Amerivantage Classic (HMO)

Formulario 2016 (Lista de Medicamentos Cubiertos) Lea atentamente: Este documento contiene información sobre los medicamentos que cubrimos en este plan. Este formulario se actualizó el 01 de septiembre de 2016. Para obtener información más actualizada o para realizar otras consultas, comuníquese con el Servicio de Atención al Cliente de Amerivantage Classic (HMO), al 1-866-805-4589, 8 a. m. a 8 p. m., los siete días de la semana (excepto el Día de Acción de Gracias y Navidad) desde el 1.º de octubre hasta el 14 de febrero, y de lunes a viernes (excepto los feriados) desde el 15 de febrero hasta el 30 de septiembre, o visite www.myamerigroup.com/medicare. Y0114_16_24724_U_SP_204 CMS Accepted 6/18/2016 54169MUSSPMUB_204 H5746_016

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Importante para los miembros existentes: Este formulario se ha modificado desde el año pasado. Consulte este documento para asegurarse de que aún comprenda los medicamentos que usted toma. Cuando esta lista de medicamentos (formulario) se refiere a “nosotros,” “nos” o “nuestro,” está hablando de Amerigroup. Cuando se refiere a “plan” o “nuestro plan,” está hablando de Amerivantage Classic (HMO). Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la cual está actualizada al 01 de octubre de 2016. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en la tapa y contratapa. Para poder utilizar su beneficio para medicamentos recetados, por lo general, debe recurrir a farmacias de la red. Los beneficios, el formulario, la red de farmacias, y/o los copagos/coseguros pueden cambiar a partir del 1.° de enero de 2017, y periódicamente durante el año. El formulario, la red de farmacias y/o la red de proveedores pueden cambiar en cualquier momento. Se le notificará cuando sea necesario.

Fecha de entrada en vigencia 01 de octubre de 2016

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¿Qué es el formulario del Amerivantage Classic (HMO)? Un formulario es una lista de medicamentos cubiertos seleccionados por nuestro plan en consulta con un equipo de proveedores de atención de la salud, que representa las terapias recetadas consideradas como una parte necesaria de un programa de tratamiento de calidad. Nuestro plan, generalmente, cubrirá los medicamentos enumerados en nuestro formulario siempre y cuando el mismo sea médicamente necesario, la receta se complete en una farmacia de la red y se cumplan otras normas del plan. Para obtener más información sobre cómo abastecer sus recetas, consulte su Evidencia de Cobertura.

¿Puede cambiar el formulario (lista de medicamentos)? Por lo general, si está tomando un medicamento de nuestro formulario 2016 que tenía cobertura a principios de año, no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2016, excepto que esté disponible un medicamento genérico más barato o cuando se divulgue nueva información adversa sobre la seguridad o efectividad de un medicamento. Otros tipos de cambios en el formulario, como eliminar un medicamento de nuestro formulario, no afectarán a los miembros que estén tomando actualmente dicho medicamento. Seguirá disponible con la misma distribución de costos para los miembros que lo tomen durante el resto del año de cobertura. Consideramos que es importante que usted tenga acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto para casos en los que usted pueda ahorrar dinero adicional o que podamos garantizar su seguridad.

Drug Administration, FDA) considera que un medicamento de nuestro formulario no es seguro o si el fabricante del medicamento lo retira del mercado, retiraremos inmediatamente el medicamento de nuestro formulario e informaremos a los miembros que toman dicho medicamento. El formulario adjunto está actualizado al 01 de octubre de 2016. Para obtener información actualizada sobre los medicamentos que cubre nuestro plan, comuníquese con nosotros. Nuestra información de contacto figura en la tapa y contratapa. Si se realiza cualquier otro tipo de cambio en el formulario aprobado (que no sea de mantenimiento) durante el año, lo notificaremos enviándole una lista de dichos cambios o un formulario actualizado.

¿Cómo utilizo el formulario? Existen dos maneras de encontrar su medicamento dentro del formulario: Afección médica El formulario comienza en la página 9. Los medicamentos en este formulario están agrupados en categorías basadas en el tipo de afección médica para los que se utilizan. Por ejemplo, los medicamentos para tratar una afección cardíaca están enumerados en la categoría “Cardiovascular Medications”. Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que empieza en la página 9. Luego busque su medicamento bajo el nombre de la categoría correspondiente. Lista en orden alfabético

Si no está seguro en qué categoría buscar, debe buscar su medicamento en el Índice que comienza en la página 73. El Índice brinda una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos Si eliminamos medicamentos de nuestro formulario o genéricos se enumeran en el Índice. Busque en el Índice agregamos una autorización previa, límites de cantidad y encuentre su medicamento. Al lado de su medicamento y/o restricciones de terapia escalonada de un verá el número de página en la que puede encontrar medicamento, o cambiamos un medicamento a un nivel información de cobertura. Vaya a la página que se superior de distribución de costos, debemos notificar enumera en el Índice y encuentre el nombre de su dicho cambio a los miembros afectados al menos 60 días medicamento en la primera columna de la lista. antes de que dicho cambio se haga efectivo o en el momento en que el miembro solicite que le resurtan el medicamento, momento en el que el miembro recibirá suministro del medicamento por 60 días. Si la Administración de Alimentos y Medicamentos (Food and Fecha de entrada en vigencia 01 de octubre de 2016

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Puede solicitar una excepción a nuestro plan para estas restricciones o límites, o solicitar una lista de otros medicamentos similares que puedan tratar su afección Nuestro plan cubre medicamentos de marca y médica. Vea la sección “¿Cómo solicito una excepción medicamentos genéricos. Un medicamento genérico es para el formulario de Amerivantage Classic (HMO)?” en aquel aprobado por la FDA porque tiene el mismo la página 5 para obtener información sobre cómo ingrediente activo que el medicamento de marca. solicitar una excepción. Generalmente, los medicamentos genéricos son más económicos que los medicamentos de marca. ¿Qué sucede si mi medicamento no

¿Qué son los medicamentos genéricos?

¿Existen restricciones para mi cobertura?

se encuentra en el formulario?

Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe Algunos medicamentos cubiertos pueden tener requisitos comunicarse con el Servicio de Atención al Cliente y adicionales o límites de cobertura. Estos requisitos y consultar si su medicamento está cubierto. límites pueden incluir: Si le informan que nuestro plan no cubre su Autorización previa: Nuestro plan requiere que usted o medicamento, tiene dos opciones: su médico tengan una autorización previa para determinados medicamentos. Esto significa que necesita Puede solicitar al Servicio de Atención al Cliente una lista obtener aprobación de nuestro plan antes de poder de medicamentos similares que estén cubiertos por abastecer su receta. Si no obtiene la aprobación, nuestro nuestro plan. Cuando reciba la lista, muéstresela a su plan podría no cubrir el medicamento. médico y pídale que le recete un medicamento similar que esté cubierto por nuestro plan. Límites de cantidad: Para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubrirá. Puede solicitar una excepción a nuestro plan para cubrir Por ejemplo, nuestro plan ofrece 30 tabletas por receta su medicamento. Consulte lo que se describe a de irbesartan 75mg tablets. Esto puede ser adicional a continuación para obtener información sobre cómo un suministro estándar de un mes o tres meses. solicitar una excepción. Terapia escalonada: En algunos casos, nuestro plan requiere que usted pruebe ciertos medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si ambos medicamentos A y B tratan su afección médica, nuestro plan puede no cubrir el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no es efectivo para usted, entonces nuestro plan cubrirá el medicamento B. Usted puede averiguar si su medicamento tiene requisitos o límites adicionales consultando el formulario que empieza en la página 9. También puede obtener más información sobre las restricciones que se aplican a determinados medicamentos cubiertos visitando nuestro sitio web. Hemos publicado documentos en línea que explican nuestra autorización previa y las restricciones de terapia escalonada. También puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en la tapa y contratapa. Fecha de entrada en vigencia 01 de octubre de 2016

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¿Cómo solicito una excepción para ¿Qué hago antes de hablar con mi el formulario de Amerivantage médico sobre cambiar mis Classic (HMO)? medicamentos o solicitar una Puede solicitar que nuestro plan haga una excepción a excepción? nuestras reglas de cobertura. Existen varios tipos de excepciones que puede solicitarnos:

Como miembro nuevo o que continúa en nuestro plan, podría estar tomando medicamentos que no están en nuestro formulario. O podría estar tomando un Puede solicitarnos que cubramos un medicamento medicamento que está en nuestro formulario, pero su aunque no esté en nuestro formulario. Si se aprueba, capacidad para obtenerlo es limitada. Por ejemplo, puede este medicamento estará cubierto a un nivel de necesitar una autorización previa de nuestra parte antes distribución de costos predeterminado, y usted no podrá de poder abastecer su receta. Deberá hablar con su solicitarnos que le suministremos dicho medicamento a médico para decidir si debe cambiar a un medicamento un nivel de distribución de costos menor. adecuado que cubramos o solicitar una excepción al formulario para que cubramos el medicamento que está Puede solicitar que cubramos un medicamento del formulario a un nivel de distribución de costos menor tomando. Mientras consulta con su médico el curso de acción acorde para usted, podemos cubrir su si dicho medicamento no se encuentra dentro de los medicamentos especiales. Si se aprueba, esto disminuiría medicamento en ciertos casos durante los primeros 90 días en los que usted es miembro de nuestro plan. la cantidad que debe pagar por su medicamento. Para cada uno de sus medicamentos que no esté en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta por escrito para menos días) cuando vaya a una farmacia de la red. Luego de su primer suministro para 30 días, no pagaremos estos medicamentos, aunque sea miembro Por lo general, nuestro plan aprobará su solicitud de una del plan por menos de 90 días. excepción únicamente si los medicamentos alternativos incluidos en el formulario del plan, el medicamento de Si es residente de un centro de atención a largo plazo, permitiremos que vuelva a abastecer su receta hasta que menor nivel o las restricciones de utilización adicional no son favorables para tratar su afección y/o harán que le hayamos proporcionado un suministro de transición de 98 días, de acuerdo con el incremento de distribución padezca efectos médicos adversos. (a menos que tenga una receta por escrito por menos días). Cubriremos más de un reabastecimiento de estos Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para obtener una excepción medicamentos durante los primeros 90 días en los que ha sido miembro de nuestro plan. Si necesita un de formulario, nivel o restricción de utilización. Al solicitar una excepción de formulario, nivel o restricción medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, de utilización deberá enviar una declaración de su pero ya pasaron los primeros 90 días de membresía en emisor de recetas o médico justificando su solicitud. Por lo general, debemos tomar nuestra decisión dentro nuestro plan, cubriremos un suministro de emergencia de las 72 horas después de obtener la declaración en la de 31 días para ese medicamento (a menos que tenga que su emisor de recetas realiza la justificación. Puede una receta por menos días) mientras solicita una solicitar una excepción expeditiva (rápida) si usted o su excepción al formulario. médico creen que su salud corre un riesgo grave al esperar hasta 72 horas por una decisión. Si se le otorga Mientras obtenga el suministro temporal de un la solicitud de agilización, debemos darle una respuesta medicamento, debe hablar con su médico o con el médico emisor de la receta para decidir qué debe hacer dentro de las 24 horas luego de recibir la declaración cuando se termine el suministro temporal. Puede llamar justificatoria del médico o de otro emisor de recetas. Puede solicitar que eximamos las restricciones o limitaciones de cobertura de su medicamento. Por ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede solicitar que eximamos el límite y que cubramos más.

Fecha de entrada en vigencia 01 de octubre de 2016

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al Servicio de Atención al Cliente para solicitar una lista de medicamentos cubiertos que traten la misma afección médica. Esta lista puede ayudar a que su médico encuentre un medicamento cubierto que le dé resultado mientras usted sigue tramitando una excepción al formulario. Consulte la Evidencia de Cobertura para obtener más información sobre las excepciones.

red necesitarán solicitar autorización previa antes de abastecer la receta. ST - Terapia escalonada: El proceso de probar por primera vez determinado medicamento o medicamentos para determinar si el o los mismos tratarán su afección médica antes de que su plan cubra otro medicamento para dicha afección.

Para obtener más información

B/D - Parte B vs. Parte D: Este medicamento puede estar Para obtener información más detallada sobre la cubierto por los beneficios para los medicamentos cobertura de medicamentos recetados de nuestro plan, recetados de la Parte D o como un medicamento de la consulte su Evidencia de Cobertura y otros materiales Parte B bajo sus beneficios médicos, según lo determine del plan. Medicare. Si tiene alguna pregunta sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en la tapa y contratapa.

LA - Acceso limitado: Esta receta puede estar disponible solo en ciertas farmacias. Para obtener mayor información, consulte su Directorio de Farmacias o comuníquese con el Servicio de Atención al Cliente al 1-866-805-4589, 8 a. m. a 8 p. m., los siete días de la Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare semana (excepto el Día de Acción de Gracias y Navidad) al 1-800-MEDICARE (1-800-633-4227), las 24 horas del desde el 1.º de octubre hasta el 14 de febrero, y de lunes a viernes (excepto los feriados) desde el 15 de febrero día, los 7 días a la semana. Los usuarios de TTY deben hasta el 30 de septiembre. Los usuarios de TTY/TDD llamar al 1-877-486-2048. O visite deben llamar al 711. http://www.medicare.gov.

El formulario de nuestro plan El formulario 9 proporciona información de cobertura sobre los medicamentos cubiertos por nuestro plan. Si tiene problemas para encontrar su medicamento en la lista, consulte el Índice que comienza en la página 73.

INJ - Inyectable: El medicamento está disponible en formato inyectable. MO - Pedidos por correo: Medicamentos recetados que se pueden ordenar por correo.

CG - Etapa sin cobertura: Brindamos cobertura adicional La primera columna del cuadro enumera el nombre del de este medicamento recetado en la etapa sin cobertura. medicamento. Los medicamentos de marca figuran en Tenga a bien consultar su Evidencia de Cobertura para letra mayúscula (por ej., CRESTOR) y los medicamentos más información sobre esta cobertura. genéricos están enumerados en letra minúscula y cursiva (por ej., atenolol). La información en la columna Requisitos/Límites le indica si nuestro plan tiene algunos requisitos especiales para la cobertura de su medicamento. QLL - Límites de cantidad: Limita la frecuencia, cantidad o dosis de medicamento para la cual puede obtener beneficios cada vez que se le abastezca una receta (generalmente una vez por mes). PAR - Autorización previa: El proceso de obtener la aprobación para determinadas recetas antes de aprobar los beneficios. Usted, su médico u otro proveedor de la Fecha de entrada en vigencia 01 de octubre de 2016

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Distribución de costos por un suministro de un mes de un medicamento recetado y cubierto de la Parte D durante la Etapa de Cobertura Inicial: Distribución de costos Nivel 1: Genérico Preferido Farmacia de la red con distribución de costos preferida (suministro para 30 días) o Farmacia de venta por correo** (suministro para 30 días)

$4.00

Farmacia de la red con distribución de costos estándar (suministro para 30 días) o Farmacia especializada en cuidados a largo plazo (suministro para 34 días)

$9.00

Distribución de costos Nivel 2: Genérico Farmacia de la red con distribución de costos preferida (suministro para 30 días) o Farmacia de venta por correo** (suministro para 30 días)

$14.00

Farmacia de la red con distribución de costos estándar (suministro para 30 días) o Farmacia especializada en cuidados a largo plazo (suministro para 34 días)

$19.00

Distribución de costos Nivel 3: Marca Preferida Farmacia de la red con distribución de costos preferida (suministro para 30 días) o Farmacia de venta por correo** (suministro para 30 días)

$42.00

Farmacia de la red con distribución de costos estándar (suministro para 30 días) o Farmacia especializada en cuidados a largo plazo (suministro para 34 días)

$47.00

Distribución de costos Nivel 4: Marca No Preferida Farmacia de la red con distribución de costos preferida (suministro para 30 días) o Farmacia de venta por correo** (suministro para 30 días)

$95.00

Farmacia de la red con distribución de costos estándar (suministro para 30 días) o Farmacia especializada en cuidados a largo plazo (suministro para 34 días)

$100.00

Distribución de costos Nivel 5: Medicamentos Especiales* Farmacia de la red con distribución de costos preferida (suministro para 30 días) o Farmacia de venta por correo** (suministro para 30 días)

33 %

Farmacia de la red con distribución de costos estándar (suministro para 30 días) o Farmacia especializada en cuidados a largo plazo (suministro para 34 días)

33 %

Distribución de costos Nivel 6: Medicamentos de Cuidados Selectos Farmacia de la red con distribución de costos preferida (suministro para 30 días) o Farmacia de venta por correo** (suministro para 30 días)

$0.00

Farmacia de la red con distribución de costos estándar (suministro para 30 días) o Farmacia especializada en cuidados a largo plazo (suministro para 34 días)

$0.00

Tenga a bien consultar nuestra Evidencia de Cobertura para obtener más información sobre la distribución de costos.

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Farmacia de la red con distribución de costos preferida - Una farmacia de la red que brinda a los miembros de nuestro plan medicamentos cubiertos que pueden tener niveles de distribución de costos menores a los de otras farmacias de la red con distribución de costos estándar. * El suministro prolongado no está disponible para los medicamentos del Nivel 5: Medicamentos Especiales ** Farmacia de venta por correo – Servicio de venta por correo que le permite ordenar medicamentos con suministros para 30 a 90 días. Los medicamentos disponibles a través del servicio de venta por correo de nuestro plan figuran como medicamentos de “venta por correo” en nuestra lista de medicamentos.

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Medicamentos cubiertos por categoría terapéutica Leyenda Los medicamentos genéricos figuran en letra minúscula y cursiva (por ej., atenolol). Los medicamentos de marca figuran en letra mayúscula (por ej., CRESTOR). QLL - Límites de cantidad: Limita la frecuencia, cantidad o dosis de medicamento para la cual puede obtener beneficios cada vez que se le abastezca una receta (generalmente una vez por mes). PAR - Autorización previa: El proceso de obtener la aprobación para determinadas recetas antes de aprobar los beneficios. Usted, su médico u otro proveedor de la red necesitarán solicitar autorización previa antes de abastecer la receta. ST - Terapia escalonada: El proceso de probar por primera vez determinado medicamento o medicamentos para determinar si el o los mismos tratarán su afección médica antes de que su plan cubra otro medicamento para dicha afección. B/D - Parte B vs. Parte D: Este medicamento puede estar cubierto por los beneficios para los medicamentos recetados de la Parte D o como un medicamento de la Parte B bajo sus beneficios médicos, según lo determine Medicare. LA - Acceso limitado: Esta receta puede estar disponible solo en ciertas farmacias. Para obtener mayor información, consulte su Directorio de Farmacias o comuníquese con el Servicio de Atención al Cliente al 1-866-805-4589, 8 a. m. a 8 p. m., los siete días de la semana (excepto el Día de Acción de Gracias y Navidad) desde el 1.º de octubre hasta el 14 de febrero, y de lunes a viernes (excepto los feriados) desde el 15 de febrero hasta el 30 de septiembre. Los usuarios de TTY/TDD deben llamar al 711. INJ - Inyectable: El medicamento está disponible en formato inyectable. MO - Pedidos por correo: Medicamentos recetados que se pueden ordenar por correo. CG - Etapa sin cobertura: Brindamos cobertura adicional de este medicamento recetado en la etapa sin cobertura. Tenga a bien consultar su Evidencia de Cobertura para más información sobre esta cobertura.

Nombre del medicamento Anti - Infectives abacavir abacavir-lamivudinezidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET

Nivel de Requisitos/ medicamento Límites 4 5 5 2 4

2 4 5 4 4

4

MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) B/D PAR; MO MO MO

MO B/D PAR; MO MO MO MO; QLL (180 per 3 days) MO

Nombre del medicamento amantadine hcl oral capsule amantadine hcl oral tablet AMBISOME amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet, chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution 200-

Nivel de Requisitos/ medicamento Límites 3

MO

3

MO

5 4

B/D PAR; MO MO

1 1

MO MO

1 2

MO MO

3

MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 9 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento 28.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/ 5 ml amoxicillin-pot clavulanate oral suspension for reconstitution 25062.5 mg/5 ml amoxicillin-pot clavulanate oral tablet 250-125 mg amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet, chewable amphotericin b ampicillin oral capsule ampicillin oral suspension for reconstitution ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 3 gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atovaquone atovaquone-proguanil

Nivel de Requisitos/ medicamento Límites

4

3

MO

MO

2

MO

4

MO

3

MO

4 1 2

B/D PAR; MO MO MO

4

MO

4 4

MO

4

4

5 5 5 4

MO

MO; QLL (120 per 30 days) QLL (390 per 30 days) PAR; MO MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

ATRIPLA

5

azithromycin intravenous recon soln 500 mg azithromycin intravenous recon soln 500 mg (2 mg/ml) azithromycin oral packet azithromycin oral suspension for reconstitution 100 mg/ 5 ml azithromycin oral suspension for reconstitution 200 mg/ 5 ml azithromycin oral tablet aztreonam BARACLUDE ORAL SOLUTION BICILLIN C-R BICILLIN L-A CANCIDAS CAPASTAT CAYSTON cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/ 5 ml cefaclor oral suspension for reconstitution 250 mg/ 5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/ 5 ml, 500 mg/5 ml cefadroxil oral tablet

4

MO; QLL (30 per 30 days) MO

4

2

MO

4

MO

2

MO

2

MO

4 5

MO PAR; MO

4 4 5 4 5 3 2

MO MO B/D PAR; MO

2

MO

3

MO

2 3

MO MO

4

MO

PAR; MO; LA MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 10 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g cefazolin intravenous cefdinir oral capsule cefdinir oral suspension for reconstitution cefepime cefepime in dextrose, iso-osm intravenous piggyback 1 gram/50 ml cefepime in dextrose, iso-osm intravenous piggyback 2 gram/100 ml cefotaxime injection recon soln 1 gram, 2 gram, 500 mg cefotaxime injection recon soln 10 gram cefotetan cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, 2 gram cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet 100 mg cefpodoxime oral tablet 200 mg

Nivel de Requisitos/ medicamento Límites 4

MO

4

MO

4

4 2 4

4 4

4

MO MO

MO

MO

4

4

MO

4 4 4

MO

4

4

MO

3

MO

4

MO

Nombre del medicamento cefprozil oral suspension for reconstitution cefprozil oral tablet 250 mg cefprozil oral tablet 500 mg CEFTAZIDIME IN D5W ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram, 100 gram ceftriaxone intravenous cefuroxime axetil oral tablet 250 mg cefuroxime axetil oral tablet 500 mg cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous vial cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral tablet chloramphenicol sod succinate chloroquine phosphate oral tablet 250 mg chloroquine phosphate oral tablet 500 mg cidofovir

Nivel de Requisitos/ medicamento Límites 3

MO

2

MO

3

MO

4 4

MO

4 4

MO

4

MO

4

4

MO

1

MO

2

MO

4

MO

4 1

MO

2

MO

1 4

MO

4

MO

3

MO

5

B/D PAR; MO

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Nombre del medicamento ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg ciprofloxacin hcl oral tablet ciprofloxacin in 5 % dextrose ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml ciprofloxacin oral suspension clarithromycin oral suspension for reconstitution 125 mg/ 5 ml clarithromycin oral suspension for reconstitution 250 mg/ 5 ml clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr clindamycin hcl oral capsule clindamycin in 5 % dextrose clindamycin phosphate injection clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/ 6 ml clindamycin phosphate intravenous solution 600 mg/4 ml

Nivel de Requisitos/ medicamento Límites 3

2

MO; QLL (14 per 2 days)

MO; QLL (3 per 2 days)

2

MO

4

MO

4

MO

4

4 2

4

3

MO

MO

MO

3

MO; QLL (28 per 2 days)

2

MO

4

MO

4

MO

4

4

MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

clotrimazole mucous membrane COARTEM colistin (colistimethate na) COMPLERA

3

MO

4 4

MO MO

5

CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG CUBICIN DAKLINZA ORAL TABLET 30 MG, 60 MG

4

DAKLINZA ORAL TABLET 90 MG DAPSONE DARAPRIM demeclocycline DESCOVY

5

dicloxacillin didanosine oral capsule,delayed release(dr/ec) 125 mg didanosine oral capsule,delayed release(dr/ec) 200 mg didanosine oral capsule,delayed release(dr/ec) 250 mg didanosine oral capsule,delayed release(dr/ec) 400 mg DIFICID DORIBAX DOXY-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 50 mg

2 3

MO; QLL (30 per 30 days) MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) MO PAR; MO; QLL (30 per 30 days) PAR; QLL (30 per 30 days) MO MO MO QLL (30 per 30 days) MO MO; QLL (90 per 30 days)

4 5 5

3 3 4 5

4

MO; QLL (60 per 30 days)

3

MO; QLL (30 per 30 days)

4

MO; QLL (30 per 30 days)

5 4 4 4

PAR; MO

4

MO

4

MO

MO

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral tablet 100 mg doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg e.e.s. 400 oral tablet EDURANT

3

MO

2

MO

EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM

4

ery-tab oral tablet, delayed release (dr/ec) 250 mg, 333 mg erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet ethambutol EVOTAZ

3

famciclovir oral tablet 125 mg, 250 mg

3

4

MO

3 5

MO MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (870 per 30 days) PAR; MO MO

4 5 3 4 5

3

MO; QLL (960 per 30 days) MO; QLL (30 per 30 days) MO

MO

4

3

MO

2

MO

4

MO

4 5

MO MO; QLL (30 per 30 days) MO; QLL (60 per 30 days)

Nombre del medicamento famciclovir oral tablet 500 mg fluconazole in dextrose(iso-o) FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/ 50 ML fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml fluconazole oral suspension for reconstitution 10 mg/ ml fluconazole oral suspension for reconstitution 40 mg/ ml fluconazole oral tablet 100 mg fluconazole oral tablet 150 mg, 50 mg fluconazole oral tablet 200 mg flucytosine foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium gentamicin in nacl (isoosm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/

Nivel de Requisitos/ medicamento Límites 4

MO; QLL (21 per 7 days)

4 4

4

MO

4

3

MO

4

MO

3

MO

2

MO

4

MO

5 3 5

MO B/D PAR MO; QLL (60 per 30 days)

4 4

MO MO

4

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Nombre del medicamento 50 ML, 120 MG/100 ML gentamicin in nacl (isoosm) intravenous piggyback 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml gentamicin sulfate (pf) intravenous solution 60 mg/6 ml, 80 mg/8 ml GENVOYA GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 250 MG griseofulvin microsize oral suspension griseofulvin ultramicrosize HARVONI

hydroxychloroquine oral imipenem-cilastatin intravenous recon soln 250 mg imipenem-cilastatin intravenous recon soln 500 mg INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG INVANZ 1 GM ADDVANTAGE VIAL

Nivel de Requisitos/ medicamento Límites

4

4 4 4

4

5 4

4 4 5

2 3

4

5 5 4 4

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET

5

ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET MO ISENTRESS ORAL MO TABLET,CHEWABLE 100 MG MO ISENTRESS ORAL TABLET,CHEWABLE 25 MG isoniazid injection isoniazid oral solution isoniazid oral tablet 100 mg MO; QLL (30 isoniazid oral tablet per 30 days) 300 mg MO itraconazole ivermectin oral KALETRA ORAL MO SOLUTION KALETRA ORAL TABLET MO 100-25 MG KALETRA ORAL TABLET PAR; MO; QLL 200-50 MG (28 per 28 KETEK days) MO ketoconazole oral LAMISIL ORAL TABLET MO lamivudine oral solution MO lamivudine oral tablet 100 mg lamivudine oral tablet MO; QLL (120 150 mg per 30 days) lamivudine oral tablet MO; QLL (60 300 mg per 30 days) lamivudine-zidovudine MO; QLL (480 per 30 days) levofloxacin in d5w intravenous piggyback 250 mg/50 ml

4

5

5 5

3

MO; QLL (300 per 30 days) MO; QLL (120 per 30 days) MO MO; QLL (120 per 30 days) MO; QLL (180 per 30 days) MO; QLL (720 per 30 days)

4 4 1

MO MO

2

MO

4 3 4

PAR; MO MO MO; QLL (480 per 30 days) MO; QLL (300 per 30 days) MO; QLL (120 per 30 days) MO; QLL (20 per 2 days) MO MO; QLL (30 per 30 days) MO; QLL (900 per 30 days) MO

5 5 3 3 4 4 4 4 4 5

MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (60 per 30 days)

4

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin oral tablet

4

LEXIVA ORAL SUSPENSION

4

LEXIVA ORAL TABLET

5

LINCOCIN lincomycin injection linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet

4 4 5 5

linezolid-0.9% sodium chloride MALARONE mefloquine meropenem methenamine hippurate methenamine mandelate metro i.v. metronidazole in nacl (iso-os) metronidazole oral capsule metronidazole oral tablet minocycline oral capsule 100 mg, 50 mg minocycline oral capsule 75 mg minocycline oral tablet morgidox oral capsule 50 mg moxifloxacin

5

MYCAMINE

5

2

5

Nombre del medicamento

MO

Nivel de Requisitos/ medicamento Límites

nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml MO; QLL (14 nafcillin in dextrose per 2 days) iso-osm intravenous piggyback 2 gram/100 MO; QLL (1800 per 30 ml days) nafcillin injection MO; QLL (120 nafcillin intravenous per 30 days) recon soln 1 gram MO NAFCILLIN INTRAVENOUS RECON SOLN 2 GRAM PAR; MO; QLL NEBUPENT neomycin (1800 per 2 days) nevirapine oral PAR; MO; QLL suspension (28 per 2 days) nevirapine oral tablet

4

nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET

4

NOXAFIL ORAL SUSPENSION

5

nystatin oral suspension nystatin oral tablet ODEFSEY

2

4 3 4 4

MO MO MO MO

2

MO

4 4

MO MO

4

MO

2

MO

2

MO

3

MO

4 4

MO

3

MO; QLL (21 per 2 days) MO

4

MO

5 5

MO MO

5

MO

3 2 4

B/D PAR; MO MO MO; QLL (1200 per 30 days) MO; QLL (60 per 30 days) MO

3

4

MO; QLL (30 per 30 days)

4

PAR; MO

4

PAR; MO

4

MO; QLL (360 per 30 days) MO; QLL (480 per 30 days) MO; QLL (360 per 30 days) PAR; MO; QLL (630 per 30 days) MO

4 3

2 5

MO QLL (30 per 30 days)

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

ofloxacin oral tablet 400 mg OLYSIO oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml oxacillin injection oxacillin intravenous paromomycin PASER PENICILLIN G POT IN DEXTROSE penicillin g potassium penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium oral recon soln penicillin v potassium oral tablet 250 mg penicillin v potassium oral tablet 500 mg PENTAM pfizerpen-g piperacillintazobactam polymyxin b sulfate PREZCOBIX

3

MO

5 4

PAR; MO

PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG

5

5

5 5 4 4 4 5 4

MO

MO MO MO

MO MO

4

4 1

MO MO

1

MO

2

MO

4 4 4

MO

4 5

MO MO; QLL (30 per 30 days) MO; QLL (420 per 30 days) MO; QLL (180 per 30 days) MO; QLL (60 per 30 days) MO; QLL (300 per 30 days)

4 5 4

MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

PRIFTIN PRIMAQUINE pyrazinamide RELENZA DISKHALER

4 3 4 3

RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg rifabutin rifampin RIFATER rimantadine SELZENTRY

4

SIRTURO SOVALDI stavudine oral capsule 15 mg stavudine oral capsule 20 mg stavudine oral capsule 30 mg stavudine oral capsule 40 mg stavudine oral recon soln

5 5 3

STREPTOMYCIN INTRAMUSCULAR

4

4 4

MO MO MO MO; QLL (60 per 180 days) MO; QLL (180 per 30 days) MO; QLL (360 per 30 days) MO

5

MO; QLL (60 per 30 days)

5

4 4

MO; QLL (30 per 30 days) MO; QLL (240 per 30 days) MO MO

4 3

MO MO

4 4 4 4 5

MO MO MO MO MO; QLL (120 per 30 days) PAR; MO; LA PAR; MO MO; QLL (120 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (2400 per 30 days) MO

4

4 3 4 3

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

STRIBILD

5

STROMECTOL sulfadiazine oral sulfamethoxazoletrimethoprim intravenous sulfamethoxazoletrimethoprim oral suspension sulfamethoxazoletrimethoprim oral tablet SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET

3 4 4

SYNAGIS SYNERCID TAMIFLU TECHNIVIE

5 5 3 5

MO; QLL (30 per 30 days) MO MO MO

2

MO

1

MO

4 4 5

TEFLARO INTRAVENOUS RECON SOLN 400 MG TEFLARO INTRAVENOUS RECON SOLN 600 MG terbinafine hcl oral

4

tetracycline tinidazole oral tablet 250 mg tinidazole oral tablet 500 mg TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 25 MG TIVICAY ORAL TABLET 50 MG

4 2

5

2

4 4 5 5

MO; QLL (120 per 30 days) MO; QLL (360 per 30 days) MO; QLL (30 per 30 days) PAR; MO; LA

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

tobramycin in 0.225 % nacl

5

tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ

4

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG TRUVADA ORAL TABLET 200-300 MG TYBOST

5

TYGACIL TYZEKA valacyclovir

5 5 3

MO PAR; MO; QLL (56 per 28 valganciclovir oral days) tablet MO VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/ MO 100 ML, 750 MG/150 ML VANCOMYCIN IN MO; QLL (30 DEXTROSE 5 % per 30 days) INTRAVENOUS MO PIGGYBACK 1 GRAM/ MO 200 ML VANCOMYCIN IN MO DEXTROSE 5 % QLL (60 per 30 INTRAVENOUS PIGGYBACK 500 MG/ days) QLL (60 per 30 100 ML, 750 MG/150 ML days) vancomycin MO; QLL (60 intravenous per 30 days)

B/D PAR; MO; QLL (280 per 28 days)

4

MO

4 2 5

MO MO MO; QLL (30 per 30 days) QLL (30 per 30 days)

5 3

5

MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO PAR; MO MO; QLL (30 per 2 days) MO

4

4

MO

4

4

MO

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Nombre del medicamento vancomycin oral capsule 125 mg

Nivel de Requisitos/ medicamento Límites 5

vancomycin oral capsule 250 mg

5

VIDEX 2 GRAM PEDIATRIC

4

VIDEX 4 GRAM PEDIATRIC

4

VIEKIRA PAK VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE VIREAD ORAL POWDER

5 5

VIREAD ORAL TABLET 150 MG, 250 MG, 300 MG VIREAD ORAL TABLET 200 MG VITEKTA

5

voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg

4

voriconazole oral tablet 50 mg

5

ZEPATIER

5

5 4

5 5

4 5

5

5

PAR; MO; QLL (40 per 2 days) PAR; MO; QLL (80 per 2 days) MO; QLL (1200 per 30 days) MO; QLL (1200 per 30 days) PAR; MO MO; QLL (300 per 30 days) MO; QLL (120 per 30 days) MO

PAR; MO MO; QLL (240 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO PAR; MO; QLL (300 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (30 per 30 days)

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

ZIAGEN ORAL SOLUTION zidovudine oral capsule

4

zidovudine oral syrup

3

zidovudine oral tablet

3

4

MO; QLL (960 per 30 days) MO; QLL (180 per 30 days) MO; QLL (1920 per 30 days) MO; QLL (60 per 30 days) MO

ZITHROMAX ORAL 4 PACKET ZITHROMAX ORAL 4 MO TABLET 250 MG ZITHROMAX Z-PAK 4 MO ZMAX 3 MO ZYVOX INTRAVENOUS 5 PARENTERAL SOLUTION 200 MG/ 100 ML ZYVOX INTRAVENOUS 5 MO PARENTERAL SOLUTION 600 MG/ 300 ML ZYVOX ORAL 5 PAR; MO; QLL SUSPENSION FOR (1800 per 2 RECONSTITUTION days) Antineoplastic / Immunosuppressant Drugs ABRAXANE 5 MO adrucil intravenous 4 solution 2.5 gram/50 ml adrucil intravenous 4 MO solution 5 gram/100 ml, 500 mg/10 ml AFINITOR 5 PAR; MO AFINITOR DISPERZ 5 PAR; MO ALECENSA 5 MO ALIMTA 5 PAR; MO ALKERAN ORAL 4 B/D PAR; MO amifostine crystalline 5 PAR; MO anastrozole 3 MO; QLL (30 per 30 days) ARRANON 4 ARZERRA 5 PAR; MO AVASTIN 5 PAR; MO azacitidine 5 PAR; MO

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

azathioprine azathioprine sodium BELEODAQ BENDEKA bexarotene bicalutamide BICNU bleo 15k bleomycin BLINCYTO BOSULIF ORAL TABLET 100 MG

2 4 5 5 5 3 4 4 4 5 5

BOSULIF ORAL TABLET 500 MG

5

BUSULFEX CABOMETYX ORAL TABLET 20 MG

4 5

CABOMETYX ORAL TABLET 40 MG, 60 MG

5

CAPRELSA ORAL TABLET 100 MG

5

CAPRELSA ORAL TABLET 300 MG

5

carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/ DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/ DAY(80 MG X1-20 MG X3)

4

PAR; LA; QLL (90 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; MO; LA; QLL (90 per 30 days) PAR; MO; LA; QLL (30 per 30 days) MO

4

B/D PAR; MO

4 5 5 5

5

B/D PAR; MO B/D PAR PAR; MO MO PAR; MO MO MO MO PAR; MO PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (30 per 30 days)

MO MO MO PAR; MO; QLL (56 per 28 days) PAR; MO; QLL (112 per 28 days)

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COSMEGEN COTELLIC

5

cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ ml) cytarabine (pf) injection solution 20 mg/ml dacarbazine DARZALEX daunorubicin intravenous solution decitabine dexrazoxane hcl intravenous recon soln 250 mg dexrazoxane hcl intravenous recon soln 500 mg DOCEFREZ INTRAVENOUS RECON SOLN 20 MG DOCETAXEL INTRAVENOUS SOLUTION 10 MG/ML docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/ 2 ml (10 mg/ml)

4

PAR; MO; QLL (84 per 28 days) MO PAR; MO; LA; QLL (90 per 30 days) B/D PAR; MO

4

B/D PAR

4 4

B/D PAR; MO B/D PAR; MO

5 4 4

PAR; MO MO MO

5 5

4

4 5 4

MO MO; LA

5 5

MO

5

MO

5

5

5

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Nombre del medicamento docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous solution doxorubicin, pegliposomal ELITEK EMCYT EMPLICITI ENVARSUS XR epirubicin intravenous solution 200 mg/100 ml epirubicin intravenous solution 50 mg/25 ml ERBITUX ERIVEDGE

ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON

Nivel de Requisitos/ medicamento Límites 5

4 4 5 5 5 5 4 4

4 5 5

5 5 3 5 4 5

FARYDAK ORAL CAPSULE 10 MG

5

FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE

5

5 5

4

Nombre del medicamento

SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil MO intravenous flutamide MO FOLOTYN FUSILEV PAR; MO GAZYVA MO gemcitabine B/D PAR; MO intravenous recon soln B/D PAR; MO 1 gram, 200 mg gemcitabine intravenous recon soln 2 gram MO gemcitabine intravenous solution 1 PAR; MO gram/26.3 ml (38 mg/ PAR; MO; QLL ml), 200 mg/5.26 ml (38 mg/ml) (30 per 30 days) gemcitabine intravenous solution 2 PAR; MO gram/52.6 ml (38 mg/ MO ml) MO gengraf oral capsule 100 mg, 25 mg MO; QLL (60 gengraf oral capsule per 30 days) 50 mg MO; QLL (30 gengraf oral solution per 30 days) PAR; MO; QLL GILOTRIF (60 per 30 days) PAR; MO; QLL GLEEVEC ORAL TABLET 100 MG (30 per 30 days) GLEEVEC ORAL TABLET PAR; MO 400 MG PAR; MO

Nivel de Requisitos/ medicamento Límites

MO

PAR; MO

GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea

4

MO

4 4

MO

4 5 5 5 5

MO MO MO PAR; MO MO

5

5

MO

5

4

B/D PAR; MO

4

B/D PAR

4 5

B/D PAR; MO PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (60 per 30 days) MO PAR; MO PAR; MO MO MO

5

5

4 5 5 5 2

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

IBRANCE

5

ICLUSIG ORAL TABLET 15 MG

5

ICLUSIG ORAL TABLET 45 MG

5

idarubicin IFEX ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg

5 4 4

imatinib oral tablet 400 mg

5

IMBRUVICA

5

5

5

INLYTA ORAL TABLET 5 MG

5

IRESSA irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml irinotecan intravenous solution 500 mg/25 ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG

5 4

4 5 5 5

5

Nivel de Requisitos/ medicamento Límites

JAKAFI ORAL TABLET 20 MG

5

JAKAFI ORAL TABLET 25 MG

5

JAKAFI ORAL TABLET 5 MG

5

JEVTANA KADCYLA KEYTRUDA LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 14 MG/ DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2) LENVIMA ORAL CAPSULE 24 MG/ DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK) letrozole

5 5 5 5

leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg PAR; MO leucovorin calcium MO PAR; MO; QLL injection recon soln 500 mg (150 per 30 leucovorin calcium oral days) PAR; MO; QLL tablet 10 mg, 25 mg leucovorin calcium oral (100 per 30 tablet 15 mg, 5 mg days) LEUKERAN

4

MO MO

4

INLYTA ORAL TABLET 1 MG

JAKAFI ORAL TABLET 15 MG

PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days)

Nombre del medicamento

PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (120 per 30 days) MO MO

5

PAR; MO; QLL (75 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (300 per 30 days) MO PAR; MO PAR; MO PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (60 per 30 days)

5

PAR; QLL (90 per 30 days)

5

PAR; MO; QLL (90 per 30 days)

5

PAR; QLL (60 per 30 days)

3

MO; QLL (30 per 30 days) MO

4

4

MO

2

MO

4

MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 21 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento leuprolide subcutaneous kit levoleucovorin calcium intravenous recon soln LONSURF LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) LYNPARZA

LYSODREN MATULANE megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/20 ml (20 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl mercaptopurine mesna MESNEX ORAL methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mitomycin mitoxantrone

Nivel de Requisitos/ medicamento Límites 4

Nombre del medicamento

MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil PAR; MO oral suspension for PAR; MO; QLL reconstitution (1 per 28 mycophenolate mofetil days) oral tablet PAR; MO NEXAVAR

4 3

MO B/D PAR; MO

5

B/D PAR; MO

3

B/D PAR; MO

5

NILANDRON

5

nilutamide

5

NINLARO

5

3 5 4

PAR; MO; QLL (1 per 28 days) PAR; MO; QLL (480 per 30 days) MO MO PAR

5 5 5

4

PAR; MO

4

PAR; MO

3 5

PAR; MO PAR; QLL (90 per 30 days) PAR; QLL (30 per 30 days)

NIPENT NULOJIX octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml) octreotide acetate injection syringe 500 mcg/ml (1 ml) ODOMZO

PAR; MO; LA; QLL (120 per 30 days) MO; QLL (30 per 30 days) QLL (30 per 30 days) PAR; MO; QLL (3 per 28 days) MO PAR; MO PAR; MO

4

PAR; MO

5

PAR; MO

5

ONCASPAR OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution paclitaxel

5 5 5

PAR; MO; LA; QLL (30 per 30 days) PAR; MO PAR; MO MO

5 5 5

5

5

5

5 3 3 4 5 4

PAR; MO

Nivel de Requisitos/ medicamento Límites

MO MO MO

4

MO

4

MO

2

MO

5 3

MO MO

5 5

MO

4

MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 22 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

PERJETA POMALYST ORAL CAPSULE 1 MG

5 5

PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 10 MG

5 4

PAR; MO PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) MO B/D PAR; MO

POMALYST ORAL CAPSULE 2 MG

5

POMALYST ORAL CAPSULE 3 MG, 4 MG

5

5 5

PAR; MO B/D PAR; MO

REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG

5

RITUXAN SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION, EXTENDED REL RECON SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus SOLTAMOX SOMATULINE DEPOT SPRYCEL

5 5

5

5

5 5

PAR; MO; LA; QLL (60 per 30 days) PAR; MO; LA; QLL (30 per 30 days) PAR; MO; LA; QLL (150 per 30 days) PAR; MO PAR; MO

MO B/D PAR

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

STIVARGA

5

SUTENT ORAL CAPSULE 12.5 MG

5

SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG SYNRIBO TABLOID tacrolimus oral capsule 0.5 mg, 1 mg tacrolimus oral capsule 5 mg TAFINLAR

5

TAGRISSO ORAL TABLET 40 MG

5

TAGRISSO ORAL TABLET 80 MG

5

tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG

2 5

TARCEVA ORAL TABLET 25 MG

5

TARGRETIN TASIGNA

5 5

TAXOTERE INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 80 MG/4 ML (20 MG/ML) TECENTRIQ

5

5

B/D PAR; MO

4 4 5 5

B/D PAR; MO MO PAR; MO PAR; MO; QLL THALOMID ORAL CAPSULE 100 MG, 50 (30 per 30 MG days)

5 4 4

PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (90 per 30 days) PAR; MO; QLL (30 per 30 days) PAR; MO MO B/D PAR; MO

5

B/D PAR; MO

5

PAR; QLL (120 per 30 days) PAR; MO; LA; QLL (60 per 30 days) PAR; MO; LA; QLL (30 per 30 days) MO PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (90 per 30 days) PAR; MO PAR; MO; QLL (120 per 30 days) MO

5 5

LA; QLL (20 per 21 days) PAR; MO; QLL (30 per 30 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 23 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

THALOMID ORAL CAPSULE 150 MG, 200 MG thiotepa toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML tretinoin (chemotherapy) oral capsule TRISENOX TYKERB

5

UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 MG

5 5 5 4

VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG

4 4 5 5 5 5

5

5

5

PAR; MO; QLL (60 per 30 days) MO MO

MO MO MO

MO; QLL (1 per 168 days)

MO; QLL (1 per 168 days)

MO

5 5

MO PAR; MO; LA; QLL (180 per 30 days) MO PAR; MO PAR; MO PAR; LA; QLL (60 per 30 days) PAR; LA; QLL (120 per 30 days) PAR; LA; QLL (30 per 30 days)

4

Nivel de Requisitos/ medicamento Límites

VENCLEXTA STARTING PACK

5

vinblastine intravenous solution VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML vincasar pfs intravenous solution 2 mg/2 ml vincristine vinorelbine VOTRIENT

4

XALKORI

5

XGEVA

5

XTANDI

5

YERVOY YONDELIS ZALTRAP ZANOSAR ZELBORAF

5 5 5 4 5

ZOLINZA

5

ZORTRESS ORAL TABLET 0.25 MG ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG ZYDELIG

ZYKADIA

5

PAR; LA; QLL (42 per 365 days) MO

4

4

MO

4 4 5

4

MO MO PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (1.7 per 28 days) PAR; MO; QLL (120 per 30 days) PAR; MO MO PAR; MO MO PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (120 per 30 days) B/D PAR; MO

5

B/D PAR; MO

5

PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (150 per 30 days)

MO

5

5

Nombre del medicamento

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 24 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento ZYTIGA

Nivel de Requisitos/ medicamento Límites 5

PAR; MO; QLL (120 per 30 days) Autonomic / Cns Drugs, Neurology / Psych ABILIFY MAINTENA 5 MO; QLL (1 per 28 days) acetaminophen3 QLL (4500 per codeine oral solution 30 days) 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen3 MO; QLL codeine oral solution (4500 per 30 120-12 mg/5 ml days) acetaminophen3 MO; QLL (390 codeine oral tablet per 30 days) 300-15 mg acetaminophen3 MO; QLL (360 codeine oral tablet per 30 days) 300-30 mg acetaminophen3 MO; QLL (180 codeine oral tablet per 30 days) 300-60 mg ADASUVE 4 alprazolam oral tablet 3 MO; QLL (90 per 30 days) amitriptyline 4 PAR; MO amoxapine oral tablet 3 MO 100 mg, 50 mg amoxapine oral tablet 2 MO 150 mg, 25 mg AMPYRA 5 PAR; MO; LA; QLL (60 per 30 days) APOKYN 5 PAR; MO; LA APTIOM ORAL TABLET 5 ST; MO 200 MG, 400 MG, 600 MG APTIOM ORAL TABLET 4 ST; MO 800 MG aripiprazole oral 5 MO; QLL (900 solution per 30 days) aripiprazole oral tablet 5 MO; QLL (90 10 mg per 30 days)

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

aripiprazole oral tablet 15 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg, 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet,disintegrating 10 mg aripiprazole oral tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 882 MG/3.2 ML AZILECT baclofen BANZEL ORAL SUSPENSION

5

BANZEL ORAL TABLET 200 MG

4

BANZEL ORAL TABLET 400 MG

5

benztropine injection benztropine oral BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION

4 3 4

5 5 5 5

MO; QLL (60 per 30 days) MO; QLL (450 per 30 days) MO; QLL (30 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days)

5

MO; QLL (60 per 30 days)

5

PAR; MO; QLL (1.6 per 30 days)

5

PAR; MO; QLL (2.4 per 30 days)

5

PAR; MO; QLL (3.2 per 30 days)

3 2 5

MO MO PAR; MO; QLL (2400 per 30 days) PAR; MO; QLL (480 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO PAR; MO PAR

5

PAR; QLL (600 per 30 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 25 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 75 MG BRIVIACT ORAL TABLET 25 MG BRIVIACT ORAL TABLET 50 MG bromocriptine buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg

5

buprenorphine hcl sublingual tablet 8 mg

4

buprenorphinenaloxone sublingual tablet 2-0.5 mg buprenorphinenaloxone sublingual tablet 8-2 mg bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg buspirone oral tablet 10 mg, 15 mg, 5 mg buspirone oral tablet 30 mg, 7.5 mg

4

5 5 5 4 4 4 4

4

4 3 3

3

PAR; QLL (600 per 30 days) PAR; QLL (60 per 30 days) PAR; QLL (240 per 30 days) PAR; QLL (120 per 30 days) MO MO; QLL (150 per 30 days) QLL (150 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (360 per 30 days) PAR; MO; QLL (90 per 30 days) MO; QLL (135 per 30 days) MO; QLL (180 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days)

3

MO; QLL (90 per 30 days)

3

MO; QLL (45 per 30 days)

2

MO

4

MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral suspension 200 mg/10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet,chewable carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release 25-100 mg carbidopa-levodopa oral tablet extended release 50-200 mg carbidopa-levodopa oral tablet, disintegrating celecoxib oral capsule 100 mg, 200 mg

4

MO; QLL (240 per 30 days)

4

MO; QLL (120 per 30 days)

4 4

MO; QLL (5 per 28 days) MO

4

MO

celecoxib oral capsule 400 mg

4

4

2

MO

4

4

MO

2

MO

3

MO

3

MO

4

MO

4

MO

4

PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 26 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

celecoxib oral capsule 50 mg

3

CELONTIN ORAL CAPSULE 300 MG chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg clomipramine clonazepam oral tablet 0.5 mg

4

clonazepam oral tablet 1 mg

2

clonazepam oral tablet 2 mg

3

clonazepam oral tablet,disintegrating 0.125 mg clonazepam oral tablet,disintegrating 0.25 mg clonazepam oral tablet,disintegrating 0.5 mg clonazepam oral tablet,disintegrating 1 mg clonazepam oral tablet,disintegrating 2 mg clorazepate dipotassium clozapine oral tablet 100 mg clozapine oral tablet 200 mg

4 4 2 1 1 4 2

4

4

4

4

4

3 3 3

Nombre del medicamento

PAR; MO; QLL clozapine oral tablet (60 per 30 25 mg days) MO clozapine oral tablet 50 mg PAR; MO clozapine oral tablet, MO; QLL (600 disintegrating 100 mg per 30 days) clozapine oral tablet, MO; QLL (120 disintegrating 12.5 mg per 30 days) clozapine oral tablet, disintegrating 150 mg MO; QLL (60 per 30 days) clozapine oral tablet, disintegrating 200 mg MO; QLL (30 per 30 days) clozapine oral tablet, disintegrating 25 mg PAR; MO PAR; MO; QLL COPAXONE (1200 per 30 SUBCUTANEOUS SYRINGE 20 MG/ML days) PAR; MO; QLL COPAXONE SUBCUTANEOUS (600 per 30 SYRINGE 40 MG/ML days) PAR; MO; QLL cyclobenzaprine oral tablet (300 per 30 days) dantrolene PAR; MO; QLL desipramine oral (4800 per 30 desvenlafaxine days) fumarate oral tablet PAR; MO; QLL extended release 24hr (2400 per 30 100 mg days) desvenlafaxine PAR; MO; QLL fumarate oral tablet (1200 per 30 extended release 24hr days) 50 mg PAR; MO; QLL DESVENLAFAXINE (600 per 30 ORAL TABLET days) EXTENDED RELEASE 24 PAR; MO; QLL HR 100 MG (300 per 30 DESVENLAFAXINE days) ORAL TABLET MO; QLL (120 EXTENDED RELEASE 24 HR 50 MG per 30 days) MO; QLL (270 desvenlafaxine oral tablet extended per 30 days) MO; QLL (135 release 24hr 100 mg per 30 days)

Nivel de Requisitos/ medicamento Límites 2

2 4 4 4 4 4 5

5

4

MO; QLL (1080 per 30 days) MO; QLL (540 per 30 days) QLL (270 per 30 days) QLL (2160 per 30 days) QLL (180 per 30 days) QLL (135 per 30 days) QLL (1080 per 30 days) PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (12 per 28 days) PAR; MO

4 4 4

MO MO MO; QLL (120 per 30 days)

4

MO; QLL (240 per 30 days)

4

MO; QLL (120 per 30 days)

4

MO; QLL (240 per 30 days)

4

QLL (120 per 30 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 27 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento desvenlafaxine oral tablet extended release 24hr 50 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamineamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamineamphetamine oral tablet 30 mg diazepam intensol

Nivel de Requisitos/ medicamento Límites 4

4 4 3

3

4

diazepam oral concentrate

4

diazepam oral solution 5 mg/5 ml (1 mg/ml)

3

diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml) diazepam oral tablet 10 mg

3

diazepam oral tablet 2 mg

3

diazepam oral tablet 5 mg

3

diazepam rectal kit 12.5-15-17.5-20 mg diazepam rectal kit 2.5 mg, 5-7.5-10 mg diclofenac potassium diclofenac sodium oral tablet extended release 24 hr

4

3

4 2 2

QLL (240 per 30 days)

Nombre del medicamento

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg MO; QLL (180 diclofenac sodium oral per 30 days) tablet,delayed release (dr/ec) 50 mg, 75 mg MO; QLL (90 per 30 days) diclofenac sodium PAR; MO; QLL topical gel 1 % (90 per 30 diflunisal days) dihydroergotamine injection DILANTIN INFATABS PAR; MO; QLL DILANTIN ORAL (60 per 30 CAPSULE 30 MG days) diskets PAR; MO; QLL (240 per 30 divalproex oral days) capsule, sprinkle PAR; MO; QLL divalproex oral tablet (240 per 30 extended release 24 hr days) divalproex oral tablet, PAR; MO; QLL delayed release (dr/ec) (1200 per 30 125 mg, 250 mg days) divalproex oral tablet, PAR; QLL delayed release (dr/ec) (1200 per 30 500 mg days) donepezil oral tablet PAR; MO; QLL 10 mg, 5 mg (120 per 30 donepezil oral tablet, days) disintegrating PAR; MO; QLL doxepin oral (600 per 30 duloxetine oral days) capsule,delayed PAR; MO; QLL release(dr/ec) 20 mg (240 per 30 duloxetine oral days) capsule,delayed MO release(dr/ec) 30 mg duloxetine oral MO; QLL (2 capsule,delayed per 2 days) release(dr/ec) 40 mg MO duloxetine oral MO capsule,delayed release(dr/ec) 60 mg duramorph (pf) injection solution 0.5 mg/ml

Nivel de Requisitos/ medicamento Límites 3

MO

2

MO

3 3 5

QLL (1000 per 30 days) MO MO

3 3

MO MO

3 4

QLL (30 per 30 days) MO

4

MO

2

MO

3

MO

1

MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) PAR; MO MO; QLL (180 per 30 days)

1 4 4

4

MO; QLL (120 per 30 days)

3

MO; QLL (90 per 30 days)

4

MO; QLL (60 per 30 days)

4

MO; QLL (180 per 30 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 28 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento duramorph (pf) injection solution 1 mg/ml EMSAM

endocet oral tablet 10325 mg, 7.5-325 mg endocet oral tablet 5325 mg entacapone epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ethosuximide oral capsule ethosuximide oral solution etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr EXELON ORAL CAPSULE 1.5 MG, 4.5 MG

Nivel de Requisitos/ medicamento Límites

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

4

QLL (180 per 30 days)

FANAPT ORAL TABLET 1 MG

4

5

PAR; MO; QLL (30 per 30 days) MO; QLL (360 per 30 days) MO; QLL (360 per 30 days) MO MO MO; QLL (480 per 30 days)

FANAPT ORAL TABLET 10 MG FANAPT ORAL TABLET 12 MG

5

FANAPT ORAL TABLET 2 MG

4

FANAPT ORAL TABLET 4 MG

4

FANAPT ORAL TABLET 6 MG

4

FANAPT ORAL TABLET 8 MG

4

FANAPT ORAL TABLETS,DOSE PACK

4

felbamate oral suspension felbamate oral tablet 400 mg felbamate oral tablet 600 mg FELBATOL ORAL TABLET 400 MG fenoprofen oral tablet fentanyl citrate

5

ST; MO; QLL (720 per 30 days) ST; QLL (72 per 30 days) ST; MO; QLL (60 per 30 days) ST; MO; QLL (360 per 30 days) ST; MO; QLL (180 per 30 days) ST; MO; QLL (120 per 30 days) ST; MO; QLL (90 per 30 days) ST; MO; QLL (16 per 365 days) MO

4

MO

5

MO

4

MO

4 5

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED

4

MO PAR; MO; QLL (120 per 30 days) ST; MO; QLL (15 per 30 days)

4 3 4 1 4

4

4

4 4

MO; QLL (240 per 30 days)

MO; QLL (180 per 30 days)

4

PAR; MO MO; QLL (600 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (120 per 30 days) MO

3

MO

3 2 3

MO MO MO

3 3 3

4

MO; QLL (60 per 30 days)

4

4

4

PAR; MO; QLL (56 per 365 days) PAR; MO; QLL (30 per 30 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 29 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg fluphenazine decanoate fluphenazine hcl injection fluphenazine hcl oral flurbiprofen fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG

Nivel de Requisitos/ medicamento Límites

4

4

PAR; MO; QLL (180 per 30 days) PAR; MO; QLL (90 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) MO; QLL (600 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO

4

MO

2 2 3

MO MO MO; QLL (90 per 30 days) MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) MO QLL (720 per 30 days) MO; QLL (30 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) MO; QLL (60 per 30 days) MO; QLL (45 per 30 days)

4

2 2 2 2 2 3

3 3 4 4 4 4 4 4 4

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

gabapentin oral capsule 100 mg

2

gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml

2

gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG GABITRIL ORAL TABLET 16 MG galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet GEODON INTRAMUSCULAR GILENYA

4

GLATOPA

5

guanfacine oral tablet extended release 24 hr

4

guanidine haloperidol haloperidol decanoate haloperidol lactate injection

4 2 4 4

3 4

4

MO; QLL (1080 per 30 days) MO; QLL (360 per 30 days) MO; QLL (270 per 30 days) MO; QLL (2160 per 30 days) QLL (2160 per 30 days)

4

MO; QLL (180 per 30 days) MO; QLL (135 per 30 days) MO

5

MO

4

MO; QLL (30 per 30 days)

3

MO; QLL (180 per 30 days) MO; QLL (60 per 30 days) MO

4

4 4 5

PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (30 per 30 days) MO MO MO MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 30 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

haloperidol lactate oral HETLIOZ

2

hydrocodoneacetaminophen oral solution 2.5-167 mg/5 ml hydrocodoneacetaminophen oral solution 7.5-325 mg/ 15 ml hydrocodoneacetaminophen oral tablet 10-325 mg, 5325 mg, 7.5-325 mg hydrocodoneibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg hydromorphone (pf) injection solution 1 mg/ml hydromorphone (pf) injection solution 10 mg/ml hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution hydromorphone injection syringe 1 mg/ ml hydromorphone injection syringe 2 mg/ ml hydromorphone injection syringe 4 mg/ ml hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg

3

5

4

3

3

4

4

4

4 4

4

4

3 4

MO

Nombre del medicamento

ibuprofen oral suspension PAR; MO; QLL ibuprofen oral tablet (30 per 30 400 mg, 600 mg, 800 days) mg QLL (2700 per ibuprofen-oxycodone 30 days) imipramine hcl INVEGA ORAL TABLET MO; QLL EXTENDED RELEASE (2700 per 30 24HR 1.5 MG days) INVEGA ORAL TABLET EXTENDED RELEASE MO; QLL (360 24HR 3 MG per 30 days) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG MO; QLL (480 INVEGA ORAL TABLET per 30 days) EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MO; QLL (120 MG/1.5 ML, 78 MG/ per 30 days) 0.5 ML INVEGA SUSTENNA MO INTRAMUSCULAR SYRINGE 39 MG/0.25 ML MO; QLL (180 INVEGA TRINZA per 30 days) INTRAMUSCULAR SYRINGE 273 MG/ 0.875 ML INVEGA TRINZA QLL (180 per INTRAMUSCULAR 30 days) SYRINGE 410 MG/ 1.315 ML MO INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 MO; QLL (360 ML per 30 days) INVEGA TRINZA MO; QLL (180 INTRAMUSCULAR SYRINGE 819 MG/ per 30 days) 2.625 ML

Nivel de Requisitos/ medicamento Límites 1

MO

1

MO

4

MO; QLL (28 per 2 days) PAR; MO MO; QLL (240 per 30 days)

4 5

5

MO; QLL (120 per 30 days)

5

MO; QLL (60 per 30 days)

5

MO; QLL (30 per 30 days)

5

MO; QLL (2 per 28 days)

4

MO; QLL (2 per 28 days)

5

MO; QLL (0.875 per 90 days)

5

MO; QLL (1.315 per 90 days)

5

MO; QLL (1.75 per 90 days)

5

MO; QLL (2.625 per 90 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 31 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg lamotrigine oral tablet 25 mg lamotrigine oral tablet, chewable dispersible LATUDA ORAL TABLET 120 MG

4

LATUDA ORAL TABLET 20 MG

4

LATUDA ORAL TABLET 40 MG

4

4

3

2 3 5

LATUDA ORAL TABLET 60 MG

4

LATUDA ORAL TABLET 80 MG

5

levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/ 100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet 1,000 mg

4

4

Nombre del medicamento

MO; QLL (120 per 30 days)

Nivel de Requisitos/ medicamento Límites

levetiracetam oral tablet 250 mg, 500 mg, 750 mg MO; QLL (240 levetiracetam oral per 30 days) tablet extended release 24 hr 500 mg MO levetiracetam oral tablet extended release 24 hr 750 mg MO lithium carbonate oral capsule 150 mg, 300 mg MO lithium carbonate oral PAR; MO; QLL capsule 600 mg (30 per 30 lithium carbonate oral days) tablet PAR; MO; QLL lithium carbonate oral (240 per 30 tablet extended days) release PAR; MO; QLL lithium citrate oral (120 per 30 solution 8 meq/5 ml days) lorazepam oral tablet PAR; MO; QLL (75 per 30 loxapine succinate oral days) capsule 10 mg, 5 mg PAR; MO; QLL loxapine succinate oral (60 per 30 capsule 25 mg, 50 mg days) LYRICA ORAL CAPSULE 100 MG

3

MO

4

MO; QLL (180 per 30 days)

4

MO; QLL (120 per 30 days)

1

MO

2

MO

2

MO

2

MO

2

MO

3 3

MO; QLL (90 per 30 days) MO

4

MO

4

LYRICA ORAL CAPSULE 150 MG

4

LYRICA ORAL CAPSULE 200 MG

4

LYRICA ORAL CAPSULE 225 MG, 300 MG

4

LYRICA ORAL CAPSULE 25 MG

4

LYRICA ORAL CAPSULE 50 MG

4

PAR; MO; QLL (180 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (90 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (720 per 30 days) PAR; MO; QLL (360 per 30 days)

MO

4

MO

4

MO

4

4

MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 32 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento LYRICA ORAL CAPSULE 75 MG

Nivel de Requisitos/ medicamento Límites 4

LYRICA ORAL SOLUTION

4

maprotiline oral tablet 25 mg maprotiline oral tablet 50 mg maprotiline oral tablet 75 mg MARPLAN meclofenamate oral meloxicam oral suspension meloxicam oral tablet

4

memantine oral solution memantine oral tablet 10 mg memantine oral tablet 5 mg MESTINON ORAL SYRUP MESTINON TIMESPAN methadone intensol

3

methadone oral concentrate methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml

3

methadone oral tablet 10 mg methadone oral tablet 5 mg methadone oral tablet, soluble methadose oral concentrate methadose oral tablet, soluble

3

4 4 4 4 3 1

3 3 4 4 3

3 4

3 3 3 3

PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (900 per 30 days) MO; QLL (270 per 30 days) MO; QLL (135 per 30 days) MO MO MO MO; QLL (300 per 30 days) MO; QLL (30 per 30 days) MO; QLL (300 per 30 days) MO; QLL (60 per 30 days) MO; QLL (90 per 30 days) MO MO MO; QLL (180 per 30 days) MO; QLL (180 per 30 days) MO; QLL (900 per 30 days) MO; QLL (1800 per 30 days) MO; QLL (180 per 30 days) MO; QLL (360 per 30 days) QLL (30 per 30 days) MO; QLL (180 per 30 days) MO; QLL (30 per 30 days)

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

methylphenidate oral tablet MIRAPEX ORAL TABLET 0.25 MG, 0.75 MG mirtazapine oral tablet 15 mg mirtazapine oral tablet 30 mg mirtazapine oral tablet 45 mg mirtazapine oral tablet 7.5 mg mirtazapine oral tablet,disintegrating 15 mg mirtazapine oral tablet,disintegrating 30 mg mirtazapine oral tablet,disintegrating 45 mg modafinil oral tablet 100 mg

3

modafinil oral tablet 200 mg

5

molindone morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ml morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine intravenous cartridge 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml

4 4

4 2 2 2 3 4

MO; QLL (90 per 30 days) MO MO; QLL (90 per 30 days) MO; QLL (45 per 30 days) MO; QLL (30 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days)

3

MO; QLL (45 per 30 days)

3

MO; QLL (30 per 30 days)

4

PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (60 per 30 days)

4 4

MO; QLL (180 per 30 days) MO; QLL (120 per 30 days)

4

QLL (180 per 30 days)

3

MO; QLL (270 per 30 days) QLL (120 per 30 days)

4

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 33 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

morphine intravenous solution 10 mg/ml, 50 mg/ml morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml morphine intravenous solution 4 mg/ml, 8 mg/ml morphine intravenous syringe 2 mg/ml, 4 mg/ml morphine oral solution 10 mg/5 ml

4

morphine oral solution 20 mg/5 ml (4 mg/ml)

3

morphine oral tablet 15 mg morphine oral tablet 30 mg morphine oral tablet extended release 100 mg, 30 mg, 60 mg morphine oral tablet extended release 15 mg morphine oral tablet extended release 200 mg morphine rectal

3

nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone injection solution naloxone injection syringe 0.4 mg/ml naloxone injection syringe 1 mg/ml naltrexone

2 4

4

4

4

3

3 4

3

4

3

MO; QLL (120 per 30 days) QLL (120 per 30 days)

MO; QLL (180 per 30 days) QLL (120 per 30 days) MO; QLL (2700 per 30 days) MO; QLL (1350 per 30 days) MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) MO; QLL (90 per 30 days) MO; QLL (60 per 30 days)

4

MO; QLL (180 per 30 days) MO MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) MO

4

MO

4

2

MO

2

MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

NAMENDA ORAL SOLUTION NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 28-10 MG naproxen oral suspension naproxen oral tablet naproxen oral tablet, delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg naratriptan

3

nefazodone oral tablet 100 mg nefazodone oral tablet 150 mg nefazodone oral tablet 200 mg nefazodone oral tablet 250 mg nefazodone oral tablet 50 mg NEUPRO

3

nortriptyline oral capsule nortriptyline oral solution NUEDEXTA NUPLAZID

5

olanzapine intramuscular olanzapine oral tablet 10 mg

4

3

MO; QLL (300 per 30 days) MO; QLL (56 per 365 days)

3

MO; QLL (30 per 30 days)

3

MO

2

MO

1 1

MO MO

1

MO

4

2

MO; QLL (9 per 30 days) MO; QLL (180 per 30 days) MO; QLL (120 per 30 days) MO; QLL (90 per 30 days) MO; QLL (72 per 30 days) MO; QLL (360 per 30 days) MO; QLL (30 per 30 days) MO

4

MO

3

MO; QLL (60 per 30 days) PAR; LA; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (60 per 30 days)

4 3 3 4 3

3

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 34 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

olanzapine oral tablet 15 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 20 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet, disintegrating 10 mg olanzapine oral tablet, disintegrating 15 mg olanzapine oral tablet, disintegrating 20 mg olanzapine oral tablet, disintegrating 5 mg ONFI ORAL SUSPENSION

3

oxcarbazepine oral suspension oxcarbazepine oral tablet 150 mg, 300 mg oxcarbazepine oral tablet 600 mg oxycodone oral capsule

4

MO; QLL (40 per 30 days) MO; QLL (240 per 30 days) MO; QLL (30 per 30 days) MO; QLL (120 per 30 days) MO; QLL (80 per 30 days) MO; QLL (60 per 30 days) MO; QLL (40 per 30 days) MO; QLL (30 per 30 days) MO; QLL (120 per 30 days) PAR; MO; QLL (480 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (60 per 30 days) MO MO PAR; MO; QLL (120 per 30 days) MO

ONFI ORAL TABLET 10 MG

4

ONFI ORAL TABLET 20 MG

5

ORAP oxaprozin oxazepam

4 4 4

3

MO

4

MO

4

oxycodone oral concentrate oxycodone oral solution

4

MO; QLL (360 per 30 days) MO; QLL (360 per 30 days) MO; QLL (1800 per 30 days)

3 3 3 3 4 4 5 4 4

4

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

oxycodone oral tablet 10 mg, 5 mg oxycodone oral tablet 15 mg oxycodone oral tablet 20 mg, 30 mg oxycodoneacetaminophen oral solution oxycodoneacetaminophen oral tablet 10-325 mg, 2.5325 mg, 7.5-325 mg oxycodoneacetaminophen oral tablet 5-325 mg oxycodone-aspirin

3

paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg

4

4 4 3

MO; QLL (360 per 30 days) MO; QLL (540 per 30 days) MO; QLL (180 per 30 days) QLL (1800 per 30 days)

4

MO; QLL (360 per 30 days)

3

MO; QLL (360 per 30 days)

4

MO; QLL (360 per 30 days) MO; QLL (240 per 30 days)

4

MO; QLL (120 per 30 days)

4

MO; QLL (60 per 30 days)

4

MO; QLL (30 per 30 days)

2

MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) MO; QLL (60 per 30 days) MO; QLL (45 per 30 days) MO; QLL (180 per 30 days)

2 2 2 4

4

MO; QLL (90 per 30 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 35 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION PEGANONE perphenazine phenelzine phenobarbital oral elixir

Nivel de Requisitos/ medicamento Límites 4

4 4 4 3 4

phenobarbital oral tablet 100 mg

4

phenobarbital oral tablet 15 mg

4

phenobarbital oral tablet 16.2 mg

4

phenobarbital oral tablet 30 mg

4

phenobarbital oral tablet 32.4 mg

4

phenobarbital oral tablet 60 mg

4

phenobarbital oral tablet 64.8 mg

4

phenobarbital oral tablet 97.2 mg

4

PHENYTEK phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet, chewable phenytoin sodium extended

4 3

MO; QLL (60 per 30 days) MO; QLL (900 per 30 days) MO MO MO PAR; MO; QLL (3000 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (800 per 30 days) PAR; MO; QLL (741 per 30 days) PAR; MO; QLL (400 per 30 days) PAR; MO; QLL (370 per 30 days) PAR; MO; QLL (200 per 30 days) PAR; MO; QLL (185 per 30 days) PAR; MO; QLL (123 per 30 days) MO

3

MO

3

MO

3

MO

Nombre del medicamento phenytoin sodium intravenous solution phenytoin sodium intravenous syringe pimozide piroxicam POTIGA ORAL TABLET 200 MG POTIGA ORAL TABLET 300 MG, 400 MG POTIGA ORAL TABLET 50 MG pramipexole oral tablet primidone PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline pyridostigmine bromide oral tablet quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg RAZADYNE ORAL TABLET 4 MG regonol REQUIP ORAL TABLET 1 MG, 4 MG, 5 MG

Nivel de Requisitos/ medicamento Límites 4

MO

4 3 3 4 5 4 2

MO MO MO; QLL (90 per 30 days) MO; QLL (90 per 30 days) MO; QLL (270 per 30 days) MO

3 4

MO MO; QLL (120 per 30 days)

4

MO; QLL (480 per 30 days)

4

MO; QLL (240 per 30 days)

4 3

MO MO

3

4

MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (960 per 30 days) MO; QLL (80 per 30 days) MO; QLL (60 per 30 days) MO; QLL (480 per 30 days) MO

4 4

MO

3 3 3 3 3

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 36 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG REXULTI ORAL TABLET 3 MG, 4 MG

Nivel de Requisitos/ medicamento Límites 5

5

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg

4

risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet, disintegrating 0.25 mg

2

risperidone oral tablet, disintegrating 0.5 mg risperidone oral tablet, disintegrating 1 mg risperidone oral tablet, disintegrating 2 mg risperidone oral tablet, disintegrating 3 mg risperidone oral tablet, disintegrating 4 mg

4

5

PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) MO; QLL (2 per 28 days)

MO; QLL (2 per 28 days)

5

MO

3

MO; QLL (480 per 30 days) MO; QLL (1920 per 30 days) MO; QLL (960 per 30 days) MO; QLL (480 per 30 days) MO; QLL (240 per 30 days) MO; QLL (150 per 30 days) MO; QLL (120 per 30 days) MO; QLL (1920 per 30 days) MO; QLL (960 per 30 days) MO; QLL (480 per 30 days) MO; QLL (240 per 30 days) MO; QLL (150 per 30 days) MO; QLL (120 per 30 days)

2

2 2 2 2 4

4 4 4 4

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

rivastigmine tartrate

4

ropinirole oral tablet ropinirole oral tablet extended release 24 hr roweepra ROZEREM

2 4

SABRIL ORAL POWDER IN PACKET

4

SABRIL ORAL TABLET

5

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG selegiline hcl SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate

4

3 3

MO; QLL (60 per 30 days) MO MO

MO; QLL (30 per 30 days) PAR; MO; LA; QLL (180 per 30 days) PAR; MO; LA; QLL (180 per 30 days) MO; QLL (60 per 30 days)

4

MO; QLL (240 per 30 days)

4

MO; QLL (120 per 30 days)

3 4

MO PAR; MO; QLL (150 per 30 days)

4

PAR; MO; QLL (120 per 30 days)

4

PAR; MO; QLL (80 per 30 days)

5

PAR; MO; QLL (60 per 30 days)

4

PAR; MO; QLL (480 per 30 days) MO; QLL (300 per 30 days)

4

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 37 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG SPRITAM ORAL TABLET FOR SUSPENSION 1, 000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG SUBOXONE SUBLINGUAL FILM 123 MG SUBOXONE SUBLINGUAL FILM 20.5 MG SUBOXONE SUBLINGUAL FILM 4-1 MG SUBOXONE SUBLINGUAL FILM 8-2 MG sulindac oral tablet 150 mg sulindac oral tablet 200 mg sumatriptan

2

sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge

2

2 2 4

4

4

4

4

4

4

4

4

1 2 4

4

MO; QLL (60 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO

Nombre del medicamento

sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml SURMONTIL PAR; QLL (60 SYMBYAX ORAL per 30 days) CAPSULE 12-25 MG, 12-50 MG, 6-50 MG SYMBYAX ORAL PAR; QLL (120 CAPSULE 3-25 MG per 30 days) TECFIDERA tetrabenazine oral PAR; MO; QLL tablet 12.5 mg (60 per 30 days) tetrabenazine oral PAR; MO; QLL tablet 25 mg (30 per 30 days) thioridazine PAR; MO; QLL thiothixene (60 per 30 tiagabine days) tizanidine oral tablet PAR; MO; QLL tolcapone (360 per 30 topiramate oral days) capsule, sprinkle PAR; MO; QLL topiramate oral tablet (180 per 30 100 mg days) PAR; MO; QLL topiramate oral tablet (90 per 30 200 mg days) MO topiramate oral tablet 25 mg MO topiramate oral tablet MO; QLL (12 50 mg per 30 days) MO; QLL (9 tramadol oral tablet per 30 days) MO; QLL (4 tramadolper 30 days) acetaminophen tranylcypromine

Nivel de Requisitos/ medicamento Límites 4

MO; QLL (4 per 30 days)

4

MO; QLL (4 per 30 days) QLL (4 per 30 days)

4

4 4

PAR; MO MO; QLL (30 per 30 days)

4

MO; QLL (90 per 30 days) PAR; MO PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO MO MO MO MO PAR; MO

5 5

5

4 2 4 2 5 4 2

3

2

2

3 4 4

PAR; MO; QLL (480 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (1920 per 30 days) PAR; MO; QLL (960 per 30 days) MO; QLL (240 per 30 days) MO; QLL (240 per 30 days) MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 38 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento trazodone oral tablet 100 mg, 150 mg trazodone oral tablet 300 mg trazodone oral tablet 50 mg trifluoperazine oral tablet 1 mg, 2 mg trifluoperazine oral tablet 10 mg, 5 mg TRINTELLIX ORAL TABLET 10 MG TRINTELLIX ORAL TABLET 20 MG TRINTELLIX ORAL TABLET 5 MG TYSABRI valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 100 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg venlafaxine oral tablet 75 mg

Nivel de Requisitos/ medicamento Límites 2

MO

4

MO

1

MO

3

MO

4

MO

4 4 4 5 4 3 2

ST; QLL (60 per 30 days) ST; QLL (30 per 30 days) ST; QLL (120 per 30 days) PAR; MO; LA MO MO MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

venlafaxine oral tablet extended release 24hr 150 mg VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 MG venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg VERSACLOZ

4

MO; QLL (60 per 30 days)

4

MO; QLL (30 per 30 days)

4

MO; QLL (180 per 30 days)

4

MO; QLL (90 per 30 days)

5

VIIBRYD ORAL TABLET 10 MG

4

VIIBRYD ORAL TABLET 20 MG

4

VIIBRYD ORAL TABLET 40 MG

4

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) VIMPAT INTRAVENOUS

4

VIMPAT ORAL SOLUTION

4

VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG VIMPAT ORAL TABLET 200 MG VIMPAT ORAL TABLET 50 MG VOLTAREN TOPICAL GEL 1 %

4

VRAYLAR ORAL CAPSULE 1.5 MG

4

QLL (600 per 30 days) ST; MO; QLL (120 per 30 days) ST; MO; QLL (60 per 30 days) ST; MO; QLL (30 per 30 days) ST; MO; QLL (30 per 30 days) QLL (1200 per 30 days) MO; QLL (1200 per 30 days) MO; QLL (120 per 30 days) MO; QLL (80 per 30 days) MO; QLL (60 per 30 days) MO; QLL (240 per 30 days) MO; QLL (1000 per 30 days) PAR; QLL (30 per 30 days)

2

3

2

MO; QLL (60 per 30 days) MO; QLL (180 per 30 days)

3

MO; QLL (90 per 30 days)

4

MO; QLL (113 per 30 days) MO; QLL (450 per 30 days) MO; QLL (300 per 30 days) MO; QLL (225 per 30 days) MO; QLL (150 per 30 days)

3 3 4 3

4

4 4 4 3

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK XENAZINE ORAL TABLET 12.5 MG

5

PAR; QLL (30 per 30 days)

4

XENAZINE ORAL TABLET 25 MG

5

PAR; QLL (7 per 365 days) PAR; MO; LA; QLL (240 per 30 days) PAR; MO; LA; QLL (120 per 30 days) PAR; MO; LA; QLL (540 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) MO

5

XYREM

5

zaleplon oral capsule 10 mg

3

zaleplon oral capsule 5 mg

3

ZARONTIN ORAL CAPSULE zenzedi oral tablet 10 mg

4

zenzedi oral tablet 5 mg

4

ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg, 80 mg zolpidem oral

4

zonisamide oral capsule 100 mg, 50 mg zonisamide oral capsule 25 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG

3

PAR; MO; QLL (180 per 30 days) PAR; MO; QLL (90 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) MO

2

MO

5

PAR; QLL (2 per 28 days)

4

4 4 4

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

ZYPREXA RELPREVV 5 INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG Cardiovascular, Hypertension / Lipids ACCUPRIL 4 ACCURETIC ORAL 4 TABLET 20-12.5 MG, 20-25 MG acebutolol 2 ADALAT CC 4 afeditab cr 2 AGGRENOX 4

PAR; MO; QLL (2 per 28 days)

MO MO

ALDACTAZIDE ORAL TABLET 25-25 MG ALTACE ORAL CAPSULE 10 MG, 2.5 MG, 5 MG ALTOPREV

4

MO MO MO ST; MO; QLL (60 per 30 days) MO

4

MO

4

amiloride amiloridehydrochlorothiazide amiodarone intravenous solution amiodarone intravenous syringe amiodarone oral tablet 100 mg, 200 mg amiodarone oral tablet 400 mg amlodipine besylate oral tablet 10 mg, 2.5 mg amlodipine besylate oral tablet 5 mg amlodipineatorvastatin amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-20 mg, 5-40 mg

3 2

PAR; MO; QLL (30 per 30 days) MO MO

4

B/D PAR; MO

4

B/D PAR

2

MO

4

MO

1

MO; QLL (30 per 30 days)

1

MO; QLL (45 per 30 days) MO; QLL (30 per 30 days) MO

3 3

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

amlodipine-benazepril oral capsule 5-10 mg amlodipine-valsartan

2

MO

4

amlodipine-valsartanhcthiazid aspirin-dipyridamole

4

MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) ST; MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days)

ATACAND HCT ORAL TABLET 16-12.5 MG ATACAND HCT ORAL TABLET 32-12.5 MG, 32-25 MG ATACAND ORAL TABLET 16 MG, 4 MG, 8 MG ATACAND ORAL TABLET 32 MG atenolol atenololchlorthalidone atorvastatin

3

4 4

4

4 1 1 6

AVALIDE ORAL TABLET 150-12.5 MG AVALIDE ORAL TABLET 300-12.5 MG AVAPRO

4

AZOR

3

benazepril benazeprilhydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 5-6.25 mg benazeprilhydrochlorothiazide oral tablet 20-25 mg BENICAR HCT

6 2

BENICAR ORAL TABLET 20 MG, 40 MG

3

4 4

MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO MO MO; CG; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; CG MO

1

MO

3

MO; QLL (30 per 30 days) MO; QLL (30 per 30 days)

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

BENICAR ORAL TABLET 5 MG betaxolol oral BIDIL

3

bisoprolol fumarate bisoprololhydrochlorothiazide BRILINTA

2 1

bumetanide injection bumetanide oral tablet 0.5 mg, 1 mg bumetanide oral tablet 2 mg BYSTOLIC CALAN ORAL TABLET 120 MG CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG candesartan oral tablet 16 mg, 4 mg, 8 mg candesartan oral tablet 32 mg candesartanhydrochlorothiazid oral tablet 16-12.5 mg candesartanhydrochlorothiazid oral tablet 32-12.5 mg, 3225 mg captopril oral tablet 100 mg, 25 mg, 50 mg captopril oral tablet 12.5 mg captoprilhydrochlorothiazide oral tablet 25-15 mg, 50-15 mg, 50-25 mg captoprilhydrochlorothiazide oral tablet 25-25 mg CARDIZEM LA ORAL TABLET EXTENDED

4 2

MO; QLL (60 per 30 days) MO MO

3

MO

3 4

MO MO

4

MO

3

MO; QLL (60 per 30 days)

4

MO; QLL (30 per 30 days) MO; QLL (60 per 30 days)

2 3

3

3

MO; QLL (60 per 30 days) MO MO; QLL (180 per 30 days) MO MO

3

MO; QLL (30 per 30 days)

2

MO

1

MO

2

MO

1

MO

4

MO

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Nombre del medicamento RELEASE 24 HR 180 MG, 240 MG, 420 MG cartia xt carvedilol chlorothiazide oral tablet 250 mg chlorothiazide oral tablet 500 mg chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg cholestyramine (with sugar) cholestyramine light cilostazol clonidine hcl oral tablet clonidine transdermal patch clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg colestipol COREG CR CORZIDE ORAL TABLET 40-5 MG COUMADIN ORAL COZAAR ORAL TABLET 100 MG COZAAR ORAL TABLET 25 MG, 50 MG CRESTOR DEMSER DIGITEK ORAL TABLET 125 MCG DIGOX ORAL TABLET 125 MCG digoxin oral solution 50 mcg/ml digoxin oral tablet 125 mcg dilt-xr diltiazem hcl intravenous

Nivel de Requisitos/ medicamento Límites

2 1 1

MO MO MO

2

MO

4 2

MO MO

2

MO

2 2 2

MO MO MO

4 4 2 2 4 4 4 4

MO; QLL (4 per 28 days) MO; QLL (1 per 30 days) MO; QLL (30 per 30 days) MO ST; MO MO

4 3

MO MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO MO

3

MO

3

MO

4 3

3 2 4

MO MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral capsule, extended release 360 mg diltiazem hcl oral capsule, extended release 420 mg diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral capsule,extended release 24hr 360 mg diltiazem hcl oral tablet DIOVAN HCT

2

MO

4

MO

3

MO

2

MO

3

MO

2

MO

4

MO

1

MO

4

MO; QLL (30 per 30 days)

dofetilide doxazosin DYAZIDE EFFIENT

4 2 4 3

ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG enalapril maleate enalaprilhydrochlorothiazide enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml

3 3 6 6 5 5

MO MO MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (74 per 30 days) MO; CG MO; CG MO; QLL (84 per 30 days) MO; QLL (28 per 30 days)

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/ 0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml eplerenone eprosartan

5

EXFORGE

4

EXFORGE HCT

4

felodipine oral tablet extended release 24 hr 10 mg felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg fenofibrate micronized oral capsule 130 mg fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate micronized oral capsule 43 mg fenofibrate nanocrystallized 48 mg, 145 mg fenofibrate oral tablet 160 mg fenofibrate oral tablet 54 mg fenofibric acid (choline) dr capsules flecainide oral tablet 100 mg, 50 mg flecainide oral tablet 150 mg

3

4

4

4

4 3

2

4 3

3 3

3 2 3 3 4

Nombre del medicamento

MO; QLL (22.4 fluvastatin oral capsule per 30 days) 20 mg fluvastatin oral capsule 40 mg MO; QLL (8.4 fondaparinux per 30 days) subcutaneous syringe 10 mg/0.8 ml MO; QLL (11.2 fondaparinux per 30 days) subcutaneous syringe 2.5 mg/0.5 ml MO; QLL (16.8 fondaparinux per 30 days) subcutaneous syringe 5 mg/0.4 ml MO fondaparinux MO; QLL (30 subcutaneous syringe per 30 days) 7.5 mg/0.6 ml MO; QLL (30 fosinopril per 30 days) fosinoprilMO; QLL (30 hydrochlorothiazide per 30 days) oral tablet 10-12.5 mg MO fosinoprilhydrochlorothiazide oral tablet 20-12.5 mg MO furosemide injection furosemide oral solution 10 mg/ml MO furosemide oral solution 40 mg/5 ml (8 MO; QLL (30 mg/ml) per 30 days) furosemide oral tablet gemfibrozil oral MO heparin (porcine) in 5 % dex intravenous MO parenteral solution 12, 500 unit/250 ml heparin (porcine) in 5 MO; QLL (30 % dex intravenous per 30 days) parenteral solution 20, MO; QLL (30 000 unit/500 ml (40 per 30 days) unit/ml) MO heparin (porcine) in 5 % dex intravenous parenteral solution 25, MO 000 unit/250 ml(100 unit/ml), 25,000 unit/ MO 500 ml (50 unit/ml)

Nivel de Requisitos/ medicamento Límites 3 4 5

MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (24 per 30 days)

4

MO; QLL (15 per 30 days)

5

MO; QLL (12 per 30 days)

5

MO; QLL (18 per 30 days)

1 3

MO MO

2

MO

4 2

MO MO

1

MO

1 2 4

MO MO B/D PAR

4

4

MO

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

heparin (porcine) in nacl (pf) intravenous parenteral solution 1, 000 unit/500 ml, 2,000 unit/1,000 ml heparin (porcine) injection cartridge heparin (porcine) injection solution heparin(porcine) in 0.45% nacl intravenous parenteral solution 12, 500 unit/250 ml heparin(porcine) in 0.45% nacl intravenous parenteral solution 25, 000 unit/250 ml heparin(porcine) in 0.45% nacl intravenous parenteral solution 25, 000 unit/500 ml heparin, porcine (pf) injection solution hydralazine injection hydralazine oral hydrochlorothiazide HYZAAR

4

indapamide irbesartan

1 1

irbesartanhydrochlorothiazide oral tablet 150-12.5 mg irbesartanhydrochlorothiazide oral tablet 300-12.5 mg isosorbide dinitrate oral tablet 10 mg, 20 mg, 5 mg isosorbide dinitrate oral tablet 30 mg

2

B/D PAR

4

B/D PAR; MO

4

B/D PAR; MO

4

B/D PAR

4

4

B/D PAR; MO

4

MO

4 2 1 4

MO MO MO MO; QLL (30 per 30 days) MO MO; QLL (30 per 30 days) MO; QLL (60 per 30 days)

3

MO; QLL (30 per 30 days)

4

MO

3

MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

isosorbide dinitrate oral tablet extended release isosorbide mononitrate isradipine jantoven oral tablet 1 mg, 10 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg jantoven oral tablet 2 mg JUXTAPID labetalol intravenous solution labetalol oral tablet 100 mg, 200 mg labetalol oral tablet 300 mg LANOXIN ORAL TABLET 125 MCG, 62.5 MCG LIPITOR ORAL TABLET 10 MG lisinopril lisinoprilhydrochlorothiazide LOFIBRA ORAL CAPSULE 200 MG LOPID losartan oral tablet 100 mg

4

MO

2 3 1

MO MO MO

2

MO

5 4

PAR; MO; LA MO

2

MO

3

MO

3

MO

4

MO

6 6

MO; CG MO; CG

4

losartan oral tablet 25 mg, 50 mg

6

losartanhydrochlorothiazide

6

LOTENSIN ORAL TABLET 20 MG, 40 MG lovastatin oral tablet 10 mg, 20 mg

4

MO; QLL (30 per 30 days) MO MO; CG; QLL (30 per 30 days) MO; CG; QLL (60 per 30 days) MO; CG; QLL (30 per 30 days) MO

lovastatin oral tablet 40 mg

6

4 6

6

MO; CG; QLL (30 per 30 days) MO; CG; QLL (60 per 30 days)

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Nombre del medicamento MAVIK ORAL TABLET 1 MG, 2 MG MAXZIDE MAXZIDE-25MG methyclothiazide metolazone oral tablet 10 mg, 5 mg metolazone oral tablet 2.5 mg metoprolol succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg metoprolol succinate oral tablet extended release 24 hr 200 mg metoprolol tahydrochlorothiaz oral tablet 100-25 mg, 10050 mg metoprolol tahydrochlorothiaz oral tablet 50-25 mg metoprolol tartrate intravenous solution metoprolol tartrate intravenous syringe metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 37.5 mg, 75 mg mexiletine oral capsule 150 mg, 250 mg mexiletine oral capsule 200 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-25 MG MICARDIS HCT ORAL TABLET 80-12.5 MG MICARDIS ORAL TABLET 20 MG, 40 MG MICARDIS ORAL TABLET 80 MG

Nivel de Requisitos/ medicamento Límites 4

MO

4 4 3 3

MO MO MO MO

2

MO

2

MO

3

3

2

4

MO

MO

MO

MO

4 1

MO

1

3

MO

4

MO

4

MO; QLL (30 per 30 days)

4 4 4

MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (60 per 30 days)

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

MICROZIDE MINIPRESS ORAL CAPSULE 2 MG minoxidil oral moexipril moexiprilhydrochlorothiazide MULTAQ

4 4

MO MO

2 2 2

MO MO MO

3

nadolol oral tablet 20 mg, 40 mg nadolol oral tablet 80 mg nadololbendroflumethiazide niacin oral tablet extended release 24 hr 1,000 mg, 750 mg niacin oral tablet extended release 24 hr 500 mg NIACOR nicardipine intravenous solution nicardipine oral nifedical xl nifedipine oral tablet extended release 24hr 30 mg, 60 mg nifedipine oral tablet extended release 24hr 90 mg nifedipine oral tablet extended release 30 mg, 60 mg nifedipine oral tablet extended release 90 mg nimodipine nitroglycerin intravenous nitroglycerin transdermal patch 24 hour NITROSTAT NORPACE

3

MO; QLL (60 per 30 days) MO

4

MO

3

MO

4

MO; QLL (60 per 30 days)

4

MO; QLL (30 per 30 days)

3 4

MO MO

2 2 2

MO MO MO

3

MO

2

MO

3

MO

4 4

MO B/D PAR

2

MO

3 4

MO PAR; MO

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

NORVASC ORAL TABLET 10 MG, 2.5 MG NORVASC ORAL TABLET 5 MG omega-3 acid ethyl esters pacerone oral tablet 100 mg, 400 mg pacerone oral tablet 200 mg pentoxifylline perindopril erbumine pindolol oral tablet 10 mg pindolol oral tablet 5 mg PRADAXA

4

PRALUENT PEN

5

PRALUENT SYRINGE

3

MO; QLL (30 per 30 days) MO; QLL (45 per 30 days) PAR; MO

4

MO

4

2 2 2 3 2 4

5

PRAVACHOL ORAL TABLET 20 MG pravastatin oral tablet 10 mg, 20 mg, 40 mg

4

pravastatin oral tablet 80 mg prazosin oral capsule 1 mg, 2 mg prazosin oral capsule 5 mg prevalite PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml PROCARDIA PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG

1

6

2 3 2 4 4

Nombre del medicamento PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG PROMACTA ORAL TABLET 50 MG

propafenone oral tablet 150 mg, 225 mg propafenone oral MO tablet 300 mg propranolol MO intravenous MO propranolol oral MO capsule,extended release 24 hr 120 mg, MO 160 mg propranolol oral MO; QLL (60 capsule,extended per 30 days) PAR; MO; QLL release 24 hr 60 mg, 80 mg (2 per 28 propranolol oral days) PAR; MO; QLL solution propranolol oral tablet (2 per 28 10 mg, 20 mg, 40 mg, days) 80 mg MO propranolol oral tablet MO; CG; QLL 60 mg propranolol(30 per 30 hydrochlorothiazid days) quinapril oral tablet 10 MO; QLL (30 mg, 5 mg per 30 days) quinapril oral tablet 20 MO mg, 40 mg quinaprilMO hydrochlorothiazide quinidine sulfate oral MO tablet MO ramipril RANEXA MO REPATHA SURECLICK

Nivel de Requisitos/ medicamento Límites 5

3

PAR; MO; LA; QLL (30 per 30 days) PAR; MO; LA; QLL (60 per 30 days) MO

4

MO

5

4 3

MO

2

MO

2

MO

1

MO

2

MO

2

MO

1

MO

2

MO

2

MO

2

MO

1 3 5

MO MO PAR; MO; QLL (3 per 28 days) PAR; MO; QLL (3 per 28 days)

4 4 4

PAR; MO MO

REPATHA SYRINGE

5

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

reserpine oral tablet 0.1 mg rosuvastatin

1

simvastatin

6

sorine oral tablet 120 mg, 160 mg sorine oral tablet 240 mg sorine oral tablet 80 mg sotalol af oral tablet 120 mg, 160 mg sotalol af oral tablet 80 mg sotalol oral tablet 120 mg, 160 mg, 240 mg sotalol oral tablet 80 mg spironolactonhydrochlorothiaz spironolactone oral tablet 100 mg spironolactone oral tablet 25 mg, 50 mg SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 360 mg taztia xt oral capsule, extended release 300 mg TEKTURNA

2

TEKTURNA HCT

4

telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg

3

2 1 2 1 2 1 3 3 2 4

2

3

4

4 4

PAR; MO

Nombre del medicamento

telmisartanhydrochlorothiazid oral QLL (30 per 30 tablet 40-12.5 mg, 8025 mg days) MO; CG; QLL telmisartanhydrochlorothiazid oral (30 per 30 tablet 80-12.5 mg days) TENORETIC 100 MO TENORETIC 50 terazosin TIAZAC MO TIKOSYN timolol maleate oral MO tablet 10 mg, 5 mg timolol maleate oral MO tablet 20 mg torsemide oral tablet MO 10 mg, 5 mg torsemide oral tablet MO 100 mg, 20 mg trandolapril MO tranexamic acid intravenous MO triamterenehydrochlorothiazid oral MO capsule 37.5-25 mg triamtereneMO hydrochlorothiazid oral tablet TRIBENZOR MO TRICOR ORAL TABLET 48 MG TRILIPIX ORAL MO CAPSULE,DELAYED RELEASE(DR/EC) 45 MG MO; QLL (30 TWYNSTA ORAL per 30 days) TABLET 40-10 MG, 40MO; QLL (30 5 MG, 80-5 MG per 30 days) valsartan oral tablet MO; QLL (30 160 mg per 30 days) valsartan oral tablet MO; QLL (60 320 mg per 30 days) valsartan oral tablet 40 mg, 80 mg

Nivel de Requisitos/ medicamento Límites 4

MO; QLL (30 per 30 days)

4

MO; QLL (60 per 30 days)

4 4 1 4 4 2

MO MO MO MO MO MO

3

MO

2

MO

3

MO

1 3

MO MO

1

MO

1

MO

3 4

MO; QLL (30 per 30 days) MO

4

MO

4

MO; QLL (30 per 30 days)

4

MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (90 per 30 days)

4 4

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Nombre del medicamento valsartanhydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 32012.5 mg, 80-12.5 mg valsartanhydrochlorothiazide oral tablet 320-25 mg VASCEPA VASERETIC VASOTEC ORAL TABLET 2.5 MG VECAMYL verapamil intravenous solution verapamil intravenous syringe verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule, ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg verapamil oral capsule, ext rel. pellets 24 hr 360 mg verapamil oral tablet verapamil oral tablet extended release 120 mg, 120 mg (24 hours) verapamil oral tablet extended release 180 mg, 240 mg warfarin WELCHOL XARELTO ORAL TABLET 10 MG, 20 MG XARELTO ORAL TABLET 15 MG XARELTO ORAL TABLETS,DOSE PACK ZESTORETIC ZESTRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG

Nivel de Requisitos/ medicamento Límites 2

3

MO; QLL (30 per 30 days)

MO; QLL (30 per 30 days)

4 4 4

MO MO MO

4 4

MO

4 3

MO

2

MO

3

1 2

1

1 3 3 3 3 4 4

MO

MO MO

MO

MO MO MO; QLL (30 per 30 days) MO; QLL (42 per 30 days) MO; QLL (102 per 365 days) MO MO

Nombre del medicamento ZETIA

Nivel de Requisitos/ medicamento Límites 4

ZIAC ORAL TABLET 104 6.25 MG, 5-6.25 MG ZOCOR ORAL TABLET 4 10 MG, 5 MG Dermatologicals/Topical Therapy acitretin 5 acyclovir topical 4 adapalene topical gel 0.1 % alclometasone topical cream alclometasone topical ointment amcinonide ammonium lactate betamethasone dipropionate topical cream betamethasone dipropionate topical lotion betamethasone dipropionate topical ointment betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical gel betamethasone, augmented topical lotion betamethasone, augmented topical ointment

MO; QLL (30 per 30 days) MO MO

4

MO MO; QLL (30 per 30 days) MO

4

MO

3

MO

4 2 4

MO MO MO

3

MO

4

MO

2

MO

4

MO

3

MO

3

MO

4

MO

4

MO

4

MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 48 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

calcipotriene scalp

4

calcipotriene topical

4

ciclodan topical cream ciclodan topical solution ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension claravis oral capsule 10 mg, 20 mg, 40 mg claravis oral capsule 30 mg clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab clindamycin-benzoyl peroxide topical gel clobetasol scalp clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol-emollient topical cream clobetasol-emollient topical foam

3 3

MO; QLL (60 per 30 days) MO; QLL (120 per 30 days) MO PAR; MO

3

MO

4 4

MO MO

2

PAR; MO

3

MO

5

MO

3

MO

3

MO

3

MO

2

MO

4

MO

2 2

MO MO

4

MO

2 4

MO MO

3

MO

4

MO

4

Nivel de Requisitos/ medicamento Límites

CLOBEX TOPICAL LOTION clotrimazole topical cream clotrimazole topical solution clotrimazolebetamethasone topical cream clotrimazolebetamethasone topical lotion cormax scalp DENAVIR

4

MO

3

MO

2

MO

3

MO

4

MO

DERMATOP TOPICAL OINTMENT desonide desoximetasone topical cream desoximetasone topical gel desoximetasone topical ointment 0.25 % diclofenac sodium topical gel 3 %

4

MO; QLL (5 per 2 days) MO

4 4

MO MO

4

MO

4

MO

5

diflorasone DIPROLENE AF econazole topical ELIDEL

4 4 2 4

ELOCON TOPICAL SOLUTION ery pads erythromycin with ethanol erythromycin-benzoyl peroxide fluocinolone topical cream fluocinolone topical ointment

4

PAR; MO; QLL (100 per 30 days) MO MO MO PAR; MO; QLL (100 per 90 days) MO

3 2

MO MO

3

MO

4

MO

4

MO

2 3

MO

4

3

Nombre del medicamento

MO MO

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Nombre del medicamento fluocinolone topical solution fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e fluorouracil topical cream 5 % fluorouracil topical solution fluticasone topical cream fluticasone topical lotion fluticasone topical ointment gentamicin topical halobetasol propionate hydrocortisone butyrate topical cream hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone topical cream 1 % hydrocortisone topical cream 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 % hydrocortisone topical ointment 2.5 % hydrocortisone valerate hydrocortisone-min oilwht pet imiquimod

Nivel de Requisitos/ medicamento Límites 4

MO

2

MO

3 3

MO MO

4

MO

3 4

MO MO

4

MO

3

MO

4

MO

3

MO

3 4 2 4

MO MO MO MO

2

MO

1

MO

2

MO

3

MO

1

MO

2

MO

4

MO

2

MO

4

MO

Nombre del medicamento ketoconazole topical cream ketoconazole topical shampoo lidocaine hcl laryngotracheal lidocaine hcl mucous membrane lidocaine hcl urethral lidocaine topical adhesive patch, medicated lidocaine topical ointment lidocaine viscous lidocaine-prilocaine topical cream lindane topical shampoo malathion methoxsalen rapid metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical lotion mometasone topical mupirocin calcium mupirocin topical ointment myorisan oral capsule 10 mg, 20 mg, 40 mg nyamyc nystatin topical cream nystatin topical ointment nystatin topical powder nystatin-triamcinolone nystop PANRETIN permethrin topical cream PICATO podofilox

Nivel de Requisitos/ medicamento Límites 3

MO

2

MO

2

MO

2

MO

2 4

4

MO PAR; MO; QLL (90 per 30 days) MO

2 4

MO MO

4

MO

4 5 4

MO PAR; MO MO

3

MO

4

MO

2 4 2

MO MO MO

4

MO

3 2 3

MO MO MO

3

MO

4 3 5 3

MO MO MO MO

4 4

MO MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 50 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

prednicarbate rosadan topical cream rosadan topical gel SANTYL

4 2 2 4

selenium sulfide topical lotion SILVADENE silver sulfadiazine ssd sulfacetamide sodium (acne) TAZORAC TEMOVATE TOPICAL CREAM TEMOVATE TOPICAL OINTMENT thermazene tretinoin topical cream

2

MO MO MO MO; QLL (30 per 30 days) MO

3 2 2 4

MO MO MO MO

4 4

PAR; MO MO

4

MO

2 3

1

MO MO; QLL (45 per 30 days) MO; QLL (45 per 30 days) MO

2

MO

tretinoin topical gel 0.01 %, 0.025 % triamcinolone acetonide topical cream 0.025 % triamcinolone acetonide topical cream 0.1 %, 0.5 % triamcinolone acetonide topical lotion 0.025 % triamcinolone acetonide topical lotion 0.1 % triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % trianex triderm topical cream UVADEX VALCHLOR zenatane oral capsule 10 mg, 20 mg, 40 mg ZENATANE ORAL CAPSULE 30 MG

3

3

MO

4

MO

2

MO

2 1 4 5 4 3

MO MO MO MO MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

Diagnostics / Miscellaneous Agents acamprosate 4 acetic acid irrigation 2 acetylcysteine 2 intravenous ADAGEN 5 alendronate oral tablet 6 40 mg

MO MO MO MO MO; CG; QLL (30 per 30 days) MO PAR; MO; LA PAR; MO

anagrelide ARALAST NP BUPHENYL ORAL TABLET bupropion hcl (smoking deter) CARBAGLU CHANTIX

3 5 5

CHANTIX CONTINUING MONTH BOX

4

CHANTIX STARTING MONTH BOX

4

CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX E 2.75%/ D10W SUL FREE CLINIMIX E 2.75%/ D5W SULF FREE d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 25 % in water (d25w)

4

MO; QLL (60 per 30 days) PAR; MO; LA PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (56 per 28 days) PAR; MO; QLL (106 per 365 days) B/D PAR

4

B/D PAR

4

B/D PAR

2 5 4

4 4 4

MO

4

MO

4 4

MO

4

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Nombre del medicamento dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) dextrose with sodium chloride disulfiram etidronate disodium oral tablet 200 mg etidronate disodium oral tablet 400 mg EXJADE INCRELEX kionex kionex (with sorbitol) lactated ringers irrigation levocarnitine (with sugar) levocarnitine intravenous levocarnitine oral tablet midodrine neomycin-polymyxin b gu NICOTROL NS

Nivel de Requisitos/ medicamento Límites 4 4 4 4

MO MO

4 4 4

Nivel de Requisitos/ medicamento Límites

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG ORFADIN ORAL CAPSULE 20 MG PHYSIOLYTE PHYSIOSOL IRRIGATION pilocarpine hcl oral PROLASTIN-C RAVICTI

5

RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM RENVELA ORAL TABLET

5

MO

riluzole ringers irrigation risedronate oral tablet 30 mg

4 4 4

sodium chloride 0.9 % intravenous sodium chloride irrigation sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal sps (with sorbitol) oral sps (with sorbitol) rectal SYPRINE THIOLA

4 4 4 5 5

MO MO

2

MO

5 5 3 3 4

PAR; MO; LA PAR; MO; LA MO MO MO

3

B/D PAR; MO

4

B/D PAR; MO

3

MO

4 4

MO MO

3

MO; QLL (120 per 30 days)

MO PAR; LA PAR; MO; QLL (525 per 30 days) MO; QLL (180 per 30 days)

5

MO; QLL (90 per 30 days)

3

4

MO; QLL (270 per 30 days) MO MO ST; MO; QLL (30 per 30 days) MO

4

MO

5 4

PAR; MO MO

4

MO

4 4 3

LA

5

MO

4

4

Nombre del medicamento

4

4 4 4

MO

5 5

MO MO

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

water for irrigation, 4 sterile Ear, Nose / Throat Medications acetasol hc 4 acetic acid otic 3 acetic acid-aluminum 2 acetate azelastine nasal 4 chlorhexidine gluconate mucous membrane CIPRODEX denta 5000 plus dentagel fluocinolone acetonide oil otic hydrocortisone-acetic acid ipratropium bromide nasal neomycin-polymyxinhc otic ofloxacin otic paroex oral rinse periogard sf 5000 plus triamcinolone acetonide dental TYZINE NASAL DROPS 0.05 % Endocrine/Diabetes acarbose oral tablet 100 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg ACTHAR H.P. ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG ACTOPLUS MET XR ORAL TABLET, ER

1

MO

MO MO MO MO; QLL (30 per 25 days) MO

3 2 2 4

MO MO MO MO

4

MO

2 2

MO; QLL (30 per 30 days) MO

2 1 1 2 4

MO MO MO MO MO

4

MO

3 3 3 5 4

4

MO; QLL (90 per 30 days) MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) PAR; MO MO; QLL (60 per 30 days)

MO; QLL (45 per 30 days)

Nombre del medicamento MULTIPHASE 24 HR 30-1,000 MG alcohol pads ALDURAZYME AMARYL ORAL TABLET 1 MG AMARYL ORAL TABLET 2 MG AMARYL ORAL TABLET 4 MG ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) androxy BYDUREON

Nivel de Requisitos/ medicamento Límites

1 5 4 4 4 3

MO PAR; MO MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) PAR; MO; QLL (150 per 30 days)

3

PAR; MO; QLL (112.5 per 30 days)

3

PAR; MO; QLL (150 per 30 days)

4 3

PAR; MO MO; QLL (4 per 28 days) MO; QLL (2.4 per 30 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/ DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/ DOSE (250 MCG/ML) 1.2 ML cabergoline calcitonin (salmon)

3

calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule calcitriol oral solution CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

3

MO; QLL (1.2 per 30 days)

3 3 4

MO MO; QLL (4 per 30 days) MO

2 3 5

B/D PAR; MO B/D PAR; MO PAR; MO

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

cortisone CYCLOSET

4 4

CYTOMEL danazol oral desmopressin injection desmopressin nasal aerosol,spray desmopressin nasal solution desmopressin nasal spray,non-aerosol desmopressin oral dexamethasone oral elixir 0.5mg/ml dexamethasone oral solution 0.5mg/ml dexamethasone oral tablet 0.5 mg, 1.5 mg dexamethasone oral tablet 0.75 mg, 1 mg, 4 mg, 6 mg dexamethasone oral tablet 2 mg dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection doxercalciferol intravenous DUETACT ORAL TABLET 30-4 MG ELAPRASE FABRAZYME fludrocortisone fortical gauze pads 2 x 2

1

glimepiride oral tablet 1 mg

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

glimepiride oral tablet 2 mg

6

glimepiride oral tablet 4 mg

6

4 3 5 4

MO ST; MO; QLL (180 per 30 days) MO MO MO MO

glipizide oral tablet 10 mg

6

3

MO

glipizide oral tablet 5 mg

6

4

MO glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet 2.5-250 mg glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) GLUCOPHAGE ORAL TABLET 1,000 MG GLUCOPHAGE ORAL TABLET 500 MG GLUCOPHAGE ORAL TABLET 850 MG GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 MG GLUCOTROL ORAL TABLET 10 MG

1

4 4

MO MO

4

MO

1

MO

2

MO

3

MO

4

MO

4

MO

4

B/D PAR

4

MO; QLL (30 per 30 days) PAR; MO PAR; MO MO MO; QLL (4 per 30 days) MO; QLL (200 per 30 days) MO; CG; QLL (240 per 30 days)

5 5 3 3

6

6

6

2 3

MO; CG; QLL (120 per 30 days) MO; CG; QLL (60 per 30 days) MO; CG; QLL (120 per 30 days) MO; CG; QLL (240 per 30 days) MO; QLL (60 per 30 days) MO; CG; QLL (240 per 30 days) MO; CG; QLL (120 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days)

3 4

MO MO

4

MO; QLL (76 per 30 days) MO; QLL (153 per 30 days) MO; QLL (90 per 30 days) MO; QLL (120 per 30 days)

4 4 4

4

MO; QLL (80 per 30 days)

4

MO; QLL (120 per 30 days)

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

GLUCOTROL ORAL TABLET 5 MG GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 MG GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 5 MG GLUCOVANCE

4

GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 MG GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 500 MG HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50-50 HUMALOG MIX 50-50 KWIKPEN HUMALOG MIX 75-25 HUMALOG MIX 75-25 KWIKPEN HUMAPEN LUXURA HD

4

HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydrocortisone oral tablet 10 mg, 5 mg hydrocortisone oral tablet 20 mg

3 3

Nivel de Requisitos/ medicamento Límites

insulin pen needle

3

INSULIN SYRINGE (DISP) U-100 SYRINGE 0.3 ML, 1 ML, 1/2 ML JANUMET

3

3

3 3 3 3

JANUMET XR ORAL MO; QLL (120 TABLET, ER per 30 days) MULTIPHASE 24 HR 100-1,000 MG PAR; MO; QLL JANUMET XR ORAL (120 per 30 TABLET, ER days) MULTIPHASE 24 HR 50-1,000 MG, 50-500 MO; QLL (60 MG per 30 days) JANUVIA ORAL TABLET 100 MG MO; QLL (120 JANUVIA ORAL TABLET per 30 days) 25 MG JANUVIA ORAL TABLET 50 MG MO JARDIANCE MO MO JENTADUETO MO

3 3

MO MO

3

MO; QLL (200 per 30 days) MO MO

KORLYM KUVAN ORAL TABLET, SOLUBLE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH levothyroxine oral levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine intravenous liothyronine oral tablet 25 mcg, 5 mcg

4

4

4

4

4

MO; QLL (240 per 30 days) MO; QLL (60 per 30 days)

Nombre del medicamento

MO; QLL (240 per 30 days)

3 3 3 3

MO MO MO

3

MO

3

MO

2

MO

3

MO; QLL (200 per 30 days) MO; QLL (200 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days)

3

MO; QLL (60 per 30 days)

3

5 5

MO; QLL (30 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) PAR; MO PAR; MO

3 3 3 3 1 2

MO MO MO MO MO MO

5

MO

3

MO

3 3 4

3

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

liothyronine oral tablet 50 mcg metformin oral tablet 1,000 mg

4

MO

6

metformin oral tablet 500 mg

6

metformin oral tablet 850 mg

6

MO; CG; QLL (76 per 30 days) MO; CG; QLL (153 per 30 days) MO; CG; QLL (90 per 30 days) MO; CG; QLL (120 per 30 days) MO; CG; QLL (80 per 30 days) MO; QLL (75 per 30 days)

metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg metformin oral tablet extended release 24hr 500 mg metformin oral tablet, er gast.retention 24 hr 1,000 mg metformin oral tablet, er gast.retention 24 hr 500 mg methimazole oral tablet 10 mg methimazole oral tablet 5 mg methylprednisolone acetate methylprednisolone oral tablet 16 mg, 4 mg, 8 mg methylprednisolone oral tablet 32 mg methylprednisolone oral tablets,dose pack methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

6

6

4

6

4

4

MO; CG; QLL (150 per 30 days) MO; QLL (60 per 30 days) MO; QLL (120 per 30 days)

3

MO

2

MO

4

MO

4

MO

3

MO

3

MO

4

MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

methylprednisolone sodium succ intravenous MIACALCIN INJECTION MIACALCIN NASAL

4

MO

4 4

MYOZYME NAGLAZYME nateglinide oral tablet 120 mg nateglinide oral tablet 60 mg NATPARA

5 5 4

needles, insulin disp., safety NOVOPEN ECHO

3

oxandrolone oral tablet 10 mg

5

oxandrolone oral tablet 2.5 mg

3

pamidronate intravenous recon soln pamidronate intravenous solution 30 mg/10 ml (3 mg/ ml), 90 mg/10 ml (9 mg/ml) pamidronate intravenous solution 60 mg/10 ml (6 mg/ ml) paricalcitol oral capsule 1 mcg, 2 mcg paricalcitol oral capsule 4 mcg pioglitazone oral tablet 15 mg pioglitazone oral tablet 30 mg pioglitazone oral tablet 45 mg

4

B/D PAR; MO MO; QLL (4 per 30 days) PAR; MO PAR; MO; LA MO; QLL (90 per 30 days) MO; QLL (180 per 30 days) PAR; MO; LA; QLL (2 per 28 days) MO; QLL (200 per 30 days) MO; QLL (200 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (120 per 30 days) MO

4

MO

4

B/D PAR; MO

4

B/D PAR; MO

5

B/D PAR; MO

2

MO; QLL (90 per 30 days) MO; QLL (45 per 30 days) MO; QLL (30 per 30 days)

4 5

3

2 2

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Nombre del medicamento pioglitazoneglimepiride pioglitazonemetformin PRECOSE ORAL TABLET 100 MG PRECOSE ORAL TABLET 25 MG PRECOSE ORAL TABLET 50 MG prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml) prednisolone sodium phosphate oral solution 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet, disintegrating prednisone intensol prednisone oral solution prednisone oral tablet 1 mg prednisone oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg prednisone oral tablets,dose pack PROGLYCEM propylthiouracil repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg repaglinide oral tablet 2 mg SAMSCA ORAL TABLET 15 MG

Nivel de Requisitos/ medicamento Límites 4

3

MO; QLL (30 per 30 days) MO; QLL (90 per 30 days) MO; QLL (90 per 30 days) MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) MO

3

MO

4 4 4 4

4

4

5

SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG SENSIPAR ORAL TABLET 90 MG SOMAVERT STIMATE SYMLINPEN 120

3

SYMLINPEN 60

4

SYNAREL SYNJARDY

5 4

SYNTHROID TANZEUM

4 4

TAPAZOLE testosterone cypionate testosterone enanthate testosterone transdermal gel

4 4 4

testosterone transdermal gel in MO metered-dose pump MO 1.25 gram/ actuation MO; QLL (960 (1 %) per 30 days) testosterone MO; QLL (480 transdermal gel in per 30 days) metered-dose pump 10 MO; QLL (240 mg/0.5 gram / actuation per 30 days) PAR; MO; QLL testosterone transdermal gel in (30 per 30 packet 1 % (25 mg/ days) 2.5gram)

3

MO

1

MO

1

MO

5

5 5 4 5

MO

2

4

5

MO

MO MO

4

Nivel de Requisitos/ medicamento Límites

SAMSCA ORAL TABLET 30 MG

4 3

5 3 4

Nombre del medicamento

3

PAR; MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (120 per 30 days) PAR; MO MO PAR; MO; QLL (11 per 30 days) PAR; MO; QLL (6 per 30 days) PAR; MO PAR; MO; QLL (60 per 30 days) MO MO; QLL (4 per 28 days) MO MO MO PAR; MO; QLL (300 per 30 days) PAR; MO; QLL (300 per 30 days)

3

PAR; MO; QLL (120 per 30 days)

3

PAR; MO; QLL (225 per 30 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 57 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

testosterone transdermal gel in packet 1 % (50 mg/5 gram) tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg tolbutamide

3

TOUJEO SOLOSTAR TRADJENTA

3 3

triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml TRULICITY

4

unithroid VICTOZA 2-PAK

1 3

VICTOZA 3-PAK

3

VPRIV ZAVESCA zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Gastroenterology alosetron

5 5 5

APRISO ASACOL HD

2 2 3

4

4

5

5

5

3 3

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

PAR; MO; QLL atropine injection (300 per 30 syringe 0.05 mg/ml, days) 0.1 mg/ml balsalazide MO; QLL (120 budesonide oral per 30 days) CIMZIA MO; QLL (60 per 30 days) MO; QLL (180 CIMZIA POWDER FOR per 30 days) RECONST MO MO; QLL (30 CIMZIA STARTER KIT per 30 days) MO compro constulose CREON ORAL CAPSULE, DELAYED RELEASE(DR/ EC) 12,000-38,000 -60, MO; QLL (2 000 UNIT, 24,000-76, per 28 days) 000 -120,000 UNIT, 3, 000-9,500- 15,000 MO UNIT, 6,000-19,000 MO; QLL (9 30,000 UNIT per 30 days) CREON ORAL CAPSULE, MO; QLL (9 DELAYED RELEASE(DR/ per 30 days) EC) 36,000-114,000PAR; MO PAR; MO; LA 180,000 UNIT cromolyn oral PAR CYSTADANE DELZICOL ORAL CAPSULE (WITH DEL PAR; MO REL TABLETS) DEXILANT PAR; MO

4

dicyclomine oral capsule dicyclomine oral PAR; MO; QLL solution dicyclomine oral tablet (60 per 30 DIPENTUM days) diphenoxylateMO atropine oral liquid MO diphenoxylateatropine oral tablet

4 5 5

4 3 3

MO MO PAR; MO; QLL (6 per 28 days) PAR; MO; QLL (6 per 28 days) PAR; MO; QLL (6 per 28 days) PAR; MO MO MO

5

MO

4 5 3

MO MO

4

2

ST; MO; QLL (30 per 30 days) MO

4

MO

2 5 1

MO MO MO

3

MO

5

5

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

dronabinol oral capsule 10 mg

5

dronabinol oral capsule 2.5 mg, 5 mg

4

EMEND ORAL CAPSULE 125 MG

3

EMEND ORAL CAPSULE 40 MG

3

EMEND ORAL CAPSULE 80 MG

3

EMEND ORAL CAPSULE,DOSE PACK

3

EMEND ORAL SUSPENSION FOR RECONSTITUTION enulose esomeprazole sodium intravenous famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine intravenous famotidine oral suspension famotidine oral tablet 20 mg, 40 mg GATTEX 30-VIAL GATTEX ONE-VIAL gavilyte-c gavilyte-g gavilyte-n generlac glycopyrrolate injection glycopyrrolate oral tablet hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema

3

2 4

B/D PAR; MO; QLL (120 per 30 days) B/D PAR; MO; QLL (120 per 30 days) B/D PAR; MO; QLL (5 per 30 days) B/D PAR; MO; QLL (1 per 2 days) B/D PAR; MO; QLL (10 per 30 days) B/D PAR; MO; QLL (15 per 30 days) B/D PAR; QLL (15 per 30 days) MO

4 4

MO

4 4

MO MO

2

MO

5 5 2 2 2 3 4

MO MO MO MO MO MO MO

4

MO

1 4

MO

Nombre del medicamento lactulose lansoprazole oral capsule,delayed release(dr/ec) LIALDA LINZESS loperamide oral capsule meclizine oral tablet 12.5 mg, 25 mg MESALAMINE ORAL mesalamine rectal mesalamine with cleansing wipe methscopolamine oral metoclopramide hcl injection solution metoclopramide hcl injection syringe metoclopramide hcl oral solution metoclopramide hcl oral tablet misoprostol oral tablet 100 mcg misoprostol oral tablet 200 mcg MOVIPREP nizatidine oral capsule 150 mg nizatidine oral capsule 300 mg omeprazole oral capsule,delayed release(dr/ec) 10 mg, 40 mg omeprazole oral capsule,delayed release(dr/ec) 20 mg ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl intravenous

Nivel de Requisitos/ medicamento Límites 2 4

MO MO; QLL (30 per 30 days)

3 3 3

MO MO MO

2

MO

3 3 4

MO MO

4 4

MO MO

4 2

MO

2

MO

3

MO

4

MO

4 3

MO MO

4

MO

2

MO; QLL (30 per 30 days)

3

MO; QLL (30 per 30 days)

4

MO

4 4

MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 59 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

ondansetron hcl oral tablet 4 mg, 8 mg

3

ondansetron oral tablet,disintegrating 4 mg ondansetron oral tablet,disintegrating 8 mg opium tincture OSMOPREP pantoprazole intravenous pantoprazole oral

4

paregoric peg 3350-electrolytes oral recon soln 23622.74-6.74 -5.86 gram peg 3350-electrolytes oral recon soln 24022.72-6.72 -5.84 gram peg-electrolyte soln PENTASA polyethylene glycol 3350 oral prochlorperazine prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral procto-pak proctosol hc proctozone-hc propantheline ranitidine hcl injection solution 25 mg/ml ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg RELISTOR SUBCUTANEOUS SOLUTION

2 2

3

2 4 4 2

B/D PAR; MO; QLL (90 per 30 days) B/D PAR; MO; QLL (90 per 30 days) B/D PAR; MO; QLL (90 per 30 days) MO MO MO MO; QLL (30 per 30 days) MO MO

2

2 3 2

MO MO

4 4

PAR; MO PAR; MO

2

PAR; MO

2 2 1 4 4

MO MO MO MO MO

4

MO

2

MO

4

PAR; MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

RELISTOR 5 SUBCUTANEOUS SYRINGE REMICADE 5 SUCRAID 5 sucralfate oral tablet 2 sulfasalazine 2 SUPREP BOWEL PREP 3 KIT trilyte with flavor 2 packets UCERIS ORAL 5 ursodiol 4 Immunology, Vaccines / Biotechnology ACTHIB (PF) 3 ACTIMMUNE 5 ADACEL(TDAP 3 ADOLESN/ADULT)(PF) ARANESP (IN 5 POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ ML ARANESP (IN 4 POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ ML, 60 MCG/ML ARANESP (IN 4 POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/ 0.42 ML, 40 MCG/0.4 ML, 60 MCG/0.3 ML ARANESP (IN 5 POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML ARCALYST 5

PAR; MO

PAR; MO MO MO MO MO MO MO MO MO PAR; MO MO PAR; MO

PAR; MO

PAR; MO

PAR; MO

PAR; MO

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

AVONEX (WITH ALBUMIN)

5

4

PAR; MO; QLL (4 per 28 days) PAR; MO; QLL (4 per 28 days) PAR; MO; QLL (4 per 28 days) PAR; MO; QLL (4 per 28 days) MO

AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE AVONEX INTRAMUSCULAR SYRINGE KIT BCG VACCINE, LIVE (PF) BETASERON SUBCUTANEOUS KIT BEXSERO (PF) BIVIGAM BOOSTRIX TDAP BOTOX CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM CERVARIX VACCINE (PF) DAPTACEL (DTAP PEDIATRIC) (PF) DYSPORT ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) EXTAVIA SUBCUTANEOUS KIT EXTAVIA SUBCUTANEOUS RECON SOLN fomepizole GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMUNEX-C GARDASIL (PF) GARDASIL 9 (PF)

5

5

PAR; MO

5

5

3 5 3 4 5

3

MO PAR; MO MO PAR; MO PAR; MO

MO

3

MO

4 3 3

PAR; MO B/D PAR; MO B/D PAR; MO

5

PAR; MO

5

PAR

5 3 5 5

MO PAR; MO PAR; MO PAR; MO

5 3 3

PAR; MO MO MO

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML HIBERIX (PF) ILARIS (PF) IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRON A INJECTION IPOL INJECTION SUSPENSION IXIARO (PF) M-M-R II (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENOMUNE - A/C/Y/ W-135 MENOMUNE - A/C/Y/ W-135 (PF) MENVEO A-C-Y-W135-DIP (PF) NEUPOGEN NORDITROPIN FLEXPRO OCTAGAM OMNITROPE PEDVAX HIB (PF) PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/ 0.5 ML PLEGRIDY

3

MO

3

MO

PRIVIGEN

5

3

3 5 3

PAR; MO; LA MO

3 5 3

MO PAR; MO MO

3 3 3

MO MO MO

3 3

MO

3

MO

5 5

PAR; MO PAR; MO

5 5 3 5

PAR; MO PAR; MO MO PAR; MO

5

PAR; MO; QLL (1 per 28 days) PAR; MO

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Nombre del medicamento PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML PROLEUKIN PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX ROTATEQ VACCINE SYLATRON tetanus,diphtheria tox ped(pf) TETANUS-DIPHTHERIA TOXOIDS-TD THYMOGLOBULIN TICE BCG TRUMENBA TWINRIX (PF) TYPHIM VI INTRAMUSCULAR SOLUTION TYPHIM VI INTRAMUSCULAR SYRINGE

Nivel de Requisitos/ medicamento Límites 4

5

5 3 3 4 5 5 5 3

3

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

PAR; MO; QLL VAQTA (PF) 3 (12 per 28 INTRAMUSCULAR days) SUSPENSION VAQTA (PF) 3 INTRAMUSCULAR SYRINGE PAR; MO; QLL VARIVAX (PF) 3 (12 per 28 VARIZIG 3 days) XEOMIN 4 INTRAMUSCULAR MO RECON SOLN 100 MO UNIT, 50 UNIT XEOMIN 5 MO INTRAMUSCULAR RECON SOLN 200 UNIT PAR; MO YF-VAX (PF) 3 PAR; MO ZOSTAVAX (PF) 3 PAR; MO Musculoskeletal / Rheumatology B/D PAR; MO ACTEMRA 5 INTRAVENOUS VIAL alendronate oral 3 MO solution alendronate oral tablet 6 10 mg, 5 mg

3

3 3 5 3

MO PAR; MO MO

3

MO

5 4 3 3 3

B/D PAR MO MO MO

3

MO

alendronate oral tablet 35 mg, 70 mg

6

allopurinol aloprim BENLYSTA BONIVA INTRAVENOUS colchicine-probenecid COLCRYS DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML)

1 4 5 4 3 3 5 5

5

5

MO

MO MO PAR; MO

PAR; MO

MO MO PAR; MO MO; QLL (300 per 28 days) MO; CG; QLL (30 per 30 days) MO; CG; QLL (4 per 28 days) MO PAR; MO B/D PAR; MO MO MO MO PAR; MO; QLL (8 per 28 days) PAR; MO; QLL (4.08 per 28 days) PAR; MO; QLL (8 per 28 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 62 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

ENBREL SURECLICK

5

FORTEO

5

FOSAMAX ORAL TABLET 70 MG

4

FOSAMAX PLUS D

4

HUMIRA PEDIATRIC CROHN'S START

5

HUMIRA PEN

5

HUMIRA PEN CROHN'S-UC-HS START

5

HUMIRA PEN PSORIASIS-UVEITIS

5

PAR; MO; QLL (8 per 28 days) PAR; MO; QLL (3 per 28 days) ST; MO; QLL (4 per 28 days) ST; MO; QLL (4 per 28 days) PAR; MO; QLL (4.8 per 365 days) PAR; MO; QLL (3.2 per 28 days) PAR; MO; QLL (9.6 per 365 days) PAR; MO; QLL (3.2 per 28 days) PAR; MO; QLL (2 per 28 days)

5

ORENCIA (WITH MALTOSE) probenecid PROLIA

5

raloxifene

3

RIDAURA risedronate oral tablet 150 mg

4 4

risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack) risedronate oral tablet 5 mg

4

risedronate oral tablet, delayed release (dr/ec) SAVELLA ORAL TABLET 100 MG SAVELLA ORAL TABLET 12.5 MG SAVELLA ORAL TABLET PAR; MO; QLL 25 MG (3.2 per 28 SAVELLA ORAL TABLET days) 50 MG SAVELLA ORAL B/D PAR; MO TABLETS,DOSE PACK SIMPONI MO

4

3

MO PAR; MO; QLL (2 per 365 days) MO; QLL (30 per 30 days) MO ST; MO; QLL (1 per 28 days) ST; MO; QLL (4 per 28 days) ST; MO; QLL (30 per 30 days) MO; QLL (4 per 28 days) MO; QLL (60 per 30 days) MO; QLL (480 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (110 per 365 days) PAR; MO; QLL (1 per 28 days) ST; MO

4 4 4 4

MO MO MO MO

4 4 4

MO MO MO

5

KINERET

5

leflunomide oral tablet 10 mg leflunomide oral tablet 20 mg

4

MO; QLL (1 per 28 days) PAR; MO; QLL (28 per 28 days) MO

3

MO

4 4 4

Nivel de Requisitos/ medicamento Límites

ORENCIA

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/ 0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/ 0.8 ML ibandronate intravenous solution ibandronate intravenous syringe ibandronate oral

5

Nombre del medicamento

ULORIC Obstetrics / Gynecology altavera (28) ALYACEN 1/35 (28) ALYACEN 7/7/7 (28) amethia 0.15 mg-30 mcg (84)/10 mcg (7) amethyst apri aranelle (28)

3 4

4

3 3 3 3 3 5

PAR; MO; QLL (4 per 28 days) PAR; MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 63 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

aviane azurette (28) balziva (28) blisovi fe 1.5/30 (28) briellyn camila CAZIANT (28) clindamycin phosphate vaginal cryselle (28) cyclafem 1/35 (28) cyclafem 7/7/7 (28) dasetta 1/35 (28) dasetta 7/7/7 (28) delestrogen depo-estradiol drospirenone-ethinyl estradiol elinest ELLA emoquette enpresse errin estarylla ESTRACE VAGINAL estradiol oral estradiol transdermal patch semiweekly

4 4 4 4 4 4 4 4

estradiol transdermal patch weekly

4

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml ESTRING

4

falmina (28) FEMRING

4 4

gildagia gildess 1.5/30 (21) gildess 1/20 (21) GILDESS FE 1.5/30 (28) GILDESS FE 1/20 (28)

4 4 4 4 4

4 4 4 4 4 4 3 4 4 3 4 4 4 4 4 1 4

4

MO MO MO MO MO MO MO MO

Nombre del medicamento

heather hydroxyprogesterone caproate introvale jolessa jolivette junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) MO junel fe 1/20 (28) MO kariva (28) MO kelnor 1/35 (28) MO LARIN 1/20 (21) MO LARIN FE 1.5/30 (28) MO LARIN FE 1/20 (28) MO leena 28 MO lessina levonest (28) MO levonorg-eth estrad MO triphasic MO levonorgestrel-ethinyl estrad oral tablet 0.1MO 20 mg-mcg, 0.15-0.03 MO mg MO levonorgestrel-ethinyl MO estrad oral tablet 90PAR; MO PAR; MO; QLL 20 mcg levonorgestrel-ethinyl (8 per 28 estrad oral tablets, days) PAR; MO; QLL dose pack,3 month levora-28 (4 per 28 loryna (28) days) low-ogestrel (28) MO lutera (28) lyza marlissa MO; QLL (1 per 90 days) medroxyprogesterone intramuscular MO medroxyprogesterone MO; QLL (1 oral per 90 days) MENEST MO methylergonovine oral MO metronidazole vaginal MO miconazole-3 vaginal MO suppository MO

Nivel de Requisitos/ medicamento Límites 4 5

MO

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO

4

MO

4

4

MO

4 4 4 4 4 4 4

MO MO MO MO MO MO MO

1

MO

4 4 2 4

PAR; MO MO MO MO; QLL (6 per 30 days)

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas de esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 64 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/ 30 (28) MICROGESTIN FE 1/20 (28) mono-linyah mononessa (28) MYZILRA necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) NOR-QD nora-be norethindrone (contraceptive) norethindrone acetate norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mgmcg nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) orsythia ORTHO MICRONOR philith PIMTREA (28) pirmella oral tablet 135 mg-mcg portia PREMARIN ORAL PREMARIN VAGINAL PREMPRO previfem progesterone micronized

Nivel de Requisitos/ medicamento Límites 4

MO

4

MO

4

MO

4

MO

4 4 4 4 4 4 4 4 4 4 4

MO MO MO

4 4

MO MO

4 4 4 4 4 4 4 4 4 4 4

MO MO MO MO MO MO MO MO MO MO MO

4 3 3 4 4 3

MO PAR; MO MO PAR; MO MO ST; MO

MO MO MO MO MO MO MO

Nombre del medicamento quasense reclipsen (28) sprintec (28) sronyx syeda terconazole vaginal cream terconazole vaginal suppository TILIA FE tranexamic acid oral tri-estarylla tri-legest fe tri-linyah tri-previfem (28) tri-sprintec (28) trinessa (28) trivora (28) vandazole velivet triphasic regimen (28) vestura (28) viorele (28) VYFEMLA (28) XULANE ZARAH zenchent (28) ZENCHENT FE zovia 1/35e (28) zovia 1/50e (28) Ophthalmology acetazolamide oral capsule, extended release acetazolamide oral tablet 125 mg acetazolamide oral tablet 250 mg acetazolamide sodium ALPHAGAN P OPHTHALMIC DROPS 0.1 % ALPHAGAN P OPHTHALMIC DROPS 0.15 %

Nivel de Requisitos/ medicamento Límites 4 4 4 4 4 3

MO MO MO MO MO MO

4

MO

4 4 4 4 4 4 4 4 4 2 4

MO MO MO MO MO MO MO MO MO MO MO

4 4 4 4 4 4 4 4 4

MO MO MO MO MO MO MO MO MO

4

MO

2

MO

3

MO

4 3

MO MO

4

MO

Puede encontrar información sobre lo que significan los símbolos y las abreviaturas en esta tabla visitando la Leyenda en la página 9. Core_16293_CG6_v16_1610_1 65 Fecha de entrada en vigencia 01 de octubre de 2016

Nombre del medicamento apraclonidine atropine ophthalmic drops azelastine ophthalmic AZOPT bacitracin ophthalmic bacitracin-polymyxin b ophthalmic BESIVANCE BETAGAN OPHTHALMIC DROPS 0.5 % betaxolol ophthalmic BETIMOL BETOPTIC S bimatoprost BLEPHAMIDE S.O.P. brimonidine ophthalmic drops 0.15 % brimonidine ophthalmic drops 0.2 % carteolol ciprofloxacin hcl ophthalmic COMBIGAN COSOPT cromolyn ophthalmic dexamethasone sodium phosphate ophthalmic diclofenac sodium ophthalmic dorzolamide dorzolamide-timolol DUREZOL erythromycin ophthalmic fluorometholone flurbiprofen sodium gentak ophthalmic ointment gentamicin ophthalmic ILEVRO

Nivel de Requisitos/ medicamento Límites 3 2

MO MO

3 4 4 3

MO MO MO MO

4 4

MO MO

4 4 4 3 4 3

2

2 2

MO MO MO MO MO MO

MO

MO MO

3 4 2 2

MO MO MO MO

2

MO

3 2 3 2

MO MO MO MO

2 1 2

MO MO MO

2 3

MO MO

Nombre del medicamento IOPIDINE OPHTHALMIC DROPS ISOPTO CARPINE ketorolac ophthalmic LACRISERT latanoprost levobunolol ophthalmic drops 0.5 % levofloxacin ophthalmic LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral metipranolol MOXEZA neo-polycin neo-polycin hc neomycin-bacitracinpoly-hc neomycin-bacitracinpolymyxin neomycin-polymyxin bdexameth neomycin-polymyxingramicidin neomycin-polymyxinhc ophthalmic NEVANAC ofloxacin ophthalmic PATADAY PAZEO PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2% pilocarpine hcl ophthalmic drops 4 % polycin polymyxin b sulftrimethoprim prednisolone acetate prednisolone sodium phosphate ophthalmic RESTASIS

Nivel de Requisitos/ medicamento Límites 4

MO

4 2 3 2 2

MO MO MO MO MO

4

MO

3

MO

4 3 3 2 2 3

MO

3

MO

2

MO

3

MO

3

MO

3 2 3 3 4 3

MO MO MO MO MO MO

4

MO

2 1

MO

2 2

MO MO

3

MO

MO MO MO

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

SIMBRINZA sulfacetamide sodium ophthalmic drops sulfacetamide sodium ophthalmic ointment sulfacetamideprednisolone timolol maleate ophthalmic drops timolol maleate ophthalmic gel forming solution TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE 0.25 % TIMOPTIC OPHTHALMIC DROPS 0.25 % TIMOPTIC-XE TOBRADEX OPHTHALMIC OINTMENT TOBRADEX ST tobramycin tobramycindexamethasone TRAVATAN Z trifluridine VIGAMOX XALATAN ZIRGAN Respiratory And Allergy acetylcysteine solution 100 mg/ml (10 %) acetylcysteine solution 200 mg/ml (20 %) ADEMPAS ADVAIR DISKUS

4 2

ADVAIR HFA

3

AEROSPAN

4

albuterol sulfate inhalation solution for

3

MO MO

3

MO

2

MO

1

MO

3

MO

4

MO

4

MO

4 3

MO MO

3 2 3

MO MO MO

3 4 3 4 4

MO MO MO MO MO

2 3 5 3

Nombre del medicamento nebulization 0.63 mg/ 3 ml, 1.25 mg/3 ml albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/ 0.5 ml, 5 mg/ml albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release 12 hr 4 mg albuterol sulfate oral tablet extended release 12 hr 8 mg aminophylline intravenous ANORO ELLIPTA

Nivel de Requisitos/ medicamento Límites

2

B/D PAR; MO; QLL (360 per 30 days)

2

B/D PAR; MO; QLL (60 per 30 days)

2

MO

4

MO

3

MO

4

MO

4 3

ARNUITY ELLIPTA

3

ASMANEX HFA

3

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH B/D PAR; MO ACTIVATED 110 MCG (30 DOSES) B/D PAR; MO ASMANEX TWISTHALER PAR; MO; LA INHALATION AEROSOL POWDR BREATH MO; QLL (60 ACTIVATED 110 MCG per 30 days) (7 DOSES), 220 MCG MO; QLL (12 (14 DOSES) per 30 days) QLL (18 per 30 ASMANEX TWISTHALER days) B/D PAR; MO; INHALATION AEROSOL QLL (360 per POWDR BREATH ACTIVATED 220 MCG 30 days)

3

MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (13 per 30 days) MO; QLL (0.14 per 30 days)

3

3

MO; QLL (0.24 per 30 days)

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

(120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) ATROVENT HFA

4

BREO ELLIPTA

3

cetirizine oral solution 1 mg/ml CINRYZE clemastine oral tablet 2.68 mg COMBIVENT RESPIMAT

2

cromolyn inhalation

2

5 4 4

DALIRESP

4

desloratadine oral tablet desloratadine oral tablet,disintegrating diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe DULERA

3

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML epinephrine injection auto-injector epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK

3

EPIPEN JR 2-PAK

4

ESBRIET

5

FIRAZYR FLOVENT DISKUS INHALATION BLISTER

2 4

4 3

4 4 4

5 3

Nombre del medicamento

WITH DEVICE 100 MCG/ACTUATION FLOVENT DISKUS MO; QLL (26 INHALATION BLISTER per 30 days) WITH DEVICE 250 MCG/ACTUATION, 50 MO; QLL (60 MCG/ACTUATION per 30 days) MO; QLL (300 FLOVENT HFA INHALATION HFA per 30 days) AEROSOL INHALER 110 PAR; MO MCG/ACTUATION PAR; MO FLOVENT HFA INHALATION HFA MO; QLL (8 AEROSOL INHALER 220 per 30 days) B/D PAR; MO; MCG/ACTUATION QLL (240 per FLOVENT HFA INHALATION HFA 30 days) PAR; MO; QLL AEROSOL INHALER 44 MCG/ACTUATION (30 per 30 flunisolide nasal spray, days) non-aerosol 25 mcg MO; QLL (30 (0.025 %) per 30 days) fluticasone nasal MO; QLL (30 per 30 days) FORADIL AEROLIZER PAR; MO

Nivel de Requisitos/ medicamento Límites

3

MO; QLL (240 per 30 days)

3

MO; QLL (12 per 30 days)

3

MO; QLL (24 per 30 days)

3

MO; QLL (11 per 30 days)

2

MO; QLL (75 per 30 days)

1

MO; QLL (16 per 30 days) MO; QLL (60 per 30 days) B/D PAR; MO

3

ipratropium bromide inhalation ipratropium-albuterol

3

KALYDECO ORAL TABLET

5

MO; QLL (2 per 2 days) MO

LETAIRIS

5

MO; QLL (2 per 2 days) MO; QLL (2 per 2 days) PAR; QLL (270 per 30 days) PAR; MO MO; QLL (60 per 30 days)

levalbuterol hcl inhalation solution for nebulization 0.31 mg/ 3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/ 3 ml

4

PAR; MO MO; QLL (13 per 30 days) MO

2

4

B/D PAR; MO; QLL (540 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; LA; QLL (30 per 30 days) B/D PAR; MO; QLL (270 per 30 days)

B/D PAR; MO; QLL (540 per 30 days)

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Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

levocetirizine oral tablet mometasone nasal

3

montelukast oral granules in packet montelukast oral tablet montelukast oral tablet,chewable NASONEX

4

OFEV ORAL CAPSULE 150 MG

5

PERFOROMIST

4

PROAIR HFA

3

PROAIR RESPICLICK

3

promethazine injection solution promethazine oral tablet 12.5 mg, 25 mg PULMOZYME QVAR INHALATION AEROSOL 40 MCG/ ACTUATION QVAR INHALATION AEROSOL 80 MCG/ ACTUATION SEREVENT DISKUS sildenafil oral

5

SPIRIVA RESPIMAT

3

SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT

3

Nombre del medicamento

Nivel de Requisitos/ medicamento Límites

SYMBICORT

4

terbutaline oral theophylline oral elixir theophylline oral solution theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 24 hr TRACLEER

3 2 2

VENTAVIS VENTOLIN HFA

5 3

XOLAIR

5

XOPENEX HFA

4

4

MO; QLL (30 per 30 days) QLL (17 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (17 per 30 days) PAR; MO; QLL (60 per 30 days) B/D PAR; MO; QLL (120 per 30 days) MO; QLL (18 per 30 days) MO; QLL (2 per 30 days) PAR; MO

XYZAL ORAL TABLET

4

4

PAR; MO

zafirlukast

4

5 3

B/D PAR; MO MO; QLL (9 per 30 days)

3

3 4 3

3

3

3

Urologicals alfuzosin AMMONIUM CHLORIDE MO; QLL (18 bethanechol chloride per 30 days) oral tablet 10 mg, 25 mg, 5 mg MO; QLL (60 bethanechol chloride per 30 days) oral tablet 50 mg PAR; MO; QLL CIALIS ORAL TABLET (90 per 30 2.5 MG, 5 MG days) MO; QLL (4 CYSTAGON per 30 days) cytra k crystals MO; QLL (30 finasteride oral tablet per 30 days) 5 mg MO; QLL (4 flavoxate per 30 days) MYRBETRIQ

PAR; MO; QLL (11 per 30 days) MO

2

MO

2

MO

5

PAR; MO; LA; QLL (60 per 30 days) PAR; MO MO; QLL (36 per 30 days) PAR; MO; LA; QLL (6 per 28 days) MO; QLL (45 per 30 days) MO; QLL (30 per 30 days) MO; QLL (60 per 30 days)

2 4

MO

3

MO

4

MO

4

PAR; MO; QLL (30 per 30 days) MO; LA MO MO

3 2 2 4 4

MO MO; QLL (30 per 30 days)

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Nombre del medicamento oxybutynin chloride oral syrup oxybutynin chloride oral tablet oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg potassium citrate oral tablet extended release 10 meq (1,080 mg) potassium citrate oral tablet extended release 5 meq (540 mg) sodium citrate-citric acid tamsulosin tolterodine oral capsule,extended release 24hr tolterodine oral tablet

Nivel de Requisitos/ medicamento Límites 2 2 3

3

4

3

MO; QLL (600 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days)

MO; QLL (30 per 30 days) MO

MO

2

MO

2 4

MO MO; QLL (30 per 30 days)

4

MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days)

TOVIAZ

4

trospium oral tablet

4

VESICARE

4

Vitamins, Hematinics / Electrolytes AMINOSYN 10 % 4 AMINOSYN 7 % WITH 4 ELECTROLYTES AMINOSYN 8.5 % 4 AMINOSYN 8.5 %4 ELECTROLYTES AMINOSYN II 10 % 4 AMINOSYN II 15 % 4 AMINOSYN II 7 % 4 AMINOSYN II 8.5 % 4 AMINOSYN II 8.5 %4 ELECTROLYTES

B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR

Nombre del medicamento AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % calcium acetate oral capsule CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 5%D20W(SULFITE-FREE) CLINIMIX E 4.25%/ D10W SUL FREE CLINIMIX E 4.25%/ D25W SUL FREE CLINIMIX E 4.25%/ D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE dextrose-kcl-nacl fluoritab oral tablet, chewable 1 mg fluoride (2.2 mg) freamine iii 10 % HEPATAMINE 8% intralipid intravenous emulsion 20 % INTRALIPID INTRAVENOUS EMULSION 30 % IONOSOL-B IN D5W

Nivel de Requisitos/ medicamento Límites 4 4 4 4

B/D PAR B/D PAR B/D PAR B/D PAR

4 2

B/D PAR MO

4

B/D PAR

4

B/D PAR

4

B/D PAR

4

B/D PAR

4

B/D PAR

4

B/D PAR

4

B/D PAR

4

B/D PAR

4

B/D PAR

4

B/D PAR

4

B/D PAR

4

B/D PAR

4

B/D PAR

4 2

MO MO

4 4 4

B/D PAR B/D PAR B/D PAR; MO

4

B/D PAR

4

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Nombre del medicamento IONOSOL-MB IN D5W ISOLYTE S PH 7.4 ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S k-effervescent k-tab oral tablet extended release 8 meq klor-con 10 klor-con 8 klor-con m10 klor-con m15 klor-con m20 klor-con/ef lactated ringers intravenous ludent fluoride magnesium sulfate in water intravenous parenteral solution magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %) magnesium sulfate injection solution magnesium sulfate injection syringe NEPHRAMINE 5.4 % NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH 7.4 phospha 250 neutral PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE

Nivel de Requisitos/ medicamento Límites 4 4 4 4 1 2

MO

2 2 2 2 2 1 4

MO MO MO MO MO MO MO

2 4

MO

4

4

MO

4

MO

4 4 4

B/D PAR

4 4 4 2 4 4 4

MO

Nombre del medicamento potassium bicarb and chloride potassium bicarb-citric acid potassium chlorid-d50.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d50.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/ 100 ml potassium chloride intravenous piggyback 10 meq/50 ml potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral tablet extended release

Nivel de Requisitos/ medicamento Límites 2

MO

1

MO

4

4

MO

4

4

4

MO

4

4

4

MO

2

MO

1

MO

2

MO

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Nombre del medicamento potassium chloride oral tablet,er particles/ crystals potassium chloride0.45 % nacl potassium chloride-d50.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d50.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l potassium chloride-d50.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d50.9%nacl intravenous parenteral solution 20 meq/l potassium chloride-d50.9%nacl intravenous parenteral solution 40 meq/l premasol 10 % PREMASOL 6 % prenatal vitamin oral tablet PROCALAMINE 3% PROSOL 20 % ringers intravenous sodium bicarbonate intravenous solution sodium bicarbonate intravenous syringe 4.2 % (0.5 meq/ml), 7.5 % (0.9 meq/ml) SODIUM BICARBONATE INTRAVENOUS SYRINGE 8.4 % (1 MEQ/ML) sodium chloride 0.45 % intravenous parenteral solution

Nivel de Requisitos/ medicamento Límites 2

MO

4 4

MO

4

4

4

Nombre del medicamento sodium chloride 0.45 % intravenous piggyback sodium chloride 3 % sodium chloride 5 % sodium chloride intravenous sodium fluoride oral tablet sodium fluoride oral tablet,chewable sodium lactate intravenous travasol 10 % TROPHAMINE 10 % TROPHAMINE 6%

Nivel de Requisitos/ medicamento Límites 4 4 4 4

MO

2

MO

2

MO

MO

4 4 4 4

B/D PAR; MO B/D PAR; MO B/D PAR

MO

4

4 4 2

B/D PAR; MO B/D PAR MO

4 4 4 4

B/D PAR B/D PAR; MO MO

4

4

4

MO

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Índice de medicamentos: Leyenda Los medicamentos genéricos figuran en letra minúscula y cursiva (por ej., atenolol). Los medicamentos de marca figuran en letra mayúscula (por ej., CRESTOR). El Índice brinda una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos genéricos se enumeran en el Índice. Encuentre su medicamento. Al lado de su medicamento verá el número de página en la que puede encontrar información de cobertura. Vaya a la página que se enumera en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista. Nombre del Medicamento

Página

abacavir...................................................................9 abacavir-lamivudine-zidovudine..............................9 ABELCET...................................................................9 ABILIFY MAINTENA................................................25 ABRAXANE.............................................................18 acamprosate..........................................................51 acarbose oral tablet 100 mg..................................53 acarbose oral tablet 25 mg....................................53 acarbose oral tablet 50 mg....................................53 ACCUPRIL...............................................................40 ACCURETIC ORAL TABLET 20-12.5 MG, 20-25 MG......................................................................40 acebutolol..............................................................40 acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml......................................25 acetaminophen-codeine oral solution 120-12 mg/ 5 ml.....................................................................25 acetaminophen-codeine oral tablet 300-15 mg.......................................................................25 acetaminophen-codeine oral tablet 300-30 mg.......................................................................25 acetaminophen-codeine oral tablet 300-60 mg.......................................................................25 acetasol hc.............................................................53 acetazolamide oral capsule, extended release......65 acetazolamide oral tablet 125 mg.........................65 acetazolamide oral tablet 250 mg.........................65 acetazolamide sodium...........................................65 acetic acid irrigation..............................................51 acetic acid otic.......................................................53 acetic acid-aluminum acetate...............................53 acetylcysteine intravenous....................................51 acetylcysteine solution 100 mg/ml (10 %).............67 acetylcysteine solution 200 mg/ml (20 %).............67 Core_16293_CG6_v16_1610_1

73

acitretin.................................................................48 ACTEMRA INTRAVENOUS VIAL..............................62 ACTHAR H.P...........................................................53 ACTHIB (PF)............................................................60 ACTIMMUNE..........................................................60 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG............................................53 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-1,000 MG............................................53 acyclovir oral capsule..............................................9 acyclovir oral suspension 200 mg/5 ml...................9 acyclovir oral tablet.................................................9 acyclovir sodium intravenous solution.....................9 acyclovir topical.....................................................48 ADACEL(TDAP ADOLESN/ADULT)(PF)....................60 ADAGEN.................................................................51 ADALAT CC.............................................................40 adapalene topical gel 0.1 %...................................48 ADASUVE...............................................................25 adefovir....................................................................9 ADEMPAS...............................................................67 adrucil intravenous solution 2.5 gram/50 ml........18 adrucil intravenous solution 5 gram/100 ml, 500 mg/10 ml............................................................18 ADVAIR DISKUS......................................................67 ADVAIR HFA...........................................................67 AEROSPAN.............................................................67 afeditab cr.............................................................40 AFINITOR...............................................................18 AFINITOR DISPERZ.................................................18 AGGRENOX............................................................40 ALBENZA..................................................................9 albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml..........67

Fecha de entrada en vigencia 01 de octubre de 2016

albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %)...................67 albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml.................67 albuterol sulfate oral syrup....................................67 albuterol sulfate oral tablet...................................67 albuterol sulfate oral tablet extended release 12 hr 4 mg...............................................................67 albuterol sulfate oral tablet extended release 12 hr 8 mg...............................................................67 alclometasone topical cream.................................48 alclometasone topical ointment............................48 alcohol pads...........................................................53 ALDACTAZIDE ORAL TABLET 25-25 MG.................40 ALDURAZYME........................................................53 ALECENSA..............................................................18 alendronate oral solution......................................62 alendronate oral tablet 10 mg, 5 mg.....................62 alendronate oral tablet 35 mg, 70 mg...................62 alendronate oral tablet 40 mg...............................51 alfuzosin.................................................................69 ALIMTA..................................................................18 ALINIA ORAL SUSPENSION FOR RECONSTITUTION.................................................9 ALINIA ORAL TABLET................................................9 ALKERAN ORAL......................................................18 allopurinol..............................................................62 aloprim..................................................................62 alosetron................................................................58 ALPHAGAN P OPHTHALMIC DROPS 0.1 %.............65 ALPHAGAN P OPHTHALMIC DROPS 0.15 %...........65 alprazolam oral tablet...........................................25 ALTACE ORAL CAPSULE 10 MG, 2.5 MG, 5 MG......................................................................40 altavera (28)..........................................................63 ALTOPREV..............................................................40 ALYACEN 1/35 (28)................................................63 ALYACEN 7/7/7 (28)...............................................63 amantadine hcl oral capsule....................................9 amantadine hcl oral tablet......................................9 AMARYL ORAL TABLET 1 MG.................................53 AMARYL ORAL TABLET 2 MG.................................53 AMARYL ORAL TABLET 4 MG.................................53 AMBISOME..............................................................9 amcinonide............................................................48 amethia 0.15 mg-30 mcg (84)/10 mcg (7).............63 amethyst................................................................63 amifostine crystalline.............................................18

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amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml................................................................9 amiloride................................................................40 amiloride-hydrochlorothiazide..............................40 aminophylline intravenous....................................67 AMINOSYN 10 %....................................................70 AMINOSYN 7 % WITH ELECTROLYTES....................70 AMINOSYN 8.5 %...................................................70 AMINOSYN 8.5 %-ELECTROLYTES..........................70 AMINOSYN II 10 %.................................................70 AMINOSYN II 15 %.................................................70 AMINOSYN II 7 %...................................................70 AMINOSYN II 8.5 %................................................70 AMINOSYN II 8.5 %-ELECTROLYTES.......................70 AMINOSYN M 3.5 %...............................................70 AMINOSYN-HBC 7%...............................................70 AMINOSYN-PF 10 %...............................................70 AMINOSYN-PF 7 % (SULFITE-FREE)........................70 AMINOSYN-RF 5.2 %..............................................70 amiodarone intravenous solution..........................40 amiodarone intravenous syringe...........................40 amiodarone oral tablet 100 mg, 200 mg...............40 amiodarone oral tablet 400 mg.............................40 amitriptyline..........................................................25 amlodipine besylate oral tablet 10 mg, 2.5 mg.......................................................................40 amlodipine besylate oral tablet 5 mg....................40 amlodipine-atorvastatin........................................40 amlodipine-benazepril oral capsule 10-20 mg, 1040 mg, 2.5-10 mg, 5-20 mg, 5-40 mg.................40 amlodipine-benazepril oral capsule 5-10 mg.........41 amlodipine-valsartan.............................................41 amlodipine-valsartan-hcthiazid.............................41 AMMONIUM CHLORIDE........................................69 ammonium lactate................................................48 amoxapine oral tablet 100 mg, 50 mg..................25 amoxapine oral tablet 150 mg, 25 mg..................25 amoxicillin oral capsule...........................................9 amoxicillin oral suspension for reconstitution.........9 amoxicillin oral tablet..............................................9 amoxicillin oral tablet,chewable 125 mg, 250 mg.........................................................................9 amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml.....................................9–10 amoxicillin-pot clavulanate oral suspension for reconstitution 250-62.5 mg/5 ml........................10

Fecha de entrada en vigencia 01 de octubre de 2016

amoxicillin-pot clavulanate oral tablet 250-125 mg.......................................................................10 amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg.................................................10 amoxicillin-pot clavulanate oral tablet extended release 12 hr.......................................................10 amoxicillin-pot clavulanate oral tablet, chewable.............................................................10 amphotericin b.......................................................10 ampicillin oral capsule...........................................10 ampicillin oral suspension for reconstitution.........10 ampicillin sodium injection....................................10 ampicillin sodium intravenous...............................10 ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram......................................................10 ampicillin-sulbactam injection recon soln 15 gram...................................................................10 ampicillin-sulbactam intravenous recon soln 3 gram...................................................................10 AMPYRA.................................................................25 anagrelide..............................................................51 anastrozole............................................................18 ANDROGEL TRANSDERMAL GEL IN METEREDDOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)........................................................................53 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM)..................................53 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM)......................................53 androxy..................................................................53 ANORO ELLIPTA.....................................................67 APOKYN.................................................................25 apraclonidine.........................................................66 apri........................................................................63 APRISO...................................................................58 APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG......................................................................25 APTIOM ORAL TABLET 800 MG.............................25 APTIVUS ORAL CAPSULE........................................10 APTIVUS ORAL SOLUTION......................................10 ARALAST NP...........................................................51 aranelle (28)..........................................................63 ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML.............................................................60 ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/ ML.......................................................................60

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ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML, 60 MCG/0.3 ML...........................................60 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/ 0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML............60 ARCALYST...............................................................60 aripiprazole oral solution.......................................25 aripiprazole oral tablet 10 mg...............................25 aripiprazole oral tablet 15 mg...............................25 aripiprazole oral tablet 2 mg.................................25 aripiprazole oral tablet 20 mg, 30 mg...................25 aripiprazole oral tablet 5 mg.................................25 aripiprazole oral tablet,disintegrating 10 mg........25 aripiprazole oral tablet,disintegrating 15 mg........25 ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 441 MG/1.6 ML.............25 ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 662 MG/2.4 ML.............25 ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 882 MG/3.2 ML.............25 ARNUITY ELLIPTA...................................................67 ARRANON..............................................................18 ARZERRA................................................................18 ASACOL HD............................................................58 ASMANEX HFA.......................................................67 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES)................................................................67 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)............................67 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)..........................................................67–68 aspirin-dipyridamole..............................................41 ATACAND HCT ORAL TABLET 16-12.5 MG.............41 ATACAND HCT ORAL TABLET 32-12.5 MG, 32-25 MG......................................................................41 ATACAND ORAL TABLET 16 MG, 4 MG, 8 MG.......41 ATACAND ORAL TABLET 32 MG.............................41 atenolol..................................................................41 atenolol-chlorthalidone.........................................41 atorvastatin...........................................................41 atovaquone............................................................10 atovaquone-proguanil...........................................10 ATRIPLA.................................................................10

Fecha de entrada en vigencia 01 de octubre de 2016

atropine injection syringe 0.05 mg/ml, 0.1 mg/ ml........................................................................58 atropine ophthalmic drops....................................66 ATROVENT HFA......................................................68 AVALIDE ORAL TABLET 150-12.5 MG.....................41 AVALIDE ORAL TABLET 300-12.5 MG.....................41 AVAPRO.................................................................41 AVASTIN.................................................................18 aviane....................................................................64 AVONEX (WITH ALBUMIN)....................................61 AVONEX INTRAMUSCULAR PEN INJECTOR KIT......61 AVONEX INTRAMUSCULAR SYRINGE.....................61 AVONEX INTRAMUSCULAR SYRINGE KIT...............61 azacitidine.............................................................18 azathioprine...........................................................19 azathioprine sodium..............................................19 azelastine nasal.....................................................53 azelastine ophthalmic............................................66 AZILECT..................................................................25 azithromycin intravenous recon soln 500 mg........10 azithromycin intravenous recon soln 500 mg (2 mg/ml)................................................................10 azithromycin oral packet.......................................10 azithromycin oral suspension for reconstitution 100 mg/5 ml.......................................................10 azithromycin oral suspension for reconstitution 200 mg/5 ml.......................................................10 azithromycin oral tablet........................................10 AZOPT....................................................................66 AZOR......................................................................41 aztreonam.............................................................10 azurette (28)..........................................................64 bacitracin ophthalmic............................................66 bacitracin-polymyxin b ophthalmic.......................66 baclofen.................................................................25 balsalazide.............................................................58 balziva (28)............................................................64 BANZEL ORAL SUSPENSION...................................25 BANZEL ORAL TABLET 200 MG..............................25 BANZEL ORAL TABLET 400 MG..............................25 BARACLUDE ORAL SOLUTION................................10 BCG VACCINE, LIVE (PF).........................................61 BELEODAQ.............................................................19 benazepril..............................................................41 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 5-6.25 mg................................41 benazepril-hydrochlorothiazide oral tablet 20-25 mg.......................................................................41

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BENDEKA...............................................................19 BENICAR HCT.........................................................41 BENICAR ORAL TABLET 20 MG, 40 MG..................41 BENICAR ORAL TABLET 5 MG................................41 BENLYSTA...............................................................62 benztropine injection.............................................25 benztropine oral....................................................25 BESIVANCE.............................................................66 BETAGAN OPHTHALMIC DROPS 0.5 %...................66 betamethasone dipropionate topical cream.........48 betamethasone dipropionate topical lotion..........48 betamethasone dipropionate topical ointment.............................................................48 betamethasone valerate topical cream.................48 betamethasone valerate topical lotion.................48 betamethasone valerate topical ointment............48 betamethasone, augmented topical cream..........48 betamethasone, augmented topical gel................48 betamethasone, augmented topical lotion...........48 betamethasone, augmented topical ointment......48 BETASERON SUBCUTANEOUS KIT..........................61 betaxolol ophthalmic.............................................66 betaxolol oral.........................................................41 bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg.......................................................................69 bethanechol chloride oral tablet 50 mg.................69 BETIMOL................................................................66 BETOPTIC S............................................................66 bexarotene.............................................................19 BEXSERO (PF).........................................................61 bicalutamide..........................................................19 BICILLIN C-R...........................................................10 BICILLIN L-A............................................................10 BICNU....................................................................19 BIDIL.......................................................................41 bimatoprost...........................................................66 bisoprolol fumarate...............................................41 bisoprolol-hydrochlorothiazide..............................41 BIVIGAM................................................................61 bleo 15k.................................................................19 bleomycin..............................................................19 BLEPHAMIDE S.O.P................................................66 BLINCYTO...............................................................19 blisovi fe 1.5/30 (28)..............................................64 BONIVA INTRAVENOUS.........................................62 BOOSTRIX TDAP.....................................................61 BOSULIF ORAL TABLET 100 MG.............................19 BOSULIF ORAL TABLET 500 MG.............................19

Fecha de entrada en vigencia 01 de octubre de 2016

BOTOX...................................................................61 BREO ELLIPTA.........................................................68 briellyn...................................................................64 BRILINTA................................................................41 brimonidine ophthalmic drops 0.15 %...................66 brimonidine ophthalmic drops 0.2 %.....................66 BRIVIACT INTRAVENOUS.......................................25 BRIVIACT ORAL SOLUTION.....................................25 BRIVIACT ORAL TABLET 10 MG..............................26 BRIVIACT ORAL TABLET 100 MG, 75 MG...............26 BRIVIACT ORAL TABLET 25 MG..............................26 BRIVIACT ORAL TABLET 50 MG..............................26 bromocriptine........................................................26 budesonide oral.....................................................58 bumetanide injection.............................................41 bumetanide oral tablet 0.5 mg, 1 mg....................41 bumetanide oral tablet 2 mg.................................41 BUPHENYL ORAL TABLET.......................................51 buprenorphine hcl injection solution.....................26 buprenorphine hcl injection syringe.......................26 buprenorphine hcl sublingual tablet 2 mg.............26 buprenorphine hcl sublingual tablet 8 mg.............26 buprenorphine-naloxone sublingual tablet 2-0.5 mg.......................................................................26 buprenorphine-naloxone sublingual tablet 8-2 mg.......................................................................26 bupropion hcl (smoking deter)...............................51 bupropion hcl oral tablet 100 mg..........................26 bupropion hcl oral tablet 75 mg............................26 bupropion hcl oral tablet extended release 100 mg.......................................................................26 bupropion hcl oral tablet extended release 150 mg, 200 mg.........................................................26 bupropion hcl oral tablet extended release 24 hr 150 mg................................................................26 bupropion hcl oral tablet extended release 24 hr 300 mg................................................................26 buspirone oral tablet 10 mg, 15 mg, 5 mg............26 buspirone oral tablet 30 mg, 7.5 mg.....................26 BUSULFEX..............................................................19 butorphanol tartrate injection solution 1 mg/ ml........................................................................26 butorphanol tartrate injection solution 2 mg/ ml........................................................................26 butorphanol tartrate nasal....................................26 BYDUREON............................................................53 BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/ DOSE(250 MCG/ML) 2.4 ML...............................53

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BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/ DOSE (250 MCG/ML) 1.2 ML..............................53 BYSTOLIC................................................................41 cabergoline............................................................53 CABOMETYX ORAL TABLET 20 MG........................19 CABOMETYX ORAL TABLET 40 MG, 60 MG............19 CALAN ORAL TABLET 120 MG................................41 CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG......................................................................41 calcipotriene scalp.................................................49 calcipotriene topical..............................................49 calcitonin (salmon)................................................53 calcitriol intravenous solution 1 mcg/ml...............53 calcitriol oral capsule.............................................53 calcitriol oral solution............................................53 calcium acetate oral capsule.................................70 camila....................................................................64 CANCIDAS..............................................................10 candesartan oral tablet 16 mg, 4 mg, 8 mg..........41 candesartan oral tablet 32 mg..............................41 candesartan-hydrochlorothiazid oral tablet 1612.5 mg...............................................................41 candesartan-hydrochlorothiazid oral tablet 3212.5 mg, 32-25 mg..............................................41 CAPASTAT..............................................................10 CAPRELSA ORAL TABLET 100 MG..........................19 CAPRELSA ORAL TABLET 300 MG..........................19 captopril oral tablet 100 mg, 25 mg, 50 mg..........41 captopril oral tablet 12.5 mg.................................41 captopril-hydrochlorothiazide oral tablet 25-15 mg, 50-15 mg, 50-25 mg....................................41 captopril-hydrochlorothiazide oral tablet 25-25 mg.......................................................................41 CARBAGLU.............................................................51 carbamazepine oral capsule, er multiphase 12 hr........................................................................26 carbamazepine oral suspension 100 mg/5 ml.......26 carbamazepine oral suspension 200 mg/10 ml........................................................................26 carbamazepine oral tablet.....................................26 carbamazepine oral tablet extended release 12 hr 100 mg...........................................................26 carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg.............................................26 carbamazepine oral tablet,chewable....................26 carbidopa-levodopa oral tablet.............................26 carbidopa-levodopa oral tablet extended release 25-100 mg...........................................................26

Fecha de entrada en vigencia 01 de octubre de 2016

carbidopa-levodopa oral tablet extended release 50-200 mg...........................................................26 carbidopa-levodopa oral tablet,disintegrating......26 carboplatin intravenous solution...........................19 CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 420 MG.................41–42 CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM........................61 carteolol.................................................................66 cartia xt..................................................................42 carvedilol...............................................................42 CAYSTON................................................................10 CAZIANT (28).........................................................64 cefaclor oral capsule..............................................10 cefaclor oral suspension for reconstitution 125 mg/5 ml..............................................................10 cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml........................................10 cefaclor oral tablet extended release 12 hr...........10 cefadroxil oral capsule...........................................10 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml........................................10 cefadroxil oral tablet.............................................10 cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml.............11 cefazolin injection recon soln 1 gram, 500 mg......11 cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g....................................................11 cefazolin intravenous.............................................11 cefdinir oral capsule...............................................11 cefdinir oral suspension for reconstitution............11 cefepime................................................................11 cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml.....................................11 cefepime in dextrose,iso-osm intravenous piggyback 2 gram/100 ml...................................11 cefotaxime injection recon soln 1 gram, 2 gram, 500 mg................................................................11 cefotaxime injection recon soln 10 gram...............11 cefotetan...............................................................11 cefoxitin in dextrose, iso-osm................................11 cefoxitin intravenous recon soln 1 gram................11 cefoxitin intravenous recon soln 10 gram, 2 gram...................................................................11 cefpodoxime oral suspension for reconstitution.....................................................11 cefpodoxime oral tablet 100 mg............................11 cefpodoxime oral tablet 200 mg............................11

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cefprozil oral suspension for reconstitution...........11 cefprozil oral tablet 250 mg...................................11 cefprozil oral tablet 500 mg...................................11 CEFTAZIDIME IN D5W............................................11 ceftazidime injection recon soln 1 gram, 2 gram...................................................................11 ceftazidime injection recon soln 6 gram................11 ceftriaxone in dextrose,iso-os................................11 ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg..................................................11 ceftriaxone injection recon soln 10 gram, 100 gram...................................................................11 ceftriaxone intravenous.........................................11 cefuroxime axetil oral tablet 250 mg.....................11 cefuroxime axetil oral tablet 500 mg.....................11 cefuroxime sodium injection recon soln 1.5 gram, 750 mg................................................................11 cefuroxime sodium intravenous vial......................11 celecoxib oral capsule 100 mg, 200 mg.................26 celecoxib oral capsule 400 mg...............................26 celecoxib oral capsule 50 mg.................................27 CELLCEPT INTRAVENOUS.......................................19 CELONTIN ORAL CAPSULE 300 MG........................27 cephalexin oral capsule 250 mg, 500 mg..............11 cephalexin oral suspension for reconstitution.......11 cephalexin oral tablet............................................11 CEREZYME INTRAVENOUS RECON SOLN 400 UNIT....................................................................53 CERVARIX VACCINE (PF).........................................61 cetirizine oral solution 1 mg/ml.............................68 CHANTIX................................................................51 CHANTIX CONTINUING MONTH BOX....................51 CHANTIX STARTING MONTH BOX..........................51 chloramphenicol sod succinate..............................11 chlorhexidine gluconate mucous membrane.........53 chloroquine phosphate oral tablet 250 mg...........11 chloroquine phosphate oral tablet 500 mg...........11 chlorothiazide oral tablet 250 mg.........................42 chlorothiazide oral tablet 500 mg.........................42 chlorothiazide sodium...........................................42 chlorpromazine......................................................27 chlorthalidone oral tablet 25 mg, 50 mg...............42 cholestyramine (with sugar)..................................42 cholestyramine light..............................................42 CIALIS ORAL TABLET 2.5 MG, 5 MG.......................69 ciclodan topical cream...........................................49 ciclodan topical solution........................................49 ciclopirox topical cream.........................................49

Fecha de entrada en vigencia 01 de octubre de 2016

ciclopirox topical gel..............................................49 ciclopirox topical shampoo....................................49 ciclopirox topical solution......................................49 ciclopirox topical suspension.................................49 cidofovir.................................................................11 cilostazol................................................................42 CIMZIA...................................................................58 CIMZIA POWDER FOR RECONST............................58 CIMZIA STARTER KIT..............................................58 CINRYZE.................................................................68 CIPRODEX..............................................................53 ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg....................................................12 ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg.......................................................12 ciprofloxacin hcl ophthalmic..................................66 ciprofloxacin hcl oral tablet...................................12 ciprofloxacin in 5 % dextrose.................................12 ciprofloxacin lactate intravenous solution 200 mg/ 20 ml...................................................................12 ciprofloxacin lactate intravenous solution 400 mg/ 40 ml...................................................................12 ciprofloxacin oral suspension.................................12 cisplatin.................................................................19 citalopram oral solution........................................27 citalopram oral tablet 10 mg.................................27 citalopram oral tablet 20 mg.................................27 citalopram oral tablet 40 mg.................................27 cladribine...............................................................19 claravis oral capsule 10 mg, 20 mg, 40 mg...........49 claravis oral capsule 30 mg...................................49 clarithromycin oral suspension for reconstitution 125 mg/5 ml.......................................................12 clarithromycin oral suspension for reconstitution 250 mg/5 ml.......................................................12 clarithromycin oral tablet......................................12 clarithromycin oral tablet extended release 24 hr........................................................................12 clemastine oral tablet 2.68 mg..............................68 clindamycin hcl oral capsule..................................12 clindamycin in 5 % dextrose...................................12 clindamycin phosphate injection...........................12 clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml........................................12 clindamycin phosphate intravenous solution 600 mg/4 ml..............................................................12 clindamycin phosphate topical gel........................49 clindamycin phosphate topical lotion....................49

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clindamycin phosphate topical solution................49 clindamycin phosphate topical swab.....................49 clindamycin phosphate vaginal.............................64 clindamycin-benzoyl peroxide topical gel..............49 CLINIMIX 2.75%/D5W SULFIT FREE.......................70 CLINIMIX 4.25%-D20W SULF-FREE........................70 CLINIMIX 4.25%-D25W SULF-FREE........................70 CLINIMIX 4.25%/D10W SULF FREE........................70 CLINIMIX 4.25%/D5W SULFIT FREE.......................51 CLINIMIX 5%-D20W(SULFITE-FREE).......................70 CLINIMIX 5%/D15W SULFITE FREE........................70 CLINIMIX 5%/D25W SULFITE-FREE........................70 CLINIMIX E 2.75%/D10W SUL FREE.......................51 CLINIMIX E 2.75%/D5W SULF FREE.......................51 CLINIMIX E 4.25%/D10W SUL FREE.......................70 CLINIMIX E 4.25%/D25W SUL FREE.......................70 CLINIMIX E 4.25%/D5W SULF FREE.......................70 CLINIMIX E 5%/D15W SULFIT FREE........................70 CLINIMIX E 5%/D20W SULFIT FREE........................70 CLINIMIX E 5%/D25W SULFIT FREE........................70 clobetasol scalp.....................................................49 clobetasol topical cream........................................49 clobetasol topical foam.........................................49 clobetasol topical gel.............................................49 clobetasol topical lotion........................................49 clobetasol topical ointment...................................49 clobetasol topical shampoo...................................49 clobetasol-emollient topical cream.......................49 clobetasol-emollient topical foam.........................49 CLOBEX TOPICAL LOTION......................................49 CLOLAR..................................................................19 clomipramine.........................................................27 clonazepam oral tablet 0.5 mg..............................27 clonazepam oral tablet 1 mg.................................27 clonazepam oral tablet 2 mg.................................27 clonazepam oral tablet,disintegrating 0.125 mg.......................................................................27 clonazepam oral tablet,disintegrating 0.25 mg.......................................................................27 clonazepam oral tablet,disintegrating 0.5 mg......27 clonazepam oral tablet,disintegrating 1 mg.........27 clonazepam oral tablet,disintegrating 2 mg.........27 clonidine hcl oral tablet.........................................42 clonidine transdermal patch..................................42 clopidogrel oral tablet 300 mg..............................42 clopidogrel oral tablet 75 mg................................42 clorazepate dipotassium........................................27 clotrimazole mucous membrane...........................12

Fecha de entrada en vigencia 01 de octubre de 2016

clotrimazole topical cream....................................49 clotrimazole topical solution..................................49 clotrimazole-betamethasone topical cream..........49 clotrimazole-betamethasone topical lotion...........49 clozapine oral tablet 100 mg.................................27 clozapine oral tablet 200 mg.................................27 clozapine oral tablet 25 mg...................................27 clozapine oral tablet 50 mg...................................27 clozapine oral tablet,disintegrating 100 mg..........27 clozapine oral tablet,disintegrating 12.5 mg.........27 clozapine oral tablet,disintegrating 150 mg..........27 clozapine oral tablet,disintegrating 200 mg..........27 clozapine oral tablet,disintegrating 25 mg............27 COARTEM..............................................................12 colchicine-probenecid............................................62 COLCRYS................................................................62 colestipol................................................................42 colistin (colistimethate na)....................................12 COMBIGAN............................................................66 COMBIVENT RESPIMAT.........................................68 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1)......................................................19 COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3)......................................................19 COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY).............................................................19 COMPLERA.............................................................12 compro...................................................................58 constulose..............................................................58 COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ ML.......................................................................27 COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ ML.......................................................................27 COREG CR..............................................................42 cormax scalp..........................................................49 cortisone................................................................54 CORZIDE ORAL TABLET 40-5 MG...........................42 COSMEGEN............................................................19 COSOPT..................................................................66 COTELLIC................................................................19 COUMADIN ORAL..................................................42 COZAAR ORAL TABLET 100 MG.............................42 COZAAR ORAL TABLET 25 MG, 50 MG...................42 CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 120,000 UNIT, 3,000-9,500- 15,000 UNIT, 6,00019,000 -30,000 UNIT...........................................58

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CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 36,000-114,000- 180,000 UNIT..........................58 CRESTOR................................................................42 CRIXIVAN ORAL CAPSULE 200 MG.........................12 CRIXIVAN ORAL CAPSULE 400 MG.........................12 cromolyn inhalation...............................................68 cromolyn ophthalmic.............................................66 cromolyn oral.........................................................58 cryselle (28)............................................................64 CUBICIN.................................................................12 cyclafem 1/35 (28).................................................64 cyclafem 7/7/7 (28)...............................................64 cyclobenzaprine oral tablet...................................27 cyclophosphamide oral capsule.............................19 CYCLOSET...............................................................54 cyclosporine intravenous.......................................19 cyclosporine modified............................................19 cyclosporine oral capsule.......................................19 CYRAMZA...............................................................19 CYSTADANE...........................................................58 CYSTAGON.............................................................69 cytarabine..............................................................19 cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml)...................19 cytarabine (pf) injection solution 20 mg/ml..........19 CYTOMEL...............................................................54 cytra k crystals.......................................................69 d10 %-0.45 % sodium chloride...............................51 d2.5 %-0.45 % sodium chloride..............................51 d5 % and 0.9 % sodium chloride............................51 d5 %-0.45 % sodium chloride.................................51 dacarbazine...........................................................19 DAKLINZA ORAL TABLET 30 MG, 60 MG................12 DAKLINZA ORAL TABLET 90 MG.............................12 DALIRESP...............................................................68 danazol oral...........................................................54 dantrolene.............................................................27 DAPSONE...............................................................12 DAPTACEL (DTAP PEDIATRIC) (PF).........................61 DARAPRIM.............................................................12 DARZALEX..............................................................19 dasetta 1/35 (28)...................................................64 dasetta 7/7/7 (28).................................................64 daunorubicin intravenous solution........................19 decitabine..............................................................19 delestrogen............................................................64 DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS).............................................................58

Fecha de entrada en vigencia 01 de octubre de 2016

demeclocycline......................................................12 DEMSER.................................................................42 DENAVIR................................................................49 denta 5000 plus.....................................................53 dentagel.................................................................53 DEPEN TITRATABS.................................................62 depo-estradiol........................................................64 DERMATOP TOPICAL OINTMENT...........................49 DESCOVY................................................................12 desipramine oral....................................................27 desloratadine oral tablet.......................................68 desloratadine oral tablet,disintegrating................68 desmopressin injection..........................................54 desmopressin nasal aerosol,spray.........................54 desmopressin nasal solution..................................54 desmopressin nasal spray,non-aerosol..................54 desmopressin oral..................................................54 desonide................................................................49 desoximetasone topical cream..............................49 desoximetasone topical gel...................................49 desoximetasone topical ointment 0.25 %..............49 desvenlafaxine fumarate oral tablet extended release 24hr 100 mg...........................................27 desvenlafaxine fumarate oral tablet extended release 24hr 50 mg.............................................27 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG......................................27 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG........................................27 desvenlafaxine oral tablet extended release 24hr 100 mg................................................................27 desvenlafaxine oral tablet extended release 24hr 50 mg..................................................................28 dexamethasone oral elixir 0.5mg/ml.....................54 dexamethasone oral solution 0.5mg/ml................54 dexamethasone oral tablet 0.5 mg, 1.5 mg...........54 dexamethasone oral tablet 0.75 mg, 1 mg, 4 mg, 6 mg....................................................................54 dexamethasone oral tablet 2 mg...........................54 dexamethasone sodium phos (pf).........................54 dexamethasone sodium phosphate injection........54 dexamethasone sodium phosphate ophthalmic..........................................................66 DEXILANT...............................................................58 dexrazoxane hcl intravenous recon soln 250 mg.......................................................................19 dexrazoxane hcl intravenous recon soln 500 mg.......................................................................19

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dextroamphetamine oral tablet 10 mg.................28 dextroamphetamine oral tablet 5 mg...................28 dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg.........28 dextroamphetamine-amphetamine oral tablet 30 mg.......................................................................28 dextrose 10 % and 0.2 % nacl................................51 dextrose 10 % in water (d10w)..............................51 dextrose 25 % in water (d25w)..............................51 dextrose 30 % in water (d30w)..............................52 dextrose 40 % in water (d40w)..............................52 dextrose 5 % in water (d5w)..................................52 dextrose 5 %-lactated ringers................................52 dextrose 5%-0.2 % sod chloride.............................52 dextrose 5%-0.3 % sod.chloride.............................52 dextrose 50 % in water (d50w) intravenous parenteral solution.............................................52 dextrose 50 % in water (d50w) intravenous syringe................................................................52 dextrose 70 % in water (d70w)..............................52 dextrose with sodium chloride...............................52 dextrose-kcl-nacl....................................................70 diazepam intensol..................................................28 diazepam oral concentrate....................................28 diazepam oral solution 5 mg/5 ml (1 mg/ml)........28 diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml).......................................................................28 diazepam oral tablet 10 mg..................................28 diazepam oral tablet 2 mg.....................................28 diazepam oral tablet 5 mg.....................................28 diazepam rectal kit 12.5-15-17.5-20 mg...............28 diazepam rectal kit 2.5 mg, 5-7.5-10 mg...............28 diclofenac potassium.............................................28 diclofenac sodium ophthalmic...............................66 diclofenac sodium oral tablet extended release 24 hr....................................................................28 diclofenac sodium oral tablet,delayed release (dr/ ec) 25 mg............................................................28 diclofenac sodium oral tablet,delayed release (dr/ ec) 50 mg, 75 mg................................................28 diclofenac sodium topical gel 1 %..........................28 diclofenac sodium topical gel 3 %..........................49 dicloxacillin............................................................12 dicyclomine oral capsule........................................58 dicyclomine oral solution.......................................58 dicyclomine oral tablet..........................................58 didanosine oral capsule,delayed release(dr/ec) 125 mg................................................................12

Fecha de entrada en vigencia 01 de octubre de 2016

didanosine oral capsule,delayed release(dr/ec) 200 mg................................................................12 didanosine oral capsule,delayed release(dr/ec) 250 mg................................................................12 didanosine oral capsule,delayed release(dr/ec) 400 mg................................................................12 DIFICID...................................................................12 diflorasone.............................................................49 diflunisal................................................................28 DIGITEK ORAL TABLET 125 MCG............................42 DIGOX ORAL TABLET 125 MCG..............................42 digoxin oral solution 50 mcg/ml............................42 digoxin oral tablet 125 mcg...................................42 dihydroergotamine injection.................................28 DILANTIN INFATABS...............................................28 DILANTIN ORAL CAPSULE 30 MG...........................28 dilt-xr.....................................................................42 diltiazem hcl intravenous.......................................42 diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg.............................42 diltiazem hcl oral capsule, extended release 360 mg.......................................................................42 diltiazem hcl oral capsule, extended release 420 mg.......................................................................42 diltiazem hcl oral capsule,ext release degradable..........................................................42 diltiazem hcl oral capsule,extended release 12 hr........................................................................42 diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg......................42 diltiazem hcl oral capsule,extended release 24hr 360 mg................................................................42 diltiazem hcl oral tablet.........................................42 DIOVAN HCT..........................................................42 DIPENTUM.............................................................58 diphenhydramine hcl injection solution 50 mg/ ml........................................................................68 diphenhydramine hcl injection syringe..................68 diphenoxylate-atropine oral liquid........................58 diphenoxylate-atropine oral tablet........................58 DIPROLENE AF.......................................................49 diskets....................................................................28 disulfiram...............................................................52 divalproex oral capsule, sprinkle...........................28 divalproex oral tablet extended release 24 hr.......28 divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg.........................................................28

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divalproex oral tablet,delayed release (dr/ec) 500 mg.......................................................................28 DOCEFREZ INTRAVENOUS RECON SOLN 20 MG......................................................................19 DOCETAXEL INTRAVENOUS SOLUTION 10 MG/ ML.......................................................................19 docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml)..........................................................19 docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ ml).......................................................................20 dofetilide................................................................42 donepezil oral tablet 10 mg, 5 mg.........................28 donepezil oral tablet,disintegrating......................28 DORIBAX................................................................12 dorzolamide...........................................................66 dorzolamide-timolol..............................................66 doxazosin...............................................................42 doxepin oral...........................................................28 doxercalciferol intravenous...................................54 doxorubicin intravenous recon soln.......................20 doxorubicin intravenous solution..........................20 doxorubicin, peg-liposomal...................................20 DOXY-100...............................................................12 doxycycline hyclate intravenous............................12 doxycycline hyclate oral capsule............................12 doxycycline hyclate oral tablet 100 mg, 50 mg.......................................................................12 doxycycline hyclate oral tablet 20 mg...................13 doxycycline monohydrate oral tablet 100 mg.......13 doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg...........................................................13 dronabinol oral capsule 10 mg..............................59 dronabinol oral capsule 2.5 mg, 5 mg...................59 drospirenone-ethinyl estradiol...............................64 DUETACT ORAL TABLET 30-4 MG..........................54 DULERA..................................................................68 duloxetine oral capsule,delayed release(dr/ec) 20 mg.......................................................................28 duloxetine oral capsule,delayed release(dr/ec) 30 mg.......................................................................28 duloxetine oral capsule,delayed release(dr/ec) 40 mg.......................................................................28 duloxetine oral capsule,delayed release(dr/ec) 60 mg.......................................................................28 duramorph (pf) injection solution 0.5 mg/ml........28 duramorph (pf) injection solution 1 mg/ml...........29

Fecha de entrada en vigencia 01 de octubre de 2016

DUREZOL................................................................66 DYAZIDE.................................................................42 DYSPORT................................................................61 e.e.s. 400 oral tablet..............................................13 econazole topical...................................................49 EDURANT...............................................................13 EFFIENT..................................................................42 ELAPRASE...............................................................54 ELIDEL....................................................................49 elinest....................................................................64 ELIQUIS ORAL TABLET 2.5 MG...............................42 ELIQUIS ORAL TABLET 5 MG..................................42 ELITEK....................................................................20 ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML.............68 ELLA.......................................................................64 ELOCON TOPICAL SOLUTION.................................49 EMCYT....................................................................20 EMEND ORAL CAPSULE 125 MG............................59 EMEND ORAL CAPSULE 40 MG..............................59 EMEND ORAL CAPSULE 80 MG..............................59 EMEND ORAL CAPSULE,DOSE PACK......................59 EMEND ORAL SUSPENSION FOR RECONSTITUTION...............................................59 emoquette.............................................................64 EMPLICITI...............................................................20 EMSAM..................................................................29 EMTRIVA ORAL CAPSULE.......................................13 EMTRIVA ORAL SOLUTION.....................................13 enalapril maleate...................................................42 enalapril-hydrochlorothiazide...............................42 ENBREL SUBCUTANEOUS RECON SOLN.................62 ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51)..................................................................62 ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML)............................................................62 ENBREL SURECLICK................................................63 endocet oral tablet 10-325 mg, 7.5-325 mg..........29 endocet oral tablet 5-325 mg................................29 ENGERIX-B (PF)......................................................61 ENGERIX-B PEDIATRIC (PF)....................................61 enoxaparin subcutaneous solution........................42 enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml.................................................................42 enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml......................................................43 enoxaparin subcutaneous syringe 30 mg/0.3 ml........................................................................43

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enoxaparin subcutaneous syringe 40 mg/0.4 ml........................................................................43 enoxaparin subcutaneous syringe 60 mg/0.6 ml........................................................................43 enpresse.................................................................64 entacapone............................................................29 entecavir................................................................13 enulose..................................................................59 ENVARSUS XR........................................................20 epinephrine injection auto-injector.......................68 epinephrine injection syringe 0.1 mg/ml...............68 EPIPEN 2-PAK.........................................................68 EPIPEN JR 2-PAK....................................................68 epirubicin intravenous solution 200 mg/100 ml........................................................................20 epirubicin intravenous solution 50 mg/25 ml........20 epitol......................................................................29 EPIVIR HBV ORAL SOLUTION.................................13 EPIVIR ORAL SOLUTION.........................................13 eplerenone.............................................................43 eprosartan.............................................................43 EPZICOM................................................................13 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG...............................................................29 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG...............................................................29 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG...............................................................29 ERBITUX.................................................................20 ergoloid..................................................................29 ERIVEDGE...............................................................20 errin.......................................................................64 ERWINAZE..............................................................20 ery pads.................................................................49 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg.........................................................13 erythrocin (as stearate) oral tablet 250 mg...........13 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG......................................................................13 erythromycin ethylsuccinate oral tablet................13 erythromycin ophthalmic.......................................66 erythromycin oral capsule,delayed release(dr/ ec).......................................................................13 erythromycin oral tablet........................................13 erythromycin with ethanol....................................49 erythromycin-benzoyl peroxide.............................49 ESBRIET..................................................................68 escitalopram oxalate oral solution........................29

Fecha de entrada en vigencia 01 de octubre de 2016

escitalopram oxalate oral tablet 10 mg................29 escitalopram oxalate oral tablet 20 mg................29 escitalopram oxalate oral tablet 5 mg..................29 esomeprazole sodium intravenous........................59 estarylla.................................................................64 ESTRACE VAGINAL.................................................64 estradiol oral..........................................................64 estradiol transdermal patch semiweekly...............64 estradiol transdermal patch weekly......................64 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml.................................................................64 ESTRING.................................................................64 ethambutol............................................................13 ethosuximide oral capsule.....................................29 ethosuximide oral solution....................................29 etidronate disodium oral tablet 200 mg................52 etidronate disodium oral tablet 400 mg................52 etodolac oral capsule.............................................29 etodolac oral tablet...............................................29 etodolac oral tablet extended release 24 hr..........29 ETOPOPHOS...........................................................20 etoposide intravenous...........................................20 EVOMELA...............................................................20 EVOTAZ..................................................................13 EXELON ORAL CAPSULE 1.5 MG, 4.5 MG...............29 exemestane...........................................................20 EXFORGE................................................................43 EXFORGE HCT........................................................43 EXJADE...................................................................52 EXTAVIA SUBCUTANEOUS KIT...............................61 EXTAVIA SUBCUTANEOUS RECON SOLN...............61 FABRAZYME...........................................................54 falmina (28)...........................................................64 famciclovir oral tablet 125 mg, 250 mg.................13 famciclovir oral tablet 500 mg...............................13 famotidine (pf).......................................................59 famotidine (pf)-nacl (iso-os)..................................59 famotidine intravenous.........................................59 famotidine oral suspension....................................59 famotidine oral tablet 20 mg, 40 mg.....................59 FANAPT ORAL TABLET 1 MG..................................29 FANAPT ORAL TABLET 10 MG................................29 FANAPT ORAL TABLET 12 MG................................29 FANAPT ORAL TABLET 2 MG..................................29 FANAPT ORAL TABLET 4 MG..................................29 FANAPT ORAL TABLET 6 MG..................................29 FANAPT ORAL TABLET 8 MG..................................29 FANAPT ORAL TABLETS,DOSE PACK......................29

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FARESTON..............................................................20 FARYDAK ORAL CAPSULE 10 MG...........................20 FARYDAK ORAL CAPSULE 15 MG, 20 MG..............20 FASLODEX..............................................................20 felbamate oral suspension.....................................29 felbamate oral tablet 400 mg................................29 felbamate oral tablet 600 mg................................29 FELBATOL ORAL TABLET 400 MG...........................29 felodipine oral tablet extended release 24 hr 10 mg.......................................................................43 felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg.............................................................43 FEMRING...............................................................64 fenofibrate micronized oral capsule 130 mg.........43 fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg...........................................................43 fenofibrate micronized oral capsule 43 mg...........43 fenofibrate nanocrystallized 48 mg, 145 mg.........43 fenofibrate oral tablet 160 mg..............................43 fenofibrate oral tablet 54 mg................................43 fenofibric acid (choline) dr capsules......................43 fenoprofen oral tablet...........................................29 fentanyl citrate......................................................29 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/ hr........................................................................29 FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK...................................................................29 FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG.......................................29–30 FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG............................................................30 FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG............................................................30 finasteride oral tablet 5 mg...................................69 FIRAZYR..................................................................68 FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG.............20 FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG...............20 flavoxate................................................................69 flecainide oral tablet 100 mg, 50 mg.....................43 flecainide oral tablet 150 mg.................................43 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION............................68 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ ACTUATION.........................................................68

Fecha de entrada en vigencia 01 de octubre de 2016

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION.........................68 FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION.........................68 FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION...........................68 fluconazole in dextrose(iso-o)................................13 FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML................................13 fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml..................................13 fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml..................................13 fluconazole oral suspension for reconstitution 10 mg/ml.................................................................13 fluconazole oral suspension for reconstitution 40 mg/ml.................................................................13 fluconazole oral tablet 100 mg..............................13 fluconazole oral tablet 150 mg, 50 mg..................13 fluconazole oral tablet 200 mg..............................13 flucytosine.............................................................13 fludarabine intravenous recon soln.......................20 fludarabine intravenous solution...........................20 fludrocortisone......................................................54 flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)........................................................................68 fluocinolone acetonide oil otic...............................53 fluocinolone topical cream....................................49 fluocinolone topical ointment................................49 fluocinolone topical solution..................................50 fluocinonide topical cream 0.05 %.........................50 fluocinonide topical gel..........................................50 fluocinonide topical ointment................................50 fluocinonide topical solution..................................50 fluocinonide-e........................................................50 fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg).....................................................................70 fluorometholone....................................................66 fluorouracil intravenous........................................20 fluorouracil topical cream 5 %...............................50 fluorouracil topical solution...................................50 fluoxetine oral capsule 10 mg................................30 fluoxetine oral capsule 20 mg................................30 fluoxetine oral capsule 40 mg................................30 fluoxetine oral solution..........................................30 fluoxetine oral tablet 10 mg..................................30 fluoxetine oral tablet 20 mg..................................30 fluphenazine decanoate........................................30

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fluphenazine hcl injection......................................30 fluphenazine hcl oral.............................................30 flurbiprofen............................................................30 flurbiprofen sodium...............................................66 flutamide...............................................................20 fluticasone nasal....................................................68 fluticasone topical cream......................................50 fluticasone topical lotion.......................................50 fluticasone topical ointment..................................50 fluvastatin oral capsule 20 mg..............................43 fluvastatin oral capsule 40 mg..............................43 fluvoxamine oral tablet 100 mg............................30 fluvoxamine oral tablet 25 mg..............................30 fluvoxamine oral tablet 50 mg..............................30 FOLOTYN................................................................20 fomepizole.............................................................61 fondaparinux subcutaneous syringe 10 mg/0.8 ml........................................................................43 fondaparinux subcutaneous syringe 2.5 mg/0.5 ml........................................................................43 fondaparinux subcutaneous syringe 5 mg/0.4 ml........................................................................43 fondaparinux subcutaneous syringe 7.5 mg/0.6 ml........................................................................43 FORADIL AEROLIZER..............................................68 FORTEO..................................................................63 fortical...................................................................54 FOSAMAX ORAL TABLET 70 MG............................63 FOSAMAX PLUS D..................................................63 foscarnet................................................................13 fosinopril................................................................43 fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg.......................................................................43 fosinopril-hydrochlorothiazide oral tablet 20-12.5 mg.......................................................................43 fosphenytoin..........................................................30 freamine iii 10 %....................................................70 furosemide injection..............................................43 furosemide oral solution 10 mg/ml.......................43 furosemide oral solution 40 mg/5 ml (8 mg/ ml).......................................................................43 furosemide oral tablet...........................................43 FUSILEV..................................................................20 FUZEON SUBCUTANEOUS RECON SOLN................13 FYCOMPA ORAL SUSPENSION...............................30 FYCOMPA ORAL TABLET 10 MG, 12 MG................30 FYCOMPA ORAL TABLET 2 MG..............................30 FYCOMPA ORAL TABLET 4 MG..............................30

Fecha de entrada en vigencia 01 de octubre de 2016

FYCOMPA ORAL TABLET 6 MG..............................30 FYCOMPA ORAL TABLET 8 MG..............................30 gabapentin oral capsule 100 mg...........................30 gabapentin oral capsule 300 mg...........................30 gabapentin oral capsule 400 mg...........................30 gabapentin oral solution 250 mg/5 ml..................30 gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml)....................................................30 gabapentin oral tablet 600 mg..............................30 gabapentin oral tablet 800 mg..............................30 GABITRIL ORAL TABLET 12 MG..............................30 GABITRIL ORAL TABLET 16 MG..............................30 galantamine oral capsule,ext rel. pellets 24 hr........................................................................30 galantamine oral solution.....................................30 galantamine oral tablet.........................................30 GAMASTAN S/D.....................................................61 GAMMAGARD LIQUID...........................................61 GAMMAGARD S-D (IGA < 1 MCG/ML)...............61 GAMUNEX-C..........................................................61 ganciclovir sodium.................................................13 GARDASIL (PF).......................................................61 GARDASIL 9 (PF).....................................................61 GATTEX 30-VIAL.....................................................59 GATTEX ONE-VIAL..................................................59 gauze pads 2 x 2....................................................54 gavilyte-c...............................................................59 gavilyte-g...............................................................59 gavilyte-n...............................................................59 GAZYVA..................................................................20 gemcitabine intravenous recon soln 1 gram, 200 mg.......................................................................20 gemcitabine intravenous recon soln 2 gram.........20 gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)...........20 gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml)..........................................................20 gemfibrozil oral......................................................43 generlac.................................................................59 gengraf oral capsule 100 mg, 25 mg.....................20 gengraf oral capsule 50 mg...................................20 gengraf oral solution.............................................20 gentak ophthalmic ointment.................................66 gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml............13 GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML.................................................................13–14

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gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/100 ml, 80 mg/ 50 ml, 90 mg/100 ml..........................................14 gentamicin injection..............................................14 gentamicin ophthalmic..........................................66 gentamicin sulfate (ped) (pf).................................14 gentamicin sulfate (pf) intravenous solution 100 mg/10 ml............................................................14 gentamicin sulfate (pf) intravenous solution 60 mg/6 ml, 80 mg/8 ml..........................................14 gentamicin topical.................................................50 GENVOYA...............................................................14 GEODON INTRAMUSCULAR...................................30 gildagia..................................................................64 gildess 1.5/30 (21).................................................64 gildess 1/20 (21)....................................................64 GILDESS FE 1.5/30 (28)..........................................64 GILDESS FE 1/20 (28).............................................64 GILENYA.................................................................30 GILOTRIF................................................................20 GLATOPA...............................................................30 GLEEVEC ORAL TABLET 100 MG............................20 GLEEVEC ORAL TABLET 400 MG............................20 GLEOSTINE.............................................................20 glimepiride oral tablet 1 mg..................................54 glimepiride oral tablet 2 mg..................................54 glimepiride oral tablet 4 mg..................................54 glipizide oral tablet 10 mg.....................................54 glipizide oral tablet 5 mg.......................................54 glipizide oral tablet extended release 24hr 10 mg.......................................................................54 glipizide oral tablet extended release 24hr 2.5 mg.......................................................................54 glipizide oral tablet extended release 24hr 5 mg.......................................................................54 glipizide-metformin oral tablet 2.5-250 mg..........54 glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg.......................................................................54 GLUCAGEN HYPOKIT..............................................54 GLUCAGON EMERGENCY KIT (HUMAN)................54 GLUCOPHAGE ORAL TABLET 1,000 MG.................54 GLUCOPHAGE ORAL TABLET 500 MG....................54 GLUCOPHAGE ORAL TABLET 850 MG....................54 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG......................................54 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 MG......................................54 GLUCOTROL ORAL TABLET 10 MG.........................54

Fecha de entrada en vigencia 01 de octubre de 2016

GLUCOTROL ORAL TABLET 5 MG...........................55 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG........................................................55 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 MG.......................................................55 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 5 MG..........................................................55 GLUCOVANCE........................................................55 GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 MG..................................................55 GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 500 MG.....................................................55 glycopyrrolate injection.........................................59 glycopyrrolate oral tablet......................................59 GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 250 MG......................................................................14 griseofulvin microsize oral suspension...................14 griseofulvin ultramicrosize.....................................14 guanfacine oral tablet extended release 24 hr......30 guanidine...............................................................30 HALAVEN...............................................................20 halobetasol propionate.........................................50 haloperidol.............................................................30 haloperidol decanoate...........................................30 haloperidol lactate injection..................................30 haloperidol lactate oral.........................................31 HARVONI...............................................................14 HAVRIX (PF) INTRAMUSCULAR SUSPENSION........61 HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML....................................................61 HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML.......................................................61 heather..................................................................64 heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml..............43 heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ ml).......................................................................43 heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)..........43 heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml......................................................44 heparin (porcine) injection cartridge.....................44 heparin (porcine) injection solution.......................44 heparin(porcine) in 0.45% nacl intravenous parenteral solution 12,500 unit/250 ml..............44

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heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml..............44 heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/500 ml..............44 heparin, porcine (pf) injection solution..................44 HEPATAMINE 8%...................................................70 HERCEPTIN.............................................................20 HETLIOZ.................................................................31 HEXALEN................................................................20 HIBERIX (PF)...........................................................61 HUMALOG.............................................................55 HUMALOG KWIKPEN.............................................55 HUMALOG MIX 50-50............................................55 HUMALOG MIX 50-50 KWIKPEN............................55 HUMALOG MIX 75-25............................................55 HUMALOG MIX 75-25 KWIKPEN............................55 HUMAPEN LUXURA HD..........................................55 HUMIRA PEDIATRIC CROHN'S START.....................63 HUMIRA PEN..........................................................63 HUMIRA PEN CROHN'S-UC-HS START....................63 HUMIRA PEN PSORIASIS-UVEITIS..........................63 HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/ 0.2 ML, 20 MG/0.4 ML........................................63 HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/ 0.8 ML.................................................................63 HUMULIN 70/30....................................................55 HUMULIN 70/30 KWIKPEN....................................55 HUMULIN N...........................................................55 HUMULIN N KWIKPEN...........................................55 HUMULIN R............................................................55 HUMULIN R U-500 (CONC) KWIKPEN....................55 HUMULIN R U-500 (CONCENTRATED)...................55 hydralazine injection..............................................44 hydralazine oral.....................................................44 hydrochlorothiazide...............................................44 hydrocodone-acetaminophen oral solution 2.5167 mg/5 ml.......................................................31 hydrocodone-acetaminophen oral solution 7.5325 mg/15 ml.....................................................31 hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg.................................31 hydrocodone-ibuprofen oral tablet 10-200 mg, 5200 mg, 7.5-200 mg............................................31 hydrocortisone butyrate topical cream.................50 hydrocortisone butyrate topical ointment.............50 hydrocortisone butyrate topical solution...............50 hydrocortisone oral tablet 10 mg, 5 mg................55 hydrocortisone oral tablet 20 mg..........................55

Fecha de entrada en vigencia 01 de octubre de 2016

hydrocortisone rectal cream 2.5 %........................59 hydrocortisone rectal enema.................................59 hydrocortisone topical cream 1 %.........................50 hydrocortisone topical cream 2.5 %......................50 hydrocortisone topical lotion 2.5 %.......................50 hydrocortisone topical ointment 1 %.....................50 hydrocortisone topical ointment 2.5 %..................50 hydrocortisone valerate.........................................50 hydrocortisone-acetic acid.....................................53 hydrocortisone-min oil-wht pet.............................50 hydromorphone (pf) injection solution 1 mg/ ml........................................................................31 hydromorphone (pf) injection solution 10 mg/ ml........................................................................31 hydromorphone (pf) injection solution 4 mg/ ml........................................................................31 hydromorphone injection solution.........................31 hydromorphone injection syringe 1 mg/ml...........31 hydromorphone injection syringe 2 mg/ml...........31 hydromorphone injection syringe 4 mg/ml...........31 hydromorphone oral tablet 2 mg, 4 mg................31 hydromorphone oral tablet 8 mg..........................31 hydroxychloroquine oral........................................14 hydroxyprogesterone caproate.............................64 hydroxyurea...........................................................20 HYZAAR..................................................................44 ibandronate intravenous solution.........................63 ibandronate intravenous syringe...........................63 ibandronate oral....................................................63 IBRANCE.................................................................21 ibuprofen oral suspension.....................................31 ibuprofen oral tablet 400 mg, 600 mg, 800 mg.......................................................................31 ibuprofen-oxycodone.............................................31 ICLUSIG ORAL TABLET 15 MG................................21 ICLUSIG ORAL TABLET 45 MG................................21 idarubicin...............................................................21 IFEX........................................................................21 ifosfamide intravenous recon soln.........................21 ifosfamide intravenous solution............................21 ILARIS (PF)..............................................................61 ILEVRO...................................................................66 imatinib oral tablet 100 mg...................................21 imatinib oral tablet 400 mg...................................21 IMBRUVICA............................................................21 imipenem-cilastatin intravenous recon soln 250 mg.......................................................................14

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imipenem-cilastatin intravenous recon soln 500 mg.......................................................................14 imipramine hcl.......................................................31 imiquimod..............................................................50 IMOVAX RABIES VACCINE (PF)...............................61 INCRELEX...............................................................52 indapamide............................................................44 INFANRIX (DTAP) (PF)............................................61 INLYTA ORAL TABLET 1 MG...................................21 INLYTA ORAL TABLET 5 MG...................................21 insulin pen needle..................................................55 INSULIN SYRINGE (DISP) U-100 SYRINGE 0.3 ML, 1 ML, 1/2 ML......................................................55 INTELENCE ORAL TABLET 100 MG.........................14 INTELENCE ORAL TABLET 200 MG.........................14 INTELENCE ORAL TABLET 25 MG...........................14 intralipid intravenous emulsion 20 %....................70 INTRALIPID INTRAVENOUS EMULSION 30 %.........70 INTRON A INJECTION.............................................61 introvale.................................................................64 INVANZ 1 GM ADD-VANTAGE VIAL.......................14 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG................................................................31 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG...................................................................31 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG...................................................................31 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG...................................................................31 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 78 MG/0.5 ML.....................................................31 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML...................................................31 INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML.....................................................31 INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML.....................................................31 INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML.......................................................31 INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML.....................................................31 INVIRASE ORAL CAPSULE.......................................14 INVIRASE ORAL TABLET.........................................14 IONOSOL-B IN D5W...............................................70 IONOSOL-MB IN D5W............................................71 IOPIDINE OPHTHALMIC DROPS.............................66 IPOL INJECTION SUSPENSION................................61

Fecha de entrada en vigencia 01 de octubre de 2016

ipratropium bromide inhalation............................68 ipratropium bromide nasal....................................53 ipratropium-albuterol............................................68 irbesartan..............................................................44 irbesartan-hydrochlorothiazide oral tablet 15012.5 mg...............................................................44 irbesartan-hydrochlorothiazide oral tablet 30012.5 mg...............................................................44 IRESSA....................................................................21 irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml..............................................................21 irinotecan intravenous solution 500 mg/25 ml........................................................................21 ISENTRESS ORAL POWDER IN PACKET...................14 ISENTRESS ORAL TABLET.......................................14 ISENTRESS ORAL TABLET,CHEWABLE 100 MG.......14 ISENTRESS ORAL TABLET,CHEWABLE 25 MG.........14 ISOLYTE S PH 7.4....................................................71 ISOLYTE-P IN 5 % DEXTROSE..................................71 ISOLYTE-S...............................................................71 isoniazid injection..................................................14 isoniazid oral solution............................................14 isoniazid oral tablet 100 mg..................................14 isoniazid oral tablet 300 mg..................................14 ISOPTO CARPINE....................................................66 isosorbide dinitrate oral tablet 10 mg, 20 mg, 5 mg.......................................................................44 isosorbide dinitrate oral tablet 30 mg...................44 isosorbide dinitrate oral tablet extended release................................................................44 isosorbide mononitrate.........................................44 isradipine...............................................................44 ISTODAX.................................................................21 itraconazole...........................................................14 ivermectin oral.......................................................14 IXEMPRA................................................................21 IXIARO (PF).............................................................61 JAKAFI ORAL TABLET 10 MG..................................21 JAKAFI ORAL TABLET 15 MG..................................21 JAKAFI ORAL TABLET 20 MG..................................21 JAKAFI ORAL TABLET 25 MG..................................21 JAKAFI ORAL TABLET 5 MG....................................21 jantoven oral tablet 1 mg, 10 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg...................................44 jantoven oral tablet 2 mg......................................44 JANUMET...............................................................55 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG...............................................55

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JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG.............................55 JANUVIA ORAL TABLET 100 MG............................55 JANUVIA ORAL TABLET 25 MG..............................55 JANUVIA ORAL TABLET 50 MG..............................55 JARDIANCE.............................................................55 JENTADUETO.........................................................55 JEVTANA................................................................21 jolessa....................................................................64 jolivette..................................................................64 junel 1.5/30 (21)....................................................64 junel 1/20 (21).......................................................64 junel fe 1.5/30 (28)................................................64 junel fe 1/20 (28)...................................................64 JUXTAPID...............................................................44 k-effervescent........................................................71 k-tab oral tablet extended release 8 meq..............71 KADCYLA................................................................21 KALETRA ORAL SOLUTION.....................................14 KALETRA ORAL TABLET 100-25 MG.......................14 KALETRA ORAL TABLET 200-50 MG.......................14 KALYDECO ORAL TABLET.......................................68 kariva (28)..............................................................64 kelnor 1/35 (28).....................................................64 KETEK.....................................................................14 ketoconazole oral..................................................14 ketoconazole topical cream...................................50 ketoconazole topical shampoo..............................50 ketorolac ophthalmic.............................................66 KEYTRUDA..............................................................21 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG.....................................................32 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG........................................................32 KINERET.................................................................63 kionex....................................................................52 kionex (with sorbitol).............................................52 klor-con 10.............................................................71 klor-con 8...............................................................71 klor-con m10..........................................................71 klor-con m15..........................................................71 klor-con m20..........................................................71 klor-con/ef.............................................................71 KORLYM.................................................................55 KUVAN ORAL TABLET,SOLUBLE.............................55 labetalol intravenous solution...............................44 labetalol oral tablet 100 mg, 200 mg....................44 labetalol oral tablet 300 mg..................................44

Fecha de entrada en vigencia 01 de octubre de 2016

LACRISERT..............................................................66 lactated ringers intravenous..................................71 lactated ringers irrigation......................................52 lactulose................................................................59 LAMISIL ORAL TABLET............................................14 lamivudine oral solution........................................14 lamivudine oral tablet 100 mg..............................14 lamivudine oral tablet 150 mg..............................14 lamivudine oral tablet 300 mg..............................14 lamivudine-zidovudine...........................................14 lamotrigine oral tablet 100 mg, 150 mg, 200 mg.......................................................................32 lamotrigine oral tablet 25 mg................................32 lamotrigine oral tablet, chewable dispersible.......32 LANOXIN ORAL TABLET 125 MCG, 62.5 MCG........44 lansoprazole oral capsule,delayed release(dr/ ec).......................................................................59 LANTUS..................................................................55 LANTUS SOLOSTAR................................................55 LARIN 1/20 (21).....................................................64 LARIN FE 1.5/30 (28)..............................................64 LARIN FE 1/20 (28).................................................64 latanoprost............................................................66 LATUDA ORAL TABLET 120 MG.............................32 LATUDA ORAL TABLET 20 MG................................32 LATUDA ORAL TABLET 40 MG................................32 LATUDA ORAL TABLET 60 MG................................32 LATUDA ORAL TABLET 80 MG................................32 leena 28.................................................................64 leflunomide oral tablet 10 mg...............................63 leflunomide oral tablet 20 mg...............................63 LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY)................................................................21 LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2)................21 LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2)..........................................................21 LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1).........................................................21 LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK)........................21 lessina....................................................................64 LETAIRIS.................................................................68 letrozole.................................................................21 leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg......................................21 leucovorin calcium injection recon soln 500 mg.......................................................................21

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leucovorin calcium oral tablet 10 mg, 25 mg........21 leucovorin calcium oral tablet 15 mg, 5 mg..........21 LEUKERAN..............................................................21 leuprolide subcutaneous kit...................................22 levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml..............................................................68 levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml..................................68 LEVEMIR................................................................55 LEVEMIR FLEXTOUCH............................................55 levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml........................................................................32 levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml..................................32 levetiracetam intravenous.....................................32 levetiracetam oral solution 100 mg/ml.................32 levetiracetam oral solution 500 mg/5 ml (5 ml).......................................................................32 levetiracetam oral tablet 1,000 mg.......................32 levetiracetam oral tablet 250 mg, 500 mg, 750 mg.......................................................................32 levetiracetam oral tablet extended release 24 hr 500 mg................................................................32 levetiracetam oral tablet extended release 24 hr 750 mg................................................................32 levobunolol ophthalmic drops 0.5 %......................66 levocarnitine (with sugar)......................................52 levocarnitine intravenous......................................52 levocarnitine oral tablet........................................52 levocetirizine oral tablet........................................69 levofloxacin in d5w intravenous piggyback 250 mg/50 ml............................................................14 levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml................................15 levofloxacin ophthalmic.........................................66 levofloxacin oral tablet..........................................15 levoleucovorin calcium intravenous recon soln.....................................................................22 levonest (28)..........................................................64 levonorg-eth estrad triphasic................................64 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg.......................................64 levonorgestrel-ethinyl estrad oral tablet 90-20 mcg.....................................................................64 levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month......................................................64

Fecha de entrada en vigencia 01 de octubre de 2016

levora-28................................................................64 levothyroxine oral..................................................55 levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg.....................................55 LEXIVA ORAL SUSPENSION....................................15 LEXIVA ORAL TABLET.............................................15 LIALDA...................................................................59 lidocaine hcl laryngotracheal.................................50 lidocaine hcl mucous membrane...........................50 lidocaine hcl urethral.............................................50 lidocaine topical adhesive patch,medicated..........50 lidocaine topical ointment.....................................50 lidocaine viscous....................................................50 lidocaine-prilocaine topical cream.........................50 LINCOCIN...............................................................15 lincomycin injection...............................................15 lindane topical shampoo.......................................50 linezolid intravenous..............................................15 linezolid oral suspension for reconstitution...........15 linezolid oral tablet................................................15 linezolid-0.9% sodium chloride..............................15 LINZESS..................................................................59 liothyronine intravenous........................................55 liothyronine oral tablet 25 mcg, 5 mcg..................55 liothyronine oral tablet 50 mcg.............................56 LIPITOR ORAL TABLET 10 MG................................44 lisinopril.................................................................44 lisinopril-hydrochlorothiazide................................44 lithium carbonate oral capsule 150 mg, 300 mg.......................................................................32 lithium carbonate oral capsule 600 mg.................32 lithium carbonate oral tablet.................................32 lithium carbonate oral tablet extended release................................................................32 lithium citrate oral solution 8 meq/5 ml................32 LOFIBRA ORAL CAPSULE 200 MG..........................44 LONSURF................................................................22 loperamide oral capsule........................................59 LOPID.....................................................................44 lorazepam oral tablet............................................32 loryna (28).............................................................64 losartan oral tablet 100 mg...................................44 losartan oral tablet 25 mg, 50 mg.........................44 losartan-hydrochlorothiazide................................44 LOTENSIN ORAL TABLET 20 MG, 40 MG................44 lovastatin oral tablet 10 mg, 20 mg......................44 lovastatin oral tablet 40 mg..................................44

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low-ogestrel (28)....................................................64 loxapine succinate oral capsule 10 mg, 5 mg........32 loxapine succinate oral capsule 25 mg, 50 mg......32 ludent fluoride.......................................................71 LUMIGAN OPHTHALMIC DROPS 0.01 %................66 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG..............................................................22 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG................................................................22 LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED)............................................................22 lutera (28)..............................................................64 LYNPARZA..............................................................22 LYRICA ORAL CAPSULE 100 MG.............................32 LYRICA ORAL CAPSULE 150 MG.............................32 LYRICA ORAL CAPSULE 200 MG.............................32 LYRICA ORAL CAPSULE 225 MG, 300 MG..............32 LYRICA ORAL CAPSULE 25 MG...............................32 LYRICA ORAL CAPSULE 50 MG...............................32 LYRICA ORAL CAPSULE 75 MG...............................33 LYRICA ORAL SOLUTION........................................33 LYSODREN..............................................................22 lyza.........................................................................64 M-M-R II (PF).........................................................61 magnesium sulfate in water intravenous parenteral solution.............................................71 magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %)....................................................................71 magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %)..........................71 magnesium sulfate injection solution....................71 magnesium sulfate injection syringe.....................71 MALARONE............................................................15 malathion..............................................................50 maprotiline oral tablet 25 mg................................33 maprotiline oral tablet 50 mg................................33 maprotiline oral tablet 75 mg................................33 marlissa.................................................................64 MARPLAN..............................................................33 MATULANE............................................................22 MAVIK ORAL TABLET 1 MG, 2 MG.........................45 MAXZIDE................................................................45 MAXZIDE-25MG.....................................................45 meclizine oral tablet 12.5 mg, 25 mg....................59 meclofenamate oral..............................................33 medroxyprogesterone intramuscular....................64 medroxyprogesterone oral....................................64

Fecha de entrada en vigencia 01 de octubre de 2016

mefloquine.............................................................15 megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/20 ml (20 ml).........................................22 megestrol oral suspension 400 mg/10 ml (40 mg/ ml).......................................................................22 megestrol oral tablet.............................................22 MEKINIST ORAL TABLET 0.5 MG............................22 MEKINIST ORAL TABLET 2 MG...............................22 meloxicam oral suspension....................................33 meloxicam oral tablet............................................33 melphalan hcl........................................................22 memantine oral solution.......................................33 memantine oral tablet 10 mg................................33 memantine oral tablet 5 mg..................................33 MENACTRA (PF) INTRAMUSCULAR SOLUTION......61 MENEST.................................................................64 MENOMUNE - A/C/Y/W-135.................................61 MENOMUNE - A/C/Y/W-135 (PF)..........................61 MENVEO A-C-Y-W-135-DIP (PF).............................61 mercaptopurine.....................................................22 meropenem...........................................................15 MESALAMINE ORAL...............................................59 mesalamine rectal.................................................59 mesalamine with cleansing wipe...........................59 mesna....................................................................22 MESNEX ORAL.......................................................22 MESTINON ORAL SYRUP........................................33 MESTINON TIMESPAN...........................................33 metformin oral tablet 1,000 mg............................56 metformin oral tablet 500 mg...............................56 metformin oral tablet 850 mg...............................56 metformin oral tablet extended release 24 hr 500 mg.......................................................................56 metformin oral tablet extended release 24 hr 750 mg.......................................................................56 metformin oral tablet extended release 24hr 1, 000 mg................................................................56 metformin oral tablet extended release 24hr 500 mg.......................................................................56 metformin oral tablet,er gast.retention 24 hr 1, 000 mg................................................................56 metformin oral tablet,er gast.retention 24 hr 500 mg.......................................................................56 methadone intensol...............................................33 methadone oral concentrate.................................33 methadone oral solution 10 mg/5 ml....................33 methadone oral solution 5 mg/5 ml......................33 methadone oral tablet 10 mg................................33

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methadone oral tablet 5 mg..................................33 methadone oral tablet,soluble..............................33 methadose oral concentrate.................................33 methadose oral tablet,soluble...............................33 methazolamide oral...............................................66 methenamine hippurate........................................15 methenamine mandelate......................................15 methimazole oral tablet 10 mg.............................56 methimazole oral tablet 5 mg...............................56 methotrexate sodium (pf) injection recon soln......22 methotrexate sodium (pf) injection solution.........22 methotrexate sodium injection..............................22 methotrexate sodium oral.....................................22 methoxsalen rapid.................................................50 methscopolamine oral...........................................59 methyclothiazide...................................................45 methylergonovine oral..........................................64 methylphenidate oral tablet..................................33 methylprednisolone acetate..................................56 methylprednisolone oral tablet 16 mg, 4 mg, 8 mg.......................................................................56 methylprednisolone oral tablet 32 mg..................56 methylprednisolone oral tablets,dose pack...........56 methylprednisolone sodium succ injection recon soln 125 mg, 40 mg............................................56 methylprednisolone sodium succ intravenous.......56 metipranolol..........................................................66 metoclopramide hcl injection solution...................59 metoclopramide hcl injection syringe....................59 metoclopramide hcl oral solution..........................59 metoclopramide hcl oral tablet.............................59 metolazone oral tablet 10 mg, 5 mg.....................45 metolazone oral tablet 2.5 mg..............................45 metoprolol succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg...............................45 metoprolol succinate oral tablet extended release 24 hr 200 mg.......................................................45 metoprolol ta-hydrochlorothiaz oral tablet 10025 mg, 100-50 mg...............................................45 metoprolol ta-hydrochlorothiaz oral tablet 50-25 mg.......................................................................45 metoprolol tartrate intravenous solution..............45 metoprolol tartrate intravenous syringe...............45 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg..................................................................45 metoprolol tartrate oral tablet 37.5 mg, 75 mg.......................................................................45 metro i.v................................................................15

Fecha de entrada en vigencia 01 de octubre de 2016

metronidazole in nacl (iso-os)................................15 metronidazole oral capsule...................................15 metronidazole oral tablet......................................15 metronidazole topical cream.................................50 metronidazole topical gel 0.75 %..........................50 metronidazole topical lotion..................................50 metronidazole vaginal...........................................64 mexiletine oral capsule 150 mg, 250 mg...............45 mexiletine oral capsule 200 mg.............................45 MIACALCIN INJECTION...........................................56 MIACALCIN NASAL.................................................56 MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-25 MG......................................................................45 MICARDIS HCT ORAL TABLET 80-12.5 MG.............45 MICARDIS ORAL TABLET 20 MG, 40 MG................45 MICARDIS ORAL TABLET 80 MG............................45 miconazole-3 vaginal suppository.........................64 MICROGESTIN 1.5/30 (21).....................................65 MICROGESTIN 1/20 (21)........................................65 MICROGESTIN FE 1.5/30 (28)................................65 MICROGESTIN FE 1/20 (28)...................................65 MICROZIDE............................................................45 midodrine..............................................................52 MINIPRESS ORAL CAPSULE 2 MG..........................45 minocycline oral capsule 100 mg, 50 mg...............15 minocycline oral capsule 75 mg.............................15 minocycline oral tablet..........................................15 minoxidil oral.........................................................45 MIRAPEX ORAL TABLET 0.25 MG, 0.75 MG...........33 mirtazapine oral tablet 15 mg...............................33 mirtazapine oral tablet 30 mg...............................33 mirtazapine oral tablet 45 mg...............................33 mirtazapine oral tablet 7.5 mg..............................33 mirtazapine oral tablet,disintegrating 15 mg........33 mirtazapine oral tablet,disintegrating 30 mg........33 mirtazapine oral tablet,disintegrating 45 mg........33 misoprostol oral tablet 100 mcg............................59 misoprostol oral tablet 200 mcg............................59 mitomycin..............................................................22 mitoxantrone.........................................................22 modafinil oral tablet 100 mg.................................33 modafinil oral tablet 200 mg.................................33 moexipril................................................................45 moexipril-hydrochlorothiazide...............................45 molindone..............................................................33 mometasone nasal................................................69 mometasone topical..............................................50 mono-linyah...........................................................65

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mononessa (28).....................................................65 montelukast oral granules in packet.....................69 montelukast oral tablet.........................................69 montelukast oral tablet,chewable.........................69 morgidox oral capsule 50 mg................................15 morphine (pf) injection solution 0.5 mg/ml...........33 morphine (pf) injection solution 1 mg/ml..............33 morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml.................33 morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml...................33 morphine concentrate oral solution......................33 morphine intravenous cartridge 10 mg/ml, 2 mg/ ml, 4 mg/ml, 8 mg/ml.........................................33 morphine intravenous solution 10 mg/ml, 50 mg/ ml........................................................................34 morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml.........................................34 morphine intravenous solution 4 mg/ml, 8 mg/ ml........................................................................34 morphine intravenous syringe 2 mg/ml, 4 mg/ ml........................................................................34 morphine oral solution 10 mg/5 ml.......................34 morphine oral solution 20 mg/5 ml (4 mg/ml)......34 morphine oral tablet 15 mg...................................34 morphine oral tablet 30 mg...................................34 morphine oral tablet extended release 100 mg, 30 mg, 60 mg......................................................34 morphine oral tablet extended release 15 mg.......34 morphine oral tablet extended release 200 mg.......................................................................34 morphine rectal.....................................................34 MOVIPREP.............................................................59 MOXEZA.................................................................66 moxifloxacin...........................................................15 MULTAQ................................................................45 mupirocin calcium.................................................50 mupirocin topical ointment...................................50 MUSTARGEN..........................................................22 MYCAMINE............................................................15 mycophenolate mofetil oral capsule.....................22 mycophenolate mofetil oral suspension for reconstitution.....................................................22 mycophenolate mofetil oral tablet........................22 myorisan oral capsule 10 mg, 20 mg, 40 mg.........50 MYOZYME..............................................................56 MYRBETRIQ............................................................69 MYZILRA.................................................................65

Fecha de entrada en vigencia 01 de octubre de 2016

nabumetone..........................................................34 nadolol oral tablet 20 mg, 40 mg..........................45 nadolol oral tablet 80 mg......................................45 nadolol-bendroflumethiazide................................45 nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml.....................................15 nafcillin in dextrose iso-osm intravenous piggyback 2 gram/100 ml...................................15 nafcillin injection....................................................15 nafcillin intravenous recon soln 1 gram.................15 NAFCILLIN INTRAVENOUS RECON SOLN 2 GRAM..................................................................15 NAGLAZYME..........................................................56 nalbuphine injection solution 10 mg/ml................34 nalbuphine injection solution 20 mg/ml................34 naloxone injection solution....................................34 naloxone injection syringe 0.4 mg/ml...................34 naloxone injection syringe 1 mg/ml......................34 naltrexone..............................................................34 NAMENDA ORAL SOLUTION..................................34 NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK...................................................................34 NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR...................................................................34 NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 1410 MG, 28-10 MG...............................................34 naproxen oral suspension......................................34 naproxen oral tablet..............................................34 naproxen oral tablet,delayed release (dr/ec)........34 naproxen sodium oral tablet 275 mg, 550 mg......34 naratriptan............................................................34 NASONEX...............................................................69 nateglinide oral tablet 120 mg..............................56 nateglinide oral tablet 60 mg................................56 NATPARA...............................................................56 NEBUPENT.............................................................15 necon 0.5/35 (28)..................................................65 necon 1/35 (28).....................................................65 necon 1/50 (28).....................................................65 necon 10/11 (28)...................................................65 necon 7/7/7 (28)....................................................65 needles, insulin disp.,safety...................................56 nefazodone oral tablet 100 mg.............................34 nefazodone oral tablet 150 mg.............................34 nefazodone oral tablet 200 mg.............................34 nefazodone oral tablet 250 mg.............................34 nefazodone oral tablet 50 mg...............................34 neo-polycin............................................................66

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neo-polycin hc........................................................66 neomycin...............................................................15 neomycin-bacitracin-poly-hc.................................66 neomycin-bacitracin-polymyxin.............................66 neomycin-polymyxin b gu......................................52 neomycin-polymyxin b-dexameth..........................66 neomycin-polymyxin-gramicidin............................66 neomycin-polymyxin-hc ophthalmic......................66 neomycin-polymyxin-hc otic..................................53 NEPHRAMINE 5.4 %...............................................71 NEUPOGEN............................................................61 NEUPRO.................................................................34 NEVANAC...............................................................66 nevirapine oral suspension....................................15 nevirapine oral tablet............................................15 nevirapine oral tablet extended release 24 hr 100 mg.......................................................................15 nevirapine oral tablet extended release 24 hr 400 mg.......................................................................15 NEXAVAR...............................................................22 niacin oral tablet extended release 24 hr 1,000 mg, 750 mg.........................................................45 niacin oral tablet extended release 24 hr 500 mg.......................................................................45 NIACOR..................................................................45 nicardipine intravenous solution...........................45 nicardipine oral......................................................45 NICOTROL NS.........................................................52 nifedical xl..............................................................45 nifedipine oral tablet extended release 24hr 30 mg, 60 mg...........................................................45 nifedipine oral tablet extended release 24hr 90 mg.......................................................................45 nifedipine oral tablet extended release 30 mg, 60 mg.......................................................................45 nifedipine oral tablet extended release 90 mg......45 NILANDRON...........................................................22 nilutamide..............................................................22 nimodipine.............................................................45 NINLARO................................................................22 NIPENT...................................................................22 nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg..................................................................15 nitrofurantoin monohyd/m-cryst...........................15 nitroglycerin intravenous.......................................45 nitroglycerin transdermal patch 24 hour...............45 NITROSTAT.............................................................45 nizatidine oral capsule 150 mg..............................59

Fecha de entrada en vigencia 01 de octubre de 2016

nizatidine oral capsule 300 mg..............................59 NOR-QD.................................................................65 nora-be..................................................................65 NORDITROPIN FLEXPRO.........................................61 norethindrone (contraceptive)...............................65 norethindrone acetate...........................................65 norgestimate-ethinyl estradiol oral tablet 0.18/ 0.215/0.25 mg-35 mcg (28), 0.25-35 mgmcg.....................................................................65 NORMOSOL-M IN 5 % DEXTROSE..........................71 NORMOSOL-R........................................................71 NORMOSOL-R IN 5 % DEXTROSE...........................71 NORMOSOL-R PH 7.4.............................................71 NORPACE...............................................................45 nortrel 0.5/35 (28).................................................65 nortrel 1/35 (21)....................................................65 nortrel 1/35 (28)....................................................65 nortrel 7/7/7 (28)...................................................65 nortriptyline oral capsule.......................................34 nortriptyline oral solution......................................34 NORVASC ORAL TABLET 10 MG, 2.5 MG...............46 NORVASC ORAL TABLET 5 MG...............................46 NORVIR ORAL CAPSULE.........................................15 NORVIR ORAL SOLUTION.......................................15 NORVIR ORAL TABLET............................................15 NOVOPEN ECHO....................................................56 NOXAFIL ORAL SUSPENSION..................................15 NUEDEXTA.............................................................34 NULOJIX.................................................................22 NUPLAZID..............................................................34 nyamyc..................................................................50 nystatin oral suspension........................................15 nystatin oral tablet................................................15 nystatin topical cream...........................................50 nystatin topical ointment......................................50 nystatin topical powder.........................................50 nystatin-triamcinolone..........................................50 nystop....................................................................50 ocella.....................................................................65 OCTAGAM..............................................................61 octreotide acetate injection solution 1,000 mcg/ ml, 500 mcg/ml...................................................22 octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml.....................................22 octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml).....................................22 octreotide acetate injection syringe 500 mcg/ml (1 ml)..................................................................22

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ODEFSEY................................................................15 ODOMZO...............................................................22 OFEV ORAL CAPSULE 150 MG................................69 ofloxacin ophthalmic.............................................66 ofloxacin oral tablet 400 mg..................................16 ofloxacin otic.........................................................53 ogestrel (28)...........................................................65 olanzapine intramuscular......................................34 olanzapine oral tablet 10 mg.................................34 olanzapine oral tablet 15 mg.................................35 olanzapine oral tablet 2.5 mg................................35 olanzapine oral tablet 20 mg.................................35 olanzapine oral tablet 5 mg...................................35 olanzapine oral tablet 7.5 mg................................35 olanzapine oral tablet,disintegrating 10 mg.........35 olanzapine oral tablet,disintegrating 15 mg.........35 olanzapine oral tablet,disintegrating 20 mg.........35 olanzapine oral tablet,disintegrating 5 mg...........35 OLYSIO...................................................................16 omega-3 acid ethyl esters......................................46 omeprazole oral capsule,delayed release(dr/ec) 10 mg, 40 mg......................................................59 omeprazole oral capsule,delayed release(dr/ec) 20 mg..................................................................59 OMNITROPE...........................................................61 ONCASPAR.............................................................22 ondansetron hcl (pf) injection solution..................59 ondansetron hcl (pf) injection syringe...................59 ondansetron hcl intravenous.................................59 ondansetron hcl oral tablet 4 mg, 8 mg................60 ondansetron oral tablet,disintegrating 4 mg........60 ondansetron oral tablet,disintegrating 8 mg........60 ONFI ORAL SUSPENSION........................................35 ONFI ORAL TABLET 10 MG.....................................35 ONFI ORAL TABLET 20 MG.....................................35 OPDIVO..................................................................22 opium tincture.......................................................60 ORAP......................................................................35 ORENCIA................................................................63 ORENCIA (WITH MALTOSE)...................................63 ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG......52 ORFADIN ORAL CAPSULE 20 MG...........................52 orsythia..................................................................65 ORTHO MICRONOR...............................................65 OSMOPREP............................................................60 oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml.....................................16

Fecha de entrada en vigencia 01 de octubre de 2016

oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml.....................................16 oxacillin injection...................................................16 oxacillin intravenous..............................................16 oxaliplatin intravenous recon soln 100 mg............22 oxaliplatin intravenous recon soln 50 mg..............22 oxaliplatin intravenous solution............................22 oxandrolone oral tablet 10 mg..............................56 oxandrolone oral tablet 2.5 mg.............................56 oxaprozin...............................................................35 oxazepam..............................................................35 oxcarbazepine oral suspension..............................35 oxcarbazepine oral tablet 150 mg, 300 mg...........35 oxcarbazepine oral tablet 600 mg.........................35 oxybutynin chloride oral syrup...............................70 oxybutynin chloride oral tablet..............................70 oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg.............................................70 oxybutynin chloride oral tablet extended release 24hr 5 mg...........................................................70 oxycodone oral capsule.........................................35 oxycodone oral concentrate..................................35 oxycodone oral solution.........................................35 oxycodone oral tablet 10 mg, 5 mg.......................35 oxycodone oral tablet 15 mg.................................35 oxycodone oral tablet 20 mg, 30 mg.....................35 oxycodone-acetaminophen oral solution..............35 oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg.....................................35 oxycodone-acetaminophen oral tablet 5-325 mg.......................................................................35 oxycodone-aspirin..................................................35 pacerone oral tablet 100 mg, 400 mg...................46 pacerone oral tablet 200 mg.................................46 paclitaxel...............................................................22 paliperidone oral tablet extended release 24hr 1.5 mg.................................................................35 paliperidone oral tablet extended release 24hr 3 mg.......................................................................35 paliperidone oral tablet extended release 24hr 6 mg.......................................................................35 paliperidone oral tablet extended release 24hr 9 mg.......................................................................35 pamidronate intravenous recon soln.....................56 pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 90 mg/10 ml (9 mg/ml)....................56 pamidronate intravenous solution 60 mg/10 ml (6 mg/ml)............................................................56

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PANRETIN..............................................................50 pantoprazole intravenous......................................60 pantoprazole oral..................................................60 paregoric...............................................................60 paricalcitol oral capsule 1 mcg, 2 mcg...................56 paricalcitol oral capsule 4 mcg..............................56 paroex oral rinse....................................................53 paromomycin.........................................................16 paroxetine hcl oral tablet 10 mg...........................35 paroxetine hcl oral tablet 20 mg...........................35 paroxetine hcl oral tablet 30 mg...........................35 paroxetine hcl oral tablet 40 mg...........................35 paroxetine hcl oral tablet extended release 24 hr 12.5 mg...............................................................35 paroxetine hcl oral tablet extended release 24 hr 25 mg..................................................................35 paroxetine hcl oral tablet extended release 24 hr 37.5 mg...............................................................36 PASER.....................................................................16 PATADAY................................................................66 PAXIL ORAL SUSPENSION......................................36 PAZEO....................................................................66 PEDVAX HIB (PF)....................................................61 peg 3350-electrolytes oral recon soln 236-22.746.74 -5.86 gram..................................................60 peg 3350-electrolytes oral recon soln 240-22.726.72 -5.84 gram..................................................60 peg-electrolyte soln...............................................60 PEGANONE............................................................36 PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML................61 PENICILLIN G POT IN DEXTROSE............................16 penicillin g potassium............................................16 penicillin g procaine intramuscular syringe 1.2 million unit/2 ml.................................................16 penicillin g procaine intramuscular syringe 600, 000 unit/ml.........................................................16 penicillin g sodium.................................................16 penicillin v potassium oral recon soln....................16 penicillin v potassium oral tablet 250 mg..............16 penicillin v potassium oral tablet 500 mg..............16 PENTAM.................................................................16 PENTASA................................................................60 pentoxifylline.........................................................46 PERFOROMIST.......................................................69 perindopril erbumine.............................................46 periogard...............................................................53 PERJETA.................................................................23

Fecha de entrada en vigencia 01 de octubre de 2016

permethrin topical cream......................................50 perphenazine.........................................................36 pfizerpen-g.............................................................16 phenelzine..............................................................36 phenobarbital oral elixir........................................36 phenobarbital oral tablet 100 mg.........................36 phenobarbital oral tablet 15 mg...........................36 phenobarbital oral tablet 16.2 mg........................36 phenobarbital oral tablet 30 mg...........................36 phenobarbital oral tablet 32.4 mg........................36 phenobarbital oral tablet 60 mg...........................36 phenobarbital oral tablet 64.8 mg........................36 phenobarbital oral tablet 97.2 mg........................36 PHENYTEK..............................................................36 phenytoin oral suspension 100 mg/4 ml...............36 phenytoin oral suspension 125 mg/5 ml...............36 phenytoin oral tablet,chewable.............................36 phenytoin sodium extended..................................36 phenytoin sodium intravenous solution.................36 phenytoin sodium intravenous syringe..................36 philith.....................................................................65 phospha 250 neutral..............................................71 PHOSPHOLINE IODIDE...........................................66 PHYSIOLYTE...........................................................52 PHYSIOSOL IRRIGATION.........................................52 PICATO...................................................................50 pilocarpine hcl ophthalmic drops 1 %, 2 %............66 pilocarpine hcl ophthalmic drops 4 %....................66 pilocarpine hcl oral................................................52 pimozide................................................................36 PIMTREA (28).........................................................65 pindolol oral tablet 10 mg.....................................46 pindolol oral tablet 5 mg.......................................46 pioglitazone oral tablet 15 mg..............................56 pioglitazone oral tablet 30 mg..............................56 pioglitazone oral tablet 45 mg..............................56 pioglitazone-glimepiride........................................57 pioglitazone-metformin.........................................57 piperacillin-tazobactam.........................................16 pirmella oral tablet 1-35 mg-mcg..........................65 piroxicam...............................................................36 PLASMA-LYTE 148..................................................71 PLASMA-LYTE A.....................................................71 PLASMA-LYTE-56 IN 5 % DEXTROSE.......................71 PLEGRIDY...............................................................61 podofilox................................................................50 polycin...................................................................66 polyethylene glycol 3350 oral................................60

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polymyxin b sulf-trimethoprim..............................66 polymyxin b sulfate................................................16 POMALYST ORAL CAPSULE 1 MG..........................23 POMALYST ORAL CAPSULE 2 MG..........................23 POMALYST ORAL CAPSULE 3 MG, 4 MG................23 portia.....................................................................65 PORTRAZZA............................................................23 potassium bicarb and chloride...............................71 potassium bicarb-citric acid...................................71 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/ l...........................................................................71 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l..............................71 potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l..............71 potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/ l...........................................................................71 potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l................................................71 potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l................................................71 potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml........................................................................71 potassium chloride intravenous piggyback 10 meq/50 ml..........................................................71 potassium chloride oral capsule, extended release................................................................71 potassium chloride oral liquid...............................71 potassium chloride oral tablet extended release................................................................71 potassium chloride oral tablet,er particles/ crystals................................................................72 potassium chloride-0.45 % nacl.............................72 potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l..............................72 potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l..............72 potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l..............................72 potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l..............................72 potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l..............................72 potassium citrate oral tablet extended release 10 meq (1,080 mg)..................................................70

Fecha de entrada en vigencia 01 de octubre de 2016

potassium citrate oral tablet extended release 5 meq (540 mg).....................................................70 POTIGA ORAL TABLET 200 MG..............................36 POTIGA ORAL TABLET 300 MG, 400 MG................36 POTIGA ORAL TABLET 50 MG................................36 PRADAXA...............................................................46 PRALUENT PEN......................................................46 PRALUENT SYRINGE...............................................46 pramipexole oral tablet.........................................36 PRAVACHOL ORAL TABLET 20 MG.........................46 pravastatin oral tablet 10 mg, 20 mg, 40 mg........46 pravastatin oral tablet 80 mg................................46 prazosin oral capsule 1 mg, 2 mg..........................46 prazosin oral capsule 5 mg....................................46 PRECOSE ORAL TABLET 100 MG............................57 PRECOSE ORAL TABLET 25 MG..............................57 PRECOSE ORAL TABLET 50 MG..............................57 prednicarbate........................................................51 prednisolone acetate.............................................66 prednisolone oral solution 15 mg/5 ml..................57 prednisolone sodium phosphate ophthalmic.........66 prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml).............................................57 prednisolone sodium phosphate oral solution 5 mg base/5 ml (6.7 mg/5 ml)...............................57 prednisolone sodium phosphate oral tablet, disintegrating.....................................................57 prednisone intensol...............................................57 prednisone oral solution........................................57 prednisone oral tablet 1 mg..................................57 prednisone oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg...........................................................57 prednisone oral tablets,dose pack.........................57 PREMARIN ORAL....................................................65 PREMARIN VAGINAL..............................................65 premasol 10 %.......................................................72 PREMASOL 6 %......................................................72 PREMPRO..............................................................65 prenatal vitamin oral tablet..................................72 prevalite.................................................................46 previfem.................................................................65 PREZCOBIX.............................................................16 PREZISTA ORAL SUSPENSION.................................16 PREZISTA ORAL TABLET 150 MG............................16 PREZISTA ORAL TABLET 600 MG, 800 MG.............16 PREZISTA ORAL TABLET 75 MG..............................16 PRIFTIN..................................................................16 PRIMAQUINE.........................................................16

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primidone..............................................................36 PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG........46 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG...............................................................36 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG.................................................................36 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG.................................................................36 PRIVIGEN...............................................................61 PROAIR HFA...........................................................69 PROAIR RESPICLICK................................................69 probenecid.............................................................63 procainamide injection solution 100 mg/ml..........46 procainamide injection solution 500 mg/ml..........46 PROCALAMINE 3%.................................................72 PROCARDIA............................................................46 PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG........................................................46 prochlorperazine....................................................60 prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml).............................................60 prochlorperazine maleate oral..............................60 PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ ML, 4,000 UNIT/ML............................................62 PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML.................................................62 procto-pak.............................................................60 proctosol hc...........................................................60 proctozone-hc........................................................60 progesterone micronized.......................................65 PROGLYCEM..........................................................57 PROGRAF INTRAVENOUS.......................................23 PROLASTIN-C.........................................................52 PROLEUKIN............................................................62 PROLIA...................................................................63 PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG......................................................................46 PROMACTA ORAL TABLET 50 MG..........................46 promethazine injection solution............................69 promethazine oral tablet 12.5 mg, 25 mg.............69 propafenone oral tablet 150 mg, 225 mg..............46 propafenone oral tablet 300 mg............................46 propantheline........................................................60 propranolol intravenous........................................46 propranolol oral capsule,extended release 24 hr 120 mg, 160 mg..................................................46

Fecha de entrada en vigencia 01 de octubre de 2016

propranolol oral capsule,extended release 24 hr 60 mg, 80 mg......................................................46 propranolol oral solution.......................................46 propranolol oral tablet 10 mg, 20 mg, 40 mg, 80 mg.......................................................................46 propranolol oral tablet 60 mg...............................46 propranolol-hydrochlorothiazid.............................46 propylthiouracil.....................................................57 PROQUAD (PF).......................................................62 PROSOL 20 %.........................................................72 protriptyline...........................................................36 PULMOZYME.........................................................69 PURIXAN................................................................23 pyrazinamide.........................................................16 pyridostigmine bromide oral tablet.......................36 QUADRACEL (PF)....................................................62 quasense................................................................65 quetiapine oral tablet 100 mg...............................36 quetiapine oral tablet 200 mg...............................36 quetiapine oral tablet 25 mg.................................36 quetiapine oral tablet 300 mg...............................36 quetiapine oral tablet 400 mg...............................36 quetiapine oral tablet 50 mg.................................36 quinapril oral tablet 10 mg, 5 mg..........................46 quinapril oral tablet 20 mg, 40 mg........................46 quinapril-hydrochlorothiazide...............................46 quinidine sulfate oral tablet..................................46 QVAR INHALATION AEROSOL 40 MCG/ ACTUATION.........................................................69 QVAR INHALATION AEROSOL 80 MCG/ ACTUATION.........................................................69 RABAVERT (PF)......................................................62 raloxifene...............................................................63 ramipril..................................................................46 RANEXA..................................................................46 ranitidine hcl injection solution 25 mg/ml.............60 ranitidine hcl oral syrup.........................................60 ranitidine hcl oral tablet 150 mg, 300 mg.............60 RAPAMUNE ORAL SOLUTION................................23 RAVICTI..................................................................52 RAZADYNE ORAL TABLET 4 MG.............................36 REBIF (WITH ALBUMIN).........................................62 REBIF REBIDOSE.....................................................62 REBIF TITRATION PACK..........................................62 reclipsen (28).........................................................65 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION.......................................................62

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RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML........................................................62 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML....................................................62 regonol...................................................................36 RELENZA DISKHALER..............................................16 RELISTOR SUBCUTANEOUS SOLUTION..................60 RELISTOR SUBCUTANEOUS SYRINGE.....................60 REMICADE..............................................................60 RENVELA ORAL POWDER IN PACKET 0.8 GRAM..................................................................52 RENVELA ORAL POWDER IN PACKET 2.4 GRAM..................................................................52 RENVELA ORAL TABLET..........................................52 repaglinide oral tablet 0.5 mg...............................57 repaglinide oral tablet 1 mg..................................57 repaglinide oral tablet 2 mg..................................57 REPATHA SURECLICK.............................................46 REPATHA SYRINGE.................................................46 REQUIP ORAL TABLET 1 MG, 4 MG, 5 MG.............36 RESCRIPTOR ORAL TABLET....................................16 RESCRIPTOR ORAL TABLET, DISPERSIBLE...............16 reserpine oral tablet 0.1 mg..................................47 RESTASIS................................................................66 RETROVIR INTRAVENOUS......................................16 REVLIMID ORAL CAPSULE 10 MG..........................23 REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG.................................................................23 REVLIMID ORAL CAPSULE 5 MG............................23 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG...................................................................37 REXULTI ORAL TABLET 3 MG, 4 MG.......................37 REYATAZ ORAL CAPSULE 150 MG, 200 MG...........16 REYATAZ ORAL CAPSULE 300 MG..........................16 REYATAZ ORAL POWDER IN PACKET.....................16 ribasphere oral capsule.........................................16 ribasphere oral tablet 200 mg...............................16 ribavirin oral capsule.............................................16 ribavirin oral tablet 200 mg...................................16 RIDAURA................................................................63 rifabutin.................................................................16 rifampin.................................................................16 RIFATER..................................................................16 riluzole...................................................................52 rimantadine...........................................................16 ringers intravenous................................................72 ringers irrigation....................................................52 risedronate oral tablet 150 mg..............................63

Fecha de entrada en vigencia 01 de octubre de 2016

risedronate oral tablet 30 mg................................52 risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)....................................................63 risedronate oral tablet 5 mg..................................63 risedronate oral tablet,delayed release (dr/ ec).......................................................................63 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML..............................37 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 MG/2 ML.....................................................37 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML........................................................37 risperidone oral solution........................................37 risperidone oral tablet 0.25 mg.............................37 risperidone oral tablet 0.5 mg...............................37 risperidone oral tablet 1 mg..................................37 risperidone oral tablet 2 mg..................................37 risperidone oral tablet 3 mg..................................37 risperidone oral tablet 4 mg..................................37 risperidone oral tablet,disintegrating 0.25 mg......37 risperidone oral tablet,disintegrating 0.5 mg........37 risperidone oral tablet,disintegrating 1 mg...........37 risperidone oral tablet,disintegrating 2 mg...........37 risperidone oral tablet,disintegrating 3 mg...........37 risperidone oral tablet,disintegrating 4 mg...........37 RITUXAN................................................................23 rivastigmine tartrate.............................................37 ropinirole oral tablet..............................................37 ropinirole oral tablet extended release 24 hr........37 rosadan topical cream...........................................51 rosadan topical gel................................................51 rosuvastatin...........................................................47 ROTARIX.................................................................62 ROTATEQ VACCINE................................................62 roweepra...............................................................37 ROZEREM...............................................................37 SABRIL ORAL POWDER IN PACKET.........................37 SABRIL ORAL TABLET.............................................37 SAMSCA ORAL TABLET 15 MG...............................57 SAMSCA ORAL TABLET 30 MG...............................57 SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON..................23 SANTYL...................................................................51 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG.................................................................37 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG................................................................37

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SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG......................................................................37 SAVELLA ORAL TABLET 100 MG.............................63 SAVELLA ORAL TABLET 12.5 MG............................63 SAVELLA ORAL TABLET 25 MG...............................63 SAVELLA ORAL TABLET 50 MG...............................63 SAVELLA ORAL TABLETS,DOSE PACK.....................63 selegiline hcl..........................................................37 selenium sulfide topical lotion...............................51 SELZENTRY.............................................................16 SENSIPAR ORAL TABLET 30 MG.............................57 SENSIPAR ORAL TABLET 60 MG.............................57 SENSIPAR ORAL TABLET 90 MG.............................57 SEREVENT DISKUS..................................................69 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG.....................................................37 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG.....................................................37 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG.....................................................37 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG.....................................................37 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG.......................................................37 sertraline oral concentrate....................................37 sertraline oral tablet 100 mg.................................38 sertraline oral tablet 25 mg...................................38 sertraline oral tablet 50 mg...................................38 sf 5000 plus............................................................53 SIGNIFOR...............................................................23 sildenafil oral.........................................................69 SILVADENE.............................................................51 silver sulfadiazine..................................................51 SIMBRINZA.............................................................67 SIMPONI................................................................63 SIMULECT INTRAVENOUS RECON SOLN 10 MG......................................................................23 SIMULECT INTRAVENOUS RECON SOLN 20 MG......................................................................23 simvastatin............................................................47 SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG..........................................................38 sirolimus................................................................23 SIRTURO.................................................................16 sodium bicarbonate intravenous solution.............72 sodium bicarbonate intravenous syringe 4.2 % (0.5 meq/ml), 7.5 % (0.9 meq/ml)......................72

Fecha de entrada en vigencia 01 de octubre de 2016

SODIUM BICARBONATE INTRAVENOUS SYRINGE 8.4 % (1 MEQ/ML)..............................................72 sodium chloride 0.45 % intravenous parenteral solution...............................................................72 sodium chloride 0.45 % intravenous piggyback............................................................72 sodium chloride 0.9 % intravenous........................52 sodium chloride 3 %...............................................72 sodium chloride 5 %...............................................72 sodium chloride intravenous.................................72 sodium chloride irrigation......................................52 sodium citrate-citric acid.......................................70 sodium fluoride oral tablet....................................72 sodium fluoride oral tablet,chewable....................72 sodium lactate intravenous...................................72 sodium phenylbutyrate..........................................52 sodium polystyrene (sorb free)..............................52 sodium polystyrene sulfonate oral powder...........52 sodium polystyrene sulfonate oral suspension......52 sodium polystyrene sulfonate rectal......................52 SOLTAMOX............................................................23 SOMATULINE DEPOT.............................................23 SOMAVERT............................................................57 sorine oral tablet 120 mg, 160 mg........................47 sorine oral tablet 240 mg......................................47 sorine oral tablet 80 mg........................................47 sotalol af oral tablet 120 mg, 160 mg...................47 sotalol af oral tablet 80 mg...................................47 sotalol oral tablet 120 mg, 160 mg, 240 mg.........47 sotalol oral tablet 80 mg.......................................47 SOVALDI.................................................................16 SPIRIVA RESPIMAT.................................................69 SPIRIVA WITH HANDIHALER..................................69 spironolacton-hydrochlorothiaz............................47 spironolactone oral tablet 100 mg........................47 spironolactone oral tablet 25 mg, 50 mg..............47 sprintec (28)...........................................................65 SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG.........................................38 SPRITAM ORAL TABLET FOR SUSPENSION 750 MG......................................................................38 SPRYCEL.................................................................23 sps (with sorbitol) oral...........................................52 sps (with sorbitol) rectal........................................52 sronyx....................................................................65 ssd..........................................................................51 stavudine oral capsule 15 mg................................16 stavudine oral capsule 20 mg................................16

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stavudine oral capsule 30 mg................................16 stavudine oral capsule 40 mg................................16 stavudine oral recon soln.......................................16 STIMATE.................................................................57 STIOLTO RESPIMAT................................................69 STIVARGA...............................................................23 STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG.........................................................38 STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG......................................................................38 STREPTOMYCIN INTRAMUSCULAR........................16 STRIBILD.................................................................17 STROMECTOL.........................................................17 SUBOXONE SUBLINGUAL FILM 12-3 MG...............38 SUBOXONE SUBLINGUAL FILM 2-0.5 MG..............38 SUBOXONE SUBLINGUAL FILM 4-1 MG.................38 SUBOXONE SUBLINGUAL FILM 8-2 MG.................38 SUCRAID................................................................60 sucralfate oral tablet.............................................60 SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG.................................................................47 sulfacetamide sodium (acne).................................51 sulfacetamide sodium ophthalmic drops...............67 sulfacetamide sodium ophthalmic ointment.........67 sulfacetamide-prednisolone..................................67 sulfadiazine oral....................................................17 sulfamethoxazole-trimethoprim intravenous........17 sulfamethoxazole-trimethoprim oral suspension..........................................................17 sulfamethoxazole-trimethoprim oral tablet..........17 sulfasalazine..........................................................60 sulindac oral tablet 150 mg...................................38 sulindac oral tablet 200 mg...................................38 sumatriptan...........................................................38 sumatriptan succinate oral....................................38 sumatriptan succinate subcutaneous cartridge.............................................................38 sumatriptan succinate subcutaneous pen injector................................................................38 sumatriptan succinate subcutaneous solution......38 sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml...........................................................38 SUPREP BOWEL PREP KIT......................................60 SURMONTIL...........................................................38 SUSTIVA ORAL CAPSULE 200 MG..........................17 SUSTIVA ORAL CAPSULE 50 MG.............................17 SUSTIVA ORAL TABLET...........................................17 SUTENT ORAL CAPSULE 12.5 MG..........................23

Fecha de entrada en vigencia 01 de octubre de 2016

SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG......................................................................23 syeda......................................................................65 SYLATRON..............................................................62 SYMBICORT............................................................69 SYMBYAX ORAL CAPSULE 12-25 MG, 12-50 MG, 6-50 MG..............................................................38 SYMBYAX ORAL CAPSULE 3-25 MG.......................38 SYMLINPEN 120.....................................................57 SYMLINPEN 60.......................................................57 SYNAGIS.................................................................17 SYNAREL................................................................57 SYNERCID...............................................................17 SYNJARDY..............................................................57 SYNRIBO.................................................................23 SYNTHROID............................................................57 SYPRINE.................................................................52 TABLOID.................................................................23 tacrolimus oral capsule 0.5 mg, 1 mg....................23 tacrolimus oral capsule 5 mg.................................23 TAFINLAR...............................................................23 TAGRISSO ORAL TABLET 40 MG.............................23 TAGRISSO ORAL TABLET 80 MG.............................23 TAMIFLU................................................................17 tamoxifen...............................................................23 tamsulosin.............................................................70 TANZEUM..............................................................57 TAPAZOLE..............................................................57 TARCEVA ORAL TABLET 100 MG, 150 MG.............23 TARCEVA ORAL TABLET 25 MG..............................23 TARGRETIN............................................................23 TASIGNA................................................................23 TAXOTERE INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 80 MG/4 ML (20 MG/ML).......................23 TAZORAC................................................................51 taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 360 mg....................................47 taztia xt oral capsule, extended release 300 mg.......................................................................47 TECENTRIQ.............................................................23 TECFIDERA.............................................................38 TECHNIVIE..............................................................17 TEFLARO INTRAVENOUS RECON SOLN 400 MG......................................................................17 TEFLARO INTRAVENOUS RECON SOLN 600 MG......................................................................17 TEKTURNA.............................................................47 TEKTURNA HCT......................................................47

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telmisartan oral tablet 20 mg, 40 mg....................47 telmisartan oral tablet 80 mg................................47 telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg.....................................................47 telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg.......................................................................47 TEMOVATE TOPICAL CREAM.................................51 TEMOVATE TOPICAL OINTMENT...........................51 TENORETIC 100......................................................47 TENORETIC 50........................................................47 terazosin................................................................47 terbinafine hcl oral................................................17 terbutaline oral......................................................69 terconazole vaginal cream....................................65 terconazole vaginal suppository............................65 testosterone cypionate..........................................57 testosterone enanthate.........................................57 testosterone transdermal gel................................57 testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %)......................57 testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation......................57 testosterone transdermal gel in packet 1 % (25 mg/2.5gram)......................................................57 testosterone transdermal gel in packet 1 % (50 mg/5 gram)........................................................58 tetanus,diphtheria tox ped(pf)...............................62 TETANUS-DIPHTHERIA TOXOIDS-TD......................62 tetrabenazine oral tablet 12.5 mg.........................38 tetrabenazine oral tablet 25 mg............................38 tetracycline............................................................17 THALOMID ORAL CAPSULE 100 MG, 50 MG..........23 THALOMID ORAL CAPSULE 150 MG, 200 MG........24 theophylline oral elixir...........................................69 theophylline oral solution......................................69 theophylline oral tablet extended release 12 hr........................................................................69 theophylline oral tablet extended release 24 hr........................................................................69 thermazene............................................................51 THIOLA...................................................................52 thioridazine............................................................38 thiotepa.................................................................24 thiothixene.............................................................38 THYMOGLOBULIN..................................................62 tiagabine................................................................38 TIAZAC...................................................................47 TICE BCG................................................................62

Fecha de entrada en vigencia 01 de octubre de 2016

TIKOSYN.................................................................47 TILIA FE..................................................................65 timolol maleate ophthalmic drops........................67 timolol maleate ophthalmic gel forming solution...............................................................67 timolol maleate oral tablet 10 mg, 5 mg...............47 timolol maleate oral tablet 20 mg.........................47 TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE 0.25 %.........................................67 TIMOPTIC OPHTHALMIC DROPS 0.25 %................67 TIMOPTIC-XE..........................................................67 tinidazole oral tablet 250 mg................................17 tinidazole oral tablet 500 mg................................17 TIVICAY ORAL TABLET 10 MG................................17 TIVICAY ORAL TABLET 25 MG................................17 TIVICAY ORAL TABLET 50 MG................................17 tizanidine oral tablet.............................................38 TOBRADEX OPHTHALMIC OINTMENT...................67 TOBRADEX ST.........................................................67 tobramycin.............................................................67 tobramycin in 0.225 % nacl...................................17 tobramycin sulfate injection recon soln.................17 tobramycin sulfate injection solution....................17 tobramycin-dexamethasone..................................67 tolazamide oral tablet 250 mg..............................58 tolazamide oral tablet 500 mg..............................58 tolbutamide...........................................................58 tolcapone...............................................................38 tolterodine oral capsule,extended release 24hr....................................................................70 tolterodine oral tablet...........................................70 topiramate oral capsule, sprinkle..........................38 topiramate oral tablet 100 mg..............................38 topiramate oral tablet 200 mg..............................38 topiramate oral tablet 25 mg................................38 topiramate oral tablet 50 mg................................38 toposar..................................................................24 topotecan intravenous recon soln.........................24 topotecan intravenous solution.............................24 TORISEL..................................................................24 torsemide oral tablet 10 mg, 5 mg........................47 torsemide oral tablet 100 mg, 20 mg....................47 TOUJEO SOLOSTAR................................................58 TOVIAZ...................................................................70 TRACLEER...............................................................69 TRADJENTA............................................................58 tramadol oral tablet..............................................38 tramadol-acetaminophen......................................38

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trandolapril............................................................47 tranexamic acid intravenous.................................47 tranexamic acid oral..............................................65 tranylcypromine.....................................................38 travasol 10 %.........................................................72 TRAVATAN Z..........................................................67 trazodone oral tablet 100 mg, 150 mg..................39 trazodone oral tablet 300 mg................................39 trazodone oral tablet 50 mg..................................39 TREANDA INTRAVENOUS RECON SOLN.................24 TRECATOR..............................................................17 TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION...............................................24 TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/ 2 ML, 3.75 MG/2 ML...........................................24 TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML.......................................................................24 tretinoin (chemotherapy) oral capsule..................24 tretinoin topical cream..........................................51 tretinoin topical gel 0.01 %, 0.025 %.....................51 tri-estarylla............................................................65 tri-legest fe............................................................65 tri-linyah................................................................65 tri-previfem (28)....................................................65 tri-sprintec (28)......................................................65 triamcinolone acetonide dental.............................53 triamcinolone acetonide injection suspension 10 mg/ml.................................................................58 triamcinolone acetonide injection suspension 40 mg/ml.................................................................58 triamcinolone acetonide topical cream 0.025 %.........................................................................51 triamcinolone acetonide topical cream 0.1 %, 0.5 %.........................................................................51 triamcinolone acetonide topical lotion 0.025 %.........................................................................51 triamcinolone acetonide topical lotion 0.1 %........51 triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %....................................................51 triamterene-hydrochlorothiazid oral capsule 37.525 mg..................................................................47 triamterene-hydrochlorothiazid oral tablet...........47 trianex....................................................................51 TRIBENZOR............................................................47 TRICOR ORAL TABLET 48 MG.................................47 triderm topical cream............................................51 trifluoperazine oral tablet 1 mg, 2 mg...................39 trifluoperazine oral tablet 10 mg, 5 mg.................39

Fecha de entrada en vigencia 01 de octubre de 2016

trifluridine..............................................................67 TRILIPIX ORAL CAPSULE,DELAYED RELEASE(DR/ EC) 45 MG...........................................................47 trilyte with flavor packets......................................60 trimethoprim.........................................................17 trinessa (28)...........................................................65 TRINTELLIX ORAL TABLET 10 MG...........................39 TRINTELLIX ORAL TABLET 20 MG...........................39 TRINTELLIX ORAL TABLET 5 MG.............................39 TRISENOX...............................................................24 TRIUMEQ...............................................................17 trivora (28).............................................................65 TROPHAMINE 10 %................................................72 TROPHAMINE 6%...................................................72 trospium oral tablet...............................................70 TRULICITY...............................................................58 TRUMENBA............................................................62 TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG................................................17 TRUVADA ORAL TABLET 200-300 MG....................17 TWINRIX (PF).........................................................62 TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 805 MG...................................................................47 TYBOST..................................................................17 TYGACIL.................................................................17 TYKERB...................................................................24 TYPHIM VI INTRAMUSCULAR SOLUTION...............62 TYPHIM VI INTRAMUSCULAR SYRINGE..................62 TYSABRI..................................................................39 TYZEKA...................................................................17 TYZINE NASAL DROPS 0.05 %................................53 UCERIS ORAL..........................................................60 ULORIC...................................................................63 unithroid................................................................58 UNITUXIN...............................................................24 ursodiol..................................................................60 UVADEX.................................................................51 valacyclovir............................................................17 VALCHLOR..............................................................51 valganciclovir oral tablet.......................................17 valproate sodium...................................................39 valproic acid...........................................................39 valproic acid (as sodium salt) oral solution 250 mg/5 ml..............................................................39 valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml)...............39 valsartan oral tablet 160 mg.................................47 valsartan oral tablet 320 mg.................................47

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valsartan oral tablet 40 mg, 80 mg.......................47 valsartan-hydrochlorothiazide oral tablet 16012.5 mg, 160-25 mg, 320-12.5 mg, 80-12.5 mg.......................................................................48 valsartan-hydrochlorothiazide oral tablet 320-25 mg.......................................................................48 VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML.......................................................................17 VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/200 ML..............................17 VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML.......................................................................17 vancomycin intravenous........................................17 vancomycin oral capsule 125 mg...........................18 vancomycin oral capsule 250 mg...........................18 vandazole..............................................................65 VAQTA (PF) INTRAMUSCULAR SUSPENSION.........62 VAQTA (PF) INTRAMUSCULAR SYRINGE................62 VARIVAX (PF).........................................................62 VARIZIG..................................................................62 VASCEPA................................................................48 VASERETIC.............................................................48 VASOTEC ORAL TABLET 2.5 MG.............................48 VECAMYL...............................................................48 VECTIBIX................................................................24 VELCADE................................................................24 velivet triphasic regimen (28)................................65 VENCLEXTA ORAL TABLET 10 MG..........................24 VENCLEXTA ORAL TABLET 100 MG........................24 VENCLEXTA ORAL TABLET 50 MG..........................24 VENCLEXTA STARTING PACK..................................24 venlafaxine oral capsule,extended release 24hr 150 mg................................................................39 venlafaxine oral capsule,extended release 24hr 37.5 mg...............................................................39 venlafaxine oral capsule,extended release 24hr 75 mg..................................................................39 venlafaxine oral tablet 100 mg..............................39 venlafaxine oral tablet 25 mg................................39 venlafaxine oral tablet 37.5 mg.............................39 venlafaxine oral tablet 50 mg................................39 venlafaxine oral tablet 75 mg................................39 venlafaxine oral tablet extended release 24hr 150 mg.......................................................................39 VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 MG.....................................................39

Fecha de entrada en vigencia 01 de octubre de 2016

venlafaxine oral tablet extended release 24hr 37.5 mg.......................................................................39 venlafaxine oral tablet extended release 24hr 75 mg.......................................................................39 VENTAVIS...............................................................69 VENTOLIN HFA.......................................................69 verapamil intravenous solution.............................48 verapamil intravenous syringe..............................48 verapamil oral capsule, 24 hr er pellet ct..............48 verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg...........................................48 verapamil oral capsule,ext rel. pellets 24 hr 360 mg.......................................................................48 verapamil oral tablet.............................................48 verapamil oral tablet extended release 120 mg, 120 mg (24 hours)...............................................48 verapamil oral tablet extended release 180 mg, 240 mg................................................................48 VERSACLOZ............................................................39 VESICARE...............................................................70 vestura (28)............................................................65 VICTOZA 2-PAK......................................................58 VICTOZA 3-PAK......................................................58 VIDEX 2 GRAM PEDIATRIC.....................................18 VIDEX 4 GRAM PEDIATRIC.....................................18 VIEKIRA PAK...........................................................18 VIGAMOX...............................................................67 VIIBRYD ORAL TABLET 10 MG................................39 VIIBRYD ORAL TABLET 20 MG................................39 VIIBRYD ORAL TABLET 40 MG................................39 VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)20 MG (23)..........................................................39 VIMPAT INTRAVENOUS.........................................39 VIMPAT ORAL SOLUTION.......................................39 VIMPAT ORAL TABLET 100 MG..............................39 VIMPAT ORAL TABLET 150 MG..............................39 VIMPAT ORAL TABLET 200 MG..............................39 VIMPAT ORAL TABLET 50 MG................................39 vinblastine intravenous solution............................24 VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ ML.......................................................................24 vincasar pfs intravenous solution 2 mg/2 ml.........24 vincristine..............................................................24 vinorelbine.............................................................24 viorele (28).............................................................65 VIRACEPT ORAL TABLET 250 MG...........................18 VIRACEPT ORAL TABLET 625 MG...........................18

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VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG.....................................................18 VIRAZOLE...............................................................18 VIREAD ORAL POWDER.........................................18 VIREAD ORAL TABLET 150 MG, 250 MG, 300 MG......................................................................18 VIREAD ORAL TABLET 200 MG...............................18 VITEKTA.................................................................18 VOLTAREN TOPICAL GEL 1 %.................................39 voriconazole intravenous.......................................18 voriconazole oral suspension for reconstitution.....................................................18 voriconazole oral tablet 200 mg............................18 voriconazole oral tablet 50 mg..............................18 VOTRIENT..............................................................24 VPRIV.....................................................................58 VRAYLAR ORAL CAPSULE 1.5 MG..........................39 VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6 MG......................................................................40 VRAYLAR ORAL CAPSULE,DOSE PACK....................40 VYFEMLA (28)........................................................65 warfarin.................................................................48 water for irrigation, sterile....................................53 WELCHOL...............................................................48 XALATAN................................................................67 XALKORI.................................................................24 XARELTO ORAL TABLET 10 MG, 20 MG.................48 XARELTO ORAL TABLET 15 MG..............................48 XARELTO ORAL TABLETS,DOSE PACK.....................48 XENAZINE ORAL TABLET 12.5 MG.........................40 XENAZINE ORAL TABLET 25 MG............................40 XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT, 50 UNIT.....................................................62 XEOMIN INTRAMUSCULAR RECON SOLN 200 UNIT....................................................................62 XGEVA....................................................................24 XOLAIR...................................................................69 XOPENEX HFA........................................................69 XTANDI...................................................................24 XULANE..................................................................65 XYREM...................................................................40 XYZAL ORAL TABLET...............................................69 YERVOY..................................................................24 YF-VAX (PF)............................................................62 YONDELIS...............................................................24 zafirlukast..............................................................69 zaleplon oral capsule 10 mg..................................40 zaleplon oral capsule 5 mg....................................40

Fecha de entrada en vigencia 01 de octubre de 2016

ZALTRAP.................................................................24 ZANOSAR...............................................................24 ZARAH....................................................................65 ZARONTIN ORAL CAPSULE.....................................40 ZAVESCA................................................................58 ZELBORAF..............................................................24 zenatane oral capsule 10 mg, 20 mg, 40 mg.........51 ZENATANE ORAL CAPSULE 30 MG.........................51 zenchent (28).........................................................65 ZENCHENT FE.........................................................65 zenzedi oral tablet 10 mg......................................40 zenzedi oral tablet 5 mg........................................40 ZEPATIER................................................................18 ZESTORETIC............................................................48 ZESTRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG......................................................................48 ZETIA......................................................................48 ZIAC ORAL TABLET 10-6.25 MG, 5-6.25 MG..........48 ZIAGEN ORAL SOLUTION.......................................18 zidovudine oral capsule.........................................18 zidovudine oral syrup.............................................18 zidovudine oral tablet............................................18 ziprasidone hcl oral capsule 20 mg........................40 ziprasidone hcl oral capsule 40 mg........................40 ziprasidone hcl oral capsule 60 mg, 80 mg............40 ZIRGAN..................................................................67 ZITHROMAX ORAL PACKET....................................18 ZITHROMAX ORAL TABLET 250 MG.......................18 ZITHROMAX Z-PAK.................................................18 ZMAX.....................................................................18

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ZOCOR ORAL TABLET 10 MG, 5 MG.......................48 zoledronic acid intravenous recon soln 4 mg.........58 zoledronic acid intravenous solution 4 mg/5 ml........................................................................58 ZOLINZA.................................................................24 zolpidem oral.........................................................40 ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML.......................................................................58 zonisamide oral capsule 100 mg, 50 mg...............40 zonisamide oral capsule 25 mg.............................40 ZORTRESS ORAL TABLET 0.25 MG.........................24 ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG............24 ZOSTAVAX (PF).......................................................62 zovia 1/35e (28).....................................................65 zovia 1/50e (28).....................................................65 ZYDELIG.................................................................24 ZYKADIA.................................................................24 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG...............................................................40 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG......................................................................40 ZYTIGA...................................................................25 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML..................................................18 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML..................................................18 ZYVOX ORAL SUSPENSION FOR RECONSTITUTION...............................................18

Fecha de entrada en vigencia 01 de octubre de 2016

AMERIGROUP Community Care of New Mexico, Inc. es un plan HMO con un contrato con Medicare. La inscripción en Amerivantage Classic depende de la renovación del contrato.

This information is available for free in other languages. Please contact our customer service number at 1-866-805-4589 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30. Español (US): Esta información está disponible sin cargo en otros idiomas. Póngase en contacto con el Servicio de Atención al Cliente llamando al número 1-866-805-4589 o, para los usuarios de TTY, al 711, de 8 a. m. a 8 p. m., los 7 días de la semana (excepto en el Día de Acción de Gracias y Navidad) desde el 1° de octubre hasta el 14 de febrero, y de lunes a viernes (excepto feriados) del 15 de febrero hasta el 30 de septiembre.

Este formulario se actualizó el 01 de septiembre de 2016. Para obtener información más actualizada o para realizar otras consultas, comuníquese con el Servicio de Atención al Cliente de Amerivantage Classic (HMO), al 1-866-805-4589 o, para usuarios de TTY, al 711, de 8 a. m. a 8 p. m., los 7 días de la semana (excepto en el Día de Acción de Gracias y Navidad) desde el 1.º de octubre hasta el 14 de febrero, y de lunes a viernes (excepto feriados) del 15 de febrero hasta el 30 de septiembre, o visite www.myamerigroup.com/medicare. 54169MUSSPMUB_204 H5746_016

NM