Formulario (Lista de medicamentos cubiertos)

2016 LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN Este formulario se actualizó en octubre de 2016. Para obtener información más reciente u otras preguntas, comuníquese con Today’s Options PFFS al 1-866-568-8921 o, para usuarios TTY, al 711, de 8:00 a. m. a 8:00 p. m. en su zona horaria local, los 7 días de la semana, o visite www.TodaysOptions.com. ®

00016137, Version: 15 Y0067_S_POST_COMPFRM_0616 CMS Accepted 06/14/2016

16S1-TONF-F-CM

Nota para miembros actuales: Este formulario ha cambiado con respecto al año pasado. Vuelva a leerlo para asegurarse de que todavía se incluyen los medicamentos que usted toma. Cuando esta lista de medicamentos (formulario) indica “nosotros”, “nos” o “nuestro”, se está haciendo referencia a Today's Options PFFS. Cuando dice “plan” o “nuestro plan”, significa Today's Options PFFS. Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, que estará vigente a partir de octubre de 2016. Comuníquese con nosotros para obtener un formulario actualizado. Nuestra información de contacto, junto con la fecha en la que actualizamos el formulario por última vez, aparece en la portada y en la contraportada. Por lo general, usted debe utilizar las farmacias de la red para utilizar su beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias, y/o los copagos o los coseguros pueden cambiar a partir del 1 de enero de 2016, y en ocasiones durante el año.

i

¿Qué es el Formulario de Today’s Options PFFS? Un formulario es una lista de medicamentos con cobertura seleccionados por Today's Options PFFS tras consultar con un equipo de proveedores de atención médica, que representa los tratamientos de medicamentos de venta con receta considerados como una parte necesaria de un programa de tratamiento de calidad. En general, Today’s Options PFFS cubre los medicamentos que aparecen en el formulario, siempre y cuando sean médicamente necesarios, la receta se haya abastecido en una farmacia de la red de Today’s Options PFFS y se sigan otras reglas del plan. Si desea obtener más información sobre cómo adquirir medicamentos recetados, consulte la Evidencia de cobertura.

¿Puede cambiar el formulario? Por lo general, si usted toma un medicamento del formulario de 2016 que al comenzar el año estaba cubierto, no suspenderemos ni reduciremos la cobertura durante el año de cobertura 2016, salvo que haya un nuevo medicamento genérico menos costoso o se publique nueva información negativa acerca de la seguridad o efectividad del medicamento. Otros tipos de cambios en el formulario, como la eliminación de un medicamento, no afectarán a los miembros que tomen el medicamento actualmente. Seguirá estando disponible durante el resto del año de cobertura, y con la misma participación en los costos, para los miembros que lo tomen. Creemos que es importante que, durante el resto del año de cobertura, usted siga teniendo acceso a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan. Se exceptúan los casos en los que existe la posibilidad de ahorrar dinero o en los que podemos resguardar su seguridad. Si eliminamos un medicamento de nuestro formulario, requerimos una autorización previa, aplicamos límites en la cantidad y/o restricciones de terapia escalonada para un medicamento, o cambiamos un medicamento a un nivel de participación en los costos más alto, notificaremos a los miembros afectados 60 días antes de que el cambio entre en vigencia o en el momento en que el miembro solicite el reabastecimiento del medicamento, que en tal caso será por un suministro para 60 días. Si la Administración de Medicamentos y Alimentos (Food and Drug Administration, FDA) considera que un medicamento del formulario no es seguro, o si el fabricante retira un medicamento del mercado, lo quitaremos de inmediato del formulario y notificaremos a los miembros que lo toman. El formulario que se adjunta estará vigente a partir de octubre de 2016. Comuníquese con nosotros para obtener información actualizada sobre los medicamentos cubiertos por Today's Options PFFS. Nuestra información de contacto aparece en la portada y la contraportada. Puede solicitar un apéndice complementario mensual del formulario en www.TodaysOptions.com o si llama a Servicios a los Miembros al número que se encuentra en la portada y en la contraportada.

¿Cómo uso el formulario? Hay dos maneras de encontrar un medicamento en el formulario: Afección médica El formulario comienza en la página 8. Los medicamentos de este formulario se agrupan en categorías, según qué tipo de afecciones médicas traten. Por ejemplo, los medicamentos que se utilizan para tratar afecciones del corazón se enumeran en la categoría “Agentes cardiovasculares”. Si sabe para qué se usa el medicamento, busque el nombre de la categoría en la lista que comienza en la página 8. Luego, busque el medicamento en esa categoría. Listado alfabético Si no está seguro de en qué categoría se encuentra, debe buscar el medicamento en el Índice que comienza en la página 111. En el Índice encontrará una lista ordenada alfabéticamente de todos los medicamentos que figuran en este documento. Se incluyen los medicamentos de marca y los genéricos. Consulte el Índice para encontrar el medicamento que desee. Junto al nombre del medicamento, verá el número de página donde se encuentra la información sobre cobertura. Vaya a la página que aparece en el Índice y busque el nombre del medicamento en la primera columna de la lista. ii

¿Qué son los medicamentos genéricos? Today’s Options PFFS cubre tanto medicamentos de marca como genéricos. Un medicamento genérico tiene la aprobación de la FDA, mediante la cual se certifica que contiene el mismo principio activo que el de marca. Por lo general, los medicamentos genéricos son más económicos que los medicamentos de marca.

¿Existen restricciones en la cobertura? Es posible que algunos medicamentos cubiertos estén sujetos a requisitos adicionales o límites en la cobertura. Por ejemplo: • Autorización previa: Today’s Options PFFS exige que usted o el médico obtenga autorización previa para obtener ciertos medicamentos. Esto significa que usted tendrá que obtener la aprobación de Today’s Options PFFS antes de abastecer sus recetas. De lo contrario, es posible que Today’s Options PFFS no cubra el medicamento. • Límites de cantidad: En el caso de determinados medicamentos, Today’s Options PFFS limita la cantidad que tendrá cobertura. Por ejemplo, Today’s Options PFFS cubre 30 comprimidos de simvastatina por receta. Esto podría ser adicional al suministro estándar de un mes o de tres meses. • Terapia escalonada: En algunos casos, Today’s Options PFFS exige que primero pruebe determinados medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento B sirven para el tratamiento de su afección médica, es posible que Today’s Options PFFS no cubra el medicamento B, a menos que usted pruebe el medicamento A primero. Si el medicamento A no le da resultado, entonces Today’s Options PFFS cubrirá el medicamento B. En el formulario que comienza en la página 8, puede averiguar si su medicamento está sujeto a requisitos o a límites adicionales. También puede obtener más información acerca de las restricciones que se aplican a medicamentos específicos cubiertos si visita nuestro sitio web. Hemos publicado en Internet los documentos que explican los detalles de nuestras restricciones de autorización previa y terapia escalonada. Usted también puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha en la que actualizamos el formulario por última vez, aparece en la portada y en la contraportada. Puede solicitar a Today's Options PFFS que haga una excepción respecto de estas restricciones o límites, o pedir una lista de otros medicamentos similares que puedan servir para tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción al formulario de Today’s Options PFFS?” en la página iv, para obtener más información sobre cómo solicitar una excepción.

¿Qué sucede si el medicamento que necesito no está incluido en el formulario? Si su medicamento no está en este formulario (lista de medicamentos cubiertos), comuníquese primero con Servicios a los Miembros y pregunte si su medicamento está cubierto. Si le informan que Today’s Options PFFS no cubre el medicamento, tiene dos opciones: • Puede solicitar a Servicios a los Miembros una lista de medicamentos similares que tengan cobertura de Today’s Options PFFS. Cuando reciba la lista, muéstresela al médico y pídale que le recete un medicamento similar que esté cubierto por Today’s Options PFFS. • Puede solicitar a Today’s Options PFFS que haga una excepción y cubra el medicamento. Consulte la información que se brinda a continuación sobre cómo solicitar una excepción. iii

¿Cómo solicito una excepción al Formulario de Today’s Options PFFS? Puede solicitar a Today’s Options PFFS que haga una excepción a las reglas de cobertura. Existen varios tipos de excepciones que puede solicitarnos. • Puede pedirnos que cubramos el medicamento, incluso si no está incluido en nuestro formulario. Si se aprueba, este medicamento será cubierto en un nivel predeterminado de participación en los costos, y usted no podrá solicitar que le proporcionemos el medicamento a un nivel más bajo de participación en los costos. • Puede solicitar que cubramos un medicamento del formulario a un nivel más bajo de participación en los costos, si este medicamento no se encuentra en el nivel de especialidad. De aprobarse, esto reduciría el monto que debe pagar por el medicamento. • Puede solicitarnos que dejemos sin efecto las restricciones o los límites en la cobertura de su medicamento. Por ejemplo, Today’s Options PFFS cubre una cantidad limitada de determinados medicamentos. Si existe un límite de cantidad para el medicamento, puede pedirnos que lo dejemos sin efecto y que cubramos una mayor cantidad. Por lo general, Today's Options PFFS solamente aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento de menor nivel de participación en los costos o las restricciones de uso adicionales no son tan eficaces para tratar la afección o le podrían causar efectos médicos adversos. Si desea solicitar una excepción al formulario, a los niveles o a las restricciones de utilización, debe comunicarse con nosotros para que tomemos una decisión de cobertura inicial. Cuando solicite una excepción al formulario, los niveles o las restricciones de utilización, deberá presentar una declaración de su médico que respalde su solicitud. Por lo general, debemos tomar una decisión antes de transcurridas 72 horas de haber recibido la declaración de la persona que emitió la receta. Puede solicitar una excepción expedita (rápida) si usted o su médico creen que su salud podría verse seriamente afectada si espera 72 horas para que tomemos una decisión. Si se acepta su solicitud para una apelación expedita, debemos tomar una decisión, a más tardar, 24 horas después de recibir la declaración de su médico u otra persona que emita la receta.

¿Qué debo hacer antes de consultar con mi médico la posibilidad de que me cambie los medicamentos o de que solicite una excepción? Como miembro nuevo o existente de nuestro plan, es posible que tome medicamentos que no se encuentran en nuestro formulario. O quizá tome un medicamento que está en el formulario, pero existen limitaciones para conseguirlo. Por ejemplo, podría necesitar nuestra autorización previa para poder adquirir su medicamento recetado. Debe hablar con su médico para decidir si debe cambiar a un medicamento adecuado que cubramos o si debe solicitar una excepción al formulario, de modo que cubramos el medicamento que usted toma. Mientras decide junto con su médico qué pasos seguirán, podemos cubrir el medicamento, en algunos casos, durante los primeros 90 días de membrecía en nuestro plan. Para cada uno de sus medicamentos que no se encuentre en nuestro formulario, o en el caso de que su capacidad para adquirir los medicamentos sea limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta emitida para menos días) cuando los adquiera en una farmacia de la red. Después de su primer suministro para 30 días, no continuaremos pagando esos medicamentos, aun cuando haya sido miembro del plan durante menos de 90 días. iv

Si reside en un centro de atención a largo plazo, le permitiremos que reabastezca su receta hasta que le hayamos otorgado un suministro de transición de 98 días de acuerdo con el incremento de preparación (a menos que la receta se indique por menos días). Cubriremos más de un reabastecimiento de estos medicamentos durante los primeros 90 días de su membrecía en el plan. Si necesita un medicamento que no está en nuestro formulario, o si existen limitaciones para conseguirlo y ya han pasado 90 días desde que se hizo miembro del plan, cubriremos un suministro de emergencia de 34 días de ese medicamento (a menos que tenga una receta médica por menos días) mientras solicita una excepción al formulario. Si es miembro actual de nuestro plan, también cubriremos un suministro temporal de transición si hay un cambio en sus medicamentos debido a un cambio en el nivel de atención. Esto podría incluir cambios no planificados en los centros de tratamiento, por ejemplo, ser dado de alta de un centro de atención aguda (hospital) o ingresar o ser dado de alta de un centro de atención a largo plazo. Para cada medicamento que no esté en nuestro formulario, o si existen limitaciones para conseguirlo, cubriremos un suministro temporal para 30 días (un suministro para hasta 34 días si usted reside en un centro de cuidados a largo plazo) cuando vaya a una farmacia de la red.

Información adicional Para obtener información más detallada sobre la cobertura de medicamentos recetados de Today’s Options PFFS, revise la Evidencia de Cobertura y otros materiales de los planes. Si tiene preguntas sobre Today's Options PFFS, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en la que actualizamos el formulario por última vez, aparece en la portada y en la contraportada. Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien visitar www.medicare.gov.

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Formulario de Today’s Options PFFS El formulario que comienza en la página siguiente ofrece información de cobertura acerca de los medicamentos cubiertos por Today’s Options PFFS. Si no puede encontrar un medicamento en la lista, vaya al Índice que comienza en la página 111. En la primera columna del cuadro, se menciona el nombre del medicamento. Los medicamentos de marca aparecen en mayúsculas (p. ej., COUMADIN) y los genéricos, en cursiva minúscula (p. ej., warfarina). La información que figura en la columna “Requisitos/Límites” le indica si Today’s Options PFFS tiene requisitos especiales para cubrir ese medicamento. • Los medicamentos que requieren autorización previa se designan con la abreviatura “PA” (Prior Authorization). • Los medicamentos con cantidad limitada se designan con la abreviatura “QL” (Quantity Limit). • Los medicamentos para terapia escalonada se designan con la abreviatura “ST” (Step Therapy). • Los medicamentos que requieren determinación sobre la cobertura para la Parte B o la Parte D de Medicare se designan con la abreviatura “B/D”. • Los medicamentos de acceso limitado se designan con la abreviatura “LA” (Limited Access). Es posible que esta receta esté disponible únicamente en determinadas farmacias. Para obtener más información, consulte el Directorio de farmacias o llame a Servicios a los Miembros al 1-866-568-8921, de 8:00 a. m. a 8:00 p. m. en su zona horaria local, los 7 días de la semana. Los usuarios de TTY/TDD deben llamar al 711. • Los medicamentos no disponibles para pedido por correo se designan con la abreviatura “NM” (No Mail-Order).

Indicaciones de nivel El monto que usted paga por las recetas depende del nivel del medicamento. Los planes de Today's Options PFFS tienen 5 niveles.

Diseño de beneficios de Today’s Options PFFS Premier Plus 150A Copagos de Today's Options (PFFS)1 Participación en los costos preferida2 Nivel

Minorista

Pedido por correo

Suministro para 30 días Suministro para 90 días2 Suministro para 90 días

Nivel 1: Medicamentos genéricos preferidos

$0

$0

$0

Nivel 2: Medicamentos genéricos

$5

$12.50

$5

Nivel 3: Medicamentos de marca preferidos

$35

$87.50

$70

Nivel 4: Medicamentos de marca no preferidos

$75

$187.50

$150

Nivel 5: Medicamentos de nivel de especialidad

33 %

No disponibles

No disponibles

1Si

usted reúne los requisitos para recibir Ayuda adicional para obtener sus medicamentos recetados, es posible que sus copagos y coseguro se reduzcan. Los miembros que reúnan los requisitos para la Ayuda adicional recibirán la “Cláusula de Evidencia de cobertura para personas que reciben ayuda adicional para el pago de sus medicamentos recetados” (Cláusula de subsidio para personas de bajos ingresos [Low Income Subsidy, LIS]). Léala para conocer sus costos. También puede comunicarse con el Servicio de Atención al Cliente. Nuestra información de contacto aparece en la portada y la contraportada. 2Disponible a través de farmacias minoristas exclusivas.

vi

Diseño de beneficios de Today’s Options PFFS Premier Plus 150A (continuación) Participación en los costos estándar

Minorista

Pedido por correo

Suministro para 30 días Suministro para 90 días2 Suministro para 90 días

Nivel Nivel 1: Medicamentos genéricos preferidos

$5

$12.50

$12.50

Nivel 2: Medicamentos genéricos

$10

$25

$25

Nivel 3: Medicamentos de marca preferidos

$45

$112.50

$112.50

Nivel 4: Medicamentos de marca no preferidos

$85

$212.50

$212.50

Nivel 5: Medicamentos de nivel de especialidad

33 %

No disponibles

No disponibles

2Disponible

a través de farmacias minoristas exclusivas.

Diseño de beneficios de Today’s Options PFFS Premier Plus 450B Copagos de Today's Options (PFFS)1 Participación en los costos preferida2 Nivel

Minorista

Pedido por correo

Suministro para 30 días Suministro para 90 días2 Suministro para 90 días

Nivel 1: Medicamentos genéricos preferidos

$2

$5

$2

Nivel 2: Medicamentos genéricos

$7

$17.50

$7

Nivel 3: Medicamentos de marca preferidos

$37

$92.50

$74

Nivel 4: Medicamentos de marca no preferidos

$90

$225

$180

Nivel 5: Medicamentos de nivel de especialidad

33 %

No disponibles

No disponibles

Participación en los costos estándar Nivel

Minorista

Pedido por correo

Suministro para 30 días Suministro para 90 días2 Suministro para 90 días

Nivel 1: Medicamentos genéricos preferidos

$7

$17.50

$17.50

Nivel 2: Medicamentos genéricos

$12

$30

$30

Nivel 3: Medicamentos de marca preferidos

$47

$117.50

$117.50

Nivel 4: Medicamentos de marca no preferidos

$100

$250

$250

Nivel 5: Medicamentos de nivel de especialidad

33 %

No disponibles

No disponibles

1Si

usted reúne los requisitos para recibir Ayuda adicional para obtener sus medicamentos recetados, es posible que sus copagos y coseguro se reduzcan. Los miembros que reúnan los requisitos para la Ayuda adicional recibirán la “Cláusula de Evidencia de cobertura para personas que reciben ayuda adicional para el pago de sus medicamentos recetados” (Cláusula de subsidio para personas de bajos ingresos [LIS]). Léala para conocer sus costos. También puede comunicarse con el Servicio de Atención al Cliente. Nuestra información de contacto aparece en la portada y la contraportada. 2Disponible a través de farmacias minoristas exclusivas. vii

Nombre del medicamento

Nivel del Requisitos/Límites medicamento

ANALGÉSICOS GOTA allopurinol tab 100 mg 1 allopurinol tab 300 mg 1 colchicine w/ probenecid tab 0.5-500 mg 2 COLCRYS TAB 0.6MG 3 probenecid tab 500 mg 2 ULORIC TAB 40MG 3 ULORIC TAB 80MG 3

QL (120 tabs / 30 days) ST ST

ANTIINFLAMATORIOS NO ESTEROIDEOS (AINE) celecoxib cap 50 mg 2 celecoxib cap 100 mg 2 celecoxib cap 200 mg 2 celecoxib cap 400 mg 2 diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 252 mg diclofenac sodium tab delayed release 502 mg diclofenac sodium tab delayed release 752 mg diclofenac sodium tab sr 24hr 100 mg 2 diflunisal tab 500 mg 2 etodolac cap 200 mg 2 etodolac cap 300 mg 2 etodolac tab 400 mg 2 etodolac tab 500 mg 2 etodolac tab sr 24hr 400 mg 2 etodolac tab sr 24hr 500 mg 2 etodolac tab sr 24hr 600 mg 2 flurbiprofen tab 50 mg 2 flurbiprofen tab 100 mg 2 ibuprofen susp 100 mg/5ml 2 ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 ketoprofen cap 50 mg 2 ketoprofen cap 75 mg 2 MELOXICAM SUSP 7.5 MG/5ML 2 meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 nabumetone tab 500 mg 2

QL QL QL QL

(60 (60 (60 (60

caps caps caps caps

/ / / /

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

30 30 30 30

days) days) days) days)

8

Nombre del medicamento nabumetone tab 750 mg naproxen dr tab 375mg naproxen dr tab 500mg naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg piroxicam cap 10 mg piroxicam cap 20 mg sulindac tab 150 mg sulindac tab 200 mg

Nivel del Requisitos/Límites medicamento 2 1 1 1 1 2 1 1 1 2 2 1 1

ANALGÉSICOS OPIOIDES acetaminophen w/ codeine soln 120-12 mg/5ml acetaminophen w/ codeine tab 300-15 mg acetaminophen w/ codeine tab 300-30 mg acetaminophen w/ codeine tab 300-60 mg butorphanol tartrate inj 1 mg/ml butorphanol tartrate inj 2 mg/ml nalbuphine hcl inj 10 mg/ml nalbuphine hcl inj 20 mg/ml tramadol hcl tab 50 mg tramadol-acetaminophen tab 37.5-325 mg

2

QL (5000 mL / 30 days)

2

QL (400 tabs / 30 days)

2

QL (400 tabs / 30 days)

2

QL (400 tabs / 30 days)

2 2 2 2 2 2

QL (240 tabs / 30 days) QL (240 tabs / 30 days)

ANALGÉSICOS OPIOIDES, CII DURAMORPH INJ 0.5MG/ML DURAMORPH INJ 1MG/ML endocet tab 5-325mg endocet tab 7.5-325 endocet tab 10-325mg fentanyl citrate lozenge on a mcg fentanyl citrate lozenge on a mcg fentanyl citrate lozenge on a mcg fentanyl citrate lozenge on a mcg

2 2 2 2 2 handle 200 5 handle 400 5 handle 600 5 handle 800 5

B/D B/D QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (120 lozenges / 30 days), PA QL (120 lozenges / 30 days), PA QL (120 lozenges / 30 days), PA QL (120 lozenges / 30 days), PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

9

Nombre del medicamento

Nivel del Requisitos/Límites medicamento fentanyl citrate lozenge on a handle 12005 QL (120 lozenges / 30 mcg days), PA fentanyl citrate lozenge on a handle 16005 QL (120 lozenges / 30 mcg days), PA fentanyl td patch 72hr 12 mcg/hr 2 QL (10 patches / 30 days) fentanyl td patch 72hr 25 mcg/hr 2 QL (10 patches / 30 days) fentanyl td patch 72hr 50 mcg/hr 2 QL (10 patches / 30 days), PA fentanyl td patch 72hr 75 mcg/hr 2 QL (10 patches / 30 days), PA fentanyl td patch 72hr 100 mcg/hr 2 QL (10 patches / 30 days), PA FENTORA TAB 100MCG 5 QL (120 tabs / 30 days), PA FENTORA TAB 200MCG 5 QL (120 tabs / 30 days), PA FENTORA TAB 400MCG 5 QL (120 tabs / 30 days), PA FENTORA TAB 600MCG 5 QL (120 tabs / 30 days), PA FENTORA TAB 800MCG 5 QL (120 tabs / 30 days), PA hydrocodone-acetaminophen soln 2 QL (5400 mL / 30 days) 7.5-325 mg/15ml hydrocodone-acetaminophen tab 5-325 2 QL (360 tabs / 30 days) mg hydrocodone-acetaminophen tab 7.5-3252 QL (360 tabs / 30 days) mg hydrocodone-acetaminophen tab 10-325 2 QL (360 tabs / 30 days) mg hydrocodone-ibuprofen tab 7.5-200 mg 2 QL (150 tabs / 30 days) hydromorphone hcl liqd 1 mg/ml 2 hydromorphone hcl preservative free (pf)2 B/D inj 10 mg/ml hydromorphone hcl tab 2 mg 2 QL (270 tabs / 30 days) hydromorphone hcl tab 4 mg 2 QL (270 tabs / 30 days) hydromorphone hcl tab 8 mg 2 QL (270 tabs / 30 days) methadone con 10mg/ml 2 QL (120 mL / 30 days) methadone hcl soln 5 mg/5ml 2 QL (600 mL / 30 days) methadone hcl soln 10 mg/5ml 2 QL (600 mL / 30 days) methadone hcl tab 5 mg 2 QL (240 tabs / 30 days) methadone hcl tab 10 mg 2 QL (240 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

10

Nombre del medicamento

Nivel del medicamento MORPHINE SUL INJ 2MG/ML 2 MORPHINE SUL INJ 4MG/ML 2 MORPHINE SUL INJ 8MG/ML 2 morphine sulfate beads cap sr 24hr 30 mg2 morphine sulfate beads cap sr 24hr 45 mg2 morphine sulfate beads cap sr 24hr 60 mg2 morphine sulfate beads cap sr 24hr 75 mg2 morphine sulfate beads cap sr 24hr 90 mg2 morphine sulfate beads cap sr 24hr 120 2 mg morphine sulfate cap sr 24hr 10 mg 2 morphine sulfate cap sr 24hr 20 mg 2 morphine sulfate cap sr 24hr 30 mg 2 morphine sulfate cap sr 24hr 50 mg 2 morphine sulfate cap sr 24hr 60 mg 2 morphine sulfate cap sr 24hr 80 mg 5 morphine sulfate cap sr 24hr 100 mg 5 morphine sulfate inj pf 0.5 mg/ml 2 morphine sulfate inj pf 1 mg/ml 2 MORPHINE SULFATE IV SOLN 1 MG/ML 2 morphine sulfate iv soln pf 4 mg/ml 2 morphine sulfate iv soln pf 8 mg/ml 2 MORPHINE SULFATE IV SOLN PF 10 2 MG/ML MORPHINE SULFATE IV SOLN PF 15 2 MG/ML MORPHINE SULFATE ORAL SOLN 10 2 MG/5ML MORPHINE SULFATE ORAL SOLN 20 2 MG/5ML MORPHINE SULFATE ORAL SOLN 100 2 MG/5ML (20 MG/ML) MORPHINE SULFATE TAB 15 MG 2 MORPHINE SULFATE TAB 30 MG 2 morphine sulfate tab cr 15 mg 2 morphine sulfate tab cr 30 mg 2 morphine sulfate tab cr 60 mg 2 morphine sulfate tab cr 100 mg 2 morphine sulfate tab cr 200 mg 2 oxycodone hcl cap 5 mg 2 oxycodone hcl conc 100 mg/5ml (20 2 mg/ml) OXYCODONE HCL SOLN 5 MG/5ML 2

Requisitos/Límites B/D B/D B/D QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 B/D B/D B/D B/D B/D B/D

caps caps caps caps caps caps

/ / / / / /

30 30 30 30 30 30

days) days) days) days) days) days)

caps caps caps caps caps caps caps

/ / / / / / /

30 30 30 30 30 30 30

days) days) days) days) days) days) days)

B/D

QL QL QL QL QL QL QL QL

(180 tabs / 30 days) (180 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (60 tabs / 30 days) (180 caps / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

11

Nombre del medicamento

Nivel del medicamento hcl tab 5 mg 2 hcl tab 10 mg 2 hcl tab 15 mg 2 hcl tab 20 mg 2 hcl tab 30 mg 2 w/ acetaminophen soln 5-325 2

oxycodone oxycodone oxycodone oxycodone oxycodone oxycodone mg/5ml oxycodone w/ acetaminophen tab 2 2.5-325 mg oxycodone w/ acetaminophen tab 5-325 2 mg oxycodone w/ acetaminophen tab 2 7.5-325 mg oxycodone w/ acetaminophen tab 10-3252 mg

Requisitos/Límites QL QL QL QL QL QL

(180 tabs (180 tabs (180 tabs (180 tabs (180 tabs (1800 mL

/ / / / / /

30 30 30 30 30 30

days) days) days) days) days) days)

QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days)

ANESTÉSICOS ANESTÉSICOS LOCALES lidocaine lidocaine lidocaine lidocaine lidocaine inj 0.5% lidocaine inj 1%

hcl hcl hcl hcl hcl

local local local local local

inj 0.5% inj 1% inj 1.5% inj 2% preservative free (pf)

2 2 2 2 2

B/D B/D B/D B/D B/D

hcl local preservative free (pf) 2

B/D

ANTIINFECCIOSOS ANTIBACTERIANOS, DIVERSOS amikacin sulfate inj 1 gm/4ml (250 mg/ml) amikacin sulfate inj 500 mg/2ml (250 mg/ml) gentam/nacl inj 0.9mg/ml gentam/nacl inj 1.4mg/ml gentamicin in saline inj 0.8 mg/ml gentamicin in saline inj 1 mg/ml gentamicin in saline inj 1.2 mg/ml gentamicin in saline inj 1.6 mg/ml gentamicin in saline inj 2 mg/ml gentamicin sulfate inj 10 mg/ml gentamicin sulfate inj 40 mg/ml gentamicin sulfate iv soln 10 mg/ml neomycin sulfate tab 500 mg

2 2 2 2 2 2 2 2 2 2 2 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

12

Nombre del medicamento

Nivel del Requisitos/Límites medicamento paromomycin sulfate cap 250 mg 2 streptomycin sulfate for inj 1 gm 2 sulfadiazine tab 500mg 4 tobramycin nebu soln 300 mg/5ml 5 B/D, NM tobramycin sulfate for inj 1.2 gm 2 tobramycin sulfate inj 1.2 gm/30ml (40 2 mg/ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 2 mg/ml) (base equiv) tobramycin sulfate inj 10 mg/ml (base 2 equivalent) tobramycin sulfate inj 80 mg/2ml (40 2 mg/ml) (base equiv)

ANTIINFECCIOSOS, DIVERSOS ALBENZA TAB 200MG 4 ALINIA SUS 100/5ML 4 ALINIA TAB 500MG 4 atovaquone susp 750 mg/5ml 5 AZACTAM/DEX INJ 1GM 4 AZACTAM/DEX INJ 2GM 5 aztreonam for inj 1 gm 2 aztreonam for inj 2 gm 2 BILTRICIDE TAB 600MG 3 CAYSTON INH 75MG 5 clindamycin hcl cap 75 mg 1 clindamycin hcl cap 150 mg 1 clindamycin hcl cap 300 mg 1 clindamycin palmitate hcl for soln 75 2 mg/5ml (base equiv) clindamycin phosphate in d5w iv soln 3002 mg/50ml clindamycin phosphate in d5w iv soln 6002 mg/50ml clindamycin phosphate in d5w iv soln 9002 mg/50ml clindamycin phosphate inj 9 gm/60ml 2 clindamycin phosphate inj 300 mg/2ml 2 clindamycin phosphate inj 600 mg/4ml 2 clindamycin phosphate inj 900 mg/6ml 2 clindamycin phosphate iv soln 300 2 mg/2ml clindamycin phosphate iv soln 600 2 mg/4ml

NM, LA, PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

13

Nombre del medicamento

Nivel del Requisitos/Límites medicamento 2

clindamycin phosphate iv soln 900 mg/6ml colistimethate sodium for inj 150 mg 2 CUBICIN SOL 500MG 5 dapsone tab 25 mg 2 dapsone tab 100 mg 2 daptomycin for iv soln 500 mg 5 DARAPRIM TAB 25MG 4 emverm chw 100mg 4 imipenem-cilastatin intravenous for soln 2 250 mg imipenem-cilastatin intravenous for soln 2 500 mg INVANZ INJ 1GM 4 ivermectin tab 3 mg 2 LINEZOLID FOR SUSP 100 MG/5ML 5 LINEZOLID IN SODIUM CHLORIDE IV 5 SOLN 600 MG/300ML-0.9% linezolid iv soln 600 mg/300ml (2 mg/ml)5 LINEZOLID TAB 600 MG 5 meropenem iv for soln 1 gm 2 meropenem iv for soln 500 mg 2 methenamine hippurate tab 1 gm 2 metronidazole in nacl 0.79% iv soln 500 2 mg/100ml metronidazole tab 250 mg 1 metronidazole tab 500 mg 1 NEBUPENT INH 300MG 4 nitrofurantoin macrocrystalline cap 50 mg4 nitrofurantoin macrocrystalline cap 100 4 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg

4

PENTAM 300 INJ 300MG SIVEXTRO INJ 200MG SIVEXTRO TAB 200MG sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml

4 5 5 2

B/D PA; PA applies if 65 years and older after a 90 day supply in a calendar year PA; PA applies if 65 years and older after a 90 day supply in a calendar year PA; PA applies if 65 years and older after a 90 day supply in a calendar year

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

14

Nombre del medicamento sulfamethoxazole-trimethoprim susp 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 mg sulfamethoxazole-trimethoprim tab 800-160 mg SYNERCID INJ 500MG trimethoprim tab 100 mg TYGACIL INJ 50MG vancomycin hcl cap 125 mg vancomycin hcl cap 250 mg vancomycin hcl for inj 10 gm vancomycin hcl for inj 500 mg vancomycin hcl for inj 1000 mg vancomycin hcl for inj 5000 mg VANCOMYCIN INJ 1 GM VANCOMYCIN INJ 500MG vancomycin inj 750mg VANCOMYCIN INJ 750MG ZYVOX TAB 600MG

Nivel del Requisitos/Límites medicamento 2 1 1 5 1 5 5 5 2 2 2 2 4 4 2 4 5

ANTIMICÓTICOS ABELCET INJ 5MG/ML 5 AMBISOME INJ 50MG 5 amphotericin b for inj 50 mg 2 CANCIDAS INJ 50MG 5 CANCIDAS INJ 70MG 5 fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole in dextrose inj 200 mg/100ml2 fluconazole in dextrose inj 400 mg/200ml2 fluconazole in nacl 0.9% inj 200 2 mg/100ml fluconazole in nacl 0.9% inj 400 2 mg/200ml fluconazole tab 50 mg 2 fluconazole tab 100 mg 2 fluconazole tab 150 mg 2 fluconazole tab 200 mg 2 fluconazole/ inj nacl 100 2 flucytosine cap 250 mg 5 flucytosine cap 500 mg 5 griseofulvin microsize susp 125 mg/5ml 2

B/D B/D B/D

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

15

Nombre del medicamento griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 125 mg griseofulvin ultramicrosize tab 250 mg itraconazole cap 100 mg ketoconazole tab 200 mg MYCAMINE INJ 50MG MYCAMINE INJ 100MG NOXAFIL SUS 40MG/ML NOXAFIL TAB 100MG nystatin tab 500000 unit terbinafine hcl tab 250 mg voriconazole for inj 200 mg voriconazole for susp 40 mg/ml voriconazole tab 50 mg voriconazole tab 200 mg

Nivel del medicamento 2 2 2 2 2 5 5 5 5 2 1 2 5 5 5

Requisitos/Límites

PA PA

QL (90 tabs / 365 days)

ANTIMALÁRICOS atovaquone-proguanil hcl tab 62.5-25 mg2 atovaquone-proguanil hcl tab 250-100 2 mg chloroquine phosphate tab 250 mg 2 chloroquine phosphate tab 500 mg 2 COARTEM TAB 20-120MG 4 mefloquine hcl tab 250 mg 2 PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap 324 mg 2

PA

AGENTES ANTIRRETROVIRALES abacavir sulfate tab 300 mg (base equiv)2 APTIVUS CAP 250MG 5 APTIVUS SOL 5 CRIXIVAN CAP 200MG 4 CRIXIVAN CAP 400MG 4 didanosine delayed release capsule 125 2 mg didanosine delayed release capsule 200 2 mg didanosine delayed release capsule 250 2 mg didanosine delayed release capsule 400 2 mg EDURANT TAB 25MG 5 EMTRIVA CAP 200MG 3 EMTRIVA SOL 10MG/ML 3 PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

16

Nombre del medicamento FUZEON INJ 90MG INTELENCE TAB 25MG INTELENCE TAB 100MG INTELENCE TAB 200MG INVIRASE CAP 200MG INVIRASE TAB 500MG ISENTRESS CHW 25MG ISENTRESS CHW 100MG ISENTRESS POW 100MG ISENTRESS TAB 400MG lamivudine oral soln 10 mg/ml lamivudine tab 150 mg lamivudine tab 300 mg LEXIVA SUS 50MG/ML LEXIVA TAB 700MG NEVIRAPINE SUSP 50 MG/5ML nevirapine tab 200 mg nevirapine tab sr 24hr 100 mg nevirapine tab sr 24hr 400 mg NORVIR CAP 100MG NORVIR SOL 80MG/ML NORVIR TAB 100MG PREZISTA SUS 100MG/ML PREZISTA TAB 75MG PREZISTA TAB 150MG PREZISTA TAB 600MG PREZISTA TAB 800MG RESCRIPTOR TAB 100 MG RESCRIPTOR TAB 200MG RETROVIR INJ 10MG/ML REYATAZ CAP 150MG REYATAZ CAP 200MG REYATAZ CAP 300MG REYATAZ POW 50MG SELZENTRY TAB 150MG SELZENTRY TAB 300MG stavudine cap 15 mg stavudine cap 20 mg stavudine cap 30 mg stavudine cap 40 mg stavudine for oral soln 1 mg/ml SUSTIVA CAP 50MG

Nivel del Requisitos/Límites medicamento 5 NM 4 5 5 5 5 3 5 3 5 2 2 2 4 5 2 2 2 2 3 3 3 5 3 3 5 5 4 4 3 5 5 5 5 5 5 2 2 2 2 2 3

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

17

Nombre del medicamento SUSTIVA CAP 200MG SUSTIVA TAB 600MG TIVICAY TAB 10MG TIVICAY TAB 25MG TIVICAY TAB 50MG TYBOST TAB 150MG VIDEX SOL 2GM VIDEX SOL 4GM VIRACEPT TAB 250MG VIRACEPT TAB 625MG VIRAMUNE XR TAB 100MG VIREAD POW 40MG/GM VIREAD TAB 150MG VIREAD TAB 200MG VIREAD TAB 250MG VIREAD TAB 300MG VITEKTA TAB 85MG VITEKTA TAB 150MG ZIAGEN SOL 20MG/ML zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg

Nivel del Requisitos/Límites medicamento 3 5 3 5 5 3 4 4 5 5 4 5 5 5 5 5 5 5 3 2 2 2

AGENTES ANTIRRETROVIRALES COMBINADOS abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg ATRIPLA TAB COMPLERA TAB DESCOVY TAB 200/25 EPZICOM TAB 600-300 EVOTAZ TAB 300-150 GENVOYA TAB KALETRA SOL KALETRA TAB 100-25MG KALETRA TAB 200-50MG lamivudine-zidovudine tab 150-300 mg ODEFSEY TAB PREZCOBIX TAB 800-150 STRIBILD TAB TRIUMEQ TAB TRUVADA TAB 100-150 TRUVADA TAB 133-200 TRUVADA TAB 167-250

5 5 5 5 5 5 5 5 3 5 5 5 5 5 5 5 5 5

QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

18

Nombre del medicamento TRUVADA TAB 200-300

Nivel del Requisitos/Límites medicamento 5 QL (30 tabs / 30 days)

AGENTES ANTITUBERCULOSOS CAPASTAT SUL INJ 1GM cycloserine cap 250 mg ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg isoniazid inj 100 mg/ml isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg paser gra 4gm PRIFTIN TAB 150MG pyrazinamide tab 500 mg rifabutin cap 150 mg rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg RIFATER TAB SIRTURO TAB 100MG TRECATOR TAB 250MG

4 5 2 2 2 2 1 1 3 4 2 2 2 2 2 4 5 4

LA, PA

ANTIVIRALES acyclovir cap 200 mg acyclovir sodium for inj 500 mg acyclovir sodium iv soln 50 mg/ml acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg adefovir dipivoxil tab 10 mg BARACLUDE SOL .05MG/ML DAKLINZA TAB 30MG DAKLINZA TAB 60MG DAKLINZA TAB 90MG entecavir tab 0.5 mg entecavir tab 1 mg EPIVIR HBV SOL 5MG/ML famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg ganciclovir sodium for inj 500 mg HARVONI TAB 90-400MG lamivudine tab 100 mg (hbv) moderiba pak 600/day

1 2 2 2 1 1 5 3 5 5 5 5 5 4 2 2 2 2 5 2 5

B/D B/D

NM, PA NM, PA NM, PA

B/D NM, PA NM

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

19

Nombre del medicamento moderiba pak 800/day moderiba pak 1000/day MODERIBA PAK 1200/DAY PEG-INTRON KIT 50MCG RP PEG-INTRON KIT 80MCG RP PEG-INTRON KIT 120 RP PEG-INTRON KIT 150 RP PEGASYS INJ PEGASYS INJ 180MCG/M PEGASYS INJ PROCLICK PEGINTRON KIT 50MCG PEGINTRON KIT 80MCG PEGINTRON KIT 120MCG PEGINTRON KIT 150MCG REBETOL SOL 40MG/ML RELENZA MIS DISKHALE ribapak pak 600/day ribapak pak 800/day ribapak pak 1000/day ribapak pak 1200/day ribasphere cap 200mg ribasphere tab 200mg ribasphere tab 400mg ribasphere tab 600mg ribavirin cap 200 mg ribavirin tab 200 mg rimantadine hydrochloride tab 100 mg SOVALDI TAB 400MG TAMIFLU CAP 30MG TAMIFLU CAP 45MG TAMIFLU CAP 75MG TAMIFLU SUS 6MG/ML TYZEKA TAB 600MG valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg VALCYTE SOL 50MG/ML valganciclovir hcl tab 450 mg (base equivalent)

Nivel del medicamento 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 3 5 5 5 5 2 2 2 5 2 2 2 5 3 3 3 3 5 2 2 5 5

Requisitos/Límites NM NM NM NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM

PA PA PA PA PA PA PA PA PA PA PA

NM NM NM NM NM NM NM NM NM NM NM, PA

CEFALOSPORINAS cefaclor cap 250 mg cefaclor cap 500 mg cefaclor er tab 500mg

2 2 3

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

20

Nombre del medicamento

Nivel del Requisitos/Límites medicamento cefaclor for susp 125 mg/5ml 2 cefaclor for susp 250 mg/5ml 2 cefaclor for susp 375 mg/5ml 2 cefadroxil cap 500 mg 1 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 cefazolin inj 1gm/50ml 3 cefazolin sodium for inj 1 gm 2 cefazolin sodium for inj 10 gm 2 cefazolin sodium for inj 20 gm 2 cefazolin sodium for inj 500 mg 2 cefazolin sodium for iv soln 1 gm 2 CEFAZOLIN SOL 3 cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefepime hcl for inj 1 gm 2 cefepime hcl for inj 2 gm 2 cefixime for susp 100 mg/5ml 2 cefixime for susp 200 mg/5ml 2 cefotaxime sodium for inj 1 gm 2 cefotaxime sodium for inj 2 gm 2 cefotaxime sodium for inj 500 mg 2 cefoxitin sodium for inj 10 gm 2 cefoxitin sodium for iv soln 1 gm 2 cefoxitin sodium for iv soln 2 gm 2 cefpodoxime proxetil for susp 50 mg/5ml2 cefpodoxime proxetil for susp 100 2 mg/5ml cefpodoxime proxetil tab 100 mg 2 cefpodoxime proxetil tab 200 mg 2 cefprozil for susp 125 mg/5ml 2 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 ceftazidime for inj 1 gm 2 ceftazidime for inj 2 gm 2 ceftazidime for inj 6 gm 2 CEFTAZIDIME/ SOL D5W 1GM 4 CEFTAZIDIME/ SOL D5W 2GM 4 ceftriaxone sodium for inj 1 gm 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

21

Nombre del medicamento ceftriaxone sodium for inj 2 gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 250 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 mg cefuroxime sodium for iv soln 1.5 gm cephalexin cap 250 mg cephalexin cap 500 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml SUPRAX CAP 400MG suprax chw 100mg suprax chw 200mg SUPRAX SUS 500/5ML tazicef inj 1gm tazicef inj 2gm tazicef inj 6gm TEFLARO INJ 400MG TEFLARO INJ 600MG

Nivel del Requisitos/Límites medicamento 2 2 2 2 2 2 2 2 2 2 2 2 1 1 2 2 3 4 4 3 2 2 2 4 4

ERITROMICINAS/MACRÓLIDOS azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml azithromycin iv for soln 500 mg AZITHROMYCIN POWD PACK FOR SUSP GM azithromycin tab 250 mg azithromycin tab 500 mg azithromycin tab 600 mg clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab sr 24hr 500 mg DIFICID TAB 200MG e.e.s. 400 tab 400mg ery-tab tab 250mg ec

2 2 2 12 1 1 1 2 2 2 2 2 5 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

22

Nombre del medicamento

Nivel del Requisitos/Límites medicamento ery-tab tab 333mg ec 2 ery-tab tab 500mg ec 2 erythrocin inj 500mg 4 erythrocin tab 250mg 2 erythromycin ethylsuccinate tab 400 mg 2 erythromycin tab 250 mg 2 erythromycin tab 500 mg 2 erythromycin w/ delayed release particles2 cap 250 mg

FLUOROQUINOLONAS ciprofloxacin 200 mg/100ml in d5w 2 ciprofloxacin 400 mg/200ml in d5w 2 ciprofloxacin for oral susp 250 mg/5ml 2 (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml 2 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv)1 ciprofloxacin hcl tab 250 mg (base equiv)1 ciprofloxacin hcl tab 500 mg (base equiv)1 ciprofloxacin hcl tab 750 mg (base equiv)1 ciprofloxacin iv soln 200 mg/20ml (1%) 2 ciprofloxacin iv soln 400 mg/40ml (1%) 2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr2 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr2 1000 mg(base eq) levofloxacin in d5w iv soln 250 mg/50ml 2 levofloxacin in d5w iv soln 500 mg/100ml2 levofloxacin in d5w iv soln 750 mg/150ml2 levofloxacin iv soln 25 mg/ml 2 levofloxacin oral soln 25 mg/ml 2 levofloxacin tab 250 mg 1 levofloxacin tab 500 mg 1 levofloxacin tab 750 mg 1

PENICILINAS amoxicillin & k clavulanate 200-28.5 mg amoxicillin & k clavulanate 400-57 mg amoxicillin & k clavulanate 200-28.5 mg/5ml amoxicillin & k clavulanate 250-62.5 mg/5ml

chew tab

2

chew tab

2

for susp

2

for susp

2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

23

Nombre del medicamento

Nivel del Requisitos/Límites medicamento 2

amoxicillin & k clavulanate for susp 400-57 mg/5ml amoxicillin & k clavulanate for susp 2 600-42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 2 mg amoxicillin & k clavulanate tab 500-125 2 mg amoxicillin & k clavulanate tab 875-125 2 mg amoxicillin & k clavulanate tab sr 12hr 2 1000-62.5 mg amoxicillin (trihydrate) cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 mg 1 amoxicillin (trihydrate) chew tab 250 mg 1 amoxicillin (trihydrate) for susp 125 1 mg/5ml amoxicillin (trihydrate) for susp 200 1 mg/5ml amoxicillin (trihydrate) for susp 250 1 mg/5ml amoxicillin (trihydrate) for susp 400 1 mg/5ml amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 1 ampicillin & sulbactam sodium for inj 1.5 2 (1-0.5) gm ampicillin & sulbactam sodium for inj 3 2 (2-1) gm ampicillin & sulbactam sodium for inj 15 2 (10-5) gm ampicillin & sulbactam sodium for iv soln 2 3 (2-1) gm ampicillin & sulbactam sodium for iv soln 2 15 (10-5) gm ampicillin cap 250 mg 1 ampicillin cap 500 mg 1 ampicillin for susp 125 mg/5ml 2 ampicillin for susp 250 mg/5ml 2 ampicillin sodium for inj 1 gm 2 ampicillin sodium for inj 2 gm 2 ampicillin sodium for inj 125 mg 2 ampicillin sodium for inj 250 mg 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

24

Nombre del medicamento

Nivel del Requisitos/Límites medicamento ampicillin sodium for inj 500 mg 2 ampicillin sodium for iv soln 1 gm 2 ampicillin sodium for iv soln 2 gm 2 ampicillin sodium for iv soln 10 gm 2 BICILLIN L-A INJ 600000 4 BICILLIN L-A INJ 1200000 4 BICILLIN L-A INJ 2400000 4 dicloxacillin sodium cap 250 mg 2 dicloxacillin sodium cap 500 mg 2 nafcillin sodium for inj 1 gm 2 nafcillin sodium for inj 2 gm 5 nafcillin sodium for inj 10 gm 5 nafcillin sodium for iv soln 1 gm 2 nafcillin sodium for iv soln 2 gm 5 oxacillin sodium for inj 1 gm 2 oxacillin sodium for inj 2 gm 2 oxacillin sodium for inj 10 gm 5 pen g proc inj 600000 3 PENICILL GK/ INJ DEX 2MU 4 PENICILL GK/ INJ DEX 3MU 4 penicillin g potassium for inj 5000000 unit2 penicillin g potassium for inj 20000000 2 unit penicillin g sodium for inj 5000000 unit 2 penicillin v potassium for soln 125 1 mg/5ml penicillin v potassium for soln 250 1 mg/5ml penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 piperacillin sod-tazobactam na for inj 2 3.375 gm (3-0.375 gm) piperacillin sod-tazobactam sod for inj 2 2.25 gm (2-0.25 gm) piperacillin sod-tazobactam sod for inj 4.52 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 2 40.5 gm (36-4.5 gm)

TETRACICLINAS doxy 100 inj 100mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate for inj 100 mg

2 2 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

25

Nombre del medicamento doxycycline hyclate tab 20 mg doxycycline hyclate tab 100 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 100 mg doxycycline monohydrate tab 50 mg doxycycline monohydrate tab 75 mg doxycycline monohydrate tab 100 mg doxycycline monohydrate tab 150 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl cap 100 mg morgidox cap 1x50mg

Nivel del Requisitos/Límites medicamento 2 2 2 2 2 2 2 2 2 2 2 2

AGENTES ANTINEOPLÁSICOS AGENTES ALQUILANTES BENDEKA INJ 100/4ML 5 BICNU INJ 100MG 4 BUSULFEX INJ 6MG/ML 5 CYCLOPHOSPH CAP 25MG 4 CYCLOPHOSPH CAP 50MG 4 cyclophosphamide for inj 1 gm 5 cyclophosphamide for inj 2 gm 2 cyclophosphamide for inj 500 mg 5 dacarbazine for inj 100 mg 2 dacarbazine for inj 200 mg 2 EMCYT CAP 140MG 4 GLEOSTINE CAP 5MG 4 GLEOSTINE CAP 10MG 4 GLEOSTINE CAP 40MG 4 GLEOSTINE CAP 100MG 4 HEXALEN CAP 50MG 5 IFEX INJ 3GM 4 ifosfamide for inj 1 gm 2 IFOSFAMIDE INJ 3GM 4 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 2 ifosfamide iv inj 3 gm/60ml (50 mg/ml) 2 LEUKERAN TAB 2MG 4 melphalan hcl for inj 50 mg (base equiv) 5 MUSTARGEN INJ 10MG 4 TREANDA INJ 25MG 5 TREANDA INJ 45/0.5ML 5 TREANDA INJ 100MG 5 TREANDA INJ 180/2ML 5

B/D, NM B/D B/D B/D B/D B/D B/D B/D B/D B/D

B/D B/D B/D B/D B/D B/D, B/D B/D, B/D, B/D, B/D,

NM NM NM NM NM

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

26

Nombre del medicamento

Nivel del Requisitos/Límites medicamento

ANTRACICLINAS daunorubicin hcl inj 5 mg/ml (base equiv)2 doxorubicin hcl for inj 50 mg 2 doxorubicin hcl inj 2 mg/ml 2 doxorubicin hcl liposomal inj (for iv 5 infusion) 2 mg/ml epirubicin hcl iv soln 50 mg/25ml (2 2 mg/ml) epirubicin hcl iv soln 200 mg/100ml (2 2 mg/ml) idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5 idarubicin hcl iv inj 10 mg/10ml (1 5 mg/ml) idarubicin hcl iv inj 20 mg/20ml (1 5 mg/ml)

B/D B/D B/D B/D B/D B/D B/D B/D B/D

ANTIBIÓTICOS bleomycin sulfate for bleomycin sulfate for mitomycin for iv soln mitomycin for iv soln mitomycin for iv soln

inj 15 unit inj 30 unit 5 mg 20 mg 40 mg

2 2 2 2 2

B/D B/D B/D B/D B/D

ANTIMETABOLITOS adrucil inj 2.5g/50m 2 adrucil inj 5gm/100m 2 adrucil inj 500/10ml 2 ALIMTA INJ 100MG 5 ALIMTA INJ 500MG 5 azacitidine for inj 100 mg 5 cladribine iv soln 10 mg/10ml (1 mg/ml) 5 cytarabine inj 20 mg/ml 2 fludarabine phosphate for inj 50 mg 2 fludarabine phosphate inj 25 mg/ml 2 fluorouracil inj 1 gm/20ml (50 mg/ml) 2 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 2 fluorouracil inj 5 gm/100ml (50 mg/ml) 2 fluorouracil inj 500 mg/10ml (50 mg/ml) 2 gemcitabine hcl for inj 1 gm 5 gemcitabine hcl for inj 2 gm 5 gemcitabine hcl for inj 200 mg 5 GEMCITABINE HCL INJ 1 GM/26.3ML (38 5 MG/ML) (BASE EQUIV)

B/D B/D B/D B/D B/D B/D, NM B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

27

Nombre del medicamento

Nivel del Requisitos/Límites medicamento GEMCITABINE HCL INJ 2 GM/52.6ML (38 5 B/D MG/ML) (BASE EQUIV) GEMCITABINE HCL INJ 200 MG/5.26ML 5 B/D (38 MG/ML) (BASE EQUIV) mercaptopurine tab 50 mg 2 methotrexate sodium for inj 1 gm 2 B/D METHOTREXATE SODIUM INJ 50 MG/2ML2 B/D (25 MG/ML) methotrexate sodium inj 250 mg/10ml 2 B/D (25 mg/ml) methotrexate sodium inj pf 50 mg/2ml 2 B/D (25 mg/ml) methotrexate sodium inj pf 100 mg/4ml 2 B/D (25 mg/ml) methotrexate sodium inj pf 200 mg/8ml 2 B/D (25 mg/ml) methotrexate sodium inj pf 250 mg/10ml2 B/D (25 mg/ml) methotrexate sodium inj pf 1000 2 B/D mg/40ml (25 mg/ml) NIPENT INJ 10MG 5 B/D PURIXAN SUS 20MG/ML 5 NM TABLOID TAB 40MG 4

ANTIMITÓTICOS, TAXOIDES ABRAXANE INJ 100MG 5 DOCETAXEL FOR INJ CONC 20 MG/ML 5 DOCETAXEL FOR INJ CONC 80 MG/4ML 5 (20 MG/ML) DOCETAXEL INJ 20MG/2ML 2 DOCETAXEL INJ 80MG/8ML 5 docetaxel inj 140/7ml 5 DOCETAXEL INJ 160/16ML 5 DOCETAXEL INJ 200MG/20 5 paclitaxel iv conc 30 mg/5ml (6 mg/ml) 2 paclitaxel iv conc 100 mg/16.7ml (6 2 mg/ml) paclitaxel iv conc 150 mg/25ml (6 mg/ml)2 paclitaxel iv conc 300 mg/50ml (6 mg/ml)2

B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

ANTIMITÓTICOS, ALCALOIDES DE LA VINCA vinblastine sulfate inj 1 mg/ml vincasar pfs inj 1mg/ml vincristine sulfate iv soln 1 mg/ml

3 2 2

B/D B/D B/D

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

28

Nombre del medicamento vinorelbine tartrate inj 10 mg/ml (base equiv) vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv)

Nivel del Requisitos/Límites medicamento 2 B/D 2

B/D

MODIFICADORES DE LA RESPUESTA BIOLÓGICA AVASTIN INJ AVASTIN INJ 400/16ML BELEODAQ INJ 500MG ERIVEDGE CAP 150MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG HERCEPTIN INJ 440MG IBRANCE CAP 75MG IBRANCE CAP 100MG IBRANCE CAP 125MG ISTODAX INJ 10MG KADCYLA INJ 100MG KADCYLA INJ 160MG KEYTRUDA INJ 100MG/4M KEYTRUDA SOL 50MG LYNPARZA CAP 50MG NINLARO CAP 2.3MG NINLARO CAP 3MG NINLARO CAP 4MG PROLEUKIN INJ 22MU RITUXAN INJ 100MG RITUXAN INJ 500MG TECENTRIQ INJ 1200/20 VELCADE INJ 3.5MG VENCLEXTA TAB 10MG VENCLEXTA TAB 50MG VENCLEXTA TAB 100MG VENCLEXTA TAB START PK YERVOY INJ 50MG YERVOY INJ 200MG ZOLINZA CAP 100MG

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 4 4 5 5 5 5 5

B/D, NM, LA B/D, NM, LA NM, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA B/D, NM NM, LA, PA NM, LA, PA NM, LA, PA B/D, NM B/D, NM B/D, NM NM, PA NM, PA NM, LA, PA NM, PA NM, PA NM, PA B/D, NM NM, LA, PA NM, LA, PA NM, LA, PA B/D, NM NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, PA NM, PA NM, PA

AGENTES ANTINEOPLÁSICOS HORMONALES anastrozole tab 1 mg bicalutamide tab 50 mg DEPO-PROVERA INJ 400/ML exemestane tab 25 mg

2 2 4 2

B/D

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

29

Nombre del medicamento FARESTON TAB 60MG FASLODEX INJ 250MG flutamide cap 125 mg hydroxyprogesterone caproate im in oil 1.25 gm/5ml letrozole tab 2.5 mg leuprolide acetate inj kit 5 mg/ml LUPR DEP-PED INJ 7.5MG LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG LUPR DEP-PED INJ 30MG LUPRON DEPOT INJ 3.75MG LUPRON DEPOT INJ 11.25MG LYSODREN TAB 500MG megestrol acetate susp 40 mg/ml

Nivel del Requisitos/Límites medicamento 5 5 B/D 2 4 B/D 2 2 5 5 5 5 5 5 3 4

MEGESTROL ACETATE SUSP 625 MG/5ML5 megestrol acetate tab 20 mg 4 megestrol acetate tab 40 mg

4

NILANDRON TAB 150MG nilutamide tab 150 mg SOLTAMOX SOL 10MG/5ML tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) TRELSTAR MIX INJ 3.75MG TRELSTAR MIX INJ 11.25MG XTANDI CAP 40MG ZYTIGA TAB 250MG

5 5 4 1

NM, NM, NM, NM, NM, NM, NM,

PA PA PA PA PA PA PA

PA; PA if 65 years and older PA PA; PA if 65 years and older PA; PA if 65 years and older

1 5 5 5 5

NM, NM, NM, NM,

PA PA LA, PA LA, PA

5 5 5 5 5 5 5 5 5 5

NM, NM, NM, NM, NM, NM, NM, NM, NM, NM,

PA PA PA PA PA PA PA LA, PA PA PA

INHIBIDORES DE LA QUINASA AFINITOR DIS TAB 2MG AFINITOR DIS TAB 3MG AFINITOR DIS TAB 5MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG AFINITOR TAB 10MG ALECENSA CAP 150MG BOSULIF TAB 100MG BOSULIF TAB 500MG

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

30

Nombre del medicamento CABOMETYX TAB 20MG CABOMETYX TAB 40MG CABOMETYX TAB 60MG CAPRELSA TAB 100MG CAPRELSA TAB 300MG COMETRIQ KIT 60MG COMETRIQ KIT 100MG COMETRIQ KIT 140MG COTELLIC TAB 20MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG ICLUSIG TAB 15MG ICLUSIG TAB 45MG imatinib mesylate tab 100 mg (base equivalent) imatinib mesylate tab 400 mg (base equivalent) IMBRUVICA CAP 140MG INLYTA TAB 1MG INLYTA TAB 5MG IRESSA TAB 250MG JAKAFI TAB 5MG JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG LENVIMA CAP 8 MG LENVIMA CAP 10 MG LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 20 MG LENVIMA CAP 24 MG MEKINIST TAB 0.5MG MEKINIST TAB 2MG NEXAVAR TAB 200MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG SPRYCEL TAB 80MG SPRYCEL TAB 100MG SPRYCEL TAB 140MG

Nivel del medicamento 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Requisitos/Límites

5

NM, PA

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM,

NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM,

LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, PA

LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, PA PA PA PA PA PA

PA PA PA PA PA PA PA PA PA PA PA PA PA PA

PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

31

Nombre del medicamento STIVARGA TAB 40MG SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG TAFINLAR CAP 50MG TAFINLAR CAP 75MG TAGRISSO TAB 40MG TAGRISSO TAB 80MG TARCEVA TAB 25MG TARCEVA TAB 100MG TARCEVA TAB 150MG TASIGNA CAP 150MG TASIGNA CAP 200MG TYKERB TAB 250MG VOTRIENT TAB 200MG XALKORI CAP 200MG XALKORI CAP 250MG ZELBORAF TAB 240MG ZYDELIG TAB 100MG ZYDELIG TAB 150MG ZYKADIA CAP 150MG

Nivel del medicamento 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Requisitos/Límites NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM,

LA, PA PA PA PA LA, LA, LA, LA, LA, LA, LA, PA PA LA, LA, LA, LA, LA, LA, LA, LA,

PA

PA PA PA PA PA PA PA

PA PA PA PA PA PA PA PA

DIVERSOS bexarotene cap 75 mg 5 DROXIA CAP 200MG 3 DROXIA CAP 300MG 3 DROXIA CAP 400MG 3 hydroxyurea cap 500 mg 2 LONSURF TAB 15-6.14 5 LONSURF TAB 20-8.19 5 MATULANE CAP 50MG 5 mitoxantrone hcl inj conc 20 mg/10ml (2 2 mg/ml) mitoxantrone hcl inj conc 25 mg/12.5ml 2 (2 mg/ml) mitoxantrone hcl inj conc 30 mg/15ml (2 2 mg/ml) ODOMZO CAP 200MG 5 POMALYST CAP 1MG 5 POMALYST CAP 2MG 5 POMALYST CAP 3MG 5 POMALYST CAP 4MG 5

NM, PA

NM, PA NM, PA LA B/D, NM B/D, NM B/D, NM NM, NM, NM, NM, NM,

LA, LA, LA, LA, LA,

PA PA PA PA PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

32

Nombre del medicamento SYLATRON KIT 200MCG SYLATRON KIT 300MCG SYLATRON KIT 600MCG SYNRIBO INJ 3.5MG tretinoin cap 10 mg TRISENOX SOL 10MG/10M

Nivel del medicamento 5 5 5 5 5 5

Requisitos/Límites

2 2 2 2 2 2 2 5 5 5 5

B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

NM, NM, NM, NM,

PA PA PA PA

B/D

AGENTES BASADOS EN PLATINO carboplatin iv soln 50 mg/5ml carboplatin iv soln 150 mg/15ml carboplatin iv soln 450 mg/45ml carboplatin iv soln 600 mg/60ml cisplatin inj 50 mg/50ml (1 mg/ml) cisplatin inj 100 mg/100ml (1 mg/ml) cisplatin inj 200 mg/200ml (1 mg/ml) oxaliplatin for iv inj 50 mg oxaliplatin for iv inj 100 mg oxaliplatin iv soln 50 mg/10ml oxaliplatin iv soln 100 mg/20ml

AGENTES PROTECTORES amifostine crystalline for inj 500 mg 5 dexrazoxane for inj 250 mg 5 ELITEK INJ 1.5MG 5 ELITEK INJ 7.5MG 5 FUSILEV INJ 50MG 5 leucovorin calcium for inj 50 mg 2 leucovorin calcium for inj 100 mg 2 leucovorin calcium for inj 200 mg 2 leucovorin calcium for inj 350 mg 2 leucovorin calcium for inj 500 mg 2 leucovorin calcium tab 5 mg 2 leucovorin calcium tab 10 mg 2 leucovorin calcium tab 15 mg 2 leucovorin calcium tab 25 mg 2 levoleucovor sol 250mg/25 5 levoleucovorin calcium for iv inj 50 mg 5 (base equiv) levoleucovorin calcium inj 175 mg/17.5ml5 (base equiv) mesna inj 100 mg/ml 2 MESNEX TAB 400MG 5

B/D B/D B/D B/D B/D, NM B/D B/D B/D B/D B/D

B/D, NM B/D, NM B/D, NM B/D

INHIBIDORES DE TOPOISOMERASAS etoposide inj 500 mg/25ml (20 mg/ml)

2

B/D

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

33

Nombre del medicamento

Nivel del medicamento irinotecan hcl inj 40 mg/2ml (20 mg/ml) 2 irinotecan hcl inj 100 mg/5ml (20 mg/ml)2 irinotecan hcl inj 500 mg/25ml (20 2 mg/ml) toposar inj 1gm/50ml 2 topotecan hcl for inj 4 mg 5

Requisitos/Límites B/D B/D B/D B/D B/D

CARDIOVASCULARES COMBINACIONES DE INHIBIDORES DE LA ENZIMA CONVERTIDORA DE ANGIOTENSINA (ECA) amlodipine besylate-benazepril hcl cap 1 2.5-10 mg amlodipine besylate-benazepril hcl cap 1 5-10 mg amlodipine besylate-benazepril hcl cap 1 5-20 mg amlodipine besylate-benazepril hcl cap 1 5-40 mg amlodipine besylate-benazepril hcl cap 1 10-20 mg amlodipine besylate-benazepril hcl cap 1 10-40 mg benazepril & hydrochlorothiazide tab 1 5-6.25 mg benazepril & hydrochlorothiazide tab 1 10-12.5 mg benazepril & hydrochlorothiazide tab 1 20-12.5 mg benazepril & hydrochlorothiazide tab 1 20-25 mg captopril & hydrochlorothiazide tab 25-151 mg captopril & hydrochlorothiazide tab 25-251 mg captopril & hydrochlorothiazide tab 50-151 mg captopril & hydrochlorothiazide tab 50-251 mg enalapril maleate & hydrochlorothiazide 1 tab 5-12.5 mg enalapril maleate & hydrochlorothiazide 1 tab 10-25 mg fosinopril sodium & hydrochlorothiazide 1 tab 10-12.5 mg

QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

34

Nombre del medicamento

Nivel del Requisitos/Límites medicamento fosinopril sodium & hydrochlorothiazide 1 tab 20-12.5 mg lisinopril & hydrochlorothiazide tab 1 10-12.5 mg lisinopril & hydrochlorothiazide tab 1 20-12.5 mg lisinopril & hydrochlorothiazide tab 20-251 mg moexipril-hydrochlorothiazide tab 1 7.5-12.5 mg moexipril-hydrochlorothiazide tab 1 15-12.5 mg moexipril-hydrochlorothiazide tab 15-25 1 mg quinapril-hydrochlorothiazide tab 10-12.51 mg quinapril-hydrochlorothiazide tab 20-12.51 mg quinapril-hydrochlorothiazide tab 20-25 1 mg

INHIBIDORES DE ECA benazepril hcl tab 5 mg benazepril hcl tab 10 mg benazepril hcl tab 20 mg benazepril hcl tab 40 mg captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg captopril tab 100 mg enalapril maleate tab 2.5 mg enalapril maleate tab 5 mg enalapril maleate tab 10 mg enalapril maleate tab 20 mg fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg lisinopril tab 2.5 mg lisinopril tab 5 mg lisinopril tab 10 mg lisinopril tab 20 mg lisinopril tab 30 mg lisinopril tab 40 mg moexipril hcl tab 7.5 mg

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

35

Nombre del medicamento moexipril hcl tab 15 mg perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg perindopril erbumine tab 8 mg quinapril hcl tab 5 mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg ramipril cap 1.25 mg ramipril cap 2.5 mg ramipril cap 5 mg ramipril cap 10 mg trandolapril tab 1 mg trandolapril tab 2 mg trandolapril tab 4 mg

Nivel del Requisitos/Límites medicamento 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

ANTAGONISTAS DE LOS RECEPTORES DE LA ALDOSTERONA eplerenone tab 25 mg eplerenone tab 50 mg spironolactone tab 25 mg spironolactone tab 50 mg spironolactone tab 100 mg

2 2 1 1 1

ALFABLOQUEADORES doxazosin mesylate tab 1 doxazosin mesylate tab 2 doxazosin mesylate tab 4 doxazosin mesylate tab 8 prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg terazosin hcl cap 1 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg terazosin hcl cap 10 mg

mg mg mg mg

2 2 2 2 2 2 2 1 1 1 1

QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

COMBINACIONES DE ANTAGONISTAS DE LOS RECEPTORES DE LA ANGIOTENSINA II amlodipine besylate-valsartan tab 5-160 1 mg amlodipine besylate-valsartan tab 5-320 1 mg amlodipine besylate-valsartan tab 10-1601 mg

QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

36

Nombre del medicamento

Nivel del medicamento amlodipine besylate-valsartan tab 10-3201 mg amlodipine-valsartan-hydrochlorothiazid 1 e tab 5-160-12.5 mg amlodipine-valsartan-hydrochlorothiazid 1 e tab 5-160-25 mg amlodipine-valsartan-hydrochlorothiazid 1 e tab 10-160-12.5 mg amlodipine-valsartan-hydrochlorothiazid 1 e tab 10-160-25 mg amlodipine-valsartan-hydrochlorothiazid 1 e tab 10-320-25 mg AZOR TAB 5-20MG 3 AZOR TAB 5-40MG 3 AZOR TAB 10-20MG 3 AZOR TAB 10-40MG 3 BENICAR HCT TAB 20-12.5 3 BENICAR HCT TAB 40-12.5 3 BENICAR HCT TAB 40-25MG 3 ENTRESTO TAB 24-26MG 4 ENTRESTO TAB 49-51MG 4 ENTRESTO TAB 97-103MG 4 irbesartan-hydrochlorothiazide tab 1 150-12.5 mg irbesartan-hydrochlorothiazide tab 1 300-12.5 mg losartan potassium & hydrochlorothiazide1 tab 50-12.5 mg losartan potassium & hydrochlorothiazide1 tab 100-12.5 mg losartan potassium & hydrochlorothiazide1 tab 100-25 mg TRIBENZOR20- TAB 5-12.5MG 3 TRIBENZOR40- TAB 5-12.5MG 3 TRIBENZOR40- TAB 5-25MG 3 TRIBENZOR40- TAB 10-12.5 3 TRIBENZOR40- TAB 10-25MG 3 valsartan-hydrochlorothiazide tab 1 80-12.5 mg valsartan-hydrochlorothiazide tab 1 160-12.5 mg valsartan-hydrochlorothiazide tab 160-251 mg

Requisitos/Límites

QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

PA PA PA

QL QL QL QL

(30 (30 (30 (30

tabs tabs tabs tabs

/ / / /

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

30 30 30 30

days) days) days) days)

37

Nombre del medicamento

Nivel del Requisitos/Límites medicamento 1

valsartan-hydrochlorothiazide tab 320-12.5 mg valsartan-hydrochlorothiazide tab 320-251 mg

ANTAGONISTAS DE LOS RECEPTORES DE LA ANGIOTENSINA II BENICAR TAB 5MG BENICAR TAB 20MG BENICAR TAB 40MG irbesartan tab 75 mg irbesartan tab 150 mg irbesartan tab 300 mg losartan potassium tab 25 mg losartan potassium tab 50 mg losartan potassium tab 100 mg valsartan tab 40 mg valsartan tab 80 mg valsartan tab 160 mg valsartan tab 320 mg

3 3 3 1 1 1 1 1 1 1 1 1 1

ANTIARRÍTMICOS amiodarone hcl inj 150 mg/3ml (50 mg/ml) amiodarone hcl inj 450 mg/9ml (50 mg/ml) amiodarone hcl inj 900 mg/18ml (50 mg/ml) amiodarone hcl tab 100 mg amiodarone hcl tab 200 mg amiodarone hcl tab 400 mg disopyramide phosphate cap 100 mg

2

disopyramide phosphate cap 150 mg

4

dofetilide cap 125 mcg (0.125 mg) dofetilide cap 250 mcg (0.25 mg) dofetilide cap 500 mcg (0.5 mg) flecainide acetate tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg MULTAQ TAB 400MG

2 2 2 2 2 2 2 2 2 4

2 2 2 1 2 4

PA; PA if 65 years and older PA; PA if 65 years and older NM NM NM

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

38

Nombre del medicamento NORPACE CAP 100MG CR NORPACE CAP 150MG CR pacerone tab 100mg pacerone tab 200mg pacerone tab 400mg propafenone hcl cap sr 12hr 225 mg propafenone hcl cap sr 12hr 325 mg propafenone hcl cap sr 12hr 425 mg propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg quinidine gluconate tab cr 324 mg quinidine sulfate tab 200 mg quinidine sulfate tab 300 mg sorine tab 80mg sorine tab 120mg sorine tab 160mg sorine tab 240mg sotalol hcl (afib/afl) tab 80 mg sotalol hcl (afib/afl) tab 120 mg sotalol hcl (afib/afl) tab 160 mg sotalol hcl tab 80 mg sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg TIKOSYN CAP 125MCG TIKOSYN CAP 250MCG TIKOSYN CAP 500MCG

Nivel del Requisitos/Límites medicamento 4 PA; PA if 65 years and older 4 PA; PA if 65 years and older 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 4 NM 4 NM 4 NM

ANTILIPÉMICOS, INHIBIDORES DE LA HMG-CoA REDUCTASA atorvastatin calcium tab equivalent) atorvastatin calcium tab equivalent) atorvastatin calcium tab equivalent) atorvastatin calcium tab equivalent) CRESTOR TAB 5MG CRESTOR TAB 10MG CRESTOR TAB 20MG CRESTOR TAB 40MG

10 mg (base

1

QL (30 tabs / 30 days)

20 mg (base

1

QL (30 tabs / 30 days)

40 mg (base

1

QL (30 tabs / 30 days)

80 mg (base

1

QL (30 tabs / 30 days)

3 3 3 3

QL QL QL QL

(30 (30 (30 (30

tabs tabs tabs tabs

/ / / /

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

30 30 30 30

days) days) days) days)

39

Nombre del medicamento lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg rosuvastatin calcium tab 5 mg rosuvastatin calcium tab 10 mg rosuvastatin calcium tab 20 mg rosuvastatin calcium tab 40 mg simvastatin tab 5 mg simvastatin tab 10 mg simvastatin tab 20 mg simvastatin tab 40 mg simvastatin tab 80 mg

Nivel del medicamento 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Requisitos/Límites QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL

(30 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days)

ANTILIPÉMICOS, DIVERSOS cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm choline fenofibrate cap dr 45 mg (fenofibric acid equiv) choline fenofibrate cap dr 135 mg (fenofibric acid equiv) colestipol hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm fenofibrate micronized cap 67 mg fenofibrate micronized cap 134 mg fenofibrate micronized cap 200 mg fenofibrate tab 48 mg fenofibrate tab 54 mg fenofibrate tab 145 mg fenofibrate tab 160 mg gemfibrozil tab 600 mg JUXTAPID CAP 5MG JUXTAPID CAP 10MG JUXTAPID CAP 20MG JUXTAPID CAP 30MG JUXTAPID CAP 40MG

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 5 5 5 5 5

NM, NM, NM, NM, NM,

LA, LA, LA, LA, LA,

PA PA PA PA PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

40

Nombre del medicamento

Nivel del medicamento JUXTAPID CAP 60MG 5 KYNAMRO INJ 200MG/ML 5 niacin tab cr 500 mg (antihyperlipidemic)2 niacin tab cr 750 mg (antihyperlipidemic)2 niacin tab cr 1000 mg 2 (antihyperlipidemic) niacor tab 500mg 2 omega-3-acid ethyl esters cap 1 gm 2 PRALUENT INJ 75MG/ML 5 PRALUENT INJ 150MG/ML 5 prevalite pow 4gm 2 prevalite pow 4gm pk 2 VASCEPA CAP 1GM 4 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 ZETIA TAB 10MG 3

Requisitos/Límites NM, LA, PA NM, PA QL (90 tabs / 30 days)

NM, PA NM, PA

COMBINACIONES DE BETABLOQUEADORES Y DIURÉTICOS atenolol & chlorthalidone tab 50-25 mg atenolol & chlorthalidone tab 100-25 mg bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg bisoprolol & hydrochlorothiazide tab 5-6.25 mg bisoprolol & hydrochlorothiazide tab 10-6.25 mg metoprolol & hydrochlorothiazide tab 50-25 mg metoprolol & hydrochlorothiazide tab 100-25 mg metoprolol & hydrochlorothiazide tab 100-50 mg propranolol & hydrochlorothiazide tab 40-25 mg propranolol & hydrochlorothiazide tab 80-25 mg

2 2 1 1 1 2 2 2 2 2

BETABLOQUEADORES acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg atenolol tab 25 mg atenolol tab 50 mg atenolol tab 100 mg bisoprolol fumarate tab 5 mg bisoprolol fumarate tab 10 mg

1 1 1 1 1 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

41

Nombre del medicamento

Nivel del Requisitos/Límites medicamento 4 4 4 4 1 1 1 1 2 2 2 sr 24hr 25 mg 2 QL (60 tabs / 30 days)

BYSTOLIC TAB 2.5MG BYSTOLIC TAB 5MG BYSTOLIC TAB 10MG BYSTOLIC TAB 20MG carvedilol tab 3.125 mg carvedilol tab 6.25 mg carvedilol tab 12.5 mg carvedilol tab 25 mg labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg metoprolol succinate tab (tartrate equiv) metoprolol succinate tab sr 24hr 50 mg 2 (tartrate equiv) metoprolol succinate tab sr 24hr 100 mg 2 (tartrate equiv) metoprolol succinate tab sr 24hr 200 mg 2 (tartrate equiv) metoprolol tartrate inj 1 mg/ml 2 metoprolol tartrate tab 25 mg 1 metoprolol tartrate tab 50 mg 1 metoprolol tartrate tab 100 mg 1 nadolol tab 20 mg 2 nadolol tab 40 mg 2 nadolol tab 80 mg 2 pindolol tab 5 mg 2 pindolol tab 10 mg 2 propranolol hcl cap sr 24hr 60 mg 2 propranolol hcl cap sr 24hr 80 mg 2 propranolol hcl cap sr 24hr 120 mg 2 propranolol hcl cap sr 24hr 160 mg 2 propranolol hcl inj 1 mg/ml 2 propranolol hcl oral soln 20 mg/5ml 2 propranolol hcl oral soln 40 mg/5ml 2 propranolol hcl tab 10 mg 1 propranolol hcl tab 20 mg 1 propranolol hcl tab 40 mg 1 propranolol hcl tab 60 mg 1 propranolol hcl tab 80 mg 1 timolol maleate tab 5 mg 2 timolol maleate tab 10 mg 2

QL (60 tabs / 30 days) QL (45 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

42

Nombre del medicamento timolol maleate tab 20 mg

Nivel del Requisitos/Límites medicamento 2

BLOQUEADORES DE LOS CANALES DEL CALCIO afeditab tab 30mg cr 2 afeditab tab 60mg cr 2 amlodipine besylate tab 2.5 mg 1 amlodipine besylate tab 5 mg 1 amlodipine besylate tab 10 mg 1 diltiazem hcl cap sr 12hr 60 mg 2 diltiazem hcl cap sr 12hr 90 mg 2 diltiazem hcl cap sr 12hr 120 mg 2 diltiazem hcl cap sr 24hr 120 mg 2 diltiazem hcl cap sr 24hr 180 mg 2 diltiazem hcl cap sr 24hr 240 mg 2 diltiazem hcl coated beads cap sr 24hr 2 120 mg diltiazem hcl coated beads cap sr 24hr 2 180 mg diltiazem hcl coated beads cap sr 24hr 2 240 mg diltiazem hcl coated beads cap sr 24hr 2 300 mg diltiazem hcl coated beads cap sr 24hr 2 360 mg diltiazem hcl extended release beads cap 2 sr 24hr 120 mg diltiazem hcl extended release beads cap 2 sr 24hr 180 mg diltiazem hcl extended release beads cap 2 sr 24hr 240 mg diltiazem hcl extended release beads cap 2 sr 24hr 300 mg diltiazem hcl extended release beads cap 2 sr 24hr 360 mg diltiazem hcl extended release beads cap 2 sr 24hr 420 mg diltiazem hcl iv soln 25 mg/5ml (5 mg/ml)2 diltiazem hcl iv soln 50 mg/10ml (5 2 mg/ml) diltiazem hcl iv soln 125 mg/25ml (5 2 mg/ml) diltiazem hcl tab 30 mg 1 diltiazem hcl tab 60 mg 1 diltiazem hcl tab 90 mg 1

QL (60 tabs / 30 days) QL (45 tabs / 30 days) QL (45 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

43

Nombre del medicamento

Nivel del medicamento diltiazem hcl tab 120 mg 1 felodipine tab sr 24hr 2.5 mg 2 felodipine tab sr 24hr 5 mg 2 felodipine tab sr 24hr 10 mg 2 isradipine cap 2.5 mg 2 isradipine cap 5 mg 2 nicardipine hcl cap 20 mg 2 nicardipine hcl cap 30 mg 2 nifedical xl tab 30mg 2 nifedical xl tab 60mg 2 nifedipine tab sr 24hr 30 mg 2 nifedipine tab sr 24hr 60 mg 2 nifedipine tab sr 24hr 90 mg 2 nifedipine tab sr 24hr osmotic release 30 2 mg nifedipine tab sr 24hr osmotic release 60 2 mg nifedipine tab sr 24hr osmotic release 90 2 mg nimodipine cap 30 mg 5 NYMALIZE SOL 60/20ML 5 taztia xt cap 120mg/24 2 taztia xt cap 180mg/24 2 taztia xt cap 240mg/24 2 taztia xt cap 300mg/24 2 taztia xt cap 360mg/24 2 verapamil hcl cap sr 24hr 100 mg 2 verapamil hcl cap sr 24hr 120 mg 2 verapamil hcl cap sr 24hr 180 mg 2 verapamil hcl cap sr 24hr 200 mg 2 verapamil hcl cap sr 24hr 240 mg 2 verapamil hcl cap sr 24hr 300 mg 2 VERAPAMIL HCL CAP SR 24HR 360 MG 2 verapamil hcl iv soln 2.5 mg/ml 2 verapamil hcl tab 40 mg 1 verapamil hcl tab 80 mg 1 verapamil hcl tab 120 mg 1 verapamil hcl tab cr 120 mg 1 verapamil hcl tab cr 180 mg 1 verapamil hcl tab cr 240 mg 1

Requisitos/Límites

QL (30 tabs / 30 days) QL (60 tabs / 30 days)

QL (30 tabs / 30 days) QL (60 tabs / 30 days)

QL (30 tabs / 30 days)

GLUCÓSIDOS DIGITÁLICOS

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

44

Nombre del medicamento digitek tab 0.25mg digitek tab 0.125mg digoxin inj 0.25 mg/ml DIGOXIN ORAL SOLN 0.05 MG/ML digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg)

Nivel del Requisitos/Límites medicamento 2 PA; PA if 65 years and older 2 QL (30 tabs / 30 days) 2 2 PA; PA if 65 years and older 2 QL (30 tabs / 30 days) 2 PA; PA if 65 years and older

INHIBIDORES DIRECTOS DE LA RENINA/COMBINACIONES TEKTURNA TEKTURNA TEKTURNA TEKTURNA TEKTURNA TEKTURNA

HCT TAB 150-12.5 HCT TAB 150-25MG HCT TAB 300-12.5 HCT TAB 300-25MG TAB 150MG TAB 300MG

3 3 3 3 3 3

QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

DIURÉTICOS acetazolamide cap sr 12hr 500 mg 2 acetazolamide tab 125 mg 2 acetazolamide tab 250 mg 2 amiloride & hydrochlorothiazide tab 5-50 1 mg amiloride hcl tab 5 mg 2 bumetanide inj 0.25 mg/ml 2 bumetanide tab 0.5 mg 2 bumetanide tab 1 mg 2 bumetanide tab 2 mg 2 chlorothiazide tab 250 mg 2 chlorothiazide tab 500 mg 2 chlorthalidone tab 25 mg 2 chlorthalidone tab 50 mg 2 furosemide inj 10 mg/ml 2 FUROSEMIDE INJ 10 MG/ML 2 furosemide oral soln 8 mg/ml 1 furosemide oral soln 10 mg/ml 1 furosemide tab 20 mg 1 furosemide tab 40 mg 1 furosemide tab 80 mg 1 hydrochlorothiazide cap 12.5 mg 1 hydrochlorothiazide tab 12.5 mg 1 hydrochlorothiazide tab 25 mg 1 hydrochlorothiazide tab 50 mg 1 PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

45

Nombre del medicamento

Nivel del Requisitos/Límites medicamento indapamide tab 1.25 mg 1 indapamide tab 2.5 mg 1 methazolamide tab 25 mg 2 methazolamide tab 50 mg 2 methyclothiazide tab 5 mg 2 metolazone tab 2.5 mg 2 metolazone tab 5 mg 2 metolazone tab 10 mg 2 spironolactone & hydrochlorothiazide tab 2 25-25 mg torsemide inj 50mg/5ml 2 torsemide tab 5 mg 1 torsemide tab 10 mg 1 torsemide tab 20 mg 1 torsemide tab 100 mg 1 triamterene & hydrochlorothiazide cap 1 37.5-25 mg triamterene & hydrochlorothiazide tab 1 37.5-25 mg triamterene & hydrochlorothiazide tab 1 75-50 mg

DIVERSOS clonidine hcl tab 0.1 mg 1 clonidine hcl tab 0.2 mg 1 clonidine hcl tab 0.3 mg 1 clonidine hcl td patch weekly 0.1 mg/24hr2 clonidine hcl td patch weekly 0.2 mg/24hr2 clonidine hcl td patch weekly 0.3 mg/24hr2 DEMSER CAP 250MG 5 hydralazine hcl inj 20 mg/ml 2 hydralazine hcl tab 10 mg 2 hydralazine hcl tab 25 mg 2 hydralazine hcl tab 50 mg 2 hydralazine hcl tab 100 mg 2 midodrine hcl tab 2.5 mg 2 midodrine hcl tab 5 mg 2 midodrine hcl tab 10 mg 2 minoxidil tab 2.5 mg 2 minoxidil tab 10 mg 2 RANEXA TAB 500MG 3 RANEXA TAB 1000MG 3

NITRATOS PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

46

Nombre del medicamento

Nivel del Requisitos/Límites medicamento isosorbide dinitrate tab 5 mg 2 isosorbide dinitrate tab 10 mg 2 isosorbide dinitrate tab 20 mg 2 isosorbide dinitrate tab 30 mg 2 isosorbide dinitrate tab cr 40 mg 2 isosorbide mononitrate tab 10 mg 1 isosorbide mononitrate tab 20 mg 1 isosorbide mononitrate tab sr 24hr 30 mg1 isosorbide mononitrate tab sr 24hr 60 mg1 isosorbide mononitrate tab sr 24hr 120 1 mg minitran dis 0.1mg/hr 2 minitran dis 0.2mg/hr 2 minitran dis 0.4mg/hr 2 minitran dis 0.6mg/hr 2 nitro-bid oin 2% 3 NITRO-DUR DIS 0.3MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 nitroglycerin sl tab 0.3 mg 2 nitroglycerin sl tab 0.4 mg 2 nitroglycerin sl tab 0.6 mg 2 nitroglycerin td patch 24hr 0.1 mg/hr 2 nitroglycerin td patch 24hr 0.2 mg/hr 2 nitroglycerin td patch 24hr 0.4 mg/hr 2 nitroglycerin td patch 24hr 0.6 mg/hr 2 NITROSTAT SUB 0.3MG 3 NITROSTAT SUB 0.4MG 3 NITROSTAT SUB 0.6MG 3

HIPERTENSIÓN ARTERIAL PULMONAR ADEMPAS TAB 0.5MG

5

ADEMPAS TAB 1.5MG

5

ADEMPAS TAB 1MG

5

ADEMPAS TAB 2.5MG

5

ADEMPAS TAB 2MG

5

LETAIRIS TAB 5MG

5

LETAIRIS TAB 10MG

5

QL (90 tabs NM, LA, PA QL (90 tabs NM, LA, PA QL (90 tabs NM, LA, PA QL (90 tabs NM, LA, PA QL (90 tabs NM, LA, PA QL (30 tabs NM, LA, PA QL (30 tabs NM, LA, PA

/ 30 days), / 30 days), / 30 days), / 30 days), / 30 days), / 30 days), / 30 days),

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

47

Nombre del medicamento OPSUMIT TAB 10MG REMODULIN INJ 1MG/ML REMODULIN INJ 2.5MG/ML REMODULIN INJ 5MG/ML REMODULIN INJ 10MG/ML REVATIO SUS 10MG/ML sildenafil citrate tab 20 mg TRACLEER TAB 62.5MG TRACLEER TAB 125MG UPTRAVI TAB 200/800 UPTRAVI TAB 200MCG UPTRAVI TAB 400MCG UPTRAVI TAB 600MCG UPTRAVI TAB 800MCG UPTRAVI TAB 1000MCG UPTRAVI TAB 1200MCG UPTRAVI TAB 1400MCG UPTRAVI TAB 1600MCG

Nivel del Requisitos/Límites medicamento 5 QL (30 tabs / 30 days), NM, LA, PA 5 B/D, NM, LA 5 B/D, NM, LA 5 B/D, NM, LA 5 B/D, NM, LA 5 QL (224 mL / 30 days), NM, PA 2 QL (90 tabs / 30 days), NM, PA 5 QL (120 tabs / 30 days), NM, LA, PA 5 QL (60 tabs / 30 days), NM, LA, PA 5 NM, LA, PA 5 QL (480 tabs / 30 days), NM, LA, PA 5 QL (240 tabs / 30 days), NM, LA, PA 5 QL (150 tabs / 30 days), NM, LA, PA 5 QL (120 tabs / 30 days), NM, LA, PA 5 QL (90 tabs / 30 days), NM, LA, PA 5 QL (60 tabs / 30 days), NM, LA, PA 5 QL (60 tabs / 30 days), NM, LA, PA 5 QL (60 tabs / 30 days), NM, LA, PA

SISTEMA NERVIOSO CENTRAL ANSIOLÍTICOS alprazolam tab 0.5 mg alprazolam tab 0.25 mg alprazolam tab 1 mg alprazolam tab 2 mg buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg fluvoxamine maleate tab 25 mg

1 1 1 1 2 2 2 2 2 2

QL QL QL QL

(240 (480 (120 (150

tabs tabs tabs tabs

/ / / /

30 30 30 30

days) days) days) days)

QL (45 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

48

Nombre del medicamento fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg lorazepam con 2mg/ml lorazepam inj 2 mg/ml lorazepam inj 4 mg/ml lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg

Nivel del medicamento 2 2 2 2 2 1 1 1

Requisitos/Límites QL (45 tabs / 30 days) QL (150 mL / 30 days)

QL (150 tabs / 30 days) QL (150 tabs / 30 days) QL (150 tabs / 30 days)

ANTICONVULSIVOS APTIOM TAB 200MG 4 APTIOM TAB 400MG 5 APTIOM TAB 600MG 5 APTIOM TAB 800MG 5 BANZEL SUS 40MG/ML 5 BANZEL TAB 200MG 4 BANZEL TAB 400MG 5 BRIVIACT INJ 50MG/5ML 4 BRIVIACT SOL 10MG/ML 5 BRIVIACT TAB 10MG 5 BRIVIACT TAB 25MG 5 BRIVIACT TAB 50MG 5 BRIVIACT TAB 75MG 5 BRIVIACT TAB 100MG 5 carbamazepine cap sr 12hr 100 mg 2 carbamazepine cap sr 12hr 200 mg 2 carbamazepine cap sr 12hr 300 mg 2 carbamazepine chew tab 100 mg 2 carbamazepine susp 100 mg/5ml 2 carbamazepine tab 200 mg 2 carbamazepine tab sr 12hr 100 mg 2 carbamazepine tab sr 12hr 200 mg 2 carbamazepine tab sr 12hr 400 mg 2 CELONTIN CAP 300MG 4 clonazepam orally disintegrating tab 0.5 2 mg clonazepam orally disintegrating tab 0.252 mg clonazepam orally disintegrating tab 2 0.125 mg clonazepam orally disintegrating tab 1 mg2 clonazepam orally disintegrating tab 2 mg2 clonazepam tab 0.5 mg 1

QL QL QL QL PA PA PA PA PA PA PA PA PA PA

(180 tabs / 30 days) (90 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days)

QL (240 tabs / 30 days) QL (480 tabs / 30 days) QL (960 tabs / 30 days) QL (120 tabs / 30 days) QL (300 tabs / 30 days) QL (240 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

49

Nombre del medicamento clonazepam tab 1 mg clonazepam tab 2 mg clorazepate dipotassium tab 3.75 mg

Nivel del medicamento 1 1 2

clorazepate dipotassium tab 7.5 mg

2

clorazepate dipotassium tab 15 mg

2

diazepam con 5mg/ml

2

diazepam inj 5 mg/ml diazepam oral soln 1 mg/ml

2 2

DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG diazepam tab 2 mg

2

diazepam tab 5 mg

1

diazepam tab 10 mg

1

dilantin cap 30mg dilantin cap 100mg dilantin chw 50mg DILANTIN-125 SUS 125/5ML divalproex sodium cap delayed release sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr 24 hr 250 mg divalproex sodium tab sr 24 hr 500 mg epitol tab 200mg ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml felbamate susp 600 mg/5ml felbamate tab 400 mg

3 3 3 3 2

Requisitos/Límites QL QL QL PA QL PA QL PA QL PA

(120 tabs / 30 days) (300 tabs / 30 days) (120 tabs / 30 days), (120 tabs / 30 days), (180 tabs / 30 days), (240 mL / 30 days),

QL (1200 mL / 30 days), PA

2 2 1

QL (120 tabs / 30 days), PA QL (120 tabs / 30 days), PA QL (120 tabs / 30 days), PA

2 2 2 2 2 2 2 2 5 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

50

Nombre del medicamento

Nivel del Requisitos/Límites medicamento felbamate tab 600 mg 2 FYCOMPA SUS 0.5MG/ML 4 QL (720 mL / 30 days), PA FYCOMPA TAB 2MG 4 QL (180 tabs / 30 days), PA FYCOMPA TAB 4MG 4 QL (90 tabs / 30 days), PA FYCOMPA TAB 6MG 4 QL (60 tabs / 30 days), PA FYCOMPA TAB 8MG 4 QL (30 tabs / 30 days), PA FYCOMPA TAB 10MG 4 QL (30 tabs / 30 days), PA FYCOMPA TAB 12MG 4 QL (30 tabs / 30 days), PA gabapentin cap 100 mg 1 QL (1080 caps / 30 days) gabapentin cap 300 mg 1 QL (360 caps / 30 days) gabapentin cap 400 mg 1 QL (270 caps / 30 days) gabapentin oral soln 250 mg/5ml 2 QL (2160 mL / 30 days) gabapentin tab 600 mg 2 QL (180 tabs / 30 days) gabapentin tab 800 mg 2 QL (120 tabs / 30 days) GABITRIL TAB 12MG 4 GABITRIL TAB 16MG 4 lamotrigine tab 25 mg 1 lamotrigine tab 100 mg 1 lamotrigine tab 150 mg 1 lamotrigine tab 200 mg 1 lamotrigine tab chewable dispersible 5 mg2 lamotrigine tab chewable dispersible 25 2 mg lamotrigine tab sr 24hr 25 mg 2 lamotrigine tab sr 24hr 50 mg 2 lamotrigine tab sr 24hr 100 mg 2 lamotrigine tab sr 24hr 200 mg 2 lamotrigine tab sr 24hr 250 mg 2 lamotrigine tab sr 24hr 300 mg 2 LEVETIRACETA INJ 5MG/ML 4 LEVETIRACETA INJ 10MG/ML 4 LEVETIRACETA INJ 15MG/ML 4 levetiracetam inj 500 mg/5ml (100 2 mg/ml) levetiracetam oral soln 100 mg/ml 2 levetiracetam tab 250 mg 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

51

Nombre del medicamento levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab 1000 mg levetiracetam tab sr 24hr 500 mg levetiracetam tab sr 24hr 750 mg LYRICA CAP 25MG LYRICA CAP 50MG LYRICA CAP 75MG LYRICA CAP 100MG LYRICA CAP 150MG LYRICA CAP 200MG LYRICA CAP 225MG LYRICA CAP 300MG LYRICA SOL 20MG/ML ONFI SUS 2.5MG/ML ONFI TAB 10MG ONFI TAB 20MG oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg PEGANONE TAB 250MG PHENOBARB INJ 65MG/ML

Nivel del medicamento 2 2 2 2 2 3 3 3 3 3 3 3 3 3 5 4 5 2 2 2 2 4 4

phenobarbital elixir 20 mg/5ml

4

phenobarbital sodium inj 130 mg/ml

4

phenobarbital tab 15 mg

4

phenobarbital tab 16.2 mg

4

phenobarbital tab 30 mg

4

phenobarbital tab 32.4 mg

4

phenobarbital tab 60 mg

4

phenobarbital tab 64.8 mg

4

phenobarbital tab 97.2 mg

4

Requisitos/Límites

QL QL QL QL QL QL QL QL QL PA PA PA

(120 caps / 30 days) (120 caps / 30 days) (120 caps / 30 days) (120 caps / 30 days) (120 caps / 30 days) (90 caps / 30 days) (60 caps / 30 days) (60 caps / 30 days) (946 mL / 30 days)

PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older

if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

52

Nombre del medicamento

Nivel del Requisitos/Límites medicamento phenobarbital tab 100 mg 4 PA; PA if 65 years and older phenytek cap 200mg 3 phenytek cap 300mg 3 phenytoin chew tab 50 mg 2 phenytoin sodium extended cap 100 mg 2 phenytoin sodium extended cap 200 mg 2 phenytoin sodium extended cap 300 mg 2 phenytoin sodium inj 50 mg/ml 2 phenytoin susp 125 mg/5ml 2 POTIGA TAB 50MG 4 POTIGA TAB 200MG 5 QL (180 tabs / 30 days) POTIGA TAB 300MG 5 QL (90 tabs / 30 days) POTIGA TAB 400MG 5 QL (90 tabs / 30 days) primidone tab 50 mg 2 primidone tab 250 mg 2 roweepra tab 500mg 2 SABRIL POW 500MG 5 QL (180 packets / 30 days), NM, LA, PA SABRIL TAB 500MG 5 QL (180 tabs / 30 days), NM, LA, PA SPRITAM TAB 250MG 4 SPRITAM TAB 500MG 4 SPRITAM TAB 750MG 4 SPRITAM TAB 1000MG 4 TEGRETOL SUS 100/5ML 4 TEGRETOL TAB 200MG 4 TEGRETOL-XR TAB 100MG 4 TEGRETOL-XR TAB 200MG 4 TEGRETOL-XR TAB 400MG 4 tiagabine hcl tab 2 mg 2 tiagabine hcl tab 4 mg 2 topiramate sprinkle cap 15 mg 2 topiramate sprinkle cap 25 mg 2 topiramate tab 25 mg 1 topiramate tab 50 mg 1 topiramate tab 100 mg 1 topiramate tab 200 mg 1 valproate sodium inj 100 mg/ml 2 valproate sodium syrup 250 mg/5ml 2 (base equiv) valproic acid cap 250 mg 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

53

Nombre del medicamento

Nivel del medicamento 4 4 4 5 5 5 2 2 2

Requisitos/Límites

donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 23 mg EXELON DIS 4.6MG/24

2

QL (30 tabs / 30 days)

EXELON DIS 9.5MG/24

4

EXELON DIS 13.3/24

4

VIMPAT INJ 200MG/20 VIMPAT SOL 10MG/ML VIMPAT TAB 50MG VIMPAT TAB 100MG VIMPAT TAB 150MG VIMPAT TAB 200MG zonisamide cap 25 mg zonisamide cap 50 mg zonisamide cap 100 mg

QL QL QL QL QL

(1200 mL / 30 days) (180 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days)

ANTIDEMENCIALES 2 2 2 2 4

galantamine hydrobromide cap sr 24hr 8 2 mg galantamine hydrobromide cap sr 24hr 162 mg galantamine hydrobromide cap sr 24hr 242 mg galantamine hydrobromide oral soln 4 2 mg/ml galantamine hydrobromide tab 4 mg 2 galantamine hydrobromide tab 8 mg 2 galantamine hydrobromide tab 12 mg 2 memantine hcl oral solution 2 mg/ml 2 memantine hcl tab 5 mg 2 memantine hcl tab 10 mg 2 NAMENDA XR CAP 7MG 4 NAMENDA XR CAP 14MG 4 NAMENDA XR CAP 21MG 4 NAMENDA XR CAP 28MG 4 NAMENDA XR CAP TITRATIO 4 NAMZARIC CAP 7-10MG 4

QL (30 tabs / 30 days)

QL (30 days) QL (30 days) QL (30 days) QL (30

patches / 30 patches / 30 patches / 30 caps / 30 days)

QL (30 caps / 30 days)

QL (180 tabs / 30 days) QL (90 tabs / 30 days) PA; PA; PA; PA; PA; PA; PA; PA;

PA PA PA PA PA PA PA PA

if if if if if if if if

< < < < < < < <

30 30 30 30 30 30 30 30

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

yrs yrs yrs yrs yrs yrs yrs yrs

54

Nombre del medicamento

Nivel del Requisitos/Límites medicamento NAMZARIC CAP 14-10MG 4 NAMZARIC CAP 21-10MG 4 NAMZARIC CAP 28-10MG 4 rivastigmine tartrate cap 1.5 mg 2 rivastigmine tartrate cap 3 mg 2 rivastigmine tartrate cap 4.5 mg 2 rivastigmine tartrate cap 6 mg 2 rivastigmine td patch 24hr 4.6 mg/24hr 2 QL (30 patches / 30 days) rivastigmine td patch 24hr 9.5 mg/24hr 2 QL (30 patches / 30 days) rivastigmine td patch 24hr 13.3 mg/24hr 2 QL (30 patches / 30 days)

ANTIDEPRESIVOS amitriptyline hcl tab 10 mg

4

amitriptyline hcl tab 25 mg

4

amitriptyline hcl tab 50 mg

4

amitriptyline hcl tab 75 mg

4

amitriptyline hcl tab 100 mg

4

amitriptyline hcl tab 150 mg

4

amoxapine tab 25 mg amoxapine tab 50 mg amoxapine tab 100 mg amoxapine tab 150 mg BRINTELLIX TAB 5MG BRINTELLIX TAB 10MG BRINTELLIX TAB 20MG bupropion hcl tab 75 mg bupropion hcl tab 100 mg bupropion hcl tab sr 12hr 100 mg bupropion hcl tab sr 12hr 150 mg bupropion hcl tab sr 12hr 200 mg bupropion hcl tab sr 24hr 150 mg bupropion hcl tab sr 24hr 300 mg citalopram hydrobromide oral soln 10 mg/5ml

2 2 2 2 4 4 4 2 2 2 2 2 2 2 2

PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older

if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and

QL (120 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days)

QL (90 tabs / 30 days) QL (30 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

55

Nombre del medicamento citalopram hydrobromide tab 10 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) citalopram hydrobromide tab 40 mg (base equiv) clomipramine hcl cap 25 mg

Nivel del Requisitos/Límites medicamento 1 QL (45 tabs / 30 days) 1

QL (45 tabs / 30 days)

1

QL (30 tabs / 30 days)

4

PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older

clomipramine hcl cap 50 mg

4

clomipramine hcl cap 75 mg

4

desipramine hcl tab 10 mg desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg doxepin hcl cap 10 mg

2 2 2 2 2 2 4

doxepin hcl cap 25 mg

4

doxepin hcl cap 50 mg

4

doxepin hcl cap 75 mg

4

doxepin hcl cap 100 mg

4

doxepin hcl cap 150 mg

4

doxepin hcl conc 10 mg/ml

4

duloxetine hcl enteric coated pellets cap 2 20 mg duloxetine hcl enteric coated pellets cap 2 30 mg duloxetine hcl enteric coated pellets cap 2 60 mg EMSAM DIS 6MG/24HR 5 EMSAM DIS 9MG/24HR

5

EMSAM DIS 12MG/24H

5

PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older QL (60

if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and caps / 30 days)

QL (60 caps / 30 days) QL (60 caps / 30 days) QL (30 patches / 30 days), PA QL (30 patches / 30 days), PA QL (30 patches / 30 days), PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

56

Nombre del medicamento

Nivel del medicamento escitalopram oxalate soln 5 mg/5ml (base2 equiv) escitalopram oxalate tab 5 mg (base 2 equiv) escitalopram oxalate tab 10 mg (base 2 equiv) escitalopram oxalate tab 20 mg (base 2 equiv) FETZIMA CAP 20MG 4 FETZIMA CAP 40MG 4 FETZIMA CAP 80MG 4 FETZIMA CAP 120MG 4 FETZIMA CAP TITRATIO 4 fluoxetine hcl cap 10 mg 1 fluoxetine hcl cap 20 mg 1 fluoxetine hcl cap 40 mg 1 fluoxetine hcl solution 20 mg/5ml 2 fluoxetine hcl tab 10 mg 2 fluoxetine hcl tab 20 mg 2 imipramine hcl tab 10 mg 4 imipramine hcl tab 25 mg

4

imipramine hcl tab 50 mg

4

maprotiline hcl tab 25 mg 2 maprotiline hcl tab 50 mg 2 maprotiline hcl tab 75 mg 2 MARPLAN TAB 10MG 4 mirtazapine orally disintegrating tab 15 2 mg mirtazapine orally disintegrating tab 30 2 mg mirtazapine orally disintegrating tab 45 2 mg mirtazapine tab 7.5 mg 1 mirtazapine tab 15 mg 1 mirtazapine tab 30 mg 1 mirtazapine tab 45 mg 1 nefazodone hcl tab 50 mg 2 nefazodone hcl tab 100 mg 2 nefazodone hcl tab 150 mg 2 nefazodone hcl tab 200 mg 2

Requisitos/Límites QL (600 mL / 30 days) QL (45 tabs / 30 days) QL (45 tabs / 30 days) QL (60 tabs / 30 days) QL QL QL QL

(180 caps / 30 days) (90 caps / 30 days) (30 caps / 30 days) (30 caps / 30 days)

QL (30 caps / 30 days) QL (120 caps / 30 days)

QL (45 tabs / 30 days) PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older

QL (180 tabs / 30 days) QL (30 tabs / 30 days)

QL (45 tabs / 30 days) QL (45 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

57

Nombre del medicamento nefazodone hcl tab 250 mg nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml paroxetine hcl tab 10 mg paroxetine hcl tab 20 mg paroxetine hcl tab 30 mg paroxetine hcl tab 40 mg PAXIL SUS 10MG/5ML phenelzine sulfate tab 15 mg PRISTIQ TAB 25MG PRISTIQ TAB 50MG PRISTIQ TAB 100MG protriptyline hcl tab 5 mg protriptyline hcl tab 10 mg sertraline hcl oral conc 20 mg/ml sertraline hcl tab 25 mg sertraline hcl tab 50 mg sertraline hcl tab 100 mg SURMONTIL CAP 25MG

Nivel del medicamento 2 1 1 1 1 2 1 1 1 1 4 2 3 3 3 2 2 2 1 1 1 4

SURMONTIL CAP 50MG

4

SURMONTIL CAP 100MG

4

tranylcypromine sulfate tab 10 mg trazodone hcl tab 50 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg trimipramine maleate cap 25 mg

2 1 1 1 4

trimipramine maleate cap 50 mg

4

trimipramine maleate cap 100 mg

4

Requisitos/Límites

QL QL QL QL QL

(45 tabs (45 tabs (60 tabs (45 tabs (900 mL

/ / / / /

30 30 30 30 30

days) days) days) days) days)

QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

QL (45 tabs / 30 days) QL (45 tabs / 30 days) QL (240 caps / 30 days), PA; PA if 65 years and older QL (120 caps / 30 days), PA; PA if 65 years and older QL (60 caps / 30 days), PA; PA if 65 years and older

QL (240 caps / 30 days), PA; PA if 65 years and older QL (120 caps / 30 days), PA; PA if 65 years and older QL (60 caps / 30 days), PA; PA if 65 years and older

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

58

Nombre del medicamento

Nivel del medicamento TRINTELLIX TAB 5MG 4 TRINTELLIX TAB 10MG 4 TRINTELLIX TAB 20MG 4 venlafaxine hcl cap sr 24hr 37.5 mg (base2 equivalent) venlafaxine hcl cap sr 24hr 75 mg (base 2 equivalent) venlafaxine hcl cap sr 24hr 150 mg (base2 equivalent) venlafaxine hcl tab 25 mg 2 venlafaxine hcl tab 37.5 mg 2 venlafaxine hcl tab 50 mg 2 venlafaxine hcl tab 75 mg 2 venlafaxine hcl tab 100 mg 2 VIIBRYD KIT 4 VIIBRYD KIT STARTER 4 VIIBRYD TAB 10MG 4 VIIBRYD TAB 20MG 4 VIIBRYD TAB 40MG 4

Requisitos/Límites QL QL QL QL

(120 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 caps / 30 days)

QL (30 caps / 30 days) QL (60 caps / 30 days)

QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

AGENTES ANTIPARKINSONIANOS amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg APOKYN INJ 10MG/ML AZILECT TAB 0.5MG AZILECT TAB 1MG BENZTROPINE MESYLATE INJ 1 MG/ML benztropine mesylate tab 0.5 mg

2 2 2 5 3 3 2 4

benztropine mesylate tab 1 mg

4

benztropine mesylate tab 2 mg

4

NM, LA, PA

PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older

bromocriptine mesylate cap 5 mg (base 2 equivalent) bromocriptine mesylate tab 2.5 mg (base2 equivalent) carbidopa & levodopa orally 2 disintegrating tab 10-100 mg carbidopa & levodopa orally 2 disintegrating tab 25-100 mg carbidopa & levodopa orally 2 disintegrating tab 25-250 mg PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

59

Nombre del medicamento

Nivel del Requisitos/Límites medicamento carbidopa & levodopa tab 10-100 mg 2 carbidopa & levodopa tab 25-100 mg 2 carbidopa & levodopa tab 25-250 mg 2 carbidopa & levodopa tab cr 25-100 mg 2 carbidopa & levodopa tab cr 50-200 mg 2 CARBIDOPA-LEVODOPA-ENTACAPONE 2 TABS 12.5-50-200 MG CARBIDOPA-LEVODOPA-ENTACAPONE 2 TABS 18.75-75-200 MG CARBIDOPA-LEVODOPA-ENTACAPONE 2 TABS 25-100-200 MG CARBIDOPA-LEVODOPA-ENTACAPONE 2 TABS 31.25-125-200 MG CARBIDOPA-LEVODOPA-ENTACAPONE 2 TABS 37.5-150-200 MG CARBIDOPA-LEVODOPA-ENTACAPONE 2 TABS 50-200-200 MG ENTACAPONE TAB 200 MG 2 NEUPRO DIS 1MG/24HR 4 NEUPRO DIS 2MG/24HR 4 NEUPRO DIS 3MG/24HR 4 NEUPRO DIS 4MG/24HR 4 NEUPRO DIS 6MG/24HR 4 NEUPRO DIS 8MG/24HR 4 pramipexole dihydrochloride tab 0.5 mg 2 pramipexole dihydrochloride tab 0.25 mg2 pramipexole dihydrochloride tab 0.75 mg2 pramipexole dihydrochloride tab 0.125 2 mg pramipexole dihydrochloride tab 1 mg 2 pramipexole dihydrochloride tab 1.5 mg 2 ropinirole hydrochloride tab 0.5 mg 2 ropinirole hydrochloride tab 0.25 mg 2 ropinirole hydrochloride tab 1 mg 2 ropinirole hydrochloride tab 2 mg 2 ropinirole hydrochloride tab 3 mg 2 ropinirole hydrochloride tab 4 mg 2 ropinirole hydrochloride tab 5 mg 2 selegiline hcl cap 5 mg 2 selegiline hcl tab 5 mg 2

ANTIPSICÓTICOS ABILIFY DISC TAB 10MG ABILIFY MAIN INJ 300MG

5 5

QL (60 tabs / 30 days) QL (1 injection / 28 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

60

Nombre del medicamento ABILIFY MAIN INJ 400MG aripiprazole oral solution 1 mg/ml aripiprazole orally disintegrating tab 10 mg aripiprazole orally disintegrating tab 15 mg aripiprazole tab 2 mg aripiprazole tab 5 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 20 mg aripiprazole tab 30 mg chlorpromaz inj 25mg/ml chlorpromaz inj 50mg/2ml chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg CLOZAPINE ORALLY DISINTEGRATING TAB 12.5 MG CLOZAPINE ORALLY DISINTEGRATING TAB 25 MG CLOZAPINE ORALLY DISINTEGRATING TAB 100 MG CLOZAPINE ORALLY DISINTEGRATING TAB 150 MG CLOZAPINE ORALLY DISINTEGRATING TAB 200 MG clozapine tab 25 mg clozapine tab 50 mg clozapine tab 100 mg clozapine tab 200 mg FANAPT PAK FANAPT TAB 1MG

Nivel del medicamento 5 5 5

Requisitos/Límites

5

QL (60 tabs / 30 days)

5 5 5 5 5 5 4 4 2 2 2 2 2 2

QL QL QL QL QL QL

2

PA

2

QL (270 tabs / 30 days), PA QL (180 tabs / 30 days), PA QL (135 tabs / 30 days), PA

5 5 2 2 2 2 4 4

FANAPT TAB 2MG

4

FANAPT TAB 4MG

4

FANAPT TAB 6MG

4

QL (1 injection / 28 days) QL (900ml / 30 days) QL (60 tabs / 30 days)

(30 (30 (30 (30 (30 (30

tabs tabs tabs tabs tabs tabs

/ / / / / /

30 30 30 30 30 30

days) days) days) days) days) days)

PA

QL QL ST QL ST QL ST QL ST QL ST

(270 tabs / 30 days) (135 tabs / 30 days) (60 tabs / 30 days), (60 tabs / 30 days), (60 tabs / 30 days), (60 tabs / 30 days),

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

61

Nombre del medicamento

Nivel del Requisitos/Límites medicamento FANAPT TAB 8MG 4 QL (60 tabs / 30 days), ST FANAPT TAB 10MG 4 QL (60 tabs / 30 days), ST FANAPT TAB 12MG 4 QL (60 tabs / 30 days), ST FAZACLO TAB 150 ODT 5 QL (180 tabs / 30 days), PA FAZACLO TAB 200 ODT 5 QL (135 tabs / 30 days), PA fluphenazine decanoate inj 25 mg/ml 2 fluphenazine hcl elixir 2.5 mg/5ml 2 fluphenazine hcl inj 2.5 mg/ml 2 fluphenazine hcl oral conc 5 mg/ml 2 fluphenazine hcl tab 1 mg 2 fluphenazine hcl tab 2.5 mg 2 fluphenazine hcl tab 5 mg 2 fluphenazine hcl tab 10 mg 2 GEODON INJ 20MG 4 QL (6 mL / 3 days) haloperidol decanoate im soln 50 mg/ml 2 haloperidol decanoate im soln 100 mg/ml2 haloperidol lactate inj 5 mg/ml 2 haloperidol lactate oral conc 2 mg/ml 2 haloperidol tab 0.5 mg 2 haloperidol tab 1 mg 2 haloperidol tab 2 mg 2 haloperidol tab 5 mg 2 haloperidol tab 10 mg 2 haloperidol tab 20 mg 2 INVEGA SUST INJ 39/0.25 4 QL (1 injection / 28 days) INVEGA SUST INJ 78/0.5ML 5 QL (1 injection / 28 days) INVEGA SUST INJ 117/0.75 5 QL (1 injection / 28 days) INVEGA SUST INJ 156MG/ML 5 QL (1 injection / 28 days) INVEGA SUST INJ 234/1.5 5 QL (1 injection / 28 days) INVEGA TAB 1.5MG 4 QL (30 tabs / 30 days) INVEGA TAB 3MG 4 QL (30 tabs / 30 days) INVEGA TAB 6MG 4 QL (60 tabs / 30 days) INVEGA TAB 9MG 4 QL (30 tabs / 30 days) INVEGA TRINZ INJ 273MG 5 QL (1 syringe / 90 days) INVEGA TRINZ INJ 410MG 5 QL (1 syringe / 90 days) INVEGA TRINZ INJ 546MG 5 QL (1 syringe / 90 days) INVEGA TRINZ INJ 819MG 5 QL (1 syringe / 90 days) LATUDA TAB 20MG 4 QL (240 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

62

Nombre del medicamento LATUDA TAB 40MG LATUDA TAB 60MG LATUDA TAB 80MG LATUDA TAB 120MG loxapine succinate cap 5 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 50 mg molindone hcl tab 5 mg molindone hcl tab 10 mg molindone hcl tab 25 mg NUPLAZID TAB 17MG

Nivel del medicamento 4 4 4 4 2 2 2 2 2 2 2 5

olanzapine for im inj 10 mg 2 olanzapine orally disintegrating tab 5 mg 2 olanzapine orally disintegrating tab 10 mg2 olanzapine orally disintegrating tab 15 mg2 olanzapine orally disintegrating tab 20 mg2 olanzapine tab 2.5 mg 2 olanzapine tab 5 mg 2 olanzapine tab 7.5 mg 2 olanzapine tab 10 mg 2 olanzapine tab 15 mg 2 olanzapine tab 20 mg 2 paliperidone tab sr 24hr 1.5 mg 2 paliperidone tab sr 24hr 3 mg 2 paliperidone tab sr 24hr 6 mg 2 paliperidone tab sr 24hr 9 mg 2 perphenazine tab 2 mg 2 perphenazine tab 4 mg 2 perphenazine tab 8 mg 2 perphenazine tab 16 mg 2 pimozide tab 1 mg 2 pimozide tab 2 mg 2 quetiapine fumarate tab 25 mg 2 quetiapine fumarate tab 50 mg 2 quetiapine fumarate tab 100 mg 2 quetiapine fumarate tab 200 mg 2 quetiapine fumarate tab 300 mg 2 quetiapine fumarate tab 400 mg 2 REXULTI TAB 0.5MG 5

Requisitos/Límites QL QL QL QL

(30 (60 (60 (30

tabs tabs tabs tabs

/ / / /

30 30 30 30

days) days) days) days)

QL (60 tabs / 30 days), NM, LA, PA QL (3 vials / 1 day) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days)

QL QL QL QL QL QL QL ST

(90 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (180 tabs / 30 days),

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

63

Nombre del medicamento

Nivel del Requisitos/Límites medicamento REXULTI TAB 0.25MG 5 QL (360 tabs / 30 days), ST REXULTI TAB 1MG 5 QL (90 tabs / 30 days), ST REXULTI TAB 2MG 5 QL (60 tabs / 30 days), ST REXULTI TAB 3MG 5 QL (30 tabs / 30 days), ST REXULTI TAB 4MG 5 QL (30 tabs / 30 days), ST RISPERDAL INJ 12.5MG 4 QL (2 injections / 28 days) RISPERDAL INJ 25MG 4 QL (2 injections / 28 days) RISPERDAL INJ 37.5MG 5 QL (2 injections / 28 days) RISPERDAL INJ 50MG 5 QL (2 injections / 28 days) risperidone orally disintegrating tab 0.5 2 QL (90 tabs / 30 days) mg risperidone orally disintegrating tab 0.25 2 QL (90 tabs / 30 days) mg risperidone orally disintegrating tab 1 mg2 QL (60 tabs / 30 days) risperidone orally disintegrating tab 2 mg2 QL (60 tabs / 30 days) risperidone orally disintegrating tab 3 mg2 QL (60 tabs / 30 days) risperidone orally disintegrating tab 4 mg2 QL (120 tabs / 30 days) risperidone soln 1 mg/ml 2 QL (240 mL / 30 days) risperidone tab 0.5 mg 2 QL (90 tabs / 30 days) risperidone tab 0.25 mg 2 QL (90 tabs / 30 days) risperidone tab 1 mg 2 QL (60 tabs / 30 days) risperidone tab 2 mg 2 QL (60 tabs / 30 days) risperidone tab 3 mg 2 QL (60 tabs / 30 days) risperidone tab 4 mg 2 QL (120 tabs / 30 days) SAPHRIS SUB 2.5MG 4 QL (240 tabs / 30 days) SAPHRIS SUB 5MG 4 QL (120 tabs / 30 days) SAPHRIS SUB 10MG 4 QL (60 tabs / 30 days) SEROQUEL XR TAB 50MG 4 QL (120 tabs / 30 days) SEROQUEL XR TAB 150MG 4 QL (30 tabs / 30 days) SEROQUEL XR TAB 200MG 4 QL (30 tabs / 30 days) SEROQUEL XR TAB 300MG 4 QL (60 tabs / 30 days) SEROQUEL XR TAB 400MG 4 QL (60 tabs / 30 days) thioridazine hcl tab 10 mg 4 PA; PA if 65 years and older

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

64

Nombre del medicamento thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thioridazine hcl tab 100 mg thiothixene cap 1 mg thiothixene cap 2 mg thiothixene cap 5 mg thiothixene cap 10 mg trifluoperazine hcl tab 1 mg trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 5 mg trifluoperazine hcl tab 10 mg VERSACLOZ SUS 50MG/ML VRAYLAR CAP 1.5-3MG VRAYLAR CAP 1.5MG VRAYLAR CAP 3MG VRAYLAR CAP 4.5MG VRAYLAR CAP 6MG ziprasidone hcl ziprasidone hcl ziprasidone hcl ziprasidone hcl ZYPREXA RELP ZYPREXA RELP ZYPREXA RELP

cap 20 mg cap 40 mg cap 60 mg cap 80 mg INJ 210MG INJ 300MG INJ 405MG

Nivel del Requisitos/Límites medicamento 4 PA; PA if 65 years and older 4 PA; PA if 65 years and older 4 PA; PA if 65 years and older 2 2 2 2 2 2 2 2 5 QL (600 mL / 30 days), PA 4 ST 5 QL (120 caps / 30 days), ST 5 QL (60 caps / 30 days), ST 5 QL (30 caps / 30 days), ST 5 QL (30 caps / 30 days), ST 2 QL (60 caps / 30 days) 2 QL (60 caps / 30 days) 2 QL (90 caps / 30 days) 2 QL (90 caps / 30 days) 5 QL (2 vials / 28 days), PA 5 QL (2 vials / 28 days), PA 5 QL (1 vial / 28 days), PA

TRASTORNO POR DÉFICIT DE ATENCIÓN E HIPERACTIVIDAD amphetamine-dextroamphetamine 24hr 5 mg amphetamine-dextroamphetamine 24hr 10 mg amphetamine-dextroamphetamine 24hr 15 mg amphetamine-dextroamphetamine 24hr 20 mg amphetamine-dextroamphetamine 24hr 25 mg

cap sr2

QL (90 caps / 30 days)

cap sr2

QL (90 caps / 30 days)

cap sr2

QL (30 caps / 30 days)

cap sr2

QL (30 caps / 30 days)

cap sr2

QL (30 caps / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

65

Nombre del medicamento

Nivel del Requisitos/Límites medicamento amphetamine-dextroamphetamine cap sr2 QL (30 caps / 30 days) 24hr 30 mg amphetamine-dextroamphetamine tab 5 2 QL (360 tabs / 30 days) mg amphetamine-dextroamphetamine tab 2 QL (240 tabs / 30 days) 7.5 mg amphetamine-dextroamphetamine tab 2 QL (180 tabs / 30 days) 10 mg amphetamine-dextroamphetamine tab 2 QL (144 tabs / 30 days) 12.5 mg amphetamine-dextroamphetamine tab 2 QL (120 tabs / 30 days) 15 mg amphetamine-dextroamphetamine tab 2 QL (90 tabs / 30 days) 20 mg amphetamine-dextroamphetamine tab 2 QL (60 tabs / 30 days) 30 mg guanfacine hcl tab sr 24hr 1 mg (base 4 PA; PA if 65 years and equiv) older guanfacine hcl tab sr 24hr 2 mg (base 4 PA; PA if 65 years and equiv) older guanfacine hcl tab sr 24hr 3 mg (base 4 PA; PA if 65 years and equiv) older guanfacine hcl tab sr 24hr 4 mg (base 4 PA; PA if 65 years and equiv) older methylphenidate hcl soln 5 mg/5ml 2 QL (1800 mL / 30 days) methylphenidate hcl soln 10 mg/5ml 2 QL (900 mL / 30 days) methylphenidate hcl tab 5 mg 2 QL (180 tabs / 30 days) methylphenidate hcl tab 10 mg 2 QL (180 tabs / 30 days) methylphenidate hcl tab 20 mg 2 QL (90 tabs / 30 days) methylphenidate hcl tab cr 10 mg 2 QL (90 tabs / 30 days) methylphenidate hcl tab cr 20 mg 2 QL (90 tabs / 30 days) STRATTERA CAP 10MG 4 QL (120 caps / 30 days) STRATTERA CAP 18MG 4 QL (120 caps / 30 days) STRATTERA CAP 25MG 4 QL (120 caps / 30 days) STRATTERA CAP 40MG 4 QL (60 caps / 30 days) STRATTERA CAP 60MG 4 QL (30 caps / 30 days) STRATTERA CAP 80MG 4 QL (30 caps / 30 days) STRATTERA CAP 100MG 4 QL (30 caps / 30 days)

HIPNÓTICOS HETLIOZ CAP 20MG ROZEREM TAB 8MG SILENOR TAB 3MG SILENOR TAB 6MG

5 4 3 3

NM, LA, PA QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

66

Nombre del medicamento temazepam cap 7.5 mg

temazepam cap 15 mg

zolpidem tartrate tab 5 mg

zolpidem tartrate tab 10 mg

Nivel del Requisitos/Límites medicamento 2 QL (30 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year 2 QL (60 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year 4 QL (30 tabs / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year 4 QL (30 tabs / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year

MIGRAÑA dihydroergotamine mesylate inj 1 mg/ml 2 naratriptan hcl tab 1 mg (base equiv) 2 naratriptan hcl tab 2.5 mg (base equiv) 2 RELPAX TAB 20MG 3 RELPAX TAB 40MG 3 rizatriptan benzoate oral disintegrating 2 tab 5 mg (base eq) rizatriptan benzoate oral disintegrating 2 tab 10 mg (base eq) rizatriptan benzoate tab 5 mg (base 2 equivalent) rizatriptan benzoate tab 10 mg (base 2 equivalent) SUMATRIPTAN NASAL SPRAY 5 MG/ACT 2 SUMATRIPTAN NASAL SPRAY 20 MG/ACT 2 sumatriptan succinate inj 6 mg/0.5ml

2

sumatriptan succinate solution auto-injector 4 mg/0.5ml sumatriptan succinate solution auto-injector 6 mg/0.5ml SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML

2 2 2 2

QL QL QL QL QL

(9 tabs / 30 days) (9 tabs / 30 days) (12 tabs / 30 days) (12 tabs / 30 days) (18 tabs / 30 days)

QL (18 tabs / 30 days) QL (18 tabs / 30 days) QL (18 tabs / 30 days) QL (24 days) QL (12 days) QL (12 days) QL (12 days) QL (12 days) QL (12 days) QL (12 days)

inhalers / 30 inhalers / 30 injections / 30 injections / 30 injections / 30 injections / 30 injections / 30

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

67

Nombre del medicamento

Nivel del Requisitos/Límites medicamento sumatriptan succinate solution prefilled 2 QL (12 injections / 30 syringe 6 mg/0.5ml days) sumatriptan succinate tab 25 mg 2 QL (9 tabs / 30 days) sumatriptan succinate tab 50 mg 2 QL (9 tabs / 30 days) sumatriptan succinate tab 100 mg 2 QL (9 tabs / 30 days) zolmitriptan orally disintegrating tab 2.5 2 QL (12 tabs / 30 days) mg zolmitriptan orally disintegrating tab 5 mg2 QL (12 tabs / 30 days) zolmitriptan tab 2.5 mg 2 QL (12 tabs / 30 days) zolmitriptan tab 5 mg 2 QL (12 tabs / 30 days)

DIVERSOS lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab cr 300 mg lithium carbonate tab cr 450 mg LITHIUM SOL 8MEQ/5ML NUEDEXTA CAP 20-10MG pyridostigmine bromide tab 60 mg riluzole tab 50 mg tetrabenazine tab 12.5 mg

1 1 1 1 2 2 3 3 2 2 5

tetrabenazine tab 25 mg

5

PA

QL (240 tabs / 30 days), NM, PA QL (120 tabs / 30 days), NM, PA

AGENTES PARA LA ESCLEROSIS MÚLTIPLE AMPYRA TAB 10MG BETASERON INJ 0.3MG

5 5

COPAXONE INJ 40MG/ML

5

GILENYA CAP 0.5MG

5

glatopa inj 20mg/ml

5

TYSABRI INJ 300/15ML

5

NM, LA, PA QL (14 syringes / 28 days), NM, PA QL (12 syringes / 28 days), NM, PA QL (28 caps / 28 days), NM, PA QL (30 syringes / 30 days), NM, PA NM, LA, PA

AGENTES PARA TERAPIA MUSCULOESQUELÉTICA baclofen tab 10 mg baclofen tab 20 mg dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dantrolene sodium cap 100 mg

2 2 2 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

68

Nombre del medicamento

Nivel del Requisitos/Límites medicamento tizanidine hcl tab 2 mg (base equivalent) 2 tizanidine hcl tab 4 mg (base equivalent) 2

NARCOLEPSIA/CATAPLEXIA armodafinil tab 50 mg

2

armodafinil tab 150 mg

2

ARMODAFINIL TAB 200 MG

2

armodafinil tab 250 mg

2

NUVIGIL TAB 50MG

4

NUVIGIL TAB 150MG

4

NUVIGIL TAB 200MG

4

NUVIGIL TAB 250MG

4

XYREM SOL 500MG/ML

5

QL (150 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (150 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (540 mL / 30 days), LA, PA

PSICOTERAPÉUTICOS, DIVERSOS acamprosate calcium tab delayed release2 333 mg buprenorphine hcl sl tab 2 mg (base 2 equiv) buprenorphine hcl sl tab 8 mg (base 2 equiv) buprenorphine hcl-naloxone hcl sl tab 2 2-0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-22 mg (base equiv) bupropion hcl (smoking deterrent) tab sr 2 12hr 150 mg CHANTIX PAK 0.5& 1MG 4 CHANTIX PAK 1MG 4 CHANTIX TAB 0.5MG 4 CHANTIX TAB 1MG 4 disulfiram tab 250 mg 2 disulfiram tab 500 mg 2 naloxone hcl inj 0.4 mg/ml 2 naloxone hcl inj 4 mg/10ml 2 naloxone hcl soln cartridge 0.4 mg/ml 2

PA PA QL (120 tabs / 30 days), PA QL (120 tabs / 30 days), PA

PA PA PA PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

69

Nombre del medicamento naloxone hcl soln prefilled syringe 2 mg/2ml naltrexone hcl tab 50 mg NICOTROL INH NICOTROL NS SPR 10MG/ML SUBOXONE MIS 2-0.5MG

Nivel del Requisitos/Límites medicamento 2 2 4 4 4

SUBOXONE MIS 4-1MG

4

SUBOXONE MIS 8-2MG

4

SUBOXONE MIS 12-3MG

4

QL (120 SL films / 30 days), PA QL (120 SL films / 30 days), PA QL (120 SL films / 30 days), PA QL (60 SL films / 30 days), PA

SISTEMA ENDOCRINO Y METABÓLICO ANDRÓGENOS ANDRODERM DIS 2MG/24HR

4

ANDRODERM DIS 4MG/24HR

4

AXIRON SOL 30MG/ACT

3

oxandrolone tab 2.5 mg oxandrolone tab 10 mg testosterone cypionate im inj in oil 100 mg/ml testosterone cypionate im inj in oil 200 mg/ml testosterone enanthate im inj in oil 200 mg/ml

2 5 2

QL (30 patches / 30 days), PA QL (30 patches / 30 days), PA QL (440 mL / 30 days), PA PA PA PA

2

PA

2

PA

ANTIDIABÉTICOS, INYECTABLES ALCOHOL SWABS BYDUREON INJ 2MG BYDUREON PEN INJ 2MG BYETTA INJ 5MCG BYETTA INJ 10MCG GAUZE PADS 2" X 2" HUMULIN R INJ U-500 HUMULIN R INJ U-500 INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE LANTUS INJ 100/ML LANTUS INJ SOLOSTAR

3 3 3 4 4 3 5 5 2 2 2 3 3

QL QL QL QL

(4 (4 (1 (1

vials / 28 days) pens / 28 days) pen / 30 days) pen / 30 days)

B/D

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

70

Nombre del medicamento LEVEMIR INJ LEVEMIR INJ FLEXTOUC NOVOLIN INJ 70/30 NOVOLIN N INJ U-100 NOVOLIN R INJ U-100 NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL NOVOLOG MIX INJ 70/30 NOVOLOG MIX INJ FLEXPEN SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG TOUJEO SOLO INJ 300IU/ML TRESIBA FLEX INJ 100UNIT TRESIBA FLEX INJ 200UNIT TRULICITY INJ 0.75/0.5 TRULICITY INJ 1.5/0.5 VICTOZA INJ 18MG/3ML

Nivel del Requisitos/Límites medicamento 3 3 3 (brand RELION not covered) 3 (brand RELION not covered) 3 (brand RELION not covered) 3 3 3 3 3 4 QL (8 pens / 30 days), PA 5 QL (4 pens / 30 days), PA 3 3 3 4 QL (4 pens / 28 days) 4 QL (4 pens / 28 days) 3 QL (3 pens / 30 days)

ANTIDIABÉTICOS, ADMINISTRACIÓN ORAL acarbose tab 25 mg acarbose tab 50 mg acarbose tab 100 mg FARXIGA TAB 5MG FARXIGA TAB 10MG glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 5 mg glipizide tab 10 mg glipizide tab sr 24hr 2.5 mg GLIPIZIDE TAB SR 24HR 2.5 MG glipizide tab sr 24hr 5 mg glipizide tab sr 24hr 10 mg GLIPIZIDE XL TAB 5MG glipizide-metformin hcl tab 2.5-250 mg glipizide-metformin hcl tab 2.5-500 mg glipizide-metformin hcl tab 5-500 mg INVOKAMET TAB 50-500MG INVOKAMET TAB 50-1000

2 2 2 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3

QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL

(60 tabs / 30 days) (30 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (120 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

71

Nombre del medicamento

Nivel del medicamento INVOKAMET TAB 150-500 3 INVOKAMET TAB 150-1000 3 INVOKANA TAB 100MG 3 INVOKANA TAB 300MG 3 JANUMET TAB 50-500MG 3 JANUMET TAB 50-1000 3 JANUMET XR TAB 50-500MG 3 JANUMET XR TAB 50-1000 3 JANUMET XR TAB 100-1000 3 JANUVIA TAB 25MG 3 JANUVIA TAB 50MG 3 JANUVIA TAB 100MG 3 JENTADUETO TAB 2.5-500 3 JENTADUETO TAB 2.5-850 3 JENTADUETO TAB 2.5-1000 3 JENTADUETO TAB XR 3 JENTADUETO TAB XR 3 metformin hcl tab 500 mg 1 metformin hcl tab 850 mg 1 metformin hcl tab 1000 mg 1 metformin hcl tab sr 24hr 500 mg 1 metformin hcl tab sr 24hr 750 mg 1 nateglinide tab 60 mg 1 nateglinide tab 120 mg 1 pioglitazone hcl tab 15 mg (base equiv) 1 pioglitazone hcl tab 30 mg (base equiv) 1 pioglitazone hcl tab 45 mg (base equiv) 1 repaglinide tab 0.5 mg 1 repaglinide tab 1 mg 1 repaglinide tab 2 mg 1 TRADJENTA TAB 5MG 3 XIGDUO XR TAB 5-500MG 3 XIGDUO XR TAB 5-1000MG 3 XIGDUO XR TAB 10-500MG 3 XIGDUO XR TAB 10-1000 3

Requisitos/Límites QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL

(60 tabs / 30 days) (60 tabs / 30 days) (90 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (150 tabs / 30 days) (90 tabs / 30 days) (75 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (120 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days)

BISFOSFONATOS alendronate alendronate alendronate alendronate alendronate

sodium sodium sodium sodium sodium

tab tab tab tab tab

5 mg 10 mg 35 mg 40 mg 70 mg

1 1 1 1 1

QL (4 tabs / 28 days) QL (4 tabs / 28 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

72

Nombre del medicamento ibandronate sodium tab 150 mg (base equivalent) pamidronate disodium iv soln 3 mg/ml pamidronate disodium iv soln 9 mg/ml pamidronate inj 6mg/ml zoledronic acid inj conc for iv infusion 4 mg/5ml zoledronic acid iv soln 5 mg/100ml

Nivel del Requisitos/Límites medicamento 2 B/D, QL (1 tab / 30 days) 2 2 2 2

B/D B/D B/D B/D, NM

2

B/D, NM

AGONISTAS DE LOS RECEPTORES DE CALCIO SENSIPAR TAB 30MG

3

SENSIPAR TAB 60MG

5

SENSIPAR TAB 90MG

5

QL (120 tabs / 30 days), NM QL (60 tabs / 30 days), NM QL (120 tabs / 30 days), NM

AGENTES QUELANTES CHEMET CAP 100MG DEPEN TITRA TAB 250MG EXJADE TAB 125MG EXJADE TAB 250MG EXJADE TAB 500MG FERRIPROX SOL 100MG/ML FERRIPROX TAB 500MG kionex pow kionex sus 15gm/60 sodium polystyrene sulfonate oral susp 15 gm/60ml sodium polystyrene sulfonate powder sps sus 15gm/60 SYPRINE CAP 250MG

4 5 5 5 5 5 5 2 2 2

NM, NM, NM, NM, NM,

LA, LA, LA, LA, LA,

PA PA PA PA PA

2 2 5

ANTICONCEPTIVOS altavera tab apri tab aranelle tab aubra tab 0.1-0.02 aviane tab balziva tab bekyree tab blisovi fe tab 1.5/30 blisovi fe tab 1/20 briellyn tab camila tab 0.35mg

2 2 2 2 2 2 2 2 2 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

73

Nombre del medicamento

Nivel del Requisitos/Límites medicamento 2 2 2 2 2 2 2

caziant pak cryselle-28 tab 28 tabs cyclafem tab 1/35 cyclafem tab 7/7/7 deblitane tab 0.35mg delyla tab 0.1-0.02 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) desogestrel & ethinyl estradiol tab 0.15 2 mg-30 mcg drospirenone-ethinyl estradiol tab 3-0.02 2 mg DROSPIRENONE-ETHINYL ESTRADIOL 2 TAB 3-0.02 MG drospirenone-ethinyl estradiol tab 3-0.03 2 mg DROSPIRENONE-ETHINYL ESTRADIOL 2 TAB 3-0.03 MG ELLA TAB 30MG 4 emoquette tab 2 enpresse-28 tab 2 errin tab 0.35mg 2 falmina tab 2 gildagia tab 0.4-35 2 gildess tab 1.5/30 2 heather tab 0.35mg 2 introvale tab 2 JOLIVETTE TAB 0.35MG 2 juleber tab 2 junel 1.5/30 tab 2 junel 1/20 tab 2 junel fe tab 1.5/30 2 junel fe tab 1/20 2 kariva tab 28 day 2 kelnor tab 1/35 2 kimidess tab 2 larin fe tab 1.5/30 2 larin fe tab 1/20 2 larin tab 1.5/30 2 larin tab 1/20 2 larissia tab 2 leena tab 2 lessina tab 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

74

Nombre del medicamento

Nivel del Requisitos/Límites medicamento 2 2

levonest tab levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg LEVONORGESTREL & ETHINYL 2 ESTRADIOL (91-DAY) TAB 0.15-0.03 MG levonorgestrel & ethinyl estradiol tab 0.1 2 mg-20 mcg levonorgestrel tab 0.75 mg 2 levonorgestrel tab 1.5 mg 2 levonorgestrel-eth estra tab 2 0.05-30/0.075-40/0.125-30mg-mcg levora-28 tab 0.15/30 2 loryna tab 3-0.02mg 2 lutera tab 2 lyza tab 0.35mg 2 marlissa tab 0.15/30 2 medroxyprogesterone acetate im susp 2 150 mg/ml MEDROXYPROGESTERONE ACETATE IM 2 SUSP PREFILLED SYR 150 MG/ML MONONESSA TAB 2 myzilra tab 2 necon tab 0.5/35 2 necon tab 1/35 2 NECON TAB 1/50-28 2 NECON TAB 7/7/7 2 necon tab 10/11-28 3 nikki tab 3-0.02mg 2 norelgestromin-ethinyl estradiol td ptwk 2 150-35 mcg/24hr NORETHINDRONE ACE & ETHINYL 2 ESTRADIOL TAB 1 MG-20 MCG NORETHINDRONE ACE & ETHINYL 2 ESTRADIOL TAB 1.5 MG-30 MCG NORETHINDRONE ACE & ETHINYL 2 ESTRADIOL-FE TAB 1 MG-20 MCG NORETHINDRONE ACE & ETHINYL 2 ESTRADIOL-FE TAB 1.5 MG-30 MCG norethindrone tab 0.35 mg 2 NORETHINDRONE TAB 0.35 MG 2 norgestimate & ethinyl estradiol tab 0.25 2 mg-35 mcg

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

75

Nombre del medicamento norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg norlyroc tab 0.35mg nortrel tab 0.5/35 nortrel tab 1/35 nortrel tab 7/7/7 NUVARING MIS orsythia tab philith tab 0.4-35 pimtrea tab pirmella tab 1/35 portia-28 tab previfem tab quasense tab reclipsen tab sharobel tab 0.35mg sprintec 28 tab 28 day tarina fe tab 1/20 tri-legest tab fe tri-previfem tab tri-sprintec tab TRINESSA TAB trivora-28 tab velivet pak vienva tab 0.1-20 viorele tab vyfemla tab 0.4-35 zarah tab 3-0.03mg zenchent tab zovia 1/35e tab zovia 1/50e tab

Nivel del Requisitos/Límites medicamento 2 2 2 2 2 2 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

ENDOMETRIOSIS danazol cap 50 mg danazol cap 100 mg danazol cap 200 mg SYNAREL SOL 2MG/ML

2 2 2 5

REEMPLAZO DE ENZIMAS ADAGEN INJ 250/ML ALDURAZYME INJ 2.9MG/5M BUPHENYL TAB 500MG

5 5 5

NM, LA, PA NM, LA, PA NM, LA, PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

76

Nombre del medicamento

Nivel del medicamento CARBAGLU TAB 200MG 5 CERDELGA CAP 84MG 5 CEREZYME INJ 200UNIT 5 CEREZYME INJ 400UNIT 5 CYSTADANE POW 5 CYSTAGON CAP 50MG 4 CYSTAGON CAP 150MG 4 FABRAZYME INJ 5MG 5 FABRAZYME INJ 35MG 5 KUVAN POW 100MG 5 KUVAN POW 500MG 5 KUVAN TAB 100MG 5 levocarnitine inj 200 mg/ml 2 levocarnitine oral soln 1 gm/10ml (10%) 2 levocarnitine tab 330 mg 2 LUMIZYME INJ 50MG 5 MYOZYME INJ 50MG 5 NAGLAZYME INJ 1MG/ML 5 ORFADIN CAP 2MG 5 ORFADIN CAP 5MG 5 ORFADIN CAP 10MG 5 ORFADIN CAP 20MG 5 ORFADIN SUS 4MG/ML 5 RAVICTI LIQ 1.1GM/ML 5 sodium phenylbutyrate oral powder 3 5 gm/teaspoonful ZAVESCA CAP 100MG 5

Requisitos/Límites NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, B/D B/D B/D NM, NM, NM, NM, NM, NM, NM, NM, NM, NM

LA, PA LA, LA, LA LA, LA, LA, LA, LA, LA, LA,

PA

LA, LA, LA, LA, LA, LA, LA, LA, PA

PA PA PA PA PA PA PA PA

PA PA PA PA PA PA PA PA PA

NM, LA, PA

ESTRÓGENOS DELESTROGEN INJ 10MG/ML estrace vag cre 0.1mg/gm estradiol tab 0.5 mg

4 4 4

estradiol tab 1 mg

4

estradiol tab 2 mg

4

estradiol td patch weekly 0.1 mg/24hr

4

estradiol td patch weekly 0.05 mg/24hr 4 estradiol td patch weekly 0.06 mg/24hr 4

PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older

if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and if 65 years and

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

77

Nombre del medicamento

Nivel del Requisitos/Límites medicamento estradiol td patch weekly 0.025 mg/24hr 4 PA; PA if 65 years and older estradiol td patch weekly 0.075 mg/24hr 4 PA; PA if 65 years and older estradiol td patch weekly 0.0375 mg/24hr4 PA; PA if 65 years and (37.5 mcg/24hr) older estradiol valerate im in oil 20 mg/ml 2 estradiol valerate im in oil 40 mg/ml 2 jinteli tab 1mg-5mcg 4 PA; PA if 65 years and older norethindrone acetate-ethinyl estradiol 4 PA; PA if 65 years and tab 1 mg-5 mcg older VAGIFEM TAB 10MCG 4

GLUCOCORTICOIDES a-hydrocort inj 100mg cortisone acetate tab 25 mg dexamethason con 1mg/ml dexamethasone elixir 0.5 mg/5ml dexamethasone sod phosphate preservative free inj 10 mg/ml dexamethasone sodium phosphate mg/ml dexamethasone sodium phosphate mg/ml dexamethasone sodium phosphate mg/5ml dexamethasone sodium phosphate 100 mg/10ml dexamethasone sodium phosphate 120 mg/30ml dexamethasone soln 0.5 mg/5ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1 mg dexamethasone tab 1.5 mg dexamethasone tab 2 mg dexamethasone tab 4 mg dexamethasone tab 6 mg fludrocortisone acetate tab 0.1 mg hydrocortisone tab 5 mg hydrocortisone tab 10 mg hydrocortisone tab 20 mg

2 2 2 2 2 inj 4 2 inj 10 2 inj 20 2 inj

2

inj

2 2 1 1 1 1 1 1 1 2 2 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

78

Nombre del medicamento

Nivel del Requisitos/Límites medicamento methylprednisolone acetate inj susp 40 2 B/D mg/ml methylprednisolone acetate inj susp 80 2 B/D mg/ml methylprednisolone sodium succinate for 2 B/D inj 40 mg methylprednisolone sodium succinate for 2 B/D inj 125 mg methylprednisolone sodium succinate for 2 B/D inj 1000 mg methylprednisolone tab 4 mg 2 B/D methylprednisolone tab 8 mg 2 B/D methylprednisolone tab 16 mg 2 B/D methylprednisolone tab 32 mg 2 B/D methylprednisolone tab therapy pack 4 2 mg (21) prednisolone sod phosph oral soln 6.7 2 B/D mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 2 B/D mg/5ml (base equiv) prednisolone sodium phosphate oral soln 2 B/D 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp 1 B/D solution equivalent) prednisone con 5mg/ml 3 B/D prednisone oral soln 5 mg/5ml 2 B/D prednisone tab 1 mg 1 B/D prednisone tab 2.5 mg 1 B/D prednisone tab 5 mg 1 B/D prednisone tab 10 mg 1 B/D prednisone tab 20 mg 1 B/D prednisone tab 50 mg 1 B/D prednisone tab therapy pack 5 mg (21) 2 prednisone tab therapy pack 5 mg (48) 2 prednisone tab therapy pack 10 mg (21) 2 prednisone tab therapy pack 10 mg (48) 2 SOLU-CORTEF INJ 250MG 4

AGENTES PARA ELEVAR EL NIVEL DE GLUCOSA GLUCAGEN INJ HYPOKIT GLUCAGON KIT 1MG KORLYM TAB 300MG PROGLYCEM SUS 50MG/ML

3 3 5 4

NM, LA, PA

HORMONAS DE CRECIMIENTO HUMANO PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

79

Nombre del medicamento NORDITROPIN NORDITROPIN NORDITROPIN NORDITROPIN

INJ INJ INJ INJ

5/1.5ML 10/1.5ML 15/1.5ML 30/3ML

Nivel del medicamento 5 5 5 5

Requisitos/Límites NM, NM, NM, NM,

PA PA PA PA

DIVERSOS cabergoline tab 0.5 mg calcitonin (salmon) nasal soln 200 unit/act FORTICAL SPR 200/ACT INCRELEX INJ 40MG/4ML methylergonovine maleate tab 0.2 mg MIACALCIN INJ 200/ML octreotide acetate inj 50 mcg/ml (0.05 mg/ml) octreotide acetate inj 100 mcg/ml (0.1 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) octreotide acetate inj 1000 mcg/ml (1 mg/ml) PROLIA SOL 60MG/ML

2 2

raloxifene hcl tab 60 mg SANDOSTATIN KIT LAR 10MG SANDOSTATIN KIT LAR 20MG SANDOSTATIN KIT LAR 30MG SIGNIFOR INJ 0.3MG/ML SIGNIFOR INJ 0.6MG/ML SIGNIFOR INJ 0.9MG/ML SOMATULINE INJ 60/0.2ML SOMATULINE INJ 90/0.3ML SOMATULINE INJ 120/.5ML SOMAVERT INJ 10MG SOMAVERT INJ 15MG SOMAVERT INJ 20MG SOMAVERT INJ 25MG SOMAVERT INJ 30MG XGEVA INJ

2 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

3 5 2 5 2

NM, LA, PA B/D NM, PA

2

NM, PA

5

NM, PA

5

NM, PA

5

NM, PA

4

QL (1 syringe / 180 days), NM NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM,

PA PA PA LA, LA, LA, PA PA PA LA, LA, LA, LA, LA, PA

PA PA PA

PA PA PA PA PA

HORMONAS PARATIROIDES FORTEO SOL 600/2.4

5

QL (1 pen / 28 days), NM, PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

80

Nombre del medicamento NATPARA NATPARA NATPARA NATPARA

INJ INJ INJ INJ

25MCG 50MCG 75MCG 100MCG

Nivel del medicamento 5 5 5 5

Requisitos/Límites NM, NM, NM, NM,

PA PA PA PA

AGENTES AGLUTINANTES DE FOSFATO calcium acetate (phosphate binder) cap 2 667 mg (169 mg ca) calcium acetate (phosphate binder) tab 2 667 mg RENVELA PAK 0.8GM 5 RENVELA PAK 2.4GM 5 RENVELA TAB 800MG 5

PROGESTINAS medroxyprogesterone acetate tab 2.5 mg1 medroxyprogesterone acetate tab 5 mg 1 medroxyprogesterone acetate tab 10 mg 1 norethindrone acetate tab 5 mg 2

AGENTES PARA LA TIROIDES levothyroxine sodium tab 25 mcg levothyroxine sodium tab 50 mcg levothyroxine sodium tab 75 mcg levothyroxine sodium tab 88 mcg levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg levothyroxine sodium tab 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 300 mcg LEVOXYL TAB 25MCG LEVOXYL TAB 50MCG LEVOXYL TAB 75MCG LEVOXYL TAB 88MCG LEVOXYL TAB 100MCG LEVOXYL TAB 112MCG LEVOXYL TAB 125MCG LEVOXYL TAB 137MCG LEVOXYL TAB 150MCG LEVOXYL TAB 175MCG LEVOXYL TAB 200MCG liothyronine sodium tab 5 mcg

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

81

Nombre del medicamento liothyronine sodium tab 25 mcg liothyronine sodium tab 50 mcg methimazole tab 5 mg methimazole tab 10 mg propylthiouracil tab 50 mg SYNTHROID TAB 25MCG SYNTHROID TAB 50MCG SYNTHROID TAB 75MCG SYNTHROID TAB 88MCG SYNTHROID TAB 100MCG SYNTHROID TAB 112MCG SYNTHROID TAB 125MCG SYNTHROID TAB 137MCG SYNTHROID TAB 150MCG SYNTHROID TAB 175MCG SYNTHROID TAB 200MCG SYNTHROID TAB 300MCG UNITHROID TAB 25MCG UNITHROID TAB 50MCG UNITHROID TAB 75MCG UNITHROID TAB 88MCG UNITHROID TAB 100MCG UNITHROID TAB 112MCG UNITHROID TAB 125MCG UNITHROID TAB 150MCG UNITHROID TAB 175MCG UNITHROID TAB 200MCG UNITHROID TAB 300MCG

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

VASOPRESINAS desmopressin acetate inj 4 mcg/ml DESMOPRESSIN ACETATE NASAL SOLN 0.01% (REFRIGERATED) desmopressin acetate nasal spray soln 0.01% desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg desmopressin acetate tab 0.2 mg

2 2 2 2 2 2

GASTROINTESTINALES ANTIEMÉTICOS compro sup 25mg

2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

82

Nombre del medicamento

Nivel del Requisitos/Límites medicamento dronabinol cap 2.5 mg 2 B/D, QL (60 caps / 30 days) dronabinol cap 5 mg 2 B/D, QL (60 caps / 30 days) dronabinol cap 10 mg 5 B/D, QL (60 caps / 30 days) EMEND CAP 40MG 4 B/D EMEND CAP 80MG 4 B/D EMEND CAP 125MG 4 B/D EMEND PAK 80 & 125 4 B/D EMEND SUS 125MG 4 B/D granisetron hcl inj 0.1 mg/ml 2 granisetron hcl inj 1 mg/ml 2 granisetron hcl inj 4 mg/4ml (1 mg/ml) 2 granisetron hcl tab 1 mg 2 B/D meclizine hcl tab 12.5 mg 2 meclizine hcl tab 25 mg 2 metoclopramide hcl inj 5 mg/ml 2 metoclopramide hcl soln 5 mg/5ml (10 1 mg/10ml) metoclopramide hcl tab 5 mg 1 metoclopramide hcl tab 10 mg 1 ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2 ondansetron hcl inj 40 mg/20ml (2 2 mg/ml) ondansetron hcl oral soln 4 mg/5ml 2 B/D ondansetron hcl tab 4 mg 2 B/D ondansetron hcl tab 8 mg 2 B/D ondansetron hcl tab 24 mg 2 B/D ondansetron orally disintegrating tab 4 2 B/D mg ondansetron orally disintegrating tab 8 2 B/D mg phenadoz sup 12.5mg 4 PA; PA if 65 years and older phenergan sup 12.5mg 4 PA; PA if 65 years and older phenergan sup 25mg 4 PA; PA if 65 years and older phenergan sup 50mg 4 PA; PA if 65 years and older prochlorperazine edisylate inj 5 mg/ml 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

83

Nombre del medicamento

Nivel del Requisitos/Límites medicamento prochlorperazine maleate tab 5 mg (base1 equivalent) prochlorperazine maleate tab 10 mg 1 (base equivalent) prochlorperazine suppos 25 mg 2 promethazine hcl inj 25 mg/ml 4 PA; PA if 65 years and older promethazine hcl inj 50 mg/ml 4 PA; PA if 65 years and older promethazine hcl suppos 12.5 mg 4 PA; PA if 65 years and older promethazine hcl suppos 25 mg 4 PA; PA if 65 years and older promethazine hcl suppos 50 mg 4 PA; PA if 65 years and older promethazine hcl syrup 6.25 mg/5ml 4 PA; PA if 65 years and older promethazine hcl tab 12.5 mg 4 PA; PA if 65 years and older promethazine hcl tab 25 mg 4 PA; PA if 65 years and older promethazine hcl tab 50 mg 4 PA; PA if 65 years and older promethegan sup 25mg 4 PA; PA if 65 years and older promethegan sup 50mg 4 PA; PA if 65 years and older TRANSDERM-SC DIS 1MG 4 QL (10 patches / 30 days), PA; PA if 65 years and older

ANTIESPASMÓDICOS CUVPOSA SOL 1MG/5ML 4 dicyclomine hcl cap 10 mg 1 dicyclomine hcl oral soln 10 mg/5ml 2 dicyclomine hcl tab 20 mg 1 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml)2 glycopyrrolate tab 1 mg 2 glycopyrrolate tab 2 mg 2

ANTAGONISTAS DEL RECEPTOR H2 famotidine for susp 40 mg/5ml famotidine in nacl 0.9% iv soln 20 mg/50ml famotidine inj 20 mg/2ml

2 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

84

Nombre del medicamento

Nivel del Requisitos/Límites medicamento famotidine inj 40 mg/4ml 2 famotidine inj 200 mg/20ml 2 famotidine tab 20 mg 1 famotidine tab 40 mg 1 ranitidine hcl inj 50 mg/2ml (25 mg/ml) 2 ranitidine hcl syrup 15 mg/ml (75 2 mg/5ml) ranitidine hcl tab 150 mg 1 ranitidine hcl tab 300 mg 1 ranitidine inj 150/6ml 2

ENFERMEDAD INFLAMATORIA INTESTINAL APRISO CAP 0.375GM 3 ASACOL HD TAB 800MG 4 balsalazide disodium cap 750 mg 2 budesonide delayed release particles cap 5 3 mg CANASA SUP 1000MG 5 DELZICOL CAP 400MG 4 DIPENTUM CAP 250MG 5 hydrocortisone enema 100 mg/60ml 2 HYDROCORTISONE ENEMA 100 MG/60ML2 mesalamine enema 4 gm 2 mesalamine rectal enema 4 gm & 2 cleanser wipe kit MESALAMINE TAB DELAYED RELEASE 8002 MG sulfasalazin tab 500mg dr 2 sulfasalazine tab 500 mg 2 UCERIS TAB 9MG 5

LAXANTES bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit constulose sol 10gm/15 enulose sol 10gm/15 gavilyte-c sol gavilyte-g sol gavilyte-n sol flav pk generlac sol 10gm/15 GOLYTELY SOL lactulose (encephalopathy) solution 10 gm/15ml lactulose solution 10 gm/15ml

2 2 2 1 1 2 2 3 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

85

Nombre del medicamento

Nivel del Requisitos/Límites medicamento 4 3 1

MOVIPREP SOL NULYTELY SOL FLAV PKS PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM PEG 3350-KCL-NA BICARB-NACL-NA 1 SULFATE FOR SOLN 240 GM peg 3350-kcl-sod bicarb-nacl for soln 4202 gm polyethylene glycol 3350 oral packet 2 polyethylene glycol 3350 oral powder 2 RELISTOR INJ 8/0.4ML 5 RELISTOR INJ 12/0.6ML 5 SUPREP BOWEL SOL PREP 4 trilyte sol 2

PA PA

DIVERSOS alosetron hcl tab 0.5 mg (base equiv) alosetron hcl tab 1 mg (base equiv) AMITIZA CAP 8MCG AMITIZA CAP 24MCG cromolyn sodium oral conc 100 mg/5ml diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 mg GATTEX KIT 5MG LINZESS CAP 145MCG LINZESS CAP 290MCG loperamide hcl cap 2 mg misoprostol tab 100 mcg misoprostol tab 200 mcg MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG SUCRAID SOL 8500/ML sucralfate tab 1 gm ursodiol cap 300 mg ursodiol tab 250 mg ursodiol tab 500 mg XIFAXAN TAB 550MG

5 5 3 3 5 2

PA PA QL (60 caps / 30 days) QL (60 caps / 30 days)

2 5 3 3 1 2 2 3 3 5 2 2 2 2 5

NM, LA, PA QL (60 caps / 30 days) QL (30 caps / 30 days)

QL (60 tabs / 30 days) QL (30 tabs / 30 days) LA

PA

ENZIMAS PANCREÁTICAS CREON CAP 3000UNIT CREON CAP 6000UNIT CREON CAP 12000UNT

3 3 3

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

86

Nombre del medicamento CREON CAP 24000UNT CREON CAP 36000UNT ZENPEP CAP 3000UNIT ZENPEP CAP 5000UNIT ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 40000UNT

Nivel del Requisitos/Límites medicamento 3 3 4 4 4 4 4 4 4

INHIBIDORES DE LA BOMBA DE PROTONES DEXILANT CAP 30MG DR DEXILANT CAP 60MG DR esomeprazole magnesium cap delayed release 20 mg (base eq) esomeprazole magnesium cap delayed release 40 mg (base eq) esomeprazole sodium for intravenous soln 20 mg (base equiv) esomeprazole sodium for intravenous soln 40 mg (base equiv) NEXIUM CAP 20MG NEXIUM CAP 40MG NEXIUM GRA 2.5MG DR NEXIUM GRA 5MG DR NEXIUM GRA 10MG DR

3 3 2

QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days)

2

QL (30 caps / 30 days)

NEXIUM GRA 20MG DR

3

NEXIUM GRA 40MG DR

3

2 2 3 3 3 3 3

omeprazole cap delayed release 10 mg 1 omeprazole cap delayed release 20 mg 1 omeprazole cap delayed release 40 mg 1 pantoprazole sodium ec tab 20 mg (base 1 equiv) pantoprazole sodium ec tab 40 mg (base 1 equiv)

QL (30 caps / 30 days) QL (30 caps / 30 days)

QL (30 days) QL (30 days) QL (30 days) QL (30 QL (60 QL (30 QL (30

packets / 30 packets / 30 packets / 30 caps / 30 days) caps / 30 days) caps / 30 days) tabs / 30 days)

QL (30 tabs / 30 days)

GENITOURINARIOS HIPERPLASIA PROSTÁTICA BENIGNA alfuzosin hcl tab sr 24hr 10 mg dutasteride cap 0.5 mg dutasteride-tamsulosin hcl cap 0.5-0.4 mg

2 2 2

QL (30 tabs / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

87

Nombre del medicamento finasteride tab 5 mg tamsulosin hcl cap 0.4 mg

Nivel del Requisitos/Límites medicamento 1 2

DIVERSOS bethanechol chloride tab 5 mg 2 bethanechol chloride tab 10 mg 2 bethanechol chloride tab 25 mg 2 bethanechol chloride tab 50 mg 2 ELMIRON CAP 100MG 4 POTASSIUM CITRATE TAB CR 5 MEQ (5402 MG) POTASSIUM CITRATE TAB CR 10 MEQ 2 (1080 MG) potassium citrate tab cr 15 meq (1620 2 mg)

ANTIESPASMÓDICOS URINARIOS MYRBETRIQ TAB 25MG MYRBETRIQ TAB 50MG oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab 5 mg oxybutynin chloride tab sr 24hr 5 mg oxybutynin chloride tab sr 24hr 10 mg oxybutynin chloride tab sr 24hr 15 mg tolterodine tartrate cap sr 24hr 2 mg tolterodine tartrate cap sr 24hr 4 mg tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg TOVIAZ TAB 4MG TOVIAZ TAB 8MG trospium chloride tab 20 mg VESICARE TAB 5MG VESICARE TAB 10MG

4 4 1 2 2 2 2 2 2 2 2 3 3 2 4 4

QL (60 tabs / 30 days) QL (30 tabs / 30 days)

QL QL QL QL QL

(30 (60 (60 (30 (30

tabs / 30 days) tabs / 30 days) tabs / 30 days) caps / 30 days) caps / 30 days)

QL QL QL QL QL

(30 (30 (60 (30 (30

tabs tabs tabs tabs tabs

/ / / / /

30 30 30 30 30

days) days) days) days) days)

ANTIINFECCIOSOS VAGINALES clindamycin phosphate vaginal cream 2%2 metronidazole vaginal gel 0.75% 2 terconazole vaginal cream 0.4% 2 terconazole vaginal cream 0.8% 2 TERCONAZOLE VAGINAL CREAM 0.8% 2 terconazole vaginal suppos 80 mg 2 VANDAZOLE GEL 0.75% 2

HEMATOLÓGICOS ANTICOAGULANTES COUMADIN TAB 1MG

4

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

88

Nombre del medicamento

Nivel del Requisitos/Límites medicamento 4 4 4 4 4 4 4 4 3 3 2 2 2 2 5 5 5 2 2

COUMADIN TAB 2.5MG COUMADIN TAB 2MG COUMADIN TAB 3MG COUMADIN TAB 4MG COUMADIN TAB 5MG COUMADIN TAB 6MG COUMADIN TAB 7.5MG COUMADIN TAB 10MG ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG enoxaparin sodium inj 30 mg/0.3ml enoxaparin sodium inj 40 mg/0.4ml enoxaparin sodium inj 60 mg/0.6ml enoxaparin sodium inj 80 mg/0.8ml enoxaparin sodium inj 100 mg/ml enoxaparin sodium inj 120 mg/0.8ml enoxaparin sodium inj 150 mg/ml enoxaparin sodium inj 300 mg/3ml fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml fondaparinux sodium subcutaneous inj 5 5 mg/0.4ml fondaparinux sodium subcutaneous inj 5 7.5 mg/0.6ml fondaparinux sodium subcutaneous inj 105 mg/0.8ml HEP SOD/NACL INJ 25000UNT 3 HEPARIN SODIUM (PORCINE) 40 3 UNIT/ML IN D5W HEPARIN SODIUM (PORCINE) 50 3 UNIT/ML IN D5W HEPARIN SODIUM (PORCINE) 100 3 UNIT/ML IN D5W heparin sodium (porcine) inj 1000 unit/ml2 heparin sodium (porcine) inj 5000 unit/ml2 heparin sodium (porcine) inj 10000 2 unit/ml heparin sodium (porcine) inj 20000 2 unit/ml jantoven tab 1mg 1 jantoven tab 2.5mg 1 jantoven tab 2mg 1 jantoven tab 3mg 1

B/D B/D B/D B/D

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

89

Nombre del medicamento jantoven tab 4mg jantoven tab 5mg jantoven tab 6mg jantoven tab 7.5mg jantoven tab 10mg PRADAXA CAP 75MG PRADAXA CAP 110MG PRADAXA CAP 150MG warfarin sodium tab 1 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg warfarin sodium tab 10 mg XARELTO STAR TAB 15/20MG XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG

Nivel del Requisitos/Límites medicamento 1 1 1 1 1 3 3 3 1 1 1 1 1 1 1 1 1 3 3 3 3

FACTORES DE CRECIMIENTO HEMATOPOYÉTICOS GRANIX INJ 300/0.5 GRANIX INJ 480/0.8 LEUKINE INJ 250MCG MOZOBIL INJ NEUMEGA INJ 5MG NEUPOGEN INJ 300/0.5 NEUPOGEN INJ 300MCG NEUPOGEN INJ 480/0.8 NEUPOGEN INJ 480MCG PROCRIT INJ 2000/ML PROCRIT INJ 3000/ML PROCRIT INJ 4000/ML PROCRIT INJ 10000/ML PROCRIT INJ 20000/ML PROCRIT INJ 40000/ML

5 5 5 5 5 5 5 5 5 3 3 3 3 5 5

NM, NM, NM, NM, NM NM, NM, NM, NM, NM, NM, NM, NM, NM, NM,

PA PA PA PA PA PA PA PA PA PA PA PA PA PA

DIVERSOS anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg cilostazol tab 50 mg cilostazol tab 100 mg

2 2 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

90

Nombre del medicamento CINRYZE SOL 500 UNIT FIRAZYR INJ 30MG/3ML pentoxifylline tab cr 400 mg PROMACTA TAB 12.5MG

Nivel del medicamento 5 5 2 5

PROMACTA TAB 25MG

5

PROMACTA TAB 50MG

5

PROMACTA TAB 75MG

5

tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) tranexamic acid tab 650 mg

2

Requisitos/Límites NM, LA, PA NM, PA QL (360 tabs / 30 days), NM, LA, PA QL (180 tabs / 30 days), NM, LA, PA QL (90 tabs / 30 days), NM, LA, PA QL (60 tabs / 30 days), NM, LA, PA

2

INHIBIDORES DE LA AGREGACIÓN PLAQUETARIA AGGRENOX CAP 25-200MG ASPIRIN-DIPYRIDAMOLE CAP SR 12HR 25-200 MG BRILINTA TAB 60MG BRILINTA TAB 90MG clopidogrel bisulfate tab 75 mg (base equiv) EFFIENT TAB 5MG EFFIENT TAB 10MG ZONTIVITY TAB 2.08MG

4 2 3 3 1 4 4 4

AGENTES INMUNOLÓGICOS FÁRMACOS ANTIRREUMÁTICOS MODIFICADORES DE LA ENFERMEDAD (FAME) CIMZIA KIT CIMZIA KIT STARTER CIMZIA PREFL KIT 200MG/ML HUMIRA INJ 10MG/0.2 HUMIRA KIT 20MG/0.4 HUMIRA KIT 40MG/0.8 HUMIRA PEDIA INJ CROHNS HUMIRA PEN INJ 40MG/0.8 HUMIRA PEN INJ CROHNS HUMIRA PEN INJ PSORIASI hydroxychloroquine sulfate tab 200 mg leflunomide tab 10 mg leflunomide tab 20 mg

5 5 5 5 5 5 5 5 5 5 2 2 2

NM, NM, NM, NM, NM, NM, NM, NM, NM, NM,

PA PA PA PA PA PA PA PA PA PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

91

Nombre del medicamento

Nivel del Requisitos/Límites medicamento methotrexate sodium tab 2.5 mg (base 2 equiv) REMICADE INJ 100MG 5 NM, PA

INMUNOGLOBULINAS BIVIGAM INJ 10% CARIMUNE NF INJ 6GM CARIMUNE NF INJ 12GM FLEBOGAMMA INJ 5% FLEBOGAMMA INJ 10/200ML FLEBOGAMMA INJ 20/400ML FLEBOGAMMA INJ DIF 5% FLEBOGAMMA INJ DIF 10% GAMASTAN S/D INJ GAMMAGARD INJ 1GM/10ML GAMMAGARD INJ 2.5GM/25 GAMMAGARD INJ 5GM/50ML GAMMAGARD INJ 10GM/100 GAMMAGARD INJ 20GM/200 GAMMAGARD INJ 30GM/300 GAMMAGARD SD INJ 2.5GM HU GAMMAGARD SD INJ 5GM HU GAMMAGARD SD INJ 10GM HU GAMMAKED INJ 1GM/10ML GAMMAKED INJ 2.5GM/25 GAMMAKED INJ 5GM/50ML GAMMAKED INJ 10GM/100 GAMMAKED INJ 20GM/200 GAMMAPLEX INJ 2.5GM GAMMAPLEX INJ 5GM GAMMAPLEX INJ 10GM GAMUNEX-C INJ 1GM/10ML GAMUNEX-C INJ 2.5GM/25 GAMUNEX-C INJ 5GM/50ML GAMUNEX-C INJ 10GM/100 GAMUNEX-C INJ 20GM/200 GAMUNEX-C INJ 40/400ML OCTAGAM INJ 1GM OCTAGAM INJ 2.5GM OCTAGAM INJ 2GM/20ML OCTAGAM INJ 5GM OCTAGAM INJ 10GM OCTAGAM INJ 25GM

5 5 5 5 5 5 5 5 3 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA B/D, NM NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

92

Nombre del medicamento PRIVIGEN PRIVIGEN PRIVIGEN PRIVIGEN

INJ INJ INJ INJ

5 GRAMS 10GRAMS 20GRAMS 40GRAMS

Nivel del medicamento 5 5 5 5

Requisitos/Límites

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

NM, LA, PA NM, PA B/D, NM B/D, NM B/D, NM B/D, NM NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, PA NM, PA NM, PA NM, PA

NM, NM, NM, NM,

PA PA PA PA

INMUNOMODULADORES ACTIMMUNE INJ 2MU/0.5 ARCALYST INJ 220MG INTRON A INJ 10MU INTRON A INJ 18MU INTRON A INJ 25MU INTRON A INJ 50MU REVLIMID CAP 2.5MG REVLIMID CAP 5MG REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 20MG REVLIMID CAP 25MG THALOMID CAP 50MG THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG

INMUNOSUPRESORES azathioprine inj 100mg 2 azathioprine tab 50 mg 2 BENLYSTA INJ 120MG 5 BENLYSTA INJ 400MG 5 cyclosporine cap 25 mg 2 cyclosporine cap 100 mg 2 cyclosporine iv soln 50 mg/ml 2 cyclosporine modified cap 25 mg 2 cyclosporine modified cap 50 mg 2 cyclosporine modified cap 100 mg 2 cyclosporine modified oral soln 100 2 mg/ml gengraf cap 25mg 2 gengraf cap 50mg 2 gengraf cap 100mg 2 gengraf sol 100mg/ml 2 mycophenolate mofetil cap 250 mg 2 mycophenolate mofetil for oral susp 200 5 mg/ml mycophenolate mofetil tab 500 mg 2

B/D B/D NM, PA NM, PA B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

93

Nombre del medicamento mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) NEORAL CAP 25MG NEORAL CAP 100MG NEORAL SOL 100MG/ML NULOJIX INJ 250MG PROGRAF CAP 0.5MG PROGRAF CAP 1MG PROGRAF CAP 5MG RAPAMUNE SOL 1MG/ML SANDIMMUNE SOL 100MG/ML sirolimus tab 0.5 mg sirolimus tab 1 mg SIROLIMUS TAB 2 MG tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg ZORTRESS TAB 0.5MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.75MG

Nivel del Requisitos/Límites medicamento 2 B/D 5

B/D

3 3 3 5 4 4 5 5 3 2 2 5 2 2 5 5 4 5

B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

B/D B/D B/D

VACUNAS ACTHIB INJ ADACEL INJ BCG VACCINE INJ BEXSERO INJ BOOSTRIX INJ CERVARIX INJ COMVAX INJ DAPTACEL INJ DIP/TET PED INJ 25-5LFU ENGERIX-B INJ 10/0.5ML ENGERIX-B INJ 20MCG/ML GARDASIL 9 INJ GARDASIL INJ HAVRIX INJ 720UNIT HAVRIX INJ 1440UNIT HIBERIX SOL 10MCG IMOVAX RABIE INJ 2.5/ML INFANRIX INJ IPOL INJ INACTIVE

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

94

Nombre del medicamento IXIARO INJ KINRIX INJ M-M-R II INJ MENACTRA INJ MENHIBRIX INJ MENOMUNE INJ A/C/Y/W MENVEO INJ PEDIARIX INJ 0.5ML PEDVAX HIB INJ PENTACEL INJ PROQUAD INJ QUADRACEL INJ RABAVERT INJ RECOMBIVA HB INJ 5MCG/0.5 RECOMBIVA HB INJ 10MCG/ML RECOMBIVA-HB INJ 40MCG/ML ROTARIX SUS ROTATEQ SOL SYNAGIS INJ 50MG SYNAGIS INJ 100MG/ML TENIVAC INJ 5-2LF TET/DIP TOX INJ 2-2 LF TRUMENBA INJ TWINRIX INJ TYPHIM VI INJ VAQTA INJ 25/0.5ML VAQTA INJ 50UNT/ML VARIVAX INJ YF-VAX INJ ZOSTAVAX INJ

Nivel del medicamento 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 5 3 3 3 3 3 3 3 3 3 3

Requisitos/Límites

B/D B/D B/D

NM NM B/D B/D

QL (1 vial per lifetime)

SUPLEMENTOS NUTRICIONALES ELECTROLITOS KLOR-CON 8 TAB 8MEQ ER KLOR-CON 10 TAB 10MEQ ER klor-con m15 tab 15meq er klor-con pow 20meq MAGNESIUM SU INJ 2GM/50ML MAGNESIUM SU INJ 4G/100ML MAGNESIUM SU INJ 20/500ML MAGNESIUM SU INJ 40G/1000 MAGNESIUM SU INJ 80MG/ML magnesium sulfate inj 50%

2 2 2 2 3 3 3 3 3 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

95

Nombre del medicamento

Nivel del Requisitos/Límites medicamento MAGNESIUM SULFATE INJ 50% 2 magnesium sulfate iv soln 2 gm/50ml (402 mg/ml) MG SO4/D5W INJ 10MG/ML 3 MG SO4/D5W INJ 20MG/ML 3 potassium chloride cap cr 8 meq 2 potassium chloride cap cr 10 meq 2 potassium chloride microencapsulated 2 crys cr tab 10 meq potassium chloride microencapsulated 2 crys cr tab 20 meq POTASSIUM CHLORIDE ORAL SOLN 10% 2 (20 MEQ/15ML) POTASSIUM CHLORIDE ORAL SOLN 20% 2 (40 MEQ/15ML) potassium chloride tab cr 8 meq (600 mg)2 POTASSIUM CHLORIDE TAB CR 10 MEQ 2 POTASSIUM CHLORIDE TAB CR 20 MEQ 2 (1500 MG) SODIUM CHLORIDE INJ 2.5 MEQ/ML 2 (14.6%) SODIUM FLUORIDE CHEW; TAB; 1.1 (0.52 F) MG/ML SOLN TPN ELECTROL INJ 4 B/D

NUTRICIÓN INTRAVENOSA amino acid infusion 6% AMINOSYN 7% INJ /LYTES AMINOSYN II INJ 7% AMINOSYN II INJ 8.5% AMINOSYN II INJ 8.5/LYTE AMINOSYN II INJ 10% AMINOSYN INJ 8.5% AMINOSYN INJ 8.5/LYTE AMINOSYN INJ 10% AMINOSYN M INJ 3.5% AMINOSYN-HBC INJ 7% AMINOSYN-PF INJ 7% AMINOSYN-PF INJ 10% AMINOSYN-RF INJ 5.2% CLINIMIX INJ 2.75/D5W CLINIMIX INJ 4.25/D5W CLINIMIX INJ 4.25/D10 CLINIMIX INJ 4.25/D20

2 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

96

Nombre del medicamento CLINIMIX INJ 4.25/D25 CLINIMIX INJ 5%/D15W CLINIMIX INJ 5%/D20W CLINIMIX INJ 5%/D25W FAT EMULSION IV SOLN 20% FREAMINE HBC INJ 6.9% FREAMINE III INJ 10% HEPATAMINE SOL 8% INTRALIPID INJ 20% INTRALIPID INJ 30% NEPHRAMINE INJ 5.4% premasol sol 10% PROCALAMINE INJ 3% PROSOL INJ 20% TRAVASOL INJ 10% TROPHAMINE INJ 10%

Nivel del medicamento 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Requisitos/Límites B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

SOLUCIONES DE REEMPLAZO INTRAVENOSAS D5W/LYTES INJ #48 3 D5W/NACL INJ 0.3% 2 D10W/NACL INJ 0.2% 3 DEXTROSE 2.5% W/ SODIUM CHLORIDE 2 0.45% DEXTROSE 5% IN LACTATED RINGERS 2 DEXTROSE 5% W/ SODIUM CHLORIDE 2 0.2% DEXTROSE 5% W/ SODIUM CHLORIDE 2 0.9% DEXTROSE 5% W/ SODIUM CHLORIDE 2 0.33% DEXTROSE 5% W/ SODIUM CHLORIDE 2 0.45% DEXTROSE 5% W/ SODIUM CHLORIDE 2 0.225% DEXTROSE 10% W/ SODIUM CHLORIDE 2 0.45% DEXTROSE INJ 5% 2 DEXTROSE INJ 10% 2 DEXTROSE INJ 50% 2 DEXTROSE INJ 70% 2 IONOSOL-B/ INJ D5W 4 IONOSOL-MB INJ /D5W 4 ISOLYTE-P INJ /D5W 4 ISOLYTE-S INJ 4 PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

97

Nombre del medicamento

Nivel del Requisitos/Límites medicamento KCL 10 MEQ/L (0.075%) IN DEXTROSE 2 5% & NACL 0.45% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%2 & NACL 0.2% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%2 & NACL 0.9% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%2 & NACL 0.33% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%2 & NACL 0.45% INJ KCL 20 MEQ/L (0.15%) IN NACL 0.9% INJ2 kcl 20 meq/l (0.15%) in nacl 0.45% inj 2 KCL 20 MEQ/L (0.15%) IN NACL 0.45% 2 INJ KCL 30 MEQ/L (0.224%) IN DEXTROSE 2 5% & NACL 0.45% INJ KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% 2 & NACL 0.45% INJ KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ 2 KCL/D5W/NACL INJ 0.3/0.9% 2 KCL/D5W/NACL INJ 0.15/0.2 3 LACTATED RINGER'S SOLUTION 2 NORMOSOL -M INJ /D5W 2 NORMOSOL -R INJ /D5W 4 NORMOSOL-R INJ PH 7.4 4 PLASMA-LYTE INJ 56/D5W 4 PLASMA-LYTE INJ -148 4 PLASMA-LYTE INJ -A 4 POTASSIUM CHLORIDE 20 MEQ/L 2 (0.15%) IN DEXTROSE 5% INJ POTASSIUM CHLORIDE 40 MEQ/L (0.3%)2 IN DEXTROSE 5% INJ potassium chloride inj 2 meq/ml 2 POTASSIUM CHLORIDE INJ 10 MEQ/50ML2 POTASSIUM CHLORIDE INJ 10 2 MEQ/100ML POTASSIUM CHLORIDE INJ 20 MEQ/50ML2 POTASSIUM CHLORIDE INJ 20 2 MEQ/100ML POTASSIUM CHLORIDE INJ 40 2 MEQ/100ML RINGER'S SOLUTION 2 SODIUM CHLORIDE INJ 0.45% 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

98

Nombre del medicamento SODIUM CHLORIDE INJ 3% SODIUM CHLORIDE INJ 5% SODIUM CHLORIDE IV SOLN 0.9%

Nivel del Requisitos/Límites medicamento 2 2 2

VITAMINAS calcitriol cap 0.5 mcg calcitriol cap 0.25 mcg calcitriol inj 1 mcg/ml calcitriol oral soln 1 mcg/ml paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

2 2 2 2 2 2 2 2

B/D B/D B/D B/D B/D B/D B/D

OFTALMOLÓGICOS ANTIINFECCIOSOS/ANTIINFLAMATORIOS bacitracin-polymyxin-neomycin-hc ophth 2 oint 1% blephamide oin s.o.p. 4 neomycin-polymyxin-dexamethasone 2 ophth oint 0.1% neomycin-polymyxin-dexamethasone 2 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 2 sulfacetamide sodium-prednisolone 2 ophth soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% 3 TOBRADEX ST SUS 0.3-0.05 3 tobramycin-dexamethasone ophth susp 2 0.3-0.1% ZYLET SUS 0.5-0.3% 3

ANTIINFECCIOSOS bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint BESIVANCE SUS 0.6% CILOXAN OIN 0.3% OP ciprofloxacin hcl ophth soln 0.3% erythromycin ophth oint 5 mg/gm gatifloxacin ophth soln 0.5% gentak oin 0.3% op gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% ilotycin oin op

2 2 3 3 2 1 2 2 2 1 1

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

99

Nombre del medicamento MOXEZA SOL 0.5% NATACYN SUS 5% OP neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ofloxacin ophth soln 0.3% polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% sulfacetamide sodium ophth oint 10% sulfacetamide sodium ophth soln 10% tobramycin ophth soln 0.3% TOBREX OIN 0.3% OP trifluridine ophth soln 1% VIGAMOX DRO 0.5% ZIRGAN GEL 0.15%

Nivel del Requisitos/Límites medicamento 3 4 2 2 2 1 2 2 1 4 2 3 4

ANTIINFLAMATORIOS ALREX SUS 0.2% 3 BROMFENAC SODIUM OPHTH SOLN 2 0.09% (BASE EQUIV) (ONCE-DAILY) bromfenac sodium ophth soln 0.09% 2 (base equivalent) dexamethasone sodium phosphate ophth 2 soln 0.1% diclofenac sodium ophth soln 0.1% 2 DUREZOL EMU 0.05% 3 FLUOROMETHOLONE OPHTH SUSP 0.1% 2 flurbiprofen sodium ophth soln 0.03% 1 ILEVRO DRO 0.3% OP 3 ketorolac tromethamine ophth soln 0.4% 2 ketorolac tromethamine ophth soln 0.5% 2 LOTEMAX GEL 0.5% 3 LOTEMAX OIN 0.5% 3 LOTEMAX SUS 0.5% 3 MAXIDEX SUS 0.1% OP 3 pred sod pho sol 1% op 3 PREDNISOLONE ACETATE OPHTH SUSP 2 1%

ANTIALÉRGICOS azelastine hcl ophth soln 0.05% BEPREVE DRO 1.5% cromolyn sodium ophth soln 4%

2 3 1

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

100

Nombre del medicamento LASTACAFT SOL 0.25% PATADAY SOL 0.2% PAZEO DRO 0.7%

Nivel del Requisitos/Límites medicamento 4 3 3

ANTIGLAUCOMA ALPHAGAN P SOL 0.1% 3 AZOPT SUS 1% OP 3 betaxolol hcl ophth soln 0.5% 2 BETOPTIC-S SUS 0.25% OP 3 brimonidine tartrate ophth soln 0.2% 1 BRIMONIDINE TARTRATE OPHTH SOLN 2 0.15% carteolol hcl ophth soln 1% 1 COMBIGAN SOL 0.2/0.5% 3 dorzolamide hcl ophth soln 2% 2 dorzolamide hcl-timolol maleate ophth 2 soln 22.3-6.8 mg/ml ISTALOL SOL 0.5% OP 3 latanoprost ophth soln 0.005% 1 levobunolol hcl ophth soln 0.5% 2 LUMIGAN SOL 0.01% 3 metipranolol ophth soln 0.3% 2 PHOSPHOLINE SOL 0.125%OP 4 PILOCARPINE HCL OPHTH SOLN 1% 2 PILOCARPINE HCL OPHTH SOLN 2% 2 PILOCARPINE HCL OPHTH SOLN 4% 2 SIMBRINZA SUS 1-0.2% 3 TIMOLOL MALEATE OPHTH GEL FORMING2 SOLN 0.5% TIMOLOL MALEATE OPHTH GEL FORMING2 SOLN 0.25% timolol maleate ophth soln 0.5% 1 timolol maleate ophth soln 0.25% 1 TRAVATAN Z DRO 0.004% 3

DIVERSOS naphazoline hcl ophth soln 0.1% PROLENSA SOL 0.07% proparacaine hcl ophth soln 0.5% RESTASIS EMU 0.05%

1 3 1 3

QL (64 vials / 30 days)

RESPIRATORIOS COMBINACIONES DE ANTICOLINÉRGICOS/ANTAGONISTAS BETA ANORO ELLIPT AER 62.5-25

3

QL (60 inhalations / 30 days)

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

101

Nombre del medicamento COMBIVENT AER 20-100 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml

Nivel del Requisitos/Límites medicamento 4 QL (2 inhalers / 30 days) 2 B/D

ANTICOLINÉRGICOS ATROVENT HFA AER 17MCG INCRUSE ELPT INH 62.5MCG ipratropium bromide inhal soln 0.02% ipratropium bromide nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray)

4 3 2 2

QL (2 inhalers / 30 days) QL (1 inhaler / 30 days) B/D

2

ANTIHISTAMÍNICOS ASTEPRO SPR 0.15% azelastine hcl nasal spray 0.1% (137 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 mcg/spray) cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) diphenhydramine hcl inj 50 mg/ml hydroxyzine hcl im soln 25 mg/ml

3 2

hydroxyzine hcl im soln 50 mg/ml

4

levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg olopatadine hcl nasal soln 0.6%

2

2 2 2 4

PA; PA if 65 years and older PA; PA if 65 years and older

2 2

ANTAGONISTAS BETA albuterol sulfate mg/ml) albuterol sulfate (base equiv) albuterol sulfate mg/3ml) albuterol sulfate (base equiv) albuterol sulfate albuterol sulfate albuterol sulfate albuterol sulfate albuterol sulfate

soln nebu 0.5% (5

2

B/D

soln nebu 0.63 mg/3ml 2

B/D

soln nebu 0.083% (2.5 2

B/D

soln nebu 1.25 mg/3ml 2

B/D

syrup 2 mg/5ml tab 2 mg tab 4 mg tab sr 12hr 4 mg tab sr 12hr 8 mg

1 2 2 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

102

Nombre del medicamento levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) PERFOROMIST NEB 20MCG SEREVENT DIS AER 50MCG terbutaline sulfate inj 1 mg/ml terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg VENTOLIN HFA AER XOPENEX HFA AER

Nivel del Requisitos/Límites medicamento 2 B/D 4 3 5 2 2 3 3

B/D QL (60 inhalations / 30 days)

QL (2 inhalers / 30 days) QL (2 inhalers / 30 days)

ANTAGONISTAS DE LOS RECEPTORES DE LEUCOTRIENOS montelukast sodium chew tab 4 mg (base2 equiv) montelukast sodium chew tab 5 mg (base2 equiv) montelukast sodium oral granules packet2 4 mg (base equiv) montelukast sodium tab 10 mg (base 2 equiv) zafirlukast tab 10 mg 2 zafirlukast tab 20 mg 2

ESTABILIZADORES DE CÉLULAS CEBADAS cromolyn sodium soln nebu 20 mg/2ml

2

B/D

2 2 5 5 4 3 3 5 5 5 5 5 5 5 5 5 5 5

B/D B/D NM, LA, PA NM, LA, PA

DIVERSOS acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% ARALAST NP INJ 500MG ARALAST NP INJ 1000MG DALIRESP TAB 500MCG EPIPEN 2-PAK INJ 0.3MG EPIPEN-JR INJ 2-PAK ESBRIET CAP 267MG KALYDECO PAK 50MG KALYDECO PAK 75MG KALYDECO TAB 150MG OFEV CAP 100MG OFEV CAP 150MG ORKAMBI TAB 200-125 PROLASTIN-C INJ 1000MG PULMOZYME SOL 1MG/ML XOLAIR SOL 150MG ZEMAIRA INJ 1000MG

NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, LA, PA B/D, NM NM, LA, PA NM, LA, PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

103

Nombre del medicamento

Nivel del Requisitos/Límites medicamento

ESTEROIDES NASALES flunisolide nasal soln 25 mcg/act (0.025%) fluticasone propionate nasal susp 50 mcg/act mometasone furoate nasal susp 50 mcg/act NASONEX SPR 50MCG/AC

2

QL (2 bottles / 30 days)

2

QL (1 bottle / 30 days)

2

QL (2 bottles / 30 days)

3

QL (2 inhalers / 30 days)

ARNUITY ELPT INH 100MCG

3

ARNUITY ELPT INH 200MCG

3

QL (30 inhalations / 30 days) QL (30 inhalations / 30 days) B/D B/D QL (120 inhalations / 30 days) QL (120 inhalations / 30 days) QL (240 inhalations / 30 days) QL (2 inhalers / 30 days) QL (2 inhalers / 30 days) QL (2 inhalers / 30 days) QL (2 inhalers / 30 days) QL (2 inhalers / 30 days)

ESTEROIDES INHALADOS

budesonide inhalation susp 0.5 mg/2ml 2 budesonide inhalation susp 0.25 mg/2ml 2 FLOVENT DISK AER 50MCG 3 FLOVENT DISK AER 100MCG

3

FLOVENT DISK AER 250MCG

3

FLOVENT HFA AER 44MCG FLOVENT HFA AER 110MCG FLOVENT HFA AER 220MCG PULMICORT INH 90MCG PULMICORT INH 180MCG

3 3 3 3 3

COMBINACIONES DE ESTEROIDES/ANTAGONISTAS BETA ADVAIR DISKU AER 100/50

3

ADVAIR DISKU AER 250/50

3

ADVAIR DISKU AER 500/50

3

ADVAIR HFA AER 45/21 ADVAIR HFA AER 115/21 ADVAIR HFA AER 230/21 BREO ELLIPTA INH 100-25 BREO ELLIPTA INH 200-25 SYMBICORT AER 80-4.5 SYMBICORT AER 160-4.5

3 3 3 3 3 3 3

QL (60 inhalations / 30 days) QL (60 inhalations / 30 days) QL (60 inhalations / 30 days) QL (1 inhaler / 30 days) QL (1 inhaler / 30 days) QL (1 inhaler / 30 days) QL (60 blisters / 30 days) QL (60 blisters / 30 days) QL (1 inhaler / 30 days) QL (1 inhaler / 30 days)

XANTINAS aminophylline inj 25 mg/ml elixophyllin elx 80/15ml

2 4

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

104

Nombre del medicamento theo-24 cap 100mg cr theo-24 cap 200mg cr theo-24 cap 300mg cr theo-24 cap 400mg er theophylline soln 80 mg/15ml theophylline tab sr 12hr 100 mg theophylline tab sr 12hr 200 mg theophylline tab sr 12hr 300 mg theophylline tab sr 12hr 450 mg theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600 mg

Nivel del Requisitos/Límites medicamento 4 4 4 4 2 2 2 2 2 2 2

TÓPICOS DERMATOLOGÍA, ACNÉ adapalene cream 0.1% 2 adapalene gel 0.1% 2 AVITA CRE 0.025% 2 AVITA GEL 0.025% 2 benzoyl peroxide-erythromycin gel 5-3% 2 claravis cap 10mg 2 claravis cap 20mg 2 claravis cap 30mg 2 claravis cap 40mg 2 clindamax gel 1% 2 clindamycin phosphate gel 1% 2 clindamycin phosphate lotion 1% 2 clindamycin phosphate soln 1% 2 clindamycin phosphate swab 1% 2 erythromycin gel 2% 2 erythromycin pads 2% 2 erythromycin soln 2% 2 isotretinoin cap 10 mg 2 isotretinoin cap 20 mg 2 isotretinoin cap 40 mg 2 myorisan cap 10mg 2 myorisan cap 20mg 2 myorisan cap 30mg 2 myorisan cap 40mg 2 sulfacetamide sodium lotion 10% (acne) 2 tretinoin cream 0.1% 2 tretinoin cream 0.05% 2 tretinoin cream 0.025% 2 TRETINOIN GEL 0.01% 2 PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

105

Nombre del medicamento tretinoin gel 0.025% zenatane cap 10mg zenatane cap 20mg zenatane cap 30mg zenatane cap 40mg

Nivel del Requisitos/Límites medicamento 2 2 2 2 2

DERMATOLOGÍA, ANTIBIÓTICOS gentamicin sulfate cream 0.1% gentamicin sulfate oint 0.1% mupirocin oint 2% SILVER SULFADIAZINE CREAM 1% SSD CRE 1% SULFAMYLON CRE 85MG/GM SULFAMYLON PAK 5%

2 2 1 2 2 4 5

DERMATOLOGÍA, ANTIMICÓTICOS ciclopirox gel 0.77% ciclopirox olamine cream 0.77% (base equiv) ciclopirox olamine susp 0.77% (base equiv) ciclopirox shampoo 1% clotrimazole cream 1% clotrimazole soln 1% econazole nitrate cream 1% ketoconazole cream 2% nyamyc pow 100000 nystatin cream 100000 unit/gm nystatin oint 100000 unit/gm nystatin topical powder nystop pow 100000

2 2 2 2 2 2 2 2 2 2 2 2 2

DERMATOLOGÍA, ANTIPRURIGINOSOS DOXEPIN HCL CREAM 5% hydrocortisone rectal cream 2.5% procto-med cre hc 2.5% procto-pak cre 1% proctozone cre -hc 2.5% PRUDOXIN CRE 5%

2 2 2 2 2 2

DERMATOLOGÍA, ANTIPSORIÁSICOS acitretin cap 10 mg acitretin cap 17.5 mg acitretin cap 25 mg calcipotriene cream 0.005% calcipotriene oint 0.005%

5 5 5 2 2

PA PA PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

106

Nombre del medicamento calcipotriene soln 0.005% (50 mcg/ml) calcitrene oin 0.005% 8-MOP CAP 10MG TAZORAC CRE 0.1% TAZORAC CRE 0.05%

Nivel del Requisitos/Límites medicamento 2 2 4 4 PA 4 PA

DERMATOLOGÍA, ANTISEBORREICOS ketoconazole shampoo 2% selenium sulfide lotion 2.5%

1 1

DERMATOLOGÍA, CORTICOESTEROIDES ala cort cre 1% 1 alclometasone dipropionate cream 0.05%2 alclometasone dipropionate oint 0.05% 2 betamethasone dipropionate augmented 2 cream 0.05% betamethasone dipropionate augmented 2 gel 0.05% betamethasone dipropionate augmented 2 lotion 0.05% betamethasone dipropionate augmented 2 oint 0.05% betamethasone dipropionate cream 2 0.05% betamethasone dipropionate lotion 2 0.05% betamethasone dipropionate oint 0.05% 2 betamethasone valerate cream 0.1% 2 betamethasone valerate lotion 0.1% 2 betamethasone valerate oint 0.1% 2 clobetasol propionate cream 0.05% 2 clobetasol propionate emollient base 2 cream 0.05% clobetasol propionate gel 0.05% 2 clobetasol propionate oint 0.05% 2 clobetasol propionate soln 0.05% 2 cormax scalp sol 0.05% 2 DESONIDE CREAM 0.05% 2 desonide lotion 0.05% 2 desonide oint 0.05% 2 desoximetasone cream 0.05% 2 desoximetasone cream 0.25% 2 desoximetasone gel 0.05% 2 DESOXIMETASONE OINT 0.05% 2 PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

107

Nombre del medicamento desoximetasone oint 0.25% diflorasone diacetate cream 0.05% diflorasone diacetate oint 0.05% fluocin acet oil body fluocin acet oil scalp fluocinolone acetonide cream 0.01% fluocinolone acetonide cream 0.025% fluocinolone acetonide oint 0.025% fluocinolone acetonide soln 0.01% fluocinonide cream 0.05% fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05% fluticasone propionate cream 0.05% fluticasone propionate oint 0.005% halobetasol propionate cream 0.05% halobetasol propionate oint 0.05% hydrocortisone butyrate cream 0.1% hydrocortisone butyrate oint 0.1% hydrocortisone butyrate soln 0.1% hydrocortisone cream 1% hydrocortisone cream 2.5% hydrocortisone lotion 2.5% hydrocortisone oint 1% hydrocortisone oint 2.5% hydrocortisone valerate cream 0.2% hydrocortisone valerate oint 0.2% lokara lot 0.05% mometasone furoate cream 0.1% mometasone furoate oint 0.1% mometasone furoate solution 0.1% (lotion) texacort sol 2.5% triamcinolone acetonide cream 0.1% triamcinolone acetonide cream 0.5% triamcinolone acetonide cream 0.025% triamcinolone acetonide lotion 0.1% triamcinolone acetonide lotion 0.025% triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5%

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

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

108

Nombre del medicamento triamcinolone acetonide oint 0.025% triderm cre 0.1%

Nivel del Requisitos/Límites medicamento 1 1

DERMATOLOGÍA, ANESTÉSICOS LOCALES lidocaine lidocaine lidocaine lidocaine

hcl gel 2% hcl soln 4% oint 5% patch 5%

lidocaine-prilocaine cream 2.5-2.5%

2 1 2 2 2

QL (3 patches / 1 day), PA B/D

DERMATOLOGÍA, DIVERSOS PARA LA PIEL Y LA MEMBRANA MUCOSA acyclovir oint 5% diclofenac sodium gel 1% ELIDEL CRE 1% fluorouracil cream 5% fluorouracil soln 2% fluorouracil soln 5% imiquimod cream 5% lactic acid (ammonium lactate) cream 12% lactic acid (ammonium lactate) lotion 12% metronidazole cream 0.75% metronidazole gel 0.75% metronidazole lotion 0.75% PANRETIN GEL 0.1% podofilox soln 0.5% rosadan cre 0.75% tacrolimus oint 0.1% tacrolimus oint 0.03% TARGRETIN GEL 1% VALCHLOR GEL 0.016% VOLTAREN GEL 1%

2 2 4 2 2 2 2 2

PA

2 2 2 2 5 2 2 2 2 5 5 3

PA PA NM, PA NM, LA, PA

DERMATOLOGÍA, ESCABICIDAS Y PEDICULICIDAS EURAX CRE 10% EURAX LOT 10% malathion lotion 0.5% permethrin cream 5%

4 4 2 2

DERMATOLOGÍA, AGENTES PARA EL CUIDADO DE LESIONES acetic acid irrigation soln 0.25% REGRANEX GEL 0.01% SANTYL OIN 250/GM

1 5 4

PA

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

109

Nombre del medicamento SODIUM CHLORIDE IRRIGATION SOLN 0.9% WATER FOR IRRIGATION, STERILE IRRIGATION SOLN

Nivel del Requisitos/Límites medicamento 1 2

AGENTES PARA BOCA/GARGANTA/DIENTES cevimeline hcl cap 30 mg chlorhexidine gluconate soln 0.12% clotrimazole troche 10 mg lidocaine hcl viscous soln 2% nystatin susp 100000 unit/ml periogard sol 0.12% PILOCARPINE HCL TAB 5 MG pilocarpine hcl tab 7.5 mg triamcinolone acetonide dental paste 0.1%

2 1 2 1 2 1 2 2 2

ÓTICOS acetic acid 2% in aluminum acetate otic soln acetic acid otic soln 2% CIPRODEX SUS 0.3-0.1% fluocinolone acetonide (otic) oil 0.01% neomycin-polymyxin-hc otic soln 1% neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ofloxacin otic soln 0.3%

2 2 3 2 2 2 2

PA: Autorización previa; QL: Límites de cantidad ; ST: Terapia escalonada; NM: No disponible para venta por correo; B/D: Cubierto por las Partes B o D de Medicare; LA: Acceso limitado

110

Índice 8 8-MOP CAP 10MG ........................... 107 A abacavir sulfate tab 300 mg (base equiv) ......................................................16 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg .........................18 ABELCET INJ 5MG/ML ........................15 ABILIFY DISC TAB 10MG....................60 ABILIFY MAIN INJ 300MG ..................60 ABILIFY MAIN INJ 400MG ..................61 ABRAXANE INJ 100MG .......................28 acamprosate calcium tab delayed release 333 mg ...........................................69 acarbose tab 100 mg.........................71 acarbose tab 25 mg ..........................71 acarbose tab 50 mg ..........................71 acebutolol hcl cap 200 mg .................41 acebutolol hcl cap 400 mg .................41 acetaminophen w/ codeine soln 120-12 mg/5ml ............................................ 9 acetaminophen w/ codeine tab 300-15 mg ....................................................... 9 acetaminophen w/ codeine tab 300-30 mg ....................................................... 9 acetaminophen w/ codeine tab 300-60 mg ....................................................... 9 acetazolamide cap sr 12hr 500 mg ......45 acetazolamide tab 125 mg .................45 acetazolamide tab 250 mg .................45 acetic acid 2% in aluminum acetate otic soln............................................... 110 acetic acid irrigation soln 0.25% ....... 109 acetic acid otic soln 2% ................... 110 acetylcysteine inhal soln 10% ........... 103 acetylcysteine inhal soln 20% ........... 103 acitretin cap 10 mg ......................... 106 acitretin cap 17.5 mg ...................... 106 acitretin cap 25 mg ......................... 106 ACTHIB INJ ......................................94 ACTIMMUNE INJ 2MU/0.5...................93 acyclovir cap 200 mg ........................19 acyclovir oint 5% ............................ 109 acyclovir sodium for inj 500 mg ..........19 acyclovir sodium iv soln 50 mg/ml ......19

acyclovir susp 200 mg/5ml ................ 19 acyclovir tab 400 mg ........................ 19 acyclovir tab 800 mg ........................ 19 ADACEL INJ ..................................... 94 ADAGEN INJ 250/ML ......................... 76 adapalene cream 0.1% ................... 105 adapalene gel 0.1%........................ 105 adefovir dipivoxil tab 10 mg .............. 19 ADEMPAS TAB 0.5MG ....................... 47 ADEMPAS TAB 1.5MG ....................... 47 ADEMPAS TAB 1MG .......................... 47 ADEMPAS TAB 2.5MG ....................... 47 ADEMPAS TAB 2MG .......................... 47 adrucil inj 2.5g/50m ......................... 27 adrucil inj 500/10ml ......................... 27 adrucil inj 5gm/100m ....................... 27 ADVAIR DISKU AER 100/50 ............. 104 ADVAIR DISKU AER 250/50 ............. 104 ADVAIR DISKU AER 500/50 ............. 104 ADVAIR HFA AER 115/21 ................ 104 ADVAIR HFA AER 230/21 ................ 104 ADVAIR HFA AER 45/21 .................. 104 afeditab tab 30mg cr ........................ 43 afeditab tab 60mg cr ........................ 43 AFINITOR DIS TAB 2MG .................... 30 AFINITOR DIS TAB 3MG .................... 30 AFINITOR DIS TAB 5MG .................... 30 AFINITOR TAB 10MG ........................ 30 AFINITOR TAB 2.5MG ....................... 30 AFINITOR TAB 5MG .......................... 30 AFINITOR TAB 7.5MG ....................... 30 AGGRENOX CAP 25-200MG ............... 91 a-hydrocort inj 100mg ...................... 78 ala cort cre 1% .............................. 107 ALBENZA TAB 200MG ....................... 13 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) ....................................... 102 albuterol sulfate soln nebu 0.5% (5 mg/ml) ......................................... 102 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) .................................. 102 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) .................................. 102 albuterol sulfate syrup 2 mg/5ml ..... 102 albuterol sulfate tab 2 mg ............... 102 111

albuterol sulfate tab 4 mg ................ 102 albuterol sulfate tab sr 12hr 4 mg ..... 102 albuterol sulfate tab sr 12hr 8 mg ..... 102 alclometasone dipropionate cream 0.05% .................................................... 107 alclometasone dipropionate oint 0.05% .................................................... 107 ALCOHOL SWABS .............................70 ALDURAZYME INJ 2.9MG/5M ..............76 ALECENSA CAP 150MG ......................30 alendronate sodium tab 10 mg ...........72 alendronate sodium tab 35 mg ...........72 alendronate sodium tab 40 mg ...........72 alendronate sodium tab 5 mg .............72 alendronate sodium tab 70 mg ...........72 alfuzosin hcl tab sr 24hr 10 mg...........87 ALIMTA INJ 100MG ...........................27 ALIMTA INJ 500MG ...........................27 ALINIA SUS 100/5ML ........................13 ALINIA TAB 500MG ...........................13 allopurinol tab 100 mg........................ 8 allopurinol tab 300 mg........................ 8 alosetron hcl tab 0.5 mg (base equiv) .86 alosetron hcl tab 1 mg (base equiv) ....86 ALPHAGAN P SOL 0.1% ................... 101 alprazolam tab 0.25 mg .....................48 alprazolam tab 0.5 mg.......................48 alprazolam tab 1 mg .........................48 alprazolam tab 2 mg .........................48 ALREX SUS 0.2% ............................ 100 altavera tab .....................................73 amantadine hcl cap 100 mg ...............59 amantadine hcl syrup 50 mg/5ml ........59 amantadine hcl tab 100 mg ................59 AMBISOME INJ 50MG ........................15 amifostine crystalline for inj 500 mg....33 amikacin sulfate inj 1 gm/4ml (250 mg/ml) ............................................12 amikacin sulfate inj 500 mg/2ml (250 mg/ml) ............................................12 amiloride & hydrochlorothiazide tab 5-50 mg ..................................................45 amiloride hcl tab 5 mg .......................45 amino acid infusion 6% .....................96 aminophylline inj 25 mg/ml .............. 104 AMINOSYN 7% INJ /LYTES .................96

AMINOSYN II INJ 10% ...................... 96 AMINOSYN II INJ 7% ........................ 96 AMINOSYN II INJ 8.5% ..................... 96 AMINOSYN II INJ 8.5/LYTE ................ 96 AMINOSYN INJ 10% ......................... 96 AMINOSYN INJ 8.5% ........................ 96 AMINOSYN INJ 8.5/LYTE ................... 96 AMINOSYN M INJ 3.5% ..................... 96 AMINOSYN-HBC INJ 7% .................... 96 AMINOSYN-PF INJ 10% ..................... 96 AMINOSYN-PF INJ 7% ...................... 96 AMINOSYN-RF INJ 5.2% ................... 96 amiodarone hcl inj 150 mg/3ml (50 mg/ml) ........................................... 38 amiodarone hcl inj 450 mg/9ml (50 mg/ml) ........................................... 38 amiodarone hcl inj 900 mg/18ml (50 mg/ml) ........................................... 38 amiodarone hcl tab 100 mg ............... 38 amiodarone hcl tab 200 mg ............... 38 amiodarone hcl tab 400 mg ............... 38 AMITIZA CAP 24MCG ........................ 86 AMITIZA CAP 8MCG .......................... 86 amitriptyline hcl tab 10 mg ................ 55 amitriptyline hcl tab 100 mg .............. 55 amitriptyline hcl tab 150 mg .............. 55 amitriptyline hcl tab 25 mg ................ 55 amitriptyline hcl tab 50 mg ................ 55 amitriptyline hcl tab 75 mg ................ 55 amlodipine besylate tab 10 mg .......... 43 amlodipine besylate tab 2.5 mg ......... 43 amlodipine besylate tab 5 mg ............ 43 amlodipine besylate-benazepril hcl cap 10-20 mg ........................................ 34 amlodipine besylate-benazepril hcl cap 10-40 mg ........................................ 34 amlodipine besylate-benazepril hcl cap 2.5-10 mg ....................................... 34 amlodipine besylate-benazepril hcl cap 5-10 mg.......................................... 34 amlodipine besylate-benazepril hcl cap 5-20 mg.......................................... 34 amlodipine besylate-benazepril hcl cap 5-40 mg.......................................... 34 amlodipine besylate-valsartan tab 10-160 mg ................................................. 36 112

amlodipine besylate-valsartan tab 10-320 mg ..................................................37 amlodipine besylate-valsartan tab 5-160 mg ..................................................36 amlodipine besylate-valsartan tab 5-320 mg ..................................................36 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ..........................37 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg ............................37 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg ............................37 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg ...........................37 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg ..............................37 amoxapine tab 100 mg ......................55 amoxapine tab 150 mg ......................55 amoxapine tab 25 mg........................55 amoxapine tab 50 mg........................55 amoxicillin & k clavulanate chew tab 200-28.5 mg ....................................23 amoxicillin & k clavulanate chew tab 400-57 mg .......................................23 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml .............................23 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml .............................23 amoxicillin & k clavulanate for susp 400-57 mg/5ml ................................24 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml .............................24 amoxicillin & k clavulanate tab 250-125 mg ..................................................24 amoxicillin & k clavulanate tab 500-125 mg ..................................................24 amoxicillin & k clavulanate tab 875-125 mg ..................................................24 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg ..................................24 amoxicillin (trihydrate) cap 250 mg .....24 amoxicillin (trihydrate) cap 500 mg .....24 amoxicillin (trihydrate) chew tab 125 mg ......................................................24 amoxicillin (trihydrate) chew tab 250 mg ......................................................24

amoxicillin (trihydrate) for susp 125 mg/5ml ........................................... 24 amoxicillin (trihydrate) for susp 200 mg/5ml ........................................... 24 amoxicillin (trihydrate) for susp 250 mg/5ml ........................................... 24 amoxicillin (trihydrate) for susp 400 mg/5ml ........................................... 24 amoxicillin (trihydrate) tab 500 mg .... 24 amoxicillin (trihydrate) tab 875 mg .... 24 amphetamine-dextroamphetamine cap sr 24hr 10 mg ..................................... 65 amphetamine-dextroamphetamine cap sr 24hr 15 mg ..................................... 65 amphetamine-dextroamphetamine cap sr 24hr 20 mg ..................................... 65 amphetamine-dextroamphetamine cap sr 24hr 25 mg ..................................... 65 amphetamine-dextroamphetamine cap sr 24hr 30 mg ..................................... 66 amphetamine-dextroamphetamine cap sr 24hr 5 mg ....................................... 65 amphetamine-dextroamphetamine tab 10 mg ................................................. 66 amphetamine-dextroamphetamine tab 12.5 mg .......................................... 66 amphetamine-dextroamphetamine tab 15 mg ................................................. 66 amphetamine-dextroamphetamine tab 20 mg ................................................. 66 amphetamine-dextroamphetamine tab 30 mg ................................................. 66 amphetamine-dextroamphetamine tab 5 mg ................................................. 66 amphetamine-dextroamphetamine tab 7.5 mg............................................ 66 amphotericin b for inj 50 mg ............. 15 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ...................................... 24 ampicillin & sulbactam sodium for inj 15 (10-5) gm ....................................... 24 ampicillin & sulbactam sodium for inj 3 (2-1) gm ......................................... 24 ampicillin & sulbactam sodium for iv soln 15 (10-5) gm................................... 24 ampicillin & sulbactam sodium for iv soln 3 113

(2-1) gm .........................................24 ampicillin cap 250 mg........................24 ampicillin cap 500 mg........................24 ampicillin for susp 125 mg/5ml ...........24 ampicillin for susp 250 mg/5ml ...........24 ampicillin sodium for inj 1 gm.............24 ampicillin sodium for inj 125 mg .........24 ampicillin sodium for inj 2 gm.............24 ampicillin sodium for inj 250 mg .........24 ampicillin sodium for inj 500 mg .........25 ampicillin sodium for iv soln 1 gm .......25 ampicillin sodium for iv soln 10 gm .....25 ampicillin sodium for iv soln 2 gm .......25 AMPYRA TAB 10MG ...........................68 anagrelide hcl cap 0.5 mg ..................90 anagrelide hcl cap 1 mg .....................90 anastrozole tab 1 mg ........................29 ANDRODERM DIS 2MG/24HR..............70 ANDRODERM DIS 4MG/24HR..............70 ANORO ELLIPT AER 62.5-25 ............. 101 APOKYN INJ 10MG/ML .......................59 apri tab ...........................................73 APRISO CAP 0.375GM .......................85 APTIOM TAB 200MG ..........................49 APTIOM TAB 400MG ..........................49 APTIOM TAB 600MG ..........................49 APTIOM TAB 800MG ..........................49 APTIVUS CAP 250MG .........................16 APTIVUS SOL ...................................16 ARALAST NP INJ 1000MG ................. 103 ARALAST NP INJ 500MG .................. 103 aranelle tab ......................................73 ARCALYST INJ 220MG .......................93 aripiprazole oral solution 1 mg/ml .......61 aripiprazole orally disintegrating tab 10 mg ..................................................61 aripiprazole orally disintegrating tab 15 mg ..................................................61 aripiprazole tab 10 mg.......................61 aripiprazole tab 15 mg.......................61 aripiprazole tab 2 mg ........................61 aripiprazole tab 20 mg.......................61 aripiprazole tab 30 mg.......................61 aripiprazole tab 5 mg ........................61 armodafinil tab 150 mg .....................69 ARMODAFINIL TAB 200 MG ................69

armodafinil tab 250 mg ..................... 69 armodafinil tab 50 mg ...................... 69 ARNUITY ELPT INH 100MCG ............ 104 ARNUITY ELPT INH 200MCG ............ 104 ASACOL HD TAB 800MG .................... 85 ASPIRIN-DIPYRIDAMOLE CAP SR 12HR 25-200 MG ...................................... 91 ASTEPRO SPR 0.15% ...................... 102 atenolol & chlorthalidone tab 100-25 mg ...................................................... 41 atenolol & chlorthalidone tab 50-25 mg ...................................................... 41 atenolol tab 100 mg ......................... 41 atenolol tab 25 mg ........................... 41 atenolol tab 50 mg ........................... 41 atorvastatin calcium tab 10 mg (base equivalent) ...................................... 39 atorvastatin calcium tab 20 mg (base equivalent) ...................................... 39 atorvastatin calcium tab 40 mg (base equivalent) ...................................... 39 atorvastatin calcium tab 80 mg (base equivalent) ...................................... 39 atovaquone susp 750 mg/5ml ............ 13 atovaquone-proguanil hcl tab 250-100 mg ...................................................... 16 atovaquone-proguanil hcl tab 62.5-25 mg ...................................................... 16 ATRIPLA TAB ................................... 18 ATROVENT HFA AER 17MCG ............ 102 aubra tab 0.1-0.02 ........................... 73 AVASTIN INJ ................................... 29 AVASTIN INJ 400/16ML..................... 29 aviane tab ....................................... 73 AVITA CRE 0.025% ........................ 105 AVITA GEL 0.025% ........................ 105 AXIRON SOL 30MG/ACT .................... 70 azacitidine for inj 100 mg .................. 27 AZACTAM/DEX INJ 1GM .................... 13 AZACTAM/DEX INJ 2GM .................... 13 azathioprine inj 100mg ..................... 93 azathioprine tab 50 mg ..................... 93 azelastine hcl nasal spray 0.1% (137 mcg/spray) ................................... 102 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) ................................... 102 114

azelastine hcl ophth soln 0.05% ....... 100 AZILECT TAB 0.5MG ..........................59 AZILECT TAB 1MG.............................59 azithromycin for susp 100 mg/5ml ......22 azithromycin for susp 200 mg/5ml ......22 azithromycin iv for soln 500 mg ..........22 AZITHROMYCIN POWD PACK FOR SUSP 1 GM ..................................................22 azithromycin tab 250 mg ...................22 azithromycin tab 500 mg ...................22 azithromycin tab 600 mg ...................22 AZOPT SUS 1% OP ......................... 101 AZOR TAB 10-20MG ..........................37 AZOR TAB 10-40MG ..........................37 AZOR TAB 5-20MG ............................37 AZOR TAB 5-40MG ............................37 aztreonam for inj 1 gm ......................13 aztreonam for inj 2 gm ......................13 B bacitracin ophth oint 500 unit/gm .......99 bacitracin-polymyxin b ophth oint .......99 bacitracin-polymyxin-neomycin-hc ophth oint 1% ...........................................99 baclofen tab 10 mg ...........................68 baclofen tab 20 mg ...........................68 balsalazide disodium cap 750 mg ........85 balziva tab .......................................73 BANZEL SUS 40MG/ML ......................49 BANZEL TAB 200MG ..........................49 BANZEL TAB 400MG ..........................49 BARACLUDE SOL .05MG/ML ...............19 BCG VACCINE INJ .............................94 bekyree tab......................................73 BELEODAQ INJ 500MG.......................29 benazepril & hydrochlorothiazide tab 10-12.5 mg ......................................34 benazepril & hydrochlorothiazide tab 20-12.5 mg ......................................34 benazepril & hydrochlorothiazide tab 20-25 mg ........................................34 benazepril & hydrochlorothiazide tab 5-6.25 mg .......................................34 benazepril hcl tab 10 mg ...................35 benazepril hcl tab 20 mg ...................35 benazepril hcl tab 40 mg ...................35 benazepril hcl tab 5 mg .....................35

BENDEKA INJ 100/4ML ..................... 26 BENICAR HCT TAB 20-12.5................ 37 BENICAR HCT TAB 40-12.5................ 37 BENICAR HCT TAB 40-25MG .............. 37 BENICAR TAB 20MG ......................... 38 BENICAR TAB 40MG ......................... 38 BENICAR TAB 5MG ........................... 38 BENLYSTA INJ 120MG ....................... 93 BENLYSTA INJ 400MG ....................... 93 benzoyl peroxide-erythromycin gel 5-3% .................................................... 105 BENZTROPINE MESYLATE INJ 1 MG/ML 59 benztropine mesylate tab 0.5 mg ....... 59 benztropine mesylate tab 1 mg .......... 59 benztropine mesylate tab 2 mg .......... 59 BEPREVE DRO 1.5% ....................... 100 BESIVANCE SUS 0.6% ...................... 99 betamethasone dipropionate augmented cream 0.05%................................. 107 betamethasone dipropionate augmented gel 0.05% ..................................... 107 betamethasone dipropionate augmented lotion 0.05% ................................. 107 betamethasone dipropionate augmented oint 0.05% .................................... 107 betamethasone dipropionate cream 0.05% .......................................... 107 betamethasone dipropionate lotion 0.05% .................................................... 107 betamethasone dipropionate oint 0.05% .................................................... 107 betamethasone valerate cream 0.1% 107 betamethasone valerate lotion 0.1% 107 betamethasone valerate oint 0.1% ... 107 BETASERON INJ 0.3MG ..................... 68 betaxolol hcl ophth soln 0.5% .......... 101 bethanechol chloride tab 10 mg ......... 88 bethanechol chloride tab 25 mg ......... 88 bethanechol chloride tab 5 mg ........... 88 bethanechol chloride tab 50 mg ......... 88 BETOPTIC-S SUS 0.25% OP ............ 101 bexarotene cap 75 mg ...................... 32 BEXSERO INJ ................................... 94 bicalutamide tab 50 mg .................... 29 BICILLIN L-A INJ 1200000 ................ 25 BICILLIN L-A INJ 2400000 ................ 25 115

BICILLIN L-A INJ 600000 ...................25 BICNU INJ 100MG .............................26 BILTRICIDE TAB 600MG ....................13 bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit .......................85 bisoprolol & hydrochlorothiazide tab 10-6.25 mg ......................................41 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg .....................................41 bisoprolol & hydrochlorothiazide tab 5-6.25 mg .......................................41 bisoprolol fumarate tab 10 mg ............41 bisoprolol fumarate tab 5 mg .............41 BIVIGAM INJ 10% .............................92 bleomycin sulfate for inj 15 unit..........27 bleomycin sulfate for inj 30 unit..........27 blephamide oin s.o.p. ........................99 blisovi fe tab 1.5/30 ..........................73 blisovi fe tab 1/20 .............................73 BOOSTRIX INJ ..................................94 BOSULIF TAB 100MG.........................30 BOSULIF TAB 500MG.........................30 BREO ELLIPTA INH 100-25 ............... 104 BREO ELLIPTA INH 200-25 ............... 104 briellyn tab ......................................73 BRILINTA TAB 60MG .........................91 BRILINTA TAB 90MG .........................91 BRIMONIDINE TARTRATE OPHTH SOLN 0.15% ........................................... 101 brimonidine tartrate ophth soln 0.2% 101 BRINTELLIX TAB 10MG ......................55 BRINTELLIX TAB 20MG ......................55 BRINTELLIX TAB 5MG ........................55 BRIVIACT INJ 50MG/5ML ...................49 BRIVIACT SOL 10MG/ML ....................49 BRIVIACT TAB 100MG .......................49 BRIVIACT TAB 10MG .........................49 BRIVIACT TAB 25MG .........................49 BRIVIACT TAB 50MG .........................49 BRIVIACT TAB 75MG .........................49 BROMFENAC SODIUM OPHTH SOLN 0.09% (BASE EQUIV) (ONCE-DAILY) . 100 bromfenac sodium ophth soln 0.09% (base equivalent) ............................ 100 bromocriptine mesylate cap 5 mg (base equivalent) ......................................59

bromocriptine mesylate tab 2.5 mg (base equivalent) ...................................... 59 budesonide delayed release particles cap 3 mg .............................................. 85 budesonide inhalation susp 0.25 mg/2ml .................................................... 104 budesonide inhalation susp 0.5 mg/2ml .................................................... 104 bumetanide inj 0.25 mg/ml ............... 45 bumetanide tab 0.5 mg ..................... 45 bumetanide tab 1 mg ....................... 45 bumetanide tab 2 mg ....................... 45 BUPHENYL TAB 500MG ..................... 76 buprenorphine hcl sl tab 2 mg (base equiv) ............................................. 69 buprenorphine hcl sl tab 8 mg (base equiv) ............................................. 69 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) ...................... 69 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)............................... 69 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg ................................... 69 bupropion hcl tab 100 mg ................. 55 bupropion hcl tab 75 mg ................... 55 bupropion hcl tab sr 12hr 100 mg ...... 55 bupropion hcl tab sr 12hr 150 mg ...... 55 bupropion hcl tab sr 12hr 200 mg ...... 55 bupropion hcl tab sr 24hr 150 mg ...... 55 bupropion hcl tab sr 24hr 300 mg ...... 55 buspirone hcl tab 10 mg ................... 48 buspirone hcl tab 15 mg ................... 48 buspirone hcl tab 30 mg ................... 48 buspirone hcl tab 5 mg ..................... 48 buspirone hcl tab 7.5 mg .................. 48 BUSULFEX INJ 6MG/ML ..................... 26 butorphanol tartrate inj 1 mg/ml .......... 9 butorphanol tartrate inj 2 mg/ml .......... 9 BYDUREON INJ 2MG ......................... 70 BYDUREON PEN INJ 2MG................... 70 BYETTA INJ 10MCG .......................... 70 BYETTA INJ 5MCG ............................ 70 BYSTOLIC TAB 10MG ........................ 42 BYSTOLIC TAB 2.5MG ....................... 42 BYSTOLIC TAB 20MG ........................ 42 BYSTOLIC TAB 5MG .......................... 42 116

C cabergoline tab 0.5 mg ......................80 CABOMETYX TAB 20MG .....................31 CABOMETYX TAB 40MG .....................31 CABOMETYX TAB 60MG .....................31 calcipotriene cream 0.005% ............. 106 calcipotriene oint 0.005% ................ 106 calcipotriene soln 0.005% (50 mcg/ml) .................................................... 107 calcitonin (salmon) nasal soln 200 unit/act ......................................................80 calcitrene oin 0.005%...................... 107 calcitriol cap 0.25 mcg .......................99 calcitriol cap 0.5 mcg ........................99 calcitriol inj 1 mcg/ml ........................99 calcitriol oral soln 1 mcg/ml ...............99 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) .........................81 calcium acetate (phosphate binder) tab 667 mg ...........................................81 camila tab 0.35mg ............................73 CANASA SUP 1000MG .......................85 CANCIDAS INJ 50MG .........................15 CANCIDAS INJ 70MG .........................15 CAPASTAT SUL INJ 1GM ....................19 CAPRELSA TAB 100MG ......................31 CAPRELSA TAB 300MG ......................31 captopril & hydrochlorothiazide tab 25-15 mg ..................................................34 captopril & hydrochlorothiazide tab 25-25 mg ..................................................34 captopril & hydrochlorothiazide tab 50-15 mg ..................................................34 captopril & hydrochlorothiazide tab 50-25 mg ..................................................34 captopril tab 100 mg .........................35 captopril tab 12.5 mg ........................35 captopril tab 25 mg ...........................35 captopril tab 50 mg ...........................35 CARBAGLU TAB 200MG ......................77 carbamazepine cap sr 12hr 100 mg.....49 carbamazepine cap sr 12hr 200 mg.....49 carbamazepine cap sr 12hr 300 mg.....49 carbamazepine chew tab 100 mg ........49 carbamazepine susp 100 mg/5ml........49 carbamazepine tab 200 mg ................49

carbamazepine tab sr 12hr 100 mg .... 49 carbamazepine tab sr 12hr 200 mg .... 49 carbamazepine tab sr 12hr 400 mg .... 49 carbidopa & levodopa orally disintegrating tab 10-100 mg................................. 59 carbidopa & levodopa orally disintegrating tab 25-100 mg................................. 59 carbidopa & levodopa orally disintegrating tab 25-250 mg................................. 59 carbidopa & levodopa tab 10-100 mg . 60 carbidopa & levodopa tab 25-100 mg . 60 carbidopa & levodopa tab 25-250 mg . 60 carbidopa & levodopa tab cr 25-100 mg ...................................................... 60 carbidopa & levodopa tab cr 50-200 mg ...................................................... 60 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG ...................... 60 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG .................... 60 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 25-100-200 MG ....................... 60 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 31.25-125-200 MG .................. 60 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG .................... 60 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG ....................... 60 carboplatin iv soln 150 mg/15ml ........ 33 carboplatin iv soln 450 mg/45ml ........ 33 carboplatin iv soln 50 mg/5ml ............ 33 carboplatin iv soln 600 mg/60ml ........ 33 CARIMUNE NF INJ 12GM ................... 92 CARIMUNE NF INJ 6GM ..................... 92 carteolol hcl ophth soln 1% ............. 101 carvedilol tab 12.5 mg ...................... 42 carvedilol tab 25 mg ......................... 42 carvedilol tab 3.125 mg .................... 42 carvedilol tab 6.25 mg ...................... 42 CAYSTON INH 75MG ......................... 13 caziant pak ...................................... 74 cefaclor cap 250 mg ......................... 20 cefaclor cap 500 mg ......................... 20 cefaclor er tab 500mg ....................... 20 cefaclor for susp 125 mg/5ml ............ 21 cefaclor for susp 250 mg/5ml ............ 21 117

cefaclor for susp 375 mg/5ml .............21 cefadroxil cap 500 mg .......................21 cefadroxil for susp 250 mg/5ml ..........21 cefadroxil for susp 500 mg/5ml ..........21 cefadroxil tab 1 gm ...........................21 cefazolin inj 1gm/50ml ......................21 cefazolin sodium for inj 1 gm..............21 cefazolin sodium for inj 10 gm ............21 cefazolin sodium for inj 20 gm ............21 cefazolin sodium for inj 500 mg ..........21 cefazolin sodium for iv soln 1 gm ........21 CEFAZOLIN SOL ...............................21 cefdinir cap 300 mg ..........................21 cefdinir for susp 125 mg/5ml..............21 cefdinir for susp 250 mg/5ml..............21 cefepime hcl for inj 1 gm ...................21 cefepime hcl for inj 2 gm ...................21 cefixime for susp 100 mg/5ml ............21 cefixime for susp 200 mg/5ml ............21 cefotaxime sodium for inj 1 gm ..........21 cefotaxime sodium for inj 2 gm ..........21 cefotaxime sodium for inj 500 mg .......21 cefoxitin sodium for inj 10 gm ............21 cefoxitin sodium for iv soln 1 gm ........21 cefoxitin sodium for iv soln 2 gm ........21 cefpodoxime proxetil for susp 100 mg/5ml ......................................................21 cefpodoxime proxetil for susp 50 mg/5ml ......................................................21 cefpodoxime proxetil tab 100 mg ........21 cefpodoxime proxetil tab 200 mg ........21 cefprozil for susp 125 mg/5ml ............21 cefprozil for susp 250 mg/5ml ............21 cefprozil tab 250 mg .........................21 cefprozil tab 500 mg .........................21 ceftazidime for inj 1 gm .....................21 ceftazidime for inj 2 gm .....................21 ceftazidime for inj 6 gm .....................21 CEFTAZIDIME/ SOL D5W 1GM ............21 CEFTAZIDIME/ SOL D5W 2GM ............21 ceftriaxone sodium for inj 1 gm ..........21 ceftriaxone sodium for inj 10 gm ........22 ceftriaxone sodium for inj 2 gm ..........22 ceftriaxone sodium for inj 250 mg .......22 ceftriaxone sodium for inj 500 mg .......22 ceftriaxone sodium for iv soln 1 gm .....22

ceftriaxone sodium for iv soln 2 gm .... 22 cefuroxime axetil tab 250 mg ............ 22 cefuroxime axetil tab 500 mg ............ 22 cefuroxime sodium for inj 1.5 gm ....... 22 cefuroxime sodium for inj 7.5 gm ....... 22 cefuroxime sodium for inj 750 mg ...... 22 cefuroxime sodium for iv soln 1.5 gm . 22 celecoxib cap 100 mg ......................... 8 celecoxib cap 200 mg ......................... 8 celecoxib cap 400 mg ......................... 8 celecoxib cap 50 mg ........................... 8 CELONTIN CAP 300MG ...................... 49 cephalexin cap 250 mg ..................... 22 cephalexin cap 500 mg ..................... 22 cephalexin for susp 125 mg/5ml ........ 22 cephalexin for susp 250 mg/5ml ........ 22 CERDELGA CAP 84MG ....................... 77 CEREZYME INJ 200UNIT .................... 77 CEREZYME INJ 400UNIT .................... 77 CERVARIX INJ .................................. 94 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) ....................................... 102 cevimeline hcl cap 30 mg ................ 110 CHANTIX PAK 0.5& 1MG ................... 69 CHANTIX PAK 1MG ........................... 69 CHANTIX TAB 0.5MG ........................ 69 CHANTIX TAB 1MG ........................... 69 CHEMET CAP 100MG ......................... 73 chlorhexidine gluconate soln 0.12%.. 110 chloroquine phosphate tab 250 mg ..... 16 chloroquine phosphate tab 500 mg ..... 16 chlorothiazide tab 250 mg ................. 45 chlorothiazide tab 500 mg ................. 45 chlorpromaz inj 25mg/ml .................. 61 chlorpromaz inj 50mg/2ml ................ 61 chlorpromazine hcl tab 10 mg ............ 61 chlorpromazine hcl tab 100 mg .......... 61 chlorpromazine hcl tab 200 mg .......... 61 chlorpromazine hcl tab 25 mg ............ 61 chlorpromazine hcl tab 50 mg ............ 61 chlorthalidone tab 25 mg .................. 45 chlorthalidone tab 50 mg .................. 45 cholestyramine light powder 4 gm/dose ...................................................... 40 cholestyramine light powder packets 4 gm ...................................................... 40 118

cholestyramine powder 4 gm/dose ......40 cholestyramine powder packets 4 gm ..40 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) ........................40 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) ........................40 ciclopirox gel 0.77% ........................ 106 ciclopirox olamine cream 0.77% (base equiv) ........................................... 106 ciclopirox olamine susp 0.77% (base equiv) ........................................... 106 ciclopirox shampoo 1% .................... 106 cilostazol tab 100 mg ........................90 cilostazol tab 50 mg ..........................90 CILOXAN OIN 0.3% OP ......................99 CIMZIA KIT ......................................91 CIMZIA KIT STARTER ........................91 CIMZIA PREFL KIT 200MG/ML.............91 CINRYZE SOL 500 UNIT .....................91 CIPRODEX SUS 0.3-0.1% ................ 110 ciprofloxacin 200 mg/100ml in d5w .....23 ciprofloxacin 400 mg/200ml in d5w .....23 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) ..........................23 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) .......................23 ciprofloxacin hcl ophth soln 0.3% ........99 ciprofloxacin hcl tab 100 mg (base equiv) ......................................................23 ciprofloxacin hcl tab 250 mg (base equiv) ......................................................23 ciprofloxacin hcl tab 500 mg (base equiv) ......................................................23 ciprofloxacin hcl tab 750 mg (base equiv) ......................................................23 ciprofloxacin iv soln 200 mg/20ml (1%) ......................................................23 ciprofloxacin iv soln 400 mg/40ml (1%) ......................................................23 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) ............................23 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) .............................23 cisplatin inj 100 mg/100ml (1 mg/ml) .33 cisplatin inj 200 mg/200ml (1 mg/ml) .33 cisplatin inj 50 mg/50ml (1 mg/ml) .....33

citalopram hydrobromide oral soln 10 mg/5ml ........................................... 55 citalopram hydrobromide tab 10 mg (base equiv) ............................................. 56 citalopram hydrobromide tab 20 mg (base equiv) ............................................. 56 citalopram hydrobromide tab 40 mg (base equiv) ............................................. 56 cladribine iv soln 10 mg/10ml (1 mg/ml) ...................................................... 27 claravis cap 10mg .......................... 105 claravis cap 20mg .......................... 105 claravis cap 30mg .......................... 105 claravis cap 40mg .......................... 105 clarithromycin for susp 125 mg/5ml ... 22 clarithromycin for susp 250 mg/5ml ... 22 clarithromycin tab 250 mg ................ 22 clarithromycin tab 500 mg ................ 22 clarithromycin tab sr 24hr 500 mg ..... 22 clindamax gel 1%........................... 105 clindamycin hcl cap 150 mg ............... 13 clindamycin hcl cap 300 mg ............... 13 clindamycin hcl cap 75 mg ................ 13 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) ........................ 13 clindamycin phosphate gel 1% ......... 105 clindamycin phosphate in d5w iv soln 300 mg/50ml ......................................... 13 clindamycin phosphate in d5w iv soln 600 mg/50ml ......................................... 13 clindamycin phosphate in d5w iv soln 900 mg/50ml ......................................... 13 clindamycin phosphate inj 300 mg/2ml 13 clindamycin phosphate inj 600 mg/4ml 13 clindamycin phosphate inj 9 gm/60ml . 13 clindamycin phosphate inj 900 mg/6ml 13 clindamycin phosphate iv soln 300 mg/2ml ........................................... 13 clindamycin phosphate iv soln 600 mg/4ml ........................................... 13 clindamycin phosphate iv soln 900 mg/6ml ........................................... 14 clindamycin phosphate lotion 1% ..... 105 clindamycin phosphate soln 1% ....... 105 clindamycin phosphate swab 1% ...... 105 clindamycin phosphate vaginal cream 2% 119

......................................................88 CLINIMIX INJ 2.75/D5W ....................96 CLINIMIX INJ 4.25/D10 .....................96 CLINIMIX INJ 4.25/D20 .....................96 CLINIMIX INJ 4.25/D25 .....................97 CLINIMIX INJ 4.25/D5W ....................96 CLINIMIX INJ 5%/D15W ....................97 CLINIMIX INJ 5%/D20W ....................97 CLINIMIX INJ 5%/D25W ....................97 clobetasol propionate cream 0.05% .. 107 clobetasol propionate emollient base cream 0.05% ................................. 107 clobetasol propionate gel 0.05% ....... 107 clobetasol propionate oint 0.05% ...... 107 clobetasol propionate soln 0.05% ..... 107 clomipramine hcl cap 25 mg ...............56 clomipramine hcl cap 50 mg ...............56 clomipramine hcl cap 75 mg ...............56 clonazepam orally disintegrating tab 0.125 mg .........................................49 clonazepam orally disintegrating tab 0.25 mg ..................................................49 clonazepam orally disintegrating tab 0.5 mg ..................................................49 clonazepam orally disintegrating tab 1 mg ......................................................49 clonazepam orally disintegrating tab 2 mg ......................................................49 clonazepam tab 0.5 mg .....................49 clonazepam tab 1 mg ........................50 clonazepam tab 2 mg ........................50 clonidine hcl tab 0.1 mg.....................46 clonidine hcl tab 0.2 mg.....................46 clonidine hcl tab 0.3 mg.....................46 clonidine hcl td patch weekly 0.1 mg/24hr ......................................................46 clonidine hcl td patch weekly 0.2 mg/24hr ......................................................46 clonidine hcl td patch weekly 0.3 mg/24hr ......................................................46 clopidogrel bisulfate tab 75 mg (base equiv) .............................................91 clorazepate dipotassium tab 15 mg .....50 clorazepate dipotassium tab 3.75 mg ..50 clorazepate dipotassium tab 7.5 mg ....50 clotrimazole cream 1% .................... 106

clotrimazole soln 1% ...................... 106 clotrimazole troche 10 mg ............... 110 CLOZAPINE ORALLY DISINTEGRATING TAB 100 MG .................................... 61 CLOZAPINE ORALLY DISINTEGRATING TAB 12.5 MG ................................... 61 CLOZAPINE ORALLY DISINTEGRATING TAB 150 MG .................................... 61 CLOZAPINE ORALLY DISINTEGRATING TAB 200 MG .................................... 61 CLOZAPINE ORALLY DISINTEGRATING TAB 25 MG ...................................... 61 clozapine tab 100 mg ....................... 61 clozapine tab 200 mg ....................... 61 clozapine tab 25 mg ......................... 61 clozapine tab 50 mg ......................... 61 COARTEM TAB 20-120MG .................. 16 colchicine w/ probenecid tab 0.5-500 mg ........................................................ 8 COLCRYS TAB 0.6MG .......................... 8 colestipol hcl granule packets 5 gm .... 40 colestipol hcl granules 5 gm .............. 40 colestipol hcl tab 1 gm ...................... 40 colistimethate sodium for inj 150 mg .. 14 COMBIGAN SOL 0.2/0.5% ............... 101 COMBIVENT AER 20-100 ................. 102 COMETRIQ KIT 100MG ...................... 31 COMETRIQ KIT 140MG ...................... 31 COMETRIQ KIT 60MG ....................... 31 COMPLERA TAB ................................ 18 compro sup 25mg ............................ 82 COMVAX INJ .................................... 94 constulose sol 10gm/15 .................... 85 COPAXONE INJ 40MG/ML .................. 68 cormax scalp sol 0.05% .................. 107 cortisone acetate tab 25 mg .............. 78 COTELLIC TAB 20MG ........................ 31 COUMADIN TAB 10MG ...................... 89 COUMADIN TAB 1MG ........................ 88 COUMADIN TAB 2.5MG ..................... 89 COUMADIN TAB 2MG ........................ 89 COUMADIN TAB 3MG ........................ 89 COUMADIN TAB 4MG ........................ 89 COUMADIN TAB 5MG ........................ 89 COUMADIN TAB 6MG ........................ 89 COUMADIN TAB 7.5MG ..................... 89 120

CREON CAP 12000UNT ......................86 CREON CAP 24000UNT ......................87 CREON CAP 3000UNIT .......................86 CREON CAP 36000UNT ......................87 CREON CAP 6000UNIT .......................86 CRESTOR TAB 10MG .........................39 CRESTOR TAB 20MG .........................39 CRESTOR TAB 40MG .........................39 CRESTOR TAB 5MG ...........................39 CRIXIVAN CAP 200MG .......................16 CRIXIVAN CAP 400MG .......................16 cromolyn sodium ophth soln 4% ....... 100 cromolyn sodium oral conc 100 mg/5ml ......................................................86 cromolyn sodium soln nebu 20 mg/2ml .................................................... 103 cryselle-28 tab 28 tabs ......................74 CUBICIN SOL 500MG.........................14 CUVPOSA SOL 1MG/5ML ....................84 cyclafem tab 1/35 .............................74 cyclafem tab 7/7/7 ............................74 CYCLOPHOSPH CAP 25MG ..................26 CYCLOPHOSPH CAP 50MG ..................26 cyclophosphamide for inj 1 gm ...........26 cyclophosphamide for inj 2 gm ...........26 cyclophosphamide for inj 500 mg ........26 cycloserine cap 250 mg .....................19 cyclosporine cap 100 mg ...................93 cyclosporine cap 25 mg .....................93 cyclosporine iv soln 50 mg/ml ............93 cyclosporine modified cap 100 mg ......93 cyclosporine modified cap 25 mg ........93 cyclosporine modified cap 50 mg ........93 cyclosporine modified oral soln 100 mg/ml ......................................................93 CYSTADANE POW..............................77 CYSTAGON CAP 150MG .....................77 CYSTAGON CAP 50MG .......................77 cytarabine inj 20 mg/ml ....................27 D D10W/NACL INJ 0.2% .......................97 D5W/LYTES INJ #48 .........................97 D5W/NACL INJ 0.3% .........................97 dacarbazine for inj 100 mg ................26 dacarbazine for inj 200 mg ................26 DAKLINZA TAB 30MG ........................19

DAKLINZA TAB 60MG ....................... 19 DAKLINZA TAB 90MG ....................... 19 DALIRESP TAB 500MCG .................. 103 danazol cap 100 mg ......................... 76 danazol cap 200 mg ......................... 76 danazol cap 50 mg ........................... 76 dantrolene sodium cap 100 mg .......... 68 dantrolene sodium cap 25 mg ............ 68 dantrolene sodium cap 50 mg ............ 68 dapsone tab 100 mg ......................... 14 dapsone tab 25 mg .......................... 14 DAPTACEL INJ ................................. 94 daptomycin for iv soln 500 mg ........... 14 DARAPRIM TAB 25MG ....................... 14 daunorubicin hcl inj 5 mg/ml (base equiv) ...................................................... 27 deblitane tab 0.35mg........................ 74 DELESTROGEN INJ 10MG/ML ............. 77 delyla tab 0.1-0.02 ........................... 74 DELZICOL CAP 400MG ...................... 85 DEMSER CAP 250MG ........................ 46 DEPEN TITRA TAB 250MG ................. 73 DEPO-PROVERA INJ 400/ML .............. 29 DESCOVY TAB 200/25 ...................... 18 desipramine hcl tab 10 mg ................ 56 desipramine hcl tab 100 mg .............. 56 desipramine hcl tab 150 mg .............. 56 desipramine hcl tab 25 mg ................ 56 desipramine hcl tab 50 mg ................ 56 desipramine hcl tab 75 mg ................ 56 desmopressin acetate inj 4 mcg/ml .... 82 DESMOPRESSIN ACETATE NASAL SOLN 0.01% (REFRIGERATED) ................... 82 desmopressin acetate nasal spray soln 0.01% ............................................ 82 desmopressin acetate nasal spray soln 0.01% (refrigerated) ........................ 82 desmopressin acetate tab 0.1 mg ....... 82 desmopressin acetate tab 0.2 mg ....... 82 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5).................. 74 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg ..................................... 74 DESONIDE CREAM 0.05% ............... 107 desonide lotion 0.05% .................... 107 desonide oint 0.05%....................... 107 121

desoximetasone cream 0.05% .......... 107 desoximetasone cream 0.25% .......... 107 desoximetasone gel 0.05% .............. 107 DESOXIMETASONE OINT 0.05% ....... 107 desoximetasone oint 0.25% ............. 108 dexamethason con 1mg/ml ................78 dexamethasone elixir 0.5 mg/5ml .......78 dexamethasone sod phosphate preservative free inj 10 mg/ml ...........78 dexamethasone sodium phosphate inj 10 mg/ml .............................................78 dexamethasone sodium phosphate inj 100 mg/10ml .........................................78 dexamethasone sodium phosphate inj 120 mg/30ml .........................................78 dexamethasone sodium phosphate inj 20 mg/5ml ...........................................78 dexamethasone sodium phosphate inj 4 mg/ml .............................................78 dexamethasone sodium phosphate ophth soln 0.1% ...................................... 100 dexamethasone soln 0.5 mg/5ml ........78 dexamethasone tab 0.5 mg ................78 dexamethasone tab 0.75 mg ..............78 dexamethasone tab 1 mg ..................78 dexamethasone tab 1.5 mg ................78 dexamethasone tab 2 mg ..................78 dexamethasone tab 4 mg ..................78 dexamethasone tab 6 mg ..................78 DEXILANT CAP 30MG DR ...................87 DEXILANT CAP 60MG DR ...................87 dexrazoxane for inj 250 mg ...............33 DEXTROSE 10% W/ SODIUM CHLORIDE 0.45% .............................................97 DEXTROSE 2.5% W/ SODIUM CHLORIDE 0.45% .............................................97 DEXTROSE 5% IN LACTATED RINGERS97 DEXTROSE 5% W/ SODIUM CHLORIDE 0.2% ...............................................97 DEXTROSE 5% W/ SODIUM CHLORIDE 0.225% ...........................................97 DEXTROSE 5% W/ SODIUM CHLORIDE 0.33% .............................................97 DEXTROSE 5% W/ SODIUM CHLORIDE 0.45% .............................................97 DEXTROSE 5% W/ SODIUM CHLORIDE

0.9% .............................................. 97 DEXTROSE INJ 10% ......................... 97 DEXTROSE INJ 5% ........................... 97 DEXTROSE INJ 50% ......................... 97 DEXTROSE INJ 70% ......................... 97 diazepam con 5mg/ml ...................... 50 diazepam inj 5 mg/ml ....................... 50 diazepam oral soln 1 mg/ml .............. 50 DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG ................................ 50 DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG ............................... 50 DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG ................................ 50 diazepam tab 10 mg ......................... 50 diazepam tab 2 mg........................... 50 diazepam tab 5 mg........................... 50 diclofenac potassium tab 50 mg ........... 8 diclofenac sodium gel 1% ................ 109 diclofenac sodium ophth soln 0.1% .. 100 diclofenac sodium tab delayed release 25 mg ................................................... 8 diclofenac sodium tab delayed release 50 mg ................................................... 8 diclofenac sodium tab delayed release 75 mg ................................................... 8 diclofenac sodium tab sr 24hr 100 mg .. 8 dicloxacillin sodium cap 250 mg ......... 25 dicloxacillin sodium cap 500 mg ......... 25 dicyclomine hcl cap 10 mg ................ 84 dicyclomine hcl oral soln 10 mg/5ml ... 84 dicyclomine hcl tab 20 mg ................. 84 didanosine delayed release capsule 125 mg ................................................. 16 didanosine delayed release capsule 200 mg ................................................. 16 didanosine delayed release capsule 250 mg ................................................. 16 didanosine delayed release capsule 400 mg ................................................. 16 DIFICID TAB 200MG ......................... 22 diflorasone diacetate cream 0.05%... 108 diflorasone diacetate oint 0.05% ...... 108 diflunisal tab 500 mg .......................... 8 digitek tab 0.125mg ......................... 45 digitek tab 0.25mg ........................... 45 122

digoxin inj 0.25 mg/ml ......................45 DIGOXIN ORAL SOLN 0.05 MG/ML ......45 digoxin tab 125 mcg (0.125 mg).........45 digoxin tab 250 mcg (0.25 mg) ..........45 dihydroergotamine mesylate inj 1 mg/ml ......................................................67 dilantin cap 100mg ...........................50 dilantin cap 30mg .............................50 dilantin chw 50mg ............................50 DILANTIN-125 SUS 125/5ML ..............50 diltiazem hcl cap sr 12hr 120 mg ........43 diltiazem hcl cap sr 12hr 60 mg ..........43 diltiazem hcl cap sr 12hr 90 mg ..........43 diltiazem hcl cap sr 24hr 120 mg ........43 diltiazem hcl cap sr 24hr 180 mg ........43 diltiazem hcl cap sr 24hr 240 mg ........43 diltiazem hcl coated beads cap sr 24hr 120 mg ..................................................43 diltiazem hcl coated beads cap sr 24hr 180 mg ..................................................43 diltiazem hcl coated beads cap sr 24hr 240 mg ..................................................43 diltiazem hcl coated beads cap sr 24hr 300 mg ..................................................43 diltiazem hcl coated beads cap sr 24hr 360 mg ..................................................43 diltiazem hcl extended release beads cap sr 24hr 120 mg ................................43 diltiazem hcl extended release beads cap sr 24hr 180 mg ................................43 diltiazem hcl extended release beads cap sr 24hr 240 mg ................................43 diltiazem hcl extended release beads cap sr 24hr 300 mg ................................43 diltiazem hcl extended release beads cap sr 24hr 360 mg ................................43 diltiazem hcl extended release beads cap sr 24hr 420 mg ................................43 diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) ............................................43 diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) ......................................................43 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) ............................................43 diltiazem hcl tab 120 mg ...................44 diltiazem hcl tab 30 mg .....................43

diltiazem hcl tab 60 mg ..................... 43 diltiazem hcl tab 90 mg ..................... 43 DIP/TET PED INJ 25-5LFU ................. 94 DIPENTUM CAP 250MG ..................... 85 diphenhydramine hcl inj 50 mg/ml ... 102 diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml ........................................... 86 diphenoxylate w/ atropine tab 2.5-0.025 mg ................................................. 86 disopyramide phosphate cap 100 mg .. 38 disopyramide phosphate cap 150 mg .. 38 disulfiram tab 250 mg ....................... 69 disulfiram tab 500 mg ....................... 69 divalproex sodium cap delayed release sprinkle 125 mg ............................... 50 divalproex sodium tab delayed release 125 mg ........................................... 50 divalproex sodium tab delayed release 250 mg ........................................... 50 divalproex sodium tab delayed release 500 mg ........................................... 50 divalproex sodium tab sr 24 hr 250 mg50 divalproex sodium tab sr 24 hr 500 mg50 DOCETAXEL FOR INJ CONC 20 MG/ML 28 DOCETAXEL FOR INJ CONC 80 MG/4ML (20 MG/ML) ..................................... 28 docetaxel inj 140/7ml ....................... 28 DOCETAXEL INJ 160/16ML ................ 28 DOCETAXEL INJ 200MG/20 ................ 28 DOCETAXEL INJ 20MG/2ML ............... 28 DOCETAXEL INJ 80MG/8ML ............... 28 dofetilide cap 125 mcg (0.125 mg) ..... 38 dofetilide cap 250 mcg (0.25 mg)....... 38 dofetilide cap 500 mcg (0.5 mg) ........ 38 donepezil hydrochloride orally disintegrating tab 10 mg ................... 54 donepezil hydrochloride orally disintegrating tab 5 mg ..................... 54 donepezil hydrochloride tab 10 mg ..... 54 donepezil hydrochloride tab 23 mg ..... 54 donepezil hydrochloride tab 5 mg ....... 54 dorzolamide hcl ophth soln 2% ........ 101 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 101 doxazosin mesylate tab 1 mg ............ 36 doxazosin mesylate tab 2 mg ............ 36 123

doxazosin mesylate tab 4 mg .............36 doxazosin mesylate tab 8 mg .............36 doxepin hcl cap 10 mg.......................56 doxepin hcl cap 100 mg .....................56 doxepin hcl cap 150 mg .....................56 doxepin hcl cap 25 mg.......................56 doxepin hcl cap 50 mg.......................56 doxepin hcl cap 75 mg.......................56 doxepin hcl conc 10 mg/ml ................56 DOXEPIN HCL CREAM 5% ................ 106 doxorubicin hcl for inj 50 mg ..............27 doxorubicin hcl inj 2 mg/ml ................27 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .............................27 doxy 100 inj 100mg ..........................25 doxycycline hyclate cap 100 mg .........25 doxycycline hyclate cap 50 mg ...........25 doxycycline hyclate for inj 100 mg ......25 doxycycline hyclate tab 100 mg ..........26 doxycycline hyclate tab 20 mg ............26 doxycycline monohydrate cap 100 mg .26 doxycycline monohydrate cap 50 mg ...26 doxycycline monohydrate tab 100 mg .26 doxycycline monohydrate tab 150 mg .26 doxycycline monohydrate tab 50 mg ...26 doxycycline monohydrate tab 75 mg ...26 dronabinol cap 10 mg ........................83 dronabinol cap 2.5 mg .......................83 dronabinol cap 5 mg .........................83 drospirenone-ethinyl estradiol tab 3-0.02 mg ..................................................74 DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG .................................74 drospirenone-ethinyl estradiol tab 3-0.03 mg ..................................................74 DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG .................................74 DROXIA CAP 200MG ..........................32 DROXIA CAP 300MG ..........................32 DROXIA CAP 400MG ..........................32 duloxetine hcl enteric coated pellets cap 20 mg .............................................56 duloxetine hcl enteric coated pellets cap 30 mg .............................................56 duloxetine hcl enteric coated pellets cap 60 mg .............................................56

DURAMORPH INJ 0.5MG/ML ................. 9 DURAMORPH INJ 1MG/ML ................... 9 DUREZOL EMU 0.05% ..................... 100 dutasteride cap 0.5 mg ..................... 87 dutasteride-tamsulosin hcl cap 0.5-0.4 mg ................................................. 87 E e.e.s. 400 tab 400mg ....................... 22 econazole nitrate cream 1% ............ 106 EDURANT TAB 25MG ........................ 16 EFFIENT TAB 10MG .......................... 91 EFFIENT TAB 5MG ............................ 91 ELIDEL CRE 1% ............................. 109 ELIQUIS TAB 2.5MG ......................... 89 ELIQUIS TAB 5MG ............................ 89 ELITEK INJ 1.5MG ............................ 33 ELITEK INJ 7.5MG ............................ 33 elixophyllin elx 80/15ml .................. 104 ELLA TAB 30MG ............................... 74 ELMIRON CAP 100MG ....................... 88 EMCYT CAP 140MG ........................... 26 EMEND CAP 125MG .......................... 83 EMEND CAP 40MG ............................ 83 EMEND CAP 80MG ............................ 83 EMEND PAK 80 & 125 ....................... 83 EMEND SUS 125MG .......................... 83 emoquette tab ................................. 74 EMSAM DIS 12MG/24H ..................... 56 EMSAM DIS 6MG/24HR ..................... 56 EMSAM DIS 9MG/24HR ..................... 56 EMTRIVA CAP 200MG........................ 16 EMTRIVA SOL 10MG/ML .................... 16 emverm chw 100mg ......................... 14 enalapril maleate & hydrochlorothiazide tab 10-25 mg .................................. 34 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg ................................. 34 enalapril maleate tab 10 mg .............. 35 enalapril maleate tab 2.5 mg ............. 35 enalapril maleate tab 20 mg .............. 35 enalapril maleate tab 5 mg ................ 35 endocet tab 10-325mg........................ 9 endocet tab 5-325mg ......................... 9 endocet tab 7.5-325 ........................... 9 ENGERIX-B INJ 10/0.5ML .................. 94 ENGERIX-B INJ 20MCG/ML ................ 94 124

enoxaparin sodium inj 100 mg/ml .......89 enoxaparin sodium inj 120 mg/0.8ml ..89 enoxaparin sodium inj 150 mg/ml .......89 enoxaparin sodium inj 30 mg/0.3ml ....89 enoxaparin sodium inj 300 mg/3ml .....89 enoxaparin sodium inj 40 mg/0.4ml ....89 enoxaparin sodium inj 60 mg/0.6ml ....89 enoxaparin sodium inj 80 mg/0.8ml ....89 enpresse-28 tab ...............................74 ENTACAPONE TAB 200 MG .................60 entecavir tab 0.5 mg .........................19 entecavir tab 1 mg ............................19 ENTRESTO TAB 24-26MG ...................37 ENTRESTO TAB 49-51MG ...................37 ENTRESTO TAB 97-103MG .................37 enulose sol 10gm/15 .........................85 EPIPEN 2-PAK INJ 0.3MG ................. 103 EPIPEN-JR INJ 2-PAK ....................... 103 epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) ............................................27 epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) ............................................27 epitol tab 200mg ..............................50 EPIVIR HBV SOL 5MG/ML ...................19 eplerenone tab 25 mg .......................36 eplerenone tab 50 mg .......................36 EPZICOM TAB 600-300 ......................18 ERIVEDGE CAP 150MG ......................29 errin tab 0.35mg ..............................74 ery-tab tab 250mg ec ........................22 ery-tab tab 333mg ec ........................23 ery-tab tab 500mg ec ........................23 erythrocin inj 500mg .........................23 erythrocin tab 250mg ........................23 erythromycin ethylsuccinate tab 400 mg ......................................................23 erythromycin gel 2% ....................... 105 erythromycin ophth oint 5 mg/gm.......99 erythromycin pads 2% .................... 105 erythromycin soln 2% ..................... 105 erythromycin tab 250 mg...................23 erythromycin tab 500 mg...................23 erythromycin w/ delayed release particles cap 250 mg ......................................23 ESBRIET CAP 267MG ....................... 103 escitalopram oxalate soln 5 mg/5ml (base

equiv) ............................................. 57 escitalopram oxalate tab 10 mg (base equiv) ............................................. 57 escitalopram oxalate tab 20 mg (base equiv) ............................................. 57 escitalopram oxalate tab 5 mg (base equiv) ............................................. 57 esomeprazole magnesium cap delayed release 20 mg (base eq) ................... 87 esomeprazole magnesium cap delayed release 40 mg (base eq) ................... 87 esomeprazole sodium for intravenous soln 20 mg (base equiv) .......................... 87 esomeprazole sodium for intravenous soln 40 mg (base equiv) .......................... 87 estrace vag cre 0.1mg/gm ................ 77 estradiol tab 0.5 mg ......................... 77 estradiol tab 1 mg ............................ 77 estradiol tab 2 mg ............................ 77 estradiol td patch weekly 0.025 mg/24hr ...................................................... 78 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) .............................. 78 estradiol td patch weekly 0.05 mg/24hr ...................................................... 77 estradiol td patch weekly 0.06 mg/24hr ...................................................... 77 estradiol td patch weekly 0.075 mg/24hr ...................................................... 78 estradiol td patch weekly 0.1 mg/24hr 77 estradiol valerate im in oil 20 mg/ml .. 78 estradiol valerate im in oil 40 mg/ml .. 78 ethambutol hcl tab 100 mg................ 19 ethambutol hcl tab 400 mg................ 19 ethosuximide cap 250 mg ................. 50 ethosuximide soln 250 mg/5ml .......... 50 etodolac cap 200 mg .......................... 8 etodolac cap 300 mg .......................... 8 etodolac tab 400 mg ........................... 8 etodolac tab 500 mg ........................... 8 etodolac tab sr 24hr 400 mg................ 8 etodolac tab sr 24hr 500 mg................ 8 etodolac tab sr 24hr 600 mg................ 8 etoposide inj 500 mg/25ml (20 mg/ml) ...................................................... 33 EURAX CRE 10% ............................ 109 125

EURAX LOT 10% ............................. 109 EVOTAZ TAB 300-150........................18 EXELON DIS 13.3/24 .........................54 EXELON DIS 4.6MG/24 ......................54 EXELON DIS 9.5MG/24 ......................54 exemestane tab 25 mg ......................29 EXJADE TAB 125MG ..........................73 EXJADE TAB 250MG ..........................73 EXJADE TAB 500MG ..........................73 F FABRAZYME INJ 35MG .......................77 FABRAZYME INJ 5MG.........................77 falmina tab ......................................74 famciclovir tab 125 mg ......................19 famciclovir tab 250 mg ......................19 famciclovir tab 500 mg ......................19 famotidine for susp 40 mg/5ml ...........84 famotidine in nacl 0.9% iv soln 20 mg/50ml .........................................84 famotidine inj 20 mg/2ml...................84 famotidine inj 200 mg/20ml ...............85 famotidine inj 40 mg/4ml...................85 famotidine tab 20 mg ........................85 famotidine tab 40 mg ........................85 FANAPT PAK .....................................61 FANAPT TAB 10MG ............................62 FANAPT TAB 12MG ............................62 FANAPT TAB 1MG ..............................61 FANAPT TAB 2MG ..............................61 FANAPT TAB 4MG ..............................61 FANAPT TAB 6MG ..............................61 FANAPT TAB 8MG ..............................62 FARESTON TAB 60MG ........................30 FARXIGA TAB 10MG ..........................71 FARXIGA TAB 5MG ............................71 FARYDAK CAP 10MG ..........................29 FARYDAK CAP 15MG ..........................29 FARYDAK CAP 20MG ..........................29 FASLODEX INJ 250MG .......................30 FAT EMULSION IV SOLN 20% .............97 FAZACLO TAB 150 ODT .....................62 FAZACLO TAB 200 ODT .....................62 felbamate susp 600 mg/5ml ...............50 felbamate tab 400 mg .......................50 felbamate tab 600 mg .......................51 felodipine tab sr 24hr 10 mg ..............44

felodipine tab sr 24hr 2.5 mg ............. 44 felodipine tab sr 24hr 5 mg ............... 44 fenofibrate micronized cap 134 mg ..... 40 fenofibrate micronized cap 200 mg ..... 40 fenofibrate micronized cap 67 mg....... 40 fenofibrate tab 145 mg ..................... 40 fenofibrate tab 160 mg ..................... 40 fenofibrate tab 48 mg ....................... 40 fenofibrate tab 54 mg ....................... 40 fentanyl citrate lozenge on a handle 1200 mcg ................................................ 10 fentanyl citrate lozenge on a handle 1600 mcg ................................................ 10 fentanyl citrate lozenge on a handle 200 mcg .................................................. 9 fentanyl citrate lozenge on a handle 400 mcg .................................................. 9 fentanyl citrate lozenge on a handle 600 mcg .................................................. 9 fentanyl citrate lozenge on a handle 800 mcg .................................................. 9 fentanyl td patch 72hr 100 mcg/hr ..... 10 fentanyl td patch 72hr 12 mcg/hr ....... 10 fentanyl td patch 72hr 25 mcg/hr ....... 10 fentanyl td patch 72hr 50 mcg/hr ....... 10 fentanyl td patch 72hr 75 mcg/hr ....... 10 FENTORA TAB 100MCG ..................... 10 FENTORA TAB 200MCG ..................... 10 FENTORA TAB 400MCG ..................... 10 FENTORA TAB 600MCG ..................... 10 FENTORA TAB 800MCG ..................... 10 FERRIPROX SOL 100MG/ML ............... 73 FERRIPROX TAB 500MG .................... 73 FETZIMA CAP 120MG ........................ 57 FETZIMA CAP 20MG .......................... 57 FETZIMA CAP 40MG .......................... 57 FETZIMA CAP 80MG .......................... 57 FETZIMA CAP TITRATIO .................... 57 finasteride tab 5 mg ......................... 88 FIRAZYR INJ 30MG/3ML .................... 91 FLEBOGAMMA INJ 10/200ML ............. 92 FLEBOGAMMA INJ 20/400ML ............. 92 FLEBOGAMMA INJ 5% ....................... 92 FLEBOGAMMA INJ DIF 10% ............... 92 FLEBOGAMMA INJ DIF 5% ................. 92 flecainide acetate tab 100 mg ............ 38 126

flecainide acetate tab 150 mg .............38 flecainide acetate tab 50 mg ..............38 FLOVENT DISK AER 100MCG ............ 104 FLOVENT DISK AER 250MCG ............ 104 FLOVENT DISK AER 50MCG .............. 104 FLOVENT HFA AER 110MCG.............. 104 FLOVENT HFA AER 220MCG.............. 104 FLOVENT HFA AER 44MCG ............... 104 fluconazole for susp 10 mg/ml ............15 fluconazole for susp 40 mg/ml ............15 fluconazole in dextrose inj 200 mg/100ml ......................................................15 fluconazole in dextrose inj 400 mg/200ml ......................................................15 fluconazole in nacl 0.9% inj 200 mg/100ml ........................................15 fluconazole in nacl 0.9% inj 400 mg/200ml ........................................15 fluconazole tab 100 mg .....................15 fluconazole tab 150 mg .....................15 fluconazole tab 200 mg .....................15 fluconazole tab 50 mg .......................15 fluconazole/ inj nacl 100 ....................15 flucytosine cap 250 mg ......................15 flucytosine cap 500 mg ......................15 fludarabine phosphate for inj 50 mg ....27 fludarabine phosphate inj 25 mg/ml ....27 fludrocortisone acetate tab 0.1 mg ......78 flunisolide nasal soln 25 mcg/act (0.025%)....................................... 104 fluocin acet oil body ........................ 108 fluocin acet oil scalp ........................ 108 fluocinolone acetonide (otic) oil 0.01% .................................................... 110 fluocinolone acetonide cream 0.01% . 108 fluocinolone acetonide cream 0.025% 108 fluocinolone acetonide oint 0.025% ... 108 fluocinolone acetonide soln 0.01% .... 108 fluocinonide cream 0.05%................ 108 fluocinonide emulsified base cream 0.05% .................................................... 108 fluocinonide gel 0.05% .................... 108 fluocinonide oint 0.05% ................... 108 fluocinonide soln 0.05%................... 108 FLUOROMETHOLONE OPHTH SUSP 0.1% .................................................... 100

fluorouracil cream 5% .................... 109 fluorouracil inj 1 gm/20ml (50 mg/ml) 27 fluorouracil inj 2.5 gm/50ml (50 mg/ml) ...................................................... 27 fluorouracil inj 5 gm/100ml (50 mg/ml) ...................................................... 27 fluorouracil inj 500 mg/10ml (50 mg/ml) ...................................................... 27 fluorouracil soln 2%........................ 109 fluorouracil soln 5%........................ 109 fluoxetine hcl cap 10 mg ................... 57 fluoxetine hcl cap 20 mg ................... 57 fluoxetine hcl cap 40 mg ................... 57 fluoxetine hcl solution 20 mg/5ml ...... 57 fluoxetine hcl tab 10 mg ................... 57 fluoxetine hcl tab 20 mg ................... 57 fluphenazine decanoate inj 25 mg/ml . 62 fluphenazine hcl elixir 2.5 mg/5ml ...... 62 fluphenazine hcl inj 2.5 mg/ml ........... 62 fluphenazine hcl oral conc 5 mg/ml .... 62 fluphenazine hcl tab 1 mg ................. 62 fluphenazine hcl tab 10 mg ............... 62 fluphenazine hcl tab 2.5 mg .............. 62 fluphenazine hcl tab 5 mg ................. 62 flurbiprofen sodium ophth soln 0.03% .................................................... 100 flurbiprofen tab 100 mg ...................... 8 flurbiprofen tab 50 mg ........................ 8 flutamide cap 125 mg ....................... 30 fluticasone propionate cream 0.05% . 108 fluticasone propionate nasal susp 50 mcg/act ........................................ 104 fluticasone propionate oint 0.005% .. 108 fluvoxamine maleate tab 100 mg ....... 49 fluvoxamine maleate tab 25 mg ......... 48 fluvoxamine maleate tab 50 mg ......... 49 fondaparinux sodium subcutaneous inj 10 mg/0.8ml ........................................ 89 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml .................................. 89 fondaparinux sodium subcutaneous inj 5 mg/0.4ml ........................................ 89 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml .................................. 89 FORTEO SOL 600/2.4 ....................... 80 FORTICAL SPR 200/ACT .................... 80 127

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg ................................34 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg ................................35 fosinopril sodium tab 10 mg ...............35 fosinopril sodium tab 20 mg ...............35 fosinopril sodium tab 40 mg ...............35 FREAMINE HBC INJ 6.9% ...................97 FREAMINE III INJ 10% ......................97 furosemide inj 10 mg/ml....................45 FUROSEMIDE INJ 10 MG/ML ...............45 furosemide oral soln 10 mg/ml ...........45 furosemide oral soln 8 mg/ml .............45 furosemide tab 20 mg .......................45 furosemide tab 40 mg .......................45 furosemide tab 80 mg .......................45 FUSILEV INJ 50MG ............................33 FUZEON INJ 90MG ............................17 FYCOMPA SUS 0.5MG/ML ...................51 FYCOMPA TAB 10MG .........................51 FYCOMPA TAB 12MG .........................51 FYCOMPA TAB 2MG ...........................51 FYCOMPA TAB 4MG ...........................51 FYCOMPA TAB 6MG ...........................51 FYCOMPA TAB 8MG ...........................51 G gabapentin cap 100 mg .....................51 gabapentin cap 300 mg .....................51 gabapentin cap 400 mg .....................51 gabapentin oral soln 250 mg/5ml........51 gabapentin tab 600 mg .....................51 gabapentin tab 800 mg .....................51 GABITRIL TAB 12MG .........................51 GABITRIL TAB 16MG .........................51 galantamine hydrobromide cap sr 24hr 16 mg ..................................................54 galantamine hydrobromide cap sr 24hr 24 mg ..................................................54 galantamine hydrobromide cap sr 24hr 8 mg ..................................................54 galantamine hydrobromide oral soln 4 mg/ml .............................................54 galantamine hydrobromide tab 12 mg .54 galantamine hydrobromide tab 4 mg ...54 galantamine hydrobromide tab 8 mg ...54 GAMASTAN S/D INJ...........................92

GAMMAGARD INJ 10GM/100 .............. 92 GAMMAGARD INJ 1GM/10ML ............. 92 GAMMAGARD INJ 2.5GM/25 .............. 92 GAMMAGARD INJ 20GM/200 .............. 92 GAMMAGARD INJ 30GM/300 .............. 92 GAMMAGARD INJ 5GM/50ML ............. 92 GAMMAGARD SD INJ 10GM HU .......... 92 GAMMAGARD SD INJ 2.5GM HU ......... 92 GAMMAGARD SD INJ 5GM HU ............ 92 GAMMAKED INJ 10GM/100 ................ 92 GAMMAKED INJ 1GM/10ML ................ 92 GAMMAKED INJ 2.5GM/25 ................. 92 GAMMAKED INJ 20GM/200 ................ 92 GAMMAKED INJ 5GM/50ML ................ 92 GAMMAPLEX INJ 10GM...................... 92 GAMMAPLEX INJ 2.5GM..................... 92 GAMMAPLEX INJ 5GM ....................... 92 GAMUNEX-C INJ 10GM/100 ............... 92 GAMUNEX-C INJ 1GM/10ML ............... 92 GAMUNEX-C INJ 2.5GM/25 ................ 92 GAMUNEX-C INJ 20GM/200 ............... 92 GAMUNEX-C INJ 40/400ML ................ 92 GAMUNEX-C INJ 5GM/50ML ............... 92 ganciclovir sodium for inj 500 mg ....... 19 GARDASIL 9 INJ ............................... 94 GARDASIL INJ ................................. 94 gatifloxacin ophth soln 0.5% ............. 99 GATTEX KIT 5MG ............................. 86 GAUZE PADS 2" X 2" ........................ 70 gavilyte-c sol ................................... 85 gavilyte-g sol ................................... 85 gavilyte-n sol flav pk ........................ 85 gemcitabine hcl for inj 1 gm .............. 27 gemcitabine hcl for inj 2 gm .............. 27 gemcitabine hcl for inj 200 mg ........... 27 GEMCITABINE HCL INJ 1 GM/26.3ML (38 MG/ML) (BASE EQUIV) ...................... 27 GEMCITABINE HCL INJ 2 GM/52.6ML (38 MG/ML) (BASE EQUIV) ...................... 28 GEMCITABINE HCL INJ 200 MG/5.26ML (38 MG/ML) (BASE EQUIV) ................ 28 gemfibrozil tab 600 mg ..................... 40 generlac sol 10gm/15 ....................... 85 gengraf cap 100mg .......................... 93 gengraf cap 25mg ............................ 93 gengraf cap 50mg ............................ 93 128

gengraf sol 100mg/ml .......................93 gentak oin 0.3% op...........................99 gentam/nacl inj 0.9mg/ml..................12 gentam/nacl inj 1.4mg/ml..................12 gentamicin in saline inj 0.8 mg/ml ......12 gentamicin in saline inj 1 mg/ml .........12 gentamicin in saline inj 1.2 mg/ml ......12 gentamicin in saline inj 1.6 mg/ml ......12 gentamicin in saline inj 2 mg/ml .........12 gentamicin sulfate cream 0.1% ........ 106 gentamicin sulfate inj 10 mg/ml .........12 gentamicin sulfate inj 40 mg/ml .........12 gentamicin sulfate iv soln 10 mg/ml ....12 gentamicin sulfate oint 0.1% ............ 106 gentamicin sulfate ophth oint 0.3% .....99 gentamicin sulfate ophth soln 0.3% ....99 GENVOYA TAB ..................................18 GEODON INJ 20MG ...........................62 gildagia tab 0.4-35 ............................74 gildess tab 1.5/30 .............................74 GILENYA CAP 0.5MG .........................68 GILOTRIF TAB 20MG .........................31 GILOTRIF TAB 30MG .........................31 GILOTRIF TAB 40MG .........................31 glatopa inj 20mg/ml ..........................68 GLEOSTINE CAP 100MG .....................26 GLEOSTINE CAP 10MG ......................26 GLEOSTINE CAP 40MG ......................26 GLEOSTINE CAP 5MG ........................26 glimepiride tab 1 mg .........................71 glimepiride tab 2 mg .........................71 glimepiride tab 4 mg .........................71 glipizide tab 10 mg ...........................71 glipizide tab 5 mg .............................71 glipizide tab sr 24hr 10 mg ................71 glipizide tab sr 24hr 2.5 mg ...............71 GLIPIZIDE TAB SR 24HR 2.5 MG .........71 glipizide tab sr 24hr 5 mg ..................71 GLIPIZIDE XL TAB 5MG .....................71 glipizide-metformin hcl tab 2.5-250 mg ......................................................71 glipizide-metformin hcl tab 2.5-500 mg ......................................................71 glipizide-metformin hcl tab 5-500 mg ..71 GLUCAGEN INJ HYPOKIT ....................79 GLUCAGON KIT 1MG .........................79

glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) ...................................................... 84 glycopyrrolate tab 1 mg .................... 84 glycopyrrolate tab 2 mg .................... 84 GOLYTELY SOL ................................. 85 granisetron hcl inj 0.1 mg/ml............. 83 granisetron hcl inj 1 mg/ml ............... 83 granisetron hcl inj 4 mg/4ml (1 mg/ml) ...................................................... 83 granisetron hcl tab 1 mg ................... 83 GRANIX INJ 300/0.5 ......................... 90 GRANIX INJ 480/0.8 ......................... 90 griseofulvin microsize susp 125 mg/5ml ...................................................... 15 griseofulvin microsize tab 500 mg ...... 16 griseofulvin ultramicrosize tab 125 mg 16 griseofulvin ultramicrosize tab 250 mg 16 guanfacine hcl tab sr 24hr 1 mg (base equiv) ............................................. 66 guanfacine hcl tab sr 24hr 2 mg (base equiv) ............................................. 66 guanfacine hcl tab sr 24hr 3 mg (base equiv) ............................................. 66 guanfacine hcl tab sr 24hr 4 mg (base equiv) ............................................. 66 H halobetasol propionate cream 0.05% 108 halobetasol propionate oint 0.05% ... 108 haloperidol decanoate im soln 100 mg/ml ...................................................... 62 haloperidol decanoate im soln 50 mg/ml ...................................................... 62 haloperidol lactate inj 5 mg/ml .......... 62 haloperidol lactate oral conc 2 mg/ml . 62 haloperidol tab 0.5 mg ...................... 62 haloperidol tab 1 mg......................... 62 haloperidol tab 10 mg ....................... 62 haloperidol tab 2 mg......................... 62 haloperidol tab 20 mg ....................... 62 haloperidol tab 5 mg......................... 62 HARVONI TAB 90-400MG .................. 19 HAVRIX INJ 1440UNIT ...................... 94 HAVRIX INJ 720UNIT ........................ 94 heather tab 0.35mg.......................... 74 HEP SOD/NACL INJ 25000UNT ........... 89 HEPARIN SODIUM (PORCINE) 100 129

UNIT/ML IN D5W ..............................89 HEPARIN SODIUM (PORCINE) 40 UNIT/ML IN D5W ...........................................89 HEPARIN SODIUM (PORCINE) 50 UNIT/ML IN D5W ...........................................89 heparin sodium (porcine) inj 1000 unit/ml ......................................................89 heparin sodium (porcine) inj 10000 unit/ml ............................................89 heparin sodium (porcine) inj 20000 unit/ml ............................................89 heparin sodium (porcine) inj 5000 unit/ml ......................................................89 HEPATAMINE SOL 8% .......................97 HERCEPTIN INJ 440MG ......................29 HETLIOZ CAP 20MG ..........................66 HEXALEN CAP 50MG ..........................26 HIBERIX SOL 10MCG .........................94 HUMIRA INJ 10MG/0.2 ......................91 HUMIRA KIT 20MG/0.4 ......................91 HUMIRA KIT 40MG/0.8 ......................91 HUMIRA PEDIA INJ CROHNS...............91 HUMIRA PEN INJ 40MG/0.8 ................91 HUMIRA PEN INJ CROHNS ..................91 HUMIRA PEN INJ PSORIASI ................91 HUMULIN R INJ U-500 .......................70 hydralazine hcl inj 20 mg/ml ..............46 hydralazine hcl tab 10 mg ..................46 hydralazine hcl tab 100 mg ................46 hydralazine hcl tab 25 mg ..................46 hydralazine hcl tab 50 mg ..................46 hydrochlorothiazide cap 12.5 mg ........45 hydrochlorothiazide tab 12.5 mg .........45 hydrochlorothiazide tab 25 mg ...........45 hydrochlorothiazide tab 50 mg ...........45 hydrocodone-acetaminophen soln 7.5-325 mg/15ml .............................10 hydrocodone-acetaminophen tab 10-325 mg ..................................................10 hydrocodone-acetaminophen tab 5-325 mg ..................................................10 hydrocodone-acetaminophen tab 7.5-325 mg ..................................................10 hydrocodone-ibuprofen tab 7.5-200 mg ......................................................10 hydrocortisone butyrate cream 0.1%. 108

hydrocortisone butyrate oint 0.1% ... 108 hydrocortisone butyrate soln 0.1% ... 108 hydrocortisone cream 1% ............... 108 hydrocortisone cream 2.5% ............. 108 hydrocortisone enema 100 mg/60ml .. 85 HYDROCORTISONE ENEMA 100 MG/60ML ...................................................... 85 hydrocortisone lotion 2.5%.............. 108 hydrocortisone oint 1% ................... 108 hydrocortisone oint 2.5% ................ 108 hydrocortisone rectal cream 2.5% .... 106 hydrocortisone tab 10 mg ................. 78 hydrocortisone tab 20 mg ................. 78 hydrocortisone tab 5 mg ................... 78 hydrocortisone valerate cream 0.2% 108 hydrocortisone valerate oint 0.2% .... 108 hydromorphone hcl liqd 1 mg/ml........ 10 hydromorphone hcl preservative free (pf) inj 10 mg/ml ................................... 10 hydromorphone hcl tab 2 mg ............. 10 hydromorphone hcl tab 4 mg ............. 10 hydromorphone hcl tab 8 mg ............. 10 hydroxychloroquine sulfate tab 200 mg ...................................................... 91 hydroxyprogesterone caproate im in oil 1.25 gm/5ml ................................... 30 hydroxyurea cap 500 mg .................. 32 hydroxyzine hcl im soln 25 mg/ml .... 102 hydroxyzine hcl im soln 50 mg/ml .... 102 I ibandronate sodium tab 150 mg (base equivalent) ...................................... 73 IBRANCE CAP 100MG........................ 29 IBRANCE CAP 125MG........................ 29 IBRANCE CAP 75MG ......................... 29 ibuprofen susp 100 mg/5ml ................. 8 ibuprofen tab 400 mg ......................... 8 ibuprofen tab 600 mg ......................... 8 ibuprofen tab 800 mg ......................... 8 ICLUSIG TAB 15MG .......................... 31 ICLUSIG TAB 45MG .......................... 31 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) ...................................................... 27 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) ...................................................... 27 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 130

......................................................27 IFEX INJ 3GM ...................................26 ifosfamide for inj 1 gm ......................26 IFOSFAMIDE INJ 3GM ........................26 ifosfamide iv inj 1 gm/20ml (50 mg/ml) ......................................................26 ifosfamide iv inj 3 gm/60ml (50 mg/ml) ......................................................26 ILEVRO DRO 0.3% OP ..................... 100 ilotycin oin op ...................................99 imatinib mesylate tab 100 mg (base equivalent) ......................................31 imatinib mesylate tab 400 mg (base equivalent) ......................................31 IMBRUVICA CAP 140MG .....................31 imipenem-cilastatin intravenous for soln 250 mg ...........................................14 imipenem-cilastatin intravenous for soln 500 mg ...........................................14 imipramine hcl tab 10 mg ..................57 imipramine hcl tab 25 mg ..................57 imipramine hcl tab 50 mg ..................57 imiquimod cream 5% ...................... 109 IMOVAX RABIE INJ 2.5/ML .................94 INCRELEX INJ 40MG/4ML ...................80 INCRUSE ELPT INH 62.5MCG ............ 102 indapamide tab 1.25 mg ....................46 indapamide tab 2.5 mg ......................46 INFANRIX INJ ...................................94 INLYTA TAB 1MG ..............................31 INLYTA TAB 5MG ..............................31 INSULIN PEN NEEDLE ........................70 INSULIN SAFETY NEEDLES .................70 INSULIN SYRINGE.............................70 INTELENCE TAB 100MG .....................17 INTELENCE TAB 200MG .....................17 INTELENCE TAB 25MG .......................17 INTRALIPID INJ 20% .........................97 INTRALIPID INJ 30% .........................97 INTRON A INJ 10MU ..........................93 INTRON A INJ 18MU ..........................93 INTRON A INJ 25MU ..........................93 INTRON A INJ 50MU ..........................93 introvale tab ....................................74 INVANZ INJ 1GM ..............................14 INVEGA SUST INJ 117/0.75 ...............62

INVEGA SUST INJ 156MG/ML ............. 62 INVEGA SUST INJ 234/1.5 ................ 62 INVEGA SUST INJ 39/0.25 ................ 62 INVEGA SUST INJ 78/0.5ML .............. 62 INVEGA TAB 1.5MG .......................... 62 INVEGA TAB 3MG ............................. 62 INVEGA TAB 6MG ............................. 62 INVEGA TAB 9MG ............................. 62 INVEGA TRINZ INJ 273MG................. 62 INVEGA TRINZ INJ 410MG................. 62 INVEGA TRINZ INJ 546MG................. 62 INVEGA TRINZ INJ 819MG................. 62 INVIRASE CAP 200MG ...................... 17 INVIRASE TAB 500MG ...................... 17 INVOKAMET TAB 150-1000 ............... 72 INVOKAMET TAB 150-500 ................. 72 INVOKAMET TAB 50-1000 ................. 71 INVOKAMET TAB 50-500MG .............. 71 INVOKANA TAB 100MG ..................... 72 INVOKANA TAB 300MG ..................... 72 IONOSOL-B/ INJ D5W ....................... 97 IONOSOL-MB INJ /D5W .................... 97 IPOL INJ INACTIVE ........................... 94 ipratropium bromide inhal soln 0.02% .................................................... 102 ipratropium bromide nasal soln 0.03% (21 mcg/spray) ................................... 102 ipratropium bromide nasal soln 0.06% (42 mcg/spray) ................................... 102 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml ......................... 102 irbesartan tab 150 mg ...................... 38 irbesartan tab 300 mg ...................... 38 irbesartan tab 75 mg ........................ 38 irbesartan-hydrochlorothiazide tab 150-12.5 mg ................................... 37 irbesartan-hydrochlorothiazide tab 300-12.5 mg ................................... 37 IRESSA TAB 250MG .......................... 31 irinotecan hcl inj 100 mg/5ml (20 mg/ml) ...................................................... 34 irinotecan hcl inj 40 mg/2ml (20 mg/ml) ...................................................... 34 irinotecan hcl inj 500 mg/25ml (20 mg/ml) ........................................... 34 ISENTRESS CHW 100MG ................... 17 131

ISENTRESS CHW 25MG .....................17 ISENTRESS POW 100MG ....................17 ISENTRESS TAB 400MG .....................17 ISOLYTE-P INJ /D5W .........................97 ISOLYTE-S INJ..................................97 isoniazid inj 100 mg/ml .....................19 isoniazid syrup 50 mg/5ml .................19 isoniazid tab 100 mg .........................19 isoniazid tab 300 mg .........................19 isosorbide dinitrate tab 10 mg ............47 isosorbide dinitrate tab 20 mg ............47 isosorbide dinitrate tab 30 mg ............47 isosorbide dinitrate tab 5 mg ..............47 isosorbide dinitrate tab cr 40 mg ........47 isosorbide mononitrate tab 10 mg .......47 isosorbide mononitrate tab 20 mg .......47 isosorbide mononitrate tab sr 24hr 120 mg ..................................................47 isosorbide mononitrate tab sr 24hr 30 mg ......................................................47 isosorbide mononitrate tab sr 24hr 60 mg ......................................................47 isotretinoin cap 10 mg ..................... 105 isotretinoin cap 20 mg ..................... 105 isotretinoin cap 40 mg ..................... 105 isradipine cap 2.5 mg ........................44 isradipine cap 5 mg ...........................44 ISTALOL SOL 0.5% OP .................... 101 ISTODAX INJ 10MG ...........................29 itraconazole cap 100 mg ....................16 ivermectin tab 3 mg ..........................14 IXIARO INJ ......................................95 J JAKAFI TAB 10MG .............................31 JAKAFI TAB 15MG .............................31 JAKAFI TAB 20MG .............................31 JAKAFI TAB 25MG .............................31 JAKAFI TAB 5MG ...............................31 jantoven tab 10mg............................90 jantoven tab 1mg .............................89 jantoven tab 2.5mg...........................89 jantoven tab 2mg .............................89 jantoven tab 3mg .............................89 jantoven tab 4mg .............................90 jantoven tab 5mg .............................90 jantoven tab 6mg .............................90

jantoven tab 7.5mg .......................... 90 JANUMET TAB 50-1000 ..................... 72 JANUMET TAB 50-500MG .................. 72 JANUMET XR TAB 100-1000............... 72 JANUMET XR TAB 50-1000 ................ 72 JANUMET XR TAB 50-500MG.............. 72 JANUVIA TAB 100MG ........................ 72 JANUVIA TAB 25MG .......................... 72 JANUVIA TAB 50MG .......................... 72 JENTADUETO TAB 2.5-1000 ............... 72 JENTADUETO TAB 2.5-500 ................ 72 JENTADUETO TAB 2.5-850 ................ 72 JENTADUETO TAB XR ........................ 72 jinteli tab 1mg-5mcg ........................ 78 JOLIVETTE TAB 0.35MG .................... 74 juleber tab ...................................... 74 junel 1.5/30 tab ............................... 74 junel 1/20 tab .................................. 74 junel fe tab 1.5/30 ........................... 74 junel fe tab 1/20 .............................. 74 JUXTAPID CAP 10MG ........................ 40 JUXTAPID CAP 20MG ........................ 40 JUXTAPID CAP 30MG ........................ 40 JUXTAPID CAP 40MG ........................ 40 JUXTAPID CAP 5MG .......................... 40 JUXTAPID CAP 60MG ........................ 41 K KADCYLA INJ 100MG ........................ 29 KADCYLA INJ 160MG ........................ 29 KALETRA SOL .................................. 18 KALETRA TAB 100-25MG ................... 18 KALETRA TAB 200-50MG ................... 18 KALYDECO PAK 50MG ..................... 103 KALYDECO PAK 75MG ..................... 103 KALYDECO TAB 150MG ................... 103 kariva tab 28 day ............................. 74 KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% & NACL 0.45% INJ...................... 98 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.2% INJ ............................. 98 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.33% INJ ........................... 98 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.45% INJ ........................... 98 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.9% INJ ............................. 98 132

kcl 20 meq/l (0.15%) in nacl 0.45% inj ......................................................98 KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ ..................................................98 KCL 20 MEQ/L (0.15%) IN NACL 0.9% INJ ......................................................98 KCL 30 MEQ/L (0.224%) IN DEXTROSE 5% & NACL 0.45% INJ ......................98 KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & NACL 0.45% INJ ...............................98 KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ ......................................................98 KCL/D5W/NACL INJ 0.15/0.2..............98 KCL/D5W/NACL INJ 0.3/0.9% ............98 kelnor tab 1/35 ................................74 ketoconazole cream 2% ................... 106 ketoconazole shampoo 2% ............... 107 ketoconazole tab 200 mg ...................16 ketoprofen cap 50 mg ........................ 8 ketoprofen cap 75 mg ........................ 8 ketorolac tromethamine ophth soln 0.4% .................................................... 100 ketorolac tromethamine ophth soln 0.5% .................................................... 100 KEYTRUDA INJ 100MG/4M .................29 KEYTRUDA SOL 50MG .......................29 kimidess tab.....................................74 KINRIX INJ.......................................95 kionex pow ......................................73 kionex sus 15gm/60 ..........................73 KLOR-CON 10 TAB 10MEQ ER .............95 KLOR-CON 8 TAB 8MEQ ER ................95 klor-con m15 tab 15meq er ................95 klor-con pow 20meq..........................95 KORLYM TAB 300MG .........................79 KUVAN POW 100MG ..........................77 KUVAN POW 500MG ..........................77 KUVAN TAB 100MG ...........................77 KYNAMRO INJ 200MG/ML ...................41 L labetalol hcl tab 100 mg ....................42 labetalol hcl tab 200 mg ....................42 labetalol hcl tab 300 mg ....................42 LACTATED RINGER'S SOLUTION .........98 lactic acid (ammonium lactate) cream 12% .............................................. 109

lactic acid (ammonium lactate) lotion 12% .................................................... 109 lactulose (encephalopathy) solution 10 gm/15ml ......................................... 85 lactulose solution 10 gm/15ml ........... 85 lamivudine oral soln 10 mg/ml ........... 17 lamivudine tab 100 mg (hbv)............. 19 lamivudine tab 150 mg ..................... 17 lamivudine tab 300 mg ..................... 17 lamivudine-zidovudine tab 150-300 mg ...................................................... 18 lamotrigine tab 100 mg ..................... 51 lamotrigine tab 150 mg ..................... 51 lamotrigine tab 200 mg ..................... 51 lamotrigine tab 25 mg ...................... 51 lamotrigine tab chewable dispersible 25 mg ................................................. 51 lamotrigine tab chewable dispersible 5 mg ...................................................... 51 lamotrigine tab sr 24hr 100 mg.......... 51 lamotrigine tab sr 24hr 200 mg.......... 51 lamotrigine tab sr 24hr 25 mg ........... 51 lamotrigine tab sr 24hr 250 mg.......... 51 lamotrigine tab sr 24hr 300 mg.......... 51 lamotrigine tab sr 24hr 50 mg ........... 51 LANTUS INJ 100/ML ......................... 70 LANTUS INJ SOLOSTAR ..................... 70 larin fe tab 1.5/30 ............................ 74 larin fe tab 1/20 ............................... 74 larin tab 1.5/30 ................................ 74 larin tab 1/20 .................................. 74 larissia tab ...................................... 74 LASTACAFT SOL 0.25%................... 101 latanoprost ophth soln 0.005% ........ 101 LATUDA TAB 120MG ......................... 63 LATUDA TAB 20MG ........................... 62 LATUDA TAB 40MG ........................... 63 LATUDA TAB 60MG ........................... 63 LATUDA TAB 80MG ........................... 63 leena tab......................................... 74 leflunomide tab 10 mg ...................... 91 leflunomide tab 20 mg ...................... 91 LENVIMA CAP 10 MG ........................ 31 LENVIMA CAP 14 MG ........................ 31 LENVIMA CAP 18 MG ........................ 31 LENVIMA CAP 20 MG ........................ 31 133

LENVIMA CAP 24 MG .........................31 LENVIMA CAP 8 MG ...........................31 lessina tab .......................................74 LETAIRIS TAB 10MG ..........................47 LETAIRIS TAB 5MG ...........................47 letrozole tab 2.5 mg ..........................30 leucovorin calcium for inj 100 mg .......33 leucovorin calcium for inj 200 mg .......33 leucovorin calcium for inj 350 mg .......33 leucovorin calcium for inj 50 mg .........33 leucovorin calcium for inj 500 mg .......33 leucovorin calcium tab 10 mg .............33 leucovorin calcium tab 15 mg .............33 leucovorin calcium tab 25 mg .............33 leucovorin calcium tab 5 mg ...............33 LEUKERAN TAB 2MG..........................26 LEUKINE INJ 250MCG ........................90 leuprolide acetate inj kit 5 mg/ml .......30 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) .................... 103 LEVEMIR INJ ....................................71 LEVEMIR INJ FLEXTOUC .....................71 LEVETIRACETA INJ 10MG/ML..............51 LEVETIRACETA INJ 15MG/ML..............51 LEVETIRACETA INJ 5MG/ML ...............51 levetiracetam inj 500 mg/5ml (100 mg/ml) ............................................51 levetiracetam oral soln 100 mg/ml ......51 levetiracetam tab 1000 mg ................52 levetiracetam tab 250 mg ..................51 levetiracetam tab 500 mg ..................52 levetiracetam tab 750 mg ..................52 levetiracetam tab sr 24hr 500 mg .......52 levetiracetam tab sr 24hr 750 mg .......52 levobunolol hcl ophth soln 0.5% ....... 101 levocarnitine inj 200 mg/ml ...............77 levocarnitine oral soln 1 gm/10ml (10%) ......................................................77 levocarnitine tab 330 mg ...................77 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) ....................... 102 levocetirizine dihydrochloride tab 5 mg .................................................... 102 levofloxacin in d5w iv soln 250 mg/50ml ......................................................23 levofloxacin in d5w iv soln 500 mg/100ml

...................................................... 23 levofloxacin in d5w iv soln 750 mg/150ml ...................................................... 23 levofloxacin iv soln 25 mg/ml ............ 23 levofloxacin oral soln 25 mg/ml.......... 23 levofloxacin tab 250 mg .................... 23 levofloxacin tab 500 mg .................... 23 levofloxacin tab 750 mg .................... 23 levoleucovor sol 250mg/25 ................ 33 levoleucovorin calcium for iv inj 50 mg (base equiv) .................................... 33 levoleucovorin calcium inj 175 mg/17.5ml (base equiv) .................................... 33 levonest tab .................................... 75 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg ............... 75 LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG ...................................................... 75 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg ..................................... 75 levonorgestrel tab 0.75 mg ............... 75 levonorgestrel tab 1.5 mg ................. 75 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg... 75 levora-28 tab 0.15/30....................... 75 levothyroxine sodium tab 100 mcg ..... 81 levothyroxine sodium tab 112 mcg ..... 81 levothyroxine sodium tab 125 mcg ..... 81 levothyroxine sodium tab 137 mcg ..... 81 levothyroxine sodium tab 150 mcg ..... 81 levothyroxine sodium tab 175 mcg ..... 81 levothyroxine sodium tab 200 mcg ..... 81 levothyroxine sodium tab 25 mcg ....... 81 levothyroxine sodium tab 300 mcg ..... 81 levothyroxine sodium tab 50 mcg ....... 81 levothyroxine sodium tab 75 mcg ....... 81 levothyroxine sodium tab 88 mcg ....... 81 LEVOXYL TAB 100MCG ...................... 81 LEVOXYL TAB 112MCG ...................... 81 LEVOXYL TAB 125MCG ...................... 81 LEVOXYL TAB 137MCG ...................... 81 LEVOXYL TAB 150MCG ...................... 81 LEVOXYL TAB 175MCG ...................... 81 LEVOXYL TAB 200MCG ...................... 81 LEVOXYL TAB 25MCG........................ 81 134

LEVOXYL TAB 50MCG ........................81 LEVOXYL TAB 75MCG ........................81 LEVOXYL TAB 88MCG ........................81 LEXIVA SUS 50MG/ML .......................17 LEXIVA TAB 700MG ...........................17 lidocaine hcl gel 2% ........................ 109 lidocaine hcl local inj 0.5% .................12 lidocaine hcl local inj 1%....................12 lidocaine hcl local inj 1.5% .................12 lidocaine hcl local inj 2%....................12 lidocaine hcl local preservative free (pf) inj 0.5% ...............................................12 lidocaine hcl local preservative free (pf) inj 1% .................................................12 lidocaine hcl soln 4% ....................... 109 lidocaine hcl viscous soln 2% ........... 110 lidocaine oint 5% ............................ 109 lidocaine patch 5%.......................... 109 lidocaine-prilocaine cream 2.5-2.5% . 109 LINEZOLID FOR SUSP 100 MG/5ML .....14 LINEZOLID IN SODIUM CHLORIDE IV SOLN 600 MG/300ML-0.9% ...............14 linezolid iv soln 600 mg/300ml (2 mg/ml) ......................................................14 LINEZOLID TAB 600 MG ....................14 LINZESS CAP 145MCG .......................86 LINZESS CAP 290MCG .......................86 liothyronine sodium tab 25 mcg ..........82 liothyronine sodium tab 5 mcg............81 liothyronine sodium tab 50 mcg ..........82 lisinopril & hydrochlorothiazide tab 10-12.5 mg ......................................35 lisinopril & hydrochlorothiazide tab 20-12.5 mg ......................................35 lisinopril & hydrochlorothiazide tab 20-25 mg ..................................................35 lisinopril tab 10 mg ...........................35 lisinopril tab 2.5 mg ..........................35 lisinopril tab 20 mg ...........................35 lisinopril tab 30 mg ...........................35 lisinopril tab 40 mg ...........................35 lisinopril tab 5 mg .............................35 lithium carbonate cap 150 mg ............68 lithium carbonate cap 300 mg ............68 lithium carbonate cap 600 mg ............68 lithium carbonate tab 300 mg.............68

lithium carbonate tab cr 300 mg ........ 68 lithium carbonate tab cr 450 mg ........ 68 LITHIUM SOL 8MEQ/5ML ................... 68 lokara lot 0.05% ............................ 108 LONSURF TAB 15-6.14 ...................... 32 LONSURF TAB 20-8.19 ...................... 32 loperamide hcl cap 2 mg ................... 86 lorazepam con 2mg/ml ..................... 49 lorazepam inj 2 mg/ml ...................... 49 lorazepam inj 4 mg/ml ...................... 49 lorazepam tab 0.5 mg ....................... 49 lorazepam tab 1 mg ......................... 49 lorazepam tab 2 mg ......................... 49 loryna tab 3-0.02mg ......................... 75 losartan potassium & hydrochlorothiazide tab 100-12.5 mg .............................. 37 losartan potassium & hydrochlorothiazide tab 100-25 mg................................. 37 losartan potassium & hydrochlorothiazide tab 50-12.5 mg................................ 37 losartan potassium tab 100 mg .......... 38 losartan potassium tab 25 mg ............ 38 losartan potassium tab 50 mg ............ 38 LOTEMAX GEL 0.5% ....................... 100 LOTEMAX OIN 0.5% ....................... 100 LOTEMAX SUS 0.5% ....................... 100 lovastatin tab 10 mg......................... 40 lovastatin tab 20 mg......................... 40 lovastatin tab 40 mg......................... 40 loxapine succinate cap 10 mg ............ 63 loxapine succinate cap 25 mg ............ 63 loxapine succinate cap 5 mg .............. 63 loxapine succinate cap 50 mg ............ 63 LUMIGAN SOL 0.01% ..................... 101 LUMIZYME INJ 50MG ........................ 77 LUPR DEP-PED INJ 11.25MG .............. 30 LUPR DEP-PED INJ 15MG .................. 30 LUPR DEP-PED INJ 30MG .................. 30 LUPR DEP-PED INJ 7.5MG ................. 30 LUPRON DEPOT INJ 11.25MG............. 30 LUPRON DEPOT INJ 3.75MG .............. 30 lutera tab ........................................ 75 LYNPARZA CAP 50MG ....................... 29 LYRICA CAP 100MG .......................... 52 LYRICA CAP 150MG .......................... 52 LYRICA CAP 200MG .......................... 52 135

LYRICA CAP 225MG ...........................52 LYRICA CAP 25MG ............................52 LYRICA CAP 300MG ...........................52 LYRICA CAP 50MG ............................52 LYRICA CAP 75MG ............................52 LYRICA SOL 20MG/ML .......................52 LYSODREN TAB 500MG ......................30 lyza tab 0.35mg ...............................75 M MAGNESIUM SU INJ 20/500ML ...........95 MAGNESIUM SU INJ 2GM/50ML ..........95 MAGNESIUM SU INJ 40G/1000 ...........95 MAGNESIUM SU INJ 4G/100ML ...........95 MAGNESIUM SU INJ 80MG/ML ............95 magnesium sulfate inj 50% ................95 MAGNESIUM SULFATE INJ 50% ..........96 magnesium sulfate iv soln 2 gm/50ml (40 mg/ml) ............................................96 malathion lotion 0.5% ..................... 109 maprotiline hcl tab 25 mg ..................57 maprotiline hcl tab 50 mg ..................57 maprotiline hcl tab 75 mg ..................57 marlissa tab 0.15/30 .........................75 MARPLAN TAB 10MG .........................57 MATULANE CAP 50MG .......................32 MAXIDEX SUS 0.1% OP ................... 100 meclizine hcl tab 12.5 mg ..................83 meclizine hcl tab 25 mg .....................83 medroxyprogesterone acetate im susp 150 mg/ml .......................................75 MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML .......75 medroxyprogesterone acetate tab 10 mg ......................................................81 medroxyprogesterone acetate tab 2.5 mg ......................................................81 medroxyprogesterone acetate tab 5 mg ......................................................81 mefloquine hcl tab 250 mg .................16 megestrol acetate susp 40 mg/ml .......30 MEGESTROL ACETATE SUSP 625 MG/5ML ......................................................30 megestrol acetate tab 20 mg ..............30 megestrol acetate tab 40 mg ..............30 MEKINIST TAB 0.5MG ........................31 MEKINIST TAB 2MG ..........................31

MELOXICAM SUSP 7.5 MG/5ML ............ 8 meloxicam tab 15 mg ......................... 8 meloxicam tab 7.5 mg ........................ 8 melphalan hcl for inj 50 mg (base equiv) ...................................................... 26 memantine hcl oral solution 2 mg/ml .. 54 memantine hcl tab 10 mg ................. 54 memantine hcl tab 5 mg ................... 54 MENACTRA INJ ................................ 95 MENHIBRIX INJ ................................ 95 MENOMUNE INJ A/C/Y/W .................. 95 MENVEO INJ .................................... 95 mercaptopurine tab 50 mg ................ 28 meropenem iv for soln 1 gm .............. 14 meropenem iv for soln 500 mg .......... 14 mesalamine enema 4 gm .................. 85 mesalamine rectal enema 4 gm & cleanser wipe kit ........................................... 85 MESALAMINE TAB DELAYED RELEASE 800 MG ................................................. 85 mesna inj 100 mg/ml ....................... 33 MESNEX TAB 400MG......................... 33 metformin hcl tab 1000 mg ............... 72 metformin hcl tab 500 mg ................. 72 metformin hcl tab 850 mg ................. 72 metformin hcl tab sr 24hr 500 mg ...... 72 metformin hcl tab sr 24hr 750 mg ...... 72 methadone con 10mg/ml .................. 10 methadone hcl soln 10 mg/5ml .......... 10 methadone hcl soln 5 mg/5ml ............ 10 methadone hcl tab 10 mg ................. 10 methadone hcl tab 5 mg ................... 10 methazolamide tab 25 mg ................. 46 methazolamide tab 50 mg ................. 46 methenamine hippurate tab 1 gm ...... 14 methimazole tab 10 mg .................... 82 methimazole tab 5 mg ...................... 82 methotrexate sodium for inj 1 gm ...... 28 methotrexate sodium inj 250 mg/10ml (25 mg/ml) ..................................... 28 METHOTREXATE SODIUM INJ 50 MG/2ML (25 MG/ML) ..................................... 28 methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) ..................................... 28 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) ........................ 28 136

methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) ......................................28 methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) ......................................28 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) ......................................28 methotrexate sodium tab 2.5 mg (base equiv) .............................................92 methyclothiazide tab 5 mg .................46 methylergonovine maleate tab 0.2 mg 80 methylphenidate hcl soln 10 mg/5ml ...66 methylphenidate hcl soln 5 mg/5ml.....66 methylphenidate hcl tab 10 mg ..........66 methylphenidate hcl tab 20 mg ..........66 methylphenidate hcl tab 5 mg ............66 methylphenidate hcl tab cr 10 mg .......66 methylphenidate hcl tab cr 20 mg .......66 methylprednisolone acetate inj susp 40 mg/ml .............................................79 methylprednisolone acetate inj susp 80 mg/ml .............................................79 methylprednisolone sodium succinate for inj 1000 mg .....................................79 methylprednisolone sodium succinate for inj 125 mg .......................................79 methylprednisolone sodium succinate for inj 40 mg .........................................79 methylprednisolone tab 16 mg ...........79 methylprednisolone tab 32 mg ...........79 methylprednisolone tab 4 mg .............79 methylprednisolone tab 8 mg .............79 methylprednisolone tab therapy pack 4 mg (21) ...........................................79 metipranolol ophth soln 0.3% ........... 101 metoclopramide hcl inj 5 mg/ml .........83 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) ........................................83 metoclopramide hcl tab 10 mg ...........83 metoclopramide hcl tab 5 mg .............83 metolazone tab 10 mg .......................46 metolazone tab 2.5 mg ......................46 metolazone tab 5 mg ........................46 metoprolol & hydrochlorothiazide tab 100-25 mg .......................................41 metoprolol & hydrochlorothiazide tab 100-50 mg .......................................41

metoprolol & hydrochlorothiazide tab 50-25 mg ........................................ 41 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) ................................ 42 metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) ................................ 42 metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) ................................ 42 metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) ................................ 42 metoprolol tartrate inj 1 mg/ml .......... 42 metoprolol tartrate tab 100 mg .......... 42 metoprolol tartrate tab 25 mg............ 42 metoprolol tartrate tab 50 mg............ 42 metronidazole cream 0.75% ............ 109 metronidazole gel 0.75% ................ 109 metronidazole in nacl 0.79% iv soln 500 mg/100ml ....................................... 14 metronidazole lotion 0.75% ............. 109 metronidazole tab 250 mg................. 14 metronidazole tab 500 mg................. 14 metronidazole vaginal gel 0.75% ....... 88 mexiletine hcl cap 150 mg ................. 38 mexiletine hcl cap 200 mg ................. 38 mexiletine hcl cap 250 mg ................. 38 MG SO4/D5W INJ 10MG/ML ............... 96 MG SO4/D5W INJ 20MG/ML ............... 96 MIACALCIN INJ 200/ML ..................... 80 midodrine hcl tab 10 mg ................... 46 midodrine hcl tab 2.5 mg .................. 46 midodrine hcl tab 5 mg ..................... 46 minitran dis 0.1mg/hr ....................... 47 minitran dis 0.2mg/hr ....................... 47 minitran dis 0.4mg/hr ....................... 47 minitran dis 0.6mg/hr ....................... 47 minocycline hcl cap 100 mg ............... 26 minocycline hcl cap 50 mg ................ 26 minocycline hcl cap 75 mg ................ 26 minoxidil tab 10 mg.......................... 46 minoxidil tab 2.5 mg......................... 46 mirtazapine orally disintegrating tab 15 mg ................................................. 57 mirtazapine orally disintegrating tab 30 mg ................................................. 57 mirtazapine orally disintegrating tab 45 mg ................................................. 57 137

mirtazapine tab 15 mg ......................57 mirtazapine tab 30 mg ......................57 mirtazapine tab 45 mg ......................57 mirtazapine tab 7.5 mg .....................57 misoprostol tab 100 mcg ...................86 misoprostol tab 200 mcg ...................86 mitomycin for iv soln 20 mg ...............27 mitomycin for iv soln 40 mg ...............27 mitomycin for iv soln 5 mg .................27 mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) ............................................32 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) ........................................32 mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) ............................................32 M-M-R II INJ ....................................95 moderiba pak 1000/day .....................20 MODERIBA PAK 1200/DAY .................20 moderiba pak 600/day ......................19 moderiba pak 800/day ......................20 moexipril hcl tab 15 mg .....................36 moexipril hcl tab 7.5 mg ....................35 moexipril-hydrochlorothiazide tab 15-12.5 mg ......................................35 moexipril-hydrochlorothiazide tab 15-25 mg ..................................................35 moexipril-hydrochlorothiazide tab 7.5-12.5 mg .....................................35 molindone hcl tab 10 mg ...................63 molindone hcl tab 25 mg ...................63 molindone hcl tab 5 mg .....................63 mometasone furoate cream 0.1% ..... 108 mometasone furoate nasal susp 50 mcg/act ......................................... 104 mometasone furoate oint 0.1% ........ 108 mometasone furoate solution 0.1% (lotion) .......................................... 108 MONONESSA TAB .............................75 montelukast sodium chew tab 4 mg (base equiv) ........................................... 103 montelukast sodium chew tab 5 mg (base equiv) ........................................... 103 montelukast sodium oral granules packet 4 mg (base equiv) .......................... 103 montelukast sodium tab 10 mg (base equiv) ........................................... 103

morgidox cap 1x50mg ...................... 26 MORPHINE SUL INJ 2MG/ML .............. 11 MORPHINE SUL INJ 4MG/ML .............. 11 MORPHINE SUL INJ 8MG/ML .............. 11 morphine sulfate beads cap sr 24hr 120 mg ................................................. 11 morphine sulfate beads cap sr 24hr 30 mg ...................................................... 11 morphine sulfate beads cap sr 24hr 45 mg ...................................................... 11 morphine sulfate beads cap sr 24hr 60 mg ...................................................... 11 morphine sulfate beads cap sr 24hr 75 mg ...................................................... 11 morphine sulfate beads cap sr 24hr 90 mg ...................................................... 11 morphine sulfate cap sr 24hr 10 mg ... 11 morphine sulfate cap sr 24hr 100 mg . 11 morphine sulfate cap sr 24hr 20 mg ... 11 morphine sulfate cap sr 24hr 30 mg ... 11 morphine sulfate cap sr 24hr 50 mg ... 11 morphine sulfate cap sr 24hr 60 mg ... 11 morphine sulfate cap sr 24hr 80 mg ... 11 morphine sulfate inj pf 0.5 mg/ml ...... 11 morphine sulfate inj pf 1 mg/ml ......... 11 MORPHINE SULFATE IV SOLN 1 MG/ML11 MORPHINE SULFATE IV SOLN PF 10 MG/ML ............................................ 11 MORPHINE SULFATE IV SOLN PF 15 MG/ML ............................................ 11 morphine sulfate iv soln pf 4 mg/ml ... 11 morphine sulfate iv soln pf 8 mg/ml ... 11 MORPHINE SULFATE ORAL SOLN 10 MG/5ML .......................................... 11 MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) ........................ 11 MORPHINE SULFATE ORAL SOLN 20 MG/5ML .......................................... 11 MORPHINE SULFATE TAB 15 MG ........ 11 MORPHINE SULFATE TAB 30 MG ........ 11 morphine sulfate tab cr 100 mg ......... 11 morphine sulfate tab cr 15 mg ........... 11 morphine sulfate tab cr 200 mg ......... 11 morphine sulfate tab cr 30 mg ........... 11 morphine sulfate tab cr 60 mg ........... 11 MOVANTIK TAB 12.5MG .................... 86 138

MOVANTIK TAB 25MG .......................86 MOVIPREP SOL .................................86 MOXEZA SOL 0.5% ......................... 100 MOZOBIL INJ ...................................90 MULTAQ TAB 400MG .........................38 mupirocin oint 2% .......................... 106 MUSTARGEN INJ 10MG ......................26 MYCAMINE INJ 100MG .......................16 MYCAMINE INJ 50MG ........................16 mycophenolate mofetil cap 250 mg .....93 mycophenolate mofetil for oral susp 200 mg/ml .............................................93 mycophenolate mofetil tab 500 mg .....93 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)..................94 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)..................94 myorisan cap 10mg......................... 105 myorisan cap 20mg......................... 105 myorisan cap 30mg......................... 105 myorisan cap 40mg......................... 105 MYOZYME INJ 50MG ..........................77 MYRBETRIQ TAB 25MG ......................88 MYRBETRIQ TAB 50MG ......................88 myzilra tab.......................................75 N nabumetone tab 500 mg..................... 8 nabumetone tab 750 mg..................... 9 nadolol tab 20 mg .............................42 nadolol tab 40 mg .............................42 nadolol tab 80 mg .............................42 nafcillin sodium for inj 1 gm ...............25 nafcillin sodium for inj 10 gm .............25 nafcillin sodium for inj 2 gm ...............25 nafcillin sodium for iv soln 1 gm .........25 nafcillin sodium for iv soln 2 gm .........25 NAGLAZYME INJ 1MG/ML ...................77 nalbuphine hcl inj 10 mg/ml ................ 9 nalbuphine hcl inj 20 mg/ml ................ 9 naloxone hcl inj 0.4 mg/ml.................69 naloxone hcl inj 4 mg/10ml ................69 naloxone hcl soln cartridge 0.4 mg/ml .69 naloxone hcl soln prefilled syringe 2 mg/2ml ...........................................70 naltrexone hcl tab 50 mg ...................70 NAMENDA XR CAP 14MG ....................54

NAMENDA XR CAP 21MG ................... 54 NAMENDA XR CAP 28MG ................... 54 NAMENDA XR CAP 7MG ..................... 54 NAMENDA XR CAP TITRATIO.............. 54 NAMZARIC CAP 14-10MG .................. 55 NAMZARIC CAP 21-10MG .................. 55 NAMZARIC CAP 28-10MG .................. 55 NAMZARIC CAP 7-10MG .................... 54 naphazoline hcl ophth soln 0.1% ...... 101 naproxen dr tab 375mg ...................... 9 naproxen dr tab 500mg ...................... 9 naproxen sodium tab 275 mg .............. 9 naproxen sodium tab 550 mg .............. 9 naproxen susp 125 mg/5ml ................. 9 naproxen tab 250 mg ......................... 9 naproxen tab 375 mg ......................... 9 naproxen tab 500 mg ......................... 9 naratriptan hcl tab 1 mg (base equiv) . 67 naratriptan hcl tab 2.5 mg (base equiv) ...................................................... 67 NASONEX SPR 50MCG/AC ............... 104 NATACYN SUS 5% OP ..................... 100 nateglinide tab 120 mg ..................... 72 nateglinide tab 60 mg ....................... 72 NATPARA INJ 100MCG ...................... 81 NATPARA INJ 25MCG ........................ 81 NATPARA INJ 50MCG ........................ 81 NATPARA INJ 75MCG ........................ 81 NEBUPENT INH 300MG ..................... 14 necon tab 0.5/35 ............................. 75 necon tab 1/35 ................................ 75 NECON TAB 1/50-28 ......................... 75 necon tab 10/11-28 .......................... 75 NECON TAB 7/7/7 ............................ 75 nefazodone hcl tab 100 mg ............... 57 nefazodone hcl tab 150 mg ............... 57 nefazodone hcl tab 200 mg ............... 57 nefazodone hcl tab 250 mg ............... 58 nefazodone hcl tab 50 mg ................. 57 neomycin sulfate tab 500 mg ............. 12 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin ... 100 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ..... 100 neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................... 99 139

neomycin-polymyxin-dexamethasone ophth susp 0.1% ..............................99 neomycin-polymyxin-hc ophth susp ....99 neomycin-polymyxin-hc otic soln 1% 110 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ................ 110 NEORAL CAP 100MG..........................94 NEORAL CAP 25MG ...........................94 NEORAL SOL 100MG/ML ....................94 NEPHRAMINE INJ 5.4% .....................97 NEUMEGA INJ 5MG ...........................90 NEUPOGEN INJ 300/0.5 .....................90 NEUPOGEN INJ 300MCG ....................90 NEUPOGEN INJ 480/0.8 .....................90 NEUPOGEN INJ 480MCG ....................90 NEUPRO DIS 1MG/24HR ....................60 NEUPRO DIS 2MG/24HR ....................60 NEUPRO DIS 3MG/24HR ....................60 NEUPRO DIS 4MG/24HR ....................60 NEUPRO DIS 6MG/24HR ....................60 NEUPRO DIS 8MG/24HR ....................60 NEVIRAPINE SUSP 50 MG/5ML ...........17 nevirapine tab 200 mg ......................17 nevirapine tab sr 24hr 100 mg ...........17 nevirapine tab sr 24hr 400 mg ...........17 NEXAVAR TAB 200MG........................31 NEXIUM CAP 20MG ...........................87 NEXIUM CAP 40MG ...........................87 NEXIUM GRA 10MG DR ......................87 NEXIUM GRA 2.5MG DR .....................87 NEXIUM GRA 20MG DR ......................87 NEXIUM GRA 40MG DR ......................87 NEXIUM GRA 5MG DR ........................87 niacin tab cr 1000 mg (antihyperlipidemic) ......................................................41 niacin tab cr 500 mg (antihyperlipidemic) ......................................................41 niacin tab cr 750 mg (antihyperlipidemic) ......................................................41 niacor tab 500mg .............................41 nicardipine hcl cap 20 mg ..................44 nicardipine hcl cap 30 mg ..................44 NICOTROL INH .................................70 NICOTROL NS SPR 10MG/ML ..............70 nifedical xl tab 30mg .........................44 nifedical xl tab 60mg .........................44

nifedipine tab sr 24hr 30 mg.............. 44 nifedipine tab sr 24hr 60 mg.............. 44 nifedipine tab sr 24hr 90 mg.............. 44 nifedipine tab sr 24hr osmotic release 30 mg ................................................. 44 nifedipine tab sr 24hr osmotic release 60 mg ................................................. 44 nifedipine tab sr 24hr osmotic release 90 mg ................................................. 44 nikki tab 3-0.02mg ........................... 75 NILANDRON TAB 150MG ................... 30 nilutamide tab 150 mg ...................... 30 nimodipine cap 30 mg ...................... 44 NINLARO CAP 2.3MG ........................ 29 NINLARO CAP 3MG ........................... 29 NINLARO CAP 4MG ........................... 29 NIPENT INJ 10MG............................. 28 nitro-bid oin 2% ............................... 47 NITRO-DUR DIS 0.3MG/HR ................ 47 NITRO-DUR DIS 0.8MG/HR ................ 47 nitrofurantoin macrocrystalline cap 100 mg ................................................. 14 nitrofurantoin macrocrystalline cap 50 mg ...................................................... 14 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............. 14 nitroglycerin sl tab 0.3 mg................. 47 nitroglycerin sl tab 0.4 mg................. 47 nitroglycerin sl tab 0.6 mg................. 47 nitroglycerin td patch 24hr 0.1 mg/hr . 47 nitroglycerin td patch 24hr 0.2 mg/hr . 47 nitroglycerin td patch 24hr 0.4 mg/hr . 47 nitroglycerin td patch 24hr 0.6 mg/hr . 47 NITROSTAT SUB 0.3MG .................... 47 NITROSTAT SUB 0.4MG .................... 47 NITROSTAT SUB 0.6MG .................... 47 NORDITROPIN INJ 10/1.5ML.............. 80 NORDITROPIN INJ 15/1.5ML.............. 80 NORDITROPIN INJ 30/3ML ................ 80 NORDITROPIN INJ 5/1.5ML ............... 80 norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr ............................. 75 NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG .......... 75 NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG........ 75 140

NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG ......75 NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG ....75 norethindrone acetate tab 5 mg ..........81 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg ................................78 norethindrone tab 0.35 mg ................75 NORETHINDRONE TAB 0.35 MG ..........75 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg ......................................75 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg ....76 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg ......................................76 norlyroc tab 0.35mg ..........................76 NORMOSOL -M INJ /D5W ...................98 NORMOSOL -R INJ /D5W ...................98 NORMOSOL-R INJ PH 7.4 ...................98 NORPACE CAP 100MG CR ...................39 NORPACE CAP 150MG CR ...................39 nortrel tab 0.5/35 .............................76 nortrel tab 1/35 ................................76 nortrel tab 7/7/7 ...............................76 nortriptyline hcl cap 10 mg ................58 nortriptyline hcl cap 25 mg ................58 nortriptyline hcl cap 50 mg ................58 nortriptyline hcl cap 75 mg ................58 nortriptyline hcl soln 10 mg/5ml .........58 NORVIR CAP 100MG ..........................17 NORVIR SOL 80MG/ML ......................17 NORVIR TAB 100MG ..........................17 NOVOLIN INJ 70/30 ..........................71 NOVOLIN N INJ U-100 .......................71 NOVOLIN R INJ U-100 .......................71 NOVOLOG INJ 100/ML .......................71 NOVOLOG INJ FLEXPEN .....................71 NOVOLOG INJ PENFILL ......................71 NOVOLOG MIX INJ 70/30 ...................71 NOVOLOG MIX INJ FLEXPEN ...............71 NOXAFIL SUS 40MG/ML .....................16 NOXAFIL TAB 100MG.........................16 NUEDEXTA CAP 20-10MG ...................68 NULOJIX INJ 250MG ..........................94 NULYTELY SOL FLAV PKS ...................86 NUPLAZID TAB 17MG ........................63

NUVARING MIS ................................ 76 NUVIGIL TAB 150MG ........................ 69 NUVIGIL TAB 200MG ........................ 69 NUVIGIL TAB 250MG ........................ 69 NUVIGIL TAB 50MG .......................... 69 nyamyc pow 100000 ...................... 106 NYMALIZE SOL 60/20ML ................... 44 nystatin cream 100000 unit/gm ....... 106 nystatin oint 100000 unit/gm .......... 106 nystatin susp 100000 unit/ml .......... 110 nystatin tab 500000 unit ................... 16 nystatin topical powder ................... 106 nystop pow 100000 ........................ 106 O OCTAGAM INJ 10GM ......................... 92 OCTAGAM INJ 1GM ........................... 92 OCTAGAM INJ 2.5GM ........................ 92 OCTAGAM INJ 25GM ......................... 92 OCTAGAM INJ 2GM/20ML .................. 92 OCTAGAM INJ 5GM ........................... 92 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ........................................... 80 octreotide acetate inj 1000 mcg/ml (1 mg/ml) ........................................... 80 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) ........................................... 80 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) ........................................... 80 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ........................................... 80 ODEFSEY TAB .................................. 18 ODOMZO CAP 200MG ....................... 32 OFEV CAP 100MG ........................... 103 OFEV CAP 150MG ........................... 103 ofloxacin ophth soln 0.3% ............... 100 ofloxacin otic soln 0.3% .................. 110 olanzapine for im inj 10 mg ............... 63 olanzapine orally disintegrating tab 10 mg ...................................................... 63 olanzapine orally disintegrating tab 15 mg ...................................................... 63 olanzapine orally disintegrating tab 20 mg ...................................................... 63 olanzapine orally disintegrating tab 5 mg ...................................................... 63 olanzapine tab 10 mg ....................... 63 141

olanzapine tab 15 mg ........................63 olanzapine tab 2.5 mg .......................63 olanzapine tab 20 mg ........................63 olanzapine tab 5 mg ..........................63 olanzapine tab 7.5 mg .......................63 olopatadine hcl nasal soln 0.6% ........ 102 omega-3-acid ethyl esters cap 1 gm....41 omeprazole cap delayed release 10 mg87 omeprazole cap delayed release 20 mg87 omeprazole cap delayed release 40 mg87 ondansetron hcl inj 4 mg/2ml (2 mg/ml) ......................................................83 ondansetron hcl inj 40 mg/20ml (2 mg/ml) ............................................83 ondansetron hcl oral soln 4 mg/5ml ....83 ondansetron hcl tab 24 mg ................83 ondansetron hcl tab 4 mg ..................83 ondansetron hcl tab 8 mg ..................83 ondansetron orally disintegrating tab 4 mg ..................................................83 ondansetron orally disintegrating tab 8 mg ..................................................83 ONFI SUS 2.5MG/ML .........................52 ONFI TAB 10MG ................................52 ONFI TAB 20MG ................................52 OPSUMIT TAB 10MG ..........................48 ORFADIN CAP 10MG ..........................77 ORFADIN CAP 20MG ..........................77 ORFADIN CAP 2MG ...........................77 ORFADIN CAP 5MG ...........................77 ORFADIN SUS 4MG/ML ......................77 ORKAMBI TAB 200-125 ................... 103 orsythia tab .....................................76 oxacillin sodium for inj 1 gm ..............25 oxacillin sodium for inj 10 gm .............25 oxacillin sodium for inj 2 gm ..............25 oxaliplatin for iv inj 100 mg................33 oxaliplatin for iv inj 50 mg .................33 oxaliplatin iv soln 100 mg/20ml ..........33 oxaliplatin iv soln 50 mg/10ml ............33 oxandrolone tab 10 mg......................70 oxandrolone tab 2.5 mg.....................70 oxcarbazepine susp 300 mg/5ml (60 mg/ml) ............................................52 oxcarbazepine tab 150 mg .................52 oxcarbazepine tab 300 mg .................52

oxcarbazepine tab 600 mg ................ 52 oxybutynin chloride syrup 5 mg/5ml ... 88 oxybutynin chloride tab 5 mg ............ 88 oxybutynin chloride tab sr 24hr 10 mg 88 oxybutynin chloride tab sr 24hr 15 mg 88 oxybutynin chloride tab sr 24hr 5 mg . 88 oxycodone hcl cap 5 mg .................... 11 oxycodone hcl conc 100 mg/5ml (20 mg/ml) ........................................... 11 OXYCODONE HCL SOLN 5 MG/5ML ..... 11 oxycodone hcl tab 10 mg .................. 12 oxycodone hcl tab 15 mg .................. 12 oxycodone hcl tab 20 mg .................. 12 oxycodone hcl tab 30 mg .................. 12 oxycodone hcl tab 5 mg .................... 12 oxycodone w/ acetaminophen soln 5-325 mg/5ml ........................................... 12 oxycodone w/ acetaminophen tab 10-325 mg ................................................. 12 oxycodone w/ acetaminophen tab 2.5-325 mg ................................................. 12 oxycodone w/ acetaminophen tab 5-325 mg ................................................. 12 oxycodone w/ acetaminophen tab 7.5-325 mg ................................................. 12 P pacerone tab 100mg......................... 39 pacerone tab 200mg......................... 39 pacerone tab 400mg......................... 39 paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) ........................................... 28 paclitaxel iv conc 150 mg/25ml (6 mg/ml) ...................................................... 28 paclitaxel iv conc 30 mg/5ml (6 mg/ml) ...................................................... 28 paclitaxel iv conc 300 mg/50ml (6 mg/ml) ...................................................... 28 paliperidone tab sr 24hr 1.5 mg ......... 63 paliperidone tab sr 24hr 3 mg ............ 63 paliperidone tab sr 24hr 6 mg ............ 63 paliperidone tab sr 24hr 9 mg ............ 63 pamidronate disodium iv soln 3 mg/ml 73 pamidronate disodium iv soln 9 mg/ml 73 pamidronate inj 6mg/ml.................... 73 PANRETIN GEL 0.1% ...................... 109 pantoprazole sodium ec tab 20 mg (base 142

equiv) .............................................87 pantoprazole sodium ec tab 40 mg (base equiv) .............................................87 paricalcitol cap 1 mcg ........................99 paricalcitol cap 2 mcg ........................99 paricalcitol cap 4 mcg ........................99 paromomycin sulfate cap 250 mg .......13 paroxetine hcl tab 10 mg ...................58 paroxetine hcl tab 20 mg ...................58 paroxetine hcl tab 30 mg ...................58 paroxetine hcl tab 40 mg ...................58 paser gra 4gm ..................................19 PATADAY SOL 0.2% ........................ 101 PAXIL SUS 10MG/5ML .......................58 PAZEO DRO 0.7% ........................... 101 PEDIARIX INJ 0.5ML ..........................95 PEDVAX HIB INJ ...............................95 PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM...............86 PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM...............86 peg 3350-kcl-sod bicarb-nacl for soln 420 gm ..................................................86 PEGANONE TAB 250MG .....................52 PEGASYS INJ ....................................20 PEGASYS INJ 180MCG/M ...................20 PEGASYS INJ PROCLICK ....................20 PEG-INTRON KIT 120 RP....................20 PEGINTRON KIT 120MCG ...................20 PEG-INTRON KIT 150 RP....................20 PEGINTRON KIT 150MCG ...................20 PEGINTRON KIT 50MCG .....................20 PEG-INTRON KIT 50MCG RP ...............20 PEGINTRON KIT 80MCG .....................20 PEG-INTRON KIT 80MCG RP ...............20 pen g proc inj 600000 .......................25 PENICILL GK/ INJ DEX 2MU ................25 PENICILL GK/ INJ DEX 3MU ................25 penicillin g potassium for inj 20000000 unit .................................................25 penicillin g potassium for inj 5000000 unit ......................................................25 penicillin g sodium for inj 5000000 unit ......................................................25 penicillin v potassium for soln 125 mg/5ml ......................................................25

penicillin v potassium for soln 250 mg/5ml ...................................................... 25 penicillin v potassium tab 250 mg ...... 25 penicillin v potassium tab 500 mg ...... 25 PENTACEL INJ .................................. 95 PENTAM 300 INJ 300MG.................... 14 pentoxifylline tab cr 400 mg .............. 91 PERFOROMIST NEB 20MCG ............. 103 perindopril erbumine tab 2 mg ........... 36 perindopril erbumine tab 4 mg ........... 36 perindopril erbumine tab 8 mg ........... 36 periogard sol 0.12% ....................... 110 permethrin cream 5% ..................... 109 perphenazine tab 16 mg ................... 63 perphenazine tab 2 mg ..................... 63 perphenazine tab 4 mg ..................... 63 perphenazine tab 8 mg ..................... 63 phenadoz sup 12.5mg ...................... 83 phenelzine sulfate tab 15 mg ............. 58 phenergan sup 12.5mg ..................... 83 phenergan sup 25mg ........................ 83 phenergan sup 50mg ........................ 83 PHENOBARB INJ 65MG/ML ................ 52 phenobarbital elixir 20 mg/5ml .......... 52 phenobarbital sodium inj 130 mg/ml .. 52 phenobarbital tab 100 mg ................. 53 phenobarbital tab 15 mg ................... 52 phenobarbital tab 16.2 mg ................ 52 phenobarbital tab 30 mg ................... 52 phenobarbital tab 32.4 mg ................ 52 phenobarbital tab 60 mg ................... 52 phenobarbital tab 64.8 mg ................ 52 phenobarbital tab 97.2 mg ................ 52 phenytek cap 200mg ........................ 53 phenytek cap 300mg ........................ 53 phenytoin chew tab 50 mg ................ 53 phenytoin sodium extended cap 100 mg ...................................................... 53 phenytoin sodium extended cap 200 mg ...................................................... 53 phenytoin sodium extended cap 300 mg ...................................................... 53 phenytoin sodium inj 50 mg/ml ......... 53 phenytoin susp 125 mg/5ml .............. 53 philith tab 0.4-35 ............................. 76 PHOSPHOLINE SOL 0.125%OP ......... 101 143

PILOCARPINE HCL OPHTH SOLN 1% . 101 PILOCARPINE HCL OPHTH SOLN 2% . 101 PILOCARPINE HCL OPHTH SOLN 4% . 101 PILOCARPINE HCL TAB 5 MG ............ 110 pilocarpine hcl tab 7.5 mg ................ 110 pimozide tab 1 mg ............................63 pimozide tab 2 mg ............................63 pimtrea tab ......................................76 pindolol tab 10 mg ............................42 pindolol tab 5 mg ..............................42 pioglitazone hcl tab 15 mg (base equiv) ......................................................72 pioglitazone hcl tab 30 mg (base equiv) ......................................................72 pioglitazone hcl tab 45 mg (base equiv) ......................................................72 piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) .....................25 piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) ........................25 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) .................................25 piperacillin sod-tazobactam sod for inj 40.5 gm (36-4.5 gm) ........................25 pirmella tab 1/35 ..............................76 piroxicam cap 10 mg .......................... 9 piroxicam cap 20 mg .......................... 9 PLASMA-LYTE INJ -148 ......................98 PLASMA-LYTE INJ 56/D5W .................98 PLASMA-LYTE INJ -A .........................98 podofilox soln 0.5% ........................ 109 polyethylene glycol 3350 oral packet ...86 polyethylene glycol 3350 oral powder ..86 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% ....................... 100 POMALYST CAP 1MG .........................32 POMALYST CAP 2MG .........................32 POMALYST CAP 3MG .........................32 POMALYST CAP 4MG .........................32 portia-28 tab ....................................76 POTASSIUM CHLORIDE 20 MEQ/L (0.15%) IN DEXTROSE 5% INJ ...........98 POTASSIUM CHLORIDE 40 MEQ/L (0.3%) IN DEXTROSE 5% INJ .......................98 potassium chloride cap cr 10 meq .......96 potassium chloride cap cr 8 meq .........96

POTASSIUM CHLORIDE INJ 10 MEQ/100ML ..................................... 98 POTASSIUM CHLORIDE INJ 10 MEQ/50ML ...................................................... 98 potassium chloride inj 2 meq/ml ........ 98 POTASSIUM CHLORIDE INJ 20 MEQ/100ML ..................................... 98 POTASSIUM CHLORIDE INJ 20 MEQ/50ML ...................................................... 98 POTASSIUM CHLORIDE INJ 40 MEQ/100ML ..................................... 98 potassium chloride microencapsulated crys cr tab 10 meq ........................... 96 potassium chloride microencapsulated crys cr tab 20 meq ........................... 96 POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)................................ 96 POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)................................ 96 POTASSIUM CHLORIDE TAB CR 10 MEQ ...................................................... 96 POTASSIUM CHLORIDE TAB CR 20 MEQ (1500 MG) ...................................... 96 potassium chloride tab cr 8 meq (600 mg) ...................................................... 96 POTASSIUM CITRATE TAB CR 10 MEQ (1080 MG) ...................................... 88 potassium citrate tab cr 15 meq (1620 mg) ................................................ 88 POTASSIUM CITRATE TAB CR 5 MEQ (540 MG) ................................................ 88 POTIGA TAB 200MG ......................... 53 POTIGA TAB 300MG ......................... 53 POTIGA TAB 400MG ......................... 53 POTIGA TAB 50MG ........................... 53 PRADAXA CAP 110MG ....................... 90 PRADAXA CAP 150MG ....................... 90 PRADAXA CAP 75MG ......................... 90 PRALUENT INJ 150MG/ML ................. 41 PRALUENT INJ 75MG/ML ................... 41 pramipexole dihydrochloride tab 0.125 mg ................................................. 60 pramipexole dihydrochloride tab 0.25 mg ...................................................... 60 pramipexole dihydrochloride tab 0.5 mg ...................................................... 60 144

pramipexole dihydrochloride tab 0.75 mg ......................................................60 pramipexole dihydrochloride tab 1 mg .60 pramipexole dihydrochloride tab 1.5 mg ......................................................60 pravastatin sodium tab 10 mg ............40 pravastatin sodium tab 20 mg ............40 pravastatin sodium tab 40 mg ............40 pravastatin sodium tab 80 mg ............40 prazosin hcl cap 1 mg........................36 prazosin hcl cap 2 mg........................36 prazosin hcl cap 5 mg........................36 pred sod pho sol 1% op ................... 100 PREDNISOLONE ACETATE OPHTH SUSP 1% ............................................... 100 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) ...................79 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) .........................79 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) ........................79 prednisolone syrup 15 mg/5ml (usp solution equivalent)...........................79 prednisone con 5mg/ml .....................79 prednisone oral soln 5 mg/5ml ...........79 prednisone tab 1 mg .........................79 prednisone tab 10 mg .......................79 prednisone tab 2.5 mg ......................79 prednisone tab 20 mg .......................79 prednisone tab 5 mg .........................79 prednisone tab 50 mg .......................79 prednisone tab therapy pack 10 mg (21) ......................................................79 prednisone tab therapy pack 10 mg (48) ......................................................79 prednisone tab therapy pack 5 mg (21) ......................................................79 prednisone tab therapy pack 5 mg (48) ......................................................79 premasol sol 10% .............................97 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) .................................99 prevalite pow 4gm ............................41 prevalite pow 4gm pk ........................41 previfem tab ....................................76 PREZCOBIX TAB 800-150 ..................18

PREZISTA SUS 100MG/ML ................. 17 PREZISTA TAB 150MG ...................... 17 PREZISTA TAB 600MG ...................... 17 PREZISTA TAB 75MG ........................ 17 PREZISTA TAB 800MG ...................... 17 PRIFTIN TAB 150MG ......................... 19 PRIMAQUINE TAB 26.3MG ................. 16 primidone tab 250 mg ...................... 53 primidone tab 50 mg ........................ 53 PRISTIQ TAB 100MG ........................ 58 PRISTIQ TAB 25MG .......................... 58 PRISTIQ TAB 50MG .......................... 58 PRIVIGEN INJ 10GRAMS ................... 93 PRIVIGEN INJ 20GRAMS ................... 93 PRIVIGEN INJ 40GRAMS ................... 93 PRIVIGEN INJ 5 GRAMS .................... 93 probenecid tab 500 mg ....................... 8 PROCALAMINE INJ 3% ...................... 97 prochlorperazine edisylate inj 5 mg/ml 83 prochlorperazine maleate tab 10 mg (base equivalent) ...................................... 84 prochlorperazine maleate tab 5 mg (base equivalent) ...................................... 84 prochlorperazine suppos 25 mg.......... 84 PROCRIT INJ 10000/ML..................... 90 PROCRIT INJ 2000/ML ...................... 90 PROCRIT INJ 20000/ML..................... 90 PROCRIT INJ 3000/ML ...................... 90 PROCRIT INJ 4000/ML ...................... 90 PROCRIT INJ 40000/ML..................... 90 procto-med cre hc 2.5% ................. 106 procto-pak cre 1% ......................... 106 proctozone cre -hc 2.5% ................. 106 PROGLYCEM SUS 50MG/ML ............... 79 PROGRAF CAP 0.5MG ........................ 94 PROGRAF CAP 1MG .......................... 94 PROGRAF CAP 5MG .......................... 94 PROLASTIN-C INJ 1000MG .............. 103 PROLENSA SOL 0.07% .................... 101 PROLEUKIN INJ 22MU ....................... 29 PROLIA SOL 60MG/ML ...................... 80 PROMACTA TAB 12.5MG .................... 91 PROMACTA TAB 25MG ...................... 91 PROMACTA TAB 50MG ...................... 91 PROMACTA TAB 75MG ...................... 91 promethazine hcl inj 25 mg/ml .......... 84 145

promethazine hcl inj 50 mg/ml ...........84 promethazine hcl suppos 12.5 mg .......84 promethazine hcl suppos 25 mg .........84 promethazine hcl suppos 50 mg .........84 promethazine hcl syrup 6.25 mg/5ml ..84 promethazine hcl tab 12.5 mg ............84 promethazine hcl tab 25 mg ...............84 promethazine hcl tab 50 mg ...............84 promethegan sup 25mg .....................84 promethegan sup 50mg .....................84 propafenone hcl cap sr 12hr 225 mg ...39 propafenone hcl cap sr 12hr 325 mg ...39 propafenone hcl cap sr 12hr 425 mg ...39 propafenone hcl tab 150 mg...............39 propafenone hcl tab 225 mg...............39 propafenone hcl tab 300 mg...............39 proparacaine hcl ophth soln 0.5% ..... 101 propranolol & hydrochlorothiazide tab 40-25 mg ........................................41 propranolol & hydrochlorothiazide tab 80-25 mg ........................................41 propranolol hcl cap sr 24hr 120 mg .....42 propranolol hcl cap sr 24hr 160 mg .....42 propranolol hcl cap sr 24hr 60 mg .......42 propranolol hcl cap sr 24hr 80 mg .......42 propranolol hcl inj 1 mg/ml ................42 propranolol hcl oral soln 20 mg/5ml ....42 propranolol hcl oral soln 40 mg/5ml ....42 propranolol hcl tab 10 mg ..................42 propranolol hcl tab 20 mg ..................42 propranolol hcl tab 40 mg ..................42 propranolol hcl tab 60 mg ..................42 propranolol hcl tab 80 mg ..................42 propylthiouracil tab 50 mg .................82 PROQUAD INJ ...................................95 PROSOL INJ 20% ..............................97 protriptyline hcl tab 10 mg .................58 protriptyline hcl tab 5 mg...................58 PRUDOXIN CRE 5% ......................... 106 PULMICORT INH 180MCG ................. 104 PULMICORT INH 90MCG .................. 104 PULMOZYME SOL 1MG/ML ................ 103 PURIXAN SUS 20MG/ML.....................28 pyrazinamide tab 500 mg ..................19 pyridostigmine bromide tab 60 mg ......68

Q QUADRACEL INJ ............................... 95 quasense tab ................................... 76 quetiapine fumarate tab 100 mg ........ 63 quetiapine fumarate tab 200 mg ........ 63 quetiapine fumarate tab 25 mg .......... 63 quetiapine fumarate tab 300 mg ........ 63 quetiapine fumarate tab 400 mg ........ 63 quetiapine fumarate tab 50 mg .......... 63 quinapril hcl tab 10 mg ..................... 36 quinapril hcl tab 20 mg ..................... 36 quinapril hcl tab 40 mg ..................... 36 quinapril hcl tab 5 mg ....................... 36 quinapril-hydrochlorothiazide tab 10-12.5 mg ................................................. 35 quinapril-hydrochlorothiazide tab 20-12.5 mg ................................................. 35 quinapril-hydrochlorothiazide tab 20-25 mg ................................................. 35 quinidine gluconate tab cr 324 mg...... 39 quinidine sulfate tab 200 mg ............. 39 quinidine sulfate tab 300 mg ............. 39 quinine sulfate cap 324 mg ............... 16 R RABAVERT INJ ................................. 95 raloxifene hcl tab 60 mg ................... 80 ramipril cap 1.25 mg ........................ 36 ramipril cap 10 mg ........................... 36 ramipril cap 2.5 mg .......................... 36 ramipril cap 5 mg ............................. 36 RANEXA TAB 1000MG ....................... 46 RANEXA TAB 500MG ......................... 46 ranitidine hcl inj 50 mg/2ml (25 mg/ml) ...................................................... 85 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ......................................... 85 ranitidine hcl tab 150 mg .................. 85 ranitidine hcl tab 300 mg .................. 85 ranitidine inj 150/6ml ....................... 85 RAPAMUNE SOL 1MG/ML ................... 94 RAVICTI LIQ 1.1GM/ML ..................... 77 REBETOL SOL 40MG/ML .................... 20 reclipsen tab .................................... 76 RECOMBIVA HB INJ 10MCG/ML .......... 95 RECOMBIVA HB INJ 5MCG/0.5 ........... 95 RECOMBIVA-HB INJ 40MCG/ML .......... 95 146

REGRANEX GEL 0.01% .................... 109 RELENZA MIS DISKHALE....................20 RELISTOR INJ 12/0.6ML ....................86 RELISTOR INJ 8/0.4ML ......................86 RELPAX TAB 20MG ............................67 RELPAX TAB 40MG ............................67 REMICADE INJ 100MG .......................92 REMODULIN INJ 10MG/ML .................48 REMODULIN INJ 1MG/ML ...................48 REMODULIN INJ 2.5MG/ML ................48 REMODULIN INJ 5MG/ML ...................48 RENVELA PAK 0.8GM .........................81 RENVELA PAK 2.4GM .........................81 RENVELA TAB 800MG ........................81 repaglinide tab 0.5 mg ......................72 repaglinide tab 1 mg .........................72 repaglinide tab 2 mg .........................72 RESCRIPTOR TAB 100 MG ..................17 RESCRIPTOR TAB 200MG ...................17 RESTASIS EMU 0.05% ..................... 101 RETROVIR INJ 10MG/ML ....................17 REVATIO SUS 10MG/ML .....................48 REVLIMID CAP 10MG .........................93 REVLIMID CAP 15MG .........................93 REVLIMID CAP 2.5MG ........................93 REVLIMID CAP 20MG .........................93 REVLIMID CAP 25MG .........................93 REVLIMID CAP 5MG ..........................93 REXULTI TAB 0.25MG ........................64 REXULTI TAB 0.5MG..........................63 REXULTI TAB 1MG ............................64 REXULTI TAB 2MG ............................64 REXULTI TAB 3MG ............................64 REXULTI TAB 4MG ............................64 REYATAZ CAP 150MG ........................17 REYATAZ CAP 200MG ........................17 REYATAZ CAP 300MG ........................17 REYATAZ POW 50MG .........................17 ribapak pak 1000/day .......................20 ribapak pak 1200/day .......................20 ribapak pak 600/day .........................20 ribapak pak 800/day .........................20 ribasphere cap 200mg .......................20 ribasphere tab 200mg .......................20 ribasphere tab 400mg .......................20 ribasphere tab 600mg .......................20

ribavirin cap 200 mg......................... 20 ribavirin tab 200 mg ......................... 20 rifabutin cap 150 mg ........................ 19 rifampin cap 150 mg ........................ 19 rifampin cap 300 mg ........................ 19 rifampin for inj 600 mg ..................... 19 RIFATER TAB ................................... 19 riluzole tab 50 mg ............................ 68 rimantadine hydrochloride tab 100 mg 20 RINGER'S SOLUTION ........................ 98 RISPERDAL INJ 12.5MG .................... 64 RISPERDAL INJ 25MG ....................... 64 RISPERDAL INJ 37.5MG .................... 64 RISPERDAL INJ 50MG ....................... 64 risperidone orally disintegrating tab 0.25 mg ................................................. 64 risperidone orally disintegrating tab 0.5 mg ................................................. 64 risperidone orally disintegrating tab 1 mg ...................................................... 64 risperidone orally disintegrating tab 2 mg ...................................................... 64 risperidone orally disintegrating tab 3 mg ...................................................... 64 risperidone orally disintegrating tab 4 mg ...................................................... 64 risperidone soln 1 mg/ml .................. 64 risperidone tab 0.25 mg .................... 64 risperidone tab 0.5 mg...................... 64 risperidone tab 1 mg ........................ 64 risperidone tab 2 mg ........................ 64 risperidone tab 3 mg ........................ 64 risperidone tab 4 mg ........................ 64 RITUXAN INJ 100MG......................... 29 RITUXAN INJ 500MG......................... 29 rivastigmine tartrate cap 1.5 mg ........ 55 rivastigmine tartrate cap 3 mg ........... 55 rivastigmine tartrate cap 4.5 mg ........ 55 rivastigmine tartrate cap 6 mg ........... 55 rivastigmine td patch 24hr 13.3 mg/24hr ...................................................... 55 rivastigmine td patch 24hr 4.6 mg/24hr ...................................................... 55 rivastigmine td patch 24hr 9.5 mg/24hr ...................................................... 55 rizatriptan benzoate oral disintegrating 147

tab 10 mg (base eq) .........................67 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) ...........................67 rizatriptan benzoate tab 10 mg (base equivalent) ......................................67 rizatriptan benzoate tab 5 mg (base equivalent) ......................................67 ropinirole hydrochloride tab 0.25 mg ...60 ropinirole hydrochloride tab 0.5 mg .....60 ropinirole hydrochloride tab 1 mg .......60 ropinirole hydrochloride tab 2 mg .......60 ropinirole hydrochloride tab 3 mg .......60 ropinirole hydrochloride tab 4 mg .......60 ropinirole hydrochloride tab 5 mg .......60 rosadan cre 0.75% ......................... 109 rosuvastatin calcium tab 10 mg ..........40 rosuvastatin calcium tab 20 mg ..........40 rosuvastatin calcium tab 40 mg ..........40 rosuvastatin calcium tab 5 mg ............40 ROTARIX SUS ...................................95 ROTATEQ SOL ..................................95 roweepra tab 500mg .........................53 ROZEREM TAB 8MG ...........................66 S SABRIL POW 500MG .........................53 SABRIL TAB 500MG...........................53 SANDIMMUNE SOL 100MG/ML ............94 SANDOSTATIN KIT LAR 10MG ............80 SANDOSTATIN KIT LAR 20MG ............80 SANDOSTATIN KIT LAR 30MG ............80 SANTYL OIN 250/GM ....................... 109 SAPHRIS SUB 10MG ..........................64 SAPHRIS SUB 2.5MG .........................64 SAPHRIS SUB 5MG............................64 selegiline hcl cap 5 mg ......................60 selegiline hcl tab 5 mg .......................60 selenium sulfide lotion 2.5% ............ 107 SELZENTRY TAB 150MG .....................17 SELZENTRY TAB 300MG .....................17 SENSIPAR TAB 30MG ........................73 SENSIPAR TAB 60MG ........................73 SENSIPAR TAB 90MG ........................73 SEREVENT DIS AER 50MCG .............. 103 SEROQUEL XR TAB 150MG .................64 SEROQUEL XR TAB 200MG .................64 SEROQUEL XR TAB 300MG .................64

SEROQUEL XR TAB 400MG ................ 64 SEROQUEL XR TAB 50MG .................. 64 sertraline hcl oral conc 20 mg/ml ....... 58 sertraline hcl tab 100 mg .................. 58 sertraline hcl tab 25 mg .................... 58 sertraline hcl tab 50 mg .................... 58 sharobel tab 0.35mg ........................ 76 SIGNIFOR INJ 0.3MG/ML ................... 80 SIGNIFOR INJ 0.6MG/ML ................... 80 SIGNIFOR INJ 0.9MG/ML ................... 80 sildenafil citrate tab 20 mg ................ 48 SILENOR TAB 3MG ........................... 66 SILENOR TAB 6MG ........................... 66 SILVER SULFADIAZINE CREAM 1% ... 106 SIMBRINZA SUS 1-0.2% ................. 101 simvastatin tab 10 mg ...................... 40 simvastatin tab 20 mg ...................... 40 simvastatin tab 40 mg ...................... 40 simvastatin tab 5 mg ........................ 40 simvastatin tab 80 mg ...................... 40 sirolimus tab 0.5 mg......................... 94 sirolimus tab 1 mg ........................... 94 SIROLIMUS TAB 2 MG ....................... 94 SIRTURO TAB 100MG ....................... 19 SIVEXTRO INJ 200MG ....................... 14 SIVEXTRO TAB 200MG ...................... 14 SODIUM CHLORIDE INJ 0.45% .......... 98 SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%) .......................................... 96 SODIUM CHLORIDE INJ 3% ............... 99 SODIUM CHLORIDE INJ 5% ............... 99 SODIUM CHLORIDE IRRIGATION SOLN 0.9% ............................................ 110 SODIUM CHLORIDE IV SOLN 0.9% ..... 99 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ............................... 96 sodium phenylbutyrate oral powder 3 gm/teaspoonful ................................ 77 sodium polystyrene sulfonate oral susp 15 gm/60ml ......................................... 73 sodium polystyrene sulfonate powder . 73 SOLTAMOX SOL 10MG/5ML ............... 30 SOLU-CORTEF INJ 250MG ................. 79 SOMATULINE INJ 120/.5ML ............... 80 SOMATULINE INJ 60/0.2ML ............... 80 SOMATULINE INJ 90/0.3ML ............... 80 148

SOMAVERT INJ 10MG ........................80 SOMAVERT INJ 15MG ........................80 SOMAVERT INJ 20MG ........................80 SOMAVERT INJ 25MG ........................80 SOMAVERT INJ 30MG ........................80 sorine tab 120mg..............................39 sorine tab 160mg..............................39 sorine tab 240mg..............................39 sorine tab 80mg ...............................39 sotalol hcl (afib/afl) tab 120 mg ..........39 sotalol hcl (afib/afl) tab 160 mg ..........39 sotalol hcl (afib/afl) tab 80 mg ...........39 sotalol hcl tab 120 mg .......................39 sotalol hcl tab 160 mg .......................39 sotalol hcl tab 240 mg .......................39 sotalol hcl tab 80 mg .........................39 SOVALDI TAB 400MG ........................20 spironolactone & hydrochlorothiazide tab 25-25 mg ........................................46 spironolactone tab 100 mg .................36 spironolactone tab 25 mg ..................36 spironolactone tab 50 mg ..................36 sprintec 28 tab 28 day .......................76 SPRITAM TAB 1000MG.......................53 SPRITAM TAB 250MG ........................53 SPRITAM TAB 500MG ........................53 SPRITAM TAB 750MG ........................53 SPRYCEL TAB 100MG ........................31 SPRYCEL TAB 140MG ........................31 SPRYCEL TAB 20MG ..........................31 SPRYCEL TAB 50MG ..........................31 SPRYCEL TAB 70MG ..........................31 SPRYCEL TAB 80MG ..........................31 sps sus 15gm/60 ..............................73 SSD CRE 1% .................................. 106 stavudine cap 15 mg .........................17 stavudine cap 20 mg .........................17 stavudine cap 30 mg .........................17 stavudine cap 40 mg .........................17 stavudine for oral soln 1 mg/ml ..........17 STIVARGA TAB 40MG ........................32 STRATTERA CAP 100MG ....................66 STRATTERA CAP 10MG ......................66 STRATTERA CAP 18MG ......................66 STRATTERA CAP 25MG ......................66 STRATTERA CAP 40MG ......................66

STRATTERA CAP 60MG ...................... 66 STRATTERA CAP 80MG ...................... 66 streptomycin sulfate for inj 1 gm........ 13 STRIBILD TAB.................................. 18 SUBOXONE MIS 12-3MG ................... 70 SUBOXONE MIS 2-0.5MG .................. 70 SUBOXONE MIS 4-1MG ..................... 70 SUBOXONE MIS 8-2MG ..................... 70 SUCRAID SOL 8500/ML ..................... 86 sucralfate tab 1 gm .......................... 86 sulfacetamide sodium lotion 10% (acne) .................................................... 105 sulfacetamide sodium ophth oint 10% .................................................... 100 sulfacetamide sodium ophth soln 10% .................................................... 100 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ........................ 99 sulfadiazine tab 500mg ..................... 13 sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml................................ 14 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml................................ 15 sulfamethoxazole-trimethoprim tab 400-80 mg ...................................... 15 sulfamethoxazole-trimethoprim tab 800-160 mg .................................... 15 SULFAMYLON CRE 85MG/GM ........... 106 SULFAMYLON PAK 5% .................... 106 sulfasalazin tab 500mg dr ................. 85 sulfasalazine tab 500 mg................... 85 sulindac tab 150 mg ........................... 9 sulindac tab 200 mg ........................... 9 SUMATRIPTAN NASAL SPRAY 20 MG/ACT ...................................................... 67 SUMATRIPTAN NASAL SPRAY 5 MG/ACT ...................................................... 67 sumatriptan succinate inj 6 mg/0.5ml . 67 sumatriptan succinate solution auto-injector 4 mg/0.5ml .................. 67 sumatriptan succinate solution auto-injector 6 mg/0.5ml .................. 67 SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML ................... 67 SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML ................... 67 149

sumatriptan succinate solution prefilled syringe 6 mg/0.5ml ...........................68 sumatriptan succinate tab 100 mg ......68 sumatriptan succinate tab 25 mg ........68 sumatriptan succinate tab 50 mg ........68 SUPRAX CAP 400MG ..........................22 suprax chw 100mg ............................22 suprax chw 200mg ............................22 SUPRAX SUS 500/5ML .......................22 SUPREP BOWEL SOL PREP .................86 SURMONTIL CAP 100MG ....................58 SURMONTIL CAP 25MG ......................58 SURMONTIL CAP 50MG ......................58 SUSTIVA CAP 200MG ........................18 SUSTIVA CAP 50MG ..........................17 SUSTIVA TAB 600MG ........................18 SUTENT CAP 12.5MG .........................32 SUTENT CAP 25MG ...........................32 SUTENT CAP 37.5MG .........................32 SUTENT CAP 50MG ...........................32 SYLATRON KIT 200MCG .....................33 SYLATRON KIT 300MCG .....................33 SYLATRON KIT 600MCG .....................33 SYMBICORT AER 160-4.5 ................. 104 SYMBICORT AER 80-4.5................... 104 SYMLINPEN 60 INJ 1000MCG .............71 SYMLNPEN 120 INJ 1000MCG .............71 SYNAGIS INJ 100MG/ML ....................95 SYNAGIS INJ 50MG ...........................95 SYNAREL SOL 2MG/ML ......................76 SYNERCID INJ 500MG .......................15 SYNRIBO INJ 3.5MG ..........................33 SYNTHROID TAB 100MCG ..................82 SYNTHROID TAB 112MCG ..................82 SYNTHROID TAB 125MCG ..................82 SYNTHROID TAB 137MCG ..................82 SYNTHROID TAB 150MCG ..................82 SYNTHROID TAB 175MCG ..................82 SYNTHROID TAB 200MCG ..................82 SYNTHROID TAB 25MCG ....................82 SYNTHROID TAB 300MCG ..................82 SYNTHROID TAB 50MCG ....................82 SYNTHROID TAB 75MCG ....................82 SYNTHROID TAB 88MCG ....................82 SYPRINE CAP 250MG .........................73

T TABLOID TAB 40MG ......................... 28 tacrolimus cap 0.5 mg ...................... 94 tacrolimus cap 1 mg ......................... 94 tacrolimus cap 5 mg ......................... 94 tacrolimus oint 0.03% .................... 109 tacrolimus oint 0.1% ...................... 109 TAFINLAR CAP 50MG ........................ 32 TAFINLAR CAP 75MG ........................ 32 TAGRISSO TAB 40MG ....................... 32 TAGRISSO TAB 80MG ....................... 32 TAMIFLU CAP 30MG .......................... 20 TAMIFLU CAP 45MG .......................... 20 TAMIFLU CAP 75MG .......................... 20 TAMIFLU SUS 6MG/ML ...................... 20 tamoxifen citrate tab 10 mg (base equivalent) ...................................... 30 tamoxifen citrate tab 20 mg (base equivalent) ...................................... 30 tamsulosin hcl cap 0.4 mg ................. 88 TARCEVA TAB 100MG ....................... 32 TARCEVA TAB 150MG ....................... 32 TARCEVA TAB 25MG ......................... 32 TARGRETIN GEL 1% ....................... 109 tarina fe tab 1/20 ............................. 76 TASIGNA CAP 150MG ....................... 32 TASIGNA CAP 200MG ....................... 32 tazicef inj 1gm ................................. 22 tazicef inj 2gm ................................. 22 tazicef inj 6gm ................................. 22 TAZORAC CRE 0.05% ..................... 107 TAZORAC CRE 0.1% ....................... 107 taztia xt cap 120mg/24 ..................... 44 taztia xt cap 180mg/24 ..................... 44 taztia xt cap 240mg/24 ..................... 44 taztia xt cap 300mg/24 ..................... 44 taztia xt cap 360mg/24 ..................... 44 TECENTRIQ INJ 1200/20 ................... 29 TEFLARO INJ 400MG ......................... 22 TEFLARO INJ 600MG ......................... 22 TEGRETOL SUS 100/5ML ................... 53 TEGRETOL TAB 200MG ..................... 53 TEGRETOL-XR TAB 100MG ................ 53 TEGRETOL-XR TAB 200MG ................ 53 TEGRETOL-XR TAB 400MG ................ 53 TEKTURNA HCT TAB 150-12.5 ........... 45 150

TEKTURNA HCT TAB 150-25MG ..........45 TEKTURNA HCT TAB 300-12.5 ............45 TEKTURNA HCT TAB 300-25MG ..........45 TEKTURNA TAB 150MG ......................45 TEKTURNA TAB 300MG ......................45 temazepam cap 15 mg ......................67 temazepam cap 7.5 mg .....................67 TENIVAC INJ 5-2LF ...........................95 terazosin hcl cap 1 mg.......................36 terazosin hcl cap 10 mg .....................36 terazosin hcl cap 2 mg.......................36 terazosin hcl cap 5 mg.......................36 terbinafine hcl tab 250 mg .................16 terbutaline sulfate inj 1 mg/ml ......... 103 terbutaline sulfate tab 2.5 mg .......... 103 terbutaline sulfate tab 5 mg ............. 103 terconazole vaginal cream 0.4% .........88 terconazole vaginal cream 0.8% .........88 TERCONAZOLE VAGINAL CREAM 0.8% 88 terconazole vaginal suppos 80 mg ......88 testosterone cypionate im inj in oil 100 mg/ml .............................................70 testosterone cypionate im inj in oil 200 mg/ml .............................................70 testosterone enanthate im inj in oil 200 mg/ml .............................................70 TET/DIP TOX INJ 2-2 LF.....................95 tetrabenazine tab 12.5 mg .................68 tetrabenazine tab 25 mg ....................68 texacort sol 2.5% ........................... 108 THALOMID CAP 100MG ......................93 THALOMID CAP 150MG ......................93 THALOMID CAP 200MG ......................93 THALOMID CAP 50MG ........................93 theo-24 cap 100mg cr ..................... 105 theo-24 cap 200mg cr ..................... 105 theo-24 cap 300mg cr ..................... 105 theo-24 cap 400mg er ..................... 105 theophylline soln 80 mg/15ml .......... 105 theophylline tab sr 12hr 100 mg ....... 105 theophylline tab sr 12hr 200 mg ....... 105 theophylline tab sr 12hr 300 mg ....... 105 theophylline tab sr 12hr 450 mg ....... 105 theophylline tab sr 24hr 400 mg ....... 105 theophylline tab sr 24hr 600 mg ....... 105 thioridazine hcl tab 10 mg..................64

thioridazine hcl tab 100 mg ............... 65 thioridazine hcl tab 25 mg ................. 65 thioridazine hcl tab 50 mg ................. 65 thiothixene cap 1 mg ........................ 65 thiothixene cap 10 mg ...................... 65 thiothixene cap 2 mg ........................ 65 thiothixene cap 5 mg ........................ 65 tiagabine hcl tab 2 mg ...................... 53 tiagabine hcl tab 4 mg ...................... 53 TIKOSYN CAP 125MCG ...................... 39 TIKOSYN CAP 250MCG ...................... 39 TIKOSYN CAP 500MCG ...................... 39 TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%.................................. 101 TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.5% ................................... 101 timolol maleate ophth soln 0.25% .... 101 timolol maleate ophth soln 0.5% ...... 101 timolol maleate tab 10 mg ................ 42 timolol maleate tab 20 mg ................ 43 timolol maleate tab 5 mg .................. 42 TIVICAY TAB 10MG........................... 18 TIVICAY TAB 25MG........................... 18 TIVICAY TAB 50MG........................... 18 tizanidine hcl tab 2 mg (base equivalent) ...................................................... 69 tizanidine hcl tab 4 mg (base equivalent) ...................................................... 69 TOBRADEX OIN 0.3-0.1% ................. 99 TOBRADEX ST SUS 0.3-0.05.............. 99 tobramycin nebu soln 300 mg/5ml ..... 13 tobramycin ophth soln 0.3% ............ 100 tobramycin sulfate for inj 1.2 gm ....... 13 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv)......................... 13 tobramycin sulfate inj 10 mg/ml (base equivalent) ...................................... 13 tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv)......................... 13 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv)......................... 13 tobramycin-dexamethasone ophth susp 0.3-0.1% ........................................ 99 TOBREX OIN 0.3% OP .................... 100 tolterodine tartrate cap sr 24hr 2 mg .. 88 tolterodine tartrate cap sr 24hr 4 mg .. 88 151

tolterodine tartrate tab 1 mg ..............88 tolterodine tartrate tab 2 mg ..............88 topiramate sprinkle cap 15 mg ...........53 topiramate sprinkle cap 25 mg ...........53 topiramate tab 100 mg ......................53 topiramate tab 200 mg ......................53 topiramate tab 25 mg........................53 topiramate tab 50 mg........................53 toposar inj 1gm/50ml ........................34 topotecan hcl for inj 4 mg ..................34 torsemide inj 50mg/5ml ....................46 torsemide tab 10 mg .........................46 torsemide tab 100 mg .......................46 torsemide tab 20 mg .........................46 torsemide tab 5 mg ...........................46 TOUJEO SOLO INJ 300IU/ML ..............71 TOVIAZ TAB 4MG ..............................88 TOVIAZ TAB 8MG ..............................88 TPN ELECTROL INJ ............................96 TRACLEER TAB 125MG ......................48 TRACLEER TAB 62.5MG .....................48 TRADJENTA TAB 5MG ........................72 tramadol hcl tab 50 mg ...................... 9 tramadol-acetaminophen tab 37.5-325 mg ................................................... 9 trandolapril tab 1 mg.........................36 trandolapril tab 2 mg.........................36 trandolapril tab 4 mg.........................36 tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) ....................................91 tranexamic acid tab 650 mg ...............91 TRANSDERM-SC DIS 1MG ..................84 tranylcypromine sulfate tab 10 mg ......58 TRAVASOL INJ 10% ..........................97 TRAVATAN Z DRO 0.004% ............... 101 trazodone hcl tab 100 mg ..................58 trazodone hcl tab 150 mg ..................58 trazodone hcl tab 50 mg ....................58 TREANDA INJ 100MG ........................26 TREANDA INJ 180/2ML ......................26 TREANDA INJ 25MG ..........................26 TREANDA INJ 45/0.5ML .....................26 TRECATOR TAB 250MG ......................19 TRELSTAR MIX INJ 11.25MG ..............30 TRELSTAR MIX INJ 3.75MG ................30 TRESIBA FLEX INJ 100UNIT ...............71

TRESIBA FLEX INJ 200UNIT ............... 71 tretinoin cap 10 mg .......................... 33 tretinoin cream 0.025% .................. 105 tretinoin cream 0.05% .................... 105 tretinoin cream 0.1% ...................... 105 TRETINOIN GEL 0.01% ................... 105 tretinoin gel 0.025% ....................... 106 triamcinolone acetonide cream 0.025% .................................................... 108 triamcinolone acetonide cream 0.1% 108 triamcinolone acetonide cream 0.5% 108 triamcinolone acetonide dental paste 0.1% ............................................ 110 triamcinolone acetonide lotion 0.025% .................................................... 108 triamcinolone acetonide lotion 0.1% . 108 triamcinolone acetonide oint 0.025% 109 triamcinolone acetonide oint 0.1% ... 108 triamcinolone acetonide oint 0.5% ... 108 triamterene & hydrochlorothiazide cap 37.5-25 mg ..................................... 46 triamterene & hydrochlorothiazide tab 37.5-25 mg ..................................... 46 triamterene & hydrochlorothiazide tab 75-50 mg ........................................ 46 TRIBENZOR20- TAB 5-12.5MG ........... 37 TRIBENZOR40- TAB 10-12.5.............. 37 TRIBENZOR40- TAB 10-25MG ............ 37 TRIBENZOR40- TAB 5-12.5MG ........... 37 TRIBENZOR40- TAB 5-25MG .............. 37 triderm cre 0.1% ........................... 109 trifluoperazine hcl tab 1 mg ............... 65 trifluoperazine hcl tab 10 mg ............. 65 trifluoperazine hcl tab 2 mg ............... 65 trifluoperazine hcl tab 5 mg ............... 65 trifluridine ophth soln 1% ................ 100 tri-legest tab fe ................................ 76 trilyte sol ........................................ 86 trimethoprim tab 100 mg .................. 15 trimipramine maleate cap 100 mg ...... 58 trimipramine maleate cap 25 mg ........ 58 trimipramine maleate cap 50 mg ........ 58 TRINESSA TAB ................................. 76 TRINTELLIX TAB 10MG ..................... 59 TRINTELLIX TAB 20MG ..................... 59 TRINTELLIX TAB 5MG ....................... 59 152

tri-previfem tab ................................76 TRISENOX SOL 10MG/10M .................33 tri-sprintec tab .................................76 TRIUMEQ TAB...................................18 trivora-28 tab ...................................76 TROPHAMINE INJ 10% ......................97 trospium chloride tab 20 mg ..............88 TRULICITY INJ 0.75/0.5 .....................71 TRULICITY INJ 1.5/0.5 ......................71 TRUMENBA INJ .................................95 TRUVADA TAB 100-150 .....................18 TRUVADA TAB 133-200 .....................18 TRUVADA TAB 167-250 .....................18 TRUVADA TAB 200-300 .....................19 TWINRIX INJ ....................................95 TYBOST TAB 150MG ..........................18 TYGACIL INJ 50MG............................15 TYKERB TAB 250MG ..........................32 TYPHIM VI INJ ..................................95 TYSABRI INJ 300/15ML......................68 TYZEKA TAB 600MG ..........................20 U UCERIS TAB 9MG ..............................85 ULORIC TAB 40MG ............................. 8 ULORIC TAB 80MG ............................. 8 UNITHROID TAB 100MCG ..................82 UNITHROID TAB 112MCG ..................82 UNITHROID TAB 125MCG ..................82 UNITHROID TAB 150MCG ..................82 UNITHROID TAB 175MCG ..................82 UNITHROID TAB 200MCG ..................82 UNITHROID TAB 25MCG ....................82 UNITHROID TAB 300MCG ..................82 UNITHROID TAB 50MCG ....................82 UNITHROID TAB 75MCG ....................82 UNITHROID TAB 88MCG ....................82 UPTRAVI TAB 1000MCG .....................48 UPTRAVI TAB 1200MCG .....................48 UPTRAVI TAB 1400MCG .....................48 UPTRAVI TAB 1600MCG .....................48 UPTRAVI TAB 200/800.......................48 UPTRAVI TAB 200MCG .......................48 UPTRAVI TAB 400MCG .......................48 UPTRAVI TAB 600MCG .......................48 UPTRAVI TAB 800MCG .......................48 ursodiol cap 300 mg ..........................86

ursodiol tab 250 mg ......................... 86 ursodiol tab 500 mg ......................... 86 V VAGIFEM TAB 10MCG ....................... 78 valacyclovir hcl tab 1 gm ................... 20 valacyclovir hcl tab 500 mg ............... 20 VALCHLOR GEL 0.016% .................. 109 VALCYTE SOL 50MG/ML .................... 20 valganciclovir hcl tab 450 mg (base equivalent) ...................................... 20 valproate sodium inj 100 mg/ml ........ 53 valproate sodium syrup 250 mg/5ml (base equiv) .................................... 53 valproic acid cap 250 mg................... 53 valsartan tab 160 mg ....................... 38 valsartan tab 320 mg ....................... 38 valsartan tab 40 mg ......................... 38 valsartan tab 80 mg ......................... 38 valsartan-hydrochlorothiazide tab 160-12.5 mg ................................... 37 valsartan-hydrochlorothiazide tab 160-25 mg ................................................. 37 valsartan-hydrochlorothiazide tab 320-12.5 mg ................................... 38 valsartan-hydrochlorothiazide tab 320-25 mg ................................................. 38 valsartan-hydrochlorothiazide tab 80-12.5 mg ..................................... 37 vancomycin hcl cap 125 mg............... 15 vancomycin hcl cap 250 mg............... 15 vancomycin hcl for inj 10 gm ............. 15 vancomycin hcl for inj 1000 mg ......... 15 vancomycin hcl for inj 500 mg ........... 15 vancomycin hcl for inj 5000 mg ......... 15 VANCOMYCIN INJ 1 GM..................... 15 VANCOMYCIN INJ 500MG .................. 15 vancomycin inj 750mg ...................... 15 VANCOMYCIN INJ 750MG .................. 15 VANDAZOLE GEL 0.75% ................... 88 VAQTA INJ 25/0.5ML ........................ 95 VAQTA INJ 50UNT/ML ....................... 95 VARIVAX INJ ................................... 95 VASCEPA CAP 1GM ........................... 41 VELCADE INJ 3.5MG ......................... 29 velivet pak ...................................... 76 VENCLEXTA TAB 100MG .................... 29 153

VENCLEXTA TAB 10MG ......................29 VENCLEXTA TAB 50MG ......................29 VENCLEXTA TAB START PK ................29 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) ......................................59 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) ......................................59 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) ......................................59 venlafaxine hcl tab 100 mg ................59 venlafaxine hcl tab 25 mg ..................59 venlafaxine hcl tab 37.5 mg ...............59 venlafaxine hcl tab 50 mg ..................59 venlafaxine hcl tab 75 mg ..................59 VENTOLIN HFA AER ......................... 103 verapamil hcl cap sr 24hr 100 mg .......44 verapamil hcl cap sr 24hr 120 mg .......44 verapamil hcl cap sr 24hr 180 mg .......44 verapamil hcl cap sr 24hr 200 mg .......44 verapamil hcl cap sr 24hr 240 mg .......44 verapamil hcl cap sr 24hr 300 mg .......44 VERAPAMIL HCL CAP SR 24HR 360 MG 44 verapamil hcl iv soln 2.5 mg/ml ..........44 verapamil hcl tab 120 mg ..................44 verapamil hcl tab 40 mg ....................44 verapamil hcl tab 80 mg ....................44 verapamil hcl tab cr 120 mg ...............44 verapamil hcl tab cr 180 mg ...............44 verapamil hcl tab cr 240 mg ...............44 VERSACLOZ SUS 50MG/ML ................65 VESICARE TAB 10MG ........................88 VESICARE TAB 5MG ..........................88 VICTOZA INJ 18MG/3ML ....................71 VIDEX SOL 2GM ...............................18 VIDEX SOL 4GM ...............................18 vienva tab 0.1-20 .............................76 VIGAMOX DRO 0.5% ....................... 100 VIIBRYD KIT ....................................59 VIIBRYD KIT STARTER .......................59 VIIBRYD TAB 10MG ...........................59 VIIBRYD TAB 20MG ...........................59 VIIBRYD TAB 40MG ...........................59 VIMPAT INJ 200MG/20 ......................54 VIMPAT SOL 10MG/ML .......................54 VIMPAT TAB 100MG ..........................54 VIMPAT TAB 150MG ..........................54

VIMPAT TAB 200MG.......................... 54 VIMPAT TAB 50MG ........................... 54 vinblastine sulfate inj 1 mg/ml ........... 28 vincasar pfs inj 1mg/ml .................... 28 vincristine sulfate iv soln 1 mg/ml ...... 28 vinorelbine tartrate inj 10 mg/ml (base equiv) ............................................. 29 vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv)......................... 29 viorele tab ....................................... 76 VIRACEPT TAB 250MG ...................... 18 VIRACEPT TAB 625MG ...................... 18 VIRAMUNE XR TAB 100MG ................ 18 VIREAD POW 40MG/GM .................... 18 VIREAD TAB 150MG ......................... 18 VIREAD TAB 200MG ......................... 18 VIREAD TAB 250MG ......................... 18 VIREAD TAB 300MG ......................... 18 VITEKTA TAB 150MG ........................ 18 VITEKTA TAB 85MG .......................... 18 VOLTAREN GEL 1% ........................ 109 voriconazole for inj 200 mg ............... 16 voriconazole for susp 40 mg/ml ......... 16 voriconazole tab 200 mg ................... 16 voriconazole tab 50 mg ..................... 16 VOTRIENT TAB 200MG ...................... 32 VRAYLAR CAP 1.5-3MG ..................... 65 VRAYLAR CAP 1.5MG ........................ 65 VRAYLAR CAP 3MG ........................... 65 VRAYLAR CAP 4.5MG ........................ 65 VRAYLAR CAP 6MG ........................... 65 vyfemla tab 0.4-35 ........................... 76 W warfarin sodium tab 1 mg ................. 90 warfarin sodium tab 10 mg................ 90 warfarin sodium tab 2 mg ................. 90 warfarin sodium tab 2.5 mg............... 90 warfarin sodium tab 3 mg ................. 90 warfarin sodium tab 4 mg ................. 90 warfarin sodium tab 5 mg ................. 90 warfarin sodium tab 6 mg ................. 90 warfarin sodium tab 7.5 mg............... 90 WATER FOR IRRIGATION, STERILE IRRIGATION SOLN ......................... 110 WELCHOL PAK 3.75GM ..................... 41 WELCHOL TAB 625MG ...................... 41 154

X XALKORI CAP 200MG ........................32 XALKORI CAP 250MG ........................32 XARELTO STAR TAB 15/20MG.............90 XARELTO TAB 10MG ..........................90 XARELTO TAB 15MG ..........................90 XARELTO TAB 20MG ..........................90 XGEVA INJ .......................................80 XIFAXAN TAB 550MG ........................86 XIGDUO XR TAB 10-1000 ..................72 XIGDUO XR TAB 10-500MG ................72 XIGDUO XR TAB 5-1000MG ................72 XIGDUO XR TAB 5-500MG .................72 XOLAIR SOL 150MG ........................ 103 XOPENEX HFA AER .......................... 103 XTANDI CAP 40MG ............................30 XYREM SOL 500MG/ML ......................69 Y YERVOY INJ 200MG ...........................29 YERVOY INJ 50MG ............................29 YF-VAX INJ ......................................95 Z zafirlukast tab 10 mg ...................... 103 zafirlukast tab 20 mg ...................... 103 zarah tab 3-0.03mg ..........................76 ZAVESCA CAP 100MG ........................77 ZELBORAF TAB 240MG ......................32 ZEMAIRA INJ 1000MG ..................... 103 zenatane cap 10mg ......................... 106 zenatane cap 20mg ......................... 106 zenatane cap 30mg ......................... 106 zenatane cap 40mg ......................... 106 zenchent tab ....................................76 ZENPEP CAP 10000UNT .....................87 ZENPEP CAP 15000UNT .....................87 ZENPEP CAP 20000UNT .....................87 ZENPEP CAP 25000UNT .....................87 ZENPEP CAP 3000UNIT ......................87 ZENPEP CAP 40000UNT .....................87 ZENPEP CAP 5000UNIT ......................87 ZETIA TAB 10MG ..............................41

ZIAGEN SOL 20MG/ML ...................... 18 zidovudine cap 100 mg ..................... 18 zidovudine syrup 10 mg/ml ............... 18 zidovudine tab 300 mg ..................... 18 ziprasidone hcl cap 20 mg ................. 65 ziprasidone hcl cap 40 mg ................. 65 ziprasidone hcl cap 60 mg ................. 65 ziprasidone hcl cap 80 mg ................. 65 ZIRGAN GEL 0.15% ........................ 100 zoledronic acid inj conc for iv infusion 4 mg/5ml ........................................... 73 zoledronic acid iv soln 5 mg/100ml ..... 73 ZOLINZA CAP 100MG........................ 29 zolmitriptan orally disintegrating tab 2.5 mg ................................................. 68 zolmitriptan orally disintegrating tab 5 mg ...................................................... 68 zolmitriptan tab 2.5 mg .................... 68 zolmitriptan tab 5 mg ....................... 68 zolpidem tartrate tab 10 mg .............. 67 zolpidem tartrate tab 5 mg ................ 67 zonisamide cap 100 mg .................... 54 zonisamide cap 25 mg ...................... 54 zonisamide cap 50 mg ...................... 54 ZONTIVITY TAB 2.08MG .................... 91 ZORTRESS TAB 0.25MG .................... 94 ZORTRESS TAB 0.5MG ...................... 94 ZORTRESS TAB 0.75MG .................... 94 ZOSTAVAX INJ ................................. 95 zovia 1/35e tab ................................ 76 zovia 1/50e tab ................................ 76 ZYDELIG TAB 100MG ........................ 32 ZYDELIG TAB 150MG ........................ 32 ZYKADIA CAP 150MG ........................ 32 ZYLET SUS 0.5-0.3% ........................ 99 ZYPREXA RELP INJ 210MG................. 65 ZYPREXA RELP INJ 300MG................. 65 ZYPREXA RELP INJ 405MG................. 65 ZYTIGA TAB 250MG .......................... 30 ZYVOX TAB 600MG ........................... 15

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Servicios a los Miembros Este formulario se actualizó en octubre de 2016. Para obtener información más reciente o hacer otras preguntas, comuníquese con Today's Options PFFS al 1-866-568-8921 o, para usuarios de TTY, al 711, de 8:00 a. m. a 8:00 p. m., en su zona horaria local, los 7 días de la semana, o visite www.TodaysOptions.com. ®

This information is available for free in other languages. Please call member service number at 1-866-568-8921, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 711) 7 days a week. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de servicio al cliente al 1-866-568-8921, de 8:00 a. m. a 8:00 p. m. en su zona horaria local (los usuarios de TTY deben llamar al 711) los 7 días de la semana. Today's Options PFFS es un plan de Medicare Advantage con un contrato de Medicare. La inscripción en Today’s Options PFFS depende de la renovación del contrato. ®

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