Lista de medicamentos cubiertos (Vademécum

Transcripción

GuildNet
Gold Plus FIDA Plan
MMP-POS
Lista de medicamentos cubiertos (Vademécum) de 2016
Este vademécum se actualizó el 8/19/2015. Para obtener información más reciente o si tiene otras preguntas,
comuníquese con el Plan al 800-815-0000 o, para usuarios de teléfonos de texto (TTY), al 800-662-1220. Se atiende de
lunes a domingo, de 8 a.m. a 8 p.m., o visite www.guildnetny.org.
16143v7
H0811_GN252Sp_MEM16_Formulary_Accepted
GuildNet Gold Plus FIDA Plan | 2016
Lista de medicamentos cubiertos (Vademécum)
Esta es una lista de medicamentos que pueden recibir los participantes del plan GuildNet Gold
Plus FIDA.
 El GuildNet Gold Plus FIDA es un plan de gestión de cuidados que trabaja con Medicare y el
Departamento de Salud del estado de Nueva York (Medicaid) para proporcionar los
beneficios de ambos programas a los participantes a través de la demostración Fully
Integrated Duals Advantage (FIDA).
 La lista de medicamentos cubiertos y/o las redes de farmacias y proveedores puede cambiar a lo
largo del año. Le enviaremos una notificación antes de hacer algún cambio que le pueda afectar.
 Los beneficios pueden cambiar el 1º de enero de cada año.
 Siempre puede revisar la lista actualizada de medicamentos cubiertos del plan GuildNet Gold
Plus FIDA en www.guildnetny.org o llamando a Servicios del Participante al número 1-800815-0000. Los usuarios de TTY/TDD, deben llamar al 1-800-662-1220.
 Puede haber limitaciones y restricciones. Para obtener más información, llame a Servicios del
Participante del plan GuildNet Gold Plus FIDA o lea el Manual del Participante de GuildNet
Gold Plus FIDA Plan.
 No se aceptan copagos por ningún medicamento cubierto.
 Puede obtener esta información de forma gratuita en otros formatos como letra grande, braille
o audio. Llame al 1-800-815-0000 o TTY 1-800-662-1220 entre las 8 a.m. y las 8 p.m., de
lunes a domingo. La llamada es gratuita.
 You can get this information for free in other languages. Call 1-800-815-0000 or TTY/TDD
1-800-662-1220, Monday through Sunday, 8am to 8pm. The call is free.
 Usted puede obtener esta información en otros idiomas gratis. Llame al 1-800-815-0000 o
TTY/TDD al 1-800-662-1220, de lunes a domingo de 8am a 8pm. La llamada es gratis.
 Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare il numero verde
1-800-815-0000 o 1-800-662-1220 mediante un telefono testuale per non udenti (TTY/TDD),
da lunedì a domenica, dalle 8 alle 20. La chiamata è gratuita.
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Si tiene alguna pregunta, llame al plan GuildNet Gold Plus FIDA al 1-800-815-0000, de lunes a
domingo, de 8 a.m. a 8 p.m. Los usuarios de TTY/TDD deben llamar al 1-800-662-1220. La
llamada es gratuita. Para más información, visite www.guildnetny.org.
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 您可以免費獲得本信息的其他語言版本。請撥打 1-800-815-0000 或聽障／語障人士專線
(TTY/TDD) 1-800-662-1220，星期一至星期日上午 8 時至晚上 8 時。撥打該電話免費。
 Вы можете бесплатно получить эту информацию на других языках. Позвоните по
телефону 1-800-815-0000 и TTY/TDD 1-800-662-1220. Служба работает с понедельника
по воскресенье с 08:00 до 20:00 ч. Звонок бесплатный.
 Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo 1-800-815-0000 oswa
TTY/TDD 1-800-662-1220, lendi jiska dimanch, depi 8am jiska 8pm. Koutfil la gratis.
 다른 언어로 작성된 이 정보를 무료로 얻으실 수 있습니다. 월요일 - 일요일 오전 8시부터 오후
8시 사이에 1-800-815-0000번이나 TTY/TDD 1-800-662-1220번으로 전화주세요. 통화는
무료입니다.
 El estado de Nueva York ha creado un programa de defensoría del participante llamado
Independent Consumer Advocacy Network (ICAN) para proporcionarle a los participantes
ayuda confidencial y gratuita en cualquier servicio ofrecido por el plan GuildNet Gold Plus
FIDA. Puede comunicarse con ICAN llamando gratis al 1-844-614-8800 o en línea en
icannys.org.
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Preguntas frecuentes (FAQ)
Aquí podrá encontrar respuestas a sus preguntas acerca de la lista de medicamentos cubiertos.
Puede leer todas las FAQ para obtener información o buscar una pregunta con su respuesta.
1.
¿Qué medicamentos de prescripción están en la lista de
medicamentos cubiertos?
(llamaremos a la lista de medicamentos cubiertos la “lista de
medicamentos” para abreviar).
Los medicamentos de la lista de medicamentos cubiertos que empieza en la página 2 son los
medicamentos cubiertos por el plan GuildNet Gold Plus FIDA. Estos medicamentos están
disponibles en las farmacias dentro de nuestra red. Una farmacia está en nuestra red si tenemos
un acuerdo con ellos para que trabajen con nosotros y le brinden servicios. Denominamos a
estas farmacias “farmacias de la red”.
 El plan GuildNet Gold Plus FIDA cubrirá todos los medicamentos de la lista de medicamentos si:
 su médico u otro recetador de la red le dice que necesita los medicamentos para mejorar
su salud o mantenerse saludable;
 el medicamento es médicamente necesario para su enfermedad y
 usted surte la prescripción en una farmacia de la red del plan GuildNet Gold Plus FIDA.
 El plan GuildNet Gold Plus FIDA puede tener pasos adicionales para acceder a ciertos
medicamentos (consulte la pregunta no. 5 a continuación). En algunos casos, es posible que
deba hacer algo antes de poder recibir su medicamento, como probar otros primero.
También puede ver una lista actualizada de medicamentos que cubrimos en nuestro sitio web en
www.guildnetny.org o llamar a Servicios para Participantes al 1-800-815-0000. Los usuarios de
TTY/TDD, deben llamar al 1-800-662-1220.
2.
¿La lista de medicamentos cambia en algún momento?
Sí. El plan GuildNet Gold Plus FIDA puede agregar o quitar medicamentos de la lista de
medicamentos durante el año. Por lo general, la lista de medicamentos solo cambia si:
 aparece un nuevo medicamento que funciona tan bien como un medicamento que está en
la lista de medicamentos actual o
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 tenemos conocimiento de que un medicamento no es seguro.
También podemos cambiar nuestras normas sobre los medicamentos. Por ejemplo, podemos:
 Decidir si exigiremos o no una aprobación previa para un medicamento. (La aprobación
previa es el permiso del plan GuildNet Gold Plus FIDA o de su equipo interdisciplinario
(IDT) antes de que pueda obtener un medicamento).
 Agregar o cambiar la cantidad de medicamento que puede recibir (llamado “cantidades limitadas”).
 Agregar o cambiar restricciones de terapia escalonada sobre un medicamento. (Terapia
escalonada significa que debe probar un medicamento antes de que cubramos otro).
(Para obtener más información sobre estas normas de medicamentos consulte la página iv.)
Le informaremos cuando un medicamento que esté tomando se elimine de la lista de
medicamentos. También le informaremos cuando cambiemos nuestras normas para la cobertura
de un medicamento. Las preguntas 3, 4 y 7 a continuación tienen más información sobre lo que
sucede cuando cambia la lista de medicamentos.
 Siempre puede consultar la lista de medicamentos actualizada del plan GuildNet Gold Plus
FIDA en línea en www.guildnetny.org. También puede llamar a Servicios para Participantes
al 1-800-815-0000 para verificar la lista de medicamentos actual. Los usuarios de TTY/TDD,
deben llamar al 1-800-662-1220.
3.
¿Qué sucede cuando aparece un medicamento más económico
que funciona tan bien como un medicamento actual de la lista de
medicamentos?
Si aparece un medicamento más económico que funciona tan bien como un medicamento actual
de la lista de medicamentos:

Su farmacéutico puede darle el medicamento más económico la próxima vez que usted
surta su prescripción. Si usted y su proveedor deciden que el medicamento más
económico no es conveniente para usted, su proveedor puede informar al farmacéutico
que debe seguir entregándole el medicamento que toma actualmente.

El plan GuildNet Gold Plus FIDA puede decidir eliminar el medicamento más costoso de
la lista de medicamentos. Si usted toma un medicamento que eliminamos de la lista de
medicamentos porque aparece un medicamento más económico que funciona igual, le
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informaremos al menos 60 días antes de eliminarlo de la lista de medicamentos o cuando
usted solicite el resurtido. Entonces podrá recibir un suministro de 60 días del
medicamento antes de que se haga el cambio en la lista de medicamentos. Recibirá una
carta al menos 60 días antes de la entrada en vigencia del cambio.
4.
¿Qué sucede cuando descubrimos que un medicamento no es seguro?
Si la Administración de Drogas y Alimentos (FDA) indica que un medicamento que usted toma no
es seguro, lo quitaremos de la lista de medicamentos de inmediato. También le enviaremos una
carta y lo llamaremos para informarle que el medicamento no seguro se ha eliminado de la lista
de medicamentos. Si recibe esta carta, debe llamar a su administrador de atención o médico que
emite la prescripción para obtener una prescripción de reemplazo.
5.
¿Existen restricciones o límites sobre la cobertura de
medicamentos? ¿O hay algo que deba hacer para poder obtener
ciertos medicamentos?
Sí, algunos medicamentos tienen normas de cobertura o límites respecto de la cantidad que
puede recibir. En algunos casos, usted, su médico o algún otro recetador deben hacer algo antes
de poder obtener el medicamento. Por ejemplo:
 Aprobación previa (o autorización previa): Para algunos medicamentos, usted, su
médico u otro recetador deben obtener aprobación del plan GuildNet Gold Plus FIDA o de
su equipo interdisciplinario (IDT) antes de surtir la prescripción. Si no recibe la aprobación,
el plan GuildNet Gold Plus FIDA tal vez no cubra el medicamento.
 Cantidades limitadas: En ocasiones, el plan GuildNet Gold Plus FIDA limita la cantidad de
medicamento que puede obtener
 Terapia escalonada: A veces el plan GuildNet Gold Plus FIDA le exige realizar una terapia
escalonada. Esto significa que tendrá que probar medicamentos en un cierto orden para su
enfermedad. Es posible que deba probar un medicamento antes de que cubramos otro. Si
su médico considera que el primer medicamento no es conveniente para usted, entonces
cubriremos el segundo.
Puede saber si su medicamento tiene límites o requisitos adicionales consultando las tablas que
aparecen a partir de la página 2. También puede obtener más información al visitar nuestro sitio
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web www.guildnetny.org Publicamos en línea documentos que explican nuestras restricciones de
autorización previa y terapia escalonada. También puede pedirnos una copia.
Puede solicitar una “excepción” a estos límites. Consulte la pregunta 11 para obtener más
información sobre las excepciones.
 Si se encuentra en un centro de cuidados para ancianos u otro centro de atención prolongada
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 necesite (a menos que tenga una prescripción
para menos días), sea o no un nuevo participante del plan GuildNet Gold Plus FIDA. Esto le
dará tiempo para hablar con su médico u otro recetador. Este lo podrá ayudar a decidir si
existe un medicamento similar en la lista de medicamentos que pueda tomar en lugar del otro
o si debe solicitar una excepción. Consulte la pregunta 11 para obtener más información
sobre las excepciones.
6.
¿Cómo sabrá si el medicamento que desea tiene limitaciones o si
hay algo que debe hacer para obtener el medicamento?
La lista de medicamentos cubiertos de la página 2 tiene una columna llamada “Acciones
necesarias, restricciones o límites sobre el uso”.
7.
¿Qué sucede si cambiamos nuestras normas sobre cómo cubrimos
ciertos medicamentos? Por ejemplo, si agregamos la autorización
previa (aprobación), cantidades limitadas o restricciones de terapia
escalonada a un medicamento.
Le informaremos si agregamos la aprobación previa, cantidades limitadas o restricciones de
terapia escalonada a un medicamento. Le informaremos al menos 60 días antes de agregar la
restricción o la próxima vez que solicite un resurtido. Entonces podrá recibir un suministro de 60
días del medicamento antes de que se haga el cambio en la lista de medicamentos. Esto le dará
tiempo para hablar con su médico u otro recetador sobre qué se debe hacer a continuación.
8.
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¿Cómo puede encontrar un medicamento en la lista de
medicamentos?
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Existen dos maneras de encontrar un medicamento:
 Puede buscar por orden alfabético (si sabe cómo se escribe el nombre del medicamento) o
 Puede buscar por enfermedad.
Para buscar por orden alfabético, ingrese en la sección de Listado alfabético en la página 137.
Luego busque el nombre de su medicamento en la lista.
Para buscar por enfermedad, encuentre la sección titulada “Lista de medicamentos por
enfermedad” en la página 2. Luego busque su enfermedad. Por ejemplo, si tiene una enfermedad
cardíaca, deberá buscar en la categoría: Cardiovascular, Hipertensión/Lípidos. Allí es donde
encontrará los medicamentos para tratar enfermedades cardíacas.
9.
¿Qué sucede si el medicamento que desea tomar no aparece en la
lista de medicamentos?
Si no ve su medicamento en la lista de medicamentos, llame a Servicios para Participantes al
1-800-815-0000 (los usuarios de TTY/TDD deben llamar al 1-800-662-1220) y consulte al respecto. Si
se entera de que el plan GuildNet Gold Plus FIDA no cubre el medicamento, puede hacer lo siguiente:
 Pida a Servicios para Participantes que le brinde una lista de los medicamentos que sean
como el que usted desea. Luego, muestre la lista a su médico o recetador. Este puede recetar
un medicamento de la lista de medicamentos que sea similar al que usted desea. O bien
 Puede pedir al plan o a su equipo interdisciplinario (IDT) que hagan una excepción para
cubrir su medicamento. Consulte la pregunta 11 para obtener más información sobre las
excepciones.
10. ¿Qué sucede si es un nuevo participante del plan GuildNet Gold
Plus FIDA y no puede encontrar su medicamento en la lista de
medicamentos o tiene un problema para obtener su medicamento?
Podemos ayudarlo. Debemos cubrir hasta 90 días de suministros temporales de su
medicamento, según sea necesario, durante los primeros 90 días en que usted sea participante
del plan GuildNet Gold Plus FIDA. Esto le dará tiempo para hablar con su médico u otro
recetador. Este lo podrá ayudar a decidir si existe un medicamento similar en la lista de
medicamentos que pueda tomar en lugar del otro o si debe solicitar una excepción.
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Cubriremos hasta 90 días de suministros temporales de su medicamento si:
 toma un medicamento que no está en nuestra lista de medicamentos o
 las normas del plan de salud no le permiten recibir la cantidad que ordenó su recetador o
 el medicamento requiere la aprobación previa del plan GuildNet Gold Plus FIDA o de su
equipo interdisciplinario (IDT) o
 toma un medicamento que forma parte de una restricción de terapia escalonada.
Si vive en un centro de cuidados para ancianos u otro centro de atención prolongada, puede
resurtir su prescripción
hasta por 98 días. Durante esos 90 días, puede resurtir el medicamento múltiples veces. Esto le
da tiempo al recetador para que cambie sus medicamentos por aquellos que aparecen en la lista
de medicamentos o para que pida una excepción.
Si es miembro actual de nuestro plan y experimenta un cambio en el nivel de atención, como una
admisión o alta de un centro de atención prolongada, tendrá permitido un resurtido anticipado de sus
medicamentos, según sea necesario, para ayudarlo en la transición a su nuevo nivel de atención.
11. ¿Puede solicitar una excepción para cubrir su medicamento?
Sí. Puede solicitar al plan GuildNet Gold Plus FIDA o a su equipo interdisciplinario (IDT) que
haga una excepción para cubrir un medicamento que no aparece en la lista de medicamentos.
También puede solicitar al plan GuildNet Gold Plus FIDA o a su IDT que cambie las normas
sobre su medicamento.
 Por ejemplo, el plan GuildNet Gold Plus FIDA puede limitar la cantidad de medicamento
que cubriremos. Si su medicamento tiene un límite, puede solicitarnos, tanto a nosotros
como a su IDT, que cambiemos el límite para cubrir más.
 Otros ejemplos: Puede solicitarnos, a nosotros o a su IDT, que eliminemos las restricciones
de terapia escalonada o los requisitos de aprobación previa.
12. ¿Cuánto tarda en obtenerse una excepción?
Primero, el plan GuildNet Gold Plus FIDA o su equipo interdisciplinario (IDT) deben recibir una
declaración del recetador, fundamentando su solicitud de excepción. Después de recibir la
declaración, usted recibirá una decisión sobre su solicitud de excepción en un plazo de 72 horas.
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Si usted o el recetador consideran que su salud puede verse perjudicada si tiene que esperar 72
horas para obtener la decisión, puede solicitar una excepción acelerada. Esta es una decisión
más rápida. Si el recetador fundamenta su solicitud, recibirá la decisión en un plazo de 24 horas
desde la recepción de la declaración respaldatoria del recetador.
13. ¿Cómo puede solicitar una excepción?
Para solicitar una excepción, llame a su administrador de atención. Su administrador de atención
trabajará con usted y su proveedor para ayudarlo a solicitar una excepción.
14. ¿Qué son los medicamentos genéricos?
Los medicamentos genéricos tienen la misma composición de ingredientes que los de marca.
Generalmente tienen un costo menor que los de marca y no tienen nombres conocidos. Los
medicamentos genéricos están aprobados por la Administración de Drogas y Alimentos (FDA).
El plan GuildNet Gold Plus FIDA cubre tanto medicamentos de marca como genéricos.
15. ¿Qué son los medicamentos OTC?
OTC viene del inglés over-the-counter que significa medicamentos de venta libre. El plan GuildNet
Gold Plus FIDA cubre algunos medicamentos de venta libre cuando su proveedor los prescribe.
Puede consultar la lista de medicamentos del plan GuildNet Gold Plus FIDA para saber qué
medicamentos de venta libre están cubiertos.
Los ejemplos de medicamentos de venta libre cubiertos son: aspirina, paracetamol, Advil,
antiácidos, medicamentos para refriados y alergias, cremas antibióticas, laxantes, parches y
chicles de nicotina y vitaminas.
16. ¿Cubre el plan GuildNet Gold Plus FIDA los productos de venta
libre que no sean medicamentos?
El plan GuildNet Gold Plus FIDA cubre algunos productos de venta libre que no son
medicamentos cuando su proveedor los prescribe.
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Puede consultar la lista de medicamentos del plan GuildNet Gold Plus FIDA para saber qué
productos de venta libre que no son medicamentos están cubiertos. Los ejemplos incluyen:
protectores solares (SPF 15+), champú tópico Sebex y pomada A&D.
Los artículos adicionales de venta libre que no están incluidos en la lista de medicamentos se
pueden obtener usando su tarjeta OTC del plan GuildNet Gold Plus FIDA en alguna farmacia
participante. Los artículos cubiertos por su tarjeta del Plan OTC incluyen: curitas, caramelos para
la tos, dentífrico y medias de soporte médico de alta y baja compresión. Para mayor información,
lea el Capítulo 4 de su Manual del Participante.
17. ¿Cuál es su copago?
No se le cobrará copago por medicamentos de la lista de medicamentos.
18. ¿Qué son los niveles de medicamentos?
Cada medicamento de la lista de medicamentos cubiertos pertenece a uno de estos cuatro niveles.

Nivel 1: medicamentos genéricos de Medicare Parte D.

Nivel 2: medicamentos de marca de Medicare Parte D.

Nivel 3: medicamentos prescritos cubiertos por Medicaid (no de la Parte D).

Nivel 4: artículos de venta libre (OTC).
Todos los medicamentos y artículos de nuestra lista de medicamentos tienen un copago de $0.
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Lista de medicamentos cubiertos
La lista de medicamentos cubiertos que comienza en la siguiente página le brinda información
sobre los medicamentos cubiertos por el plan GuildNet Gold Plus FIDA. Si tiene problemas para
encontrar su medicamento en la lista, consulte el ìndice que comienza en la página 137.
La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca
aparecen en mayúsculas (por ejemplo, SYNTHROID) y los genéricos aparecen en minúscula y
cursiva (por ejemplo, atenolol).
La información en la columna de acciones necesarias, restricciones o límites sobre el uso le
informa si el plan GuildNet Gold Plus FIDA tiene normas para cubrir su medicamento.
Nota: El * junto a un medicamento quiere decir que el medicamento no es un “medicamento de la
Parte D”. Estos medicamentos tienen normas diferentes para las apelaciones. Una apelación es
una manera formal de pedir una revisión y cambio en la decisión de cobertura si usted considera
que hubo un error. Por ejemplo, el plan GuildNet Gold Plus FIDA o su equipo interdisciplinario
(IDT) pueden decidir que un medicamento que usted desea no esté cubierto o que Medicare o
Medicaid dejen de cubrirlo.
Si usted, su doctor o algún otro recetador no está de acuerdo con la decisión, puede apelar. Para
solicitar instrucciones sobre cómo apelar, llame a Servicios para Participantes al 1-800-815-0000
(los usuarios de TTY/TDD deben llamar al 1-800-662-1220) o a Defensoría del Participante de
FIDA al 1-844-614-8800 (TTY 711). También puede leer el Manual del Participante para saber
cómo apelar una decisión.
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Abajo podrá encontrar una lista de abreviaciones que pueden aparecer en las siguientes páginas en la columna
de requerimientos/límites, que le dice si hay algún requerimiento especial para el financiamiento de su
medicamento.
Lista de abreviaciones
*: El * junto a un medicamento quiere decir que el medicamento no es un “medicamento de la Parte D”.
Estos medicamentos tienen normas diferentes para las apelaciones. Una apelación es una manera formal de
pedir una revisión y cambio en la decisión de cobertura si usted considera que hubo un error. Por ejemplo, el
plan GuildNet Gold Plus FIDA o su equipo interdisciplinario (IDT) pueden decidir que un medicamento que
usted desea no esté cubierto o que Medicare o Medicaid dejen de cubrirlo. Si usted, su doctor o algún otro
recetador no está de acuerdo con la decisión, puede apelar. Para solicitar instrucciones sobre cómo apelar,
llame a Servicios para Participantes al 1-800-815-0000; los usuarios de TTY/TDD deben llamar al 1-800-6621220 o a la Defensoría del Participante (ICAN) al 1-844-614-8800. También puede leer el Manual del
Participante para saber cómo apelar una decisión.
B/D PA: Este medicamento de prescripción puede estar cubierto por Medicare Parte B o D, dependiendo de
las circunstancias. Puede ser necesario presentar información que describa el uso y entorno del medicamento
para poder determinarlo.
LA: Disponibilidad limitada. Este medicamento de prescripción puede estar disponible solo en ciertas
farmacias. Para obtener más información, llame a Servicios al Cliente.
MO: Medicamento de pedido por correo. Este medicamento por prescripción está disponible a través de
nuestro servicio de pedido por correo, así como también a través de nuestra red de farmacias minoristas.
Considere usar el servicio de pedido por correo para sus medicamentos a largo plazo (de mantenimiento,
como los medicamentos para la hipertensión). Las red de farmacias minoristas pueden ser más adecuadas para
las prescripciones a corto plazo (como los antibióticos).
PA: Autorización previa. El plan le exige a usted o a su médico obtener autorización previa para ciertos
medicamentos Esto significa que deberá recibir la aprobación antes de surtir sus prescripciones. Si no recibe
aprobación, tal vez no cubramos el medicamento.
QL: Cantidades limitadas. Para ciertos medicamentos, el plan limita la cantidad que cubriremos.
ST: Terapia escalonada. En algunos casos el plan le exige que primero pruebe otros medicamentos para tratar
su enfermedad, antes de que cubramos otro medicamento para esa condición. Por ejemplo, si el Medicamento
A y el B tratan su enfermedad, tal vez no cubramos el Medicamento B a menos que usted pruebe el A
primero. Si el Medicamento A no es adecuado para usted, cubriremos el B.
Lista de medicamentos por enfermedad
Los medicamentos en esta sección están agrupados en categorías, dependiendo del tipo de enfermedad para el
que es usado. Por ejemplo, si tiene una enfermedad cardíaca, deberá buscar en la categoría: Cardiovascular,
Hipertensión/Lípidos. Allí es donde encontrará los medicamentos para tratar enfermedades cardíacas.
Si tiene alguna pregunta, llame Al plan GuildNet Gold Plus FIDA al 1-800-815-0000, de lunes a domingo
entre las 8 a.m. y las 8 p.m. Los usuarios de TTY/TDD, deben llamar al 1-800-662-1220. La llamada es
gratuita. Para más información, visite www.guildnetny.org.
1
NOMBRE DEL MEDICAMENTO
NIVEL
CUÁNTO LE
ACCIONES NECESARIAS,
COSTARÁ EL
RESTRICCIONES O
MEDICAMENTO LÍMITES DE USO
ANTIINFECCIOSOS
AGENTES ANTIFÚNGICOS
ABELCET INTRAVENOUS SUSPENSION
2
$0
B/D PA; MO
AMBISOME INTRAVENOUS SUSPENSION
FOR RECONSTITUTION
2
$0
B/D PA; MO
amphotericin b injection recon soln
1
$0
B/D PA; MO
CANCIDAS INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
clotrimazole mucous membrane troche
1
$0
MO
fluconazole in dextrose(iso-o) intravenous
piggyback 400 mg/200 ml
1
$0
B/D PA
fluconazole oral suspension for reconstitution
1
$0
MO
fluconazole oral tablet
1
$0
MO
flucytosine oral capsule
1
$0
MO
griseofulvin microsize oral suspension
1
$0
MO
griseofulvin microsize oral tablet
1
$0
MO
griseofulvin ultramicrosize oral tablet
1
$0
MO
itraconazole oral capsule
1
$0
MO; QL (120 per 30 days)
ketoconazole oral tablet
1
$0
MO
NOXAFIL ORAL SUSPENSION
2
$0
MO
nystatin oral suspension
1
$0
MO
nystatin oral tablet
1
$0
MO
terbinafine hcl oral tablet
1
$0
voriconazole intravenous solution
1
$0
B/D PA; MO
VORICONAZOLE ORAL SUSPENSION
FOR RECONSTITUTION
2
$0
MO
VORICONAZOLE ORAL TABLET 200 MG
2
$0
MO
voriconazole oral tablet 50 mg
1
$0
MO
ANTIVIRALES
abacavir oral tablet
1
$0
MO
Puede consultar el significado de los símbolos y abreviaturas de esta tabla en la página 1.
Si tiene alguna pregunta, llame al plan GuildNet Gold Plus FIDA al 1-800-815-0000, de lunes a domingo
2
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
abacavir-lamivudine-zidovudine oral tablet
1
$0
MO
acyclovir oral capsule
1
$0
MO
acyclovir oral suspension 200 mg/5 ml
1
$0
MO
acyclovir oral tablet
1
$0
MO
acyclovir sodium intravenous solution
1
$0
B/D PA; MO
ADEFOVIR ORAL TABLET
2
$0
MO
amantadine hcl oral capsule
1
$0
MO
amantadine hcl oral solution
1
$0
MO
amantadine hcl oral tablet
1
$0
MO
APTIVUS ORAL CAPSULE
2
$0
MO
APTIVUS ORAL SOLUTION
2
$0
ATRIPLA ORAL TABLET
2
$0
MO
BARACLUDE ORAL SOLUTION
2
$0
MO
CIDOFOVIR INTRAVENOUS SOLUTION
2
$0
B/D PA; MO
COMPLERA ORAL TABLET
2
$0
MO
CRIXIVAN ORAL CAPSULE 200 MG, 400
MG
2
$0
MO
didanosine oral capsule,delayed release(dr/ec)
1
$0
MO
EDURANT ORAL TABLET
2
$0
MO
EMTRIVA ORAL CAPSULE
2
$0
MO
EMTRIVA ORAL SOLUTION
2
$0
MO
ENTECAVIR ORAL TABLET
2
$0
MO
EPIVIR HBV ORAL SOLUTION
2
$0
MO
EPIVIR ORAL SOLUTION
2
$0
MO
EPZICOM ORAL TABLET
2
$0
MO
EVOTAZ ORAL TABLET
2
$0
MO
famciclovir oral tablet 125 mg
1
$0
1
$0
1
$0
3
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
foscarnet intravenous solution
1
$0
MO
FUZEON SUBCUTANEOUS RECON SOLN
2
$0
MO
ganciclovir sodium intravenous recon soln
1
$0
B/D PA; MO
HARVONI ORAL TABLET
2
$0
PA; MO; QL (28 per 28 days)
INTELENCE ORAL TABLET 100 MG, 200
MG
2
$0
MO
INTELENCE ORAL TABLET 25 MG
2
$0
INVIRASE ORAL CAPSULE
2
$0
MO
INVIRASE ORAL TABLET
2
$0
MO
ISENTRESS ORAL POWDER IN PACKET
2
$0
MO
ISENTRESS ORAL TABLET
2
$0
MO
ISENTRESS ORAL TABLET,CHEWABLE
2
$0
MO
KALETRA ORAL SOLUTION
2
$0
MO
KALETRA ORAL TABLET
2
$0
MO
lamivudine oral solution
1
$0
MO
lamivudine oral tablet
1
$0
MO
LAMIVUDINE-ZIDOVUDINE ORAL
TABLET
2
$0
MO
LEXIVA ORAL SUSPENSION
2
$0
MO
LEXIVA ORAL TABLET
2
$0
MO
nevirapine oral suspension
1
$0
MO
nevirapine oral tablet
1
$0
MO
nevirapine oral tablet extended release 24 hr
1
$0
MO
NORVIR ORAL CAPSULE
2
$0
MO
NORVIR ORAL SOLUTION
2
$0
MO
NORVIR ORAL TABLET
2
$0
MO
PREZCOBIX ORAL TABLET
2
$0
MO
PREZISTA ORAL SUSPENSION
2
$0
MO
4
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
PREZISTA ORAL TABLET 150 MG, 600
MG, 75 MG, 800 MG
2
$0
MO
RELENZA DISKHALER INHALATION
BLISTER WITH DEVICE
2
$0
RESCRIPTOR ORAL TABLET
2
$0
MO
RESCRIPTOR ORAL TABLET,
DISPERSIBLE
2
$0
MO
RETROVIR INTRAVENOUS SOLUTION
2
$0
MO
REYATAZ ORAL CAPSULE 150 MG, 200
MG, 300 MG
2
$0
MO
REYATAZ ORAL POWDER IN PACKET
2
$0
MO
ribavirin oral capsule
1
$0
PA; MO
ribavirin oral tablet 200 mg
1
$0
PA; MO
rimantadine oral tablet
1
$0
MO
SELZENTRY ORAL TABLET
2
$0
MO
SOVALDI ORAL TABLET
2
$0
stavudine oral capsule
1
$0
MO
stavudine oral recon soln
1
$0
MO
STRIBILD ORAL TABLET
2
$0
MO
SUSTIVA ORAL CAPSULE
2
$0
MO
SUSTIVA ORAL TABLET
2
$0
MO
SYNAGIS INTRAMUSCULAR SOLUTION
50 MG/0.5 ML
2
$0
PA; MO; LA
TAMIFLU ORAL CAPSULE 30 MG
2
$0
TAMIFLU ORAL CAPSULE 45 MG, 75 MG
2
$0
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION
2
$0
TIVICAY ORAL TABLET
2
$0
MO
TRIUMEQ ORAL TABLET
2
$0
MO
TRUVADA ORAL TABLET
2
$0
MO
5
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
TYBOST ORAL TABLET
2
$0
MO
TYZEKA ORAL TABLET
2
$0
MO
valacyclovir oral tablet
1
$0
VALCYTE ORAL RECON SOLN
2
$0
MO
VALGANCICLOVIR ORAL TABLET
2
$0
MO
VIDEX 2 GRAM PEDIATRIC ORAL
RECON SOLN
2
$0
MO
VIEKIRA PAK ORAL TABLETS,DOSE
PACK
2
$0
PA; MO; QL (112 per 28
days)
VIRACEPT ORAL TABLET
2
$0
MO
VIRAMUNE XR ORAL TABLET
EXTENDED RELEASE 24 HR 100 MG
2
$0
MO
VIRAZOLE INHALATION RECON SOLN
2
$0
B/D PA; MO
VIREAD ORAL POWDER
2
$0
MO
VIREAD ORAL TABLET
2
$0
MO
VITEKTA ORAL TABLET
2
$0
MO
ZIAGEN ORAL SOLUTION
2
$0
MO
zidovudine oral capsule
1
$0
MO
zidovudine oral syrup
1
$0
MO
zidovudine oral tablet
1
$0
MO
cefaclor oral capsule
1
$0
MO
cefaclor oral tablet extended release 12 hr
1
$0
MO
cefadroxil oral capsule
1
$0
MO
cefadroxil oral suspension for reconstitution
250 mg/5 ml, 500 mg/5 ml
1
$0
MO
cefadroxil oral tablet
1
$0
MO
cefazolin in dextrose (iso-os) intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml
1
$0
B/D PA; MO
CEFALOSPORINAS
6
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
cefazolin injection recon soln 1 gram, 500 mg
1
$0
B/D PA; MO
cefazolin injection recon soln 10 gram
1
$0
B/D PA
cefdinir oral capsule
1
$0
MO
cefdinir oral suspension for reconstitution
1
$0
MO
cefditoren pivoxil oral tablet 200 mg
1
$0
MO
cefepime injection recon soln
1
$0
B/D PA; MO
cefixime oral suspension for reconstitution
1
$0
MO
cefotaxime injection recon soln 1 gram, 2
gram, 500 mg
1
$0
B/D PA
cefotetan injection recon soln
1
$0
cefotetan intravenous recon soln
1
$0
cefoxitin in dextrose, iso-osm intravenous
piggyback
1
$0
B/D PA
cefoxitin intravenous recon soln 1 gram
1
$0
B/D PA; MO
cefoxitin intravenous recon soln 10 gram, 2
gram
1
$0
B/D PA
cefpodoxime oral suspension for reconstitution
1
$0
MO
cefpodoxime oral tablet
1
$0
MO
cefprozil oral suspension for reconstitution
1
$0
MO
cefprozil oral tablet
1
$0
MO
ceftazidime injection recon soln 1 gram, 2
gram
1
$0
B/D PA; MO
ceftazidime injection recon soln 6 gram
1
$0
ceftriaxone injection recon soln 10 gram
1
$0
B/D PA
ceftriaxone injection recon soln 250 mg, 500
mg
1
$0
B/D PA; MO
ceftriaxone intravenous recon soln
1
$0
B/D PA; MO
cefuroxime axetil oral tablet
1
$0
MO
cefuroxime sodium injection recon soln 1.5
gram, 750 mg
1
$0
B/D PA; MO
7
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
cefuroxime sodium intravenous recon soln
1
$0
B/D PA
cephalexin oral capsule
1
$0
MO
cephalexin oral suspension for reconstitution
1
$0
MO
cephalexin oral tablet
1
$0
MO
SUPRAX ORAL CAPSULE
2
$0
MO
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML, 200
MG/5 ML
2
$0
MO
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 500 MG/5 ML
2
$0
SUPRAX ORAL TABLET,CHEWABLE
2
$0
MO
TEFLARO INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
ERITROMICINAS / OTROS MACRÓLIDOS
azithromycin intravenous recon soln 500 mg
1
$0
B/D PA; MO
azithromycin intravenous recon soln 500 mg (2
mg/ml)
1
$0
B/D PA
azithromycin oral packet
1
$0
MO
azithromycin oral suspension for reconstitution
1
$0
MO
azithromycin oral tablet
1
$0
MO
clarithromycin oral suspension for
reconstitution
1
$0
MO
clarithromycin oral tablet
1
$0
MO
clarithromycin oral tablet extended release 24
hr
1
$0
MO
e.e.s. 400 oral tablet
1
$0
MO
ERYPED 200 ORAL SUSPENSION FOR
RECONSTITUTION
2
$0
MO
ERYTHROCIN (AS STEARATE) ORAL
TABLET 250 MG
2
$0
MO
ERYTHROCIN INTRAVENOUS RECON
SOLN 500 MG
2
$0
B/D PA
8
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
erythromycin ethylsuccinate oral tablet
1
$0
MO
erythromycin oral capsule,delayed
release(dr/ec)
1
$0
MO
erythromycin oral tablet
1
$0
MO
ALBENZA ORAL TABLET
2
$0
MO
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION
2
$0
ALINIA ORAL TABLET
2
$0
amikacin injection solution 500 mg/2 ml
1
$0
B/D PA; MO
ATOVAQUONE ORAL SUSPENSION
2
$0
MO
atovaquone-proguanil oral tablet
1
$0
MO
aztreonam injection recon soln 1 gram
1
$0
MO
baciim intramuscular recon soln
1
$0
B/D PA
bacitracin intramuscular recon soln
1
$0
B/D PA; MO
CAPASTAT INJECTION RECON SOLN
2
$0
B/D PA
CAYSTON INHALATION SOLUTION FOR
NEBULIZATION
2
$0
chloramphenicol sod succinate intravenous
recon soln
1
$0
B/D PA
chloroquine phosphate oral tablet
1
$0
MO
clindamycin hcl oral capsule
1
$0
MO
clindamycin pediatric oral recon soln
1
$0
clindamycin phosphate intravenous solution
600 mg/4 ml
1
$0
B/D PA; MO
COARTEM ORAL TABLET
2
$0
MO
COLISTIN (COLISTIMETHATE NA)
INJECTION RECON SOLN
2
$0
B/D PA; MO
CUBICIN INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
CYCLOSERINE ORAL CAPSULE
1
$0
MO
ANTIINFECCIOSOS DIVERSOS
9
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
DAPSONE ORAL TABLET
2
$0
MO
DARAPRIM ORAL TABLET
2
$0
MO
ethambutol oral tablet
1
$0
MO
gentamicin in nacl (iso-osm) intravenous
1
$0
B/D PA; MO
1
$0
MO
piggyback 70 mg/50 ml, 80 mg/50 ml, 90
mg/100 ml
1
$0
GENTAMICIN IN NACL (ISO-OSM)
INTRAVENOUS PIGGYBACK 80 MG/100
ML
2
$0
B/D PA
gentamicin injection solution 40 mg/ml
1
$0
B/D PA; MO
hydroxychloroquine oral tablet
1
$0
MO
imipenem-cilastatin intravenous recon soln
1
$0
B/D PA; MO
INVANZ INJECTION RECON SOLN
2
$0
B/D PA; MO
INVANZ INTRAVENOUS RECON SOLN
2
$0
B/D PA
isoniazid injection solution
1
$0
isoniazid oral solution
1
$0
MO
isoniazid oral tablet
1
$0
MO
ivermectin oral tablet
1
$0
MO
LINEZOLID INTRAVENOUS
PARENTERAL SOLUTION
2
$0
PA
LINEZOLID ORAL TABLET
2
$0
PA; MO
mefloquine oral tablet
1
$0
MO
meropenem intravenous recon soln 500 mg
1
$0
B/D PA; MO
metronidazole in nacl (iso-os) intravenous
piggyback
1
$0
MO
metronidazole oral capsule
1
$0
MO
10
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
metronidazole oral tablet
1
$0
MO
NEBUPENT INHALATION RECON SOLN
2
$0
B/D PA; MO
neomycin oral tablet
1
$0
MO
paromomycin oral capsule
1
$0
MO
PASER ORAL GRANULES DR FOR SUSP
IN PACKET
2
$0
MO
PENTAM INJECTION RECON SOLN
2
$0
B/D PA; MO
polymyxin b sulfate injection recon soln
1
$0
PRIFTIN ORAL TABLET
2
$0
MO
PRIMAQUINE ORAL TABLET
2
$0
MO
pyrazinamide oral tablet
1
$0
MO
quinine sulfate oral capsule
1
$0
PA; MO
rifabutin oral capsule
1
$0
MO
rifampin intravenous recon soln
1
$0
B/D PA; MO
rifampin oral capsule
1
$0
MO
SIRTURO ORAL TABLET
2
$0
MO; LA
STREPTOMYCIN INTRAMUSCULAR
RECON SOLN
2
$0
B/D PA; MO
SYNERCID INTRAVENOUS RECON SOLN
2
$0
B/D PA
tinidazole oral tablet
1
$0
MO
TOBRAMYCIN IN 0.225 % NACL
INHALATION SOLUTION FOR
NEBULIZATION
2
$0
B/D PA; MO
tobramycin in 0.9 % nacl intravenous
1
$0
MO
tobramycin sulfate injection solution
1
$0
B/D PA; MO
TRECATOR ORAL TABLET
2
$0
MO
TYGACIL INTRAVENOUS RECON SOLN
2
$0
MO
XIFAXAN ORAL TABLET 550 MG
2
$0
MO
11
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ZYVOX INTRAVENOUS PARENTERAL
SOLUTION 600 MG/300 ML
2
$0
PA; MO
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION
2
$0
PA; MO
ZYVOX ORAL TABLET
2
$0
PA; MO
amoxicillin oral capsule
1
$0
MO
amoxicillin oral suspension for reconstitution
1
$0
MO
amoxicillin oral tablet
1
$0
MO
amoxicillin oral tablet,chewable 125 mg, 250
mg
1
$0
MO
amoxicillin-pot clavulanate oral suspension for
reconstitution
1
$0
MO
amoxicillin-pot clavulanate oral tablet
1
$0
MO
amoxicillin-pot clavulanate oral tablet
extended release 12 hr
1
$0
MO
amoxicillin-pot clavulanate oral
tablet,chewable
1
$0
MO
ampicillin oral capsule
1
$0
MO
ampicillin oral suspension for reconstitution
1
$0
MO
ampicillin sodium injection recon soln 1 gram,
10 gram, 125 mg
1
$0
B/D PA; MO
ampicillin sodium intravenous recon soln
1
$0
B/D PA
ampicillin-sulbactam injection recon soln 15
gram
1
$0
B/D PA
ampicillin-sulbactam injection recon soln 3
gram
1
$0
B/D PA; MO
ampicillin-sulbactam intravenous recon soln
1.5 gram
1
$0
BICILLIN C-R INTRAMUSCULAR
SYRINGE
2
$0
PENICILINAS
B/D PA; MO
12
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
BICILLIN L-A INTRAMUSCULAR
SYRINGE
2
$0
MO
dicloxacillin oral capsule
1
$0
MO
NAFCILLIN IN DEXTROSE ISO-OSM
INTRAVENOUS PIGGYBACK 1 GRAM/50
ML
2
$0
B/D PA
nafcillin injection recon soln 1 gram
1
$0
B/D PA; MO
NAFCILLIN INJECTION RECON SOLN 10
GRAM
2
$0
B/D PA; MO
nafcillin intravenous recon soln 2 gram
2
$0
B/D PA; MO
oxacillin in dextrose(iso-osm) intravenous
piggyback 1 gram/50 ml
1
$0
B/D PA
OXACILLIN IN DEXTROSE(ISO-OSM)
INTRAVENOUS PIGGYBACK 2 GRAM/50
ML
2
$0
B/D PA; MO
OXACILLIN INJECTION RECON SOLN 10
GRAM
2
$0
B/D PA; MO
oxacillin intravenous recon soln 2 gram
1
$0
B/D PA
penicillin g potassium injection recon soln 5
million unit
1
$0
B/D PA; MO
penicillin g procaine intramuscular syringe 1.2
million unit/2 ml
1
$0
B/D PA; MO
penicillin g procaine intramuscular syringe
600,000 unit/ml
1
$0
B/D PA
penicillin g sodium injection recon soln
1
$0
B/D PA; MO
penicillin v potassium oral recon soln
1
$0
MO
penicillin v potassium oral tablet
1
$0
MO
piperacillin-tazobactam intravenous recon soln
2.25 gram, 3.375 gram, 4.5 gram
1
$0
B/D PA; MO
2
$0
B/D PA; MO
QUINOLONAS
AVELOX IN NACL (ISO-OSMOTIC)
INTRAVENOUS PIGGYBACK
13
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ciprofloxacin (mixture) oral tablet, er
multiphase 24 hr
1
$0
MO
ciprofloxacin hcl oral tablet
1
$0
MO
ciprofloxacin lactate intravenous solution 400
mg/40 ml
1
$0
B/D PA
ciprofloxacin oral suspension,microcapsule
recon
1
$0
levofloxacin in d5w intravenous piggyback 500
mg/100 ml
1
$0
MO
levofloxacin intravenous solution
1
$0
B/D PA; MO
levofloxacin oral solution
1
$0
MO
levofloxacin oral tablet
1
$0
MO
moxifloxacin oral tablet
1
$0
MO
ofloxacin oral tablet 400 mg
1
$0
sulfadiazine oral tablet
1
$0
MO
sulfamethoxazole-trimethoprim intravenous
solution
1
$0
B/D PA; MO
sulfamethoxazole-trimethoprim oral suspension
1
$0
MO
sulfamethoxazole-trimethoprim oral tablet
1
$0
MO
demeclocycline oral tablet
1
$0
MO
doxy-100 intravenous recon soln
1
$0
B/D PA; MO
doxycycline hyclate intravenous recon soln
1
$0
B/D PA
doxycycline hyclate oral capsule
1
$0
MO
doxycycline hyclate oral tablet 100 mg, 20 mg
1
$0
MO
doxycycline hyclate oral tablet 50 mg
1
$0
doxycycline hyclate oral tablet,delayed release
(dr/ec)
1
$0
MO
doxycycline monohydrate oral capsule
1
$0
MO
SULFATOS / AGENTES RELACIONADOS
TETRACICLINAS
14
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
doxycycline monohydrate oral tablet
1
$0
MO
minocycline oral capsule
1
$0
MO
minocycline oral tablet
1
$0
MO
minocycline oral tablet extended release 24 hr
1
$0
MO
morgidox oral capsule
1
$0
MO
ORACEA ORAL CAPSULE,IR & DELAY
REL,BIPHASE
2
$0
MO
tetracycline oral capsule
1
$0
MO
methenamine hippurate oral tablet
1
$0
MO
nitrofurantoin macrocrystal oral capsule 100
mg, 50 mg
1
$0
PA; MO
nitrofurantoin monohyd/m-cryst oral capsule
1
$0
PA; MO
trimethoprim oral tablet
1
$0
MO
vancomycin intravenous recon soln 1,000 mg,
10 gram, 500 mg
1
$0
B/D PA; MO
VANCOMYCIN INTRAVENOUS RECON
SOLN 750 MG
1
$0
B/D PA; MO
VANCOMYCIN ORAL CAPSULE
2
$0
MO
AMIFOSTINE CRYSTALLINE
INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
dexrazoxane hcl intravenous recon soln 250 mg
1
$0
B/D PA
ELITEK INTRAVENOUS RECON SOLN 1.5
MG
2
$0
B/D PA
leucovorin calcium injection recon soln 100
mg, 350 mg
1
$0
B/D PA; MO
AGENTES DEL TRACTO URINARIO
VANCOMICINA
MEDICAMENTOS
ANTINEOPLÁSTICOS /
INMUNOSUPRESORES
AGENTES ADICIONALES
15
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
leucovorin calcium oral tablet
1
$0
MO
LEVOLEUCOVORIN CALCIUM
INTRAVENOUS SOLUTION
2
$0
B/D PA
mesna intravenous solution
1
$0
B/D PA; MO
MESNEX ORAL TABLET
2
$0
MO
XGEVA SUBCUTANEOUS SOLUTION
2
$0
B/D PA; MO
MEDICAMENTOS ANTINEOPLÁSTICOS /
INMUNOSUPRESORES
ABRAXANE INTRAVENOUS
SUSPENSION FOR RECONSTITUTION
2
$0
B/D PA; MO
adrucil intravenous solution 500 mg/10 ml
1
$0
B/D PA; MO
AFINITOR DISPERZ ORAL TABLET FOR
SUSPENSION
2
$0
PA; MO
AFINITOR ORAL TABLET
2
$0
PA; MO
ALIMTA INTRAVENOUS RECON SOLN
500 MG
2
$0
B/D PA; MO
anastrozole oral tablet
1
$0
MO
ASTAGRAF XL ORAL
CAPSULE,EXTENDED RELEASE 24HR
2
$0
B/D PA; MO
AVASTIN INTRAVENOUS SOLUTION
2
$0
B/D PA; MO
AZACITIDINE INJECTION RECON SOLN
2
$0
MO
AZASAN ORAL TABLET
2
$0
B/D PA; MO
azathioprine oral tablet
1
$0
B/D PA; MO
BELEODAQ INTRAVENOUS RECON
SOLN
2
$0
B/D PA; MO
bicalutamide oral tablet
1
$0
MO
BICNU INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
bleomycin injection recon soln 30 unit
1
$0
B/D PA; MO
BOSULIF ORAL TABLET
2
$0
PA; MO
BUSULFEX INTRAVENOUS SOLUTION
2
$0
B/D PA
16
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
CAPRELSA ORAL TABLET
2
$0
MO
carboplatin intravenous solution
1
$0
B/D PA; MO
CELLCEPT INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
CELLCEPT ORAL SUSPENSION FOR
RECONSTITUTION
2
$0
B/D PA; MO
cisplatin intravenous solution
1
$0
B/D PA; MO
cladribine intravenous solution
1
$0
B/D PA; MO
COMETRIQ ORAL CAPSULE
2
$0
PA; MO
CYCLOPHOSPHAMIDE ORAL CAPSULE
2
$0
B/D PA; MO
cyclosporine intravenous solution
1
$0
B/D PA
cyclosporine modified oral capsule
1
$0
B/D PA; MO
cyclosporine modified oral solution
1
$0
B/D PA; MO
cyclosporine oral capsule
1
$0
B/D PA; MO
cytarabine injection solution
1
$0
B/D PA; MO
dacarbazine intravenous recon soln 200 mg
1
$0
B/D PA; MO
daunorubicin intravenous solution
1
$0
B/D PA
DAUNOXOME INTRAVENOUS SOLUTION
2
$0
MO
DECITABINE INTRAVENOUS RECON
SOLN
2
$0
B/D PA; MO
doxorubicin intravenous solution 50 mg/25 ml
1
$0
B/D PA; MO
DROXIA ORAL CAPSULE
2
$0
MO
ELIGARD SUBCUTANEOUS SYRINGE
2
$0
PA; MO
EMCYT ORAL CAPSULE
2
$0
MO
EPIRUBICIN INTRAVENOUS SOLUTION
50 MG/25 ML
2
$0
B/D PA; MO
ERIVEDGE ORAL CAPSULE
2
$0
PA; MO
ERWINAZE INTRAMUSCULAR RECON
SOLN
2
$0
PA; MO
etoposide intravenous solution
1
$0
B/D PA; MO
exemestane oral tablet
1
$0
MO
17
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
FARESTON ORAL TABLET
2
$0
MO
FARYDAK ORAL CAPSULE
2
$0
PA; MO
FASLODEX INTRAMUSCULAR SYRINGE
2
$0
B/D PA; MO
FLUDARABINE INTRAVENOUS RECON
SOLN
2
$0
B/D PA; MO
fluorouracil intravenous solution 2.5 gram/50
ml
1
$0
B/D PA; MO
flutamide oral capsule
1
$0
MO
GAZYVA INTRAVENOUS SOLUTION
2
$0
B/D PA; MO
GEMCITABINE INTRAVENOUS RECON
SOLN 1 GRAM
2
$0
B/D PA; MO
gengraf oral capsule
1
$0
B/D PA; MO
gengraf oral solution
1
$0
B/D PA; MO
GILOTRIF ORAL TABLET
2
$0
PA; MO
GLEEVEC ORAL TABLET 100 MG
2
$0
PA; MO
GLEEVEC ORAL TABLET 400 MG
2
$0
GLEOSTINE ORAL CAPSULE
2
$0
MO
HERCEPTIN INTRAVENOUS RECON
SOLN
2
$0
B/D PA; MO
HEXALEN ORAL CAPSULE
2
$0
MO
hydroxyurea oral capsule
1
$0
MO
IBRANCE ORAL CAPSULE
2
$0
ICLUSIG ORAL TABLET
2
$0
PA; MO
idarubicin intravenous solution
1
$0
B/D PA
IFOSFAMIDE INTRAVENOUS RECON
SOLN 1 GRAM
2
$0
B/D PA; MO
IMBRUVICA ORAL CAPSULE
2
$0
PA; MO
INLYTA ORAL TABLET
2
$0
PA; MO
IRINOTECAN INTRAVENOUS SOLUTION
100 MG/5 ML
2
$0
B/D PA; MO
18
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ISTODAX INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
JAKAFI ORAL TABLET 10 MG, 15 MG, 20
MG, 5 MG
2
$0
PA; MO
JAKAFI ORAL TABLET 25 MG
2
$0
KADCYLA INTRAVENOUS RECON SOLN
100 MG
2
$0
B/D PA; MO
KEYTRUDA INTRAVENOUS RECON
SOLN
2
$0
B/D PA; MO
LENVIMA ORAL CAPSULE
2
$0
PA; MO
letrozole oral tablet
1
$0
MO
LEUKERAN ORAL TABLET
2
$0
MO
leuprolide subcutaneous kit
1
$0
MO
LOMUSTINE ORAL CAPSULE
2
$0
MO
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
2
$0
PA; MO
2
$0
PA; MO
2
$0
PA; MO
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT
2
$0
PA; MO
LUPRON DEPOT-PED INTRAMUSCULAR
KIT 11.25 MG, 15 MG
2
$0
PA; MO
LYNPARZA ORAL CAPSULE
2
$0
PA; MO
LYSODREN ORAL TABLET
2
$0
MO
MATULANE ORAL CAPSULE
2
$0
MO
megestrol oral tablet
1
$0
PA; MO
MEKINIST ORAL TABLET
2
$0
PA; MO
melphalan hcl intravenous recon soln
1
$0
B/D PA
mercaptopurine oral tablet
1
$0
MO
methotrexate sodium (pf) injection recon soln
1
$0
B/D PA
19
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
methotrexate sodium (pf) injection solution
1
$0
B/D PA; MO
methotrexate sodium oral tablet
1
$0
B/D PA; MO
mitomycin intravenous recon soln 20 mg
1
$0
B/D PA; MO
mitoxantrone intravenous concentrate
1
$0
B/D PA; MO
MUSTARGEN INJECTION RECON SOLN
2
$0
B/D PA; MO
mycophenolate mofetil oral capsule
1
$0
B/D PA; MO
mycophenolate mofetil oral suspension for
reconstitution
1
$0
B/D PA; MO
mycophenolate mofetil oral tablet
1
$0
B/D PA; MO
mycophenolate sodium oral tablet,delayed
release (dr/ec)
1
$0
B/D PA; MO
NEORAL ORAL CAPSULE
2
$0
B/D PA; MO
NEORAL ORAL SOLUTION
2
$0
B/D PA; MO
NEXAVAR ORAL TABLET
2
$0
PA; MO
NILANDRON ORAL TABLET
2
$0
MO
NULOJIX INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
OCTREOTIDE ACETATE INJECTION
SOLUTION 1,000 MCG/ML, 500 MCG/ML
2
$0
PA; MO
octreotide acetate injection solution 100
mcg/ml, 200 mcg/ml, 50 mcg/ml
1
$0
PA; MO
octreotide acetate injection syringe 100 mcg/ml
(1 ml), 50 mcg/ml (1 ml)
1
$0
PA; MO
octreotide acetate injection syringe 500 mcg/ml
(1 ml)
2
$0
PA; MO
ONCASPAR INJECTION SOLUTION
2
$0
PA; MO
OPDIVO INTRAVENOUS SOLUTION 40
MG/4 ML
2
$0
PA; MO
OXALIPLATIN INTRAVENOUS
SOLUTION 100 MG/20 ML
2
$0
B/D PA; MO
PACLITAXEL INTRAVENOUS
CONCENTRATE
2
$0
B/D PA; MO
20
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
PERJETA INTRAVENOUS SOLUTION
2
$0
B/D PA; MO
POMALYST ORAL CAPSULE
2
$0
PA; MO
PURIXAN ORAL SUSPENSION
2
$0
MO
RAPAMUNE ORAL SOLUTION
2
$0
B/D PA; MO
RAPAMUNE ORAL TABLET
2
$0
B/D PA; MO
REVLIMID ORAL CAPSULE
2
$0
PA; MO; LA
RHEUMATREX ORAL TABLETS,DOSE
PACK 2.5 MG
2
$0
B/D PA; MO
RHEUMATREX ORAL TABLETS,DOSE
PACK 2.5 MG (DOSE PACK 12), 2.5 MG
(DOSE PACK 16), 2.5 MG (DOSE PACK 20),
2.5 MG (DOSE PACK 8)
2
$0
B/D PA
RITUXAN INTRAVENOUS
CONCENTRATE
2
$0
PA; MO
SANDIMMUNE ORAL CAPSULE
2
$0
B/D PA; MO
SANDIMMUNE ORAL SOLUTION
2
$0
B/D PA; MO
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT
2
$0
PA; MO
SIGNIFOR SUBCUTANEOUS SOLUTION
2
$0
PA; MO
SIMULECT INTRAVENOUS RECON SOLN
20 MG
2
$0
B/D PA; MO
sirolimus oral tablet
1
$0
B/D PA; MO
SOLTAMOX ORAL SOLUTION
2
$0
MO
SOMATULINE DEPOT SUBCUTANEOUS
SYRINGE
2
$0
B/D PA; MO
SPRYCEL ORAL TABLET 100 MG, 140 MG,
80 MG
2
$0
SPRYCEL ORAL TABLET 20 MG, 50 MG
2
$0
PA; MO
SPRYCEL ORAL TABLET 70 MG
2
$0
STIVARGA ORAL TABLET
2
$0
PA; MO
SUTENT ORAL CAPSULE
2
$0
PA; MO
21
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
SYNRIBO SUBCUTANEOUS RECON SOLN
2
$0
B/D PA; MO
TABLOID ORAL TABLET
2
$0
MO
tacrolimus oral capsule 0.5 mg, 1 mg
1
$0
B/D PA; MO
TACROLIMUS ORAL CAPSULE 5 MG
2
$0
B/D PA; MO
TAFINLAR ORAL CAPSULE
2
$0
PA; MO
tamoxifen oral tablet
1
$0
MO
TARCEVA ORAL TABLET 100 MG, 25 MG
2
$0
PA; MO
TARCEVA ORAL TABLET 150 MG
2
$0
TARGRETIN ORAL CAPSULE
2
$0
PA; MO
TARGRETIN TOPICAL GEL
2
$0
MO
TASIGNA ORAL CAPSULE
2
$0
PA; MO
THALOMID ORAL CAPSULE
2
$0
PA; MO
toposar intravenous solution
1
$0
B/D PA; MO
TOPOTECAN INTRAVENOUS RECON
SOLN
2
$0
B/D PA; MO
TREANDA INTRAVENOUS RECON SOLN
100 MG
2
$0
B/D PA; MO
TREANDA INTRAVENOUS SOLUTION 45
MG/0.5 ML
2
$0
B/D PA; MO
TRELSTAR INTRAMUSCULAR
2
$0
B/D PA; MO
TRELSTAR INTRAMUSCULAR SYRINGE
11.25 MG/2 ML, 3.75 MG/2 ML
2
$0
B/D PA; MO
TRETINOIN (CHEMOTHERAPY) ORAL
CAPSULE
2
$0
MO
TRISENOX INTRAVENOUS SOLUTION
2
$0
B/D PA; MO
TYKERB ORAL TABLET
2
$0
PA; MO
VELCADE INJECTION RECON SOLN
2
$0
B/D PA; MO
VINBLASTINE INTRAVENOUS
SOLUTION
2
$0
B/D PA; MO
22
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
vincasar pfs intravenous solution 1 mg/ml
1
$0
B/D PA
vincristine intravenous solution 1 mg/ml
1
$0
B/D PA; MO
vinorelbine intravenous solution 50 mg/5 ml
1
$0
B/D PA; MO
VOTRIENT ORAL TABLET
2
$0
PA; MO
XALKORI ORAL CAPSULE
2
$0
PA; MO
XTANDI ORAL CAPSULE
2
$0
days)
YERVOY INTRAVENOUS SOLUTION 50
MG/10 ML (5 MG/ML)
2
$0
PA; MO
ZALTRAP INTRAVENOUS SOLUTION 100
MG/4 ML (25 MG/ML)
2
$0
B/D PA; MO
ZELBORAF ORAL TABLET
2
$0
PA; MO
ZOLINZA ORAL CAPSULE
2
$0
MO
ZORTRESS ORAL TABLET
2
$0
B/D PA; MO
ZYDELIG ORAL TABLET
2
$0
PA; MO
ZYKADIA ORAL CAPSULE
2
$0
days)
ZYTIGA ORAL TABLET
2
$0
MO
APTIOM ORAL TABLET
2
$0
PA; MO
BANZEL ORAL SUSPENSION
2
$0
MO
BANZEL ORAL TABLET
2
$0
PA; MO
carbamazepine oral capsule, er multiphase 12
hr
1
$0
MO
carbamazepine oral suspension 100 mg/5 ml
1
$0
MO
carbamazepine oral tablet
1
$0
MO
carbamazepine oral tablet extended release 12
hr
1
$0
MO
MEDICAMENTOS AUTÓNOMOS /
CNS, NEUROLOGÍA / PSIQUIATRÍA
ANTICONVULSIVOS
23
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
carbamazepine oral tablet,chewable
1
$0
MO
CELONTIN ORAL CAPSULE 300 MG
2
$0
MO
clonazepam oral tablet
1
$0
PA; MO
clonazepam oral tablet,disintegrating
1
$0
PA; MO
DIASTAT RECTAL KIT
2
$0
PA; MO
diazepam rectal kit
1
$0
PA; MO
DILANTIN 30 MG ORAL CAPSULE
2
$0
MO
divalproex oral capsule, sprinkle
1
$0
MO
divalproex oral tablet extended release 24 hr
1
$0
MO
divalproex oral tablet,delayed release (dr/ec)
1
$0
MO
epitol oral tablet
1
$0
MO
ethosuximide oral capsule
1
$0
MO
ethosuximide oral solution
1
$0
MO
felbamate oral suspension
1
$0
MO
felbamate oral tablet
1
$0
MO
fosphenytoin injection solution 100 mg pe/2 ml
1
$0
B/D PA; MO
FYCOMPA ORAL TABLET
2
$0
PA; MO
gabapentin oral capsule
1
$0
MO
gabapentin oral solution 250 mg/5 ml
1
$0
MO
gabapentin oral tablet 600 mg, 800 mg
1
$0
MO
GABITRIL ORAL TABLET 12 MG, 16 MG
2
$0
MO
lamotrigine oral tablet
1
$0
MO
lamotrigine oral tablet extended release 24hr
1
$0
MO
lamotrigine oral tablet, chewable dispersible
1
$0
MO
lamotrigine oral tablet,disintegrating
1
$0
MO
lamotrigine oral tablets,dose pack 25 mg (35)
1
$0
levetiracetam in nacl (iso-os) intravenous
piggyback 1,000 mg/100 ml, 1,500 mg/100 ml
1
$0
B/D PA
24
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
levetiracetam in nacl (iso-os) intravenous
1
$0
B/D PA; MO
levetiracetam intravenous solution
1
$0
B/D PA; MO
levetiracetam oral solution 100 mg/ml
1
$0
MO
levetiracetam oral tablet
1
$0
MO
levetiracetam oral tablet extended release 24
hr
1
$0
MO
LYRICA ORAL CAPSULE
2
$0
MO
LYRICA ORAL SOLUTION
2
$0
MO
ONFI ORAL SUSPENSION
2
$0
PA; MO
ONFI ORAL TABLET 10 MG, 20 MG
2
$0
PA; MO
oxcarbazepine oral suspension
1
$0
MO
oxcarbazepine oral tablet
1
$0
MO
PEGANONE ORAL TABLET
2
$0
MO
phenobarbital oral elixir
1
$0
PA; MO
phenobarbital oral tablet 100 mg
1
$0
PA
phenobarbital oral tablet 15 mg, 16.2 mg, 30
mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
1
$0
PA; MO
PHENYTEK ORAL CAPSULE
2
$0
MO
phenytoin oral suspension 125 mg/5 ml
1
$0
MO
phenytoin oral tablet,chewable
1
$0
MO
phenytoin sodium extended oral capsule
1
$0
MO
phenytoin sodium intravenous solution
1
$0
B/D PA; MO
phenytoin sodium intravenous syringe
1
$0
B/D PA
POTIGA ORAL TABLET
2
$0
PA; MO
primidone oral tablet
1
$0
MO
SABRIL ORAL POWDER IN PACKET
2
$0
PA; MO
SABRIL ORAL TABLET
2
$0
PA; MO
TEGRETOL XR ORAL TABLET
EXTENDED RELEASE 12 HR 100 MG
2
$0
MO
25
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
tiagabine oral tablet
1
$0
MO
topiramate oral capsule, sprinkle
1
$0
PA; MO
TOPIRAMATE ORAL
CAPSULE,SPRINKLE,ER 24HR
2
$0
PA; MO
topiramate oral tablet
1
$0
PA; MO
valproate sodium intravenous solution
1
$0
B/D PA; MO
valproic acid (as sodium salt) oral solution 250
mg/5 ml
1
$0
MO
valproic acid oral capsule
1
$0
MO
VIMPAT INTRAVENOUS SOLUTION
2
$0
PA
VIMPAT ORAL SOLUTION
2
$0
PA; MO
VIMPAT ORAL TABLET
2
$0
PA; MO
zonisamide oral capsule
1
$0
PA; MO
APOKYN SUBCUTANEOUS CARTRIDGE
2
$0
PA; MO
AZILECT ORAL TABLET
2
$0
MO
benztropine injection solution
1
$0
B/D PA; MO
benztropine oral tablet
1
$0
PA; MO
bromocriptine oral capsule
1
$0
MO
bromocriptine oral tablet
1
$0
MO
carbidopa oral tablet
1
$0
MO
carbidopa-levodopa oral tablet
1
$0
MO
carbidopa-levodopa oral tablet extended
release
1
$0
MO
carbidopa-levodopa oral tablet,disintegrating
1
$0
MO
carbidopa-levodopa-entacapone oral tablet
1
$0
MO
entacapone oral tablet
1
$0
MO
NEUPRO TRANSDERMAL PATCH 24
HOUR
2
$0
PA; MO
AGENTES ANTI-PARKINSON
26
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
pramipexole oral tablet
1
$0
MO
pramipexole oral tablet extended release 24 hr
0.375 mg, 0.75 mg, 1.5 mg
1
$0
MO
ropinirole oral tablet
1
$0
MO
ropinirole oral tablet extended release 24 hr
1
$0
MO
selegiline hcl oral capsule
1
$0
MO
selegiline hcl oral tablet
1
$0
MO
tolcapone oral tablet
1
$0
MO
trihexyphenidyl oral elixir
1
$0
PA; MO
trihexyphenidyl oral tablet
1
$0
PA; MO
dihydroergotamine injection solution
1
$0
MO
migergot rectal suppository
1
$0
MO
naratriptan oral tablet
1
$0
rizatriptan oral tablet
1
$0
rizatriptan oral tablet,disintegrating
1
$0
sumatriptan nasal spray,non-aerosol
1
$0
MO
sumatriptan succinate oral tablet
1
$0
sumatriptan succinate subcutaneous cartridge
4 mg/0.5 ml
1
$0
sumatriptan succinate subcutaneous pen
injector
1
$0
sumatriptan succinate subcutaneous solution
1
$0
zolmitriptan oral tablet
1
$0
zolmitriptan oral tablet,disintegrating
1
$0
2
$0
PA; MO
MIGRAÑAS / TERAPIA DE CEFALEA EN
RACIMOS
MISCELLANEOUS NEUROLOGICAL
THERAPY
AMPYRA ORAL TABLET EXTENDED
RELEASE 12 HR
27
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
COPAXONE SUBCUTANEOUS SYRINGE
20 MG/ML
2
$0
COPAXONE SUBCUTANEOUS SYRINGE
40 MG/ML
2
$0
donepezil oral tablet
1
$0
donepezil oral tablet,disintegrating
1
$0
EXELON TRANSDERMAL PATCH 24
HOUR
2
$0
galantamine oral capsule,ext rel. pellets 24 hr
1
$0
galantamine oral solution
1
$0
MO
galantamine oral tablet
1
$0
MO
GILENYA ORAL CAPSULE
2
$0
MO
GLATOPA SUBCUTANEOUS SYRINGE
2
$0
PA; MO
HORIZANT ORAL TABLET EXTENDED
RELEASE
2
$0
MO
NAMENDA ORAL SOLUTION
2
$0
PA; MO
NAMENDA ORAL TABLET
2
$0
PA; MO
NAMENDA TITRATION PAK ORAL
TABLETS,DOSE PACK
2
$0
PA; MO
NUEDEXTA ORAL CAPSULE
2
$0
MO
rivastigmine tartrate oral capsule 1.5 mg
1
$0
rivastigmine tartrate oral capsule 3 mg
1
$0
rivastigmine tartrate oral capsule 4.5 mg, 6 mg
1
$0
TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
2
$0
MO
TYSABRI INTRAVENOUS SOLUTION
2
$0
PA; MO
XENAZINE ORAL TABLET
2
$0
PA; MO; LA
1
$0
MO
RELAJANTES MUSCULARES / TERAPIA
ANTIESPASMÓDICA
baclofen oral tablet
28
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
cyclobenzaprine oral tablet
1
$0
PA; MO
dantrolene oral capsule
1
$0
MO
meprobamate oral tablet
1
$0
PA; MO
MESTINON ORAL SYRUP
2
$0
MO
MESTINON TIMESPAN ORAL TABLET
EXTENDED RELEASE
2
$0
MO
metaxalone oral tablet
1
$0
PA; MO
pyridostigmine bromide oral tablet
1
$0
MO
regonol injection solution
2
$0
B/D PA
tizanidine oral capsule
1
$0
MO
tizanidine oral tablet
1
$0
MO
acetaminophen-codeine oral solution 300 mg30 mg /12.5 ml
1
$0
QL (4500 per 30 days)
acetaminophen-codeine oral tablet 300-15 mg,
300-30 mg
1
$0
acetaminophen-codeine oral tablet 300-60 mg
1
$0
buprenorphine hcl injection syringe
1
$0
B/D PA; QL (267 per 30
days)
buprenorphine hcl sublingual tablet 2 mg
1
$0
buprenorphine hcl sublingual tablet 8 mg
1
$0
butalbital-acetaminop-caf-cod oral capsule
1
$0
days)
codeine sulfate oral tablet
1
$0
diskets oral tablet,soluble
1
$0
QL (30 per 30 days)
DURAMORPH (PF) INJECTION SOLUTION
0.5 MG/ML
2
$0
B/D PA; MO; QL (4000 per
30 days)
DURAMORPH (PF) INJECTION SOLUTION
1 MG/ML
2
$0
B/D PA; QL (2000 per 30
days)
endocet oral tablet 10-325 mg, 5-325 mg, 7.5325 mg
1
$0
ANALGÉSICOS NARCÓTICOS
29
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
endocet oral tablet 2.5-325 mg
1
$0
FENTANYL CITRATE BUCCAL LOZENGE
ON A HANDLE 1,200 MCG
2
$0
ON A HANDLE 1,600 MCG
2
$0
ON A HANDLE 200 MCG
2
$0
days)
ON A HANDLE 400 MCG
2
$0
days)
ON A HANDLE 600 MCG
2
$0
ON A HANDLE 800 MCG
2
$0
fentanyl transdermal patch 72 hour 100 mcg/hr
1
$0
fentanyl transdermal patch 72 hour 12 mcg/hr,
25 mcg/hr, 50 mcg/hr, 75 mcg/hr
1
$0
hydrocodone-acetaminophen oral solution 10325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 5-163
mg/7.5ml(7.5ml)
1
$0
hydrocodone-acetaminophen oral solution 7.5325 mg/15 ml
1
$0
hydrocodone-acetaminophen oral tablet 10300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5325 mg, 7.5-300 mg, 7.5-325 mg
1
$0
hydrocodone-ibuprofen oral tablet
1
$0
hydromorphone (pf) injection solution 10
mg/ml
1
$0
B/D PA; MO; QL (120 per 30
days)
hydromorphone oral liquid
1
$0
hydromorphone oral tablet
1
$0
ibuprofen-oxycodone oral tablet
1
$0
30
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
KADIAN ORAL
CAPSULE,EXTEND.RELEASE PELLETS
200 MG
2
$0
levorphanol tartrate oral tablet
1
$0
methadone injection solution
1
$0
days)
methadone intensol oral concentrate
1
$0
methadone oral concentrate
1
$0
methadone oral solution 10 mg/5 ml
1
$0
methadone oral solution 5 mg/5 ml
1
$0
methadone oral tablet 10 mg
1
$0
methadone oral tablet 5 mg
1
$0
methadone oral tablet,soluble
1
$0
QL (30 per 30 days)
methadose oral concentrate
1
$0
methadose oral tablet,soluble
1
$0
morphine (pf) injection solution 0.5 mg/ml
1
$0
B/D PA; QL (2400 per 30
days)
morphine (pf) injection solution 1 mg/ml
1
$0
B/D PA; MO; QL (1200 per
30 days)
morphine concentrate oral solution
1
$0
morphine intravenous syringe 10 mg/ml
1
$0
days)
morphine intravenous syringe 8 mg/ml
1
$0
days)
morphine oral capsule, er multiphase 24 hr 120
mg
1
$0
morphine oral capsule, er multiphase 24 hr 30
mg, 45 mg, 60 mg, 75 mg, 90 mg
1
$0
morphine oral capsule,extend.release pellets
1
$0
morphine oral solution
1
$0
morphine oral tablet
1
$0
31
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
morphine oral tablet extended release 100 mg
1
$0
morphine oral tablet extended release 15 mg,
30 mg, 60 mg
1
$0
morphine oral tablet extended release 200 mg
1
$0
oxycodone oral capsule
1
$0
oxycodone oral concentrate
1
$0
oxycodone oral solution
1
$0
oxycodone oral tablet 10 mg, 15 mg, 20 mg
1
$0
oxycodone oral tablet 30 mg
1
$0
oxycodone oral tablet 5 mg
1
$0
oxycodone-acetaminophen oral tablet 10-325
mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
1
$0
oxycodone-aspirin oral tablet
1
$0
oxymorphone oral tablet 10 mg
1
$0
oxymorphone oral tablet 5 mg
1
$0
oxymorphone oral tablet extended release 12
hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
1
$0
hr 30 mg
1
$0
hr 40 mg
1
$0
reprexain oral tablet
1
$0
zamicet oral solution
1
$0
ACEPHEN RECTAL SUPPOSITORY 120
MG, 650 MG
4
$0
MO; *
ACEPHEN RECTAL SUPPOSITORY 325
MG
4
$0
*
acetadryl oral tablet
4
$0
*
acetaminophen extra strength oral tablet
4
$0
*
ANALGÉSICOS NO NARCÓTICOS
32
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
acetaminophen oral drops,suspension
4
$0
*
acetaminophen oral liquid
4
$0
*
acetaminophen oral tablet
4
$0
MO; *
acetaminophen pm extra str oral tablet
4
$0
*
acetaminophen pm oral tablet
4
$0
*
acetaminophen rectal suppository 120 mg, 650
mg
4
$0
*
added strength headache relief oral tablet
4
$0
*
ADDED STRENGTH PAIN RELIEVER
ORAL TABLET
4
$0
*
adult low dose aspirin oral tablet,delayed
release (dr/ec)
4
$0
MO; *
aspir-81 oral tablet,delayed release (dr/ec)
4
$0
*
aspirin childrens oral tablet,chewable
4
$0
*
aspirin low dose oral tablet,delayed release
(dr/ec)
4
$0
MO; *
aspirin low-strength oral tablet,chewable
4
$0
*
aspirin oral tablet 325 mg
4
$0
MO; *
aspirin oral tablet,chewable
4
$0
MO; *
aspirin oral tablet,delayed release (dr/ec) 325
mg, 500 mg, 81 mg
4
$0
MO; *
aspirin oral tablet,delayed release (dr/ec) 650
mg
4
$0
*
aspirin rectal suppository
4
$0
MO; *
aspirin, buffered oral tablet
4
$0
*
aspir-trin oral tablet,delayed release (dr/ec)
4
$0
MO; *
athenol oral tablet
4
$0
*
bayer advanced oral tablet
4
$0
*
bayer aspirin oral tablet
4
$0
MO; *
bufferin oral tablet 325 mg
4
$0
*
33
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
buprenorphine-naloxone sublingual tablet
1
$0
butorphanol tartrate injection solution 1 mg/ml
1
$0
butorphanol tartrate injection solution 2 mg/ml
1
$0
butorphanol tartrate nasal spray,non-aerosol
1
$0
celecoxib oral capsule
1
$0
MO
child aspirin oral tablet,chewable
4
$0
*
child pain rel-fever reducer rectal suppository
4
$0
*
children's aspirin oral tablet,chewable
4
$0
MO; *
children's fever reducing rectal suppository
4
$0
*
children's pain relief oral liquid
4
$0
*
children's silapap oral liquid
4
$0
*
diclofenac potassium oral tablet
1
$0
MO
diclofenac sodium oral tablet extended release
24 hr
1
$0
MO
diclofenac sodium oral tablet,delayed release
(dr/ec)
1
$0
MO
diclofenac sodium topical drops
1
$0
MO
diclofenac-misoprostol oral tablet,ir & delay
rel,biphasic
1
$0
MO
diflunisal oral tablet
1
$0
MO
diphenhydramine-acetaminophen oral tablet
4
$0
*
e.c. prin oral tablet,delayed release (dr/ec)
4
$0
*
ecotrin low strength oral tablet,delayed release
(dr/ec)
4
$0
MO; *
enteric coated aspirin oral tablet,delayed
release (dr/ec)
4
$0
*
etodolac oral capsule
1
$0
MO
etodolac oral tablet
1
$0
MO
etodolac oral tablet extended release 24 hr
1
$0
MO
34
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ex-strength medi-tabs oral tablet
4
$0
*
ex-strength medi-tabs pm oral tablet
4
$0
*
fenoprofen oral tablet
1
$0
MO
fever reducer rectal suppository
4
$0
*
feverall rectal suppository 120 mg, 325 mg,
650 mg
4
$0
*
flurbiprofen oral tablet
1
$0
MO
headache formula added str oral tablet
4
$0
*
headache formula oral tablet
4
$0
*
headache pm oral tablet
4
$0
*
headache relief (asa-acet-caf) oral tablet
4
$0
*
ibu-drops oral drops,suspension
4
$0
*
ibuprofen ib oral tablet
4
$0
*
ibuprofen oral capsule
4
$0
*
ibuprofen oral drops,suspension
4
$0
*
ibuprofen oral suspension
1
$0
MO
ibuprofen oral tablet 100 mg
4
$0
*
ibuprofen oral tablet 200 mg
4
$0
MO; *
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
1
$0
MO
infants ibu-drops oral drops,suspension
4
$0
*
infant's ibuprofen oral drops,suspension
4
$0
*
INFANT'S MEDI-PROFEN ORAL
DROPS,SUSPENSION
4
$0
*
infant's non-aspirin oral drops,suspension
4
$0
*
INFANT'S PAIN RELIEF ORAL
DROPS,SUSPENSION 80 MG/0.8 ML
4
$0
*
infant's pain reliever oral drops,suspension
4
$0
*
infants profenib oral drops,suspension
4
$0
*
i-prin oral tablet
4
$0
*
ketoprofen oral capsule
1
$0
MO
35
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ketoprofen oral capsule,ext rel. pellets 24 hr
200 mg
1
$0
MO
lite coat aspirin oral tablet
4
$0
*
lo-dose aspirin oral tablet,delayed release
(dr/ec)
4
$0
*
MAPAP (ACETAMINOPHEN) ORAL
CAPSULE
4
$0
MO; *
masophen oral tablet
4
$0
*
meclofenamate oral capsule
1
$0
MO
medi-profen oral tablet
4
$0
*
medi-tabs oral tablet
4
$0
*
medi-tabs pm oral tablet
4
$0
*
mefenamic acid oral capsule
1
$0
MO
meloxicam oral suspension
1
$0
MO
meloxicam oral tablet
1
$0
MO
migraine formula oral tablet
4
$0
*
migraine pain reliever oral tablet
4
$0
*
migraine relief oral tablet
4
$0
*
nabumetone oral tablet
1
$0
MO
nalbuphine injection solution 10 mg/ml
1
$0
days)
nalbuphine injection solution 20 mg/ml
1
$0
days)
naloxone injection syringe 1 mg/ml
1
$0
MO
naltrexone oral tablet
1
$0
MO
NAPRELAN CR ORAL TABLET, ER
MULTIPHASE 24 HR
2
$0
MO
naproxen oral suspension
1
$0
MO
naproxen oral tablet
1
$0
MO
naproxen oral tablet,delayed release (dr/ec)
1
$0
MO
36
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
naproxen sodium oral tablet 275 mg, 550 mg
1
$0
MO
non-aspirin extra strength oral capsule
4
$0
*
non-aspirin extra strength oral liquid
4
$0
*
non-aspirin extra strength oral tablet
4
$0
*
non-aspirin nightime oral tablet
4
$0
*
non-aspirin oral tablet
4
$0
*
non-aspirin pain relief oral tablet 500 mg
4
$0
*
non-aspirin pain relief pm oral tablet
4
$0
*
non-aspirin pm oral tablet
4
$0
*
NUCYNTA ER ORAL TABLET EXTENDED
RELEASE 12 HR
2
$0
MO
NUCYNTA ORAL TABLET
2
$0
MO
oxaprozin oral tablet
1
$0
MO
pain relief adult oral liquid
4
$0
*
pain relief extra strength oral tablet
4
$0
*
pain relief oral capsule
4
$0
*
pain relief oral liquid
4
$0
*
pain relief oral tablet 500 mg
4
$0
*
pain relief pm oral tablet
4
$0
*
pain relief pm rapid release oral tablet
4
$0
*
pain relief regular strength oral tablet
4
$0
*
pain reliever (acetam-aspirin) oral tablet
4
$0
*
pain reliever extra strength oral tablet
4
$0
*
pain reliever oral capsule
4
$0
*
pain reliever oral tablet
4
$0
*
pain reliever pm ex-strength oral tablet
4
$0
*
pain reliever pm oral tablet 25-500 mg
4
$0
*
pain-off oral tablet
4
$0
*
pamprin max oral tablet
4
$0
*
37
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
percogesic extra strength oral tablet
4
$0
MO; *
percogesic oral tablet
4
$0
*
pharbetol oral tablet
4
$0
*
piroxicam oral capsule
1
$0
MO
provil oral tablet
4
$0
*
severe allergy oral tablet
4
$0
*
SUBOXONE SUBLINGUAL FILM 12-3 MG
2
$0
SUBOXONE SUBLINGUAL FILM 2-0.5 MG,
4-1 MG, 8-2 MG
2
$0
sulindac oral tablet
1
$0
MO
super pain relief oral tablet
4
$0
*
tactinal extra strength oral tablet
4
$0
*
tactinal oral tablet
4
$0
*
tolmetin oral capsule
1
$0
MO
tolmetin oral tablet
1
$0
MO
tramadol oral tablet
1
$0
tramadol oral tablet extended release 24 hr
100 mg, 200 mg
1
$0
tramadol oral tablet, er multiphase 24 hr 300
mg
1
$0
tramadol-acetaminophen oral tablet
1
$0
TRI-BUFFERED ASPIRIN ORAL TABLET
4
$0
MO; *
tylophen oral capsule
4
$0
*
VOLTAREN GEL TOPICAL GEL 1 %
2
$0
ST; MO
wal-profen oral capsule
4
$0
*
wal-profen oral tablet
4
$0
*
$0
MEDICAMENTOS PSICOTERAPÉUTICOS
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10 MG
2
38
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON 300
MG
2
$0
B/D PA; MO
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING
2
$0
B/D PA
ABILIFY ORAL TABLET 10 MG
2
$0
ABILIFY ORAL TABLET 15 MG, 20 MG
2
$0
2
$0
2
$0
2
$0
alprazolam oral tablet
1
$0
PA; MO
alprazolam oral tablet extended release 24 hr
1
$0
PA; MO
alprazolam oral tablet,disintegrating
1
$0
PA; MO
amitriptyline oral tablet
1
$0
PA; MO
amoxapine oral tablet
1
$0
MO
amphetamine salt combo oral tablet
1
$0
MO
aripiprazole oral tablet 10 mg
1
$0
1
$0
1
$0
ARIPIPRAZOLE ORAL TABLET 20 MG
2
$0
ARIPIPRAZOLE ORAL TABLET 30 MG
2
$0
1
$0
BRINTELLIX ORAL TABLET
2
$0
MO
BRISDELLE ORAL CAPSULE
2
$0
MO
bupropion hcl oral tablet
1
$0
MO
bupropion hcl oral tablet extended release
1
$0
MO
bupropion hcl oral tablet extended release 24
hr
1
$0
MO
buspirone oral tablet
1
$0
MO
chlorpromazine injection solution
1
$0
MO
39
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
chlorpromazine oral tablet
1
$0
MO
citalopram oral solution
1
$0
MO
citalopram oral tablet
1
$0
MO
clomipramine oral capsule
1
$0
PA; MO
clonidine hcl oral tablet extended release 12 hr
1
$0
MO
clorazepate dipotassium oral tablet
1
$0
PA; MO
clozapine oral tablet 100 mg, 25 mg, 50 mg
1
$0
MO
clozapine oral tablet 200 mg
1
$0
clozapine oral tablet,disintegrating 100 mg,
12.5 mg, 25 mg
1
$0
CLOZAPINE ORAL
TABLET,DISINTEGRATING 150 MG, 200
MG
2
$0
desipramine oral tablet
1
$0
MO
dexmethylphenidate oral capsule,er biphasic
50-50
1
$0
MO
dexmethylphenidate oral tablet
1
$0
MO
dextroamphetamine oral capsule, extended
release
1
$0
MO
dextroamphetamine oral tablet
1
$0
MO
dextroamphetamine-amphetamine oral
capsule,extended release 24hr
1
$0
MO
diazepam intensol oral concentrate
1
$0
PA; MO
diazepam oral solution 5 mg/5 ml
1
$0
PA; MO
diazepam oral tablet
1
$0
PA; MO
doxepin oral capsule
1
$0
PA; MO
doxepin oral concentrate
1
$0
PA; MO
duloxetine oral capsule,delayed release(dr/ec)
1
$0
MO
EMSAM TRANSDERMAL PATCH 24
HOUR
2
$0
MO
40
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ergoloid oral tablet
1
$0
PA; MO
escitalopram oxalate oral solution
1
$0
MO
escitalopram oxalate oral tablet
1
$0
MO
eszopiclone oral tablet
1
$0
FANAPT ORAL TABLET
2
$0
FANAPT ORAL TABLETS,DOSE PACK
2
$0
FAZACLO ORAL
TABLET,DISINTEGRATING 150 MG, 200
MG
2
$0
FETZIMA ORAL CAPSULE,EXT REL 24HR
DOSE PACK
2
$0
FETZIMA ORAL CAPSULE,EXTENDED
RELEASE 24 HR
2
$0
fluoxetine oral capsule
1
$0
MO
fluoxetine oral capsule,delayed release(dr/ec)
1
$0
MO
fluoxetine oral solution
1
$0
MO
fluoxetine oral tablet 10 mg, 20 mg
1
$0
MO
FLUOXETINE ORAL TABLET 60 MG
2
$0
MO
fluphenazine decanoate injection solution
1
$0
B/D PA; MO
fluphenazine hcl injection solution
1
$0
B/D PA; MO
fluphenazine hcl oral concentrate
1
$0
MO
fluphenazine hcl oral elixir
1
$0
MO
fluphenazine hcl oral tablet
1
$0
MO
fluvoxamine oral capsule,extended release
24hr
1
$0
MO
fluvoxamine oral tablet
1
$0
MO
FORFIVO XL ORAL TABLET EXTENDED
RELEASE 24 HR
2
$0
MO
GEODON INTRAMUSCULAR RECON
SOLN
2
$0
B/D PA; MO
guanfacine oral tablet extended release 24 hr
1
$0
MO
41
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
guanidine oral tablet
1
$0
MO
haloperidol decanoate intramuscular solution
1
$0
B/D PA; MO
haloperidol lactate injection solution
1
$0
B/D PA; MO
haloperidol lactate oral concentrate
1
$0
MO
haloperidol oral tablet
1
$0
MO
HETLIOZ ORAL CAPSULE
2
$0
imipramine hcl oral tablet
1
$0
PA; MO
imipramine pamoate oral capsule
1
$0
PA; MO
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 1.5 MG, 3 MG, 9 MG
2
$0
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 6 MG
2
$0
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE
2
$0
B/D PA; MO
INVEGA TRINZA INTRAMUSCULAR
SYRINGE
2
$0
B/D PA; MO
IRENKA ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
2
$0
MO
KHEDEZLA ORAL TABLET EXTENDED
RELEASE 24HR
2
$0
MO
LATUDA ORAL TABLET
2
$0
MO
lithium carbonate oral capsule
1
$0
MO
lithium carbonate oral tablet
1
$0
MO
lithium carbonate oral tablet extended release
1
$0
MO
lithium citrate oral solution 8 meq/5 ml
1
$0
MO
lorazepam intensol oral concentrate
1
$0
PA; MO
lorazepam oral tablet
1
$0
PA; MO
loxapine succinate oral capsule
1
$0
MO
maprotiline oral tablet
1
$0
MO
MARPLAN ORAL TABLET
2
$0
MO
42
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
metadate er oral tablet extended release
1
$0
MO
methamphetamine oral tablet
1
$0
MO
methylphenidate oral capsule, er biphasic 3070 10 mg, 50 mg, 60 mg
1
$0
MO
methylphenidate oral capsule,er biphasic 50-50
1
$0
MO
methylphenidate oral solution
1
$0
MO
methylphenidate oral tablet
1
$0
MO
methylphenidate oral tablet extended release
1
$0
MO
methylphenidate oral tablet extended release
24hr 18 mg
1
$0
MO
mirtazapine oral tablet
1
$0
MO
mirtazapine oral tablet,disintegrating
1
$0
MO
modafinil oral tablet
1
$0
PA; MO
nefazodone oral tablet
1
$0
MO
nortriptyline oral capsule
1
$0
MO
nortriptyline oral solution
1
$0
MO
olanzapine intramuscular recon soln
1
$0
MO
olanzapine oral tablet
1
$0
MO
olanzapine oral tablet,disintegrating
1
$0
MO
olanzapine-fluoxetine oral capsule
1
$0
MO
ORAP ORAL TABLET
2
$0
MO
oxazepam oral capsule
1
$0
PA; MO
paroxetine hcl oral tablet
1
$0
MO
paroxetine hcl oral tablet extended release 24
hr
1
$0
MO
PAXIL ORAL SUSPENSION
2
$0
MO
perphenazine oral tablet
1
$0
MO
perphenazine-amitriptyline oral tablet
1
$0
PA; MO
phenelzine oral tablet
1
$0
MO
43
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
PRISTIQ ORAL TABLET EXTENDED
RELEASE 24 HR
2
$0
MO
protriptyline oral tablet
1
$0
MO
quetiapine oral tablet
1
$0
MO
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE
2
$0
B/D PA; MO
risperidone oral solution
1
$0
MO
risperidone oral tablet
1
$0
MO
risperidone oral tablet,disintegrating
1
$0
MO
ROZEREM ORAL TABLET
2
$0
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 10 MG, 5 MG
2
$0
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 2.5 MG
2
$0
MO
SEROQUEL XR ORAL TABLET
EXTENDED RELEASE 24 HR
2
$0
MO
sertraline oral concentrate
1
$0
MO
sertraline oral tablet
1
$0
MO
STRATTERA ORAL CAPSULE
2
$0
MO
SURMONTIL ORAL CAPSULE
2
$0
PA; MO
temazepam oral capsule
1
$0
PA; MO
thioridazine oral tablet
1
$0
PA; MO
thiothixene oral capsule
1
$0
MO
tranylcypromine oral tablet
1
$0
MO
trazodone oral tablet
1
$0
MO
trifluoperazine oral tablet
1
$0
MO
venlafaxine oral capsule,extended release 24hr
1
$0
MO
venlafaxine oral tablet
1
$0
MO
venlafaxine oral tablet extended release 24hr
150 mg, 37.5 mg, 75 mg
1
$0
MO
44
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
VERSACLOZ ORAL SUSPENSION
2
$0
VIIBRYD ORAL TABLET
2
$0
MO
VIIBRYD ORAL TABLETS,DOSE PACK 10
MG (7)-20 MG (7)-40 MG (16)
2
$0
XYREM ORAL SOLUTION
2
$0
MO; LA
ziprasidone hcl oral capsule
1
$0
MO
zolpidem oral tablet
1
$0
zolpidem oral tablet,ext release multiphase
1
$0
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 210
MG
2
$0
B/D PA
amiodarone intravenous solution
1
$0
B/D PA; MO
amiodarone intravenous syringe
1
$0
amiodarone oral tablet
1
$0
MO
flecainide oral tablet
1
$0
MO
mexiletine oral capsule
1
$0
MO
MULTAQ ORAL TABLET
2
$0
MO
pacerone oral tablet 100 mg, 200 mg, 400 mg
1
$0
MO
procainamide injection solution 100 mg/ml
1
$0
MO
procainamide injection solution 500 mg/ml
1
$0
propafenone oral capsule,extended release 12
hr
1
$0
MO
propafenone oral tablet
1
$0
MO
quinidine gluconate injection solution
1
$0
MO
quinidine gluconate oral tablet extended
release
1
$0
MO
quinidine sulfate oral tablet
1
$0
MO
CARDIOVASCULAR,
HIPERTENSIÓN / LÍPIDOS
AGENTES ANTIARRÍTMICOS
45
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
sorine oral tablet 120 mg, 160 mg, 80 mg
1
$0
MO
sorine oral tablet 240 mg
1
$0
sotalol af oral tablet 120 mg
1
$0
MO
sotalol oral tablet 160 mg, 240 mg, 80 mg
1
$0
MO
TIKOSYN ORAL CAPSULE
2
$0
MO
acebutolol oral capsule
1
$0
MO
afeditab cr oral tablet extended release
1
$0
MO
amiloride oral tablet
1
$0
MO
amiloride-hydrochlorothiazide oral tablet
1
$0
MO
amlodipine oral tablet
1
$0
MO
amlodipine-benazepril oral capsule
1
$0
MO
amlodipine-valsartan oral tablet
1
$0
MO
amlodipine-valsartan-hcthiazid oral tablet
1
$0
MO
atenolol oral tablet
1
$0
MO
atenolol-chlorthalidone oral tablet
1
$0
MO
AZOR ORAL TABLET
2
$0
MO
benazepril oral tablet
1
$0
MO
benazepril-hydrochlorothiazide oral tablet
1
$0
MO
BENICAR HCT ORAL TABLET
2
$0
MO
BENICAR ORAL TABLET
2
$0
betaxolol oral tablet
1
$0
MO
bisoprolol fumarate oral tablet
1
$0
MO
bisoprolol-hydrochlorothiazide oral tablet
1
$0
MO
bumetanide injection solution
1
$0
MO
bumetanide oral tablet
1
$0
MO
BYSTOLIC ORAL TABLET
2
$0
MO
candesartan oral tablet
1
$0
MO
TERAPIA ANTIHIPERTENSIVA
46
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
candesartan-hydrochlorothiazid oral tablet
1
$0
MO
captopril oral tablet
1
$0
MO
captopril-hydrochlorothiazide oral tablet
1
$0
MO
cartia xt oral capsule,extended release 24hr
1
$0
MO
carvedilol oral tablet
1
$0
MO
chlorothiazide oral tablet
1
$0
MO
chlorothiazide sodium intravenous recon soln
1
$0
MO
chlorthalidone oral tablet 25 mg, 50 mg
1
$0
MO
clonidine hcl oral tablet
1
$0
MO
clonidine transdermal patch weekly
1
$0
MO
COREG CR ORAL CAPSULE, ER
MULTIPHASE 24 HR
2
$0
ST; MO
DEMSER ORAL CAPSULE
2
$0
PA; MO
diltiazem hcl intravenous recon soln
1
$0
B/D PA
diltiazem hcl intravenous solution
1
$0
B/D PA
diltiazem hcl oral capsule, extended release
180 mg, 360 mg, 420 mg
1
$0
MO
diltiazem hcl oral capsule,extended release 12
hr
1
$0
MO
diltiazem hcl oral capsule,extended release
24hr 120 mg, 240 mg, 300 mg
1
$0
MO
diltiazem hcl oral tablet
1
$0
MO
diltiazem hcl oral tablet extended release 24 hr
180 mg, 300 mg, 420 mg
1
$0
diltiazem hcl oral tablet extended release 24 hr
240 mg, 360 mg
1
$0
MO
dilt-xr oral capsule,ext release degradable
1
$0
MO
doxazosin oral tablet
1
$0
MO
enalapril maleate oral tablet
1
$0
MO
enalapril-hydrochlorothiazide oral tablet
1
$0
MO
47
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
EPANED ORAL RECON SOLN
2
$0
MO
eplerenone oral tablet
1
$0
MO
eprosartan oral tablet
1
$0
MO
felodipine oral tablet extended release 24 hr
1
$0
MO
fosinopril oral tablet
1
$0
MO
fosinopril-hydrochlorothiazide oral tablet
1
$0
MO
furosemide injection solution
1
$0
B/D PA; MO
furosemide injection syringe
1
$0
B/D PA; MO
furosemide oral solution 10 mg/ml, 40 mg/5 ml
1
$0
MO
furosemide oral tablet
1
$0
MO
hydralazine injection solution
1
$0
B/D PA; MO
hydralazine oral tablet
1
$0
MO
hydrochlorothiazide oral capsule
1
$0
MO
hydrochlorothiazide oral tablet
1
$0
MO
indapamide oral tablet
1
$0
MO
irbesartan oral tablet
1
$0
MO
irbesartan-hydrochlorothiazide oral tablet
1
$0
MO
isradipine oral capsule
1
$0
MO
labetalol intravenous solution
1
$0
B/D PA; MO
labetalol intravenous syringe 20 mg/4 ml (5
mg/ml)
1
$0
B/D PA
labetalol oral tablet
1
$0
MO
lisinopril oral tablet
1
$0
MO
lisinopril-hydrochlorothiazide oral tablet
1
$0
MO
losartan oral tablet
1
$0
MO
losartan-hydrochlorothiazide oral tablet
1
$0
MO
matzim la oral tablet extended release 24 hr
1
$0
MO
methyclothiazide oral tablet
1
$0
MO
48
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
methyldopa-hydrochlorothiazide oral tablet
1
$0
PA; MO
metolazone oral tablet
1
$0
MO
metoprolol succinate oral tablet extended
release 24 hr
1
$0
MO
metoprolol ta-hydrochlorothiaz oral tablet
1
$0
MO
metoprolol tartrate intravenous solution
1
$0
B/D PA; MO
metoprolol tartrate oral tablet
1
$0
MO
minoxidil oral tablet
1
$0
MO
moexipril oral tablet
1
$0
MO
moexipril-hydrochlorothiazide oral tablet
1
$0
MO
nadolol oral tablet
1
$0
MO
nadolol-bendroflumethiazide oral tablet
1
$0
MO
nicardipine intravenous solution
1
$0
MO
nicardipine oral capsule
1
$0
MO
nifedical xl oral tablet extended release 24hr
1
$0
MO
nifedipine oral tablet extended release 24hr
1
$0
MO
nimodipine oral capsule
1
$0
MO
perindopril erbumine oral tablet
1
$0
MO
pindolol oral tablet
1
$0
MO
prazosin oral capsule
1
$0
MO
propranolol intravenous solution
1
$0
B/D PA
propranolol oral capsule,extended release 24
hr
1
$0
MO
propranolol oral solution
1
$0
MO
propranolol oral tablet
1
$0
MO
propranolol-hydrochlorothiazid oral tablet
1
$0
MO
quinapril oral tablet
1
$0
MO
quinapril-hydrochlorothiazide oral tablet
1
$0
MO
ramipril oral capsule
1
$0
MO
49
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
REMODULIN INJECTION SOLUTION
2
$0
B/D PA; MO
reserpine oral tablet
1
$0
PA; MO
spironolactone oral tablet
1
$0
MO
spironolacton-hydrochlorothiaz oral tablet
1
$0
MO
taztia xt oral capsule, extended release
1
$0
MO
TEKAMLO ORAL TABLET
2
$0
MO
TEKTURNA HCT ORAL TABLET
2
$0
MO
TEKTURNA ORAL TABLET
2
$0
MO
telmisartan oral tablet
1
$0
MO
telmisartan-hydrochlorothiazid oral tablet
1
$0
MO
terazosin oral capsule
1
$0
MO
timolol maleate oral tablet
1
$0
MO
torsemide oral tablet
1
$0
MO
trandolapril oral tablet
1
$0
MO
trandolapril-verapamil oral tablet, ir & er,
biphasic 24hr
1
$0
MO
triamterene-hydrochlorothiazid oral capsule
1
$0
MO
triamterene-hydrochlorothiazid oral tablet
1
$0
MO
valsartan oral tablet
1
$0
MO
valsartan-hydrochlorothiazide oral tablet
1
$0
MO
verapamil intravenous solution
1
$0
B/D PA; MO
verapamil intravenous syringe
1
$0
B/D PA
verapamil oral capsule, 24 hr er pellet ct
1
$0
MO
verapamil oral capsule,ext rel. pellets 24 hr
1
$0
MO
verapamil oral tablet
1
$0
MO
verapamil oral tablet extended release
1
$0
MO
1
$0
PA; MO
GLUCÓSIDOS CARDÍACOS
digitek oral tablet
50
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
digox oral tablet
1
$0
MO
digoxin injection solution
1
$0
PA; MO
digoxin oral solution 50 mcg/ml
1
$0
PA; MO
digoxin oral tablet
1
$0
PA; MO
LANOXIN ORAL TABLET
2
$0
PA; MO
AGGRENOX ORAL CAPSULE, ER
MULTIPHASE 12 HR
2
$0
MO
BRILINTA ORAL TABLET
2
$0
MO
cilostazol oral tablet
1
$0
MO
clopidogrel oral tablet 300 mg
1
$0
clopidogrel oral tablet 75 mg
1
$0
MO
COUMADIN ORAL TABLET
2
$0
MO
EFFIENT ORAL TABLET
2
$0
MO
ELIQUIS ORAL TABLET
2
$0
MO
enoxaparin subcutaneous solution
1
$0
enoxaparin subcutaneous syringe 100 mg/ml
1
$0
ENOXAPARIN SUBCUTANEOUS
SYRINGE 120 MG/0.8 ML
2
$0
ENOXAPARIN SUBCUTANEOUS
SYRINGE 150 MG/ML
2
$0
enoxaparin subcutaneous syringe 30 mg/0.3 ml
1
$0
1
$0
1
$0
1
$0
FONDAPARINUX SUBCUTANEOUS
SYRINGE 10 MG/0.8 ML
2
$0
fondaparinux subcutaneous syringe 2.5 mg/0.5
ml
1
$0
TERAPIA DE COAGULACIÓN
51
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
fondaparinux subcutaneous syringe 5 mg/0.4
ml
1
$0
FONDAPARINUX SUBCUTANEOUS
SYRINGE 7.5 MG/0.6 ML
2
$0
FRAGMIN SUBCUTANEOUS SOLUTION
2
$0
FRAGMIN SUBCUTANEOUS SYRINGE
10,000 ANTI-XA UNIT/ML
2
$0
12,500 ANTI-XA UNIT/0.5 ML
2
$0
2
$0
2
$0
MO; QL (21.6 per 30 days)
2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTIXA UNIT/0.2 ML
2
$0
2
$0
heparin (porcine) in 5 % dex intravenous
parenteral solution 20,000 unit/500 ml (40
unit/ml), 25,000 unit/250 ml(100 unit/ml)
1
$0
B/D PA
heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/500 ml (50
unit/ml)
1
$0
B/D PA; MO
heparin (porcine) in nacl (pf) intravenous
parenteral solution 1,000 unit/500 ml
1
$0
B/D PA
heparin (porcine) in nacl (pf) intravenous
parenteral solution 2,000 unit/1,000 ml
2
$0
B/D PA
heparin (porcine) injection solution
1
$0
B/D PA; MO
heparin, porcine (pf) injection syringe
1
$0
B/D PA; MO
jantoven oral tablet
1
$0
MO
MEPHYTON ORAL TABLET
3
$0
MO; *
52
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
pentoxifylline oral tablet extended release
1
$0
MO
PRADAXA ORAL CAPSULE
2
$0
ST; MO
PROMACTA ORAL TABLET
2
$0
PA; MO
tranexamic acid intravenous solution
1
$0
B/D PA; MO
VITAMIN K INJECTION SOLUTION
3
$0
MO; *
VITAMIN K1 INJECTION SOLUTION
3
$0
MO; *
warfarin oral tablet
1
$0
MO
XARELTO ORAL TABLET
2
$0
MO
XARELTO ORAL TABLETS,DOSE PACK
2
$0
MO
AGENTES QUE BAJAN EL COLESTEROL /
LÍPIDOS
amlodipine-atorvastatin oral tablet
1
$0
MO
atorvastatin oral tablet
1
$0
MO
cholestyramine light oral powder in packet
1
$0
MO
colestipol oral granules
1
$0
MO
colestipol oral tablet
1
$0
MO
CRESTOR ORAL TABLET
2
$0
MO
fenofibrate micronized oral capsule
1
$0
MO
fenofibrate nanocrystallized oral tablet
1
$0
MO
fenofibrate oral tablet 160 mg, 54 mg
1
$0
MO
fenofibric acid (choline) oral capsule,delayed
release(dr/ec)
1
$0
MO
fluvastatin oral capsule
1
$0
MO
gemfibrozil oral tablet
1
$0
MO
JUXTAPID ORAL CAPSULE 10 MG, 20 MG,
5 MG
2
$0
PA; MO; LA
JUXTAPID ORAL CAPSULE 30 MG, 40 MG,
60 MG
2
$0
PA; MO
lovastatin oral tablet
1
$0
MO
niacin oral tablet
4
$0
MO; *
53
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
niacin oral tablet extended release 24 hr
1
$0
MO
niacin oral tablet extended release 250 mg, 500
mg, 750 mg
4
$0
MO; *
omega-3 acid ethyl esters oral capsule
1
$0
MO
pravastatin oral tablet
1
$0
MO
prevalite oral powder
1
$0
MO
simvastatin oral tablet
1
$0
MO
VYTORIN 10-10 ORAL TABLET
2
$0
MO
2
$0
MO
2
$0
MO
2
$0
MO
WELCHOL ORAL POWDER IN PACKET
2
$0
MO
WELCHOL ORAL TABLET
2
$0
MO
ZETIA ORAL TABLET
2
$0
MO
MO
AGENTES CARDIOVASCULARES VARIOS
RANEXA ORAL TABLET EXTENDED
RELEASE 12 HR
2
$0
VECAMYL ORAL TABLET
2
$0
ISORDIL ORAL TABLET
2
$0
MO
isosorbide dinitrate oral tablet
1
$0
MO
isosorbide dinitrate oral tablet extended
release
1
$0
MO
isosorbide mononitrate oral tablet
1
$0
MO
isosorbide mononitrate oral tablet extended
release 24 hr
1
$0
MO
nitro-bid transdermal ointment
1
$0
MO
nitroglycerin intravenous solution
1
$0
B/D PA
nitroglycerin transdermal patch 24 hour
1
$0
MO
NITRATOS
54
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
nitroglycerin translingual spray,non-aerosol
1
$0
MO
NITROSTAT SUBLINGUAL TABLET
2
$0
MO
acitretin oral capsule 10 mg
1
$0
MO
ACITRETIN ORAL CAPSULE 17.5 MG, 25
MG
2
$0
MO
calcipotriene topical cream
1
$0
MO
calcipotriene topical ointment
1
$0
MO
calcipotriene topical solution
1
$0
MO
calcitrene topical ointment
2
$0
MO
calcitriol topical ointment
1
$0
MO
COSENTYX PEN (2 PENS)
SUBCUTANEOUS PEN INJECTOR
2
$0
ST; MO
COSENTYX PEN SUBCUTANEOUS PEN
INJECTOR
2
$0
ST; MO
selenium sulfide topical suspension
1
$0
MO
silver sulfadiazine topical cream
1
$0
MO
ssd topical cream
1
$0
MO
SAL-PLANT TOPICAL GEL
4
$0
MO; *
wart remover topical gel
4
$0
*
ammonium lactate topical cream
1
$0
MO
ammonium lactate topical lotion
1
$0
MO
CARAC TOPICAL CREAM
2
$0
MO
diaper rash relief topical ointment
4
$0
*
DERMATOLÓGICOS / TERAPIA
TÓPICA
ANTIPSORIÁTICO / ANTISEBORRÉICO
TERAPIA DE QUEMADOS
QUERATOLÍTICOS
DERMATOLÓGICOS VARIOS
55
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
diclofenac sodium topical gel
1
$0
PA; MO
ELIDEL TOPICAL CREAM
2
$0
ST; MO
fluorouracil topical cream
1
$0
MO
fluorouracil topical solution
1
$0
MO
imiquimod topical cream in packet
1
$0
MO
methoxsalen rapid oral capsule
1
$0
MO
PANRETIN TOPICAL GEL
2
$0
MO
podofilox topical solution
1
$0
MO
REGRANEX TOPICAL GEL
2
$0
tacrolimus topical ointment
1
$0
MO
VALCHLOR TOPICAL GEL
2
$0
MO
zinc oxide topical ointment
4
$0
*
zinc oxide topical ointment 20 %
4
$0
MO; *
ZYCLARA TOPICAL CREAM IN
METERED-DOSE PUMP 2.5 %
2
$0
MO
ZYCLARA TOPICAL CREAM IN PACKET
2
$0
MO
adapalene topical cream
1
$0
PA; MO
adapalene topical gel
1
$0
PA; MO
amnesteem oral capsule
1
$0
MO
benzoyl peroxide topical lotion 5 %
4
$0
MO; *
claravis oral capsule
1
$0
MO
clindamycin phosphate topical foam
1
$0
MO
clindamycin phosphate topical gel
1
$0
MO
clindamycin phosphate topical lotion
1
$0
MO
clindamycin phosphate topical solution
1
$0
MO
clindamycin phosphate topical swab
1
$0
MO
TERAPIA PARA EL ACNÉ
56
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
clindamycin-benzoyl peroxide topical gel 1-5
%
1
$0
MO
ery pads topical swab
1
$0
MO
erythromycin with ethanol topical gel
1
$0
MO
erythromycin with ethanol topical solution
1
$0
MO
erythromycin with ethanol topical swab
1
$0
MO
erythromycin-benzoyl peroxide topical gel
1
$0
MO
metronidazole topical cream
1
$0
MO
metronidazole topical gel
1
$0
MO
metronidazole topical lotion
1
$0
MO
rosadan topical cream
1
$0
MO
rosadan topical gel
1
$0
MO
TAZORAC TOPICAL CREAM
2
$0
MO
TAZORAC TOPICAL GEL
2
$0
MO
tretinoin microspheres topical gel with pump
1
$0
PA; MO
tretinoin topical cream
1
$0
PA; MO
tretinoin topical gel
1
$0
PA; MO
lidocaine (pf) injection solution 10 mg/ml (1
%), 40 mg/ml (4 %), 5 mg/ml (0.5 %)
1
$0
B/D PA; MO
lidocaine (pf) injection solution 15 mg/ml (1.5
%)
1
$0
B/D PA
lidocaine hcl injection solution 10 mg/ml (1 %),
20 mg/ml (2 %)
1
$0
B/D PA; MO
lidocaine hcl laryngotracheal solution
1
$0
MO
lidocaine hcl mucous membrane gel
1
$0
MO
lidocaine hcl mucous membrane jelly in
applicator
1
$0
MO
lidocaine hcl mucous membrane solution 2 %
1
$0
ANESTÉSICOS TÓPICOS
57
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
lidocaine hcl mucous membrane solution 4 %
(40 mg/ml)
1
$0
MO
lidocaine hcl urethral gel
1
$0
lidocaine topical adhesive patch,medicated
1
$0
PA; MO
lidocaine topical ointment
1
$0
MO
lidocaine-prilocaine topical cream
1
$0
MO
lta pre-attached laryngotracheal solution
1
$0
bacitracin topical ointment
4
$0
MO; *
bacitracin zinc topical packet
4
$0
*
bacitraycin plus topical ointment 500
unit/gram
4
$0
*
gentamicin topical cream
1
$0
MO
gentamicin topical ointment
1
$0
MO
mupirocin calcium topical cream
1
$0
MO
mupirocin topical ointment
1
$0
MO
sulfacetamide sodium (acne) topical suspension
1
$0
MO
TRIPLE ANTIBIOTIC TOPICAL
OINTMENT
4
$0
MO; *
antifungal (tolnaftate) topical cream
4
$0
*
ANTIFUNGAL (TOLNAFTATE) TOPICAL
POWDER
4
$0
MO; *
athlete's foot (terbinafine) topical cream
4
$0
*
athlete's foot (tolnaftate) topical cream
4
$0
*
athlete's foot af topical cream
4
$0
*
baza antifungal topical cream
4
$0
MO; *
ciclodan topical cream
1
$0
MO
ciclodan topical solution
1
$0
MO
ANTIBACTERIALES TÓPICOS
ANTIFÚNGIDOS TÓPICOS
58
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ciclopirox topical cream
1
$0
MO
ciclopirox topical gel
1
$0
MO
ciclopirox topical shampoo
1
$0
MO
ciclopirox topical solution
1
$0
MO
ciclopirox topical suspension
1
$0
MO
clotrimazole topical cream
1
$0
MO
clotrimazole topical solution
1
$0
MO
clotrimazole-betamethasone topical cream
1
$0
MO
clotrimazole-betamethasone topical lotion
1
$0
MO
econazole topical cream
1
$0
MO
inzo antifungal topical cream
4
$0
*
jock itch (terbinafine) topical cream
4
$0
*
ketoconazole topical cream
1
$0
MO
ketoconazole topical shampoo
1
$0
MO
micatin topical cream
4
$0
*
miconazole nitrate topical cream
4
$0
MO; *
nuzole topical cream
4
$0
*
nyamyc topical powder
1
$0
MO
nystatin topical cream
1
$0
MO
nystatin topical ointment
1
$0
MO
nystatin topical powder
1
$0
MO
nystatin-triamcinolone topical cream
1
$0
MO
nystatin-triamcinolone topical ointment
1
$0
MO
nystop topical powder
1
$0
MO
podactin topical powder
4
$0
*
secura antifungal topical cream
4
$0
MO; *
tolnaftate topical cream
4
$0
*
tolnaftate topical powder
4
$0
*
ANTIVIRALES TÓPICOS
59
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ABREVA TOPICAL CREAM
4
$0
MO; *
acyclovir topical ointment
1
$0
MO
DENAVIR TOPICAL CREAM
2
$0
MO
ala-cort topical cream
1
$0
MO
alclometasone topical cream
1
$0
MO
alclometasone topical ointment
1
$0
MO
amcinonide topical cream
1
$0
MO
amcinonide topical lotion
1
$0
MO
amcinonide topical ointment
1
$0
MO
beta-hc topical lotion
4
$0
MO; *
betamethasone dipropionate topical cream
1
$0
MO
betamethasone dipropionate topical lotion
1
$0
MO
betamethasone dipropionate topical ointment
1
$0
MO
betamethasone valerate topical cream
1
$0
MO
betamethasone valerate topical foam
1
$0
MO
betamethasone valerate topical lotion
1
$0
MO
betamethasone valerate topical ointment
1
$0
MO
betamethasone, augmented topical cream
1
$0
MO
betamethasone, augmented topical gel
1
$0
MO
betamethasone, augmented topical lotion
1
$0
MO
betamethasone, augmented topical ointment
1
$0
MO
clobetasol topical foam
1
$0
MO
clobetasol topical gel
1
$0
MO
clobetasol topical lotion
1
$0
MO
clobetasol topical ointment
1
$0
MO
clobetasol topical shampoo
1
$0
MO
clobetasol topical solution
1
$0
MO
CORTICOSTEROIDES TÓPICOS
60
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
clobetasol-emollient topical cream
1
$0
MO
cormax topical solution
1
$0
MO
dermarest eczema (hydrocort) topical lotion
4
$0
*
desonide topical cream
1
$0
MO
desonide topical lotion
1
$0
MO
desonide topical ointment
1
$0
MO
desoximetasone topical cream
1
$0
MO
desoximetasone topical gel
1
$0
MO
desoximetasone topical ointment
1
$0
MO
diflorasone topical cream
1
$0
MO
diflorasone topical ointment
1
$0
MO
fluocinolone topical cream
1
$0
MO
fluocinolone topical oil
1
$0
MO
fluocinolone topical ointment
1
$0
MO
fluocinolone topical solution
1
$0
MO
fluocinonide topical cream 0.1 %
1
$0
MO
fluocinonide topical gel
1
$0
MO
fluocinonide topical ointment
1
$0
MO
fluocinonide topical solution
1
$0
MO
fluocinonide-e topical cream
1
$0
MO
fluticasone topical cream
1
$0
MO
fluticasone topical lotion
1
$0
MO
fluticasone topical ointment
1
$0
MO
halobetasol propionate topical cream
1
$0
MO
halobetasol propionate topical ointment
1
$0
MO
HYDRO SKIN TOPICAL LOTION
4
$0
MO; *
hydrocortisone acetate topical cream
4
$0
*
hydrocortisone butyrate topical ointment
1
$0
MO
hydrocortisone butyrate topical solution
1
$0
MO
61
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
hydrocortisone butyr-emollient topical cream
1
$0
MO
hydrocortisone topical cream 1 %, 2.5 %
1
$0
MO
hydrocortisone topical lotion 2.5 %
1
$0
MO
hydrocortisone topical ointment 1 %, 2.5 %
1
$0
MO
hydrocortisone valerate topical cream
1
$0
MO
hydrocortisone valerate topical ointment
1
$0
MO
MEDI-CORTISONE TOPICAL CREAM
4
$0
*
mometasone topical cream
1
$0
MO
mometasone topical ointment
1
$0
MO
mometasone topical solution
1
$0
MO
prednicarbate topical cream
1
$0
MO
prednicarbate topical ointment
1
$0
MO
triamcinolone acetonide topical aerosol
1
$0
MO
triamcinolone acetonide topical cream
1
$0
MO
triamcinolone acetonide topical lotion
1
$0
MO
triamcinolone acetonide topical ointment 0.025
%, 0.1 %, 0.5 %
1
$0
MO
trianex topical ointment
1
$0
MO
triderm topical cream
1
$0
MO
2
$0
MO
lice killing (permethrin) topical liquid
4
$0
*
lice treatment (permethrin) topical liquid
4
$0
*
LICE TREATMENT TOPICAL LIQUID 1 %
4
$0
*
lindane topical lotion
1
$0
MO
lindane topical shampoo
1
$0
MO
ENZIMAS TÓPICAS
SANTYL TOPICAL OINTMENT
ESCABICIDAS / PEDICULICIDAS
TÓPICOS
62
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
malathion topical lotion
1
$0
MO
permethrin topical cream
1
$0
MO
permethrin topical liquid
4
$0
MO; *
PYRETHRIN LICE TREATMENT M
TOPICAL LIQUID
4
$0
*
DIAGNÓSTICOS / AGENTES VARIOS
SOLUCIONES DE IRRIGACIÓN
lactated ringers irrigation solution
1
$0
MO
neomycin-polymyxin b gu irrigation solution
1
$0
MO
acamprosate oral tablet,delayed release (dr/ec)
1
$0
MO
ADAGEN INTRAMUSCULAR SOLUTION
2
$0
B/D PA; MO
alendronate oral tablet 40 mg
1
$0
anagrelide oral capsule
1
$0
MO
ARALAST NP INTRAVENOUS RECON
SOLN 500 MG
2
$0
B/D PA; MO
CARBAGLU ORAL TABLET,
DISPERSIBLE
2
$0
PA; MO; LA
cevimeline oral capsule
1
$0
MO
CHEMET ORAL CAPSULE
2
$0
MO
CLINIMIX 4.25%/D5W SULFIT FREE
INTRAVENOUS PARENTERAL SOLUTION
2
$0
B/D PA
CLINIMIX E 2.75%/D10W SUL FREE
2
$0
B/D PA
CLINIMIX E 2.75%/D5W SULF FREE
2
$0
B/D PA
d10 % & 0.45 % sodium chloride intravenous
parenteral solution
1
$0
d2.5 %-0.45 % sodium chloride intravenous
parenteral solution
1
$0
AGENTES VARIOS
B/D PA
63
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
d5 % and 0.9 % sodium chloride intravenous
parenteral solution
1
$0
B/D PA; MO
d5 %-0.45 % sodium chloride intravenous
parenteral solution
1
$0
B/D PA; MO
dextrose 10 % and 0.2 % nacl intravenous
parenteral solution
1
$0
B/D PA
dextrose 10 % in water (d10w) intravenous
parenteral solution
1
$0
B/D PA; MO
parenteral solution
1
$0
B/D PA
syringe
1
$0
B/D PA
parenteral solution
1
$0
B/D PA
parenteral solution
1
$0
B/D PA
parenteral solution
1
$0
B/D PA; MO
dextrose 5 %-lactated ringers intravenous
parenteral solution
1
$0
B/D PA; MO
dextrose 5%-0.2 % sod chloride intravenous
parenteral solution
1
$0
B/D PA
dextrose 5%-0.3 % sod.chloride intravenous
parenteral solution
1
$0
B/D PA
parenteral solution
1
$0
B/D PA; MO
syringe
1
$0
B/D PA
parenteral solution
1
$0
B/D PA; MO
dextrose with sodium chloride intravenous
parenteral solution
1
$0
B/D PA
disulfiram oral tablet
1
$0
MO
64
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
etidronate disodium oral tablet
1
$0
MO
EXJADE ORAL TABLET, DISPERSIBLE
2
$0
MO
FERRIPROX ORAL TABLET
2
$0
PA; MO
FOSRENOL ORAL POWDER IN PACKET
2
$0
FOSRENOL ORAL TABLET,CHEWABLE
2
$0
MO
INCRELEX SUBCUTANEOUS SOLUTION
2
$0
B/D PA; MO
KIONEX ORAL POWDER
2
$0
MO
levocarnitine (with sugar) oral solution
1
$0
B/D PA; MO
levocarnitine intravenous solution
1
$0
B/D PA; MO
levocarnitine oral tablet
1
$0
B/D PA; MO
midodrine oral tablet
1
$0
MO
NORTHERA ORAL CAPSULE
2
$0
PA; MO
pilocarpine hcl oral tablet
1
$0
MO
RAVICTI ORAL LIQUID
2
$0
PA; MO
RENVELA ORAL POWDER IN PACKET
2
$0
MO
riluzole oral tablet
1
$0
MO
risedronate oral tablet 30 mg
1
$0
MO
sodium chloride 0.9 % intravenous parenteral
solution
1
$0
MO
sodium chloride irrigation solution
1
$0
MO
sodium polystyrene (sorb free) oral suspension
1
$0
SYPRINE ORAL CAPSULE
2
$0
MO
VELPHORO ORAL TABLET,CHEWABLE
2
$0
MO
zoledronic acid-mannitol-water intravenous
solution
1
$0
B/D PA; MO
buproban oral tablet extended release
1
$0
MO
CHANTIX CONTINUING MONTH BOX
ORAL TABLET
2
$0
MO
DISUASORIOS DEL TABACO
65
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
CHANTIX ORAL TABLET
2
$0
MO
CHANTIX STARTING MONTH BOX ORAL
TABLETS,DOSE PACK
2
$0
MO
nicotine (polacrilex) buccal gum
4
$0
MO; *
nicotine (polacrilex) buccal lozenge 2 mg
4
$0
MO; *
nicotine transdermal patch 24 hour 14 mg/24
hr, 21 mg/24 hr, 7 mg/24 hr
4
$0
MO; *
NICOTROL INHALATION CARTRIDGE
2
$0
MO
NICOTROL NS NASAL SPRAY,NONAEROSOL
2
$0
MO
nts step 1 transdermal patch 24 hour
4
$0
*
quit 2 buccal gum
4
$0
*
quit 4 buccal gum
4
$0
*
stop smoking aid buccal lozenge
4
$0
*
12 HOUR NASAL SPRAY NASAL
SPRAY,NON-AEROSOL
4
$0
*
afrin no drip(oxymetazolin) nasal mist
4
$0
*
altamist nasal aerosol,spray
4
$0
*
AYR SALINE NASAL DROPS
4
$0
MO; *
azelastine nasal aerosol,spray
1
$0
azelastine nasal spray,non-aerosol
1
$0
chlorhexidine gluconate mucous membrane
mouthwash
1
$0
MO
denta 5000 plus dental cream
1
$0
MO
dentagel dental gel
1
$0
MO
DRISTAN LONG LASTING NASAL MIST
4
$0
*
MEDICAMENTOS PARA OÍDOS,
NARIZ Y GARGANTA
AGENTES VARIOS
66
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ipratropium bromide nasal spray,non-aerosol
0.03 %
1
$0
ipratropium bromide nasal spray,non-aerosol
0.06 %
1
$0
little remedies nasal aerosol,spray
4
$0
*
nasal moisturizing nasal aerosol,spray
4
$0
*
NASAL SPRAY (OXYMETAZOLINE)
NASAL SPRAY,NON-AEROSOL
4
$0
*
nasal spray (sodium chloride) nasal
aerosol,spray
4
$0
*
OCEAN NASAL NASAL AEROSOL,SPRAY
4
$0
MO; *
olopatadine nasal spray,non-aerosol
1
$0
oralone dental paste
1
$0
MO
periogard mucous membrane mouthwash
1
$0
MO
saline mist nasal aerosol,spray
4
$0
MO; *
saline nasal mist nasal aerosol,spray
4
$0
*
saline nasal nasal aerosol,spray
4
$0
*
saline nose nasal aerosol,spray
4
$0
*
sf 5000 plus dental cream
1
$0
MO
sf dental gel
1
$0
MO
sinex ultra fine mist 12-hour nasal mist
4
$0
*
sinus relief (oxymetazoline) nasal mist
4
$0
*
triamcinolone acetonide dental paste
1
$0
MO
vicks qlearquil(oxymetazoline) nasal mist
4
$0
*
acetasol hc otic drops
1
$0
MO
acetic acid otic solution
1
$0
MO
fluocinolone acetonide oil otic drops
1
$0
MO
hydrocortisone-acetic acid otic drops
1
$0
MO
ofloxacin otic drops
1
$0
MO
PREPARACIONES ÓTICAS VARIAS
67
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ESTEROIDES ÓTICOS / ANTIBIÓTICOS
CORTISPORIN-TC OTIC
DROPS,SUSPENSION
2
$0
MO
neomycin-polymyxin-hc otic drops,suspension
1
$0
MO
neomycin-polymyxin-hc otic solution
1
$0
MO
ACTHAR H.P. INJECTION GEL
2
$0
PA; MO
A-HYDROCORT INJECTION RECON SOLN
2
$0
B/D PA; MO
cortisone oral tablet
1
$0
MO
dexamethasone intensol oral drops
1
$0
MO
dexamethasone oral elixir
1
$0
MO
dexamethasone oral tablet
1
$0
MO
dexamethasone sodium phosphate injection
solution
1
$0
B/D PA; MO
fludrocortisone oral tablet
1
$0
MO
hydrocortisone oral tablet
1
$0
MO
KENALOG INJECTION SUSPENSION
2
$0
MO
methylprednisolone acetate injection
suspension
1
$0
B/D PA; MO
methylprednisolone oral tablet
1
$0
MO
methylprednisolone oral tablets,dose pack
1
$0
MO
methylprednisolone sodium succ injection
recon soln 125 mg, 40 mg
1
$0
B/D PA; MO
millipred oral tablet
1
$0
MO
prednisolone sodium phosphate oral solution
15 mg/5 ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5
ml (6.7 mg/5 ml)
1
$0
MO
prednisolone sodium phosphate oral
tablet,disintegrating
1
$0
MO
ENDOCRINO / DIABETES
HORMONAS SUPRARRENALES
68
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
prednisone intensol oral concentrate
1
$0
MO
prednisone oral solution
1
$0
MO
prednisone oral tablet
1
$0
MO
prednisone oral tablets,dose pack 10 mg
1
$0
MO
RAYOS ORAL TABLET,DELAYED
RELEASE (DR/EC)
2
$0
MO
SOLU-CORTEF (PF) INJECTION RECON
SOLN 100 MG/2 ML, 250 MG/2 ML
2
$0
B/D PA; MO
triamcinolone acetonide injection suspension
10 mg/ml
1
$0
MO
triamcinolone acetonide injection suspension
40 mg/ml
1
$0
veripred 20 oral solution
1
$0
methimazole oral tablet 10 mg, 5 mg
1
$0
MO
propylthiouracil oral tablet
1
$0
MO
acarbose oral tablet
1
$0
MO
ACTOPLUS MET XR ORAL TABLET, ER
MULTIPHASE 24 HR 15-1,000 MG
2
$0
ST; MO; QL (60 per 30 days)
ACTOPLUS MET XR ORAL TABLET, ER
MULTIPHASE 24 HR 30-1,000 MG
2
$0
ST; MO; QL (30 per 30 days)
ALCOHOL PADS TOPICAL PADS,
MEDICATED
2
$0
MO
BYDUREON SUBCUTANEOUS PEN
INJECTOR
2
$0
MO
BYDUREON SUBCUTANEOUS
SUSPENSION,EXTENDED REL RECON
2
$0
MO
BYETTA SUBCUTANEOUS PEN
INJECTOR
2
$0
MO
CYCLOSET ORAL TABLET
2
$0
ST; MO
AGENTES ANTITIROIDEOS
TERAPIA PARA DIABETES
FARXIGA ORAL TABLET
2
$0
MO
69
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
GAUZE PADS 2X2
2
$0
MO
glimepiride oral tablet
1
$0
MO
glipizide oral tablet
1
$0
MO
glipizide oral tablet extended release 24hr
1
$0
MO
glipizide-metformin oral tablet 2.5-250 mg
1
$0
glipizide-metformin oral tablet 2.5-500 mg, 5500 mg
1
$0
GLUCAGEN HYPOKIT INJECTION RECON
SOLN
2
$0
MO
GLUCAGON EMERGENCY KIT (HUMAN)
INJECTION KIT
2
$0
MO
HUMALOG KWIKPEN SUBCUTANEOUS
INSULIN PEN
2
$0
MO
HUMALOG MIX 50-50 KWIKPEN
SUBCUTANEOUS INSULIN PEN
2
$0
MO
HUMALOG MIX 50-50 SUBCUTANEOUS
SUSPENSION
2
$0
MO
HUMALOG MIX 75-25 KWIKPEN
2
$0
MO
HUMALOG MIX 75-25 SUBCUTANEOUS
SUSPENSION
2
$0
MO
HUMALOG SUBCUTANEOUS
CARTRIDGE
2
$0
MO
HUMALOG SUBCUTANEOUS SOLUTION
100 UNIT/ML
2
$0
MO
HUMALOG SUBCUTANEOUS SOLUTION
100 UNIT/ML (PREFILLED SYRINGE)
2
$0
HUMULIN 70/30 KWIKPEN
2
$0
MO
HUMULIN 70/30 SUBCUTANEOUS
SUSPENSION
2
$0
MO
70
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
HUMULIN N KWIKPEN SUBCUTANEOUS
INSULIN PEN
2
$0
MO
HUMULIN N SUBCUTANEOUS
SUSPENSION
2
$0
MO
HUMULIN R INJECTION SOLUTION
2
$0
MO
HUMULIN R U-500 "CONCENTRATED"
SUBCUTANEOUS SOLUTION
2
$0
MO
INSULIN PEN NEEDLE
2
$0
MO
INSULIN SYRINGE (DISP) U-100 0.3 ML,
1/2 ML, 1 ML
2
$0
MO
JANUMET ORAL TABLET
2
$0
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR
2
$0
JANUVIA ORAL TABLET
2
$0
JARDIANCE ORAL TABLET
2
$0
MO
KOMBIGLYZE XR ORAL TABLET, ER
MULTIPHASE 24 HR 2.5-1,000 MG
2
$0
KOMBIGLYZE XR ORAL TABLET, ER
MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG
2
$0
LEVEMIR FLEXTOUCH SUBCUTANEOUS
INSULIN PEN
2
$0
MO
LEVEMIR SUBCUTANEOUS SOLUTION
2
$0
MO
metformin oral tablet
1
$0
MO
metformin oral tablet extended release 24 hr
1
$0
MO
metformin oral tablet extended release 24hr
1,000 mg
1
$0
MO
nateglinide oral tablet
1
$0
MO
NEEDLES, INSULIN DISP.,SAFETY
2
$0
MO
NOVOFINE NEEDLE
2
$0
MO
NOVOLIN 70/30 SUBCUTANEOUS
SUSPENSION
2
$0
MO
71
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
NOVOLIN N SUBCUTANEOUS
SUSPENSION
2
$0
MO
NOVOLIN R INJECTION SOLUTION
2
$0
MO
NOVOLOG FLEXPEN SUBCUTANEOUS
INSULIN PEN
2
$0
MO
NOVOLOG MIX 70-30 FLEXPEN
2
$0
MO
NOVOLOG MIX 70-30 SUBCUTANEOUS
SOLUTION
2
$0
MO
NOVOLOG PENFILL SUBCUTANEOUS
CARTRIDGE
2
$0
MO
NOVOLOG SUBCUTANEOUS SOLUTION
2
$0
MO
NOVOTWIST NEEDLE
2
$0
MO
ONGLYZA ORAL TABLET
2
$0
pioglitazone oral tablet
1
$0
MO
pioglitazone-glimepiride oral tablet
1
$0
pioglitazone-metformin oral tablet
1
$0
PROGLYCEM ORAL SUSPENSION
2
$0
MO
repaglinide oral tablet 0.5 mg
1
$0
repaglinide oral tablet 1 mg
1
$0
repaglinide oral tablet 2 mg
1
$0
SYMLINPEN 120 SUBCUTANEOUS PEN
INJECTOR
2
$0
MO
SYMLINPEN 60 SUBCUTANEOUS PEN
INJECTOR
2
$0
MO
tolazamide oral tablet
1
$0
MO
tolbutamide oral tablet
1
$0
MO
VICTOZA 3-PAK SUBCUTANEOUS PEN
INJECTOR
2
$0
MO
XIGDUO XR ORAL TABLET, IR & ER,
BIPHASIC 24HR
2
$0
MO
72
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
HORMONAS VARIAS
ALDURAZYME INTRAVENOUS
SOLUTION
2
$0
B/D PA; MO
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP
2
$0
MO
ANDROGEL TRANSDERMAL GEL IN
PACKET
2
$0
MO
ANDROID ORAL CAPSULE
2
$0
MO
cabergoline oral tablet
1
$0
calcitonin (salmon) nasal spray,non-aerosol
1
$0
MO
calcitriol intravenous solution 1 mcg/ml
1
$0
B/D PA; MO
calcitriol oral capsule
1
$0
B/D PA; MO
calcitriol oral solution
1
$0
B/D PA; MO
CEREZYME INTRAVENOUS RECON
SOLN 400 UNIT
2
$0
B/D PA; MO
chorionic gonadotropin, human intramuscular
recon soln
1
$0
PA; MO
danazol oral capsule
1
$0
MO
desmopressin injection solution
1
$0
MO
desmopressin nasal solution
1
$0
MO
desmopressin nasal spray,non-aerosol
1
$0
MO
desmopressin oral tablet
1
$0
MO
ELAPRASE INTRAVENOUS SOLUTION
2
$0
B/D PA; MO
ELELYSO INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
FABRAZYME INTRAVENOUS RECON
SOLN 35 MG
2
$0
B/D PA; MO
fortical nasal spray,non-aerosol
1
$0
MO
KORLYM ORAL TABLET
2
$0
PA; MO
KUVAN ORAL TABLET,SOLUBLE
2
$0
PA; MO
MIACALCIN INJECTION SOLUTION
2
$0
B/D PA; MO
73
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
MYOZYME INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
NAGLAZYME INTRAVENOUS SOLUTION
2
$0
B/D PA; MO
NATPARA SUBCUTANEOUS CARTRIDGE
2
$0
PA; MO
novarel intramuscular recon soln
1
$0
PA; MO
OXANDROLONE ORAL TABLET 10 MG
2
$0
MO
oxandrolone oral tablet 2.5 mg
1
$0
MO
pamidronate intravenous solution
1
$0
B/D PA; MO
paricalcitol oral capsule
1
$0
B/D PA; MO
PREGNYL INTRAMUSCULAR RECON
SOLN
2
$0
PA; MO
SAMSCA ORAL TABLET 15 MG
2
$0
SAMSCA ORAL TABLET 30 MG
2
$0
SENSIPAR ORAL TABLET
2
$0
MO
SOMAVERT SUBCUTANEOUS RECON
SOLN
2
$0
B/D PA; MO
SYNAREL NASAL SPRAY,NON-AEROSOL
2
$0
MO
testosterone enanthate intramuscular oil
1
$0
B/D PA; MO
VPRIV INTRAVENOUS RECON SOLN
2
$0
B/D PA; MO
ZAVESCA ORAL CAPSULE
2
$0
MO
ZEMPLAR INTRAVENOUS SOLUTION
2
$0
B/D PA; MO
zoledronic acid intravenous solution
1
$0
B/D PA; MO
ZOMETA INTRAVENOUS SOLUTION 4
MG/100 ML
2
$0
B/D PA; MO
LEVOTHYROXINE INTRAVENOUS
RECON SOLN 100 MCG
2
$0
MO
levothyroxine oral tablet
1
$0
MO
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,
137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg,
50 mcg, 75 mcg, 88 mcg
1
$0
MO
HORMONAS TIROIDEAS
74
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
liothyronine intravenous solution
1
$0
MO
liothyronine oral tablet
1
$0
MO
SYNTHROID ORAL TABLET
2
$0
MO
unithroid oral tablet 100 mcg, 112 mcg, 125
mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300
mcg, 50 mcg, 75 mcg, 88 mcg
1
$0
MO
GASTROENTEROLOGÍA
ANTIDIARRÉICOS / ANTIESPASMÓDICOS
anti-diarrhea oral tablet
4
$0
*
ANTI-DIARRHEAL (LOPERAMIDE) ORAL
TABLET
4
$0
MO; *
anti-diarrheal oral suspension
4
$0
*
atropine injection syringe 0.05 mg/ml, 0.1
mg/ml
1
$0
BISMATROL ORAL SUSPENSION 262
MG/15 ML
4
$0
MO; *
BISMATROL ORAL TABLET,CHEWABLE
4
$0
*
bismuth maximum strength oral suspension
4
$0
*
bismuth oral suspension
4
$0
*
bismuth oral tablet,chewable
4
$0
*
diamode oral tablet
4
$0
*
diarrhea relief (bismuth subs) oral suspension
4
$0
*
dicyclomine oral capsule
1
$0
PA; MO
dicyclomine oral solution
1
$0
PA; MO
dicyclomine oral tablet
1
$0
PA; MO
diotame oral tablet,chewable
4
$0
*
glycopyrrolate injection solution
1
$0
MO
glycopyrrolate oral tablet
1
$0
MO
kaopectate (bismuth subsalicy) oral suspension
4
$0
MO; *
kaopectate ex str (bismuth ss) oral suspension
4
$0
*
75
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
k-pec antidiarrheal (bism sub) oral suspension
4
$0
*
loperamide oral capsule
1
$0
MO
loperamide oral tablet
4
$0
*
medi-bismuth oral tablet,chewable
4
$0
*
methscopolamine oral tablet
1
$0
MO
pepto-bismol oral tablet,chewable
4
$0
MO; *
pink bismuth maximum strength oral
suspension
4
$0
*
pink bismuth oral suspension
4
$0
*
pink bismuth oral tablet,chewable
4
$0
MO; *
soothe regular strength oral suspension
4
$0
*
stomach relief max strength oral suspension
4
$0
*
stomach relief oral suspension
4
$0
*
stomach relief oral tablet,chewable
4
$0
*
stomach relief original oral suspension
4
$0
*
ACID GONE ANTACID ORAL
SUSPENSION
4
$0
*
ADVANCED ANTACID-ANTIGAS ORAL
SUSPENSION
4
$0
*
ALMACONE ORAL SUSPENSION
4
$0
*
ALMACONE-2 ORAL SUSPENSION
4
$0
*
alophen oral tablet,delayed release (dr/ec)
4
$0
*
aluminum hydroxide gel oral suspension 320
mg/5 ml
4
$0
MO; *
aluminum hydroxide gel oral suspension 600
mg/5 ml
4
$0
*
AMITIZA ORAL CAPSULE
2
$0
antacid anti-gas double str oral suspension
4
$0
*
AGENTES GASTROINTESTINALES
VARIOS
76
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
antacid anti-gas oral suspension
4
$0
*
antacid extra-strength oral suspension
4
$0
*
antacid liquid oral suspension
4
$0
*
antacid maximum strength oral suspension
4
$0
*
antacid oral suspension
4
$0
*
antacid oral tablet,chewable 550-110 mg
4
$0
*
antacid plus anti-gas oral suspension
4
$0
*
antacid regular strength oral suspension
4
$0
*
ANTACID TABLET ORAL
TABLET,CHEWABLE
4
$0
*
antacid ultra strength oral tablet,chewable
1,177 mg
4
$0
*
antacid with simethicone oral suspension
4
$0
*
antacid-antigas oral suspension
4
$0
*
antacid-simethicone ds oral suspension
4
$0
*
APRISO ORAL CAPSULE,EXTENDED
RELEASE 24HR
2
$0
MO
balsalazide oral capsule
1
$0
MO
bisacodyl oral tablet,delayed release (dr/ec)
4
$0
MO; *
bisa-lax oral tablet,delayed release (dr/ec)
4
$0
*
BUDESONIDE ORAL
CAPSULE,DELAYED,EXTEND.RELEASE
2
$0
MO
CANASA RECTAL SUPPOSITORY
2
$0
MO
child suppository rectal suppository
4
$0
*
children's pepto oral tablet,chewable
4
$0
*
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT
2
$0
B/D PA; ST; MO
CIMZIA SUBCUTANEOUS SYRINGE KIT
2
$0
ST; MO
citrate of magnesia oral solution
4
$0
*
CLEARLAX ORAL POWDER
4
$0
MO; *
77
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
col-rite oral capsule
4
$0
*
comfort gel extra strength oral suspension
4
$0
*
comfort gel oral suspension
4
$0
*
compro rectal suppository
1
$0
MO
constulose oral solution
1
$0
MO
cromolyn oral concentrate
1
$0
MO
CYSTADANE ORAL POWDER
2
$0
MO
dimenhydrinate oral tablet
4
$0
MO; *
DIOCTO ORAL LIQUID
4
$0
*
DIPENTUM ORAL CAPSULE
2
$0
MO
DOC-Q-LACE ORAL CAPSULE
4
$0
MO; *
docu oral liquid
4
$0
MO; *
docu soft oral capsule
4
$0
*
docusate sodium oral capsule
4
$0
MO; *
docusil oral capsule
4
$0
*
DRONABINOL ORAL CAPSULE 10 MG
2
$0
days)
dronabinol oral capsule 2.5 mg, 5 mg
1
$0
days)
dss oral capsule 250 mg
4
$0
*
ducodyl oral tablet,delayed release (dr/ec)
4
$0
*
dulcolax stool softener (dss) oral capsule
4
$0
MO; *
EMEND ORAL CAPSULE 125 MG
2
$0
days)
2
$0
day)
2
$0
days)
EMEND ORAL CAPSULE,DOSE PACK
2
$0
days)
78
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ENEMA RECTAL ENEMA 19-7 GRAM/118
ML
4
$0
*
enulose oral solution
1
$0
MO
FIBER (CALCIUM POLYCARBOPHIL)
ORAL TABLET
4
$0
MO; *
fiber (psyllium husk/sugar) oral powder
4
$0
*
FIBER (WITH ASPARTAME) ORAL
POWDER
4
$0
*
fiber laxative (husk/sugar) oral powder
4
$0
*
fiber laxative (methylcellulo) oral tablet
4
$0
*
fiber laxative (psyllium) s/f oral powder
4
$0
*
FIBER ORAL POWDER
4
$0
*
fiber smooth (sucrose) oral powder
4
$0
*
fiber smooth oral powder
4
$0
*
fiber therapy (ca polycarboph) oral tablet
4
$0
*
FIBER THERAPY (PSYLLIUM SEED)
ORAL POWDER
4
$0
*
fiber therapy (psyllium) oral powder
4
$0
*
FIBER THERAPY ORAL POWDER
4
$0
*
FIBER THERAPY ORAL TABLET
4
$0
*
fiber-lax oral tablet
4
$0
MO; *
fiber-tabs oral tablet
4
$0
*
flanax antacid oral suspension
4
$0
*
foaming antacid oral suspension
4
$0
*
foaming antacid oral tablet,chewable
4
$0
*
GATTEX ONE-VIAL SUBCUTANEOUS
KIT
2
$0
PA; MO
gavilax oral powder
4
$0
MO; *
gavilyte-c oral recon soln
1
$0
MO
gavilyte-g oral recon soln
1
$0
MO
79
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
gavilyte-n oral recon soln
1
$0
MO
generlac oral solution
1
$0
MO
gentlelax oral powder
4
$0
*
geri-kot oral tablet
4
$0
*
geri-lanta oral suspension
4
$0
*
geri-mox antacid-antigas oral suspension
4
$0
*
glycerin (adult) rectal suppository
4
$0
*
glycerin (child) rectal suppository
4
$0
*
glycolax oral powder
4
$0
*
granisetron (pf) intravenous solution 100
mcg/ml
1
$0
B/D PA; MO
granisetron hcl intravenous solution 1 mg/ml (1
ml)
1
$0
B/D PA; MO
granisetron hcl oral tablet
1
$0
day)
hydrocortisone rectal enema
1
$0
MO
KONSYL (SUGAR) ORAL POWDER 3.4
GRAM/11 GRAM
4
$0
*
KONSYL SUGAR-FREE ORAL POWDER
IN PACKET
4
$0
MO; *
lactulose oral solution 10 gram/15 ml
1
$0
MO
laxa clear oral powder
4
$0
*
laxacin oral tablet
4
$0
*
laxative (glycerin-pediatric) rectal suppository
4
$0
*
laxative maximum strength oral tablet
4
$0
*
laxative oral tablet 15 mg, 17.2 mg, 25 mg
4
$0
*
laxative oral tablet,delayed release (dr/ec)
4
$0
*
laxative peg 3350 oral powder
4
$0
*
laxative pills oral tablet
4
$0
*
80
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
laxative plus stool softener oral tablet
4
$0
*
laxative-senna oral tablet
4
$0
*
LIALDA ORAL TABLET,DELAYED
RELEASE (DR/EC)
2
$0
MO
LINZESS ORAL CAPSULE
2
$0
liquid antacid oral suspension 200-200-20
mg/5 ml
4
$0
*
LOTRONEX ORAL TABLET
2
$0
MO
magnesium citrate oral solution
4
$0
MO; *
masanti double strength oral suspension
4
$0
*
meclizine oral tablet 12.5 mg, 25 mg
1
$0
MO
meclizine oral tablet,chewable
4
$0
MO; *
medi-lax oral tablet
4
$0
*
medi-laxx oral tablet
4
$0
*
medi-natural oral tablet
4
$0
*
medi-natural senna-stool oral tablet
4
$0
*
mesalamine with cleansing wipe rectal enema
kit
1
$0
MO
metoclopramide hcl injection solution
1
$0
B/D PA; MO
metoclopramide hcl injection syringe
1
$0
B/D PA
metoclopramide hcl oral solution
1
$0
MO
metoclopramide hcl oral tablet
1
$0
MO
MI-ACID ORAL TABLET,CHEWABLE
4
$0
*
MILK OF MAGNESIA ORAL SUSPENSION
4
$0
MO; *
mineral oil extra heavy oral oil
4
$0
*
MOTION SICKNESS ORAL TABLET
4
$0
*
motion sickness relief oral tablet
4
$0
*
MOVIPREP ORAL POWDER IN PACKET
2
$0
MO
natural fiber laxative (sugar) oral powder , 3.4
gram/12 gram
4
$0
*
81
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
natural fiber laxative smooth oral powder
4
$0
*
natural laxative oral tablet
4
$0
*
natural veg laxative(sennosid) oral tablet
4
$0
*
natural vegetable (psyllium) oral powder
4
$0
*
natural vegetable oral powder
4
$0
*
natural vegetable powder oral powder
4
$0
*
ondansetron hcl (pf) injection solution
1
$0
B/D PA; MO
ondansetron hcl (pf) injection syringe
1
$0
B/D PA
ondansetron hcl oral solution
1
$0
days)
ondansetron hcl oral tablet 24 mg
1
$0
B/D PA; QL (1 per 1 day)
ondansetron hcl oral tablet 4 mg, 8 mg
1
$0
days)
ondansetron oral tablet,disintegrating
1
$0
days)
p-col rite oral tablet
4
$0
*
peg 3350-electrolytes oral recon soln 23622.74-6.74 -5.86 gram
1
$0
MO
peg 3350-electrolytes oral recon soln 24022.72-6.72 -5.84 gram
1
$0
peg-3350 with flavor packs oral recon soln
1
$0
peg-electrolyte soln oral recon soln
1
$0
peri-colace oral tablet
4
$0
MO; *
polyethylene glycol 3350 oral powder
1
$0
MO
powderlax oral powder
4
$0
*
prochlorperazine edisylate injection solution
10 mg/2 ml (5 mg/ml)
1
$0
MO
prochlorperazine maleate oral tablet
1
$0
MO
prochlorperazine rectal suppository
1
$0
MO
procto-pak rectal cream
1
$0
MO
82
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
proctosol hc rectal cream
1
$0
MO
proctozone-hc rectal cream
1
$0
MO
purelax oral powder
4
$0
*
REGULOID ORAL POWDER
4
$0
MO; *
RELISTOR SUBCUTANEOUS SOLUTION
2
$0
MO
RELISTOR SUBCUTANEOUS SYRINGE
2
$0
MO
REMICADE INTRAVENOUS RECON SOLN
2
$0
PA; MO
ri-gel ii oral suspension
4
$0
*
ri-gel oral suspension
4
$0
*
riginic oral suspension
4
$0
*
ri-mox oral suspension
4
$0
*
ri-mox plus oral suspension
4
$0
*
SANCUSO TRANSDERMAL PATCH
WEEKLY
2
$0
days)
SANI-SUPP (ADULT) RECTAL
SUPPOSITORY
4
$0
MO; *
SENEXON-S ORAL TABLET
4
$0
MO; *
senna lax oral tablet
4
$0
MO; *
senna laxative oral tablet
4
$0
*
SENNA ORAL TABLET
4
$0
*
senna plus oral tablet
4
$0
MO; *
senna-extra oral tablet
4
$0
*
senna-s oral tablet
4
$0
MO; *
senno oral tablet
4
$0
*
sennosides-docusate sodium oral tablet
4
$0
*
sen-o-tab oral tablet
4
$0
*
silace oral liquid
4
$0
MO; *
sodium bicarbonate oral tablet 650 mg
4
$0
MO; *
soluble fiber oral tablet
4
$0
*
83
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
stimulant laxative plus oral tablet
4
$0
*
stool softener oral capsule 100 mg, 50 mg
4
$0
*
stool softener oral capsule 250 mg
4
$0
MO; *
stool softener oral liquid
4
$0
*
stool softener-laxative oral tablet
4
$0
*
stool softener-stimulant laxat oral tablet
4
$0
*
sulfasalazine oral tablet
1
$0
MO
sulfazine ec oral tablet,delayed release (dr/ec)
1
$0
MO
sulfazine oral tablet
1
$0
MO
suppository adult rectal suppository
4
$0
*
TRANSDERM-SCOP TRANSDERMAL
PATCH 72 HOUR
2
$0
travel sickness oral tablet
4
$0
*
trilyte with flavor packets oral recon soln
1
$0
MO
ursodiol oral capsule
1
$0
MO
ursodiol oral tablet
1
$0
MO
vegetable laxative oral tablet
4
$0
*
wal-mucil fiber (aspartame) oral powder
4
$0
*
wal-mucil natural fiber lax oral powder
4
$0
*
woman's laxative oral tablet,delayed release
(dr/ec)
4
$0
*
women's gentle laxative(bisac) oral
tablet,delayed release (dr/ec)
4
$0
*
women's laxative (bisacodyl) oral
tablet,delayed release (dr/ec)
4
$0
*
women's stool softener oral capsule
4
$0
*
ZENPEP ORAL CAPSULE,DELAYED
RELEASE(DR/EC)
2
$0
MO
TERAPIA DE ÚLCERA
84
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
acid control (ranitidine) oral tablet 150 mg
4
$0
*
acid controller oral tablet
4
$0
*
acid reducer (famotidine) oral tablet
4
$0
*
acid reducer (ranitidine) oral tablet
4
$0
*
amoxicil-clarithromy-lansopraz oral combo
pack
1
$0
MO
CARAFATE ORAL SUSPENSION
2
$0
MO
cimetidine hcl oral solution
1
$0
MO
cimetidine oral tablet
1
$0
MO
DEXILANT ORAL CAPSULE,BIPHASE
DELAYED RELEAS
2
$0
MO
esomeprazole sodium intravenous recon soln
1
$0
B/D PA
famotidine (pf) intravenous solution
1
$0
B/D PA; MO
famotidine (pf)-nacl (iso-os) intravenous
piggyback
1
$0
B/D PA
famotidine oral suspension
1
$0
MO
famotidine oral tablet 10 mg
4
$0
MO; *
famotidine oral tablet 20 mg, 40 mg
1
$0
MO
heartburn prevention oral tablet
4
$0
*
heartburn relief (ranitidine) oral tablet
4
$0
*
lansoprazole oral capsule,delayed
release(dr/ec)
1
$0
MO
misoprostol oral tablet
1
$0
MO
nizatidine oral capsule
1
$0
MO
nizatidine oral solution
1
$0
MO
omeprazole oral capsule,delayed release(dr/ec)
1
$0
MO
omeprazole oral tablet,delayed release (dr/ec)
4
$0
MO; *
pantoprazole oral tablet,delayed release
(dr/ec)
1
$0
MO
pepcid ac oral tablet 20 mg
4
$0
MO; *
85
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ranitidine hcl injection solution 25 mg/ml
1
$0
B/D PA; MO
ranitidine hcl oral capsule
1
$0
MO
ranitidine hcl oral syrup
1
$0
MO
ranitidine hcl oral tablet 150 mg, 300 mg
1
$0
MO
ranitidine hcl oral tablet 75 mg
4
$0
MO; *
sucralfate oral tablet
1
$0
MO
wal-zan 150 oral tablet
4
$0
*
zantac maximum strength oral tablet
4
$0
MO; *
ACTIMMUNE SUBCUTANEOUS
SOLUTION
2
$0
PA; MO
ARCALYST SUBCUTANEOUS RECON
SOLN
2
$0
PA; MO
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT
2
$0
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT
2
$0
AVONEX INTRAMUSCULAR SYRINGE
KIT
2
$0
EGRIFTA SUBCUTANEOUS RECON SOLN
1 MG
2
$0
PA
EXTAVIA SUBCUTANEOUS KIT
2
$0
ILARIS (PF) SUBCUTANEOUS RECON
SOLN
2
$0
PA; MO; LA
INTRON A INJECTION RECON SOLN
2
$0
B/D PA; MO
INTRON A INJECTION SOLUTION 6
MILLION UNIT/ML
2
$0
B/D PA; MO
LEUKINE INJECTION RECON SOLN
2
$0
PA; MO
INMUNOLOGÍA, VACUNAS /
BIOTECNOLOGÍA
MEDICAMENTOS DE BIOTECNOLOGÍA
86
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
MOZOBIL SUBCUTANEOUS SOLUTION
2
$0
B/D PA; MO
NEUMEGA SUBCUTANEOUS RECON
SOLN
2
$0
days)
NEUPOGEN INJECTION SOLUTION
2
$0
PA; MO
NEUPOGEN INJECTION SYRINGE
2
$0
PA; MO
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN INJECTOR 10
MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10
MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
2
$0
PA; MO
NORDITROPIN NORDIFLEX
SUBCUTANEOUS PEN INJECTOR
2
$0
PA; MO
PEGINTRON REDIPEN SUBCUTANEOUS
PEN INJECTOR KIT
2
$0
PEGINTRON SUBCUTANEOUS KIT
2
$0
PROCRIT INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000
UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML
2
$0
PROCRIT INJECTION SOLUTION 40,000
UNIT/ML
2
$0
PROLEUKIN INTRAVENOUS RECON
SOLN
2
$0
B/D PA; MO
REBIF (WITH ALBUMIN)
SUBCUTANEOUS SYRINGE
2
$0
REBIF REBIDOSE SUBCUTANEOUS PEN
INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML
2
$0
REBIF REBIDOSE SUBCUTANEOUS PEN
INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML
(6)
2
$0
PA; MO; QL (4.2 per 180
days)
REBIF TITRATION PACK
2
$0
SYLATRON SUBCUTANEOUS KIT
2
$0
PA; MO
VACUNAS / INMUNOLÓGICOS VARIOS
87
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ACTHIB (PF) INTRAMUSCULAR RECON
SOLN
2
$0
MO
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION
2
$0
MO
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE
2
$0
MO
BCG VACCINE, LIVE (PF)
PERCUTANEOUS SUSPENSION FOR
RECONSTITUTION
2
$0
B/D PA
BEXSERO (PF) INTRAMUSCULAR
SYRINGE
2
$0
BOOSTRIX TDAP INTRAMUSCULAR
SUSPENSION
2
$0
MO
BOOSTRIX TDAP INTRAMUSCULAR
SYRINGE
2
$0
MO
CERVARIX VACCINE (PF)
2
$0
MO
COMVAX (PF) INTRAMUSCULAR
SUSPENSION
2
$0
MO
DAPTACEL (DTAP PEDIATRIC) (PF)
2
$0
MO
ENGERIX-B (PF) INTRAMUSCULAR
SYRINGE
2
$0
B/D PA; MO
ENGERIX-B PEDIATRIC (PF)
2
$0
B/D PA; MO
ENGERIX-B PEDIATRIC (PF)
2
$0
B/D PA
fomepizole intravenous solution
1
$0
B/D PA; MO
GAMMAGARD LIQUID INJECTION
SOLUTION
2
$0
PA; MO
GAMUNEX-C INJECTION SOLUTION 1
GRAM/10 ML (10 %)
2
$0
PA; MO
88
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
GARDASIL (PF) INTRAMUSCULAR
SUSPENSION
2
$0
MO
GARDASIL (PF) INTRAMUSCULAR
SYRINGE
2
$0
MO
GARDASIL 9 (PF) INTRAMUSCULAR
SUSPENSION
2
$0
MO
GARDASIL 9 (PF) INTRAMUSCULAR
SYRINGE
2
$0
MO
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML
2
$0
MO
SYRINGE 1,440 ELISA UNIT/ML
2
$0
B/D PA; MO
SYRINGE 720 ELISA UNIT/0.5 ML
2
$0
HYPERRAB S/D (PF) INTRAMUSCULAR
SOLUTION
2
$0
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN
2
$0
MO
INFANRIX (DTAP) (PF)
2
$0
MO
INFANRIX (DTAP) (PF)
2
$0
MO
IPOL INJECTION SUSPENSION
2
$0
MO
IPOL INJECTION SYRINGE
2
$0
MO
IXIARO (PF) INTRAMUSCULAR SYRINGE
2
$0
MO
KINRIX (PF) INTRAMUSCULAR
SUSPENSION
2
$0
KINRIX (PF) INTRAMUSCULAR SYRINGE
2
$0
MENACTRA (PF) INTRAMUSCULAR
SOLUTION
2
$0
MO
MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN
2
$0
MO
89
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT
2
$0
MO
M-M-R II (PF) SUBCUTANEOUS RECON
SOLN
2
$0
MO
PEDVAX HIB (PF) INTRAMUSCULAR
SOLUTION
2
$0
MO
PROQUAD (PF) SUBCUTANEOUS
2
$0
QUADRACEL (PF) INTRAMUSCULAR
SUSPENSION
2
$0
RABAVERT (PF) INTRAMUSCULAR
2
$0
MO
RECOMBIVAX HB (PF)
INTRAMUSCULAR SUSPENSION 10
MCG/ML, 40 MCG/ML
2
$0
B/D PA; MO
RECOMBIVAX HB (PF)
INTRAMUSCULAR SYRINGE 10 MCG/ML
2
$0
B/D PA; MO
RECOMBIVAX HB (PF)
INTRAMUSCULAR SYRINGE 5 MCG/0.5
ML
2
$0
B/D PA
ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION
2
$0
ROTATEQ VACCINE ORAL SUSPENSION
2
$0
MO
TENIVAC (PF) INTRAMUSCULAR
SYRINGE
2
$0
MO
tetanus toxoid,adsorbed (pf) intramuscular
suspension
1
$0
B/D PA; MO
TETANUS,DIPHTHERIA TOX PED(PF)
2
$0
MO
TETANUS-DIPHTHERIA TOXOIDS-TD
2
$0
B/D PA; MO
TRUMENBA INTRAMUSCULAR SYRINGE
2
$0
90
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION
2
$0
B/D PA; MO
TWINRIX (PF) INTRAMUSCULAR
SYRINGE
2
$0
B/D PA; MO
TYPHIM VI INTRAMUSCULAR
SOLUTION
2
$0
TYPHIM VI INTRAMUSCULAR SYRINGE
2
$0
MO
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 25 UNIT/0.5 ML
2
$0
B/D PA; MO
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 50 UNIT/ML
2
$0
MO
VAQTA (PF) INTRAMUSCULAR SYRINGE
2
$0
VARIVAX (PF) SUBCUTANEOUS
2
$0
VARIZIG INTRAMUSCULAR SOLUTION
2
$0
YF-VAX (PF) SUBCUTANEOUS
2
$0
MO
ZOSTAVAX (PF) SUBCUTANEOUS
2
$0
allopurinol oral tablet
1
$0
MO
colchicine-probenecid oral tablet
1
$0
MO
COLCRYS ORAL TABLET
2
$0
MO
probenecid oral tablet
1
$0
MO
ULORIC ORAL TABLET
2
$0
MO
alendronate oral solution
1
$0
alendronate oral tablet 10 mg, 5 mg
1
$0
alendronate oral tablet 35 mg, 70 mg
1
$0
MO
MUSULOESQUELÉTICO /
REUMATOLOGÍA
TERAPIA DE GOTA
TERAPIA DE OSTEOPORÓSIS
91
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
FORTEO SUBCUTANEOUS PEN
INJECTOR
2
$0
ibandronate oral tablet
1
$0
PROLIA SUBCUTANEOUS SYRINGE
2
$0
B/D PA; MO
raloxifene oral tablet
1
$0
MO
risedronate oral tablet 150 mg, 35 mg, 5 mg
1
$0
MO
risedronate oral tablet 35 mg (12 pack)
1
$0
risedronate oral tablet,delayed release (dr/ec)
1
$0
MO
ACTEMRA INTRAVENOUS SOLUTION
200 MG/10 ML (20 MG/ML)
2
$0
B/D PA; ST; MO
BENLYSTA INTRAVENOUS RECON SOLN
120 MG
2
$0
B/D PA; MO
CUPRIMINE ORAL CAPSULE
2
$0
MO
DEPEN TITRATABS ORAL TABLET
2
$0
PA; MO
ENBREL SUBCUTANEOUS RECON SOLN
2
$0
ENBREL SUBCUTANEOUS SYRINGE 25
MG/0.5ML (0.51)
2
$0
ENBREL SUBCUTANEOUS SYRINGE 50
MG/ML (0.98 ML)
2
$0
ENBREL SURECLICK SUBCUTANEOUS
PEN INJECTOR
2
$0
HUMIRA CROHN'S DIS START PCK
SUBCUTANEOUS PEN INJECTOR KIT
2
$0
HUMIRA PED CROHN'S STARTER PK
SUBCUTANEOUS SYRINGE KIT
2
$0
HUMIRA SUBCUTANEOUS SYRINGE KIT
10 MG/0.2 ML
2
$0
20 MG/0.4 ML
2
$0
OTROS REUMATOLÓGICOS
92
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
40 MG/0.8 ML
2
$0
leflunomide oral tablet
1
$0
ORENCIA (WITH MALTOSE)
INTRAVENOUS RECON SOLN
2
$0
B/D PA; ST; MO
SAVELLA ORAL TABLET
2
$0
SAVELLA ORAL TABLETS,DOSE PACK
2
$0
camila oral tablet
1
$0
MO
COMBIPATCH TRANSDERMAL PATCH
SEMIWEEKLY
2
$0
MO
DELESTROGEN INTRAMUSCULAR OIL
10 MG/ML
2
$0
B/D PA; MO
DEPO-PROVERA INTRAMUSCULAR
SOLUTION
2
$0
B/D PA; MO
DEPO-SUBQ PROVERA 104
2
$0
MO
errin oral tablet
1
$0
MO
ESTRACE VAGINAL CREAM
2
$0
MO
estradiol oral tablet
1
$0
PA; MO
estradiol transdermal patch semiweekly
1
$0
MO
estradiol transdermal patch weekly
1
$0
MO
estradiol valerate intramuscular oil 20 mg/ml,
40 mg/ml
1
$0
B/D PA; MO
heather oral tablet
1
$0
MO
jencycla oral tablet
1
$0
MO
JINTELI ORAL TABLET
2
$0
MO
jolivette oral tablet
1
$0
MO
lyza oral tablet
1
$0
MO
OBSTETRICIA / GINECOLOGÍA
ESTRÓGENOS / PROGESTINA
93
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
medroxyprogesterone intramuscular
suspension
1
$0
medroxyprogesterone intramuscular syringe
1
$0
medroxyprogesterone oral tablet
1
$0
MO
norethindrone (contraceptive) oral tablet
1
$0
MO
norethindrone acetate oral tablet
1
$0
MO
PREMARIN INJECTION RECON SOLN
2
$0
B/D PA; MO
PREMARIN VAGINAL CREAM
2
$0
MO
progesterone micronized oral capsule
1
$0
MO
VAGIFEM VAGINAL TABLET
2
$0
MO
VIVELLE-DOT TRANSDERMAL PATCH
SEMIWEEKLY
2
$0
MO
3-day vaginal vaginal cream
4
$0
*
CLEOCIN VAGINAL SUPPOSITORY
2
$0
MO
clindamycin phosphate vaginal cream
1
$0
MO
clotrimazole 3 day vaginal cream
4
$0
MO; *
clotrimazole vaginal cream
4
$0
MO; *
clotrimazole-3 vaginal cream
4
$0
*
clotrimazole-7 vaginal cream
4
$0
*
metronidazole vaginal gel
1
$0
MO
miconazole 7 vaginal suppository
4
$0
MO; *; QL (7 per 30 days)
miconazole nitrate vaginal suppository
4
$0
*; QL (7 per 30 days)
miconazole-3 vaginal suppository
1
$0
NUVARING VAGINAL RING
2
$0
MO
terconazole vaginal cream
1
$0
MO
terconazole vaginal suppository
1
$0
tranexamic acid oral tablet
1
$0
MO
OG/GYN VARIOS
94
vandazole vaginal gel
NIVEL
1
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
$0
MO
ANTICONCEPTIVOS ORALES / AGENTES
RELACIONADOS
altavera (28) oral tablet
1
$0
MO
alyacen 1/35 (28) oral tablet
1
$0
MO
alyacen 7/7/7 (28) oral tablet
1
$0
MO
amethia lo oral tablets,dose pack,3 month
1
$0
MO
amethia oral tablets,dose pack,3 month
1
$0
MO
amethyst oral tablet
1
$0
MO
apri oral tablet
1
$0
MO
aranelle (28) oral tablet
1
$0
MO
ashlyna oral tablets,dose pack,3 month
1
$0
MO
aubra oral tablet
1
$0
MO
aviane oral tablet
1
$0
MO
azurette (28) oral tablet
1
$0
MO
balziva (28) oral tablet
1
$0
MO
briellyn oral tablet
1
$0
MO
camrese lo oral tablets,dose pack,3 month
1
$0
MO
camrese oral tablets,dose pack,3 month
1
$0
MO
caziant (28) oral tablet
1
$0
MO
chateal oral tablet
1
$0
MO
cryselle (28) oral tablet
1
$0
MO
cyclafem 1/35 (28) oral tablet
1
$0
MO
cyclafem 7/7/7 (28) oral tablet
1
$0
MO
dasetta 1/35 (28) oral tablet
1
$0
MO
dasetta 7/7/7 (28) oral tablet
1
$0
MO
daysee oral tablets,dose pack,3 month
1
$0
MO
elinest oral tablet
1
$0
MO
ELLA ORAL TABLET
2
$0
MO
95
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
emoquette oral tablet
1
$0
MO
enpresse oral tablet
1
$0
MO
enskyce oral tablet
1
$0
MO
estarylla oral tablet
1
$0
MO
falmina (28) oral tablet
1
$0
MO
gildess fe oral tablet
1
$0
MO
gildess oral tablet
1
$0
MO
introvale oral tablets,dose pack,3 month
1
$0
MO
jolessa oral tablets,dose pack,3 month
1
$0
MO
junel 1.5/30 (21) oral tablet
1
$0
MO
junel 1/20 (21) oral tablet
1
$0
MO
junel fe 1.5/30 (28) oral tablet
1
$0
MO
junel fe 1/20 (28) oral tablet
1
$0
MO
junel fe 24 oral tablet
1
$0
MO
kariva (28) oral tablet
1
$0
MO
kelnor 1/35 (28) oral tablet
1
$0
MO
kurvelo oral tablet
1
$0
MO
l norgest/e.estradiol-e.estrad oral tablets,dose
pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)
1
$0
MO
l norgest/e.estradiol-e.estrad oral tablets,dose
pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)
1
$0
lessina oral tablet
1
$0
MO
levonorgestrel oral tablet 1.5 mg
4
$0
*
levonorgestrel-ethinyl estrad oral tablet 0.1-20
mg-mcg, 0.15-0.03 mg
1
$0
MO
levonorgestrel-ethinyl estrad oral tablet 90-20
mcg
1
$0
levonorgestrel-ethinyl estrad oral tablets,dose
pack,3 month
1
$0
MO
96
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
levora-28 oral tablet
1
$0
MO
low-ogestrel (28) oral tablet
1
$0
MO
lutera (28) oral tablet
1
$0
MO
marlissa oral tablet
1
$0
MO
microgestin 1.5/30 (21) oral tablet
1
$0
MO
microgestin 1/20 (21) oral tablet
1
$0
MO
microgestin fe 1.5/30 (28) oral tablet
1
$0
MO
microgestin fe 1/20 (28) oral tablet
1
$0
MO
mono-linyah oral tablet
1
$0
MO
mononessa (28) oral tablet
1
$0
MO
myzilra oral tablet
1
$0
MO
necon 0.5/35 (28) oral tablet
1
$0
MO
necon 1/35 (28) oral tablet
1
$0
MO
necon 10/11 (28) oral tablet
1
$0
MO
necon 7/7/7 (28) oral tablet
1
$0
MO
NEXT CHOICE ONE DOSE ORAL TABLET
4
$0
*
norgestimate-ethinyl estradiol oral tablet
1
$0
MO
nortrel 0.5/35 (28) oral tablet
1
$0
MO
nortrel 1/35 (21) oral tablet
1
$0
MO
nortrel 1/35 (28) oral tablet
1
$0
MO
nortrel 7/7/7 (28) oral tablet
1
$0
MO
ogestrel (28) oral tablet
1
$0
MO
orsythia oral tablet
1
$0
MO
philith oral tablet
1
$0
MO
pirmella oral tablet
1
$0
MO
portia oral tablet
1
$0
MO
previfem oral tablet
1
$0
MO
quasense oral tablets,dose pack,3 month
1
$0
MO
reclipsen (28) oral tablet
1
$0
MO
97
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
sprintec (28) oral tablet
1
$0
MO
sronyx oral tablet
1
$0
MO
syeda oral tablet
1
$0
MO
tilia fe oral tablet
1
$0
MO
tri-estarylla oral tablet
1
$0
MO
tri-legest fe oral tablet
1
$0
MO
tri-linyah oral tablet
1
$0
MO
trinessa (28) oral tablet
1
$0
MO
tri-previfem (28) oral tablet
1
$0
MO
tri-sprintec (28) oral tablet
1
$0
MO
trivora (28) oral tablet
1
$0
MO
velivet triphasic regimen (28) oral tablet
1
$0
MO
vestura (28) oral tablet
1
$0
MO
viorele (28) oral tablet
1
$0
MO
wera (28) oral tablet
1
$0
MO
wymzya fe oral tablet,chewable
1
$0
MO
zarah oral tablet
1
$0
MO
zenchent (28) oral tablet
1
$0
MO
zenchent fe oral tablet,chewable
1
$0
MO
zeosa oral tablet,chewable
1
$0
MO
zovia 1/35e (28) oral tablet
1
$0
MO
zovia 1/50e (28) oral tablet
1
$0
MO
METHYLERGONOVINE INJECTION
SOLUTION
1
$0
B/D PA; MO
methylergonovine oral tablet
1
$0
MO
OXITOCINAS
OFTALMOLOGÍA
ANTIBIÓTICOS
98
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
AZASITE OPHTHALMIC DROPS
2
$0
MO
bacitracin ophthalmic ointment
1
$0
MO
bacitracin-polymyxin b ophthalmic ointment
1
$0
MO
CILOXAN OPHTHALMIC OINTMENT
2
$0
MO
ciprofloxacin hcl ophthalmic drops
1
$0
MO
erythromycin ophthalmic ointment
1
$0
MO
garamycin ophthalmic drops
1
$0
gatifloxacin ophthalmic drops
1
$0
MO
gentak ophthalmic ointment
1
$0
MO
gentamicin ophthalmic drops
1
$0
MO
gentamicin ophthalmic ointment
1
$0
MO
levofloxacin ophthalmic drops
1
$0
MO
NATACYN OPHTHALMIC
DROPS,SUSPENSION
2
$0
MO
neomycin-bacitracin-polymyxin ophthalmic
ointment
1
$0
MO
neomycin-polymyxin-gramicidin ophthalmic
drops
1
$0
MO
neo-polycin ophthalmic ointment
1
$0
ofloxacin ophthalmic drops
1
$0
polycin ophthalmic ointment
1
$0
polymyxin b sulf-trimethoprim ophthalmic
drops
1
$0
MO
tobramycin ophthalmic drops
1
$0
MO
TOBREX OPHTHALMIC OINTMENT
2
$0
MO
VIGAMOX OPHTHALMIC DROPS
2
$0
MO
trifluridine ophthalmic drops
1
$0
MO
ZIRGAN OPHTHALMIC GEL
2
$0
MO
MO
ANTIVIRALES
BETA-BLOQUEADORES
99
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
betaxolol ophthalmic drops
1
$0
MO
BETIMOL OPHTHALMIC DROPS 0.25 %
2
$0
MO
BETOPTIC S OPHTHALMIC
DROPS,SUSPENSION
2
$0
MO
carteolol ophthalmic drops
1
$0
MO
levobunolol ophthalmic drops 0.5 %
1
$0
MO
metipranolol ophthalmic drops
1
$0
MO
timolol maleate ophthalmic drops
1
$0
MO
timolol maleate ophthalmic gel forming
solution
1
$0
MO
2
$0
MO
cyclopentolate ophthalmic drops 1 %
1
$0
MO
cyclopentolate ophthalmic drops 2 %
1
$0
tropicamide ophthalmic drops
1
$0
MO
1
$0
MO
AKWA TEARS (POLYVINYL ALCOHOL)
OPHTHALMIC DROPS
4
$0
MO; *
AKWA TEARS OPHTHALMIC OINTMENT
4
$0
MO; *
altachlore ophthalmic drops
4
$0
*
altachlore ophthalmic ointment
4
$0
*
ARTIFICIAL TEARS (PETRO/MIN)
OPHTHALMIC OINTMENT
4
$0
MO; *
MIÓTICOS INHIBIDORES DE
COLINESTERASA
PHOSPHOLINE IODIDE OPHTHALMIC
DROPS
MIDRIASIS CICLOPÉGICA
MIÓTICOS DE ACCIÓN DIRECTA
pilocarpine hcl ophthalmic drops 1 %, 2 %, 4
%
OFTALMOLÓGICOS VARIOS
100
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ARTIFICIAL TEARS OPHTHALMIC
DROPS 0.5-0.6 %
4
$0
*
artificial tears(hypromellose) ophthalmic drops
4
$0
*
azelastine ophthalmic drops
1
$0
MO
cromolyn ophthalmic drops
1
$0
MO
epinastine ophthalmic drops
1
$0
MO
for sty relief ophthalmic ointment
4
$0
*
gonak ophthalmic drops
4
$0
*
goniosoft ophthalmic drops
4
$0
*
goniotaire ophthalmic drops
4
$0
*
goniovisc ophthalmic drops
4
$0
MO; *
LASTACAFT OPHTHALMIC DROPS
2
$0
MO
LUBRICANT EYE (PG-PEG 400)
OPHTHALMIC DROPS
4
$0
*
lubricant eye (polyv alcohol) ophthalmic drops
4
$0
*
lubricant eye ophthalmic ointment 56.8-41.5 %,
83-15 %
4
$0
*
LUBRICATING PLUS OPHTHALMIC
DROPPERETTE
4
$0
*
NATURAL BALANCE OPHTHALMIC
DROPS
4
$0
MO; *
PATADAY OPHTHALMIC DROPS
2
$0
ST; MO
polyvinyl alcohol ophthalmic drops
4
$0
*
pure & gentle eye ophthalmic drops
4
$0
*
RESTASIS OPHTHALMIC DROPPERETTE
2
$0
sochlor ophthalmic drops
4
$0
*
sochlor ophthalmic ointment
4
$0
*
sodium chloride ophthalmic drops
4
$0
MO; *
sodium chloride ophthalmic ointment
4
$0
MO; *
tears again ophthalmic drops
4
$0
MO; *
101
tears again ophthalmic ointment
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
4
$0
MO; *
bromfenac ophthalmic drops
1
$0
MO
diclofenac sodium ophthalmic drops
1
$0
MO
flurbiprofen sodium ophthalmic drops
1
$0
MO
ILEVRO OPHTHALMIC
DROPS,SUSPENSION
2
$0
MO
ketorolac ophthalmic drops
1
$0
MO
acetazolamide oral capsule, extended release
1
$0
MO
acetazolamide oral tablet
1
$0
MO
acetazolamide sodium injection recon soln
1
$0
MO
methazolamide oral tablet
1
$0
MO
AZOPT OPHTHALMIC
DROPS,SUSPENSION
2
$0
MO
COMBIGAN OPHTHALMIC DROPS
2
$0
MO
dorzolamide ophthalmic drops
1
$0
MO
dorzolamide-timolol ophthalmic drops
1
$0
MO
latanoprost ophthalmic drops
1
$0
MO
LUMIGAN OPHTHALMIC DROPS 0.01 %
2
$0
travoprost (benzalkonium) ophthalmic drops
1
$0
MO
1
$0
MO
AGENTES ANTIINFLAMATORIOS SIN
ESTEROIDES
MEDICAMENTOS ORALES PARA
GLAUCOMA
OTROS MEDICAMENTOS PARA
GLAUCOMA
COMBINACIONES ESTEROIDEANTIBIÓTICO
neomycin-bacitracin-poly-hc ophthalmic
ointment
102
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
neomycin-polymyxin b-dexameth ophthalmic
drops,suspension
1
$0
MO
neomycin-polymyxin b-dexameth ophthalmic
ointment
1
$0
MO
neomycin-polymyxin-hc ophthalmic
drops,suspension
1
$0
MO
neo-polycin hc ophthalmic ointment
1
$0
TOBRADEX ST OPHTHALMIC
DROPS,SUSPENSION
2
$0
MO
tobramycin-dexamethasone ophthalmic
drops,suspension
1
$0
MO
ALREX OPHTHALMIC
DROPS,SUSPENSION
2
$0
MO
dexamethasone sodium phosphate ophthalmic
drops
1
$0
MO
DUREZOL OPHTHALMIC DROPS
2
$0
MO
fluorometholone ophthalmic drops,suspension
1
$0
MO
FML S.O.P. OPHTHALMIC OINTMENT
2
$0
MO
prednisolone acetate ophthalmic
drops,suspension
1
$0
MO
prednisolone sodium phosphate ophthalmic
drops
1
$0
MO
BLEPHAMIDE S.O.P. OPHTHALMIC
OINTMENT
2
$0
MO
sulfacetamide-prednisolone ophthalmic drops
1
$0
MO
sulfacetamide sodium ophthalmic drops
1
$0
MO
sulfacetamide sodium ophthalmic ointment
1
$0
MO
ESTEROIDES
COMBINACIONES ESTEROIDESULFAMIDA
SULFAMIDAS
SIMPATICOMIMÉTICOS
103
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ALPHAGAN P OPHTHALMIC DROPS 0.1 %
2
$0
MO
apraclonidine ophthalmic drops
1
$0
MO
brimonidine ophthalmic drops
1
$0
MO
1
$0
MO
12 hour decongestant oral tablet extended
release
4
$0
*
adult cough formula dm max oral liquid
4
$0
*
adult tussin chest congestion oral liquid
4
$0
*
adult tussin cough congest dm oral liquid
4
$0
*
adult tussin dm oral syrup
4
$0
*
adult tussin multi-symp cold oral liquid
4
$0
*
ALAVERT D-12 ALLERGY-SINUS ORAL
TABLET EXTENDED RELEASE 12 HR
4
$0
aler-cap oral capsule
4
$0
*
ALL DAY ALLERGY (CETIRIZINE) ORAL
SOLUTION
4
$0
*
all day allergy (cetirizine) oral tablet
4
$0
all day allergy-d oral tablet extended release
12 hr
4
$0
allerclear d-12hr oral tablet extended release
12 hr
4
$0
allerclear oral tablet
4
$0
aller-ease oral tablet 180 mg
4
$0
aller-ease oral tablet 60 mg
4
$0
aller-fex oral tablet
4
$0
DESCONGESTIONANTES
VASOCONTRICTORES
naphazoline ophthalmic drops
RESPIRACIÓN Y ALERGIAS
AGENTES ANTIESTAMÍNICOS /
ANTIALÉRGICOS
104
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
allergy & congestion relief oral tablet extended
release 12 hr
4
$0
allergy (chlorpheniramine) oral tablet
4
$0
MO; *
allergy 4-hour oral tablet
4
$0
*
allergy complete-d oral tablet extended release
12 hr
4
$0
allergy d-12 oral tablet extended release 12 hr
4
$0
allergy medication oral capsule
4
$0
*
allergy medicine oral capsule
4
$0
*
allergy relief (cetirizine) oral tablet
4
$0
allergy relief (fexofenadine) oral tablet 180 mg
4
$0
allergy relief (fexofenadine) oral tablet 60 mg
4
$0
ALLERGY RELIEF (LORATADINE) ORAL
SOLUTION
4
$0
*
allergy relief (loratadine) oral tablet
4
$0
allergy relief (loratadine) oral
tablet,disintegrating
4
$0
allergy relief d12 oral tablet extended release
12 hr
4
$0
allergy relief(chlorpheniramn) oral tablet
4
$0
*
allergy relief(diphenhydramin) oral capsule
4
$0
*
allergy relief-d (cetirizine) oral tablet extended
release 12 hr
4
$0
allergy relief-d (loratadine) oral tablet
extended release 12 hr
4
$0
allergy-time oral tablet
4
$0
*
aller-tec d oral tablet extended release 12 hr
4
$0
aller-tec oral tablet
4
$0
allfen oral tablet
4
$0
*
ambi 60pse-400gfn oral tablet
4
$0
MO; *
ambi 60pse-4cpm oral tablet
4
$0
*
105
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
antitussive dm oral syrup
4
$0
*
APRODINE ORAL TABLET
4
$0
MO; *
benzonatate oral capsule 100 mg, 200 mg
3
$0
MO; *
biobron sf oral liquid
4
$0
*
biocotron oral liquid
4
$0
*
biogil oral liquid
4
$0
*
broncotron ped oral liquid
4
$0
*
BROTAPP DM ORAL ELIXIR
4
$0
*
BROTAPP ORAL LIQUID
4
$0
MO; *
cetiri-d oral tablet extended release 12 hr
4
$0
cetirizine oral solution 1 mg/ml
1
$0
MO
cetirizine oral tablet
4
$0
cetirizine oral tablet,chewable
4
$0
cetirizine-pseudoephedrine oral tablet extended
release 12 hr
4
$0
chest congestion relief d oral tablet
4
$0
*
CHEST CONGESTION RELIEF ORAL
TABLET
4
$0
*
CHEST CONGESTION RELIEF PE ORAL
TABLET
4
$0
*
chest-sinus congestion relief oral tablet
4
$0
*
child allergy relf(cetirizine) oral solution
4
$0
*
child chest congestion + cough oral liquid
4
$0
*
child delsym cough+chest dm oral liquid
4
$0
*
child mucinex chest congestion oral liquid
4
$0
*
CHILD MUCUS RELIEF COUGH ORAL
LIQUID
4
$0
*
CHILD MUCUS RELIEF EXPECTORANT
ORAL LIQUID
4
$0
*
106
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
children's allergy complete oral solution
4
$0
*
children's allergy relief(lor) oral solution
4
$0
*
children's allergy(cetirizine) oral solution
4
$0
*
children's aller-tec oral solution
4
$0
*
children's cetirizine oral solution
4
$0
*
children's cetirizine oral tablet,chewable
4
$0
children's chest congestion oral liquid
4
$0
*
CHILDREN'S COLD & COUGH DM ORAL
SOLUTION
4
$0
*
children's cold & cough oral solution
4
$0
*
children's cough oral liquid
4
$0
*
children's dibromm dm cold & c oral solution
4
$0
*
children's mucinex cough oral liquid
4
$0
*
CHILDREN'S SILFEDRINE ORAL LIQUID
4
$0
*
children's wal-zyr oral solution
4
$0
*
children's wal-zyr oral tablet,chewable
4
$0
child's all day allergy(cetir) oral solution
4
$0
*
chlorhist oral tablet
4
$0
*
chlorpheniramine maleate oral tablet
4
$0
*
chlortabs oral tablet
4
$0
*
CLARINEX ORAL SYRUP
2
$0
MO
clemastine oral syrup
1
$0
PA; MO
clemastine oral tablet 2.68 mg
1
$0
PA; MO
CODITUSS DM ORAL LIQUID
4
$0
MO; *
cold & cough dm oral solution
4
$0
*
cold & cough elixir oral solution
4
$0
*
COLD HEAD CONGESTION NIGHTTIME
ORAL TABLET
4
$0
*
cold multi-symptom (chlorphen) oral tablet
4
$0
*
107
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
complete allergy medicine oral capsule
4
$0
*
complete allergy oral capsule
4
$0
*
CONGESTAC ORAL TABLET
4
$0
*
cough & cold mucus relief cf oral liquid
4
$0
*
cough & cold oral liquid
4
$0
*
cough control (dextromethorph) oral capsule
4
$0
*
cough control (guaifenesin) oral liquid
4
$0
*
cough control cf (pe) oral liquid
4
$0
*
cough control dm max oral liquid
4
$0
*
cough control dm oral liquid
4
$0
*
cough control dm oral syrup
4
$0
*
cough formula dm oral syrup
4
$0
*
cough relief oral capsule
4
$0
*
COUGH SUPPRESSANT-EXPECTORANT
ORAL SYRUP
4
$0
*
cough syrup dm oral syrup
4
$0
*
COUGHTAB ORAL TABLET
4
$0
*
cyproheptadine oral syrup
1
$0
PA; MO
cyproheptadine oral tablet
1
$0
PA; MO
delsym cough+chest congest dm oral liquid
4
$0
*
desgen dm oral liquid 5-10-100 mg/5 ml
4
$0
*
desloratadine oral tablet
1
$0
MO
desloratadine oral tablet,disintegrating
1
$0
MO
despec-dm (phenyleph-dm-guaif) oral liquid 510-100 mg/5 ml
4
$0
*
diabetic siltussin das-na oral liquid
4
$0
*
diabetic siltussin-dm max str oral liquid
4
$0
*
diabetic siltussin-dm oral liquid
4
$0
*
diabetic tussin dm oral liquid 10-100 mg/5 ml
4
$0
MO; *
108
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
diabetic tussin dm oral liquid 10-200 mg/5 ml
4
$0
*
diabetic tussin ex oral liquid
4
$0
MO; *
diabetic tussin max st oral liquid
4
$0
MO; *
diabetic tussin mucus relief oral liquid
4
$0
*
diphedryl oral capsule
4
$0
*
diphenhydramine hcl injection solution 50
mg/ml
1
$0
B/D PA; MO
diphenhydramine hcl oral capsule
4
$0
MO; *
dm max oral liquid
4
$0
*
double-tussin dm oral liquid
4
$0
*
ENDACOF - DM ORAL SOLUTION
4
$0
*
endacon oral liquid
4
$0
*
epinephrine injection auto-injector 0.3 mg/0.3
ml (1:1,000)
1
$0
MO
epinephrine injection syringe 0.1 mg/ml
(1:10,000)
1
$0
B/D PA; MO
EPIPEN 2-PAK INJECTION AUTOINJECTOR
2
$0
EPIPEN JR 2-PAK INJECTION AUTOINJECTOR
2
$0
expectorant oral liquid
4
$0
*
fenesin ir oral tablet
4
$0
*
fenesin pe ir oral tablet
4
$0
*
fexofenadine oral tablet 180 mg
4
$0
fexofenadine oral tablet 60 mg
4
$0
geri-tussin oral liquid
4
$0
*
g-tron oral liquid
4
$0
*
guaiasorb dm oral liquid
4
$0
*
guaifenesin oral liquid
4
$0
*
guaifenesin oral tablet 200 mg
4
$0
MO; *
109
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
guaifenesin oral tablet extended release 12hr
4
$0
MO; *
guaifenesin-dm oral liquid
4
$0
*
hydroxyzine hcl intramuscular solution
1
$0
B/D PA; MO
intense cough reliever oral liquid 30-200 mg/5
ml
4
$0
*
KIDKARE COUGH/COLD ORAL LIQUID
4
$0
*
levocetirizine oral solution
1
$0
MO
levocetirizine oral tablet
1
$0
liquibid d-r oral tablet
4
$0
*
loradamed oral tablet
4
$0
loratadine oral solution
4
$0
MO; *
loratadine oral tablet
4
$0
loratadine oral tablet,disintegrating
4
$0
loratadine-d oral tablet extended release 12 hr
4
$0
maxiphen oral tablet
4
$0
MO; *
medifin expectorant mucus rlf oral liquid
4
$0
*
medi-phedrine oral tablet
4
$0
*
medi-phedrine oral tablet extended release
4
$0
*
medi-phedryl oral capsule
4
$0
*
medi-tussin dm diabetic oral liquid
4
$0
*
medi-tussin dm oral syrup
4
$0
*
medi-tussin oral liquid
4
$0
*
mucinex allergy oral tablet
4
$0
MUCINEX DM ORAL TABLET EXTENDED
RELEASE 12 HR
4
$0
MO; *
mucinex fast-max dm max oral liquid
4
$0
*
mucinex oral tablet extended release 12hr 600
mg
4
$0
MO; *
mucosa oral tablet
4
$0
*
110
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
mucus dm max oral tablet extended release 12
hr
4
$0
*
mucus dm oral tablet extended release 12 hr
4
$0
*
mucus relief chest oral tablet
4
$0
*
mucus relief cough oral liquid
4
$0
*
mucus relief d (phenylephrine) oral tablet
4
$0
*
mucus relief d (pseudoephed) oral tablet
4
$0
*
mucus relief er oral tablet extended release
12hr
4
$0
*
mucus relief oral tablet 200 mg
4
$0
*
mucus relief oral tablet 400 mg
4
$0
MO; *
multi-symptom cold night time oral tablet
4
$0
*
NASAL DECONGESTANT (PSEUDOEPH)
ORAL LIQUID
4
$0
*
NASAL DECONGESTANT (PSEUDOEPH)
ORAL TABLET
4
$0
*
nasal decongestant (pseudoeph) oral tablet
extended release
4
$0
*
neo-tuss oral liquid
4
$0
*
night time cold oral tablet
4
$0
*
organ-i nr oral tablet
4
$0
MO; *
pediatric cough & cold oral liquid 1-15-5 mg/5
ml
4
$0
*
pharbechlor oral tablet
4
$0
*
pharbedryl oral capsule
4
$0
*
pres gen oral liquid
4
$0
*
promethazine oral tablet
1
$0
PA; MO
pseudoephedrine hcl oral liquid
4
$0
MO; *
pseudoephedrine hcl oral tablet 30 mg
4
$0
MO; *
pseudoephedrine hcl oral tablet 60 mg
4
$0
*
111
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
pseudoephedrine hcl oral tablet extended
release
4
$0
MO; *
refenesen oral tablet
4
$0
*
refenesen pe oral tablet
4
$0
*
ri-tussin dm oral syrup
4
$0
*
ri-tussin oral liquid
4
$0
*
SCOT-TUSSIN DM ORAL LIQUID
4
$0
*
siltussin dm das oral liquid
4
$0
*
SILTUSSIN SA ORAL LIQUID
4
$0
MO; *
siltussin-dm oral syrup
4
$0
*
sinus & allergy non-drowsy oral tablet
extended release
4
$0
*
sinus 12 hour oral tablet extended release
4
$0
*
sorbugen nr oral liquid
4
$0
*
SUDOGEST SINUS & ALLERGY ORAL
TABLET
4
$0
*
suphedrin 12 hour oral tablet extended release
4
$0
*
suphedrin oral liquid
4
$0
*
suphedrin oral tablet
4
$0
*
suphedrine 12 hour oral tablet extended
release
4
$0
*
suphedrine oral tablet
4
$0
*
tusnel diabetic oral liquid
4
$0
*
tussin cf cough-cold oral liquid
4
$0
*
TUSSIN CF ORAL LIQUID
4
$0
MO; *
tussin chest congestion oral liquid
4
$0
*
tussin cough &chest congestion oral liquid
4
$0
*
tussin cough (dm only) oral capsule
4
$0
*
tussin cough dm oral liquid
4
$0
*
112
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
tussin dm clear oral syrup
4
$0
*
tussin dm cough & chest oral liquid
4
$0
*
tussin dm cough & chest oral syrup
4
$0
*
tussin dm cough oral syrup
4
$0
*
tussin dm max oral liquid
4
$0
*
tussin dm oral liquid
4
$0
*
TUSSIN DM ORAL SYRUP 10-100 MG/5
ML
4
$0
*
tussin expectorant oral liquid
4
$0
*
tussin honey oral liquid
4
$0
*
tussin oral liquid
4
$0
*
tussin oral tablet
4
$0
*
tussi-pres oral liquid
4
$0
*
valu-dryl allergy oral capsule
4
$0
*
valu-tapp oral liquid
4
$0
*
vicks qlearquil allergy oral tablet
4
$0
wal-dryl allergy oral capsule
4
$0
*
wal-fex allergy oral tablet 180 mg
4
$0
wal-itin oral tablet
4
$0
wal-zyr (cetirizine) oral tablet
4
$0
acetylcysteine solution
1
$0
B/D PA; MO
ADCIRCA ORAL TABLET
2
$0
ADEMPAS ORAL TABLET
2
$0
PA; MO; LA
ADVAIR DISKUS INHALATION BLISTER
WITH DEVICE
2
$0
ADVAIR HFA INHALATION HFA
AEROSOL INHALER
2
$0
AGENTES PULMONARES
113
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5
mg /3 ml (0.083 %)
1
$0
days)
albuterol sulfate inhalation solution for
nebulization 5 mg/ml
1
$0
days)
albuterol sulfate oral syrup
1
$0
MO
albuterol sulfate oral tablet
1
$0
MO
albuterol sulfate oral tablet extended release
12 hr
1
$0
MO
ANORO ELLIPTA INHALATION BLISTER
WITH DEVICE
2
$0
MO
ASMANEX HFA INHALATION HFA
AEROSOL INHALER
2
$0
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED
110 MCG (30 DOSES), 220 MCG (120
DOSES), 220 MCG (30 DOSES), 220 MCG
(60 DOSES)
2
$0
ASMANEX TWISTHALER INHALATION
110 MCG (7 DOSES), 220 MCG (14 DOSES)
2
$0
QL (2 per 30 days)
ATROVENT HFA INHALATION HFA
AEROSOL INHALER
2
$0
budesonide inhalation suspension for
nebulization 0.25 mg/2 ml, 0.5 mg/2 ml
1
$0
days)
budesonide nasal spray,non-aerosol
1
$0
MO
CINRYZE INTRAVENOUS RECON SOLN
2
$0
PA; MO
COMBIVENT RESPIMAT INHALATION
MIST
2
$0
cromolyn inhalation solution for nebulization
1
$0
days)
DALIRESP ORAL TABLET
2
$0
MO
114
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15
ML
2
$0
MO
ESBRIET ORAL CAPSULE
2
$0
PA; MO
FIRAZYR SUBCUTANEOUS SYRINGE
2
$0
PA; MO
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 50 MCG/ACTUATION
2
$0
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 250
MCG/ACTUATION
2
$0
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
2
$0
AEROSOL INHALER 220
MCG/ACTUATION
2
$0
AEROSOL INHALER 44 MCG/ACTUATION
2
$0
flunisolide nasal spray,non-aerosol 25 mcg
(0.025 %)
1
$0
fluticasone nasal spray,suspension
1
$0
FORADIL AEROLIZER INHALATION
CAPSULE, W/INHALATION DEVICE
2
$0
ipratropium bromide inhalation solution
1
$0
days)
ipratropium-albuterol inhalation solution for
nebulization
1
$0
days)
KALYDECO ORAL GRANULES IN
PACKET
2
$0
KALYDECO ORAL TABLET
2
$0
LETAIRIS ORAL TABLET
2
$0
levalbuterol hcl inhalation solution for
nebulization 0.31 mg/3 ml, 0.63 mg/3 ml
1
$0
B/D PA; MO
115
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
levalbuterol hcl inhalation solution for
nebulization 1.25 mg/0.5 ml
1
$0
days)
metaproterenol oral syrup
1
$0
MO
metaproterenol oral tablet
1
$0
MO
montelukast oral granules in packet
1
$0
MO
montelukast oral tablet
1
$0
MO
montelukast oral tablet,chewable
1
$0
MO
NASONEX NASAL SPRAY,NONAEROSOL
2
$0
OFEV ORAL CAPSULE
2
$0
OPSUMIT ORAL TABLET
2
$0
PA; MO; LA
PERFOROMIST INHALATION SOLUTION
FOR NEBULIZATION
2
$0
days)
PROAIR HFA INHALATION HFA
AEROSOL INHALER
2
$0
PROVENTIL HFA INHALATION HFA
AEROSOL INHALER
2
$0
PULMOZYME INHALATION SOLUTION
2
$0
B/D PA; MO
SEREVENT DISKUS INHALATION
BLISTER WITH DEVICE
2
$0
sildenafil oral tablet
1
$0
SYMBICORT INHALATION HFA
AEROSOL INHALER
2
$0
terbutaline oral tablet
1
$0
MO
terbutaline subcutaneous solution
1
$0
B/D PA; MO
theochron oral tablet extended release 12 hr
1
$0
theophylline oral solution
1
$0
theophylline oral tablet extended release
1
$0
MO
theophylline oral tablet extended release 12 hr
1
$0
MO
triamcinolone acetonide nasal aerosol,spray
1
$0
116
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
TUDORZA PRESSAIR INHALATION
400 MCG/ACTUATION
2
$0
MO
TUDORZA PRESSAIR INHALATION
400 MCG/ACTUATION (30 ACTUAT)
2
$0
VENTOLIN HFA INHALATION HFA
AEROSOL INHALER
2
$0
VERAMYST NASAL SPRAY,SUSPENSION
2
$0
XOLAIR SUBCUTANEOUS RECON SOLN
2
$0
PA; MO; QL (8.4 per 28 days)
zafirlukast oral tablet
1
$0
MO
flavoxate oral tablet
1
$0
MO
GELNIQUE TRANSDERMAL GEL IN
PACKET
2
$0
ST; MO
MYRBETRIQ ORAL TABLET EXTENDED
RELEASE 24 HR
2
$0
MO
oxybutynin chloride oral syrup
1
$0
MO
oxybutynin chloride oral tablet
1
$0
MO
oxybutynin chloride oral tablet extended
release 24hr
1
$0
MO
tolterodine oral capsule,extended release 24hr
1
$0
MO
tolterodine oral tablet
1
$0
MO
trospium oral capsule,extended release 24hr
1
$0
MO
trospium oral tablet
1
$0
MO
VESICARE ORAL TABLET
2
$0
MO
1
$0
MO
UROLÓGICOS
ANTICOLINÉRGICOS /
ANTIESPASMÓDICOS
TERAPIA DE HIPERPLASIA BENINGNA
DE PRÓSTATA
alfuzosin oral tablet extended release 24 hr
117
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
finasteride oral tablet 5 mg
1
$0
MO
tamsulosin oral capsule,extended release 24hr
1
$0
MO
1
$0
MO
CIALIS ORAL TABLET 2.5 MG, 5 MG
2
$0
CYSTAGON ORAL CAPSULE
2
$0
MO
ELMIRON ORAL CAPSULE
2
$0
MO
potassium citrate oral tablet extended release
10 meq (1,080 mg), 5 meq (540 mg)
1
$0
MO
alcalak oral tablet,chewable
4
$0
*
antacid ext str (calcium carb) oral
tablet,chewable
4
$0
*
ANTACID EXTRA-STRENGTH ORAL
TABLET,CHEWABLE
4
$0
*
antacid oral tablet,chewable 200 mg calcium
(500 mg)
4
$0
*
antacid ultra strength oral tablet,chewable 400
mg (1,000 mg)
4
$0
*
CALCITRATE ORAL TABLET
4
$0
MO; *
calcium 500 + d (d3) oral tablet
4
$0
*
calcium 500 + d oral tablet 500 mg(1,250mg) 200 unit
4
$0
MO; *
calcium 500 + d oral tablet 500 mg(1,250mg) 400 unit
4
$0
*
calcium 500 + d oral tablet,chewable
4
$0
MO; *
calcium 500 oral tablet
4
$0
*
ESTIMULANTES COLINÉRGICOS
bethanechol chloride oral tablet
UROLÓGICOS VARIOS
VITAMINAS, HEMATÍNICOS /
ELECTROLITOS
ELECTROLITOS
118
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
calcium 500 with d oral tablet
4
$0
MO; *
CALCIUM 600 + D(3) ORAL TABLET 600
MG(1,500MG) -200 UNIT, 600
MG(1,500MG) -400 UNIT
4
$0
MO; *
calcium 600 oral tablet
4
$0
*
calcium 600 with vitamin d3 oral tablet
4
$0
*
calcium 600 with vitamin d3 oral
tablet,chewable
4
$0
MO; *
calcium acetate oral capsule
1
$0
MO
calcium acetate oral tablet 667 mg
1
$0
MO
calcium antacid oral tablet,chewable 200 mg
calcium (500 mg)
4
$0
MO; *
CALCIUM ANTACID ORAL
TABLET,CHEWABLE 300 MG (750 MG)
4
$0
*
calcium antacid oral tablet,chewable 320 mg
(750 mg), 400 mg (1,000 mg)
4
$0
*
calcium antacid tropical oral tablet,chewable
4
$0
*
calcium carbonate oral tablet 500 mg calcium
(1,250 mg), 600 mg (1,500 mg)
4
$0
MO; *
calcium carbonate oral tablet,chewable 200 mg
calcium (500 mg), 400 mg (1,000 mg)
4
$0
*
calcium carbonate-vitamin d3 oral tablet 500
mg(1,250mg) -125 unit, 500 mg(1,250mg) -200
unit, 500mg (1,250mg) -600 unit
4
$0
*
calcium carbonate-vitamin d3 oral tablet 600
mg(1,500mg) -200 unit, 600 mg(1,500mg) -400
unit
4
$0
MO; *
calcium carbonate-vitamin d3 oral
tablet,chewable 500-100 mg-unit
4
$0
MO; *
calcium citrate + d oral tablet
4
$0
*
calcium citrate + oral tablet
4
$0
*
calcium citrate oral tablet 200 mg (950 mg)
4
$0
*
calcium citrate oral tablet 250 mg calcium
4
$0
MO; *
119
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
calcium citrate-vitamin d3 oral tablet 200-125
mg-unit
4
$0
*
calcium citrate-vitamin d3 oral tablet 315-200
mg-unit
4
$0
MO; *
calcium gluconate oral tablet 45 mg (500 mg)
4
$0
MO; *
calcium gluconate oral tablet 60 mg (650 mg)
4
$0
*
calcium with vitamin d oral tablet
4
$0
*
calcium+d oral tablet 500 mg(1,250mg) -200
unit
4
$0
*
CITRUS CALCIUM ORAL TABLET 200 MG
CALCIUM -250 UNIT
4
$0
*
CITRUS CALCIUM ORAL TABLET 315-250
MG-UNIT
4
$0
MO; *
dextrose-kcl-nacl intravenous solution
1
$0
B/D PA
eliphos oral tablet
1
$0
MO
flavor chews antacid oral tablet,chewable
4
$0
*
hi-cal plus vit d oral tablet
4
$0
*
high potency calcium oral tablet
4
$0
*
klor-con 10 oral tablet extended release
1
$0
MO
klor-con 8 oral tablet extended release
1
$0
MO
klor-con m15 oral tablet,er particles/crystals
1
$0
MO
klor-con m20 oral tablet,er particles/crystals
1
$0
MO
klor-con oral packet
1
$0
MO
k-tab oral tablet extended release 8 meq
1
$0
lactated ringers intravenous parenteral
solution
1
$0
MO
laxative dietary supplement oral tablet
4
$0
*
MAG 64 ORAL TABLET EXTENDED
RELEASE
4
$0
MO; *
magnesium oxide oral tablet
4
$0
MO; *
120
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
magnesium sulfate injection solution
1
$0
B/D PA; MO
magnesium sulfate injection syringe
1
$0
B/D PA
NORMOSOL-R IN 5 % DEXTROSE
2
$0
B/D PA
oral electrolytes oral solution
4
$0
*
ORALYTE ORAL SOLUTION
4
$0
*
oyster shell + d3 oral tablet
4
$0
*
oyster shell calcium 500 oral tablet
4
$0
MO; *
oyster shell calcium-vit d3 oral tablet 250-125
mg-unit
4
$0
MO; *
oystercal-d oral tablet
4
$0
*
PEDIALYTE ORAL SOLUTION
4
$0
MO; *
pedialyte singles oral solution
4
$0
*
pediatric electrolyte oral solution
4
$0
*
pediatric freezer pops oral solution
4
$0
*
potassium bicarb and chloride oral tablet,
effervescent
1
$0
MO
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 10 meq/l, 30 meq/l, 40
meq/l
1
$0
B/D PA
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 20 meq/l
1
$0
B/D PA; MO
potassium chloride in 0.9%nacl intravenous
parenteral solution 20 meq/l, 40 meq/l
1
$0
B/D PA
potassium chloride in 5 % dex intravenous
parenteral solution 20 meq/l, 30 meq/l, 40
meq/l
1
$0
B/D PA
potassium chloride in lr-d5 intravenous
1
$0
B/D PA; MO
potassium chloride intravenous piggyback 10
meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40
meq/100 ml
1
$0
121
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
potassium chloride intravenous solution
1
$0
MO
potassium chloride oral capsule, extended
release
1
$0
MO
potassium chloride oral liquid
1
$0
MO
potassium chloride oral tablet extended release
8 meq
1
$0
MO
potassium chloride oral tablet,er
particles/crystals
1
$0
MO
potassium chloride-0.45 % nacl intravenous
parenteral solution
1
$0
potassium chloride-d5-0.2%nacl intravenous
1
$0
B/D PA; MO
parenteral solution 30 meq/l, 40 meq/l
1
$0
B/D PA
1
$0
B/D PA
1
$0
B/D PA; MO
1
$0
B/D PA
ringers intravenous parenteral solution
1
$0
B/D PA
smooth antacid oral tablet,chewable
4
$0
*
sodium chloride 0.45 % intravenous parenteral
solution
1
$0
MO
sodium chloride 3 % intravenous parenteral
solution
1
$0
MO
sodium chloride 5 % intravenous parenteral
solution
1
$0
sodium chloride intravenous parenteral
solution
1
$0
sodium lactate intravenous solution
1
$0
super calcium oral tablet
4
$0
MO
*
122
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
TUMS ULTRA ORAL
TABLET,CHEWABLE 400 MG (1,000 MG)
4
$0
MO; *
ultra strength antacid oral tablet,chewable
4
$0
*
ultra strength calcium antacid oral
tablet,chewable
4
$0
*
amino acids 15 % intravenous parenteral
solution
1
$0
B/D PA
AMINOSYN 10 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
AMINOSYN 8.5 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
AMINOSYN 8.5 %-ELECTROLYTES
2
$0
B/D PA
AMINOSYN II 10 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
PARENTERAL SOLUTION
2
$0
B/D PA
PARENTERAL SOLUTION
2
$0
B/D PA
AMINOSYN II 8.5 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
AMINOSYN II 8.5 %-ELECTROLYTES
2
$0
B/D PA
AMINOSYN M 3.5 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
AMINOSYN-HBC 7% INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
AMINOSYN-PF 10 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
AMINOSYN-PF 7 % (SULFITE-FREE)
2
$0
B/D PA
PRODUCTOS VARIOS DE NUTRICIÓN
123
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
AMINOSYN-RF 5.2 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
CLINIMIX 5%/D15W SULFITE FREE
2
$0
B/D PA
CLINIMIX 5%/D25W SULFITE-FREE
2
$0
B/D PA
CLINIMIX 2.75%/D5W SULFIT FREE
2
$0
B/D PA
CLINIMIX 4.25%/D10W SULF FREE
2
$0
B/D PA
CLINIMIX 4.25%-D20W SULF-FREE
2
$0
B/D PA
CLINIMIX 4.25%-D25W SULF-FREE
2
$0
B/D PA
CLINIMIX 5%-D20W(SULFITE-FREE)
2
$0
B/D PA
2
$0
B/D PA
2
$0
B/D PA
CLINIMIX E 4.25%/D5W SULF FREE
2
$0
B/D PA
CLINIMIX E 5%/D15W SULFIT FREE
2
$0
B/D PA
2
$0
B/D PA
2
$0
B/D PA
electrolyte-48 in d5w intravenous parenteral
solution
1
$0
B/D PA
HEPATAMINE 8% INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
124
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
INTRALIPID INTRAVENOUS EMULSION
20 %
2
$0
B/D PA; MO
INTRALIPID INTRAVENOUS EMULSION
30 %
2
$0
B/D PA
IONOSOL-B IN D5W INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
IONOSOL-MB IN D5W INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
ISOLYTE-P IN 5 % DEXTROSE
2
$0
ISOLYTE-S INTRAVENOUS PARENTERAL
SOLUTION
2
$0
liposyn iii intravenous emulsion 10 %
1
$0
B/D PA
liposyn iii intravenous emulsion 20 %
1
$0
B/D PA; MO
NEPHRAMINE 5.4 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
NORMOSOL-M IN 5 % DEXTROSE
2
$0
B/D PA
NORMOSOL-R PH 7.4 INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
PLASMA-LYTE 148 INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
PLASMA-LYTE A INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
PLASMA-LYTE-56 IN 5 % DEXTROSE
2
$0
B/D PA
PREMASOL 10 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA; MO
PREMASOL 6 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
PROCALAMINE 3% INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
125
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
PROSOL 20 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA; MO
TRAVASOL 10 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA; MO
TROPHAMINE 10 % INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA; MO
TROPHAMINE 6% INTRAVENOUS
PARENTERAL SOLUTION
2
$0
B/D PA
a thru z advanced formula oral tablet
4
$0
*
a thru z select 50+ formula oral tablet
4
$0
*
a thru z select oral tablet 500-300-250 mcg
4
$0
*
abc plus oral tablet
4
$0
MO; *
animal chews oral tablet,chewable
4
$0
*
animal shapes complete oral tablet,chewable
4
$0
*
AQUASOL E ORAL DROPS
4
$0
MO; *
ascorbic acid oral tablet 250 mg, 500 mg
4
$0
*
ascorbic acid oral tablet,chewable
4
$0
*
ascorbic acid with rose hips oral tablet
4
$0
*
b complex-vitamin c-folic acid oral tablet
4
$0
MO; *
BALANCED B-100 ORAL TABLET 100 MG
4
$0
*
b-complex with vitamin c oral tablet
4
$0
MO; *
beta carotene oral capsule
4
$0
MO; *
biotin oral capsule 2,500 mcg, 5 mg
4
$0
MO; *
biotin oral tablet 1 mg, 300 mcg
4
$0
MO; *
biotin oral tablet 800 mcg
4
$0
*
c-1000 oral tablet
4
$0
*
c-1000 with rose hips oral tablet
4
$0
*
c-250 oral tablet
4
$0
*
VITAMINAS / HEMATÍNICOS
126
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
c-500 oral tablet
4
$0
*
c-500 oral tablet,chewable
4
$0
*
CALCIDOL ORAL DROPS
4
$0
*
centamin oral liquid
4
$0
*
central vite with lutein oral tablet
4
$0
*
central-vite oral tablet 18-400 mg-mcg
4
$0
*
central-vite senior oral tablet
4
$0
*
central-vite with lycopene oral tablet
4
$0
*
central-vite women's under 50 oral tablet
4
$0
*
century adults 50+ oral tablet
4
$0
*
century mature oral tablet 0.4-300-250 mgmcg-mcg, 500-300-250 mcg
4
$0
*
century oral tablet 18-400 mg-mcg
4
$0
*
century ultimate women's oral tablet 18-400
mg-mcg
4
$0
*
CEROVITE ADVANCED FORMULA ORAL
TABLET
4
$0
MO; *
CEROVITE ORAL LIQUID
4
$0
MO; *
CERTAVITE SENIOR-ANTIOXIDANT
ORAL TABLET
4
$0
MO; *
chewable multi vitamin oral tablet,chewable
4
$0
*
child vitamin with minerals oral
tablet,chewable
4
$0
*
children's chewable complete oral
tablet,chewable
4
$0
*
children's chewable oral tablet,chewable
4
$0
*
children's chewable vitamin oral
tablet,chewable
4
$0
*
children's chewable w/minerals oral
tablet,chewable
4
$0
*
children's iron oral drops
4
$0
*
127
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
children's multivit w/extra c oral
tablet,chewable
4
$0
*
children's vitamin with iron oral
tablet,chewable
4
$0
*
CHILD'S CHEWABLE VITAMINS/IRON
ORAL TABLET,CHEWABLE
4
$0
*
child's vitamin with iron oral tablet,chewable
4
$0
*
child's vitamin with vitamin c oral
tablet,chewable
4
$0
*
cholecalciferol (vitamin d3) oral capsule 1,000
unit, 5,000 unit, 50,000 unit
4
$0
MO; *
cholecalciferol (vitamin d3) oral capsule
10,000 unit, 2,000 unit, 400 unit
4
$0
*
complete 50+ oral tablet
4
$0
*
complete multi 50+ oral tablet
4
$0
*
complete multivitamin oral tablet
4
$0
*
complete multivitamin-mineral oral tablet
4
$0
*
complete senior oral tablet 0.4-300-250 mgmcg-mcg
4
$0
MO; *
cyanocobalamin (vitamin b-12) injection
solution
3
$0
MO; *
D-2000 ORAL CAPSULE
4
$0
MO; *
daily multiple oral tablet 18-400 mg-mcg
4
$0
*
daily multivitamin with iron oral tablet
4
$0
*
daily vitamin formula + iron oral tablet
4
$0
*
dialyvite 800 oral tablet
4
$0
MO; *
dialyvite vitamin d oral capsule
4
$0
MO; *
dino-life oral tablet,chewable
4
$0
*
dino-life with extra c oral tablet,chewable
4
$0
*
dino-life with iron-zinc oral tablet,chewable
4
$0
*
128
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
ELDERTONIC ORAL ELIXIR
4
$0
MO; *
ergocalciferol (vitamin d2) oral capsule
3
$0
MO; *
ergocalciferol (vitamin d2) oral drops
4
$0
MO; *
essentia oral tablet
4
$0
*
ezfe 200 oral capsule
4
$0
MO; *
FERATE ORAL TABLET 240 MG (27 MG
IRON)
4
$0
MO; *
FER-IRON ORAL DROPS
4
$0
*
FERREX 150 ORAL CAPSULE
4
$0
MO; *
ferrous gluconate oral tablet 236 mg (27 mg
iron), 256 mg (28 mg iron)
4
$0
*
ferrous gluconate oral tablet 240 mg (27 mg
iron), 324 mg (36 mg iron), 324 mg (38 mg
iron), 325 mg (36 mg iron)
4
$0
MO; *
ferrous sulfate oral drops
4
$0
MO; *
ferrous sulfate oral liquid
4
$0
MO; *
ferrous sulfate oral solution
4
$0
MO; *
ferrous sulfate oral tablet,delayed release
(dr/ec)
4
$0
MO; *
fluoritab oral tablet,chewable 0.5 mg fluoride
(1.1 mg)
1
$0
MO
folic acid oral tablet 1 mg
3
$0
MO; *
folic acid oral tablet 400 mcg, 800 mcg
4
$0
MO; *
fruit c oral tablet,chewable
4
$0
*
fruit c-500 oral tablet,chewable
4
$0
*
full spectrum b-vitamin c oral tablet
4
$0
*
GERIATON ORAL LIQUID
4
$0
*
gummi bear multivitamin oral tablet,chewable
4
$0
*
gummy swirls oral tablet,chewable
4
$0
*
honey bears oral tablet,chewable
4
$0
*
129
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
honey bears with iron-zinc oral tablet,chewable
4
$0
*
hydroxocobalamin intramuscular solution
3
$0
MO; *
iferex 150 oral capsule
4
$0
MO; *
iron high potency oral tablet
4
$0
*
kid's vitamins + extra c oral tablet,chewable
4
$0
*
kid's vitamins + iron oral tablet,chewable
4
$0
*
kid's vitamins oral tablet,chewable
4
$0
*
little animals oral tablet,chewable
4
$0
*
little animals-iron oral tablet,chewable
4
$0
*
lumitene oral capsule
4
$0
*
lysiplex plus oral liquid
4
$0
MO; *
multi complete with iron oral tablet
4
$0
*
multi-day with iron oral tablet
4
$0
*
MULTI-DELYN ORAL LIQUID
4
$0
MO; *
MULTI-DELYN WITH IRON ORAL LIQUID
4
$0
*
multivital platinum oral tablet 500-300-250
mcg
4
$0
*
multivitamin with minerals oral liquid
4
$0
*
multi-vite oral tablet
4
$0
*
myferon 150 oral capsule
4
$0
MO; *
NEPHRONEX ORAL LIQUID
4
$0
*
one daily multivitamin-iron oral tablet
4
$0
*
one daily plus iron oral tablet 18-400 mg-mcg
4
$0
*
one daily women's health oral tablet
4
$0
*
one daily women's oral tablet 18 mg iron-400
mcg-450 mg ca
4
$0
*
one-a-day teen advantage oral tablet
4
$0
*
pantothenic acid oral tablet
4
$0
MO; *
POLY-IRON ORAL CAPSULE
4
$0
MO; *
130
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
POLY-VITAMIN ORAL DROPS
4
$0
*
POLY-VITAMIN WITH IRON ORAL
DROPS 1,500 UNIT-400 UNIT-10 MG/ML
4
$0
*
POLYVITAMIN/IRON ORAL
TABLET,CHEWABLE
4
$0
*
POLY-VITAMINS ORAL
TABLET,CHEWABLE
4
$0
*
prenatal vitamin oral tablet
1
$0
PROSIGHT ORAL TABLET
4
$0
*
pyridoxine injection solution
3
$0
MO; *
pyridoxine oral tablet 100 mg, 25 mg, 50 mg
4
$0
*
pyridoxine oral tablet 250 mg
4
$0
MO; *
RENA-VITE ORAL TABLET
4
$0
MO; *
sentry oral tablet 18-400 mg-mcg
4
$0
*
sentry senior oral tablet
4
$0
*
sodium fluoride oral tablet
1
$0
soothing pureway-c oral tablet
4
$0
*
spectravite adult 50+ oral tablet
4
$0
*
spectravite advanced formula oral tablet
4
$0
*
spectravite senior oral tablet 500-300-250 mcg
4
$0
*
spectravite ultra women oral tablet
4
$0
*
stress 500 oral tablet
4
$0
*
stress formula 600 c oral tablet
4
$0
*
STRESS FORMULA ORAL TABLET
4
$0
*
STRESS FORMULA WITH IRON ORAL
TABLET
4
$0
MO; *
super b complex-vitamin c oral tablet
4
$0
*
super b-50 complex oral capsule
4
$0
*
THERA VITAMIN ORAL TABLET
4
$0
MO; *
THERA-M ORAL TABLET
4
$0
*
131
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
THERA-M ORAL TABLET 9 MG IRON-400
MCG
4
$0
MO; *
therapeutic-m oral tablet 9 mg iron-400 mcg
4
$0
*
thera-tabs m oral tablet
4
$0
*
thiamine hcl injection solution
3
$0
MO; *
thiamine hcl oral tablet 100 mg, 50 mg
4
$0
*
thiamine hcl oral tablet 250 mg
4
$0
MO; *
TRI-VITA ORAL DROPS
4
$0
*
TRI-VITAMIN ORAL DROPS
4
$0
MO; *
vitacel (with lutein) oral tablet
4
$0
MO; *
vitalets oral tablet,chewable
4
$0
*
vitamin a oral capsule 10,000 unit
4
$0
MO; *
vitamin a oral capsule 25,000 unit, 8,000 unit
4
$0
*
vitamin b complex oral capsule
4
$0
*
VITAMIN B-1 ORAL TABLET
4
$0
MO; *
VITAMIN B-12 ORAL TABLET 1,000 MCG,
500 MCG
4
$0
MO; *
VITAMIN B-6 ORAL TABLET 100 MG, 25
MG, 50 MG
4
$0
MO; *
vitamin b-6 oral tablet 200 mg, 250 mg
4
$0
*
vitamin c oral tablet 1,000 mg, 250 mg
4
$0
MO; *
vitamin c oral tablet 100 mg
4
$0
*
VITAMIN C ORAL TABLET,CHEWABLE
500 MG
4
$0
MO; *
vitamin c with rose hips oral tablet
4
$0
MO; *
VITAMIN D2 ORAL CAPSULE
3
$0
MO; *
vitamin d3 oral capsule 1,000 unit, 2,000 unit,
400 unit
4
$0
MO; *
vitamin e (dl, acetate) oral capsule 400 unit
4
$0
MO; *
132
NIVEL
CUÁNTO LE
COSTARÁ EL
RESTRICCIONES O
vitamin e oral capsule 100 unit, 200 unit, 400
unit
4
$0
MO; *
VITAMINS B COMPLEX ORAL CAPSULE
4
$0
MO; *
yelets oral tablet
4
$0
*
zoo chews oral tablet,chewable
4
$0
*
133
Índice
1
12 hour decongestant .......... 104
12 HOUR NASAL SPRAY . 66
3
3-day vaginal ........................ 94
A
a thru z advanced formula .. 126
a thru z select ...................... 126
a thru z select 50+ formula . 126
abacavir .................................. 2
abacavir-lamivudinezidovudine .......................... 3
abc plus ............................... 126
ABELCET .............................. 2
ABILIFY .............................. 39
ABILIFY DISCMELT ......... 38
ABILIFY MAINTENA ........ 39
ABRAXANE ........................ 16
ABREVA ............................. 60
acamprosate .......................... 63
acarbose ................................ 69
acebutolol ............................. 46
ACEPHEN ........................... 32
acetadryl ............................... 32
acetaminophen ...................... 33
acetaminophen extra strength
.......................................... 32
acetaminophen pm................ 33
acetaminophen pm extra str.. 33
acetaminophen-codeine ........ 29
acetasol hc ............................ 67
acetazolamide ..................... 102
acetazolamide sodium ........ 102
acetic acid ............................. 67
acetylcysteine ..................... 113
acid control (ranitidine) ........ 85
acid controller ....................... 85
ACID GONE ANTACID ..... 76
acid reducer (famotidine) ..... 85
acid reducer (ranitidine) ....... 85
acitretin ................................. 55
ACITRETIN ......................... 55
ACTEMRA .......................... 92
ACTHAR H.P. ..................... 68
ACTHIB (PF) ....................... 88
ACTIMMUNE ..................... 86
ACTOPLUS MET XR ......... 69
acyclovir ........................... 3, 60
acyclovir sodium .................... 3
ADACEL(TDAP
ADOLESN/ADULT)(PF) 88
ADAGEN ............................. 63
adapalene .............................. 56
ADCIRCA .......................... 113
added strength headache relief
.......................................... 33
ADDED STRENGTH PAIN
RELIEVER ....................... 33
ADEFOVIR ............................ 3
ADEMPAS ......................... 113
adrucil ................................... 16
adult cough formula dm max
........................................ 104
adult low dose aspirin ........... 33
adult tussin chest congestion
........................................ 104
adult tussin cough congest dm
........................................ 104
adult tussin dm.................... 104
adult tussin multi-symp cold
........................................ 104
ADVAIR DISKUS ............. 113
ADVAIR HFA ................... 113
ADVANCED ANTACIDANTIGAS ........................ 76
afeditab cr ............................. 46
AFINITOR ........................... 16
AFINITOR DISPERZ .......... 16
afrin no drip(oxymetazolin).. 66
AGGRENOX........................ 51
A-HYDROCORT ................. 68
AKWA TEARS .................. 100
AKWA TEARS
(POLYVINYL ALCOHOL)
........................................100
ala-cort ..................................60
ALAVERT D-12 ALLERGYSINUS.............................104
ALBENZA .............................9
albuterol sulfate ..................114
alcalak .................................118
alclometasone .......................60
ALCOHOL PADS ................69
ALDURAZYME ..................73
alendronate .....................63, 91
aler-cap ............................... 104
alfuzosin .............................117
ALIMTA...............................16
ALINIA ..................................9
all day allergy (cetirizine) ...104
ALL DAY ALLERGY
(CETIRIZINE) ...............104
all day allergy-d ..................104
allerclear .............................104
allerclear d-12hr..................104
aller-ease .............................104
aller-fex............................... 104
allergy & congestion relief .105
allergy (chlorpheniramine) .105
allergy 4-hour .....................105
allergy complete-d ..............105
allergy d-12 .........................105
allergy medication ..............105
allergy medicine .................105
allergy relief (cetirizine) .....105
allergy relief (fexofenadine)
........................................105
allergy relief (loratadine) ....105
ALLERGY RELIEF
(LORATADINE) ............105
allergy relief d12.................105
allergy relief(chlorpheniramn)
........................................105
134
allergy relief(diphenhydramin)
........................................ 105
allergy relief-d (cetirizine) . 105
allergy relief-d (loratadine) 105
allergy-time ........................ 105
aller-tec ............................... 105
aller-tec d ............................ 105
allfen ................................... 105
allopurinol ............................ 91
ALMACONE ....................... 76
ALMACONE-2 .................... 76
alophen ................................. 76
ALPHAGAN P ................... 104
alprazolam ............................ 39
ALREX............................... 103
altachlore ............................ 100
altamist ................................. 66
altavera (28).......................... 95
aluminum hydroxide gel....... 76
alyacen 1/35 (28) .................. 95
alyacen 7/7/7 (28) ................. 95
amantadine hcl........................ 3
ambi 60pse-400gfn ............. 105
ambi 60pse-4cpm ............... 105
AMBISOME .......................... 2
amcinonide ........................... 60
amethia ................................. 95
amethia lo ............................. 95
amethyst ............................... 95
AMIFOSTINE
CRYSTALLINE............... 15
amikacin ................................. 9
amiloride............................... 46
amiloride-hydrochlorothiazide
.......................................... 46
amino acids 15 % ............... 123
AMINOSYN 10 % ............. 123
AMINOSYN 8.5 % ............ 123
AMINOSYN 8.5 %ELECTROLYTES ......... 123
AMINOSYN II 10 % ......... 123
AMINOSYN II 15 % ......... 123
AMINOSYN II 7 % ........... 123
AMINOSYN II 8.5 % ........ 123
AMINOSYN II 8.5 %antacid liquid ........................77
ELECTROLYTES.......... 123
antacid maximum strength ...77
AMINOSYN M 3.5 %........ 123
antacid plus anti-gas .............77
AMINOSYN-HBC 7%....... 123
antacid regular strength ........77
AMINOSYN-PF 10 % ....... 123
ANTACID TABLET ............77
AMINOSYN-PF 7 %
antacid ultra strength ....77, 118
(SULFITE-FREE) .......... 123
antacid with simethicone ......77
AMINOSYN-RF 5.2 % ...... 124
antacid-antigas ......................77
amiodarone ........................... 45
antacid-simethicone ds .........77
AMITIZA ............................. 76
anti-diarrhea ..........................75
amitriptyline ......................... 39
anti-diarrheal.........................75
amlodipine ............................ 46
ANTI-DIARRHEAL
amlodipine-atorvastatin ........ 53
(LOPERAMIDE) ..............75
amlodipine-benazepril .......... 46
antifungal (tolnaftate) ...........58
amlodipine-valsartan ............ 46
ANTIFUNGAL
amlodipine-valsartan-hcthiazid
(TOLNAFTATE) .............58
.......................................... 46
antitussive dm .....................106
ammonium lactate ................ 55
APOKYN .............................26
amnesteem ............................ 56
apraclonidine ......................104
amoxapine ............................ 39
apri ........................................95
amoxicil-clarithromy-lansopraz
APRISO ................................ 77
.......................................... 85
APRODINE ........................106
amoxicillin ............................ 12
APTIOM ...............................23
amoxicillin-pot clavulanate .. 12
APTIVUS ...............................3
amphetamine salt combo ...... 39
AQUASOL E......................126
amphotericin b ........................ 2
ARALAST NP......................63
ampicillin .............................. 12
aranelle (28) ..........................95
ampicillin sodium ................. 12
ARCALYST .........................86
ampicillin-sulbactam ............ 12
aripiprazole ...........................39
AMPYRA ............................. 27
ARIPIPRAZOLE ..................39
anagrelide ............................. 63
ARTIFICIAL TEARS ........101
anastrozole ............................ 16
ARTIFICIAL TEARS
ANDROGEL ........................ 73
(PETRO/MIN) ................100
ANDROID............................ 73
artificial tears(hypromellose)
animal chews ...................... 126
........................................101
animal shapes complete ...... 126
ascorbic acid .......................126
ANORO ELLIPTA............. 114
ascorbic acid with rose hips 126
antacid .......................... 77, 118
ashlyna ..................................95
antacid anti-gas ..................... 77
ASMANEX HFA ...............114
antacid anti-gas double str .... 76
ASMANEX TWISTHALER
antacid ext str (calcium carb)
........................................114
........................................ 118
aspir-81 .................................33
antacid extra-strength ........... 77
aspirin ...................................33
ANTACID EXTRAaspirin childrens....................33
STRENGTH ................... 118
aspirin low dose ....................33
135
aspirin low-strength .............. 33
baclofen ................................ 28
bisoprolol fumarate ...............46
aspirin, buffered ................... 33
BALANCED B-100 ........... 126
bisoprolol-hydrochlorothiazide
aspir-trin ............................... 33
balsalazide ............................ 77
..........................................46
ASTAGRAF XL .................. 16
balziva (28) ........................... 95
bleomycin .............................16
atenolol ................................. 46
BANZEL .............................. 23
BLEPHAMIDE S.O.P. .......103
atenolol-chlorthalidone......... 46
BARACLUDE........................ 3
BOOSTRIX TDAP ...............88
athenol .................................. 33
bayer advanced ..................... 33
BOSULIF .............................16
athlete's foot (terbinafine) .... 58
bayer aspirin ......................... 33
briellyn ..................................95
athlete's foot (tolnaftate) ....... 58
baza antifungal ..................... 58
BRILINTA ...........................51
athlete's foot af ..................... 58
BCG VACCINE, LIVE (PF) 88
brimonidine.........................104
atorvastatin ........................... 53
b-complex with vitamin c ... 126
BRINTELLIX .......................39
ATOVAQUONE .................... 9
BELEODAQ ........................ 16
BRISDELLE.........................39
atovaquone-proguanil ............. 9
benazepril ............................. 46
bromfenac ...........................102
ATRIPLA ............................... 3
benazepril-hydrochlorothiazide
bromocriptine .......................26
atropine ................................. 75
.......................................... 46
broncotron ped ....................106
ATROVENT HFA ............. 114
BENICAR ............................ 46
BROTAPP ..........................106
aubra ..................................... 95
BENICAR HCT ................... 46
BROTAPP DM ...................106
AVASTIN ............................ 16
BENLYSTA ......................... 92
budesonide ..........................114
AVELOX IN NACL (ISObenzonatate ......................... 106
BUDESONIDE.....................77
OSMOTIC)....................... 13
benzoyl peroxide .................. 56
bufferin .................................33
aviane ................................... 95
benztropine ........................... 26
bumetanide ...........................46
AVONEX ............................. 86
beta carotene ....................... 126
buprenorphine hcl .................29
AVONEX (WITH ALBUMIN)
beta-hc .................................. 60
buprenorphine-naloxone .......34
.......................................... 86
betamethasone dipropionate . 60
buproban ...............................65
AYR SALINE ...................... 66
betamethasone valerate......... 60
bupropion hcl ........................39
AZACITIDINE .................... 16
betamethasone, augmented ... 60
buspirone ..............................39
AZASAN.............................. 16
betaxolol ....................... 46, 100
BUSULFEX .........................16
AZASITE ............................. 99
bethanechol chloride........... 118
butalbital-acetaminop-caf-cod
azathioprine .......................... 16
BETIMOL .......................... 100
..........................................29
azelastine ...................... 66, 101
BETOPTIC S ...................... 100
butorphanol tartrate ..............34
AZILECT ............................. 26
BEXSERO (PF) .................... 88
BYDUREON ........................69
azithromycin ........................... 8
bicalutamide ......................... 16
BYETTA ..............................69
AZOPT ............................... 102
BICILLIN C-R ..................... 12
BYSTOLIC...........................46
AZOR ................................... 46
BICILLIN L-A ..................... 13
C
aztreonam ............................... 9
BICNU.................................. 16
c-1000 .................................126
azurette (28).......................... 95
biobron sf............................ 106
c-1000 with rose hips..........126
biocotron ............................. 106
c-250 ...................................126
B
b complex-vitamin c-folic acid
biogil ................................... 106
c-500 ...................................127
........................................ 126
biotin................................... 126
cabergoline ...........................73
baciim ..................................... 9
bisacodyl ............................... 77
CALCIDOL ........................127
bacitracin .................... 9, 58, 99
bisa-lax ................................. 77
calcipotriene .........................55
bacitracin zinc ...................... 58
BISMATROL ....................... 75
calcitonin (salmon) ...............73
bacitracin-polymyxin b ........ 99
bismuth ................................. 75
CALCITRATE ...................118
bacitraycin plus .................... 58
bismuth maximum strength .. 75
calcitrene...............................55
136
calcitriol .......................... 55, 73
carteolol .............................. 100
CERTAVITE SENIORcalcium 500 ........................ 118
cartia xt ................................. 47
ANTIOXIDANT ............127
calcium 500 + d .................. 118
carvedilol .............................. 47
CERVARIX VACCINE (PF)
calcium 500 + d (d3) .......... 118
CAYSTON ............................. 9
..........................................88
calcium 500 with d ............. 119
caziant (28) ........................... 95
cetiri-d.................................106
calcium 600 ........................ 119
cefaclor ................................... 6
cetirizine .............................106
CALCIUM 600 + D(3) ....... 119
cefadroxil ................................ 6
cetirizine-pseudoephedrine .106
calcium 600 with vitamin d3
cefazolin ................................. 7
cevimeline.............................63
........................................ 119
cefazolin in dextrose (iso-os) . 6
CHANTIX ............................66
calcium acetate ................... 119
cefdinir.................................... 7
CHANTIX CONTINUING
calcium antacid ................... 119
cefditoren pivoxil ................... 7
MONTH BOX ..................65
CALCIUM ANTACID ...... 119
cefepime ................................. 7
CHANTIX STARTING
calcium antacid tropical ..... 119
cefixime .................................. 7
MONTH BOX ..................66
calcium carbonate ............... 119
cefotaxime .............................. 7
chateal ...................................95
calcium carbonate-vitamin d3
cefotetan ................................. 7
CHEMET ..............................63
........................................ 119
cefoxitin .................................. 7
CHEST CONGESTION
calcium citrate .................... 119
cefoxitin in dextrose, iso-osm 7
RELIEF...........................106
calcium citrate + ................. 119
cefpodoxime ........................... 7
chest congestion relief d .....106
calcium citrate + d .............. 119
cefprozil .................................. 7
CHEST CONGESTION
calcium citrate-vitamin d3 .. 120
ceftazidime ............................. 7
RELIEF PE .....................106
calcium gluconate ............... 120
ceftriaxone .............................. 7
chest-sinus congestion relief
calcium with vitamin d ....... 120
cefuroxime axetil .................... 7
........................................106
calcium+d ........................... 120
cefuroxime sodium ............. 7, 8
chewable multi vitamin ......127
camila ................................... 93
celecoxib ............................... 34
child allergy relf(cetirizine) 106
camrese ................................. 95
CELLCEPT .......................... 17
child aspirin ..........................34
camrese lo ............................. 95
CELLCEPT INTRAVENOUS
child chest congestion + cough
CANASA ............................. 77
.......................................... 17
........................................106
CANCIDAS ........................... 2
CELONTIN .......................... 24
child delsym cough+chest dm
candesartan ........................... 46
centamin ............................. 127
........................................106
candesartan-hydrochlorothiazid
central vite with lutein ........ 127
child mucinex chest congestion
.......................................... 47
central-vite .......................... 127
........................................106
CAPASTAT ........................... 9
central-vite senior ............... 127
CHILD MUCUS RELIEF
CAPRELSA ......................... 17
central-vite with lycopene .. 127
COUGH ..........................106
captopril ................................ 47
central-vite women's under 50
CHILD MUCUS RELIEF
captopril-hydrochlorothiazide
........................................ 127
EXPECTORANT ...........106
.......................................... 47
century ................................ 127
child pain rel-fever reducer ..34
CARAC ................................ 55
century adults 50+ .............. 127
child suppository ..................77
CARAFATE ......................... 85
century mature .................... 127
child vitamin with minerals 127
CARBAGLU ........................ 63
century ultimate women's ... 127
children's allergy complete .107
carbamazepine ................ 23, 24
cephalexin ............................... 8
children's allergy relief(lor) 107
carbidopa .............................. 26
CEREZYME ........................ 73
children's allergy(cetirizine)
carbidopa-levodopa .............. 26
CEROVITE ........................ 127
........................................107
carbidopa-levodopaCEROVITE ADVANCED
children's aller-tec ...............107
entacapone ........................ 26
FORMULA .................... 127
children's aspirin ...................34
carboplatin ............................ 17
children's cetirizine .............107
137
children's chest congestion . 107
children's chewable ............ 127
children's chewable complete
........................................ 127
children's chewable vitamin127
children's chewable w/minerals
........................................ 127
children's cold & cough ...... 107
CHILDREN'S COLD &
COUGH DM .................. 107
children's cough .................. 107
children's dibromm dm cold &
c ...................................... 107
children's fever reducing ...... 34
children's iron ..................... 127
children's mucinex cough ... 107
children's multivit w/extra c128
children's pain relief ............. 34
children's pepto..................... 77
children's silapap .................. 34
CHILDREN'S SILFEDRINE
........................................ 107
children's vitamin with iron 128
children's wal-zyr ............... 107
child's all day allergy(cetir) 107
CHILD'S CHEWABLE
VITAMINS/IRON ......... 128
child's vitamin with iron ..... 128
child's vitamin with vitamin c
........................................ 128
chloramphenicol sod succinate
............................................ 9
chlorhexidine gluconate ....... 66
chlorhist .............................. 107
chloroquine phosphate............ 9
chlorothiazide ....................... 47
chlorothiazide sodium .......... 47
chlorpheniramine maleate .. 107
chlorpromazine ............... 39, 40
chlortabs ............................. 107
chlorthalidone ....................... 47
cholecalciferol (vitamin d3)128
cholestyramine light ............. 53
chorionic gonadotropin, human
.......................................... 73
CIALIS ............................... 118
ciclodan ................................ 58
ciclopirox .............................. 59
CIDOFOVIR .......................... 3
cilostazol............................... 51
CILOXAN ............................ 99
cimetidine ............................. 85
cimetidine hcl ....................... 85
CIMZIA ................................ 77
CIMZIA POWDER FOR
RECONST ........................ 77
CINRYZE ........................... 114
ciprofloxacin ......................... 14
ciprofloxacin (mixture)......... 14
ciprofloxacin hcl ............. 14, 99
ciprofloxacin lactate ............. 14
cisplatin ................................ 17
citalopram ............................. 40
citrate of magnesia................ 77
CITRUS CALCIUM .......... 120
cladribine .............................. 17
claravis.................................. 56
CLARINEX ........................ 107
clarithromycin ........................ 8
CLEARLAX ......................... 77
clemastine ........................... 107
CLEOCIN ............................. 94
clindamycin hcl ...................... 9
clindamycin pediatric ............. 9
clindamycin phosphate .... 9, 56,
94
clindamycin-benzoyl peroxide
.......................................... 57
CLINIMIX 5%/D15W
SULFITE FREE ............. 124
CLINIMIX 5%/D25W
SULFITE-FREE ............. 124
CLINIMIX 2.75%/D5W
SULFIT FREE ................ 124
CLINIMIX 4.25%/D10W
SULF FREE ................... 124
CLINIMIX 4.25%/D5W
SULFIT FREE ..................63
CLINIMIX 4.25%-D20W
SULF-FREE ...................124
CLINIMIX 4.25%-D25W
SULF-FREE ...................124
CLINIMIX 5%D20W(SULFITE-FREE) 124
CLINIMIX E 2.75%/D10W
SUL FREE ........................63
SULF FREE......................63
SUL FREE ......................124
SUL FREE ......................124
SULF FREE....................124
CLINIMIX E 5%/D15W
SULFIT FREE ................124
CLINIMIX E 5%/D20W
SULFIT FREE ................124
CLINIMIX E 5%/D25W
SULFIT FREE ................124
clobetasol ..............................60
clobetasol-emollient .............61
clomipramine ........................40
clonazepam ...........................24
clonidine ...............................47
clonidine hcl ...................40, 47
clopidogrel ............................51
clorazepate dipotassium........40
clotrimazole ................2, 59, 94
clotrimazole 3 day ................94
clotrimazole-3 .......................94
clotrimazole-7 .......................94
clotrimazole-betamethasone .59
clozapine ...............................40
CLOZAPINE ........................40
COARTEM.............................9
codeine sulfate ......................29
CODITUSS DM .................107
colchicine-probenecid...........91
COLCRYS ............................91
138
cold & cough dm ................ 107
cough formula dm .............. 108
danazol ..................................73
cold & cough elixir............. 107
cough relief ......................... 108
dantrolene .............................29
COLD HEAD CONGESTION
COUGH SUPPRESSANTDAPSONE ............................10
NIGHTTIME .................. 107
EXPECTORANT ........... 108
DAPTACEL (DTAP
cold multi-symptom
cough syrup dm .................. 108
PEDIATRIC) (PF) ............88
(chlorphen) ..................... 107
COUGHTAB ...................... 108
DARAPRIM .........................10
colestipol .............................. 53
COUMADIN ........................ 51
dasetta 1/35 (28) ...................95
COLISTIN
CRESTOR ............................ 53
dasetta 7/7/7 (28) ..................95
(COLISTIMETHATE NA) 9
CRIXIVAN ............................ 3
daunorubicin .........................17
col-rite .................................. 78
cromolyn ............... 78, 101, 114
DAUNOXOME ....................17
COMBIGAN ...................... 102
cryselle (28) .......................... 95
daysee ...................................95
COMBIPATCH .................... 93
CUBICIN................................ 9
DECITABINE ......................17
COMBIVENT RESPIMAT 114
CUPRIMINE ........................ 92
DELESTROGEN .................93
COMETRIQ ......................... 17
cyanocobalamin (vitamin b-12)
delsym cough+chest congest
comfort gel ........................... 78
........................................ 128
dm ...................................108
comfort gel extra strength .... 78
cyclafem 1/35 (28)................ 95
demeclocycline .....................14
COMPLERA .......................... 3
cyclafem 7/7/7 (28) .............. 95
DEMSER ..............................47
complete 50+ ...................... 128
cyclobenzaprine .................... 29
DENAVIR ............................60
complete allergy ................. 108
cyclopentolate ..................... 100
denta 5000 plus .....................66
complete allergy medicine . 108
CYCLOPHOSPHAMIDE .... 17
dentagel.................................66
complete multi 50+ ............ 128
CYCLOSERINE .................... 9
DEPEN TITRATABS ..........92
complete multivitamin........ 128
CYCLOSET ......................... 69
DEPO-PROVERA ................93
complete multivitamin-mineral
cyclosporine.......................... 17
DEPO-SUBQ PROVERA 104
........................................ 128
cyclosporine modified .......... 17
..........................................93
complete senior .................. 128
cyproheptadine ................... 108
dermarest eczema (hydrocort)
compro .................................. 78
CYSTADANE ...................... 78
..........................................61
COMVAX (PF) .................... 88
CYSTAGON ...................... 118
desgen dm ...........................108
CONGESTAC .................... 108
cytarabine ............................. 17
desipramine...........................40
constulose ............................. 78
desloratadine .......................108
D
COPAXONE ........................ 28
d10 % & 0.45 % sodium
desmopressin ........................73
COREG CR .......................... 47
chloride ............................. 63
desonide ................................ 61
cormax .................................. 61
d2.5 %-0.45 % sodium
desoximetasone.....................61
cortisone ............................... 68
chloride ............................. 63
despec-dm (phenyleph-dmCORTISPORIN-TC ............. 68
D-2000 ................................ 128
guaif)............................... 108
COSENTYX PEN ................ 55
d5 % and 0.9 % sodium
dexamethasone .....................68
COSENTYX PEN (2 PENS) 55
chloride ............................. 64
dexamethasone intensol ........68
cough & cold ...................... 108
d5 %-0.45 % sodium chloride
dexamethasone sodium
cough & cold mucus relief cf
.......................................... 64
phosphate ..................68, 103
........................................ 108
dacarbazine ........................... 17
DEXILANT ..........................85
cough control
daily multiple ...................... 128
dexmethylphenidate ..............40
(dextromethorph)............ 108
daily multivitamin with iron
dexrazoxane hcl ....................15
cough control (guaifenesin) 108
........................................ 128
dextroamphetamine ..............40
cough control cf (pe) .......... 108
daily vitamin formula + iron
dextroamphetaminecough control dm ................ 108
........................................ 128
amphetamine.....................40
cough control dm max ........ 108
DALIRESP ......................... 114
139
dextrose 10 % and 0.2 % nacl
diclofenac-misoprostol ......... 34
DRISTAN LONG LASTING
.......................................... 64
dicloxacillin .......................... 13
..........................................66
dextrose 10 % in water (d10w)
dicyclomine .......................... 75
dronabinol .............................78
.......................................... 64
didanosine............................... 3
DRONABINOL ....................78
diflorasone ............................ 61
DROXIA...............................17
.......................................... 64
diflunisal ............................... 34
dss .........................................78
digitek ................................... 50
ducodyl .................................78
.......................................... 64
digox ..................................... 51
dulcolax stool softener (dss) .78
digoxin .................................. 51
duloxetine .............................40
.......................................... 64
dihydroergotamine................ 27
DURAMORPH (PF) ............29
DILANTIN 30 MG .............. 24
DUREZOL .........................103
.......................................... 64
diltiazem hcl ......................... 47
E
dextrose 5 % in water (d5w) 64
dilt-xr .................................... 47
e.c. prin .................................34
dextrose 5 %-lactated ringers64
dimenhydrinate ..................... 78
e.e.s. 400 .................................8
dextrose 5%-0.2 % sod
dino-life .............................. 128
econazole ..............................59
chloride ............................. 64
dino-life with extra c .......... 128
ecotrin low strength ..............34
dextrose 5%-0.3 %
dino-life with iron-zinc ....... 128
EDURANT .............................3
sod.chloride ...................... 64
DIOCTO ............................... 78
EFFIENT ..............................51
diotame ................................. 75
EGRIFTA .............................86
.......................................... 64
DIPENTUM ......................... 78
ELAPRASE ..........................73
diphedryl ............................. 109
ELDERTONIC ...................129
.......................................... 64
diphenhydramine hcl .......... 109
electrolyte-48 in d5w ..........124
dextrose with sodium chloride
diphenhydramineELELYSO ............................73
.......................................... 64
acetaminophen .................. 34
ELIDEL ................................ 56
dextrose-kcl-nacl ................ 120
diskets ................................... 29
ELIGARD.............................17
diabetic siltussin das-na...... 108
disulfiram.............................. 64
elinest ....................................95
diabetic siltussin-dm........... 108
divalproex ............................. 24
eliphos.................................120
diabetic siltussin-dm max str
dm max ............................... 109
ELIQUIS...............................51
........................................ 108
DOC-Q-LACE...................... 78
ELITEK ................................ 15
diabetic tussin dm ....... 108, 109
docu ...................................... 78
ELIXOPHYLLIN ...............115
diabetic tussin ex ................ 109
docu soft ............................... 78
ELLA ....................................95
diabetic tussin max st ......... 109
docusate sodium ................... 78
ELMIRON ..........................118
diabetic tussin mucus relief 109
docusil .................................. 78
EMCYT ................................ 17
dialyvite 800 ....................... 128
donepezil .............................. 28
EMEND ................................ 78
dialyvite vitamin d .............. 128
dorzolamide ........................ 102
emoquette .............................96
diamode ................................ 75
dorzolamide-timolol ........... 102
EMSAM ...............................40
diaper rash relief ................... 55
double-tussin dm ................ 109
EMTRIVA ..............................3
diarrhea relief (bismuth subs)
doxazosin .............................. 47
enalapril maleate ...................47
.......................................... 75
doxepin ................................. 40
enalapril-hydrochlorothiazide
DIASTAT ............................. 24
doxorubicin........................... 17
..........................................47
diazepam......................... 24, 40
doxy-100 ............................... 14
ENBREL...............................92
diazepam intensol ................. 40
doxycycline hyclate .............. 14
ENBREL SURECLICK .......92
diclofenac potassium ............ 34
doxycycline monohydrate ... 14,
ENDACOF - DM ...............109
diclofenac sodium .. 34, 56, 102
15
endacon ............................... 109
140
endocet ........................... 29, 30
ESTRACE ............................ 93
FERRIPROX ........................65
ENEMA................................ 79
estradiol ................................ 93
ferrous gluconate ................129
ENGERIX-B (PF) ................ 88
estradiol valerate................... 93
ferrous sulfate .....................129
ENGERIX-B PEDIATRIC
eszopiclone ........................... 41
FETZIMA .............................41
(PF) ................................... 88
ethambutol ............................ 10
fever reducer .........................35
enoxaparin ............................ 51
ethosuximide ........................ 24
feverall ..................................35
ENOXAPARIN .................... 51
etidronate disodium .............. 65
fexofenadine .......................109
enpresse ................................ 96
etodolac ................................ 34
FIBER ...................................79
enskyce ................................. 96
etoposide............................... 17
FIBER (CALCIUM
entacapone ............................ 26
EVOTAZ ................................ 3
POLYCARBOPHIL) ........79
ENTECAVIR ......................... 3
EXELON .............................. 28
fiber (psyllium husk/sugar)...79
enteric coated aspirin ............ 34
exemestane ........................... 17
FIBER (WITH ASPARTAME)
enulose.................................. 79
EXJADE ............................... 65
..........................................79
EPANED .............................. 48
expectorant ......................... 109
fiber laxative (husk/sugar) ....79
epinastine............................ 101
ex-strength medi-tabs ........... 35
fiber laxative (methylcellulo)
epinephrine ......................... 109
ex-strength medi-tabs pm ..... 35
..........................................79
EPIPEN 2-PAK .................. 109
EXTAVIA ............................ 86
fiber laxative (psyllium) s/f ..79
EPIPEN JR 2-PAK ............. 109
ezfe 200 .............................. 129
fiber smooth ..........................79
EPIRUBICIN ....................... 17
fiber smooth (sucrose) ..........79
F
epitol ..................................... 24
FABRAZYME ..................... 73
FIBER THERAPY ...............79
EPIVIR ................................... 3
falmina (28) .......................... 96
fiber therapy (ca polycarboph)
EPIVIR HBV.......................... 3
famciclovir.............................. 3
..........................................79
eplerenone ............................ 48
famotidine............................. 85
FIBER THERAPY
eprosartan ............................. 48
famotidine (pf) ...................... 85
(PSYLLIUM SEED) ........79
EPZICOM .............................. 3
famotidine (pf)-nacl (iso-os) 85
fiber therapy (psyllium) ........79
ergocalciferol (vitamin d2) . 129
FANAPT .............................. 41
fiber-lax ................................ 79
ergoloid................................. 41
FARESTON ......................... 18
fiber-tabs ...............................79
ERIVEDGE .......................... 17
FARXIGA ............................ 69
finasteride ...........................118
errin ...................................... 93
FARYDAK ........................... 18
FIRAZYR ...........................115
ERWINAZE ......................... 17
FASLODEX ......................... 18
flanax antacid........................79
ery pads ................................ 57
FAZACLO............................ 41
flavor chews antacid ...........120
ERYPED 200 ......................... 8
felbamate .............................. 24
flavoxate .............................117
ERYTHROCIN ...................... 8
felodipine .............................. 48
flecainide ..............................45
ERYTHROCIN (AS
fenesin ir ............................. 109
FLOVENT DISKUS ..........115
STEARATE) ...................... 8
fenesin pe ir ........................ 109
FLOVENT HFA .................115
erythromycin .................... 9, 99
fenofibrate ............................ 53
fluconazole .............................2
erythromycin ethylsuccinate .. 9
fenofibrate micronized ......... 53
fluconazole in dextrose(iso-o) 2
erythromycin with ethanol ... 57
fenofibrate nanocrystallized . 53
flucytosine ..............................2
erythromycin-benzoyl peroxide
fenofibric acid (choline) ....... 53
FLUDARABINE ..................18
.......................................... 57
fenoprofen ............................ 35
fludrocortisone ......................68
ESBRIET ............................ 115
fentanyl ................................. 30
flunisolide ...........................115
escitalopram oxalate ............. 41
FENTANYL CITRATE ....... 30
fluocinolone ..........................61
esomeprazole sodium ........... 85
FERATE ............................. 129
fluocinolone acetonide oil ....67
essentia ............................... 129
FER-IRON.......................... 129
fluocinonide ..........................61
estarylla ................................ 96
FERREX 150 ...................... 129
fluocinonide-e .......................61
141
fluoritab .............................. 129
garamycin ............................. 99
glycopyrrolate .......................75
fluorometholone ................. 103
GARDASIL (PF) .................. 89
gonak ..................................101
fluorouracil ..................... 18, 56
GARDASIL 9 (PF) ............... 89
goniosoft .............................101
fluoxetine.............................. 41
gatifloxacin ........................... 99
goniotaire ............................101
FLUOXETINE ..................... 41
GATTEX ONE-VIAL .......... 79
goniovisc.............................101
fluphenazine decanoate ........ 41
GAUZE PAD ....................... 70
granisetron (pf) .....................80
fluphenazine hcl ................... 41
gavilax .................................. 79
granisetron hcl ......................80
flurbiprofen........................... 35
gavilyte-c .............................. 79
griseofulvin microsize ............2
flurbiprofen sodium ............ 102
gavilyte-g .............................. 79
griseofulvin ultramicrosize .....2
flutamide............................... 18
gavilyte-n .............................. 80
g-tron ..................................109
fluticasone .................... 61, 115
GAZYVA ............................. 18
guaiasorb dm ......................109
fluvastatin ............................. 53
GELNIQUE ........................ 117
guaifenesin ..................109, 110
fluvoxamine.......................... 41
GEMCITABINE .................. 18
guaifenesin-dm ...................110
FML S.O.P. ........................ 103
gemfibrozil ........................... 53
guanfacine.............................41
foaming antacid .................... 79
generlac ................................ 80
guanidine ..............................42
folic acid ............................. 129
gengraf .................................. 18
gummi bear multivitamin ...129
fomepizole ............................ 88
gentak ................................... 99
gummy swirls .....................129
fondaparinux................... 51, 52
gentamicin ................ 10, 58, 99
H
FONDAPARINUX ........ 51, 52
gentamicin in nacl (iso-osm) 10
halobetasol propionate ..........61
for sty relief ........................ 101
GENTAMICIN IN NACL
haloperidol ............................42
FORADIL AEROLIZER ... 115
(ISO-OSM) ....................... 10
haloperidol decanoate ...........42
FORFIVO XL ...................... 41
gentlelax ............................... 80
haloperidol lactate ................42
FORTEO .............................. 92
GEODON ............................. 41
HARVONI ..............................4
fortical .................................. 73
GERIATON........................ 129
HAVRIX (PF) ......................89
foscarnet ................................. 4
geri-kot ................................. 80
headache formula..................35
fosinopril .............................. 48
geri-lanta ............................... 80
headache formula added str ..35
fosinopril-hydrochlorothiazide
geri-mox antacid-antigas ...... 80
headache pm .........................35
.......................................... 48
geri-tussin ........................... 109
headache relief (asa-acet-caf)
fosphenytoin ......................... 24
gildess ................................... 96
..........................................35
FOSRENOL ......................... 65
gildess fe ............................... 96
heartburn prevention .............85
FRAGMIN ........................... 52
GILENYA ............................ 28
heartburn relief (ranitidine) ..85
fruit c .................................. 129
GILOTRIF ............................ 18
heather ..................................93
fruit c-500 ........................... 129
GLATOPA ........................... 28
heparin (porcine) ..................52
full spectrum b-vitamin c ... 129
GLEEVEC ............................ 18
heparin (porcine) in 5 % dex 52
furosemide ............................ 48
GLEOSTINE ........................ 18
heparin (porcine) in nacl (pf) 52
FUZEON ................................ 4
glimepiride............................ 70
heparin, porcine (pf) .............52
FYCOMPA .......................... 24
glipizide ................................ 70
HEPATAMINE 8% ............124
glipizide-metformin .............. 70
HERCEPTIN ........................18
G
gabapentin ............................ 24
GLUCAGEN HYPOKIT ..... 70
HETLIOZ .............................42
GABITRIL ........................... 24
GLUCAGON EMERGENCY
HEXALEN ...........................18
galantamine .......................... 28
KIT (HUMAN)................. 70
hi-cal plus vit d ...................120
GAMMAGARD LIQUID .... 88
glycerin (adult) ..................... 80
high potency calcium ..........120
GAMUNEX-C ..................... 88
glycerin (child) ..................... 80
honey bears .........................129
ganciclovir sodium ................. 4
glycolax ................................ 80
honey bears with iron-zinc .130
142
HORIZANT ......................... 28
ibuprofen ib .......................... 35
ipratropium-albuterol ..........115
HUMALOG ......................... 70
ibuprofen-oxycodone............ 30
i-prin .....................................35
HUMALOG KWIKPEN ...... 70
ICLUSIG .............................. 18
irbesartan ..............................48
HUMALOG MIX 50-50 ...... 70
idarubicin .............................. 18
irbesartan-hydrochlorothiazide
HUMALOG MIX 50-50
iferex 150 ............................ 130
..........................................48
KWIKPEN ....................... 70
IFOSFAMIDE ...................... 18
IRENKA ...............................42
HUMALOG MIX 75-25 ...... 70
ILARIS (PF) ......................... 86
IRINOTECAN ......................18
HUMALOG MIX 75-25
ILEVRO ............................. 102
iron high potency ................130
KWIKPEN ....................... 70
IMBRUVICA ....................... 18
ISENTRESS ...........................4
HUMIRA ........................ 92, 93
imipenem-cilastatin .............. 10
ISOLYTE-P IN 5 %
HUMIRA CROHN'S DIS
imipramine hcl ...................... 42
DEXTROSE ...................125
START PCK .................... 92
imipramine pamoate ............. 42
ISOLYTE-S ........................125
HUMIRA PED CROHN'S
imiquimod ............................ 56
isoniazid ................................ 10
STARTER PK .................. 92
IMOVAX RABIES VACCINE
ISORDIL ..............................54
HUMULIN 70/30 ................. 70
(PF) ................................... 89
isosorbide dinitrate ...............54
HUMULIN 70/30 KWIKPEN
INCRELEX .......................... 65
isosorbide mononitrate .........54
.......................................... 70
indapamide ........................... 48
isradipine ..............................48
HUMULIN N ....................... 71
INFANRIX (DTAP) (PF) ..... 89
ISTODAX.............................19
HUMULIN N KWIKPEN .... 71
infants ibu-drops ................... 35
itraconazole.............................2
HUMULIN R ....................... 71
infant's ibuprofen .................. 35
ivermectin .............................10
HUMULIN R U-500 ............ 71
INFANT'S MEDI-PROFEN 35
IXIARO (PF) ........................89
hydralazine ........................... 48
infant's non-aspirin ............... 35
J
HYDRO SKIN ..................... 61
INFANT'S PAIN RELIEF ... 35
JAKAFI ................................ 19
hydrochlorothiazide .............. 48
infant's pain reliever ............. 35
jantoven ................................ 52
hydrocodone-acetaminophen 30
infants profenib..................... 35
JANUMET ...........................71
hydrocodone-ibuprofen ........ 30
INLYTA ............................... 18
JANUMET XR .....................71
hydrocortisone .......... 62, 68, 80
INSULIN PEN NEEDLE ..... 71
JANUVIA .............................71
hydrocortisone acetate .......... 61
INSULIN SYRINGE (DISP)
JARDIANCE ........................71
hydrocortisone butyrate ........ 61
U-100 0.3 ML, 1/2 ML, 1
jencycla .................................93
hydrocortisone butyr-emollient
ML .................................... 71
JINTELI ................................ 93
.......................................... 62
INTELENCE .......................... 4
jock itch (terbinafine) ...........59
hydrocortisone valerate ........ 62
intense cough reliever ......... 110
jolessa ...................................96
hydrocortisone-acetic acid.... 67
INTRALIPID...................... 125
jolivette .................................93
hydromorphone .................... 30
INTRON A ........................... 86
junel 1.5/30 (21) ...................96
hydromorphone (pf) ............. 30
introvale ................................ 96
junel 1/20 (21) ......................96
hydroxocobalamin .............. 130
INVANZ ............................... 10
junel fe 1.5/30 (28) ...............96
hydroxychloroquine ............. 10
INVEGA ............................... 42
junel fe 1/20 (28) ..................96
hydroxyurea .......................... 18
INVEGA SUSTENNA ......... 42
junel fe 24 .............................96
hydroxyzine hcl .................. 110
INVEGA TRINZA ............... 42
JUXTAPID ...........................53
HYPERRAB S/D (PF) ......... 89
INVIRASE ............................. 4
K
inzo antifungal ...................... 59
KADCYLA...........................19
I
ibandronate ........................... 92
IONOSOL-B IN D5W........ 125
KADIAN ..............................31
IBRANCE ............................ 18
IONOSOL-MB IN D5W .... 125
KALETRA .............................4
ibu-drops............................... 35
IPOL ..................................... 89
KALYDECO ......................115
ibuprofen .............................. 35
ipratropium bromide ..... 67, 115
143
kaopectate (bismuth subsalicy)
LASTACAFT ..................... 101
LIALDA ...............................81
.......................................... 75
latanoprost .......................... 102
lice killing (permethrin) ........62
kaopectate ex str (bismuth ss)
LATUDA.............................. 42
LICE TREATMENT ............62
.......................................... 75
laxa clear............................... 80
lice treatment (permethrin) ...62
kariva (28) ............................ 96
laxacin .................................. 80
lidocaine ...............................58
kelnor 1/35 (28) .................... 96
laxative ................................. 80
lidocaine (pf) ........................57
KENALOG........................... 68
laxative (glycerin-pediatric) . 80
lidocaine hcl....................57, 58
ketoconazole ..................... 2, 59
laxative dietary supplement 120
lidocaine-prilocaine ..............58
ketoprofen....................... 35, 36
laxative maximum strength .. 80
lindane ..................................62
ketorolac ............................. 102
laxative peg 3350.................. 80
LINEZOLID .........................10
KEYTRUDA ........................ 19
laxative pills ......................... 80
LINZESS ..............................81
KHEDEZLA......................... 42
laxative plus stool softener ... 81
liothyronine...........................75
KIDKARE COUGH/COLD
laxative-senna ....................... 81
liposyn iii ............................125
........................................ 110
leflunomide........................... 93
liquibid d-r ..........................110
kid's vitamins ...................... 130
LENVIMA............................ 19
liquid antacid ........................81
kid's vitamins + extra c ....... 130
lessina ................................... 96
lisinopril ................................ 48
kid's vitamins + iron ........... 130
LETAIRIS .......................... 115
lisinopril-hydrochlorothiazide
KINRIX (PF) ........................ 89
letrozole ................................ 19
..........................................48
KIONEX............................... 65
leucovorin calcium ......... 15, 16
lite coat aspirin .....................36
klor-con .............................. 120
LEUKERAN ........................ 19
lithium carbonate ..................42
klor-con 10 ......................... 120
LEUKINE ............................. 86
lithium citrate........................42
klor-con 8 ........................... 120
leuprolide .............................. 19
little animals .......................130
klor-con m15 ...................... 120
levalbuterol hcl ........... 115, 116
little animals-iron................130
klor-con m20 ...................... 120
LEVEMIR ............................ 71
little remedies .......................67
KOMBIGLYZE XR ............. 71
LEVEMIR FLEXTOUCH ... 71
lo-dose aspirin ......................36
KONSYL (SUGAR) ............ 80
levetiracetam ........................ 25
LOMUSTINE .......................19
KONSYL SUGAR-FREE .... 80
levetiracetam in nacl (iso-os)
loperamide ............................76
KORLYM............................. 73
.................................... 24, 25
loradamed ...........................110
k-pec antidiarrheal (bism sub)
levobunolol ......................... 100
loratadine ............................110
.......................................... 76
levocarnitine ......................... 65
loratadine-d .........................110
k-tab.................................... 120
levocarnitine (with sugar)..... 65
lorazepam .............................42
kurvelo .................................. 96
levocetirizine ...................... 110
lorazepam intensol ................42
KUVAN ............................... 73
levofloxacin .................... 14, 99
losartan .................................48
levofloxacin in d5w .............. 14
losartan-hydrochlorothiazide 48
L
l norgest/e.estradiol-e.estrad . 96
LEVOLEUCOVORIN
LOTRONEX.........................81
labetalol ................................ 48
CALCIUM........................ 16
lovastatin...............................53
lactated ringers ............. 63, 120
levonorgestrel ....................... 96
low-ogestrel (28) ..................97
lactulose................................ 80
levonorgestrel-ethinyl estrad 96
loxapine succinate ................42
lamivudine .............................. 4
levora-28 ............................... 97
lta pre-attached .....................58
LAMIVUDINElevorphanol tartrate............... 31
lubricant eye .......................101
ZIDOVUDINE ................... 4
levothyroxine ........................ 74
LUBRICANT EYE (PG-PEG
lamotrigine ........................... 24
LEVOTHYROXINE ............ 74
400) .................................101
LANOXIN ............................ 51
levoxyl .................................. 74
lubricant eye (polyv alcohol)
lansoprazole .......................... 85
LEXIVA ................................. 4
........................................101
144
LUBRICATING PLUS ...... 101
medi-profen .......................... 36
methyldopaLUMIGAN ......................... 102
medi-tabs .............................. 36
hydrochlorothiazide ..........49
lumitene .............................. 130
medi-tabs pm ........................ 36
methylergonovine .................98
LUPRON DEPOT ................ 19
medi-tussin ......................... 110
METHYLERGONOVINE ...98
LUPRON DEPOT (3
medi-tussin dm ................... 110
methylphenidate ...................43
MONTH) .......................... 19
medi-tussin dm diabetic...... 110
methylprednisolone ..............68
LUPRON DEPOT (4
medroxyprogesterone ........... 94
methylprednisolone acetate ..68
MONTH) .......................... 19
mefenamic acid..................... 36
methylprednisolone sodium
LUPRON DEPOT (6
mefloquine ............................ 10
succ ...................................68
MONTH) .......................... 19
megestrol .............................. 19
metipranolol ........................100
LUPRON DEPOT-PED ....... 19
MEKINIST ........................... 19
metoclopramide hcl ..............81
lutera (28) ............................. 97
meloxicam ............................ 36
metolazone ............................49
LYNPARZA......................... 19
melphalan hcl ....................... 19
metoprolol succinate .............49
LYRICA ............................... 25
MENACTRA (PF) ............... 89
metoprolol ta-hydrochlorothiaz
lysiplex plus........................ 130
MENOMUNE - A/C/Y/W-135
..........................................49
LYSODREN......................... 19
(PF) ................................... 89
metoprolol tartrate ................49
lyza ....................................... 93
MENVEO A-C-Y-W-135-DIP
metronidazole .....10, 11, 57, 94
(PF) ................................... 90
metronidazole in nacl (iso-os)
M
MAG 64.............................. 120
MEPHYTON ........................ 52
..........................................10
magnesium citrate ................ 81
meprobamate ........................ 29
mexiletine .............................45
magnesium oxide................ 120
mercaptopurine ..................... 19
MIACALCIN .......................73
magnesium sulfate .............. 121
meropenem ........................... 10
MI-ACID ..............................81
malathion .............................. 63
mesalamine with cleansing
micatin ..................................59
MAPAP
wipe .................................. 81
miconazole 7 .........................94
(ACETAMINOPHEN) ..... 36
mesna .................................... 16
miconazole nitrate ..........59, 94
maprotiline ........................... 42
MESNEX.............................. 16
miconazole-3 ........................94
marlissa................................. 97
MESTINON ......................... 29
microgestin 1.5/30 (21) ........97
MARPLAN .......................... 42
MESTINON TIMESPAN .... 29
microgestin 1/20 (21) ...........97
masanti double strength ........ 81
metadate er ........................... 43
microgestin fe 1.5/30 (28) ....97
masophen .............................. 36
metaproterenol .................... 116
microgestin fe 1/20 (28) .......97
MATULANE ....................... 19
metaxalone............................ 29
midodrine ..............................65
matzim la .............................. 48
metformin ............................. 71
migergot ................................ 27
maxiphen ............................ 110
methadone ............................ 31
migraine formula ..................36
meclizine .............................. 81
methadone intensol ............... 31
migraine pain reliever ...........36
meclofenamate ..................... 36
methadose ............................. 31
migraine relief ......................36
medi-bismuth........................ 76
methamphetamine ................ 43
MILK OF MAGNESIA ........81
MEDI-CORTISONE ............ 62
methazolamide.................... 102
millipred ...............................68
medifin expectorant mucus rlf
methenamine hippurate ........ 15
mineral oil extra heavy .........81
........................................ 110
methimazole ......................... 69
minocycline ..........................15
medi-lax................................ 81
methotrexate sodium ............ 20
minoxidil...............................49
medi-laxx.............................. 81
methotrexate sodium (pf)19, 20
mirtazapine ...........................43
medi-natural ......................... 81
methoxsalen rapid................. 56
misoprostol ...........................85
medi-natural senna-stool ...... 81
methscopolamine .................. 76
mitomycin .............................20
medi-phedrine..................... 110
methyclothiazide .................. 48
mitoxantrone .........................20
medi-phedryl ...................... 110
M-M-R II (PF) ......................90
145
modafinil .............................. 43
mupirocin calcium ................ 58
natural laxative .....................82
moexipril .............................. 49
MUSTARGEN ..................... 20
natural veg laxative(sennosid)
moexipril-hydrochlorothiazide
mycophenolate mofetil ......... 20
..........................................82
.......................................... 49
mycophenolate sodium ......... 20
natural vegetable ...................82
mometasone.......................... 62
myferon 150 ....................... 130
natural vegetable (psyllium) .82
mono-linyah ......................... 97
MYOZYME ......................... 74
natural vegetable powder ......82
mononessa (28) .................... 97
MYRBETRIQ .................... 117
NEBUPENT .........................11
montelukast ........................ 116
myzilra .................................. 97
necon 0.5/35 (28) ..................97
morgidox .............................. 15
necon 1/35 (28) .....................97
N
morphine......................... 31, 32
nabumetone .......................... 36
necon 10/11 (28) ...................97
morphine (pf)........................ 31
nadolol .................................. 49
necon 7/7/7 (28) ....................97
morphine concentrate ........... 31
nadolol-bendroflumethiazide 49
NEEDLES, INSULIN
MOTION SICKNESS .......... 81
nafcillin ................................. 13
DISP.,SAFETY ................71
motion sickness relief ........... 81
NAFCILLIN ......................... 13
nefazodone ............................43
MOVIPREP .......................... 81
NAFCILLIN IN DEXTROSE
neomycin ..............................11
moxifloxacin......................... 14
ISO-OSM.......................... 13
neomycin-bacitracin-poly-hc
MOZOBIL............................ 87
NAGLAZYME ..................... 74
........................................102
mucinex .............................. 110
nalbuphine ............................ 36
neomycin-bacitracinmucinex allergy .................. 110
naloxone ............................... 36
polymyxin .........................99
MUCINEX DM .................. 110
naltrexone ............................. 36
neomycin-polymyxin b gu ....63
mucinex fast-max dm max . 110
NAMENDA.......................... 28
neomycin-polymyxin bmucosa................................ 110
NAMENDA TITRATION
dexameth.........................103
mucus dm ........................... 111
PAK .................................. 28
neomycin-polymyxinmucus dm max ................... 111
naphazoline......................... 104
gramicidin .........................99
mucus relief ........................ 111
NAPRELAN CR .................. 36
neomycin-polymyxin-hc......68,
mucus relief chest ............... 111
naproxen ............................... 36
103
mucus relief cough ............. 111
naproxen sodium .................. 37
neo-polycin ...........................99
mucus relief d (phenylephrine)
naratriptan ............................. 27
neo-polycin hc ....................103
........................................ 111
nasal decongestant
NEORAL ..............................20
mucus relief d (pseudoephed)
(pseudoeph) .................... 111
neo-tuss ............................... 111
........................................ 111
NASAL DECONGESTANT
NEPHRAMINE 5.4 %........125
mucus relief er .................... 111
(PSEUDOEPH) .............. 111
NEPHRONEX ....................130
MULTAQ ............................. 45
nasal moisturizing................. 67
NEUMEGA ..........................87
multi complete with iron .... 130
NASAL SPRAY
NEUPOGEN.........................87
multi-day with iron ............. 130
(OXYMETAZOLINE) ..... 67
NEUPRO ..............................26
MULTI-DELYN ................ 130
nasal spray (sodium chloride)
nevirapine ...............................4
MULTI-DELYN WITH IRON
.......................................... 67
NEXAVAR...........................20
........................................ 130
NASONEX ......................... 116
NEXT CHOICE ONE DOSE
multi-symptom cold night time
NATACYN .......................... 99
..........................................97
........................................ 111
nateglinide ............................ 71
niacin .............................. 53, 54
multivital platinum ............. 130
NATPARA ........................... 74
nicardipine ............................49
multivitamin with minerals 130
NATURAL BALANCE ..... 101
nicotine .................................66
multi-vite ............................ 130
natural fiber laxative (sugar) 81
nicotine (polacrilex)..............66
mupirocin ............................. 58
natural fiber laxative smooth 82
NICOTROL ..........................66
146
NICOTROL NS.................... 66
NOVOLOG FLEXPEN ........ 72
oralone ..................................67
nifedical xl ............................ 49
NOVOLOG MIX 70-30 ....... 72
ORALYTE .........................121
nifedipine.............................. 49
NOVOLOG MIX 70-30
ORAP ...................................43
night time cold .................... 111
FLEXPEN ........................ 72
ORENCIA (WITH
NILANDRON ...................... 20
NOVOLOG PENFILL ......... 72
MALTOSE) ......................93
nimodipine............................ 49
NOVOTWIST ...................... 72
organ-i nr ............................111
nitro-bid ................................ 54
NOXAFIL .............................. 2
orsythia .................................97
nitrofurantoin macrocrystal .. 15
nts step 1 ............................... 66
oxacillin ................................ 13
nitrofurantoin monohyd/mNUCYNTA .......................... 37
OXACILLIN ........................13
cryst .................................. 15
NUCYNTA ER .................... 37
oxacillin in dextrose(iso-osm)
nitroglycerin ................... 54, 55
NUEDEXTA ........................ 28
..........................................13
NITROSTAT ........................ 55
NULOJIX ............................. 20
OXACILLIN IN
nizatidine .............................. 85
NUVARING ......................... 94
DEXTROSE(ISO-OSM) ..13
non-aspirin ............................ 37
nuzole ................................... 59
OXALIPLATIN ...................20
non-aspirin extra strength ..... 37
nyamyc ................................. 59
oxandrolone ..........................74
non-aspirin nightime ............ 37
nystatin ............................. 2, 59
OXANDROLONE ...............74
non-aspirin pain relief .......... 37
nystatin-triamcinolone .......... 59
oxaprozin ..............................37
non-aspirin pain relief pm .... 37
nystop ................................... 59
oxazepam ..............................43
non-aspirin pm...................... 37
oxcarbazepine .......................25
O
NORDITROPIN FLEXPRO 87
OCEAN NASAL .................. 67
oxybutynin chloride ............117
NORDITROPIN NORDIFLEX
octreotide acetate .................. 20
oxycodone.............................32
.......................................... 87
OCTREOTIDE ACETATE .. 20
oxycodone-acetaminophen ...32
norethindrone (contraceptive)
OFEV.................................. 116
oxycodone-aspirin ................32
.......................................... 94
ofloxacin ................... 14, 67, 99
oxymorphone ........................32
norethindrone acetate ........... 94
ogestrel (28) .......................... 97
oyster shell + d3..................121
norgestimate-ethinyl estradiol
olanzapine............................. 43
oyster shell calcium 500 .....121
.......................................... 97
olanzapine-fluoxetine ........... 43
oyster shell calcium-vit d3..121
NORMOSOL-M IN 5 %
olopatadine ........................... 67
oystercal-d ..........................121
DEXTROSE ................... 125
omega-3 acid ethyl esters ..... 54
P
NORMOSOL-R IN 5 %
omeprazole ........................... 85
pacerone ................................ 45
DEXTROSE ................... 121
ONCASPAR......................... 20
PACLITAXEL .....................20
NORMOSOL-R PH 7.4 ..... 125
ondansetron .......................... 82
pain relief ..............................37
NORTHERA ........................ 65
ondansetron hcl..................... 82
pain relief adult .....................37
nortrel 0.5/35 (28) ................ 97
ondansetron hcl (pf).............. 82
pain relief extra strength .......37
nortrel 1/35 (21) ................... 97
one daily multivitamin-iron 130
pain relief pm ........................37
nortrel 1/35 (28) ................... 97
one daily plus iron .............. 130
pain relief pm rapid release ..37
nortrel 7/7/7 (28) .................. 97
one daily women's .............. 130
pain relief regular strength....37
nortriptyline .......................... 43
one daily women's health ... 130
pain reliever ..........................37
NORVIR................................. 4
one-a-day teen advantage ... 130
pain reliever (acetam-aspirin)
novarel .................................. 74
ONFI..................................... 25
..........................................37
NOVOFINE ......................... 71
ONGLYZA ........................... 72
pain reliever extra strength ...37
NOVOLIN 70/30.................. 71
OPDIVO ............................... 20
pain reliever pm ....................37
NOVOLIN N ........................ 72
OPSUMIT .......................... 116
pain reliever pm ex-strength .37
NOVOLIN R ........................ 72
ORACEA.............................. 15
pain-off .................................37
NOVOLOG .......................... 72
oral electrolytes .................. 121
pamidronate ..........................74
147
pamprin max ......................... 37
phenelzine............................. 43
potassium chloride in 0.9%nacl
PANRETIN .......................... 56
phenobarbital ........................ 25
........................................121
pantoprazole ......................... 85
PHENYTEK ......................... 25
potassium chloride in 5 % dex
pantothenic acid.................. 130
phenytoin .............................. 25
........................................121
paricalcitol ............................ 74
phenytoin sodium ................. 25
potassium chloride in lr-d5 .121
paromomycin ........................ 11
phenytoin sodium extended .. 25
potassium chloride-0.45 % nacl
paroxetine hcl ....................... 43
philith.................................... 97
........................................122
PASER ................................. 11
PHOSPHOLINE IODIDE .. 100
potassium chloride-d5PATADAY ......................... 101
pilocarpine hcl .............. 65, 100
0.2%nacl .........................122
PAXIL .................................. 43
pindolol................................. 49
potassium chloride-d5p-col rite ............................... 82
pink bismuth ......................... 76
0.3%nacl .........................122
PEDIALYTE ...................... 121
pink bismuth maximum
potassium chloride-d5pedialyte singles ................. 121
strength ............................. 76
0.9%nacl .........................122
pediatric cough & cold ....... 111
pioglitazone .......................... 72
potassium citrate .................118
pediatric electrolyte ............ 121
pioglitazone-glimepiride ...... 72
POTIGA ...............................25
pediatric freezer pops ......... 121
pioglitazone-metformin ........ 72
powderlax .............................82
PEDVAX HIB (PF) .............. 90
piperacillin-tazobactam ........ 13
PRADAXA ...........................53
peg 3350-electrolytes ........... 82
pirmella................................. 97
pramipexole ..........................27
peg-3350 with flavor packs .. 82
piroxicam .............................. 38
pravastatin.............................54
PEGANONE ........................ 25
PLASMA-LYTE 148 ......... 125
prazosin.................................49
peg-electrolyte soln .............. 82
PLASMA-LYTE A ............ 125
prednicarbate ........................62
PEGINTRON ....................... 87
PLASMA-LYTE-56 IN 5 %
prednisolone acetate ...........103
PEGINTRON REDIPEN ..... 87
DEXTROSE ................... 125
prednisolone sodium phosphate
penicillin g potassium........... 13
podactin ................................ 59
..................................68, 103
penicillin g procaine ............. 13
podofilox .............................. 56
prednisone.............................69
penicillin g sodium ............... 13
polycin .................................. 99
prednisone intensol ...............69
penicillin v potassium........... 13
polyethylene glycol 3350 ..... 82
PREGNYL ............................74
PENTAM ............................. 11
POLY-IRON ...................... 130
PREMARIN .........................94
pentoxifylline ....................... 53
polymyxin b sulfate .............. 11
PREMASOL 10 % .............125
pepcid ac ............................... 85
polymyxin b sulf-trimethoprim
PREMASOL 6 % ...............125
pepto-bismol ......................... 76
.......................................... 99
prenatal vitamin oral tablet .131
percogesic ............................. 38
polyvinyl alcohol ................ 101
pres gen ............................... 111
percogesic extra strength ...... 38
POLY-VITAMIN ............... 131
prevalite ................................ 54
PERFOROMIST ................ 116
POLY-VITAMIN WITH
previfem ................................ 97
peri-colace ............................ 82
IRON .............................. 131
PREZCOBIX ..........................4
perindopril erbumine ............ 49
POLYVITAMIN/IRON ..... 131
PREZISTA .........................4, 5
periogard............................... 67
POLY-VITAMINS ............. 131
PRIFTIN ...............................11
PERJETA ............................. 21
POMALYST ........................ 21
PRIMAQUINE .....................11
permethrin ............................ 63
portia..................................... 97
primidone ..............................25
perphenazine......................... 43
potassium bicarb and chloride
PRISTIQ ...............................44
perphenazine-amitriptyline... 43
........................................ 121
PROAIR HFA ....................116
pharbechlor ......................... 111
potassium chlorid-d5probenecid ............................91
pharbedryl........................... 111
0.45%nacl ....................... 121
procainamide ........................45
pharbetol ............................... 38
potassium chloride...... 121, 122
PROCALAMINE 3% .........125
148
prochlorperazine ................... 82
quit 4 ..................................... 66
ringers .................................122
prochlorperazine edisylate.... 82
risedronate ......................65, 92
R
prochlorperazine maleate ..... 82
RABAVERT (PF) ................ 90
RISPERDAL CONSTA .......44
PROCRIT ............................. 87
raloxifene .............................. 92
risperidone ............................44
procto-pak............................. 82
ramipril ................................. 49
ri-tussin ............................... 112
proctosol hc .......................... 83
RANEXA ............................. 54
ri-tussin dm .........................112
proctozone-hc ....................... 83
ranitidine hcl ......................... 86
RITUXAN ............................21
progesterone micronized ...... 94
RAPAMUNE........................ 21
rivastigmine tartrate ..............28
PROGLYCEM ..................... 72
RAVICTI .............................. 65
rizatriptan ..............................27
PROLEUKIN ....................... 87
RAYOS ................................ 69
ropinirole ..............................27
PROLIA ............................... 92
REBIF (WITH ALBUMIN) . 87
rosadan ..................................57
PROMACTA........................ 53
REBIF REBIDOSE .............. 87
ROTARIX ............................90
promethazine ...................... 111
REBIF TITRATION PACK. 87
ROTATEQ VACCINE .........90
propafenone .......................... 45
reclipsen (28) ........................ 97
ROZEREM ...........................44
propranolol ........................... 49
RECOMBIVAX HB (PF) .... 90
S
propranolol-hydrochlorothiazid
refenesen ............................. 112
SABRIL ................................ 25
.......................................... 49
refenesen pe ........................ 112
saline mist .............................67
propylthiouracil .................... 69
regonol .................................. 29
saline nasal............................67
PROQUAD (PF) .................. 90
REGRANEX ........................ 56
saline nasal mist ....................67
PROSIGHT ........................ 131
REGULOID.......................... 83
saline nose ............................67
PROSOL 20 % ................... 126
RELENZA DISKHALER ...... 5
SAL-PLANT ........................55
protriptyline .......................... 44
RELISTOR ........................... 83
SAMSCA ..............................74
PROVENTIL HFA ............. 116
REMICADE ......................... 83
SANCUSO ...........................83
provil .................................... 38
REMODULIN ...................... 50
SANDIMMUNE...................21
pseudoephedrine hcl ... 111, 112
RENA-VITE ....................... 131
SANDOSTATIN LAR
PULMOZYME................... 116
RENVELA ........................... 65
DEPOT .............................21
pure & gentle eye ............... 101
repaglinide ............................ 72
SANI-SUPP (ADULT) .........83
purelax .................................. 83
reprexain ............................... 32
SANTYL ..............................62
PURIXAN ............................ 21
RESCRIPTOR ........................ 5
SAPHRIS (BLACK
pyrazinamide ........................ 11
reserpine ............................... 50
CHERRY).........................44
PYRETHRIN LICE
RESTASIS.......................... 101
SAVELLA ............................93
TREATMENT M ............. 63
RETROVIR ............................ 5
SCOT-TUSSIN DM ...........112
pyridostigmine bromide ....... 29
REVLIMID .......................... 21
secura antifungal ...................59
pyridoxine........................... 131
REYATAZ ............................. 5
selegiline hcl .........................27
RHEUMATREX .................. 21
selenium sulfide ....................55
Q
QUADRACEL (PF) ............. 90
ribavirin .................................. 5
SELZENTRY .........................5
quasense ............................... 97
rifabutin ................................ 11
SENEXON-S ........................83
quetiapine ............................. 44
rifampin ................................ 11
SENNA .................................83
quinapril ............................... 49
ri-gel ..................................... 83
senna lax ...............................83
quinapril-hydrochlorothiazide
ri-gel ii .................................. 83
senna laxative .......................83
.......................................... 49
riginic.................................... 83
senna plus .............................83
quinidine gluconate .............. 45
riluzole .................................. 65
senna-extra ............................83
quinidine sulfate ................... 45
rimantadine ............................. 5
senna-s ..................................83
quinine sulfate ...................... 11
ri-mox ................................... 83
senno .....................................83
quit 2..................................... 66
ri-mox plus ........................... 83
sennosides-docusate sodium .83
149
sen-o-tab ............................... 83
sorbugen nr ......................... 112
sulfamethoxazole-trimethoprim
SENSIPAR ........................... 74
sorine .................................... 46
..........................................14
sentry .................................. 131
sotalol ................................... 46
sulfasalazine .........................84
sentry senior ....................... 131
sotalol af ............................... 46
sulfazine ................................ 84
SEREVENT DISKUS ........ 116
SOVALDI .............................. 5
sulfazine ec ...........................84
SEROQUEL XR .................. 44
spectravite adult 50+ .......... 131
sulindac .................................38
sertraline ............................... 44
spectravite advanced formula
sumatriptan ...........................27
severe allergy........................ 38
........................................ 131
sumatriptan succinate ...........27
sf 67
spectravite senior ................ 131
super b complex-vitamin c .131
sf 5000 plus .......................... 67
spectravite ultra women...... 131
super b-50 complex ............131
SIGNIFOR ........................... 21
spironolactone ...................... 50
super calcium ......................122
silace ..................................... 83
spironolacton-hydrochlorothiaz
super pain relief ....................38
sildenafil ............................. 116
.......................................... 50
suphedrin ............................112
siltussin dm das .................. 112
sprintec (28) .......................... 98
suphedrin 12 hour ...............112
SILTUSSIN SA .................. 112
SPRYCEL ............................ 21
suphedrine...........................112
siltussin-dm ........................ 112
sronyx ................................... 98
suphedrine 12 hour .............112
silver sulfadiazine ................. 55
ssd ......................................... 55
suppository adult ..................84
SIMULECT .......................... 21
stavudine................................. 5
SUPRAX ................................8
simvastatin............................ 54
stimulant laxative plus .......... 84
SURMONTIL .......................44
sinex ultra fine mist 12-hour 67
STIVARGA .......................... 21
SUSTIVA ...............................5
sinus & allergy non-drowsy 112
stomach relief ....................... 76
SUTENT ...............................21
sinus 12 hour ...................... 112
stomach relief max strength . 76
syeda .....................................98
sinus relief (oxymetazoline) . 67
stomach relief original .......... 76
SYLATRON .........................87
sirolimus ............................... 21
stool softener ........................ 84
SYMBICORT .....................116
SIRTURO ............................. 11
stool softener-laxative .......... 84
SYMLINPEN 120 ................72
smooth antacid.................... 122
stool softener-stimulant laxat84
SYMLINPEN 60 ..................72
sochlor ................................ 101
stop smoking aid ................... 66
SYNAGIS ...............................5
sodium bicarbonate .............. 83
STRATTERA ....................... 44
SYNAREL ............................74
sodium chloride .... 65, 101, 122
STREPTOMYCIN ............... 11
SYNERCID ..........................11
sodium chloride 0.45 %...... 122
stress 500 ............................ 131
SYNRIBO.............................22
sodium chloride 0.9 %.......... 65
STRESS FORMULA ......... 131
SYNTHROID .......................75
sodium chloride 3 %........... 122
stress formula 600 c ............ 131
SYPRINE .............................65
sodium chloride 5 %........... 122
STRESS FORMULA WITH
T
sodium fluoride .................. 131
IRON .............................. 131
TABLOID.............................22
sodium lactate..................... 122
STRIBILD .............................. 5
tacrolimus .......................22, 56
sodium polystyrene (sorb free)
SUBOXONE ........................ 38
TACROLIMUS ....................22
.......................................... 65
sucralfate .............................. 86
tactinal ..................................38
SOLTAMOX ........................ 21
SUDOGEST SINUS &
tactinal extra strength ...........38
soluble fiber .......................... 83
ALLERGY ..................... 112
TAFINLAR ..........................22
SOLU-CORTEF (PF)........... 69
sulfacetamide sodium ......... 103
TAMIFLU ..............................5
SOMATULINE DEPOT ...... 21
sulfacetamide sodium (acne) 58
tamoxifen ..............................22
SOMAVERT ........................ 74
sulfacetamide-prednisolone 103
tamsulosin ...........................118
soothe regular strength ......... 76
sulfadiazine........................... 14
TARCEVA ...........................22
soothing pureway-c ............ 131
TARGRETIN .......................22
150
TASIGNA ............................ 22
TOBRAMYCIN IN 0.225 %
trihexyphenidyl .....................27
TAZORAC ........................... 57
NACL ............................... 11
tri-legest fe ............................98
taztia xt ................................. 50
tobramycin in 0.9 % nacl ...... 11
tri-linyah ...............................98
tears again ................... 101, 102
tobramycin sulfate ................ 11
trilyte with flavor packets .....84
TECFIDERA ........................ 28
tobramycin-dexamethasone 103
trimethoprim .........................15
TEFLARO .............................. 8
TOBREX .............................. 99
trinessa (28) ..........................98
TEGRETOL XR ................... 25
tolazamide ............................ 72
TRIPLE ANTIBIOTIC .........58
TEKAMLO .......................... 50
tolbutamide ........................... 72
tri-previfem (28) ...................98
TEKTURNA ........................ 50
tolcapone .............................. 27
TRISENOX ..........................22
TEKTURNA HCT ............... 50
tolmetin................................. 38
tri-sprintec (28) .....................98
telmisartan ............................ 50
tolnaftate ............................... 59
TRIUMEQ ..............................5
telmisartan-hydrochlorothiazid
tolterodine........................... 117
TRI-VITA ...........................132
.......................................... 50
topiramate ............................. 26
TRI-VITAMIN ...................132
temazepam ............................ 44
TOPIRAMATE .................... 26
trivora (28) ............................98
TENIVAC (PF) .................... 90
toposar .................................. 22
TROPHAMINE 10 %.........126
terazosin ............................... 50
TOPOTECAN ...................... 22
TROPHAMINE 6%............126
terbinafine hcl ......................... 2
torsemide .............................. 50
tropicamide .........................100
terbutaline ........................... 116
tramadol ................................ 38
trospium .............................. 117
terconazole ........................... 94
tramadol-acetaminophen ...... 38
TRUMENBA ........................90
testosterone enanthate .......... 74
trandolapril ........................... 50
TRUVADA.............................5
tetanus toxoid,adsorbed (pf) . 90
trandolapril-verapamil .......... 50
TUDORZA PRESSAIR .....117
TETANUS,DIPHTHERIA
tranexamic acid............... 53, 94
TUMS ULTRA ...................123
TOX PED(PF) .................. 90
TRANSDERM-SCOP .......... 84
tusnel diabetic .....................112
TETANUS-DIPHTHERIA
tranylcypromine.................... 44
tussin ...................................113
TOXOIDS-TD.................. 90
TRAVASOL 10 % ............. 126
TUSSIN CF ........................112
tetracycline ........................... 15
travel sickness....................... 84
tussin cf cough-cold ............112
THALOMID......................... 22
travoprost (benzalkonium) . 102
tussin chest congestion .......112
theochron ............................ 116
trazodone .............................. 44
tussin cough &chest congestion
theophylline ........................ 116
TREANDA ........................... 22
........................................112
THERA VITAMIN ............ 131
TRECATOR ......................... 11
tussin cough (dm only) .......112
THERA-M .................. 131, 132
TRELSTAR .......................... 22
tussin cough dm ..................112
therapeutic-m ...................... 132
tretinoin ................................ 57
tussin dm .............................113
thera-tabs m ........................ 132
TRETINOIN
TUSSIN DM .......................113
thiamine hcl ........................ 132
(CHEMOTHERAPY) ...... 22
tussin dm clear ....................113
thioridazine ........................... 44
tretinoin microspheres .......... 57
tussin dm cough ..................113
thiothixene ............................ 44
triamcinolone acetonide 62, 67,
tussin dm cough & chest.....113
tiagabine ............................... 26
69, 116
tussin dm max .....................113
TIKOSYN ............................ 46
triamterene-hydrochlorothiazid
tussin expectorant ...............113
tilia fe.................................... 98
.......................................... 50
tussin honey ........................113
timolol maleate ............. 50, 100
trianex ................................... 62
tussi-pres .............................113
tinidazole .............................. 11
TRI-BUFFERED ASPIRIN . 38
TWINRIX (PF) .....................91
TIVICAY ............................... 5
triderm .................................. 62
TYBOST.................................6
tizanidine .............................. 29
tri-estarylla............................ 98
TYGACIL.............................11
TOBRADEX ST ................ 103
trifluoperazine ...................... 44
TYKERB ..............................22
tobramycin ............................ 99
trifluridine............................. 99
tylophen ................................ 38
151
TYPHIM VI ......................... 91
vestura (28) ........................... 98
VPRIV ..................................74
TYSABRI ............................. 28
vicks qlearquil allergy ........ 113
VYTORIN 10-10 ..................54
TYZEKA ................................ 6
vicks qlearquil(oxymetazoline)
VYTORIN 10-20 ..................54
.......................................... 67
VYTORIN 10-40 ..................54
U
ULORIC ............................... 91
VICTOZA 3-PAK ................ 72
VYTORIN 10-80 ..................54
ultra strength antacid .......... 123
VIDEX 2 GRAM PEDIATRIC
W
ultra strength calcium antacid
............................................ 6
wal-dryl allergy ..................113
........................................ 123
VIEKIRA PAK....................... 6
wal-fex allergy ....................113
unithroid ............................... 75
VIGAMOX ........................... 99
wal-itin ................................ 113
ursodiol ................................. 84
VIIBRYD ............................. 45
wal-mucil fiber (aspartame) .84
VIMPAT ............................... 26
wal-mucil natural fiber lax ...84
V
VAGIFEM ............................ 94
VINBLASTINE.................... 22
wal-profen.............................38
valacyclovir ............................ 6
vincasar pfs ........................... 23
wal-zan 150 ..........................86
VALCHLOR ........................ 56
vincristine ............................. 23
wal-zyr (cetirizine) .............113
VALCYTE ............................. 6
vinorelbine ............................ 23
warfarin.................................53
VALGANCICLOVIR ............ 6
viorele (28) ........................... 98
wart remover .........................55
valproate sodium .................. 26
VIRACEPT ............................ 6
WELCHOL...........................54
valproic acid ......................... 26
VIRAMUNE XR .................... 6
wera (28) ...............................98
valproic acid (as sodium salt)
VIRAZOLE ............................ 6
woman's laxative ..................84
.......................................... 26
VIREAD ................................. 6
women's gentle laxative(bisac)
valsartan ............................... 50
vitacel (with lutein) ............ 132
..........................................84
valsartan-hydrochlorothiazide
vitalets ................................ 132
women's laxative (bisacodyl)84
.......................................... 50
vitamin a ............................. 132
women's stool softener .........84
valu-dryl allergy ................. 113
vitamin b complex .............. 132
wymzya fe ............................98
valu-tapp ............................. 113
VITAMIN B-1 .................... 132
X
vancomycin .......................... 15
VITAMIN B-12 .................. 132
XALKORI ............................23
VANCOMYCIN .................. 15
vitamin b-6 ......................... 132
XARELTO ...........................53
vandazole .............................. 95
VITAMIN B-6 .................... 132
XENAZINE ..........................28
VAQTA (PF) ........................ 91
vitamin c ............................. 132
XGEVA ................................ 16
VARIVAX (PF) ................... 91
VITAMIN C ....................... 132
XIFAXAN ............................11
VARIZIG ............................. 91
vitamin c with rose hips...... 132
XIGDUO XR ........................72
VECAMYL .......................... 54
VITAMIN D2 ..................... 132
XOLAIR .............................117
vegetable laxative ................. 84
vitamin d3 ........................... 132
XTANDI ...............................23
VELCADE ........................... 22
vitamin e ............................. 133
XYREM ................................ 45
velivet triphasic regimen (28)
vitamin e (dl, acetate) ......... 132
Y
.......................................... 98
VITAMIN K ......................... 53
yelets ...................................133
VELPHORO......................... 65
VITAMIN K1 ....................... 53
YERVOY .............................23
venlafaxine ........................... 44
VITAMINS B COMPLEX . 133
YF-VAX (PF) .......................91
VENTOLIN HFA ............... 117
VITEKTA ............................... 6
Z
VERAMYST ...................... 117
VIVELLE-DOT.................... 94
zafirlukast ...........................117
verapamil .............................. 50
VOLTAREN GEL ................ 38
ZALTRAP ............................23
veripred 20............................ 69
voriconazole ........................... 2
zamicet ..................................32
VERSACLOZ ...................... 45
VORICONAZOLE ................. 2
zantac maximum strength .....86
VESICARE ........................ 117
VOTRIENT .......................... 23
zarah .....................................98
152
ZAVESCA ........................... 74
ZELBORAF ......................... 23
ZEMPLAR ........................... 74
zenchent (28) ........................ 98
zenchent fe............................ 98
ZENPEP ............................... 84
zeosa ..................................... 98
ZETIA .................................. 54
ZIAGEN ................................. 6
zidovudine .............................. 6
zinc oxide ............................. 56
ziprasidone hcl ...................... 45
ZIRGAN ............................... 99
zoledronic acid ..................... 74
zoledronic acid-mannitol-water
.......................................... 65
ZOLINZA ............................. 23
zolmitriptan .......................... 27
zolpidem ............................... 45
ZOMETA ............................. 74
zonisamide ............................ 26
zoo chews ........................... 133
ZORTRESS ..........................23
ZOSTAVAX (PF) ................91
zovia 1/35e (28) ....................98
zovia 1/50e (28) ....................98
ZYCLARA ...........................56
ZYDELIG .............................23
ZYKADIA ............................23
ZYPREXA RELPREVV ......45
ZYTIGA ...............................23
ZYVOX ................................ 12
153
Este vademécum se actualizó el 8/19/2015. Para obtener información más reciente o si tiene otras preguntas,
comuníquese con el Plan al 800-815-0000 o, para usuarios de teléfonos de texto (TTY), al 800-662-1220. Se atiende de
lunes a domingo, de 8 a.m. a 8 p.m., o visite www.guildnetny.org.

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