True Blue Rx (HMO) True Blue Rx Gem (HMO) True Blue Rx ... · • Nuevos medicamentos genéricos....

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Vademécum farmacológico estándar para 2020

(Lista de medicamentos cubiertos)

LEA ESTO: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

IDENTIFICACIÓN DEL VADEMÉCUM FARMACOLÓGICO: 00020347 V12

Este vademécum farmacológico fue actualizado el 01/MAYO/2020. Para obtener la información más reciente o para formular preguntas, comuníquese con Blue Cross of Idaho Care Plus, Inc. al 1-855-479-3661 o, para los usuarios de TTY, al 711, todos los días de la semana, durante las 24 horas, o visite bcidaho.com/DrugList.

Blue Cross of Idaho Care Plus, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivo de raza, color, origen nacional, edad, discapacidad o sexo. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-494-2583

(TTY: 1-800-377-1363).注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1 888-494-2583 (TTY: 1-800-377-1363)。

H1350_OP20015S_C Alternate Format

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http://bcidaho.com/DrugList

Nota a los afiliados actuales: Este vademécum farmacológico ha cambiado desde el año pasado. Revise este documento para asegurarse de que aún contenga los medicamentos que usted toma.

Cuando esta lista de medicamentos (vademécum farmacológico) se refiere a "nosotros" o "nuestro", significa Blue Cross of Idaho Care Plus, Inc. Cuando menciona “plan” o “nuestro plan”, hace referencia al Plan True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred o True Blue Rx St. Luke’s Health Partners.

Este documento incluye una lista de los medicamentos (vademécum farmacológico) para nuestro plan que} estará vigente a partir de mayo de 2020. Para obtener un vademécum farmacológico actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum farmacológico, aparece en las páginas de tapa y contratapa.

Por lo general, debe usar las farmacias de la red para utilizar su beneficio de medicamentos recetados. Los beneficios, el vademécum, la red de farmacias y/o los copagos/el coseguro pueden cambiar el 1° de enero de 2021 y periódicamente durante el año.

¿Qué es el vademécum farmacológico de True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred y el Vademécum farmacológico de True Blue Rx St. Luke’s Health Partners?

Un vademécum farmacológico es una lista de medicamentos cubiertos seleccionados por nuestro plan en consulta con un equipo de proveedores de atención médica, que representa las terapias de prescripción de medicamentos que se consideran una parte necesaria de un programa de tratamiento de calidad. En general, cubriremos los medicamentos enumerados en nuestro vademécum farmacológico, siempre y cuando el medicamento sea médicamente necesario, la receta sea suministrada en una farmacia de la red de True Blue Rx, True Blue Rx Preferred y True Blue Rx St. Luke’s Health Partners y se respeten otras reglas del plan. Para obtener más información sobre cómo adquirir sus recetas médicas, revise su Evidencia de Cobertura.

¿Puede cambiar el vademécum farmacológico (la lista de medicamentos)?

La mayoría de los cambios en la cobertura de medicamentos ocurren el 1 de enero, pero podemos agregar o eliminar medicamentos de la Lista de medicamentos durante el año, moverlos a diferentes categorías de costo compartido o agregar nuevas restricciones. Debemos seguir las reglas de Medicare para realizar estos cambios.

Cambios que pueden afectarlo este año: en los siguientes casos, el cambio de cobertura le afectará durante el año:

• Nuevos medicamentos genéricos. Podremos quitar un medicamento de marca de inmediato de nuestra Lista de medicamentos si lo reemplazamos por un medicamento genérico con una categoría de costo compartido igual o inferior y con restricciones iguales o inferiores. Además, al agregar el nuevo medicamento genérico, es posible que

decidamos mantener el medicamento de marca en nuestra Lista de medicamentos, pero lo cambiaremos inmediatamente a una categoría de costo compartido diferente o agregaremos nuevas restricciones. Si usted actualmente está tomando dicho medicamento de marca, puede que no le notifiquemos con anticipación antes de realizar el cambio, pero luego le proporcionaremos información sobre los cambios específicos que realizamos. o Si hacemos dicho cambio, usted y el

médico que le receta el medicamento pueden solicitarnos que hagamos una excepción y continuemos cubriéndole el medicamento de marca. La notificación que le enviaremos también incluirá información sobre cómo solicitar una excepción, y usted también puede encontrar información en la sección a continuación titulada “¿Cómo solicito una excepción al vademécum farmacológico de True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred y True Blue Rx St. Luke’s Health Partners?”

• Medicamentos eliminados del mercado. Si la Administración de Medicamentos y Alimentos (FDA) considera que un medicamento de nuestro vademécum farmacológico no es seguro o si el fabricante del medicamento saca el medicamento del mercado, eliminaremos de inmediato el medicamento de nuestro vademécum e informaremos a los afiliados que lo toman.

• Otros cambios. Podremos hacer otros cambios que afectan a los afiliados que actualmente toman un medicamento. Por ejemplo, podremos agregar un medicamento genérico que no sea nuevo en el mercado a fin de reemplazar un medicamento de marca que actualmente está en el vademécum farmacológico o agregar nuevas restricciones al medicamento de marca o moverlo a una categoría de costo compartido distinto. O podremos hacer cambios en base a nuevos

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lineamientos clínicos. Si eliminamos medicamentos de nuestro vademécum farmacológico, agregamos autorización previa, límites de cantidad o restricciones de terapia escalonada para un medicamento, o movemos un medicamento a una categoría de costo compartido mayor, informaremos a los afiliados afectados sobre el cambio al menos 30 días antes de que el cambio entre en vigencia, o en el momento en que el afiliado vuelva a adquirir su medicamento recetado, en cuyo caso el afiliado recibirá un suministro de 30 días del medicamento. o Si hacemos estos otros cambios, usted y el

médico que le receta el medicamento pueden solicitarnos que hagamos una excepción y continuemos cubriéndole el medicamento de marca. La notificación que le enviaremos también incluirá información sobre cómo solicitar una excepción, y usted también puede encontrar información en la sección a continuación titulada “¿Cómo solicito una excepción al vademécum farmacológico de True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred y True Blue Rx St. Luke’s Health Partners?”

Cambios que no lo afectarán si toma el medicamento actualmente. En general, si está tomando un medicamento de nuestro vademécum farmacológico 2020 que estaba cubierto al comienzo del año, no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2020, a excepción de lo descrito anteriormente. Esto significa que seguirá estando disponible al mismo costo compartido y sin nuevas restricciones para esos afiliados que lo tomen durante el resto del año de cobertura.

El vademécum farmacológico adjunto entra en vigencia a partir de mayo de 2020. Para obtener información actualizada sobre los medicamentos cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de portada y contraportada. Le enviaremos una notificación en

el caso de un cambio en el vademécum farmacológico a mitad de año no relacionado con el mantenimiento del mismo. En general, este aviso se enviará 60 días antes del cambio. Publicamos las actualizaciones del vademécum farmacológico en nuestro sitio web junto con el vademécum más actualizado.

¿Cómo debo usar el vademécum farmacológico?

Hay dos formas de averiguar si su medicamento está en el vademécum farmacológico:

Afección médica

El vademécum farmacológico comienza en la página ocho. Los medicamentos de este vademécum se agrupan en categorías según el tipo de afección médica que tratan. Por ejemplo, los medicamentos usados para tratar una afección cardíaca se enumeran en la categoría Medicamentos cardiovasculares. Si sabe para qué se usa el medicamento, busque el nombre de la categoría en la lista que comienza en la página ocho. Luego busque en el nombre de categoría para su medicamento.

Lista alfabética

Si no está seguro en qué categoría buscar, debe buscar su medicamento en el Índice al final del vademécum farmacológico. El índice proporciona un listado por orden alfabético de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos genéricos están enumerados en el índice. Busque en el índice para encontrar su medicamento. Al lado de su medicamento, encontrará el número de página en la que puede encontrar la información de cobertura. Vaya a la página enumerada en el índice y busque el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos?

Cubrimos medicamentos de marca y medicamentos genéricos. Los medicamentos genéricos aprobados por la FDA tienen el mismo

ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los de marca.

¿Hay restricciones en mi cobertura?

Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Estos requisitos y límites podrán incluir:

• Autorización previa: Requerimos que usted o su médico obtengan una autorización previa para ciertos medicamentos. Esto significa que deberá pedirnos autorización antes de adquirir sus medicamentos recetados. Si no obtiene la autorización, no podremos cubrir el medicamento.

• Límites de cantidad: Para determinados medicamentos, limitamos la cantidad que cubriremos. Por ejemplo, proporcionaremos 30 comprimidos por receta para Januvia. Esto puede ser adicional al suministro estándar de un mes o tres meses.

• Terapia escalonada: En algunos casos, requerimos que primero pruebe determinados medicamentos para tratar su afección médica antes de cubrir otro medicamento para la misma. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que no cubramos el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona para usted, entonces cubriremos el medicamento B.

Puede averiguar si su medicamento tiene requisitos o límites adicionales buscando en el vademécum farmacológico que comienza en la página ocho. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos visitando nuestro sitio web. Hemos publicado en línea documentos que explican nuestra autorización previa y las restricciones de la terapia escalonada.

También podrá pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum farmacológico, aparece en las páginas de tapa y contratapa.

Puede pedirnos que hagamos una excepción a estas restricciones o límites, o una lista de otros medicamentos similares que pueden tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción al vademécum de True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred y True Blue Rx St. Luke’s Health Partners?” que se encuentra en esta página para obtener información acerca de cómo solicitar una excepción.

¿Qué sucede si mi medicamento no está en el vademécum farmacológico?

Si su medicamento no está incluido en este vademécum (lista de medicamentos cubiertos), primero debe comunicarse con Servicio de Atención al Cliente y preguntar si su medicamento está cubierto.

Si sabe que no cubrimos su medicamento, tiene dos opciones:

• Puede solicitar al Servicio de Atención al Cliente una lista de medicamentos similares que cubrimos. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que cubramos.

• Nos puede pedir que hagamos una excepción para cubrir su medicamento. Consulte a continuación para obtener información sobre cómo solicitar una excepción.


¿Cómo solicito una excepción al vademécum farmacológico de True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred y True Blue Rx St. Luke’s Health Partners?

Nos puede pedir que hagamos una excepción a nuestras normas sobre cobertura. Hay varios tipos de excepciones que puede solicitarnos.

• Puede pedirnos que cubramos un medicamento incluso si el mismo no está en nuestro vademécum farmacológico. Si es aprobado, este medicamento se cubrirá a un nivel de costo compartido predeterminado y no podrá pedirnos que suministremos el medicamento a un nivel de costo compartido menor.

• Puede pedirnos que cubramos un medicamento del vademécum farmacológico a un nivel de costo compartido menor si este medicamento no está en la categoría de medicamentos de especialidad. Si es aprobado, esto reducirá la cantidad que usted debe pagar por su medicamento.

• Puede pedirnos que retiremos las restricciones o los límites de cobertura de su medicamento. Por ejemplo, para determinados medicamentos, limitamos la cantidad que cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que retiremos el límite y cubramos una cantidad mayor.

En general, solo aprobaremos su solicitud de una excepción si los medicamentos alternativos incluidos en el vademécum farmacológico del plan, el medicamento de costo compartido menor o las restricciones de uso adicionales no son tan eficaces para tratar su afección o provocan efectos médicos adversos.

Debe comunicarse con nosotros para pedir una decisión de cobertura inicial para una excepción del vademécum, de la categoría o de la restricción de uso. Cuando solicita una excepción al vademécum farmacológico, a la categoría o a la restricción de uso, debe presentar una declaración de su médico o de quien le receta el medicamento que respalde la solicitud. En general, debemos tomar nuestra decisión dentro de las 72 horas a partir de la recepción de la declaración de respaldo de su médico. Puede solicitar una excepción expedita (rápida) si usted o su médico consideran que su salud podría estar en grave peligro si espera hasta 72 horas para recibir la decisión. Si se concede su solicitud expedita, debemos tomar una decisión en el plazo máximo de 24 horas a partir de la recepción de la declaración de respaldo de su médico o de quien le receta el medicamento.

¿Qué puedo hacer antes de hablar con mi médico sobre cambios en mis medicamentos o sobre la solicitud de una excepción?

Como afiliado nuevo o continuo de nuestro plan, es posible que esté tomando medicamentos que no están en nuestro vademécum farmacológico. También es posible que tome un medicamento que está en nuestro vademécum, pero su capacidad para obtenerlo sea limitada. Por ejemplo, es posible que deba pedirnos autorización previa antes de adquirir su medicamento recetado. Debe hablar con su médico para decidir si desea cambiarse a un medicamento adecuado que cubrimos o solicitar una excepción al vademécum farmacológico para que cubramos el medicamento que toma. Mientras habla con su médico para determinar el curso de acción correcto para usted, es posible que cubramos su medicamento en determinados casos, en el transcurso de los primeros 90 días durante los cuales usted es afiliado de nuestro plan.

Para cada uno de los medicamentos que no esté en nuestro vademécum farmacológico, o si su capacidad para obtener sus medicamentos es

limitada, cubriremos un suministro temporal de 30 días. Si su receta es para menos días, permitiremos que obtenga una receta varias veces de manera que tenga suministro de su medicamento para un máximo de 30 días. Después de su primer suministro de 30 días, no pagaremos estos medicamentos, aunque haya sido afiliado del plan por menos de 90 días.

Si usted es residente de un centro de cuidado a largo plazo y necesita un medicamento que no está en nuestro vademécum farmacológico o si su capacidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90 días como afiliado de nuestro plan, cubriremos un suministro de emergencia del medicamento de 31 días mientras usted solicita una excepción al vademécum.

Cuando se produce un cambio en su nivel de atención, como el ingreso en un centro de atención a largo plazo, es posible que necesite más medicamentos. Es posible que se rechacen las solicitudes para recibir más medicamentos si solicita un nuevo suministro demasiado pronto. Si esto ocurre, su farmacia puede pedirnos que anulemos el rechazo para que obtenga nuevamente su medicamento recetado.

Para más información

Para obtener más información sobre su cobertura de medicamentos recetados de True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred o True Blue Rx St. Luke’s Health Partners, consulte su Evidencia de Cobertura y otra documentación del plan.

Si tiene alguna pregunta acerca de True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred o True Blue Rx St. Luke’s Health Partners, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum farmacológico, aparece en las páginas de tapa y contratapa.

Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227)

las 24 horas del día, los siete días de la semana. Los usuarios de TTY deben llamar al 1-877-4862048. O visite http://www.medicare.gov.

Vademécum farmacológico de True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred y True Blue Rx St. Luke’s Health Partners

El vademécum farmacológico que comienza en la página ocho brinda información de cobertura acerca de los medicamentos que cubrimos. Si tiene dificultad para hallar su medicamento en la lista, vaya al índice al final del vademécum.

La primera columna del cuadro indica el nombre del medicamento. Los medicamentos de marca están en mayúscula (por ejemplo, NOXAFIL) y los medicamentos genéricos están en cursiva minúscula (por ejemplo, digoxina).

La información de la columna Requisitos/Límites le indica si hay requisitos especiales para la cobertura de su medicamento.


http://www.medicare.gov

Los medicamentos genéricos se muestran en letras minúsculas cursivas Los MEDICAMENTOS DE MARCA se muestran en letras mayúsculas

PA - Autorización Previa QL - Límites de Cantidad ST - Terapia Escalonada NM - No disponible para pedido por correo postal B/D - Con cobertura de Medicare B o D*

LA - Acceso Limitado * Este medicamento puede estar cubierto por la Parte B o D de Medicare, según las circunstancias. Es posible que deba enviarse información que describa el uso y las

circunstancias de empleo del medicamento para tomar la determinación.

8

Vademécum farmacológico 00020347 V12 Nombre del medicamento Categoría del Requisitos/límites

medicamento

ANALGÉSICOS

GOTA allopurinol tab 2 colchicine w/ probenecid 3 COLCRYS 3 QL (120 tabs / 30

days) MITIGARE 3 QL (60 caps / 30

days) probenecid 2

AINE (antiinflamatorios no esteroideos)celecoxib CAPS 50mg 3 QL (240 caps / 30

days) celecoxib CAPS 100mg 3 QL (120 caps / 30



days) diclofenac potassium 3 QL (120 tabs / 30

days) diclofenac sodium TB24 3 diclofenac sodium TBEC 2 diflunisal TABS 3 etodolac 3 flurbiprofen TABS 100mg 2 ibu tab 600mg 1 ibu tab 800mg 1 ibuprofen SUSP 3 ibuprofen TABS 400mg, 600mg, 800mg

1

meloxicam TABS 1 nabumetone TABS 2 naproxen TABS 250mg, 375mg, 500mg

1

naproxen dr 2 naproxen sodium TABS 275mg, 550mg 3 piroxicam CAPS 3 sulindac TABS 2




circunstancias de empleo del medicamento para tomar la determinación. Un servicio de Blue Cross of Idaho Care Plus, Inc. | Powered by Blue Cross of Idaho Care Plus, Inc.

9

ANALGÉSICOS OPIOIDES acetaminophen w/ codeine 300-15mg 2 QL (400 tabs / 30

days) acetaminophen w/ codeine 300-30mg 2 QL (360 tabs / 30

days) acetaminophen w/ codeine 300-60mg 2 QL (180 tabs / 30

days) acetaminophen w/ codeine soln 2 QL (2700 mL / 30

days) butorphanol tartrate SOLN 1mg/ml, 2mg/ml

4

nalbuphine hcl SOLN 4 tramadol hcl tab 50 mg 2 QL (240 tabs / 30

days) tramadol-acetaminophen 3 QL (240 tabs / 30

days)

ANALGÉSICOS OPIOIDES, CII endocet 2.5-325mg 3 QL (360 tabs / 30

days) endocet 5-325mg 3 QL (360 tabs / 30

days) endocet 7.5-325mg 3 QL (240 tabs / 30

days) endocet 10-325mg 3 QL (180 tabs / 30

days) fentanyl citrate LPOP 5 QL (120 lozenges /

30 days), PA

fentanyl patch 12 mcg/hr 4 QL (10 patches / 30 days), PA





hydroco/apap tab 5-325mg 3 QL (240 tabs / 30 days)

Nombre del medicamento Categoría del Requisitos/límites medicamento





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hydroco/apap tab 7.5-325 3 QL (180 tabs / 30 days)

hydroco/apap tab 10-325mg 3 QL (180 tabs / 30 days)

hydrocodone-acetaminophen 7.5-325 mg/15ml

4 QL (2700 mL / 30 days)

hydrocodone-ibuprofen tab 7.5-200 mg 3 QL (150 tabs / 30 days)

hydromorphone hcl LIQD 4 QL (600 mL / 30 days)

hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

4 B/D

hydromorphone hcl TABS 3 QL (180 tabs / 30 days)

HYSINGLA ER 3 QL (30 tabs / 30 days), PA

lorcet hd tab 10-325mg 3 QL (180 tabs / 30 days)

lorcet plus tab 7.5-325 3 QL (180 tabs / 30 days)

lorcet tab 5-325mg 3 QL (240 tabs / 30 days)

methadone hcl SOLN 5mg/5ml, 10mg/5ml

3 QL (450 mL / 30 days), PA

methadone hcl 5mg 3 QL (90 tabs / 30 days), PA

methadone hcl 10mg 3 QL (90 tabs / 30 days), PA

methadone hcl intensol 3 QL (90 mL / 30 days), PA

morphine ext-rel tab 3 QL (90 tabs / 30 days), PA

morphine sul inj 1mg/ml 4 B/D

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

4 B/D

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml

4 B/D

morphine sulfate TABS 3 QL (180 tabs / 30 days)

morphine sulfate oral soln 10mg/5ml 3 QL (900 mL / 30 days)






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NUCYNTA ER 3 QL (60 tabs / 30 days), PA

oxycodone hcl CAPS 4 QL (180 caps / 30 days)

oxycodone hcl CONC 4 QL (180 mL / 30 days)

oxycodone hcl SOLN 4 QL (900 mL / 30 days)

oxycodone hcl TABS 3 QL (180 tabs / 30 days)

oxycodone w/ acetaminophen 2.5-325mg

3 QL (360 tabs / 30 days)

oxycodone w/ acetaminophen 5-325mg 3 QL (360 tabs / 30 days)

oxycodone w/ acetaminophen 7.5-325mg


oxycodone w/ acetaminophen 10-325mg



ANESTÉSICOS

ANESTÉSICOS LOCALES lidocaine hcl (local anesth.) 2 B/D

lidocaine inj 0.5% 2 B/D

lidocaine inj 1% 2 B/D

lidocaine inj 1.5% preservative free (pf) 2 B/D

ANTIINFECCIOSOS

ANTIBACTERIANOS-VARIOS amikacin sulfate SOLN 4 gentamicin in saline 2 gentamicin sulfate SOLN 2 neomycin sulfate TABS 2 paromomycin sulfate CAPS 4 streptomycin sulfate SOLR 5 SULFADIAZINE TABS 4 tobramycin NEBU 5 NM, PA





12

tobramycin inj 1.2 gm/30ml 3 tobramycin inj 1.2gm 5 tobramycin inj 10mg/ml 3 tobramycin inj 80mg/2ml 3 tobramycin sulfate SOLN 3

ANTIINFECCIOSOS - VARIOS albendazole TABS 5 ALINIA 5 atovaquone SUSP 5 aztreonam 4 CAYSTON 5 NM, LA, PA clindamycin cap 75mg 1 clindamycin cap 300 mg 1 clindamycin hcl cap 150 mg 1 clindamycin phosphate in d5w 4 CLINDAMYCIN PHOSPHATE IN NACL 4 clindamycin phosphate inj 3 clindamycin soln 75mg/5ml 4 colistimethate sodium SOLR 4 dapsone TABS 3 daptomycin 5 EMVERM 5 QL (12 tabs / 365

days) ertapenem sodium 4 imipenem-cilastatin 3 ivermectin TABS 3 linezolid in sodium chloride 4 linezolid inj 4 linezolid susp 5 linezolid tab 600mg 4 meropenem 4 methenamine hippurate 3 metronidazole TABS 2 metronidazole in nacl 2 nitrofurantoin macrocrystal 50mg, 100mg

3

nitrofurantoin monohyd macro 3 pentamidine isethionate inh 4 B/D

pentamidine isethionate inj 4






13

praziquantel TABS 3 SIVEXTRO 5 sulfamethoxazole-trimethop ds 1 sulfamethoxazole-trimethoprim inj 4 sulfamethoxazole-trimethoprim susp 3 sulfamethoxazole-trimethoprim tab 400-80mg

1

SYNERCID 5 tigecycline 5 trimethoprim TABS 2 vancomycin hcl CAPS 125mg 4 QL (120 caps / 30

days) vancomycin hcl CAPS 250mg 5 QL (240 caps / 30

days) vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

4

VANCOMYCIN IN NACL 4

ANTIMICÓTICOS ABELCET 5 B/D AMBISOME 5 B/D amphotericin b SOLR 4 B/D

caspofungin acetate 5 fluconazole SUSR 3 fluconazole TABS 50mg, 100mg, 200mg

3

fluconazole TABS 150mg 1 fluconazole inj nacl 200 3 fluconazole inj nacl 400 3 flucytosine CAPS 5 griseofulvin microsize 4 griseofulvin ultramicrosize 4 itraconazole CAPS 4 PA

ketoconazole TABS 3 PA

MYCAMINE 5 NOXAFIL SUSP 5 QL (630 mL / 30

days) nystatin TABS 3






14

posaconazole 5 QL (93 tabs / 30 days)

terbinafine hcl TABS 1 QL (90 tabs / year)

voriconazole SOLR 5 PA

voriconazole SUSR 5 PA

voriconazole TABS 50mg 4 voriconazole TABS 200mg 5

ANTIPALÚDICOS atovaquone-proguanil hcl 4 chloroquine phosphate TABS 3 COARTEM 4 mefloquine hcl 3 primaquine phosphate 26.3mg 3 PRIMAQUINE PHOSPHATE 26.3mg 3 quinine sulfate CAPS 4 PA

AGENTES ANTIRRETROVIRALES abacavir sulfate SOLN 4 abacavir sulfate TABS 3 APTIVUS 5 atazanavir sulfate 4 CRIXIVAN 4 didanosine 4 EDURANT 5 efavirenz CAPS 50mg 4 efavirenz CAPS 200mg 5 efavirenz TABS 5 EMTRIVA 3 fosamprenavir tab 700 mg 5 FUZEON 5 NM INTELENCE 25mg 4 INTELENCE 100mg, 200mg 5 INVIRASE 5 ISENTRESS CHEW 25mg 3 ISENTRESS CHEW 100mg 5 ISENTRESS PACK 3 ISENTRESS TABS 5 ISENTRESS HD 5 lamivudine 3 LEXIVA SUSP 4






15

nevirapine susp 50 mg/5ml 4 nevirapine tab 100mg er 4 nevirapine tab 200mg 3 nevirapine tab 400mg er 4 NORVIR PACK 4 NORVIR SOLN 4 PIFELTRO 5 PREZISTA SUSP 5 QL (400 mL / 30

days) PREZISTA TABS 75mg 4 QL (480 tabs / 30




days) RESCRIPTOR 4 REYATAZ PACK 5 ritonavir 3 SELZENTRY SOLN 5 SELZENTRY TABS 25mg 4 SELZENTRY TABS 75mg, 150mg, 300mg

5

stavudine 3 tenofovir disoproxil fumarate 3 TIVICAY 10mg 3 TIVICAY 25mg, 50mg 5 TROGARZO 5 NM, LA TYBOST 4 VIDEX EC 125MG 4 VIDEX PEDIATRIC 4 VIRACEPT 5 VIREAD POWD 5 VIREAD TABS 150mg, 200mg, 250mg 5 zidovudine cap 100mg 4 zidovudine syp 50mg/5ml 4 zidovudine tab 300mg 3






16

AGENTES ANTIRRETROVIRALES COMBINADOS abacavir sulfate-lamivudine 3 abacavir sulfate-lamivudine-zidovudine 5 ATRIPLA 5 BIKTARVY 5 CIMDUO 5 COMPLERA 5 DELSTRIGO 5 DESCOVY 5 DOVATO 5 EVOTAZ 5 GENVOYA 5 JULUCA 5 KALETRA TAB 100-25MG 4 KALETRA TAB 200-50MG 5 lamivudine-zidovudine 4 lopinavir-ritonavir 4 ODEFSEY 5 PREZCOBIX 5 STRIBILD 5 SYMFI 5 SYMFI LO 5 SYMTUZA 5 TEMIXYS 5 TRIUMEQ 5 TRUVADA TAB 100-150 5 QL (30 tabs / 30

days) TRUVADA TAB 133-200 5 QL (30 tabs / 30



days)

AGENTES ANTITUBERCULOSOS cycloserine CAPS 5 ethambutol hcl TABS 3 isoniazid TABS 1 isoniazid syp 50mg/5ml 4 PASER D/R 4






17

PRIFTIN 4 pyrazinamide TABS 4

rifabutin 4

rifampin CAPS 3

rifampin SOLR 4

RIFATER 4 SIRTURO 5 LA, PA TRECATOR 4

ANTIVIRALES acyclovir CAPS; TABS 2

acyclovir SUSP 4

acyclovir sodium 4 B/D

adefovir dipivoxil 5 NM

BARACLUDE SOLN 5 NM entecavir 4 NM

EPCLUSA 5 NM, PA EPIVIR HBV SOLN 4 NM famciclovir 3

ganciclovir sodium 4 B/D

HARVONI 5 NM, PA lamivudine (hbv) 4 NM

MAVYRET 5 NM, PA oseltamivir phosphate CAPS 30mg 3 QL (168 caps / year)

oseltamivir phosphate CAPS 45mg, 75mg

3 QL (84 caps / year)

oseltamivir phosphate SUSR 3 QL (1080 mL / year)

PEGASYS 5 NM, PA PEGASYS PROCLICK 5 NM, PA RELENZA DISKHALER 3 QL (6 inhalers /

year)

ribavirin cap 200mg 3 NM

ribavirin tab 200mg 4 NM

rimantadine hydrochloride 3

valacyclovir hcl TABS 3

valganciclovir hcl 5

VEMLIDY 5 VOSEVI 5 NM, PA






18

CEFALOSPORINAS cefaclor CAPS 3 cefaclor SUSR 4 CEFACLOR ER TAB 500MG 4 cefadroxil CAPS 2 cefadroxil SUSR 3 cefadroxil TABS 4 CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

3

cefazolin inj 3 cefazolin sodium SOLR 1gm 3 CEFAZOLIN SODIUM 1 GM/50ML 3 cefdinir CAPS 2 cefdinir SUSR 4 cefepime for inj 4 cefixime SUSR 4 cefoxitin for inj 4 cefpodoxime proxetil SUSR 4 cefpodoxime proxetil TABS 3 cefprozil 3 ceftazidime SOLR 3 CEFTAZIDIME/DEXTROSE 4 ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

3

cefuroxime axetil 3 cefuroxime sodium 3 cephalexin CAPS 250mg, 500mg 1 cephalexin SUSR 3 tazicef SOLR 3 TEFLARO 5

ERITROMICINAS/MACRÓLIDOS azithromycin PACK; SOLR; SUSR 3 azithromycin TABS 1 clarithromycin TABS 3 clarithromycin er 3 clarithromycin for susp 4 DIFICID 5 e.e.s. 400 4 ery-tab 4






19

ERYTHROCIN LACTOBIONATE 4 erythrocin stearate 4 erythromycin base 4 erythromycin cap 250mg ec 4 erythromycin ethylsuccinate TABS 4 erythromycin tab ec 4

FLUOROQUINOLONAS CIPRO SUSR 500mg/5ml 4 ciprofloxacin hcl tab 100mg 4 ciprofloxacin hcl tab 250mg, 500mg, 750mg

1

ciprofloxacin in d5w 3 levofloxacin TABS 1 levofloxacin in d5w 3 levofloxacin inj 25mg/ml 4 levofloxacin oral soln 25 mg/ml 4

PENICILINAS amoxicillin CAPS; SUSR; TABS 1 amoxicillin CHEW 2 amoxicillin & pot clavulanate 200-28.5 chw tabs

4

amoxicillin & pot clavulanate 200/5ml susr

3

amoxicillin & pot clavulanate 250-125 tabs

4


4

amoxicillin & pot clavulanate 400-57 chw tabs

4


3


2


3


2






20

amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs

4

ampicillin & sulbactam sodium 4 ampicillin cap 500mg 2 ampicillin inj 4 ampicillin sodium 4 BICILLIN L-A 4 dicloxacillin sodium 3 nafcillin sodium for inj 1gm, 2gm 4 nafcillin sodium for inj 10gm 5 NAFCILLIN SODIUM FOR INJ 10GM 4 oxacillin sodium SOLR 1gm, 2gm 4 oxacillin sodium SOLR 10gm 5 PENICILLIN G POT IN DEXTROSE 2MU 4 PENICILLIN G POT IN DEXTROSE 3MU 4 PENICILLIN G PROCAINE 4 penicillin g sodium 4 penicillin v potassium SOLR 2 penicillin v potassium TABS 1 penicilln gk inj 5mu 4 penicilln gk inj 20mu 4 pfizerpen-g inj 5mu 4 pfizerpen-g inj 20mu 4 piper/tazoba inj 2-0.25gm 4 piper/tazoba inj 3-0.375gm 4 piper/tazoba inj 4-0.5gm 4 piper/tazoba inj 12-1.5gm 4 piper/tazoba inj 36-4.5gm 4

TETRACICLINAS doxy 100 4 doxycycline (monohydrate) CAPS 50mg, 100mg

2

doxycycline (monohydrate) TABS 50mg, 75mg, 100mg

3

doxycycline hyclate CAPS 3 doxycycline hyclate SOLR 4 doxycycline hyclate 20 mg 3 doxycycline hyclate 100 mg 3 minocycline hcl CAPS 2






21

mondoxyne nl cap 100mg 2

tetracycline hcl CAPS 4


AGENTES ANTINEOPLÁSICOS

AGENTES ALQUILANTES BENDEKA 5 B/D, NM cyclophosphamide CAPS 3 B/D

cyclophosphamide SOLR 5 B/D

EMCYT 4 GLEOSTINE 10mg 4

GLEOSTINE 40mg, 100mg 5

LEUKERAN 5

ANTRACICLINAS adriamycin SOLN 4 B/D

doxorubicin hcl 4 B/D

doxorubicin hcl liposomal 5 B/D

epirubicin hcl 4 B/D

ANTIMETABOLITOS adrucil inj 3 B/D

ALIMTA 5 B/D azacitidine 5 B/D

cytarabine 20mg/ml 3 B/D

fluorouracil SOLN 3 B/D

gemcitabine inj soln 4 B/D

gemcitabine inj solr 4 B/D

mercaptopurine TABS 3

methotrexate sodium inj soln 2 B/D

methotrexate sodium inj solr 2 B/D

PURIXAN 5 NM TABLOID 5

ANTIMITÓTICOS, TAXOIDES ABRAXANE 5 B/D docetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml

5 B/D

DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

5 B/D

docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

5 B/D





22

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

5 B/D

paclitaxel 4 B/D

TAXOTERE 5

B/D

ANTIMITÓTICOS, ALCALOIDES DE LA VINCAvincristine sulfate 2 B/D

vinorelbine tartrate 3

B/D

MODIFICADORES DE RESPUESTA BIOLÓGICAAVASTIN 5 LA, PA BORTEZOMIB 5 PA DAURISMO 5 NM, LA, PA ERIVEDGE 5 NM, LA, PA FARYDAK 5 NM, LA, PA HERCEPTIN 5 PA HERCEPTIN HYLECTA 5 PA IBRANCE CAPS 5 QL (21 caps / 28

days), NM, LA, PA

IDHIFA 5 QL (30 tabs / 30 days), NM, LA, PA

KADCYLA 5 B/D KANJINTI 5 NM, PA KEYTRUDA 5 NM, PA KISQALI 5 NM, PA KISQALI FEMARA 200 DOSE 5 NM, PA KISQALI FEMARA 400 DOSE 5 NM, PA KISQALI FEMARA 600 DOSE 5 NM, PA LYNPARZA 5 NM, LA, PA MVASI 5 NM, LA, PA NINLARO 5 NM, PA ODOMZO 5 NM, LA, PA OGIVRI 5 NM, PA RITUXAN 5 LA, PA RITUXAN HYCELA 5 NM, LA, PA RUBRACA 5 NM, LA, PA RUXIENCE 5 NM, PA TALZENNA 5 NM, LA, PA TECENTRIQ 5 NM, LA, PA TIBSOVO 5 NM, LA, PA TRAZIMERA 5 NM, PA






23

TRUXIMA 5 NM, PA VELCADE 5 PA VENCLEXTA 10mg 4 NM, LA, PA

VENCLEXTA 50mg, 100mg 5 NM, LA, PA

VENCLEXTA STARTING PACK 5 NM, LA, PA VERZENIO 5 NM, LA, PA ZEJULA 5 NM, LA, PA ZIRABEV 5 PA ZOLINZA 5

NM, PA

AGENTES ANTINEOPLÁSICOS HORMONALESabiraterone acetate 5 NM, PA

anastrozole TABS 1

bicalutamide 2

DEPO-PROVERA INJ 400/ML 4 B/D ERLEADA 5 NM, LA, PA exemestane 4

flutamide 3

fulvestrant 5 B/D

letrozole TABS 1

leuprolide inj 1mg/0.2 3 NM, PA

LUPRON DEPOT (1-MONTH) 3.75mg 5 NM, PA

LUPRON DEPOT INJ 11.25MG (3-MONTH)

5 NM, PA

LYSODREN 3

megestrol ac sus 40mg/ml 3

megestrol ac tab 20mg 3

megestrol ac tab 40mg 3

megestrol sus 625mg/5ml 4 PA

nilutamide 5

NUBEQA 5 NM, LA, PA SOLTAMOX 5 tamoxifen citrate TABS 1

toremifene citrate 5

TRELSTAR DEP INJ 3.75MG 5 NM, PA TRELSTAR LA INJ 11.25MG 5 NM, PA XTANDI 5 NM, LA, PA ZYTIGA 500mg 5 NM, LA, PA






24

INMUNOMODULADORES POMALYST 1mg, 2mg 5 QL (21 caps / 21

days), NM, LA, PA

POMALYST 3mg, 4mg 5 QL (21 caps / 28 days), NM, LA, PA

REVLIMID 5 QL (28 caps / 28 days), NM, LA, PA

THALOMID 50mg, 100mg 5 QL (28 caps / 28 days), NM, PA

THALOMID 150mg, 200mg 5 QL (56 caps / 28 days), NM, PA

INHIBIDORES DE QUINASAS AFINITOR 10mg 5 QL (30 tabs / 30

days), NM, PA

AFINITOR DISPERZ 2mg 5 QL (150 tabs / 30 days), NM, PA



ALECENSA 5 NM, LA, PA

ALUNBRIG 5 NM, LA, PA AYVAKIT 5 QL (30 tabs / 30

days), NM, LA, PA

BALVERSA 5 NM, LA, PA BOSULIF 5 NM, PA BRAFTOVI 5 NM, LA, PA BRUKINSA 5 NM, LA, PA CABOMETYX 5 QL (30 tabs / 30

days), NM, LA, PA

CALQUENCE 5 NM, LA, PA CAPRELSA 5 NM, LA, PA COMETRIQ 5 NM, LA, PA COPIKTRA 5 NM, LA, PA COTELLIC 5 NM, LA, PA erlotinib hcl 25mg 5 QL (90 tabs / 30

days), NM, PA erlotinib hcl 100mg, 150mg 5 QL (30 tabs / 30

days), NM, PA






25

everolimus 5 QL (30 tabs / 30 days), NM, PA

GILOTRIF TAB 20MG 5 NM, LA, PA GILOTRIF TAB 30MG 5 NM, LA, PA GILOTRIF TAB 40MG 5 NM, LA, PA ICLUSIG 5 NM, LA, PA imatinib mesylate 100mg 5 QL (90 tabs / 30

days), NM, PA

imatinib mesylate 400mg 5 QL (60 tabs / 30 days), NM, PA

IMBRUVICA 5 NM, LA, PA INLYTA 1mg 5 QL (180 tabs / 30

days), NM, LA, PA

INLYTA 5mg 5 QL (120 tabs / 30 days), NM, LA, PA

INREBIC 5 NM, LA, PA

IRESSA 5 NM, LA, PA JAKAFI 5 QL (60 tabs / 30

days), NM, LA, PA

LENVIMA 4 MG DAILY DOSE 5 NM, LA, PA LENVIMA 8 MG DAILY DOSE 5 NM, LA, PA LENVIMA 10 MG DAILY DOSE 5 NM, LA, PA LENVIMA 12MG DAILY DOSE 5 NM, LA, PA LENVIMA 14 MG DAILY DOSE 5 NM, LA, PA LENVIMA 18 MG DAILY DOSE 5 NM, LA, PA LENVIMA 20 MG DAILY DOSE 5 NM, LA, PA LENVIMA 24 MG DAILY DOSE 5 NM, LA, PA LORBRENA 5 NM, LA, PA MEKINIST 5 NM, LA, PA MEKTOVI 5 NM, LA, PA NERLYNX 5 NM, LA, PA NEXAVAR 5 NM, LA, PA PIQRAY 200MG DAILY DOSE 5 NM, PA PIQRAY 250MG DAILY DOSE 5 NM, PA PIQRAY 300MG DAILY DOSE 5 NM, PA ROZLYTREK 5 NM, LA, PA RYDAPT 5 NM, PA SPRYCEL 5 NM, PA






26

STIVARGA 5 NM, LA, PA SUTENT 5 QL (30 caps / 30

days), NM, PA

TAFINLAR 5 NM, LA, PA TAGRISSO 5 QL (30 tabs / 30

days), NM, LA, PA

TASIGNA 5 NM, PA

TURALIO 5 NM, LA, PA TYKERB 5 NM, LA, PA VITRAKVI 5 NM, LA, PA VIZIMPRO 5 NM, LA, PA VOTRIENT 5 NM, LA, PA XALKORI 5 NM, LA, PA XOSPATA 5 NM, LA, PA ZELBORAF 5 NM, LA, PA ZYDELIG 5 NM, LA, PA ZYKADIA 5 NM, LA, PA

VARIOS bexarotene 5 NM, PA

hydroxyurea CAPS 2

LONSURF 5 NM, PA MATULANE 5 LA SYLATRON 200mcg, 300mcg 5 PA

SYNRIBO 5 NM, PA TAZVERIK 5 NM, LA, PA tretinoin (chemotherapy) 5

XPOVIO 60 MG ONCE WEEKLY 5 NM, LA, PA XPOVIO 80 MG ONCE WEEKLY 5 NM, LA, PA XPOVIO 80 MG TWICE WEEKLY 5 NM, LA, PA XPOVIO 100 MG ONCE WEEKLY 5 NM, LA, PA

AGENTES BASADOS EN EL PLATINO carboplatin 3 B/D

cisplatin SOLN 3 B/D

oxaliplatin inj 50mg 5 B/D

oxaliplatin inj 50mg/10ml 4 B/D

oxaliplatin inj 100mg 5 B/D

oxaliplatin inj 100mg/20ml 4 B/D

AGENTES PROTECTORES leucovorin calcium SOLN 500mg/50ml 4 B/D






27

leucovorin calcium SOLR 4 B/D

leucovorin calcium TABS 5mg, 10mg 3 leucovorin calcium TABS 15mg, 25mg 4 MESNEX TABS 5

INHIBIDORES DE TOPOISOMERASA etoposide SOLN 3 B/D

irinotecan hcl 4 B/D

toposar 3 B/D


CARDIOVASCULAR

COMBINACIONES DEL INHIBIDOR DE LA ECA amlodipine besylate-benazepril hcl cap 2.5-10 mg

1

amlodipine besylate-benazepril hcl cap 5-10 mg

1


1


1


1


1

benazepril & hydrochlorothiazide 1 captopril & hydrochlorothiazide 1 enalapril maleate & hydrochlorothiazide 1 fosinopril sodium & hydrochlorothiazide 1 lisinopril & hydrochlorothiazide 1 quinapril-hydrochlorothiazide 1

INHIBIDORES DE LA ECA benazepril hcl TABS 1 captopril TABS 1 enalapril maleate TABS 1 fosinopril sodium 1 lisinopril TABS 1 moexipril hcl 1 perindopril erbumine 1 quinapril hcl 1





28

ramipril 1 trandolapril 1

ANTAGONISTAS DEL RECEPTOR DE LA ALDOSTERONAeplerenone 3 spironolactone TABS 1

ALFABLOQUEANTES doxazosin mesylate TABS 2 prazosin hcl 3 terazosin hcl 1mg, 2mg, 5mg 1 terazosin hcl 10mg 2

COMBINACIONES DE ANTAGONISTAS DE LOS RECEPTORES DE LA

ANGIOTENSINA II amlodipine besylate-olmesartan medoxomil

1

amlodipine besylate-valsartan tab 1 amlodipine-valsartan-hydrochlorothiazide tab

1

ENTRESTO 3 irbesartan-hydrochlorothiazide 1 losartan-hydrochlorothiazide 1 olmesartan medoxomil-amlodipine-hydrochlorothiazide

1

olmesartan medoxomil-hydrochlorothiazide

1

valsartan-hydrochlorothiazide 1

ANTAGONISTAS DE LOS RECEPTORES DE LA ANGIOTENSINA IIirbesartan 1 losartan potassium 1 olmesartan medoxomil TABS 1 telmisartan 1 valsartan 1

ANTIARRÍTMICOS amiodarone hcl soln 2 amiodarone tab 100mg 4 amiodarone tab 200mg 1 amiodarone tab 400mg 4 disopyramide phosphate 4 dofetilide 4 flecainide acetate 3






29

MULTAQ 4 NORPACE CR 4 pacerone 100mg, 400mg 4 pacerone 200mg 1 propafenone hcl 2 propafenone hcl 12hr 4 quinidine sulfate 2 sorine 2 sotalol hcl 2 sotalol hcl (afib/afl) 2

ANTILIPÉMICOS, INHIBIDORES DE LA HMG-CoA REDUCTASA atorvastatin calcium TABS 1 lovastatin 1 pravastatin sodium 1 rosuvastatin calcium 1 QL (30 tabs / 30

days) simvastatin TABS 5mg, 10mg, 20mg, 40mg

1

simvastatin TABS 80mg 1 QL (30 tabs / 30 days)

ANTILIPÉMICOS, VARIOS cholestyramine 3 cholestyramine light pack 4 cholestyramine light powd 3 colesevelam hcl 4 colestipol hcl gran 4 colestipol hcl pack 4 colestipol hcl tabs 3 ezetimibe 3 fenofibrate TABS 48mg, 54mg, 145mg, 160mg

3

fenofibrate micronized 67mg, 134mg, 200mg

3

gemfibrozil TABS 1 JUXTAPID 5 NM, LA, PA niacin (antihyperlipidemic) 4 niacin er (antihyperlipidemic) 500mg 4 QL (60 tabs / 30

days)






30

niacin er (antihyperlipidemic) 750mg, 1000mg

4

niacor 4 PRALUENT 3 NM, PA

prevalite PACK 4 prevalite POWD 3 VASCEPA 4

COMBINACIONES DE BETABLOQUEANTES Y DIURÉTICOSatenolol & chlorthalidone 2 bisoprolol & hydrochlorothiazide 1 metoprolol & hydrochlorothiazide 3 propranolol & hydrochlorothiazide 3

BETABLOQUEANTES acebutolol hcl CAPS 2 atenolol TABS 1 bisoprolol fumarate 2 BYSTOLIC 2.5mg, 5mg, 10mg 4 QL (30 tabs / 30

days) BYSTOLIC 20mg 4 QL (60 tabs / 30

days) carvedilol 1 labetalol hcl TABS 3 metoprolol succinate 2 metoprolol tartrate SOCT 3 metoprolol tartrate SOLN 3 metoprolol tartrate TABS 25mg, 50mg, 100mg

1

nadolol TABS 3 pindolol 3 propranolol cap er 3 propranolol hcl TABS 2 propranolol oral sol 3 timolol maleate TABS 3

BLOQUEADORES DE LOS CANALES DE CALCIOamlodipine besylate TABS 1 cartia xt 2 dilt-xr cap 2 diltiazem cap 240mg cd 2 diltiazem cap 360mg cd 4






31

diltiazem cap er/12hr 4 diltiazem hcl TABS 2 diltiazem hcl coated beads CP24 4 diltiazem hcl coated beads cap sr 24hr 2 diltiazem hcl extended release beads cap sr

2

diltiazem inj 2 felodipine 2 isradipine 3 nicardipine hcl CAPS 4 nifedipine TB24 2 nifedipine er 2 nimodipine CAPS 5 NYMALIZE 5 taztia xt 2 tiadylt er 2 verapamil cap er 100mg, 200mg, 300mg, 360mg

4

verapamil cap er 120mg, 180mg, 240mg

3

verapamil hcl SOLN 4 verapamil hcl TABS 1 verapamil hcl TBCR 2 verapamil tab er 2

GLUCÓSIDOS DIGITÁLICOS digitek .25mg 2 PA; PA if 70 years

and older

digitek .125mg 2 QL (30 tabs / 30 days)

digox 125mcg 2 QL (30 tabs / 30 days)

digox 250mcg 2 PA; PA if 70 years and older

digoxin TABS 125mcg 2 QL (30 tabs / 30 days)

digoxin TABS 250mcg 2 PA; PA if 70 years and older

digoxin inj 4






32

digoxin sol 50mcg/ml 4 PA; PA if 70 years and older

DIURÉTICOS acetazolamide CP12 4 acetazolamide TABS 3 amiloride & hydrochlorothiazide 2 amiloride hcl TABS 2 bumetanide inj 0.25/ml 3 bumetanide tab 3 chlorothiazide TABS 3 chlorthalidone 2 furosemide SOLN 2 furosemide TABS 1 furosemide inj 2 hydrochlorothiazide CAPS; TABS 1 indapamide 2 methazolamide TABS 4 metolazone 3 spironolactone & hydrochlorothiazide 3 torsemide tabs 2 triamterene & hydrochlorothiazide cap 37.5-25 mg

1

triamterene & hydrochlorothiazide tabs 1

VARIOS aliskiren fumarate 4 clonidine hcl TABS 1 clonidine hcl ptwk 4 CORLANOR 4 DEMSER 5 PA hydralazine hcl SOLN 4 hydralazine hcl TABS 2 midodrine hcl 3 minoxidil TABS 2 NORTHERA 100mg 5 QL (90 caps / 30

days), NM, LA, PA NORTHERA 200mg, 300mg 5 QL (180 caps / 30

days), NM, LA, PA ranolazine 4






33

NITRATOS isosorb mononitrate tab 2 isosorbide dinitrate 5mg, 10mg, 20mg, 30mg

3

isosorbide mononitrate er 1 minitran 2 NITRO-BID 3 NITRO-DUR DIS 0.3MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 nitroglycerin SUBL 3 nitroglycerin td patch 2

HIPERTENSIÓN ARTERIAL PULMONAR ADEMPAS 5 QL (90 tabs / 30

days), NM, LA, PA ambrisentan 5 QL (30 tabs / 30

days), NM, LA, PA bosentan 62.5mg 5 QL (120 tabs / 30

days), NM, LA, PA bosentan 125mg 5 QL (60 tabs / 30

days), NM, LA, PA OPSUMIT 5 QL (30 tabs / 30

days), NM, LA, PA sildenafil citrate tab 20 mg (pulmonary hypertension)

3 QL (90 tabs / 30 days), NM, PA

treprostinil 5 NM, LA, PA

VENTAVIS 5 NM, PA


SISTEMA NERVIOSO CENTRAL

ANSIOLÍTICOS alprazolam tab 0.5mg 2 QL (150 tabs / 30

days) alprazolam tab 0.25mg 2 QL (150 tabs / 30

days) alprazolam tab 1mg 2 QL (150 tabs / 30

days) alprazolam tab 2 mg 2 QL (150 tabs / 30

days) buspirone hcl TABS 5mg, 10mg, 15mg 1 buspirone hcl TABS 7.5mg, 30mg 3





34

fluvoxamine maleate TABS 2 lorazepam SOLN 2 lorazepam TABS 2 QL (150 tabs / 30

days) lorazepam intensol 3 QL (150 mL / 30

days)

ANTICONVULSIVOS APTIOM 5 QL (60 tabs / 30

days) BANZEL SUS 40MG/ML 5 PA BANZEL TAB 200MG 5 PA BANZEL TAB 400MG 5 PA BRIVIACT INJ 50MG/5ML 4 PA BRIVIACT SOL 10MG/ML 5 PA BRIVIACT TAB 10MG 5 PA BRIVIACT TAB 25MG 5 PA BRIVIACT TAB 50MG 5 PA BRIVIACT TAB 75MG 5 PA BRIVIACT TAB 100MG 5 PA carbamazepine CHEW; TABS 3 carbamazepine CP12; SUSP; TB12 4 CELONTIN 4 clobazam 4 PA

clonazepam TABS 2mg 2 QL (300 tabs / 30 days)

clonazepam TABS .5mg, 1mg 2 QL (90 tabs / 30 days)

clonazepam TBDP 2mg 3 QL (300 tabs / 30 days)

clonazepam TBDP .125mg, .25mg, .5mg, 1mg


clorazepate dipotassium 4 QL (180 tabs / 30 days), PA; PA if 65 years and older

DIASTAT ACUDIAL 4 DIASTAT PEDIATRIC 4 diazepam TABS 2 QL (120 tabs / 30

days), PA; PA if 65 years and older

diazepam gel 4






35

diazepam inj 3

diazepam intensol 3 QL (240 mL / 30 days), PA; PA if 65 years and older

diazepam oral soln 1 mg/ml 3 QL (1200 mL / 30 days), PA; PA if 65 years and older

DILANTIN CAP 30MG 3 DILANTIN CAP 100MG 3 DILANTIN CHEW TAB 50MG 3 DILANTIN-125 SUSP 4 divalproex sodium CSDR 4

divalproex sodium TB24; TBEC 3

EPIDIOLEX 5 QL (600 mL / 30 days), NM, LA, PA

epitol 3

ethosuximide CAPS; SOLN 4

felbamate SUSP 5

felbamate TABS 4

FYCOMPA SUSP 5 QL (720 mL / 30 days), PA

FYCOMPA TABS 2mg 4 QL (60 tabs / 30 days), PA

FYCOMPA TABS 4mg, 6mg 5 QL (60 tabs / 30 days), PA

FYCOMPA TABS 8mg, 10mg, 12mg 5 QL (30 tabs / 30 days), PA

gabapentin CAPS 100mg 2 QL (1080 caps / 30 days)



gabapentin SOLN 3 QL (2160 mL / 30 days)

gabapentin TABS 600mg 3 QL (180 tabs / 30 days)

gabapentin TABS 800mg 3 QL (120 tabs / 30 days)






36

lamotrigine CHEW 3 lamotrigine TABS 1 lamotrigine TB24 4 levetiracetam SOLN 4 levetiracetam TABS 2 levetiracetam TB24 3 levetiracetam in sodium chloride 4 levetiracetam oral soln 100 mg/ml 3 NAYZILAM 4 oxcarbazepine SUSP 4 oxcarbazepine TABS 3 PEGANONE 4 phenobarbital ELIX 4 PA; PA if 70 years

and older

phenobarbital TABS 3 PA; PA if 70 years and older

PHENOBARBITAL SODIUM SOLN 65mg/ml

4 PA; PA if 70 years and older

phenobarbital sodium SOLN 65mg/ml, 130mg/ml


PHENYTEK 3 phenytoin CHEW; SUSP 3 phenytoin sodium extended 3 phenytoin sodium inj 50mg/ml 3 pregabalin CAPS 25mg, 50mg, 75mg, 100mg, 150mg

3 QL (120 caps / 30 days), PA

pregabalin CAPS 200mg 3 QL (90 caps / 30 days), PA

pregabalin CAPS 225mg, 300mg 3 QL (60 caps / 30 days), PA

pregabalin SOLN 4 QL (900 mL / 30 days), PA

primidone TABS 2 roweepra 2 roweepra xr 3 SPRITAM 4 subvenite tab 1 SYMPAZAN 5mg 4 PA

SYMPAZAN 10mg, 20mg 5 PA

tiagabine hcl 4






37

topiramate CPSP 3 topiramate TABS 2 valproate sodium SOLN 3 valproate sodium oral soln 3 valproic acid CAPS 3 VALTOCO 4 vigabatrin powd pack 500mg 5 QL (180 packets /

30 days), NM, LA, PA

vigabatrin tab 500mg 5 QL (180 tabs / 30 days), NM, LA, PA

vigadrone 5 QL (180 packets / 30 days), NM, LA, PA

VIMPAT 50mg 4 QL (120 tabs / 30 days)

VIMPAT 100mg, 150mg, 200mg 5 QL (60 tabs / 30 days)

VIMPAT INJ 200MG/20ML 5 VIMPAT SOL 10MG/ML 5 QL (1200 mL / 30

days) zonisamide CAPS 2

ANTIDEMENCIA donepezil hydrochloride TABS 5mg 2 QL (30 tabs / 30

days) donepezil hydrochloride TABS 10mg 2 donepezil hydrochloride TBDP 5mg 2 QL (30 tabs / 30

days) donepezil hydrochloride TBDP 10mg 2 galantamine hydrobromide SOLN 4 galantamine hydrobromide TABS 3 QL (60 tabs / 30

days) galantamine hydrobromide er 3 QL (30 caps / 30

days) memantine hcl cp24 4 PA; PA if < 30 yrs

memantine soln 4 PA; PA if < 30 yrs

memantine tabs 3 PA; PA if < 30 yrs

NAMZARIC 4






38

rivastigmine tartrate 1.5mg, 3mg 4 QL (90 caps / 30 days)

rivastigmine tartrate 4.5mg, 6mg 4 QL (60 caps / 30 days)

rivastigmine td patch 24hr 4.6 mg/24hr 4 QL (30 patches / 30 days)

rivastigmine td patch 24hr 9.5 mg/24hr 4 QL (30 patches / 30 days)

rivastigmine td patch 24hr 13.3 mg/24hr

4 QL (30 patches / 30 days)

ANTIDEPRESIVOS amitriptyline hcl TABS 3 amoxapine 3 bupropion hcl TABS 3 bupropion hcl TB12 2 bupropion hcl TB24 150mg, 300mg 3 citalopram hydrobromide SOLN 3 citalopram hydrobromide TABS 1 clomipramine hcl CAPS 4 PA

desipramine hcl TABS 4 desvenlafaxine succinate 4 QL (30 tabs / 30

days), PA doxepin hcl CAPS; CONC 3 DRIZALMA SPRINKLE 20mg, 30mg, 60mg

4 QL (60 caps / 30 days), PA

DRIZALMA SPRINKLE 40mg 4 QL (90 caps / 30 days), PA

duloxetine hcl CPEP 20mg, 30mg, 60mg

3 QL (60 caps / 30 days)

EMSAM 5 QL (30 patches / 30 days), PA

escitalopram oxalate SOLN 4 escitalopram oxalate TABS 1 FETZIMA 20mg, 40mg 4 QL (60 caps / 30

days), PA FETZIMA 80mg, 120mg 4 QL (30 caps / 30

days), PA FETZIMA TITRATION PACK 4 PA fluoxetine cap 10mg 1 fluoxetine cap 20mg 1






39

fluoxetine cap 40mg 2 fluoxetine hcl SOLN 2 imipramine hcl TABS 2 maprotiline hcl 3 MARPLAN TAB 10MG 4 QL (180 tabs / 30

days) mirtazapine TABS 7.5mg 3 mirtazapine TABS 15mg, 30mg, 45mg 1 mirtazapine TBDP 3 nefazodone hcl 4 nortriptyline hcl CAPS 2 nortriptyline hcl SOLN 4 paroxetine hcl tabs 2 PAXIL SUSP 4 QL (900 mL / 30

days) phenelzine sulfate TABS 3 protriptyline hcl 4 sertraline hcl CONC 4 sertraline hcl TABS 1 tranylcypromine sulfate 4 trazodone hcl TABS 50mg, 100mg, 150mg

1

trimipramine maleate CAPS 25mg 4 QL (240 caps / 30 days)



TRINTELLIX 5mg 4 QL (120 tabs / 30 days)



venlafaxine hcl CP24; TABS 2 VIIBRYD STARTER PACK 4 VIIBRYD TAB 4 QL (30 tabs / 30

days)






40

AGENTES ANTIPARKINSONIANOS amantadine hcl CAPS 3 QL (120 caps / 30

days) amantadine hcl SYRP 2 amantadine hcl TABS 3 APOKYN 5 QL (20 cartridges /


benztropine mesylate inj 4 benztropine mesylate tab 0.5mg 3 PA; PA if 70 years

and older

benztropine mesylate tab 1mg 3 PA; PA if 70 years and older

benztropine mesylate tab 2mg 3 PA; PA if 70 years and older

bromocriptine mesylate CAPS; TABS 4 carbidopa-levodopa TABS 2 carbidopa-levodopa TBCR 3 carbidopa-levodopa TBDP 4 carbidopa/levodopa/entacapone 4 entacapone 4 NEUPRO 4 pramipexole tab 0.5mg 1 pramipexole tab 0.25mg 1 pramipexole tab 0.75mg 1 pramipexole tab 0.125mg 1 pramipexole tab 1.5mg 1 pramipexole tab 1mg 1 rasagiline mesylate TABS 4 ropinirole tab 0.5mg 2 ropinirole tab 0.25mg 2 ropinirole tab 1mg 2 ropinirole tab 2mg 2 ropinirole tab 3mg 2 ropinirole tab 4mg 2 ropinirole tab 5mg 2 selegiline hcl CAPS; TABS 3 trihexyphenidyl hcl 3 PA; PA if 70 years

and older






41

ANTIPSICÓTICOS ABILIFY MAINTENA 5 QL (1 injection / 28

days)

aripiprazole odt 5 QL (60 tabs / 30 days)

aripiprazole oral solution 1 mg/ml 5 QL (900 mL / 30 days)

aripiprazole tab 4 QL (30 tabs / 30 days)

ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml

5 QL (1 injection / 28 days)

ARISTADA 1064mg/3.9ml 5 QL (1 injection / 56 days)

ARISTADA INITIO 5 CAPLYTA 4 QL (30 caps / 30

days)

chlorpromazine hcl TABS 4

CHLORPROMAZINE INJ 4 clozapine odt 12.5mg, 25mg 4 PA

clozapine odt 100mg 4 QL (270 tabs / 30 days), PA



clozapine tab 25mg 3

clozapine tab 50mg 3

clozapine tab 100mg 4 QL (270 tabs / 30 days)

clozapine tab 200mg 4 QL (135 tabs / 30 days)

FANAPT 4 QL (60 tabs / 30 days), PA

FANAPT TITRATION PACK 4 PA fluphenazine decanoate SOLN 4

fluphenazine hcl 4

GEODON SOLR 4 QL (6 mL / 3 days)

haloperidol TABS 3

haloperidol conc 2mg/ml 2






42

haloperidol decanoate SOLN 3

haloperidol lactate inj 5mg/ml 3

INVEGA SUST INJ 39 MG/0.25 ML 4 QL (1 injection / 28 days)



INVEGA SUST INJ 156MG/ML 5 QL (1 injection / 28 days)


INVEGA TRINZA 5 QL (1 injection / 90 days)

LATUDA 20mg, 40mg, 60mg, 120mg 4 QL (30 tabs / 30 days)

LATUDA 80mg 4 QL (60 tabs / 30 days)

loxapine succinate 3

molindone hcl 4

NUPLAZID CAPS 5 QL (30 caps / 30 days), NM, LA, PA

NUPLAZID TABS 10MG 5 QL (30 tabs / 30 days), NM, LA, PA

olanzapine SOLR 4 QL (3 vials / 1 day)

olanzapine TABS 2.5mg, 5mg, 10mg 2 QL (60 tabs / 30 days)

olanzapine TABS 7.5mg, 15mg, 20mg 2 QL (30 tabs / 30 days)

olanzapine TBDP 5mg, 15mg, 20mg 4 QL (30 tabs / 30 days)

olanzapine TBDP 10mg 4 QL (60 tabs / 30 days)

paliperidone 1.5mg, 3mg, 9mg 4 QL (30 tabs / 30 days)

paliperidone 6mg 4 QL (60 tabs / 30 days)

perphenazine TABS 3

PERSERIS 5 QL (1 injection / 30 days)

pimozide 4






43

quetiapine fumarate TABS 2

quetiapine fumarate TB24 50mg, 300mg, 400mg

4 QL (60 tabs / 30 days), PA

quetiapine fumarate TB24 150mg, 200mg

4 QL (30 tabs / 30 days), PA

REXULTI 3mg, 4mg 5 QL (30 tabs / 30 days)

REXULTI .25mg, .5mg, 1mg, 2mg 5 QL (60 tabs / 30 days)

RISPERDAL INJ 12.5MG 4 QL (2 injections / 28 days)

RISPERDAL INJ 25MG 4 QL (2 injections / 28 days)

RISPERDAL INJ 37.5MG 5 QL (2 injections / 28 days)

RISPERDAL INJ 50MG 5 QL (2 injections / 28 days)

risperidone SOLN 3 QL (240 mL / 30 days)

risperidone TABS 2

risperidone TBDP 1mg, 2mg, 3mg, 4mg


risperidone TBDP .25mg, .5mg 4 QL (90 tabs / 30 days)

SAPHRIS 4 QL (60 tabs / 30 days)

SECUADO 4 QL (30 patches / 30 days)

thioridazine hcl TABS 3

thiothixene 4

trifluoperazine hcl 3

VERSACLOZ 5 QL (600 mL / 30 days), PA

VRAYLAR 1.5mg 5 QL (60 caps / 30 days), PA

VRAYLAR 3mg, 4.5mg, 6mg 5 QL (30 caps / 30 days), PA

VRAYLAR THERAPY PACK 4 PA






44

ziprasidone hcl 4 QL (60 caps / 30 days)

ziprasidone mesylate 4 QL (6 injections / 3 days)

ZYPREXA RELPREVV 300mg 5 QL (2 vials / 28 days), PA

ZYPREXA RELPREVV 405mg 5 QL (1 vial / 28 days), PA

ZYPREXA RELPREVV INJ 210MG 4 QL (2 vials / 28 days), PA

TRASTORNO POR DÉFICIT DE ATENCIÓN E HIPERACTIVIDAD

(TDAH) amphetamine-dextroamphetamine cap sr 24hr 5 mg


amphetamine-dextroamphetamine cap sr 24hr 10 mg










amphetamine-dextroamphetamine tab 5 mg


amphetamine-dextroamphetamine tab 7.5 mg




amphetamine-dextroamphetamine tab 12.5 mg








atomoxetine hcl 10mg, 18mg, 25mg 4 QL (120 caps / 30 days)






45

atomoxetine hcl 40mg 4 QL (60 caps / 30 days)

atomoxetine hcl 60mg, 80mg, 100mg 4 QL (30 caps / 30 days)

dexmethylphenidate hcl TABS 2.5mg, 5mg


dexmethylphenidate hcl TABS 10mg 3 QL (60 tabs / 30 days)

guanfacine er (adhd) 3 PA; PA if 70 years and older

metadate er tab 20mg 4 QL (90 tabs / 30 days)

methylphenidate hcl TABS 5mg, 10mg 3 QL (180 tabs / 30 days)

methylphenidate hcl TABS 20mg 3 QL (90 tabs / 30 days)

methylphenidate hcl oral soln 5mg/5ml 4 QL (1800 mL / 30 days)

methylphenidate hcl oral soln 10mg/5ml

4 QL (900 mL / 30 days)

methylphenidate hcl tbcr 10 mg 4 QL (90 tabs / 30 days)

methylphenidate hcl tbcr 20mg 4 QL (90 tabs / 30 days)

HIPNÓTICOS doxepin hcl (sleep) 3 QL (30 tabs / 30

days)

HETLIOZ 5 NM, LA, PA

temazepam 7.5mg 4 QL (30 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year






46

temazepam 15mg 4 QL (60 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year

zolpidem tartrate TABS 2 QL (30 tabs / 30 days), PA; PA applies if 70 years and older after a 90 day supply in a calendar year

MIGRAÑA AIMOVIG 3 QL (1 pen / 30

days), PA

dihydroergotamine mesylate inj 1 mg/ml

5

dihydroergotamine mesylate nasal spr 4 mg/ml

5 QL (8 mL / 30 days), PA

eletriptan hydrobromide 4 QL (12 tabs / 30 days)

EMGALITY SOAJ 3 QL (2 pens / 30 days), PA

EMGALITY SOSY 120mg/ml 3 QL (2 syringes / 30 days), PA

ergotamine w/ caffeine TABS 4

naratriptan hcl 3 QL (12 tabs / 30 days)

rizatriptan benzoate 3 QL (18 tabs / 30 days)

rizatriptan benzoate odt 3 QL (18 tabs / 30 days)

sumatriptan SOLN 5mg/act 4 QL (24 inhalers / 30 days)

sumatriptan SOLN 20mg/act 4 QL (12 inhalers / 30 days)

sumatriptan inj 4mg/0.5ml 4 QL (18 injections / 30 days)

sumatriptan inj 6mg/0.5ml 4 QL (12 injections / 30 days)






47

sumatriptan succinate TABS 2 QL (12 tabs / 30 days)

zolmitriptan TABS 4 QL (12 tabs / 30 days)

zolmitriptan odt 4 QL (12 tabs / 30 days)

VARIOS AUSTEDO 6mg 5 QL (60 tabs / 30

days), NM, PA

AUSTEDO 9mg, 12mg 5 QL (120 tabs / 30 days), NM, PA

lithium carbonate CAPS 1

lithium carbonate TABS 2

lithium carbonate er 2

LITHIUM SOLN 8MEQ/5ML 4 LYRICA CR 3 QL (60 tabs / 30

days), PA

NUEDEXTA 4 QL (60 caps / 30 days), PA

pyridostigmine tab 60mg 3

riluzole 3

tetrabenazine 12.5mg 5 QL (240 tabs / 30 days), NM, PA

tetrabenazine 25mg 5 QL (120 tabs / 30 days), NM, PA

AGENTES PARA LA ESCLEROSIS MÚLTIPLE BETASERON 5 QL (14 syringes / 28

days), NM, PA

dalfampridine TB12 5 NM, PA

GILENYA 5 QL (28 caps / 28 days), NM, PA

glatiramer acetate 20mg/ml 5 QL (30 syringes / 30 days), NM, PA

glatiramer acetate 40mg/ml 5 QL (12 syringes / 28 days), NM, PA

glatopa 20mg/ml 5 QL (30 syringes / 30 days), NM, PA

glatopa 40mg/ml 5 QL (12 syringes / 28 days), NM, PA






48

AGENTES DE TERAPIA OSTEOMUSCULAR baclofen TABS 10mg, 20mg 3 cyclobenzaprine hcl TABS 5mg, 10mg 3 PA; PA if 70 years

and older

dantrolene sodium CAPS 4 tizanidine hcl TABS 2

NARCOLEPSIA/CATAPLEXIA armodafinil 50mg 3 QL (90 tabs / 30

days), PA armodafinil 150mg, 200mg, 250mg 3 QL (30 tabs / 30

days), PA XYREM 5 QL (540 mL / 30

days), NM, LA, PA

PSICOTERAPÉUTICO-VARIOS acamprosate calcium 4 buprenorphine hcl SUBL 3 QL (90 tabs / 30

days), PA buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg

4 QL (90 films / 30 days)

buprenorphine hcl-naloxone hcl dihydrate 4-1mg






buprenorphine hcl-naloxone hcl sl 2 QL (90 tabs / 30 days)

bupropion hcl (smoking deterrent) 3 CHANTIX 4 PA CHANTIX CONTINUING MONTH 4 PA CHANTIX STARTER PACK 4 PA disulfiram TABS 3 naloxone inj 0.4mg/ml 2 naloxone inj 1mg/ml 2 naltrexone hcl TABS 3 NARCAN 3 NICOTROL INHALER 4 NICOTROL NS 4 VIVITROL 5






49


ENDOCRINOS Y METABÓLICOS

ANDRÓGENOS ANADROL-50 5 PA ANDRODERM 4 QL (30 patches / 30

days), PA oxandrolone tab 2.5mg 3 PA

oxandrolone tab 10mg 4 PA

testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm

4 QL (300 grams / 30 days), PA

testosterone cypionate SOLN 3 PA

testosterone enanthate SOLN 3 PA

ANTIDIABÉTICOS, INYECTABLES BASAGLAR KWIKPEN 3 BD ALCOHOL SWABS 3 BD ULTRAFINE INSULIN SYRINGE 3 BD ULTRAFINE/NANO PEN NEEDLES 3 BYDUREON BCISE 3 QL (4 pens / 28

days) BYDUREON PEN 3 QL (4 pens / 28

days) BYETTA 4 QL (1 pen / 30 days)

FIASP 3 FIASP FLEXTOUCH 3 FIASP PENFILL 3 GAUZE PADS 2" X 2" 3 HUMULIN R INJ U-500 5 B/D HUMULIN R U-500 KWIKPEN 5 INSULIN PEN NEEDLE 3 INSULIN SAFETY NEEDLES 3 INSULIN SYRINGE 3 LEVEMIR 3 LEVEMIR FLEXTOUCH 3 NOVOLIN 70/30 3 (brand RELION not

covered)

NOVOLIN 70/30 FLEXPEN 3 (brand RELION not covered)

NOVOLIN N 3 (brand RELION not covered)





50

NOVOLIN N FLEXPEN 3 (brand RELION not covered)

NOVOLIN R 3 (brand RELION not covered)

NOVOLIN R FLEXPEN 3 (brand RELION not covered)

NOVOLOG 3 NOVOLOG 70/30 FLEXPEN 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 70/30 3 NOVOLOG PENFILL 3 OZEMPIC INJ 0.25 OR 0.5MG/DOSE 3 QL (1 pen / 28 days)

OZEMPIC INJ 1MG/DOSE 3 QL (2 pens / 28 days)

SOLIQUA 100/33 3 QL (10 pens / 30 days)

TRESIBA FLEXTOUCH 3 TRESIBA INJ 3 TRULICITY 3 QL (4 pens / 28

days) VICTOZA 3 QL (3 pens / 30

days) XULTOPHY 100/3.6 3 QL (5 pens / 30

days)

ANTIDIABÉTICOS, ORALES acarbose TABS 3 FARXIGA 3 QL (30 tabs / 30

days) glimepiride 1mg, 2mg 2 QL (90 tabs / 30

days) glimepiride 4mg 2 QL (60 tabs / 30

days) glip/metform tab 2.5-250mg 1 QL (240 tabs / 30

days) glip/metform tab 2.5-500mg 1 QL (120 tabs / 30

days) glip/metform tab 5-500mg 1 QL (120 tabs / 30

days) glipizide TABS 5mg 1 QL (240 tabs / 30

days)






51

glipizide TABS 10mg 1 QL (120 tabs / 30 days)

glipizide TB24 2.5mg, 5mg 1 QL (90 tabs / 30 days)

glipizide TB24 10mg 1 QL (60 tabs / 30 days)

glipizide xl 2.5mg, 5mg 1 QL (90 tabs / 30 days)

glipizide xl 10mg 1 QL (60 tabs / 30 days)

JANUMET 3 QL (60 tabs / 30 days)

JANUMET XR TAB 50-500MG 3 QL (60 tabs / 30 days)

JANUMET XR TAB 50-1000 3 QL (60 tabs / 30 days)

JANUMET XR TAB 100-1000 3 QL (30 tabs / 30 days)

JANUVIA 3 QL (30 tabs / 30 days)

JARDIANCE 10mg 3 QL (60 tabs / 30 days)

JARDIANCE 25mg 3 QL (30 tabs / 30 days)

JENTADUETO 3 QL (60 tabs / 30 days)

JENTADUETO TAB XR 2.5-1000 MG 3 QL (60 tabs / 30 days)

JENTADUETO TAB XR 5-1000 MG 3 QL (30 tabs / 30 days)

metformin er 500mg 1 QL (120 tabs / 30 days); (generic of GLUCOPHAGE XR)

metformin er 750mg 1 QL (60 tabs / 30 days); (generic of GLUCOPHAGE XR)

metformin hcl TABS 500mg 1 QL (150 tabs / 30 days)







52


nateglinide 1 QL (90 tabs / 30 days)

pioglitazone hcl 1 QL (30 tabs / 30 days)

repaglinide 2mg 1 QL (240 tabs / 30 days)

repaglinide .5mg, 1mg 1 QL (120 tabs / 30 days)

SYNJARDY TAB 5-500MG 3 QL (120 tabs / 30 days)

SYNJARDY TAB 5-1000MG 3 QL (60 tabs / 30 days)

SYNJARDY TAB 12.5-500MG 3 QL (60 tabs / 30 days)

SYNJARDY TAB 12.5-1000MG 3 QL (60 tabs / 30 days)

SYNJARDY XR TAB 5-1000MG 3 QL (60 tabs / 30 days)


SYNJARDY XR TAB 12.5-1000MG 3 QL (60 tabs / 30 days)


TRADJENTA 3 QL (30 tabs / 30 days)

XIGDUO XR TAB 2.5-1000MG 3 QL (60 tabs / 30 days)

XIGDUO XR TAB 5-500MG 3 QL (60 tabs / 30 days)




BISFOSFONATOS alendronate sodium tab 5 mg 1 alendronate sodium tab 10 mg 1






53

alendronate sodium tab 35 mg 1 alendronate sodium tab 40 mg 3 alendronate sodium tab 70 mg 1 ibandronate sodium tabs 3 B/D

PAMIDRONATE DISODIUM 6mg/ml 3 B/D

pamidronate disodium 30mg/10ml, 90mg/10ml

3 B/D

pamidronate inj 30mg 3 B/D

pamidronate inj 90mg 3 B/D

zoledronic acid inj 4mg/100ml 4 B/D, NM

zoledronic acid inj 5mg/100ml 4 B/D, NM

zoledronic inj 4mg/5ml 4 B/D, NM

AGENTES QUELANTES CHEMET 4 deferasirox TABS 5 NM, PA

JADENU 180mg 5 NM, LA, PA

JADENU SPRINKLE 5 NM, LA, PA kionex sus 15gm/60ml 3 LOKELMA 3 penicillamine TABS 5 sodium polystyrene sulfonate powder 3 sodium polystyrene sulfonate susp 3 sps susp 15gm/60ml 3 trientine hcl 5 PA

ANTICONCEPTIVOS altavera tab 2 alyacen 1/35 2 apri 2

aranelle 3 aubra 2 aviane 2 balziva 3 bekyree 3 blisovi fe 1.5/30 2 briellyn 3 camila 2 caziant pak 2






54

cryselle-28 2 cyclafem 1/35 2 cyclafem 7/7/7 2 cyred tab 2 dasetta 1/35 2 dasetta 7/7/7 2 deblitane 2 desogestrel & ethinyl estradiol 2 desogestrel-ethinyl estradiol (biphasic) 3 drospirenone-ethinyl estradiol 3 ELLA 3 eluryng 4 emoquette 2 enpresse-28 2 enskyce 2 errin 2 estarylla tab 0.25-35 2 ethynodiol diacet & eth estrad 2 ethynodiol tab 1-50 3 etonogestrel-ethinyl estradiol 4 falmina 2 femynor 2 gianvi tab 3-0.02mg 3 heather 2 incassia 2 introvale 3 isibloom 2 jasmiel 3 jolessa tab 0.15-0.03 mg 3 jolivette 2 juleber 2 junel 1.5/30 2 junel 1/20 2 junel fe 1.5/30 2 junel fe 1/20 2 kariva 3 kelnor 1/35 2 kelnor 1/50 3 kurvelo 2






55

larin 1.5/30 2 larin 1/20 2 larin fe 1.5/30 2 larin fe 1/20 2 larissia tab 2 leena tab 3 lessina 2 levonest 2 levonor/ethi tab 2 levonorgestrel & eth estradiol 2 levonorgestrel-ethinyl estradiol (91-day) 3 levora 0.15/30-28 2 loryna 3 low-ogestrel 2 lutera 2 lyza 2 marlissa 2 medroxyprogesterone acetate (contraceptive)

2

microgestin 1.5/30 2 microgestin 1/20 2 microgestin fe 1.5/30 2 microgestin fe 1/20 2 mili 2 mono-linyah tab 0.25-35 2 necon 0.5/35-28 3 nikki 3 nora-be tab 0.35mg 2 norethindrone (contraceptive) 2 norethindrone acet & eth estra 2 norgest/ethi tab 0.25/35 2 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

3

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

2

nortrel 0.5/35 (28) 3






56

nortrel 1/35 2 nortrel 7/7/7 2 ocella tab 3-0.03mg 3 orsythia 2 philith 3 pimtrea 3 pirmella 1/35 2 portia-28 2 previfem 2 reclipsen 2 setlakin tab 3 sharobel 2 sprintec 28 2 sronyx 2 syeda 3 tarina fe 1/20 2 tilia fe 3 tri-estarylla 2 tri-legest fe 3 tri-linyah 2 tri-lo marzia 3 tri-lo-estarylla 3 tri-lo-sprintec 3 tri-mili 2 tri-previfem 2 tri-sprintec 2 tri-vylibra 2 tri-vylibra lo 3 trivora-28 2 tulana 2 velivet 2 vienva 2 viorele 3 vyfemla 3 vylibra 2 xulane dis 150-35 4 zarah 3 zovia 1/35e 2






57

ENDOMETRIOSIS danazol CAPS 4 SYNAREL 5

REEMPLAZOS DE ENZIMAS ALDURAZYME 5 NM, LA, PA CARBAGLU 5 NM, LA, PA CERDELGA 5 NM, PA CEREZYME 5 NM, LA, PA CYSTADANE 5 NM, LA CYSTAGON 4 NM, LA, PA FABRAZYME 5 NM, LA, PA KUVAN 5 NM, LA, PA levocarnitine (metabolic modifiers) 4 B/D

LUMIZYME 5 NM, LA, PA miglustat 5 NM, PA

NAGLAZYME 5 NM, LA, PA nitisinone 5 NM, PA

NITYR 5 NM, LA, PA ORFADIN 5 NM, LA, PA sodium phenylbutyrate 5 NM, PA

ESTRÓGENOS DELESTROGEN 10mg/ml 4 estradiol PTWK 3 estradiol TABS 2 estradiol vaginal cream 3 estradiol vaginal tab 4 estradiol valerate inj 4 fyavolv 3 jinteli 3 norethindrone acetate-ethinyl estradiol 3 yuvafem vaginal tablet 10mcg 4

GLUCOCORTICOIDES cortisone acetate TABS 4 DEXAMETHASONE CONC 4 dexamethasone ELIX; SOLN 3 dexamethasone TABS 2 dexamethasone sodium phosphate 2






58

fludrocortisone acetate TABS 2

hydrocortisone TABS 3

methylpr ss inj 3 B/D

methylpred pak 4mg 2

methylpred tab 4mg 3 B/D




methylprednisolone acetate 2 B/D

pred sod pho sol 5mg/5ml 4 B/D

prednisolone sodium phosphate SOLN 15mg/5ml

2 B/D

prednisolone sol 15mg/5ml 2 B/D

prednisolone sol 25mg/5ml 4 B/D

PREDNISONE CON 5MG/ML 4 B/D prednisone pak 5mg 3

prednisone pak 10mg 3

prednisone sol 5mg/5ml 4 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D





SOLU-CORTEF 4

AGENTES QUE ELEVAN EL NIVEL DE LA GLUCOSAGLUCAGEN HYPOKIT 3 GLUCAGON EMERGENCY KIT 3 PROGLYCEM SUS 50MG/ML 4

VARIOS cabergoline 3

calcitonin (salmon) 3 B/D

cinacalcet hcl 30mg, 90mg 5 B/D, QL (120 tabs / 30 days), NM

cinacalcet hcl 60mg 5 B/D, QL (60 tabs / 30 days), NM

FORTEO 5 PA GENOTROPIN 5 NM, PA GENOTROPIN MINIQUICK .2mg 3 NM, PA






59

GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg

5 NM, PA

INCRELEX 5 NM, LA, PA

KORLYM 5 NM, LA, PA LUPRON DEP-PED INJ 7.5MG 5 NM, PA LUPRON DEP-PED INJ 11.25MG (3-MONTH)

5 NM, PA

LUPRON DEPOT-PED (1-MONTH 5 NM, PA LUPRON DEPOT-PED (3-MONTH 5 NM, PA NATPARA 5 NM, PA octreotide acetate 50mcg/ml, 100mcg/ml, 200mcg/ml

4 NM, PA

octreotide acetate 500mcg/ml, 1000mcg/ml

5 NM, PA

OSPHENA 3 PA PROLIA 4 QL (1 injection / 180

days), NM

raloxifene tab 60mg 3

SIGNIFOR 5 NM, LA, PA SOMATULINE DEPOT 5 NM, PA SOMAVERT 5 NM, LA, PA TYMLOS 5 NM, PA XGEVA 5

NM, PA

AGENTES AGLUTINANTES DEL FOSFATOAURYXIA 5 QL (360 tabs / 30

days), PA

calcium acetate (phosphate binder) CAPS


calcium acetate (phosphate binder) TABS


sevelamer carbonate PACK 2.4gm 5 QL (180 packets / 30 days)

sevelamer carbonate PACK .8gm 5 QL (540 packets / 30 days)

sevelamer carbonate TABS 4 QL (540 tabs / 30 days)






60

PROGESTINAS medroxyprogesterone acetate tab 1 norethindrone acetate TABS 3

AGENTES TIROIDEOS euthyrox 2 levo-t 2 levothyroxine sodium TABS 2 levoxyl 2 liothyronine sodium TABS 3 methimazole TABS 1 propylthiouracil TABS 3 SYNTHROID 4 unithroid 2

VASOPRESINAS desmopressin acetate spray 4 desmopressin acetate spray refrigerated 4 desmopressin acetate tabs 3 desmopressin inj 4mcg/ml 4 STIMATE 5 NM


GASTROINTESTINAL

ANTIEMÉTICOS aprepitant 4 B/D

aprepitant pak 80mg & 125mg 4 B/D

compro supp 4 dronabinol 4 B/D, QL (60 caps /

30 days)

EMEND SUSR 4 B/D granisetron hcl SOLN 3 granisetron hcl TABS 4 B/D

meclizine hcl TABS 2 metoclopramide hcl SOLN 2 metoclopramide hcl TABS 1 metoclopramide hcl inj 2 ondansetron hcl TABS 3 B/D

ondansetron hcl inj 2 ondansetron hcl oral soln 4 B/D

ondansetron odt 2 B/D

prochlorperazine inj 4





61

prochlorperazine maleate TABS 2 prochlorperazine supp 4 promethazine hcl SYRP; TABS 2 PA; PA if 70 years

and older

promethazine hcl inj 4 PA; PA if 70 years and older

scopolamine 4 QL (10 patches / 30 days), PA; PA if 70 years and older

ANTIESPASMÓDICOS dicyclomine hcl cap 10mg 3 dicyclomine hcl soln 10mg/5ml 4 dicyclomine hcl tab 20mg 3 glycopyrrolate tab 1mg 3 glycopyrrolate tab 2mg 3

ANTAGONISTAS DE LOS RECEPTORES H2famotidine SUSR 4 famotidine TABS 20mg, 40mg 1 famotidine in nacl 2 famotidine inj 2 ranitidine hcl inj 3 ranitidine hcl tab 150mg 1 ranitidine hcl tab 300mg 1 ranitidine syrup 3

ENFERMEDAD INTESTINAL INFLAMATORIAbalsalazide disodium 3 budesonide ec 4 colocort 4 hydrocortisone (enema) 4 mesalamine CPDR 4 mesalamine ENEM 4 mesalamine SUPP 5 mesalamine TBEC 1.2gm 4 mesalamine w/ cleanser 4 sulfasalazine TABS 2 sulfasalazine ec 3






62

LAXANTES constulose 3 enulose 3 gavilyte-c 2 gavilyte-g 2 gavilyte-n/flavor pack 2 generlac 3 GOLYTELY 3 lactulose SOLN 3 lactulose (encephalopathy) 3 NULYTELY/FLAVOR PACKS 3 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

2

peg 3350-potassium chloride-sod bicarbonate-sod chloride

2

PLENVU 4 SUPREP BOWEL PREP KIT 4 trilyte 2

VARIOS alosetron hcl 5 PA

AMITIZA CAP 8MCG 3 QL (180 caps / 30 days)

AMITIZA CAP 24MCG 3 QL (60 caps / 30 days)

cromolyn sodium (mastocytosis) 5 diphenoxylate w/ atropine LIQD 4 diphenoxylate w/ atropine TABS 3 GATTEX 5 NM, LA, PA LINZESS 4 QL (30 caps / 30

days) loperamide hcl CAPS 3 misoprostol TABS 3 MOVANTIK 12.5mg 3 QL (60 tabs / 30

days) MOVANTIK 25mg 3 QL (30 tabs / 30

days) RELISTOR SOLN 5 PA

sucralfate TABS 2 ursodiol CAPS 3






63

ursodiol TABS 4 XIFAXAN 550mg 5 PA

ENZIMAS PANCREÁTICAS CREON 3 ZENPEP 4

INHIBIDORES DE LA BOMBA DE PROTONESDEXILANT 4 QL (30 caps / 30

days) esomeprazole magnesium CPDR 4 QL (30 caps / 30

days), ST lansoprazole CPDR 3 QL (30 caps / 30

days) omeprazole cap 10mg 1 omeprazole cap 20mg 1 omeprazole cap 40mg 1 pantoprazole sodium SOLR 4 pantoprazole sodium tbec 1


GENITOURINARIO

HIPERPLASIA PROSTÁTICA BENIGNA alfuzosin hcl 2 QL (30 tabs / 30

days) dutasteride CAPS 3 QL (30 caps / 30

days) dutasteride-tamsulosin hcl 4 QL (30 caps / 30

days) finasteride TABS 5mg 1 tamsulosin hcl 2

VARIOS bethanechol chloride TABS 3 potassium citrate (alkalinizer) er tabs 4

ANTIESPASMÓDICOS URINARIOS MYRBETRIQ 4 QL (30 tabs / 30

days) oxybutynin chloride SYRP 3 oxybutynin chloride TABS 3 oxybutynin chloride TB24 5mg 3 QL (30 tabs / 30

days)





64

oxybutynin chloride TB24 10mg, 15mg 3 QL (60 tabs / 30 days)

tolterodine tartrate CP24 4 QL (30 caps / 30 days), ST

tolterodine tartrate TABS 4 ST

TOVIAZ 3 QL (30 tabs / 30 days)

trospium chloride TABS 3 QL (60 tabs / 30 days)

ANTIINFECCIOSOS VAGINALES clindamycin phosphate vaginal 3 metronidazole vaginal 4 terconazole vaginal 3 vandazole 4


HEMATOLÓGICO

ANTICOAGULANTES COUMADIN 3 ELIQUIS 2.5mg 3 QL (60 tabs / 30

days) ELIQUIS 5mg 3 QL (74 tabs / 30

days) ELIQUIS STARTER PACK 3 QL (74 tabs / 30

days) enoxaparin sodium 4 fondaparinux sodium 2.5mg/0.5ml 4 fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

5

heparin sod (porcine) in d5w 3 heparin sod inj 1000/ml 3 B/D

heparin sod inj 5000/ml 3 B/D



HEPARIN SODIUM/NACL 0.45% 3 jantoven 1 PRADAXA 4 QL (60 caps / 30

days) warfarin sodium 1 XARELTO 2.5mg 3 QL (60 tabs / 30

days)





65

XARELTO 10mg, 15mg, 20mg 3 QL (30 tabs / 30 days)

XARELTO STARTER PACK 3 QL (51 tabs / 30 days)

FACTORES DE CRECIMIENTO HEMATOPOYÉTICOSPROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

3 NM, PA

PROCRIT 20000unit/ml, 40000unit/ml 5 NM, PA

ZARXIO 5 NM, PA

VARIOS anagrelide hcl 4 BERINERT 5 QL (24 boxes / 30

days), NM, LA, PA cilostazol 2 DROXIA 3 ENDARI 5 NM, LA, PA HAEGARDA 2000unit 5 QL (30 vials / 30

days), NM, LA, PA HAEGARDA 3000unit 5 QL (20 vials / 30

days), NM, LA, PA icatibant acetate 5 QL (9 syringes / 30

days), NM, PA pentoxifylline TBCR 2 PROMACTA PACK 12.5mg 5 QL (360 packets /


PROMACTA TABS 12.5mg, 25mg 5 QL (30 tabs / 30 days), NM, LA, PA

PROMACTA TABS 50mg, 75mg 5 QL (60 tabs / 30 days), NM, LA, PA

tranexamic acid SOLN 4 tranexamic acid TABS 3

INHIBIDORES DE AGREGACIÓN PLAQUETARIAaspirin-dipyridamole 4 BRILINTA 3 clopidogrel tab 75mg 1 prasugrel hcl 3






66


AGENTES INMUNOLÓGICOS

FÁRMACOS ANTIRREUMÁTICOS MODIFICADORES DE LA

ENFERMEDAD (FARME) ENBREL SOLR 5 QL (16 vials / 28

days), NM, PA ENBREL SOSY 25mg/0.5ml 5 QL (16 syringes / 28

days), NM, PA ENBREL SOSY 50mg/ml 5 QL (8 syringes / 28

days), NM, PA ENBREL MINI 5 QL (8 injections / 28

days), NM, PA ENBREL SURECLICK 5 QL (8 injections / 28

days), NM, PA HUMIRA 10mg/0.1ml, 20mg/0.2ml 5 QL (2 injections / 28

days), NM, PA HUMIRA 40mg/0.4ml 5 QL (6 injections / 28

days), NM, PA HUMIRA INJ 10MG/0.2ML 5 QL (2 syringes / 28

days), NM, PA HUMIRA KIT 20MG/0.4ML 5 QL (2 syringes / 28

days), NM, PA HUMIRA KIT 40MG/0.8ML 5 QL (6 syringes / 28

days), NM, PA HUMIRA PEDIATRIC CROHNS DISEASE 5 NM, PA HUMIRA PEN 5 QL (6 pens / 28

days), NM, PA HUMIRA PEN CD/UC/HS STARTER 5 NM, PA HUMIRA PEN INJ CD/UC/HS STARTER 5 NM, PA HUMIRA PEN INJ PS/UV STARTER 5 NM, PA HUMIRA PEN-PS/UV STARTER 5 NM, PA hydroxychloroquine sulfate 3 leflunomide TABS 3 QL (30 tabs / 30

days) methotrexate sodium tabs 3 REMICADE 5 NM, PA RENFLEXIS 5 NM, LA, PA RINVOQ 5 QL (30 tabs / 30

days), NM, PA SKYRIZI 5 QL (7 injections /

year), NM, PA





67

STELARA SOLN 45mg/0.5ml 5 QL (1 vial / 28 days), NM, LA, PA

STELARA SOSY 5 QL (1 syringe / 28 days), NM, PA

XATMEP 4 B/D XELJANZ 5 QL (60 tabs / 30

days), NM, PA

XELJANZ XR 5 QL (30 tabs / 30 days), NM, PA

INMUNOGLOBULINAS BIVIGAM 5 NM, PA GAMASTAN S/D 3 B/D, NM GAMMAGARD LIQUID 5 NM, PA GAMMAGARD S/D 5 NM, PA GAMMAKED 5 NM, PA GAMMAPLEX 5 NM, PA GAMMAPLEX 10GM/100ML 5 NM, PA GAMUNEX-C 5 NM, PA OCTAGAM 5 NM, PA PANZYGA 5 NM, PA PRIVIGEN 5 NM, PA

INMUNOMODULADORES ACTIMMUNE 5 NM, LA, PA ARCALYST 5 NM, PA INTRON-A INJ 10MU 5 B/D INTRON-A INJ 18MU 5 B/D INTRON-A INJ 25MU 5 B/D INTRON-A INJ 50MU 5 B/D

INMUNOSUPRESORES azathioprine TABS 3 B/D

BENLYSTA 5 NM, PA cyclosporine CAPS; SOLN 4 B/D

cyclosporine modified (for microemulsion)

4 B/D

everolimus (immunosuppressant) .5mg, .75mg

5 B/D

everolimus (immunosuppressant) .25mg

4 B/D






68

gengraf 4 B/D

mycophenolate mofetil CAPS; TABS 3 B/D

mycophenolate mofetil SUSR 5 B/D

mycophenolate sodium tbec 4 B/D

NULOJIX 5 B/D PROGRAF PACK 4 B/D SANDIMMUNE SOLN 100mg/ml 3 B/D

sirolimus SOLN 5 B/D

sirolimus TABS 2mg 5 B/D

sirolimus TABS .5mg, 1mg 4 B/D

tacrolimus CAPS 4 B/D

ZORTRESS TAB 0.5MG 5 B/D ZORTRESS TAB 0.25MG 5 B/D ZORTRESS TAB 0.75MG 5 B/D ZORTRESS TAB 1MG 5 B/D

VACUNAS ACTHIB 3 ADACEL 3 BCG VACCINE 3 BEXSERO 3 BOOSTRIX 3 DAPTACEL 3 DIPHTHERIA/TETANUS TOXOID 3 B/D ENGERIX-B SUSP 3 B/D GARDASIL 9 3 HAVRIX 3 HIBERIX 3 IMOVAX RABIES (H.D.C.V.) 3 B/D INFANRIX 3 IPOL INACTIVATED IPV 3 IXIARO 3 KINRIX 3 M-M-R II 3 MENACTRA 3 MENVEO 3 PEDIARIX 3 PEDVAX HIB 3 PENTACEL 3 PROQUAD 3






69

QUADRACEL 3 RABAVERT 3 B/D RECOMBIVAX HB 3 B/D ROTARIX 3 ROTATEQ 3 SHINGRIX 3 QL (2 vials per

lifetime)

TDVAX 3 B/D TENIVAC 3 B/D TRUMENBA 3 TWINRIX INJ 3 TYPHIM VI 3 VAQTA 3 VARIVAX 3 YF-VAX 3 ZOSTAVAX 3 QL (1 vial per

lifetime)


COMPLEMENTOS NUTRICIONALES

ELECTROLITOS klor-con 8 2 klor-con 10 2 klor-con m10 2 klor-con m15 2 klor-con m20 2 klor-con pak 20meq 4 klor-con spr cap 8meq 3 klor-con spr cap 10meq 3 MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

3

magnesium sulfate SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50%

3

MAGNESIUM SULFATE IN D5W 3 magnesium sulfate in dextrose 3 magnesium sulfate inj 50% 3 potassium chloride CPCR 3 potassium chloride PACK 4





70

potassium chloride SOLN 10%, 20% 4

potassium chloride TBCR 2

potassium chloride microencapsulated crystals er

2

sodium chloride SOLN 2.5meq/ml 3

sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

2

TPN ELECTROLYTES 4 B/D

NUTRICIÓN INTRAVENOSA (IV) AMINOSYN II INJ 10% 4 B/D

AMINOSYN-PF 7% 4 B/D AMINOSYN-PF INJ 10% 4 B/D CLINIMIX 4.25%/DEXTROSE 5% 4 B/D CLINIMIX 5%/DEXTROSE 15% 4 B/D CLINIMIX 5%/DEXTROSE 20% 4 B/D CLINIMIX INJ 4.25/D10 4 B/D clinisol sf 15% 4 B/D

CLINOLIPID 4 B/D FREAMINE HBC 6.9% 4 B/D FREAMINE III 4 B/D hepatamine 4 B/D

INTRALIPID 30% 4 B/D INTRALIPID INJ 20% 4 B/D NEPHRAMINE 4 B/D NUTRILIPID INJ 20% 4 B/D plenamine 4 B/D

PREMASOL 10% 4 B/D PROCALAMINE 4 B/D PROSOL 4 B/D TRAVASOL 4 B/D TROPHAMINE INJ 10% 4 B/D

SOLUCIONES DE REEMPLAZO INTRAVENOSO (IV) dextrose 2.5%/nacl 0.45% 2

dextrose 5% 2

DEXTROSE 5% /ELECTROLYTE 3 dextrose 5%/nacl 0.2% 2

DEXTROSE 5%/NACL 0.3% 4 dextrose 5%/nacl 0.9% 2

dextrose 5%/nacl 0.45% 2






71

dextrose 5%/nacl 0.225% 2 dextrose 5%/potassium chl 2 dextrose 10% flex contain 2 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3

dextrose 10%/nacl 0.45% 2 dextrose 50% 2 dextrose in lactated ringers 2 dextrose inj 70% 2 ISOLYTE P 4 ISOLYTE S 4 kcl0.15%/d5w/nacl0.2% 3 KCL 0.3%/D5W/NACL 0.9% 4 kcl 0.3%/d5w/nacl 0.45% 3 kcl 0.15%/d5w/nacl 0.9% 3 KCL 0.15%/D5W/NACL 0.225% 4 kcl 0.075%/d5w/nacl 0.45% 3 kcl/d5w inj 0.3% 2 kcl/d5w/nacl inj 0.22%/0.45% 3 kcl/d5w/nacl inj .15/.45% 3 kcl/nacl inj 0.3-0.9 2 kcl/nacl inj 0.15%-0.9% 2 lactated ringer's 2 NORMOSOL-M IN D5W 4 NORMOSOL-R 4 NORMOSOL-R IN D5W 4 PLASMA-LYTE A 4 PLASMA-LYTE-148 4 pot chloride inj 2meq/ml 2 potassium chloride SOLN 2meq/ml 2 POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

2

potassium chloride in nacl 2 sodium chloride SOLN 3%, 5% 3 sodium chloride 0.45% 3 sodium chloride inj 0.9% 3






72

VITAMINAS calcitriol CAPS 2 B/D

calcitriol inj 4 B/D

calcitriol oral soln 1 mcg/ml 4 B/D

M-NATAL PLUS 3 paricalcitol CAPS 4 B/D

PNV FOLIC ACID + IRON MUL 3 PRENATAL 3 PRENATAL PLUS 3 PRENATAL PLUS LOW IRON 3 RAYALDEE 5 TRICARE 3


OFTÁLMICOS

ANTIINFECCIOSO/ANTIINFLAMATORIO bacitracin-poly-neomycin-hc 3 BLEPHAMIDE OINT 4 neomycin-polymy-dexameth 2 neomycin-polymyxin-hc (ophth) 4 sulfacetamide sod-prednisolone 2 TOBRADEX OINT 3 TOBRADEX ST 3 tobramycin-dexamethasone 4 ZYLET 3

ANTIINFECCIOSOS AZASITE 4 bacitracin (ophthalmic) 3 bacitracin-polymyxin b (ophth) 2 BESIVANCE 3 CILOXAN OINT 3 ciprofloxacin hcl (ophth) 2 erythromycin (ophth) 2 gatifloxacin (ophth) 3 gentak 2 gentamicin sulfate soln (ophth) 2 MOXEZA 3 moxifloxacin hcl (ophth) 3 NATACYN 4 neomycin-bacitracin zn-polymyxin 3





73

neomycin-polymyxin-gramicidin 3 ofloxacin (ophth) 2 polymyxin b-trimethoprim 2 sulfacetamide sodium (ophth) 3 tobramycin (ophth) 2 trifluridine 3 ZIRGAN 4

ANTIINFLAMATORIOS ALREX 3 bromfenac sodium (ophth) 4 BROMSITE 4 dexamethasone sodium phosphate (ophth)

3

diclofenac sodium (ophth) 3 DUREZOL 3 fluorometholone 3 flurbiprofen sodium 3 ILEVRO 3 ketorolac tromethamine (ophth) .4% 3 ketorolac tromethamine (ophth) .5% 2 LOTEMAX GEL; OINT 3 loteprednol etabonate 3 prednisolone acetate (ophth) 3 PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

3

PROLENSA 3

ANTIALÉRGICOS azelastine drop 0.05% 3 BEPREVE 3 cromolyn sodium (ophth) 1 LASTACAFT 4 olopatadine hcl 0.2% 4 PAZEO 3

ANTIGLAUCOMA ALPHAGAN P SOL 0.1% 3 AZOPT 3 betaxolol hcl (ophth) 3






74

BETOPTIC-S 3 brimonidine sol 0.2% 1 brimonidine sol 0.15% 4 carteolol hcl (ophth) 2 COMBIGAN 3 dorzolamide hcl 2 dorzolamide hcl-timolol maleate 2 latanoprost SOLN 2 levobunolol hcl 2 LUMIGAN 3 PHOSPHOLINE IODIDE 4 pilocarpine hcl SOLN 3 RHOPRESSA 3 SIMBRINZA 3 timolol maleate (ophth) soln 1 timolol maleate gel 4 timolol maleate ophth soln 0.5% (once-daily)

4

travoprost 4

VARIOS ATROPINE SULFATE SOLN 1% 3 CYSTARAN 5 NM, LA, PA proparacaine hcl SOLN 3 RESTASIS 3 QL (60 single use

vials / 30 days) RESTASIS MULTIDOSE 3 QL (1 bottle / 30

days)


RESPIRATORIOS

COMBINACIONES DE ANTICOLINÉRGICOS/BETA AGONISTAS ANORO ELLIPTA 3 QL (60 blisters / 30

days) BEVESPI AEROSPHERE 3 QL (1 inhaler / 30

days) COMBIVENT RESPIMAT 4 QL (2 inhalers / 30

days) ipratropium-albuterol nebu 3 B/D TRELEGY ELLIPTA 3 QL (60 blisters / 30

days)





75

ANTICOLINÉRGICOS ATROVENT HFA 4 QL (2 inhalers / 30

days)

INCRUSE ELLIPTA 3 QL (30 blisters / 30 days)

ipratropium bromide SOLN 2 B/D

ipratropium bromide (nasal) 3

ANTIHISTAMÍNICOS azelastine spr 0.1% 3

azelastine spr 0.15% 3

cetirizine syrup 2

cyproheptadine hcl SYRP; TABS 3 PA; PA if 70 years and older

diphenhydramine hcl inj 50mg/ml 3

hydroxyzine hcl SYRP 3 PA; PA if 70 years and older

hydroxyzine hcl TABS 2 PA; PA if 70 years and older

hydroxyzine hcl inj 4 PA; PA if 70 years and older

hydroxyzine pamoate CAPS 25mg, 50mg


levocetirizine dihydrochloride SOLN 4

levocetirizine dihydrochloride TABS 2

BETA AGONISTAS albuterol sulfate AERS 108mcg/act 3 QL (2 inhalers / 30

days); (generic of Proair HFA)

albuterol sulfate AERS 108mcg/act 3 QL (2 inhalers / 30 days); (generic of Ventolin HFA)

albuterol sulfate NEBU .63mg/3ml, 1.25mg/3ml, 2.5mg/0.5ml

3 B/D

albuterol sulfate NEBU .083% 2 B/D

albuterol sulfate SYRP 2

albuterol sulfate TABS 4

albuterol sulfate TB12 3

levalbuterol hcl NEBU 1.25mg/3ml 4 B/D






76

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml

4 B/D

levalbuterol tartrate hfa 3 QL (2 inhalers / 30 days)

SEREVENT DISKUS 3 QL (60 inhalations / 30 days)

terbutaline sulfate TABS 4

VENTOLIN HFA 3 QL (2 inhalers / 30 days)

MODULADORES DE LEUCOTRIENOS montelukast sodium CHEW 2

montelukast sodium PACK 4

montelukast sodium TABS 1

zafirlukast 3

AGENTES ESTABILIZADORES DE MASTOCITOScromolyn sod neb 20mg/2ml 3 B/D

VARIOS acetylcysteine SOLN 10%, 20% 3 B/D

ARALAST NP 5 NM, LA, PA DALIRESP 4 epinephrine (anaphylaxis) .15mg/0.3ml, .3mg/0.3ml

3 (generic of EpiPen)

epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

3 (generic of Adrenaclick)

ESBRIET 5 NM, PA KALYDECO 5 NM, PA NUCALA 5 NM, LA, PA OFEV 5 NM, PA ORKAMBI 5 NM, PA PROLASTIN-C 5 NM, LA, PA PULMOZYME 5 NM, PA SYMDEKO 5 NM, LA, PA SYMJEPI 4 THEO-24 4 theophylline 4

theophylline tab er 12hr 300 mg 4

theophylline tab er 12hr 450 mg 4

theophylline tab sr 24hr 3

TRIKAFTA 5 NM, LA, PA






77

XOLAIR 5 NM, LA, PA

ZEMAIRA 5 NM, LA, PA

ESTEROIDES NASALES flunisolide (nasal) 3 QL (3 bottles / 30

days)

fluticasone propionate (nasal) 2 QL (1 bottle / 30 days)

INHALANTES ESTEROIDES ARNUITY ELLIPTA 3 QL (30 inhalations /

30 days)

budesonide (inhalation) .25mg/2ml, .5mg/2ml

4 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist

3 QL (120 inhalations / 30 days)

FLOVENT DISKUS 250mcg/blist 3 QL (240 inhalations / 30 days)

FLOVENT HFA 3 QL (2 inhalers / 30 days)

PULMICORT FLEXHALER 4 QL (2 inhalers / 30 days)

COMBINACIONES DE ESTEROIDES/BETA AGONISTAS ADVAIR DISKUS 3 QL (60 inhalations /

30 days)

ADVAIR HFA 3 QL (1 inhaler / 30 days)

BREO ELLIPTA 3 QL (60 blisters / 30 days)

SYMBICORT 3 QL (1 inhaler / 30 days)


USO TÓPICO

DERMATOLOGÍA, ACNÉ amnesteem 4 PA

avita 4 QL (45 grams / 30 days), PA

benzoyl peroxide-erythromycin 4

claravis 4 PA

clindamycin phosphate (topical) GEL 4 QL (75 grams / 30 days)





78

clindamycin phosphate (topical) LOTN 3 clindamycin phosphate (topical) SOLN 4 QL (60 mL / 30

days)

ery pad 2% 3 erythromycin (acne aid) GEL 4 erythromycin (acne aid) SOLN 3 isotretinoin CAPS 4 PA

myorisan 4 PA

sulfacetamide sodium (acne) 4 tretinoin CREA 4 QL (45 grams / 30

days), PA tretinoin GEL .01%, .025% 4 QL (45 grams / 30

days), PA zenatane 4 PA

DERMATOLOGÍA, ANTIBIÓTICOS gentamicin sulfate (topical) CREA 4 gentamicin sulfate (topical) OINT 3 mupirocin OINT 2 QL (220 grams / 30

days) silver sulfadiazine CREA 2 ssd 2 SULFAMYLON CREA 4

DERMATOLOGÍA, ANTIFÚNGICOS ciclopirox CREA 3 QL (90 grams / 30

days) ciclopirox SUSP 3 QL (60 mL / 30

days)

clotrimazole (topical) CREA 3 clotrimazole (topical) SOLN 3 QL (30 mL / 30

days)

clotrimazole w/ betamethasone CREA 3 ketoconazole cream 3 QL (60 grams / 30

days) nyamyc 3 QL (60 grams / 30

days) nystatin (topical) CREA; OINT 3 nystatin (topical) POWD 3 QL (60 grams / 30

days) nystop 3 QL (60 grams / 30

days)






79

DERMATOLOGÍA, ANTIPSORIÁSICOS acitretin 4 PA

calcipotriene CREA; OINT 4 QL (120 grams / 30 days), PA

calcipotriene SOLN 4 QL (120 mL / 30 days), PA

calcitrene 4 QL (120 grams / 30 days), PA

tazarotene CREA 3 QL (60 grams / 30 days), PA

TAZORAC CREA .05% 4 QL (60 grams / 30 days), PA

DERMATOLOGÍA, ANTISEBORREICOS ketoconazole shampoo 2 selenium sulfide LOTN 2

DERMATOLOGÍA, CORTICOSTEROIDES ala-cort cre 1% 1 ala-cort cre 2.5% 2 alclometasone dipropionate CREA 4 alclometasone dipropionate OINT 3 betamethasone dipropionate (topical) CREA; LOTN

3

betamethasone dipropionate (topical) OINT

4

betamethasone dipropionate augmented CREA

3

betamethasone dipropionate augmented GEL; LOTN; OINT

4

betamethasone valerate CREA; LOTN; OINT

3

ENSTILAR 4 QL (120 grams / 30 days), PA

fluocinolone acetonide CREA; OINT 3 fluocinolone acetonide OIL 4 fluocinolone acetonide SOLN 4 QL (90 mL / 30

days) fluocinolone acetonide oil body 4






80

fluocinonide CREA .05% 4 QL (120 grams / 30 days)

fluocinonide GEL 4 QL (60 grams / 30 days)

fluocinonide OINT 4 QL (60 grams / 30 days)

fluocinonide SOLN 4 QL (60 mL / 30 days)

fluocinonide emulsified base 4 QL (120 grams / 30 days)

fluticasone propionate CREA; OINT 3 halobetasol propionate CREA; OINT 4 QL (50 grams / 30

days) hydrocortisone (topical) cream 1% 1 hydrocortisone (topical) cream 2.5% 2 hydrocortisone (topical) lotion 2.5% 3 hydrocortisone (topical) oint 2.5% 2 hydrocortisone butyrate cream 0.1% 4 QL (45 grams / 30

days) hydrocortisone butyrate oint 0.1% 4 QL (45 grams / 30

days) mometasone furoate CREA; OINT; SOLN

3

TEXACORT SOLN 2.5% 4 triamcinolone acetonide (topical) CREA .1%

2 QL (454 grams / 30 days)

triamcinolone acetonide (topical) CREA .025%, .5%

2

triamcinolone acetonide (topical) LOTN 3 triamcinolone acetonide (topical) OINT .025%, .1%, .5%

2

DERMATOLOGÍA, ANESTÉSICOS LOCALESglydo 3 QL (30 mL / 30

days), PA

lidocaine PTCH 5% 4 QL (3 patches / 1 day), PA

lidocaine hcl GEL 3 QL (30 mL / 30 days), PA

lidocaine hcl SOLN 4% 3 QL (50 mL / 30 days), PA






81

lidocaine oint 5% 4 QL (50 grams / 30 days), PA

lidocaine-prilocaine 3 QL (30 grams / 30 days), PA

DERMATOLOGÍA, PIEL Y MEMBRANAS MUCOSAS VARIASammonium lactate CREA 2 ammonium lactate LOTN 3 diclofenac sodium (topical) 1% gel 3 QL (1000 grams /

30 days), PA

fluorouracil (topical) CREA 5% 4 QL (40 grams / 30 days)

fluorouracil (topical) SOLN 3 QL (10 mL / 30 days)

imiquimod CREA 5% 3 QL (24 packets / 30 days)

metronidazole (topical) CREA; LOTN 4 metronidazole gel 0.75% 4 PANRETIN 5 QL (60 grams / 30

days) PICATO .05% 4 QL (2 tubes / 30

days) PICATO .015% 4 QL (3 tubes / 30

days) podofilox SOLN 3 procto-med hc 3 procto-pak 3 proctosol hc cre 2.5% 3 proctozone-hc 3 RECTIV 4 QL (30 grams / 30

days) rosadan cre 0.75% 4 tacrolimus (topical) 4 QL (100 grams / 30

days) TARGRETIN GEL 5 QL (60 grams / 30

days), NM, PA VALCHLOR 5 QL (60 grams / 30

days), NM, LA, PA






82

DERMATOLOGÍA, ESCABICIDAS Y PEDICULICIDAS malathion 4 permethrin cre 5% 3

DERMATOLOGÍA, AGENTES PARA TRATAMIENTO DE HERIDASacetic acid .25% 2 REGRANEX 5 QL (30 grams / 30

days), PA SANTYL 4 sodium chlor sol 0.9% irr 2 water for irrigation, sterile 2

BOCA/GARGANTA/AGENTES DENTALES cevimeline hcl 4 chlorhexidine gluconate (mouth-throat) 1 clotrimazole LOZG 4 lidocaine hcl (mouth-throat) 2 nystatin (mouth-throat) 3 paroex sol 0.12% 1 periogard 1 pilocarpine hcl (oral) 4 triamcinolone acetonide (mouth) 3

ÓTICO acetic acid (otic) 3 CIPRODEX 3 flac 4 fluocinolone acetonide (otic) 4 neomycin-polymyxin-hc (otic) 3 ofloxacin (otic) 4



Índice

A abacavir sulfate ................................14 abacavir sulfate-lamivudine................16 abacavir sulfate-lamivudine-zidovudine16 ABELCET..........................................13 ABILIFY MAINTENA ...........................41 abiraterone acetate ...........................23 ABRAXANE.......................................21 acamprosate calcium.........................48 acarbose..........................................50 acebutolol hcl ...................................30 acetaminophen w/ codeine 300-15mg .. 9 acetaminophen w/ codeine 300-30mg .. 9 acetaminophen w/ codeine 300-60mg .. 9 acetaminophen w/ codeine soln ........... 9 acetazolamide ..................................32 acetic acid........................................82 acetic acid (otic) ...............................82 acetylcysteine ..................................76 acitretin...........................................79 ACTHIB ...........................................68 ACTIMMUNE.....................................67 acyclovir ..........................................17 acyclovir sodium ...............................17 ADACEL ...........................................68 adefovir dipivoxil ..............................17 ADEMPAS.........................................33 adriamycin .......................................21 adrucil inj ........................................21 ADVAIR DISKUS ...............................77 ADVAIR HFA.....................................77 AFINITOR ........................................24 AFINITOR DISPERZ ...........................24 AIMOVIG .........................................46 ala-cort cre 1% ................................79 ala-cort cre 2.5%..............................79 albendazole......................................12 albuterol sulfate................................75 alclometasone dipropionate................79 ALDURAZYME ...................................57 ALECENSA .......................................24 alendronate sodium tab 10 mg ...........52 alendronate sodium tab 35 mg ...........53 alendronate sodium tab 40 mg ...........53 alendronate sodium tab 5 mg .............52

alendronate sodium tab 70 mg .......... 53 alfuzosin hcl .................................... 63 ALIMTA ........................................... 21 ALINIA............................................ 12 aliskiren fumarate ............................ 32 allopurinol tab.................................... 8 alosetron hcl.................................... 62 ALPHAGAN P SOL 0.1%..................... 73 alprazolam tab 0.25mg ..................... 33 alprazolam tab 0.5mg....................... 33 alprazolam tab 1mg.......................... 33 alprazolam tab 2 mg......................... 33 ALREX ............................................ 73 altavera tab..................................... 53 ALUNBRIG....................................... 24 alyacen 1/35 ................................... 53 amantadine hcl ................................ 40 AMBISOME ...................................... 13 ambrisentan .................................... 33 amikacin sulfate............................... 11 amiloride & hydrochlorothiazide ......... 32 amiloride hcl.................................... 32 AMINOSYN II INJ 10%...................... 70 AMINOSYN-PF 7%............................ 70 AMINOSYN-PF INJ 10%..................... 70 amiodarone hcl soln ......................... 28 amiodarone tab 100mg ..................... 28 amiodarone tab 200mg ..................... 28 amiodarone tab 400mg ..................... 28 AMITIZA CAP 24MCG ........................ 62 AMITIZA CAP 8MCG.......................... 62 amitriptyline hcl ............................... 38 amlodipine besylate.......................... 30 amlodipine besylate-benazepril hcl cap 10-20 mg........................................ 27 amlodipine besylate-benazepril hcl cap 10-40 mg........................................ 27 amlodipine besylate-benazepril hcl cap 2.5-10 mg....................................... 27 amlodipine besylate-benazepril hcl cap 510 mg............................................. 27 amlodipine besylate-benazepril hcl cap 520 mg............................................. 27 amlodipine besylate-benazepril hcl cap 540 mg............................................. 27

83

84

amlodipine besylate-olmesartan medoxomil .......................................28 amlodipine besylate-valsartan tab.......28 amlodipine-valsartan-hydrochlorothiazide tab..................................................28 ammonium lactate ............................81 amnesteem ......................................77 amoxapine .......................................38 amoxicillin .......................................19 amoxicillin & pot clavulanate 200/5ml susr ................................................19 amoxicillin & pot clavulanate 200-28.5 chw tabs..........................................19 amoxicillin & pot clavulanate 250/5ml susr ................................................19 amoxicillin & pot clavulanate 250-125 tabs ................................................19 amoxicillin & pot clavulanate 400/5ml susr ................................................19 amoxicillin & pot clavulanate 400-57 chw tabs ................................................19 amoxicillin & pot clavulanate 500-125 tabs ................................................19 amoxicillin & pot clavulanate 600/5ml susr ................................................19 amoxicillin & pot clavulanate 875-125 tabs ................................................19 amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs.................................20 amphetamine-dextroamphetamine cap sr 24hr 10 mg......................................44 amphetamine-dextroamphetamine cap sr 24hr 15 mg......................................44 amphetamine-dextroamphetamine cap sr 24hr 20 mg......................................44 amphetamine-dextroamphetamine cap sr 24hr 25 mg......................................44 amphetamine-dextroamphetamine cap sr 24hr 30 mg......................................44 amphetamine-dextroamphetamine cap sr 24hr 5 mg........................................44 amphetamine-dextroamphetamine tab 10 mg .............................................44 amphetamine-dextroamphetamine tab 12.5 mg ..........................................44 amphetamine-dextroamphetamine tab 15 mg .............................................44

amphetamine-dextroamphetamine tab 20 mg............................................. 44 amphetamine-dextroamphetamine tab 30 mg............................................. 44 amphetamine-dextroamphetamine tab 5 mg .............................................. 44 amphetamine-dextroamphetamine tab 7.5 mg............................................ 44 amphotericin b................................. 13 ampicillin & sulbactam sodium ........... 20 ampicillin cap 500mg ........................ 20 ampicillin inj .................................... 20 ampicillin sodium ............................. 20 ANADROL-50 ................................... 49 anagrelide hcl .................................. 65 anastrozole ..................................... 23 ANDRODERM ................................... 49 ANORO ELLIPTA............................... 74 APOKYN .......................................... 40 aprepitant ....................................... 60 aprepitant pak 80mg & 125mg........... 60 apri ................................................ 53 APTIOM........................................... 34 APTIVUS ......................................... 14 ARALAST NP .................................... 76 aranelle .......................................... 53 ARCALYST ....................................... 67 aripiprazole odt................................ 41 aripiprazole oral solution 1 mg/ml ...... 41 aripiprazole tab................................ 41 ARISTADA ....................................... 41 ARISTADA INITIO............................. 41 armodafinil ...................................... 48 ARNUITY ELLIPTA............................. 77 aspirin-dipyridamole ......................... 65 atazanavir sulfate............................. 14 atenolol .......................................... 30 atenolol & chlorthalidone................... 30 atomoxetine hcl ..........................44, 45 atorvastatin calcium ......................... 29 atovaquone ..................................... 12 atovaquone-proguanil hcl .................. 14 ATRIPLA.......................................... 16 ATROPINE SULFATE.......................... 74 ATROVENT HFA................................ 75 aubra.............................................. 53 AURYXIA ......................................... 59 AUSTEDO........................................ 47


AVASTIN..........................................22 aviane .............................................53 avita ...............................................77 AYVAKIT ..........................................24 azacitidine .......................................21 AZASITE ..........................................72 azathioprine .....................................67 azelastine drop 0.05%.......................73 azelastine spr 0.1% ..........................75 azelastine spr 0.15%.........................75 azithromycin ....................................18 AZOPT.............................................73 aztreonam .......................................12 B bacitracin (ophthalmic)......................72 bacitracin-polymyxin b (ophth) ...........72 bacitracin-poly-neomycin-hc ..............72 baclofen ..........................................48 balsalazide disodium .........................61 BALVERSA .......................................24 balziva ............................................53 BANZEL SUS 40MG/ML ......................34 BANZEL TAB 200MG..........................34 BANZEL TAB 400MG..........................34 BARACLUDE .....................................17 BASAGLAR KWIKPEN.........................49 BCG VACCINE...................................68 BD ALCOHOL SWABS ........................49 BD ULTRAFINE INSULIN SYRINGE.......49 BD ULTRAFINE/NANO PEN NEEDLES....49 bekyree ...........................................53 benazepril & hydrochlorothiazide ........27 benazepril hcl ...................................27 BENDEKA.........................................21 BENLYSTA........................................67 benzoyl peroxide-erythromycin...........77 benztropine mesylate inj....................40 benztropine mesylate tab 0.5mg.........40 benztropine mesylate tab 1mg ...........40 benztropine mesylate tab 2mg ...........40 BEPREVE..........................................73 BERINERT........................................65 BESIVANCE......................................72 betamethasone dipropionate (topical)..79 betamethasone dipropionate augmented ......................................................79 betamethasone valerate ....................79

BETASERON .................................... 47 betaxolol hcl (ophth) ........................ 73 bethanechol chloride......................... 63 BETOPTIC-S .................................... 74 BEVESPI AEROSPHERE...................... 74 bexarotene...................................... 26 BEXSERO ........................................ 68 bicalutamide.................................... 23 BICILLIN L-A ................................... 20 BIKTARVY ....................................... 16 bisoprolol & hydrochlorothiazide......... 30 bisoprolol fumarate .......................... 30 BIVIGAM ......................................... 67 BLEPHAMIDE ................................... 72 blisovi fe 1.5/30............................... 53 BOOSTRIX....................................... 68 BORTEZOMIB................................... 22 bosentan......................................... 33 BOSULIF ......................................... 24 BRAFTOVI ....................................... 24 BREO ELLIPTA ................................. 77 briellyn ........................................... 53 BRILINTA ........................................ 65 brimonidine sol 0.15% ...................... 74 brimonidine sol 0.2%........................ 74 BRIVIACT INJ 50MG/5ML .................. 34 BRIVIACT SOL 10MG/ML ................... 34 BRIVIACT TAB 100MG....................... 34 BRIVIACT TAB 10MG ........................ 34 BRIVIACT TAB 25MG ........................ 34 BRIVIACT TAB 50MG ........................ 34 BRIVIACT TAB 75MG ........................ 34 bromfenac sodium (ophth) ................ 73 bromocriptine mesylate..................... 40 BROMSITE....................................... 73 BRUKINSA....................................... 24 budesonide (inhalation) .................... 77 budesonide ec.................................. 61 bumetanide inj 0.25/ml..................... 32 bumetanide tab................................ 32 buprenorphine hcl ............................ 48 buprenorphine hcl-naloxone hcl dihydrate 12-3mg........................................... 48 buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg.......................................... 48 buprenorphine hcl-naloxone hcl dihydrate 4-1mg ............................................ 48

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86

buprenorphine hcl-naloxone hcl dihydrate 8-2mg .............................................48 buprenorphine hcl-naloxone hcl sl .......48 bupropion hcl ...................................38 bupropion hcl (smoking deterrent) ......48 buspirone hcl....................................33 butorphanol tartrate........................... 9 BYDUREON BCISE.............................49 BYDUREON PEN................................49 BYETTA ...........................................49 BYSTOLIC ........................................30 C cabergoline ......................................58 CABOMETYX.....................................24 calcipotriene.....................................79 calcitonin (salmon)............................58 calcitrene.........................................79 calcitriol...........................................72 calcitriol inj ......................................72 calcitriol oral soln 1 mcg/ml ...............72 calcium acetate (phosphate binder).....59 CALQUENCE .....................................24 camila .............................................53 CAPLYTA..........................................41 CAPRELSA........................................24 captopril ..........................................27 captopril & hydrochlorothiazide...........27 CARBAGLU.......................................57 carbamazepine .................................34 carbidopa/levodopa/entacapone .........40 carbidopa-levodopa...........................40 carboplatin.......................................26 carteolol hcl (ophth)..........................74 cartia xt...........................................30 carvedilol .........................................30 caspofungin acetate ..........................13 CAYSTON.........................................12 caziant pak ......................................53 cefaclor ...........................................18 CEFACLOR ER TAB 500MG .................18 cefadroxil.........................................18 CEFAZOLIN IN DEXTROSE 2GM/100ML4% .................................................18 cefazolin inj......................................18 cefazolin sodium ...............................18 CEFAZOLIN SODIUM 1 GM/50ML ........18 cefdinir ............................................18 cefepime for inj ................................18

cefixime .......................................... 18 cefoxitin for inj ................................ 18 cefpodoxime proxetil ........................ 18 cefprozil .......................................... 18 ceftazidime...................................... 18 CEFTAZIDIME/DEXTROSE.................. 18 ceftriaxone sodium ........................... 18 cefuroxime axetil ............................. 18 cefuroxime sodium ........................... 18 celecoxib........................................... 8 CELONTIN ....................................... 34 cephalexin....................................... 18 CERDELGA ...................................... 57 CEREZYME ...................................... 57 cetirizine syrup ................................ 75 cevimeline hcl.................................. 82 CHANTIX......................................... 48 CHANTIX CONTINUING MONTH.......... 48 CHANTIX STARTER PACK .................. 48 CHEMET.......................................... 53 chlorhexidine gluconate (mouth-throat) ...................................................... 82 chloroquine phosphate ...................... 14 chlorothiazide .................................. 32 chlorpromazine hcl ........................... 41 CHLORPROMAZINE INJ ..................... 41 chlorthalidone .................................. 32 cholestyramine ................................ 29 cholestyramine light pack.................. 29 cholestyramine light powd................. 29 ciclopirox ........................................ 78 cilostazol......................................... 65 CILOXAN......................................... 72 CIMDUO.......................................... 16 cinacalcet hcl ................................... 58 CIPRO............................................. 19 CIPRODEX....................................... 82 ciprofloxacin hcl (ophth).................... 72 ciprofloxacin hcl tab.......................... 19 ciprofloxacin in d5w.......................... 19 cisplatin .......................................... 26 citalopram hydrobromide .................. 38 claravis ........................................... 77 clarithromycin.................................. 18 clarithromycin er .............................. 18 clarithromycin for susp ..................... 18 clindamycin cap 300 mg.................... 12 clindamycin cap 75mg ...................... 12


clindamycin hcl cap 150 mg ...............12 clindamycin phosphate (topical).... 77, 78 clindamycin phosphate in d5w ............12 CLINDAMYCIN PHOSPHATE IN NACL....12 clindamycin phosphate inj..................12 clindamycin phosphate vaginal ...........64 clindamycin soln 75mg/5ml................12 CLINIMIX 4.25%/DEXTROSE 5% ........70 CLINIMIX 5%/DEXTROSE 15% ...........70 CLINIMIX 5%/DEXTROSE 20% ...........70 CLINIMIX INJ 4.25/D10 .....................70 clinisol sf 15% ..................................70 CLINOLIPID......................................70 clobazam .........................................34 clomipramine hcl ..............................38 clonazepam......................................34 clonidine hcl .....................................32 clonidine hcl ptwk .............................32 clopidogrel tab 75mg.........................65 clorazepate dipotassium ....................34 clotrimazole .....................................82 clotrimazole (topical).........................78 clotrimazole w/ betamethasone ..........78 clozapine odt....................................41 clozapine tab 100mg .........................41 clozapine tab 200mg .........................41 clozapine tab 25mg ...........................41 clozapine tab 50mg ...........................41 COARTEM ........................................14 colchicine w/ probenecid ..................... 8 COLCRYS .......................................... 8 colesevelam hcl ................................29 colestipol hcl gran .............................29 colestipol hcl pack.............................29 colestipol hcl tabs .............................29 colistimethate sodium........................12 colocort ...........................................61 COMBIGAN.......................................74 COMBIVENT RESPIMAT......................74 COMETRIQ.......................................24 COMPLERA.......................................16 compro supp ....................................60 constulose .......................................62 COPIKTRA........................................24 CORLANOR ......................................32 cortisone acetate ..............................57 COTELLIC ........................................24

COUMADIN...................................... 64 CREON............................................ 63 CRIXIVAN........................................ 14 cromolyn sod neb 20mg/2ml ............. 76 cromolyn sodium (mastocytosis) ........ 62 cromolyn sodium (ophth) .................. 73 cryselle-28 ...................................... 54 cyclafem 1/35.................................. 54 cyclafem 7/7/7 ................................ 54 cyclobenzaprine hcl .......................... 48 cyclophosphamide ............................ 21 cycloserine ...................................... 16 cyclosporine .................................... 67 cyclosporine modified (for microemulsion) ................................ 67 cyproheptadine hcl ........................... 75 cyred tab ........................................ 54 CYSTADANE .................................... 57 CYSTAGON...................................... 57 CYSTARAN ...................................... 74 cytarabine ....................................... 21 D dalfampridine .................................. 47 DALIRESP ....................................... 76 danazol........................................... 57 dantrolene sodium ........................... 48 dapsone .......................................... 12 DAPTACEL ....................................... 68 daptomycin ..................................... 12 dasetta 1/35.................................... 54 dasetta 7/7/7 .................................. 54 DAURISMO...................................... 22 deblitane......................................... 54 deferasirox ...................................... 53 DELESTROGEN................................. 57 DELSTRIGO ..................................... 16 DEMSER.......................................... 32 DEPO-PROVERA INJ 400/ML .............. 23 DESCOVY ........................................ 16 desipramine hcl................................ 38 desmopressin acetate spray .............. 60 desmopressin acetate spray refrigerated ...................................................... 60 desmopressin acetate tabs ................ 60 desmopressin inj 4mcg/ml ................ 60 desogestrel & ethinyl estradiol ........... 54 desogestrel-ethinyl estradiol (biphasic)54

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88

desvenlafaxine succinate ...................38 dexamethasone ................................57 DEXAMETHASONE.............................57 dexamethasone sodium phosphate .....57 dexamethasone sodium phosphate (ophth)............................................73 DEXILANT ........................................63 dexmethylphenidate hcl.....................45 dextrose 10% flex contain .................71 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%...............................................71 dextrose 10%/nacl 0.45% .................71 dextrose 2.5%/nacl 0.45% ................70 dextrose 5% ....................................70 DEXTROSE 5% /ELECTROLYTE ...........70 dextrose 5%/nacl 0.2% .....................70 dextrose 5%/nacl 0.225% .................71 DEXTROSE 5%/NACL 0.3%................70 dextrose 5%/nacl 0.45% ...................70 dextrose 5%/nacl 0.9% .....................70 dextrose 5%/potassium chl ................71 dextrose 50%...................................71 dextrose in lactated ringers................71 dextrose inj 70% ..............................71 DIASTAT ACUDIAL ............................34 DIASTAT PEDIATRIC .........................34 diazepam.........................................34 diazepam gel....................................34 diazepam inj ....................................35 diazepam intensol .............................35 diazepam oral soln 1 mg/ml ...............35 diclofenac potassium .......................... 8 diclofenac sodium .............................. 8 diclofenac sodium (ophth)..................73 diclofenac sodium (topical) 1% gel......81 dicloxacillin sodium ...........................20 dicyclomine hcl cap 10mg ..................61 dicyclomine hcl soln 10mg/5ml ...........61 dicyclomine hcl tab 20mg ..................61 didanosine .......................................14 DIFICID ...........................................18 diflunisal........................................... 8 digitek .............................................31 digox...............................................31 digoxin ............................................31 digoxin inj........................................31 digoxin sol 50mcg/ml ........................32

dihydroergotamine mesylate inj 1 mg/ml ...................................................... 46 dihydroergotamine mesylate nasal spr 4 mg/ml.......................................... 46 DILANTIN CAP 100MG ...................... 35 DILANTIN CAP 30MG ........................ 35 DILANTIN CHEW TAB 50MG............... 35 DILANTIN-125 SUSP......................... 35 diltiazem cap 240mg cd .................... 30 diltiazem cap 360mg cd .................... 30 diltiazem cap er/12hr........................ 31 diltiazem hcl .................................... 31 diltiazem hcl coated beads ................ 31 diltiazem hcl coated beads cap sr 24hr 31 diltiazem hcl extended release beads cap sr ................................................... 31 diltiazem inj .................................... 31 dilt-xr cap ....................................... 30 diphenhydramine hcl inj 50mg/ml ...... 75 diphenoxylate w/ atropine ................. 62 DIPHTHERIA/TETANUS TOXOID ......... 68 disopyramide phosphate ................... 28 disulfiram........................................ 48 divalproex sodium ............................ 35 docetaxel ........................................ 21 DOCETAXEL................................21, 22 dofetilide......................................... 28 donepezil hydrochloride .................... 37 dorzolamide hcl................................ 74 dorzolamide hcl-timolol maleate......... 74 DOVATO ......................................... 16 doxazosin mesylate .......................... 28 doxepin hcl...................................... 38 doxepin hcl (sleep) ........................... 45 doxorubicin hcl ................................ 21 doxorubicin hcl liposomal .................. 21 doxy 100......................................... 20 doxycycline (monohydrate) ............... 20 doxycycline hyclate .......................... 20 doxycycline hyclate 100 mg............... 20 doxycycline hyclate 20 mg ................ 20 DRIZALMA SPRINKLE ........................ 38 dronabinol....................................... 60 drospirenone-ethinyl estradiol............ 54 DROXIA .......................................... 65 duloxetine hcl .................................. 38 DUREZOL ........................................ 73 dutasteride...................................... 63


dutasteride-tamsulosin hcl .................63 E e.e.s. 400 ........................................18 EDURANT.........................................14 efavirenz .........................................14 eletriptan hydrobromide ....................46 ELIQUIS ..........................................64 ELIQUIS STARTER PACK ....................64 ELLA ...............................................54 eluryng............................................54 EMCYT.............................................21 EMEND ............................................60 EMGALITY........................................46 emoquette .......................................54 EMSAM............................................38 EMTRIVA .........................................14 EMVERM ..........................................12 enalapril maleate ..............................27 enalapril maleate & hydrochlorothiazide ......................................................27 ENBREL ...........................................66 ENBREL MINI ...................................66 ENBREL SURECLICK ..........................66 ENDARI ...........................................65 endocet 10-325mg............................. 9 endocet 2.5-325mg............................ 9 endocet 5-325mg .............................. 9 endocet 7.5-325mg............................ 9 ENGERIX-B ......................................68 enoxaparin sodium............................64 enpresse-28 .....................................54 enskyce ...........................................54 ENSTILAR ........................................79 entacapone ......................................40 entecavir .........................................17 ENTRESTO .......................................28 enulose ...........................................62 EPCLUSA .........................................17 EPIDIOLEX.......................................35 epinephrine (anaphylaxis)..................76 epirubicin hcl....................................21 epitol ..............................................35 EPIVIR HBV......................................17 eplerenone.......................................28 ergotamine w/ caffeine ......................46 ERIVEDGE........................................22 ERLEADA .........................................23

erlotinib hcl ..................................... 24 errin ............................................... 54 ertapenem sodium ........................... 12 ery pad 2% ..................................... 78 ery-tab ........................................... 18 ERYTHROCIN LACTOBIONATE ............ 19 erythrocin stearate ........................... 19 erythromycin (acne aid) .................... 78 erythromycin (ophth) ....................... 72 erythromycin base............................ 19 erythromycin cap 250mg ec .............. 19 erythromycin ethylsuccinate .............. 19 erythromycin tab ec ......................... 19 ESBRIET ......................................... 76 escitalopram oxalate......................... 38 esomeprazole magnesium ................. 63 estarylla tab 0.25-35 ........................ 54 estradiol.......................................... 57 estradiol vaginal cream ..................... 57 estradiol vaginal tab ......................... 57 estradiol valerate inj......................... 57 ethambutol hcl................................. 16 ethosuximide ................................... 35 ethynodiol diacet & eth estrad ........... 54 ethynodiol tab 1-50 .......................... 54 etodolac............................................ 8 etonogestrel-ethinyl estradiol ............ 54 etoposide ........................................ 27 euthyrox ......................................... 60 everolimus ...................................... 25 everolimus (immunosuppressant) ...... 67 EVOTAZ .......................................... 16 exemestane..................................... 23 ezetimibe ........................................ 29 F FABRAZYME..................................... 57 falmina ........................................... 54 famciclovir ...................................... 17 famotidine....................................... 61 famotidine in nacl............................. 61 famotidine inj .................................. 61 FANAPT........................................... 41 FANAPT TITRATION PACK.................. 41 FARXIGA......................................... 50 FARYDAK ........................................ 22 felbamate........................................ 35 felodipine ........................................ 31

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90

femynor...........................................54 fenofibrate .......................................29 fenofibrate micronized .......................29 fentanyl citrate .................................. 9 fentanyl patch 100 mcg/hr .................. 9 fentanyl patch 12 mcg/hr.................... 9 fentanyl patch 25 mcg/hr.................... 9 fentanyl patch 50 mcg/hr.................... 9 fentanyl patch 75 mcg/hr.................... 9 FETZIMA..........................................38 FETZIMA TITRATION PACK.................38 FIASP ..............................................49 FIASP FLEXTOUCH ............................49 FIASP PENFILL..................................49 finasteride .......................................63 flac .................................................82 flecainide acetate..............................28 FLOVENT DISKUS .............................77 FLOVENT HFA...................................77 fluconazole.......................................13 fluconazole inj nacl 200 .....................13 fluconazole inj nacl 400 .....................13 flucytosine .......................................13 fludrocortisone acetate ......................58 flunisolide (nasal) .............................77 fluocinolone acetonide .......................79 fluocinolone acetonide (otic)...............82 fluocinolone acetonide oil body ...........79 fluocinonide .....................................80 fluocinonide emulsified base...............80 fluorometholone ...............................73 fluorouracil.......................................21 fluorouracil (topical) ..........................81 fluoxetine cap 10mg..........................38 fluoxetine cap 20mg..........................38 fluoxetine cap 40mg..........................39 fluoxetine hcl ...................................39 fluphenazine decanoate .....................41 fluphenazine hcl................................41 flurbiprofen ....................................... 8 flurbiprofen sodium ...........................73 flutamide .........................................23 fluticasone propionate .......................80 fluticasone propionate (nasal) ............77 fluvoxamine maleate .........................34 fondaparinux sodium.........................64 FORTEO...........................................58 fosamprenavir tab 700 mg .................14

fosinopril sodium.............................. 27 fosinopril sodium & hydrochlorothiazide ...................................................... 27 FREAMINE HBC 6.9%........................ 70 FREAMINE III................................... 70 fulvestrant ...................................... 23 furosemide ...................................... 32 furosemide inj.................................. 32 FUZEON.......................................... 14 fyavolv ........................................... 57 FYCOMPA ........................................ 35 G gabapentin ...................................... 35 galantamine hydrobromide ................ 37 galantamine hydrobromide er ............ 37 GAMASTAN S/D ............................... 67 GAMMAGARD LIQUID........................ 67 GAMMAGARD S/D ............................ 67 GAMMAKED ..................................... 67 GAMMAPLEX .................................... 67 GAMMAPLEX 10GM/100ML................. 67 GAMUNEX-C .................................... 67 ganciclovir sodium............................ 17 GARDASIL 9 .................................... 68 gatifloxacin (ophth) .......................... 72 GATTEX .......................................... 62 GAUZE PADS 2 ................................ 49 gavilyte-c ........................................ 62 gavilyte-g........................................ 62 gavilyte-n/flavor pack ....................... 62 gemcitabine inj soln ......................... 21 gemcitabine inj solr .......................... 21 gemfibrozil ...................................... 29 generlac.......................................... 62 gengraf........................................... 68 GENOTROPIN................................... 58 GENOTROPIN MINIQUICK .............58, 59 gentak ............................................ 72 gentamicin in saline.......................... 11 gentamicin sulfate ............................ 11 gentamicin sulfate (topical) ............... 78 gentamicin sulfate soln (ophth).......... 72 GENVOYA........................................ 16 GEODON ......................................... 41 gianvi tab 3-0.02mg ......................... 54 GILENYA ......................................... 47 GILOTRIF TAB 20MG......................... 25 GILOTRIF TAB 30MG......................... 25


GILOTRIF TAB 40MG .........................25 glatiramer acetate 20mg/ml ...............47 glatiramer acetate 40mg/ml ...............47 glatopa ............................................47 GLEOSTINE......................................21 glimepiride.......................................50 glip/metform tab 2.5-250mg ..............50 glip/metform tab 2.5-500mg ..............50 glip/metform tab 5-500mg.................50 glipizide ..................................... 50, 51 glipizide xl .......................................51 GLUCAGEN HYPOKIT .........................58 GLUCAGON EMERGENCY KIT ..............58 glycopyrrolate tab 1mg......................61 glycopyrrolate tab 2mg......................61 glydo...............................................80 GOLYTELY........................................62 granisetron hcl .................................60 griseofulvin microsize ........................13 griseofulvin ultramicrosize..................13 guanfacine er (adhd).........................45 H HAEGARDA ......................................65 halobetasol propionate ......................80 haloperidol.......................................41 haloperidol conc 2mg/ml....................41 haloperidol decanoate .......................42 haloperidol lactate inj 5mg/ml ............42 HARVONI .........................................17 HAVRIX ...........................................68 heather ...........................................54 heparin sod (porcine) in d5w ..............64 heparin sod inj 1000/ml.....................64 heparin sod inj 10000/ml ...................64 heparin sod inj 20000/ml ...................64 heparin sod inj 5000/ml.....................64 HEPARIN SODIUM/NACL 0.45%..........64 hepatamine......................................70 HERCEPTIN ......................................22 HERCEPTIN HYLECTA ........................22 HETLIOZ..........................................45 HIBERIX ..........................................68 HUMIRA...........................................66 HUMIRA INJ 10MG/0.2ML...................66 HUMIRA KIT 20MG/0.4ML ..................66 HUMIRA KIT 40MG/0.8ML ..................66 HUMIRA PEDIATRIC CROHNS DISEASE66

HUMIRA PEN.................................... 66 HUMIRA PEN CD/UC/HS STARTER ...... 66 HUMIRA PEN INJ CD/UC/HS STARTER. 66 HUMIRA PEN INJ PS/UV STARTER....... 66 HUMIRA PEN-PS/UV STARTER............ 66 HUMULIN R INJ U-500 ...................... 49 HUMULIN R U-500 KWIKPEN ............. 49 hydralazine hcl................................. 32 hydrochlorothiazide .......................... 32 hydroco/apap tab 10-325mg ............. 10 hydroco/apap tab 5-325mg ................. 9 hydroco/apap tab 7.5-325................. 10 hydrocodone-acetaminophen 7.5-325 mg/15ml ......................................... 10 hydrocodone-ibuprofen tab 7.5-200 mg ...................................................... 10 hydrocortisone................................. 58 hydrocortisone (enema) .................... 61 hydrocortisone (topical) cream 1%..... 80 hydrocortisone (topical) cream 2.5% .. 80 hydrocortisone (topical) lotion 2.5% ... 80 hydrocortisone (topical) oint 2.5% ..... 80 hydrocortisone butyrate cream 0.1% .. 80 hydrocortisone butyrate oint 0.1% ..... 80 hydromorphone hcl .......................... 10 hydroxychloroquine sulfate................ 66 hydroxyurea .................................... 26 hydroxyzine hcl................................ 75 hydroxyzine hcl inj ........................... 75 hydroxyzine pamoate ....................... 75 HYSINGLA ER .................................. 10 I ibandronate sodium tabs ................... 53 IBRANCE......................................... 22 ibu tab 600mg ................................... 8 ibu tab 800mg ................................... 8 ibuprofen .......................................... 8 icatibant acetate .............................. 65 ICLUSIG.......................................... 25 IDHIFA ........................................... 22 ILEVRO ........................................... 73 imatinib mesylate............................. 25 IMBRUVICA ..................................... 25 imipenem-cilastatin .......................... 12 imipramine hcl ................................. 39 imiquimod ....................................... 81 IMOVAX RABIES (H.D.C.V.) ............... 68

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incassia ...........................................54 INCRELEX ........................................59 INCRUSE ELLIPTA .............................75 indapamide ......................................32 INFANRIX ........................................68 INLYTA ............................................25 INREBIC ..........................................25 INSULIN PEN NEEDLE ........................49 INSULIN SAFETY NEEDLES.................49 INSULIN SYRINGE.............................49 INTELENCE ......................................14 INTRALIPID 30% ..............................70 INTRALIPID INJ 20%.........................70 INTRON-A INJ 10MU..........................67 INTRON-A INJ 18MU..........................67 INTRON-A INJ 25MU..........................67 INTRON-A INJ 50MU..........................67 introvale ..........................................54 INVEGA SUST INJ 117 MG/0.75 ML .....42 INVEGA SUST INJ 156MG/ML .............42 INVEGA SUST INJ 234 MG/1.5 ML.......42 INVEGA SUST INJ 39 MG/0.25 ML.......42 INVEGA SUST INJ 78 MG/0.5 ML.........42 INVEGA TRINZA................................42 INVIRASE ........................................14 IPOL INACTIVATED IPV......................68 ipratropium bromide .........................75 ipratropium bromide (nasal)...............75 ipratropium-albuterol nebu ................74 irbesartan ........................................28 irbesartan-hydrochlorothiazide ...........28 IRESSA............................................25 irinotecan hcl ...................................27 ISENTRESS ......................................14 ISENTRESS HD.................................14 isibloom...........................................54 ISOLYTE P........................................71 ISOLYTE S .......................................71 isoniazid ..........................................16 isoniazid syp 50mg/5ml .....................16 isosorb mononitrate tab.....................33 isosorbide dinitrate ...........................33 isosorbide mononitrate er ..................33 isotretinoin.......................................78 isradipine.........................................31 itraconazole .....................................13 ivermectin........................................12 IXIARO............................................68

J JADENU .......................................... 53 JADENU SPRINKLE ........................... 53 JAKAFI............................................ 25 jantoven ......................................... 64 JANUMET ........................................ 51 JANUMET XR TAB 100-1000............... 51 JANUMET XR TAB 50-1000 ................ 51 JANUMET XR TAB 50-500MG.............. 51 JANUVIA ......................................... 51 JARDIANCE ..................................... 51 jasmiel............................................ 54 JENTADUETO ................................... 51 JENTADUETO TAB XR 2.5-1000 MG .... 51 JENTADUETO TAB XR 5-1000 MG ....... 51 jinteli.............................................. 57 jolessa tab 0.15-0.03 mg .................. 54 jolivette .......................................... 54 juleber ............................................ 54 JULUCA........................................... 16 junel 1.5/30 .................................... 54 junel 1/20 ....................................... 54 junel fe 1.5/30................................. 54 junel fe 1/20 ................................... 54 JUXTAPID........................................ 29 K KADCYLA ........................................ 22 KALETRA TAB 100-25MG................... 16 KALETRA TAB 200-50MG................... 16 KALYDECO ...................................... 76 KANJINTI ........................................ 22 kariva ............................................. 54 kcl 0.075%/d5w/nacl 0.45% ............. 71 KCL 0.15%/D5W/NACL 0.225% ......... 71 kcl 0.15%/d5w/nacl 0.9% ................. 71 kcl 0.3%/d5w/nacl 0.45% ................. 71 KCL 0.3%/D5W/NACL 0.9% .............. 71 kcl/d5w inj 0.3%.............................. 71 kcl/d5w/nacl inj .15/.45% ................. 71 kcl/d5w/nacl inj 0.22%/0.45% .......... 71 kcl/nacl inj 0.15%-0.9% ................... 71 kcl/nacl inj 0.3-0.9 ........................... 71 kcl0.15%/d5w/nacl0.2% ................... 71 kelnor 1/35 ..................................... 54 kelnor 1/50 ..................................... 54 ketoconazole ................................... 13 ketoconazole cream.......................... 78 ketoconazole shampoo...................... 79


ketorolac tromethamine (ophth) .........73 KEYTRUDA .......................................22 KINRIX ............................................68 kionex sus 15gm/60ml ......................53 KISQALI ..........................................22 KISQALI FEMARA 200 DOSE...............22 KISQALI FEMARA 400 DOSE...............22 KISQALI FEMARA 600 DOSE...............22 klor-con 10 ......................................69 klor-con 8 ........................................69 klor-con m10....................................69 klor-con m15....................................69 klor-con m20....................................69 klor-con pak 20meq ..........................69 klor-con spr cap 10meq .....................69 klor-con spr cap 8meq.......................69 KORLYM...........................................59 kurvelo ............................................54 KUVAN ............................................57 L labetalol hcl .....................................30 lactated ringer's................................71 lactulose ..........................................62 lactulose (encephalopathy) ................62 lamivudine .......................................14 lamivudine (hbv) ..............................17 lamivudine-zidovudine.......................16 lamotrigine ......................................36 lansoprazole.....................................63 larin 1.5/30......................................55 larin 1/20.........................................55 larin fe 1.5/30 ..................................55 larin fe 1/20 .....................................55 larissia tab .......................................55 LASTACAFT ......................................73 latanoprost ......................................74 LATUDA...........................................42 leena tab .........................................55 leflunomide ......................................66 LENVIMA 10 MG DAILY DOSE .............25 LENVIMA 12MG DAILY DOSE ..............25 LENVIMA 14 MG DAILY DOSE .............25 LENVIMA 18 MG DAILY DOSE .............25 LENVIMA 20 MG DAILY DOSE .............25 LENVIMA 24 MG DAILY DOSE .............25 LENVIMA 4 MG DAILY DOSE...............25 LENVIMA 8 MG DAILY DOSE...............25

lessina ............................................ 55 letrozole.......................................... 23 leucovorin calcium.......................26, 27 LEUKERAN....................................... 21 leuprolide inj 1mg/0.2 ...................... 23 levalbuterol hcl ................................ 75 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml ........................................ 76 levalbuterol tartrate hfa .................... 76 LEVEMIR ......................................... 49 LEVEMIR FLEXTOUCH ....................... 49 levetiracetam................................... 36 levetiracetam in sodium chloride ........ 36 levetiracetam oral soln 100 mg/ml ..... 36 levobunolol hcl................................. 74 levocarnitine (metabolic modifiers)..... 57 levocetirizine dihydrochloride............. 75 levofloxacin ..................................... 19 levofloxacin in d5w ........................... 19 levofloxacin inj 25mg/ml ................... 19 levofloxacin oral soln 25 mg/ml.......... 19 levonest.......................................... 55 levonor/ethi tab ............................... 55 levonorgestrel & eth estradiol ............ 55 levonorgestrel-ethinyl estradiol (91-day) ...................................................... 55 levora 0.15/30-28 ............................ 55 levo-t ............................................. 60 levothyroxine sodium........................ 60 levoxyl............................................ 60 LEXIVA ........................................... 14 lidocaine ......................................... 80 lidocaine hcl .................................... 80 lidocaine hcl (local anesth.) ............... 11 lidocaine hcl (mouth-throat) .............. 82 lidocaine inj 0.5% ............................ 11 lidocaine inj 1% ............................... 11 lidocaine inj 1.5% preservative free (pf) ...................................................... 11 lidocaine oint 5% ............................. 81 lidocaine-prilocaine........................... 81 linezolid in sodium chloride................ 12 linezolid inj...................................... 12 linezolid susp ................................... 12 linezolid tab 600mg .......................... 12 LINZESS ......................................... 62 liothyronine sodium .......................... 60

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94

lisinopril...........................................27 lisinopril & hydrochlorothiazide ...........27 lithium carbonate..............................47 lithium carbonate er ..........................47 LITHIUM SOLN 8MEQ/5ML .................47 LOKELMA .........................................53 LONSURF.........................................26 loperamide hcl..................................62 lopinavir-ritonavir .............................16 lorazepam........................................34 lorazepam intensol............................34 LORBRENA.......................................25 lorcet hd tab 10-325mg .....................10 lorcet plus tab 7.5-325 ......................10 lorcet tab 5-325mg ...........................10 loryna .............................................55 losartan potassium............................28 losartan-hydrochlorothiazide ..............28 LOTEMAX.........................................73 loteprednol etabonate .......................73 lovastatin.........................................29 low-ogestrel .....................................55 loxapine succinate ............................42 LUMIGAN.........................................74 LUMIZYME .......................................57 LUPRON DEPOT (1-MONTH) ...............23 LUPRON DEPOT INJ 11.25MG (3-MONTH) ......................................................23 LUPRON DEPOT-PED (1-MONTH ..........59 LUPRON DEPOT-PED (3-MONTH ..........59 LUPRON DEP-PED INJ 11.25MG (3MONTH)...........................................59 LUPRON DEP-PED INJ 7.5MG..............59 lutera ..............................................55 LYNPARZA........................................22 LYRICA CR .......................................47 LYSODREN.......................................23 lyza.................................................55 M magnesium sulfate............................69 MAGNESIUM SULFATE .......................69 MAGNESIUM SULFATE IN D5W ...........69 magnesium sulfate in dextrose ...........69 magnesium sulfate inj 50%................69 malathion ........................................82 maprotiline hcl .................................39 marlissa...........................................55 MARPLAN TAB 10MG .........................39

MATULANE ...................................... 26 MAVYRET ........................................ 17 meclizine hcl.................................... 60 medroxyprogesterone acetate (contraceptive) ................................ 55 medroxyprogesterone acetate tab ...... 60 mefloquine hcl ................................. 14 megestrol ac sus 40mg/ml ................ 23 megestrol ac tab 20mg ..................... 23 megestrol ac tab 40mg ..................... 23 megestrol sus 625mg/5ml................. 23 MEKINIST ....................................... 25 MEKTOVI......................................... 25 meloxicam ........................................ 8 memantine hcl cp24 ......................... 37 memantine soln ............................... 37 memantine tabs ............................... 37 MENACTRA ...................................... 68 MENVEO ......................................... 68 mercaptopurine ............................... 21 meropenem..................................... 12 mesalamine..................................... 61 mesalamine w/ cleanser.................... 61 MESNEX.......................................... 27 metadate er tab 20mg ...................... 45 metformin er ................................... 51 metformin hcl .............................51, 52 methadone hcl ................................. 10 methadone hcl 10mg ........................ 10 methadone hcl 5mg.......................... 10 methadone hcl intensol ..................... 10 methazolamide ................................ 32 methenamine hippurate .................... 12 methimazole.................................... 60 methotrexate sodium inj soln ............ 21 methotrexate sodium inj solr ............. 21 methotrexate sodium tabs................. 66 methylphenidate hcl ......................... 45 methylphenidate hcl oral soln ............ 45 methylphenidate hcl tbcr 10 mg......... 45 methylphenidate hcl tbcr 20mg.......... 45 methylpr ss inj................................. 58 methylpred pak 4mg ........................ 58 methylpred tab 16mg ....................... 58 methylpred tab 32mg ....................... 58 methylpred tab 4mg ......................... 58 methylpred tab 8mg ......................... 58 methylprednisolone acetate ............... 58


metoclopramide hcl...........................60 metoclopramide hcl inj ......................60 metolazone ......................................32 metoprolol & hydrochlorothiazide ........30 metoprolol succinate .........................30 metoprolol tartrate............................30 metronidazole ..................................12 metronidazole (topical)......................81 metronidazole gel 0.75% ...................81 metronidazole in nacl ........................12 metronidazole vaginal .......................64 microgestin 1.5/30............................55 microgestin 1/20 ..............................55 microgestin fe 1.5/30 ........................55 microgestin fe 1/20...........................55 midodrine hcl ...................................32 miglustat .........................................57 mili .................................................55 minitran ..........................................33 minocycline hcl .................................20 minoxidil..........................................32 mirtazapine......................................39 misoprostol ......................................62 MITIGARE ......................................... 8 M-M-R II..........................................68 M-NATAL PLUS .................................72 moexipril hcl ....................................27 molindone hcl...................................42 mometasone furoate .........................80 mondoxyne nl cap 100mg ..................21 mono-linyah tab 0.25-35 ...................55 montelukast sodium ..........................76 morphine ext-rel tab .........................10 morphine sul inj 1mg/ml....................10 morphine sulfate...............................10 MORPHINE SULFATE..........................10 morphine sulfate oral soln 100mg/5ml.11 morphine sulfate oral soln 10mg/5ml ..10 morphine sulfate oral soln 20mg/5ml ..11 MOVANTIK .......................................62 MOXEZA ..........................................72 moxifloxacin hcl (ophth) ....................72 MULTAQ ..........................................29 mupirocin ........................................78 MVASI .............................................22 MYCAMINE .......................................13 mycophenolate mofetil ......................68

mycophenolate sodium tbec .............. 68 myorisan......................................... 78 MYRBETRIQ..................................... 63 N nabumetone ...................................... 8 nadolol ........................................... 30 nafcillin sodium for inj....................... 20 NAFCILLIN SODIUM FOR INJ 10GM..... 20 NAGLAZYME .................................... 57 nalbuphine hcl ................................... 9 naloxone inj 0.4mg/ml...................... 48 naloxone inj 1mg/ml......................... 48 naltrexone hcl.................................. 48 NAMZARIC ...................................... 37 naproxen .......................................... 8 naproxen dr....................................... 8 naproxen sodium ............................... 8 naratriptan hcl ................................. 46 NARCAN.......................................... 48 NATACYN ........................................ 72 nateglinide ...................................... 52 NATPARA ........................................ 59 NAYZILAM....................................... 36 necon 0.5/35-28 .............................. 55 nefazodone hcl................................. 39 neomycin sulfate.............................. 11 neomycin-bacitracin zn-polymyxin...... 72 neomycin-polymy-dexameth.............. 72 neomycin-polymyxin-gramicidin......... 73 neomycin-polymyxin-hc (ophth)......... 72 neomycin-polymyxin-hc (otic)............ 82 NEPHRAMINE................................... 70 NERLYNX......................................... 25 NEUPRO.......................................... 40 nevirapine susp 50 mg/5ml ............... 15 nevirapine tab 100mg er ................... 15 nevirapine tab 200mg....................... 15 nevirapine tab 400mg er ................... 15 NEXAVAR ........................................ 25 niacin (antihyperlipidemic) ................ 29 niacin er (antihyperlipidemic) .......29, 30 niacor ............................................. 30 nicardipine hcl ................................. 31 NICOTROL INHALER ......................... 48 NICOTROL NS.................................. 48 nifedipine ........................................ 31 nifedipine er .................................... 31

95

96

nikki................................................55 nilutamide........................................23 nimodipine .......................................31 NINLARO .........................................22 nitisinone.........................................57 NITRO-BID.......................................33 NITRO-DUR DIS 0.3MG/HR ................33 NITRO-DUR DIS 0.8MG/HR ................33 nitrofurantoin macrocrystal ................12 nitrofurantoin monohyd macro ...........12 nitroglycerin.....................................33 nitroglycerin td patch ........................33 NITYR..............................................57 nora-be tab 0.35mg ..........................55 norethindrone (contraceptive) ............55 norethindrone acet & eth estra ...........55 norethindrone acetate .......................60 norethindrone acetate-ethinyl estradiol57 norgest/ethi tab 0.25/35....................55 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ....55 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg ....55 NORMOSOL-M IN D5W ......................71 NORMOSOL-R...................................71 NORMOSOL-R IN D5W.......................71 NORPACE CR....................................29 NORTHERA.......................................32 nortrel 0.5/35 (28)............................55 nortrel 1/35 .....................................56 nortrel 7/7/7 ....................................56 nortriptyline hcl ................................39 NORVIR PACK...................................15 NORVIR SOLN ..................................15 NOVOLIN 70/30................................49 NOVOLIN 70/30 FLEXPEN ..................49 NOVOLIN N ......................................49 NOVOLIN N FLEXPEN.........................50 NOVOLIN R ......................................50 NOVOLIN R FLEXPEN.........................50 NOVOLOG........................................50 NOVOLOG 70/30 FLEXPEN .................50 NOVOLOG FLEXPEN...........................50 NOVOLOG MIX 70/30 ........................50 NOVOLOG PENFILL............................50 NOXAFIL..........................................13 NUBEQA ..........................................23 NUCALA...........................................76

NUCYNTA ER ................................... 11 NUEDEXTA ...................................... 47 NULOJIX ......................................... 68 NULYTELY/FLAVOR PACKS................. 62 NUPLAZID CAPS............................... 42 NUPLAZID TABS 10MG...................... 42 NUTRILIPID INJ 20%........................ 70 nyamyc........................................... 78 NYMALIZE ....................................... 31 nystatin .......................................... 13 nystatin (mouth-throat) .................... 82 nystatin (topical).............................. 78 nystop ............................................ 78 O ocella tab 3-0.03mg ......................... 56 OCTAGAM ....................................... 67 octreotide acetate ............................ 59 ODEFSEY ........................................ 16 ODOMZO......................................... 22 OFEV .............................................. 76 ofloxacin (ophth).............................. 73 ofloxacin (otic)................................. 82 OGIVRI ........................................... 22 olanzapine....................................... 42 olmesartan medoxomil...................... 28 olmesartan medoxomil-amlodipinehydrochlorothiazide .......................... 28 olmesartan medoxomilhydrochlorothiazide .......................... 28 olopatadine hcl 0.2% ........................ 73 omeprazole cap 10mg....................... 63 omeprazole cap 20mg....................... 63 omeprazole cap 40mg....................... 63 ondansetron hcl ............................... 60 ondansetron hcl inj........................... 60 ondansetron hcl oral soln .................. 60 ondansetron odt............................... 60 OPSUMIT ........................................ 33 ORFADIN......................................... 57 ORKAMBI ........................................ 76 orsythia .......................................... 56 oseltamivir phosphate....................... 17 OSPHENA........................................ 59 oxacillin sodium ............................... 20 oxaliplatin inj 100mg ........................ 26 oxaliplatin inj 100mg/20ml................ 26 oxaliplatin inj 50mg .......................... 26 oxaliplatin inj 50mg/10ml.................. 26


oxandrolone tab 10mg.......................49 oxandrolone tab 2.5mg......................49 oxcarbazepine ..................................36 oxybutynin chloride..................... 63, 64 oxycodone hcl ..................................11 oxycodone w/ acetaminophen 10-325mg ......................................................11 oxycodone w/ acetaminophen 2.5-325mg ......................................................11 oxycodone w/ acetaminophen 5-325mg ......................................................11 oxycodone w/ acetaminophen 7.5-325mg ......................................................11 OZEMPIC INJ 0.25 OR 0.5MG/DOSE ....50 OZEMPIC INJ 1MG/DOSE ...................50 P pacerone .........................................29 paclitaxel .........................................22 paliperidone .....................................42 pamidronate disodium .......................53 PAMIDRONATE DISODIUM .................53 pamidronate inj 30mg .......................53 pamidronate inj 90mg .......................53 PANRETIN ........................................81 pantoprazole sodium .........................63 pantoprazole sodium tbec ..................63 PANZYGA.........................................67 paricalcitol .......................................72 paroex sol 0.12% .............................82 paromomycin sulfate .........................11 paroxetine hcl tabs ...........................39 PASER D/R.......................................16 PAXIL ..............................................39 PAZEO.............................................73 PEDIARIX.........................................68 PEDVAX HIB.....................................68 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate .............................................62 peg 3350-potassium chloride-sod bicarbonate-sod chloride....................62 PEGANONE.......................................36 PEGASYS .........................................17 PEGASYS PROCLICK..........................17 penicillamine ....................................53 PENICILLIN G POT IN DEXTROSE 2MU.20 PENICILLIN G POT IN DEXTROSE 3MU.20 PENICILLIN G PROCAINE ...................20

penicillin g sodium............................ 20 penicillin v potassium ....................... 20 penicilln gk inj 20mu ........................ 20 penicilln gk inj 5mu .......................... 20 PENTACEL ....................................... 68 pentamidine isethionate inh............... 12 pentamidine isethionate inj ............... 12 pentoxifylline ................................... 65 perindopril erbumine ........................ 27 periogard ........................................ 82 permethrin cre 5% ........................... 82 perphenazine................................... 42 PERSERIS ....................................... 42 pfizerpen-g inj 20mu ........................ 20 pfizerpen-g inj 5mu .......................... 20 phenelzine sulfate ............................ 39 phenobarbital .................................. 36 phenobarbital sodium ....................... 36 PHENOBARBITAL SODIUM ................. 36 PHENYTEK....................................... 36 phenytoin........................................ 36 phenytoin sodium extended............... 36 phenytoin sodium inj 50mg/ml .......... 36 philith ............................................. 56 PHOSPHOLINE IODIDE...................... 74 PICATO........................................... 81 PIFELTRO........................................ 15 pilocarpine hcl ................................. 74 pilocarpine hcl (oral)......................... 82 pimozide ......................................... 42 pimtrea........................................... 56 pindolol........................................... 30 pioglitazone hcl ................................ 52 piper/tazoba inj 12-1.5gm................. 20 piper/tazoba inj 2-0.25gm................. 20 piper/tazoba inj 3-0.375gm ............... 20 piper/tazoba inj 36-4.5gm................. 20 piper/tazoba inj 4-0.5gm .................. 20 PIQRAY 200MG DAILY DOSE.............. 25 PIQRAY 250MG DAILY DOSE.............. 25 PIQRAY 300MG DAILY DOSE.............. 25 pirmella 1/35................................... 56 piroxicam .......................................... 8 PLASMA-LYTE A ............................... 71 PLASMA-LYTE-148............................ 71 plenamine ....................................... 70 PLENVU........................................... 62

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98

PNV FOLIC ACID + IRON MUL.............72 podofilox..........................................81 polymyxin b-trimethoprim..................73 POMALYST .......................................24 portia-28 .........................................56 posaconazole....................................14 pot chloride inj 2meq/ml....................71 potassium chloride ................ 69, 70, 71 POTASSIUM CHLORIDE......................71 potassium chloride in nacl ..................71 potassium chloride microencapsulated crystals er........................................70 potassium citrate (alkalinizer) er tabs..63 PRADAXA.........................................64 PRALUENT........................................30 pramipexole tab 0.125mg ..................40 pramipexole tab 0.25mg....................40 pramipexole tab 0.5mg......................40 pramipexole tab 0.75mg....................40 pramipexole tab 1.5mg......................40 pramipexole tab 1mg ........................40 prasugrel hcl ....................................65 pravastatin sodium ...........................29 praziquantel .....................................13 prazosin hcl......................................28 pred sod pho sol 5mg/5ml .................58 prednisolone acetate (ophth)..............73 prednisolone sodium phosphate ..........58 PREDNISOLONE SODIUM PHOSPHATE (OPHTH) ..........................................73 prednisolone sol 15mg/5ml ................58 prednisolone sol 25mg/5ml ................58 PREDNISONE CON 5MG/ML ................58 prednisone pak 10mg ........................58 prednisone pak 5mg..........................58 prednisone sol 5mg/5ml ....................58 prednisone tab 10mg ........................58 prednisone tab 1mg ..........................58 prednisone tab 2.5mg .......................58 prednisone tab 20mg ........................58 prednisone tab 50mg ........................58 prednisone tab 5mg ..........................58 pregabalin........................................36 PREMASOL 10% ...............................70 PRENATAL........................................72 PRENATAL PLUS................................72 PRENATAL PLUS LOW IRON................72 prevalite ..........................................30

previfem ......................................... 56 PREZCOBIX ..................................... 16 PREZISTA........................................ 15 PRIFTIN .......................................... 17 primaquine phosphate ...................... 14 PRIMAQUINE PHOSPHATE ................. 14 primidone........................................ 36 PRIVIGEN ........................................ 67 probenecid ........................................ 8 PROCALAMINE ................................. 70 prochlorperazine inj.......................... 60 prochlorperazine maleate .................. 61 prochlorperazine supp....................... 61 PROCRIT ......................................... 65 procto-med hc ................................. 81 procto-pak ...................................... 81 proctosol hc cre 2.5% ....................... 81 proctozone-hc.................................. 81 PROGLYCEM SUS 50MG/ML ............... 58 PROGRAF ........................................ 68 PROLASTIN-C .................................. 76 PROLENSA....................................... 73 PROLIA ........................................... 59 PROMACTA...................................... 65 promethazine hcl ............................. 61 promethazine hcl inj ......................... 61 propafenone hcl ............................... 29 propafenone hcl 12hr........................ 29 proparacaine hcl .............................. 74 propranolol & hydrochlorothiazide ...... 30 propranolol cap er ............................ 30 propranolol hcl................................. 30 propranolol oral sol........................... 30 propylthiouracil ................................ 60 PROQUAD ....................................... 68 PROSOL .......................................... 70 protriptyline hcl................................ 39 PULMICORT FLEXHALER .................... 77 PULMOZYME .................................... 76 PURIXAN......................................... 21 pyrazinamide................................... 17 pyridostigmine tab 60mg .................. 47 Q QUADRACEL .................................... 69 quetiapine fumarate ......................... 43 quinapril hcl .................................... 27 quinapril-hydrochlorothiazide............. 27 quinidine sulfate .............................. 29


quinine sulfate..................................14 R RABAVERT .......................................69 raloxifene tab 60mg ..........................59 ramipril ...........................................28 ranitidine hcl inj................................61 ranitidine hcl tab 150mg ....................61 ranitidine hcl tab 300mg ....................61 ranitidine syrup ................................61 ranolazine ........................................32 rasagiline mesylate ...........................40 RAYALDEE........................................72 reclipsen..........................................56 RECOMBIVAX HB ..............................69 RECTIV............................................81 REGRANEX.......................................82 RELENZA DISKHALER ........................17 RELISTOR ........................................62 REMICADE .......................................66 RENFLEXIS.......................................66 repaglinide.......................................52 RESCRIPTOR ....................................15 RESTASIS ........................................74 RESTASIS MULTIDOSE ......................74 REVLIMID ........................................24 REXULTI ..........................................43 REYATAZ .........................................15 RHOPRESSA.....................................74 ribavirin cap 200mg ..........................17 ribavirin tab 200mg...........................17 rifabutin ..........................................17 rifampin...........................................17 RIFATER ..........................................17 riluzole ............................................47 rimantadine hydrochloride .................17 RINVOQ...........................................66 RISPERDAL INJ 12.5MG.....................43 RISPERDAL INJ 25MG........................43 RISPERDAL INJ 37.5MG.....................43 RISPERDAL INJ 50MG........................43 risperidone.......................................43 ritonavir ..........................................15 RITUXAN .........................................22 RITUXAN HYCELA..............................22 rivastigmine tartrate .........................38 rivastigmine td patch 24hr 13.3 mg/24hr ......................................................38

rivastigmine td patch 24hr 4.6 mg/24hr ...................................................... 38 rivastigmine td patch 24hr 9.5 mg/24hr ...................................................... 38 rizatriptan benzoate ......................... 46 rizatriptan benzoate odt .................... 46 ropinirole tab 0.25mg ....................... 40 ropinirole tab 0.5mg ......................... 40 ropinirole tab 1mg............................ 40 ropinirole tab 2mg............................ 40 ropinirole tab 3mg............................ 40 ropinirole tab 4mg............................ 40 ropinirole tab 5mg............................ 40 rosadan cre 0.75%........................... 81 rosuvastatin calcium......................... 29 ROTARIX......................................... 69 ROTATEQ ........................................ 69 roweepra ........................................ 36 roweepra xr..................................... 36 ROZLYTREK..................................... 25 RUBRACA........................................ 22 RUXIENCE....................................... 22 RYDAPT .......................................... 25 S SANDIMMUNE.................................. 68 SANTYL........................................... 82 SAPHRIS ......................................... 43 scopolamine .................................... 61 SECUADO........................................ 43 selegiline hcl.................................... 40 selenium sulfide ............................... 79 SELZENTRY ..................................... 15 SEREVENT DISKUS........................... 76 sertraline hcl ................................... 39 setlakin tab ..................................... 56 sevelamer carbonate ........................ 59 sharobel.......................................... 56 SHINGRIX ....................................... 69 SIGNIFOR ....................................... 59 sildenafil citrate tab 20 mg (pulmonary hypertension) .................................. 33 silver sulfadiazine............................. 78 SIMBRINZA ..................................... 74 simvastatin ..................................... 29 sirolimus ......................................... 68 SIRTURO......................................... 17 SIVEXTRO ....................................... 13

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100

SKYRIZI ..........................................66 sodium chlor sol 0.9% irr...................82 sodium chloride .......................... 70, 71 sodium chloride 0.45% ......................71 sodium chloride inj 0.9% ...................71 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ......................................70 sodium phenylbutyrate ......................57 sodium polystyrene sulfonate powder ..53 sodium polystyrene sulfonate susp......53 SOLIQUA 100/33 ..............................50 SOLTAMOX.......................................23 SOLU-CORTEF ..................................58 SOMATULINE DEPOT .........................59 SOMAVERT.......................................59 sorine..............................................29 sotalol hcl ........................................29 sotalol hcl (afib/afl) ...........................29 spironolactone ..................................28 spironolactone & hydrochlorothiazide ..32 sprintec 28.......................................56 SPRITAM..........................................36 SPRYCEL..........................................25 sps susp 15gm/60ml .........................53 sronyx.............................................56 ssd..................................................78 stavudine.........................................15 STELARA..........................................67 STIMATE..........................................60 STIVARGA........................................26 streptomycin sulfate..........................11 STRIBILD.........................................16 subvenite tab ...................................36 sucralfate.........................................62 sulfacetamide sodium (acne)..............78 sulfacetamide sodium (ophth) ............73 sulfacetamide sod-prednisolone ..........72 SULFADIAZINE .................................11 sulfamethoxazole-trimethop ds...........13 sulfamethoxazole-trimethoprim inj......13 sulfamethoxazole-trimethoprim susp ...13 sulfamethoxazole-trimethoprim tab 400-80mg........................................13 SULFAMYLON ...................................78 sulfasalazine ....................................61 sulfasalazine ec ................................61 sulindac ............................................ 8 sumatriptan .....................................46

sumatriptan inj 4mg/0.5ml................ 46 sumatriptan inj 6mg/0.5ml................ 46 sumatriptan succinate....................... 47 SUPREP BOWEL PREP KIT.................. 62 SUTENT .......................................... 26 syeda ............................................. 56 SYLATRON....................................... 26 SYMBICORT..................................... 77 SYMDEKO........................................ 76 SYMFI............................................. 16 SYMFI LO ........................................ 16 SYMJEPI.......................................... 76 SYMPAZAN ...................................... 36 SYMTUZA ........................................ 16 SYNAREL......................................... 57 SYNERCID....................................... 13 SYNJARDY TAB 12.5-1000MG ............ 52 SYNJARDY TAB 12.5-500MG .............. 52 SYNJARDY TAB 5-1000MG................. 52 SYNJARDY TAB 5-500MG................... 52 SYNJARDY XR TAB 10-1000MG .......... 52 SYNJARDY XR TAB 12.5-1000MG ....... 52 SYNJARDY XR TAB 25-1000MG .......... 52 SYNJARDY XR TAB 5-1000MG ............ 52 SYNRIBO......................................... 26 SYNTHROID..................................... 60 T TABLOID......................................... 21 tacrolimus ....................................... 68 tacrolimus (topical) .......................... 81 TAFINLAR........................................ 26 TAGRISSO....................................... 26 TALZENNA....................................... 22 tamoxifen citrate.............................. 23 tamsulosin hcl ................................. 63 TARGRETIN ..................................... 81 tarina fe 1/20 .................................. 56 TASIGNA......................................... 26 TAXOTERE....................................... 22 tazarotene....................................... 79 tazicef ............................................ 18 TAZORAC ........................................ 79 taztia xt .......................................... 31 TAZVERIK ....................................... 26 TDVAX ............................................ 69 TECENTRIQ ..................................... 22 TEFLARO......................................... 18 telmisartan...................................... 28


temazepam ................................ 45, 46 TEMIXYS..........................................16 TENIVAC..........................................69 tenofovir disoproxil fumarate..............15 terazosin hcl.....................................28 terbinafine hcl ..................................14 terbutaline sulfate.............................76 terconazole vaginal ...........................64 testosterone.....................................49 testosterone cypionate ......................49 testosterone enanthate......................49 tetrabenazine ...................................47 tetracycline hcl .................................21 TEXACORT SOLN 2.5%......................80 THALOMID .......................................24 THEO-24..........................................76 theophylline .....................................76 theophylline tab er 12hr 300 mg.........76 theophylline tab er 12hr 450 mg.........76 theophylline tab sr 24hr.....................76 thioridazine hcl .................................43 thiothixene.......................................43 tiadylt er..........................................31 tiagabine hcl ....................................36 TIBSOVO .........................................22 tigecycline .......................................13 tilia fe..............................................56 timolol maleate.................................30 timolol maleate (ophth) soln ..............74 timolol maleate gel ...........................74 timolol maleate ophth soln 0.5% (oncedaily) ..............................................74 TIVICAY...........................................15 tizanidine hcl ....................................48 TOBRADEX.......................................72 TOBRADEX ST ..................................72 tobramycin.......................................11 tobramycin (ophth) ...........................73 tobramycin inj 1.2 gm/30ml ...............12 tobramycin inj 1.2gm ........................12 tobramycin inj 10mg/ml ....................12 tobramycin inj 80mg/2ml...................12 tobramycin sulfate ............................12 tobramycin-dexamethasone ...............72 tolterodine tartrate ...........................64 topiramate .......................................37 toposar............................................27

toremifene citrate ............................ 23 torsemide tabs................................. 32 TOVIAZ........................................... 64 TPN ELECTROLYTES.......................... 70 TRADJENTA ..................................... 52 tramadol hcl tab 50 mg....................... 9 tramadol-acetaminophen .................... 9 trandolapril...................................... 28 tranexamic acid ............................... 65 tranylcypromine sulfate..................... 39 TRAVASOL....................................... 70 travoprost ....................................... 74 TRAZIMERA ..................................... 22 trazodone hcl................................... 39 TRECATOR ...................................... 17 TRELEGY ELLIPTA............................. 74 TRELSTAR DEP INJ 3.75MG ............... 23 TRELSTAR LA INJ 11.25MG................ 23 treprostinil ...................................... 33 TRESIBA FLEXTOUCH........................ 50 TRESIBA INJ.................................... 50 tretinoin.......................................... 78 tretinoin (chemotherapy) .................. 26 triamcinolone acetonide (mouth)........ 82 triamcinolone acetonide (topical)........ 80 triamterene & hydrochlorothiazide cap 37.5-25 mg ..................................... 32 triamterene & hydrochlorothiazide tabs32 TRICARE ......................................... 72 trientine hcl ..................................... 53 tri-estarylla ..................................... 56 trifluoperazine hcl ............................ 43 trifluridine ....................................... 73 trihexyphenidyl hcl ........................... 40 TRIKAFTA........................................ 76 tri-legest fe ..................................... 56 tri-linyah ......................................... 56 tri-lo marzia .................................... 56 tri-lo-estarylla.................................. 56 tri-lo-sprintec .................................. 56 trilyte ............................................. 62 trimethoprim ................................... 13 tri-mili ............................................ 56 trimipramine maleate ....................... 39 TRINTELLIX ..................................... 39 tri-previfem ..................................... 56 tri-sprintec ...................................... 56

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TRIUMEQ .........................................16 trivora-28 ........................................56 tri-vylibra ........................................56 tri-vylibra lo .....................................56 TROGARZO ......................................15 TROPHAMINE INJ 10% ......................70 trospium chloride ..............................64 TRULICITY .......................................50 TRUMENBA.......................................69 TRUVADA TAB 100-150 .....................16 TRUVADA TAB 133-200 .....................16 TRUVADA TAB 167-250 .....................16 TRUVADA TAB 200-300 .....................16 TRUXIMA .........................................23 tulana .............................................56 TURALIO..........................................26 TWINRIX INJ ....................................69 TYBOST ...........................................15 TYKERB ...........................................26 TYMLOS...........................................59 TYPHIM VI .......................................69 U unithroid..........................................60 ursodiol ..................................... 62, 63 V valacyclovir hcl .................................17 VALCHLOR .......................................81 valganciclovir hcl ..............................17 valproate sodium ..............................37 valproate sodium oral soln .................37 valproic acid.....................................37 valsartan .........................................28 valsartan-hydrochlorothiazide.............28 VALTOCO.........................................37 vancomycin hcl.................................13 VANCOMYCIN IN NACL ......................13 vandazole ........................................64 VAQTA.............................................69 VARIVAX..........................................69 VASCEPA .........................................30 VELCADE .........................................23 velivet .............................................56 VEMLIDY..........................................17 VENCLEXTA......................................23 VENCLEXTA STARTING PACK..............23 venlafaxine hcl .................................39 VENTAVIS........................................33 VENTOLIN HFA .................................76

verapamil cap er .............................. 31 verapamil hcl................................... 31 verapamil tab er .............................. 31 VERSACLOZ..................................... 43 VERZENIO....................................... 23 VICTOZA......................................... 50 VIDEX EC 125MG ............................. 15 VIDEX PEDIATRIC ............................ 15 vienva ............................................ 56 vigabatrin powd pack 500mg ............. 37 vigabatrin tab 500mg ....................... 37 vigadrone........................................ 37 VIIBRYD STARTER PACK ................... 39 VIIBRYD TAB ................................... 39 VIMPAT........................................... 37 VIMPAT INJ 200MG/20ML.................. 37 VIMPAT SOL 10MG/ML ...................... 37 vincristine sulfate ............................. 22 vinorelbine tartrate........................... 22 viorele ............................................ 56 VIRACEPT........................................ 15 VIREAD........................................... 15 VITRAKVI ........................................ 26 VIVITROL ........................................ 48 VIZIMPRO ....................................... 26 voriconazole .................................... 14 VOSEVI........................................... 17 VOTRIENT ....................................... 26 VRAYLAR......................................... 43 VRAYLAR THERAPY PACK................... 43 vyfemla .......................................... 56 vylibra ............................................ 56 W warfarin sodium ............................... 64 water for irrigation, sterile................ 82 X XALKORI ......................................... 26 XARELTO....................................64, 65 XARELTO STARTER PACK .................. 65 XATMEP .......................................... 67 XELJANZ ......................................... 67 XELJANZ XR .................................... 67 XGEVA............................................ 59 XIFAXAN ......................................... 63 XIGDUO XR TAB 10-1000MG ............. 52 XIGDUO XR TAB 10-500MG ............... 52 XIGDUO XR TAB 2.5-1000MG ............ 52 XIGDUO XR TAB 5-1000MG ............... 52


XIGDUO XR TAB 5-500MG .................52 XOLAIR............................................77 XOSPATA .........................................26 XPOVIO 100 MG ONCE WEEKLY ..........26 XPOVIO 60 MG ONCE WEEKLY............26 XPOVIO 80 MG ONCE WEEKLY............26 XPOVIO 80 MG TWICE WEEKLY ..........26 XTANDI ...........................................23 xulane dis 150-35 .............................56 XULTOPHY 100/3.6 ...........................50 XYREM.............................................48 Y YF-VAX............................................69 yuvafem vaginal tablet 10mcg ............57 Z zafirlukast........................................76 zarah ..............................................56 ZARXIO ...........................................65 ZEJULA............................................23 ZELBORAF .......................................26 ZEMAIRA .........................................77 zenatane .........................................78 ZENPEP ...........................................63 zidovudine cap 100mg.......................15 zidovudine syp 50mg/5ml ..................15

zidovudine tab 300mg ...................... 15 ziprasidone hcl................................. 44 ziprasidone mesylate ........................ 44 ZIRABEV ......................................... 23 ZIRGAN .......................................... 73 zoledronic acid inj 4mg/100ml ........... 53 zoledronic acid inj 5mg/100ml ........... 53 zoledronic inj 4mg/5ml ..................... 53 ZOLINZA......................................... 23 zolmitriptan ..................................... 47 zolmitriptan odt ............................... 47 zolpidem tartrate ............................. 46 zonisamide ...................................... 37 ZORTRESS TAB 0.25MG .................... 68 ZORTRESS TAB 0.5MG...................... 68 ZORTRESS TAB 0.75MG .................... 68 ZORTRESS TAB 1MG......................... 68 ZOSTAVAX ...................................... 69 zovia 1/35e ..................................... 56 ZYDELIG ......................................... 26 ZYKADIA......................................... 26 ZYLET............................................. 72 ZYPREXA RELPREVV ......................... 44 ZYPREXA RELPREVV INJ 210MG ......... 44 ZYTIGA ........................................... 23

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DECLARACIÓN SOBRE NO DISCRIMINACIÓN Blue Cross of Idaho y Blue Cross of Idaho Care Plus, Inc. (en conjunto, Blue Cross of Idaho) cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Blue Cross of Idaho: • Brinda ayuda y servicios gratuitos a las personas con

discapacidades para que se comuniquen de maneraeficaz con nosotros, por ejemplo:

o Intérpretes de lenguaje de señas calificadoso Información escrita en otros formatos (letra

grande, audio, formatos electrónicos accesibles,otros formatos)

• Información escrita en otros formatos (letra grande,audio,formatos electrónicos accesibles, otros formatos)

o Intérpretes calificados o Información escrita en otros idiomas

Si necesita estos servicios, póngase en contacto conel Departamentode Servicio de Atención al Cliente de Blue Cross of Idaho. Llame al 1-800-627-1188 (los usuarios de TTY deben llamar al 1-800-377-1363) o al número de teléfono de atención al cliente que se encuentra aldorso de su credencial. Si considera que Blue Cross of Idaho no le ha ofrecido estos servicios o lo ha discriminado de otra

manera debido a su raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo ante el Departamento de Reclamos y Apelaciones deBlue Cross of Idaho, en la siguiente dirección: Manager, Grievances and Appeals 3000 E. Pine Ave., Meridian, ID 83642 Telephone: 1-800-274-4018 Fax: 208-331-7493 Email: grievances&[email protected]: 1-800-377-1363 Puede presentar un reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para presentar un reclamo, nuestro equipo de Reclamos y Apelaciones está disponible para ayudarlo. También puede presentar una queja de derechos civiles ante el Departamento de Salud y Servicios Humanos delos Estados Unidos, Oficina de Derechos Civiles, por medio del portal de reclamos de la Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo o teléfono a: Departamento de Salud y Servicios Humanos de losEE. UU., 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-3681019, 800-537-7697 (TTY). Los formularios de reclamos están disponibles en http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: Si habla árabe, chino, francés, alemán, coreano, japonés, persa (farsi), rumano, ruso, serbocroata, español, fulfulde sudánico, tagalo, ucraniano o vietnamita, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-627-1188 (los usuarios de TTY deben llamar al 1-800-377-1363).

Arabic: العربية اذكر اللغة، فإن خدمات المساعدة اللغوية إذا كنت تتحدثمملحوظة:

Bantu: ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 1-800-627-1188 (TTY: 1-800-377-1363). Chinese:注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-627-1188（TTY：1-800-3771363）。 Farsi:

گان يالت زبانی بصورت رايد، تسهيتوجه: اگر به زبان فارسی گفتگو می کن 1188-627-800-1برای شما فراهم می باشد. با

)TTY: 1-800-377-1363( د. يريتماس بگFrench: ATTENTION: Si vous parlez français, des servicesd’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-627-1188 (ATS : 1-800-377-1363). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-627-1188 (TTY: 1-800377-1363). Japanese:注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-627-1188（TTY:1-800377-1363）まで、お電話にてご連絡ください。 Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-627-1188 (TTY: 1-800-377-1363)번으로 전화해 주십시오.

)رقم هاتف الصم 1188-627-800-1 اتصل برقم تتوافر لك بالمجان. .1363-377-800-1)والبكم:

Nepali: ध्यान दिनुहोस्: तपार्इंले नेपाली बोल्नुहुन्छ भने तपार्इंकोनिम्ति भाषा सहायता सेवाहरू निःशुल्क रूपमा उपलब्ध छ। फोन गर्नुहोस् 1-800-627-1188 (टिटिवाइ: 1-800-3771363) । Romanian: ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-627-1188 (TTY: 1-800-377-1363). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-627-1188 (телетайп: 1-800-377-1363). Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-627-1188 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-377-1363). Spanish:ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-627-1188 (TTY: 1-800-377-1363). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wikanang walang bayad. Tumawag sa 1-800-627-1188 (TTY: 1-800-377-1363). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-627-1188 (TTY: 1-800-377-1363). Form No. 3-1187S (02-20)

Multi-language Interpreter Services

mailto:grievances&[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

http://www.hhs.gov/ocr/office/file/index.html

3000 East Pine Avenue | Meridian, Idaho | 83642-5995 Dirección postal: PO Box 8406 | Boise, Idaho | 83707-2406

1-888-494-2583 | TTY 1-800-377-1363

Este vademécum farmacológico fue actualizado el 01/MAYO/2020. Para obtener la información más reciente o para formular preguntas, comuníquese con el Servicio de Atención al Cliente de Blue Cross of Idaho Care Plus, Inc. al 1-855-479-3661 o, para los usuarios de TTY, al 711, todos los días de la semana, durante las 24 horas, o visite bcidaho.com/DrugList.

H1350_OP20015S_C _Alternate Format

Un servicio de Blue Cross of Idaho Care Plus, Inc. | Formulario n.° 16-596S (09-19) Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-596S (09-19)

http://bcidaho.com/DrugList

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