VNSNY CHOICE FIDA Complete

Transcripción

2015 Lista de Medicamentos Cubiertos (Formulario)
To enroll in VNSNY CHOICE FIDA Complete
and learn more about other options for your health care,
call the Enrollment Broker (New York Medicaid Choice) toll-free at:
1-855-600-FIDA
TTY for the hearing impaired: 1-888-329-1541
8:30 am – 8:00 pm, Monday – Friday
10 am – 6 pm, Saturday
or visit nymedicaidchoice.com
2015
LISTA DE MEDICAMENTOS
CUBIERTOS (FORMULARIO)
( Plan Medicare-Medicaid )
Questions about the VNSNY CHOICE FIDA Complete Medicare-Medicaid health plan?
Call CHOICE toll-free:
1-866-783-1444
TTY: 711
8 am – 8 pm, 7 days a week
ID del Formulario : 15436.001, Version: 12
Vigencia: 01 de Julio 2015
llame gratis a CHOICE a:
1-866-783-1444
TTY: 711
de 8 a.m. - 8 p.m., los 7 días de la semana
1250 Broadway, New York, NY 10001
vnsnychoice.org
vnsnychoice.org
H8490_2015 Formulary_16702_Sp Accepted 12152014
260 Madison Avenue, 8 FL, NY, NY 10016
Approvals:
Account:
Creative:
Production:
MCA:
Client:
Regulatory:
Name & Date:
Name & Date:
•
917-214-6648
Name & Date:
•
917-873-5496
Mandatories:
Website:
Phone:
Hours:
©
SM
Footnote:
CMS Code:
Client: VNSNY—Choice
Job Number: VC-454-14_FIDA
Participant Handbook Cover—English
4-color process plus and over all satin AQ
Bleed: 17.75” wide x 11.25” tall
Trim: 17.5” wide x 11” tall
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Paper: TBD
Score: Die score is preferred over roto score to
prevent cracking and ink imperfections
Printer Note: Adjust spine
width to meet the thickness
of the text paper wieight and
number of pages to be inserted
(estimated at 100 pages)
VNSNY CHOICE FIDA Complete | 2015 Lista de medicamentos cubiertos
(Formulario)
Esta es una lista de los medicamentos que los Participantes pueden obtener en
VNSNY CHOICE FIDA Complete.
 VNSNY CHOICE FIDA Complete es un plan de atención médica
administrada que contrata con Medicare y el Departamento de Salud del
Estado de New York (Medicaid) para proveer beneficios de los dos
programas a los participantes mediante la demostración de Ventaja doble
completamente integrada (Fully Integrated Duals Advantage, FIDA). La
inscripción en VNSNY CHOICE FIDA Complete depende de la renovación
del contrato.
 Los beneficios, la Lista de medicamentos cubiertos y las redes de farmacias
y proveedores pueden cambiar periódicamente en todo el año y el 1 de
enero de cada año.
 Siempre puede revisar la Lista de medicamentos cubiertos actualizada de
VNSNY CHOICE FIDA Complete, en línea, en vnsnychoice.org o al llamar a
Servicios para participantes de VNSNY CHOICE FIDA Complete al 1-866783-1444.
 Puede haber ciertas limitaciones y restricciones. Para obtener más
información, llame a Servicios para participantes de VNSNY CHOICE FIDA
Complete o lea el Manual para participantes de VNSNY CHOICE FIDA
Complete.
 No hay copagos para ningún medicamento cubierto.
 Puede obtener esta información gratis en otros formatos, como Braille o
texto con letras grandes. Llame al 1-866-783-1444. La llamada es gratis.
 Puede obtener esta información en otros idiomas sin costo. Llame al
1-866-783-1444 y el TTY es 711, de 8 a. m. a 8 p. m., los 7 días de la
semana. La llamada es gratis.
您可以免費取得此資訊的其他語言版本。請在早上 8 時至晚上 8 時致電
1-866-783-1444 (TTY 是 711) 此專線一星期七天均提供服務。此為免付費電話。
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Si tiene preguntas, llame a VNSNY CHOICE FIDA Complete al 1-866-783-1444,
los 7 días a la semana de 8 a. m. a 8 p. m. La llamada es gratis. Para obtener
más información, visite vnsnychoice.org
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다른 언어로 된 정보를 무료로 얻을 수 있습니다. 주 7일 오전 8시에서 오후
8시 사이에 1-866-783-1444번(TTY 사용자는 711번)으로 문의해 주십시오.
통화는 무료입니다.
Вы можете получить эту информацию бесплатно и на других языках.
Звоните по телефону 1-866-783-1444 (телетайп: 711) ежедневно с 8:00
до 20:00. Звонок бесплатный.
È possibile ottenere gratuitamente queste informazioni in altre lingue.
Chiamare il numero 1-866-783-1444 (il numero TTY è 711) dalle 8:00 alle
20:00, 7 giorni alla settimana. La chiamata è gratuita.
Ou kapab jwenn enfòmasyon sa a pou gratis nan lòt lang. Rele
1-866-783-1444 ak (TTY se 711) ant 8 di maten jiska 8 di swa, 7 jou pa
semèn. Apèl la gratis.
 El Estado de Nueva York ha creado un programa de defensa para los
participantes, denominado Red Independiente de Defensa del Consumidor
(Consumer Advocacy Network, ICAN) para proporcionar a los participantes
ayuda gratuita y confidencial en todos los servicios que ofrece VNSNY
CHOICE FIDA Complete. Puede comunicarse con ICAN llamando
gratuitamente al 1-844-614-8800 o en su página web en en icannys.org.
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Preguntas frecuentes (FAQ)
Encuentre aquí las respuestas para preguntas que tenga acerca de esta Lista de
medicamentos cubiertos. Puede leer todas las Preguntas frecuentes para
aprender más o para buscar una pregunta y respuesta.
1. ¿Qué medicamentos con receta médica están incluidos en la Lista de
medicamentos con receta médica cubiertos? (Llamamos a la Lista de
medicamentos cubiertos “Lista de medicamentos” en forma
abreviada).
Los medicamentos en la Lista de medicamentos cubiertos que empieza en la
página 13 son los medicamentos cubiertos por VNSNY CHOICE FIDA
Complete. Estos medicamentos están disponibles en farmacias dentro de
nuestra red. Una farmacia está en nuestra red si tenemos un acuerdo con ellos
para trabajar con nosotros y proporcionarle servicios a usted. Nos referimos a
estas farmacias como “farmacias de la red”.
 VNSNY CHOICE FIDA Complete cubrirá todos los medicamentos en la Lista
de medicamentos si:
 su médico u otra persona de la red que emita una receta médica dice que
los necesita para mejorar o mantenerse saludable,
 el medicamento es médicamente necesario para su condición, y
 usted surte la receta médica en una farmacia de la red de VNSNY
CHOICE FIDA Complete.
 VNSNY CHOICE FIDA Complete podría tener pasos adicionales para tener
acceso a ciertos medicamentos (consulte la pregunta N.° 5 a continuación).
En algunos casos, es posible que tenga que hacer algo antes de poder
obtener un medicamento, como probar otros medicamentos primero.
También puede ver una lista actualizada de los medicamentos que cubrimos,
en nuestro sitio web en vnsnychoice.org o llamar a Servicios para participantes
al 1-866-783-1444.
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2. ¿Cambia alguna vez la Lista de medicamentos?
Sí. VNSNY CHOICE FIDA Complete podría agregar o retirar medicamentos de
la Lista de medicamentos durante el año. En general, la Lista de medicamentos
solo cambiará si:
 aparece un nuevo medicamento que funciona tan bien como un
medicamento que está en la Lista de medicamentos ahora, o
 nos enteramos que un medicamento no es seguro.
También podemos cambiar nuestras reglas acerca de los medicamentos. Por
ejemplo, podríamos:
 Decidir requerir o no requerir una aprobación previa para un
medicamento. (Aprobación previa es un permiso de VNSNY CHOICE
FIDA Complete o de su Equipo interdisciplinario (IDT) antes de que
pueda obtener un medicamento).
 Aprobar o cambiar la cantidad de un medicamento que puede obtener
(conocido como "límites de cantidad").
 Agregar o cambiar las restricciones de la terapia de pasos para un
medicamento. (Terapia de pasos significa que debe probar un
medicamento antes de que cubramos otro medicamento).
(Para obtener más información acerca de las reglas para estos
medicamentos, consulte la página 6).
Le indicaremos cuando un medicamento que está tomando sea eliminado de la
Lista de medicamentos. También le informaremos cuando cambiemos nuestras
reglas para cubrir un medicamento. Las preguntas 3, 4 y 7 a continuación
tienen más información sobre lo que sucede cuando la Lista de medicamentos
cambia.
 Siempre puede revisar la Lista de medicamentos actualizada de VNSNY
CHOICE FIDA Complete en línea en vnsnychoice.org
También puede llamar a Servicios para participantes para revisar la Lista de
medicamentos al número 1-866-783-1444.
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3. ¿Qué sucede cuando aparece un medicamento más barato que
funciona tan bien como un medicamento que está en la Lista de
medicamentos ahora?
Si un medicamento más barato está disponible y funciona tan bien como un
medicamento en la Lista de medicamentos ahora:
 Su farmacéutico podría darle un medicamento más barato la próxima vez
que surta su receta médica. Si usted y su proveedor deciden que el
medicamento más barato no es correcto para usted, su proveedor puede
indicar al farmacéutico que continúe dándole el medicamento que toma
ahora.
 VNSNY CHOICE FIDA Complete podría decidir sacar el medicamento
más costoso de la Lista de medicamentos. Si está tomando un
medicamento que retiramos de la Lista de medicamentos porque
aparece un medicamento más barato que funciona tan bien como el otro
medicamento, le informaremos al menos 60 días antes de retirarlo de la
Lista de medicamentos o cuando usted pida que le surtan el
medicamento. Luego puede obtener un suministro del medicamento para
60 días antes de que se haga el cambio a la Lista de medicamentos. Si
hay un cambio en la cobertura de un medicamento que está tomando, el
plan le enviará un aviso, normalmente con 60 días de anticipación, para
informarle.
4. ¿Qué sucede cuando descubrimos que un medicamento no es
seguro?
Si la Administración de Medicamentos y Alimentos (Food and Drug
Administration, FDA) indica que un medicamento que está tomando no es
seguro, lo sacaremos de la Lista de medicamentos de inmediato. También le
enviaremos una carta y le llamaremos para indicarle que el medicamento que
no es seguro se retiró de la Lista de medicamentos. Su proveedor también
estará enterado de este cambio y puede trabajar con usted para encontrar
otros medicamentos para su condición.
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5. ¿Existe alguna restricción o límite para la cobertura de
medicamentos? O bien, ¿existe alguna acción que se exija tomar para
obtener ciertos medicamentos?
Sí, algunos medicamentos tienen reglas de cobertura o límites sobre la
cantidad que puede obtener. En algunos casos, es posible que tenga que
hacer algo antes de poder obtener un medicamento. Por ejemplo:
Aprobación previa (o autorización previa): Para algunos medicamentos,
usted o su médico u otra persona que emita la receta médica deben
obtener aprobación de VNSNY CHOICE FIDA Complete o de su Equipo
interdisciplinario (IDT) antes de que pueda surtir su receta médica. Si no
obtiene la aprobación, es posible que VNSNY CHOICE FIDA Complete no
cubra el medicamento.
Límites de cantidad: Algunas veces VNSNY CHOICE FIDA Complete limita
la cantidad de un medicamento que puede obtener.
Terapia de pasos: Algunas veces VNSNY CHOICE FIDA Complete
requiere que siga una terapia de pasos. Esto significa que tendrá que
probar los medicamentos en cierto orden para su condición médica. Es
posible que tenga que probar un medicamento antes de que cubramos
otro medicamento. Si su médico considera que el primer medicamento no
funciona para usted, entonces cubriremos el segundo.
Puede averiguar si su medicamento tiene requisitos o límites adicionales al
observar las tablas que empiezan en la página 13. También puede obtener
más información al visitar nuestro sitio web en vnsnychoice.org. Hemos
publicado documentos en línea que explican las restricciones de autorización
previa y de terapia de pasos. También puede pedirnos que le enviemos una
copia.
Puede pedir una "excepción" de estos límites. Consulte la pregunta 11 para
obtener más información sobre las excepciones.
 Si usted se encuentra en un centro de enfermería especializada o en otro
centro de atención de largo plazo y necesita un medicamento que no está
en la Lista de medicamentos o si no puede obtener fácilmente el
medicamento que necesita, podemos ayudarle. Cubriremos un suministro
de emergencia para 31 días del medicamento que necesita (a menos que
tenga una receta médica para menos días), ya sea o no que usted sea un
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nuevo participante de VNSNY CHOICE FIDA Complete. Esto le dará tiempo
para hablar con su médico u otra persona que emita las recetas médicas. Él
o ella pueden ayudarle a decidir si hay un medicamento similar en la Lista
de medicamentos que puede tomar en su lugar o si debe solicitar una
excepción. Consulte la pregunta 11 para obtener más información acerca de
las excepciones.
6.
¿Cómo sabrá si el medicamento que desea tiene limitaciones o si hay
acciones que debe tomar para obtener el medicamento?
La Lista de medicamentos cubiertos en la página 13 tiene una columna
rotulada “Requisitos/Limites”.
7. ¿Qué sucede si cambiamos nuestras reglas sobre la manera en que
cubrimos algunos medicamentos? Por ejemplo, si agregamos
autorización previa (aprobación), límites de cantidad o restricciones
de terapia de pasos para un medicamento.
Le informaremos si agregamos autorización previa, límites de cantidad o
restricciones de terapia de pasos para un medicamento. Le informaremos al
menos 60 días antes de que se agregue la restricción o la próxima vez que
pida que se le surta su receta médica. Luego puede obtener un suministro del
medicamento para 60 días antes de que se haga el cambio a la Lista de
medicamentos. Esto le da tiempo para hablar con su médico u otra persona
que emita las recetas médicas acerca de lo que tiene que hacer después.
8. ¿Cómo puede saber si un medicamento está en la Lista de
medicamentos?
Hay dos formas de encontrar un medicamento:
 Puede buscar alfabéticamente (si sabe cómo deletrear el
medicamento) o
 Puede buscar por condición médica.
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más información, visite vnsnychoice.org 7
Para buscar alfabéticamente, vaya a la sección Listado alfabético en la página
I-1. Luego busque el nombre de su medicamento en la lista.
Para buscar por condición médica, busque la sección rotulada “Lista de
medicamentos por condición médica” en la página 13. Luego busque su
condición médica. Por ejemplo, si tiene una condición del corazón, debe buscar
en esa categoría. Allí es donde encontrará los medicamentos que tratan las
condiciones del corazón.
9. ¿Qué sucede si el medicamento que desea no está en la Lista de
medicamentos?
Si no ve su medicamento en la Lista de medicamentos, llame a Servicios para
participantes al 1-866-783-1444 y pregunte sobre este. Si se entera que
VNSNY CHOICE FIDA Complete no cubrirá el medicamento, puede hacer una
de estas cosas:
 Pedir a Servicios para participantes una lista de medicamentos similares al
que desea tomar. Luego muestre la lista a su médico o a otra persona que
emita las recetas médicas. Él o ella pueden recetarle un medicamento de
la Lista de medicamentos que sea similar al que usted desea tomar. O
bien
 Puede solicitar al plan o a su Equipo interdisciplinario (IDT) que haga una
excepción y cubra el medicamento. Consulte la pregunta 11 para obtener
más información acerca de las excepciones.
10. ¿Qué sucede si usted es un nuevo participante de VNSNY CHOICE
FIDA Complete y no puede encontrar su medicamento en la Lista de
medicamentos o tiene un problema para obtener su medicamento?
Podemos ayudarle. Debemos cubrir hasta 90 días de suministro temporal de su
medicamento, según sea necesario, durante los primeros 90 días que es un
participante de VNSNY CHOICE FIDA Complete. Esto le dará tiempo para
hablar con su médico u otra persona que emita las recetas médicas. Él o ella
pueden ayudarle a decidir si hay un medicamento similar en la Lista de
medicamentos que pueda tomar en su lugar o si debe solicitar una excepción.
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más información, visite vnsnychoice.org 8
Cubriremos hasta 90 días de suministro temporal de su medicamento si:
 usted está tomando un medicamento que no está en nuestra Lista de
medicamentos, o bien
 las reglas del plan de salud no le permiten obtener la cantidad que le
ordenó la persona que emite la receta médica, o
 el medicamento requiere aprobación previa de VNSNY CHOICE FIDA
Complete o de su Equipo interdisciplinario (IDT), o
 usted está tomando un medicamento que es parte de una restricción de
terapia de pasos.
Si vive en un centro de enfermería especializada u otro centro de atención de
largo plazo, puede surtir su receta médica hasta para 98 días. Puede surtir el
medicamento varias veces durante 98 días. Esto le da a la persona que emite
las recetas médicas, tiempo para cambiar sus medicamentos a unos que estén
en la Lista de medicamentos o pedir una excepción.
Si experimenta un cambio en su nivel de atención, como que lo trasladen del
hospital a su hogar, y necesita un medicamento que no está en nuestro
formulario o si su capacidad para obtener sus medicamentos es limitada, pero
ya pasaron los primeros 90 días de su afiliación en nuestro plan, cubriremos un
suministro temporal único de hasta 30 días (o 31 días si es residente en un
centro de atención de largo plazo) cuando vaya a una farmacia de la red.
Durante este período, debe utilizar el proceso de excepciones del plan si desea
tener una cobertura continua del medicamento después de terminarse el
suministro temporal. Para solicitar un suministro temporal de un medicamento,
llame a Servicios para Participantes.
11. ¿Puede solicitar una excepción para cubrir su medicamento?
Sí. Puede pedir a VNSNY CHOICE FIDA Complete o a su Equipo
interdisciplinario (IDT) que haga una excepción para cubrir un medicamento
que no está en la Lista de medicamentos.
También puede pedir a VNSNY CHOICE FIDA Complete o a su IDT que
cambien las reglas para su medicamento.
 Por ejemplo, VNSNY CHOICE FIDA Complete podría limitar la cantidad de
un medicamento que cubriremos. Si su medicamento tiene
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un límite, puede pedirnos a nosotros o a su IDT que cambiemos el límite y
cubramos más.
 Otros ejemplos: Puede pedirnos a nosotros o a su IDT que retiremos las
restricciones de terapia de pasos o los requisitos de aprobación previa.
12. ¿Cuánto tiempo tarda obtener una excepción?
Primero, VNSNY CHOICE FIDA Complete o su Equipo interdisciplinario (IDT)
deben recibir una declaración de la persona que emite las recetas médicas
apoyando su solicitud de una excepción. Después de que recibamos la
declaración, usted recibirá una decisión sobre su solicitud de excepción en un
plazo de 72 horas.
Si usted o la persona que emite las recetas médicas consideran que su salud
puede verse afectada si tiene que esperar 72 horas para la decisión, puede
pedir una excepción expedita. Esto es una decisión más rápida. Si la persona
que emite las recetas médicas apoya su solicitud, usted recibirá una decisión
en un plazo de 24 horas de haber recibido la declaración de apoyo de la
persona que emite las recetas médicas.
13. ¿Cómo puede pedir una excepción?
Para solicitar una excepción, llame a su Administrador de atención. Su
Administrador de atención trabajará con usted y con su proveedor para pedir
una excepción.
14. ¿Qué son medicamentos genéricos?
Los medicamentos genéricos están hechos de los mismos ingredientes que los
medicamentos de marca. Estos usualmente cuestan menos que el
medicamento de marca y usualmente no tienen nombres reconocidos. Los
medicamentos genéricos están aprobados por la Administración de
Medicamentos y Alimentos (FDA).
VNSNY CHOICE FIDA Complete cubre medicamentos de marca y
medicamentos genéricos.
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15. ¿Qué son medicamentos OTC?
OTC quiere decir “de venta libre”. VNSNY CHOICE FIDA Complete cubre
algunos medicamentos OTC cuando su proveedor se los indica con una receta
médica.
Puede leer la Lista de medicamentos de VNSNY CHOICE FIDA Complete para
saber qué medicamentos OTC están cubiertos.
16. ¿VNSNY CHOICE FIDA Complete cubre productos OTC que no son
medicamentos?
VNSNY CHOICE FIDA Complete cubre algunos productos OTC que no son
medicamentos cuando se colocan por escrito en recetas de su proveedor.
Ejemplos de productos OTC que no son medicamentos son los hisopos con
alcohol y vendas de gasa.
Puede leer la Lista de medicamentos de VNSNY CHOICE FIDA Complete para
saber qué productos OTC que no son medicamentos están cubiertos.
17. ¿Cuál es su copago?
No se le cobrará un copago por los medicamentos que están en la Lista de
medicamentos.
18. ¿Qué son niveles de medicamentos?
Los niveles son grupos de medicamentos. Cada medicamento de la Lista de
medicamentos del plan está en uno de los 4 niveles. No hay ningún costo para
usted por los medicamentos de cualquiera de los niveles.
Los medicamentos del Nivel 1 son los medicamentos genéricos.
Los medicamentos del Nivel 2 son los medicamentos de marca.
Los medicamentos del Nivel 3 son los medicamentos con receta
médica que no son de Medicare.
Los medicamentos del Nivel 4 son los medicamentos de OTC que no
son de Medicare.
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Lista de medicamentos cubiertos
La Lista de medicamentos cubiertos que comienza en la página 13 le da
información acerca de los medicamentos cubiertos por VNSNY CHOICE FIDA
Complete. Si tiene problemas para encontrar su medicamento en la lista, vaya
al Índice que empieza en la página I-1.
La primera columna del cuadro incluye el nombre del medicamento. Los
medicamentos de marca aparecen en letra mayúscula (p.ej., COSMEGEN) y
los medicamentos genéricos aparecen con itálicas y letra minúscula (p.ej.,
cartia).
La información en la columna de las acciones necesarias, restricciones o
límites de uso le indica si VNSNY CHOICE FIDA Complete tiene alguna regla
para cubrir su medicamento.
Nota: el “*” junto a un medicamento significa que el medicamento no es un
“medicamento de la Parte D”. Estos medicamentos tienen reglas diferentes para
las apelaciones. Una apelación es una manera formal para solicitar una revisión
y para cambiar una decisión de cobertura si considera que fue un error. Por
ejemplo, VNSNY CHOICE FIDA Complete o su Equipo interdisciplinario (IDT)
pueden decidir que un medicamento que desea no esté cubierto o ya no esté
cubierto por Medicare o Medicaid. Si usted o su médico u otra persona que emita
las recetas médicas no están de acuerdo con la decisión, pueden presentar una
apelación. Para pedir instrucciones sobre cómo presentar una apelación, llame a
Servicios para participantes al 1-866-783-1444 o al al Red Independiente de
Defensa del Consumidor (Consumer Advocacy Network, ICAN) al 1-844-6148800. También puede leer el Manual para participantes para saber cómo
presentar una apelación de una decisión.
Aquí están los significados de los códigos que se usan en la columna
“Requisitos/Límites:
PA = Previa autorización PA NSO = Autorización previa, Solo nuevos inicios
PA BvD = Autorización previa, Cubierto bajo la Parte B o D de Medicare
PA-HRM = Autorización previa, Medicamentos de alto riesgo
PA for ESRD Only = Autorización previa, Solo para enfermedad renal en fase
terminal QL = Limites de cantidad ST = Terapia por pasos
NM = No disponible el pedido por correo GC = Cobertura durante el período
sin cobertura LA = Acceso limitado
* = Medicamentos que no son parte D o artículos OTC cubiertos por Medicaid.
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Nivel
Lo que le
costará a
usted el
(Acetaminophen)
(Acetaminophen)
(Tylenol 8 Hour)
4
4
4
$0
$0
$0
(Acetaminophen)
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Tencon)
1
$0
(Esgic)
1
$0
(Fiorinal)
1
$0
(Butorphanol
Tartrate)
1
$0
2
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
Nombre del medicamento
Medidas necesarias,
restricciones o
límites de uso
Analgesics
Analgesics, Miscellaneous
acephen *
acetaminophen * oral
acetaminophen * oral
acetaminophen * rectal suppository
120 mg, 650 mg
acetaminophen-codeine oral
solution
acetaminophen-codeine oral tablet
300-15 mg, 300-30 mg
acetaminophen-codeine oral tablet
300-60 mg
buprenorphine hcl injection
(Acetaminophen
with Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Buprenorphine
HCl)
butalb-acetaminophen-caffeine oral
(Esgic)
capsule 50-325-40 mg
(Fioricet with
butalbital-acetaminop-caf-cod
Codeine)
butalbital-acetaminophen
butalbital-acetaminophen-caff oral
tablet 50-325-40 mg
butalbital-aspirin-caffeine oral
capsule
butorphanol tartrate nasal
BUTRANS
children's mapap *
children's non-aspirin * oral
children's non-aspirin * oral
children's pain & fever relief * oral
children's pain reliever * oral
children's pain reliever * oral
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
(Infants' Tylenol)
(Acetaminophen)
(Acetaminophen)
QL (2700 per 30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
QL (5 per 28 days)
QL (4 per 28 days)
Puede encontrar información acerca del significado de los símbolos y abreviaturas de esta tabla en las
páginas 11-12 de este documento..
los 7 días a la semana de 8 a. m. a 8 p. m. La llamada es gratis. Para obtener más
información, visite vnsnychoice.org
Vigente: 1 de Julio de 2015
Formula rio de VNSNY CHOICE FIDA Complete
13
ID del formulario: 15436.001, Versión: 12
Nivel
Lo que le
costará a
usted el
4
$0
1
$0
1
$0
2
$0
(Actiq)
1
$0
(Duragesic)
1
$0
(Duragesic)
1
$0
(Acetaminophen)
4
$0
(Hycet)
1
$0
children's silapap *
codeine sulfate oral tablet
codeine-butalbital-asa-caffein oral
capsule 30-50-325-40 mg
DURAMORPH (PF)
fentanyl citrate
fentanyl transdermal patch 72 hour
100 mcg/hr
fentanyl transdermal patch 72 hour
12 mcg/hr, 25 mcg/hr, 37.5
mcg/hour, 50 mcg/hr, 62.5
mcg/hour, 75 mcg/hr, 87.5
mcg/hour
feverall * rectal suppository 120
mg, 325 mg, 650 mg
hydrocodone-acetaminophen oral
solution
tablet 10-300 mg, 5-300 mg, 7.5300 mg
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
hydrocodone-ibuprofen
hydromorphone (pf) injection
solution 10 mg/ml
hydromorphone (pf) injection
solution 4 mg/ml
hydromorphone injection solution
hydromorphone injection syringe 2
mg/ml
hydromorphone oral liquid
(Tylenol Sore
Throat)
(Codeine Sulfate)
(Fiorinal with
Codeine #3)
(Norco)
1
$0
(Norco)
1
$0
(Ibudone)
(Hydromorphone
HCl/PF)
1
$0
1
$0
(Dilaudid)
1
$0
1
$0
1
$0
1
$0
(Hydromorphone
HCl)
(Hydromorphone
HCl)
(Dilaudid)
Medidas necesarias,
restricciones o
límites de uso
PA-HRM; QL (180 per
30 days)
PA; QL (120 per 30
days)
PA; QL (20 per 30
days)
PA; QL (10 per 30
days)
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
14
Nivel
Lo que le
costará a
usted el
(Dilaudid)
1
$0
(Dilaudid)
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
1
4
4
4
4
4
$0
$0
$0
$0
$0
$0
2
$0
1
$0
4
4
$0
$0
hydromorphone oral tablet 2 mg, 4
mg
hydromorphone oral tablet 8 mg
infant acetaminophen *
infantaire *
infant's pain reliever *
jr. acetaminophen *
junior mapap *
LAZANDA
levorphanol tartrate
mapap (acetaminophen) * oral
liquid 500 mg/15 ml
mapap arthritis pain *
mapap extra strength *
methadone hcl oral tablet,soluble
40 mg
methadone injection
methadone oral
methadone oral
morphine concentrate oral solution
morphine concentrate oral syringe
morphine injection solution 10
mg/ml, 15 mg/ml, 8 mg/ml
morphine injection syringe
morphine intramuscular
morphine intravenous
morphine intravenous solution 25
mg/ml, 50 mg/ml
(Levorphanol
Tartrate)
(Acetaminophen)
(Acetaminophen)
(Tylenol Sore
Throat)
(Infants' Tylenol)
(Tylenol)
(Acetaminophen)
(Tylenol 8 Hour)
(Tylenol)
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
(Diskets)
1
$0
(Methadone HCl)
(Methadone HCl)
(Diskets)
(Msir)
(Morphine Sulfate)
1
1
1
1
1
$0
$0
$0
$0
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
1
1
1
$0
$0
$0
(Morphine Sulfate)
1
$0
Medidas necesarias,
restricciones o
límites de uso
PA; QL (30 per 30
days)
QL (90 per 30 days)
15
Nivel
Lo que le
costará a
usted el
(Morphine Sulfate)
(Msir)
(Msir)
1
1
1
1
$0
$0
$0
$0
(MS Contin)
1
$0
(MS Contin)
1
$0
(Morphine Sulfate)
(Acetaminophen)
(Tylenol Sore
Throat)
(Acetaminophen)
(Acetaminophen)
1
4
$0
$0
4
$0
4
4
2
2
$0
$0
$0
$0
(Oxycodone
HCl/Acetaminophe
n)
1
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Percodan)
(Oxycodone HCl)
(Oxycodone HCl)
(Percolone)
1
1
1
1
$0
$0
$0
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Xolox)
1
$0
morphine intravenous
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml
MORPHINE ORAL TABLET
morphine oral tablet extended
release 100 mg, 30 mg, 60 mg
morphine oral tablet extended
release 15 mg, 200 mg
morphine rectal
non-aspirin extra strength * oral
non-aspirin extra strength * oral
non-aspirin jr strength *
nortemp * oral
NUCYNTA
NUCYNTA ER
oxycodone hcl-acetaminophen oral
solution 5-325 mg/5 ml
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
tablet 5-500 mg
oxycodone hcl-aspirin
oxycodone oral concentrate
oxycodone oral solution
oxycodone oral tablet
oxycodone-acetaminophen oral
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
tablet 10-650 mg
tablet 7.5-500 mg
Medidas necesarias,
restricciones o
límites de uso
QL (60 per 30 days)
16
Nivel
Lo que le
costará a
usted el
1
$0
2
$0
2
$0
(Opana)
1
$0
(Opana ER)
1
$0
(Opana ER)
1
$0
4
$0
4
$0
(Tylenol 8 Hour)
4
$0
(Acetaminophen)
(Acetaminophen)
(Tylenol)
(Tylenol)
(Acetaminophen)
(Tylenol Sore
q-pap * oral liquid
Throat)
q-pap * oral tablet
(Tylenol)
silapap *
(Acetaminophen)
tactinal *
(Tylenol)
tactinal extra strength *
(Tylenol)
tramadol oral tablet
(Ultram)
tramadol-acetaminophen
(Ultracet)
xylon 10
(Ibudone)
Nonsteroidal Anti-Inflammatory Agents
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
4
4
4
1
1
1
$0
$0
$0
$0
$0
$0
$0
oxycodone-aspirin
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG,
15 MG, 20 MG, 30 MG, 40 MG, 60
MG
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
oxymorphone oral tablet
oxymorphone oral tablet extended
release 12 hr 10 mg, 15 mg, 20 mg,
5 mg, 7.5 mg
oxymorphone oral tablet extended
release 12 hr 30 mg, 40 mg
pain relief adult *
pain relief * oral capsule
pain relief * oral tablet extended
release
pain reliever jr strength *
pain reliever * oral
pharbetol *
q-pap extra strength *
q-pap * oral drops
(Percodan)
Medidas necesarias,
restricciones o
límites de uso
QL (60 per 30 days)
(Tylenol Sore
Throat)
(Acetaminophen)
QL (60 per 30 days)
17
advil * oral tablet
advil * oral tablet,chewable
aspirin * oral tablet
aspirin * oral tablet,chewable
(Motrin Ib)
(Ibuprofen)
(Ecotrin)
(Bayer Chewable
Aspirin)
aspirin * oral tablet,delayed release
(Ecotrin)
(dr/ec) 325 mg, 500 mg, 81 mg
aspirin * rectal
(Aspirin)
(Aspirin/Calcium
aspirin, buffered *
Carbonate/Mag)
aspir-low *
(Ecotrin)
(Aspirin/Calcium
bufferin * oral tablet 325 mg
Carbonate/Mag)
CALDOLOR INTRAVENOUS
RECON SOLN
celecoxib
(Celebrex)
(Children'S
children's advil *
Motrin)
(Choline Sal/Mag
choline,magnesium salicylate
Salicylate)
COMFORT PAC-IBUPROFEN
COMFORT PAC-MELOXICAM
COMFORT PAC-NAPROXEN
diclofenac potassium
(Cataflam)
diclofenac sodium oral tablet
(Voltaren-XR)
extended release 24 hr
diclofenac sodium oral
(Diclofenac
tablet,delayed release (dr/ec)
Sodium)
diclofenac sodium topical gel
(Solaraze)
diclofenac-misoprostol
(Arthrotec 50)
diflunisal
(Diflunisal)
e.c. prin *
(Ecotrin)
etodolac
(Etodolac)
(Fenoprofen
fenoprofen oral tablet
Calcium)
Nivel
Lo que le
costará a
usted el
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
1
$0
4
$0
1
$0
1
1
1
1
$0
$0
$0
$0
1
$0
1
$0
1
1
1
4
1
$0
$0
$0
$0
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
QL (60 per 30 days)
18
Nivel
Lo que le
costará a
usted el
2
1
$0
$0
4
$0
4
4
$0
$0
(Ibuprofen)
1
$0
(Motrin Ib)
4
$0
(Ibuprofen)
1
$0
indomethacin oral capsule 25 mg
(Indomethacin)
1
$0
indomethacin oral capsule 50 mg
(Indomethacin)
1
$0
(Indomethacin)
1
$0
(Indocin I.V.)
(Infants' Motrin)
(Ketoprofen)
1
4
3
1
$0
$0
$0
$0
(Ketoprofen)
1
$0
(Toradol)
1
$0
(Toradol)
1
$0
1
$0
1
$0
1
$0
FLECTOR
flurbiprofen
ibuprofen * 100 mg/5 ml susp
children's (otc)
ibuprofen jr strength *
ibuprofen * oral
ibuprofen oral suspension 100 mg/5
ml
ibuprofen * oral tablet 100 mg, 200
mg
ibuprofen oral tablet 400 mg, 600
mg, 800 mg
indomethacin oral capsule,
extended release
indomethacin sodium
infant's ibuprofen *
INFANT'S MOTRIN *
ketoprofen oral capsule
ketoprofen oral capsule,ext rel.
pellets 24 hr 200 mg
ketorolac injection cartridge 15
mg/ml
ketorolac injection cartridge 30
mg/ml
ketorolac injection solution 15
mg/ml
ketorolac injection solution 30
mg/ml (1 ml)
ketorolac intramuscular solution
(Ansaid)
(Children'S
Motrin)
(Ibuprofen)
(Advil)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
Medidas necesarias,
restricciones o
límites de uso
PA
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (60 per
30 days)
PA-HRM
QL (40 per 30 days)
QL (20 per 30 days)
QL (40 per 30 days)
QL (20 per 30 days)
QL (20 per 30 days)
19
Nivel
Lo que le
costará a
usted el
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
(Ec-Naprosyn)
1
$0
(Anaprox)
1
$0
(Feldene)
(Salsalate)
(Bayer Chewable
Aspirin)
(Ecotrin)
(Sulindac)
(Tolmetin Sodium)
(Aspirin/Calcium
Carbonate/Mag)
1
1
$0
$0
4
$0
4
1
1
$0
$0
$0
4
$0
(Advil)
2
4
$0
$0
glydo
(Lidocaine HCl)
1
$0
lidocaine (pf) injection solution
(Xylocaine-MPF)
1
$0
lidocaine hcl injection solution
(Xylocaine)
1
$0
lidocaine hcl laryngotracheal
lidocaine hcl mucous membrane gel
lidocaine hcl mucous membrane
jelly in applicator
lidocaine hcl mucous membrane
solution
(Xylocaine)
(Lidocaine HCl)
1
1
$0
$0
(Lidocaine HCl)
1
$0
(Xylocaine)
1
$0
ketorolac oral
mefenamic acid
meloxicam
nabumetone
naproxen oral suspension
naproxen oral tablet
naproxen oral tablet,delayed
release (dr/ec)
naproxen sodium oral tablet 275
mg, 550 mg
piroxicam
salsalate
st joseph aspirin *
st. joseph aspirin *
sulindac oral
tolmetin
tri-buffered aspirin *
VOLTAREN TOPICAL
wal-profen * oral
(Ketorolac
Tromethamine)
(Ponstel)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
Medidas necesarias,
restricciones o
límites de uso
QL (20 per 30 days)
Anesthetics
Local Anesthetics
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
20
Nivel
Lo que le
costará a
usted el
lidocaine hcl urethral
lidocaine topical adhesive
patch,medicated
(Lidocaine HCl)
1
$0
(Lidoderm)
1
$0
lidocaine topical ointment
(Lidocaine)
1
$0
lidocaine-prilocaine topical
(EMLA)
1
$0
lidocaine-prilocaine topical kit
(Lidocaine/Prilocai
ne)
1
$0
2
$0
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate
(Campral)
1
$0
buprenorphine hcl sublingual
1
$0
1
$0
1
2
$0
$0
2
$0
2
$0
2
$0
1
1
1
1
$0
$0
$0
$0
LIDODERM
Medidas necesarias,
restricciones o
límites de uso
PA
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD
PA
Anti-Addiction/Substance Abuse Treatment Agents
buprenorphine-naloxone
bupropion hcl sr 150 mg tablet f/c
CHANTIX
CHANTIX CONTINUING
MONTH BOX
CHANTIX CONTINUING
MONTH PAK
CHANTIX STARTING MONTH
BOX
disulfiram
naloxone
naltrexone hcl
naltrexone
NICODERM CQ *
TRANSDERMAL PATCH 24
HOUR 14 MG/24 HR, 21 MG/24
HR
(Subutex)
(Buprenorphine
HCl/Naloxone
HCl)
(Zyban)
(Antabuse)
(Naloxone HCl)
(Revia)
(Revia)
PA; QL (90 per 30
days)
PA; QL (90 per 30
days)
QL (56 per 28 days)
QL (56 per 28 days)
QL (53 per 28 days)
4
$0
21
Nivel
Lo que le
costará a
usted el
4
$0
(Nicorette)
(Nicorette)
(Nicorette)
4
4
4
$0
$0
$0
(Nicoderm Cq)
4
$0
(Nicoderm Cq)
4
$0
2
$0
2
$0
2
$0
(Xanax)
1
$0
(Xanax XR)
1
$0
(Xanax XR)
1
$0
(Alprazolam)
1
$0
(Chlordiazepoxide
HCl)
1
$0
(Klonopin)
1
$0
(Klonopin)
1
$0
(Clonazepam)
1
$0
(Clonazepam)
1
$0
NICODERM CQ *
TRANSDERMAL PATCH 24
HOUR 7 MG/24 HR
nicorelief * buccal gum
nicorette * buccal gum 2 mg
nicotine (polacrilex) *
nicotine * transdermal patch 24
hour 14 mg/24 hr, 7 mg/24 hr
nicotine * transdermal patch 24
hour 21 mg/24 hr, 22 mg/24 hr
NICOTROL
ZUBSOLV SUBLINGUAL
TABLET 1.4-0.36 MG, 5.7-1.4 MG
ZUBSOLV SUBLINGUAL
TABLET 8.6-2.1 MG
Medidas necesarias,
restricciones o
límites de uso
PA; QL (90 per 30
days)
PA; QL (60 per 30
days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet
alprazolam oral tablet extended
release 24 hr 0.5 mg
alprazolam oral tablet extended
release 24 hr 1 mg, 2 mg, 3 mg
alprazolam oral
tablet,disintegrating
chlordiazepoxide hcl
clonazepam oral tablet 0.5 mg, 1
mg
clonazepam oral tablet 2 mg
clonazepam oral
tablet,disintegrating 0.125 mg, 0.25
mg, 0.5 mg, 1 mg
clonazepam oral
tablet,disintegrating 2 mg
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
22
Nivel
Lo que le
costará a
usted el
(Tranxene T-Tab)
1
$0
(Tranxene T-Tab)
1
$0
2
$0
1
1
1
1
1
$0
$0
$0
$0
$0
clorazepate dipotassium oral tablet
15 mg
clorazepate dipotassium oral tablet
3.75 mg, 7.5 mg
DIASTAT ACUDIAL RECTAL
KIT 12.5-15-17.5-20 MG
diazepam injection
diazepam intensol
diazepam oral solution
diazepam oral tablet
diazepam rectal
(Diazepam)
(Diazepam)
(Diazepam)
(Valium)
(Diastat Acudial)
estazolam oral tablet 1 mg
(Estazolam)
1
$0
estazolam oral tablet 2 mg
(Estazolam)
1
$0
Medidas necesarias,
restricciones o
límites de uso
QL (60 per 30 days)
QL (10 per 28 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (60
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
23
Nivel
Lo que le
costará a
usted el
flurazepam oral capsule 15 mg
(Flurazepam HCl)
1
$0
flurazepam oral capsule 30 mg
(Flurazepam HCl)
1
$0
lorazepam injection solution
lorazepam injection syringe
lorazepam oral tablet
(Ativan)
(Ativan)
(Ativan)
(Midazolam
HCl/PF)
(Midazolam
HCl/PF)
(Midazolam HCl)
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
ONFI ORAL SUSPENSION
2
$0
ONFI ORAL TABLET 10 MG, 20
MG
2
$0
midazolam (pf) injection
midazolam (pf) injection syringe 2
mg/2 ml (1 mg/ml)
midazolam oral syrup 2 mg/ml
Medidas necesarias,
restricciones o
límites de uso
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
QL (90 per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
QL (10 per 30 days)
PA NSO; QL (480 per
30 days)
PA NSO; QL (60 per
30 days)
24
Nivel
Lo que le
costará a
usted el
temazepam oral capsule 15 mg,
22.5 mg, 30 mg
(Restoril)
1
$0
temazepam oral capsule 7.5 mg
(Restoril)
1
$0
triazolam oral tablet 0.125 mg
(Halcion)
1
$0
Medidas necesarias,
restricciones o
límites de uso
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
hypnotic drug); QL
(120 per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
hypnotic drug); QL
(120 per 30 days)
25
triazolam oral tablet 0.25 mg
(Halcion)
Lo que le
costará a
usted el
Medidas necesarias,
restricciones o
límites de uso
1
$0
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
2
$0
PA BvD
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Nivel
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl (iso-osm)
intravenous piggyback
gentamicin injection solution
gentamicin sulfate (ped) (pf)
gentamicin sulfate (pf) intravenous
solution
neomycin
streptomycin intramuscular
(Gentamicin In
Nacl, Iso-Osm)
(Garamycin)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin
Sulfate)
TOBI PODHALER INHALATION
2
$0
tobramycin in 0.225 % nacl
(Tobi)
1
$0
PA BvD
(Tobramycin/Sodiu
tobramycin in 0.9 % nacl
1
$0
m Chloride)
tobramycin sulfate injection
(Nebcin)
1
$0
solution
Antibacterials, Miscellaneous
bacitracin intramuscular
(Bacitracin)
1
$0
(Chloramphenicol
chloramphenicol sod succinate
1
$0
Sod Succ)
clindamycin hcl
(Cleocin HCl)
1
$0
(Cleocin Phosphate
clindamycin in 5 % dextrose
1
$0
In D5w)
26
clindamycin palmitate hcl
clindamycin phosphate injection
clindamycin phosphate intravenous
solution
colistin (colistimethate na)
CUBICIN
linezolid
methenamine hippurate
methenamine mandelate oral tablet
1 gram
(Cleocin Palmitate)
(Cleocin
Phosphate)
(Cleocin
Phosphate)
(Coly-Mycin M
Parenteral)
(Zyvox)
(Hiprex)
(Methenamine
Mandelate)
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
$0
1
$0
2
1
1
$0
$0
$0
1
$0
nitrofurantoin macrocrystal oral
capsule
(Macrodantin)
1
$0
nitrofurantoin monohyd/m-cryst
(Macrobid)
1
$0
2
1
$0
$0
1
$0
(Vancomycin HCl)
1
$0
(Vancomycin
HCl/D5W)
1
$0
SYNERCID
trimethoprim
vancomycin in d5w intravenous
piggyback
vancomycin intravenous recon soln
1,000 mg, 10 gram, 750 mg
vancomycin intravenous recon soln
500 mg
(Trimethoprim)
(Vancomycin
HCl/D5W)
Medidas necesarias,
restricciones o
límites de uso
PA-HRM; (High Risk
with over 90 days
cumulative use of
nitrofurantoin drugs);
PA-HRM; (High Risk
with over 90 days
cumulative use of
nitrofurantoin drugs);
27
Nivel
Lo que le
costará a
usted el
1
$0
2
$0
2
$0
2
$0
(Cefaclor)
1
$0
(Cefaclor)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
(Cefazolin Sodium)
1
$0
1
$0
1
$0
(Cefazolin Sodium)
1
$0
(Cefazolin Sodium)
(Cefdinir)
(Spectracef)
(Maxipime)
1
1
1
1
2
$0
$0
$0
$0
$0
2
$0
1
1
$0
$0
vancomycin oral capsule
XIFAXAN ORAL TABLET 200
MG
XIFAXAN ORAL TABLET 550
MG
ZYVOX ORAL
Cephalosporins
cefaclor oral capsule
cefaclor oral suspension for
reconstitution 125 mg/5 ml, 250
mg/5 ml, 375 mg/5 ml
cefadroxil oral capsule
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500
mg/5 ml
cefadroxil oral tablet
cefazolin in dextrose (iso-os)
intravenous piggyback 1 gram/50
ml
cefazolin in dextrose (iso-os)
ml
cefazolin injection recon soln
cefazolin injection recon soln 100
gram, 300 g
cefazolin intravenous
cefdinir
cefditoren pivoxil
cefepime
CEFEPIME IN DEXTROSE 5 %
CEFEPIME IN DEXTROSE,ISOOSM INTRAVENOUS
PIGGYBACK
cefotaxime
cefoxitin
(Vancocin HCl)
(Cefazolin
Sodium/Dextrose,
Iso)
(Ancef)
(Claforan)
(Mefoxin)
Medidas necesarias,
restricciones o
límites de uso
PA; QL (9 per 30 days)
ST; QL (60 per 30
days)
28
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
$0
(Ceftazidime)
1
$0
(Cedax)
(Ceftriaxone
Na/Dextrose, Iso)
(Rocephin)
(Ceftriaxone
Na/Dextrose, Iso)
(Ceftin)
1
$0
1
$0
1
$0
1
$0
1
$0
(Zinacef)
1
$0
(Zinacef)
(Cefuroxime
Sodium/Dextrose,
Iso)
(Keflex)
1
$0
1
$0
1
$0
(Cephalexin)
1
$0
(Cephalexin)
1
$0
2
$0
2
$0
2
$0
2
$0
(Zithromax)
1
$0
(Biaxin)
1
$0
cefoxitin in dextrose, iso-osm
ml
cefpodoxime
cefprozil
ceftazidime intravenous recon soln
1 gram, 2 gram
ceftibuten
ceftriaxone in dextrose,iso-os
ceftriaxone injection recon soln
ceftriaxone intravenous
cefuroxime axetil oral tablet
cefuroxime sodium injection recon
soln 1.5 gram, 750 mg
cefuroxime sodium intravenous
cefuroxime-dextrose (iso-osm)
cephalexin oral capsule
cephalexin oral suspension for
reconstitution
cephalexin oral tablet
MEFOXIN IN DEXTROSE (ISOOSM)
SUPRAX ORAL TABLET
SUPRAX ORAL
TABLET,CHEWABLE
TEFLARO
Macrolides
azithromycin
clarithromycin oral suspension for
reconstitution
(Cefoxitin
Sodium/Dextrose,
Iso)
(Cefpodoxime
Proxetil)
(Cefprozil)
Medidas necesarias,
restricciones o
límites de uso
29
Nivel
Lo que le
costará a
usted el
(Biaxin)
1
$0
(Biaxin XL)
1
$0
2
2
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
2
1
2
1
$0
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
clarithromycin oral tablet
clarithromycin oral tablet extended
release 24 hr
DIFICID
ERYTHROCIN
erythromycin base oral
tablet,delayed release (dr/ec) 250
mg, 500 mg
ERYTHROMYCIN BASE ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythromycin ethylsuccinate oral
suspension for reconstitution
erythromycin ethylsuccinate oral
tablet
erythromycin oral capsule,delayed
release(dr/ec)
(Erythromycin
Base)
(Eryped 200)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Base)
(Erythromycin
erythromycin oral tablet
Base)
erythromycin stearate oral tablet
(Erythromycin
250 mg
Stearate)
Miscellaneous B-Lactam Antibiotics
aztreonam
(Azactam)
CAYSTON
imipenem-cilastatin
(Primaxin)
INVANZ
meropenem
(Merrem)
Penicillins
amoxicillin oral capsule
(Amoxicillin)
amoxicillin oral suspension for
(Amoxil)
reconstitution
amoxicillin oral tablet
(Amoxicillin)
amoxicillin oral tablet,chewable
(Amoxicillin)
125 mg, 250 mg
Medidas necesarias,
restricciones o
límites de uso
QL (20 per 10 days)
LA
30
Nivel
Lo que le
costará a
usted el
(Augmentin)
1
$0
(Augmentin)
1
$0
(Augmentin XR)
1
$0
1
$0
1
$0
(Totacillin-N)
1
$0
(Totacillin-N)
1
$0
(Unasyn)
1
$0
(Unasyn)
1
2
2
$0
$0
$0
1
$0
2
$0
1
1
$0
$0
1
$0
1
1
$0
$0
1
$0
1
$0
amoxicillin-pot clavulanate oral
tablet
tablet extended release 12 hr
tablet,chewable
ampicillin
ampicillin sodium injection recon
soln
ampicillin sodium intravenous
recon soln
ampicillin-sulbactam injection
recon soln
ampicillin-sulbactam intravenous
BICILLIN C-R
BICILLIN L-A
dicloxacillin
nafcillin in dextrose iso-osm
nafcillin injection
nafcillin intravenous recon soln
oxacillin in dextrose(iso-osm)
oxacillin injection recon soln
oxacillin intravenous recon soln
penicillin g pot in dextrose
penicillin g potassium injection
recon soln
(Amoxicillin/Potas
sium Clav)
(Ampicillin
Trihydrate)
(Dicloxacillin
Sodium)
(Nafcillin In
Dextrose,Iso-Osm)
(Unipen)
(Nallpen)
(Oxacillin
Sodium/Dextrose,
Iso)
(Oxacillin Sodium)
(Oxacillin Sodium)
(Pen G
Pot/DextroseWater)
(Penicillin G
Potassium)
Medidas necesarias,
restricciones o
límites de uso
31
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
(Zosyn)
1
$0
(Cipro)
(Cipro)
(Cipro I.V.)
1
1
1
$0
$0
$0
(Cipro I.V.)
1
$0
(Levaquin)
1
$0
(Levofloxacin)
(Levaquin)
(Avelox)
(Ofloxacin)
1
1
1
1
$0
$0
$0
$0
(Sulfadiazine)
(Sulfamethoxazole/
Trimethoprim)
(Sulfamethoxazole/
Trimethoprim)
1
$0
1
$0
1
$0
(Bactrim)
1
$0
(Azulfidine)
(Sulfamethoxazole/
Trimethoprim)
(Azulfidine)
(Azulfidine)
1
$0
1
$0
1
1
$0
$0
(Morgidox)
1
$0
(Doryx)
1
$0
penicillin g procaine
penicillin v potassium
piperacillin-tazobactam intravenous
recon soln
Quinolones
ciprofloxacin
ciprofloxacin hcl oral
ciprofloxacin in 5 % dextrose
ciprofloxacin lactate intravenous
solution 400 mg/40 ml
levofloxacin in d5w intravenous
piggyback
levofloxacin intravenous
levofloxacin oral
moxifloxacin
ofloxacin oral
Sulfonamides
sulfadiazine oral
sulfamethoxazole-trimethoprim
intravenous
sulfamethoxazole-trimethoprim oral
suspension
sulfamethoxazole-trimethoprim oral
tablet
sulfasalazine
sulfatrim
sulfazine
sulfazine ec
Tetracyclines
doxycycline hyclate oral capsule
100 mg
doxycycline hyclate 100 mg tab f/c
(Penicillin G
Procaine)
(Penicillin V
Potassium)
Medidas necesarias,
restricciones o
límites de uso
32
Nivel
Lo que le
costará a
usted el
(Doxycycline
Hyclate)
1
$0
(Adoxa)
1
$0
(Morgidox)
1
$0
(Adoxa)
1
$0
(Doryx)
1
$0
(Adoxa)
1
$0
(Vibramycin)
1
$0
(Adoxa)
1
$0
(Minocin)
(Minocycline HCl)
(Ala-Tet)
1
1
1
2
$0
$0
$0
$0
Anticancer Agents
ABRAXANE
2
$0
ADCETRIS
2
$0
AFINITOR DISPERZ
2
$0
2
$0
2
$0
2
$0
1
2
$0
$0
doxycycline hyclate intravenous
doxycycline hyclate oral capsule
100 mg
doxycycline hyclate oral capsule 50
mg
doxycycline hyclate oral tablet 100
mg
doxycycline hyclate oral tablet 20
mg
doxycycline monohydrate oral
capsule
tablet
minocycline oral capsule
minocycline oral tablet
tetracycline
TYGACIL
Medidas necesarias,
restricciones o
límites de uso
Anticancer Agents
AFINITOR ORAL TABLET 10
MG
AFINITOR ORAL TABLET 2.5
MG, 5 MG, 7.5 MG
ALIMTA INTRAVENOUS
RECON SOLN
anastrozole
ARRANON
(Arimidex)
PA NSO; QL (4 per 21
days)
PA NSO; QL (112 per
28 days)
PA NSO; QL (56 per
28 days)
PA NSO; QL (28 per
28 days)
33
ARZERRA
AVASTIN
azacitidine
BELEODAQ
bicalutamide
bleomycin
(Vidaza)
(Casodex)
(Bleomycin
Sulfate)
BLINCYTO
BOSULIF ORAL TABLET 100
MG
BOSULIF ORAL TABLET 500
MG
CAPRELSA ORAL TABLET 100
MG
CAPRELSA ORAL TABLET 300
MG
carboplatin intravenous solution
cisplatin
(Carboplatin)
(Cisplatin)
COMETRIQ
cyclophosphamide intravenous
recon soln
CYCLOPHOSPHAMIDE ORAL
CAPSULE
cyclophosphamide oral tablet
CYRAMZA
cytarabine
cytarabine (pf) injection recon soln
cytarabine (pf) injection solution
dacarbazine intravenous recon soln
dactinomycin
decitabine
(Cyclophosphamid
e)
(Cyclophosphamid
e)
(Cytarabine)
(Cytarabine/PF)
(Cytarabine/PF)
(Dtic-Dome IV)
(Dactinomycin)
(Dacogen)
Nivel
Lo que le
costará a
usted el
2
2
1
2
1
$0
$0
$0
$0
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
1
$0
$0
2
$0
1
$0
2
$0
1
$0
2
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
Medidas necesarias,
restricciones o
límites de uso
PA NSO
PA NSO
PA NSO
PA BvD
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (112 per
28 days)
PA BvD
PA BvD; ST
PA BvD; ST
PA NSO
PA BvD
PA BvD
PA BvD
34
Nivel
Lo que le
costará a
usted el
(Doxorubicin HCl)
1
$0
(Doxil)
1
$0
(Doxil)
1
2
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
ERIVEDGE
2
$0
ETOPOPHOS
etoposide intravenous
exemestane
FARESTON
2
1
1
2
$0
$0
$0
$0
FARYDAK
2
$0
FASLODEX
FIRMAGON KIT W DILUENT
SYRINGE
floxuridine
(FUDR)
fludarabine
(Fludara)
fluorouracil intravenous solution
2.5 gram/50 ml, 5 gram/100 ml, 500 (Fluorouracil)
mg/10 ml
2
$0
2
$0
1
1
$0
$0
doxorubicin hcl intravenous recon
soln 10 mg
doxorubicin hcl peg-liposomal
intravenous suspension 2 mg/ml
doxorubicin, peg-liposomal
DROXIA
ELIGARD SUBCUTANEOUS
SYRINGE 22.5 MG
SYRINGE 30 MG
SYRINGE 45 MG
SYRINGE 7.5 MG
EMCYT
epirubicin intravenous solution 50
mg/25 ml
ERBITUX INTRAVENOUS
SOLUTION
(Ellence)
(Etoposide)
(Aromasin)
Medidas necesarias,
restricciones o
límites de uso
PA BvD
PA BvD
PA BvD
QL (1 per 84 days)
QL (1 per 112 days)
QL (1 per 168 days)
QL (1 per 28 days)
PA NSO
PA NSO; QL (30 per
30 days)
days)
PA BvD
PA BvD
1
$0
35
Nivel
Lo que le
costará a
usted el
1
$0
GAZYVA
2
$0
gemcitabine intravenous recon soln
(Gemzar)
1 gram
1
$0
GILOTRIF
2
$0
2
$0
2
$0
HALAVEN
2
$0
HERCEPTIN
HEXALEN
hydroxyurea
2
2
1
$0
$0
$0
IBRANCE
2
$0
ICLUSIG ORAL TABLET 15 MG
2
$0
ICLUSIG ORAL TABLET 45 MG
2
$0
1
1
$0
$0
1
$0
IMBRUVICA
2
$0
INLYTA ORAL TABLET 1 MG
2
$0
INLYTA ORAL TABLET 5 MG
2
$0
ISTODAX
IXEMPRA
2
2
$0
$0
flutamide
(Flutamide)
GLEEVEC ORAL TABLET 100
MG
GLEEVEC ORAL TABLET 400
MG
ifosfamide intravenous recon soln
ifosfamide intravenous solution
ifosfamide-mesna
(Hydrea)
(Ifex)
(Ifex)
(Ifosfamide/Mesna
)
Medidas necesarias,
restricciones o
límites de uso
PA NSO; QL (40 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (24 per
28 days)
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA NSO; QL (120 per
30 days)
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
36
Nivel
Lo que le
costará a
usted el
JAKAFI
2
$0
JEVTANA
KADCYLA INTRAVENOUS
RECON SOLN
KEYTRUDA INTRAVENOUS
RECON SOLN
2
$0
2
$0
2
$0
KYPROLIS
2
$0
LENVIMA
letrozole
LEUKERAN
2
1
2
$0
$0
$0
1
$0
1
2
2
2
2
2
$0
$0
$0
$0
$0
$0
2
$0
LYNPARZA
2
$0
LYSODREN
2
$0
MARQIBO
2
$0
MATULANE
MEGACE ES
megestrol oral suspension
2
2
1
$0
$0
$0
1
$0
2
$0
leuprolide
lomustine
LUPRON DEPOT
LUPRON DEPOT (3 MONTH)
LUPRON DEPOT-PED
LUPRON DEPOT-PED (3
MONTH) INTRAMUSCULAR
SYRINGE KIT
megestrol oral tablet
MEKINIST ORAL TABLET 0.5
MG
(Femara)
(Leuprolide
Acetate)
(Gleostine)
(Megace)
(Megestrol
Acetate)
Medidas necesarias,
restricciones o
límites de uso
PA NSO; QL (60 per
30 days)
PA NSO
PA NSO
days)
PA NSO
QL (1 per 28 days)
QL (1 per 84 days)
QL (1 per 84 days)
QL (1 per 168 days)
QL (1 per 28 days)
QL (1 per 84 days)
PA NSO; QL (480 per
30 days)
days)
PA NSO; QL (90 per
30 days)
37
Nivel
Lo que le
costará a
usted el
2
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
1
2
$0
$0
$0
NEXAVAR
2
$0
NILANDRON
ONCASPAR
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
oxaliplatin intravenous solution 100
(Eloxatin)
mg/20 ml
paclitaxel
(Paclitaxel)
PERJETA
2
2
$0
$0
2
$0
1
$0
1
2
$0
$0
POMALYST
2
$0
PROLEUKIN
PURIXAN
2
2
$0
$0
REVLIMID
2
$0
RITUXAN
SOLTAMOX
2
2
$0
$0
MEKINIST ORAL TABLET 2 MG
melphalan hcl intravenous
mercaptopurine
methotrexate sodium (pf) injection
recon soln
methotrexate sodium (pf) injection
solution
methotrexate sodium injection
methotrexate sodium oral
mitomycin intravenous recon soln
mitoxantrone
MUSTARGEN
(Alkeran)
(Purinethol)
(Methotrexate
Sodium/PF)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Mitomycin)
(Novantrone)
Medidas necesarias,
restricciones o
límites de uso
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA BvD; ST
PA BvD
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; LA; QL (21
per 28 days)
PA NSO
38
Nivel
Lo que le
costará a
usted el
SPRYCEL ORAL TABLET 100
MG, 140 MG, 50 MG, 70 MG, 80
MG
2
$0
SPRYCEL ORAL TABLET 20 MG
2
$0
STIVARGA
2
$0
SUTENT
2
$0
SYLVANT
2
$0
SYNRIBO
2
$0
TABLOID
2
$0
TAFINLAR
2
$0
1
$0
2
$0
2
$0
TARGRETIN ORAL
2
$0
TARGRETIN TOPICAL
2
$0
TASIGNA
2
$0
TEMODAR INTRAVENOUS
toposar intravenous
topotecan intravenous
2
1
1
$0
$0
$0
2
$0
tamoxifen
(Tamoxifen
Citrate)
TARCEVA ORAL TABLET 100
MG, 25 MG
TARCEVA ORAL TABLET 150
MG
TORISEL
(Etoposide)
(Hycamtin)
Medidas necesarias,
restricciones o
límites de uso
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (84 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO
PA NSO; QL (28 per
28 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (420 per
30 days)
PA NSO; QL (60 per
28 days)
PA NSO; QL (112 per
28 days)
PA NSO; (vial only)
PA BvD; QL (4 per 28
days)
TREANDA INTRAVENOUS
2
$0
RECON SOLN
TREANDA INTRAVENOUS
2
$0
SOLUTION
39
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
SYRINGE 11.25 MG/2 ML
tretinoin (chemotherapy)
TREXALL
TYKERB
VALSTAR
VECTIBIX INTRAVENOUS
SOLUTION
VELCADE
Nivel
Lo que le
costará a
usted el
QL (1 per 168 days)
2
$0
2
$0
2
$0
2
$0
1
2
2
2
$0
$0
$0
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
VOTRIENT
2
$0
XALKORI
2
$0
XTANDI
2
$0
2
$0
2
$0
2
$0
vinblastine intravenous
vincristine
vincristine sulfate intravenous
solution 1 mg/ml
vinorelbine intravenous solution
YERVOY INTRAVENOUS
SOLUTION
ZALTRAP INTRAVENOUS
SOLUTION
ZELBORAF
Medidas necesarias,
restricciones o
límites de uso
(Tretinoin)
(Vinblastine
Sulfate)
(Vincristine
Sulfate)
(Vincristine
Sulfate)
(Navelbine)
QL (1 per 84 days)
QL (1 per 168 days)
QL (1 per 28 days)
(capsule: 10mg)
PA BvD; ST
PA NSO
PA NSO
PA BvD
PA BvD
PA BvD
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
PA NSO; QL (240 per
30 days)
40
Nivel
Lo que le
costará a
usted el
2
$0
2
$0
2
$0
ZYDELIG
2
$0
ZYKADIA
2
$0
ZYTIGA
2
$0
1
$0
1
$0
1
$0
2
2
$0
$0
(Carbatrol)
1
$0
(Tegretol)
1
$0
(Tegretol XR)
1
$0
(Carbamazepine)
1
$0
2
$0
2
$0
1
$0
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA
Medidas necesarias,
restricciones o
límites de uso
QL (1 per 84 days)
QL (1 per 28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection solution 0.4
(Atropine Sulfate)
mg/ml
atropine injection syringe 0.05
(Atropine Sulfate)
mg/ml, 0.1 mg/ml
(Propantheline
propantheline
Bromide)
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
carbamazepine oral capsule, er
multiphase 12 hr
carbamazepine oral suspension
carbamazepine oral tablet extended
release 12 hr
carbamazepine oral tablet,chewable
CELONTIN ORAL CAPSULE 300
MG
DILANTIN
divalproex oral capsule, sprinkle
(Depakote
Sprinkle)
ST
ST
41
Nivel
Lo que le
costará a
usted el
(Depakote ER)
1
$0
(Depakote)
1
$0
(Zarontin)
(Felbatol)
(Cerebyx)
(Neurontin)
(Neurontin)
1
1
1
2
1
1
$0
$0
$0
$0
$0
$0
(Neurontin)
1
$0
2
$0
2
$0
(Lamictal)
1
$0
(Lamictal XR)
1
$0
(Lamictal)
1
$0
(Lamictal (Blue))
1
$0
(Keppra)
(Keppra)
(Keppra)
1
1
1
$0
$0
$0
(Keppra XR)
1
$0
2
2
2
1
2
2
$0
$0
$0
$0
$0
$0
divalproex oral tablet extended
release 24 hr
divalproex oral tablet,delayed
release (dr/ec)
ethosuximide
felbamate
fosphenytoin
FYCOMPA
gabapentin oral capsule
gabapentin oral solution
gabapentin oral tablet 600 mg, 800
mg
GABITRIL ORAL TABLET 12
MG, 16 MG
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2
MG
lamotrigine oral tablet
lamotrigine oral tablet extended
release 24hr
lamotrigine oral tablet, chewable
dispersible
lamotrigine oral tablets,dose pack
25 mg (35)
levetiracetam intravenous
levetiracetam oral solution
levetiracetam oral tablet
levetiracetam oral tablet extended
release 24 hr
LUMINAL
LYRICA ORAL CAPSULE
LYRICA ORAL SOLUTION
oxcarbazepine
OXTELLAR XR
PEGANONE
(Trileptal)
Medidas necesarias,
restricciones o
límites de uso
ST
QL (2 per 30 days)
QL (90 per 30 days)
ST
42
Nivel
Lo que le
costará a
usted el
Medidas necesarias,
restricciones o
límites de uso
(Phenobarbital)
1
$0
QL (90 per 30 days)
(Phenobarbital)
1
$0
(Phenobarbital)
(Phenobarbital
Sodium)
1
$0
1
$0
(Dilantin-125)
1
$0
(Dilantin)
(Phenytoin
Sodium)
(Dilantin)
1
$0
1
$0
1
$0
2
$0
2
$0
(Gabitril)
(Topamax)
1
2
2
1
1
$0
$0
$0
$0
$0
(Qudexy XR)
1
$0
(Topamax)
1
$0
2
$0
(Depacon)
(Depakene)
2
1
1
$0
$0
$0
(Depakene)
1
$0
2
$0
phenobarbital oral elixir
phenobarbital oral tablet 100 mg,
15 mg, 16.2 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection
solution
phenytoin oral suspension 125 mg/5
ml
phenytoin oral
phenytoin sodium
phenytoin sodium extended
POTIGA ORAL TABLET 200 MG,
300 MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone
QUDEXY XR
SABRIL
tiagabine
topiramate oral capsule, sprinkle
topiramate oral capsule,sprinkle,er
24hr
topiramate oral tablet
TRILEPTAL ORAL
SUSPENSION
TROKENDI XR
valproate sodium
valproic acid
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
VIMPAT INTRAVENOUS
(Mysoline)
QL (2 per 30 days)
ST; QL (90 per 30
days)
ST; QL (270 per 30
days)
ST
ST
ST; QL (200 per 5
days)
43
Nivel
Lo que le
costará a
usted el
VIMPAT ORAL SOLUTION
2
$0
VIMPAT ORAL TABLET
2
$0
(Zonegran)
1
$0
(Aricept)
(Aricept Odt)
1
1
$0
$0
1
$0
(Razadyne ER)
1
$0
(Razadyne)
(Razadyne)
1
1
2
2
2
$0
$0
$0
$0
$0
2
$0
2
$0
1
$0
1
$0
(Wellbutrin)
1
2
1
$0
$0
$0
(Wellbutrin SR)
1
$0
zonisamide
Medidas necesarias,
restricciones o
límites de uso
ST; QL (1200 per 30
days)
ST; QL (60 per 30
days)
Antidementia Agents
Antidementia Agents
donepezil oral tablet
donepezil oral tablet,disintegrating
EXELON TRANSDERMAL
PATCH 24 HOUR 4.6 MG/24 HR,
9.5 MG/24 HR
galantamine oral capsule,ext rel.
pellets 24 hr
galantamine oral solution
galantamine oral tablet
NAMENDA ORAL SOLUTION
NAMENDA ORAL TABLET
NAMENDA TITRATION PAK
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
rivastigmine tartrate
(Exelon)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
QL (28 per 28 days)
QL (30 per 30 days)
QL (60 per 30 days)
Antidepressants
Antidepressants
amitriptyline
amoxapine
BRINTELLIX
bupropion hcl oral tablet
bupropion hcl oral tablet extended
release , 150 mg
(Amitriptyline
HCl)
(Amoxapine)
PA NSO-HRM
ST
44
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Cymbalta)
1
$0
(Cymbalta)
1
$0
(Prozac)
2
1
2
1
$0
$0
$0
$0
(Prozac Weekly)
1
$0
(Fluoxetine HCl)
(Fluoxetine HCl)
1
1
$0
$0
1
$0
1
$0
1
$0
1
1
$0
$0
2
$0
1
2
1
1
1
$0
$0
$0
$0
$0
bupropion hcl oral tablet extended
release 24 hr
citalopram oral solution
citalopram oral tablet
clomipramine
desipramine oral
doxepin oral
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
duloxetine oral capsule,delayed
release(dr/ec) 30 mg
EMSAM
escitalopram oxalate
FETZIMA
fluoxetine oral capsule
fluoxetine oral capsule,delayed
release(dr/ec)
fluoxetine oral solution
fluoxetine oral tablet 10 mg, 20 mg
FLUOXETINE ORAL TABLET 60
MG
fluvoxamine oral capsule,extended
release 24hr
fluvoxamine oral tablet
imipramine hcl
imipramine pamoate
(Wellbutrin XL)
(Citalopram
Hydrobromide)
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Lexapro)
(Luvox CR)
(Fluvoxamine
Maleate)
(Tofranil)
(Tofranil-Pm)
KHEDEZLA
maprotiline
MARPLAN
mirtazapine
nefazodone
nortriptyline oral capsule
(Maprotiline HCl)
(Remeron)
(Nefazodone HCl)
(Pamelor)
Medidas necesarias,
restricciones o
límites de uso
QL (30 per 30 days)
PA NSO-HRM
PA NSO-HRM
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
ST
PA NSO-HRM
PA NSO-HRM
ST; QL (30 per 30
days)
45
Nivel
Lo que le
costará a
usted el
(Nortriptyline HCl)
(Symbyax)
(Paxil)
1
1
1
$0
$0
$0
(Paxil CR)
1
$0
2
$0
1
$0
1
$0
2
$0
ST; QL (30 per 30
days)
$0
$0
$0
$0
$0
$0
QL (30 per 30 days)
PA NSO-HRM
(Parnate)
(Trazodone HCl)
1
1
2
2
1
1
(Effexor XR)
1
$0
(Venlafaxine HCl)
1
$0
(Venlafaxine HCl)
1
$0
2
$0
1
2
$0
$0
2
$0
nortriptyline oral solution
olanzapine-fluoxetine
paroxetine hcl oral tablet
paroxetine hcl oral tablet extended
release 24 hr
PAXIL ORAL SUSPENSION
perphenazine-amitriptyline
phenelzine
(Perphenazine/Ami
triptyline HCl)
(Nardil)
PRISTIQ
protriptyline
sertraline
SILENOR
SURMONTIL
tranylcypromine
trazodone
venlafaxine oral capsule,extended
release 24hr
venlafaxine oral tablet
venlafaxine oral tablet extended
release 24hr 150 mg, 37.5 mg, 75
mg
VIIBRYD
(Vivactil)
(Zoloft)
Medidas necesarias,
restricciones o
límites de uso
PA NSO-HRM
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
BYDUREON
BYETTA SUBCUTANEOUS PEN
INJECTOR 10 MCG/DOSE(250
MCG/ML) 2.4 ML
BYETTA SUBCUTANEOUS PEN
INJECTOR 5 MCG/DOSE (250
MCG/ML) 1.2 ML
CYCLOSET
QL (90 per 30 days)
QL (4 per 28 days)
QL (2.4 per 28 days)
2
$0
2
$0
46
Nivel
Lo que le
costará a
usted el
GLYXAMBI
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 501,000 MG
INVOKAMET ORAL TABLET
50-500 MG
INVOKANA ORAL TABLET 100
MG
INVOKANA ORAL TABLET 300
MG
JANUMET
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 1001,000 MG, 50-500 MG
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 501,000 MG
JANUVIA
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
JARDIANCE
2
$0
JENTADUETO
2
$0
KORLYM
2
$0
(Glucophage)
(Glucophage)
(Glucophage)
1
1
1
$0
$0
$0
(Glucophage XR)
1
$0
(Glucophage XR)
1
$0
(Fortamet)
1
$0
(Starlix)
(Actos)
(Duetact)
1
1
1
$0
$0
$0
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended
release 24 hr 500 mg
release 24 hr 750 mg
release 24hr
nateglinide
pioglitazone
pioglitazone-glimepiride
Medidas necesarias,
restricciones o
límites de uso
QL (30 per 30 days)
ST; QL (60 per 30
days)
ST; QL (120 per 30
days)
ST; QL (60 per 30
days)
ST; QL (30 per 30
days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
ST; QL (30 per 30
days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
47
pioglitazone-metformin
PRANDIMET
repaglinide
SYMLINPEN 120
(Actoplus Met)
(Prandin)
Nivel
Lo que le
costará a
usted el
Medidas necesarias,
restricciones o
límites de uso
1
2
1
$0
$0
$0
2
$0
QL (90 per 30 days)
PA; QL (10.8 per 28
days)
QL (30 per 30 days)
QL (4 per 28 days)
SYMLINPEN 60
2
$0
TRADJENTA
2
$0
TRULICITY
2
$0
VICTOZA
2
$0
Insulins
HUMALOG KWIKPEN
2
$0
QL (30 per 28 days)
HUMALOG MIX 50-50
2
$0
QL (40 per 28 days)
HUMALOG MIX 50-50
QL (30 per 28 days)
2
$0
KWIKPEN
HUMALOG MIX 75-25
2
$0
QL (40 per 28 days)
HUMALOG MIX 75-25
QL (30 per 28 days)
2
$0
KWIKPEN
HUMALOG SUBCUTANEOUS
2
$0
QL (40 per 28 days)
HUMULIN 70/30
2
$0
QL (40 per 28 days)
HUMULIN 70/30 KWIKPEN
2
$0
QL (30 per 28 days)
HUMULIN 70/30 PEN
2
$0
QL (30 per 28 days)
HUMULIN N
2
$0
QL (40 per 28 days)
HUMULIN N KWIKPEN
2
$0
QL (30 per 28 days)
HUMULIN N PEN
2
$0
QL (30 per 28 days)
HUMULIN R
2
$0
QL (40 per 28 days)
HUMULIN R U-500
QL (40 per 28 days)
2
$0
"CONCENTRATED"
LANTUS
2
$0
QL (40 per 28 days)
LANTUS SOLOSTAR
2
$0
QL (30 per 28 days)
NOVOLIN 70/30
2
$0
QL (40 per 28 days)
NOVOLIN N
2
$0
QL (40 per 28 days)
NOVOLIN R
2
$0
QL (40 per 28 days)
NOVOLOG
2
$0
QL (40 per 28 days)
NOVOLOG FLEXPEN
2
$0
QL (30 per 28 days)
NOVOLOG MIX 70-30
2
$0
QL (40 per 28 days)
48
Nivel
Lo que le
costará a
usted el
2
2
$0
$0
QL (30 per 28 days)
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
1
1
1
1
$0
$0
$0
$0
(Glucotrol XL)
1
$0
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Glucotrol XL)
1
$0
1
$0
1
$0
(Glynase)
1
$0
(Glynase)
1
$0
(Glynase)
1
$0
glyburide oral tablet 1.25 mg
(Glyburide)
1
$0
glyburide oral tablet 2.5 mg
(Glyburide)
1
$0
glyburide oral tablet 5 mg
(Glyburide)
1
$0
(Glucovance)
1
$0
(Glucovance)
1
$0
(Tolazamide)
(Tolazamide)
(Tolbutamide)
1
1
1
$0
$0
$0
NOVOLOG MIX 70-30 FLEXPEN
TOUJEO SOLOSTAR
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended
release 24hr 10 mg
glipizide oral tablet extended
release 24hr 2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5250 mg
glipizide-metformin oral tablet 2.5500 mg, 5-500 mg
glyburide micronized oral tablet 1.5
mg
glyburide micronized oral tablet 3
mg
glyburide micronized oral tablet 6
mg
glyburide-metformin oral tablet
1.25-250 mg
glyburide-metformin oral tablet 2.5500 mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide
(Glipizide/Metform
in HCl)
(Glipizide/Metform
in HCl)
Medidas necesarias,
restricciones o
límites de uso
QL (30 per 30 days)
QL (60 per 30 days)
PA-HRM; QL (400 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (280 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
QL (60 per 30 days)
Antifungals
49
Nivel
Lo que le
costará a
usted el
4
$0
2
4
$0
$0
4
$0
2
1
4
4
4
4
4
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
Antifungals
3 day vaginal *
ABELCET
af *
aloe vesta * topical ointment 2 %
AMBISOME
amphotericin b
antifungal (tolnaftate) * topical
antifungal (tolnaftate) * topical
antifungal * topical solution
athlete's foot (clotrimazole) *
baza antifungal *
CANCIDAS
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
ciclopirox topical suspension
(Miconazole
Nitrate)
(Tinactin)
(Miconazole
Nitrate)
(Amphotericin B)
(Tolnaftate)
(Tolnaftate)
(Undecylenic Acid)
(Lotrimin AF)
(Nuzole)
(Ciclodan)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox
Olamine)
(Ciclodan)
(Lotrimin AF)
(Clotrimazole)
(Gyne-Lotrimin)
(Clotrimazole)
(Clotrimazole)
(Lotrimin)
(Gyne-Lotrimin)
(Clotrimazole)
(Gyne-Lotrimin)
PA BvD
PA BvD
PA BvD
ciclopirox-ure-camph-menth-euc
1
$0
clotrimazole * 1% cream (otc)
4
$0
clotrimazole * 1% solution (otc)
4
$0
clotrimazole 3 day *
4
$0
clotrimazole mucous membrane
1
$0
clotrimazole topical cream 1 %
1
$0
clotrimazole topical solution 1 %
1
$0
clotrimazole * vaginal cream
4
$0
clotrimazole * vaginal tablet
4
$0
clotrimazole-3 *
4
$0
clotrimazole-betamethasone topical
(Lotrisone)
1
$0
cream
clotrimazole-betamethasone topical (Clotrimazole/Beta
1
$0
lotion
methasone Dip)
50
critic-aid clear af *
dermafungal *
desenex * topical cream
econazole topical
elon dual defense *
fluconazole
fluconazole in dextrose(iso-o)
fluconazole in nacl (iso-osm)
flucytosine
fungi cure *
FUNGI-NAIL * TOPICAL
fungoid-d *
griseofulvin microsize oral tablet
inzo antifungal *
itraconazole
ketoconazole oral
ketoconazole topical cream
ketoconazole topical shampoo
LAMISIL (AEROSOL) *
lamisil af *
LAMISIL AT * TOPICAL
LOTRIMIN ULTRA *
micatin *
miconazole 7 * vaginal suppository
miconazole nitrate * topical cream
miconazole nitrate * vaginal
miconazole nitrate * vaginal
(Miconazole
Nitrate)
(Miconazole
Nitrate)
(Lotrimin AF)
(Econazole Nitrate)
(Undecylenic Acid)
(Diflucan)
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Clotrimazole)
(Tinactin)
(Grifulvin V)
(Nuzole)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Tolnaftate)
(Nuzole)
(Miconazole
Nitrate)
(Nuzole)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
1
4
1
$0
$0
$0
$0
1
$0
1
$0
1
4
4
4
1
4
1
1
1
1
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
51
miconazole nitrate * vaginal kit 200
(Monistat 3)
mg- 2 % (9 gram)
miconazole nitrate vaginal
(Monistat 3)
suppository 200 mg
MONISTAT 3 * VAGINAL
COMB PACK,PREFILL APPL &
CREAM
MONISTAT 3 * VAGINAL KIT
(Miconazole
monistat 7 * vaginal
Nitrate)
myco nail a *
(Undecylenic Acid)
NOXAFIL ORAL
nystatin
(Nystatin)
NYSTATIN (BULK) POWDER 1
BILLION UNIT
nystatin oral
(Nystatin)
nystatin oral
(Nystatin)
nystatin topical
(Nystatin)
(Nystatin/Triamcin
nystatin-triamcinolone
)
podactin *
(Tolnaftate)
terbinafine hcl oral
(Lamisil)
terbinafine hcl * topical
(Desenex)
tolnaftate * topical
(Tinactin)
tolnaftate * topical
(Tolnaftate)
(Miconazole
triple paste af *
Nitrate)
voriconazole intravenous
(Vfend IV)
voriconazole oral
(Vfend)
Nivel
Lo que le
costará a
usted el
4
$0
1
$0
4
$0
4
$0
4
$0
4
2
1
$0
$0
$0
1
$0
1
1
1
$0
$0
$0
1
$0
4
1
4
4
4
$0
$0
$0
$0
$0
4
$0
1
1
$0
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
Antihistamines
Antihistamines
alavert d-12 allergy-sinus *
aller-chlor * oral syrup
(Claritin-D 12
Hour)
(Chlorpheniramine
Maleate)
52
aller-chlor * oral tablet
allerclear d-12hr *
allerclear d-24hr *
allergy (chlorpheniramine) *
allergy relief (cetirizine) * oral
allergy relief (loratadine) * oral
allerhist-1 *
aller-tec d *
ambi 60pse-4cpm *
aprodine *
banophen allergy *
banophen * oral capsule 25 mg
banophen * oral
benadryl allergy * oral tablet
(Chlor-Trimeton)
(Claritin-D 12
Hour)
(Claritin-D 24
Hour)
(Chlor-Trimeton)
(Zyrtec)
(Claritin)
(Tavist-1)
(Zyrtec-D)
(Pseudoephed/Chlo
rpheniramine)
(Pseudoephedrine/
Triprolidine)
(Zzzquil)
(Benadryl)
(Diphenhydramine
HCl)
(Diphenhydramine
HCl)
(Cetirizine HCl)
(Zyrtec)
(Zyrtec)
(Zyrtec-D)
(Dimetapp)
(Dimetapp)
(Cetirizine HCl)
cetirizine * oral solution
cetirizine * oral tablet
cetirizine * oral tablet,chewable
cetirizine-pseudoephedrine *
child triaminic cold & allergy *
child wal-tap cold-allergy *
children's aller-tec *
children's cetirizine * oral
(Zyrtec)
tablet,chewable 5 mg
CHILDREN'S CLARITIN * ORAL
children's wal-dryl allergy * oral
(Zzzquil)
children's wal-zyr * oral
(Zyrtec)
CHILDREN'S ZYRTEC
ALLERGY *
CLARITIN *
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
53
CLARITIN LIQUI-GEL *
CLARITIN REDITABS *
CLARITIN-D 12 HOUR *
CLARITIN-D 24 HOUR *
(Clemastine
Fumarate)
clemastine * oral tablet 1.34 mg
(Tavist-1)
(Clemastine
clemastine oral tablet 2.68 mg
Fumarate)
(Triaminic Cold
cold & cough * oral liquid
and Cough)
(Diphenhydramine
compoz *
HCl)
(Cyproheptadine
cyproheptadine
HCl)
dailyhist-1 *
(Tavist-1)
dayhist allergy *
(Tavist-1)
dimaphen (pe) *
(Dimetapp)
(Triaminic Cold
dimetapp cold-congestion *
and Cough)
diphenhist * oral capsule
(Benadryl)
diphenhist * oral
(Zzzquil)
(Diphenhydramine
diphenhist * oral tablet 25 mg
HCl)
diphenhydramine hcl injection
(Diphenhydramine
solution 50 mg/ml
HCl)
diphenhydramine hcl injection
(Diphenhydramine
syringe
HCl)
diphenhydramine hcl * oral capsule (Benadryl)
diphenhydramine hcl * oral tablet
(Diphenhydramine
50 mg
HCl)
(Chlorpheniramine
ed chlorped jr *
Maleate)
levocetirizine
(Xyzal)
loradamed *
(Claritin)
clemastine oral syrup
Nivel
Lo que le
costará a
usted el
4
4
4
4
$0
$0
$0
$0
1
$0
4
$0
1
$0
4
$0
4
$0
1
$0
4
4
4
$0
$0
$0
4
$0
4
4
$0
$0
4
$0
1
$0
1
$0
4
$0
4
$0
4
$0
1
4
$0
$0
Medidas necesarias,
restricciones o
límites de uso
PA-HRM
PA-HRM
PA-HRM
54
loratadine * oral
loratadine * oral
loratadine-d * oral tablet extended
release 12 hr
loratadine-d * oral tablet extended
release 24 hr
phenylephrine-chlorpheniramine *
oral tablet 4-10 mg
promethazine oral syrup
q-dryl * oral liquid
q-tapp *
siladryl sa *
simply sleep *
sinus & allergy (pseudoephed) *
sleep aid (diphenhydramine) * oral
sleep-tabs *
sudogest cold & allergy *
(Claritin)
(Claritin)
(Claritin-D 12
Hour)
(Claritin-D 24
Hour)
(Phenylephrine/Chl
orpheniramine)
(Promethazine
HCl)
(Zzzquil)
(Pseudoephedrine/
Brompheniramin)
(Zzzquil)
(Diphenhydramine
HCl)
(Pseudoephed/Chlo
rpheniramine)
(Zzzquil)
(Diphenhydramine
HCl)
(Pseudoephed/Chlo
rpheniramine)
TRIAMINIC COLD & COUGH
NT (PE) *
ultra sleep (doxylamine succ) *
unisom sleepgels *
wal-act d cold & allergy *
wal-dryl allergy * oral
wal-dryl allergy * oral
wal-finate *
(Doxylamine
Succinate)
(Benadryl)
(Pseudoephedrine/
Triprolidine)
(Benadryl)
(Diphenhydramine
HCl)
(Chlor-Trimeton)
Nivel
Lo que le
costará a
usted el
4
4
$0
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
PA-HRM
55
wal-finate-d *
wal-itin *
wal-itin d *
wal-itin d 12 hour *
wal-phed * oral tablet 4-60 mg
wal-phed pe sinus & allergy *
wal-sleep z * oral capsule
wal-sleep z * oral liquid
wal-sleep z * oral
wal-som * oral capsule
wal-tap *
wal-zyr (cetirizine) * oral
wal-zyr (cetirizine) * oral
wal-zyr d *
z-sleep *
ZYRTEC * ORAL CAPSULE
ZYRTEC * ORAL TABLET
ZYRTEC * ORAL
TABLET,DISINTEGRATING
(Pseudoephed/Chlo
rpheniramine)
(Claritin)
(Claritin-D 24
Hour)
(Claritin-D 12
Hour)
(Pseudoephed/Chlo
rpheniramine)
(Phenylephrine/Chl
orpheniramine)
(Benadryl)
(Zzzquil)
(Unisom
Sleepmelts)
(Benadryl)
(Dimetapp)
(Cetirizine HCl)
(Zyrtec)
(Zyrtec-D)
(Zzzquil)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
4
2
1
1
1
1
$0
$0
$0
$0
$0
$0
Medidas necesarias,
restricciones o
límites de uso
Anti-Infectives (Skin And Mucous Membrane)
Anti-Infectives (Skin And Mucous Membrane)
ABREVA *
AVC VAGINAL
clindamycin phosphate vaginal
(Cleocin)
metronidazole vaginal
(Metrogel-Vaginal)
terconazole vaginal cream
(Terazol 7)
terconazole vaginal suppository
(Terconazole)
Antimigraine Agents
56
Nivel
Lo que le
costará a
usted el
(Amerge)
(Maxalt)
1
1
2
1
1
$0
$0
$0
$0
$0
(Maxalt Mlt)
1
$0
(Imitrex)
(Imitrex)
1
1
$0
$0
(Imitrex)
1
$0
(Imitrex)
1
$0
(Imitrex)
1
$0
(Zomig)
1
$0
(Zomig Zmt)
1
$0
2
1
1
1
2
2
1
1
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
Antimigraine Agents
dihydroergotamine injection
dihydroergotamine nasal
ERGOMAR
naratriptan
rizatriptan oral tablet
rizatriptan oral
sumatriptan nasal spray
sumatriptan oral tablet
sumatriptan succinate subcutaneous
cartridge 6 mg/0.5 ml
pen injector
solution
zolmitriptan oral tablet
zolmitriptan oral
(D.H.E.45)
(Migranal)
Medidas necesarias,
restricciones o
límites de uso
QL (30 per 28 days)
QL (4 per 28 days)
QL (40 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (12 per 28 days)
QL (18 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (12 per 28 days)
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT
dapsone
ethambutol
isoniazid oral
PASER
PRIFTIN
pyrazinamide
rifabutin
rifampin
rifampin
RIFATER
SIRTURO
(Dapsone)
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
PA; QL (188 per 168
days)
57
Nivel
Lo que le
costará a
usted el
2
$0
4
1
4
4
1
$0
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
(Granisetron
HCl/PF)
1
$0
(Kytril)
1
$0
(Granisetron HCl)
1
$0
(Meclizine HCl)
4
$0
(Meclizine HCl)
4
$0
(Antivert)
1
$0
(Dimenhydrinate)
(Zofran Odt)
(Ondansetron
HCl/PF)
(Zofran)
4
1
$0
$0
1
$0
1
$0
1
$0
1
1
$0
$0
TRECATOR
Medidas necesarias,
restricciones o
límites de uso
Antinausea Agents
Antinausea Agents
ambizine *
dimenhydrinate injection solution
dramamine * oral tablet
driminate *
dronabinol
EMEND INTRAVENOUS RECON
SOLN
EMEND ORAL CAPSULE 125
MG, 40 MG
(Meclizine HCl)
(Dimenhydrinate)
(Dimenhydrinate)
(Dimenhydrinate)
(Marinol)
EMEND ORAL CAPSULE 80 MG
EMEND ORAL CAPSULE,DOSE
PACK
granisetron (pf) intravenous
solution
granisetron hcl intravenous solution
1 mg/ml (1 ml)
granisetron hcl oral
meclizine * 12.5 mg caplet caplet
(otc)
meclizine * 25 mg tablet (otc)
meclizine oral tablet 12.5 mg, 25
mg
motion sickness *
ondansetron
ondansetron hcl (pf) injection
ondansetron hcl oral
prochlorperazine edisylate injection
(Compazine)
solution
prochlorperazine maleate
(Compazine)
prochlorperazine maleate oral
(Compazine)
QL (2 per 28 days)
PA BvD; QL (1 per 1
day)
PA BvD; QL (2 per 1
day)
PA BvD; QL (3 per 1
day)
PA BvD
PA BvD
PA BvD
58
promethazine hcl
promethazine oral tablet
promethazine rectal
TRANSDERM-SCOP
travel sickness (meclizine) *
wal-dram *
(Phenergan)
(Promethazine
HCl)
(Phenergan)
(Bonine)
(Dimenhydrinate)
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
2
4
4
$0
$0
$0
$0
2
2
1
1
2
1
2
2
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
2
$0
$0
1
$0
2
2
1
$0
$0
$0
1
2
2
$0
$0
$0
Medidas necesarias,
restricciones o
límites de uso
PA-HRM
PA-HRM
PA-HRM
QL (10 per 30 days)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone
atovaquone-proguanil
BILTRICIDE
chloroquine phosphate oral
COARTEM
DARAPRIM
hydroxychloroquine oral
ivermectin oral
mefloquine
metronidazole in nacl (iso-os)
metronidazole oral
NEBUPENT
paromomycin
PENTAM
PRIMAQUINE
quinine sulfate
(Mepron)
(Malarone)
(Aralen Phosphate)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Metronidazole/So
dium Chloride)
(Flagyl)
(Paromomycin
Sulfate)
(Qualaquin)
PA BvD
QL (90 per 30 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral
APOKYN
AZILECT
(Amantadine HCl)
QL (60 per 30 days)
59
Nivel
Lo que le
costará a
usted el
1
$0
1
1
1
1
$0
$0
$0
$0
(Sinemet CR)
1
$0
(Stalevo 50)
(Comtan)
1
1
$0
$0
2
$0
(Mirapex)
(Requip)
1
1
$0
$0
(Requip XL)
1
$0
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl
HCl)
1
1
$0
$0
1
$0
benztropine oral
bromocriptine
cabergoline
carbidopa
carbidopa-levodopa oral tablet
carbidopa-levodopa oral tablet
extended release
carbidopa-levodopa-entacapone
entacapone
(Benztropine
Mesylate)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet CR)
NEUPRO
pramipexole oral tablet
ropinirole oral tablet
ropinirole oral tablet extended
release 24 hr
selegiline hcl oral capsule
selegiline hcl oral tablet
trihexyphenidyl
Medidas necesarias,
restricciones o
límites de uso
PA-HRM
ST; QL (30 per 30
days)
PA-HRM
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10
MG
ABILIFY DISCMELT ORAL
MG
ABILIFY INTRAMUSCULAR
ABILIFY MAINTENA
ABILIFY ORAL SOLUTION
ABILIFY ORAL TABLET 10 MG,
15 MG, 20 MG, 30 MG, 5 MG
ABILIFY ORAL TABLET 2 MG
QL (90 per 30 days)
2
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
QL (60 per 30 days)
QL (1 per 28 days)
QL (30 per 30 days)
QL (60 per 30 days)
60
Nivel
Lo que le
costará a
usted el
(Abilify)
1
$0
(Abilify)
(Chlorpromazine
HCl)
(Clozaril)
(Clozaril)
(Clozaril)
1
$0
1
$0
1
1
1
$0
$0
$0
(Fazaclo)
1
$0
(Fazaclo)
1
$0
(Fazaclo)
1
$0
2
$0
2
$0
aripiprazole oral tablet 10 mg, 15
mg, 20 mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
chlorpromazine
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating
100 mg, 12.5 mg, 25 mg
150 mg
200 mg
FANAPT ORAL TABLET
FANAPT ORAL TABLETS,DOSE
PACK
FAZACLO ORAL
MG
FAZACLO ORAL
MG
fluphenazine decanoate
fluphenazine hcl
GEODON INTRAMUSCULAR
haloperidol
haloperidol decanoate
intramuscular solution 100 mg/ml
haloperidol decanoate
intramuscular solution 50 mg/ml
(Fluphenazine
Decanoate)
(Fluphenazine
HCl)
Medidas necesarias,
restricciones o
límites de uso
QL (30 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
ST; QL (90 per 30
days)
ST; QL (180 per 30
days)
ST; QL (120 per 30
days)
ST; QL (60 per 30
days)
ST; QL (8 per 28 days)
2
$0
ST; QL (180 per 30
days)
2
$0
ST; QL (120 per 30
days)
1
$0
1
$0
2
1
$0
$0
QL (6 per 28 days)
(Haloperidol)
(Haloperidol
1
$0
Decanoate)
(Haldol Decanoate
1
$0
50)
(Haloperidol
haloperidol lactate
1
$0
Lactate)
61
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR 1.5
MG, 3 MG, 9 MG
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR 6
MG
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE
117 MG/0.75 ML
INVEGA SUSTENNA
156 MG/ML
INVEGA SUSTENNA
234 MG/1.5 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 39
MG/0.25 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 78
MG/0.5 ML
LATUDA ORAL TABLET 120
MG, 20 MG, 40 MG, 60 MG
Medidas necesarias,
restricciones o
límites de uso
2
$0
ST; QL (30 per 30
days)
2
$0
ST; QL (60 per 30
days)
2
$0
QL (1 per 28 days)
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
(Loxitane)
(Zyprexa)
(Zyprexa)
1
1
1
$0
$0
$0
(Zyprexa Zydis)
1
$0
(Zyprexa Zydis)
1
$0
(Perphenazine)
(Seroquel)
2
1
1
$0
$0
$0
LATUDA ORAL TABLET 80 MG
loxapine succinate
olanzapine intramuscular
olanzapine oral tablet
olanzapine oral
tablet,disintegrating 10 mg, 15 mg,
5 mg
olanzapine oral
tablet,disintegrating 20 mg
ORAP
perphenazine
quetiapine
Nivel
Lo que le
costará a
usted el
ST; QL (30 per 30
days)
ST; QL (60 per 30
days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (31 per 30 days)
QL (90 per 30 days)
62
Nivel
Lo que le
costará a
usted el
(Risperdal)
(Risperdal)
2
1
1
$0
$0
$0
(Risperdal M-Tab)
1
$0
(Risperdal M-Tab)
1
$0
2
$0
2
$0
ST; QL (60 per 30
days)
ST; QL (60 per 30
days)
2
$0
ST; QL (30 per 30
days)
1
1
$0
$0
1
$0
2
$0
1
$0
2
$0
1
1
2
2
2
$0
$0
$0
$0
$0
RISPERDAL CONSTA
risperidone oral solution
risperidone oral tablet
risperidone oral
tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg
risperidone oral
tablet,disintegrating 3 mg, 4 mg
SAPHRIS (BLACK CHERRY)
SEROQUEL XR ORAL TABLET
EXTENDED RELEASE 24 HR
150 MG, 300 MG, 400 MG, 50 MG
SEROQUEL XR ORAL TABLET
200 MG
thioridazine
(Thioridazine HCl)
thiothixene
(Navane)
(Trifluoperazine
trifluoperazine
HCl)
VERSACLOZ
ziprasidone hcl
ZYPREXA RELPREVV
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 210 MG, 405
MG
(Geodon)
Medidas necesarias,
restricciones o
límites de uso
QL (4 per 28 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA NSO-HRM
ST; QL (540 per 30
days)
QL (60 per 30 days)
QL (2 per 28 days)
Antivirals (Systemic)
Antiretrovirals
abacavir
abacavir-lamivudine-zidovudine
APTIVUS
ATRIPLA
COMPLERA
(Ziagen)
(Trizivir)
63
Nivel
Lo que le
costará a
usted el
Medidas necesarias,
restricciones o
límites de uso
CRIXIVAN ORAL CAPSULE 200
2
$0
MG, 400 MG
didanosine
(Videx EC)
1
$0
EDURANT
2
$0
EMTRIVA
2
$0
EPIVIR HBV ORAL SOLUTION
2
$0
EPZICOM
2
$0
EVOTAZ
2
$0
FUZEON SUBCUTANEOUS
2
$0
INTELENCE
2
$0
INVIRASE
2
$0
ISENTRESS
2
$0
KALETRA
2
$0
lamivudine
(Epivir)
1
$0
lamivudine-zidovudine
(Combivir)
1
$0
LEXIVA
2
$0
nevirapine oral suspension
(Viramune)
1
$0
nevirapine oral tablet
(Viramune)
1
$0
nevirapine oral tablet extended
(Viramune XR)
1
$0
release 24 hr
NORVIR
2
$0
PREZCOBIX
2
$0
PREZISTA
2
$0
RESCRIPTOR
2
$0
RETROVIR INTRAVENOUS
2
$0
REYATAZ ORAL CAPSULE 150
2
$0
MG, 200 MG, 300 MG
REYATAZ ORAL POWDER IN
2
$0
PACKET
SELZENTRY
2
$0
stavudine
(Zerit)
1
$0
STRIBILD
2
$0
SUSTIVA
2
$0
TIVICAY
2
$0
TRIUMEQ
2
$0
64
Nivel
Lo que le
costará a
usted el
2
2
2
2
$0
$0
$0
$0
2
$0
2
2
2
1
1
1
$0
$0
$0
$0
$0
$0
1
2
1
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
HARVONI
2
$0
OLYSIO
2
$0
SOVALDI
2
$0
VIEKIRA PAK
2
$0
TRUVADA
VIDEX 2 GRAM PEDIATRIC
VIRACEPT ORAL TABLET
VIRAMUNE XR ORAL TABLET
100 MG
VIREAD
VITEKTA
ZIAGEN ORAL SOLUTION
zidovudine oral capsule
zidovudine oral syrup
zidovudine oral tablet
Antivirals, Miscellaneous
foscarnet
RELENZA DISKHALER
rimantadine
SYNAGIS
TAMIFLU ORAL CAPSULE 30
MG
MG
MG
TAMIFLU ORAL SUSPENSION
FOR RECONSTITUTION
Hcv Antivirals
(Retrovir)
(Retrovir)
(Zidovudine)
(Foscavir)
(Flumadine)
Medidas necesarias,
restricciones o
límites de uso
PA BvD
PA; QL (30 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (112 per 28
days)
65
Interferons
INTRON A INJECTION
PEGASYS
PEGASYS PROCLICK
SUBCUTANEOUS PEN
INJECTOR
PEGINTRON
PEGINTRON REDIPEN
SYLATRON
SYLATRON 4-PACK
SUBCUTANEOUS KIT 200 MCG,
300 MCG
Nucleosides And Nucleotides
acyclovir oral capsule
(Zovirax)
acyclovir oral suspension 200 mg/5
(Zovirax)
ml
acyclovir oral tablet
(Zovirax)
acyclovir sodium intravenous recon (Acyclovir
soln
Sodium)
acyclovir sodium intravenous
(Acyclovir
solution
Sodium)
adefovir
(Hepsera)
entecavir
(Baraclude)
famciclovir
(Famvir)
ganciclovir sodium
(Cytovene)
ribavirin oral capsule 200 mg
(Rebetol)
ribavirin oral tablet 200 mg, 400
(Copegus)
mg, 600 mg
TYZEKA
valacyclovir
(Valtrex)
valganciclovir
(Valcyte)
VIRAZOLE
Nivel
Lo que le
costará a
usted el
2
2
$0
$0
2
$0
2
2
$0
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
1
$0
2
1
1
2
$0
$0
$0
$0
Medidas necesarias,
restricciones o
límites de uso
PA NSO
PA
PA
PA
PA
days)
days)
PA BvD
PA BvD
PA BvD
PA BvD
Blood Products/Modifiers/Volume Expanders
Anticoagulants
66
Nivel
Lo que le
costará a
usted el
(Lovenox)
2
2
1
$0
$0
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Heparin Sodium
in 5% Dextrose)
1
$0
1
$0
1
$0
CEPROTIN (BLUE BAR)
ELIQUIS
enoxaparin subcutaneous solution
enoxaparin subcutaneous syringe
100 mg/ml
120 mg/0.8 ml, 80 mg/0.8 ml
150 mg/ml
30 mg/0.3 ml
40 mg/0.4 ml
60 mg/0.6 ml
fondaparinux subcutaneous syringe
10 mg/0.8 ml
2.5 mg/0.5 ml
5 mg/0.4 ml
7.5 mg/0.6 ml
heparin (porcine) in 5 % dex
intravenous parenteral solution
12,500 unit/250 ml, 20,000 unit/500
ml (40 unit/ml)
HEPARIN (PORCINE) IN 5 %
DEX INTRAVENOUS
PARENTERAL SOLUTION
25,000 UNIT/250 ML(100
UNIT/ML), 25,000 UNIT/500 ML
(50 UNIT/ML)
heparin (porcine) in nacl (pf)
1,000 unit/500 ml
(Heparin
Sodium,Porcine/Ns
/PF)
Medidas necesarias,
restricciones o
límites de uso
QL (36 per 30 days)
QL (36 per 30 days)
QL (34 per 30 days)
QL (18 per 30 days)
QL (24 per 30 days)
QL (15 per 30 days)
QL (12 per 30 days)
QL (18 per 30 days)
67
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
IPRIVASK
2
$0
jantoven
(Coumadin)
PRADAXA
warfarin
(Coumadin)
XARELTO
Blood Formation Modifiers
EPOGEN INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/2 ML, 20,000
UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
GRANIX
LEUKINE INJECTION RECON
SOLN
1
2
1
2
$0
$0
$0
$0
heparin (porcine) injection
heparin, porcine (pf) injection
heparin, porcine (pf) intravenous
syringe 100 unit/ml
HEPARIN-0.45% NACL 25,000
UNITS/250 ML (100 UNITS/ML)
BAG LATEX-FREE, OUTER
HEPARIN-0.45% NACL 25,000
UNITS/500 ML (50 UNITS/ML)
BAG LATEX-FREE, OUTER
heparin-d5w 25,000 units/250 ml
(100 units/ml) bag excel container
heparin-d5w 25,000 units/500 ml
(50 units/ml) bag excel container
(Heparin
Sodium,Porcine)
(Monoject Prefill
Advanced)
(Monoject Prefill
Advanced)
(Heparin Sodium
in 5% Dextrose)
(Heparin Sodium
in 5% Dextrose)
Medidas necesarias,
restricciones o
límites de uso
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA; QL (24 per 28
days)
QL (60 per 30 days)
PA; QL (12 per 28
days)
2
$0
2
$0
2
$0
MIRCERA
2
$0
MOZOBIL
NEULASTA SUBCUTANEOUS
SYRINGE
2
$0
2
$0
PA; QL (0.6 per 28
days)
68
Nivel
Lo que le
costará a
usted el
NEUMEGA
NEUPOGEN
PROCRIT INJECTION
SOLUTION 10,000 UNIT/ML,
2,000 UNIT/ML, 20,000 UNIT/2
ML, 20,000 UNIT/ML, 3,000
UNIT/ML, 4,000 UNIT/ML
PROCRIT INJECTION
SOLUTION 40,000 UNIT/ML
2
2
$0
$0
Medidas necesarias,
restricciones o
límites de uso
PA; QL (12 per 28
days)
2
$0
2
$0
PROMACTA
2
$0
Hematologic Agents, Miscellaneous
aminocaproic acid oral
(Amicar)
anagrelide
(Agrylin)
1
1
$0
$0
protamine
(Protamine Sulfate)
1
$0
tranexamic acid intravenous
(Tranexamic Acid)
tranexamic acid oral
(Lysteda)
Platelet-Aggregation Inhibitors
AGGRENOX
BRILINTA
cilostazol
(Pletal)
clopidogrel
(Plavix)
EFFIENT
pentoxifylline
(Pentoxifylline)
Volume Expanders
ALBUKED-25
ALBUKED-5
ALBUMIN, HUMAN 25 %
ALBUMIN, HUMAN 5 %
ALBUMINAR 25 %
ALBUMINAR 5 %
ALBURX (HUMAN) 5 %
ALBUTEIN 25 %
ALBUTEIN 5 %
1
1
$0
$0
2
2
1
1
2
1
$0
$0
$0
$0
$0
$0
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
PA; QL (30 per 30
days)
PA BvD; (PA for
ESRD Only)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
69
BUMINATE 25 %
BUMINATE 5 %
FLEXBUMIN 25 %
FLEXBUMIN 5 %
KEDBUMIN
PLASBUMIN 25 %
PLASBUMIN 5 %
Nivel
Lo que le
costará a
usted el
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
Medidas necesarias,
restricciones o
límites de uso
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
AMINOSYN 10 %
AMINOSYN 3.5 %
AMINOSYN 7 %
AMINOSYN 7 % WITH
ELECTROLYTES
AMINOSYN 8.5 %
AMINOSYN 8.5 %ELECTROLYTES
AMINOSYN II 10 %
AMINOSYN II 15 %
AMINOSYN II 7 %
AMINOSYN II 8.5 %
AMINOSYN II 8.5 %ELECTROLYTES
AMINOSYN M 3.5 %
AMINOSYN-HBC 7%
AMINOSYN-PF 10 %
AMINOSYN-PF 7 % (SULFITEFREE)
AMINOSYN-RF 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE
CLINIMIX 5%/D25W SULFITEFREE
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
70
CLINIMIX 2.75%/D5W SULFIT
FREE
CLINIMIX 4.25%/D10W SULF
FREE
CLINIMIX 4.25%/D5W SULFIT
FREE
CLINIMIX 4.25%-D20W SULFFREE
CLINIMIX 4.25%-D25W SULFFREE
CLINIMIX 5%-D20W(SULFITEFREE)
CLINIMIX E 2.75%/D10W SUL
FREE
CLINIMIX E 2.75%/D5W SULF
FREE
FREE
FREE
CLINIMIX E 4.25%/D5W SULF
FREE
CLINIMIX E 5%/D15W SULFIT
FREE
FREE
FREE
CLINISOL SF 15 %
cysteine (l-cysteine) intravenous
solution
d10 % & 0.45 % sodium chloride
d2.5 %-0.45 % sodium chloride
(Cysteine HCl)
(Dextrose 10 %
and 0.45 % NaCl)
(Dextrose 2.5 %
and 0.45 % NaCl)
Nivel
Lo que le
costará a
usted el
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
71
Nivel
Lo que le
costará a
usted el
Medidas necesarias,
restricciones o
límites de uso
(Dextrose 5 % and
1
$0
0.9 % NaCl)
(Dextrose 5 %-0.45
d5 %-0.45 % sodium chloride
1
$0
% NaCl)
dex4 glucose * oral tablet,chewable (Dextrose)
4
$0
(Dextrose 10 %
dextrose 10 % and 0.2 % nacl
1
$0
and 0.2 % NaCl)
dextrose 10 % in water (d10w)
(Dextrose 10 % in
PA BvD
1
$0
intravenous
Water)
(Dextrose 2.5 % in
PA BvD
dextrose 2.5 % in water(d2.5w)
1
$0
Water)
(Dextrose 20 % in
PA BvD
1
$0
Water)
(Dextrose 25 % in
PA BvD
1
$0
Water)
(Dextrose 40 % in
PA BvD
1
$0
Water)
(Dextrose 5% In
dextrose 5 % in ringers
1
$0
Ringers)
(Dextrose 5 % in
1
$0
intravenous
Water)
(Dextrose 5%dextrose 5 %-lactated ringers
1
$0
Lactated Ringers)
(Dextrose 5 %-0.2
dextrose 5%-0.2 % sod chloride
1
$0
% NaCl)
(Dextrose 5 % and
dextrose 5%-0.3 % sod.chloride
1
$0
0.3 % NaCl)
(Dextrose 50 % in
PA BvD
1
$0
Water)
(Dextrose 70 % in
PA BvD
1
$0
Water)
(Dextrose 5 %-0.2
dextrose with sodium chloride
1
$0
% NaCl)
FREAMINE HBC 6.9 %
2
$0
PA BvD
FREAMINE III 10 %
2
$0
PA BvD
gluco burst *
(Dextrose)
4
$0
d5 % and 0.9 % sodium chloride
72
glucose gel *
glucose * oral tablet,chewable
glutose 15 *
HEPATAMINE 8%
HEPATASOL 8 %
insta-glucose *
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN
LIPOSYN II
LIPOSYN III
NEPHRAMINE 5.4 %
NUTRILIPID
PERIKABIVEN
potassium chloride in lr-d5
PREMASOL 10 %
PREMASOL 6 %
PROCALAMINE 3%
PROSOL 20 %
TRAVASOL 10 %
TROPHAMINE 10 %
TROPHAMINE 6%
(Dextrose)
(Dextrose)
(Dextrose)
(Dextrose/Dextrin/
Maltose)
(Potassium
Chloride In Lr-D5)
Nivel
Lo que le
costará a
usted el
4
4
4
2
2
$0
$0
$0
$0
$0
4
$0
2
$0
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
1
$0
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet
clonidine hcl-chlorthalidone
(Catapres)
(Clonidine
HCl/Chlorthalidon
e)
clonidine transdermal patch weekly
QL (4 per 28 days)
(Catapres-Tts 1)
1
$0
0.1 mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly
QL (8 per 28 days)
(Catapres-Tts 1)
1
$0
0.3 mg/24 hr
doxazosin
(Cardura)
1
$0
73
Nivel
Lo que le
costará a
usted el
(Tenex)
(Midodrine HCl)
1
1
$0
$0
(Medi-Phenyl)
4
$0
NORTHERA
2
$0
phenylephrine hcl injection
(Vazculep)
prazosin oral
(Minipress)
sudogest pe *
(Medi-Phenyl)
wal-phed pe *
(Medi-Phenyl)
Angiotensin Ii Receptor Antagonists
BENICAR
BENICAR HCT
candesartan
(Atacand)
candesartan-hydrochlorothiazid
(Atacand HCT)
irbesartan
(Avapro)
irbesartan-hydrochlorothiazide
(Avalide)
losartan
(Cozaar)
losartan-hydrochlorothiazide
(Hyzaar)
telmisartan
(Micardis)
telmisartan-hydrochlorothiazid
(Micardis HCT)
TRIBENZOR
valsartan
(Diovan)
valsartan-hydrochlorothiazide
(Diovan HCT)
Angiotensin-Converting Enzyme Inhibitors
benazepril
(Lotensin)
benazepril-hydrochlorothiazide
(Lotensin HCT)
captopril
(Captopril)
(Captopril/Hydroch
captopril-hydrochlorothiazide
lorothiazide)
enalapril maleate
(Vasotec)
(Enalaprilat
enalaprilat intravenous injectable
Dihydrate)
enalapril-hydrochlorothiazide
(Vaseretic)
1
1
4
4
$0
$0
$0
$0
2
2
1
1
1
1
1
1
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
guanfacine oral tablet
midodrine
nasal decongestant (pe) * oral
tablet 10 mg
Medidas necesarias,
restricciones o
límites de uso
PA-HRM
PA; QL (180 per 30
days)
ST
ST
ST
74
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Cordarone)
1
$0
(Cordarone)
1
$0
(Norpace)
1
$0
1
$0
1
$0
1
$0
1
2
$0
$0
(Procainamide
HCl)
1
$0
(Rythmol SR)
1
$0
(Rythmol)
(Quinidine
Gluconate)
1
$0
1
$0
fosinopril
fosinopril-hydrochlorothiazide
lisinopril
lisinopril-hydrochlorothiazide
moexipril
moexipril-hydrochlorothiazide
perindopril erbumine
quinapril
quinapril-hydrochlorothiazide
ramipril
trandolapril
Antiarrhythmic Agents
amiodarone hcl oral tablet 100 mg,
200 mg, 400 mg
amiodarone oral
disopyramide phosphate oral
capsule
flecainide
lidocaine (pf) intravenous syringe
50 mg/5 ml (1 %)
lidocaine in 5 % dextrose (pf)
intravenous parenteral solution 8
mg/ml (0.8 %)
mexiletine
MULTAQ
procainamide injection
propafenone oral capsule,extended
release 12 hr
propafenone oral tablet
quinidine gluconate oral
(Fosinopril
Sodium)
(Fosinopril/Hydroc
hlorothiazide)
(Zestril)
(Zestoretic)
(Univasc)
(Uniretic)
(Aceon)
(Accupril)
(Accuretic)
(Altace)
(Mavik)
(Flecainide
Acetate)
(Lidocaine
HCl/PF)
(Lidocaine
HCl/D5w/PF)
(Mexiletine HCl)
Medidas necesarias,
restricciones o
límites de uso
75
Nivel
Lo que le
costará a
usted el
Medidas necesarias,
restricciones o
límites de uso
quinidine sulfate
(Quinidine Sulfate)
1
$0
TIKOSYN
2
$0
Beta-Adrenergic Blocking Agents
acebutolol oral
(Sectral)
1
$0
atenolol
(Tenormin)
1
$0
atenolol-chlorthalidone
(Tenoretic 50)
1
$0
betaxolol oral
(Kerlone)
1
$0
bisoprolol fumarate
(Zebeta)
1
$0
bisoprolol-hydrochlorothiazide
(Ziac)
1
$0
BYSTOLIC
2
$0
carvedilol
(Coreg)
1
$0
esmolol intravenous
(Esmolol HCl)
1
$0
PA BvD
labetalol intravenous solution
(Trandate)
1
$0
labetalol oral
(Trandate)
1
$0
metoprolol succinate
(Toprol XL)
1
$0
metoprolol ta-hydrochlorothiaz
(Lopressor HCT)
1
$0
(Metoprolol
metoprolol tartrate intravenous
1
$0
Tartrate)
metoprolol tartrate oral
(Lopressor)
1
$0
nadolol
(Corgard)
1
$0
pindolol
(Pindolol)
1
$0
propranolol intravenous
(Propranolol HCl)
1
$0
propranolol oral capsule,extended
(Inderal LA)
1
$0
release 24 hr
propranolol oral solution
(Propranolol HCl)
1
$0
propranolol oral tablet
(Propranolol HCl)
1
$0
(Propranolol/Hydro
propranolol-hydrochlorothiazid
1
$0
chlorothiazid)
sotalol hcl oral tablet 120 mg, 160
(Betapace)
1
$0
mg, 240 mg, 80 mg
sotalol oral
(Betapace)
1
$0
timolol maleate oral
(Timolol Maleate)
1
$0
Calcium-Channel Blocking Agents
cartia xt
(Cardizem CD)
1
$0
diltiazem hcl intravenous
(Cardizem CD)
1
$0
76
diltiazem hcl oral capsule, extended
(Cardizem CD)
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended
(Cardizem CD)
release 12 hr
diltiazem hcl oral capsule,extended
(Cardizem CD)
release 24hr
diltiazem hcl oral tablet
(Cardizem CD)
diltiazem hcl oral tablet extended
(Cardizem LA)
release 24 hr
dilt-xr
(Cardizem CD)
matzim la
(Cardizem CD)
taztia xt
(Cardizem CD)
verapamil intravenous syringe
(Verapamil HCl)
verapamil oral capsule, 24 hr er
(Verelan Pm)
pellet ct
verapamil oral capsule,ext rel.
(Verelan)
pellets 24 hr
verapamil oral tablet
(Calan)
verapamil oral tablet extended
(Calan SR)
release
Cardiovascular Agents, Miscellaneous
ADRENALIN 1 MG/ML VIAL
SUV
adrenalin injection solution 1
(Epinephrine)
mg/ml (1:1,000) (1ml)
DEMSER
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
digitek oral tablet 125 mcg
(Lanoxin)
1
$0
digitek oral tablet 250 mcg
(Lanoxin)
1
$0
digoxin injection
(Digoxin)
1
$0
Medidas necesarias,
restricciones o
límites de uso
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days)
PA-HRM; QL (30 per
30 days)
PA-HRM
77
Nivel
Lo que le
costará a
usted el
2
$0
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
(Epinephrine)
1
$0
(Adrenaclick)
1
$0
(Epinephrine)
1
$0
2
2
$0
$0
1
$0
2
1
$0
$0
DIGOXIN ORAL SOLUTION
digoxin oral tablet
(Lanoxin)
dobutamine in d5w intravenous
parenteral solution
dobutamine intravenous solution
dopamine in 5 % dextrose
intravenous solution
dopamine intravenous solution
ephedrine sulfate injection solution
epinephrine 1 mg/ml ampul latexfree
epinephrine injection auto-injector
epinephrine injection syringe 0.1
mg/ml (1:10,000)
EPIPEN 2-PAK
EPIPEN JR 2-PAK
(Dobutamine
HCl/D5W)
(Dobutamine HCl)
(Dopamine
HCl/D5W)
(Dopamine HCl)
(Ephedrine Sulfate)
ethamolin
FIRAZYR
hydralazine
(Ethanolamine
Oleate)
(Hydralazine HCl)
LANOXIN ORAL TABLET 187.5
MCG, 62.5 MCG
milrinone
milrinone in 5 % dextrose
intravenous piggyback 40 mg/200
ml (200 mcg/ml)
2
$0
(Milrinone Lactate)
1
$0
(Milrinone
Lactate/D5W)
1
$0
Medidas necesarias,
restricciones o
límites de uso
PA-HRM; QL (300 per
30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
PA BvD
PA BvD
PA BvD
PA BvD
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
PA BvD
PA BvD
78
norepinephrine bitartrate
papaverine injection solution
papaverine oral
RANEXA
Dihydropyridines
amlodipine
amlodipine-benazepril
AZOR
CLEVIPREX INTRAVENOUS
EMULSION
EXFORGE
EXFORGE HCT
felodipine
isradipine
nicardipine oral
nifedipine oral tablet extended
release 24hr 30 mg
release 24hr 60 mg, 90 mg
release 30 mg, 60 mg
Diuretics
amiloride oral
amiloride-hydrochlorothiazide
bumetanide
chlorothiazide
chlorothiazide sodium
chlorthalidone oral tablet 25 mg, 50
mg
DYRENIUM
furosemide injection
furosemide oral solution
furosemide oral tablet
(Levophed
Bitartrate)
(Papaverine HCl)
(Papaverine HCl)
(Norvasc)
(Lotrel)
Nivel
Lo que le
costará a
usted el
1
$0
1
1
2
$0
$0
$0
1
1
2
$0
$0
$0
2
$0
(Felodipine)
(Isradipine)
(Nicardipine HCl)
1
1
1
1
1
$0
$0
$0
(Adalat CC)
1
$0
(Procardia XL)
1
$0
(Adalat CC)
1
$0
(Midamor)
(Amiloride/Hydroc
hlorothiazide)
(Bumetanide)
(Chlorothiazide)
(Sodium Diuril)
1
$0
1
$0
1
1
1
$0
$0
$0
(Chlorthalidone)
1
$0
(Furosemide)
(Furosemide)
(Lasix)
2
1
1
1
$0
$0
$0
$0
Medidas necesarias,
restricciones o
límites de uso
PA BvD
PA
PA
ST
ST
ST
79
Nivel
Lo que le
costará a
usted el
(Microzide)
(Hydrochlorothiazi
de)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Dyazide)
1
$0
(Maxzide)
1
$0
(Caduet)
(Lipitor)
(Questran)
(Cholestyramine/A
spartame)
1
1
1
$0
$0
$0
1
$0
(Questran)
1
$0
(Colestid)
1
2
$0
$0
(Slo-Niacin)
4
$0
(Antara)
(Tricor)
(Lofibra)
(Fibricor)
(Trilipix)
(Lopid)
(Inositol/Choline/V
it B Comp)
(Mevacor)
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
4
$0
1
$0
(Niacin)
4
$0
hydrochlorothiazide oral capsule
hydrochlorothiazide oral tablet
indapamide
methyclothiazide
metolazone
torsemide oral
triamterene-hydrochlorothiazid oral
capsule
triamterene-hydrochlorothiazid oral
tablet
Dyslipidemics
amlodipine-atorvastatin
atorvastatin
cholestyramine (with sugar) oral
cholestyramine-aspartame oral
powder 4 gram
cholestyramine-aspartame oral
powder in packet 4 gram
colestipol
CRESTOR
endur-acin * oral tablet extended
release 500 mg
fenofibrate micronized
fenofibrate nanocrystallized
fenofibrate oral tablet
fenofibric acid
fenofibric acid (choline)
gemfibrozil oral
lipogen *
lovastatin
niacin * oral capsule, extended
release 500 mg
Medidas necesarias,
restricciones o
límites de uso
80
niacin * oral tablet 100 mg, 50 mg,
(Slo-Niacin)
500 mg
niacin oral tablet extended release
(Niaspan)
24 hr
niacin * oral tablet extended
(Slo-Niacin)
release 500 mg
omega-3 acid ethyl esters
(Lovaza)
pravastatin
(Pravachol)
simvastatin
(Zocor)
VASCEPA
WELCHOL
ZETIA
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
(Inspra)
spironolactone
(Aldactone)
spironolacton-hydrochlorothiaz
(Aldactazide)
Vasodilators
isosorbide dinitrate oral
(Isochron)
(Isosorbide
isosorbide dinitrate sublingual
Dinitrate)
(Isosorbide
isosorbide mononitrate oral tablet
Mononitrate)
isosorbide mononitrate oral tablet
(Imdur)
minitran transdermal patch 24 hour
(Nitro-Dur)
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour
(Nitro-Dur)
0.4 mg/hr
minoxidil oral
(Minoxidil)
NITRO-BID
nitroglycerin in 5 % dextrose
(Nitroglycerin/D5
W)
nitroglycerin intravenous
(Nitroglycerin)
Nivel
Lo que le
costará a
usted el
4
$0
1
$0
4
$0
1
1
1
2
2
2
$0
$0
$0
$0
$0
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
2
$0
$0
1
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
81
nitroglycerin transdermal patch 24
hour 0.1 mg/hr, 0.2 mg/hr, 0.6
mg/hr
nitroglycerin transdermal patch 24
hour 0.4 mg/hr
NITROSTAT
PROGLYCEM
Nivel
Lo que le
costará a
usted el
Medidas necesarias,
restricciones o
límites de uso
QL (30 per 30 days)
(Nitro-Dur)
1
$0
(Nitro-Dur)
1
$0
2
2
$0
$0
Central Nervous System Agents
amphetamine salt combo
(Adderall)
1
$0
AMPYRA
2
$0
(Cafcit)
(Cafcit)
(Caffeine/Sodium
Benzoate)
1
1
$0
$0
1
$0
(Kapvay)
1
$0
(Focalin)
1
$0
(Dexedrine)
1
$0
(Dexedrine)
1
$0
(Adderall XR)
1
$0
QL (60 per 30 days)
Central Nervous System Agents
caffeine citrated intravenous
caffeine citrated oral
caffeine-sodium benzoate
clonidine hcl oral tablet extended
release 12 hr
dexmethylphenidate oral tablet
dextroamphetamine oral capsule,
extended release
dextroamphetamine oral tablet
dextroamphetamine-amphetamine
oral capsule,extended release 24hr
10 mg, 15 mg, 5 mg
dextroamphetamine-amphetamine
oral capsule,extended release 24hr
20 mg, 25 mg, 30 mg
flumazenil
guanfacine oral tablet extended
release 24 hr
lithium carbonate oral capsule
lithium carbonate oral tablet
lithium carbonate oral tablet
extended release
QL (60 per 30 days)
PA; QL (60 per 30
days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
(Adderall XR)
1
$0
(Romazicon)
1
$0
(Intuniv)
1
$0
(Eskalith)
(Lithobid)
1
1
$0
$0
(Lithobid)
1
$0
82
Nivel
Lo que le
costará a
usted el
(Lithium Citrate)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Ritalin LA)
1
$0
(Methylin)
(Ritalin)
1
1
$0
$0
(Ritalin-SR)
1
$0
(Concerta)
1
$0
(Concerta)
1
$0
(Rilutek)
2
2
1
2
2
$0
$0
$0
$0
$0
2
$0
1
1
1
$0
$0
$0
lithium citrate oral solution
methylphenidate oral capsule, er
biphasic 30-70 10 mg, 20 mg, 50
mg, 60 mg
methylphenidate oral capsule, er
biphasic 30-70 30 mg
methylphenidate oral capsule,er
methylphenidate oral solution
methylphenidate oral tablet
extended release
extended release 24hr 18 mg, 27
mg, 54 mg
extended release 24hr 36 mg
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
Medidas necesarias,
restricciones o
límites de uso
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
XENAZINE
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
ashlyna
deblitane
desog-e.estradiol/e.estradiol
(Seasonique)
(Nor-Q-D)
(Mircette)
QL (91 per 84 days)
83
Nivel
Lo que le
costará a
usted el
(Desogen)
1
$0
(Yaz)
1
2
1
$0
$0
$0
1
$0
1
1
1
1
4
$0
$0
$0
$0
$0
1
$0
desogestrel-ethinyl estradiol oral
tablet 0.1/.125/.15-25 mg-mcg,
0.15-0.03 mg
drospirenone-ethinyl estradiol
ELLA
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
gildess 24 fe
l norgest&e estradiol-e estrad
levonorgestrel 1.5 mg tablet (rx)
levonorgestrel oral tablet 0.75 mg
levonorgestrel * oral tablet 1.5 mg
levonorgestrel-ethin estradiol oral
tablet 0.1-20 mg-mcg, 0.15-0.03
mg, 50-30 (6)/75-40 (5)/125-30(10)
levonorgestrel-ethin estradiol oral
tablets,dose pack,3 month 0.15-30
mg-mcg
levonorgestrel-ethinyl estrad oral
tablet
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month
l-norgest-eth estr/ethin estra
next choice one dose 1.5 mg tb (rx)
1.5 mg
norelgestromin/ethin.estradiol
noreth-ethinyl estradiol/iron
norethindrone
norethindrone (contraceptive)
norethindrone ac-eth estradiol oral
tablet 1-20 mg-mcg, 1.5-30 mg-mcg
(Yaz)
(Ethynodiol DEthinyl Estradiol)
(Loestrin Fe)
(Seasonique)
(Plan B One-Step)
(Plan B One-Step)
(Plan B One-Step)
(Amethyst)
QL (91 per 84 days)
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
(LevonorgestrelEthin Estradiol)
1
$0
(Amethyst)
1
$0
1
$0
1
$0
(Plan B One-Step)
1
$0
(Ortho Evra)
(Femcon Fe)
(Nor-Q-D)
(Nor-Q-D)
1
1
1
1
$0
$0
$0
$0
(Loestrin)
1
$0
(LevonorgestrelEthin Estradiol)
(Seasonique)
Medidas necesarias,
restricciones o
límites de uso
QL (91 per 84 days)
QL (91 per 84 days)
QL (6 per 365 days)
QL (3 per 28 days)
84
Nivel
Lo que le
costará a
usted el
(Loestrin Fe)
1
$0
(Modicon)
1
$0
(Norinyl 1+50)
(Ortho-Cyclen)
(Norgestrel-Ethinyl
Estradiol)
1
1
$0
$0
1
$0
2
4
3
1
$0
$0
$0
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
norethindrone-e.estradiol-iron oral
tablet 1 mg-20 mcg (21)/75 mg (7),
1 mg-20 mcg (24)/75 mg (4), 120(5)/1-30(7) /1mg-35mcg (9), 1.5
mg-30 mcg (21)/75 mg (7)
norethindrone-ethinyl estrad oral
tablet 0.4-35 mg-mcg, 0.5-35 mgmcg, 0.5-35/1-35 mg-mcg/mg-mcg,
0.5/0.75/1 mg- 35 mcg, 0.5/1/0.5-35
mg-mcg, 1-35 mg-mcg
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
NUVARING
opcicon one-step *
PLAN B ONE-STEP *
tarina fe
(Plan B One-Step)
(Loestrin Fe)
Medidas necesarias,
restricciones o
límites de uso
ST; QL (1 per 28 days)
QL (6 per 365 days)
QL (6 per 365 days)
Cough And Cold Products
Cough And Cold Products
30pse-150gfn-15dm *
(Trispec Pse)
adt robitussin peak cld dm max *
(G-Zyncof)
(Pseudoephedrine
adult nasal decongestant *
HCl)
(Dextromethorphan
adult robitussin lingering cld *
Hbr)
adult robitussin peak cold dm *
(G-Zyncof)
(Robitussin
adult wal-tussin *
Mucus-Chest
Congest)
adult wal-tussin dm max *
(G-Zyncof)
(Guaifenesin/Dextr
alka-seltzer plus mucus-conges *
omethorphan)
85
(Dalka-seltzer plus sinus-cough *
Methorphan/Pe/Ac
etaminophen)
(Dm/Phenyleph/Ch
ambi 10peh-4cpm-20dm *
lorpheniramine)
ambi 20dm-4cpm *
(Coricidin Hbp)
(Guaifenesin/Dm/P
ambi 40pse-400gfn-20dm *
seudoephedrine)
(D-Methorphan
ambi 60pse-4cpm-20dm *
Hb/P-Ephed
HCl/Cp)
benzonatate *
(Zonatuss)
(D-Methorphan
bio-dtuss dmx *
Hb/P-Epd
HCl/Bpm)
(Guaifenesin/Dm/P
bionel *
seudoephedrine)
bionel pediatric *
(Trispec Pse)
biospec dmx *
(G-Zyncof)
(D-Methorphan
bromphenex dm *
Hb/P-Epd
HCl/Bpm)
(D-Methorphan
brompheniramine-pseudoeph-dm *
Hb/P-Epd
oral liquid
HCl/Bpm)
(D-Methorphan
brompheniramine-pseudoeph-dm *
Hb/P-Epd
oral syrup
HCl/Bpm)
(Brompheniram/Ph
brompheniram-phenylephrine-dm *
enylephrine/Dm)
broncotron-s *
(G-Zyncof)
cardec dm (phenyleph-chlorphn) * (Accuhist Pdx)
cheratussin ac *
(M-Clear Wc)
cheratussin dac *
(Tusnel C)
chest congestion relief + dm *
(Allfen Dm)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
3
$0
4
4
4
4
4
$0
$0
$0
$0
$0
Medidas necesarias,
restricciones o
límites de uso
86
chest congestion relief d *
chest congestion relief pe *
child cough & sore throat *
child mucinex chest congestion *
child mucus relief cough *
child plus cough & runny nose *
child triaminic cough-congest *
child wal-tussin cough relief *
children's chest congestion *
(Guaifenesin/Pseud
oephedrne HCl)
(Maxiphen)
(D-Methorphan
Hb/Acetaminophen
)
(Robitussin
Mucus-Chest
Congest)
(G-Zyncof)
(Dextromethorphn/
Acetaminoph/Cp)
(Guaifenesin/Dextr
omethorphan)
(Dextromethorphan
Hbr)
(Robitussin
Mucus-Chest
Congest)
CHILDREN'S DIMETAPP COLD
&FLU *
children's flu relief *
children's mucinex cough *
children's silfedrine *
children's sudafed *
children's sudafed pe cough *
chlophedianol-guaifenesin *
chlorpheniramine-phenyleph-dm *
codituss dm *
(Childrens Tylenol
Plus Cold)
(G-Zyncof)
(Pseudoephedrine
HCl)
(Pseudoephedrine
HCl)
(Dextromethorphan
/Phenylephrine)
(Vanacof G)
(Dm/Phenyleph/Ch
lorpheniramine)
(Pyrilamine/Pe/De
xtromethorphan)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
87
(Comtrex Cold and
Cough)
(Dm
cold multi-symptom day/night *
Hb/Pe/Acetaminop
hen/Chlorph)
(Dm/Pe/Acetamino
cold multi-symptom nighttime *
phen/Doxylamine)
(Dm
cold relief m/s day/night *
Hb/Pe/Acetaminop
hen/Chlorph)
(Dcold-flu relief * oral liquid 12.5-30Methorphan/Aceta
1,000 mg/30 ml
min/Doxylamn)
(Vicks Dayquilcold-flu relief, day/night *
Nyquil)
(Guaifenesin/Pseud
congestac *
oephedrne HCl)
(Guaifenesin/Dextr
coricidin hbp * oral capsule
omethorphan)
cough & cold * oral
(Coricidin Hbp)
cough & runny nose * oral liquid 1- (Vicks Children'S
5 mg/5 ml
Nyquil)
coughtab *
(Allfen)
(Guaifenesin/Dextr
creo-terpin (dm-guaifenesin) *
omethorphan)
DALLERGY DM *
daytime cold & cough *
(Triaminic)
(Ddaytime cold-flu *
Methorphan/Pe/Ac
etaminophen)
(Dextromethorphan
day-time cough *
Hbr)
daytime mucus relief dm *
(G-Zyncof)
(Vicks Dayquildaytime-nighttime *
Nyquil)
cold multi-symptom *
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
88
daytime-nighttime cold-flu *
daytime-nighttime cough *
decongestant cough *
delsym cough+chest congest dm *
despec-dm (pseudoeph-dm-guaif) *
oral tablet 30-10-200 mg
dexchlorphen-pse-chlophedianol *
dextromethorphan polistirex *
diabetic siltussin das-na *
diabetic tussin dm *
diabetic tussin ex * oral
dimaphen dm *
d-methorphan hb-p-epd hcl-bpm *
oral syrup 2-30-10 mg/5 ml
dm-phenyleph-chlorpheniramine *
oral drops 1-2-3 mg/ml
dm-phenyleph-chlorpheniramine *
oral liquid 2-5-15 mg/5 ml, 4-10-15
mg/5 ml
double-tussin dm *
ed bron gp *
entre-cough *
exefen dmx *
expectorant max strength *
(Dm/Pe/Acetamino
phen/Doxylamine)
(Dextromethorphan
Hb/Doxylamine)
(Trispec Pse)
(G-Zyncof)
(Guaifenesin/Dm/P
seudoephedrine)
(DChlorphenira/Pse/C
hlophedian)
(Delsym)
(Robitussin
Mucus-Chest
Congest)
(G-Zyncof)
(Robitussin
Mucus-Chest
Congest)
(Brompheniram/Ph
enylephrine/Dm)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(Dm/Phenyleph/Ch
lorpheniramine)
(Dm/Phenyleph/Ch
lorpheniramine)
(G-Zyncof)
(Despec)
(Trispec Pse)
(Guaifenesin/Dm/P
seudoephedrine)
(Dextromethorphan
/Pseudoephed)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
89
expectorant * oral
flu formula daytime-nighttime *
flu severe cold-congestion *
flu-severe cold-cough * oral
powder in packet 10-20-650 mg
guaiatussin ac *
guaifenesin dac *
guaifenesin * oral tablet 200 mg
guaifenesin * oral tablet extended
release 12hr
head congestion day-night *
hydrocodone bit-homatrop me-br *
oral syrup 5-1.5 mg/5 ml
hydrocodone-chlorpheniramine *
hydrocodone-homatropine * oral
syrup 5-1.5 mg/5 ml
hydrocodone-homatropine * oral
tablet
infants' non-aspirin cold *
intense cough reliever * oral liquid
kidkare cough/cold *
liquibid d-r *
lohist peb dm *
lortuss ex * oral syrup
(Robitussin
Mucus-Chest
Congest)
(Dm/Pe/Acetamino
ph/Diphenhydram)
(Theraflu)
(DMethorphan/Pe/Ac
etaminophen)
(M-Clear Wc)
(Tusnel C)
(Allfen)
(Mucinex)
(Dm
Hb/Pe/Acetaminop
hen/Chlorph)
(Hydrocodone
Bit/Homatrop MeBr)
(Tussionex)
(Hydrocodone
Bit/Homatrop MeBr)
(Tussigon)
(Dm/Pseudoephed/
Acetaminophen)
(G-Zyncof)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Maxiphen)
(Ala-Hist Dm)
(Tusnel C)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
3
$0
3
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
Medidas necesarias,
restricciones o
límites de uso
90
mar-cof bp *
mar-cof cg *
maximum strength flu *
medi-brom *
mesehist dm *
mucinex fast-max dm max *
mucus dm *
mucus dm max *
mucus relief * oral tablet 400 mg
multi-symptom cold night time *
multi-symptom cold-cough *
nasal & sinus decongestant *
neo-tuss *
NEXAFED *
night time cold-flu * oral
night time cold-flu relief * oral
liquid
night time * oral capsule
nighttime cold-flu *
nighttime cough *
(Bromphenira/Pseu
doephed/Codein)
(M-Clear Wc)
(Coricidin Hbp)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(G-Zyncof)
(Mucinex Dm)
(Mucinex Dm)
(Allfen)
(Theraflu)
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Sudafed 12-Hour)
(G-Zyncof)
(Dm/PEphed/Acetaminop
h/Doxylam)
h/Doxylam)
h/Doxylam)
(DMethorphan/Aceta
min/Doxylamn)
(Dextromethorphan
Hb/Doxylamine)
Nivel
Lo que le
costará a
usted el
3
$0
3
4
$0
$0
4
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
91
nite time cold-flu * oral
nite time-d cold-flu relief *
nohist-dm *
non-aspirin cold *
non-aspirin flu * oral tablet 30-15500 mg
pecgen dmx *
pedia relief *
pedia relief infant *
pediacare multi-symptom cold *
phenylhistine dh *
poly-tussin *
(DMethorphan/Aceta
min/Doxylamn)
h/Doxylam)
(Dm/Phenyleph/Ch
lorpheniramine)
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Dm/Pseudoephed/
Acetaminophen)
(G-Zyncof)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Dextromethorphan
/Pseudoephed)
(Dextromethorphan
/Phenylephrine)
(P-Ephed
HCl/Cod/Chlorphe
nir)
(Chlorcyclizine/Co
deine)
POLY-TUSSIN DM *
promethazine-codeine *
promethazine-dm *
promethazine-phenyleph-codeine *
pseudoephedrine hcl * oral
pseudoephedrine hcl * oral
(Promethazine
HCl/Codeine)
(D-Methorphan
Hb/Prometh HCl)
(Promethazine/Phe
nyleph/Codeine)
(Pseudoephedrine
HCl)
(Sudafed 12-Hour)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
3
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
92
q-tapp dm *
q-tussin *
q-tussin dm *
refenesen *
refenesen pe *
relcof c *
REZIRA *
robafen *
robafen cough *
robafen dm *
robitussin cough & cold cf *
robitussin cough-chest-cong dm *
robitussin dm max *
ROBITUSSIN LONG-ACTING *
robitussin pediatric *
rydex *
safe tussin dm *
scot-tussin dm *
scot-tussin expectorant *
siltussin dm das *
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(Robitussin
Mucus-Chest
Congest)
(Guaifenesin/Dextr
omethorphan)
(Allfen)
(Maxiphen)
(M-Clear Wc)
(Robitussin
Mucus-Chest
Congest)
(Dextromethorphan
Hbr)
(Guaifenesin/Dextr
omethorphan)
(Giltuss)
(Guaifenesin/Dextr
omethorphan)
(G-Zyncof)
(Dextromethorphan
Hbr)
(Bromphenira/Pseu
doephed/Codein)
(G-Zyncof)
(Vicks Children'S
Nyquil)
(Robitussin
Mucus-Chest
Congest)
(G-Zyncof)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
4
3
3
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
93
siltussin sa *
sudogest *
suphedrin * oral
suphedrine pe day-night *
suphedrine severe cold max str *
(Robitussin
Mucus-Chest
Congest)
(Sudafed 12-Hour)
(Pseudoephedrine
HCl)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
(Dm/Pseudoephed/
Acetaminophen)
THERAFLU NIGHTTIME
SEVERE COLD *
THERAFLU SEVERE COLDCOUGH *
triacting m-sym cold/cough *
triaminic cold & cough (pe) *
triaminic cough-nasal congesti *
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Dextromethorphan
/Phenylephrine)
(Robitussin
Pediatric)
TRIAMINIC COUGH-SORE
THROAT *
tri-dex pe *
trigofen dm *
trymine cg *
tusnel diabetic *
TUSNEL PEDIATRIC * ORAL
LIQUID
tussin cf cough-cold *
tussin cf * oral
tussin cold-congestion *
(Dm/Phenyleph/Ch
lorpheniramine)
(Accuhist Pdx)
(M-Clear Wc)
(G-Zyncof)
(Giltuss)
(Guaifenesin/Dm/P
seudoephedrine)
(Guaifenesin/Dm/P
seudoephedrine)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
94
Nivel
Lo que le
costará a
usted el
(Dextromethorphan
Hbr)
4
$0
(G-Zyncof)
4
$0
(G-Zyncof)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
(G-Zyncof)
4
3
4
$0
$0
$0
(Evoxac)
1
$0
(Peridex)
1
$0
tussin cough (dm only) * oral
tussin dm cough & chest * oral
liquid 10-200 mg/5 ml
tussin dm max * oral liquid 10-100
mg/5 ml
tussin dm * oral syrup 15-100 mg/5
ml
tussin maximum strength cough *
tussin pe * oral liquid
valu-tapp dm *
vicks dayquil cough *
vicks nature fusion cough *
virdec dm *
wal-phed * oral tablet 30 mg
wal-phed pe day-night *
wal-tussin cough *
wal-tussin cough & cold cf *
wal-tussin dm *
zephrex-d *
ZONATUSS *
zyncof *
(Guaifenesin/Dextr
omethorphan)
(Dextromethorphan
Hbr)
(Despec)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(Dextromethorphan
Hbr)
(Dextromethorphan
Hbr)
(Accuhist Pdx)
(Sudafed 12-Hour)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
(Dextromethorphan
Hbr)
(Giltuss)
(Guaifenesin/Dextr
omethorphan)
(Sudafed 12-Hour)
Medidas necesarias,
restricciones o
límites de uso
Dental And Oral Agents
Dental And Oral Agents
cevimeline
chlorhexidine gluconate mucous
membrane
95
Nivel
Lo que le
costará a
usted el
4
$0
1
3
$0
$0
1
$0
(Soriatane)
(Benzoyl Peroxide)
2
1
4
$0
$0
$0
(Benzoyl Peroxide)
4
$0
(Benzoyl Peroxide)
(Zovirax)
4
1
1
1
1
1
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
(Lac-Hydrin)
1
$0
(Lac-Hydrin)
1
$0
2
$0
(Benzoyl Peroxide)
4
$0
(Benzac Ac)
(Benzoyl Peroxide)
3
4
$0
$0
PHOS-FLUR * DENTAL
SOLUTION
pilocarpine hcl oral
PREVIDENT 5000 SENSITIVE *
triamcinolone acetonide dental
paste 0.1 %
(Salagen)
(Triamcinolone
Acetonide)
Medidas necesarias,
restricciones o
límites de uso
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acne medication * topical gel 10 %
acne medication * topical lotion 10
%
acne-clear *
acyclovir topical
ALCOHOL PADS
ALCOHOL PREP PADS
ALCOH-WIPE
aluminum chloride
amlactin * topical lotion
ammonium lactate * 12% cream
fragrance free (otc)
ammonium lactate * 12% lotion
(otc)
ammonium lactate topical cream 12
%
ammonium lactate topical lotion 12
%
ANACAINE
benzoyl peroxide * 10% gel
aqueous (otc)
benzoyl peroxide * topical gel 10 %
benzoyl peroxide * topical gel 5 %
(Drysol)
(Lac-Hydrin
Twelve)
(Ammonium
Lactate)
(Lac-Hydrin
Twelve)
QL (30 per 30 days)
96
Nivel
Lo que le
costará a
usted el
(Benzoyl Peroxide)
4
$0
(Calcipotriene)
(Dovonex)
(Calcipotriene)
(Vectical)
4
1
1
1
1
$0
$0
$0
$0
$0
4
$0
2
2
2
1
1
$0
$0
$0
$0
$0
4
$0
(Aldara)
1
$0
(Isotretinoin)
1
$0
4
4
1
1
2
4
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
2
$0
benzoyl peroxide * topical lotion 5
%
BETADINE SPRAY *
calcipotriene
calcipotriene topical cream
calcipotriene topical solution
calcitriol topical
CASTELLANI PAINT MODIFIED
*
CONDYLOX TOPICAL GEL
COSENTYX PEN (2 PENS)
FLUOROPLEX
fluorouracil topical cream
fluorouracil topical solution
geri-hydrolac * topical
imiquimod
isotretinoin oral capsule 10 mg, 20
mg, 30 mg, 40 mg
LACTINOL HX *
lobana bath *
mafenide acetate
methoxsalen rapid
PANRETIN
persa-gel *
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podofilox
podophyllum resin
potassium hydroxide
SANTYL
(Carac)
(Fluorouracil)
(Lac-Hydrin
Twelve)
(Mineral Oil)
(Mafenide Acetate)
(Oxsoralen-Ultra)
(Benzoyl Peroxide)
(Condylox)
(Podophyllum
Resin)
(Potassium
Hydroxide)
Medidas necesarias,
restricciones o
límites de uso
PA
PA NSO; QL (24 per
30 days)
QL (3 per 56 days)
QL (2 per 56 days)
97
silver nitrate applicators
skin treatment *
(Silver Nitrate
Applicator)
(Lac-Hydrin
Twelve)
VALCHLOR
zinc oxide * topical ointment
(Boudreauxs)
ZOVIRAX TOPICAL CREAM
Dermatological Antibacterials
bacitracin * topical
(Bacitracin)
bacitraycin plus * topical ointment
(Bacitracin)
500 unit/gram
clindamycin phosphate topical gel (Cleocin T)
clindamycin phosphate topical
(Cleocin T)
lotion
clindamycin phosphate topical
(Cleocin T)
solution
clindamycin phosphate topical swab (Cleocin T)
(Erythromycin
erythromycin base-ethanol
Base/Ethanol)
erythromycin with ethanol topical
(Emgel)
gel
(Erythromycin
solution
Base/Ethanol)
(Erythromycin
swab
Base/Ethanol)
(Gentamicin
gentamicin topical
Sulfate)
metronidazole topical cream 0.75 % (Metrocream)
metronidazole topical
(Nydamax)
metronidazole topical
(Metrolotion)
mupirocin
(Centany)
mupirocin calcium
(Bactroban)
(Neosporin G.U.
neomycin-polymyxin b gu
Irrigant)
selenium sulfide
(Selenium Sulfide)
Nivel
Lo que le
costará a
usted el
1
$0
4
$0
2
4
2
$0
$0
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
1
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
QL (15 per 30 days)
98
silver nitrate topical
(Silver Nitrate)
silver sulfadiazine topical cream 1
(Silvadene)
%
sulfacetamide sodium (acne)
(Klaron)
Dermatological Anti-Inflammatory Agents
alclometasone topical cream
(Aclovate)
(Alclometasone
alclometasone topical ointment
Dipropionate)
aquanil hc *
(Cortizone-10)
beta-hc *
(Cortizone-10)
betamethasone dipropionate topical
(Diprosone)
cream
betamethasone dipropionate topical (Betamethasone
lotion
Dipropionate)
betamethasone dipropionate topical (Betamethasone
ointment
Dipropionate)
betamethasone valerate topical
(Betamethasone
cream
Valerate)
(Luxiq)
foam
(Betamethasone
lotion
Valerate)
(Betamethasone
ointment
Valerate)
betamethasone, augmented topical
(Diprolene AF)
cream
betamethasone, augmented topical (Betamethasone
gel
Dipropionate)
(Diprolene)
lotion
(Diprolene)
ointment
clobetasol propionate topical
(Clobetasol
solution 0.05 %
Propionate)
clobetasol topical cream
(Temovate)
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
$0
1
$0
1
$0
4
4
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
99
clobetasol topical foam
clobetasol topical gel
clobetasol topical lotion
clobetasol topical ointment
clobetasol topical shampoo
clobetasol topical solution
clobetasol-emollient topical
clocortolone pivalate
CORDRAN TOPICAL
OINTMENT
cortizone-10 * topical cream
CORTIZONE-10 * TOPICAL
LOTION
cortizone-10 * topical ointment
dermarest eczema (hydrocort) *
desonide topical cream
desonide topical ointment
desoximetasone
ELIDEL
fluocinonide topical cream 0.05 %
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
fluocinonide-emollient base
fluticasone topical cream
fluticasone topical ointment
(Olux)
(Temovate)
(Clobex)
(Temovate)
(Clobex)
(Clobetasol
Propionate)
(Temovate)
(Cloderm)
(Hydrocortisone)
(Hydrocortisone)
(Cortizone-10)
(Desowen)
(Tridesilon)
(Topicort)
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone
Propionate)
(Ultravate)
(Cortizone-10)
Nivel
Lo que le
costará a
usted el
1
1
1
1
1
$0
$0
$0
$0
$0
1
$0
1
1
$0
$0
2
$0
4
$0
4
$0
4
4
1
1
1
2
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
PA; (PA for Ages
halobetasol propionate
1
$0
hydro skin * topical
4
$0
hydrocortisone * 1% cream
(Hydrocortisone)
4
$0
maximum strength (otc)
hydrocortisone * 1% lotion (otc)
(Cortizone-10)
3
$0
hydrocortisone * 1% ointment
(Hydrocortisone)
4
$0
carton (otc)
100
Nivel
Lo que le
costará a
usted el
1
$0
4
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
(Hydrocortisone)
4
$0
(Anusol-HC)
1
$0
(Rederm)
3
$0
(Rederm)
1
$0
(Hydrocortisone)
4
$0
(Hydrocortisone)
1
$0
(Hydrocortisone
Valerate)
1
$0
(Westcort)
1
$0
(Elocon)
(Hydrocortisone)
(Dermatop)
(Hydrocortisone)
(Hydrocortisone)
(Protopic)
(Triamcinolone
Acetonide)
1
4
1
4
4
1
$0
$0
$0
$0
$0
$0
1
$0
hydrocortisone acet-aloe vera
topical gel
hydrocortisone acetate * topical
cream 1 %
hydrocortisone acetate-urea
hydrocortisone butyrate
hydrocortisone butyr-emollient
hydrocortisone rectal cream 1 %
hydrocortisone rectal cream 2.5 %
hydrocortisone rectal enema
hydrocortisone * topical cream 0.5
%
hydrocortisone topical cream 1 %,
2.5 %
hydrocortisone * topical lotion 1 %
hydrocortisone topical lotion 2 %,
2.5 %
hydrocortisone * topical ointment
0.5 %
hydrocortisone topical ointment 1
%, 2.5 %
hydrocortisone valerate topical
cream
hydrocortisone valerate topical
ointment
mometasone
neosporin anti-itch *
prednicarbate
preparation h hydrocortisone *
recort plus *
tacrolimus topical
triamcinolone acetonide topical
cream
(Nuzon)
(Hydrocortisone
Acetate)
(Hydrocortisone
Acetate/Urea)
(Locoid)
(Locoid)
(Anusol-HC)
(Hydrocortisone)
(Cortenema)
Medidas necesarias,
restricciones o
límites de uso
101
Nivel
Lo que le
costará a
usted el
(Kenalog)
1
$0
(Triderm)
1
$0
(Triamcinolone
Acetonide)
1
$0
1
1
2
1
1
$0
$0
$0
$0
$0
4
$0
4
$0
4
1
1
4
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
lotion
ointment 0.025 %, 0.05 %, 0.1 %,
0.5 %
triderm topical cream
Dermatological Retinoids
adapalene topical cream
(Differin)
adapalene topical gel 0.1 %
(Differin)
TAZORAC TOPICAL CREAM
tretinoin microspheres
(Retin-A Micro)
tretinoin topical
(Retin-A)
Scabicides And Pediculicides
lice cream rinse *
(Nix)
(Piperonyl
lice killing *
Butoxide/Pyrethrin
s)
lice treatment * topical liquid 1 %
(Nix)
malathion
(Ovide)
permethrin topical cream
(Elimite)
permethrin * topical liquid
(Nix)
Medidas necesarias,
restricciones o
límites de uso
PA
PA
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE
BD INSULIN PEN NEEDLE UF
SHORT
BD INSULIN SYRINGE ULTRAFINE SYRINGE 0.3 ML 31 X
5/16", 1 ML 31 X 5/16", 1/2 ML 31
X 5/16"
INSULIN PEN NEEDLE NEEDLE
INSULIN SYRINGE
NEEDLELESS
102
INSULIN SYRINGE SYRINGE
INSULIN SYRINGE-NEEDLE U100 SYRINGE
SURE COMFORT INS. SYR. U100
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
$0
4
$0
2
2
$0
$0
2
$0
2
$0
2
$0
2
2
$0
$0
2
$0
2
$0
2
2
2
1
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Medidas necesarias,
restricciones o
límites de uso
Disinfectants (For Non-Dermatologic Use)
Disinfectants (For Non-Dermatologic Use)
iodine *
(Iodine)
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
CIMZIA
CIMZIA POWDER FOR
RECONST
CREON
ELAPRASE
ELITEK INTRAVENOUS RECON
SOLN
FABRAZYME INTRAVENOUS
RECON SOLN
KRYSTEXXA
KUVAN
LINZESS
lipase-protease-amylase
(Zenpep)
LOTRONEX
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
VIMIZIM
PA
PA
QL (30 per 30 days)
PA BvD
PA
103
VPRIV
ZAVESCA
ZENPEP
Nivel
Lo que le
costará a
usted el
2
2
2
$0
$0
$0
2
4
1
4
1
4
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
1
4
4
1
1
$0
$0
$0
$0
$0
$0
4
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
AKTEN (PF)
alaway *
(Zaditor)
altacaine
(Tetcaine)
altamist *
(Little Remedies)
apraclonidine
(Iopidine)
artificial tears (petro/min) *
(Genteal Pm)
(Dextran
artificial tears (pf) * ophthalmic
70/Hypromellose/P
dropperette 0.1-0.3 %
F)
artificial tears * ophthalmic drops
(Tears Naturale)
0.1-0.3 %
artificial tears * ophthalmic drops (Polyvinyl
0.5-0.6 %
Alcohol/Povidone)
artificial tears * ophthalmic
(Petrolat,Wht/Min
ointment
Oil/Sod Chl)
(Glycerin/Propylen
artificial tears(glycerin-peg) *
e Glycol)
(Genteal Mild To
artificial tears(hypromellose) *
Moderate)
atropine ophthalmic drops
(Isopto Atropine)
atropine ophthalmic ointment
(Atropine Sulfate)
ayr saline * nasal aerosol,spray
(Little Remedies)
ayr saline * nasal drops
(Sodium Chloride)
azelastine nasal
(Astepro)
azelastine ophthalmic
(Optivar)
(Dextran
bion tears (pf) *
70/Hypromellose/P
F)
carteolol
(Carteolol HCl)
QL (30 per 25 days)
104
Nivel
Lo que le
costará a
usted el
1
$0
2
$0
1
2
4
$0
$0
$0
4
$0
1
$0
4
$0
4
$0
4
4
4
$0
$0
$0
(Isopto
Homatropine)
1
$0
(Atrovent)
1
$0
(Atrovent)
1
$0
4
$0
4
2
$0
$0
4
$0
4
$0
4
$0
4
$0
cromolyn ophthalmic
CYCLOGYL OPHTHALMIC
DROPS 0.5 %
cyclopentolate
CYSTARAN
deep sea nasal *
dristan long lasting *
epinastine
eq gentle *
(Cromolyn
Sodium)
(Cyclogyl)
(Little Remedies)
(Oxymetazoline
HCl)
(Elestat)
(Genteal Mild To
Moderate)
GENTEAL MILD TO
MODERATE *
GENTEAL GEL *
GENTEAL MILD *
GENTEAL SEVERE *
homatropine hbr
ipratropium bromide nasal
spray,non-aerosol 0.03 %
ipratropium bromide nasal
spray,non-aerosol 0.06 %
isopto tears *
ketotifen fumarate *
LACRISERT
liquitears *
lubricant dry eye relief *
lubricant eye (cmc-glycer)(pf) *
lubricant eye (cmc-glycerin) *
(Genteal Mild To
Moderate)
(Zaditor)
(Polyvinyl
Alcohol)
(Carboxymethylcel
lulose Sodium)
(Carboxymethylcel
l/Glycerin/PF)
(Refresh Optive)
Medidas necesarias,
restricciones o
límites de uso
QL (30 per 28 days)
QL (15 per 10 days)
105
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
(Refresh Tears)
4
$0
(Refresh Optive)
(Genteal Pm)
(Sodium Chloride)
(Naphazoline HCl)
(Afrin)
(Genteal Mild To
Moderate)
(Dextran
70/Hypromellose/P
F)
(Genteal Mild To
Moderate)
(Oxymetazoline
HCl)
(Petrolat,Wht/Min
Oil/Sod Chl)
(Little Remedies)
(Patanase)
4
4
4
1
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Mydfrin)
(Proparacaine HCl)
4
1
2
2
1
1
$0
$0
$0
$0
$0
$0
(Proparacaine HCl)
1
$0
lubricant eye (pg-peg 400)(pf) *
lubricant eye (polyv alcohol) *
lubricant eye (propyl glycol) *
lubricant eye drops * ophthalmic
dropperette
lubricant eye drops * ophthalmic
drops
lubricating drops *
lubrifresh pm *
muro 128 *
naphazoline
nasal decongestant (oxymetazl) *
natural balance *
natural tears (pf) *
nature's tears *
neo-synephrine 12 h spr (oxym) *
nighttime relief eye *
ocean nasal *
olopatadine
PATADAY
PATANOL
phenylephrine hcl ophthalmic
proparacaine
proparacaine hcl ophthalmic drops
0.5 %
(Propylene
Glycol/Peg
400/PF)
(Polyvinyl
Alcohol)
(Propylene Glycol)
(Carboxymethylcel
lulose Sodium)
Medidas necesarias,
restricciones o
límites de uso
ST
ST
106
proparacaine-fluorescein sod
pure & gentle eye *
(Proparacaine/Fluo
rescein Sod)
(Genteal Mild To
Moderate)
REFRESH CLASSIC (PF) *
REFRESH LACRI-LUBE *
REFRESH LIQUIGEL *
REFRESH OPTIVE *
retaine cmc *
saline mist *
sea soft nasal mist *
sochlor * ophthalmic
sodium chloride * ophthalmic
STERILE LUBRICANT *
tears again * ophthalmic drops
tears again * ophthalmic ointment
TEARS NATURALE II *
tetracaine hcl
(Carboxymethylcel
lulose Sodium)
(Little Remedies)
(Little Remedies)
(Sodium Chloride)
(Sodium Chloride)
(Polyvinyl
Alcohol)
(Lanolin/Min
Oil/Petrolat, Wht)
(Tetcaine)
(Lanolin/Min
ultra fresh pm *
Oil/Petrolat, Wht)
(Oxymetazoline
vicks qlearquil(oxymetazoline) *
HCl)
vicks sinex 12-hour *
(Afrin)
wal-zyr (ketotifen) *
(Zaditor)
zyrtec itchy eye drops (keto) *
(Zaditor)
Eye, Ear, Nose, Throat Anti-Infectives Agents
acetic acid otic
(Vosol)
bacitracin ophthalmic
(Bacitracin)
(Bacitracin/Polymy
bacitracin-polymyxin b ophthalmic
xin B Sulfate)
CIPRODEX
ciprofloxacin hcl ophthalmic
(Ciloxan)
Nivel
Lo que le
costará a
usted el
1
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
1
$0
$0
4
$0
4
$0
4
4
4
$0
$0
$0
1
1
$0
$0
1
$0
2
1
$0
$0
Medidas necesarias,
restricciones o
límites de uso
107
Nivel
Lo que le
costará a
usted el
(Ilotycin)
(Zymaxid)
(Garamycin)
1
2
1
1
1
$0
$0
$0
$0
$0
(Garamycin)
1
$0
(Quixin)
1
2
2
$0
$0
$0
1
$0
1
$0
1
$0
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
4
$0
1
$0
1
$0
1
$0
2
1
$0
$0
ciprofloxacin hcl otic
COLY-MYCIN S
erythromycin ophthalmic
gatifloxacin
gentamicin ophthalmic
gentamicin sulfate ophthalmic
ointment 0.3 % (3 mg/gram)
levofloxacin ophthalmic
MOXEZA
NATACYN
neomy sulf-bacitrac zn-poly-hc
neomycin-bacitracin-poly-hc
neomycin-bacitracin-polymyxin
neomycin-polymyxin b-dexameth
neomycin-polymyxin-gramicidin
neomycin-polymyxin-hc
ofloxacin ophthalmic
ofloxacin otic
polymyxin b sulf-trimethoprim
REFRESH OPTIVE ADVANCED
*
sulfacetamide sodium
sulfacetamide sodium ophthalmic
drops 10 %
sulfacetamide-prednisolone
TOBRADEX ST
tobramycin
(Cetraxal)
(Neomy
Sulf/Bacitrac
Zn/Poly/HC)
(Neomy
Sulf/Bacitrac
Zn/Poly/HC)
(Neomy
Sulf/Bacitra/Polym
yxin B)
(Maxitrol)
(Neosporin)
(Oticin HC)
(Ocuflox)
(Ocuflox)
(Polytrim)
(Sulfacetamide
Sodium)
(Sulfacetamide
Sodium)
(Sulfacetamide/Pre
dnisolone Sp)
(Tobrex)
Medidas necesarias,
restricciones o
límites de uso
108
trifluridine
(Viroptic)
VIGAMOX
ZYLET
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
ALREX
(Bromfenac
bromfenac
Sodium)
dexamethasone sodium phosphate
(Dexasol)
ophthalmic
(Diclofenac
diclofenac sodium ophthalmic
Sodium)
DUREZOL
fluorometholone
(FML)
flurbiprofen sodium
(Ocufen)
fluticasone nasal
(Flonase)
ILEVRO
ketorolac ophthalmic
(Acular)
LOTEMAX
NASONEX
NEVANAC
prednisolone acetate
(Omnipred)
prednisolone sodium phosphate
(Prednisolone Sod
ophthalmic
Phosphate)
PROLENSA
RESTASIS
Nivel
Lo que le
costará a
usted el
1
2
2
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
2
1
1
1
2
1
2
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
2
2
$0
$0
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
Medidas necesarias,
restricciones o
límites de uso
QL (16 per 30 days)
QL (34 per 28 days)
QL (60 per 30 days)
Gastrointestinal Agents
Antiflatulents
anti-gas maximum strength *
bicarsim forte *
gas free extra strength *
gas relief 80 *
gas relief extra strength * oral
gas relief * oral
gas-x ultra-strength *
(Gas-X)
(Simethicone)
(Gas-X)
(Gas-X)
(Gas-X)
(Gas-X)
(Gas-X)
109
mi-acid gas relief *
(Gas-X)
mylanta gas *
(Gas-X)
mytab gas *
(Gas-X)
mytab gas maximum strength *
(Gas-X)
simethicone * oral capsule 180 mg (Gas-X)
simethicone * oral
(Infants' Mylicon)
Antiulcer Agents And Acid Suppressants
acid reducer (famotidine) *
(Pepcid Ac)
acid reducer (ranitidine) * oral
(Zantac)
tablet 150 mg
acid relief (cimetidine) *
(Tagamet Hb)
amoxicil-clarithromy-lansopraz
(Prevpac)
CARAFATE ORAL SUSPENSION
cimetidine hcl oral
(Cimetidine HCl)
cimetidine oral tablet 200 mg, 300
(Tagamet)
mg, 400 mg, 800 mg
cvs cimetidine * 200 mg tablet (otc) (Tagamet Hb)
esomeprazole sodium
(Nexium I.V.)
famotidine (pf)
(Famotidine/PF)
(Famotidine In
famotidine (pf)-nacl (iso-os)
Nacl,Iso-Osm/PF)
famotidine oral tablet 20 mg, 40 mg (Pepcid)
lansoprazole * dr 15 mg capsule
(Prevacid 24hr)
2x14 day course (otc)
lansoprazole oral capsule,delayed
(Prevacid)
release(dr/ec) 15 mg, 30 mg
misoprostol
(Cytotec)
(Omeprazole
omeprazole magnesium *
Magnesium)
omeprazole oral capsule,delayed
(Prilosec)
release(dr/ec)
omeprazole * oral tablet,delayed
(Omeprazole)
release (dr/ec)
omeprazole-sodium bicarbonate
(Zegerid)
oral capsule 20-1.1 mg-gram
Nivel
Lo que le
costará a
usted el
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
1
2
1
$0
$0
$0
$0
1
$0
4
1
1
$0
$0
$0
1
$0
1
$0
4
$0
1
$0
1
$0
4
$0
1
$0
4
$0
3
$0
Medidas necesarias,
restricciones o
límites de uso
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
110
pantoprazole intravenous
(Pantoprazole
Sodium)
(Protonix)
pantoprazole oral
PRILOSEC OTC *
pub famotidine * 20 mg tablet max
(Pepcid Ac)
strength (otc)
ra omepraz-bicarb 20-1,100 cap
(Zegerid Otc)
3x14 day course (otc)
ranitidine hcl injection
(Zantac)
ranitidine hcl oral syrup
(Ranitidine HCl)
ranitidine hcl oral tablet 150 mg,
(Zantac)
300 mg
ranitidine hcl * oral tablet 75 mg
(Zantac)
sucralfate oral suspension
(Sucralfate)
sucralfate oral tablet
(Carafate)
wal-zan 75 *
(Zantac)
zantac 75 *
(Zantac)
Gastrointestinal Agents, Other
acid gone antacid *
(Gaviscon)
almacone * oral suspension
(Mylanta)
almacone-2 *
(Mylanta)
aluminum hydroxide gel * oral
(Alternagel)
suspension 320 mg/5 ml
AMITIZA
(Calcium
antacid anti-gas * oral
Carbonate/Simethi
cone)
antacid * oral tablet,chewable 200
(Tums)
mg calcium (500 mg)
antacid plus anti-gas * oral
(Mylanta)
suspension
anti-diarrheal *
(Pepto-Bismol)
anti-diarrheal (loperamide) * oral
(Loperamide HCl)
capsule
anti-diarrheal (loperamide) * oral (Imodium A-D)
Nivel
Lo que le
costará a
usted el
1
$0
1
4
$0
$0
4
$0
4
$0
1
1
$0
$0
1
$0
4
1
1
4
4
$0
$0
$0
$0
$0
4
4
4
$0
$0
$0
4
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
QL (60 per 30 days)
111
Nivel
Lo que le
costará a
usted el
(Pepto-Bismol)
4
$0
(Pepto-Bismol)
(Tums)
4
2
4
$0
$0
$0
(Tums)
4
$0
(Tums)
4
$0
4
$0
4
4
4
2
4
1
4
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
4
4
$0
$0
$0
(Mylanta)
4
$0
(Almacone)
4
$0
(Robinul)
(Robinul)
1
1
$0
$0
bismatrol * oral suspension 262
mg/15 ml
bismatrol * oral tablet,chewable
BUPHENYL ORAL TABLET
calci-chew *
calcium antacid * oral
tablet,chewable
calcium carbonate * oral
tablet,chewable 500 mg calcium
(1,250 mg)
CALCIUM CARBONATEVITAMIN D3 * ORAL
TABLET,CHEWABLE 500-100
MG-UNIT
cal-gest antacid *
children's pepto *
children's soothe *
CHOLBAM
comfort gel extra strength *
cromolyn oral
diamode *
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
diphenoxylate-atropine oral liquid
diphenoxylate-atropine oral tablet
flanax antacid *
foaming antacid *
gelusil antacid & anti-gas * oral
suspension
gelusil antacid & anti-gas * oral
tablet,chewable
glycopyrrolate
glycopyrrolate
(Tums)
(Tums)
(Tums)
(Mylanta)
(Gastrocrom)
(Imodium A-D)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
(Mylanta)
(Gaviscon)
Medidas necesarias,
restricciones o
límites de uso
112
Nivel
Lo que le
costará a
usted el
4
4
4
1
1
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
(Uromag)
4
$0
(Magox 400)
4
$0
(Mylanta)
(Pamine)
(Reglan)
(Metoclopramide
HCl)
(Reglan)
(Mylanta)
(Calcium
Carb/Magnesium
Hydrox)
(Mylanta)
(Mylanta)
(Almacone)
4
1
1
$0
$0
$0
1
$0
1
4
$0
$0
4
$0
4
4
4
2
2
4
4
$0
$0
$0
$0
$0
$0
$0
RELISTOR SUBCUTANEOUS
2
$0
RELISTOR SUBCUTANEOUS
2
$0
4
4
$0
$0
imodium a-d * oral liquid
IMODIUM A-D * ORAL TABLET
kaopectate (bismuth subsalicy) *
lactulose
loperamide oral
loperamide * oral
maalox advanced * oral suspension
MAGNEBIND 300 *
magnesium oxide * oral capsule
500 mg
magnesium oxide * oral tablet 250
mg, 400 mg, 500 mg
masanti double strength *
methscopolamine oral
metoclopramide hcl injection
metoclopramide hcl oral
metoclopramide hcl oral
mi-acid * oral suspension
mi-acid * oral tablet,chewable
mintox *
mintox maximum strength *
mintox plus *
MOVANTIK
NUTRESTORE
pep-t-med *
phillips *
ri-gel ii *
ri-mox *
(Loperamide HCl)
(Pepto-Bismol)
(Lactulose)
(Loperamide HCl)
(Loperamide HCl)
(Mylanta)
(Pepto-Bismol)
(Magox 400)
(Mylanta)
(Mylanta)
Medidas necesarias,
restricciones o
límites de uso
QL (30 per 30 days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
113
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
1
1
$0
$0
$0
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Miralax)
(Sof-Lax)
(Sof-Lax)
(Docusate Sodium)
(Surfak)
(Docusate Sodium)
(Docusate Sodium)
(Sof-Lax)
(Docusate Sodium)
(Sof-Lax)
(Enema)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Enema)
4
$0
(Docusate Sodium)
4
$0
(Docusol Plus)
4
$0
(Calcium
Polycarbophil)
4
$0
sodium bicarbonate * oral tablet
650 mg
soothe (bismuth subsalicylate) *
oral
soothe regular strength *
stomach relief * oral
ultra strength antacid *
ursodiol oral capsule
ursodiol oral tablet
Laxatives
alophen *
bisac-evac *
bisacodyl * oral
bisacodyl * rectal
biscolax *
clearlax * oral
colace * oral capsule 100 mg
doc-q-lace * oral
docu *
docusate calcium *
docusate sodium * oral
docusol *
dok * oral capsule
dok * oral tablet
dulcolax stool softener (dss) *
enema disposable *
enema * rectal enema * 19-7
gram/118 ml
enemeez * rectal enema 283 mg/5
ml
enemeez * rectal enema 283-20
mg/5 ml
equalactin *
(Sodium
Bicarbonate)
(Bismuth
Subsalicylate)
(Pepto-Bismol)
(Bismuth
Subsalicylate)
(Tums)
(Actigall)
(Urso)
Medidas necesarias,
restricciones o
límites de uso
114
Nivel
Lo que le
costará a
usted el
(Fibercon)
(Citrucel)
(Psyllium Seed)
(Psyllium Seed
(With Sugar))
4
4
4
$0
$0
$0
4
$0
(Citrucel)
4
$0
(Citrucel)
(Fibercon)
(Miralax)
(Miralax)
(Miralax)
(Psyllium Seed)
(Metamucil)
(Fibercon)
4
4
4
4
3
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Psyllium Husk)
4
$0
(Miralax)
(Milk Of
Magnesia)
(Mineral Oil)
4
$0
4
$0
4
2
$0
$0
4
$0
4
$0
1
1
1
4
$0
$0
$0
$0
1
$0
4
$0
fiber (calcium polycarbophil) *
fiber laxative * oral tablet
fiber smooth *
fiber therapy (psyllium/sugar) *
fiber therapy * oral powder 2
gram/19 gram
fiber therapy * oral tablet
fiber-lax *
FLEET BISACODYL *
gentlelax *
glycolax * oral powder
healthylax *
hydrocil instant *
konsyl (sugar) * oral
konsyl fiber *
konsyl sugar-free * oral powder in
packet
laxative peg 3350 *
milk of magnesia *
mineral oil laxative *
MOVIPREP
natural fiber laxative therapy *
oral saline laxative * oral
peg 3350-electrolytes
PEG 3350-GRX
peg 3350-na sulf,bicarb,cl-kcl
peg3350 *
peg-electrolyte soln
peri-colace *
(Psyllium Seed
(With Sugar))
(Na Phos,M-B/Na
Phos,Di-Ba)
(Golytely)
(Golytely)
(Miralax)
(Nulytely with
Flavor Packs)
(Sennosides/Docus
ate Sodium)
Medidas necesarias,
restricciones o
límites de uso
115
Nivel
Lo que le
costará a
usted el
(Sof-Lax)
(Na Phos,M-B/Na
Phos,Di-Ba)
(Polyethylene
Glycol 3350)
4
$0
4
$0
1
$0
(Miralax)
4
$0
(Docusate Sodium)
(Miralax)
(Psyllium Seed
(With Sugar))
(Sennosides)
(Senokot)
(Senokot)
(Sennosides)
(Sennosides)
(Senokot)
(Sennosides/Docus
ate Sodium)
(Sennosides/Docus
ate Sodium)
(Docusate Sodium)
(Colace)
(Miralax)
(Nulytely with
Flavor Packs)
(Dulcolax)
4
4
$0
$0
4
$0
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
4
4
$0
$0
$0
1
$0
4
$0
(Phoslo)
(Calcium Acetate)
(Calcium
Carbonate/Mag
Carb/Fa)
(Calcium Acetate)
1
1
$0
$0
1
$0
4
2
$0
$0
phillips liqui-gels *
phosphate laxative * oral
polyethylene glycol 3350 oral
powder
polyethylene glycol 3350 * oral
powder in packet
promolaxin *
purelax *
reguloid * oral powder
senexon * oral syrup
senexon * oral tablet
senna lax *
senna * oral capsule
senna * oral syrup 8.8 mg/5 ml
senna * oral tablet
senna with docusate sodium *
senokot-s *
silace * oral liquid
silace * oral syrup
smoothlax * oral
sodium chloride-nahco3-kcl-peg
oral recon soln 420 gram
the magic bullet *
Phosphate Binders
calcium acetate oral capsule
calcium acetate oral tablet
calcium carbonate-mag carb-fa
calphron *
PHOSLYRA
Medidas necesarias,
restricciones o
límites de uso
116
RENAGEL
RENVELA
sodium polystyrene sulfonate oral
powder
sodium polystyrene sulfonate oral
suspension 15 gram/60 ml
sodium polystyrene sulfonate rectal
enema 30 gram/120 ml
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
Nivel
Lo que le
costará a
usted el
2
2
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
2
$0
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
2
2
2
$0
$0
$0
$0
Medidas necesarias,
restricciones o
límites de uso
Genitourinary Agents
Antispasmodics, Urinary
oxybutynin chloride oral tablet
(Oxybutynin
Chloride)
oxybutynin chloride oral tablet
(Ditropan XL)
extended release 24hr
tolterodine oral capsule,extended
(Detrol LA)
release 24hr
tolterodine oral tablet
(Detrol)
TOVIAZ
trospium oral capsule,extended
(Sanctura XR)
release 24hr
trospium oral tablet
(Sanctura)
Genitourinary Agents, Miscellaneous
alfuzosin
(Uroxatral)
tamsulosin
(Flomax)
terazosin
(Terazosin HCl)
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln
DEPEN TITRATABS
EXJADE
FERRIPROX
(Desferal)
PA BvD
117
sodium thiosulfate intravenous
(Sodium
solution 1 gram/10 ml (100 mg/ml),
Thiosulfate)
12.5 gram/50 ml (250 mg/ml)
SYPRINE
Nivel
Lo que le
costará a
usted el
1
$0
2
$0
Medidas necesarias,
restricciones o
límites de uso
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
ANDRODERM
ANDROGEL TRANSDERMAL
GEL IN METERED-DOSE PUMP
1.25 GRAM/ ACTUATION (1 %)
GEL IN METERED-DOSE PUMP
20.25 MG/1.25 GRAM (1.62 %)
GEL IN PACKET 1 % (25
MG/2.5GRAM), 1 % (50 MG/5
GRAM)
GEL IN PACKET 1.62 % (20.25
MG/1.25 GRAM), 1.62 % (40.5
MG/2.5 GRAM)
danazol oral
fluoxymesterone
oxandrolone
2
$0
2
$0
PA; QL (30 per 30
days)
PA; QL (300 per 30
days)
$0
PA; QL (150 per 30
days)
2
2
$0
2
$0
1
1
1
$0
$0
$0
1
$0
testosterone enanthate
testosterone transdermal gel in
(Androgel)
packet 1 % (25 mg/2.5gram)
Estrogens And Antiestrogens
1
$0
1
$0
COMBIPATCH
2
$0
DUAVEE
ESTRACE VAGINAL
2
2
$0
$0
testosterone cypionate
(Danazol)
(Fluoxymesterone)
(Oxandrin)
(DepoTestosterone)
(Delatestryl)
PA; QL (300 per 30
days)
PA; QL (150 per 30
days)
PA
PA; QL (150 per 30
days)
PA-HRM; QL (8 per 28
days)
PA-HRM
118
Nivel
Lo que le
costará a
usted el
Medidas necesarias,
restricciones o
límites de uso
PA-HRM
days)
days)
estradiol oral
estradiol transdermal patch
semiweekly
(Estrace)
1
$0
(Vivelle-Dot)
1
$0
estradiol transdermal patch weekly
(Climara)
1
$0
estradiol valerate
estradiol/norethindrone acet
estradiol-norethindrone acet
(Delestrogen)
(Activella)
(Activella)
1
1
1
$0
$0
$0
ESTRASORB
2
$0
estropipate
(Ogen)
FEMRING
MENEST
norethindrone ac-eth estradiol oral
(Femhrt)
tablet 1-5 mg-mcg
PREMARIN INJECTION
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
PREMPRO
raloxifene
(Evista)
VAGIFEM
Glucocorticoids/Mineralocorticoids
betamethasone acet,sod phos
(Celestone)
cortisone
(Cortisone Acetate)
dexamethasone oral
(Dexamethasone)
dexamethasone oral
(Dexamethasone)
dexamethasone sodium phosphate
(Dexamethasone
injection
Sod Phosphate)
(Fludrocortisone
fludrocortisone
Acetate)
hydrocortisone oral
(Cortef)
(Hydrocortisone
hydrocortisone sod succinate
Sod Succinate)
methylprednisolone
(Medrol)
1
2
2
$0
$0
$0
1
$0
2
2
2
2
2
1
2
$0
$0
$0
$0
$0
$0
$0
1
1
1
1
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
PA-HRM
PA-HRM
PA-HRM; QL (97.44
per 28 days)
PA-HRM
QL (1 per 84 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (18 per 28 days)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
119
Nivel
Lo que le
costará a
usted el
(Depo-Medrol)
1
$0
(A-Methapred)
1
$0
(A-Methapred)
1
$0
(Orapred)
1
$0
(Prednisone)
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
2
2
2
2
$0
$0
$0
$0
$0
methylprednisolone acetate
methylprednisolone sodium succ
injection recon soln 125 mg, 40 mg
intravenous
oral solution
prednisone
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML
triamcinolone acetonide injection
(Triamcinolone
Acetonide)
Medidas necesarias,
restricciones o
límites de uso
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
Pituitary
desmopressin injection
desmopressin nasal
desmopressin nasal
desmopressin oral
GENOTROPIN
GENOTROPIN MINIQUICK
HUMATROPE
INCRELEX
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN
INJECTOR 10 MG/1.5 ML (6.7
MG/ML), 15 MG/1.5 ML (10
MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
NORDITROPIN NORDIFLEX
NUTROPIN AQ NUSPIN
NUTROPIN AQ
SUBCUTANEOUS
NUTROPIN SUBCUTANEOUS
RECON SOLN 10 MG
(Desmopressin
Acetate)
(DDAVP)
(Desmopressin
Acetate)
(DDAVP)
QL (15 per 30 days)
QL (15 per 30 days)
PA
PA
PA
PA
2
$0
2
2
$0
$0
2
$0
2
$0
PA
PA
PA
PA
120
octreotide acetate injection solution
1,000 mcg/ml, 100 mcg/ml, 200
(Sandostatin)
mcg/ml, 500 mcg/ml
octreotide acetate injection solution (Octreotide
50 mcg/ml
Acetate)
(Octreotide
octreotide acetate injection syringe
Acetate)
OMNITROPE
PREGNYL
SAIZEN
SAIZEN CLICK.EASY
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6
MG
SOMATULINE DEPOT
SOMAVERT
SUPPRELIN LA
TEV-TROPIN
vasopressin
(Pitressin)
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION
medroxyprogesterone
(Depo-Provera)
intramuscular suspension
medroxyprogesterone
(Medroxyprogester
intramuscular syringe
one Acetate)
medroxyprogesterone oral
(Provera)
norethindrone acetate
(Aygestin)
progesterone
(Progesterone)
progesterone micronized
(Prometrium)
Thyroid And Antithyroid Agents
(Levothyroxine
levothyroxine intravenous
Sodium)
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
2
2
2
1
$0
$0
$0
$0
$0
2
$0
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
PA
PA
PA
PA
QL (1 per 28 days)
QL (1 per 360 days)
PA
QL (10 per 28 days)
QL (1 per 84 days)
QL (1 per 84 days)
121
Nivel
Lo que le
costará a
usted el
(Levoxyl)
(Cytomel)
1
1
$0
$0
(Tapazole)
1
$0
(Propylthiouracil)
1
$0
Immunological Agents
ARCALYST
ASTAGRAF XL
2
2
$0
$0
AUBAGIO
2
$0
1
$0
1
$0
levothyroxine oral
liothyronine oral
methimazole oral tablet 10 mg, 5
mg
propylthiouracil
Medidas necesarias,
restricciones o
límites de uso
Immunological Agents
azathioprine
azathioprine sodium
(Imuran)
(Azathioprine
Sodium)
PA BvD
PA; QL (28 per 28
days)
PA BvD
PA BvD
CARIMUNE NF
PA BvD
NANOFILTERED
2
$0
INTRAVENOUS RECON SOLN
CELLCEPT INTRAVENOUS
2
$0
PA BvD
cyclosporine intravenous
(Sandimmune)
1
$0
PA BvD
cyclosporine modified
(Neoral)
1
$0
PA BvD
cyclosporine oral capsule
(Sandimmune)
1
$0
PA BvD
cyclosporine, modified
(Neoral)
1
$0
PA BvD
ENBREL
2
$0
PA
ENBREL SURECLICK
2
$0
PA
FLEBOGAMMA DIF
2
$0
PA BvD
GAMASTAN S/D
2
$0
PA BvD
GAMMAGARD LIQUID
2
$0
PA BvD
GAMMAPLEX
2
$0
PA BvD
GAMUNEX-C INJECTION
PA BvD
2
$0
SOLUTION
HUMIRA
2
$0
PA
HUMIRA CROHN'S DIS START
PA
2
$0
PCK
HUMIRA PEN
2
$0
PA
HYPERRAB S/D (PF)
2
$0
122
Nivel
Lo que le
costará a
usted el
HYQVIA
ILARIS (PF)
IMOGAM RABIES-HT (PF)
2
2
2
$0
$0
$0
KINERET
2
$0
1
1
1
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
1
1
$0
$0
$0
TYSABRI
2
$0
ZORTRESS
2
$0
leflunomide
mycophenolate mofetil
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA
ORENCIA (WITH MALTOSE)
PRIVIGEN
PROGRAF INTRAVENOUS
RAPAMUNE ORAL SOLUTION
RAPAMUNE ORAL TABLET 1
MG, 2 MG
RIDAURA
sirolimus
tacrolimus oral
(Arava)
(Cellcept)
(Myfortic)
(Rapamune)
(Hecoria)
Medidas necesarias,
restricciones o
límites de uso
PA BvD
PA
PA; QL (18.76 per 28
days)
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
Vaccines
ACTHIB (PF)
2
$0
ADACEL(TDAP
2
$0
ADOLESN/ADULT)(PF)
BCG VACCINE, LIVE (PF)
2
$0
PA BvD
BEXSERO (PF)
2
$0
BOOSTRIX TDAP
2
$0
CERVARIX VACCINE (PF)
2
$0
COMVAX (PF)
2
$0
DAPTACEL (DTAP PEDIATRIC)
2
$0
(PF)
123
ENGERIX-B (PF)
ENGERIX-B PEDIATRIC (PF)
GARDASIL (PF)
GARDASIL 9 (PF)
HAVRIX (PF)
INTRAMUSCULAR
SUSPENSION
HAVRIX (PF)
IMOVAX RABIES VACCINE
(PF)
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
IPOL
IXIARO (PF)
KINRIX (PF)
MENACTRA (PF)
INTRAMUSCULAR SOLUTION
MENHIBRIX (PF)
MENOMUNE - A/C/Y/W-135 (PF)
MENVEO A-C-Y-W-135-DIP (PF)
MENVEO MENA COMPONENT
(PF)
MENVEO MENCYW-135
COMPNT (PF)
M-M-R II (PF)
PEDIARIX (PF)
PEDVAX HIB (PF)
PENTACEL (PF)
PENTACEL ACTHIB
COMPONENT (PF)
PENTACEL DTAP-IPV COMPNT
(PF)
PROQUAD (PF)
QUADRACEL (PF)
Nivel
Lo que le
costará a
usted el
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
2
$0
$0
Medidas necesarias,
restricciones o
límites de uso
PA BvD
PA BvD
PA BvD
124
RABAVERT (PF)
RECOMBIVAX HB (PF)
ROTARIX
ROTATEQ VACCINE
TENIVAC (PF)
INTRAMUSCULAR
TETANUS TOXOID,ADSORBED
(PF)
TETANUS,DIPHTHERIA TOX
PED(PF)
TETANUS-DIPHTHERIA
TOXOIDS-TD
TICE BCG
TRUMENBA
TWINRIX (PF)
TYPHIM VI INTRAMUSCULAR
VAQTA (PF)
VARIVAX (PF)
YF-VAX (PF)
ZOSTAVAX (PF)
Nivel
Lo que le
costará a
usted el
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
2
2
1
1
2
2
$0
$0
$0
$0
$0
$0
1
1
$0
$0
2
$0
Medidas necesarias,
restricciones o
límites de uso
PA BvD
PA BvD
PA BvD
PA BvD
QL (1 per 365 days)
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
APRISO
ASACOL HD
balsalazide
(Colazal)
budesonide oral
(Entocort EC)
DELZICOL
DIPENTUM
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation
GLYCINE IRRIGATION
LACTATED RINGERS
IRRIGATION
(Acetic Acid)
125
ringers irrigation
sodium chloride irrigation
sorbitol irrigation
sorbitol-mannitol
water for irrigation, sterile
(Tis-U-Sol)
(Sodium Chloride
Irrig Solution)
(Sorbitol Solution)
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
(Alendronate
alendronate oral solution
Sodium)
alendronate oral tablet 10 mg, 40
(Fosamax)
mg, 5 mg
alendronate oral tablet 35 mg, 70
(Fosamax)
mg
calcitonin (salmon)
(Miacalcin)
calcitriol intravenous solution 1
(Calcitriol)
mcg/ml
calcitriol oral
(Rocaltrol)
1
$0
doxercalciferol intravenous
(Doxercalciferol)
1
$0
doxercalciferol oral
(Hectorol)
1
$0
etidronate disodium
(Etidronate
Disodium)
1
$0
FORTEO
2
$0
FORTICAL
2
$0
ibandronate intravenous solution
(Ibandronate
Sodium)
1
$0
ibandronate oral
(Boniva)
1
$0
QL (4 per 28 days)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA; QL (2.4 per 28
days)
PA BvD; (PA for
ESRD Only); QL (3 per
84 days)
QL (1 per 28 days)
126
Nivel
Lo que le
costará a
usted el
MIACALCIN INJECTION
2
$0
NATPARA
2
$0
(Zemplar)
1
$0
(Actonel)
2
1
$0
$0
XGEVA
2
$0
ZEMPLAR INTRAVENOUS
2
$0
(Zometa)
(Zoledronic
Acid/Mannitol and
Water)
1
$0
1
$0
(Reclast)
1
$0
2
$0
2
$0
ACTEMRA SUBCUTANEOUS
2
$0
ACTIMMUNE
allopurinol
amifostine crystalline
2
1
1
$0
$0
$0
1
$0
2
2
2
2
$0
$0
$0
$0
paricalcitol oral
PROLIA
risedronate oral tablet 150 mg
zoledronic acid intravenous
zoledronic acid-mannitol-water
ZOMETA INTRAVENOUS
SOLUTION 4 MG/100 ML
Medidas necesarias,
restricciones o
límites de uso
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
QL (1 per 180 days)
QL (1 per 28 days)
PA; QL (1.7 per 28
days)
PA BvD; (PA for
ESRD Only)
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS
SOLUTION
anticoag citrate phos dextrose
AVODART
AVONEX (WITH ALBUMIN)
AVONEX INTRAMUSCULAR
AVONEX INTRAMUSCULAR
(Zyloprim)
(Ethyol)
(Citrate Phosphate
Dextros Soln)
PA; QL (40 per 30
days)
PA; QL (3.6 per 28
days)
ST
ST
ST
127
Nivel
Lo que le
costará a
usted el
2
$0
2
1
$0
$0
2
$0
2
$0
1
2
1
$0
$0
$0
1
$0
2
$0
2
$0
1
$0
(Acetic Acid)
(Droperidol)
2
4
1
2
$0
$0
$0
$0
(Ergoloid
Mesylates)
1
$0
(Acetic Acid)
(Acetic Acid)
(Proscar)
(Fomepizole)
2
4
4
1
1
2
$0
$0
$0
$0
$0
$0
GILENYA
2
$0
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
(HUMAN)
2
$0
2
$0
BENLYSTA INTRAVENOUS
RECON SOLN
BETASERON SUBCUTANEOUS
bethanechol chloride
BOTOX INJECTION RECON
SOLN 100 UNIT
BOTOX INJECTION RECON
SOLN 200 UNIT
buspirone
CERDELGA
colchicine oral tablet
colchicine-probenecid
COLCRYS
COPAXONE SUBCUTANEOUS
SYRINGE
CURITY GAUZE TOPICAL
BANDAGE 2 X 2 "
CYSTADANE
douche vinegar & water extra *
droperidol injection solution
ELMIRON
ergoloid
EXTAVIA SUBCUTANEOUS
extra cleansing douche *
feminine care douche *
finasteride oral tablet 5 mg
fomepizole
FUSILEV
(Urecholine)
(Vanspar)
(Colcrys)
(Colchicine/Proben
ecid)
Medidas necesarias,
restricciones o
límites de uso
PA
ST
PA
ST
PA; QL (28 per 28
days)
128
Nivel
Lo que le
costará a
usted el
(Guanidine HCl)
(Hydroxyzine HCl)
1
1
$0
$0
(Hydroxyzine HCl)
1
$0
(Hydroxyzine HCl)
(Vistaril)
1
1
2
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
2
2
2
4
4
$0
$0
$0
$0
$0
$0
1
$0
OTEZLA
2
$0
OTEZLA STARTER
2
$0
2
$0
2
$0
guanidine
hydroxyzine hcl intramuscular
hydroxyzine hcl oral syrup 10 mg/5
ml
hydroxyzine hcl oral tablet
hydroxyzine pamoate
JALYN
LEMTRADA
leucovorin calcium injection recon
soln 100 mg, 200 mg, 350 mg
leucovorin calcium oral
levocarnitine (with sugar)
levocarnitine oral
levoleucovorin calcium
mesna
MESNEX ORAL
MESTINON ORAL SYRUP
MESTINON TIMESPAN
MINERAL OIL *
mineral oil light *
morrhuate sodium
PLEGRIDY SUBCUTANEOUS
PEN INJECTOR
PLEGRIDY SUBCUTANEOUS
SYRINGE 125 MCG/0.5 ML
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Levocarnitine
(With Sugar))
(Carnitor)
(Levoleucovorin
Calcium)
(Mesnex)
(Mineral Oil)
(Sodium
Morrhuate)
Medidas necesarias,
restricciones o
límites de uso
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (30 per 30 days)
PA; QL (9.6 per 365
days)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
ST
ST
129
probenecid
PROCYSBI
pyridostigmine bromide
REBIF (WITH ALBUMIN)
REBIF REBIDOSE
REBIF TITRATION PACK
REMICADE
SENSIPAR
(Probenecid)
(Mestinon)
SIMPONI ARIA
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML
SIMPONI SUBCUTANEOUS PEN
INJECTOR 50 MG/0.5 ML
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML
SIMPONI SUBCUTANEOUS
SYRINGE 50 MG/0.5 ML
SOLIRIS
STELARA SUBCUTANEOUS
SYRINGE
STERILE PADS TOPICAL
BANDAGE 2 X 2 "
summer's eve disposable douche *
(Acetic Acid)
vaginal solution
summers eve extra cleansing *
(Acetic Acid)
SUSPENDOL-S *
SYNAREL
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)240 MG (46), 240 MG
Nivel
Lo que le
costará a
usted el
1
2
1
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
4
$0
4
4
2
$0
$0
$0
2
2
$0
$0
Medidas necesarias,
restricciones o
límites de uso
PA
PA; QL (12 per 28
days)
PA; QL (0.5 per 28
days)
PA; QL (0.5 per 28
days)
PA
PA; QL (14 per 30
days)
PA; QL (60 per 30
days)
130
Nivel
Lo que le
costará a
usted el
THALOMID
2
$0
TYBOST
2
$0
ULORIC
2
$0
XELJANZ
2
$0
(Diamox Sequels)
1
$0
(Acetazolamide)
(Acetazolamide
Sodium)
1
$0
1
$0
2
$0
2
1
1
1
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
(Neptazane)
(Metipranolol)
1
1
2
$0
$0
$0
(Isopto Carpine)
1
$0
(Timolol Maleate)
2
1
$0
$0
Medidas necesarias,
restricciones o
límites de uso
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
ST; QL (30 per 30
days)
PA; QL (60 per 30
days)
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule,
extended release
acetazolamide oral tablet
acetazolamide sodium
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT
betaxolol ophthalmic
bimatoprost
brimonidine
COMBIGAN
dorzolamide
dorzolamide-timolol
latanoprost
levobunolol
LUMIGAN OPHTHALMIC
DROPS 0.01 %
methazolamide oral
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic drops 1
%, 2 %, 4 %
SIMBRINZA
timolol maleate ophthalmic drops
(Betaxolol HCl)
(Bimatoprost)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(drops: 0.15%, 0.20%)
131
timolol maleate ophthalmic gel
forming solution
TRAVATAN Z
travoprost (benzalkonium)
(Timoptic-Xe)
(Travoprost
(Benzalkonium))
Nivel
Lo que le
costará a
usted el
1
$0
2
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
Replacement Preparations
Replacement Preparations
(Ca/D3/Mag
ca-d3-mag ox-zinc-cop-mang-bor *
Ox/Zinc/Cop/Mang
oral tablet,chewable
/Bor)
(Calcium
calcionate *
Glubionate)
calcitrate *
(Calcium Citrate)
(Citracal-Vitamin
calcitrate-vitamin d *
D)
calcium 500 + d (d3) *
(Os-Cal 500+D3)
calcium 500 + d * oral tablet 500
(Os-Cal 500+D3)
mg(1,250mg) -400 unit
calcium 500 with d *
(Os-Cal 500+D3)
calcium 600 *
(Caltrate 600)
(Calcium
calcium 600 + d(3) * oral capsule
Carbonate/Vitamin
D3)
calcium 600 + d(3) * oral tablet
(Os-Cal 500+D3)
(Calcium
calcium 600 with vitamin d3 * oral Carbonate/Vitamin
D3)
(Calcium
calcium carbonate * oral
Carbonate)
calcium carbonate * oral tablet 260
(Caltrate 600)
mg calcium (648 mg)
(Calcium
calcium carbonate-vitamin d2 *
Carbonate/Vitamin
D2)
132
Nivel
Lo que le
costará a
usted el
(Calcium
Carbonate/Vitamin
D3)
4
$0
(Os-Cal 500+D3)
4
$0
(Os-Cal 500+D)
4
$0
(Calcium Chloride)
(Citracal-Vitamin
D)
(Calcium
Gluconate)
(Calcium
Gluconate)
1
$0
4
$0
1
$0
4
$0
(Calcium Lactate)
4
$0
(Os-Cal 500+D3)
4
4
$0
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
1
$0
oral capsule 600 mg(1,500mg) -100
unit, 600 mg(1,500mg) -400 unit,
600 mg(1,500mg) -500 unit
oral tablet
oral tablet,chewable 500
mg(1,250mg) -400 unit
calcium chloride intravenous
calcium citrate-vitamin d3 * oral
tablet 315-250 mg-unit
calcium gluconate intravenous
calcium gluconate * oral tablet 45
mg (500 mg)
calcium lactate * oral tablet 84 mg
(648 mg), 85 mg (650 mg)
calcium+d * oral tablet
CALTRATE 600 + D *
CALTRATE-600 + D VIT D3
(800) *
CENTRUM PRO NUTRIENTS *
citracal + d maximum *
citric acid-sodium citrate
citrus calcium * oral tablet
coral calcium * oral tablet
electrolyte-48 in d5w
(Citracal-Vitamin
D)
(Citric
Acid/Sodium
Citrate)
(Citracal-Vitamin
D)
(Caltrate 600)
(Electrolyte-48
Solution/D5W)
(Pedialyte)
(Os-Cal 500+D3)
Medidas necesarias,
restricciones o
límites de uso
PA BvD; (PA for
ESRD Only)
enfalyte *
4
$0
hi-cal plus vit d *
4
$0
HYPERLYTE CR
2
$0
133
IONOSOL-B IN D5W
IONOSOL-MB IN D5W
ISOLYTE M IN 5 % DEXTROSE
ISOLYTE-H IN 5 % DEXTROSE
ISOLYTE-P IN 5 % DEXTROSE
ISOLYTE-S
KELP (IODINE) *
KLOR-CON
klor-con 10
(Potassium
Chloride)
KLOR-CON 8
klor-con m10
klor-con m15
klor-con m20
(Potassium
Chloride)
(Potassium
Chloride)
(Potassium
Chloride)
KLOR-CON/EF
liquid calcium with vitamin d *
mag 64 *
mag-delay *
mag-g *
magnesium (oxide/aa chelate) *
magnesium chloride injection
magnesium gluconate * oral tablet
magnesium * oral tablet 250 mg
(Calcium
Carbonate/Vitamin
D3)
(Magnesium
Chloride)
(Magnesium
Chloride)
(Magonate)
(Magnesium
Oxide/Mag Aa
Chelate)
(Magnesium
Chloride)
(Magonate)
(Magnesium)
Nivel
Lo que le
costará a
usted el
2
2
2
2
2
2
4
1
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
4
$0
$0
Medidas necesarias,
restricciones o
límites de uso
134
Nivel
Lo que le
costará a
usted el
(Magnesium
Sulfate/D5W)
1
$0
(Magnesium
Sulfate in Water)
1
$0
1
$0
4
$0
2
$0
2
2
2
2
4
4
4
4
4
4
4
4
4
4
1
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
magnesium sulfate in d5w
ml
magnesium sulfate in water
ml (4 %), 4 gram/50 ml (8 %)
magnesium sulfate injection
natural calcium *
NORMOSOL-M IN 5 %
DEXTROSE
NORMOSOL-R
NORMOSOL-R PH 7.4
NUTRILYTE
NUTRILYTE II
oralyte *
oysco 500/d * oral tablet
oysco d *
oysco-500 *
oyster shell calcium 500 *
oyster shell calcium-vit d3 *
oystercal-d *
pediatric electrolyte * oral solution
pediatric freezer pops *
PHOS-NAK *
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN 5 %
DEXTROSE
potassium acetate intravenous
potassium bicarb and chloride
potassium bicarb-citric acid
(Magnesium
Sulfate)
(Caltrate 600)
(Pedialyte)
(Os-Cal 500+D3)
(Os-Cal 500+D3)
(Caltrate 600)
(Caltrate 600)
(Os-Cal 500+D3)
(Os-Cal 500+D3)
(Pedialyte)
(Pedialyte)
(K-Phos Neutral)
(Potassium
Acetate)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
Medidas necesarias,
restricciones o
límites de uso
135
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
$0
(Potassium
Chloride In D5w)
1
$0
(Potassium
Chloride)
1
$0
(Micro-K)
1
$0
(Kaochlor)
(Klor-Con)
1
1
$0
$0
(Klor-Con 8)
1
$0
(Klor-Con 8)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
potassium bicarbonate-cit ac oral
tablet, effervescent 25 meq
potassium chlorid-d5-0.45%nacl
potassium chloride in 0.9%nacl
meq/l, 40 meq/l
potassium chloride in 5 % dex
meq/l, 30 meq/l, 40 meq/l
potassium chloride intravenous
potassium chloride oral capsule,
extended release
potassium chloride oral liquid
potassium chloride oral packet
potassium chloride oral tablet
extended release
potassium chloride oral tablet,er
particles/crystals 10 meq
potassium chloride oral tablet,er
particles/crystals 20 meq
potassium chloride-0.45 % nacl
potassium chloride-d5-0.2%nacl
meq/l
(Klor-Con-Ef)
(Potassium
Chloride/D50.45nacl)
(Potassium
Chloride In
0.9%NaCl)
(Potassium
Chloride)
(Potassium
Chloride-0.45%
NaCl)
(Potassium
Chloride/D50.2%NaCl)
(Potassium
(Potassium
Medidas necesarias,
restricciones o
límites de uso
136
potassium citrate-citric acid oral
packet
potassium citrate-citric acid oral
solution 1,100-334 mg/5 ml
(Potassium
Citrate/Citric Acid)
(Potassium
Citrate/Citric Acid)
(Potassium
potassium phosphate dibasic
Phos,M-Basic-DBasic)
ringers intravenous
(Ringers Solution)
sodium acetate intravenous
(Sodium Acetate)
(Sodium
sodium bicarbonate intravenous
Bicarbonate)
(Sodium Chloride
sodium chloride 0.45 % intravenous
0.45 %)
sodium chloride 0.9 % injection
(0.9 % Sodium
solution
Chloride)
(0.9 % Sodium
sodium chloride 0.9 % intravenous
Chloride)
(Sodium Chloride
sodium chloride 3 %
3 %)
(Sodium Chloride
sodium chloride 5 %
5 %)
sodium chloride intravenous
(Sodium Chloride)
(Citric
sodium citrate-citric acid
Acid/Sodium
Citrate)
sodium lactate intravenous
(Sodium Lactate)
(Sodium Phos,Msodium phosphate
Basic-D-Basic)
(Sod/Pot/K Cit/Sod
sod-pot-k cit-sod cit-cit acid
Cit/Cit Acid)
TPN ELECTROLYTES
TPN ELECTROLYTES II
Nivel
Lo que le
costará a
usted el
1
$0
1
$0
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
2
$0
$0
2
$0
Medidas necesarias,
restricciones o
límites de uso
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
QL (60 per 30 days)
137
ADVAIR HFA
BREO ELLIPTA
DULERA
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 100 MCG/ACTUATION,
50 MCG/ACTUATION
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 250 MCG/ACTUATION
FLOVENT HFA INHALATION
HFA AEROSOL INHALER 110
MCG/ACTUATION
MCG/ACTUATION
MCG/ACTUATION
QVAR
Antileukotrienes
montelukast
zafirlukast
Bronchodilators
albuterol sulfate inhalation solution
for nebulization
albuterol sulfate oral syrup
albuterol sulfate oral tablet
albuterol sulfate oral tablet
ANORO ELLIPTA
ATROVENT HFA
COMBIVENT RESPIMAT
metaproterenol oral
Nivel
Lo que le
costará a
usted el
2
2
2
$0
$0
$0
2
$0
2
$0
Medidas necesarias,
restricciones o
límites de uso
QL (12 per 28 days)
QL (60 per 30 days)
QL (13 per 28 days)
QL (60 per 30 days)
QL (12 per 28 days)
2
$0
QL (24 per 28 days)
2
$0
2
$0
2
$0
(Singulair)
(Accolate)
1
1
$0
$0
(Albuterol Sulfate)
1
$0
(Albuterol Sulfate)
(Albuterol Sulfate)
1
1
$0
$0
(Vospire ER)
1
$0
2
2
2
$0
$0
$0
1
$0
(Metaproterenol
Sulfate)
PA BvD
QL (60 per 30 days)
QL (8 per 30 days)
138
Nivel
Lo que le
costará a
usted el
2
2
2
2
$0
$0
$0
$0
1
$0
1
$0
(Theophylline
Anhydrous)
1
$0
(Theophylline/D5
W)
1
$0
1
$0
1
$0
1
$0
TUDORZA PRESSAIR
Respiratory Tract Agents, Other
acetylcysteine
(Acetadote)
acetylcysteine solution
(Acetadote)
ARALAST NP
(Cromolyn
cromolyn inhalation
Sodium)
cromolyn * nasal
(Nasalcrom)
DALIRESP
2
$0
QL (1 per 28 days)
1
1
2
$0
$0
$0
PA BvD
PA BvD
1
$0
4
2
$0
$0
ESBRIET
2
$0
KALYDECO
2
$0
PROAIR HFA
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA WITH HANDIHALER
terbutaline oral
terbutaline subcutaneous
theophylline anhydrous oral tablet
extended release 12 hr 100 mg, 200
mg, 300 mg
theophylline in dextrose 5 %
mg/100 ml, 200 mg/50 ml, 400
mg/250 ml, 400 mg/500 ml, 800
mg/250 ml
theophylline oral
theophylline oral
theophylline oral
(Terbutaline
Sulfate)
(Terbutaline
Sulfate)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
Medidas necesarias,
restricciones o
límites de uso
QL (17 per 25 days)
QL (60 per 30 days)
QL (4 per 30 days)
QL (30 per 30 days)
PA BvD
QL (30 per 30 days)
PA; QL (270 per 30
days)
PA; QL (60 per 30
days)
139
OFEV
sodium chloride * inhalation
solution for nebulization 0.9 %
XOLAIR
ZEMAIRA
(Pulmosal)
Nivel
Lo que le
costará a
usted el
2
$0
3
$0
2
2
$0
$0
Medidas necesarias,
restricciones o
límites de uso
PA; QL (60 per 30
days)
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
(Baclofen)
1
$0
carisoprodol
(Soma)
1
$0
chlorzoxazone
(Parafon Forte
DSC)
1
$0
1
$0
1
$0
(Fexmid)
1
$0
(Dantrium)
(Dantrium)
(Skelaxin)
(Robaxin)
(Zanaflex)
1
1
1
1
1
$0
$0
$0
$0
$0
2
2
2
$0
$0
$0
COMFORT PACCYCLOBENZAPRINE
COMFORT PAC-TIZANIDINE
cyclobenzaprine oral tablet 10 mg,
5 mg
dantrolene
dantrolene sodium
metaxalone
methocarbamol oral
tizanidine
PA-HRM; QL (120 per
30 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
Sleep Disorder Agents
Sleep Disorder Agents
NUVIGIL
ROZEREM
XYREM
PA
LA
140
Nivel
Lo que le
costará a
usted el
zaleplon
(Sonata)
1
$0
zolpidem oral tablet
(Ambien)
1
$0
zolpidem oral tablet,ext release
multiphase
(Ambien CR)
1
$0
1
$0
Medidas necesarias,
restricciones o
límites de uso
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
(Phentolamine
phentolamine injection
Mesylate)
PA
Vasodilating Agents
Vasodilating Agents
141
Nivel
Lo que le
costará a
usted el
ADCIRCA
2
$0
ADEMPAS
2
$0
1
$0
LETAIRIS
2
$0
OPSUMIT
2
$0
ORENITRAM
REMODULIN
2
2
$0
$0
REVATIO INTRAVENOUS
2
$0
1
$0
TRACLEER
2
$0
TYVASO
TYVASO REFILL KIT
TYVASO STARTER KIT
VENTAVIS
2
2
2
2
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
epoprostenol (glycine)
sildenafil oral tablet 20 mg
(Flolan)
(Revatio)
Medidas necesarias,
restricciones o
límites de uso
PA; QL (60 per 30
days)
PA; QL (90 per 30
days)
PA BvD
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA
PA BvD
PA; QL (37.5 per 1
day)
PA; QL (90 per 30
days)
PA; LA; QL (60 per 30
days)
PA BvD
PA BvD
PA BvD
PA BvD
Vitamins And Minerals
Vitamins And Minerals
a thru z advanced formula *
a thru z high potency * oral tablet
a thru z select 50+ formula *
a thru z select * oral tablet
a thru z select * oral tablet 300600-300 mcg, 500-300-250 mcg
a thru z select women's *
abc plus *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin WMinerals/Lutein)
(Biocel)
(Biocel)
(Multivits WFe,Other Min/Lut)
(Biocel)
142
adult one daily gummies *
adults 50+ daily formula *
adults' daily formula *
airshield * oral tablet, effervescent
5,000-1000-30 unit-mg-unit
animal chews *
animal shape vitamins *
animal shapes plus iron *
antioxidant *
antioxidant formula *
antioxidant vitamins * oral tablet
antioxidant vitamins * oral tablet
1,000 unit-200 mg-60 unit-2 mg
apatate forte *
(One-A-Day
Vitacraves)
(Biocel)
(Multivitamin/Iron/
Folic Acid)
(Vit A,C, and
E/Dietary Supp
No.12)
(Multivitamin)
(Multivitamin)
(Multivitamins
with Iron)
(Beta-Carotene(A)
W-C and E/Min)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin with
Minerals)
(Ocuvite with
Lutein)
(Multivitamin with
Minerals)
ascorbic acid * oral tablet extended
(Ascorbic Acid)
release 1,500 mg
ascorbic acid * oral
(Ascorbic Acid)
(Vitamin B
b complete *
Complex)
(Vitamin B
b complex 1 *
Complex)
(Vitamin B
b complex-vitamin b12 *
Complex)
b complex-vitamin c-folic acid *
(Dialyvite 800)
(Vitamin B
b-100 complex * oral tablet
Complex)
b-12 dots *
(B-12)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
143
b-50 complex * oral tablet
bal b-100 *
bal b-50 *
balance b-100 *
balance b-50 *
balanced b-100 * oral
balanced b-100 * oral tablet 100
mg
balanced b-150 *
balanced b-50 * oral tablet
b-complex * oral tablet
b-complex with vitamin c * oral
capsule
b-complex with vitamin c * oral
tablet
bee-zee *
biosupp *
biotin * oral tablet 300 mcg
biovol *
c complex *
calcidol *
centamin *
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vit B Complex
100 Cmb
#3/Herbs)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(B Complex with
Vitamin C)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Biotin)
(Multivitamin with
Minerals)
(Ascorbic Acid)
(Drisdol)
(Multivits WMin/Ferrous Gluc)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
144
Nivel
Lo que le
costará a
usted el
(Biocel)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
central vite with lutein *
central-vite for seniors *
central-vite * oral tablet 18-400
mg-mcg
central-vite select * oral tablet
central-vite senior *
centram-care *
centravites 50 plus *
centrum complete *
centrum * oral liquid
centrum silver * oral tablet
centrum ultra women's *
century adults 50+ *
century advanced formula *
century mature * oral tablet
century mature * oral tablet 0.4300-250 mg-mcg-mcg, 500-300-250
mcg
century * oral tablet 18-400 mgmcg
century ultimate women's * oral
tablet 18-400 mg-mcg
cerovite *
cerovite advanced formula *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
Medidas necesarias,
restricciones o
límites de uso
145
Nivel
Lo que le
costará a
usted el
Medidas necesarias,
restricciones o
límites de uso
(Multivitamin
4
$0
W/Iron, Minerals)
(Multivitamin Wcerovite senior *
4
$0
Minerals/Lutein)
certavite senior-antioxidant *
(Biocel)
4
$0
certavite-antioxid (iron gluc) * oral (Multivits W4
$0
liquid 9 mg iron/15 ml
Min/Ferrous Gluc)
(Multivitamin/Iron/
certavite-antioxidant *
4
$0
Folic Acid)
chewable multi vitamin *
(Multivitamin)
4
$0
chewable-vite *
(Multivitamin)
4
$0
(Multivitamins
chewable-vite with iron *
4
$0
with Iron)
(Pedi Mv
child complete multivitamin *
No.58/Ferrous
4
$0
Fumarate)
(Multivitamin
child vitamin with minerals *
4
$0
W/Iron, Minerals)
children's chewable *
(Multivitamin)
4
$0
children's chewable complete * oral
(Multivitamin)
4
$0
tablet,chewable
children's chewable vitamin *
(Multivitamin)
4
$0
(Multivitamin
children's chewable w/minerals *
4
$0
W/Iron, Minerals)
(Pedi Mv
children's complete vitamin *
No.67/Ferrous
4
$0
Fumarate)
children's multivit w/extra c *
(Multivitamin)
4
$0
(Multivitamins
children's vitamin with iron *
4
$0
with Iron)
childs chew vite *
(Multivitamin)
4
$0
(Multivitamins
child's chewable vitamins/iron *
4
$0
with Iron)
(Multivitamins
child's vitamin with iron *
4
$0
with Iron)
child's vitamin with vitamin c *
(Multivitamin)
4
$0
cerovite jr *
146
childs/iron *
compete *
complete 50+ *
complete multi 50+ *
complete multivitamin * oral tablet
complete multivitamin * oral tablet
0.4-300-250 mg-mcg-mcg
complete multivitamin-mineral *
oral tablet
complete senior * oral tablet
complete senior * oral tablet 0.4300-250 mg-mcg-mcg
cyanocobalamin (vitamin b-12) *
injection
oral drops 1,000 mcg/ml
oral tablet 1,000 mcg, 100 mcg, 250
mcg, 500 mcg
daily gummies *
daily multiple * oral tablet
daily multiple * oral tablet 18-400
mg-mcg
daily multi-vitamin *
daily multivitamin with iron *
daily multivitamin-minerals *
daily multi-vitamins/iron *
(Multivitamins
with Iron)
(Multivitamin
W/Iron, Minerals)
(Biocel)
(Biocel)
(Multivits,Th WFe,Other Min)
(Biocel)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin
W/Iron, Minerals)
(Biocel)
(Cyanocobalamin
(Vitamin B-12))
(Cyanocobalamin
(Vitamin B-12))
(B-12)
(One-A-Day
Vitacraves)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
147
Nivel
Lo que le
costará a
usted el
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
(Drisdol)
3
$0
(Drisdol)
4
$0
4
$0
4
$0
4
4
$0
$0
daily teen multi-vitamin *
daily value *
daily vitamin *
daily vitamin formula *
daily vitamin formula + iron *
daily vitamin formula-minerals *
daily vitamin with iron *
daily vites/iron *
daily-vite *
dino-life *
dino-life with extra c *
dino-life with iron-zinc *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamins
with Iron)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin
W/Iron, Minerals)
ECEE PLUS *
eldertonic *
ellis tonic *
ergocalciferol (vitamin d2) * oral
capsule
ergocalciferol (vitamin d2) * oral
drops
essentia *
essential balance with lutein *
essential daily *
essential one daily *
(B1,B2,B3,B6,B12
/Dexpan/Zn/Mang)
(Multivitamin with
Minerals)
(Multivitamin/Iron/
Folic Acid)
(Tab A Vite)
(Multivitamin)
Medidas necesarias,
restricciones o
límites de uso
148
Nivel
Lo que le
costará a
usted el
3
$0
3
$0
4
$0
3
$0
4
4
$0
$0
4
$0
4
$0
(Ferrous Fumarate)
4
$0
(Fergon)
(Fer-In-Sol)
(Ferrous Sulfate)
(Ferrous Sulfate)
4
4
4
4
$0
$0
$0
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
(Multivitamin
W/Iron, Minerals)
4
$0
(Multivitamin)
4
$0
(Pedi Mv
No.79/Ferrous
Fumarate)
4
$0
(Multivitamin)
4
$0
(Folic Acid)
3
4
$0
$0
fe fumarate-doss-fa-bcomp and c *
fe fumarate-vit c-b12-if-fa * oral
capsule 110-0.5 mg
ferate * oral tablet
ferotrinsic *
ferretts * oral tablet
ferrex 150 *
ferrex 150 plus *
ferrocite *
ferrous fumarate * oral tablet 324
mg (106 mg iron)
ferrous gluconate * oral tablet
ferrous sulfate * oral
ferrous sulfate * oral tablet 325 mg
(65 mg iron)
ferrous sulfate * oral tablet,delayed
release (dr/ec) 324 mg (65 mg iron)
flintstones complete (iron) * oral
tablet,chewable
flintstones multivitamin * oral
tablet,chewable
flintstones with iron *
flintstones/extra c * oral
tablet,chewable
folic acid * 1 mg tablet (rx)
FOLIC ACID * ORAL CAPSULE
(Fe
Fumarate/Doss/Fa/
Bcomp and C)
(Fe Fumarate/Vit
C/B12-If/Fa)
(Fergon)
(Fe Fumarate/Vit
C/B12-If/Fa)
(Ferrous Fumarate)
(Pic 200)
(Iron Aspgly and
Ps Cmplx/C/Sucac)
(Ferrous Fumarate)
Medidas necesarias,
restricciones o
límites de uso
149
folic acid * oral tablet 1 mg, 400
mcg, 800 mcg
fosfree *
fruity chews *
geravim *
geriaton *
germ defense *
gummi bear multivitamin *
gummy swirls *
hair vitamins *
hair,skin & nails * oral tablet
hair,skin & nails * oral tablet 1 mg
iron-66.7 mcg-1,000 mcg
healthy eyes *
hemocyte *
hi-b complex *
high potency multivit-multimin *
honey bears *
honey bears with iron-zinc *
icaps plus *
iferex 150 *
iron high potency *
i-vite *
kid's vitamins + extra c *
(Folic Acid)
(Calcium/Multivita
mins W-Iron)
(Multivitamin)
(Pediavit)
(Pediavit)
(Vit A,C, and
E/Dietary Supp
No.12)
(Multivitamin)
(Multivitamin)
(Multivitamins
with Iron)
(Multivitamin with
Minerals)
(Mv,Ca,Min/Iron
Gluc/Fa/Biotin)
(Ocuvite with
Lutein)
(Ferrous Fumarate)
(Vitamin B
Complex)
(Multivitamin)
(Multivitamin
W/Iron, Minerals)
(Multivitamin with
Minerals)
(Pic 200)
(Fergon)
(Ocuvite with
Lutein)
(Multivitamin)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
150
kids vitamins + iron *
kid's vitamins + iron *
(Ped Multivit
#17/Iron Fumarate)
(Multivitamins
with Iron)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
kid's vitamins * oral
tablet,chewable
(Multivitamin)
4
$0
life-pack women's *
(Multivitamin
W/Iron, Minerals)
4
$0
4
4
$0
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
LIQUI-E *
little animals *
little animals/iron *
lysiplex plus * oral liquid
MACUVITE *
MACUVITE EYE CARE *
maximum daily multivitamin *
mega multiple/chelated mineral *
mega multivitamin with mineral *
oral tablet
men's multi-vitamin *
men's one daily * oral tablet
(Multivitamin)
(Multivitamins
with Iron)
(Pediavit)
(Tab A Vite)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin)
(Multivitamin with
Minerals)
MEPHYTON *
milltrium senior *
multi complete with iron *
multi-day with iron *
multi-delyn *
multi-delyn with iron *
multilex *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin/Ferr
ous Gluconate)
(Multivitamin
W/Iron, Minerals)
Medidas necesarias,
restricciones o
límites de uso
151
multilex-t&m *
multiple vitamin-minerals *
multiple vitamins *
multiple vitamins with iron *
multivital platinum * oral tablet
multivital platinum * oral tablet
500-300-250 mcg
multi-vitamin hp/minerals *
multivitamin * oral tablet
multivitamin with iron *
multivitamin with minerals * oral
liquid
multivitamin with minerals * oral
tablet
multivitamins with min no.7-fa *
oral capsule 1 mg
multi-vite *
multi-vite 50 & over *
my favorite multiple *
my-vitalife *
NASCOBAL *
(Multivitamin with
Minerals)
(Multivitamin)
(Multivitamins
with Iron)
(Biocel)
(Multivitamins,The
r W-Minerals)
(Multivitamin)
(Multivitamins
with Iron)
(Multivitamin with
Minerals)
(Multivitamins
with Min No.7/Fa)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin with
Minerals)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
3
$0
Medidas necesarias,
restricciones o
límites de uso
(Vitamin B
4
$0
Complex)
(Vit B Complex
natural b-100 complex *
100 Cmb
4
$0
#2/Herbs)
nephro-vite *
(Dialyvite 800)
4
$0
natural b-100 *
152
Nivel
Lo que le
costará a
usted el
(Niacinamide)
4
$0
(Niacinamide)
4
$0
(Pic 200)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin)
(Multivitamins,The
rapeutic)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin)
(Tab A Vite)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamin)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
(Quintabs)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
niacinamide * oral tablet 500 mg
niacinamide * oral tablet extended
release
nu-iron *
ocutabs *
once daily *
oncovite *
one daily 50 plus *
one daily complete * oral tablet
one daily energy * oral tablet
one daily essential * oral tablet
one daily maximum (with ca) *
one daily men's 50+ * oral tablet
one daily multi-vit w-mineral *
one daily multivitamin * oral tablet
one daily multivitamin * oral tablet
400 mcg
(Multivitamin/Iron/
Folic Acid)
one daily * oral tablet
(Multivitamin)
(Multivitamins
one daily plus iron * oral tablet
with Iron)
one daily plus iron * oral tablet 18- (Multivitamin/Iron/
400 mg-mcg
Folic Acid)
(Multivitamin with
one daily plus minerals *
Minerals)
(Multivitamins
one daily with iron *
with Iron)
one daily multivitamin-iron *
Medidas necesarias,
restricciones o
límites de uso
153
one-a-day essential *
(Multivitamin)
(Multivitamin with
one-a-day maximum formula *
Minerals)
one-a-day teen advantage * oral
(Multivitamin/Iron/
tablet 18-400 mg-mcg
Folic Acid)
one-a-day teen advantage * oral
(Multivits,Ca,Mine
tablet 9 mg iron-400 mcg
rals/Iron/Fa)
(Ocuvite with
opti-vitamins *
Lutein)
pedi m.vit no.17 with fluoride oral (Pedi Mvi No.82
drops 0.25 mg/ml
with Fluoride)
pediatric multivitamin *
(Multivitamin)
pharmacist favorite multi-vit *
(Multivitamin)
phytonadione * oral tablet 100 mcg (Phytonadione)
poly-iron *
(Pic 200)
(Pediatric Multivit
poly-vita *
Comb No.20)
(Ped Multivit
poly-vita (iron) *
#46/Iron Sulfate)
(Pediatric Multivit
poly-vitamin *
Comb No.20)
poly-vitamin with iron * oral drops (Ped Multivit
1,500 unit-400 unit-10 mg/ml
#46/Iron Sulfate)
(Multivitamin
polyvitamin/iron *
W/Iron, Minerals)
poly-vitamins *
(Multivitamin)
prenatal formula * oral tablet 28(Classic Prenatal)
0.8 mg
prenatal * oral tablet 28-0.8 mg
(Classic Prenatal)
(Prenatal
prenatal vit#96-ferrous fum-fa *
Vit#96/Ferrous
Fum/Fa)
prenatal vitamin with minerals *
(Classic Prenatal)
prenatal vitamins oral tablet 27 mg (Pnv with
iron- 1 mg
Ca,No.72/Iron/Fa)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
Medidas necesarias,
restricciones o
límites de uso
(All Rx Prenatal
Vitamins Covered)
154
prenatal vitamins with iron
prenatal vit-iron fumarate-fa *
prosight *
pyridoxine * injection
ra central-vite select * tab p/f
scooby-doo one a day *
sentry * oral tablet 18-400 mg-mcg
sentry senior *
sodium fluoride oral tablet
sodium fluoride * oral
tablet,chewable 0.25 mg fluorid
(0.55 mg)
spectravite adult 50+ * oral tablet
spectravite advanced formula * oral
tablet
spectravite * oral liquid
(Pnv119/Iron
Fumarate/Fa/Dss)
(Classic Prenatal)
(A/C/E/Zinc/Sod
Selenate/Copper)
(Pyridoxine HCl)
(Multivitamin
W/Iron, Minerals)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Pedi Mvi No.82
with Fluoride)
(Sodium Fluoride)
Nivel
Lo que le
costará a
usted el
2
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
1
$0
3
$0
Medidas necesarias,
restricciones o
límites de uso
(Biocel)
4
$0
(Multivitamin/Iron/
4
$0
Folic Acid)
(Pediavit)
4
$0
(Multivitamins
spectravite * oral tablet,chewable
4
$0
with Iron)
(Multivitamin
spectravite senior * oral tablet
4
$0
W/Iron, Minerals)
(Multivitamin Wspectravite senior w-lycopene *
4
$0
Minerals/Lutein)
(Multivitamin/Iron/
spectravite ultra women *
4
$0
Folic Acid)
(Multivits,Stress
stress 500 plus zinc *
4
$0
Formula/Zinc)
(Multivits,Stress
stress b with zinc *
4
$0
Formula/Zinc)
(Vitamin B
stress b-biotin *
4
$0
Complex)
155
stress formula *
stress formula plus iron *
stress formula with iron *
stress formula with zinc *
stuart prenatal *
sunvite *
super b complex-vitamin c *
super b/c *
super b-50 complex *
super b-50 complex plus *
super multiple * oral tablet
super multivitamin *
super quints b-50 *
super thera vite m *
superior 35 *
superplex-t *
support *
support-500 *
tab-a-vite *
(Multivits,Stress
Formula)
(Iron/Multivits,Stre
ss Formula)
(Vit B
Comp/C/Fa/Iron/Vi
t E)
(Multivits,Stress
Formula/Zinc)
(Classic Prenatal)
(Mv-Min/Iron
Fum/Fa/Lyco/Lutn/
K)
(Vita-Bee with C)
(B Complex with
Vitamin C)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Multivitamin
W/Iron, Minerals)
(Multivitamin)
(Vitamin B
Complex)
(Multivitamins,The
r W-Minerals)
(Multivitamin
W/Iron, Minerals)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(B Complex with
Vitamin C)
(Multivitamin)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
156
(Multivitamins
with Iron)
(Multivitamin with
tab-a-vite-minerals *
Minerals)
(Multivits,Ca,Mine
thera m plus (ferrous fumarat) *
rals/Iron/Fa)
(Multivitamins,The
thera vitamin *
rapeutic)
(Multivit,Ther
theradex m *
Iron,Ca,Fa and
Min)
(Multivits,Th Wthera-m * oral tablet
Fe,Other Min)
(Multivit,Ther
thera-m * oral tablet 27-0.4 mg
Iron,Ca,Fa and
Min)
thera-m * oral tablet 9 mg iron-400 (Multivits,Ca,Mine
mcg
rals/Iron/Fa)
(Multivitamin with
theramill forte * oral capsule
Minerals)
(Multivitamins,The
therapeutic liquid *
rapeutic)
therapeutic m + beta-carotene *
(Tab A Vite)
(Multivitamins
therapeutic vitamins/minerals *
with Min No.7/Fa)
therapeutic-m * oral tablet 9 mg
(Multivits,Ca,Mine
iron-400 mcg
rals/Iron/Fa)
(Multivit,Ther
therapeutic-m vitamin/minerals *
Iron,Ca,Fa and
oral tablet 27-0.4 mg
Min)
(Multivitamins,The
thera-tabs *
rapeutic)
(Multivitamin
theratrum complete 50 plus *
W/Iron, Minerals)
(Multivitamin Wtheratrum complete 50 plus/lut *
Minerals/Lutein)
tab-a-vite/iron *
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
157
therems *
therems-h *
therems-m *
thiamine hcl * injection
thiamine hcl * oral tablet 500 mg
total b/c *
totalday multiple *
tri-vi-sol *
tri-vita *
tri-vitamin *
ultra b-100 complex * oral tablet
unicomplex-m *
vision *
vision formula *
vision formula (with lutein) *
vision plus lutein *
vit b cmplx 3-fa-vit c-biotin * oral
tablet 1-60-300 mg-mg-mcg
(Multivitamins,The
rapeutic)
(Thiamine HCl)
(Thiamine HCl)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(Vit A
Palmitate/Vit C/Vit
D3)
(Pedi Multivits
A,C, and D3
No.21)
(Pedi Multivits
A,C, and D3
No.21)
(Vitamin B
Complex)
(Multivitamin
W/Iron, Minerals)
(Beta-Carotene(A)
W-C and E/Min)
(Beta-Carotene(A)
W-C and E/Min)
(Ocuvite with
Lutein)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
3
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
Medidas necesarias,
restricciones o
límites de uso
158
Nivel
Lo que le
costará a
usted el
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Pyridoxine HCl)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
4
$0
4
$0
4
$0
vit b cmplx no3-fa-c-biot-zinc *
vitabee/c *
vitalets * oral tablet,chewable
vitamin a * oral capsule 10,000
unit, 25,000 unit
vitamin b complex *
vitamin b complex with c *
vitamin b-1 * oral tablet
vitamin b-100 complex *
vitamin b12-folic acid * oral
vitamin b-6 * oral tablet 100 mg, 25
mg, 250 mg, 50 mg
vitamin c * oral capsule, extended
release
vitamin c * oral syrup
vitamin c * oral tablet 1,000 mg,
250 mg, 500 mg
vitamin c * oral tablet extended
release
vitamin c * oral tablet,chewable
250 mg, 500 mg
vitamins & minerals *
vitamins b complex * oral capsule
vitamins b complex * oral tablet
(Vit B Cmplx
No3/Fa/C/Biot/Zin
c)
(Vita-Bee with C)
(Multivitamins
with Iron)
(Vitamin A)
(Vitamin B
Complex)
(B Complex with
Vitamin C)
(Thiamine HCl)
(Vitamin B
Complex)
(Cyanocobalamin/
Folic Acid)
(Multivitamins,The
r W-Minerals)
(Vitamin B
Complex)
(Vitamin B
Complex)
Medidas necesarias,
restricciones o
límites de uso
159
vitamins b complex * oral tablet
500 mg-400 mcg- 18 mg iron
vitamins for hair * oral tablet
vitrum senior * oral tablet
(Vit B
Comp/C/Fa/Iron/Vi
t E)
(Multivitamin)
vitrum senior * oral tablet 500-300(Biocel)
250 mcg
women's daily multivitamin *
(Tab A Vite)
(Multivitamin/Iron/
yelets *
Folic Acid)
zoo chews *
(Multivitamin)
Nivel
Lo que le
costará a
usted el
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Medidas necesarias,
restricciones o
límites de uso
160
INDEX
3
3 day vaginal ................... 49, 50
30pse-150gfn-15dm ............... 85
8
8-MOP .................................. 96
A
a thru z advanced formula .... 142
a thru z high potency............ 142
a thru z select ....................... 142
a thru z select 50+ formula ... 142
a thru z select women's ........ 142
abacavir ................................. 63
abacavir-lamivudine-zidovudine
.......................................... 63
abc plus ............................... 142
ABELCET ............................. 50
ABILIFY ............................... 60
ABILIFY DISCMELT ........... 60
ABILIFY MAINTENA ......... 60
ABRAXANE ......................... 33
ABREVA .............................. 56
acamprosate ........................... 21
acarbose................................. 46
acebutolol .............................. 76
acephen ................................. 13
acetaminophen ....................... 13
acetaminophen-codeine ......... 13
acetazolamide ...................... 131
acetazolamide sodium .......... 131
acetic acid .................... 107, 125
acetylcysteine ...................... 139
acid gone antacid ................. 111
acid reducer (famotidine) ..... 110
acid reducer (ranitidine) ....... 110
acid relief (cimetidine) ......... 110
acitretin ................................. 96
acne medication ..................... 96
acne-clear .............................. 96
ACTEMRA ......................... 127
ACTHIB (PF)...................... 123
ACTIMMUNE .................... 127
acyclovir ..........................66, 96
acyclovir sodium ................... 66
ADACEL(TDAP
ADOLESN/ADULT)(PF) 123
ADAGEN ........................... 103
adapalene ............................ 102
ADCETRIS ........................... 33
ADCIRCA ................... 141, 142
adefovir ................................. 66
ADEMPAS ......................... 142
adrenalin ............................... 77
ADRENALIN ....................... 77
adt robitussin peak cld dm max
.......................................... 85
adult nasal decongestant ........ 85
adult one daily gummies ...... 143
adult robitussin lingering cld . 85
adult robitussin peak cold dm 85
adult wal-tussin ..................... 85
adult wal-tussin dm max ........ 85
adults 50+ daily formula ...... 143
adults' daily formula ............ 143
ADVAIR DISKUS .............. 137
ADVAIR HFA .................... 138
advil .................................17, 18
af 50
AFINITOR ............................ 33
AFINITOR DISPERZ ........... 33
AGGRENOX ........................ 69
airshield .............................. 143
AKTEN (PF) ....................... 104
alavert d-12 allergy-sinus ...... 52
alaway ................................. 104
ALBENZA ............................ 59
ALBUKED-25 ....................... 69
ALBUKED-5 ......................... 69
ALBUMIN, HUMAN 25 % ... 69
ALBUMIN, HUMAN 5 % ..... 69
ALBUMINAR 25 % .............. 69
ALBUMINAR 5 % ................ 69
ALBURX (HUMAN) 5 % ..... 69
ALBUTEIN 25 % .................. 69
ALBUTEIN 5 % .................... 69
albuterol sulfate ................... 138
alclometasone ........................ 99
ALCOHOL PADS ................. 96
ALCOHOL PREP PADS ....... 96
ALCOH-WIPE ...................... 96
ALDURAZYME ................. 103
alendronate .......................... 126
alfuzosin .............................. 117
ALIMTA ............................... 33
ALINIA ................................. 59
alka-seltzer plus mucus-conges
.......................................... 85
alka-seltzer plus sinus-cough.. 86
aller-chlor ........................ 52, 53
allerclear d-12hr ..................... 53
allerclear d-24hr ..................... 53
allergy (chlorpheniramine) ..... 53
allergy relief (cetirizine) ......... 53
allergy relief (loratadine) ........ 53
allerhist-1............................... 53
aller-tec d ............................... 53
allopurinol ........................... 127
almacone ............................. 111
almacone-2 .......................... 111
aloe vesta ............................... 50
alophen ................................ 114
ALPHAGAN P .................... 131
I-1
alprazolam ............................. 22
ALREX ............................... 109
altacaine .............................. 104
altamist ................................ 104
aluminum chloride ................. 96
aluminum hydroxide gel ...... 111
amantadine hcl....................... 59
ambi 10peh-4cpm-20dm ........ 86
ambi 20dm-4cpm ................... 86
ambi 40pse-400gfn-20dm ...... 86
ambi 60pse-4cpm................... 53
ambi 60pse-4cpm-20dm......... 86
AMBISOME ......................... 50
ambizine ................................ 58
amifostine crystalline ........... 127
amiloride ............................... 79
amiloride-hydrochlorothiazide79
AMINO ACIDS 15 % ........... 70
aminocaproic acid .................. 69
AMINOSYN 10 % ................ 70
AMINOSYN 3.5 % ............... 70
AMINOSYN 7 % .................. 70
AMINOSYN 7 % WITH
ELECTROLYTES ............. 70
AMINOSYN 8.5 % ............... 70
AMINOSYN 8.5 %ELECTROLYTES ............. 70
AMINOSYN II 10 % ............. 70
AMINOSYN II 15 % ............. 70
AMINOSYN II 7 %............... 70
AMINOSYN II 8.5 % ............ 70
AMINOSYN II 8.5 %ELECTROLYTES ............. 70
AMINOSYN M 3.5 % ........... 70
AMINOSYN-HBC 7% .......... 70
AMINOSYN-PF 10 % ........... 70
AMINOSYN-PF 7 %
(SULFITE-FREE).............. 70
AMINOSYN-RF 5.2 % ......... 70
amiodarone ............................ 75
amiodarone hcl ...................... 75
AMITIZA ............................ 111
amitriptyline .......................... 44
amlactin ................................ 96
amlodipine ............................ 79
amlodipine-atorvastatin ......... 80
amlodipine-benazepril ........... 79
ammonium lactate ................. 96
amoxapine ............................. 44
amoxicil-clarithromy-lansopraz
........................................ 110
amoxicillin ............................ 30
amoxicillin-pot clavulanate ... 31
amphetamine salt combo ....... 82
amphotericin b ...................... 50
ampicillin .............................. 31
ampicillin sodium .................. 31
ampicillin-sulbactam ............. 31
AMPYRA ............................. 82
ANACAINE.......................... 96
anagrelide .............................. 69
anastrozole ............................ 33
ANDRODERM ................... 118
ANDROGEL ...................... 118
animal chews ....................... 143
animal shape vitamins ......... 143
animal shapes plus iron ....... 143
ANORO ELLIPTA ............. 138
antacid................................. 111
antacid anti-gas ................... 111
antacid plus anti-gas ............ 111
anticoag citrate phos dextrose
........................................ 127
anti-diarrheal ....................... 111
anti-diarrheal (loperamide) .. 111
antifungal .............................. 50
antifungal (tolnaftate) ............ 50
anti-gas maximum strength.. 109
antioxidant .......................... 143
antioxidant formula ............. 143
antioxidant vitamins ............ 143
apatate forte......................... 143
APOKYN .............................. 59
apraclonidine ....................... 104
APRISO............................... 125
aprodine ................................. 53
APTIOM ............................... 41
APTIVUS .............................. 63
aquanil hc .............................. 99
ARALAST NP..................... 139
ARCALYST ........................ 122
aripiprazole ............................ 61
ARRANON ........................... 33
artificial tears ....................... 104
artificial tears (petro/min)..... 104
artificial tears (pf) ................ 104
artificial tears(glycerin-peg) . 104
artificial tears(hypromellose) 104
ARZERRA ............................ 34
ASACOL HD ...................... 125
ascorbic acid ........................ 143
ashlyna .................................. 83
aspirin .................................... 18
aspirin, buffered ..................... 18
aspir-low ................................ 18
ASSURE ID INSULIN
SAFETY .......................... 102
ASTAGRAF XL .................. 122
atenolol .................................. 76
atenolol-chlorthalidone .......... 76
athlete's foot (clotrimazole) .... 50
atorvastatin ............................ 80
atovaquone............................. 59
atovaquone-proguanil ............ 59
ATRIPLA .............................. 63
atropine .......................... 41, 104
ATROVENT HFA ............... 138
AUBAGIO .......................... 122
AVASTIN ............................. 34
AVC VAGINAL.................... 56
AVODART ......................... 127
AVONEX ............................ 127
AVONEX (WITH ALBUMIN)
........................................ 127
ayr saline ............................. 104
azacitidine .............................. 34
I-2
azathioprine ......................... 122
azathioprine sodium ............. 122
azelastine ............................. 104
AZILECT .............................. 59
azithromycin .......................... 29
AZOPT................................ 131
AZOR.................................... 79
aztreonam .............................. 30
B
b complete ........................... 143
b complex 1 ......................... 143
b complex-vitamin b12 ........ 143
b complex-vitamin c-folic acid
........................................ 143
b-100 complex ..................... 143
b-12 dots.............................. 143
b-50 complex ....................... 144
bacitracin ................. 26, 98, 107
bacitracin-polymyxin b ........ 107
bacitraycin plus...................... 98
baclofen ............................... 140
bal b-100 ............................. 144
bal b-50 ............................... 144
balance b-100 ...................... 144
balance b-50 ........................ 144
balanced b-100 .................... 144
balanced b-150 .................... 144
balanced b-50 ...................... 144
balsalazide ........................... 125
banophen ............................... 53
banophen allergy ................... 53
BANZEL ............................... 41
baza antifungal ...................... 50
BCG VACCINE, LIVE (PF) 123
b-complex............................ 144
b-complex with vitamin c .... 144
BD INSULIN PEN NEEDLE
UF SHORT ...................... 102
BD INSULIN SYRINGE
ULTRA-FINE.................. 102
bee-zee ................................ 144
BELEODAQ ......................... 34
benadryl allergy..................... 53
benazepril.............................. 74
benazepril-hydrochlorothiazide
.......................................... 74
BENICAR ............................. 74
BENICAR HCT .................... 74
BENLYSTA........................ 128
benzonatate ........................... 86
benzoyl peroxide ..............96, 97
benztropine ........................... 60
BETADINE SPRAY ............. 97
beta-hc .................................. 99
betamethasone acet,sod phos 119
betamethasone dipropionate .. 99
betamethasone valerate.......... 99
betamethasone, augmented .... 99
BETASERON ..................... 128
betaxolol ........................ 76, 131
bethanechol chloride ........... 128
BETHKIS ............................. 26
BEXSERO (PF) .................. 123
bicalutamide .......................... 34
bicarsim forte ...................... 109
BICILLIN C-R ...................... 31
BICILLIN L-A ...................... 31
BILTRICIDE ........................ 59
bimatoprost ......................... 131
bio-dtuss dmx ........................ 86
bion tears (pf) ...................... 104
bionel .................................... 86
bionel pediatric ...................... 86
biospec dmx .......................... 86
biosupp ............................... 144
biotin................................... 144
biovol .................................. 144
bisac-evac ........................... 114
bisacodyl ............................. 114
biscolax ............................... 114
bismatrol ............................. 112
bisoprolol fumarate ............... 76
bisoprolol-hydrochlorothiazide
.......................................... 76
bleomycin .............................. 34
BLINCYTO ........................... 34
BOOSTRIX TDAP .............. 123
BOSULIF .............................. 34
BOTOX ............................... 128
BREO ELLIPTA ................. 138
BRILINTA ............................ 69
brimonidine ......................... 131
BRINTELLIX........................ 44
bromfenac ............................ 109
bromocriptine ........................ 60
bromphenex dm ..................... 86
brompheniramine-pseudoephdm ..................................... 86
brompheniram-phenylephrinedm ..................................... 86
broncotron-s........................... 86
budesonide ........................... 125
bufferin .................................. 18
bumetanide ............................ 79
BUMINATE 25 % ................. 70
BUMINATE 5 % ................... 70
BUPHENYL ........................ 112
buprenorphine hcl ............ 13, 21
buprenorphine-naloxone ........ 21
bupropion hcl ............. 21, 44, 45
buspirone ............................. 128
butalb-acetaminophen-caffeine
.......................................... 13
butalbital-acetaminop-caf-cod 13
butalbital-acetaminophen ....... 13
butalbital-acetaminophen-caff 13
butalbital-aspirin-caffeine ...... 13
butorphanol tartrate ................ 13
BUTRANS ............................ 13
BYDUREON ......................... 46
BYETTA ............................... 46
BYSTOLIC ........................... 76
C
c complex ............................ 144
cabergoline ............................ 60
I-3
ca-d3-mag ox-zinc-cop-mangbor ................................... 132
caffeine citrated ..................... 82
caffeine-sodium benzoate ...... 82
calci-chew ........................... 112
calcidol ................................ 144
calcionate ............................ 132
calcipotriene .......................... 97
calcitonin (salmon) .............. 126
calcitrate .............................. 132
calcitrate-vitamin d .............. 132
calcitriol ........................ 97, 126
calcium 500 + d ................... 132
calcium 500 + d (d3) ............ 132
calcium 500 with d .............. 132
calcium 600 ......................... 132
calcium 600 + d(3)............... 132
calcium 600 with vitamin d3 132
calcium acetate .................... 116
calcium antacid .................... 112
calcium carbonate ........ 112, 132
calcium carbonate-mag carb-fa
........................................ 116
calcium carbonate-vitamin d2
........................................ 132
calcium carbonate-vitamin d3
........................................ 133
CALCIUM CARBONATEVITAMIN D3 .................. 112
calcium chloride .................. 133
calcium citrate-vitamin d3 ... 133
calcium gluconate ................ 133
calcium lactate ..................... 133
calcium+d ............................ 133
CALDOLOR ......................... 18
cal-gest antacid .................... 112
calphron............................... 116
CALTRATE 600 + D .......... 133
CALTRATE-600 + D VIT D3
(800) ................................ 133
CANCIDAS .......................... 50
candesartan ............................ 74
candesartan-hydrochlorothiazid
.......................................... 74
CAPASTAT .......................... 57
CAPRELSA .......................... 34
captopril ................................ 74
captopril-hydrochlorothiazide 74
CARAFATE ....................... 110
carbamazepine....................... 41
carbidopa .............................. 60
carbidopa-levodopa ............... 60
carbidopa-levodopa-entacapone
.......................................... 60
carboplatin ............................ 34
cardec dm (phenyleph-chlorphn)
.......................................... 86
CARIMUNE NF
NANOFILTERED........... 122
carisoprodol ........................ 140
carteolol .............................. 104
cartia xt ................................. 76
carvedilol .............................. 76
CASTELLANI PAINT
MODIFIED ....................... 97
CAYSTON ........................... 30
cefaclor ................................. 28
cefadroxil .............................. 28
cefazolin................................ 28
cefazolin in dextrose (iso-os) . 28
cefdinir .................................. 28
cefditoren pivoxil .................. 28
cefepime................................ 28
CEFEPIME IN DEXTROSE 5
%....................................... 28
CEFEPIME IN
DEXTROSE,ISO-OSM ..... 28
cefotaxime............................. 28
cefoxitin ................................ 28
cefoxitin in dextrose, iso-osm 29
cefpodoxime.......................... 29
cefprozil ................................ 29
ceftazidime ............................ 29
ceftibuten .............................. 29
ceftriaxone ............................. 29
ceftriaxone in dextrose,iso-os . 29
cefuroxime axetil ................... 29
cefuroxime sodium ................ 29
cefuroxime-dextrose (iso-osm)
.......................................... 29
celecoxib ............................... 18
CELLCEPT INTRAVENOUS
........................................ 122
CELONTIN ........................... 41
centamin .............................. 144
central vite with lutein.......... 145
central-vite ........................... 145
central-vite for seniors ......... 145
central-vite select ......... 145, 155
central-vite senior ................ 145
centram-care ........................ 145
centravites 50 plus ............... 145
centrum................................ 145
centrum complete................. 145
CENTRUM PRO NUTRIENTS
........................................ 133
centrum silver ...................... 145
centrum ultra women's ......... 145
century................................. 145
century adults 50+................ 145
century advanced formula .... 145
century mature ..................... 145
century ultimate women's ..... 145
cephalexin.............................. 29
CEPROTIN (BLUE BAR) .... 66,
67
CERDELGA ........................ 128
CEREZYME........................ 103
cerovite ................................ 145
cerovite advanced formula ... 145
cerovite jr............................. 146
cerovite senior ..................... 146
certavite senior-antioxidant .. 146
certavite-antioxid (iron gluc) 146
certavite-antioxidant ............ 146
I-4
CERVARIX VACCINE (PF)
........................................ 123
cetirizine ................................ 53
cetirizine-pseudoephedrine .... 53
cevimeline ............................. 95
CHANTIX ............................. 21
CHANTIX CONTINUING
MONTH BOX ................... 21
CHANTIX CONTINUING
MONTH PAK ................... 21
CHANTIX STARTING
MONTH BOX ................... 21
cheratussin ac ........................ 86
cheratussin dac ...................... 86
chest congestion relief + dm .. 86
chest congestion relief d......... 87
chest congestion relief pe ....... 87
chewable multi vitamin ........ 146
chewable-vite ...................... 146
chewable-vite with iron ....... 146
child complete multivitamin 146
child cough & sore throat ....... 87
child mucinex chest congestion
.......................................... 87
child mucus relief cough ........ 87
child plus cough & runny nose
.......................................... 87
child triaminic cold & allergy 53
child triaminic cough-congest 87
child vitamin with minerals .. 146
child wal-tap cold-allergy ...... 53
child wal-tussin cough relief .. 87
children's advil....................... 18
children's aller-tec.................. 53
children's cetirizine ................ 53
children's chest congestion ..... 87
children's chewable .............. 146
children's chewable complete
........................................ 146
children's chewable vitamin . 146
children's chewable w/minerals
........................................ 146
CHILDREN'S CLARITIN .... 53
children's complete vitamin . 146
CHILDREN'S DIMETAPP
COLD &FLU .................... 87
children's flu relief................. 87
children's mapap .................... 13
children's mucinex cough ...... 87
children's multivit w/extra c. 146
children's non-aspirin ............ 13
children's pain & fever relief . 13
children's pain reliever........... 13
children's pepto ................... 112
children's silapap ................... 14
children's silfedrine ............... 87
children's soothe .................. 112
children's sudafed .................. 87
children's sudafed pe cough ... 87
children's vitamin with iron . 146
children's wal-dryl allergy ..... 53
children's wal-zyr .................. 53
CHILDREN'S ZYRTEC
ALLERGY ........................ 53
childs chew vite ................... 146
child's chewable vitamins/iron
........................................ 146
child's vitamin with iron ...... 146
child's vitamin with vitamin c
........................................ 146
childs/iron ........................... 147
chlophedianol-guaifenesin ..... 87
chloramphenicol sod succinate
.......................................... 26
chlordiazepoxide hcl ............. 22
chlorhexidine gluconate......... 95
chloroquine phosphate ........... 59
chlorothiazide ........................ 79
chlorothiazide sodium ........... 79
chlorpheniramine-phenyleph-dm
.......................................... 87
chlorpromazine ..................... 61
chlorthalidone ....................... 79
chlorzoxazone ..................... 140
CHOLBAM ......................... 112
cholestyramine (with sugar) ... 80
cholestyramine-aspartame ...... 80
choline,magnesium salicylate . 18
ciclopirox............................... 50
ciclopirox-ure-camph-menth-euc
.......................................... 50
cilostazol ............................... 69
cimetidine ............................ 110
cimetidine hcl ...................... 110
CIMZIA............................... 103
CIMZIA POWDER FOR
RECONST ....................... 103
CIPRODEX ......................... 107
ciprofloxacin .......................... 32
ciprofloxacin hcl .... 32, 107, 108
ciprofloxacin in 5 % dextrose . 32
ciprofloxacin lactate ............... 32
cisplatin ................................. 34
citalopram .............................. 45
citracal + d maximum .......... 133
citric acid-sodium citrate ...... 133
citrus calcium....................... 133
clarithromycin .................. 29, 30
CLARITIN ............................ 53
CLARITIN LIQUI-GEL ........ 54
CLARITIN REDITABS......... 54
CLARITIN-D 12 HOUR........ 54
CLARITIN-D 24 HOUR........ 54
clearlax ................................ 114
clemastine .............................. 54
CLEVIPREX ......................... 79
clindamycin hcl...................... 26
clindamycin in 5 % dextrose .. 26
clindamycin palmitate hcl ...... 27
clindamycin phosphate .... 27, 56,
98
CLINIMIX 5%/D15W
SULFITE FREE................. 70
CLINIMIX 5%/D25W
SULFITE-FREE ................ 70
I-5
CLINIMIX 2.75%/D5W
SULFIT FREE ................... 71
CLINIMIX 4.25%/D10W SULF
FREE ................................. 71
CLINIMIX 4.25%/D5W
SULFIT FREE ................... 71
CLINIMIX 4.25%-D20W
SULF-FREE ...................... 71
CLINIMIX 4.25%-D25W
SULF-FREE ...................... 71
CLINIMIX 5%D20W(SULFITE-FREE) ... 71
CLINIMIX E 2.75%/D10W
SUL FREE......................... 71
SULF FREE ...................... 71
SUL FREE......................... 71
SUL FREE......................... 71
SULF FREE ...................... 71
CLINIMIX E 5%/D15W
SULFIT FREE ................... 71
CLINIMIX E 5%/D20W
SULFIT FREE ................... 71
CLINIMIX E 5%/D25W
SULFIT FREE ................... 71
CLINISOL SF 15 % .............. 71
clobetasol ...................... 99, 100
clobetasol propionate ............. 99
clobetasol-emollient ............. 100
clocortolone pivalate ............ 100
clomipramine ......................... 45
clonazepam............................ 22
clonidine ................................ 73
clonidine hcl .................... 73, 82
clonidine hcl-chlorthalidone... 73
clopidogrel ............................ 69
clorazepate dipotassium ......... 23
clotrimazole ........................... 50
clotrimazole 3 day ................. 50
clotrimazole-3 ....................... 50
clotrimazole-betamethasone .. 50
clozapine ............................... 61
COARTEM ........................... 59
codeine sulfate ...................... 14
codeine-butalbital-asa-caffein 14
codituss dm ........................... 87
colace .................................. 114
colchicine ............................ 128
colchicine-probenecid ......... 128
COLCRYS .......................... 128
cold & cough ......................... 54
cold multi-symptom .............. 88
cold multi-symptom day/night 88
cold multi-symptom nighttime
.......................................... 88
cold relief m/s day/night ........ 88
cold-flu relief ........................ 88
cold-flu relief, day/night ........ 88
colestipol............................... 80
colistin (colistimethate na)..... 27
COLY-MYCIN S ................ 108
COMBIGAN ....................... 131
COMBIPATCH .................. 118
COMBIVENT RESPIMAT . 138
COMETRIQ.......................... 34
comfort gel extra strength .... 112
COMFORT PACCYCLOBENZAPRINE ... 140
COMFORT PAC-IBUPROFEN
.......................................... 18
COMFORT PACMELOXICAM .................. 18
COMFORT PAC-NAPROXEN
.......................................... 18
COMFORT PAC-TIZANIDINE
........................................ 140
compete............................... 147
COMPLERA ......................... 63
complete 50+....................... 147
complete multi 50+ ............. 147
complete multivitamin ......... 147
complete multivitamin-mineral
........................................ 147
complete senior .................... 147
compoz .................................. 54
COMVAX (PF) ................... 123
CONDYLOX ......................... 97
congestac ............................... 88
COPAXONE ....................... 128
coral calcium ....................... 133
CORDRAN ......................... 100
coricidin hbp .......................... 88
cortisone .............................. 119
cortizone-10 ......................... 100
CORTIZONE-10 ................. 100
COSENTYX PEN (2 PENS).. 97
cough & cold ......................... 88
cough & runny nose ............... 88
coughtab ................................ 88
CREON ............................... 103
creo-terpin (dm-guaifenesin) .. 88
CRESTOR ............................. 80
critic-aid clear af .................... 51
CRIXIVAN ........................... 64
cromolyn ............. 105, 112, 139
CUBICIN .............................. 27
CURITY GAUZE ................ 128
cyanocobalamin (vitamin b-12)
........................................ 147
cyclobenzaprine ................... 140
CYCLOGYL ....................... 105
cyclopentolate ...................... 105
cyclophosphamide ................. 34
CYCLOPHOSPHAMIDE ...... 34
CYCLOSET .......................... 46
cyclosporine ......................... 122
cyclosporine modified .......... 122
cyclosporine, modified ......... 122
cyproheptadine....................... 54
CYRAMZA ........................... 34
CYSTADANE ..................... 128
CYSTARAN........................ 105
cysteine (l-cysteine) ............... 71
I-6
cytarabine .............................. 34
cytarabine (pf) ....................... 34
D
d10 % & 0.45 % sodium
chloride.............................. 71
d2.5 %-0.45 % sodium chloride
.......................................... 71
d5 % and 0.9 % sodium chloride
.......................................... 72
d5 %-0.45 % sodium chloride 72
dacarbazine ............................ 34
dactinomycin ......................... 34
daily gummies ..................... 147
daily multiple....................... 147
daily multi-vitamin .............. 147
daily multivitamin with iron. 147
daily multivitamin-minerals . 147
daily multi-vitamins/iron ..... 147
daily teen multi-vitamin ....... 148
daily value ........................... 148
daily vitamin ........................ 148
daily vitamin formula .......... 148
daily vitamin formula + iron 148
daily vitamin formula-minerals
........................................ 148
daily vitamin with iron......... 148
daily vites/iron ..................... 148
dailyhist-1.............................. 54
daily-vite ............................. 148
DALIRESP.......................... 139
DALLERGY DM .................. 88
danazol ................................ 118
dantrolene ............................ 140
dantrolene sodium ............... 140
dapsone ................................. 57
DAPTACEL (DTAP
PEDIATRIC) (PF) ........... 123
DARAPRIM .......................... 59
dayhist allergy ....................... 54
daytime cold & cough ............ 88
daytime cold-flu .................... 88
day-time cough ...................... 88
daytime mucus relief dm ....... 88
daytime-nighttime ................. 88
daytime-nighttime cold-flu .... 89
daytime-nighttime cough ....... 89
deblitane................................ 83
decitabine .............................. 34
decongestant cough ............... 89
deep sea nasal...................... 105
deferoxamine ...................... 117
delsym cough+chest congest dm
.......................................... 89
DELZICOL ......................... 125
DEMSER .............................. 77
DEPEN TITRATABS ......... 117
DEPO-PROVERA .............. 121
dermafungal .......................... 51
dermarest eczema (hydrocort)
........................................ 100
desenex ................................. 51
desipramine ........................... 45
desmopressin ....................... 120
desog-e.estradiol/e.estradiol .. 83
desogestrel-ethinyl estradiol .. 84
desonide .............................. 100
desoximetasone ................... 100
despec-dm (pseudoeph-dmguaif) ................................. 89
dex4 glucose ......................... 72
dexamethasone .................... 119
dexamethasone sodium
phosphate ................. 109, 119
dexchlorphen-pse-chlophedianol
.......................................... 89
dexmethylphenidate .............. 82
dextroamphetamine ............... 82
dextroamphetamineamphetamine ..................... 82
dextromethorphan polistirex .. 89
dextrose 10 % and 0.2 % nacl 72
.......................................... 72
dextrose 2.5 % in water(d2.5w)
.......................................... 72
.......................................... 72
.......................................... 72
.......................................... 72
dextrose 5 % in ringers........... 72
dextrose 5 % in water (d5w)... 72
dextrose 5 %-lactated ringers . 72
dextrose 5%-0.2 % sod chloride
.......................................... 72
dextrose 5%-0.3 % sod.chloride
.......................................... 72
.......................................... 72
.......................................... 72
dextrose with sodium chloride 72
diabetic siltussin das-na ......... 89
diabetic tussin dm .................. 89
diabetic tussin ex.................... 89
diamode ............................... 112
DIASTAT ACUDIAL............ 23
diazepam ............................... 23
diazepam intensol .................. 23
diclofenac potassium.............. 18
diclofenac sodium .......... 18, 109
diclofenac-misoprostol ........... 18
dicloxacillin ........................... 31
dicyclomine ......................... 112
didanosine.............................. 64
DIFICID ................................ 30
diflunisal ................................ 18
digitek.................................... 77
digoxin ............................ 77, 78
DIGOXIN .............................. 78
dihydroergotamine ........... 56, 57
DILANTIN ............................ 41
diltiazem hcl .................... 76, 77
dilt-xr ..................................... 77
I-7
dimaphen (pe) ........................ 54
dimaphen dm ......................... 89
dimenhydrinate ...................... 58
dimetapp cold-congestion ...... 54
dino-life ............................... 148
dino-life with extra c............ 148
dino-life with iron-zinc ........ 148
DIPENTUM ........................ 125
diphenhist .............................. 54
diphenhydramine hcl ............. 54
diphenoxylate-atropine ........ 112
disopyramide phosphate......... 75
disulfiram .............................. 21
divalproex........................ 41, 42
d-methorphan hb-p-epd hcl-bpm
.......................................... 89
dm-phenyleph-chlorpheniramine
.......................................... 89
dobutamine ............................ 78
dobutamine in d5w ................ 78
doc-q-lace ............................ 114
docu..................................... 114
docusate calcium ................. 114
docusate sodium .................. 114
docusol ................................ 114
dok ...................................... 114
donepezil ............................... 44
dopamine ............................... 78
dopamine in 5 % dextrose ...... 78
dorzolamide ......................... 131
dorzolamide-timolol ............ 131
double-tussin dm ................... 89
douche vinegar & water extra
........................................ 128
doxazosin .............................. 73
doxepin.................................. 45
doxercalciferol..................... 126
doxorubicin hcl ...................... 35
doxorubicin hcl peg-liposomal
.......................................... 35
doxorubicin, peg-liposomal ... 35
doxycycline hyclate ......... 32, 33
doxycycline monohydrate...... 33
dramamine ............................ 58
driminate ............................... 58
dristan long lasting .............. 105
dronabinol ............................. 58
droperidol............................ 128
drospirenone-ethinyl estradiol 84
DROXIA ............................... 35
DUAVEE ............................ 118
dulcolax stool softener (dss) 114
DULERA ............................ 138
duloxetine ............................. 45
DURAMORPH (PF) ............. 14
DUREZOL .......................... 109
DYRENIUM ......................... 79
E
e.c. prin ................................. 18
ECEE PLUS........................ 148
econazole .............................. 51
ed bron gp ............................. 89
ed chlorped jr ........................ 54
EDURANT ........................... 64
EFFIENT .............................. 69
ELAPRASE ........................ 103
eldertonic ............................ 148
electrolyte-48 in d5w ........... 133
ELIDEL .............................. 100
ELIGARD ............................. 35
ELIQUIS............................... 67
ELITEK .............................. 103
ELLA .................................... 84
ellis tonic............................. 148
ELMIRON .......................... 128
elon dual defense ................... 51
EMCYT ................................ 35
EMEND ................................ 58
EMSAM................................ 45
EMTRIVA ............................ 64
enalapril maleate ................... 74
enalaprilat ............................. 74
enalapril-hydrochlorothiazide 74
ENBREL............................. 122
ENBREL SURECLICK ....... 122
endur-acin .............................. 80
enema .................................. 114
enema disposable ................. 114
enemeez ............................... 114
enfalyte ................................ 133
ENGERIX-B (PF) ................ 124
ENGERIX-B PEDIATRIC (PF)
........................................ 124
enoxaparin ............................. 67
entacapone ............................. 60
entecavir ................................ 66
entre-cough ............................ 89
ephedrine sulfate .................... 78
epinastine ............................. 105
epinephrine ............................ 78
EPIPEN 2-PAK ..................... 78
EPIPEN JR 2-PAK ................ 78
epirubicin ............................... 35
EPIVIR HBV ......................... 64
eplerenone ............................. 81
EPOGEN ............................... 68
epoprostenol (glycine).......... 142
EPZICOM ............................. 64
eq gentle .............................. 105
equalactin ............................ 114
ERBITUX.............................. 35
ergocalciferol (vitamin d2) ... 148
ergoloid ............................... 128
ERGOMAR ........................... 57
ERIVEDGE ........................... 35
ERYTHROCIN ..................... 30
erythromycin.................. 30, 108
erythromycin base .................. 30
ERYTHROMYCIN BASE .... 30
erythromycin base-ethanol ..... 98
erythromycin ethylsuccinate... 30
erythromycin stearate ............. 30
erythromycin with ethanol ..... 98
ESBRIET............................. 139
escitalopram oxalate............... 45
esmolol .................................. 76
I-8
esomeprazole sodium........... 110
essentia ................................ 148
essential balance with lutein. 148
essential daily ...................... 148
essential one daily................ 148
estazolam............................... 23
ESTRACE ........................... 118
estradiol ............................... 119
estradiol valerate.................. 119
estradiol/norethindrone acet . 119
estradiol-norethindrone acet . 119
ESTRASORB ...................... 119
estropipate ........................... 119
ethambutol............................. 57
ethamolin ............................... 78
ethinyl estradiol/drospirenone 84
ethosuximide ......................... 42
ethynodiol d-ethinyl estradiol. 84
etidronate disodium ............. 126
etodolac ................................. 18
ETOPOPHOS ........................ 35
etoposide ............................... 35
EVOTAZ............................... 64
exefen dmx ............................ 89
EXELON............................... 44
exemestane ............................ 35
EXFORGE ............................ 79
EXFORGE HCT.................... 79
EXJADE ............................. 117
expectorant ............................ 90
expectorant max strength ....... 89
EXTAVIA ........................... 128
extra cleansing douche ......... 128
F
FABRAZYME .................... 103
famciclovir ............................ 66
famotidine ................... 110, 111
famotidine (pf) ..................... 110
famotidine (pf)-nacl (iso-os)110
FANAPT ............................... 61
FARESTON .......................... 35
FARYDAK ........................... 35
FASLODEX.......................... 35
FAZACLO ............................ 61
fe fumarate-doss-fa-bcomp and
c ...................................... 149
fe fumarate-vit c-b12-if-fa ... 149
felbamate .............................. 42
felodipine .............................. 79
feminine care douche........... 128
FEMRING .......................... 119
fenofibrate ............................. 80
fenofibrate micronized .......... 80
fenofibrate nanocrystallized ... 80
fenofibric acid ....................... 80
fenofibric acid (choline) ........ 80
fenoprofen ............................. 18
fentanyl ................................. 14
fentanyl citrate ...................... 14
ferate ................................... 149
ferotrinsic ............................ 149
ferretts ................................. 149
ferrex 150 ............................ 149
ferrex 150 plus .................... 149
FERRIPROX ...................... 117
ferrocite............................... 149
ferrous fumarate .................. 149
ferrous gluconate ................. 149
ferrous sulfate...................... 149
FETZIMA ............................. 45
feverall .................................. 14
fiber (calcium polycarbophil)
........................................ 115
fiber laxative ....................... 115
fiber smooth ........................ 115
fiber therapy ........................ 115
fiber therapy (psyllium/sugar)
........................................ 115
fiber-lax .............................. 115
finasteride ........................... 128
FIRAZYR ............................. 78
FIRMAGON KIT W DILUENT
SYRINGE ......................... 35
flanax antacid ...................... 112
FLEBOGAMMA DIF .......... 122
flecainide ............................... 75
FLECTOR ............................. 19
FLEET BISACODYL .......... 115
FLEXBUMIN 25 % ............... 70
FLEXBUMIN 5 % ................. 70
flintstones complete (iron) ... 149
flintstones multivitamin ....... 149
flintstones with iron ............. 149
flintstones/extra c ................. 149
FLOVENT DISKUS ............ 138
FLOVENT HFA .................. 138
floxuridine ............................. 35
flu formula daytime-nighttime 90
flu severe cold-congestion...... 90
fluconazole ............................ 51
fluconazole in dextrose(iso-o) 51
fluconazole in nacl (iso-osm) . 51
flucytosine ............................. 51
fludarabine ............................. 35
fludrocortisone ..................... 119
flumazenil .............................. 82
fluocinonide ......................... 100
fluocinonide-emollient base . 100
fluorometholone ................... 109
FLUOROPLEX ..................... 97
fluorouracil ...................... 35, 97
fluoxetine ............................... 45
FLUOXETINE ...................... 45
fluoxymesterone .................. 118
fluphenazine decanoate .......... 61
fluphenazine hcl ..................... 61
flurazepam ............................. 24
flurbiprofen............................ 19
flurbiprofen sodium ............. 109
flu-severe cold-cough............. 90
flutamide ............................... 36
fluticasone ................... 100, 109
fluvoxamine ........................... 45
foaming antacid ................... 112
folic acid ...................... 149, 150
FOLIC ACID ....................... 149
I-9
fomepizole ........................... 128
fondaparinux ......................... 67
FORTEO ............................. 126
FORTICAL ......................... 126
foscarnet ................................ 65
fosfree ................................. 150
fosinopril ............................... 75
fosinopril-hydrochlorothiazide
.......................................... 75
fosphenytoin .......................... 42
FREAMINE HBC 6.9 %........ 72
FREAMINE III 10 %............. 72
fruity chews ......................... 150
fungi cure .............................. 51
FUNGI-NAIL ........................ 51
fungoid-d ............................... 51
furosemide ............................. 79
FUSILEV ............................ 128
FUZEON ............................... 64
FYCOMPA ........................... 42
G
gabapentin ............................. 42
GABITRIL ............................ 42
galantamine ........................... 44
GAMASTAN S/D ............... 122
GAMMAGARD LIQUID .... 122
GAMMAPLEX ................... 122
GAMUNEX-C..................... 122
ganciclovir sodium ................ 66
GARDASIL (PF) ................. 124
GARDASIL 9 (PF) .............. 124
gas free extra strength .......... 109
gas relief .............................. 109
gas relief 80 ......................... 109
gas relief extra strength ........ 109
gas-x ultra-strength .............. 109
gatifloxacin .......................... 108
GAZYVA .............................. 36
gelusil antacid & anti-gas ..... 112
gemcitabine ........................... 36
gemfibrozil ............................ 80
GENOTROPIN ................... 120
GENOTROPIN MINIQUICK
........................................ 120
gentamicin................ 26, 98, 108
gentamicin in nacl (iso-osm).. 26
gentamicin sulfate ............... 108
gentamicin sulfate (ped) (pf).. 26
gentamicin sulfate (pf) ........... 26
GENTEAL MILD TO
MODERATE .................. 105
GENTEAL GEL ................. 105
GENTEAL MILD ............... 105
GENTEAL SEVERE .......... 105
gentlelax.............................. 115
GEODON ............................. 61
geravim ............................... 150
geriaton ............................... 150
geri-hydrolac ......................... 97
germ defense ....................... 150
gildess 24 fe .......................... 84
GILENYA........................... 128
GILOTRIF ............................ 36
GLEEVEC ............................ 36
glimepiride ............................ 49
glipizide ................................ 49
glipizide-metformin ............... 49
GLUCAGEN HYPOKIT..... 128
GLUCAGON EMERGENCY
KIT (HUMAN) ............... 128
gluco burst ............................ 72
glucose .................................. 73
glucose gel ............................ 73
glutose 15.............................. 73
glyburide ............................... 49
glyburide micronized ............. 49
glyburide-metformin ............. 49
GLYCINE ........................... 125
glycolax .............................. 115
glycopyrrolate ..................... 112
glydo ..................................... 20
GLYXAMBI ......................... 47
granisetron (pf) ...................... 58
granisetron hcl....................... 58
GRANIX ............................... 68
griseofulvin microsize ............ 51
guaiatussin ac......................... 90
guaifenesin............................. 90
guaifenesin dac ...................... 90
guanfacine ....................... 74, 82
guanidine ............................. 129
gummi bear multivitamin ..... 150
gummy swirls ...................... 150
H
hair vitamins ........................ 150
hair,skin & nails ................... 150
HALAVEN ............................ 36
halobetasol propionate ......... 100
haloperidol............................. 61
haloperidol decanoate ............ 61
haloperidol lactate .................. 61
HARVONI ............................ 65
HAVRIX (PF) ..................... 124
head congestion day-night ...... 90
healthy eyes ......................... 150
healthylax ............................ 115
hemocyte ............................. 150
heparin (porcine) .................... 68
heparin (porcine) in 5 % dex . 67,
68
HEPARIN (PORCINE) IN 5 %
DEX .................................. 67
heparin (porcine) in nacl (pf) .. 67
HEPARIN(PORCINE) IN
0.45% NACL ..................... 68
heparin, porcine (pf)............... 68
HEPATAMINE 8% ............... 73
HEPATASOL 8 % ................. 73
HERCEPTIN ......................... 36
HEXALEN ............................ 36
hi-b complex ........................ 150
hi-cal plus vit d .................... 133
high potency multivit-multimin
........................................ 150
homatropine hbr ................... 105
honey bears .......................... 150
I-10
honey bears with iron-zinc ... 150
HUMALOG .......................... 48
HUMALOG KWIKPEN ........ 48
HUMALOG MIX 50-50 ........ 48
HUMALOG MIX 50-50
KWIKPEN ........................ 48
HUMALOG MIX 75-25 ........ 48
HUMALOG MIX 75-25
KWIKPEN ........................ 48
HUMATROPE .................... 120
HUMIRA ............................ 122
HUMIRA CROHN'S DIS
START PCK.................... 122
HUMIRA PEN .................... 122
HUMULIN 70/30 .................. 48
HUMULIN 70/30 KWIKPEN 48
HUMULIN 70/30 PEN .......... 48
HUMULIN N ........................ 48
HUMULIN N KWIKPEN ..... 48
HUMULIN N PEN ................ 48
HUMULIN R ........................ 48
HUMULIN R U-500.............. 48
hydralazine ............................ 78
hydro skin ............................ 100
hydrochlorothiazide ............... 80
hydrocil instant .................... 115
hydrocodone bit-homatrop mebr ....................................... 90
hydrocodone-acetaminophen . 14
hydrocodone-chlorpheniramine
.......................................... 90
hydrocodone-homatropine ..... 90
hydrocodone-ibuprofen .......... 14
hydrocortisone ...... 100, 101, 119
hydrocortisone acet-aloe vera
........................................ 101
hydrocortisone acetate ......... 101
hydrocortisone acetate-urea . 101
hydrocortisone butyrate ....... 101
hydrocortisone butyr-emollient
........................................ 101
hydrocortisone sod succinate 119
hydrocortisone valerate ....... 101
hydromorphone ................14, 15
hydromorphone (pf) .............. 14
hydroxychloroquine .............. 59
hydroxyurea .......................... 36
hydroxyzine hcl ................... 129
hydroxyzine pamoate .......... 129
HYPERLYTE CR ............... 133
HYPERRAB S/D (PF) ........ 122
HYQVIA ............................ 123
I
ibandronate ......................... 126
IBRANCE ............................. 36
ibuprofen ............................... 19
ibuprofen jr strength .............. 19
icaps plus ............................ 150
ICLUSIG .............................. 36
iferex 150 ............................ 150
ifosfamide ............................. 36
ifosfamide-mesna .................. 36
ILARIS (PF) ....................... 123
ILEVRO.............................. 109
IMBRUVICA........................ 36
imipenem-cilastatin ............... 30
imipramine hcl ...................... 45
imipramine pamoate .............. 45
imiquimod ............................. 97
imodium a-d ........................ 113
IMODIUM A-D .................. 113
IMOGAM RABIES-HT (PF)
........................................ 123
IMOVAX RABIES VACCINE
(PF) ................................. 124
INCRELEX......................... 120
indapamide ............................ 80
indomethacin ......................... 19
indomethacin sodium ............ 19
INFANRIX (DTAP) (PF) .... 124
infant acetaminophen ............ 15
infantaire ............................... 15
infant's ibuprofen................... 19
INFANT'S MOTRIN............. 19
infants' non-aspirin cold ......... 90
infant's pain reliever ............... 15
INLYTA ................................ 36
insta-glucose .......................... 73
INSULIN PEN NEEDLE..... 102
INSULIN SYRINGE ........... 103
INSULIN SYRINGE
NEEDLELESS ................ 102
INSULIN SYRINGE-NEEDLE
U-100............................... 103
INTELENCE ......................... 64
intense cough reliever ............ 90
INTRALIPID ......................... 73
INTRON A ............................ 66
INVANZ ............................... 30
INVEGA ............................... 62
INVEGA SUSTENNA .......... 62
INVIRASE ............................ 64
INVOKAMET ....................... 47
INVOKANA.......................... 47
inzo antifungal ....................... 51
iodine ................................... 103
IONOSOL-B IN D5W ......... 134
IONOSOL-MB IN D5W ...... 134
IPOL .................................... 124
ipratropium bromide ............ 105
IPRIVASK ............................ 68
irbesartan ............................... 74
irbesartan-hydrochlorothiazide
.......................................... 74
iron high potency ................. 150
ISENTRESS .......................... 64
ISOLYTE M IN 5 %
DEXTROSE .................... 134
ISOLYTE-H IN 5 %
DEXTROSE .................... 134
ISOLYTE-P IN 5 %
DEXTROSE .................... 134
ISOLYTE-S ......................... 134
isoniazid ................................ 57
isopto tears........................... 105
isosorbide dinitrate................. 81
I-11
isosorbide mononitrate........... 81
isotretinoin ............................ 97
isradipine ............................... 79
ISTODAX ............................. 36
itraconazole ........................... 51
ivermectin.............................. 59
i-vite .................................... 150
IXEMPRA ............................. 36
IXIARO (PF) ....................... 124
J
JAKAFI ................................. 37
JALYN ................................ 129
jantoven ................................. 68
JANUMET ............................ 47
JANUMET XR ...................... 47
JANUVIA ............................. 47
JARDIANCE ......................... 47
JENTADUETO ..................... 47
JEVTANA ............................. 37
jr. acetaminophen .................. 15
junior mapap .......................... 15
K
KABIVEN ............................. 73
KADCYLA ........................... 37
KALETRA ............................ 64
KALYDECO ....................... 139
kaopectate (bismuth subsalicy)
........................................ 113
KEDBUMIN ......................... 70
KELP (IODINE).................. 134
ketoconazole .......................... 51
ketoprofen ............................. 19
ketorolac .................. 19, 20, 109
ketotifen fumarate ................ 105
KEYTRUDA ......................... 37
KHEDEZLA ......................... 45
kidkare cough/cold ................ 90
kid's vitamins ....................... 151
kid's vitamins + extra c ........ 150
kids vitamins + iron ............. 151
kid's vitamins + iron ............ 151
KINERET............................ 123
KINRIX (PF) ...................... 124
KLOR-CON ........................ 134
klor-con 10 .......................... 134
KLOR-CON 8 ..................... 134
klor-con m10 ....................... 134
klor-con m15 ....................... 134
klor-con m20 ....................... 134
KLOR-CON/EF .................. 134
konsyl (sugar)...................... 115
konsyl fiber ......................... 115
konsyl sugar-free ................. 115
KORLYM ............................. 47
KRYSTEXXA .................... 103
KUVAN .............................. 103
KYPROLIS ........................... 37
L
l norgest&e estradiol-e estrad 84
labetalol ................................ 76
LACRISERT ....................... 105
LACTATED RINGERS ...... 125
LACTINOL HX .................... 97
lactulose .............................. 113
LAMICTAL .......................... 42
LAMISIL (AEROSOL) ......... 51
lamisil af ............................... 51
LAMISIL AT ........................ 51
lamivudine ............................ 64
lamivudine-zidovudine .......... 64
lamotrigine ............................ 42
LANOXIN ............................ 78
lansoprazole ........................ 110
LANTUS .............................. 48
LANTUS SOLOSTAR .......... 48
latanoprost........................... 131
LATUDA .............................. 62
laxative peg 3350 ................ 115
LAZANDA ........................... 15
leflunomide ......................... 123
LEMTRADA ...................... 129
LENVIMA ............................ 37
LETAIRIS........................... 142
letrozole ................................ 37
leucovorin calcium............... 129
LEUKERAN.......................... 37
LEUKINE.............................. 68
leuprolide ............................... 37
levetiracetam.......................... 42
levobunolol .......................... 131
levocarnitine ........................ 129
levocarnitine (with sugar)..... 129
levocetirizine ......................... 54
levofloxacin ................... 32, 108
levofloxacin in d5w ............... 32
levoleucovorin calcium ........ 129
levonorgestrel ........................ 84
levonorgestrel-ethin estradiol . 84
levonorgestrel-ethinyl estrad .. 84
levorphanol tartrate ................ 15
levothyroxine ............... 121, 122
LEXIVA ................................ 64
lice cream rinse .................... 102
lice killing ............................ 102
lice treatment ....................... 102
lidocaine ................................ 21
lidocaine (pf) ................... 20, 75
lidocaine hcl .................... 20, 21
lidocaine in 5 % dextrose (pf) 75
lidocaine-prilocaine ............... 21
LIDODERM .......................... 21
life-pack women's ................ 151
linezolid ................................. 27
LINZESS ............................. 103
liothyronine ......................... 122
lipase-protease-amylase ....... 103
lipogen ................................... 80
LIPOSYN II .......................... 73
LIPOSYN III ......................... 73
liquibid d-r ............................. 90
liquid calcium with vitamin d
........................................ 134
LIQUI-E .............................. 151
liquitears .............................. 105
lisinopril ................................ 75
lisinopril-hydrochlorothiazide 75
I-12
lithium carbonate ................... 82
lithium citrate ........................ 83
little animals ........................ 151
little animals/iron ................. 151
l-norgest-eth estr/ethin estra ... 84
lobana bath ............................ 97
lohist peb dm ......................... 90
lomustine ............................... 37
loperamide ........................... 113
loradamed .............................. 54
loratadine ............................... 55
loratadine-d ........................... 55
lorazepam oral solution .......... 24
lortuss ex ............................... 90
losartan .................................. 74
losartan-hydrochlorothiazide .. 74
LOTEMAX ......................... 109
LOTRIMIN ULTRA ............. 51
LOTRONEX ....................... 103
lovastatin ............................... 80
loxapine succinate ................. 62
lubricant dry eye relief ......... 105
lubricant eye (cmc-glycer)(pf)
........................................ 105
lubricant eye (cmc-glycerin) 105
lubricant eye (pg-peg 400)(pf)
........................................ 106
lubricant eye (polyv alcohol) 106
lubricant eye (propyl glycol) 106
lubricant eye drops............... 106
lubricating drops .................. 106
lubrifresh pm ....................... 106
LUMIGAN .......................... 131
LUMINAL ............................ 42
LUMIZYME ....................... 103
LUPRON DEPOT ................. 37
.......................................... 37
.......................................... 37
.......................................... 37
LUPRON DEPOT-PED ........ 37
LUPRON DEPOT-PED (3
MONTH) .......................... 37
LYNPARZA ......................... 37
LYRICA ............................... 42
lysiplex plus ........................ 151
LYSODREN ......................... 37
M
maalox advanced ................. 113
MACUVITE ....................... 151
MACUVITE EYE CARE .... 151
mafenide acetate.................... 97
mag 64 ................................ 134
mag-delay ........................... 134
mag-g .................................. 134
MAGNEBIND 300 ............. 113
magnesium .......................... 134
magnesium (oxide/aa chelate)
........................................ 134
magnesium chloride ............ 134
magnesium gluconate .......... 134
magnesium oxide ................ 113
magnesium sulfate ............... 135
magnesium sulfate in d5w ... 135
magnesium sulfate in water . 135
malathion ............................ 102
mapap (acetaminophen)......... 15
mapap arthritis pain ............... 15
mapap extra strength ............. 15
maprotiline ............................ 45
mar-cof bp ............................. 91
mar-cof cg ............................. 91
MARPLAN ........................... 45
MARQIBO ........................... 37
masanti double strength ....... 113
MATULANE ........................ 37
matzim la .............................. 77
maximum daily multivitamin
........................................ 151
maximum strength flu ........... 91
meclizine ............................... 58
medi-brom............................. 91
medroxyprogesterone ........... 121
mefenamic acid ...................... 20
mefloquine ............................. 59
MEFOXIN IN DEXTROSE
(ISO-OSM) ........................ 29
mega multiple/chelated mineral
........................................ 151
mega multivitamin with mineral
........................................ 151
MEGACE ES......................... 37
megestrol ............................... 37
MEKINIST ...................... 37, 38
meloxicam ............................. 20
melphalan hcl intravenous ...... 38
MENACTRA (PF) ............... 124
MENEST ............................. 119
MENHIBRIX (PF)............... 124
MENOMUNE - A/C/Y/W-135
(PF).................................. 124
men's multi-vitamin ............. 151
men's one daily .................... 151
MENVEO A-C-Y-W-135-DIP
(PF).................................. 124
MENVEO MENA
COMPONENT (PF)......... 124
MENVEO MENCYW-135
COMPNT (PF)................. 124
MEPHYTON ....................... 151
mercaptopurine ...................... 38
meropenem ............................ 30
mesehist dm ........................... 91
mesna .................................. 129
MESNEX ............................ 129
MESTINON ........................ 129
MESTINON TIMESPAN .... 129
metaproterenol ..................... 138
metaxalone........................... 140
metformin .............................. 47
methadone ............................. 15
methadone hcl ........................ 15
methazolamide ..................... 131
methenamine hippurate .......... 27
I-13
methenamine mandelate......... 27
methimazole ........................ 122
methocarbamol .................... 140
methotrexate sodium.............. 38
methotrexate sodium (pf) ....... 38
methoxsalen rapid .................. 97
methscopolamine ................. 113
methyclothiazide.................... 80
methylphenidate .................... 83
methylprednisolone ............. 119
methylprednisolone acetate .. 120
........................................ 120
metipranolol ........................ 131
metoclopramide hcl ............. 113
metolazone ............................ 80
metoprolol succinate .............. 76
metoprolol ta-hydrochlorothiaz
.......................................... 76
metoprolol tartrate ................. 76
metronidazole ............ 56, 59, 98
metronidazole in nacl (iso-os) 59
mexiletine .............................. 75
MIACALCIN ...................... 127
mi-acid ................................ 113
mi-acid gas relief ................. 110
micatin .................................. 51
miconazole 7 ......................... 51
miconazole nitrate ........... 51, 52
midazolam ............................. 24
midazolam (pf) ...................... 24
midodrine .............................. 74
milk of magnesia ................. 115
milltrium senior ................... 151
milrinone ............................... 78
milrinone in 5 % dextrose ...... 78
MINERAL OIL ................... 129
mineral oil laxative .............. 115
mineral oil light ................... 129
minitran ................................. 81
minocycline ........................... 33
minoxidil ............................... 81
mintox ................................. 113
mintox maximum strength ... 113
mintox plus ......................... 113
MIRCERA ............................ 68
mirtazapine ........................... 45
misoprostol ......................... 110
mitomycin ............................. 38
mitoxantrone ......................... 38
M-M-R II (PF) .................... 124
moexipril ............................... 75
moexipril-hydrochlorothiazide
.......................................... 75
mometasone ........................ 101
MONISTAT 3 ....................... 52
monistat 7 ............................. 52
montelukast ......................... 138
morphine ..........................15, 16
MORPHINE.......................... 16
morphine concentrate ............ 15
morrhuate sodium................ 129
motion sickness ..................... 58
MOVANTIK ....................... 113
MOVIPREP ........................ 115
MOXEZA ........................... 108
moxifloxacin ......................... 32
MOZOBIL ............................ 68
mucinex fast-max dm max..... 91
mucus dm.............................. 91
mucus dm max ...................... 91
mucus relief........................... 91
MULTAQ ............................. 75
multi complete with iron ..... 151
multi-day with iron .............. 151
multi-delyn .......................... 151
multi-delyn with iron ........... 151
multilex ............................... 151
multilex-t&m ...................... 152
multiple vitamin-minerals.... 152
multiple vitamins ................. 152
multiple vitamins with iron.. 152
multi-symptom cold night time
.......................................... 91
multi-symptom cold-cough .... 91
multivital platinum............... 152
multivitamin ........................ 152
multi-vitamin hp/minerals .... 152
multivitamin with iron ......... 152
multivitamin with minerals .. 152
multivitamins with min no.7-fa
........................................ 152
multi-vite ............................. 152
multi-vite 50 & over............. 152
mupirocin .............................. 98
mupirocin calcium ................. 98
muro 128 ............................. 106
MUSTARGEN ...................... 38
my favorite multiple ............. 152
myco nail a ............................ 52
mycophenolate mofetil ......... 123
mycophenolate sodium ........ 123
mylanta gas .......................... 110
MYOZYME ........................ 103
mytab gas............................. 110
mytab gas maximum strength
........................................ 110
my-vitalife ........................... 152
N
nabumetone ........................... 20
nadolol................................... 76
nafcillin ................................. 31
nafcillin in dextrose iso-osm .. 31
NAGLAZYME .................... 103
naloxone ................................ 21
naltrexone .............................. 21
naltrexone hcl ........................ 21
NAMENDA........................... 44
NAMENDA TITRATION PAK
.......................................... 44
NAMENDA XR .................... 44
naphazoline .......................... 106
naproxen ................................ 20
naproxen sodium.................... 20
naratriptan.............................. 57
nasal & sinus decongestant .... 91
I-14
nasal decongestant (oxymetazl)
........................................ 106
nasal decongestant (pe) .......... 74
NASCOBAL ....................... 152
NASONEX .......................... 109
NATACYN ......................... 108
nateglinide ............................. 47
NATPARA .......................... 127
natural b-100 ....................... 152
natural b-100 complex ......... 152
natural balance ..................... 106
natural calcium .................... 135
natural fiber laxative therapy 115
natural tears (pf) .................. 106
nature's tears ........................ 106
NEBUPENT .......................... 59
nefazodone ............................ 45
neomy sulf-bacitrac zn-poly-hc
........................................ 108
neomycin ............................... 26
neomycin-bacitracin-poly-hc 108
neomycin-bacitracin-polymyxin
........................................ 108
neomycin-polymyxin b gu ..... 98
neomycin-polymyxin bdexameth ......................... 108
neomycin-polymyxingramicidin ....................... 108
neomycin-polymyxin-hc ...... 108
neosporin anti-itch ............... 101
neo-synephrine 12 h spr (oxym)
........................................ 106
neo-tuss ................................. 91
NEPHRAMINE 5.4 % ........... 73
nephro-vite .......................... 152
NEULASTA .......................... 68
NEUMEGA ........................... 69
NEUPOGEN ......................... 69
NEUPRO............................... 60
NEVANAC ......................... 109
nevirapine .............................. 64
NEXAFED ............................ 91
NEXAVAR ........................... 38
niacin ...............................80, 81
niacinamide ......................... 153
nicardipine ............................ 79
NICODERM CQ ..............21, 22
nicorelief ............................... 22
nicorette ................................ 22
nicotine ................................. 22
nicotine (polacrilex) .............. 22
NICOTROL .......................... 22
nifedipine .............................. 79
night time .............................. 91
night time cold-flu ................. 91
night time cold-flu relief ........ 91
nighttime cold-flu .................. 91
nighttime cough..................... 91
nighttime relief eye.............. 106
NILANDRON ....................... 38
nite time cold-flu ................... 92
nite time-d cold-flu relief....... 92
NITRO-BID .......................... 81
nitrofurantoin macrocrystal ... 27
nitrofurantoin monohyd/m-cryst
.......................................... 27
nitroglycerin .....................81, 82
nitroglycerin in 5 % dextrose . 81
NITROSTAT ........................ 82
nohist-dm .............................. 92
non-aspirin cold..................... 92
non-aspirin extra strength ...... 16
non-aspirin flu ....................... 92
non-aspirin jr strength ........... 16
NORDITROPIN FLEXPRO 120
NORDITROPIN NORDIFLEX
........................................ 120
norelgestromin/ethin.estradiol 84
norepinephrine bitartrate ....... 79
noreth-ethinyl estradiol/iron .. 84
norethindrone ........................ 84
norethindrone (contraceptive) 84
norethindrone acetate .......... 121
norethindrone ac-eth estradiol
.................................. 84, 119
norethindrone-e.estradiol-iron 85
norethindrone-ethinyl estrad... 85
norethindrone-mestranol ........ 85
norgestimate-ethinyl estradiol 85
norgestrel-ethinyl estradiol..... 85
NORMOSOL-M IN 5 %
DEXTROSE .................... 135
NORMOSOL-R ................... 135
NORMOSOL-R PH 7.4 ....... 135
nortemp ................................. 16
NORTHERA ......................... 74
nortriptyline ..................... 45, 46
NORVIR ............................... 64
NOVOLIN 70/30 ................... 48
NOVOLIN N ......................... 48
NOVOLIN R ......................... 48
NOVOLOG ........................... 48
NOVOLOG FLEXPEN ......... 48
NOVOLOG MIX 70-30 ......... 48
NOVOLOG MIX 70-30
FLEXPEN.......................... 49
NOXAFIL ............................. 52
NUCYNTA ........................... 16
NUCYNTA ER...................... 16
NUEDEXTA ......................... 83
nu-iron ................................. 153
NULOJIX ............................ 123
NUTRESTORE ................... 113
NUTRILIPID......................... 73
NUTRILYTE....................... 135
NUTRILYTE II ................... 135
NUTROPIN ......................... 120
NUTROPIN AQ .................. 120
NUTROPIN AQ NUSPIN ... 120
NUVARING .......................... 85
NUVIGIL ............................ 140
nystatin .................................. 52
NYSTATIN (BULK) ............. 52
nystatin-triamcinolone ........... 52
I-15
O
ocean nasal .......................... 106
OCTAGAM......................... 123
octreotide acetate ................. 121
ocutabs ................................ 153
OFEV .................................. 140
ofloxacin ....................... 32, 108
olanzapine ............................. 62
olanzapine-fluoxetine ............ 46
olopatadine .......................... 106
OLYSIO ................................ 65
omega-3 acid ethyl esters ....... 81
omeprazole .......................... 110
omeprazole magnesium ....... 110
omeprazole-sodium bicarbonate
................................ 110, 111
OMNITROPE...................... 121
ONCASPAR ......................... 38
once daily ............................ 153
oncovite ............................... 153
ondansetron ........................... 58
ondansetron hcl...................... 58
ondansetron hcl (pf) ............... 58
one daily .............................. 153
one daily 50 plus .................. 153
one daily complete ............... 153
one daily energy .................. 153
one daily essential................ 153
one daily maximum (with ca)
........................................ 153
one daily men's 50+ ............. 153
one daily multi-vit w-mineral
........................................ 153
one daily multivitamin ......... 153
one daily multivitamin-iron . 153
one daily plus iron ............... 153
one daily plus minerals ........ 153
one daily with iron ............... 153
one-a-day essential .............. 154
one-a-day maximum formula154
one-a-day teen advantage ..... 154
ONFI ..................................... 24
opcicon one-step ................... 85
OPDIVO ............................... 38
OPSUMIT ........................... 142
opti-vitamins ....................... 154
oral saline laxative............... 115
oralyte ................................. 135
ORAP ................................... 62
ORENCIA........................... 123
ORENCIA (WITH MALTOSE)
........................................ 123
ORENITRAM ..................... 142
ORFADIN........................... 103
OTEZLA ............................. 129
OTEZLA STARTER........... 129
oxacillin ................................ 31
oxacillin in dextrose(iso-osm) 31
oxaliplatin ............................. 38
oxandrolone ........................ 118
oxcarbazepine ....................... 42
OXTELLAR XR ................... 42
oxybutynin chloride............. 117
oxycodone ............................. 16
oxycodone hcl-acetaminophen
.......................................... 16
oxycodone hcl-aspirin ........... 16
oxycodone-acetaminophen .... 16
oxycodone-aspirin ................. 17
OXYCONTIN ....................... 17
oxymorphone ........................ 17
oysco 500/d ......................... 135
oysco d ................................ 135
oysco-500............................ 135
oyster shell calcium 500 ...... 135
oyster shell calcium-vit d3 ... 135
oystercal-d........................... 135
P
paclitaxel ............................... 38
pain relief .............................. 17
pain relief adult ..................... 17
pain reliever .......................... 17
pain reliever jr strength.......... 17
PANRETIN........................... 97
pantoprazole ........................ 111
papaverine ............................. 79
paricalcitol ........................... 127
paromomycin ......................... 59
paroxetine hcl ........................ 46
PASER .................................. 57
PATADAY .......................... 106
PATANOL .......................... 106
PAXIL ................................... 46
pecgen dmx............................ 92
pedi m.vit no.17 with fluoride
........................................ 154
pedia relief ............................. 92
pedia relief infant ................... 92
pediacare multi-symptom cold92
PEDIARIX (PF) .................. 124
pediatric electrolyte .............. 135
pediatric freezer pops ........... 135
pediatric multivitamin .......... 154
PEDVAX HIB (PF) ............. 124
peg 3350-electrolytes ........... 115
PEG 3350-GRX ................... 115
peg 3350-na sulf,bicarb,cl-kcl
........................................ 115
peg3350 ............................... 115
PEGANONE.......................... 42
PEGASYS ............................. 66
PEGASYS PROCLICK ......... 66
peg-electrolyte soln .............. 115
PEGINTRON ........................ 66
PEGINTRON REDIPEN ....... 66
penicillin g pot in dextrose ..... 31
penicillin g potassium ............ 31
penicillin g procaine ............... 32
penicillin v potassium ............ 32
PENTACEL (PF) ................. 124
PENTACEL ACTHIB
COMPONENT (PF)......... 124
PENTACEL DTAP-IPV
COMPNT (PF)................. 124
PENTAM .............................. 59
pentoxifylline ......................... 69
I-16
pep-t-med ............................ 113
peri-colace ........................... 115
PERIKABIVEN .................... 73
perindopril erbumine ............. 75
PERJETA .............................. 38
permethrin ........................... 102
perphenazine.......................... 62
perphenazine-amitriptyline .... 46
persa-gel ................................ 97
pharbetol ............................... 17
pharmacist favorite multi-vit 154
phenelzine ............................. 46
phenobarbital ......................... 43
phenobarbital sodium............. 43
phentolamine ....................... 141
phenylephrine hcl .......... 74, 106
phenylephrine-chlorpheniramine
.......................................... 55
phenylhistine dh .................... 92
phenytoin............................... 43
phenytoin sodium .................. 43
phenytoin sodium extended ... 43
phillips ................................ 113
phillips liqui-gels ................. 116
PHOS-FLUR ......................... 96
PHOSLYRA ........................ 116
PHOS-NAK......................... 135
phosphate laxative ............... 116
PHOSPHOLINE IODIDE.... 131
phosphorus #1 ..................... 135
phytonadione ....................... 154
PICATO ................................ 97
pilocarpine hcl ............... 96, 131
pindolol ................................. 76
pioglitazone ........................... 47
pioglitazone-glimepiride ........ 47
pioglitazone-metformin ......... 48
piperacillin-tazobactam.......... 32
piroxicam .............................. 20
PLAN B ONE-STEP ............. 85
PLASBUMIN 25 % ............... 70
PLASBUMIN 5 % ................. 70
PLASMA-LYTE 148 .......... 135
PLASMA-LYTE A ............. 135
PLASMA-LYTE-56 IN 5 %
DEXTROSE.................... 135
PLEGRIDY......................... 129
podactin ................................ 52
podofilox ............................... 97
podophyllum resin ................. 97
polyethylene glycol 3350..... 116
poly-iron ............................. 154
polymyxin b sulf-trimethoprim
........................................ 108
poly-tussin............................. 92
POLY-TUSSIN DM.............. 92
poly-vita .............................. 154
poly-vita (iron) .................... 154
poly-vitamin ........................ 154
poly-vitamin with iron ......... 154
polyvitamin/iron .................. 154
poly-vitamins ...................... 154
POMALYST ......................... 38
potassium acetate ................ 135
potassium bicarb and chloride
........................................ 135
potassium bicarb-citric acid . 135
potassium bicarbonate-cit ac 136
potassium chlorid-d5-0.45%nacl
........................................ 136
potassium chloride .............. 136
potassium chloride in 0.9%nacl
........................................ 136
potassium chloride in 5 % dex
........................................ 136
potassium chloride in lr-d5 .... 73
potassium chloride-0.45 % nacl
........................................ 136
........................................ 136
........................................ 136
........................................ 136
potassium citrate-citric acid.. 137
potassium hydroxide .............. 97
potassium phosphate dibasic 137
POTIGA ................................ 43
PRADAXA............................ 68
pramipexole ........................... 60
PRANDIMET ........................ 48
pravastatin ............................. 81
prazosin ................................. 74
prednicarbate ....................... 101
prednisolone acetate ............. 109
................................ 109, 120
prednisone ........................... 120
PREGNYL .......................... 121
PREMARIN ........................ 119
PREMASOL 10 % ................. 73
PREMASOL 6 %................... 73
PREMPHASE...................... 119
PREMPRO .......................... 119
prenatal ................................ 154
prenatal formula ................... 154
prenatal vit#96-ferrous fum-fa
........................................ 154
prenatal vitamin with minerals
........................................ 154
prenatal vitamins .......... 154, 155
prenatal vit-iron fumarate-fa 155
preparation h hydrocortisone 101
PREVIDENT 5000 SENSITIVE
.......................................... 96
PREZCOBIX ......................... 64
PREZISTA ............................ 64
PRIFTIN ................................ 57
PRILOSEC OTC ................. 111
PRIMAQUINE ...................... 59
primidone .............................. 43
PRISTIQ................................ 46
PRIVIGEN .......................... 123
PROAIR HFA ..................... 139
probenecid ........................... 130
procainamide ......................... 75
I-17
PROCALAMINE 3% ............ 73
prochlorperazine edisylate ..... 58
prochlorperazine maleate ....... 58
PROCRIT .............................. 69
PROCYSBI ......................... 130
progesterone ........................ 121
progesterone micronized ...... 121
PROGLYCEM ...................... 82
PROGRAF .......................... 123
PROLENSA ........................ 109
PROLEUKIN ........................ 38
PROLIA .............................. 127
PROMACTA......................... 69
promethazine ................... 55, 59
promethazine hcl ................... 59
promethazine-codeine ............ 92
promethazine-dm ................... 92
promethazine-phenylephcodeine .............................. 92
promolaxin .......................... 116
propafenone ........................... 75
propantheline ......................... 41
proparacaine ........................ 106
proparacaine hcl .................. 106
proparacaine-fluorescein sod 107
propranolol ............................ 76
propranolol-hydrochlorothiazid
.......................................... 76
propylthiouracil ................... 122
PROQUAD (PF).................. 124
prosight ............................... 155
PROSOL 20 % ...................... 73
protamine .............................. 69
protriptyline ........................... 46
pseudoephedrine hcl .............. 92
PULMOZYME .................... 103
pure & gentle eye................. 107
purelax ................................ 116
PURIXAN ............................. 38
pyrazinamide ......................... 57
pyridostigmine bromide ....... 130
pyridoxine ........................... 155
Q
q-dryl .................................... 55
q-pap ..................................... 17
q-pap extra strength ............... 17
q-tapp .................................... 55
q-tapp dm .............................. 93
q-tussin ................................. 93
q-tussin dm............................ 93
QUADRACEL (PF) ............ 124
QUDEXY XR ....................... 43
quetiapine .............................. 62
QUILLIVANT XR ................ 83
quinapril ................................ 75
quinapril-hydrochlorothiazide 75
quinidine gluconate ............... 75
quinidine sulfate .................... 76
quinine sulfate ....................... 59
QVAR ................................. 138
R
RABAVERT (PF) ............... 125
raloxifene ............................ 119
ramipril ................................. 75
RANEXA.............................. 79
ranitidine hcl ....................... 111
RAPAMUNE ...................... 123
REBIF (WITH ALBUMIN) 130
REBIF REBIDOSE ............. 130
REBIF TITRATION PACK 130
RECOMBIVAX HB (PF) .... 125
recort plus ........................... 101
refenesen ............................... 93
refenesen pe .......................... 93
REFRESH CLASSIC (PF) .. 107
REFRESH LACRI-LUBE ... 107
REFRESH LIQUIGEL ........ 107
REFRESH OPTIVE ............ 107
REFRESH OPTIVE
ADVANCED .................. 108
reguloid ............................... 116
relcof c .................................. 93
RELENZA DISKHALER ..... 65
RELISTOR ......................... 113
REMICADE ........................ 130
REMODULIN ..................... 142
RENAGEL .......................... 117
RENVELA .......................... 117
repaglinide ............................. 48
RESCRIPTOR ....................... 64
RESTASIS .......................... 109
retaine cmc .......................... 107
RETROVIR ........................... 64
REVATIO ........................... 142
REVLIMID ........................... 38
REYATAZ ............................ 64
REZIRA ................................ 93
ribavirin ................................. 66
RIDAURA ........................... 123
rifabutin ................................. 57
rifampin ................................. 57
RIFATER .............................. 57
ri-gel ii ................................. 113
riluzole .................................. 83
rimantadine ............................ 65
ri-mox .................................. 113
ringers.......................... 126, 137
risedronate ........................... 127
RISPERDAL CONSTA ......... 63
risperidone ............................. 63
RITUXAN ............................. 38
rivastigmine tartrate ............... 44
rizatriptan .............................. 57
robafen .................................. 93
robafen cough ........................ 93
robafen dm............................. 93
robitussin cough & cold cf ..... 93
robitussin cough-chest-cong dm
.......................................... 93
robitussin dm max.................. 93
ROBITUSSIN LONG-ACTING
.......................................... 93
robitussin pediatric ................. 93
ropinirole ............................... 60
ROTARIX ........................... 125
ROTATEQ VACCINE ........ 125
I-18
ROZEREM .......................... 140
rydex ..................................... 93
S
SABRIL ................................ 43
safe tussin dm ........................ 93
SAIZEN .............................. 121
SAIZEN CLICK.EASY ....... 121
saline mist ........................... 107
salsalate ................................. 20
SANDOSTATIN LAR DEPOT
........................................ 121
SANTYL ............................... 97
SAPHRIS (BLACK CHERRY)
.......................................... 63
SAVELLA ............................ 83
scooby-doo one a day .......... 155
scot-tussin dm........................ 93
scot-tussin expectorant ........... 93
sea soft nasal mist ................ 107
selegiline hcl.......................... 60
selenium sulfide ..................... 98
SELZENTRY ........................ 64
senexon ............................... 116
senna ................................... 116
senna lax.............................. 116
senna with docusate sodium . 116
senokot-s ............................. 116
SENSIPAR .......................... 130
sentry................................... 155
sentry senior ........................ 155
SEREVENT DISKUS ......... 139
SEROQUEL XR.................... 63
SEROSTIM ......................... 121
sertraline ................................ 46
silace ................................... 116
siladryl sa .............................. 55
silapap ................................... 17
sildenafil oral tablet 20 mg... 142
SILENOR .............................. 46
siltussin dm das ..................... 93
siltussin sa ............................. 94
silver nitrate........................... 99
silver nitrate applicators ........ 98
silver sulfadiazine.................. 99
SIMBRINZA ...................... 131
simethicone ......................... 110
simply sleep .......................... 55
SIMPONI ............................ 130
SIMPONI ARIA ................. 130
simvastatin ............................ 81
sinus & allergy (pseudoephed)
.......................................... 55
sirolimus ............................. 123
SIRTURO ............................. 57
skin treatment ........................ 98
sleep aid (diphenhydramine) .. 55
sleep-tabs .............................. 55
smoothlax............................ 116
sochlor ................................ 107
sodium acetate..................... 137
sodium bicarbonate ...... 114, 137
sodium chloride ... 107, 126, 137,
140
sodium chloride 0.45 % ....... 137
sodium chloride 0.9 % ......... 137
sodium chloride 3 % ............ 137
sodium chloride 5 % ............ 137
sodium chloride-nahco3-kcl-peg
........................................ 116
sodium citrate-citric acid ..... 137
sodium fluoride ................... 155
sodium lactate ..................... 137
sodium phosphate ................ 137
sodium polystyrene sulfonate
........................................ 117
sodium thiosulfate ............... 118
sod-pot-k cit-sod cit-cit acid 137
SOLIRIS ............................. 130
SOLTAMOX ........................ 38
SOLU-CORTEF (PF) .......... 120
SOMATULINE DEPOT ..... 121
SOMAVERT ...................... 121
soothe (bismuth subsalicylate)
........................................ 114
soothe regular strength ......... 114
sorbitol ................................ 126
sorbitol-mannitol.................. 126
sotalol .................................... 76
sotalol hcl .............................. 76
SOVALDI ............................. 65
spectravite............................ 155
spectravite adult 50+ ............ 155
spectravite advanced formula
........................................ 155
spectravite senior ................. 155
spectravite senior w-lycopene
........................................ 155
spectravite ultra women ....... 155
SPIRIVA RESPIMAT ......... 139
SPIRIVA WITH
HANDIHALER ............... 139
spironolactone........................ 81
spironolacton-hydrochlorothiaz
.......................................... 81
SPRYCEL ............................. 39
st joseph aspirin ..................... 20
st. joseph aspirin .................... 20
stavudine ............................... 64
STELARA ........................... 130
STERILE LUBRICANT ...... 107
STERILE PADS .................. 130
STIVARGA ........................... 39
stomach relief ...................... 114
STRATTERA ........................ 83
streptomycin .......................... 26
stress 500 plus zinc .............. 155
stress b with zinc .................. 155
stress b-biotin....................... 155
stress formula....................... 156
stress formula plus iron ........ 156
stress formula with iron........ 156
stress formula with zinc ....... 156
STRIBILD ............................. 64
stuart prenatal ...................... 156
sucralfate ............................. 111
sudogest ................................. 94
I-19
sudogest cold & allergy ......... 55
sudogest pe ............................ 74
sulfacetamide sodium .......... 108
sulfacetamide sodium (acne) .. 99
sulfacetamide-prednisolone.. 108
sulfadiazine ........................... 32
sulfamethoxazole-trimethoprim
.......................................... 32
sulfasalazine .......................... 32
sulfatrim ................................ 32
sulfazine ................................ 32
sulfazine ec ............................ 32
sulindac ................................. 20
sumatriptan nasal spray .......... 57
sumatriptan succinate............. 57
summer's eve disposable douche
........................................ 130
summers eve extra cleansing 130
sunvite ................................. 156
super b complex-vitamin c ... 156
super b/c .............................. 156
super b-50 complex ............. 156
super b-50 complex plus ...... 156
super multiple ...................... 156
super multivitamin ............... 156
super quints b-50 ................. 156
super thera vite m ................ 156
superior 35........................... 156
superplex-t ........................... 156
suphedrin ............................... 94
suphedrine pe day-night ......... 94
suphedrine severe cold max str
.......................................... 94
support ................................ 156
support-500 ......................... 156
SUPPRELIN LA ................. 121
SUPRAX ............................... 29
SURE COMFORT INS. SYR.
U-100 .............................. 103
SURMONTIL........................ 46
SUSPENDOL-S .................. 130
SUSTIVA .............................. 64
SUTENT ............................... 39
SYLATRON ......................... 66
SYLATRON 4-PACK ........... 66
SYLVANT ............................ 39
SYMLINPEN 120 ................. 48
SYMLINPEN 60 ................... 48
SYNAGIS ............................. 65
SYNAREL .......................... 130
SYNERCID .......................... 27
SYNRIBO ............................. 39
SYPRINE............................ 118
T
tab-a-vite ............................. 156
tab-a-vite/iron...................... 157
tab-a-vite-minerals .............. 157
TABLOID ............................. 39
tacrolimus .................... 101, 123
tactinal .................................. 17
tactinal extra strength ............ 17
TAFINLAR ........................... 39
TAMIFLU............................. 65
tamoxifen .............................. 39
tamsulosin ........................... 117
TARCEVA ........................... 39
TARGRETIN ........................ 39
tarina fe ................................. 85
TASIGNA ............................. 39
TAZORAC ......................... 102
taztia xt ................................. 77
tears again ........................... 107
TEARS NATURALE II ...... 107
TECFIDERA ...................... 130
TEFLARO ............................ 29
telmisartan............................. 74
telmisartan-hydrochlorothiazid
.......................................... 74
temazepam ............................ 25
TEMODAR ........................... 39
TENIVAC (PF) ................... 125
terazosin .............................. 117
terbinafine hcl ....................... 52
terbutaline ........................... 139
terconazole............................. 56
testosterone .......................... 118
testosterone cypionate .......... 118
testosterone enanthate .......... 118
TETANUS
TOXOID,ADSORBED (PF)
........................................ 125
TETANUS,DIPHTHERIA TOX
PED(PF) .......................... 125
TETANUS-DIPHTHERIA
TOXOIDS-TD ................. 125
tetracaine hcl........................ 107
tetracycline ............................ 33
TEV-TROPIN...................... 121
THALOMID ........................ 131
the magic bullet ................... 116
theophylline ......................... 139
theophylline anhydrous ........ 139
theophylline in dextrose 5 % 139
thera m plus (ferrous fumarat)
........................................ 157
thera vitamin ........................ 157
theradex m ........................... 157
THERAFLU NIGHTTIME
SEVERE COLD ................ 94
THERAFLU SEVERE COLDCOUGH ............................. 94
thera-m ................................ 157
theramill forte ...................... 157
therapeutic liquid ................. 157
therapeutic m + beta-carotene
........................................ 157
therapeutic vitamins/minerals
........................................ 157
therapeutic-m ....................... 157
therapeutic-m vitamin/minerals
........................................ 157
thera-tabs ............................. 157
theratrum complete 50 plus .. 157
theratrum complete 50 plus/lut
........................................ 157
therems ................................ 158
I-20
therems-h............................. 158
therems-m............................ 158
thiamine hcl ......................... 158
thioridazine ............................ 63
thiothixene ............................. 63
tiagabine ................................ 43
TICE BCG........................... 125
TIKOSYN ............................. 76
timolol maleate .......76, 131, 132
TIVICAY .............................. 64
tizanidine ............................. 140
TOBI PODHALER................ 26
TOBRADEX ST.................. 108
tobramycin .......................... 108
tobramycin in 0.225 % nacl ... 26
tobramycin in 0.9 % nacl ....... 26
tobramycin sulfate ................. 26
tolazamide ............................. 49
tolbutamide ............................ 49
tolmetin ................................. 20
tolnaftate ............................... 52
tolterodine ........................... 117
topiramate.............................. 43
toposar intravenous ................ 39
topotecan ............................... 39
TORISEL .............................. 39
torsemide ............................... 80
total b/c................................ 158
totalday multiple .................. 158
TOUJEO SOLOSTAR ........... 49
TOVIAZ .............................. 117
TPN ELECTROLYTES....... 137
TPN ELECTROLYTES II ... 137
TRACLEER ........................ 142
TRADJENTA ........................ 48
tramadol ................................ 17
tramadol-acetaminophen ........ 17
trandolapril ............................ 75
tranexamic acid...................... 69
TRANSDERM-SCOP ........... 59
tranylcypromine ..................... 46
TRAVASOL 10 %................. 73
TRAVATAN Z ................... 132
travel sickness (meclizine) ..... 59
travoprost (benzalkonium) ... 132
trazodone .............................. 46
TREANDA ........................... 39
TRECATOR ......................... 58
TRELSTAR .......................... 40
tretinoin............................... 102
tretinoin (chemotherapy) ....... 40
tretinoin microspheres ......... 102
TREXALL ............................ 40
triacting m-sym cold/cough ... 94
triamcinolone acetonide. 96, 101,
102, 120
triaminic cold & cough (pe) ... 94
TRIAMINIC COLD & COUGH
NT (PE)............................. 55
triaminic cough-nasal congesti
.......................................... 94
TRIAMINIC COUGH-SORE
THROAT .......................... 94
triamterene-hydrochlorothiazid
.......................................... 80
triazolam ..........................25, 26
TRIBENZOR ........................ 74
tri-buffered aspirin ................ 20
triderm ................................ 102
tri-dex pe ............................... 94
trifluoperazine ....................... 63
trifluridine ........................... 109
trigofen dm............................ 94
trihexyphenidyl ..................... 60
TRILEPTAL ......................... 43
trimethoprim ......................... 27
triple paste af ......................... 52
TRIUMEQ ............................ 64
tri-vi-sol .............................. 158
tri-vita ................................. 158
tri-vitamin ........................... 158
TROKENDI XR .................... 43
TROPHAMINE 10 % ........... 73
TROPHAMINE 6% .............. 73
trospium............................... 117
TRULICITY .......................... 48
TRUMENBA....................... 125
TRUVADA ........................... 65
trymine cg .............................. 94
TUDORZA PRESSAIR ....... 139
tusnel diabetic ........................ 94
TUSNEL PEDIATRIC .......... 94
tussin cf ................................. 94
tussin cf cough-cold ............... 94
tussin cold-congestion ............ 94
tussin cough (dm only) ........... 95
tussin dm ............................... 95
tussin dm cough & chest ........ 95
tussin dm max ........................ 95
tussin maximum strength cough
.......................................... 95
tussin pe ................................. 95
TWINRIX (PF) .................... 125
TYBOST ............................. 131
TYGACIL ............................. 33
TYKERB ............................... 40
TYPHIM VI ........................ 125
TYSABRI ............................ 123
TYVASO ............................. 142
TYVASO REFILL KIT ....... 142
TYVASO STARTER KIT ... 142
TYZEKA ............................... 66
U
ULORIC .............................. 131
ultra b-100 complex ............. 158
ultra fresh pm....................... 107
ultra sleep (doxylamine succ) . 55
ultra strength antacid ............ 114
unicomplex-m ...................... 158
unisom sleepgels .................... 55
ursodiol................................ 114
V
VAGIFEM ........................... 119
valacyclovir ........................... 66
VALCHLOR ......................... 98
valganciclovir ........................ 66
I-21
valproate sodium ................... 43
valproic acid .......................... 43
valproic acid (as sodium salt) . 43
valsartan ................................ 74
valsartan-hydrochlorothiazide 74
VALSTAR ............................ 40
valu-tapp dm.......................... 95
vancomycin ..................... 27, 28
vancomycin in d5w ................ 27
VAQTA (PF) ....................... 125
VARIVAX (PF) .................. 125
VASCEPA ............................ 81
vasopressin .......................... 121
VECTIBIX ............................ 40
VELCADE ............................ 40
venlafaxine ............................ 46
VENTAVIS ......................... 142
verapamil............................... 77
VERSACLOZ ....................... 63
vicks dayquil cough ............... 95
vicks nature fusion cough ...... 95
vicks qlearquil(oxymetazoline)
........................................ 107
vicks sinex 12-hour.............. 107
VICTOZA ............................. 48
.......................................... 65
.......................................... 65
VIEKIRA PAK...................... 65
VIGAMOX ......................... 109
VIIBRYD .............................. 46
VIMIZIM ............................ 103
VIMPAT ......................... 43, 44
vinblastine ............................. 40
vincristine .............................. 40
vincristine sulfate................... 40
vinorelbine ............................ 40
VIRACEPT ........................... 65
VIRAMUNE XR ................... 65
VIRAZOLE ........................... 66
virdec dm............................... 95
VIREAD ............................... 65
vision .................................. 158
vision formula ..................... 158
vision formula (with lutein) . 158
vision plus lutein ................. 158
vit b cmplx 3-fa-vit c-biotin . 158
vit b cmplx no3-fa-c-biot-zinc
........................................ 159
vitabee/c .............................. 159
vitalets................................. 159
vitamin a ............................. 159
vitamin b complex ............... 159
vitamin b complex with c .... 159
vitamin b-1 .......................... 159
vitamin b-100 complex ........ 159
vitamin b12-folic acid ......... 159
vitamin b-6 .......................... 159
vitamin c ............................. 159
vitamins & minerals ............ 159
vitamins b complex ...... 159, 160
vitamins for hair .................. 160
VITEKTA ............................. 65
vitrum senior ....................... 160
VOLTAREN ......................... 20
voriconazole .......................... 52
VOTRIENT .......................... 40
VPRIV ................................ 104
W
wal-act d cold & allergy ........ 55
wal-dram ............................... 59
wal-dryl allergy ..................... 55
wal-finate .............................. 55
wal-finate-d ........................... 56
wal-itin .................................. 56
wal-itin d ............................... 56
wal-itin d 12 hour .................. 56
wal-phed ..........................56, 95
wal-phed pe ........................... 74
wal-phed pe day-night ........... 95
wal-phed pe sinus & allergy .. 56
wal-profen ............................. 20
wal-sleep z ............................ 56
wal-som ................................. 56
wal-tap ................................... 56
wal-tussin cough .................... 95
wal-tussin cough & cold cf..... 95
wal-tussin dm......................... 95
wal-zan 75 ........................... 111
wal-zyr (cetirizine) ................. 56
wal-zyr (ketotifen) ............... 107
wal-zyr d................................ 56
warfarin ................................. 68
water for irrigation, sterile .... 126
WELCHOL ........................... 81
women's daily multivitamin . 160
X
XALKORI ............................. 40
XARELTO ............................ 68
XELJANZ ........................... 131
XENAZINE ........................... 83
XGEVA ............................... 127
XIFAXAN ............................. 28
XOLAIR .............................. 140
XTANDI ............................... 40
xylon 10 ................................. 17
XYREM .............................. 140
Y
yelets ................................... 160
YERVOY .............................. 40
YF-VAX (PF) ...................... 125
Z
zafirlukast ............................ 138
zaleplon ............................... 141
ZALTRAP ............................. 40
zantac 75.............................. 111
ZAVESCA .......................... 104
ZELBORAF .......................... 40
ZEMAIRA ........................... 140
ZEMPLAR .......................... 127
ZENPEP .............................. 104
zephrex-d ............................... 95
ZETIA ................................... 81
ZIAGEN ................................ 65
zidovudine ............................. 65
I-22
zinc oxide .............................. 98
ziprasidone hcl....................... 63
ZOLADEX ............................ 41
zoledronic acid .................... 127
........................................ 127
ZOLINZA ............................. 41
zolmitriptan ........................... 57
zolpidem .............................. 141
ZOMETA............................ 127
ZONATUSS.......................... 95
zonisamide ............................ 44
zoo chews ........................... 160
ZORTRESS ........................ 123
ZOSTAVAX (PF) ............... 125
ZOVIRAX ............................ 98
z-sleep ................................... 56
ZUBSOLV ............................ 22
ZYDELIG.............................. 41
ZYKADIA ............................. 41
ZYLET ................................ 109
zyncof .................................... 95
ZYPREXA RELPREVV ........ 63
ZYRTEC ............................... 56
zyrtec itchy eye drops (keto) 107
ZYTIGA ................................ 41
ZYVOX ................................. 28
I-23
2015 List of Covered Drugs (Formulary)
Para inscribirse en VNSNY CHOICE FIDA Complete y conocer más
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o visite nymedicaidchoice.com
2015
LIST OF COVERED DRUGS
(FORMULARY)
(Medicare-Medicaid Plan)
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VNSNY CHOICE FIDA Complete

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