Sharp Advantage - Sharp Health Plan

Transcripción

Sharp Advantage (HMO)
Formulario para 2016
(Lista de medicamentos cubiertos)
LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
Formulario de Sharp Advantage 2016 Part D válido desdel 1 de septiembre, 2016
ID de Formulario: 16490.001, Version: 17
Este formulario se actualizó el 25/08/2016. Para obtener información más reciente u otras preguntas, por favor
póngase en contacto con Sharp Advantage Servicios de Miembros al 1-855-820-2112. El horario es de 8:00 de
la mañana a 6:00, hora del Pacifico, de lunes a viernes. Para los usuarios de TTY llame a 711, o visite
www.sharphealthplan.com/sharpadvantage.
Nota a los miembros actuales: Este formulario ha cambiado desde el año pasado. Por favor, revise este
documento para asegurarse de que todavía contiene los medicamentos que toma.
Cuando en esta lista de medicamentos (formulario) dice “nosotros”, “nos” o “nuestro”, se hace referencia a
Sharp Advantage. Cuando dice “plan” o “nuestro plan”, se hace referencia a Sharp Advantage.
Este documento incluye una lista de medicamentos (formulario) de nuestro plan, la cual estará en vigencia
desde el 1 de septiembre, 2016. Para obtener el formulario actualizado, comuníquese con nosotros.
Nuestra información de contacto, y la fecha de la última actualización del formulario, aparece en las
páginas de la portada y la contraportada.
Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de medicamentos con receta. Los
beneficios, el formulario, la red de farmacias, la prima y/o los copagos o el coseguro pueden cambiar el 1 de
enero y de vez en cuando durante el año.
H5386_SA COMP FORMULARY SP
i
¿En qué consiste el formulario de Sharp Advantage?
Un formulario es una lista de medicamentos cubiertos seleccionados por Sharp Advantage con la
colaboración de un equipo de proveedores de atención médica, que representa los tratamientos con receta que
se consideran parte necesaria de un programa de tratamiento de calidad. Normalmente, Sharp Advantage
cubrirá los medicamentos incluidos en el formulario siempre que el medicamento sea necesario desde el punto
de vista médico, el medicamento con receta se obtenga en una farmacia de la red de Sharp Advantage y se
cumpla con otras normas del plan. Para obtener más información sobre cómo obtener sus medicamentos con
receta, consulte la Evidencia de cobertura.
¿El formulario (lista de medicamentos) puede modificarse?
En general, si usted está tomando un medicamento de nuestro formulario de 2016 que estaba cubierto al
comienzo del año, no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de
cobertura 2016, excepto cuando esté disponible un nuevo medicamento genérico de menor costo o cuando se
dé a conocer nueva información adversa acerca de la seguridad o eficacia del medicamento. Otros tipos de
cambios en nuestro formulario, como la eliminación de un medicamento, no afectarán a los miembros que
estén actualmente tomando ese medicamento. Continuará disponible al mismo costo compartido para aquellos
miembros que deban tomarlo por el resto del año de cobertura. Consideramos que es importante que tenga
acceso continuo, durante el resto del año de cobertura, a los medicamentos del formulario que estaban
disponibles cuando eligió nuestro plan, salvo en los casos en los que usted podría ahorrar más dinero o en que
nosotros podríamos garantizarle mayor seguridad.
Si retiramos medicamentos de nuestro formulario, agregamos autorizaciones previas, límites de cantidad o
restricciones en tratamientos escalonados en relación con un medicamento, o si pasamos un medicamento a un
nivel superior de costo compartido, debemos notificar sobre el cambio a los miembros afectados al menos 60
días antes de que entre en vigencia dicho cambio o cuando el miembro solicite una reposición del
medicamento, momento en el cual el miembro recibirá un suministro de medicamento para 60 días. Si la
Administración de Drogas y Alimentos considera que un medicamento de nuestro formulario es inseguro o si
el fabricante del medicamento lo retira del mercado, eliminaremos de inmediato dicho medicamento de nuestro
formulario y notificaremos a los miembros que toman el medicamento en cuestión. El formulario adjunto
estará vigente desde el 1 de septiembre, 2016. Para recibir información actualizada sobre los medicamentos
cubiertos por Sharp Advantage, comuníquese con nosotros. Nuestra información de contacto aparece en las
páginas de la portada y la contraportada. En el caso de que haya cambios no mantenimiento en el formulario a
mitad de año, se lo notificaremos por escrito para que tenga los cambios. Publicaremos una versión actualizada
del formulario de Sharp Advantage en nuestro sitio web en www.sharphealthplan.com/sharpadvantage. Si
desea una versión impresa de las correcciones, le enviaremos a usted a su petición.
¿Cómo utilizo el formulario?
Hay dos maneras de encontrar su medicamento dentro del formulario:
Condición médica
El formulario empieza en la página 1. Los medicamentos de este formulario están agrupados en categorías
según el tipo de enfermedad para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados
para tratar una enfermedad cardíaca se agrupan en la categoría “Medicamentos cardíacos”. Si sabe para qué se
utiliza su medicamento, busque el nombre de la categoría en la lista que comienza 1. Después busque el
ii
medicamento debajo del nombre de esa categoría.
Listado alfabético
Si no está seguro de qué categoría debe consultar, busque su medicamento en el índice que comienza en la
página I-1. El índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento.
En el índice se incluyen tanto los medicamentos de marca como los genéricos. Busque su medicamento en el
índice. Junto a su medicamento, verá el número de página donde puede encontrar información acerca de la
cobertura. Vaya a la página que figura en el índice y busque el nombre de su medicamento en la primera
columna de la lista.
¿Qué son los medicamentos genéricos?
Sharp Advantage cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está
aprobado por la Administración de Drogas y Alimentos (FDA, por sus siglas en inglés) dado que se considera
que tiene el mismo ingrediente activo que el medicamento de marca. Normalmente, los medicamentos
genéricos cuestan menos que los de marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y
límites pueden incluir:
• Autorización previa (PA, por sus siglas en inglés):
Sharp Advantage exige que usted o su médico obtengan una autorización previa para determinados
medicamentos. Esto significa que necesitará contar con la aprobación de Sharp Advantage antes de
obtener sus medicamentos con receta. Si no consigue la autorización, es posible que Sharp Advantage
no cubra el medicamento.
• Límites de cantidad (QL, por sus siglas en inglés):
Para ciertos medicamentos, Sharp Advantage limita la cantidad del medicamento que cubrirá Sharp
Advantage. Por ejemplo, Sharp Advantage proporciona un inhalador por receta de QVAR. Esto puede
ser complementario a un suministro estándar para un mes o tres meses.
• Tratamiento escalonado (ST, por sus siglas en inglés):
En algunos casos, Sharp Advantage requiere que usted primero pruebe ciertos medicamentos para
tratar su enfermedad antes de que cubramos otro medicamento para esa enfermedad. Por ejemplo, si
tanto el medicamento A como el medicamento B se utilizan para tratar su enfermedad, es posible que
Sharp Advantage no cubra el medicamento B si usted no prueba primero el medicamento A. Si el
medicamento A no funciona para usted, entonces Sharp Advantage cubrirá el medicamento B.
Puede consultar el formulario que comienza en la página 1 para averiguar si su medicamento tiene algún otro
requisito o límite. También puede obtener más información sobre las restricciones que se aplican a
medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado documentos en línea que explican
nuestras restricciones en autorizaciones y tratamientos escalonados. También puede pedir que le enviemos una
copia. Nuestra información de contacto, y la fecha de la última actualización del formulario, aparece en las
páginas de la portada y la contraportada.
Puede solicitar a Sharp Advantage que haga una excepción a estas restricciones o límites o puede solicitarle
una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección, “¿Cómo
solicito una excepción al formulario de Sharp Advantage?” en la página iv para obtener información acerca
de cómo solicitar una excepción.
iii
¿Qué debo hacer si mi medicamento no está en el formulario?
Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe ponerse
en contacto con Servicios de Miembros y preguntar si su medicamento está cubierto. Si resulta que Sharp
Advantage no cubre su medicamento, tiene dos alternativas:
•
Puede solicitar de Servicios de Miembro una lista de medicamentos similares cubiertos por Sharp
Advantage. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento
similar que esté cubierto por Sharp Advantage.
•
Puede solicitar a Sharp Advantage que haga una excepción y cubra el medicamento. Consulte más
abajo para obtener información sobre cómo solicitar una excepción.
¿Cómo puedo solicitar que se haga una excepción al formulario de Sharp Advantage?
Puede solicitar a Sharp Advantage que haga una excepción a nuestras normas de cobertura. Hay varios tipos
de excepciones que puede solicitarnos.
•
Puede pedirnos que cubramos su medicamento, aun que no está en nuestro formulario. Si se aprueba, el
medicamento quedará cubierto a un nivel de costo compartido predeterminado y usted no podrá
pedirnos que proporcionemos el medicamento a un nivel de costo compartido menor.
•
Puede pedirnos que cubramos un medicamento del formulario a un nivel de costo compartido menor si
este medicamento no está incluido en el nivel de medicamentos especializados. Si se aprueba, esto
reduciría el monto que usted debe pagar por su medicamento.
•
Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Por
ejemplo: para ciertos medicamentos, Sharp Advantage limita la cantidad del medicamento que
cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción
al límite y cubramos una cantidad mayor.
Por lo general, Sharp Advantage solo aprobará su pedido de excepción si los demás medicamentos incluidos
en el formulario del plan, el medicamento de menor costo compartido o las restricciones de uso adicionales
no fueran tan efectivos para tratar su enfermedad o pudieran causarle efectos médicos adversos.
Debe ponerse en contacto con nosotros para solicitarnos una decisión inicial de cobertura respecto de una
excepción al formulario, al nivel o a la restricción de uso. Cuando solicita una excepción al formulario, al
nivel o a la restricción de uso, debe presentar una declaración de su médico o de la persona que emite la
receta que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas a partir
de la fecha en que recibimos la declaración que respalda su solicitud por parte de la persona que emite la
receta. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que esperar 72 horas
para tomar la decisión podría perjudicar gravemente su salud. Si se le concede el trámite rápido de la
excepción, debemos comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber
recibido la declaración de respaldo de la persona autorizada para dar recetas.
iv
¿Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos que tomo o la
solicitud de una excepción?
Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no están
incluidos en el formulario. También es posible que esté tomando un medicamento incluido en el formulario
pero su capacidad de conseguirlo esté limitada. Por ejemplo, puede necesitar nuestra autorización previa para
obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar su
medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al formulario para que le
cubramos su medicamento. Mientras evalúa con su médico el procedimiento adecuado para su caso, podemos
cubrir su medicamento en ciertos casos durante los primeros 90 días en que usted es miembro de nuestro plan.
Para cada uno de los medicamentos que no están incluidos en el formulario o si su capacidad para conseguir
los medicamentos es limitada, cubriremos suministros temporales para 30 días (a menos que tenga una receta
para menos días) cuando acuda a una farmacia de la red. Después del primer suministro para 30 días, no
seguiremos pagando estos medicamentos, aunque haga menos de 90 días que usted es miembro del plan.
Si reside en un centro de atención a largo plazo, le permitiremos volver a obtener su receta hasta que le
hayamos provisto un suministro de transición de 98 días, conforme al incremento de provisión (a menos que
tenga una receta para menos días). Cubriremos más de resurtido de estos medicamentos durante los primeros
90 días en que usted sea miembro del plan. Si necesita un medicamento que no está en el formulario o si su
capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en
nuestro plan, cubriremos un suministro de emergencia del medicamento para 31 días (a menos que tenga una
receta para menos días) mientras solicita la excepción al formulario.
Para obtener más información
Para obtener información más detallada sobre la cobertura de medicamentos con receta de Sharp Advantage,
consulte la Evidencia de Cobertura y la demás documentación del plan.
Si tiene alguna pregunta sobre Sharp Advantage, comuníquese con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización del formulario, aparece en las páginas de la portada y la
contraportada.
Si tiene preguntas generales sobre su cobertura de medicamentos con receta de Medicare, llame a Medicare al
1-800-MEDICARE (1-800-633-4227), durante las 24 horas, los 7 días de la semana. Los usuarios de
TTY/TDD deben llamar al 1-877-486-2048. O visite www.medicare.gov.
Formulario de Sharp Advantage
El formulario que comienza en la página 1 proporciona información sobre la cobertura de algunos de los
medicamentos que cubre Sharp Advantage. Si tiene alguna dificultad para encontrar su medicamento en la
lista, consulte el índice que comienza en la página I-1.
En la primera columna de la tabla figura el nombre del medicamento. Los medicamentos de marca están en
letra mayúscula (por ejemplo, CRESTOR) y los medicamentos genéricos están en letra minúscula y cursiva
(por ejemplo, lisinopril).
La información de la columna de Requisitos/límites indica si Sharp Advantage tiene algún requisito
especial para la cobertura del medicamento.
v
Las siguientes abreviaturas se pueden encontrar dentro de este documento
COBERTURA DE NOTAS ABREVIATURAS
ABREVIATURA
PA
DESCRIPCIÓN
Restricción de Autorización Previa
EXPLICACIÓN
Usted (o su proveedor) tiene la
obligación de obtener
autorización previa de Sharp
Advantage antes de surtir su
receta para este medicamento.
Sin la previa autorización, no
podemos cubrir esta
medicamento.
Este medicamento puede ser
elegible para el pago de la Parte
B o la Parte D de Medicare.
Usted (o su proveedor) están
obligados a obtener autorización
de nosotros para determinar que
este medicamento esté cubierto
por la Parte D de Medicare antes
de surtir su receta para este
medicamento. Sin la previa
autorización, no podemos cubrir
esta medicamento.
Si usted tiene 65 años o más,
usted (o su proveedor) tiene la
obligación de obtener una
autorización previa antes de
surtir su receta para este
medicamento. Sin autorización
previa, es posible que no cubra
este medicamento.
PA BvD
Restricción de Autorización Previa Para
La Parte B vs Parte D Determinación
PA HRM
Restricciones Autorización Previa Para
Los Miembros de 65 Años y Mayores
PA NSO
Restricción de Autorización Previa Sólo Para
Miembros Nuevos
Si es un nuevo miembro, usted (o
su proveedor) tiene la obligación
de obtener una autorización
previa antes de surtir su receta
para este medicamento. Sin la
previa autorización, es posible
que no cubra este medicamento.
Restricciones Límite de Cantidad
Limitamos la cantidad de este
medicamento que esté cubierto
por receta, o dentro de un
periodo específico.
QL
vi
ST
Terapia Escalonada Restricción
Antes de que cubremos este
medicamento, debe primero
probar otro medicamento(s) para
el tratamiento de su condición
médical. Este medicamento sólo
puede ser cubierta si el otro
medicamento(s) no funciona para
usted.
LA
Medicamento de Acceso Limitado
Esta receta puede estar solo
disponible en algunas farmacias.
Para más información consulte su
Directorio de Farmacias o llame
a Servicios de Miembros al 1855-820-2112 para obtener
información adicional. (Los
usuarios de TTY deben llamar al
711.) Para su conveniencia,
nuestras horas de oficina son: El
horario es de 8:00 de la mañana a
6:00, hora del Pacifico, de lunes a
viernes.
NM
Sin Pedido Por Correo
Este medicamento no está
disponible a través de pedidos
por correo.
vii
Tabla de contenido
Analgesics ........................................................................................................................................................................................................................................................................................................ 3
Anesthetics ................................................................................................................................................................................................................................................................................................. 10
Anti-Addiction/Substance Abuse Treatment Agents ................................................................................................................................................................... 11
Antianxiety Agents ........................................................................................................................................................................................................................................................................ 12
Antibacterials ......................................................................................................................................................................................................................................................................................... 13
Anticancer Agents ........................................................................................................................................................................................................................................................................... 23
Anticholinergic Agents ............................................................................................................................................................................................................................................................. 33
Anticonvulsants .................................................................................................................................................................................................................................................................................. 34
Antidementia Agents .................................................................................................................................................................................................................................................................. 38
Antidepressants ................................................................................................................................................................................................................................................................................... 39
Antidiabetic Agents ...................................................................................................................................................................................................................................................................... 42
Antifungals ................................................................................................................................................................................................................................................................................................ 48
Antihistamines ...................................................................................................................................................................................................................................................................................... 50
Anti-Infectives (Skin And Mucous Membrane) .................................................................................................................................................................................. 50
Antimigraine Agents ................................................................................................................................................................................................................................................................... 51
Antimycobacterials ........................................................................................................................................................................................................................................................................ 52
Antinausea Agents ......................................................................................................................................................................................................................................................................... 52
Antiparasite Agents ...................................................................................................................................................................................................................................................................... 54
Antiparkinsonian Agents ...................................................................................................................................................................................................................................................... 54
Antipsychotic Agents ................................................................................................................................................................................................................................................................. 56
Antivirals (Systemic) ................................................................................................................................................................................................................................................................... 60
Blood Products/Modifiers/Volume Expanders ..................................................................................................................................................................................... 66
Caloric Agents ...................................................................................................................................................................................................................................................................................... 69
Cardiovascular Agents ............................................................................................................................................................................................................................................................. 74
Central Nervous System Agents ................................................................................................................................................................................................................................. 86
Contraceptives ...................................................................................................................................................................................................................................................................................... 88
Dental And Oral Agents ........................................................................................................................................................................................................................................................ 95
Dermatological Agents ............................................................................................................................................................................................................................................................ 96
Devices ......................................................................................................................................................................................................................................................................................................... 102
Enzyme Replacement/Modifiers ............................................................................................................................................................................................................................ 103
Eye, Ear, Nose, Throat Agents ................................................................................................................................................................................................................................. 104
Gastrointestinal Agents ....................................................................................................................................................................................................................................................... 109
Genitourinary Agents ............................................................................................................................................................................................................................................................. 114
Heavy Metal Antagonists ................................................................................................................................................................................................................................................. 114
Hormonal Agents, Stimulant/Replacement/Modifying ....................................................................................................................................................... 115
Immunological Agents .......................................................................................................................................................................................................................................................... 121
Inflammatory Bowel Disease Agents ............................................................................................................................................................................................................... 130
Irrigating Solutions .................................................................................................................................................................................................................................................................... 130
Metabolic Bone Disease Agents .............................................................................................................................................................................................................................. 131
Miscellaneous Therapeutic Agents ..................................................................................................................................................................................................................... 132
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Formulario de Sharp Advantage 2016 Part D
ID de Formulario: 16490.001, Versión: 17
1
Valido desdel: 01/09/16
Ophthalmic Agents .................................................................................................................................................................................................................................................................... 138
Replacement Preparations .............................................................................................................................................................................................................................................. 139
Respiratory Tract Agents ................................................................................................................................................................................................................................................. 144
Skeletal Muscle Relaxants ............................................................................................................................................................................................................................................... 148
Sleep Disorder Agents ........................................................................................................................................................................................................................................................... 148
Vasodilating Agents .................................................................................................................................................................................................................................................................. 149
Vitamins And Minerals ....................................................................................................................................................................................................................................................... 150
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2
Nombre de Medicamento
Nivel
Requisitos/Limites
Analgesics
Analgesics, Miscellaneous
acetaminophen-codeine 120 mg-12 mg/5
ml solution 120-12 mg/5 ml
acetaminophen-codeine oral solution 300
mg-30 mg /12.5 ml
acetaminophen-codeine oral tablet 300-15
mg, 300-30 mg
acetaminophen-codeine oral tablet 300-60
mg
ALLZITAL ORAL TABLET 25-325
MG
ascomp with codeine oral capsule
30-50-325-40 mg
BELBUCA BUCCAL FILM 150
MCG, 300 MCG, 450 MCG, 600 MCG,
75 MCG, 750 MCG, 900 MCG
buprenorphine hcl injection syringe 0.3
mg/ml
butalbital compound w/codeine oral
capsule 30-50-325-40 mg
butalbital-acetaminop-caf-cod oral
capsule 50-300-40-30 mg, 50-325-40-30
mg
butalbital-acetaminophen oral tablet
50-325 mg
butalbital-acetaminophen-caff oral
capsule 50-325-40 mg
butalbital-acetaminophen-caff oral tablet
50-325-40 mg
butalbital-aspirin-caffeine oral capsule
50-325-40 mg
butorphanol tartrate nasal
spray,non-aerosol 10 mg/ml
(Acetaminophen with
Codeine)
(Acetaminophen with
Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
2
QL (2700 per 30 days)
2
2
2
2
(Fiorinal with Codeine
#3)
2
4
ST; QL (60 per 30 days)
(Buprenorphine HCl)
2
(Fiorinal with Codeine
#3)
(Fioricet with Codeine)
2
2
(Tencon)
2
(Esgic)
2
(Esgic)
2
(Fiorinal)
2
(Butorphanol Tartrate)
2
QL (5 per 28 days)
Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan por ir a las
páginas de introducción de este documento.
3
BUTRANS TRANSDERMAL
PATCH WEEKLY 10 MCG/HOUR,
15 MCG/HOUR, 20 MCG/HOUR, 5
MCG/HOUR, 7.5 MCG/HOUR
capacet oral capsule 50-325-40 mg
codeine sulfate oral tablet 15 mg, 30 mg,
60 mg
EMBEDA ORAL CAPSULE,ORAL
ONLY,EXT.REL PELL 100-4 MG,
20-0.8 MG, 30-1.2 MG, 50-2 MG,
60-2.4 MG, 80-3.2 MG
endocet oral tablet 10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325 mg
endodan oral tablet 4.8355-325 mg
fentanyl citrate buccal lozenge on a
handle 1,200 mcg, 1,600 mcg, 200 mcg,
400 mcg, 600 mcg, 800 mcg
fentanyl transdermal patch 72 hour 100
mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5
mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75
mcg/hr, 87.5 mcg/hour
hydrocodone-acetaminophen oral solution
10-325 mg/15 ml(15 ml), 2.5-167 mg/5
ml, 7.5-325 mg/15 ml
hydrocodone-acetaminophen oral tablet
10-300 mg, 5-300 mg, 7.5-300 mg
hydrocodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg,
7.5-325 mg
hydrocodone-ibuprofen oral tablet 10-200
mg, 2.5-200 mg, 5-200 mg, 7.5-200 mg
hydromorphone (pf) injection solution 10
mg/ml
hydromorphone (pf) injection solution 4
mg/ml
Nivel
Requisitos/Limites
3
QL (4 per 28 days)
2
2
4
QL (60 per 30 days)
(Xolox)
2
(Percodan)
(Actiq)
2
5
PA; QL (120 per 30
days)
(Duragesic)
2
QL (10 per 30 days)
(Hycet)
2
(Norco)
2
(Norco)
2
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
(Ibudone)
2
(Dilaudid-HP)
2
(Dilaudid)
2
(Esgic)
(Codeine Sulfate)
4
hydromorphone injection solution 2
mg/ml
hydromorphone injection syringe 2 mg/ml
hydromorphone oral liquid 1 mg/ml
hydromorphone oral tablet 2 mg, 4 mg
hydromorphone oral tablet 8 mg
HYSINGLA ER ORAL
TABLET,ORAL ONLY,EXT.REL.24
HR 100 MG, 120 MG, 20 MG, 30 MG,
40 MG, 60 MG, 80 MG
LAZANDA NASAL
SPRAY,NON-AEROSOL 100
MCG/SPRAY, 300 MCG/SPRAY, 400
MCG/SPRAY
lorcet (hydrocodone) oral tablet 5-325
mg
lorcet hd oral tablet 10-325 mg
lorcet plus oral tablet 7.5-325 mg
margesic oral capsule 50-325-40 mg
methadone injection solution 10 mg/ml
methadone oral solution 10 mg/5 ml, 5
mg/5 ml
methadone oral tablet 10 mg, 5 mg
methadose oral tablet,soluble 40 mg
morphine (pf) in 0.9 % nacl intravenous
pt controlled analgesia syring 50 mg/25
ml (2 mg/ml)
morphine 10 mg/ml carpuject 10 mg/ml
morphine 8 mg/ml syringe 8 mg/ml
morphine concentrate oral solution 100
mg/5 ml (20 mg/ml)
morphine concentrate oral syringe 20
mg/ml
Nivel
(Hydromorphone HCl)
2
(Hydromorphone HCl)
(Dilaudid)
(Dilaudid)
(Dilaudid)
2
2
2
2
3
Requisitos/Limites
QL (30 per 30 days)
5
PA; QL (30 per 30
days)
(Norco)
2
(Norco)
(Norco)
(Esgic)
(Methadone HCl)
(Methadone HCl)
2
2
2
2
2
(Diskets)
(Diskets)
(Morphine
Sulfate/0.9% Nacl/PF)
2
2
2
QL (90 per 30 days)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
2
2
2
2
2
(Morphine Sulfate)
2
5
morphine in dextrose 5 % injection pt
controlled analgesia syring 100 mg/50 ml
(2 mg/ml), 50 mg/25 ml (2 mg/ml)
morphine injection solution 15 mg/ml, 8
mg/ml
morphine injection syringe 10 mg/ml
morphine intramuscular pen injector 10
mg/0.7 ml
morphine intravenous cartridge 15 mg/ml
morphine intravenous solution 25 mg/ml,
50 mg/ml
morphine intravenous syringe 10 mg/ml, 2
mg/ml, 4 mg/ml, 8 mg/ml
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml (4
mg/ml)
MORPHINE ORAL TABLET 15 MG,
30 MG
morphine oral tablet extended release 100
mg, 30 mg, 60 mg
morphine oral tablet extended release 15
mg, 200 mg
morphine rectal suppository 10 mg, 20
mg, 30 mg, 5 mg
NUCYNTA ER ORAL TABLET
EXTENDED RELEASE 12 HR 100
MG, 150 MG, 200 MG, 250 MG, 50
MG
NUCYNTA ORAL TABLET 100 MG,
50 MG, 75 MG
oxycodone oral capsule 5 mg
oxycodone oral concentrate 20 mg/ml
oxycodone oral solution 5 mg/5 ml
oxycodone oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
Nivel
Requisitos/Limites
(Morphine
Sulfate/D5W)
2
(Morphine Sulfate)
2
(Morphine Sulfate)
(Morphine Sulfate)
2
2
(Morphine Sulfate)
(Morphine Sulfate)
2
2
(Morphine Sulfate)
2
(Morphine Sulfate)
(Morphine Sulfate)
2
2
4
(MS Contin)
2
(MS Contin)
2
(Morphine Sulfate)
2
(Oxycodone HCl)
(Oxycodone HCl)
(Oxycodone HCl)
(Roxicodone)
3
QL (60 per 30 days)
3
2
2
2
2
6
oxycodone oral tablet,oral only,ext.rel.12
hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg,
60 mg
oxycodone oral tablet,oral only,ext.rel.12
hr 80 mg
oxycodone-acetaminophen oral solution
5-325 mg/5 ml
oxycodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg,
7.5-325 mg
10-650 mg
7.5-500 mg
oxycodone-aspirin oral tablet 4.8355-325
mg
OXYCONTIN ORAL
HR 10 MG, 15 MG, 20 MG, 30 MG, 40
MG, 60 MG
OXYCONTIN ORAL
HR 80 MG
oxymorphone oral tablet 10 mg, 5 mg
oxymorphone oral tablet extended release
12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
oxymorphone oral tablet extended release
12 hr 30 mg, 40 mg
reprexain oral tablet 10-200 mg, 2.5-200
mg, 5-200 mg
roxicet oral solution 5-325 mg/5 ml
tencon oral tablet 50-325 mg
tramadol oral tablet 50 mg
tramadol-acetaminophen oral tablet
37.5-325 mg
Nivel
Requisitos/Limites
(Oxycontin)
2
QL (60 per 30 days)
(Oxycontin)
5
(Oxycodone
HCl/Acetaminophen)
(Xolox)
2
2
(Xolox)
2
(Xolox)
2
(Percodan)
2
3
QL (60 per 30 days)
3
(Opana)
(Opana ER)
2
2
QL (60 per 30 days)
(Opana ER)
2
(Ibudone)
2
(Oxycodone
HCl/Acetaminophen)
(Tencon)
(Ultram)
(Ultracet)
2
2
2
2
7
Nivel
Requisitos/Limites
3
(includes Vicodin,
Vicodin ES and
per 30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
2
2
4
QL (60 per 30 days)
vicodin es oral tablet 7.5-300 mg
(Norco)
2
vicodin hp oral tablet 10-300 mg
(Norco)
2
vicodin oral tablet 5-300 mg
(Norco)
2
XARTEMIS XR ORAL TAB,ORAL
ONLY,IR - ER, BIPHASE 7.5-325 MG
xylon 10 oral tablet 10-200 mg
zebutal oral capsule 50-325-40 mg
ZOHYDRO ER ORAL CAPSULE,
ORAL ONLY, ER 12HR 10 MG, 15
MG, 20 MG, 30 MG, 40 MG, 50 MG
Nonsteroidal Anti-Inflammatory
Agents
CALDOLOR INTRAVENOUS
RECON SOLN 400 MG/4 ML (100
MG/ML)
celecoxib oral capsule 100 mg, 200 mg,
400 mg, 50 mg
choline,magnesium salicylate oral liquid
500 mg/5 ml
diclofenac potassium oral tablet 50 mg
diclofenac sodium oral tablet extended
release 24 hr 100 mg
diclofenac sodium oral tablet,delayed
release (dr/ec) 25 mg, 50 mg, 75 mg
diclofenac sodium topical gel 3 %
diclofenac-misoprostol oral
tablet,ir,delayed rel,biphasic 50-200
mg-mcg, 75-200 mg-mcg
(Ibudone)
(Esgic)
4
(Celebrex)
2
(Choline Sal/Mag
Salicylate)
(Diclofenac Potassium)
(Voltaren-XR)
2
(Diclofenac Sodium)
2
(Voltaren)
(Arthrotec 50)
5
2
QL (60 per 30 days)
2
2
8
diflunisal oral tablet 500 mg
etodolac oral capsule 200 mg, 300 mg
etodolac oral tablet 400 mg, 500 mg
etodolac oral tablet extended release 24
hr 400 mg, 500 mg, 600 mg
fenoprofen oral capsule 200 mg
fenoprofen oral tablet 600 mg
FLECTOR TRANSDERMAL
PATCH 12 HOUR 1.3 %
flurbiprofen oral tablet 100 mg, 50 mg
ibuprofen oral suspension 100 mg/5 ml
ibuprofen oral tablet 400 mg, 600 mg,
800 mg
indomethacin oral capsule 25 mg
indomethacin oral capsule 50 mg
indomethacin oral capsule, extended
release 75 mg
indomethacin sodium intravenous recon
soln 1 mg
ketoprofen oral capsule 50 mg, 75 mg
ketoprofen oral capsule,ext rel. pellets 24
hr 200 mg
ketorolac 30 mg/ml carpuject luer lock,
10's,l/f 30 mg/ml
ketorolac injection cartridge 15 mg/ml
Nivel
(Diflunisal)
(Etodolac)
(Etodolac)
(Etodolac)
2
2
2
2
(Nalfon)
(Fenoprofen Calcium)
2
2
3
(Flurbiprofen)
(Ibuprofen)
(Ibuprofen)
2
2
1
(Indomethacin)
(Indomethacin)
(Indomethacin)
2
2
2
(Indomethacin
Sodium)
(Ketoprofen)
(Ketoprofen)
2
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
ketorolac injection cartridge 30 mg/ml
(Ketorolac
Tromethamine)
ketorolac injection solution 15 mg/ml
(Ketorolac
Tromethamine)
ketorolac injection solution 30 mg/ml (1 (Ketorolac
ml)
Tromethamine)
ketorolac injection syringe 30 mg/ml
(Ketorolac
Tromethamine)
ketorolac intramuscular solution 60 mg/2 (Ketorolac
ml
Tromethamine)
Requisitos/Limites
PA
QL (60 per 30 days)
2
2
2
QL (20 per 30 days)
2
QL (40 per 30 days)
2
QL (20 per 30 days)
2
QL (40 per 30 days)
2
QL (20 per 30 days)
2
QL (20 per 30 days)
2
QL (20 per 30 days)
9
Nivel
(Ketorolac
Tromethamine)
mefenamic acid oral capsule 250 mg
(Ponstel)
meloxicam oral suspension 7.5 mg/5 ml
(Mobic)
meloxicam oral tablet 15 mg, 7.5 mg
(Mobic)
nabumetone oral tablet 500 mg, 750 mg
(Nabumetone)
naproxen oral suspension 125 mg/5 ml
(Naprosyn)
naproxen oral tablet 250 mg, 375 mg, 500 (Naprosyn)
mg
naproxen oral tablet,delayed release
(Ec-Naprosyn)
(dr/ec) 375 mg, 500 mg
naproxen sodium oral tablet 275 mg, 550 (Anaprox)
mg
piroxicam oral capsule 10 mg, 20 mg
(Feldene)
sulindac oral tablet 150 mg, 200 mg
(Sulindac)
tolmetin oral capsule 400 mg
(Tolmetin Sodium)
tolmetin oral tablet 200 mg, 600 mg
(Tolmetin Sodium)
VOLTAREN TOPICAL GEL 1 %
ketorolac oral tablet 10 mg
2
Requisitos/Limites
QL (20 per 30 days)
2
2
1
2
2
1
2
1
2
2
2
2
2
Anesthetics
Local Anesthetics
glydo mucous membrane jelly in
applicator 2 %
lidocaine (pf) injection solution 15 mg/ml
(1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5
%)
lidocaine (pf) intravenous syringe 100
mg/5 ml (2 %)
lidocaine 2% viscous soln 2 %
lidocaine hcl injection solution 10 mg/ml
(1 %), 20 mg/ml (2 %)
lidocaine hcl mucous membrane gel 2 %
lidocaine hcl mucous membrane solution
2 %, 4 % (40 mg/ml)
lidocaine topical adhesive
patch,medicated 5 %
lidocaine topical ointment 5 %
(Lidocaine HCl)
2
(Xylocaine-MPF)
2
(Lidocaine HCl/PF)
2
(Xylocaine)
(Xylocaine)
2
2
(Lidocaine HCl)
(Xylocaine)
2
2
(Lidoderm)
2
(Lidocaine)
2
PA
10
Nivel
lidocaine-prilocaine topical cream 2.5-2.5 (EMLA)
%
Requisitos/Limites
2
Anti-Addiction/Substance Abuse
Treatment Agents
Anti-Addiction/Substance Abuse
Treatment Agents
acamprosate oral tablet,delayed release
(dr/ec) 333 mg
buprenorphine hcl sublingual tablet 2 mg,
8 mg
buprenorphine-naloxone sublingual tablet
2-0.5 mg, 8-2 mg
bupropion hcl (smoking deter) oral tablet
extended release 150 mg
CHANTIX CONTINUING MONTH
BOX ORAL TABLET 1 MG
CHANTIX ORAL TABLET 0.5 MG, 1
MG
CHANTIX STARTING MONTH
BOX ORAL TABLETS,DOSE PACK
0.5 MG (11)- 1 MG (42)
disulfiram oral tablet 250 mg, 500 mg
naloxone injection solution 0.4 mg/ml
naloxone injection syringe 0.4 mg/ml, 1
mg/ml
naltrexone oral tablet 50 mg
NARCAN NASAL
SPRAY,NON-AEROSOL 4
MG/ACTUATION
NICOTROL INHALATION
CARTRIDGE 10 MG
ZUBSOLV SUBLINGUAL TABLET
1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71
MG, 5.7-1.4 MG, 8.6-2.1 MG
(Acamprosate
Calcium)
(Buprenorphine HCl)
2
(Buprenorphine
HCl/Naloxone HCl)
(Zyban)
2
2
PA; QL (90 per 30
days)
PA; QL (90 per 30
days)
2
3
3
3
QL (53 per 28 days)
(Antabuse)
(Naloxone HCl)
(Naloxone HCl)
2
2
2
(Revia)
2
4
QL (4 per 30 days)
4
3
PA; QL (90 per 30
days)
11
Nivel
Requisitos/Limites
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg
alprazolam oral tablet extended release
24 hr 0.5 mg, 1 mg, 2 mg
alprazolam oral tablet extended release
24 hr 3 mg
chlordiazepoxide hcl oral capsule 10 mg,
25 mg, 5 mg
clonazepam oral tablet 0.5 mg, 1 mg
clonazepam oral tablet 2 mg
clonazepam oral tablet,disintegrating
0.125 mg, 0.25 mg, 0.5 mg, 1 mg
clonazepam oral tablet,disintegrating 2
mg
clorazepate dipotassium oral tablet 15 mg
clorazepate dipotassium oral tablet 3.75
mg, 7.5 mg
diazepam injection syringe 5 mg/ml
diazepam intensol oral concentrate 5
mg/ml
diazepam oral solution 5 mg/5 ml (1
mg/ml)
diazepam oral tablet 10 mg, 2 mg, 5 mg
diazepam rectal kit 12.5-15-17.5-20 mg,
2.5 mg, 5-7.5-10 mg
estazolam oral tablet 1 mg
estazolam oral tablet 2 mg
flurazepam oral capsule 15 mg
flurazepam oral capsule 30 mg
lorazepam intensol oral concentrate 2
mg/ml
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
midazolam oral syrup 2 mg/ml
(Xanax)
2
(Xanax XR)
2
(Xanax XR)
2
QL (90 per 30 days)
(Chlordiazepoxide
HCl)
(Klonopin)
(Klonopin)
(Clonazepam)
2
2
2
2
QL (90 per 30 days)
QL (90 per 30 days)
(Clonazepam)
2
(Tranxene T-Tab)
(Tranxene T-Tab)
2
2
QL (60 per 30 days)
(Diazepam)
(Diazepam)
2
2
QL (10 per 28 days)
(Diazepam)
2
(Valium)
(Diastat)
2
2
(Estazolam)
(Estazolam)
(Flurazepam HCl)
(Flurazepam HCl)
(Ativan)
2
2
2
2
2
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
(Ativan)
(Midazolam HCl)
2
2
QL (90 per 30 days)
QL (10 per 30 days)
12
ONFI ORAL SUSPENSION 2.5
MG/ML
temazepam oral capsule 15 mg, 22.5 mg,
30 mg
temazepam oral capsule 7.5 mg
triazolam oral tablet 0.125 mg
triazolam oral tablet 0.25 mg
Nivel
Requisitos/Limites
4
(Restoril)
2
PA NSO; QL (480 per
30 days)
QL (30 per 30 days)
(Restoril)
(Halcion)
(Halcion)
2
2
2
QL (60 per 30 days)
5
PA BvD
Antibacterials
Aminoglycosides
BETHKIS INHALATION
SOLUTION FOR NEBULIZATION
300 MG/4 ML
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 100 mg/50 ml,
60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml,
80 mg/50 ml, 90 mg/100 ml
gentamicin injection solution 40 mg/ml
gentamicin ped 20 mg/2 ml vial
latex-free, sdv 20 mg/2 ml
gentamicin sulfate (pf) intravenous
solution 80 mg/8 ml
neomycin oral tablet 500 mg
streptomycin intramuscular recon soln 1
gram
TOBI PODHALER INHALATION
CAPSULE, W/INHALATION
DEVICE 28 MG
tobramycin in 0.225 % nacl inhalation
solution for nebulization 300 mg/5 ml
tobramycin in 0.9 % nacl intravenous
piggyback 60 mg/50 ml, 80 mg/100 ml
tobramycin sulfate injection solution 10
mg/ml, 40 mg/ml
Antibacterials, Miscellaneous
baciim intramuscular recon soln 50,000
unit
(Gentamicin In Nacl,
Iso-Osm)
2
(Gentamicin Sulfate)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin Sulfate)
2
2
2
2
2
5
(Tobi)
5
PA BvD
(Tobramycin/Sodium
Chloride)
(Tobramycin Sulfate)
2
(Bacitracin)
2
2
13
bacitracin intramuscular recon soln
50,000 unit
chloramphenicol sod succinate
intravenous recon soln 1 gram
clindamycin 75 mg/5 ml soln 75 mg/5 ml
clindamycin hcl oral capsule 150 mg, 300
mg, 75 mg
clindamycin in 5 % dextrose intravenous
piggyback 300 mg/50 ml, 600 mg/50 ml,
900 mg/50 ml
clindamycin pediatric oral recon soln 75
mg/5 ml
clindamycin phosphate injection solution
150 mg/ml
clindamycin phosphate intravenous
solution 600 mg/4 ml
colistin (colistimethate na) injection
recon soln 150 mg
CUBICIN INTRAVENOUS RECON
SOLN 500 MG
CUBICIN RF INTRAVENOUS
RECON SOLN 500 MG
linezolid intravenous parenteral solution
600 mg/300 ml
linezolid oral suspension for
reconstitution 100 mg/5 ml
linezolid oral tablet 600 mg
methenamine hippurate oral tablet 1
gram
metronidazole in nacl (iso-os)
intravenous piggyback 500 mg/100 ml
metronidazole oral capsule 375 mg
metronidazole oral tablet 250 mg, 500 mg
nitrofurantoin macrocrystal oral capsule
100 mg, 25 mg, 50 mg
Nivel
(Bacitracin)
2
(Chloramphenicol Sod
Succ)
(Cleocin Palmitate)
(Cleocin HCl)
2
(Cleocin Phosphate In
D5w)
2
(Cleocin Palmitate)
2
(Cleocin Phosphate)
2
(Cleocin Phosphate)
2
(Coly-Mycin M
Parenteral)
5
Requisitos/Limites
2
2
5
5
(Zyvox)
5
(Zyvox)
5
(Zyvox)
(Hiprex)
5
2
(Metronidazole/Sodiu
m Chloride)
(Flagyl)
(Flagyl)
(Macrodantin/Macrobi
d)
2
2
2
2
14
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg (75/25)
nitrofurantoin oral suspension 25 mg/5 ml
polymyxin b sulfate injection recon soln
500,000 unit
SYNERCID INTRAVENOUS
RECON SOLN 500 MG
trimethoprim oral tablet 100 mg
vancomycin hcl 1g/200 ml bag 1
gram/200 ml
vancomycin intravenous recon soln 1,000
mg, 10 gram, 750 mg
vancomycin intravenous recon soln 500
mg
vancomycin oral capsule 125 mg, 250 mg
XIFAXAN ORAL TABLET 200 MG
XIFAXAN ORAL TABLET 550 MG
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
Cephalosporins
cefaclor oral capsule 250 mg, 500 mg
cefaclor oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
cefaclor oral tablet extended release 12
hr 500 mg
cefadroxil oral capsule 500 mg
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500 mg/5 ml
cefadroxil oral tablet 1 gram
cefazolin in dextrose (iso-os) intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml
cefazolin injection recon soln 1 gram, 10
gram, 500 mg
cefdinir oral capsule 300 mg
Nivel
Requisitos/Limites
(Macrobid)
2
(Macrobid)
2
(Furadantin)
(Polymyxin B Sulfate)
2
2
5
(Trimethoprim)
(Vancomycin Hcl In
Dextrose 5 %)
(Vancomycin HCl)
2
2
(Vancomycin Hcl In
Dextrose 5 %)
(Vancocin HCl)
2
2
5
5
5
5
(Cefaclor)
(Cefaclor)
2
2
(Cefaclor)
2
(Cefadroxil)
(Cefadroxil)
2
2
(Cefadroxil)
(Cefazolin
Sodium/Dextrose, Iso)
(Cefazolin Sodium)
2
2
(Cefdinir)
2
PA; QL (9 per 30 days)
PA
2
15
cefdinir oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml
cefditoren pivoxil oral tablet 200 mg, 400
mg
CEFEPIME 2 GM INJECTION 2
GRAM/100 ML
CEFEPIME IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK 1
GRAM/50 ML, 2 GRAM/50 ML
cefepime injection recon soln 1 gram, 2
gram
cefixime oral suspension for
cefotaxime injection recon soln 1 gram,
10 gram, 2 gram, 500 mg
cefoxitin in dextrose, iso-osm intravenous
piggyback 2 gram/50 ml
cefoxitin intravenous recon soln 1 gram,
10 gram, 2 gram
cefpodoxime oral suspension for
cefpodoxime oral tablet 100 mg, 200 mg
cefprozil oral suspension for
cefprozil oral tablet 250 mg, 500 mg
ceftazidime injection recon soln 2 gram, 6
gram
ceftibuten oral capsule 400 mg
ceftibuten oral suspension for
ceftriaxone 1 gm piggyback 50ml
galaxycontainer 1 gram/50 ml
ceftriaxone 1 gm vial 10's, fliptop,l/f 1
gram
ceftriaxone 2 gm piggyback 50ml
galaxycontainer 2 gram/50 ml
Nivel
(Cefdinir)
2
(Spectracef)
2
Requisitos/Limites
4
4
(Maxipime)
2
(Suprax)
2
(Claforan)
2
(Cefoxitin
(Cefoxitin Sodium)
2
(Cefpodoxime Proxetil)
2
(Cefpodoxime Proxetil)
(Cefprozil)
2
2
(Cefprozil)
(Fortaz)
2
2
(Cedax)
(Cedax)
2
2
(Ceftriaxone
Na/Dextrose, Iso)
(Rocephin)
2
(Ceftriaxone
Na/Dextrose, Iso)
2
2
2
16
ceftriaxone injection recon soln 10 gram,
250 mg, 500 mg
ceftriaxone intravenous recon soln 1
gram, 2 gram
cefuroxime axetil oral tablet 250 mg, 500
mg
cefuroxime sodium injection recon soln
1.5 gram, 750 mg
cefuroxime sodium intravenous recon soln
7.5 gram
cephalexin oral capsule 250 mg, 500 mg,
750 mg
cephalexin oral suspension for
cephalexin oral tablet 250 mg, 500 mg
MEFOXIN IN DEXTROSE
(ISO-OSM) INTRAVENOUS
PIGGYBACK 1 GRAM/50 ML, 2
GRAM/50 ML
SUPRAX ORAL SUSPENSION FOR
SUPRAX ORAL
TABLET,CHEWABLE 100 MG, 200
MG
tazicef injection recon soln 2 gram, 6
gram
TEFLARO INTRAVENOUS RECON
SOLN 400 MG, 600 MG
Macrolides
azithromycin intravenous recon soln 500
mg
azithromycin oral packet 1 gram
azithromycin oral suspension for
azithromycin oral tablet 250 mg, 250 mg
(6 pack), 600 mg
azithromycin oral tablet 500 mg
Nivel
(Rocephin)
2
(Ceftriaxone
Na/Dextrose, Iso)
(Ceftin)
2
(Zinacef)
2
(Zinacef)
2
(Keflex)
1
(Cephalexin)
1
(Cephalexin)
1
4
Requisitos/Limites
2
4
4
(Fortaz)
2
4
(Zithromax)
2
(Zithromax)
(Zithromax)
2
2
(Zithromax)
2
(Zithromax)
2
17
clarithromycin oral suspension for
clarithromycin oral tablet 250 mg, 500
mg
clarithromycin oral tablet extended
release 24 hr 500 mg
DIFICID ORAL TABLET 200 MG
e.e.s. 400 oral tablet 400 mg
e.e.s. granules oral suspension for
ery-tab oral tablet,delayed release
(dr/ec) 250 mg, 500 mg
ERY-TAB ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythrocin (as stearate) oral tablet 250
mg
ERYTHROCIN INTRAVENOUS
RECON SOLN 1,000 MG, 500 MG
erythromycin ethylsuccinate oral tablet
400 mg
erythromycin oral capsule,delayed
release(dr/ec) 250 mg
erythromycin oral tablet 250 mg, 500 mg
Miscellaneous B-Lactam
Antibiotics
aztreonam injection recon soln 1 gram
CAYSTON INHALATION
SOLUTION FOR NEBULIZATION
75 MG/ML
imipenem-cilastatin intravenous recon
soln 250 mg, 500 mg
INVANZ INJECTION RECON SOLN
1 GRAM
meropenem intravenous recon soln 500
mg
Nivel
(Biaxin)
2
(Biaxin)
2
(Clarithromycin)
2
(Erythromycin
Ethylsuccinate)
(Eryped 200)
(Erythromycin Base)
5
2
Requisitos/Limites
QL (20 per 10 days)
2
2
4
(Erythromycin
Stearate)
2
4
(Erythromycin
Ethylsuccinate)
(Erythromycin Base)
2
(Erythromycin Base)
2
(Azactam)
2
5
(Primaxin)
2
LA
2
4
(Merrem)
2
18
meropenem iv 1 gm vial outer, latex-free
1 gram
Penicillins
amoxicillin oral capsule 250 mg, 500 mg
amoxicillin oral suspension for
reconstitution 125 mg/5 ml, 200 mg/5 ml,
250 mg/5 ml, 400 mg/5 ml
amoxicillin oral tablet 500 mg, 875 mg
amoxicillin oral tablet,chewable 125 mg,
250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution 200-28.5
mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5
ml, 600-42.9 mg/5 ml
amoxicillin-pot clavulanate oral tablet
250-125 mg, 500-125 mg, 875-125 mg
amoxicillin-pot clavulanate oral tablet
extended release 12 hr 1,000-62.5 mg
amoxicillin-pot clavulanate oral
tablet,chewable 200-28.5 mg, 400-57 mg
ampicillin 2 gm vial 10's, latex-free 2
gram
ampicillin oral capsule 250 mg, 500 mg
ampicillin oral suspension for
ampicillin sodium injection recon soln 1
gram, 10 gram, 125 mg
ampicillin sodium intravenous recon soln
2 gram
ampicillin-sulbactam 1.5 gm vl p/f,
latex-free 1.5 gram
ampicillin-sulbactam injection recon soln
15 gram, 3 gram
ampicillin-sulbactam intravenous recon
soln 1.5 gram
Nivel
(Merrem)
2
(Amoxicillin)
(Amoxicillin)
1
1
(Amoxicillin)
(Amoxicillin)
1
1
(Augmentin)
2
(Augmentin)
2
(Augmentin XR)
2
(Amoxicillin/Potassium
Clav)
(Ampicillin Sodium)
2
(Ampicillin Trihydrate)
(Ampicillin Trihydrate)
1
1
(Ampicillin Sodium)
2
(Ampicillin Sodium)
2
(Unasyn)
2
(Unasyn)
2
(Unasyn)
2
Requisitos/Limites
2
19
BICILLIN C-R INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/ 2
ML(600K/600K), 1,200,000 UNIT/ 2
ML(900K/300K)
BICILLIN L-A INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/2 ML,
2,400,000 UNIT/4 ML, 600,000
UNIT/ML
dicloxacillin oral capsule 250 mg, 500 mg
nafcillin 2 gm vial sterile, latex-free 2
gram
nafcillin injection recon soln 1 gram, 10
gram
nafcillin intravenous recon soln 2 gram
oxacillin 1 gm add-vantage vl
add-vantage, inner 1 gram
oxacillin in dextrose(iso-osm)
intravenous piggyback 1 gram/50 ml, 2
gram/50 ml
oxacillin injection recon soln 10 gram
oxacillin intravenous recon soln 2 gram
penicillin g pot in dextrose intravenous
piggyback 1 million unit/50 ml, 2 million
unit/50 ml, 3 million unit/50 ml
penicillin g potassium injection recon soln
5 million unit
penicillin g procaine intramuscular
syringe 1.2 million unit/2 ml, 600,000
unit/ml
penicillin gk 20 million unit 20 million
unit
penicillin v potassium oral recon soln 125
mg/5 ml, 250 mg/5 ml
penicillin v potassium oral tablet 250 mg,
500 mg
pfizerpen-g injection recon soln 20 million
unit
Nivel
Requisitos/Limites
4
4
(Dicloxacillin Sodium)
(Nafcillin Sodium)
2
2
(Nafcillin Sodium)
2
(Nafcillin Sodium)
(Oxacillin Sodium)
2
2
(Oxacillin
2
(Oxacillin Sodium)
(Oxacillin Sodium)
(Pen G
Pot/Dextrose-Water)
2
2
2
(Penicillin G
Potassium)
(Penicillin G Procaine)
2
(Penicillin G
Potassium)
(Penicillin V
Potassium)
(Penicillin V
Potassium)
(Penicillin G
Potassium)
2
2
2
2
2
20
piperacillin-tazobactam intravenous
recon soln 2.25 gram, 3.375 gram, 4.5
gram
piperacil-tazobact 40.5 gram p/f,
latex-free 40.5 gram
Quinolones
ciprofloxacin (mixture) oral tablet, er
multiphase 24 hr 1,000 mg, 500 mg
ciprofloxacin hcl oral tablet 100 mg, 250
mg, 500 mg, 750 mg
ciprofloxacin in 5 % dextrose intravenous
piggyback 200 mg/100 ml
ciprofloxacin lactate intravenous solution
400 mg/40 ml
ciprofloxacin oral
suspension,microcapsule recon 250 mg/5
ml, 500 mg/5 ml
ciprofloxacn-d5w 400 mg/200 ml
p/f,latex/f, in d5w 400 mg/200 ml
levofloxacin in d5w intravenous
levofloxacin intravenous solution 25
mg/ml
levofloxacin oral solution 250 mg/10 ml
levofloxacin oral tablet 250 mg, 500 mg,
750 mg
moxifloxacin oral tablet 400 mg
ofloxacin oral tablet 400 mg
Sulfonamides
sulfadiazine oral tablet 500 mg
sulfamethoxazole-trimethoprim
intravenous solution 400-80 mg/5 ml
sulfamethoxazole-trimethoprim oral
suspension 200-40 mg/5 ml
sulfamethoxazole-trimethoprim oral
tablet 400-80 mg, 800-160 mg
Nivel
(Zosyn)
2
(Zosyn)
2
(Cipro XR)
2
(Cipro)
1
(Cipro I.V.)
2
(Ciprofloxacin Lactate)
2
(Cipro)
2
(Cipro I.V.)
2
(Levaquin)
2
(Levofloxacin)
2
(Levaquin)
(Levaquin)
2
1
(Avelox)
(Ofloxacin)
2
2
(Sulfadiazine)
(Sulfamethoxazole/Tri
methoprim)
(Sulfamethoxazole/Tri
methoprim)
(Bactrim)
2
2
Requisitos/Limites
2
1
21
Nivel
sulfasalazine oral tablet 500 mg
(Azulfidine)
sulfasalazine oral tablet,delayed release
(Azulfidine)
(dr/ec) 500 mg
sulfatrim oral suspension 200-40 mg/5 ml (Sulfamethoxazole/Tri
methoprim)
Tetracyclines
demeclocycline oral tablet 150 mg, 300
(Demeclocycline HCl)
mg
doxy 100 vial 10's, p/f 100 mg
(Doxycycline Hyclate)
doxycycline hyclate 100 mg cap 100 mg
(Morgidox)
doxycycline hyclate 100 mg tab 100 mg
(Doryx)
doxycycline hyclate intravenous recon
(Doxycycline Hyclate)
soln 100 mg
doxycycline hyclate oral capsule 100 mg (Adoxa)
doxycycline hyclate oral capsule 50 mg
(Morgidox)
doxycycline hyclate oral tablet 100 mg,
(Avidoxy)
50 mg
doxycycline hyclate oral tablet 20 mg
(Doryx)
doxycycline hyclate oral tablet,delayed
(Doryx)
release (dr/ec) 100 mg, 150 mg, 200 mg,
50 mg, 75 mg
doxycycline mono 100 mg cap 100 mg
(Adoxa)
doxycycline mono 100 mg tablet f/c 100
(Avidoxy)
mg
doxycycline mono 50 mg tablet 50 mg
(Avidoxy)
doxycycline monohydrate oral capsule
(Adoxa)
150 mg, 50 mg, 75 mg
doxycycline monohydrate oral suspension (Vibramycin)
for reconstitution 25 mg/5 ml
doxycycline monohydrate oral tablet 150 (Avidoxy)
mg, 75 mg
MINOCIN INTRAVENOUS RECON
SOLN 100 MG
minocycline oral capsule 100 mg, 50 mg, (Minocin)
75 mg
Requisitos/Limites
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
5
2
22
minocycline oral tablet 100 mg, 50 mg,
75 mg
minocycline oral tablet extended release
24 hr 135 mg, 45 mg, 90 mg
tetracycline oral capsule 250 mg, 500 mg
TYGACIL INTRAVENOUS RECON
SOLN 50 MG
Nivel
(Minocycline HCl)
2
(Minocycline HCl)
2
(Tetracycline HCl)
2
5
Requisitos/Limites
Anticancer Agents
Anticancer Agents
ABRAXANE INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 100 MG
ADCETRIS INTRAVENOUS
RECON SOLN 50 MG
adriamycin intravenous recon soln 10 mg,
20 mg, 50 mg
adriamycin intravenous solution 10 mg/5
ml
adrucil 2,500 mg/50 ml vial outer,
latex-free 2.5 gram/50 ml
adrucil intravenous solution 500 mg/10 ml
AFINITOR DISPERZ ORAL
TABLET FOR SUSPENSION 2 MG, 3
MG, 5 MG
AFINITOR ORAL TABLET 10 MG
AFINITOR ORAL TABLET 2.5 MG,
5 MG, 7.5 MG
ALECENSA ORAL CAPSULE 150
MG
ALIMTA INTRAVENOUS RECON
SOLN 500 MG
anastrozole oral tablet 1 mg
AVASTIN INTRAVENOUS
SOLUTION 25 MG/ML, 25 MG/ML
(16 ML)
5
5
(Doxorubicin HCl)
2
PA NSO; QL (4 per 21
days)
PA BvD
(Doxorubicin HCl)
2
PA BvD
(Fluorouracil)
2
PA BvD
(Fluorouracil)
2
5
PA BvD
PA NSO; QL (112 per
28 days)
5
days)
days)
PA NSO; QL (240 per
30 days)
5
5
5
(Arimidex)
2
5
PA NSO
23
Nivel
azacitidine injection recon soln 100 mg
BELEODAQ INTRAVENOUS
RECON SOLN 500 MG
BENDEKA INTRAVENOUS
SOLUTION 25 MG/ML
bexarotene oral capsule 75 mg
(Vidaza)
bicalutamide oral tablet 50 mg
bleomycin injection recon soln 30 unit
bleomycin sulfate 15 unit vial latex-free
15 unit
BLINCYTO INTRAVENOUS KIT 35
MCG
BOSULIF ORAL TABLET 100 MG
5
5
PA NSO
5
PA NSO
(Targretin)
5
PA NSO; QL (420 per
30 days)
(Casodex)
(Bleomycin Sulfate)
(Bleomycin Sulfate)
2
2
2
5
5
BOSULIF ORAL TABLET 500 MG
5
CABOMETYX ORAL TABLET 20
MG, 60 MG
CABOMETYX ORAL TABLET 40
MG
CAPRELSA ORAL TABLET 100 MG
5
CAPRELSA ORAL TABLET 300 MG
5
carboplatin intravenous solution 10
mg/ml
cladribine intravenous solution 10 mg/10
ml
COMETRIQ ORAL CAPSULE 100
MG/DAY(80 MG X1-20 MG X1), 140
MG/DAY(80 MG X1-20 MG X3), 60
MG/DAY (20 MG X 3/DAY)
COTELLIC ORAL TABLET 20 MG
Requisitos/Limites
5
5
PA BvD
PA BvD
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
days)
days)
days)
days)
days)
(Carboplatin)
2
(Cladribine)
2
PA BvD
5
PA NSO; QL (112 per
28 days)
5
PA NSO; LA; QL (63
per 28 days)
PA BvD
cyclophosphamide intravenous recon soln (Cyclophosphamide)
1 gram, 2 gram, 500 mg
2
24
CYCLOPHOSPHAMIDE ORAL
CAPSULE 25 MG, 50 MG
cyclophosphamide oral tablet 25 mg, 50
mg
CYRAMZA INTRAVENOUS
(50 ML)
dactinomycin intravenous recon soln 0.5
mg
DARZALEX INTRAVENOUS
SOLUTION 20 MG/ML
DAUNOXOME INTRAVENOUS
SOLUTION 2 MG/ML
decitabine intravenous recon soln 50 mg
docetaxel 160 mg/16 ml vial mdv 160
mg/16 ml (10 mg/ml)
docetaxel intravenous solution 20 mg/2
ml (final), 80 mg/4 ml (20 mg/ml), 80
mg/8 ml (10 mg/ml)
doxorubicin, peg-liposomal intravenous
suspension 2 mg/ml
DROXIA ORAL CAPSULE 200 MG,
300 MG, 400 MG
ELIGARD SUBCUTANEOUS
SYRINGE 22.5 MG (3 MONTH)
SYRINGE 30 MG (4 MONTH)
SYRINGE 45 MG (6 MONTH)
SYRINGE 7.5 MG (1 MONTH)
EMCYT ORAL CAPSULE 140 MG
EMPLICITI INTRAVENOUS
RECON SOLN 300 MG, 400 MG
ERIVEDGE ORAL CAPSULE 150
MG
Nivel
(Cyclophosphamide)
(Dactinomycin)
Requisitos/Limites
4
PA BvD; ST
2
PA BvD; ST
5
PA NSO
2
5
PA NSO; LA
3
(Dacogen)
(Taxotere)
5
5
(Taxotere)
5
(Doxil)
5
PA BvD
3
4
QL (1 per 84 days)
4
QL (1 per 112 days)
4
QL (1 per 168 days)
4
3
5
5
PA NSO
days)
25
ETOPOPHOS INTRAVENOUS
RECON SOLN 100 MG
etoposide intravenous solution 20 mg/ml
exemestane oral tablet 25 mg
FARESTON ORAL TABLET 60 MG
FARYDAK ORAL CAPSULE 10
MG, 15 MG, 20 MG
FASLODEX INTRAMUSCULAR
SYRINGE 250 MG/5 ML
floxuridine injection recon soln 0.5 gram
fluorouracil 5,000 mg/100 ml latex-free 5
gram/100 ml
fluorouracil intravenous solution 1
gram/20 ml, 2.5 gram/50 ml, 500 mg/10
ml
flutamide oral capsule 125 mg
GAZYVA INTRAVENOUS
SOLUTION 1,000 MG/40 ML
gemcitabine intravenous recon soln 1
gram
GILOTRIF ORAL TABLET 20 MG,
30 MG, 40 MG
GLEOSTINE ORAL CAPSULE 10
MG, 100 MG, 40 MG
HERCEPTIN INTRAVENOUS
RECON SOLN 440 MG
HEXALEN ORAL CAPSULE 50 MG
hydroxyurea oral capsule 500 mg
IBRANCE ORAL CAPSULE 100 MG,
125 MG, 75 MG
ICLUSIG ORAL TABLET 15 MG
Nivel
4
(Etoposide)
(Aromasin)
2
2
5
5
PA NSO
5
(Floxuridine)
(Fluorouracil)
2
2
PA BvD
PA BvD
(Fluorouracil)
2
PA BvD
(Flutamide)
2
5
PA NSO
(Gemzar)
5
5
days)
4
5
5
2
5
(Hydrea)
5
ICLUSIG ORAL TABLET 45 MG
ifosfamide 1 gm/20 ml vial suv 1 gram/20
ml
Requisitos/Limites
5
(Ifex)
2
PA NSO
days)
days)
days)
PA BvD
26
Nivel
Requisitos/Limites
ifosfamide intravenous recon soln 1 gram
ifosfamide-mesna intravenous kit 1-1
gram, 3,000-1,000 mg
imatinib oral tablet 100 mg
(Ifex)
(Ifosfamide/Mesna)
2
5
PA BvD
PA BvD
(Gleevec)
5
imatinib oral tablet 400 mg
(Gleevec)
5
days)
days)
PA NSO
IMBRUVICA ORAL CAPSULE 140
MG
IMLYGIC INJECTION
SUSPENSION 10EXP6 (1 MILLION)
PFU/ML
IMLYGIC INJECTION
SUSPENSION 10EXP8 (100
MILLION) PFU/ML
INLYTA ORAL TABLET 1 MG
5
INLYTA ORAL TABLET 5 MG
5
IRESSA ORAL TABLET 250 MG
5
irinotecan intravenous solution 100 mg/5 (Camptosar)
ml, 500 mg/25 ml
IXEMPRA 15 MG KIT WITH
DILUENT 15 MG
IXEMPRA INTRAVENOUS RECON
SOLN 45 MG
JAKAFI ORAL TABLET 10 MG, 15
MG, 20 MG, 25 MG, 5 MG
KEYTRUDA INTRAVENOUS
RECON SOLN 50 MG
KEYTRUDA INTRAVENOUS
SOLUTION 100 MG/4 ML (25
MG/ML)
KYPROLIS INTRAVENOUS
RECON SOLN 30 MG
2
5
days)
5
days)
5
PA NSO; QL (180 per
30 days)
days)
days)
5
5
5
5
days)
PA NSO
5
PA NSO
5
days)
27
KYPROLIS INTRAVENOUS
RECON SOLN 60 MG
LENVIMA ORAL CAPSULE 10
MG/DAY (10 MG X 1/DAY), 14
MG/DAY(10 MG X 1-4 MG X 1), 18
MG/DAY (10 MG X 1-4 MG X2), 20
MG/DAY (10 MG X 2), 24
MG/DAY(10 MG X 2-4 MG X 1), 8
MG/DAY (4 MG X 2)
letrozole oral tablet 2.5 mg
LEUKERAN ORAL TABLET 2 MG
leuprolide subcutaneous kit 1 mg/0.2 ml
lipodox 50 intravenous suspension 2
mg/ml
lipodox intravenous suspension 2 mg/ml
lomustine oral capsule 10 mg, 100 mg, 40
mg
LONSURF ORAL TABLET 15-6.14
MG
LONSURF ORAL TABLET 20-8.19
MG
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
11.25 MG, 22.5 MG
30 MG
45 MG
LUPRON DEPOT
3.75 MG, 7.5 MG
LYNPARZA ORAL CAPSULE 50
MG
LYSODREN ORAL TABLET 500 MG
Nivel
Requisitos/Limites
5
5
days)
PA NSO
(Leuprolide Acetate)
(Doxil)
2
4
2
5
PA BvD
(Doxil)
(Lomustine)
5
2
PA BvD
5
5
PA NSO; QL (100 per
28 days)
days)
QL (1 per 84 days)
5
QL (1 per 84 days)
5
QL (1 per 168 days)
(Femara)
5
5
5
PA NSO; QL (480 per
30 days)
3
28
MARQIBO INTRAVENOUS KIT 5
MG/31 ML(0.16 MG/ML) FINAL
MATULANE ORAL CAPSULE 50
MG
megestrol oral tablet 20 mg, 40 mg
MEKINIST ORAL TABLET 0.5 MG
Requisitos/Limites
5
days)
5
(Megestrol Acetate)
2
5
5
MEKINIST ORAL TABLET 2 MG
melphalan hcl intravenous recon soln 50
mg
mercaptopurine oral tablet 50 mg
methotrexate 50 mg/2 ml vial latex-free,
5's, mdv 25 mg/ml
methotrexate sodium (pf) injection recon
soln 1 gram
methotrexate sodium (pf) injection
solution 25 mg/ml
methotrexate sodium oral tablet 2.5 mg
mitoxantrone intravenous concentrate 2
mg/ml
NEXAVAR ORAL TABLET 200 MG
Nivel
days)
days)
(Alkeran)
5
(Mercaptopurine)
(Methotrexate Sodium)
2
2
PA BvD
(Methotrexate
Sodium/PF)
2
PA BvD
2
PA BvD
(Mitoxantrone HCl)
2
2
PA BvD; ST
5
PA NSO; QL (120 per
30 days)
NILANDRON ORAL TABLET 150
MG
nilutamide oral tablet 150 mg
(Nilandron)
NINLARO ORAL CAPSULE 2.3 MG,
3 MG, 4 MG
ODOMZO ORAL CAPSULE 200 MG
ONCASPAR INJECTION
SOLUTION 750 UNIT/ML
onxol intravenous concentrate 6 mg/ml
(Paclitaxel)
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
oxaliplatin intravenous solution 100
(Eloxatin)
mg/20 ml
3
2
5
5
5
days)
PA NSO; LA
PA NSO
2
5
PA NSO
5
29
Nivel
paclitaxel intravenous concentrate 6
(Paclitaxel)
mg/ml
PERJETA INTRAVENOUS
MG/ML)
POMALYST ORAL CAPSULE 1 MG,
2 MG, 3 MG, 4 MG
PORTRAZZA INTRAVENOUS
MG/ML)
PROLEUKIN INTRAVENOUS
RECON SOLN 22 MILLION UNIT
PURIXAN ORAL SUSPENSION 20
MG/ML
REVLIMID ORAL CAPSULE 10
MG, 15 MG, 2.5 MG, 20 MG, 25 MG,
5 MG
RITUXAN INTRAVENOUS
CONCENTRATE 10 MG/ML
SOLTAMOX ORAL SOLUTION 10
MG/5 ML
SPRYCEL ORAL TABLET 100 MG,
140 MG, 50 MG, 70 MG, 80 MG
SPRYCEL ORAL TABLET 20 MG
2
STIVARGA ORAL TABLET 40 MG
5
SUTENT ORAL CAPSULE 12.5 MG,
25 MG, 37.5 MG, 50 MG
SYLVANT INTRAVENOUS RECON
SOLN 100 MG, 400 MG
SYNRIBO SUBCUTANEOUS
RECON SOLN 3.5 MG
TABLOID ORAL TABLET 40 MG
TAFINLAR ORAL CAPSULE 50
MG, 75 MG
5
Requisitos/Limites
5
PA NSO
5
days)
PA NSO; QL (100 per
21 days)
5
5
5
5
PA NSO; LA
5
PA NSO
4
5
5
5
5
3
5
days)
days)
days)
days)
PA NSO
days)
PA NSO; QL (120 per
30 days)
30
TAGRISSO ORAL TABLET 40 MG,
80 MG
tamoxifen oral tablet 10 mg, 20 mg
TARCEVA ORAL TABLET 100 MG,
25 MG
TARCEVA ORAL TABLET 150 MG
(Tamoxifen Citrate)
Nivel
Requisitos/Limites
5
PA NSO; LA; QL (30
per 30 days)
2
5
5
TARGRETIN ORAL CAPSULE 75
MG
TARGRETIN TOPICAL GEL 1 %
5
TASIGNA ORAL CAPSULE 150 MG,
200 MG
TECENTRIQ INTRAVENOUS
SOLUTION 1,200 MG/20 ML (60
MG/ML)
TEMODAR INTRAVENOUS
RECON SOLN 100 MG
teniposide intravenous solution 50 mg/5
ml
thiotepa injection recon soln 15 mg
toposar intravenous solution 20 mg/ml
topotecan hcl 4 mg/4 ml vial
suv,latex-free 4 mg/4 ml (1 mg/ml)
topotecan intravenous recon soln 4 mg
TORISEL INTRAVENOUS RECON
SOLN 30 MG/3 ML (10 MG/ML)
(FIRST)
TREANDA 25 MG VIAL 25 MG
TREANDA INTRAVENOUS
RECON SOLN 100 MG
TREANDA INTRAVENOUS
SOLUTION 180 MG/2 ML, 45 MG/0.5
ML
TRELSTAR 22.5 MG SYRINGE
WITH MIXJECT 22.5 MG/2 ML
5
5
5
5
(Teniposide)
5
(Thiotepa)
(Etoposide)
(Hycamtin)
5
2
5
(Hycamtin)
5
5
days)
days)
PA NSO; QL (420 per
30 days)
days)
PA NSO; QL (112 per
28 days)
days)
PA NSO; (vial only)
PA BvD; QL (4 per 28
days)
5
5
5
5
QL (1 per 168 days)
31
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 22.5 MG
SYRINGE 11.25 MG/2 ML
SYRINGE 3.75 MG/2 ML
tretinoin (chemotherapy) oral capsule 10
mg
TREXALL ORAL TABLET 10 MG,
15 MG, 5 MG, 7.5 MG
TYKERB ORAL TABLET 250 MG
UNITUXIN INTRAVENOUS
SOLUTION 3.5 MG/ML
VALSTAR INTRAVESICAL
SOLUTION 40 MG/ML
VECTIBIX INTRAVENOUS
MG/ML)
VELCADE INJECTION RECON
SOLN 3.5 MG
VENCLEXTA ORAL TABLET 10
MG, 50 MG
VENCLEXTA ORAL TABLET 100
MG
VENCLEXTA STARTING PACK
ORAL TABLETS,DOSE PACK 10
MG-50 MG- 100 MG
vinblastine intravenous solution 1 mg/ml
vincasar pfs 2 mg/2 ml vial 2 mg/2 ml
vincasar pfs intravenous solution 1 mg/ml
vincristine 2 mg/2 ml vial p/f, sdv 2 mg/2
ml
vincristine intravenous solution 1 mg/ml
vinorelbine intravenous solution 50 mg/5
ml
Nivel
Requisitos/Limites
5
QL (1 per 168 days)
5
QL (1 per 84 days)
5
(Tretinoin)
5
(capsule: 10mg)
4
PA BvD; ST
5
5
PA NSO
5
5
PA NSO
5
PA NSO
4
PA NSO; LA
5
PA NSO; LA
5
PA NSO; LA
(Vinblastine Sulfate)
(Vincristine Sulfate)
2
2
2
2
PA BvD
PA BvD
PA BvD
PA BvD
(Navelbine)
2
2
PA BvD
32
Nivel
Requisitos/Limites
VOTRIENT ORAL TABLET 200 MG
5
XALKORI ORAL CAPSULE 200
MG, 250 MG
XTANDI ORAL CAPSULE 40 MG
5
YERVOY INTRAVENOUS
MG/ML)
YONDELIS INTRAVENOUS
RECON SOLN 1 MG
ZALTRAP INTRAVENOUS
MG/ML)
ZELBORAF ORAL TABLET 240 MG
5
PA NSO; QL (120 per
30 days)
days)
PA NSO; QL (120 per
30 days)
PA NSO
5
PA NSO
5
PA NSO
5
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA ORAL CAPSULE 100 MG
ZYDELIG ORAL TABLET 100 MG,
150 MG
ZYKADIA ORAL CAPSULE 150 MG
4
PA NSO; QL (240 per
30 days)
QL (1 per 84 days)
4
QL (1 per 28 days)
ZYTIGA ORAL TABLET 250 MG
5
5
5
5
5
days)
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection solution 0.4 mg/ml, 1
(Atropine Sulfate)
mg/ml
atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate)
mg/ml
propantheline oral tablet 15 mg
(Propantheline
Bromide)
2
2
2
33
Nivel
STIOLTO RESPIMAT
INHALATION MIST 2.5-2.5
MCG/ACTUATION
3
Requisitos/Limites
QL (4 per 28 days)
Anticonvulsants
Anticonvulsants
APTIOM ORAL TABLET 200 MG,
400 MG, 600 MG, 800 MG
BANZEL ORAL SUSPENSION 40
MG/ML
BANZEL ORAL TABLET 200 MG,
400 MG
BRIVIACT INTRAVENOUS
SOLUTION 50 MG/5 ML
BRIVIACT ORAL SOLUTION 10
MG/ML
BRIVIACT ORAL TABLET 10 MG,
100 MG, 25 MG, 50 MG, 75 MG
carbamazepine oral capsule, er
multiphase 12 hr 100 mg, 200 mg, 300 mg
carbamazepine oral suspension 100 mg/5
ml
carbamazepine oral tablet 200 mg
carbamazepine oral tablet extended
release 12 hr 100 mg, 200 mg, 400 mg
carbamazepine oral tablet,chewable 100
mg
CELONTIN ORAL CAPSULE 300
MG
DILANTIN ORAL CAPSULE 30 MG
divalproex oral capsule, sprinkle 125 mg
divalproex oral tablet extended release 24
hr 250 mg, 500 mg
divalproex oral tablet,delayed release
(dr/ec) 125 mg, 250 mg, 500 mg
epitol oral tablet 200 mg
ethosuximide oral capsule 250 mg
4
4
4
4
QL (80 per 30 days)
4
5
QL (60 per 30 days)
(Carbatrol)
2
(Tegretol)
2
(Tegretol)
(Tegretol XR)
2
2
(Carbamazepine)
2
3
(Depakote Sprinkle)
(Depakote ER)
2
2
2
(Depakote)
2
(Tegretol)
(Zarontin)
2
2
34
ethosuximide oral solution 250 mg/5 ml
felbamate oral suspension 600 mg/5 ml
felbamate oral tablet 400 mg, 600 mg
fosphenytoin 500 mg pe/10 ml
10's,sdv,latex-free 500 mg pe/10 ml
fosphenytoin injection solution 100 mg
pe/2 ml
FYCOMPA ORAL SUSPENSION 0.5
MG/ML
FYCOMPA ORAL TABLET 10 MG,
12 MG, 2 MG, 4 MG, 6 MG, 8 MG
gabapentin oral capsule 100 mg, 300 mg,
400 mg
gabapentin oral solution 250 mg/5 ml
gabapentin oral tablet 600 mg, 800 mg
GABITRIL ORAL TABLET 12 MG,
16 MG
GRALISE 30-DAY STARTER PACK
ORAL TABLET EXTENDED
RELEASE 24 HR 300 MG (9)- 600 MG
(69)
GRALISE ORAL TABLET
MG, 600 MG
LAMICTAL ODT STARTER (BLUE)
ORAL TABLET DISINTEGRATING,
DOSE PK 25 MG (21) -50 MG (7)
LAMICTAL ODT STARTER
(GREEN) ORAL TABLET
DISINTEGRATING, DOSE PK 50
MG (42) -100 MG (14)
(ORANGE) ORAL TABLET
DISINTEGRATING, DOSE PK 25
MG(14)-50 MG (14)-100 MG (7)
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2 MG
Nivel
(Zarontin)
(Felbatol)
(Felbatol)
(Cerebyx)
2
2
2
2
(Cerebyx)
2
Requisitos/Limites
4
4
(Neurontin)
2
(Neurontin)
(Neurontin)
2
2
3
4
4
4
4
4
4
35
lamotrigine oral tablet 100 mg, 150 mg,
200 mg, 25 mg
lamotrigine oral tablet disintegrating,
dose pk 25 mg (21) -50 mg (7), 25
mg(14)-50 mg (14)-100 mg (7), 50 mg
(42) -100 mg (14)
lamotrigine oral tablet extended release
24hr 100 mg, 200 mg, 25 mg, 250 mg,
300 mg, 50 mg
lamotrigine oral tablet, chewable
dispersible 25 mg, 5 mg
lamotrigine oral tablet,disintegrating 100
mg, 200 mg, 25 mg, 50 mg
lamotrigine oral tablets,dose pack 25 mg
(35)
levetiracetam in nacl (iso-os) intravenous
piggyback 1,000 mg/100 ml, 1,500
mg/100 ml, 500 mg/100 ml
levetiracetam intravenous solution 500
mg/5 ml
levetiracetam oral solution 100 mg/ml
levetiracetam oral tablet 1,000 mg, 250
mg, 500 mg, 750 mg
levetiracetam oral tablet extended release
24 hr 500 mg, 750 mg
LYRICA ORAL CAPSULE 100 MG,
150 MG, 200 MG, 225 MG, 25 MG,
300 MG, 50 MG, 75 MG
LYRICA ORAL SOLUTION 20
MG/ML
oxcarbazepine oral suspension 300 mg/5
ml
oxcarbazepine oral tablet 150 mg, 300
mg, 600 mg
OXTELLAR XR ORAL TABLET
MG, 300 MG, 600 MG
Nivel
(Lamictal)
2
(Lamictal Odt (Blue))
2
(Lamictal XR)
2
(Lamictal)
2
(Lamictal Odt)
2
(Lamictal (Blue))
2
(Levetiracetam In Nacl
(Iso-Os))
2
(Keppra)
2
(Keppra)
(Keppra)
2
2
(Keppra XR)
2
Requisitos/Limites
3
QL (90 per 30 days)
3
(Trileptal)
2
(Trileptal)
2
4
36
PEGANONE ORAL TABLET 250
MG
phenobarbital oral elixir 20 mg/5 ml (4
mg/ml)
phenobarbital oral tablet 100 mg, 15 mg,
16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2
mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection solution
130 mg/ml, 65 mg/ml
phenytoin oral suspension 125 mg/5 ml
phenytoin oral tablet,chewable 50 mg
phenytoin sodium extended oral capsule
100 mg, 200 mg, 300 mg
phenytoin sodium intravenous solution 50
mg/ml
phenytoin sodium intravenous syringe 50
mg/ml
POTIGA ORAL TABLET 200 MG,
300 MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone oral tablet 250 mg, 50 mg
SABRIL ORAL POWDER IN
PACKET 500 MG
SABRIL ORAL TABLET 500 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 1,000 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 250 MG, 500 MG, 750
MG
TEGRETOL XR ORAL TABLET
MG
tiagabine oral tablet 2 mg, 4 mg
topiragen oral tablet 100 mg, 200 mg, 25
mg, 50 mg
Nivel
Requisitos/Limites
3
(Phenobarbital)
2
(Phenobarbital)
2
QL (90 per 30 days)
(Phenobarbital)
(Phenobarbital
Sodium)
(Dilantin-125)
(Dilantin)
(Dilantin)
2
2
QL (2 per 30 days)
(Phenytoin Sodium)
2
(Phenytoin Sodium)
2
(Mysoline)
2
2
2
4
QL (90 per 30 days)
4
2
5
5
4
4
ST ; QL (60 per 30
days)
ST ; QL (120 per 30
days)
3
(Gabitril)
(Topamax)
2
2
37
topiramate oral capsule, sprinkle 15 mg,
25 mg
topiramate oral capsule,sprinkle,er 24hr
100 mg, 150 mg, 200 mg, 25 mg, 50 mg
topiramate oral tablet 100 mg, 200 mg,
25 mg, 50 mg
TROKENDI XR ORAL
CAPSULE,EXTENDED RELEASE
24HR 100 MG, 200 MG, 25 MG, 50
MG
valproate sodium intravenous solution
500 mg/5 ml (100 mg/ml)
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
valproic acid oral capsule 250 mg
VIMPAT INTRAVENOUS
SOLUTION 200 MG/20 ML
VIMPAT ORAL SOLUTION 10
MG/ML
VIMPAT ORAL TABLET 100 MG,
150 MG, 200 MG, 50 MG
zonisamide oral capsule 100 mg, 25 mg,
50 mg
Nivel
(Topamax)
2
(Qudexy XR)
2
(Topamax)
2
Requisitos/Limites
4
(Depacon)
2
(Depakene)
2
(Depakene)
2
4
QL (200 per 5 days)
4
4
QL (60 per 30 days)
(Zonegran)
2
(Aricept)
(Donepezil HCl)
2
2
QL (30 per 30 days)
QL (30 per 30 days)
(Razadyne ER)
2
QL (30 per 30 days)
(Galantamine Hbr)
(Razadyne)
2
2
QL (60 per 30 days)
(Namenda)
(Namenda)
2
2
QL (60 per 30 days)
Antidementia Agents
Antidementia Agents
donepezil oral tablet 10 mg, 23 mg, 5 mg
donepezil oral tablet,disintegrating 10
mg, 5 mg
galantamine oral capsule,ext rel. pellets
24 hr 16 mg, 24 mg, 8 mg
galantamine oral solution 4 mg/ml
galantamine oral tablet 12 mg, 4 mg, 8
mg
memantine oral solution 2 mg/ml
memantine oral tablet 10 mg, 5 mg
38
Nivel
memantine oral tablets,dose pack 5-10
(Namenda)
mg
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK 7-14-21-28 MG
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR 14
MG, 21 MG, 28 MG, 7 MG
NAMZARIC ORAL
CAPSULE,SPRINKLE,ER 24HR
14-10 MG, 28-10 MG
rivastigmine tartrate oral capsule 1.5 mg, (Exelon)
3 mg, 4.5 mg, 6 mg
rivastigmine transdermal patch 24 hour
(Exelon)
13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24
hr
Requisitos/Limites
2
QL (49 per 28 days)
3
QL (28 per 28 days)
3
QL (30 per 30 days)
3
2
QL (60 per 30 days)
2
QL (30 per 30 days)
Antidepressants
Antidepressants
amitriptyline oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
amoxapine oral tablet 100 mg, 150 mg,
25 mg, 50 mg
BRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
buproban oral tablet extended release 150
mg
bupropion hcl oral tablet 100 mg, 75 mg
bupropion hcl oral tablet extended release
100 mg, 150 mg, 200 mg
bupropion hcl oral tablet extended release
24 hr 150 mg, 300 mg
citalopram oral solution 10 mg/5 ml
citalopram oral tablet 10 mg, 20 mg, 40
mg
clomipramine oral capsule 25 mg, 50 mg,
75 mg
(Amitriptyline HCl)
2
(Amoxapine)
2
4
(Wellbutrin SR)
2
(Wellbutrin)
(Wellbutrin SR)
2
2
(Wellbutrin XL)
2
(Citalopram
Hydrobromide)
(Celexa)
2
(Anafranil)
2
1
QL (30 per 30 days)
39
desipramine oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
DESVENLAFAXINE FUMARATE
ORAL TABLET EXTENDED
RELEASE 24HR 100 MG, 50 MG
doxepin oral capsule 10 mg, 100 mg, 150
mg, 25 mg, 50 mg, 75 mg
doxepin oral concentrate 10 mg/ml
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
EMSAM TRANSDERMAL PATCH
24 HOUR 12 MG/24 HR, 6 MG/24
HR, 9 MG/24 HR
escitalopram oxalate oral solution 5 mg/5
ml
escitalopram oxalate oral tablet 10 mg,
20 mg, 5 mg
FETZIMA ORAL CAPSULE,EXT
REL 24HR DOSE PACK 20 MG (2)40 MG (26)
FETZIMA ORAL
CAPSULE,EXTENDED RELEASE 24
HR 120 MG, 20 MG, 40 MG, 80 MG
fluoxetine oral capsule 10 mg, 20 mg, 40
mg
fluoxetine oral capsule,delayed
fluoxetine oral solution 20 mg/5 ml (4
mg/ml)
fluoxetine oral tablet 10 mg, 20 mg
FLUOXETINE ORAL TABLET 60
MG
Nivel
(Norpramin)
Requisitos/Limites
2
3
(Doxepin HCl)
2
(Doxepin HCl)
(Duloxetine)
2
2
(Duloxetine)
2
(Duloxetine)
2
4
(Lexapro)
2
(Lexapro)
2
QL (30 per 30 days)
(Cymbalta); QL (60 per
30 days)
(Cymbalta); QL (30 per
30 days)
(Irenka); QL (30 per 30
days)
QL (30 per 30 days)
4
4
(Prozac)
1
(Prozac Weekly)
2
(Fluoxetine HCl)
2
(Fluoxetine HCl)
2
4
40
fluvoxamine oral capsule,extended
release 24hr 100 mg, 150 mg
fluvoxamine oral tablet 100 mg, 25 mg,
50 mg
imipramine hcl oral tablet 10 mg, 25 mg,
50 mg
imipramine pamoate oral capsule 100 mg,
125 mg, 150 mg, 75 mg
maprotiline oral tablet 25 mg, 50 mg, 75
mg
MARPLAN ORAL TABLET 10 MG
mirtazapine oral tablet 15 mg, 30 mg, 45
mg, 7.5 mg
mirtazapine oral tablet,disintegrating 15
mg, 30 mg, 45 mg
nefazodone oral tablet 100 mg, 150 mg,
200 mg, 250 mg, 50 mg
nortriptyline oral capsule 10 mg, 25 mg,
50 mg, 75 mg
nortriptyline oral solution 10 mg/5 ml
olanzapine-fluoxetine oral capsule 12-25
mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50
mg
paroxetine hcl oral tablet 10 mg, 20 mg,
30 mg, 40 mg
paroxetine hcl oral tablet extended
release 24 hr 12.5 mg, 25 mg, 37.5 mg
PAXIL ORAL SUSPENSION 10
MG/5 ML
perphenazine-amitriptyline oral tablet
2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg,
4-50 mg
phenelzine oral tablet 15 mg
PRISTIQ ORAL TABLET
MG, 25 MG, 50 MG
protriptyline oral tablet 10 mg, 5 mg
Nivel
(Fluvoxamine Maleate)
2
(Fluvoxamine Maleate)
2
(Tofranil)
2
(Tofranil-Pm)
2
(Maprotiline HCl)
2
(Remeron)
4
2
(Remeron)
2
(Nefazodone HCl)
2
(Pamelor)
2
(Nortriptyline HCl)
(Symbyax)
2
2
(Paxil)
2
(Paxil CR)
2
Requisitos/Limites
4
(Perphenazine/Amitript
yline HCl)
2
(Nardil)
2
4
(Protriptyline HCl)
QL (30 per 30 days)
2
41
sertraline oral concentrate 20 mg/ml
sertraline oral tablet 100 mg, 25 mg, 50
mg
SILENOR ORAL TABLET 3 MG, 6
MG
SURMONTIL ORAL CAPSULE 100
MG, 25 MG, 50 MG
tranylcypromine oral tablet 10 mg
trazodone oral tablet 100 mg, 150 mg,
300 mg, 50 mg
trimipramine oral capsule 100 mg, 25 mg,
50 mg
TRINTELLIX ORAL TABLET 10
MG, 20 MG, 5 MG
venlafaxine oral capsule,extended release
24hr 150 mg, 37.5 mg, 75 mg
venlafaxine oral tablet 100 mg, 25 mg,
37.5 mg, 50 mg, 75 mg
venlafaxine oral tablet extended release
24hr 150 mg, 37.5 mg, 75 mg
venlafaxine oral tablet extended release
24hr 225 mg
VIIBRYD ORAL TABLET 10 MG, 20
MG, 40 MG
VIIBRYD ORAL TABLETS,DOSE
PACK 10 MG (7)- 20 MG (23), 10 MG
(7)-20 MG (7)-40 MG (16)
Nivel
(Zoloft)
(Zoloft)
Requisitos/Limites
2
1
3
QL (30 per 30 days)
4
(Parnate)
(Trazodone HCl)
2
1
(Trimipramine
Maleate)
2
4
(Effexor XR)
2
(Venlafaxine HCl)
2
(Venlafaxine HCl)
2
(Venlafaxine HCl)
3
4
4
Antidiabetic Agents
Antidiabetic Agents,
Miscellaneous
acarbose oral tablet 100 mg, 25 mg, 50
mg
ACTOPLUS MET XR ORAL
TABLET, ER MULTIPHASE 24 HR
15-1,000 MG, 30-1,000 MG
(Precose)
2
QL (90 per 30 days)
3
QL (60 per 30 days)
42
Nivel
alogliptin oral tablet 12.5 mg, 25 mg,
(Nesina)
6.25 mg
alogliptin-metformin oral tablet
(Kazano)
12.5-1,000 mg, 12.5-500 mg
alogliptin-pioglitazone oral tablet 12.5-15 (Oseni)
mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg,
25-30 mg, 25-45 mg
CYCLOSET ORAL TABLET 0.8 MG
GLYSET ORAL TABLET 100 MG, 25
MG, 50 MG
GLYXAMBI ORAL TABLET 10-5
MG, 25-5 MG
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 50-1,000
MG, 50-500 MG
INVOKANA ORAL TABLET 100
MG, 300 MG
JANUMET ORAL TABLET 50-1,000
MG, 50-500 MG
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG,
50-1,000 MG, 50-500 MG
JANUVIA ORAL TABLET 100 MG,
25 MG, 50 MG
JARDIANCE ORAL TABLET 10
MG, 25 MG
JENTADUETO ORAL TABLET
2.5-1,000 MG, 2.5-500 MG, 2.5-850
MG
JENTADUETO XR ORAL TABLET,
IR - ER, BIPHASIC 24HR 2.5-1,000
MG, 5-1,000 MG
KAZANO ORAL TABLET 12.5-1,000
MG, 12.5-500 MG
KORLYM ORAL TABLET 300 MG
metformin oral tablet 1,000 mg
(Glucophage)
Requisitos/Limites
4
QL (30 per 30 days)
4
QL (60 per 30 days)
4
QL (30 per 30 days)
4
3
QL (90 per 30 days)
3
ST
3
ST
3
ST
3
3
3
3
ST
3
3
4
QL (60 per 30 days)
5
PA; QL (112 per 28
days)
QL (75 per 30 days)
1
43
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended release 24
hr 500 mg
metformin oral tablet extended release 24
hr 750 mg
metformin oral tablet extended release
24hr 1,000 mg
metformin oral tablet extended release
24hr 500 mg
miglitol oral tablet 100 mg, 25 mg, 50 mg
nateglinide oral tablet 120 mg, 60 mg
NESINA ORAL TABLET 12.5 MG, 25
MG, 6.25 MG
OSENI ORAL TABLET 12.5-15 MG,
12.5-30 MG, 12.5-45 MG, 25-15 MG,
25-30 MG, 25-45 MG
pioglitazone oral tablet 15 mg, 30 mg, 45
mg
pioglitazone-glimepiride oral tablet 30-2
mg, 30-4 mg
pioglitazone-metformin oral tablet
15-500 mg, 15-850 mg
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg
repaglinide-metformin oral tablet 1-500
mg, 2-500 mg
SYMLINPEN 120 SUBCUTANEOUS
PEN INJECTOR 2,700 MCG/2.7 ML
SYMLINPEN 60 SUBCUTANEOUS
PEN INJECTOR 1,500 MCG/1.5 ML
SYNJARDY ORAL TABLET
12.5-1,000 MG, 12.5-500 MG, 5-1,000
MG, 5-500 MG
TRADJENTA ORAL TABLET 5 MG
Nivel
Requisitos/Limites
(Glucophage)
(Glucophage)
(Glucophage XR)
1
1
2
QL (90 per 30 days)
(Glucophage XR)
2
QL (90 per 30 days)
(Fortamet)
2
QL (60 per 30 days)
(Fortamet)
2
(Glyset)
(Starlix)
2
2
4
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
4
QL (30 per 30 days)
(Actos)
2
QL (30 per 30 days)
(Duetact)
2
QL (30 per 30 days)
(Actoplus Met)
2
QL (90 per 30 days)
(Prandin)
(Prandimet)
2
2
4
QL (10.8 per 28 days)
4
QL (6 per 28 days)
3
ST
3
44
Nivel
TRULICITY SUBCUTANEOUS PEN
INJECTOR 0.75 MG/0.5 ML, 1.5
MG/0.5 ML
VICTOZA 3-PAK SUBCUTANEOUS
PEN INJECTOR 0.6 MG/0.1 ML (18
MG/3 ML)
Insulins
HUMALOG 100 UNITS/ML
CARTRIDGE 5'S, OUTER 100
UNIT/ML
HUMALOG KWIKPEN
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML
HUMALOG KWIKPEN
200 UNIT/ML (3 ML)
HUMALOG MIX 50-50 KWIKPEN
100 UNIT/ML (50-50)
HUMALOG MIX 50-50
SUBCUTANEOUS SUSPENSION 100
UNIT/ML (50-50)
HUMALOG MIX 75-25 KWIKPEN
100 UNIT/ML (75-25)
HUMALOG MIX 75-25
SUBCUTANEOUS SUSPENSION 100
UNIT/ML (75-25)
HUMALOG SUBCUTANEOUS
HUMALOG SUBCUTANEOUS
(PREFILLED SYRINGE)
HUMULIN 70/30 KWIKPEN
100 UNIT/ML (70-30)
Requisitos/Limites
3
3
3
QL (30 per 28 days)
3
QL (30 per 28 days)
3
QL (12 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (30 per 28 days)
45
Nivel
HUMULIN 70/30 SUBCUTANEOUS
SUSPENSION 100 UNIT/ML (70-30)
HUMULIN N KWIKPEN
100 UNIT/ML (3 ML)
HUMULIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
HUMULIN R INJECTION
HUMULIN R U-500 (CONC)
KWIKPEN SUBCUTANEOUS
INSULIN PEN 500 UNIT/ML (3 ML)
HUMULIN R U-500
(CONCENTRATED)
SUBCUTANEOUS SOLUTION 500
UNIT/ML
LANTUS SOLOSTAR
100 UNIT/ML (3 ML)
LANTUS SUBCUTANEOUS
NOVOLIN 70/30 SUBCUTANEOUS
SUSPENSION 100 UNIT/ML (70-30)
NOVOLIN N SUBCUTANEOUS
NOVOLIN R INJECTION
NOVOLOG FLEXPEN
100 UNIT/ML
NOVOLOG MIX 70-30 FLEXPEN
100 UNIT/ML (70-30)
NOVOLOG MIX 70-30
SUBCUTANEOUS SOLUTION 100
UNIT/ML (70-30)
Requisitos/Limites
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
QL (40 per 28 days)
3
QL (24 per 28 days)
3
QL (40 per 28 days)
3
3
3
QL (40 per 28 days)
3
QL (40 per 28 days)
3
QL (40 per 28 days)
3
QL (30 per 28 days)
3
QL (30 per 28 days)
3
QL (40 per 28 days)
46
NOVOLOG PENFILL
SUBCUTANEOUS CARTRIDGE 100
UNIT/ML
NOVOLOG SUBCUTANEOUS
TOUJEO SOLOSTAR
300 UNIT/ML (1.5 ML)
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended release 24hr
10 mg
glipizide oral tablet extended release 24hr
2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5-250
mg
glipizide-metformin oral tablet 2.5-500
mg, 5-500 mg
glyburide micronized oral tablet 1.5 mg
glyburide micronized oral tablet 3 mg
glyburide micronized oral tablet 6 mg
glyburide oral tablet 1.25 mg
glyburide oral tablet 2.5 mg
glyburide oral tablet 5 mg
glyburide-metformin oral tablet 1.25-250
mg
glyburide-metformin oral tablet 2.5-500
mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide oral tablet 500 mg
Nivel
Requisitos/Limites
3
QL (30 per 28 days)
3
QL (40 per 28 days)
3
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
(Glucotrol XL)
1
1
1
1
2
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Glucotrol XL)
2
QL (30 per 30 days)
(Glipizide/Metformin
HCl)
(Glipizide/Metformin
HCl)
(Glynase)
(Glynase)
(Glynase)
(Glyburide)
(Glyburide)
(Glyburide)
(Glucovance)
2
2
2
2
2
2
2
2
2
(Glucovance)
2
(Tolazamide)
(Tolazamide)
(Tolbutamide)
2
2
2
QL (60 per 30 days)
47
Nivel
Requisitos/Limites
Antifungals
Antifungals
ABELCET INTRAVENOUS
SUSPENSION 5 MG/ML
AMBISOME INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 50 MG
amphotericin b injection recon soln 50 mg
CANCIDAS INTRAVENOUS
ciclopirox topical cream 0.77 %
ciclopirox topical gel 0.77 %
ciclopirox topical shampoo 1 %
ciclopirox topical solution 8 %
ciclopirox topical suspension 0.77 %
ciclopirox-ure-camph-menth-euc topical
solution 8 %
clotrimazole mucous membrane troche 10
mg
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
clotrimazole-betamethasone topical
cream 1-0.05 %
clotrimazole-betamethasone topical
lotion 1-0.05 %
econazole topical cream 1 %
EXELDERM TOPICAL CREAM 1 %
EXELDERM TOPICAL SOLUTION
1%
fluconazole in dextrose(iso-o)
fluconazole in nacl (iso-osm) intravenous
fluconazole oral suspension for
reconstitution 10 mg/ml, 40 mg/ml
5
PA BvD
5
PA BvD
(Amphotericin B)
2
5
PA BvD
(Loprox)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox Olamine)
(Ciclodan)
2
2
2
2
2
2
(Clotrimazole)
2
(Clotrimazole)
(Clotrimazole)
(Lotrisone)
2
2
2
(Clotrimazole/Betamet
hasone Dip)
(Econazole Nitrate)
2
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Diflucan)
2
2
4
4
2
2
48
fluconazole oral tablet 100 mg, 150 mg,
200 mg, 50 mg
fluconazole-nacl 400 mg/200 ml
10's,latex-free, p/f 400 mg/200 ml
flucytosine oral capsule 250 mg, 500 mg
griseofulvin microsize oral suspension 125
mg/5 ml
griseofulvin microsize oral tablet 500 mg
griseofulvin ultramicrosize oral tablet 125
mg, 250 mg
itraconazole oral capsule 100 mg
ketoconazole oral tablet 200 mg
ketoconazole topical cream 2 %
ketoconazole topical shampoo 2 %
miconazole-3 vaginal suppository 200 mg
NOXAFIL INTRAVENOUS
SOLUTION 300 MG/16.7 ML
NOXAFIL ORAL SUSPENSION 200
MG/5 ML (40 MG/ML)
NOXAFIL ORAL
(DR/EC) 100 MG
nyamyc topical powder 100,000
unit/gram
nystatin oral suspension 100,000 unit/ml
nystatin oral tablet 500,000 unit
nystatin topical cream 100,000 unit/gram
nystatin topical ointment 100,000
unit/gram
nystatin topical powder 100,000
unit/gram
nystatin-triamcinolone topical cream
100,000-0.1 unit/g-%
nystatin-triamcinolone topical ointment
100,000-0.1 unit/gram-%
nystop topical powder 100,000 unit/gram
Nivel
(Diflucan)
2
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Griseofulvin,
Microsize)
(Grifulvin V)
(Gris-Peg)
2
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Miconazole Nitrate)
2
2
2
2
2
5
Requisitos/Limites
5
2
2
2
5
5
(Nystatin)
2
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin)
2
2
2
2
(Nystatin)
2
(Nystatin/Triamcin)
2
(Nystatin/Triamcin)
2
(Nystatin)
2
49
SPORANOX ORAL SOLUTION 10
MG/ML
terbinafine hcl oral tablet 250 mg
voriconazole intravenous solution 200 mg
voriconazole oral suspension for
reconstitution 200 mg/5 ml (40 mg/ml)
voriconazole oral tablet 200 mg, 50 mg
Nivel
Requisitos/Limites
4
(Lamisil)
(Vfend IV)
(Vfend)
2
2
5
(Vfend)
5
Antihistamines
Antihistamines
carbinoxamine maleate oral liquid 4 mg/5 (Carbinoxamine
ml
Maleate)
carbinoxamine maleate oral tablet 4 mg (Carbinoxamine
Maleate)
clemastine oral tablet 2.68 mg
(Clemastine Fumarate)
cyproheptadine oral syrup 2 mg/5 ml
(Cyproheptadine HCl)
cyproheptadine oral tablet 4 mg
(Cyproheptadine HCl)
diphenhydramine hcl injection solution 50 (Diphenhydramine
mg/ml
HCl)
diphenhydramine hcl injection syringe 50 (Diphenhydramine
mg/ml
HCl)
levocetirizine oral solution 2.5 mg/5 ml
(Xyzal)
levocetirizine oral tablet 5 mg
(Xyzal)
promethazine oral syrup 6.25 mg/5 ml
(Promethazine HCl)
2
2
2
2
2
2
2
2
2
2
Anti-Infectives (Skin And Mucous
Membrane)
Anti-Infectives (Skin And Mucous
Membrane)
AVC VAGINAL VAGINAL CREAM
15 %
clindamycin phosphate vaginal cream 2 %
metronidazole vaginal gel 0.75 %
terconazole vaginal cream 0.4 %, 0.8 %
terconazole vaginal suppository 80 mg
3
(Cleocin)
(Metrogel-Vaginal)
(Terazol 7)
(Terconazole)
2
2
2
2
50
Nivel
Requisitos/Limites
Antimigraine Agents
Antimigraine Agents
almotriptan malate oral tablet 12.5 mg,
6.25 mg
dihydroergotamine injection solution 1
mg/ml
dihydroergotamine nasal
spray,non-aerosol 0.5 mg/pump act. (4
mg/ml)
ERGOMAR SUBLINGUAL TABLET
2 MG
naratriptan oral tablet 1 mg, 2.5 mg
rizatriptan oral tablet 10 mg, 5 mg
rizatriptan oral tablet,disintegrating 10
mg, 5 mg
sumatriptan 6 mg/0.5 ml syrng
p/f,dehp/f,pvc/f 6 mg/0.5 ml
sumatriptan nasal spray,non-aerosol 20
mg/actuation, 5 mg/actuation
sumatriptan succinate oral tablet 100 mg,
25 mg, 50 mg
sumatriptan succinate subcutaneous
cartridge 4 mg/0.5 ml
cartridge 6 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 4 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml, 6 mg/0.5 ml
(auto-injector)
solution 6 mg/0.5 ml
zolmitriptan oral tablet 2.5 mg, 5 mg
zolmitriptan oral tablet,disintegrating 2.5
mg, 5 mg
(Axert)
2
QL (12 per 28 days)
(D.H.E.45)
2
QL (30 per 28 days)
(Migranal)
2
QL (8 per 28 days)
4
QL (40 per 28 days)
(Amerge)
(Maxalt)
(Maxalt Mlt)
2
2
2
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
(Sumatriptan
Succinate)
(Imitrex)
2
QL (4 per 28 days)
2
QL (12 per 28 days)
(Imitrex)
2
QL (18 per 28 days)
(Sumatriptan
Succinate)
(Imitrex)
2
QL (4 per 28 days)
2
QL (4 per 28 days)
(Sumatriptan
Succinate)
(Sumatriptan
Succinate)
2
QL (4 per 28 days)
2
QL (4 per 28 days)
(Imitrex)
2
QL (4 per 28 days)
(Zomig)
(Zomig Zmt)
2
2
QL (12 per 28 days)
QL (12 per 28 days)
51
Nivel
Requisitos/Limites
Antimycobacterials
Antimycobacterials
CAPASTAT INJECTION RECON
SOLN 1 GRAM
dapsone oral tablet 100 mg, 25 mg
ethambutol oral tablet 100 mg, 400 mg
isoniazid oral solution 50 mg/5 ml
isoniazid oral tablet 100 mg, 300 mg
PASER ORAL GRANULES DR FOR
SUSP IN PACKET 4 GRAM
PRIFTIN ORAL TABLET 150 MG
pyrazinamide oral tablet 500 mg
rifabutin oral capsule 150 mg
rifampin intravenous recon soln 600 mg
rifampin oral capsule 150 mg, 300 mg
RIFATER ORAL TABLET 50-120-300
MG
SIRTURO ORAL TABLET 100 MG
4
(Dapsone)
(Myambutol)
(Isoniazid)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
2
2
2
1
4
4
2
2
2
2
4
5
TRECATOR ORAL TABLET 250 MG
PA; QL (188 per 168
days)
4
Antinausea Agents
Antinausea Agents
AKYNZEO ORAL CAPSULE 300-0.5
MG
compro rectal suppository 25 mg
(Compazine)
dimenhydrinate injection solution 50
(Dimenhydrinate)
mg/ml
dronabinol oral capsule 10 mg, 2.5 mg, 5 (Marinol)
mg
EMEND INTRAVENOUS RECON
SOLN 115 MG, 150 MG
EMEND ORAL CAPSULE 125 MG,
80 MG
EMEND ORAL CAPSULE 40 MG
EMEND ORAL CAPSULE,DOSE
PACK 125 MG (1)- 80 MG (2)
3
PA BvD
2
2
2
4
QL (2 per 28 days)
4
PA BvD
4
4
PA BvD
52
EMEND ORAL SUSPENSION FOR
RECONSTITUTION 125 MG (25 MG/
ML FINAL CONC.)
granisetron (pf) intravenous solution 100
mcg/ml
granisetron hcl intravenous solution 1
mg/ml (1 ml)
granisetron hcl oral tablet 1 mg
granisol oral solution 1 mg/5 ml
meclizine oral tablet 12.5 mg, 25 mg
ondansetron hcl (pf) injection solution 4
mg/2 ml
ondansetron hcl (pf) injection syringe 4
mg/2 ml
ondansetron hcl oral solution 4 mg/5 ml
ondansetron hcl oral tablet 24 mg, 4 mg,
8 mg
ondansetron oral tablet,disintegrating 4
mg, 8 mg
phenadoz rectal suppository 12.5 mg, 25
mg
prochlorperazine edisylate injection
solution 10 mg/2 ml (5 mg/ml)
prochlorperazine maleate oral tablet 10
mg, 5 mg
prochlorperazine rectal suppository 25
mg
promethazine oral tablet 12.5 mg, 25 mg,
50 mg
promethazine rectal suppository 12.5 mg,
25 mg, 50 mg
promethegan rectal suppository 12.5 mg,
25 mg, 50 mg
TRANSDERM-SCOP
TRANSDERMAL PATCH 3 DAY 1.5
MG (1 MG OVER 3 DAYS)
Nivel
4
Requisitos/Limites
PA BvD
(Granisetron HCl/PF)
2
(Granisetron HCl)
2
(Granisetron HCl)
(Granisetron HCl)
(Meclizine HCl)
(Ondansetron HCl/PF)
2
2
2
2
(Ondansetron HCl/PF)
2
(Zofran)
(Zofran)
2
2
PA BvD
PA BvD
(Zofran Odt)
2
PA BvD
(Phenergan)
2
(Prochlorperazine
Edisylate)
(Compazine)
2
(Compazine)
2
(Promethazine HCl)
2
(Phenergan)
2
(Phenergan)
2
PA BvD
PA BvD
1
4
QL (10 per 30 days)
53
Nivel
Requisitos/Limites
Antiparasite Agents
Antiparasite Agents
ALBENZA ORAL TABLET 200 MG
ALINIA ORAL SUSPENSION FOR
ALINIA ORAL TABLET 500 MG
atovaquone oral suspension 750 mg/5 ml
atovaquone-proguanil oral tablet 250-100
mg, 62.5-25 mg
chloroquine phosphate oral tablet 250
mg, 500 mg
COARTEM ORAL TABLET 20-120
MG
DARAPRIM ORAL TABLET 25 MG
EMVERM ORAL
TABLET,CHEWABLE 100 MG
hydroxychloroquine oral tablet 200 mg
ivermectin oral tablet 3 mg
mefloquine oral tablet 250 mg
NEBUPENT INHALATION RECON
SOLN 300 MG
paromomycin oral capsule 250 mg
PENTAM INJECTION RECON
SOLN 300 MG
PRIMAQUINE ORAL TABLET 26.3
MG
quinine sulfate oral capsule 324 mg
tinidazole oral tablet 250 mg, 500 mg
4
4
(Mepron)
(Malarone)
(Chloroquine
Phosphate)
4
5
2
2
4
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin Sulfate)
4
2
QL (6 per 21 days)
2
2
2
4
PA BvD
2
4
4
QL (90 per 30 days)
(Qualaquin)
(Tindamax)
2
2
(Amantadine HCl)
(Amantadine HCl)
(Amantadine HCl)
2
2
2
5
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral capsule 100 mg
amantadine hcl oral solution 50 mg/5 ml
amantadine hcl oral tablet 100 mg
APOKYN SUBCUTANEOUS
CARTRIDGE 10 MG/ML
QL (60 per 30 days)
54
AZILECT ORAL TABLET 0.5 MG, 1
MG
benztropine injection solution 2 mg/2 ml
benztropine oral tablet 0.5 mg, 1 mg, 2
mg
bromocriptine oral capsule 5 mg
bromocriptine oral tablet 2.5 mg
cabergoline oral tablet 0.5 mg
carbidopa oral tablet 25 mg
carbidopa-levodopa oral tablet 10-100
mg, 25-100 mg, 25-250 mg
carbidopa-levodopa oral tablet extended
release 25-100 mg, 50-200 mg
carbidopa-levodopa oral
tablet,disintegrating 10-100 mg, 25-100
mg, 25-250 mg
carbidopa-levodopa-entacapone oral
tablet 12.5-50-200 mg, 18.75-75-200 mg,
25-100-200 mg, 31.25-125-200 mg,
37.5-150-200 mg, 50-200-200 mg
entacapone oral tablet 200 mg
NEUPRO TRANSDERMAL PATCH
24 HOUR 1 MG/24 HOUR, 2 MG/24
HOUR, 3 MG/24 HOUR, 4 MG/24
HOUR, 6 MG/24 HOUR, 8 MG/24
HOUR
pramipexole oral tablet 0.125 mg, 0.25
mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
ropinirole oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg, 5 mg
ropinirole oral tablet extended release 24
hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg
selegiline hcl oral capsule 5 mg
selegiline hcl oral tablet 5 mg
trihexyphenidyl oral elixir 0.4 mg/ml
trihexyphenidyl oral tablet 2 mg, 5 mg
Nivel
Requisitos/Limites
3
(Cogentin)
(Benztropine Mesylate)
2
2
(Parlodel)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet CR)
2
2
2
2
2
(Sinemet CR)
2
(Carbidopa/Levodopa)
2
(Stalevo 50)
2
(Comtan)
2
3
(Mirapex)
2
(Requip)
2
(Requip XL)
2
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl HCl)
(Trihexyphenidyl HCl)
2
2
2
2
55
Nivel
Requisitos/Limites
Antipsychotic Agents
Antipsychotic Agents
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 300 MG
ABILIFY MAINTENA
INTRAMUSCULAR
RECON 400 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SYRING 300 MG, 400 MG
aripiprazole oral solution 1 mg/ml
aripiprazole oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
aripiprazole oral tablet,disintegrating 10
mg
aripiprazole oral tablet,disintegrating 15
mg
ARISTADA INTRAMUSCULAR
SYRING 441 MG/1.6 ML
chlorpromazine injection solution 25
mg/ml
chlorpromazine oral tablet 10 mg, 100
mg, 200 mg, 25 mg, 50 mg
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
5
5
QL (1 per 28 days)
5
QL (1 per 28 days)
(Abilify)
(Abilify)
2
2
QL (30 per 30 days)
(Abilify)
(Abilify Discmelt)
2
2
QL (60 per 30 days)
QL (90 per 30 days)
(Abilify Discmelt)
2
QL (60 per 30 days)
5
5
5
(Chlorpromazine HCl)
2
(Chlorpromazine HCl)
2
(Clozaril)
(Clozaril)
2
2
56
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating 100
mg, 12.5 mg, 150 mg, 200 mg, 25 mg
FANAPT ORAL TABLET 1 MG, 10
MG, 12 MG, 2 MG, 4 MG, 6 MG, 8
MG
FANAPT ORAL TABLETS,DOSE
PACK 1MG(2)-2MG(2)4MG(2)-6MG(2)
fluphenazine decanoate injection solution
25 mg/ml
fluphenazine hcl injection solution 2.5
mg/ml
fluphenazine hcl oral concentrate 5 mg/ml
fluphenazine hcl oral elixir 2.5 mg/5 ml
fluphenazine hcl oral tablet 1 mg, 10 mg,
2.5 mg, 5 mg
GEODON INTRAMUSCULAR
RECON SOLN 20 MG/ML (FINAL
CONC.)
haloperidol decanoate intramuscular
solution 100 mg/ml
haloperidol decanoate intramuscular
solution 50 mg/ml
haloperidol lactate injection solution 5
mg/ml
haloperidol lactate oral concentrate 2
mg/ml
haloperidol oral tablet 0.5 mg, 1 mg, 10
mg, 2 mg, 20 mg, 5 mg
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 117
MG/0.75 ML, 156 MG/ML, 234
MG/1.5 ML
INVEGA SUSTENNA
MG/0.25 ML, 78 MG/0.5 ML
Nivel
(Clozaril)
(Fazaclo)
Requisitos/Limites
2
2
QL (90 per 30 days)
ST
4
ST ; QL (60 per 30
days)
4
ST ; QL (8 per 28 days)
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
2
(Fluphenazine HCl)
(Fluphenazine HCl)
(Fluphenazine HCl)
2
2
2
2
4
(Haloperidol
Decanoate)
(Haldol Decanoate 50)
2
(Haloperidol Lactate)
2
(Haloperidol Lactate)
2
(Haloperidol)
2
QL (6 per 28 days)
2
5
3
57
INVEGA TRINZA
MG/0.875 ML, 410 MG/1.315 ML, 546
MG/1.75 ML, 819 MG/2.625 ML
LATUDA ORAL TABLET 120 MG,
20 MG, 40 MG, 60 MG, 80 MG
loxapine succinate oral capsule 10 mg, 25
mg, 5 mg, 50 mg
molindone oral tablet 10 mg
NUPLAZID ORAL TABLET 17 MG
olanzapine intramuscular recon soln 10
mg
olanzapine oral tablet 10 mg, 15 mg, 2.5
mg, 20 mg, 5 mg, 7.5 mg
olanzapine oral tablet,disintegrating 10
mg, 15 mg, 5 mg
olanzapine oral tablet,disintegrating 20
mg
paliperidone oral tablet extended release
24hr 1.5 mg, 3 mg, 9 mg
paliperidone oral tablet extended release
24hr 6 mg
perphenazine oral tablet 16 mg, 2 mg, 4
mg, 8 mg
pimozide oral tablet 1 mg, 2 mg
quetiapine oral tablet 100 mg, 200 mg, 25
mg, 300 mg, 400 mg, 50 mg
REXULTI ORAL TABLET 0.25 MG
REXULTI ORAL TABLET 0.5 MG
REXULTI ORAL TABLET 1 MG, 2
MG, 3 MG, 4 MG
Nivel
Requisitos/Limites
5
4
(Loxapine Succinate)
2
(Molindone HCl)
(Molindone HCl)
(Molindone HCl)
2
2
2
5
(Zyprexa)
2
days)
QL (30 per 30 days)
(Zyprexa)
2
QL (30 per 30 days)
(Zyprexa Zydis)
2
QL (30 per 30 days)
(Zyprexa Zydis)
2
QL (31 per 30 days)
(Invega)
2
QL (30 per 30 days)
(Invega)
2
QL (60 per 30 days)
(Perphenazine)
2
(Orap)
(Seroquel)
2
2
QL (90 per 30 days)
5
5
5
QL (60 per 30 days)
QL (30 per 30 days)
58
RISPERDAL CONSTA
INTRAMUSCULAR SYRINGE 12.5
MG/2 ML, 25 MG/2 ML, 37.5 MG/2
ML, 50 MG/2 ML
risperidone oral solution 1 mg/ml
risperidone oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg
risperidone oral tablet,disintegrating 0.25
mg, 0.5 mg, 1 mg, 2 mg
risperidone oral tablet,disintegrating 3
mg, 4 mg
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 10 MG, 2.5
MG, 5 MG
SEROQUEL XR ORAL TABLET
MG, 300 MG, 400 MG, 50 MG
SEROQUEL XR ORAL TABLET
MG
thioridazine oral tablet 10 mg, 100 mg,
25 mg, 50 mg
thiothixene oral capsule 1 mg, 10 mg, 2
mg, 5 mg
trifluoperazine oral tablet 1 mg, 10 mg, 2
mg, 5 mg
VERSACLOZ ORAL SUSPENSION
50 MG/ML
VRAYLAR ORAL CAPSULE 1.5
MG, 3 MG, 4.5 MG, 6 MG
VRAYLAR ORAL CAPSULE,DOSE
PACK 1.5 MG (1)- 3 MG (6)
ziprasidone hcl oral capsule 20 mg, 40
mg, 60 mg, 80 mg
ZYPREXA RELPREVV 405 MG VL
KIT W/ DILUENT, OUTER 405 MG
Nivel
Requisitos/Limites
4
QL (4 per 28 days)
(Risperdal)
(Risperdal)
2
2
QL (60 per 30 days)
(Risperdal M-Tab)
2
QL (60 per 30 days)
(Risperdal M-Tab)
2
4
ST ; QL (60 per 30
days)
4
ST ; QL (60 per 30
days)
4
ST ; QL (30 per 30
days)
(Thioridazine HCl)
2
(Thiothixene)
2
(Trifluoperazine HCl)
2
5
(Geodon)
5
ST ; QL (540 per 30
days)
QL (30 per 30 days)
4
QL (7 per 30 days)
2
QL (60 per 30 days)
5
59
Nivel
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 210 MG
Requisitos/Limites
5
Antivirals (Systemic)
Antiretrovirals
abacavir oral tablet 300 mg
(Ziagen)
abacavir-lamivudine-zidovudine oral
(Trizivir)
tablet 300-150-300 mg
APTIVUS ORAL CAPSULE 250 MG
APTIVUS ORAL SOLUTION 100
MG/ML
ATRIPLA ORAL TABLET
600-200-300 MG
COMPLERA ORAL TABLET
200-25-300 MG
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
DESCOVY ORAL TABLET 200-25
MG
didanosine oral capsule,delayed
(Videx EC)
release(dr/ec) 125 mg, 200 mg, 250 mg,
400 mg
EDURANT ORAL TABLET 25 MG
EMTRIVA ORAL CAPSULE 200 MG
EMTRIVA ORAL SOLUTION 10
MG/ML
EPIVIR HBV ORAL SOLUTION 25
MG/5 ML (5 MG/ML)
EPZICOM ORAL TABLET 600-300
MG
EVOTAZ ORAL TABLET 300-150
MG
FUZEON SUBCUTANEOUS
RECON SOLN 90 MG
GENVOYA ORAL TABLET
150-150-200-10 MG
2
5
5
4
5
5
4
5
2
5
3
3
4
5
5
5
5
60
INTELENCE ORAL TABLET 100
MG, 200 MG
INTELENCE ORAL TABLET 25 MG
INVIRASE ORAL CAPSULE 200 MG
INVIRASE ORAL TABLET 500 MG
ISENTRESS ORAL POWDER IN
PACKET 100 MG
ISENTRESS ORAL TABLET 400 MG
ISENTRESS ORAL
TABLET,CHEWABLE 100 MG, 25
MG
KALETRA ORAL SOLUTION
400-100 MG/5 ML
KALETRA ORAL TABLET 100-25
MG
KALETRA ORAL TABLET 200-50
MG
lamivudine oral solution 10 mg/ml
lamivudine oral tablet 100 mg, 150 mg,
300 mg
lamivudine-zidovudine oral tablet
150-300 mg
LEXIVA ORAL SUSPENSION 50
MG/ML
LEXIVA ORAL TABLET 700 MG
nevirapine oral suspension 50 mg/5 ml
nevirapine oral tablet 200 mg
nevirapine oral tablet extended release 24
hr 100 mg, 400 mg
NORVIR ORAL CAPSULE 100 MG
NORVIR ORAL SOLUTION 80
MG/ML
NORVIR ORAL TABLET 100 MG
ODEFSEY ORAL TABLET 200-25-25
MG
Nivel
Requisitos/Limites
5
3
5
5
3
5
3
5
3
5
(Epivir)
(Epivir)
2
2
(Combivir)
5
3
(Viramune)
(Viramune)
(Viramune XR)
5
2
2
2
3
3
3
5
61
Nivel
PREZCOBIX ORAL TABLET 800-150
MG-MG
PREZISTA ORAL SUSPENSION 100
MG/ML
PREZISTA ORAL TABLET 150 MG,
75 MG
PREZISTA ORAL TABLET 400 MG,
600 MG, 800 MG
RESCRIPTOR ORAL TABLET 200
MG
RESCRIPTOR ORAL TABLET,
DISPERSIBLE 100 MG
RETROVIR INTRAVENOUS
SOLUTION 10 MG/ML
REYATAZ ORAL CAPSULE 150
MG, 200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET 50 MG
SELZENTRY ORAL TABLET 150
MG, 300 MG
stavudine oral capsule 15 mg, 20 mg, 30
(Zerit)
mg, 40 mg
stavudine oral recon soln 1 mg/ml
(Zerit)
STRIBILD ORAL TABLET
150-150-200-300 MG
SUSTIVA ORAL CAPSULE 200 MG,
50 MG
SUSTIVA ORAL TABLET 600 MG
TIVICAY ORAL TABLET 10 MG
TIVICAY ORAL TABLET 25 MG, 50
MG
TRIUMEQ ORAL TABLET
600-50-300 MG
TRUVADA ORAL TABLET 100-150
MG, 133-200 MG, 167-250 MG,
200-300 MG
Requisitos/Limites
5
4
3
5
4
4
3
5
5
5
2
2
5
4
4
4
5
5
5
62
VIDEX 2 GRAM PEDIATRIC ORAL
RECON SOLN 10 MG/ML (FINAL)
VIDEX 4 GM PEDIATRIC SOLN 10
MG/ML (FINAL)
VIRACEPT ORAL TABLET 250 MG,
625 MG
VIRAMUNE XR ORAL TABLET
MG
VIREAD ORAL POWDER 40
MG/SCOOP (40 MG/GRAM)
VIREAD ORAL TABLET 150 MG,
200 MG, 250 MG, 300 MG
VITEKTA ORAL TABLET 150 MG,
85 MG
ZIAGEN ORAL SOLUTION 20
MG/ML
zidovudine oral capsule 100 mg
zidovudine oral syrup 10 mg/ml
zidovudine oral tablet 300 mg
Antivirals, Miscellaneous
foscarnet intravenous solution 24 mg/ml
RELENZA DISKHALER
INHALATION BLISTER WITH
DEVICE 5 MG/ACTUATION
rimantadine oral tablet 100 mg
SYNAGIS 100 MG/1 ML VIAL 100
MG/ML
SYNAGIS INTRAMUSCULAR
TAMIFLU ORAL CAPSULE 30 MG,
45 MG, 75 MG
TAMIFLU ORAL SUSPENSION
FOR RECONSTITUTION 6 MG/ML
Nivel
Requisitos/Limites
3
3
4
3
5
5
5
4
(Retrovir)
(Retrovir)
(Zidovudine)
2
2
2
(Foscavir)
2
4
(Flumadine)
2
5
PA BvD
5
3
3
63
Nivel
Hcv Antivirals
DAKLINZA ORAL TABLET 30 MG,
60 MG, 90 MG
EPCLUSA ORAL TABLET 400-100
MG
HARVONI ORAL TABLET 90-400
MG
OLYSIO ORAL CAPSULE 150 MG
5
5
5
5
SOVALDI ORAL TABLET 400 MG
5
TECHNIVIE ORAL TABLET
12.5-75-50 MG
VIEKIRA PAK ORAL
TABLETS,DOSE PACK 12.5 MG-75
MG -50 MG/250 MG
ZEPATIER ORAL TABLET 50-100
MG
Interferons
INTRON A 25 MILLION UNIT/2.5
ML 10 MILLION UNIT/ML
INTRON A INJECTION RECON
SOLN 10 MILLION UNIT (1 ML)
INTRON A INJECTION RECON
SOLN 18 MILLION UNIT (1 ML), 50
MILLION UNIT (1 ML)
INTRON A INJECTION SOLUTION
6 MILLION UNIT/ML
PEGASYS PROCLICK
SUBCUTANEOUS PEN INJECTOR
135 MCG/0.5 ML, 180 MCG/0.5 ML
PEGASYS SUBCUTANEOUS
SOLUTION 180 MCG/ML
PEGASYS SUBCUTANEOUS
SYRINGE 180 MCG/0.5 ML
5
5
Requisitos/Limites
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (30 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (56 per 28
days)
PA; QL (112 per 28
days)
5
PA; QL (30 per 30
days)
4
PA NSO
4
PA NSO
4
PA NSO
4
PA NSO
5
PA
5
PA
5
PA
64
PEGINTRON SUBCUTANEOUS
KIT 120 MCG/0.5 ML, 150 MCG/0.5
ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML
SYLATRON SUBCUTANEOUS KIT
200 MCG, 300 MCG, 600 MCG
Nucleosides And Nucleotides
acyclovir oral capsule 200 mg
acyclovir oral suspension 200 mg/5 ml
acyclovir oral tablet 400 mg, 800 mg
acyclovir sodium intravenous solution 50
mg/ml
adefovir oral tablet 10 mg
BARACLUDE ORAL SOLUTION
0.05 MG/ML
cidofovir intravenous solution 75 mg/ml
entecavir oral tablet 0.5 mg, 1 mg
famciclovir oral tablet 125 mg, 250 mg,
500 mg
ganciclovir sodium intravenous recon soln
500 mg
ribasphere oral capsule 200 mg
ribasphere oral tablet 200 mg, 400 mg,
600 mg
ribasphere ribapak oral tablets,dose pack
200 mg (7)- 400 mg (7), 400-400 mg
(28)-mg (28), 600-400 mg (28)-mg
(28), 600-600 mg (28)-mg (28)
ribavirin oral capsule 200 mg
ribavirin oral tablet 200 mg
TYZEKA ORAL TABLET 600 MG
valacyclovir oral tablet 1 gram, 500 mg
VALCYTE ORAL RECON SOLN 50
MG/ML
valganciclovir oral tablet 450 mg
VIRAZOLE INHALATION RECON
SOLN 6 GRAM
Nivel
5
PA
5
days)
(Zovirax)
(Zovirax)
(Zovirax)
(Acyclovir Sodium)
2
2
2
2
(Hepsera)
5
4
(Vistide)
(Baraclude)
(Famvir)
5
5
2
(Cytovene)
2
(Rebetol)
(Copegus)
2
2
(Ribatab)
5
(Rebetol)
(Copegus)
2
2
5
2
4
(Valtrex)
(Valcyte)
Requisitos/Limites
5
5
PA BvD
PA BvD
PA BvD
65
Nivel
Requisitos/Limites
Blood Products/Modifiers/Volume
Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
INTRAVENOUS RECON SOLN 500
UNIT
ELIQUIS ORAL TABLET 2.5 MG, 5
MG
enoxaparin subcutaneous solution 300
mg/3 ml
enoxaparin subcutaneous syringe 100
mg/ml, 120 mg/0.8 ml, 150 mg/ml
enoxaparin subcutaneous syringe 30
mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml,
80 mg/0.8 ml
fondaparinux subcutaneous syringe 10
mg/0.8 ml
fondaparinux subcutaneous syringe 2.5
mg/0.5 ml
fondaparinux subcutaneous syringe 5
mg/0.4 ml
fondaparinux subcutaneous syringe 7.5
mg/0.6 ml
heparin (porcine) in 5 % dex intravenous
parenteral solution 12,500 unit/250 ml,
20,000 unit/500 ml (40 unit/ml), 25,000
unit/500 ml (50 unit/ml)
heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/250
ml(100 unit/ml)
heparin (porcine) in nacl (pf)
intravenous parenteral solution 1,000
unit/500 ml
heparin (porcine) injection solution 1,000
unit/ml, 10,000 unit/ml, 20,000 unit/ml,
5,000 unit/ml
5
3
(Lovenox)
2
(Lovenox)
5
(Lovenox)
2
(Arixtra)
2
QL (24 per 30 days)
(Arixtra)
2
QL (15 per 30 days)
(Arixtra)
2
QL (12 per 30 days)
(Arixtra)
2
QL (18 per 30 days)
(Heparin
Sodium,Porcine/D5W)
2
(Heparin Sod,Pork In
0.45% NaCl)
2
(Heparin
Sodium,Porcine/Ns/PF
)
(Heparin
Sodium,Porcine)
2
2
66
heparin, porcine (pf) injection solution
5,000 unit/0.5 ml
heparin, porcine (pf) injection syringe
5,000 unit/0.5 ml
heparin-0.45% nacl 25,000 units/250 ml
(100 units/ml) bag latex-free, inner
25,000 unit/250 ml
heparin-d5w 25,000 units/250 ml (100
units/ml) bag excel container 25,000
unit/250 ml(100 unit/ml)
IPRIVASK SUBCUTANEOUS
RECON SOLN 15 MG
jantoven oral tablet 1 mg, 10 mg, 2 mg,
2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
PRADAXA ORAL CAPSULE 110
MG, 150 MG, 75 MG
SAVAYSA ORAL TABLET 15 MG,
30 MG, 60 MG
warfarin oral tablet 1 mg, 10 mg, 2 mg,
2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
XARELTO ORAL TABLET 10 MG,
15 MG, 20 MG
XARELTO ORAL TABLETS,DOSE
PACK 15 MG (42)- 20 MG (9)
Blood Formation Modifiers
CINRYZE INTRAVENOUS RECON
SOLN 500 UNIT (5 ML)
EPOGEN 10,000 UNITS/ML VIAL
SDV, P/F, OUTER 10,000 UNIT/ML
EPOGEN INJECTION SOLUTION
2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML,
4,000 UNIT/ML
GRANIX SUBCUTANEOUS
SYRINGE 300 MCG/0.5 ML, 480
MCG/0.8 ML
Nivel
(Heparin
Sodium,Porcine/PF)
(Monoject Prefill
Advanced)
(Heparin Sod,Pork In
0.45% NaCl)
2
(Heparin
Sodium,Porcine/D5W)
2
2
2
5
(Coumadin)
Requisitos/Limites
PA; QL (24 per 28
days)
1
4
4
(Coumadin)
1
3
3
5
PA
3
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
3
5
67
Nivel
LEUKINE INJECTION RECON
SOLN 250 MCG
MIRCERA INJECTION SYRINGE
100 MCG/0.3 ML, 200 MCG/0.3 ML,
50 MCG/0.3 ML, 75 MCG/0.3 ML
MOZOBIL SUBCUTANEOUS
SOLUTION 24 MG/1.2 ML (20
MG/ML)
NEULASTA SUBCUTANEOUS
SYRINGE 6 MG/0.6ML
NEULASTA SUBCUTANEOUS
SYRINGE, W/ WEARABLE
INJECTOR 6 MG/0.6 ML
NEUMEGA SUBCUTANEOUS
RECON SOLN 5 MG
NEUPOGEN INJECTION
SOLUTION 300 MCG/ML, 480
MCG/1.6 ML
NEUPOGEN INJECTION SYRINGE
300 MCG/0.5 ML, 480 MCG/0.8 ML
PROCRIT 10,000 UNITS/ML VIAL
4'S, MDV, OUTER 20,000 UNIT/2 ML
PROCRIT INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
3,000 UNIT/ML, 4,000 UNIT/ML
20,000 UNIT/ML
40,000 UNIT/ML
PROMACTA ORAL TABLET 12.5
MG, 25 MG, 50 MG, 75 MG
ZARXIO INJECTION SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
Hematologic Agents,
Miscellaneous
aminocaproic acid oral solution 250
(Aminocaproic Acid)
mg/ml (25 %)
Requisitos/Limites
5
4
PA; QL (0.6 per 28
days)
5
5
5
5
5
5
3
3
5
5
5
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
PA; QL (30 per 30
days)
5
2
68
aminocaproic acid oral tablet 1,000 mg,
500 mg
anagrelide oral capsule 0.5 mg, 1 mg
protamine intravenous solution 10 mg/ml
tranexamic acid intravenous solution
1,000 mg/10 ml (100 mg/ml)
tranexamic acid oral tablet 650 mg
Platelet-Aggregation Inhibitors
aspirin-dipyridamole oral capsule, er
multiphase 12 hr 25-200 mg
BRILINTA ORAL TABLET 60 MG,
90 MG
cilostazol oral tablet 100 mg, 50 mg
clopidogrel oral tablet 300 mg, 75 mg
dipyridamole oral tablet 25 mg, 50 mg,
75 mg
EFFIENT ORAL TABLET 10 MG, 5
MG
pentoxifylline oral tablet extended
release 400 mg
Nivel
(Aminocaproic Acid)
2
(Agrylin)
(Protamine Sulfate)
(Tranexamic Acid)
2
2
2
(Lysteda)
2
(Aggrenox)
2
Requisitos/Limites
QL (30 per 30 days)
3
(Pletal)
(Plavix)
(Persantine)
2
2
2
3
(Pentoxifylline)
QL (30 per 30 days)
2
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
INTRAVENOUS PARENTERAL
SOLUTION 15 %
AMINOSYN 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
AMINOSYN 3.5 % INTRAVENOUS
PARENTERAL SOLUTION 3.5 %
AMINOSYN 7 % INTRAVENOUS
AMINOSYN 7 % WITH
ELECTROLYTES INTRAVENOUS
AMINOSYN 8.5 % INTRAVENOUS
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
69
Nivel
AMINOSYN 8.5 %-ELECTROLYTES
SOLUTION 8.5 %
AMINOSYN II 10 %
SOLUTION 10 %
AMINOSYN II 15 %
SOLUTION 15 %
AMINOSYN II 7 % INTRAVENOUS
AMINOSYN II 8.5 %
SOLUTION 8.5 %
AMINOSYN II 8.5
%-ELECTROLYTES
SOLUTION 8.5 %
AMINOSYN M 3.5 %
SOLUTION 3.5 %
AMINOSYN-HBC 7%
SOLUTION 7 %
AMINOSYN-PF 10 %
SOLUTION 10 %
AMINOSYN-PF 7 %
(SULFITE-FREE) INTRAVENOUS
AMINOSYN-RF 5.2 %
SOLUTION 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE INTRAVENOUS
Requisitos/Limites
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
70
Nivel
CLINIMIX 5%/D25W
SULFITE-FREE INTRAVENOUS
CLINIMIX 2.75%/D5W SULFIT
FREE INTRAVENOUS
CLINIMIX 4.25%/D10W SULF FREE
SOLUTION 4.25 %
CLINIMIX 4.25%/D5W SULFIT
FREE INTRAVENOUS
CLINIMIX 4.25%-D20W SULF-FREE
SOLUTION 4.25 %
CLINIMIX 4.25%-D25W SULF-FREE
SOLUTION 4.25 %
CLINIMIX
5%-D20W(SULFITE-FREE)
SOLUTION 5 %
CLINIMIX E 2.75%/D10W SUL
FREE INTRAVENOUS
CLINIMIX E 2.75%/D5W SULF
FREE INTRAVENOUS
FREE INTRAVENOUS
FREE INTRAVENOUS
CLINIMIX E 4.25%/D5W SULF
FREE INTRAVENOUS
Requisitos/Limites
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
71
CLINIMIX E 5%/D15W SULFIT
FREE INTRAVENOUS
FREE INTRAVENOUS
FREE INTRAVENOUS
CLINISOL SF 15 % INTRAVENOUS
cysteine (l-cysteine) intravenous solution
50 mg/ml
dextrose 10 % in water (d10w)
intravenous parenteral solution 10 %
intravenous solution
intravenous syringe
dextrose 5 % in ringers intravenous
parenteral solution 5 %
dextrose 5 % in water (d5w) intravenous
parenteral solution
intravenous parenteral solution
intravenous syringe
FREAMINE HBC 6.9 %
SOLUTION 6.9 %
Nivel
Requisitos/Limites
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
(Cysteine HCl)
2
PA BvD
(Dextrose 10 % in
Water)
(Dextrose 10 % in
Water)
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5 % In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
2
PA BvD
2
PA BvD
2
PA BvD
2
PA BvD
2
PA BvD
2
2
2
PA BvD
2
PA BvD
2
PA BvD
4
PA BvD
72
Nivel
FREAMINE III 10 %
SOLUTION 10 %
HEPATAMINE 8% INTRAVENOUS
HEPATASOL 8 % INTRAVENOUS
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN INTRAVENOUS
EMULSION 3.31-9.8-3.9 %
NEPHRAMINE 5.4 %
SOLUTION 5.4 %
NUTRILIPID INTRAVENOUS
EMULSION 20 %
PERIKABIVEN INTRAVENOUS
EMULSION 2.36-6.8-3.5 %
PREMASOL 10 % INTRAVENOUS
PREMASOL 6 % INTRAVENOUS
PROCALAMINE 3%
SOLUTION 3 %
PROSOL 20 % INTRAVENOUS
PARENTERAL SOLUTION
TRAVASOL 10 % INTRAVENOUS
TROPHAMINE 10 %
SOLUTION 10 %
TROPHAMINE 6% INTRAVENOUS
Requisitos/Limites
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
4
PA BvD
73
Nivel
Requisitos/Limites
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet 0.1 mg, 0.2 mg,
0.3 mg
clonidine transdermal patch weekly 0.1
mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly 0.3
mg/24 hr
clorpres oral tablet 0.1-15 mg, 0.2-15 mg,
0.3-15 mg
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8
mg
guanfacine oral tablet 1 mg, 2 mg
midodrine oral tablet 10 mg, 2.5 mg, 5
mg
NORTHERA ORAL CAPSULE 100
MG, 200 MG, 300 MG
phenylephrine hcl injection solution 10
mg/ml
prazosin oral capsule 1 mg, 2 mg, 5 mg
Angiotensin Ii Receptor
Antagonists
BENICAR HCT ORAL TABLET
20-12.5 MG, 40-12.5 MG, 40-25 MG
BENICAR ORAL TABLET 20 MG, 40
MG, 5 MG
candesartan oral tablet 16 mg, 32 mg, 4
mg, 8 mg
candesartan-hydrochlorothiazid oral
tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg
EDARBI ORAL TABLET 40 MG, 80
MG
EDARBYCLOR ORAL TABLET
40-12.5 MG, 40-25 MG
ENTRESTO ORAL TABLET 24-26
MG, 49-51 MG, 97-103 MG
(Catapres)
1
(Catapres-Tts 1)
2
QL (4 per 28 days)
(Catapres-Tts 1)
2
QL (8 per 28 days)
(Clonidine
HCl/Chlorthalidone)
(Cardura)
2
(Tenex)
(Midodrine HCl)
2
2
2
5
(Vazculep)
2
(Minipress)
2
PA; QL (180 per 30
days)
3
3
(Atacand)
2
(Atacand HCT)
2
4
ST
4
ST
3
PA; QL (60 per 30
days)
74
eprosartan oral tablet 600 mg
irbesartan oral tablet 150 mg, 300 mg, 75
mg
irbesartan-hydrochlorothiazide oral
tablet 150-12.5 mg, 300-12.5 mg
losartan oral tablet 100 mg, 25 mg, 50
mg
losartan-hydrochlorothiazide oral tablet
100-12.5 mg, 100-25 mg, 50-12.5 mg
telmisartan oral tablet 20 mg, 40 mg, 80
mg
telmisartan-hydrochlorothiazid oral
tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg
TEVETEN HCT ORAL TABLET
600-12.5 MG, 600-25 MG
TRIBENZOR ORAL TABLET
20-5-12.5 MG, 40-10-12.5 MG, 40-10-25
MG, 40-5-12.5 MG, 40-5-25 MG
valsartan oral tablet 160 mg, 320 mg, 40
mg, 80 mg
valsartan-hydrochlorothiazide oral tablet
160-12.5 mg, 160-25 mg, 320-12.5 mg,
320-25 mg, 80-12.5 mg
Angiotensin-Converting Enzyme
Inhibitors
benazepril oral tablet 10 mg, 20 mg, 40
mg, 5 mg
benazepril-hydrochlorothiazide oral
tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg,
5-6.25 mg
captopril oral tablet 100 mg, 12.5 mg, 25
mg, 50 mg
captopril-hydrochlorothiazide oral tablet
25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg
enalapril maleate oral tablet 10 mg, 2.5
mg, 20 mg, 5 mg
Nivel
(Teveten)
(Avapro)
2
2
(Avalide)
2
(Cozaar)
1
(Hyzaar)
2
(Micardis)
2
(Micardis HCT)
2
Requisitos/Limites
3
ST
3
ST
(Diovan)
2
(Diovan HCT)
2
(Lotensin)
1
(Lotensin HCT)
2
(Captopril)
2
(Captopril/Hydrochlor
othiazide)
(Vasotec)
2
1
75
enalaprilat intravenous solution 1.25
mg/ml
enalapril-hydrochlorothiazide oral tablet
10-25 mg, 5-12.5 mg
fosinopril oral tablet 10 mg, 20 mg, 40
mg
fosinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg
lisinopril oral tablet 10 mg, 2.5 mg, 20
mg, 30 mg, 40 mg, 5 mg
lisinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
moexipril oral tablet 15 mg, 7.5 mg
moexipril-hydrochlorothiazide oral tablet
15-12.5 mg, 15-25 mg, 7.5-12.5 mg
perindopril erbumine oral tablet 2 mg, 4
mg, 8 mg
quinapril oral tablet 10 mg, 20 mg, 40
mg, 5 mg
quinapril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
ramipril oral capsule 1.25 mg, 10 mg, 2.5
mg, 5 mg
trandolapril oral tablet 1 mg, 2 mg, 4 mg
Antiarrhythmic Agents
amiodarone intravenous solution 50
mg/ml
amiodarone intravenous syringe 150 mg/3
ml
amiodarone oral tablet 100 mg, 200 mg,
400 mg
disopyramide phosphate oral capsule 100
mg, 150 mg
dofetilide oral capsule 125 mcg, 250 mcg,
500 mcg
flecainide oral tablet 100 mg, 150 mg, 50
mg
Nivel
(Enalaprilat Dihydrate)
2
(Vaseretic)
2
(Fosinopril Sodium)
2
(Fosinopril/Hydrochlor
othiazide)
(Zestril)
2
(Zestoretic)
1
(Moexipril HCl)
(Moexipril/Hydrochlor
othiazide)
(Aceon)
2
2
(Accupril)
2
(Accuretic)
2
(Altace)
2
(Mavik)
2
(Amiodarone HCl)
2
(Amiodarone HCl)
2
(Cordarone)
2
(Norpace)
2
(Tikosyn)
2
(Tambocor)
2
Requisitos/Limites
1
2
76
lidocaine (pf) intravenous syringe 50
mg/5 ml (1 %)
lidocaine in 5 % dextrose (pf)
intravenous parenteral solution 8 mg/ml
(0.8 %)
mexiletine oral capsule 150 mg, 200 mg,
250 mg
MULTAQ ORAL TABLET 400 MG
pacerone oral tablet 100 mg, 200 mg, 400
mg
procainamide injection solution 100
mg/ml, 500 mg/ml
propafenone oral capsule,extended
propafenone oral tablet 150 mg, 225 mg,
300 mg
quinidine gluconate oral tablet extended
release 324 mg
quinidine sulfate oral tablet 200 mg, 300
mg
quinidine sulfate oral tablet extended
release 300 mg
TIKOSYN ORAL CAPSULE 125
MCG, 250 MCG, 500 MCG
Beta-Adrenergic Blocking Agents
acebutolol oral capsule 200 mg, 400 mg
atenolol oral tablet 100 mg, 25 mg, 50 mg
atenolol-chlorthalidone oral tablet 100-25
mg, 50-25 mg
betaxolol oral tablet 10 mg, 20 mg
bisoprolol fumarate oral tablet 10 mg, 5
mg
bisoprolol-hydrochlorothiazide oral tablet
10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg
BYSTOLIC ORAL TABLET 10 MG,
2.5 MG, 20 MG, 5 MG
Nivel
(Lidocaine HCl/PF)
2
(Lidocaine
HCl/D5w/PF)
2
(Mexiletine HCl)
2
(Cordarone)
3
2
(Procainamide HCl)
2
(Rythmol SR)
2
(Rythmol)
2
(Quinidine Gluconate)
2
(Quinidine Sulfate)
2
(Quinidine Sulfate)
2
Requisitos/Limites
3
(Sectral)
(Tenormin)
(Tenoretic 50)
2
1
1
(Betaxolol HCl)
(Zebeta)
2
2
(Ziac)
2
3
77
carvedilol oral tablet 12.5 mg, 25 mg,
3.125 mg, 6.25 mg
esmolol intravenous solution 100 mg/10
ml (10 mg/ml)
labetalol intravenous solution 5 mg/ml
labetalol oral tablet 100 mg, 200 mg, 300
mg
metoprolol succinate oral tablet extended
release 24 hr 100 mg, 200 mg, 25 mg, 50
mg
metoprolol ta-hydrochlorothiaz oral
tablet 100-25 mg, 100-50 mg, 50-25 mg
metoprolol tartrate intravenous solution 5
mg/5 ml
metoprolol tartrate oral tablet 100 mg, 25
mg, 50 mg
metoprolol tartrate oral tablet 37.5 mg,
75 mg
nadolol oral tablet 20 mg, 40 mg, 80 mg
pindolol oral tablet 10 mg, 5 mg
propranolol intravenous solution 1 mg/ml
propranolol oral capsule,extended release
24 hr 120 mg, 160 mg, 60 mg, 80 mg
propranolol oral solution 20 mg/5 ml (4
mg/ml), 40 mg/5 ml (8 mg/ml)
propranolol oral tablet 10 mg, 20 mg, 40
mg, 60 mg, 80 mg
propranolol-hydrochlorothiazid oral
tablet 40-25 mg, 80-25 mg
sorine oral tablet 120 mg, 160 mg, 240
mg, 80 mg
sotalol 120 mg tablet 120 mg
sotalol af oral tablet 120 mg
sotalol oral tablet 160 mg, 240 mg, 80 mg
timolol maleate oral tablet 10 mg, 20 mg,
5 mg
Nivel
(Coreg)
1
(Brevibloc)
2
(Labetalol HCl)
(Trandate)
2
2
(Toprol XL)
2
(Lopressor HCT)
2
(Lopressor)
2
(Lopressor)
1
(Lopressor)
2
(Corgard)
(Pindolol)
(Propranolol HCl)
(Inderal LA)
2
2
2
2
(Propranolol HCl)
2
(Propranolol HCl)
2
(Propranolol/Hydrochl
orothiazid)
(Betapace)
2
(Betapace)
(Betapace)
(Betapace)
(Timolol Maleate)
2
2
2
2
Requisitos/Limites
PA BvD
2
78
Calcium-Channel Blocking Agents
cartia xt oral capsule,extended release
24hr 120 mg, 180 mg, 240 mg, 300 mg
diltiazem 24hr er 180 mg cap 180 mg
diltiazem 24hr er 360 mg cap 360 mg
diltiazem hcl intravenous recon soln 100
mg
diltiazem hcl intravenous solution 5
mg/ml
diltiazem hcl oral capsule, extended
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended
diltiazem hcl oral capsule,extended
release 24hr 120 mg, 240 mg, 300 mg
diltiazem hcl oral tablet 120 mg, 30 mg,
60 mg, 90 mg
diltiazem hcl oral tablet extended release
24 hr 180 mg, 240 mg, 300 mg, 360 mg,
420 mg
dilt-xr oral capsule,ext release
degradable 120 mg, 180 mg, 240 mg
matzim la oral tablet extended release 24
hr 180 mg, 240 mg, 300 mg, 360 mg, 420
mg
taztia xt oral capsule, extended release
120 mg, 180 mg, 240 mg, 300 mg, 360 mg
verapamil intravenous syringe 2.5 mg/ml
verapamil oral capsule, 24 hr er pellet ct
100 mg, 200 mg, 300 mg
verapamil oral capsule,ext rel. pellets 24
hr 120 mg, 180 mg, 240 mg, 360 mg
verapamil oral tablet 120 mg, 40 mg, 80
mg
verapamil oral tablet extended release
120 mg, 180 mg, 240 mg
Nivel
(Cardizem CD)
2
(Cardizem CD)
(Cardizem CD)
(Cardizem CD)
2
2
2
(Cardizem CD)
2
(Cardizem CD)
2
(Cardizem CD)
2
(Cardizem CD)
2
(Cardizem CD)
1
(Cardizem LA)
2
(Cardizem CD)
2
(Cardizem CD)
2
(Cardizem CD)
2
(Verapamil HCl)
(Verelan Pm)
2
2
(Verelan)
2
(Calan)
1
(Calan SR)
2
Requisitos/Limites
79
Cardiovascular Agents,
Miscellaneous
CORLANOR ORAL TABLET 5 MG,
7.5 MG
DEMSER ORAL CAPSULE 250 MG
digitek oral tablet 125 mcg, 250 mcg
digox 125 mcg tablet 125 mcg
digox 250 mcg tablet 250 mcg
digoxin 0.25 mg/ml syringe 250 mcg/ml
digoxin injection solution 250 mcg/ml
DIGOXIN ORAL SOLUTION 50
MCG/ML
digoxin oral tablet 125 mcg, 250 mcg
dobutamine in d5w intravenous
parenteral solution 1,000 mg/250 ml
(4,000 mcg/ml), 250 mg/250 ml (1
mg/ml), 500 mg/250 ml (2,000 mcg/ml)
dobutamine intravenous solution 250
mg/20 ml (12.5 mg/ml)
dopamine in 5 % dextrose intravenous
solution 200 mg/250 ml (800 mcg/ml),
400 mg/250 ml (1,600 mcg/ml), 800
mg/250 ml (3,200 mcg/ml)
dopamine intravenous solution 200 mg/5
ml (40 mg/ml), 400 mg/5 ml (80 mg/ml),
800 mg/10 ml (80 mg/ml), 800 mg/5 ml
(160 mg/ml)
ephedrine sulfate injection solution 50
mg/ml
epinephrine hcl (pf) intravenous solution
1 mg/ml (1 ml)
epinephrine injection auto-injector 0.15
mg/0.15 ml, 0.3 mg/0.3 ml
epinephrine injection solution 1 mg/ml (1
ml)
epinephrine injection syringe 0.1 mg/ml
Nivel
3
(Lanoxin)
(Lanoxin)
(Lanoxin)
(Digoxin)
(Digoxin)
5
2
2
2
2
2
3
Requisitos/Limites
ST
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Lanoxin)
(Dobutamine
HCl/D5W)
2
2
QL (30 per 30 days)
PA BvD
(Dobutamine HCl)
2
PA BvD
(Dopamine HCl/D5W)
2
PA BvD
(Dopamine HCl)
2
PA BvD
(Ephedrine Sulfate)
2
(Epinephrine HCl/PF)
2
(Adrenaclick)
2
(Epinephrine)
2
(Epinephrine)
2
80
EPIPEN 2-PAK INJECTION
AUTO-INJECTOR 0.3 MG/0.3 ML
EPIPEN JR 2-PAK INJECTION
AUTO-INJECTOR 0.15 MG/0.3 ML
ethamolin intravenous solution 5 %
FIRAZYR SUBCUTANEOUS
SYRINGE 30 MG/3 ML
hydralazine injection solution 20 mg/ml
hydralazine oral tablet 10 mg, 100 mg, 25
mg, 50 mg
LANOXIN ORAL TABLET 187.5
MCG, 62.5 MCG
milrinone in 5 % dextrose intravenous
piggyback 20 mg/100 ml (200 mcg/ml),
40 mg/200 ml (200 mcg/ml)
milrinone intravenous solution 1 mg/ml
norepinephrine bitartrate intravenous
solution 1 mg/ml
papaverine injection solution 30 mg/ml
papaverine oral capsule, extended release
150 mg
RANEXA ORAL TABLET
EXTENDED RELEASE 12 HR 1,000
MG, 500 MG
Dihydropyridines
afeditab cr oral tablet extended release
30 mg, 60 mg
amlodipine oral tablet 10 mg, 2.5 mg, 5
mg
amlodipine-benazepril oral capsule 10-20
mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20
mg, 5-40 mg
amlodipine-valsartan oral tablet 10-160
mg, 10-320 mg, 5-160 mg, 5-320 mg
Nivel
Requisitos/Limites
3
3
(Ethanolamine Oleate)
2
5
(Hydralazine HCl)
(Hydralazine HCl)
2
2
4
QL (30 per 30 days)
(Milrinone
Lactate/D5W)
5
PA BvD
(Milrinone Lactate)
(Levophed Bitartrate)
5
2
PA BvD
PA BvD
(Papaverine HCl)
(Papaverine HCl)
2
2
PA
PA
3
(Adalat CC)
2
(Norvasc)
1
(Lotrel)
2
(Exforge)
2
81
amlodipine-valsartan-hcthiazid oral
tablet 10-160-12.5 mg, 10-160-25 mg,
10-320-25 mg, 5-160-12.5 mg, 5-160-25
mg
AZOR ORAL TABLET 10-20 MG,
10-40 MG, 5-20 MG, 5-40 MG
CLEVIPREX INTRAVENOUS
EMULSION 50 MG/100 ML
felodipine oral tablet extended release 24
hr 10 mg, 2.5 mg, 5 mg
isradipine oral capsule 2.5 mg, 5 mg
nicardipine oral capsule 20 mg, 30 mg
nifedical xl oral tablet extended release
24hr 30 mg, 60 mg
nifedipine er 30 mg tablet f/c 30 mg
nifedipine oral tablet extended release
24hr 30 mg
nifedipine oral tablet extended release
24hr 60 mg, 90 mg
Diuretics
amiloride oral tablet 5 mg
amiloride-hydrochlorothiazide oral tablet
5-50 mg
bumetanide injection solution 0.25 mg/ml
bumetanide oral tablet 0.5 mg, 1 mg, 2
mg
chlorothiazide oral tablet 250 mg, 500 mg
chlorothiazide sodium intravenous recon
soln 500 mg
chlorthalidone oral tablet 25 mg, 50 mg
DYRENIUM ORAL CAPSULE 100
MG, 50 MG
furosemide injection solution 10 mg/ml
furosemide injection syringe 10 mg/ml
furosemide oral solution 10 mg/ml, 40
mg/5 ml (8 mg/ml)
Nivel
(Exforge HCT)
Requisitos/Limites
2
3
ST
4
(Felodipine)
2
(Isradipine)
(Nicardipine HCl)
(Procardia XL)
2
2
2
(Adalat CC)
(Adalat CC)
2
2
(Procardia XL)
2
(Amiloride HCl)
(Amiloride/Hydrochlor
othiazide)
(Bumetanide)
(Bumetanide)
2
2
(Chlorothiazide)
(Sodium Diuril)
1
2
(Chlorthalidone)
1
4
(Furosemide)
(Furosemide)
(Furosemide)
2
2
2
2
2
82
furosemide oral tablet 20 mg, 40 mg, 80
mg
hydrochlorothiazide oral capsule 12.5 mg
hydrochlorothiazide oral tablet 12.5 mg,
25 mg, 50 mg
indapamide oral tablet 1.25 mg, 2.5 mg
methyclothiazide oral tablet 5 mg
metolazone oral tablet 10 mg, 2.5 mg, 5
mg
torsemide oral tablet 10 mg, 100 mg, 20
mg, 5 mg
triamterene-hydrochlorothiazid oral
capsule 37.5-25 mg, 50-25 mg
triamterene-hydrochlorothiazid oral
tablet 37.5-25 mg, 75-50 mg
Dyslipidemics
ALTOPREV ORAL TABLET
MG, 40 MG, 60 MG
amlodipine-atorvastatin oral tablet 10-10
mg, 10-20 mg, 10-40 mg, 10-80 mg,
2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10
mg, 5-20 mg, 5-40 mg, 5-80 mg
atorvastatin oral tablet 10 mg, 20 mg, 40
mg, 80 mg
cholestyramine light oral powder in
packet 4 gram
cholestyramine packet 4 gram
colestipol hcl granules packet 5 gram
colestipol oral granules 5 gram
colestipol oral tablet 1 gram
CRESTOR ORAL TABLET 10 MG,
20 MG, 40 MG, 5 MG
fenofibrate micronized oral capsule 130
mg, 134 mg, 200 mg, 43 mg, 67 mg
Nivel
(Lasix)
1
(Microzide)
(Hydrochlorothiazide)
1
1
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
1
2
2
(Demadex)
2
(Dyazide)
2
(Maxzide)
2
Requisitos/Limites
4
(Caduet)
2
(Lipitor)
1
(Questran)
2
(Questran)
(Colestid)
(Colestid)
(Colestid)
2
2
2
2
2
(Lofibra)
2
83
fenofibrate nanocrystallized oral tablet
145 mg, 48 mg
fenofibrate oral tablet 120 mg, 160 mg,
40 mg, 54 mg
fenofibric acid (choline) oral
capsule,delayed release(dr/ec) 135 mg,
45 mg
fenofibric acid oral tablet 105 mg, 35 mg
fluvastatin oral capsule 20 mg, 40 mg
gemfibrozil oral tablet 600 mg
JUXTAPID ORAL CAPSULE 10 MG,
20 MG, 30 MG, 40 MG, 5 MG, 60 MG
KYNAMRO SUBCUTANEOUS
SYRINGE 200 MG/ML
lovastatin oral tablet 10 mg, 20 mg, 40
mg
niacin oral tablet extended release 24 hr
1,000 mg, 500 mg, 750 mg
niacor oral tablet 500 mg
omega-3 acid ethyl esters oral capsule 1
gram
PRALUENT PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML, 75
MG/ML
PRALUENT SYRINGE
SUBCUTANEOUS SYRINGE 150
MG/ML, 75 MG/ML
pravastatin oral tablet 10 mg, 20 mg, 40
mg, 80 mg
prevalite oral powder 4 gram
prevalite packet outer 4 gram
Nivel
Requisitos/Limites
(Tricor)
2
(Lofibra)
2
(Trilipix)
2
(Fibricor)
(Lescol)
(Lopid)
2
2
2
5
PA
5
(Mevacor)
1
(Niaspan)
2
(Niacin)
(Lovaza)
2
2
5
5
(Pravachol)
1
(Cholestyramine/Aspar
tame)
(Cholestyramine/Aspar
tame)
2
REPATHA PUSHTRONEX
SUBCUTANEOUS WEARABLE
INJECTOR 420 MG/3.5 ML
2
5
PA; QL (3.5 per 28
days)
84
REPATHA SURECLICK
140 MG/ML
REPATHA SYRINGE
MG/ML
rosuvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
simvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
simvastatin oral tablet 80 mg
VASCEPA ORAL CAPSULE 1
GRAM
VYTORIN 10-10 ORAL TABLET
10-10 MG
10-20 MG
10-40 MG
10-80 MG
WELCHOL ORAL POWDER IN
PACKET 3.75 GRAM
WELCHOL ORAL TABLET 625 MG
ZETIA ORAL TABLET 10 MG
Renin-Angiotensin-Aldosterone
System Inhibitors
eplerenone oral tablet 25 mg, 50 mg
spironolactone oral tablet 100 mg, 25 mg,
50 mg
spironolacton-hydrochlorothiaz oral
tablet 25-25 mg
Vasodilators
BIDIL ORAL TABLET 20-37.5 MG
isosorbide dinitrate oral tablet 10 mg, 20
mg, 30 mg, 5 mg
Nivel
Requisitos/Limites
5
5
(Crestor)
2
(Zocor)
1
(Zocor)
1
3
QL (30 per 30 days)
4
4
4
4
3
3
4
(Inspra)
(Aldactone)
2
2
(Aldactazide)
2
(Isochron)
3
2
85
isosorbide dinitrate oral tablet extended
release 40 mg
isosorbide dinitrate sublingual tablet 2.5
mg, 5 mg
isosorbide mononitrate oral tablet 10 mg,
20 mg
isosorbide mononitrate oral tablet
extended release 24 hr 120 mg, 30 mg, 60
mg
minitran transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour 0.4
mg/hr
minoxidil oral tablet 10 mg, 2.5 mg
NITRO-BID TRANSDERMAL
OINTMENT 2 %
nitroglycerin in 5 % dextrose intravenous
solution 100 mg/250 ml (400 mcg/ml), 25
mg/250 ml (100 mcg/ml), 50 mg/250 ml
(200 mcg/ml)
nitroglycerin intravenous solution 50
mg/10 ml (5 mg/ml)
nitroglycerin transdermal patch 24 hour
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
nitroglycerin transdermal patch 24 hour
0.4 mg/hr
NITROSTAT SUBLINGUAL
TABLET 0.3 MG, 0.4 MG, 0.6 MG
PROGLYCEM ORAL SUSPENSION
50 MG/ML
Nivel
Requisitos/Limites
(Isochron)
2
(Isosorbide Dinitrate)
1
(Isosorbide
Mononitrate)
(Imdur)
2
(Nitro-Dur)
2
QL (30 per 30 days)
(Nitro-Dur)
2
QL (60 per 30 days)
(Minoxidil)
2
2
(Nitroglycerin/D5W)
2
(Nitroglycerin)
2
(Nitro-Dur)
2
QL (30 per 30 days)
(Nitro-Dur)
2
QL (60 per 30 days)
2
3
4
Central Nervous System Agents
Central Nervous System Agents
AMPYRA ORAL TABLET
MG
caffeine citrated intravenous solution 60
mg/3 ml (20 mg/ml)
5
(Cafcit)
PA; QL (60 per 30
days)
2
86
caffeine citrated oral solution 60 mg/3 ml
(20 mg/ml)
caffeine-sodium benzoate injection
solution 250 mg/ml (125 mg/ml caffeine)
clonidine hcl oral tablet extended release
12 hr 0.1 mg
dexmethylphenidate oral tablet 10 mg,
2.5 mg, 5 mg
dextroamphetamine oral capsule,
extended release 10 mg, 15 mg, 5 mg
dextroamphetamine oral tablet 10 mg, 5
mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15
mg, 5 mg
capsule,extended release 24hr 20 mg, 25
mg, 30 mg
tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30
mg, 5 mg, 7.5 mg
flumazenil intravenous solution 0.1 mg/ml
guanfacine oral tablet extended release
24 hr 1 mg, 2 mg, 3 mg, 4 mg
lithium carbonate oral capsule 150 mg,
300 mg, 600 mg
lithium carbonate oral tablet 300 mg
lithium carbonate oral tablet extended
release 300 mg, 450 mg
lithium citrate oral solution 8 meq/5 ml
methylphenidate cd 20 mg cap 20 mg
methylphenidate cd 40 mg cap 40 mg
methylphenidate oral capsule, er biphasic
30-70 10 mg, 50 mg, 60 mg
methylphenidate oral capsule, er biphasic
30-70 30 mg
Nivel
Requisitos/Limites
(Cafcit)
2
(Caffeine/Sodium
Benzoate)
(Kapvay)
2
(Focalin)
2
QL (60 per 30 days)
(Dexedrine)
2
(Dexedrine)
2
(Adderall XR)
2
QL (30 per 30 days)
(Adderall XR)
2
QL (60 per 30 days)
(Adderall)
2
QL (60 per 30 days)
(Romazicon)
(Intuniv)
2
2
(Lithium Carbonate)
2
(Lithobid)
(Lithobid)
2
2
(Lithium Citrate)
(Metadate Cd)
(Metadate Cd)
(Metadate Cd)
2
2
2
2
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Metadate Cd)
2
QL (60 per 30 days)
2
87
methylphenidate oral capsule,er biphasic
50-50 20 mg, 40 mg
methylphenidate oral solution 10 mg/5
ml, 5 mg/5 ml
methylphenidate oral tablet 10 mg, 20
mg, 5 mg
methylphenidate oral tablet extended
release 10 mg, 20 mg
release 24hr 36 mg
NUEDEXTA ORAL CAPSULE 20-10
MG
QUILLIVANT XR ORAL
SUSPENSION,EXT REL
24HR,RECON 5 MG/ML (25 MG/5
ML)
riluzole oral tablet 50 mg
SAVELLA ORAL TABLET 100 MG,
12.5 MG, 25 MG, 50 MG
SAVELLA ORAL TABLETS,DOSE
PACK 12.5 MG (5)-25 MG(8)-50
MG(42)
STRATTERA ORAL CAPSULE 10
MG, 100 MG, 18 MG, 25 MG, 40 MG,
60 MG, 80 MG
tetrabenazine oral tablet 12.5 mg, 25 mg
Nivel
Requisitos/Limites
(Metadate Cd)
2
QL (30 per 30 days)
(Methylin)
2
(Ritalin)
2
QL (90 per 30 days)
(Methylphenidate HCl)
2
QL (90 per 30 days)
(Concerta)
2
QL (30 per 30 days)
(Concerta)
2
QL (60 per 30 days)
3
QL (60 per 30 days)
3
(Rilutek)
2
3
QL (60 per 30 days)
3
QL (60 per 30 days)
3
(Xenazine)
5
(Amethyst)
(Modicon)
2
2
(Modicon)
2
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
altavera (28) oral tablet 0.15-0.03 mg
alyacen 1/35 (28) oral tablet 1-35
mg-mcg
alyacen 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
88
amethia lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
amethia oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
apri oral tablet 0.15-0.03 mg
aranelle (28) oral tablet 0.5/1/0.5-35
mg-mcg
ashlyna oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
aubra oral tablet 0.1-20 mg-mcg
aviane oral tablet 0.1-20 mg-mcg
azurette (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
balziva (28) oral tablet 0.4-35 mg-mcg
bekyree (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
blisovi 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
blisovi fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
blisovi fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
briellyn oral tablet 0.4-35 mg-mcg
camila oral tablet 0.35 mg
camrese lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
camrese oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
caziant (28) oral tablet 0.1/.125/.15-25
mg-mcg
cryselle (28) oral tablet 0.3-30 mg-mcg
Nivel
Requisitos/Limites
(Seasonique)
2
QL (91 per 84 days)
(Seasonique)
2
QL (91 per 84 days)
(Desogen)
(Modicon)
2
2
(Seasonique)
2
(Amethyst)
(Amethyst)
(Mircette)
2
2
2
(Modicon)
(Mircette)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Modicon)
(Nor-Q-D)
(Seasonique)
2
2
2
QL (91 per 84 days)
(Seasonique)
2
QL (91 per 84 days)
(Desogen)
2
(Norgestrel-Ethinyl
Estradiol)
(Modicon)
2
cyclafem 1/35 (28) oral tablet 1-35
mg-mcg
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 (Modicon)
mg- 35 mcg
2
2
89
cyred oral tablet 0.15-0.03 mg
dasetta 1/35 (28) oral tablet 1-35
mg-mcg
dasetta 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
daysee oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
deblitane oral tablet 0.35 mg
delyla (28) oral tablet 0.1-20 mg-mcg
desog-e.estradiol/e.estradiol oral tablet
0.15-0.02 mgx21 /0.01 mg x 5
desogestrel-ethinyl estradiol oral tablet
0.15-0.03 mg
drospirenone-ethinyl estradiol oral tablet
3-0.02 mg, 3-0.03 mg
elinest oral tablet 0.3-30 mg-mcg
ELLA ORAL TABLET 30 MG
emoquette oral tablet 0.15-0.03 mg
enpresse oral tablet 50-30 (6)/75-40
(5)/125-30(10)
enskyce oral tablet 0.15-0.03 mg
errin oral tablet 0.35 mg
estarylla oral tablet 0.25-35 mg-mcg
falmina (28) oral tablet 0.1-20 mg-mcg
gianvi (28) oral tablet 3-0.02 mg
gildagia oral tablet 0.4-35 mg-mcg
gildess 1.5/30 (21) oral tablet 1.5-30
mg-mcg
gildess 1/20 (21) oral tablet 1-20 mg-mcg
gildess 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
gildess fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
gildess fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
Nivel
(Desogen)
(Modicon)
2
2
(Modicon)
2
(Seasonique)
2
(Nor-Q-D)
(Amethyst)
(Mircette)
2
2
2
(Desogen)
2
(Yaz)
2
(Norgestrel-Ethinyl
Estradiol)
2
(Desogen)
(Amethyst)
4
2
2
(Desogen)
(Nor-Q-D)
(Ortho-Cyclen)
(Amethyst)
(Yaz)
(Modicon)
(Loestrin)
2
2
2
2
2
2
2
(Loestrin)
(Loestrin Fe)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
Requisitos/Limites
QL (91 per 84 days)
QL (6 per 365 days)
90
heather oral tablet 0.35 mg
introvale oral tablets,dose pack,3 month
0.15-30 mg-mcg
jencycla oral tablet 0.35 mg
jolessa oral tablets,dose pack,3 month
0.15-30 mg-mcg
jolivette oral tablet 0.35 mg
juleber oral tablet 0.15-0.03 mg
junel 1.5/30 (21) oral tablet 1.5-30
mg-mcg
junel 1/20 (21) oral tablet 1-20 mg-mcg
junel fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
junel fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
junel fe 24 oral tablet 1 mg-20 mcg
(24)/75 mg (4)
kariva (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
kelnor 1/35 (28) oral tablet 1-35 mg-mcg
kimidess (28) oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
kurvelo oral tablet 0.15-0.03 mg
l norgest/e.estradiol-e.estrad oral
tablets,dose pack,3 month 0.10 mg-20
mcg (84)/10 mcg (7), 0.15 mg-30 mcg
(84)/10 mcg (7)
larin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
larin 1/20 (21) oral tablet 1-20 mg-mcg
larin 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
larin fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
larin fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
Nivel
Requisitos/Limites
(Nor-Q-D)
(Levonorgestrel-Ethin
Estradiol)
(Nor-Q-D)
Estradiol)
(Nor-Q-D)
(Desogen)
(Loestrin)
2
2
QL (91 per 84 days)
2
2
QL (91 per 84 days)
(Loestrin)
(Loestrin Fe)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Mircette)
2
(Demulen 1-50-21)
(Mircette)
2
2
(Amethyst)
(Seasonique)
2
2
(Loestrin)
2
(Loestrin)
(Loestrin Fe)
2
2
(Loestrin Fe)
2
(Loestrin Fe)
2
2
2
2
QL (91 per 84 days)
91
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg
lessina oral tablet 0.1-20 mg-mcg
levonest (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
levonor-eth estrad 0.15-0.03 outer
0.15-0.03 mg
levonorgestrel oral tablet 0.75 mg
levonorgestrel oral tablet 1.5 mg
levonorgestrel-ethinyl estrad oral tablet
0.1-20 mg-mcg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month 0.15-30
mg-mcg
levonorg-eth estrad triphasic oral tablet
50-30 (6)/75-40 (5)/125-30(10)
levora-28 oral tablet 0.15-0.03 mg
lomedia 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
loryna (28) oral tablet 3-0.02 mg
low-ogestrel (28) oral tablet 0.3-30
mg-mcg
lutera (28) oral tablet 0.1-20 mg-mcg
lyza oral tablet 0.35 mg
marlissa oral tablet 0.15-0.03 mg
microgestin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
microgestin 1/20 (21) oral tablet 1-20
mg-mcg
microgestin fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
microgestin fe 1/20 (28) oral tablet 1
mg-20 mcg (21)/75 mg (7)
mono-linyah oral tablet 0.25-35 mg-mcg
mononessa (28) oral tablet 0.25-35
mg-mcg
Nivel
Requisitos/Limites
(Modicon)
(Amethyst)
(Amethyst)
2
2
2
(Amethyst)
2
QL (91 per 84 days)
(Plan B One-Step)
(Plan B One-Step)
(Amethyst)
2
2
2
QL (6 per 365 days)
(Amethyst)
2
QL (91 per 84 days)
(Amethyst)
2
QL (91 per 84 days)
(Amethyst)
(Loestrin Fe)
2
2
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
(Amethyst)
(Nor-Q-D)
(Amethyst)
(Loestrin)
2
2
(Loestrin)
2
(Loestrin Fe)
2
(Loestrin Fe)
2
(Ortho-Cyclen)
(Ortho-Cyclen)
2
2
2
2
2
2
92
myzilra oral tablet 50-30 (6)/75-40
(5)/125-30(10)
necon 0.5/35 (28) oral tablet 0.5-35
mg-mcg
necon 1/35 (28) oral tablet 1-35 mg-mcg
necon 1/50 (28) oral tablet 1-50 mg-mcg
necon 10/11 (28) oral tablet 0.5-35/1-35
mg-mcg/mg-mcg
necon 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
next choice one dose oral tablet 1.5 mg
nikki (28) oral tablet 3-0.02 mg
nora-be oral tablet 0.35 mg
norethindrone (contraceptive) oral tablet
0.35 mg
norethindrone ac-eth estradiol oral tablet
1-20 mg-mcg
norethindrone-e.estradiol-iron oral tablet
1 mg-20 mcg (24)/75 mg (4)
norg-ee 0.18-0.215-0.25/0.035 3x28 day
regimen 0.18/0.215/0.25 mg-35 mcg (28)
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-25 mcg, 0.25-35
mg-mcg
norlyroc oral tablet 0.35 mg
nortrel 0.5/35 (28) oral tablet 0.5-35
mg-mcg
nortrel 1/35 (21) oral tablet 1-35
mg-mcg
nortrel 1/35 (28) oral tablet 1-35
mg-mcg
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
NUVARING VAGINAL RING
0.12-0.015 MG/24 HR
ocella oral tablet 3-0.03 mg
Nivel
(Amethyst)
2
(Modicon)
2
(Modicon)
(Norinyl 1+50)
(Modicon)
2
2
2
(Modicon)
2
(Plan B One-Step)
(Yaz)
(Nor-Q-D)
(Nor-Q-D)
2
2
2
2
(Loestrin)
2
(Loestrin Fe)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Nor-Q-D)
(Modicon)
2
2
(Modicon)
2
(Modicon)
2
(Modicon)
2
3
(Yaz)
Requisitos/Limites
QL (6 per 365 days)
QL (1 per 28 days)
2
93
Nivel
(Norgestrel-Ethinyl
Estradiol)
orsythia oral tablet 0.1-20 mg-mcg
(Amethyst)
philith oral tablet 0.4-35 mg-mcg
(Modicon)
pimtrea (28) oral tablet 0.15-0.02 mgx21 (Mircette)
/0.01 mg x 5
pirmella oral tablet 0.5/0.75/1 mg- 35
(Modicon)
mcg, 1-35 mg-mcg
portia oral tablet 0.15-0.03 mg
(Amethyst)
previfem oral tablet 0.25-35 mg-mcg
(Ortho-Cyclen)
quasense oral tablets,dose pack,3 month (Levonorgestrel-Ethin
0.15-30 mg-mcg
Estradiol)
reclipsen (28) oral tablet 0.15-0.03 mg
(Desogen)
setlakin oral tablets,dose pack,3 month
0.15-30 mg-mcg
Estradiol)
sharobel oral tablet 0.35 mg
(Nor-Q-D)
sprintec (28) oral tablet 0.25-35 mg-mcg (Ortho-Cyclen)
sronyx oral tablet 0.1-20 mg-mcg
(Amethyst)
syeda oral tablet 3-0.03 mg
(Yaz)
tarina fe 1/20 (28) oral tablet 1 mg-20
(Loestrin Fe)
mcg (21)/75 mg (7)
tilia fe oral tablet 1-20(5)/1-30(7)
(Loestrin Fe)
/1mg-35mcg (9)
tri-estarylla oral tablet 0.18/0.215/0.25
(Ortho-Cyclen)
mg-35 mcg (28)
tri-legest fe oral tablet 1-20(5)/1-30(7) (Loestrin Fe)
/1mg-35mcg (9)
tri-linyah oral tablet 0.18/0.215/0.25
(Ortho-Cyclen)
mg-35 mcg (28)
tri-lo-estarylla oral tablet 0.18/0.215/0.25 (Ortho-Cyclen)
mg-25 mcg
tri-lo-marzia oral tablet 0.18/0.215/0.25 (Ortho-Cyclen)
mg-25 mcg
tri-lo-sprintec oral tablet 0.18/0.215/0.25 (Ortho-Cyclen)
mg-25 mcg
ogestrel (28) oral tablet 0.5-50 mg-mcg
Requisitos/Limites
2
2
2
2
2
2
2
2
QL (91 per 84 days)
2
2
QL (91 per 84 days)
2
2
2
2
2
2
2
2
2
2
2
2
94
trinessa (28) oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-previfem (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
tri-sprintec (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
trivora (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
velivet triphasic regimen (28) oral tablet
0.1/.125/.15-25 mg-mcg
vestura (28) oral tablet 3-0.02 mg
vienva oral tablet 0.1-20 mg-mcg
viorele (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
vyfemla (28) oral tablet 0.4-35 mg-mcg
wera (28) oral tablet 0.5-35 mg-mcg
wymzya fe oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)
xulane transdermal patch weekly 150-35
mcg/24 hr
zarah oral tablet 3-0.03 mg
zenchent (28) oral tablet 0.4-35 mg-mcg
zenchent fe oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)
zeosa oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)
zovia 1/35e (28) oral tablet 1-35 mg-mcg
zovia 1/50e (28) oral tablet 1-50 mg-mcg
Nivel
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Ortho-Cyclen)
2
(Amethyst)
2
(Desogen)
2
(Yaz)
(Amethyst)
(Mircette)
2
2
2
(Modicon)
(Modicon)
(Femcon Fe)
2
2
2
(Ortho Evra)
2
(Yaz)
(Modicon)
(Femcon Fe)
2
2
2
(Femcon Fe)
2
(Demulen 1-50-21)
(Demulen 1-50-21)
2
2
(Evoxac)
(Peridex)
2
2
(Triamcinolone
Acetonide)
2
Requisitos/Limites
QL (3 per 28 days)
Dental And Oral Agents
Dental And Oral Agents
cevimeline oral capsule 30 mg
chlorhexidine gluconate mucous
membrane mouthwash 0.12 %
oralone dental paste 0.1 %
95
periogard mucous membrane mouthwash
0.12 %
pilocarpine hcl oral tablet 5 mg, 7.5 mg
sodium fluoride oral tablet,chewable 0.25
mg fluorid (0.55 mg)
triamcinolone acetonide dental paste 0.1
%
Nivel
(Peridex)
2
(Salagen)
(Sodium Fluoride)
2
2
(Triamcinolone
Acetonide)
2
Requisitos/Limites
Dermatological Agents
Dermatological Agents, Other
8-MOP ORAL CAPSULE 10 MG
acitretin oral capsule 10 mg, 17.5 mg, 25
mg
acyclovir topical ointment 5 %
ALCOHOL PADS TOPICAL PADS,
MEDICATED
ALCOHOL PREP PADS
ammonium lactate topical cream 12 %
ammonium lactate topical lotion 12 %
ANACAINE TOPICAL OINTMENT
10 %
calcipotriene scalp solution 0.005 %
calcipotriene topical cream 0.005 %
calcipotriene topical ointment 0.005 %
calcitrene topical ointment 0.005 %
calcitriol topical ointment 3 mcg/gram
CONDYLOX TOPICAL GEL 0.5 %
COSENTYX (150 MG/ML) 300 MG
DOSE-2 PENS 150 MG/ML
COSENTYX (150 MG/ML) 300 MG
DOSE-2 SYRINGES 150 MG/ML
COSENTYX PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML
COSENTYX SUBCUTANEOUS
SYRINGE 150 MG/ML
DENAVIR TOPICAL CREAM 1 %
fluorouracil topical cream 0.5 %, 5 %
(Soriatane)
(Zovirax)
(Lac-Hydrin)
(Lac-Hydrin)
(Calcipotriene)
(Dovonex)
(Calcipotriene)
(Calcipotriene)
(Vectical)
4
5
2
1
QL (30 per 30 days)
1
2
2
4
2
2
2
2
2
4
5
PA
5
PA
5
PA
5
PA
4
2
(Carac)
96
Nivel
fluorouracil topical solution 2 %, 5 %
imiquimod topical cream in packet 5 %
(Fluorouracil)
(Aldara)
2
2
methoxsalen rapid oral capsule 10 mg
PANRETIN TOPICAL GEL 0.1 %
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podocon topical liquid 25 %
podofilox topical solution 0.5 %
potassium hydroxide topical solution 5 %
REGRANEX TOPICAL GEL 0.01 %
(Oxsoralen-Ultra)
5
5
3
3
2
2
2
4
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM
TALTZ AUTOINJECTOR
SUBCUTANEOUS
AUTO-INJECTOR 80 MG/ML
TALTZ SYRINGE
MG/ML
TOLAK TOPICAL CREAM 4 %
VALCHLOR TOPICAL GEL 0.016 %
VEREGEN TOPICAL OINTMENT
15 %
zenatane oral capsule 10 mg, 20 mg, 30
mg, 40 mg
ZOVIRAX TOPICAL CREAM 5 %
Dermatological Antibacterials
clindamycin phosphate topical foam 1 %
clindamycin phosphate topical gel 1 %
clindamycin phosphate topical lotion 1 %
clindamycin phosphate topical solution 1
%
clindamycin phosphate topical swab 1 %
clindamycin-benzoyl peroxide topical gel
1-5 %, 1.2 %(1 % base) -5 %
(Podophyllum Resin)
(Condylox)
(Potassium Hydroxide)
Requisitos/Limites
days)
QL (3 per 56 days)
QL (2 per 56 days)
PA; QL (30 per 30
days)
4
5
PA
5
PA
4
5
4
(Isotretinoin)
2
3
(Evoclin)
(Cleocin T)
(Cleocin T)
(Cleocin T)
2
2
2
2
(Cleocin T)
(Duac)
2
2
QL (15 per 30 days)
97
Nivel
(Erythromycin
Base/Ethanol)
erythromycin with ethanol topical gel 2 % (Emgel)
erythromycin with ethanol topical
(Erythromycin
solution 2 %
Base/Ethanol)
erythromycin with ethanol topical swab 2 (Erythromycin
%
Base/Ethanol)
erythromycin-benzoyl peroxide topical
(Benzamycin)
gel 3-5 %
gentamicin topical cream 0.1 %
gentamicin topical ointment 0.1 %
metronidazole topical cream 0.75 %
(Metrocream)
metronidazole topical gel 0.75 %, 1 %
(Rosadan)
metronidazole topical lotion 0.75 %
(Metrolotion)
mupirocin calcium topical cream 2 %
(Bactroban)
mupirocin topical ointment 2 %
neomycin-polymyxin b gu irrigation
(Neosporin G.U.
solution 40 mg-200,000 unit/ml
Irrigant)
neuac topical gel 1.2 %(1 % base) -5 %
(Duac)
rosadan topical cream 0.75 %
(Metrocream)
selenium sulfide topical lotion 2.5 %
(Selenium Sulfide)
selenium sulfide topical shampoo 2.25 % (Selenium Sulfide)
silver nitrate topical ointment 10 %
(Silver Nitrate)
silver nitrate topical solution 0.5 %, 10 %, (Silver Nitrate)
25 %, 50 %
silver sulfadiazine topical cream 1 %
(Silvadene)
ssd topical cream 1 %
(Silvadene)
sulfacetamide sodium (acne) topical
(Klaron)
suspension 10 %
Dermatological
Anti-Inflammatory Agents
ala-cort topical cream 1 %
(Anusol-HC)
ala-scalp topical lotion 2 %
(Scalacort)
alclometasone topical cream 0.05 %
(Alclometasone
Dipropionate)
ery pads topical swab 2 %
Requisitos/Limites
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
98
Nivel
(Alclometasone
Dipropionate)
betamethasone dipropionate topical
(Betamethasone
cream 0.05 %
Dipropionate)
(Betamethasone
lotion 0.05 %
Dipropionate)
(Betamethasone
ointment 0.05 %
Dipropionate)
betamethasone valerate topical cream 0.1 (Betamethasone
%
Valerate)
betamethasone valerate topical foam 0.12 (Luxiq)
%
betamethasone valerate topical lotion 0.1 (Betamethasone
%
Valerate)
betamethasone valerate topical ointment (Betamethasone
0.1 %
Valerate)
betamethasone, augmented topical cream (Diprolene AF)
0.05 %
betamethasone, augmented topical gel
(Betamethasone
0.05 %
Dipropionate)
betamethasone, augmented topical lotion (Diprolene)
0.05 %
betamethasone, augmented topical
(Diprolene)
ointment 0.05 %
clobetasol 0.05% cream 0.05 %
(Temovate)
clobetasol scalp solution 0.05 %
(Clobetasol
Propionate)
clobetasol topical foam 0.05 %
(Olux)
clobetasol topical gel 0.05 %
(Clobetasol
Propionate)
clobetasol topical lotion 0.05 %
(Clobex)
clobetasol topical ointment 0.05 %
(Temovate)
clobetasol topical shampoo 0.05 %
(Clobex)
clobetasol-emollient topical cream 0.05 % (Temovate)
clocortolone pivalate topical cream 0.1 % (Cloderm)
colocort rectal enema 100 mg/60 ml
(Cortenema)
alclometasone topical ointment 0.05 %
Requisitos/Limites
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
99
cormax scalp solution 0.05 %
desonide topical cream 0.05 %
desonide topical lotion 0.05 %
desonide topical ointment 0.05 %
desoximetasone topical cream 0.05 %,
0.25 %
desoximetasone topical gel 0.05 %
desoximetasone topical ointment 0.05 %,
0.25 %
diflorasone topical cream 0.05 %
diflorasone topical ointment 0.05 %
ELIDEL TOPICAL CREAM 1 %
fluocinonide 0.05% cream 0.05 %
fluocinonide topical gel 0.05 %
fluocinonide topical ointment 0.05 %
fluocinonide topical solution 0.05 %
fluocinonide-e topical cream 0.05 %
fluticasone topical cream 0.05 %
fluticasone topical ointment 0.005 %
Nivel
(Clobetasol
Propionate)
(Desowen)
(Desowen)
(Desonide)
(Topicort)
2
(Topicort)
(Topicort)
2
2
(Psorcon)
(Diflorasone Diacetate)
2
2
3
2
2
2
2
2
2
2
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone
Propionate)
halobetasol propionate topical cream 0.05 (Ultravate)
%
halobetasol propionate topical ointment
(Ultravate)
0.05 %
hydrocortisone 1% ointment carton (otc) (Hydrocortisone)
1%
hydrocortisone acet-aloe vera topical gel (Hydrocortisone
2%
Acetate/Aloe V)
hydrocortisone buty 0.1% cream 0.1 %
(Hydrocortisone
Butyrate)
hydrocortisone butyrate topical ointment (Locoid)
0.1 %
hydrocortisone butyrate topical solution (Locoid)
0.1 %
Requisitos/Limites
2
2
2
2
2
2
2
2
2
2
2
100
Nivel
hydrocortisone butyr-emollient topical
cream 0.1 %
hydrocortisone rectal enema 100 mg/60
ml
hydrocortisone topical cream 1 %, 2.5 %
hydrocortisone topical lotion 2.5 %
hydrocortisone topical ointment 1 %, 2.5
%
hydrocortisone valerate topical cream 0.2
%
hydrocortisone valerate topical ointment
0.2 %
mometasone topical cream 0.1 %
mometasone topical ointment 0.1 %
mometasone topical solution 0.1 %
ONFI ORAL TABLET 10 MG, 20 MG
(Hydrocortisone
Butyrate)
(Cortenema)
2
(Anusol-HC)
(Scalacort)
(Hydrocortisone)
2
2
2
(Hydrocortisone
Valerate)
(Westcort)
2
(Elocon)
(Elocon)
(Elocon)
2
2
2
4
prednicarbate topical cream 0.1 %
prednicarbate topical ointment 0.1 %
procto-med hc rectal cream 2.5 %
procto-pak rectal cream 1 %
proctosol hc rectal cream 2.5 %
proctozone-hc rectal cream 2.5 %
tacrolimus topical ointment 0.03 %, 0.1
%
triamcinolone acetonide topical cream
0.025 %, 0.1 %, 0.5 %
triamcinolone acetonide topical lotion
0.025 %, 0.1 %
triamcinolone acetonide topical ointment
0.025 %, 0.1 %, 0.5 %
trianex topical ointment 0.05 %
(Dermatop)
(Dermatop)
(Hydrocortisone)
(Anusol-HC)
(Hydrocortisone)
(Hydrocortisone)
(Protopic)
2
2
2
2
2
2
2
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Hydrocortisone
Acetate/Urea)
2
u-cort topical cream 1-10 %
Requisitos/Limites
2
2
days)
2
2
2
2
101
Dermatological Retinoids
adapalene topical cream 0.1 %
adapalene topical gel 0.1 %
TAZORAC TOPICAL CREAM 0.05
%, 0.1 %
tretinoin gel micro 0.04% tube 0.04 %
tretinoin gel micro 0.1% tube 0.1 %
tretinoin microspheres topical gel with
pump 0.04 %, 0.1 %
tretinoin topical cream 0.025 %, 0.05 %,
0.1 %
tretinoin topical gel 0.01 %, 0.025 %,
0.05 %
Scabicides And Pediculicides
EURAX TOPICAL CREAM 10 %
EURAX TOPICAL LOTION 10 %
malathion topical lotion 0.5 %
permethrin topical cream 5 %
spinosad topical suspension 0.9 %
Nivel
Requisitos/Limites
(Differin)
(Differin)
2
2
4
(Retin-A Micro)
(Retin-A Micro)
(Retin-A Micro)
2
2
2
PA
PA
PA
(Retin-A)
2
PA
(Retin-A)
2
PA
(Ovide)
(Elimite)
(Natroba)
3
3
2
2
2
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 GAUGE X 1/2"
BD INSULIN SYR 0.3 ML 31GX5/16
0.3 ML 31 GAUGE X 5/16
BD INSULIN SYR 0.5 ML 31GX5/16"
0.5 ML 31 GAUGE X 5/16
BD INSULIN SYR 1 ML 31GX5/16" 1
ML 31 GAUGE X 5/16
BD ULTRA-FINE PEN NDL
8MMX31G SHORT 31 GAUGE X
5/16"
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 0.3 ML 29, 1 ML 29
GAUGE X 1/2", 1/2 ML 28 GAUGE
2
2
2
2
2
2
102
Nivel
PEN NEEDLE, DIABETIC NEEDLE
29 GAUGE X 1/2"
VGO 40 DISPOSABLE DEVICE
Requisitos/Limites
2
2
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN INTRAMUSCULAR
ALDURAZYME INTRAVENOUS
SOLUTION 2.9 MG/5 ML
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
CREON ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000
-60,000 UNIT, 24,000-76,000 -120,000
UNIT, 3,000-9,500- 15,000 UNIT,
36,000-114,000- 180,000 UNIT,
6,000-19,000 -30,000 UNIT
ELAPRASE INTRAVENOUS
SOLUTION 6 MG/3 ML
ELITEK INTRAVENOUS RECON
SOLN 1.5 MG, 7.5 MG
FABRAZYME INTRAVENOUS
RECON SOLN 35 MG
KANUMA INTRAVENOUS
SOLUTION 2 MG/ML
KRYSTEXXA INTRAVENOUS
SOLUTION 8 MG/ML
KUVAN ORAL TABLET,SOLUBLE
100 MG
MYOZYME INTRAVENOUS
RECON SOLN 50 MG
NAGLAZYME INTRAVENOUS
SOLUTION 5 MG/5 ML
ORFADIN ORAL CAPSULE 10 MG,
2 MG, 5 MG
5
5
5
3
5
5
5
5
PA
5
5
5
5
5
103
Nivel
pancrelipase 5000 oral capsule,delayed
(Lipase/Protease/Amyl
release(dr/ec) 5,000-17,000 -27,000 unit ase)
PERTZYE ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 16,000-57,50060,500 UNIT, 8,000-28,750- 30,250
UNIT
PULMOZYME INHALATION
SOLUTION 1 MG/ML
STRENSIQ SUBCUTANEOUS
VIMIZIM INTRAVENOUS
SOLUTION 5 MG/5 ML (1 MG/ML)
VPRIV INTRAVENOUS RECON
SOLN 400 UNIT
ZAVESCA ORAL CAPSULE 100 MG
ZENPEP ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000
-55,000 UNIT, 15,000-51,000 -82,000
UNIT, 20,000-68,000 -109,000 UNIT,
25,000-85,000- 136,000 UNIT,
3,000-10,000- 16,000 UNIT,
40,000-136,000- 218,000 UNIT,
5,000-17,000 -27,000 UNIT
Requisitos/Limites
2
4
5
PA BvD
5
PA; LA
5
PA
5
5
3
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents,
Miscellaneous
AKTEN (PF) OPHTHALMIC GEL
3.5 %
alcaine ophthalmic drops 0.5 %
altacaine ophthalmic drops 0.5 %
apraclonidine ophthalmic drops 0.5 %
atropine ophthalmic drops 1 %
atropine ophthalmic ointment 1 %
atropine-care ophthalmic drops 1 %
4
(Proparacaine HCl)
(Tetravisc)
(Iopidine)
(Isopto Atropine)
(Atropine Sulfate)
(Isopto Atropine)
2
2
2
2
2
2
104
azelastine nasal aerosol,spray 137 mcg
(0.1 %)
azelastine nasal spray,non-aerosol 0.15 %
(205.5 mcg)
azelastine ophthalmic drops 0.05 %
BEPREVE OPHTHALMIC DROPS
1.5 %
carteolol ophthalmic drops 1 %
cromolyn ophthalmic drops 4 %
cyclopentolate ophthalmic drops 0.5 %, 1
%, 2 %
CYSTARAN OPHTHALMIC DROPS
0.44 %
epinastine ophthalmic drops 0.05 %
flucaine ophthalmic drops 0.25-0.5 %
homatropaire ophthalmic drops 5 %
homatropine hbr ophthalmic drops 5 %
ipratropium bromide nasal
spray,non-aerosol 0.03 %
ipratropium bromide nasal
spray,non-aerosol 0.06 %
LACRISERT OPHTHALMIC
INSERT 5 MG
naphazoline ophthalmic drops 0.1 %
olopatadine nasal spray,non-aerosol 0.6
%
olopatadine ophthalmic drops 0.1 %
PATADAY OPHTHALMIC DROPS
0.2 %
phenylephrine hcl ophthalmic drops 10 %,
2.5 %
proparacaine ophthalmic drops 0.5 %
tetracaine hcl (pf) ophthalmic drops 0.5
%
TYZINE NASAL DROPS 0.1 %
Nivel
Requisitos/Limites
(Astepro)
2
QL (30 per 25 days)
(Astepro)
2
QL (30 per 25 days)
(Azelastine HCl)
2
4
ST
(Carteolol HCl)
(Cromolyn Sodium)
(Cyclogyl)
2
2
2
5
(Elestat)
(Proparacaine/Fluoresc
ein Sod)
(Isopto Homatropine)
(Isopto Homatropine)
(Atrovent)
2
2
2
2
2
QL (30 per 28 days)
(Atrovent)
2
QL (15 per 10 days)
3
(Naphazoline HCl)
(Patanase)
1
2
(Patanol)
2
4
ST
(Mydfrin)
2
(Proparacaine HCl)
(Tetracaine HCl/PF)
2
2
4
105
TYZINE NASAL
SPRAY,NON-AEROSOL 0.1 %
Eye, Ear, Nose, Throat
Anti-Infectives Agents
acetasol hc otic drops 1-2 %
acetic acid otic solution 2 %
bacitracin ophthalmic ointment 500
unit/gram
bacitracin-polymyxin b ophthalmic
ointment 500-10,000 unit/gram
bleph-10 ophthalmic drops 10 %
BLEPHAMIDE OPHTHALMIC
DROPS,SUSPENSION 10-0.2 %
BLEPHAMIDE S.O.P.
OPHTHALMIC OINTMENT 10-0.2 %
CILOXAN OPHTHALMIC
OINTMENT 0.3 %
CIPRODEX OTIC
DROPS,SUSPENSION 0.3-0.1 %
ciprofloxacin hcl ophthalmic drops 0.3 %
ciprofloxacin hcl otic dropperette 0.2 %
COLY-MYCIN S OTIC
DROPS,SUSPENSION 3.3-3-10-0.5
MG/ML
CORTISPORIN-TC OTIC
DROPS,SUSPENSION 3.3-3-10-0.5
MG/ML
erythromycin ophthalmic ointment 5
mg/gram (0.5 %)
gatifloxacin ophthalmic drops 0.5 %
gentak ophthalmic ointment 0.3 % (3
mg/gram)
gentamicin ophthalmic drops 0.3 %
gentamicin ophthalmic ointment 0.3 % (3
mg/gram)
Nivel
Requisitos/Limites
4
(Vosol HC)
(Acetic Acid)
(Bacitracin)
2
2
2
(Bacitracin/Polymyxin
B Sulfate)
(Sulfacetamide
Sodium)
2
2
3
2
4
3
(Ciloxan)
(Cetraxal)
2
2
4
3
(Ilotycin)
2
(Zymaxid)
(Garamycin)
2
2
(Garamycin)
(Garamycin)
2
2
106
hydrocortisone-acetic acid otic drops 1-2
%
levofloxacin ophthalmic drops 0.5 %
MOXEZA OPHTHALMIC DROPS,
VISCOUS 0.5 %
NATACYN OPHTHALMIC
DROPS,SUSPENSION 5 %
neomycin-bacitracin-poly-hc ophthalmic
ointment 3.5-400-10,000 mg-unit/g-1%
neomycin-bacitracin-polymyxin
ophthalmic ointment 3.5-400-10,000
mg-unit-unit/g
neomycin-polymyxin b-dexameth
ophthalmic drops,suspension
3.5mg/ml-10,000 unit/ml-0.1 %
ophthalmic ointment 3.5 mg/g-10,000
unit/g-0.1 %
neomycin-polymyxin-gramicidin
ophthalmic drops 1.75 mg-10,000
unit-0.025mg/ml
neomycin-polymyxin-hc ophthalmic
drops,suspension 3.5-10,000-10
mg-unit-mg/ml
neomycin-polymyxin-hc otic
drops,suspension 3.5-10,000-1
mg/ml-unit/ml-%
neomycin-polymyxin-hc otic solution
3.5-10,000-1 mg/ml-unit/ml-%
neo-polycin hc ophthalmic ointment
3.5-400-10,000 mg-unit/g-1%
neo-polycin ophthalmic ointment
3.5-400-10,000 mg-unit-unit/g
ofloxacin ophthalmic drops 0.3 %
ofloxacin otic drops 0.3 %
polymyxin b sulf-trimethoprim
ophthalmic drops 10,000 unit- 1 mg/ml
Nivel
(Vosol HC)
2
(Levofloxacin)
2
3
Requisitos/Limites
3
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymyxin)
2
(Maxitrol)
2
(Maxitrol)
2
(Neosporin)
2
(Neomycin/Polymyxin
B Sulf/HC)
2
(Neomycin/Polymyxin
B Sulf/HC)
2
(Cortisporin)
2
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymyxin)
(Ocuflox)
(Ocuflox)
(Polytrim)
2
2
2
2
2
2
107
sulfacetamide sodium ophthalmic drops
10 %
sulfacetamide sodium ophthalmic
ointment 10 %
sulfacetamide-prednisolone ophthalmic
drops 10 %-0.23 % (0.25 %)
TOBRADEX OPHTHALMIC
OINTMENT 0.3-0.1 %
TOBRADEX ST OPHTHALMIC
tobramycin ophthalmic drops 0.3 %
tobramycin-dexamethasone ophthalmic
drops,suspension 0.3-0.1 %
trifluridine ophthalmic drops 1 %
VIGAMOX OPHTHALMIC DROPS
0.5 %
ZIRGAN OPHTHALMIC GEL 0.15 %
ZYLET OPHTHALMIC
Eye, Ear, Nose, Throat
Anti-Inflammatory Agents
ALREX OPHTHALMIC
DROPS,SUSPENSION 0.2 %
bromfenac ophthalmic drops 0.09 %
dexamethasone sodium phosphate
ophthalmic drops 0.1 %
diclofenac sodium ophthalmic drops 0.1
%
DUREZOL OPHTHALMIC DROPS
0.05 %
flunisolide nasal spray,non-aerosol 25
mcg (0.025 %)
fluocinolone acetonide oil otic drops 0.01
%
fluorometholone ophthalmic
drops,suspension 0.1 %
Nivel
(Sulfacetamide
Sodium)
(Sulfacetamide
Sodium)
(Sulfacetamide/Prednis
olone Sp)
Requisitos/Limites
2
2
2
4
3
(Tobrex)
(Tobradex)
2
2
(Viroptic)
2
3
4
3
3
(Bromfenac Sodium)
(Dexasol)
2
2
(Diclofenac Sodium)
2
ST
3
(Flunisolide)
2
(Dermotic)
2
(FML)
2
QL (50 per 25 days)
108
flurbiprofen sodium ophthalmic drops
0.03 %
fluticasone nasal spray,suspension 50
mcg/actuation
ILEVRO OPHTHALMIC
ketorolac ophthalmic drops 0.4 %, 0.5 %
LOTEMAX OPHTHALMIC
DROPS,GEL 0.5 %
LOTEMAX OPHTHALMIC
LOTEMAX OPHTHALMIC
OINTMENT 0.5 %
NEVANAC OPHTHALMIC
prednisolone acetate ophthalmic
drops,suspension 1 %
prednisolone sodium phosphate
ophthalmic drops 1 %
PROLENSA OPHTHALMIC DROPS
0.07 %
RESTASIS OPHTHALMIC
DROPPERETTE 0.05 %
triamcinolone acetonide nasal
aerosol,spray 55 mcg
Nivel
(Ocufen)
2
(Fluticasone
Propionate)
1
Requisitos/Limites
3
(Acular)
2
3
3
3
3
(Omnipred)
2
(Prednisolone Sod
Phosphate)
2
3
3
QL (60 per 30 days)
(Triamcinolone
Acetonide)
2
(Prevpac)
2
Gastrointestinal Agents
Antiulcer Agents And Acid
Suppressants
amoxicil-clarithromy-lansopraz oral
combo pack 500-500-30 mg
CARAFATE ORAL SUSPENSION
100 MG/ML
cimetidine hcl oral solution 300 mg/5 ml
cimetidine oral tablet 200 mg, 300 mg,
400 mg, 800 mg
3
(Cimetidine HCl)
(Cimetidine)
2
2
(Rx Product Only)
109
DEXILANT ORAL
CAPSULE,BIPHASE DELAYED
RELEAS 30 MG, 60 MG
esomeprazole sodium intravenous recon
soln 20 mg, 40 mg
famotidine (pf) intravenous solution 20
mg/2 ml
famotidine (pf)-nacl (iso-os)
famotidine 40 mg/4 ml vial 25's,outer 10
mg/ml
famotidine oral suspension 40 mg/5 ml (8
mg/ml)
famotidine oral tablet 20 mg, 40 mg
lansoprazole oral capsule,delayed
release(dr/ec) 15 mg, 30 mg
misoprostol oral tablet 100 mcg, 200 mcg
nizatidine oral capsule 150 mg, 300 mg
nizatidine oral solution 150 mg/10 ml
omeprazole oral capsule,delayed
release(dr/ec) 10 mg, 20 mg, 40 mg
pantoprazole oral tablet,delayed release
(dr/ec) 20 mg, 40 mg
ranitidine hcl 50 mg/2 ml vial sdv 50 mg/2
ml (25 mg/ml)
ranitidine hcl injection solution 25 mg/ml
ranitidine hcl oral capsule 150 mg, 300
mg
ranitidine hcl oral syrup 15 mg/ml
ranitidine hcl oral tablet 150 mg, 300 mg
sucralfate oral suspension 100 mg/ml
sucralfate oral tablet 1 gram
Gastrointestinal Agents, Other
AMITIZA ORAL CAPSULE 24 MCG,
8 MCG
BUPHENYL ORAL TABLET 500 MG
Nivel
3
Requisitos/Limites
ST
(Nexium I.V.)
2
(Famotidine)
2
(Famotidine In
Nacl,Iso-Osm/PF)
(Famotidine)
2
(Pepcid)
2
(Rx Product Only)
(Pepcid)
(Prevacid)
1
2
(Rx Product Only)
(Rx Product Only)
(Cytotec)
(Nizatidine)
(Nizatidine)
(Prilosec)
2
2
2
2
(Protonix)
2
(Zantac)
2
(Rx Product Only)
(Zantac)
(Ranitidine HCl)
2
2
(Rx Product Only)
(Rx Product Only)
(Ranitidine HCl)
(Zantac)
(Sucralfate)
(Carafate)
2
1
2
2
(Rx Product Only)
(Rx Product Only)
3
QL (60 per 30 days)
2
5
110
CARBAGLU ORAL TABLET,
DISPERSIBLE 200 MG
constulose oral solution 10 gram/15 ml
cromolyn oral concentrate 100 mg/5 ml
dicyclomine oral capsule 10 mg
dicyclomine oral solution 10 mg/5 ml
dicyclomine oral tablet 20 mg
diphenoxylate-atropine oral liquid
2.5-0.025 mg/5 ml
diphenoxylate-atropine oral tablet
2.5-0.025 mg
enulose oral solution 10 gram/15 ml
GATTEX 5 MG 30-VIAL KIT 5 MG
GATTEX ONE-VIAL
SUBCUTANEOUS KIT 5 MG
generlac oral solution 10 gram/15 ml
glycopyrrolate injection solution 0.2
mg/ml
glycopyrrolate oral tablet 1 mg, 2 mg
kionex 15 gm/60 ml suspension 15
gram/60 ml
kionex oral powder
Nivel
Requisitos/Limites
5
(Lactulose)
(Gastrocrom)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
2
5
2
2
2
2
(Lactulose)
2
5
5
2
(Lactulose)
(Robinul)
2
2
(Robinul)
(Sodium Polystyrene
Sulfonate)
(Sodium Polystyrene
Sulfonate)
(Lactulose)
2
2
lactulose oral solution 10 gram/15 ml
LINZESS ORAL CAPSULE 145
MCG, 290 MCG
loperamide oral capsule 2 mg
(Loperamide HCl)
LOTRONEX ORAL TABLET 0.5
MG, 1 MG
methscopolamine oral tablet 2.5 mg, 5 mg (Methscopolamine
Bromide)
metoclopramide hcl injection solution 5
(Metoclopramide HCl)
mg/ml
metoclopramide hcl oral solution 5 mg/5 (Metoclopramide HCl)
ml
PA
PA
2
2
3
QL (30 per 30 days)
2
5
2
2
2
111
metoclopramide hcl oral tablet 10 mg, 5
mg
MOVANTIK ORAL TABLET 12.5
MG, 25 MG
NUTRESTORE ORAL POWDER IN
PACKET 5 GRAM
OCALIVA ORAL TABLET 10 MG, 5
MG
RAVICTI ORAL LIQUID 1.1
GRAM/ML
RELISTOR SUBCUTANEOUS
RELISTOR SUBCUTANEOUS
SYRINGE 12 MG/0.6 ML, 8 MG/0.4
ML
sodium polystyrene (sorb free) oral
suspension 15 gram/60 ml
sodium polystyrene sulfonate rectal
enema 30 gram/120 ml
sps 15 gm/60 ml suspension 15 gram/60
ml
ursodiol oral capsule 300 mg
ursodiol oral tablet 250 mg, 500 mg
VELPHORO ORAL
TABLET,CHEWABLE 500 MG
VIBERZI ORAL TABLET 100 MG, 75
MG
Laxatives
gavilyte-c oral recon soln 240-22.72-6.72
-5.84 gram
gavilyte-g oral recon soln 236-22.74-6.74
-5.86 gram
gavilyte-n oral recon soln 420 gram
Nivel
(Reglan)
Requisitos/Limites
1
3
4
5
5
4
4
(Sodium Polystyrene
Sulfonate)
(Sodium Polystyrene
Sulfonate)
(Sodium Polystyrene
Sulfonate)
(Actigall)
(Urso)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
2
2
2
2
2
4
5
(Golytely)
2
(Golytely)
2
(Nulytely with Flavor
Packs)
2
MOVIPREP ORAL POWDER IN
PACKET 100-7.5-2.691 GRAM
PA; QL (30 per 30
days)
PA
3
112
peg 3350-electrolytes oral recon soln
236-22.74-6.74 -5.86 gram,
240-22.72-6.72 -5.84 gram
peg-electrolyte soln oral recon soln 420
gram
polyethylene glycol 3350 oral powder 17
gram/dose
polyethylene glycol 3350 oral powder in
packet 17 gram
PREPOPIK ORAL POWDER IN
PACKET 10 MG-3.5 GRAM-12
GRAM
trilyte with flavor packets oral recon soln
420 gram
Phosphate Binders
AURYXIA ORAL TABLET 210 MG
IRON
calcium acetate oral capsule 667 mg
calcium acetate oral tablet 667 mg
eliphos oral tablet 667 mg
FOSRENOL ORAL POWDER IN
PACKET 1,000 MG, 750 MG
FOSRENOL ORAL
TABLET,CHEWABLE 1,000 MG, 500
MG, 750 MG
magnebind 400 oral tablet 400-200-1 mg
Nivel
(Golytely)
2
Packs)
(Gavilyte-N)
2
(Polyethylene Glycol
3350)
2
Requisitos/Limites
2
4
Packs)
2
4
(Phoslo)
(Calcium Acetate)
(Calcium Acetate)
2
2
2
4
4
(Calcium
Carbonate/Mag
Carb/Fa)
PHOSLYRA ORAL SOLUTION 667
MG (169 MG CALCIUM)/5 ML
RENAGEL ORAL TABLET 400 MG,
800 MG
RENVELA ORAL POWDER IN
PACKET 0.8 GRAM, 2.4 GRAM
RENVELA ORAL TABLET 800 MG
2
4
3
3
3
113
Nivel
Requisitos/Limites
Genitourinary Agents
Antispasmodics, Urinary
flavoxate oral tablet 100 mg
MYRBETRIQ ORAL TABLET
MG, 50 MG
oxybutynin chloride oral syrup 5 mg/5 ml
oxybutynin chloride oral tablet 5 mg
oxybutynin chloride oral tablet extended
tolterodine oral capsule,extended release
24hr 2 mg, 4 mg
tolterodine oral tablet 1 mg, 2 mg
TOVIAZ ORAL TABLET
EXTENDED RELEASE 24 HR 4 MG,
8 MG
trospium oral capsule,extended release
24hr 60 mg
trospium oral tablet 20 mg
VESICARE ORAL TABLET 10 MG, 5
MG
Genitourinary Agents,
Miscellaneous
alfuzosin oral tablet extended release 24
hr 10 mg
tamsulosin oral capsule,extended release
24hr 0.4 mg
terazosin oral capsule 1 mg, 10 mg, 2 mg,
5 mg
(Flavoxate HCl)
2
3
(Oxybutynin Chloride)
(Oxybutynin Chloride)
(Ditropan XL)
2
2
2
(Detrol LA)
2
(Detrol)
2
3
(Trospium Chloride)
2
(Trospium Chloride)
2
3
(Uroxatral)
2
(Flomax)
2
(Terazosin HCl)
1
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln 2 gram, (Desferal)
500 mg
DEPEN TITRATABS ORAL
TABLET 250 MG
2
PA BvD
5
114
EXJADE ORAL TABLET,
DISPERSIBLE 125 MG
EXJADE ORAL TABLET,
DISPERSIBLE 250 MG, 500 MG
FERRIPROX ORAL SOLUTION 100
MG/ML
FERRIPROX ORAL TABLET 500
MG
sodium thiosulfate intravenous solution 1
gram/10 ml (100 mg/ml), 12.5 gram/50
ml (250 mg/ml)
SYPRINE ORAL CAPSULE 250 MG
Nivel
Requisitos/Limites
4
5
5
5
(Sodium Thiosulfate)
2
5
Hormonal Agents,
Stimulant/Replacement/Modifying
Androgens
ANDRODERM TRANSDERMAL
PATCH 24 HOUR 2 MG/24 HOUR, 4
MG/24 HR
ANDROGEL TRANSDERMAL GEL
IN METERED-DOSE PUMP 20.25
MG/1.25 GRAM (1.62 %)
ANDROGEL TRANSDERMAL GEL
IN PACKET 1.62 % (20.25 MG/1.25
GRAM), 1.62 % (40.5 MG/2.5 GRAM)
androxy oral tablet 10 mg
AXIRON TRANSDERMAL
SOLUTION IN METERED PUMP
W/APP 30 MG/ACTUATION (1.5
ML)
danazol oral capsule 100 mg, 200 mg, 50
mg
oxandrolone oral tablet 10 mg, 2.5 mg
testosterone cypionate intramuscular oil
100 mg/ml, 200 mg/ml
testosterone enanthate intramuscular oil
200 mg/ml
(Fluoxymesterone)
3
PA; QL (30 per 30
days)
3
PA; QL (150 per 30
days)
3
PA; QL (150 per 30
days)
2
3
PA; QL (180 per 28
days)
(Danazol)
2
(Oxandrin)
(Depo-Testosterone)
2
2
PA
(Testosterone
Enanthate)
2
115
testosterone transdermal gel 50 mg/5
gram (1 %)
testosterone transdermal gel in
metered-dose pump 1.25 gram/ actuation
(1 %)
testosterone transdermal gel in packet 1
% (25 mg/2.5gram)
testosterone transdermal gel in packet 1
% (50 mg/5 gram)
Estrogens And Antiestrogens
COMBIPATCH TRANSDERMAL
PATCH SEMIWEEKLY 0.05-0.14
MG/24 HR, 0.05-0.25 MG/24 HR
DUAVEE ORAL TABLET 0.45-20
MG
ESTRACE VAGINAL CREAM 0.01
% (0.1 MG/GRAM)
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
estradiol transdermal patch semiweekly
0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05
mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr
estradiol transdermal patch weekly 0.025
mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24
hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1
mg/24 hr
estradiol valerate intramuscular oil 10
mg/ml, 20 mg/ml, 40 mg/ml
estradiol-norethindrone acet oral tablet
0.5-0.1 mg, 1-0.5 mg
ESTRING VAGINAL RING 2 MG
estropipate oral tablet 0.75 mg, 1.5 mg, 3
mg
FEMRING VAGINAL RING 0.05
MG/24 HR, 0.1 MG/24 HR
fyavolv oral tablet 1-5 mg-mcg
jinteli oral tablet 1-5 mg-mcg
Nivel
(Testim)
2
(Vogelxo)
2
(Androgel)
2
(Testim)
2
3
Requisitos/Limites
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
QL (8 per 28 days)
3
3
(Estrace)
(Vivelle-Dot)
2
2
QL (8 per 28 days)
(Climara)
2
QL (4 per 28 days)
(Delestrogen)
2
(Activella)
2
QL (1 per 84 days)
(Estropipate)
4
2
4
QL (1 per 84 days)
(Femhrt)
(Femhrt)
2
2
116
MENEST ORAL TABLET 0.3 MG,
0.625 MG, 1.25 MG, 2.5 MG
mimvey lo oral tablet 0.5-0.1 mg
mimvey oral tablet 1-0.5 mg
norethindrone ac-eth estradiol oral tablet
1-5 mg-mcg
PREMARIN INJECTION RECON
SOLN 25 MG
PREMARIN ORAL TABLET 0.3 MG,
0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
PREMARIN VAGINAL CREAM
0.625 MG/GRAM
PREMPHASE ORAL TABLET 0.625
MG (14)/ 0.625MG-5MG(14)
PREMPRO ORAL TABLET 0.3-1.5
MG, 0.45-1.5 MG, 0.625-2.5 MG,
0.625-5 MG
raloxifene oral tablet 60 mg
VAGIFEM VAGINAL TABLET 10
MCG
Glucocorticoids/Mineralocorticoid
s
a-hydrocort injection recon soln 100 mg
betamethasone acet,sod phos injection
suspension 6 mg/ml
cortisone oral tablet 25 mg
dexamethasone oral elixir 0.5 mg/5 ml
dexamethasone oral tablet 0.5 mg, 0.75
mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg
injection solution 10 mg/ml, 4 mg/ml
fludrocortisone oral tablet 0.1 mg
hydrocortisone oral tablet 10 mg, 20 mg,
5 mg
Nivel
Requisitos/Limites
4
(Activella)
(Activella)
(Femhrt)
2
2
2
3
3
3
3
3
(Evista)
2
3
(Hydrocortisone Sod
Succinate)
(Celestone)
2
(Cortisone Acetate)
(Dexamethasone)
(Dexamethasone)
2
2
1
(Dexamethasone Sod
Phosphate)
(Fludrocortisone
Acetate)
(Cortef)
2
QL (18 per 28 days)
2
PA BvD
PA BvD
PA BvD
2
2
PA BvD
117
methylprednisolone 125 mg vial 2ml sdv,
25's,l/f 125 mg
methylprednisolone acetate injection
suspension 40 mg/ml, 80 mg/ml
methylprednisolone oral tablet 16 mg, 32
mg, 4 mg, 8 mg
methylprednisolone oral tablets,dose pack
4 mg
methylprednisolone sodium succ injection
recon soln 125 mg, 40 mg
methylprednisolone ss 1 gm vl
mdv,latex-free 1,000 mg
prednisolone sodium phosphate oral
solution 15 mg/5 ml (3 mg/ml), 25 mg/5
ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5
ml)
PREDNISONE INTENSOL ORAL
CONCENTRATE 5 MG/ML
prednisone oral solution 5 mg/5 ml
prednisone oral tablet 1 mg, 2.5 mg, 20
mg, 5 mg, 50 mg
prednisone oral tablet 10 mg
prednisone oral tablets,dose pack 10 mg,
5 mg
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML, 250
MG/2 ML
triamcinolone acetonide injection
suspension 10 mg/ml, 40 mg/ml
Pituitary
desmopressin injection solution 4 mcg/ml
desmopressin nasal solution 0.1 mg/ml
(refrigerate)
desmopressin nasal spray,non-aerosol 10
mcg/spray (0.1 ml)
desmopressin oral tablet 0.1 mg, 0.2 mg
Nivel
Requisitos/Limites
(Solu-Medrol)
2
(Depo-Medrol)
2
(Medrol)
2
PA BvD
(Medrol)
2
PA BvD
(Solu-Medrol)
2
(Solu-Medrol)
2
(Pediapred)
2
PA BvD
3
PA BvD
(Prednisone)
(Prednisone)
2
1
PA BvD
PA BvD
(Prednisone)
(Prednisone)
1
2
PA BvD
PA BvD
4
(Triamcinolone
Acetonide)
2
(Desmopressin
Acetate)
(DDAVP)
2
2
QL (15 per 30 days)
(Desmopressin
Acetate)
(DDAVP)
2
QL (15 per 30 days)
2
118
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2
MG/0.25 ML
SUBCUTANEOUS SYRINGE 0.4
MG/0.25 ML, 0.6 MG/0.25 ML, 0.8
MG/0.25 ML, 1 MG/0.25 ML, 1.2
MG/0.25 ML, 1.4 MG/0.25 ML, 1.6
MG/0.25 ML, 1.8 MG/0.25 ML, 2
MG/0.25 ML
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36
UNIT/ML), 5 MG/ML (15 UNIT/ML)
INCRELEX SUBCUTANEOUS
SOLUTION 10 MG/ML
LUPRON DEPOT-PED (3 MONTH)
30 MG
LUPRON DEPOT-PED
INTRAMUSCULAR KIT 11.25 MG,
15 MG, 7.5 MG (PED)
NORDITROPIN FLEXPRO
10 MG/1.5 ML (6.7 MG/ML), 15
MG/1.5 ML (10 MG/ML), 30 MG/3
ML (10 MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
octreotide acet 50 mcg/ml syr
outer,single-dose,10 50 mcg/ml (1 ml)
octreotide acetate injection solution 1,000
mcg/ml
octreotide acetate injection solution 100
mcg/ml, 200 mcg/ml, 500 mcg/ml
octreotide acetate injection solution 50
mcg/ml
Nivel
Requisitos/Limites
4
PA
5
PA
5
PA
5
5
QL (1 per 84 days)
5
5
(Octreotide Acetate)
2
(Sandostatin)
5
(Sandostatin)
2
(Octreotide Acetate)
2
PA
119
Nivel
SAIZEN CLICK.EASY
SUBCUTANEOUS CARTRIDGE 8.8
MG/1.5 ML (FNL)
SAIZEN SUBCUTANEOUS RECON
SOLN 5 MG, 8.8 MG
SANDOSTATIN LAR 10 MG KIT 10
MG
MG
MG
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
RECON 10 MG, 20 MG, 30 MG
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3 ML
SOMAVERT SUBCUTANEOUS
RECON SOLN 10 MG, 15 MG, 20
MG, 25 MG, 30 MG
STIMATE NASAL
MCG/SPRAY (0.1 ML)
SUPPRELIN LA IMPLANT KIT 50
MG (65 MCG/DAY)
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION 400
MG/ML
hydroxyprogesterone caproate
(Hydroxyprogesterone
intramuscular oil 250 mg/ml
Caproate)
medroxyprogesterone intramuscular
(Depo-Provera)
suspension 150 mg/ml
Requisitos/Limites
5
PA
5
PA
5
5
5
5
5
PA
5
QL (1 per 28 days)
5
4
5
QL (1 per 360 days)
4
QL (10 per 28 days)
2
PA NSO
2
QL (1 per 84 days)
120
medroxyprogesterone intramuscular
syringe 150 mg/ml
medroxyprogesterone oral tablet 10 mg,
2.5 mg, 5 mg
MEGACE ES ORAL SUSPENSION
625 MG/5 ML
megestrol oral suspension 400 mg/10 ml
(40 mg/ml), 625 mg/5 ml
norethindrone acetate oral tablet 5 mg
progesterone in oil intramuscular oil 50
mg/ml
progesterone micronized oral capsule 100
mg, 200 mg
Thyroid And Antithyroid Agents
levothyroxine intravenous recon soln 100
mcg, 200 mcg, 500 mcg
levothyroxine oral tablet 100 mcg, 112
mcg, 125 mcg, 137 mcg, 150 mcg, 175
mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg,
75 mcg, 88 mcg
liothyronine intravenous solution 10
mcg/ml
liothyronine oral tablet 25 mcg, 5 mcg, 50
mcg
methimazole oral tablet 10 mg, 5 mg
propylthiouracil oral tablet 50 mg
Nivel
(Medroxyprogesterone
Acetate)
(Provera)
2
Requisitos/Limites
QL (1 per 84 days)
2
5
(Megace Es)
2
(Aygestin)
(Progesterone)
2
2
(Prometrium)
2
(Levothyroxine
Sodium)
(Levoxyl)
2
(Triostat)
2
(Cytomel)
2
(Tapazole)
(Propylthiouracil)
2
2
1
Immunological Agents
Immunological Agents
ARCALYST SUBCUTANEOUS
RECON SOLN 220 MG
ASTAGRAF XL ORAL
24HR 0.5 MG, 1 MG, 5 MG
AUBAGIO ORAL TABLET 14 MG, 7
MG
azathioprine oral tablet 50 mg
(Imuran)
5
4
PA BvD
5
PA; QL (28 per 28
days)
PA BvD
2
121
azathioprine sodium injection recon soln
100 mg
CARIMUNE NF NANOFILTERED
GRAM
CELLCEPT INTRAVENOUS
MG
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT 400 MG (200
MG X 2 VIALS)
CIMZIA SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200
MG/ML X 2)
cyclosporine intravenous solution 250
mg/5 ml
cyclosporine modified oral capsule 100
mg, 25 mg, 50 mg
cyclosporine modified oral solution 100
mg/ml
cyclosporine oral capsule 100 mg, 25 mg
ENBREL SUBCUTANEOUS RECON
SOLN 25 MG (1 ML)
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML (0.51), 50
MG/ML (0.98 ML)
ENBREL SURECLICK
50 MG/ML (0.98 ML)
ENVARSUS XR ORAL TABLET
EXTENDED RELEASE 24 HR 0.75
MG, 1 MG, 4 MG
FLEBOGAMMA DIF
INTRAVENOUS SOLUTION 10 %, 5
%
Nivel
(Azathioprine Sodium)
Requisitos/Limites
2
PA BvD
5
PA BvD
4
PA BvD
5
PA
5
PA
(Sandimmune)
2
PA BvD
(Neoral)
2
PA BvD
(Neoral)
2
PA BvD
(Sandimmune)
2
5
PA BvD
PA
5
PA
5
PA
4
PA BvD
5
PA BvD
122
Nivel
GAMASTAN S/D
INTRAMUSCULAR SOLUTION
15-18 % RANGE
GAMMAGARD LIQUID
INJECTION SOLUTION 10 %
GAMMAPLEX INTRAVENOUS
SOLUTION 5 %
GAMUNEX-C 20 GRAM/200 ML
VIAL P/F,LTX-FR,SUV,OUTER 20
GRAM/200 ML (10 %)
GAMUNEX-C INJECTION
SOLUTION 1 GRAM/10 ML (10 %)
gengraf oral capsule 100 mg, 25 mg, 50
(Neoral)
mg
gengraf oral solution 100 mg/ml
(Neoral)
HUMIRA PEN CROHN'S-UC-HS
START SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8 ML
HUMIRA PEN SUBCUTANEOUS
PEN INJECTOR KIT 40 MG/0.8 ML
HUMIRA SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2 ML, 20
MG/0.4 ML, 40 MG/0.8 ML
HYPERRAB S/D (PF)
UNIT/ML, 150 UNIT/ML (10 ML)
HYQVIA IG COMPONENT
SUBCUTANEOUS SOLUTION 2.5
GRAM/25 ML (10 %)
HYQVIA SUBCUTANEOUS
SOLUTION 10 GRAM /100 ML (10
%), 2.5 GRAM /25 ML (10 %), 20
GRAM /200 ML (10 %), 30 GRAM
/300 ML (10 %), 5 GRAM /50 ML (10
%)
Requisitos/Limites
3
PA BvD
5
PA BvD
5
PA BvD
5
PA BvD
5
PA BvD
2
PA BvD
2
5
PA BvD
PA
5
PA
5
PA
4
5
PA BvD
5
PA BvD
123
ILARIS (PF) SUBCUTANEOUS
RECON SOLN 180 MG/1.2 ML (150
MG/ML)
IMOGAM RABIES-HT (PF)
UNIT/ML
KINERET SUBCUTANEOUS
SYRINGE 100 MG/0.67 ML
leflunomide oral tablet 10 mg, 20 mg
mycophenolate mofetil oral capsule 250
mg
mycophenolate mofetil oral suspension
for reconstitution 200 mg/ml
mycophenolate mofetil oral tablet 500 mg
mycophenolate sodium oral
tablet,delayed release (dr/ec) 180 mg,
360 mg
NULOJIX INTRAVENOUS RECON
SOLN 250 MG
OCTAGAM INTRAVENOUS
SOLUTION 10 %, 5 %
ORENCIA (WITH MALTOSE)
MG
ORENCIA SUBCUTANEOUS
SYRINGE 125 MG/ML
PRIVIGEN INTRAVENOUS
SOLUTION 10 %
PROGRAF INTRAVENOUS
SOLUTION 5 MG/ML
RAPAMUNE ORAL SOLUTION 1
MG/ML
RIDAURA ORAL CAPSULE 3 MG
sirolimus oral tablet 0.5 mg, 1 mg
sirolimus oral tablet 2 mg
tacrolimus oral capsule 0.5 mg, 1 mg, 5
mg
Nivel
5
Requisitos/Limites
PA
4
5
PA; QL (18.76 per 28
days)
(Arava)
(Cellcept)
2
2
PA BvD
(Cellcept)
5
PA BvD
(Cellcept)
(Myfortic)
2
2
PA BvD
PA BvD
5
PA BvD
5
PA BvD
5
PA
5
PA
5
PA BvD
4
PA BvD
5
PA BvD
5
2
5
2
PA BvD
PA BvD
PA BvD
(Rapamune)
(Rapamune)
(Hecoria)
124
Nivel
Requisitos/Limites
TYSABRI INTRAVENOUS
ZORTRESS ORAL TABLET 0.25 MG
5
ZORTRESS ORAL TABLET 0.5 MG,
0.75 MG
Vaccines
ACTHIB (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION 2
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
BCG (TICE STRAIN) VIAL
LATEX-FREE, OUTER 50 MG
BCG VACCINE, LIVE (PF)
PERCUTANEOUS SUSPENSION
FOR RECONSTITUTION 50 MG
BEXSERO (PF) INTRAMUSCULAR
SYRINGE 50-50-50-25 MCG/0.5 ML
BOOSTRIX TDAP
2.5-8-5 LF-MCG-LF/0.5ML
BOOSTRIX TDAP
INTRAMUSCULAR SYRINGE
2.5-8-5 LF-MCG-LF/0.5ML
CERVARIX VACCINE (PF)
INTRAMUSCULAR SYRINGE 20-20
MCG/0.5 ML
COMVAX (PF) INTRAMUSCULAR
SUSPENSION 5-7.5-125 MCG/0.5 ML
5
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
PA BvD; QL (120 per
30 days)
4
3
3
3
3
PA BvD
3
PA BvD
3
3
3
3
3
125
Nivel
DAPTACEL (DTAP PEDIATRIC)
(PF) INTRAMUSCULAR
SUSPENSION 15-10-5
LF-MCG-LF/0.5ML
ENGERIX-B (PF)
MCG/ML
ENGERIX-B 20 MCG/ML VIAL
10'S,ADULT,P/F,OUTER 20
MCG/ML
ENGERIX-B PEDIATRIC (PF)
10 MCG/0.5 ML
MCG/0.5 ML
GARDASIL (PF)
20-40-40-20 MCG/0.5 ML
GARDASIL (PF)
INTRAMUSCULAR SYRINGE
20-40-40-20 MCG/0.5 ML
GARDASIL 9 (PF)
0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR SYRINGE 0.5
ML
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA
UNIT/ML
HAVRIX (PF) INTRAMUSCULAR
SYRINGE 1,440 ELISA UNIT/ML,
720 ELISA UNIT/0.5 ML
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN
2.5 UNIT
Requisitos/Limites
3
3
days)
3
days)
3
days)
3
days)
3
3
3
3
3
3
3
PA BvD
126
Nivel
INFANRIX (DTAP) (PF)
25-58-10 LF-MCG-LF/0.5ML
IPOL INJECTION SUSPENSION
40-8-32 UNIT/0.5 ML
IPOL INJECTION SYRINGE 40-8-32
UNIT/0.5 ML
IXIARO (PF) INTRAMUSCULAR
KINRIX (PF) INTRAMUSCULAR
SUSPENSION 25 LF-58 MCG-10
LF/0.5 ML
KINRIX (PF) INTRAMUSCULAR
SYRINGE 25 LF-58 MCG-10 LF/0.5
ML
MENACTRA (PF)
MCG/0.5 ML
MENHIBRIX (PF)
INTRAMUSCULAR RECON SOLN
5-2.5 MCG/0.5 ML
MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN 50
MCG
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5
MCG/0.5 ML
MENVEO MENA COMPONENT
(PF) INTRAMUSCULAR RECON
SOLN 10 MCG /0.5 ML (FINAL)
MENVEO MENCYW-135 COMPNT
SOLN 5 MCG X 3/ 0.5 ML (FINAL)
M-M-R II (PF) SUBCUTANEOUS
RECON SOLN 1,000-12,500
TCID50/0.5 ML
Requisitos/Limites
3
3
3
3
3
3
3
3
3
3
3
3
3
QL (2 per 365 days)
127
Nivel
PEDIARIX (PF) INTRAMUSCULAR
SYRINGE 10 MCG-25LF-25
MCG-10LF/0.5 ML
PEDVAX HIB (PF)
INTRAMUSCULAR SOLUTION 7.5
MCG/0.5 ML
PENTACEL (PF)
INTRAMUSCULAR KIT 15 LF
UNIT-20 MCG-5 LF/0.5 ML
PENTACEL ACTHIB COMPONENT
SOLN 10 MCG/0.5 ML
PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10EXP3-4.3-33.99 TCID50/0.5
QUADRACEL (PF)
15 LF-48 MCG- 5 LF UNIT/0.5ML
RABAVERT (PF)
FOR RECONSTITUTION 2.5 UNIT
RECOMBIVAX HB (PF)
10 MCG/ML, 40 MCG/ML
RECOMBIVAX HB (PF)
MCG/ML, 5 MCG/0.5 ML
ROTARIX ORAL SUSPENSION
FOR RECONSTITUTION 10EXP6
CCID50/ML
ROTATEQ VACCINE ORAL
SUSPENSION 2 ML
TENIVAC (PF) INTRAMUSCULAR
SYRINGE 5-2 LF UNIT/0.5 ML
Requisitos/Limites
3
3
3
3
3
QL (2 per 365 days)
3
3
PA BvD
3
days)
3
days)
3
3
3
128
TETANUS TOXOID,ADSORBED
(PF) INTRAMUSCULAR
SUSPENSION 5 LF UNIT/0.5 ML
TETANUS,DIPHTHERIA TOX
PED(PF) INTRAMUSCULAR
SUSPENSION 5-25 LF UNIT/0.5 ML
tetanus-diphtheria toxoids-td
intramuscular suspension 2-2 lf unit/0.5
ml
TRUMENBA INTRAMUSCULAR
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION 720 ELISA UNIT -20
MCG/ML
TWINRIX (PF) INTRAMUSCULAR
SYRINGE 720 ELISA UNIT -20
MCG/ML
TYPHIM VI INTRAMUSCULAR
SOLUTION 25 MCG/0.5 ML
TYPHIM VI INTRAMUSCULAR
VAQTA (PF) INTRAMUSCULAR
VAQTA (PF) INTRAMUSCULAR
SYRINGE 25 UNIT/0.5 ML, 50
UNIT/ML
VAQTA 25 UNITS/0.5 ML VIAL
SDV, OUTER 25 UNIT/0.5 ML
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 1,350 UNIT/0.5
ML
YF-VAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10 EXP4.74
UNIT/0.5 ML
Nivel
3
Requisitos/Limites
PA BvD
3
(Tetanus, Diphtheria
Tox,Adult)
3
3
3
3
3
3
3
3
3
3
QL (2 per 365 days)
3
129
Nivel
ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 19,400
UNIT/0.65 ML
3
Requisitos/Limites
QL (1 per 365 days)
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease
Agents
alosetron oral tablet 0.5 mg, 1 mg
APRISO ORAL
24HR 0.375 GRAM
ASACOL HD ORAL
(DR/EC) 800 MG
balsalazide oral capsule 750 mg
budesonide oral
capsule,delayed,extend.release 3 mg
DELZICOL DR 400 MG CAPSULE
400 MG
DELZICOL ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 400 MG
DIPENTUM ORAL CAPSULE 250
MG
(Alosetron HCl)
5
3
3
(Colazal)
(Entocort EC)
2
5
3
3
4
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation solution 0.25 %
LACTATED RINGERS
IRRIGATION SOLUTION
ringers irrigation solution
sodium chloride irrigation solution 0.9 %
sorbitol irrigation solution 3 %, 3.3 %
sorbitol-mannitol urethral solution
2.7-0.54 g/100 ml
(Acetic Acid)
2
3
(Ringers Solution)
(Sodium Chloride Irrig
Solution)
(Sorbitol Solution)
(Mannitol/Sorbitol
Solution)
2
2
2
2
130
water for irrigation, sterile irrigation
solution
Nivel
Requisitos/Limites
(Water For
Irrigation,Sterile)
2
(Alendronate Sodium)
(Fosamax)
2
1
(Fosamax)
(Miacalcin)
1
2
QL (4 per 28 days)
(Calcitriol)
(Rocaltrol)
(Rocaltrol)
(Doxercalciferol)
2
2
2
2
(Hectorol)
2
(Etidronate Disodium)
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate oral solution 70 mg/75 ml
alendronate oral tablet 10 mg, 40 mg, 5
mg
alendronate oral tablet 35 mg, 70 mg
calcitonin (salmon) nasal
spray,non-aerosol 200 unit/actuation
calcitriol intravenous solution 1 mcg/ml
calcitriol oral capsule 0.25 mcg, 0.5 mcg
calcitriol oral solution 1 mcg/ml
doxercalciferol intravenous solution 4
mcg/2 ml
doxercalciferol oral capsule 0.5 mcg, 1
mcg, 2.5 mcg
etidronate disodium oral tablet 200 mg,
400 mg
FORTEO SUBCUTANEOUS PEN
INJECTOR 20 MCG/DOSE - 600
MCG/2.4 ML
FORTICAL NASAL
UNIT/ACTUATION
ibandronate intravenous solution 3 mg/3
ml
ibandronate intravenous syringe 3 mg/3
ml
ibandronate oral tablet 150 mg
MIACALCIN INJECTION
NATPARA SUBCUTANEOUS
CARTRIDGE 100 MCG/DOSE, 25
MCG/DOSE, 50 MCG/DOSE, 75
MCG/DOSE
4
4
(Ibandronate Sodium)
2
QL (3 per 84 days)
(Boniva)
2
QL (3 per 84 days)
(Boniva)
2
3
QL (1 per 28 days)
5
131
pamidronate intravenous solution 30
mg/10 ml (3 mg/ml), 60 mg/10 ml (6
mg/ml), 90 mg/10 ml (9 mg/ml)
paricalcitol oral capsule 1 mcg, 2 mcg, 4
mcg
PROLIA SUBCUTANEOUS
SYRINGE 60 MG/ML
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
risedronate oral tablet 35 mg (12 pack),
35 mg (4 pack)
risedronate sodium 35 mg tab f/c,
once-a-week 35 mg
XGEVA SUBCUTANEOUS
SOLUTION 120 MG/1.7 ML (70
MG/ML)
ZEMPLAR INTRAVENOUS
SOLUTION 2 MCG/ML, 5 MCG/ML
zoledronic acid intravenous solution 4
mg/5 ml
zoledronic acid-mannitol-water
intravenous solution 5 mg/100 ml
ZOMETA INTRAVENOUS
Nivel
(Pamidronate
Disodium)
2
(Zemplar)
2
Requisitos/Limites
3
QL (1 per 180 days)
(Actonel)
(Actonel)
(Actonel)
2
2
2
QL (1 per 28 days)
QL (30 per 28 days)
QL (4 per 28 days)
(Actonel)
2
QL (4 per 28 days)
5
PA
3
(Zometa)
2
(Zoledronic
Acid/Mannitol and
Water)
(Reclast)
2
2
5
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS
MG/ML), 400 MG/20 ML (20
MG/ML), 80 MG/4 ML (20 MG/ML)
ACTEMRA SUBCUTANEOUS
SYRINGE 162 MG/0.9 ML
ACTIMMUNE SUBCUTANEOUS
SOLUTION 100 MCG/0.5 ML
5
PA
5
PA
5
132
allopurinol oral tablet 100 mg, 300 mg
allopurinol sodium intravenous recon soln
500 mg
amifostine crystalline intravenous recon
soln 500 mg
ammonium chloride intravenous solution
5 meq/ml
anticoag citrate phos dextrose solution
2.63-222 gram-mg/100ml
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT 30 MCG
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT 30 MCG/0.5 ML
AVONEX INTRAMUSCULAR
SYRINGE KIT 30 MCG/0.5 ML
BENLYSTA INTRAVENOUS
BETASERON SUBCUTANEOUS
KIT 0.3 MG
bethanechol chloride oral tablet 10 mg,
25 mg, 5 mg, 50 mg
BOTOX INJECTION RECON SOLN
100 UNIT
BOTOX INJECTION RECON SOLN
200 UNIT
buspirone oral tablet 10 mg, 15 mg, 30
mg, 5 mg, 7.5 mg
CERDELGA ORAL CAPSULE 84
MG
colchicine oral tablet 0.6 mg
colchicine-probenecid oral tablet 0.5-500
mg
COPAXONE SUBCUTANEOUS
SYRINGE 20 MG/ML, 40 MG/ML
CYSTADANE ORAL POWDER 1
GRAM/1.7 ML
Nivel
(Zyloprim)
(Allopurinol Sodium)
2
2
(Amifostine
Crystalline)
(Ammonium Chloride)
2
(Citrate Phosphate
Dextros Soln)
2
(Urecholine)
(Buspirone HCl)
2
5
ST
5
ST
5
ST
5
PA
5
ST
2
3
3
2
5
(Colcrys)
(Colchicine/Probenecid
)
Requisitos/Limites
PA
2
2
5
5
133
dexrazoxane hcl intravenous recon soln
250 mg
droperidol injection solution 2.5 mg/ml
dutasteride oral capsule 0.5 mg
dutasteride-tamsulosin oral capsule, er
multiphase 24 hr 0.5-0.4 mg
ELMIRON ORAL CAPSULE 100 MG
ergoloid oral tablet 1 mg
EXTAVIA SUBCUTANEOUS KIT
0.3 MG
finasteride oral tablet 5 mg
fomepizole intravenous solution 1
gram/ml
FUSILEV INTRAVENOUS RECON
SOLN 50 MG
GAUZE PAD TOPICAL BANDAGE
2X2"
GILENYA ORAL CAPSULE 0.5 MG
GLUCAGEN HYPOKIT INJECTION
RECON SOLN 1 MG
GLUCAGON EMERGENCY KIT
(HUMAN) INJECTION KIT 1 MG
guanidine oral tablet 125 mg
hydroxyzine hcl intramuscular solution
25 mg/ml, 50 mg/ml
hydroxyzine hcl oral solution 10 mg/5 ml
hydroxyzine hcl oral tablet 10 mg, 25 mg,
50 mg
hydroxyzine pamoate oral capsule 100
mg, 25 mg, 50 mg
KEVEYIS ORAL TABLET 50 MG
LEMTRADA INTRAVENOUS
leucovorin calcium 200 mg vial sdv, p/f,
latex-free 200 mg
Nivel
Requisitos/Limites
(Totect)
2
(Droperidol)
(Avodart)
(Jalyn)
2
2
2
QL (30 per 30 days)
(Ergoloid Mesylates)
4
2
5
ST
(Proscar)
(Fomepizole)
2
5
5
1
5
3
QL (28 per 28 days)
4
(Guanidine HCl)
(Hydroxyzine HCl)
2
2
(Hydroxyzine HCl)
(Hydroxyzine HCl)
2
2
(Vistaril)
2
5
5
(Leucovorin Calcium)
PA NSO; QL (120 per
30 days)
PA
2
134
leucovorin calcium injection recon soln
100 mg, 350 mg
leucovorin calcium oral tablet 10 mg, 15
mg, 25 mg, 5 mg
levocarnitine (with sugar) oral solution
100 mg/ml
levocarnitine intravenous solution 200
mg/ml
levocarnitine oral tablet 330 mg
mesna intravenous solution 100 mg/ml
MESNEX ORAL TABLET 400 MG
MESTINON ORAL SYRUP 60 MG/5
ML
MESTINON TIMESPAN ORAL
TABLET EXTENDED RELEASE 180
MG
methylergonovine injection solution 0.2
mg/ml (1 ml)
methylergonovine oral tablet 0.2 mg
morrhuate sodium intravenous solution 5
%
MYOBLOC INTRAMUSCULAR
SOLUTION 10,000 UNIT/2 ML, 2,500
UNIT/0.5 ML, 5,000 UNIT/ML
NPLATE SUBCUTANEOUS RECON
SOLN 250 MCG, 500 MCG
ORENCIA CLICKJECT
SUBCUTANEOUS
AUTO-INJECTOR 125 MG/ML
ORFADIN ORAL SUSPENSION 4
MG/ML
OTEZLA ORAL TABLET 30 MG
Nivel
2
2
(Levocarnitine (With
Sugar))
(Carnitor)
2
(Carnitor)
(Mesnex)
2
2
5
4
Requisitos/Limites
2
4
(Methylergonovine
Maleate)
(Methergine)
(Sodium Morrhuate)
2
2
2
4
QL (1 per 90 days)
5
5
PA
5
5
OTEZLA STARTER ORAL
TABLETS,DOSE PACK 10 MG (4)-20
MG (4)-30 MG (47), 10 MG (4)-20 MG
(4)-30 MG(19)
5
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
135
Nivel
OTREXUP (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.4 ML,
12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5
MG/0.4 ML, 20 MG/0.4 ML, 22.5
MG/0.4 ML, 25 MG/0.4 ML, 7.5
MG/0.4 ML
PLEGRIDY SUBCUTANEOUS PEN
INJECTOR 125 MCG/0.5 ML, 63
MCG/0.5 ML- 94 MCG/0.5 ML
PLEGRIDY SUBCUTANEOUS
SYRINGE 125 MCG/0.5 ML, 63
MCG/0.5 ML- 94 MCG/0.5 ML
probenecid oral tablet 500 mg
(Probenecid)
PROCYSBI ORAL CAPSULE,
DELAYED REL SPRINKLE 25 MG,
75 MG
pyridostigmine bromide oral tablet 60 mg (Mestinon)
pyridostigmine bromide oral tablet
(Mestinon)
extended release 180 mg
RASUVO (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.2 ML,
12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5
MG/0.35 ML, 20 MG/0.4 ML, 22.5
MG/0.45 ML, 25 MG/0.5 ML, 27.5
MG/0.55 ML, 30 MG/0.6 ML, 7.5
MG/0.15 ML
REBIF (WITH ALBUMIN)
MCG/0.5 ML, 44 MCG/0.5 ML
REBIF REBIDOSE
22 MCG/0.5 ML, 44 MCG/0.5 ML,
8.8MCG/0.2ML-22 MCG/0.5ML (6)
REBIF TITRATION PACK
SUBCUTANEOUS SYRINGE
8.8MCG/0.2ML-22 MCG/0.5ML (6)
3
Requisitos/Limites
5
ST
5
ST
2
5
2
2
3
5
5
5
136
Nivel
REMICADE INTRAVENOUS
RECON SOLN 100 MG
SENSIPAR ORAL TABLET 30 MG
SENSIPAR ORAL TABLET 60 MG,
90 MG
SIGNIFOR SUBCUTANEOUS
SOLUTION 0.3 MG/ML (1 ML), 0.6
MG/ML (1 ML), 0.9 MG/ML (1 ML)
SIMPONI ARIA INTRAVENOUS
SOLUTION 12.5 MG/ML
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML, 50 MG/0.5
ML
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML, 50 MG/0.5
ML
STELARA SUBCUTANEOUS
SYRINGE 45 MG/0.5 ML, 90 MG/ML
STERILE PADS 2" X 2" 2 X 2 "
SYNAREL NASAL
SPRAY,NON-AEROSOL 2 MG/ML
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)- 240
MG (46), 240 MG
THALOMID ORAL CAPSULE 100
MG, 150 MG, 200 MG, 50 MG
TYBOST ORAL TABLET 150 MG
ULORIC ORAL TABLET 40 MG, 80
MG
XELJANZ ORAL TABLET 5 MG
5
Requisitos/Limites
PA
3
5
5
QL (60 per 30 days)
5
PA
5
PA
5
PA
5
PA
1
5
5
QL (14 per 30 days)
5
QL (60 per 30 days)
5
days)
QL (30 per 30 days)
QL (30 per 30 days)
4
3
5
PA; QL (60 per 30
days)
137
Nivel
XELJANZ XR ORAL TABLET
MG
ZINBRYTA SUBCUTANEOUS
SYRINGE 150 MG/ML
Requisitos/Limites
5
PA; QL (30 per 30
days)
5
ST
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule, extended
release 500 mg
acetazolamide oral tablet 125 mg, 250 mg
acetazolamide sodium injection recon
soln 500 mg
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT OPHTHALMIC
DROPS,SUSPENSION 1 %
betaxolol ophthalmic drops 0.5 %
BETOPTIC S OPHTHALMIC
bimatoprost ophthalmic drops 0.03 %
brimonidine ophthalmic drops 0.15 %, 0.2
%
COMBIGAN OPHTHALMIC DROPS
0.2-0.5 %
dorzolamide ophthalmic drops 2 %
dorzolamide-timolol ophthalmic drops
22.3-6.8 mg/ml
latanoprost ophthalmic drops 0.005 %
levobunolol ophthalmic drops 0.25 %, 0.5
%
LUMIGAN OPHTHALMIC DROPS
0.01 %
methazolamide oral tablet 25 mg, 50 mg
metipranolol ophthalmic drops 0.3 %
PHOSPHOLINE IODIDE
OPHTHALMIC DROPS 0.125 %
(Diamox Sequels)
2
(Acetazolamide)
(Acetazolamide
Sodium)
2
2
3
3
(Betaxolol HCl)
2
4
(Bimatoprost)
(Alphagan P)
2
2
(drops: 0.15%, 0.20%)
3
(Trusopt)
(Cosopt)
2
2
(Xalatan)
(Betagan)
2
2
3
(Neptazane)
(Metipranolol)
2
2
3
138
pilocarpine hcl ophthalmic drops 1 %, 2
%, 4 %
SIMBRINZA OPHTHALMIC
DROPS,SUSPENSION 1-0.2 %
timolol maleate ophthalmic drops 0.25 %,
0.5 %
timolol maleate ophthalmic gel forming
solution 0.25 %, 0.5 %
TRAVATAN Z OPHTHALMIC
DROPS 0.004 %
travoprost (benzalkonium) ophthalmic
drops 0.004 %
ZIOPTAN (PF) OPHTHALMIC
DROPPERETTE 0.0015 %
Nivel
(Isopto Carpine)
Requisitos/Limites
2
3
(Timoptic)
2
(Timoptic-Xe)
2
(Travoprost
(Benzalkonium))
3
2
4
QL (30 per 30 days)
Replacement Preparations
Replacement Preparations
calcium chloride intravenous solution 100
mg/ml (10 %)
calcium chloride intravenous syringe 100
mg/ml (10 %)
calcium gluconate intravenous solution
100 mg/ml (10%)
d10 %-0.45 % sodium chloride
d2.5 %-0.45 % sodium chloride
d5 % and 0.9 % sodium chloride
d5 %-0.45 % sodium chloride intravenous
parenteral solution
dextrose 10 % and 0.2 % nacl intravenous
parenteral solution
dextrose 5 %-lactated ringers intravenous
parenteral solution
dextrose 5%-0.2 % sod chloride
(Calcium Chloride)
2
(Calcium Chloride)
2
(Calcium Gluconate)
2
(Dextrose 10 % and
0.45 % NaCl)
(Dextrose 2.5 % and
0.45 % NaCl)
(Dextrose 5 % and 0.9
% NaCl)
(Dextrose 5 %-0.45 %
NaCl)
% NaCl)
(Dextrose 5%-Lactated
Ringers)
(Dextrose 5 %-0.2 %
NaCl)
2
2
2
2
2
2
2
139
dextrose 5%-0.3 % sod.chloride
dextrose with sodium chloride
intravenous parenteral solution 5-0.2 %
dextrose-kcl-nacl intravenous solution
5-0.224-0.225 %
effer-k oral tablet, effervescent 25 meq
electrolyte-48 in d5w intravenous
parenteral solution
HYPERLYTE CR INTRAVENOUS
SOLUTION 25-20-5-5-30-30 MEQ/20
ML
IONOSOL-B IN D5W
SOLUTION 5 %
IONOSOL-MB IN D5W
SOLUTION 5 %
ISOLYTE M IN 5 % DEXTROSE
SOLUTION
ISOLYTE-H IN 5 % DEXTROSE
SOLUTION 5 %
ISOLYTE-P IN 5 % DEXTROSE
SOLUTION 5 %
ISOLYTE-S INTRAVENOUS
PARENTERAL SOLUTION
k-effervescent oral tablet, effervescent 25
meq
klor-con 10 oral tablet extended release
10 meq
klor-con m10 tablet 10 meq
klor-con m15 oral tablet,er
particles/crystals 15 meq
Nivel
% NaCl)
(Dextrose 5 %-0.2 %
NaCl)
(Potassium
Chloride/D5-0.2%NaC
l)
(Klor-Con-Ef)
(Electrolyte-48
Solution/D5W)
Requisitos/Limites
2
2
2
2
2
4
4
4
4
4
4
4
(Klor-Con-Ef)
2
(Potassium Chloride)
2
2
2
140
klor-con m20 oral tablet,er
klor-con sprinkle oral capsule, extended
release 10 meq, 8 meq
magnesium chloride injection solution 200
mg/ml (20 %)
magnesium sulf in 0.45% nacl intravenous
solution 20 gram/500 ml (40 mg/ml)
magnesium sulfate in d5w intravenous
piggyback 1 gram/100 ml, 4 gram/100 ml
magnesium sulfate in water intravenous
parenteral solution 20 gram/500 ml (4
%), 40 gram/1,000 ml (4 %)
magnesium sulfate in water intravenous
piggyback 2 gram/50 ml (4 %), 4
gram/100 ml (4 %), 4 gram/50 ml (8 %)
magnesium sulfate injection solution 4
meq/ml (50 %)
magnesium sulfate injection syringe 4
meq/ml
NORMOSOL-M IN 5 % DEXTROSE
SOLUTION
NORMOSOL-R PH 7.4
SOLUTION
NUTRILYTE II INTRAVENOUS
SOLUTION 35-20-5 MEQ/20 ML
NUTRILYTE INTRAVENOUS
SOLUTION 25-40.6-5 MEQ/20 ML
phospha 250 neutral oral tablet 250 mg
PLASMA-LYTE 148 INTRAVENOUS
PARENTERAL SOLUTION
PLASMA-LYTE A INTRAVENOUS
PARENTERAL SOLUTION
Nivel
2
2
(Magnesium Chloride)
2
(Magnesium Sulf In
0.45% NaCl)
(Magnesium
Sulfate/D5W)
(Magnesium Sulfate in
Water)
2
(Magnesium Sulfate in
Water)
2
(Magnesium Sulfate)
2
(Magnesium Sulfate)
2
Requisitos/Limites
2
2
4
4
4
4
(K-Phos Neutral)
2
4
4
141
PLASMA-LYTE-56 IN 5 %
DEXTROSE INTRAVENOUS
potassium acetate intravenous solution 2
meq/ml, 4 meq/ml
potassium bicarb and chloride oral tablet,
effervescent 25 meq
potassium bicarb-citric acid oral tablet,
effervescent 25 meq
potassium chlorid-d5-0.45%nacl
intravenous parenteral solution 10 meq/l,
20 meq/l, 30 meq/l, 40 meq/l
potassium chloride in 0.9%nacl
40 meq/l
potassium chloride in 5 % dex
30 meq/l, 40 meq/l
potassium chloride in lr-d5 intravenous
parenteral solution 20 meq/l
potassium chloride intravenous piggyback
10 meq/100 ml, 20 meq/100 ml, 30
meq/100 ml, 40 meq/100 ml
potassium chloride intravenous solution 2
meq/ml
potassium chloride oral capsule, extended
release 10 meq, 8 meq
potassium chloride oral liquid 20 meq/15
ml, 40 meq/15 ml
potassium chloride oral packet 20 meq
potassium chloride oral tablet extended
release 8 meq
potassium chloride oral tablet,er
potassium chloride oral tablet,er
Nivel
Requisitos/Limites
4
(Potassium Acetate)
2
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
2
(Potassium
Chloride/D5-0.45nacl)
2
(Potassium Chloride In
0.9%NaCl)
2
D5w)
2
Lr-D5)
2
2
2
2
(Klor-Con)
(K-Tab ER)
2
2
(K-Tab ER)
2
2
2
2
142
potassium chloride-0.45 % nacl
intravenous parenteral solution 20 meq/l
potassium chloride-d5-0.2%nacl
20 meq/l, 30 meq/l, 40 meq/l
intravenous parenteral solution 20 meq/l
40 meq/l
potassium citrate oral tablet extended
release 10 meq (1,080 mg), 15 meq, 5
meq (540 mg)
potassium citrate-citric acid oral packet
3,300-1,002 mg
potassium cl 10 meq/50 ml sol 10 meq/50
ml
potassium cl 20 meq/50 ml sol 20 meq/50
ml
potassium cl er 10 meq tablet f/c 10 meq
potassium phosphate m-/d-basic
intravenous solution 3 mmol/ml
ringers intravenous parenteral solution
sodium acetate intravenous solution 2
meq/ml, 4 meq/ml
sodium bicarbonate intravenous solution
1 meq/ml (8.4 %)
sodium bicarbonate intravenous syringe
10 meq/10 ml (8.4 %), 4.2 % (0.5
meq/ml), 7.5 % (0.9 meq/ml), 8.4 % (1
meq/ml)
sodium chloride 0.45 % intravenous
parenteral solution 0.45 %
sodium chloride 0.9 % intravenous
parenteral solution 0.9 %
Nivel
(Potassium
Chloride-0.45% NaCl)
(Potassium
Chloride/D5-0.2%NaC
l)
(Potassium
Chloride/D5-0.3%NaC
l)
(Potassium
Chloride/D5-0.9%NaC
l)
(Urocit-K)
2
(Potassium
Citrate/Citric Acid)
2
2
(K-Tab ER)
(Potassium
Phos,M-Basic-D-Basic)
(Ringers Solution)
(Sodium Acetate)
2
2
(Sodium Bicarbonate)
2
(Sodium Bicarbonate)
2
(Sodium Chloride 0.45
%)
(0.9 % Sodium
Chloride)
2
Requisitos/Limites
2
2
2
2
2
2
2
2
143
sodium chloride 3 % intravenous
sodium chloride 5 % intravenous
sodium chloride intravenous parenteral
solution 2.5 meq/ml, 4 meq/ml
sodium lactate intravenous parenteral
solution 167 meq/l
sodium lactate intravenous solution 5
meq/ml
sodium phosphate intravenous solution 3
mmol/ml
TPN ELECTROLYTES II IV SOLN
25'S,20ML/50ML FTV 18-18-5-4.5-35
MEQ/20 ML
TPN ELECTROLYTES
INTRAVENOUS SOLUTION 35-20-5
MEQ/20 ML
virt-phos 250 neutral oral tablet 250 mg
Nivel
(Sodium Chloride 3 %)
2
(Sodium Chloride 5 %)
2
(Sodium Chloride)
2
(Sodium Lactate)
2
(Sodium Lactate)
2
(Sodium
Phos,M-Basic-D-Basic)
2
Requisitos/Limites
4
4
(K-Phos Neutral)
2
Respiratory Tract Agents
Anti-Inflammatories, Inhaled
Corticosteroids
ADVAIR DISKUS INHALATION
BLISTER WITH DEVICE 100-50
MCG/DOSE, 250-50 MCG/DOSE,
500-50 MCG/DOSE
ADVAIR HFA INHALATION HFA
AEROSOL INHALER 115-21
MCG/ACTUATION, 230-21
MCG/ACTUATION
BREO ELLIPTA INHALATION
BLISTER WITH DEVICE 100-25
MCG/DOSE, 200-25 MCG/DOSE
3
QL (60 per 30 days)
3
QL (12 per 28 days)
3
QL (60 per 30 days)
144
DULERA INHALATION HFA
AEROSOL INHALER 100-5
MCG/ACTUATION
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 50
MCG/ACTUATION
FLOVENT DISKUS INHALATION
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
AEROSOL INHALER 220
MCG/ACTUATION
AEROSOL INHALER 44
MCG/ACTUATION
QVAR INHALATION AEROSOL 40
MCG/ACTUATION, 80
MCG/ACTUATION
Antileukotrienes
montelukast oral granules in packet 4 mg
montelukast oral tablet 10 mg
montelukast oral tablet,chewable 4 mg, 5
mg
zafirlukast oral tablet 10 mg, 20 mg
Bronchodilators
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml,
2.5 mg /3 ml (0.083 %), 5 mg/ml
albuterol sulfate oral syrup 2 mg/5 ml
albuterol sulfate oral tablet 2 mg, 4 mg
albuterol sulfate oral tablet extended
release 12 hr 4 mg, 8 mg
Nivel
Requisitos/Limites
3
QL (13 per 28 days)
3
QL (60 per 30 days)
3
3
QL (12 per 28 days)
3
QL (24 per 28 days)
3
3
(Singulair)
(Singulair)
(Singulair)
2
2
2
(Accolate)
2
(Albuterol Sulfate)
2
(Albuterol Sulfate)
(Albuterol Sulfate)
(Vospire ER)
2
2
2
PA BvD
145
ATROVENT HFA INHALATION
HFA AEROSOL INHALER 17
MCG/ACTUATION
COMBIVENT RESPIMAT
INHALATION MIST 20-100
MCG/ACTUATION
elixophyllin oral elixir 80 mg/15 ml
FORADIL AEROLIZER
INHALATION CAPSULE,
W/INHALATION DEVICE 12 MCG
ipratropium bromide inhalation solution
0.02 %
ipratropium-albuterol inhalation solution
for nebulization 0.5 mg-3 mg(2.5 mg
base)/3 ml
metaproterenol oral syrup 10 mg/5 ml
metaproterenol oral tablet 10 mg, 20 mg
(Theophylline
Anhydrous)
Nivel
Requisitos/Limites
3
3
QL (8 per 30 days)
2
3
(Ipratropium Bromide)
2
PA BvD
(Ipratropium/Albuterol
Sulfate)
2
PA BvD
(Metaproterenol
Sulfate)
(Metaproterenol
Sulfate)
2
PROAIR HFA INHALATION HFA
AEROSOL INHALER 90
MCG/ACTUATION
PROAIR RESPICLICK
INHALATION AEROSOL POWDR
BREATH ACTIVATED 90
MCG/ACTUATION
SEREVENT DISKUS INHALATION
MCG/DOSE
SPIRIVA RESPIMAT INHALATION
MIST 1.25 MCG/ACTUATION, 2.5
MCG/ACTUATION
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE,
W/INHALATION DEVICE 18 MCG
2
3
3
3
3
3
146
STRIVERDI RESPIMAT
INHALATION MIST 2.5
MCG/ACTUATION
terbutaline oral tablet 2.5 mg, 5 mg
terbutaline subcutaneous solution 1
mg/ml
theochron oral tablet extended release 12
hr 100 mg, 200 mg, 300 mg
theophylline in dextrose 5 % intravenous
parenteral solution 200 mg/100 ml, 200
mg/50 ml, 400 mg/250 ml, 400 mg/500
ml, 800 mg/250 ml
theophylline oral solution 80 mg/15 ml
theophylline oral tablet extended release
12 hr 100 mg, 200 mg, 300 mg, 450 mg
theophylline oral tablet extended release
400 mg, 600 mg
TUDORZA PRESSAIR
INHALATION AEROSOL POWDR
BREATH ACTIVATED 400
MCG/ACTUATION, 400
MCG/ACTUATION (30 ACTUAT)
VENTOLIN HFA INHALATION
HFA AEROSOL INHALER 90
MCG/ACTUATION
Respiratory Tract Agents, Other
acetylcysteine intravenous solution 200
mg/ml (20 %)
acetylcysteine solution 100 mg/ml (10
%), 200 mg/ml (20 %)
CINQAIR INTRAVENOUS
SOLUTION 10 MG/ML
cromolyn inhalation solution for
nebulization 20 mg/2 ml
DALIRESP ORAL TABLET 500
MCG
Nivel
Requisitos/Limites
3
(Terbutaline Sulfate)
(Terbutaline Sulfate)
2
2
(Theophylline
Anhydrous)
(Theophylline/D5W)
2
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
2
2
2
2
3
QL (2 per 28 days)
3
(Acetadote)
2
PA BvD
(Acetadote)
2
PA BvD
5
PA
2
PA BvD
3
QL (30 per 30 days)
(Cromolyn Sodium)
147
Nivel
Requisitos/Limites
ESBRIET ORAL CAPSULE 267 MG
5
KALYDECO ORAL GRANULES IN
PACKET 50 MG, 75 MG
KALYDECO ORAL TABLET 150
MG
NUCALA SUBCUTANEOUS
RECON SOLN 100 MG
OFEV ORAL CAPSULE 100 MG, 150
MG
ORKAMBI ORAL TABLET 200-125
MG
PROLASTIN-C INTRAVENOUS
RECON SOLN 1,000 MG
XOLAIR SUBCUTANEOUS RECON
SOLN 150 MG
5
PA; QL (270 per 30
days)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
days)
PA
5
5
5
5
PA; QL (120 per 30
days)
5
5
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen oral tablet 10 mg, 20 mg
carisoprodol oral tablet 250 mg, 350 mg
chlorzoxazone oral tablet 500 mg
cyclobenzaprine oral tablet 10 mg, 5 mg,
7.5 mg
dantrolene oral capsule 100 mg, 25 mg,
50 mg
metaxall oral tablet 800 mg
metaxalone oral tablet 400 mg, 800 mg
methocarbamol oral tablet 500 mg, 750
mg
revonto intravenous recon soln 20 mg
tizanidine oral capsule 2 mg, 4 mg, 6 mg
tizanidine oral tablet 2 mg, 4 mg
(Baclofen)
(Soma)
(Parafon Forte DSC)
(Fexmid)
2
2
2
2
(Dantrium)
2
(Skelaxin)
(Skelaxin)
(Robaxin)
2
2
2
(Dantrium)
(Zanaflex)
(Zanaflex)
2
2
2
(Nuvigil)
2
Sleep Disorder Agents
Sleep Disorder Agents
armodafinil oral tablet 150 mg, 200 mg,
250 mg, 50 mg
PA
148
BELSOMRA ORAL TABLET 10 MG,
15 MG, 20 MG, 5 MG
eszopiclone oral tablet 1 mg, 2 mg, 3 mg
HETLIOZ ORAL CAPSULE 20 MG
NUVIGIL ORAL TABLET 150 MG,
200 MG, 250 MG, 50 MG
ROZEREM ORAL TABLET 8 MG
XYREM ORAL SOLUTION 500
MG/ML
zaleplon oral capsule 10 mg, 5 mg
zolpidem oral tablet 10 mg, 5 mg
zolpidem oral tablet,ext release
multiphase 12.5 mg, 6.25 mg
Nivel
(Lunesta)
(Sonata)
(Ambien)
(Ambien CR)
Requisitos/Limites
3
QL (30 per 30 days)
2
5
3
QL (30 per 30 days)
PA
PA
3
5
LA
2
2
2
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
5
2
PA; QL (60 per 30
days)
PA; QL (90 per 30
days)
PA; QL (30 per 30
days)
PA BvD
5
PA BvD
5
Vasodilating Agents
Vasodilating Agents
ADCIRCA ORAL TABLET 20 MG
ADEMPAS ORAL TABLET 0.5 MG,
1 MG, 1.5 MG, 2 MG, 2.5 MG
CIALIS ORAL TABLET 2.5 MG, 5
MG
epoprostenol (glycine) intravenous recon (Flolan)
soln 0.5 mg
epoprostenol (glycine) intravenous recon (Flolan)
soln 1.5 mg
LETAIRIS ORAL TABLET 10 MG, 5
MG
OPSUMIT ORAL TABLET 10 MG
5
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.25 MG, 1
MG, 2.5 MG
3
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA
5
PA
3
5
149
Nivel
Requisitos/Limites
REMODULIN INJECTION
SOLUTION 1 MG/ML, 10 MG/ML,
2.5 MG/ML, 5 MG/ML
sildenafil intravenous solution 10 mg/12.5 (Revatio)
ml
sildenafil oral tablet 20 mg
(Revatio)
5
PA BvD
5
PA; QL (37.5 per 1 day)
2
TRACLEER ORAL TABLET 125
MG, 62.5 MG
TYVASO INHALATION SOLUTION
FOR NEBULIZATION 1.74 MG/2.9
ML (0.6 MG/ML)
TYVASO REFILL KIT
INHALATION SOLUTION FOR
NEBULIZATION 1.74 MG/2.9 ML
(0.6 MG/ML)
TYVASO STARTER KIT
INHALATION SOLUTION FOR
NEBULIZATION 1.74 MG/2.9 ML
UPTRAVI ORAL TABLET 1,000
MCG, 1,200 MCG, 1,400 MCG, 1,600
MCG, 400 MCG, 600 MCG, 800 MCG
UPTRAVI ORAL TABLET 200 MCG
5
5
PA; QL (90 per 30
days)
days)
PA BvD
5
PA BvD
5
PA BvD
5
PA; QL (60 per 30
days)
5
UPTRAVI ORAL TABLETS,DOSE
PACK 200 MCG (140)- 800 MCG (60)
5
PA; QL (240 per 30
days)
PA; QL (200 per 365
days)
Vitamins And Minerals
Vitamins And Minerals
multivit-fluor 0.5 mg tab chew chewable,
d/f, s/f 0.5 mg
pnv prenatal plus multivit tab s/f,
gluten-free 27 mg iron- 1 mg
prenatal vitamin plus low iron oral tablet
27 mg iron- 1 mg
sodium fluoride oral tablet 1 mg fluoride
(2.2 mg)
(Pedi M.Vit No.17 with
Fluoride)
(Pnv with
Ca,No.72/Iron/Fa)
(Pnv with
Ca,No.72/Iron/Fa)
(Pedi M.Vit No.17 with
Fluoride)
2
3
3
(All Rx Prenatal
Vitamins Covered)
(All Rx Prenatal
Vitamins Covered)
2
150
Nivel
VITAFOL FE+ (WITH DOCUSATE)
ORAL CAPSULE 90 MG IRON-1 MG
-50 MG-200 MG
Requisitos/Limites
3
151
INDICE
8-MOP ...................................................................... 96
abacavir .................................................................... 60
abacavir-lamivudine-zidovudine
............................................................................................... 60
ABELCET .......................................................... 48
ABILIFY MAINTENA ................. 56
ABRAXANE .................................................. 23
acamprosate ....................................................... 11
acarbose ................................................................... 42
acebutolol ............................................................... 77
acetaminophen-codeine ........................... 3
acetasol hc ......................................................... 106
acetazolamide ............................................... 138
acetazolamide sodium ....................... 138
acetic acid ........................................... 106, 130
acetylcysteine ................................................ 147
acitretin .................................................................... 96
ACTEMRA ................................................... 132
ACTHIB (PF) ............................................ 125
ACTIMMUNE ........................................ 132
ACTOPLUS MET XR ..................... 42
acyclovir ....................................................... 65, 96
acyclovir sodium ........................................... 65
ADACEL(TDAP
ADOLESN/ADULT)(PF) ...... 125
ADAGEN ........................................................ 103
adapalene ............................................................ 102
ADCETRIS ...................................................... 23
ADCIRCA ...................................................... 149
adefovir ..................................................................... 65
ADEMPAS .................................................... 149
adriamycin ............................................................ 23
adrucil ......................................................................... 23
ADVAIR DISKUS ............................ 144
ADVAIR HFA ........................................ 144
afeditab cr ............................................................. 81
AFINITOR ....................................................... 23
AFINITOR DISPERZ .................... 23
a-hydrocort ...................................................... 117
AKTEN (PF) .............................................. 104
AKYNZEO ....................................................... 52
ala-cort ...................................................................... 98
ex
d
In
ala-scalp ................................................................... 98
ALBENZA ......................................................... 54
albuterol sulfate ......................................... 145
alcaine ..................................................................... 104
alclometasone ........................................ 98, 99
ALCOHOL PADS ................................. 96
ALCOHOL PREP PADS ............ 96
ALDURAZYME ................................. 103
ALECENSA .................................................... 23
alendronate ...................................................... 131
alfuzosin ............................................................... 114
ALIMTA ............................................................... 23
ALINIA .................................................................. 54
allopurinol ......................................................... 133
allopurinol sodium .................................. 133
ALLZITAL ........................................................... 3
almotriptan malate ................................... 51
alogliptin ................................................................. 43
alogliptin-metformin ............................... 43
alogliptin-pioglitazone ......................... 43
alosetron .............................................................. 130
ALPHAGAN P ....................................... 138
alprazolam ............................................................ 12
ALREX ............................................................... 108
altacaine ............................................................... 104
altavera (28) .................................................... 88
ALTOPREV .................................................... 83
alyacen 1/35 (28) ....................................... 88
alyacen 7/7/7 (28) ..................................... 88
amantadine hcl ................................................ 54
AMBISOME ................................................... 48
amethia ..................................................................... 89
amethia lo .............................................................. 89
amifostine crystalline ......................... 133
amiloride ................................................................. 82
amiloride-hydrochlorothiazide
............................................................................................... 82
AMINO ACIDS 15 % ....................... 69
aminocaproic acid ........................... 68, 69
AMINOSYN 10 % ................................. 69
AMINOSYN 3.5 % ............................... 69
AMINOSYN 7 % ..................................... 69
ex
d
In
I-1
AMINOSYN 7 % WITH
ELECTROLYTES ................................. 69
AMINOSYN 8.5 % ............................... 69
AMINOSYN 8.5
%-ELECTROLYTES ........................ 70
AMINOSYN II 10 % .......................... 70
AMINOSYN II 15 % .......................... 70
AMINOSYN II 7 % ............................. 70
AMINOSYN II 8.5 % ........................ 70
AMINOSYN II 8.5
%-ELECTROLYTES ........................ 70
AMINOSYN M 3.5 % ...................... 70
AMINOSYN-HBC 7% .................... 70
AMINOSYN-PF 10 % ..................... 70
AMINOSYN-PF 7 %
(SULFITE-FREE) ................................. 70
AMINOSYN-RF 5.2 % .................. 70
amiodarone .......................................................... 76
AMITIZA ........................................................ 110
amitriptyline ...................................................... 39
amlodipine ............................................................. 81
amlodipine-atorvastatin ..................... 83
amlodipine-benazepril ........................... 81
amlodipine-valsartan .............................. 81
amlodipine-valsartan-hcthiazid
............................................................................................... 82
ammonium chloride .............................. 133
ammonium lactate ..................................... 96
amoxapine ............................................................ 39
amoxicil-clarithromy-lansopraz
........................................................................................... 109
amoxicillin ............................................................ 19
amoxicillin-pot clavulanate ........... 19
amphotericin b ................................................ 48
ampicillin ................................................................ 19
ampicillin sodium ........................................ 19
ampicillin-sulbactam .............................. 19
AMPYRA ........................................................... 86
ANACAINE .................................................... 96
anagrelide .............................................................. 69
anastrozole ........................................................... 23
ANDRODERM ..................................... 115
ex
d
In
ANDROGEL ............................................. 115
androxy ................................................................. 115
anticoag citrate phos dextrose
........................................................................................... 133
APOKYN ............................................................ 54
apraclonidine ................................................. 104
apri .................................................................................. 89
APRISO .............................................................. 130
APTIOM ............................................................... 34
APTIVUS ............................................................. 60
aranelle (28) ..................................................... 89
ARCALYST ................................................ 121
aripiprazole ......................................................... 56
ARISTADA ..................................................... 56
armodafinil ....................................................... 148
ASACOL HD ............................................. 130
ascomp with codeine ................................... 3
ashlyna ....................................................................... 89
aspirin-dipyridamole ............................... 69
ASSURE ID INSULIN
SAFETY ............................................................ 102
ASTAGRAF XL ................................... 121
atenolol ..................................................................... 77
atenolol-chlorthalidone ....................... 77
atorvastatin ......................................................... 83
atovaquone ........................................................... 54
atovaquone-proguanil ............................ 54
ATRIPLA ............................................................ 60
atropine ...................................................... 33, 104
atropine-care ................................................. 104
ATROVENT HFA ............................ 146
AUBAGIO ..................................................... 121
aubra ............................................................................ 89
AURYXIA ..................................................... 113
AVASTIN ........................................................... 23
AVC VAGINAL ....................................... 50
aviane .......................................................................... 89
AVONEX ......................................................... 133
AVONEX (WITH ALBUMIN)
........................................................................................... 133
AXIRON ........................................................... 115
azacitidine ............................................................. 24
azathioprine .................................................... 121
azathioprine sodium ............................. 122
azelastine ............................................................ 105
ex
d
In
AZILECT ............................................................ 55
azithromycin ...................................................... 17
AZOPT ................................................................. 138
AZOR ........................................................................ 82
aztreonam .............................................................. 18
azurette (28) .................................................... 89
baciim .......................................................................... 13
bacitracin ................................................ 14, 106
bacitracin-polymyxin b ................... 106
baclofen ................................................................. 148
balsalazide ........................................................ 130
balziva (28) ........................................................ 89
BANZEL .............................................................. 34
BARACLUDE ............................................. 65
BCG VACCINE, LIVE (PF)
........................................................................................... 125
BD INSULIN PEN NEEDLE
UF SHORT ................................................... 102
BD INSULIN SYRINGE
ULTRA-FINE .......................................... 102
bekyree (28) ..................................................... 89
BELBUCA ............................................................. 3
BELEODAQ ................................................... 24
BELSOMRA ............................................... 149
benazepril ............................................................... 75
benazepril-hydrochlorothiazide
............................................................................................... 75
BENDEKA ....................................................... 24
BENICAR .......................................................... 74
BENICAR HCT ........................................ 74
BENLYSTA ................................................. 133
benztropine .......................................................... 55
BEPREVE ....................................................... 105
betamethasone acet,sod phos
........................................................................................... 117
betamethasone dipropionate ........ 99
betamethasone valerate ...................... 99
betamethasone, augmented ............ 99
BETASERON ........................................... 133
betaxolol .................................................. 77, 138
bethanechol chloride ............................ 133
BETHKIS ............................................................ 13
BETOPTIC S .............................................. 138
bexarotene ............................................................ 24
BEXSERO (PF) ...................................... 125
ex
d
In
I-2
bicalutamide ....................................................... 24
BICILLIN C-R ............................................ 20
BICILLIN L-A ............................................ 20
BIDIL ........................................................................ 85
bimatoprost ..................................................... 138
bisoprolol fumarate .................................. 77
bisoprolol-hydrochlorothiazide
............................................................................................... 77
bleomycin ............................................................... 24
bleph-10 ................................................................ 106
BLEPHAMIDE ...................................... 106
BLEPHAMIDE S.O.P. ................ 106
BLINCYTO ...................................................... 24
blisovi 24 fe .......................................................... 89
blisovi fe 1.5/30 (28) .............................. 89
blisovi fe 1/20 (28) ................................... 89
BOOSTRIX TDAP ............................ 125
BOSULIF ............................................................ 24
BOTOX ............................................................... 133
BREO ELLIPTA .................................. 144
briellyn ....................................................................... 89
BRILINTA ........................................................ 69
brimonidine ...................................................... 138
BRINTELLIX .............................................. 39
BRIVIACT ........................................................ 34
bromfenac .......................................................... 108
bromocriptine ................................................... 55
budesonide ......................................................... 130
bumetanide ........................................................... 82
BUPHENYL ............................................... 110
buprenorphine hcl ................................ 3, 11
buprenorphine-naloxone .................... 11
buproban ................................................................. 39
bupropion hcl .................................................... 39
bupropion hcl (smoking deter)
............................................................................................... 11
buspirone ............................................................. 133
butalbital compound w/codeine .... 3
butalbital-acetaminop-caf-cod ...... 3
butalbital-acetaminophen .................... 3
butalbital-acetaminophen-caff ...... 3
butalbital-aspirin-caffeine ................... 3
butorphanol tartrate ................................... 3
BUTRANS ............................................................ 4
BYSTOLIC ........................................................ 77
ex
d
In
cabergoline ........................................................... 55
CABOMETYX ............................................ 24
caffeine citrated ................................. 86, 87
caffeine-sodium benzoate ................. 87
calcipotriene ....................................................... 96
calcitonin (salmon) .............................. 131
calcitrene ................................................................ 96
calcitriol .................................................... 96, 131
calcium acetate ........................................... 113
calcium chloride ........................................ 139
calcium gluconate ................................... 139
CALDOLOR ...................................................... 8
camila .......................................................................... 89
camrese ..................................................................... 89
camrese lo .............................................................. 89
CANCIDAS ..................................................... 48
candesartan ......................................................... 74
candesartan-hydrochlorothiazid
............................................................................................... 74
capacet .......................................................................... 4
CAPASTAT ..................................................... 52
CAPRELSA ..................................................... 24
captopril ................................................................... 75
captopril-hydrochlorothiazide ... 75
CARAFATE ............................................... 109
CARBAGLU .............................................. 111
carbamazepine ................................................ 34
carbidopa ................................................................ 55
carbidopa-levodopa .................................. 55
carbidopa-levodopa-entacapone
............................................................................................... 55
carbinoxamine maleate ....................... 50
carboplatin ........................................................... 24
CARIMUNE NF
NANOFILTERED ........................... 122
carisoprodol .................................................... 148
carteolol ............................................................... 105
cartia xt .................................................................... 79
carvedilol ................................................................ 78
CAYSTON ........................................................ 18
caziant (28) ....................................................... 89
cefaclor ...................................................................... 15
cefadroxil ............................................................... 15
cefazolin ................................................................... 15
cefazolin in dextrose (iso-os) .... 15
ex
d
In
cefdinir ............................................................ 15, 16
cefditoren pivoxil ......................................... 16
cefepime ................................................................... 16
CEFEPIME IN DEXTROSE 5
% ........................................................................................ 16
CEFEPIME IN
DEXTROSE,ISO-OSM .................. 16
cefixime .................................................................... 16
cefotaxime ............................................................ 16
cefoxitin ................................................................... 16
cefoxitin in dextrose, iso-osm ..... 16
cefpodoxime ....................................................... 16
cefprozil .................................................................... 16
ceftazidime ........................................................... 16
ceftibuten ................................................................ 16
ceftriaxone ................................................ 16, 17
ceftriaxone in dextrose,iso-os .... 16
cefuroxime axetil ........................................ 17
cefuroxime sodium .................................... 17
celecoxib ..................................................................... 8
CELLCEPT INTRAVENOUS
........................................................................................... 122
CELONTIN ..................................................... 34
cephalexin ............................................................. 17
CEPROTIN (BLUE BAR) ........ 66
CERDELGA ............................................... 133
CEREZYME ............................................... 103
CERVARIX VACCINE (PF)
........................................................................................... 125
cevimeline .............................................................. 95
CHANTIX ......................................................... 11
CHANTIX CONTINUING
MONTH BOX .............................................. 11
CHANTIX STARTING
MONTH BOX .............................................. 11
chloramphenicol sod succinate
............................................................................................... 14
chlordiazepoxide hcl ............................... 12
chlorhexidine gluconate ...................... 95
chloroquine phosphate .......................... 54
chlorothiazide ................................................... 82
chlorothiazide sodium ........................... 82
chlorpromazine ............................................... 56
chlorthalidone .................................................. 82
chlorzoxazone .............................................. 148
ex
d
In
I-3
cholestyramine (with sugar) ....... 83
cholestyramine light ................................ 83
choline,magnesium salicylate ......... 8
CIALIS ................................................................. 149
ciclopirox ............................................................... 48
ciclopirox-ure-camph-menth-euc
............................................................................................... 48
cidofovir ................................................................... 65
cilostazol ................................................................. 69
CILOXAN ...................................................... 106
cimetidine ........................................................... 109
cimetidine hcl ................................................ 109
CIMZIA ............................................................. 122
CIMZIA POWDER FOR
RECONST ...................................................... 122
CINQAIR ........................................................ 147
CINRYZE .......................................................... 67
CIPRODEX .................................................. 106
ciprofloxacin ...................................................... 21
ciprofloxacin (mixture) .................... 21
ciprofloxacin hcl ............................ 21, 106
ciprofloxacin in 5 % dextrose ..... 21
ciprofloxacin lactate ............................... 21
citalopram ............................................................. 39
cladribine ................................................................ 24
clarithromycin ................................................. 18
clemastine .............................................................. 50
CLEVIPREX .................................................. 82
clindamycin hcl ............................................... 14
clindamycin in 5 % dextrose ........ 14
clindamycin palmitate hcl ................ 14
clindamycin pediatric ............................. 14
clindamycin phosphate
........................................................................ 14, 50, 97
clindamycin-benzoyl peroxide ... 97
CLINIMIX 5%/D15W
SULFITE FREE ....................................... 70
CLINIMIX 5%/D25W
SULFITE-FREE ...................................... 71
CLINIMIX 2.75%/D5W
SULFIT FREE ............................................ 71
CLINIMIX 4.25%/D10W SULF
FREE ......................................................................... 71
CLINIMIX 4.25%/D5W
SULFIT FREE ............................................ 71
ex
d
In
CLINIMIX 4.25%-D20W
SULF-FREE ................................................... 71
CLINIMIX 4.25%-D25W
SULF-FREE ................................................... 71
CLINIMIX
5%-D20W(SULFITE-FREE)
............................................................................................... 71
CLINIMIX E 2.75%/D10W
SUL FREE ......................................................... 71
SULF FREE .................................................... 71
SUL FREE ......................................................... 71
SUL FREE ......................................................... 71
SULF FREE .................................................... 71
CLINIMIX E 5%/D15W
SULFIT FREE ............................................ 72
CLINIMIX E 5%/D20W
SULFIT FREE ............................................ 72
CLINIMIX E 5%/D25W
SULFIT FREE ............................................ 72
CLINISOL SF 15 % ............................. 72
clobetasol ............................................................... 99
clobetasol-emollient ................................. 99
clocortolone pivalate ............................... 99
clomipramine .................................................... 39
clonazepam .......................................................... 12
clonidine ................................................................... 74
clonidine hcl ............................................. 74, 87
clopidogrel ............................................................ 69
clorazepate dipotassium ..................... 12
clorpres ...................................................................... 74
clotrimazole ........................................................ 48
clotrimazole-betamethasone ........ 48
clozapine ...................................................... 56, 57
COARTEM ...................................................... 54
codeine sulfate ..................................................... 4
colchicine ............................................................ 133
colchicine-probenecid ......................... 133
colestipol ................................................................. 83
colistin (colistimethate na) ........... 14
colocort ..................................................................... 99
COLY-MYCIN S ................................. 106
ex
d
In
COMBIGAN .............................................. 138
COMBIPATCH ...................................... 116
COMBIVENT RESPIMAT
........................................................................................... 146
COMETRIQ .................................................... 24
COMPLERA .................................................. 60
compro ....................................................................... 52
COMVAX (PF) ....................................... 125
CONDYLOX ................................................. 96
constulose ........................................................... 111
COPAXONE ............................................... 133
CORLANOR ................................................. 80
cormax ................................................................... 100
cortisone ............................................................... 117
CORTISPORIN-TC ........................ 106
COSENTYX .................................................... 96
COSENTYX (2 SYRINGES)
............................................................................................... 96
COSENTYX PEN .................................. 96
COSENTYX PEN (2 PENS)
............................................................................................... 96
COTELLIC ....................................................... 24
CREON ............................................................... 103
CRESTOR .......................................................... 83
CRIXIVAN ...................................................... 60
cromolyn ................................ 105, 111, 147
cryselle (28) ...................................................... 89
CUBICIN ............................................................. 14
CUBICIN RF ................................................ 14
cyclafem 1/35 (28) ................................... 89
cyclafem 7/7/7 (28) ................................. 89
cyclobenzaprine ......................................... 148
cyclopentolate .............................................. 105
cyclophosphamide ........................... 24, 25
CYCLOPHOSPHAMIDE ......... 25
CYCLOSET ..................................................... 43
cyclosporine .................................................... 122
cyclosporine modified ........................ 122
cyproheptadine ............................................... 50
CYRAMZA ...................................................... 25
cyred ............................................................................. 90
CYSTADANE .......................................... 133
CYSTARAN ............................................... 105
cysteine (l-cysteine) ............................... 72
ex
d
In
I-4
ex
d
In
139
d2.5 %-0.45 % sodium chloride
........................................................................................... 139
d5 % and 0.9 % sodium chloride
........................................................................................... 139
........................................................................................... 139
dactinomycin ..................................................... 25
DAKLINZA .................................................... 64
DALIRESP .................................................... 147
danazol ................................................................... 115
dantrolene .......................................................... 148
dapsone ..................................................................... 52
DAPTACEL (DTAP
PEDIATRIC) (PF) ............................. 126
DARAPRIM .................................................. 54
DARZALEX .................................................. 25
dasetta 1/35 (28) ........................................ 90
dasetta 7/7/7 (28) ...................................... 90
DAUNOXOME ......................................... 25
daysee .......................................................................... 90
deblitane .................................................................. 90
decitabine ............................................................... 25
deferoxamine ................................................. 114
delyla (28) ........................................................... 90
DELZICOL ................................................... 130
demeclocycline ................................................ 22
DEMSER ............................................................. 80
DENAVIR ......................................................... 96
DEPEN TITRATABS .................. 114
DEPO-PROVERA ............................. 120
DESCOVY ......................................................... 60
desipramine ......................................................... 40
desmopressin .................................................. 118
desog-e.estradiol/e.estradiol ......... 90
desogestrel-ethinyl estradiol ......... 90
desonide ................................................................ 100
desoximetasone .......................................... 100
DESVENLAFAXINE
FUMARATE ................................................. 40
dexamethasone ........................................... 117
............................................................................ 108, 117
DEXILANT ................................................. 110
...........................................................................................
dexmethylphenidate ................................. 87
dexrazoxane hcl ........................................ 134
dextroamphetamine ................................. 87
dextroamphetamine-amphetamine
............................................................................................... 87
dextrose 10 % and 0.2 % nacl
........................................................................................... 139
............................................................................................... 72
............................................................................................... 72
............................................................................................... 72
............................................................................................... 72
dextrose 5 % in ringers ........................ 72
dextrose 5 % in water (d5w) ...... 72
dextrose 5 %-lactated ringers
........................................................................................... 139
dextrose 5%-0.2 % sod chloride
........................................................................................... 139
dextrose 5%-0.3 % sod.chloride
........................................................................................... 140
............................................................................................... 72
............................................................................................... 72
dextrose with sodium chloride
........................................................................................... 140
dextrose-kcl-nacl ..................................... 140
diazepam ................................................................. 12
diazepam intensol ........................................ 12
diclofenac potassium .................................. 8
diclofenac sodium ............................ 8, 108
diclofenac-misoprostol ............................. 8
dicloxacillin ......................................................... 20
dicyclomine ...................................................... 111
didanosine .............................................................. 60
DIFICID ............................................................... 18
diflorasone ........................................................ 100
diflunisal ...................................................................... 9
digitek ......................................................................... 80
digox ............................................................................. 80
digoxin ....................................................................... 80
DIGOXIN ........................................................... 80
ex
d
In
dihydroergotamine .................................... 51
DILANTIN ...................................................... 34
diltiazem hcl ....................................................... 79
dilt-xr .......................................................................... 79
dimenhydrinate ............................................... 52
DIPENTUM ................................................ 130
diphenhydramine hcl ............................... 50
diphenoxylate-atropine .................... 111
dipyridamole ...................................................... 69
disopyramide phosphate ..................... 76
disulfiram ............................................................... 11
divalproex .............................................................. 34
dobutamine .......................................................... 80
dobutamine in d5w ..................................... 80
docetaxel ................................................................. 25
dofetilide ................................................................. 76
donepezil ................................................................. 38
dopamine ................................................................. 80
dopamine in 5 % dextrose ................ 80
dorzolamide ..................................................... 138
dorzolamide-timolol ............................. 138
doxazosin ............................................................... 74
doxepin ...................................................................... 40
doxercalciferol ............................................ 131
doxorubicin, peg-liposomal ........... 25
doxy-100 ................................................................. 22
doxycycline hyclate .................................. 22
doxycycline monohydrate ................ 22
dronabinol ............................................................. 52
droperidol ........................................................... 134
drospirenone-ethinyl estradiol ... 90
DROXIA .............................................................. 25
DUAVEE ......................................................... 116
DULERA ......................................................... 145
duloxetine .............................................................. 40
DUREZOL .................................................... 108
dutasteride ........................................................ 134
dutasteride-tamsulosin ..................... 134
DYRENIUM ................................................. 82
e.e.s. 400 .................................................................. 18
e.e.s. granules ................................................... 18
econazole ................................................................ 48
EDARBI ................................................................ 74
EDARBYCLOR ....................................... 74
EDURANT ...................................................... 60
ex
d
In
I-5
effer-k ...................................................................... 140
EFFIENT ............................................................ 69
ELAPRASE .................................................. 103
electrolyte-48 in d5w ........................... 140
ELIDEL .............................................................. 100
ELIGARD .......................................................... 25
elinest .......................................................................... 90
eliphos ..................................................................... 113
ELIQUIS ............................................................... 66
ELITEK .............................................................. 103
elixophyllin ...................................................... 146
ELLA ......................................................................... 90
ELMIRON ..................................................... 134
EMBEDA ................................................................ 4
EMCYT .................................................................. 25
EMEND ..................................................... 52, 53
emoquette ............................................................... 90
EMPLICITI ...................................................... 25
EMSAM ................................................................. 40
EMTRIVA ......................................................... 60
EMVERM .......................................................... 54
enalapril maleate ......................................... 75
enalaprilat ............................................................. 76
enalapril-hydrochlorothiazide .... 76
ENBREL ........................................................... 122
ENBREL SURECLICK ............ 122
endocet .......................................................................... 4
endodan ........................................................................ 4
ENGERIX-B (PF) .............................. 126
........................................................................................... 126
enoxaparin ............................................................ 66
enpresse .................................................................... 90
enskyce ...................................................................... 90
entacapone ............................................................ 55
entecavir .................................................................. 65
ENTRESTO ..................................................... 74
enulose .................................................................... 111
ENVARSUS XR ................................... 122
EPCLUSA .......................................................... 64
ephedrine sulfate .......................................... 80
epinastine ............................................................ 105
epinephrine ........................................................... 80
epinephrine hcl (pf) ................................. 80
EPIPEN 2-PAK .......................................... 81
ex
d
In
EPIPEN JR 2-PAK ............................... 81
epitol ............................................................................. 34
EPIVIR HBV .................................................. 60
eplerenone ............................................................. 85
EPOGEN .............................................................. 67
epoprostenol (glycine) ..................... 149
eprosartan ............................................................. 75
EPZICOM .......................................................... 60
ergoloid ................................................................. 134
ERGOMAR ..................................................... 51
ERIVEDGE ..................................................... 25
errin ............................................................................... 90
ery pads .................................................................... 98
ery-tab ........................................................................ 18
ERY-TAB ............................................................ 18
ERYTHROCIN ......................................... 18
erythrocin (as stearate) .................... 18
erythromycin ...................................... 18, 106
erythromycin ethylsuccinate ........ 18
erythromycin with ethanol .............. 98
erythromycin-benzoyl peroxide
............................................................................................... 98
ESBRIET .......................................................... 148
escitalopram oxalate .............................. 40
esmolol ....................................................................... 78
esomeprazole sodium .......................... 110
estarylla ................................................................... 90
estazolam ............................................................... 12
ESTRACE ....................................................... 116
estradiol ................................................................ 116
estradiol valerate ...................................... 116
estradiol-norethindrone acet .... 116
ESTRING ........................................................ 116
estropipate ........................................................ 116
eszopiclone ........................................................ 149
ethambutol ............................................................ 52
ethamolin ................................................................ 81
ethosuximide .......................................... 34, 35
etidronate disodium .............................. 131
etodolac ........................................................................ 9
ETOPOPHOS ................................................ 26
etoposide ................................................................. 26
EURAX .............................................................. 102
EVOTAZ .............................................................. 60
EXELDERM ................................................. 48
ex
d
In
exemestane ........................................................... 26
EXJADE ............................................................ 115
EXTAVIA ....................................................... 134
FABRAZYME ........................................ 103
falmina (28) ...................................................... 90
famciclovir ............................................................ 65
famotidine .......................................................... 110
famotidine (pf) .......................................... 110
famotidine (pf)-nacl (iso-os)
........................................................................................... 110
FANAPT .............................................................. 57
FARESTON .................................................... 26
FARYDAK ...................................................... 26
FASLODEX .................................................... 26
felbamate ................................................................ 35
felodipine ................................................................ 82
FEMRING .................................................... 116
fenofibrate ............................................................ 84
fenofibrate micronized ......................... 83
fenofibrate nanocrystallized ......... 84
fenofibric acid .................................................. 84
fenofibric acid (choline) ................... 84
fenoprofen ................................................................. 9
fentanyl ......................................................................... 4
fentanyl citrate ................................................... 4
FERRIPROX ............................................. 115
FETZIMA .......................................................... 40
finasteride .......................................................... 134
FIRAZYR .......................................................... 81
flavoxate .............................................................. 114
FLEBOGAMMA DIF ................. 122
flecainide ................................................................. 76
FLECTOR ............................................................. 9
FLOVENT DISKUS ...................... 145
FLOVENT HFA ................................... 145
floxuridine ............................................................. 26
flucaine .................................................................. 105
fluconazole ................................................ 48, 49
fluconazole in dextrose(iso-o)
............................................................................................... 48
fluconazole in nacl (iso-osm)
.................................................................................... 48, 49
flucytosine ............................................................. 49
fludrocortisone ............................................ 117
flumazenil .............................................................. 87
ex
d
In
I-6
flunisolide ........................................................... 108
fluocinolone acetonide oil ............. 108
fluocinonide ..................................................... 100
fluocinonide-e ............................................... 100
fluorometholone ........................................ 108
fluorouracil .................................... 26, 96, 97
fluoxetine ............................................................... 40
FLUOXETINE ........................................... 40
fluphenazine decanoate ....................... 57
fluphenazine hcl ............................................. 57
flurazepam ............................................................ 12
flurbiprofen ............................................................. 9
flurbiprofen sodium .............................. 109
flutamide ................................................................. 26
fluticasone .......................................... 100, 109
fluvastatin .............................................................. 84
fluvoxamine ........................................................ 41
fomepizole ......................................................... 134
fondaparinux ..................................................... 66
FORADIL AEROLIZER ....... 146
FORTEO .......................................................... 131
FORTICAL .................................................. 131
foscarnet .................................................................. 63
fosinopril ................................................................. 76
fosinopril-hydrochlorothiazide
............................................................................................... 76
fosphenytoin ....................................................... 35
FOSRENOL ................................................ 113
FREAMINE HBC 6.9 % .............. 72
FREAMINE III 10 % ........................ 73
furosemide ................................................. 82, 83
FUSILEV ......................................................... 134
FUZEON ............................................................. 60
fyavolv .................................................................... 116
FYCOMPA ....................................................... 35
gabapentin ............................................................ 35
GABITRIL ........................................................ 35
galantamine ........................................................ 38
GAMASTAN S/D ............................... 123
GAMMAGARD LIQUID .... 123
GAMMAPLEX ...................................... 123
GAMUNEX-C ......................................... 123
ganciclovir sodium ..................................... 65
GARDASIL (PF) ................................. 126
GARDASIL 9 (PF) ........................... 126
ex
d
In
gatifloxacin ...................................................... 106
GATTEX 30-VIAL ............................ 111
GATTEX ONE-VIAL .................. 111
GAUZE PAD ............................................ 134
gavilyte-c ............................................................. 112
gavilyte-g ............................................................ 112
gavilyte-n ............................................................ 112
GAZYVA ............................................................. 26
gemcitabine ......................................................... 26
gemfibrozil ........................................................... 84
generlac ................................................................. 111
gengraf ................................................................... 123
GENOTROPIN ...................................... 119
........................................................................................... 119
gentak ...................................................................... 106
gentamicin .................................. 13, 98, 106
gentamicin in nacl (iso-osm) ...... 13
gentamicin sulfate (ped) (pf) ... 13
gentamicin sulfate (pf) ....................... 13
GENVOYA ...................................................... 60
GEODON ........................................................... 57
gianvi (28) ........................................................... 90
gildagia ..................................................................... 90
gildess 1.5/30 (21) .................................... 90
gildess 1/20 (21) .......................................... 90
gildess 24 fe ......................................................... 90
gildess fe 1.5/30 (28) ............................. 90
gildess fe 1/20 (28) .................................. 90
GILENYA ...................................................... 134
GILOTRIF ........................................................ 26
GLEOSTINE ................................................. 26
glimepiride ............................................................ 47
glipizide .................................................................... 47
glipizide-metformin .................................. 47
GLUCAGEN HYPOKIT ....... 134
GLUCAGON EMERGENCY
KIT (HUMAN) ...................................... 134
glyburide ................................................................. 47
glyburide micronized .............................. 47
glyburide-metformin ............................... 47
glycopyrrolate .............................................. 111
glydo ............................................................................. 10
GLYSET ............................................................... 43
GLYXAMBI ................................................... 43
ex
d
In
GRALISE ............................................................ 35
GRALISE 30-DAY STARTER
PACK ........................................................................ 35
granisetron (pf) ............................................ 53
granisetron hcl ................................................ 53
granisol ..................................................................... 53
GRANIX .............................................................. 67
griseofulvin microsize ............................ 49
griseofulvin ultramicrosize ............. 49
guanfacine .................................................. 74, 87
guanidine ............................................................. 134
halobetasol propionate ..................... 100
haloperidol ............................................................ 57
haloperidol decanoate ........................... 57
haloperidol lactate ..................................... 57
HARVONI ......................................................... 64
HAVRIX (PF) ........................................... 126
heather ....................................................................... 91
heparin (porcine) ....................................... 66
heparin (porcine) in 5 % dex
.................................................................................... 66, 67
heparin (porcine) in nacl (pf)
............................................................................................... 66
heparin(porcine) in 0.45% nacl
............................................................................................... 67
heparin, porcine (pf) ............................. 67
HEPATAMINE 8% ............................. 73
HEPATASOL 8 % .................................. 73
HERCEPTIN ................................................. 26
HETLIOZ ........................................................ 149
HEXALEN ........................................................ 26
homatropaire ................................................. 105
homatropine hbr ........................................ 105
HUMALOG .................................................... 45
HUMALOG KWIKPEN ............ 45
HUMALOG MIX 50-50 ............... 45
HUMALOG MIX 50-50
KWIKPEN ........................................................ 45
HUMALOG MIX 75-25 ............... 45
HUMALOG MIX 75-25
KWIKPEN ........................................................ 45
HUMIRA ......................................................... 123
HUMIRA PEN ....................................... 123
ex
d
In
I-7
HUMIRA PEN
CROHN'S-UC-HS START
ex
d
In
123
HUMULIN 70/30 .................................... 46
HUMULIN 70/30 KWIKPEN
............................................................................................... 45
HUMULIN N ............................................... 46
HUMULIN N KWIKPEN ....... 46
HUMULIN R ............................................... 46
HUMULIN R U-500 (CONC)
KWIKPEN ........................................................ 46
HUMULIN R U-500
(CONCENTRATED) ....................... 46
hydralazine .......................................................... 81
hydrochlorothiazide ................................. 83
hydrocodone-acetaminophen ........... 4
hydrocodone-ibuprofen ........................... 4
hydrocortisone ............... 100, 101, 117
hydrocortisone acet-aloe vera
........................................................................................... 100
hydrocortisone butyrate ................. 100
hydrocortisone butyr-emollient
........................................................................................... 101
hydrocortisone valerate ................... 101
hydrocortisone-acetic acid .......... 107
hydromorphone .................................................. 5
hydromorphone (pf) .................................. 4
hydroxychloroquine ................................. 54
hydroxyprogesterone caproate
........................................................................................... 120
hydroxyurea ....................................................... 26
hydroxyzine hcl .......................................... 134
hydroxyzine pamoate ......................... 134
HYPERLYTE CR .............................. 140
HYPERRAB S/D (PF) ................. 123
HYQVIA ........................................................... 123
HYQVIA IG COMPONENT
........................................................................................... 123
HYSINGLA ER ............................................ 5
ibandronate ...................................................... 131
IBRANCE .......................................................... 26
ibuprofen ..................................................................... 9
ICLUSIG .............................................................. 26
ifosfamide ................................................... 26, 27
ifosfamide-mesna ......................................... 27
...........................................................................................
ILARIS (PF) ................................................ 124
ILEVRO ............................................................. 109
imatinib ..................................................................... 27
IMBRUVICA ................................................ 27
imipenem-cilastatin .................................. 18
imipramine hcl ................................................. 41
imipramine pamoate ............................... 41
imiquimod .............................................................. 97
IMLYGIC ........................................................... 27
IMOGAM RABIES-HT (PF)
........................................................................................... 124
IMOVAX RABIES VACCINE
(PF) ............................................................................ 126
INCRELEX .................................................. 119
indapamide ........................................................... 83
indomethacin ......................................................... 9
indomethacin sodium ................................. 9
INFANRIX (DTAP) (PF) ...... 127
INLYTA ................................................................ 27
INSULIN SYRINGE-NEEDLE
U-100 ....................................................................... 102
INTELENCE ................................................. 61
INTRALIPID ................................................ 73
INTRON A ....................................................... 64
introvale ................................................................... 91
INVANZ ............................................................... 18
INVEGA SUSTENNA ................... 57
INVEGA TRINZA ............................... 58
INVIRASE ........................................................ 61
INVOKAMET ............................................. 43
INVOKANA .................................................. 43
IONOSOL-B IN D5W .................. 140
IONOSOL-MB IN D5W ........... 140
IPOL ........................................................................ 127
ipratropium bromide ............ 105, 146
ipratropium-albuterol ........................ 146
IPRIVASK ......................................................... 67
irbesartan ............................................................... 75
irbesartan-hydrochlorothiazide
............................................................................................... 75
IRESSA ................................................................... 27
irinotecan ............................................................... 27
ISENTRESS .................................................... 61
ISOLYTE M IN 5 %
DEXTROSE ................................................ 140
ex
d
In
ISOLYTE-H IN 5 %
DEXTROSE ................................................ 140
ISOLYTE-P IN 5 %
DEXTROSE ................................................ 140
ISOLYTE-S ................................................... 140
isoniazid ................................................................... 52
isosorbide dinitrate ........................ 85, 86
isosorbide mononitrate ........................ 86
isradipine ................................................................ 82
itraconazole ........................................................ 49
ivermectin .............................................................. 54
IXEMPRA ......................................................... 27
IXIARO (PF) .............................................. 127
JAKAFI ................................................................. 27
jantoven .................................................................... 67
JANUMET ........................................................ 43
JANUMET XR .......................................... 43
JANUVIA ........................................................... 43
JARDIANCE ................................................ 43
jencycla ..................................................................... 91
JENTADUETO ......................................... 43
JENTADUETO XR ............................ 43
jinteli ......................................................................... 116
jolessa .......................................................................... 91
jolivette ...................................................................... 91
juleber ......................................................................... 91
junel 1.5/30 (21) .......................................... 91
junel 1/20 (21) ................................................ 91
junel fe 1.5/30 (28) .................................. 91
junel fe 1/20 (28) ........................................ 91
junel fe 24 ............................................................... 91
JUXTAPID ....................................................... 84
KABIVEN .......................................................... 73
KALETRA ........................................................ 61
KALYDECO .............................................. 148
KANUMA ..................................................... 103
kariva (28) .......................................................... 91
KAZANO ............................................................ 43
k-effervescent ................................................ 140
kelnor 1/35 (28) ........................................... 91
ketoconazole ...................................................... 49
ketoprofen ................................................................. 9
ketorolac ........................................... 9, 10, 109
KEVEYIS ........................................................ 134
KEYTRUDA ................................................. 27
ex
d
In
I-8
kimidess (28) ................................................... 91
KINERET ....................................................... 124
KINRIX (PF) ............................................. 127
kionex ...................................................................... 111
klor-con 10 ....................................................... 140
klor-con m10 .................................................. 140
klor-con m15 .................................................. 140
klor-con m20 .................................................. 141
klor-con sprinkle ....................................... 141
KORLYM ........................................................... 43
KRYSTEXXA .......................................... 103
kurvelo ....................................................................... 91
KUVAN ............................................................. 103
KYNAMRO .................................................... 84
KYPROLIS ........................................... 27, 28
l norgest/e.estradiol-e.estrad ....... 91
labetalol ................................................................... 78
LACRISERT .............................................. 105
LACTATED RINGERS ........... 130
lactulose ............................................................... 111
LAMICTAL .................................................... 35
(BLUE) .................................................................... 35
(GREEN) ............................................................. 35
(ORANGE) ....................................................... 35
lamivudine ............................................................. 61
lamivudine-zidovudine .......................... 61
lamotrigine ........................................................... 36
LANOXIN ......................................................... 81
lansoprazole .................................................... 110
LANTUS .............................................................. 46
LANTUS SOLOSTAR .................... 46
larin 1.5/30 (21) .......................................... 91
larin 1/20 (21) ................................................ 91
larin 24 fe ............................................................... 91
larin fe 1.5/30 (28) ................................... 91
larin fe 1/20 (28) ......................................... 91
latanoprost ....................................................... 138
LATUDA ............................................................. 58
LAZANDA ........................................................... 5
leena 28 ..................................................................... 92
leflunomide ....................................................... 124
LEMTRADA ............................................. 134
ex
d
In
LENVIMA ......................................................... 28
lessina .......................................................................... 92
LETAIRIS ...................................................... 149
letrozole .................................................................... 28
leucovorin calcium ................... 134, 135
LEUKERAN .................................................. 28
LEUKINE .......................................................... 68
leuprolide ................................................................ 28
levetiracetam ..................................................... 36
levetiracetam in nacl (iso-os) .... 36
levobunolol ........................................................ 138
levocarnitine ................................................... 135
levocarnitine (with sugar) .......... 135
levocetirizine ...................................................... 50
levofloxacin .......................................... 21, 107
levofloxacin in d5w ................................... 21
levonest (28) ..................................................... 92
levonorgestrel ................................................... 92
levonorgestrel-ethinyl estrad ....... 92
levonorg-eth estrad triphasic ....... 92
levora-28 ................................................................. 92
levothyroxine ................................................. 121
LEXIVA ................................................................. 61
lidocaine ................................................................... 10
lidocaine (pf) ........................................ 10, 77
lidocaine hcl ........................................................ 10
lidocaine in 5 % dextrose (pf)
............................................................................................... 77
lidocaine viscous ........................................... 10
lidocaine-prilocaine .................................. 11
linezolid .................................................................... 14
LINZESS .......................................................... 111
liothyronine ...................................................... 121
lipodox ....................................................................... 28
lipodox 50 .............................................................. 28
lisinopril ................................................................... 76
lisinopril-hydrochlorothiazide .... 76
lithium carbonate ........................................ 87
lithium citrate ................................................... 87
lomedia 24 fe ..................................................... 92
lomustine ................................................................. 28
LONSURF ........................................................ 28
loperamide ........................................................ 111
lorazepam .............................................................. 12
lorazepam intensol ..................................... 12
ex
d
In
lorcet (hydrocodone) ................................ 5
lorcet hd ....................................................................... 5
lorcet plus .................................................................. 5
loryna (28) .......................................................... 92
losartan ..................................................................... 75
losartan-hydrochlorothiazide ...... 75
LOTEMAX ................................................... 109
LOTRONEX ............................................... 111
lovastatin ................................................................ 84
low-ogestrel (28) ........................................ 92
loxapine succinate ...................................... 58
LUMIGAN ................................................... 138
LUPRON DEPOT ................................. 28
............................................................................................... 28
............................................................................................... 28
............................................................................................... 28
LUPRON DEPOT-PED ........... 119
LUPRON DEPOT-PED (3
MONTH) .......................................................... 119
lutera (28) ........................................................... 92
LYNPARZA ................................................... 28
LYRICA ................................................................ 36
LYSODREN ................................................... 28
lyza ................................................................................. 92
magnebind 400 ............................................ 113
magnesium chloride .............................. 141
magnesium sulf in 0.45% nacl
........................................................................................... 141
magnesium sulfate .................................. 141
magnesium sulfate in d5w ............ 141
magnesium sulfate in water ....... 141
malathion ............................................................ 102
maprotiline ........................................................... 41
margesic ...................................................................... 5
marlissa .................................................................... 92
MARPLAN ...................................................... 41
MARQIBO ........................................................ 29
MATULANE ................................................ 29
matzim la ................................................................ 79
meclizine .................................................................. 53
medroxyprogesterone ......... 120, 121
mefenamic acid ............................................... 10
ex
d
In
I-9
mefloquine ............................................................. 54
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................................................... 17
MEGACE ES ............................................. 121
megestrol ................................................. 29, 121
MEKINIST ....................................................... 29
meloxicam ............................................................. 10
melphalan hcl .................................................... 29
memantine ................................................. 38, 39
MENACTRA (PF) ............................ 127
MENEST .......................................................... 117
MENHIBRIX (PF) ............................ 127
MENOMUNE - A/C/Y/W-135
(PF) ............................................................................ 127
MENVEO A-C-Y-W-135-DIP
(PF) ............................................................................ 127
MENVEO MENA
COMPONENT (PF) ........................ 127
MENVEO MENCYW-135
COMPNT (PF) ........................................ 127
mercaptopurine .............................................. 29
meropenem ................................................ 18, 19
mesna ....................................................................... 135
MESNEX ......................................................... 135
MESTINON ................................................ 135
MESTINON TIMESPAN ...... 135
metaproterenol ............................................ 146
metaxall ............................................................... 148
metaxalone ....................................................... 148
metformin ................................................... 43, 44
methadone ................................................................. 5
methadose ................................................................. 5
methazolamide ............................................ 138
methenamine hippurate ....................... 14
methimazole .................................................... 121
methocarbamol ........................................... 148
methotrexate sodium .............................. 29
methotrexate sodium (pf) .............. 29
methoxsalen rapid ...................................... 97
methscopolamine ...................................... 111
methyclothiazide .......................................... 83
methylergonovine .................................... 135
methylphenidate ................................. 87, 88
methylprednisolone ............................... 118
methylprednisolone acetate ....... 118
ex
d
In
ex
d
In
methylprednisolone sodium succ
........................................................................................... 118
metipranolol .................................................... 138
metoclopramide hcl ................ 111, 112
metolazone ........................................................... 83
metoprolol succinate ............................... 78
metoprolol ta-hydrochlorothiaz
............................................................................................... 78
metoprolol tartrate ................................... 78
metronidazole ............................ 14, 50, 98
metronidazole in nacl (iso-os)
............................................................................................... 14
mexiletine .............................................................. 77
MIACALCIN ............................................ 131
miconazole-3 ...................................................... 49
microgestin 1.5/30 (21) ..................... 92
microgestin 1/20 (21) ........................... 92
microgestin fe 1.5/30 (28) .............. 92
microgestin fe 1/20 (28) ................... 92
midazolam ............................................................. 12
midodrine ............................................................... 74
miglitol ...................................................................... 44
milrinone ................................................................. 81
milrinone in 5 % dextrose ................ 81
mimvey ................................................................... 117
mimvey lo ........................................................... 117
minitran .................................................................... 86
MINOCIN .......................................................... 22
minocycline ............................................... 22, 23
minoxidil ................................................................. 86
MIRCERA ........................................................ 68
mirtazapine .......................................................... 41
misoprostol ....................................................... 110
mitoxantrone ..................................................... 29
M-M-R II (PF) ......................................... 127
moexipril ................................................................. 76
moexipril-hydrochlorothiazide
............................................................................................... 76
molindone ............................................................... 58
mometasone .................................................... 101
mono-linyah ........................................................ 92
mononessa (28) ............................................ 92
montelukast ..................................................... 145
morphine .............................................................. 5, 6
MORPHINE ....................................................... 6
morphine (pf) in 0.9 % nacl ............. 5
morphine concentrate ................................ 5
morphine in dextrose 5 % .................... 6
morrhuate sodium ................................... 135
MOVANTIK .............................................. 112
MOVIPREP .................................................. 112
MOXEZA ........................................................ 107
moxifloxacin ...................................................... 21
MOZOBIL .......................................................... 68
MULTAQ ........................................................... 77
multivitamin with fluoride ........... 150
mupirocin ............................................................... 98
mupirocin calcium ...................................... 98
mycophenolate mofetil ..................... 124
mycophenolate sodium ..................... 124
MYOBLOC ................................................... 135
MYOZYME ................................................. 103
MYRBETRIQ ........................................... 114
myzilra ....................................................................... 93
nabumetone ......................................................... 10
nadolol ....................................................................... 78
nafcillin ..................................................................... 20
NAGLAZYME ....................................... 103
naloxone .................................................................. 11
naltrexone ............................................................. 11
NAMENDA XR ....................................... 39
NAMZARIC .................................................. 39
naphazoline ...................................................... 105
naproxen ................................................................. 10
naproxen sodium .......................................... 10
naratriptan ........................................................... 51
NARCAN ........................................................... 11
NATACYN ................................................... 107
nateglinide ............................................................. 44
NATPARA .................................................... 131
NEBUPENT .................................................... 54
necon 0.5/35 (28) ....................................... 93
necon 1/35 (28) ............................................. 93
necon 1/50 (28) ............................................. 93
necon 10/11 (28) ......................................... 93
necon 7/7/7 (28) ........................................... 93
nefazodone ............................................................ 41
neomycin ................................................................. 13
neomycin-bacitracin-poly-hc ... 107
ex
d
In
I-10
ex
d
In
neomycin-bacitracin-polymyxin
........................................................................................... 107
neomycin-polymyxin b gu ................ 98
........................................................................................... 107
neomycin-polymyxin-gramicidin
........................................................................................... 107
neomycin-polymyxin-hc ................. 107
neo-polycin ....................................................... 107
neo-polycin hc .............................................. 107
NEPHRAMINE 5.4 % ..................... 73
NESINA ................................................................ 44
neuac ............................................................................ 98
NEULASTA .................................................... 68
NEUMEGA ..................................................... 68
NEUPOGEN .................................................. 68
NEUPRO ............................................................. 55
NEVANAC ................................................... 109
nevirapine ............................................................... 61
NEXAVAR ....................................................... 29
next choice one dose ................................ 93
niacin ............................................................................ 84
niacor ........................................................................... 84
nicardipine ............................................................ 82
NICOTROL ..................................................... 11
nifedical xl ............................................................ 82
nifedipine ................................................................ 82
nikki (28) .............................................................. 93
NILANDRON ............................................. 29
nilutamide .............................................................. 29
NINLARO ......................................................... 29
NITRO-BID .................................................... 86
nitrofurantoin ................................................... 15
nitrofurantoin macrocrystal ......... 14
nitrofurantoin monohyd/m-cryst
............................................................................................... 15
nitroglycerin ....................................................... 86
nitroglycerin in 5 % dextrose ...... 86
NITROSTAT ................................................. 86
nizatidine ............................................................. 110
nora-be ....................................................................... 93
NORDITROPIN FLEXPRO
........................................................................................... 119
norepinephrine bitartrate ................. 81
ex
d
In
norethindrone (contraceptive)
93
norethindrone acetate ........................ 121
norethindrone ac-eth estradiol
................................................................................ 93, 117
norethindrone-e.estradiol-iron ... 93
norgestimate-ethinyl estradiol ... 93
norlyroc .................................................................... 93
NORMOSOL-M IN 5 %
DEXTROSE ................................................ 141
NORMOSOL-R PH 7.4 ............. 141
NORTHERA ................................................. 74
nortrel 0.5/35 (28) .................................... 93
nortrel 1/35 (21) .......................................... 93
nortrel 1/35 (28) .......................................... 93
nortrel 7/7/7 (28) ....................................... 93
nortriptyline ........................................................ 41
NORVIR ............................................................... 61
NOVOLIN 70/30 ....................................... 46
NOVOLIN N ................................................. 46
NOVOLIN R .................................................. 46
NOVOLOG ...................................................... 47
NOVOLOG FLEXPEN ................. 46
NOVOLOG MIX 70-30 .................. 46
NOVOLOG MIX 70-30
FLEXPEN .......................................................... 46
NOVOLOG PENFILL .................... 47
NOXAFIL .......................................................... 49
NPLATE ........................................................... 135
NUCALA ........................................................ 148
NUCYNTA .......................................................... 6
NUCYNTA ER ............................................. 6
NUEDEXTA .................................................. 88
NULOJIX ........................................................ 124
NUPLAZID ..................................................... 58
NUTRESTORE ..................................... 112
NUTRILIPID ............................................... 73
NUTRILYTE ............................................ 141
NUTRILYTE II ..................................... 141
NUVARING .................................................. 93
NUVIGIL ........................................................ 149
nyamyc ...................................................................... 49
nystatin ..................................................................... 49
nystatin-triamcinolone ......................... 49
nystop .......................................................................... 49
...............................................................................................
OCALIVA ....................................................... 112
ocella ............................................................................ 93
OCTAGAM .................................................. 124
octreotide acetate .................................... 119
ODEFSEY .......................................................... 61
ODOMZO ........................................................... 29
OFEV ..................................................................... 148
ofloxacin .................................................. 21, 107
ogestrel (28) ..................................................... 94
olanzapine ............................................................. 58
olanzapine-fluoxetine ............................ 41
olopatadine ....................................................... 105
OLYSIO ................................................................. 64
omega-3 acid ethyl esters ................. 84
omeprazole ....................................................... 110
ONCASPAR ................................................... 29
ondansetron ......................................................... 53
ondansetron hcl .............................................. 53
ondansetron hcl (pf) ............................... 53
ONFI ........................................................... 13, 101
onxol ............................................................................. 29
OPDIVO ................................................................ 29
OPSUMIT ....................................................... 149
oralone ....................................................................... 95
ORENCIA ...................................................... 124
ORENCIA (WITH MALTOSE)
........................................................................................... 124
ORENCIA CLICKJECT ......... 135
ORENITRAM ......................................... 149
ORFADIN ...................................... 103, 135
ORKAMBI .................................................... 148
orsythia ..................................................................... 94
OSENI ...................................................................... 44
OTEZLA ........................................................... 135
OTEZLA STARTER ..................... 135
OTREXUP (PF) ..................................... 136
oxacillin .................................................................... 20
oxacillin in dextrose(iso-osm)
............................................................................................... 20
oxaliplatin ............................................................. 29
oxandrolone .................................................... 115
oxcarbazepine .................................................. 36
OXTELLAR XR ...................................... 36
oxybutynin chloride .............................. 114
oxycodone ......................................................... 6, 7
ex
d
In
I-11
oxycodone-acetaminophen ................. 7
oxycodone-aspirin .......................................... 7
OXYCONTIN .................................................. 7
oxymorphone ........................................................ 7
pacerone ................................................................... 77
paclitaxel ................................................................ 30
paliperidone ........................................................ 58
pamidronate .................................................... 132
pancrelipase 5000 .................................... 104
PANRETIN ..................................................... 97
pantoprazole ................................................... 110
papaverine ............................................................. 81
paricalcitol ........................................................ 132
paromomycin .................................................... 54
paroxetine hcl ................................................... 41
PASER ..................................................................... 52
PATADAY .................................................... 105
PAXIL ...................................................................... 41
PEDIARIX (PF) .................................... 128
PEDVAX HIB (PF) .......................... 128
peg 3350-electrolytes .......................... 113
PEGANONE .................................................. 37
PEGASYS ........................................................... 64
PEGASYS PROCLICK ................. 64
peg-electrolyte soln ............................... 113
PEGINTRON ............................................... 65
PEN NEEDLE, DIABETIC
........................................................................................... 103
penicillin g pot in dextrose .............. 20
penicillin g potassium ............................ 20
penicillin g procaine ................................. 20
penicillin v potassium ............................. 20
PENTACEL (PF) ................................. 128
PENTACEL ACTHIB
COMPONENT (PF) ........................ 128
PENTAM ............................................................. 54
pentoxifylline .................................................... 69
PERIKABIVEN ........................................ 73
perindopril erbumine ............................... 76
periogard ................................................................. 96
PERJETA ............................................................ 30
permethrin ......................................................... 102
perphenazine ...................................................... 58
perphenazine-amitriptyline ............ 41
PERTZYE ....................................................... 104
ex
d
In
pfizerpen-g ............................................................ 20
phenadoz ................................................................. 53
phenelzine .............................................................. 41
phenobarbital .................................................... 37
phenobarbital sodium ............................ 37
phenylephrine hcl .......................... 74, 105
phenytoin ................................................................ 37
phenytoin sodium ......................................... 37
phenytoin sodium extended ........... 37
philith .......................................................................... 94
PHOSLYRA ................................................ 113
phospha 250 neutral ............................. 141
PHOSPHOLINE IODIDE ..... 138
PICATO ................................................................. 97
pilocarpine hcl .................................. 96, 139
pimozide ................................................................... 58
pimtrea (28) ...................................................... 94
pindolol ..................................................................... 78
pioglitazone ......................................................... 44
pioglitazone-glimepiride .................... 44
pioglitazone-metformin ....................... 44
piperacillin-tazobactam ...................... 21
pirmella ..................................................................... 94
piroxicam ............................................................... 10
PLASMA-LYTE 148 ...................... 141
PLASMA-LYTE A ............................ 141
PLASMA-LYTE-56 IN 5 %
DEXTROSE ................................................ 142
PLEGRIDY .................................................. 136
podocon ..................................................................... 97
podofilox ................................................................. 97
polyethylene glycol 3350 ............... 113
polymyxin b sulfate .................................. 15
polymyxin b sulf-trimethoprim
........................................................................................... 107
POMALYST ................................................... 30
portia ............................................................................ 94
PORTRAZZA .............................................. 30
potassium acetate .................................... 142
potassium bicarb and chloride
........................................................................................... 142
potassium bicarb-citric acid ...... 142
potassium chlorid-d5-0.45%nacl
........................................................................................... 142
potassium chloride .................. 142, 143
ex
d
In
ex
d
In
potassium chloride in 0.9%nacl
........................................................................................... 142
potassium chloride in 5 % dex
........................................................................................... 142
potassium chloride in lr-d5 ......... 142
potassium chloride-0.45 % nacl
........................................................................................... 143
........................................................................................... 143
........................................................................................... 143
........................................................................................... 143
potassium citrate ...................................... 143
potassium citrate-citric acid ..... 143
potassium hydroxide ............................... 97
potassium phosphate m-/d-basic
........................................................................................... 143
POTIGA ................................................................ 37
PRADAXA ....................................................... 67
PRALUENT PEN .................................. 84
PRALUENT SYRINGE .............. 84
pramipexole ........................................................ 55
pravastatin ............................................................ 84
prazosin .................................................................... 74
prednicarbate ................................................ 101
prednisolone acetate ............................ 109
prednisolone sodium phosphate
............................................................................ 109, 118
prednisone .......................................................... 118
PREDNISONE INTENSOL
........................................................................................... 118
PREMARIN ................................................ 117
PREMASOL 10 % .................................. 73
PREMASOL 6 % ...................................... 73
PREMPHASE ........................................... 117
PREMPRO .................................................... 117
prenatal plus (calcium carb) ... 150
prenatal vitamin plus low iron
........................................................................................... 150
PREPOPIK .................................................... 113
prevalite .................................................................... 84
previfem .................................................................... 94
PREZCOBIX ................................................. 62
PREZISTA ........................................................ 62
I-12
PRIFTIN .............................................................. 52
PRIMAQUINE .......................................... 54
primidone ............................................................... 37
PRISTIQ ............................................................... 41
PRIVIGEN .................................................... 124
PROAIR HFA .......................................... 146
PROAIR RESPICLICK ............ 146
probenecid ......................................................... 136
procainamide ..................................................... 77
PROCALAMINE 3% ........................ 73
prochlorperazine ........................................... 53
prochlorperazine edisylate .............. 53
prochlorperazine maleate ................. 53
PROCRIT ........................................................... 68
procto-med hc ............................................... 101
procto-pak ......................................................... 101
proctosol hc ..................................................... 101
proctozone-hc ............................................... 101
PROCYSBI .................................................... 136
progesterone in oil .................................. 121
progesterone micronized ................ 121
PROGLYCEM ............................................ 86
PROGRAF .................................................... 124
PROLASTIN-C ...................................... 148
PROLENSA ................................................. 109
PROLEUKIN ............................................... 30
PROLIA ............................................................. 132
PROMACTA ................................................. 68
promethazine .......................................... 50, 53
promethegan ...................................................... 53
propafenone ........................................................ 77
propantheline .................................................... 33
proparacaine .................................................. 105
propranolol .......................................................... 78
propranolol-hydrochlorothiazid
............................................................................................... 78
propylthiouracil ......................................... 121
PROQUAD (PF) ................................... 128
PROSOL 20 % .............................................. 73
protamine ............................................................... 69
protriptyline ........................................................ 41
PULMOZYME ....................................... 104
PURIXAN ......................................................... 30
pyrazinamide ..................................................... 52
pyridostigmine bromide .................. 136
ex
d
In
QUADRACEL (PF) ........................ 128
quasense ................................................................... 94
quetiapine ............................................................... 58
QUILLIVANT XR ............................... 88
quinapril ................................................................... 76
quinapril-hydrochlorothiazide ... 76
quinidine gluconate ................................... 77
quinidine sulfate ............................................ 77
quinine sulfate .................................................. 54
QVAR .................................................................... 145
RABAVERT (PF) ............................... 128
raloxifene ........................................................... 117
ramipril ..................................................................... 76
RANEXA ............................................................ 81
ranitidine hcl .................................................. 110
RAPAMUNE ............................................ 124
RASUVO (PF) .......................................... 136
RAVICTI .......................................................... 112
REBIF (WITH ALBUMIN)
........................................................................................... 136
REBIF REBIDOSE .......................... 136
REBIF TITRATION PACK
........................................................................................... 136
reclipsen (28) ................................................... 94
RECOMBIVAX HB (PF) ........ 128
REGRANEX ................................................. 97
RELENZA DISKHALER ......... 63
RELISTOR ................................................... 112
REMICADE ............................................... 137
REMODULIN ......................................... 150
RENAGEL .................................................... 113
RENVELA ..................................................... 113
repaglinide ............................................................ 44
repaglinide-metformin .......................... 44
REPATHA PUSHTRONEX
............................................................................................... 84
REPATHA SURECLICK ......... 85
REPATHA SYRINGE ................... 85
reprexain .................................................................... 7
RESCRIPTOR ............................................. 62
RESTASIS ...................................................... 109
RETROVIR ..................................................... 62
REVLIMID ...................................................... 30
revonto ................................................................... 148
REXULTI ........................................................... 58
ex
d
In
REYATAZ ........................................................ 62
ribasphere .............................................................. 65
ribasphere ribapak ..................................... 65
ribavirin .................................................................... 65
RIDAURA .................................................... 124
rifabutin ................................................................... 52
rifampin .................................................................... 52
RIFATER ........................................................... 52
riluzole ....................................................................... 88
rimantadine ......................................................... 63
ringers ...................................................... 130, 143
risedronate ........................................................ 132
RISPERDAL CONSTA ................ 59
risperidone ............................................................ 59
RITUXAN ......................................................... 30
rivastigmine ......................................................... 39
rivastigmine tartrate ............................... 39
rizatriptan ............................................................. 51
ropinirole ................................................................ 55
rosadan ...................................................................... 98
rosuvastatin ......................................................... 85
ROTARIX ...................................................... 128
ROTATEQ VACCINE ............... 128
roxicet ............................................................................ 7
ROZEREM ................................................... 149
SABRIL .................................................................. 37
SAIZEN .............................................................. 120
SAIZEN CLICK.EASY ............. 120
SANDOSTATIN LAR DEPOT
........................................................................................... 120
SANTYL ............................................................... 97
SAPHRIS (BLACK CHERRY)
............................................................................................... 59
SAVAYSA .......................................................... 67
SAVELLA .......................................................... 88
selegiline hcl ....................................................... 55
selenium sulfide .............................................. 98
SELZENTRY ................................................ 62
SENSIPAR .................................................... 137
SEREVENT DISKUS .................. 146
SEROQUEL XR ....................................... 59
SEROSTIM ................................................... 120
sertraline ................................................................. 42
setlakin ...................................................................... 94
sharobel .................................................................... 94
ex
d
In
I-13
SIGNIFOR .................................................... 137
sildenafil ............................................................... 150
SILENOR ............................................................ 42
silver nitrate ........................................................ 98
silver sulfadiazine ........................................ 98
SIMBRINZA .............................................. 139
SIMPONI ......................................................... 137
SIMPONI ARIA ................................... 137
simvastatin ........................................................... 85
sirolimus ............................................................... 124
SIRTURO ........................................................... 52
sodium acetate ............................................. 143
sodium bicarbonate ............................... 143
sodium chloride ........................... 130, 144
sodium chloride 0.45 % .................... 143
sodium chloride 0.9 % ....................... 143
sodium chloride 3 % ............................. 144
sodium chloride 5 % ............................. 144
sodium fluoride ................................ 96, 150
sodium lactate .............................................. 144
sodium phosphate .................................... 144
sodium polystyrene (sorb free)
........................................................................................... 112
sodium polystyrene sulfonate
........................................................................................... 112
sodium thiosulfate ................................... 115
SOLTAMOX .................................................. 30
SOLU-CORTEF (PF) ................... 118
SOMATULINE DEPOT .......... 120
SOMAVERT ............................................... 120
sorbitol ................................................................... 130
sorbitol-mannitol ...................................... 130
sorine ............................................................................ 78
sotalol .......................................................................... 78
sotalol af .................................................................. 78
SOVALDI ........................................................... 64
spinosad ................................................................ 102
SPIRIVA RESPIMAT .................. 146
SPIRIVA WITH
HANDIHALER .................................... 146
spironolactone ................................................. 85
spironolacton-hydrochlorothiaz
............................................................................................... 85
SPORANOX ................................................... 50
sprintec (28) ..................................................... 94
ex
d
In
SPRITAM ........................................................... 37
SPRYCEL ........................................................... 30
sps ................................................................................. 112
sronyx ......................................................................... 94
ssd ..................................................................................... 98
stavudine ................................................................. 62
STELARA ...................................................... 137
STERILE PADS .................................... 137
STIMATE ........................................................ 120
STIOLTO RESPIMAT ................... 34
STIVARGA ...................................................... 30
STRATTERA ............................................... 88
STRENSIQ .................................................... 104
streptomycin ...................................................... 13
STRIBILD .......................................................... 62
STRIVERDI RESPIMAT ...... 147
sucralfate ............................................................ 110
sulfacetamide sodium ......................... 108
sulfacetamide sodium (acne) ..... 98
sulfacetamide-prednisolone ........ 108
sulfadiazine .......................................................... 21
sulfamethoxazole-trimethoprim
............................................................................................... 21
sulfasalazine ....................................................... 22
sulfatrim .................................................................. 22
sulindac ..................................................................... 10
sumatriptan ......................................................... 51
sumatriptan succinate ........................... 51
SUPPRELIN LA .................................. 120
SUPRAX .............................................................. 17
SURMONTIL .............................................. 42
SUSTIVA ............................................................. 62
SUTENT ............................................................... 30
syeda ............................................................................. 94
SYLATRON ................................................... 65
SYLVANT ......................................................... 30
SYMLINPEN 120 ................................... 44
SYMLINPEN 60 ...................................... 44
SYNAGIS ........................................................... 63
SYNAREL ..................................................... 137
SYNERCID ..................................................... 15
SYNJARDY .................................................... 44
SYNRIBO ........................................................... 30
SYPRINE ........................................................ 115
TABLOID ........................................................... 30
ex
d
In
tacrolimus ........................................... 101, 124
TAFINLAR ..................................................... 30
TAGRISSO ....................................................... 31
TALTZ AUTOINJECTOR ...... 97
TALTZ SYRINGE ............................... 97
TAMIFLU ......................................................... 63
tamoxifen ............................................................... 31
tamsulosin .......................................................... 114
TARCEVA ........................................................ 31
TARGRETIN ............................................... 31
tarina fe 1/20 (28) .................................... 94
TASIGNA ........................................................... 31
tazicef .......................................................................... 17
TAZORAC .................................................... 102
taztia xt .................................................................... 79
TECENTRIQ ................................................. 31
TECFIDERA ............................................. 137
TECHNIVIE ................................................... 64
TEFLARO ......................................................... 17
TEGRETOL XR ....................................... 37
telmisartan ........................................................... 75
telmisartan-hydrochlorothiazid
............................................................................................... 75
temazepam ........................................................... 13
TEMODAR ...................................................... 31
tencon .............................................................................. 7
teniposide ............................................................... 31
TENIVAC (PF) ....................................... 128
terazosin ............................................................... 114
terbinafine hcl .................................................. 50
terbutaline ......................................................... 147
terconazole ........................................................... 50
testosterone ...................................................... 116
testosterone cypionate ...................... 115
testosterone enanthate ...................... 115
TETANUS
TOXOID,ADSORBED (PF)
........................................................................................... 129
TETANUS,DIPHTHERIA
TOX PED(PF) .......................................... 129
tetanus-diphtheria toxoids-td
........................................................................................... 129
tetrabenazine ..................................................... 88
tetracaine hcl (pf) .................................. 105
tetracycline .......................................................... 23
ex
d
In
I-14
TEVETEN HCT ........................................ 75
THALOMID ............................................... 137
theochron ............................................................ 147
theophylline ..................................................... 147
theophylline in dextrose 5 % .... 147
thioridazine .......................................................... 59
thiotepa ..................................................................... 31
thiothixene ............................................................ 59
tiagabine .................................................................. 37
TICE BCG ...................................................... 125
TIKOSYN ........................................................... 77
tilia fe .......................................................................... 94
timolol maleate ................................ 78, 139
tinidazole ................................................................ 54
TIVICAY ............................................................. 62
tizanidine ............................................................. 148
TOBI PODHALER .............................. 13
TOBRADEX ............................................... 108
TOBRADEX ST .................................... 108
tobramycin ........................................................ 108
tobramycin in 0.225 % nacl ........... 13
tobramycin in 0.9 % nacl .................. 13
tobramycin sulfate ..................................... 13
tobramycin-dexamethasone ...... 108
TOLAK ................................................................... 97
tolazamide ............................................................. 47
tolbutamide .......................................................... 47
tolmetin ..................................................................... 10
tolterodine ......................................................... 114
topiragen ................................................................. 37
topiramate ............................................................ 38
toposar ....................................................................... 31
topotecan ................................................................ 31
TORISEL ............................................................. 31
torsemide ................................................................ 83
TOUJEO SOLOSTAR ..................... 47
TOVIAZ ............................................................. 114
TPN ELECTROLYTES ............ 144
TPN ELECTROLYTES II .... 144
TRACLEER ................................................ 150
TRADJENTA ............................................... 44
tramadol ...................................................................... 7
tramadol-acetaminophen ...................... 7
trandolapril .......................................................... 76
tranexamic acid ............................................. 69
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TRANSDERM-SCOP ..................... 53
tranylcypromine ............................................ 42
TRAVASOL 10 % ................................... 73
TRAVATAN Z ....................................... 139
travoprost (benzalkonium) ....... 139
trazodone ................................................................ 42
TREANDA ....................................................... 31
TRECATOR ................................................... 52
TRELSTAR .......................................... 31, 32
tretinoin ................................................................ 102
tretinoin (chemotherapy) ................ 32
tretinoin microspheres ...................... 102
TREXALL ......................................................... 32
triamcinolone acetonide
.................................................. 96, 101, 109, 118
triamterene-hydrochlorothiazid
............................................................................................... 83
trianex .................................................................... 101
triazolam ................................................................. 13
TRIBENZOR ................................................ 75
tri-estarylla .......................................................... 94
trifluoperazine ................................................. 59
trifluridine ......................................................... 108
trihexyphenidyl .............................................. 55
tri-legest fe ........................................................... 94
tri-linyah ................................................................. 94
tri-lo-estarylla .................................................. 94
tri-lo-marzia ....................................................... 94
tri-lo-sprintec .................................................... 94
trilyte with flavor packets ............ 113
trimethoprim ...................................................... 15
trimipramine ...................................................... 42
trinessa (28) ...................................................... 95
TRINTELLIX .............................................. 42
tri-previfem (28) ......................................... 95
tri-sprintec (28) ............................................ 95
TRIUMEQ ........................................................ 62
trivora (28) ......................................................... 95
TROKENDI XR ...................................... 38
TROPHAMINE 10 % ....................... 73
TROPHAMINE 6% ............................. 73
trospium ............................................................... 114
TRULICITY ................................................... 45
TRUMENBA ............................................. 129
TRUVADA ...................................................... 62
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TUDORZA PRESSAIR ............ 147
TWINRIX (PF) ....................................... 129
TYBOST ............................................................ 137
TYGACIL .......................................................... 23
TYKERB .............................................................. 32
TYPHIM VI ................................................. 129
TYSABRI ........................................................ 125
TYVASO ........................................................... 150
TYVASO REFILL KIT ............. 150
TYVASO STARTER KIT ..... 150
TYZEKA .............................................................. 65
TYZINE .............................................. 105, 106
u-cort ........................................................................ 101
ULORIC ............................................................ 137
UNITUXIN ..................................................... 32
UPTRAVI ....................................................... 150
ursodiol .................................................................. 112
VAGIFEM ..................................................... 117
valacyclovir ......................................................... 65
VALCHLOR .................................................. 97
VALCYTE ......................................................... 65
valganciclovir .................................................... 65
valproate sodium .......................................... 38
valproic acid ....................................................... 38
valproic acid (as sodium salt) ... 38
valsartan .................................................................. 75
valsartan-hydrochlorothiazide ... 75
VALSTAR .......................................................... 32
vancomycin .......................................................... 15
vancomycin in dextrose 5 % ......... 15
VAQTA (PF) ............................................... 129
VARIVAX (PF) ...................................... 129
VASCEPA .......................................................... 85
VECTIBIX ......................................................... 32
VELCADE ......................................................... 32
velivet triphasic regimen (28) ... 95
VELPHORO ............................................... 112
VENCLEXTA .............................................. 32
VENCLEXTA STARTING
PACK ........................................................................ 32
venlafaxine ........................................................... 42
VENTOLIN HFA ............................... 147
verapamil ................................................................ 79
VEREGEN ........................................................ 97
VERSACLOZ ............................................... 59
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VESICARE ................................................... 114
vestura (28) ....................................................... 95
VGO 40 ................................................................ 103
VIBERZI ........................................................... 112
vicodin ............................................................................ 8
vicodin es .................................................................... 8
vicodin hp ................................................................... 8
VICTOZA ........................................................... 45
VIDEX 2 GRAM PEDIATRIC
............................................................................................... 63
VIDEX 4 GRAM PEDIATRIC
............................................................................................... 63
VIEKIRA PAK .......................................... 64
vienva ........................................................................... 95
VIGAMOX .................................................... 108
VIIBRYD ............................................................. 42
VIMIZIM ......................................................... 104
VIMPAT ............................................................... 38
vinblastine ............................................................. 32
vincasar pfs .......................................................... 32
vincristine ............................................................... 32
vinorelbine ............................................................. 32
viorele (28) ......................................................... 95
VIRACEPT ....................................................... 63
VIRAMUNE XR ..................................... 63
VIRAZOLE ...................................................... 65
VIREAD ............................................................... 63
virt-phos 250 neutral ........................... 144
VITAFOL FE+ (WITH
DOCUSATE) ............................................. 151
VITEKTA ........................................................... 63
VOLTAREN ................................................... 10
voriconazole ........................................................ 50
VOTRIENT ...................................................... 33
VPRIV ................................................................... 104
VRAYLAR ....................................................... 59
vyfemla (28) ..................................................... 95
VYTORIN 10-10 ....................................... 85
VYTORIN 10-20 ....................................... 85
VYTORIN 10-40 ....................................... 85
VYTORIN 10-80 ....................................... 85
warfarin .................................................................... 67
water for irrigation, sterile ......... 131
WELCHOL ....................................................... 85
wera (28) ............................................................... 95
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wymzya fe ............................................................. 95
XALKORI ......................................................... 33
XARELTO ........................................................ 67
XARTEMIS XR ........................................... 8
XELJANZ ....................................................... 137
XELJANZ XR .......................................... 138
XGEVA ............................................................... 132
XIFAXAN ......................................................... 15
XOLAIR ............................................................ 148
XTANDI ............................................................... 33
xulane .......................................................................... 95
xylon 10 ....................................................................... 8
XYREM ............................................................. 149
YERVOY ............................................................. 33
YF-VAX (PF) ............................................ 129
YONDELIS ...................................................... 33
zafirlukast ......................................................... 145
zaleplon ................................................................. 149
ZALTRAP .......................................................... 33
zarah ............................................................................. 95
ZARXIO ............................................................... 68
ZAVESCA ...................................................... 104
zebutal ............................................................................ 8
ZELBORAF .................................................... 33
ZEMPLAR .................................................... 132
zenatane ................................................................... 97
zenchent (28) ................................................... 95
zenchent fe ............................................................ 95
ZENPEP ............................................................ 104
zeosa ............................................................................. 95
ZEPATIER ........................................................ 64
ZETIA ....................................................................... 85
ZIAGEN ............................................................... 63
zidovudine .............................................................. 63
ZINBRYTA ................................................. 138
ZIOPTAN (PF) ....................................... 139
ziprasidone hcl ................................................. 59
ZIRGAN ........................................................... 108
ZOHYDRO ER ............................................. 8
ZOLADEX ........................................................ 33
zoledronic acid ............................................ 132
........................................................................................... 132
ZOLINZA ........................................................... 33
zolmitriptan ........................................................ 51
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zolpidem ............................................................... 149
ZOMETA ......................................................... 132
zonisamide ............................................................ 38
ZORTRESS .................................................. 125
ZOSTAVAX (PF) ................................ 130
zovia 1/35e (28) ........................................... 95
zovia 1/50e (28) ........................................... 95
ZOVIRAX .......................................................... 97
ZUBSOLV .......................................................... 11
ZYDELIG .......................................................... 33
ZYKADIA ......................................................... 33
ZYLET ................................................................. 108
ZYPREXA RELPREVV ... 59, 60
ZYTIGA ................................................................ 33
ZYVOX ................................................................... 15
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Este formulario se actualizó el 25/08/2016. Para obtener información más reciente u otras
preguntas, por favor póngase en contacto con Sharp Advantage Servicios de Miembros al
1-855-820-2112. El horario es de 8:00 de la mañana a 6:00, hora del Pacifico, de lunes a viernes.
Para los usuarios de TTY llame a 711, o visite www.sharphealthplan.com/sharpadvantage.
Sharp Advantage es ofrecido por Sharp Health Plan. Sharp Advantage es un HMO plan con un
contracto con Medicare. La inscripción en Sharp Advantage depende de la renovación del contrato.
This information is available for free in other languages. Please call our Customer Care number at
1-855-820-2112 for additional information. (TTY users should call 711.) Hours are 8:00 a.m. to
6:00 p.m., Monday to Friday. Customer Care also has free language interpreter services available
for non-English speakers. Please contact Sharp Advantage if you need information in another
format.
Esta información puede obtenerse sin cargo en otros idiomas. Si desea más información, llame a
nuestro servicio de atención a los miembros al 1-855-820-2112. (Los usuarios de TTY deben
llamar al 711.) El horario es de 8:00 de la mañana a 6:00 de la tarde de lunes a viernes. Alguien
que hable español le podrá ayudar. Este es un servicio gratuito. Por favor, póngase en contacto con
Sharp Advantage si usted necesita información en otro forma.
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Usted recibirá aviso cuando sea necesario.

Sharp Advantage - Sharp Health Plan

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