroxil oral suspension reconstituted 250MG/5ML, 500 MG/5MLDURICEF 2cefadroxil oral tablet 1 GM DURICEF 2cefazolin sodium injection solution reconstituted1 GMKEFZOL 2cefdinir oral capsule 300 MG OMNICEF 2cefdinir oral suspension reconstituted 125MG/5ML, 250 MG/5MLcefepime hcl injection solution reconstituted 1GM, 2 GMcefoxitin sodium intravenous solutionreconstituted 1 GM, 2 GMcefpodoxime proxetil oral suspensionreconstituted 100 MG/5MLcefpodoxime proxetil oral suspensionreconstituted 50 MG/5MLOMNICEF 2MAXIPIME 2MEFOXIN 2 PAVANTIN 2VANTIN 1LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 17 de 150

Medicamentocefpodoxime proxetil oral tablet 100 MG, 200MGcefprozil oral suspension reconstituted 125MG/5ML, 250 MG/5MLReferencia deMarcaVANTIN 2CEFZIL 2cefprozil oral tablet 250 MG, 500 MG CEFZIL 2ceftriaxone sodium intravenous solutionreconstituted 1 GMceftriaxone sodium injection solutionreconstituted 250 MG, 500 MGROCEPHIN 2Nivel Requisitos /LímitesROCEPHIN 2 PAcefuroxime axetil oral tablet 250 MG, 500 MG KETAB 1cefuroxime sodium injection solutionreconstituted 7.5 GMcefuroxime sodium injection solutionreconstituted 1.5 GM, 750 MGZINACEF 2ZINACEF 2 PAcephalexin oral capsule 250 MG, 500 MG KEFLEX 1cephalexin oral suspension reconstituted 125MG/5ML, 250 MG/5MLKEFLEX 1cephalexin oral tablet 250 MG, 500 MG KEFLEX 1SUPRAX ORAL SUSPENSIONRECONSTITUTED(cefixime)100 MG/5ML, 200 MG/5ML, 500 MG/5MLSUPRAX ORAL TABLET CHEWABLE(cefixime)100 MG, 200 MGEritromicinas / Otros Macrólidosazithromycin intravenous solution reconstituted500 MGZITHROMAX 2azithromycin oral tablet 600 MG ZITHROMAX 2azithromycin oral suspension reconstituted 100MG/5ML33ZITHROMAX 2 QL (30 ML / 5 día(s))azithromycin oral tablet 500 MG ZITHROMAX 2 QL (4 / 4 día(s))azithromycin oral suspension reconstituted 200MG/5MLZITHROMAX 2 QL (68 ML / 5 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 18 de 150

MedicamentoReferencia deMarcaNivel Requisitos /Límitesazithromycin oral tablet 250 MG ZITHROMAX 2 QL (8 / 7 día(s))clarithromycin oral suspension reconstituted 125MG/5ML, 250 MG/5MLBIAXIN 2clarithromycin oral tablet 250 MG, 500 MG BIAXIN 2clarithromycin er oral tablet extended release 24hr 500 MGERYTHROCIN STEARATE ORAL TABLET(erythromycin stearate)250 MGBIAXIN XL 2erythromycin base oral tablet 250 MG ERYTHROCIN 1erythromycin base oral tablet 500 MG ERYTHROCIN 2erythromycin ethylsuccinate oral tablet 400 MG E.E.S. 2Misceláneos Anti-infectivosALBENZA ORAL TABLET(albendazole)200 MGALINIA ORAL SUSPENSIONRECONSTITUTED(nitazoxanide)100 MG/5MLALINIA ORAL TABLET(nitazoxanide)500 MGaztreonam injection solution reconstituted 1 GM AZACTAM 2bacitracin intramuscular solution reconstituted50000 UNITBILTRICIDE ORAL TABLET(praziquantel)600 MGCAPASTAT SULFATE INJECTIONSOLUTION RECONSTITUTED(capreomycin sulfate)1 GMchloramphenicol sod succinate intravenoussolution reconstituted 1 GMCHLOROMYCETIN 2 PA3133324LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 19 de 150

Medicamentochloroquine phosphate oral tablet 250 MG, 500MGReferencia deMarcaARALEN 2clindamycin hcl oral capsule 150 MG CLEOCIN 1clindamycin hcl oral capsule 300 MG, 75 MG CLEOCIN 2clindamycin phosphate intravenous solution 600MG/4MLcolistimethate sodium injection solutionreconstituted 150 MGCUBICIN INTRAVENOUS SOLUTIONRECONSTITUTED(daptomycin)500 MGNivel Requisitos /LímitesCLEOCIN 2 PACOLY-MYCIN 2 PAdapsone oral tablet 100 MG, 25 MG 3DARAPRIM ORAL TABLET(pyrimethamine)25 MG5 PAethambutol hcl oral tablet 100 MG, 400 MG MYAMBUTOL 2 CGgentamicin sulfate injection solution 40 MG/ML 2gentamicin sulfate intravenous solution 10MG/MLhydroxychloroquine sulfate oral tablet 200 MG PLAQUENIL 1INVANZ INJECTION SOLUTIONRECONSTITUTED(ertapenem sodium)1 GMisoniazid injection solution 100 MG/ML 2 CGisoniazid oral syrup 50 MG/5ML 2 CGisoniazid oral tablet 100 MG 2 CGisoniazid oral tablet 300 MG 1 CGKETEK ORAL TABLET(telithromycin)300 MG, 400 MG3234LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 20 de 150

MedicamentoMALARONE ORAL TABLET(atovaquone-proguanil hcl)250-100 MGMALARONE ORAL TABLET(atovaquone-proguanil hcl)62.5-25 MGReferencia deMarcamefloquine hcl oral tablet 250 MG LARIAM 2MEPRON ORAL SUSPENSION(atovaquone)750 MG/5MLmeropenem intravenous solution reconstituted500 MGNivel Requisitos /Límites235MERREM 2metronidazole oral tablet 250 MG, 500 MG FLAGYL 2metronidazole in nacl intravenous solution 500-0.79 MG/100ML-%MYCOBUTIN ORAL CAPSULE(rifabutin)150 MGNEBUPENT INHALATION SOLUTIONRECONSTITUTED(pentamidine isethionate)300 MGFLAGYL 2neomycin sulfate oral tablet 500 MG 2paromomycin sulfate oral capsule 250 MG 2PASER ORAL PACKET(aminosalicylic acid)4 GMPENTAM INJECTION SOLUTIONRECONSTITUTED(pentamidine isethionate)300 MG3333 PApolymyxin b sulfate injection solutionreconstituted 500000 UNIT2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 21 de 150

MedicamentoPRIFTIN ORAL TABLET(rifapentine)150 MGReferencia deMarcaprimaquine phosphate oral tablet 26.3 MG 3PRIMAXIN IV INTRAVENOUS SOLUTIONRECONSTITUTED(imipenem-cilastatin)250-250 MG, 500-500 MGpyrazinamide oral tablet 500 MG 2QUALAQUIN ORAL CAPSULE(quinine sulfate)324 MGrifampin intravenous solution reconstituted 600MGNivel Requisitos /LímitesRIFADIN 2 CGrifampin oral capsule 150 MG, 300 MG RIFADIN 2 CGSEROMYCIN ORAL CAPSULE(cycloserine)250 MGstreptomycin sulfate intramuscular solutionreconstituted 1 GMSTROMECTOL ORAL TABLET(ivermectin)3 MGSYNERCID INTRAVENOUS SOLUTIONRECONSTITUTED(quinupristin-dalfopristin)150-350 MGTOBI INHALATION NEBULIZATIONSOLUTION(tobramycin)300 MG/5MLtobramycin sulfate injection solution 10 MG/ML,80 MG/2MLTRECATOR ORAL TABLET(ethionamide)250 MG3243335 PA5 PA; QL (56 ML / 28día(s))2 PA3LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 22 de 150

MedicamentoTYGACIL INTRAVENOUS SOLUTIONRECONSTITUTED(tigecycline)50 MGXIFAXAN ORAL TABLET(rifaximin)200 MGZYVOX INTRAVENOUS SOLUTION(linezolid)2 MG/MLZYVOX ORAL SUSPENSIONRECONSTITUTED(linezolid)100 MG/5MLZYVOX ORAL TABLET(linezolid)600 MGPenicilinasReferencia deMarcaamoxicillin oral capsule 250 MG, 500 MG AMOXIL 1amoxicillin oral suspension reconstituted 125MG/5ML, 200 MG/5MLamoxicillin oral suspension reconstituted 250MG/5ML, 400 MG/5MLLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 23 de 150Nivel Requisitos /Límites3 PA4555AMOXIL 2AMOXIL 1amoxicillin oral tablet 500 MG AMOXIL 2amoxicillin oral tablet 875 MG AMOXIL 1amoxicillin oral tablet chewable 125 MG, 250MGamoxicillin-pot clavulanate oral suspensionreconstituted 200-28.5 MG/5ML, 250-62.5MG/5ML, 400-57 MG/5ML, 600-42.9 MG/5MLamoxicillin-pot clavulanate oral tablet 250-125MG, 500-125 MG, 875-125 MGamoxicillin-pot clavulanate oral tablet chewable200-28.5 MG, 400-57 MGamoxicillin-pot clavulanate er oral tabletextended release 12 hr 1000-62.5 MGAMOXIL 2AUGMENTIN 2AUGMENTIN 2AUGMENTIN 2AUGMENTIN XR 2

MedicamentoReferencia deMarcaampicillin oral capsule 250 MG, 500 MG 1ampicillin oral suspension reconstituted 125MG/5ML, 250 MG/5MLampicillin sodium intravenous solutionreconstituted 10 GMampicillin sodium injection solution reconstituted1 GM, 125 MGampicillin-sulbactam sodium injection solutionreconstituted 3 (2-1) GMampicillin-sulbactam sodium intravenous solutionreconstituted 15 (10-5) GMoxacillin sodium in dextrose intravenous1 GM/50MLBICILLIN C-R INTRAMUSCULARSUSPENSION(penicillin g benzathine & proc)1200000 UNIT/2MLBICILLIN C-R 900/300 INTRAMUSCULARSUSPENSION(penicillin g benzathine & proc)900000-300000 UNIT/2MLdicloxacillin sodium oral capsule 250 MG, 500MGMOXATAG ORAL TABLET EXTENDEDRELEASE 24 HR(amoxicillin er)775 MGnafcillin sodium injection solution reconstituted 1GMoxacillin sodium injection solution reconstituted 1GMpenicillin g potassium injection solutionreconstituted 5000000 UNITpenicillin g procaine intramuscular suspension600000 UNIT/MLNivel Requisitos /Límites212 PAUNASYN 2 PAUNASYN 2 PA133DYNAPEN 1NALLPEN 2 PA41PFIZERPEN 2PFIZERPEN 1LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 24 de 150

Medicamentopenicillin g sodium injection solutionreconstituted 5000000 UNITpenicillin v potassium oral solution reconstituted125 MG/5ML, 250 MG/5MLpenicillin v potassium oral tablet 250 MG, 500MGpiperacillin sod-tazobactam so intravenoussolution reconstituted 3-0.375 GM, 4-0.5 GMQuinolonasAVELOX ABC PACK ORAL TABLET(moxifloxacin hcl)400 MGCIPRO ORAL SUSPENSIONRECONSTITUTED(ciprofloxacin)250 MG/5ML (5%), 500 MG/5ML (10%)Referencia deMarcaPFIZERPEN 2PEN-V 1PEN-V 1ZOSYN 1ciprofloxacin intravenous solution 400 MG/40ML CIPRO I.V.. 2ciprofloxacin hcl oral tablet 100 MG, 250 MG,500 MG, 750 MGciprofloxacin in d5w intravenous solution 200MG/100MLciprofloxacin-ciproflox hcl er oral tablet extendedrelease 24 hr 1000 MG, 500 MGNivel Requisitos /Límites34CIPRO 1CIPRO I.V. 2CIPRO XR 2levofloxacin intravenous solution 25 MG/ML LEVAQUIN 2levofloxacin oral solution 25 MG/ML LEVAQUIN 2levofloxacin oral tablet 250 MG, 750 MG LEVAQUIN 2levofloxacin oral tablet 500 MG LEVAQUIN 1levofloxacin in d5w intravenous solution 500MG/100MLNOROXIN ORAL TABLET(norfloxacin)400 MGLEVAQUIN 2ofloxacin oral tablet 200 MG, 300 MG, 400 MG FLOXIN 2Sulfas y Agentes Relacionados4LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 25 de 150

MedicamentoReferencia deMarcasulfadiazine oral tablet 500 MG 2sulfamethoxazole-tmp ds oral tablet 800-160 MG BACTRIM 1sulfamethoxazole-trimethoprim intravenoussolution 400-80 MG/5MLsulfamethoxazole-trimethoprim oral suspension200-40 MG/5MLsulfamethoxazole-trimethoprim oral tablet 400-80MGTetraciclinasBACTRIM 2BACTRIM 1BACTRIM 1demeclocycline hcl oral tablet 150 MG, 300 MG DEMECLOCYN 2doxycycline hyclate intravenous solutionreconstituted 100 MGdoxycycline hyclate oral capsule 100 MG, 50 MG 1doxycycline hyclate oral tablet 100 MG 1doxycycline hyclate oral tablet 20 MG 2doxycycline hyclate oral tablet delayed release100 MG, 75 MGdoxycycline monohydrate oral suspensionreconstituted 25 MG/5MLdoxycycline monohydrate oral tablet 150 MG, 50MG, 75 MGminocycline hcl oral capsule 100 MG, 50 MG MINOCIN 1minocycline hcl oral capsule 75 MG MINOCIN 2minocycline hcl oral tablet 100 MG, 50 MG, 75MGminocycline hcl er oral tablet extended release 24hr 135 MG, 45 MG, 90 MGORACEA ORAL CAPSULE DELAYEDRELEASE(doxycycline (rosacea))40 MGVancomicinaNivel Requisitos /Límites2222MINOCIN 2MINOCIN 2vancomycin hcl oral capsule 125 MG, 250 MG VANCOCIN 54LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 26 de 150

Medicamentovancomycin hcl intravenous solutionreconstituted 1000 MGCardiovasculares, Hipertensión / LípidosAgentes AntiarrítmicosBETAPACE AF ORAL TABLET(sotalol hcl af)80 MGReferencia deMarcaNivel Requisitos /LímitesVANCOCIN 2 PA4 MTflecainide acetate oral tablet 100 MG, 50 MG TAMBOCOR 1 MT; CGflecainide acetate oral tablet 150 MG MEXITIL 2 MT; CGmexiletine hcl oral capsule 150 MG, 200 MG,250 MGMULTAQ ORAL TABLET(dronedarone hcl)400 MGPACERONE ORAL TABLET(amiodarone hcl)200 MGPACERONE ORAL TABLET(amiodarone hcl)100 MGPACERONE ORAL TABLET(amiodarone hcl)400 MGTAMBOCOR 2 MT; CG4 MT1 MT; CG2 MT; CG2 MT; CGprocainamide hcl injection solution 500 MG/ML 2 CGpropafenone hcl oral tablet 150 MG, 225 MG RYTHMOL 1 MT; CGpropafenone hcl oral tablet 300 MG RYTHMOL 2 MT; CGpropafenone hcl er oral capsule extended release12 hour 225 MG, 325 MG, 425 MGquinidine gluconate er oral tabletextendedrelease 324 MGRYTHMOL 2 MT; CG2 MT; CGquinidine sulfate oral tablet 200 MG, 300 MG 1 MT; CGquinidine sulfate er oral tablet extendedrelease300 MG2 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 27 de 150

MedicamentoSORINE ORAL TABLET(sotalol hcl)120 MGSORINE ORAL TABLET(sotalol hcl)160 MG, 80 MGSORINE ORAL TABLET(sotalol hcl)240 MGReferencia deMarcasotalol hcl intravenous solution 150 MG/10ML 4Nivel Requisitos /Límites2 MT; CG1 MT; CG2 MT; CGsotalol hcl (af) oral tablet 120 MG BETAPACE 1 MT; CGTIKOSYN ORAL CAPSULE(dofetilide)125 MCG, 250 MCG, 500 MCGGlicósidos Cardíacos3 MTdigoxin injection solution 0.25 MG/ML LANOXIN 2 CGdigoxin oral solution 0.05 MG/ML LANOXIN 2 MT; CGdigoxin oral tablet 0.125 MG, 0.25 MG LANOXIN 1 MT; CGLANOXIN ORAL TABLET(digoxin)0.125 MG, 0.25 MGLípidos / Agentes Reductores Del ColesterolADVICOR ORAL TABLET EXTENDEDRELEASE 24 HR(niacin-lovastatin er)500-20 MGADVICOR ORAL TABLET EXTENDEDRELEASE 24 HR(niacin-lovastatin er)1000-20 MG, 1000-40 MG, 750-20 MGALTOPREV ORAL TABLET EXTENDEDRELEASE 24 HR(lovastatin er)40 MG, 60 MG3 MT4 MT; QL (30 / 30día(s))4 MT; QL (60 / 30día(s))4 MT; QL (30 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 28 de 150

MedicamentoANTARA ORAL CAPSULE(fenofibrate micronized)130 MG, 43 MGatorvastatin calcium oral tablet 10 MG, 20 MG,40 MG, 80 MGReferencia deMarcaNivel Requisitos /Límites4 MTLIPITOR 2 MT; CG; QL (30 / 30día(s))cholestyramine light oral packet 4 GM QUESTRAN 2 MT; CGcolestipol hcl oral granules 5 GM COLESTID 2 MT; CGcolestipol hcl oral tablet 1 GM COLESTID 2 MT; CGCRESTOR ORAL TABLET(rosuvastatin calcium)10 MG, 20 MG, 40 MG, 5 MGfenofibrate oral tablet 145 MG, 160 MG, 48 MG,54 MGfenofibrate micronized oral capsule 134 MG, 200MG, 67 MGFENOGLIDE ORAL TABLET(fenofibrate)120 MG, 40 MG4 MT; QL (30 / 30día(s))TRICOR 2 MT; CGLOFIBRA 2 MT; CG4 MTfluvastatin sodium oral capsule 20 MG LESCOL 2 MT; CG; QL (30 / 30día(s))fluvastatin sodium oral capsule 40 MG LESCOL 2 MT; CG; QL (60 / 30día(s))gemfibrozil oral tablet 600 MG LOPID 1 MT; CGLIPOFEN ORAL CAPSULE(fenofibrate)50 MG4 MTlovastatin oral tablet 10 MG, 20 MG, 40 MG MEVACOR 1 MT; CGLOVAZA ORAL CAPSULE(omega-3-acid ethyl esters)1 GMNIASPAN ORAL TABLETEXTENDEDRELEASE(niacin er (antihyperlipidemic))1000 MG, 500 MG, 750 MG3 MT; QL (120 / 30día(s))3 QL (60 / 30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 29 de 150

Medicamentopravastatin sodium oral tablet 10 MG, 20 MG, 40MG, 80 MGprevalite oral powder(cholestyramine light)4 GM/DOSESIMCOR ORAL TABLET EXTENDEDRELEASE 24 HR(niacin-simvastatin er)500-20 MGSIMCOR ORAL TABLET EXTENDEDRELEASE 24 HR(niacin-simvastatin er)750-20 MGsimvastatin oral tablet 10 MG, 20 MG, 40 MG, 5MG, 80 MGVYTORIN ORAL TABLET(ezetimibe-simvastatin)10-10 MG, 10-20 MG, 10-40 MG, 10-80 MGWELCHOL ORAL PACKET(colesevelam hcl)3.75 GMWELCHOL ORAL TABLET(colesevelam hcl)625 MGZETIA ORAL TABLET(ezetimibe)10 MGAgentes Cardiovasculares MisceláneosRANEXA ORAL TABLET EXTENDEDRELEASE 12 HR(ranolazine er)1000 MG, 500 MGNitratosisosorbide dinitrate oral tablet 10 MG, 20 MG,30 MG, 5 MGisosorbide dinitrate sublingual tablet sublingual2.5 MGReferencia deMarcaNivel Requisitos /LímitesPRAVACHOLL 1 MT; CG; QL (30 / 30día(s))2 MT; CG4 MT; QL (30 / 30día(s))4 MT; QL (60 / 30día(s))ZOCOR 1 MT; CG; QL (30 / 30día(s))3 MT; QL (30 / 30día(s))3 MT3 MT3 MT; QL (30 / 30día(s))3 MT; QL (60 / 30día(s))ISORDIL 1 MT; CGISORDIL 1 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 30 de 150

Medicamentoisosorbide dinitrate er oral tablet extendedrelease40 MGisosorbide mononitrate oral tablet 10 MG, 20MGisosorbide mononitrate er oral tablet extendedrelease 24 hr 120 MG, 30 MG, 60 MGNITRO-BID TRANSDERMAL OINTMENT(nitroglycerin)2 %nitroglycerin transdermal patch 24 hr 0.1MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HRNITROSTAT SUBLINGUAL TABLETSUBLINGUAL(nitroglycerin)0.3 MG, 0.4 MG, 0.6 MGTratamiento AntihipertensivoReferencia deMarcaNivel Requisitos /LímitesDILATRATE-SR 2 MT; CGIMDUR 1 MT; CGIMDUR 1 MT; CG2 MT; CGMINITRAN 2 MT; CG3 MTacebutolol hcl oral capsule 200 MG, 400 MG SECTRAL 1 MT; CGafeditab cr oral tablet extended release 24 hr(nifedipine er)30 MG, 60 MGAFEDITAB CR ORAL TABLET EXTENDEDRELEASE 24 HR(nifedipine er)60 MG1 MT; CG2 MT; CGamiloride hcl oral tablet 5 MG MIDAMOR 2 MT; CGamiloride-hydrochlorothiazide oral tablet 5-50MGamlodipine besy-benazepril hcl oral capsule 10-20 MG, 10-40 MG, 2.5-10 MG, 5-10 MG, 5-20MG, 5-40 MGamlodipine besylate oral tablet 10 MG, 2.5 MG, 5MGATACAND ORAL TABLET(candesartan cilexetil)16 MG, 32 MG, 4 MG, 8 MGMODURETIC 1 MT; CGLOTREL 2 MT; CGNORVASC 1 MT; CG4 MT; QL (30 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 31 de 150

MedicamentoATACAND HCT ORAL TABLET(candesartan cilexetil-hctz)16-12.5 MG, 32-12.5 MG, 32-25 MGReferencia deMarcaNivel Requisitos /Límites4 MT; QL (30 / 30día(s))atenolol oral tablet 100 MG, 25 MG, 50 MG TENORMIN 1 MT; CGatenolol-chlorthalidone oral tablet 100-25 MG,50-25 MGAZOR ORAL TABLET(amlodipine-olmesartan)10-20 MG, 10-40 MG, 5-20 MG, 5-40 MGbenazepril hcl oral tablet 10 MG, 20 MG, 40 MG,5 MGbenazepril-hydrochlorothiazide oral tablet 10-12.5 MG, 20-12.5 MG, 20-25 MG, 5-6.25 MGBENICAR ORAL TABLET(olmesartan medoxomil)20 MG, 40 MG, 5 MGBENICAR HCT ORAL TABLET(olmesartan medoxomil-hctz)20-12.5 MG, 40-12.5 MG, 40-25 MGTENORETIC 1 MT; CG4 MTLOTENSIN 1 MT; CGLOTENSIN HCT 1 MT; CG4 MT; QL (30 / 30día(s))4 MT; QL (30 / 30día(s))betaxolol hcl oral tablet 10 MG, 20 MG KERLON 1 MT; CGbisoprolol fumarate oral tablet 10 MG, 5 MG ZEBETA 1 MT; CGbisoprolol-hydrochlorothiazide oral tablet 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MGZIAC 1 MT; CGbumetanide injection solution 0.25 MG/ML BUMEX 1 CGbumetanide oral tablet 0.5 MG, 1 MG, 2 MG BUMEX 1 MT; CGBYSTOLIC ORAL TABLET(nebivolol hcl)10 MG, 2.5 MG, 20 MG, 5 MGcaptopril oral tablet 100 MG, 12.5 MG, 25 MG,50 MGcaptopril-hydrochlorothiazide oral tablet 25-15MG, 25-25 MG, 50-15 MG, 50-25 MGcartia xt oral capsule extended release 24 hour(diltiazem hcl coated beads)120 MG, 240 MG, 300 MG4 MTCAPOTEN 1 MT; CGCAPOZIDE 1 MT; CGCARDIZEM 1 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 32 de 150

Medicamentocartia xt oral capsule extended release 24 hour(diltiazem hcl coated beads)180 MGcarvedilol oral tablet 12.5 MG, 25 MG, 3.125MG, 6.25 MGReferencia deMarcaLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 33 de 150Nivel Requisitos /LímitesCARDIZEM 1 MT; CGCOREG 1 MT; CGchlorothiazide oral tablet 250 MG, 500 MG 1 MT; CGchlorthalidone oral tablet 25 MG, 50 MG 1 MT; CGclonidine hcl oral tablet 0.1 MG, 0.2 MG, 0.3 MG CATAPRESS 1 MT; CGclorpres oral tablet(clonidine-chlorthalidone)0.1-15 MG, 0.2-15 MGCLORPRES ORAL TABLET(clonidine-chlorthalidone)0.3-15 MGCOREG CR ORAL CAPSULE EXTENDEDRELEASE 24 HOUR(carvedilol phosphate er)10 MG, 20 MG, 40 MG, 80 MGDEMSER ORAL CAPSULE(metyrosine)250 MGDIBENZYLINE ORAL CAPSULE(phenoxybenzamine hcl)10 MG2 MT; CG4 MT4 MTdiltiazem hcl intravenous solution 50 MG/10ML 1 CGdiltiazem hcl oral tablet 120 MG, 30 MG, 60 MG,90 MGdiltiazem hcl er oral capsule extended release 12hour 120 MG, 60 MG, 90 MGdiltiazem hcl er beads oral capsule extendedrelease 24 hour 420 MGdilt-xr oral capsule extended release 24 hour 180MG, 240 MGDIOVAN ORAL TABLET(valsartan)160 MG, 320 MG, 40 MG, 80 MGCARDIZEM 1 MT; CGCARDIZEM SR 1 MT; CGCARDIZEM CD 2 MT; CGDILACOR XR 1 MT; CG334 MT; QL (30 / 30día(s))

Medicamentodoxazosin mesylate oral tablet 1 MG, 2 MG, 4MG, 8 MGDYRENIUM ORAL CAPSULE(triamterene)50 MGEDECRIN ORAL TABLET(ethacrynic acid)25 MGenalapril maleate oral tablet 10 MG, 2.5 MG, 20MG, 5 MGenalapril-hydrochlorothiazide oral tablet 10-25MG, 5-12.5 MGReferencia deMarcaNivel Requisitos /LímitesCARDURA 1 MT; CG4 MT4 MTVASOTEC 1 MT; CGVASERETIC 1 MT; CGeplerenone oral tablet 25 MG, 50 MG INSPRA 2 MT; CGEXFORGE ORAL TABLET(amlodipine besylate-valsartan)10-160 MG, 10-320 MG, 5-160 MG, 5-320 MGEXFORGE HCT ORAL TABLET(amlodipine-valsartan-hctz)10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG,5-160-12.5 MG, 5-160-25 MGfelodipine er oral tablet extended release 24 hr10 MG, 2.5 MG, 5 MGfosinopril sodium oral tablet 10 MG, 20 MG, 40MGfosinopril sodium-hctz oral tablet 10-12.5 MG,20-12.5 MG4 MT4 MTPLENDIL 2 MT; CGMONOPRIL 1 MT; CGMONOPRIL HCT 1 MT; CGfurosemide injection solution 10 MG/ML LASIX 2 CGfurosemide oral solution 10 MG/ML, 8 MG/ML LASIX 1 MT; CGfurosemide oral tablet 20 MG, 40 MG, 80 MG LASIX 1 MT; CGguanfacine hcl oral tablet 1 MG, 2 MG 2 MThydralazine hcl injection solution 20 MG/ML 2 CGhydralazine hcl oral tablet 10 MG, 100 MG, 25MG, 50 MG1 CGhydrochlorothiazide oral capsule 12.5 MG 1 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 34 de 150

Medicamentohydrochlorothiazide oral tablet 12.5 MG, 25 MG,50 MGReferencia deMarcaNivel Requisitos /Límites1 MT; CGindapamide oral tablet 1.25 MG, 2.5 MG 1 MT; CGirbesartan oral tablet 150 MG, 300 MG, 75 MG AVAPRO 2 MT; CG; QL (30 / 30día(s))irbesartan-hydrochlorothiazide oral tablet 150-12.5 MG, 300-12.5 MGAVALIDE 2 MT; CG; QL (30 / 30día(s))isradipine oral capsule 2.5 MG, 5 MG DYNACIR 2 MT; CGlabetalol hcl intravenous solution 5 MG/ML TRANDATE 2 CGlabetalol hcl oral tablet 100 MG, 200 MG, 300MGLEVATOL ORAL TABLET(penbutolol sulfate)20 MGlisinopril oral tablet 10 MG, 2.5 MG, 20 MG, 30MG, 40 MG, 5 MGlisinopril-hydrochlorothiazide oral tablet 10-12.5MG, 20-12.5 MG, 20-25 MGlosartan potassium oral tablet 100 MG, 25 MG,50 MGlosartan potassium-hctz oral tablet 100-12.5 MG,100-25 MG, 50-12.5 MGmatzim la oral tablet extended release 24 hr(diltiazem hcl er coated beads)180 MG, 240 MG, 300 MG, 360 MG, 420 MGTRANDATE/NORMODYNEZESTRILPRINIVILZESTORETICPRINZIDE1 MT; CG4 MT1 MT; CG1 MT; CGCOZAAR 1 MT; CGHYZAAR 1 MT; CG2 MT; CGmethyclothiazide oral tablet 5 MG 1 MTmetolazone oral tablet 10 MG, 2.5 MG, 5 MG ZARAZOLYN 1 MT; CGmetoprolol succinate er oral tablet extendedrelease 24 hr 100 MG, 200 MG, 25 MG, 50 MGmetoprolol tartrate intravenous solution 1MG/MLmetoprolol tartrate oral tablet 100 MG, 25 MG,50 MGTOPROL XL 2 MT; CGLOPRESSOR 2 CGLOPRESSOR 1 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 35 de 150

Medicamentometoprolol-hydrochlorothiazide oral tablet 100-25 MG, 100-50 MG, 50-25 MGReferencia deMarcaNivel Requisitos /LímitesLOPRESSOR HCT 1 MT; CGminoxidil oral tablet 10 MG, 2.5 MG 1 CGmoexipril hcl oral tablet 15 MG, 7.5 MG UNIVASC 1 MT; CGmoexipril-hydrochlorothiazide oral tablet 15-12.5MG, 15-25 MG, 7.5-12.5 MGUNIRETIC 1 MT; CGnadolol oral tablet 20 MG, 40 MG, 80 MG CORGARD 1 MT; CGnadolol-bendroflumethiazide oral tablet 40-5MG, 80-5 MGCORZIDE 2 MT; CGnicardipine hcl oral capsule 20 MG CARDENE 1 MT; CGnicardipine hcl oral capsule 30 MG CARDENE 2 MT; CGnifediac cc oral tablet extended release 24 hr(nifedipine er)90 MGnifedical xl oral tablet extended release 24 hr(nifedipine er osmotic)30 MGnifedical xl oral tablet extended release 24 hr(nifedipine er osmotic)60 MGnifedipine er osmotic oral tablet extended release24 hr 90 MGADALAT CC 2 MT; CGPROCARDIA XL 1 MT; CGPROCARDIA XL 2 MT; CGPROCARDIA XL 2 MT; CGnimodipine oral capsule 30 MG NIMOTOP 2 MT; CGnisoldipine er oral tablet extended release 24 hr20 MG, 30 MG, 40 MGperindopril erbumine oral tablet 2 MG, 4 MG, 8MGSULAR 2 MT; CGACEON 2 MT; CGpindolol oral tablet 10 MG, 5 MG VISKEN 1 MT; CGprazosin hcl oral capsule 1 MG, 2 MG MINIPRESS 1 MT; CGprazosin hcl oral capsule 5 MG MINIPRESS 2 MT; CGpropranolol hcl intravenous solution 1 MG/ML INDERAL 2 CGpropranolol hcl oral solution 20 MG/5ML, 40MG/5MLINDERAL 2 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 36 de 150

Medicamentopropranolol hcl oral tablet 10 MG, 20 MG, 40MG, 80 MGReferencia deMarcaNivel Requisitos /LímitesINDERAL 1 MT; CGpropranolol hcl oral tablet 60 MG INDERAL 2 MT; CGpropranolol hcl er oral capsule extended release24 hour 120 MG, 160 MG, 80 MGpropranolol hcl er oral capsule extended release24 hour 60 MGpropranolol-hctz oral tablet 40-25 MG, 80-25MGquinapril hcl oral tablet 10 MG, 20 MG, 40 MG,5 MGquinapril-hydrochlorothiazide oral tablet 10-12.5MG, 20-12.5 MG, 20-25 MGramipril oral capsule 1.25 MG, 10 MG, 2.5 MG,5 MGREMODULIN INJECTION SOLUTION(treprostinil sodium)1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/MLINDERAL LA 2 MT; CGINDERAL LA 1 MT; CGINDERIDE 1 MT; CGACCUPRIL 1 MT; CGACCURETIC 1 MT; CGALTACE 1 MT; CG5 LAspironolactone oral tablet 100 MG ALDACTONE 2 MT; CGspironolactone oral tablet 25 MG, 50 MG ALDACTONE 1 MT; CGspironolactone-hctz oral tablet 25-25 MG ALDACTONE 1 MT; CGtaztia xt oral capsule extended release 24 hour(diltiazem hcl er beads)120 MG, 240 MG, 300 MGtaztia xt oral capsule extended release 24 hour(diltiazem hcl er beads)180 MG, 360 MGTEKTURNA ORAL TABLET(aliskiren fumarate)150 MG, 300 MGTEKTURNA HCT ORAL TABLET(aliskiren-hydrochlorothiazide)150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25MGTIAZAC 1 MT; CGTIAZAC 1 MT; CG4 MT; QL (30 / 30día(s))4 MT; QL (30 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 37 de 150

Medicamentoterazosin hcl oral capsule 1 MG, 10 MG, 2 MG, 5MGTEVETEN ORAL TABLET(eprosartan mesylate)400 MG, 600 MGTEVETEN HCT ORAL TABLET(eprosartan mesylate-hctz)600-12.5 MG, 600-25 MGReferencia deMarcaNivel Requisitos /LímitesHYTRIN 1 MT; CG4 MT; QL (30 / 30día(s))4 MT; QL (30 / 30día(s))timolol maleate oral tablet 10 MG, 20 MG, 5 MG BLOCADREN 2 MT; CGtorsemide oral tablet 10 MG, 20 MG, 5 MG DEMADEX 1 MT; CGtorsemide oral tablet 100 MG DEMADEX 2 MT; CGtrandolapril oral tablet 1 MG, 2 MG, 4 MG MAVIK 1 MT; CGtriamterene-hctz oral capsule 37.5-25 MG DYAZIDE 1 MT; CGtriamterene-hctz oral tablet 37.5-25 MG, 75-50MGTWYNSTA ORAL TABLET(telmisartan-amlodipine)40-10 MG, 40-5 MG, 80-10 MG, 80-5 MGvalsartan-hydrochlorothiazide oral tablet 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG,80-12.5 MGverapamil hcl oral tablet 120 MG, 40 MG, 80MGverapamil hcl er oral capsule extended release 24hour 360 MGverapamil hcl er oral capsule extended release 24hour 100 MG, 200 MG, 240 MG, 300 MGverapamil hcl er oral capsule extended release 24hour 120 MG, 180 MGverapamil hcl er oral tablet extendedrelease 120MG, 180 MG, 240 MGMAXZIDE 1 MT; CG4 MTDIOVAN HCT 2 MT; CG; QL (30 / 30día(s))CALAN 1 MT; CGVERELAN 2 MTVERELAN 2 MT; CGVERELAN 1 MT; CGCALAN SR 1 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 38 de 150

MedicamentoTratamiento para La CoagulaciónAGGRENOX ORAL CAPSULE EXTENDEDRELEASE 12 HOUR(aspirin-dipyridamole er)25-200 MGReferencia deMarcaNivel Requisitos /Límites3 MTcilostazol oral tablet 100 MG PLETAL 2 MT; CGcilostazol oral tablet 50 MG PLETAL 1 MT; CGclopidogrel bisulfate oral tablet 300 MG PLAVIX 2 CGclopidogrel bisulfate oral tablet 75 MG PLAVIX 2 MT; CGCOUMADIN ORAL TABLET(warfarin sodium)1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5MG, 6 MG, 7.5 MGCYKLOKAPRON INTRAVENOUSSOLUTION(tranexamic acid)100 MG/MLEFFIENT ORAL TABLET(prasugrel hcl)10 MG, 5 MGenoxaparin sodium subcutaneous solution 40MG/0.4MLenoxaparin sodium subcutaneous solution 60MG/0.6MLenoxaparin sodium subcutaneous solution 120MG/0.8MLenoxaparin sodium subcutaneous solution 80MG/0.8MLenoxaparin sodium injection solution 300MG/3MLenoxaparin sodium subcutaneous solution 100MG/MLenoxaparin sodium subcutaneous solution 150MG/ML3 MT24 MTLOVENOX 2 QL (11.2 ML / 30día(s))LOVENOX 2 QL (16.8 ML / 30día(s))LOVENOX 5 QL (22.4 ML / 30día(s))LOVENOX 2 QL (22.4 ML / 30día(s))LOVENOX 2 QL (28 ML / 30 día(s))LOVENOX 2 QL (28 ML / 30 día(s))LOVENOX 5 QL (28 ML / 30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 39 de 150

Medicamentoenoxaparin sodium subcutaneous solution 30MG/0.3MLfondaparinux sodium subcutaneous solution 5MG/0.4MLfondaparinux sodium subcutaneous solution 2.5MG/0.5MLfondaparinux sodium subcutaneous solution 7.5MG/0.6MLfondaparinux sodium subcutaneous solution 10MG/0.8MLheparin (porcine) in d5w intravenous solution 40-5 UNIT/ML-%heparin (porcine) in nacl injection solution 100-0.45 UNIT/ML-%, 2-0.9 UNIT/ML-%, 50-0.45UNIT/ML-%heparin sodium (porcine) injection solution 1000UNIT/ML, 10000 UNIT/ML, 20000 UNIT/ML,5000 UNIT/MLjantoven oral tablet(warfarin sodium)1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5MG, 6 MG, 7.5 MGpentoxifylline er oral tablet extendedrelease 400MGPRADAXA ORAL CAPSULE(dabigatran etexilate mesylate)150 MG, 75 MGPROMACTA ORAL TABLET(eltrombopag olamine)12.5 MG, 25 MG, 50 MG, 75 MGtranexamic acid intravenous solution 100MG/MLwarfarin sodium tablet 1 MG, 10 MG, 2 MG, 2.5MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MGReferencia deMarcaNivel Requisitos /LímitesLOVENOX 2 QL (8.4 ML / 30día(s))ARIXTRA 5 QL (12 ML / 30 día(s))ARIXTRA 2 QL (15 ML / 30 día(s))ARIXTRA 5 QL (18 ML / 30 día(s))ARIXTRA 5 QL (24 ML / 30 día(s))2 PA2 PA2 PACOUMADIN 1 MT; CGTRENTAL 1 MT; CGCYKLOKAPRON 23 MT5 LACOUMADIN 1 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 40 de 150

MedicamentoXARELTO ORAL TABLET(rivaroxaban)10 MG, 15 MG, 20 MGDermatológicos / Tratamiento TópicoAnestésicos TópicosReferencia deMarcalidocaine external ointment 5 % XYLOCAINE 2lidocaine hcl external gel 2 % 1lidocaine hcl external solution 4 % 2lidocaine hcl (pf) injection solution 0.5 % 2lidocaine hcl (pf) injection solution 1 % 1lidocaine viscous mouth/throat solution 2 % 1lidocaine-prilocaine external cream 2.5-2.5 % EMLA 2LIDODERM EXTERNAL PATCH(lidocaine)5 %SYNERA EXTERNAL PATCH(lidocaine-tetracaine)70-70 MGAntibacteriales TópicosALTABAX EXTERNAL OINTMENT(retapamulin)1 %BACTROBAN EXTERNAL OINTMENT(mupirocin)2 %BACTROBAN EXTERNAL CREAM(mupirocin calcium)2 %gentamicin sulfate external cream 0.1 % 1gentamicin sulfate external ointment 0.1 % 1PHISOHEX EXTERNAL LIQUID†(hexachlorophene)3 %sulfacetamide sodium external suspension 10 % SILVADENE 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 41 de 150Nivel Requisitos /Límites3 MT344124

MedicamentoSULFAMYLON EXTERNAL CREAM(mafenide acetate)85 MG/GMSULFAMYLON EXTERNAL PACKET(mafenide acetate)5 %Antifungales TópicosReferencia deMarcaciclopirox external gel 0.77 % LOPROX 2ciclopirox external solution 8 % PENLAC 1ciclopirox olamine external cream 0.77 % LOPROX 2ciclopirox olamine external suspension 0.77 % LOPROX 2clotrimazole external cream 1 % MYCELEX 2clotrimazole external solution 1 % MYCELEX 1clotrimazole-betamethasone external cream 1-0.05 %LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 42 de 150Nivel Requisitos /Límites44LOTRISONE 1econazole nitrate external cream 1 % SPECTAZOLE 2EXELDERM EXTERNAL CREAM(sulconazole nitrate)1 %EXTINA EXTERNAL FOAM(ketoconazole)2 %ketoconazole external cream 2 % NIZORAL 2ketoconazole external shampoo 2 % NIZORAL 2MENTAX EXTERNAL CREAM(butenafine hcl)1 %nyamyc external powder(nystatin)100000 UNIT/GMnystatin external cream 100000 UNIT/GM MYCOSTATIN 2nystatin external ointment 100000 UNIT/GM MYCOSTATIN 1nystatin-triamcinolone external cream 100000-0.1 UNIT/GM-%MYCOLOG 24442

Medicamentonystatin-triamcinolone external ointment 100000-0.1 UNIT/GM-%NYSTOP EXTERNAL POWDER(nystatin)100000 UNIT/GMOXISTAT EXTERNAL CREAM(oxiconazole nitrate)1 %OXISTAT EXTERNAL LOTION(oxiconazole nitrate)1 %Antipsoriasis/ AntiseborreicaReferencia deMarcaMYCOLOG 2calcipotriene external cream 0.005 % DOVONEX 2calcipotriene external ointment 0.005 % DOVONEX 2calcipotriene external solution 0.005 % DOVONEX 2selenium sulfide external lotion 2.5 % TERSI FOAM 1SORIATANE ORAL CAPSULE(acitretin)10 MG, 17.5 MG, 25 MGSTELARA SUBCUTANEOUS SOLUTION(ustekinumab)45 MG/0.5ML, 90 MG/MLTACLONEX EXTERNAL OINTMENT(calcipotriene-betameth diprop)0.005-0.064 %TACLONEX EXTERNAL SUSPENSION(calcipotriene-betameth diprop)0.005-0.064 %VECTICAL EXTERNAL OINTMENT(calcitriol)3 MCG/GMCorticoesteroides TópicosALA SCALP EXTERNAL LOTION(hydrocortisone)2 %Nivel Requisitos /Límites24455 PA4434LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 43 de 150

Medicamentoalclometasone dipropionate external cream 0.05%alclometasone dipropionate external ointment0.05 %Referencia deMarcaACLOVATE 2ACLOVATE 2amcinonide external cream 0.1 % CYCLOCORT 2amcinonide external lotion 0.1 % CYCLOCORT 2amcinonide external ointment 0.1 % CYCLOCORT 2betamethasone dipropionate external cream 0.05%betamethasone dipropionate external lotion 0.05%betamethasone dipropionate external ointment0.05 %betamethasone dipropionate aug external cream0.05 %betamethasone dipropionate aug external lotion0.05 %betamethasone dipropionate aug externalointment 0.05 %DIPROLENE 2DIPROLENE 2DIPROLENE 2betamethasone valerate external cream 0.1 % 2betamethasone valerate external lotion 0.1 % 2betamethasone valerate external ointment 0.1 % 2CAPEX EXTERNAL SHAMPOO(fluocinolone acetonide)0.01 %clobetasol propionate external gel 0.05 % TEMOVATE 2clobetasol propionate external ointment 0.05 % 2clobetasol propionate external solution 0.05 % 2clobetasol propionate e external cream 0.05 % 2CLOBEX EXTERNAL LOTION(clobetasol propionate)0.05 %Nivel Requisitos /Límites22244LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 44 de 150

MedicamentoCLOBEX EXTERNAL SHAMPOO(clobetasol propionate)0.05 %CLOBEX SPRAY EXTERNAL LIQUID†(clobetasol propionate)0.05 %CLODERM PUMP EXTERNAL CREAM(clocortolone pivalate)0.1 %CORDRAN EXTERNAL TAPE(flurandrenolide)4 MCG/SQCMReferencia deMarcadesonide external cream 0.05 % DESOWEN 2desonide external lotion 0.05 % 2desonide external ointment 0.05 % 2desoximetasone external cream 0.05 %, 0.25 % TOPICORT 2desoximetasone external gel 0.05 % TOPICORT 2desoximetasone external ointment 0.25 % TOPICORT 2diflorasone diacetate external cream 0.05 % PSORCON 2diflorasone diacetate external ointment 0.05 % PSORCON 2fluocinolone acetonide external cream 0.01 %,0.025 %Nivel Requisitos /Límites4444SYNARAL 2fluocinolone acetonide external ointment 0.025 % SYNARAL 2fluocinolone acetonide external solution 0.01 % 2fluocinonide external gel 0.05 % LIDEX 2fluocinonide external ointment 0.05 % LIDEX 2fluocinonide external solution 0.05 % LIDEX 2fluocinonide-e external cream 0.05 % LIDEX-E 2fluticasone propionate external cream 0.05 % CUTIVATE 2fluticasone propionate external lotion 0.05 % CUTIVATE 2fluticasone propionate external ointment 0.005 % CUTIVATE 2halobetasol propionate external cream 0.05 % ULTRAVATE 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 45 de 150

MedicamentoReferencia deMarcahalobetasol propionate external ointment 0.05 % ULTRAVATE 2HALOG EXTERNAL CREAM(halcinonide)0.1 %HALOG EXTERNAL OINTMENT(halcinonide)0.1 %hydrocortisone external cream 1 %, 2.5 % ALACORT 1hydrocortisone external lotion 2.5 % ALACORT 2hydrocortisone external ointment 1 %, 2.5 % ALACORT 1hydrocortisone valerate external cream 0.2 % WESTCORT 2hydrocortisone valerate external ointment 0.2 % WESTCORT 2KENALOG EXTERNAL AEROSOL,SOLUTION(triamcinolone acetonide)LUXIQ EXTERNAL FOAM(betamethasone valerate)0.12 %mometasone furoate external cream 0.1 % ELOCON 2mometasone furoate external ointment 0.1 % ELOCON 2mometasone furoate external solution 0.1 % ELOCON 2OLUX-E EXTERNAL FOAM(clobetasol propionate emulsion)0.05 %prednicarbate external cream 0.1 % DERMATAP 2prednicarbate external ointment 0.1 % DERMATAP 2triamcinolone acetonide external cream 0.025 % 1triamcinolone acetonide external cream 0.5 % 2triamcinolone acetonide external lotion 0.025 %,0.1 %triamcinolone acetonide external ointment 0.025%Nivel Requisitos /Límites4444421LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 46 de 150

Medicamentotriamcinolone acetonide external ointment 0.1 %,0.5 %triderm external cream(triamcinolone acetonide)%VANOS EXTERNAL CREAM(fluocinonide)0.1 %VERDESO EXTERNAL FOAM(desonide)0.05 %Enzimas TópicosSANTYL EXTERNAL OINTMENT(collagenase)250 UNIT/GMEscabicidas Tópicos / PediculicidasReferencia deMarcalindane external lotion 1 % 2lindane external shampoo 1 % 2permethrin external cream 5 % ELIMITE 2ULESFIA EXTERNAL LOTION(benzyl alcohol)5 %Dermatológicos Misceláneos8-MOP ORAL CAPSULE(methoxsalen)10 MGammonium lactate external cream 12 % LAC-HYDRIN 1ammonium lactate external lotion 12 % LAC-HYDRIN 1CARAC EXTERNAL CREAM(fluorouracil)0.5 %ELIDEL EXTERNAL CREAM(pimecrolimus)1 %fluorouracil external cream 5 % EFUDEX 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 47 de 150Nivel Requisitos /Límites2244343 PA43

MedicamentoReferencia deMarcafluorouracil external solution 2 %, 5 % EFUDEX 2imiquimod external cream 5 % ALDARA 2OXSORALEN ULTRA ORAL CAPSULE(methoxsalen rapid)10 MGPANRETIN EXTERNAL GEL(alitretinoin)0.1 %podofilox external solution 0.5 % CONDYLOX 2PROTOPIC EXTERNAL OINTMENT(tacrolimus)0.03 %, 0.1 %SOLARAZE TRANSDERMAL GEL(diclofenac sodium)3 %U-CORT EXTERNAL CREAM(urea-hc acetate)1-10 %VEREGEN EXTERNAL OINTMENT(sinecatechins)15 %ZONALON EXTERNAL CREAM(doxepin hcl (antipruritic))5 %Tratamiento para AcnéACANYA EXTERNAL GEL(clindamycin phos-benzoyl perox)1.2-2.5 %adapalene external cream 0.1 % DIFFERIN 2adapalene external gel 0.1 % DIFFERIN 2AMNESTEEM ORAL CAPSULE(isotretinoin)10 MG, 20 MG, 40 MGAZELEX EXTERNAL CREAM(azelaic acid)20 %LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 48 de 150Nivel Requisitos /Límites5 PA5 PA33443424

Medicamentobenzoyl peroxide-erythromycin external gel 5-3%CLARAVIS ORAL CAPSULE(isotretinoin)10 MG, 20 MG, 30 MG, 40 MGReferencia deMarcaBENZAMYCIN 2clindamycin phosphate external foam 1 % CLEOCIN 2clindamycin phosphate external gel 1 % CLEOCIN 2clindamycin phosphate external lotion 1 % CLEOCIN 2clindamycin phosphate external solution 1 % CLEOCIN 1clindamycin phosphate external swab 1 % CLEOCIN 2ery external pad 2 % ERYCETTE 2erythromycin external gel 2 % 2erythromycin external solution 2 % 2FINACEA EXTERNAL GEL(azelaic acid)15 %METROGEL EXTERNAL GEL(metronidazole)1 %metronidazole external cream 0.75 % METROCREAM 2metronidazole external gel 0.75 % METROGEL 2metronidazole external lotion 0.75 % METROLOTION 2TAZORAC EXTERNAL GEL(tazarotene)0.05 %, 0.1 %tretinoin external cream 0.025 %, 0.05 %, 0.1 % RETIN-A 2tretinoin external gel 0.01 %, 0.025 % RETIN-A 2ZIANA EXTERNAL GEL(clindamycin-tretinoin)1.2-0.025 %Nivel Requisitos /Límites24434LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 49 de 150

MedicamentoTratamiento para Quemadurasssd external cream(silver sulfadiazine)1 %Diagnósticos /Agentes MisceláneosAgentes MiscelaneosACTONEL ORAL TABLET(risedronate sodium)30 MGADAGEN INTRAMUSCULAR SOLUTION(pegademase bovine)250 UNIT/MLReferencia deMarcaSILVADENE 2Nivel Requisitos /Límites4 QL (30 / 30 día(s))5 PAalendronate sodium oral tablet 40 MG FOSAMAX 2 CG; QL (30 / 30día(s))anagrelide hcl oral capsule 0.5 MG AGRYLIN 1 MT; CGanagrelide hcl oral capsule 1 MG AGRYLIN 2 MT; CGANTABUSE ORAL TABLET(disulfiram)250 MG, 500 MGARALAST NP INTRAVENOUS SOLUTIONRECONSTITUTED(alpha1-proteinase inhibitor)400 MGBUPHENYL ORAL TABLET(sodium phenylbutyrate)500 MGCHEMET ORAL CAPSULE(succimer)100 MG35 LA5 PAdextrose intravenous solution 10 % 2 PAdextrose intravenous solution 5 % 1 PAdextrose in lactated ringers intravenous solution5 %dextrose-nacl intravenous solution 10-0.45 %, 5-0.33 %322LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 50 de 150

Medicamentodextrose-nacl intravenous solution 10-0.2 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.45 %, 5-0.9 %Referencia deMarcaNivel Requisitos /Límites2 PAdisulfiram oral tablet 250 MG, 500 MG ANTABUSE 2 CGetidronate disodium oral tablet 200 MG, 400 MG DIDRONEL 2 CGEVOXAC ORAL CAPSULE(cevimeline hcl)30 MGEXJADE ORAL TABLET SOLUBLE(deferasirox)125 MGEXJADE ORAL TABLET SOLUBLE(deferasirox)250 MG, 500 MGFOSRENOL ORAL TABLET CHEWABLE(lanthanum carbonate)1000 MG, 500 MG, 750 MGINCRELEX SUBCUTANEOUS SOLUTION(mecasermin)40 MG/4MLKAYEXALATE ORAL POWDER(sodium polystyrene sulfonate)43 PA; LA5 PA; LA45 PA; LA3levocarnitine oral solution 1 GM/10ML CARNITOR 2 PA; CGlevocarnitine oral tablet 330 MG CARNITOR 2 PA; CGmidodrine hcl oral tablet 10 MG, 2.5 MG, 5 MG CATNITOR 2 CGORFADIN ORAL CAPSULE(nitisinone)10 MG, 2 MG, 5 MGpilocarpine hcl oral tablet 5 MG, 7.5 MG SALAGEN 2RECLAST INTRAVENOUS SOLUTION(zoledronic acid)5 MG/100MLRENAGEL ORAL TABLET(sevelamer hcl)400 MG, 800 MG5 PA; LA2 PA4LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 51 de 150

MedicamentoRILUTEK ORAL TABLET(riluzole)50 MGSKELID ORAL TABLET(tiludronate disodium)200 MGReferencia deMarcasodium chloride intravenous solution 0.9 % 1sodium chloride irrigation solution 0.9 % 1Nivel Requisitos /Límites5 PAsodium phenylbutyrate oral powder 5 PAsodium polystyrene sulfonate oral suspension 15GM/60MLsterile water for irrigation irrigation solution 1SYPRINE ORAL CAPSULE(trientine hcl)250 MGProductos para dejar de Fumarbuproban oral tablet extended release 12 hr(bupropion hcl er (smoking det))150 mgCHANTIX ORAL TABLET(varenicline tartrate)0.5 MG, 1 MGCHANTIX STARTING MONTH PAK ORALTABLET(varenicline tartrate)0.5 MG X 11 & 1 MG X 42NICOTROL INHALATION INHALER(nicotine)10 MGNICOTROL NS NASAL SOLUTION(nicotine)10 MG/MLSoluciones Irrigantes42 CGZYBAN 2 CGlactated ringers irrigation solution 1 PA33335LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 52 de 150

Medicamentoneomycin-polymyxin b gu irrigation solution 40-200000Referencia deMarcaLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 53 de 150Nivel Requisitos /Límitesringers irrigation irrigation solution 1 PAGastroenterologíaAntidiarreicos / Antiespasmódicosdiphenoxylate-atropine oral liquid† 2.5-0.025MG/5MLdiphenoxylate-atropine oral tablet 2.5-0.025 MG LOMOTIL 2glycopyrrolate injection solution 4 MG/20ML ROBINUL 2glycopyrrolate oral tablet 1 MG, 2 MG ROBINUL FORTE 2loperamide hcl oral capsule 2 MG IMODIUM 1methscopolamine bromide oral tablet 2.5 MG PAMIDE 2MOTOFEN ORAL TABLET(difenoxin-atropine)1-0.025 MGAgentes Gastrointestinales MisceláneosAMITIZA ORAL CAPSULE(lubiprostone)24 MCG, 8 MCGANZEMET ORAL TABLET(dolasetron mesylate)100 MG, 50 MGAPRISO ORAL CAPSULE EXTENDEDRELEASE 24 HOUR(mesalamine er)0.375 GMASACOL ORAL TABLET DELAYEDRELEASE(mesalamine)400 MGASACOL HD ORAL TABLET DELAYEDRELEASE(mesalamine)800 MGbalsalazide disodium oral capsule 750 MG COLOZAL 222434 PA; QL (1 / 1 día(s))4 MT3 MT; QL (180 / 30día(s))4

Medicamentobudesonide er oral capsule extended release 24hour 3 MGCANASA RE SUPPOSITORY(mesalamine)1000 MGcompro re suppository(prochlorperazine)25 mgReferencia deMarcaENTOCORT EC 5constulose oral solution 10 GM/15ML GENERALAC 1CREON ORAL CAPSULE DELAYEDRELEASE PARTICLES(pancrelipase (lip-prot-amyl))12000 UNIT, 24000 UNIT, 3000-9500 UNIT,36000 UNIT, 6000 UNITLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 54 de 150Nivel Requisitos /Límites323 MTcromolyn sodium oral concentrate 100 MG/5ML GASTROCROM 2 CGCYSTADANE ORAL POWDER(betaine)DELZICOL ORAL CAPSULE DELAYEDRELEASE(mesalamine)400 MGDIPENTUM ORAL CAPSULE(olsalazine sodium)250 MG33 MT; QL (180 / 30día(s))3 MTdronabinol oral capsule 2.5 MG, 5 MG MARINOL 2 PAdronabinol oral capsule 10 MG MARINOL 5 PA; QL (60 / 30día(s))EMEND ORAL CAPSULE(aprepitant)125 MG, 40 MGEMEND ORAL CAPSULE(aprepitant)80 MGEMEND ORAL CAPSULE(aprepitant)80 & 125 MG3 PA; QL (1 / 1 día(s))3 PA; QL (2 / 2 día(s))3 PA; QL (3 / 3 día(s))

MedicamentoReferencia deMarcaenulose oral solution 10 GM/15ML GENERALAC 2GASTROCROM ORAL CONCENTRATE(cromolyn sodium)100 MG/5MLGAVILYTE-C ORAL SOLUTIONRECONSTITUTED(peg 3350-kcl-nabcb-nacl-nasulf)240 GMCOLYTE WITHFLAVOR PACKETSLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 55 de 150Nivel Requisitos /Límitesgranisetron hcl oral tablet 1 MG GRANISOL 2 PA; QL (2 / 1 día(s))hydrocortisone re enema 100 MG/60ML 2lactulose oral solution 10 GM/15ML 1LIALDA ORAL TABLET DELAYEDRELEASE(mesalamine)1.2 GMLOTRONEX ORAL TABLET(alosetron hcl)0.5 MG, 1 MGmeclizine hcl oral tablet 12.5 MG, 25 MG ANTIVERT 23145 PA; MTmesalamine-cleanser re kit 4 GM ROWASA 2 CGmetoclopramide hcl injection solution 5 MG/ML REGLAN 1metoclopramide hcl oral solution 5 MG/5ML REGLAN 1metoclopramide hcl oral tablet 10 MG, 5 MG REGLAN 1METOZOLV ODT ORAL TABLETDISPERSIBLE(metoclopramide hcl)10 MG, 5 MGondansetron oral tablet dispersible 4 MG, 8 MG ZOFRAN 2 PA; QL (12 / 5 día(s))ondansetron hcl injection solution 40 MG/20ML ZOFRAN 2ondansetron hcl oral tablet 24 MG ZOFRAN 2 PA; QL (1 / 1 día(s))ondansetron hcl oral tablet 4 MG ZOFRAN 2 PA; QL (12 / 5 día(s))ondansetron hcl oral tablet 8 MG ZOFRAN 1 PA; QL (12 / 5 día(s))ondansetron hcl oral solution 4 MG/5ML ZOFRAN 2 PA; QL (150 ML / 5día(s))4

MedicamentoOSMOPREP ORAL TABLET(sod phos mono-sod phos dibasic)1.102-0.398 GMPENTASA ORAL CAPSULE EXTENDEDRELEASE(mesalamine er)250 MGPENTASA ORAL CAPSULE EXTENDEDRELEASE(mesalamine er)500 MGReferencia deMarcapolyethylene glycol 3350 oral powder 2prochlorperazine edisylate injection solution 5MG/MLprochlorperazine maleate oral tablet 10 MG, 5MGproctozone-hc re cream(hydrocortisone)2.5 %RELISTOR SUBCUTANEOUS KIT(methylnaltrexone bromide)12 MG/0.6MLREMICADE INTRAVENOUS SOLUTIONRECONSTITUTED(infliximab)100 MGANUSOL-HCLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 56 de 150Nivel Requisitos /Límites33 MT; QL (120 / 30día(s))3 MT; QL (240 / 30día(s))21 MT35 PAsulfasalazine oral tablet 500 MG AZULFIDINE 1 MTsulfazine ec oral tablet delayed release(sulfasalazine)500 mgAZULFIDINE 1 MTursodiol oral capsule 300 MG URSO FORTE 2 MTursodiol oral tablet 250 MG, 500 MG URSO FORTE 2 MTZENPEP ORAL CAPSULE DELAYEDRELEASE PARTICLES(pancrelipase (lip-prot-amyl))10000 UNIT, 15000 UNIT, 20000 UNIT, 5000UNIT4 MT

MedicamentoTratamientos para las ÚlcerasACIPHEX ORAL TABLET DELAYEDRELEASE(rabeprazole sodium)20 MGcarafate oral suspension(sucralfate)1 gm/10mlcimetidine oral tablet 200 MG, 300 MG, 400 MG,800 MGReferencia deMarcacimetidine hcl oral solution 300 MG/5ML 1Nivel Requisitos /Límitescimetidine hcl injection solution 150 MG/ML 2 PAfamotidine oral suspension reconstituted 40MG/5ML421PEPCID 2famotidine oral tablet 20 MG, 40 MG PEPCID 1HELIDAC ORAL MISC(metronid-tetracyc-bis subsal)lansoprazole oral capsule delayed release 15MG, 30 MG4PREVACID 2 QL (30 / 30 día(s))misoprostol oral tablet 100 MCG, 200 MCG CYTOTEC 2NEXIUM ORAL CAPSULE DELAYEDRELEASE(esomeprazole magnesium)20 MG, 40 MGNEXIUM ORAL PACKET(esomeprazole magnesium)10 MG, 20 MG, 40 MGnizatidine oral capsule 150 MG AXID 1nizatidine oral capsule 300 MG AXID 2nizatidine oral solution 15 MG/ML AXID 2omeprazole oral capsule delayed release 10 MG,20 MG, 40 MG4 QL (30 / 30 día(s))4 QL (30 / 30 día(s))PRILOSEC 2 QL (30 / 30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 57 de 150

Medicamentopantoprazole sodium intravenous solutionreconstituted 40 MGpantoprazole sodium oral tablet delayed release20 MG, 40 MGReferencia deMarcaNivel Requisitos /LímitesPROTONIX IV 2 PAPROTONIX 2 QL (30 / 30 día(s))PYLERA ORAL CAPSULE(bis subcit-metronid-tetracyc)140-125-125 MGranitidine hcl oral capsule 150 MG, 300 MG ZANTAC 1ranitidine hcl oral syrup 15 MG/ML ZANTAC 2ranitidine hcl oral tablet 150 MG, 300 MG ZANTAC 1ranitidine hcl injection solution 150 MG/6ML ZANTAC 2 PAsucralfate oral tablet 1 GM CARAFATE 2Inmunología, Vacunas / Medicamentos BiotecnológicosMedicamentos BiotecnológicosACTIMMUNE SUBCUTANEOUS SOLUTION(interferon gamma-1b)2000000 UNIT/0.5MLARCALYST SUBCUTANEOUS SOLUTIONRECONSTITUTED(rilonacept)220 MGAVONEX INTRAMUSCULAR KIT(interferon beta-1a)30 MCGAVONEX PREFILLED INTRAMUSCULARKIT(interferon beta-1a)30 MCG/0.5MLBETASERON SUBCUTANEOUS SOLUTIONRECONSTITUTED(interferon beta-1b)0.3 MG45 PA55 QL (4 / 28 día(s))5 QL (4 / 28 día(s))5 QL (15 / 30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 58 de 150

MedicamentoHUMATROPE INJECTION SOLUTIONRECONSTITUTED(somatropin)12 MG, 24 MG, 5 MG, 6 MGINFERGEN SUBCUTANEOUS INJECTABLE(interferon alfacon-1)15 MCG/0.5MLINTRON-A INJECTION SOLUTION(interferon alfa-2b)6000000 UNIT/MLINTRON-A INJECTION SOLUTIONRECONSTITUTED(interferon alfa-2b)10000000 UNITLEUKINE INJECTION SOLUTION(sargramostim)500 MCG/MLLEUKINE INTRAVENOUS SOLUTIONRECONSTITUTED(sargramostim)250 MCGNEULASTA SUBCUTANEOUS SOLUTION(pegfilgrastim)6 MG/0.6MLNEUMEGA SUBCUTANEOUS SOLUTIONRECONSTITUTED(oprelvekin)5 MGNEUPOGEN INJECTION SOLUTION(filgrastim)480 MCG/1.6MLNEUPOGEN INJECTION SOLUTION(filgrastim)300 MCG/0.5MLNEUPOGEN INJECTION SOLUTION(filgrastim)480 MCG/0.8MLReferencia deMarcaNivel Requisitos /Límites553 PA3 PA5 PA5 PA5 QL (1.2 ML / 30día(s))5 PA; QL (21 / 21día(s))5 QL (25.6 ML / 30día(s))5 QL (5 ML / 30 día(s))5 QL (8 ML / 30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 59 de 150

MedicamentoNORDITROPIN FLEXPRO SUBCUTANEOUSSOLUTION(somatropin)10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5MLNORDITROPIN NORDIFLEX PENSUBCUTANEOUS SOLUTION(somatropin)30 MG/3MLPEGASYS SUBCUTANEOUS SOLUTION(peginterferon alfa-2a)180 MCG/0.5ML, 180 MCG/MLPEGASYS PROCLICK SUBCUTANEOUSSOLUTION(peginterferon alfa-2a)135 MCG/0.5MLPROCRIT INJECTION SOLUTION(epoetin alfa)10000 UNIT/ML, 2000 UNIT/ML, 3000UNIT/ML, 4000 UNIT/MLPROCRIT INJECTION SOLUTION(epoetin alfa)20000 UNIT/ML, 40000 UNIT/MLPROLEUKIN INTRAVENOUS SOLUTIONRECONSTITUTED(aldesleukin)22000000 UNITSYLATRON SUBCUTANEOUS KIT(peginterferon alfa-2b)296 MCG, 444 MCG, 888 MCGVacunas / Misceláneos InmunológicosACTHIB INTRAMUSCULAR SOLUTIONRECONSTITUTED(haemophilus b polysac conj vac)Referencia deMarcaNivel Requisitos /Límites555 QL (4 ML / 28 día(s))5 QL (4 ML / 28 día(s))355 PA53ADACEL INTRAMUSCULAR SUSPENSION(tetanus-diphth-acell pertussis)5-2-15.53LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 60 de 150

MedicamentoATGAM INTRAVENOUS INJECTABLE(lymphocyte,anti-thymo imm glob)50 MG/MLBOOSTRIX INTRAMUSCULARSUSPENSION(tetanus-diphth-acell pertussis)5-2.5-18.5BOTOX INJECTION SOLUTIONRECONSTITUTED(onabotulinumtoxina)100 UNITCERVARIX INTRAMUSCULARSUSPENSION(hpv bivalent (16 & 18) vaccine)Referencia deMarcaNivel Requisitos /Límites5 PA33 PA3COMVAX INTRAMUSCULAR SUSPENSION(haemophil b poly cnj-hepatit b)7.5-5 MCG/0.5MLDAPTACEL INTRAMUSCULARSUSPENSION(diphth-acell pertussis-tetanus)10-15-5ENGERIX-B INJECTION SUSPENSION(hepatitis b vac recombinant)10 MCG/0.5ML, 20 MCG/MLfomepizole intravenous solution 1 GM/ML ANTIZOL 2 PAGAMASTAN S/D INTRAMUSCULARINJECTABLE(immune globulin (human))3333 PAGAMMAPLEX INTRAVENOUS SOLUTION(immune globulin (human))10 GM/200MLGAMUNEX-C INJECTION SOLUTION(immune globulin (human))1 GM/10ML5 PA3 PALA - Esta receta puede estar sólo disponible en algunas farmacias.Página 61 de 150

MedicamentoGARDASIL INTRAMUSCULARSUSPENSION(hpv quadrivalent vaccine)Referencia deMarcaNivel Requisitos /Límites3HAVRIX INTRAMUSCULAR SUSPENSION(hepatitis a vaccine)1440 EL U/ML, 720 EL U/0.5MLIMOVAX RABIES INTRAMUSCULARINJECTABLE(rabies virus vaccine, hdc)2.5 UNIT/MLINFANRIX INTRAMUSCULAR SUSPENSION(diphth-acell pertussis-tetanus)25-58-10IPOL INJECTION INJECTABLE(poliovirus vaccine inactivated)3333IXIARO INTRAMUSCULAR SUSPENSION(japanese encephalitis vac inac)3MENACTRA INTRAMUSCULARINJECTABLE(meningococcal a c y&w-135 conj)3MENOMUNE SUBCUTANEOUSINJECTABLE(meningococcal vac a,c,y,w-135)3MENVEO INTRAMUSCULAR SOLUTIONRECONSTITUTED(meningococcal a c y&w-135 olig)3M-M-R II SUBCUTANEOUS INJECTABLE(measles, mumps & rubella vac)3LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 62 de 150

MedicamentoPEDVAX HIB INTRAMUSCULARSOLUTION(haemophilus b polysac conj vac)Referencia deMarcaNivel Requisitos /Límites3PROQUAD SUBCUTANEOUS INJECTABLE(measles-mumps-rubella-varicell)3RABAVERT INTRAMUSCULARSUSPENSION RECONSTITUTED(rabies vaccine, pcec)3RECOMBIVAX HB INJECTION SUSPENSION(hepatitis b vac recombinant)10 MCG/ML, 40 MCG/MLROTATEQ ORAL SUSPENSION(rotavirus vac live pentavalent)33tetanus toxoid adsorbed intramuscular solution 5LFUtetanus-diphtheria toxoids td intramuscularsuspension 2-2 LF/0.5MLTWINRIX INTRAMUSCULAR SUSPENSION(hepatitis a-hep b recomb vac)720-20TYPHIM VI INTRAMUSCULAR SOLUTION(typhoid vi polysaccharide vacc)25 MCG/0.5MLVAQTA INTRAMUSCULAR SUSPENSION(hepatitis a vaccine)25 UNIT/0.5MLVARIVAX SUBCUTANEOUS INJECTABLE(varicella virus vaccine live)1350 PFU/0.5MLYF-VAX SUBCUTANEOUS INJECTABLE(yellow fever vaccine)2333333LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 63 de 150

MedicamentoZOSTAVAX SUBCUTANEOUS SOLUTIONRECONSTITUTED(zoster vaccine live)19400 UNT/0.65MLMedicamentos Antineoplásicos e InmunosupresoresAgentes Adyuvantesamifostine intravenous solution reconstituted 500MGELITEK INTRAVENOUS SOLUTIONRECONSTITUTED(rasburicase)1.5 MGleucovorin calcium injection solutionreconstituted 100 MG, 350 MGleucovorin calcium oral tablet 10 MG, 15 MG, 25MG, 5 MGReferencia deMarcaNivel Requisitos /Límites3ETHYOL 55 PA1 CG2 CGmesna intravenous solution 100 MG/ML MESNEX 2 PAXGEVA SUBCUTANEOUS SOLUTION(denosumab)120 MG/1.7MLMedicamentos Antineoplásicos e InmunosupresoresAFINITOR ORAL TABLET(everolimus)10 MG, 2.5 MG, 5 MG, 7.5 MGALIMTA INTRAVENOUS SOLUTIONRECONSTITUTED(pemetrexed disodium)500 MG5 PAanastrozole oral tablet 1 MG ARIMIDEX 1 MT; CGARIMIDEX ORAL TABLET(anastrozole)1 MGAROMASIN ORAL TABLET(exemestane)25 MG553 MT3 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 64 de 150

MedicamentoAVASTIN INTRAVENOUS SOLUTION(bevacizumab)100 MG/4MLAZASAN ORAL TABLET(azathioprine)100 MG, 75 MGReferencia deMarcaLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 65 de 150Nivel Requisitos /Límites3 PA3 PA; MTazathioprine oral tablet 50 MG IMURAN 1 PA; MT; CGbicalutamide oral tablet 50 MG CASODEX 2 CGBOSULIF ORAL TABLET(bosutinib)100 MGBOSULIF ORAL TABLET(bosutinib)500 MGCAPRELSA ORAL TABLET(vandetanib)100 MG, 300 MGCEENU ORAL CAPSULE(lomustine)10 MG, 40 MGCELLCEPT ORAL SUSPENSIONRECONSTITUTED(mycophenolate mofetil)200 MG/MLCOMETRIQ (100 MG DAILY DOSE) ORALKIT(cabozantinib s-malate)1 X 80 & 1 X 20 MGCOMETRIQ (140 MG DAILY DOSE) ORALKIT(cabozantinib s-malate)1 X 80 & 3 X 20 MGCOMETRIQ (60 MG DAILY DOSE) ORALKIT(cabozantinib s-malate)20 MG55 QL (30 / 30 día(s))5 LA35 PA; MT5 PA5 PA5 PAcyclophosphamide oral tablet 25 MG, 50 MG 2 PA; CG

MedicamentoReferencia deMarcaNivel Requisitos /Límitescyclosporine intravenous solution 50 MG/ML SANDIMMUNE 2 PA; CGcyclosporine oral capsule 100 MG, 25 MG SANDIMMUNE 2 PA; MT; CGcyclosporine modified oral capsule 50 MG NEORAL 2 PA; MT; CGDROXIA ORAL CAPSULE(hydroxyurea)200 MG, 300 MG, 400 MGELIGARD SUBCUTANEOUS KIT(leuprolide acetate)7.5 MGELIGARD SUBCUTANEOUS KIT(leuprolide acetate (3 month))22.5 MGELIGARD SUBCUTANEOUS KIT(leuprolide acetate (4 month))30 MGELIGARD SUBCUTANEOUS KIT(leuprolide acetate (6 month))45 MGEMCYT ORAL CAPSULE(estramustine phosphate sodium)140 MGERIVEDGE ORAL CAPSULE(vismodegib)150 MG43 PA3 PA3 PA3 PA35 PAexemestane oral tablet 25 MG AROMASIN 2 MT; CGFARESTON ORAL TABLET(toremifene citrate)60 MGFASLODEX INTRAMUSCULAR SOLUTION(fulvestrant)250 MG/5MLFEMARA ORAL TABLET(letrozole)2.5 MG3 MT5 PA3 MTflutamide oral capsule 125 MG 2 CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 66 de 150

MedicamentoGENGRAF ORAL CAPSULE(cyclosporine modified)100 MG, 25 MGGENGRAF ORAL SOLUTION(cyclosporine modified)100 MG/MLGLEEVEC ORAL TABLET(imatinib mesylate)100 MG, 400 MGHALAVEN INTRAVENOUS SOLUTION(eribulin mesylate)1 MG/2MLHEXALEN ORAL CAPSULE(altretamine)50 MGReferencia deMarcaLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 67 de 150Nivel Requisitos /Límites2 PA; MT; CG2 PA; MT; CG555 PAhydroxyurea oral capsule 500 MG HYDREA 2 CGICLUSIG ORAL TABLET(ponatinib hcl)15 MG, 45 MGINLYTA ORAL TABLET(axitinib)1 MG, 5 MGJAKAFI ORAL TABLET(ruxolitinib phosphate)10 MG, 15 MG, 20 MG, 25 MG, 5 MGKADCYLA INTRAVENOUS SOLUTIONRECONSTITUTED(ado-trastuzumab emtansine)100 MG5 PA5 PA55 PAletrozole oral tablet 2.5 MG FEMARA 1 MT; CGLEUKERAN ORAL TABLET(chlorambucil)2 MGleuprolide acetate injection kit 1 MG/0.2ML 2 PA; CGLUPRON DEPOT INTRAMUSCULAR KIT(leuprolide acetate)3.75 MG, 7.5 MG35 PA

MedicamentoLUPRON DEPOT INTRAMUSCULAR KIT(leuprolide acetate (3 month))22.5 MGLUPRON DEPOT INTRAMUSCULAR KIT(leuprolide acetate (4 month))30 MGLUPRON DEPOT INTRAMUSCULAR KIT(leuprolide acetate (6 month))45 MGLUPRON DEPOT-PED INTRAMUSCULARKIT(leuprolide acetate)11.25 MG, 15 MGLUPRON DEPOT-PED INTRAMUSCULARKIT(leuprolide acetate (3 month))11.25 MG (Ped)LYSODREN ORAL TABLET(mitotane)500 MGMATULANE ORAL CAPSULE(procarbazine hcl)50 MGReferencia deMarcaNivel Requisitos /Límites5 PA5 PA5 PA5 PA5 PA35 PAmegestrol acetate oral suspension 40 MG/ML MEGACE 2 PA; CGmegestrol acetate oral tablet 20 MG, 40 MG MEGACE 1 PA; CGMEKINIST ORAL TABLET(trametinib dimethyl sulfoxide)0.5 MG, 2 MG5 PAmercaptopurine oral tablet 50 MG 2 CGmethotrexate oral tablet 2.5 MG 2 PA; CGmethotrexate sodium injection solutionreconstituted 1 GMmethotrexate sodium (pf) injection solution 25MG/MLmitoxantrone hcl intravenous concentrate 25MG/12.5ML2 PA; CG2 PA; CG2 PA; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 68 de 150

MedicamentoReferencia deMarcaLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 69 de 150Nivel Requisitos /Límitesmycophenolate mofetil oral capsule 250 MG CELLCEPT 2 PA; MT; CGmycophenolate mofetil oral tablet 500 MG CELLCEPT 2 PA; MT; CGNEXAVAR ORAL TABLET(sorafenib tosylate)200 MGNILANDRON ORAL TABLET(nilutamide)150 MGNULOJIX INTRAVENOUS SOLUTIONRECONSTITUTED(belatacept)250 MGoctreotide acetate injection solution 100MCG/ML, 200 MCG/ML, 50 MCG/MLoctreotide acetate injection solution 1000MCG/ML, 500 MCG/MLPOMALYST ORAL CAPSULE(pomalidomide)1 MG, 2 MG, 3 MG, 4 MGPROGRAF ORAL CAPSULE(tacrolimus)0.5 MG, 1 MGPROGRAF ORAL CAPSULE(tacrolimus)5 MGRAPAMUNE ORAL SOLUTION(sirolimus)1 MG/MLRAPAMUNE ORAL TABLET(sirolimus)0.5 MG, 1 MGRAPAMUNE ORAL TABLET(sirolimus)2 MGREVLIMID ORAL CAPSULE(lenalidomide)10 MG, 15 MG, 25 MG, 5 MG5 PA; LA35 PASANDOSTATIN 2 PASANDOSTATIN 5 PA5 PA3 PA; MT5 PA; MT3 PA; MT3 PA; MT5 PA; MT5 PA; LA

MedicamentoRITUXAN INTRAVENOUS CONCENTRATE(rituximab)10 MG/MLSANDOSTATIN LAR DEPOTINTRAMUSCULAR KIT(octreotide acetate)10 MG, 20 MG, 30 MGSOLTAMOX ORAL SOLUTION(tamoxifen citrate)10 MG/5MLSOMATULINE DEPOT SUBCUTANEOUSSOLUTION(lanreotide acetate)120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3MLSPRYCEL ORAL TABLET(dasatinib)100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80MGSTIVARGA ORAL TABLET(regorafenib)40 MGSUTENT ORAL CAPSULE(sunitinib malate)12.5 MG, 25 MG, 50 MGSYNRIBO SUBCUTANEOUS SOLUTIONRECONSTITUTED(omacetaxine mepesuccinate)3.5 MGTABLOID ORAL TABLET(thioguanine)40 MGReferencia deMarcaNivel Requisitos /Límites5 PA5 PA3 PA; MT5 PA55 PA; QL (120 / 30día(s))5 PA5 PAtacrolimus oral capsule 0.5 MG, 1 MG PROGRAF 2 PA; MT; CGTAFINLAR ORAL CAPSULE(dabrafenib mesylate)50 MG, 75 MG35 PAtamoxifen citrate oral tablet 10 MG, 20 MG 1 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 70 de 150

MedicamentoTARCEVA ORAL TABLET(erlotinib)100 MG, 150 MG, 25 MGTARGRETIN EXTERNAL GEL(bexarotene)1 %TARGRETIN ORAL CAPSULE(bexarotene)75 MGTASIGNA ORAL CAPSULE(nilotinib)150 MG, 200 MGTHALOMID ORAL CAPSULE(thalidomide)100 MG, 150 MG, 200 MG, 50 MGTRELSTAR DEPOT MIXJECTINTRAMUSCULAR SUSPENSIONRECONSTITUTED(triptorelin pamoate)3.75 MGTRELSTAR LA MIXJECT INTRAMUSCULARSUSPENSION RECONSTITUTED(triptorelin pamoate)11.25 MGReferencia deMarcatretinoin oral capsule 10 MG RETIN-A 5TYKERB ORAL TABLET(lapatinib ditosylate)250 MGVELCADE INTRAVENOUS SOLUTIONRECONSTITUTED(bortezomib)3.5 MGVIDAZA INJECTION SUSPENSIONRECONSTITUTED(azacitidine)100 MGNivel Requisitos /Límites5 PA5 PA5 PA55 PA5 PA5 PA5 LA55LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 71 de 150

MedicamentoVOTRIENT ORAL TABLET(pazopanib hcl)200 MGXALKORI ORAL CAPSULE(crizotinib)200 MG, 250 MGXTANDI ORAL CAPSULE(enzalutamide)40 MGZALTRAP INTRAVENOUS SOLUTION(ziv-aflibercept)100 MG/4MLZELBORAF ORAL TABLET(vemurafenib)240 MGZOLINZA ORAL CAPSULE(vorinostat)100 MGZORTRESS ORAL TABLET(everolimus)0.25 MGZORTRESS ORAL TABLET(everolimus)0.5 MG, 0.75 MGZYTIGA ORAL TABLET(abiraterone acetate)250 MGMedicamentos Autonómicos y del Sistema Nervioso CentralMedicamentos PsicoterapéuticosABILIFY INTRAMUSCULAR SOLUTION(aripiprazole)9.75 MG/1.3MLABILIFY ORAL SOLUTION(aripiprazole)1 MG/MLReferencia deMarcaNivel Requisitos /Límites555 QL (120 / 30 día(s))5 PA55 PA3 PA; MT5 PA; MT533LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 72 de 150

MedicamentoABILIFY ORAL TABLET(aripiprazole)10 MG, 15 MG, 2 MG, 5 MGABILIFY ORAL TABLET(aripiprazole)20 MG, 30 MGABILIFY DISCMELT ORAL TABLETDISPERSIBLE(aripiprazole)10 MG, 15 MGABILIFY MAINTENA INTRAMUSCULARSUSPENSION RECONSTITUTED(aripiprazole)300 MGalprazolam oral tablet 0.25 MG, 0.5 MG, 1 MG,2 MGalprazolam oral tablet dispersible 0.25 MG, 0.5MG, 1 MG, 2 MGalprazolam er oral tablet extended release 24 hr0.5 MGalprazolam xr oral tablet extended release 24 hr1 MG, 2 MG, 3 MGamitriptyline hcl oral tablet 10 MG, 100 MG, 150MG, 25 MG, 50 MG, 75 MGamoxapine oral tablet 100 MG, 150 MG, 25 MG,50 MGAPLENZIN ORAL TABLET EXTENDEDRELEASE 24 HR(bupropion hbr er)174 MG, 348 MG, 522 MGBUDEPRION SR ORAL TABLET EXTENDEDRELEASE 12 HR(bupropion hcl er (sr))100 MG, 150 MGReferencia deMarcaLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 73 de 150Nivel Requisitos /LímitesXANAX 2 CGNIRAVAM 2 CG3535XANAX XR 2 CG; QL (120 / 30día(s))XANAX XR 2 CG; QL (120 / 30día(s))2 PA; MT; CG2 MT; CGMTWELLBUTRIN SR 1 MT; CGbupropion hcl oral tablet 100 MG, 75 MG WELLBUTRIN 1 MT; CGbupropion hcl er (sr) oral tablet extended release12 hr 200 MGWELLBUTRIN SR 1 MT; CG

Medicamentobupropion hcl er (xl) oral tablet extended release24 hr 150 MG, 300 MGbuspirone hcl oral tablet 10 MG, 15 MG, 30 MG,5 MG, 7.5 MGReferencia deMarcaNivel Requisitos /LímitesWELLBUTRIN XL 1 MT; CG1 CGchlorpromazine hcl injection solution 25 MG/ML 2 CGchlorpromazine hcl oral tablet 10 MG, 100 MG,200 MG, 25 MG, 50 MGcitalopram hydrobromide oral solution 10MG/5MLcitalopram hydrobromide oral tablet 10 MG, 20MG, 40 MGclomipramine hcl oral capsule 25 MG, 50 MG,75 MGclorazepate dipotassium oral tablet 15 MG, 3.75MG, 7.5 MGclozapine oral tablet 100 MG, 200 MG, 25 MG,50 MGCLOZARIL ORAL TABLET(clozapine)100 MG, 25 MGCYMBALTA ORAL CAPSULE DELAYEDRELEASE PARTICLES(duloxetine hcl)20 MG, 30 MG, 60 MGDAYTRANA TRANSDERMAL PATCH(methylphenidate)15 MG/9HRdesipramine hcl oral tablet 10 MG, 100 MG, 150MG, 25 MG, 50 MG, 75 MGdextroamphetamine sulfate er oral capsuleextended release 24 hour 10 MG, 15 MG, 5 MG2 MT; CGCELEXA 2 MT; CGCELEXA 1 MT; CGANAFRANIL 2 MTTRANXENE T-TAB 1 CGCLOZARIL 2 CG43 MTNORPRAMIN 2 MT; CGDEXEDRINE 2 CGdiazepam oral solution 1 MG/ML VALIUM 1 CGdiazepam oral tablet 10 MG, 2 MG, 5 MG VALIUM 1 CGdoxepin hcl oral capsule 10 MG, 100 MG, 150MG, 25 MG, 50 MG, 75 MG42 PA; MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 74 de 150

MedicamentoReferencia deMarcaNivel Requisitos /Límitesdoxepin hcl oral concentrate 10 MG/ML 2 PA; MT; CGEMSAM TRANSDERMAL PATCH 24 HR(selegiline)12 MG/24HR, 6 MG/24HR, 9 MG/24HR3 MTescitalopram oxalate oral solution 5 MG/5ML LEXAPRO 2 MT; CGescitalopram oxalate oral tablet 5 MG LEXAPRO 2 MT; CG; QL (120 / 30día(s))escitalopram oxalate oral tablet 20 MG LEXAPRO 2 MT; CG; QL (30 / 30día(s))escitalopram oxalate oral tablet 10 MG LEXAPRO 2 MT; CG; QL (60 / 30día(s))FANAPT ORAL TABLET(iloperidone)1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8MGFANAPT TITRATION PACK ORAL TABLET(iloperidone)1 & 2 & 4 & 6 MGFAZACLO ORAL TABLET DISPERSIBLE(clozapine)100 MG, 12.5 MG, 150 MG, 200 MG, 25 MGfluoxetine hcl oral capsule 10 MG, 20 MG, 40MGPROZAC 1 MT; CGfluoxetine hcl oral solution 20 MG/5ML PROZAC 1 MT; CGfluoxetine hcl oral tablet 10 MG, 20 MG PROZAC 1 MT; CGfluoxetine hcl oral capsule delayed release 90MGfluphenazine decanoate injection solution 25MG/MLPROZAC WEEKLY 2 MT; CG; QL (4 / 30día(s))3332 CGfluphenazine hcl injection solution 2.5 MG/ML 2 CGfluphenazine hcl oral concentrate 5 MG/ML 2 MT; CGfluphenazine hcl oral elixir 2.5 MG/5ML 2 MT; CGfluphenazine hcl oral tablet 1 MG, 10 MG, 2.5MG, 5 MG2 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 75 de 150

MedicamentoReferencia deMarcaNivel Requisitos /Límitesfluvoxamine maleate oral tablet 100 MG, 25 MG 2 MT; CGfluvoxamine maleate oral tablet 50 MG 1 MT; CGfluvoxamine maleate er oral capsule extendedrelease 24 hour 100 MG, 150 MGGEODON INTRAMUSCULAR SOLUTIONRECONSTITUTED(ziprasidone mesylate)20 MGhaloperidol oral tablet 0.5 MG, 1 MG, 10 MG, 2MG, 20 MG, 5 MGhaloperidol decanoate intramuscular solution100 MG/ML, 50 MG/MLLUVOX CR 2 MTHALDOL 2 MT; CGHALDOL 2 CGhaloperidol lactate injection solution 5 MG/ML HALDOL 2 CGhaloperidol lactate oral concentrate 2 MG/ML HALDOL 2 MT; CGimipramine hcl oral tablet 10 MG, 25 MG, 50MGimipramine pamoate oral capsule 100 MG, 125MG, 150 MG, 75 MGINTUNIV ORAL TABLET EXTENDEDRELEASE 24 HR(guanfacine hcl er)1 MG, 2 MG, 3 MG, 4 MGINVEGA ORAL TABLET EXTENDEDRELEASE 24 HR(paliperidone er)1.5 MG, 3 MG, 6 MG, 9 MGINVEGA SUSTENNA INTRAMUSCULARSUSPENSION(paliperidone palmitate)39 MG/0.25ML, 78 MG/0.5MLINVEGA SUSTENNA INTRAMUSCULARSUSPENSION(paliperidone palmitate)117 MG/0.75ML, 156 MG/ML, 234 MG/1.5MLTOFRANIL 2 PA; MT; CGTOFRANIL 2 PA; MT; CG333 MT35LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 76 de 150

MedicamentoLATUDA ORAL TABLET(lurasidone hcl)20 MG, 40 MG, 80 MGLATUDA ORAL TABLET(lurasidone hcl)120 MGLEXAPRO ORAL SOLUTION(escitalopram oxalate)5 MG/5MLLEXAPRO ORAL TABLET(escitalopram oxalate)10 MG, 20 MG, 5 MGlithium carbonate oral capsule 150 MG, 300 MG,600 MGReferencia deMarcaNivel Requisitos /Límites3 MT5 MT4 MT4 MT; QL (30 / 30día(s))1 MT; CGlithium carbonate oral tablet 300 MG 1 MT; CGlithium carbonate er oral tablet extendedrelease300 MGlithium carbonate er oral tablet extendedrelease450 MG1 MT; CG2 MT; CGlithium citrate oral solution 8 MEQ/5ML 2 MT; CGlorazepam oral tablet 0.5 MG, 1 MG, 2 MG ATIVAN 2 CGloxapine succinate oral capsule 10 MG, 25 MG, 5MG, 50 MGLUNESTA ORAL TABLET(eszopiclone)1 MG, 2 MG, 3 MGmaprotiline hcl oral tablet 25 MG, 50 MG, 75MGMARPLAN ORAL TABLET(isocarboxazid)10 MGMETADATE ER ORAL TABLETEXTENDEDRELEASE(methylphenidate hcl er)20 MGLOXITANE 2 MT; CG4 QL (30 / 30 día(s))2 MT; CG3 MTRITALIN-SR 2 CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 77 de 150

Medicamentomirtazapine oral tablet 15 MG, 30 MG, 45 MG,7.5 MGReferencia deMarcaNivel Requisitos /LímitesREMERON 1 MT; CGmirtazapine oral tablet dispersible 15 MG, 30MG, 45 MGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 78 de 150REMERON ODT 2 MT; CGmodafinil oral tablet 100 MG, 200 MG PROVIGIL 2 CG; QL (30 / 30día(s))NARDIL ORAL TABLET(phenelzine sulfate)15 MGnefazodone hcl oral tablet 100 MG, 150 MG, 200MG, 250 MG, 50 MGnortriptyline hcl oral capsule 10 MG, 25 MG, 50MG, 75 MGNUVIGIL ORAL TABLET(armodafinil)250 MG, 50 MGolanzapine intramuscular solution reconstituted10 MG3 MT2 MT; CGPAMELOR 2 MT; CGZYPREXA 2 CGolanzapine oral tablet 20 MG ZYPREXA 2 MTolanzapine oral tablet 10 MG, 15 MG, 2.5 MG, 5MG, 7.5 MGolanzapine oral tablet dispersible 10 MG, 15 MG,20 MG, 5 MGolanzapine-fluoxetine hcl oral capsule 12-25 MG,12-50 MG, 3-25 MG, 6-25 MG, 6-50 MGORAP ORAL TABLET(pimozide)1 MG, 2 MGparoxetine hcl oral tablet 10 MG, 20 MG, 30MG, 40 MGparoxetine hcl er oral tablet extended release 24hr 12.5 MG, 25 MG, 37.5 MGPAXIL ORAL SUSPENSION(paroxetine hcl)10 MG/5ML4 QL (30 / 30 día(s))ZYPREXA 2 MT; CGZYPREXA 2 MT; CGSYMBYAX 2 MT; CG3 MTPAXIL 1 MT; CGPAXIL 2 MT; CG3 MT

Medicamentoperphenazine oral tablet 16 MG, 2 MG, 4 MG, 8MGperphenazine-amitriptyline oral tablet 2-10 MG,2-25 MG, 4-10 MG, 4-25 MG, 4-50 MGReferencia deMarcaLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 79 de 150Nivel Requisitos /Límites2 MT; CG2 MT; CGphenelzine sulfate oral tablet 15 MG NARDIL 2 MT; CGPRISTIQ ORAL TABLET EXTENDEDRELEASE 24 HR(desvenlafaxine succinate er)100 MG, 50 MG3 MTprotriptyline hcl oral tablet 10 MG, 5 MG VIVACTIL 2 MT; CGquetiapine fumarate oral tablet 100 MG, 200MG, 25 MG, 300 MG, 400 MG, 50 MGRISPERDAL CONSTA INTRAMUSCULARSUSPENSION RECONSTITUTED(risperidone microspheres)25 MGRISPERDAL CONSTA INTRAMUSCULARSUSPENSION RECONSTITUTED(risperidone microspheres)37.5 MG, 50 MGrisperidone oral tablet 0.25 MG, 0.5 MG, 1 MG,2 MGSEROQUEL 2 MT; CGRISPERDAL 1 MT; CGrisperidone oral tablet 3 MG, 4 MG RISPERDAL 2 MT; CGrisperidone oral tablet dispersible 0.25 MG, 0.5MG, 1 MG, 2 MG, 3 MG, 4 MGRISPERDAL 2 MT; CGrisperidone oral solution 1 MG/ML RISPERDAL 2 MT; CG; QL (480 ML/ 30 día(s))ROZEREM ORAL TABLET(ramelteon)8 MGSAPHRIS SUBLINGUAL TABLETSUBLINGUAL(asenapine maleate)10 MG, 5 MG353 QL (30 / 30 día(s))3 MTsertraline hcl oral concentrate 20 MG/ML ZOLOFT 2 MT; CGsertraline hcl oral tablet 100 MG, 25 MG, 50 MG ZOLOFT 1 MT; CG

MedicamentoSTRATTERA ORAL CAPSULE(atomoxetine hcl)10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60MG, 80 MGSYMBYAX ORAL CAPSULE(olanzapine-fluoxetine hcl)12-25 MG, 12-50 MG, 3-25 MG, 6-25 MG, 6-50MGthioridazine hcl oral tablet 10 MG, 100 MG, 25MG, 50 MGthiothixene oral capsule 1 MG, 10 MG, 2 MG, 5MGReferencia deMarcaNivel Requisitos /Límites3 QL (60 / 30 día(s))4 MT2 PA; MT; CG2 PA; MT; CGtranylcypromine sulfate oral tablet 10 MG 2 MT; CGtrazodone hcl oral tablet 100 MG, 150 MG, 300MG, 50 MGtrifluoperazine hcl oral tablet 1 MG, 10 MG, 2MG, 5 MGtrimipramine maleate oral capsule 100 MG, 25MG, 50 MGvenlafaxine hcl oral tablet 100 MG, 37.5 MG, 50MG2 MT; CG2 MT; CGSURMONTIL 2 MT2 MT; CGvenlafaxine hcl oral tablet 25 MG, 75 MG EFFEXOR 1 MT; CGvenlafaxine hcl er oral capsule extended release24 hour 150 MG, 37.5 MG, 75 MGvenlafaxine hcl er oral tablet extended release 24hr 150 MG, 37.5 MG, 75 MGVIIBRYD ORAL KIT(vilazodone hcl)10 & 20 & 40 MGVIIBRYD ORAL TABLET(vilazodone hcl)10 MG, 20 MG, 40 MGVYVANSE ORAL CAPSULE(lisdexamfetamine dimesylate)20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MGEFFEXOR XR 1 MT; CGEFFEXOR XR 2 MT; CG33 MT4LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 80 de 150

MedicamentoXYREM ORAL SOLUTION(sodium oxybate)500 MG/MLReferencia deMarcaNivel Requisitos /Límites5 LAzaleplon oral capsule 10 MG, 5 MG SONATA 2 QL (30 / 30 día(s))ziprasidone hcl oral capsule 20 MG, 40 MG, 60MG, 80 MGGEODON 2 MT; CGzolpidem tartrate oral tablet 10 MG, 5 MG AMBIEN 2 QL (30 / 30 día(s))zolpidem tartrate er oral tablet extendedrelease12.5 MG, 6.25 MGAgentes AntiparkinsonAPOKYN SUBCUTANEOUS SOLUTION(apomorphine hcl)10 MG/MLAZILECT ORAL TABLET(rasagiline mesylate)0.5 MG, 1 MGAMBIEN CR 2 QL (30 / 30 día(s))5 PA; LA4 MTbromocriptine mesylate oral capsule 5 MG PARLODEL 2 MT; CGbromocriptine mesylate oral tablet 2.5 MG PARLODEL 2 MT; CGcarbidopa-levodopa oral tablet 10-100 MG, 25-250 MGSINEMET 1 MT; CGcarbidopa-levodopa oral er tablet 25-100 MG SINEMET CR 2 MT; CGcarbidopa-levodopa oral tablet dispersible 10-100 MG, 25-100 MG, 25-250 MGcarbidopa-levodopa er oral tabletextendedrelease 25-100 MG, 50-200 MGPARCOPA ODT 2 MT; CGSTALEVO 2 MT; CGentacapone oral tablet 200 MG COMTAN 2 MTLODOSYN ORAL TABLET(carbidopa)25 MGpramipexole dihydrochloride oral tablet 0.125MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG4 MTCOMTAN 1 MT; CGropinirole hcl oral tablet 0.25 MG MIRAPEX 1 MT; CGropinirole hcl oral tablet 0.5 MG, 1 MG, 2 MG, 3MG, 4 MG, 5 MGMIRAPEX 2 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 81 de 150

Medicamentoropinirole hcl er oral tablet extended release 24hr 12 MG, 2 MG, 4 MG, 6 MG, 8 MGReferencia deMarcaNivel Requisitos /LímitesREQUIP 2 MT; CGselegiline hcl oral capsule 5 MG ELDEPRYL 2 MT; CGselegiline hcl oral tablet 5 MG ELDEPRYL 2 MT; CGTASMAR ORAL TABLET(tolcapone)100 MG5 PA; MTtrihexyphenidyl hcl oral elixir 0.4 MG/ML 2 MTtrihexyphenidyl hcl oral tablet 2 MG, 5 MG 2 MTZELAPAR ORAL TABLET DISPERSIBLE(selegiline hcl)1.25 MGAnalgésicos Narcóticosacetaminophen-codeine oral solution 120-12MG/5MLacetaminophen-codeine #2 oral tablet 300-15MGacetaminophen-codeine #3 oral tablet 300-30MGacetaminophen-codeine #4 oral tablet 300-60MGapap-caff-dihydrocodeine oral tablet 712.8-60-32MGASCOMP-CODEINE ORAL CAPSULE(butalbital-asa-caff-codeine)50-325-40-30 MGAVINZA ORAL CAPSULE EXTENDEDRELEASE 24 HOUR(morphine sulfate er beads)120 MG, 30 MG, 45 MG, 60 MG, 75 MG, 90MGbutalbital-apap-caff-cod oral capsule 50-325-40-30 MGTYLENOL-CODEINE 2TYLENOL-CODEINE 2TYLENOL-CODEINE 2FIORINAL WITHCODEINE #3FIORICET WITHCODEINE4 MT2224 QL (60 / 30 día(s))2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 82 de 150

MedicamentoCO-GESIC ORAL TABLET(hydrocodone-acetaminophen)5-500 MGduramorph injection solution 0.5 MG/ML, 1MG/MLENDOCET ORAL TABLET(oxycodone-acetaminophen)10-325 MG, 10-650 MG, 5-325 MG, 7.5-325MG, 7.5-500 MGENDODAN ORAL TABLET(oxycodone-aspirin)4.8355-325 MGfentanyl transdermal patch 72 hr 100 MCG/HR,12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75MCG/HRfentanyl citrate buccal lollipop 1200 MCG, 1600MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCGhydrocodone-acetaminophen oral solution 7.5-325 MG/15ML, 7.5-500 MG/15MLhydrocodone-acetaminophen oral tablet 10-325MG, 10-500 MG, 10-650 MG, 10-660 MG, 10-750MG, 2.5-500 MG, 5-325 MG, 7.5-325 MG, 7.5-500 MG, 7.5-650 MG, 7.5-750 MGReferencia deMarcaXODOL 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 83 de 150Nivel Requisitos /LímitesASTRAMORPH-PF 2 PAPERCOCET 2 QL (120 / 30 día(s))PERCODAN 2 QL (120 / 30 día(s))DURAGESIC 2 CG; QL (10 / 30día(s))ACTIQ 5 QL (120 / 30 día(s))XODOL 2XODOL 2hydrocodone-ibuprofen oral tablet 7.5-200 MG VICOPROFEN 2 QL (120 / 30 día(s))hydromorphone hcl oral tablet 2 MG, 4 MG, 8MGhydromorphone hcl pf injection solution 500MG/50MLKADIAN ORAL CAPSULE EXTENDEDRELEASE 24 HOUR(morphine sulfate er)10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60MG, 80 MGLAZANDA NASAL SOLUTION(fentanyl citrate)100 MCG/ACT, 400 MCG/ACTDILAUDID 2DILAUDID 2levorphanol tartrate oral tablet 2 MG 24 QL (90 / 30 día(s))5 LA

MedicamentoReferencia deMarcaNivel Requisitos /Límitesmethadone hcl injection solution 10 MG/ML DILAUDID 2 CGmethadone hcl oral concentrate 10 MG/ML DILAUDID 2 CGmethadone hcl oral solution 10 MG/5ML, 5MG/5MLDILAUDID 2 CGmethadone hcl oral tablet 10 MG, 5 MG DILAUDID 2 CGmorphine sulfate oral solution 10 MG/5ML, 20MG/5MLASTRAMORPH-PF 2morphine sulfate oral tablet 15 MG ASTRAMORPH-PF 1morphine sulfate oral tablet 30 MG ASTRAMORPH-PF 2morphine sulfate (concentrate) oral solution 20MG/MLmorphine sulfate er oral tablet extendedrelease15 MG, 200 MG, 30 MG, 60 MGmorphine sulfate er oral tablet extendedrelease100 MGOPANA ER (CRUSH RESISTANT) ORALTABLET EXTENDED RELEASE 12 HR(oxymorphone er (crush resist))10 MG, 20 MG, 30 MG, 5 MGASTRAMORPH-PF 2KADIAN 2 CG; QL (90 / 30día(s))oxycodone hcl oral capsule 5 MG OXYCONTIN 2oxycodone hcl oral concentrate 20 MG/ML OXYCONTIN 2oxycodone hcl oral tablet 10 MG, 20 MG, 30MG, 5 MGKADIAN 2 QL (90 / 30 día(s))OXYCONTIN 2oxycodone hcl oral tablet 15 MG OXYCONTIN 1oxycodone-acetaminophen oral capsule 5-500MGoxycodone-acetaminophen oral tablet 2.5-325MGoxycodone-aspirin oral tablet 4.8355-325 MG PERCODAN 24 QL (90 / 30 día(s))PERCOCET 2 QL (120 / 30 día(s))PERCOCET 2 QL (120 / 30 día(s))oxycodone-ibuprofen oral tablet 5-400 MG 2 QL (120 / 30 día(s))oxymorphone hcl oral tablet 10 MG, 5 MG OPANA 2stagesic oral capsule 5-500 MG 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 84 de 150

MedicamentoSYNALGOS-DC ORAL CAPSULE(dihydrocodeine compound)356.4-30-16 MGhydrocodone-acetaminophen oral tablet5-300 MGhydrocodone-acetaminophen oral tablet7.5-300 MGhydrocodone-acetaminophen oral tablet10-300 MGhydrocodone-acetaminophen oral tablet10-300 MG, 7.5-300 MGAnalgésicos No NarcóticosARTHROTEC ORAL TABLET DELAYEDRELEASE(diclofenac-misoprostol)50-0.2 MG, 75-0.2 MGbutorphanol tartrate injection solution 1 MG/ML,2 MG/MLReferencia deMarcaNivel Requisitos /Límites4XODOL 2XODOL 2XODOL 2XODOL 2butorphanol tartrate nasal solution 10 MG/ML 2 QL (5 ML / 3 día(s))CELEBREX ORAL CAPSULE(celecoxib)100 MG, 200 MG, 400 MG, 50 MGdiclofenac potassium oral tablet 50 MG CATAFLAM 2diclofenac sodium oral tablet delayed release 25MG, 50 MG, 75 MGdiclofenac sodium er oral tablet extended release24 hr 100 MGVOLTAREN-XR 2VOLTAREN-XR 2diflunisal oral tablet 500 MG 2etodolac oral capsule 200 MG, 300 MG 2etodolac oral tablet 400 MG, 500 MG 2etodolac er oral tablet extended release 24 hr 400MG, 500 MG, 600 MGfenoprofen calcium oral tablet 600 MG 2423 QL (60 / 30 día(s))2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 85 de 150

MedicamentoFLECTOR TRANSDERMAL PATCH(diclofenac epolamine)1.3 %Referencia deMarcaflurbiprofen oral tablet 100 MG, 50 MG 2ibuprofen oral suspension 100 MG/5ML 2ibuprofen oral tablet 400 MG, 600 MG, 800 MG 2ketoprofen oral capsule 50 MG, 75 MG 2ketoprofen er oral capsule extended release 24hour 200 MGmeclofenamate sodium oral capsule 100 MG, 50MGmefenamic acid oral capsule 250 MG PONSTEL 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 86 de 150Nivel Requisitos /Límites4 QL (60 / 30 día(s))meloxicam oral tablet 15 MG, 7.5 MG MOBIC 2 QL (30 / 30 día(s))meloxicam oral suspension 7.5 MG/5ML MOBIC 2 QL (300 ML / 30día(s))nabumetone oral tablet 500 MG, 750 MG RELAFEN 2naloxone hcl injection solution 1 MG/ML 2naltrexone hcl oral tablet 50 MG REVIA 2naproxen oral suspension 125 MG/5ML EC-NAPROSYN 2naproxen oral tablet 250 MG, 375 MG, 500 MG NAPROSYN 2naproxen dr oral tablet delayed release 375 MG,500 MGnaproxen sodium oral tablet 275 MG, 550 MG ANAPROX DS 2NUCYNTA ORAL TABLET(tapentadol hcl)100 MG, 50 MG, 75 MGoxaprozin oral tablet 600 MG DAYPRO 2piroxicam oral capsule 10 MG, 20 MG FELDENE 2sulindac oral tablet 150 MG, 200 MG CLINORIL 2tolmetin sodium oral capsule 400 MG 2tolmetin sodium oral tablet 200 MG, 600 MG 22224 QL (180 / 30 día(s))tramadol hcl oral tablet 50 MG ULTRAM ER 2 QL (240 / 30 día(s))

Medicamentotramadol-acetaminophen oral tablet 37.5-325MGVOLTAREN TRANSDERMAL GEL(diclofenac sodium)1 %AnticonvulsivosBANZEL ORAL SUSPENSION(rufinamide)40 MG/MLBANZEL ORAL TABLET(rufinamide)200 MGBANZEL ORAL TABLET(rufinamide)400 MGReferencia deMarcaNivel Requisitos /LímitesULTRACET 2 QL (40 / 5 día(s))33 PA; MT3 PA; MT5 PA; MTcarbamazepine oral suspension 100 MG/5ML TEGRETOL 2 MT; CGcarbamazepine oral tablet chewable 100 MG TEGRETOL 1 MT; CGcarbamazepine er oral capsule extended release12 hour 100 MG, 200 MG, 300 MGcarbamazepine er oral tablet extended release 12hr 200 MG, 400 MGCARBATROL ORAL CAPSULE EXTENDEDRELEASE 12 HOUR(carbamazepine er)100 MG, 200 MG, 300 MGCELONTIN ORAL CAPSULE(methsuximide)300 MGTEGRETOL XR 2 MT; CGTEGRETOL XR 2 MT; CG4 MT3 MTclonazepam oral tablet 0.5 MG, 1 MG, 2 MG KLONOPIN 2 CGclonazepam oral tablet dispersible 0.125 MG,0.25 MG, 0.5 MG, 1 MG, 2 MGDEPAKENE ORAL SYRUP(valproate sodium)250 MG/5ML2 CG3 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 87 de 150

MedicamentoDEPAKENE ORAL CAPSULE(valproic acid)250 MGDEPAKOTE ORAL TABLET DELAYEDRELEASE(divalproex sodium)125 MG, 250 MG, 500 MGDEPAKOTE ER ORAL TABLET EXTENDEDRELEASE 24 HR(divalproex sodium er)250 MG, 500 MGDEPAKOTE SPRINKLES ORAL CAPSULESPRINKLE(divalproex sodium)125 MGReferencia deMarcaNivel Requisitos /Límites3 MT4 MT4 MT4 MTdiazepam re gel 2.5 MG, 20 MG VALIUM 1 CGDILANTIN ORAL SUSPENSION(phenytoin)125 MG/5MLDILANTIN ORAL CAPSULE(phenytoin sodium extended)100 MG, 30 MGDILANTIN INFATABS ORAL TABLETCHEWABLE(phenytoin)50 MG3 MT3 MT3 MTdivalproex sodium oral capsule sprinkle 125 MG DEPAKOTE 2 MT; CGdivalproex sodium oral tablet delayed release125 MG, 250 MG, 500 MGdivalproex sodium er oral tablet extended release24 hr 250 MG, 500 MGepitol oral tablet(carbamazepine)200 mgDEPAKOTE ER 2 MT; CGDEPAKOTE ER 2 MT; CGTEGRETOL 1 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 88 de 150

MedicamentoEQUETRO ORAL CAPSULE EXTENDEDRELEASE 12 HOUR(carbamazepine er (antipsych))100 MG, 200 MG, 300 MGReferencia deMarcaNivel Requisitos /Límites4 MTethosuximide oral capsule 250 MG ZARONTIN 2 MT; CGethosuximide oral solution 250 MG/5ML ZARONTIN 2 MT; CGfelbamate oral suspension 600 MG/5ML FELBATOL 2 MT; CGfelbamate oral tablet 400 MG, 600 MG FELBATOL 2 MT; CGFELBATOL ORAL SUSPENSION(felbamate)600 MG/5MLFELBATOL ORAL TABLET(felbamate)400 MG, 600 MGfosphenytoin sodium injection solution 100 MGPE/2MLgabapentin oral capsule 100 MG, 300 MG, 400MG3 MT3 MTNEURONTIN 2 PANEURONTIN 2 MT; CGgabapentin oral solution 250 MG/5ML NEURONTIN 2 MT; CGgabapentin oral tablet 600 MG, 800 MG NEURONTIN 2 MT; CGlamotrigine oral tablet 100 MG, 150 MG, 200MG, 25 MGLAMICTAL 1 MT; CGlamotrigine oral tablet chewable 25 MG LAMICTAL 1 MT; CGlamotrigine oral tablet chewable 5 MG LAMICTAL 2 MT; CGlamotrigine er oral tablet extended release 24 hr100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50MGLAMICTAL 2 MT; CGlevetiracetam intravenous solution 500 MG/5ML KEPPRA 2 CGlevetiracetam oral solution 100 MG/ML KEPPRA 2 MT; CGlevetiracetam oral tablet 1000 MG, 250 MG, 500MG, 750 MGlevetiracetam er oral tablet extended release 24hr 500 MG, 750 MGKEPPRA 2 MT; CGKEPPRA 2 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 89 de 150

MedicamentoLYRICA ORAL CAPSULE(pregabalin)100 MG, 150 MG, 200 MG, 225 MG, 25 MG,300 MG, 50 MG, 75 MGLYRICA ORAL SOLUTION(pregabalin)20 MG/MLONFI ORAL TABLET(clobazam)10 MG, 20 MG, 5 MGReferencia deMarcaLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 90 de 150Nivel Requisitos /Límites3 MT3 MToxcarbazepine oral suspension 300 MG/5ML TRILEPTAL 1 MT; CGoxcarbazepine oral tablet 150 MG TRILEPTAL 1 MT; CGoxcarbazepine oral tablet 300 MG, 600 MG TRILEPTAL 2 MT; CGPEGANONE ORAL TABLET(ethotoin)250 MG33 MTphenobarbital oral elixir 20 MG/5ML 1 PA; CGphenobarbital oral tablet 100 MG, 15 MG, 60MGphenobarbital oral tablet 16.2 MG, 30 MG, 32.4MG, 64.8 MG, 97.2 MGPHENYTEK ORAL CAPSULE(phenytoin sodium extended)200 MG, 300 MG2 PA; CG1 PA; CG4 MTphenytoin oral suspension 125 MG/5ML DILANTIN 2 MT; CGphenytoin oral tablet chewable 50 MG DILANTIN 2 MT; CGphenytoin sodium injection solution 50 MG/ML DILANTIN 2 CGphenytoin sodium extended oral capsule 100 MG DILANTIN 1 MT; CGPOTIGA ORAL TABLET(ezogabine)200 MG, 300 MG, 400 MG, 50 MG3 MTprimidone oral tablet 250 MG, 50 MG MYSOLINE 1 MT; CGSABRIL ORAL PACKET(vigabatrin)500 MG5 PA; MT; LA

MedicamentoSABRIL ORAL TABLET(vigabatrin)500 MGSTAVZOR ORAL CAPSULE DELAYEDRELEASE(valproic acid)125 MG, 250 MG, 500 MGTEGRETOL ORAL SUSPENSION(carbamazepine)100 MG/5MLTEGRETOL ORAL TABLET(carbamazepine)200 MGTEGRETOL-XR ORAL TABLET EXTENDEDRELEASE 12 HR(carbamazepine er)100 MG, 200 MG, 400 MGReferencia deMarcaNivel Requisitos /Límites5 PA; MT; LA4 MT3 MT3 MT3 MTtiagabine hcl oral tablet 2 MG, 4 MG GABITRIL 2 MT; CGtopiramate oral capsule sprinkle 15 MG, 25 MG TOPAMAX 2 MT; CGtopiramate oral tablet 100 MG, 200 MG, 25 MG,50 MGTRILEPTAL ORAL SUSPENSION(oxcarbazepine)300 MG/5MLvalproate sodium intravenous solution 100MG/MLTOPAMAX 1 MT; CG3 MTDEPACON 2 CGvalproic acid oral capsule 250 MG DEPAKENE 2 MT; CGvalproic acid oral syrup 250 MG/5ML DEPAKENE 2 MT; CGVIMPAT INTRAVENOUS SOLUTION(lacosamide)200 MG/20MLVIMPAT ORAL SOLUTION(lacosamide)10 MG/ML33 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 91 de 150

MedicamentoVIMPAT ORAL TABLET(lacosamide)100 MG, 150 MG, 200 MG, 50 MGReferencia deMarcaLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 92 de 150Nivel Requisitos /Límites3 MTzonisamide oral capsule 100 MG, 25 MG ZONEGRAN 1 MT; CGzonisamide oral capsule 50 MG ZONEGRAN 2 MT; CGMigraña / Tratamiento para el dolor de CabezaAXERT ORAL TABLET(almotriptan malate)6.25 MGAXERT ORAL TABLET(almotriptan malate)12.5 MGERGOMAR SUBLINGUAL TABLETSUBLINGUAL(ergotamine tartrate)2 MGFROVA ORAL TABLET(frovatriptan succinate)2.5 MGMIGERGOT RE SUPPOSITORY(ergotamine-caffeine)2-100 MG4 QL (18 / 28 día(s))4 QL (24 / 28 día(s))34 QL (27 / 28 día(s))naratriptan hcl oral tablet 1 MG, 2.5 MG AMERGE 2 QL (18 / 28 día(s))RELPAX ORAL TABLET(eletriptan hydrobromide)20 MG, 40 MG24 QL (18 / 28 día(s))rizatriptan benzoate oral tablet 10 MG, 5 MG MAXALT 2 QL (27 / 28 día(s))rizatriptan benzoate oral tablet dispersible 10MG, 5 MGsumatriptan succinate oral tablet 100 MG, 25MG, 50 MGsumatriptan succinate subcutaneous solution 6MG/0.5MLTREXIMET ORAL TABLET(sumatriptan-naproxen sodium)85-500 MGMAXALT MLT 2 QL (27 / 28 día(s))IMITREX 2 QL (18 / 28 día(s))IMITREX 2 QL (8 ML / 28 día(s))4 QL (18 / 28 día(s))

MedicamentoTratamiento Neurológico MisceláneoCOPAXONE SUBCUTANEOUS KIT(glatiramer acetate)20 MG/MLReferencia deMarcaNivel Requisitos /Límites5 QL (30 / 30 día(s))donepezil hcl oral tablet 10 MG, 5 MG ARICEPT 1 MT; CG; QL (30 / 30día(s))donepezil hcl oral tablet dispersible 10 MG, 5MGEXELON TRANSDERMAL PATCH 24 HR(rivastigmine)13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HRgalantamine hydrobromide oral solution 4MG/MLgalantamine hydrobromide oral tablet 12 MG, 4MG, 8 MGgalantamine hydrobromide er oral capsuleextended release 24 hour 16 MG, 24 MG, 8 MGGILENYA ORAL CAPSULE(fingolimod hcl)0.5 MGNAMENDA ORAL SOLUTION(memantine hcl)10 MG/5MLNAMENDA ORAL TABLET(memantine hcl)10 MG, 5 MGNAMENDA TITRATION PAK ORAL TABLET(memantine hcl)5 (28)-10 (21) MGNUEDEXTA ORAL CAPSULE(dextromethorphan-quinidine)20-10 MGrivastigmine tartrate oral capsule 1.5 MG, 3 MG,4.5 MG, 6 MGARICEPT ODT 1 MT; CG; QL (30 / 30día(s))3 MTRAZADYNE 2 MT; CGRAZADYNE 2 MT; CGRAZADYNE 2 MT; CG5 QL (30 / 30 día(s))3 MT; QL (300 ML / 30día(s))3 MT; QL (60 / 30día(s))3 QL (49 / 28 día(s))EXELON 2 MT; CG3LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 93 de 150

MedicamentoTYSABRI INTRAVENOUS CONCENTRATE(natalizumab)300 MG/15MLXENAZINE ORAL TABLET(tetrabenazine)12.5 MG, 25 MGRelajantes Musculares / Terapia EspasmódicaReferencia deMarcabaclofen oral tablet 10 MG, 20 MG 2dantrolene sodium oral capsule 100 MG, 25 MG,50 MGMESTINON ORAL TABLETEXTENDEDRELEASE(pyridostigmine bromide er)180 MGDANTRIUM 2Nivel Requisitos /Límites5 PA; LA5 MT; LApyridostigmine bromide oral tablet 60 MG MESTINON 2 CGtizanidine hcl oral tablet 2 MG ZANAFLEX 2ZANAFLEX ORAL CAPSULE(tizanidine hcl)2 MG, 4 MG, 6 MGZANAFLEX ORAL TABLET(tizanidine hcl)4 MGMedicamentos Endocrinos / Medicamentos para la DiabetesAgentes Antitiroideosmethimazole oral tablet 10 MG, 5 MG TAPAZOLE 1 MT; CGpropylthiouracil oral tablet 50 MG 1 MT; CGHormonas AdrenalesCELESTONE ORAL SOLUTION(betamethasone)0.6 MG/5MLcortisone acetate oral tablet 25 MG 1dexamethasone oral elixir 0.5 MG/5ML 1dexamethasone oral tablet 0.5 MG, 0.75 MG, 1MG, 1.5 MG, 2 MG, 4 MG, 6 MG34241LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 94 de 150

Medicamentodexamethasone intensol oral concentrate(dexamethasone)1 mg/mldexamethasone sodium phosphate injectionsolution 4 MG/MLReferencia deMarcaNivel Requisitos /Límitesfludrocortisone acetate oral tablet 0.1 MG 1 CGhydrocortisone oral tablet 10 MG, 20 MG, 5 MG CORTEF 2methylprednisolone oral tablet 16 MG, 4 MG, 8MG11MEDROL 2methylprednisolone oral tablet 32 MG MEDROL 1methylprednisolone (pak) oral tablet 4 MG MEDROL 2methylprednisolone acetate injection suspension40 MG/ML, 80 MG/MLmethylprednisolone sodium succ injectionsolution reconstituted 125 MG, 40 MGORAPRED ORAL SOLUTION(prednisolone sodium phosphate)15 MG/5MLORAPRED ODT ORAL TABLETDISPERSIBLE(prednisolone sodium phosphate)15 MG, 30 MGprednisolone sodium phosphate oral solution 25MG/5ML, 6.7 (5 Base) MG/5MLDEPO-MEDROL 1DEPO-MEDROL 1PRED FORTE 2prednisone oral solution 5 MG/5ML PRELONE 1prednisone oral tablet 1 MG, 10 MG, 2.5 MG, 20MG, 5 MG, 50 MGprednisone intensol oral concentrate(prednisone)5 mg/mlveripred 20 oral solution(prednisolone sodium phosphate)20 mg/5ml24122LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 95 de 150

MedicamentoHormonas Tiroideoslevothroid oral tablet(levothyroxine sodium)100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg,175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75mcg, 88 mcglevothyroxine sodium oral tablet100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg,200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88mcglevoxyl oral tablet(levothyroxine sodium)100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg,175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88mcgliothyronine sodium intravenous solution 10MCG/MLliothyronine sodium oral tablet 25 MCG, 5 MCG,50 MCGSYNTHROID ORAL TABLET(levothyroxine sodium)100 MCG, 112 MCG, 125 MCG, 137 MCG, 150MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG,50 MCG, 75 MCG, 88 MCGunithroid oral tablet(levothyroxine sodium)100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg,200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88mcgHormonas MisceláneasALDURAZYME INTRAVENOUS SOLUTION(laronidase)2.9 MG/5MLANDROGEL TRANSDERMAL GEL(testosterone)50 MG/5GMReferencia deMarcaNivel Requisitos /LímitesSYNTHROID 1 MT; CGSYNTHROID 1 MT; CGSYNTHROID 1 MT; CGCYTOMEL 2 CGCYTOMEL 2 MT; CG3 MTSYNTHROID 1 MT; CG5 PA3LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 96 de 150

MedicamentoANDROGEL PUMP TRANSDERMAL GEL(testosterone)20.25 MG/ACT (1.62%)androxy oral tablet(fluoxymesterone)10 mgAXIRON TRANSDERMAL SOLUTION(testosterone)30 MG/ACTReferencia deMarcaNivel Requisitos /Límitescabergoline oral tablet 0.5 MG 2 CG; QL (20 / 30día(s))calcitriol intravenous solution 1 MCG/ML VECTICAL 2 PA; CGcalcitriol oral capsule 0.25 MCG, 0.5 MCG VECTICAL 2 PA; CGcalcitriol oral solution 1 MCG/ML VECTICAL 2 PA; CGCEREZYME INTRAVENOUS SOLUTIONRECONSTITUTED(imiglucerase)200 UNITdanazol oral capsule 200 MG, 50 MG 2 CGdanazol oral capsule 100 MG 2 CG; QL (60 / 30día(s))desmopressin ace spray refrig nasal solution 0.01%DDAVP 2 CGdesmopressin acetate oral tablet 0.1 MG, 0.2 MG DDAVP 2 CGdesmopressin acetate injection solution 4MCG/MLELAPRASE INTRAVENOUS SOLUTION(idursulfase)6 MG/3MLELELYSO INTRAVENOUS SOLUTIONRECONSTITUTED(taliglucerase alfa)200 UNITDDAVP 2 PA; CG32355 PA5 PALA - Esta receta puede estar sólo disponible en algunas farmacias.Página 97 de 150

MedicamentoFABRAZYME INTRAVENOUS SOLUTIONRECONSTITUTED(agalsidase beta)35 MGFORTICAL NASAL SOLUTION(calcitonin (salmon))200 UNIT/ACTKUVAN ORAL TABLET SOLUBLE(sapropterin dihydrochloride)100 MGReferencia deMarcaNivel Requisitos /LímitesMIACALCIN 2 MT; CGmethyltestosterone oral tablet 10 MG METHITEST 3MIACALCIN INJECTION SOLUTION(calcitonin (salmon))200 UNIT/MLNAGLAZYME INTRAVENOUS SOLUTION(galsulfase)1 MG/ML55 PA; LA3 PA5 PA; LAoxandrolone oral tablet 2.5 MG OXANDRIN 2 CG; QL (60 / 30día(s))oxandrolone oral tablet 10 MG OXANDRIN 5 QL (60 / 30 día(s))pamidronate disodium intravenous solution 30MG/10ML, 90 MG/10MLSENSIPAR ORAL TABLET(cinacalcet hcl)30 MGSENSIPAR ORAL TABLET(cinacalcet hcl)90 MGSENSIPAR ORAL TABLET(cinacalcet hcl)60 MGSOMAVERT SUBCUTANEOUS SOLUTIONRECONSTITUTED(pegvisomant)10 MG, 15 MG, 20 MG2 PA; CG3 QL (60 / 30 día(s))5 QL (120 / 30 día(s))5 QL (60 / 30 día(s))5 LALA - Esta receta puede estar sólo disponible en algunas farmacias.Página 98 de 150

MedicamentoSTIMATE NASAL SOLUTION(desmopressin acetate)1.5 MG/MLSYNAREL NASAL SOLUTION(nafarelin acetate)2 MG/MLTESTIM TRANSDERMAL GEL(testosterone)50 MG/5GMTESTRED ORAL CAPSULE(methyltestosterone)10 MGZAVESCA ORAL CAPSULE(miglustat)100 MGZEMPLAR ORAL CAPSULE(paricalcitol)1 MCG, 2 MCG, 4 MCGzoledronic acid intravenous concentrate4 MG/5MLZOMETA INTRAVENOUS SOLUTION(zoledronic acid)4 MG/100MLZOMETA INTRAVENOUS CONCENTRATE(zoledronic acid)4 MG/5MLTratamiento para la DiabetesReferencia deMarcaNivel Requisitos /Límites45 PA445 PA; LA; QL (90 / 30día(s))4 PAZOMETA 2 PA52 PAacarbose oral tablet 50 MG PRECOSE 2 MT; CG; QL (180 / 30día(s))acarbose oral tablet 25 MG PRECOSE 2 MT; CG; QL (360 / 30día(s))acarbose oral tablet 100 MG PRECOSE 2 MT; CG; QL (90 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 99 de 150

Medicamentoalcohol preps xx padINSULIN SYRINGE XX MISC(insulin syringe-needle u-100)29G X 1/2" 1 MLINSULIN SYRINGE ULTRAFINE XX MISC(insulin syringe-needle u-100)30G X 1/2" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X5/16" 1 MLPEN NEEDLE ULTRAFINE XX MISC(insulin pen needle)29G X 12.7MMBYETTA 10 MCG PEN SUBCUTANEOUSSOLUTION(exenatide)10 MCG/0.04MLBYETTA 5 MCG PEN SUBCUTANEOUSSOLUTION(exenatide)5 MCG/0.02MLCYCLOSET ORAL TABLET(bromocriptine mesylate)0.8 MGReferencia deMarcaBD, CURAD,CURITY, EASYTOUCH, FIFTY50,REALITY, QC, SURECOMFORT, WEBCOL1ST TIER,AUTOSHIELD, BD,CLICKFINE, EASYCOMFORT, EASYTOUCH, FIFTY50,INCONTROL,LITETOUCH,NOVOTWIST,PRODIGY, SURE-COMFORT, SURE-FINE, UNIFINE1ST TIER, BD,COMFORT EZ, EASYTOUCH, NOVOFINE,SURE-COMFORT,SURE-FINE, UNIFINE1ST TIER, BD,AUTOSHIELD, EASYTOUCH,INCONTROL,UNIFINENivel Requisitos /Límites3 QL (100 / 30 día(s))3 QL (100 / 30 día(s))3 QL (100 / 30 día(s))3 QL (100 / 30 día(s))3 MT; QL (4.8 ML / 30día(s))3 MT; QL (2.4 ML / 30día(s))3 MTglimepiride oral tablet 2 MG AMARYL 1 MT; CG; QL (120 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 100 de 150

MedicamentoReferencia deMarcaNivel Requisitos /Límitesglimepiride oral tablet 1 MG AMARYL 1 MT; CG; QL (240 / 30día(s))glimepiride oral tablet 4 MG AMARYL 1 MT; CG; QL (60 / 30día(s))glipizide oral tablet 10 MG GLUCOTROL 1 MT; CG; QL (120 / 30día(s))glipizide oral tablet 5 MG GLUCOTROL 1 MT; CG; QL (240 / 30día(s))glipizide er oral tablet extended release 24 hr 5MGglipizide er oral tablet extended release 24 hr 2.5MGglipizide er oral tablet extended release 24 hr 10MGglipizide-metformin hcl oral tablet 2.5-500 MG,5-500 MGGLUCOTROL XL 1 MT; CG; QL (120 / 30día(s))GLUCOTROL XL 1 MT; CG; QL (240 / 30día(s))GLUCOTROL XL 1 MT; CG; QL (60 / 30día(s))1 MT; CG; QL (120 / 30día(s))glipizide-metformin hcl oral tablet 2.5-250 MG 1 MT; CG; QL (240 / 30día(s))GLUCAGON EMERGENCY INJECTION KIT(glucagon (rdna))1 MGglyburide oral tablet 5 MG DIABETA 1 MT; CG; QL (120 / 30día(s))glyburide oral tablet 2.5 MG DIABETA 1 MT; CG; QL (240 / 30día(s))glyburide oral tablet 1.25 MG DIABETA 1 MT; CG; QL (480 / 30día(s))glyburide micronized oral tablet 3 MG GLYNASE 1 MT; CG; QL (120 / 30día(s))glyburide micronized oral tablet 1.5 MG GLYNASE 1 MT; CG; QL (240 / 30día(s))glyburide micronized oral tablet 6 MG GLYNASE 1 MT; CG; QL (60 / 30día(s))glyburide-metformin oral tablet 2.5-500 MG, 5-500 MG3GLUCOVANCE 1 MT; CG; QL (120 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 101 de 150

MedicamentoReferencia deMarcaNivel Requisitos /Límitesglyburide-metformin oral tablet 1.25-250 MG GLUCOVANCE 1 MT; CG; QL (240 / 30día(s))GLYSET ORAL TABLET(miglitol)50 MGGLYSET ORAL TABLET(miglitol)25 MGGLYSET ORAL TABLET(miglitol)100 MGHUMALOG SUBCUTANEOUS SOLUTION(insulin lispro (human))100 UNIT/ML3 MT; QL (180 / 30día(s))3 MT; QL (360 / 30día(s))3 MT; QL (90 / 30día(s))3 MT; QL (30 ML / 30día(s))HUMALOG MIX 50/50 SUBCUTANEOUSSUSPENSION(insulin lispro prot & lispro)(50-50) 100 UNIT/MLHUMALOG MIX 50/50 KWIKPENSUBCUTANEOUS SUSPENSION(insulin lispro prot & lispro)(50-50) 100 UNIT/MLHUMALOG MIX 75/25 SUBCUTANEOUSSUSPENSION(insulin lispro prot & lispro)(75-25) 100 UNIT/MLHUMALOG MIX 75/25 KWIKPENSUBCUTANEOUS SUSPENSION(insulin lispro prot & lispro)(75-25) 100 UNIT/MLHUMULIN 70/30 SUBCUTANEOUSSUSPENSION(insulin isophane & regular)(70-30) 100 UNIT/MLHUMULIN 70/30 PEN SUBCUTANEOUSSUSPENSION(insulin isophane & regular)(70-30) 100 UNIT/ML3 MT; QL (30 ML / 30día(s))4 MT; QL (30 ML / 30día(s))3 MT; QL (30 ML / 30día(s))4 MT; QL (30 ML / 30día(s))3 MT; QL (30 ML / 30día(s))4 MT; QL (30 ML / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 102 de 150

MedicamentoHUMULIN N SUBCUTANEOUSSUSPENSION(insulin isophane human)100 UNIT/MLHUMULIN N PEN SUBCUTANEOUSSUSPENSION(insulin isophane human)100 UNIT/MLHUMULIN R INJECTION SOLUTION(insulin regular human)100 UNIT/MLHUMULIN R U-500 (CONCENTRATED)SUBCUTANEOUS SOLUTION(insulin regular human (conc))500 UNIT/MLJANUMET ORAL TABLET(sitagliptin-metformin hcl)50-1000 MG, 50-500 MGJANUVIA ORAL TABLET(sitagliptin phosphate)100 MG, 25 MG, 50 MGJENTADUETO ORAL TABLET(linagliptin-metformin hcl)2.5-1000 MG, 2.5-500 MG, 2.5-850 MGGAUZE XX MISC(gauze pads & dressings)Referencia deMarcaNivel Requisitos /Límites3 MT; QL (30 ML / 30día(s))4 MT; QL (30 ML / 30día(s))3 MT; QL (30 ML / 30día(s))3 MT; QL (40 ML / 30día(s))4 MT; QL (60 / 30día(s))4 MT; QL (30 / 30día(s))3 MT; QL (60 / 30día(s))3KOMBIGLYZE XR ORAL TABLETEXTENDED RELEASE 24 HR(saxagliptin-metformin er)2.5-1000 MG, 5-1000 MG, 5-500 MGLANTUS SUBCUTANEOUS SOLUTION(insulin glargine)100 UNIT/MLLEVEMIR SUBCUTANEOUS SOLUTION(insulin detemir)100 UNIT/ML3 MT; QL (30 / 30día(s))3 MT; QL (30 ML / 30día(s))3 MT; QL (30 ML / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 103 de 150

MedicamentoLEVEMIR FLEXPEN SUBCUTANEOUSSOLUTION(insulin detemir)100 UNIT/MLmetformin hcl oral tablet 1000 MG, 500 MG, 850MGmetformin hcl er oral tablet extended release 24hr 500 MG, 750 MGmetformin hcl er (osm) oral tablet extendedrelease 24 hr 1000 MGONGLYZA ORAL TABLET(saxagliptin hcl)2.5 MG, 5 MGpioglitazone hcl oral tablet 15 MG, 30 MG, 45MGpioglitazone hcl-glimepiride oral tablet 30-2 MG,30-4 MGpioglitazone hcl-metformin hcl oral tablet 15-500MG, 15-850 MGPRANDIMET ORAL TABLET(repaglinide-metformin hcl)1-500 MG, 2-500 MGPRANDIN ORAL TABLET(repaglinide)2 MGPRANDIN ORAL TABLET(repaglinide)1 MGPRANDIN ORAL TABLET(repaglinide)0.5 MGPROGLYCEM ORAL SUSPENSION(diazoxide)50 MG/MLRIOMET ORAL SOLUTION(metformin hcl)500 MG/5MLReferencia deMarcaNivel Requisitos /Límites4 MT; QL (30 ML / 30día(s))GLUCOPHAGE 1 MT; CGGLUCOPHAGE XR 1 MT; CGFORTAMET 1 MT; CG3 MT; QL (30 / 30día(s))ACTOS 2 MT; CG; QL (30 / 30día(s))DUETACT 2 MT; CG; QL (30 / 30día(s))ACTOPLUS MET 2 MT; CG; QL (90 / 30día(s))4 MT; QL (150 / 30día(s))3 MT; QL (240 / 30día(s))3 MT; QL (480 / 30día(s))3 MT; QL (960 / 30día(s))34 MT; QL (765 ML / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 104 de 150

MedicamentoSYMLINPEN 120 SUBCUTANEOUSSOLUTION(pramlintide acetate)2700 MCG/2.7MLSYMLINPEN 60 SUBCUTANEOUSSOLUTION(pramlintide acetate)1500 MCG/1.5MLReferencia deMarcaNivel Requisitos /Límites3 MT; QL (10.8 ML / 30día(s))3 MT; QL (6 ML / 30día(s))tolazamide oral tablet 250 MG 2 MT; CG; QL (120 / 30día(s))tolazamide oral tablet 500 MG 2 MT; CG; QL (60 / 30día(s))tolbutamide oral tablet 500 MG 2 MT; CG; QL (180 / 30día(s))TRADJENTA ORAL TABLET(linagliptin)5 MGMedicamentos Musculoesqueletales / Medicamentos ReumatológicosAgentes ReumatológicosACTEMRA INTRAVENOUS SOLUTION(tocilizumab)200 MG/10MLBENLYSTA INTRAVENOUS SOLUTIONRECONSTITUTED(belimumab)120 MGDEPEN TITRATABS ORAL TABLET(penicillamine)250 MGENBREL SUBCUTANEOUS SOLUTION(etanercept)50 MG/MLENBREL SUBCUTANEOUS KIT(etanercept)25 MG3 MT; QL (30 / 30día(s))53 PA45 QL (4 ML / 28 día(s))5 QL (8 / 28 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 105 de 150

MedicamentoENBREL SUBCUTANEOUS SOLUTION(etanercept)25 MG/0.5MLHUMIRA SUBCUTANEOUS KIT(adalimumab)20 MG/0.4MLHUMIRA SUBCUTANEOUS KIT(adalimumab)40 MG/0.8MLHUMIRA PEN-CROHNS STARTERSUBCUTANEOUS KIT(adalimumab)40 MG/0.8MLReferencia deMarcaNivel Requisitos /Límites5 QL (8 ML / 28 día(s))5 QL (0.8 / 30 día(s))5 QL (3.2 / 28 día(s))5 QL (6 / 30 día(s))leflunomide oral tablet 10 MG, 20 MG ARAVA 2 CG; QL (30 / 30día(s))ORENCIA INTRAVENOUS SOLUTIONRECONSTITUTED(abatacept)250 MGRIDAURA ORAL CAPSULE(auranofin)3 MGSAVELLA ORAL TABLET(milnacipran hcl)100 MG, 12.5 MG, 25 MG, 50 MGSAVELLA TITRATION PACK ORAL MISC(milnacipran hcl)12.5 & 25 & 50 MGTerapia para la Gota533 MTallopurinol oral tablet 100 MG, 300 MG ZYLOPRIM 1 MT; CGcolchicine-probenecid oral tablet 0.5-500 MG 2 MT; CGCOLCRYS ORAL TABLET(colchicine)0.6 MGprobenecid oral tablet 500 MG 2 CG33LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 106 de 150

MedicamentoULORIC ORAL TABLET(febuxostat)40 MG, 80 MGTratamiento para la OsteoporosisACTONEL ORAL TABLET(risedronate sodium)150 MGACTONEL ORAL TABLET(risedronate sodium)5 MGACTONEL ORAL TABLET(risedronate sodium)35 MGReferencia deMarcaNivel Requisitos /Límites4 MTalendronate sodium oral solution 70 MG/75ML FOSAMAX 2 MT4 MT; QL (1 / 30 día(s))4 MT; QL (30 / 30día(s))4 MT; QL (4 / 28 día(s))alendronate sodium oral tablet 10 MG, 5 MG FOSAMAX 1 MT; CG; QL (30 / 30día(s))alendronate sodium oral tablet 35 MG, 70 MG FOSAMAX 1 MT; CG; QL (4 / 28día(s))BONIVA INTRAVENOUS SOLUTION(ibandronate sodium)3 MG/3MLEVISTA ORAL TABLET(raloxifene hcl)60 MGFORTEO SUBCUTANEOUS SOLUTION(teriparatide (recombinant))600 MCG/2.4ML3 PA3 MT5 MT; QL (2.4 ML / 28día(s))ibandronate sodium oral tablet 150 MG BONIVA 2 MT; CG; QL (1 / 30día(s))PROLIA SUBCUTANEOUS SOLUTION(denosumab)60 MG/ML3 PALA - Esta receta puede estar sólo disponible en algunas farmacias.Página 107 de 150

MedicamentoMedicamentos Obstétricos / GinecologíaContraceptivos Orales y Agentes Relacionadosapri oral tablet(desogestrel-ethinyl estradiol)0.15-30 mg-mcgaranelle oral tablet(norethin-eth estrad triphasic)0.5/1/0.5-35 mg-mcgaviane oral tablet(levonorgestrel-ethinyl estrad)0.1-20 mg-mcgbalziva oral tablet(norethindrone-eth estradiol)0.4-35 mg-mcgcryselle-28 oral tablet(norgestrel-ethinyl estradiol)0.3-30 mg-mcgcyclafem 1/35 oral tablet(norethindrone-eth estradiol)1-35 mg-mcgcyclafem 7/7/7 oral tablet(norethin-eth estrad triphasic)0.5/0.75/1-35 mg-mcgdrospirenone-ethinyl estradiol oral tablet 3-0.03MGemoquette oral tablet(desogestrel-ethinyl estradiol)0.15-30 mg-mcgenpresse-28 oral tablet(levonorg-eth estrad triphasic)gianvi oral tablet(drospirenone-ethinyl estradiol)3-0.02 mggildagia oral tablet(norethindrone-eth estradiol)0.4-35 mg-mcgReferencia deMarcaORTHO-CEPT 2TRI-NORINYL 2Nivel Requisitos /Límites2OVCON 22NORINYL 2NORINYL 2YASMIN 2DESOGEN 21YAZ 2OVCON 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 108 de 150

Medicamentojunel 1.5/30 oral tablet(norethindrone acet-ethinyl est)1.5-30 mg-mcgjunel 1/20 oral tablet(norethindrone acet-ethinyl est)1-20 mg-mcgjunel fe 1.5/30 oral tablet(norethin ace-eth estrad-fe)1.5-30 mg-mcgjunel fe 1/20 oral tablet(norethin ace-eth estrad-fe)1-20 mg-mcgkariva oral tablet(desogestrel-ethinyl estradiol)0.15-0.02/0.01 mg (21/5)kelnor 1/35 oral tablet(ethynodiol diac-eth estradiol)1-35 mg-mcgleena oral tablet(norethin-eth estrad triphasic)0.5/1/0.5-35 mg-mcglessina oral tablet(levonorgestrel-ethinyl estrad)0.1-20 mg-mcglevonest oral tablet(levonorg-eth estrad triphasic)levora 0.15/30 (28) oral tablet(levonorgestrel-ethinyl estrad)0.15-30 mg-mcgloryna oral tablet(drospirenone-ethinyl estradiol)3-0.02 mglow-ogestrel oral tablet(norgestrel-ethinyl estradiol)0.3-30 mg-mcgReferencia deMarcaLOESTRIN 2LOESTRIN 2LOESTRIN FE 2LOESTRIN FE 2MIRCETTE 2TRI-NORINYL 2Nivel Requisitos /Límites22PLAN B 1NORDETTE 2YAZ 22LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 109 de 150

Medicamentolutera oral tablet(levonorgestrel-ethinyl estrad)0.1-20 mg-mcgReferencia deMarcamarlissa oral tablet 0.15-30 mg-mcg NORDETTE 2Nivel Requisitos /Límites2microgestin 1.5/30 oral tablet(norethindrone acet-ethinyl est)1.5-30 mg-mcgmicrogestin 1/20 oral tablet(norethindrone acet-ethinyl est)1-20 mg-mcgmicrogestin fe 1.5/30 oral tablet(norethin ace-eth estrad-fe)1.5-30 mg-mcgmicrogestin fe 1/20 oral tablet(norethin ace-eth estrad-fe)1-20 mg-mcgmononessa oral tablet(norgestimate-eth estradiol)0.25-35 mg-mcgnecon 0.5/35 (28) oral tablet(norethindrone-eth estradiol)0.5-35 mg-mcgnecon 1/35 (28) oral tablet(norethindrone-eth estradiol)1-35 mg-mcgnecon 10/11 (28) oral tablet(norethin-eth estrad biphasic)35 mcgnecon 7/7/7 oral tablet(norethin-eth estrad triphasic)0.5/0.75/1-35 mg-mcgnortrel 0.5/35 (28) oral tablet(norethindrone-eth estradiol)0.5-35 mg-mcgLOESTRINLOESTRINLOESTRIN FE 2LOESTRIN FE 2ORTHO-CYCLEN 1NORINYL 2NORINYL 2NORINYL 2NORINYL 2ORTHO-NOVUM 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 110 de 150

Medicamentonortrel 1/35 (21) oral tablet(norethindrone-eth estradiol)1-35 mg-mcgnortrel 1/35 (28) oral tablet(norethindrone-eth estradiol)1-35 mg-mcgnortrel 7/7/7 oral tablet(norethin-eth estrad triphasic)0.5/0.75/1-35 mg-mcgogestrel oral tablet(norgestrel-ethinyl estradiol)0.5-50 mg-mcgorsythia oral tablet(levonorgestrel-ethinyl estrad)0.1-20 mg-mcgportia-28 oral tablet(levonorgestrel-ethinyl estrad)0.15-30 mg-mcgprevifem oral tablet(norgestimate-eth estradiol)0.25-35 mg-mcgquasense oral tablet(levonorgest-eth estrad 91-day)0.15-0.03 mgreclipsen oral tablet(desogestrel-ethinyl estradiol)0.15-30 mg-mcgsprintec 28 oral tablet(norgestimate-eth estradiol)0.25-35 mg-mcgsronyx oral tablet(levonorgestrel-ethinyl estrad)0.1-20 mg-mcgtri-legest fe oral tablet(norethindron-ethinyl estrad-fe)1-20/1-30/1-35 mg-mcgReferencia deMarcaORTHO-NOVUM 1ORTHO-NOVUM 1ORTHO-NOVUM 2Nivel Requisitos /Límites22NORDETTE 2ORTHO-CYCLEN 2ORTHO-CEPT 2ORTHO-CYCLEN 1ESTROSTEP FE 222LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 111 de 150

Medicamentotrinessa (28) oral tablet(norgestim-eth estrad triphasic)0.18/0.215/0.25 mg-35 mcgtri-previfem oral tablet(norgestim-eth estrad triphasic)0.18/0.215/0.25 mg-35 mcgtri-sprintec oral tablet(norgestim-eth estrad triphasic)0.18/0.215/0.25 mg-35 mcgtrivora (28) oral tablet(levonorg-eth estrad triphasic)velivet oral tablet(desogest-eth estrad triphasic)0.1/0.125/0.15 -0.025 mgzovia 1/35e (28) oral tablet(ethynodiol diac-eth estradiol)1-35 mg-mcgzovia 1/50e (28) oral tablet(ethynodiol diac-eth estradiol)1-50 mg-mcgEstrógenos / ProgestinaANGELIQ ORAL TABLET(drospirenone-estradiol)0.5-1 MGcamila oral tablet(norethindrone)0.35 mgCENESTIN ORAL TABLET(estrogens conj synthetic a)0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MGCOMBIPATCH TRANSDERMAL PATCHBIWEEKLY(estradiol-norethindrone acet)0.05-0.14 MG/DAY, 0.05-0.25 MG/DAYReferencia deMarcaORTHO TRI-CYCLEN 1ORTHO TRI-CYCLEN 2ORTHO TRI-CYCLEN 2ORTHO TRI-CYCLEN 2Nivel Requisitos /LímitesNOR-Q-D 2 MT122444LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 112 de 150

MedicamentoCRINONE VAGINAL GEL(progesterone)8 %DEPO-PROVERA INTRAMUSCULARSUSPENSION(medroxyprogesterone acetate)400 MG/MLDIVIGEL TRANSDERMAL GEL(estradiol)1 MG/GMELESTRIN TRANSDERMAL GEL(estradiol)0.52 MG/0.87 GM (0.06%)ENJUVIA ORAL TABLET(estrogens conj synthetic b)0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MGerrin oral tablet(norethindrone)0.35 mgESTRACE VAGINAL CREAM(estradiol)0.1 MG/GMReferencia deMarcaNivel Requisitos /Límites434 QL (30 GM / 30 día(s))4 QL (144 GM / 30día(s))4NOR-Q-D 23 MTestradiol oral tablet 0.5 MG, 1 MG, 2 MG NOR-Q-D 1 CGestradiol-norethindrone acet oral tablet 0.5-0.1MG, 1-0.5 MGESTRING VAGINAL RING(estradiol)2 MGACTIVELLA 24 MTestropipate oral tablet 0.75 MG, 1.5 MG 1 CGestropipate oral tablet 3 MG 2 CGEVAMIST TRANSDERMAL SOLUTION(estradiol)1.53 MG/SPRAYFEMRING VAGINAL RING(estradiol acetate)0.05 MG/24HR, 0.1 MG/24HR4 QL (16.2 ML / 30día(s))4 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 113 de 150

Medicamentomedroxyprogesterone acetate oral tablet 10 MG,2.5 MG, 5 MGmedroxyprogesterone acetate intramuscularsuspension 150 MG/MLMENEST ORAL TABLET(esterified estrogens)0.3 MG, 0.625 MG, 1.25 MG, 2.5 MGMENOSTAR TRANSDERMAL PATCHWEEKLY(estradiol)14 MCG/24HRNORA-BE ORAL TABLET(norethindrone)0.35 MGReferencia deMarcaPROVERA 1LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 114 de 150Nivel Requisitos /LímitesPROVERA 1 QL (1 ML / 90 día(s))MICRONOR 23 PAnorethindrone acetate oral tablet 5 MG AYGESTIN 2 MTPREFEST ORAL TABLET(estradiol-norgestimate)1/1-0.09 MG (15/15)PREMARIN INJECTION SOLUTIONRECONSTITUTED(estrogens conjugated)25 MGPREMARIN ORAL TABLET(estrogens conjugated)0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MGPREMARIN VAGINAL CREAM(estrogens, conjugated)0.625 MG/GMPREMPHASE ORAL TABLET(conj estrog-medroxyprogest ace)0.625-5 MGPREMPRO ORAL TABLET(conj estrog-medroxyprogest ace)0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MGprogesterone micronized oral capsule 100 MG,200 MG4 QL (4 / 28 día(s))4333 MTPROMETRIUM 2 MT3 QL (28 / 28 día(s))3 QL (28 / 28 día(s))

MedicamentoVAGIFEM VAGINAL TABLET(estradiol)10 MCGVIVELLE-DOT TRANSDERMAL PATCHBIWEEKLY(estradiol)0.025 MG/24HR, 0.0375 MG/24HR, 0.05MG/24HR, 0.075 MG/24HR, 0.1 MG/24HRAgentes Misceláneos para Obstetricia y GinecologíaCLEOCIN VAGINAL CREAM(clindamycin phosphate)2 %CLEOCIN VAGINAL SUPPOSITORY(clindamycin phosphate)100 MGReferencia deMarcaCLEOCIN 2Nivel Requisitos /Límites3 MT4 QL (10 / 35 día(s))miconazole 3 vaginal suppository 200 MG 2 QL (3 / 3 día(s))NUVARING VAGINAL RING(etonogestrel-ethinyl estradiol)0.12-0.015 MG/24HRterconazole vaginal suppository 80 MG TERAZOL 3 2 QL (3 / 3 día(s))terconazole vaginal cream 0.4 %, 0.8 % TERAZOL 3 1 QL (45 GM / 7 día(s))VANDAZOLE VAGINAL GEL(metronidazole)0.75 %Oxitocinas44CLEOCIN 2methylergonovine maleate oral tablet 0.2 MG METHERGINE 2 CGMedicamentos para Oído, Nariz y GargantaEsteroides Óticos / AntibióticosCIPRODEX OTIC SUSPENSION(ciprofloxacin-dexamethasone)0.3-0.1 %neomycin-polymyxin-hc otic solution 3.5-10000-1 CORTISPORIN 2neomycin-polymyxin-hc otic suspension 3.5-10000-1CORTISPORIN 23LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 115 de 150

MedicamentoAgentes MisceláneosASTEPRO NASAL SOLUTION(azelastine hcl)0.15 %Referencia deMarcaNivel Requisitos /Límites3 QL (60 ML / 30 día(s))azelastine hcl nasal solution 137 MCG/SPRAY OPTIVAR 2 QL (30 ML / 30 día(s))BACTROBAN NASAL NASAL OINTMENT(mupirocin calcium)2 %ipratropium bromide nasal solution 0.06 % ATROVENT 1 QL (15 ML / 30 día(s))ipratropium bromide nasal solution 0.03 % ATROVENT 1 QL (30 ML / 30 día(s))PATANASE NASAL SOLUTION(olopatadine hcl)0.6 %PERIOGARD MOUTH/THROAT SOLUTION(chlorhexidine gluconate)0.12 %triamcinolone acetonide mouth/throat paste 0.1%TYZINE NASAL SOLUTION(tetrahydrozoline hcl)0.05 %, 0.1 %Preparaciones Óticas, Misceláneasacetasol hc otic solution(hydrocortisone-acetic acid)2-1 %NASACORT AQ 244 QL (61 GM / 30 día(s))13VOSOL HC 2acetic acid otic solution 2 % 2DERMOTIC OTIC OIL(fluocinolone acetonide)0.01 %fluocinolone acetonide otic oil 0.01 % DERMOTIC 2ofloxacin otic solution 0.3 % OCUFLOX 13LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 116 de 150

MedicamentoMedicamentos Respiratorios yAlergiasAgentes PulmonaresADCIRCA ORAL TABLET(tadalafil (pah))20 MGADVAIR DISKUS INHALATION AEROSOLPOWDER, BREATH ACTIVATED(fluticasone-salmeterol)100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSEADVAIR HFA INHALATION AEROSOL†(fluticasone-salmeterol)115-21 MCG/ACT, 230-21 MCG/ACT, 45-21MCG/ACTReferencia deMarcaNivel Requisitos /Límites5 MT; QL (60 / 30día(s))3 MT; QL (60 / 30día(s))3 MT; QL (12 GM / 30día(s))albuterol sulfate oral syrup 2 MG/5ML VOSPIRE ER 2 MT; CGalbuterol sulfate oral tablet 2 MG, 4 MG VOSPIRE ER 1 MT; CGalbuterol sulfate inhalation nebulization solution(2.5 MG/3ML) 0.083%, (5 MG/ML) 0.5%albuterol sulfate er oral tablet extended release12 hr 4 MG, 8 MGALVESCO INHALATION AEROSOL,SOLUTION(ciclesonide)80 MCG/ACTALVESCO INHALATION AEROSOL,SOLUTION(ciclesonide)160 MCG/ACTVOSPIRE ER 2 PA; MT; CGVOSPIRE ER 2 MT; CGaminophylline intravenous solution 25 MG/ML 2ASMANEX 120 METERED DOSESINHALATION AEROSOL POWDER, BREATHACTIVATED(mometasone furoate)220 MCG/INH4 QL (12.2 GM / 30día(s))4 QL (18.3 GM / 30día(s))4 QL (240 / 30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 117 de 150

MedicamentoASMANEX 30 METERED DOSESINHALATION AEROSOL POWDER, BREATHACTIVATED(mometasone furoate)220 MCG/INHASMANEX 60 METERED DOSESINHALATION AEROSOL POWDER, BREATHACTIVATED(mometasone furoate)220 MCG/INHATROVENT HFA INHALATION AEROSOL,SOLUTION(ipratropium bromide hfa)17 MCG/ACTBECONASE AQ NASAL SUSPENSION(beclomethasone diprop monohyd)42 MCG/SPRAYCOMBIVENT INHALATION AEROSOL†(ipratropium-albuterol)18-103 MCG/ACTCOMBIVENT RESPIMAT INHALATIONAEROSOL, SOLUTION(ipratropium-albuterol)20-100 MCG/ACTcromolyn sodium inhalation nebulization solution20 MG/2MLDALIRESP ORAL TABLET(roflumilast)500 MCGDULERA INHALATION AEROSOL†(mometasone furo-formoterol fum)100-5 MCG/ACT, 200-5 MCG/ACTFIRAZYR SUBCUTANEOUS SOLUTION(icatibant acetate)30 MG/3MLReferencia deMarcaNivel Requisitos /Límites4 QL (60 / 30 día(s))4 QL (120 / 30 día(s))3 MT; QL (25.8 GM / 30día(s))4 QL (50 GM / 30 día(s))3 MT; QL (29.4 GM / 30día(s))3 MT; QL (8 GM / 30día(s))NASALCROM 2 PA; MT; CG3 MT3 MT; QL (13 GM / 30día(s))5 QL (9 ML / 3 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 118 de 150

MedicamentoFLOVENT DISKUS INHALATION AEROSOLPOWDER, BREATH ACTIVATED(fluticasone propionate (inhal))100 MCG/BLIST, 50 MCG/BLISTFLOVENT DISKUS INHALATION AEROSOLPOWDER, BREATH ACTIVATED(fluticasone propionate (inhal))250 MCG/BLISTFLOVENT HFA INHALATION AEROSOL†(fluticasone propionate hfa)110 MCG/ACTFLOVENT HFA INHALATION AEROSOL†(fluticasone propionate hfa)44 MCG/ACTFLOVENT HFA INHALATION AEROSOL†(fluticasone propionate hfa)220 MCG/ACTReferencia deMarcaflunisolide nasal solution 29 MCG/ACT (0.025%) VERAMYST 2fluticasone propionate nasal suspension 50MCG/ACTFORADIL AEROLIZER INHALATIONCAPSULE(formoterol fumarate)12 MCGLETAIRIS ORAL TABLET(ambrisentan)10 MG, 5 MGMAXAIR AUTOHALER INHALATIONAEROSOL, BREATH ACTIVATED(pirbuterol acetate)200 MCG/INHLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 119 de 150Nivel Requisitos /Límites4 QL (120 / 30 día(s))4 QL (300 / 30 día(s))4 QL (12 GM / 30 día(s))4 QL (20.8 GM / 30día(s))4 QL (36 GM / 30 día(s))FLONASE 2 QL (16 GM / 30 día(s))3 MT; QL (120 / 30día(s))5 LA; QL (30 / 30día(s))metaproterenol sulfate oral syrup 10 MG/5ML 2 MT; CGmetaproterenol sulfate oral tablet 10 MG, 20 MG 2 MT; CG4 QL (28 GM / 30 día(s))montelukast sodium oral tablet 10 MG SINGULAIR 2 CG; QL (30 / 30día(s))montelukast sodium oral tablet chewable 4 MG, 5MGSINGULAIR 2 CG; QL (30 / 30día(s))

MedicamentoReferencia deMarcaNivel Requisitos /Límitesmontelukast sodium oral packet 4 MG SINGULAIR 2 QL (30 / 30 día(s))NASACORT AQ NASAL AEROSOL,SOLUTION(triamcinolone acetonide)55 MCG/ACTOMNARIS NASAL SUSPENSION(ciclesonide)50 MCG/ACTPROAIR HFA INHALATION AEROSOL,SOLUTION(albuterol sulfate hfa)108 (90 Base) MCG/ACTPROVENTIL HFA INHALATION AEROSOL,SOLUTION(albuterol sulfate hfa)108 (90 Base) MCG/ACTPULMICORT FLEXHALER INHALATIONAEROSOL POWDER, BREATH ACTIVATED(budesonide)90 MCG/ACTPULMICORT FLEXHALER INHALATIONAEROSOL POWDER, BREATH ACTIVATED(budesonide)180 MCG/ACTPULMOZYME INHALATION SOLUTION(dornase alfa)1 MG/MLQVAR INHALATION AEROSOL, SOLUTION(beclomethasone dipropionate)40 MCG/ACT, 80 MCG/ACTRHINOCORT AQUA NASAL SUSPENSION(budesonide)32 MCG/ACTSEREVENT DISKUS INHALATIONAEROSOL POWDER, BREATH ACTIVATED(salmeterol xinafoate)50 MCG/DOSE4 QL (33 GM / 30 día(s))4 QL (25 GM / 30 día(s))3 MT; QL (17 GM / 30día(s))3 MT; QL (20.1 GM / 30día(s))4 QL (2 / 30 día(s))4 QL (3 / 30 día(s))5 PA5 MT; QL (17.4 GM / 30día(s))4 QL (25.8 GM / 30día(s))3 MT; QL (120 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 120 de 150

MedicamentoReferencia deMarcaNivel Requisitos /Límitessildenafil citrate oral tablet 20 MG REVATIO 2 MT; QL (90 / 30día(s))SPIRIVA HANDIHALER INHALATIONCAPSULE(tiotropium bromide monohydrate)18 MCGSYMBICORT INHALATION AEROSOL†(budesonide-formoterol fumarate)160-4.5 MCG/ACT, 80-4.5 MCG/ACTterbutaline sulfate injection solution 1 MG/ML 2 CG3 MT; QL (60 / 30día(s))terbutaline sulfate oral tablet 2.5 MG ELIXOPHYLLIN 1 MT; CGterbutaline sulfate oral tablet 5 MG ELIXOPHYLLIN 2 MT; CGtheophylline er oral tablet extended release 12 hr100 MG, 300 MGtheophylline er oral tablet extended release 12 hr200 MG, 450 MGtheophylline er oral tablet extended release 24 hr400 MG, 600 MGTRACLEER ORAL TABLET(bosentan)125 MG, 62.5 MGVERAMYST NASAL SUSPENSION(fluticasone furoate)27.5 MCG/SPRAYXOLAIR SUBCUTANEOUS SOLUTIONRECONSTITUTED(omalizumab)150 MGXOPENEX HFA INHALATION AEROSOL†(levalbuterol tartrate)45 MCG/ACTZYFLO ORAL TABLET(zileuton)600 MGELIXOPHYLLIN 1ELIXOPHYLLIN 2ELIXOPHYLLIN 24 MT; QL (20.4 GM / 30día(s))5 LA; QL (60 / 30día(s))4 QL (20 GM / 30 día(s))5 LA; QL (6 / 28 día(s))4 MT; QL (45 GM / 30día(s))3LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 121 de 150

MedicamentoZYFLO CR ORAL TABLET EXTENDEDRELEASE 12 HR(zileuton er)600 MGAntihistamínicos / Agentes AntialergénosCLARINEX-D 24 HOUR ORAL TABLETEXTENDED RELEASE 24 HR(desloratadine-pseudoephed er)5-240 MGReferencia deMarcacyproheptadine hcl oral syrup 2 MG/5ML 2cyproheptadine hcl oral tablet 4 MG 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 122 de 150Nivel Requisitos /Límites34 QL (30 / 30 día(s))desloratadine oral tablet 5 MG CLARINEX 2 QL (30 / 30 día(s))desloratadine oral tablet dispersible 2.5 MG, 5MGdiphenhydramine hcl injection solution 50MG/MLCLARINEX REDITAB 2 QL (30 / 30 día(s))diphenhydramine hcl oral capsule 50 MG 2EPIPEN 2-PAK INJECTION DEVICE(epinephrine)0.3 MG/0.3MLEPIPEN JR 2-PAK INJECTION DEVICE(epinephrine)0.15 MG/0.3ML23 QL (4 / 2 día(s))3 QL (4 / 2 día(s))levocetirizine dihydrochloride oral tablet 5 MG XYZAL 1 QL (30 / 30 día(s))PALGIC ORAL LIQUID†(carbinoxamine maleate)4 MG/5MLPALGIC ORAL TABLET(carbinoxamine maleate)4 MGPHENADOZ RE SUPPOSITORY(promethazine hcl)12.5 MGSEMPREX-D ORAL CAPSULE(acrivastine-pseudoephedrine)8-60 MG2224

MedicamentoXYZAL ORAL SOLUTION(levocetirizine dihydrochloride)2.5 MG/5MLOftalmologíaAgentes Anti-inflamatorios No EsteroidalesReferencia deMarcadiclofenac sodium ophthalmic solution 0.1 % VOLTAREN 2ketorolac tromethamine ophthalmic solution 0.4%, 0.5 %NEVANAC OPHTHALMIC SUSPENSION(nepafenac)0.1 %OCUFEN OPHTHALMIC SOLUTION(flurbiprofen sodium)0.03 %AntibióticosAZASITE OPHTHALMIC SOLUTION(azithromycin)1 %Nivel Requisitos /Límites4ACULAR LS 2bacitracin ophthalmic ointment 500 UNIT/GM 1bacitracin-polymyxin b ophthalmic ointment 500-10000 UNIT/GMBESIVANCE OPHTHALMIC SUSPENSION(besifloxacin hcl)0.6 %CILOXAN OPHTHALMIC OINTMENT(ciprofloxacin hcl)0.3 %ciprofloxacin hcl ophthalmic solution 0.3 % CIPRO 1erythromycin ophthalmic ointment 5 MG/GM ILOTYCIN 1gentak ophthalmic ointment(gentamicin sulfate)0.3 %GARAMYCIN 1gentamicin sulfate ophthalmic solution 0.3 % 1levofloxacin ophthalmic solution 0.5 % LEVAQUIN 2324144LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 123 de 150

MedicamentoNATACYN OPHTHALMIC SUSPENSION(natamycin)5 %neomycin-bacitracin zn-polymyx ophthalmicointment 5-400-10000neomycin-polymyxin-gramicidin ophthalmicsolutionReferencia deMarcaNivel Requisitos /Límites32NEOSPORIN 2ofloxacin ophthalmic solution 0.3 % OCUFLOX 1polymyxin b-trimethoprim ophthalmic solution10000-0.1 UNIT/ML-%POLYTRIM 1tobramycin sulfate ophthalmic solution 0.3 % TOBREX 1VIGAMOX OPHTHALMIC SOLUTION(moxifloxacin hcl)0.5 %AntiviralesVIROPTIC OPHTHALMIC SOLUTION(trifluridine)1 %Beta - Bloqueadoresbetaxolol hcl ophthalmic solution 0.5 % KERLONE 2 MT; CGcarteolol hcl ophthalmic solution 1 % 1 MT; CGlevobunolol hcl ophthalmic solution 0.5 % BETAGAN 2 MT; CGmetipranolol ophthalmic solution 0.3 % OPTIPRANOLOL 2 MT; CGtimolol maleate ophthalmic solution 0.25 %, 0.5%TIMOPTIC OCUDOSE OPHTHALMICSOLUTION(timolol maleate pf)0.25 %, 0.5 %TIMOPTIC-XE OPHTHALMIC GELFORMING SOLUTION(timolol maleate)0.25 %, 0.5 %TIMOPTIC 1 MT; CG424 MT4 4 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 124 de 150

MedicamentoEsteroidesdexamethasone sodium phosphate ophthalmicsolution 0.1 %FML OPHTHALMIC OINTMENT(fluorometholone)0.1 %FML FORTE OPHTHALMIC SUSPENSION(fluorometholone)0.25 %MAXIDEX OPHTHALMIC SUSPENSION(dexamethasone)0.1 %PRED MILD OPHTHALMIC SUSPENSION(prednisolone acetate)0.12 %Referencia deMarcaprednisolone acetate ophthalmic suspension 1 % OMNIPRED 1prednisolone sodium phosphate ophthalmicsolution 1 %VEXOL OPHTHALMIC SUSPENSION(rimexolone)1 %Combinación de Esteroides y Antibióticosbacitra-neomycin-polymyxin-hc ophthalmicointment 1 %neomycin-polymyxin-dexameth ophthalmicointment 3.5-10000-0.1neomycin-polymyxin-dexameth ophthalmicsuspension 3.5-10000-0.1neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1tobramycin-dexamethasone ophthalmicsuspension 0.3-0.1 %PRED FORTE 2TOBRADEX 2Nivel Requisitos /Límites1344342112LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 125 de 150

MedicamentoCombinación de Esteroides y SulfonamidasBLEPHAMIDE OPHTHALMIC SUSPENSION(sulfacetamide-prednisolone)10-0.2 %sulfacetamide-prednisolone ophthalmic solution10-0.23 %Inhibidores Mióticos De ColinesterasaPHOSPHOLINE IODIDE OPHTHALMICSOLUTION RECONSTITUTED(echothiophate iodide)0.125 %Medicamentos Orales Para La GlaucomaReferencia deMarcaNivel Requisitos /Límitesacetazolamide oral tablet 125 MG, 250 MG DIAMOX SEQUELS 2 MT; CGacetazolamide er oral capsule extended release12 hour 500 MGDIAMOX SEQUELS 2 MT; CGmethazolamide oral tablet 25 MG, 50 MG NEPTAZANE 2 MT; CGMisceláneos OftálmicosALOCRIL OPHTHALMIC SOLUTION(nedocromil sodium)2 %ALOMIDE OPHTHALMIC SOLUTION(lodoxamide tromethamine)0.1 %BEPREVE OPHTHALMIC SOLUTION(bepotastine besilate)1.5 %cromolyn sodium ophthalmic solution 4 % GASTROCROM 1ELESTAT OPHTHALMIC SOLUTION(epinastine hcl)0.05 %EMADINE OPHTHALMIC SOLUTION(emedastine difumarate)0.05 %31344444LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 126 de 150

MedicamentoPATADAY OPHTHALMIC SOLUTION(olopatadine hcl)0.2 %Referencia deMarcaproparacaine hcl ophthalmic solution 0.5 % ALCAINE 2RESTASIS OPHTHALMIC EMULSION(cyclosporine)0.05 %Otros Medicamentos para la GlaucomaAZOPT OPHTHALMIC SUSPENSION(brinzolamide)1 %COMBIGAN OPHTHALMIC SOLUTION(brimonidine tartrate-timolol)0.2-0.5 %Nivel Requisitos /Límites3 QL (2.5 ML / 30día(s))3 MT; QL (60 / 30día(s))3 MT; QL (10 ML / 30día(s))3 MT; QL (10 ML / 30día(s))dorzolamide hcl ophthalmic solution 2 % TRUSOPT 2 MT; CGdorzolamide hcl-timolol mal ophthalmic solution22.3-6.8 MG/MLCOSOPT 2 MT; CGlatanoprost ophthalmic solution 0.005 % XALATAN 2 MT; CG; QL (2.5 ML /30 día(s))LUMIGAN OPHTHALMIC SOLUTION(bimatoprost)0.01 %TRAVATAN Z OPHTHALMIC SOLUTION(travoprost (bak free))0.004 %3 MT; QL (2.5 ML / 30día(s))4 MT; QL (5 ML / 30día(s))travoprost ophthalmic solution 0.004 % 2 MT; CGSimpatomiméticosALPHAGAN P OPHTHALMIC SOLUTION(brimonidine tartrate)0.1 %ALPHAGAN P OPHTHALMIC SOLUTION(brimonidine tartrate)0.15 %3 MT4 MTapraclonidine hcl ophthalmic solution 0.5 % IOPIDINE 2 MT; CGbrimonidine tartrate ophthalmic solution 0.15 % ALPHAGAN P 2 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 127 de 150

MedicamentoReferencia deMarcaNivel Requisitos /Límitesbrimonidine tartrate ophthalmic solution 0.2 % 1 MT; CGSulfonamidassulfacetamide sodium ophthalmic ointment 10 % 2sulfacetamide sodium ophthalmic solution 10 % BLEPH-10 1Vasoconstrictores Descongestionantesnaphazoline hcl ophthalmic solution 0.1 % 1UrológicosAntiespasmódicos AnticolinérgicosENABLEX ORAL TABLET EXTENDEDRELEASE 24 HR(darifenacin hydrobromide er)15 MG, 7.5 MGflavoxate hcl oral tablet 100 MG 2 CGGELNIQUE TRANSDERMAL GEL(oxybutynin chloride)10 %oxybutynin chloride oral syrup 5 MG/5ML 1 CGoxybutynin chloride oral tablet 5 MG 1 CGoxybutynin chloride er oral tablet extendedrelease 24 hr 10 MG, 15 MGoxybutynin chloride er oral tablet extendedrelease 24 hr 5 MGOXYTROL TRANSDERMAL PATCHBIWEEKLY(oxybutynin)3.9 MG/24HRSANCTURA XR ORAL CAPSULEEXTENDED RELEASE 24 HOUR(trospium chloride er)60 MGTOVIAZ ORAL TABLET EXTENDEDRELEASE 24 HR(fesoterodine fumarate er)8 MGDITROPAN XL 2 CG3 QL (30 / 30 día(s))4 QL (30 GM / 30 día(s))DITROPAN XL 2 CG; QL (30 / 30día(s))4 QL (8 / 28 día(s))44LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 128 de 150

MedicamentoReferencia deMarcaNivel Requisitos /Límitestrospium chloride oral tablet 20 MG 2 CGVESICARE ORAL TABLET(solifenacin succinate)10 MG, 5 MGEstimulantes Anticolinérgicosbethanechol chloride oral tablet 10 MG, 25 MG,50 MGURECHOLINE 2 CGbethanechol chloride oral tablet 5 MG URECHOLINE 1 CGUrológicos Misceláneosammonium chloride intravenous solution 5MEQ/MLCYSTAGON ORAL CAPSULE(cysteamine bitartrate)150 MG, 50 MGELMIRON ORAL CAPSULE(pentosan polysulfate sodium)100 MGOtros Medicamentos GenitourinariosCIALIS ORAL TABLET(tadalafil)2.5 MG, 5 MGCIALIS ORAL TABLET(tadalafil)10 MG, 20 MGLEVITRA ORAL TABLET(vardenafil hcl)10 MG, 2.5 MG, 20 MG, 5 MGVIAGRA ORAL TABLET(sildenafil citrate)100 MG, 25 MG, 50 MGTerapia para la Hiperplasia Benigna de la PróstataAVODART ORAL CAPSULE(dutasteride)0.5 MG433 MT; LA344 QL (6 / 30 día(s))4 QL (6 / 30 día(s))4 QL (6 / 30 día(s))4 MTfinasteride oral tablet 5 MG PROSCAR 1 MT; CGLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 129 de 150

MedicamentoRAPAFLO ORAL CAPSULE(silodosin)4 MG, 8 MGReferencia deMarcaLA - Esta receta puede estar sólo disponible en algunas farmacias.Página 130 de 150Nivel Requisitos /Límites4 MTtamsulosin hcl oral capsule 0.4 MG FLOMAX 1 MT; CGUROXATRAL ORAL TABLET EXTENDEDRELEASE 24 HR(alfuzosin hcl er)10 MGVitaminas, Hemáticos / ElectrolítosElectrolítos4 MTcalcium acetate oral capsule 667 MG 2 CGkcl in dextrose-nacl intravenous solution 10-5-0.45 MEQ/L-%-%, 20-5-0.2 MEQ/L-%-%, 20-5-0.225 MEQ/L-%-%, 20-5-0.33 MEQ/L-%-%, 20-5-0.45 MEQ/L-%-%, 20-5-0.9 MEQ/L-%-%, 30-5-0.45 MEQ/L-%-%, 40-5-0.45 MEQ/L-%-%, 40-5-0.9 MEQ/L-%-%kcl-lactated ringers-d5w intravenous solution 20MEQ/LKLOR-CON ORAL TABLETEXTENDEDRELEASE(potassium chloride er)8 MEQKLOR-CON 10 ORAL TABLETEXTENDEDRELEASE(potassium chloride)10 MEQKLOR-CON M15 ORAL TABLETEXTENDEDRELEASE(potassium chloride crys er)15 MEQKLOR-CON M20 ORAL TABLETEXTENDEDRELEASE(potassium chloride crys er)20 MEQlactated ringers intravenous solution 2magnesium sulfate injection solution 50 % 2221 MT; CG1 MT; CG2 MT; CG1 MT; CG

Medicamentopotassium chloride intravenous solution 10MEQ/100ML, 2 MEQ/ML, 20 MEQ/100ML, 30MEQ/100ML, 40 MEQ/100MLpotassium chloride crys er oral tabletextendedrelease 10 MEQpotassium chloride er oral capsule extendedrelease 10 MEQ, 8 MEQpotassium chloride in dextrose intravenoussolution 20-5 MEQ/L-%, 40-5 MEQ/L-%potassium chloride in nacl intravenous solution20-0.45 MEQ/L-%, 20-0.9 MEQ/L-%, 40-0.9MEQ/L-%Referencia deMarcaNivel Requisitos /Límites21 MT; CGMICRO-K 2 MTringers intravenous solution 2sodium chloride injection solution 2.5 MEQ/ML 2sodium chloride intravenous solution 0.45 %, 3%, 5 %sodium lactate intravenous solution 167 MEQ/L,5 MEQ/MLTPN ELECTROLYTES INTRAVENOUSSOLUTION(parenteral electrolytes)22223Productos Misceláneos para la NutriciónAMINOSYN II INTRAVENOUS SOLUTION(amino acid infusion)10 %, 15 %, 7 %, 8.5 %AMINOSYN II/ELECTROLYTESINTRAVENOUS SOLUTION(amino acid electrolyte infusion)8.5 %AMINOSYN M INTRAVENOUS SOLUTION(amino acid electrolyte infusion)3.5 %3 PA3 PA3 PALA - Esta receta puede estar sólo disponible en algunas farmacias.Página 131 de 150

MedicamentoAMINOSYN/ELECTROLYTESINTRAVENOUS SOLUTION(amino acid electrolyte infusion)8.5 %AMINOSYN-HBC INTRAVENOUSSOLUTION(amino acid infusion)7 %AMINOSYN-PF INTRAVENOUS SOLUTION(amino acid infusion)10 %, 7 %INTRALIPID INTRAVENOUS EMULSION(fat emulsion)30 %ISOLYTE-M IN D5W INTRAVENOUSSOLUTION(electrolyte-m in dextrose)Referencia deMarcaNivel Requisitos /Límites3 PA3 PA3 PA3 PA3 PAliposyn iii intravenous emulsion(fat emulsion)10 %, 20 %Vitaminas / HemáticosINTRALIPID 1 PAprenatal/iron oral tablet 2LA - Esta receta puede estar sólo disponible en algunas farmacias.Página 132 de 150

Índice de Medicamentos1ST TIER ............................ 1008-Mop .................................... 47Abacavir Sulfate .............. 10, 17Abacavir Sulfate-Lamivudine........................................... 12Abacavir-Lamivudine-Zidovudine ........................ 15Abatacept ............................ 106Abelcet .................................... 9Abilify ............................. 72, 73Abilify Discmelt .................... 73Abilify Maintena ................... 73Abiraterone Acetate .............. 72Acanya .................................. 48Acarbose................................ 99ACCUPRIL ........................... 37ACCURETIC ........................ 37Acebutolol HCl ..................... 31ACEON ................................. 36Acetaminophen-Codeine ....... 82Acetaminophen-Codeine #2 .. 82Acetaminophen-Codeine #3 .. 82Acetaminophen-Codeine #4 .. 82Acetasol HC ........................ 116Acetazolamide ..................... 126Acetazolamide ER............... 126Acetic Acid ......................... 116Aciphex ................................. 57Acitretin ................................ 43ACLOVATE ................... 43, 44Acrivastine-Pseudoephedrine......................................... 122Actemra ............................... 105ACTHIB ................................ 60Actimmune ............................ 58ACTIQ .................................. 83ACTIVELLA ...................... 113Actonel .......................... 50, 107ACTOPLUS MET............... 104ACTOS................................ 104ACULAR LS....................... 123Acyclovir ......................... 10, 11Acyclovir Sodium ................. 11Adacel ................................... 60Adagen .................................. 50ADALAT CC ........................ 36Adalimumab ........................ 106Adapalene.............................. 48Página 133 de 150Adcirca ............................... 116Adefovir Dipivoxil ............... 12Ado-Trastuzumab Emtansine 67Advair Diskus ..................... 117Advair HFA ........................ 117Advicor ................................. 28Afeditab CR .......................... 31Afinitor ................................. 64Agalsidase beta ..................... 97Aggrenox .............................. 39AGRYLIN ............................ 50Ala Scalp .............................. 43ALACORT ........................... 46Albendazole .......................... 19Albenza ................................. 19Albuterol Sulfate ................ 117Albuterol Sulfate ER .......... 117Albuterol Sulfate HFA ....... 120ALCAINE ........................... 126Alclometasone Dipropionate 43,44Alcohol Preps ....................... 99ALDACTONE ...................... 37ALDARA ............................. 48Aldesleukin ........................... 60Aldurazyme .......................... 96Alendronate Sodium ..... 50, 107Alfuzosin HCl ER ............... 129Alimta ................................... 64Alinia .................................... 19Aliskiren Fumarate ............... 37Aliskiren-Hydrochlorothiazide.......................................... 37Alitretinoin ........................... 48Allopurinol ......................... 106Almotriptan Malate .............. 92Alocril ................................. 126Alomide .............................. 126Alosetron HCl ....................... 55Alpha1-Proteinase Inhibitor . 50Alphagan P ......................... 127ALPHAGAN P ................... 127Alprazolam ........................... 73Alprazolam ER ..................... 73Alprazolam XR ..................... 73Altabax ................................. 41ALTACE .............................. 37Altoprev ................................ 28Altretamine ........................... 67Alvesco ............................... 117Amantadine HCl ................... 11AMARYL ........................... 100AMBIEN ............................... 81AMBIEN CR ........................ 81Ambisome ............................... 9Ambrisentan ........................ 119Amcinonide ........................... 44AMERGE .............................. 92Amifostine ............................. 64Amiloride HCl ...................... 31Amiloride-Hydrochlorothiazide........................................... 31Amino Acd ElectrolyteInfusion ........................... 131Amino Acid Infusion .......... 131Aminophylline .................... 117Aminosalicylic Acid ............. 21Aminosyn II ........................ 131Aminosyn II/Electrolytes .... 131Aminosyn M ....................... 131Aminosyn/Electrolytes ........ 131Aminosyn-HBC .................. 131Aminosyn-PF ...................... 131Amiodarone HCl ................... 27Amitiza .................................. 53Amitriptyline HCl ................. 73Amlodipine Besy-BenazeprilHCl .................................... 31Amlodipine Besylate ............. 31Amlodipine Besylate-Valsartan........................................... 34Amlodipine-Olmesartan ........ 32Amlodipine-Valsartan-HCTZ........................................... 34Ammonium Chloride .......... 129Ammonium Lactate .............. 47Amnesteem ........................... 48Amoxapine ............................ 73Amoxicillin ........................... 23Amoxicillin ER ..................... 24Amoxicillin-Pot Clavulanate 23Amoxicillin-Pot ClavulanateER ..................................... 23AMOXIL ............................... 23AMPHOCIN ........................... 9Amphotericin B ....................... 9

Amphotericin B Lipid ............. 9Amphotericin B Liposome ...... 9Ampicillin ............................. 24Ampicillin Sodium ................ 24Ampicillin-Sulbactam Sodium........................................... 24ANAFRANIL........................ 74Anagrelide HCl ..................... 50ANAPROX DS ..................... 86Anastrozole ........................... 64ANCOBON ............................. 9AndroGel ............................... 96AndroGel Pump .................... 96Androxy ................................. 97Angeliq ................................ 112Anidulafungin ......................... 9Antabuse................................ 50ANTABUSE ......................... 51Antara .................................... 29ANTIVERT ........................... 55ANTIZOL ............................. 61ANUSOL-HC........................ 56Anzemet ................................ 53APAP-Caff-Dihydrocodeine . 82Aplenzin ................................ 73Apokyn .................................. 81Apomorphine HCl ................. 81Apraclonidine HCl .............. 127Aprepitant.............................. 54Apri...................................... 108Apriso .................................... 53Aptivus .................................. 11Aralast NP ............................. 50ARALEN .............................. 20Aranelle ............................... 108ARAVA .............................. 106Arcalyst ................................. 58ARICEPT .............................. 93ARICEPT ODT ..................... 93Arimidex ............................... 64ARIMIDEX ........................... 64Aripiprazole .................... 72, 73ARIXTRA ............................. 40Armodafinil ........................... 78Aromasin ............................... 64AROMASIN ......................... 66Arthrotec ............................... 85Asacol.................................... 53Asacol HD ............................. 53Ascomp-Codeine ................... 82Página 134 de 150Asenapine Maleate ............... 79Asmanex 120 Metered Doses........................................ 117Asmanex 30 Metered Doses 117Asmanex 60 Metered Doses 118Aspirin-Dipyridamole ER .... 39Astepro ............................... 116ASTRAMORPH-PF ....... 83, 84Atacand ................................. 31Atacand HCT ........................ 32Atazanavir Sulfate ................ 14Atenolol ................................ 32Atenolol-Chlorthalidone ....... 32Atgam ................................... 61ATIVAN ............................... 77Atomoxetine HCl .................. 80Atorvastatin Calcium ............ 29Atovaquone ........................... 21Atovaquone-Proguanil HCl .. 21Atripla ................................... 11ATROVENT ....................... 116Atrovent HFA ..................... 118AUGMENTIN ...................... 23AUGMENTIN XR ............... 23Auranofin ............................ 106AUTOSHIELD ................... 100AVALIDE ............................ 35AVAPRO .............................. 35Avastin .................................. 65Avelox ABC Pack ................ 25Aviane ................................. 108AVINZA ............................... 82Avodart ............................... 129Avonex ................................. 58Avonex Prefilled ................... 58Axert ..................................... 92AXID .................................... 57Axiron ................................... 97Axitinib ................................. 67AYGESTIN ........................ 114Azacitidine ............................ 71AZACTAM .......................... 19Azasan .................................. 65AzaSite ............................... 123AzaTHIOprine ...................... 65Azelaic Acid ................... 48, 49Azelastine HCl .................... 116Azelex ................................... 48Azilect ................................... 81Azithromycin .......... 18, 19, 123Azopt ................................... 127Azor ....................................... 32Aztreonam ............................. 19AZULFIDINE ....................... 56Bacitracin ...................... 19, 123Bacitracin-Polymyxin B ...... 123Bacitra-Neomycin-Polymyxin-HC ................................... 125Baclofen ................................ 94BACTRIM ............................ 26Bactroban .............................. 41Bactroban Nasal .................. 116Balsalazide Disodium ........... 53Balziva ................................. 108Banzel ................................... 87Baraclude .............................. 11BD ................................. 99, 100BD Insulin Syringe ............. 100BD Insulin Syringe Ultrafine......................................... 100BD Pen Needle Ultrafine .... 100Beclomethasone DipropMonohyd ......................... 118Beclomethasone Dipropionate......................................... 120Beconase AQ ...................... 118Belatacept .............................. 69Belimumab .......................... 105Benazepril HCl ...................... 32Benazepril-Hydrochlorothiazide ......... 32Benicar .................................. 32Benicar HCT ......................... 32Benlysta ............................... 105BENZAMYCIN .................... 49Benzoyl Peroxide-Erythromycin .................... 49Benzyl Alcohol ..................... 47Bepotastine Besilate ............ 126Bepreve ............................... 126Besifloxacin HCl ................. 123Besivance ............................ 123BETAGAN ......................... 124Betaine .................................. 54Betamethasone ...................... 94Betamethasone Dipropionate 44Betamethasone DipropionateAug .................................... 44Betamethasone Valerate .. 44, 46BETAPACE .......................... 28

Betapace AF .......................... 27Betaseron ............................... 58Betaxolol HCl ............... 32, 124Bethanechol Chloride .......... 128Bevacizumab ......................... 65Bexarotene ............................ 71BIAXIN ................................. 19BIAXIN XL .......................... 19Bicalutamide ......................... 65Bicillin C-R ........................... 24Bicillin C-R 900/300 ............. 24Biltricide................................ 19Bimatoprost ......................... 127Bis Subcit-Metronid-Tetracyc........................................... 58Bisoprolol Fumarate .............. 32Bisoprolol-Hydrochlorothiazide........................................... 32BLEPH-10 .......................... 127Blephamide ......................... 125BLOCADREN ...................... 38Boceprevir ............................. 16Boniva ................................. 107BONIVA ............................. 107Boostrix ................................. 61Bortezomib ............................ 71Bosentan .............................. 121Bosulif ................................... 65Bosutinib ............................... 65Botox ..................................... 61Brimonidine Tartrate ........... 127Brimonidine Tartrate-Timolol......................................... 127Brinzolamide ....................... 127Bromocriptine Mesylate 81, 100Budeprion SR ........................ 73Budesonide .......................... 120Budesonide ER ...................... 54Budesonide-FormoterolFumarate.......................... 121Bumetanide ........................... 32BUMEX ................................ 32Buphenyl ............................... 50Buproban ............................... 52Bupropion HBr ER................ 73Bupropion HCl ...................... 73Bupropion HCl ER (SmokingDet).................................... 52Bupropion HCl ER (SR) ....... 73Bupropion HCl ER (XL) ....... 74Página 135 de 150Buspirone HCl ...................... 74Butalbital-APAP-Caff-Cod .. 82Butalbital-ASA-Caff-Codeine.......................................... 82Butenafine HCl ..................... 42Butorphanol Tartrate ............ 85Byetta 10 MCG Pen ............ 100Byetta 5 MCG Pen .............. 100Bystolic ................................. 32Cabergoline ........................... 97Cabozantinib S-Malate ......... 65CALAN ................................ 38CALAN SR .......................... 38Calcipotriene ......................... 43Calcipotriene-Betameth Diprop.......................................... 43Calcitonin (Salmon) .............. 98Calcitriol ......................... 43, 97Calcium Acetate ................. 130Camila ................................ 112Canasa ................................... 54Cancidas ................................. 9Candesartan Cilexetil ............ 31Candesartan Cilexetil-HCTZ 32Capastat Sulfate .................... 19Capex .................................... 44CAPOTEN ............................ 32CAPOZIDE .......................... 32Caprelsa ................................ 65Capreomycin Sulfate ............ 19Captopril ............................... 32Captopril-Hydrochlorothiazide.......................................... 32Carac ..................................... 47Carafate ................................ 57CARAFATE ......................... 58Carbamazepine ......... 87, 88, 91Carbamazepine ER ......... 87, 91Carbamazepine ER (Antipsych).......................................... 89Carbatrol ............................... 87Carbidopa ............................. 81Carbidopa-Levodopa ............ 81Carbidopa-Levodopa ER ...... 81Carbinoxamine Maleate ...... 122CARDENE ........................... 36CARDIZEM ................... 32, 33CARDIZEM CD ................... 33CARDIZEM SR ................... 33CARDURA ........................... 34CARNITOR .......................... 51Carteolol HCl ...................... 124Cartia XT ........................ 32, 33Carvedilol .............................. 33Carvedilol Phosphate ER ...... 33CASODEX ............................ 65Caspofungin Acetate ............... 9CATAFLAM ......................... 85CATAPRESS ........................ 33CATNITOR .......................... 51CECLOR ............................... 17Cedax .................................... 17CEENU ................................. 65Cefaclor ................................. 17Cefaclor ER ........................... 17Cefadroxil ............................. 17Cefazolin Sodium .................. 17Cefdinir ................................. 17Cefepime HCl ....................... 17Cefixime ................................ 18Cefoxitin Sodium .................. 17Cefpodoxime Proxetil ..... 17, 18Cefprozil ............................... 18Ceftibuten .............................. 17Ceftriaxone Sodium .............. 18Cefuroxime Axetil ................ 18Cefuroxime Sodium .............. 18CEFZIL ................................. 18CELEBREX .......................... 85Celecoxib .............................. 85Celestone ............................... 94CELEXA ............................... 74CellCept ................................ 65CELLCEPT ........................... 69Celontin ................................. 87Cenestin ............................... 112Cephalexin ............................ 18Cerezyme .............................. 97Cervarix ................................. 61Cevimeline HCl .................... 51Chantix .................................. 52Chantix Starting Month Pak .. 52Chemet .................................. 50Chlorambucil ......................... 67Chloramphenicol SodSuccinate ........................... 19Chlorhexidine Gluconate .... 116CHLOROMYCETIN ............ 19Chloroquine Phosphate ......... 20Chlorothiazide ....................... 33

Chlorpromazine HCl ............. 74Chlorthalidone ....................... 33Cholestyramine Light ...... 29, 30Cialis ................................... 129Ciclesonide .................. 117, 120Ciclopirox.............................. 42Ciclopirox Olamine ............... 42Cilostazol .............................. 39Ciloxan ................................ 123Cimetidine ............................. 57Cimetidine HCl ..................... 57Cinacalcet HCl ...................... 98Cipro...................................... 25CIPRO ........................... 25, 123CIPRO I.V ............................. 25CIPRO I.V. ............................ 25CIPRO XR ............................ 25Ciprodex .............................. 115Ciprofloxacin ........................ 25Ciprofloxacin HCl ......... 25, 123Ciprofloxacin in D5W ........... 25Ciprofloxacin-Ciproflox HClER...................................... 25Ciprofloxacin-Dexamethasone......................................... 115Citalopram Hydrobromide .... 74Claravis ................................. 49CLARINEX ........................ 122CLARINEX REDITAB ...... 122Clarinex-D 24 Hour ............ 122Clarithromycin ...................... 19Clarithromycin ER ................ 19Cleocin ................................ 115CLEOCIN ............... 20, 49, 115CLICKFINE ........................ 100Clindamycin HCl .................. 20Clindamycin Phos-BenzoylPerox ................................. 48Clindamycin Phosphate.. 20, 49,115Clindamycin-Tretinoin .......... 49CLINORIL ............................ 86Clobazam .............................. 90Clobetasol Propionate ..... 44, 45Clobetasol Propionate E ........ 44Clobetasol PropionateEmulsion ........................... 46Clobex ................................... 44Clobex Spray ......................... 45Clocortolone Pivalate ............ 45Página 136 de 150Cloderm Pump ...................... 45Clomipramine HCl ............... 74Clonazepam .......................... 87Clonidine HCl ....................... 33Clonidine-Chlorthalidone ..... 33Clopidogrel Bisulfate ............ 39Clorazepate Dipotassium ...... 74Clorpres ................................ 33Clotrimazole ..................... 9, 42Clotrimazole-Betamethasone 42Clozapine ........................ 74, 75Clozaril ................................. 74CLOZARIL .......................... 74Co-Gesic ............................... 83Colchicine ........................... 106Colchicine-Probenecid ....... 106Colcrys ................................ 106Colesevelam HCl .................. 30COLESTID ........................... 29Colestipol HCl ...................... 29Colistimethate Sodium ......... 20Collagenase ........................... 47COLOZAL ........................... 53COLY-MYCIN ..................... 20COLYTE WITH FLAVORPACKETS ........................ 55Combigan ........................... 127CombiPatch ........................ 112Combivent .......................... 118Combivent Respimat .......... 118COMBIVIR .......................... 13Cometriq (100 mg Daily Dose).......................................... 65Cometriq (140 mg Daily Dose).......................................... 65Cometriq (60 mg Daily Dose).......................................... 65COMFORT EZ ................... 100Complera .............................. 11Compro ................................. 54COMTAN ............................. 81Comvax ................................. 61CONDYLOX ........................ 48Conj Estrog-MedroxyprogestAce .................................. 114Constulose ............................ 54Copaxone .............................. 93COPEGUS ............................ 14Cordran ................................. 45COREG ................................. 33Coreg CR .............................. 33CORGARD ........................... 36CORTEF ............................... 95Cortisone Acetate .................. 94CORTISPORIN .................. 115CORZIDE ............................. 36COSOPT ............................. 127Coumadin .............................. 39COUMADIN ......................... 40COZAAR .............................. 35Creon ..................................... 54Crestor ................................... 29Crinone ................................ 113Crixivan ................................. 11Crizotinib .............................. 72Cromolyn Sodium .. 54, 55, 118,126Cryselle-28 .......................... 108Cubicin .................................. 20CURAD ................................. 99CURITY ................................ 99CUTIVATE ........................... 45Cyclafem 1/35 ..................... 108Cyclafem 7/7/7 .................... 108CYCLOCORT ...................... 44Cyclophosphamide ................ 65Cycloserine ........................... 22Cycloset ............................... 100Cyclosporine ................. 66, 126Cyclosporine Modified ... 66, 67Cyklokapron .......................... 39CYKLOKAPRON ................ 40Cymbalta ............................... 74Cyproheptadine HCl ........... 122Cystadane .............................. 54Cystagon ............................. 129Cysteamine Bitartrate .......... 129CYTOMEL ........................... 96CYTOTEC ............................ 57CYTOVENE ......................... 12Dabigatran Etexilate Mesylate........................................... 40Dabrafenib Mesylate ............. 70Daliresp ............................... 118Danazol ................................. 97DANTRIUM ......................... 94Dantrolene Sodium ............... 94Dapsone ................................. 20Daptacel ................................ 61DAPTOmycin ....................... 20

Daraprim ............................... 20Darifenacin Hydrobromide ER......................................... 128Darunavir Ethanolate ............ 14Dasatinib ............................... 70DAYPRO .............................. 86Daytrana ................................ 74DDAVP ................................. 97Deferasirox ............................ 51Delavirdine Mesylate ............ 14Delzicol ................................. 54DEMADEX ........................... 38Demeclocycline HCl ............. 26DEMECLOCYN ................... 26Demser .................................. 33Denosumab.................... 64, 107DEPACON ............................ 91Depakene ......................... 87, 88DEPAKENE.......................... 91Depakote ............................... 88DEPAKOTE.......................... 88Depakote ER ......................... 88DEPAKOTE ER ................... 88Depakote Sprinkles ............... 88Depen Titratabs ................... 105DEPO-MEDROL .................. 95Depo-Provera ...................... 113DERMATAP ......................... 46DERMOTI .......................... 116DermOtic ............................. 116Desipramine HCl................... 74Desloratadine ...................... 122Desloratadine-Pseudoephed ER......................................... 122Desmopressin Ace SprayRefrig ................................ 97Desmopressin Acetate ..... 97, 98DESOGEN .......................... 108Desogest-Eth Estrad Triphasic......................................... 112Desogestrel-Ethinyl Estradiol......................... 108, 109, 111Desonide.......................... 45, 47DESOWEN ........................... 45Desoximetasone .................... 45Desvenlafaxine Succinate ER........................................... 79Dexamethasone ....... 94, 95, 125Dexamethasone Intensol ....... 95Página 137 de 150Dexamethasone SodiumPhosphate .................. 95, 124DEXEDRINE ....................... 74Dextroamphetamine Sulfate ER.......................................... 74Dextromethorphan-Quinidine.......................................... 93Dextrose ................................ 50Dextrose in Lactated Ringers 50Dextrose-NaCl ................ 50, 51DIABETA ........................... 101DIAMOX SEQUELS ......... 126Diazepam ........................ 74, 88Diazoxide ............................ 104Dibenzyline ........................... 33Diclofenac Epolamine .......... 86Diclofenac Potassium ........... 85Diclofenac Sodium .. 48, 85, 87,123Diclofenac Sodium ER ......... 85Diclofenac-Misoprostol ........ 85Dicloxacillin Sodium ............ 24Didanosine ...................... 11, 16DIDRONEL .......................... 51Difenoxin-Atropine .............. 53DIFFERIN ............................ 48Diflorasone Diacetate ........... 45DIFLUCAN ............................ 9Diflunisal .............................. 85Digoxin ................................. 28Dihydrocodeine Compound .. 85DILACOR XR ...................... 33Dilantin ................................. 88DILANTIN ........................... 90Dilantin Infatabs ................... 88DILATRATE-SR ................. 31DILAUDID ..................... 83, 84Diltiazem HCl ....................... 33Diltiazem HCl Coated Beads.................................... 32, 33Diltiazem HCl ER ................. 33Diltiazem HCl ER Beads 33, 37Diltiazem HCl ER CoatedBeads ................................ 35Dilt-XR ................................. 33Diovan .................................. 33DIOVAN HCT ..................... 38Dipentum .............................. 54Diphenhydramine HCl ........ 122Diphenoxylate-Atropine ....... 53Diphth-Acell Pertussis-Tetanus..................................... 61, 62DIPROLENE ........................ 44Disulfiram ....................... 50, 51DITROPAN XL .................. 128Divalproex Sodium ............... 88Divalproex Sodium ER ......... 88Divigel ................................. 113Dofetilide .............................. 28Dolasetron Mesylate ............. 53Donepezil HCl ...................... 93Dornase Alfa ....................... 120Dorzolamide HCl ................ 127Dorzolamide HCl-Timolol Mal......................................... 127DOVONEX ........................... 43Doxazosin Mesylate .............. 34Doxepin HCl ................... 74, 75Doxepin HCl (Antipruritic) ... 48Doxycycline (Rosacea) ......... 26Doxycycline Hyclate ............. 26Doxycycline Monohydrate .... 26Dronabinol ............................ 54Dronedarone HCl .................. 27Drospirenone-Estradiol ....... 112Drospirenone-Ethinyl Estradiol................................. 108, 109Droxia ................................... 66DUETACT .......................... 104Dulera .................................. 118Duloxetine HCl ..................... 74DURAGESIC ........................ 83Duramorph ............................ 83DURICEF ............................. 17Dutasteride .......................... 129DYAZIDE ............................. 38DYNACIR ............................ 35DYNAPEN ........................... 24Dyrenium .............................. 34E.E.S. .................................... 19EASY COMFORT .............. 100EASY TOUCH ............. 99, 100Echothiophate Iodide .......... 126EC-NAPROSYN ................... 86Econazole Nitrate .................. 42Edecrin .................................. 34Edurant .................................. 11Efavirenz ............................... 15Efavirenz-Emtricitab-Tenofovir........................................... 11

EFFEXOR XR ...................... 80Effient.................................... 39EFUDEX ............................... 47Elaprase ................................. 97ELDEPRYL .......................... 82Electrolyte-M in Dextrose ... 132Elelyso ................................... 97Elestat .................................. 126Elestrin ................................ 113Eletriptan Hydrobromide ...... 92Elidel ..................................... 47Eligard ................................... 66ELIMITE ............................... 47Elitek ..................................... 64ELIXOPHYLLIN................ 121Elmiron................................ 129ELOCON .............................. 46Eltrombopag Olamine ........... 40Elviteg-Cobicis-Emtricit-Tenof........................................... 15Emadine .............................. 126Emcyt .................................... 66Emedastine Difumarate ....... 126Emend ................................... 54EMLA ................................... 41Emoquette............................ 108Emsam ................................... 75Emtricitabine ................... 11, 12Emtricitabine-Tenofovir ........ 16Emtricitab-Rilpivir-Tenofovir........................................... 11Emtriva ............................ 11, 12Enablex................................ 128Enalapril Maleate .................. 34Enalapril-Hydrochlorothiazide........................................... 34Enbrel .......................... 105, 106Endocet.................................. 83Endodan ................................ 83Enfuvirtide ............................ 12Engerix-B .............................. 61Enjuvia ................................ 113Enoxaparin Sodium ............... 39Enpresse-28 ......................... 108Entacapone ............................ 81Entecavir ............................... 11ENTOCORT EC ................... 54Enulose .................................. 55Enzalutamide ......................... 72Epinastine HCl .................... 126Página 138 de 150Epinephrine ......................... 122EpiPen 2-Pak ...................... 122EpiPen Jr 2-Pak .................. 122Epitol .................................... 88Epivir .................................... 12EPIVIR ................................. 13Epivir HBV ........................... 12Eplerenone ............................ 34Epoetin Alfa .......................... 60Eprosartan Mesylate ............. 38Eprosartan Mesylate-HCTZ . 38Epzicom ................................ 12Equetro ................................. 89Eraxis ...................................... 9Ergomar ................................ 92Ergotamine Tartrate .............. 92Ergotamine-Caffeine ............ 92Eribulin Mesylate ................. 67Erivedge ................................ 66Erlotinib ................................ 71Errin ................................... 113Ertapenem Sodium ............... 20Ery ........................................ 49ERYCETTE .......................... 49ERYTHROCIN .................... 19Erythrocin Stearate ............... 19Erythromycin ................ 49, 123Erythromycin Base ............... 19Erythromycin Ethylsuccinate 19Erythromycin Stearate .......... 19Escitalopram Oxalate ...... 75, 77Esomeprazole Magnesium .... 57Esterified Estrogens ............ 114Estrace ................................ 113Estradiol .............. 113, 114, 115Estradiol Acetate ................ 113Estradiol-Norethindrone Acet................................ 112, 113Estradiol-Norgestimate ....... 114Estramustine PhosphateSodium .............................. 66Estring ................................. 113Estrogens Conj Synthetic A 112Estrogens Conj Synthetic B 113Estrogens Conjugated ......... 114Estrogens, Conjugated ........ 114Estropipate .......................... 113ESTROSTEP FE ................ 111Eszopiclone ........................... 77Etanercept ................... 105, 106Ethacrynic Acid .................... 34Ethambutol HCl .................... 20Ethionamide .......................... 22Ethosuximide ........................ 89Ethotoin ................................. 90Ethynodiol Diac-Eth Estradiol................................. 109, 112ETHYOL ............................... 64Etidronate Disodium ............. 51Etodolac ................................ 85Etodolac ER .......................... 85Etonogestrel-Ethinyl Estradiol......................................... 115Etravirine ............................... 12Evamist ............................... 113Everolimus ...................... 64, 72Evista ................................... 107Evoxac ................................... 51Exelderm ............................... 42Exelon ................................... 93EXELON ............................... 93Exemestane ..................... 64, 66Exenatide ............................. 100Exforge .................................. 34Exforge HCT ......................... 34Exjade ................................... 51Extina .................................... 42Ezetimibe .............................. 30Ezetimibe-Simvastatin .......... 30Ezogabine .............................. 90Fabrazyme ............................. 97Famciclovir ........................... 12Famotidine ............................ 57FAMVIR ............................... 12Fanapt .................................... 75Fanapt Titration Pack ............ 75Fareston ................................. 66Faslodex ................................ 66Fat Emulsion ....................... 132FazaClo ................................. 75Febuxostat ........................... 107Felbamate .............................. 89Felbatol ................................. 89FELBATOL .......................... 89FELDENE ............................. 86Felodipine ER ....................... 34Femara ................................... 66FEMARA .............................. 67Femring ............................... 113Fenofibrate ............................ 29

Fenofibrate Micronized ......... 29Fenoglide ............................... 29Fenoprofen Calcium .............. 85FENTANYL.......................... 83FENTANYL Citrate .............. 83Fesoterodine Fumarate ER .. 128FIFTY50........................ 99, 100Filgrastim .............................. 59Finacea .................................. 49Finasteride ........................... 129Fingolimod HCl .................... 93FIORICET WITH CODEINE........................................... 82FIORINAL WITH CODEINE#3 ....................................... 82Firazyr ................................. 118FLAGYL ............................... 21Flavoxate HCl ..................... 128Flecainide Acetate ................. 27Flector ................................... 86FLOMAX ............................ 129FLONASE ........................... 119Flovent Diskus .................... 118Flovent HFA ....................... 119FLOXIN ................................ 25Fluconazole ............................. 9Fluconazole in Dextrose.......... 9Flucytosine .............................. 9Fludrocortisone Acetate ........ 95FLUMADINE ....................... 15Flunisolide ........................... 119Fluocinolone Acetonide . 44, 45,116Fluocinonide.................... 45, 47Fluocinonide-E ...................... 45Fluorometholone ......... 124, 125Fluorouracil ........................... 47Fluoxetine HCl ...................... 75Fluoxymesterone ................... 97Fluphenazine Decanoate ....... 75Fluphenazine HCl ................. 75Flurandrenolide ..................... 45Flurbiprofen .......................... 86Flurbiprofen Sodium ........... 123Flutamide .............................. 66Fluticasone Furoate ............. 121Fluticasone Propionate .. 45, 119Fluticasone Propionate HFA......................................... 119Página 139 de 150Fluticasone Propionate (Inhal)........................................ 118Fluticasone-Salmeterol ....... 117Fluvastatin Sodium ............... 29Fluvoxamine Maleate ........... 76Fluvoxamine Maleate ER ..... 76FML .................................... 124FML Forte .......................... 125Fomepizole ........................... 61Fondaparinux Sodium .......... 40Foradil Aerolizer ................ 119Formoterol Fumarate .......... 119FORTAMET ....................... 104Forteo .................................. 107Fortical .................................. 98FOSAMAX ................... 50, 107Fosamprenavir Calcium ........ 13Foscarnet Sodium ................. 12FOSCAVIR .......................... 12Fosfomycin Tromethamine .. 10Fosinopril Sodium ................ 34Fosinopril Sodium-HCTZ .... 34Fosphenytoin Sodium ........... 89Fosrenol ................................ 51Frova ..................................... 92Frovatriptan Succinate .......... 92Fulvestrant ............................ 66Furosemide ........................... 34Fuzeon .................................. 12Gabapentin ............................ 89GABITRIL ........................... 91Galantamine Hydrobromide . 93Galantamine Hydrobromide ER.......................................... 93Galsulfase ............................. 98GAMASTAN S/D ................ 61Gammaplex ........................... 61Gamunex-C ........................... 61Ganciclovir Sodium .............. 12GARAMYCIN ................... 123Gardasil ................................. 62Gastrocrom ........................... 55GASTROCROM .......... 54, 126Gauze Pads & Dressings .... 103GaviLyte-C ........................... 55Gelnique ............................. 128Gemfibrozil ........................... 29GENERALAC ................ 54, 55Gengraf ................................. 67Gentak ................................. 123Gentamicin Sulfate .. 20, 41, 123Geodon .................................. 76GEODON .............................. 81Gianvi .................................. 108Gildagia .............................. 108Gilenya .................................. 93Glatiramer Acetate ................ 93Gleevec ................................. 67Glimepiride ......................... 100Glipizide .............................. 101Glipizide ER ........................ 101Glipizide-Metformin HCl ... 101Glucagon (rDNA) ............... 101Glucagon Emergency .......... 101GLUCOPHAGE ................. 104GLUCOPHAGE XR ........... 104GLUCOTROL .................... 101GLUCOTROL XL .............. 101GLUCOVANCE ................. 101Glyburide ............................ 101Glyburide Micronized ......... 101Glyburide-Metformin .......... 101Glycopyrrolate ...................... 53GLYNASE .......................... 101Glyset .................................. 102Granisetron HCl .................... 55GRANISOL .......................... 55GRIFULVIN ........................... 9Griseofulvin Microsize ........... 9Griseofulvin Ultramicrosize .... 9GRIS-PEG ............................... 9Guanfacine HCl .................... 34Guanfacine HCl ER .............. 76Haemophil B Poly Cnj-HepatitB ........................................ 61Haemophilus B Polysac ConjVac .............................. 60, 63Halaven ................................. 67Halcinonide ........................... 46HALDOL .............................. 76Halobetasol Propionate ......... 45Halog ..................................... 46Haloperidol ........................... 76Haloperidol Decanoate .......... 76Haloperidol Lactate ............... 76Havrix ................................... 62Helidac .................................. 57Heparin (Porcine) in D5W .... 40Heparin (Porcine) in NaCl .... 40Heparin Sodium (Porcine) .... 40

Hepatitis A Vaccine ........ 62, 63Hepatitis A-Hep B RecombVac .................................... 63Hepatitis B Vac Recombinant..................................... 61, 63Hepsera.................................. 12Hexachlorophene .................. 41Hexalen ................................. 67HIPREX ................................ 10HPV Bivalent (16 & 18)Vaccine.............................. 61HPV Quadrivalent Vaccine ... 62HUMALOG ........................ 102HUMALOG Mix 50/50 ...... 102HUMALOG Mix 50/50KwikPen .......................... 102HUMALOG Mix 75/25 ...... 102HUMALOG Mix 75/25KwikPen .......................... 102Humatrope ............................. 59HUMIRA ............................ 106HUMIRA Pen-Crohns Starter......................................... 106HUMULIN 70/30 ................ 102HUMULIN 70/30 Pen ......... 102HUMULIN N ...................... 103HUMULIN N Pen ............... 103HUMULIN R ...................... 103HUMULIN R U-500(CONCENTRATED) ...... 103Hydralazine HCl ................... 34HYDREA .............................. 67Hydrochlorothiazide........ 34, 35Hydrocodone-Acetaminophen..................................... 83, 85Hydrocodone-Ibuprofen ........ 83Hydrocortisone ... 43, 46, 55, 56,95Hydrocortisone Valerate ....... 46Hydrocortisone-Acetic Acid116Hydromorphone HCl............. 83Hydromorphone HCl PF ....... 83Hydroxychloroquine Sulfate . 20Hydroxyurea.................... 66, 67HYTRIN................................ 38HYZAAR .............................. 35Ibandronate Sodium ............ 107Ibuprofen ............................... 86Icatibant Acetate ................. 118Iclusig .................................... 67Página 140 de 150Idursulfase ............................ 97Iloperidone ............................ 75ILOTYCIN ......................... 123Imatinib Mesylate ................. 67IMDUR ................................. 31Imiglucerase ......................... 97Imipenem-Cilastatin ............. 22Imipramine HCl .................... 76Imipramine Pamoate ............. 76Imiquimod ............................ 48IMITREX ............................. 92Immune Globulin (Human) .. 61IMODIUM ............................ 53Imovax Rabies ...................... 62IMURAN .............................. 65Incivek .................................. 12INCONTROL ..................... 100Increlex ................................. 51Indapamide ........................... 35INDERAL ....................... 36, 37INDERAL LA ...................... 37INDERIDE ........................... 37Indinavir Sulfate ................... 11Infanrix ................................. 62Infergen ................................. 59Infliximab ............................. 56Inlyta ..................................... 67INSPRA ................................ 34Insulin Detemir ........... 103, 104Insulin Glargine .................. 103Insulin Isophane & Regular 102Insulin Isophane Human ..... 103Insulin Lispro (Human) ...... 102Insulin Lispro Prot & Lispro........................................ 102Insulin Pen Needle .............. 100Insulin Regular Human ....... 103Insulin Regular Human (Conc)........................................ 103Insulin Syringe-Needle U-100........................................ 100Intelence ............................... 12Interferon Alfa-2B ................ 59Interferon alfacon-1 .............. 59Interferon Beta-1a ................. 58Interferon Beta-1b ................ 58Interferon Gamma-1B .......... 58Intralipid ............................. 132INTRALIPID ...................... 132Intron-A ................................ 59Intuniv ................................... 76INVANZ ............................... 20Invega .................................... 76Invega Sustenna .................... 76Invirase ............................ 12, 13IOPIDINE ........................... 127Ipol ........................................ 62Ipratropium Bromide .......... 116Ipratropium Bromide HFA.. 118Ipratropium-Albuterol ......... 118Irbesartan ............................... 35Irbesartan-Hydrochlorothiazide........................................... 35Isentress ................................. 13Isocarboxazid ........................ 77Isolyte-M in D5W ............... 132Isoniazid ................................ 20ISORDIL ............................... 30Isosorbide Dinitrate ............... 30Isosorbide Dinitrate ER ......... 31Isosorbide Mononitrate ......... 31Isosorbide Mononitrate ER ... 31Isotretinoin ...................... 48, 49Isradipine ............................... 35Itraconazole ............................. 9Ivermectin ............................. 22Ixiaro ..................................... 62Jakafi ..................................... 67Jantoven ................................ 40Janumet ............................... 103Januvia ................................ 103Japanese Encephalitis Vac Inac........................................... 62Jentadueto ........................... 103Junel 1.5/30 ......................... 109Junel 1/20 ............................ 109Junel FE 1.5/30 ................... 109Junel FE 1/20 ...................... 109Kadcyla ................................. 67Kadian ................................... 83KADIAN ............................... 84Kaletra ................................... 13Kariva ................................. 109Kayexalate ............................. 51KCl in Dextrose-NaCl ......... 130KCl-Lactated Ringers-D5W 130KEFLEX ............................... 18KEFZOL ............................... 17Kelnor 1/35 ......................... 109Kenalog ................................. 46

KEPPRA ............................... 89KERLON .............................. 32KERLONE .......................... 124KETAB ................................. 18Ketek ..................................... 20Ketoconazole ..................... 9, 42Ketoprofen ............................ 86Ketoprofen ER ...................... 86Ketorolac Tromethamine .... 123Kling Flexible Gauze .......... 103KLONOPIN .......................... 87Klor-Con ............................. 130Klor-Con 10 ........................ 130Klor-Con M15 ..................... 130Klor-Con M20 ..................... 130Kombiglyze XR .................. 103Kuvan .................................... 98Labetalol HCl ........................ 35LAC-HYDRIN ...................... 47Lacosamide ..................... 91, 92Lactated Ringers ........... 52, 130Lactulose ............................... 55LAMICTAL .......................... 89LAMISIL .............................. 10Lamivudine ..................... 12, 13Lamivudine-Zidovudine........ 13Lamotrigine ........................... 89Lamotrigine ER ..................... 89Lanoxin ................................. 28LANOXIN ............................ 28Lanreotide Acetate ................ 70Lansoprazole ......................... 57Lanthanum Carbonate ........... 51Lantus .................................. 103Lapatinib Ditosylate .............. 71LARIAM ............................... 21Laronidase ............................. 96LASIX ................................... 34Latanoprost.......................... 127Latuda.................................... 77Lazanda ................................. 83Leena ................................... 109Leflunomide ........................ 106Lenalidomide ........................ 69LESCOL................................ 29Lessina ................................ 109Letairis ................................ 119Letrozole ......................... 66, 67Leucovorin Calcium .............. 64Leukeran................................ 67Página 141 de 150Leukine ................................. 59Leuprolide Acetate ... 66, 67, 68Leuprolide Acetate (3 Month).................................... 66, 68Leuprolide Acetate (4 Month).................................... 66, 68Leuprolide Acetate (6 Month).................................... 66, 68Levalbuterol Tartrate .......... 121LEVAQUIN ................. 25, 123Levatol .................................. 35Levemir ............................... 103Levemir FlexPen ................ 104Levetiracetam ....................... 89Levetiracetam ER ................. 89Levitra ................................. 129Levobunolol HCl ................ 124Levocarnitine ........................ 51Levocetirizine Dihydrochloride........................................ 122Levofloxacin ................. 25, 123Levofloxacin in D5W ........... 25Levonest .............................. 109Levonorgest-Eth Estrad 91-Day........................................ 111Levonorgestrel-Ethinyl Estrad................ 108, 109, 110, 111Levonorg-Eth Estrad Triphasic........................ 108, 109, 112Levora 0.15/30 (28) ............ 109Levorphanol Tartrate ............ 83Levothroid ............................. 96Levothyroxine Sodium ......... 96Levoxyl .................................. 96Lexapro ................................. 77LEXAPRO ............................ 75Lexiva ................................... 13Lialda .................................... 55LIDEX .................................. 45LIDEX-E .............................. 45Lidocaine .............................. 41Lidocaine HCl ...................... 41Lidocaine HCl (PF) .............. 41Lidocaine Viscous ................ 41Lidocaine-Prilocaine ............. 41Lidocaine-Tetracaine ............ 41Lidoderm .............................. 41Linagliptin .......................... 105Linagliptin-Metformin HCl 103Lindane ................................. 47Linezolid ............................... 23Liothyronine Sodium ............ 96LIPITOR ............................... 29Lipofen .................................. 29Liposyn III ........................... 132Lisdexamfetamine Dimesylate........................................... 80Lisinopril ............................... 35Lisinopril-Hydrochlorothiazide........................................... 35LITETOUCH ...................... 100Lithium Carbonate ................ 77Lithium Carbonate ER .......... 77Lithium Citrate ...................... 77Lodosyn ................................. 81Lodoxamide Tromethamine 126LOESTRIN ................. 109, 110LOESTRIN FE ............ 109, 110LOFIBRA ............................. 29LOMOTIL ............................. 53Lomustine ............................. 65Loperamide HCl .................... 53LOPID ................................... 29Lopinavir-Ritonavir .............. 13LOPRESSOR ........................ 35LOPRESSOR HCT ............... 36LOPROX ............................... 42LORazepam .......................... 77Loryna ................................. 109Losartan Potassium ............... 35Losartan Potassium-HCTZ ... 35LOTENSIN ........................... 32LOTENSIN HCT .................. 32LOTREL ............................... 31LOTRISONE ........................ 42Lotronex ................................ 55Lovastatin .............................. 29Lovastatin ER ........................ 28Lovaza ................................... 29LOVENOX ........................... 39Low-Ogestrel ....................... 109Loxapine Succinate ............... 77LOXITANE .......................... 77Lubiprostone ......................... 53Lumigan .............................. 127Lunesta .................................. 77Lupron Depot .................. 67, 68Lupron Depot-Ped ................. 68Lurasidone HCl ..................... 77Lutera .................................. 110

LUVOX CR .......................... 76Luxiq ..................................... 46Lymphocyte,Anti-Thymo ImmGlob ................................... 61Lyrica .................................... 90Lysodren................................ 68Mafenide Acetate ............ 41, 42Magnesium Sulfate ............. 130Malarone ............................... 21Maprotiline HCl .................... 77Maraviroc .............................. 15MARINOL ............................ 54Marlissa ............................... 110Marplan ................................. 77Matulane................................ 68Matzim LA ............................. 35MAVIK ................................. 38Maxair Autohaler ................ 119MAXALT.............................. 92MAXALT MLT .................... 92Maxidex .............................. 125MAXIPIME .......................... 17MAXZIDE ............................ 38Measles, Mumps & RubellaVac .................................... 62Measles-Mumps-Rubella-Varicell .............................. 63Mecasermin ........................... 51Meclizine HCl ....................... 55Meclofenamate Sodium ........ 86MEDROL .............................. 95Medroxyprogesterone Acetate................................. 113, 114Mefenamic Acid .................... 86Mefloquine HCl .................... 21MEFOXIN ............................ 17MEGACE .............................. 68Megestrol Acetate ................. 68Mekinist ................................ 68Meloxicam ............................ 86Memantine HCl ..................... 93Menactra................................ 62Menest ................................. 114Meningococcal A C Y&W-135Conj ................................... 62Meningococcal A C Y&W-135Olig.................................... 62Meningococcal Vac A,C,Y,W-135 ..................................... 62Menomune ............................ 62Página 142 de 150Menostar ............................. 114Mentax .................................. 42Menveo ................................. 62Mepron ................................. 21Mercaptopurine ..................... 68Meropenem ........................... 21MERREM ............................. 21Mesalamine ............... 53, 54, 55Mesalamine ER .............. 53, 56Mesalamine-Cleanser ........... 55Mesna ................................... 64MESNEX .............................. 64Mestinon ............................... 94MESTINON ......................... 94Metadate ER ......................... 77Metaproterenol Sulfate ....... 119Metformin HCl ................... 104Metformin HCl ER ............. 104Metformin HCl ER (OSM) . 104Methadone HCl .................... 84Methazolamide ................... 126Methenamine Hippurate ....... 10METHERGINE .................. 115Methimazole ......................... 94Methitest ............................... 98METHITEST ........................ 98Methotrexate ......................... 68Methotrexate Sodium ........... 68Methotrexate Sodium (PF) ... 68Methoxsalen ......................... 47Methoxsalen Rapid ............... 48Methscopolamine Bromide .. 53Methsuximide ....................... 87Methyclothiazide .................. 35Methylergonovine Maleate . 115Methylnaltrexone Bromide ... 56Methylphenidate ................... 74Methylphenidate HCl ER ..... 77Methylprednisolone .............. 95Methylprednisolone (Pak) .... 95Methylprednisolone Acetate . 95Methylprednisolone SodiumSucc .................................. 95Methyltestosterone ............... 99Metipranolol ....................... 124Metoclopramide HCl ............ 55Metolazone ........................... 35Metoprolol Succinate ER ..... 35Metoprolol Tartrate .............. 35Metoprolol-Hydrochlorothiazide ......... 36Metozolv ODT ...................... 55METROCREAM .................. 49Metrogel ................................ 49METROGEL ......................... 49METROLOTION .................. 49Metronidazole ......... 21, 49, 115Metronidazole in NaCl .......... 21Metronid-Tetracyc-Bis Subsal........................................... 57Metyrosine ............................ 33MEVACOR ........................... 29Mexiletine HCl ...................... 27MEXITIL .............................. 27Miacalcin ............................... 98MIACALCIN ........................ 98Micafungin Sodium .............. 10Miconazole 3 ....................... 115Microgestin 1.5/30 .............. 110Microgestin 1/20 ................. 110Microgestin FE 1.5/30 ........ 110Microgestin FE 1/20 ........... 110MICRO-K ........................... 130MICRONOR ....................... 114MIDAMOR ........................... 31Midodrine HCl ...................... 51Migergot ................................ 92Miglitol ............................... 102Miglustat ............................... 99Milnacipran HCl ................. 106MINIPRESS .......................... 36MINITRAN ........................... 31MINOCIN ............................. 26Minocycline HCl ................... 26Minocycline HCl ER ............. 26Minoxidil ............................... 36MIRAPEX ............................. 81MIRCETTE ......................... 109Mirtazapine ........................... 78Misoprostol ........................... 57Mitotane ................................ 68Mitoxantrone HCl ................. 68M-M-R II .............................. 62MOBIC ................................. 86Modafinil ............................... 78MODURETIC ....................... 31Moexipril HCl ....................... 36Moexipril-Hydrochlorothiazide........................................... 36

Mometasone Furoate .... 46, 117,118Mometasone Furo-FormoterolFum ................................. 118MonoNessa .......................... 110MONOPRIL .......................... 34MONOPRIL HCT ................. 34Montelukast Sodium ........... 119Monurol ................................. 10Morphine Sulfate................... 84Morphine Sulfate (Concentrate)........................................... 84Morphine Sulfate ER ...... 83, 84Morphine Sulfate ER Beads .. 82Motofen ................................. 53Moxatag ................................ 24Moxifloxacin HCl ......... 25, 124Multaq ................................... 27Mupirocin .............................. 41Mupirocin Calcium ....... 41, 116MYAMBUTOL .................... 20Mycamine.............................. 10MYCELEX ....................... 9, 42Mycobutin ............................. 21MYCOLOG .......................... 42Mycophenolate Mofetil ... 65, 69MYCOSTATIN .............. 10, 42MYSOLINE .......................... 90Nabumetone .......................... 86Nadolol .................................. 36Nadolol-Bendroflumethiazide........................................... 36Nafarelin Acetate .................. 98Nafcillin Sodium ................... 24Naglazyme ............................ 98NALLPEN ............................ 24Naloxone HCl ....................... 86Naltrexone HCl ..................... 86Namenda ............................... 93Namenda Titration Pak ......... 93Naphazoline HCl ................. 127NAPROSYN ......................... 86Naproxen ............................... 86Naproxen DR ........................ 86Naproxen Sodium ................. 86Naratriptan HCl ..................... 92Nardil .................................... 78NARDIL................................ 79Nasacort AQ ........................ 119NASACORT AQ ................ 116Página 143 de 150NASALCROM ................... 118Natacyn ............................... 123Natalizumab .......................... 94Natamycin ........................... 123Nebivolol HCl ...................... 32Nebupent ............................... 21Necon 0.5/35 (28) ............... 110Necon 1/35 (28) .................. 110Necon 10/11 (28) ................ 110Necon 7/7/7 ......................... 110Nedocromil Sodium ............ 126Nefazodone HCl ................... 78Nelfinavir Mesylate .............. 16Neomycin Sulfate ................. 21Neomycin-Bacitracin Zn-Polymyx .......................... 123Neomycin-Polymyxin B GU 53Neomycin-Polymyxin-Dexameth ........................ 125Neomycin-Polymyxin-Gramicidin ...................... 124Neomycin-Polymyxin-HC . 115,125NEORAL .............................. 66NEOSPORIN ...................... 124Nepafenac ........................... 123NEPTAZANE ..................... 126Neulasta ................................ 59Neumega ............................... 59Neupogen .............................. 59NEURONTIN ....................... 89Nevanac .............................. 123Nevirapine ...................... 13, 16Nevirapine ER ...................... 16NEXAVAR ........................... 69NEXIUM .............................. 57Niacin ER(Antihyperlipidemic) ........ 29Niacin-Lovastatin ER ........... 28Niacin-Simvastatin ER ......... 30Niaspan ................................. 29Nicardipine HCl .................... 36Nicotine ................................ 52Nicotrol ................................. 52Nicotrol NS ........................... 52Nifediac CC .......................... 36Nifedical XL .......................... 36Nifedipine ER ................. 31, 36Nifedipine ER Osmotic ........ 36Nilandron .............................. 69Nilotinib ................................ 71Nilutamide ............................. 69Nimodipine ........................... 36NIMOTOP ............................ 36NIRAVAM ........................... 73Nisoldipine ER ...................... 36Nitazoxanide ......................... 19Nitisinone .............................. 51Nitro-Bid ............................... 31Nitroglycerin ......................... 31Nitrostat ................................. 31Nizatidine .............................. 57NIZORAL ......................... 9, 42Nora-BE .............................. 114NORDETTE ....... 109, 110, 111Norditropin FlexPro .............. 60Norditropin NordiFlex Pen ... 60Norethin Ace-Eth Estrad-FE................................. 109, 110Norethindrone ..... 112, 113, 114Norethindrone Acetate ........ 114Norethindrone Acet-Ethinyl Est................................. 109, 110Norethindrone-Eth Estradiol......................... 108, 110, 111Norethindron-Ethinyl Estrad-Fe......................................... 111Norethin-Eth Estrad Biphasic......................................... 110Norethin-Eth Estrad Triphasic................. 108, 109, 110, 111Norfloxacin ........................... 25Norgestimate-Eth Estradiol 110,111Norgestim-Eth Estrad Triphasic......................................... 112Norgestrel-Ethinyl Estradiol......................... 108, 109, 111NORINYL ................... 108, 110NORMODYNE ..................... 35Noroxin ................................. 25NORPRAMIN ....................... 74NOR-Q-D .................... 112, 113Nortrel 0.5/35 (28) .............. 110Nortrel 1/35 (21) ................. 111Nortrel 1/35 (28) ................. 111Nortrel 7/7/7 ........................ 111Nortriptyline HCl .................. 78NORVASC ........................... 31Norvir .................................... 13

NOVOFINE ........................ 100NOVOTWIST ..................... 100Noxafil .................................. 10Nucynta ................................. 86Nuedexta ............................... 93Nulojix .................................. 69NuvaRing ............................ 115Nuvigil .................................. 78Nyamyc .................................. 42Nystatin ..................... 10, 42, 43Nystatin-Triamcinolone ........ 42Nystop ................................... 43Octreotide Acetate ........... 69, 70Ocufen ................................. 123OCUFLOX .......................... 124OCUFLOX I ....................... 116Ofloxacin ............... 25, 116, 124Ogestrel ............................... 111Olanzapine ............................ 78Olanzapine-Fluoxetine HCl . 78,80Olmesartan Medoxomil......... 32Olmesartan Medoxomil-HCTZ........................................... 32Olopatadine HCl ......... 116, 126Olsalazine Sodium ................ 54Olux-E ................................... 46Omacetaxine Mepesuccinate. 70Omalizumab ........................ 121Omega-3-acid Ethyl Esters ... 29Omeprazole ........................... 57Omnaris ............................... 120OMNICEF ............................. 17OMNIPRED ........................ 125OnabotulinumtoxinA ............ 61Ondansetron .......................... 55Ondansetron HCl................... 55Onfi ....................................... 90Onglyza ............................... 104OPANA ................................. 84Opana ER (Crush Resistant) . 84Oprelvekin ............................. 59OPTIPRANOLOL .............. 124OPTIVAR ........................... 116Oracea ................................... 26Orap ....................................... 78Orapred.................................. 95Orapred ODT ........................ 95Orencia ................................ 106Orfadin .................................. 51Página 144 de 150Orsythia .............................. 111ORTHO TRI-CYCLEN ...... 112ORTHO-CEPT ........... 108, 111ORTHO-CYCLEN ..... 110, 111ORTHO-NOVUM ...... 110, 111Oseltamivir Phosphate .......... 15OsmoPrep ............................. 56OVCON .............................. 108Oxacillin Sodium .................. 24Oxacillin Sodium in Dextrose.......................................... 24OXANDRIN ......................... 98Oxandrolone ......................... 98Oxaprozin ............................. 86Oxcarbazepine ................ 90, 91Oxiconazole Nitrate .............. 43Oxistat ................................... 43Oxsoralen Ultra .................... 48Oxybutynin ......................... 128Oxybutynin Chloride .......... 128Oxybutynin Chloride ER .... 128Oxycodone HCl .................... 84Oxycodone-Acetaminophen 83,84Oxycodone-Aspirin ........ 83, 84Oxycodone-Ibuprofen ........... 84OXYCONTIN ...................... 84Oxymorphone ER (CrushResist) ............................... 84Oxymorphone HCl ............... 84Oxytrol ................................ 128Pacerone ............................... 27Palgic .................................. 122Paliperidone ER .................... 76Paliperidone Palmitate .......... 76PAMELOR ........................... 78PAMIDE ............................... 53Pamidronate Disodium ......... 98Pancrelipase (Lip-Prot-Amyl).................................... 54, 56Panretin ................................. 48Pantoprazole Sodium ............ 58PARCOPA ODT .................. 81Parenteral Electrolytes ........ 131Paricalcitol ............................ 99PARLODEL ......................... 81Paromomycin Sulfate ........... 21Paroxetine HCl ..................... 78Paroxetine HCl ER ............... 78Paser ..................................... 21Pataday ................................ 126Patanase ............................... 116Paxil ...................................... 78PAXIL ................................... 78Pazopanib HCl ...................... 72Pedvax HIB ........................... 63PEG 3350-KCl-NaBcb-NaCl-NaSulf ............................... 55Pegademase Bovine .............. 50Peganone ............................... 90Pegasys .................................. 60Pegasys ProClick .................. 60Pegfilgrastim ......................... 59Peginterferon alfa-2a ............. 60Peginterferon alfa-2b............. 60Pegvisomant .......................... 98Pemetrexed Disodium ........... 64Penbutolol Sulfate ................. 35Penicillamine ....................... 105Penicillin G Benzathine & Proc........................................... 24Penicillin G Potassium .......... 24Penicillin G Procaine ............ 24Penicillin G Sodium .............. 25Penicillin V Potassium .......... 25PENLAC ............................... 42Pentam ................................... 21Pentamidine Isethionate ........ 21Pentasa .................................. 56Pentosan Polysulfate Sodium......................................... 129Pentoxifylline ER .................. 40PEN-V ................................... 25PEPCID ................................. 57PERCOCET .................... 83, 84PERCODAN ................... 83, 84Perindopril Erbumine ............ 36Periogard ............................. 116Permethrin ............................. 47Perphenazine ......................... 79Perphenazine-Amitriptyline .. 79PFIZERPEN .................... 24, 25Phenadoz ............................. 122Phenelzine Sulfate ........... 78, 79Phenobarbital ........................ 90Phenoxybenzamine HCl ........ 33Phenytek ................................ 90Phenytoin ........................ 88, 90Phenytoin Sodium ................. 90

Phenytoin Sodium Extended 88,90Phisohex ................................ 41Phospholine Iodide .............. 126Pilocarpine HCl ..................... 51Pimecrolimus ........................ 47Pimozide................................ 78Pindolol ................................. 36Pioglitazone HCl ................. 104Pioglitazone HCl-Glimepiride......................................... 104Pioglitazone HCl-MetforminHCl .................................. 104Piperacillin Sod-TazobactamSo ...................................... 25Pirbuterol Acetate ............... 119Piroxicam .............................. 86PLAN B............................... 109PLAQUENIL ........................ 20PLAVIX ................................ 39PLENDIL .............................. 34PLETAL ................................ 39Podofilox ............................... 48Poliovirus Vaccine Inactivated........................................... 62Polyethylene Glycol 3350 ..... 56Polymyxin B Sulfate ............. 21Polymyxin B-Trimethoprim 124POLYTRIM ........................ 124Pomalidomide ....................... 69Pomalyst ................................ 69Ponatinib HCl ........................ 67PONSTEL ............................. 86Portia-28 ............................. 111Posaconazole ......................... 10Potassium Chloride ............. 130Potassium Chloride Crys ER......................................... 130Potassium Chloride ER ....... 130Potassium Chloride in Dextrose......................................... 130Potassium Chloride in NaCl 131Potiga .................................... 90Pradaxa .................................. 40Pramipexole Dihydrochloride........................................... 81Pramlintide Acetate ............. 105PrandiMet ............................ 104Prandin ................................ 104Prasugrel HCl ........................ 39Página 145 de 150PRAVACHOL ...................... 30Pravastatin Sodium ............... 30Praziquantel .......................... 19Prazosin HCl ......................... 36PRECOSE ............................. 99PRED FORTE .............. 95, 125Pred Mild ............................ 125Prednicarbate ........................ 46Prednisolone Acetate .......... 125Prednisolone SodiumPhosphate .................. 95, 125Prednisone ............................ 95Prednisone Intensol .............. 95Prefest ................................. 114Pregabalin ............................. 90PRELONE ............................ 95Premarin ............................. 114Premphase ........................... 114Prempro .............................. 114Prenatal/Iron ....................... 132PREVACID .......................... 57Prevalite ............................... 30Previfem .............................. 111Prezista ................................. 14Priftin .................................... 22PRILOSEC ........................... 57Primaquine Phosphate .......... 22Primaxin IV .......................... 22Primidone ............................. 90Primsol .................................. 10PRINZIDE ............................ 35Pristiq .................................... 79ProAir HFA ........................ 120Probenecid .......................... 106Procainamide HCl ................ 27Procarbazine HCl .................. 68PROCARDIA XL ................. 36Prochlorperazine ................... 54Prochlorperazine Edisylate ... 56Prochlorperazine Maleate ..... 56Procrit ................................... 60Proctozone-HC ..................... 56PRODIGY .......................... 100Progesterone ....................... 113Progesterone Micronized .... 114Proglycem ........................... 104Prograf .................................. 69PROGRAF ............................ 70Proleukin ............................... 60Prolia ................................... 107PROLOPRIM ........................ 10Promacta ............................... 40Promethazine HCl ............... 122PROMETRIUM .................. 114Propafenone HCl ................... 27Propafenone HCl ER ............. 27Proparacaine HCl ................ 126Propranolol HCl .............. 36, 37Propranolol HCl ER .............. 37Propranolol-HCTZ ................ 37Propylthiouracil ..................... 94ProQuad ................................ 63PROSCAR .......................... 129PROTONIX .......................... 58PROTONIX IV ..................... 58Protopic ................................. 48Protriptyline HCl ................... 79Proventil HFA ..................... 120PROVERA .......................... 114PROVIGIL ............................ 78PROZAC ............................... 75PROZAC WEEKLY ............. 75PSORCON ............................ 45Pulmicort Flexhaler ............. 120Pulmozyme ......................... 120Pylera .................................... 58Pyrazinamide ......................... 22Pyridostigmine Bromide ....... 94Pyridostigmine Bromide ER . 94Pyrimethamine ...................... 20QC ......................................... 99Qualaquin .............................. 22Quasense ............................. 111QUESTRAN ......................... 29Quetiapine Fumarate ............. 79Quinapril HCl ........................ 37Quinapril-Hydrochlorothiazide........................................... 37Quinidine Gluconate ER ....... 27Quinidine Sulfate .................. 27Quinidine Sulfate ER ............ 27Quinine Sulfate ..................... 22Quinupristin-Dalfopristin ...... 22Qvar ..................................... 120Rabavert ................................ 63Rabeprazole Sodium ............. 57Rabies Vaccine, PCEC .......... 63Rabies Virus Vaccine, HDC . 62Raloxifene HCl ................... 107Raltegravir Potassium ........... 13

Ramelteon ............................. 79Ramipril ................................ 37Ranexa ................................... 30Ranitidine HCl ...................... 58Ranolazine ER....................... 30Rapaflo ................................ 129Rapamune.............................. 69Rasagiline Mesylate .............. 81Rasburicase ........................... 64RAZADYNE ......................... 93REALITY.............................. 99REBETOL ............................. 14Reclast ................................... 51Reclipsen ............................. 111Recombivax HB .................... 63REGLAN .............................. 55Regorafenib ........................... 70Relenza Diskhaler ................. 14Relistor .................................. 56Relpax ................................... 92REMERON ........................... 78REMERON ODT .................. 78Remicade ............................... 56Remodulin ............................. 37Renagel.................................. 51Repaglinide ......................... 104Repaglinide-Metformin HCl......................................... 104REQUIP ................................ 82Rescriptor .............................. 14Restasis................................ 126Retapamulin .......................... 41RETIN-A ......................... 49, 71Retrovir ................................. 14RETROVIR ........................... 17REVATIO ........................... 120REVIA .................................. 86Revlimid ................................ 69Reyataz .................................. 14Rhinocort Aqua ................... 120RibaPak ................................. 14RIBATAB ............................. 15RIBATAB ............................. 14Ribavirin.......................... 14, 15Ridaura ................................ 106Rifabutin................................ 21RIFADIN .............................. 22Rifampin................................ 22Rifapentine ............................ 22Rifaximin .............................. 23Página 146 de 150Rilonacept ............................. 58Rilpivirine HCl ..................... 11Rilutek .................................. 52Riluzole ................................. 52Rimantadine HCl .................. 15Rimexolone ......................... 125Ringers ................................ 131Ringers Irrigation .................. 53Riomet ................................ 104Risedronate Sodium ...... 50, 107RISPERDAL ........................ 79RISPERDAL Consta ............ 79Risperidone ........................... 79Risperidone Microspheres .... 79RITALIN-SR ........................ 77Ritonavir ............................... 13Rituxan ................................. 70Rituximab ............................. 70Rivaroxaban .......................... 40Rivastigmine ......................... 93Rivastigmine Tartrate ........... 93Rizatriptan Benzoate ............ 92ROBINUL ............................ 53ROBINUL FORTE ............... 53ROCEPHIN .......................... 18Roflumilast ......................... 118Ropinirole HCl ..................... 81Ropinirole HCl ER ............... 82Rosuvastatin Calcium ........... 29RotaTeq ................................ 63Rotavirus Vac Live Pentavalent.......................................... 63ROWASA ............................. 55Rozerem ................................ 79Rufinamide ........................... 87Ruxolitinib Phosphate .......... 67RYTHMOL .......................... 27Sabril ............................... 90, 91SALAGEN ........................... 51Salmeterol Xinafoate .......... 120Sanctura XR ........................ 128SANDIMMUNE ................... 66SANDOSTATIN .................. 69Sandostatin LAR Depot ........ 70Santyl .................................... 47Saphris .................................. 79Sapropterin Dihydrochloride 98Saquinavir Mesylate ....... 12, 13Sargramostim ........................ 59Savella ................................ 106Savella Titration Pack ......... 106Saxagliptin HCl ................... 104Saxagliptin-Metformin ER .. 103SECTRAL ............................. 31Selegiline ............................... 75Selegiline HCl ....................... 82Selenium Sulfide ................... 43Selzentry ............................... 15Semprex-D .......................... 122Sensipar ................................. 98Serevent Diskus .................. 120Seromycin ............................. 22SEROQUEL .......................... 79Sertraline HCl ....................... 79Sevelamer HCl ...................... 51Sildenafil Citrate ......... 120, 129Silodosin ............................. 129SILVADENE .................. 41, 50Silver Sulfadiazine ................ 50Simcor ................................... 30Simvastatin ............................ 30Sinecatechins ......................... 48SINEMET ............................. 81SINEMET CR ....................... 81SINGULAIR ....................... 119Sirolimus ............................... 69Sitagliptin Phosphate .......... 103Sitagliptin-Metformin HCl .. 103Skelid .................................... 52Sod Phos Mono-Sod PhosDibasic .............................. 56Sodium Chloride ........... 52, 131Sodium Lactate ................... 131Sodium Oxybate .................... 81Sodium Phenylbutyrate ... 50, 52Sodium Polystyrene Sulfonate..................................... 51, 52Solaraze ................................. 48Solifenacin Succinate .......... 128Soltamox ............................... 70Somatropin ...................... 59, 60Somatuline Depot .................. 70Somavert ............................... 98SONATA .............................. 81SORAfenib Tosylate ............. 69Soriatane ............................... 43Sorine .................................... 28Sotalol HCl ............................ 28Sotalol HCl (AF) ................... 28Sotalol HCl AF ..................... 27

SPECTAZOLE...................... 42Spiriva HandiHaler ............. 120Spironolactone ...................... 37Spironolactone-HCTZ ........... 37SPORANOX ........................... 9Sprintec 28 .......................... 111Sprycel .................................. 70Sronyx.................................. 111SSD ........................................ 50Stagesic ................................. 84STALEVO ............................ 81Stavudine ......................... 15, 17Stavzor .................................. 91Stelara.................................... 43Sterile Water for Irrigation .... 52Stimate .................................. 98Stivarga ................................. 70Strattera ................................. 80Streptomycin Sulfate ............. 22Stribild ................................... 15Stromectol ............................. 22Succimer................................ 50Sucralfate ........................ 57, 58SULAR.................................. 36Sulconazole Nitrate ............... 42Sulfacetamide Sodium .. 41, 127Sulfacetamide-Prednisolone 125Sulfadiazine ........................... 26Sulfamethoxazole-TMP DS .. 26Sulfamethoxazole-Trimethoprim .................... 26Sulfamylon ...................... 41, 42Sulfasalazine ......................... 56Sulfazine EC .......................... 56Sulindac ................................. 86Sumatriptan Succinate........... 92Sumatriptan-Naproxen Sodium........................................... 92Sunitinib Malate .................... 70Suprax ................................... 18SURE COMFORT ................ 99SURE-COMFORT .............. 100SURMONTIL ....................... 80Sustiva ................................... 15Sutent .................................... 70Sylatron ................................. 60Symbicort ............................ 121Symbyax................................ 80SYMBYAX ........................... 78SymlinPen 120 .................... 105Página 147 de 150SymlinPen 60 ...................... 105SYMMETREL ..................... 11Synalgos-DC ......................... 85SYNARAL ........................... 45Synarel .................................. 98Synera ................................... 41Synercid ................................ 22Synribo ................................. 70Synthroid .............................. 96SYNTHROID ....................... 96Syprine .................................. 52Tabloid .................................. 70Taclonex ............................... 43Tacrolimus ................ 48, 69, 70Tadalafil .............................. 129Tadalafil (PAH) .................. 116Tafinlar ................................. 70Taliglucerase Alfa ................ 97TAMBOCOR ....................... 27Tamiflu ................................. 15Tamoxifen Citrate ................. 70Tamsulosin HCl .................. 129TAPAZOLE ......................... 94Tapentadol HCl .................... 86Tarceva ................................. 71Targretin ............................... 71Tasigna ................................. 71Tasmar .................................. 82Tazarotene ............................ 49Tazorac ................................. 49Taztia XT .............................. 37TEGRETOL ......................... 91TEGRETOL ................... 87, 88TEGRETOL XR ................... 87TEGRETOL-XR ................... 91Tekturna ................................ 37Tekturna HCT ....................... 37Telaprevir ............................. 12Telbivudine ........................... 16Telithromycin ....................... 20Telmisartan-Amlodipine ....... 38TEMOVATE ........................ 44Tenofovir Disoproxil Fumarate.......................................... 16TENORETIC ........................ 32TENORMIN ......................... 32TERAZOL 3 ....................... 115Terazosin HCl ....................... 38Terbinafine HCl .................... 10Terbutaline Sulfate ............. 121Terconazole ......................... 115Teriparatide (Recombinant) 107TERSI FOAM ....................... 43Testim ................................... 99Testosterone .............. 96, 97, 99Testred ................................... 99Tetanus Toxoid Adsorbed ..... 63Tetanus-Diphth-Acell Pertussis..................................... 60, 61Tetanus-Diphtheria Toxoids Td........................................... 63Tetrabenazine ........................ 94Tetrahydrozoline HCl ......... 116Teveten .................................. 38Teveten HCT ......................... 38Thalidomide .......................... 71Thalomid ............................... 71Theophylline ER ................. 121Thioguanine .......................... 70Thioridazine HCl .................. 80Thiothixene ........................... 80Tiagabine HCl ....................... 91TIAZAC ................................ 37Tigecycline ............................ 23Tikosyn ................................. 28Tiludronate Disodium ........... 52Timolol Maleate ............ 38, 124Timolol Maleate PF ............ 124TIMOPTIC .......................... 124Timoptic Ocudose ............... 124Timoptic-XE ....................... 124Tiotropium BromideMonohydrate ................... 120Tipranavir .............................. 11Tizanidine HCl ...................... 94Tobi ....................................... 22TOBRADEX ....................... 125Tobramycin ........................... 22Tobramycin Sulfate ....... 22, 124Tobramycin-Dexamethasone......................................... 125TOBREX ............................. 124Tocilizumab ........................ 105TOFRANIL ........................... 76Tolazamide .......................... 105Tolbutamide ........................ 105Tolcapone .............................. 82Tolmetin Sodium .................. 86TOPAMAX ........................... 91TOPICORT ........................... 45

Topiramate ............................ 91TOPROL XL ......................... 35Toremifene Citrate ................ 66Torsemide.............................. 38Toviaz.................................. 128TPN Electrolytes ................. 131Tracleer ............................... 121Tradjenta ............................. 105Tramadol HCl ....................... 86Tramadol-Acetaminophen .... 87Trametinib Dimethyl Sulfoxide........................................... 68TRANDATE ......................... 35Trandolapril ........................... 38tranexamic acid ..................... 40Tranexamic Acid ............. 39, 40TRANXENE T-TAB ............ 74Tranylcypromine Sulfate....... 80Travatan Z ........................... 127Travoprost ........................... 127Travoprost (BAK Free) ....... 127Trazodone HCl ...................... 80Trecator ................................. 22Trelstar Depot Mixject .......... 71Trelstar LA Mixject .............. 71TRENTAL ............................ 40Treprostinil Sodium .............. 37Tretinoin .......................... 49, 71Treximet ................................ 92Triamcinolone Acetonide ..... 46,47, 116, 119Triamterene ........................... 34Triamterene-HCTZ ............... 38TRICOR ................................ 29Triderm.................................. 47Trientine HCl ........................ 52Trifluoperazine HCl .............. 80Trifluridine .......................... 124Trihexyphenidyl HCl ............ 82Tri-Legest Fe ....................... 111Trileptal ................................. 91TRILEPTAL ......................... 90Trimethoprim ........................ 10Trimethoprim HCl................. 10Trimipramine Maleate ........... 80TriNessa (28)....................... 112TRI-NORINYL ........... 108, 109Tri-Previfem ........................ 112Triptorelin Pamoate............... 71Tri-Sprintec ......................... 112Página 148 de 150Trivora (28) ........................ 112Trizivir .................................. 15Trospium Chloride .............. 128Trospium Chloride ER ....... 128TRUSOPT .......................... 127Truvada ................................. 16Twinrix ................................. 63Twynsta ................................ 38Tygacil .................................. 23Tykerb ................................... 71TYLENOL-CODEINE ......... 82Typhim VI ............................ 63Typhoid VI PolysaccharideVacc .................................. 63Tysabri .................................. 94Tyzeka .................................. 16Tyzine ................................. 116U-Cort ................................... 48Ulesfia ................................... 47Uloric .................................. 107ULTRACET ......................... 87ULTRAM ER ....................... 86ULTRAVATE ...................... 45UNASYN ............................. 24UNIFINE ............................ 100UNIRETIC ........................... 36Unithroid .............................. 96UNIVASC ............................ 36Urea-HC Acetate .................. 48URECHOLINE ................... 128Uroxatral ............................. 129URSO FORTE ...................... 56Ursodiol ................................ 56Ustekinumab ......................... 43Vagifem .............................. 115Valacyclovir HCl .................. 16Valcyte .................................. 16Valganciclovir HCl ............... 16VALIUM ........................ 74, 88Valproate Sodium ........... 87, 91Valproic Acid ................. 88, 91Valsartan ............................... 33Valsartan-Hydrochlorothiazide.......................................... 38VALTREX ........................... 16VANCOCIN ................... 26, 27Vancomycin HCl ............ 26, 27Vandazole ........................... 115Vandetanib ............................ 65Vanos .................................... 47VANTIN ......................... 17, 18Vaqta ..................................... 63Vardenafil HCl .................... 129Varenicline Tartrate .............. 52Varicella Virus Vaccine Live 63Varivax .................................. 63VASERETIC ......................... 34VASOTEC ............................ 34Vectical ................................. 43VECTICAL ........................... 97Velcade ................................. 71Velivet ................................. 112Vemurafenib ......................... 72Venlafaxine HCl ................... 80Venlafaxine HCl ER ............. 80Veramyst ............................. 121VERAMYST ....................... 119Verapamil HCl ...................... 38Verapamil HCl ER ................ 38Verdeso ................................. 47Veregen ................................. 48VERELAN ............................ 38Veripred 20 ........................... 95Vesicare ............................... 128Vexol ................................... 125Vfend ..................................... 10VFEND ................................. 10Viagra .................................. 129VICOPROFEN ..................... 83Victrelis ................................. 16Vidaza ................................... 71Videx ..................................... 16VIDEX EC ............................ 11Vigabatrin ....................... 90, 91Vigamox .............................. 124Viibryd .................................. 80Vilazodone HCl .................... 80Vimpat ............................. 91, 92Viracept ................................. 16Viramune ............................... 16VIRAMUNE ......................... 13Viramune XR ........................ 16Viread .................................... 16Viroptic ............................... 124VIROPTIC .......................... 124VISKEN ................................ 36Vismodegib ........................... 66VIVACTIL ............................ 79Vivelle-Dot ......................... 115Voltaren ................................. 87

VOLTAREN ....................... 123VOLTAREN-XR .................. 85Voriconazole ......................... 10Vorinostat .............................. 72VOSOL HC ......................... 116VOSPIRE ER ...................... 117Votrient ................................. 72Vytorin .................................. 30Vyvanse ................................. 80warfarin sodium .................... 40Warfarin Sodium ............. 39, 40WEBCOL .............................. 99Welchol ................................. 30WELLBUTRIN ..................... 73WELLBUTRIN SR ............... 73WELLBUTRIN XL .............. 74WESTCORT ......................... 46XALATAN ......................... 127Xalkori .................................. 72XANAX ................................ 73XANAX XR .......................... 73Xarelto ................................... 40Xenazine................................ 94Xgeva .................................... 64Xifaxan .................................. 23XODOL ........................... 83, 85Xolair .................................. 121Xopenex HFA ..................... 121Xtandi .................................... 72XYLOCAINE ....................... 41Xyrem.................................... 81Xyzal ................................... 122XYZAL ............................... 122YASMIN ............................ 108YAZ ............................ 108, 109Yellow Fever Vaccine .......... 63YF-VAX ............................... 63Zaleplon ................................ 81Zaltrap ................................... 72Zanaflex ................................ 94ZANAFLEX ......................... 94Zanamivir ............................. 14ZANTAC .............................. 58ZARAZOLYN ...................... 35ZARONTIN .......................... 89Zavesca ................................. 99ZEBETA ............................... 32Zelapar .................................. 82Zelboraf ................................ 72Zemplar ................................. 99Zenpep .................................. 56Zerit ...................................... 17ZERIT ................................... 15ZESTRIL .............................. 35Zetia ...................................... 30ZIAC ..................................... 32Ziagen ................................... 17ZIAGEN ............................... 10Ziana ..................................... 49Zidovudine ...................... 14, 17Zileuton ............................... 121Zileuton ER ........................ 121ZINACEF .............................. 18Ziprasidone HCl .................... 81Ziprasidone Mesylate ............ 76ZITHROMAX ................. 18, 19Ziv-Aflibercept ..................... 72ZOCOR ................................. 30ZOFRAN ............................... 55Zoledronic Acid .............. 51, 99Zolinza .................................. 72ZOLOFT ............................... 79Zolpidem Tartrate ................. 81Zolpidem Tartrate ER ........... 81Zometa .................................. 99ZOMETA .............................. 99Zonalon ................................. 48ZONEGRAN ......................... 92Zonisamide ............................ 92Zortress ................................. 72Zostavax ................................ 64Zoster Vaccine Live .............. 64ZOSYN ................................. 25Zovia 1/35E (28) ................. 112Zovia 1/50E (28) ................. 112ZOVIRAX ....................... 10, 11ZYBAN ................................. 52Zyflo .................................... 121Zyflo CR ............................. 121ZYLOPRIM ........................ 106ZYPREXA ............................ 78Zytiga .................................... 72Zyvox .................................... 23Página 149 de 150

Este formulario fue actualizado el 14 de agosto de 2013. Para información más reciente, o para otras preguntas,por favor, comuníquese con el Departamento de Servicios al Afiliado de MMM al 787-620-2397 (Área Metro),1-866-333-5470 (libre de cargos); o usuarios de TTY deben llamar al 1-866-333-5469, lunes a domingo de8:00 a.m. a 8:00 p.m. o visite www.mmm-pr.MMM Healthcare, Inc. es un plan de salud con un contrato Medicare.Este documento podría estar disponible en diferentes formatos, incluyendo Braille, letras grandes, audio o enotros idiomas. Por favor comuníquese con nuestro número de Servicios al Afiliado al 787-620-2397 (ÁreaMetro), 1-866-333-5470 (libre de cargos) para información adicional. Lunes a domingo de 8:00 a.m. a 8:00p.m. Usuarios TTY deben llamar al 1-866-333-5469. Servicios al Afiliado también ofrece servicios deintérprete de idiomas de manera gratuita para afiliados que no hablen español.This document may be available in alternate formats such as Braille, large print, audio or other languages.Please contact our Member Services number at 787-620-2397 (Metro Area), 1-866-333-5470 (toll free) foradditional information. Monday through Sunday, from 8:00 a.m. to 8:00 p.m. (TTY users should call1-866-333-5469. Member Services also offers free language interpreter services available for non-Spanishspeaking members.H4003 – MMM Healthcare, Inc.Y0049_2014 1085 0001 2File & Use 08202013Página 150 de 150