lista de medicamentos cubiertos/ formulario 2020...cubiertos “lista de medicamentos”). los...

Lista de medicamentos

cubiertos/Formulario 2020

Aetna Better HealthSM Premier PlanAetna Better Health Premier Plan (plan de Medicare y Medicaid) es un

plan de salud que tiene contratos con Medicare y Medicaid de Illinois para brindar los beneficios de ambos programas a los inscritos.

Para obtener información más reciente o si tiene otras preguntas, comuníquese con nosotros al 1‑866‑600‑2139 (TTY: 711), durante las

24 horas, los 7 días de la semana, o bien visite www.aetnabetterhealth.com/illinois

92.05.300.2-IL Q Actualizado el 07/01/2020 H2506_20DRUG LST SP FINAL ACCEPTED

http://www.aetnabetterhealth.com/illinois

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Aetna Better Health Premier Plan | 2020 Lista de medicamentos cubiertos (Formulario)

IntroducciónEste documento se denomina Lista de medicamentos cubiertos (también se conoce como Lista de medicamentos). Le indica qué medicamentos con receta y productos y medicamentos de venta libre están cubiertos por Aetna Better Health Premier Plan. La Lista de medicamentos también indica si hay alguna norma o restricción especial respecto de los medicamentos cubiertos por Aetna Better Health Premier Plan. Los términos clave y sus definiciones aparecen en el último capítulo del Manual para miembros.

ÍndiceA. Avisos ...............................................................................................................................................................III

B. Preguntas frecuentes.....................................................................................................................................IV

B1. ¿Qué medicamentos con receta figuran en la Lista de medicamentos cubiertos? (Para abreviarla, denominamos a la Lista de medicamentos cubiertos “Lista de medicamentos”). ...................................................................................................................IV

B2. ¿Se modifica la Lista de medicamentos en algún momento? .........................................................IV

B3. ¿Qué sucede cuando la Lista de medicamentos cambia?.................................................................V

B4. ¿Hay alguna restricción o limitación en la cobertura de medicamentos? ¿O se debe tomar alguna medida para obtener ciertos medicamentos? .....................................VI

B5. ¿Cómo sabrá si el medicamento que desea tiene limitaciones o si debe tomar alguna medida para obtener el medicamento? ...................................................................VII

B6. ¿Qué sucede si modificamos nuestras normas sobre la cobertura de algunos medicamentos? Por ejemplo, autorizaciones previas (aprobación), límites de cantidad o restricciones de tratamiento escalonado. ...................................................VII

B7. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos? ..................................VII

B8. ¿Qué sucede si el medicamento que desea tomar no figura en la Lista de medicamentos? .................................................................................................................... VIII

B9. ¿Qué sucede si usted es un miembro nuevo de Aetna Better Health Premier Plan y no puede encontrar su medicamento en la Lista de medicamentos, o si tiene algún problema para obtener su medicamento? ......................................................... VIII

B10. ¿Puede solicitar una excepción para que se cubra su medicamento? ............................................X

B11. ¿Cómo puede solicitar una excepción? ...............................................................................................X

B12. ¿Cuánto tiempo lleva obtener una excepción? ..................................................................................X

Si tiene alguna pregunta, llame a Aetna Better Health Premier Plan al 1‑866‑600‑2139 (TTY: 711), durante las 24 horas, los 7 días de la semana. La llamada es gratuita. Para obtener más información, visite www.aetnabetterhealth.com/illinois.


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Si tiene alguna pregunta, llame a Aetna Better Health Premier Plan al 1-866-600-2139 (TTY: 711), durante las 24 horas, los 7 días de la semana. La llamada es gratuita. Para obtener más información, visite www.aetnabetterhealth.com/illinois.

B13. ¿Qué son los medicamentos genéricos? .............................................................................................X

B14. ¿Qué son los medicamentos de venta libre (OTC)? ..........................................................................X

B15. ¿Aetna Better Health Premier Plan cubre productos OTC que no sean medicamentos? ...........XI

B16. ¿Cuál es su copago? .............................................................................................................................XI

B17. ¿Qué son los niveles de medicamentos? ...........................................................................................XI

C. Lista de medicamentos cubiertos ...............................................................................................................XII

D. Lista de medicamentos por afección médica ..............................................................................................1

E. Índice de medicamentos cubiertos .............................................................................................................81

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A. AvisosEsta es una lista de medicamentos que los miembros pueden obtener en Aetna Better Health Premier Plan.

❖ Aetna Better Health Premier Plan es un plan de salud que tiene contratos con Medicare y Medicaid de Illinois para brindar los beneficios de los dos programas a los miembros inscritos.

❖ ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1‑866‑600‑2139 (TTY: 711), durante las 24 horas, los 7 días de la semana. La llamada es gratuita.

ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1‑866‑600‑2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

❖ Puede obtener este documento de forma gratuita en otros formatos, como tamaño de letra grande, braille o audio. Llame al 1‑866‑600‑2139 (TTY: 711), durante las 24 horas, los 7 días de la semana. La llamada es gratuita.

❖ Si desea realizar una solicitud permanente para recibir los materiales en un idioma que no sea inglés o en otro formato, puede llamar al Departamento de Servicios para Miembros al 1‑866‑600‑2139 (TTY: 711), durante las 24 horas, los 7 días de la semana. La llamada es gratuita.

❖ Para cambiar su solicitud permanente para materiales, llame al Departamento de Servicios para Miembros al 1‑866‑600‑2139 (TTY: 711), durante las 24 horas, los 7 días de la semana.

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B. Preguntas frecuentesAquí encontrará las respuestas a las preguntas que tenga sobre esta Lista de medicamentos cubiertos. Para obtener más información o para buscar una pregunta y su respuesta, puede leer todas las preguntas frecuentes.

B1.¿QuémedicamentosconrecetafiguranenlaLista de medicamentos cubiertos? (Para abreviarla, denominamos a la Lista de medicamentos cubiertos “Lista de medicamentos”).

Los medicamentos que figuran en la Lista de medicamentos cubiertos que comienza en la página 1 son los medicamentos cubiertos por Aetna Better Health Premier Plan. Estos medicamentos están disponibles en las farmacias dentro de nuestra red. Una farmacia se encuentra dentro de nuestra red si tenemos un contrato para que trabaje con nosotros y le proporcione servicios. Nos referimos a estas farmacias como “farmacias de la red”.

• Aetna Better Health Premier Plan cubrirá todos los medicamentos que sean médicamente necesarios de la Lista de medicamentos en los siguientes casos:

° si su médico u otra persona autorizada a dar recetas le indica que los necesita para sentirse mejor o mantenerse saludable, y

° si usted obtiene el medicamento con receta en una farmacia de la red de Aetna Better Health Premier Plan.

• Aetna Better Health Premier Plan puede tener pasos adicionales para acceder a ciertos medicamentos (consulte la pregunta B4 a continuación).

También puede consultar la lista actualizada de medicamentos que cubrimos en nuestro sitio web en www.aetnabetterhealth.com/illinois o puede llamar al Departamento de Servicios para Miembros al 1‑866‑600‑2139 (TTY: 711), durante las 24 horas, los 7 días de la semana. La llamada es gratuita.

B2.¿SemodificalaListademedicamentosenalgúnmomento?Sí, y Aetna Better Health Premier Plan debe seguir las normas de Medicare y Medicaid al hacer cambios. Es posible que incorporemos o eliminemos medicamentos de la Lista de medicamentos durante el año. Por ejemplo, podríamos realizar lo siguiente:

• Decidir solicitar o no solicitar la aprobación previa para un medicamento. (La aprobación previa es una autorización de Aetna Better Health Premier Plan antes de que pueda obtener un medicamento).

• Incorporar o modificar la cantidad de un medicamento que puede obtener (lo que se denomina “límites de cantidad”).

• Incorporar o modificar restricciones de tratamiento escalonado respecto de un medicamento. (El tratamiento escalonado significa que usted debe probar un medicamento antes de que cubramos otro medicamento).

Para obtener más información sobre estas normas de medicamentos, consulte la pregunta B4.


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Si está tomando un medicamento que estaba cubierto al comienzo del año, por lo general, no eliminaremos ni cambiaremos la cobertura de ese medicamento durante el resto del año a menos que suceda lo siguiente:

• se desarrolla un medicamento nuevo y más económico que funciona tan bien como el medicamento que actualmente figura en la Lista de medicamentos, o

• nos enteramos de que el medicamento no es seguro, o

• se retira un medicamento del mercado.

En las preguntas B3 y B6 a continuación, encontrará más información sobre lo que sucede cuando se modifica la Lista de medicamentos.

• Siempre puede verificar la Lista de medicamentos actualizada de Aetna Better Health Premier Plan por Internet en www.aetnabetterhealth.com/illinois.

• También puede llamar al Departamento de Servicios para Miembros para consultar la Lista de medicamentos actual al 1‑866‑600‑2139 (TTY: 711), durante las 24 horas, los 7 días de la semana. La llamada es gratuita.

B3. ¿Qué sucede cuando la Lista de medicamentos cambia?Algunos cambios en la Lista de medicamentos se aplicarán inmediatamente. Por ejemplo:

• Un nuevo medicamento genérico se encuentra disponible. A veces, se desarrolla un medicamento genérico nuevo que funciona tan bien como el medicamento de marca que actualmente figura en la Lista de medicamentos. Cuando eso ocurre, podemos eliminar el medicamento de marca y agregar el medicamento genérico nuevo, pero el costo del nuevo medicamento será el mismo. Cuando agreguemos el nuevo medicamento genérico, también podemos decidir mantener el medicamento de marca en la lista pero cambiar sus normas o límites de cobertura.

° Es probable que no le informemos antes de realizar este cambio, pero le enviaremos información sobre el cambio específico que hicimos una vez que entre en efecto.

° Usted o su proveedor pueden solicitar una excepción de estos cambios. Le enviaremos un aviso con los pasos que puede tomar para solicitar una excepción. Para obtener más información sobre las excepciones, consulte la pregunta B10.

• Se retira un medicamento del mercado. Si la Administración de Drogas y Alimentos (FDA) indica que el medicamento que usted toma no es seguro o si el fabricante retira el medicamento del mercado, lo eliminaremos de la Lista de medicamentos. Si usted toma el medicamento, se lo informaremos. Le enviaremos una carta para informarle. También le informaremos al médico que le extiende la receta sobre el cambio. Hable con su médico para encontrar otro medicamento para su afección.

Podemos efectuar otros cambios que afecten los medicamentos que toma. Le informaremos por adelantado sobre estos otros cambios en la Lista de medicamentos. Estos cambios pueden suceder si:

• la FDA proporciona nuevas pautas o existen nuevas pautas clínicas sobre un medicamento;


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• incorporamos un medicamento genérico que es nuevo en el mercado; y

° reemplazamos un medicamento de marca que actualmente se encuentra en la Lista de medicamentos o

° cambiamos las normas o límites de cobertura para el medicamento de marca.

• incorporamos un medicamento genérico que no es nuevo en el mercado; y

° reemplazamos un medicamento de marca que actualmente se encuentra en la Lista de medicamentos o

° cambiamos las normas o límites de cobertura para el medicamento de marca

Cuando estos cambios tengan lugar, haremos lo siguiente:

• se lo notificaremos al menos 30 días antes de que hagamos el cambio en la Lista de medicamentos o

• se lo informaremos y le daremos un suministro del medicamento para 30 días en un entorno para pacientes externos y un suministro del medicamento para 31 días en un centro de atención a largo plazo después de que solicite un resurtido.

Esto le dará tiempo para consultar con su médico o la persona autorizada a dar recetas. Ellos pueden ayudarlo a decidir lo siguiente:

• si hay un medicamento similar en la Lista de medicamentos que pueda tomar en su lugar o

• si debe solicitar una excepción a estos cambios. Para obtener más información sobre las excepciones, consulte la pregunta B10.

B4. ¿Hay alguna restricción o limitación en la cobertura de medicamentos? ¿O se debe tomar alguna medida para obtener ciertos medicamentos?

Sí, algunos medicamentos tienen normas de cobertura o limitaciones en la cantidad que puede obtener. En algunos casos, usted, su médico u otra persona autorizada a dar recetas deben realizar algo antes para poder obtener un medicamento. Por ejemplo:

• Aprobación previa (o autorización previa): para algunos medicamentos, usted o su médico u otra persona autorizada a dar recetas deben conseguir la aprobación de Aetna Better Health Premier Plan antes de obtener su medicamento con receta. Es posible que Aetna Better Health Premier Plan no cubra el medicamento si no obtiene la aprobación.

• Límites de cantidad: en ocasiones, Aetna Better Health Premier Plan limita la cantidad que puede obtener de un medicamento.

• Tratamiento escalonado: a veces, Aetna Better Health Premier Plan solicita que haga un tratamiento escalonado. Esto significa que usted deberá probar medicamentos en un determinado orden para su afección médica. Es posible que deba probar un medicamento antes de que cubramos otro medicamento. Si su médico considera que el primer medicamento no es adecuado para usted, entonces, cubriremos el segundo.

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Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando las tablas en la página 1 - 80. También puede obtener más información en nuestro sitio web en www.aetnabetterhealth.com/illinois. Hemos publicado documentos en Internet que explican nuestras restricciones de tratamiento escalonado y autorización previa. También puede pedirnos que le enviemos una copia.

Puede solicitar una excepción de estas limitaciones. Esto le dará tiempo para consultar con su médico o la persona autorizada a dar recetas. Ellos pueden ayudarlo a decidir si hay un medicamento similar en la Lista de medicamentos que pueda tomar en su lugar o si debe solicitar una excepción. Para obtener más información sobre las excepciones, consulte la pregunta B10-B12.

B5. ¿Cómo sabrá si el medicamento que desea tiene limitaciones o si debe tomar alguna medida para obtener el medicamento?

La Lista de medicamentos cubiertos de la página 1 tiene una columna titulada “Acciones necesarias, restricciones o límites de uso”.

B6.¿Quésucedesimodificamosnuestrasnormassobrelacoberturade algunos medicamentos? Por ejemplo, autorizaciones previas (aprobación), límites de cantidad o restricciones de tratamiento escalonado.

En algunos casos, le notificaremos con antelación si incorporamos aprobaciones previas, límites de cantidad o restricciones de tratamiento escalonado respecto de un medicamento. Consulte la pregunta B3 para obtener más información sobre este aviso anticipado y cuáles son las situaciones en las que es posible que no le podamos avisar con antelación cuando cambien nuestras normas respecto de los medicamentos de la Lista de medicamentos.

B7. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos?Hay dos formas para encontrar un medicamento:

• puede buscar por orden alfabético (si sabe cómo se escribe el medicamento) o

• puede buscar por afección médica.

Para buscar por orden alfabético, vaya a la sección del Índice de medicamentos cubiertos. Podrá encontrarlo en la página 81. El Índice proporciona un listado alfabético de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los genéricos se encuentran en el Índice. Consulte el Índice y busque su medicamento. Junto al medicamento, verá el número de página en el que puede encontrar la información de cobertura.

Para buscar por afección médica, busque la sección titulada “Lista de medicamentos por afección médica” en la página 1. Los medicamentos en esta sección están agrupados en categorías dependiendo del tipo de afecciones médicas que estén acostumbrados a tratar. Por ejemplo, si tiene una afección cardíaca, debe buscar en la categoría “Cardiovascular”. Allí encontrará los medicamentos que sirven para tratar las afecciones cardíacas.


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B8.¿QuésucedesielmedicamentoquedeseatomarnofiguraenlaLista de medicamentos?

Si no encuentra su medicamento en la Lista de medicamentos, llame al Departamento de Servicios para Miembros al 1‑866‑600‑2139 (TTY: 711), durante las 24 horas, los 7 días de la semana, y pregunte acerca de esto. La llamada es gratuita. Si le informan que Aetna Better Health Premier Plan no cubrirá el medicamento, usted puede hacer lo siguiente:

• Pedirle al Departamento de Servicios para miembros una lista de los medicamentos que sean similares al que desea tomar. Luego, muéstrele la lista a su médico u otra persona autorizada a dar recetas. Pueden recetarle un medicamento de la Lista de medicamentos que sea similar al que desea tomar. O bien

• Puede solicitarle al plan realizar una excepción y cubrir el medicamento. Para obtener más información sobre las excepciones, consulte las preguntas B10-B12.

B9. ¿Qué sucede si usted es un miembro nuevo de Aetna Better Health Premier Plan y no puede encontrar su medicamento en la Lista demedicamentos,ositienealgúnproblemaparaobtenersumedicamento?

Nosotros podemos ayudarles. Podemos cubrir un suministro temporal de su medicamento para 30 días en un entorno para pacientes externos y un suministro de su medicamento para 31 días en un centro de atención a largo plazo durante los primeros 90 días como miembro de Aetna Better Health Premier Plan. Esto le dará tiempo para consultar con su médico o la persona autorizada a dar recetas. Ellos pueden ayudarlo a decidir si hay un medicamento similar en la Lista de medicamentos que pueda tomar en su lugar o si debe solicitar una excepción.

Si su medicamento con receta está indicado para menos días, le permitiremos obtener varios resurtidos hasta llegar a un suministro máximo para 30 días del medicamento en un entorno para pacientes externos y un suministro del medicamento para 31 días en centros de atención a largo plazo.

Cubriremos un suministro del medicamento para 30 días en un entorno para pacientes externos y un suministro del medicamento para 31 días en un centro de atención a largo plazo en las siguientes situaciones:

• si toma un medicamento que no se encuentra en nuestra Lista de medicamentos, o

• si las normas del plan de salud no le permiten obtener la cantidad solicitada por la persona autorizada a dar recetas, o

• si el medicamento requiere la aprobación previa de Aetna Better Health Premier Plan, o

• si toma un medicamento que forma parte de una restricción de tratamiento escalonado.

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Si se encuentra en un hogar de convalecencia u otro centro de atención a largo plazo, y necesita un medicamento que no figura en la Lista de medicamentos, o si no puede obtener con facilidad el medicamento que necesita, nosotros podemos ayudar. Si usted ha sido miembro del plan por más de 90 días, vive en un centro de atención a largo plazo y necesita un suministro de inmediato, haremos lo siguiente:

• Cubriremos un suministro de 31 días del medicamento que necesite (a menos que tenga una receta por menos días), independientemente de que sea o no un miembro nuevo de Aetna Better Health Premier Plan.

• Esto se suma al suministro temporal durante los primeros 90 días de su membresía en Aetna Better Health Premier Plan.

Miembros actuales con un cambio en el nivel de atención

• Cubriremos un suministro temporal para 31 días por única vez si se traslada de un hospital o un centro de atención a largo plazo a un entorno de vivienda y:

° necesita un medicamento que no se encuentra en nuestra Lista de medicamentos; o

° su capacidad para obtener el medicamento es limitada.

• Cubriremos un suministro temporal para 31 días por única vez (consulte la nota a continuación para conocer las excepciones) si se muda a un entorno de atención a largo plazo o fuera de uno y:

° necesita un medicamento que no se encuentra en nuestra Lista de medicamentos; o

° su capacidad para obtener el medicamento es limitada.

Nota: las formas de dosificación oral sólida de marca, como en el caso de los comprimidos o las cápsulas, se limitan a surtidos de 14 días con excepciones, según lo exigido por las normas de la Parte D de Medicare. Para obtener un suministro temporal de un medicamento, llame al Departamento de Servicios para miembros.

Durante el tiempo en el que esté obteniendo un suministro temporal de un medicamento, debe hablar con su proveedor para decidir qué hacer cuando se agote este suministro temporal.

• Puede cambiar a un medicamento diferente cubierto por el plan o solicitarle al plan que haga una excepción para usted y cubra el medicamento actual. Por ejemplo, usted puede pedirle al plan que cubra un medicamento, aunque no esté en la Lista de medicamentos. O puede pedirle al plan que cubra el medicamento sin límites.

• Si su proveedor dice que usted tiene una razón médica válida para obtener una excepción, puede ayudarlo a solicitarla.

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B10. ¿Puede solicitar una excepción para que se cubra su medicamento?Sí. Puede solicitar una excepción de Aetna Better Health Premier Plan para cubrir un medicamento que no figure en la Lista de medicamentos.

También puede solicitarnos que cambiemos las normas para su medicamento.

• Por ejemplo, Aetna Better Health Premier Plan puede limitar la cantidad de un medicamento que cubriremos. Si su medicamento tiene un límite, puede solicitarnos que cambiemos el límite y cubramos más.

• Otros ejemplos: puede solicitarnos que omitamos las restricciones de tratamiento escalonado o los requisitos de aprobación previa.

B11. ¿Cómo puede solicitar una excepción?Para solicitar una excepción, llame al Departamento de Servicios para miembros. Un representante del Departamento de Servicios para miembros trabajará con usted y su proveedor para ayudarlo a solicitar una excepción. También puede leer el Capítulo 9 del Manual para miembros para obtener información sobre las excepciones.

B12. ¿Cuánto tiempo lleva obtener una excepción?Primero, debemos recibir una declaración de la persona autorizada a darle recetas que respalde su solicitud de una excepción. Después de que recibamos la declaración, le informaremos nuestra decisión sobre su solicitud de excepción dentro de las 72 horas.

Si usted o la persona autorizada a dar recetas consideran que su salud puede perjudicarse si debe esperar 72 horas para recibir una decisión, puede solicitar una excepción acelerada. Esta es una decisión más rápida. Si la persona autorizada a dar recetas respalda su solicitud, le notificaremos nuestra decisión dentro de las 24 horas después de haber recibido la declaración de respaldo de la persona autorizada a dar recetas.

B13. ¿Qué son los medicamentos genéricos?Los medicamentos genéricos están compuestos por los mismos ingredientes activos que los medicamentos de marca. Generalmente, cuestan menos que los medicamentos de marca y no tienen nombres conocidos. Los medicamentos genéricos están aprobados por la Administración de Alimentos y Medicamentos (FDA).

Aetna Better Health Premier Plan cubre tanto los medicamentos de marca como los genéricos.

B14. ¿Qué son los medicamentos de venta libre (OTC)? La sigla en inglés OTC significa “de venta libre”. Aetna Better Health Premier Plan cubre algunos medicamentos OTC cuando su proveedor los indica como medicamentos con receta.

Para saber qué medicamentos OTC están cubiertos, puede leer la Lista de medicamentos de Aetna Better Health Premier Plan.

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B15. ¿Aetna Better Health Premier Plan cubre productos OTC que no sean medicamentos?

Aetna Better Health Premier Plan cubre algunos productos OTC que no sean medicamentos cuando su proveedor los receta.

Entre los ejemplos de productos OTC que no son medicamentos se incluyen paños con alcohol y apósitos de gasa. No existen costos compartidos ni copagos.

Para saber qué productos OTC que no son medicamentos están cubiertos, puede leer la Lista de medicamentos de Aetna Better Health Premier Plan.

B16. ¿Cuál es su copago? Como miembro de Aetna Better Health Premier Plan, no tiene copagos por los medicamentos con receta y OTC, siempre y cuando siga las normas de Aetna Better Health Premier Plan.

B17. ¿Qué son los niveles de medicamentos?Los niveles son grupos de medicamentos en nuestra Lista de medicamentos.

• Los medicamentos del Nivel 1 son medicamentos genéricos y de marca con receta de la Parte D.

• Los medicamentos del Nivel 2 son medicamentos genéricos y de marca con receta de la Parte D.

• Los medicamentos del Nivel 3 son medicamentos de venta libre y con receta que no son de la Parte D.

Ningún nivel tiene copago.

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C. Lista de medicamentos cubiertosLa siguiente Lista de medicamentos cubiertos le proporciona información sobre los medicamentos cubiertos por Aetna Better Health Premier Plan. Si tiene alguna dificultad para encontrar el medicamento que toma en la lista, consulte el Índice de medicamentos cubiertos que comienza en la página 81. En el índice se encuentran todos los medicamentos cubiertos por Aetna Better Health Premier Plan por orden alfabético.

En la primera columna de esta tabla se indica el nombre del medicamento. Los medicamentos de marca están en letra mayúscula (como PRADAXA) y los medicamentos genéricos están en letra minúscula y cursiva (como amoxicilina).

La información incluida en la columna de acciones necesarias, restricciones o límites de uso indica si Aetna Better Health Premier Plan tiene alguna norma especial para la cobertura del medicamento.

Aquíestánlossignificadosdeloscódigosutilizadosenlacolumna“Accionesnecesarias,restricciones o límites de uso”:

* = Productos OTC o medicamentos que no son de la Parte D y están cubiertos por Medicaid

PA = Autorización previa QL = Límites de cantidades ST = Tratamiento escalonado

NM = No disponible para pedido por correo

B/D = Cubiertos por la Parte B o la Parte D de Medicare LA = Acceso limitado

Ayuda adicional es un programa de Medicare que ayuda a las personas con ingresos y recursos limitados a reducir los costos de los medicamentos con receta de la Parte D de Medicare, como las primas, los deducibles y los copagos. La Ayuda adicional también se llama “subsidio por bajos ingresos” o “LIS”.

Nota: El asterisco (*) al lado del medicamento indica que el medicamento no es un “medicamento de la Parte D”. El monto que paga cuando obtiene uno de estos medicamentos con receta no se tiene en cuenta en sus costos totales de medicamentos (es decir, el monto que usted paga no lo ayuda a calificar para la cobertura en situaciones catastróficas).

• Además, si recibe Ayuda adicional para pagar sus medicamentos con receta, no recibirá ninguna Ayuda adicional para pagar estos medicamentos. Para obtener más información sobre la Ayuda adicional, consulte el siguiente recuadro.

• Estos medicamentos también tienen diferentes normas en cuanto a las apelaciones. Una apelación es una manera formal de solicitarnos que revisemos una decisión de cobertura y que la modifiquemos, si considera que hubo un error. Por ejemplo, podríamos decidir que un medicamento que usted desea no esté cubierto o que ya no tiene cobertura de Medicare o Medicaid.

XIII


• Si usted o su médico no están de acuerdo con nuestra decisión, pueden apelar. Para solicitar indicaciones sobre cómo presentar una apelación, llame al Departamento de Servicios para Miembros al 1‑866‑600‑2139 (TTY: 711), durante las 24 horas, los 7 días de la semana. La llamada es gratuita. También puede leer el Manual para miembros en el Capítulo 9 para obtener información sobre cómo apelar una decisión.

1

D. Lista de medicamentos por afección médicaLos medicamentos en esta sección están agrupados en categorías dependiendo del tipo de afecciones médicas que estén acostumbrados a tratar. Por ejemplo, si tiene una afección cardíaca, debe buscar en la categoría “Cardiovascular”. Allí encontrará los medicamentos que sirven para tratar las afecciones cardíacas.

Nombre del medicamento

Costo del medica-mento (Nivel)

Acciones necesarias, restricciones o límites de uso

ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATIONGOUT - DRUGS TO TREAT GOUT

allopurinol tab $0(1)colchicine w/ probenecid $0(1)COLCRYS $0(2) QL (120 tabs / 30 days)MITIGARE $0(2) QL (60 caps / 30 days)probenecid $0(1)

MISCELLANEOUSacephen $0(3) NM; *acetaminophen LIQD $0(3) NM; *acetaminophen SOLN $0(3) NM; *acetaminophen SUPP 120mg $0(3) NM; *acetaminophen TABS $0(3) NM; *acetaminophen childrens $0(3) NM; *acetaminophen extra stren $0(3) NM; *aspir-low $0(3) NM; *aspirin CHEW; TABS; TBEC $0(3) NM; *aspirin adult low dose $0(3) NM; *aspirin adult low strengt $0(3) NM; *aspirin low dose $0(3) NM; *aspirin low strength $0(3) NM; *aspirin-acetaminophen-caffeine $0(3) NM; *childrens acetaminophen SUSP $0(3) NM; *childrens silapap $0(3) NM; *ed-apap $0(3) NM; *eq aspirin ec $0(3) NM; *feverall childrens $0(3) NM; *FEVERALL INFANTS $0(3) NM; *feverall junior strength $0(3) NM; *gnp acetaminophen $0(3) NM; *

* - Productos OTC o medicamentos que no son de la Parte D y están cubiertos por Medicaid PA - Autorización previa QL - Límites de cantidad ST - Tratamiento escalonado NM - No disponible para pedido por correo B/D - Cubiertos por la Parte B o la Parte D de Medicare LA - Acceso limitadoN.º de identificación del formulario: 00020350 v12




* - Productos OTC o medicamentos que no son de la Parte D y están cubiertos por Medicaid PA - Autorización previa QL - Límites de cantidad ST - Tratamiento escalonado NM - No disponible para pedido por correo B/D - Cubiertos por la Parte B o la Parte D de Medicare LA - Acceso limitadoN.º de identificación del formulario: 00020350 v12 2

gnp adult aspirin low str $0(3) NM; *gnp aspirin $0(3) NM; *gnp aspirin low dose $0(3) NM; *gnp headache relief extra $0(3) NM; *gnp infants pain relief $0(3) NM; *gnp infants pain/fever $0(3) NM; *gnp migraine relief $0(3) NM; *gnp pain & fever children $0(3) NM; *gnp pain relief TABS $0(3) NM; *gnp pain relief extra str TABS $0(3) NM; *goodsense aspirin $0(3) NM; *goodsense aspirin adult l $0(3) NM; *goodsense pain & fever in $0(3) NM; *mapap LIQD; TABS $0(3) NM; *migraine formula $0(3) NM; *non-aspirin childrens $0(3) NM; *pain & fever $0(3) NM; *pain & fever childrens SOLN; SUSP $0(3) NM; *pain & fever extra streng $0(3) NM; *pain & fever infants $0(3) NM; *pain relief extra strengt TABS $0(3) NM; *pain reliever plus $0(3) NM; *pharbetol $0(3) NM; *pharbetol extra strength $0(3) NM; *qc aspirin $0(3) NM; *qc aspirin low dose $0(3) NM; *qc chewable aspirin low d $0(3) NM; *qc enteric aspirin $0(3) NM; *qc headache relief $0(3) NM; *qc non-aspirin childrens SUSP $0(3) NM; *qc non-aspirin extra stre $0(3) NM; *qc pain relief $0(3) NM; *qc pain relief childrens $0(3) NM; *qc pain relief extra stre $0(3) NM; *qc pain relief infants $0(3) NM; *tri-buffered aspirin $0(3) NM; *





NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATIONall day pain relief $0(3) NM; *all day relief $0(3) NM; *celecoxib CAPS 50mg $0(1) QL (240 caps / 30 days)celecoxib CAPS 100mg $0(1) QL (120 caps / 30 days)celecoxib CAPS 200mg $0(1) QL (60 caps / 30 days)celecoxib CAPS 400mg $0(1) QL (30 caps / 30 days)diclofenac potassium $0(1) QL (120 tabs / 30 days)diclofenac sodium TB24; TBEC $0(1)diflunisal TABS $0(1)etodolac $0(1)etodolac er $0(1)flurbiprofen TABS 100mg $0(1)gnp all day pain relief $0(3) NM; *gnp ibuprofen TABS $0(3) NM; *gnp naproxen sodium TABS $0(3) NM; *goodsense naproxen sodium $0(3) NM; *ibu tab 600mg $0(1)ibu tab 800mg $0(1)ibu-200 $0(3) NM; *ibuprofen SUSP $0(1)ibuprofen TABS 200mg $0(3) NM; *ibuprofen TABS 400mg, 600mg, 800mg $0(1)meloxicam TABS $0(1)nabumetone TABS $0(1)naproxen TABS $0(1)naproxen dr $0(1)naproxen sodium TABS 220mg $0(3) NM; *naproxen sodium TABS 275mg, 550mg $0(1)piroxicam CAPS $0(1)qc ibuprofen ib $0(3) NM; *qc naproxen sodium $0(3) NM; *sulindac TABS $0(1)

OPIOID ANALGESICS - DRUGS TO TREAT PAINacetaminophen w/ codeine 300-15mg $0(1) QL (400 tabs / 30 days)acetaminophen w/ codeine 300-30mg $0(1) QL (360 tabs / 30 days)





acetaminophen w/ codeine 300-60mg $0(1) QL (180 tabs / 30 days)acetaminophen w/ codeine soln $0(1) QL (2700 mL / 30 days)buprenorphine patch $0(1) QL (4 patches / 28 days), PAbutorphanol tartrate SOLN 1mg/ml, 2mg/ml $0(2)nalbuphine hcl SOLN $0(2)tramadol hcl tab 50 mg $0(1) QL (240 tabs / 30 days)tramadol-acetaminophen $0(1) QL (240 tabs / 30 days)

OPIOID ANALGESICS, CII - DRUGS TO TREAT PAINendocet 2.5-325mg $0(1) QL (360 tabs / 30 days)endocet 5-325mg $0(1) QL (360 tabs / 30 days)endocet 7.5-325mg $0(1) QL (240 tabs / 30 days)endocet 10-325mg $0(1) QL (180 tabs / 30 days)fentanyl citrate LPOP $0(2) QL (120 lozenges / 30 days), PAfentanyl patch 12 mcg/hr $0(1) QL (10 patches / 30 days), PAfentanyl patch 25 mcg/hr $0(1) QL (10 patches / 30 days), PAfentanyl patch 50 mcg/hr $0(1) QL (10 patches / 30 days), PAfentanyl patch 75 mcg/hr $0(1) QL (10 patches / 30 days), PAfentanyl patch 100 mcg/hr $0(1) QL (10 patches / 30 days), PAhydroco/apap tab 5-325mg $0(1) QL (240 tabs / 30 days)hydroco/apap tab 7.5-325 $0(1) QL (180 tabs / 30 days)hydroco/apap tab 10-325mg $0(1) QL (180 tabs / 30 days)hydrocodone-acetaminophen 7.5-325 mg/15ml $0(1) QL (2700 mL / 30 days)hydrocodone-ibuprofen tab 7.5-200 mg $0(1) QL (150 tabs / 30 days)hydromorphone hcl LIQD $0(1) QL (600 mL / 30 days)hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

$0(2) B/D

hydromorphone hcl TABS $0(1) QL (180 tabs / 30 days)HYSINGLA ER $0(2) QL (30 tabs / 30 days), PAlorcet hd tab 10-325mg $0(1) QL (180 tabs / 30 days)lorcet plus tab 7.5-325 $0(1) QL (180 tabs / 30 days)lorcet tab 5-325mg $0(1) QL (240 tabs / 30 days)methadone hcl SOLN 5mg/5ml, 10mg/5ml $0(1) QL (450 mL / 30 days), PAmethadone hcl 5mg $0(1) QL (90 tabs / 30 days), PAmethadone hcl 10mg $0(1) QL (90 tabs / 30 days), PAmethadone hcl intensol $0(1) QL (90 mL / 30 days), PAmorphine ext-rel tab $0(1) QL (90 tabs / 30 days), PA





morphine sul inj 1mg/ml $0(2) B/DMORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

$0(2) B/D

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

$0(2) B/D

morphine sulfate TABS $0(1) QL (180 tabs / 30 days)morphine sulfate oral soln 10mg/5ml $0(1) QL (900 mL / 30 days)morphine sulfate oral soln 20mg/5ml $0(1) QL (900 mL / 30 days)morphine sulfate oral soln 100mg/5ml $0(1) QL (180 mL / 30 days)NUCYNTA ER $0(2) QL (60 tabs / 30 days), PAoxycodone hcl CAPS $0(1) QL (180 caps / 30 days)oxycodone hcl CONC $0(1) QL (180 mL / 30 days)oxycodone hcl SOLN $0(1) QL (900 mL / 30 days)oxycodone hcl TABS $0(1) QL (180 tabs / 30 days)oxycodone w/ acetaminophen 2.5-325mg $0(1) QL (360 tabs / 30 days)oxycodone w/ acetaminophen 5-325mg $0(1) QL (360 tabs / 30 days)oxycodone w/ acetaminophen 7.5-325mg $0(1) QL (240 tabs / 30 days)oxycodone w/ acetaminophen 10-325mg $0(1) QL (180 tabs / 30 days)OXYCONTIN $0(2) QL (60 tabs / 30 days), PA

ANESTHETICS - DRUGS FOR NUMBINGLOCAL ANESTHETICS

lidocaine hcl (local anesth.) $0(1) B/Dlidocaine inj 0.5% $0(1) B/Dlidocaine inj 1% $0(1) B/Dlidocaine inj 1.5% preservative free (pf) $0(1) B/D

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONSANTI-BACTERIALS - MISCELLANEOUS

amikacin sulfate SOLN $0(1)gentamicin in saline $0(1)gentamicin sulfate SOLN $0(1)neomycin sulfate TABS $0(1)paromomycin sulfate CAPS $0(1)streptomycin sulfate SOLR $0(2)SULFADIAZINE TABS $0(2)tobramycin NEBU $0(2) NM, PAtobramycin inj 1.2 gm/30ml $0(1)





tobramycin inj 1.2gm $0(2)tobramycin inj 10mg/ml $0(1)tobramycin inj 80mg/2ml $0(1)tobramycin sulfate SOLN $0(1)

ANTI-INFECTIVES - MISCELLANEOUSalbendazole TABS $0(2)ALINIA $0(2)atovaquone SUSP $0(2)aztreonam $0(1)CAYSTON $0(2) NM, LA, PAclindamycin cap 75mg $0(1)clindamycin cap 300mg $0(1)clindamycin hcl cap 150 mg $0(1)clindamycin phosphate in d5w $0(1)CLINDAMYCIN PHOSPHATE IN NACL $0(2)clindamycin phosphate inj $0(1)clindamycin soln 75mg/5ml $0(1)colistimethate sodium SOLR $0(1)dapsone TABS $0(1)daptomycin $0(2)EMVERM $0(2) QL (12 tabs / 365 days)ertapenem sodium $0(1)imipenem-cilastatin $0(1)ivermectin TABS $0(1)linezolid in sodium chloride $0(2)linezolid inj $0(1)linezolid susp $0(2)linezolid tab 600mg $0(1)meropenem $0(1)methenamine hippurate $0(1)metronidazole TABS $0(1)metronidazole in nacl $0(1)nitrofurantoin macrocrystal 50mg, 100mg $0(2)nitrofurantoin monohyd macro $0(2)pentamidine isethionate inh $0(1) B/Dpentamidine isethionate inj $0(1)





praziquantel TABS $0(1)reeses pinworm medicine SUSP $0(3) NM; *SIVEXTRO $0(2)sulfamethoxazole-trimethop ds $0(1)sulfamethoxazole-trimethoprim inj $0(1)sulfamethoxazole-trimethoprim susp $0(1)sulfamethoxazole-trimethoprim tab 400-80mg $0(1)SYNERCID $0(2)tigecycline $0(2)trimethoprim TABS $0(1)vancomycin hcl CAPS 125mg $0(1) QL (120 caps / 30 days)vancomycin hcl CAPS 250mg $0(2) QL (240 caps / 30 days)vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

$0(1)

VANCOMYCIN IN NACL $0(2)ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS

ABELCET $0(2) B/DAMBISOME $0(2) B/Damphotericin b SOLR $0(1) B/Dcaspofungin acetate $0(2)fluconazole SUSR; TABS $0(1)fluconazole inj nacl 200 $0(1)fluconazole inj nacl 400 $0(1)flucytosine CAPS $0(2)griseofulvin microsize $0(1)griseofulvin ultramicrosize $0(1)itraconazole CAPS $0(1) PAketoconazole TABS $0(1) PAMYCAMINE $0(2)NOXAFIL SUSP $0(2) QL (630 mL / 30 days)nystatin TABS $0(1)posaconazole $0(2) QL (93 tabs / 30 days)terbinafine hcl TABS $0(1) QL (90 tabs / year)voriconazole SOLR $0(2) PAvoriconazole SUSR $0(2) PAvoriconazole TABS 50mg $0(1)





voriconazole TABS 200mg $0(2)ANTIMALARIALS - DRUGS TO TREAT MALARIA

atovaquone-proguanil hcl $0(1)chloroquine phosphate TABS $0(1)COARTEM $0(2)mefloquine hcl $0(1)primaquine phosphate 26.3mg $0(1)PRIMAQUINE PHOSPHATE 26.3mg $0(2)quinine sulfate CAPS $0(1) PA

ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTIONabacavir sulfate $0(1) NMAPTIVUS $0(2) NMatazanavir sulfate $0(1) NMCRIXIVAN $0(2) NMdidanosine $0(1) NMEDURANT $0(2) NMefavirenz CAPS 50mg $0(1) NMefavirenz CAPS 200mg $0(2) NMefavirenz TABS $0(2) NMEMTRIVA $0(2) NMfosamprenavir tab 700 mg $0(2) NMFUZEON $0(2) NMINTELENCE $0(2) NMINVIRASE $0(2) NMISENTRESS $0(2) NMISENTRESS HD $0(2) NMlamivudine $0(1) NMLEXIVA SUSP $0(2) NMnevirapine susp 50 mg/5ml $0(1) NMnevirapine tab 100mg er $0(1) NMnevirapine tab 200mg $0(1) NMnevirapine tab 400mg er $0(1) NMNORVIR PACK $0(2) NMNORVIR SOLN $0(2) NMPIFELTRO $0(2) NMPREZISTA SUSP $0(2) QL (400 mL / 30 days), NM





PREZISTA TABS 75mg $0(2) QL (480 tabs / 30 days), NMPREZISTA TABS 150mg $0(2) QL (240 tabs / 30 days), NMPREZISTA TABS 600mg $0(2) QL (60 tabs / 30 days), NMPREZISTA TABS 800mg $0(2) QL (30 tabs / 30 days), NMREYATAZ PACK $0(2) NMritonavir $0(1) NMSELZENTRY $0(2) NMstavudine $0(1) NMtenofovir disoproxil fumarate $0(1) NMTIVICAY $0(2) NMTROGARZO $0(2) NM, LATYBOST $0(2) NMVIRACEPT $0(2) NMVIREAD POWD $0(2) NMVIREAD TABS 150mg, 200mg, 250mg $0(2) NMzidovudine cap 100mg $0(1) NMzidovudine syp 50mg/5ml $0(1) NMzidovudine tab 300mg $0(1) NM

ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTIONabacavir sulfate-lamivudine $0(1) NMabacavir sulfate-lamivudine-zidovudine $0(2) NMATRIPLA $0(2) NMBIKTARVY $0(2) NMCIMDUO $0(2) NMCOMPLERA $0(2) NMDELSTRIGO $0(2) NMDESCOVY $0(2) NMDOVATO $0(2) NMEVOTAZ $0(2) NMGENVOYA $0(2) NMJULUCA $0(2) NMKALETRA TAB 100-25MG $0(2) NMKALETRA TAB 200-50MG $0(2) NMlamivudine-zidovudine $0(1) NMlopinavir-ritonavir $0(1) NMODEFSEY $0(2) NM





PREZCOBIX $0(2) NMSTRIBILD $0(2) NMSYMFI $0(2) NMSYMFI LO $0(2) NMSYMTUZA $0(2) NMTEMIXYS $0(2) NMTRIUMEQ $0(2) NMTRUVADA TAB 100-150 $0(2) QL (30 tabs / 30 days), NMTRUVADA TAB 133-200 $0(2) QL (30 tabs / 30 days), NMTRUVADA TAB 167-250 $0(2) QL (30 tabs / 30 days), NMTRUVADA TAB 200-300 $0(2) QL (30 tabs / 30 days), NM

ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIScycloserine CAPS $0(2)ethambutol hcl TABS $0(1)isoniazid TABS $0(1)isoniazid syp 50mg/5ml $0(1)PASER D/R $0(2)PRIFTIN $0(2)pyrazinamide TABS $0(1)rifabutin $0(1)rifampin CAPS; SOLR $0(1)RIFATER $0(2)SIRTURO $0(2) LA, PATRECATOR $0(2)

ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONSacyclovir CAPS; SUSP; TABS $0(1)acyclovir sodium $0(1) B/Dadefovir dipivoxil $0(2) NMBARACLUDE SOLN $0(2) NMentecavir $0(1) NMEPCLUSA $0(2) NM, PAEPIVIR HBV SOLN $0(2) NMfamciclovir TABS $0(1)ganciclovir sodium $0(1) B/DHARVONI TABS $0(2) NM, PAlamivudine (hbv) $0(1) NM





MAVYRET $0(2) NM, PAoseltamivir phosphate CAPS 30mg $0(1) QL (168 caps / year)oseltamivir phosphate CAPS 45mg, 75mg $0(1) QL (84 caps / year)oseltamivir phosphate SUSR $0(1) QL (1080 mL / year)PEGASYS $0(2) NM, PAPEGASYS PROCLICK $0(2) NM, PARELENZA DISKHALER $0(2) QL (6 inhalers / year)ribavirin 200mg $0(1) NMrimantadine hydrochloride $0(1)valacyclovir hcl TABS $0(1)valganciclovir hcl $0(2)VEMLIDY $0(2) NMVOSEVI $0(2) NM, PA

CEPHALOSPORINS - DRUGS TO TREAT INFECTIONScefaclor $0(1)CEFACLOR MONOHYDRATE ER $0(2)cefadroxil $0(1)CEFAZOLIN IN DEXTROSE 2GM/100ML-4% $0(2)cefazolin inj $0(1)cefazolin sodium SOLR 1gm $0(1)CEFAZOLIN SODIUM 1 GM/50ML $0(2)cefdinir $0(1)cefepime hcl $0(1)cefixime SUSR $0(1)cefoxitin sodium $0(1)cefpodoxime proxetil $0(1)cefprozil $0(1)ceftazidime SOLR $0(1)CEFTAZIDIME/DEXTROSE $0(2)ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

$0(1)

cefuroxime axetil $0(1)cefuroxime sodium $0(1)cephalexin CAPS 250mg, 500mg $0(1)cephalexin SUSR $0(1)tazicef SOLR $0(1)





TEFLARO $0(2)ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS

azithromycin PACK; SOLR; SUSR; TABS $0(1)clarithromycin TABS $0(1)clarithromycin er $0(1)clarithromycin for susp $0(1)DIFICID $0(2)e.e.s 400 $0(1)ery-tab $0(1)ERYTHROCIN LACTOBIONATE $0(2)erythrocin stearate $0(1)erythromycin base $0(1)erythromycin cap 250mg ec $0(1)erythromycin ethylsuccinate TABS $0(1)erythromycin tab ec $0(1)

FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONSCIPRO SUSR 500mg/5ml $0(2)ciprofloxacin hcl tab $0(1)ciprofloxacin in d5w $0(1)levofloxacin TABS $0(1)levofloxacin in d5w $0(1)levofloxacin inj 25mg/ml $0(1)levofloxacin oral soln 25 mg/ml $0(1)moxifloxacin hcl TABS $0(1)

PENICILLINS - DRUGS TO TREAT INFECTIONSamoxicillin $0(1)amoxicillin & pot clavulanate 200-28.5 chw tabs $0(1)amoxicillin & pot clavulanate 200/5ml susr $0(1)amoxicillin & pot clavulanate 250-125 tabs $0(1)amoxicillin & pot clavulanate 250/5ml susr $0(1)amoxicillin & pot clavulanate 400-57 chw tabs $0(1)amoxicillin & pot clavulanate 400/5ml susr $0(1)amoxicillin & pot clavulanate 500-125 tabs $0(1)amoxicillin & pot clavulanate 600/5ml susr $0(1)amoxicillin & pot clavulanate 875-125 tabs $0(1)





amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs

$0(1)

ampicillin & sulbactam sodium $0(1)ampicillin cap 500mg $0(1)ampicillin inj $0(1)ampicillin sodium $0(1)BICILLIN L-A $0(2)dicloxacillin sodium $0(1)nafcillin sodium 1gm, 2gm $0(1)nafcillin sodium 10gm $0(2)NAFCILLIN SODIUM FOR INJ 10GM $0(2)oxacillin sodium SOLR 1gm, 2gm $0(1)oxacillin sodium SOLR 10gm $0(2)PENICILLIN G POT IN DEXTROSE 2MU $0(2)PENICILLIN G POT IN DEXTROSE 3MU $0(2)PENICILLIN G PROCAINE $0(2)penicillin g sodium $0(1)penicillin v potassium $0(1)penicilln gk inj 5mu $0(1)penicilln gk inj 20mu $0(1)pfizerpen-g inj 5mu $0(1)pfizerpen-g inj 20mu $0(1)piper/tazoba inj 2-0.25gm $0(1)piper/tazoba inj 3-0.375gm $0(1)piper/tazoba inj 4-0.5gm $0(1)piper/tazoba inj 12-1.5gm $0(1)piper/tazoba inj 36-4.5gm $0(1)

TETRACYCLINES - DRUGS TO TREAT INFECTIONSdoxy 100 $0(1)doxycycline (monohydrate) CAPS 50mg, 100mg

$0(1)

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

$0(1)

doxycycline hyclate CAPS $0(1)doxycycline hyclate SOLR $0(1)doxycycline hyclate TABS 20mg, 100mg $0(1)





minocycline hcl CAPS $0(1)mondoxyne nl cap 100mg $0(1)tetracycline hcl CAPS $0(1)

ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCERALKYLATING AGENTS

BENDEKA $0(2) B/D, NMcyclophosphamide CAPS $0(1) B/Dcyclophosphamide SOLR $0(2) B/DEMCYT $0(2)GLEOSTINE $0(2)LEUKERAN $0(2)

ANTHRACYCLINESadriamycin SOLN $0(1) B/Ddoxorubicin hcl $0(1) B/Ddoxorubicin hcl liposomal $0(2) B/Depirubicin hcl $0(1) B/D

ANTIMETABOLITESadrucil inj $0(1) B/DALIMTA $0(2) B/Dazacitidine $0(2) B/D, NMcytarabine 20mg/ml $0(1) B/Dfluorouracil SOLN $0(1) B/Dgemcitabine inj soln $0(1) B/Dgemcitabine inj solr $0(1) B/Dmercaptopurine TABS $0(1)methotrexate sodium inj soln $0(1) B/Dmethotrexate sodium inj solr $0(1) B/DPURIXAN $0(2) NMTABLOID $0(2)

ANTIMITOTIC, TAXOIDSABRAXANE $0(2) B/Ddocetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml

$0(2) B/D

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

$0(2) B/D





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

$0(2) B/D

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

$0(2) B/D

paclitaxel $0(1) B/DTAXOTERE $0(2) B/D

ANTIMITOTIC, VINCA ALKALOIDSvincristine sulfate $0(1) B/Dvinorelbine tartrate $0(1) B/D

BIOLOGIC RESPONSE MODIFIERSAVASTIN $0(2) NM, LA, PABORTEZOMIB $0(2) NM, PADAURISMO $0(2) NM, LA, PAERIVEDGE $0(2) NM, LA, PAFARYDAK $0(2) NM, LA, PAHERCEPTIN $0(2) NM, PAHERCEPTIN HYLECTA $0(2) NM, PAHERZUMA $0(2) NM, PAIBRANCE CAPS $0(2) QL (21 caps / 28 days), NM, LA,

PAIBRANCE TABS $0(2) QL (21 tabs / 28 days), NM, LA,

PAIDHIFA $0(2) QL (30 tabs / 30 days), NM, LA,

PAKADCYLA $0(2) B/D, NMKANJINTI $0(2) NM, PAKEYTRUDA $0(2) NM, PAKISQALI $0(2) NM, PAKISQALI FEMARA 200 DOSE $0(2) NM, PAKISQALI FEMARA 400 DOSE $0(2) NM, PAKISQALI FEMARA 600 DOSE $0(2) NM, PALYNPARZA $0(2) NM, LA, PAMVASI $0(2) NM, LA, PANINLARO $0(2) NM, PAODOMZO $0(2) NM, LA, PAOGIVRI $0(2) NM, PAONTRUZANT $0(2) NM, PA





RITUXAN $0(2) NM, LA, PARITUXAN HYCELA $0(2) NM, LA, PARUBRACA $0(2) NM, LA, PARUXIENCE $0(2) NM, PATALZENNA $0(2) NM, LA, PATECENTRIQ $0(2) NM, LA, PATIBSOVO $0(2) NM, LA, PATRAZIMERA $0(2) NM, PATRUXIMA $0(2) NM, PAVELCADE $0(2) NM, PAVENCLEXTA $0(2) NM, LA, PAVENCLEXTA STARTING PACK $0(2) NM, LA, PAVERZENIO $0(2) NM, LA, PAZEJULA $0(2) NM, LA, PAZIRABEV $0(2) NM, PAZOLINZA $0(2) NM, PA

HORMONAL ANTINEOPLASTIC AGENTSabiraterone acetate $0(2) NM, PAanastrozole TABS $0(1)bicalutamide $0(1)DEPO-PROVERA INJ 400/ML $0(2) B/DERLEADA $0(2) NM, LA, PAexemestane $0(1)flutamide $0(1)fulvestrant $0(2) B/Dletrozole TABS $0(1)leuprolide inj 1mg/0.2 $0(1) NM, PALUPRON DEPOT (1-MONTH) 3.75mg $0(2) NM, PALUPRON DEPOT INJ 11.25MG (3-MONTH) $0(2) NM, PALYSODREN $0(2)megestrol ac sus 40mg/ml $0(2)megestrol ac tab 20mg $0(2)megestrol ac tab 40mg $0(2)megestrol sus 625mg/5ml $0(2) PAnilutamide $0(2)NUBEQA $0(2) NM, LA, PA





SOLTAMOX $0(2)tamoxifen citrate TABS $0(1)toremifene citrate $0(2)TRELSTAR DEP INJ 3.75MG $0(2) NM, PATRELSTAR LA INJ 11.25MG $0(2) NM, PAXTANDI $0(2) NM, LA, PAZYTIGA 500mg $0(2) NM, LA, PA

IMMUNOMODULATORSPOMALYST CAP 1MG $0(2) QL (21 caps / 21 days), NM, LA,

PAPOMALYST CAP 2MG $0(2) QL (21 caps / 21 days), NM, LA,



PAREVLIMID $0(2) QL (28 caps / 28 days), NM, LA,

PATHALOMID 50mg, 100mg $0(2) QL (28 caps / 28 days), NM, PATHALOMID 150mg, 200mg $0(2) QL (56 caps / 28 days), NM, PA

KINASE INHIBITORSAFINITOR 10mg $0(2) QL (30 tabs / 30 days), NM, PAAFINITOR DISPERZ 2mg $0(2) QL (150 tabs / 30 days), NM, PAAFINITOR DISPERZ 3mg $0(2) QL (90 tabs / 30 days), NM, PAAFINITOR DISPERZ 5mg $0(2) QL (60 tabs / 30 days), NM, PAALECENSA $0(2) NM, LA, PAALUNBRIG $0(2) NM, LA, PAAYVAKIT $0(2) QL (30 tabs / 30 days), NM, LA,

PABALVERSA $0(2) NM, LA, PABOSULIF $0(2) NM, PABRAFTOVI $0(2) NM, LA, PABRUKINSA $0(2) NM, LA, PACABOMETYX $0(2) QL (30 tabs / 30 days), NM, LA,

PACALQUENCE $0(2) NM, LA, PACAPRELSA $0(2) NM, LA, PA





COMETRIQ $0(2) NM, LA, PACOPIKTRA $0(2) NM, LA, PACOTELLIC $0(2) NM, LA, PAerlotinib hcl 25mg $0(2) QL (90 tabs / 30 days), NM, PAerlotinib hcl 100mg, 150mg $0(2) QL (30 tabs / 30 days), NM, PAeverolimus $0(2) QL (30 tabs / 30 days), NM, PAGILOTRIF TAB 20MG $0(2) NM, LA, PAGILOTRIF TAB 30MG $0(2) NM, LA, PAGILOTRIF TAB 40MG $0(2) NM, LA, PAICLUSIG $0(2) NM, LA, PAimatinib mesylate 100mg $0(2) QL (90 tabs / 30 days), NM, PAimatinib mesylate 400mg $0(2) QL (60 tabs / 30 days), NM, PAIMBRUVICA $0(2) NM, LA, PAINLYTA 1mg $0(2) QL (180 tabs / 30 days), NM, LA,

PAINLYTA 5mg $0(2) QL (120 tabs / 30 days), NM, LA,

PAINREBIC $0(2) NM, LA, PAIRESSA $0(2) NM, LA, PAJAKAFI $0(2) QL (60 tabs / 30 days), NM, LA,

PALENVIMA 4 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 8 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 10 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 12MG DAILY DOSE $0(2) NM, LA, PALENVIMA 14 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 18 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 20 MG DAILY DOSE $0(2) NM, LA, PALENVIMA 24 MG DAILY DOSE $0(2) NM, LA, PALORBRENA $0(2) NM, LA, PAMEKINIST $0(2) NM, LA, PAMEKTOVI $0(2) NM, LA, PANERLYNX $0(2) NM, LA, PANEXAVAR $0(2) NM, LA, PAPEMAZYRE $0(2) NM, LA, PAPIQRAY 200MG DAILY DOSE $0(2) NM, PAPIQRAY 250MG DAILY DOSE $0(2) NM, PA





PIQRAY 300MG DAILY DOSE $0(2) NM, PAROZLYTREK $0(2) NM, LA, PARYDAPT $0(2) NM, PASPRYCEL $0(2) NM, PASTIVARGA $0(2) NM, LA, PASUTENT $0(2) QL (30 caps / 30 days), NM, PATAFINLAR $0(2) NM, LA, PATAGRISSO $0(2) QL (30 tabs / 30 days), NM, LA,

PATASIGNA $0(2) NM, PATURALIO $0(2) NM, LA, PATYKERB $0(2) NM, LA, PAVITRAKVI $0(2) NM, LA, PAVIZIMPRO $0(2) NM, LA, PAVOTRIENT $0(2) NM, LA, PAXALKORI $0(2) NM, LA, PAXOSPATA $0(2) NM, LA, PAZELBORAF $0(2) NM, LA, PAZYDELIG $0(2) NM, LA, PAZYKADIA $0(2) NM, LA, PA

MISCELLANEOUSbexarotene $0(2) NM, PAhydroxyurea CAPS $0(1)LONSURF $0(2) NM, PAMATULANE $0(2) LASYLATRON 200mcg, 300mcg $0(2) NM, PASYNRIBO $0(2) NM, PATAZVERIK $0(2) NM, LA, PAtretinoin (chemotherapy) $0(2)XPOVIO 60 MG ONCE WEEKLY $0(2) NM, LA, PAXPOVIO 80 MG ONCE WEEKLY $0(2) NM, LA, PAXPOVIO 80 MG TWICE WEEKLY $0(2) NM, LA, PAXPOVIO 100 MG ONCE WEEKLY $0(2) NM, LA, PA

PLATINUM-BASED AGENTScarboplatin $0(1) B/Dcisplatin SOLN $0(1) B/D





oxaliplatin inj 50mg $0(2) B/Doxaliplatin inj 50mg/10ml $0(1) B/Doxaliplatin inj 100mg $0(2) B/Doxaliplatin inj 100mg/20ml $0(1) B/D

PROTECTIVE AGENTSleucovorin calcium SOLN 500mg/50ml $0(1) B/Dleucovorin calcium SOLR $0(1) B/Dleucovorin calcium TABS $0(1)MESNEX TABS $0(2)

TOPOISOMERASE INHIBITORSetoposide SOLN $0(1) B/Dirinotecan hcl $0(1) B/Dtoposar $0(1) B/D

CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONSACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE

amlodipine--benazepril hcl cap 10-20 mg $0(1)amlodipine-benazepril hcl cap 2.5-10 mg $0(1)amlodipine-benazepril hcl cap 5-10 mg $0(1)amlodipine-benazepril hcl cap 5-20 mg $0(1)amlodipine-benazepril hcl cap 5-40 mg $0(1)amlodipine-benazepril hcl cap 10-40mg $0(1)benazepril & hydrochlorothiazide $0(1)captopril & hydrochlorothiazide $0(1)enalapril maleate & hydrochlorothiazide $0(1)fosinopril sodium & hydrochlorothiazide $0(1)lisinopril & hydrochlorothiazide $0(1)quinapril-hydrochlorothiazide $0(1)

ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSUREbenazepril hcl TABS $0(1)captopril TABS $0(1)enalapril maleate TABS $0(1)fosinopril sodium $0(1)lisinopril TABS $0(1)moexipril hcl $0(1)perindopril erbumine $0(1)quinapril hcl $0(1)





ramipril $0(1)trandolapril $0(1)

ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSUREeplerenone $0(1)spironolactone TABS $0(1)

ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSUREdoxazosin mesylate TABS $0(1)prazosin hcl $0(1)terazosin hcl $0(1)

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE

amlodipine besylate-olmesartan medoxomil $0(1)amlodipine besylate-valsartan tab 5-160 mg $0(1)amlodipine besylate-valsartan tab 5-320 mg $0(1)amlodipine besylate-valsartan tab 10-160 mg $0(1)amlodipine besylate-valsartan tab 10-320 mg $0(1)amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

$0(1)

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

$0(1)

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

$0(1)


$0(1)


$0(1)

candesartan cilexetil-hydrochlorothiazide $0(1)ENTRESTO $0(2)irbesartan-hydrochlorothiazide $0(1)losartan-hydrochlorothiazide $0(1)olmesartan medoxomil-amlodipine-hydrochlorothiazide

$0(1)

olmesartan medoxomil-hydrochlorothiazide $0(1)telmisartan-amlodipine $0(1)telmisartan-hydrochlorothiazide $0(1)valsartan-hydrochlorothiazide $0(1)





ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSUREcandesartan cilexetil $0(1)irbesartan $0(1)losartan potassium TABS $0(1)olmesartan medoxomil TABS $0(1)telmisartan $0(1)valsartan $0(1)

ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHMamiodarone hcl soln $0(1)amiodarone tab 100mg $0(1)amiodarone tab 200mg $0(1)amiodarone tab 400mg $0(1)disopyramide phosphate $0(2)dofetilide $0(1) NMflecainide acetate $0(1)MULTAQ $0(2)NORPACE CR $0(2)pacerone $0(1)propafenone hcl $0(1)propafenone hcl 12hr $0(1)quinidine sulfate $0(1)sorine $0(1)sotalol hcl $0(1)sotalol hcl (afib/afl) $0(1)

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROLatorvastatin calcium TABS $0(1)lovastatin $0(1)pravastatin sodium $0(1)rosuvastatin calcium $0(1) QL (30 tabs / 30 days)simvastatin TABS 5mg, 10mg, 20mg, 40mg $0(1)simvastatin TABS 80mg $0(1) QL (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROLcholestyramine $0(1)cholestyramine light pack $0(1)cholestyramine light powd $0(1)colesevelam hcl $0(1)





colestipol hcl gran $0(1)colestipol hcl pack $0(1)colestipol hcl tabs $0(1)ezetimibe $0(1)ezetimibe-simvastatin $0(1)fenofibrate TABS 48mg, 54mg, 145mg, 160mg

$0(1)

fenofibrate micronized 67mg, 134mg, 200mg $0(1)gemfibrozil TABS $0(1)JUXTAPID $0(2) NM, LA, PAniacin (antihyperlipidemic) $0(1)niacin er (antihyperlipidemic) 500mg $0(1) QL (60 tabs / 30 days)niacin er (antihyperlipidemic) 750mg, 1000mg $0(1)niacor $0(1)PRALUENT $0(2) NM, PAprevalite $0(1)VASCEPA $0(2)

BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS

atenolol & chlorthalidone $0(1)bisoprolol & hydrochlorothiazide $0(1)metoprolol & hctz tab 50-25mg $0(1)metoprolol & hctz tab 100-25mg $0(1)metoprolol & hctz tab 100-50mg $0(1)propranolol & hydrochlorothiazide $0(1)

BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONSacebutolol hcl CAPS $0(1)atenolol TABS $0(1)betaxolol hcl $0(1)bisoprolol fumarate $0(1)BYSTOLIC 2.5mg, 5mg, 10mg $0(2) QL (30 tabs / 30 days)BYSTOLIC 20mg $0(2) QL (60 tabs / 30 days)carvedilol $0(1)labetalol hcl TABS $0(1)metoprolol succinate $0(1)metoprolol tartrate SOCT $0(1)





metoprolol tartrate SOLN $0(1)metoprolol tartrate TABS 25mg, 50mg, 100mg $0(1)nadolol TABS $0(1)pindolol $0(1)propranolol cap er $0(1)propranolol hcl TABS $0(1)propranolol oral sol $0(1)timolol maleate TABS $0(1)

CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS

amlodipine besylate TABS $0(1)cartia xt cap 120/24hr $0(1)cartia xt cap 180/24hr $0(1)cartia xt cap 240/24hr $0(1)cartia xt cap 300/24hr $0(1)dilt-xr cap $0(1)diltiazem cap 240mg cd $0(1)diltiazem cap 360mg cd $0(1)diltiazem cap er/12hr $0(1)diltiazem hcl TABS $0(1)diltiazem hcl coated beads CP24 $0(1)diltiazem hcl coated beads cap sr 24hr $0(1)diltiazem hcl extended release beads cap sr $0(1)diltiazem inj $0(1)felodipine $0(1)isradipine $0(1)nicardipine hcl CAPS $0(1)nifedipine TB24 $0(1)nifedipine er $0(1)nimodipine CAPS $0(2)NYMALIZE 60mg/20ml $0(2)taztia xt $0(1)tiadylt er $0(1)verapamil cap er $0(1)verapamil hcl SOLN; TABS $0(1)verapamil hcl tab er $0(1)





DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONSdigitek .25mg $0(1) PA; PA if 70 years and olderdigitek .125mg $0(1) QL (30 tabs / 30 days)digox 125mcg $0(1) QL (30 tabs / 30 days)digox 250mcg $0(1) PA; PA if 70 years and olderdigoxin TABS 125mcg $0(1) QL (30 tabs / 30 days)digoxin TABS 250mcg $0(1) PA; PA if 70 years and olderdigoxin inj $0(1)digoxin sol 50mcg/ml $0(1) PA; PA if 70 years and older

DIURETICS - DRUGS TO TREAT HEART CONDITIONSacetazolamide CP12; TABS $0(1)amiloride & hydrochlorothiazide $0(1)amiloride hcl TABS $0(1)bumetanide $0(1)chlorothiazide TABS $0(1)chlorthalidone $0(1)furosemide SOLN; TABS $0(1)furosemide inj $0(1)hydrochlorothiazide CAPS; TABS $0(1)indapamide $0(1)methazolamide TABS $0(1)metolazone $0(1)spironolactone & hydrochlorothiazide $0(1)torsemide tabs $0(1)triamterene & hydrochlorothiazide cap 37.5-25 mg

$0(1)

triamterene & hydrochlorothiazide tabs $0(1)MISCELLANEOUS

aliskiren fumarate $0(1)clonidine hcl TABS $0(1)clonidine hcl ptwk $0(1)CORLANOR $0(2)DEMSER $0(2) PAhydralazine hcl SOLN; TABS $0(1)midodrine hcl $0(1)minoxidil TABS $0(1)





NORTHERA 100mg $0(2) QL (90 caps / 30 days), NM, LA, PA

NORTHERA 200mg, 300mg $0(2) QL (180 caps / 30 days), NM, LA, PA

ranolazine $0(1)NITRATES - DRUGS TO TREAT HEART CONDITIONS

isosorb mononitrate tab $0(1)isosorbide dinitrate 5mg, 10mg, 20mg, 30mg $0(1)isosorbide mononitrate er $0(1)minitran $0(1)NITRO-BID $0(2)NITRO-DUR DIS 0.3MG/HR $0(2)NITRO-DUR DIS 0.8MG/HR $0(2)nitroglycerin SOLN .4mg/spray $0(1)nitroglycerin SUBL $0(1)nitroglycerin td patch $0(1)

PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSIONADEMPAS $0(2) QL (90 tabs / 30 days), NM, LA,

PAambrisentan $0(2) QL (30 tabs / 30 days), NM, LA,

PAbosentan 62.5mg $0(2) QL (120 tabs / 30 days), NM, LA,

PAbosentan 125mg $0(2) QL (60 tabs / 30 days), NM, LA,

PAOPSUMIT $0(2) QL (30 tabs / 30 days), NM, LA,

PAsildenafil citrate tab 20 mg (pulmonary hypertension)

$0(1) QL (90 tabs / 30 days), NM, PA

treprostinil $0(2) NM, LA, PAVENTAVIS $0(2) NM, PA

CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERSANTIANXIETY - DRUGS TO TREAT ANXIETY

alprazolam tab 0.5mg $0(1) QL (150 tabs / 30 days)alprazolam tab 0.25mg $0(1) QL (150 tabs / 30 days)alprazolam tab 1mg $0(1) QL (150 tabs / 30 days)alprazolam tab 2mg $0(1) QL (150 tabs / 30 days)buspirone hcl TABS $0(1)





fluvoxamine maleate TABS $0(1)lorazepam SOLN $0(1)lorazepam TABS $0(1) QL (150 tabs / 30 days)lorazepam intensol $0(1) QL (150 mL / 30 days)

ANTICONVULSANTS - DRUGS TO TREAT SEIZURESAPTIOM $0(2) QL (60 tabs / 30 days)BANZEL SUS 40MG/ML $0(2) PABANZEL TAB 200MG $0(2) PABANZEL TAB 400MG $0(2) PABRIVIACT INJ 50MG/5ML $0(2) PABRIVIACT SOL 10MG/ML $0(2) PABRIVIACT TAB 10MG $0(2) PABRIVIACT TAB 25MG $0(2) PABRIVIACT TAB 50MG $0(2) PABRIVIACT TAB 75MG $0(2) PABRIVIACT TAB 100MG $0(2) PAcarbamazepine CHEW; CP12; SUSP; TABS; TB12

$0(1)

CELONTIN $0(2)clobazam $0(1) PAclonazepam TABS 2mg $0(1) QL (300 tabs / 30 days)clonazepam TABS .5mg, 1mg $0(1) QL (90 tabs / 30 days)clonazepam TBDP 2mg $0(1) QL (300 tabs / 30 days)clonazepam TBDP .125mg, .25mg, .5mg, 1mg $0(1) QL (90 tabs / 30 days)clorazepate dipotassium $0(1) QL (180 tabs / 30 days), PA; PA if

65 years and olderDIASTAT ACUDIAL $0(2)DIASTAT PEDIATRIC $0(2)diazepam TABS $0(1) QL (120 tabs / 30 days), PA; PA if

65 years and olderdiazepam gel $0(1)diazepam inj $0(1)diazepam intensol $0(1) QL (240 mL / 30 days), PA; PA if

65 years and olderdiazepam oral soln 1 mg/ml $0(1) QL (1200 mL / 30 days), PA; PA if

65 years and olderDILANTIN CAP 30MG $0(2)





DILANTIN CAP 100MG $0(2)DILANTIN CHEW TAB 50MG $0(2)DILANTIN-125 SUSP $0(2)divalproex sodium CSDR; TB24; TBEC $0(1)EPIDIOLEX $0(2) QL (600 mL / 30 days), NM, LA,

PAepitol $0(1)ethosuximide CAPS; SOLN $0(1)felbamate SUSP $0(2)felbamate TABS $0(1)FYCOMPA SUSP $0(2) QL (720 mL / 30 days), PAFYCOMPA TABS 2mg, 4mg, 6mg $0(2) QL (60 tabs / 30 days), PAFYCOMPA TABS 8mg, 10mg, 12mg $0(2) QL (30 tabs / 30 days), PAgabapentin CAPS 100mg $0(1) QL (1080 caps / 30 days)gabapentin CAPS 300mg $0(1) QL (360 caps / 30 days)gabapentin CAPS 400mg $0(1) QL (270 caps / 30 days)gabapentin SOLN $0(1) QL (2160 mL / 30 days)gabapentin TABS 600mg $0(1) QL (180 tabs / 30 days)gabapentin TABS 800mg $0(1) QL (120 tabs / 30 days)lamotrigine CHEW; TABS; TB24 $0(1)levetiracetam SOLN; TABS; TB24 $0(1)levetiracetam in sodium chloride $0(1)levetiracetam oral soln 100 mg/ml $0(1)NAYZILAM $0(2)oxcarbazepine $0(1)PEGANONE $0(2)phenobarbital ELIX; TABS $0(2) PA; PA if 70 years and olderphenobarbital sodium SOLN $0(2) PA; PA if 70 years and olderPHENYTEK $0(2)phenytoin CHEW; SUSP $0(1)phenytoin sodium extended $0(1)phenytoin sodium inj 50mg/ml $0(1)pregabalin CAPS 25mg, 50mg, 75mg, 100mg, 150mg

$0(1) QL (120 caps / 30 days), PA

pregabalin CAPS 200mg $0(1) QL (90 caps / 30 days), PApregabalin CAPS 225mg, 300mg $0(1) QL (60 caps / 30 days), PA





pregabalin SOLN $0(1) QL (900 mL / 30 days), PAprimidone TABS $0(1)roweepra $0(1)roweepra xr $0(1)SPRITAM $0(2)subvenite tab $0(1)SYMPAZAN $0(2) PAtiagabine hcl $0(1)topiramate CPSP; TABS $0(1)valproate sodium SOLN $0(1)valproic acid CAPS $0(1)VALTOCO $0(2)vigabatrin powd pack 500mg $0(2) QL (180 packets / 30 days), NM,

LA, PAvigabatrin tab 500mg $0(2) QL (180 tabs / 30 days), NM, LA,

PAvigadrone $0(2) QL (180 packets / 30 days), NM,

LA, PAVIMPAT 50mg $0(2) QL (120 tabs / 30 days)VIMPAT 100mg, 150mg, 200mg $0(2) QL (60 tabs / 30 days)VIMPAT INJ 200MG/20ML $0(2)VIMPAT SOL 10MG/ML $0(2) QL (1200 mL / 30 days)zonisamide CAPS $0(1)

ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSSdonepezil hydrochloride TABS 5mg $0(1) QL (30 tabs / 30 days)donepezil hydrochloride TABS 10mg $0(1)donepezil hydrochloride TBDP 5mg $0(1) QL (30 tabs / 30 days)donepezil hydrochloride TBDP 10mg $0(1)galantamine hydrobromide SOLN $0(1)galantamine hydrobromide TABS $0(1) QL (60 tabs / 30 days)galantamine hydrobromide er $0(1) QL (30 caps / 30 days)memantine hcl cp24 $0(1) PA; PA if < 30 yrsmemantine soln $0(1) PA; PA if < 30 yrsmemantine tabs $0(1) PA; PA if < 30 yrsmemantine titration pak $0(2) PA; PA if < 30 yrsNAMZARIC $0(2)rivastigmine tartrate 1.5mg, 3mg $0(1) QL (90 caps / 30 days)





rivastigmine tartrate 4.5mg, 6mg $0(1) QL (60 caps / 30 days)rivastigmine td patch 24hr 4.6 mg/24hr $0(1) QL (30 patches / 30 days)rivastigmine td patch 24hr 9.5 mg/24hr $0(1) QL (30 patches / 30 days)rivastigmine td patch 24hr 13.3 mg/24hr $0(1) QL (30 patches / 30 days)

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSIONamitriptyline hcl TABS $0(2)amoxapine tab 25mg $0(2)amoxapine tab 50mg $0(2)amoxapine tab 100mg $0(2)amoxapine tab 150mg $0(2)bupropion hcl TABS $0(1)bupropion hcl TB12 $0(1)bupropion hcl TB24 150mg, 300mg $0(1)citalopram hydrobromide $0(1)clomipramine hcl CAPS $0(2) PAdesipramine hcl TABS $0(2)desvenlafaxine succinate $0(1) QL (30 tabs / 30 days), PAdoxepin hcl CAPS; CONC $0(2)DRIZALMA SPRINKLE 20mg, 30mg, 60mg $0(2) QL (60 caps / 30 days), PADRIZALMA SPRINKLE 40mg $0(2) QL (90 caps / 30 days), PAduloxetine hcl CPEP 20mg, 30mg, 60mg $0(1) QL (60 caps / 30 days)EMSAM $0(2) QL (30 patches / 30 days), PAescitalopram oxalate $0(1)FETZIMA 20mg, 40mg $0(2) QL (60 caps / 30 days), PAFETZIMA 80mg, 120mg $0(2) QL (30 caps / 30 days), PAFETZIMA TITRATION PACK $0(2) PAfluoxetine cap 10mg $0(1)fluoxetine cap 20mg $0(1)fluoxetine cap 40mg $0(1)fluoxetine hcl SOLN $0(1)imipramine hcl TABS $0(2)maprotiline hcl $0(1)MARPLAN TAB 10MG $0(2) QL (180 tabs / 30 days)mirtazapine TABS; TBDP $0(1)nefazodone hcl $0(1)nortriptyline hcl CAPS; SOLN $0(2)





paroxetine hcl tabs $0(2)PAXIL SUSP $0(2) QL (900 mL / 30 days)phenelzine sulfate TABS $0(1)protriptyline hcl $0(2)sertraline hcl CONC; TABS $0(1)tranylcypromine sulfate $0(1)trazodone hcl TABS 50mg, 100mg, 150mg $0(1)trimipramine maleate CAPS 25mg $0(2) QL (240 caps / 30 days)trimipramine maleate CAPS 50mg $0(2) QL (120 caps / 30 days)trimipramine maleate CAPS 100mg $0(2) QL (60 caps / 30 days)TRINTELLIX 5mg $0(2) QL (120 tabs / 30 days)TRINTELLIX 10mg $0(2) QL (60 tabs / 30 days)TRINTELLIX 20mg $0(2) QL (30 tabs / 30 days)venlafaxine hcl CP24; TABS $0(1)VIIBRYD STARTER PACK $0(2)VIIBRYD TAB $0(2) QL (30 tabs / 30 days)

ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASEamantadine hcl CAPS $0(1) QL (120 caps / 30 days)amantadine hcl SYRP; TABS $0(1)APOKYN $0(2) QL (20 cartridges / 30 days),

NM, LA, PAbenztropine mesylate inj $0(1)benztropine mesylate tab 0.5mg $0(2) PA; PA if 70 years and olderbenztropine mesylate tab 1mg $0(2) PA; PA if 70 years and olderbenztropine mesylate tab 2mg $0(2) PA; PA if 70 years and olderbromocriptine mesylate CAPS; TABS $0(1)carbidopa-levodopa $0(1)carbidopa/levodopa/entacapone $0(1)entacapone $0(1)NEUPRO $0(2)pramipexole tab 0.5mg $0(1)pramipexole tab 0.25mg $0(1)pramipexole tab 0.75mg $0(1)pramipexole tab 0.125mg $0(1)pramipexole tab 1.5mg $0(1)pramipexole tab 1mg $0(1)





rasagiline mesylate TABS $0(1)ropinirole tab 0.5mg $0(1)ropinirole tab 0.25mg $0(1)ropinirole tab 1mg $0(1)ropinirole tab 2mg $0(1)ropinirole tab 3mg $0(1)ropinirole tab 4mg $0(1)ropinirole tab 5mg $0(1)selegiline hcl CAPS; TABS $0(1)trihexyphenidyl hcl $0(2) PA; PA if 70 years and older

ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSESABILIFY MAINTENA $0(2) QL (1 injection / 28 days)aripiprazole odt $0(2) QL (60 tabs / 30 days)aripiprazole oral solution 1 mg/ml $0(2) QL (900 mL / 30 days)aripiprazole tab $0(1) QL (30 tabs / 30 days)ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml

$0(2) QL (1 injection / 28 days)

ARISTADA 1064mg/3.9ml $0(2) QL (1 injection / 56 days)ARISTADA INITIO $0(2)CAPLYTA $0(2) QL (30 caps / 30 days)chlorpromazine hcl TABS $0(1)CHLORPROMAZINE INJ $0(2)clozapine odt 12.5mg, 25mg $0(1) PAclozapine odt 100mg $0(1) QL (270 tabs / 30 days), PAclozapine odt 150mg $0(1) QL (180 tabs / 30 days), PAclozapine odt 200mg $0(1) QL (135 tabs / 30 days), PAclozapine tab 25mg $0(1)clozapine tab 50mg $0(1)clozapine tab 100mg $0(1) QL (270 tabs / 30 days)clozapine tab 200mg $0(1) QL (135 tabs / 30 days)FANAPT $0(2) QL (60 tabs / 30 days), PAFANAPT TITRATION PACK $0(2) PAfluphenazine decanoate SOLN $0(1)fluphenazine hcl $0(1)GEODON SOLR $0(2) QL (6 mL / 3 days)haloperidol TABS $0(1)





haloperidol conc 2mg/ml $0(1)haloperidol decanoate SOLN $0(1)haloperidol lactate inj 5mg/ml $0(1)INVEGA SUST INJ 39 MG/0.25 ML $0(2) QL (1 injection / 28 days)INVEGA SUST INJ 78 MG/0.5 ML $0(2) QL (1 injection / 28 days)INVEGA SUST INJ 117 MG/0.75 ML $0(2) QL (1 injection / 28 days)INVEGA SUST INJ 156MG/ML $0(2) QL (1 injection / 28 days)INVEGA SUST INJ 234 MG/1.5 ML $0(2) QL (1 injection / 28 days)INVEGA TRINZA $0(2) QL (1 injection / 90 days)LATUDA 20mg, 40mg, 60mg, 120mg $0(2) QL (30 tabs / 30 days)LATUDA 80mg $0(2) QL (60 tabs / 30 days)loxapine succinate $0(1)molindone hcl $0(1)NUPLAZID CAPS $0(2) QL (30 caps / 30 days), NM, LA,

PANUPLAZID TABS 10MG $0(2) QL (30 tabs / 30 days), NM, LA,

PAolanzapine SOLR $0(1) QL (3 vials / 1 day)olanzapine TABS 2.5mg, 5mg, 10mg $0(1) QL (60 tabs / 30 days)olanzapine TABS 7.5mg, 15mg, 20mg $0(1) QL (30 tabs / 30 days)olanzapine TBDP 5mg, 15mg, 20mg $0(1) QL (30 tabs / 30 days)olanzapine TBDP 10mg $0(1) QL (60 tabs / 30 days)paliperidone 1.5mg, 3mg, 9mg $0(1) QL (30 tabs / 30 days)paliperidone 6mg $0(1) QL (60 tabs / 30 days)perphenazine TABS $0(1)PERSERIS $0(2) QL (1 injection / 30 days)pimozide $0(1)quetiapine fumarate TABS $0(1)quetiapine fumarate TB24 50mg, 300mg, 400mg

$0(1) QL (60 tabs / 30 days), PA

quetiapine fumarate TB24 150mg, 200mg $0(1) QL (30 tabs / 30 days), PAREXULTI 3mg, 4mg $0(2) QL (30 tabs / 30 days)REXULTI .25mg, .5mg, 1mg, 2mg $0(2) QL (60 tabs / 30 days)RISPERDAL INJ 12.5MG $0(2) QL (2 injections / 28 days)RISPERDAL INJ 25MG $0(2) QL (2 injections / 28 days)RISPERDAL INJ 37.5MG $0(2) QL (2 injections / 28 days)RISPERDAL INJ 50MG $0(2) QL (2 injections / 28 days)





risperidone SOLN $0(1) QL (240 mL / 30 days)risperidone TABS $0(1)risperidone TBDP 1mg, 2mg, 3mg, 4mg $0(1) QL (60 tabs / 30 days)risperidone TBDP .25mg, .5mg $0(1) QL (90 tabs / 30 days)SAPHRIS $0(2) QL (60 tabs / 30 days)SECUADO $0(2) QL (30 patches / 30 days)thioridazine hcl TABS $0(1)thiothixene $0(1)trifluoperazine hcl $0(1)VERSACLOZ $0(2) QL (600 mL / 30 days), PAVRAYLAR 1.5mg $0(2) QL (60 caps / 30 days), PAVRAYLAR 3mg, 4.5mg, 6mg $0(2) QL (30 caps / 30 days), PAVRAYLAR THERAPY PACK $0(2) PAziprasidone hcl $0(1) QL (60 caps / 30 days)ziprasidone mesylate $0(1) QL (6 injections / 3 days)ZYPREXA RELPREVV 300mg $0(2) QL (2 vials / 28 days), PAZYPREXA RELPREVV 405mg $0(2) QL (1 vial / 28 days), PAZYPREXA RELPREVV INJ 210MG $0(2) QL (2 vials / 28 days), PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHDamphetamine-dextroamphetamine cap sr 24hr 5 mg

$0(1) QL (90 caps / 30 days)

amphetamine-dextroamphetamine cap sr 24hr 10 mg

$0(1) QL (90 caps / 30 days)


$0(1) QL (30 caps / 30 days)


$0(1) QL (30 caps / 30 days)


$0(1) QL (30 caps / 30 days)


$0(1) QL (30 caps / 30 days)

amphetamine-dextroamphetamine tab 5 mg $0(1) QL (120 tabs / 30 days)amphetamine-dextroamphetamine tab 7.5 mg $0(1) QL (120 tabs / 30 days)amphetamine-dextroamphetamine tab 10 mg $0(1) QL (120 tabs / 30 days)amphetamine-dextroamphetamine tab 12.5 mg $0(1) QL (120 tabs / 30 days)amphetamine-dextroamphetamine tab 15 mg $0(1) QL (90 tabs / 30 days)amphetamine-dextroamphetamine tab 20 mg $0(1) QL (90 tabs / 30 days)





amphetamine-dextroamphetamine tab 30 mg $0(1) QL (60 tabs / 30 days)atomoxetine hcl 10mg, 18mg, 25mg $0(1) QL (120 caps / 30 days)atomoxetine hcl 40mg $0(1) QL (60 caps / 30 days)atomoxetine hcl 60mg, 80mg, 100mg $0(1) QL (30 caps / 30 days)dexmethylphenidate hcl TABS 2.5mg, 5mg $0(1) QL (120 tabs / 30 days)dexmethylphenidate hcl TABS 10mg $0(1) QL (60 tabs / 30 days)guanfacine er (adhd) $0(2) PA; PA if 70 years and oldermetadate er tab 20mg $0(1) QL (90 tabs / 30 days)methylphenidate hcl TABS 5mg, 10mg $0(1) QL (180 tabs / 30 days)methylphenidate hcl TABS 20mg $0(1) QL (90 tabs / 30 days)methylphenidate hcl oral soln 5mg/5ml $0(1) QL (1800 mL / 30 days)methylphenidate hcl oral soln 10mg/5ml $0(1) QL (900 mL / 30 days)methylphenidate hcl tbcr 10 mg $0(1) QL (90 tabs / 30 days)methylphenidate hcl tbcr 20mg $0(1) QL (90 tabs / 30 days)

HYPNOTICS - DRUGS TO TREAT INSOMNIABELSOMRA $0(2) QL (30 tabs / 30 days)doxepin hcl (sleep) $0(1) QL (30 tabs / 30 days)eszopiclone $0(2) QL (30 tabs / 30 days), PA; PA

applies if 70 years and older after a 90 day supply in a

calendar yearHETLIOZ $0(2) NM, LA, PAtemazepam 7.5mg $0(1) QL (30 caps / 30 days), PA; PA


calendar yeartemazepam 15mg $0(1) QL (60 caps / 30 days), PA; PA


calendar yearzaleplon $0(2) QL (60 caps / 30 days), PA; PA


calendar yearzolpidem tartrate TABS $0(2) QL (30 tabs / 30 days), PA; PA


calendar year





MIGRAINE - DRUGS TO TREAT SEVERE HEADACHESAIMOVIG $0(2) QL (1 pen / 30 days), NM, PAdihydroergotamine mesylate inj 1 mg/ml $0(2)dihydroergotamine mesylate nasal spr 4 mg/ml $0(2) QL (8 mL / 30 days), PAeletriptan hydrobromide $0(1) QL (12 tabs / 30 days)EMGALITY SOAJ $0(2) QL (2 pens / 30 days), NM, PAEMGALITY SOSY 120mg/ml $0(2) QL (2 syringes / 30 days), NM,

PAergotamine w/ caffeine TABS $0(1)naratriptan hcl $0(1) QL (12 tabs / 30 days)rizatriptan benzoate $0(1) QL (18 tabs / 30 days)rizatriptan benzoate odt $0(1) QL (18 tabs / 30 days)sumatriptan SOLN 5mg/act $0(1) QL (24 inhalers / 30 days)sumatriptan SOLN 20mg/act $0(1) QL (12 inhalers / 30 days)sumatriptan inj 4mg/0.5ml $0(1) QL (18 injections / 30 days)sumatriptan inj 6mg/0.5ml $0(1) QL (12 injections / 30 days)sumatriptan succinate TABS $0(1) QL (12 tabs / 30 days)zolmitriptan TABS $0(1) QL (12 tabs / 30 days)zolmitriptan odt $0(1) QL (12 tabs / 30 days)

MISCELLANEOUSAUSTEDO 6mg $0(2) QL (60 tabs / 30 days), NM, PAAUSTEDO 9mg, 12mg $0(2) QL (120 tabs / 30 days), NM, PAINGREZZA CAPS $0(2) QL (30 caps / 30 days), NM, PAINGREZZA CPPK $0(2) QL (28 caps / 28 days), NM, PAlithium carbonate CAPS; TABS $0(1)lithium carbonate er $0(1)LITHIUM SOLN 8MEQ/5ML $0(2)LYRICA CR $0(2) QL (60 tabs / 30 days), PANUEDEXTA $0(2) QL (60 caps / 30 days), PApyridostigmine tab 60mg $0(1)riluzole $0(1)tetrabenazine 12.5mg $0(2) QL (240 tabs / 30 days), NM, PAtetrabenazine 25mg $0(2) QL (120 tabs / 30 days), NM, PA

MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSISBETASERON $0(2) QL (14 syringes / 28 days), NM,

PA





dalfampridine TB12 $0(2) NM, PAGILENYA CAP 0.5MG $0(2) QL (28 caps / 28 days), NM, PAglatiramer acetate 20mg/ml $0(2) QL (30 syringes / 30 days), NM,

PAglatiramer acetate 40mg/ml $0(2) QL (12 syringes / 28 days), NM,

PAglatopa 20mg/ml $0(2) QL (30 syringes / 30 days), NM,

PAglatopa 40mg/ml $0(2) QL (12 syringes / 28 days), NM,

PAMUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS

baclofen TABS 10mg, 20mg $0(1)carisoprodol TABS 350mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and oldercyclobenzaprine hcl TABS 5mg, 10mg $0(2) PA; PA if 70 years and olderdantrolene sodium CAPS $0(1)methocarbamol TABS $0(2) PA; PA if 70 years and oldertizanidine hcl TABS $0(1)

NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERSarmodafinil 50mg $0(1) QL (90 tabs / 30 days), PAarmodafinil 150mg, 200mg, 250mg $0(1) QL (30 tabs / 30 days), PAXYREM $0(2) QL (540 mL / 30 days), NM, LA,

PAPSYCHOTHERAPEUTIC-MISC

acamprosate calcium $0(1)buprenorphine hcl SUBL $0(1) QL (90 tabs / 30 days), PAbuprenorphine hcl-naloxone hcl dihydrate 2-0.5mg

$0(1) QL (90 films / 30 days)

buprenorphine hcl-naloxone hcl dihydrate 4-1mg

$0(1) QL (90 films / 30 days)


$0(1) QL (90 films / 30 days)


$0(1) QL (60 films / 30 days)

buprenorphine hcl-naloxone hcl sl $0(1) QL (90 tabs / 30 days)bupropion hcl (smoking deterrent) $0(1)CHANTIX $0(2) PACHANTIX CONTINUING MONTH $0(2) PA





CHANTIX STARTER PACK $0(2) PAdisulfiram TABS $0(1)gnp nicotine mini lozenge $0(3) NM; *gnp nicotine polacrilex $0(3) NM; *gnp nicotine polacrilex m $0(3) NM; *gnp nicotine transdermal $0(3) NM; *goodsense nicotine gum $0(3) NM; *goodsense nicotine polacr $0(3) NM; *naloxone inj 0.4mg/ml $0(1)naloxone inj 1mg/ml $0(1)naltrexone hcl TABS $0(1)NARCAN $0(2)nicorelief $0(3) NM; *nicotine $0(3) NM; *nicotine polacrilex GUM; LOZG $0(3) NM; *NICOTINE TRANSDERMAL SYST KIT $0(3) NM; *nicotine transdermal syst PT24 $0(3) NM; *NICOTROL INHALER $0(2)NICOTROL NS $0(2)VIVITROL $0(2) NM

ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONESANDROGENS - DRUGS TO REGULATE MALE HORMONES

ANADROL-50 $0(2) PAANDRODERM $0(2) QL (30 patches / 30 days), PAoxandrolone TABS $0(1) PAtestosterone GEL 1%, 25mg/2.5gm, 50mg/5gm

$0(1) QL (300 grams / 30 days), PA

testosterone cypionate SOLN $0(1) PAtestosterone enanthate SOLN $0(1) PA

ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETESBASAGLAR KWIKPEN $0(2)BD ALCOHOL SWABS $0(2)BD ULTRAFINE INSULIN SYRINGE $0(2)BD ULTRAFINE/NANO PEN NEEDLES $0(2)BYDUREON BCISE $0(2) QL (4 pens / 28 days)BYDUREON PEN $0(2) QL (4 pens / 28 days)





BYETTA $0(2) QL (1 pen / 30 days)FIASP $0(2)FIASP FLEXTOUCH $0(2)FIASP PENFILL $0(2)GAUZE PADS 2” X 2” $0(2)HUMULIN R INJ U-500 $0(2) B/DHUMULIN R U-500 KWIKPEN $0(2)INSULIN PEN NEEDLE $0(2)INSULIN SAFETY NEEDLES $0(2)INSULIN SYRINGE $0(2)LEVEMIR $0(2)LEVEMIR FLEXTOUCH $0(2)NOVOLIN 70/30 $0(2) (brand RELION not covered)NOVOLIN 70/30 FLEXPEN $0(2) (brand RELION not covered)NOVOLIN N $0(2) (brand RELION not covered)NOVOLIN N FLEXPEN $0(2) (brand RELION not covered)NOVOLIN R $0(2) (brand RELION not covered)NOVOLIN R FLEXPEN $0(2) (brand RELION not covered)NOVOLOG $0(2)NOVOLOG 70/30 FLEXPEN $0(2)NOVOLOG FLEXPEN $0(2)NOVOLOG MIX 70/30 $0(2)NOVOLOG PENFILL $0(2)OZEMPIC INJ 0.25 OR 0.5MG/DOSE $0(2) QL (1 pen / 28 days)OZEMPIC INJ 1MG/DOSE $0(2) QL (2 pens / 28 days)SOLIQUA 100/33 $0(2) QL (10 pens / 30 days)TRESIBA FLEXTOUCH $0(2)TRESIBA INJ $0(2)TRULICITY $0(2) QL (4 pens / 28 days)VICTOZA $0(2) QL (3 pens / 30 days)XULTOPHY 100/3.6 $0(2) QL (5 pens / 30 days)

ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETESacarbose TABS $0(1)FARXIGA $0(2) QL (30 tabs / 30 days)glimepiride 1mg, 2mg $0(2) QL (90 tabs / 30 days)glimepiride 4mg $0(2) QL (60 tabs / 30 days)





glip/metform tab 2.5-250mg $0(1) QL (240 tabs / 30 days)glip/metform tab 2.5-500mg $0(1) QL (120 tabs / 30 days)glip/metform tab 5-500mg $0(1) QL (120 tabs / 30 days)glipizide TABS 5mg $0(1) QL (240 tabs / 30 days)glipizide TABS 10mg $0(1) QL (120 tabs / 30 days)glipizide TB24 2.5mg, 5mg $0(1) QL (90 tabs / 30 days)glipizide TB24 10mg $0(1) QL (60 tabs / 30 days)glipizide xl 2.5mg, 5mg $0(1) QL (90 tabs / 30 days)glipizide xl 10mg $0(1) QL (60 tabs / 30 days)glyburide TABS 1.25mg $0(2) QL (480 tabs / 30 days), PA; PA if

70 years and olderglyburide TABS 2.5mg $0(2) QL (240 tabs / 30 days), PA; PA if

70 years and olderglyburide TABS 5mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and olderglyburide micronized 1.5mg $0(2) QL (240 tabs / 30 days), PA; PA if

70 years and olderglyburide micronized 3mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and olderglyburide micronized 6mg $0(2) QL (60 tabs / 30 days), PA; PA if

70 years and olderglyburide-metformin tab 1.25-250 mg $0(2) QL (240 tabs / 30 days), PA; PA if

70 years and olderglyburide-metformin tab 2.5-500 mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and olderglyburide-metformin tab 5-500mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and olderGLYXAMBI $0(2) QL (30 tabs / 30 days)JANUMET $0(2) QL (60 tabs / 30 days)JANUMET XR TAB 50-500MG $0(2) QL (60 tabs / 30 days)JANUMET XR TAB 50-1000 $0(2) QL (60 tabs / 30 days)JANUMET XR TAB 100-1000 $0(2) QL (30 tabs / 30 days)JANUVIA $0(2) QL (30 tabs / 30 days)JARDIANCE 10mg $0(2) QL (60 tabs / 30 days)JARDIANCE 25mg $0(2) QL (30 tabs / 30 days)JENTADUETO $0(2) QL (60 tabs / 30 days)JENTADUETO TAB XR 2.5-1000 MG $0(2) QL (60 tabs / 30 days)JENTADUETO TAB XR 5-1000 MG $0(2) QL (30 tabs / 30 days)





metformin er 500mg $0(1) QL (120 tabs / 30 days); (generic of GLUCOPHAGE XR)

metformin er 750mg $0(1) QL (60 tabs / 30 days); (generic of GLUCOPHAGE XR)

metformin hcl TABS 500mg $0(1) QL (150 tabs / 30 days)metformin hcl TABS 850mg $0(1) QL (90 tabs / 30 days)metformin hcl TABS 1000mg $0(1) QL (75 tabs / 30 days)nateglinide $0(1) QL (90 tabs / 30 days)pioglitazone hcl $0(1) QL (30 tabs / 30 days)repaglinide 2mg $0(1) QL (240 tabs / 30 days)repaglinide .5mg, 1mg $0(1) QL (120 tabs / 30 days)RYBELSUS $0(2) QL (30 tabs / 30 days)SYNJARDY TAB 5-500MG $0(2) QL (120 tabs / 30 days)SYNJARDY TAB 5-1000MG $0(2) QL (60 tabs / 30 days)SYNJARDY TAB 12.5-500MG $0(2) QL (60 tabs / 30 days)SYNJARDY TAB 12.5-1000MG $0(2) QL (60 tabs / 30 days)SYNJARDY XR TAB 5-1000MG $0(2) QL (60 tabs / 30 days)SYNJARDY XR TAB 10-1000MG $0(2) QL (60 tabs / 30 days)SYNJARDY XR TAB 12.5-1000MG $0(2) QL (60 tabs / 30 days)SYNJARDY XR TAB 25-1000MG $0(2) QL (30 tabs / 30 days)TRADJENTA $0(2) QL (30 tabs / 30 days)TRIJARDY XR TAB ER 24HR 5-2.5-1000MG $0(2) QL (60 tabs / 30 days)TRIJARDY XR TAB ER 24HR 10-5-1000 MG $0(2) QL (30 tabs / 30 days)TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG $0(2) QL (60 tabs / 30 days)TRIJARDY XR TAB ER 24HR 25-5-1000 MG $0(2) QL (30 tabs / 30 days)XIGDUO XR TAB 2.5-1000MG $0(2) QL (60 tabs / 30 days)XIGDUO XR TAB 5-500MG $0(2) QL (60 tabs / 30 days)XIGDUO XR TAB 5-1000MG $0(2) QL (60 tabs / 30 days)XIGDUO XR TAB 10-500MG $0(2) QL (30 tabs / 30 days)XIGDUO XR TAB 10-1000MG $0(2) QL (30 tabs / 30 days)

BISPHOSPHONATES - DRUGS TO TREAT BONE LOSSalendronate sodium soln 70mg/75ml $0(1)alendronate sodium tab 5 mg $0(1)alendronate sodium tab 10 mg $0(1)alendronate sodium tab 35 mg $0(1)alendronate sodium tab 40 mg $0(1)





alendronate sodium tab 70 mg $0(1)ibandronate sodium tabs $0(1) B/DPAMIDRONATE DISODIUM 6mg/ml $0(2) B/Dpamidronate disodium 30mg/10ml, 90mg/10ml

$0(1) B/D

pamidronate inj 30mg $0(1) B/Dpamidronate inj 90mg $0(1) B/Drisedronate sodium TABS 5mg, 35mg, 150mg $0(1)risedronate sodium TBEC $0(1)zoledronic acid inj 4mg/100ml $0(1) B/D, NMzoledronic acid inj 5mg/100ml $0(1) B/D, NMzoledronic inj 4mg/5ml $0(1) B/D, NM

CHELATING AGENTSCHEMET $0(2)clovique $0(2) PAdeferasirox tab $0(2) NM, PAJADENU 180mg $0(2) NM, LA, PAJADENU SPRINKLE $0(2) NM, LA, PAkionex sus 15gm/60ml $0(1)LOKELMA $0(2)penicillamine TABS $0(2)sodium polystyrene sulfonate powder $0(1)sodium polystyrene sulfonate susp $0(1)sps susp 15gm/60ml $0(1)trientine hcl $0(2) PAVELTASSA $0(2) LA, PA

CONTRACEPTIVES - DRUGS FOR BIRTH CONTROLaftera $0(3) NM; *altavera tab $0(1)alyacen 1/35 $0(1)amethia $0(1)amethia lo $0(1)apri $0(1)aranelle $0(1)ashlyna $0(1)aubra $0(1)





aviane $0(1)balziva $0(1)bekyree $0(1)blisovi 24 fe $0(1)blisovi fe 1.5/30 $0(1)briellyn $0(1)camila $0(1)camrese lo $0(1)caziant pak $0(1)cryselle-28 $0(1)cyclafem 1/35 $0(1)cyclafem 7/7/7 $0(1)cyred tab $0(1)dasetta 1/35 $0(1)dasetta 7/7/7 $0(1)deblitane $0(1)desogestrel & ethinyl estradiol $0(1)desogestrel-ethinyl estradiol (biphasic) $0(1)drospirenone-ethinyl estradiol $0(1)drospirenone-ethinyl estradiol-levomefolate calcium

$0(1)

econtra ez $0(3) NM; *econtra one-step $0(3) NM; *ELLA $0(2)eluryng $0(1)emoquette $0(1)enpresse-28 $0(1)enskyce $0(1)errin $0(1)estarylla tab 0.25-35 $0(1)ethynodiol diacet & eth estrad $0(1)ethynodiol tab 1-50 $0(1)etonogestrel-ethinyl estradiol $0(1)falmina $0(1)fayosim $0(1)femynor $0(1)





gianvi $0(1)hailey 24 fe $0(1)heather $0(1)incassia $0(1)introvale $0(1)isibloom $0(1)jasmiel $0(1)jolessa tab 0.15-0.03 mg $0(1)jolivette $0(1)juleber $0(1)junel 1.5/30 $0(1)junel 1/20 $0(1)junel fe 1.5/30 $0(1)junel fe 1/20 $0(1)junel fe 24 $0(1)kaitlib fe $0(1)kariva $0(1)kelnor 1/35 $0(1)kelnor 1/50 $0(1)kurvelo $0(1)larin 1.5/30 $0(1)larin 1/20 $0(1)larin fe 1.5/30 $0(1)larin fe 1/20 $0(1)larissia tab $0(1)layolis fe $0(1)leena $0(1)lessina $0(1)levonest $0(1)levonor/ethi tab $0(1)levonorgestrel & eth estradiol $0(1)levonorgestrel (emergency oc) $0(3) NM; *levonorgestrel-ethinyl estradiol (91-day) $0(1)levora 0.15/30-28 $0(1)loryna $0(1)low-ogestrel $0(1)





lutera $0(1)lyza $0(1)marlissa $0(1)medroxyprogesterone acetate (contraceptive) $0(1)melodetta 24 fe $0(1)mibelas 24 fe $0(1)microgestin 1.5/30 $0(1)microgestin 1/20 $0(1)microgestin fe 1.5/30 $0(1)microgestin fe 1/20 $0(1)mili $0(1)mono-linyah tab 0.25-35 $0(1)my choice $0(3) NM; *my way $0(3) NM; *necon 0.5/35-28 $0(1)new day $0(3) NM; *nikki $0(1)nora-be tab $0(1)nore/eth/fer chw 0.4mg-35 $0(1)noreth/ethin chw fe $0(1)norethin acet & estrad-fe $0(1)norethindrone (contraceptive) $0(1)norethindrone acet & eth estra $0(1)norgest/ethi tab 0.25/35 $0(1)norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

$0(1)

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

$0(1)

nortrel 0.5/35 (28) $0(1)nortrel 1/35 $0(1)nortrel 7/7/7 $0(1)ocella tab 3-0.03mg $0(1)opcicon one-step $0(3) NM; *option 2 $0(3) NM; *orsythia $0(1)philith $0(1)





pimtrea $0(1)pirmella 1/35 $0(1)portia-28 $0(1)previfem $0(1)reclipsen $0(1)rivelsa $0(1)setlakin tab $0(1)sharobel $0(1)sprintec 28 $0(1)sronyx $0(1)syeda $0(1)take action $0(3) NM; *tarina 24 fe $0(1)tarina fe 1/20 $0(1)tilia fe $0(1)tri-estarylla $0(1)tri-legest fe $0(1)tri-linyah $0(1)tri-lo marzia $0(1)tri-lo-estarylla $0(1)tri-lo-sprintec $0(1)tri-mili $0(1)tri-previfem $0(1)tri-sprintec $0(1)tri-vylibra $0(1)tri-vylibra lo $0(1)trivora-28 $0(1)tulana $0(1)tydemy $0(1)velivet $0(1)vienva $0(1)viorele $0(1)vyfemla $0(1)vylibra $0(1)wymzya fe $0(1)xulane $0(1)





zarah $0(1)zovia 1/35e $0(1)

ENDOMETRIOSISdanazol CAPS $0(1)SYNAREL $0(2)

ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIESALDURAZYME $0(2) NM, LA, PACARBAGLU $0(2) NM, LA, PACERDELGA $0(2) NM, PACEREZYME $0(2) NM, LA, PACYSTADANE $0(2) NM, LACYSTAGON $0(2) NM, LA, PAFABRAZYME $0(2) NM, LA, PAKUVAN $0(2) NM, LA, PAlevocarnitine (metabolic modifiers) $0(1) B/DLUMIZYME $0(2) NM, LA, PAmiglustat $0(2) NM, PANAGLAZYME $0(2) NM, LA, PAnitisinone $0(2) NM, PANITYR $0(2) NM, LA, PAORFADIN $0(2) NM, LA, PAsodium phenylbutyrate $0(2) NM, PA

ESTROGENS - DRUGS TO REGULATE FEMALE HORMONESDELESTROGEN 10mg/ml $0(2)estradiol PTWK; TABS $0(2)estradiol vaginal cream $0(1)estradiol vaginal tab $0(1)estradiol valerate OIL $0(1)fyavolv $0(2)jinteli $0(2)norethindrone acetate-ethinyl estradiol $0(2)yuvafem vaginal tablet 10 mcg $0(1)

GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSEcortisone acetate TABS $0(1)DEXAMETHASONE CONC $0(2)dexamethasone ELIX; SOLN; TABS $0(1)





dexamethasone sodium phosphate $0(1)fludrocortisone acetate TABS $0(1)hydrocortisone TABS $0(1)methylpr ss inj $0(1) B/Dmethylpred pak 4mg $0(1)methylpred tab 4mg $0(1) B/Dmethylpred tab 8mg $0(1) B/Dmethylpred tab 16mg $0(1) B/Dmethylpred tab 32mg $0(1) B/Dmethylprednisolone acetate $0(1) B/Dpred sod pho sol 5mg/5ml $0(1) B/Dprednisolone sodium phosphate SOLN 15mg/5ml

$0(1) B/D

prednisolone sol 15mg/5ml $0(1) B/Dprednisolone sol 25mg/5ml $0(1) B/DPREDNISONE CON 5MG/ML $0(2) B/Dprednisone pak 5mg $0(1)prednisone pak 10mg $0(1)prednisone sol 5mg/5ml $0(1) B/Dprednisone tab 1mg $0(1) B/Dprednisone tab 2.5mg $0(1) B/Dprednisone tab 5mg $0(1) B/Dprednisone tab 10mg $0(1) B/Dprednisone tab 20mg $0(1) B/Dprednisone tab 50mg $0(1) B/DSOLU-CORTEF $0(2)

GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGARdiazoxide SUSP $0(1)GLUCAGEN HYPOKIT $0(2)GLUCAGON EMERGENCY KIT $0(2)GVOKE HYPOPEN 2-PACK $0(2)GVOKE PFS $0(2)PROGLYCEM SUS 50MG/ML $0(2)

MISCELLANEOUScabergoline $0(1)calcitonin (salmon) $0(1) B/D





cinacalcet hcl 30mg, 90mg $0(2) B/D, QL (120 tabs / 30 days), NMcinacalcet hcl 60mg $0(2) B/D, QL (60 tabs / 30 days), NMFORTEO $0(2) NM, PAGENOTROPIN $0(2) NM, PAGENOTROPIN MINIQUICK $0(2) NM, PAINCRELEX $0(2) NM, LA, PAKORLYM $0(2) NM, LA, PALUPRON DEP-PED INJ 7.5MG $0(2) NM, PALUPRON DEP-PED INJ 11.25MG (3-MONTH) $0(2) NM, PALUPRON DEPOT-PED (1-MONTH $0(2) NM, PALUPRON DEPOT-PED (3-MONTH $0(2) NM, PANATPARA $0(2) NM, PAoctreotide acetate 50mcg/ml, 100mcg/ml, 200mcg/ml

$0(1) NM, PA

octreotide acetate 500mcg/ml, 1000mcg/ml $0(2) NM, PAOSPHENA $0(2) PAPROLIA $0(2) QL (1 injection / 180 days), NMraloxifene hcl $0(1)SIGNIFOR $0(2) NM, LA, PASOMATULINE DEPOT $0(2) NM, PASOMAVERT $0(2) NM, LA, PATYMLOS $0(2) NM, PAXGEVA $0(2) NM, PA

PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELSAURYXIA $0(2) QL (360 tabs / 30 days), PAcalcium acetate (phosphate binder) CAPS $0(1) QL (360 caps / 30 days)calcium acetate (phosphate binder) TABS $0(1) QL (360 tabs / 30 days)sevelamer carbonate PACK 2.4gm $0(2) QL (180 packets / 30 days)sevelamer carbonate PACK .8gm $0(2) QL (540 packets / 30 days)sevelamer carbonate TABS $0(1) QL (540 tabs / 30 days)

PROGESTINS - DRUGS TO REGULATE FEMALE HORMONESmedroxyprogesterone acetate tab $0(1)norethindrone acetate TABS $0(1)

THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELSeuthyrox $0(1)levo-t $0(1)





levothyroxine sodium TABS $0(1)levoxyl $0(1)liothyronine sodium TABS $0(1)methimazole TABS $0(1)propylthiouracil TABS $0(1)SYNTHROID $0(2)unithroid $0(1)

VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONESdesmopressin acetate spray $0(1)desmopressin acetate spray refrigerated $0(1)desmopressin acetate tabs $0(1)desmopressin inj 4mcg/ml $0(1)STIMATE $0(2) NM

GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERSANTACIDS

acid gone $0(3) NM; *almacone $0(3) NM; *almacone double strength $0(3) NM; *ALUMINUM HYDROXIDE $0(3) NM; *antacid CHEW 500mg $0(3) NM; *antacid SUSP $0(3) NM; *antacid anti-gas maximum $0(3) NM; *antacid calcium extra str $0(3) NM; *antacid calcium regular s $0(3) NM; *antacid extra strength $0(3) NM; *antacid fast relief $0(3) NM; *antacid maximum strength $0(3) NM; *antacid plus anti-gas fas $0(3) NM; *antacid plus anti-gas rel $0(3) NM; *cal-gest antacid $0(3) NM; *calcium antacid $0(3) NM; *calcium antacid extra str $0(3) NM; *fast acting antacid plus $0(3) NM; *GAVISCON CHEW $0(3) NM; *GAVISCON EXTRA STRENGTH SUSP $0(3) NM; *GAVISCON EXTRA STRENGTH R $0(3) NM; *





gnp antacid & anti-gas/re $0(3) NM; *gnp antacid and anti-gas/ $0(3) NM; *gnp antacid anti-gas $0(3) NM; *gnp antacid anti-gas/maxi $0(3) NM; *gnp antacid extra strengt $0(3) NM; *gnp antacid/regular stren $0(3) NM; *mag-al plus $0(3) NM; *mag-al plus xs $0(3) NM; *magnesium oxide TABS 400mg $0(3) NM; *mi-acid $0(3) NM; *mi-acid maximum strength $0(3) NM; *mintox $0(3) NM; *mintox maximum strength $0(3) NM; *mintox plus $0(3) NM; *qc antacid $0(3) NM; *qc antacid/anti-gas $0(3) NM; *rulox $0(3) NM; *SODIUM BICARBONATE POWD $0(3) NM; *sodium bicarbonate (antacid) $0(3) NM; *tums smoothies $0(3) NM; *

ANTI-DIARRHEALanti-diarrheal CAPS; TABS $0(3) NM; *bismatrol $0(3) NM; *bismatrol maximum strengt $0(3) NM; *gnp anti-diarrheal $0(3) NM; *gnp loperamide hcl $0(3) NM; *gnp pink bismuth $0(3) NM; *goodsense stomach relief $0(3) NM; *hm loperamide hcl $0(3) NM; *kao-tin SUSP $0(3) NM; *loperamide hcl SUSP $0(3) NM; *peptic relief $0(3) NM; *qc anti-diarrheal $0(3) NM; *sm anti-diarrheal $0(3) NM; *stomach relief $0(3) NM; *stomach relief maximum st $0(3) NM; *





ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITINGaprepitant $0(1) B/Daprepitant pak 80mg & 125mg $0(1) B/Dcompro $0(1)driminate $0(3) NM; *dronabinol $0(1) B/D, QL (60 caps / 30 days)EMEND SUSR $0(2) B/Dgnp motion sickness relie $0(3) NM; *granisetron hcl SOLN $0(1)granisetron hcl TABS $0(1) B/Dhm motion relief $0(3) NM; *hm motion sickness relief $0(3) NM; *meclizine hcl CHEW $0(3) NM; *meclizine hcl TABS 12.5mg $0(3) NM; *meclizine hcl TABS 12.5mg, 25mg $0(2)metoclopramide hcl SOLN; TABS $0(1)metoclopramide hcl inj $0(1)motion-time $0(3) NM; *ondansetron hcl TABS $0(1) B/Dondansetron hcl inj $0(1)ondansetron hcl oral soln $0(1) B/Dondansetron odt $0(1) B/Dprochlorperazine inj $0(1)prochlorperazine maleate TABS $0(1)prochlorperazine supp $0(1)promethazine hcl SYRP; TABS $0(2) PA; PA if 70 years and olderpromethazine hcl inj $0(2) PA; PA if 70 years and olderscopolamine $0(2) QL (10 patches / 30 days), PA;

PA if 70 years and oldersm motion sickness $0(3) NM; *travel sickness $0(3) NM; *

ANTISPASMODICS - DRUGS FOR STOMACH SPASMSdicyclomine hcl cap 10mg $0(2)dicyclomine hcl soln 10mg/5ml $0(2)dicyclomine hcl tab 20mg $0(2)glycopyrrolate tab 1mg $0(1)





glycopyrrolate tab 2mg $0(1)H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID

acid reducer TABS $0(3) NM; *famotidine SUSR $0(1)famotidine TABS 10mg $0(3) NM; *famotidine TABS 20mg, 40mg $0(1)famotidine in nacl $0(1)famotidine inj $0(1)gnp acid reducer $0(3) NM; *goodsense acid reducer $0(3) NM; *heartburn relief 10mg $0(3) NM; *nizatidine CAPS $0(1)qc acid controller $0(3) NM; *ranitidine hcl $0(3) NM; *

INFLAMMATORY BOWEL DISEASEbalsalazide disodium $0(1)budesonide ec $0(1)colocort $0(1)hydrocortisone (enema) $0(1)mesalamine CPDR $0(1)mesalamine ENEM $0(1)mesalamine SUPP $0(2)mesalamine TBEC 1.2gm $0(1)mesalamine w/ cleanser $0(1)sulfasalazine TABS $0(1)sulfasalazine ec $0(1)

LAXATIVESbisac-evac $0(3) NM; *bisacodyl SUPP $0(3) NM; *bisacodyl ec $0(3) NM; *biscolax $0(3) NM; *calcium polycarbophil $0(3) NM; *CITRUCEL FIBER LAXATIVE $0(3) NM; *clearlax $0(3) NM; *colace 2-in-1 $0(3) NM; *COLACE CLEAR $0(3) NM; *





constulose $0(1)cvs glycerin adult 2gm $0(3) NM; *docu $0(3) NM; *docusate sodium CAPS; LIQD $0(3) NM; *docusil $0(3) NM; *DOCUSOL KIDS $0(3) NM; *DOCUSOL MINI $0(3) NM; *DOCUSOL PLUS MINI-ENEMA $0(3) NM; *dok $0(3) NM; *dok plus $0(3) NM; *ducodyl $0(3) NM; *ENEMEEZ MINI $0(3) NM; *ENEMEEZ PLUS $0(3) NM; *enulose $0(1)fiber laxative $0(3) NM; *fiber-lax $0(3) NM; *FLEET LIQUID GLYCERIN SUP $0(3) NM; *gavilax $0(3) NM; *gavilyte-c $0(1)gavilyte-g $0(1)gavilyte-n/flavor pack $0(1)generlac $0(1)glycerin (laxative) $0(3) NM; *gnp clearlax $0(3) NM; *gnp enema $0(3) NM; *gnp fiber therapy $0(3) NM; *gnp gentle laxative $0(3) NM; *gnp laxative $0(3) NM; *gnp laxative pills $0(3) NM; *gnp milk of magnesia $0(3) NM; *gnp senna lax $0(3) NM; *gnp senna plus $0(3) NM; *gnp stool softener $0(3) NM; *gnp stool softener/stimul $0(3) NM; *gnp womens gentle laxativ $0(3) NM; *gnp womens laxative $0(3) NM; *





GOLYTELY $0(2)goodsense clearlax $0(3) NM; *healthylax $0(3) NM; *hm clearlax $0(3) NM; *hm milk of magnesia $0(3) NM; *hm stool softener $0(3) NM; *kao-tin CAPS $0(3) NM; *KONSYL $0(3) NM; *KONSYL DAILY FIBER PACK 28.3%, 100% $0(3) NM; *konsyl daily fiber POWD 28.3% $0(3) NM; *KONSYL DAILY FIBER POWD 100% $0(3) NM; *KONSYL-D $0(3) NM; *lactulose SOLN $0(1)lactulose (encephalopathy) $0(1)laxative $0(3) NM; *milk of magnesia $0(3) NM; *natural fiber therapy $0(3) NM; *NULYTELY/FLAVOR PACKS $0(2)PEDIA-LAX LIQD $0(3) NM; *PEDIA-LAX SUPP 2.8gm $0(3) NM; *pediatric enema $0(3) NM; *peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

$0(1)

peg 3350-potassium chloride-sod bicarbonate-sod chloride

$0(1)

PLENVU $0(2)polyethylene glycol 3350 PACK; POWD $0(3) NM; *qc enema $0(3) NM; *qc gentle laxative $0(3) NM; *qc milk of magnesia $0(3) NM; *qc natura-lax $0(3) NM; *qc natural vegetable laxa $0(3) NM; *qc stool softener $0(3) NM; *qc stool softener plus la $0(3) NM; *qc stool softener plus st $0(3) NM; *reguloid POWD 28.3%, 48.57%, 58.6% $0(3) NM; *





senna laxative $0(3) NM; *SENNA LEAVES $0(3) NM; *senna-lax $0(3) NM; *senna-s $0(3) NM; *senna-tabs $0(3) NM; *senna-time $0(3) NM; *senna-time s $0(3) NM; *sennosides $0(3) NM; *sennosides-docusate sodium $0(3) NM; *senokot extra strength $0(3) NM; *silace $0(3) NM; *sm clearlax $0(3) NM; *sm milk of magnesia $0(3) NM; *sm stool softener $0(3) NM; *sodium phosphates $0(3) NM; *soluble fiber $0(3) NM; *SORBITOL SOLN 70% $0(3) NM; *stimulant laxative $0(3) NM; *stool softener $0(3) NM; *stool softener extra stre $0(3) NM; *stool softener plus laxat $0(3) NM; *SUPREP BOWEL PREP KIT $0(2)trilyte $0(1)vegetable laxative+stool $0(3) NM; *

MISCELLANEOUSalosetron hcl $0(2) PAAMITIZA CAP 8MCG $0(2) QL (180 caps / 30 days)AMITIZA CAP 24MCG $0(2) QL (60 caps / 30 days)cromolyn sodium (mastocytosis) $0(2)diphenoxylate w/ atropine $0(2)formula em $0(3) NM; *GATTEX $0(2) NM, LA, PAgnp nausea relief $0(3) NM; *LINZESS $0(2) QL (30 caps / 30 days)loperamide hcl CAPS $0(1)misoprostol TABS $0(1)





MOVANTIK 12.5mg $0(2) QL (60 tabs / 30 days)MOVANTIK 25mg $0(2) QL (30 tabs / 30 days)RELISTOR SOLN $0(2) PAsucralfate TABS $0(1)ursodiol CAPS; TABS $0(1)XIFAXAN 550mg $0(2) PA

PANCREATIC ENZYMESCREON $0(2)ZENPEP $0(2)

PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACIDDEXILANT $0(2) QL (30 caps / 30 days)esomeprazole magnesium CPDR $0(1) QL (30 caps / 30 days), STlansoprazole CPDR $0(1) QL (30 caps / 30 days)omeprazole cap 10mg $0(1)omeprazole cap 20mg $0(1)omeprazole cap 40mg $0(1)pantoprazole sodium SOLR $0(1)pantoprazole sodium tbec $0(1)rabeprazole sodium $0(1) QL (30 tabs / 30 days)

GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONSBENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE

alfuzosin hcl $0(1) QL (30 tabs / 30 days)dutasteride CAPS $0(1) QL (30 caps / 30 days)dutasteride-tamsulosin hcl $0(1) QL (30 caps / 30 days)finasteride TABS 5mg $0(1)tamsulosin hcl $0(1)

MISCELLANEOUSbethanechol chloride TABS $0(1)potassium citrate (alkalinizer) er tabs $0(1)sodium citrate & citric acid $0(1)

URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCEMYRBETRIQ $0(2) QL (30 tabs / 30 days)oxybutynin chloride SYRP $0(1)oxybutynin chloride TABS $0(1)oxybutynin chloride TB24 5mg $0(1) QL (30 tabs / 30 days)oxybutynin chloride TB24 10mg, 15mg $0(1) QL (60 tabs / 30 days)





tolterodine tartrate cap er $0(1) QL (30 caps / 30 days), STtolterodine tartrate tabs $0(1) STTOVIAZ $0(2) QL (30 tabs / 30 days)trospium chloride TABS $0(1) QL (60 tabs / 30 days)

VAGINAL ANTI-INFECTIVESclindamycin phosphate vaginal $0(1)clotrimazole 3 $0(3) NM; *clotrimazole vaginal $0(3) NM; *3 day vaginal $0(3) NM; *gnp clotrimazole 3 $0(3) NM; *gnp miconazole 3 $0(3) NM; *gnp miconazole 7 $0(3) NM; *gnp tioconazole 1 $0(3) NM; *metronidazole vaginal $0(1)miconazole 3 $0(3) NM; *miconazole 3 combination $0(3) NM; *miconazole 3 combo pack $0(3) NM; *miconazole 7 $0(3) NM; *miconazole nitrate vaginal CREA $0(3) NM; *miconazole nitrate vaginal KIT $0(3) NM; *miconazole nitrate vaginal SUPP 100mg $0(3) NM; *qc 3 day vaginal cream $0(3) NM; *qc miconazole 7 $0(3) NM; *terconazole vaginal $0(1)tioconazole 1 $0(3) NM; *vandazole $0(1)

HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERSANTICOAGULANTS - BLOOD THINNERS

COUMADIN $0(2)ELIQUIS 2.5mg $0(2) QL (60 tabs / 30 days)ELIQUIS 5mg $0(2) QL (74 tabs / 30 days)ELIQUIS STARTER PACK $0(2) QL (74 tabs / 30 days)enoxaparin sodium $0(1)fondaparinux sodium 2.5mg/0.5ml $0(1)fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

$0(2)





heparin sod (porcine) in d5w $0(2)heparin sod inj 1000/ml $0(1) B/Dheparin sod inj 5000/ml $0(1) B/Dheparin sod inj 10000/ml $0(1) B/Dheparin sod inj 20000/ml $0(1) B/DHEPARIN SODIUM/NACL 0.45% $0(2)jantoven $0(1)PRADAXA $0(2) QL (60 caps / 30 days)warfarin sodium $0(1)XARELTO 2.5mg $0(2) QL (60 tabs / 30 days)XARELTO 10mg, 15mg, 20mg $0(2) QL (30 tabs / 30 days)XARELTO STARTER PACK $0(2) QL (51 tabs / 30 days)

HEMATOPOIETIC GROWTH FACTORSPROCRIT $0(2) NM, PAZARXIO $0(2) NM, PA

IRONFERAHEME $0(3) NM; *ferrous sulfate TABS 325mg $0(3) NM; *FERROUS SULFATE TBEC 324mg $0(3) NM; *ferrous sulfate TBEC 325mg $0(3) NM; *INFED $0(3) NM; *INJECTAFER $0(3) NM; *sodium ferric gluconate complex in sucrose $0(3) NM; *VENOFER $0(3) NM; *

MISCELLANEOUSanagrelide hcl $0(1)BERINERT $0(2) QL (24 boxes / 30 days), NM, LA,

PAcilostazol $0(1)DROXIA $0(2)ENDARI $0(2) NM, LA, PAHAEGARDA 2000unit $0(2) QL (30 vials / 30 days), NM, LA,

PAHAEGARDA 3000unit $0(2) QL (20 vials / 30 days), NM, LA,

PAicatibant acetate $0(2) QL (9 syringes / 30 days), NM,

PA





pentoxifylline TBCR $0(1)PROMACTA PACK 12.5mg $0(2) QL (360 packets / 30 days), NM,

LA, PAPROMACTA PACK 25mg $0(2) QL (180 packets / 30 days), NM,

LA, PAPROMACTA TABS 12.5mg, 25mg $0(2) QL (30 tabs / 30 days), NM, LA,

PAPROMACTA TABS 50mg, 75mg $0(2) QL (60 tabs / 30 days), NM, LA,

PAtranexamic acid SOLN; TABS $0(1)

PLATELET AGGREGATION INHIBITORSaspirin-dipyridamole $0(1)BRILINTA $0(2)clopidogrel tab 75mg $0(1)prasugrel hcl $0(1)

IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEMDISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS

ENBREL SOLR $0(2) QL (16 vials / 28 days), NM, PAENBREL SOSY 25mg/0.5ml $0(2) QL (16 syringes / 28 days), NM,

PAENBREL SOSY 50mg/ml $0(2) QL (8 syringes / 28 days), NM,

PAENBREL MINI $0(2) QL (8 injections / 28 days), NM,

PAENBREL SURECLICK $0(2) QL (8 injections / 28 days), NM,

PAHUMIRA 10mg/0.1ml, 20mg/0.2ml $0(2) QL (2 injections / 28 days), NM,

PAHUMIRA 40mg/0.4ml $0(2) QL (6 injections / 28 days), NM,

PAHUMIRA INJ 10MG/0.2ML $0(2) QL (2 syringes / 28 days), NM,

PAHUMIRA KIT 20MG/0.4ML $0(2) QL (2 syringes / 28 days), NM,

PAHUMIRA KIT 40MG/0.8ML $0(2) QL (6 syringes / 28 days), NM,

PAHUMIRA PEDIATRIC CROHNS DISEASE $0(2) NM, PAHUMIRA PEN $0(2) QL (6 pens / 28 days), NM, PA





HUMIRA PEN CD/UC/HS STARTER $0(2) NM, PAHUMIRA PEN INJ CD/UC/HS STARTER $0(2) NM, PAHUMIRA PEN INJ PS/UV STARTER $0(2) NM, PAHUMIRA PEN-PS/UV STARTER $0(2) NM, PAhydroxychloroquine sulfate $0(1)leflunomide TABS $0(1) QL (30 tabs / 30 days)methotrexate sodium tabs $0(1)REMICADE $0(2) NM, PARENFLEXIS $0(2) NM, LA, PARINVOQ $0(2) QL (30 tabs / 30 days), NM, PASKYRIZI $0(2) QL (7 injections / year), NM, PASTELARA SOLN 45mg/0.5ml $0(2) QL (1 vial / 28 days), NM, LA, PASTELARA SOSY $0(2) QL (1 syringe / 28 days), NM, PAXATMEP $0(2) B/DXELJANZ $0(2) QL (60 tabs / 30 days), NM, PAXELJANZ XR $0(2) QL (30 tabs / 30 days), NM, PA

IMMUNOGLOBULINSBIVIGAM $0(2) NM, PAGAMASTAN S/D $0(2) B/D, NMGAMMAGARD LIQUID $0(2) NM, PAGAMMAGARD S/D $0(2) NM, PAGAMMAKED $0(2) NM, PAGAMMAPLEX $0(2) NM, PAGAMMAPLEX 10GM/100ML $0(2) NM, PAGAMUNEX-C $0(2) NM, PAOCTAGAM $0(2) NM, PAPANZYGA $0(2) NM, PAPRIVIGEN $0(2) NM, PA

IMMUNOMODULATORSACTIMMUNE $0(2) NM, LA, PAARCALYST $0(2) NM, PAINTRON-A INJ 10MU $0(2) B/D, NMINTRON-A INJ 18MU $0(2) B/D, NMINTRON-A INJ 25MU $0(2) B/D, NMINTRON-A INJ 50MU $0(2) B/D, NM





IMMUNOSUPPRESSANTSazathioprine TABS $0(1) B/DBENLYSTA $0(2) NM, PAcyclosporine CAPS; SOLN $0(1) B/D, NMcyclosporine modified (for microemulsion) $0(1) B/D, NMeverolimus (immunosuppressant) .5mg, .75mg $0(2) B/D, NMeverolimus (immunosuppressant) .25mg $0(1) B/D, NMgengraf $0(1) B/D, NMmycophenolate mofetil CAPS; TABS $0(1) B/D, NMmycophenolate mofetil SUSR $0(2) B/D, NMmycophenolate sodium tbec $0(1) B/D, NMNULOJIX $0(2) B/D, NMPROGRAF PACK $0(2) B/D, NMSANDIMMUNE SOLN 100mg/ml $0(2) B/D, NMsirolimus SOLN $0(2) B/D, NMsirolimus TABS 2mg $0(2) B/D, NMsirolimus TABS .5mg, 1mg $0(1) B/D, NMtacrolimus CAPS $0(1) B/D, NMZORTRESS TAB 0.5MG $0(2) B/D, NMZORTRESS TAB 0.25MG $0(2) B/D, NMZORTRESS TAB 0.75MG $0(2) B/D, NMZORTRESS TAB 1MG $0(2) B/D, NM

VACCINESACTHIB $0(2)ADACEL $0(2)BCG VACCINE $0(2)BEXSERO $0(2)BOOSTRIX $0(2)DAPTACEL $0(2)DIPHTHERIA/TETANUS TOXOID $0(2) B/DENGERIX-B SUSP $0(2) B/DGARDASIL 9 $0(2)HAVRIX $0(2)HIBERIX $0(2)IMOVAX RABIES (H.D.C.V.) $0(2) B/DINFANRIX $0(2)





IPOL INACTIVATED IPV $0(2)IXIARO $0(2)KINRIX $0(2)M-M-R II $0(2)MENACTRA $0(2)MENVEO $0(2)PEDIARIX $0(2)PEDVAX HIB $0(2)PENTACEL $0(2)PROQUAD $0(2)QUADRACEL $0(2)RABAVERT $0(2) B/DRECOMBIVAX HB $0(2) B/DROTARIX $0(2)ROTATEQ $0(2)SHINGRIX $0(2) QL (2 vials per lifetime)TDVAX $0(2) B/DTENIVAC $0(2) B/DTRUMENBA $0(2)TWINRIX INJ $0(2)TYPHIM VI $0(2)VAQTA $0(2)VARIVAX $0(2)YF-VAX $0(2)ZOSTAVAX $0(2) QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTSELECTROLYTES

klor-con 8 $0(1)klor-con 10 $0(1)klor-con m10 $0(1)klor-con m15 $0(1)klor-con m20 $0(1)klor-con pak 20meq $0(1)klor-con spr cap 8meq $0(1)klor-con spr cap 10meq $0(1)





MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

$0(2)

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

$0(2)

MAGNESIUM SULFATE IN D5W $0(2)magnesium sulfate in dextrose $0(2)magnesium sulfate inj 50% $0(2)potassium chloride CPCR $0(1)potassium chloride PACK $0(1)potassium chloride SOLN 10%, 20% $0(1)potassium chloride TBCR $0(1)potassium chloride microencapsulated crystals er

$0(1)

sodium chloride SOLN 2.5meq/ml $0(1)sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

$0(1)

TPN ELECTROLYTES $0(2) B/DIV NUTRITION

AMINOSYN II INJ 10% $0(2) B/DAMINOSYN-PF 7% $0(2) B/DAMINOSYN-PF INJ 10% $0(2) B/DCLINIMIX 4.25%/DEXTROSE 5% $0(2) B/DCLINIMIX 5%/DEXTROSE 15% $0(2) B/DCLINIMIX 5%/DEXTROSE 20% $0(2) B/DCLINIMIX INJ 4.25/D10 $0(2) B/Dclinisol sf 15% $0(1) B/DCLINOLIPID $0(2) B/DFREAMINE HBC 6.9% $0(2) B/DFREAMINE III $0(2) B/Dhepatamine $0(2) B/DINTRALIPID 30% $0(2) B/DINTRALIPID INJ 20% $0(2) B/DNEPHRAMINE $0(2) B/DNUTRILIPID INJ 20% $0(2) B/Dplenamine $0(1) B/D





PREMASOL SOL 10% $0(2) B/DPROCALAMINE $0(2) B/DPROSOL $0(2) B/DTRAVASOL $0(2) B/DTROPHAMINE INJ 10% $0(2) B/D

IV REPLACEMENT SOLUTIONSdextrose 2.5%/nacl 0.45% $0(1)dextrose 5% $0(1)DEXTROSE 5% /ELECTROLYTE $0(2)dextrose 5%/nacl 0.2% $0(1)DEXTROSE 5%/NACL 0.3% $0(2)dextrose 5%/nacl 0.9% $0(1)dextrose 5%/nacl 0.45% $0(1)dextrose 5%/nacl 0.225% $0(1)dextrose 5%/potassium chl $0(1)dextrose 10% flex contain $0(1)DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% $0(2)dextrose 10%/nacl 0.45% $0(1)dextrose 50% $0(1)dextrose in lactated ringers $0(1)dextrose inj 70% $0(1)ISOLYTE P $0(2)ISOLYTE S $0(2)kcl0.15%/d5w/nacl0.2% $0(1)KCL 0.3%/D5W/NACL 0.9% $0(2)kcl 0.3%/d5w/nacl 0.45% $0(1)kcl 0.15%/d5w/nacl 0.9% $0(1)KCL 0.15%/D5W/NACL 0.225% $0(2)kcl 0.075%/d5w/nacl 0.45% $0(1)kcl/d5w inj 0.3% $0(1)kcl/d5w/nacl inj 0.22%/0.45% $0(1)kcl/d5w/nacl inj .15/.45% $0(1)kcl/nacl inj 0.3-0.9 $0(1)kcl/nacl inj 0.15%-0.9% $0(1)lactated ringer’s $0(1)NORMOSOL-M IN D5W $0(2)





NORMOSOL-R $0(2)NORMOSOL-R IN D5W $0(2)PLASMA-LYTE A $0(2)PLASMA-LYTE-148 $0(2)pot chloride inj 2meq/ml $0(1)potassium chloride SOLN 2meq/ml $0(1)POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

$0(1)

potassium chloride in nacl $0(1)sodium chloride SOLN 3%, 5% $0(1)sodium chloride 0.45% $0(1)sodium chloride inj 0.9% $0(1)

MINERALScalcium carbonate (antacid) $0(3) NM; *calcium carbonate-vitamin d $0(3) NM; *GALZIN $0(3) NM; *MAGNEBIND 300 $0(3) NM; *magnesium oxide (mg supplement) $0(3) NM; *

VITAMINScalcitriol CAPS $0(1) B/Dcalcitriol inj $0(1) B/Dcalcitriol oral soln 1 mcg/ml $0(1) B/Dcyanocobalamin SOLN 1000mcg/ml $0(3) NM; *ergocalciferol CAPS; SOLN $0(3) NM; *folic acid SOLN $0(3) NM; *folic acid TABS 1mg $0(3) NM; *hydroxocobalamin acetate $0(3) NM; *INFUVITE PEDIATRIC $0(3) NM; *M-NATAL PLUS $0(2)paricalcitol CAPS $0(1) B/Dphytonadione SOLN 10mg/ml $0(3) NM; *phytonadione TABS $0(3) NM; *PNV FOLIC ACID + IRON MUL $0(2)PRENATAL $0(2)PRENATAL PLUS $0(2)





PRENATAL PLUS LOW IRON $0(2)pyridoxine hcl SOLN $0(3) NM; *RAYALDEE $0(2)renal caps $0(3) NM; *thiamine hcl SOLN $0(3) NM; *TRICARE $0(2)virt-caps $0(3) NM; *

OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONSANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION

bacitracin-poly-neomycin-hc $0(1)BLEPHAMIDE OINT $0(2)neomycin-polymy-dexameth $0(1)neomycin-polymyxin-hc (ophth) $0(1)sulfacetamide sod-prednisolone $0(1)TOBRADEX OINT $0(2)TOBRADEX ST $0(2)tobramycin-dexamethasone $0(1)ZYLET $0(2)

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONSAZASITE $0(2)bacitracin (ophthalmic) $0(1)bacitracin-polymyxin b (ophth) $0(1)BESIVANCE $0(2)CILOXAN OINT $0(2)ciprofloxacin hcl (ophth) $0(1)erythromycin (ophth) $0(1)gatifloxacin (ophth) $0(1)gentak $0(1)gentamicin sulfate soln (ophth) $0(1)MOXEZA $0(2)moxifloxacin hcl (ophth) $0(1)NATACYN $0(2)neomycin-bacitracin zn-polymyxin $0(1)neomycin-polymyxin-gramicidin $0(1)ofloxacin (ophth) $0(1)polymyxin b-trimethoprim $0(1)





sulfacetamide sodium (ophth) $0(1)tobramycin (ophth) $0(1)trifluridine $0(1)ZIRGAN $0(2)

ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATIONALREX $0(2)bromfenac sodium (ophth) $0(1)BROMSITE $0(2)dexamethasone sodium phosphate (ophth) $0(1)diclofenac sodium (ophth) $0(1)DUREZOL $0(2)FLAREX $0(2)fluorometholone $0(1)flurbiprofen sodium $0(1)ILEVRO $0(2)ketorolac tromethamine (ophth) $0(1)LOTEMAX GEL; OINT $0(2)loteprednol etabonate $0(1)prednisolone acetate (ophth) $0(1)PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

$0(2)

PROLENSA $0(2)ANTIALLERGICS - DRUGS TO TREAT ALLERGIES

azelastine drop 0.05% $0(1)BEPREVE $0(2)cromolyn sodium (ophth) $0(1)LASTACAFT $0(2)olopatadine hcl 0.2% $0(1)PAZEO $0(2)ZERVIATE $0(2)

ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMAALPHAGAN P SOL 0.1% $0(2)AZOPT $0(2)betaxolol hcl (ophth) $0(1)BETOPTIC-S $0(2)brimonidine sol 0.2% $0(1)





brimonidine sol 0.15% $0(1)carteolol hcl (ophth) $0(1)COMBIGAN $0(2)dorzolamide hcl $0(1)dorzolamide hcl-timolol maleate $0(1)latanoprost SOLN $0(1)levobunolol hcl $0(1)LUMIGAN $0(2)PHOSPHOLINE IODIDE $0(2)pilocarpine hcl SOLN $0(1)RHOPRESSA $0(2)SIMBRINZA $0(2)timolol maleate (ophth) soln $0(1)timolol maleate gel $0(1)timolol maleate ophth soln 0.5% (once-daily) $0(1)travoprost $0(1)

MISCELLANEOUSakwa tears $0(3) NM; *artificial tears 1.4% $0(3) NM; *ATROPINE SULFATE SOLN 1% $0(2)CYSTARAN $0(2) NM, LA, PAgenteal tears liquid drop $0(3) NM; *genteal tears mild $0(3) NM; *gnp artificial tears $0(3) NM; *gnp lubricant pm $0(3) NM; *liquitears $0(3) NM; *MURO 128 SOLN 2% $0(3) NM; *natural balance tears $0(3) NM; *natures tears $0(3) NM; *proparacaine hcl SOLN $0(1)puralube $0(3) NM; *refresh lacri-lube $0(3) NM; *refresh p.m. $0(3) NM; *RESTASIS $0(2) QL (60 single use vials / 30 days)RESTASIS MULTIDOSE $0(2) QL (1 bottle / 30 days)sodium chloride hypertonic $0(3) NM; *





systane nighttime $0(3) NM; *RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPDANORO ELLIPTA $0(2) QL (60 blisters / 30 days)BEVESPI AEROSPHERE $0(2) QL (1 inhaler / 30 days)COMBIVENT RESPIMAT $0(2) QL (2 inhalers / 30 days)ipratropium-albuterol nebu $0(1) B/DTRELEGY ELLIPTA $0(2) QL (60 blisters / 30 days)

ANTICHOLINERGICS - DRUGS TO TREAT COPDATROVENT HFA $0(2) QL (2 inhalers / 30 days)INCRUSE ELLIPTA $0(2) QL (30 blisters / 30 days)ipratropium bromide SOLN $0(1) B/Dipratropium bromide (nasal) $0(1)

ANTIHISTAMINES - DRUGS TO TREAT ALLERGIESall day allergy $0(3) NM; *all day allergy childrens $0(3) NM; *all-day allergy childrens $0(3) NM; *allergy TABS 10mg $0(3) NM; *allergy childrens $0(3) NM; *allergy non-drowsy $0(3) NM; *allergy relief TABS 10mg $0(3) NM; *allergy relief childrens LIQD $0(3) NM; *azelastine spr 0.1% $0(1)azelastine spr 0.15% $0(1)banophen CAPS; LIQD; TABS $0(3) NM; *cetirizine hcl $0(3) NM; *cetirizine hcl allergy ch $0(3) NM; *cetirizine hcl childrens $0(3) NM; *cetirizine hydrochloride $0(3) NM; *cetirizine syrup $0(1)childrens loratadine $0(3) NM; *complete allergy medicine $0(3) NM; *cyproheptadine hcl SYRP; TABS $0(2) PA; PA if 70 years and olderdiphenhist $0(3) NM; *diphenhydramine hcl CAPS $0(3) NM; *diphenhydramine hcl LIQD $0(3) NM; *





diphenhydramine hcl TABS 25mg $0(3) NM; *diphenhydramine hcl inj 50mg/ml $0(1)gnp all day allergy $0(3) NM; *gnp all day allergy child $0(3) NM; *gnp allergy CAPS $0(3) NM; *gnp allergy TABS 25mg $0(3) NM; *gnp allergy antihistamine $0(3) NM; *gnp allergy relief CAPS; CHEW; TBDP $0(3) NM; *gnp allergy relief for ki $0(3) NM; *gnp childrens allergy $0(3) NM; *gnp loratadine $0(3) NM; *gnp loratadine childrens $0(3) NM; *goodsense all day allergy $0(3) NM; *hm all day allergy childr $0(3) NM; *hm cetirizine hcl childre $0(3) NM; *hm loratadine $0(3) NM; *hydroxyzine hcl SYRP; TABS $0(2) PA; PA if 70 years and olderhydroxyzine hcl inj $0(2) PA; PA if 70 years and olderhydroxyzine pamoate CAPS 25mg, 50mg $0(2) PA; PA if 70 years and olderlevocetirizine dihydrochloride $0(1)loratadine CAPS; CHEW; TABS $0(3) NM; *loratadine childrens $0(3) NM; *pharbedryl $0(3) NM; *qc all day allergy $0(3) NM; *qc childrens allergy $0(3) NM; *qc loratadine allergy rel $0(3) NM; *siladryl allergy $0(3) NM; *sm all day allergy childr $0(3) NM; *sm loratadine $0(3) NM; *

BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPDalbuterol sulfate AERS 108mcg/act $0(1) QL (2 inhalers / 30 days);

(generic of Proair HFA)albuterol sulfate AERS 108mcg/act $0(1) QL (2 inhalers / 30 days);

(generic of Ventolin HFA)albuterol sulfate NEBU $0(1) B/Dalbuterol sulfate SYRP $0(1)





albuterol sulfate TABS $0(1)albuterol sulfate TB12 $0(1)levalbuterol hcl NEBU $0(1) B/Dlevalbuterol hcl soln nebu conc 1.25 mg/0.5ml $0(1) B/Dlevalbuterol tartrate hfa $0(1) QL (2 inhalers / 30 days)SEREVENT DISKUS $0(2) QL (60 inhalations / 30 days)terbutaline sulfate TABS $0(1)VENTOLIN HFA $0(2) QL (2 inhalers / 30 days)

COUGH AND COLDchildrens mucus relief ex $0(3) NM; *cough & chest congestion SYRP $0(3) NM; *cough syrup $0(3) NM; *dextromethorphan-guaifenesin $0(3) NM; *diabetic siltussin das-na $0(3) NM; *diabetic siltussin-dm $0(3) NM; *diabetic siltussin-dm max $0(3) NM; *gnp nasal decongestant $0(3) NM; *gnp nasal decongestant/ma $0(3) NM; *gnp tussin dm $0(3) NM; *gnp tussin dm cough $0(3) NM; *gnp tussin dm max $0(3) NM; *gnp tussin mucus & chest $0(3) NM; *guaifenesin LIQD; SOLN $0(3) NM; *hm tussin adult $0(3) NM; *hm tussin adult cough & c $0(3) NM; *mucinex chest congestion $0(3) NM; *nasal decongestant $0(3) NM; *promethazine w/codeine $0(3) NM; *promethazine-phenylephrine-codeine $0(3) NM; *pseudoephedrine hcl TABS 30mg $0(3) NM; *qc tussin dm cough & ches $0(3) NM; *qc tussin mucus + chest c $0(3) NM; *robafen $0(3) NM; *robafen dm $0(3) NM; *robafen dm cough $0(3) NM; *robafen dm cough clear $0(3) NM; *





robafen dm cough/chest co $0(3) NM; *siltussin dm das $0(3) NM; *siltussin sa $0(3) NM; *siltussin-dm $0(3) NM; *sm tussin mucus + chest c $0(3) NM; *sudogest 30mg $0(3) NM; *tusnel diabetic $0(3) NM; *tussin dm $0(3) NM; *tussin dm cough + chest c $0(3) NM; *tussin dm max $0(3) NM; *tussin dm max adult $0(3) NM; *tussin mucus & chest cong $0(3) NM; *tussin mucus + chest cong $0(3) NM; *

LEUKOTRIENE MODULATORSmontelukast sodium CHEW; PACK; TABS $0(1)zafirlukast $0(1)

MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIEScromolyn sodium nebu $0(1) B/D

MISCELLANEOUSacetylcysteine SOLN 10%, 20% $0(1) B/DARALAST NP $0(2) NM, LA, PADALIRESP $0(2)epinephrine (anaphylaxis) .15mg/0.3ml, .3mg/0.3ml

$0(1) (generic of EpiPen)

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

$0(1) (generic of Adrenaclick)

ESBRIET $0(2) NM, PAFASENRA $0(2) NM, LA, PAFASENRA PEN $0(2) NM, LA, PAKALYDECO $0(2) NM, PANUCALA $0(2) NM, LA, PAOFEV $0(2) NM, PAORKAMBI $0(2) NM, PAPROLASTIN-C $0(2) NM, LA, PAPULMOZYME $0(2) NM, PAsaline .65% $0(3) NM; *





SYMDEKO $0(2) NM, LA, PASYMJEPI $0(2)THEO-24 $0(2)theophylline $0(1)theophylline tab er 12hr 300 mg $0(1)theophylline tab er 12hr 450 mg $0(1)theophylline tab sr 24hr $0(1)TRIKAFTA $0(2) NM, LA, PAXOLAIR $0(2) NM, LA, PAZEMAIRA $0(2) NM, LA, PA

NASAL STEROIDS - DRUGS TO TREAT ALLERGIESflunisolide (nasal) $0(1) QL (3 bottles / 30 days)fluticasone propionate (nasal) $0(1) QL (1 bottle / 30 days)

STEROID INHALANTS - DRUGS TO TREAT ASTHMAARNUITY ELLIPTA $0(2) QL (30 inhalations / 30 days)budesonide (inhalation) .25mg/2ml, .5mg/2ml $0(1) B/DFLOVENT DISKUS 50mcg/blist, 100mcg/blist $0(2) QL (120 inhalations / 30 days)FLOVENT DISKUS 250mcg/blist $0(2) QL (240 inhalations / 30 days)FLOVENT HFA $0(2) QL (2 inhalers / 30 days)PULMICORT FLEXHALER $0(2) QL (2 inhalers / 30 days)

STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPDADVAIR DISKUS $0(2) QL (60 inhalations / 30 days)ADVAIR HFA $0(2) QL (1 inhaler / 30 days)BREO ELLIPTA $0(2) QL (60 blisters / 30 days)SYMBICORT $0(2) QL (1 inhaler / 30 days)

TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONSDERMATOLOGY, ACNE

acne medication 5 GEL $0(3) NM; *ACNE MEDICATION 5 LOTN $0(3) NM; *acne medication 10 GEL $0(3) NM; *ACNE MEDICATION 10 LOTN $0(3) NM; *amnesteem $0(1) PAavita $0(1) QL (45 grams / 30 days), PABENZOYL PEROXIDE GEL 2.5% $0(3) NM; *benzoyl peroxide GEL 5%, 10% $0(3) NM; *BENZOYL PEROXIDE CLEANSER $0(3) NM; *





benzoyl peroxide-erythromycin $0(1)claravis $0(1) PAclindamycin phosphate (topical) GEL $0(1) QL (75 grams / 30 days)clindamycin phosphate (topical) LOTN $0(1)clindamycin phosphate (topical) SOLN $0(1) QL (60 mL / 30 days)ery pad 2% $0(1)erythromycin (acne aid) $0(1)isotretinoin CAPS $0(1) PAmyorisan $0(1) PAsulfacetamide sodium (acne) $0(1)tretinoin CREA $0(1) QL (45 grams / 30 days), PAtretinoin GEL .01%, .025% $0(1) QL (45 grams / 30 days), PAzenatane $0(1) PA

DERMATOLOGY, ANTIBIOTICSbacitracin (topical) $0(3) NM; *bacitracin zinc OINT $0(3) NM; *double antibiotic $0(3) NM; *gentamicin sulfate (topical) $0(1)gnp bacitracin zinc $0(3) NM; *gnp triple antibiotic $0(3) NM; *gnp triple antibiotic plu $0(3) NM; *mupirocin OINT $0(1) QL (220 grams / 30 days)silver sulfadiazine CREA $0(1)sm antibiotic $0(3) NM; *ssd $0(1)SULFAMYLON CREA $0(2)triple antibiotic $0(3) NM; *triple antibiotic first a $0(3) NM; *triple antibiotic plus $0(3) NM; *

DERMATOLOGY, ANTIFUNGALSantifungal CREA 2% $0(3) NM; *ciclopirox CREA $0(1) QL (90 grams / 30 days)ciclopirox SUSP $0(1) QL (60 mL / 30 days)clotrimazole (topical) CREA 1% $0(1)clotrimazole (topical) CREA 1% $0(3) NM; *clotrimazole (topical) SOLN $0(1) QL (30 mL / 30 days)





clotrimazole anti-fungal $0(3) NM; *clotrimazole antifungal $0(3) NM; *clotrimazole w/ betamethasone CREA $0(1)gnp athletes foot $0(3) NM; *gnp terbinafine hydrochlo $0(3) NM; *ketoconazole cream $0(1) QL (60 grams / 30 days)miconazole nitrate (topical) $0(3) NM; *nyamyc $0(1) QL (60 grams / 30 days)nystatin (topical) $0(1)nystatin pow 100000 $0(1) QL (60 grams / 30 days)nystop $0(1) QL (60 grams / 30 days)remedy antifungal CREA $0(3) NM; *sm antifungal clotrimazol $0(3) NM; *terbinafine hcl (topical) $0(3) NM; *

DERMATOLOGY, ANTIPSORIATICSacitretin $0(1) PAcalcipotriene CREA; OINT $0(1) QL (120 grams / 30 days), PAcalcipotriene SOLN $0(1) QL (120 mL / 30 days), PAcalcitrene $0(1) QL (120 grams / 30 days), PAtazarotene CREA $0(1) QL (60 grams / 30 days), PATAZORAC CREA .05% $0(2) QL (60 grams / 30 days), PA

DERMATOLOGY, ANTISEBORRHEICSketoconazole shampoo $0(1)selenium sulfide LOTN $0(1)

DERMATOLOGY, CORTICOSTEROIDSala-cort $0(1)alclometasone dipropionate $0(1)anti-itch maximum strengt $0(3) NM; *betamethasone dipropionate (topical) $0(1)betamethasone dipropionate augmented $0(1)betamethasone valerate CREA; LOTN; OINT $0(1)ENSTILAR $0(2) QL (120 grams / 30 days), PAfluocinolone acetonide CREA; OIL; OINT $0(1)fluocinolone acetonide SOLN $0(1) QL (90 mL / 30 days)fluocinolone acetonide oil body $0(1)fluocinonide CREA .05% $0(1) QL (120 grams / 30 days)





fluocinonide GEL $0(1) QL (60 grams / 30 days)fluocinonide OINT $0(1) QL (60 grams / 30 days)fluocinonide SOLN $0(1) QL (60 mL / 30 days)fluocinonide emulsified base $0(1) QL (120 grams / 30 days)fluticasone propionate CREA; OINT $0(1)gnp hydrocortisone $0(3) NM; *gnp hydrocortisone maximu $0(3) NM; *gnp hydrocortisone plus $0(3) NM; *gnp hydrocortisone/aloe $0(3) NM; *halobetasol propionate CREA; OINT $0(1) QL (50 grams / 30 days)hydrocortisone (topical) $0(3) NM; *hydrocortisone (topical) cream 1% $0(1)hydrocortisone (topical) cream 2.5% $0(1)hydrocortisone (topical) lotion 2.5% $0(1)hydrocortisone (topical) oint 2.5% $0(1)hydrocortisone butyrate cream 0.1% $0(1) QL (45 grams / 30 days)hydrocortisone butyrate oint 0.1% $0(1) QL (45 grams / 30 days)hydrocortisone maximum st $0(3) NM; *hydrocortisone-aloe vera $0(3) NM; *mometasone furoate CREA; OINT; SOLN $0(1)sm hydrocortisone $0(3) NM; *sm hydrocortisone maximum $0(3) NM; *TEXACORT SOLN 2.5% $0(2)triamcinolone acetonide (topical) CREA .1% $0(1) QL (454 grams / 30 days)triamcinolone acetonide (topical) CREA .025%, .5%

$0(1)

triamcinolone acetonide (topical) LOTN $0(1)triamcinolone acetonide (topical) OINT .025%, .1%, .5%

$0(1)

DERMATOLOGY, LOCAL ANESTHETICSglydo $0(1) QL (30 mL / 30 days), PAlidocaine PTCH 5% $0(1) QL (3 patches / 1 day), PAlidocaine hcl GEL $0(1) QL (30 mL / 30 days), PAlidocaine hcl SOLN 4% $0(1) QL (50 mL / 30 days), PAlidocaine oint 5% $0(1) QL (50 grams / 30 days), PAlidocaine-prilocaine $0(1) QL (30 grams / 30 days), PA





DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANEALOE VESTA PROTECTIVE $0(3) NM; *ammonium lactate CREA; LOTN $0(1)anu-med $0(3) NM; *aplicare povidone-iodine $0(3) NM; *ARTHRITIS PAIN RELIEVING $0(3) NM; *BETADINE 5% $0(3) NM; *betasept surgical scrub $0(3) NM; *capsaicin CREA .025% $0(3) NM; *dibucaine (rectal) $0(3) NM; *diclofenac sodium (topical) 1% gel $0(1) QL (1000 grams / 30 days), PAfluorouracil (topical) CREA 5% $0(1) QL (40 grams / 30 days)fluorouracil (topical) SOLN $0(1) QL (10 mL / 30 days)gnp antiseptic skin clean $0(3) NM; *gnp povidone-iodine $0(3) NM; *gnp vitamin a & d $0(3) NM; *gnp zinc oxide $0(3) NM; *imiquimod CREA 5% $0(1) QL (24 packets / 30 days)lidocaine CREA 4% $0(3) NM; *lidocaine (anorectal) $0(3) NM; *metronidazole (topical) CREA; LOTN $0(1)metronidazole gel 0.75% $0(1)PANRETIN $0(2) QL (60 grams / 30 days)PICATO .05% $0(2) QL (2 tubes / 30 days)PICATO .015% $0(2) QL (3 tubes / 30 days)podofilox SOLN $0(1)povidone-iodine OINT $0(3) NM; *povidone-iodine SOLN $0(3) NM; *povidone-iodine SWAB 10% $0(3) NM; *pramoxine hcl (rectal) $0(3) NM; *procto-med hc $0(1)procto-pak $0(1)proctosol hc cre 2.5% $0(1)proctozone-hc $0(1)PROSHIELD PLUS SKIN PROTE $0(3) NM; *qc povidone iodine $0(3) NM; *





RECTIV $0(2) QL (30 grams / 30 days)REMEDY NUTRASHIELD $0(3) NM; *rosadan $0(1)tacrolimus (topical) $0(1) QL (100 grams / 30 days)TARGRETIN GEL $0(2) QL (60 grams / 30 days), NM, PAVALCHLOR $0(2) QL (60 grams / 30 days), NM, LA,

PAvitamins a & d (topical) $0(3) NM; *zinc oxide (topical) $0(3) NM; *

DERMATOLOGY, SCABICIDES AND PEDICULIDESgnp lice treatment $0(3) NM; *hm lice treatment $0(3) NM; *lice killing maximum stre $0(3) NM; *lice killing shampoo $0(3) NM; *lice treatment $0(3) NM; *malathion $0(1)permethrin cre 5% $0(1)

DERMATOLOGY, WOUND CARE AGENTSacetic acid .25% $0(1)REGRANEX $0(2) QL (30 grams / 30 days), PASANTYL $0(2)sodium chlor sol 0.9% irr $0(1)water for irrigation, sterile $0(1)

MOUTH/THROAT/DENTAL AGENTScevimeline hcl $0(1)chlorhexidine gluconate (mouth-throat) $0(1)clotrimazole LOZG $0(1)lidocaine hcl (mouth-throat) $0(1)nystatin (mouth-throat) $0(1)paroex sol 0.12% $0(1)periogard $0(1)pilocarpine hcl (oral) $0(1)triamcinolone acetonide (mouth) $0(1)

OTIC - DRUGS TO TREAT CONDITIONS OF THE EARacetic acid (otic) $0(1)CIPRODEX $0(2)





ear drops $0(3) NM; *ear drops earwax removal $0(3) NM; *earwax removal kit $0(3) NM; *flac $0(1)fluocinolone acetonide (otic) $0(1)gnp ear drops $0(3) NM; *gnp ear systems $0(3) NM; *neomycin-polymyxin-hc (otic) $0(1)ofloxacin (otic) $0(1)SWIM EAR $0(3) NM; *

81

E. Índice de medicamentos cubiertosNombre del medicamento Página n.º Nombre del medicamento Página n.º

E. Índice de medicamentos cubiertosNombre del medicamento Página n.º3

3 day vaginal ........................................................... 58

A

abacavir sulfate ........................................................ 8abacavir sulfate-lamivudine..................................... 9abacavir sulfate-lamivudine-zidovudine ................. 9ABELCET ................................................................... 7ABILIFY MAINTENA ................................................ 32abiraterone acetate ................................................ 16ABRAXANE .............................................................. 14acamprosate calcium ............................................. 37acarbose ................................................................. 39acebutolol hcl ......................................................... 23acephen..................................................................... 1acetaminophen ......................................................... 1acetaminophen childrens ......................................... 1acetaminophen extra stren ...................................... 1acetaminophen w/ codeine 300-15mg .................... 3acetaminophen w/ codeine 300-30mg .................... 3acetaminophen w/ codeine 300-60mg .................... 4acetaminophen w/ codeine soln .............................. 4acetazolamide ........................................................ 25acetic acid ............................................................... 79acetic acid (otic) ...................................................... 79acetylcysteine .......................................................... 73acid gone ................................................................. 50acid reducer ............................................................ 53acitretin ................................................................... 76acne medication 5 .................................................. 74ACNE MEDICATION 5 ............................................ 74acne medication 10 ................................................ 74ACNE MEDICATION 10 .......................................... 74ACTHIB ................................................................... 62ACTIMMUNE .......................................................... 61acyclovir .................................................................. 10acyclovir sodium ..................................................... 10ADACEL ................................................................... 62adefovir dipivoxil .................................................... 10ADEMPAS ............................................................... 26adriamycin .............................................................. 14adrucil inj ................................................................ 14ADVAIR DISKUS...................................................... 74ADVAIR HFA ........................................................... 74AFINITOR ................................................................ 17

AFINITOR DISPERZ ................................................ 17aftera ....................................................................... 42AIMOVIG ................................................................. 36akwa tears .............................................................. 69ala-cort .................................................................... 76albendazole .............................................................. 6albuterol sulfate ............................................... 71, 72alclometasone dipropionate .................................. 76ALDURAZYME ........................................................ 47ALECENSA .............................................................. 17alendronate sodium soln 70mg/75ml ................... 41alendronate sodium tab 5 mg ............................... 41alendronate sodium tab 10 mg ............................. 41alendronate sodium tab 35 mg ............................. 41alendronate sodium tab 40 mg ............................. 41alendronate sodium tab 70 mg ............................. 42alfuzosin hcl ............................................................ 57ALIMTA ................................................................... 14ALINIA ....................................................................... 6aliskiren fumarate .................................................. 25all day allergy.......................................................... 70all day allergy childrens ......................................... 70all-day allergy childrens ......................................... 70all day pain relief ...................................................... 3all day relief .............................................................. 3allergy ...................................................................... 70allergy childrens...................................................... 70allergy non-drowsy ................................................. 70allergy relief ............................................................ 70allergy relief childrens ............................................ 70allopurinol tab .......................................................... 1almacone ................................................................ 50almacone double strength ..................................... 50ALOE VESTA PROTECTIVE ..................................... 78alosetron hcl ........................................................... 56ALPHAGAN P SOL 0.1% ........................................ 68alprazolam tab 0.5mg ............................................ 26alprazolam tab 0.25mg .......................................... 26alprazolam tab 1mg ............................................... 26alprazolam tab 2mg ............................................... 26ALREX ...................................................................... 68altavera tab ............................................................ 42ALUMINUM HYDROXIDE ...................................... 50ALUNBRIG .............................................................. 17alyacen 1/35 ........................................................... 42amantadine hcl ....................................................... 31

82

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºAMBISOME ............................................................... 7ambrisentan ........................................................... 26amethia ................................................................... 42amethia lo ............................................................... 42amikacin sulfate ....................................................... 5amiloride hcl ........................................................... 25amiloride & hydrochlorothiazide ........................... 25AMINOSYN II INJ 10% ............................................ 64AMINOSYN-PF 7% ................................................. 64AMINOSYN-PF INJ 10% ......................................... 64amiodarone hcl soln ............................................... 22amiodarone tab 100mg ......................................... 22amiodarone tab 200mg ......................................... 22amiodarone tab 400mg ......................................... 22AMITIZA CAP 8MCG .............................................. 56AMITIZA CAP 24MCG ............................................ 56amitriptyline hcl ...................................................... 30amlodipine-benazepril hcl cap 2.5-10 mg ............. 20amlodipine-benazepril hcl cap 5-10 mg ................ 20amlodipine-benazepril hcl cap 5-20 mg ................ 20amlodipine-benazepril hcl cap 5-40 mg ................ 20amlodipine--benazepril hcl cap 10-20 mg ............. 20amlodipine-benazepril hcl cap 10-40mg ............... 20amlodipine besylate ............................................... 24amlodipine besylate-olmesartan medoxomil ........ 21amlodipine besylate-valsartan tab 5-160 mg ........ 21amlodipine besylate-valsartan tab 5-320 mg ........ 21amlodipine besylate-valsartan tab 10-160 mg ..... 21amlodipine besylate-valsartan tab 10-320 mg ..... 21amlodipine-valsartan-hydrochlorothiazide 5-160-

12.5mg ................................................................ 21amlodipine-valsartan-hydrochlorothiazide 5-160-

25mg ................................................................... 21amlodipine-valsartan-hydrochlorothiazide 10-

160-12.5mg ......................................................... 21amlodipine-valsartan-hydrochlorothiazide 10-

160-25mg ............................................................ 21amlodipine-valsartan-hydrochlorothiazide 10-

320-25mg ............................................................ 21ammonium lactate ................................................. 78amnesteem ............................................................. 74amoxapine tab 25mg ............................................. 30amoxapine tab 50mg ............................................. 30amoxapine tab 100mg ........................................... 30amoxapine tab 150mg ........................................... 30amoxicillin ............................................................... 12amoxicillin & pot clavulanate 200/5ml susr .......... 12

amoxicillin & pot clavulanate 200-28.5 chw tabs . 12amoxicillin & pot clavulanate 250/5ml susr .......... 12amoxicillin & pot clavulanate 250-125 tabs .......... 12amoxicillin & pot clavulanate 400/5ml susr .......... 12amoxicillin & pot clavulanate 400-57 chw tabs .... 12amoxicillin & pot clavulanate 500-125 tabs .......... 12amoxicillin & pot clavulanate 600/5ml susr .......... 12amoxicillin & pot clavulanate 875-125 tabs .......... 12amoxicillin & pot clavulanate er 12hr 1000-62.5

tabs ..................................................................... 13amphetamine-dextroamphetamine cap sr 24hr

5 mg .................................................................... 34amphetamine-dextroamphetamine cap sr 24hr

10 mg .................................................................. 34amphetamine-dextroamphetamine cap sr 24hr




30 mg .................................................................. 34amphetamine-dextroamphetamine tab 5 mg ....... 34amphetamine-dextroamphetamine tab 7.5 mg .... 34amphetamine-dextroamphetamine tab 10 mg ..... 34amphetamine-dextroamphetamine tab 12.5 mg .. 34amphetamine-dextroamphetamine tab 15 mg ..... 34amphetamine-dextroamphetamine tab 20 mg ..... 34amphetamine-dextroamphetamine tab 30 mg ..... 35amphotericin b ......................................................... 7ampicillin cap 500mg ............................................. 13ampicillin inj ........................................................... 13ampicillin sodium ................................................... 13ampicillin & sulbactam sodium ............................. 13ANADROL-50 ......................................................... 38anagrelide hcl ......................................................... 59anastrozole ............................................................. 16ANDRODERM ......................................................... 38ANORO ELLIPTA .................................................... 70antacid .................................................................... 50antacid anti-gas maximum .................................... 50antacid calcium extra str........................................ 50antacid calcium regular s ....................................... 50antacid extra strength ............................................ 50antacid fast relief .................................................... 50antacid maximum strength .................................... 50antacid plus anti-gas fas ........................................ 50

83

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºantacid plus anti-gas rel ......................................... 50anti-diarrheal .......................................................... 51antifungal ................................................................ 75anti-gas/and gnp antacid ....................................... 51anti-itch maximum strengt ..................................... 76anu-med .................................................................. 78aplicare povidone-iodine ........................................ 78APOKYN .................................................................. 31aprepitant ............................................................... 52aprepitant pak 80mg & 125mg .............................. 52apri .......................................................................... 42APTIOM .................................................................. 27APTIVUS .................................................................... 8ARALAST NP ........................................................... 73aranelle ................................................................... 42ARCALYST ............................................................... 61aripiprazole odt ...................................................... 32aripiprazole oral solution 1 mg/ml ........................ 32aripiprazole tab ...................................................... 32ARISTADA ............................................................... 32ARISTADA INITIO ................................................... 32armodafinil ............................................................. 37ARNUITY ELLIPTA .................................................. 74ARTHRITIS PAIN RELIEVING .................................. 78artificial tears .......................................................... 69ashlyna .................................................................... 42aspirin ....................................................................... 1aspirin-acetaminophen-caffeine .............................. 1aspirin adult low dose .............................................. 1aspirin adult low strengt .......................................... 1aspirin-dipyridamole .............................................. 60aspirin low dose ........................................................ 1aspirin low strength .................................................. 1aspir-low ................................................................... 1atazanavir sulfate ..................................................... 8atenolol ................................................................... 23atenolol & chlorthalidone ...................................... 23atomoxetine hcl ...................................................... 35atorvastatin calcium ............................................... 22atovaquone ............................................................... 6atovaquone-proguanil hcl ........................................ 8ATRIPLA .................................................................... 9ATROPINE SULFATE .............................................. 69ATROVENT HFA...................................................... 70aubra ...................................................................... 42AURYXIA ................................................................. 49AUSTEDO................................................................ 36

AVASTIN.................................................................. 15aviane ...................................................................... 43avita ........................................................................ 74AYVAKIT .................................................................. 17azacitidine ............................................................... 14AZASITE .................................................................. 67azathioprine ............................................................ 62azelastine drop 0.05% ............................................ 68azelastine spr 0.1% ................................................. 70azelastine spr 0.15% ............................................... 70azithromycin ........................................................... 12AZOPT ..................................................................... 68aztreonam................................................................. 6

B

bacitracin (ophthalmic) .......................................... 67bacitracin-polymyxin b (ophth) .............................. 67bacitracin-poly-neomycin-hc .................................. 67bacitracin (topical) .................................................. 75bacitracin zinc ........................................................ 75baclofen .................................................................. 37balsalazide disodium ............................................. 53BALVERSA ............................................................... 17balziva ..................................................................... 43banophen ................................................................ 70BANZEL SUS 40MG/ML ......................................... 27BANZEL TAB 200MG ............................................. 27BANZEL TAB 400MG ............................................. 27BARACLUDE ........................................................... 10BASAGLAR KWIKPEN ............................................. 38BCG VACCINE ......................................................... 62BD ALCOHOL SWABS ............................................ 38BD ULTRAFINE INSULIN SYRINGE ....................... 38BD ULTRAFINE/NANO PEN NEEDLES .................. 38bekyree .................................................................... 43BELSOMRA ............................................................. 35benazepril hcl ......................................................... 20benazepril & hydrochlorothiazide ......................... 20BENDEKA ................................................................ 14BENLYSTA ............................................................... 62benzoyl peroxide..................................................... 74BENZOYL PEROXIDE ............................................. 74BENZOYL PEROXIDE CLEANSER .......................... 74benzoyl peroxide-erythromycin ............................. 75benztropine mesylate inj ........................................ 31benztropine mesylate tab 0.5mg ........................... 31benztropine mesylate tab 1mg .............................. 31

84

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºbenztropine mesylate tab 2mg .............................. 31BEPREVE ................................................................. 68BERINERT ............................................................... 59BESIVANCE ............................................................. 67BETADINE ............................................................... 78betamethasone dipropionate augmented ............. 76betamethasone dipropionate (topical) .................. 76betamethasone valerate ........................................ 76betasept surgical scrub .......................................... 78BETASERON ........................................................... 36betaxolol hcl ........................................................... 23betaxolol hcl (ophth)............................................... 68bethanechol chloride .............................................. 57BETOPTIC-S ............................................................ 68BEVESPI AEROSPHERE .......................................... 70bexarotene .............................................................. 19BEXSERO ................................................................ 62bicalutamide ........................................................... 16BICILLIN L-A ........................................................... 13BIKTARVY .................................................................. 9bisac-evac ............................................................... 53bisacodyl ................................................................. 53bisacodyl ec ............................................................ 53biscolax ................................................................... 53bismatrol ................................................................. 51bismatrol maximum strengt .................................. 51bisoprolol fumarate................................................ 23bisoprolol & hydrochlorothiazide .......................... 23BIVIGAM ................................................................. 61BLEPHAMIDE ......................................................... 67blisovi 24 fe ............................................................. 43blisovi fe 1.5/30....................................................... 43BOOSTRIX ............................................................... 62BORTEZOMIB ......................................................... 15bosentan ................................................................. 26BOSULIF ................................................................. 17BRAFTOVI ............................................................... 17BREO ELLIPTA ........................................................ 74briellyn .................................................................... 43BRILINTA ................................................................ 60brimonidine sol 0.2% .............................................. 68brimonidine sol 0.15%............................................ 69BRIVIACT INJ 50MG/5ML ...................................... 27BRIVIACT SOL 10MG/ML ....................................... 27BRIVIACT TAB 10MG ............................................. 27BRIVIACT TAB 25MG ............................................. 27BRIVIACT TAB 50MG ............................................. 27

BRIVIACT TAB 75MG ............................................. 27BRIVIACT TAB 100MG ........................................... 27bromfenac sodium (ophth) .................................... 68bromocriptine mesylate ......................................... 31BROMSITE .............................................................. 68BRUKINSA .............................................................. 17budesonide ec ......................................................... 53budesonide (inhalation) ......................................... 74bumetanide ............................................................. 25buprenorphine hcl .................................................. 37buprenorphine hcl-naloxone hcl dihydrate

2-0.5mg ............................................................... 37buprenorphine hcl-naloxone hcl dihydrate 4-1mg 37buprenorphine hcl-naloxone hcl dihydrate 8-2mg 37buprenorphine hcl-naloxone hcl dihydrate 12-

3mg ..................................................................... 37buprenorphine hcl-naloxone hcl sl ........................ 37buprenorphine patch ............................................... 4bupropion hcl ......................................................... 30bupropion hcl (smoking deterrent) ........................ 37buspirone hcl .......................................................... 26butorphanol tartrate ................................................ 4BYDUREON BCISE ................................................. 38BYDUREON PEN .................................................... 38BYETTA ................................................................... 39BYSTOLIC ................................................................ 23

C

cabergoline ............................................................. 48CABOMETYX ........................................................... 17calcipotriene ........................................................... 76calcitonin (salmon) ................................................. 48calcitrene ................................................................. 76calcitriol .................................................................. 66calcitriol inj ............................................................. 66calcitriol oral soln 1 mcg/ml................................... 66calcium acetate (phosphate binder) ...................... 49calcium antacid ...................................................... 50calcium antacid extra str........................................ 50calcium carbonate (antacid) .................................. 66calcium carbonate-vitamin d ................................. 66calcium polycarbophil ............................................ 53cal-gest antacid ....................................................... 50CALQUENCE ........................................................... 17camila ..................................................................... 43camrese lo ............................................................... 43candesartan cilexetil ............................................... 22

85

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºcandesartan cilexetil-hydrochlorothiazide ............ 21CAPLYTA ................................................................. 32CAPRELSA ............................................................... 17capsaicin ................................................................. 78captopril .................................................................. 20captopril & hydrochlorothiazide ............................ 20CARBAGLU ............................................................. 47carbamazepine ....................................................... 27carbidopa-levodopa ............................................... 31carbidopa/levodopa/entacapone .......................... 31carboplatin ............................................................. 19carisoprodol ............................................................ 37carteolol hcl (ophth) ............................................... 69cartia xt cap 120/24hr ............................................ 24cartia xt cap 180/24hr ............................................ 24cartia xt cap 240/24hr ............................................ 24cartia xt cap 300/24hr ............................................ 24carvedilol................................................................. 23caspofungin acetate ................................................. 7CAYSTON .................................................................. 6caziant pak ............................................................. 43cefaclor ................................................................... 11CEFACLOR MONOHYDRATE ER ........................... 11cefadroxil ................................................................ 11CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ........ 11cefazolin inj ............................................................. 11cefazolin sodium ..................................................... 11CEFAZOLIN SODIUM 1 GM/50ML ........................ 11cefdinir .................................................................... 11cefepime hcl ............................................................ 11cefixime ................................................................... 11cefoxitin sodium ..................................................... 11cefpodoxime proxetil .............................................. 11cefprozil .................................................................. 11ceftazidime .............................................................. 11CEFTAZIDIME/DEXTROSE ..................................... 11ceftriaxone sodium ................................................. 11cefuroxime axetil .................................................... 11cefuroxime sodium ................................................. 11celecoxib ................................................................... 3CELONTIN .............................................................. 27cephalexin ............................................................... 11CERDELGA .............................................................. 47CEREZYME .............................................................. 47cetirizine hcl ............................................................ 70cetirizine hcl allergy ch ........................................... 70cetirizine hcl childrens ............................................ 70

cetirizine hydrochloride .......................................... 70cetirizine syrup ........................................................ 70cevimeline hcl ......................................................... 79CHANTIX ................................................................. 37CHANTIX CONTINUING MONTH ......................... 37CHANTIX STARTER PACK ...................................... 38CHEMET .................................................................. 42childrens acetaminophen ......................................... 1childrens loratadine ............................................... 70childrens mucus relief ex ........................................ 72childrens silapap ...................................................... 1chlorhexidine gluconate (mouth-throat)................ 79chloroquine phosphate ............................................ 8chlorothiazide ......................................................... 25chlorpromazine hcl................................................. 32CHLORPROMAZINE INJ ......................................... 32chlorthalidone ........................................................ 25cholestyramine ....................................................... 22cholestyramine light pack ...................................... 22cholestyramine light powd ..................................... 22ciclopirox ................................................................. 75cilostazol ................................................................. 59CILOXAN ................................................................. 67CIMDUO ................................................................... 9cinacalcet hcl .......................................................... 49CIPRO ...................................................................... 12CIPRODEX ............................................................... 79ciprofloxacin hcl (ophth) ........................................ 67ciprofloxacin hcl tab ............................................... 12ciprofloxacin in d5w ............................................... 12cisplatin ................................................................... 19citalopram hydrobromide ...................................... 30CITRUCEL FIBER LAXATIVE ................................... 53claravis .................................................................... 75clarithromycin......................................................... 12clarithromycin er .................................................... 12clarithromycin for susp .......................................... 12clearlax .................................................................... 53clindamycin cap 75mg ............................................. 6clindamycin cap 300mg ........................................... 6clindamycin hcl cap 150 mg ..................................... 6clindamycin phosphate in d5w ................................ 6clindamycin phosphate inj ....................................... 6CLINDAMYCIN PHOSPHATE IN NACL.................... 6clindamycin phosphate (topical) ............................ 75clindamycin phosphate vaginal ............................. 58clindamycin soln 75mg/5ml ..................................... 6

86

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºCLINIMIX 4.25%/DEXTROSE 5% ........................... 64CLINIMIX 5%/DEXTROSE 15% .............................. 64CLINIMIX 5%/DEXTROSE 20% .............................. 64CLINIMIX INJ 4.25/D10 .......................................... 64clinisol sf 15% ......................................................... 64CLINOLIPID ............................................................ 64clobazam ................................................................ 27clomipramine hcl .................................................... 30clonazepam ............................................................ 27clonidine hcl ............................................................ 25clonidine hcl ptwk ................................................... 25clopidogrel tab 75mg ............................................. 60clorazepate dipotassium ........................................ 27clotrimazole ............................................................ 79clotrimazole 3 ......................................................... 58clotrimazole anti-fungal ......................................... 76clotrimazole antifungal .......................................... 76clotrimazole (topical) .............................................. 75clotrimazole vaginal ............................................... 58clotrimazole w/ betamethasone ............................ 76clovique ................................................................... 42clozapine odt .......................................................... 32clozapine tab 25mg ................................................ 32clozapine tab 50mg ................................................ 32clozapine tab 100mg .............................................. 32clozapine tab 200mg .............................................. 32COARTEM ................................................................. 8colace 2-in-1............................................................ 53COLACE CLEAR ...................................................... 53colchicine w/ probenecid .......................................... 1COLCRYS .................................................................. 1colesevelam hcl ....................................................... 22colestipol hcl gran .................................................. 23colestipol hcl pack .................................................. 23colestipol hcl tabs ................................................... 23colistimethate sodium .............................................. 6colocort ................................................................... 53COMBIGAN ............................................................ 69COMBIVENT RESPIMAT......................................... 70COMETRIQ ............................................................. 18COMPLERA ............................................................... 9complete allergy medicine ...................................... 70compro .................................................................... 52constulose ............................................................... 54COPIKTRA ............................................................... 18CORLANOR............................................................. 25cortisone acetate .................................................... 47

COTELLIC ................................................................ 18cough & chest congestion ....................................... 72cough syrup ............................................................ 72COUMADIN ............................................................ 58CREON .................................................................... 57CRIXIVAN .................................................................. 8cromolyn sodium (mastocytosis) ........................... 56cromolyn sodium nebu .......................................... 73cromolyn sodium (ophth) ....................................... 68cryselle-28 ............................................................... 43cvs glycerin adult .................................................... 54cyanocobalamin ..................................................... 66cyclafem 1/35.......................................................... 43cyclafem 7/7/7 ........................................................ 43cyclobenzaprine hcl ................................................ 37cyclophosphamide .................................................. 14cycloserine .............................................................. 10cyclosporine ............................................................ 62cyclosporine modified (for microemulsion) ........... 62cyproheptadine hcl ................................................. 70cyred tab ................................................................. 43CYSTADANE ........................................................... 47CYSTAGON ............................................................. 47CYSTARAN .............................................................. 69cytarabine ............................................................... 14

D

dalfampridine ......................................................... 37DALIRESP ................................................................ 73danazol ................................................................... 47dantrolene sodium ................................................. 37dapsone .................................................................... 6DAPTACEL .............................................................. 62daptomycin ............................................................... 6dasetta 1/35 ............................................................ 43dasetta 7/7/7 .......................................................... 43DAURISMO ............................................................. 15deblitane ................................................................. 43deferasirox tab ....................................................... 42DELESTROGEN ....................................................... 47DELSTRIGO ............................................................... 9DEMSER .................................................................. 25DEPO-PROVERA INJ 400/ML ................................. 16DESCOVY .................................................................. 9desipramine hcl ...................................................... 30desmopressin acetate spray................................... 50desmopressin acetate spray refrigerated .............. 50

87

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºdesmopressin acetate tabs..................................... 50desmopressin inj 4mcg/ml ..................................... 50desogestrel & ethinyl estradiol ............................... 43desogestrel-ethinyl estradiol (biphasic) ................. 43desvenlafaxine succinate ........................................ 30dexamethasone ...................................................... 47DEXAMETHASONE................................................. 47dexamethasone sodium phosphate ...................... 48dexamethasone sodium phosphate (ophth) ......... 68DEXILANT ............................................................... 57dexmethylphenidate hcl ......................................... 35dextromethorphan-guaifenesin ............................. 72dextrose 2.5%/nacl 0.45% ...................................... 65dextrose 5% ............................................................ 65DEXTROSE 5% /ELECTROLYTE ............................. 65dextrose 5%/nacl 0.2% ........................................... 65DEXTROSE 5%/NACL 0.3% .................................... 65dextrose 5%/nacl 0.9% ........................................... 65dextrose 5%/nacl 0.45% ......................................... 65dextrose 5%/nacl 0.225% ....................................... 65dextrose 5%/potassium chl .................................... 65dextrose 10% flex contain ...................................... 65dextrose 10%/nacl 0.45% ....................................... 65DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% ... 65dextrose 50% .......................................................... 65dextrose inj 70% ..................................................... 65dextrose in lactated ringers .................................... 65diabetic siltussin das-na ......................................... 72diabetic siltussin-dm ............................................... 72diabetic siltussin-dm max ...................................... 72DIASTAT ACUDIAL ................................................. 27DIASTAT PEDIATRIC .............................................. 27diazepam ................................................................ 27diazepam gel........................................................... 27diazepam inj ........................................................... 27diazepam intensol .................................................. 27diazepam oral soln 1 mg/ml .................................. 27diazoxide ................................................................. 48dibucaine (rectal) .................................................... 78diclofenac potassium ............................................... 3diclofenac sodium .................................................... 3diclofenac sodium (ophth) ..................................... 68diclofenac sodium (topical) 1% gel ........................ 78dicloxacillin sodium ................................................ 13dicyclomine hcl cap 10mg ...................................... 52dicyclomine hcl soln 10mg/5ml ............................. 52dicyclomine hcl tab 20mg ...................................... 52

didanosine ................................................................ 8DIFICID .................................................................... 12diflunisal ................................................................... 3digitek ...................................................................... 25digox ........................................................................ 25digoxin..................................................................... 25digoxin inj ............................................................... 25digoxin sol 50mcg/ml ............................................. 25dihydroergotamine mesylate inj 1 mg/ml ............. 36dihydroergotamine mesylate nasal spr 4 mg/ml .. 36DILANTIN-125 SUSP .............................................. 28DILANTIN CAP 30MG ............................................ 27DILANTIN CAP 100MG .......................................... 28DILANTIN CHEW TAB 50MG ................................. 28diltiazem cap 240mg cd ......................................... 24diltiazem cap 360mg cd ......................................... 24diltiazem cap er/12hr ............................................. 24diltiazem hcl ............................................................ 24diltiazem hcl coated beads..................................... 24diltiazem hcl coated beads cap sr 24hr ................. 24diltiazem hcl extended release beads cap sr ......... 24diltiazem inj ............................................................ 24dilt-xr cap ................................................................ 24diphenhist ............................................................... 70diphenhydramine hcl ....................................... 70, 71diphenhydramine hcl inj 50mg/ml ........................ 71diphenoxylate w/ atropine ..................................... 56DIPHTHERIA/TETANUS TOXOID........................... 62disopyramide phosphate ....................................... 22disulfiram ................................................................ 38divalproex sodium .................................................. 28docetaxel ........................................................... 14, 15DOCETAXEL ...................................................... 14, 15docu ........................................................................ 54docusate sodium .................................................... 54docusil ..................................................................... 54DOCUSOL KIDS ...................................................... 54DOCUSOL MINI...................................................... 54DOCUSOL PLUS MINI-ENEMA .............................. 54dofetilide ................................................................. 22dok .......................................................................... 54dok plus ................................................................... 54donepezil hydrochloride ......................................... 29dorzolamide hcl ...................................................... 69dorzolamide hcl-timolol maleate ........................... 69double antibiotic ..................................................... 75DOVATO ................................................................... 9

88

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºdoxazosin mesylate ................................................ 21doxepin hcl.............................................................. 30doxepin hcl (sleep) .................................................. 35doxorubicin hcl ....................................................... 14doxorubicin hcl liposomal ...................................... 14doxy 100 .................................................................. 13doxycycline hyclate ................................................. 13doxycycline (monohydrate) .................................... 13driminate ................................................................ 52DRIZALMA SPRINKLE ............................................ 30dronabinol .............................................................. 52drospirenone-ethinyl estradiol ............................... 43drospirenone-ethinyl estradiol-levomefolate

calcium ................................................................ 43DROXIA ................................................................... 59ducodyl .................................................................... 54duloxetine hcl ......................................................... 30DUREZOL ................................................................ 68dutasteride .............................................................. 57dutasteride-tamsulosin hcl ..................................... 57

E

ear drops ................................................................. 80ear drops earwax removal ..................................... 80earwax removal kit ................................................. 80econtra ez ............................................................... 43econtra one-step ..................................................... 43ed-apap ..................................................................... 1EDURANT ................................................................. 8e.e.s 400 .................................................................. 12efavirenz.................................................................... 8eletriptan hydrobromide ........................................ 36ELIQUIS ................................................................... 58ELIQUIS STARTER PACK ........................................ 58ELLA ........................................................................ 43eluryng .................................................................... 43EMCYT .................................................................... 14EMEND ................................................................... 52EMGALITY ............................................................... 36emoquette ............................................................... 43EMSAM ................................................................... 30EMTRIVA ................................................................... 8EMVERM ................................................................... 6enalapril maleate ................................................... 20enalapril maleate & hydrochlorothiazide .............. 20ENBREL ................................................................... 60ENBREL MINI.......................................................... 60

ENBREL SURECLICK ............................................... 60ENDARI ................................................................... 59endocet 2.5-325mg ................................................... 4endocet 5-325mg ...................................................... 4endocet 7.5-325mg ................................................... 4endocet 10-325mg .................................................... 4ENEMEEZ MINI....................................................... 54ENEMEEZ PLUS ...................................................... 54ENGERIX-B .............................................................. 62enoxaparin sodium ................................................ 58enpresse-28 ............................................................. 43enskyce .................................................................... 43ENSTILAR ................................................................ 76entacapone ............................................................. 31entecavir ................................................................. 10ENTRESTO .............................................................. 21enulose .................................................................... 54EPCLUSA ................................................................. 10EPIDIOLEX .............................................................. 28epinephrine (anaphylaxis) ...................................... 73epirubicin hcl .......................................................... 14epitol ....................................................................... 28EPIVIR HBV ............................................................. 10eplerenone .............................................................. 21eq aspirin ec .............................................................. 1ergocalciferol .......................................................... 66ergotamine w/ caffeine ........................................... 36ERIVEDGE ............................................................... 15ERLEADA ................................................................. 16erlotinib hcl ............................................................. 18errin ......................................................................... 43ertapenem sodium ................................................... 6ery pad 2% .............................................................. 75ery-tab ..................................................................... 12ERYTHROCIN LACTOBIONATE ............................. 12erythrocin stearate ................................................. 12erythromycin (acne aid) ......................................... 75erythromycin base .................................................. 12erythromycin cap 250mg ec ................................... 12erythromycin ethylsuccinate .................................. 12erythromycin (ophth) .............................................. 67erythromycin tab ec ................................................ 12ESBRIET .................................................................. 73escitalopram oxalate .............................................. 30esomeprazole magnesium ..................................... 57estarylla tab 0.25-35 ............................................... 43estradiol .................................................................. 47

89

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºestradiol vaginal cream .......................................... 47estradiol vaginal tab ............................................... 47estradiol valerate .................................................... 47eszopiclone ............................................................. 35ethambutol hcl ....................................................... 10ethosuximide .......................................................... 28ethynodiol diacet & eth estrad ............................... 43ethynodiol tab 1-50 ................................................ 43etodolac .................................................................... 3etodolac er ................................................................ 3etonogestrel-ethinyl estradiol ................................. 43etoposide ................................................................ 20euthyrox .................................................................. 49everolimus............................................................... 18everolimus (immunosuppressant) ......................... 62EVOTAZ ..................................................................... 9exemestane ............................................................. 16ezetimibe ................................................................. 23ezetimibe-simvastatin ............................................. 23

F

FABRAZYME ........................................................... 47falmina .................................................................... 43famciclovir .............................................................. 10famotidine............................................................... 53famotidine inj ......................................................... 53famotidine in nacl................................................... 53FANAPT ................................................................... 32FANAPT TITRATION PACK ..................................... 32FARXIGA .................................................................. 39FARYDAK ................................................................ 15FASENRA................................................................. 73FASENRA PEN ........................................................ 73fast acting antacid plus .......................................... 50fayosim .................................................................... 43felbamate ................................................................ 28felodipine ................................................................ 24femynor ................................................................... 43fenofibrate .............................................................. 23fenofibrate micronized ........................................... 23fentanyl citrate .......................................................... 4fentanyl patch 12 mcg/hr ......................................... 4fentanyl patch 25 mcg/hr ......................................... 4fentanyl patch 50 mcg/hr ......................................... 4fentanyl patch 75 mcg/hr ......................................... 4fentanyl patch 100 mcg/hr ....................................... 4FERAHEME ............................................................. 59

ferrous sulfate ......................................................... 59FERROUS SULFATE ................................................ 59FETZIMA ................................................................. 30FETZIMA TITRATION PACK ................................... 30feverall childrens ...................................................... 1FEVERALL INFANTS ................................................. 1feverall junior strength ............................................. 1FIASP ....................................................................... 39FIASP FLEXTOUCH ................................................. 39FIASP PENFILL ........................................................ 39fiber-lax ................................................................... 54fiber laxative ........................................................... 54finasteride ............................................................... 57flac ........................................................................... 80FLAREX .................................................................... 68flecainide acetate .................................................... 22FLEET LIQUID GLYCERIN SUP .............................. 54FLOVENT DISKUS ................................................... 74FLOVENT HFA ........................................................ 74fluconazole ................................................................ 7fluconazole inj nacl 200 ........................................... 7fluconazole inj nacl 400 ........................................... 7flucytosine ................................................................. 7fludrocortisone acetate .......................................... 48flunisolide (nasal) ................................................... 74fluocinolone acetonide ........................................... 76fluocinolone acetonide oil body ............................. 76fluocinolone acetonide (otic) .................................. 80fluocinonide ...................................................... 76, 77fluocinonide emulsified base ................................. 77fluorometholone ..................................................... 68fluorouracil ............................................................. 14fluorouracil (topical) ............................................... 78fluoxetine cap 10mg ............................................... 30fluoxetine cap 20mg ............................................... 30fluoxetine cap 40mg ............................................... 30fluoxetine hcl .......................................................... 30fluphenazine decanoate ......................................... 32fluphenazine hcl ..................................................... 32flurbiprofen ............................................................... 3flurbiprofen sodium ............................................... 68flutamide ................................................................. 16fluticasone propionate ........................................... 77fluticasone propionate (nasal) ............................... 74fluvoxamine maleate .............................................. 27folic acid .................................................................. 66fondaparinux sodium ............................................. 58

90

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºformula em ............................................................. 56FORTEO .................................................................. 49fosamprenavir tab 700 mg ...................................... 8fosinopril sodium .................................................... 20fosinopril sodium & hydrochlorothiazide .............. 20FREAMINE HBC 6.9%............................................. 64FREAMINE III .......................................................... 64fulvestrant ............................................................... 16furosemide .............................................................. 25furosemide inj ......................................................... 25FUZEON .................................................................... 8fyavolv ..................................................................... 47FYCOMPA ............................................................... 28

G

gabapentin .............................................................. 28galantamine hydrobromide ................................... 29galantamine hydrobromide er ............................... 29GALZIN ................................................................... 66GAMASTAN S/D ..................................................... 61GAMMAGARD LIQUID ........................................... 61GAMMAGARD S/D ................................................. 61GAMMAKED ........................................................... 61GAMMAPLEX .......................................................... 61GAMMAPLEX 10GM/100ML ................................. 61GAMUNEX-C ........................................................... 61ganciclovir sodium.................................................. 10GARDASIL 9 ............................................................ 62gatifloxacin (ophth) ................................................ 67GATTEX ................................................................... 56GAUZE PADS 2 ....................................................... 39gavilax ..................................................................... 54gavilyte-c ................................................................. 54gavilyte-g ................................................................. 54gavilyte-n/flavor pack ............................................. 54GAVISCON .............................................................. 50GAVISCON EXTRA STRENGTH .............................. 50GAVISCON EXTRA STRENGTH R ........................... 50gemcitabine inj soln................................................ 14gemcitabine inj solr ................................................ 14gemfibrozil .............................................................. 23generlac................................................................... 54gengraf .................................................................... 62GENOTROPIN ........................................................ 49GENOTROPIN MINIQUICK .................................... 49gentak ..................................................................... 67gentamicin in saline.................................................. 5

gentamicin sulfate .................................................... 5gentamicin sulfate soln (ophth) ............................. 67gentamicin sulfate (topical) .................................... 75genteal tears liquid drop ........................................ 69genteal tears mild ................................................... 69GENVOYA ................................................................. 9GEODON ................................................................ 32gianvi ....................................................................... 44GILENYA CAP 0.5MG ............................................. 37GILOTRIF TAB 20MG ............................................. 18GILOTRIF TAB 30MG ............................................. 18GILOTRIF TAB 40MG ............................................. 18glatiramer acetate 20mg/ml .................................. 37glatiramer acetate 40mg/ml .................................. 37glatopa .................................................................... 37GLEOSTINE ............................................................. 14glimepiride .............................................................. 39glipizide ................................................................... 40glipizide xl ............................................................... 40glip/metform tab 2.5-250mg .................................. 40glip/metform tab 2.5-500mg .................................. 40glip/metform tab 5-500mg ..................................... 40GLUCAGEN HYPOKIT ............................................ 48GLUCAGON EMERGENCY KIT .............................. 48glyburide ................................................................. 40glyburide-metformin tab 1.25-250 mg .................. 40glyburide-metformin tab 2.5-500 mg .................... 40glyburide-metformin tab 5-500mg ........................ 40glyburide micronized .............................................. 40glycerin (laxative) .................................................... 54glycopyrrolate tab 1mg .......................................... 52glycopyrrolate tab 2mg .......................................... 53glydo ........................................................................ 77GLYXAMBI .............................................................. 40gnp acetaminophen ................................................. 1gnp acid reducer ..................................................... 53gnp adult aspirin low str .......................................... 2gnp all day allergy .................................................. 71gnp all day allergy child ......................................... 71gnp all day pain relief ............................................... 3gnp allergy .............................................................. 71gnp allergy antihistamine ....................................... 71gnp allergy relief ..................................................... 71gnp allergy relief for ki ............................................ 71gnp antacid

and anti-gas/ 51gnp antacid anti-gas ............................................... 51

91

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºgnp antacid anti-gas/maxi ..................................... 51gnp antacid & anti-gas/re....................................... 51gnp antacid extra strengt ....................................... 51gnp antacid/regular stren ...................................... 51gnp anti-diarrheal .................................................. 51gnp antiseptic skin clean ........................................ 78gnp artificial tears .................................................. 69gnp aspirin ................................................................ 2gnp aspirin low dose ................................................ 2gnp athletes foot ..................................................... 76gnp bacitracin zinc ................................................. 75gnp childrens allergy .............................................. 71gnp clearlax ............................................................ 54gnp clotrimazole 3 .................................................. 58gnp ear drops ......................................................... 80gnp ear systems ...................................................... 80gnp enema .............................................................. 54gnp fiber therapy .................................................... 54gnp gentle laxative .................................................. 54gnp headache relief extra ........................................ 2gnp hydrocortisone ................................................ 77gnp hydrocortisone/aloe ........................................ 77gnp hydrocortisone maximu .................................. 77gnp hydrocortisone plus ......................................... 77gnp ibuprofen ........................................................... 3gnp infants pain/fever .............................................. 2gnp infants pain relief .............................................. 2gnp laxative ............................................................. 54gnp laxative pills ..................................................... 54gnp lice treatment .................................................. 79gnp loperamide hcl ................................................. 51gnp loratadine ........................................................ 71gnp loratadine childrens ........................................ 71gnp lubricant pm .................................................... 69gnp miconazole 3 ................................................... 58gnp miconazole 7 ................................................... 58gnp migraine relief ................................................... 2gnp milk of magnesia ............................................. 54gnp motion sickness relie ....................................... 52gnp naproxen sodium .............................................. 3gnp nasal decongestant ......................................... 72gnp nasal decongestant/ma ................................... 72gnp nausea relief .................................................... 56gnp nicotine mini lozenge ...................................... 38gnp nicotine polacrilex ........................................... 38gnp nicotine polacrilex m ....................................... 38gnp nicotine transdermal ....................................... 38

gnp pain & fever children ......................................... 2gnp pain relief ........................................................... 2gnp pain relief extra str ............................................ 2gnp pink bismuth .................................................... 51gnp povidone-iodine ............................................... 78gnp senna lax .......................................................... 54gnp senna plus ........................................................ 54gnp stool softener ................................................... 54gnp stool softener/stimul ....................................... 54gnp terbinafine hydrochlo ...................................... 76gnp tioconazole 1 ................................................... 58gnp triple antibiotic ................................................ 75gnp triple antibiotic plu .......................................... 75gnp tussin dm ......................................................... 72gnp tussin dm cough .............................................. 72gnp tussin dm max ................................................. 72gnp tussin mucus & chest ....................................... 72gnp vitamin a & d ................................................... 78gnp womens gentle laxativ ..................................... 54gnp womens laxative .............................................. 54gnp zinc oxide ......................................................... 78GOLYTELY ............................................................... 55goodsense acid reducer .......................................... 53goodsense all day allergy ....................................... 71goodsense aspirin ..................................................... 2goodsense aspirin adult l ......................................... 2goodsense clearlax ................................................. 55goodsense naproxen sodium ................................... 3goodsense nicotine gum ......................................... 38goodsense nicotine polacr ...................................... 38goodsense pain & fever in ........................................ 2goodsense stomach relief ....................................... 51granisetron hcl ........................................................ 52griseofulvin microsize ............................................... 7griseofulvin ultramicrosize ....................................... 7guaifenesin .............................................................. 72guanfacine er (adhd) .............................................. 35GVOKE HYPOPEN 2-PACK .................................... 48GVOKE PFS ............................................................. 48

H

HAEGARDA ............................................................. 59hailey 24 fe .............................................................. 44halobetasol propionate .......................................... 77haloperidol ............................................................. 32haloperidol conc 2mg/ml ....................................... 33haloperidol decanoate ........................................... 33

92

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºhaloperidol lactate inj 5mg/ml............................... 33HARVONI ................................................................ 10HAVRIX .................................................................... 62healthylax ............................................................... 55heartburn relief ...................................................... 53heather .................................................................... 44heparin sod inj 1000/ml ......................................... 59heparin sod inj 5000/ml ......................................... 59heparin sod inj 10000/ml ....................................... 59heparin sod inj 20000/ml ....................................... 59HEPARIN SODIUM/NACL 0.45%........................... 59heparin sod (porcine) in d5w ................................. 59hepatamine ............................................................. 64HERCEPTIN ............................................................. 15HERCEPTIN HYLECTA ............................................ 15HERZUMA ............................................................... 15HETLIOZ.................................................................. 35HIBERIX ................................................................... 62hm all day allergy childr ......................................... 71hm cetirizine hcl childre ......................................... 71hm clearlax ............................................................. 55hm lice treatment ................................................... 79hm loperamide hcl ................................................. 51hm loratadine ......................................................... 71hm milk of magnesia .............................................. 55hm motion relief ..................................................... 52hm motion sickness relief ....................................... 52hm stool softener .................................................... 55hm tussin adult ....................................................... 72hm tussin adult cough & c ...................................... 72HUMIRA .................................................................. 60HUMIRA INJ 10MG/0.2ML ..................................... 60HUMIRA KIT 20MG/0.4ML .................................... 60HUMIRA KIT 40MG/0.8ML .................................... 60HUMIRA PEDIATRIC CROHNS DISEASE ............... 60HUMIRA PEN .......................................................... 60HUMIRA PEN CD/UC/HS STARTER ....................... 61HUMIRA PEN INJ CD/UC/HS STARTER ................. 61HUMIRA PEN INJ PS/UV STARTER ........................ 61HUMIRA PEN-PS/UV STARTER.............................. 61HUMULIN R INJ U-500 ........................................... 39HUMULIN R U-500 KWIKPEN ............................... 39hydralazine hcl ....................................................... 25hydrochlorothiazide ............................................... 25hydroco/apap tab 5-325mg ..................................... 4hydroco/apap tab 7.5-325 ....................................... 4hydroco/apap tab 10-325mg ................................... 4

hydrocodone-acetaminophen 7.5-325 mg/15ml .... 4hydrocodone-ibuprofen tab 7.5-200 mg ................. 4hydrocortisone ........................................................ 48hydrocortisone-aloe vera ....................................... 77hydrocortisone butyrate cream 0.1% .................... 77hydrocortisone butyrate oint 0.1% ........................ 77hydrocortisone (enema) ......................................... 53hydrocortisone maximum st .................................. 77hydrocortisone (topical) ......................................... 77hydrocortisone (topical) cream 1% ........................ 77hydrocortisone (topical) cream 2.5% ..................... 77hydrocortisone (topical) lotion 2.5% ...................... 77hydrocortisone (topical) oint 2.5% ......................... 77hydromorphone hcl .................................................. 4hydroxocobalamin acetate .................................... 66hydroxychloroquine sulfate ................................... 61hydroxyurea ............................................................ 19hydroxyzine hcl ....................................................... 71hydroxyzine hcl inj .................................................. 71hydroxyzine pamoate ............................................. 71HYSINGLA ER ........................................................... 4

I

ibandronate sodium tabs ....................................... 42IBRANCE ................................................................. 15ibu-200 ...................................................................... 3ibuprofen .................................................................. 3ibu tab 600mg .......................................................... 3ibu tab 800mg .......................................................... 3icatibant acetate ..................................................... 59ICLUSIG ................................................................... 18IDHIFA ..................................................................... 15ILEVRO .................................................................... 68imatinib mesylate ................................................... 18IMBRUVICA ............................................................. 18imipenem-cilastatin .................................................. 6imipramine hcl........................................................ 30imiquimod............................................................... 78IMOVAX RABIES (H.D.C.V.) .................................... 62incassia ................................................................... 44INCRELEX ................................................................ 49INCRUSE ELLIPTA .................................................. 70indapamide ............................................................. 25INFANRIX ................................................................ 62INFED ...................................................................... 59INFUVITE PEDIATRIC ............................................. 66INGREZZA ............................................................... 36

93

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºINJECTAFER ............................................................ 59INLYTA .................................................................... 18INREBIC .................................................................. 18INSULIN PEN NEEDLE ........................................... 39INSULIN SAFETY NEEDLES .................................... 39INSULIN SYRINGE .................................................. 39INTELENCE ............................................................... 8INTRALIPID 30% .................................................... 64INTRALIPID INJ 20% ............................................... 64INTRON-A INJ 10MU .............................................. 61INTRON-A INJ 18MU .............................................. 61INTRON-A INJ 25MU .............................................. 61INTRON-A INJ 50MU .............................................. 61introvale .................................................................. 44INVEGA SUST INJ 39 MG/0.25 ML ........................ 33INVEGA SUST INJ 78 MG/0.5 ML .......................... 33INVEGA SUST INJ 117 MG/0.75 ML ...................... 33INVEGA SUST INJ 156MG/ML ............................... 33INVEGA SUST INJ 234 MG/1.5 ML ........................ 33INVEGA TRINZA ..................................................... 33INVIRASE................................................................... 8IPOL INACTIVATED IPV .......................................... 63ipratropium-albuterol nebu ................................... 70ipratropium bromide ............................................. 70ipratropium bromide (nasal) ................................. 70irbesartan ............................................................... 22irbesartan-hydrochlorothiazide ............................. 21IRESSA ..................................................................... 18irinotecan hcl .......................................................... 20ISENTRESS ................................................................ 8ISENTRESS HD ......................................................... 8isibloom .................................................................. 44ISOLYTE P ............................................................... 65ISOLYTE S ............................................................... 65isoniazid .................................................................. 10isoniazid syp 50mg/5ml ......................................... 10isosorbide dinitrate ................................................ 26isosorbide mononitrate er...................................... 26isosorb mononitrate tab ........................................ 26isotretinoin .............................................................. 75isradipine ................................................................ 24itraconazole .............................................................. 7ivermectin ................................................................. 6IXIARO ..................................................................... 63

J

JADENU ................................................................... 42

JADENU SPRINKLE ................................................. 42JAKAFI ..................................................................... 18jantoven .................................................................. 59JANUMET ................................................................ 40JANUMET XR TAB 50-500MG ................................ 40JANUMET XR TAB 50-1000 .................................... 40JANUMET XR TAB 100-1000 ................................. 40JANUVIA .................................................................. 40JARDIANCE ............................................................. 40jasmiel ..................................................................... 44JENTADUETO .......................................................... 40JENTADUETO TAB XR 2.5-1000 MG ..................... 40JENTADUETO TAB XR 5-1000 MG ........................ 40jinteli ....................................................................... 47jolessa tab 0.15-0.03 mg ........................................ 44jolivette .................................................................... 44juleber ..................................................................... 44JULUCA ..................................................................... 9junel 1.5/30 ............................................................. 44junel 1/20 ................................................................ 44junel fe 1.5/30 ......................................................... 44junel fe 1/20 ............................................................ 44junel fe 24 ............................................................... 44JUXTAPID ................................................................ 23

K

KADCYLA ................................................................ 15kaitlib fe .................................................................. 44KALETRA TAB 100-25MG ........................................ 9KALETRA TAB 200-50MG ........................................ 9KALYDECO .............................................................. 73KANJINTI ................................................................. 15kao-tin ............................................................... 51, 55kariva ...................................................................... 44KCL 0.3%/D5W/NACL 0.9%................................... 65kcl 0.3%/d5w/nacl 0.45% ....................................... 65kcl0.15%/d5w/nacl0.2% ......................................... 65kcl 0.15%/d5w/nacl 0.9% ....................................... 65KCL 0.15%/D5W/NACL 0.225% ............................ 65kcl 0.075%/d5w/nacl 0.45% ................................... 65kcl/d5w inj 0.3% ...................................................... 65kcl/d5w/nacl inj 0.22%/0.45% ................................ 65kcl/d5w/nacl inj .15/.45% ....................................... 65kcl/nacl inj 0.3-0.9 .................................................. 65kcl/nacl inj 0.15%-0.9% .......................................... 65kelnor 1/35 .............................................................. 44kelnor 1/50 .............................................................. 44

94

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºketoconazole ............................................................. 7ketoconazole cream ............................................... 76ketoconazole shampoo .......................................... 76ketorolac tromethamine (ophth)............................ 68KEYTRUDA .............................................................. 15KINRIX ..................................................................... 63kionex sus 15gm/60ml ........................................... 42KISQALI ................................................................... 15KISQALI FEMARA 200 DOSE ................................. 15KISQALI FEMARA 400 DOSE ................................. 15KISQALI FEMARA 600 DOSE ................................. 15klor-con 8 ................................................................ 63klor-con 10 .............................................................. 63klor-con m10 ........................................................... 63klor-con m15 ........................................................... 63klor-con m20 ........................................................... 63klor-con pak 20meq ............................................... 63klor-con spr cap 8meq ........................................... 63klor-con spr cap 10meq ......................................... 63KONSYL .................................................................. 55KONSYL-D .............................................................. 55konsyl daily fiber ..................................................... 55KONSYL DAILY FIBER ............................................ 55KORLYM.................................................................. 49kurvelo .................................................................... 44KUVAN .................................................................... 47

L

labetalol hcl ............................................................ 23lactated ringer’s ...................................................... 65lactulose .................................................................. 55lactulose (encephalopathy) .................................... 55lamivudine ................................................................ 8lamivudine (hbv) ..................................................... 10lamivudine-zidovudine ............................................. 9lamotrigine .............................................................. 28lansoprazole ........................................................... 57larin 1.5/30 ............................................................. 44larin 1/20 ................................................................ 44larin fe 1.5/30 ......................................................... 44larin fe 1/20 ............................................................ 44larissia tab .............................................................. 44LASTACAFT ............................................................. 68latanoprost ............................................................. 69LATUDA .................................................................. 33laxative .................................................................... 55layolis fe .................................................................. 44

leena ........................................................................ 44leflunomide ............................................................. 61LENVIMA 4 MG DAILY DOSE ................................ 18LENVIMA 8 MG DAILY DOSE ................................ 18LENVIMA 10 MG DAILY DOSE .............................. 18LENVIMA 12MG DAILY DOSE ............................... 18LENVIMA 14 MG DAILY DOSE .............................. 18LENVIMA 18 MG DAILY DOSE .............................. 18LENVIMA 20 MG DAILY DOSE .............................. 18LENVIMA 24 MG DAILY DOSE .............................. 18lessina ..................................................................... 44letrozole .................................................................. 16leucovorin calcium ................................................. 20LEUKERAN .............................................................. 14leuprolide inj 1mg/0.2 ............................................ 16levalbuterol hcl ....................................................... 72levalbuterol hcl soln nebu conc 1.25 mg/0.5ml .... 72levalbuterol tartrate hfa ......................................... 72LEVEMIR ................................................................. 39LEVEMIR FLEXTOUCH ........................................... 39levetiracetam .......................................................... 28levetiracetam in sodium chloride .......................... 28levetiracetam oral soln 100 mg/ml ........................ 28levobunolol hcl ....................................................... 69levocarnitine (metabolic modifiers) ....................... 47levocetirizine dihydrochloride ................................ 71levofloxacin ............................................................. 12levofloxacin in d5w ................................................. 12levofloxacin inj 25mg/ml ........................................ 12levofloxacin oral soln 25 mg/ml ............................. 12levonest ................................................................... 44levonor/ethi tab ...................................................... 44levonorgestrel (emergency oc) ................................ 44levonorgestrel & eth estradiol ................................ 44levonorgestrel-ethinyl estradiol (91-day) ............... 44levora 0.15/30-28 ................................................... 44levo-t ....................................................................... 49levothyroxine sodium ............................................. 50levoxyl ..................................................................... 50LEXIVA ....................................................................... 8lice killing maximum stre ....................................... 79lice killing shampoo ................................................ 79lice treatment .......................................................... 79lidocaine ............................................................ 77, 78lidocaine (anorectal) ............................................... 78lidocaine hcl ............................................................ 77lidocaine hcl (local anesth.) ...................................... 5

95

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºlidocaine hcl (mouth-throat) .................................. 79lidocaine inj 0.5% ..................................................... 5lidocaine inj 1% ........................................................ 5lidocaine inj 1.5% preservative free (pf) ................... 5lidocaine oint 5% .................................................... 77lidocaine-prilocaine ................................................ 77linezolid inj ................................................................ 6linezolid in sodium chloride ..................................... 6linezolid susp ............................................................ 6linezolid tab 600mg .................................................. 6LINZESS .................................................................. 56liothyronine sodium ............................................... 50liquitears ................................................................. 69lisinopril .................................................................. 20lisinopril & hydrochlorothiazide ............................ 20lithium carbonate ................................................... 36lithium carbonate er ............................................... 36LITHIUM SOLN 8MEQ/5ML .................................. 36LOKELMA ................................................................ 42LONSURF ................................................................ 19loperamide hcl .................................................. 51, 56lopinavir-ritonavir .................................................... 9loratadine ............................................................... 71loratadine childrens ............................................... 71lorazepam ............................................................... 27lorazepam intensol ................................................. 27LORBRENA ............................................................. 18lorcet hd tab 10-325mg ............................................ 4lorcet plus tab 7.5-325 ............................................. 4lorcet tab 5-325mg ................................................... 4loryna ...................................................................... 44losartan-hydrochlorothiazide ................................ 21losartan potassium................................................. 22LOTEMAX ................................................................ 68loteprednol etabonate ............................................ 68lovastatin ................................................................ 22low-ogestrel ............................................................. 44loxapine succinate .................................................. 33LUMIGAN ............................................................... 69LUMIZYME .............................................................. 47LUPRON DEPOT (1-MONTH) ................................ 16LUPRON DEPOT INJ 11.25MG (3-MONTH) ......... 16LUPRON DEPOT-PED (1-MONTH ......................... 49LUPRON DEPOT-PED (3-MONTH ......................... 49LUPRON DEP-PED INJ 7.5MG ............................... 49LUPRON DEP-PED INJ 11.25MG (3-MONTH) ...... 49lutera ....................................................................... 45

LYNPARZA .............................................................. 15LYRICA CR ............................................................... 36LYSODREN.............................................................. 16lyza .......................................................................... 45

M

mag-al plus ............................................................. 51mag-al plus xs ......................................................... 51MAGNEBIND 300 ................................................... 66magnesium oxide ................................................... 51magnesium oxide (mg supplement) ....................... 66magnesium sulfate ................................................. 64MAGNESIUM SULFATE .......................................... 64MAGNESIUM SULFATE IN D5W ........................... 64magnesium sulfate in dextrose .............................. 64magnesium sulfate inj 50% .................................... 64malathion ............................................................... 79mapap ....................................................................... 2maprotiline hcl ....................................................... 30marlissa .................................................................. 45MARPLAN TAB 10MG ............................................ 30MATULANE ............................................................. 19MAVYRET ................................................................ 11meclizine hcl ........................................................... 52medroxyprogesterone acetate (contraceptive) ...... 45medroxyprogesterone acetate tab ......................... 49mefloquine hcl .......................................................... 8megestrol ac sus 40mg/ml ..................................... 16megestrol ac tab 20mg ........................................... 16megestrol ac tab 40mg ........................................... 16megestrol sus 625mg/5ml ...................................... 16MEKINIST ................................................................ 18MEKTOVI ................................................................ 18melodetta 24 fe ....................................................... 45meloxicam ................................................................ 3memantine hcl cp24 ............................................... 29memantine soln ...................................................... 29memantine tabs ...................................................... 29memantine titration pak ........................................ 29MENACTRA ............................................................. 63MENVEO ................................................................. 63mercaptopurine ...................................................... 14meropenem .............................................................. 6mesalamine ............................................................ 53mesalamine w/ cleanser ......................................... 53MESNEX .................................................................. 20metadate er tab 20mg ............................................ 35

96

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºmetformin er ........................................................... 41metformin hcl ......................................................... 41methadone hcl .......................................................... 4methadone hcl 5mg .................................................. 4methadone hcl 10mg................................................ 4methadone hcl intensol ............................................ 4methazolamide ....................................................... 25methenamine hippurate .......................................... 6methimazole ........................................................... 50methocarbamol ...................................................... 37methotrexate sodium inj soln ................................ 14methotrexate sodium inj solr ................................. 14methotrexate sodium tabs ..................................... 61methylphenidate hcl ............................................... 35methylphenidate hcl oral soln ............................... 35methylphenidate hcl tbcr 10 mg ............................ 35methylphenidate hcl tbcr 20mg ............................. 35methylprednisolone acetate ................................... 48methylpred pak 4mg .............................................. 48methylpred tab 4mg ............................................... 48methylpred tab 8mg ............................................... 48methylpred tab 16mg ............................................. 48methylpred tab 32mg ............................................. 48methylpr ss inj ........................................................ 48metoclopramide hcl ............................................... 52metoclopramide hcl inj .......................................... 52metolazone ............................................................. 25metoprolol & hctz tab 50-25mg ............................. 23metoprolol & hctz tab 100-25mg ........................... 23metoprolol & hctz tab 100-50mg ........................... 23metoprolol succinate .............................................. 23metoprolol tartrate ........................................... 23, 24metronidazole ........................................................... 6metronidazole gel 0.75% ........................................ 78metronidazole in nacl ............................................... 6metronidazole (topical) .......................................... 78metronidazole vaginal ............................................ 58mi-acid .................................................................... 51mi-acid maximum strength .................................... 51mibelas 24 fe .......................................................... 45miconazole 3 ........................................................... 58miconazole 3 combination ..................................... 58miconazole 3 combo pack ..................................... 58miconazole 7 ........................................................... 58miconazole nitrate (topical) ................................... 76miconazole nitrate vaginal ..................................... 58microgestin 1.5/30 .................................................. 45

microgestin 1/20 ..................................................... 45microgestin fe 1.5/30 .............................................. 45microgestin fe 1/20 ................................................. 45midodrine hcl .......................................................... 25miglustat ................................................................. 47migraine formula ...................................................... 2mili .......................................................................... 45milk of magnesia .................................................... 55minitran .................................................................. 26minocycline hcl ....................................................... 14minoxidil ................................................................. 25mintox ..................................................................... 51mintox maximum strength ..................................... 51mintox plus ............................................................. 51mirtazapine ............................................................. 30misoprostol ............................................................. 56MITIGARE ................................................................. 1M-M-R II .................................................................. 63M-NATAL PLUS ...................................................... 66moexipril hcl ........................................................... 20molindone hcl ......................................................... 33mometasone furoate .............................................. 77mondoxyne nl cap 100mg ...................................... 14mono-linyah tab 0.25-35 ........................................ 45montelukast sodium ............................................... 73morphine ext-rel tab ................................................. 4morphine sulfate ...................................................... 5MORPHINE SULFATE ............................................... 5morphine sulfate oral soln 10mg/5ml ..................... 5morphine sulfate oral soln 20mg/5ml ..................... 5morphine sulfate oral soln 100mg/5ml ................... 5morphine sul inj 1mg/ml .......................................... 5motion-time ............................................................ 52MOVANTIK ............................................................. 57MOXEZA ................................................................. 67moxifloxacin hcl ...................................................... 12moxifloxacin hcl (ophth) ......................................... 67mucinex chest congestion ...................................... 72MULTAQ ................................................................. 22mupirocin ................................................................ 75MURO 128 .............................................................. 69MVASI ..................................................................... 15MYCAMINE ............................................................... 7my choice ................................................................ 45mycophenolate mofetil ........................................... 62mycophenolate sodium tbec .................................. 62myorisan ................................................................. 75

97

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºMYRBETRIQ ............................................................ 57my way .................................................................... 45

N

nabumetone ............................................................. 3nadolol .................................................................... 24nafcillin sodium ...................................................... 13NAFCILLIN SODIUM FOR INJ 10GM ..................... 13NAGLAZYME........................................................... 47nalbuphine hcl .......................................................... 4naloxone inj 0.4mg/ml ........................................... 38naloxone inj 1mg/ml .............................................. 38naltrexone hcl ......................................................... 38NAMZARIC .............................................................. 29naproxen ................................................................... 3naproxen dr .............................................................. 3naproxen sodium ..................................................... 3naratriptan hcl........................................................ 36NARCAN ................................................................. 38nasal decongestant................................................. 72NATACYN ................................................................ 67nateglinide .............................................................. 41NATPARA ................................................................ 49natural balance tears ............................................. 69natural fiber therapy .............................................. 55natures tears ........................................................... 69NAYZILAM .............................................................. 28necon 0.5/35-28 ...................................................... 45nefazodone hcl ....................................................... 30neomycin-bacitracin zn-polymyxin ........................ 67neomycin-polymy-dexameth .................................. 67neomycin-polymyxin-gramicidin ............................ 67neomycin-polymyxin-hc (ophth)............................. 67neomycin-polymyxin-hc (otic) ................................ 80neomycin sulfate ...................................................... 5NEPHRAMINE......................................................... 64NERLYNX ................................................................ 18NEUPRO ................................................................. 31nevirapine susp 50 mg/5ml ...................................... 8nevirapine tab 100mg er .......................................... 8nevirapine tab 200mg .............................................. 8nevirapine tab 400mg er .......................................... 8new day ................................................................... 45NEXAVAR ................................................................ 18niacin (antihyperlipidemic) .................................... 23niacin er (antihyperlipidemic) ................................ 23niacor ...................................................................... 23

nicardipine hcl ........................................................ 24nicorelief ................................................................. 38nicotine ................................................................... 38nicotine polacrilex .................................................. 38nicotine transdermal syst ....................................... 38NICOTINE TRANSDERMAL SYST .......................... 38NICOTROL INHALER .............................................. 38NICOTROL NS ........................................................ 38nifedipine ................................................................ 24nifedipine er ............................................................ 24nikki ......................................................................... 45nilutamide ............................................................... 16nimodipine .............................................................. 24NINLARO ................................................................ 15nitisinone ................................................................ 47NITRO-BID .............................................................. 26NITRO-DUR DIS 0.3MG/HR ................................... 26NITRO-DUR DIS 0.8MG/HR ................................... 26nitrofurantoin macrocrystal ..................................... 6nitrofurantoin monohyd macro ............................... 6nitroglycerin ............................................................ 26nitroglycerin td patch ............................................. 26NITYR ...................................................................... 47nizatidine ................................................................ 53non-aspirin childrens ............................................... 2nora-be tab ............................................................. 45nore/eth/fer chw 0.4mg-35 .................................... 45noreth/ethin chw fe ................................................ 45norethin acet & estrad-fe ....................................... 45norethindrone acetate ............................................ 49norethindrone acetate-ethinyl estradiol ................ 47norethindrone acet & eth estra .............................. 45norethindrone (contraceptive) ............................... 45norgest/ethi tab 0.25/35 ......................................... 45norgestimate-ethinyl estradiol (triphasic) 0.18-

25/0.215-25/0.25-25 mg-mcg ............................ 45norgestimate-ethinyl estradiol (triphasic) 0.18-

35/0.215-35/0.25-35 mg-mcg ............................ 45NORMOSOL-M IN D5W ........................................ 65NORMOSOL-R ........................................................ 66NORMOSOL-R IN D5W ......................................... 66NORPACE CR .......................................................... 22NORTHERA ............................................................. 26nortrel 0.5/35 (28) .................................................. 45nortrel 1/35 ............................................................. 45nortrel 7/7/7 ........................................................... 45nortriptyline hcl ...................................................... 30

98

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºNORVIR PACK ........................................................... 8NORVIR SOLN .......................................................... 8NOVOLIN 70/30 ..................................................... 39NOVOLIN 70/30 FLEXPEN..................................... 39NOVOLIN N ............................................................ 39NOVOLIN N FLEXPEN ............................................ 39NOVOLIN R ............................................................ 39NOVOLIN R FLEXPEN ............................................ 39NOVOLOG .............................................................. 39NOVOLOG 70/30 FLEXPEN ................................... 39NOVOLOG FLEXPEN .............................................. 39NOVOLOG MIX 70/30 ........................................... 39NOVOLOG PENFILL ............................................... 39NOXAFIL ................................................................... 7NUBEQA ................................................................. 16NUCALA .................................................................. 73NUCYNTA ER ............................................................ 5NUEDEXTA ............................................................. 36NULOJIX .................................................................. 62NULYTELY/FLAVOR PACKS ................................... 55NUPLAZID CAPS .................................................... 33NUPLAZID TABS 10MG ......................................... 33NUTRILIPID INJ 20% .............................................. 64nyamyc .................................................................... 76NYMALIZE ............................................................... 24nystatin ..................................................................... 7nystatin (mouth-throat) .......................................... 79nystatin pow 100000 .............................................. 76nystatin (topical) ..................................................... 76nystop...................................................................... 76

O

ocella tab 3-0.03mg ................................................ 45OCTAGAM .............................................................. 61octreotide acetate ................................................... 49ODEFSEY ................................................................... 9ODOMZO ............................................................... 15OFEV ....................................................................... 73ofloxacin (ophth) .................................................... 67ofloxacin (otic) ........................................................ 80OGIVRI .................................................................... 15olanzapine .............................................................. 33olmesartan medoxomil .......................................... 22olmesartan medoxomil-amlodipine-

hydrochlorothiazide ........................................... 21olmesartan medoxomil-hydrochlorothiazide ........ 21olopatadine hcl 0.2% .............................................. 68

omeprazole cap 10mg ............................................ 57omeprazole cap 20mg ............................................ 57omeprazole cap 40mg ............................................ 57ondansetron hcl ...................................................... 52ondansetron hcl inj................................................. 52ondansetron hcl oral soln ...................................... 52ondansetron odt ..................................................... 52ONTRUZANT .......................................................... 15opcicon one-step..................................................... 45OPSUMIT ................................................................ 26option 2 ................................................................... 45ORFADIN ................................................................ 47ORKAMBI ................................................................ 73orsythia ................................................................... 45oseltamivir phosphate ............................................ 11OSPHENA ............................................................... 49oxacillin sodium ...................................................... 13oxaliplatin inj 50mg ................................................ 20oxaliplatin inj 50mg/10ml ...................................... 20oxaliplatin inj 100mg .............................................. 20oxaliplatin inj 100mg/20ml .................................... 20oxandrolone ........................................................... 38oxcarbazepine ........................................................ 28oxybutynin chloride ................................................ 57oxycodone hcl ........................................................... 5oxycodone w/ acetaminophen 2.5-325mg .............. 5oxycodone w/ acetaminophen 5-325mg ................. 5oxycodone w/ acetaminophen 7.5-325mg .............. 5oxycodone w/ acetaminophen 10-325mg ............... 5OXYCONTIN ............................................................. 5OZEMPIC INJ 0.25 OR 0.5MG/DOSE .................... 39OZEMPIC INJ 1MG/DOSE ...................................... 39

P

pacerone ................................................................. 22paclitaxel ................................................................. 15pain & fever ............................................................... 2pain & fever childrens............................................... 2pain & fever extra streng .......................................... 2pain & fever infants .................................................. 2pain relief extra strengt ............................................ 2pain reliever plus ...................................................... 2paliperidone ............................................................ 33pamidronate disodium .......................................... 42PAMIDRONATE DISODIUM .................................. 42pamidronate inj 30mg ............................................ 42pamidronate inj 90mg ............................................ 42

99

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºPANRETIN ............................................................... 78pantoprazole sodium ............................................. 57pantoprazole sodium tbec ..................................... 57PANZYGA ................................................................ 61paricalcitol .............................................................. 66paroex sol 0.12% .................................................... 79paromomycin sulfate ............................................... 5paroxetine hcl tabs ................................................. 31PASER D/R .............................................................. 10PAXIL ....................................................................... 31PAZEO ..................................................................... 68PEDIA-LAX .............................................................. 55PEDIARIX ................................................................ 63pediatric enema ...................................................... 55PEDVAX HIB ........................................................... 63peg 3350-kcl-sod bicarb-sod chloride-sod sulfate. 55peg 3350-potassium chloride-sod bicarbonate-

sod chloride ........................................................ 55PEGANONE ............................................................ 28PEGASYS ................................................................. 11PEGASYS PROCLICK .............................................. 11PEMAZYRE .............................................................. 18penicillamine .......................................................... 42PENICILLIN G POT IN DEXTROSE 2MU ................ 13PENICILLIN G POT IN DEXTROSE 3MU ................ 13PENICILLIN G PROCAINE ...................................... 13penicillin g sodium .................................................. 13penicillin v potassium ............................................. 13penicilln gk inj 5mu ................................................ 13penicilln gk inj 20mu .............................................. 13PENTACEL .............................................................. 63pentamidine isethionate inh .................................... 6pentamidine isethionate inj ..................................... 6pentoxifylline .......................................................... 60peptic relief ............................................................. 51perindopril erbumine ............................................. 20periogard ................................................................ 79permethrin cre 5% .................................................. 79perphenazine .......................................................... 33PERSERIS ................................................................ 33pfizerpen-g inj 5mu ................................................ 13pfizerpen-g inj 20mu .............................................. 13pharbedryl .............................................................. 71pharbetol .................................................................. 2pharbetol extra strength .......................................... 2phenelzine sulfate ................................................... 31phenobarbital ......................................................... 28

phenobarbital sodium ............................................ 28PHENYTEK .............................................................. 28phenytoin ................................................................ 28phenytoin sodium extended ................................... 28phenytoin sodium inj 50mg/ml .............................. 28philith ...................................................................... 45PHOSPHOLINE IODIDE ......................................... 69phytonadione .......................................................... 66PICATO ................................................................... 78PIFELTRO .................................................................. 8pilocarpine hcl ........................................................ 69pilocarpine hcl (oral) .............................................. 79pimozide ................................................................. 33pimtrea ................................................................... 46pindolol ................................................................... 24pioglitazone hcl ....................................................... 41piper/tazoba inj 2-0.25gm ...................................... 13piper/tazoba inj 3-0.375gm.................................... 13piper/tazoba inj 4-0.5gm ........................................ 13piper/tazoba inj 12-1.5gm ...................................... 13piper/tazoba inj 36-4.5gm ...................................... 13PIQRAY 200MG DAILY DOSE ................................ 18PIQRAY 250MG DAILY DOSE ................................ 18PIQRAY 300MG DAILY DOSE ................................ 19pirmella 1/35 .......................................................... 46piroxicam .................................................................. 3PLASMA-LYTE-148 ................................................. 66PLASMA-LYTE A ..................................................... 66plenamine ............................................................... 64PLENVU .................................................................. 55PNV FOLIC ACID + IRON MUL .............................. 66podofilox ................................................................. 78polyethylene glycol 3350 ........................................ 55polymyxin b-trimethoprim ..................................... 67POMALYST CAP 1MG ............................................ 17POMALYST CAP 2MG ............................................ 17POMALYST CAP 3MG ............................................ 17POMALYST CAP 4MG ............................................ 17portia-28 ................................................................. 46posaconazole ............................................................ 7potassium chloride ........................................... 64, 66POTASSIUM CHLORIDE ........................................ 66potassium chloride in nacl ..................................... 66potassium chloride microencapsulated crystals

er ......................................................................... 64potassium citrate (alkalinizer) er tabs ................... 57pot chloride inj 2meq/ml ........................................ 66

100

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºpovidone-iodine ...................................................... 78PRADAXA ................................................................ 59PRALUENT .............................................................. 23pramipexole tab 0.5mg .......................................... 31pramipexole tab 0.25mg ........................................ 31pramipexole tab 0.75mg ........................................ 31pramipexole tab 0.125mg ...................................... 31pramipexole tab 1.5mg .......................................... 31pramipexole tab 1mg ............................................. 31pramoxine hcl (rectal) ............................................ 78prasugrel hcl ........................................................... 60pravastatin sodium ................................................ 22praziquantel ............................................................. 7prazosin hcl ............................................................ 21prednisolone acetate (ophth) ................................. 68prednisolone sodium phosphate ........................... 48PREDNISOLONE SODIUM PHOSPHATE

(OPHTH) ............................................................. 68prednisolone sol 15mg/5ml ................................... 48prednisolone sol 25mg/5ml ................................... 48PREDNISONE CON 5MG/ML ................................ 48prednisone pak 5mg ............................................... 48prednisone pak 10mg ............................................. 48prednisone sol 5mg/5ml......................................... 48prednisone tab 1mg ............................................... 48prednisone tab 2.5mg ............................................ 48prednisone tab 5mg ............................................... 48prednisone tab 10mg ............................................. 48prednisone tab 20mg ............................................. 48prednisone tab 50mg ............................................. 48pred sod pho sol 5mg/5ml ..................................... 48pregabalin ......................................................... 28, 29PREMASOL SOL 10% ............................................. 65PRENATAL .............................................................. 66PRENATAL PLUS .................................................... 66PRENATAL PLUS LOW IRON ................................. 67prevalite .................................................................. 23previfem .................................................................. 46PREZCOBIX ............................................................. 10PREZISTA .............................................................. 8, 9PRIFTIN ................................................................... 10primaquine phosphate ............................................. 8PRIMAQUINE PHOSPHATE ..................................... 8primidone ............................................................... 29PRIVIGEN ................................................................ 61probenecid ................................................................ 1PROCALAMINE ....................................................... 65

prochlorperazine inj ............................................... 52prochlorperazine maleate ...................................... 52prochlorperazine supp ........................................... 52PROCRIT ................................................................. 59procto-med hc ........................................................ 78procto-pak .............................................................. 78proctosol hc cre 2.5% ............................................. 78proctozone-hc ......................................................... 78PROGLYCEM SUS 50MG/ML ................................ 48PROGRAF ................................................................ 62PROLASTIN-C ......................................................... 73PROLENSA .............................................................. 68PROLIA .................................................................... 49PROMACTA ............................................................ 60promethazine hcl .................................................... 52promethazine hcl inj ............................................... 52promethazine-phenylephrine-codeine ................... 72promethazine w/codeine ........................................ 72propafenone hcl ..................................................... 22propafenone hcl 12hr ............................................. 22proparacaine hcl .................................................... 69propranolol cap er ................................................. 24propranolol hcl ....................................................... 24propranolol & hydrochlorothiazide ....................... 23propranolol oral sol ............................................... 24propylthiouracil ...................................................... 50PROQUAD .............................................................. 63PROSHIELD PLUS SKIN PROTE ............................ 78PROSOL .................................................................. 65protriptyline hcl ...................................................... 31pseudoephedrine hcl .............................................. 72PULMICORT FLEXHALER ....................................... 74PULMOZYME.......................................................... 73puralube ................................................................. 69PURIXAN ................................................................. 14pyrazinamide .......................................................... 10pyridostigmine tab 60mg ....................................... 36pyridoxine hcl ......................................................... 67

Q

qc 3 day vaginal cream .......................................... 58qc acid controller .................................................... 53qc all day allergy ..................................................... 71qc antacid ............................................................... 51qc antacid/anti-gas ................................................. 51qc anti-diarrheal ..................................................... 51qc aspirin .................................................................. 2

101

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºqc aspirin low dose ................................................... 2qc chewable aspirin low d ........................................ 2qc childrens allergy ................................................. 71qc enema ................................................................ 55qc enteric aspirin ...................................................... 2qc gentle laxative .................................................... 55qc headache relief .................................................... 2qc ibuprofen ib ......................................................... 3qc loratadine allergy rel ......................................... 71qc miconazole 7 ...................................................... 58qc milk of magnesia ............................................... 55qc naproxen sodium ................................................. 3qc natura-lax .......................................................... 55qc natural vegetable laxa ....................................... 55qc non-aspirin childrens ........................................... 2qc non-aspirin extra stre .......................................... 2qc pain relief ............................................................. 2qc pain relief childrens ............................................. 2qc pain relief extra stre ............................................ 2qc pain relief infants ................................................. 2qc povidone iodine ................................................. 78qc stool softener ..................................................... 55qc stool softener plus la ......................................... 55qc stool softener plus st .......................................... 55qc tussin dm cough & ches ..................................... 72qc tussin mucus + chest c ....................................... 72QUADRACEL ........................................................... 63quetiapine fumarate .............................................. 33quinapril hcl ............................................................ 20quinapril-hydrochlorothiazide ............................... 20quinidine sulfate ..................................................... 22quinine sulfate .......................................................... 8

R

RABAVERT .............................................................. 63rabeprazole sodium ............................................... 57raloxifene hcl .......................................................... 49ramipril ................................................................... 21ranitidine hcl ........................................................... 53ranolazine ............................................................... 26rasagiline mesylate ................................................. 32RAYALDEE .............................................................. 67reclipsen .................................................................. 46RECOMBIVAX HB ................................................... 63RECTIV .................................................................... 79reeses pinworm medicine ......................................... 7refresh lacri-lube .................................................... 69

refresh p.m. ............................................................. 69REGRANEX .............................................................. 79reguloid ................................................................... 55RELENZA DISKHALER ............................................ 11RELISTOR ................................................................ 57remedy antifungal .................................................. 76REMEDY NUTRASHIELD ........................................ 79REMICADE .............................................................. 61renal caps ............................................................... 67RENFLEXIS .............................................................. 61repaglinide .............................................................. 41RESTASIS ................................................................ 69RESTASIS MULTIDOSE .......................................... 69REVLIMID ................................................................ 17REXULTI .................................................................. 33REYATAZ ................................................................... 9RHOPRESSA ........................................................... 69ribavirin 200mg ...................................................... 11rifabutin .................................................................. 10rifampin .................................................................. 10RIFATER .................................................................. 10riluzole .................................................................... 36rimantadine hydrochloride .................................... 11RINVOQ .................................................................. 61risedronate sodium ................................................ 42RISPERDAL INJ 12.5MG ......................................... 33RISPERDAL INJ 25MG ............................................ 33RISPERDAL INJ 37.5MG ......................................... 33RISPERDAL INJ 50MG ............................................ 33risperidone .............................................................. 34ritonavir .................................................................... 9RITUXAN ................................................................. 16RITUXAN HYCELA .................................................. 16rivastigmine tartrate ......................................... 29, 30rivastigmine td patch 24hr 4.6 mg/24hr................ 30rivastigmine td patch 24hr 9.5 mg/24hr................ 30rivastigmine td patch 24hr 13.3 mg/24hr ............. 30rivelsa ...................................................................... 46rizatriptan benzoate ............................................... 36rizatriptan benzoate odt ........................................ 36robafen ................................................................... 72robafen dm ............................................................. 72robafen dm cough .................................................. 72robafen dm cough/chest co ................................... 73robafen dm cough clear ......................................... 72ropinirole tab 0.5mg ............................................... 32ropinirole tab 0.25mg............................................. 32

102

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºropinirole tab 1mg .................................................. 32ropinirole tab 2mg .................................................. 32ropinirole tab 3mg .................................................. 32ropinirole tab 4mg .................................................. 32ropinirole tab 5mg .................................................. 32rosadan ................................................................... 79rosuvastatin calcium .............................................. 22ROTARIX ................................................................. 63ROTATEQ ................................................................ 63roweepra ................................................................. 29roweepra xr ............................................................ 29ROZLYTREK ............................................................ 19RUBRACA ................................................................ 16rulox ........................................................................ 51RUXIENCE ............................................................... 16RYBELSUS ............................................................... 41RYDAPT ................................................................... 19

S

saline ....................................................................... 73SANDIMMUNE ....................................................... 62SANTYL ................................................................... 79SAPHRIS .................................................................. 34scopolamine............................................................ 52SECUADO ............................................................... 34selegiline hcl ............................................................ 32selenium sulfide ...................................................... 76SELZENTRY ............................................................... 9senna-lax ................................................................. 56senna laxative ......................................................... 56SENNA LEAVES ....................................................... 56senna-s .................................................................... 56senna-tabs .............................................................. 56senna-time .............................................................. 56senna-time s ............................................................ 56sennosides .............................................................. 56sennosides-docusate sodium ................................. 56senokot extra strength ............................................ 56SEREVENT DISKUS ................................................. 72sertraline hcl ........................................................... 31setlakin tab ............................................................. 46sevelamer carbonate .............................................. 49sharobel .................................................................. 46SHINGRIX ................................................................ 63SIGNIFOR ................................................................ 49silace ....................................................................... 56siladryl allergy ......................................................... 71

sildenafil citrate tab 20 mg (pulmonary hypertension) ...................................................... 26

siltussin-dm ............................................................. 73siltussin dm das ...................................................... 73siltussin sa ............................................................... 73silver sulfadiazine ................................................... 75SIMBRINZA ............................................................. 69simvastatin .............................................................. 22sirolimus ................................................................. 62SIRTURO ................................................................. 10SIVEXTRO .................................................................. 7SKYRIZI ................................................................... 61sm all day allergy childr ......................................... 71sm antibiotic ........................................................... 75sm anti-diarrheal .................................................... 51sm antifungal clotrimazol ...................................... 76sm clearlax .............................................................. 56sm hydrocortisone .................................................. 77sm hydrocortisone maximum ................................ 77sm loratadine.......................................................... 71sm milk of magnesia .............................................. 56sm motion sickness................................................. 52sm stool softener .................................................... 56sm tussin mucus + chest c ...................................... 73SODIUM BICARBONATE ....................................... 51sodium bicarbonate (antacid) ................................ 51sodium chloride ................................................ 64, 66sodium chloride 0.45% ........................................... 66sodium chloride hypertonic ................................... 69sodium chloride inj 0.9% ........................................ 66sodium chlor sol 0.9% irr ....................................... 79sodium citrate & citric acid .................................... 57sodium ferric gluconate complex in sucrose ......... 59sodium fluoride chew\; tab\; 1.1 (0.5 f) mg/ml

soln ...................................................................... 64sodium phenylbutyrate .......................................... 47sodium phosphates ................................................ 56sodium polystyrene sulfonate powder ................... 42sodium polystyrene sulfonate susp ....................... 42SOLIQUA 100/33 ................................................... 39SOLTAMOX ............................................................. 17soluble fiber ............................................................ 56SOLU-CORTEF ........................................................ 48SOMATULINE DEPOT ............................................ 49SOMAVERT ............................................................. 49SORBITOL ............................................................... 56sorine ...................................................................... 22

103

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºsotalol hcl ................................................................ 22sotalol hcl (afib/afl) ................................................. 22spironolactone ........................................................ 21spironolactone & hydrochlorothiazide .................. 25sprintec 28 .............................................................. 46SPRITAM ................................................................. 29SPRYCEL ................................................................. 19sps susp 15gm/60ml ............................................... 42sronyx ...................................................................... 46ssd ........................................................................... 75stavudine................................................................... 9STELARA ................................................................. 61STIMATE ................................................................. 50stimulant laxative ................................................... 56STIVARGA ............................................................... 19stomach relief ......................................................... 51stomach relief maximum st ................................... 51stool softener .......................................................... 56stool softener extra stre ......................................... 56stool softener plus laxat ......................................... 56streptomycin sulfate ................................................. 5STRIBILD ................................................................. 10subvenite tab .......................................................... 29sucralfate ................................................................ 57sudogest .................................................................. 73sulfacetamide sodium (acne) ................................. 75sulfacetamide sodium (ophth) ............................... 68sulfacetamide sod-prednisolone ............................ 67SULFADIAZINE ......................................................... 5sulfamethoxazole-trimethop ds ............................... 7sulfamethoxazole-trimethoprim inj ......................... 7sulfamethoxazole-trimethoprim susp ..................... 7sulfamethoxazole-trimethoprim tab 400-80mg ...... 7SULFAMYLON ........................................................ 75sulfasalazine ........................................................... 53sulfasalazine ec....................................................... 53sulindac ..................................................................... 3sumatriptan ............................................................ 36sumatriptan inj 4mg/0.5ml .................................... 36sumatriptan inj 6mg/0.5ml .................................... 36sumatriptan succinate ............................................ 36SUPREP BOWEL PREP KIT ..................................... 56SUTENT ................................................................... 19SWIM EAR ............................................................... 80syeda ....................................................................... 46SYLATRON .............................................................. 19SYMBICORT ............................................................ 74

SYMDEKO ............................................................... 74SYMFI ...................................................................... 10SYMFI LO ................................................................ 10SYMJEPI ................................................................... 74SYMPAZAN ............................................................. 29SYMTUZA ................................................................ 10SYNAREL ................................................................. 47SYNERCID ................................................................. 7SYNJARDY TAB 5-500MG ...................................... 41SYNJARDY TAB 5-1000MG .................................... 41SYNJARDY TAB 12.5-500MG ................................. 41SYNJARDY TAB 12.5-1000MG ............................... 41SYNJARDY XR TAB 5-1000MG ............................... 41SYNJARDY XR TAB 10-1000MG ............................ 41SYNJARDY XR TAB 12.5-1000MG ......................... 41SYNJARDY XR TAB 25-1000MG ............................ 41SYNRIBO ................................................................. 19SYNTHROID ............................................................ 50systane nighttime .................................................... 70

T

TABLOID ................................................................. 14tacrolimus ............................................................... 62tacrolimus (topical) ................................................. 79TAFINLAR ................................................................ 19TAGRISSO ............................................................... 19take action .............................................................. 46TALZENNA .............................................................. 16tamoxifen citrate .................................................... 17tamsulosin hcl ......................................................... 57TARGRETIN ............................................................. 79tarina 24 fe ............................................................. 46tarina fe 1/20 .......................................................... 46TASIGNA ................................................................. 19TAXOTERE .............................................................. 15tazarotene ............................................................... 76tazicef ...................................................................... 11TAZORAC ................................................................ 76taztia xt ................................................................... 24TAZVERIK ................................................................ 19TDVAX ..................................................................... 63TECENTRIQ ............................................................. 16TEFLARO ................................................................. 12telmisartan .............................................................. 22telmisartan-amlodipine .......................................... 21telmisartan-hydrochlorothiazide ........................... 21temazepam ............................................................. 35

104

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºTEMIXYS .................................................................. 10TENIVAC ................................................................. 63tenofovir disoproxil fumarate .................................. 9terazosin hcl ............................................................ 21terbinafine hcl ........................................................... 7terbinafine hcl (topical) .......................................... 76terbutaline sulfate .................................................. 72terconazole vaginal ................................................ 58testosterone ............................................................ 38testosterone cypionate ........................................... 38testosterone enanthate .......................................... 38tetrabenazine .......................................................... 36tetracycline hcl ........................................................ 14TEXACORT SOLN 2.5% .......................................... 77THALOMID ............................................................. 17THEO-24 ................................................................. 74theophylline ............................................................ 74theophylline tab er 12hr 300 mg ........................... 74theophylline tab er 12hr 450 mg ........................... 74theophylline tab sr 24hr ......................................... 74thiamine hcl ............................................................ 67thioridazine hcl ....................................................... 34thiothixene .............................................................. 34tiadylt er .................................................................. 24tiagabine hcl ........................................................... 29TIBSOVO ................................................................. 16tigecycline .................................................................. 7tilia fe ...................................................................... 46timolol maleate ....................................................... 24timolol maleate gel ................................................. 69timolol maleate (ophth) soln .................................. 69timolol maleate ophth soln 0.5% (once-daily) ....... 69tioconazole 1........................................................... 58TIVICAY ..................................................................... 9tizanidine hcl........................................................... 37TOBRADEX ............................................................. 67TOBRADEX ST ........................................................ 67tobramycin ................................................................ 5tobramycin-dexamethasone .................................. 67tobramycin inj 1.2gm ............................................... 6tobramycin inj 1.2 gm/30ml ..................................... 5tobramycin inj 10mg/ml ........................................... 6tobramycin inj 80mg/2ml ......................................... 6tobramycin (ophth) ................................................. 68tobramycin sulfate.................................................... 6tolterodine tartrate cap er ..................................... 58tolterodine tartrate tabs ......................................... 58

topiramate .............................................................. 29toposar .................................................................... 20toremifene citrate ................................................... 17torsemide tabs ........................................................ 25TOVIAZ .................................................................... 58TPN ELECTROLYTES .............................................. 64TRADJENTA ............................................................. 41tramadol-acetaminophen ........................................ 4tramadol hcl tab 50 mg ............................................ 4trandolapril ............................................................. 21tranexamic acid ...................................................... 60tranylcypromine sulfate ......................................... 31TRAVASOL .............................................................. 65travel sickness ......................................................... 52travoprost ............................................................... 69TRAZIMERA ............................................................ 16trazodone hcl .......................................................... 31TRECATOR .............................................................. 10TRELEGY ELLIPTA .................................................. 70TRELSTAR DEP INJ 3.75MG ................................... 17TRELSTAR LA INJ 11.25MG ................................... 17treprostinil .............................................................. 26TRESIBA FLEXTOUCH ............................................ 39TRESIBA INJ ............................................................ 39tretinoin .................................................................. 75tretinoin (chemotherapy) ....................................... 19triamcinolone acetonide (mouth) .......................... 79triamcinolone acetonide (topical) .......................... 77triamterene & hydrochlorothiazide cap 37.5-

25 mg .................................................................. 25triamterene & hydrochlorothiazide tabs ............... 25tri-buffered aspirin ................................................... 2TRICARE .................................................................. 67trientine hcl ............................................................. 42tri-estarylla .............................................................. 46trifluoperazine hcl .................................................. 34trifluridine ............................................................... 68trihexyphenidyl hcl ................................................. 32TRIJARDY XR TAB ER 24HR 5-2.5-1000MG .......... 41TRIJARDY XR TAB ER 24HR 10-5-1000 MG .......... 41TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG ..... 41TRIJARDY XR TAB ER 24HR 25-5-1000 MG .......... 41TRIKAFTA ................................................................ 74tri-legest fe .............................................................. 46tri-linyah .................................................................. 46tri-lo-estarylla ......................................................... 46tri-lo marzia ............................................................ 46

105

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºtri-lo-sprintec .......................................................... 46trilyte ....................................................................... 56trimethoprim ............................................................ 7tri-mili ...................................................................... 46trimipramine maleate ............................................ 31TRINTELLIX ............................................................. 31triple antibiotic ....................................................... 75triple antibiotic first a ............................................. 75triple antibiotic plus ............................................... 75tri-previfem ............................................................. 46tri-sprintec ............................................................... 46TRIUMEQ ................................................................ 10trivora-28 ................................................................ 46tri-vylibra ................................................................. 46tri-vylibra lo............................................................. 46TROGARZO ............................................................... 9TROPHAMINE INJ 10% .......................................... 65trospium chloride ................................................... 58TRULICITY ............................................................... 39TRUMENBA ............................................................ 63TRUVADA TAB 100-150 ......................................... 10TRUVADA TAB 133-200 ......................................... 10TRUVADA TAB 167-250 ......................................... 10TRUVADA TAB 200-300 ......................................... 10TRUXIMA ................................................................ 16tulana ...................................................................... 46tums smoothies ...................................................... 51TURALIO ................................................................. 19tusnel diabetic ........................................................ 73tussin dm ................................................................ 73tussin dm cough + chest c ...................................... 73tussin dm max ........................................................ 73tussin dm max adult ............................................... 73tussin mucus + chest cong...................................... 73tussin mucus & chest cong ..................................... 73TWINRIX INJ ............................................................ 63TYBOST ..................................................................... 9tydemy ..................................................................... 46TYKERB ................................................................... 19TYMLOS .................................................................. 49TYPHIM VI ............................................................... 63

U

unithroid ................................................................. 50ursodiol ................................................................... 57

V

valacyclovir hcl ....................................................... 11VALCHLOR .............................................................. 79valganciclovir hcl .................................................... 11valproate sodium ................................................... 29valproic acid ........................................................... 29valsartan ................................................................. 22valsartan-hydrochlorothiazide............................... 21VALTOCO ................................................................ 29vancomycin hcl ......................................................... 7VANCOMYCIN IN NACL ........................................... 7vandazole ................................................................ 58VAQTA ..................................................................... 63VARIVAX .................................................................. 63VASCEPA ................................................................. 23vegetable laxative+stool ......................................... 56VELCADE ................................................................. 16velivet ...................................................................... 46VELTASSA ............................................................... 42VEMLIDY ................................................................. 11VENCLEXTA ............................................................ 16VENCLEXTA STARTING PACK................................ 16venlafaxine hcl ........................................................ 31VENOFER ................................................................ 59VENTAVIS ................................................................ 26VENTOLIN HFA ...................................................... 72verapamil cap er ..................................................... 24verapamil hcl .......................................................... 24verapamil hcl tab er ............................................... 24VERSACLOZ ............................................................ 34VERZENIO ............................................................... 16VICTOZA ................................................................. 39vienva ...................................................................... 46vigabatrin powd pack 500mg ................................ 29vigabatrin tab 500mg ............................................. 29vigadrone ................................................................ 29VIIBRYD STARTER PACK ........................................ 31VIIBRYD TAB ........................................................... 31VIMPAT ................................................................... 29VIMPAT INJ 200MG/20ML ..................................... 29VIMPAT SOL 10MG/ML ......................................... 29vincristine sulfate .................................................... 15vinorelbine tartrate ................................................ 15viorele ...................................................................... 46VIRACEPT .................................................................. 9VIREAD ...................................................................... 9virt-caps .................................................................. 67

106

Nombre del medicamento Página n.º Nombre del medicamento Página n.ºvitamins a & d (topical) .......................................... 79VITRAKVI ................................................................. 19VIVITROL ................................................................. 38VIZIMPRO ............................................................... 19voriconazole .......................................................... 7, 8VOSEVI .................................................................... 11VOTRIENT ............................................................... 19VRAYLAR ................................................................. 34VRAYLAR THERAPY PACK ...................................... 34vyfemla .................................................................... 46vylibra ..................................................................... 46

W

warfarin sodium ..................................................... 59water for irrigation, sterile .................................... 79wymzya fe ............................................................... 46

X

XALKORI ................................................................. 19XARELTO ................................................................. 59XARELTO STARTER PACK ...................................... 59XATMEP .................................................................. 61XELJANZ .................................................................. 61XELJANZ XR ............................................................ 61XGEVA ..................................................................... 49XIFAXAN .................................................................. 57XIGDUO XR TAB 2.5-1000MG ............................... 41XIGDUO XR TAB 5-500MG .................................... 41XIGDUO XR TAB 5-1000MG .................................. 41XIGDUO XR TAB 10-500MG .................................. 41XIGDUO XR TAB 10-1000MG ................................ 41XOLAIR .................................................................... 74XOSPATA ................................................................ 19XPOVIO 60 MG ONCE WEEKLY ............................ 19XPOVIO 80 MG ONCE WEEKLY ............................ 19XPOVIO 80 MG TWICE WEEKLY ............................ 19XPOVIO 100 MG ONCE WEEKLY .......................... 19XTANDI ................................................................... 17xulane ..................................................................... 46XULTOPHY 100/3.6 ............................................... 39XYREM .................................................................... 37

Y

YF-VAX .................................................................... 63yuvafem vaginal tablet 10 mcg .............................. 47

Z

zafirlukast ............................................................... 73zaleplon ................................................................... 35zarah ....................................................................... 47ZARXIO .................................................................... 59ZEJULA .................................................................... 16ZELBORAF .............................................................. 19ZEMAIRA ................................................................. 74zenatane ................................................................. 75ZENPEP ................................................................... 57ZERVIATE ................................................................ 68zidovudine cap 100mg ............................................. 9zidovudine syp 50mg/5ml ........................................ 9zidovudine tab 300mg .............................................. 9zinc oxide (topical) .................................................. 79ziprasidone hcl ....................................................... 34ziprasidone mesylate .............................................. 34ZIRABEV .................................................................. 16ZIRGAN ................................................................... 68zoledronic acid inj 4mg/100ml .............................. 42zoledronic acid inj 5mg/100ml .............................. 42zoledronic inj 4mg/5ml .......................................... 42ZOLINZA ................................................................. 16zolmitriptan ............................................................ 36zolmitriptan odt ...................................................... 36zolpidem tartrate .................................................... 35zonisamide .............................................................. 29ZORTRESS TAB 0.5MG .......................................... 62ZORTRESS TAB 0.25MG ........................................ 62ZORTRESS TAB 0.75MG ........................................ 62ZORTRESS TAB 1MG ............................................. 62ZOSTAVAX .............................................................. 63zovia 1/35e .............................................................. 47ZYDELIG .................................................................. 19ZYKADIA ................................................................. 19ZYLET ...................................................................... 67ZYPREXA RELPREVV ............................................... 34ZYPREXA RELPREVV INJ 210MG ........................... 34ZYTIGA .................................................................... 17

Aviso de no discriminación

Aetna, Inc. cumple con las leyes federales de derechos civiles vigentes y no discrimina por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo. Aetna, Inc. no excluye a las personas ni las trata de manera diferente debido a su raza, color, nacionalidad, edad, discapacidad o sexo.Aetna, Inc.:

Proporciona auxiliares y servicios gratuitos a las personas con discapacidades paracomunicarse efectivamente con nosotros, tales como:

o Intérpretes de lenguaje de señas calificadoso Información escrita en diferentes formatos (letra grande, audio, formatos

electrónicos accesibles, otros formatos)

Proporciona servicios de idiomas gratuitos a personas cuya lengua materna no es el inglés, tales como:

o Intérpretes calificadoso Información escrita en otros idiomas

Si necesita estos servicios, póngase en contacto con el coordinador de Derechos Civiles de Medicaid de Aetna.

Si usted cree que Aetna, Inc. no le ha proporcionado estos servicios o si se sintió discriminado de otra forma por cuestiones de su raza, color, nacionalidad, edad, discapacidad o sexo, puede interponer una queja ante: Coordinador de Derechos Civiles de Medicaid de Aetna, 4500 East Cotton Center Boulevard,Phoenix, AZ 85040, 1-888-234-7358, TTY 711, 860-900-7667 (fax), [email protected] interponer una queja en persona o por correo, fax o correo electrónico. Si necesita ayuda para interponer una queja, el coordinador de Derechos Civiles de Medicaid de Aetna está disponible para ayudarlo.

También puede presentar un reclamo ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Sociales de los Estados Unidos por vía electrónica a través del portal de reclamos de la Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf; o bien, puede hacerlo por correo o por teléfono: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)Los formularios de reclamos están disponibles en http://www.hhs.gov/ocr/office/file/index.html

aetnabetterhealth.com/illinois IL-18-11-07S

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-385-4104 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-385-4104 (TTY: 711).

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-385-4104 (TTY: 711).

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 1-800-385-4104 (TTY: 711)。

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-385-4104 (TTY: 711) 번으로 전화해 주십시오.

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-385-4104 (TTY: 711).

Arabic:

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-385-4104 (телетайп: 711).

Gujarati: સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-385-4104 (TTY: 711).

Urdu:

IL-16-09-09

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-385-4104 (TTY: 711).

Italian: ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-385-4104 (TTY: 711).

Hindi: ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-800-385-4104 (TTY: 711) पर कॉल करें।

French: ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-385-4104 (ATS: 711).

Greek: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-385-4104 (TTY: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-385-4104 (TTY: 711).


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

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

mailto:[email protected]

http://aetnabetterhealth.com/illinois

IL-16-09-09

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-385-4104 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-385-4104 (TTY: 711).

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-385-4104 (TTY: 711).

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 1-800-385-4104 (TTY: 711)。

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-385-4104 (TTY: 711) 번으로 전화해 주십시오.

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-385-4104 (TTY: 711).

Arabic:

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-385-4104 (телетайп: 711).

Gujarati: સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-385-4104 (TTY: 711).

Urdu:

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-385-4104 (TTY: 711).

Italian: ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-385-4104 (TTY: 711).

Hindi: ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-800-385-4104 (TTY: 711) पर कॉल करें।

French: ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-385-4104 (ATS: 711).

Greek: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-385-4104 (TTY: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-385-4104 (TTY: 711).


http://aetnabetterhealth.com/illinois

Información útil

Aetna Better Health Premier Plan3200 Highland Ave., MC F661Downers Grove, IL 60515

Departamento de Servicios para Miembros1-866-600-2139 (TTY: 711).

Para obtener información más reciente o si tiene otras preguntas, comuníquese con nosotros al 1-866-600-2139 (TTY: 711), durante las 24 horas, los 7 días de la semana, o bien visite www.aetnabetterhealth.com/illinois

©2020 Aetna Inc. 92.05.300.2-IL Q (07/20)Actualizado el 07/01/2020


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