Lista de Medicamentos - Blue Cross and Blue Shield of Illinois

Transcripción

Lista de medicamentos de 2016
(Lista de medicamentos cubiertos)
Blue Cross Community MMAI (Plan Medicare-Medicaid)SM
POR FAVOR LEA ESTO:
ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
Si tiene preguntas, llame a Blue Cross Community MMAI al 1-877-723-7702. TTY/TDD: 711. Las horas de oficina
son de 8:00 a.m. a 8:00 p.m., Hora Centro, los 7 días de la semana. Se usarán tecnologías alternativas (por
ejemplo, correo de voz) los fines de semana y los días feriados federales. Si deja un mensaje, un representante
de Atención al Cliente le llamará en el transcurso de un día laboral, a más tardar. La llamada es gratuita.
Para preguntas acerca de la inscripción, llame a: Servicios de inscripción de clientes residentes de Illinois
1-877-912-8880 (TTY: 1-866-565-8576) Sitio web: enrollhfs.illinois.gov
HPMS Approved Formulary File ID: 00016055, Versión 14
Esta Lista de medicamentos se actualizó el 6/2/2016.
H0927_BEN_IL_RX16SPA Accepted 09052015
230005.0616
Blue Cross Community MMAI
Lista de medicamentos cubiertos de 2016
(Lista de medicamentos)
Blue Cross Community MMAI es un plan médico que tiene contratos tanto con Medicare como Illinois
Medicaid para proporcionar los beneficios de ambos programas a los inscriptos.
La Lista de medicamentos cubiertos y/o las redes de farmacias y proveedores pueden cambiar a lo largo de
todo el año. Le enviaremos un aviso antes de hacer cualquier cambio que lo afecte a usted.
Los beneficios pueden cambiar el 1.º de enero de cada año. Puede consultar siempre en línea la Lista de
medicamentos cubiertos más actualizada de Blue Cross Community MMAI en el sitio
www.bcbsilcommunitymmai.com.
Puede obtener esta información de forma gratuita en otros formatos, como letra grande, Braille o en audio.
Llame al 1-877-723-7702 TTY/TDD: 711. La llamada es gratuita.
Pueden aplicarse limitaciones y restricciones. Para obtener más información, llame a Servicios para el
asegurado de Blue Cross Community MMAI o lea el Manual del asegurado de Blue Cross Community MMAI.
Usted puede obtener este documento en español o hablar con alguien, de forma gratuita, acerca de esta
información en otros idiomas. Llame al 1-877-723-7702 TTY/TDD: 711. La llamada es gratuita.
You can get this document in Spanish, or speak with someone about this information in other languages for
free. Call 1-877-723-7702. TTY/TDD: 711. The call is free.
Si tiene alguna pregunta, por favor llame a Blue Cross Community MMAI al 1-877-723-7702 (TTY/TDD: 711), de
8:00 a. m. a 8:00 p. m. Hora Centro, los siete (7) días de la semana. Los fines de semana y días feriados se usará un
buzón de voz. Si deja un mensaje de voz, un representante de servicio al cliente le devolverá la llamada a más tardar el
siguiente día laborable. La llamada es gratuita. Para más información, visite www.bcbsilcommunitymmai.com.
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Preguntas frecuentes
Encuentre aquí las respuestas a preguntas que tenga acerca de esta Lista de medicamentos cubiertos. Puede leer
todas las Preguntas frecuentes para obtener más información o puede buscar una pregunta y su respuesta.
1. ¿Qué medicamentos con receta están en la Lista de medicamentos cubiertos?
(Para abreviar, llamamos la Lista de medicamentos cubiertos “Lista de
medicamentos”.)
Los medicamentos de la Lista de medicamentos cubiertos que comienza en la página 1 son los medicamentos
cubiertos por Blue Cross Community MMAI. Estos medicamentos están disponibles en las farmacias dentro de
nuestra red. Una farmacia está en nuestra red si tenemos un acuerdo con esta para que trabaje con nosotros y le
proporcione servicios a usted. Nos referimos a estas farmacias como “farmacias de la red”.
Blue Cross Community MMAI cubrirá todos los medicamentos médicamente necesarios de la Lista de
medicamentos si:
• su médico u otra persona que receta diga que usted los necesita para mejorarse o permanecer saludable, y
• usted surte la receta en una farmacia de la red de Blue Cross Community MMAI.
Blue Cross Community MMAI podría requerir pasos adicionales para acceder a ciertos medicamentos (consulte la
pregunta #5 a continuación)
Puede también ver la lista actualizada de medicamentos que cubrimos en nuestro sitio web, en
www.bcbsilcommunitymmai.com o llamar a Servicios para el asegurado al 1-877-723-7702 TTY/TDD: 711.
Las horas de oficina son de 8:00 a.m. a 8:00 p.m., Hora Centro, los 7 días de la semana. Se usarán tecnologías
alternativas (por ejemplo, correo de voz) los fines de semana y los días feriados federales. Si deja un mensaje, un
representante de Atención al Cliente le llamará en el transcurso de un día laboral, a más tardar. La llamada es gratuita.
2. ¿Cambia alguna vez la Lista de medicamentos?
Sí. Blue Cross Community MMAI podría agregar o eliminar medicamentos de la Lista de medicamentos durante el
año. Generalmente, la Lista de medicamentos cambiará solamente si:
• aparece un nuevo medicamento más económico que funciona tan bien como el medicamento de la Lista
de medicamentos ahora, o
• averiguamos que un medicamento no es seguro.
También podríamos cambiar nuestras normas en relación a medicamentos. Por ejemplo, podríamos:
•D
ecidir requerir o no requerir aprobación previa para un medicamento. (La aprobaciónprevia es un permiso
de Blue Cross Community MMAI antes de que usted pueda obtener un medicamento).
• Agregar o modificar la cantidad de un medicamento que usted puede obtener (esto se llama “límites de
cantidad”).
• Agregar o modificar las restricciones de terapia escalonada para un medicamento. (Terapia escalonada
significa que usted debe probar un medicamento antes de que nosotros cubramos otro medicamento).
(Para obtener más información acerca de estas normas respecto a los medicamentos, consulte la páginas 1-117.)
Nosotros le avisaremos cuando un medicamento que usted está tomando sea eliminado de la Lista de
medicamentos. También le avisaremos cuando modifiquemos nuestras normas para la cobertura de un
medicamento. Las Preguntas 3, 4 y 7 a continuación contienen más información acerca de lo que sucede cuando
cambia la Lista de medicamentos.
ii
Puede consultar siempre en línea la Lista de medicamentos actualizada de Blue Cross Community MMAI en el sitio
www.bcbsilcommunitymmai.com.
También puede llamar a Servicios para el asegurado para consultar la Lista de medicamentos actual, llamando al
1-877-723-7702 TTY/TDD: 711.
3. ¿Qué sucede cuando aparece un medicamento más económico que funciona tan
bien como el medicamento de la Lista de medicamentos ahora?
Si está tomando un medicamento que es eliminado porque aparece un medicamento más económico que funciona
igual de bien, le avisaremos. Lo haremos al menos 60 días antes de eliminarlo de la Lista de medicamentos o cuando
usted pida volver a surtirse. En ese momento, puede obtener un suministro de 60 días del medicamento antes de
que se realice la modificación a la Lista de medicamentos. Le enviaremos una carta avisándole que se ha producido
una modificación.
4. ¿Qué sucede cuando averiguamos que un medicamento no es seguro?
Si la Administración de Alimentos y Medicamentos (Food and Drug Administration, FDA) dice que un medicamento
que usted está tomando no es seguro, lo eliminaremos de la Lista de medicamentos de inmediato. También le
enviaremos una carta avisándole al respecto. Comuníquese con su médico para obtener más instrucciones. No deje
de tomar sus medicamentos hasta que haya hablado con su médico.
5. ¿ Existe alguna restricción o límite sobre la cobertura de medicamentos? ¿O hay
acciones que se deban efectuar a fin de obtener ciertos medicamentos?
Sí, algunos medicamentos tienen normas sobre cobertura o límites en la cantidad que usted puede obtener. En
algunos casos, usted y su médico u otra persona que recetan deben hacer algo antes de que usted pueda obtener el
medicamento. Por ejemplo:
• Aprobación previa (o autorización previa): Para algunos medicamentos, usted o su médico u otra persona que
receta deben obtener la aprobación de Blue Cross Community MMAI antes de que usted pueda surtir sus
medicamentos con receta. Si no obtiene la aprobación, Blue Cross Medicare posiblemente no cubra el medicamento.
• Límites que rige la cantidad: Algunas veces, Blue Cross Community MMAI limita la cantidad de un medicamento
que usted puede obtener.
• Terapia escalonada: Algunas veces, Blue Cross Community MMAI requiere que usted realice una terapia
escalonada. Esto significa que probará medicamentos en un cierto orden para su problema de salud. Es posible que
deba probar un medicamento antes de que cubramos otro medicamento. Si su médico cree que el primer
medicamento no funciona para usted, entonces cubriremos el segundo medicamento.
Puede averiguar si su medicamento tiene algún requisito o límite adicionales consultando las tablas de la página vii.
También puede obtener más información visitando nuestro sitio web en www.bcbsilcommunitymmai.com.
Hemos publicado documentos en línea que explican nuestras restricciones de autorización previa y terapia
escalonada. Usted puede solicitarnos también que le enviemos una copia.
Puede solicitar una “excepción” de estos límites. Consulte la pregunta 11 para obtener más información acerca de las
excepciones.
• Si se encuentra en un hogar de atención médica especializada o centro de atención de largo plazo y necesita un
medicamento que no está en la Lista de medicamentos, o si no puede obtener con facilidad el medicamento que
necesita, podemos ayudarlo. Cubriremos un suministro de emergencia de 31 días del medicamento que necesita (a
menos que tenga una receta por menos días), ya sea que usted sea o no un asegurado nuevo de Blue Cross
Community MMAI. Esto le dará tiempo para hablar con su médico u otra persona que receta Él o ella pueden
iii
ayudarlo a decidir si existe un medicamento similar en la Lista de medicamentos que pueda tomar en su lugar o si
debería 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 se requiere que
realice acciones para obtener el medicamento?
La Lista de medicamentos cubiertos de las páginas 1-117 tiene una columna titulada “Acciones necesarias,
restricciones o límites de uso”.
7. ¿Qué sucede si modificamos nuestras normas acerca de cómo cubrimos algunos
medicamentos? Por ejemplo, si agregamos autorización (aprobación) previa,
límites que rigen la cantidad y/o restricciones de terapia escalona para un
medicamento.
Le avisaremos si agregamos autorización (aprobación) previa, límites que rigen la cantidad y/o restricciones de terapia
escalona para un medicamento. Lo haremos al menos 60 días antes de que se agregue la restricción o cuando usted
pida volver a surtirse. En ese momento, puede obtener un suministro de 60 días del medicamento antes de que se
realice la modificación a la Lista de medicamentos. Esto le dará tiempo para hablar con su médico u otra persona que
receta acerca de qué hacer.
8. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos?
Hay dos formas de encontrar un medicamento:
• Puede buscarlo alfabéticamente (si sabe cómo se escribe el medicamento), o
• Puede buscarlo por problema de salud.
Para buscar alfabéticamente, vaya a la sección de Listado alfabético. Puede encontrarla en el índice que comienza
en la página 118.
Para buscar por problema de salud, busque la sección titulada “Lista de medicamentos por problema de salud” de
las páginas 1-117. Los medicamentos incluidos en esta sección están agrupados por categorías según el tipo de
problemas de salud que tratan. Por ejemplo, si tiene un problema cardíaco, debe buscar en la categoría, benazepril.
Allí es donde encontrará medicamentos que tratan los problemas cardíacos.
9. ¿Qué sucede si el medicamento que desea tomar no está en la Lista de
medicamentos?
Si no ve su medicamento en la Lista de medicamentos, llame a Servicios para el asegurado al 1-877-723-7702
TTY/TDD: 711 y pregunte al respecto. Si se entera de que Blue Cross Community MMAI no cubrirá el medicamento,
puede hacer una de estas cosas:
• Pedirle a Servicios para el asegurado un lista de los medicamentos similares al que usted desea tomar. Luego,
mostrarle la lista a su médico u otra persona que receta. Él o ella pueden recetarle un medicamento de la Lista de
medicamentos que sea similar al que usted desea tomar.
O
• Puede pedirle a su plan médico que haga una excepción para cubrir su medicamento. Consulte la pregunta 11 para
obtener más información acerca de las excepciones.
10. ¿ Qué sucede si usted es un asegurado nuevo de Blue Cross Community MMAI y
no puede encontrar su medicamento en la Lista de medicamentos o si tiene
problemas para obtener su medicamento?
Podemos ayudarlo. Podríamos cubrir un suministro provisional de 30 días de su medicamento durante los primeros
90 días para los medicamentos de la Parte D de Medicare y 180 días para los medicamentos de Medicaid como
asegurado de Blue Cross Community MMAI. Esto le dará tiempo para hablar con su médico u otra persona que
receta. Él o ella pueden ayudarlo a decidir si existe un medicamento similar en la Lista de medicamentos que pueda
tomar en su lugar o si debería solicitar una excepción
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Cubriremos un suministro de 30 días de su medicamento si:
• está tomando un medicamento que no está en nuestra Lista de medicamentos, o
• las normas del plan médico no le permiten obtener la cantidad pedida por la persona que receta, o
• el medicamento requiere aprobación previa de Blue Cross Community MMAI, o
• usted está tomando un medicamentos que es parte de una restricción de terapia escalonada.
Si vive en un hogar de atención médica especializada o un centro de atención de largo plazo, puede volver a surtir su
receta por 91 días. Puede volver a surtir el medicamento múltiples veces durante sus primeros 90 días en el plan.
Esto le da a la persona autorizada para recetar tiempo para cambiar sus medicamentos por aquellos que están en la
Lista de medicamentos o para pedir una excepción.
Existen circunstancias en las que pueden ocurrir transiciones no planificadas para los asegurados y en las que los
regímenes de medicamentos con receta pueden no encontrarse en la lista de medicamentos. Estas circunstancias
suelen involucrar cambios en los niveles de atención, en los cuales el asegurado cambia de un entorno de tratamiento
a otro. Para estas transiciones no planificadas, usted tendrá que usar nuestros procesos de excepciones y
apelaciones. Las determinaciones y nuevas determinaciones de cobertura se procesarán tan expeditivamente como
lo requiera su afección médica.
A fin de evitar una brecha provisional en la atención cuando un asegurado recibe el alta hospitalaria para volver a su
hogar, se les permite a los asegurados tener disponible un suministro completo para paciente ambulatorio a fin de
continuar el tratamiento una vez que se acabe el suministro limitado proporcionado al momento del alta hospitalaria.
Este suministro para paciente ambulatorio está disponible con anticipación al alta hospitalaria de una internación de la
Parte A.
Cuando un asegurado es internado o recibe el alta hospitalaria de un centro de atención de largo plazo, no tiene
acceso al resto de la receta dispensada previamente. Nos aseguraremos de que cuente con un nuevo surtido al
momento de la internación o del alta hospitalaria Se proporciona una invalidación única de las ediciones de “nuevo
surtido demasiado rápido” para cada medicamento que estará afectado debido a que el asegurado es internado o
recibe el alta hospitalaria de un centro de atención de largo plazo. Las ediciones de nuevo surtido temprano no se
usan para limitar el acceso apropiado y necesario de un asegurado al beneficio de la Parte D, y dichos asegurados
tienen permitido el acceso a un nuevo surtido durante la internación o el alta hospitalaria.
Para pedir un suministro temporal, llame a Servicios para el asegurado (los números de teléfono están impresos en la
contratapa de este folleto).
Durante el tiempo en que esté recibiendo un suministro provisional de un medicamento, debe hablar con el proveedor
para decidir qué hacer cuando se termina su suministro provisional. Puede cambiar por un medicamento diferente
que esté cubierto por el plan o pedirle al plan que haga una excepción para usted y cubra su medicamento actual. Las
siguientes secciones le dan más información acerca de estas opciones.
11. ¿Puede solicitar una excepción para que se cubra su medicamento?
Sí. Puede solicitarle a Blue Cross Community MMAI que haga una excepción para cubrir un medicamento que no
está en la Lista de medicamentos.
También puede solicitarnos que modifiquemos las normas respecto a su medicamento.
• Por ejemplo, Blue Cross Community MMAI podría limitar la cantidad de un medicamento que cubre. Si su
medicamento tiene un límite, puede solicitarnos que modifiquemos el límite y cubramos más.
• Otros ejemplos: Puede solicitar que se eliminen las restricciones de terapia escalonada o los requisitos de
aprobación previa.
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12. ¿Cuánto tiempo se tarda en obtener una excepción?
En primer lugar, debe recibir una declaración de la persona que receta apoyando su solicitud de excepción. Luego de
que recibamos la declaración, le brindaremos una decisión acerca de su excepción dentro de las 72 horas.
Si usted o la persona que receta piensan que puede dañarse su salud si usted espera 72 horas para una decisión,
puede solicitar una excepción acelerada. Esta es una decisión más rápida. Si la persona que receta apoya su solicitud,
le brindaremos una decisión dentro de las 24 de haber recibido la declaración de apoyo de la persona que receta.
13. ¿Cómo puede solicitar una excepción?
Para solicitar una excepción, llame a Servicios para el asegurado al 1-877-723-7702 TTY/TDD: 711. Un representante
de Servicios para el asegurado trabajará con usted y su proveedor para ayudarlos a solicitar una excepción.
14. ¿Qué son los medicamentos genéricos?
Los medicamentos genéricos están fabricados con los mismos componentes que los medicamentos de marca.
Generalmente cuestan menos que los medicamentos de marca y generalmente no tienen nombres conocidos. Los
medicamentos genéricos están aprobados por la Administración de Alimentos y Medicamentos (Food and Drug
Administration, FDA).
Blue Cross Community MMAI cubre tanto los medicamentos de marca como los genéricos.
15. ¿Qué son los medicamentos OTC?
OTC es una sigla en inglés que significa “over-the-counter”, es decir de venta libre. Blue Cross Community MMAI
cubre algunos medicamentos de venta libre cuando se compran con una receta escrita por su proveedor. Puede leer
la Lista de medicamentos de Blue Cross Community MMAI para ver qué medicamentos de venta libre están
cubiertos.
16. ¿ Cubre Blue Cross Community MMAI los productos de venta libre que no son
medicamentos?
Blue Cross Community MMAI cubre productos de venta libre que no son medicamentos cuando los receta su
proveedor.
Puede leer la Lista de medicamentos de Blue Cross Community MMAI para ver qué productos de venta libre que
nos medicamentos están cubiertos.
17. ¿Cuál es su copago?
El copago para los asegurados de Blue Cross Community MMAI es $0.
Los asegurados de Blue Cross Community MMAI que viven en hogares de atención médica especializada u otros
centros de atención de largo plazo. Algunos asegurados que obtienen atención de largo plazo en la comunidad
tampoco tendrán copagos.
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Lista de medicamentos cubiertos
La lista de medicamentos cubiertos que comienza en la página 1 le brinda información acerca de los medicamentos
cubierto por Blue Cross Community MMAI. Si tiene problemas para encontrar su medicamento en la lista, consulte el
Índice que comienza en la página 118.
La primera columna del cuadro muestra el nombre del medicamento. Los medicamentos de marca están en
mayúsculas (por ejemplo, CELEBREX) y los medicamentos genéricos están en minúsculas cursivas (por ejemplo,
butorfanol).
La información de la columna Acciones necesarias, restricciones o límites de uso le indica si Blue Cross Community
MMAI tiene alguna norma respecto a la cobertura de su medicamento.
CLAVE
Mayúsculas = NOMBRE DE LA MARCA
Minúsculas cursiva = genéricos
Nivel 1 = medicamentos genéricos
Nivel 2 = medicamentos de marca
Nivel 3 = medicamentos de venta libre
BD = medicamentos que pueden estar cubiertos por la Parte B de Medicare o la Parte D de Medicare, según las
circunstancias
AP = autorización previa
TE = terapia escalonada
LC = se aplican restricciones con límite que rige la cantidad.
MC = medicamento cubierto por Medicaid; pueden aplicarse normas de apelación diferentes
* = medicamentos de distribución limitada. Este medicamento con receta puede estar disponible solo en ciertas
farmacias. Para obtener más información, consulte el Directorio de farmacias o llame al Coordinador de cuidados.
# = medicamentos de alto riesgo (HRM). Medicamentos que podrían no ser seguros en pacientes de más de
65 años.
2016 DOSAGE FORM ABBREVIATIONS KEY
caps
cápsulas
lotn
loción
chew tabs
comprimidos masticables
mcg
microgramo
conc
concentrado
mEq
miliequivalente
crm
crema
mg
miligramo
DR
liberación demorada
mL
mililitro
ER
liberación extendida
NF
fuera de la lista de medicamentos
g
gramo
ODT
comprimidos de
desintegración oral
hr
hora
oint
ungüento
IM
intramuscular
SL
sublingual
inhal
inhalación
soln
solución
inj
inyección
supp
supositorios
IR
liberación inmediata
susp
suspensión
IV
intravenoso
tabs
comprimidos
liq
líquido
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AVISO: La sigla MC al lado de un medicamento significa que el medicamento no es un “Medicamento de la
Parte D”. La cantidad que paga cuando surte una receta para este medicamento no cuenta hacia los costos
totales de medicamentos (es decir, la cantidad que usted paga no lo ayuda a reunir los requisitos para cobertura
para casos catastróficos). Asimismo, si recibe ayuda adicional para pagar sus medicamentos con receta, no
obtendrá ayuda adicional para pagar estos medicamentos. Estos medicamentos tienen también diferentes
normas para las apelaciones. Una apelación es un modo formal de pedir que se revise una decisión de cobertura
y se cambie si usted cree que se ha cometido un error. Por ejemplo, nosotros podríamos decidir que un
medicamento que usted desea no está cubierto o que ya no está cubierto por Medicare o Medicaid. Si usted o
su médico están en desacuerdo respecto de nuestra decisión, pueden apelarla. Para pedir instrucciones sobre
cómo apelar, llame a Servicios para el asegurado al 1-877-723-7702. TTY/TDD: 711. También puede leer el Manual
del asegurado para obtener más información acerca de cómo apelar una decisión.
viii
2016
Nombre del medicamento
Medicamentos analgésicos
ABSTRAL - fentanyl citrate sl tab 100 mcg
Cuánto le cuesta el Acciones necesarias,
medicamento (nivel restricciones o límites en el
de copago)
uso
$0(2)
PA, QL (120 tablets/30 days)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
acetaminophen cap 500 mg
$0(3)
MC
acetaminophen chew tab 80 mg
$0(3)
MC
acetaminophen chew tab 160 mg
$0(3)
MC
acetaminophen elixir 160 mg/5ml
$0(3)
MC
acetaminophen liquid 160 mg/5ml
$0(3)
MC
acetaminophen soln 100 mg/ml
$0(3)
MC
acetaminophen soln 160 mg/5ml
$0(3)
MC
acetaminophen susp 80 mg/0.8ml
$0(3)
MC
acetaminophen susp 160 mg/5ml
$0(3)
MC
acetaminophen w/ codeine soln 120-12 mg/5ml
$0(1)
QL (2700 mls/30 days)
acetaminophen w/ codeine tab 300-15 mg
$0(1)
QL (360 tablets/30 days)
$0(1)
$0(1)
butorphanol tartrate inj 1 mg/ml
$0(2)
butorphanol tartrate inj 2 mg/ml
$0(2)
butorphanol tartrate nasal soln 10 mg/ml
$0(2)
celecoxib cap 50 mg
$0(1)
QL (60 capsules/30 days)
celecoxib cap 100 mg
$0(1)
$0(1)
$0(1)
codeine sulfate tab 15 mg
$0(1)
$0(1)
$0(1)
diclofenac potassium tab 50 mg
$0(1)
diclofenac sodium gel 1%
$0(1)
diclofenac sodium tab delayed release 25 mg
$0(1)
$0(1)
$0(1)
diclofenac sodium tab sr 24hr 100 mg
$0(1)
diclofenac w/ misoprostol tab delayed release 50-0.2 mg
$0(1)
$0(1)
ST
Usted puede encontrar información acerca del significado de los símbolos y abreviaturas que aparecen en esta
tabla al ingresar en la sección "Lista de medicamentos cubiertos".
1
2016
etodolac cap 200 mg
de copago)
uso
$0(1)
etodolac cap 300 mg
$0(1)
etodolac tab sr 24hr 400 mg
$0(1)
$0(1)
$0(1)
etodolac tab 400 mg
$0(1)
etodolac tab 500 mg
$0(1)
fentanyl citrate lozenge on a handle 200 mcg
$0(1)
PA, QL (120
lozenges/30 days)
$0(1)
PA, QL (120
lozenges/30 days)
$0(1)
PA, QL (120
lozenges/30 days)
$0(1)
PA, QL (120
lozenges/30 days)
$0(1)
PA, QL (120
lozenges/30 days)
$0(1)
PA, QL (120
lozenges/30 days)
fentanyl td patch 72hr 12 mcg/hr
$0(2)
QL (15 patches/30 days)
$0(2)
$0(2)
$0(2)
$0(2)
flurbiprofen tab 50 mg
$0(1)
$0(1)
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
$0(2)
hydrocodone-acetaminophen tab 10-325 mg
$0(2)
$0(2)
hydrocodone-acetaminophen tab 7.5-300 mg
$0(2)
$0(2)
hydrocodone-acetaminophen tab 7.5-325 mg
$0(2)
$0(2)
hydrocodone-ibuprofen tab 5-200 mg
$0(2)
hydrocodone-ibuprofen tab 7.5-200 mg
$0(2)
hydrocodone-ibuprofen tab 10-200 mg
$0(2)
hydromorphone hcl liqd 1 mg/ml
$0(1)
hydromorphone hcl preservative free inj 10 mg/ml
$0(2)
BD
hydromorphone hcl tab 2 mg
$0(2)
2
2016
de copago)
uso
$0(2)
$0(2)
ibuprofen cap 200 mg
$0(3)
MC
ibuprofen susp 100 mg/5ml
$0(1)
ibuprofen tab 200 mg
$0(3)
$0(1)
$0(1)
$0(1)
ketoprofen cap 50 mg
$0(1)
$0(1)
LAZANDA - fentanyl citrate nasal spray 100 mcg/act
$0(2)
PA, QL (30 bottles/30 days)
LAZANDA - fentanyl citrate nasal spray 400 mcg/act
$0(2)
PA, QL (30 bottles/30 days)
LEVORPHANOL TARTRATE - levorphanol tartrate tab
2 mg
meloxicam tab 7.5 mg
$0(2)
meloxicam tab 15 mg
$0(1)
methadone hcl tab 5 mg
$0(1)
methadone hcl tab 10 mg
$0(1)
MORPHINE SULFATE - morphine sulfate tab 15 mg
$0(2)
MORPHINE SULFATE - morphine sulfate tab 30 mg
$0(2)
morphine sulfate beads cap sr 24hr 120 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
morphine sulfate inj pf 0.5 mg/ml
$0(2)
BD
morphine sulfate inj pf 1 mg/ml
$0(2)
BD
morphine sulfate oral soln 10 mg/5ml
$0(2)
morphine sulfate oral soln 20 mg/5ml
$0(2)
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)
$0(2)
morphine sulfate tab cr 15 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
nabumetone tab 500 mg
$0(1)
$0(1)
MC
$0(1)
3
2016
naproxen sodium tab 220 mg
de copago)
uso
$0(3)
MC
$0(1)
$0(1)
naproxen susp 125 mg/5ml
$0(1)
naproxen tab ec 375 mg
$0(1)
$0(1)
naproxen tab 250 mg
$0(1)
naproxen tab 375 mg
$0(1)
naproxen tab 500 mg
$0(1)
NUCYNTA ER - tapentadol hcl tab sr 12hr 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
oxaprozin tab 600 mg
$0(1)
oxycodone hcl tab 5 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
oxycodone w/ acetaminophen tab 2.5-325 mg
$0(2)
oxycodone w/ acetaminophen tab 5-325 mg
$0(2)
oxycodone w/ acetaminophen tab 7.5-325 mg
$0(2)
oxycodone w/ acetaminophen tab 10-325 mg
$0(2)
oxycodone-aspirin tab 4.8355-325 mg
$0(2)
piroxicam cap 10 mg
$0(1)
piroxicam cap 20 mg
$0(1)
sulindac tab 150 mg
$0(1)
sulindac tab 200 mg
$0(1)
tolmetin sodium cap 400 mg
$0(1)
tramadol hcl tab sr 24hr 100 mg
$0(1)
$0(1)
$0(1)
tramadol hcl tab 50 mg
$0(1)
tramadol-acetaminophen tab 37.5-325 mg
$0(1)
TYLENOL - acetaminophen tab 325 mg
$0(3)
MC
TYLENOL EXTRA STRENGTH - acetaminophen tab
500 mg
$0(3)
MC
4
2016
VOLTAREN - diclofenac sodium gel 1%
de copago)
uso
$0(2)
ST
ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 10 mg
ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 10 mg
$0(2)
PA, QL (60 capsules/30 days)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
Medicamentos anestésicos
lidocaine hcl gel 2%
$0(2)
lidocaine hcl local inj 1%
$0(1)
lidocaine hcl local preservative free inj 1%
$0(1)
lidocaine hcl soln 4%
$0(1)
lidocaine hcl viscous soln 2%
$0(1)
lidocaine oint 5%
$0(1)
lidocaine patch 5%
$0(1)
lidocaine-prilocaine cream 2.5-2.5%
$0(1)
$0(1)
PA, QL (90 patches/30 days)
LMX 4 - lidocaine cream 4%
$0(3)
Agentes contra las adicciones y para tratar el abuso de sustancias
$0(1)
acamprosate calcium tab delayed release 333 mg
MC
buprenorphine hcl sl tab 2 mg
$0(1)
PA
buprenorphine hcl sl tab 8 mg
$0(1)
PA
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg
$0(1)
PA
buprenorphine hcl-naloxone hcl sl tab 8-2 mg
$0(1)
PA
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
$0(1)
BUTRANS - buprenorphine td patch weekly 5 mcg/hr
$0(1)
BUTRANS - buprenorphine td patch weekly 7.5 mcg/hr
$0(1)
$0(1)
$0(1)
5
2016
de copago)
uso
$0(1)
CHANTIX - varenicline tartrate tab 0.5 mg
$0(1)
CHANTIX - varenicline tartrate tab 1 mg
$0(1)
CHANTIX CONTINUING MONTH - varenicline tartrate tab
1 mg
CHANTIX STARTING MONTH PACK - varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack
disulfiram tab 250 mg
$0(1)
disulfiram tab 500 mg
$0(1)
NALOXONE HCL - naloxone hcl inj 1 mg/ml
$0(2)
naloxone hcl inj 0.4 mg/ml
$0(1)
naltrexone hcl tab 50 mg
$0(1)
NARCAN - naloxone hcl nasal spray 4 mg/0.1ml
$0(2)
NICODERM CQ - nicotine td patch 24hr 7 mg/24hr
$0(3)
MC
NICODERM CQ - nicotine td patch 24hr 14 mg/24hr
$0(3)
MC
NICORETTE - nicotine polacrilex lozenge 4 mg
$0(3)
MC
nicotine polacrilex gum 2 mg
$0(3)
MC
nicotine polacrilex gum 4 mg
$0(3)
MC
nicotine polacrilex lozenge 2 mg
$0(3)
MC
nicotine td patch 24hr 21 mg/24hr
$0(3)
MC
NICOTINE TRANSDERMAL SYSTEM - nicotine td patch
24 hr kit 21-14-7 mg/24hr
NICOTROL INHALER - nicotine inhaler system 10 mg
(4 mg delivered)
NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/
spray)
SUBOXONE - buprenorphine hcl-naloxone hcl sl film
2-0.5 mg
4-1 mg
8-2 mg
12-3 mg
VIVITROL - naltrexone for im extended release susp
380 mg
Medicamentos antibacteriales
amikacin sulfate inj 500 mg/2ml (250 mg/ml)
$0(3)
MC
amikacin sulfate inj 1 gm/4ml (250 mg/ml)
$0(1)
amoxicillin (trihydrate) cap 250 mg
$0(1)
amoxicillin (trihydrate) cap 500 mg
$0(1)
$0(1)
$0(1)
$0(2)
$0(2)
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
$0(1)
6
2016
amoxicillin (trihydrate) for susp 125 mg/5ml
de copago)
uso
$0(1)
$0(1)
$0(1)
$0(1)
amoxicillin (trihydrate) tab 500 mg
$0(1)
amoxicillin (trihydrate) tab 875 mg
$0(1)
amoxicillin & k clavulanate chew tab 200-28.5 mg
$0(1)
amoxicillin & k clavulanate chew tab 400-57 mg
$0(1)
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml
$0(1)
amoxicillin & k clavulanate for susp 400-57 mg/5ml
$0(1)
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
$0(1)
amoxicillin & k clavulanate tab 250-125 mg
$0(1)
$0(1)
$0(1)
AMPICILLIN - ampicillin for susp 125 mg/5ml
$0(2)
AMPICILLIN - ampicillin for susp 250 mg/5ml
$0(2)
ampicillin & sulbactam sodium for inj 2-1 gm
$0(1)
ampicillin cap 250 mg
$0(1)
ampicillin cap 500 mg
$0(1)
AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm
$0(2)
AMPICILLIN SODIUM - ampicillin sodium for iv soln 2 gm
$0(2)
ampicillin sodium for inj 250 mg
$0(1)
ampicillin sodium for inj 500 mg
$0(1)
ampicillin sodium for inj 1 gm
$0(1)
ampicillin sodium for inj 2 gm
$0(1)
ampicillin sodium for iv soln 10 gm
$0(1)
AVELOX - moxifloxacin hcl 400 mg/250ml in sodium
chloride 0.8% inj
AZACTAM - aztreonam in dextrose inj 1 gm/50 ml
$0(1)
AZACTAM - aztreonam in dextrose inj 2 gm/50 ml
$0(2)
AZITHROMYCIN - azithromycin powd pack for susp 1 gm
$0(2)
azithromycin for susp 100 mg/5ml
$0(1)
azithromycin for susp 200 mg/5ml
$0(1)
azithromycin iv for soln 500 mg
$0(1)
azithromycin tab 250 mg
$0(1)
$0(1)
$0(1)
aztreonam for inj 1 gm
$0(1)
$0(2)
7
2016
aztreonam for inj 2 gm
de copago)
uso
$0(1)
BICILLIN L-A - penicillin g benzathine intramuscular susp
600000 unit/ml
1200000 unit/2ml
2400000 unit/4ml
cefaclor cap 250 mg
$0(2)
cefaclor cap 500 mg
$0(1)
cefadroxil cap 500 mg
$0(1)
cefadroxil for susp 250 mg/5ml
$0(1)
cefadroxil for susp 500 mg/5ml
$0(1)
cefadroxil tab 1 gm
$0(1)
cefazolin sodium for inj 500 mg
$0(1)
cefazolin sodium for inj 1 gm
$0(1)
$0(1)
$0(1)
cefdinir cap 300 mg
$0(1)
cefdinir for susp 125 mg/5ml
$0(1)
cefdinir for susp 250 mg/5ml
$0(1)
cefepime hcl for inj 1 gm
$0(1)
cefepime hcl for inj 2 gm
$0(1)
cefotaxime sodium for inj 500 mg
$0(1)
cefotaxime sodium for inj 1 gm
$0(1)
$0(1)
$0(1)
cefoxitin sodium for inj 10 gm
$0(1)
cefoxitin sodium for iv soln 1 gm
$0(1)
cefoxitin sodium for iv soln 2 gm
$0(1)
cefpodoxime proxetil for susp 50 mg/5ml
$0(1)
cefpodoxime proxetil for susp 100 mg/5ml
$0(1)
cefpodoxime proxetil tab 100 mg
$0(1)
cefpodoxime proxetil tab 200 mg
$0(1)
cefprozil for susp 125 mg/5ml
$0(1)
cefprozil for susp 250 mg/5ml
$0(1)
cefprozil tab 250 mg
$0(1)
cefprozil tab 500 mg
$0(1)
ceftazidime for inj 1 gm
$0(1)
$0(1)
$0(2)
$0(2)
$0(1)
8
2016
de copago)
uso
$0(1)
ceftazidime for iv soln 1 gm
$0(1)
ceftazidime for iv soln 2 gm
$0(1)
CEFTRIAXONE IN ISO-OSMOTIC - ceftriaxone sodium in
dextrose inj 20 mg/ml
CEFTRIAXONE IN ISO-OSMOTIC - ceftriaxone sodium in
dextrose inj 40 mg/ml
ceftriaxone sodium for inj 250 mg
$0(2)
ceftriaxone sodium for inj 500 mg
$0(1)
ceftriaxone sodium for inj 1 gm
$0(1)
$0(1)
$0(1)
ceftriaxone sodium for iv soln 1 gm
$0(1)
ceftriaxone sodium for iv soln 2 gm
$0(1)
CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv
soln 1 gm and dextrose 3.74%
CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv
soln 2 gm and dextrose 2.22%
cefuroxime axetil tab 250 mg
$0(2)
cefuroxime axetil tab 500 mg
$0(1)
cefuroxime sodium for inj 750 mg
$0(1)
cefuroxime sodium for inj 1.5 gm
$0(1)
cefuroxime sodium for inj 7.5 gm
$0(1)
cefuroxime sodium for iv soln 1.5 gm
$0(1)
cephalexin cap 250 mg
$0(1)
$0(1)
$0(1)
cephalexin for susp 125 mg/5ml
$0(1)
cephalexin for susp 250 mg/5ml
$0(1)
CHLORAMPHENICOL SODIUM SUCCINATE chloramphenicol sodium succinate for iv inj 1 gm
ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)
$0(2)
ciprofloxacin for oral susp 500 mg/5ml (10%)
(10 gm/100ml)
CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg
$0(1)
ciprofloxacin hcl tab sr 24hr 500 mg
$0(1)
ciprofloxacin hcl tab sr 24hr 1000 mg
$0(1)
ciprofloxacin hcl tab 250 mg
$0(1)
$0(1)
$0(2)
$0(1)
$0(2)
$0(1)
$0(1)
$0(2)
9
2016
de copago)
uso
$0(1)
ciprofloxacin iv soln 200 mg/20ml (1%)
$0(1)
ciprofloxacin iv soln 400 mg/40ml (1%)
$0(1)
ciprofloxacin 200 mg/100ml in d5w
$0(1)
ciprofloxacin 400 mg/200ml in d5w
$0(1)
CLAFORAN/D5W - cefotaxime sodium in d5w iv soln
1 gm/50ml
CLAFORAN/D5W - cefotaxime sodium in d5w iv soln
2 gm/50ml
clarithromycin for susp 125 mg/5ml
$0(2)
clarithromycin for susp 250 mg/5ml
$0(1)
clarithromycin tab sr 24hr 500 mg
$0(1)
clarithromycin tab 250 mg
$0(1)
clarithromycin tab 500 mg
$0(1)
clindamycin hcl cap 75 mg
$0(1)
$0(1)
$0(1)
clindamycin phosphate in d5w iv soln 300 mg/50ml
$0(1)
$0(1)
$0(1)
clindamycin phosphate inj 300 mg/2ml
$0(1)
$0(1)
$0(1)
clindamycin phosphate inj 9 gm/60ml
$0(1)
clindamycin phosphate iv soln 600 mg/4ml
$0(1)
clindamycin phosphate iv soln 900 mg/6ml
$0(1)
clindamycin phosphate vaginal cream 2%
$0(1)
colistimethate sodium for inj 150 mg
$0(1)
CUBICIN - daptomycin for iv soln 500 mg
$0(2)
DALVANCE - dalbavancin hcl for iv soln 500 mg
$0(2)
demeclocycline hcl tab 150 mg
$0(1)
demeclocycline hcl tab 300 mg
$0(1)
dicloxacillin sodium cap 250 mg
$0(1)
dicloxacillin sodium cap 500 mg
$0(1)
DIFICID - fidaxomicin tab 200 mg
$0(2)
doxycycline hyclate cap 50 mg
$0(1)
$0(1)
doxycycline hyclate for inj 100 mg
$0(1)
$0(2)
$0(1)
10
2016
doxycycline hyclate tab 20 mg
de copago)
uso
$0(1)
$0(1)
doxycycline monohydrate cap 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
doxycycline monohydrate tab 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
E.E.S. GRANULES - erythromycin ethylsuccinate for susp
200 mg/5ml
ERY-TAB - erythromycin tab delayed release 250 mg
$0(2)
$0(2)
$0(2)
ERYPED 200 - erythromycin ethylsuccinate for susp
200 mg/5ml
ERYPED 400 - erythromycin ethylsuccinate for susp
400 mg/5ml
ERYTHROCIN LACTOBIONATE - erythromycin
lactobionate for inj 500 mg
ERYTHROCIN STEARATE - erythromycin stearate tab
250 mg
ERYTHROMYCIN BASE - erythromycin tab 250 mg
$0(2)
ERYTHROMYCIN BASE - erythromycin tab 500 mg
$0(2)
FORTAZ - ceftazidime for inj 500 mg
$0(2)
FORTAZ - ceftazidime sodium in d5w inj 1 gm/50ml
$0(2)
FORTAZ - ceftazidime sodium in d5w inj 2 gm/50ml
$0(2)
gentamicin in saline inj 0.8 mg/ml
$0(1)
gentamicin in saline inj 1 mg/ml
$0(1)
$0(1)
$0(1)
gentamicin sulfate inj 10 mg/ml
$0(1)
gentamicin sulfate inj 40 mg/ml
$0(1)
gentamicin sulfate iv soln 10 mg/ml
$0(1)
GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE
- gentamicin in saline inj 0.9 mg/ml
GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE
- gentamicin in saline inj 1.4 mg/ml
imipenem-cilastatin intravenous for soln 250 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
11
2016
imipenem-cilastatin intravenous for soln 500 mg
de copago)
uso
$0(1)
INVANZ - ertapenem sodium for inj 1 gm
$0(2)
INVANZ - ertapenem sodium for iv inj 1 gm
$0(2)
levofloxacin in d5w iv soln 250 mg/50ml
$0(1)
$0(1)
$0(1)
levofloxacin iv soln 25 mg/ml
$0(1)
levofloxacin oral soln 25 mg/ml
$0(1)
levofloxacin tab 250 mg
$0(1)
$0(1)
$0(1)
linezolid for susp 100 mg/5ml
$0(1)
linezolid in sodium chloride iv soln 600 mg/300ml-0.9%
$0(1)
linezolid iv soln 600 mg/300ml (2 mg/ml)
$0(1)
linezolid tab 600 mg
$0(1)
meropenem iv for soln 500 mg
$0(1)
meropenem iv for soln 1 gm
$0(1)
methenamine hippurate tab 1 gm
$0(1)
METRO IV - metronidazole in nacl 0.74% iv soln
500 mg/100ml
metronidazole cap 375 mg
$0(2)
metronidazole in nacl 0.79% iv soln 500 mg/100ml
$0(1)
metronidazole tab 250 mg
$0(1)
metronidazole tab 500 mg
$0(1)
metronidazole vaginal gel 0.75%
$0(1)
minocycline hcl cap 50 mg
$0(1)
$0(1)
$0(1)
minocycline hcl tab 50 mg
$0(1)
$0(1)
$0(1)
moxifloxacin hcl tab 400 mg
$0(1)
NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm
$0(2)
NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm
$0(2)
nafcillin sodium for inj 1 gm
$0(1)
$0(1)
$0(1)
neomycin sulfate tab 500 mg
$0(1)
PA
PA
$0(1)
12
2016
neomycin-polymyxin b gu irrigation soln
de copago)
uso
$0(1)
nitrofurantoin macrocrystalline cap 50 mg#
$0(2)
PA
nitrofurantoin macrocrystalline cap 100 mg#
$0(2)
PA
nitrofurantoin monohydrate macrocrystalline cap 100 mg#
$0(2)
PA
nitrofurantoin susp 25 mg/5ml#
$0(2)
PA
OFLOXACIN - ofloxacin tab 400 mg
$0(2)
paromomycin sulfate cap 250 mg
$0(1)
penicillin g potassium for inj 5000000 unit
$0(1)
penicillin g potassium for inj 20000000 unit
$0(1)
PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g
potassium inj 20000 unit/ml in dextrose
PENICILLIN G SODIUM - penicillin g sodium for inj
5000000 unit
penicillin v potassium for soln 125 mg/5ml
$0(2)
penicillin v potassium for soln 250 mg/5ml
$0(1)
penicillin v potassium tab 250 mg
$0(1)
penicillin v potassium tab 500 mg
$0(1)
piperacillin sod-tazobactam na for inj 3.375 gm
(3-0.375 gm)
piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm)
$0(1)
piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm)
$0(1)
SIVEXTRO - tedizolid phosphate tab 200 mg
$0(2)
SIVEXTRO - tedizolid phosphate for iv soln 200 mg
$0(2)
STREPTOMYCIN SULFATE - streptomycin sulfate for inj
1 gm
SULFADIAZINE - sulfadiazine tab 500 mg
$0(2)
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml
$0(1)
sulfamethoxazole-trimethoprim tab 400-80 mg
$0(1)
sulfamethoxazole-trimethoprim tab 800-160 mg
$0(1)
SULFAMETHOXAZOLE/TRIMETHOPRIM sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml
SUPRAX - cefixime cap 400 mg
$0(2)
SUPRAX - cefixime chew tab 100 mg
$0(2)
SUPRAX - cefixime chew tab 200 mg
$0(2)
SYNERCID - quinupristin-dalfopristin for inj 500 mg
(150-350 mg)
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
PA
$0(2)
$0(2)
13
2016
TEFLARO - ceftaroline fosamil for iv soln 400 mg
de copago)
uso
$0(2)
TEFLARO - ceftaroline fosamil for iv soln 600 mg
$0(2)
tetracycline hcl cap 250 mg
$0(1)
tetracycline hcl cap 500 mg
$0(1)
tobramycin sulfate for inj 1.2 gm
$0(1)
tobramycin sulfate inj 10 mg/ml
$0(1)
tobramycin sulfate inj 80 mg/2ml (40 mg/ml)
$0(1)
tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml)
$0(1)
tobramycin sulfate inj 2 gm/50ml (40 mg/ml)
$0(1)
trimethoprim tab 100 mg
$0(1)
TYGACIL - tigecycline for iv soln 50 mg
$0(2)
vancomycin hcl cap 125 mg
$0(1)
vancomycin hcl cap 250 mg
$0(1)
vancomycin hcl for inj 500 mg
$0(1)
$0(1)
$0(1)
vancomycin hcl for inj 10 gm
$0(1)
VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in
dextrose inj 500 mg/100ml
dextrose inj 750 mg/150ml
dextrose inj 1 gm/200ml
XIFAXAN - rifaximin tab 550 mg
$0(2)
ZINACEF - cefuroxime in sterile water inj 1.5 gm/50ml
$0(2)
ZOSYN - piperacillin sod-tazobactam sod in dex iv soln
2-0.25gm/50ml
ZOSYN - piperacillin sod-tazobactam sod in dex iv soln
4-0.5gm/100ml
ZOSYN - piperacillin sod-tazobactam sod in dex iv sol
3-0.375gm/50ml
ZYVOX - linezolid for susp 100 mg/5ml
Medicamentos anticonvulsantes
APTIOM - eslicarbazepine acetate tab 200 mg
$0(2)
$0(2)
$0(2)
$0(2)
BANZEL - rufinamide susp 40 mg/ml
$0(2)
BANZEL - rufinamide tab 200 mg
$0(2)
BANZEL - rufinamide tab 400 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
PA
$0(2)
14
2016
carbamazepine cap sr 12hr 100 mg
de copago)
uso
$0(1)
$0(1)
$0(1)
carbamazepine chew tab 100 mg
$0(1)
carbamazepine susp 100 mg/5ml
$0(1)
carbamazepine tab sr 12hr 100 mg
$0(1)
$0(1)
$0(1)
carbamazepine tab 200 mg
$0(1)
CELONTIN - methsuximide cap 300 mg
$0(2)
clonazepam orally disintegrating tab 0.125 mg
$0(1)
$0(1)
$0(1)
clonazepam orally disintegrating tab 1 mg
$0(1)
$0(1)
clonazepam tab 0.5 mg
$0(1)
clonazepam tab 1 mg
$0(1)
clonazepam tab 2 mg
$0(1)
clorazepate dipotassium tab 3.75 mg
$0(1)
$0(1)
clorazepate dipotassium tab 15 mg
$0(1)
DIASTAT ACUDIAL - diazepam rectal gel delivery system
10 mg
DIASTAT ACUDIAL - diazepam rectal gel delivery system
20 mg
DIASTAT PEDIATRIC - diazepam rectal gel delivery system
2.5 mg
DIAZEPAM - diazepam oral soln 1 mg/ml
$0(2)
QL (5 twin pack(s)/30 days)
$0(2)
$0(2)
$0(2)
PA, QL (1200 mls/30 days)
DIAZEPAM - diazepam rectal gel delivery system 2.5 mg
$0(2)
DIAZEPAM - diazepam rectal gel delivery system 10 mg
$0(2)
DIAZEPAM - diazepam rectal gel delivery system 20 mg
$0(2)
diazepam conc 5 mg/ml
$0(1)
diazepam tab 2 mg
$0(1)
diazepam tab 5 mg
$0(1)
diazepam tab 10 mg
$0(1)
DILANTIN - phenytoin sodium extended cap 30 mg
$0(2)
divalproex sodium cap delayed release sprinkle 125 mg
$0(1)
divalproex sodium tab delayed release 125 mg
$0(1)
$0(1)
15
2016
de copago)
uso
$0(1)
divalproex sodium tab sr 24 hr 250 mg
$0(1)
$0(1)
ethosuximide cap 250 mg
$0(1)
ethosuximide soln 250 mg/5ml
$0(1)
felbamate susp 600 mg/5ml
$0(1)
felbamate tab 400 mg
$0(1)
felbamate tab 600 mg
$0(1)
fosphenytoin sodium inj 100 mg/2ml
$0(1)
fosphenytoin sodium inj 500 mg/10ml
$0(1)
FYCOMPA - perampanel tab 2 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
gabapentin cap 100 mg
$0(1)
$0(1)
$0(1)
gabapentin oral soln 250 mg/5ml
$0(1)
gabapentin tab 600 mg
$0(1)
gabapentin tab 800 mg
$0(1)
GABITRIL - tiagabine hcl tab 12 mg
$0(2)
GABITRIL - tiagabine hcl tab 16 mg
$0(2)
lamotrigine orally disintegrating tab 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
lamotrigine tab chewable dispersible 5 mg
$0(1)
$0(1)
lamotrigine tab 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
LEVETIRACETAM - levetiracetam in sodium chloride iv
soln 500 mg/100ml
soln 1000 mg/100ml
$0(2)
$0(2)
16
2016
soln 1500 mg/100ml
levetiracetam inj 500 mg/5ml (100 mg/ml)
de copago)
uso
$0(2)
$0(1)
levetiracetam oral soln 100 mg/ml
$0(1)
levetiracetam tab 250 mg
$0(1)
$0(1)
$0(1)
$0(1)
LYRICA - pregabalin soln 20 mg/ml
$0(1)
LYRICA - pregabalin cap 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
ONFI - clobazam suspension 2.5 mg/ml
$0(2)
ONFI - clobazam tab 5 mg
$0(2)
$0(2)
$0(2)
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
$0(1)
oxcarbazepine tab 150 mg
$0(1)
$0(1)
$0(1)
PEGANONE - ethotoin tab 250 mg
$0(2)
PHENOBARBITAL - phenobarbital tab 15 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
phenobarbital elixir 20 mg/5ml#
$0(2)
PA
PHENOBARBITAL SODIUM - phenobarbital sodium inj
65 mg/ml#
PHENOBARBITAL SODIUM - phenobarbital sodium inj
130 mg/ml#
phenobarbital tab 16.2 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
17
2016
phenytoin chew tab 50 mg
de copago)
uso
$0(1)
phenytoin sodium extended cap 100 mg
$0(1)
$0(1)
$0(1)
phenytoin susp 125 mg/5ml
$0(1)
POTIGA - ezogabine tab 50 mg
$0(2)
$0(2)
$0(2)
$0(2)
primidone tab 50 mg
$0(1)
primidone tab 250 mg
$0(1)
SABRIL - vigabatrin tab 500 mg*
$0(2)
SABRIL - vigabatrin powd pack 500 mg*
$0(2)
TEGRETOL-XR - carbamazepine tab sr 12hr 100 mg
$0(2)
tiagabine hcl tab 2 mg
$0(1)
tiagabine hcl tab 4 mg
$0(1)
topiramate sprinkle cap 15 mg
$0(1)
$0(1)
topiramate tab 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
valproate sodium inj 100 mg/ml
$0(1)
valproate sodium syrup 250 mg/5ml
$0(1)
valproic acid cap 250 mg
$0(1)
VIMPAT - lacosamide tab 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml)
$0(1)
VIMPAT - lacosamide oral solution 10 mg/ml
$0(1)
zonisamide cap 25 mg
$0(1)
$0(1)
Agentes contra la demencia
donepezil hydrochloride orally disintegrating tab 5 mg
$0(1)
donepezil hydrochloride orally disintegrating tab 10 mg
$0(1)
donepezil hydrochloride tab 5 mg
$0(1)
$0(1)
18
2016
de copago)
uso
$0(1)
$0(1)
ergoloid mesylates tab 1 mg#
$0(1)
EXELON - rivastigmine td patch 24hr 4.6 mg/24hr
$0(1)
$0(1)
$0(1)
GALANTAMINE HYDROBROMIDE - galantamine
hydrobromide oral soln 4 mg/ml
galantamine hydrobromide cap sr 24hr 8 mg
$0(2)
$0(1)
$0(1)
galantamine hydrobromide tab 4 mg
$0(1)
$0(1)
$0(1)
memantine hcl oral solution 2 mg/ml
$0(1)
PA
memantine hcl tab 5 mg
$0(1)
PA
memantine hcl tab 10 mg
$0(1)
PA
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
$0(1)
PA
NAMENDA - memantine hcl oral solution 2 mg/ml
$0(1)
PA
NAMENDA - memantine hcl tab 5 mg
$0(1)
PA
NAMENDA - memantine hcl tab 10 mg
$0(1)
PA
NAMENDA TITRATION PAK - memantine hcl tab 5 mg (28)
& 10 mg (21) titration pak
NAMENDA XR - memantine hcl cap sr 24hr 7 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
NAMENDA XR TITRATION PACK - memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack
rivastigmine tartrate cap 1.5 mg
$0(1)
PA
rivastigmine tartrate cap 3 mg
$0(1)
rivastigmine tartrate cap 4.5 mg
$0(1)
rivastigmine tartrate cap 6 mg
$0(1)
rivastigmine td patch 24hr 4.6 mg/24hr
$0(1)
$0(1)
Medicamentos antidepresivos
ABILIFY MAINTENA - aripiprazole im for extended release
susp 300 mg
$0(1)
PA
$0(1)
$0(1)
$0(2)
PA, QL (1 syringe
or vial/30 days)
19
2016
de copago)
uso
$0(2)
PA, QL (1 syringe
susp 400 mg
or vial/30 days)
amitriptyline hcl tab 10 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
AMOXAPINE - amoxapine tab 25 mg
$0(2)
$0(2)
$0(2)
$0(2)
ARIPIPRAZOLE ODT - aripiprazole orally disintegrating tab
10 mg
15 mg
aripiprazole oral solution 1 mg/ml
$0(2)
$0(2)
$0(1)
aripiprazole tab 2 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
BRINTELLIX - vortioxetine hbr tab 5 mg
$0(2)
$0(2)
$0(2)
bupropion hcl tab sr 12hr 100 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
bupropion hcl tab 75 mg
$0(1)
bupropion hcl tab 100 mg
$0(1)
citalopram hydrobromide oral soln 10 mg/5ml
$0(1)
citalopram hydrobromide tab 10 mg
$0(1)
$0(1)
$0(1)
clomipramine hcl cap 25 mg#
$0(2)
PA
20
2016
de copago)
uso
$0(2)
PA
$0(2)
PA
desipramine hcl tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
DOXEPIN HCL - doxepin hcl cap 75 mg#
$0(2)
PA
doxepin hcl cap 10 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
doxepin hcl conc 10 mg/ml#
$0(2)
PA
duloxetine hcl enteric coated pellets cap 20 mg
$0(1)
$0(1)
$0(1)
EMSAM - selegiline td patch 24hr 6 mg/24hr
$0(2)
$0(2)
$0(2)
escitalopram oxalate soln 5 mg/5ml
$0(1)
escitalopram oxalate tab 5 mg
$0(1)
$0(1)
$0(1)
FETZIMA - levomilnacipran hcl cap sr 24hr 20 mg
$0(2)
$0(2)
$0(2)
$0(2)
FETZIMA TITRATION PACK - levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack
fluoxetine hcl cap delayed release 90 mg
$0(2)
$0(1)
fluoxetine hcl cap 10 mg
$0(1)
$0(1)
$0(1)
fluoxetine hcl solution 20 mg/5ml
$0(1)
fluoxetine hcl tab 10 mg
$0(1)
fluoxetine hcl tab 20 mg
$0(1)
21
2016
fluvoxamine maleate tab 25 mg
de copago)
uso
$0(1)
$0(1)
$0(1)
imipramine hcl tab 10 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
MAPROTILINE HCL - maprotiline hcl tab 25 mg
$0(2)
$0(2)
$0(2)
MARPLAN - isocarboxazid tab 10 mg
$0(2)
mirtazapine orally disintegrating tab 15 mg
$0(1)
$0(1)
$0(1)
mirtazapine tab 7.5 mg
$0(1)
mirtazapine tab 15 mg
$0(1)
$0(1)
$0(1)
NEFAZODONE HCL - nefazodone hcl tab 100 mg
$0(2)
$0(2)
$0(2)
nefazodone hcl tab 50 mg
$0(1)
nefazodone hcl tab 250 mg
$0(1)
NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml
$0(2)
nortriptyline hcl cap 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
paroxetine hcl tab sr 24hr 12.5 mg
$0(1)
paroxetine hcl tab sr 24hr 25 mg
$0(1)
$0(1)
paroxetine hcl tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
PAXIL - paroxetine hcl oral susp 10 mg/5ml
$0(2)
phenelzine sulfate tab 15 mg
$0(1)
PRISTIQ - desvenlafaxine succinate tab sr 24hr 25 mg
$0(2)
$0(2)
22
2016
de copago)
uso
$0(2)
protriptyline hcl tab 5 mg
$0(1)
protriptyline hcl tab 10 mg
$0(1)
quetiapine fumarate tab 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
REXULTI - brexpiprazole tab 0.25 mg
$0(2)
$0(2)
REXULTI - brexpiprazole tab 1 mg
$0(2)
$0(2)
$0(2)
$0(2)
SEROQUEL XR - quetiapine fumarate tab sr 24hr 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
sertraline hcl oral conc 20 mg/ml
$0(1)
sertraline hcl tab 25 mg
$0(1)
$0(1)
$0(1)
SURMONTIL - trimipramine maleate cap 25 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
tranylcypromine sulfate tab 10 mg
$0(1)
trazodone hcl tab 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
trimipramine maleate cap 25 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
TRINTELLIX - vortioxetine hbr tab 5 mg
$0(2)
$0(2)
$0(2)
23
2016
venlafaxine hcl cap sr 24hr 37.5 mg
de copago)
uso
$0(1)
venlafaxine hcl cap sr 24hr 75 mg
$0(1)
$0(1)
venlafaxine hcl tab sr 24hr 37.5 mg
$0(1)
venlafaxine hcl tab sr 24hr 75 mg
$0(1)
$0(1)
venlafaxine hcl tab 25 mg
$0(1)
venlafaxine hcl tab 37.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
VIIBRYD - vilazodone hcl tab 10 mg
$0(2)
$0(2)
$0(2)
VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10
(7) & 20 (23) mg
Medicamentos antieméticos
ALER-DRYL - diphenhydramine hcl tab 50 mg
$0(2)
QL (1 kit/30 days)
$0(3)
MC
ALOXI - palonosetron hcl iv soln 0.25 mg/5ml
$0(2)
BENADRYL ALLERGY CHILDRENS - diphenhydramine hcl
chew tab 12.5 mg
liquid 12.5 mg/5ml
CHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/
ml
CHLORPROMAZINE HCL - chlorpromazine hcl inj
50 mg/2ml
chlorpromazine hcl tab 10 mg
$0(3)
MC
$0(3)
MC
$0(2)
PA
$0(2)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
diphenhydramine hcl cap 25 mg#
$0(3)
MC
diphenhydramine hcl inj 50 mg/ml
$0(1)
diphenhydramine hcl tab 25 mg
$0(3)
MC
DRAMAMINE - dimenhydrinate tab 50 mg
$0(3)
MC
dronabinol cap 2.5 mg
$0(1)
BD
dronabinol cap 5 mg
$0(1)
BD
dronabinol cap 10 mg
$0(1)
BD
24
2016
EMEND - aprepitant capsule therapy pack 80 & 125 mg
de copago)
uso
$0(2)
BD
EMEND - fosaprepitant dimeglumine for iv infusion 150 mg
$0(2)
EMEND - aprepitant capsule 40 mg
$0(2)
BD
$0(2)
BD
$0(2)
BD
EMETROL - fructose-dextrose-phosphoric acid oral soln
$0(3)
MC
granisetron hcl tab 1 mg
$0(1)
BD
hydroxyzine hcl syrup 10 mg/5ml#
$0(2)
PA
hydroxyzine hcl tab 10 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
meclizine hcl chew tab 25 mg
$0(3)
MC
meclizine hcl tab 12.5 mg
$0(1)
meclizine hcl tab 25 mg
$0(1)
metoclopramide hcl inj 5 mg/ml
$0(1)
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)
$0(1)
metoclopramide hcl tab 5 mg
$0(1)
$0(1)
ondansetron hcl inj 4 mg/2ml (2 mg/ml)
$0(1)
ondansetron hcl inj 40 mg/20ml (2 mg/ml)
$0(1)
ondansetron hcl oral soln 4 mg/5ml
$0(1)
BD
ondansetron hcl tab 4 mg
$0(1)
BD
$0(1)
BD
$0(1)
BD
ondansetron orally disintegrating tab 4 mg
$0(1)
BD
ondansetron orally disintegrating tab 8 mg
$0(1)
BD
perphenazine tab 2 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
prochlorperazine edisylate inj 5 mg/ml
$0(1)
prochlorperazine maleate tab 5 mg
$0(1)
$0(1)
prochlorperazine suppos 25 mg
$0(1)
promethazine hcl suppos 12.5 mg#
$0(2)
PA
promethazine hcl suppos 25 mg#
$0(2)
PA
promethazine hcl syrup 6.25 mg/5ml#
$0(2)
PA
promethazine hcl tab 12.5 mg#
$0(2)
PA
25
2016
promethazine hcl tab 25 mg#
de copago)
uso
$0(2)
PA
Medicamentos antimicóticos
AMBISOME - amphotericin b liposome iv for susp 50 mg
$0(2)
PA
$0(2)
BD
AMPHOTERICIN B - amphotericin b for inj 50 mg
$0(2)
BD
CANCIDAS - caspofungin acetate for iv soln 50 mg
$0(2)
CANCIDAS - caspofungin acetate for iv soln 70 mg
$0(2)
clotrimazole troche 10 mg
$0(1)
CRESEMBA - isavuconazonium sulfate cap 186 mg
$0(2)
PA
CRESEMBA - isavuconazonium sulfate for iv soln 372 mg
$0(2)
PA
fluconazole for susp 10 mg/ml
$0(1)
fluconazole for susp 40 mg/ml
$0(1)
fluconazole in dextrose inj 200 mg/100ml
$0(1)
fluconazole in dextrose inj 400 mg/200ml
$0(1)
fluconazole in nacl 0.9% inj 200 mg/100ml
$0(1)
fluconazole in nacl 0.9% inj 400 mg/200ml
$0(1)
fluconazole tab 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
flucytosine cap 250 mg
$0(1)
flucytosine cap 500 mg
$0(1)
griseofulvin microsize susp 125 mg/5ml
$0(1)
griseofulvin ultramicrosize tab 125 mg
$0(1)
griseofulvin ultramicrosize tab 250 mg
$0(1)
GYNE-LOTRIMIN - clotrimazole vaginal cream 1%
$0(3)
MC
GYNE-LOTRIMIN 3 - clotrimazole vaginal cream 2%
$0(3)
MC
itraconazole cap 100 mg
$0(1)
ketoconazole tab 200 mg
$0(1)
LAMISIL AT - terbinafine hcl cream 1%
$0(3)
MC
miconazole nitrate vaginal app 200 mg & 2% cream 9 gm
kit
miconazole nitrate vaginal cream 2%
$0(3)
MC
$0(3)
MC
miconazole nitrate vaginal cream 4% (200 mg/5gm)
$0(3)
MC
miconazole nitrate vaginal suppos 100 mg
$0(3)
MC
miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm
kit
MYCAMINE - micafungin sodium for iv soln 50 mg
$0(3)
MC
$0(2)
26
2016
MYCAMINE - micafungin sodium for iv soln 100 mg
de copago)
uso
$0(2)
NOXAFIL - posaconazole tab delayed release 100 mg
$0(2)
PA
NOXAFIL - posaconazole susp 40 mg/ml
$0(2)
PA
NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml)
$0(2)
PA
nystatin susp 100000 unit/ml
$0(1)
nystatin tab 500000 unit
$0(1)
terbinafine hcl tab 250 mg
$0(1)
terconazole vaginal cream 0.4%
$0(1)
terconazole vaginal cream 0.8%
$0(1)
terconazole vaginal suppos 80 mg
$0(1)
tolnaftate aerosol 1%
$0(3)
MC
VAGISTAT-1 - tioconazole vaginal oint 6.5%
$0(3)
MC
voriconazole for inj 200 mg
$0(1)
PA
voriconazole for susp 40 mg/ml
$0(1)
PA
voriconazole tab 50 mg
$0(1)
PA
voriconazole tab 200 mg
Agentes contra la gota
allopurinol tab 100 mg
$0(1)
PA
allopurinol tab 300 mg
$0(1)
ALOPRIM - allopurinol sodium for inj 500 mg
$0(2)
colchicine w/ probenecid tab 0.5-500 mg
$0(1)
COLCRYS - colchicine tab 0.6 mg
$0(1)
probenecid tab 500 mg
$0(1)
ULORIC - febuxostat tab 40 mg
$0(1)
ULORIC - febuxostat tab 80 mg
Agentes antiinflamatorios
aspirin chew tab 81 mg
$0(1)
$0(3)
MC
aspirin tab delayed release 81 mg
$0(3)
MC
aspirin tab delayed release 325 mg
$0(3)
MC
aspirin tab 325 mg
$0(3)
MC
aspirin tab 81 mg
$0(3)
MC
celecoxib cap 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
diclofenac potassium tab 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
ST
27
2016
de copago)
uso
$0(1)
$0(1)
diclofenac sodium tab sr 24hr 100 mg
$0(1)
$0(1)
$0(1)
etodolac cap 200 mg
$0(1)
etodolac cap 300 mg
$0(1)
$0(1)
$0(1)
$0(1)
etodolac tab 400 mg
$0(1)
etodolac tab 500 mg
$0(1)
$0(1)
$0(1)
ibuprofen cap 200 mg
$0(3)
ibuprofen susp 100 mg/5ml
$0(1)
$0(3)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
meloxicam tab 7.5 mg
$0(1)
meloxicam tab 15 mg
$0(1)
$0(1)
$0(1)
$0(3)
$0(1)
$0(1)
naproxen susp 125 mg/5ml
$0(1)
$0(1)
$0(1)
naproxen tab 250 mg
$0(1)
naproxen tab 375 mg
$0(1)
naproxen tab 500 mg
$0(1)
oxaprozin tab 600 mg
$0(1)
piroxicam cap 10 mg
$0(1)
piroxicam cap 20 mg
$0(1)
MC
MC
MC
28
2016
sulindac tab 150 mg
de copago)
uso
$0(1)
sulindac tab 200 mg
$0(1)
tolmetin sodium cap 400 mg
$0(1)
Agentes contra las migrañas
butalbital-acetaminophen-caff w/ cod cap
50-300-40-30 mg#
$0(2)
$0(2)
PA, QL (180
capsules/30 days)
50-325-40-30 mg#
$0(2)
PA, QL (180
capsules/30 days)
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg#
$0(2)
PA, QL (180
capsules/30 days)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg
$0(2)
MIGRANAL - dihydroergotamine mesylate nasal spray
4 mg/ml
naratriptan hcl tab 1 mg
$0(1)
$0(1)
naratriptan hcl tab 2.5 mg
$0(1)
propranolol hcl cap sr 24hr 60 mg
$0(1)
$0(1)
$0(1)
$0(1)
propranolol hcl inj 1 mg/ml
$0(1)
propranolol hcl tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
rizatriptan benzoate orally disintegrating tab 5 mg
$0(1)
rizatriptan benzoate orally disintegrating tab 10 mg
$0(1)
rizatriptan benzoate tab 5 mg
$0(1)
rizatriptan benzoate tab 10 mg
$0(1)
SUMATRIPTAN - sumatriptan nasal spray 5 mg/act
$0(2)
ST
QL (12 units (2
packages)/30 days)
29
2016
SUMATRIPTAN - sumatriptan nasal spray 20 mg/act
de copago)
uso
$0(2)
QL (12 units (2
packages)/30 days)
SUMATRIPTAN SUCCINATE - sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml
sumatriptan succinate inj 6 mg/0.5ml
$0(1)
sumatriptan succinate solution auto-injector 4 mg/0.5ml
$0(1)
sumatriptan succinate solution auto-injector 6 mg/0.5ml
$0(1)
sumatriptan succinate solution cartridge 4 mg/0.5ml
$0(1)
sumatriptan succinate solution cartridge 6 mg/0.5ml
$0(1)
sumatriptan succinate tab 25 mg
$0(1)
$0(1)
$0(1)
TIMOLOL MALEATE - timolol maleate tab 5 mg
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
Agentes antimiasténicos
GUANIDINE HCL - guanidine hcl tab 125 mg
$0(1)
MESTINON - pyridostigmine bromide syrup 60 mg/5ml
$0(2)
MESTINON TIMESPAN - pyridostigmine bromide tab cr
180 mg
pyridostigmine bromide tab cr 180 mg
$0(1)
pyridostigmine bromide tab 60 mg
Medicamentos antimicobacteriales
CAPASTAT SULFATE - capreomycin sulfate for inj 1 gm
$0(1)
CYCLOSERINE - cycloserine cap 250 mg
$0(2)
DAPSONE - dapsone tab 25 mg
$0(1)
DAPSONE - dapsone tab 100 mg
$0(1)
ethambutol hcl tab 100 mg
$0(1)
ethambutol hcl tab 400 mg
$0(1)
ISONIAZID - isoniazid inj 100 mg/ml
$0(2)
isoniazid tab 100 mg
$0(1)
isoniazid tab 300 mg
$0(1)
PASER - aminosalicylic acid cr granules packet 4 gm
$0(2)
$0(1)
$0(2)
$0(1)
$0(2)
30
2016
PRIFTIN - rifapentine tab 150 mg
de copago)
uso
$0(2)
pyrazinamide tab 500 mg
$0(1)
rifabutin cap 150 mg
$0(1)
rifampin cap 150 mg
$0(1)
rifampin cap 300 mg
$0(1)
rifampin for inj 600 mg
$0(1)
SIRTURO - bedaquiline fumarate tab 100 mg
$0(2)
TRECATOR - ethionamide tab 250 mg
Medicamentos antineoplásicos
ABRAXANE - paclitaxel protein-bound particles for iv susp
100 mg
AFINITOR - everolimus tab 2.5 mg
$0(2)
$0(2)
AFINITOR - everolimus tab 5 mg
$0(2)
AFINITOR - everolimus tab 7.5 mg
$0(2)
AFINITOR - everolimus tab 10 mg
$0(2)
AFINITOR DISPERZ - everolimus tab for oral susp 2 mg
$0(2)
$0(2)
$0(2)
ALECENSA - alectinib hcl cap 150 mg
$0(2)
ALIMTA - pemetrexed disodium for iv soln 100 mg
$0(2)
ALIMTA - pemetrexed disodium for iv soln 500 mg
$0(2)
amifostine crystalline for inj 500 mg
$0(1)
anastrozole tab 1 mg
$0(1)
ARRANON - nelarabine iv soln 5 mg/ml
$0(2)
ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml*
$0(2)
ARZERRA - ofatumumab conc for iv infusion
1000 mg/50ml*
AVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)*
$0(2)
AVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)*
$0(2)
azacitidine for inj 100 mg
$0(1)
BELEODAQ - belinostat for iv inj 500 mg*
$0(2)
BENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/
ml)
bexarotene cap 75 mg
$0(2)
bicalutamide tab 50 mg
$0(1)
BICNU - carmustine for inj 100 mg
$0(2)
bleomycin sulfate for inj 15 unit
$0(1)
BD
bleomycin sulfate for inj 30 unit
$0(1)
BD
$0(2)
PA, QL (240
capsules/30 days)
$0(2)
$0(1)
PA
31
2016
BLINCYTO - blinatumomab for iv infusion 35 mcg*
de copago)
uso
$0(2)
BOSULIF - bosutinib tab 100 mg
$0(2)
BOSULIF - bosutinib tab 500 mg
$0(2)
BUSULFEX - busulfan inj 6 mg/ml
$0(2)
CAPRELSA - vandetanib tab 100 mg*
$0(2)
CAPRELSA - vandetanib tab 300 mg*
$0(2)
carboplatin iv soln 50 mg/5ml
$0(1)
$0(1)
$0(1)
$0(1)
CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml)
$0(1)
cisplatin inj 50 mg/50ml (1 mg/ml)
$0(1)
cisplatin inj 100 mg/100ml (1 mg/ml)
$0(1)
cladribine iv soln 10 mg/10ml (1 mg/ml)
$0(1)
CLOLAR - clofarabine iv soln 1 mg/ml
$0(2)
COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit*
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x
20 mg (100 dose) kit*
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x
20 mg (140 dose) kit*
$0(2)
$0(2)
COSMEGEN - dactinomycin for inj 0.5 mg
$0(2)
COTELLIC - cobimetinib fumarate tab 20 mg*
$0(2)
CYCLOPHOSPHAMIDE - cyclophosphamide cap 25 mg
$0(2)
BD
CYCLOPHOSPHAMIDE - cyclophosphamide cap 50 mg
$0(2)
BD
cyclophosphamide for inj 500 mg
$0(1)
cyclophosphamide for inj 1 gm
$0(1)
cyclophosphamide for inj 2 gm
$0(1)
CYRAMZA - ramucirumab iv soln 100 mg/10ml (for
infusion)*
CYRAMZA - ramucirumab iv soln 500 mg/50ml (for
infusion)*
cytarabine inj pf 20 mg/ml
$0(2)
$0(1)
BD
cytarabine inj pf 100 mg/ml
$0(1)
BD
cytarabine inj 20 mg/ml
$0(1)
BD
DACARBAZINE - dacarbazine for inj 100 mg
$0(2)
dacarbazine for inj 200 mg
$0(1)
DARZALEX - daratumumab iv soln 100 mg/5ml*
$0(2)
DARZALEX - daratumumab iv soln 400 mg/20ml*
$0(2)
$0(2)
BD
PA, QL (112
capsules/28 days)
$0(2)
32
2016
daunorubicin hcl inj 5 mg/ml
de copago)
uso
$0(1)
DAUNOXOME - daunorubicin citrate liposome inj 2 mg/ml
$0(2)
decitabine for inj 50 mg
$0(1)
dexrazoxane for inj 250 mg
$0(1)
dexrazoxane for inj 500 mg
$0(1)
DOCEFREZ - docetaxel for inj 20 mg
$0(2)
DOCETAXEL - docetaxel for inj conc 20 mg/ml
$0(2)
DOCETAXEL - docetaxel for inj conc 80 mg/4ml (20 mg/ml)
$0(2)
DOCETAXEL - docetaxel for inj conc 140 mg/7ml (20 mg/
ml)
DOCETAXEL - docetaxel for inj conc 160 mg/8ml (20 mg/
ml)
DOCETAXEL - docetaxel soln for iv infusion 20 mg/2ml
$0(2)
$0(2)
$0(2)
$0(2)
docetaxel for inj conc 20 mg/ml
$0(1)
docetaxel for inj conc 80 mg/4ml (20 mg/ml)
$0(1)
doxorubicin hcl for inj 10 mg
$0(1)
BD
doxorubicin hcl for inj 50 mg
$0(1)
BD
doxorubicin hcl inj 2 mg/ml
$0(1)
BD
doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml
$0(1)
BD
ELITEK - rasburicase for iv soln 1.5 mg
$0(2)
ELITEK - rasburicase for iv soln 7.5 mg
$0(2)
EMCYT - estramustine phosphate sodium cap 140 mg
$0(2)
EMPLICITI - elotuzumab for iv soln 300 mg
$0(2)
EMPLICITI - elotuzumab for iv soln 400 mg
$0(2)
epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)
$0(1)
epirubicin hcl iv soln 200 mg/100ml (2 mg/ml)
$0(1)
ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml)
$0(2)
ERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml)
$0(2)
ERIVEDGE - vismodegib cap 150 mg*
$0(2)
ERWINAZE - asparaginase erwinia chrysanthemi for inj
10000 unit
ETOPOPHOS - etoposide phosphate iv for inj 100 mg
$0(2)
etoposide inj 100 mg/5ml (20 mg/ml)
$0(1)
etoposide inj 500 mg/25ml (20 mg/ml)
$0(1)
etoposide inj 1 gm/50ml (20 mg/ml)
$0(1)
exemestane tab 25 mg
$0(1)
$0(2)
$0(2)
$0(2)
33
2016
FARESTON - toremifene citrate tab 60 mg
de copago)
uso
$0(2)
FARYDAK - panobinostat lactate cap 10 mg
$0(2)
$0(2)
$0(2)
FASLODEX - fulvestrant inj 250 mg/5ml
$0(2)
fludarabine phosphate for inj 50 mg
$0(1)
fludarabine phosphate inj 25 mg/ml
$0(1)
fluorouracil inj 500 mg/10ml (50 mg/ml)
$0(1)
BD
fluorouracil inj 1 gm/20ml (50 mg/ml)
$0(1)
BD
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
$0(1)
BD
fluorouracil inj 5 gm/100ml (50 mg/ml)
$0(1)
BD
flutamide cap 125 mg
$0(1)
FOLOTYN - pralatrexate iv inj 20 mg/ml
$0(2)
FOLOTYN - pralatrexate iv inj 40 mg/2ml
$0(2)
GAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml
(25 mg/ml)
gemcitabine hcl for inj 200 mg
$0(2)
gemcitabine hcl for inj 1 gm
$0(1)
gemcitabine hcl for inj 2 gm
$0(1)
gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml)
$0(1)
gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml)
$0(1)
gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml)
$0(1)
GILOTRIF - afatinib dimaleate tab 20 mg
$0(2)
$0(2)
$0(2)
GLEEVEC - imatinib mesylate tab 100 mg
$0(2)
GLEEVEC - imatinib mesylate tab 400 mg
$0(2)
GLEOSTINE - lomustine cap 5 mg
$0(2)
$0(2)
$0(2)
$0(2)
HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml)
$0(2)
HERCEPTIN - trastuzumab for iv soln 440 mg*
$0(2)
HEXALEN - altretamine cap 50 mg
$0(2)
hydroxyurea cap 500 mg
$0(1)
IBRANCE - palbociclib cap 75 mg
$0(2)
$0(2)
$0(2)
$0(1)
PA
34
2016
ICLUSIG - ponatinib hcl tab 15 mg
de copago)
uso
$0(2)
ICLUSIG - ponatinib hcl tab 45 mg
$0(2)
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)
$0(1)
$0(1)
$0(1)
IFEX - ifosfamide for inj 3 gm
$0(2)
IFOSFAMIDE - ifosfamide for inj 3 gm
$0(2)
ifosfamide for inj 1 gm
$0(1)
ifosfamide iv inj 1 gm/20ml (50 mg/ml)
$0(1)
ifosfamide iv inj 3 gm/60ml (50 mg/ml)
$0(1)
imatinib mesylate tab 100 mg
$0(1)
imatinib mesylate tab 400 mg
$0(1)
IMBRUVICA - ibrutinib cap 140 mg
$0(2)
IMLYGIC - talimogene laherparepvec intralesional inj
1000000 unit/ml
IMLYGIC - talimogene laherparepvec intralesional inj
100000000 unit/ml
INLYTA - axitinib tab 1 mg*
$0(2)
$0(2)
INLYTA - axitinib tab 5 mg*
$0(2)
IRESSA - gefitinib tab 250 mg
$0(2)
IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml)
$0(1)
irinotecan hcl inj 40 mg/2ml (20 mg/ml)
$0(1)
irinotecan hcl inj 100 mg/5ml (20 mg/ml)
$0(1)
ISTODAX - romidepsin for iv inj 10 mg
$0(2)
IXEMPRA KIT - ixabepilone for iv infusion 15 mg
$0(2)
IXEMPRA KIT - ixabepilone for iv infusion 45 mg
$0(2)
JAKAFI - ruxolitinib phosphate tab 5 mg*
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion)
$0(2)
KADCYLA - ado-trastuzumab emtansine for iv soln 100 mg
$0(2)
KADCYLA - ado-trastuzumab emtansine for iv soln 160 mg
$0(2)
KEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/
ml)*
KEYTRUDA - pembrolizumab for iv soln 50 mg*
$0(2)
PA, QL (120
capsules/30 days)
$0(2)
$0(2)
35
2016
LENVIMA 10MG DAILY DOSE - lenvatinib cap therapy
pack 10 mg
pack 10 & 4 mg
pack 10 (2) mg
pack 10 (2) & 4 mg
letrozole tab 2.5 mg
Cuánto le cuesta el
medicamento (nivel
de copago)
$0(2)
Acciones necesarias,
restricciones o límites en el
uso
$0(2)
$0(2)
$0(2)
$0(1)
LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg
$0(2)
LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg
$0(2)
LEUCOVORIN CALCIUM - leucovorin calcium for inj 50 mg
$0(2)
LEUCOVORIN CALCIUM - leucovorin calcium for inj
500 mg
leucovorin calcium for inj 100 mg
$0(2)
$0(1)
$0(1)
leucovorin calcium tab 5 mg
$0(1)
leucovorin calcium tab 25 mg
$0(1)
LEUKERAN - chlorambucil tab 2 mg
$0(1)
LONSURF - trifluridine-tipiracil tab 15-6.14 mg
$0(2)
LONSURF - trifluridine-tipiracil tab 20-8.19 mg
$0(2)
LYNPARZA - olaparib cap 50 mg
$0(2)
MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml
(0.16 mg/ml)
MATULANE - procarbazine hcl cap 50 mg*
$0(2)
$0(2)
PA
MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg
$0(2)
MEKINIST - trametinib dimethyl sulfoxide tab 2 mg
$0(2)
melphalan hcl for inj 50 mg
$0(1)
mercaptopurine tab 50 mg
$0(1)
mesna inj 100 mg/ml
$0(1)
MESNEX - mesna tab 400 mg
$0(2)
methotrexate sodium for inj 1 gm
$0(1)
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
methotrexate sodium inj 250 mg/10ml (25 mg/ml)
$0(1)
$0(1)
PA, QL (480
capsules/30 days)
36
2016
de copago)
uso
$0(1)
methotrexate sodium tab 2.5 mg
$0(1)
MITOMYCIN - mitomycin for iv soln 5 mg
$0(2)
mitomycin for iv soln 20 mg
$0(1)
mitomycin for iv soln 40 mg
$0(1)
mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml)
$0(1)
mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)
$0(1)
$0(1)
MUSTARGEN - mechlorethamine hcl for inj 10 mg
$0(2)
NEXAVAR - sorafenib tosylate tab 200 mg*
$0(2)
NILANDRON - nilutamide tab 150 mg
$0(2)
NINLARO - ixazomib citrate cap 2.3 mg
$0(2)
NINLARO - ixazomib citrate cap 3 mg
$0(2)
NINLARO - ixazomib citrate cap 4 mg
$0(2)
NIPENT - pentostatin for inj 10 mg
$0(2)
ODOMZO - sonidegib phosphate cap 200 mg*
$0(2)
ONCASPAR - pegaspargase inj 750 unit/ml
$0(2)
OPDIVO - nivolumab iv soln 40 mg/4ml
$0(2)
OPDIVO - nivolumab iv soln 100 mg/10ml
$0(2)
oxaliplatin for iv inj 50 mg
$0(1)
oxaliplatin for iv inj 100 mg
$0(1)
oxaliplatin iv soln 50 mg/10ml
$0(1)
oxaliplatin iv soln 100 mg/20ml
$0(1)
paclitaxel iv conc 30 mg/5ml (6 mg/ml)
$0(1)
paclitaxel iv conc 100 mg/16.7ml (6 mg/ml)
$0(1)
paclitaxel iv conc 300 mg/50ml (6 mg/ml)
$0(1)
PANRETIN - alitretinoin gel 0.1%
$0(2)
PERJETA - pertuzumab soln for iv infusion 420 mg/14ml
(30 mg/ml)*
POMALYST - pomalidomide cap 1 mg*
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/
ml)
PROLEUKIN - aldesleukin for iv soln 22000000 unit
$0(2)
PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/
ml)*
REVLIMID - lenalidomide caps 2.5 mg*
$0(2)
$0(2)
$0(2)
37
2016
medicamento (nivel
de copago)
$0(2)
uso
REVLIMID - lenalidomide cap 10 mg*
$0(2)
$0(2)
$0(2)
$0(2)
RITUXAN - rituximab iv soln 100 mg/10ml*
$0(2)
PA
RITUXAN - rituximab iv soln 500 mg/50ml*
$0(2)
PA
SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml
$0(2)
SPRYCEL - dasatinib tab 20 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
STIVARGA - regorafenib tab 40 mg*
$0(2)
SUTENT - sunitinib malate cap 12.5 mg
$0(2)
SUTENT - sunitinib malate cap 25 mg
$0(2)
SUTENT - sunitinib malate cap 37.5 mg
$0(2)
SUTENT - sunitinib malate cap 50 mg
$0(2)
SYLATRON - peginterferon alfa-2b for inj kit 200 mcg
$0(2)
PA
$0(2)
PA
$0(2)
PA
SYLATRON - peginterferon alfa-2b for inj kit 4 x 200 mcg
$0(2)
PA
$0(2)
PA
SYLVANT - siltuximab for iv infusion 100 mg
$0(2)
SYLVANT - siltuximab for iv infusion 400 mg
$0(2)
SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg
$0(2)
TABLOID - thioguanine tab 40 mg
$0(2)
TAFINLAR - dabrafenib mesylate cap 50 mg
$0(2)
PA, QL (120
capsules/30 days)
TAFINLAR - dabrafenib mesylate cap 75 mg
$0(2)
PA, QL (120
capsules/30 days)
TAGRISSO - osimertinib mesylate tab 40 mg*
$0(2)
TAGRISSO - osimertinib mesylate tab 80 mg*
$0(2)
tamoxifen citrate tab 10 mg
$0(1)
tamoxifen citrate tab 20 mg
$0(1)
TARCEVA - erlotinib hcl tab 25 mg
$0(2)
$0(2)
38
2016
de copago)
uso
$0(2)
TARGRETIN - bexarotene cap 75 mg
$0(2)
PA
TARGRETIN - bexarotene gel 1%
$0(2)
TASIGNA - nilotinib hcl cap 150 mg
$0(2)
PA, QL (120
capsules/30 days)
TASIGNA - nilotinib hcl cap 200 mg
$0(2)
PA, QL (120
capsules/30 days)
TAXOTERE - docetaxel for inj conc 20 mg/ml
$0(2)
TAXOTERE - docetaxel for inj conc 80 mg/4ml (20 mg/ml)
$0(2)
TEMODAR - temozolomide for iv soln 100 mg
$0(2)
THALOMID - thalidomide cap 50 mg
$0(2)
$0(2)
$0(2)
$0(2)
THIOTEPA - thiotepa for inj 15 mg
$0(2)
TOPOTECAN HCL - topotecan hcl inj 4 mg/4ml (for
infusion)
topotecan hcl for inj 4 mg
$0(2)
TORISEL - temsirolimus soln for iv infusion 25 mg/ml
$0(2)
TREANDA - bendamustine hcl iv soln 180 mg/2ml (90 mg/
ml)
TREANDA - bendamustine hcl for iv soln 25 mg
$0(2)
TREANDA - bendamustine hcl for iv soln 100 mg
$0(2)
tretinoin cap 10 mg
$0(1)
TRISENOX - arsenic trioxide inj 10 mg/10ml (1 mg/ml)
$0(2)
TYKERB - lapatinib ditosylate tab 250 mg*
$0(2)
UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml)
$0(2)
UVADEX - methoxsalen soln 20 mcg/ml
$0(2)
VECTIBIX - panitumumab iv soln 100 mg/5ml
$0(2)
VECTIBIX - panitumumab iv soln 400 mg/20ml
$0(2)
VELCADE - bortezomib for inj 3.5 mg
$0(2)
VENCLEXTA - venetoclax tab 10 mg
$0(2)
$0(2)
$0(2)
VENCLEXTA STARTING PACK - venetoclax tab therapy
starter pack 10 & 50 & 100 mg
$0(2)
PA, QL (1 pack (42
tablets)/28 days)
VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml
$0(2)
BD
vincristine sulfate iv soln 1 mg/ml
$0(1)
vinorelbine tartrate inj 10 mg/ml
$0(1)
$0(1)
$0(2)
PA
39
2016
vinorelbine tartrate inj 50 mg/5ml (10 mg/ml)
de copago)
uso
$0(1)
VOTRIENT - pazopanib hcl tab 200 mg*
$0(2)
XALKORI - crizotinib cap 200 mg*
$0(2)
XALKORI - crizotinib cap 250 mg*
$0(2)
XTANDI - enzalutamide cap 40 mg*
$0(2)
YERVOY - ipilimumab soln for iv infusion 50 mg/10ml
(5 mg/ml)*
YERVOY - ipilimumab soln for iv infusion 200 mg/40ml
(5 mg/ml)*
YONDELIS - trabectedin for inj 1 mg
$0(2)
ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion)
$0(2)
ZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion)
$0(2)
ZANOSAR - streptozocin for inj 1 gm
$0(2)
ZELBORAF - vemurafenib tab 240 mg*
$0(2)
ZOLINZA - vorinostat cap 100 mg
$0(2)
ZYDELIG - idelalisib tab 100 mg*
$0(2)
ZYDELIG - idelalisib tab 150 mg*
$0(2)
ZYKADIA - ceritinib cap 150 mg*
$0(2)
ZYTIGA - abiraterone acetate tab 250 mg*
Medicamentos antiparasitarios
ALBENZA - albendazole tab 200 mg
$0(2)
ALINIA - nitazoxanide tab 500 mg
$0(2)
ALINIA - nitazoxanide for susp 100 mg/5ml
$0(2)
atovaquone susp 750 mg/5ml
$0(1)
atovaquone-proguanil hcl tab 62.5-25 mg
$0(1)
atovaquone-proguanil hcl tab 250-100 mg
$0(1)
BILTRICIDE - praziquantel tab 600 mg
$0(2)
chloroquine phosphate tab 250 mg
$0(1)
chloroquine phosphate tab 500 mg
$0(1)
COARTEM - artemether-lumefantrine tab 20-120 mg
$0(2)
DARAPRIM - pyrimethamine tab 25 mg
$0(2)
hydroxychloroquine sulfate tab 200 mg
$0(1)
ivermectin tab 3 mg
$0(1)
lindane lotion 1%
$0(1)
lindane shampoo 1%
$0(1)
malathion lotion 0.5%
$0(1)
PA, QL (120
capsules/30 days)
$0(2)
$0(2)
PA, QL (120
capsules/30 days)
PA, QL (150
capsules/30 days)
$0(2)
40
2016
mefloquine hcl tab 250 mg
de copago)
uso
$0(1)
NEBUPENT - pentamidine isethionate for nebulization soln
300 mg
PENTAM 300 - pentamidine isethionate for soln 300 mg
$0(2)
BD
$0(2)
BD
permethrin cream 5%
$0(1)
permethrin creme rinse 1%
$0(3)
MC
permethrin lotion 1%
$0(3)
MC
PRIMAQUINE PHOSPHATE - primaquine phosphate tab
26.3 mg
Agentes contra la enfermedad de Parkinson
ALER-DRYL - diphenhydramine hcl tab 50 mg
$0(2)
AMANTADINE HCL - amantadine hcl tab 100 mg
$0(2)
amantadine hcl cap 100 mg
$0(1)
amantadine hcl syrup 50 mg/5ml
$0(1)
APOKYN - apomorphine hydrochloride inj 10 mg/ml*
$0(2)
AZILECT - rasagiline mesylate tab 0.5 mg
$0(1)
AZILECT - rasagiline mesylate tab 1 mg
$0(1)
chew tab 12.5 mg
liquid 12.5 mg/5ml
benztropine mesylate tab 0.5 mg#
$0(3)
MC
$0(3)
MC
$0(2)
PA
benztropine mesylate tab 1 mg#
$0(2)
PA
benztropine mesylate tab 2 mg#
$0(2)
PA
bromocriptine mesylate cap 5 mg
$0(1)
bromocriptine mesylate tab 2.5 mg
$0(1)
carbidopa & levodopa orally disintegrating tab 10-100 mg
$0(1)
$0(1)
$0(1)
carbidopa & levodopa tab cr 25-100 mg
$0(1)
carbidopa & levodopa tab cr 50-200 mg
$0(1)
carbidopa & levodopa tab 10-100 mg
$0(1)
$0(1)
$0(1)
carbidopa tab 25 mg
$0(1)
CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopalevodopa-entacapone tabs 12.5-50-200 mg
$0(1)
$0(3)
MC
$0(1)
41
2016
CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopalevodopa-entacapone tabs 25-100-200 mg
CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopalevodopa-entacapone tabs 50-200-200 mg
diphenhydramine hcl cap 25 mg#
de copago)
uso
$0(1)
$0(1)
$0(1)
$0(1)
$0(3)
MC
diphenhydramine hcl inj 50 mg/ml
$0(1)
diphenhydramine hcl tab 25 mg
$0(3)
entacapone tab 200 mg
$0(1)
NEUPRO - rotigotine td patch 24hr 1 mg/24hr
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
pramipexole dihydrochloride tab 0.125 mg
$0(1)
$0(1)
$0(1)
$0(1)
pramipexole dihydrochloride tab 1 mg
$0(1)
$0(1)
ropinirole hydrochloride tab 0.25 mg
$0(1)
ropinirole hydrochloride tab 0.5 mg
$0(1)
ropinirole hydrochloride tab 1 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
selegiline hcl cap 5 mg
$0(1)
selegiline hcl tab 5 mg
$0(1)
tolcapone tab 100 mg
Medicamentos antipsicóticos
susp 300 mg
$0(1)
$0(2)
PA, QL (1 syringe
or vial/30 days)
susp 400 mg
$0(2)
PA, QL (1 syringe
or vial/30 days)
MC
42
2016
ADASUVE - loxapine aerosol powder breath activated
10 mg
10 mg
15 mg
de copago)
uso
$0(2)
PA
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
CHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/
ml
CHLORPROMAZINE HCL - chlorpromazine hcl inj
50 mg/2ml
$0(2)
PA
$0(2)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
clozapine orally disintegrating tab 25 mg
$0(1)
clozapine orally disintegrating tab 100 mg
$0(1)
clozapine tab 25 mg
$0(1)
clozapine tab 50 mg
$0(1)
clozapine tab 100 mg
$0(1)
clozapine tab 200 mg
$0(1)
FANAPT - iloperidone tab 1 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak
$0(2)
PA, QL (7 packs (56
tablets)/28 days)
FAZACLO - clozapine orally disintegrating tab 12.5 mg
$0(2)
FAZACLO - clozapine orally disintegrating tab 25 mg
$0(2)
43
2016
de copago)
uso
$0(2)
$0(2)
$0(2)
fluphenazine decanoate inj 25 mg/ml
$0(1)
PA
FLUPHENAZINE HCL - fluphenazine hcl elixir 2.5 mg/5ml
$0(2)
PA
FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml
$0(2)
PA
FLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml
$0(2)
PA
fluphenazine hcl tab 1 mg
$0(1)
PA
fluphenazine hcl tab 2.5 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
GEODON - ziprasidone mesylate for inj 20 mg
$0(2)
PA, QL (60 vials/30 days)
haloperidol decanoate im soln 50 mg/ml
$0(1)
PA
haloperidol decanoate im soln 100 mg/ml
$0(1)
PA
haloperidol lactate inj 5 mg/ml
$0(1)
PA
haloperidol lactate oral conc 2 mg/ml
$0(1)
PA
haloperidol tab 0.5 mg
$0(1)
PA
haloperidol tab 1 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
INVEGA - paliperidone tab sr 24hr 1.5 mg
$0(2)
INVEGA - paliperidone tab sr 24hr 3 mg
$0(2)
$0(2)
$0(2)
INVEGA SUSTENNA - paliperidone palmitate im extendedrelease susp 39 mg/0.25ml
INVEGA SUSTENNA - paliperidone palmitate im extendrelease susp 117 mg/0.75ml
INVEGA SUSTENNA - paliperidone palmitate im extendedrelease susp 156 mg/ml
INVEGA TRINZA - paliperidone palmitate im extendrelease susp 273 mg/0.875ml
$0(2)
PA, QL (1 kit/30 days)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
44
2016
LATUDA - lurasidone hcl tab 20 mg
de copago)
uso
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
loxapine succinate cap 5 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
MOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg
$0(2)
PA
MOLINDONE HYDROCHLORIDE - molindone hcl tab
10 mg
MOLINDONE HYDROCHLORIDE - molindone hcl tab
25 mg
olanzapine for im inj 10 mg
$0(2)
PA
$0(2)
PA
$0(1)
olanzapine orally disintegrating tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
olanzapine tab 2.5 mg
$0(1)
olanzapine tab 5 mg
$0(1)
$0(1)
olanzapine tab 10 mg
$0(1)
$0(1)
$0(1)
ORAP - pimozide tab 1 mg
$0(2)
ORAP - pimozide tab 2 mg
$0(2)
paliperidone tab sr 24hr 1.5 mg
$0(1)
paliperidone tab sr 24hr 3 mg
$0(1)
$0(1)
$0(1)
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
45
2016
pimozide tab 1 mg
de copago)
uso
$0(1)
pimozide tab 2 mg
$0(1)
prochlorperazine edisylate inj 5 mg/ml
$0(1)
$0(1)
$0(1)
prochlorperazine suppos 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
RISPERDAL CONSTA - risperidone microspheres for inj
12.5 mg
25 mg
37.5 mg
50 mg
risperidone orally disintegrating tab 0.25 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
risperidone orally disintegrating tab 1 mg
$0(1)
$0(1)
$0(1)
$0(1)
risperidone soln 1 mg/ml
$0(1)
risperidone tab 0.25 mg
$0(1)
$0(1)
risperidone tab 1 mg
$0(1)
$0(1)
$0(1)
$0(1)
46
2016
SAPHRIS - asenapine maleate sl tab 2.5 mg
de copago)
uso
$0(2)
SAPHRIS - asenapine maleate sl tab 5 mg
$0(2)
SAPHRIS - asenapine maleate sl tab 10 mg
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
thioridazine hcl tab 10 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
thiothixene cap 1 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
trifluoperazine hcl tab 1 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
VERSACLOZ - clozapine susp 50 mg/ml
$0(2)
VRAYLAR - cariprazine hcl cap therapy pack 1.5 mg (1) &
3 mg (6)
VRAYLAR - cariprazine hcl cap 1.5 mg
$0(2)
$0(2)
VRAYLAR - cariprazine hcl cap 3 mg
$0(2)
$0(2)
$0(2)
ziprasidone hcl cap 20 mg
$0(1)
$0(1)
$0(1)
$0(1)
ZYPREXA RELPREVV - olanzapine pamoate for extended
rel im susp 210 mg
rel im susp 300 mg
rel im susp 405 mg
Agentes antiespasmódicos
baclofen tab 10 mg
$0(2)
$0(2)
$0(2)
PA, QL (1 vial/28 days)
$0(1)
47
2016
baclofen tab 20 mg
de copago)
uso
$0(1)
dantrolene sodium cap 25 mg
$0(1)
$0(1)
$0(1)
tizanidine hcl cap 2 mg
$0(1)
$0(1)
$0(1)
tizanidine hcl tab 2 mg
$0(1)
tizanidine hcl tab 4 mg
Medicamentos antivirales
abacavir sulfate tab 300 mg
$0(1)
$0(1)
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg
acyclovir cap 200 mg
$0(1)
acyclovir sodium for inj 500 mg
$0(1)
BD
acyclovir sodium iv soln 50 mg/ml
$0(1)
BD
acyclovir susp 200 mg/5ml
$0(1)
acyclovir tab 400 mg
$0(1)
acyclovir tab 800 mg
$0(1)
adefovir dipivoxil tab 10 mg
$0(1)
AMANTADINE HCL - amantadine hcl tab 100 mg
$0(2)
amantadine hcl cap 100 mg
$0(1)
amantadine hcl syrup 50 mg/5ml
$0(1)
APTIVUS - tipranavir cap 250 mg
$0(2)
APTIVUS - tipranavir oral soln 100 mg/ml
$0(2)
ATRIPLA - efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg
BARACLUDE - entecavir oral soln 0.05 mg/ml
$0(2)
cidofovir iv inj 75 mg/ml
$0(1)
COMPLERA - emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg
CRIXIVAN - indinavir sulfate cap 200 mg
$0(2)
$0(1)
CRIXIVAN - indinavir sulfate cap 400 mg
$0(1)
DAKLINZA - daclatasvir dihydrochloride tab 30 mg
$0(2)
PA
DAKLINZA - daclatasvir dihydrochloride tab 60 mg
$0(2)
PA
didanosine delayed release capsule 125 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
48
2016
EDURANT - rilpivirine hcl tab 25 mg
de copago)
uso
$0(2)
EMTRIVA - emtricitabine caps 200 mg
$0(2)
EMTRIVA - emtricitabine soln 10 mg/ml
$0(2)
entecavir tab 0.5 mg
$0(1)
entecavir tab 1 mg
$0(1)
EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv)
$0(1)
EPZICOM - abacavir sulfate-lamivudine tab 600-300 mg
$0(2)
EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg
$0(2)
famciclovir tab 125 mg
$0(1)
$0(1)
$0(1)
FUZEON - enfuvirtide for inj 90 mg
$0(2)
QL (60 vials/30 days)
ganciclovir sodium for inj 500 mg
$0(1)
BD
GENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg
HARVONI - ledipasvir-sofosbuvir tab 90-400 mg
$0(2)
$0(2)
PA
INTELENCE - etravirine tab 25 mg
$0(2)
$0(2)
$0(2)
INTRON A - interferon alfa-2b inj 6000000 unit/ml
$0(2)
INTRON A - interferon alfa-2b inj 10000000 unit/ml
$0(2)
INTRON A - interferon alfa-2b for inj 10000000 unit
$0(2)
$0(2)
$0(2)
INTRON A W/DILUENT - interferon alfa-2b for inj
10000000 unit
18000000 unit
50000000 unit
INVIRASE - saquinavir mesylate cap 200 mg
$0(2)
$0(2)
INVIRASE - saquinavir mesylate tab 500 mg
$0(2)
ISENTRESS - raltegravir potassium tab 400 mg
$0(2)
ISENTRESS - raltegravir potassium packet for susp
100 mg
ISENTRESS - raltegravir potassium chew tab 25 mg
$0(2)
QL (60 packets/30 days)
$0(1)
ISENTRESS - raltegravir potassium chew tab 100 mg
$0(1)
KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml)
$0(2)
$0(2)
$0(2)
49
2016
KALETRA - lopinavir-ritonavir tab 100-25 mg
de copago)
uso
$0(2)
KALETRA - lopinavir-ritonavir tab 200-50 mg
$0(2)
lamivudine oral soln 10 mg/ml
$0(1)
lamivudine tab 100 mg (hbv)
$0(1)
lamivudine tab 150 mg
$0(1)
lamivudine tab 300 mg
$0(1)
lamivudine-zidovudine tab 150-300 mg
$0(1)
LEXIVA - fosamprenavir calcium tab 700 mg
$0(2)
LEXIVA - fosamprenavir calcium susp 50 mg/ml
$0(2)
NEVIRAPINE - nevirapine susp 50 mg/5ml
$0(2)
nevirapine tab sr 24hr 100 mg
$0(1)
nevirapine tab sr 24hr 400 mg
$0(1)
nevirapine tab 200 mg
$0(1)
NORVIR - ritonavir cap 100 mg
$0(2)
NORVIR - ritonavir tab 100 mg
$0(2)
NORVIR - ritonavir oral soln 80 mg/ml
$0(2)
OLYSIO - simeprevir sodium cap 150 mg
$0(2)
PA
PEG-INTRON - peginterferon alfa-2b for inj kit
50 mcg/0.5ml
80 mcg/0.5ml
120 mcg/0.5ml
150 mcg/0.5ml
PEG-INTRON REDIPEN - peginterferon alfa-2b for inj kit
50 mcg/0.5ml
80 mcg/0.5ml
120 mcg/0.5ml
150 mcg/0.5ml
PEG-INTRON REDIPEN PAK 4 - peginterferon alfa-2b for
inj kit 50 mcg/0.5ml
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
50
2016
PEGASYS - peginterferon alfa-2a inj 180 mcg/ml
de copago)
uso
$0(2)
PA
PEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml
$0(2)
PA
PEGASYS PROCLICK - peginterferon alfa-2a inj
135 mcg/0.5ml
PEGASYS PROCLICK - peginterferon alfa-2a inj
180 mcg/0.5ml
PREZCOBIX - darunavir-cobicistat tab 800-150 mg
$0(2)
PA
$0(2)
PA
$0(2)
PREZISTA - darunavir ethanolate susp 100 mg/ml
$0(2)
PREZISTA - darunavir ethanolate tab 75 mg
$0(2)
$0(2)
$0(2)
$0(2)
REBETOL - ribavirin soln 40 mg/ml
$0(2)
RESCRIPTOR - delavirdine mesylate tab 100 mg
$0(2)
RESCRIPTOR - delavirdine mesylate tab 200 mg
$0(2)
RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml
$0(2)
REYATAZ - atazanavir sulfate oral powder packet 50 mg
$0(2)
REYATAZ - atazanavir sulfate cap 150 mg
$0(2)
$0(2)
$0(2)
RIBASPHERE - ribavirin tab 400 mg
$0(2)
RIBASPHERE - ribavirin tab 600 mg
$0(2)
RIBASPHERE RIBAPAK - ribavirin tab 400 mg
$0(2)
RIBASPHERE RIBAPAK - ribavirin tab 600 mg
$0(2)
ribavirin cap 200 mg
$0(1)
ribavirin tab 200 mg
$0(1)
rimantadine hydrochloride tab 100 mg
$0(1)
SELZENTRY - maraviroc tab 150 mg
$0(2)
SELZENTRY - maraviroc tab 300 mg
$0(2)
SOVALDI - sofosbuvir tab 400 mg
$0(2)
PA
stavudine cap 15 mg
$0(1)
stavudine cap 20 mg
$0(1)
stavudine cap 30 mg
$0(1)
stavudine cap 40 mg
$0(1)
stavudine for oral soln 1 mg/ml
$0(1)
STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg
SUSTIVA - efavirenz tab 600 mg
$0(2)
$0(2)
SUSTIVA - efavirenz cap 50 mg
$0(2)
51
2016
SUSTIVA - efavirenz cap 200 mg
de copago)
uso
$0(2)
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
TAMIFLU - oseltamivir phosphate for susp 6 mg/ml
$0(2)
TAMIFLU - oseltamivir phosphate cap 30 mg
$0(2)
$0(2)
$0(2)
TECHNIVIE - ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg
TIVICAY - dolutegravir sodium tab 50 mg
$0(2)
PA
$0(2)
TRIUMEQ - abacavir-dolutegravir-lamivudine tab
600-50-300 mg
TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab
200-300 mg
TYBOST - cobicistat tab 150 mg
$0(2)
$0(2)
$0(2)
TYZEKA - telbivudine tab 600 mg
$0(2)
valacyclovir hcl tab 500 mg
$0(1)
valacyclovir hcl tab 1 gm
$0(1)
VALCYTE - valganciclovir hcl for soln 50 mg/ml
$0(2)
valganciclovir hcl tab 450 mg
$0(1)
VIDEX - didanosine for soln 2 gm
$0(2)
VIDEX - didanosine for soln 4 gm
$0(2)
VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg
VIRACEPT - nelfinavir mesylate tab 250 mg
$0(2)
PA
$0(2)
VIRACEPT - nelfinavir mesylate tab 625 mg
$0(2)
VIRAMUNE - nevirapine susp 50 mg/5ml
$0(2)
VIRAMUNE XR - nevirapine tab sr 24hr 100 mg
$0(2)
VIRAZOLE - ribavirin for inhal soln 6 gm
$0(2)
VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/
gm
VIREAD - tenofovir disoproxil fumarate tab 150 mg
$0(2)
QL (240 grams/30 days)
$0(2)
$0(2)
$0(2)
$0(2)
VITEKTA - elvitegravir tab 85 mg
$0(2)
52
2016
VITEKTA - elvitegravir tab 150 mg
de copago)
uso
$0(2)
ZEPATIER - elbasvir-grazoprevir tab 50-100 mg
$0(2)
PA
ZIAGEN - abacavir sulfate soln 20 mg/ml
$0(2)
zidovudine cap 100 mg
$0(1)
zidovudine syrup 10 mg/ml
$0(1)
zidovudine tab 300 mg
Medicamentos ansiolíticos
buspirone hcl tab 5 mg
$0(1)
buspirone hcl tab 7.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
clonazepam tab 0.5 mg
$0(1)
clonazepam tab 1 mg
$0(1)
clonazepam tab 2 mg
$0(1)
$0(1)
$0(1)
clorazepate dipotassium tab 15 mg
$0(1)
DIAZEPAM - diazepam oral soln 1 mg/ml
$0(2)
diazepam conc 5 mg/ml
$0(1)
diazepam tab 2 mg
$0(1)
diazepam tab 5 mg
$0(1)
diazepam tab 10 mg
$0(1)
DOXEPIN HCL - doxepin hcl cap 75 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
doxepin hcl conc 10 mg/ml#
$0(2)
PA
$0(1)
$0(1)
$0(1)
$0(1)
53
2016
escitalopram oxalate soln 5 mg/5ml
de copago)
uso
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
lorazepam tab 0.5 mg
$0(1)
lorazepam tab 1 mg
$0(1)
lorazepam tab 2 mg
$0(1)
$0(1)
paroxetine hcl tab sr 24hr 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
PAXIL - paroxetine hcl oral susp 10 mg/5ml
$0(2)
sertraline hcl oral conc 20 mg/ml
$0(1)
$0(1)
$0(1)
$0(1)
venlafaxine hcl cap sr 24hr 37.5 mg
$0(1)
$0(1)
$0(1)
venlafaxine hcl tab sr 24hr 37.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
venlafaxine hcl tab 37.5 mg
$0(1)
$0(1)
$0(1)
Agentes bipolares
susp 300 mg
$0(1)
$0(2)
PA, QL (1 syringe
or vial/30 days)
54
2016
de copago)
uso
$0(2)
PA, QL (1 syringe
susp 400 mg
or vial/30 days)
10 mg
15 mg
$0(2)
$0(2)
$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)
EQUETRO - carbamazepine cap sr 12hr 100 mg
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
LITHIUM - lithium oral solution 8 meq/5ml
$0(2)
lithium carbonate cap 150 mg
$0(1)
$0(1)
$0(1)
lithium carbonate tab cr 300 mg
$0(1)
lithium carbonate tab cr 450 mg
$0(1)
55
2016
lithium carbonate tab 300 mg
de copago)
uso
$0(1)
olanzapine for im inj 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
olanzapine tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
12.5 mg
25 mg
37.5 mg
50 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
risperidone soln 1 mg/ml
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
56
2016
de copago)
uso
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
valproic acid cap 250 mg
$0(1)
VRAYLAR - cariprazine hcl cap therapy pack 1.5 mg (1) &
3 mg (6)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
Reguladores de la glucosa en sangre
acarbose tab 25 mg
$0(1)
$0(1)
acarbose tab 50 mg
$0(1)
acarbose tab 100 mg
$0(1)
ALCOHOL SWABS
$0(1)
BYDUREON - exenatide extended release for susp peninjector 2 mg
BYDUREON - exenatide for inj extended release susp
2 mg
CYCLOSET - bromocriptine mesylate tab 0.8 mg
$0(1)
$0(1)
$0(2)
GAUZE PADS 2" X 2"
$0(1)
glimepiride tab 1 mg
$0(1)
$0(1)
$0(1)
glipizide tab sr 24hr 2.5 mg
$0(1)
glipizide tab sr 24hr 5 mg
$0(1)
glipizide tab sr 24hr 10 mg
$0(1)
glipizide tab 5 mg
$0(1)
glipizide tab 10 mg
$0(1)
glipizide-metformin hcl tab 2.5-250 mg
$0(1)
glipizide-metformin hcl tab 2.5-500 mg
$0(1)
glipizide-metformin hcl tab 5-500 mg
$0(1)
GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg
$0(1)
57
2016
de copago)
uso
GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit
$0(1)
1 mg
GLUCOSE - glucose chew tab 4 gm
$0(3)
MC
HUMALOG - insulin lispro (human) soln cartridge 100 unit/
ml
HUMALOG - insulin lispro (human) inj 100 unit/ml
$0(1)
HUMALOG KWIKPEN - insulin lispro (human) soln peninjector 100 unit/ml
HUMALOG KWIKPEN - insulin lispro (human) soln peninjector 200 unit/ml
HUMALOG MIX 50/50 - insulin lispro prot & lispro (human)
inj 100 unit/ml (50-50)
HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50)
HUMALOG MIX 75/25 - insulin lispro prot & lispro (human)
inj 100 unit/ml (75-25)
HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25)
HUMULIN N - insulin nph (human) (isophane) inj 100 unit/
ml
HUMULIN N KWIKPEN - insulin nph (human) (isophane)
susp pen-injector 100 unit/ml
HUMULIN R - insulin regular (human) inj 100 unit/ml
$0(1)
HUMULIN R U-500 (CONCENTRATE) - insulin regular
(human) inj 500 unit/ml
HUMULIN R U-500 KWIKPEN - insulin regular (human)
soln pen-injector 500 unit/ml
HUMULIN 70/30 - insulin nph isophane & regular human inj
100 unit/ml (70-30)
HUMULIN 70/30 KWIKPEN - insulin nph & regular susp
pen-inj 100 unit/ml (70-30)
INSTA-GLUCOSE - glucose gel 77.4%
$0(1)
INSULIN INJECTION DEVICE
$0(1)
INSULIN SYRINGE/NEEDLE
$0(1)
INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg
$0(1)
$0(1)
$0(1)
INVOKAMET - canagliflozin-metformin hcl tab
150-1000 mg
INVOKANA - canagliflozin tab 100 mg
$0(1)
$0(1)
INVOKANA - canagliflozin tab 300 mg
$0(1)
JANUMET - sitagliptin-metformin hcl tab 50-500 mg
$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(3)
MC
58
2016
JANUMET - sitagliptin-metformin hcl tab 50-1000 mg
de copago)
uso
$0(1)
JANUMET XR - sitagliptin-metformin hcl tab sr 24hr
50-500 mg
50-1000 mg
100-1000 mg
JANUVIA - sitagliptin phosphate tab 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
JARDIANCE - empagliflozin tab 10 mg
$0(2)
JARDIANCE - empagliflozin tab 25 mg
$0(2)
JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg
$0(2)
$0(2)
$0(2)
KOMBIGLYZE XR - saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg
5-500 mg
5-1000 mg
LANTUS - insulin glargine inj 100 unit/ml
$0(1)
$0(1)
$0(1)
LANTUS SOLOSTAR - insulin glargine soln pen-injector
100 unit/ml
LEVEMIR - insulin detemir inj 100 unit/ml
$0(1)
LEVEMIR FLEXPEN - insulin detemir soln pen-injector 100
unit/ml
LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector
100 unit/ml
metformin hcl tab sr 24hr 500 mg
$0(1)
$0(1)
metformin hcl tab sr 24hr 750 mg
$0(1)
metformin hcl tab 500 mg
$0(1)
$0(1)
$0(1)
nateglinide tab 60 mg
$0(1)
nateglinide tab 120 mg
$0(1)
ONGLYZA - saxagliptin hcl tab 2.5 mg
$0(1)
ONGLYZA - saxagliptin hcl tab 5 mg
$0(1)
pioglitazone hcl tab 15 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
59
2016
de copago)
uso
$0(1)
pioglitazone hcl-glimepiride tab 30-2 mg
$0(1)
pioglitazone hcl-glimepiride tab 30-4 mg
$0(1)
pioglitazone hcl-metformin hcl tab 15-500 mg
$0(1)
pioglitazone hcl-metformin hcl tab 15-850 mg
$0(1)
PROGLYCEM - diazoxide susp 50 mg/ml
$0(2)
repaglinide tab 0.5 mg
$0(1)
repaglinide tab 1 mg
$0(1)
repaglinide tab 2 mg
$0(1)
SM GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm
$0(3)
MC
SYMLINPEN 120 - pramlintide acetate pen-inj
2700 mcg/2.7ml (1000 mcg/ml)
SYMLINPEN 60 - pramlintide acetate pen-inj
1500 mcg/1.5ml (1000 mcg/ml)
SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg
$0(1)
$0(2)
SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg
$0(2)
SYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg
$0(2)
SYNJARDY - empagliflozin-metformin hcl tab
12.5-1000 mg
TOUJEO SOLOSTAR - insulin glargine soln pen-injector
300 unit/ml
TRADJENTA - linagliptin tab 5 mg
$0(2)
$0(2)
VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml)
WELCHOL - colesevelam hcl tab 625 mg
$0(1)
QL (1 package/30 days)
$0(1)
$0(1)
$0(2)
WELCHOL - colesevelam hcl packet for susp 3.75 gm
$0(2)
Hemoderivados/Modificadores de la sangre/Expansores del volumen sanguíneo
AGGRENOX - aspirin-dipyridamole cap sr 12hr 25-200 mg
$0(2)
anagrelide hcl cap 0.5 mg
$0(1)
anagrelide hcl cap 1 mg
$0(1)
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled
syringe 10 mcg/0.4ml
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
60
2016
de copago)
uso
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
syringe 500 mcg/ml
ARANESP ALBUMIN FREE - darbepoetin alfa soln inj
$0(2)
PA
25 mcg/ml
$0(2)
PA
40 mcg/ml
$0(2)
PA
60 mcg/ml
$0(2)
PA
100 mcg/ml
$0(2)
PA
200 mcg/ml
$0(2)
PA
300 mcg/ml
BRILINTA - ticagrelor tab 60 mg
$0(1)
BRILINTA - ticagrelor tab 90 mg
$0(1)
cilostazol tab 50 mg
$0(1)
cilostazol tab 100 mg
$0(1)
clopidogrel bisulfate tab 75 mg
$0(1)
COUMADIN - warfarin sodium tab 1 mg
$0(2)
$0(2)
COUMADIN - warfarin sodium tab 2.5 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
COUMADIN - warfarin sodium tab 7.5 mg
$0(2)
$0(2)
dipyridamole tab 25 mg#
$0(2)
$0(2)
$0(2)
EFFIENT - prasugrel hcl tab 5 mg
$0(1)
EFFIENT - prasugrel hcl tab 10 mg
$0(1)
ELIQUIS - apixaban tab 2.5 mg
$0(1)
ELIQUIS - apixaban tab 5 mg
$0(1)
61
2016
enoxaparin sodium inj 30 mg/0.3ml
de copago)
uso
$0(1)
QL (30 syringes/90 days)
$0(1)
$0(1)
$0(1)
enoxaparin sodium inj 100 mg/ml
$0(1)
$0(1)
enoxaparin sodium inj 150 mg/ml
$0(1)
enoxaparin sodium inj 300 mg/3ml
$0(1)
EPOGEN - epoetin alfa inj 2000 unit/ml
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
$0(1)
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
$0(1)
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
$0(1)
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
$0(1)
GRANIX - tbo-filgrastim soln prefilled syringe
300 mcg/0.5ml
GRANIX - tbo-filgrastim soln prefilled syringe
480 mcg/0.8ml
heparin sodium (porcine) inj 1000 unit/ml
$0(2)
$0(1)
$0(1)
$0(1)
heparin sodium (porcine) pf inj 5000 unit/0.5ml
$0(1)
heparin sodium (porcine) 40 unit/ml in d5w
$0(1)
LEUKINE - sargramostim lyophilized for inj 250 mcg
$0(2)
MOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml
(20 mg/ml)
NEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml
$0(2)
NEULASTA ONPRO KIT - pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml
PRADAXA - dabigatran etexilate mesylate cap 75 mg
$0(2)
$0(2)
$0(2)
$0(2)
PROCRIT - epoetin alfa inj 2000 unit/ml
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
$0(1)
$0(2)
62
2016
de copago)
uso
$0(2)
PA
$0(2)
PA
$0(2)
PA
PROMACTA - eltrombopag olamine tab 12.5 mg*
$0(2)
PA
PROMACTA - eltrombopag olamine tab 25 mg*
$0(2)
PA
$0(2)
PA
$0(2)
PA
tranexamic acid iv soln 1000 mg/10ml (100 mg/ml)
$0(1)
tranexamic acid tab 650 mg
$0(1)
warfarin sodium tab 1 mg
$0(1)
$0(1)
warfarin sodium tab 2.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
warfarin sodium tab 7.5 mg
$0(1)
$0(1)
XARELTO - rivaroxaban tab 10 mg
$0(1)
$0(1)
$0(1)
XARELTO STARTER PACK - rivaroxaban tab starter
therapy pack 15 mg & 20 mg
ZONTIVITY - vorapaxar sulfate tab 2.08 mg
Agentes cardiovasculares
acebutolol hcl cap 200 mg
$0(1)
acebutolol hcl cap 400 mg
$0(1)
ACETAZOLAMIDE - acetazolamide tab 125 mg
$0(2)
acetazolamide cap sr 12hr 500 mg
$0(1)
acetazolamide tab 250 mg
$0(1)
amiloride & hydrochlorothiazide tab 5-50 mg
$0(1)
amiloride hcl tab 5 mg
$0(1)
amiodarone hcl tab 200 mg
$0(1)
amiodarone hcl tab 400 mg
$0(1)
amlodipine besylate tab 2.5 mg
$0(1)
amlodipine besylate tab 5 mg
$0(1)
amlodipine besylate tab 10 mg
$0(1)
amlodipine besylate-atorvastatin calcium tab 2.5-10 mg
$0(1)
$0(2)
$0(1)
63
2016
de copago)
uso
$0(1)
$0(1)
amlodipine besylate-atorvastatin calcium tab 5-10 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
amlodipine besylate-benazepril hcl cap 2.5-10 mg
$0(1)
amlodipine besylate-benazepril hcl cap 5-10 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
amlodipine besylate-valsartan tab 5-160 mg
$0(1)
$0(1)
$0(1)
$0(1)
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg
$0(1)
$0(1)
10-160-12.5 mg
$0(1)
$0(1)
$0(1)
atenolol & chlorthalidone tab 50-25 mg
$0(1)
atenolol & chlorthalidone tab 100-25 mg
$0(1)
atenolol tab 25 mg
$0(1)
atenolol tab 50 mg
$0(1)
atenolol tab 100 mg
$0(1)
atorvastatin calcium tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
benazepril & hydrochlorothiazide tab 5-6.25 mg
$0(1)
$0(1)
64
2016
de copago)
uso
$0(1)
benazepril & hydrochlorothiazide tab 20-25 mg
$0(1)
benazepril hcl tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
betaxolol hcl tab 10 mg
$0(1)
betaxolol hcl tab 20 mg
$0(1)
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
$0(1)
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
$0(1)
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
$0(1)
bisoprolol fumarate tab 5 mg
$0(1)
bisoprolol fumarate tab 10 mg
$0(1)
bumetanide inj 0.25 mg/ml
$0(1)
bumetanide tab 0.5 mg
$0(1)
bumetanide tab 1 mg
$0(1)
bumetanide tab 2 mg
$0(1)
candesartan cilexetil tab 4 mg
$0(1)
$0(1)
$0(1)
$0(1)
candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg
$0(1)
candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg
$0(1)
candesartan cilexetil-hydrochlorothiazide tab 32-25 mg
$0(1)
captopril tab 12.5 mg
$0(1)
captopril tab 25 mg
$0(1)
captopril tab 50 mg
$0(1)
captopril tab 100 mg
$0(1)
carvedilol tab 3.125 mg
$0(1)
$0(1)
$0(1)
carvedilol tab 25 mg
$0(1)
CHLOROTHIAZIDE - chlorothiazide tab 250 mg
$0(2)
chlorothiazide tab 500 mg
$0(1)
CHLORTHALIDONE - chlorthalidone tab 25 mg
$0(2)
CHLORTHALIDONE - chlorthalidone tab 50 mg
$0(2)
cholestyramine light powder packets 4 gm
$0(1)
cholestyramine light powder 4 gm/dose
$0(1)
65
2016
cholestyramine powder packets 4 gm
de copago)
uso
$0(1)
cholestyramine powder 4 gm/dose
$0(1)
choline fenofibrate cap dr 45 mg
$0(1)
choline fenofibrate cap dr 135 mg
$0(1)
clonidine hcl tab 0.1 mg
$0(1)
$0(1)
$0(1)
clonidine hcl td patch weekly 0.1 mg/24hr
$0(1)
$0(1)
$0(1)
colestipol hcl granule packets 5 gm
$0(1)
colestipol hcl granules 5 gm
$0(1)
colestipol hcl tab 1 gm
$0(1)
CORLANOR - ivabradine hcl tab 5 mg
$0(2)
CORLANOR - ivabradine hcl tab 7.5 mg
$0(2)
CRESTOR - rosuvastatin calcium tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
DEMSER - metyrosine cap 250 mg
$0(2)
DIGOXIN - digoxin oral soln 0.05 mg/ml#
$0(2)
digoxin tab 125 mcg (0.125 mg)#
$0(1)
digoxin tab 250 mcg (0.25 mg)#
$0(2)
diltiazem hcl cap sr 12hr 60 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
diltiazem hcl coated beads cap sr 24hr 120 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
diltiazem hcl coated beads tab sr 24hr 180 mg
$0(1)
$0(1)
$0(1)
$0(1)
66
2016
de copago)
uso
$0(1)
diltiazem hcl extended release beads cap sr 24hr 120 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
diltiazem hcl tab 30 mg
$0(1)
$0(1)
$0(1)
$0(1)
doxazosin mesylate tab 1 mg
$0(1)
$0(1)
$0(1)
$0(1)
enalapril maleate & hydrochlorothiazide tab 5-12.5 mg
$0(1)
enalapril maleate & hydrochlorothiazide tab 10-25 mg
$0(1)
enalapril maleate tab 2.5 mg
$0(1)
enalapril maleate tab 5 mg
$0(1)
$0(1)
$0(1)
eplerenone tab 25 mg
$0(1)
eplerenone tab 50 mg
$0(1)
eprosartan mesylate tab 600 mg
$0(1)
felodipine tab sr 24hr 2.5 mg
$0(1)
felodipine tab sr 24hr 5 mg
$0(1)
felodipine tab sr 24hr 10 mg
$0(1)
fenofibrate micronized cap 67 mg
$0(1)
$0(1)
$0(1)
fenofibrate tab 48 mg
$0(1)
$0(1)
$0(1)
$0(1)
flecainide acetate tab 50 mg
$0(1)
$0(1)
$0(1)
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg
$0(1)
67
2016
fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg
de copago)
uso
$0(1)
fosinopril sodium tab 10 mg
$0(1)
$0(1)
$0(1)
furosemide inj 10 mg/ml
$0(1)
furosemide oral soln 10 mg/ml
$0(1)
furosemide tab 20 mg
$0(1)
$0(1)
$0(1)
gemfibrozil tab 600 mg
$0(1)
hydralazine hcl tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
hydrochlorothiazide cap 12.5 mg
$0(1)
hydrochlorothiazide tab 12.5 mg
$0(1)
hydrochlorothiazide tab 25 mg
$0(1)
hydrochlorothiazide tab 50 mg
$0(1)
indapamide tab 1.25 mg
$0(1)
indapamide tab 2.5 mg
$0(1)
irbesartan tab 75 mg
$0(1)
$0(1)
$0(1)
irbesartan-hydrochlorothiazide tab 150-12.5 mg
$0(1)
irbesartan-hydrochlorothiazide tab 300-12.5 mg
$0(1)
ISOSORBIDE DINITRATE - isosorbide dinitrate tab 30 mg
$0(2)
isosorbide dinitrate tab cr 40 mg
$0(1)
isosorbide dinitrate tab 5 mg
$0(1)
$0(1)
$0(1)
isosorbide mononitrate tab sr 24hr 30 mg
$0(1)
$0(1)
$0(1)
isosorbide mononitrate tab 10 mg
$0(1)
isosorbide mononitrate tab 20 mg
$0(1)
isradipine cap 2.5 mg
$0(1)
isradipine cap 5 mg
$0(1)
JUXTAPID - lomitapide mesylate cap 5 mg*
$0(2)
PA
68
2016
de copago)
uso
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
KYNAMRO - mipomersen sodium soln prefilled syringe
200 mg/ml*
labetalol hcl tab 100 mg
$0(2)
PA
$0(1)
$0(1)
LIDOCAINE HCL - lidocaine hcl iv inj 10 mg/ml
$0(2)
lisinopril & hydrochlorothiazide tab 10-12.5 mg
$0(1)
lisinopril & hydrochlorothiazide tab 20-12.5 mg
$0(1)
lisinopril & hydrochlorothiazide tab 20-25 mg
$0(1)
lisinopril tab 2.5 mg
$0(1)
lisinopril tab 5 mg
$0(1)
lisinopril tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
LIVALO - pitavastatin calcium tab 1 mg
$0(2)
$0(2)
$0(2)
losartan potassium & hydrochlorothiazide tab 50-12.5 mg
$0(1)
losartan potassium & hydrochlorothiazide tab 100-12.5 mg
$0(1)
losartan potassium & hydrochlorothiazide tab 100-25 mg
$0(1)
losartan potassium tab 25 mg
$0(1)
$0(1)
$0(1)
lovastatin tab 10 mg
$0(1)
$0(1)
$0(1)
methazolamide tab 25 mg
$0(1)
methazolamide tab 50 mg
$0(1)
metolazone tab 2.5 mg
$0(1)
metolazone tab 5 mg
$0(1)
metolazone tab 10 mg
$0(1)
metoprolol & hydrochlorothiazide tab 50-25 mg
$0(1)
$0(1)
69
2016
metoprolol & hydrochlorothiazide tab 100-25 mg
de copago)
uso
$0(1)
metoprolol succinate tab sr 24hr 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
metoprolol tartrate tab 25 mg
$0(1)
$0(1)
$0(1)
mexiletine hcl cap 150 mg
$0(1)
$0(1)
$0(1)
midodrine hcl tab 2.5 mg
$0(1)
midodrine hcl tab 5 mg
$0(1)
midodrine hcl tab 10 mg
$0(1)
minoxidil tab 2.5 mg
$0(1)
minoxidil tab 10 mg
$0(1)
moexipril hcl tab 7.5 mg
$0(1)
moexipril hcl tab 15 mg
$0(1)
moexipril-hydrochlorothiazide tab 7.5-12.5 mg
$0(1)
moexipril-hydrochlorothiazide tab 15-12.5 mg
$0(1)
moexipril-hydrochlorothiazide tab 15-25 mg
$0(1)
MULTAQ - dronedarone hcl tab 400 mg
$0(1)
nadolol tab 20 mg
$0(1)
nadolol tab 40 mg
$0(1)
nadolol tab 80 mg
$0(1)
niacin cap cr 250 mg
$0(3)
MC
niacin cap cr 500 mg
$0(3)
MC
niacin tab cr 500 mg
$0(1)
$0(1)
$0(1)
$0(3)
MC
$0(3)
MC
niacin tab 50 mg
$0(3)
MC
niacin tab 100 mg
$0(3)
MC
niacin tab 250 mg
$0(3)
MC
niacin tab 500 mg
$0(3)
MC
NIACIN TR - niacin tab cr 1000 mg
$0(3)
MC
nicardipine hcl cap 20 mg
$0(1)
70
2016
nicardipine hcl cap 30 mg
de copago)
uso
$0(1)
nifedipine tab sr 24hr 30 mg
$0(1)
$0(1)
$0(1)
nifedipine tab sr 24hr osmotic release 30 mg
$0(1)
$0(1)
$0(1)
NISOLDIPINE ER - nisoldipine tab sr 24hr 25.5 mg
$0(2)
nisoldipine tab sr 24hr 8.5 mg
$0(1)
nisoldipine tab sr 24hr 17 mg
$0(1)
nisoldipine tab sr 24hr 34 mg
$0(1)
NITRO-BID - nitroglycerin oint 2%
$0(2)
nitroglycerin td patch 24hr 0.1 mg/hr
$0(1)
$0(1)
$0(1)
$0(1)
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
$0(1)
NITROSTAT - nitroglycerin sl tab 0.3 mg
$0(1)
$0(1)
$0(1)
NORTHERA - droxidopa cap 100 mg
$0(2)
PA
$0(2)
PA
$0(2)
PA
omega-3-acid ethyl esters cap 1 gm
$0(1)
pentoxifylline tab cr 400 mg
$0(1)
perindopril erbumine tab 2 mg
$0(1)
$0(1)
$0(1)
phenoxybenzamine hcl cap 10 mg
$0(1)
pindolol tab 5 mg
$0(1)
pindolol tab 10 mg
$0(1)
PRALUENT - alirocumab subcutaneous soln pen-injector
75 mg/ml
PRALUENT - alirocumab subcutaneous soln pen-injector
150 mg/ml
PRALUENT - alirocumab subcutaneous soln prefilled
syringe 75 mg/ml
PRALUENT - alirocumab subcutaneous soln prefilled
syringe 150 mg/ml
$0(2)
PA, QL (2 pens/28 days)
$0(2)
$0(2)
PA, QL (2 syringes/28 days)
$0(2)
71
2016
pravastatin sodium tab 10 mg
de copago)
uso
$0(1)
$0(1)
$0(1)
$0(1)
prazosin hcl cap 1 mg
$0(1)
$0(1)
$0(1)
propafenone hcl cap sr 12hr 225 mg
$0(1)
$0(1)
$0(1)
propafenone hcl tab 150 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
propranolol hcl inj 1 mg/ml
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
quinapril hcl tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
quinapril-hydrochlorothiazide tab 10-12.5 mg
$0(1)
quinapril-hydrochlorothiazide tab 20-12.5 mg
$0(1)
quinapril-hydrochlorothiazide tab 20-25 mg
$0(1)
quinidine gluconate tab cr 324 mg
$0(1)
QUINIDINE SULFATE - quinidine sulfate tab 200 mg
$0(2)
quinidine sulfate tab 300 mg
$0(1)
ramipril cap 1.25 mg
$0(1)
ramipril cap 2.5 mg
$0(1)
ramipril cap 5 mg
$0(1)
ramipril cap 10 mg
$0(1)
RANEXA - ranolazine tab sr 12hr 500 mg
$0(1)
72
2016
RANEXA - ranolazine tab sr 12hr 1000 mg
de copago)
uso
$0(1)
REPATHA - evolocumab subcutaneous soln prefilled
syringe 140 mg/ml
REPATHA SURECLICK - evolocumab subcutaneous soln
auto-injector 140 mg/ml
simvastatin tab 5 mg
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
SLO-NIACIN - niacin tab cr 500 mg
$0(3)
MC
sotalol hcl (afib/afl) tab 80 mg
$0(1)
$0(1)
$0(1)
sotalol hcl tab 80 mg
$0(1)
$0(1)
$0(1)
$0(1)
spironolactone & hydrochlorothiazide tab 25-25 mg
$0(1)
spironolactone tab 25 mg
$0(1)
$0(1)
$0(1)
TEKTURNA - aliskiren fumarate tab 150 mg
$0(1)
TEKTURNA - aliskiren fumarate tab 300 mg
$0(1)
TEKTURNA HCT - aliskiren-hydrochlorothiazide tab
150-12.5 mg
150-25 mg
300-12.5 mg
300-25 mg
telmisartan tab 20 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
telmisartan-hydrochlorothiazide tab 40-12.5 mg
$0(1)
telmisartan-hydrochlorothiazide tab 80-12.5 mg
$0(1)
telmisartan-hydrochlorothiazide tab 80-25 mg
$0(1)
terazosin hcl cap 1 mg
$0(1)
73
2016
de copago)
uso
$0(1)
$0(1)
$0(1)
TIKOSYN - dofetilide cap 125 mcg (0.125 mg)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
torsemide tab 5 mg
$0(1)
torsemide tab 10 mg
$0(1)
torsemide tab 20 mg
$0(1)
torsemide tab 100 mg
$0(1)
trandolapril tab 1 mg
$0(1)
$0(1)
$0(1)
triamterene & hydrochlorothiazide cap 37.5-25 mg
$0(1)
triamterene & hydrochlorothiazide tab 37.5-25 mg
$0(1)
triamterene & hydrochlorothiazide tab 75-50 mg
$0(1)
valsartan tab 40 mg
$0(1)
valsartan tab 80 mg
$0(1)
valsartan tab 160 mg
$0(1)
valsartan tab 320 mg
$0(1)
valsartan-hydrochlorothiazide tab 80-12.5 mg
$0(1)
$0(1)
valsartan-hydrochlorothiazide tab 160-25 mg
$0(1)
$0(1)
valsartan-hydrochlorothiazide tab 320-25 mg
$0(1)
VASCEPA - icosapent ethyl cap 1 gm
$0(1)
verapamil hcl cap sr 24hr 100 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
verapamil hcl tab cr 120 mg
$0(1)
$0(1)
74
2016
de copago)
uso
$0(1)
verapamil hcl tab 40 mg
$0(1)
$0(1)
$0(1)
VYTORIN - ezetimibe-simvastatin tab 10-10 mg
$0(1)
$0(1)
$0(1)
$0(1)
WELCHOL - colesevelam hcl tab 625 mg
$0(2)
WELCHOL - colesevelam hcl packet for susp 3.75 gm
$0(2)
ZETIA - ezetimibe tab 10 mg
Agentes del sistema nervioso central
amphetamine-dextroamphetamine cap sr 24hr 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
AMPYRA - dalfampridine tab sr 12hr 10 mg*
$0(2)
PA
AVONEX - interferon beta-1a im prefilled syringe kit
30 mcg/0.5ml
AVONEX - interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)
AVONEX PEN - interferon beta-1a im auto-injector kit
30 mcg/0.5ml
BETASERON - interferon beta-1b for inj kit 0.3 mg
$0(2)
$0(2)
$0(2)
$0(2)
PA, QL (15 vials/
syringes/30 days)
clonidine hcl tab sr 12hr 0.1 mg
$0(1)
COPAXONE - glatiramer acetate soln prefilled syringe
20 mg/ml
COPAXONE - glatiramer acetate soln prefilled syringe
40 mg/ml
dexmethylphenidate hcl tab 2.5 mg
$0(2)
$0(2)
$0(1)
dexmethylphenidate hcl tab 5 mg
$0(1)
dexmethylphenidate hcl tab 10 mg
$0(1)
dextroamphetamine sulfate cap sr 24hr 5 mg
$0(1)
$0(1)
$0(1)
dextroamphetamine sulfate tab 5 mg
$0(1)
75
2016
dextroamphetamine sulfate tab 10 mg
de copago)
uso
$0(1)
$0(1)
$0(1)
$0(1)
Glatopa - glatiramer acetate soln prefilled syringe 20 mg/ml
$0(2)
LYRICA - pregabalin soln 20 mg/ml
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
methylphenidate hcl tab cr 20 mg
$0(1)
methylphenidate hcl tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)
$0(1)
$0(1)
NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap
20-10 mg
PLEGRIDY - peginterferon beta-1a soln pen-injector
125 mcg/0.5ml
PLEGRIDY - peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml
PLEGRIDY STARTER PACK - peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack
PLEGRIDY STARTER PACK - peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack
riluzole tab 50 mg
$0(1)
STRATTERA - atomoxetine hcl cap 10 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
76
2016
medicamento (nivel
de copago)
$0(2)
uso
$0(2)
$0(2)
$0(1)
tetrabenazine tab 25 mg
$0(1)
TYSABRI - natalizumab for iv inj conc 300 mg/15ml*
$0(2)
PA
XENAZINE - tetrabenazine tab 12.5 mg*
$0(2)
XENAZINE - tetrabenazine tab 25 mg*
Agentes dentales y orales
benzocaine dental gel 7.5%
$0(2)
$0(3)
MC
chlorhexidine gluconate soln 0.12%
$0(1)
$0(1)
$0(1)
doxycycline hyclate for inj 100 mg
$0(1)
$0(1)
$0(1)
KEPIVANCE - palifermin for iv inj 6.25 mg
$0(2)
pilocarpine hcl tab 5 mg
$0(1)
pilocarpine hcl tab 7.5 mg
$0(1)
triamcinolone acetonide dental paste 0.1%
Agentes dermatológicos
acitretin cap 10 mg
$0(1)
acitretin cap 17.5 mg
$0(1)
acitretin cap 25 mg
$0(1)
acyclovir oint 5%
$0(1)
alclometasone dipropionate cream 0.05%
$0(1)
alclometasone dipropionate oint 0.05%
$0(1)
ALOE VESTA ANTIFUNGAL - miconazole nitrate ointment
2%
ALOE VESTA SKIN CONDITIONER - dimethicone lotion
3%
aluminum sulfate & calcium acetate powd pack
$0(3)
MC
$0(3)
MC
$0(3)
MC
AZELEX - azelaic acid cream 20%
$0(2)
bacitracin oint 500 unit/gm
$0(3)
MC
bacitracin zinc oint 500 unit/gm
$0(3)
MC
benzoyl peroxide-erythromycin gel 5-3%
$0(1)
TECFIDERA - dimethyl fumarate capsule delayed release
120 mg
TECFIDERA - dimethyl fumarate capsule delayed release
240 mg
TECFIDERA STARTER PACK - dimethyl fumarate capsule
dr starter pack 120 mg & 240 mg
tetrabenazine tab 12.5 mg
$0(1)
77
2016
betamethasone dipropionate augmented cream 0.05%
de copago)
uso
$0(1)
betamethasone dipropionate augmented gel 0.05%
$0(1)
betamethasone dipropionate augmented lotion 0.05%
$0(1)
betamethasone dipropionate augmented oint 0.05%
$0(1)
betamethasone dipropionate cream 0.05%
$0(1)
betamethasone dipropionate lotion 0.05%
$0(1)
betamethasone dipropionate oint 0.05%
$0(1)
betamethasone valerate cream 0.1%
$0(1)
betamethasone valerate lotion 0.1%
$0(1)
betamethasone valerate oint 0.1%
$0(1)
BOUDREAUXS BUTT PASTE - zinc oxide oint 16%
$0(3)
MC
CALAMINE - calamine lotion
$0(3)
MC
calcipotriene cream 0.005%
$0(1)
calcipotriene oint 0.005%
$0(1)
calcipotriene soln 0.005% (50 mcg/ml)
$0(1)
capsaicin cream 0.025%
$0(3)
MC
capsaicin cream 0.075%
$0(3)
MC
CAPZASIN-P - capsaicin cream 0.035%
$0(3)
MC
CARAC - fluorouracil cream 0.5%
$0(2)
chlorhexidine gluconate liquid 4%
$0(3)
ciclopirox gel 0.77%
$0(1)
ciclopirox olamine cream 0.77%
$0(1)
ciclopirox olamine susp 0.77%
$0(1)
ciclopirox shampoo 1%
$0(1)
ciclopirox solution 8%
$0(1)
clindamycin phosphate gel 1%
$0(1)
clindamycin phosphate lotion 1%
$0(1)
clindamycin phosphate soln 1%
$0(1)
clindamycin phosphate swab 1%
$0(1)
clindamycin phosphate-benzoyl peroxide gel 1-5%
$0(1)
clobetasol propionate cream 0.05%
$0(1)
clobetasol propionate emollient base cream 0.05%
$0(1)
clobetasol propionate gel 0.05%
$0(1)
clobetasol propionate oint 0.05%
$0(1)
clobetasol propionate soln 0.05%
$0(1)
clotrimazole cream 1%
$0(1)
clotrimazole w/ betamethasone cream 1-0.05%
$0(1)
clotrimazole w/ betamethasone lotion 1-0.05%
$0(1)
MC
78
2016
DENAVIR - penciclovir cream 1%
de copago)
uso
$0(2)
desonide cream 0.05%
$0(1)
desonide lotion 0.05%
$0(1)
desonide oint 0.05%
$0(1)
DESOXIMETASONE - desoximetasone cream 0.05%
$0(2)
desoximetasone cream 0.25%
$0(1)
desoximetasone gel 0.05%
$0(1)
desoximetasone oint 0.25%
$0(1)
diaper rash products - ointment
$0(3)
MC
dibucaine oint 1%
$0(3)
MC
$0(1)
ST
$0(1)
DIFLORASONE DIACETATE - diflorasone diacetate oint
0.05%
dimethicone lotion 1%
$0(2)
econazole nitrate cream 1%
$0(1)
ELIDEL - pimecrolimus cream 1%
$0(2)
ST
ENCARE - nonoxynol-9 vaginal suppos 100 mg
$0(3)
MC
erythromycin pads 2%
$0(1)
erythromycin soln 2%
$0(1)
FINACEA - azelaic acid foam 15%
$0(2)
FINACEA - azelaic acid gel 15%
$0(2)
fluocinolone acetonide cream 0.01%
$0(1)
fluocinonide cream 0.05%
$0(1)
fluocinonide emulsified base cream 0.05%
$0(1)
fluocinonide gel 0.05%
$0(1)
fluocinonide oint 0.05%
$0(1)
fluocinonide soln 0.05%
$0(1)
fluorouracil cream 5%
$0(1)
fluorouracil soln 2%
$0(1)
fluorouracil soln 5%
$0(1)
fluticasone propionate cream 0.05%
$0(1)
fluticasone propionate oint 0.005%
$0(1)
FUNGOID TINCTURE - miconazole nitrate soln 2%
$0(3)
GENTAMICIN SULFATE - gentamicin sulfate cream 0.1%
$0(2)
GENTAMICIN SULFATE - gentamicin sulfate oint 0.1%
$0(2)
halobetasol propionate cream 0.05%
$0(1)
halobetasol propionate oint 0.05%
$0(1)
$0(3)
MC
MC
79
2016
HEMORRHOIDAL - rectal protectant-emollient ointments
de copago)
uso
$0(3)
MC
hydrocortisone acetate cream 1%
$0(3)
MC
hydrocortisone butyrate cream 0.1%
$0(1)
hydrocortisone butyrate oint 0.1%
$0(1)
hydrocortisone butyrate soln 0.1%
$0(1)
hydrocortisone cream 0.5%
$0(3)
hydrocortisone cream 1%
$0(1)
hydrocortisone cream 1%
$0(3)
hydrocortisone cream 2.5%
$0(1)
hydrocortisone lotion 1%
$0(3)
hydrocortisone lotion 2.5%
$0(1)
hydrocortisone oint 0.5%
$0(3)
hydrocortisone oint 1%
$0(1)
hydrocortisone oint 2.5%
$0(1)
hydrocortisone valerate cream 0.2%
$0(1)
hydrocortisone valerate oint 0.2%
$0(1)
hydrocortisone-aloe vera cream 1%
$0(3)
MC
imiquimod cream 5%
$0(1)
PA
isotretinoin cap 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
ketoconazole cream 2%
$0(1)
ketoconazole shampoo 2%
$0(1)
lactic acid (ammonium lactate) cream 12%
$0(1)
lactic acid (ammonium lactate) lotion 12%
$0(1)
LAMISIL AT - terbinafine hcl cream 1%
$0(3)
MC
lubricant gels - gel
$0(3)
MC
methoxsalen rapid cap 10 mg
$0(1)
metronidazole cream 0.75%
$0(1)
metronidazole gel 0.75%
$0(1)
metronidazole gel 1%
$0(1)
metronidazole lotion 0.75%
$0(1)
miconazole nitrate aerosol pow 2%
$0(3)
MC
miconazole nitrate cream 2%
$0(3)
MC
miconazole nitrate powder 2%
$0(3)
MC
mometasone furoate cream 0.1%
$0(1)
mometasone furoate oint 0.1%
$0(1)
MC
MC
MC
MC
80
2016
mometasone furoate solution 0.1% (lotion)
de copago)
uso
$0(1)
mupirocin oint 2%
$0(1)
neomycin-bacitracin-polymyxin-pramoxine oint 1%
$0(3)
MC
NEOSPORIN ORIGINAL - neomycin-bacitracin-polymyxin
oint
NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH
- neomycin-polymyxin w/ pramoxine cream 1%
NUPERCAINAL - dibucaine rectal ointment 1%
$0(3)
MC
$0(3)
MC
$0(3)
MC
nystatin cream 100000 unit/gm
$0(1)
nystatin oint 100000 unit/gm
$0(1)
nystatin topical powder
$0(1)
nystatin-triamcinolone cream 100000-0.1 unit/gm-%
$0(1)
nystatin-triamcinolone oint 100000-0.1 unit/gm-%
$0(1)
OPTIONS CONCEPTROL VAGINAL CONTRACEPTIVE nonoxynol-9 gel 4%
OPTIONS GYNOL II VAGINAL CONTRACEPTIVE nonoxynol-9 gel 3%
ORACEA - doxycycline cap delayed release 40 mg
$0(3)
MC
$0(3)
MC
phenylephrine in hard fat rectal suppos 0.25%
$0(3)
MC
PICATO - ingenol mebutate gel 0.015%
$0(1)
QL (3 tubes/30 days)
PICATO - ingenol mebutate gel 0.05%
$0(1)
QL (2 tubes/30 days)
podofilox soln 0.5%
$0(1)
POLYSPORIN - bacitracin-polymyxin b oint
$0(3)
MC
povidone-iodine oint 10%
$0(3)
MC
povidone-iodine soln 7.5%
$0(3)
MC
povidone-iodine soln 10%
$0(3)
MC
povidone-iodine swabs 10%
$0(3)
MC
prednicarbate cream 0.1%
$0(1)
prednicarbate oint 0.1%
$0(1)
PREMIUM CONDOMS LUBRICATED - condoms latex
lubricated
PROSHIELD PLUS SKIN PROTECTANT - dimethicone
cream 1%
PROSHIELD PROTECTIVE HAND CREAM - skin
protectants misc - cream
pyreth-piperonyl butox sham-permeth aero-nit remover gel
kit
pyrethrins-piperonyl butoxide liq 0.33-4%
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
pyrethrins-piperonyl butoxide shampoo 0.33-4%
$0(3)
MC
SANTYL - collagenase oint 250 unit/gm
$0(1)
$0(2)
81
2016
SEA-CLENS WOUND CLEANSER - wound cleansers liquid
selenium sulfide lotion 2.5%
de copago)
uso
$0(3)
MC
$0(1)
SHUR-SEAL - nonoxynol-9 gel 2%
$0(3)
MC
silver sulfadiazine cream 1%
$0(1)
skin protectants misc - ointment
$0(3)
MC
STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml
$0(2)
PA
STELARA - ustekinumab soln prefilled syringe 90 mg/ml
$0(2)
PA
sulfacetamide sodium lotion 10%
$0(1)
SWEEN CREAM - vitamins a & d cream
$0(3)
MC
tacrolimus oint 0.03%
$0(1)
ST
tacrolimus oint 0.1%
$0(1)
ST
TAZORAC - tazarotene cream 0.05%
$0(2)
TAZORAC - tazarotene cream 0.1%
$0(2)
TAZORAC - tazarotene gel 0.05%
$0(2)
TAZORAC - tazarotene gel 0.1%
$0(2)
tretinoin cream 0.025%
$0(1)
$0(1)
$0(1)
tretinoin gel 0.01%
$0(1)
tretinoin gel 0.025%
$0(1)
TRIAMCINOLONE ACETONIDE - triamcinolone acetonide
oint 0.5%
triamcinolone acetonide cream 0.025%
$0(2)
$0(1)
$0(1)
triamcinolone acetonide lotion 0.025%
$0(1)
triamcinolone acetonide lotion 0.1%
$0(1)
triamcinolone acetonide oint 0.025%
$0(1)
triamcinolone acetonide oint 0.1%
$0(1)
TRIPLE PASTE - zinc oxide oint 12.8%
$0(3)
MC
TRIXAICIN - capsicum oleoresin cream 0.025%
$0(3)
MC
TROJAN - condoms latex non-lubricated
$0(3)
MC
UVADEX - methoxsalen soln 20 mcg/ml
$0(2)
VALCHLOR - mechlorethamine hcl gel 0.016%*
$0(2)
VCF VAGINAL CONTRACEPTIVE FILM - nonoxynol-9 film
28%
VCF VAGINAL CONTRACEPTIVE FOAM - nonoxynol-9
foam 12.5%
$0(3)
MC
$0(3)
MC
$0(1)
82
2016
vitamins a & d oint
de copago)
uso
$0(3)
MC
$0(2)
ST
zinc oxide oint 20%
$0(3)
MC
zinc oxide oint 40%
$0(3)
MC
zinc oxide oint 10%
Sutitutos/modificadores de enzimas
ADAGEN - pegademase bovine inj 250 unit/ml*
$0(3)
MC
ALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml
(500 unit/5ml)*
BUPHENYL - sodium phenylbutyrate tab 500 mg
$0(2)
CEREZYME - imiglucerase for inj 400 unit*
$0(2)
CREON - pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit
6000-19000-30000 unit
12000-38000-60000 unit
24000-76000-120000 unit
36000-114000-180000 unit
CYSTADANE - betaine powder for oral solution
$0(1)
CYSTAGON - cysteamine bitartrate cap 50 mg*
$0(2)
CYSTAGON - cysteamine bitartrate cap 150 mg*
$0(2)
ELAPRASE - idursulfase soln for iv infusion 6 mg/3ml
(2 mg/ml)*
ELELYSO - taliglucerase alfa for inj 200 unit*
$0(2)
FABRAZYME - agalsidase beta for iv soln 5 mg*
$0(2)
FABRAZYME - agalsidase beta for iv soln 35 mg*
$0(2)
KUVAN - sapropterin dihydrochloride soluble tab 100 mg*
$0(2)
PA
KUVAN - sapropterin dihydrochloride powder packet
100 mg*
KUVAN - sapropterin dihydrochloride powder packet
500 mg*
MYOZYME - alglucosidase alfa for iv soln 50 mg*
$0(2)
PA
$0(2)
PA
NAGLAZYME - galsulfase soln for iv infusion 1 mg/ml*
$0(2)
ORFADIN - nitisinone cap 2 mg*
$0(2)
$0(2)
$0(2)
sodium phenylbutyrate oral powder 3 gm/teaspoonful
$0(1)
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
$0(2)
$0(2)
83
2016
de copago)
uso
STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml*
$0(2)
$0(2)
STRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml*
$0(2)
$0(2)
VIOKACE - pancrelipase (lip-prot-amyl) tab
10440-39150-39150 unit
VIOKACE - pancrelipase (lip-prot-amyl) tab
20880-78300-78300 unit
VPRIV - velaglucerase alfa for inj 400 unit
$0(2)
ZAVESCA - miglustat cap 100 mg*
$0(2)
ZENPEP - pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit
5000-17000-27000 unit
10000-34000-55000 unit
15000-51000-82000 unit
20000-68000-109000 unit
25000-85000-136000 unit
40000-136000-218000 unit
Agentes gastrointestinales
alosetron hcl tab 0.5 mg
$0(1)
alosetron hcl tab 1 mg
$0(1)
alum & mag hydroxide-simethicone susp
200-200-20 mg/5ml
ALUMINUM HYDROXIDE - aluminum hydroxide gel susp
320 mg/5ml
AMITIZA - lubiprostone cap 8 mcg
$0(3)
MC
$0(3)
MC
$0(1)
PA
AMITIZA - lubiprostone cap 24 mcg
$0(1)
PA
BENEFIBER - wheat dextrin oral powder
$0(3)
MC
bisacodyl suppos 10 mg
$0(3)
MC
bisacodyl tab delayed release 5 mg
$0(3)
MC
bismuth subsalicylate chew tab 262 mg
$0(3)
MC
bismuth subsalicylate susp 262 mg/15ml
$0(3)
MC
bismuth subsalicylate susp 525 mg/15ml
$0(3)
MC
calcium carbonate (antacid) chew tab 500 mg
$0(3)
MC
calcium carbonate (antacid) chew tab 750 mg
$0(3)
MC
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
84
2016
calcium carbonate tab 600 mg
de copago)
uso
$0(3)
MC
calcium carbonate tab 1250 mg (500 mg elemental ca)
$0(3)
MC
calcium carbonate-cholecalciferol tab 600 mg-400 unit
$0(3)
MC
calcium carbonate-mag hydroxide chew tab 700-300 mg
$0(3)
MC
CHENODAL - chenodiol tab 250 mg*
$0(2)
cimetidine hcl soln 300 mg/5ml
$0(1)
cimetidine tab 200 mg
$0(1)
$0(1)
$0(1)
$0(1)
CITRUCEL FIBER LAXATIVE - methylcellulose powder
laxative
COLACE - docusate sodium cap 50 mg
$0(3)
MC
$0(3)
MC
cromolyn sodium oral conc 100 mg/5ml
$0(1)
DEXILANT - dexlansoprazole cap delayed release 30 mg
$0(2)
DEXILANT - dexlansoprazole cap delayed release 60 mg
$0(2)
dicyclomine hcl tab 20 mg
$0(1)
docusate calcium cap 240 mg
$0(3)
MC
docusate sodium cap 100 mg
$0(3)
MC
docusate sodium cap 250 mg
$0(3)
MC
docusate sodium liquid 150 mg/15ml
$0(3)
MC
docusate sodium syrup 60 mg/15ml
$0(3)
MC
docusate sodium tab 100 mg
$0(3)
MC
EQL NATURAL FIBER - psyllium powder 92%
$0(3)
MC
esomeprazole magnesium cap delayed release 20 mg
$0(1)
esomeprazole magnesium cap delayed release 40 mg
$0(1)
ESOMEPRAZOLE SODIUM - esomeprazole sodium for
intravenous soln 20 mg
esomeprazole sodium for intravenous soln 40 mg
$0(2)
EX-LAX - sennosides tab 15 mg
$0(3)
famotidine for susp 40 mg/5ml
$0(1)
famotidine inj 20 mg/2ml
$0(1)
$0(1)
$0(1)
famotidine tab 10 mg
$0(3)
$0(1)
$0(1)
FIBERCON - calcium polycarbophil tab 625 mg
$0(3)
$0(1)
MC
MC
MC
85
2016
FLEET LIQUID GLYCERIN SUPPOSITORIES - glycerin
enema adult 5.4 gm/average delivered dose
GATTEX - teduglutide (rdna) for inj kit 5 mg*
de copago)
uso
$0(3)
MC
$0(2)
PA
GAVISCON - aluminum hydroxide-magnesium trisilicate
chew tab 80-14.2 mg
GAVISCON - aluminum hydroxide-magnesium carbonate
susp 95-358 mg/15ml
GAVISCON EXTRA STRENGTH RELIEF FORMULA
- aluminum hydroxide-magnesium carbonate susp
508-475 mg/10ml
GELUSIL - alum & mag hydroxide-simethicone chew tab
200-200-25 mg
GLYCERIN - glycerin liquid
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
glycerin suppos 1 gm
$0(3)
MC
glycerin suppos 1.2 gm
$0(3)
MC
glycerin suppos 2 gm
$0(3)
MC
glycerin suppos 80.7%
$0(3)
MC
glycerin topical liquid
$0(3)
MC
glycopyrrolate tab 1 mg
$0(1)
glycopyrrolate tab 2 mg
$0(1)
KONSYL - psyllium powder 60.3%
$0(3)
MC
KONSYL - psyllium powder 71.67%
$0(3)
MC
KONSYL - psyllium powder 100%
$0(3)
MC
KONSYL-D - psyllium powder 52.3%
$0(3)
MC
lactulose (encephalopathy) solution 10 gm/15ml
$0(1)
lactulose solution 10 gm/15ml
$0(1)
lansoprazole cap delayed release 15 mg
$0(1)
lansoprazole cap delayed release 30 mg
$0(1)
LINZESS - linaclotide cap 145 mcg
$0(1)
PA
LINZESS - linaclotide cap 290 mcg
$0(1)
PA
loperamide hcl cap 2 mg
$0(1)
loperamide hcl liq 1 mg/7.5ml
$0(3)
MC
loperamide hcl liq 1 mg/5ml (0.2 mg/ml)
$0(3)
MC
loperamide hcl tab 2 mg
$0(3)
MC
magnesium citrate soln
$0(3)
MC
magnesium hydroxide susp 400 mg/5ml
$0(3)
MC
magnesium oxide tab 400 mg
$0(3)
MC
METAMUCIL MULTIHEALTH FIBER - psyllium powder
55.46%
$0(3)
MC
86
2016
METAMUCIL MULTIHEALTH FIBER - psyllium powder
63%
methscopolamine bromide tab 2.5 mg
de copago)
uso
$0(3)
MC
$0(1)
methscopolamine bromide tab 5 mg
$0(1)
methylcellulose tab 500 mg
$0(3)
metoclopramide hcl inj 5 mg/ml
$0(1)
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)
$0(1)
$0(1)
$0(1)
misoprostol tab 100 mcg
$0(1)
misoprostol tab 200 mcg
$0(1)
MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm
MYLANTA DOUBLE-STRENGTH - alum & mag hydroxidesimethicone susp 400-400-40 mg/5ml
NEXIUM - esomeprazole magnesium for delayed release
susp packet 2.5 mg
susp packet 5 mg
susp packet 10 mg
susp packet 20 mg
susp packet 40 mg
nizatidine cap 150 mg
$0(2)
nizatidine cap 300 mg
$0(1)
NUTRISOURCE FIBER - guar gum oral powder
$0(3)
MC
OMEPRAZOLE - omeprazole delayed release tab 20 mg
$0(3)
MC
omeprazole cap delayed release 10 mg
$0(1)
$0(1)
$0(1)
pantoprazole sodium ec tab 20 mg
$0(1)
pantoprazole sodium ec tab 40 mg
$0(1)
PEDIA-LAX - glycerin liquid suppos 2.8 gm (2.7 ml)
$0(3)
MC
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
$0(1)
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
$0(1)
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
$0(1)
polyethylene glycol 3350 oral packet
$0(1)
polyethylene glycol 3350 oral powder
$0(1)
MC
$0(3)
MC
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
87
2016
psyllium cap 0.52 gm
de copago)
uso
$0(3)
MC
psyllium powder 28.3%
$0(3)
MC
psyllium powder 30%
$0(3)
MC
$0(3)
MC
psyllium powder 33%
$0(3)
MC
$0(3)
MC
psyllium powder 49%
$0(3)
MC
$0(3)
MC
psyllium powder 68%
$0(3)
MC
psyllium powder 95%
$0(3)
MC
PYLERA - bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg
rabeprazole sodium ec tab 20 mg
$0(1)
ranitidine hcl cap 150 mg
$0(1)
ranitidine hcl cap 300 mg
$0(1)
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
$0(1)
ranitidine hcl tab 75 mg
$0(3)
$0(1)
$0(1)
RELISTOR - methylnaltrexone bromide inj kit 12 mg/0.6ml
$0(2)
PA
RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml
(20 mg/ml)
RELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml
(20 mg/ml)
SENNA - senna syrup 176 mg/5ml
$0(2)
PA
$0(2)
PA
$0(3)
MC
sennosides syrup 8.8 mg/5ml
$0(3)
MC
sennosides tab 8.6 mg
$0(3)
MC
sennosides-docusate sodium tab 8.6-50 mg
$0(3)
MC
sodium bicarbonate tab 325 mg
$0(3)
MC
sodium bicarbonate tab 650 mg
$0(3)
MC
sodium phosphates - soln
$0(3)
MC
sucralfate tab 1 gm
$0(1)
SUPREP BOWEL PREP - sodium sulfate-potassium
sulfate-magnesium sulfate oral soln
TUMS ULTRA 1000 - calcium carbonate (antacid) chew tab
1000 mg
ursodiol cap 300 mg
$0(2)
XIFAXAN - rifaximin tab 550 mg
$0(2)
$0(1)
$0(3)
MC
MC
$0(1)
88
2016
Agentes genitourinarios
alfuzosin hcl tab sr 24hr 10 mg
de copago)
uso
$0(1)
bethanechol chloride tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
calcium acetate cap 667 mg
$0(1)
calcium acetate tab 667 mg
$0(1)
CUPRIMINE - penicillamine cap 250 mg
$0(2)
DEPEN TITRATABS - penicillamine tab 250 mg
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
dutasteride cap 0.5 mg
$0(1)
dutasteride-tamsulosin hcl cap 0.5-0.4 mg
$0(1)
finasteride tab 5 mg
$0(1)
FOSRENOL - lanthanum carbonate chew tab 500 mg
$0(1)
$0(1)
$0(1)
FOSRENOL - lanthanum carbonate oral powder pack
750 mg
FOSRENOL - lanthanum carbonate oral powder pack
1000 mg
methylergonovine maleate tab 0.2 mg
$0(1)
MYRBETRIQ - mirabegron tab sr 24 hr 25 mg
$0(1)
MYRBETRIQ - mirabegron tab sr 24 hr 50 mg
$0(1)
neomycin-polymyxin b gu irrigation soln
$0(1)
oxybutynin chloride syrup 5 mg/5ml
$0(1)
oxybutynin chloride tab sr 24hr 5 mg
$0(1)
$0(1)
$0(1)
oxybutynin chloride tab 5 mg
$0(1)
PHOSLYRA - calcium acetate oral soln 667 mg/5ml
$0(1)
$0(1)
$0(1)
$0(1)
RAPAFLO - silodosin cap 4 mg
$0(1)
$0(1)
$0(1)
89
2016
RAPAFLO - silodosin cap 8 mg
de copago)
uso
$0(1)
RENVELA - sevelamer carbonate tab 800 mg
$0(2)
RENVELA - sevelamer carbonate packet 0.8 gm
$0(2)
RENVELA - sevelamer carbonate packet 2.4 gm
$0(2)
tamsulosin hcl cap 0.4 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
tolterodine tartrate cap sr 24hr 2 mg
$0(1)
tolterodine tartrate cap sr 24hr 4 mg
$0(1)
tolterodine tartrate tab 1 mg
$0(1)
tolterodine tartrate tab 2 mg
$0(1)
TOVIAZ - fesoterodine fumarate tab sr 24hr 4 mg
$0(1)
TOVIAZ - fesoterodine fumarate tab sr 24hr 8 mg
$0(1)
trospium chloride cap sr 24hr 60 mg
$0(1)
trospium chloride tab 20 mg
$0(1)
VESICARE - solifenacin succinate tab 5 mg
$0(1)
VESICARE - solifenacin succinate tab 10 mg
$0(1)
Agentes hormonales, estimulantes/sustitutos/modificadores (adrenal)
CORTISONE ACETATE - cortisone acetate tab 25 mg
$0(2)
DEXAMETHASONE - dexamethasone tab 1 mg
$0(2)
DEXAMETHASONE - dexamethasone tab 2 mg
$0(2)
dexamethasone elixir 0.5 mg/5ml
$0(1)
dexamethasone sodium phosphate inj 4 mg/ml
$0(1)
dexamethasone sodium phosphate inj 20 mg/5ml
$0(1)
dexamethasone sodium phosphate inj 120 mg/30ml
$0(1)
dexamethasone tab 0.5 mg
$0(1)
$0(1)
$0(1)
dexamethasone tab 4 mg
$0(1)
dexamethasone tab 6 mg
$0(1)
fludrocortisone acetate tab 0.1 mg
$0(1)
H.P. ACTHAR - corticotropin inj gel 80 unit/ml*
$0(2)
hydrocortisone tab 5 mg
$0(1)
$0(1)
$0(1)
methylprednisolone sodium succinate for inj 40 mg
$0(1)
PA
90
2016
de copago)
uso
$0(1)
$0(1)
methylprednisolone tab therapy pack 4 mg (21)
$0(1)
methylprednisolone tab 4 mg
$0(1)
BD
$0(1)
BD
$0(1)
BD
$0(1)
BD
MYALEPT - metreleptin for subcutaneous inj 11.3 mg*
$0(2)
PA
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml
base)
prednisolone sod phosphate oral soln 15 mg/5ml
$0(1)
BD
$0(1)
BD
prednisolone syrup 15 mg/5ml
$0(1)
BD
PREDNISONE - prednisone tab 50 mg
$0(2)
BD
PREDNISONE - prednisone oral soln 5 mg/5ml
$0(2)
BD
PREDNISONE - prednisone tab therapy pack 5 mg (21)
$0(1)
$0(1)
$0(1)
$0(1)
prednisone tab 1 mg
$0(1)
BD
prednisone tab 2.5 mg
$0(1)
BD
prednisone tab 5 mg
$0(1)
BD
prednisone tab 10 mg
$0(1)
BD
$0(1)
prednisone tab 20 mg
Agentes hormonales, estimulantes/sustitutos/modificadores (pituitarios)
$0(1)
chorionic gonadotropin for inj 10000 unit
BD
desmopressin acetate inj 4 mcg/ml
$0(1)
desmopressin acetate nasal soln 0.01% (refrigerated)
$0(1)
desmopressin acetate nasal spray soln 0.01%
$0(1)
(refrigerated)
desmopressin acetate tab 0.1 mg
$0(1)
desmopressin acetate tab 0.2 mg
$0(1)
EGRIFTA - tesamorelin acetate for inj 1 mg*
$0(2)
PA
EGRIFTA - tesamorelin acetate for inj 2 mg*
$0(2)
PA
INCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)*
$0(2)
OMNITROPE - somatropin for inj 5.8 mg*
$0(1)
PA
OMNITROPE - somatropin inj 5 mg/1.5ml*
$0(2)
PA
OMNITROPE - somatropin inj 10 mg/1.5ml*
$0(2)
PA
$0(1)
91
2016
de copago)
uso
STIMATE - desmopressin acetate nasal soln 1.5 mg/ml
$0(2)
Agentes hormonales, estimulantes/sustitutos/modificadores (hormonas/modificadores sexuales)
ANADROL-50 - oxymetholone tab 50 mg
$0(2)
PA
ANDRODERM - testosterone td patch 24hr 2 mg/24hr
$0(1)
ANDRODERM - testosterone td patch 24hr 4 mg/24hr
$0(1)
ANDROGEL - testosterone td gel 25 mg/2.5gm (1%)
$0(1)
PA, QL (90 packets/30 days)
ANDROGEL - testosterone td gel 50 mg/5gm (1%)
$0(1)
ANDROGEL - testosterone td gel 20.25 mg/1.25gm
(1.62%)
ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%)
$0(1)
$0(1)
ANDROGEL PUMP - testosterone td gel 20.25 mg/act
(1.62%)
$0(1)
PA, QL (2 pump
bottles/30 days)
ANDROID - methyltestosterone cap 10 mg
$0(2)
PA
ANDROXY - fluoxymesterone tab 10 mg
$0(2)
PA
AXIRON - testosterone td soln 30 mg/act
$0(2)
PA, QL (2 pump
bottles/30 days)
danazol cap 50 mg
$0(1)
PA
danazol cap 100 mg
$0(1)
PA
danazol cap 200 mg
$0(1)
PA
DEPO-PROVERA - medroxyprogesterone acetate im susp
400 mg/ml
desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5)
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
$0(2)
DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)#
$0(2)
PA
DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)#
$0(2)
PA
DIVIGEL - estradiol td gel 1 mg/gm (0.1%)#
$0(2)
PA
drospirenone-ethinyl estradiol tab 3-0.02 mg
$0(1)
drospirenone-ethinyl estradiol tab 3-0.03 mg
$0(1)
ELLA - ulipristal acetate tab 30 mg
$0(1)
ESTRACE - estradiol vaginal cream 0.1 mg/gm
$0(2)
estradiol & norethindrone acetate tab 0.5-0.1 mg#
$0(2)
PA
estradiol & norethindrone acetate tab 1-0.5 mg#
$0(2)
PA
estradiol tab 0.5 mg#
$0(2)
PA
estradiol tab 1 mg#
$0(2)
PA
estradiol tab 2 mg#
$0(2)
PA
estradiol td patch weekly 0.025 mg/24hr#
$0(2)
PA
$0(1)
$0(1)
$0(1)
92
2016
de copago)
uso
$0(2)
PA
estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
ESTROPIPATE - estropipate tab 3 mg#
$0(2)
PA
estropipate tab 0.75 mg#
$0(2)
PA
estropipate tab 1.5 mg#
$0(2)
PA
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg
$0(1)
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7)
0.01mg(7)
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg
$0(1)
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
$0(1)
levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg
$0(1)
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mgmcg
levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg
$0(1)
medroxyprogesterone acetate im susp 150 mg/ml
$0(1)
medroxyprogesterone acetate tab 2.5 mg
$0(1)
medroxyprogesterone acetate tab 5 mg
$0(1)
medroxyprogesterone acetate tab 10 mg
$0(1)
megestrol acetate susp 40 mg/ml#
$0(2)
PA
megestrol acetate tab 20 mg#
$0(2)
PA
megestrol acetate tab 40 mg#
$0(2)
PA
MENEST - esterified estrogens tab 0.3 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
methyltestosterone cap 10 mg
$0(1)
PA
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
$0(1)
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
$0(1)
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
$0(1)
norethindrone & ethinyl estradiol-fe chew tab
0.4 mg-35 mcg
norethindrone & ethinyl estradiol-fe chew tab
0.8 mg-25 mcg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
93
2016
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mgmcg
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
de copago)
uso
$0(1)
$0(1)
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg
$0(1)
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg
$0(1)
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg
$0(1)
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)
$0(1)
norethindrone acetate tab 5 mg
$0(1)
norethindrone tab 0.35 mg
$0(1)
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg
$0(1)
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
$0(1)
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mgmcg
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mgmcg
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg
$0(1)
oxandrolone tab 2.5 mg
$0(1)
PA
oxandrolone tab 10 mg
$0(1)
PA
PREMARIN - estrogens, conjugated vaginal cream
0.625 mg/gm
PREMARIN - estrogens, conjugated tab 0.3 mg#
$0(1)
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14)#
PREMPRO - conjugated estrogen-medroxyprogest acetate
tab 0.3-1.5 mg#
tab 0.45-1.5 mg#
tab 0.625-2.5 mg#
tab 0.625-5 mg#
raloxifene hcl tab 60 mg
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
testosterone cypionate im inj in oil 100 mg/ml
$0(1)
PA
testosterone cypionate im inj in oil 200 mg/ml
$0(1)
PA
testosterone enanthate im inj in oil 200 mg/ml
$0(1)
PA
$0(1)
$0(1)
$0(1)
$0(1)
94
2016
testosterone td gel 25 mg/2.5gm (1%) (generic for
AndroGel 1%)
testosterone td gel 50 mg/5gm (1%) (generic for AndroGel
1%)
testosterone td gel 12.5 mg/act (1%) (generic for AndroGel
Pump 1%)
de copago)
uso
$0(1)
$0(1)
$0(1)
PA, QL (4 pump
bottles/30 days)
VAGIFEM - estradiol vaginal tab 10 mcg
$0(1)
Agentes hormonales, estimulantes/sustitutos/modificadores (tiroides)
$0(1)
levothyroxine sodium tab 25 mcg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
liothyronine sodium tab 5 mcg
$0(1)
$0(1)
$0(1)
NATPARA - parathyroid hormone (recombinant) for inj
cartridge 25 mcg*
cartridge 50 mcg*
cartridge 75 mcg*
cartridge 100 mcg*
SYNTHROID - levothyroxine sodium tab 25 mcg
$0(2)
PA, QL (2 cartridges/28 days)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
95
2016
de copago)
uso
$0(2)
$0(2)
Agentes hormonales, supresores (adrenal)
KORLYM - mifepristone tab 300 mg
$0(2)
LYSODREN - mitotane tab 500 mg
Agentes hormonales, supresores (paratiroides)
SENSIPAR - cinacalcet hcl tab 30 mg
$0(1)
$0(1)
PA
$0(1)
PA
Agentes hormonales, supresores (pituitarios)
bromocriptine mesylate cap 5 mg
$0(1)
PA
bromocriptine mesylate tab 2.5 mg
$0(1)
cabergoline tab 0.5 mg
$0(1)
ELIGARD - leuprolide acetate for subcutaneous inj kit
7.5 mg
ELIGARD - leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg
inj kit 30 mg
inj kit 45 mg
FIRMAGON - degarelix acetate for inj 80 mg
$0(2)
FIRMAGON - degarelix acetate for inj 120 mg
$0(2)
leuprolide acetate inj kit 5 mg/ml
$0(1)
LUPRON DEPOT - leuprolide acetate for inj kit 3.75 mg
$0(2)
LUPRON DEPOT - leuprolide acetate for inj kit 7.5 mg
$0(2)
LUPRON DEPOT - leuprolide acetate (3 month) for inj kit
11.25 mg
22.5 mg
30 mg
45 mg
LUPRON DEPOT-PED - leuprolide acetate for inj pediatric
kit 7.5 mg
kit 11.25 mg
kit 15 mg
$0(2)
$0(2)
$0(1)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
96
2016
de copago)
uso
LUPRON DEPOT-PED - leuprolide acetate (3 month) for inj
$0(2)
pediatric kit 11.25 mg
LUPRON DEPOT-PED - leuprolide acetate (3 month) for inj
$0(2)
pediatric kit 30 mg
$0(1)
PA
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
$0(1)
PA
$0(1)
PA
$0(1)
PA
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
$0(1)
PA
SIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml*
$0(2)
PA
$0(2)
PA
$0(2)
PA
SIGNIFOR LAR - pasireotide pamoate for im er susp
20 mg*
40 mg*
60 mg*
SOMATULINE DEPOT - lanreotide acetate extended
release inj 60 mg/0.2ml
SOMAVERT - pegvisomant for inj 10 mg*
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
SYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/
act)
TRELSTAR - triptorelin pamoate for im susp 3.75 mg
$0(2)
TRELSTAR - triptorelin pamoate for im susp 11.25 mg
$0(2)
TRELSTAR MIXJECT - triptorelin pamoate for im susp
3.75 mg
11.25 mg
22.5 mg
Agentes hormonales, supresores (tiroides)
methimazole tab 5 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
97
2016
methimazole tab 10 mg
de copago)
uso
$0(1)
propylthiouracil tab 50 mg
Agentes inmunológicos
ACTHIB - haemophilus b polysaccharide conjugate vaccine
for inj
ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)*
ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml
ARCALYST - rilonacept for inj 220 mg*
$0(1)
$0(2)
PA
ATGAM - lymphocyte immune globulin anti-thymocyte g inj
50 mg/ml(eq)
AZASAN - azathioprine tab 75 mg
$0(2)
BD
$0(2)
BD
AZASAN - azathioprine tab 100 mg
$0(2)
BD
AZATHIOPRINE - azathioprine sodium for inj 100 mg
$0(2)
BD
azathioprine tab 50 mg
$0(1)
BD
BCG VACCINE - bcg vaccine inj
$0(2)
BENLYSTA - belimumab for iv soln 120 mg
$0(2)
PA
BENLYSTA - belimumab for iv soln 400 mg
$0(2)
PA
BEXSERO - meningococcal vac b (recomb adsorbed) inj
prefilled syringe
BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml
CELLCEPT INTRAVENOUS - mycophenolate mofetil hcl
for iv soln 500 mg
CERVARIX - human papillomavirus (hpv) bival (type 16, 18)
recmb vac inj
CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit*
$0(2)
$0(2)
cyclosporine cap 25 mg
$0(1)
BD
cyclosporine cap 100 mg
$0(1)
BD
cyclosporine iv soln 50 mg/ml
$0(1)
BD
CYCLOSPORINE MODIFIED - cyclosporine modified cap
50 mg
cyclosporine modified cap 25 mg
$0(2)
BD
$0(1)
BD
cyclosporine modified cap 100 mg
$0(1)
BD
cyclosporine modified oral soln 100 mg/ml
$0(1)
BD
DAPTACEL - diph, acellular pert & tet tox inj 15 lf-10 mcg-5
lf/0.5ml
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
BD
$0(2)
$0(2)
$0(2)
98
2016
DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml
ELIDEL - pimecrolimus cream 1%
de copago)
uso
$0(2)
$0(2)
ST
ENBREL - etanercept for subcutaneous inj 25 mg
$0(2)
PA
ENBREL - etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml
ENBREL - etanercept subcutaneous soln prefilled syringe
50 mg/ml
ENBREL SURECLICK - etanercept subcutaneous solution
auto-injector 50 mg/ml
ENGERIX-B - hepatitis b vaccine (recombinant) susp
10 mcg/0.5ml
ENGERIX-B - hepatitis b vaccine (recombinant) susp
20 mcg/ml
FIRAZYR - icatibant acetate inj 30 mg/3ml*
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
BD
$0(2)
BD
$0(2)
GAMMAPLEX - immune globulin (human) iv soln
2.5 gm/50ml
5 gm/100ml
10 gm/200ml
20 gm/400ml
GAMUNEX-C - immune globulin (human) iv or
subcutaneous soln 1 gm/10ml
subcutaneous soln 2.5 gm/25ml
GARDASIL - human papillomavirus (hpv) quadrivalent
recombinant vac inj
GARDASIL 9 - human papillomavirus (hpv) 9-valent
recomb vac susp pref syr
GARDASIL 9 - human papillomavirus (hpv) 9-valent
recomb vac im susp
HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml
$0(2)
BD, PA
$0(2)
BD, PA
$0(2)
BD, PA
$0(2)
BD, PA
$0(1)
BD, PA
$0(1)
BD, PA
$0(1)
BD, PA
$0(1)
BD, PA
$0(1)
BD, PA
$0(1)
BD, PA
HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
99
2016
de copago)
uso
HIBERIX - haemophilus b polysaccharide conjugate vac for
$0(2)
inj 10 mcg
HUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml
$0(2)
PA
$0(2)
PA
$0(2)
PA
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK - adalimumab prefilled syringe kit 40 mg/0.8ml
HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml
$0(2)
PA
$0(2)
PA
HUMIRA PEN-CROHNS DISEASE STARTER adalimumab pen-injector kit 40 mg/0.8ml
HUMIRA PEN-PSORIASIS STARTER - adalimumab peninjector kit 40 mg/0.8ml
ILARIS - canakinumab for inj 180 mg*
$0(2)
PA
$0(2)
PA
$0(2)
PA
IMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj
$0(1)
BD
INFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10
lf/0.5ml
IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection
$0(2)
IXIARO - japanese encephalitis vaccine inactivated
adsorbed inj
KINERET - anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml
KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj
leflunomide tab 10 mg
$0(2)
leflunomide tab 20 mg
$0(1)
M-M-R II - measles, mumps & rubella virus vaccines for inj
$0(2)
MENACTRA - meningococcal (a, c, y, and w-135)
conjugate vaccine inj
MENHIBRIX - meningococcal (c & y)-haemophilus b tet tox
conj vac for inj
MENOMUNE-A/C/Y/W-135 - meningococcal vaccine a, c,
y, and w-135 inj
MENVEO - meningococcal (a, c, y, and w-135) oligo conj
vac for inj
methotrexate sodium for inj 1 gm
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
$0(2)
PA
$0(2)
$0(1)
$0(2)
$0(2)
$0(2)
$0(1)
100
2016
de copago)
uso
$0(1)
methotrexate sodium tab 2.5 mg
$0(1)
mycophenolate mofetil cap 250 mg
$0(1)
BD
mycophenolate mofetil for oral susp 200 mg/ml
$0(1)
BD
mycophenolate mofetil tab 500 mg
$0(1)
BD
mycophenolate sodium tab dr 180 mg
$0(1)
BD
mycophenolate sodium tab dr 360 mg
$0(1)
BD
NULOJIX - belatacept for iv infusion 250 mg
$0(2)
BD
PEDVAX HIB - haemophilus b polysaccharide conj vac im
susp 7.5 mcg/0.5 ml
PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly
vac for im susp
PROGRAF - tacrolimus inj 5 mg/ml
$0(2)
PROQUAD - measles-mumps-rubella-varicella virus
vaccines for inj
QUADRACEL - diph-tetanus tox ad-acell pert & polio virus,
ipv vac inj
RABAVERT - rabies vaccine, pcec for inj
$0(2)
$0(2)
BD
RAPAMUNE - sirolimus oral soln 1 mg/ml
$0(2)
BD
RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp
5 mcg/0.5ml
10 mcg/ml
40 mcg/ml
REMICADE - infliximab for iv inj 100 mg
$0(2)
BD
$0(2)
BD
$0(2)
BD
$0(2)
PA
RIDAURA - auranofin cap 3 mg
$0(2)
ROTARIX - rotavirus vaccine, live for oral susp
$0(2)
ROTATEQ - rotavirus vaccine, live oral pentavalent soln
$0(2)
SANDIMMUNE - cyclosporine oral soln 100 mg/ml
$0(2)
BD
SIMULECT - basiliximab for iv soln 10 mg
$0(2)
BD
SIMULECT - basiliximab for iv soln 20 mg
$0(2)
BD
sirolimus tab 0.5 mg
$0(1)
BD
sirolimus tab 1 mg
$0(1)
BD
sirolimus tab 2 mg
$0(1)
BD
STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml
$0(2)
PA
STELARA - ustekinumab soln prefilled syringe 90 mg/ml
$0(2)
PA
SYNAGIS - palivizumab im soln 50 mg/0.5ml*
$0(2)
SYNAGIS - palivizumab im soln 100 mg/ml*
$0(2)
tacrolimus cap 0.5 mg
$0(1)
$0(2)
$0(2)
BD
$0(2)
BD
101
2016
tacrolimus cap 1 mg
de copago)
uso
$0(1)
BD
tacrolimus cap 5 mg
$0(1)
BD
TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu
$0(1)
TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml
$0(1)
$0(2)
$0(2)
$0(2)
$0(2)
THYMOGLOBULIN - anti-thymocyte globulin for iv soln
25 mg (lymphocyte ig)
TRUMENBA - meningococcal group b vaccine im susp
prefilled syringe
TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 720-20
elu-mcg/ml
TYPHIM VI - typhoid vi polysaccharide intramuscular vac
inj 25 mcg/0.5ml
TYSABRI - natalizumab for iv inj conc 300 mg/15ml*
$0(2)
BD
VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml
$0(2)
VAQTA - hepatitis a vaccine inj susp 50 unit/ml
$0(2)
VARIVAX - varicella virus vac live for subcutaneous inj
1350 pfu/0.5ml
YF-VAX - yellow fever vaccine subcutaneous inj
$0(2)
ZORTRESS - everolimus tab 0.25 mg
$0(2)
BD
$0(2)
BD
$0(2)
BD
ZOSTAVAX - zoster vaccine live for inj 19400 unit/0.65ml
Agentes para tratar la enfermedad inflamatoria intestinal
APRISO - mesalamine cap sr 24hr 0.375 gm
$0(2)
QL (1 vaccine/lifetime)
ASACOL HD - mesalamine tab delayed release 800 mg
$0(1)
balsalazide disodium cap 750 mg
$0(1)
budesonide delayed release particles cap 3 mg
$0(1)
CANASA - mesalamine suppos 1000 mg
$0(1)
DELZICOL - mesalamine cap dr 400 mg
$0(1)
DIPENTUM - olsalazine sodium cap 250 mg
$0(2)
hydrocortisone enema 100 mg/60ml
$0(1)
hydrocortisone rectal cream 1%
$0(1)
hydrocortisone rectal cream 2.5%
$0(1)
LIALDA - mesalamine tab delayed release 1.2 gm
$0(2)
mesalamine enema 4 gm
$0(1)
$0(2)
$0(2)
$0(2)
$0(2)
PA
$0(2)
$0(2)
102
2016
PENTASA - mesalamine cap cr 250 mg
de copago)
uso
$0(2)
PENTASA - mesalamine cap cr 500 mg
$0(2)
sulfasalazine tab delayed release 500 mg
$0(1)
sulfasalazine tab 500 mg
Agentes para tratar la enfermedad ósea metabólica
alendronate sodium tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
calcitonin (salmon) nasal soln 200 unit/act
$0(1)
calcitriol cap 0.25 mcg
$0(1)
calcitriol cap 0.5 mcg
$0(1)
calcitriol inj 1 mcg/ml
$0(1)
calcitriol oral soln 1 mcg/ml
$0(1)
ETIDRONATE DISODIUM - etidronate disodium tab
200 mg
ETIDRONATE DISODIUM - etidronate disodium tab
400 mg
FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml
$0(2)
FORTICAL - calcitonin (salmon) nasal soln 200 unit/act
$0(2)
ibandronate sodium iv soln 3 mg/3ml
$0(1)
ibandronate sodium tab 150 mg
$0(1)
MIACALCIN - calcitonin (salmon) inj 200 unit/ml
$0(2)
paricalcitol cap 1 mcg
$0(1)
$0(1)
$0(1)
paricalcitol iv soln 2 mcg/ml
$0(1)
paricalcitol iv soln 5 mcg/ml
$0(1)
PROLIA - denosumab inj 60 mg/ml
$0(2)
PA
risedronate sodium tab delayed release 35 mg
$0(1)
risedronate sodium tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
QL (1 tablet/28 days)
XGEVA - denosumab inj 120 mg/1.7ml
$0(2)
ZEMPLAR - paricalcitol iv soln 2 mcg/ml
$0(1)
ZEMPLAR - paricalcitol iv soln 5 mcg/ml
$0(1)
zoledronic acid inj conc for iv infusion 4 mg/5ml
$0(1)
$0(2)
$0(2)
PA
QL (1 tablet/28 days)
103
2016
zoledronic acid iv soln 5 mg/100ml
de copago)
uso
$0(1)
ZOMETA - zoledronic acid iv soln 4 mg/100ml
Agentes oftálmicos
ALPHAGAN P - brimonidine tartrate ophth soln 0.1%
$0(2)
artificial tear ophth ointment
$0(3)
MC
artificial tear ophth solution
$0(3)
MC
azelastine hcl ophth soln 0.05%
$0(1)
AZOPT - brinzolamide ophth susp 1%
$0(2)
BACITRACIN - bacitracin ophth oint 500 unit/gm
$0(2)
bacitracin-polymyxin b ophth oint
$0(1)
bacitracin-polymyxin-neomycin-hc ophth oint 1%
$0(1)
BESIVANCE - besifloxacin hcl ophth susp 0.6%
$0(2)
betaxolol hcl ophth soln 0.5%
$0(1)
BETOPTIC-S - betaxolol hcl ophth susp 0.25%
$0(2)
brimonidine tartrate ophth soln 0.15%
$0(1)
brimonidine tartrate ophth soln 0.2%
$0(1)
bromfenac sodium ophth soln 0.09% (once-daily)
$0(1)
carteolol hcl ophth soln 1%
$0(1)
ciprofloxacin hcl ophth soln 0.3%
$0(1)
COMBIGAN - brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%
cromolyn sodium ophth soln 4%
$0(1)
dexamethasone sodium phosphate ophth soln 0.1%
$0(1)
diclofenac sodium ophth soln 0.1%
$0(1)
dorzolamide hcl ophth soln 2%
$0(1)
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml
$0(1)
DUREZOL - difluprednate ophth emulsion 0.05%
$0(1)
epinastine hcl ophth soln 0.05%
$0(1)
erythromycin ophth oint 5 mg/gm
$0(1)
fluorometholone ophth susp 0.1%
$0(1)
flurbiprofen sodium ophth soln 0.03%
$0(1)
gentamicin sulfate ophth oint 0.3%
$0(1)
gentamicin sulfate ophth soln 0.3%
$0(1)
GENTEAL SEVERE - hypromellose ophth gel 0.3%
$0(3)
MC
hypromellose ophth soln 0.3%
$0(3)
MC
hypromellose ophth soln 0.4%
$0(3)
MC
ILEVRO - nepafenac ophth susp 0.3%
$0(1)
ISOPTO TEARS - hypromellose ophth soln 0.5%
$0(3)
$0(2)
$0(1)
MC
104
2016
ISTALOL - timolol maleate ophth soln 0.5% (once-daily)
de copago)
uso
$0(2)
ketorolac tromethamine ophth soln 0.4%
$0(1)
ketorolac tromethamine ophth soln 0.5%
$0(1)
ketotifen fumarate ophth soln 0.025%
$0(3)
LACRISERT - artificial tear ophth insert
$0(2)
latanoprost ophth soln 0.005%
$0(1)
levobunolol hcl ophth soln 0.5%
$0(1)
LOTEMAX - loteprednol etabonate ophth susp 0.5%
$0(1)
LOTEMAX - loteprednol etabonate ophth gel 0.5%
$0(1)
LOTEMAX - loteprednol etabonate ophth oint 0.5%
$0(1)
LUMIGAN - bimatoprost ophth soln 0.01%
$0(1)
MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily)
$0(2)
MURO 128 - sodium chloride hypertonic ophth soln 2%
$0(3)
NAPHAZOLINE HCL - naphazoline hcl ophth soln 0.1%
$0(2)
NATACYN - natamycin ophth susp 5%
$0(2)
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt
op oin
neomycin-polymy-gramicid op sol 1.75-10000-0.025mgunt-mg/ml
neomycin-polymyxin-dexamethasone ophth oint 0.1%
$0(1)
neomycin-polymyxin-dexamethasone ophth susp 0.1%
$0(1)
NEVANAC - nepafenac ophth susp 0.1%
$0(1)
ofloxacin ophth soln 0.3%
$0(1)
olopatadine hcl ophth soln 0.1%
$0(1)
PATADAY - olopatadine hcl ophth soln 0.2%
$0(1)
PATANOL - olopatadine hcl ophth soln 0.1%
$0(2)
PHOSPHOLINE IODIDE - echothiophate iodide ophth for
soln 0.125%
pilocarpine hcl ophth soln 1%
$0(2)
$0(1)
$0(1)
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
$0(1)
polyvinyl alcohol ophth soln 1.4%
$0(3)
MC
polyvinyl alcohol-povidone ophth soln 5-6 mg/ml (0.5-0.6%)
$0(3)
MC
prednisolone acetate ophth susp 1%
$0(1)
PROLENSA - bromfenac sodium ophth soln 0.07%
$0(2)
REFRESH - polyvinyl alcohol-povidone ophth soln
1.4-0.6%
$0(3)
MC
MC
$0(1)
$0(1)
$0(1)
MC
105
2016
REFRESH CELLUVISC - carboxymethylcellulose sodium
ophth soln 1%
REFRESH PLUS - carboxymethylcellulose sodium ophth
soln 0.5%
RESTASIS - cyclosporine (ophth) emulsion 0.05%
de copago)
uso
$0(3)
MC
$0(3)
MC
$0(1)
PA
SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp
1-0.2%
sodium chloride hypertonic ophth oint 5%
$0(1)
$0(3)
MC
sodium chloride hypertonic ophth soln 5%
$0(3)
MC
sulfacetamide sodium ophth soln 10%
$0(1)
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%
SYSTANE - polyethylene glycol-propylene glycol ophth soln
0.4-0.3%
TEARS NATURALE PM - white petrolatum-mineral oil
ophth ointment
timolol maleate ophth gel forming soln 0.25%
$0(1)
timolol maleate ophth gel forming soln 0.5%
$0(1)
timolol maleate ophth soln 0.25%
$0(1)
timolol maleate ophth soln 0.5%
$0(1)
TOBRADEX - tobramycin-dexamethasone ophth oint
0.3-0.1%
tobramycin ophth soln 0.3%
$0(2)
tobramycin-dexamethasone ophth susp 0.3-0.1%
$0(1)
TRAVATAN Z - travoprost ophth soln 0.004%
$0(1)
trifluridine ophth soln 1%
$0(1)
VIGAMOX - moxifloxacin hcl ophth soln 0.5%
Agentes óticos
acetic acid otic soln 2%
$0(1)
ACETIC ACID/ALUMINUM ACETATE - acetic acid 2% in
aluminum acetate otic soln
carbamide peroxide 6.5% otic soln
$0(2)
CIPRODEX - ciprofloxacin-dexamethasone otic susp
0.3-0.1%
fluocinolone acetonide (otic) oil 0.01%
$0(2)
hydrocortisone w/ acetic acid otic soln 1-2%
$0(1)
neomycin-polymyxin-hc otic soln 1%
$0(1)
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/
ml-1%
ofloxacin otic soln 0.3%
$0(1)
$0(3)
MC
$0(3)
MC
$0(1)
$0(1)
$0(1)
$0(3)
MC
$0(1)
$0(1)
106
2016
Agentes para el tracto respiratorio/pulmonar
acetylcysteine inhal soln 10%
de copago)
uso
$0(1)
BD
acetylcysteine inhal soln 20%
$0(1)
BD
ADCIRCA - tadalafil tab 20 mg
$0(2)
ADEMPAS - riociguat tab 0.5 mg
$0(2)
ADEMPAS - riociguat tab 1 mg
$0(2)
$0(2)
ADEMPAS - riociguat tab 2 mg
$0(2)
$0(2)
ADVAIR DISKUS - fluticasone-salmeterol aer powder ba
100-50 mcg/dose
250-50 mcg/dose
500-50 mcg/dose
ADVAIR HFA - fluticasone-salmeterol inhal aerosol
45-21 mcg/act
115-21 mcg/act
230-21 mcg/act
AEROCHAMBER PLUS FLOW-VU - spacer/aerosolholding chambers - device
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
$0(1)
QL (1 inhaler/30 days)
$0(1)
$0(1)
$0(1)
QL (1 canister/30 days)
$0(1)
$0(1)
$0(3)
MC
$0(1)
BD
albuterol sulfate soln nebu 0.5% (5 mg/ml)
$0(1)
BD
albuterol sulfate soln nebu 0.63 mg/3ml
$0(1)
BD
albuterol sulfate soln nebu 1.25 mg/3ml
$0(1)
BD
albuterol sulfate syrup 2 mg/5ml
$0(1)
albuterol sulfate tab sr 12hr 4 mg
$0(1)
albuterol sulfate tab sr 12hr 8 mg
$0(1)
albuterol sulfate tab 2 mg
$0(1)
albuterol sulfate tab 4 mg
$0(1)
ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh
ARNUITY ELLIPTA - fluticasone furoate aerosol powder
breath activ 100 mcg/act
ARNUITY ELLIPTA - fluticasone furoate aerosol powder
breath activ 200 mcg/act
ASMANEX HFA - mometasone furoate inhal aerosol
suspension 100 mcg/act
$0(1)
$0(1)
QL (30 blisters/30 days)
$0(1)
$0(1)
107
2016
ASMANEX HFA - mometasone furoate inhal aerosol
suspension 200 mcg/act
ASMANEX TWISTHALER 120 METERED DOSES mometasone furoate inhal powd 220 mcg/inh
ATROVENT HFA - ipratropium bromide hfa inhal aerosol
17 mcg/act
AYR NASAL DROPS - saline nasal soln 0.65%
de copago)
uso
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
QL (2 canisters/30 days)
$0(3)
MC
azelastine hcl nasal spray 0.1% (137 mcg/spray)
$0(1)
QL (2 bottles/30 days)
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
$0(1)
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh
BROHIST D - brompheniramine & phenylephrine tab
4-10 mg
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml
$0(1)
$0(1)
$0(3)
MC
$0(3)
MC
brompheniramine & phenylephrine susp 6-10 mg/5ml#
$0(3)
MC
caffeine citrate oral soln 60 mg/3ml
$0(1)
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)
$0(3)
MC
cetirizine hcl tab 5 mg
$0(3)
MC
cetirizine hcl tab 10 mg
$0(3)
MC
CHLOR-TRIMETON - chlorpheniramine maleate tab 4 mg
$0(3)
MC
chlorpheniramine & phenylephrine liquid 4-10 mg/5ml
$0(3)
MC
chlorpheniramine & phenylephrine tab 4-10 mg
$0(3)
MC
clemastine fumarate tab 2.68 mg#
$0(2)
PA
COMBIVENT RESPIMAT - ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
CROMOLYN SODIUM - cromolyn sodium soln nebu
20 mg/2ml
DALIRESP - roflumilast tab 500 mcg
$0(2)
$0(2)
BD
DECON-A - brompheniramine & phenylephrine liqd 2-5 mg/
ml
$0(3)
$0(2)
MC
108
2016
dextromethorphan-guaifenesin liquid 10-100 mg/5ml
de copago)
uso
$0(3)
MC
diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml
$0(3)
MC
diphenhydramine-phenylephrine soln 12.5-5 mg/5ml
$0(3)
MC
diphenhydramine-phenylephrine tab 25-10 mg
$0(3)
MC
DOMETUSS-DA/CHILDREN - chlorpheniramine &
phenylephrine liquid 1-2.5 mg/5ml
DULERA - mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act
DULERA - mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act
ED CHLORPED D - chlorpheniramine & phenylephrine
liquid 2-5 mg/ml
EPIPEN 2-PAK - epinephrine solution auto-injector
0.3 mg/0.3ml (1:1000)
EPIPEN-JR 2-PAK - epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)
ESBRIET - pirfenidone cap 267 mg
$0(3)
MC
$0(2)
$0(2)
$0(3)
MC
FLOVENT DISKUS - fluticasone propionate aer pow ba
50 mcg/blister
100 mcg/blister
250 mcg/blister
FLOVENT HFA - fluticasone propionate hfa inhal aero
44 mcg/act (50/valve)
FLOVENT HFA - fluticasone propionate hfa inhal aer
FLOVENT HFA - fluticasone propionate hfa inhal aer
fluticasone propionate nasal susp 50 mcg/act
$0(1)
$0(1)
$0(1)
QL (4 inhalers/30 days)
$0(1)
$0(1)
$0(1)
$0(1)
QL (1 bottle/30 days)
FORADIL AEROLIZER - formoterol fumarate inhal cap
12 mcg
GRASTEK - timothy grass pollen allergen ext tab sl 2800
bau
guaifenesin liquid 100 mg/5ml
$0(1)
$0(2)
$0(3)
MC
guaifenesin-codeine soln 100-10 mg/5ml
$0(3)
MC
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(1)
$0(1)
$0(2)
PA, QL (270
capsules/30 days)
109
2016
de copago)
uso
INCRUSE ELLIPTA - umeclidinium br aero powd breath act
$0(1)
62.5 mcg/inh
$0(1)
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
$0(1)
KALYDECO - ivacaftor tab 150 mg
$0(2)
KALYDECO - ivacaftor packet 50 mg
$0(2)
KALYDECO - ivacaftor packet 75 mg
$0(2)
LETAIRIS - ambrisentan tab 5 mg*
$0(2)
LETAIRIS - ambrisentan tab 10 mg*
$0(2)
levocetirizine dihydrochloride tab 5 mg
$0(1)
loratadine syrup 5 mg/5ml
$0(3)
MC
loratadine tab 10 mg
$0(3)
MC
montelukast sodium chew tab 4 mg
$0(1)
montelukast sodium chew tab 5 mg
$0(1)
montelukast sodium oral granules packet 4 mg
$0(1)
montelukast sodium tab 10 mg
$0(1)
NASONEX - mometasone furoate nasal susp 50 mcg/act
$0(1)
OFEV - nintedanib esylate cap 100 mg
$0(2)
OFEV - nintedanib esylate cap 150 mg
$0(2)
olopatadine hcl nasal soln 0.6%
$0(1)
OPSUMIT - macitentan tab 10 mg*
$0(2)
ORALAIR - grass mixed pollen ext tab sl 300 ir
$0(2)
ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg
$0(2)
PHENAGIL - chlorpheniramine & phenylephrine tab
3.5-10 mg
phenylephrine hcl tab 10 mg
$0(3)
MC
$0(3)
MC
phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml
$0(3)
MC
phenylephrine-brompheniramine-dm elixir 2.5-1-5 mg/5ml
$0(3)
MC
phenylephrine-guaifenesin tab 10-400 mg
$0(3)
MC
PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act
$0(1)
PROAIR RESPICLICK - albuterol sulfate aer pow ba
108 mcg/act
PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv
soln 1000 mg*
promethazine hcl suppos 12.5 mg#
$0(1)
$0(2)
PA
promethazine hcl suppos 25 mg#
$0(2)
PA
promethazine hcl syrup 6.25 mg/5ml#
$0(2)
PA
promethazine hcl tab 12.5 mg#
$0(2)
PA
$0(2)
PA
$0(2)
110
2016
de copago)
uso
$0(2)
PA
PULMOZYME - dornase alfa inhal soln 1 mg/ml
$0(2)
BD
QVAR - beclomethasone diprop inhal aero soln 40 mcg/act
(50/valve)
QVAR - beclomethasone diprop inhal aero soln 80 mcg/act
(100/valve)
RAGWITEK - short ragweed pollen allergen extract tab sl
12 amb a 1-u
REMODULIN - treprostinil sodium inj 1 mg/ml*
$0(1)
$0(1)
$0(2)
$0(2)
BD
REMODULIN - treprostinil sodium inj 2.5 mg/ml*
$0(2)
BD
$0(2)
BD
$0(2)
BD
saline nasal spray 0.65%
$0(3)
MC
SEREVENT DISKUS - salmeterol xinafoate aer pow ba
50 mcg/dose
sildenafil citrate tab 20 mg
$0(1)
$0(1)
SPIRIVA HANDIHALER - tiotropium bromide monohydrate
inhal cap 18 mcg
SPIRIVA RESPIMAT - tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act
SPIRIVA RESPIMAT - tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act
SYMBICORT - budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act
SYMBICORT - budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act
terbutaline sulfate tab 2.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
terbutaline sulfate tab 5 mg
$0(1)
theophylline tab sr 12hr 100 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
tobramycin nebu soln 300 mg/5ml
$0(1)
BD
TRACLEER - bosentan tab 62.5 mg*
$0(2)
TRACLEER - bosentan tab 125 mg*
$0(2)
triamcinolone acetonide nasal aerosol suspension 55 mcg/
act
TRIAMINIC COLD & ALLERGY CHILDRENS chlorpheniramine & phenylephrine syrup 1-2.5 mg/5ml
$0(1)
$0(3)
MC
$0(1)
111
2016
TRIAMINIC NIGHT TIME COLD & COUGH diphenhydramine-phenylephrine syrup 6.25-2.5 mg/5ml
TYZINE PEDIATRIC NASAL DROPS - tetrahydrozoline hcl
nasal soln 0.05%
UPTRAVI - selexipag tab therapy pack 200 mcg (140) &
800 mcg (60)*
de copago)
uso
$0(3)
MC
$0(2)
$0(2)
PA, QL (1 pack (200
tablets)/28 days)
UPTRAVI - selexipag tab 200 mcg*
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
VENTAVIS - iloprost inhalation solution 10 mcg/ml
$0(2)
BD, PA, QL (270 mls/30 days)
VENTAVIS - iloprost inhalation solution 20 mcg/ml
$0(2)
BD, PA, QL (270 mls/30 days)
VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act
$0(1)
XOLAIR - omalizumab for inj 150 mg*
$0(2)
PA
XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/
act
zafirlukast tab 10 mg
$0(2)
zafirlukast tab 20 mg
Relajantes de los músculos esqueléticos
cyclobenzaprine hcl tab 5 mg#
$0(1)
$0(2)
PA
cyclobenzaprine hcl tab 7.5 mg#
$0(2)
PA
cyclobenzaprine hcl tab 10 mg#
$0(2)
PA
methocarbamol tab 500 mg#
$0(2)
methocarbamol tab 750 mg#
Agentes para tratar los trastornos del sueño
HETLIOZ - tasimelteon capsule 20 mg*
$0(2)
$0(2)
modafinil tab 100 mg
$0(1)
modafinil tab 200 mg
$0(1)
NUVIGIL - armodafinil tab 50 mg
$0(2)
$0(2)
$0(2)
$0(2)
SILENOR - doxepin hcl tab 3 mg
$0(1)
SILENOR - doxepin hcl tab 6 mg
$0(1)
XYREM - sodium oxybate oral solution 500 mg/ml*
$0(2)
$0(1)
112
2016
zaleplon cap 5 mg#
de copago)
uso
$0(1)
PA
zaleplon cap 10 mg#
$0(1)
PA
zolpidem tartrate tab 5 mg#
$0(2)
PA
zolpidem tartrate tab 10 mg#
Nutrientes/Minerales/Electrólitos terapéuticos
amino acid infusion 6%
$0(2)
PA
$0(1)
BD
$0(1)
BD
$0(1)
BD
ascorbic acid tab 500 mg
$0(3)
MC
B-1 - thiamine hcl tab 500 mg
$0(3)
MC
B-12 - cyanocobalamin tab 2500 mcg
$0(3)
MC
B-12 SUPER STRENGTH - cyanocobalamin sublingual
liquid 5000 mcg/ml
calcium carbonate-vitamin d tab 250 mg-125 unit
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
calcium citrate tab 950 mg (200 mg elemental ca)
$0(3)
MC
calcium citrate-vitamin d tab 315 mg-200 unit (elemental
ca)
calcium tab 500 mg
$0(3)
MC
$0(3)
MC
calcium tab 600 mg
$0(3)
MC
calcium w/ vitamin d tab 600 mg-200 unit
$0(3)
MC
CARBAGLU - carglumic acid tab 200 mg
$0(2)
CENTRUM SPECIALIST PRENATAL - prenatal w/fe fum-fa
tab 27-0.8 mg & dha cap 200 mg pack
CHEMET - succimer cap 100 mg
$0(3)
cholecalciferol cap 400 unit
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
cholecalciferol chew tab 400 unit
$0(3)
MC
cholecalciferol chew tab 1000 unit
$0(3)
MC
cholecalciferol drops 5000 unit/ml (1000 unit/0.2ml)
$0(3)
MC
cholecalciferol drops 400 unit/0.03ml (per drop)
$0(3)
MC
cholecalciferol drops 2000 unit/0.03ml (per drop)
$0(3)
MC
cholecalciferol oral liquid 400 unit/ml
$0(3)
MC
MC
$0(2)
113
2016
cholecalciferol tab 400 unit
de copago)
uso
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(2)
cyanocobalamin inj 1000 mcg/ml
$0(3)
MC
cyanocobalamin liquid 1000 mcg/15ml
$0(3)
MC
cyanocobalamin lozenge 500 mcg
$0(3)
MC
cyanocobalamin tab cr 1000 mcg
$0(3)
MC
cyanocobalamin tab cr 2000 mcg
$0(3)
MC
cyanocobalamin tab sl 500 mcg
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
cyanocobalamin tab 50 mcg
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(2)
dextrose inj 5%
$0(1)
dextrose inj 10%
$0(1)
dextrose 5% in lactated ringers
$0(1)
dextrose 2.5% w/ sodium chloride 0.45%
$0(1)
dextrose 5% w/ sodium chloride 0.2%
$0(1)
$0(1)
$0(1)
$0(1)
electrolyte-m in d5w soln
$0(1)
EXJADE - deferasirox tab for oral susp 125 mg*
$0(2)
$0(2)
$0(2)
fat emulsion iv soln 20%
$0(1)
BD
ferrous gluconate tab 325 mg (36 mg elemental fe)
$0(3)
MC
FERROUS SULFATE - ferrous sulfate tab ec 324 mg
(65 mg fe equivalent)
$0(3)
MC
114
2016
FERROUS SULFATE - ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)
ferrous sulfate dried tab 200 mg (65 mg elemental fe)
de copago)
uso
$0(3)
MC
$0(3)
MC
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)
$0(3)
MC
ferrous sulfate tab ec 325 mg (65 mg fe equivalent)
$0(3)
MC
ferrous sulfate tab 325 mg (65 mg elemental fe)
$0(3)
MC
folic acid tab 400 mcg
$0(3)
MC
folic acid tab 800 mcg
$0(3)
MC
fomepizole inj 1 gm/ml (for iv infusion)
$0(1)
HM VITAMIN D3 - cholecalciferol cap 4000 unit
$0(3)
JADENU - deferasirox tab 90 mg
$0(2)
$0(2)
$0(2)
KCL 0.15%/D5W/LR - potassium chloride 20 meq/l (0.15%)
in d5w lactated ringers
KCL 0.3%/D5W/LR IV LACTATED RINGERS - potassium
chloride 40 meq/l (0.3%) in d5w lactated ringers
kcl 20 meq/l (0.15%) in nacl 0.45% inj
$0(2)
kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
KP PRENATAL MULTIVITAMINS - prenatal vit w/ fe
fumarate-fa tab 28-0.8 mg
KPN PRENATAL - prenatal multivitamins & minerals w/iron
& fa tab 0.1 mg
lactated ringer's solution
$0(3)
MC
$0(3)
MC
levocarnitine oral soln 1 gm/10ml (10%)
$0(1)
levocarnitine tab 330 mg
$0(1)
magnesium sulfate inj 50%
$0(1)
MISSION PRENATAL - prenatal vit w/ fe gluconate-fa tab
30-0.4 mg
MISSION PRENATAL HP - prenatal vit w/ fe gluconate-fa
tab 30-0.8 mg
multiple vitamin tab
$0(3)
MC
$0(3)
MC
$0(3)
MC
multiple vitamins w/ iron tab
$0(3)
MC
multiple vitamins w/ minerals tab
$0(3)
MC
NASCOBAL - cyanocobalamin nasal spray 500 mcg/0.1ml
$0(3)
MC
MC
$0(2)
$0(1)
$0(1)
115
2016
de copago)
uso
NUTRICION PORVIDA - prenatal multivitamins & minerals
$0(3)
MC
w/ fe & fa tab 0.25 mg
$0(3)
MC
omega-3 fatty acids cap 300 mg
$0(3)
MC
$0(3)
MC
$0(3)
MC
omega-3 fatty acids cap delayed release 1000 mg
$0(3)
MC
omega-3 fatty acids cap delayed release 1200 mg
$0(3)
MC
ONE-A-DAY WOMENS PRENATAL - prenat w/ fe fum-fa
tab 28-0.8 mg & omega 3 cap 440 mg pak
oral electrolyte solution
$0(3)
MC
$0(3)
MC
PERRY PRENATAL - prenatal vit w/ fe fumarate-fa cap
13.5-0.4 mg
PHYSICIANS EZ USE B-12 COMPLIANCE KIT cyanocobalamin inj kit 1000 mcg/ml
potassium chloride cap cr 8 meq
$0(3)
MC
$0(3)
MC
potassium chloride cap cr 10 meq
$0(1)
potassium chloride inj 2 meq/ml
$0(1)
potassium chloride microencapsulated crys cr tab 10 meq
$0(1)
potassium chloride microencapsulated crys cr tab 20 meq
$0(1)
potassium chloride tab cr 8 meq (600 mg)
$0(1)
potassium chloride tab cr 10 meq
$0(1)
potassium chloride 20 meq/l (0.15%) in dextrose 5% inj
$0(1)
potassium chloride 40 meq/l (0.3%) in dextrose 5% inj
$0(1)
potassium citrate tab cr 5 meq (540 mg)
$0(1)
$0(1)
$0(1)
PRENATAL - prenatal vit w/ fe fumarate-fa tab 27-0.8 mg
$0(3)
MC
PRENATAL AND IRON - prenatal multivitamins & minerals
w/iron & fa tab 0.8 mg
PRENATAL MULTIVITAMIN + D - prenatal w/fe fum-fa tab
28-0.8 mg & dha cap 200 mg pack
PROFE FORTE - prenatal w/o vit a w/ fe polysac cmplx-fa
cap 155-1 mg
RA VITAMIN B-12 - cyanocobalamin liquid 1000 mcg/ml
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
SAMSCA - tolvaptan tab 15 mg
$0(2)
PA
SAMSCA - tolvaptan tab 30 mg
$0(2)
PA
sodium chloride inj 0.45%
$0(1)
sodium chloride irrigation soln 0.9%
$0(1)
sodium chloride iv soln 0.9%
$0(1)
$0(1)
116
2016
sodium polystyrene sulfonate oral susp 15 gm/60ml
de copago)
uso
$0(1)
sodium polystyrene sulfonate powder
$0(1)
sodium polystyrene sulfonate rectal susp 30 gm/120ml
$0(1)
STUART ONE - prenatal mv & min w/fe carbonyl-fa-dha
cap 27-0.8-200 mg
SUPER TWIN EPA/DHA - omega-3 fatty acids cap
1250 mg
SYPRINE - trientine hcl cap 250 mg
$0(3)
MC
$0(3)
MC
THERA-D 4000 - cholecalciferol tab 4000 unit
$0(3)
MC
THERANATAL COMPLETE - prenatal w/fe fum-fa tab
27-1 mg & vit-dha cap 300 mg pak
THERANATAL OVAVITE - prenat mv fe fum-fa tab 18-1 mg
& coenzyme q10 cap 125 mg
thiamine hcl inj 100 mg/ml
$0(3)
MC
$0(3)
MC
$0(3)
MC
thiamine hcl tab 50 mg
$0(3)
MC
thiamine hcl tab 100 mg
$0(3)
MC
VITAMIN D2 - ergocalciferol tab 400 unit
$0(3)
MC
VITAMIN D2 - ergocalciferol tab 2000 unit
$0(3)
MC
VITAMIN D3 - cholecalciferol oral liquid 1200 unit/15ml
$0(3)
MC
VITAMIN D3 - cholecalciferol tab 3000 unit
$0(3)
MC
water for irrigation, sterile irrigation soln
$0(1)
$0(2)
117
2016
ÍNDICE
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg........................................................48
abacavir sulfate tab 300 mg....................................... 48
ABILIFY MAINTENA.................................................... 19
ABRAXANE................................................................... 31
ABSTRAL........................................................................ 1
ABSTRAL........................................................................ 1
ABSTRAL........................................................................ 1
ABSTRAL........................................................................ 1
ABSTRAL........................................................................ 1
ABSTRAL........................................................................ 1
acamprosate calcium tab delayed release 333
mg.................................................................................. 5
acarbose tab 100 mg.................................................. 57
acarbose tab 25 mg.................................................... 57
acarbose tab 50 mg.................................................... 57
acebutolol hcl cap 200 mg......................................... 63
acebutolol hcl cap 400 mg......................................... 63
acetaminophen cap 500 mg......................................... 1
acetaminophen chew tab 160 mg............................... 1
acetaminophen chew tab 80 mg................................. 1
acetaminophen elixir 160 mg/5ml................................ 1
acetaminophen liquid 160 mg/5ml............................... 1
acetaminophen soln 100 mg/ml................................... 1
acetaminophen soln 160 mg/5ml.................................1
acetaminophen susp 160 mg/5ml................................1
acetaminophen susp 80 mg/0.8ml.............................. 1
acetaminophen w/ codeine soln 120-12 mg/5ml....... 1
acetaminophen w/ codeine tab 300-15 mg................ 1
ACETAZOLAMIDE....................................................... 63
acetazolamide cap sr 12hr 500 mg........................... 63
acetazolamide tab 250 mg......................................... 63
ACETIC ACID/ALUMINUM ACETATE.................... 106
acetic acid otic soln 2%............................................ 106
acetylcysteine inhal soln 10%.................................. 107
acetylcysteine inhal soln 20%.................................. 107
acitretin cap 10 mg...................................................... 77
acitretin cap 17.5 mg...................................................77
acitretin cap 25 mg...................................................... 77
ACTHIB.......................................................................... 98
ACTIMMUNE................................................................ 98
acyclovir cap 200 mg.................................................. 48
118
acyclovir oint 5%.......................................................... 77
acyclovir sodium for inj 500 mg................................. 48
acyclovir sodium iv soln 50 mg/ml............................ 48
acyclovir susp 200 mg/5ml......................................... 48
acyclovir tab 400 mg................................................... 48
acyclovir tab 800 mg................................................... 48
ADACEL........................................................................ 98
ADAGEN........................................................................83
ADASUVE..................................................................... 43
ADCIRCA.................................................................... 107
adefovir dipivoxil tab 10 mg....................................... 48
ADEMPAS................................................................... 107
ADEMPAS................................................................... 107
ADEMPAS................................................................... 107
ADEMPAS................................................................... 107
ADEMPAS................................................................... 107
ADVAIR DISKUS....................................................... 107
ADVAIR DISKUS....................................................... 107
ADVAIR DISKUS....................................................... 107
ADVAIR HFA.............................................................. 107
ADVAIR HFA.............................................................. 107
ADVAIR HFA.............................................................. 107
AEROCHAMBER PLUS FLOW-VU........................ 107
AFINITOR...................................................................... 31
AFINITOR...................................................................... 31
AFINITOR...................................................................... 31
AFINITOR...................................................................... 31
AFINITOR DISPERZ................................................... 31
AGGRENOX................................................................. 60
ALBENZA...................................................................... 40
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml).....................................................................107
albuterol sulfate soln nebu 0.5% (5 mg/ml)........... 107
albuterol sulfate soln nebu 0.63 mg/3ml................ 107
albuterol sulfate soln nebu 1.25 mg/3ml................ 107
albuterol sulfate syrup 2 mg/5ml............................. 107
albuterol sulfate tab 2 mg.........................................107
albuterol sulfate tab 4 mg.........................................107
albuterol sulfate tab sr 12hr 4 mg........................... 107
albuterol sulfate tab sr 12hr 8 mg........................... 107
alclometasone dipropionate cream 0.05%............... 77
alclometasone dipropionate oint 0.05%....................77
ALCOHOL SWABS...................................................... 57
ALDURAZYME............................................................. 83
ALECENSA................................................................... 31
alendronate sodium tab 10 mg................................ 103
alendronate sodium tab 5 mg.................................. 103
ALER-DRYL.................................................................. 24
2016
ALER-DRYL.................................................................. 41
alfuzosin hcl tab sr 24hr 10 mg................................. 89
ALIMTA.......................................................................... 31
ALIMTA.......................................................................... 31
ALINIA............................................................................ 40
ALINIA............................................................................ 40
allopurinol tab 100 mg................................................ 27
allopurinol tab 300 mg................................................ 27
ALOE VESTA ANTIFUNGAL..................................... 77
ALOE VESTA SKIN CONDITIONER........................ 77
ALOPRIM...................................................................... 27
alosetron hcl tab 0.5 mg............................................. 84
alosetron hcl tab 1 mg................................................ 84
ALOXI.............................................................................24
ALPHAGAN P............................................................ 104
alum & mag hydroxide-simethicone susp 200-200-20
mg/5ml........................................................................ 84
ALUMINUM HYDROXIDE.......................................... 84
aluminum sulfate & calcium acetate powd pack...... 77
AMANTADINE HCL..................................................... 41
AMANTADINE HCL..................................................... 48
amantadine hcl cap 100 mg....................................... 41
amantadine hcl cap 100 mg....................................... 48
amantadine hcl syrup 50 mg/5ml.............................. 41
amantadine hcl syrup 50 mg/5ml.............................. 48
AMBISOME................................................................... 26
amifostine crystalline for inj 500 mg.......................... 31
amikacin sulfate inj 1 gm/4ml (250 mg/ml)................. 6
amikacin sulfate inj 500 mg/2ml (250 mg/ml).............6
amiloride & hydrochlorothiazide tab 5-50 mg.......... 63
amiloride hcl tab 5 mg................................................ 63
amino acid infusion 15%.......................................... 113
amino acid infusion 6%............................................ 113
amino acid infusion 8%............................................ 113
amiodarone hcl tab 200 mg....................................... 63
amiodarone hcl tab 400 mg....................................... 63
AMITIZA......................................................................... 84
AMITIZA......................................................................... 84
amitriptyline hcl tab 100 mg....................................... 20
amitriptyline hcl tab 10 mg......................................... 20
amitriptyline hcl tab 150 mg....................................... 20
amlodipine besylate-atorvastatin calcium tab 10-10
mg................................................................................64
mg................................................................................64
mg................................................................................64
mg................................................................................64
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg................................................................................63
mg................................................................................64
mg................................................................................64
mg................................................................................64
mg................................................................................64
mg................................................................................64
mg................................................................................64
amlodipine besylate-benazepril hcl cap 10-20
mg................................................................................64
mg................................................................................64
amlodipine besylate-benazepril hcl cap 2.5-10
mg................................................................................64
mg................................................................................64
mg................................................................................64
mg................................................................................64
amlodipine besylate tab 10 mg.................................. 63
amlodipine besylate tab 2.5 mg................................. 63
amlodipine besylate tab 5 mg.................................... 63
amlodipine besylate-valsartan tab 10-160 mg......... 64
amlodipine besylate-valsartan tab 10-320 mg......... 64
amlodipine besylate-valsartan tab 5-160 mg........... 64
amlodipine besylate-valsartan tab 5-320 mg........... 64
10-160-12.5 mg......................................................... 64
10-160-25 mg............................................................ 64
10-320-25 mg............................................................ 64
5-160-12.5 mg........................................................... 64
5-160-25 mg.............................................................. 64
AMOXAPINE................................................................. 20
AMOXAPINE................................................................. 20
AMOXAPINE................................................................. 20
AMOXAPINE................................................................. 20
amoxicillin (trihydrate) cap 250 mg............................. 6
amoxicillin (trihydrate) cap 500 mg............................. 6
amoxicillin (trihydrate) for susp 125 mg/5ml...............7
119
2016
amoxicillin (trihydrate) tab 500 mg.............................. 7
amoxicillin (trihydrate) tab 875 mg.............................. 7
amoxicillin & k clavulanate chew tab 200-28.5
mg.................................................................................. 7
amoxicillin & k clavulanate chew tab 400-57 mg....... 7
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.......................................................................... 7
amoxicillin & k clavulanate for susp 400-57
mg/5ml.......................................................................... 7
amoxicillin & k clavulanate for susp 600-42.9
mg/5ml.......................................................................... 7
amoxicillin & k clavulanate tab 250-125 mg............... 7
amphetamine-dextroamphetamine cap sr 24hr 10
mg................................................................................75
mg................................................................................75
mg................................................................................75
mg................................................................................75
mg................................................................................75
mg................................................................................75
AMPHOTERICIN B...................................................... 26
AMPICILLIN.................................................................... 7
AMPICILLIN.................................................................... 7
ampicillin & sulbactam sodium for inj 2-1 gm............. 7
ampicillin cap 250 mg................................................... 7
ampicillin cap 500 mg................................................... 7
AMPICILLIN SODIUM................................................... 7
AMPICILLIN SODIUM................................................... 7
ampicillin sodium for inj 1 gm...................................... 7
ampicillin sodium for inj 250 mg.................................. 7
ampicillin sodium for inj 2 gm...................................... 7
ampicillin sodium for inj 500 mg.................................. 7
ampicillin sodium for iv soln 10 gm............................. 7
AMPYRA........................................................................75
ANADROL-50............................................................... 92
anagrelide hcl cap 0.5 mg.......................................... 60
anagrelide hcl cap 1 mg............................................. 60
anastrozole tab 1 mg.................................................. 31
ANDRODERM.............................................................. 92
ANDRODERM.............................................................. 92
ANDROGEL.................................................................. 92
ANDROGEL.................................................................. 92
ANDROGEL.................................................................. 92
ANDROGEL.................................................................. 92
ANDROGEL PUMP..................................................... 92
120
ANDROID...................................................................... 92
ANDROXY..................................................................... 92
ANORO ELLIPTA.......................................................107
APOKYN........................................................................ 41
APRISO....................................................................... 102
APTIOM......................................................................... 14
APTIOM......................................................................... 14
APTIOM......................................................................... 14
APTIOM......................................................................... 14
APTIVUS....................................................................... 48
APTIVUS....................................................................... 48
ARANESP ALBUMIN FREE...................................... 60
ARCALYST.................................................................... 98
ARIPIPRAZOLE ODT.................................................. 20
aripiprazole oral solution 1 mg/ml............................. 20
aripiprazole tab 10 mg................................................ 20
aripiprazole tab 2 mg.................................................. 20
2016
ARNUITY ELLIPTA.................................................... 107
ARNUITY ELLIPTA.................................................... 107
ARRANON.................................................................... 31
artificial tear ophth ointment..................................... 104
artificial tear ophth solution...................................... 104
ARZERRA..................................................................... 31
ARZERRA..................................................................... 31
ASACOL HD............................................................... 102
ascorbic acid tab 500 mg......................................... 113
ASMANEX HFA..........................................................107
ASMANEX HFA..........................................................108
ASMANEX TWISTHALER 120 METERED
DOSES..................................................................... 108
DOSES..................................................................... 108
DOSES..................................................................... 108
DOSES..................................................................... 108
DOSES..................................................................... 108
DOSES..................................................................... 108
aspirin chew tab 81 mg.............................................. 27
aspirin tab 325 mg....................................................... 27
aspirin tab 81 mg......................................................... 27
aspirin tab delayed release 325 mg.......................... 27
aspirin tab delayed release 81 mg............................ 27
atenolol & chlorthalidone tab 100-25 mg.................. 64
atenolol & chlorthalidone tab 50-25 mg.................... 64
atenolol tab 100 mg.....................................................64
atenolol tab 25 mg....................................................... 64
atenolol tab 50 mg....................................................... 64
ATGAM.......................................................................... 98
atorvastatin calcium tab 10 mg.................................. 64
atovaquone-proguanil hcl tab 250-100 mg...............40
atovaquone-proguanil hcl tab 62.5-25 mg................ 40
atovaquone susp 750 mg/5ml.................................... 40
ATRIPLA........................................................................ 48
ATROVENT HFA........................................................ 108
AVASTIN........................................................................ 31
AVASTIN........................................................................ 31
AVELOX........................................................................... 7
AVONEX........................................................................ 75
AVONEX........................................................................ 75
AVONEX PEN.............................................................. 75
AXIRON......................................................................... 92
AYR NASAL DROPS................................................ 108
azacitidine for inj 100 mg........................................... 31
AZACTAM........................................................................ 7
AZACTAM........................................................................ 7
AZASAN........................................................................ 98
AZASAN........................................................................ 98
AZATHIOPRINE........................................................... 98
azathioprine tab 50 mg............................................... 98
azelastine hcl nasal spray 0.1% (137 mcg/
spray)........................................................................ 108
azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)........................................................................ 108
azelastine hcl ophth soln 0.05%.............................. 104
AZELEX......................................................................... 77
AZILECT........................................................................ 41
AZILECT........................................................................ 41
AZITHROMYCIN............................................................ 7
azithromycin for susp 100 mg/5ml.............................. 7
azithromycin for susp 200 mg/5ml.............................. 7
azithromycin iv for soln 500 mg................................... 7
azithromycin tab 250 mg.............................................. 7
AZOPT......................................................................... 104
aztreonam for inj 1 gm.................................................. 7
aztreonam for inj 2 gm.................................................. 8
B
B-1................................................................................ 113
B-12.............................................................................. 113
B-12 SUPER STRENGTH........................................113
BACITRACIN.............................................................. 104
bacitracin oint 500 unit/gm......................................... 77
bacitracin-polymyxin b ophth oint............................ 104
bacitracin-polymyxin-neomycin-hc ophth oint
1%............................................................................. 104
bacitracin zinc oint 500 unit/gm................................. 77
baclofen tab 10 mg......................................................47
baclofen tab 20 mg......................................................48
balsalazide disodium cap 750 mg........................... 102
BANZEL......................................................................... 14
BANZEL......................................................................... 14
BANZEL......................................................................... 14
BARACLUDE................................................................ 48
BCG VACCINE............................................................. 98
BELEODAQ.................................................................. 31
BENADRYL ALLERGY CHILDRENS....................... 24
benazepril & hydrochlorothiazide tab 10-12.5
mg................................................................................64
121
2016
benazepril & hydrochlorothiazide tab 20-12.5
mg................................................................................65
benazepril & hydrochlorothiazide tab 20-25 mg...... 65
benazepril & hydrochlorothiazide tab 5-6.25 mg..... 64
benazepril hcl tab 10 mg............................................ 65
benazepril hcl tab 5 mg.............................................. 65
BENDEKA..................................................................... 31
BENEFIBER.................................................................. 84
BENLYSTA.................................................................... 98
BENLYSTA.................................................................... 98
benzocaine dental gel 7.5%....................................... 77
benzoyl peroxide-erythromycin gel 5-3%................. 77
benztropine mesylate tab 0.5 mg.............................. 41
benztropine mesylate tab 1 mg................................. 41
benztropine mesylate tab 2 mg................................. 41
BESIVANCE................................................................ 104
betamethasone dipropionate augmented cream
0.05%.......................................................................... 78
betamethasone dipropionate augmented gel
0.05%.......................................................................... 78
betamethasone dipropionate augmented lotion
0.05%.......................................................................... 78
betamethasone dipropionate augmented oint
0.05%.......................................................................... 78
betamethasone dipropionate cream 0.05%............. 78
betamethasone dipropionate lotion 0.05%............... 78
betamethasone dipropionate oint 0.05%.................. 78
betamethasone valerate cream 0.1%....................... 78
betamethasone valerate lotion 0.1%.........................78
betamethasone valerate oint 0.1%............................ 78
BETASERON................................................................ 75
betaxolol hcl ophth soln 0.5%.................................. 104
betaxolol hcl tab 10 mg.............................................. 65
betaxolol hcl tab 20 mg.............................................. 65
bethanechol chloride tab 10 mg................................ 89
bethanechol chloride tab 5 mg.................................. 89
BETOPTIC-S.............................................................. 104
bexarotene cap 75 mg................................................ 31
BEXSERO..................................................................... 98
bicalutamide tab 50 mg.............................................. 31
BICILLIN L-A................................................................... 8
BICILLIN L-A................................................................... 8
BICILLIN L-A................................................................... 8
BICNU............................................................................ 31
BILTRICIDE................................................................... 40
bisacodyl suppos 10 mg............................................. 84
bisacodyl tab delayed release 5 mg......................... 84
bismuth subsalicylate chew tab 262 mg................... 84
122
bismuth subsalicylate susp 262 mg/15ml................. 84
bismuth subsalicylate susp 525 mg/15ml................. 84
bisoprolol & hydrochlorothiazide tab 10-6.25
mg................................................................................65
bisoprolol & hydrochlorothiazide tab 2.5-6.25
mg................................................................................65
bisoprolol & hydrochlorothiazide tab 5-6.25 mg...... 65
bisoprolol fumarate tab 10 mg................................... 65
bisoprolol fumarate tab 5 mg..................................... 65
bleomycin sulfate for inj 15 unit................................. 31
bleomycin sulfate for inj 30 unit................................. 31
BLINCYTO.....................................................................32
BOOSTRIX.................................................................... 98
BOSULIF....................................................................... 32
BOSULIF....................................................................... 32
BOUDREAUXS BUTT PASTE................................... 78
BREO ELLIPTA.......................................................... 108
BREO ELLIPTA.......................................................... 108
BRILINTA....................................................................... 61
BRILINTA....................................................................... 61
brimonidine tartrate ophth soln 0.15%.................... 104
brimonidine tartrate ophth soln 0.2%...................... 104
BRINTELLIX..................................................................20
BRINTELLIX..................................................................20
BRINTELLIX..................................................................20
BROHIST D................................................................ 108
bromfenac sodium ophth soln 0.09% (oncedaily)......................................................................... 104
bromocriptine mesylate cap 5 mg............................. 41
bromocriptine mesylate cap 5 mg............................. 96
bromocriptine mesylate tab 2.5 mg........................... 41
bromocriptine mesylate tab 2.5 mg........................... 96
brompheniramine & phenylephrine elixir 1-2.5
mg/5ml...................................................................... 108
brompheniramine & phenylephrine susp 6-10
mg/5ml...................................................................... 108
budesonide delayed release particles cap 3
mg............................................................................. 102
bumetanide inj 0.25 mg/ml......................................... 65
bumetanide tab 0.5 mg............................................... 65
bumetanide tab 1 mg.................................................. 65
bumetanide tab 2 mg.................................................. 65
BUPHENYL................................................................... 83
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg........ 5
buprenorphine hcl-naloxone hcl sl tab 8-2 mg........... 5
buprenorphine hcl sl tab 2 mg..................................... 5
buprenorphine hcl sl tab 8 mg..................................... 5
bupropion hcl (smoking deterrent) tab sr 12hr 150
mg.................................................................................. 5
bupropion hcl tab 100 mg...........................................20
bupropion hcl tab 75 mg............................................. 20
bupropion hcl tab sr 12hr 100 mg............................. 20
2016
buspirone hcl tab 10 mg............................................. 53
buspirone hcl tab 5 mg............................................... 53
buspirone hcl tab 7.5 mg............................................ 53
BUSULFEX................................................................... 32
50-300-40-30 mg...................................................... 29
50-325-40-30 mg...................................................... 29
butalbital-aspirin-caff w/ codeine cap 50-325-40-30
mg................................................................................29
butorphanol tartrate inj 1 mg/ml................................... 1
butorphanol tartrate inj 2 mg/ml................................... 1
butorphanol tartrate nasal soln 10 mg/ml................... 1
BUTRANS........................................................................5
BUTRANS........................................................................5
BUTRANS........................................................................5
BUTRANS........................................................................5
BUTRANS........................................................................6
BYDUREON.................................................................. 57
BYDUREON.................................................................. 57
C
cabergoline tab 0.5 mg............................................... 96
caffeine citrate oral soln 60 mg/3ml........................ 108
CALAMINE.................................................................... 78
calcipotriene cream 0.005%....................................... 78
calcipotriene oint 0.005%........................................... 78
calcipotriene soln 0.005% (50 mcg/ml).....................78
calcitonin (salmon) nasal soln 200 unit/act............ 103
calcitriol cap 0.25 mcg.............................................. 103
calcitriol cap 0.5 mcg................................................ 103
calcitriol inj 1 mcg/ml................................................. 103
calcitriol oral soln 1 mcg/ml......................................103
calcium acetate cap 667 mg...................................... 89
calcium acetate tab 667 mg....................................... 89
calcium carbonate (antacid) chew tab 500 mg........ 84
calcium carbonate (antacid) chew tab 750 mg........ 84
calcium carbonate-cholecalciferol tab 600 mg-400
unit............................................................................... 85
calcium carbonate-mag hydroxide chew tab 700-300
mg................................................................................85
calcium carbonate tab 1250 mg (500 mg elemental
ca)................................................................................85
calcium carbonate tab 600 mg.................................. 85
calcium carbonate-vitamin d tab 250 mg-125
unit............................................................................ 113
unit............................................................................ 113
unit............................................................................ 113
unit............................................................................ 113
calcium citrate tab 950 mg (200 mg elemental
ca)............................................................................. 113
calcium citrate-vitamin d tab 315 mg-200 unit
(elemental ca)......................................................... 113
calcium tab 500 mg................................................... 113
calcium tab 600 mg................................................... 113
calcium w/ vitamin d tab 600 mg-200 unit.............. 113
CANASA...................................................................... 102
CANCIDAS.................................................................... 26
CANCIDAS.................................................................... 26
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg................................................................................65
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg................................................................................65
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg................................................................................65
candesartan cilexetil tab 16 mg................................. 65
candesartan cilexetil tab 32 mg................................. 65
candesartan cilexetil tab 4 mg................................... 65
candesartan cilexetil tab 8 mg................................... 65
CAPASTAT SULFATE..................................................30
CAPRELSA................................................................... 32
CAPRELSA................................................................... 32
capsaicin cream 0.025%.............................................78
capsaicin cream 0.075%.............................................78
captopril tab 100 mg................................................... 65
captopril tab 12.5 mg.................................................. 65
captopril tab 25 mg......................................................65
captopril tab 50 mg......................................................65
CAPZASIN-P................................................................ 78
CARAC.......................................................................... 78
CARBAGLU................................................................ 113
carbamazepine cap sr 12hr 100 mg......................... 15
carbamazepine chew tab 100 mg............................. 15
carbamazepine susp 100 mg/5ml............................. 15
carbamazepine tab 200 mg........................................15
carbamazepine tab sr 12hr 100 mg.......................... 15
carbamide peroxide 6.5% otic soln......................... 106
CARBIDOPA/LEVODOPA/ENTACAPONE.............. 41
123
2016
carbidopa & levodopa orally disintegrating tab
10-100 mg.................................................................. 41
25-100 mg.................................................................. 41
25-250 mg.................................................................. 41
carbidopa & levodopa tab 10-100 mg....................... 41
carbidopa & levodopa tab cr 25-100 mg.................. 41
carbidopa & levodopa tab cr 50-200 mg.................. 41
carbidopa tab 25 mg................................................... 41
carboplatin iv soln 150 mg/15ml................................ 32
carboplatin iv soln 50 mg/5ml.................................... 32
carteolol hcl ophth soln 1%...................................... 104
carvedilol tab 12.5 mg.................................................65
carvedilol tab 25 mg.................................................... 65
carvedilol tab 3.125 mg.............................................. 65
carvedilol tab 6.25 mg.................................................65
cefaclor cap 250 mg...................................................... 8
cefaclor cap 500 mg...................................................... 8
cefadroxil cap 500 mg................................................... 8
cefadroxil for susp 250 mg/5ml.................................... 8
cefadroxil for susp 500 mg/5ml.................................... 8
cefadroxil tab 1 gm........................................................ 8
cefazolin sodium for inj 10 gm..................................... 8
cefazolin sodium for inj 1 gm....................................... 8
cefazolin sodium for inj 20 gm..................................... 8
cefazolin sodium for inj 500 mg................................... 8
cefdinir cap 300 mg....................................................... 8
cefdinir for susp 125 mg/5ml........................................ 8
cefdinir for susp 250 mg/5ml........................................ 8
cefepime hcl for inj 1 gm.............................................. 8
cefepime hcl for inj 2 gm.............................................. 8
cefotaxime sodium for inj 10 gm..................................8
cefotaxime sodium for inj 1 gm.................................... 8
cefotaxime sodium for inj 2 gm.................................... 8
cefotaxime sodium for inj 500 mg............................... 8
cefoxitin sodium for inj 10 gm...................................... 8
cefoxitin sodium for iv soln 1 gm................................. 8
cefoxitin sodium for iv soln 2 gm................................. 8
cefpodoxime proxetil for susp 100 mg/5ml................. 8
cefpodoxime proxetil for susp 50 mg/5ml................... 8
cefpodoxime proxetil tab 100 mg................................ 8
cefpodoxime proxetil tab 200 mg................................ 8
cefprozil for susp 125 mg/5ml...................................... 8
cefprozil for susp 250 mg/5ml...................................... 8
cefprozil tab 250 mg...................................................... 8
124
cefprozil tab 500 mg...................................................... 8
ceftazidime for inj 1 gm.................................................8
ceftazidime for iv soln 1 gm......................................... 9
ceftazidime for iv soln 2 gm......................................... 9
CEFTRIAXONE/DEXTROSE....................................... 9
CEFTRIAXONE/DEXTROSE....................................... 9
CEFTRIAXONE IN ISO-OSMOTIC............................. 9
CEFTRIAXONE IN ISO-OSMOTIC............................. 9
ceftriaxone sodium for inj 10 gm................................. 9
ceftriaxone sodium for inj 1 gm................................... 9
ceftriaxone sodium for inj 250 mg............................... 9
ceftriaxone sodium for inj 2 gm................................... 9
ceftriaxone sodium for inj 500 mg............................... 9
ceftriaxone sodium for iv soln 1 gm............................ 9
ceftriaxone sodium for iv soln 2 gm............................ 9
cefuroxime axetil tab 250 mg....................................... 9
cefuroxime axetil tab 500 mg....................................... 9
cefuroxime sodium for inj 1.5 gm................................ 9
cefuroxime sodium for inj 7.5 gm................................ 9
cefuroxime sodium for inj 750 mg............................... 9
cefuroxime sodium for iv soln 1.5 gm......................... 9
celecoxib cap 100 mg................................................... 1
celecoxib cap 100 mg................................................. 27
celecoxib cap 200 mg................................................... 1
celecoxib cap 200 mg................................................. 27
celecoxib cap 400 mg................................................... 1
celecoxib cap 400 mg................................................. 27
celecoxib cap 50 mg..................................................... 1
celecoxib cap 50 mg................................................... 27
CELLCEPT INTRAVENOUS...................................... 98
CELONTIN.................................................................... 15
CENTRUM SPECIALIST PRENATAL.....................113
cephalexin cap 250 mg................................................. 9
cephalexin for susp 125 mg/5ml.................................. 9
cephalexin for susp 250 mg/5ml.................................. 9
CEREZYME.................................................................. 83
CERVARIX.................................................................... 98
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml).............108
cetirizine hcl tab 10 mg............................................ 108
cetirizine hcl tab 5 mg............................................... 108
CHANTIX......................................................................... 6
CHANTIX......................................................................... 6
CHANTIX CONTINUING MONTH............................... 6
CHANTIX STARTING MONTH PACK......................... 6
CHEMET..................................................................... 113
CHENODAL.................................................................. 85
CHLORAMPHENICOL SODIUM SUCCINATE..........9
chlorhexidine gluconate liquid 4%............................. 78
2016
chlorhexidine gluconate soln 0.12%......................... 77
chloroquine phosphate tab 250 mg...........................40
chloroquine phosphate tab 500 mg...........................40
CHLOROTHIAZIDE..................................................... 65
chlorothiazide tab 500 mg.......................................... 65
chlorpheniramine & phenylephrine liquid 4-10
mg/5ml...................................................................... 108
chlorpheniramine & phenylephrine tab 4-10
mg............................................................................. 108
CHLORPROMAZINE HCL..........................................24
chlorpromazine hcl tab 100 mg................................. 24
chlorpromazine hcl tab 10 mg................................... 24
CHLORTHALIDONE.................................................... 65
CHLORTHALIDONE.................................................... 65
CHLOR-TRIMETON.................................................. 108
cholecalciferol cap 10000 unit................................. 113
cholecalciferol cap 1000 unit................................... 113
cholecalciferol cap 400 unit......................................113
cholecalciferol cap 50000 unit................................. 113
cholecalciferol chew tab 1000 unit.......................... 113
cholecalciferol chew tab 400 unit............................ 113
cholecalciferol drops 2000 unit/0.03ml (per
drop)..........................................................................113
cholecalciferol drops 400 unit/0.03ml (per
drop)..........................................................................113
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml)................................................................ 113
cholecalciferol oral liquid 400 unit/ml...................... 113
cholecalciferol tab 1000 unit.................................... 114
cholecalciferol tab 400 unit...................................... 114
cholecalciferol tab 50000 unit.................................. 114
cholestyramine light powder 4 gm/dose................... 65
cholestyramine light powder packets 4 gm.............. 65
cholestyramine powder 4 gm/dose........................... 66
cholestyramine powder packets 4 gm...................... 66
choline fenofibrate cap dr 135 mg.............................66
choline fenofibrate cap dr 45 mg............................... 66
chorionic gonadotropin for inj 10000 unit................. 91
ciclopirox gel 0.77%.................................................... 78
ciclopirox olamine cream 0.77%................................ 78
ciclopirox olamine susp 0.77%.................................. 78
ciclopirox shampoo 1%............................................... 78
ciclopirox solution 8%..................................................78
cidofovir iv inj 75 mg/ml.............................................. 48
cilostazol tab 100 mg.................................................. 61
cilostazol tab 50 mg.................................................... 61
cimetidine hcl soln 300 mg/5ml................................. 85
cimetidine tab 200 mg.................................................85
CINRYZE....................................................................... 98
CIPRODEX................................................................. 106
ciprofloxacin 200 mg/100ml in d5w........................... 10
ciprofloxacin 400 mg/200ml in d5w........................... 10
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml).....................................................................9
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml).....................................................................9
CIPROFLOXACIN HCL................................................. 9
ciprofloxacin hcl ophth soln 0.3%............................ 104
ciprofloxacin hcl tab 250 mg........................................ 9
ciprofloxacin hcl tab 500 mg........................................ 9
ciprofloxacin hcl tab 750 mg...................................... 10
ciprofloxacin hcl tab sr 24hr 1000 mg......................... 9
ciprofloxacin hcl tab sr 24hr 500 mg........................... 9
ciprofloxacin iv soln 200 mg/20ml (1%).................... 10
ciprofloxacin iv soln 400 mg/40ml (1%).................... 10
CISPLATIN.................................................................... 32
cisplatin inj 100 mg/100ml (1 mg/ml)........................ 32
cisplatin inj 50 mg/50ml (1 mg/ml)............................ 32
citalopram hydrobromide oral soln 10 mg/5ml......... 20
citalopram hydrobromide tab 10 mg......................... 20
CITRUCEL FIBER LAXATIVE....................................85
cladribine iv soln 10 mg/10ml (1 mg/ml)................... 32
CLAFORAN/D5W......................................................... 10
CLAFORAN/D5W......................................................... 10
clarithromycin for susp 125 mg/5ml.......................... 10
clarithromycin for susp 250 mg/5ml.......................... 10
clarithromycin tab 250 mg.......................................... 10
clarithromycin tab 500 mg.......................................... 10
clarithromycin tab sr 24hr 500 mg............................. 10
clemastine fumarate tab 2.68 mg............................ 108
clindamycin hcl cap 150 mg....................................... 10
clindamycin hcl cap 300 mg....................................... 10
clindamycin hcl cap 75 mg......................................... 10
125
2016
clindamycin phosphate-benzoyl peroxide gel
1-5%............................................................................ 78
clindamycin phosphate gel 1%.................................. 78
clindamycin phosphate in d5w iv soln 300
mg/50ml...................................................................... 10
mg/50ml...................................................................... 10
mg/50ml...................................................................... 10
clindamycin phosphate inj 300 mg/2ml.....................10
clindamycin phosphate inj 9 gm/60ml....................... 10
clindamycin phosphate iv soln 600 mg/4ml............. 10
clindamycin phosphate iv soln 900 mg/6ml............. 10
clindamycin phosphate lotion 1%.............................. 78
clindamycin phosphate soln 1%................................ 78
clindamycin phosphate swab 1%.............................. 78
clindamycin phosphate vaginal cream 2%............... 10
clobetasol propionate cream 0.05%.......................... 78
clobetasol propionate emollient base cream
0.05%.......................................................................... 78
clobetasol propionate gel 0.05%............................... 78
clobetasol propionate oint 0.05%.............................. 78
clobetasol propionate soln 0.05%............................. 78
CLOLAR........................................................................ 32
clomipramine hcl cap 25 mg...................................... 20
clonazepam orally disintegrating tab 0.125 mg....... 15
clonazepam orally disintegrating tab 0.125 mg....... 53
clonazepam orally disintegrating tab 0.25 mg......... 15
clonazepam orally disintegrating tab 0.25 mg......... 53
clonazepam orally disintegrating tab 0.5 mg............15
clonazepam orally disintegrating tab 0.5 mg............53
clonazepam orally disintegrating tab 1 mg............... 15
clonazepam tab 0.5 mg.............................................. 15
clonazepam tab 0.5 mg.............................................. 53
clonazepam tab 1 mg................................................. 15
clonidine hcl tab 0.1 mg..............................................66
clonidine hcl tab sr 12hr 0.1 mg................................ 75
clonidine hcl td patch weekly 0.1 mg/24hr............... 66
126
clopidogrel bisulfate tab 75 mg.................................. 61
clorazepate dipotassium tab 15 mg.......................... 15
clorazepate dipotassium tab 15 mg.......................... 53
clorazepate dipotassium tab 3.75 mg....................... 15
clorazepate dipotassium tab 3.75 mg....................... 53
clorazepate dipotassium tab 7.5 mg......................... 15
clorazepate dipotassium tab 7.5 mg......................... 53
clotrimazole cream 1%................................................78
clotrimazole troche 10 mg.......................................... 26
clotrimazole w/ betamethasone cream 1-0.05%......78
clotrimazole w/ betamethasone lotion 1-0.05%....... 78
clozapine orally disintegrating tab 100 mg............... 43
clozapine orally disintegrating tab 25 mg................. 43
clozapine tab 100 mg.................................................. 43
clozapine tab 200 mg.................................................. 43
clozapine tab 25 mg.................................................... 43
clozapine tab 50 mg.................................................... 43
COARTEM.....................................................................40
codeine sulfate tab 15 mg............................................ 1
COLACE........................................................................ 85
colchicine w/ probenecid tab 0.5-500 mg................. 27
COLCRYS..................................................................... 27
colestipol hcl granule packets 5 gm.......................... 66
colestipol hcl granules 5 gm...................................... 66
colestipol hcl tab 1 gm................................................ 66
colistimethate sodium for inj 150 mg........................ 10
COMBIGAN................................................................ 104
COMBIVENT RESPIMAT......................................... 108
COMETRIQ................................................................... 32
COMETRIQ................................................................... 32
COMETRIQ................................................................... 32
COMPLERA.................................................................. 48
COPAXONE.................................................................. 75
COPAXONE.................................................................. 75
CORLANOR.................................................................. 66
CORLANOR.................................................................. 66
CORTISONE ACETATE.............................................. 90
COSMEGEN................................................................. 32
COTELLIC..................................................................... 32
COUMADIN................................................................... 61
COUMADIN................................................................... 61
COUMADIN................................................................... 61
COUMADIN................................................................... 61
COUMADIN................................................................... 61
COUMADIN................................................................... 61
COUMADIN................................................................... 61
COUMADIN................................................................... 61
COUMADIN................................................................... 61
CREON.......................................................................... 83
CREON.......................................................................... 83
2016
CREON.......................................................................... 83
CREON.......................................................................... 83
CREON.......................................................................... 83
CRESEMBA.................................................................. 26
CRESEMBA.................................................................. 26
CRESTOR..................................................................... 66
CRESTOR..................................................................... 66
CRESTOR..................................................................... 66
CRESTOR..................................................................... 66
CRIXIVAN...................................................................... 48
CRIXIVAN...................................................................... 48
CROMOLYN SODIUM.............................................. 108
cromolyn sodium ophth soln 4%............................. 104
cromolyn sodium oral conc 100 mg/5ml................... 85
CUBICIN........................................................................ 10
CUPRIMINE.................................................................. 89
CUPRIMINE.................................................................. 98
CUPRIMINE................................................................ 114
cyanocobalamin inj 1000 mcg/ml............................ 114
cyanocobalamin liquid 1000 mcg/15ml...................114
cyanocobalamin lozenge 500 mcg.......................... 114
cyanocobalamin tab 1000 mcg................................ 114
cyanocobalamin tab 100 mcg.................................. 114
cyanocobalamin tab 2000 mcg................................ 114
cyanocobalamin tab 50 mcg.................................... 114
cyanocobalamin tab cr 1000 mcg........................... 114
cyanocobalamin tab cr 2000 mcg........................... 114
cyanocobalamin tab sl 2500 mcg............................ 114
cyanocobalamin tab sl 500 mcg.............................. 114
cyclobenzaprine hcl tab 10 mg................................ 112
cyclobenzaprine hcl tab 5 mg.................................. 112
cyclobenzaprine hcl tab 7.5 mg............................... 112
CYCLOPHOSPHAMIDE............................................. 32
CYCLOPHOSPHAMIDE............................................. 32
cyclophosphamide for inj 1 gm.................................. 32
cyclophosphamide for inj 2 gm.................................. 32
cyclophosphamide for inj 500 mg.............................. 32
CYCLOSERINE............................................................ 30
CYCLOSET................................................................... 57
cyclosporine cap 100 mg............................................ 98
cyclosporine cap 25 mg.............................................. 98
cyclosporine iv soln 50 mg/ml.................................... 98
CYCLOSPORINE MODIFIED.................................... 98
cyclosporine modified cap 100 mg............................ 98
cyclosporine modified cap 25 mg.............................. 98
cyclosporine modified oral soln 100 mg/ml.............. 98
CYRAMZA..................................................................... 32
CYRAMZA..................................................................... 32
CYSTADANE................................................................ 83
CYSTAGON.................................................................. 83
CYSTAGON.................................................................. 83
cytarabine inj 20 mg/ml............................................... 32
cytarabine inj pf 100 mg/ml........................................ 32
cytarabine inj pf 20 mg/ml.......................................... 32
D
DACARBAZINE............................................................ 32
dacarbazine for inj 200 mg.........................................32
DAKLINZA..................................................................... 48
DAKLINZA..................................................................... 48
DALIRESP.................................................................. 108
DALVANCE................................................................... 10
danazol cap 100 mg.................................................... 92
danazol cap 200 mg.................................................... 92
danazol cap 50 mg...................................................... 92
dantrolene sodium cap 100 mg................................. 48
dantrolene sodium cap 25 mg................................... 48
dantrolene sodium cap 50 mg................................... 48
DAPSONE..................................................................... 30
DAPSONE..................................................................... 30
DAPTACEL.................................................................... 98
DARAPRIM................................................................... 40
DARZALEX................................................................... 32
DARZALEX................................................................... 32
daunorubicin hcl inj 5 mg/ml...................................... 33
DAUNOXOME.............................................................. 33
decitabine for inj 50 mg.............................................. 33
DECON-A.................................................................... 108
DELZICOL................................................................... 102
demeclocycline hcl tab 150 mg................................. 10
demeclocycline hcl tab 300 mg................................. 10
DEMSER....................................................................... 66
DENAVIR....................................................................... 79
DEPEN TITRATABS.................................................... 89
DEPEN TITRATABS.................................................... 98
DEPEN TITRATABS.................................................. 114
DEPO-PROVERA........................................................ 92
desipramine hcl tab 100 mg....................................... 21
desipramine hcl tab 10 mg......................................... 21
desipramine hcl tab 150 mg....................................... 21
desmopressin acetate inj 4 mcg/ml........................... 91
desmopressin acetate nasal soln 0.01%
(refrigerated).............................................................. 91
desmopressin acetate nasal spray soln 0.01%....... 91
(refrigerated).............................................................. 91
desmopressin acetate tab 0.1 mg............................. 91
127
2016
desmopressin acetate tab 0.2 mg............................. 91
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5)..................................................................... 92
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg..............92
desogestrel & ethinyl estradiol tab 0.15 mg-30
mcg..............................................................................92
desonide cream 0.05%............................................... 79
desonide lotion 0.05%................................................. 79
desonide oint 0.05%.................................................... 79
DESOXIMETASONE................................................... 79
desoximetasone cream 0.25%...................................79
desoximetasone gel 0.05%........................................ 79
desoximetasone oint 0.25%....................................... 79
DEXAMETHASONE.................................................... 90
DEXAMETHASONE.................................................... 90
dexamethasone elixir 0.5 mg/5ml..............................90
dexamethasone sodium phosphate inj 120
mg/30ml...................................................................... 90
dexamethasone sodium phosphate inj 20
mg/5ml........................................................................ 90
dexamethasone sodium phosphate inj 4 mg/ml...... 90
dexamethasone sodium phosphate ophth soln
0.1%.......................................................................... 104
dexamethasone tab 0.5 mg........................................90
dexamethasone tab 0.75 mg..................................... 90
dexamethasone tab 1.5 mg........................................90
dexamethasone tab 4 mg........................................... 90
dexamethasone tab 6 mg........................................... 90
DEXILANT..................................................................... 85
DEXILANT..................................................................... 85
dexmethylphenidate hcl tab 10 mg........................... 75
dexmethylphenidate hcl tab 2.5 mg.......................... 75
dexmethylphenidate hcl tab 5 mg............................. 75
dexrazoxane for inj 250 mg........................................33
dexrazoxane for inj 500 mg........................................33
dextroamphetamine sulfate cap sr 24hr 10 mg....... 75
dextroamphetamine sulfate cap sr 24hr 15 mg....... 75
dextroamphetamine sulfate cap sr 24hr 5 mg......... 75
dextroamphetamine sulfate tab 10 mg..................... 76
dextroamphetamine sulfate tab 5 mg....................... 75
dextromethorphan-guaifenesin liquid 10-100
mg/5ml...................................................................... 109
dextrose 2.5% w/ sodium chloride 0.45%.............. 114
dextrose 5% in lactated ringers............................... 114
dextrose 5% w/ sodium chloride 0.2%................... 114
dextrose 5% w/ sodium chloride 0.33%................. 114
dextrose 5% w/ sodium chloride 0.45%................. 114
dextrose 5% w/ sodium chloride 0.9%................... 114
dextrose inj 10%........................................................ 114
dextrose inj 5%.......................................................... 114
diaper rash products - ointment................................. 79
128
DIASTAT ACUDIAL......................................................15
DIASTAT ACUDIAL......................................................15
DIASTAT PEDIATRIC.................................................. 15
DIAZEPAM.................................................................... 15
DIAZEPAM.................................................................... 15
DIAZEPAM.................................................................... 15
DIAZEPAM.................................................................... 15
DIAZEPAM.................................................................... 53
diazepam conc 5 mg/ml..............................................15
diazepam conc 5 mg/ml..............................................53
diazepam tab 10 mg................................................... 15
diazepam tab 10 mg................................................... 53
diazepam tab 2 mg......................................................15
diazepam tab 2 mg......................................................53
diazepam tab 5 mg......................................................15
diazepam tab 5 mg......................................................53
dibucaine oint 1%........................................................ 79
diclofenac potassium tab 50 mg.................................. 1
diclofenac potassium tab 50 mg................................ 27
diclofenac sodium gel 1%............................................. 1
diclofenac sodium gel 1%...........................................27
diclofenac sodium ophth soln 0.1%........................ 104
diclofenac sodium tab delayed release 25 mg........... 1
diclofenac sodium tab delayed release 25 mg........ 27
diclofenac sodium tab sr 24hr 100 mg........................1
diclofenac sodium tab sr 24hr 100 mg..................... 28
diclofenac w/ misoprostol tab delayed release 50-0.2
mg.................................................................................. 1
mg................................................................................28
mg.................................................................................. 1
mg................................................................................28
dicloxacillin sodium cap 250 mg................................ 10
dicloxacillin sodium cap 500 mg................................ 10
dicyclomine hcl tab 20 mg.......................................... 85
didanosine delayed release capsule 125 mg........... 48
DIFICID.......................................................................... 10
DIFLORASONE DIACETATE..................................... 79
DIGOXIN........................................................................66
digoxin tab 125 mcg (0.125 mg)................................66
digoxin tab 250 mcg (0.25 mg).................................. 66
2016
DILANTIN...................................................................... 15
diltiazem hcl cap sr 12hr 120 mg.............................. 66
diltiazem hcl cap sr 12hr 60 mg................................ 66
diltiazem hcl cap sr 12hr 90 mg................................ 66
diltiazem hcl coated beads cap sr 24hr 120 mg...... 66
diltiazem hcl coated beads tab sr 24hr 180 mg....... 66
diltiazem hcl extended release beads cap sr 24hr
120 mg....................................................................... 67
180 mg....................................................................... 67
240 mg....................................................................... 67
300 mg....................................................................... 67
360 mg....................................................................... 67
420 mg....................................................................... 67
diltiazem hcl tab 120 mg............................................ 67
diltiazem hcl tab 30 mg............................................... 67
dimethicone lotion 1%................................................. 79
DIPENTUM................................................................. 102
diphenhydramine hcl cap 25 mg............................... 24
diphenhydramine hcl cap 25 mg............................... 42
diphenhydramine hcl inj 50 mg/ml.............................24
diphenhydramine hcl inj 50 mg/ml.............................42
diphenhydramine hcl tab 25 mg................................ 24
diphenhydramine hcl tab 25 mg................................ 42
diphenhydramine-phenylephrine liq 6.25-2.5
mg/5ml...................................................................... 109
diphenhydramine-phenylephrine soln 12.5-5
mg/5ml...................................................................... 109
diphenhydramine-phenylephrine tab 25-10 mg..... 109
DIPHTHERIA/TETANUS TOXOID.............................99
dipyridamole tab 25 mg.............................................. 61
disulfiram tab 250 mg.................................................... 6
disulfiram tab 500 mg.................................................... 6
divalproex sodium cap delayed release sprinkle 125
mg................................................................................15
mg................................................................................29
mg................................................................................55
divalproex sodium tab delayed release 125 mg...... 15
divalproex sodium tab sr 24 hr 250 mg.................... 16
DIVIGEL......................................................................... 92
DIVIGEL......................................................................... 92
DIVIGEL......................................................................... 92
DOCEFREZ.................................................................. 33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
docetaxel for inj conc 20 mg/ml................................. 33
docetaxel for inj conc 80 mg/4ml (20 mg/ml)........... 33
docusate calcium cap 240 mg................................... 85
docusate sodium cap 100 mg.................................... 85
docusate sodium cap 250 mg.................................... 85
docusate sodium liquid 150 mg/15ml....................... 85
docusate sodium syrup 60 mg/15ml......................... 85
docusate sodium tab 100 mg.....................................85
DOMETUSS-DA/CHILDREN................................... 109
donepezil hydrochloride orally disintegrating tab 10
mg................................................................................18
donepezil hydrochloride orally disintegrating tab 5
mg................................................................................18
donepezil hydrochloride tab 10 mg........................... 19
donepezil hydrochloride tab 23 mg........................... 19
donepezil hydrochloride tab 5 mg............................. 18
dorzolamide hcl ophth soln 2%............................... 104
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml........................................................................ 104
129
2016
doxazosin mesylate tab 1 mg.................................... 67
DOXEPIN HCL............................................................. 21
DOXEPIN HCL............................................................. 53
doxepin hcl cap 100 mg............................................. 21
doxepin hcl cap 10 mg............................................... 21
doxepin hcl conc 10 mg/ml........................................ 21
doxepin hcl conc 10 mg/ml........................................ 53
doxorubicin hcl for inj 10 mg...................................... 33
doxorubicin hcl for inj 50 mg...................................... 33
doxorubicin hcl inj 2 mg/ml.........................................33
doxorubicin hcl liposomal inj (for iv infusion) 2 mg/
ml................................................................................. 33
doxycycline hyclate cap 100 mg................................10
doxycycline hyclate cap 100 mg................................77
doxycycline hyclate cap 50 mg.................................. 10
doxycycline hyclate cap 50 mg.................................. 77
doxycycline hyclate for inj 100 mg............................ 10
doxycycline hyclate for inj 100 mg............................ 77
doxycycline hyclate tab 100 mg................................ 11
doxycycline hyclate tab 100 mg................................ 77
doxycycline hyclate tab 20 mg...................................11
doxycycline hyclate tab 20 mg...................................77
doxycycline monohydrate cap 100 mg..................... 11
doxycycline monohydrate cap 150 mg..................... 11
doxycycline monohydrate cap 50 mg....................... 11
doxycycline monohydrate cap 75 mg....................... 11
doxycycline monohydrate tab 100 mg...................... 11
doxycycline monohydrate tab 150 mg...................... 11
doxycycline monohydrate tab 50 mg........................ 11
doxycycline monohydrate tab 75 mg........................ 11
DRAMAMINE................................................................ 24
dronabinol cap 10 mg................................................. 24
dronabinol cap 2.5 mg................................................ 24
dronabinol cap 5 mg................................................... 24
drospirenone-ethinyl estradiol tab 3-0.02 mg.......... 92
drospirenone-ethinyl estradiol tab 3-0.03 mg.......... 92
DULERA...................................................................... 109
130
DULERA...................................................................... 109
duloxetine hcl enteric coated pellets cap 20 mg...... 21
DUREZOL................................................................... 104
dutasteride cap 0.5 mg............................................... 89
dutasteride-tamsulosin hcl cap 0.5-0.4 mg.............. 89
E
E.E.S. GRANULES...................................................... 11
econazole nitrate cream 1%...................................... 79
ED CHLORPED D..................................................... 109
EDURANT..................................................................... 49
EFFIENT........................................................................ 61
EFFIENT........................................................................ 61
EGRIFTA....................................................................... 91
EGRIFTA....................................................................... 91
ELAPRASE................................................................... 83
electrolyte-m in d5w soln.......................................... 114
ELELYSO.......................................................................83
ELIDEL........................................................................... 79
ELIDEL........................................................................... 99
ELIGARD....................................................................... 96
ELIGARD....................................................................... 96
ELIGARD....................................................................... 96
ELIGARD....................................................................... 96
ELIQUIS......................................................................... 61
ELIQUIS......................................................................... 61
ELITEK........................................................................... 33
ELITEK........................................................................... 33
ELLA...............................................................................92
EMCYT.......................................................................... 33
EMEND.......................................................................... 25
EMEND.......................................................................... 25
EMEND.......................................................................... 25
EMEND.......................................................................... 25
EMEND.......................................................................... 25
EMETROL..................................................................... 25
EMPLICITI..................................................................... 33
EMPLICITI..................................................................... 33
EMSAM.......................................................................... 21
EMSAM.......................................................................... 21
EMSAM.......................................................................... 21
EMTRIVA....................................................................... 49
EMTRIVA....................................................................... 49
enalapril maleate & hydrochlorothiazide tab 10-25
mg................................................................................67
2016
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg................................................................................67
enalapril maleate tab 10 mg...................................... 67
enalapril maleate tab 2.5 mg..................................... 67
enalapril maleate tab 20 mg...................................... 67
enalapril maleate tab 5 mg.........................................67
ENBREL........................................................................ 99
ENBREL........................................................................ 99
ENBREL........................................................................ 99
ENBREL SURECLICK................................................ 99
ENCARE........................................................................ 79
ENGERIX-B.................................................................. 99
ENGERIX-B.................................................................. 99
enoxaparin sodium inj 100 mg/ml............................. 62
enoxaparin sodium inj 120 mg/0.8ml........................ 62
enoxaparin sodium inj 150 mg/ml............................. 62
enoxaparin sodium inj 300 mg/3ml........................... 62
enoxaparin sodium inj 30 mg/0.3ml.......................... 62
entacapone tab 200 mg.............................................. 42
entecavir tab 0.5 mg................................................... 49
entecavir tab 1 mg....................................................... 49
epinastine hcl ophth soln 0.05%............................. 104
EPIPEN 2-PAK........................................................... 109
EPIPEN-JR 2-PAK..................................................... 109
epirubicin hcl iv soln 200 mg/100ml (2 mg/ml)........ 33
epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)............. 33
EPIVIR HBV.................................................................. 49
eplerenone tab 25 mg................................................. 67
eplerenone tab 50 mg................................................. 67
EPOGEN....................................................................... 62
EPOGEN....................................................................... 62
EPOGEN....................................................................... 62
EPOGEN....................................................................... 62
EPOGEN....................................................................... 62
eprosartan mesylate tab 600 mg............................... 67
EPZICOM...................................................................... 49
EQL NATURAL FIBER................................................ 85
EQUETRO..................................................................... 55
EQUETRO..................................................................... 55
EQUETRO..................................................................... 55
ERBITUX....................................................................... 33
ERBITUX....................................................................... 33
ergoloid mesylates tab 1 mg...................................... 19
ERIVEDGE.................................................................... 33
ERWINAZE................................................................... 33
ERYPED 200................................................................ 11
ERYPED 400................................................................ 11
ERY-TAB....................................................................... 11
ERY-TAB....................................................................... 11
ERY-TAB....................................................................... 11
ERYTHROCIN LACTOBIONATE...............................11
ERYTHROCIN STEARATE........................................ 11
ERYTHROMYCIN BASE............................................ 11
ERYTHROMYCIN BASE............................................ 11
erythromycin ophth oint 5 mg/gm............................ 104
erythromycin pads 2%................................................ 79
erythromycin soln 2%.................................................. 79
ESBRIET..................................................................... 109
escitalopram oxalate soln 5 mg/5ml..........................21
escitalopram oxalate soln 5 mg/5ml..........................54
escitalopram oxalate tab 10 mg................................ 21
escitalopram oxalate tab 5 mg...................................21
escitalopram oxalate tab 5 mg...................................54
esomeprazole magnesium cap delayed release 20
mg................................................................................85
esomeprazole magnesium cap delayed release 40
mg................................................................................85
ESOMEPRAZOLE SODIUM...................................... 85
esomeprazole sodium for intravenous soln 40
mg................................................................................85
ESTRACE......................................................................92
estradiol & norethindrone acetate tab 0.5-0.1
mg................................................................................92
estradiol & norethindrone acetate tab 1-0.5 mg...... 92
estradiol tab 0.5 mg.....................................................92
estradiol tab 1 mg........................................................ 92
estradiol tab 2 mg........................................................ 92
estradiol td patch weekly 0.025 mg/24hr.................. 92
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr)................................................................... 93
estradiol td patch weekly 0.05 mg/24hr.................... 93
estradiol td patch weekly 0.06 mg/24hr.................... 93
estradiol td patch weekly 0.075 mg/24hr.................. 93
estradiol td patch weekly 0.1 mg/24hr...................... 93
ESTROPIPATE............................................................. 93
estropipate tab 0.75 mg.............................................. 93
estropipate tab 1.5 mg................................................ 93
ethambutol hcl tab 100 mg.........................................30
ethambutol hcl tab 400 mg.........................................30
ethosuximide cap 250 mg.......................................... 16
ethosuximide soln 250 mg/5ml.................................. 16
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg..............................................................................93
ETIDRONATE DISODIUM........................................ 103
ETIDRONATE DISODIUM........................................ 103
etodolac cap 200 mg..................................................... 2
etodolac cap 200 mg...................................................28
etodolac cap 300 mg..................................................... 2
131
2016
etodolac cap 300 mg...................................................28
etodolac tab 400 mg......................................................2
etodolac tab 400 mg................................................... 28
etodolac tab 500 mg......................................................2
etodolac tab 500 mg................................................... 28
etodolac tab sr 24hr 400 mg........................................ 2
etodolac tab sr 24hr 400 mg...................................... 28
ETOPOPHOS............................................................... 33
etoposide inj 100 mg/5ml (20 mg/ml)....................... 33
etoposide inj 1 gm/50ml (20 mg/ml).......................... 33
etoposide inj 500 mg/25ml (20 mg/ml)..................... 33
EVOTAZ......................................................................... 49
EXELON........................................................................ 19
EXELON........................................................................ 19
EXELON........................................................................ 19
exemestane tab 25 mg............................................... 33
EXJADE....................................................................... 114
EXJADE....................................................................... 114
EXJADE....................................................................... 114
EX-LAX.......................................................................... 85
F
FABRAZYME................................................................ 83
FABRAZYME................................................................ 83
famciclovir tab 125 mg................................................ 49
famotidine for susp 40 mg/5ml.................................. 85
famotidine inj 200 mg/20ml........................................ 85
famotidine inj 20 mg/2ml.............................................85
famotidine inj 40 mg/4ml.............................................85
famotidine tab 10 mg.................................................. 85
FANAPT......................................................................... 43
FANAPT......................................................................... 43
FANAPT......................................................................... 43
FANAPT......................................................................... 43
FANAPT......................................................................... 43
FANAPT......................................................................... 43
FANAPT......................................................................... 43
FANAPT TITRATION PACK....................................... 43
FARESTON................................................................... 34
FARYDAK...................................................................... 34
FARYDAK...................................................................... 34
FARYDAK...................................................................... 34
FASLODEX................................................................... 34
fat emulsion iv soln 20%.......................................... 114
132
FAZACLO...................................................................... 43
FAZACLO...................................................................... 43
FAZACLO...................................................................... 44
FAZACLO...................................................................... 44
FAZACLO...................................................................... 44
felbamate susp 600 mg/5ml....................................... 16
felbamate tab 400 mg................................................. 16
felbamate tab 600 mg................................................. 16
felodipine tab sr 24hr 10 mg...................................... 67
felodipine tab sr 24hr 2.5 mg..................................... 67
felodipine tab sr 24hr 5 mg........................................ 67
fenofibrate micronized cap 134 mg........................... 67
fenofibrate micronized cap 200 mg........................... 67
fenofibrate micronized cap 67 mg............................. 67
fenofibrate tab 145 mg................................................ 67
fenofibrate tab 160 mg................................................ 67
fenofibrate tab 48 mg.................................................. 67
fenofibrate tab 54 mg.................................................. 67
fentanyl citrate lozenge on a handle 1200 mcg......... 2
fentanyl citrate lozenge on a handle 1600 mcg......... 2
fentanyl citrate lozenge on a handle 200 mcg........... 2
fentanyl td patch 72hr 100 mcg/hr...............................2
fentanyl td patch 72hr 12 mcg/hr................................. 2
ferrous gluconate tab 325 mg (36 mg elemental
fe).............................................................................. 114
FERROUS SULFATE................................................ 114
FERROUS SULFATE................................................ 115
ferrous sulfate dried tab 200 mg (65 mg elemental
fe).............................................................................. 115
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml
elemental fe)............................................................115
ferrous sulfate tab 325 mg (65 mg elemental
fe).............................................................................. 115
ferrous sulfate tab ec 325 mg (65 mg fe
equivalent)............................................................... 115
FETZIMA....................................................................... 21
FETZIMA....................................................................... 21
FETZIMA....................................................................... 21
FETZIMA....................................................................... 21
FETZIMA TITRATION PACK......................................21
FIBERCON.................................................................... 85
FINACEA....................................................................... 79
FINACEA....................................................................... 79
finasteride tab 5 mg.....................................................89
FIRAZYR....................................................................... 99
FIRMAGON................................................................... 96
2016
FIRMAGON................................................................... 96
flecainide acetate tab 100 mg.................................... 67
flecainide acetate tab 150 mg.................................... 67
flecainide acetate tab 50 mg...................................... 67
FLEET LIQUID GLYCERIN SUPPOSITORIES....... 86
FLOVENT DISKUS.................................................... 109
FLOVENT DISKUS.................................................... 109
FLOVENT DISKUS.................................................... 109
FLOVENT HFA........................................................... 109
FLOVENT HFA........................................................... 109
FLOVENT HFA........................................................... 109
fluconazole for susp 10 mg/ml................................... 26
fluconazole for susp 40 mg/ml................................... 26
fluconazole in dextrose inj 200 mg/100ml................ 26
fluconazole in dextrose inj 400 mg/200ml................ 26
fluconazole in nacl 0.9% inj 200 mg/100ml.............. 26
fluconazole in nacl 0.9% inj 400 mg/200ml.............. 26
fluconazole tab 100 mg.............................................. 26
fluconazole tab 50 mg.................................................26
flucytosine cap 250 mg............................................... 26
flucytosine cap 500 mg............................................... 26
fludarabine phosphate for inj 50 mg......................... 34
fludarabine phosphate inj 25 mg/ml.......................... 34
fludrocortisone acetate tab 0.1 mg............................ 90
fluocinolone acetonide (otic) oil 0.01%................... 106
fluocinolone acetonide cream 0.01%........................ 79
fluocinonide cream 0.05%.......................................... 79
fluocinonide emulsified base cream 0.05%.............. 79
fluocinonide gel 0.05%................................................ 79
fluocinonide oint 0.05%............................................... 79
fluocinonide soln 0.05%.............................................. 79
fluorometholone ophth susp 0.1%...........................104
fluorouracil cream 5%................................................. 79
fluorouracil inj 1 gm/20ml (50 mg/ml)........................34
fluorouracil inj 2.5 gm/50ml (50 mg/ml).................... 34
fluorouracil inj 500 mg/10ml (50 mg/ml)................... 34
fluorouracil inj 5 gm/100ml (50 mg/ml)..................... 34
fluorouracil soln 2%..................................................... 79
fluorouracil soln 5%..................................................... 79
fluoxetine hcl cap 10 mg............................................ 21
fluoxetine hcl cap delayed release 90 mg................ 21
fluoxetine hcl solution 20 mg/5ml.............................. 21
fluoxetine hcl tab 10 mg............................................. 21
fluoxetine hcl tab 20 mg............................................. 21
fluphenazine decanoate inj 25 mg/ml....................... 44
FLUPHENAZINE HCL................................................. 44
fluphenazine hcl tab 10 mg........................................ 44
fluphenazine hcl tab 1 mg.......................................... 44
fluphenazine hcl tab 2.5 mg....................................... 44
fluphenazine hcl tab 5 mg.......................................... 44
flurbiprofen sodium ophth soln 0.03%.................... 104
flurbiprofen tab 100 mg................................................. 2
flurbiprofen tab 100 mg............................................... 28
flurbiprofen tab 50 mg................................................... 2
flurbiprofen tab 50 mg................................................. 28
flutamide cap 125 mg................................................. 34
fluticasone propionate cream 0.05%.........................79
fluticasone propionate nasal susp 50 mcg/act.......109
fluticasone propionate oint 0.005%........................... 79
fluvoxamine maleate tab 100 mg.............................. 22
fluvoxamine maleate tab 25 mg................................ 22
fluvoxamine maleate tab 50 mg................................ 22
folic acid tab 400 mcg............................................... 115
folic acid tab 800 mcg............................................... 115
FOLOTYN......................................................................34
FOLOTYN......................................................................34
fomepizole inj 1 gm/ml (for iv infusion)................... 115
fondaparinux sodium subcutaneous inj 10
mg/0.8ml..................................................................... 62
fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml..................................................................... 62
fondaparinux sodium subcutaneous inj 5
mg/0.4ml..................................................................... 62
fondaparinux sodium subcutaneous inj 7.5
mg/0.6ml..................................................................... 62
FORADIL AEROLIZER............................................. 109
FORTAZ......................................................................... 11
FORTAZ......................................................................... 11
FORTAZ......................................................................... 11
FORTEO...................................................................... 103
FORTICAL...................................................................103
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg................................................................................67
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg................................................................................68
fosinopril sodium tab 10 mg....................................... 68
fosphenytoin sodium inj 100 mg/2ml........................ 16
fosphenytoin sodium inj 500 mg/10ml...................... 16
FOSRENOL.................................................................. 89
FOSRENOL.................................................................. 89
FOSRENOL.................................................................. 89
FOSRENOL.................................................................. 89
FOSRENOL.................................................................. 89
FUNGOID TINCTURE.................................................79
furosemide inj 10 mg/ml............................................. 68
furosemide oral soln 10 mg/ml.................................. 68
133
2016
furosemide tab 20 mg................................................. 68
FUZEON........................................................................ 49
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
G
gabapentin cap 100 mg.............................................. 16
gabapentin oral soln 250 mg/5ml.............................. 16
gabapentin tab 600 mg............................................... 16
gabapentin tab 800 mg............................................... 16
GABITRIL...................................................................... 16
GABITRIL...................................................................... 16
GALANTAMINE HYDROBROMIDE.......................... 19
galantamine hydrobromide cap sr 24hr 16 mg........ 19
galantamine hydrobromide cap sr 24hr 24 mg........ 19
galantamine hydrobromide cap sr 24hr 8 mg.......... 19
galantamine hydrobromide tab 12 mg...................... 19
galantamine hydrobromide tab 4 mg........................ 19
galantamine hydrobromide tab 8 mg........................ 19
GAMMAPLEX............................................................... 99
GAMMAPLEX............................................................... 99
GAMMAPLEX............................................................... 99
GAMMAPLEX............................................................... 99
GAMUNEX-C................................................................ 99
GAMUNEX-C................................................................ 99
GAMUNEX-C................................................................ 99
GAMUNEX-C................................................................ 99
GAMUNEX-C................................................................ 99
GAMUNEX-C................................................................ 99
ganciclovir sodium for inj 500 mg.............................. 49
GARDASIL.................................................................... 99
GARDASIL 9.................................................................99
GARDASIL 9.................................................................99
GATTEX......................................................................... 86
GAUZE PADS 2" X 2"................................................. 57
GAVISCON.................................................................... 86
GAVISCON.................................................................... 86
GAVISCON EXTRA STRENGTH RELIEF
FORMULA.................................................................. 86
GAZYVA.........................................................................34
GELUSIL........................................................................86
gemcitabine hcl for inj 1 gm....................................... 34
gemcitabine hcl for inj 200 mg...................................34
gemcitabine hcl for inj 2 gm....................................... 34
134
gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml)............ 34
gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml)........ 34
gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml)............ 34
gemfibrozil tab 600 mg............................................... 68
gentamicin in saline inj 0.8 mg/ml............................. 11
gentamicin in saline inj 1 mg/ml................................ 11
GENTAMICIN SULFATE............................................. 79
GENTAMICIN SULFATE............................................. 79
GENTAMICIN SULFATE/0.9% SODIUM
CHLORIDE.................................................................11
GENTAMICIN SULFATE/0.9% SODIUM
CHLORIDE.................................................................11
gentamicin sulfate inj 10 mg/ml................................. 11
gentamicin sulfate inj 40 mg/ml................................. 11
gentamicin sulfate iv soln 10 mg/ml.......................... 11
gentamicin sulfate ophth oint 0.3%......................... 104
gentamicin sulfate ophth soln 0.3%........................ 104
GENTEAL SEVERE.................................................. 104
GENVOYA..................................................................... 49
GEODON....................................................................... 44
GILOTRIF...................................................................... 34
GILOTRIF...................................................................... 34
GILOTRIF...................................................................... 34
Glatopa - glatiramer acetate soln prefilled syringe 20
mg/ml.......................................................................... 76
GLEEVEC......................................................................34
GLEEVEC......................................................................34
GLEOSTINE..................................................................34
GLEOSTINE..................................................................34
GLEOSTINE..................................................................34
GLEOSTINE..................................................................34
glimepiride tab 1 mg.................................................... 57
glipizide-metformin hcl tab 2.5-250 mg.....................57
glipizide-metformin hcl tab 2.5-500 mg.....................57
glipizide-metformin hcl tab 5-500 mg........................ 57
glipizide tab 10 mg...................................................... 57
glipizide tab 5 mg........................................................ 57
glipizide tab sr 24hr 10 mg.........................................57
glipizide tab sr 24hr 2.5 mg........................................57
glipizide tab sr 24hr 5 mg........................................... 57
GLUCAGEN HYPOKIT............................................... 57
GLUCAGON EMERGENCY KIT............................... 58
GLUCOSE..................................................................... 58
GLYCERIN.................................................................... 86
glycerin suppos 1.2 gm............................................... 86
glycerin suppos 1 gm.................................................. 86
glycerin suppos 2 gm.................................................. 86
glycerin suppos 80.7%................................................ 86
2016
glycerin topical liquid................................................... 86
glycopyrrolate tab 1 mg.............................................. 86
glycopyrrolate tab 2 mg.............................................. 86
granisetron hcl tab 1 mg............................................. 25
GRANIX......................................................................... 62
GRANIX......................................................................... 62
GRASTEK................................................................... 109
griseofulvin microsize susp 125 mg/5ml................... 26
griseofulvin ultramicrosize tab 125 mg..................... 26
griseofulvin ultramicrosize tab 250 mg..................... 26
guaifenesin-codeine soln 100-10 mg/5ml.............. 109
guaifenesin liquid 100 mg/5ml................................. 109
GUANIDINE HCL......................................................... 30
GYNE-LOTRIMIN......................................................... 26
GYNE-LOTRIMIN 3..................................................... 26
H
H.P. ACTHAR............................................................... 90
HALAVEN...................................................................... 34
halobetasol propionate cream 0.05%....................... 79
halobetasol propionate oint 0.05%............................ 79
haloperidol decanoate im soln 100 mg/ml................44
haloperidol decanoate im soln 50 mg/ml.................. 44
haloperidol lactate inj 5 mg/ml................................... 44
haloperidol lactate oral conc 2 mg/ml....................... 44
haloperidol tab 0.5 mg................................................ 44
haloperidol tab 10 mg................................................. 44
haloperidol tab 1 mg................................................... 44
haloperidol tab 20 mg................................................. 44
HARVONI...................................................................... 49
HAVRIX.......................................................................... 99
HAVRIX.......................................................................... 99
HEMORRHOIDAL........................................................ 80
heparin sodium (porcine) 40 unit/ml in d5w............. 62
heparin sodium (porcine) inj 10000 unit/ml.............. 62
heparin sodium (porcine) inj 1000 unit/ml................ 62
heparin sodium (porcine) inj 20000 unit/ml.............. 62
heparin sodium (porcine) inj 5000 unit/ml................ 62
heparin sodium (porcine) pf inj 5000 unit/0.5ml.......62
HERCEPTIN................................................................. 34
HETLIOZ..................................................................... 112
HEXALEN...................................................................... 34
HIBERIX...................................................................... 100
HM VITAMIN D3........................................................ 115
HUMALOG.................................................................... 58
HUMALOG.................................................................... 58
HUMALOG KWIKPEN.................................................58
HUMALOG KWIKPEN.................................................58
HUMALOG MIX 50/50................................................ 58
HUMALOG MIX 50/50 KWIKPEN............................. 58
HUMALOG MIX 75/25................................................ 58
HUMALOG MIX 75/25 KWIKPEN............................. 58
HUMIRA...................................................................... 100
HUMIRA...................................................................... 100
HUMIRA...................................................................... 100
HUMIRA PEDIATRIC CROHNS DISEASE
STARTER PACK..................................................... 100
HUMIRA PEN............................................................. 100
HUMIRA PEN-CROHNS DISEASE STARTER..... 100
HUMIRA PEN-PSORIASIS STARTER................... 100
HUMULIN 70/30........................................................... 58
HUMULIN 70/30 KWIKPEN....................................... 58
HUMULIN N.................................................................. 58
HUMULIN N KWIKPEN.............................................. 58
HUMULIN R.................................................................. 58
HUMULIN R U-500 (CONCENTRATE).................... 58
HUMULIN R U-500 KWIKPEN.................................. 58
hydralazine hcl tab 100 mg........................................ 68
hydralazine hcl tab 10 mg.......................................... 68
hydrochlorothiazide cap 12.5 mg.............................. 68
hydrochlorothiazide tab 12.5 mg............................... 68
hydrochlorothiazide tab 25 mg...................................68
hydrochlorothiazide tab 50 mg...................................68
hydrocodone-acetaminophen soln 7.5-325
mg/15ml........................................................................ 2
hydrocodone-acetaminophen tab 10-300 mg............ 2
hydrocodone-acetaminophen tab 10-325 mg............ 2
hydrocodone-acetaminophen tab 5-300 mg.............. 2
hydrocodone-acetaminophen tab 5-325 mg.............. 2
hydrocodone-acetaminophen tab 7.5-300 mg........... 2
hydrocodone-acetaminophen tab 7.5-325 mg........... 2
hydrocodone-ibuprofen tab 10-200 mg....................... 2
hydrocodone-ibuprofen tab 5-200 mg......................... 2
hydrocodone-ibuprofen tab 7.5-200 mg......................2
hydrocortisone acetate cream 1%............................. 80
hydrocortisone-aloe vera cream 1%......................... 80
hydrocortisone butyrate cream 0.1%........................ 80
hydrocortisone butyrate oint 0.1%............................. 80
hydrocortisone butyrate soln 0.1%............................ 80
hydrocortisone cream 0.5%........................................80
hydrocortisone cream 1%........................................... 80
hydrocortisone cream 1%........................................... 80
hydrocortisone cream 2.5%........................................80
hydrocortisone enema 100 mg/60ml...................... 102
hydrocortisone lotion 1%............................................ 80
hydrocortisone lotion 2.5%......................................... 80
hydrocortisone oint 0.5%............................................ 80
hydrocortisone oint 1%............................................... 80
hydrocortisone oint 2.5%............................................ 80
hydrocortisone rectal cream 1%.............................. 102
135
2016
hydrocortisone rectal cream 2.5%...........................102
hydrocortisone tab 10 mg........................................... 90
hydrocortisone tab 20 mg........................................... 90
hydrocortisone tab 5 mg............................................. 90
hydrocortisone valerate cream 0.2%........................ 80
hydrocortisone valerate oint 0.2%............................. 80
hydrocortisone w/ acetic acid otic soln 1-2%......... 106
hydromorphone hcl liqd 1 mg/ml................................. 2
hydromorphone hcl preservative free inj 10 mg/
ml................................................................................... 2
hydromorphone hcl tab 2 mg....................................... 2
hydroxychloroquine sulfate tab 200 mg.................... 40
hydroxyurea cap 500 mg............................................ 34
hydroxyzine hcl syrup 10 mg/5ml.............................. 25
hydroxyzine hcl syrup 10 mg/5ml.............................. 54
hydroxyzine hcl syrup 10 mg/5ml............................ 109
hydroxyzine hcl tab 10 mg......................................... 25
hydroxyzine hcl tab 10 mg....................................... 109
hypromellose ophth soln 0.3%................................ 104
hypromellose ophth soln 0.4%................................ 104
I
ibandronate sodium iv soln 3 mg/3ml..................... 103
ibandronate sodium tab 150 mg..............................103
IBRANCE....................................................................... 34
IBRANCE....................................................................... 34
IBRANCE....................................................................... 34
ibuprofen cap 200 mg................................................... 3
ibuprofen cap 200 mg................................................. 28
ibuprofen susp 100 mg/5ml.......................................... 3
ibuprofen susp 100 mg/5ml........................................ 28
ibuprofen tab 200 mg.................................................... 3
ibuprofen tab 200 mg.................................................. 28
ibuprofen tab 400 mg.................................................... 3
ibuprofen tab 400 mg.................................................. 28
ibuprofen tab 600 mg.................................................... 3
ibuprofen tab 600 mg.................................................. 28
ibuprofen tab 800 mg.................................................... 3
ibuprofen tab 800 mg.................................................. 28
ICLUSIG........................................................................ 35
ICLUSIG........................................................................ 35
idarubicin hcl iv inj 10 mg/10ml (1 mg/ml)................ 35
idarubicin hcl iv inj 20 mg/20ml (1 mg/ml)................ 35
136
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).................... 35
IFEX............................................................................... 35
IFOSFAMIDE................................................................ 35
ifosfamide for inj 1 gm................................................ 35
ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 35
ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 35
ILARIS..........................................................................100
ILEVRO........................................................................104
imatinib mesylate tab 100 mg.................................... 35
imatinib mesylate tab 400 mg.................................... 35
IMBRUVICA.................................................................. 35
imipenem-cilastatin intravenous for soln 250
mg................................................................................11
imipenem-cilastatin intravenous for soln 500
mg................................................................................12
imipramine hcl tab 10 mg........................................... 22
imiquimod cream 5%................................................... 80
IMLYGIC........................................................................ 35
IMLYGIC........................................................................ 35
IMOVAX RABIES (H.D.C.V.).................................... 100
INCRELEX.................................................................... 91
INCRUSE ELLIPTA................................................... 110
indapamide tab 1.25 mg............................................. 68
indapamide tab 2.5 mg............................................... 68
INFANRIX.................................................................... 100
INLYTA........................................................................... 35
INLYTA........................................................................... 35
INSTA-GLUCOSE........................................................ 58
INSULIN INJECTION DEVICE.................................. 58
INSULIN SYRINGE/NEEDLE.....................................58
INTELENCE.................................................................. 49
INTELENCE.................................................................. 49
INTELENCE.................................................................. 49
INTRON A..................................................................... 49
INTRON A..................................................................... 49
INTRON A..................................................................... 49
INTRON A..................................................................... 49
INTRON A..................................................................... 49
INTRON A W/DILUENT.............................................. 49
INVANZ.......................................................................... 12
INVANZ.......................................................................... 12
INVEGA......................................................................... 44
INVEGA......................................................................... 44
INVEGA......................................................................... 44
INVEGA......................................................................... 44
INVEGA SUSTENNA.................................................. 44
INVEGA SUSTENNA.................................................. 44
INVEGA SUSTENNA.................................................. 44
2016
INVEGA SUSTENNA.................................................. 44
INVEGA SUSTENNA.................................................. 44
INVEGA TRINZA..........................................................44
INVEGA TRINZA..........................................................44
INVEGA TRINZA..........................................................45
INVEGA TRINZA..........................................................45
INVIRASE...................................................................... 49
INVIRASE...................................................................... 49
INVOKAMET................................................................. 58
INVOKAMET................................................................. 58
INVOKAMET................................................................. 58
INVOKAMET................................................................. 58
INVOKANA.................................................................... 58
INVOKANA.................................................................... 58
IPOL INACTIVATED IPV.......................................... 100
ipratropium bromide nasal soln 0.03% (21 mcg/
spray)........................................................................ 110
ipratropium bromide nasal soln 0.06% (42 mcg/
spray)........................................................................ 110
irbesartan-hydrochlorothiazide tab 150-12.5 mg..... 68
irbesartan-hydrochlorothiazide tab 300-12.5 mg..... 68
irbesartan tab 150 mg................................................. 68
irbesartan tab 300 mg................................................. 68
irbesartan tab 75 mg................................................... 68
IRESSA.......................................................................... 35
IRINOTECAN................................................................ 35
irinotecan hcl inj 100 mg/5ml (20 mg/ml)................. 35
irinotecan hcl inj 40 mg/2ml (20 mg/ml)....................35
ISENTRESS.................................................................. 49
ISENTRESS.................................................................. 49
ISENTRESS.................................................................. 49
ISENTRESS.................................................................. 49
ISONIAZID.................................................................... 30
isoniazid tab 100 mg................................................... 30
isoniazid tab 300 mg................................................... 30
ISOPTO TEARS.........................................................104
ISOSORBIDE DINITRATE.......................................... 68
isosorbide dinitrate tab 10 mg................................... 68
isosorbide dinitrate tab 20 mg................................... 68
isosorbide dinitrate tab 5 mg......................................68
isosorbide dinitrate tab cr 40 mg............................... 68
isosorbide mononitrate tab 10 mg............................. 68
isosorbide mononitrate tab 20 mg............................. 68
isosorbide mononitrate tab sr 24hr 120 mg............. 68
isosorbide mononitrate tab sr 24hr 30 mg................68
isosorbide mononitrate tab sr 24hr 60 mg................68
isotretinoin cap 10 mg.................................................80
isradipine cap 2.5 mg.................................................. 68
isradipine cap 5 mg..................................................... 68
ISTALOL...................................................................... 105
ISTODAX....................................................................... 35
itraconazole cap 100 mg............................................ 26
ivermectin tab 3 mg..................................................... 40
IXEMPRA KIT............................................................... 35
IXEMPRA KIT............................................................... 35
IXIARO......................................................................... 100
J
JADENU...................................................................... 115
JADENU...................................................................... 115
JADENU...................................................................... 115
JAKAFI........................................................................... 35
JAKAFI........................................................................... 35
JAKAFI........................................................................... 35
JAKAFI........................................................................... 35
JAKAFI........................................................................... 35
JANUMET......................................................................58
JANUMET......................................................................59
JANUMET XR...............................................................59
JANUMET XR...............................................................59
JANUMET XR...............................................................59
JANUVIA........................................................................59
JANUVIA........................................................................59
JANUVIA........................................................................59
JARDIANCE.................................................................. 59
JARDIANCE.................................................................. 59
JENTADUETO.............................................................. 59
JENTADUETO.............................................................. 59
JENTADUETO.............................................................. 59
JEVTANA....................................................................... 35
JUXTAPID..................................................................... 68
JUXTAPID..................................................................... 69
JUXTAPID..................................................................... 69
JUXTAPID..................................................................... 69
JUXTAPID..................................................................... 69
JUXTAPID..................................................................... 69
K
KADCYLA...................................................................... 35
KADCYLA...................................................................... 35
KALETRA...................................................................... 49
KALETRA...................................................................... 50
KALETRA...................................................................... 50
KALYDECO................................................................. 110
KALYDECO................................................................. 110
KALYDECO................................................................. 110
KCL 0.15%/D5W/LR.................................................. 115
KCL 0.3%/D5W/LR IV LACTATED RINGERS....... 115
kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%
inj............................................................................... 115
inj............................................................................... 115
137
2016
inj............................................................................... 115
inj............................................................................... 115
kcl 20 meq/l (0.15%) in nacl 0.45% inj................... 115
inj............................................................................... 115
inj............................................................................... 115
KEPIVANCE.................................................................. 77
ketoconazole cream 2%............................................. 80
ketoconazole shampoo 2%........................................ 80
ketoconazole tab 200 mg........................................... 26
ketoprofen cap 50 mg................................................... 3
ketoprofen cap 50 mg................................................. 28
ketoprofen cap 75 mg................................................... 3
ketoprofen cap 75 mg................................................. 28
ketorolac tromethamine ophth soln 0.4%............... 105
ketorolac tromethamine ophth soln 0.5%............... 105
ketotifen fumarate ophth soln 0.025%.................... 105
KEYTRUDA................................................................... 35
KEYTRUDA................................................................... 35
KINERET..................................................................... 100
KINRIX......................................................................... 100
KOMBIGLYZE XR........................................................ 59
KOMBIGLYZE XR........................................................ 59
KOMBIGLYZE XR........................................................ 59
KONSYL........................................................................ 86
KONSYL........................................................................ 86
KONSYL........................................................................ 86
KONSYL-D.................................................................... 86
KORLYM........................................................................ 96
KPN PRENATAL........................................................ 115
KP PRENATAL MULTIVITAMINS............................ 115
KUVAN........................................................................... 83
KUVAN........................................................................... 83
KUVAN........................................................................... 83
KYNAMRO.................................................................... 69
L
labetalol hcl tab 100 mg............................................. 69
LACRISERT................................................................ 105
lactated ringer's solution........................................... 115
lactic acid (ammonium lactate) cream 12%............. 80
lactic acid (ammonium lactate) lotion 12%............... 80
lactulose (encephalopathy) solution 10
gm/15ml...................................................................... 86
lactulose solution 10 gm/15ml................................... 86
LAMISIL AT................................................................... 26
LAMISIL AT................................................................... 80
138
lamivudine oral soln 10 mg/ml................................... 50
lamivudine tab 100 mg (hbv)..................................... 50
lamivudine tab 150 mg................................................50
lamivudine tab 300 mg................................................50
lamivudine-zidovudine tab 150-300 mg.................... 50
lamotrigine orally disintegrating tab 100 mg............ 16
lamotrigine orally disintegrating tab 25 mg...............16
lamotrigine tab 100 mg............................................... 16
lamotrigine tab 25 mg................................................. 16
lamotrigine tab 25 mg................................................. 55
lamotrigine tab chewable dispersible 25 mg............ 16
lamotrigine tab chewable dispersible 25 mg............ 55
lamotrigine tab chewable dispersible 5 mg.............. 16
lamotrigine tab chewable dispersible 5 mg.............. 55
lansoprazole cap delayed release 15 mg................. 86
lansoprazole cap delayed release 30 mg................. 86
LANTUS......................................................................... 59
LANTUS SOLOSTAR.................................................. 59
latanoprost ophth soln 0.005%................................ 105
LATUDA......................................................................... 45
LATUDA......................................................................... 45
LATUDA......................................................................... 45
LATUDA......................................................................... 45
LATUDA......................................................................... 45
LAZANDA........................................................................ 3
LAZANDA........................................................................ 3
leflunomide tab 10 mg.............................................. 100
leflunomide tab 20 mg.............................................. 100
LENVIMA 10MG DAILY DOSE.................................. 36
LETAIRIS..................................................................... 110
LETAIRIS..................................................................... 110
letrozole tab 2.5 mg.....................................................36
LEUCOVORIN CALCIUM........................................... 36
leucovorin calcium for inj 100 mg.............................. 36
2016
leucovorin calcium tab 25 mg.................................... 36
leucovorin calcium tab 5 mg...................................... 36
LEUKERAN................................................................... 36
LEUKINE....................................................................... 62
leuprolide acetate inj kit 5 mg/ml............................... 96
LEVEMIR....................................................................... 59
LEVEMIR FLEXPEN................................................... 59
LEVEMIR FLEXTOUCH..............................................59
LEVETIRACETAM........................................................16
LEVETIRACETAM........................................................16
LEVETIRACETAM........................................................17
levetiracetam inj 500 mg/5ml (100 mg/ml)............... 17
levetiracetam oral soln 100 mg/ml............................ 17
levetiracetam tab 1000 mg......................................... 17
levetiracetam tab 250 mg........................................... 17
levobunolol hcl ophth soln 0.5%..............................105
levocarnitine oral soln 1 gm/10ml (10%)................ 115
levocarnitine tab 330 mg.......................................... 115
levocetirizine dihydrochloride tab 5 mg.................. 110
levofloxacin in d5w iv soln 250 mg/50ml.................. 12
levofloxacin in d5w iv soln 500 mg/100ml................ 12
levofloxacin in d5w iv soln 750 mg/150ml................ 12
levofloxacin iv soln 25 mg/ml..................................... 12
levofloxacin oral soln 25 mg/ml................................. 12
levofloxacin tab 250 mg.............................................. 12
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg............................................................. 93
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg..............................................................................93
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg..............................................................................93
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg........................ 93
levonorgestrel-ethinyl estradiol (continuous) tab
90-20 mcg.................................................................. 93
0.01mg(7)................................................................... 93
0.01mg(7)................................................................... 93
LEVORPHANOL TARTRATE....................................... 3
levothyroxine sodium tab 100 mcg........................... 95
levothyroxine sodium tab 112 mcg............................ 95
levothyroxine sodium tab 25 mcg.............................. 95
LEXIVA........................................................................... 50
LEXIVA........................................................................... 50
LIALDA........................................................................ 102
LIDOCAINE HCL..........................................................69
lidocaine hcl gel 2%...................................................... 5
lidocaine hcl local inj 1%.............................................. 5
lidocaine hcl local preservative free inj 1%................ 5
lidocaine hcl soln 4%.....................................................5
lidocaine hcl viscous soln 2%...................................... 5
lidocaine oint 5%............................................................ 5
lidocaine patch 5%.........................................................5
lidocaine-prilocaine cream 2.5-2.5%........................... 5
lindane lotion 1%......................................................... 40
lindane shampoo 1%................................................... 40
linezolid for susp 100 mg/5ml.................................... 12
linezolid in sodium chloride iv soln 600
mg/300ml-0.9%......................................................... 12
linezolid iv soln 600 mg/300ml (2 mg/ml)................. 12
linezolid tab 600 mg.................................................... 12
LINZESS........................................................................ 86
LINZESS........................................................................ 86
liothyronine sodium tab 25 mcg................................. 95
liothyronine sodium tab 50 mcg................................. 95
liothyronine sodium tab 5 mcg................................... 95
lisinopril & hydrochlorothiazide tab 10-12.5 mg....... 69
lisinopril & hydrochlorothiazide tab 20-12.5 mg....... 69
lisinopril & hydrochlorothiazide tab 20-25 mg.......... 69
lisinopril tab 10 mg...................................................... 69
lisinopril tab 2.5 mg..................................................... 69
lisinopril tab 5 mg........................................................ 69
LITHIUM........................................................................ 55
lithium carbonate cap 150 mg................................... 55
lithium carbonate tab 300 mg.................................... 56
lithium carbonate tab cr 300 mg................................ 55
lithium carbonate tab cr 450 mg................................ 55
LIVALO........................................................................... 69
LIVALO........................................................................... 69
LIVALO........................................................................... 69
LMX 4...............................................................................5
LONSURF..................................................................... 36
LONSURF..................................................................... 36
loperamide hcl cap 2 mg............................................ 86
139
2016
loperamide hcl liq 1 mg/5ml (0.2 mg/ml).................. 86
loperamide hcl liq 1 mg/7.5ml.................................... 86
loperamide hcl tab 2 mg............................................. 86
loratadine syrup 5 mg/5ml........................................ 110
loratadine tab 10 mg................................................. 110
lorazepam tab 0.5 mg................................................. 54
lorazepam tab 1 mg.................................................... 54
lorazepam tab 2 mg.................................................... 54
losartan potassium & hydrochlorothiazide tab
100-12.5 mg.............................................................. 69
losartan potassium & hydrochlorothiazide tab 100-25
mg................................................................................69
losartan potassium & hydrochlorothiazide tab
50-12.5 mg.................................................................69
losartan potassium tab 100 mg................................. 69
losartan potassium tab 25 mg................................... 69
losartan potassium tab 50 mg................................... 69
LOTEMAX................................................................... 105
LOTEMAX................................................................... 105
LOTEMAX................................................................... 105
lovastatin tab 10 mg.................................................... 69
loxapine succinate cap 10 mg................................... 45
loxapine succinate cap 5 mg..................................... 45
lubricant gels - gel....................................................... 80
LUMIGAN.................................................................... 105
LUPRON DEPOT......................................................... 96
LUPRON DEPOT......................................................... 96
LUPRON DEPOT......................................................... 96
LUPRON DEPOT......................................................... 96
LUPRON DEPOT......................................................... 96
LUPRON DEPOT......................................................... 96
LUPRON DEPOT-PED............................................... 96
LUPRON DEPOT-PED............................................... 96
LUPRON DEPOT-PED............................................... 96
LUPRON DEPOT-PED............................................... 97
LUPRON DEPOT-PED............................................... 97
LYNPARZA.................................................................... 36
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 76
LYRICA.......................................................................... 76
140
LYRICA.......................................................................... 76
LYRICA.......................................................................... 76
LYRICA.......................................................................... 76
LYRICA.......................................................................... 76
LYRICA.......................................................................... 76
LYRICA.......................................................................... 76
LYRICA.......................................................................... 76
LYSODREN................................................................... 96
M
magnesium citrate soln............................................... 86
magnesium hydroxide susp 400 mg/5ml.................. 86
magnesium oxide tab 400 mg................................... 86
magnesium sulfate inj 50%...................................... 115
malathion lotion 0.5%.................................................. 40
MAPROTILINE HCL.................................................... 22
MAPROTILINE HCL.................................................... 22
MAPROTILINE HCL.................................................... 22
MARPLAN..................................................................... 22
MARQIBO......................................................................36
MATULANE................................................................... 36
meclizine hcl chew tab 25 mg................................... 25
meclizine hcl tab 12.5 mg...........................................25
meclizine hcl tab 25 mg.............................................. 25
medroxyprogesterone acetate im susp 150 mg/
ml................................................................................. 93
medroxyprogesterone acetate tab 10 mg.................93
medroxyprogesterone acetate tab 2.5 mg............... 93
medroxyprogesterone acetate tab 5 mg................... 93
mefloquine hcl tab 250 mg......................................... 41
megestrol acetate susp 40 mg/ml............................. 93
megestrol acetate tab 20 mg..................................... 93
megestrol acetate tab 40 mg..................................... 93
MEKINIST......................................................................36
MEKINIST......................................................................36
meloxicam tab 15 mg.................................................... 3
meloxicam tab 15 mg.................................................. 28
meloxicam tab 7.5 mg................................................... 3
meloxicam tab 7.5 mg................................................. 28
melphalan hcl for inj 50 mg........................................ 36
memantine hcl oral solution 2 mg/ml........................ 19
memantine hcl tab 10 mg........................................... 19
memantine hcl tab 5 mg............................................. 19
memantine hcl tab 5 mg (28) & 10 mg (21) titration
pak............................................................................... 19
MENACTRA................................................................ 100
MENEST........................................................................ 93
MENEST........................................................................ 93
MENEST........................................................................ 93
MENEST........................................................................ 93
MENHIBRIX................................................................ 100
MENOMUNE-A/C/Y/W-135...................................... 100
2016
MENVEO..................................................................... 100
mercaptopurine tab 50 mg......................................... 36
meropenem iv for soln 1 gm...................................... 12
meropenem iv for soln 500 mg.................................. 12
mesalamine enema 4 gm......................................... 102
mesna inj 100 mg/ml................................................... 36
MESNEX........................................................................36
MESTINON................................................................... 30
MESTINON TIMESPAN.............................................. 30
METAMUCIL MULTIHEALTH FIBER........................ 86
METAMUCIL MULTIHEALTH FIBER........................ 87
metformin hcl tab 1000 mg........................................ 59
metformin hcl tab 500 mg...........................................59
metformin hcl tab 850 mg...........................................59
metformin hcl tab sr 24hr 500 mg............................. 59
metformin hcl tab sr 24hr 750 mg............................. 59
methadone hcl tab 10 mg............................................. 3
methadone hcl tab 5 mg............................................... 3
methazolamide tab 25 mg.......................................... 69
methazolamide tab 50 mg.......................................... 69
methenamine hippurate tab 1 gm............................. 12
methimazole tab 10 mg.............................................. 98
methimazole tab 5 mg................................................ 97
methocarbamol tab 500 mg..................................... 112
methocarbamol tab 750 mg..................................... 112
methotrexate sodium for inj 1 gm.............................. 36
methotrexate sodium for inj 1 gm............................100
methotrexate sodium inj 250 mg/10ml (25 mg/
ml)................................................................................36
ml)............................................................................. 100
methotrexate sodium inj 50 mg/2ml (25 mg/ml)...... 37
ml)............................................................................. 101
methotrexate sodium inj pf 1000 mg/40ml (25 mg/
ml)................................................................................36
ml)............................................................................. 100
ml)................................................................................36
ml)............................................................................. 100
ml)................................................................................36
ml)............................................................................. 100
ml)................................................................................36
ml)............................................................................. 100
ml)................................................................................36
ml)............................................................................. 100
methotrexate sodium tab 2.5 mg............................... 37
methotrexate sodium tab 2.5 mg.............................101
methoxsalen rapid cap 10 mg................................... 80
methscopolamine bromide tab 2.5 mg..................... 87
methscopolamine bromide tab 5 mg......................... 87
methylcellulose tab 500 mg........................................87
methylergonovine maleate tab 0.2 mg..................... 89
methylphenidate hcl tab 10 mg................................. 76
methylphenidate hcl tab 20 mg................................. 76
methylphenidate hcl tab 5 mg.................................... 76
methylphenidate hcl tab cr 20 mg............................. 76
methylprednisolone sodium succinate for inj 1000
mg................................................................................91
mg................................................................................91
mg................................................................................90
methylprednisolone tab 16 mg...................................91
methylprednisolone tab 32 mg...................................91
methylprednisolone tab 4 mg..................................... 91
methylprednisolone tab 8 mg..................................... 91
methylprednisolone tab therapy pack 4 mg (21)..... 91
methyltestosterone cap 10 mg...................................93
metoclopramide hcl inj 5 mg/ml................................. 25
metoclopramide hcl inj 5 mg/ml................................. 87
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml).....................................................................25
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml).....................................................................87
metoclopramide hcl tab 10 mg.................................. 25
metoclopramide hcl tab 10 mg.................................. 87
metoclopramide hcl tab 5 mg.....................................25
metoclopramide hcl tab 5 mg.....................................87
metolazone tab 10 mg................................................ 69
metolazone tab 2.5 mg............................................... 69
metolazone tab 5 mg.................................................. 69
metoprolol & hydrochlorothiazide tab 100-25
mg................................................................................70
metoprolol & hydrochlorothiazide tab 50-25 mg...... 69
metoprolol succinate tab sr 24hr 100 mg................. 70
metoprolol succinate tab sr 24hr 200 mg................. 70
metoprolol succinate tab sr 24hr 25 mg................... 70
metoprolol succinate tab sr 24hr 50 mg................... 70
metoprolol tartrate tab 100 mg.................................. 70
metoprolol tartrate tab 25 mg.....................................70
metoprolol tartrate tab 50 mg.....................................70
METRO IV..................................................................... 12
metronidazole cap 375 mg......................................... 12
metronidazole cream 0.75%...................................... 80
metronidazole gel 0.75%............................................ 80
141
2016
metronidazole gel 1%..................................................80
metronidazole in nacl 0.79% iv soln 500
mg/100ml....................................................................12
metronidazole lotion 0.75%........................................ 80
metronidazole tab 250 mg.......................................... 12
metronidazole tab 500 mg.......................................... 12
metronidazole vaginal gel 0.75%.............................. 12
mexiletine hcl cap 150 mg......................................... 70
MIACALCIN................................................................ 103
miconazole nitrate aerosol pow 2%.......................... 80
miconazole nitrate cream 2%.................................... 80
miconazole nitrate powder 2%...................................80
miconazole nitrate vaginal app 200 mg & 2% cream
9 gm kit...................................................................... 26
miconazole nitrate vaginal cream 2%....................... 26
miconazole nitrate vaginal cream 4% (200
mg/5gm)..................................................................... 26
miconazole nitrate vaginal supp 200 mg & 2% cream
9 gm kit...................................................................... 26
miconazole nitrate vaginal suppos 100 mg.............. 26
midodrine hcl tab 10 mg............................................. 70
midodrine hcl tab 2.5 mg............................................ 70
midodrine hcl tab 5 mg............................................... 70
MIGERGOT................................................................... 29
MIGRANAL....................................................................29
minocycline hcl cap 100 mg....................................... 12
minocycline hcl cap 50 mg......................................... 12
minocycline hcl cap 75 mg......................................... 12
minocycline hcl tab 100 mg........................................12
minocycline hcl tab 50 mg.......................................... 12
minocycline hcl tab 75 mg.......................................... 12
minoxidil tab 10 mg..................................................... 70
minoxidil tab 2.5 mg.................................................... 70
mirtazapine orally disintegrating tab 15 mg............. 22
mirtazapine tab 15 mg................................................ 22
mirtazapine tab 7.5 mg............................................... 22
misoprostol tab 100 mcg............................................ 87
misoprostol tab 200 mcg............................................ 87
MISSION PRENATAL................................................115
MISSION PRENATAL HP......................................... 115
MITOMYCIN.................................................................. 37
mitomycin for iv soln 20 mg....................................... 37
mitomycin for iv soln 40 mg....................................... 37
mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml)..... 37
142
mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/
ml)................................................................................37
mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/
ml)................................................................................76
M-M-R II...................................................................... 100
modafinil tab 100 mg................................................ 112
modafinil tab 200 mg................................................ 112
moexipril hcl tab 15 mg.............................................. 70
moexipril hcl tab 7.5 mg............................................. 70
moexipril-hydrochlorothiazide tab 15-12.5 mg......... 70
moexipril-hydrochlorothiazide tab 15-25 mg............ 70
moexipril-hydrochlorothiazide tab 7.5-12.5 mg........ 70
MOLINDONE HYDROCHLORIDE............................ 45
mometasone furoate cream 0.1%............................. 80
mometasone furoate oint 0.1%.................................. 80
mometasone furoate solution 0.1% (lotion)..............81
montelukast sodium chew tab 4 mg....................... 110
montelukast sodium chew tab 5 mg....................... 110
montelukast sodium oral granules packet 4
mg............................................................................. 110
montelukast sodium tab 10 mg............................... 110
MORPHINE SULFATE.................................................. 3
MORPHINE SULFATE.................................................. 3
morphine sulfate beads cap sr 24hr 120 mg..............3
morphine sulfate beads cap sr 24hr 30 mg................ 3
morphine sulfate inj pf 0.5 mg/ml................................ 3
morphine sulfate inj pf 1 mg/ml................................... 3
morphine sulfate oral soln 100 mg/5ml (20 mg/
ml).................................................................................. 3
morphine sulfate oral soln 10 mg/5ml......................... 3
morphine sulfate oral soln 20 mg/5ml......................... 3
morphine sulfate tab cr 100 mg................................... 3
morphine sulfate tab cr 15 mg..................................... 3
morphine sulfate tab cr 200 mg................................... 3
MOVIPREP................................................................... 87
MOXEZA..................................................................... 105
moxifloxacin hcl tab 400 mg...................................... 12
MOZOBIL...................................................................... 62
MULTAQ........................................................................ 70
multiple vitamins w/ iron tab.....................................115
multiple vitamins w/ minerals tab............................ 115
multiple vitamin tab....................................................115
2016
mupirocin oint 2%........................................................ 81
MURO 128.................................................................. 105
MUSTARGEN............................................................... 37
MYALEPT...................................................................... 91
MYCAMINE................................................................... 26
MYCAMINE................................................................... 27
mycophenolate mofetil cap 250 mg........................ 101
mycophenolate mofetil for oral susp 200 mg/
ml............................................................................... 101
mycophenolate mofetil tab 500 mg......................... 101
mycophenolate sodium tab dr 180 mg................... 101
mycophenolate sodium tab dr 360 mg................... 101
MYLANTA DOUBLE-STRENGTH............................. 87
MYOZYME.................................................................... 83
MYRBETRIQ................................................................. 89
MYRBETRIQ................................................................. 89
N
nabumetone tab 500 mg............................................... 3
nabumetone tab 500 mg............................................ 28
nabumetone tab 750 mg............................................... 3
nabumetone tab 750 mg............................................ 28
nadolol tab 20 mg........................................................ 70
nadolol tab 40 mg........................................................ 70
nadolol tab 80 mg........................................................ 70
NAFCILLIN SODIUM................................................... 12
NAFCILLIN SODIUM................................................... 12
nafcillin sodium for inj 10 gm..................................... 12
nafcillin sodium for inj 1 gm....................................... 12
nafcillin sodium for inj 2 gm....................................... 12
NAGLAZYME................................................................ 83
NALOXONE HCL........................................................... 6
naloxone hcl inj 0.4 mg/ml............................................6
naltrexone hcl tab 50 mg.............................................. 6
NAMENDA.................................................................... 19
NAMENDA.................................................................... 19
NAMENDA.................................................................... 19
NAMENDA TITRATION PAK......................................19
NAMENDA XR............................................................. 19
NAMENDA XR............................................................. 19
NAMENDA XR............................................................. 19
NAMENDA XR............................................................. 19
NAMENDA XR TITRATION PACK............................ 19
NAPHAZOLINE HCL................................................. 105
naproxen sodium tab 220 mg...................................... 4
naproxen sodium tab 220 mg.................................... 28
naproxen susp 125 mg/5ml.......................................... 4
naproxen susp 125 mg/5ml........................................ 28
naproxen tab 250 mg.................................................... 4
naproxen tab 250 mg.................................................. 28
naproxen tab 375 mg.................................................... 4
naproxen tab 375 mg.................................................. 28
naproxen tab 500 mg.................................................... 4
naproxen tab 500 mg.................................................. 28
naproxen tab ec 375 mg...............................................4
naproxen tab ec 375 mg............................................ 28
naproxen tab ec 500 mg...............................................4
naproxen tab ec 500 mg............................................ 28
naratriptan hcl tab 1 mg..............................................29
naratriptan hcl tab 2.5 mg.......................................... 29
NARCAN.......................................................................... 6
NASCOBAL................................................................ 115
NASONEX................................................................... 110
NATACYN.................................................................... 105
nateglinide tab 120 mg............................................... 59
nateglinide tab 60 mg................................................. 59
NATPARA...................................................................... 95
NATPARA...................................................................... 95
NATPARA...................................................................... 95
NATPARA...................................................................... 95
NEBUPENT................................................................... 41
NEFAZODONE HCL....................................................22
NEFAZODONE HCL....................................................22
NEFAZODONE HCL....................................................22
nefazodone hcl tab 250 mg........................................22
nefazodone hcl tab 50 mg.......................................... 22
neomycin-bacitracin-polymyxin-pramoxine oint
1%............................................................................... 81
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin....................... 105
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml........................... 105
neomycin-polymyxin b gu irrigation soln.................. 13
neomycin-polymyxin b gu irrigation soln.................. 89
neomycin-polymyxin-dexamethasone ophth oint
0.1%.......................................................................... 105
neomycin-polymyxin-dexamethasone ophth susp
0.1%.......................................................................... 105
neomycin-polymyxin-hc otic soln 1%...................... 106
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%................................................................ 106
neomycin sulfate tab 500 mg..................................... 12
NEOSPORIN ORIGINAL............................................ 81
NEOSPORIN PLUS PAIN RELIEF MAXIMUM
STRENGTH............................................................... 81
NEULASTA.................................................................... 62
NEULASTA ONPRO KIT............................................ 62
NEUPRO....................................................................... 42
NEUPRO....................................................................... 42
NEUPRO....................................................................... 42
143
2016
NEUPRO....................................................................... 42
NEUPRO....................................................................... 42
NEUPRO....................................................................... 42
NEVANAC................................................................... 105
NEVIRAPINE................................................................ 50
nevirapine tab 200 mg................................................ 50
nevirapine tab sr 24hr 100 mg...................................50
nevirapine tab sr 24hr 400 mg...................................50
NEXAVAR...................................................................... 37
NEXIUM......................................................................... 87
NEXIUM......................................................................... 87
NEXIUM......................................................................... 87
NEXIUM......................................................................... 87
NEXIUM......................................................................... 87
niacin cap cr 250 mg.................................................. 70
niacin cap cr 500 mg.................................................. 70
niacin tab 100 mg........................................................ 70
niacin tab 250 mg........................................................ 70
niacin tab 500 mg........................................................ 70
niacin tab 50 mg.......................................................... 70
niacin tab cr 1000 mg................................................. 70
niacin tab cr 250 mg................................................... 70
niacin tab cr 500 mg................................................... 70
niacin tab cr 750 mg................................................... 70
niacin tab cr 750 mg................................................... 70
NIACIN TR.................................................................... 70
nicardipine hcl cap 20 mg.......................................... 70
nicardipine hcl cap 30 mg.......................................... 71
NICODERM CQ............................................................. 6
NICODERM CQ............................................................. 6
NICORETTE....................................................................6
nicotine polacrilex gum 2 mg....................................... 6
nicotine polacrilex gum 4 mg....................................... 6
nicotine polacrilex lozenge 2 mg................................. 6
nicotine td patch 24hr 21 mg/24hr...............................6
NICOTINE TRANSDERMAL SYSTEM....................... 6
NICOTROL INHALER................................................... 6
NICOTROL NS............................................................... 6
nifedipine tab sr 24hr 30 mg...................................... 71
nifedipine tab sr 24hr osmotic release 30 mg.......... 71
NILANDRON................................................................. 37
NINLARO....................................................................... 37
NINLARO....................................................................... 37
NINLARO....................................................................... 37
NIPENT.......................................................................... 37
NISOLDIPINE ER........................................................ 71
nisoldipine tab sr 24hr 17 mg.................................... 71
nisoldipine tab sr 24hr 34 mg.................................... 71
144
nisoldipine tab sr 24hr 8.5 mg................................... 71
NITRO-BID.................................................................... 71
nitrofurantoin macrocrystalline cap 100 mg............. 13
nitrofurantoin macrocrystalline cap 50 mg............... 13
nitrofurantoin monohydrate macrocrystalline cap 100
mg................................................................................13
nitrofurantoin susp 25 mg/5ml................................... 13
nitroglycerin td patch 24hr 0.1 mg/hr........................ 71
nitroglycerin tl soln 0.4 mg/spray (400 mcg/
spray).......................................................................... 71
NITROSTAT.................................................................. 71
NITROSTAT.................................................................. 71
NITROSTAT.................................................................. 71
nizatidine cap 150 mg................................................. 87
nizatidine cap 300 mg................................................. 87
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg................................................................. 93
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg................................................................. 93
norethindrone & ethinyl estradiol tab 0.4 mg-35
mcg..............................................................................93
norethindrone & ethinyl estradiol tab 0.5 mg-35
mcg..............................................................................93
norethindrone & ethinyl estradiol tab 1 mg-35
mcg..............................................................................93
norethindrone ace & ethinyl estradiol-fe tab 1.5
mg-30 mcg................................................................. 94
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg..............................................................................94
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg..............................................................................94
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg..............................................................................94
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24)..................................................................... 94
norethindrone acetate tab 5 mg................................ 94
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg....................................................................... 94
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg....................................................................... 94
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35
mg-mcg....................................................................... 94
norethindrone tab 0.35 mg......................................... 94
norgestimate & ethinyl estradiol tab 0.25 mg-35
mcg..............................................................................94
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg......................... 94
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg......................... 94
2016
norgestrel & ethinyl estradiol tab 0.3 mg-30
mcg..............................................................................94
NORTHERA.................................................................. 71
NORTHERA.................................................................. 71
NORTHERA.................................................................. 71
NORTRIPTYLINE HCL............................................... 22
nortriptyline hcl cap 10 mg......................................... 22
NORVIR......................................................................... 50
NORVIR......................................................................... 50
NORVIR......................................................................... 50
NOXAFIL....................................................................... 27
NOXAFIL....................................................................... 27
NOXAFIL....................................................................... 27
NUCYNTA ER.................................................................4
NUCYNTA ER.................................................................4
NUCYNTA ER.................................................................4
NUCYNTA ER.................................................................4
NUCYNTA ER.................................................................4
NUEDEXTA................................................................... 76
NULOJIX..................................................................... 101
NUPERCAINAL............................................................ 81
NUTRICION PORVIDA............................................. 116
NUTRISOURCE FIBER.............................................. 87
NUVIGIL...................................................................... 112
NUVIGIL...................................................................... 112
NUVIGIL...................................................................... 112
NUVIGIL...................................................................... 112
nystatin cream 100000 unit/gm................................. 81
nystatin oint 100000 unit/gm...................................... 81
nystatin susp 100000 unit/ml..................................... 27
nystatin tab 500000 unit............................................. 27
nystatin topical powder............................................... 81
nystatin-triamcinolone cream 100000-0.1 unit/gm%..................................................................................81
nystatin-triamcinolone oint 100000-0.1 unit/gm%..................................................................................81
O
octreotide acetate inj 1000 mcg/ml (1 mg/ml).......... 97
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)......... 97
ODOMZO...................................................................... 37
OFEV........................................................................... 110
OFEV........................................................................... 110
OFLOXACIN................................................................. 13
ofloxacin ophth soln 0.3%........................................ 105
ofloxacin otic soln 0.3%............................................ 106
olanzapine for im inj 10 mg........................................ 45
olanzapine for im inj 10 mg........................................ 56
olanzapine orally disintegrating tab 10 mg............... 45
olanzapine orally disintegrating tab 5 mg................. 45
olanzapine orally disintegrating tab 5 mg................. 56
olanzapine tab 10 mg................................................. 45
olanzapine tab 2.5 mg................................................ 45
olanzapine tab 5 mg.................................................... 45
olanzapine tab 5 mg.................................................... 56
olopatadine hcl nasal soln 0.6%..............................110
olopatadine hcl ophth soln 0.1%............................. 105
OLYSIO.......................................................................... 50
omega-3-acid ethyl esters cap 1 gm.........................71
omega-3 fatty acids cap 1000 mg........................... 116
omega-3 fatty acids cap 1200 mg........................... 116
omega-3 fatty acids cap 300 mg............................. 116
omega-3 fatty acids cap 435 mg............................. 116
omega-3 fatty acids cap delayed release 1000
mg............................................................................. 116
omega-3 fatty acids cap delayed release 1200
mg............................................................................. 116
OMEPRAZOLE............................................................. 87
omeprazole cap delayed release 10 mg.................. 87
OMNITROPE................................................................ 91
OMNITROPE................................................................ 91
OMNITROPE................................................................ 91
ONCASPAR.................................................................. 37
ondansetron hcl inj 40 mg/20ml (2 mg/ml)............... 25
ondansetron hcl inj 4 mg/2ml (2 mg/ml)................... 25
ondansetron hcl oral soln 4 mg/5ml.......................... 25
ondansetron hcl tab 24 mg........................................ 25
ondansetron hcl tab 4 mg...........................................25
ondansetron hcl tab 8 mg...........................................25
ondansetron orally disintegrating tab 4 mg.............. 25
ondansetron orally disintegrating tab 8 mg.............. 25
ONE-A-DAY WOMENS PRENATAL....................... 116
ONFI............................................................................... 17
145
2016
ONFI............................................................................... 17
ONFI............................................................................... 17
ONFI............................................................................... 17
ONGLYZA...................................................................... 59
ONGLYZA...................................................................... 59
OPDIVO......................................................................... 37
OPDIVO......................................................................... 37
OPSUMIT.................................................................... 110
OPTIONS CONCEPTROL VAGINAL
CONTRACEPTIVE................................................... 81
OPTIONS GYNOL II VAGINAL
CONTRACEPTIVE................................................... 81
ORACEA........................................................................81
ORALAIR..................................................................... 110
oral electrolyte solution............................................. 116
ORAP............................................................................. 45
ORAP............................................................................. 45
ORFADIN....................................................................... 83
ORFADIN....................................................................... 83
ORFADIN....................................................................... 83
ORKAMBI.................................................................... 110
oxaliplatin for iv inj 100 mg........................................ 37
oxaliplatin for iv inj 50 mg...........................................37
oxaliplatin iv soln 100 mg/20ml..................................37
oxaliplatin iv soln 50 mg/10ml.................................... 37
oxandrolone tab 10 mg............................................... 94
oxandrolone tab 2.5 mg.............................................. 94
oxaprozin tab 600 mg................................................... 4
oxaprozin tab 600 mg................................................. 28
oxcarbazepine susp 300 mg/5ml (60 mg/ml)........... 17
oxcarbazepine tab 150 mg......................................... 17
oxybutynin chloride syrup 5 mg/5ml..........................89
oxybutynin chloride tab 5 mg..................................... 89
oxybutynin chloride tab sr 24hr 10 mg..................... 89
oxybutynin chloride tab sr 24hr 15 mg..................... 89
oxybutynin chloride tab sr 24hr 5 mg........................89
oxycodone-aspirin tab 4.8355-325 mg....................... 4
oxycodone hcl tab 10 mg............................................. 4
oxycodone hcl tab 5 mg............................................... 4
oxycodone w/ acetaminophen tab 10-325 mg........... 4
oxycodone w/ acetaminophen tab 2.5-325 mg.......... 4
oxycodone w/ acetaminophen tab 5-325 mg............. 4
oxycodone w/ acetaminophen tab 7.5-325 mg.......... 4
P
paclitaxel iv conc 100 mg/16.7ml (6 mg/ml)............. 37
paclitaxel iv conc 300 mg/50ml (6 mg/ml)................ 37
146
paclitaxel iv conc 30 mg/5ml (6 mg/ml).................... 37
paliperidone tab sr 24hr 1.5 mg................................ 45
paliperidone tab sr 24hr 3 mg.................................... 45
PANRETIN.....................................................................37
pantoprazole sodium ec tab 20 mg........................... 87
pantoprazole sodium ec tab 40 mg........................... 87
paricalcitol cap 1 mcg............................................... 103
paricalcitol iv soln 2 mcg/ml..................................... 103
paricalcitol iv soln 5 mcg/ml..................................... 103
paromomycin sulfate cap 250 mg............................. 13
paroxetine hcl tab 10 mg............................................ 22
paroxetine hcl tab sr 24hr 12.5 mg........................... 22
paroxetine hcl tab sr 24hr 25 mg.............................. 22
paroxetine hcl tab sr 24hr 25 mg.............................. 54
PASER........................................................................... 30
PATADAY..................................................................... 105
PATANOL.................................................................... 105
PAXIL............................................................................. 22
PAXIL............................................................................. 54
PEDIA-LAX....................................................................87
PEDVAX HIB.............................................................. 101
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm................................................................................87
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240
gm................................................................................87
peg 3350-kcl-sod bicarb-nacl for soln 420 gm......... 87
PEGANONE.................................................................. 17
PEGASYS..................................................................... 51
PEGASYS..................................................................... 51
PEGASYS PROCLICK................................................ 51
PEGASYS PROCLICK................................................ 51
PEG-INTRON............................................................... 50
PEG-INTRON............................................................... 50
PEG-INTRON............................................................... 50
PEG-INTRON............................................................... 50
PEG-INTRON REDIPEN............................................ 50
2016
PEG-INTRON REDIPEN PAK 4................................ 50
penicillin g potassium for inj 20000000 unit............. 13
penicillin g potassium for inj 5000000 unit............... 13
PENICILLIN G POTASSIUM IN DEXTROSE.......... 13
PENICILLIN G SODIUM............................................. 13
penicillin v potassium for soln 125 mg/5ml.............. 13
penicillin v potassium for soln 250 mg/5ml.............. 13
penicillin v potassium tab 250 mg............................. 13
penicillin v potassium tab 500 mg............................. 13
PENTACEL................................................................. 101
PENTAM 300................................................................ 41
PENTASA.................................................................... 103
PENTASA.................................................................... 103
pentoxifylline tab cr 400 mg....................................... 71
perindopril erbumine tab 2 mg................................... 71
PERJETA....................................................................... 37
permethrin cream 5%.................................................. 41
permethrin creme rinse 1%........................................ 41
permethrin lotion 1%................................................... 41
perphenazine tab 16 mg............................................. 25
perphenazine tab 16 mg............................................. 45
perphenazine tab 2 mg............................................... 25
PERRY PRENATAL................................................... 116
PHENAGIL.................................................................. 110
phenelzine sulfate tab 15 mg..................................... 22
PHENOBARBITAL....................................................... 17
PHENOBARBITAL....................................................... 17
PHENOBARBITAL....................................................... 17
PHENOBARBITAL....................................................... 17
phenobarbital elixir 20 mg/5ml................................... 17
PHENOBARBITAL SODIUM...................................... 17
PHENOBARBITAL SODIUM...................................... 17
phenobarbital tab 16.2 mg......................................... 17
phenoxybenzamine hcl cap 10 mg........................... 71
phenylephrine-brompheniramine-dm elixir 2.5-1-5
mg/5ml...................................................................... 110
phenylephrine-guaifenesin tab 10-400 mg............. 110
phenylephrine hcl tab 10 mg................................... 110
phenylephrine in hard fat rectal suppos 0.25%....... 81
phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml..... 110
phenytoin chew tab 50 mg......................................... 18
phenytoin sodium extended cap 100 mg................. 18
phenytoin susp 125 mg/5ml....................................... 18
PHOSLYRA................................................................... 89
PHOSPHOLINE IODIDE.......................................... 105
PHYSICIANS EZ USE B-12 COMPLIANCE
KIT............................................................................. 116
PICATO.......................................................................... 81
PICATO.......................................................................... 81
pilocarpine hcl ophth soln 1%.................................. 105
pilocarpine hcl tab 5 mg............................................. 77
pilocarpine hcl tab 7.5 mg.......................................... 77
pimozide tab 1 mg....................................................... 46
pimozide tab 2 mg....................................................... 46
pindolol tab 10 mg....................................................... 71
pindolol tab 5 mg......................................................... 71
pioglitazone hcl-glimepiride tab 30-2 mg.................. 60
pioglitazone hcl-glimepiride tab 30-4 mg.................. 60
pioglitazone hcl-metformin hcl tab 15-500 mg......... 60
pioglitazone hcl-metformin hcl tab 15-850 mg......... 60
pioglitazone hcl tab 15 mg......................................... 59
piperacillin sod-tazobactam na for inj 3.375 gm
(3-0.375 gm).............................................................. 13
piperacillin sod-tazobactam sod for inj 2.25 gm
(2-0.25 gm)................................................................ 13
piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5
gm).............................................................................. 13
piroxicam cap 10 mg..................................................... 4
piroxicam cap 10 mg................................................... 28
piroxicam cap 20 mg..................................................... 4
piroxicam cap 20 mg................................................... 28
PLEGRIDY.................................................................... 76
PLEGRIDY.................................................................... 76
PLEGRIDY STARTER PACK..................................... 76
PLEGRIDY STARTER PACK..................................... 76
podofilox soln 0.5%..................................................... 81
polyethylene glycol 3350 oral packet........................ 87
polyethylene glycol 3350 oral powder.......................87
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1%.................................................................... 105
POLYSPORIN............................................................... 81
polyvinyl alcohol ophth soln 1.4%........................... 105
147
2016
polyvinyl alcohol-povidone ophth soln 5-6 mg/ml
(0.5-0.6%)................................................................ 105
POMALYST................................................................... 37
POMALYST................................................................... 37
POMALYST................................................................... 37
POMALYST................................................................... 37
PORTRAZZA................................................................ 37
potassium chloride 20 meq/l (0.15%) in dextrose 5%
inj............................................................................... 116
potassium chloride 40 meq/l (0.3%) in dextrose 5%
inj............................................................................... 116
potassium chloride cap cr 10 meq.......................... 116
potassium chloride cap cr 8 meq............................ 116
potassium chloride inj 2 meq/ml.............................. 116
potassium chloride microencapsulated crys cr tab 10
meq........................................................................... 116
potassium chloride microencapsulated crys cr tab 20
meq........................................................................... 116
potassium chloride tab cr 10 meq........................... 116
potassium chloride tab cr 8 meq (600 mg)............ 116
potassium citrate tab cr 10 meq (1080 mg)........... 116
potassium citrate tab cr 15 meq (1620 mg)........... 116
potassium citrate tab cr 5 meq (540 mg)............... 116
POTIGA......................................................................... 18
POTIGA......................................................................... 18
POTIGA......................................................................... 18
POTIGA......................................................................... 18
povidone-iodine oint 10%........................................... 81
povidone-iodine soln 10%.......................................... 81
povidone-iodine soln 7.5%......................................... 81
povidone-iodine swabs 10%...................................... 81
PRADAXA..................................................................... 62
PRADAXA..................................................................... 62
PRADAXA..................................................................... 62
PRALUENT................................................................... 71
PRALUENT................................................................... 71
PRALUENT................................................................... 71
PRALUENT................................................................... 71
pramipexole dihydrochloride tab 0.125 mg.............. 42
pramipexole dihydrochloride tab 0.25 mg................ 42
pramipexole dihydrochloride tab 0.5 mg.................. 42
pramipexole dihydrochloride tab 0.75 mg................ 42
pramipexole dihydrochloride tab 1.5 mg.................. 42
pramipexole dihydrochloride tab 1 mg...................... 42
pravastatin sodium tab 10 mg................................... 72
prazosin hcl cap 1 mg.................................................72
148
prednicarbate cream 0.1%......................................... 81
prednicarbate oint 0.1%.............................................. 81
prednisolone acetate ophth susp 1%..................... 105
prednisolone sod phosphate oral soln 15
mg/5ml........................................................................ 91
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base)............................................................. 91
prednisolone syrup 15 mg/5ml...................................91
PREDNISONE.............................................................. 91
PREDNISONE.............................................................. 91
PREDNISONE.............................................................. 91
PREDNISONE.............................................................. 91
PREDNISONE.............................................................. 91
PREDNISONE.............................................................. 91
prednisone tab 10 mg................................................. 91
prednisone tab 1 mg................................................... 91
prednisone tab 2.5 mg................................................ 91
prednisone tab 20 mg................................................. 91
prednisone tab 5 mg................................................... 91
PREMARIN................................................................... 94
PREMARIN................................................................... 94
PREMARIN................................................................... 94
PREMARIN................................................................... 94
PREMARIN................................................................... 94
PREMARIN................................................................... 94
PREMIUM CONDOMS LUBRICATED......................81
PREMPHASE............................................................... 94
PREMPRO.................................................................... 94
PREMPRO.................................................................... 94
PREMPRO.................................................................... 94
PREMPRO.................................................................... 94
PRENATAL.................................................................. 116
PRENATAL AND IRON............................................. 116
PRENATAL MULTIVITAMIN + D............................. 116
PREZCOBIX................................................................. 51
PREZISTA..................................................................... 51
PREZISTA..................................................................... 51
PREZISTA..................................................................... 51
PREZISTA..................................................................... 51
PREZISTA..................................................................... 51
PRIFTIN......................................................................... 31
PRIMAQUINE PHOSPHATE...................................... 41
primidone tab 250 mg................................................. 18
primidone tab 50 mg................................................... 18
PRISTIQ........................................................................ 22
PRISTIQ........................................................................ 22
PRISTIQ........................................................................ 23
PROAIR HFA.............................................................. 110
PROAIR RESPICLICK.............................................. 110
probenecid tab 500 mg............................................... 27
2016
prochlorperazine edisylate inj 5 mg/ml..................... 25
prochlorperazine edisylate inj 5 mg/ml..................... 46
prochlorperazine maleate tab 10 mg........................ 25
prochlorperazine maleate tab 10 mg........................ 46
prochlorperazine maleate tab 5 mg.......................... 25
prochlorperazine maleate tab 5 mg.......................... 46
prochlorperazine suppos 25 mg................................ 25
prochlorperazine suppos 25 mg................................ 46
PROCRIT...................................................................... 62
PROCRIT...................................................................... 62
PROCRIT...................................................................... 62
PROCRIT...................................................................... 63
PROCRIT...................................................................... 63
PROCRIT...................................................................... 63
PROFE FORTE..........................................................116
PROGLYCEM............................................................... 60
PROGRAF.................................................................. 101
PROLASTIN-C........................................................... 110
PROLENSA................................................................ 105
PROLEUKIN................................................................. 37
PROLIA........................................................................103
PROMACTA.................................................................. 63
PROMACTA.................................................................. 63
PROMACTA.................................................................. 63
PROMACTA.................................................................. 63
promethazine hcl suppos 12.5 mg............................ 25
promethazine hcl suppos 12.5 mg.......................... 110
promethazine hcl suppos 25 mg............................... 25
promethazine hcl suppos 25 mg............................. 110
promethazine hcl syrup 6.25 mg/5ml........................ 25
promethazine hcl syrup 6.25 mg/5ml...................... 110
promethazine hcl tab 12.5 mg................................... 25
promethazine hcl tab 12.5 mg................................. 110
promethazine hcl tab 25 mg...................................... 26
promethazine hcl tab 25 mg.................................... 110
promethazine hcl tab 50 mg...................................... 26
promethazine hcl tab 50 mg.................................... 111
propafenone hcl cap sr 12hr 225 mg........................ 72
propafenone hcl tab 150 mg...................................... 72
propranolol hcl cap sr 24hr 120 mg.......................... 29
propranolol hcl cap sr 24hr 60 mg............................ 29
propranolol hcl inj 1 mg/ml......................................... 29
propranolol hcl inj 1 mg/ml......................................... 72
propranolol hcl tab 10 mg...........................................29
propylthiouracil tab 50 mg.......................................... 98
PROQUAD.................................................................. 101
PROSHIELD PLUS SKIN PROTECTANT................ 81
PROSHIELD PROTECTIVE HAND CREAM........... 81
protriptyline hcl tab 10 mg.......................................... 23
protriptyline hcl tab 5 mg............................................ 23
psyllium cap 0.52 gm.................................................. 88
psyllium powder 28.3%............................................... 88
psyllium powder 30.9%............................................... 88
psyllium powder 30%.................................................. 88
psyllium powder 33%.................................................. 88
psyllium powder 48.57%............................................. 88
psyllium powder 49%.................................................. 88
psyllium powder 58.6%............................................... 88
psyllium powder 68%.................................................. 88
psyllium powder 95%.................................................. 88
PULMOZYME............................................................. 111
PURIXAN....................................................................... 37
PYLERA......................................................................... 88
pyrazinamide tab 500 mg........................................... 31
pyreth-piperonyl butox sham-permeth aero-nit
remover gel kit.......................................................... 81
pyrethrins-piperonyl butoxide liq 0.33-4%................ 81
pyrethrins-piperonyl butoxide shampoo
0.33-4%...................................................................... 81
pyridostigmine bromide tab 60 mg............................ 30
pyridostigmine bromide tab cr 180 mg..................... 30
Q
QUADRACEL............................................................. 101
quetiapine fumarate tab 100 mg................................23
quetiapine fumarate tab 25 mg.................................. 23
149
2016
quinapril hcl tab 10 mg............................................... 72
quinapril hcl tab 5 mg................................................. 72
quinapril-hydrochlorothiazide tab 10-12.5 mg.......... 72
quinapril-hydrochlorothiazide tab 20-12.5 mg.......... 72
quinapril-hydrochlorothiazide tab 20-25 mg............. 72
quinidine gluconate tab cr 324 mg............................ 72
QUINIDINE SULFATE................................................. 72
quinidine sulfate tab 300 mg...................................... 72
QVAR........................................................................... 111
QVAR........................................................................... 111
R
RABAVERT................................................................. 101
rabeprazole sodium ec tab 20 mg.............................88
RAGWITEK................................................................. 111
raloxifene hcl tab 60 mg............................................. 94
ramipril cap 1.25 mg................................................... 72
ramipril cap 10 mg....................................................... 72
ramipril cap 2.5 mg......................................................72
ramipril cap 5 mg......................................................... 72
RANEXA........................................................................ 72
RANEXA........................................................................ 73
ranitidine hcl cap 150 mg........................................... 88
ranitidine hcl cap 300 mg........................................... 88
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)............... 88
ranitidine hcl tab 150 mg............................................ 88
ranitidine hcl tab 300 mg............................................ 88
ranitidine hcl tab 75 mg.............................................. 88
RAPAFLO...................................................................... 89
RAPAFLO...................................................................... 90
RAPAMUNE................................................................ 101
RA VITAMIN B-12......................................................116
REBETOL...................................................................... 51
RECOMBIVAX HB..................................................... 101
RECOMBIVAX HB..................................................... 101
RECOMBIVAX HB..................................................... 101
REFRESH................................................................... 105
REFRESH CELLUVISC............................................ 106
REFRESH PLUS....................................................... 106
RELISTOR.....................................................................88
RELISTOR.....................................................................88
RELISTOR.....................................................................88
REMICADE................................................................. 101
150
REMODULIN.............................................................. 111
REMODULIN.............................................................. 111
REMODULIN.............................................................. 111
REMODULIN.............................................................. 111
RENVELA...................................................................... 90
RENVELA...................................................................... 90
RENVELA...................................................................... 90
repaglinide tab 0.5 mg................................................ 60
repaglinide tab 1 mg................................................... 60
repaglinide tab 2 mg................................................... 60
REPATHA...................................................................... 73
REPATHA SURECLICK.............................................. 73
RESCRIPTOR.............................................................. 51
RESCRIPTOR.............................................................. 51
RESTASIS................................................................... 106
RETROVIR IV INFUSION.......................................... 51
REVLIMID......................................................................37
REVLIMID......................................................................38
REVLIMID......................................................................38
REVLIMID......................................................................38
REVLIMID......................................................................38
REVLIMID......................................................................38
REXULTI........................................................................ 23
REXULTI........................................................................ 23
REXULTI........................................................................ 23
REXULTI........................................................................ 23
REXULTI........................................................................ 23
REXULTI........................................................................ 23
REXULTI........................................................................ 46
REXULTI........................................................................ 46
REXULTI........................................................................ 46
REXULTI........................................................................ 46
REXULTI........................................................................ 46
REXULTI........................................................................ 46
REYATAZ....................................................................... 51
REYATAZ....................................................................... 51
REYATAZ....................................................................... 51
REYATAZ....................................................................... 51
RIBASPHERE............................................................... 51
RIBASPHERE............................................................... 51
RIBASPHERE RIBAPAK............................................ 51
RIBASPHERE RIBAPAK............................................ 51
ribavirin cap 200 mg.................................................... 51
ribavirin tab 200 mg.....................................................51
RIDAURA.................................................................... 101
rifabutin cap 150 mg................................................... 31
rifampin cap 150 mg................................................... 31
rifampin cap 300 mg................................................... 31
rifampin for inj 600 mg................................................ 31
riluzole tab 50 mg........................................................ 76
rimantadine hydrochloride tab 100 mg..................... 51
risedronate sodium tab 150 mg............................... 103
2016
risedronate sodium tab 30 mg................................. 103
risedronate sodium tab 35 mg................................. 103
risedronate sodium tab 5 mg................................... 103
risedronate sodium tab delayed release 35
mg............................................................................. 103
RISPERDAL CONSTA................................................ 46
risperidone orally disintegrating tab 0.25 mg........... 46
risperidone orally disintegrating tab 0.25 mg........... 56
risperidone orally disintegrating tab 0.5 mg............. 46
risperidone orally disintegrating tab 0.5 mg............. 56
risperidone orally disintegrating tab 1 mg................ 46
risperidone soln 1 mg/ml............................................ 46
risperidone soln 1 mg/ml............................................ 56
risperidone tab 0.25 mg.............................................. 46
risperidone tab 0.25 mg.............................................. 56
risperidone tab 0.5 mg................................................ 46
risperidone tab 0.5 mg................................................ 56
risperidone tab 1 mg................................................... 46
RITUXAN....................................................................... 38
RITUXAN....................................................................... 38
rivastigmine tartrate cap 1.5 mg................................ 19
rivastigmine tartrate cap 3 mg................................... 19
rivastigmine tartrate cap 4.5 mg................................ 19
rivastigmine tartrate cap 6 mg................................... 19
rivastigmine td patch 24hr 13.3 mg/24hr.................. 19
rivastigmine td patch 24hr 4.6 mg/24hr.................... 19
rivastigmine td patch 24hr 9.5 mg/24hr.................... 19
rizatriptan benzoate orally disintegrating tab 10
mg................................................................................29
rizatriptan benzoate orally disintegrating tab 5
mg................................................................................29
rizatriptan benzoate tab 10 mg.................................. 29
rizatriptan benzoate tab 5 mg.................................... 29
ropinirole hydrochloride tab 0.25 mg........................ 42
ropinirole hydrochloride tab 0.5 mg...........................42
ropinirole hydrochloride tab 1 mg.............................. 42
ROTARIX..................................................................... 101
ROTATEQ....................................................................101
S
SABRIL.......................................................................... 18
SABRIL.......................................................................... 18
saline nasal spray 0.65%......................................... 111
SAMSCA..................................................................... 116
SAMSCA..................................................................... 116
SANDIMMUNE........................................................... 101
SANTYL......................................................................... 81
SAPHRIS....................................................................... 47
SAPHRIS....................................................................... 47
SAPHRIS....................................................................... 47
SEA-CLENS WOUND CLEANSER...........................82
selegiline hcl cap 5 mg............................................... 42
selegiline hcl tab 5 mg................................................ 42
selenium sulfide lotion 2.5%...................................... 82
SELZENTRY................................................................. 51
SELZENTRY................................................................. 51
SENNA........................................................................... 88
sennosides-docusate sodium tab 8.6-50 mg........... 88
sennosides syrup 8.8 mg/5ml.................................... 88
sennosides tab 8.6 mg................................................88
SENSIPAR.....................................................................96
SENSIPAR.....................................................................96
SENSIPAR.....................................................................96
SEREVENT DISKUS.................................................111
SEROQUEL XR........................................................... 23
SEROQUEL XR........................................................... 23
SEROQUEL XR........................................................... 23
SEROQUEL XR........................................................... 23
SEROQUEL XR........................................................... 23
SEROQUEL XR........................................................... 47
SEROQUEL XR........................................................... 47
SEROQUEL XR........................................................... 47
SEROQUEL XR........................................................... 47
SEROQUEL XR........................................................... 47
SEROQUEL XR........................................................... 57
SEROQUEL XR........................................................... 57
SEROQUEL XR........................................................... 57
SEROQUEL XR........................................................... 57
SEROQUEL XR........................................................... 57
151
2016
sertraline hcl oral conc 20 mg/ml.............................. 23
sertraline hcl oral conc 20 mg/ml.............................. 54
sertraline hcl tab 100 mg............................................ 23
sertraline hcl tab 100 mg............................................ 54
sertraline hcl tab 25 mg.............................................. 23
SHUR-SEAL..................................................................82
SIGNIFOR..................................................................... 97
SIGNIFOR..................................................................... 97
SIGNIFOR..................................................................... 97
SIGNIFOR LAR............................................................ 97
SIGNIFOR LAR............................................................ 97
SIGNIFOR LAR............................................................ 97
sildenafil citrate tab 20 mg....................................... 111
SILENOR..................................................................... 112
SILENOR..................................................................... 112
silver sulfadiazine cream 1%..................................... 82
SIMBRINZA................................................................ 106
SIMULECT.................................................................. 101
SIMULECT.................................................................. 101
simvastatin tab 10 mg................................................. 73
simvastatin tab 5 mg................................................... 73
sirolimus tab 0.5 mg.................................................. 101
sirolimus tab 1 mg..................................................... 101
sirolimus tab 2 mg..................................................... 101
SIRTURO.......................................................................31
SIVEXTRO.................................................................... 13
SIVEXTRO.................................................................... 13
skin protectants misc - ointment................................ 82
SLO-NIACIN..................................................................73
SM GLUCOSE............................................................. 60
sodium bicarbonate tab 325 mg................................ 88
sodium bicarbonate tab 650 mg................................ 88
sodium chloride hypertonic ophth oint 5%............. 106
sodium chloride hypertonic ophth soln 5%............ 106
sodium chloride inj 0.45%........................................ 116
sodium chloride irrigation soln 0.9%....................... 116
sodium chloride iv soln 0.9%................................... 116
sodium phenylbutyrate oral powder 3 gm/
teaspoonful.................................................................83
sodium phosphates - soln.......................................... 88
sodium polystyrene sulfonate oral susp 15
gm/60ml....................................................................117
sodium polystyrene sulfonate powder.................... 117
sodium polystyrene sulfonate rectal susp 30
gm/120ml................................................................. 117
SOLTAMOX................................................................... 38
152
SOMATULINE DEPOT................................................ 97
SOMAVERT.................................................................. 97
SOMAVERT.................................................................. 97
SOMAVERT.................................................................. 97
SOMAVERT.................................................................. 97
SOMAVERT.................................................................. 97
sotalol hcl (afib/afl) tab 120 mg................................. 73
sotalol hcl (afib/afl) tab 160 mg................................. 73
sotalol hcl (afib/afl) tab 80 mg................................... 73
sotalol hcl tab 120 mg.................................................73
sotalol hcl tab 80 mg................................................... 73
SOVALDI....................................................................... 51
SPIRIVA HANDIHALER............................................ 111
SPIRIVA RESPIMAT................................................. 111
SPIRIVA RESPIMAT................................................. 111
spironolactone & hydrochlorothiazide tab 25-25
mg................................................................................73
spironolactone tab 100 mg......................................... 73
spironolactone tab 25 mg........................................... 73
spironolactone tab 50 mg........................................... 73
SPRYCEL...................................................................... 38
SPRYCEL...................................................................... 38
SPRYCEL...................................................................... 38
SPRYCEL...................................................................... 38
SPRYCEL...................................................................... 38
SPRYCEL...................................................................... 38
stavudine cap 15 mg................................................... 51
stavudine cap 20 mg................................................... 51
stavudine cap 30 mg................................................... 51
stavudine cap 40 mg................................................... 51
stavudine for oral soln 1 mg/ml................................. 51
STELARA...................................................................... 82
STELARA...................................................................... 82
STELARA.................................................................... 101
STELARA.................................................................... 101
STIMATE....................................................................... 92
STIVARGA.....................................................................38
STRATTERA................................................................. 76
STRATTERA................................................................. 76
STRATTERA................................................................. 76
STRATTERA................................................................. 76
STRATTERA................................................................. 76
STRATTERA................................................................. 76
STRATTERA................................................................. 76
STRENSIQ.................................................................... 84
STRENSIQ.................................................................... 84
STRENSIQ.................................................................... 84
STRENSIQ.................................................................... 84
2016
STREPTOMYCIN SULFATE...................................... 13
STRIBILD...................................................................... 51
STUART ONE............................................................ 117
SUBOXONE.................................................................... 6
SUBOXONE.................................................................... 6
SUBOXONE.................................................................... 6
SUBOXONE.................................................................... 6
sucralfate tab 1 gm......................................................88
sulfacetamide sodium lotion 10%.............................. 82
sulfacetamide sodium ophth soln 10%................... 106
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%....................................................... 106
SULFADIAZINE............................................................ 13
SULFAMETHOXAZOLE/TRIMETHOPRIM.............. 13
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml........................................................................ 13
sulfamethoxazole-trimethoprim tab 400-80 mg....... 13
sulfamethoxazole-trimethoprim tab 800-160 mg..... 13
sulfasalazine tab 500 mg......................................... 103
sulfasalazine tab delayed release 500 mg............. 103
sulindac tab 150 mg...................................................... 4
sulindac tab 150 mg.................................................... 29
sulindac tab 200 mg...................................................... 4
sulindac tab 200 mg.................................................... 29
SUMATRIPTAN............................................................ 29
SUMATRIPTAN............................................................ 30
SUMATRIPTAN SUCCINATE.....................................30
sumatriptan succinate inj 6 mg/0.5ml....................... 30
sumatriptan succinate solution auto-injector 4
mg/0.5ml..................................................................... 30
sumatriptan succinate solution auto-injector 6
mg/0.5ml..................................................................... 30
sumatriptan succinate solution cartridge 4
mg/0.5ml..................................................................... 30
sumatriptan succinate solution cartridge 6
mg/0.5ml..................................................................... 30
sumatriptan succinate tab 100 mg............................ 30
sumatriptan succinate tab 25 mg.............................. 30
sumatriptan succinate tab 50 mg.............................. 30
SUPER TWIN EPA/DHA.......................................... 117
SUPRAX........................................................................ 13
SUPRAX........................................................................ 13
SUPRAX........................................................................ 13
SUPREP BOWEL PREP............................................ 88
SURMONTIL................................................................. 23
SURMONTIL................................................................. 23
SURMONTIL................................................................. 23
SUSTIVA........................................................................ 51
SUSTIVA........................................................................ 51
SUSTIVA........................................................................ 52
SUTENT........................................................................ 38
SUTENT........................................................................ 38
SUTENT........................................................................ 38
SUTENT........................................................................ 38
SWEEN CREAM.......................................................... 82
SYLATRON................................................................... 38
SYLATRON................................................................... 38
SYLATRON................................................................... 38
SYLATRON................................................................... 38
SYLATRON................................................................... 38
SYLATRON................................................................... 52
SYLATRON................................................................... 52
SYLATRON................................................................... 52
SYLATRON................................................................... 52
SYLATRON................................................................... 52
SYLVANT....................................................................... 38
SYLVANT....................................................................... 38
SYMBICORT...............................................................111
SYMBICORT...............................................................111
SYMLINPEN 120......................................................... 60
SYMLINPEN 60........................................................... 60
SYNAGIS.................................................................... 101
SYNAGIS.................................................................... 101
SYNAREL...................................................................... 97
SYNERCID.................................................................... 13
SYNJARDY................................................................... 60
SYNJARDY................................................................... 60
SYNJARDY................................................................... 60
SYNJARDY................................................................... 60
SYNRIBO...................................................................... 38
SYNTHROID................................................................. 95
SYNTHROID................................................................. 95
SYNTHROID................................................................. 95
SYNTHROID................................................................. 95
SYNTHROID................................................................. 95
SYNTHROID................................................................. 95
SYNTHROID................................................................. 95
SYNTHROID................................................................. 95
SYNTHROID................................................................. 95
SYNTHROID................................................................. 96
SYNTHROID................................................................. 96
SYNTHROID................................................................. 96
SYPRINE..................................................................... 117
SYSTANE.................................................................... 106
T
TABLOID........................................................................38
tacrolimus cap 0.5 mg.............................................. 101
tacrolimus cap 1 mg.................................................. 102
tacrolimus cap 5 mg.................................................. 102
tacrolimus oint 0.03%.................................................. 82
tacrolimus oint 0.1%.................................................... 82
TAFINLAR..................................................................... 38
TAFINLAR..................................................................... 38
TAGRISSO.................................................................... 38
153
2016
TAGRISSO.................................................................... 38
TAMIFLU........................................................................52
TAMIFLU........................................................................52
TAMIFLU........................................................................52
TAMIFLU........................................................................52
tamoxifen citrate tab 10 mg........................................38
tamoxifen citrate tab 20 mg........................................38
tamsulosin hcl cap 0.4 mg......................................... 90
TARCEVA...................................................................... 38
TARCEVA...................................................................... 38
TARCEVA...................................................................... 39
TARGRETIN.................................................................. 39
TARGRETIN.................................................................. 39
TASIGNA....................................................................... 39
TASIGNA....................................................................... 39
TAXOTERE................................................................... 39
TAXOTERE................................................................... 39
TAZORAC...................................................................... 82
TAZORAC...................................................................... 82
TAZORAC...................................................................... 82
TAZORAC...................................................................... 82
TEARS NATURALE PM........................................... 106
TECFIDERA.................................................................. 77
TECFIDERA.................................................................. 77
TECFIDERA STARTER PACK...................................77
TECHNIVIE................................................................... 52
TEFLARO...................................................................... 14
TEFLARO...................................................................... 14
TEGRETOL-XR............................................................ 18
TEKTURNA................................................................... 73
TEKTURNA................................................................... 73
TEKTURNA HCT......................................................... 73
TEKTURNA HCT......................................................... 73
TEKTURNA HCT......................................................... 73
TEKTURNA HCT......................................................... 73
telmisartan-hydrochlorothiazide tab 40-12.5 mg..... 73
telmisartan-hydrochlorothiazide tab 80-12.5 mg..... 73
telmisartan-hydrochlorothiazide tab 80-25 mg.........73
telmisartan tab 20 mg................................................. 73
TEMODAR.................................................................... 39
TENIVAC..................................................................... 102
terazosin hcl cap 10 mg............................................. 74
terazosin hcl cap 10 mg............................................. 90
terazosin hcl cap 1 mg............................................... 73
terbinafine hcl tab 250 mg.......................................... 27
154
terbutaline sulfate tab 2.5 mg.................................. 111
terbutaline sulfate tab 5 mg..................................... 111
terconazole vaginal cream 0.4%............................... 27
terconazole vaginal cream 0.8%............................... 27
terconazole vaginal suppos 80 mg........................... 27
testosterone cypionate im inj in oil 100 mg/ml......... 94
testosterone cypionate im inj in oil 200 mg/ml......... 94
testosterone enanthate im inj in oil 200 mg/ml........ 94
testosterone td gel 12.5 mg/act (1%) (generic for
AndroGel Pump 1%)................................................ 95
testosterone td gel 25 mg/2.5gm (1%) (generic for
AndroGel 1%)............................................................ 95
testosterone td gel 50 mg/5gm (1%) (generic for
AndroGel 1%)............................................................ 95
TETANUS/DIPHTHERIA TOXOID.......................... 102
tetrabenazine tab 12.5 mg......................................... 77
tetrabenazine tab 25 mg............................................. 77
tetracycline hcl cap 250 mg....................................... 14
tetracycline hcl cap 500 mg....................................... 14
THALOMID.................................................................... 39
THALOMID.................................................................... 39
THALOMID.................................................................... 39
THALOMID.................................................................... 39
THALOMID..................................................................102
THALOMID..................................................................102
THALOMID..................................................................102
THALOMID..................................................................102
theophylline tab sr 12hr 100 mg.............................. 111
THERA-D 4000.......................................................... 117
THERANATAL COMPLETE..................................... 117
THERANATAL OVAVITE.......................................... 117
thiamine hcl inj 100 mg/ml....................................... 117
thiamine hcl tab 100 mg........................................... 117
thiamine hcl tab 50 mg............................................. 117
thioridazine hcl tab 100 mg........................................ 47
thioridazine hcl tab 10 mg.......................................... 47
THIOTEPA..................................................................... 39
thiothixene cap 10 mg.................................................47
thiothixene cap 1 mg................................................... 47
THYMOGLOBULIN.................................................... 102
tiagabine hcl tab 2 mg................................................ 18
tiagabine hcl tab 4 mg................................................ 18
TIKOSYN....................................................................... 74
2016
TIKOSYN....................................................................... 74
TIKOSYN....................................................................... 74
TIMOLOL MALEATE................................................... 30
TIMOLOL MALEATE................................................... 30
TIMOLOL MALEATE................................................... 30
TIMOLOL MALEATE................................................... 74
TIMOLOL MALEATE................................................... 74
TIMOLOL MALEATE................................................... 74
timolol maleate ophth gel forming soln 0.25%....... 106
timolol maleate ophth gel forming soln 0.5%......... 106
timolol maleate ophth soln 0.25%........................... 106
timolol maleate ophth soln 0.5%............................. 106
TIVICAY......................................................................... 52
tizanidine hcl cap 2 mg............................................... 48
tizanidine hcl tab 2 mg................................................ 48
tizanidine hcl tab 4 mg................................................ 48
TOBRADEX................................................................ 106
tobramycin-dexamethasone ophth susp
0.3-0.1%................................................................... 106
tobramycin nebu soln 300 mg/5ml.......................... 111
tobramycin ophth soln 0.3%.................................... 106
tobramycin sulfate for inj 1.2 gm............................... 14
tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml)........ 14
tobramycin sulfate inj 10 mg/ml................................. 14
tobramycin sulfate inj 2 gm/50ml (40 mg/ml)........... 14
tobramycin sulfate inj 80 mg/2ml (40 mg/ml)........... 14
tolcapone tab 100 mg................................................. 42
tolmetin sodium cap 400 mg........................................ 4
tolmetin sodium cap 400 mg...................................... 29
tolnaftate aerosol 1%.................................................. 27
tolterodine tartrate cap sr 24hr 2 mg........................ 90
tolterodine tartrate cap sr 24hr 4 mg........................ 90
tolterodine tartrate tab 1 mg....................................... 90
tolterodine tartrate tab 2 mg....................................... 90
topiramate sprinkle cap 15 mg.................................. 18
topiramate tab 100 mg................................................ 18
topiramate tab 25 mg.................................................. 18
TOPOTECAN HCL...................................................... 39
topotecan hcl for inj 4 mg........................................... 39
TORISEL....................................................................... 39
torsemide tab 100 mg................................................. 74
torsemide tab 10 mg................................................... 74
torsemide tab 20 mg................................................... 74
torsemide tab 5 mg..................................................... 74
TOUJEO SOLOSTAR..................................................60
TOVIAZ.......................................................................... 90
TOVIAZ.......................................................................... 90
TRACLEER................................................................. 111
TRACLEER................................................................. 111
TRADJENTA................................................................. 60
tramadol-acetaminophen tab 37.5-325 mg................ 4
tramadol hcl tab 50 mg................................................. 4
tramadol hcl tab sr 24hr 100 mg................................. 4
trandolapril tab 1 mg................................................... 74
tranexamic acid iv soln 1000 mg/10ml (100 mg/
ml)................................................................................63
tranexamic acid tab 650 mg....................................... 63
tranylcypromine sulfate tab 10 mg............................ 23
TRAVATAN Z.............................................................. 106
trazodone hcl tab 100 mg...........................................23
trazodone hcl tab 50 mg............................................. 23
TREANDA..................................................................... 39
TREANDA..................................................................... 39
TREANDA..................................................................... 39
TRECATOR................................................................... 31
TRELSTAR.................................................................... 97
TRELSTAR.................................................................... 97
TRELSTAR MIXJECT..................................................97
tretinoin cap 10 mg......................................................39
tretinoin cream 0.025%............................................... 82
tretinoin cream 0.05%................................................. 82
tretinoin cream 0.1%................................................... 82
tretinoin gel 0.01%....................................................... 82
tretinoin gel 0.025%.....................................................82
TRIAMCINOLONE ACETONIDE............................... 82
triamcinolone acetonide cream 0.025%................... 82
triamcinolone acetonide cream 0.1%........................ 82
triamcinolone acetonide cream 0.5%........................ 82
triamcinolone acetonide dental paste 0.1%............. 77
triamcinolone acetonide lotion 0.025%..................... 82
triamcinolone acetonide lotion 0.1%......................... 82
triamcinolone acetonide nasal aerosol suspension
55 mcg/act............................................................... 111
triamcinolone acetonide oint 0.025%........................ 82
triamcinolone acetonide oint 0.1%............................ 82
155
2016
TRIAMINIC COLD & ALLERGY CHILDRENS...... 111
TRIAMINIC NIGHT TIME COLD & COUGH.......... 112
triamterene & hydrochlorothiazide cap 37.5-25
mg................................................................................74
triamterene & hydrochlorothiazide tab 37.5-25
mg................................................................................74
triamterene & hydrochlorothiazide tab 75-50
mg................................................................................74
trifluoperazine hcl tab 10 mg......................................47
trifluoperazine hcl tab 1 mg........................................ 47
trifluridine ophth soln 1%.......................................... 106
trimethoprim tab 100 mg.............................................14
trimipramine maleate cap 100 mg............................. 23
trimipramine maleate cap 25 mg............................... 23
trimipramine maleate cap 50 mg............................... 23
TRINTELLIX.................................................................. 23
TRINTELLIX.................................................................. 23
TRINTELLIX.................................................................. 23
TRIPLE PASTE............................................................ 82
TRISENOX.................................................................... 39
TRIUMEQ...................................................................... 52
TRIXAICIN..................................................................... 82
TROJAN........................................................................ 82
trospium chloride cap sr 24hr 60 mg........................ 90
trospium chloride tab 20 mg...................................... 90
TRUMENBA................................................................ 102
TRUVADA...................................................................... 52
TUMS ULTRA 1000..................................................... 88
TWINRIX..................................................................... 102
TYBOST........................................................................ 52
TYGACIL....................................................................... 14
TYKERB........................................................................ 39
TYLENOL........................................................................ 4
TYLENOL EXTRA STRENGTH................................... 4
TYPHIM VI.................................................................. 102
TYSABRI....................................................................... 77
TYSABRI..................................................................... 102
TYZEKA......................................................................... 52
TYZINE PEDIATRIC NASAL DROPS.................... 112
U
ULORIC......................................................................... 27
ULORIC......................................................................... 27
UNITUXIN......................................................................39
UPTRAVI..................................................................... 112
UPTRAVI..................................................................... 112
UPTRAVI..................................................................... 112
UPTRAVI..................................................................... 112
UPTRAVI..................................................................... 112
UPTRAVI..................................................................... 112
UPTRAVI..................................................................... 112
156
UPTRAVI..................................................................... 112
UPTRAVI..................................................................... 112
ursodiol cap 300 mg.................................................... 88
UVADEX........................................................................ 39
UVADEX........................................................................ 82
V
VAGIFEM....................................................................... 95
VAGISTAT-1.................................................................. 27
valacyclovir hcl tab 1 gm............................................ 52
valacyclovir hcl tab 500 mg........................................ 52
VALCHLOR................................................................... 82
VALCYTE.......................................................................52
valganciclovir hcl tab 450 mg.....................................52
valproate sodium inj 100 mg/ml................................. 18
valproate sodium syrup 250 mg/5ml......................... 18
valproic acid cap 250 mg........................................... 18
valproic acid cap 250 mg........................................... 57
valsartan-hydrochlorothiazide tab 160-12.5 mg...... 74
valsartan-hydrochlorothiazide tab 160-25 mg.......... 74
valsartan-hydrochlorothiazide tab 320-12.5 mg...... 74
valsartan-hydrochlorothiazide tab 320-25 mg.......... 74
valsartan-hydrochlorothiazide tab 80-12.5 mg.........74
valsartan tab 160 mg.................................................. 74
valsartan tab 320 mg.................................................. 74
valsartan tab 40 mg.....................................................74
valsartan tab 80 mg.....................................................74
vancomycin hcl cap 125 mg...................................... 14
vancomycin hcl cap 250 mg...................................... 14
vancomycin hcl for inj 1000 mg................................. 14
vancomycin hcl for inj 10 gm..................................... 14
vancomycin hcl for inj 5000 mg................................. 14
vancomycin hcl for inj 500 mg................................... 14
VANCOMYCIN HCL IN DEXTROSE........................ 14
VAQTA......................................................................... 102
VAQTA......................................................................... 102
VARIVAX..................................................................... 102
VASCEPA...................................................................... 74
VCF VAGINAL CONTRACEPTIVE FILM................. 82
VCF VAGINAL CONTRACEPTIVE FOAM............... 82
VECTIBIX...................................................................... 39
VECTIBIX...................................................................... 39
VELCADE...................................................................... 39
VENCLEXTA................................................................. 39
VENCLEXTA................................................................. 39
VENCLEXTA................................................................. 39
VENCLEXTA STARTING PACK................................ 39
venlafaxine hcl cap sr 24hr 150 mg.......................... 24
venlafaxine hcl cap sr 24hr 150 mg.......................... 54
venlafaxine hcl cap sr 24hr 37.5 mg......................... 24
2016
venlafaxine hcl cap sr 24hr 37.5 mg......................... 54
venlafaxine hcl cap sr 24hr 75 mg............................ 24
venlafaxine hcl cap sr 24hr 75 mg............................ 54
venlafaxine hcl tab 100 mg........................................ 24
venlafaxine hcl tab 100 mg........................................ 54
venlafaxine hcl tab 25 mg.......................................... 24
venlafaxine hcl tab 37.5 mg....................................... 24
venlafaxine hcl tab 37.5 mg....................................... 54
venlafaxine hcl tab sr 24hr 150 mg........................... 24
venlafaxine hcl tab sr 24hr 150 mg........................... 54
venlafaxine hcl tab sr 24hr 37.5 mg.......................... 24
venlafaxine hcl tab sr 24hr 37.5 mg.......................... 54
venlafaxine hcl tab sr 24hr 75 mg............................. 24
venlafaxine hcl tab sr 24hr 75 mg............................. 54
VENTAVIS................................................................... 112
VENTAVIS................................................................... 112
VENTOLIN HFA......................................................... 112
verapamil hcl cap sr 24hr 100 mg............................. 74
verapamil hcl tab 120 mg........................................... 75
verapamil hcl tab 40 mg............................................. 75
verapamil hcl tab 80 mg............................................. 75
verapamil hcl tab cr 120 mg...................................... 74
VERSACLOZ................................................................ 47
VESICARE.................................................................... 90
VESICARE.................................................................... 90
VICTOZA....................................................................... 60
VIDEX............................................................................ 52
VIDEX............................................................................ 52
VIEKIRA PAK................................................................52
VIGAMOX....................................................................106
VIIBRYD.........................................................................24
VIIBRYD.........................................................................24
VIIBRYD.........................................................................24
VIIBRYD STARTER PACK......................................... 24
VIMPAT.......................................................................... 18
VIMPAT.......................................................................... 18
VIMPAT.......................................................................... 18
VIMPAT.......................................................................... 18
VIMPAT.......................................................................... 18
VIMPAT.......................................................................... 18
VINBLASTINE SULFATE............................................ 39
vincristine sulfate iv soln 1 mg/ml............................. 39
vinorelbine tartrate inj 10 mg/ml................................ 39
vinorelbine tartrate inj 50 mg/5ml (10 mg/ml).......... 40
VIOKACE....................................................................... 84
VIOKACE....................................................................... 84
VIRACEPT.................................................................... 52
VIRACEPT.................................................................... 52
VIRAMUNE................................................................... 52
VIRAMUNE XR............................................................ 52
VIRAZOLE..................................................................... 52
VIREAD..........................................................................52
VIREAD..........................................................................52
VIREAD..........................................................................52
VIREAD..........................................................................52
VIREAD..........................................................................52
VITAMIN D2................................................................ 117
VITAMIN D2................................................................ 117
VITAMIN D3................................................................ 117
VITAMIN D3................................................................ 117
vitamins a & d oint.......................................................83
VITEKTA........................................................................ 52
VITEKTA........................................................................ 53
VIVITROL........................................................................ 6
VOLTAREN...................................................................... 5
VOLTAREN....................................................................29
VOLTAREN....................................................................83
voriconazole for inj 200 mg........................................ 27
voriconazole for susp 40 mg/ml................................. 27
voriconazole tab 200 mg............................................ 27
voriconazole tab 50 mg.............................................. 27
VOTRIENT.................................................................... 40
VPRIV............................................................................ 84
VRAYLAR...................................................................... 47
VRAYLAR...................................................................... 47
VRAYLAR...................................................................... 47
VRAYLAR...................................................................... 47
VRAYLAR...................................................................... 47
VRAYLAR...................................................................... 57
VRAYLAR...................................................................... 57
VRAYLAR...................................................................... 57
VRAYLAR...................................................................... 57
VRAYLAR...................................................................... 57
VYTORIN....................................................................... 75
VYTORIN....................................................................... 75
VYTORIN....................................................................... 75
VYTORIN....................................................................... 75
W
warfarin sodium tab 10 mg.........................................63
warfarin sodium tab 1 mg........................................... 63
warfarin sodium tab 2.5 mg........................................63
157
2016
warfarin sodium tab 7.5 mg........................................63
water for irrigation, sterile irrigation soln................ 117
WELCHOL..................................................................... 60
WELCHOL..................................................................... 60
WELCHOL..................................................................... 75
WELCHOL..................................................................... 75
X
XALKORI....................................................................... 40
XALKORI....................................................................... 40
XARELTO...................................................................... 63
XARELTO...................................................................... 63
XARELTO...................................................................... 63
XARELTO STARTER PACK....................................... 63
XENAZINE.................................................................... 77
XENAZINE.................................................................... 77
XGEVA......................................................................... 103
XIFAXAN........................................................................14
XIFAXAN........................................................................88
XOLAIR........................................................................112
XOPENEX HFA.......................................................... 112
XTANDI.......................................................................... 40
XYREM........................................................................ 112
Y
YERVOY........................................................................ 40
YERVOY........................................................................ 40
YF-VAX........................................................................ 102
YONDELIS.................................................................... 40
Z
zafirlukast tab 10 mg................................................. 112
zafirlukast tab 20 mg................................................. 112
zaleplon cap 10 mg................................................... 113
zaleplon cap 5 mg..................................................... 113
ZALTRAP....................................................................... 40
ZALTRAP....................................................................... 40
ZANOSAR..................................................................... 40
ZAVESCA...................................................................... 84
ZELBORAF................................................................... 40
ZEMPLAR................................................................... 103
ZEMPLAR................................................................... 103
ZENPEP........................................................................ 84
ZENPEP........................................................................ 84
ZENPEP........................................................................ 84
ZENPEP........................................................................ 84
ZENPEP........................................................................ 84
ZENPEP........................................................................ 84
158
ZENPEP........................................................................ 84
ZEPATIER..................................................................... 53
ZETIA............................................................................. 75
ZIAGEN..........................................................................53
zidovudine cap 100 mg............................................... 53
zidovudine syrup 10 mg/ml........................................ 53
zidovudine tab 300 mg................................................53
ZINACEF....................................................................... 14
zinc oxide oint 10%..................................................... 83
zinc oxide oint 20%..................................................... 83
zinc oxide oint 40%..................................................... 83
ziprasidone hcl cap 20 mg......................................... 47
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
zoledronic acid inj conc for iv infusion 4
mg/5ml...................................................................... 103
zoledronic acid iv soln 5 mg/100ml......................... 104
ZOLINZA........................................................................40
zolpidem tartrate tab 10 mg..................................... 113
zolpidem tartrate tab 5 mg....................................... 113
ZOMETA...................................................................... 104
zonisamide cap 100 mg..............................................18
zonisamide cap 25 mg................................................ 18
zonisamide cap 50 mg................................................ 18
ZONTIVITY....................................................................63
ZORTRESS.................................................................102
ZORTRESS.................................................................102
ZORTRESS.................................................................102
ZOSTAVAX.................................................................. 102
ZOSYN........................................................................... 14
ZOSYN........................................................................... 14
ZOSYN........................................................................... 14
ZYDELIG....................................................................... 40
ZYDELIG....................................................................... 40
ZYKADIA....................................................................... 40
2016
ZYPREXA RELPREVV............................................... 47
ZYTIGA.......................................................................... 40
ZYVOX........................................................................... 14
159
La Lista de medicamentos puede cambiar en cualquier momento. Recibirá una notificación cuando sea necesario.
Si tiene preguntas, llame a Blue Cross Community MMAI al 1-877-723-7702. TTY/TDD: 711. Las horas de
oficina son de 8:00 a.m. a 8:00 p.m., Hora Centro, los 7 días de la semana. Se usarán tecnologías alternativas
(por ejemplo, correo de voz) los fines de semana y los días feriados federales. Si deja un mensaje, un
representante de Atención al Cliente le llamará en el transcurso de un día laboral, a más tardar. La llamada
es gratuita.
Para preguntas acerca de la inscripción, llame a: Servicios de inscripción de clientes residentes de Illinois
1-877-912-8880 (TTY: 1-866-565-8576)
Sitio web: enrollhfs.illinois.gov
HPMS Approved Formulary File ID: 00016055, Versión 14
Esta Lista de medicamentos se actualizó el 6/2/2016.
El Plan Medicare-Medicaid proporcionado por Blue Cross and Blue Shield of Illinois, una división de Health
Care Service Corporation, una compañía mutua de reserva legal (HCSC), licenciataria independiente de Blue
Cross and Blue Shield Association. HCSC es un plan médico que tiene contratos tanto con Medicare como
Illinois Medicaid para proporcionar los beneficios de ambos programas a los inscriptos. La inscripción en el
plan de HCSC depende de la renovación del contrato.

Lista de Medicamentos - Blue Cross and Blue Shield of Illinois

Transcripción

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