ELA Flex - MMM

Para más informaciónPara información más detallada sobre la cubierta de medicamentos recetados que ofrece MMM, por favorconsulte su Evidencia de Cubierta y otros materiales del plan.Si tiene alguna pregunta sobre MMM, por favor comuníquese con nosotros. Nuestra información decontacto, al igual que la fecha en que este formulario fue actualizado, aparece en la portada y contraportada.Si tiene preguntas generales sobre la cubierta de medicamentos recetados de Medicare, por favorcomuníquese con Medicare al 1-800-MEDICARE (1-800-633-4227), 24 horas al día/7 días a la semana.Usuarios de TTY deben llamar al 1-877-486-2048. O visite www.medicare.gov.Formulario de 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 enla página 118.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:ELA Flex(HMO-POS)NivelMedicamentoCopagopor cantidadal detal(30 días)Copagopor cantidadal detal(90 días)Copagopor ordenpor correo(90 días)1 Genérico Preferido $4.00 $12.00 $8.002 Marca Preferida $8.00 $24.00 $16.003 Marca No Preferida $12.00 $36.00 $24.004 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.6

El plan ofrece cubierta adicional durante la brecha para los siguientes niveles:ELA Flex(HMO-POS)Nivel MedicamentoCopago porcantidad al detal(30 días)1 Genérico Preferido $5.002 Marca Preferida $20.003 Marca No Preferida $35.004 Especialidad 30%Luego de que su costo de bolsillo anual por medicamentos alcance $4,550, usted paga $0 de copago pormedicamentos genéricos (incluyendo medicamentos de marca considerados genéricos) y por todos los demásmedicamentos.Para información más detallada sobre cómo los niveles de copago son aplicados, por favor revise suEvidencia de Cubierta (EOC, por sus siglas en inglés).Símbolos y abreviaturas utilizadas en el FormularioPA - medicamentos que requieren preautorizaciónQL (##/##) - medicamentos con límite de cantidad; la cantidad en paréntesis especifica la cantidad límite quele podemos suplir en el número máximo autorizado de días.ST - terapia escalonadaLA - medicamentos con acceso limitado (ej. Medicamentos de especialidad)MT - medicamentos de mantenimiento (ej. Envío por correo, suplido de 90 días)CG - medicamentos cubiertos durante su brecha de cubierta7

Tabla de ContenidoAnti-infectivos _________________________________________________________________________ 9Cardiovasculares, Hipertensión / Lípidos ____________________________________________________ 26Dermatológicos / Tratamiento Tópico ______________________________________________________ 37Diagnósticos / Agentes Misceláneos _______________________________________________________ 44Gastroenterología ______________________________________________________________________ 47Inmunología, Vacunas / Medicamentos Biotecnológicos _______________________________________ 51Medicamentos Antineoplásicos e Inmunosupresores ___________________________________________ 57Medicamentos Autonómicos y del Sistema Nervioso Central ____________________________________ 66Medicamentos Endocrinos / Medicamentos para la Diabetes ____________________________________ 86Medicamentos Musculoesqueletales / Medicamentos Reumatológicos _____________________________ 95Medicamentos Obstétricos / Ginecología ____________________________________________________ 97Medicamentos para Oído, Nariz y Garganta ________________________________________________ 104Medicamentos Respiratorios y para Alergias ________________________________________________ 106Oftalmología _________________________________________________________________________ 109Urológicos __________________________________________________________________________ 114Vitaminas, Hematínicos / Electrolitos _____________________________________________________ 115Índice de Medicamentos ________________________________________________________________ 1188

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 MGReferenciade MarcaNivel Requisitos /Límites4 PA4 PAAMPHOCIN 1 PAclotrimazole mouth/throat troche 10 MG MYCELEX 1ERAXIS INTRAVENOUS SOLUTIONRECONSTITUTED(anidulafungin)100 MGfluconazole oral suspension reconstituted 10MG/ML, 40 MG/MLfluconazole oral tablet 100 MG, 200 MG, 50 MGDIFLUCANDIFLUCAN4 PA2 PA11fluconazole oral tablet 150 MGDIFLUCAN1 QL (2 / 7 día(s))fluconazole in dextrose intravenous solution 400MG/200MLDIFLUCANflucytosine oral capsule 250 MG, 500 MG ANCOBON 4griseofulvin microsize oral suspension 125MG/5MLgriseofulvin ultramicrosize oral tablet 125 MG,250 MGGRIFULVIN 1GRIS-PEG 11 PAitraconazole oral capsule 100 MG SPORANOX 1 QL (120 / 30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.9

MedicamentoReferenciade Marcaketoconazole oral tablet 200 MG EXTINA 1MYCAMINE INTRAVENOUS SOLUTIONRECONSTITUTED(micafungin sodium)50 MGMYCAMINE INTRAVENOUS SOLUTIONRECONSTITUTED(micafungin sodium)100 MGNOXAFIL ORAL SUSPENSION(posaconazole)40 MG/MLnystatin mouth/throat suspension 100000UNIT/MLMYCOSTATIN 1nystatin oral tablet 500000 UNIT MYCOSTATIN 1terbinafine hcl oral tablet 250 MG LAMISIL 1VFEND ORAL SUSPENSIONRECONSTITUTED(voriconazole)40 MG/MLvoriconazole intravenous solution reconstituted200 MGNivel Requisitos /Límites2 PA4 PA44VFEND 1voriconazole oral tablet 200 MG, 50 MG VFEND 4Agentes del Tracto Urinariomethenamine hippurate oral tablet 1 GM HIPREX 1trimethoprim oral tablet 100 MG PROLOPRIM 1Antiviralesabacavir sulfate oral tablet 300 MG ZIAGEN 1 MTacyclovir oral capsule 200 MG ZOVIRAX 1acyclovir oral suspension 200 MG/5MLZOVIRAX1acyclovir oral tablet 400 MG, 800 MGZOVIRAX1LA - Esta receta puede estar sólo disponible en algunas farmacias.10

Medicamentoacyclovir sodium intravenous solutionreconstituted 500 MGReferenciade MarcaZOVIRAXNivel Requisitos /Límitesamantadine hcl oral capsule 100 MG SYMMETREL 1 MTamantadine hcl oral syrup 50 MG/5ML SYMMETREL 1 MTamantadine hcl oral tablet 100 MG SYMMETREL 1 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 MG14 MT4 MT4 MT2 PA; MT4 PA; MT4 MT2 MTVIDEX EC 1 MT4 MT2 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.11

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 MGReferenciade MarcaNivel Requisitos /Límites2 MT2 MT2 MT2 MT4 MTfamciclovir oral tablet 125 MG, 500 MG FAMVIR 1 QL (21 / 7 día(s))famciclovir oral tablet 250 MG FAMVIR 1 QL (60 / 30 día(s))foscarnet sodium intravenous solution 24 MG/ML FOSCAVIR 1FUZEON 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 MG4 MTCYTOVENE 1 PA4 PA; MT4 PA; QL (168 / 28día(s))4 MT2 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.12

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 MGReferenciade MarcaNivel Requisitos /Límites4 MT4 MT4 MT2 MT4 MT4 MTlamivudine oral tablet 150 MG, 300 MG EPIVIR 1 MTlamivudine-zidovudine oral tablet 150-300 MG COMBIVIR 1 MTLEXIVA ORAL SUSPENSION(fosamprenavir calcium)50 MG/MLLEXIVA ORAL TABLET(fosamprenavir calcium)700 MG2 MT4 MTnevirapine oral tablet 200 MG VIRAMUNE 1 MTNORVIR ORAL CAPSULE(ritonavir)100 MGNORVIR ORAL SOLUTION(ritonavir)80 MG/MLNORVIR ORAL TABLET(ritonavir)100 MG2 MT2 MT2 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.13

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 MGRESCRIPTOR 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 MGribasphere oral tablet(ribavirin)600 MGReferenciade MarcaNivel Requisitos /Límites2 MT2 MT4 MT2 MT22 MT4 MT4 PAREBETOL 1 PACOPEGUS 1 PARIBATAB 1 PARIBATAB 4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.14

MedicamentoReferenciade Marcarimantadine hcl oral tablet 100 MG FLUMADINE 1SELZENTRY ORAL TABLET(maraviroc)150 MG, 300 MGstavudine oral capsule 15 MG, 20 MG, 30 MG,40 MGNivel Requisitos /Límites4 MTZERIT 1 MTstavudine oral solution reconstituted 1 MG/ML ZERIT 1 MTSTRIBILD 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 MGTRUVADA ORAL TABLET(emtricitabine-tenofovir)200-300 MG4 MT2 MT2 MT2 QL (42 / 180 día(s))2 QL (56 / 365 día(s))2 QL (600 ML / 180día(s))2 QL (84 / 180 día(s))4 MT4 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.15

MedicamentoTYZEKA ORAL TABLET(telbivudine)600 MGvalacyclovir hcl oral tablet 1 GM, 500 MGVALCYTE 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 MGZERIT ORAL SOLUTION RECONSTITUTED(stavudine)1 MG/MLReferenciade MarcaVALTREXNivel Requisitos /Límites4 PA; MT1 QL (30 / 30 día(s))444 PA2 MT4 MT2 MT2 MT4 MT4 MT2 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.16

MedicamentoZIAGEN ORAL SOLUTION(abacavir sulfate)20 MG/MLReferenciade MarcaNivel Requisitos /Límites2 MTzidovudine oral capsule 100 MG RETROVIR 1 MTzidovudine oral syrup 50 MG/5MLRETROVIR1 MTzidovudine oral tablet 300 MGRETROVIR1 MTCefalosporinascefaclor oral capsule 250 MG, 500 MG CECLOR 1cefaclor er oral tablet extended release 12 hr 500MGCECLOR CD 1cefadroxil oral capsule 500 MG DURICEF 1cefadroxil oral suspension reconstituted 250MG/5ML, 500 MG/5MLcefadroxil oral tablet 1 GMcefazolin sodium injection solution reconstituted1 GMDURICEFDURICEF11KEFZOL 1cefdinir oral capsule 300 MG OMNICEF 1cefdinir 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/5ML, 50 MG/5MLcefpodoxime proxetil oral tablet 100 MG, 200MGcefprozil oral suspension reconstituted 125MG/5ML, 250 MG/5MLOMNICEF 1MAXIPIME 1MEFOXIN 1 PAVANTIN 1VANTIN 1CEFZIL 1cefprozil oral tablet 250 MG, 500 MG CEFZIL 1LA - Esta receta puede estar sólo disponible en algunas farmacias.17

Medicamentoceftriaxone sodium intravenous solutionreconstituted 1 GMceftriaxone sodium injection solutionreconstituted 250 MG, 500 MGReferenciade MarcaROCEPHIN 1Nivel Requisitos /LímitesROCEPHIN 1 PAcefuroxime axetil oral tablet 250 MG, 500 MG KETAB 1cefuroxime sodium injection solutionreconstituted 7.5 GMcefuroxime sodium injection solutionreconstituted 1.5 GM, 750 MGZINACEF 1ZINACEF 1 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 MGazithromycin oral tablet 600 MGZITHROMAX 1ZITHROMAX221azithromycin oral suspension reconstituted 100MG/5MLazithromycin oral tablet 500 MGazithromycin oral suspension reconstituted 200MG/5MLazithromycin oral tablet 250 MGZITHROMAXZITHROMAXZITHROMAXZITHROMAX1 QL (30 ML / 5día(s))1 QL (4 / 4 día(s))1 QL (68 ML / 5día(s))1 QL (8 / 7 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.18

Medicamentoclarithromycin oral suspension reconstituted 125MG/5ML, 250 MG/5MLReferenciade MarcaBIAXIN 1clarithromycin oral tablet 250 MG, 500 MG BIAXIN 1clarithromycin er oral tablet extended release 24hr 500 MGERYTHROCIN STEARATE ORAL TABLET(erythromycin stearate)250 MGBIAXIN XL 1erythromycin base oral tablet 250 MG, 500 MG ERYTHROCIN 1erythromycin ethylsuccinate oral tablet 400 MG E.E.S. 1Anti-infectivos MisceláneosALBENZA ORAL TABLET(albendazole)200 MGALINIA ORAL SUSPENSIONRECONSTITUTED(nitazoxanide)100 MG/5MLALINIA ORAL TABLET(nitazoxanide)500 MGaztreonam injection solution reconstituted 1 GM AZACTAM 1baciim intramuscular solution reconstituted50000 UNITbacitracin intramuscular solution reconstituted50000 UNITCAPASTAT SULFATE INJECTIONSOLUTION RECONSTITUTED(capreomycin sulfate)1 GMchloramphenicol sod succinate intravenoussolution reconstituted 1 GMchloroquine phosphate oral tablet 250 MG, 500MGNivel Requisitos /LímitesCHLOROMYCETIN 1 PAARALEN 11222112LA - Esta receta puede estar sólo disponible en algunas farmacias.19

Medicamentoclindamycin hcl oral capsule 150 MG, 300 MG,75 MGclindamycin phosphate intravenous solution 600MG/4MLcolistimethate sodium injection solutionreconstituted 150 MGCUBICIN INTRAVENOUS SOLUTIONRECONSTITUTED(daptomycin)500 MGReferenciade MarcaCLEOCIN 1Nivel Requisitos /LímitesCLEOCIN 1 PACOLY-MYCIN 1 PAdapsone oral tablet 100 MG, 25 MG 2DARAPRIM ORAL TABLET(pyrimethamine)25 MGethambutol hcl oral tablet 100 MG, 400 MG MYAMBUTOL 1gentamicin sulfate injection solution 40 MG/ML 1gentamicin sulfate intravenous solution 10MG/MLhydroxychloroquine sulfate oral tablet 200 MG PLAQUENIL 1imipenem-cilastatin intravenous solutionreconstituted 250-250 MG, 500-500 MGINVANZ INJECTION SOLUTIONRECONSTITUTED(ertapenem sodium)1 GMPRIMAXIN 1isoniazid injection solution 100 MG/ML 1isoniazid oral syrup 50 MG/5ML 1isoniazid oral tablet 100 MG, 300 MG 1MALARONE ORAL TABLET(atovaquone-proguanil hcl)250-100 MGMALARONE ORAL TABLET(atovaquone-proguanil hcl)62.5-25 MG4 PA21222LA - Esta receta puede estar sólo disponible en algunas farmacias.20

MedicamentoReferenciade Marcamefloquine hcl oral tablet 250 MG LARIAM 1MEPRON ORAL SUSPENSION(atovaquone)750 MG/5MLmeropenem intravenous solution reconstituted500 MGMERREM 1metronidazole oral tablet 250 MG, 500 MG FLAGYL 1metronidazole in nacl intravenous solution 500-0.79 MG/100ML-%MYCOBUTIN ORAL CAPSULE(rifabutin)150 MGNEBUPENT INHALATION SOLUTIONRECONSTITUTED(pentamidine isethionate)300 MGFLAGYL 1neomycin sulfate oral tablet 500 MG 1paromomycin sulfate oral capsule 250 MG 1PASER ORAL PACKET(aminosalicylic acid)4 GMPENTAM INJECTION SOLUTIONRECONSTITUTED(pentamidine isethionate)300 MGpolymyxin b sulfate injection solutionreconstituted 500000 UNITPRIFTIN ORAL TABLET(rifapentine)150 MGprimaquine phosphate oral tablet 26.3 MG 2PRIMAXIN IV INTRAVENOUS SOLUTIONRECONSTITUTED(imipenem-cilastatin)250-250 MG, 500-500 MGNivel Requisitos /Límites4 PA2222 PA122LA - Esta receta puede estar sólo disponible en algunas farmacias.21

MedicamentoReferenciade Marcapyrazinamide oral tablet 500 MG 1rifampin intravenous solution reconstituted 600MGRIFADIN 1rifampin oral capsule 150 MG, 300 MG RIFADIN 1SEROMYCIN 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 MGTYGACIL INTRAVENOUS SOLUTIONRECONSTITUTED(tigecycline)50 MGZYVOX INTRAVENOUS SOLUTION(linezolid)2 MG/MLZYVOX ORAL SUSPENSIONRECONSTITUTED(linezolid)100 MG/5MLNivel Requisitos /Límites2224 PA4 PA; QL (56 ML / 28día(s))1 PA22 PA4 PA4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.22

MedicamentoZYVOX ORAL TABLET(linezolid)600 MGPenicilinasReferenciade Marcaamoxicillin oral capsule 250 MG, 500 MG AMOXIL 1amoxicillin oral suspension reconstituted 125MG/5ML, 200 MG/5ML, 250 MG/5ML, 400MG/5MLamoxicillin oral tablet 500 MG, 875 MGamoxicillin 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 MGAMOXILAMOXILAMOXILAUGMENTIN 1AUGMENTINAUGMENTINAUGMENTIN XR 1ampicillin 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) GMNivel Requisitos /Límites4 PA11111111 PAUNASYN 1 PAUNASYN 1 PALA - Esta receta puede estar sólo disponible en algunas farmacias.23

MedicamentoBACTOCILL IN DEXTROSE INTRAVENOUSSOLUTION(oxacillin sodium in dextrose)1 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, 500MGnafcillin sodium injection solution reconstituted 1GMoxacillin sodium injection solution reconstituted 1GMpenicillin g potassium injection solutionreconstituted 5000000 UNITpenicillin g procaine intramuscular suspension600000 UNIT/MLpenicillin 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 MGReferenciade MarcaDYNAPEN 1Nivel Requisitos /LímitesNALLPEN 1 PAPFIZERPEN 1PFIZERPENPFIZERPEN122111PEN-V 1PEN-V 1ZOSYN 1ciprofloxacin intravenous solution 400 MG/40ML CIPRO I.V. 12LA - Esta receta puede estar sólo disponible en algunas farmacias.24

Medicamentociprofloxacin 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 MGReferenciade MarcaCIPRO 1CIPRO I.V. 1CIPRO XR 1levofloxacin intravenous solution 25 MG/ML LEVAQUIN 1levofloxacin oral solution 25 MG/ML LEVAQUIN 1levofloxacin oral tablet 250 MG, 500 MG, 750MGlevofloxacin in d5w intravenous solution 500MG/100MLLEVAQUINLEVAQUINofloxacin oral tablet 200 MG, 300 MG, 400 MG FLOXIN 1Sulfas y Agentes Relacionadossulfadiazine oral tablet 500 MG 1sulfamethoxazole-tmp ds oral tablet 800-160 MG BACTRIM 1sulfamethoxazole-trimethoprim intravenoussolution 400-80 MG/5MLsulfamethoxazole-trimethoprim oral suspension200-40 MG/5MLsulfamethoxazole-trimethoprim oral tablet 400-80MGTetraciclinasBACTRIMBACTRIMBACTRIMdemeclocycline hcl oral tablet 150 MG, 300 MG DEMECLOCYN 1doxycycline hyclate intravenous solutionreconstituted 100 MGdoxycycline hyclate oral capsule 100 MG, 50 MG 1doxycycline hyclate oral tablet 100 MG, 20 MG 1doxycycline hyclate oral tablet delayed release100 MG, 75 MGdoxycycline monohydrate oral suspensionreconstituted 25 MG/5MLNivel Requisitos /Límites11111111LA - Esta receta puede estar sólo disponible en algunas farmacias.25

Medicamentodoxycycline monohydrate oral tablet 150 MG, 50MG, 75 MGminocycline hcl oral capsule 100 MG, 50 MG, 75MGminocycline hcl oral tablet 100 MG, 50 MG, 75MGminocycline hcl er oral tablet extended release 24hr 135 MG, 45 MG, 90 MGVancomicinaReferenciade MarcaNivel Requisitos /Límites1MINOCIN 1MINOCINMINOCINvancomycin hcl oral capsule 125 MG, 250 MG VANCOCIN 4vancomycin hcl intravenous solutionreconstituted 1000 MGCardiovasculares, Hipertensión / LípidosAgentes Antiarrítmicosflecainide acetate oral tablet 100 MG, 150 MG,50 MGmexiletine hcl oral capsule 150 MG, 200 MG,250 MGPACERONE ORAL TABLET(amiodarone hcl)100 MGPACERONE ORAL TABLET(amiodarone hcl)200 MG, 400 MGVANCOCIN 1 PATAMBOCOR 1 MTMEXITIL 1 MTprocainamide hcl injection solution 500 MG/ML 1propafenone hcl oral tablet 150 MG, 225 MG,300 MGpropafenone hcl er oral capsule extended release12 hour 225 MG, 325 MG, 425 MGquinidine gluconate er oral tabletextendedrelease 324 MG111 MT1 MTRYTHMO-POSL 1 MTRYTHMO-POSL 1 MT1 MTquinidine sulfate oral tablet 200 MG, 300 MG 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.26

Medicamentoquinidine sulfate er oral tablet extendedrelease300 MGSORINE ORAL TABLET(sotalol hcl)120 MGSORINE ORAL TABLET(sotalol hcl)160 MG, 240 MG, 80 MGReferenciade MarcaNivel Requisitos /Límites1 MT1 MT1 MTsotalol hcl (af) oral tablet 120 MG BETAPACE 1 MTTIKOSYN ORAL CAPSULE(dofetilide)125 MCG, 250 MCG, 500 MCGGlicósidos Cardíacosdigoxin injection solution 0.25 MG/ML LANOXIN 12 MTdigoxin oral solution 0.05 MG/ML LANOXIN 1 MTdigoxin oral tablet 0.125 MG, 0.25 MG LANOXIN 1 MTLANOXIN ORAL TABLET(digoxin)0.125 MG, 0.25 MGLípidos / Agentes Reductores de Colesterolatorvastatin calcium oral tablet 10 MG, 20 MG,40 MG, 80 MG2 MTLIPITOR 1 MT; QL (30 / 30día(s))cholestyramine light oral packet 4 GM QUESTRAN 1 MTcolestipol hcl oral granules 5 GM COLESTID 1 MTcolestipol hcl oral tablet 1 GM COLESTID 1 MTCRESTOR 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 MGTRICOR 1 MTLOFIBRA 1 MT3 ST; MT; QL (30 /30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.27

MedicamentoReferenciade MarcaNivel Requisitos /Límitesfluvastatin sodium oral capsule 20 MG LESCOL 1 MT; QL (30 / 30día(s))fluvastatin sodium oral capsule 40 MG LESCOL 1 MT; QL (60 / 30día(s))gemfibrozil oral tablet 600 MG LOPID 1 MTlovastatin oral tablet 10 MG, 20 MG, 40 MG MEVACOR 1 MTLOVAZA ORAL CAPSULE(omega-3-acid ethyl esters)1 GMNIASPAN ORAL TABLETEXTENDEDRELEASE(niacin er (antihyperlipidemic))1000 MG, 500 MG, 750 MGpravastatin sodium oral tablet 10 MG, 20 MG, 40MG, 80 MGPREVALITE ORAL POWDER(cholestyramine light)4 GM/DOSEsimvastatin 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 MG2 PA; MT; QL (120 /30 día(s))2 QL (60 / 30 día(s))PRAVACHOL 1 MT; QL (30 / 30día(s))1 MTZOCOR 1 MT; QL (30 / 30día(s))2 ST; MT; QL (30 /30 día(s))2 MT2 MT2 ST; MT; QL (30 /30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.28

MedicamentoAgentes 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 MGisosorbide 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 AntihipertensivoReferenciade MarcaNivel Requisitos /LímitesISORDIL 1 MTISORDIL 1 MTDILATRATE-SR 1 MTIMDUR 1 MTIMDUR 1 MT2 PA; MT; QL (60 /30 día(s))1 MTMINITRAN 1 MT2 MTacebutolol hcl oral capsule 200 MG, 400 MG SECTRAL 1 MTAFEDITAB CR ORAL TABLET EXTENDEDRELEASE 24 HR(nifedipine er)30 MG, 60 MG1 MTamiloride hcl oral tablet 5 MG MIDAMOR 1 MTamiloride-hydrochlorothiazide oral tablet 5-50MGMODURETIC 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.29

MedicamentoCARTIA XT ORAL CAPSULE EXTENDEDRELEASE 24 HOUR(diltiazem hcl coated beads)120 MG, 240 MG, 300 MGCARTIA XT ORAL CAPSULE EXTENDEDRELEASE 24 HOUR(diltiazem hcl coated beads)180 MGcarvedilol oral tablet 12.5 MG, 25 MG, 3.125MG, 6.25 MGReferenciade MarcaNivel Requisitos /LímitesCARDIZEM 1 MTCARDIZEM 1 MTCOREG 1 MTchlorothiazide oral tablet 250 MG, 500 MG 1 MTchlorthalidone oral tablet 25 MG, 50 MG 1 MTclonidine hcl oral tablet 0.1 MG, 0.2 MG, 0.3 MG CATAPRESS 1 MTCLORPRES ORAL TABLET(clonidine-chlorthalidone)0.1-15 MG, 0.2-15 MGDEMSER ORAL CAPSULE(metyrosine)250 MGDIBENZYLINE ORAL CAPSULE(phenoxybenzamine hcl)10 MGdiltiazem hcl intravenous solution 50 MG/10ML 1diltiazem 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 MGdoxazosin mesylate oral tablet 1 MG, 2 MG, 4MG, 8 MGenalapril maleate oral tablet 10 MG, 2.5 MG, 20MG, 5 MG1 MTCARDIZEM 1 MTCARDIZEM SR 1 MTCARDIZEM CD 1 MTDILACOR XR 1 MTCARDURA 1 MTVASOTEC 1 MT22LA - Esta receta puede estar sólo disponible en algunas farmacias.31

Medicamentoenalapril-hydrochlorothiazide oral tablet 10-25MG, 5-12.5 MGReferenciade MarcaNivel Requisitos /LímitesVASERETIC 1 MTeplerenone oral tablet 25 MG, 50 MG INSPRA 1 MTfelodipine 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 MGPLENDIL 1 MTMONOPRIL 1 MTMONOPRIL HCT 1 MTfurosemide injection solution 10 MG/ML LASIX 1furosemide oral solution 10 MG/ML, 8 MG/MLLASIX1 MTfurosemide oral tablet 20 MG, 40 MG, 80 MGLASIX1 MTguanfacine hcl oral tablet 1 MG, 2 MG 1 MThydralazine hcl injection solution 20 MG/ML 1hydralazine hcl oral tablet 10 MG, 100 MG, 25MG, 50 MGhydrochlorothiazide oral capsule 12.5 MG 1 MThydrochlorothiazide oral tablet 12.5 MG, 25 MG,50 MG11 MTindapamide oral tablet 1.25 MG, 2.5 MG 1 MTirbesartan oral tablet 150 MG, 300 MG, 75 MG AVAPRO 1 MT; QL (30 / 30día(s))irbesartan-hydrochlorothiazide oral tablet 150-12.5 MG, 300-12.5 MGAVALIDE 1 MT; QL (30 / 30día(s))isradipine oral capsule 2.5 MG, 5 MG DYNACIR 1 MTlabetalol hcl intravenous solution 5 MG/ML TRANDATE 1labetalol hcl oral tablet 100 MG, 200 MG, 300MGlisinopril oral tablet 10 MG, 2.5 MG, 20 MG, 30MG, 40 MG, 5 MGTRANDATE/NORMODYNE1 MTZESTRIL 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.32

Medicamentolisinopril-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 MGReferenciade MarcaNivel Requisitos /LímitesPRINZIDE 1 MTCOZAAR 1 MTHYZAAR 1 MT1 MTmethyclothiazide oral tablet 5 MG 1 MTmetolazone oral tablet 10 MG, 2.5 MG, 5 MG ZARAZOLYN 1 MTmetoprolol 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 MGmetoprolol-hydrochlorothiazide oral tablet 100-25 MG, 100-50 MG, 50-25 MGTOPROL XL 1 MTLOPRESSOR 1LOPRESSOR 1 MTLOPRESSOR HCT 1 MTminoxidil oral tablet 10 MG, 2.5 MG 1moexipril hcl oral tablet 15 MG, 7.5 MG UNIVASC 1 MTmoexipril-hydrochlorothiazide oral tablet 15-12.5MG, 15-25 MG, 7.5-12.5 MGUNIRETIC 1 MTnadolol oral tablet 20 MG, 40 MG, 80 MG CORGARD 1 MTnadolol-bendroflumethiazide oral tablet 40-5MG, 80-5 MGCORZIDE 1 MTnicardipine hcl oral capsule 20 MG, 30 MG CARDENE 1 MTNIFEDIAC CC ORAL TABLET EXTENDEDRELEASE 24 HR(nifedipine er)90 MGADALAT CC 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.33

MedicamentoNIFEDICAL XL ORAL TABLET EXTENDEDRELEASE 24 HR(nifedipine er osmotic)30 MG, 60 MGnifedipine er osmotic oral tablet extended release24 hr 90 MGReferenciade MarcaNivel Requisitos /LímitesPROCARDIA XL 1 MTPROCARDIA XL 1 MTnimodipine oral capsule 30 MG NIMOTOP 1 MTnisoldipine er oral tablet extended release 24 hr20 MG, 30 MG, 40 MGperindopril erbumine oral tablet 2 MG, 4 MG, 8MGSULAR 1 MTACEON 1 MTpindolol oral tablet 10 MG, 5 MG VISKEN 1 MTprazosin hcl oral capsule 1 MG, 2 MG, 5 MG MINIPRESS 1 MTpropranolol hcl intravenous solution 1 MG/ML INDERAL 1propranolol hcl oral solution 20 MG/5ML, 40MG/5MLpropranolol hcl oral tablet 10 MG, 20 MG, 40MG, 60 MG, 80 MGpropranolol hcl er oral capsule extended release24 hour 120 MG, 160 MG, 60 MG, 80 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/MLspironolactone oral tablet 100 MG, 25 MG, 50MGINDERALINDERAL1 MT1 MTINDERAL LA 1 MTINDERIDE 1 MTACCUPRIL 1 MTACCURETIC 1 MTALTACE 1 MT4 PA; LAALDACTONE 1 MTspironolactone-hctz oral tablet 25-25 MG ALDACTAZIDE 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.34

MedicamentoTAZTIA XT ORAL CAPSULE EXTENDEDRELEASE 24 HOUR(diltiazem hcl er beads)120 MG, 240 MG, 300 MGTAZTIA XT ORAL CAPSULE EXTENDEDRELEASE 24 HOUR(diltiazem hcl er beads)180 MG, 360 MGterazosin 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 MGReferenciade MarcaNivel Requisitos /LímitesTIAZAC 1 MTTIAZAC 1 MTHYTRIN 1 MTtimolol maleate oral tablet 10 MG, 20 MG, 5 MG BLOCADREN 1 MTtorsemide oral tablet 10 MG, 100 MG, 20 MG, 5MGDEMADEX 1 MTtrandolapril oral tablet 1 MG, 2 MG, 4 MG MAVIK 1 MTtriamterene-hctz oral capsule 37.5-25 MG DYAZIDE 1 MTtriamterene-hctz oral tablet 37.5-25 MG, 75-50MGvalsartan-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, 120 MG, 180 MG, 200 MG, 240MG, 300 MGverapamil hcl er oral tablet extendedrelease 120MG, 180 MG, 240 MGMAXZIDE 1 MT3 ST; MT; QL (30 /30 día(s))3 ST; MT; QL (30 /30 día(s))DIOVAN HCT 1 MT; QL (30 / 30día(s))CALAN 1 MTVERELAN 1 MTVERELAN 1 MTCALAN SR 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.35

MedicamentoTratamiento para la CoagulaciónAGGRENOX ORAL CAPSULE EXTENDEDRELEASE 12 HOUR(aspirin-dipyridamole er)25-200 MGReferenciade MarcaNivel Requisitos /Límites2 ST; MTcilostazol oral tablet 100 MG, 50 MG PLETAL 1 MTclopidogrel bisulfate oral tablet 300 MG PLAVIX 1clopidogrel bisulfate oral tablet 75 MG PLAVIX 1 MTCOUMADIN 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/MLenoxaparin 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/MLenoxaparin sodium subcutaneous solution 30MG/0.3MLfondaparinux sodium subcutaneous solution 5MG/0.4ML2 MT2LOVENOX 1 PA; QL (11.2 ML /30 día(s))LOVENOXLOVENOXLOVENOXLOVENOXLOVENOXLOVENOXLOVENOXARIXTRA1 PA; QL (16.8 ML /30 día(s))4 PA; QL (22.4 ML /30 día(s))1 PA; QL (22.4 ML /30 día(s))1 PA; QL (28 ML / 30día(s))1 PA; QL (28 ML / 30día(s))4 PA; QL (28 ML / 30día(s))1 PA; QL (8.4 ML /30 día(s))4 PA; QL (12 ML / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.36

Medicamentofondaparinux 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/MLXARELTO ORAL TABLET(rivaroxaban)10 MG, 15 MG, 20 MGDermatológicos / Tratamiento TópicoAnestésicos TópicosReferenciade MarcaARIXTRAARIXTRANivel Requisitos /Límites1 PA; QL (15 ML / 30día(s))4 PA; QL (18 ML / 30día(s))ARIXTRA 4 PA; QL (24 ML / 30día(s))1 PA1 PA1 PACOUMADIN 1 MTTRENTAL 1 MTCYKLOKAPRON 1lidocaine external ointment 5 % XYLOCAINE 1lidocaine hcl external gel 2 % 12 PA; MT4 PA; LA2 PA; MTLA - Esta receta puede estar sólo disponible en algunas farmacias.37

MedicamentoReferenciade Marcalidocaine hcl external solution 4 % 1lidocaine hcl (pf) injection solution 0.5 %, 1 % 1lidocaine viscous mouth/throat solution 2 % 1lidocaine-prilocaine external cream 2.5-2.5 % EMLA 1LIDODERM EXTERNAL PATCH(lidocaine)5 %Antibacteriales Tópicosgentamicin sulfate external cream 0.1 % 1gentamicin sulfate external ointment 0.1 % 1mupirocin external ointment 2 % BACTROBAN 1mupirocin calcium external cream 2 % BACTROBAN 1sulfacetamide sodium external suspension 10 % 1Antifungales Tópicosciclopirox external gel 0.77 % LOPROX 1ciclopirox external solution 8 % PENLAC 1ciclopirox olamine external cream 0.77 % LOPROX 1ciclopirox olamine external suspension 0.77 % LOPROX 1clotrimazole external cream 1 % MYCELEX 1clotrimazole external solution 1 % MYCELEX 1clotrimazole-betamethasone external cream 1-0.05 %LOTRISONE 1econazole nitrate external cream 1 % SPECTAZOLE 1EXELDERM EXTERNAL CREAM(sulconazole nitrate)1 %ketoconazole external cream 2 % NIZORAL 1ketoconazole external shampoo 2 % NIZORAL 1NYAMYC EXTERNAL POWDER(nystatin)100000 UNIT/GMNivel Requisitos /Límites2 PA31LA - Esta receta puede estar sólo disponible en algunas farmacias.38

MedicamentoReferenciade Marcanystatin external cream 100000 UNIT/GM MYCOSTATIN 1nystatin external ointment 100000 UNIT/GM MYCOSTATIN 1nystatin-triamcinolone external cream 100000-0.1 UNIT/GM-%nystatin-triamcinolone external ointment 100000-0.1 UNIT/GM-%NYSTOP EXTERNAL POWDER(nystatin)100000 UNIT/GMAntipsoriasis/ AntiseborreicoMYCOLOG 1MYCOLOG 1calcipotriene external cream 0.005 % DOVONEX 1calcipotriene external ointment 0.005 % DOVONEX 1calcipotriene external solution 0.005 % DOVONEX 1selenium 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/MLVECTICAL EXTERNAL OINTMENT(calcitriol)3 MCG/GMCorticoesteroides Tópicosalclometasone dipropionate external cream 0.05%alclometasone dipropionate external ointment0.05 %ACLOVATE 1ACLOVATE 1amcinonide external cream 0.1 % CYCLOCORT 1amcinonide external lotion 0.1 %CYCLOCORTNivel Requisitos /Límites144 PA21amcinonide external ointment 0.1 %CYCLOCORT1LA - Esta receta puede estar sólo disponible en algunas farmacias.39

Medicamentobetamethasone 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 %Referenciade MarcaDIPROLENE 1DIPROLENEDIPROLENEbetamethasone valerate external cream 0.1 % 1betamethasone valerate external lotion 0.1 % 1betamethasone valerate external ointment 0.1 % 1clobetasol propionate external gel 0.05 % TEMOVATE 1clobetasol propionate external ointment 0.05 % 1clobetasol propionate external solution 0.05 % 1clobetasol propionate e external cream 0.05 % 1desonide external cream 0.05 % DESOWEN 1desonide external lotion 0.05 % 1desonide external ointment 0.05 % 1desoximetasone external cream 0.05 %, 0.25 % TOPICORT 1desoximetasone external gel 0.05 %TOPICORTNivel Requisitos /Límites111111desoximetasone external ointment 0.25 %TOPICORT1diflorasone diacetate external cream 0.05 % PSORCON 1diflorasone diacetate external ointment 0.05 % PSORCON 1fluocinolone acetonide external cream 0.01 %,0.025 %SYNARAL 1fluocinolone acetonide external ointment 0.025 % SYNARAL 1LA - Esta receta puede estar sólo disponible en algunas farmacias.40

MedicamentoReferenciade Marcafluocinolone acetonide external solution 0.01 % 1fluocinonide external gel 0.05 % LIDEX 1fluocinonide external ointment 0.05 % LIDEX 1fluocinonide external solution 0.05 % LIDEX 1fluocinonide-e external cream 0.05 % LIDEX-E 1fluticasone propionate external cream 0.05 % CUTIVATE 1fluticasone propionate external lotion 0.05 %CUTIVATENivel Requisitos /Límites1fluticasone propionate external ointment 0.005 %CUTIVATE1halobetasol propionate external cream 0.05 % ULTRAVATE 1halobetasol propionate external ointment 0.05 % ULTRAVATE 1hydrocortisone external cream 1 %, 2.5 % ALACORT 1hydrocortisone external lotion 2.5 % ALACORT 1hydrocortisone external ointment 1 %, 2.5 % ALACORT 1hydrocortisone valerate external cream 0.2 % WESTCORT 1hydrocortisone valerate external ointment 0.2 % WESTCORT 1mometasone furoate external cream 0.1 % ELOCON 1mometasone furoate external ointment 0.1 % ELOCON 1mometasone furoate external solution 0.1 % ELOCON 1prednicarbate external cream 0.1 % DERMATAP 1prednicarbate external ointment 0.1 % DERMATAP 1triamcinolone acetonide external cream 0.025 %,0.5 %triamcinolone acetonide external lotion 0.025 %,0.1 %triamcinolone acetonide external ointment 0.025%, 0.1 %, 0.5 %TRIDERM EXTERNAL CREAM(triamcinolone acetonide)0.1 %1111LA - Esta receta puede estar sólo disponible en algunas farmacias.41

MedicamentoEnzimas TópicosSANTYL EXTERNAL OINTMENT(collagenase)250 UNIT/GMEscabicidas Tópicos / PediculicidasReferenciade Marcalindane external lotion 1 % 1lindane external shampoo 1 % 1permethrin external cream 5 % ELIMITE 1Dermatológicos Misceláneos8-MOP ORAL CAPSULE(methoxsalen)10 MGammonium lactate external cream 12 %LAC-HYDRINNivel Requisitos /Límites22 PA1ammonium lactate external lotion 12 %LAC-HYDRIN1ELIDEL EXTERNAL CREAM(pimecrolimus)1 %fluorouracil external cream 5 % EFUDEX 1fluorouracil external solution 2 %, 5 % EFUDEX 1imiquimod external cream 5 % ALDARA 1OXSORALEN ULTRA ORAL CAPSULE(methoxsalen rapid)10 MGPANRETIN EXTERNAL GEL(alitretinoin)0.1 %podofilox external solution 0.5 % CONDYLOX 1PROTOPIC EXTERNAL OINTMENT(tacrolimus)0.03 %, 0.1 %2 ST4 PA4 PA2 STLA - Esta receta puede estar sólo disponible en algunas farmacias.42

MedicamentoSOLARAZE TRANSDERMAL GEL(diclofenac sodium)3 %ZONALON EXTERNAL CREAM(doxepin hcl (antipruritic))5 %Tratamiento para Acnéadapalene external cream 0.1 %adapalene external gel 0.1 %Referenciade MarcaDIFFERINDIFFERINNivel Requisitos /Límites2 PA21 PA1 PAAMNESTEEM ORAL CAPSULE(isotretinoin)10 MG, 20 MG, 40 MGbenzoyl peroxide-erythromycin external gel 5-3%CLARAVIS ORAL CAPSULE(isotretinoin)10 MG, 20 MG, 30 MG, 40 MGclindamycin phosphate external foam 1 %1BENZAMYCIN 11CLEOCIN1clindamycin phosphate external gel 1 %clindamycin phosphate external lotion 1 %clindamycin phosphate external solution 1 %clindamycin phosphate external swab 1 %CLEOCINCLEOCINCLEOCINCLEOCIN1111ery external pad 2 % ERYCETTE 1erythromycin external gel 2 % 1erythromycin external solution 2 % 1metronidazole external cream 0.75 % METROCREAM 1metronidazole external gel 0.75 % METROGEL 1LA - Esta receta puede estar sólo disponible en algunas farmacias.43

MedicamentoReferenciade Marcametronidazole external lotion 0.75 % METROLOTION 1TAZORAC EXTERNAL GEL(tazarotene)0.05 %, 0.1 %Nivel Requisitos /Límites2 PAtretinoin external cream 0.025 %, 0.05 %, 0.1 % RETIN-A 1 PAtretinoin external gel 0.01 %, 0.025 % RETIN-A 1 PATratamiento para QuemadurasSSD EXTERNAL CREAM(silver sulfadiazine)1 %Diagnósticos / Agentes MisceláneosAgentes MisceláneosADAGEN INTRAMUSCULAR SOLUTION(pegademase bovine)250 UNIT/MLSILVADENE 14 PAalendronate sodium oral tablet 40 MG FOSAMAX 1 QL (30 / 30 día(s))anagrelide hcl oral capsule 0.5 MG, 1 MG AGRYLIN 1 MTANTABUSE 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 MG24 PA; LA4 PAdextrose intravenous solution 10 %, 5 % 1 PAdextrose in lactated ringers intravenous solution5 %21LA - Esta receta puede estar sólo disponible en algunas farmacias.44

Medicamentodextrose-nacl intravenous solution 10-0.45 %, 5-0.33 %dextrose-nacl intravenous solution 10-0.2 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.45 %, 5-0.9 %Referenciade Marcadisulfiram oral tablet 250 MG, 500 MG ANTABUSE 1etidronate disodium oral tablet 200 MG, 400 MG DIDRONEL 1EXJADE ORAL TABLET SOLUBLE(deferasirox)125 MGEXJADE ORAL TABLET SOLUBLE(deferasirox)250 MG, 500 MGINCRELEX SUBCUTANEOUS SOLUTION(mecasermin)40 MG/4MLKAYEXALATE ORAL POWDER(sodium polystyrene sulfonate)Nivel Requisitos /Límites11 PA2 PA; LA4 PA; LA4 PA; LA2levocarnitine oral solution 1 GM/10ML CARNITOR 1 PAlevocarnitine oral tablet 330 MG CARNITOR 1 PAmidodrine hcl oral tablet 10 MG, 2.5 MG, 5 MG CATNITOR 1ORFADIN ORAL CAPSULE(nitisinone)10 MG, 2 MG, 5 MGpilocarpine hcl oral tablet 5 MG, 7.5 MG 1RECLAST INTRAVENOUS SOLUTION(zoledronic acid)5 MG/100MLRENVELA ORAL PACKET(sevelamer carbonate)0.8 GM, 2.4 GMRENVELA ORAL TABLET(sevelamer carbonate)800 MG4 PA; LA2 PA22LA - Esta receta puede estar sólo disponible en algunas farmacias.45

MedicamentoRILUTEK ORAL TABLET(riluzole)50 MGReferenciade Marcasodium chloride intravenous solution 0.9 % 1sodium chloride irrigation solution 0.9 % 1Nivel Requisitos /Límites4 PAsodium phenylbutyrate oral powder 4 PAsodium polystyrene sulfonate oral suspension 15GM/60MLsterile water for irrigation irrigation solution 1SYPRINE ORAL CAPSULE(trientine hcl)250 MGzoledronic acid intravenous solution 5MG/100MLProductos para dejar de FumarBUPROBAN ORAL TABLET EXTENDEDRELEASE 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 IrrigantesRECLAST 1 PA14ZYBAN 12 PA2 PAlactated ringers irrigation solution 1 PA22LA - Esta receta puede estar sólo disponible en algunas farmacias.46

Medicamentoneomycin-polymyxin b gu irrigation solution 40-200000Referenciade MarcaNivel 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 1glycopyrrolate injection solution 4 MG/20ML ROBINUL 1glycopyrrolate oral tablet 1 MG, 2 MG ROBINUL FORTE 1loperamide hcl oral capsule 2 MG IMODIUM 1methscopolamine bromide oral tablet 2.5 MG PAMIDE 1Agentes Gastrointestinales MisceláneosAMITIZA ORAL CAPSULE(lubiprostone)24 MCG, 8 MCGASACOL ORAL TABLET DELAYEDRELEASE(mesalamine)400 MGbalsalazide disodium oral capsule 750 MG COLOZAL 1budesonide er oral capsule extended release 24hour 3 MGCANASA RE SUPPOSITORY(mesalamine)1000 MGCOMPRO RE SUPPOSITORY(prochlorperazine)25 MGENTOCORT EC 4constulose oral solution 10 GM/15ML GENERALAC 11122 MT; QL (180 / 30día(s))21LA - Esta receta puede estar sólo disponible en algunas farmacias.47

MedicamentoCREON ORAL CAPSULE DELAYEDRELEASE PARTICLES(pancrelipase (lip-prot-amyl))12000 UNIT, 24000 UNIT, 3000-9500 UNIT,36000 UNIT, 6000 UNITReferenciade Marcacromolyn sodium oral concentrate 100 MG/5ML GASTROCROM 1CYSTADANE ORAL POWDER(betaine)DELZICOL ORAL CAPSULE DELAYEDRELEASE(mesalamine)400 MGDIPENTUM ORAL CAPSULE(olsalazine sodium)250 MGNivel Requisitos /Límites2 MT22 MT; QL (180 / 30día(s))2 MTdronabinol oral capsule 2.5 MG, 5 MG MARINOL 1 PAdronabinol oral capsule 10 MG MARINOL 4 PA; QL (60 / 30día(s))EMEND ORAL CAPSULE(aprepitant)125 MG, 40 MGEMEND ORAL CAPSULE(aprepitant)80 MGEMEND ORAL CAPSULE(aprepitant)80 & 125 MGenulose oral solution 10 GM/15ML GENERALAC 1GASTROCROM ORAL CONCENTRATE(cromolyn sodium)100 MG/5MLGAVILYTE-C ORAL SOLUTIONRECONSTITUTED(peg 3350-kcl-nabcb-nacl-nasulf)240 GMCOLYTE WITHFLAVOR PACKETS2 PA; QL (1 / 1día(s))2 PA; QL (2 / 2día(s))2 PA; QL (3 / 3día(s))21LA - Esta receta puede estar sólo disponible en algunas farmacias.48

MedicamentoReferenciade MarcaNivel Requisitos /Límitesgranisetron hcl oral tablet 1 MG GRANISOL 1 PA; QL (2 / 1día(s))hydrocortisone re enema 100 MG/60ML 1lactulose oral solution 10 GM/15ML 1LOTRONEX ORAL TABLET(alosetron hcl)0.5 MG, 1 MGmeclizine hcl oral tablet 12.5 MG, 25 MG ANTIVERT 1mesalamine-cleanser re kit 4 GM ROWASA 1metoclopramide hcl injection solution 5 MG/ML REGLAN 1metoclopramide hcl oral solution 5 MG/5ML REGLAN 1metoclopramide hcl oral tablet 10 MG, 5 MG REGLAN 14 PA; MTondansetron oral tablet dispersible 4 MG, 8 MG ZOFRAN 1 PA; QL (12 / 5día(s))ondansetron hcl injection solution 40 MG/20ML ZOFRAN 1ondansetron hcl oral tablet 24 MGondansetron hcl oral tablet 4 MG, 8 MGondansetron hcl oral solution 4 MG/5MLOSMOPREP 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 MGZOFRANZOFRANZOFRANpolyethylene glycol 3350 oral powder 11 PA; QL (1 / 1día(s))1 PA; QL (12 / 5día(s))1 PA; QL (150 ML / 5día(s))22 MT; QL (120 / 30día(s))2 MT; QL (240 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.49

Medicamentoprochlorperazine 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 MGsulfasalazine oral tablet 500 MGSULFAZINE EC ORAL TABLET DELAYEDRELEASE(sulfasalazine)500 MGursodiol oral capsule 300 MGursodiol oral tablet 250 MG, 500 MGReferenciade MarcaANUSOL-HCANUSOL-HCAZULFIDINEAZULFIDINEURSO FORTEURSO FORTENivel Requisitos /Límites11 MT12 PA4 PA1 MT1 MT1 MT1 MTTratamientos para las ÚlcerasCARAFATE ORAL SUSPENSION(sucralfate)1 GM/10MLcimetidine oral tablet 200 MG, 300 MG, 400 MG,800 MGcimetidine hcl oral solution 300 MG/5ML 1cimetidine hcl injection solution 150 MG/ML 1 PAfamotidine oral suspension reconstituted 40MG/5MLPEPCID111LA - Esta receta puede estar sólo disponible en algunas farmacias.50

Medicamentofamotidine oral tablet 20 MG, 40 MGReferenciade MarcaPEPCIDNivel Requisitos /Límites1lansoprazole oral capsule delayed release 15MG, 30 MGmisoprostol oral tablet 100 MCG, 200 MCG CYTOTEC 1nizatidine oral capsule 150 MG, 300 MGPREVACID 1 QL (30 / 30 día(s))AXID1nizatidine oral solution 15 MG/MLAXID1omeprazole oral capsule delayed release 10 MG,20 MG, 40 MGpantoprazole sodium intravenous solutionreconstituted 40 MGpantoprazole sodium oral tablet delayed release20 MG, 40 MGranitidine hcl oral capsule 150 MG, 300 MGPRILOSEC 1 QL (30 / 30 día(s))PROTONIX IV 1 PAPROTONIX 1 QL (30 / 30 día(s))ZANTAC1ranitidine hcl oral syrup 15 MG/MLranitidine hcl oral tablet 150 MG, 300 MGranitidine hcl injection solution 150 MG/6MLZANTACZANTACZANTAC111 PAsucralfate oral tablet 1 GM CARAFATE 1Inmunología, Vacunas / Medicamentos BiotecnológicosMedicamentos BiotecnológicosACTIMMUNE SUBCUTANEOUS SOLUTION(interferon gamma-1b)2000000 UNIT/0.5MLARCALYST SUBCUTANEOUS SOLUTIONRECONSTITUTED(rilonacept)220 MG4 PA; MT4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.51

MedicamentoAVONEX INTRAMUSCULAR KIT(interferon beta-1a)30 MCGAVONEX PREFILLED INTRAMUSCULARKIT(interferon beta-1a)30 MCG/0.5MLBETASERON SUBCUTANEOUS SOLUTIONRECONSTITUTED(interferon beta-1b)0.3 MGHUMATROPE 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/0.6MLReferenciade MarcaNivel Requisitos /Límites4 PA; QL (4 / 28día(s))4 PA; QL (4 / 28día(s))4 PA; QL (15 / 30día(s))4 PA4 PA2 PA; MT2 PA; MT4 PA4 PA4 PA; QL (1.2 ML /30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.52

MedicamentoNEUMEGA SUBCUTANEOUS SOLUTIONRECONSTITUTED(oprelvekin)5 MGNEUPOGEN INJECTION SOLUTION(filgrastim)480 MCG/1.6MLNEUPOGEN INJECTION SOLUTION(filgrastim)300 MCG/0.5MLNEUPOGEN INJECTION SOLUTION(filgrastim)480 MCG/0.8MLNORDITROPIN 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/MLReferenciade MarcaNivel Requisitos /Límites4 PA; QL (21 / 21día(s))4 PA; QL (25.6 ML /30 día(s))4 PA; QL (5 ML / 30día(s))4 PA; QL (8 ML / 30día(s))4 PA4 PA4 PA; QL (4 ML / 28día(s))4 PA; QL (4 ML / 28día(s))2 PA4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.53

MedicamentoPROLEUKIN INTRAVENOUS SOLUTIONRECONSTITUTED(aldesleukin)22000000 UNITSYLATRON SUBCUTANEOUS KIT(peginterferon alfa-2b)296 MCG, 444 MCG, 888 MCGVacunas / Inmunológicos MisceláneosACTHIB INTRAMUSCULAR SOLUTIONRECONSTITUTED(haemophilus b polysac conj vac)Referenciade MarcaNivel Requisitos /Límites4 PA4 PA; MT2ADACEL INTRAMUSCULAR SUSPENSION(tetanus-diphth-acell pertussis)5-2-15.5ATGAM 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)24 PA22 PA2COMVAX INTRAMUSCULAR SUSPENSION(haemophil b poly cnj-hepatit b)7.5-5 MCG/0.5MLDAPTACEL INTRAMUSCULARSUSPENSION(diphth-acell pertussis-tetanus)10-15-522LA - Esta receta puede estar sólo disponible en algunas farmacias.54

MedicamentoENGERIX-B INJECTION SUSPENSION(hepatitis b vac recombinant)10 MCG/0.5ML, 20 MCG/MLReferenciade MarcaNivel Requisitos /Límitesfomepizole intravenous solution 1 GM/ML ANTIZOL 1 PAGAMASTAN S/D INTRAMUSCULARINJECTABLE(immune globulin (human))22 PAGAMMAPLEX INTRAVENOUS SOLUTION(immune globulin (human))10 GM/200MLGAMUNEX-C INJECTION SOLUTION(immune globulin (human))1 GM/10MLGARDASIL INTRAMUSCULARSUSPENSION(hpv quadrivalent vaccine)HAVRIX 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)IXIARO INTRAMUSCULAR SUSPENSION(japanese encephalitis vac inac)4 PA2 PA222222LA - Esta receta puede estar sólo disponible en algunas farmacias.55

MedicamentoMENACTRA INTRAMUSCULARINJECTABLE(meningococcal a c y&w-135 conj)Referenciade MarcaNivel Requisitos /Límites2MENOMUNE SUBCUTANEOUSINJECTABLE(meningococcal vac a,c,y,w-135)2MENVEO INTRAMUSCULAR SOLUTIONRECONSTITUTED(meningococcal a c y&w-135 olig)2M-M-R II SUBCUTANEOUS INJECTABLE(measles, mumps & rubella vac)2PEDVAX HIB INTRAMUSCULARSOLUTION(haemophilus b polysac conj vac)2PROQUAD SUBCUTANEOUS INJECTABLE(measles-mumps-rubella-varicell)2RABAVERT INTRAMUSCULARSUSPENSION RECONSTITUTED(rabies vaccine, pcec)2RECOMBIVAX HB INJECTION SUSPENSION(hepatitis b vac recombinant)10 MCG/ML, 40 MCG/MLROTATEQ ORAL SUSPENSION(rotavirus vac live pentavalent)22tetanus toxoid adsorbed intramuscular solution 5LFUtetanus-diphtheria toxoids td intramuscularsuspension 2-2 LF/0.5ML12LA - Esta receta puede estar sólo disponible en algunas farmacias.56

MedicamentoTWINRIX 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)Referenciade MarcaNivel Requisitos /Límites22222ZOSTAVAX 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 MGETHYOL 4 PA24 PAmesna intravenous solution 100 MG/ML MESNEX 1 PAXGEVA SUBCUTANEOUS SOLUTION(denosumab)120 MG/1.7ML114 PALA - Esta receta puede estar sólo disponible en algunas farmacias.57

MedicamentoMedicamentos Antineoplásicos e InmunosupresoresAFINITOR ORAL TABLET(everolimus)10 MG, 2.5 MG, 5 MG, 7.5 MGALIMTA INTRAVENOUS SOLUTIONRECONSTITUTED(pemetrexed disodium)500 MGReferenciade MarcaNivel Requisitos /Límites4 PA4 PAanastrozole oral tablet 1 MG ARIMIDEX 1 MTARIMIDEX ORAL TABLET(anastrozole)1 MGAROMASIN ORAL TABLET(exemestane)25 MGAVASTIN INTRAVENOUS SOLUTION(bevacizumab)100 MG/4MLAZASAN ORAL TABLET(azathioprine)100 MG, 75 MG2 MT2 MT2 PA2 PA; MTazathioprine oral tablet 50 MG IMURAN 1 PA; MTbicalutamide oral tablet 50 MG CASODEX 1BOSULIF ORAL TABLET(bosutinib)100 MGBOSULIF ORAL TABLET(bosutinib)500 MGCAPRELSA ORAL TABLET(vandetanib)100 MG, 300 MGCEENU ORAL CAPSULE(lomustine)10 MG, 40 MG44 QL (30 / 30 día(s))4 LA2LA - Esta receta puede estar sólo disponible en algunas farmacias.58

MedicamentoCELLCEPT 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 MGReferenciade MarcaNivel Requisitos /Límites4 PA; MT4 PA4 PA4 PAcyclophosphamide oral tablet 25 MG, 50 MG 1 PAcyclosporine intravenous solution 50 MG/ML SANDIMMUNE 1 PAcyclosporine oral capsule 100 MG, 25 MG SANDIMMUNE 1 PA; MTcyclosporine modified oral capsule 50 MG NEORAL 1 PA; MTELIGARD 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 MG2 PA2 PA2 PA2 PA2LA - Esta receta puede estar sólo disponible en algunas farmacias.59

MedicamentoERIVEDGE ORAL CAPSULE(vismodegib)150 MGReferenciade MarcaNivel Requisitos /Límites4 PAexemestane oral tablet 25 MG AROMASIN 1 MTFARESTON ORAL TABLET(toremifene citrate)60 MGFASLODEX INTRAMUSCULAR SOLUTION(fulvestrant)250 MG/5MLFEMARA ORAL TABLET(letrozole)2.5 MGflutamide oral capsule 125 MG 1GENGRAF 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 MGhydroxyurea oral capsule 500 MG HYDREA 1ICLUSIG ORAL TABLET(ponatinib hcl)15 MG, 45 MGINLYTA ORAL TABLET(axitinib)1 MG, 5 MG2 MT4 PA2 MT1 PA; MT1 PA; MT4 PA4 PA4 PA4 PA4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.60

MedicamentoJAKAFI ORAL TABLET(ruxolitinib phosphate)10 MG, 15 MG, 20 MG, 25 MG, 5 MGKADCYLA INTRAVENOUS SOLUTIONRECONSTITUTED(ado-trastuzumab emtansine)100 MGReferenciade MarcaNivel Requisitos /Límites4 PA4 PAletrozole oral tablet 2.5 MG FEMARA 1 MTLEUKERAN ORAL TABLET(chlorambucil)2 MGleuprolide acetate injection kit 1 MG/0.2ML 1 PALUPRON DEPOT INTRAMUSCULAR KIT(leuprolide acetate)3.75 MG, 7.5 MGLUPRON 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 MG24 PA4 PA4 PA4 PA4 PA4 PA2LA - Esta receta puede estar sólo disponible en algunas farmacias.61

MedicamentoMATULANE ORAL CAPSULE(procarbazine hcl)50 MGmegestrol acetate oral suspension 40 MG/MLmegestrol acetate oral tablet 20 MG, 40 MGReferenciade MarcaMEGACEMEGACENivel Requisitos /Límites4 PA1 PA1 PAMEKINIST ORAL TABLET(trametinib dimethyl sulfoxide)0.5 MG, 2 MGmercaptopurine oral tablet 50 MG 14 PAmethotrexate oral tablet 2.5 MG 1 PAmethotrexate sodium injection solutionreconstituted 1 GMmethotrexate sodium (pf) injection solution 25MG/MLmitoxantrone hcl intravenous concentrate 25MG/12.5ML1 PA1 PA1 PAmycophenolate mofetil oral capsule 250 MG CELLCEPT 1 PA; MTmycophenolate mofetil oral tablet 500 MG CELLCEPT 1 PA; MTNEXAVAR 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/MLSANDOSTATINSANDOSTATIN4 PA; LA24 PA1 PA4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.62

MedicamentoPOMALYST 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 MGRITUXAN 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/0.3MLReferenciade MarcaNivel Requisitos /Límites4 PA2 PA; MT4 PA; MT2 PA; MT2 PA; MT4 PA; MT4 PA; LA4 PA4 PA2 PA; MT4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.63

MedicamentoSPRYCEL 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 MGReferenciade MarcaNivel Requisitos /Límites4 PA4 PA; QL (120 / 30día(s))4 PA4 PAtacrolimus oral capsule 0.5 MG, 1 MG PROGRAF 1 PA; MTTAFINLAR ORAL CAPSULE(dabrafenib mesylate)50 MG, 75 MG24 PAtamoxifen citrate oral tablet 10 MG, 20 MG 1 MTTARCEVA 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 MG4 PA4 PA4 PA4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.64

MedicamentoTHALOMID 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 MGReferenciade Marcatretinoin oral capsule 10 MG RETIN-A 4TYKERB ORAL TABLET(lapatinib ditosylate)250 MGVELCADE INTRAVENOUS SOLUTIONRECONSTITUTED(bortezomib)3.5 MGVIDAZA INJECTION SUSPENSIONRECONSTITUTED(azacitidine)100 MGVOTRIENT ORAL TABLET(pazopanib hcl)200 MGXALKORI ORAL CAPSULE(crizotinib)200 MG, 250 MGXTANDI ORAL CAPSULE(enzalutamide)40 MGZALTRAP INTRAVENOUS SOLUTION(ziv-aflibercept)100 MG/4MLNivel Requisitos /Límites4 PA4 PA4 PA4 PA; LA4 PA4 PA4 PA4 PA4 QL (120 / 30 día(s))4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.65

MedicamentoZELBORAF 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 MGReferenciade MarcaMedicamentos Autonómicos y del Sistema Nervioso CentralMedicamentos PsicoterapéuticosABILIFY INTRAMUSCULAR SOLUTION(aripiprazole)9.75 MG/1.3MLABILIFY ORAL SOLUTION(aripiprazole)1 MG/MLABILIFY 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 MGNivel Requisitos /Límites4 PA4 PA2 PA; MT4 PA; MT4 PA2 ST2 ST2 ST4 ST2 STLA - Esta receta puede estar sólo disponible en algunas farmacias.66

MedicamentoABILIFY 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 MGBUDEPRION SR ORAL TABLET EXTENDEDRELEASE 12 HR(bupropion hcl er (sr))100 MG, 150 MGReferenciade MarcaXANAX 1NIRAVAM 1Nivel Requisitos /Límites4 STXANAX XR 1 QL (120 / 30día(s))XANAX XR 1 QL (120 / 30día(s))1 PA; MT1 MTWELLBUTRIN SR 1 MTbupropion hcl oral tablet 100 MG, 75 MG WELLBUTRIN 1 MTbupropion hcl er (sr) oral tablet extended release12 hr 200 MGbupropion 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 MGWELLBUTRIN SR 1 MTWELLBUTRIN XL 1 MTchlorpromazine hcl injection solution 25 MG/ML 1chlorpromazine 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 MG11 MTCELEXA 1 MTCELEXA 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.67

Medicamentoclomipramine 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 MGCYMBALTA ORAL CAPSULE DELAYEDRELEASE PARTICLES(duloxetine hcl)20 MG, 30 MG, 60 MGdesipramine 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 MGdiazepam oral solution 1 MG/MLReferenciade MarcaNivel Requisitos /LímitesANAFRANIL 1 MTTRANXENE T-TAB 1CLOZARIL 12 ST; MTNORPRAMIN 1 MTDEXEDRINE 1VALIUM1diazepam oral tablet 10 MG, 2 MG, 5 MGVALIUM1doxepin hcl oral capsule 10 MG, 100 MG, 150MG, 25 MG, 50 MG, 75 MG1 PA; MTdoxepin hcl oral concentrate 10 MG/ML 1 PA; MTEMSAM TRANSDERMAL PATCH 24 HR(selegiline)12 MG/24HR, 6 MG/24HR, 9 MG/24HRescitalopram oxalate oral solution 5 MG/5MLLEXAPRO2 MT1 MTescitalopram oxalate oral tablet 5 MGescitalopram oxalate oral tablet 20 MGescitalopram oxalate oral tablet 10 MGLEXAPROLEXAPROLEXAPRO1 MT; QL (120 / 30día(s))1 MT; QL (30 / 30día(s))1 MT; QL (60 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.68

MedicamentoFANAPT 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, 40MGfluoxetine hcl oral solution 20 MG/5MLfluoxetine hcl oral tablet 10 MG, 20 MGReferenciade MarcaPROZACPROZACPROZACNivel Requisitos /Límites2 ST2 ST21 MT1 MT1 MTfluoxetine hcl oral capsule delayed release 90MGfluphenazine decanoate injection solution 25MG/MLPROZAC WEEKLY 1 MT; QL (4 / 30día(s))fluphenazine hcl injection solution 2.5 MG/ML 1fluphenazine hcl oral concentrate 5 MG/ML 1 MTfluphenazine hcl oral elixir 2.5 MG/5ML 1 MTfluphenazine hcl oral tablet 1 MG, 10 MG, 2.5MG, 5 MGfluvoxamine maleate oral tablet 100 MG, 25 MG,50 MGfluvoxamine 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 MG11 MT1 MTLUVOX CR 1 MT2 STHALDOL 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.69

Medicamentohaloperidol decanoate intramuscular solution100 MG/ML, 50 MG/MLhaloperidol lactate injection solution 5 MG/MLhaloperidol lactate oral concentrate 2 MG/MLReferenciade MarcaHALDOLHALDOLHALDOLNivel Requisitos /Límites111 MTimipramine 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/1.5MLLATUDA ORAL TABLET(lurasidone hcl)20 MG, 40 MG, 80 MGLATUDA ORAL TABLET(lurasidone hcl)120 MGlithium carbonate oral capsule 150 MG, 300 MG,600 MGTOFRANILTOFRANIL1 PA; MT1 PA; MT22 ST; MT2 ST4 ST2 ST; MT4 ST; MT1 MTlithium carbonate oral tablet 300 MG 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.70

Medicamentolithium carbonate er oral tablet extendedrelease300 MG, 450 MGReferenciade MarcaNivel Requisitos /Límites1 MTlithium citrate oral solution 8 MEQ/5ML 1 MTlorazepam oral tablet 0.5 MG, 1 MG, 2 MG ATIVAN 1loxapine succinate oral capsule 10 MG, 25 MG, 5MG, 50 MGmaprotiline hcl oral tablet 25 MG, 50 MG, 75MGMARPLAN ORAL TABLET(isocarboxazid)10 MGMETADATE ER ORAL TABLETEXTENDEDRELEASE(methylphenidate hcl er)20 MGmirtazapine oral tablet 15 MG, 30 MG, 45 MG,7.5 MGmirtazapine oral tablet dispersible 15 MG, 30MG, 45 MGLOXITANE 1 MTRITALIN-SR 11 MT2 MTREMERON 1 MTREMERON ODT 1 MTmodafinil oral tablet 100 MG, 200 MG PROVIGIL 1 PA; 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 MGolanzapine intramuscular solution reconstituted10 MGolanzapine oral tablet 20 MG2 MT1 MTPAMELOR 1 MTZYPREXAZYPREXA11 MTolanzapine oral tablet 10 MG, 15 MG, 2.5 MG, 5MG, 7.5 MGZYPREXA1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.71

Medicamentoolanzapine 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/5MLperphenazine 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 MGReferenciade MarcaZYPREXANivel Requisitos /Límites1 MTSYMBYAX 1 MT2 MTPAXIL 1 MTPAXIL 1 MT2 ST; MT1 MT1 MTphenelzine sulfate oral tablet 15 MG NARDIL 1 MTPRISTIQ ORAL TABLET EXTENDEDRELEASE 24 HR(desvenlafaxine succinate er)100 MG, 50 MG2 ST; MTprotriptyline hcl oral tablet 10 MG, 5 MG VIVACTIL 1 MTquetiapine fumarate oral tablet 100 MG, 200MG, 300 MG, 400 MGSEROQUEL 1 MTquetiapine fumarate oral tablet 25 MG, 50 MG SEROQUEL 1 PA; MTRISPERDAL CONSTA INTRAMUSCULARSUSPENSION RECONSTITUTED(risperidone microspheres)25 MGRISPERDAL CONSTA INTRAMUSCULARSUSPENSION RECONSTITUTED(risperidone microspheres)37.5 MG, 50 MG2 ST4 STLA - Esta receta puede estar sólo disponible en algunas farmacias.72

Medicamentorisperidone oral tablet 0.25 MG, 0.5 MG, 1 MG,2 MG, 3 MG, 4 MGrisperidone oral tablet dispersible 0.25 MG, 0.5MG, 1 MG, 2 MG, 3 MG, 4 MGReferenciade MarcaNivel Requisitos /LímitesRISPERDAL 1 MTRISPERDAL 1 MTrisperidone oral solution 1 MG/ML RISPERDAL 1 MT; QL (480 ML /30 día(s))ROZEREM ORAL TABLET(ramelteon)8 MGSAPHRIS SUBLINGUAL TABLETSUBLINGUAL(asenapine maleate)10 MG, 5 MG2 ST; QL (30 / 30día(s))2 ST; MTsertraline hcl oral concentrate 20 MG/ML ZOLOFT 1 MTsertraline hcl oral tablet 100 MG, 25 MG, 50 MG ZOLOFT 1 MTSTRATTERA ORAL CAPSULE(atomoxetine hcl)10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60MG, 80 MGthioridazine hcl oral tablet 10 MG, 100 MG, 25MG, 50 MGthiothixene oral capsule 1 MG, 10 MG, 2 MG, 5MG2 PA; QL (60 / 30día(s))1 PA; MT1 PA; MTtranylcypromine sulfate oral tablet 10 MG 1 MTtrazodone 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, 25 MG, 37.5MG, 50 MG, 75 MGvenlafaxine hcl er oral capsule extended release24 hour 150 MG, 37.5 MG, 75 MG1 MT1 MTSURMONTIL 1 MT1 MTEFFEXOR XR 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.73

Medicamentovenlafaxine 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 MGXYREM ORAL SOLUTION(sodium oxybate)500 MG/MLReferenciade MarcaNivel Requisitos /Límites1 MT2 ST2 ST; MT4 LAzaleplon oral capsule 10 MG, 5 MG SONATA 1 QL (30 / 30 día(s))ziprasidone hcl oral capsule 20 MG, 40 MG, 60MG, 80 MGGEODON 1 MTzolpidem tartrate oral tablet 10 MG, 5 MG AMBIEN 1 QL (30 / 30 día(s))zolpidem tartrate er oral tablet extendedrelease12.5 MG, 6.25 MGAgentes Anti-ParkinsonAPOKYN SUBCUTANEOUS SOLUTION(apomorphine hcl)10 MG/MLAZILECT ORAL TABLET(rasagiline mesylate)0.5 MG, 1 MGbromocriptine mesylate oral capsule 5 MGAMBIEN CR 1 QL (30 / 30 día(s))4 PA; LA2 MTPARLODEL1 MTbromocriptine mesylate oral tablet 2.5 MGPARLODEL1 MTcarbidopa-levodopa oral tablet 10-100 MG, 25-100 MG, 25-250 MGcarbidopa-levodopa oral tablet dispersible 10-100 MG, 25-100 MG, 25-250 MGcarbidopa-levodopa er oral tabletextendedrelease 25-100 MG, 50-200 MGSINEMET 1 MTPARCOPA ODT 1 MTSINEMET CR 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.74

MedicamentoReferenciade MarcaNivel Requisitos /Límitesentacapone oral tablet 200 MG COMTAN 1 MTpramipexole dihydrochloride oral tablet 0.125MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MGropinirole hcl oral tablet 0.25 MG, 0.5 MG, 1MG, 2 MG, 3 MG, 4 MG, 5 MGropinirole hcl er oral tablet extended release 24hr 12 MG, 2 MG, 4 MG, 6 MG, 8 MGselegiline hcl oral capsule 5 MGCOMTAN 1 MTMIRAPEX 1 MTREQUIP 1 MTELDEPRYL1 MTselegiline hcl oral tablet 5 MG ELDEPRYL 1 MTTASMAR ORAL TABLET(tolcapone)100 MG4 PA; MTtrihexyphenidyl hcl oral elixir 0.4 MG/ML 1 MTtrihexyphenidyl hcl oral tablet 2 MG, 5 MG 1 MTAnalgésicos Narcóticosacetaminophen-codeine oral solution 120-12MG/5MLacetaminophen-codeine #2 oral tablet 300-15MGacetaminophen-codeine #3 oral tablet 300-30MGTYLENOL-CODEINETYLENOL-CODEINE111acetaminophen-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 MGbutalbital-apap-caff-cod oral capsule 50-325-40-30 MGTYLENOL-CODEINEFIORINAL WITHCODEINE #3FIORICET WITHCODEINE111 PA1 PALA - Esta receta puede estar sólo disponible en algunas farmacias.75

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 MGhydrocodone-acetaminophen oral tablet5-300 MGhydrocodone-acetaminophen oral tablet7.5-300 MGhydrocodone-acetaminophen oral tablet10-300 MGReferenciade MarcaXODOL 1Nivel Requisitos /LímitesASTRAMORPH-PF 1 PAPERCOCET 1 QL (120 / 30 día(s))PERCODAN 1 QL (120 / 30 día(s))DURAGESIC 1 PA; QL (10 / 30día(s))ACTIQ 4 PA; QL (120 / 30día(s))XODOL 1XODOL 1XODOL 1XODOL1XODOL 1hydrocodone-ibuprofen oral tablet 7.5-200 MG VICOPROFEN 1 QL (120 / 30 día(s))hydromorphone hcl oral tablet 2 MG, 4 MG, 8MGhydromorphone hcl pf injection solution 500MG/50MLDILAUDID 1DILAUDID 1LA - Esta receta puede estar sólo disponible en algunas farmacias.76

MedicamentoLAZANDA NASAL SOLUTION(fentanyl citrate)100 MCG/ACT, 400 MCG/ACTReferenciade Marcalevorphanol tartrate oral tablet 2 MG 1methadone hcl injection solution 10 MG/ML DILAUDID 1methadone hcl oral concentrate 10 MG/ML DILAUDID 1methadone hcl oral solution 10 MG/5ML, 5MG/5MLDILAUDID 1methadone hcl oral tablet 10 MG, 5 MG DILAUDID 1morphine sulfate oral solution 10 MG/5ML, 20MG/5MLmorphine sulfate oral tablet 15 MG, 30 MGmorphine sulfate (concentrate) oral solution 20MG/MLmorphine sulfate er oral tablet extendedrelease15 MG, 200 MG, 30 MG, 60 MGmorphine sulfate er oral tablet extendedrelease100 MGASTRAMORPH-PFASTRAMORPH-PFASTRAMORPH-PFoxycodone hcl oral capsule 5 MG OXYCONTIN 1oxycodone hcl oral concentrate 20 MG/ML OXYCONTIN 1oxycodone hcl oral tablet 10 MG, 15 MG, 20MG, 30 MG, 5 MGoxycodone-acetaminophen oral capsule 5-500MGoxycodone-acetaminophen oral tablet 2.5-325MGNivel Requisitos /Límites4 LA111KADIAN 1 QL (90 / 30 día(s))KADIAN 1 QL (90 / 30 día(s))OXYCONTIN 1oxycodone-aspirin oral tablet 4.8355-325 MG PERCODAN 1PERCOCET 1 QL (120 / 30 día(s))PERCOCET 1 QL (120 / 30 día(s))oxycodone-ibuprofen oral tablet 5-400 MG 1 QL (120 / 30 día(s))oxymorphone hcl oral tablet 10 MG, 5 MG OPANA 1LA - Esta receta puede estar sólo disponible en algunas farmacias.77

MedicamentoReferenciade Marcastagesic oral capsule 5-500 MG 1Analgésicos No Narcóticosbutorphanol tartrate injection solution 1 MG/ML,2 MG/MLNivel Requisitos /Límitesbutorphanol tartrate nasal solution 10 MG/ML 1 QL (5 ML / 3 día(s))CELEBREX ORAL CAPSULE(celecoxib)100 MG, 200 MG, 400 MG, 50 MGdiclofenac potassium oral tablet 50 MG CATAFLAM 1diclofenac sodium oral tablet delayed release 25MG, 50 MG, 75 MGdiclofenac sodium er oral tablet extended release24 hr 100 MGVOLTAREN-XR 1VOLTAREN-XR 1diflunisal oral tablet 500 MG 1etodolac oral capsule 200 MG, 300 MG 1etodolac oral tablet 400 MG, 500 MG 1etodolac er oral tablet extended release 24 hr 400MG, 500 MG, 600 MGfenoprofen calcium oral tablet 600 MG 1flurbiprofen oral tablet 100 MG, 50 MG 1ibuprofen oral suspension 100 MG/5ML 1ibuprofen oral tablet 400 MG, 600 MG, 800 MG 1ketoprofen oral capsule 50 MG, 75 MG 1ketoprofen er oral capsule extended release 24hour 200 MGmeclofenamate sodium oral capsule 100 MG, 50MGmefenamic acid oral capsule 250 MG PONSTEL 112 PA; QL (60 / 30día(s))meloxicam oral tablet 15 MG, 7.5 MG MOBIC 1 QL (30 / 30 día(s))111LA - Esta receta puede estar sólo disponible en algunas farmacias.78

MedicamentoReferenciade MarcaNivel Requisitos /Límitesmeloxicam oral suspension 7.5 MG/5ML MOBIC 1 QL (300 ML / 30día(s))nabumetone oral tablet 500 MG, 750 MG 1naloxone hcl injection solution 1 MG/ML 1naltrexone hcl oral tablet 50 MG REVIA 1naproxen oral suspension 125 MG/5ML EC-NAPROSYN 1naproxen oral tablet 250 MG, 375 MG, 500 MG NAPROSYN 1naproxen dr oral tablet delayed release 375 MG,500 MGnaproxen sodium oral tablet 275 MG, 550 MG ANAPROX DS 1oxaprozin oral tablet 600 MG DAYPRO 1piroxicam oral capsule 10 MG, 20 MG FELDENE 1sulindac oral tablet 150 MG, 200 MG CLINORIL 1tolmetin sodium oral capsule 400 MG 1tolmetin sodium oral tablet 200 MG, 600 MG 1tramadol hcl oral tablet 50 MG ULTRAM ER 1 QL (240 / 30 día(s))1tramadol-acetaminophen oral tablet 37.5-325MGVOLTAREN TRANSDERMAL GEL(diclofenac sodium)1 %AnticonvulsivosBANZEL ORAL SUSPENSION(rufinamide)40 MG/MLBANZEL ORAL TABLET(rufinamide)200 MGULTRACET 1 QL (40 / 5 día(s))22 PA; MT2 PA; MTLA - Esta receta puede estar sólo disponible en algunas farmacias.79

MedicamentoBANZEL ORAL TABLET(rufinamide)400 MGReferenciade MarcaNivel Requisitos /Límites4 PA; MTcarbamazepine oral suspension 100 MG/5ML TEGRETOL 1 MTcarbamazepine oral tablet chewable 100 MG TEGRETOL 1 MTcarbamazepine er oral capsule extended release12 hour 100 MG, 200 MG, 300 MGcarbamazepine er oral tablet extended release 12hr 200 MG, 400 MGCELONTIN ORAL CAPSULE(methsuximide)300 MGTEGRETOL XR 1 MTTEGRETOL XR 1 MTclonazepam oral tablet 0.5 MG, 1 MG, 2 MG 1clonazepam oral tablet dispersible 0.125 MG,0.25 MG, 0.5 MG, 1 MG, 2 MGDEPAKENE ORAL SYRUP(valproate sodium)250 MG/5MLDEPAKENE ORAL CAPSULE(valproic acid)250 MGKLONOPIN 1diazepam re gel 2.5 MG, 20 MG VALIUM 1DILANTIN ORAL SUSPENSION(phenytoin)125 MG/5MLDILANTIN ORAL CAPSULE(phenytoin sodium extended)100 MG, 30 MGDILANTIN INFATABS ORAL TABLETCHEWABLE(phenytoin)50 MG2 MT2 MT2 MT2 MT2 MT2 MTdivalproex sodium oral capsule sprinkle 125 MG DEPAKOTE 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.80

Medicamentodivalproex 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 MGReferenciade MarcaNivel Requisitos /LímitesDEPAKOTE ER 1 MTDEPAKOTE ER 1 MTTEGRETOL 1 MTethosuximide oral capsule 250 MG ZARONTIN 1 MTethosuximide oral solution 250 MG/5ML ZARONTIN 1 MTfelbamate oral suspension 600 MG/5ML FELBATOL 1 MTfelbamate oral tablet 400 MG, 600 MG FELBATOL 1 MTFELBATOL 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, 400MGgabapentin oral solution 250 MG/5ML2 MT2 MTCEREBYX 1 PANEURONTIN 1 MTNEURONTINNEURONTIN1 MTgabapentin oral tablet 600 MG, 800 MG NEURONTIN 1 MTlamotrigine oral tablet 100 MG, 150 MG, 200MG, 25 MGLAMICTAL 1 MTlamotrigine oral tablet chewable 25 MG, 5 MG LAMICTAL 1 MTlamotrigine er oral tablet extended release 24 hr100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50MGLAMICTAL 1 MTlevetiracetam intravenous solution 500 MG/5ML KEPPRA 1levetiracetam oral solution 100 MG/ML KEPPRA 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.81

Medicamentolevetiracetam oral tablet 1000 MG, 250 MG, 500MG, 750 MGlevetiracetam er oral tablet extended release 24hr 500 MG, 750 MGLYRICA 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 MGReferenciade MarcaNivel Requisitos /LímitesKEPPRA 1 MTKEPPRA 1 MT2 PA; MT2 PA; MToxcarbazepine oral suspension 300 MG/5ML TRILEPTAL 1 MToxcarbazepine oral tablet 150 MG, 300 MG, 600MGPEGANONE ORAL TABLET(ethotoin)250 MGTRILEPTAL 1 MT22 MTphenobarbital oral elixir 20 MG/5ML 1 PAphenobarbital oral tablet 100 MG, 15 MG, 16.2MG, 30 MG, 32.4 MG, 60 MG, 64.8 MG, 97.2 MG1 PAphenytoin oral suspension 125 MG/5ML DILANTIN 1 MTphenytoin oral tablet chewable 50 MG DILANTIN 1 MTphenytoin sodium injection solution 50 MG/ML DILANTIN 1phenytoin sodium extended oral capsule 100 MG DILANTIN 1 MTPOTIGA ORAL TABLET(ezogabine)200 MG, 300 MG, 400 MG, 50 MG2 MTprimidone oral tablet 250 MG, 50 MG MYSOLINE 1 MTSABRIL ORAL PACKET(vigabatrin)500 MG4 PA; MT; LALA - Esta receta puede estar sólo disponible en algunas farmacias.82

MedicamentoSABRIL ORAL TABLET(vigabatrin)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 MGReferenciade MarcaNivel Requisitos /Límites4 PA; MT; LA2 MT2 MT2 MTtiagabine hcl oral tablet 2 MG, 4 MG GABITRIL 1 MTtopiramate oral capsule sprinkle 15 MG, 25 MG TOPAMAX 1 MTtopiramate oral tablet 100 MG, 200 MG, 25 MG,50 MGTRILEPTAL ORAL SUSPENSION(oxcarbazepine)300 MG/5MLvalproate sodium intravenous solution 100MG/MLTOPAMAX 1 MTDEPACON 12 MTvalproic acid oral capsule 250 MG DEPAKENE 1 MTvalproic acid oral syrup 250 MG/5ML DEPAKENE 1 MTVIMPAT INTRAVENOUS SOLUTION(lacosamide)200 MG/20MLVIMPAT ORAL SOLUTION(lacosamide)10 MG/MLVIMPAT ORAL TABLET(lacosamide)100 MG, 150 MG, 200 MG, 50 MG22 MT2 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.83

MedicamentoReferenciade MarcaNivel Requisitos /Límiteszonisamide oral capsule 100 MG, 25 MG, 50 MG ZONEGRAN 1 MTMigraña / Tratamiento para el dolor de CabezaERGOMAR SUBLINGUAL TABLETSUBLINGUAL(ergotamine tartrate)2 MGMIGERGOT RE SUPPOSITORY(ergotamine-caffeine)2-100 MGnaratriptan hcl oral tablet 1 MG, 2.5 MG AMERGE 1 QL (18 / 28 día(s))rizatriptan benzoate oral tablet 10 MG, 5 MG MAXALT 1 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/0.5MLTratamiento Neurológico MisceláneoCOPAXONE SUBCUTANEOUS KIT(glatiramer acetate)20 MG/ML21MAXALT MLT 1 QL (27 / 28 día(s))IMITREX 1 QL (18 / 28 día(s))IMITREX 1 QL (8 ML / 28día(s))4 PA; QL (30 / 30día(s))donepezil hcl oral tablet 10 MG, 5 MG ARICEPT 1 MT; 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 MGARICEPT ODT 1 MT; QL (30 / 30día(s))2 PA; MTRAZADYNE 1 MTRAZADYNE 1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.84

Medicamentogalantamine 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 MGTYSABRI INTRAVENOUS CONCENTRATE(natalizumab)300 MG/15MLXENAZINE ORAL TABLET(tetrabenazine)12.5 MG, 25 MGRelajantes Musculares / Terapia EspasmódicaReferenciade MarcaNivel Requisitos /LímitesRAZADYNE 1 MTEXELON 1 MTbaclofen oral tablet 10 MG, 20 MG 1dantrolene sodium oral capsule 100 MG, 25 MG,50 MGMESTINON ORAL TABLETEXTENDEDRELEASE(pyridostigmine bromide er)180 MGDANTRIUM 1pyridostigmine bromide oral tablet 60 MG MESTINON 1tizanidine hcl oral tablet 2 MG, 4 MG ZANAFLEX 14 PA; QL (30 / 30día(s))2 PA; MT; QL (300ML / 30 día(s))2 PA; MT; QL (60 /30 día(s))2 PA; QL (49 / 28día(s))24 PA; LA4 PA; MT; LA2LA - Esta receta puede estar sólo disponible en algunas farmacias.85

MedicamentoReferenciade MarcaMedicamentos Endocrinos / Medicamentos para la DiabetesAgentes AntitiroideosNivel Requisitos /Límitesmethimazole oral tablet 10 MG, 5 MG TAPAZOLE 1 MTpropylthiouracil oral tablet 50 MG 1 MTHormonas Adrenalescortisone 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 MGDEXAMETHASONE INTENSOL ORALCONCENTRATE(dexamethasone)1 MG/MLdexamethasone sodium phosphate injectionsolution 4 MG/MLfludrocortisone acetate oral tablet 0.1 MG 1hydrocortisone oral tablet 10 MG, 20 MG, 5 MG CORTEF 1methylprednisolone oral tablet 16 MG, 32 MG, 4MG, 8 MGmethylprednisolone (pak) oral tablet 4 MGmethylprednisolone acetate injection suspension40 MG/ML, 80 MG/MLmethylprednisolone sodium succ injectionsolution reconstituted 125 MG, 40 MGprednisolone sodium phosphate oral solution 15MG/5ML, 25 MG/5ML, 6.7 (5 Base) MG/5MLMEDROLMEDROLDEPO-MEDROL 1DEPO-MEDROL 1PRED FORTE 1prednisone oral solution 5 MG/5ML PRELONE 1prednisone oral tablet 1 MG, 10 MG, 2.5 MG, 20MG, 5 MG, 50 MG111111LA - Esta receta puede estar sólo disponible en algunas farmacias.86

MedicamentoPREDNISONE INTENSOL ORALCONCENTRATE(prednisone)5 MG/MLVERIPRED 20 ORAL SOLUTION(prednisolone sodium phosphate)20 MG/5MLHormonas TiroideosLEVOTHROID 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 MCGLEVOXYL ORAL TABLET(levothyroxine sodium)100 MCG, 112 MCG, 125 MCG, 137 MCG, 150MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG,75 MCG, 88 MCGliothyronine 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, 175MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG,75 MCG, 88 MCGHormonas MisceláneasALDURAZYME INTRAVENOUS SOLUTION(laronidase)2.9 MG/5MLReferenciade MarcaNivel Requisitos /LímitesSYNTHROID 1 MTSYNTHROID 1 MTCYTOMEL 1CYTOMEL 1 MT112 MTSYNTHROID 1 MT4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.87

MedicamentoANDROGEL TRANSDERMAL GEL(testosterone)50 MG/5GMANDROGEL PUMP TRANSDERMAL GEL(testosterone)20.25 MG/ACT (1.62%)ANDROXY ORAL TABLET(fluoxymesterone)10 MGAXIRON TRANSDERMAL SOLUTION(testosterone)30 MG/ACTReferenciade MarcaNivel Requisitos /Límitescabergoline oral tablet 0.5 MG 1 QL (20 / 30 día(s))calcitriol intravenous solution 1 MCG/ML VECTICAL 1 PAcalcitriol oral capsule 0.25 MCG, 0.5 MCG VECTICAL 1 PAcalcitriol oral solution 1 MCG/ML VECTICAL 1 PACEREZYME INTRAVENOUS SOLUTIONRECONSTITUTED(imiglucerase)200 UNITdanazol oral capsule 200 MG, 50 MG 122124 PAdanazol oral capsule 100 MG 1 QL (60 / 30 día(s))desmopressin ace spray refrig nasal solution 0.01%DDAVP 1desmopressin acetate oral tablet 0.1 MG, 0.2 MG DDAVP 1desmopressin acetate injection solution 4MCG/MLELAPRASE INTRAVENOUS SOLUTION(idursulfase)6 MG/3MLELELYSO INTRAVENOUS SOLUTIONRECONSTITUTED(taliglucerase alfa)200 UNITDDAVP 1 PA4 PA4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.88

MedicamentoFABRAZYME INTRAVENOUS SOLUTIONRECONSTITUTED(agalsidase beta)35 MGFORTICAL NASAL SOLUTION(calcitonin (salmon))200 UNIT/ACTKUVAN ORAL TABLET SOLUBLE(sapropterin dihydrochloride)100 MGReferenciade MarcaNivel Requisitos /Límites4 PAMIACALCIN 1 MTmethyltestosterone oral tablet 10 MG METHITEST 2MIACALCIN INJECTION SOLUTION(calcitonin (salmon))200 UNIT/MLNAGLAZYME INTRAVENOUS SOLUTION(galsulfase)1 MG/ML4 PA; LA2 PA4 PA; LAoxandrolone oral tablet 2.5 MG OXANDRIN 1 PA; QL (60 / 30día(s))oxandrolone oral tablet 10 MG OXANDRIN 4 PA; QL (60 / 30día(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 MG1 PA2 QL (60 / 30 día(s))4 QL (120 / 30 día(s))4 QL (60 / 30 día(s))4 PA; LALA - Esta receta puede estar sólo disponible en algunas farmacias.89

MedicamentoSYNAREL NASAL SOLUTION(nafarelin acetate)2 MG/MLZAVESCA ORAL CAPSULE(miglustat)100 MGzoledronic acid intravenous concentrate4 MG/5MLZOMETA INTRAVENOUS SOLUTION(zoledronic acid)4 MG/100MLZOMETA INTRAVENOUS CONCENTRATE(zoledronic acid)4 MG/5MLTratamiento para la DiabetesReferenciade MarcaNivel Requisitos /Límites4 PAZOMETA 1 PA4 PA; LA; QL (90 /30 día(s))44 PAacarbose oral tablet 50 MG PRECOSE 1 MT; QL (180 / 30día(s))acarbose oral tablet 25 MG PRECOSE 1 MT; QL (360 / 30día(s))acarbose oral tablet 100 MG PRECOSE 1 MT; QL (90 / 30día(s))alcohol preps xx padBD, CURAD,CURITY, EASYTOUCH, FIFTY50,REALITY, QC,SURE COMFORT,WEBCOL2 QL (100 / 30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.90

MedicamentoINSULIN 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 MGReferenciade Marca1ST TIER,AUTOSHIELD, BD,CLICKFINE, EASYCOMFORT, EASYTOUCH, FIFTY50,INCONTROL,LITETOUCH,NOVOTWIST,PRODIGY, SURE-COMFORT, SURE-FINE, UNIFINE1ST TIER, BD,COMFORT EZ,EASY TOUCH,NOVOFINE, SURE-COMFORT, SURE-FINE, UNIFINE1ST TIER, BD,AUTOSHIELD,EASY TOUCH,INCONTROL, ,UNIFINENivel Requisitos /Límites2 QL (100 / 30 día(s))2 QL (100 / 30 día(s))2 QL (100 / 30 día(s))2 PA; MT; QL (4.8ML / 30 día(s))2 PA; MT; QL (2.4ML / 30 día(s))2 MTglimepiride oral tablet 2 MG AMARYL 1 MT; QL (120 / 30día(s))glimepiride oral tablet 1 MG AMARYL 1 MT; QL (240 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.91

MedicamentoReferenciade MarcaNivel Requisitos /Límitesglimepiride oral tablet 4 MG GLUCOTROL 1 MT; QL (60 / 30día(s))glipizide oral tablet 10 MG GLUCOTROL 1 MT; QL (120 / 30día(s))glipizide oral tablet 5 MG GLUCOTROL XL 1 MT; 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; QL (120 / 30día(s))GLUCOTROL XL 1 MT; QL (240 / 30día(s))GLUCOTROL XL 1 MT; QL (60 / 30día(s))1 MT; QL (120 / 30día(s))glipizide-metformin hcl oral tablet 2.5-250 MG 1 MT; QL (240 / 30día(s))GLUCAGON EMERGENCY INJECTION KIT(glucagon (rdna))1 MGglyburide oral tablet 5 MG DIABETA 1 MT; QL (120 / 30día(s))glyburide oral tablet 2.5 MG DIABETA 1 MT; QL (240 / 30día(s))glyburide oral tablet 1.25 MG DIABETA 1 MT; QL (480 / 30día(s))glyburide micronized oral tablet 3 MG GLYNASE 1 MT; QL (120 / 30día(s))glyburide micronized oral tablet 1.5 MG GLYNASE 1 MT; QL (240 / 30día(s))glyburide micronized oral tablet 6 MG GLYNASE 1 MT; QL (60 / 30día(s))glyburide-metformin oral tablet 2.5-500 MG, 5-500 MG2GLUCOVANCE 1 MT; QL (120 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.92

MedicamentoReferenciade MarcaNivel Requisitos /Límitesglyburide-metformin oral tablet 1.25-250 MG GLUCOVANCE 1 MT; 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/MLHUMALOG MIX 50/50 SUBCUTANEOUSSUSPENSION(insulin lispro prot & lispro)(50-50) 100 UNIT/MLHUMALOG MIX 75/25 SUBCUTANEOUSSUSPENSION(insulin lispro prot & lispro)(75-25) 100 UNIT/MLHUMULIN 70/30 SUBCUTANEOUSSUSPENSION(insulin isophane & regular)(70-30) 100 UNIT/MLHUMULIN N 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/ML2 MT; QL (180 / 30día(s))2 MT; QL (360 / 30día(s))2 MT; QL (90 / 30día(s))2 MT; QL (30 ML /30 día(s))2 MT; QL (30 ML /30 día(s))2 MT; QL (30 ML /30 día(s))2 MT; QL (30 ML /30 día(s))2 MT; QL (30 ML /30 día(s))2 MT; QL (30 ML /30 día(s))2 MT; QL (40 ML /30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.93

MedicamentoJANUMET 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 MGKLING FLEXIBLE GAUZE XX MISC(gauze pads & dressings)Referenciade MarcaNivel Requisitos /Límites3 PA; MT; QL (60 /30 día(s))3 PA; MT; QL (30 /30 día(s))2 PA; MT; QL (60 /30 día(s))2KOMBIGLYZE 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/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 MGGLUCOPHAGE 1 MTGLUCOPHAGE XR 1 MTFORTAMET 1 MT2 PA; MT; QL (30 /30 día(s))2 MT; QL (30 ML /30 día(s))2 MT; QL (30 ML /30 día(s))2 PA; MT; QL (30 /30 día(s))ACTOS 1 MT; QL (30 / 30día(s))DUETACT 1 MT; QL (30 / 30día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.94

Medicamentopioglitazone hcl-metformin hcl oral tablet 15-500MG, 15-850 MGPRANDIN ORAL TABLET(repaglinide)2 MGPRANDIN ORAL TABLET(repaglinide)1 MGPRANDIN ORAL TABLET(repaglinide)0.5 MGPROGLYCEM ORAL SUSPENSION(diazoxide)50 MG/MLSYMLINPEN 120 SUBCUTANEOUSSOLUTION(pramlintide acetate)2700 MCG/2.7MLSYMLINPEN 60 SUBCUTANEOUSSOLUTION(pramlintide acetate)1500 MCG/1.5MLReferenciade MarcaNivel Requisitos /LímitesACTOPLUS MET 1 MT; QL (90 / 30día(s))2 MT; QL (240 / 30día(s))2 MT; QL (480 / 30día(s))2 MT; QL (960 / 30día(s))22 PA; MT; QL (10.8ML / 30 día(s))2 PA; MT; QL (6 ML/ 30 día(s))tolazamide oral tablet 250 MG 1 MT; QL (120 / 30día(s))tolazamide oral tablet 500 MG 1 MT; QL (60 / 30día(s))tolbutamide oral tablet 500 MG 1 MT; QL (180 / 30día(s))TRADJENTA ORAL TABLET(linagliptin)5 MGMedicamentos Musculoesqueletales / Medicamentos ReumatológicosAgentes ReumatológicosACTEMRA INTRAVENOUS SOLUTION(tocilizumab)200 MG/10ML2 PA; MT; QL (30 /30 día(s))4 PALA - Esta receta puede estar sólo disponible en algunas farmacias.95

MedicamentoBENLYSTA INTRAVENOUS SOLUTIONRECONSTITUTED(belimumab)120 MGENBREL SUBCUTANEOUS SOLUTION(etanercept)50 MG/MLENBREL SUBCUTANEOUS KIT(etanercept)25 MGENBREL 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/0.8MLReferenciade MarcaNivel Requisitos /Límites2 PA4 PA; QL (4 ML / 28día(s))4 PA; QL (8 / 28día(s))4 PA; QL (8 ML / 28día(s))4 PA; QL (0.8 / 30día(s))4 PA; QL (3.2 / 28día(s))4 PA; QL (6 / 30día(s))leflunomide oral tablet 10 MG, 20 MG ARAVA 1 QL (30 / 30 día(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 MG4 PA22 PA; MT2 PALA - Esta receta puede estar sólo disponible en algunas farmacias.96

MedicamentoTerapia para la GotaReferenciade MarcaNivel Requisitos /Límitesallopurinol oral tablet 100 MG, 300 MG ZYLOPRIM 1 MTcolchicine-probenecid oral tablet 0.5-500 MG 1 MTCOLCRYS ORAL TABLET(colchicine)0.6 MGprobenecid oral tablet 500 MG 1Tratamiento para la Osteoporosisalendronate sodium oral solution 70 MG/75ML FOSAMAX 1 MTalendronate sodium oral tablet 10 MG, 5 MG FOSAMAX 1 MT; QL (30 / 30día(s))alendronate sodium oral tablet 35 MG, 70 MG FOSAMAX 1 MT; QL (4 / 28día(s))BONIVA INTRAVENOUS SOLUTION(ibandronate sodium)3 MG/3MLEVISTA ORAL TABLET(raloxifene hcl)60 MGFORTEO SUBCUTANEOUS SOLUTION(teriparatide (recombinant))600 MCG/2.4ML22 PA2 MT4 PA; MT; QL (2.4ML / 28 día(s))ibandronate sodium oral tablet 150 MG BONIVA 1 MT; QL (1 / 30día(s))PROLIA SUBCUTANEOUS SOLUTION(denosumab)60 MG/MLMedicamentos Obstétricos / GinecologíaContraceptivos Orales y Agentes RelacionadosAPRI ORAL TABLET(desogestrel-ethinyl estradiol)0.15-30 MG-MCGORTHO-CEPT 12 PALA - Esta receta puede estar sólo disponible en algunas farmacias.97

MedicamentoARANELLE 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-MCGJUNEL 1.5/30 ORAL TABLET(norethindrone acet-ethinyl est)1.5-30 MG-MCGReferenciade MarcaTRI-NORINYL 1Nivel Requisitos /Límites1OVCON 1NORINYL 1NORINYL 11YASMIN 1DESOGEN 11YAZ 1OVCON 1LOESTRIN 1LA - Esta receta puede estar sólo disponible en algunas farmacias.98

MedicamentoJUNEL 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-MCGLUTERA ORAL TABLET(levonorgestrel-ethinyl estrad)0.1-20 MG-MCGReferenciade MarcaLOESTRIN 1LOESTRIN FE 1LOESTRIN FE 1MIRCETTE 1TRI-NORINYL 1Nivel Requisitos /Límites11PLAN B 1NORDETTE 1YAZ 111LA - Esta receta puede estar sólo disponible en algunas farmacias.99

MedicamentoReferenciade Marcamarlissa oral tablet 0.15-30 MG-MCG NORDETTE 1Nivel Requisitos /LímitesMICROGESTIN 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-MCGNORTREL 1/35 (21) ORAL TABLET(norethindrone-eth estradiol)1-35 MG-MCGLOESTRIN 1LOESTRIN 1LOESTRIN FE 1LOESTRIN FE 1ORTHO-CYCLEN 1NORINYL 1NORINYL 1NORINYL 1NORINYL 1ORTHO-NOVUM 1ORTHO-NOVUM 1LA - Esta receta puede estar sólo disponible en algunas farmacias.100

MedicamentoNORTREL 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-MCGTRINESSA (28) ORAL TABLET(norgestim-eth estrad triphasic)0.18/0.215/0.25 MG-35 MCGReferenciade MarcaORTHO-NOVUM 1ORTHO-NOVUM 1NORDETTE 1ORTHO-CYCLEN 1ORTHO-CEPT 1ORTHO-CYCLEN 1ESTROSTEP FE 1ORTHO TRI-CYCLENNivel Requisitos /Límites11111LA - Esta receta puede estar sólo disponible en algunas farmacias.101

MedicamentoTRI-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)Referenciade MarcaORTHO TRI-CYCLENORTHO TRI-CYCLENNivel Requisitos /Límites111VELIVET 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 / ProgestinaCAMILA 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/DAYDEPO-PROVERA INTRAMUSCULARSUSPENSION(medroxyprogesterone acetate)400 MG/MLERRIN ORAL TABLET(norethindrone)0.35 MGORTHO TRI-CYCLENNOR-Q-D 1 MTNOR-Q-D 1 MT11133 QL (8 / 28 día(s))2LA - Esta receta puede estar sólo disponible en algunas farmacias.102

MedicamentoESTRACE VAGINAL CREAM(estradiol)0.1 MG/GMReferenciade Marcaestradiol oral tablet 0.5 MG, 1 MG, 2 MG ESTRACE 1estradiol-norethindrone acet oral tablet 0.5-0.1MG, 1-0.5 MGACTIVELLA 1estropipate oral tablet 0.75 MG, 1.5 MG, 3 MG 1medroxyprogesterone 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 MGNivel Requisitos /Límites2 MT1 MTPROVERA 1 QL (1 ML / 90día(s))2 PAMICRONOR 1 MTnorethindrone acetate oral tablet 5 MG AYGESTIN 1 MTPREMARIN 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 MG3 QL (5 / 35 día(s))222 MT2 QL (28 / 28 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.103

MedicamentoPREMPRO 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 MGVAGIFEM 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 GinecologíaReferenciade MarcaNivel Requisitos /LímitesPROMETRIUM 1 MTclindamycin phosphate vaginal cream 2 % CLEOCIN 12 QL (28 / 28 día(s))2 MT3 QL (10 / 35 día(s))miconazole 3 vaginal suppository 200 MG 1 QL (3 / 3 día(s))NUVARING VAGINAL RING(etonogestrel-ethinyl estradiol)0.12-0.015 MG/24HRORTHO EVRA TRANSDERMAL PATCHWEEKLY(norelgestromin-eth estradiol)150-20 MCG/24HR33 QL (3 / 28 día(s))terconazole vaginal suppository 80 MG TERAZOL 3 1 QL (3 / 3 día(s))terconazole vaginal cream 0.4 %, 0.8 % TERAZOL 3 1 QL (45 GM / 7día(s))VANDAZOLE VAGINAL GEL(metronidazole)0.75 %OxitocinasCLEOCIN 1methylergonovine maleate oral tablet 0.2 MG METHERGINE 1LA - Esta receta puede estar sólo disponible en algunas farmacias.104

MedicamentoMedicamentos para Oído, Nariz y GargantaEsteroides Óticos / AntibióticosCIPRODEX OTIC SUSPENSION(ciprofloxacin-dexamethasone)0.3-0.1 %Referenciade Marcaneomycin-polymyxin-hc otic solution 3.5-10000-1 CORTISPORIN 1neomycin-polymyxin-hc otic suspension 3.5-10000-1Agentes MisceláneosASTEPRO NASAL SOLUTION(azelastine hcl)0.15 %CORTISPORIN 1Nivel Requisitos /Límites22 ST; QL (60 ML / 30día(s))azelastine hcl nasal solution 137 MCG/SPRAY OPTIVAR 1 QL (30 ML / 30día(s))ipratropium bromide nasal solution 0.06 % ATROVENT 1 QL (15 ML / 30día(s))ipratropium bromide nasal solution 0.03 % ATROVENT 1 QL (30 ML / 30día(s))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 1VOSOL HC 1acetic acid otic solution 2 % 1DERMOTIC OTIC OIL(fluocinolone acetonide)0.01 %122LA - Esta receta puede estar sólo disponible en algunas farmacias.105

MedicamentoReferenciade Marcafluocinolone acetonide otic oil 0.01 % DERMOTIC 1ofloxacin otic solution 0.3 % OCUFLOX 1Medicamentos Respiratorios y para AlergiasAgentes 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/ACTNivel Requisitos /Límitesalbuterol sulfate oral syrup 2 MG/5ML VOSPIRE ER 1 MTalbuterol sulfate oral tablet 2 MG, 4 MG VOSPIRE ER 1 MTalbuterol 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 MG4 PA; MT; QL (60 /30 día(s))2 PA; MT; QL (60 /30 día(s))2 PA; MT; QL (12GM / 30 día(s))VOSPIRE ER 1 PA; MTVOSPIRE ER 1 MTaminophylline intravenous solution 25 MG/ML 1ATROVENT HFA INHALATION AEROSOL,SOLUTION(ipratropium bromide hfa)17 MCG/ACTCOMBIVENT INHALATION AEROSOL†(ipratropium-albuterol)18-103 MCG/ACT2 MT; QL (25.8 GM /30 día(s))2 MT; QL (29.4 GM /30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.106

MedicamentoCOMBIVENT 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/3MLReferenciade MarcaNivel Requisitos /Límites2 MT; QL (8 GM / 30día(s))NASALCROM 1 PA; MTflunisolide nasal solution 29 MCG/ACT (0.025%) VERAMYST 1fluticasone propionate nasal suspension 50MCG/ACTFORADIL AEROLIZER INHALATIONCAPSULE(formoterol fumarate)12 MCGLETAIRIS ORAL TABLET(ambrisentan)10 MG, 5 MG2 MT2 PA; MT; QL (13GM / 30 día(s))4 PA; QL (9 ML / 3día(s))FLONASE 1 QL (16 GM / 30día(s))metaproterenol sulfate oral syrup 10 MG/5ML 1 MTmetaproterenol sulfate oral tablet 10 MG, 20 MG 1 MT2 MT; QL (120 / 30día(s))4 PA; MT; LA; QL(30 / 30 día(s))montelukast sodium oral tablet 10 MG SINGULAIR 1 QL (30 / 30 día(s))montelukast sodium oral tablet chewable 4 MG, 5MGSINGULAIR 1 QL (30 / 30 día(s))montelukast sodium oral packet 4 MG SINGULAIR 1 QL (30 / 30 día(s))PROAIR HFA INHALATION AEROSOL,SOLUTION(albuterol sulfate hfa)108 (90 Base) MCG/ACT2 MT; QL (17 GM /30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.107

MedicamentoPROVENTIL HFA INHALATION AEROSOL,SOLUTION(albuterol sulfate hfa)108 (90 Base) MCG/ACTPULMOZYME INHALATION SOLUTION(dornase alfa)1 MG/MLQVAR INHALATION AEROSOL, SOLUTION(beclomethasone dipropionate)40 MCG/ACT, 80 MCG/ACTSEREVENT DISKUS INHALATIONAEROSOL POWDER, BREATH ACTIVATED(salmeterol xinafoate)50 MCG/DOSEReferenciade MarcaNivel Requisitos /Límites2 MT; QL (20.1 GM /30 día(s))4 PA; MT2 QL (17.4 GM / 30día(s))2 PA; MT; QL (120 /30 día(s))sildenafil citrate oral tablet 20 MG REVATIO 1 PA; MT; QL (90 /30 día(s))SPIRIVA HANDIHALER INHALATIONCAPSULE(tiotropium bromide monohydrate)18 MCGterbutaline sulfate injection solution 1 MG/ML 1terbutaline sulfate oral tablet 2.5 MG, 5 MG 1 MTtheophylline er oral tablet extended release 12 hr100 MG, 200 MG, 300 MG, 450 MGtheophylline er oral tablet extended release 24 hr400 MG, 600 MGTRACLEER ORAL TABLET(bosentan)125 MG, 62.5 MGXOLAIR SUBCUTANEOUS SOLUTIONRECONSTITUTED(omalizumab)150 MGXOPENEX HFA INHALATION AEROSOL†(levalbuterol tartrate)45 MCG/ACTELIXOPHYLLIN 1ELIXOPHYLLIN 12 MT; QL (60 / 30día(s))4 PA; MT; LA; QL(60 / 30 día(s))4 PA; LA; QL (6 / 28día(s))3 MT; QL (45 GM /30 día(s))LA - Esta receta puede estar sólo disponible en algunas farmacias.108

MedicamentoZYFLO ORAL TABLET(zileuton)600 MGZYFLO CR ORAL TABLET EXTENDEDRELEASE 12 HR(zileuton er)600 MGAntihistamínicos / Agentes AntialergenosReferenciade Marcacyproheptadine hcl oral syrup 2 MG/5ML 1cyproheptadine hcl oral tablet 4 MG 1Nivel Requisitos /Límites2 PA2 PAdesloratadine oral tablet 5 MG CLARINEX 1 QL (30 / 30 día(s))desloratadine oral tablet dispersible 2.5 MG, 5MGCLARINEXREDITAB1 QL (30 / 30 día(s))diphenhydramine hcl injection solution 50MG/MLdiphenhydramine hcl oral capsule 50 MG 1EPIPEN 2-PAK INJECTION DEVICE(epinephrine)0.3 MG/0.3MLEPIPEN JR 2-PAK INJECTION DEVICE(epinephrine)0.15 MG/0.3ML12 QL (4 / 2 día(s))2 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 MG111LA - Esta receta puede estar sólo disponible en algunas farmacias.109

MedicamentoOftalmologíaAgentes Anti-inflamatorios no EsteroidalesReferenciade Marcadiclofenac sodium ophthalmic solution 0.1 % VOLTAREN 1flurbiprofen sodium ophthalmic solution 0.03 % OCUFEN 1ketorolac tromethamine ophthalmic solution 0.4%, 0.5 %NEVANAC OPHTHALMIC SUSPENSION(nepafenac)0.1 %AntibióticosAZASITE OPHTHALMIC SOLUTION(azithromycin)1 %ACULAR LS 1bacitracin ophthalmic ointment 500 UNIT/GM 1bacitracin-polymyxin b ophthalmic ointment 500-10000 UNIT/GMciprofloxacin 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 1NATACYN OPHTHALMIC SUSPENSION(natamycin)5 %neomycin-bacitracin zn-polymyx ophthalmicointment 5-400-10000neomycin-polymyxin-gramicidin ophthalmicsolutionNEOSPORIN 1ofloxacin ophthalmic solution 0.3 % OCUFLOX 1Nivel Requisitos /Límites23 QL (5 ML / 30día(s))121LA - Esta receta puede estar sólo disponible en algunas farmacias.110

Medicamentopolymyxin b-trimethoprim ophthalmic solution10000-0.1 UNIT/ML-%Referenciade MarcaPOLYTRIM 1tobramycin sulfate ophthalmic solution 0.3 % TOBREX 1VIGAMOX OPHTHALMIC SOLUTION(moxifloxacin hcl)0.5 %AntiviralesTrifluridine ophthalmic solution1 %VIROPTIC OPHTHALMIC SOLUTION(trifluridine)1 %Beta - BloqueadoresVIROPTIC 1Nivel Requisitos /Límitesbetaxolol hcl ophthalmic solution 0.5 % KERLONE 1 MTcarteolol hcl ophthalmic solution 1 % 1 MTlevobunolol hcl ophthalmic solution 0.5 % BETAGAN 1 MTmetipranolol ophthalmic solution 0.3 % OPTIPRANOLOL 1 MTtimolol maleate ophthalmic solution 0.25 %, 0.5%Esteroidesdexamethasone sodium phosphate ophthalmicsolution 0.1 %FML OPHTHALMIC OINTMENT(fluorometholone)0.1 %FML FORTE OPHTHALMIC SUSPENSION(fluorometholone)0.25 %PRED MILD OPHTHALMIC SUSPENSION(prednisolone acetate)0.12 %TIMOPTIC 1 MTprednisolone acetate ophthalmic suspension 1 % OMNIPRED 1321232LA - Esta receta puede estar sólo disponible en algunas farmacias.111

Medicamentoprednisolone 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 %Combinación 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 GlaucomaReferenciade MarcaPRED FORTE 1TOBRADEX 1Nivel Requisitos /Límitesacetazolamide oral tablet 125 MG, 250 MG DIAMOX SEQUELS 1 MTacetazolamide er oral capsule extended release12 hour 500 MGDIAMOX SEQUELS 1 MTmethazolamide oral tablet 25 MG, 50 MG NEPTAZANE 1 MT31111212LA - Esta receta puede estar sólo disponible en algunas farmacias.112

MedicamentoMisceláneos OftálmicosReferenciade Marcacromolyn sodium ophthalmic solution 4 % GASTROCROM 1PATADAY OPHTHALMIC SOLUTION(olopatadine hcl)0.2 %proparacaine hcl ophthalmic solution 0.5 % ALCAINE 1RESTASIS OPHTHALMIC EMULSION(cyclosporine)0.05 %Otros Medicamentos para la GlaucomaAZOPT OPHTHALMIC SUSPENSION(brinzolamide)1 %COMBIGAN OPHTHALMIC SOLUTION(brimonidine tartrate-timolol)0.2-0.5 %dorzolamide hcl ophthalmic solution 2 % TRUSOPT 1dorzolamide hcl-timolol mal ophthalmic solution22.3-6.8 MG/MLNivel Requisitos /LímitesCOSOPT 1 MT2 QL (2.5 ML / 30día(s))2 MT; QL (60 / 30día(s))2 QL (10 ML / 30día(s))2 MT; QL (10 ML /30 día(s))latanoprost ophthalmic solution 0.005 % XALATAN 1 MT; QL (2.5 ML /30 día(s))LUMIGAN OPHTHALMIC SOLUTION(bimatoprost)0.01 %travoprost ophthalmic solution 0.004 % 1 MT2 MT; QL (2.5 ML /30 día(s))SimpatomiméticosALPHAGAN P OPHTHALMIC SOLUTION(brimonidine tartrate)0.1 %apraclonidine hcl ophthalmic solution 0.5 % IOPIDINE 12 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.113

Medicamentobrimonidine tartrate ophthalmic solution 0.15 %,0.2 %SulfonamidasReferenciade MarcaNivel Requisitos /LímitesALPHAGAN P 1 MTsulfacetamide sodium ophthalmic ointment 10 % 1sulfacetamide 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 1oxybutynin chloride oral syrup 5 MG/5ML 1oxybutynin chloride oral tablet 5 MG 1oxybutynin chloride er oral tablet extendedrelease 24 hr 10 MG, 15 MGoxybutynin chloride er oral tablet extendedrelease 24 hr 5 MGDITROPAN XL 12 ST; QL (30 / 30día(s))DITROPAN XL 1 QL (30 / 30 día(s))trospium chloride oral tablet 20 MG SANCTURA XR 1Estimulantes Anticolinérgicosbethanechol chloride oral tablet 10 MG, 25 MG,5 MG, 50 MGUrológicos Misceláneosammonium chloride intravenous solution 5MEQ/MLCYSTAGON ORAL CAPSULE(cysteamine bitartrate)150 MG, 50 MGURECHOLINE 122 MT; LALA - Esta receta puede estar sólo disponible en algunas farmacias.114

MedicamentoELMIRON ORAL CAPSULE(pentosan polysulfate sodium)100 MGTerapia para la Hiperplasia Benigna de la PróstataAVODART ORAL CAPSULE(dutasteride)0.5 MGReferenciade MarcaNivel Requisitos /Límitesfinasteride oral tablet 5 MG PROSCAR 1 MTtamsulosin hcl oral capsule 0.4 MG FLOMAX 1 MTVitaminas, Hematínicos / ElectrolitosElectrolitoscalcium acetate oral capsule 667 MG 1kcl 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 MEQ23 MT; QL (30 / 30día(s))111 MT1 MT1 MT1 MTLA - Esta receta puede estar sólo disponible en algunas farmacias.115

MedicamentoReferenciade Marcalactated ringers intravenous solution 1magnesium sulfate injection solution 50 % 1potassium 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-%Nivel Requisitos /Límites11 MTMICRO-K 1 MTringers intravenous solution 1sodium chloride injection solution 2.5 MEQ/ML 1sodium chloride intravenous solution 0.45 %, 3%, 5 %sodium lactate intravenous solution 167 MEQ/L,5 MEQ/MLTPN ELECTROLYTES INTRAVENOUSSOLUTION(parenteral electrolytes)11112Productos Misceláneos para la NutriciónAMINOSYN II INTRAVENOUS SOLUTION(amino acid infusion)10 %, 15 %, 7 %, 8.5 %AMINOSYN II/ELECTROLYTESINTRAVENOUS SOLUTION(amino acd electrolyte infusion)8.5 %AMINOSYN M INTRAVENOUS SOLUTION(amino acd electrolyte infusion)3.5 %2 PA2 PA2 PALA - Esta receta puede estar sólo disponible en algunas farmacias.116

MedicamentoAMINOSYN/ELECTROLYTESINTRAVENOUS SOLUTION(amino acd 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)Referenciade MarcaNivel Requisitos /Límites2 PA2 PA2 PA2 PA2 PALIPOSYN III INTRAVENOUS EMULSION(fat emulsion)10 %, 20 %Vitaminas / HematínicosINTRALIPID 1 PAprenatal/iron oral tablet 1LA - Esta receta puede estar sólo disponible en algunas farmacias.117

Índice de Medicamentos1ST TIER, 918-Mop, 42Abacavir Sulfate, 10, 17Abacavir Sulfate-Lamivudine,12Abacavir-Lamivudine-Zidovudine, 15Abatacept, 96Abelcet, 9Abilify, 66Abilify Discmelt, 66Abilify Maintena, 67Abiraterone Acetate, 66Acarbose, 90ACCUPRIL, 34ACCURETIC, 34Acebutolol HCl, 29ACEON, 34Acetaminophen-Codeine, 75Acetaminophen-Codeine #2,75Acetaminophen-Codeine #3,75Acetaminophen-Codeine #4,75Acetasol HC, 105Acetazolamide, 112Acetazolamide ER, 112Acetic Acid, 105Acitretin, 39ACLOVATE, 39Actemra, 95ACTHIB, 54Actimmune, 51ACTIQ, 76ACTIVELLA, 103ACTOPLUS MET, 95ACTOS, 94ACULAR LS, 110Acyclovir, 10Acyclovir Sodium, 11Adacel, 54Adagen, 44ADALAT CC, 33Adalimumab, 96Adapalene, 43Adcirca, 106Adefovir Dipivoxil, 12Ado-Trastuzumab Emtansine,61Advair Diskus, 106Advair HFA, 106Afeditab CR, 29Afinitor, 58Agalsidase beta, 89Aggrenox, 36AGRYLIN, 44ALACORT, 41Albendazole, 19Albenza, 19Albuterol Sulfate, 106Albuterol Sulfate ER, 106Albuterol Sulfate HFA, 107ALCAINE, 113Alclometasone Dipropionate,39Alcohol Preps, 90ALDACTAZIDE, 34ALDACTONE, 34ALDARA, 42Aldesleukin, 54Aldurazyme, 87Alendronate Sodium, 44, 97Alimta, 58Alinia, 19Alitretinoin, 42Allopurinol, 97Alosetron HCl, 49Alpha1-Proteinase Inhibitor,44Alphagan P, 113ALPHAGAN P, 113Alprazolam, 67Alprazolam ER, 67Alprazolam XR, 67ALTACE, 34Altretamine, 60Amantadine HCl, 11AMARYL, 91AMBIEN, 74AMBIEN CR, 74Ambisome, 9Ambrisentan, 107Amcinonide, 39AMERGE, 84Amifostine, 57Amiloride HCl, 29Amiloride-Hydrochlorothiazide, 29Amino Acd ElectrolyteInfusion, 116, 117Amino Acid Infusion, 116, 117Aminophylline, 106Aminosalicylic Acid, 21Aminosyn II, 116Aminosyn II/Electrolytes, 116Aminosyn M, 116Aminosyn/Electrolytes, 117Aminosyn-HBC, 117Aminosyn-PF, 117Amiodarone HCl, 26Amitiza, 47Amitriptyline HCl, 67Amlodipine Besy-BenazeprilHCl, 30Amlodipine Besylate, 30Ammonium Chloride, 114Ammonium Lactate, 42Amnesteem, 43Amoxapine, 67Amoxicillin, 23Amoxicillin-Pot Clavulanate,23118

Amoxicillin-Pot ClavulanateER, 23AMOXIL, 23AMPHOCIN, 9Amphotericin B, 9Amphotericin B Lipid, 9Amphotericin B Liposome, 9Ampicillin, 23Ampicillin Sodium, 23Ampicillin-Sulbactam Sodium,23ANAFRANIL, 68Anagrelide HCl, 44ANAPROX DS, 79Anastrozole, 58ANCOBON, 9AndroGel, 88AndroGel Pump, 88Androxy, 88Anidulafungin, 9Antabuse, 44ANTABUSE, 45ANTIVERT, 49ANTIZOL, 55ANUSOL-HC, 50APAP-Caff-Dihydrocodeine,75Apokyn, 74Apomorphine HCl, 74Apraclonidine HCl, 113Aprepitant, 48Apri, 97Aptivus, 11Aralast NP, 44ARALEN, 19Aranelle, 98ARAVA, 96Arcalyst, 51ARICEPT, 84ARICEPT ODT, 84Arimidex, 58ARIMIDEX, 58Aripiprazole, 66, 67ARIXTRA, 36, 37Aromasin, 58AROMASIN, 60Asacol, 47Ascomp-Codeine, 75Asenapine Maleate, 73Aspirin-Dipyridamole ER, 36Astepro, 105ASTRAMORPH-PF, 76, 77Atacand, 30Atacand HCT, 30Atazanavir Sulfate, 14Atenolol, 30Atenolol-Chlorthalidone, 30Atgam, 54ATIVAN, 71Atomoxetine HCl, 73Atorvastatin Calcium, 27Atovaquone, 21Atovaquone-Proguanil HCl, 20Atripla, 11ATROVENT, 105Atrovent HFA, 106AUGMENTIN, 23AUGMENTIN XR, 23Auranofin, 96AUTOSHIELD, 91AVALIDE, 32AVAPRO, 32Avastin, 58Avelox ABC Pack, 24Aviane, 98Avodart, 115Avonex, 52Avonex Prefilled, 52AXID, 51Axiron, 88Axitinib, 60AYGESTIN, 103Azacitidine, 65AZACTAM, 19Azasan, 58AzaSite, 110Azathioprine, 58Azelastine HCl, 105Azilect, 74Azithromycin, 18, 110Azopt, 113Aztreonam, 19AZULFIDINE, 50BACIIM, 19Bacitracin, 19, 110Bacitracin-Polymyxin B, 110Bacitra-Neomycin-Polymyxin-HC, 112Baclofen, 85Bactocill in Dextrose, 24BACTRIM, 25BACTROBAN, 38Balsalazide Disodium, 47Balziva, 98Banzel, 79, 80Baraclude, 11BD, 90, 91BD Insulin Syringe, 91BD Insulin Syringe Ultrafine,91BD Pen Needle Ultrafine, 91Beclomethasone Dipropionate,108Belatacept, 62Belimumab, 96Benazepril HCl, 30Benazepril-Hydrochlorothiazide, 30Benicar, 30Benicar HCT, 30Benlysta, 96BENZAMYCIN, 43Benzoyl Peroxide-Erythromycin, 43BETAGAN, 111Betaine, 48Betamethasone Dipropionate,40Betamethasone DipropionateAug, 40Betamethasone Valerate, 40BETAPACE, 27Betaseron, 52Betaxolol HCl, 30, 111Bethanechol Chloride, 114Bevacizumab, 58Bexarotene, 64BIAXIN, 19BIAXIN XL, 19Bicalutamide, 58Bicillin C-R, 24119

Bicillin C-R 900/300, 24Bimatoprost, 113Bisoprolol Fumarate, 30Bisoprolol-Hydrochlorothiazide, 30BLEPH-10, 114Blephamide, 112BLOCADREN, 35Boceprevir, 16Boniva, 97BONIVA, 97Boostrix, 54Bortezomib, 65Bosentan, 108Bosulif, 58Bosutinib, 58Botox, 54Brimonidine Tartrate, 113Brimonidine Tartrate-Timolol,113Brinzolamide, 113Bromocriptine Mesylate, 74,91Budeprion SR, 67Budesonide ER, 47Bumetanide, 30BUMEX, 30Buphenyl, 44Buproban, 46Bupropion HCl, 67Bupropion HCl ER (SmokingDet), 46Bupropion HCl ER (SR), 67Bupropion HCl ER (XL), 67Buspirone HCl, 67Butalbital-APAP-Caff-Cod, 75Butalbital-ASA-Caff-Codeine,75Butorphanol Tartrate, 78Byetta 10 MCG Pen, 91Byetta 5 MCG Pen, 91Cabergoline, 88Cabozantinib S-Malate, 59CALAN, 35CALAN SR, 35Calcipotriene, 39Calcitonin (Salmon), 89Calcitriol, 39, 88Calcium Acetate, 115Camila, 102Canasa, 47Cancidas, 9Candesartan Cilexetil, 30Candesartan Cilexetil-HCTZ,30Capastat Sulfate, 19CAPOTEN, 30CAPOZIDE, 30Caprelsa, 58Capreomycin Sulfate, 19Captopril, 30Captopril-Hydrochlorothiazide, 30Carafate, 50CARAFATE, 51Carbamazepine, 80, 81, 83Carbamazepine ER, 80, 83Carbidopa-Levodopa, 74Carbidopa-Levodopa ER, 74Carbinoxamine Maleate, 109CARDENE, 33CARDIZEM, 31CARDIZEM CD, 31CARDIZEM SR, 31CARDURA, 31CARNITOR, 45Carteolol HCl, 111Cartia XT, 31Carvedilol, 31CASODEX, 58Caspofungin Acetate, 9CATAFLAM, 78CATAPRESS, 31CATNITOR, 45CECLOR, 17CEENU, 58Cefaclor, 17Cefaclor ER, 17Cefadroxil, 17Cefazolin Sodium, 17Cefdinir, 17Cefepime HCl, 17Cefixime, 18Cefoxitin Sodium, 17Cefpodoxime Proxetil, 17Cefprozil, 17Ceftriaxone Sodium, 18Cefuroxime Axetil, 18Cefuroxime Sodium, 18CEFZIL, 17CELEBREX, 78Celecoxib, 78CELEXA, 67CellCept, 59CELLCEPT, 62Celontin, 80Cenestin, 102Cephalexin, 18Cerezyme, 88Cervarix, 54Chantix, 46Chantix Starting Month Pak,46Chemet, 44Chlorambucil, 61Chloramphenicol SodSuccinate, 19Chlorhexidine Gluconate, 105CHLOROMYCETIN, 19Chloroquine Phosphate, 19Chlorothiazide, 31Chlorpromazine HCl, 67Chlorthalidone, 31Cholestyramine Light, 27, 28Ciclopirox, 38Ciclopirox Olamine, 38Cilostazol, 36Cimetidine, 50Cimetidine HCl, 50Cinacalcet HCl, 89CIPRO, 25, 110CIPRO I.V, 25CIPRO I.V., 24CIPRO XR, 25Ciprodex, 105Ciprofloxacin, 24Ciprofloxacin HCl, 25, 110Ciprofloxacin in D5W, 25Ciprofloxacin-Ciproflox HClER, 25120

Ciprofloxacin-Dexamethasone,105Citalopram Hydrobromide, 67Claravis, 43CLARINEX, 109CLARINEX REDITAB, 109Clarithromycin, 19Clarithromycin ER, 19CLEOCIN, 20, 43, 104CLICKFINE, 91Clindamycin HCl, 20Clindamycin Phosphate, 20,43, 104CLINORIL, 79Clobazam, 82Clobetasol Propionate, 40Clobetasol Propionate E, 40Clomipramine HCl, 68Clonazepam, 80Clonidine HCl, 31Clonidine-Chlorthalidone, 31Clopidogrel Bisulfate, 36Clorazepate Dipotassium, 68Clorpres, 31Clotrimazole, 9, 38Clotrimazole-Betamethasone,38Clozapine, 68, 69CLOZARIL, 68Co-Gesic, 76Colchicine, 97Colchicine-Probenecid, 97Colcrys, 97Colesevelam HCl, 28COLESTID, 27Colestipol HCl, 27Colistimethate Sodium, 20Collagenase, 42COLOZAL, 47COLY-MYCIN, 20COLYTE WITH FLAVORPACKETS, 48Combigan, 113CombiPatch, 102Combivent, 106Combivent Respimat, 106COMBIVIR, 13Cometriq (100 mg DailyDose), 59Cometriq (140 mg DailyDose), 59Cometriq (60 mg Daily Dose),59COMFORT EZ, 91Complera, 11Compro, 47COMTAN, 75Comvax, 54CONDYLOX, 42Conj Estrog-MedroxyprogestAce, 103, 104Constulose, 47Copaxone, 84COPEGUS, 14COREG, 31CORGARD, 33CORTEF, 86Cortisone Acetate, 86CORTISPORIN, 105CORZIDE, 33COSOPT, 113Coumadin, 36COUMADIN, 37COZAAR, 33Creon, 48Crestor, 27Crixivan, 11Crizotinib, 65Cromolyn Sodium, 48, 106,112Cryselle-28, 98Cubicin, 20CURAD, 90CURITY, 90CUTIVATE, 41Cyclafem 1/35, 98Cyclafem 7/7/7, 98CYCLOCORT, 39Cyclophosphamide, 59Cycloserine, 22Cycloset, 91Cyclosporine, 59, 113Cyclosporine Modified, 59, 60Cyklokapron, 36CYKLOKAPRON, 37Cymbalta, 68Cyproheptadine HCl, 109Cystadane, 48Cystagon, 114Cysteamine Bitartrate, 114CYTOMEL, 87CYTOTEC, 51CYTOVENE, 12Dabigatran Etexilate Mesylate,37Dabrafenib Mesylate, 64Daliresp, 107Danazol, 88DANTRIUM, 85Dantrolene Sodium, 85Dapsone, 20Daptacel, 54Daptomycin, 20Daraprim, 20Darifenacin HydrobromideER, 114Darunavir Ethanolate, 14Dasatinib, 64DAYPRO, 79DDAVP, 88Deferasirox, 45Delavirdine Mesylate, 14Delzicol, 48DEMADEX, 35Demeclocycline HCl, 25DEMECLOCYN, 25Demser, 31Denosumab, 57, 97DEPACON, 83Depakene, 80DEPAKENE, 83DEPAKOTE, 80DEPAKOTE ER, 81DEPO-MEDROL, 86Depo-Provera, 102DERMATAP, 41DermOtic, 105DERMOTIC, 105Desipramine HCl, 68Desloratadine, 109121

Desmopressin Ace SprayRefrig, 88Desmopressin Acetate, 88DESOGEN, 98Desogest-Eth Estrad Triphasic,102Desogestrel-Ethinyl Estradiol,97, 98, 99, 101Desonide, 40DESOWEN, 40Desoximetasone, 40Desvenlafaxine Succinate ER,72Dexamethasone, 86Dexamethasone Intensol, 86Dexamethasone SodiumPhosphate, 86, 111DEXEDRINE, 68Dextroamphetamine SulfateER, 68Dextromethorphan-Quinidine,85Dextrose, 44Dextrose in Lactated Ringers,44Dextrose-NaCl, 45DIABETA, 92DIAMOX SEQUELS, 112Diazepam, 68, 80Diazoxide, 95Dibenzyline, 31Diclofenac Potassium, 78Diclofenac Sodium, 43, 78, 79,110Diclofenac Sodium ER, 78Dicloxacillin Sodium, 24Didanosine, 11, 16DIDRONEL, 45DIFFERIN, 43Diflorasone Diacetate, 40DIFLUCAN, 9Diflunisal, 78Digoxin, 27DILACOR XR, 31Dilantin, 80DILANTIN, 82Dilantin Infatabs, 80DILATRATE-SR, 29DILAUDID, 76, 77Diltiazem HCl, 31Diltiazem HCl Coated Beads,31Diltiazem HCl ER, 31Diltiazem HCl ER Beads, 31,35Diltiazem HCl ER CoatedBeads, 33Dilt-XR, 31DIOVAN HCT, 35Dipentum, 48Diphenhydramine HCl, 109Diphenoxylate-Atropine, 47Diphth-Acell Pertussis-Tetanus, 54, 55DIPROLENE, 40Disulfiram, 44, 45DITROPAN XL, 114Divalproex Sodium, 80, 81Divalproex Sodium ER, 81Dofetilide, 27Donepezil HCl, 84Dornase Alfa, 108Dorzolamide HCl, 113Dorzolamide HCl-TimololMal, 113DOVONEX, 39Doxazosin Mesylate, 31Doxepin HCl, 68Doxepin HCl (Antipruritic), 43Doxycycline Hyclate, 25Doxycycline Monohydrate, 25,26Dronabinol, 48Drospirenone-EthinylEstradiol, 98, 99DUETACT, 94Dulera, 107Duloxetine HCl, 68DURAGESIC, 76Duramorph, 76DURICEF, 17Dutasteride, 115DYAZIDE, 35DYNACIR, 32DYNAPEN, 24E.E.S., 19EASY COMFORT, 91EASY TOUCH, 90, 91Echothiophate Iodide, 112EC-NAPROSYN, 79Econazole Nitrate, 38Edurant, 11Efavirenz, 15Efavirenz-Emtricitab-Tenofovir, 11EFFEXOR XR, 73EFUDEX, 42Elaprase, 88ELDEPRYL, 75Electrolyte-M in Dextrose, 117Elelyso, 88Elidel, 42Eligard, 59ELIMITE, 42Elitek, 57ELIXOPHYLLIN, 108Elmiron, 114ELOCON, 41Eltrombopag Olamine, 37Elviteg-Cobicis-Emtricit-Tenof, 15Emcyt, 59Emend, 48EMLA, 38Emoquette, 98Emsam, 68Emtricitabine, 11, 12Emtricitabine-Tenofovir, 15Emtricitab-Rilpivir-Tenofovir,11Emtriva, 11, 12Enablex, 114Enalapril Maleate, 31Enalapril-Hydrochlorothiazide,32Enbrel, 96Endocet, 76Endodan, 76Enfuvirtide, 12Engerix-B, 55Enoxaparin Sodium, 36122

Enpresse-28, 98Entacapone, 75Entecavir, 11ENTOCORT EC, 47Enulose, 48Enzalutamide, 65Epinephrine, 109EpiPen 2-Pak, 109EpiPen Jr 2-Pak, 109Epitol, 81Epivir, 12EPIVIR, 13Epivir HBV, 12Eplerenone, 32Epoetin Alfa, 53Eprosartan Mesylate, 35Eprosartan Mesylate-HCTZ,35Epzicom, 12Eraxis, 9Ergomar, 84Ergotamine Tartrate, 84Ergotamine-Caffeine, 84Eribulin Mesylate, 60Erivedge, 60Erlotinib, 64Errin, 102Ertapenem Sodium, 20Ery, 43ERYCETTE, 43ERYTHROCIN, 19Erythrocin Stearate, 19Erythromycin, 43, 110Erythromycin Base, 19Erythromycin Ethylsuccinate,19Erythromycin Stearate, 19Escitalopram Oxalate, 68Esterified Estrogens, 103Estrace, 103ESTRACE, 103Estradiol, 103, 104Estradiol-Norethindrone Acet,102, 103Estramustine PhosphateSodium, 59Estrogens Conj Synthetic A,102Estrogens Conjugated, 103Estrogens, Conjugated, 103Estropipate, 103ESTROSTEP FE, 101Etanercept, 96Ethambutol HCl, 20Ethionamide, 22Ethosuximide, 81Ethotoin, 82Ethynodiol Diac-Eth Estradiol,99, 102ETHYOL, 57Etidronate Disodium, 45Etodolac, 78Etodolac ER, 78Etonogestrel-Ethinyl Estradiol,104Etravirine, 12Everolimus, 58, 66Evista, 97Exelderm, 38Exelon, 84EXELON, 85Exemestane, 58, 60Exenatide, 91Exjade, 45EXTINA, 10Ezetimibe, 28Ezetimibe-Simvastatin, 28Ezogabine, 82Fabrazyme, 89Famciclovir, 12Famotidine, 50, 51FAMVIR, 12Fanapt, 69Fanapt Titration Pack, 69Fareston, 60Faslodex, 60Fat Emulsion, 117FazaClo, 69Felbamate, 81Felbatol, 81FELBATOL, 81FELDENE, 79Felodipine ER, 32Femara, 60FEMARA, 61Fenofibrate, 27Fenofibrate Micronized, 27Fenoprofen Calcium, 78FENTANYL, 76FENTANYL Citrate, 76, 77FIFTY50, 90, 91Filgrastim, 53Finasteride, 115Fingolimod HCl, 85FIORICET WITH CODEINE,75FIORINAL WITH CODEINE#3, 75Firazyr, 107FLAGYL, 21Flavoxate HCl, 114Flecainide Acetate, 26FLOMAX, 115FLONASE, 107FLOXIN, 25Fluconazole, 9Fluconazole in Dextrose, 9Flucytosine, 9Fludrocortisone Acetate, 86FLUMADINE, 15Flunisolide, 107Fluocinolone Acetonide, 40,41, 105Fluocinonide, 41Fluocinonide-E, 41Fluorometholone, 111Fluorouracil, 42Fluoxetine HCl, 69Fluoxymesterone, 88Fluphenazine Decanoate, 69Fluphenazine HCl, 69Flurbiprofen, 78Flurbiprofen Sodium, 110Flutamide, 60Fluticasone Propionate, 41,107Fluticasone-Salmeterol, 106Fluvastatin Sodium, 28Fluvoxamine Maleate, 69Fluvoxamine Maleate ER, 69123

FML, 111FML Forte, 111Fomepizole, 55Fondaparinux Sodium, 36, 37Foradil Aerolizer, 107Formoterol Fumarate, 107FORTAMET, 94Forteo, 97Fortical, 89FOSAMAX, 44, 97Fosamprenavir Calcium, 13Foscarnet Sodium, 12FOSCAVIR, 12Fosinopril Sodium, 32Fosinopril Sodium-HCTZ, 32Fosphenytoin Sodium, 81Fulvestrant, 60Furosemide, 32Fuzeon, 12Gabapentin, 81GABITRIL, 83Galantamine Hydrobromide,84Galantamine HydrobromideER, 85Galsulfase, 89Gamastan S/D, 55Gammaplex, 55Gamunex-C, 55Ganciclovir Sodium, 12GARAMYCIN, 110Gardasil, 55Gastrocrom, 48GASTROCROM, 48, 112Gauze Pads & Dressings, 94Gavilyte-C, 48Gemfibrozil, 28GENERALAC, 47, 48Gengraf, 60Gentak, 110Gentamicin Sulfate, 20, 38,110Geodon, 69GEODON, 74Gianvi, 98Gildagia, 98Gilenya, 85Glatiramer Acetate, 84Gleevec, 60Glimepiride, 91, 92Glipizide, 92Glipizide ER, 92Glipizide-Metformin HCl, 92Glucagon (rDNA), 92Glucagon Emergency, 92GLUCOPHAGE, 94GLUCOPHAGE XR, 94GLUCOTROL, 92GLUCOTROL XL, 92GLUCOVANCE, 92, 93Glyburide, 92Glyburide Micronized, 92Glyburide-Metformin, 92, 93Glycopyrrolate, 47GLYNASE, 92Glyset, 93Granisetron HCl, 49GRANISOL, 49GRIFULVIN, 9Griseofulvin Microsize, 9Griseofulvin Ultramicrosize, 9GRIS-PEG, 9Guanfacine HCl, 32Guanfacine HCl ER, 70Haemophil B Poly Cnj-HepatitB, 54Haemophilus B Polysac ConjVac, 54, 56Halaven, 60HALDOL, 69, 70Halobetasol Propionate, 41Haloperidol, 69Haloperidol Decanoate, 70Haloperidol Lactate, 70Havrix, 55Heparin (Porcine) in D5W, 37Heparin (Porcine) in NaCl, 37Heparin Sodium (Porcine), 37Hepatitis A Vaccine, 55, 57Hepatitis A-Hep B RecombVac, 57Hepatitis B Vac Recombinant,55, 56Hepsera, 12Hexalen, 60HIPREX, 10HPV Bivalent (16 & 18)Vaccine, 54HPV Quadrivalent Vaccine, 55HUMALOG, 93HUMALOG Mix 50/50, 93HUMALOG Mix 75/25, 93Humatrope, 52Humira, 96Humira Pen-Crohns Starter, 96HUMULIN 70/30, 93HUMULIN N, 93HUMULIN R, 93HUMULIN R U-500(CONCENTRATED), 93Hydralazine HCl, 32HYDREA, 60Hydrochlorothiazide, 32Hydrocodone-Acetaminophen,76Hydrocodone-Ibuprofen, 76Hydrocortisone, 41, 49, 50, 86Hydrocortisone Valerate, 41Hydrocortisone-Acetic Acid,105Hydromorphone HCl, 76Hydromorphone HCl PF, 76Hydroxychloroquine Sulfate,20Hydroxyurea, 60HYTRIN, 35HYZAAR, 33Ibandronate Sodium, 97Ibuprofen, 78Icatibant Acetate, 107Iclusig, 60Idursulfase, 88Iloperidone, 69ILOTYCIN, 110Imatinib Mesylate, 60IMDUR, 29Imiglucerase, 88Imipenem-Cilastatin, 21Imipramine HCl, 70Imipramine Pamoate, 70Imiquimod, 42124

IMITREX, 84Immune Globulin (Human), 55IMODIUM, 47Imovax Rabies, 55IMURAN, 58Incivek, 12INCONTROL, 91Increlex, 45Indapamide, 32INDERAL, 34INDERAL LA, 34INDERIDE, 34Indinavir Sulfate, 11Infanrix, 55Infergen, 52Infliximab, 50Inlyta, 60INSPRA, 32Insulin Detemir, 94Insulin Glargine, 94Insulin Isophane & Regular, 93Insulin Isophane Human, 93Insulin Lispro (Human), 93Insulin Lispro Prot & Lispro,93Insulin Pen Needle, 91Insulin Regular Human, 93Insulin Regular Human(Conc), 93Insulin Syringe-Needle U-100,91Intelence, 12Interferon Alfa-2B, 52Interferon alfacon-1, 52Interferon Beta-1a, 52Interferon Beta-1b, 52Interferon Gamma-1B, 51Intralipid, 117INTRALIPID, 117Intron-A, 52Intuniv, 70INVANZ, 20Invega, 70Invega Sustenna, 70Invirase, 12, 13IOPIDINE, 113Ipol, 55Ipratropium Bromide, 105Ipratropium Bromide HFA,106Ipratropium-Albuterol, 106Irbesartan, 32Irbesartan-Hydrochlorothiazide, 32Isentress, 13Isocarboxazid, 71Isolyte-M in D5W, 117Isoniazid, 20ISORDIL, 29Isosorbide Dinitrate, 29Isosorbide Dinitrate ER, 29Isosorbide Mononitrate, 29Isosorbide Mononitrate ER, 29Isotretinoin, 43Isradipine, 32Itraconazole, 9Ivermectin, 22Ixiaro, 55Jakafi, 61Jantoven, 37Janumet, 94Januvia, 94Japanese Encephalitis VacInac, 55Jentadueto, 94Junel 1.5/30, 98Junel 1/20, 99Junel FE 1.5/30, 99Junel FE 1/20, 99Kadcyla, 61KADIAN, 77Kaletra, 13Kariva, 99Kayexalate, 45KCl in Dextrose-NaCl, 115KCl-Lactated Ringers-D5W,115KEFLEX, 18KEFZOL, 17Kelnor 1/35, 99KEPPRA, 81, 82KERLON, 30KERLONE, 111KETAB, 18Ketoconazole, 10, 38Ketoprofen, 78Ketoprofen ER, 78Ketorolac Tromethamine, 110Kling Flexible Gauze, 94KLONOPIN, 80Klor-Con, 115Klor-Con 10, 115Klor-Con M15, 115Klor-Con M20, 115Kombiglyze XR, 94Kuvan, 89Labetalol HCl, 32LAC-HYDRIN, 42Lacosamide, 83Lactated Ringers, 46, 115Lactulose, 49LAMICTAL, 81LAMISIL, 10Lamivudine, 12, 13Lamivudine-Zidovudine, 13Lamotrigine, 81Lamotrigine ER, 81Lanoxin, 27LANOXIN, 27Lanreotide Acetate, 63Lansoprazole, 51Lantus, 94Lapatinib Ditosylate, 65LARIAM, 21Laronidase, 87LASIX, 32Latanoprost, 113Latuda, 70Lazanda, 77Leena, 99Leflunomide, 96Lenalidomide, 63LESCOL, 28Lessina, 99Letairis, 107Letrozole, 60, 61Leucovorin Calcium, 57Leukeran, 61Leukine, 52Leuprolide Acetate, 59, 61125

Leuprolide Acetate (3 Month),59, 61Leuprolide Acetate (4 Month),59, 61Leuprolide Acetate (6 Month),59, 61Levalbuterol Tartrate, 108LEVAQUIN, 25, 110Levemir, 94Levetiracetam, 81, 82Levetiracetam ER, 82Levobunolol HCl, 111Levocarnitine, 45LevocetirizineDihydrochloride, 109Levofloxacin, 25, 110Levofloxacin in D5W, 25Levonest, 99Levonorgest-Eth Estrad 91-Day, 101Levonorgestrel-Ethinyl Estrad,98, 99, 101Levonorg-Eth EstradTriphasic, 98, 99, 102Levora 0.15/30 (28), 99Levorphanol Tartrate, 77Levothroid, 87Levothyroxine Sodium, 87Levoxyl, 87LEXAPRO, 68Lexiva, 13LIDEX, 41LIDEX-E, 41Lidocaine, 37, 38Lidocaine HCl, 37, 38Lidocaine HCl (PF), 38Lidocaine Viscous, 38Lidocaine-Prilocaine, 38Lidoderm, 38Linagliptin, 95Linagliptin-Metformin HCl, 94Lindane, 42Linezolid, 22, 23Liothyronine Sodium, 87LIPITOR, 27Liposyn III, 117Lisinopril, 32Lisinopril-Hydrochlorothiazide, 33LITETOUCH, 91Lithium Carbonate, 70Lithium Carbonate ER, 71Lithium Citrate, 71LOESTRIN, 98, 99, 100LOESTRIN FE, 99, 100LOFIBRA, 27LOMOTIL, 47Lomustine, 58Loperamide HCl, 47LOPID, 28Lopinavir-Ritonavir, 13LOPRESSOR, 33LOPRESSOR HCT, 33LOPROX, 38Lorazepam, 71Loryna, 99Losartan Potassium, 33Losartan Potassium-HCTZ, 33LOTENSIN, 30LOTREL, 30LOTRISONE, 38Lotronex, 49Lovastatin, 28Lovaza, 28LOVENOX, 36Low-Ogestrel, 99Loxapine Succinate, 71LOXITANE, 71Lubiprostone, 47Lumigan, 113Lupron Depot, 61Lupron Depot-Ped, 61Lurasidone HCl, 70Lutera, 99LUVOX CR, 69Lymphocyte,Anti-Thymo ImmGlob, 54Lyrica, 82Lysodren, 61Magnesium Sulfate, 115Malarone, 20Maprotiline HCl, 71Maraviroc, 15MARINOL, 48Marlissa, 100Marplan, 71Matulane, 62Matzim LA, 33MAVIK, 35MAXALT, 84MAXALT MLT, 84MAXIPIME, 17MAXZIDE, 35Measles, Mumps & RubellaVac, 56Measles-Mumps-Rubella-Varicell, 56Mecasermin, 45Meclizine HCl, 49Meclofenamate Sodium, 78MEDROL, 86MedroxyPROGESTERoneAcetate, 102, 103Mefenamic Acid, 78Mefloquine HCl, 21MEFOXIN, 17MEGACE, 62Megestrol Acetate, 62Mekinist, 62Meloxicam, 78, 79Memantine HCl, 85Menactra, 56Menest, 103Meningococcal A C Y&W-135Conj, 56Meningococcal A C Y&W-135Olig, 56Meningococcal Vac A,C,Y,W-135, 56Menomune, 56Menostar, 103Menveo, 56Mepron, 21Mercaptopurine, 62Meropenem, 21MERREM, 21Mesalamine, 47, 48Mesalamine ER, 49Mesalamine-Cleanser, 49Mesna, 57MESNEX, 57126

Mestinon, 85MESTINON, 85Metadate ER, 71Metaproterenol Sulfate, 107Metformin HCl, 94Metformin HCl ER, 94Metformin HCl ER (OSM), 94Methadone HCl, 77Methazolamide, 112Methenamine Hippurate, 10METHERGINE, 104Methimazole, 86Methitest, 89METHITEST, 89Methotrexate, 62Methotrexate Sodium, 62Methotrexate Sodium (PF), 62Methoxsalen, 42Methoxsalen Rapid, 42Methscopolamine Bromide, 47Methsuximide, 80Methyclothiazide, 33Methylergonovine Maleate,104Methylnaltrexone Bromide, 50Methylphenidate HCl ER, 71Methylprednisolone, 86Methylprednisolone (Pak), 86Methylprednisolone Acetate,86Methylprednisolone SodiumSucc, 86methyltestosterone, 89Metipranolol, 111Metoclopramide HCl, 49Metolazone, 33Metoprolol Succinate ER, 33Metoprolol Tartrate, 33Metoprolol-Hydrochlorothiazide, 33METROCREAM, 43METROGEL, 43METROLOTION, 44Metronidazole, 21, 43, 44, 104Metronidazole in NaCl, 21Metyrosine, 31MEVACOR, 28Mexiletine HCl, 26MEXITIL, 26Miacalcin, 89MIACALCIN, 89Micafungin Sodium, 10Miconazole 3, 104Microgestin 1.5/30, 100Microgestin 1/20, 100Microgestin FE 1.5/30, 100Microgestin FE 1/20, 100MICRO-K, 116MICRONOR, 103MIDAMOR, 29Midodrine HCl, 45Migergot, 84Miglitol, 93Miglustat, 90Milnacipran HCl, 96MINIPRESS, 34MINITRAN, 29MINOCIN, 26Minocycline HCl, 26Minocycline HCl ER, 26Minoxidil, 33MIRAPEX, 75MIRCETTE, 99Mirtazapine, 71Misoprostol, 51Mitotane, 61Mitoxantrone HCl, 62M-M-R II, 56MOBIC, 78, 79Modafinil, 71MODURETIC, 29Moexipril HCl, 33Moexipril-Hydrochlorothiazide, 33Mometasone Furoate, 41Mometasone Furo-FormoterolFum, 107MonoNessa, 100MONOPRIL, 32MONOPRIL HCT, 32Montelukast Sodium, 107Morphine Sulfate, 77Morphine Sulfate(Concentrate), 77Morphine Sulfate ER, 77Moxifloxacin HCl, 24, 111Mupirocin, 38Mupirocin Calcium, 38MYAMBUTOL, 20Mycamine, 10MYCELEX, 9, 38Mycobutin, 21MYCOLOG, 39Mycophenolate Mofetil, 59, 62MYCOSTATIN, 10, 39MYSOLINE, 82Nabumetone, 79Nadolol, 33Nadolol-Bendroflumethiazide,33Nafarelin Acetate, 90Nafcillin Sodium, 24Naglazyme, 89NALLPEN, 24Naloxone HCl, 79Naltrexone HCl, 79Namenda, 85Namenda Titration Pak, 85Naphazoline HCl, 114NAPROSYN, 79Naproxen, 79Naproxen DR, 79Naproxen Sodium, 79Naratriptan HCl, 84Nardil, 71NARDIL, 72NASACORT AQ, 105NASALCROM, 106Natacyn, 110Natalizumab, 85Natamycin, 110Nebupent, 21Necon 0.5/35 (28), 100Necon 1/35 (28), 100Necon 10/11 (28), 100Necon 7/7/7, 100Nefazodone HCl, 71Nelfinavir Mesylate, 16Neomycin Sulfate, 21Neomycin-Bacitracin Zn-Polymyx, 110127

Neomycin-Polymyxin B GU,47Neomycin-Polymyxin-Dexameth, 112Neomycin-Polymyxin-Gramicidin, 110Neomycin-Polymyxin-HC,105, 112NEORAL, 59NEOSPORIN, 110Nepafenac, 110NEPTAZANE, 112Neulasta, 52Neumega, 53Neupogen, 53NEURONTIN, 81Nevanac, 110Nevirapine, 13, 16Nevirapine ER, 16Nexavar, 62Niacin ER(Antihyperlipidemic), 28Niaspan, 28Nicardipine HCl, 33Nicotine, 46Nicotrol, 46Nicotrol NS, 46Nifediac CC, 33Nifedical XL, 34Nifedipine ER, 29, 33Nifedipine ER Osmotic, 34Nilandron, 62Nilotinib, 64Nilutamide, 62Nimodipine, 34NIMOTOP, 34NIRAVAM, 67Nisoldipine ER, 34Nitazoxanide, 19Nitisinone, 45Nitro-Bid, 29Nitroglycerin, 29Nitrostat, 29Nizatidine, 51NIZORAL, 38Nora-BE, 103NORDETTE, 99, 100, 101Norditropin FlexPro, 53Norditropin NordiFlex Pen, 53Norelgestromin-Eth Estradiol,104Norethin Ace-Eth Estrad-FE,99, 100Norethindrone, 102, 103Norethindrone Acetate, 103Norethindrone Acet-EthinylEst, 98, 99, 100Norethindrone-Eth Estradiol,98, 100, 101Norethindron-Ethinyl Estrad-Fe, 101Norethin-Eth Estrad Biphasic,100Norethin-Eth Estrad Triphasic,98, 99, 100, 101Norgestimate-Eth Estradiol,100, 101Norgestim-Eth EstradTriphasic, 101, 102Norgestrel-Ethinyl Estradiol,98, 99, 101NORINYL, 98, 100NORMODYNE, 32NORPRAMIN, 68NOR-Q-D, 102Nortrel 0.5/35 (28), 100Nortrel 1/35 (21), 100Nortrel 1/35 (28), 101Nortrel 7/7/7, 101Nortriptyline HCl, 71NORVASC, 30Norvir, 13NOVOFINE, 91NOVOTWIST, 91Noxafil, 10Nuedexta, 85Nulojix, 62NuvaRing, 104Nyamyc, 38Nystatin, 10, 38, 39Nystatin-Triamcinolone, 39Nystop, 39Octreotide Acetate, 62, 63OCUFEN, 110OCUFLOX, 105, 110Ofloxacin, 25, 105, 110Ogestrel, 101Olanzapine, 71, 72Olanzapine-FLUoxetine HCl,72Olmesartan Medoxomil, 30Olmesartan Medoxomil-HCTZ, 30Olopatadine HCl, 113Olsalazine Sodium, 48Omacetaxine Mepesuccinate,64Omalizumab, 108Omega-3-acid Ethyl Esters, 28Omeprazole, 51OMNICEF, 17OMNIPRED, 111OnabotulinumtoxinA, 54Ondansetron, 49Ondansetron HCl, 49Onfi, 82Onglyza, 94OPANA, 77Oprelvekin, 53OPTIPRANOLOL, 111OPTIVAR, 105Orap, 72Orencia, 96Orfadin, 45Orsythia, 101Ortho Evra, 104ORTHO TRI-CYCLEN, 101,102ORTHO-CEPT, 97, 101ORTHO-CYCLEN, 100, 101ORTHO-NOVUM, 100, 101Oseltamivir Phosphate, 15OsmoPrep, 49OVCON, 98Oxacillin Sodium, 24Oxacillin Sodium in Dextrose,24OXANDRIN, 89Oxandrolone, 89Oxaprozin, 79Oxcarbazepine, 82, 83128

Oxsoralen Ultra, 42Oxybutynin Chloride, 114Oxybutynin Chloride ER, 114Oxycodone HCl, 77Oxycodone-Acetaminophen,76, 77Oxycodone-Aspirin, 76, 77Oxycodone-Ibuprofen, 77OXYCONTIN, 77Oxymorphone HCl, 77Pacerone, 26Palgic, 109Paliperidone ER, 70Paliperidone Palmitate, 70PAMELOR, 71PAMIDE, 47Pamidronate Disodium, 89Pancrelipase (Lip-Prot-Amyl),48Panretin, 42Pantoprazole Sodium, 51PARCOPA ODT, 74Parenteral Electrolytes, 116PARLODEL, 74Paromomycin Sulfate, 21Paroxetine HCl, 72Paroxetine HCl ER, 72Paser, 21Pataday, 113Paxil, 72PAXIL, 72Pazopanib HCl, 65Pedvax HIB, 56PEG 3350-KCl-NaBcb-NaCl-NaSulf, 48Pegademase Bovine, 44Peganone, 82Pegasys, 53Pegasys ProClick, 53Pegfilgrastim, 52Peginterferon alfa-2a, 53Peginterferon alfa-2b, 54Pegvisomant, 89Pemetrexed Disodium, 58Penicillin G Benzathine &Proc, 24Penicillin G Potassium, 24Penicillin G Procaine, 24Penicillin G Sodium, 24Penicillin V Potassium, 24PENLAC, 38Pentam, 21Pentamidine Isethionate, 21Pentasa, 49Pentosan Polysulfate Sodium,114Pentoxifylline ER, 37PEN-V, 24PEPCID, 50, 51PERCOCET, 76, 77PERCODAN, 76, 77Perindopril Erbumine, 34Periogard, 105Permethrin, 42Perphenazine, 72Perphenazine-Amitriptyline,72PFIZERPEN, 24Phenadoz, 109Phenelzine Sulfate, 71, 72Phenobarbital, 82Phenoxybenzamine HCl, 31Phenytoin, 80, 82Phenytoin Sodium, 82Phenytoin Sodium Extended,80, 82Phospholine Iodide, 112Pilocarpine HCl, 45Pimecrolimus, 42Pimozide, 72Pindolol, 34Pioglitazone HCl, 94Pioglitazone HCl-Glimepiride,94Pioglitazone HCl-MetforminHCl, 95Piperacillin Sod-TazobactamSo, 24Piroxicam, 79PLAN B, 99PLAQUENIL, 20PLAVIX, 36PLENDIL, 32PLETAL, 36Podofilox, 42Poliovirus Vaccine Inactivated,55Polyethylene Glycol 3350, 49Polymyxin B Sulfate, 21Polymyxin B-Trimethoprim,110POLYTRIM, 110Pomalidomide, 63Pomalyst, 63Ponatinib HCl, 60PONSTEL, 78Portia-28, 101Posaconazole, 10Potassium Chloride, 115, 116Potassium Chloride Crys ER,115, 116Potassium Chloride ER, 115,116Potassium Chloride inDextrose, 116Potassium Chloride in NaCl,116Potiga, 82Pradaxa, 37Pramipexole Dihydrochloride,75Pramlintide Acetate, 95Prandin, 95PRAVACHOL, 28Pravastatin Sodium, 28Prazosin HCl, 34PRECOSE, 90PRED FORTE, 86, 111Pred Mild, 111Prednicarbate, 41Prednisolone Acetate, 111Prednisolone SodiumPhosphate, 86, 87, 111Prednisone, 86, 87Prednisone Intensol, 87Pregabalin, 82PRELONE, 86Premarin, 103Premphase, 103Prempro, 104Prenatal/Iron, 117129

PREVACID, 51Prevalite, 28Previfem, 101Prezista, 14Priftin, 21PRILOSEC, 51Primaquine Phosphate, 21PRIMAXIN, 20Primaxin IV, 21Primidone, 82PRINZIDE, 33Pristiq, 72ProAir HFA, 107Probenecid, 97Procainamide HCl, 26Procarbazine HCl, 62PROCARDIA XL, 34Prochlorperazine, 47Prochlorperazine Edisylate, 50Prochlorperazine Maleate, 50Procrit, 53Proctozone-HC, 50PRODIGY, 91Progesterone Micronized, 104Proglycem, 95Prograf, 63PROGRAF, 64Proleukin, 54Prolia, 97PROLOPRIM, 10Promacta, 37Promethazine HCl, 109PROMETRIUM, 104Propafenone HCl, 26Propafenone HCl ER, 26Proparacaine HCl, 113Propranolol HCl, 34Propranolol HCl ER, 34Propranolol-HCTZ, 34Propylthiouracil, 86ProQuad, 56PROSCAR, 115PROTONIX, 51PROTONIX IV, 51Protopic, 42Protriptyline HCl, 72Proventil HFA, 107PROVERA, 103PROVIGIL, 71PROZAC, 69PROZAC WEEKLY, 69PSORCON, 40Pulmozyme, 108Pyrazinamide, 22Pyridostigmine Bromide, 85Pyridostigmine Bromide ER,85Pyrimethamine, 20QC, 90Quasense, 101QUESTRAN, 27Quetiapine Fumarate, 72Quinapril HCl, 34Quinapril-Hydrochlorothiazide, 34Quinidine Gluconate ER, 26Quinidine Sulfate, 26Quinidine Sulfate ER, 27Quinupristin-Dalfopristin, 22Qvar, 108RabAvert, 56Rabies Vaccine, PCEC, 56Rabies Virus Vaccine, HDC,55Raloxifene HCl, 97Raltegravir Potassium, 13Ramelteon, 73Ramipril, 34Ranexa, 29Ranitidine HCl, 51Ranolazine ER, 29Rapamune, 63Rasagiline Mesylate, 74Rasburicase, 57RAZADYNE, 84, 85REALITY, 90REBETOL, 14Reclast, 45RECLAST, 46Reclipsen, 101Recombivax HB, 56REGLAN, 49Regorafenib, 64Relistor, 50REMERON, 71REMERON ODT, 71Remicade, 50Remodulin, 34Renvela, 45Repaglinide, 95REQUIP, 75Rescriptor, 14Restasis, 113RETIN-A, 44, 65Retrovir, 14RETROVIR, 17REVATIO, 108REVIA, 79Revlimid, 63Reyataz, 14RibaPak, 14Ribasphere, 14RIBATAB, 14Ribavirin, 14Ridaura, 96Rifabutin, 21RIFADIN, 22Rifampin, 22Rifapentine, 21Rilonacept, 51Rilpivirine HCl, 11Rilutek, 46Riluzole, 46Rimantadine HCl, 15Rimexolone, 112Ringers, 116Ringers Irrigation, 47RISPERDAL, 73RISPERDAL Consta, 72Risperidone, 73Risperidone Microspheres, 72RITALIN-SR, 71Ritonavir, 13Rituxan, 63Rituximab, 63Rivaroxaban, 37Rivastigmine, 84Rivastigmine Tartrate, 85Rizatriptan Benzoate, 84ROBINUL, 47ROBINUL FORTE, 47130

ROCEPHIN, 18Roflumilast, 107Ropinirole HCl, 75Ropinirole HCl ER, 75Rosuvastatin Calcium, 27RotaTeq, 56Rotavirus Vac LivePentavalent, 56ROWASA, 49Rozerem, 73Rufinamide, 79, 80Ruxolitinib Phosphate, 61RYTHMOL, 26Sabril, 82, 83Salmeterol Xinafoate, 108SANCTURA XR, 114SANDIMMUNE, 59SANDOSTATIN, 62Sandostatin Lar Depot, 63Santyl, 42Saphris, 73Sapropterin Dihydrochloride,89Saquinavir Mesylate, 12, 13Sargramostim, 52Savella, 96Savella Titration Pack, 96Saxagliptin HCl, 94Saxagliptin-Metformin ER, 94SECTRAL, 29Selegiline, 68Selegiline HCl, 75Selenium Sulfide, 39Selzentry, 15Sensipar, 89Serevent Diskus, 108Seromycin, 22SEROQUEL, 72Sertraline HCl, 73Sevelamer Carbonate, 45Sildenafil Citrate, 108SILVADENE, 44Silver Sulfadiazine, 44Simvastatin, 28SINEMET, 74SINEMET CR, 74SINGULAIR, 107Sirolimus, 63Sitagliptin Phosphate, 94Sitagliptin-Metformin HCl, 94Sod Phos Mono-Sod PhosDibasic, 49Sodium Chloride, 46, 116Sodium Lactate, 116Sodium Oxybate, 74Sodium Phenylbutyrate, 44, 46Sodium Polystyrene Sulfonate,45, 46Solaraze, 43Soltamox, 63Somatropin, 52, 53Somatuline Depot, 63Somavert, 89SONATA, 74Sorafenib Tosylate, 62Soriatane, 39Sorine, 27Sotalol HCl, 27Sotalol HCl (AF), 27SPECTAZOLE, 38Spiriva HandiHaler, 108Spironolactone, 34Spironolactone-HCTZ, 34SPORANOX, 9Sprintec 28, 101Sprycel, 64Sronyx, 101SSD, 44Stagesic, 78Stavudine, 15, 16Stelara, 39Sterile Water for Irrigation, 46Stivarga, 64Strattera, 73Streptomycin Sulfate, 22Stribild, 15Stromectol, 22Succimer, 44Sucralfate, 50, 51SULAR, 34Sulconazole Nitrate, 38Sulfacetamide Sodium, 38, 114Sulfacetamide-Prednisolone,112Sulfadiazine, 25Sulfamethoxazole-TMP DS,25Sulfamethoxazole-Trimethoprim, 25Sulfasalazine, 50Sulfazine EC, 50Sulindac, 79Sumatriptan Succinate, 84Sunitinib Malate, 64Suprax, 18SURE COMFORT, 90SURE-COMFORT, 91SURMONTIL, 73Sustiva, 15Sutent, 64Sylatron, 54SYMBYAX, 72SymlinPen 120, 95SymlinPen 60, 95SYMMETREL, 11SYNARAL, 40Synarel, 90Synercid, 22Synribo, 64Synthroid, 87SYNTHROID, 87Syprine, 46Tabloid, 64Tacrolimus, 42, 63, 64Tadalafil (PAH), 106Tafinlar, 64Taliglucerase Alfa, 88TAMBOCOR, 26Tamiflu, 15Tamoxifen Citrate, 63, 64Tamsulosin HCl, 115TAPAZOLE, 86Tarceva, 64Targretin, 64Tasigna, 64Tasmar, 75Tazarotene, 44Tazorac, 44Taztia XT, 35TEGRETOL, 83TEGRETOL, 80, 81131

TEGRETOL XR, 80TEGRETOL-XR, 83Telaprevir, 12Telbivudine, 16TEMOVATE, 40Tenofovir DisoproxilFumarate, 16TENORETIC, 30TENORMIN, 30TERAZOL 3, 104Terazosin HCl, 35Terbinafine HCl, 10Terbutaline Sulfate, 108Terconazole, 104Teriparatide (Recombinant),97TERSI FOAM, 39Testosterone, 88Tetanus Toxoid Adsorbed, 56Tetanus-Diphth-AcellPertussis, 54Tetanus-Diphtheria ToxoidsTd, 56Tetrabenazine, 85Tetrahydrozoline HCl, 105Teveten, 35Teveten HCT, 35Thalidomide, 65Thalomid, 65Theophylline ER, 108Thioguanine, 64Thioridazine HCl, 73Thiothixene, 73Tiagabine HCl, 83TIAZAC, 35Tigecycline, 22Tikosyn, 27Timolol Maleate, 35, 111TIMOPTIC, 111Tiotropium BromideMonohydrate, 108Tipranavir, 11Tizanidine HCl, 85Tobi, 22TOBRADEX, 112Tobramycin, 22Tobramycin Sulfate, 22, 111Tobramycin-Dexamethasone,112TOBREX, 111Tocilizumab, 95TOFRANIL, 70Tolazamide, 95Tolbutamide, 95Tolcapone, 75Tolmetin Sodium, 79TOPAMAX, 83TOPICORT, 40Topiramate, 83TOPROL XL, 33Toremifene Citrate, 60Torsemide, 35TPN Electrolytes, 116Tracleer, 108Tradjenta, 95Tramadol HCl, 79Tramadol-Acetaminophen, 79Trametinib DimethylSulfoxide, 62TRANDATE, 32Trandolapril, 35tranexamic acid, 37Tranexamic Acid, 36, 37TRANXENE T-TAB, 68Tranylcypromine Sulfate, 73Travoprost, 113Trazodone HCl, 73Trecator, 22Trelstar Depot Mixject, 65Trelstar LA Mixject, 65TRENTAL, 37Treprostinil Sodium, 34Tretinoin, 44, 65Triamcinolone Acetonide, 41,105Triamterene-HCTZ, 35TRICOR, 27Triderm, 41Trientine HCl, 46Trifluoperazine HCl, 73Trifluridine, 111Trihexyphenidyl HCl, 75Tri-Legest Fe, 101Trileptal, 83TRILEPTAL, 82Trimethoprim, 10Trimipramine Maleate, 73TriNessa (28), 101TRI-NORINYL, 98, 99Tri-Previfem, 102Triptorelin Pamoate, 65Tri-Sprintec, 102Trivora (28), 102Trizivir, 15Trospium Chloride, 114TRUSOPT, 113Truvada, 15Twinrix, 57Tygacil, 22Tykerb, 65TYLENOL-CODEINE, 75Typhim VI, 57Typhoid VI PolysaccharideVacc, 57Tysabri, 85Tyzeka, 16Tyzine, 105ULTRACET, 79ULTRAM ER, 79ULTRAVATE, 41UNASYN, 23UNIFINE, 91UNIRETIC, 33Unithroid, 87UNIVASC, 33URECHOLINE, 114URSO FORTE, 50Ursodiol, 50Ustekinumab, 39Vagifem, 104Valacyclovir HCl, 16Valcyte, 16Valganciclovir HCl, 16VALIUM, 68, 80Valproate Sodium, 80, 83Valproic Acid, 80, 83Valsartan-Hydrochlorothiazide, 35VALTREX, 16VANCOCIN, 26Vancomycin HCl, 26132

Vandazole, 104Vandetanib, 58VANTIN, 17Vaqta, 57Varenicline Tartrate, 46Varicella Virus Vaccine Live,57Varivax, 57VASERETIC, 32VASOTEC, 31Vectical, 39VECTICAL, 88Velcade, 65Velivet, 102Vemurafenib, 66Venlafaxine HCl, 73Venlafaxine HCl ER, 73, 74VERAMYST, 107Verapamil HCl, 35Verapamil HCl ER, 35VERELAN, 35Veripred 20, 87Vexol, 112Vfend, 10VFEND, 10VICOPROFEN, 76Victrelis, 16Vidaza, 65Videx, 16VIDEX EC, 11Vigabatrin, 82, 83Vigamox, 111Viibryd, 74Vilazodone HCl, 74Vimpat, 83Viracept, 16Viramune, 16VIRAMUNE, 13Viramune XR, 16Viread, 16Viroptic, 111VIROPTIC, 111VISKEN, 34Vismodegib, 60VIVACTIL, 72Vivelle-Dot, 104Voltaren, 79VOLTAREN, 110VOLTAREN-XR, 78Voriconazole, 10Vorinostat, 66VOSOL HC, 105VOSPIRE ER, 106Votrient, 65Vytorin, 28Warfarin Sodium, 36, 37WEBCOL, 90Welchol, 28WELLBUTRIN, 67WELLBUTRIN SR, 67WELLBUTRIN XL, 67WESTCORT, 41XALATAN, 113Xalkori, 65XANAX, 67XANAX XR, 67Xarelto, 37Xenazine, 85Xgeva, 57XODOL, 76Xolair, 108Xopenex HFA, 108Xtandi, 65XYLOCAINE, 37Xyrem, 74XYZAL, 109YASMIN, 98YAZ, 98, 99Yellow Fever Vaccine, 57YF-VAX, 57Zaleplon, 74Zaltrap, 65ZANAFLEX, 85ZANTAC, 51ZARAZOLYN, 33ZARONTIN, 81Zavesca, 90ZEBETA, 30Zelboraf, 66Zerit, 16ZERIT, 15ZESTRIL, 32Zetia, 28ZIAC, 30Ziagen, 17ZIAGEN, 10Zidovudine, 14, 17Zileuton, 108Zileuton ER, 109ZINACEF, 18Ziprasidone HCl, 74Ziprasidone Mesylate, 69ZITHROMAX, 18Ziv-Aflibercept, 65ZOCOR, 28ZOFRAN, 49Zoledronic Acid, 45, 46, 90Zolinza, 66ZOLOFT, 73Zolpidem Tartrate, 74Zolpidem Tartrate ER, 74Zometa, 90ZOMETA, 90Zonalon, 43ZONEGRAN, 84Zonisamide, 84Zortress, 66Zostavax, 57Zoster Vaccine Live, 57ZOSYN, 24Zovia 1/35E (28), 102Zovia 1/50E (28), 102ZOVIRAX, 10, 11ZYBAN, 46Zyflo, 108Zyflo CR, 109ZYLOPRIM, 97ZYPREXA, 71, 72Zytiga, 66Zyvox, 22, 23133

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.com.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 de 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) or 1-866-333-5470 (toll free) foradditional information. Monday through Sunday, from 8:00 a.m. to 8:00 p.m. (TTY users should call 1-866-333-5469). Member Services also offers free language interpreter services available for non-Spanishspeaking members.H4003 – MMM Healthcare,Inc.Y0049_2014 1085 0001 2File & Use 08202013134