2018 FORMULARIO COMPLETO (LISTA DE MEDICAMENTOS CUBIERTOS)

Transcripción

1 208 FORMULARIO COMPLETO (LISTA DE MEDICAMENTOS CUBIERTOS) COCHISE GILA GRAHAM GREENLEE LA PAZ PIMA PINAL SANTA CRUZ YAVAPAI YUMA FAVOR DE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS RECETADOS QUE CUBRIMOS EN ESTE PLAN Identificación de Formulario 8009 Este formulario fue actualizado el 0/08/207. Para información más reciente o si tiene otras preguntas, favor de comunicarse con University Care Advantage al (877) o, para los usuarios de TTY, 7, de 8 a.m. a 8 p.m.,7días de la semana, o visite H493_ComprehensiveFormulary.v8-SPA Accepted

2 Nota para los miembros actuales: este Formulario ha cambiado con respecto al año pasado. Revise este documento para asegurarse de que aún contiene los s que toma. Cuando esta Lista de s (Formulario) menciona nosotros, nos o nuestro, hace referencia a University Care Advantage, Inc. Cuando dice plan o nuestro plan, hace referencia a University Care Advantage (HMO SNP). Este documento incluye una lista de los s (Formulario) de nuestro plan, la cual está en vigencia desde el 0/08/207. Para obtener un Formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior. Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de s con receta. Los beneficios, el Formulario, la red de farmacias y/o los copagos/el coseguro pueden cambiar el de enero de 208 y periódicamente durante el año. University Care Advantage es una HMO SNP con un contrato de Medicare y un contrato con el programa Medicaid de Arizona. La inscripción en University Care Advantage depende de la renovación del contrato. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingu ística. Llame al (TTY: 7). El Formulario, la red de farmacias, y/o la red de proveedores pueden cambiar en cualquier momento. Usted recibirá notificación cuando sea necesario. Esta información está disponible gratis en otros idiomas. Favor de llamar al Centro de Atención al Cliente al (877) , usuarios de TTY deben llamar al 7, de 8 a.m. a 8 p.m., 7 días de la semana. This information is available for free in other languages. Please call our Customer Care Center at (877) , TTY users should call 7, 8 a.m. to 8 p.m., 7 days a week. University Care Advantage (HMO SNP) cumple con leyes federales de derechos civiles aplicables y no discrimina basándose en raza, color, origen nacional, edad, discapacidad, o sexo. Qué es el Formulario de University Care Advantage? Un Formulario es una lista de s cubiertos seleccionados por University Care Advantage con la colaboración de un equipo de proveedores de atención médica, que representa los tratamientos con receta que se considera que son parte necesaria de un programa de tratamiento de calidad. Normalmente, nuestro plan cubrirá los s incluidos en el Formulario, siempre que el sea médicamente necesario, el con receta se obtenga en una farmacia de la red de University Care Advantage y se cumpla con otras normas del plan. Para obtener más información sobre cómo obtener sus s con receta, consulte la Evidencia de cobertura. Puede cambiar el Formulario (lista de s)? En general, si usted toma un de nuestro Formulario para 208 que estaba cubierto al comienzo del año, nosotros no discontinuaremos ni reduciremos la cobertura del durante el año de cobertura 208, excepto cuando esté disponible un nuevo genérico de menor costo o cuando se dé a conocer nueva información adversa acerca de la seguridad o eficacia del. Otros tipos de A

3 cambios en el Formulario, por ejemplo, la eliminación de un, no afectarán a los miembros que estén actualmente tomando el. Por el resto del año de cobertura, continuará disponible al mismo costo compartido para aquellos miembros que estén tomándolo. Consideramos que es importante que tenga acceso continuo a los s del Formulario que estaban disponibles cuando eligió nuestro plan durante el resto del año de cobertura, salvo en los casos en los que usted podría ahorrar más dinero o que nosotros podríamos garantizarle su seguridad. Si retiramos s de nuestro Formulario, o agregamos autorizaciones previas, restricciones de límite de cantidad o de tratamiento escalonado en un, debemos notificarles a los miembros afectados por el cambio al menos 60 días antes de que entre en vigencia dicho cambio, o cuando el miembro solicite un resurtido del, momento en el cual el miembro recibirá un suministro del para 60 días. Si la Administración de Drogas y Alimentos considera que un de nuestro Formulario es inseguro o el fabricante del lo retira del mercado, eliminaremos de inmediato dicho de nuestro Formulario y les notificaremos a los miembros que toman el en cuestión. El Formulario adjunto está vigente a partir del 0/08/207. Para recibir información actualizada sobre los s cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de la portada y la portada posterior. En caso de cambios al Formulario durante el año que no son relacionados al mantenimiento, les notificaremos a nuestros miembros a través de una hoja de correcciones enviada por correo. Cómo utilizo el Formulario? Hay dos formas para encontrar su dentro del Formulario: Afección médica El Formulario comienza en la página. Los s de este Formulario están agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los s utilizados para tratar una afección cardíaca se enumeran dentro de la categoría "Medicaciones cardiovasculares". Si sabe para qué se utiliza su, busque el nombre de la categoría en la lista que empieza en la página. Luego, busque su debajo del nombre de la categoría. Listado alfabético Si no está seguro de qué categoría consultar, debe buscar su en el Índice que comienza en la página I-. El Índice proporciona una lista alfabética de todos los s incluidos en este documento. En el Índice, están tanto los s de marca como los genéricos. Busque en el Índice y encuentre su. Junto a su, verá el número de página donde puede encontrar información acerca de la cobertura. Vaya a la página que figura en el Índice y encuentre el nombre de su en la primera columna de la lista. Qué son los s genéricos? University Care Advantage cubre tanto los s de marca como los genéricos. Un genérico está aprobado por la Administración de Drogas y Alimentos (FDA) dado que se considera que tiene el mismo ingrediente activo que el de marca. Normalmente, los s genéricos cuestan menos que los de marca. B

4 Hay alguna restricción en mi cobertura? Algunos s cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y límites pueden incluir: Autorización previa: Nuestro plan exige que usted o su médico obtenga una autorización previa para determinados s. Esto significa que necesitará contar con la aprobación de nuestro plan antes de obtener sus s con receta. Si no consigue la autorización, es posible que no cubramos el. Límites de cantidad: para ciertos s, nuestro plan limita la cantidad del que cubriremos. Por ejemplo, nuestro plan proporciona 90 cápsulas en 30 días por receta para Lyrica. Esto puede ser complementario a un suministro estándar para un mes o tres meses. Tratamiento escalonado: en algunos casos, nuestro plan requiere que usted primero pruebe ciertos s para tratar su afección médica antes de que cubramos otro para esa enfermedad. Por ejemplo, si el A y el B tratan su afección médica, es posible que no cubramos el B a menos que usted pruebe primero el A. Si el A no funciona para usted, entonces cubriremos el B. Para averiguar si su tiene requisitos o límites adicionales, consulte el Formulario que empieza en la página. También puede obtener más información sobre las restricciones que se aplican a s cubiertos específicos en nuestro sitio web. Hemos publicado documentos en línea que explican nuestras restricciones de autorización previa y tratamiento escalonado. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior. Puede pedirle a University Care Advantage que haga una excepción a estas restricciones o límites, o puede solicitarle una lista de otros s similares que puedan tratar su afección médica. Consulte la sección Cómo puedo solicitar que se haga una excepción al Formulario de University Care Advantage? en la página C para obtener información acerca de cómo solicitar una excepción. Qué pasa si mi no está en el Formulario? Si el que toma no está incluido en este Formulario (lista de s cubiertos), primero debe comunicarse con nuestro Centro de Atención al Cliente y preguntar si su está cubierto. Para obtener más información, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior. Si resulta que University Care Advantage no cubre el que toma, tiene dos alternativas: Puede pedir a nuestro Centro de Atención al Cliente una lista de s similares que estén cubiertos por nuestro plan. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un similar que esté cubierto por University Care Advantage. Puede solicitar que nuestro plan haga una excepción y cubra su. Consulte a continuación para obtener información sobre cómo solicitar una excepción. C

5 Cómo puedo solicitar que se haga una excepción al Formulario de University Care Advantage? Puede solicitarnos que hagamos una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos. Puede pedirnos que cubramos un, incluso si no está en nuestro Formulario. Si se aprueba, este estará cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que le brindemos el a un nivel de costo compartido menor. Puede pedirnos que no apliquemos restricciones o límites de cobertura para su. Por ejemplo, para ciertos s, nuestro plan limita la cantidad del que cubriremos. Si su tiene un límite de cantidad, puede pedirnos que hagamos una excepción al límite y cubramos una cantidad mayor. Por lo general, University Care Advantage solo aprobará su pedido de excepción si los s alternativos incluidos en el Formulario del plan, o las restricciones de uso adicionales no fueran tan efectivos para tratar su afección o pudieran causarle efectos médicos adversos. Debe comunicarse con nosotros para solicitarnos una decisión inicial de cobertura para una excepción al Formulario o a la restricción de uso. Cuando solicita una excepción al Formulario o a la restricción de uso, debe presentar una declaración de su médico o de la persona autorizada a dar recetas que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas a partir de la fecha de haber recibido la declaración que respalda su solicitud por parte de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que esperar 72 horas para la toma de la decisión podría perjudicar gravemente su salud. Si se le concede el trámite rápido de la excepción, debemos comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber recibido la declaración de respaldo de su médico o de otra persona autorizada a dar recetas. Qué debo hacer antes de hablar con mi médico sobre el cambio de los s que tomo o la solicitud de una excepción? Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando s que no están incluidos en el Formulario. También es posible que esté tomando un incluido en el Formulario pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización previa antes de poder obtener su con receta. Debe consultar con su médico para decidir si debe cambiar su por uno apropiado que nosotros cubramos o solicitar una excepción al Formulario para que le cubramos el que toma. Mientras evalúa con su médico el procedimiento adecuado para seguir en su caso, podemos cubrir su, en ciertos casos, durante los primeros 90 días en que usted sea miembro de nuestro plan. Para cada uno de los s que no están incluidos en el Formulario o si su capacidad para conseguir los s es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta para menos días) cuando acuda a una farmacia de la red. Después del primer suministro para 30 días, no seguiremos pagando estos s, incluso si ha sido miembro del plan durante menos de 90 días. Si reside en un centro de atención a largo plazo, le permitiremos resurtir su receta hasta que le hayamos brindado un suministro de transición de entre 9 días, de manera consistente con el incremento de provisión (a menos que tenga una receta para menos días). Cubriremos más de un resurtido de estos s durante los primeros 90 días en que usted sea miembro del plan. Si necesita un que no está en D

6 el Formulario o si su capacidad para conseguir los s es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia del para 3 días (a menos que tenga una receta para menos días) mientras solicita la excepción al Formulario. Es posible que usted tenga que surtir nuevas recetas para s que estaba tomando si tiene un cambio de nivel de cuidados, por ejemplo: Miembros dados de alta de un hospital o asilo Miembros que terminan su estancia de Medicare Parte A en un centro de enfermería especializada (en las que los pagos incluyen todas las tarifas de farmacia) y quienes necesitan volver a su Formulario de plan de Parte D Miembros que pierden su estatus de hospicio para volver a los beneficios estándares de Medicare Parte A y B Miembros que terminan una estancia en un centro de cuidado a largo plazo y vuelven a la comunidad Miembros que son dados de alta de hospitales psiquiátricos con régimen de s altamente individualizados Proporcionaremos un suministro de transición para un máximo de 30 días para evitar una interrupción en la terapia. Para obtener más información Para obtener información más detallada sobre la cobertura para s con receta de su plan, consulte la Evidencia de cobertura y otra documentación del plan. Si tiene alguna pregunta sobre University Care Advantage, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior. Si tiene preguntas generales sobre su cobertura para s con receta de Medicare, llame a Medicare al -800-MEDICARE ( ), las 24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al O visite Formulario de University Care Advantage El Formulario a continuación proporciona información acerca de la cobertura de los s cubiertos por nuestro plan. Si tiene alguna dificultad para encontrar el que toma en la lista, consulte el Índice que comienza en la página I-. La primera columna de la tabla menciona el nombre del. Los s de marca están en letra mayúscula (por ejemplo, JANUVIA), y los s genéricos están en letra minúscula y cursiva (por ejemplo, metformin). La información incluida en la columna de Requisitos/límites indica si nuestro plan tiene algún requisito especial para la cobertura del. E

7 Es posible que las siguientes abreviaturas se encuentren en este documento. Abreviatura/ Descripción LA (Disponibilidad limitada) PA (Autorización previa ) PA-HRM (Autorización previa/ Medicamento de riesgo elevado) PA BvD (Autorización previa/ Parte B vs Parte D) PA para ESRD solamente (Autorización previa/ Enfermedad renal en etapa final) PA NSO (Autorización previa/ Solo para quienes estén empezando) QL (Límite de cantidad) ST (Tratamiento escalonado) Explicación Indica que el está restringido a determinadas farmacias por la Administración de Alimentos y Medicamentos. Estos s pueden obtenerse solamente en farmacias especialmente designadas para administrar los s de manera apropiada. Usted o su proveedor debe obtener autorización previa antes de que nuestro plan acepte cubrir la receta. Indica que este se considera una medicación de riesgo elevado para personas de 65 años y mayores y que el uso de este debe evitarse en esta población. Si usted tiene 65 años de edad o más y este le es recetado, se exige que usted o su proveedor obtenga autorización previa de University Care Advantage antes de surtir su receta para este. Sin autorización previa, es posible que University Care Advantage no cubra este. Este podría ser elegible para pago a través de Medicare Parte B o Parte D. Se exige que usted o su médico obtenga autorización previa de University Care Advantage para determinar que este esté cubierto a través de Medicare Parte D antes de surtir su receta para este. Sin autorización previa, es posible que University Care Advantage no cubra este. Indica que si Medicare ha identificado que usted padece de enfermedad renal en etapa final, se exige que usted o su médico obtenga autorización previa de University Care Advantage antes de surtir su receta para este. Sin autorización previa, es posible que University Care Advantage no cubra este. Si usted es un miembro nuevo, se exige que usted o su médico obtenga autorización previa de University Care Advantage antes de surtir su receta para este. Sin autorización previa, es posible que University Care Advantage no cubra este. Es posible que las cantidades dispensadas sean limitadas. Este recetado exige que usted pruebe primero otro, el cual no le sirvió. Todos los s están disponibles en un suministro extendido para 90 días. Todos los s están disponibles a través del servicio de pedido por correo. F

8 Contenido Analgésicos... 3 Anestésicos... 7 Agentes contra la adicción/tratamiento de abuso de intoxicantes...8 Agentes contra la ansiedad...9 Antibacterianos... 0 Agentes anticancerígenos... 7 Agentes anticolinérgicos...25 Anticonvulsivos Agentes antidemencia Antidepresivos Agentes antidiabéticos... 3 Antihongos Agentes contra la gota Antihistamínico Antiinfecciosos (piel y membrana mucosa) Agentes antimigrañas Antimicobacterianos...37 Agentes antináuseas Agentes antiparasitarios...39 Agentes antiparkinsonianos...40 Agentes antipsicóticos... 4 Antivirales (sistémicos) Productos/modificadores/ expansores del volumen de sangre...48 Agentes calóricos... 5 Agentes cardiovasculares Agentes del sistema central nervioso Anticonceptivos... 67

9 Agentes dentales y orales Agentes dermatológicos Dispositivos Modificadores/Reemplazos para enzimas Agentes de ojos, oídos, nariz y garganta...78 Agentes gastrointestinales... 8 Agentes genitourinarios Antagonistas de metal pesado Agentes hormonales, estimulantes/reemplazos/ modificadores Agentes inmunológicos...9 Agentes de enfermedad inflamatoria intestinal Suspensiones/sueros de irrigación Agentes metabólicos de enfermedad ósea Agentes terapéuticos misceláneos Agentes oftálmicos... 0 Preparaciones de reemplazo Agentes de la vía respiratoria Relajantes del músculo esquelético Agentes contra el trastorno del sueño Agentes vasodilatadores...09 Vitaminas y minerales...0 2

10 Nombre del Analgésicos Analgésicos, Miscellaneous acetaminophen-codeine oral solution 20-2 QL (2700 per 30 mg/5 ml acetaminophen-codeine oral tablet mg QL (360 per 30 acetaminophen-codeine oral tablet mg (Tylenol- QL (360 per 30 Codeine #3) acetaminophen-codeine oral tablet mg (Tylenol- QL (80 per 30 Codeine #4) ascomp with codeine oral capsule PA-HRM; QL (80 per mg BELBUCA BUCCAL FILM 50 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG ; AGE (Max 64 Years) QL (60 per 30 buprenorphine hcl injection solution 0.3 mg/ml (Buprenex) buprenorphine hcl injection syringe 0.3 mg/ml buprenorphine transdermal patch weekly 0 (Butrans) QL (4 per 28 mcg/hour, 5 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule mg PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) butalbital-acetaminop-caf-cod oral capsule mg, mg PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) butalbital-acetaminophen oral tablet mg (Tencon) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) butalbital-acetaminophen-caff oral capsule mg (Zebutal) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) butalbital-acetaminophen-caff oral tablet mg (Esgic) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) butalbital-aspirin-caffeine oral capsule mg (Fiorinal) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) BUTRANS TRANSDERMAL PATCH QL (4 per 28 WEEKLY 7.5 MCG/HOUR capacet oral capsule mg PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) codeine sulfate oral tablet 5 mg, 30 mg, 60 QL (80 per 30 mg endocet oral tablet mg QL (240 per 30 endocet oral tablet mg, mg QL (360 per 30 endocet oral tablet mg QL (300 per 30 3

11 Nombre del fentanyl citrate buccal lozenge on a handle, 200 mcg,, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution mg/5 ml, 5-63 mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/5 ml hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg (Actiq) PA; QL (20 per 30 (Duragesic) QL (0 per 30 QL (2700 per 30 (Hycet) QL (2700 per 30 (Lorcet HD) QL (360 per 30 (Verdrocet) QL (360 per 30 (Lorcet QL (360 per 30 (hydrocodone)) (Norco) QL (360 per 30 hydrocodone-ibuprofen oral tablet mg QL (50 per 30 hydromorphone (pf) injection solution 0 (mg/ml) (5 ml), 0 mg/ml hydromorphone injection solution 2 mg/ml, 4 mg/ml hydromorphone injection syringe 2 mg/ml, 4 (Dilaudid) mg/ml hydromorphone oral liquid mg/ml (Dilaudid) QL (200 per 30 hydromorphone oral tablet 2 mg, 4 mg, 8 mg (Dilaudid) QL (80 per 30 HYSINGLA ER ORAL TABLET, ORAL ONLY, EXT.REL.24 HR 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG QL (30 per 30 LAZANDA NASAL SPRAY, NON AEROSOL 00 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY PA; QL (30 per 30 lorcet (hydrocodone) oral tablet mg QL (360 per 30 lorcet hd oral tablet mg QL (360 per 30 lorcet plus oral tablet mg QL (360 per 30 methadone injection solution 0 mg/ml methadone oral solution 0 mg/5 ml, 5 mg/5 QL (800 per 30 ml methadone oral tablet 0 mg (Dolophine) QL (360 per 30 methadone oral tablet 5 mg (Dolophine) QL (80 per 30 methadose oral tablet, soluble 40 mg QL (90 per 30 4

12 Nombre del morphine 2 mg/ml carpuject outer, l/f, p/f, sdv 2 mg/ml morphine 4 mg/ml carpuject outer, l/f, p/f, sdv 4 mg/ml morphine 8 mg/ml syringe 8 mg/ml morphine concentrate oral solution 00 mg/5 QL (80 per 30 ml (20 mg/ml) morphine intravenous syringe 0 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml morphine oral solution 0 mg/5 ml QL (700 per 30 morphine oral solution 20 mg/5 ml (4 mg/ml) QL (300 per 30 MORPHINE ORAL TABLET 5 MG QL (80 per 30 MORPHINE ORAL TABLET 30 MG QL (20 per 30 morphine oral tablet extended release 00 mg, (MS Contin) QL (60 per mg, 60 mg morphine oral tablet extended release 5 mg, (MS Contin) QL (90 per mg morphine sulfate 0 mg/ml vial 0 mg/ml NUCYNTA ER ORAL TABLET QL (60 per 30 EXTENDED RELEASE 2 HR 00 MG, 50 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 00 MG, 50 QL (8 per 30 MG, 75 MG oxycodone oral concentrate 20 mg/ml QL (20 per 30 oxycodone oral solution 5 mg/5 ml QL (300 per 30 oxycodone oral tablet 0 mg QL (80 per 30 oxycodone oral tablet 5 mg, 30 mg (Roxicodone) QL (20 per 30 oxycodone oral tablet 20 mg QL (20 per 30 oxycodone oral tablet 5 mg (Roxicodone) QL (80 per 30 oxycodone oral tablet, oral only, ext.rel.2 hr (OxyContin) QL (60 per 30 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 60 mg oxycodone oral tablet, oral only, ext.rel.2 hr (OxyContin) QL (20 per mg oxycodone-acetaminophen oral solution QL (800 per 30 mg/5 ml oxycodone-acetaminophen oral tablet (Endocet) QL (240 per 30 mg oxycodone-acetaminophen oral tablet (Percocet) QL (360 per 30 mg, mg oxycodone-acetaminophen oral tablet (Endocet) QL (300 per 30 mg oxycodone-aspirin oral tablet mg QL (360 per 30 5

13 Nombre del OXYCONTIN ORAL TABLET, ORAL ONLY, EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET, ORAL ONLY, EXT.REL.2 HR 80 MG QL (60 per 30 QL (20 per 30 oxymorphone oral tablet 0 mg (Opana) QL (20 per 30 oxymorphone oral tablet 5 mg (Opana) QL (80 per 30 oxymorphone oral tablet extended release 2 QL (60 per 30 hr 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg reprexain oral tablet mg QL (50 per 30 tencon oral tablet mg PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 tramadol-acetaminophen oral tablet (Ultracet) QL (240 per 30 mg XTAMPZA ER ORAL CAPSULE, QL (60 per 30 SPRINKLE, ER 2HR TMPRR 3.5 MG, 8 MG, 9 MG XTAMPZA ER ORAL CAPSULE, QL (20 per 30 SPRINKLE, ER 2HR TMPRR 27 MG XTAMPZA ER ORAL CAPSULE, QL (240 per 30 SPRINKLE, ER 2HR TMPRR 36 MG zebutal oral capsule mg PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (00 MG/ML) celecoxib oral capsule 00 mg, 200 mg, 400 (Celebrex) QL (60 per 30 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release (Voltaren-XR) 24 hr 00 mg diclofenac sodium oral tablet, delayed release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac-misoprostol oral tablet, ir, delayed (Arthrotec 50) rel, biphasic mg-mcg diclofenac-misoprostol oral tablet, ir, delayed (Arthrotec 75) rel, biphasic mg-mcg diflunisal oral tablet 500 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg (Lodine) 6

14 Nombre del etodolac oral tablet 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg flurbiprofen oral tablet 00 mg, 50 mg ibuprofen oral suspension 00 mg/5 ml (Child Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg PA-HRM; QL (240 per 30 ; AGE (Max 64 Years) indomethacin oral capsule 50 mg PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) indomethacin oral capsule, extended release 75 mg PA-HRM; QL (60 per 30 ; AGE (Max 64 Years) indomethacin sodium intravenous recon soln mg ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule, ext rel. pellets 24 hr 200 mg ketorolac oral tablet 0 mg PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 5 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 25 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg naproxen oral tablet 500 mg (Naprosyn) naproxen oral tablet, delayed release (dr/ec) (EC-Naprosyn) 375 mg, 500 mg piroxicam oral capsule 0 mg, 20 mg (Feldene) sulindac oral tablet 50 mg, 200 mg Anestésicos Local Anestésicos glydo mucous membrane jelly in applicator 2 % lidocaine (pf) injection solution 0 mg/ml ( (Xylocaine- %), 5 mg/ml (.5 %), 20 mg/ml (2 %) MPF) lidocaine (pf) injection solution 40 mg/ml (4 %) lidocaine (pf) injection solution 5 mg/ml (0.5 %) (Xylocaine- MPF) 7

15 Nombre del lidocaine hcl 2% vial inner, ltx-fr, p/f, sdv 20 (Xylocaine- mg/ml (2 %) MPF) lidocaine hcl injection solution 0 mg/ml ( (Xylocaine) %), 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch, medicated 5 (Lidoderm) PA; QL (90 per 30 % lidocaine topical ointment 5 % PA; QL (90 per 30 lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % Agentes contra la adicción/ tratamiento de abuso de intoxicantes Agentes contra la adicción/tratamiento de abuso de intoxicantes acamprosate oral tablet, delayed release (dr/ec) 333 mg BUNAVAIL BUCCAL FILM MG QL (30 per 30 BUNAVAIL BUCCAL FILM MG, QL (60 per MG buprenorphine hcl sublingual tablet 2 mg, 8 PA; QL (90 per 30 mg buprenorphine-naloxone sublingual tablet 2- QL (90 per mg, 8-2 mg bupropion hcl (smoking deter) oral tablet (Zyban) extended release 2 hr 50 mg CHANTIX CONTINUING MONTH BOX QL (68 per 84 ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG QL (68 per 84 CHANTIX STARTING MONTH BOX ORAL QL (53 per 28 TABLETS, DOSE PACK 0.5 MG ()- MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, mg/ml naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY, NON-AEROSOL QL (4 per 30 2 MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION CARTRIDGE 0 MG QL (008 per 90 8

16 Nombre del SUBOXONE SUBLINGUAL FILM 2-3 MG, 8-2 MG SUBOXONE SUBLINGUAL FILM MG, 4- MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG QL (60 per 30 QL (30 per 30 QL (30 per 30 QL (60 per 30 Agentes contra la ansiedad Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, mg (Xanax) QL (20 per 30 alprazolam oral tablet 2 mg (Xanax) QL (50 per 30 buspirone oral tablet 0 mg, 5 mg, 30 mg, 5 mg, 7.5 mg chlordiazepoxide hcl oral capsule 0 mg, 25 QL (20 per 30 mg, 5 mg clonazepam oral tablet 0.5 mg, mg (Klonopin) QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 clonazepam oral tablet, disintegrating 0.25 QL (90 per 30 mg, 0.25 mg, 0.5 mg, mg clonazepam oral tablet, disintegrating 2 mg QL (300 per 30 clorazepate dipotassium oral tablet 5 mg, QL (80 per mg clorazepate dipotassium oral tablet 7.5 mg (Tranxene T- QL (80 per 30 Tab) DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT 2.5 MG diazepam injection solution 5 mg/ml QL (0 per 28 diazepam intensol oral concentrate 5 mg/ml QL (200 per 30 diazepam oral solution 5 mg/5 ml ( mg/ml) QL (200 per 30 diazepam oral tablet 0 mg, 2 mg, 5 mg (Valium) QL (20 per 30 diazepam rectal kit mg, (Diastat 0 mg AcuDial) diazepam rectal kit 2.5 mg (Diastat) lorazepam injection solution 2 mg/ml, 4 mg/ml (Ativan) QL (2 per 30 lorazepam injection syringe 2 mg/ml QL (2 per 30 lorazepam oral tablet 0.5 mg, mg (Ativan) QL (90 per 30 lorazepam oral tablet 2 mg (Ativan) QL (50 per 30 ONFI ORAL SUSPENSION 2.5 MG/ML PA NSO; QL (480 per 30 9

17 Nombre del ONFI ORAL TABLET 0 MG, 20 MG PA NSO; QL (60 per 30 temazepam oral capsule 5 mg, 30 mg (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) Antibacterianos Aminoglycosides BETHKIS INHALATION SOLUTION FOR PA BvD NEBULIZATION 300 MG/4 ML gentamicin 0 mg/ml vial sdv 60 mg/6 ml gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 00 mg/50 ml, 20 mg/00 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml gentamicin injection solution 40 mg/ml gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 00 mg/0 ml neomycin oral tablet 500 mg streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION QL (224 per 28 CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation (Tobi) PA BvD solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection solution 0 mg/ml, 40 mg/ml Antibacterianos, Miscellaneous bacitracin intramuscular recon soln 50, 000 (BACiiM) unit chloramphenicol sod succinate intravenous recon soln gram clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Pediatric) 0

18 Nombre del clindamycin hcl oral capsule 50 mg, 300 mg, (Cleocin HCl) 75 mg clindamycin in 5 % dextrose intravenous (Cleocin in 5 % piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml dextrose) clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 50 (mg/ml) (6 ml) clindamycin phosphate injection solution 50 (Cleocin) mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml (Cleocin) colistin (colistimethate na) injection recon soln (Coly-Mycin M 50 mg Parenteral) daptomycin intravenous recon soln 500 mg (Cubicin) linezolid intravenous parenteral solution 600 (Zyvox) mg/300 ml linezolid oral suspension for reconstitution (Zyvox) 00 mg/5 ml linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 mg/00 ml metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 ; AGE nitrofurantoin monohyd/m-cryst oral capsule 00 mg polymyxin b sulfate injection recon soln 500, 000 unit (Max 64 Years) (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 ; AGE (Max 64 Years)

19 Nombre del SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 mg vancomycin in dextrose 5 % intravenous piggyback gram/200 ml, 500 mg/00 ml, 750 mg/50 ml vancomycin intravenous recon soln, 000 mg, 0 gram, 5 gram, 500 mg, 750 mg vancomycin oral capsule 25 mg, 250 mg (Vancocin) XIFAXAN ORAL TABLET 200 MG PA; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG PA Cephalosporins cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/00 ml cefazolin injection recon soln gram, 0 gram, 500 mg cefazolin intravenous recon soln gram cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg cefditoren pivoxil oral tablet 400 mg (Spectracef) CEFEPIME GM INJECTION GRAM/50 ML CEFEPIME INJECTION RECON SOLN (Maxipime) GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML cefotaxime injection recon soln gram, 0 (Claforan) gram, 2 gram cefotaxime injection recon soln 500 mg cefoxitin 2 gm piggyback bag 2 gram/50 ml cefoxitin intravenous recon soln gram, 0 gram cefoxitin intravenous recon soln 2 gram 2

20 Nombre del cefpodoxime oral suspension for reconstitution 00 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 00 mg, 200 mg cefprozil oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection recon soln 2 gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for reconstitution (Cedax) 80 mg/5 ml ceftriaxone gm piggyback l/g, single use gram/50 ml ceftriaxone 2 gm piggyback l/f, single use 2 gram/50 ml ceftriaxone injection recon soln gram, 0 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln gram, 2 gram cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 750 (Zinacef) mg cefuroxime sodium intravenous recon soln.5 (Zinacef) gram, 7.5 gram cephalexin oral capsule 250 mg, 500 mg (Keflex) cephalexin oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg MEFOXIN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET, CHEWABLE 00 MG, 200 MG tazicef injection recon soln gram, 2 gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) azithromycin oral packet gram (Zithromax) 3

21 Nombre del azithromycin oral suspension for (Zithromax) reconstitution 00 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg (Zithromax Z- Pak) azithromycin oral tablet 250 mg (6 pack), 500 mg (3 pack) azithromycin oral tablet 500 mg, 600 mg (Zithromax) clarithromycin oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg clarithromycin oral tablet extended release 24 hr 500 mg DIFICID ORAL TABLET 200 MG ST; QL (20 per 0 e.e.s. 400 oral tablet 400 mg e.e.s. granules oral suspension for reconstitution 200 mg/5 ml ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 MG/5 ML ery-tab oral tablet, delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN, 000 MG, 500 MG erythromycin ethylsuccinate oral tablet 400 (E.E.S. 400) mg erythromycin oral capsule, delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram, 2 gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML LA imipenem-cilastatin intravenous recon soln (Primaxin IV) 250 mg, 500 mg INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln gram, 500 mg (Merrem) 4

22 Nombre del Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 25 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet, chewable 25 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral suspension (Augmentin) for reconstitution mg/5 ml amoxicillin-pot clavulanate oral suspension (Augmentin ES for reconstitution mg/5 ml 600) amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet 500- (Augmentin) 25 mg, mg amoxicillin-pot clavulanate oral tablet, chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln gram, 0 gram, 25 mg, 2 gram, 250 mg, 500 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln.5 (Unasyn) gram, 5 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE, 200, 000 UNIT/ 2 ML(600K/600K),, 200, 000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE, 200, 000 UNIT/2 ML, 2, 400, 000 UNIT/4 ML, 600, 000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln gram, 0 gram nafcillin intravenous recon soln 2 gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, 2 gram/50 ml 5

23 Nombre del oxacillin injection recon soln 0 gram, 2 gram oxacillin intravenous recon soln gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 (Pfizerpen-G) million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml, 600, 000 unit/ml penicillin gk 20 million unit 20 million unit (Pfizerpen-G) penicillin v potassium oral recon soln 25 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon (Zosyn) soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 00 mg, 750 mg ciprofloxacin hcl oral tablet 250 mg, 500 mg (Cipro) ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/00 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 mg/200 ml ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml ciprofloxacin oral suspension, microcapsule (Cipro) recon 250 mg/5 ml, 500 mg/5 ml levofloxacin in d5w intravenous piggyback 250 mg/50 ml, 500 mg/00 ml, 750 mg/50 ml levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 250 mg/0 ml levofloxacin oral tablet 250 mg, 500 mg, 750 (Levaquin) mg moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 300 mg, 400 mg Sulfonamides sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml 6

24 Nombre del sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) mg sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) mg sulfatrim oral suspension mg/5 ml Tetracyclines doxy-00 intravenous recon soln 00 mg doxycycline hyclate oral capsule 00 mg, 50 (Morgidox) mg doxycycline hyclate oral tablet 00 mg, 20 mg doxycycline monohydrate oral capsule 00 mg, (Monodox) 50 mg, 75 mg doxycycline monohydrate oral capsule 50 mg doxycycline monohydrate oral suspension for (Vibramycin) reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 00 mg (Avidoxy) doxycycline monohydrate oral tablet 50 mg, 50 mg, 75 mg minocycline oral capsule 00 mg, 50 mg, 75 (Minocin) mg minocycline oral tablet 00 mg, 50 mg, 75 mg tigecycline intravenous recon soln 50 mg (Tygacil) Agentes anticancerígenos Agentes anticancerígenos ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG adriamycin intravenous solution 0 mg/5 ml, PA BvD 20 mg/0 ml adrucil intravenous solution 2.5 gram/50 ml, PA BvD 500 mg/0 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG PA NSO; QL (2 per 28 AFINITOR ORAL TABLET 0 MG PA NSO; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG PA NSO; QL (28 per 28 ALECENSA ORAL CAPSULE 50 MG PA NSO; QL (240 per 30 7

25 Nombre del ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG ALUNBRIG ORAL TABLET 30 MG PA NSO; QL (80 per 30 anastrozole oral tablet mg (Arimidex) AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (6 ML) PA NSO azacitidine injection recon soln 00 mg (Vidaza) BAVENCIO INTRAVENOUS SOLUTION PA NSO 20 MG/ML BELEODAQ INTRAVENOUS RECON PA NSO SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 PA NSO MG/ML bexarotene oral capsule 75 mg (Targretin) PA NSO; QL (420 per 30 bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 5 unit (Bleo 5K) PA BvD bleomycin injection recon soln 30 unit PA BvD BLINCYTO INTRAVENOUS KIT 35 MCG PA NSO; QL (40 per 365 BOSULIF ORAL TABLET 00 MG PA NSO; QL (20 per 30 BOSULIF ORAL TABLET 500 MG PA NSO; QL (30 per 30 CABOMETYX ORAL TABLET 20 MG, 60 MG PA NSO; QL (30 per 30 CABOMETYX ORAL TABLET 40 MG PA NSO; QL (60 per 30 CAPRELSA ORAL TABLET 00 MG PA NSO; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG PA NSO; QL (30 per 30 clofarabine intravenous solution 20 mg/20 ml (Clolar) COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-20 MG X), 40 MG/DAY(80 MG X-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) PA NSO; QL (2 per 28 COTELLIC ORAL TABLET 20 MG PA NSO; LA; QL (63 per 28 cyclophosphamide intravenous recon soln gram, 2 gram, 500 mg PA BvD 8

26 Nombre del CYCLOPHOSPHAMIDE ORAL CAPSULE PA BvD; ST 25 MG, 50 MG CYRAMZA INTRAVENOUS SOLUTION 0 PA NSO MG/ML, 0 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 20 MG/ML PA NSO; LA decitabine intravenous recon soln 50 mg (Dacogen) doxorubicin intravenous solution 0 mg/5 ml, (Adriamycin) PA BvD 2 mg/ml, 20 mg/0 ml, 50 mg/25 ml doxorubicin, peg-liposomal intravenous (Doxil) PA BvD suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON SOLN PA NSO 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG PA NSO; QL (30 per 30 ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 20 mg/ml (Toposar) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 PA NSO MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil 5, 000 mg/00 ml latex-free 5 (Adrucil) PA BvD gram/00 ml fluorouracil intravenous solution gram/20 ml PA BvD fluorouracil intravenous solution 2.5 gram/50 (Adrucil) PA BvD ml, 500 mg/0 ml flutamide oral capsule 25 mg 9

27 Nombre del GAZYVA INTRAVENOUS SOLUTION, PA NSO 000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA NSO; QL (30 per 30 GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON PA NSO SOLN 50 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG PA NSO; QL (2 per 28 ICLUSIG ORAL TABLET 5 MG PA NSO; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG PA NSO; QL (30 per 30 ifosfamide intravenous recon soln gram, 3 (Ifex) PA BvD gram ifosfamide intravenous solution gram/20 ml, PA BvD 3 gram/60 ml ifosfamide-mesna intravenous kit - gram, 3, PA BvD 000-, 000 mg imatinib oral tablet 00 mg (Gleevec) PA NSO; QL (90 per 30 imatinib oral tablet 400 mg (Gleevec) PA NSO; QL (60 per 30 IMBRUVICA ORAL CAPSULE 40 MG PA NSO IMFINZI INTRAVENOUS SOLUTION 50 PA NSO MG/ML, 50 MG/ML (0 ML) IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML PA NSO; QL (4 per 365 IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML PA NSO; QL (8 per 28 INLYTA ORAL TABLET MG PA NSO; QL (80 per 30 INLYTA ORAL TABLET 5 MG PA NSO; QL (60 per 30 IRESSA ORAL TABLET 250 MG PA NSO; QL (60 per 30 IXEMPRA INTRAVENOUS RECON SOLN 5 MG, 45 MG 20

28 Nombre del JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG PA NSO; QL (60 per 30 KEYTRUDA INTRAVENOUS RECON SOLN 50 MG PA NSO; QL (4 per 2 KEYTRUDA INTRAVENOUS SOLUTION 00 MG/4 ML (25 MG/ML) PA NSO; QL (8 per 2 KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X )-2.5 PA NSO; QL (49 per 28 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 PA NSO; QL (70 per 28 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 PA NSO; QL (9 per 28 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X ), 400 MG/DAY (200 MG X 2), PA NSO; QL (63 per MG/DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN PA NSO 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION PA NSO; LA 0 MG/ML LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X 4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 8 MG/DAY (4 MG X 2) PA NSO letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit mg/0.2 ml LONSURF ORAL TABLET MG PA NSO; QL (00 per 28 LONSURF ORAL TABLET MG PA NSO; QL (80 per 28 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG 2

29 Nombre del LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG PA NSO; QL (448 per 28 LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg PA NSO-HRM; AGE (Max 64 Years) MEKINIST ORAL TABLET 0.5 MG PA NSO; QL (90 per 30 MEKINIST ORAL TABLET 2 MG PA NSO; QL (30 per 30 mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection recon soln PA BvD gram methotrexate sodium (pf) injection solution 25 PA BvD mg/ml methotrexate sodium injection solution 25 PA BvD mg/ml methotrexate sodium oral tablet 2.5 mg PA BvD; ST mitoxantrone intravenous concentrate 2 mg/ml NEXAVAR ORAL TABLET 200 MG PA NSO; QL (20 per 30 nilutamide oral tablet 50 mg (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PA NSO; QL (3 per 28 ODOMZO ORAL CAPSULE 200 MG PA NSO; LA ONCASPAR INJECTION SOLUTION 750 PA NSO UNIT/ML ONIVYDE INTRAVENOUS DISPERSION PA BvD 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION 00 PA NSO MG/0 ML, 40 MG/4 ML POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG PA NSO; QL (2 per 28 PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (6 MG/ML) PA NSO; QL (00 per 2 PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG PA NSO; LA 22

30 Nombre del RITUXAN HYCELA SUBCUTANEOUS SOLUTION 400 MG/.7 ML (20 MG/ML), 600 MG/3.4 ML (20 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 0 MG/ML RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PA NSO PA NSO PA NSO; QL (20 per 30 RYDAPT ORAL CAPSULE 25 MG PA NSO; QL (224 per 28 SOLTAMOX ORAL SOLUTION 0 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG PA NSO; QL (60 per 30 STIVARGA ORAL TABLET 40 MG PA NSO; QL (84 per 28 SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG PA NSO; QL (30 per 30 SYLVANT INTRAVENOUS RECON SOLN PA NSO 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG PA NSO; QL (28 per 28 TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA NSO; QL (20 per 30 TAGRISSO ORAL TABLET 40 MG, 80 MG PA NSO; LA; QL (30 per 30 tamoxifen oral tablet 0 mg, 20 mg TARCEVA ORAL TABLET 00 MG, 25 MG PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 50 MG PA NSO; QL (90 per 30 TARGRETIN TOPICAL GEL % PA NSO; QL (60 per 28 TASIGNA ORAL CAPSULE 50 MG, 200 MG PA NSO; QL (2 per 28 TECENTRIQ INTRAVENOUS SOLUTION, 200 MG/20 ML (60 MG/ML) PA NSO; QL (20 per 2 TEMODAR INTRAVENOUS RECON SOLN 00 MG PA NSO thiotepa injection recon soln 5 mg (Tepadina) 23

31 Nombre del toposar intravenous solution 20 mg/ml TREANDA INTRAVENOUS RECON SOLN 00 MG, 25 MG TRELSTAR.25 MG VIAL INNER, SDV QL ( per MG TRELSTAR 22.5 MG VIAL INNER, SDV QL ( per MG TRELSTAR 3.75 MG VIAL INNER, SDV 3.75 MG TRELSTAR INTRAMUSCULAR SYRINGE QL ( per MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE QL ( per MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 0 mg TREXALL ORAL TABLET 0 MG, 5 MG, PA BvD; ST 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION PA NSO 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 PA NSO MG VENCLEXTA ORAL TABLET 0 MG PA NSO; LA; QL (60 per 30 VENCLEXTA ORAL TABLET 00 MG PA NSO; LA; QL (20 per 30 VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (30 per 30 VENCLEXTA STARTING PACK ORAL TABLETS, DOSE PACK 0 MG-50 MG- 00 MG PA NSO; LA; QL (42 per 28 vinorelbine intravenous solution 0 mg/ml, 50 mg/5 ml (Navelbine) VOTRIENT ORAL TABLET 200 MG PA NSO; QL (20 per 30 XALKORI ORAL CAPSULE 200 MG, 250 MG PA NSO; QL (60 per 30 XATMEP ORAL SOLUTION 2.5 MG/ML PA BvD; ST 24

32 Nombre del XTANDI ORAL CAPSULE 40 MG PA NSO; QL (20 per 30 YERVOY INTRAVENOUS SOLUTION 200 PA NSO MG/40 ML (5 MG/ML), 50 MG/0 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN PA NSO MG ZEJULA ORAL CAPSULE 00 MG PA NSO; QL (90 per 30 ZELBORAF ORAL TABLET 240 MG PA NSO; QL (240 per 30 ZOLADEX SUBCUTANEOUS IMPLANT QL ( per MG ZOLADEX SUBCUTANEOUS IMPLANT QL ( per MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG PA NSO; QL (60 per 30 ZYKADIA ORAL CAPSULE 50 MG PA NSO; QL (40 per 28 ZYTIGA ORAL TABLET 250 MG, 500 MG PA NSO; QL (20 per 30 Agentes anticolinérgicos Antimuscarinics/Antispasmodics atropine injection syringe 0.05 mg/ml, 0. mg/ml propantheline oral tablet 5 mg Anticonvulsivos Anticonvulsivos APTIOM ORAL TABLET 200 MG, 400 MG, ST 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML ST BANZEL ORAL TABLET 200 MG, 400 MG ST BRIVIACT INTRAVENOUS SOLUTION 50 QL (80 per 30 MG/5 ML BRIVIACT ORAL SOLUTION 0 MG/ML QL (600 per 30 BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG QL (60 per 30 carbamazepine oral capsule, er multiphase 2 (Carbatrol) hr 00 mg, 200 mg, 300 mg carbamazepine oral suspension 00 mg/5 ml (Tegretol) carbamazepine oral tablet 200 mg (Tegretol) 25

33 Nombre del carbamazepine oral tablet extended release 2 (Tegretol XR) hr 00 mg, 200 mg, 400 mg carbamazepine oral tablet, chewable 00 mg CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel sprinkle (Depakote 25 mg Sprinkles) divalproex oral tablet extended release 24 hr (Depakote ER) 250 mg, 500 mg divalproex oral tablet, delayed release (dr/ec) (Depakote) 25 mg, 250 mg, 500 mg epitol oral tablet 200 mg ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) fosphenytoin injection solution 00 mg pe/2 ml, 500 mg pe/0 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 ST MG/ML FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG ST gabapentin oral capsule 00 mg, 300 mg, 400 (Neurontin) mg gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 2 MG, 6 MG ST lamotrigine oral tablet 00 mg, 50 mg, 200 (Lamictal) mg, 25 mg lamotrigine oral tablet extended release 24hr (Lamictal XR) 00 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible (Lamictal) 25 mg, 5 mg levetiracetam intravenous solution 500 mg/5 (Keppra) ml levetiracetam oral solution 00 mg/ml (Keppra) levetiracetam oral tablet, 000 mg, 250 mg (Keppra) levetiracetam oral tablet 500 mg, 750 mg (Roweepra) levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) 26

34 Nombre del LYRICA ORAL CAPSULE 00 MG, 50 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG QL (90 per 30 LYRICA ORAL SOLUTION 20 MG/ML QL (900 per 30 oxcarbazepine oral suspension 300 mg/5 ml (Trileptal) (60 mg/ml) oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG, 300 MG, 600 MG ST PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) PA NSO-HRM; AGE (Max 64 Years) phenobarbital oral tablet 00 mg, 5 mg, 6.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg PA NSO-HRM; AGE (Max 64 Years) phenytoin oral suspension 25 mg/5 ml (Dilantin-25) phenytoin oral tablet, chewable 50 mg (Dilantin Infatabs) phenytoin sodium extended oral capsule 00 (Dilantin mg Kapseal) phenytoin sodium extended oral capsule 200 (Phenytek) mg, 300 mg phenytoin sodium intravenous solution 50 mg/ml phenytoin sodium intravenous syringe 50 mg/ml POTIGA ORAL TABLET 200 MG, 300 MG, ST; QL (90 per MG POTIGA ORAL TABLET 50 MG ST; QL (270 per 30 primidone oral tablet 250 mg, 50 mg (Mysoline) ROWEEPRA ORAL TABLET, 000 MG, 500 MG, 750 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 30 SUSPENSION, 000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG ST; QL (20 per 30 tiagabine oral tablet 2 mg, 4 mg (Gabitril) 27

35 Nombre del topiramate oral capsule, sprinkle 5 mg, 25 (Topamax) mg topiramate oral capsule, sprinkle, er 24hr 00 (Qudexy XR) mg, 50 mg, 200 mg, 25 mg, 50 mg topiramate oral tablet 00 mg, 200 mg, 25 mg, 50 mg (Topamax) TROKENDI XR ORAL CAPSULE, ST; QL (30 per 30 EXTENDED RELEASE 24HR 00 MG, 25 MG, 50 MG TROKENDI XR ORAL CAPSULE, EXTENDED RELEASE 24HR 200 MG ST; QL (60 per 30 valproate sodium intravenous solution 500 (Depacon) mg/5 ml (00 mg/ml) valproic acid (as sodium salt) oral solution (Depakene) 250 mg/5 ml valproic acid oral capsule 250 mg (Depakene) VIMPAT INTRAVENOUS SOLUTION 200 ST; QL (200 per 5 MG/20 ML VIMPAT ORAL SOLUTION 0 MG/ML ST; QL (200 per 30 VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG ST; QL (60 per 30 zonisamide oral capsule 00 mg, 25 mg (Zonegran) zonisamide oral capsule 50 mg Agentes antidemencia Agentes antidemencia donepezil oral tablet 0 mg, 5 mg (Aricept) QL (30 per 30 donepezil oral tablet, disintegrating 0 mg, 5 QL (30 per 30 mg galantamine oral capsule, ext rel. pellets 24 hr (Razadyne ER) QL (30 per 30 6 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml QL (200 per 30 galantamine oral tablet 2 mg, 4 mg, 8 mg (Razadyne) QL (60 per 30 memantine oral solution 2 mg/ml QL (360 per 30 memantine oral tablet 0 mg, 5 mg (Namenda) QL (60 per 30 memantine oral tablets, dose pack 5-0 mg (Namenda QL (49 per 28 Titration Pak) NAMENDA XR ORAL CAP, SPRINKLE, QL (28 per 28 ER 24HR DOSE PACK MG NAMENDA XR ORAL CAPSULE, SPRINKLE, ER 24HR 4 MG, 2 MG, 28 MG, 7 MG QL (30 per 30 28

36 Nombre del NAMZARIC ORAL CAP, SPRINKLE, ER 24HR DOSE PACK 7/4/2/28 MG-0 MG NAMZARIC ORAL CAPSULE, SPRINKLE, ER 24HR 4-0 MG, 2-0 MG, 28-0 MG, 7-0 MG rivastigmine tartrate oral capsule.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 3.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepresivos Antidepresivos amitriptyline oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg QL (56 per 365 QL (30 per 30 QL (60 per 30 (Exelon) QL (30 per 30 PA NSO-HRM; AGE (Max 64 Years) PA NSO-HRM; AGE (Max 64 Years) bupropion hcl oral tablet 00 mg, 75 mg bupropion hcl oral tablet extended release 2 (Wellbutrin SR) hr 00 mg, 50 mg, 200 mg bupropion hcl oral tablet extended release 24 (Wellbutrin XL) hr 50 mg, 300 mg citalopram oral solution 0 mg/5 ml QL (600 per 30 citalopram oral tablet 0 mg, 20 mg, 40 mg (Celexa) QL (30 per 30 clomipramine oral capsule 25 mg, 50 mg, 75 (Anafranil) PA NSO-HRM; AGE (Max mg 64 Years) desipramine oral tablet 0 mg, 25 mg (Norpramin) PA NSO-HRM; AGE (Max 64 Years) desipramine oral tablet 00 mg, 50 mg, 50 PA NSO-HRM; AGE (Max mg, 75 mg 64 Years) desvenlafaxine succinate oral tablet extended (Pristiq) QL (30 per 30 release 24 hr 00 mg, 25 mg, 50 mg doxepin oral capsule 0 mg, 00 mg, 50 mg, PA NSO-HRM; AGE (Max 25 mg, 50 mg, 75 mg 64 Years) doxepin oral concentrate 0 mg/ml PA NSO-HRM; AGE (Max 64 Years) duloxetine oral capsule, delayed release(dr/ec) (Cymbalta) QL (60 per mg, 60 mg duloxetine oral capsule, delayed release(dr/ec) (Cymbalta) QL (30 per mg duloxetine oral capsule, delayed release(dr/ec) (Irenka) QL (30 per mg 29

37 Nombre del EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR QL (30 per 30 escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 0 mg, 20 mg, 5 mg (Lexapro) FETZIMA ORAL CAPSULE, EXT REL ST; QL (56 per HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 20 MG, 20 MG, 40 MG, 80 MG ST; QL (30 per 30 fluoxetine oral capsule 0 mg, 20 mg, 40 mg (Prozac) fluoxetine oral capsule, delayed release(dr/ec) (Prozac QL (4 per mg Weekly) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) fluoxetine oral tablet 0 mg, 20 mg (Sarafem) fluvoxamine oral capsule, extended release 24hr 00 mg, 50 mg fluvoxamine oral tablet 00 mg, 25 mg, 50 mg imipramine hcl oral tablet 0 mg, 25 mg, 50 mg (Tofranil) PA NSO-HRM; AGE (Max 64 Years) imipramine pamoate oral capsule 00 mg, 25 mg, 50 mg, 75 mg PA NSO-HRM; AGE (Max 64 Years) maprotiline oral tablet 25 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 0 MG mirtazapine oral tablet 5 mg, 30 mg, 45 mg (Remeron) mirtazapine oral tablet 7.5 mg mirtazapine oral tablet, disintegrating 5 mg, (Remeron 30 mg, 45 mg SolTab) nefazodone oral tablet 00 mg, 50 mg, 200 mg, 250 mg, 50 mg nortriptyline oral capsule 0 mg, 25 mg, 50 mg, 75 mg (Pamelor) PA NSO-HRM; AGE (Max 64 Years) nortriptyline oral solution 0 mg/5 ml PA NSO-HRM; AGE (Max 64 Years) paroxetine hcl oral tablet 0 mg, 20 mg, 30 mg, 40 mg (Paxil) PA NSO-HRM; AGE (Max 64 Years) paroxetine hcl oral tablet extended release 24 hr 2.5 mg, 25 mg, 37.5 mg (Paxil CR) PA NSO-HRM; AGE (Max 64 Years) PAXIL ORAL SUSPENSION 0 MG/5 ML PA NSO-HRM; AGE (Max 64 Years) 30

38 Nombre del perphenazine-amitriptyline oral tablet 2-0 mg, 2-25 mg, 4-0 mg, 4-25 mg, 4-50 mg PA NSO-HRM; AGE (Max 64 Years) phenelzine oral tablet 5 mg (Nardil) protriptyline oral tablet 0 mg, 5 mg PA NSO-HRM; AGE (Max 64 Years) sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 00 mg, 25 mg, 50 mg (Zoloft) SURMONTIL ORAL CAPSULE 00 MG, 25 MG, 50 MG PA NSO-HRM; AGE (Max 64 Years) tranylcypromine oral tablet 0 mg (Parnate) trazodone oral tablet 00 mg, 50 mg, 300 mg, 50 mg trimipramine oral capsule 00 mg, 25 mg, 50 mg (Surmontil) PA NSO-HRM; AGE (Max 64 Years) TRINTELLIX ORAL TABLET 0 MG, 20 ST; QL (30 per 30 MG, 5 MG venlafaxine oral capsule, extended release (Effexor XR) QL (30 per 30 24hr 50 mg venlafaxine oral capsule, extended release (Effexor XR) QL (90 per 30 24hr 37.5 mg, 75 mg venlafaxine oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD ORAL TABLET 0 MG, 20 MG, ST; QL (30 per MG VIIBRYD ORAL TABLETS, DOSE PACK 0 MG (7)- 20 MG (23) ST; QL (30 per 80 Agentes antidiabéticos Agentes antidiabéticos, Miscellaneous acarbose oral tablet 00 mg, 25 mg, 50 mg (Precose) QL (90 per 30 CYCLOSET ORAL TABLET 0.8 MG QL (80 per 30 GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT MG GLYXAMBI ORAL TABLET 0-5 MG, 25-5 ST; QL (30 per 30 MG INVOKAMET ORAL TABLET 50-, 000 ST; QL (60 per 30 MG, MG, 50-, 000 MG INVOKAMET ORAL TABLET MG ST; QL (20 per 30 INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 50-, 000 MG, MG, 50-, 000 MG, MG ST; QL (60 per 30 3

39 Nombre del INVOKANA ORAL TABLET 00 MG ST; QL (60 per 30 INVOKANA ORAL TABLET 300 MG ST; QL (30 per 30 JANUMET ORAL TABLET 50-, 000 MG, QL (60 per MG JANUMET XR ORAL TABLET, ER QL (30 per 30 MULTIPHASE 24 HR 00-, 000 MG JANUMET XR ORAL TABLET, ER QL (60 per 30 MULTIPHASE 24 HR 50-, 000 MG, MG JANUVIA ORAL TABLET 00 MG, 25 MG, QL (30 per MG JARDIANCE ORAL TABLET 0 MG, 25 ST; QL (30 per 30 MG JENTADUETO ORAL TABLET 2.5-, 000 QL (60 per 30 MG, MG, MG JENTADUETO XR ORAL TABLET, IR QL (60 per 30 ER, BIPHASIC 24HR 2.5-, 000 MG JENTADUETO XR ORAL TABLET, IR QL (30 per 30 ER, BIPHASIC 24HR 5-, 000 MG KORLYM ORAL TABLET 300 MG PA; QL (2 per 28 metformin oral tablet, 000 mg (Glucophage) QL (75 per 30 metformin oral tablet 500 mg (Glucophage) QL (50 per 30 metformin oral tablet 850 mg (Glucophage) QL (90 per 30 metformin oral tablet extended release 24 hr (Glucophage QL (20 per mg XR) metformin oral tablet extended release 24 hr (Glucophage QL (90 per mg XR) miglitol oral tablet 00 mg, 25 mg, 50 mg (Glyset) QL (90 per 30 nateglinide oral tablet 20 mg, 60 mg (Starlix) QL (90 per 30 pioglitazone oral tablet 5 mg, 30 mg, 45 mg (Actos) QL (30 per 30 pioglitazone-glimepiride oral tablet 30-2 mg, (DUETACT) QL (30 per mg pioglitazone-metformin oral tablet mg, (Actoplus QL (90 per mg MET) repaglinide oral tablet 0.5 mg QL (240 per 30 repaglinide oral tablet mg, 2 mg (Prandin) QL (240 per 30 repaglinide-metformin oral tablet -500 mg, 2- QL (50 per mg SYMLINPEN 20 SUBCUTANEOUS PEN PA; QL (0.8 per 28 INJECTOR 2, 700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR, 500 MCG/.5 ML PA; QL (6 per 28 32

40 Nombre del SYNJARDY ORAL TABLET 2.5-, 000 ST; QL (60 per 30 MG, MG, 5-, 000 MG, MG SYNJARDY XR ORAL TABLET, IR - ER, ST; QL (30 per 30 BIPHASIC 24HR 0-, 000 MG, 25-, 000 MG SYNJARDY XR ORAL TABLET, IR - ER, ST; QL (60 per 30 BIPHASIC 24HR 2.5-, 000 MG, 5-, 000 MG TRADJENTA ORAL TABLET 5 MG QL (30 per 30 TRULICITY SUBCUTANEOUS PEN QL (2 per 28 INJECTOR 0.75 MG/0.5 ML,.5 MG/0.5 ML VICTOZA 3-PAK SUBCUTANEOUS PEN QL (9 per 30 INJECTOR 0.6 MG/0. ML (8 MG/3 ML) Insulins HUMULIN R U-500 (CONC) KWIKPEN QL (24 per 28 SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 (CONCENTRATED) QL (40 per 28 SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS QL (30 per 28 INSULIN PEN 00 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION QL (40 per UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS QL (40 per 28 SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS QL (40 per 28 SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION SOLUTION 00 QL (40 per 28 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS QL (30 per 28 INSULIN PEN 00 UNIT/ML NOVOLOG MIX FLEXPEN QL (30 per 28 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG MIX SUBCUTANEOUS QL (40 per 28 SOLUTION 00 UNIT/ML (70-30) NOVOLOG PENFILL SUBCUTANEOUS QL (30 per 28 CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION QL (40 per UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (.5 ML) QL (3.5 per 28 33

41 Nombre del XULTOPHY 00/3.6 SUBCUTANEOUS INSULIN PEN 00 UNIT-3.6 MG /ML (3 ML) ST; QL (5 per 28 Sulfonylureas glimepiride oral tablet mg, 2 mg (Amaryl) QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 glipizide oral tablet 0 mg (Glucotrol) QL (20 per 30 glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 glipizide oral tablet extended release 24hr 0 (Glucotrol XL) QL (60 per 30 mg glipizide oral tablet extended release 24hr 2.5 (Glucotrol XL) QL (30 per 30 mg, 5 mg glipizide-metformin oral tablet mg QL (240 per 30 glipizide-metformin oral tablet mg, 5- QL (20 per mg glyburide micronized oral tablet.5 mg, 3 mg, 6 mg (Glynase) PA-HRM; AGE (Max 64 Years) glyburide oral tablet.25 mg, 2.5 mg, 5 mg PA-HRM; AGE (Max 64 Years) glyburide-metformin oral tablet mg PA-HRM; AGE (Max 64 Years) glyburide-metformin oral tablet mg, mg (Glucovance) PA-HRM; AGE (Max 64 Years) tolazamide oral tablet 250 mg QL (20 per 30 tolazamide oral tablet 500 mg QL (60 per 30 tolbutamide oral tablet 500 mg QL (80 per 30 Antihongos Antihongos ABELCET INTRAVENOUS SUSPENSION 5 PA BvD MG/ML AMBISOME INTRAVENOUS PA BvD SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg PA BvD CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Ciclodan) ciclopirox topical gel 0.77 % ciclopirox topical shampoo % (Loprox) ciclopirox topical solution 8 % (Ciclodan) ciclopirox topical suspension 0.77 % (Loprox (as olamine)) 34

42 Nombre del clotrimazole mucous membrane troche 0 mg clotrimazole topical cream % (Antifungal (clotrimazole)) clotrimazole topical solution % clotrimazole-betamethasone topical cream - (Lotrisone) 0.05 % clotrimazole-betamethasone topical lotion % econazole topical cream % fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/50 ml, 400 mg/200 ml fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/00 ml fluconazole oral suspension for reconstitution (Diflucan) 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 200 (Diflucan) mg, 50 mg fluconazole-dext 200 mg/00 ml inner, suv 200 mg/00 ml flucytosine oral capsule 250 mg, 500 mg (Ancobon) griseofulvin microsize oral suspension 25 mg/5 ml griseofulvin microsize oral tablet 500 mg itraconazole oral capsule 00 mg (Sporanox Pulsepak) ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % (Nizoral) miconazole-3 vaginal suppository 200 mg NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET, DELAYED RELEASE (DR/EC) 00 MG nyamyc topical powder 00, 000 unit/gram nyata topical powder 00, 000 unit/gram nystatin oral suspension 00, 000 unit/ml nystatin oral tablet 500, 000 unit nystatin topical cream 00, 000 unit/gram nystatin topical ointment 00, 000 unit/gram nystatin topical powder 00, 000 unit/gram (Nyamyc) nystatin-triamcinolone topical cream 00, unit/g-% 35

43 Nombre del nystatin-triamcinolone topical ointment 00, unit/gram-% nystop topical powder 00, 000 unit/gram terbinafine hcl oral tablet 250 mg (Lamisil) voriconazole intravenous solution 200 mg (Vfend IV) voriconazole oral suspension for reconstitution (Vfend) 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg (Vfend) Agentes contra la gota Agentes contra la gota, Other allopurinol oral tablet 00 mg, 300 mg (Zyloprim) COLCRYS ORAL TABLET 0.6 MG probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg ULORIC ORAL TABLET 40 MG, 80 MG QL (30 per 30 ZURAMPIC ORAL TABLET 200 MG ST; QL (30 per 30 Antihistamínico Antihistamínico cyproheptadine oral syrup 2 mg/5 ml PA-HRM; AGE (Max 64 Years) cyproheptadine oral tablet 4 mg PA-HRM; AGE (Max 64 Years) diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl oral elixir 2.5 mg/5 ml (Children's Allergy (diphenhyd)) PA-HRM; AGE (Max 64 Years) hydroxyzine hcl intramuscular solution 25 mg/ml PA-HRM; AGE (Max 64 Years) hydroxyzine hcl intramuscular solution 50 mg/ml PA-HRM; AGE (Max 64 Years) hydroxyzine hcl oral solution 0 mg/5 ml PA-HRM; AGE (Max 64 Years) hydroxyzine hcl oral tablet 0 mg, 25 mg, 50 mg PA-HRM; AGE (Max 64 Years) levocetirizine oral solution 2.5 mg/5 ml (Xyzal) levocetirizine oral tablet 5 mg (Xyzal) promethazine oral syrup 6.25 mg/5 ml PA-HRM; AGE (Max 64 Years) promethazine vc oral syrup mg/5 ml 36

44 Nombre del Antiinfecciosos (piel y membrana mucosa) Antiinfecciosos (piel y membrana mucosa) AVC VAGINAL VAGINAL CREAM 5 % clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Vandazole) terconazole vaginal cream 0.4 % (Terazol 7) terconazole vaginal cream 0.8 % terconazole vaginal suppository 80 mg Agentes antimigrañas Agentes antimigrañas dihydroergotamine injection solution mg/ml (D.H.E.45) QL (30 per 28 dihydroergotamine nasal spray, non-aerosol (Migranal) QL (8 per mg/pump act. (4 mg/ml) ERGOMAR SUBLINGUAL TABLET 2 MG QL (40 per 28 naratriptan oral tablet mg, 2.5 mg (Amerge) QL (8 per 28 rizatriptan oral tablet 0 mg, 5 mg (Maxalt) QL (8 per 28 rizatriptan oral tablet, disintegrating 0 mg, 5 (Maxalt-MLT) QL (8 per 28 mg sumatriptan nasal spray, non-aerosol 20 (Imitrex) QL (2 per 28 mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 00 mg, 25 mg, 50 mg (Imitrex) QL (8 per 28 sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml (Imitrex STATdose Kit Refill) QL (4 per 28 (Imitrex QL (4 per 28 STATdose Pen) (Alsuma) QL (4 per 28 sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 (Imitrex) QL (4 per 28 mg/0.5 ml sumatriptan succinate subcutaneous syringe 6 QL (4 per 28 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 mg (Zomig) QL (2 per 28 zolmitriptan oral tablet, disintegrating 2.5 mg, (Zomig ZMT) QL (2 per 28 5 mg Antimicobacterianos Antimicobacterianos CAPASTAT INJECTION RECON SOLN GRAM 37

45 Nombre del dapsone oral tablet 00 mg, 25 mg ethambutol oral tablet 00 mg ethambutol oral tablet 400 mg (Myambutol) isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 00 mg, 300 mg PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 50 mg (Mycobutin) rifampin intravenous recon soln 600 mg (Rifadin) rifampin oral capsule 50 mg, 300 mg (Rifadin) RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG PA; QL (88 per 68 TRECATOR ORAL TABLET 250 MG Agentes antináuseas Agentes antináuseas AKYNZEO ORAL CAPSULE MG PA BvD aprepitant oral capsule 25 mg (Emend) PA BvD; QL (2 per 28 aprepitant oral capsule 40 mg (Emend) PA BvD; QL ( per 28 aprepitant oral capsule 80 mg (Emend) PA BvD; QL (4 per 28 aprepitant oral capsule, dose pack 25 mg ()- 80 mg (2) (Emend) PA BvD; QL (6 per 28 compro rectal suppository 25 mg dimenhydrinate injection solution 50 mg/ml dronabinol oral capsule 0 mg, 2.5 mg, 5 mg (Marinol) PA EMEND INTRAVENOUS RECON SOLN QL (2 per MG EMEND ORAL SUSPENSION FOR RECONSTITUTION 25 MG (25 MG/ ML PA BvD; QL (6 per 28 FINAL CONC.) granisetron (pf) intravenous solution 00 mcg/ml granisetron hcl mg/ml vial sdv, latex-free, p/f mg/ml ( ml) granisetron hcl intravenous solution mg/ml granisetron hcl intravenous solution mg/ml ( ml) granisetron hcl oral tablet mg PA BvD 38

46 Nombre del meclizine oral tablet 2.5 mg PA-HRM; AGE (Max 64 Years) meclizine oral tablet 25 mg (Motion Sickness PA-HRM; AGE (Max 64 Years) (meclizine)) ondansetron hcl (pf) injection solution 4 mg/2 ml ondansetron hcl (pf) injection syringe 4 mg/2 ml ondansetron hcl oral solution 4 mg/5 ml (Zofran (as PA BvD hydrochloride)) ondansetron hcl oral tablet 24 mg PA BvD ondansetron hcl oral tablet 4 mg, 8 mg (Zofran (as PA BvD hydrochloride)) ondansetron oral tablet, disintegrating 4 mg, 8 (Zofran ODT) PA BvD mg phenadoz rectal suppository 2.5 mg, 25 mg PA-HRM; AGE (Max 64 Years) prochlorperazine edisylate injection solution 0 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 0 mg, 5 (Compazine) mg prochlorperazine rectal suppository 25 mg (Compazine) promethazine injection solution 25 mg/ml, 50 mg/ml (Phenergan) PA-HRM; AGE (Max 64 Years) promethazine oral tablet 2.5 mg, 25 mg, 50 mg PA-HRM; AGE (Max 64 Years) promethazine rectal suppository 2.5 mg, 25 mg (Phenadoz) PA-HRM; AGE (Max 64 Years) promethazine rectal suppository 50 mg (Phenergan) PA-HRM; AGE (Max 64 Years) promethegan rectal suppository 2.5 mg, 25 mg, 50 mg PA-HRM; AGE (Max 64 Years) TRANSDERM-SCOP TRANSDERMAL QL (0 per 30 PATCH 3 DAY.5 MG ( MG OVER 3 DAYS) Agentes antiparasitarios Agentes antiparasitarios ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG 39

47 Nombre del atovaquone oral suspension 750 mg/5 ml (Mepron) atovaquone-proguanil oral tablet mg (Malarone) atovaquone-proguanil oral tablet mg (Malarone Pediatric) chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG PA hydroxychloroquine oral tablet 200 mg (Plaquenil) IMPAVIDO ORAL CAPSULE 50 MG PA; QL (84 per 28 ivermectin oral tablet 3 mg (Stromectol) mefloquine oral tablet 250 mg NEBUPENT INHALATION RECON SOLN PA BvD 300 MG paromomycin oral capsule 250 mg PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG quinine sulfate oral capsule 324 mg (Qualaquin) PA; QL (42 per 7 Agentes antiparkinsonianos Agentes antiparkinsonianos amantadine hcl oral capsule 00 mg amantadine hcl oral solution 50 mg/5 ml amantadine hcl oral tablet 00 mg APOKYN SUBCUTANEOUS CARTRIDGE QL (60 per 30 0 MG/ML benztropine oral tablet 0.5 mg, mg, 2 mg PA-HRM; AGE (Max 64 Years) bromocriptine oral capsule 5 mg (Parlodel) bromocriptine oral tablet 2.5 mg (Parlodel) cabergoline oral tablet 0.5 mg carbidopa-levodopa oral tablet 0-00 mg, 25- (Sinemet) 00 mg, mg carbidopa-levodopa oral tablet extended (Sinemet CR) release mg, mg carbidopa-levodopa-entacapone oral tablet (Stalevo 50) mg carbidopa-levodopa-entacapone oral tablet (Stalevo 75) mg carbidopa-levodopa-entacapone oral tablet mg (Stalevo 00) 40

48 Nombre del carbidopa-levodopa-entacapone oral tablet (Stalevo 25) mg carbidopa-levodopa-entacapone oral tablet (Stalevo 50) mg carbidopa-levodopa-entacapone oral tablet (Stalevo 200) mg entacapone oral tablet 200 mg (Comtan) NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR QL (30 per 30 pramipexole oral tablet 0.25 mg, 0.25 mg, 0.5 (Mirapex) mg, 0.75 mg, mg,.5 mg rasagiline oral tablet 0.5 mg, mg (Azilect) ropinirole oral tablet 0.25 mg, 0.5 mg, mg, 2 (Requip) mg, 3 mg, 4 mg, 5 mg ropinirole oral tablet extended release 24 hr (Requip XL) 2 mg, 2 mg, 4 mg, 6 mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) selegiline hcl oral tablet 5 mg trihexyphenidyl oral elixir 0.4 mg/ml PA-HRM; AGE (Max 64 Years) trihexyphenidyl oral tablet 2 mg, 5 mg PA-HRM; AGE (Max 64 Years) XADAGO ORAL TABLET 00 MG, 50 MG PA; QL (30 per 30 Agentes antipsicóticos Agentes antipsicóticos ABILIFY MAINTENA INTRAMUSCULAR QL ( per 28 SUSPENSION, EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR QL ( per 28 SUSPENSION, EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution mg/ml QL (900 per 30 aripiprazole oral tablet 0 mg, 5 mg, 20 mg, (Abilify) QL (30 per mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 aripiprazole oral tablet, disintegrating 0 mg QL (90 per 30 aripiprazole oral tablet, disintegrating 5 mg QL (60 per 30 ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING, 064 MG/3.9 ML QL (3.9 per 56 4

49 Nombre del ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 44 MG/.6 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 882 MG/3.2 ML QL (.6 per 28 QL (2.4 per 28 QL (3.2 per 28 chlorpromazine injection solution 25 mg/ml chlorpromazine oral tablet 0 mg, 00 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet 00 mg (Clozaril) QL (270 per 30 clozapine oral tablet 200 mg QL (35 per 30 clozapine oral tablet 25 mg (Clozaril) QL (90 per 30 clozapine oral tablet 50 mg QL (90 per 30 clozapine oral tablet, disintegrating 00 mg, (FazaClo) ST; QL (90 per mg, 25 mg clozapine oral tablet, disintegrating 50 mg (FazaClo) ST; QL (80 per 30 clozapine oral tablet, disintegrating 200 mg (FazaClo) ST; QL (20 per 30 FANAPT ORAL TABLET MG, 0 MG, 2 ST; QL (60 per 30 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS, DOSE PACK ST; QL (8 per 28 MG(2)-2MG(2)- 4MG(2)-6MG(2) fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet mg, 0 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) QL (6 per 28 haloperidol decanoate intramuscular solution (Haldol 00 mg/ml, 50 mg/ml Decanoate) haloperidol lactate injection solution 5 mg/ml (Haldol) haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, mg, 0 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML QL (0.75 per 28 42

50 Nombre del INVEGA SUSTENNA INTRAMUSCULAR QL ( per 28 SYRINGE 56 MG/ML INVEGA SUSTENNA INTRAMUSCULAR QL (.5 per 28 SYRINGE 234 MG/.5 ML INVEGA SUSTENNA INTRAMUSCULAR QL (0.25 per 28 SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR QL (0.5 per 28 SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR QL (0.875 per 84 SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR QL (.35 per 84 SYRINGE 40 MG/.35 ML INVEGA TRINZA INTRAMUSCULAR QL (.75 per 84 SYRINGE 546 MG/.75 ML INVEGA TRINZA INTRAMUSCULAR QL (2.625 per 84 SYRINGE 89 MG/2.625 ML LATUDA ORAL TABLET 20 MG, 20 MG, QL (30 per MG, 60 MG, 80 MG loxapine succinate oral capsule 0 mg, 25 mg, 5 mg, 50 mg molindone oral tablet 0 mg QL (240 per 30 molindone oral tablet 25 mg QL (270 per 30 molindone oral tablet 5 mg QL (20 per 30 NUPLAZID ORAL TABLET 7 MG PA NSO; QL (60 per 30 olanzapine intramuscular recon soln 0 mg (Zyprexa) QL (30 per 30 olanzapine oral tablet 0 mg, 5 mg, 2.5 mg, (Zyprexa) QL (30 per mg, 5 mg, 7.5 mg olanzapine oral tablet, disintegrating 0 mg, (Zyprexa Zydis) QL (30 per 30 5 mg, 20 mg, 5 mg paliperidone oral tablet extended release 24hr (Invega) QL (30 per 30.5 mg, 3 mg, 9 mg paliperidone oral tablet extended release 24hr (Invega) QL (60 per 30 6 mg perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg pimozide oral tablet mg, 2 mg (Orap) quetiapine oral tablet 00 mg, 200 mg, 25 mg, (Seroquel) QL (90 per mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 50 mg, 200 mg, 50 mg (Seroquel XR) QL (30 per 30 43

51 Nombre del quetiapine oral tablet extended release 24 hr (Seroquel XR) QL (60 per mg, 400 mg REXULTI ORAL TABLET 0.25 MG ST; QL (20 per 30 REXULTI ORAL TABLET 0.5 MG ST; QL (60 per 30 REXULTI ORAL TABLET MG, 2 MG, 3 ST; QL (30 per 30 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR QL (4 per 28 SYRINGE 2.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution mg/ml (Risperdal) QL (480 per 30 risperidone oral tablet 0.25 mg, 0.5 mg, mg, (Risperdal) QL (60 per 30 2 mg, 3 mg, 4 mg risperidone oral tablet, disintegrating 0.25 mg QL (60 per 30 risperidone oral tablet, disintegrating 0.5 mg, (Risperdal M QL (60 per 30 mg, 2 mg TAB) risperidone oral tablet, disintegrating 3 mg, 4 (Risperdal M QL (20 per 30 mg TAB) SAPHRIS (BLACK CHERRY) ST; QL (60 per 30 SUBLINGUAL TABLET 0 MG, 2.5 MG, 5 MG thioridazine oral tablet 0 mg, 00 mg, 25 mg, 50 mg thiothixene oral capsule mg, 0 mg, 2 mg, 5 mg trifluoperazine oral tablet mg, 0 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 ST; QL (540 per 30 MG/ML VRAYLAR ORAL CAPSULE.5 MG, 3 ST; QL (30 per 30 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE, DOSE PACK ST; QL (7 per 30.5 MG ()- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 (Geodon) QL (60 per 30 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR QL (2 per 28 SUSPENSION FOR RECONSTITUTION 20 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR QL ( per 28 SUSPENSION FOR RECONSTITUTION 405 MG Antivirales (sistémicos) Antiretrovirals 44

52 Nombre del abacavir oral tablet 300 mg (Ziagen) abacavir-lamivudine oral tablet mg (Epzicom) abacavir-lamivudine-zidovudine oral tablet (Trizivir) mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 00 MG/ML ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule, delayed (Videx EC) release(dr/ec) 25 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EVOTAZ ORAL TABLET MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET, CHEWABLE 00 MG, 25 MG KALETRA ORAL TABLET MG, MG lamivudine oral solution 0 mg/ml (Epivir) lamivudine oral tablet 00 mg (Epivir HBV) lamivudine oral tablet 50 mg, 300 mg (Epivir) lamivudine-zidovudine oral tablet mg (Combivir) LEXIVA ORAL SUSPENSION 50 MG/ML 45

53 Nombre del LEXIVA ORAL TABLET 700 MG lopinavir-ritonavir oral solution mg/5 (Kaletra) ml nevirapine oral suspension 50 mg/5 ml (Viramune) nevirapine oral tablet 200 mg (Viramune) nevirapine oral tablet extended release 24 hr (Viramune XR) 00 mg, 400 mg NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 50 MG, 25 MG, 300 MG, 75 MG stavudine oral capsule 5 mg, 20 mg, 30 mg, (Zerit) 40 mg stavudine oral recon soln mg/ml (Zerit) STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 0 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VEMLIDY ORAL TABLET 25 MG QL (30 per 30 46

54 Nombre del VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG, 300 MG ZERIT ORAL RECON SOLN MG/ML ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 00 mg (Retrovir) zidovudine oral syrup 0 mg/ml (Retrovir) zidovudine oral tablet 300 mg Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) PA BvD oseltamivir oral capsule 30 mg (Tamiflu) QL (84 per 80 oseltamivir oral capsule 45 mg (Tamiflu) QL (48 per 80 oseltamivir oral capsule 75 mg (Tamiflu) QL (42 per 80 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 00 mg (Flumadine) SYNAGIS INTRAMUSCULAR SOLUTION PA 00 MG/ML, 50 MG/0.5 ML TAMIFLU ORAL SUSPENSION FOR QL (540 per 80 RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, PA; QL (28 per MG EPCLUSA ORAL TABLET MG PA; QL (28 per 28 HARVONI ORAL TABLET MG PA; QL (30 per 30 OLYSIO ORAL CAPSULE 50 MG PA; QL (28 per 28 SOVALDI ORAL TABLET 400 MG PA; QL (28 per 28 TECHNIVIE ORAL TABLET MG PA; QL (56 per 28 VIEKIRA PAK ORAL TABLETS, DOSE PA; QL (2 per 28 PACK 2.5 MG-75 MG -50 MG/250 MG VIEKIRA XR ORAL TABLET, IR - ER, PA; QL (84 per 28 BIPHASIC 24HR 8.33 MG-50 MG MG-200 MG ZEPATIER ORAL TABLET MG PA; QL (30 per 30 Interferons 47

55 Nombre del INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 35 MCG/0.5 ML, 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet 400 mg, 800 mg (Zovirax) PA NSO PA NSO PA NSO; QL (4 per 28 acyclovir sodium intravenous recon soln 500 PA BvD mg acyclovir sodium intravenous solution 50 mg/ml PA BvD adefovir oral tablet 0 mg (Hepsera) entecavir oral tablet 0.5 mg, mg (Baraclude) famciclovir oral tablet 25 mg, 250 mg, 500 mg ganciclovir sodium intravenous recon soln 500 (Cytovene) PA BvD mg ribasphere oral capsule 200 mg ribasphere oral tablet 200 mg, 400 mg, 600 mg ribavirin inhalation recon soln 6 gram (Virazole) PA BvD valacyclovir oral tablet gram, 500 mg (Valtrex) valganciclovir oral tablet 450 mg (Valcyte) Productos/modificadores/ expansores del volumen de sangre Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG 48

56 Nombre del enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 00 mg/ml, 20 mg/0.8 ml, 50 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 0 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 20, 000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25, 000 unit/250 ml(00 unit/ml) heparin (porcine) injection solution, 000 unit/ml, 0, 000 unit/ml, 20, 000 unit/ml, 5, 000 unit/ml heparin 25, 000 unit/250 ml (00 unit/ml)- 0.45% nacl bag l/f, inner, single-use 25, 000 unit/250 ml heparin, porcine (pf) injection solution 5, 000 unit/0.5 ml heparin, porcine (pf) injection syringe 5, 000 unit/0.5 ml IPRIVASK SUBCUTANEOUS RECON SOLN 5 MG jantoven oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG warfarin oral tablet mg, 0 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 0 MG, 5 MG, 20 MG XARELTO ORAL TABLETS, DOSE PACK 5 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 0, 000 UNITS/ML VIAL SDV, P/F, OUTER 0, 000 UNIT/ML (Lovenox) (Lovenox) (Arixtra) PA; QL (24 per 28 ST; QL (60 per 30 (Jantoven) PA PA; QL (2 per 28 49

57 Nombre del EPOGEN INJECTION SOLUTION 2, 000 UNIT/ML, 20, 000 UNIT/2 ML, 20, 000 UNIT/ML, 3, 000 UNIT/ML, 4, 000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 00 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 0, 000 UNIT/ML, 2, 000 UNIT/ML, 20, 000 UNIT/2 ML, 20, 000 UNIT/ML, 3, 000 UNIT/ML, 4, 000 UNIT/ML PROCRIT INJECTION SOLUTION 40, 000 UNIT/ML PROMACTA ORAL TABLET 2.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 mg (Agrylin) anagrelide oral capsule mg protamine intravenous solution 0 mg/ml PA; QL (2 per 28 PA; QL (0.6 per 28 PA; QL (2 per 28 PA; QL (6 per 28 PA; QL (30 per 30 ST tranexamic acid intravenous solution, 000 (Cyklokapron) mg/0 ml (00 mg/ml) tranexamic acid oral tablet 650 mg (Lysteda) QL (30 per 30 Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 2 hr mg (Aggrenox) BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00 mg, 50 mg 50

58 Nombre del clopidogrel oral tablet 75 mg (Plavix) dipyridamole oral tablet 25 mg, 50 mg, 75 mg EFFIENT ORAL TABLET 0 MG, 5 MG QL (30 per 30 pentoxifylline oral tablet extended release 400 mg Agentes calóricos Agentes calóricos AMINO ACIDS 5 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 5 % AMINOSYN 0 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 0 % AMINOSYN 7 % WITH ELECTROLYTES PA BvD INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %-ELECTROLYTES PA BvD INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 0 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 0 % AMINOSYN II 5 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 5 % AMINOSYN II 7 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES PA BvD INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PA BvD PARENTERAL SOLUTION 7 % AMINOSYN-PF 0 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 0 % AMINOSYN-PF 7 % (SULFITE-FREE) PA BvD INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % PA BvD 5

59 Nombre del CLINIMIX 5%/D5W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D0W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 52

60 Nombre del CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in ringer's intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 53

61 Nombre del PREMASOL 0 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 0 % PREMASOL 6 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PA BvD PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PA BvD PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % PA BvD TRAVASOL 0 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 0 % TROPHAMINE 0 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 0 % TROPHAMINE 6% INTRAVENOUS PA BvD PARENTERAL SOLUTION 6 % Agentes cardiovasculares Alpha-Adrenergic Agents clonidine hcl oral tablet 0. mg, 0.2 mg, 0.3 (Catapres) mg clonidine transdermal patch weekly 0. mg/24 (Catapres-TTS QL (4 per 28 hr ) clonidine transdermal patch weekly 0.2 mg/24 (Catapres-TTS QL (4 per 28 hr 2) clonidine transdermal patch weekly 0.3 mg/24 (Catapres-TTS QL (8 per 28 hr 3) doxazosin oral tablet mg, 2 mg, 4 mg, 8 mg (Cardura) guanfacine oral tablet mg, 2 mg PA-HRM; AGE (Max 64 Years) midodrine oral tablet 0 mg, 2.5 mg, 5 mg NORTHERA ORAL CAPSULE 00 MG, 200 PA; QL (80 per 30 MG, 300 MG phenylephrine hcl injection solution 0 mg/ml (Vazculep) prazosin oral capsule mg, 2 mg, 5 mg (Minipress) Angiotensin Ii Receptor Antagonists candesartan oral tablet 6 mg, 32 mg, 4 mg, 8 mg (Atacand) candesartan-hydrochlorothiazid oral tablet (Atacand HCT) mg, mg, mg EDARBI ORAL TABLET 40 MG, 80 MG EDARBYCLOR ORAL TABLET MG, MG 54

62 Nombre del ENTRESTO ORAL TABLET MG, 49 5 MG, MG QL (60 per 30 irbesartan oral tablet 50 mg, 300 mg, 75 mg (Avapro) irbesartan-hydrochlorothiazide oral tablet (Avalide) mg, mg losartan oral tablet 00 mg, 25 mg, 50 mg (Cozaar) losartan-hydrochlorothiazide oral tablet 00- (Hyzaar) 2.5 mg, mg, mg olmesartan oral tablet 20 mg, 40 mg, 5 mg (Benicar) olmesartan-amlodipin-hcthiazid oral tablet 20- (Tribenzor) mg, mg, mg, mg, mg olmesartan-hydrochlorothiazide oral tablet (Benicar HCT) mg, mg, mg telmisartan oral tablet 20 mg, 40 mg, 80 mg (Micardis) valsartan oral tablet 60 mg, 320 mg, 40 mg, (Diovan) 80 mg valsartan-hydrochlorothiazide oral tablet 60- (Diovan HCT) 2.5 mg, mg, mg, mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 0 mg, 5 mg benazepril oral tablet 20 mg, 40 mg (Lotensin) benazepril-hydrochlorothiazide oral tablet 0- (Lotensin HCT) 2.5 mg, mg, mg benazepril-hydrochlorothiazide oral tablet mg captopril oral tablet 00 mg, 2.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet 25-5 mg, mg, 50-5 mg, mg enalapril maleate oral tablet 0 mg, 2.5 mg, (Vasotec) 20 mg, 5 mg enalaprilat intravenous solution.25 mg/ml enalapril-hydrochlorothiazide oral tablet 0- (Vaseretic) 25 mg enalapril-hydrochlorothiazide oral tablet mg fosinopril oral tablet 0 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet mg, mg 55

63 Nombre del lisinopril oral tablet 0 mg, 2.5 mg, 20 mg, 30 (Zestril) mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet 0- (Zestoretic) 2.5 mg, mg, mg moexipril oral tablet 5 mg, 7.5 mg moexipril-hydrochlorothiazide oral tablet mg, 5-25 mg, mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril oral tablet 0 mg, 20 mg, 40 mg, 5 (Accupril) mg quinapril-hydrochlorothiazide oral tablet 0- (Accuretic) 2.5 mg, mg, mg ramipril oral capsule.25 mg, 0 mg, 2.5 mg, (Altace) 5 mg trandolapril oral tablet mg, 2 mg, 4 mg Antiarrhythmic Agents amiodarone oral tablet 00 mg, 200 mg, 400 (Pacerone) mg disopyramide phosphate oral capsule 00 mg, (Norpace) 50 mg dofetilide oral capsule 25 mcg, 250 mcg, 500 (Tikosyn) mcg flecainide oral tablet 00 mg, 50 mg, 50 mg lidocaine (pf) intravenous syringe 50 mg/5 ml ( %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 50 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 00 mg, 200 mg, 400 mg procainamide injection solution 00 mg/ml, 500 mg/ml propafenone oral tablet 50 mg, 225 mg, 300 mg quinidine sulfate oral tablet 200 mg, 300 mg Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg atenolol oral tablet 00 mg, 25 mg, 50 mg (Tenormin) atenolol-chlorthalidone oral tablet mg (Tenoretic 00) atenolol-chlorthalidone oral tablet mg (Tenoretic 50) 56

64 Nombre del betaxolol oral tablet 0 mg, 20 mg bisoprolol fumarate oral tablet 0 mg, 5 mg bisoprolol-hydrochlorothiazide oral tablet 0- (Ziac) 6.25 mg, mg, mg BYSTOLIC ORAL TABLET 0 MG, 2.5 MG, 20 MG, 5 MG BYVALSON ORAL TABLET 5-80 MG carvedilol oral tablet 2.5 mg, 25 mg, 3.25 (Coreg) mg, 6.25 mg esmolol intravenous solution 00 mg/0 ml (0 (Brevibloc) PA BvD mg/ml) labetalol intravenous solution 5 mg/ml labetalol oral tablet 00 mg, 200 mg, 300 mg metoprolol succinate oral tablet extended (Toprol XL) release 24 hr 00 mg, 200 mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet mg, mg metoprolol ta-hydrochlorothiaz oral tablet 50- (Lopressor 25 mg HCT) metoprolol tartrate intravenous solution 5 (Lopressor) mg/5 ml metoprolol tartrate intravenous syringe 5 mg/5 ml metoprolol tartrate oral tablet 00 mg, 50 mg (Lopressor) metoprolol tartrate oral tablet 25 mg nadolol oral tablet 20 mg, 40 mg, 80 mg (Corgard) pindolol oral tablet 0 mg, 5 mg propranolol intravenous solution mg/ml propranolol oral capsule, extended release 24 (Inderal LA) hr 20 mg, 60 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 0 mg, 20 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral tablet mg, mg sorine oral tablet 20 mg, 60 mg, 240 mg, 80 mg sotalol 20 mg tablet 20 mg (Sorine) sotalol af oral tablet 20 mg sotalol oral tablet 60 mg, 80 mg (Sorine) sotalol oral tablet 240 mg (Betapace) 57

65 Nombre del timolol maleate oral tablet 0 mg, 20 mg, 5 mg Calcium-Channel Blocking Agents cartia xt oral capsule, extended release 24hr 20 mg, 80 mg, 240 mg, 300 mg diltiazem 24hr er 80 mg cap 80 mg (Cartia XT) diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule, extended release (Taztia XT) 80 mg diltiazem hcl oral capsule, extended release (Tiazac) 420 mg diltiazem hcl oral capsule, extended release 2 hr 20 mg, 60 mg, 90 mg diltiazem hcl oral capsule, extended release (Cardizem CD) 24hr 20 mg, 300 mg diltiazem hcl oral capsule, extended release 24hr 240 mg (Cartia XT) diltiazem hcl oral tablet 20 mg, 30 mg, 60 mg (Cardizem) diltiazem hcl oral tablet 90 mg diltiazem hcl oral tablet extended release 24 hr (Matzim LA) 80 mg, 300 mg, 360 mg, 420 mg diltiazem hcl oral tablet extended release 24 hr (Cardizem LA) 240 mg dilt-xr oral capsule, ext release degradable 20 mg, 80 mg, 240 mg matzim la oral tablet extended release 24 hr 80 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 20 mg, 80 mg, 240 mg, 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml verapamil oral capsule, 24 hr er pellet ct 00 (Verelan PM) mg, 200 mg, 300 mg verapamil oral capsule, ext rel. pellets 24 hr (Verelan) 20 mg, 80 mg, 240 mg, 360 mg verapamil oral tablet 20 mg, 80 mg (Calan) verapamil oral tablet 40 mg verapamil oral tablet extended release 20 mg, (Calan SR) 80 mg, 240 mg Agentes cardiovasculares, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG PA; QL (60 per 30 DEMSER ORAL CAPSULE 250 MG 58

66 Nombre del digitek oral tablet 25 mcg PA-HRM; High Risk Med. PA Required for ages 65 and older and dose is greater than 25mcg per day; QL (30 per 30 ; AGE (Max 64 Years) digitek oral tablet 250 mcg PA-HRM; High Risk Med. PA Required for ages 65 and older and dose is greater than 25mcg per day; AGE (Max 64 Years) digoxin 0.25 mg/ml syringe 250 mcg/ml PA-HRM; AGE (Max 64 Years) digoxin injection solution 250 mcg/ml (Lanoxin) PA-HRM; AGE (Max 64 Years) DIGOXIN ORAL SOLUTION 50 MCG/ML PA-HRM; High Risk Med. PA Required for ages 65 and older and dose is greater than 25mcg per day; AGE (Max 64 Years) digoxin oral tablet 25 mcg (Lanoxin) PA-HRM; High Risk Med. PA Required for ages 65 and older and dose is greater than 25mcg per day; QL (30 per 30 ; AGE (Max 64 Years) digoxin oral tablet 250 mcg (Digox) PA-HRM; High Risk Med. PA Required for ages 65 and older and dose is greater than 25mcg per day; AGE (Max 64 Years) dobutamine in d5w intravenous parenteral PA BvD solution, 000 mg/250 ml (4, 000 mcg/ml), 250 mg/250 ml ( mg/ml) dobutamine in d5w intravenous parenteral PA BvD solution 500 mg/250 ml (2, 000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml PA BvD (2.5 mg/ml), 500 mg/40 ml (2.5 mg/ml) dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (, 600 mcg/ml), 800 mg/250 ml (3, 200 mcg/ml) PA BvD 59

67 Nombre del dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/0 ml (80 mg/ml), 800 mg/5 ml (60 mg/ml) PA BvD epipen jr injection auto-injector 0.5mg/0.3ml (EpiPen Jr) QL (4 per 30 epipen injection auto-injector 0.3mg/0.3ml (Adrenaclick) QL (4 per 30 FIRAZYR SUBCUTANEOUS SYRINGE 30 QL (8 per 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 0 mg, 00 mg, 25 mg, 50 mg LANOXIN ORAL TABLET 87.5 MCG PA-HRM; QL (30 per 30 ; AGE (Max 64 Years) LANOXIN ORAL TABLET 62.5 MCG PA-HRM; High Risk Med. PA Required for ages 65 and older and dose is greater than 25mcg per day; QL (60 per 30 ; AGE (Max 64 Years) milrinone in 5 % dextrose intravenous piggyback 20 mg/00 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) PA BvD milrinone intravenous solution mg/ml PA BvD norepinephrine bitartrate intravenous solution (Levophed PA BvD mg/ml (bitartrate)) RANEXA ORAL TABLET EXTENDED RELEASE 2 HR, 000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 0 mg, 2.5 mg, 5 mg (Norvasc) amlodipine-benazepril oral capsule 0-20 mg, (Lotrel) 0-40 mg, 5-0 mg, 5-20 mg, 5-40 mg amlodipine-benazepril oral capsule mg amlodipine-olmesartan oral tablet 0-20 mg, (Azor) 0-40 mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet 0-60 mg, (Exforge) mg, 5-60 mg, mg amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, mg (Exforge HCT) CLEVIPREX INTRAVENOUS EMULSION 25 MG/50 ML, 50 MG/00 ML 60

68 Nombre del felodipine oral tablet extended release 24 hr 0 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg nicardipine oral capsule 20 mg, 30 mg nifedipine oral tablet extended release 24hr 30 (Procardia XL) mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, (Adalat CC) 90 mg nifedipine oral tablet extended release 60 mg (Afeditab CR) Diuretics amiloride oral tablet 5 mg amiloride-hydrochlorothiazide oral tablet 5-50 mg bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, mg, 2 mg chlorothiazide oral tablet 250 mg, 500 mg chlorothiazide sodium intravenous recon soln (Diuril IV) 500 mg chlorthalidone oral tablet 25 mg, 50 mg furosemide injection solution 0 mg/ml furosemide injection syringe 0 mg/ml furosemide oral solution 0 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) hydrochlorothiazide oral capsule 2.5 mg (Microzide) hydrochlorothiazide oral tablet 2.5 mg, 25 mg, 50 mg indapamide oral tablet.25 mg, 2.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 0 mg, 2.5 mg, 5 mg spironolactone oral tablet 00 mg, 25 mg, 50 (Aldactone) mg spironolacton-hydrochlorothiaz oral tablet 25- (Aldactazide) 25 mg torsemide oral tablet 0 mg, 20 mg (Demadex) torsemide oral tablet 00 mg, 5 mg triamterene-hydrochlorothiazid oral capsule (Dyazide) mg triamterene-hydrochlorothiazid oral capsule mg triamterene-hydrochlorothiazid oral tablet (Maxzide mg 25mg) 6

69 Nombre del triamterene-hydrochlorothiazid oral tablet 75- (Maxzide) 50 mg Dyslipidemics amlodipine-atorvastatin oral tablet 0-0 mg, (Caduet) 0-20 mg, 0-40 mg, 0-80 mg, 5-0 mg, 5-20 mg, 5-40 mg, 5-80 mg amlodipine-atorvastatin oral tablet mg, mg, mg atorvastatin oral tablet 0 mg, 20 mg, 40 mg, (Lipitor) 80 mg cholestyramine (with sugar) oral powder 4 (Questran) gram cholestyramine light oral powder 4 gram cholestyramine light packet 4 gram cholestyramine packet 4 gram (Questran) colestipol hcl granules packet 5 gram (Colestid) colestipol oral granules 5 gram (Colestid) colestipol oral tablet gram (Colestid) ezetimibe oral tablet 0 mg (Zetia) fenofibrate micronized oral capsule 30 mg, 34 mg, 200 mg, 43 mg, 67 mg fenofibrate nanocrystallized oral tablet 45 (Tricor) mg, 48 mg fenofibrate oral tablet 60 mg, 54 mg fenofibric acid (choline) oral capsule, delayed (Trilipix) release(dr/ec) 35 mg, 45 mg fenofibric acid oral tablet 05 mg, 35 mg (Fibricor) gemfibrozil oral tablet 600 mg (Lopid) JUXTAPID ORAL CAPSULE 0 MG, 30 PA; QL (30 per 30 MG, 40 MG, 60 MG JUXTAPID ORAL CAPSULE 20 MG PA; QL (90 per 30 JUXTAPID ORAL CAPSULE 5 MG PA; QL (45 per 30 KYNAMRO SUBCUTANEOUS SYRINGE PA; QL (4 per MG/ML LIVALO ORAL TABLET MG, 2 MG, 4 QL (30 per 30 MG lovastatin oral tablet 0 mg, 20 mg, 40 mg niacin oral tablet extended release 24 hr, (Niaspan 000 mg, 500 mg, 750 mg Extended- Release) niacor oral tablet 500 mg omega-3 acid ethyl esters oral capsule gram (Lovaza) QL (20 per 30 62

70 Nombre del PRALUENT PEN SUBCUTANEOUS PEN PA; QL (2 per 28 INJECTOR 50 MG/ML, 75 MG/ML pravastatin oral tablet 0 mg pravastatin oral tablet 20 mg, 40 mg, 80 mg (Pravachol) prevalite oral powder 4 gram prevalite packet outer 4 gram REPATHA PUSHTRONEX PA; QL (3.5 per 28 SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PA; QL (3 per 28 PEN INJECTOR 40 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 40 MG/ML PA; QL (3 per 28 rosuvastatin oral tablet 0 mg, 20 mg, 40 mg, (Crestor) 5 mg simvastatin oral tablet 0 mg, 20 mg, 40 mg, 5 (Zocor) mg simvastatin oral tablet 80 mg (Zocor) QL (30 per 30 VASCEPA ORAL CAPSULE 0.5 GRAM QL (240 per 30 VASCEPA ORAL CAPSULE GRAM QL (20 per 30 WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) TEKAMLO ORAL TABLET 50-0 MG, ST 50-5 MG, MG, MG TEKTURNA HCT ORAL TABLET ST MG, MG, MG, MG TEKTURNA ORAL TABLET 50 MG, 300 ST MG Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 0 mg, 20 mg, 30 mg isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) isosorbide dinitrate oral tablet extended (ISOCHRON) release 40 mg isosorbide mononitrate oral tablet 0 mg, 20 mg 63

71 Nombre del isosorbide mononitrate oral tablet extended release 24 hr 20 mg, 30 mg, 60 mg minitran transdermal patch 24 hour 0. mg/hr, QL (30 per mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 mg/hr QL (60 per 30 minoxidil oral tablet 0 mg, 2.5 mg NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin in 5 % dextrose intravenous solution 00 mg/250 ml (400 mcg/ml), 25 mg/250 ml (00 mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 mg/0 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, (Nitrostat) 0.6 mg nitroglycerin transdermal patch 24 hour 0. (Minitran) QL (30 per 30 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.2 (Nitro-Dur) QL (30 per 30 mg/hr nitroglycerin transdermal patch 24 hour 0.4 (Nitro-Dur) QL (60 per 30 mg/hr Agentes del sistema central nervioso Agentes del sistema central nervioso AMPYRA ORAL TABLET EXTENDED PA; QL (60 per 30 RELEASE 2 HR 0 MG atomoxetine oral capsule 0 mg, 00 mg, 8 (Strattera) mg, 25 mg, 40 mg, 60 mg, 80 mg AUBAGIO ORAL TABLET 4 MG, 7 MG PA; QL (28 per 28 AUSTEDO ORAL TABLET 2 MG, 9 MG PA; QL (20 per 30 AUSTEDO ORAL TABLET 6 MG PA; QL (60 per 30 AVONEX (WITH ALBUMIN) PA INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN PA INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE PA KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 PA MG caffeine citrate intravenous solution 60 mg/3 ml (20 mg/ml) (Cafcit) 64

72 Nombre del caffeine citrate oral solution 60 mg/3 ml (20 mg/ml) COPAXONE SUBCUTANEOUS SYRINGE PA; QL (2 per MG/ML dexmethylphenidate oral tablet 0 mg, 2.5 mg, (Focalin) QL (60 per 30 5 mg dextroamphetamine oral tablet 0 mg, 5 mg (Dexedrine) QL (80 per 30 dextroamphetamine-amphetamine oral (Adderall XR) QL (30 per 30 capsule, extended release 24hr 0 mg, 5 mg, 5 mg dextroamphetamine-amphetamine oral (Adderall XR) QL (60 per 30 capsule, extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet (Adderall) QL (60 per 30 0 mg, 2.5 mg, 5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg EXTAVIA SUBCUTANEOUS KIT 0.3 MG PA flumazenil intravenous solution 0. mg/ml GILENYA ORAL CAPSULE 0.5 MG PA; QL (28 per 28 glatopa subcutaneous syringe 20 mg/ml PA; QL (30 per 30 guanfacine oral tablet extended release 24 hr (Intuniv ER) mg, 2 mg, 3 mg, 4 mg INGREZZA ORAL CAPSULE 40 MG PA; QL (60 per 30 LEMTRADA INTRAVENOUS SOLUTION PA 2 MG/.2 ML lithium carbonate oral capsule 50 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release (Lithobid) 300 mg lithium carbonate oral tablet extended release 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate hcl oral capsule, er biphasic QL (30 per mg, 20 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule, er biphasic QL (60 per mg methylphenidate hcl oral capsule, er biphasic (Ritalin LA) QL (30 per mg, 40 mg methylphenidate hcl oral capsule, er biphasic mg (Ritalin LA) QL (60 per 30 65

73 Nombre del methylphenidate hcl oral capsule, er biphasic QL (30 per mg methylphenidate hcl oral solution 0 mg/5 ml, (Methylin) QL (900 per 30 5 mg/5 ml methylphenidate hcl oral tablet 0 mg, 20 mg, (Ritalin) QL (90 per 30 5 mg methylphenidate hcl oral tablet extended (Concerta) QL (30 per 30 release 24hr 8 mg, 27 mg, 54 mg methylphenidate hcl oral tablet extended (Concerta) QL (60 per 30 release 24hr 36 mg NUEDEXTA ORAL CAPSULE 20-0 MG QL (60 per 30 OCREVUS INTRAVENOUS SOLUTION 30 PA; QL (20 per 80 MG/ML PLEGRIDY SUBCUTANEOUS PEN PA INJECTOR 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE PA 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML RADICAVA INTRAVENOUS PIGGYBACK PA; QL (2800 per MG/00 ML REBIF (WITH ALBUMIN) PA SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN PA INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK PA SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) riluzole oral tablet 50 mg (Rilutek) SAVELLA ORAL TABLET 00 MG, 2.5 QL (60 per 30 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS, DOSE PACK QL (60 per MG (5)-25 MG(8)-50 MG(42) TECFIDERA ORAL CAPSULE, DELAYED PA; QL (4 per 30 RELEASE(DR/EC) 20 MG TECFIDERA ORAL CAPSULE, DELAYED PA; QL (60 per 30 RELEASE(DR/EC) 20 MG (4)- 240 MG (46), 240 MG tetrabenazine oral tablet 2.5 mg, 25 mg (Xenazine) PA; QL (2 per 28 ZINBRYTA SUBCUTANEOUS SYRINGE 50 MG/ML PA; QL ( per 28 66

74 Nombre del Anticonceptivos Anticonceptivos altavera (28) oral tablet mg alyacen /35 (28) oral tablet -35 mg-mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg amethia lo oral tablets, dose pack, 3 month QL (9 per mg-20 mcg (84)/0 mcg (7) amethia oral tablets, dose pack, 3 month 0.5 QL (9 per 84 mg-30 mcg (84)/0 mcg (7) apri oral tablet mg aranelle (28) oral tablet 0.5// mg-mcg ashlyna oral tablets, dose pack, 3 month 0.5 mg-30 mcg (84)/0 mcg (7) aubra oral tablet mg-mcg aviane oral tablet mg-mcg azurette (28) oral tablet mgx2 /0.0 mg x 5 balziva (28) oral tablet mg-mcg bekyree (28) oral tablet mgx2 /0.0 mg x 5 blisovi 24 fe oral tablet mg-20 mcg (24)/75 mg (4) blisovi fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) blisovi fe /20 (28) oral tablet mg-20 mcg (2)/75 mg (7) briellyn oral tablet mg-mcg camila oral tablet 0.35 mg camrese lo oral tablets, dose pack, 3 month QL (9 per mg-20 mcg (84)/0 mcg (7) camrese oral tablets, dose pack, 3 month 0.5 QL (9 per 84 mg-30 mcg (84)/0 mcg (7) caziant (28) oral tablet 0./.25/.5-25 mgmcg cryselle (28) oral tablet mg-mcg cyclafem /35 (28) oral tablet -35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg cyred oral tablet mg dasetta /35 (28) oral tablet -35 mg-mcg 67

75 Nombre del dasetta 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg daysee oral tablets, dose pack, 3 month 0.5 QL (9 per 84 mg-30 mcg (84)/0 mcg (7) deblitane oral tablet 0.35 mg delyla (28) oral tablet mg-mcg desog-e.estradiol/e.estradiol oral tablet 0.5- (Viorele (28)) 0.02 mgx2 /0.0 mg x 5 desogestrel-ethinyl estradiol oral tablet 0.5- (Isibloom) 0.03 mg drospirenone-ethinyl estradiol oral tablet 3- (Nikki (28)) 0.02 mg drospirenone-ethinyl estradiol oral tablet 3- (Syeda) 0.03 mg elinest oral tablet mg-mcg ELLA ORAL TABLET 30 MG QL (6 per 365 emoquette oral tablet mg enpresse oral tablet (6)/75-40 (5)/25-30(0) enskyce oral tablet mg errin oral tablet 0.35 mg estarylla oral tablet mg-mcg ethynodiol diac-eth estradiol oral tablet -50 (Zovia /50E mg-mcg (28)) falmina (28) oral tablet mg-mcg femynor oral tablet mg-mcg gianvi (28) oral tablet mg gildagia oral tablet mg-mcg heather oral tablet 0.35 mg introvale oral tablets, dose pack, 3 month 0.5 QL (9 per 84 mg-30 mcg isibloom oral tablet mg jencycla oral tablet 0.35 mg jolessa oral tablets, dose pack, 3 month 0.5 QL (9 per 84 mg-30 mcg jolivette oral tablet 0.35 mg juleber oral tablet mg junel.5/30 (2) oral tablet.5-30 mg-mcg junel /20 (2) oral tablet -20 mg-mcg junel fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) 68

76 Nombre del junel fe /20 (28) oral tablet mg-20 mcg (2)/75 mg (7) junel fe 24 oral tablet mg-20 mcg (24)/75 mg (4) kariva (28) oral tablet mgx2 /0.0 mg x 5 kelnor /35 (28) oral tablet -35 mg-mcg kimidess (28) oral tablet mgx2 /0.0 mg x 5 kurvelo oral tablet mg l norgest/e.estradiol-e.estrad oral tablets, dose (LoSeasonique) QL (9 per 84 pack, 3 month 0.0 mg-20 mcg (84)/0 mcg (7) l norgest/e.estradiol-e.estrad oral tablets, dose (Daysee) QL (9 per 84 pack, 3 month 0.5 mg-30 mcg (84)/0 mcg (7) larin.5/30 (2) oral tablet.5-30 mg-mcg larin /20 (2) oral tablet -20 mg-mcg larin 24 fe oral tablet mg-20 mcg (24)/75 mg (4) larin fe.5/30 (28) oral tablet.5 mg-30 mcg (2)/75 mg (7) larin fe /20 (28) oral tablet mg-20 mcg (2)/75 mg (7) larissia oral tablet mg-mcg leena 28 oral tablet 0.5// mg-mcg lessina oral tablet mg-mcg levonest (28) oral tablet (6)/75-40 (5)/25-30(0) levonor-eth estrad outer (Altavera (28)) QL (9 per 84 mg levonorgestrel-ethinyl estrad oral tablet (Orsythia) mg-mcg levonorgestrel-ethinyl estrad oral tablets, dose (Jolessa) QL (9 per 84 pack, 3 month 0.5 mg-30 mcg levonorg-eth estrad triphasic oral tablet (Myzilra) QL (9 per 84 (6)/75-40 (5)/25-30(0) levora-28 oral tablet mg lomedia 24 fe oral tablet mg-20 mcg (24)/75 mg (4) loryna (28) oral tablet mg low-ogestrel (28) oral tablet mg-mcg lutera (28) oral tablet mg-mcg lyza oral tablet 0.35 mg 69

77 Nombre del marlissa oral tablet mg microgestin.5/30 (2) oral tablet.5-30 mgmcg microgestin /20 (2) oral tablet -20 mg-mcg microgestin fe.5/30 (28) oral tablet.5 mg- 30 mcg (2)/75 mg (7) microgestin fe /20 (28) oral tablet mg-20 mcg (2)/75 mg (7) mono-linyah oral tablet mg-mcg mononessa (28) oral tablet mg-mcg myzilra oral tablet (6)/75-40 (5)/25-30(0) necon 0.5/35 (28) oral tablet mg-mcg necon /50 (28) oral tablet -50 mg-mcg necon 0/ (28) oral tablet /-35 mgmcg/mg-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg nikki (28) oral tablet mg nora-be oral tablet 0.35 mg noreth-estrad-fe -0.02(2)-75 mg-20 mcg (Microgestin FE (2)/75 mg (7) /20 (28)) norethindrone (contraceptive) oral tablet 0.35 (Heather) mg norethindrone ac-eth estradiol oral tablet -20 (Larin /20 mg-mcg (2)) norethindrone-e.estradiol-iron oral tablet (Lomedia 24 mg-20 mcg (24)/75 mg (4) Fe) norgestimate-ethinyl estradiol oral tablet (Tri-Lo- 0.8/0.25/0.25 mg-25 mcg Sprintec) norgestimate-ethinyl estradiol oral tablet (Tri-Linyah) 0.8/0.25/0.25 mg-35 mcg (28) norgestimate-ethinyl estradiol oral tablet (Mono-Linyah) 35 mg-mcg norlyda oral tablet 0.35 mg norlyroc oral tablet 0.35 mg nortrel 0.5/35 (28) oral tablet mg-mcg nortrel /35 (2) oral tablet -35 mg-mcg nortrel /35 (28) oral tablet -35 mg-mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/ mg- 35 mcg 70

78 Nombre del NUVARING VAGINAL RING QL ( per 28 MG/24 HR ocella oral tablet mg ogestrel (28) oral tablet mg-mcg orsythia oral tablet mg-mcg philith oral tablet mg-mcg pimtrea (28) oral tablet mgx2 /0.0 mg x 5 pirmella oral tablet 0.5/0.75/ mg- 35 mcg, - 35 mg-mcg portia oral tablet mg previfem oral tablet mg-mcg quasense oral tablets, dose pack, 3 month 0.5 QL (9 per 84 mg-30 mcg reclipsen (28) oral tablet mg setlakin oral tablets, dose pack, 3 month 0.5 QL (9 per 84 mg-30 mcg sharobel oral tablet 0.35 mg sprintec (28) oral tablet mg-mcg sronyx oral tablet mg-mcg syeda oral tablet mg tarina fe /20 (28) oral tablet mg-20 mcg (2)/75 mg (7) tilia fe oral tablet -20(5)/-30(7) /mg-35mcg (9) tri femynor oral tablet 0.8/0.25/0.25 mg-35 mcg (28) tri-estarylla oral tablet 0.8/0.25/0.25 mg-35 mcg (28) tri-legest fe oral tablet -20(5)/-30(7) /mg- 35mcg (9) tri-linyah oral tablet 0.8/0.25/0.25 mg-35 mcg (28) tri-lo-estarylla oral tablet 0.8/0.25/0.25 mg- 25 mcg tri-lo-marzia oral tablet 0.8/0.25/0.25 mg- 25 mcg tri-lo-sprintec oral tablet 0.8/0.25/0.25 mg- 25 mcg trinessa (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) 7

79 Nombre del tri-previfem (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) tri-sprintec (28) oral tablet 0.8/0.25/0.25 mg-35 mcg (28) trivora (28) oral tablet (6)/75-40 (5)/25-30(0) velivet triphasic regimen (28) oral tablet 0./.25/.5-25 mg-mcg vestura (28) oral tablet mg vienva oral tablet mg-mcg viorele (28) oral tablet mgx2 /0.0 mg x 5 vyfemla (28) oral tablet mg-mcg wera (28) oral tablet mg-mcg xulane transdermal patch weekly QL (3 per 28 mcg/24 hr zarah oral tablet mg zenchent (28) oral tablet mg-mcg zovia /35e (28) oral tablet -35 mg-mcg zovia /50e (28) oral tablet -50 mg-mcg Agentes dentales y orales Agentes dentales y orales cevimeline oral capsule 30 mg (Evoxac) chlorhexidine gluconate mucous membrane (Paroex Oral mouthwash 0.2 % Rinse) oralone dental paste 0. % periogard mucous membrane mouthwash 0.2 % pilocarpine hcl oral tablet 5 mg, 7.5 mg (Salagen (pilocarpine)) triamcinolone acetonide dental paste 0. % (Oralone) Agentes dermatológicos Agentes dermatológicos, Other acitretin oral capsule 0 mg, 7.5 mg, 25 mg (Soriatane) acyclovir topical ointment 5 % (Zovirax) QL (30 per 30 ALCOHOL PADS TOPICAL PADS, MEDICATED ALCOHOL PREP PADS ammonium lactate topical cream 2 % (Geri-Hydrolac) ammonium lactate topical lotion 2 % (Skin Treatment) 72

80 Nombre del calcipotriene scalp solution % calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcitrene) calcitrene topical ointment % calcitriol topical ointment 3 mcg/gram (Vectical) CONDYLOX TOPICAL GEL 0.5 % COSENTYX (2 SYRINGES) PA SUBCUTANEOUS SYRINGE 50 MG/ML COSENTYX PEN (2 PENS) PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML diclofenac sodium topical drops.5 % QL (300 per 30 diclofenac sodium topical gel 3 % (Solaraze) PA; QL (00 per 28 DUPIXENT SUBCUTANEOUS SYRINGE PA 300 MG/2 ML FLECTOR TRANSDERMAL PATCH 2 PA HOUR.3 % fluorouracil topical cream 0.5 % (Carac) fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution 2 %, 5 % imiquimod topical cream in packet 5 % (Aldara) PA NSO; QL (24 per 30 methoxsalen oral capsule, liqd-filled, rapid rel (Oxsoralen 0 mg Ultra) PANRETIN TOPICAL GEL 0. % PICATO TOPICAL GEL 0.05 % QL (3 per 56 PICATO TOPICAL GEL 0.05 % QL (2 per 56 podofilox topical solution 0.5 % SANTYL TOPICAL OINTMENT 250 UNIT/GRAM SILIQ SUBCUTANEOUS SYRINGE 20 PA MG/.5 ML TALTZ AUTOINJECTOR PA SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS PA SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL 0.06 % VOLTAREN TOPICAL GEL % zenatane oral capsule 0 mg, 20 mg, 30 mg, 40 mg 73

81 Nombre del Dermatological Antibacterianos clindamycin phosphate topical gel % (Clindagel) clindamycin phosphate topical lotion % (Cleocin T) clindamycin phosphate topical solution % (Cleocin T) clindamycin phosphate topical swab % (Clindacin ETZ) ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % (Erygel) erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 % (Ery Pads) gentamicin topical cream 0. % gentamicin topical ointment 0. % metronidazole topical cream 0.75 % (MetroCream) metronidazole topical gel 0.75 % (Rosadan) metronidazole topical gel % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) mupirocin calcium topical cream 2 % (Bactroban) mupirocin topical ointment 2 % (Centany) neomycin-polymyxin b gu irrigation solution (Neosporin GU 40 mg-200, 000 unit/ml Irrigant) rosadan topical cream 0.75 % selenium sulfide topical lotion 2.5 % silver sulfadiazine topical cream % (Thermazene) ssd topical cream % sulfacetamide sodium (acne) topical (Klaron) suspension 0 % Dermatological Anti-Inflammatory Agents ala-cort topical cream %, 2.5 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0. % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 (Diprolene AF) % 74

82 Nombre del betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment (Diprolene) 0.05 % clobetasol 0.05% cream 0.05 % (Temovate) clobetasol scalp solution 0.05 % (Cormax) clobetasol-emollient topical cream 0.05 % clocortolone pivalate topical cream 0. % (Cloderm) cormax scalp solution 0.05 % desoximetasone topical cream 0.25 % (Topicort) ELIDEL TOPICAL CREAM % EUCRISA TOPICAL OINTMENT 2 % fluocinolone topical cream 0.0 % fluocinolone topical cream % (Synalar) fluocinolone topical ointment % (Synalar) fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluticasone topical cream 0.05 % (Cutivate) fluticasone topical ointment % halobetasol propionate topical cream 0.05 % (Ultravate) halobetasol propionate topical ointment 0.05 (Ultravate) % hydrocortisone topical cream % (Noble Formula HC) hydrocortisone topical cream 2.5 % (Ala-Cort) hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment % (Anti-Itch (HC)) hydrocortisone topical ointment 2.5 % mometasone topical cream 0. % (Elocon) mometasone topical ointment 0. % (Elocon) mometasone topical solution 0. % prednicarbate topical cream 0. % (Dermatop) prednicarbate topical ointment 0. % (Dermatop) procto-med hc topical cream with perineal applicator 2.5 % 75

83 Nombre del procto-pak topical cream with perineal applicator % proctosol hc topical cream with perineal applicator 2.5 % proctozone-hc topical cream with perineal applicator 2.5 % tacrolimus topical ointment 0.03 %, 0. % (Protopic) triamcinolone acetonide topical cream %, 0.5 % triamcinolone acetonide topical cream 0. % (Triderm) triamcinolone acetonide topical lotion %, 0. % triamcinolone acetonide topical ointment %, 0. %, 0.5 % Dermatological Retinoids adapalene topical cream 0. % (Differin) adapalene topical gel 0. % (Differin) tazarotene topical cream 0. % (Tazorac) TAZORAC TOPICAL CREAM 0.05 % tretinoin topical cream %, 0.05 %, 0. (Retin-A) PA % tretinoin topical gel 0.0 %, % (Retin-A) PA Scabicides And Pediculicides malathion topical lotion 0.5 % (Ovide) permethrin topical cream 5 % (Elimite) Dispositivos Dispositivos ASSURE ID INSULIN SAFETY SYRINGE ML 29 GAUGE X /2" BD INSULIN SYR 0.3 ML 6MMX3G 0.3 ML 3 GAUGE X 5/64" BD INSULIN SYR 0.5 ML 6MMX3G /2 ML 3 GAUGE X 5/64" BD INSULIN SYR ML 6MMX3G ML 3 GAUGE X 5/64" BD ULTRA-FINE PEN NDL 4MMX32G NANO 32 GAUGE X 5/32" GAUZE PAD TOPICAL BANDAGE 2 X 2 " GAUZE PADS, STERILE 2"X2" 2 X 2 " INSULIN SYRINGE-NEEDLE U-00 SYRINGE 0.3 ML 29 GAUGE (Ultilet Insulin Syringe) 76

84 Nombre del INSULIN SYRINGE-NEEDLE U-00 (Topcare Ultra SYRINGE ML 29 GAUGE X /2" Comfort) INSULIN SYRINGE-NEEDLE U-00 (Lite Touch SYRINGE /2 ML 28 GAUGE Insulin Syringe) PEN NEEDLE, DIABETIC NEEDLE 29 (incontrol Pen GAUGE X /2" Needle) VGO 40 DISPOSABLE DEVICE Modificadores/Reemplazos para enzimas Modificadores/Reemplazos para enzimas ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CERDELGA ORAL CAPSULE 84 MG PA CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE, DELAYED RELEASE(DR/EC) 2, , , 000 UNIT, 24, , , 000 UNIT, 3, 000-9, 500-5, 000 UNIT, 36, 000-4, , 000 UNIT, 6, 000-9, , 000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG KANUMA INTRAVENOUS SOLUTION 2 PA MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET, SOLUBLE 00 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 0 MG, 2 MG, PA 20 MG, 5 MG ORFADIN ORAL SUSPENSION 4 MG/ML PA PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG 77

85 Nombre del PULMOZYME INHALATION SOLUTION PA BvD MG/ML STRENSIQ SUBCUTANEOUS SOLUTION PA; LA 00 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS SOLUTION 5 PA MG/5 ML ( MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 00 MG QL (90 per 30 ZENPEP ORAL CAPSULE, DELAYED RELEASE(DR/EC) 0, , , 000 UNIT, 5, 000-5, , 000 UNIT, 20, , , 000 UNIT, 25, , , 000 UNIT, 3, 000-0, 000-6, 000 UNIT, 40, , , 000 UNIT, 5, 000-7, , 000 UNIT Agentes de ojos, oídos, nariz y garganta Agentes de ojos, oídos, nariz y garganta, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % apraclonidine ophthalmic drops 0.5 % (Iopidine) atropine ophthalmic drops % azelastine nasal aerosol, spray 37 mcg (0. QL (30 per 25 %) azelastine ophthalmic drops 0.05 % cromolyn ophthalmic drops 4 % cyclopentolate ophthalmic drops 0.5 %, %, 2 (Cyclogyl) % CYSTARAN OPHTHALMIC DROPS 0.44 % epinastine ophthalmic drops 0.05 % (Elestat) ipratropium bromide nasal spray, non-aerosol QL (30 per % ipratropium bromide nasal spray, non-aerosol QL (5 per % LACRISERT OPHTHALMIC INSERT 5 MG olopatadine ophthalmic drops 0. % (Patanol) olopatadine ophthalmic drops 0.2 % (Pataday) OTOVEL OTIC SOLUTION % (0.25 ML) phenylephrine hcl ophthalmic drops 0 %, 2.5 % 78

86 Nombre del proparacaine ophthalmic drops 0.5 % Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic solution 2 % bacitracin ophthalmic ointment 500 unit/gram bacitracin-polymyxin b ophthalmic ointment (Polycin) 500-0, 000 unit/gram bleph-0 ophthalmic drops 0 % CIPRODEX OTIC DROPS, SUSPENSION % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) COLY-MYCIN S OTIC DROPS, SUSPENSION MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) gatifloxacin ophthalmic drops 0.5 % (Zymaxid) gentak ophthalmic ointment 0.3 % (3 mg/gram) gentamicin ophthalmic drops 0.3 % gentamicin ophthalmic ointment 0.3 % (3 (Gentak) mg/gram) levofloxacin ophthalmic drops 0.5 % MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % moxifloxacin ophthalmic drops 0.5 % (Vigamox) NATACYN OPHTHALMIC DROPS, SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic (Neo-Polycin ointment , 000 mg-unit/g-% HC) neomycin-bacitracin-polymyxin ophthalmic (Neo-Polycin) ointment , 000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (Maxitrol) drops, suspension 3.5mg/ml-0, 000 unit/ml- 0. % neomycin-polymyxin b-dexameth ophthalmic (Maxitrol) ointment 3.5 mg/g-0, 000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic drops.75 mg-0, 000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops, suspension 3.5-0, mg-unit-mg/ml neomycin-polymyxin-hc otic drops, suspension 3.5-0, 000- mg/ml-unit/ml-% 79

87 Nombre del neomycin-polymyxin-hc otic solution 3.5-0, 000- mg/ml-unit/ml-% neo-polycin hc ophthalmic ointment , 000 mg-unit/g-% neo-polycin ophthalmic ointment , 000 mg-unit-unit/g ofloxacin ophthalmic drops 0.3 % (Ocuflox) ofloxacin otic drops 0.3 % (Floxin) polymyxin b sulf-trimethoprim ophthalmic (Polytrim) drops 0, 000 unit- mg/ml sulfacetamide sodium ophthalmic drops 0 % (Bleph-0) sulfacetamide sodium ophthalmic ointment 0 % sulfacetamide-prednisolone ophthalmic drops 0 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC DROPS, SUSPENSION % tobramycin ophthalmic drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic drops, (TobraDex) suspension % trifluridine ophthalmic drops % (Viroptic) VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.5 % ZYLET OPHTHALMIC DROPS, SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC DROPS, ST SUSPENSION 0.2 % BROMSITE OPHTHALMIC DROPS % dexamethasone sodium phosphate ophthalmic drops 0. % diclofenac sodium ophthalmic drops 0. % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray, non-aerosol 25 mcg (0.025 %) QL (50 per 25 fluorometholone ophthalmic drops, suspension (FML 0. % Liquifilm) flurbiprofen sodium ophthalmic drops 0.03 % (Ocufen) 80

88 Nombre del fluticasone nasal spray, suspension 50 (24 Hour mcg/actuation Allergy Relief) ILEVRO OPHTHALMIC DROPS, SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 % (Acular LS) ketorolac ophthalmic drops 0.5 % (Acular) LOTEMAX OPHTHALMIC DROPS, GEL 0.5 % LOTEMAX OPHTHALMIC DROPS, SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % prednisolone acetate ophthalmic drops, (Omnipred) suspension % prednisolone sodium phosphate ophthalmic drops % RESTASIS MULTIDOSE OPHTHALMIC QL (5.5 per 30 DROPS 0.05 % RESTASIS OPHTHALMIC DROPPERETTE QL (60 per % Agentes gastrointestinales Antiulcer Agents And Acid Suppressants CARAFATE ORAL SUSPENSION 00 MG/ML cimetidine hcl oral solution 300 mg/5 ml cimetidine oral tablet 200 mg (Acid Reducer (cimetidine)) cimetidine oral tablet 300 mg, 400 mg, 800 mg esomeprazole sodium intravenous recon soln 20 mg esomeprazole sodium intravenous recon soln (Nexium IV) 40 mg famotidine (pf) intravenous solution 20 mg/2 ml famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50 ml famotidine intravenous solution 0 mg/ml famotidine oral tablet 20 mg (Heartburn Relief (famotidine)) famotidine oral tablet 40 mg (Pepcid) 8

89 Nombre del lansoprazole oral capsule, delayed (Prevacid 24Hr) release(dr/ec) 5 mg lansoprazole oral capsule, delayed (Prevacid) release(dr/ec) 30 mg misoprostol oral tablet 00 mcg, 200 mcg (Cytotec) omeprazole oral capsule, delayed release(dr/ec) 0 mg, 20 mg, 40 mg pantoprazole intravenous recon soln 40 mg (Protonix) pantoprazole oral tablet, delayed release (Protonix) (dr/ec) 20 mg, 40 mg ranitidine hcl injection solution 25 mg/ml, 50 (Zantac) mg/2 ml (25 mg/ml) ranitidine hcl oral syrup 5 mg/ml ranitidine hcl oral tablet 50 mg (Heartburn Relief (ranitidine)) ranitidine hcl oral tablet 300 mg (Zantac) sucralfate oral tablet gram (Carafate) Agentes gastrointestinales, Other AMITIZA ORAL CAPSULE 24 MCG, 8 QL (60 per 30 MCG BUPHENYL ORAL TABLET 500 MG CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG constulose oral solution 0 gram/5 ml dicyclomine oral capsule 0 mg (Bentyl) dicyclomine oral solution 0 mg/5 ml dicyclomine oral tablet 20 mg diphenoxylate-atropine oral liquid PA-HRM; AGE (Max 64 mg/5 ml Years) diphenoxylate-atropine oral tablet mg enulose oral solution 0 gram/5 ml GATTEX 30-VIAL SUBCUTANEOUS KIT 5 PA MG generlac oral solution 0 gram/5 ml glycopyrrolate injection solution 0.2 mg/ml (Robinul) glycopyrrolate oral tablet mg (Robinul) glycopyrrolate oral tablet 2 mg (Robinul Forte) kionex 5 gm/60 ml suspension gram/60 ml kionex oral powder (Lomotil) PA-HRM; AGE (Max 64 Years) 82

90 Nombre del lactulose oral solution 0 gram/5 ml (Generlac) LINZESS ORAL CAPSULE 45 MCG, 290 MCG, 72 MCG QL (30 per 30 loperamide oral capsule 2 mg (Anti-Diarrheal (loperamide)) methscopolamine oral tablet 2.5 mg, 5 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 0 mg, 5 mg (Reglan) MOVANTIK ORAL TABLET 2.5 MG, 25 QL (30 per 30 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM OCALIVA ORAL TABLET 0 MG, 5 MG PA; QL (30 per 30 RAVICTI ORAL LIQUID. GRAM/ML PA RELISTOR ORAL TABLET 50 MG PA; QL (90 per 30 RELISTOR SUBCUTANEOUS SOLUTION PA; QL (28 per 28 2 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 2 PA; QL (28 per 28 MG/0.6 ML, 8 MG/0.4 ML sodium polystyrene (sorb free) oral suspension 5 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/20 ml sps (with sorbitol) oral suspension 5-20 gram/60 ml ursodiol oral capsule 300 mg (Actigall) ursodiol oral tablet 250 mg (URSO 250) ursodiol oral tablet 500 mg (URSO Forte) VELTASSA ORAL POWDER IN PACKET QL (30 per GRAM, 25.2 GRAM, 8.4 GRAM VIBERZI ORAL TABLET 00 MG, 75 MG ST; QL (60 per 30 XERMELO ORAL TABLET 250 MG PA; QL (90 per 30 Laxatives gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 420 gram MOVIPREP ORAL POWDER IN PACKET GRAM 83

91 Nombre del peg 3350-electrolytes oral recon soln gram peg 3350-electrolytes oral recon soln gram peg-electrolyte soln oral recon soln 420 gram (GaviLyte-G) (Colyte with Flavor Packs) (NuLYTELY with Flavor Packs) (SmoothLax) polyethylene glycol 3350 oral powder 7 gram/dose polyethylene glycol 3350 oral powder in (HealthyLax) packet 7 gram SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM trilyte with flavor packets oral recon soln 420 gram Phosphate Binders calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg (Calphron) eliphos oral tablet 667 mg PHOSLYRA ORAL SOLUTION 667 MG (69 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL TABLET 800 MG sevelamer carbonate oral powder in packet 0.8 (Renvela) gram, 2.4 gram VELPHORO ORAL TABLET, CHEWABLE 500 MG Agentes genitourinarios Antispasmodics, Urinary bethanechol chloride oral tablet 0 mg, 25 mg, 5 mg, 50 mg (Urecholine) MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended release 24hr 0 mg, 5 mg, 5 mg (Ditropan XL) tolterodine oral capsule, extended release 24hr (Detrol LA) 2 mg, 4 mg tolterodine oral tablet mg, 2 mg (Detrol) 84

92 Nombre del TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule, extended release 24hr 60 mg trospium oral tablet 20 mg VESICARE ORAL TABLET 0 MG, 5 MG Agentes genitourinarios, Miscellaneous alfuzosin oral tablet extended release 24 hr 0 mg (Uroxatral) dutasteride oral capsule 0.5 mg (Avodart) dutasteride-tamsulosin oral capsule, er (Jalyn) QL (30 per 30 multiphase 24 hr mg finasteride oral tablet 5 mg (Proscar) tamsulosin oral capsule, extended release 24hr (Flomax) 0.4 mg terazosin oral capsule mg, 0 mg, 2 mg, 5 mg Antagonistas de metal pesado Antagonistas de metal pesado CUPRIMINE ORAL CAPSULE 250 MG PA deferoxamine injection recon soln 2 gram, 500 (Desferal) PA mg DEPEN TITRATABS ORAL TABLET 250 PA MG EXJADE ORAL TABLET, DISPERSIBLE PA 25 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 00 PA MG/ML FERRIPROX ORAL TABLET 500 MG PA JADENU ORAL TABLET 80 MG, 360 MG, PA 90 MG JADENU SPRINKLE ORAL GRANULES IN PA PACKET 80 MG, 360 MG, 90 MG SYPRINE ORAL CAPSULE 250 MG PA; QL (240 per 30 Agentes hormonales, estimulantes/reemplazos/ modificadores Androgens ANADROL-50 ORAL TABLET 50 MG PA ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR PA; QL (30 per 30 85

93 Nombre del ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/.25 GRAM (.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET.62 % (20.25 MG/.25 GRAM),.62 % (40.5 MG/2.5 GRAM) androxy oral tablet 0 mg danazol oral capsule 00 mg, 200 mg, 50 mg oxandrolone oral tablet 0 mg, 2.5 mg (Oxandrin) PA; QL (50 per 30 PA; QL (50 per 30 testosterone cypionate intramuscular oil 00 (Depo- PA mg/ml, 200 mg/ml Testosterone) testosterone enanthate intramuscular oil 200 PA; QL (5 per 28 mg/ml testosterone transdermal gel 50 mg/5 gram ( (Vogelxo) PA; QL (300 per 30 %) testosterone transdermal gel in packet % (25 (AndroGel) PA; QL (300 per 30 mg/2.5gram) testosterone transdermal gel in packet % (50 (Vogelxo) PA; QL (300 per 30 mg/5 gram) Estrogens And Antiestrogens amabelz oral tablet mg, -0.5 mg COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, MG/24 HR PA-HRM; QL (8 per 28 ; AGE (Max 64 Years) DUAVEE ORAL TABLET MG PA-HRM; AGE (Max 64 Years) ESTRACE VAGINAL CREAM 0.0 % (0. MG/GRAM) estradiol oral tablet 0.5 mg, mg, 2 mg (Estrace) PA-HRM; AGE (Max 64 Years) estradiol transdermal patch semiweekly mg/24 hr, mg/24 hr (Alora) PA-HRM; QL (8 per 28 ; AGE (Max 64 Years) estradiol transdermal patch semiweekly mg/24 hr, 0.05 mg/24 hr, 0. mg/24 hr (Vivelle-Dot) PA-HRM; QL (8 per 28 ; AGE (Max 64 Years) estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0. mg/24 hr (Climara) PA-HRM; QL (4 per 28 ; AGE (Max 64 Years) estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg estradiol-norethindrone acet oral tablet -0.5 mg (Delestrogen) (Mimvey Lo) PA-HRM; AGE (Max 64 Years) (Lopreeza) PA-HRM; AGE (Max 64 Years) 86

94 Nombre del estropipate oral tablet 0.75 mg,.5 mg, 3 mg PA-HRM; AGE (Max 64 Years) FEMRING VAGINAL RING 0.05 MG/24 QL ( per 84 HR, 0. MG/24 HR lopreeza oral tablet mg, -0.5 mg PA-HRM; AGE (Max 64 Years) MENEST ORAL TABLET 0.3 MG, MG,.25 MG PA-HRM; AGE (Max 64 Years) mimvey lo oral tablet mg PA-HRM; AGE (Max 64 Years) mimvey oral tablet -0.5 mg PA-HRM; AGE (Max 64 Years) PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG,.25 MG PA-HRM; AGE (Max 64 Years) PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET MG (4)/ 0.625MG-5MG(4) PA-HRM; AGE (Max 64 Years) PREMPRO ORAL TABLET MG, MG, MG, MG PA-HRM; AGE (Max 64 Years) raloxifene oral tablet 60 mg (Evista) yuvafem vaginal tablet 0 mcg QL (8 per 28 Glucocorticoids/Mineralocorticoids a-hydrocort injection recon soln 00 mg betamethasone acet, sod phos injection suspension 6 mg/ml (Celestone Soluspan) cortisone oral tablet 25 mg PA BvD dexamethasone oral elixir 0.5 mg/5 ml PA BvD dexamethasone oral tablet 0.5 mg, 0.75 mg, PA BvD mg,.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phosphate injection solution 0 mg/ml, 4 mg/ml EMFLAZA ORAL SUSPENSION PA; QL (39 per 30 MG/ML EMFLAZA ORAL TABLET 8 MG PA; QL (30 per 30 EMFLAZA ORAL TABLET 30 MG, 36 MG, PA; QL (60 per 30 6 MG fludrocortisone oral tablet 0. mg hydrocortisone oral tablet 0 mg, 20 mg, 5 mg (Cortef) PA BvD 87

95 Nombre del methylprednisolone acetate injection (Depo-Medrol) suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 6 mg, 32 mg, (Medrol) PA BvD 4 mg, 8 mg methylprednisolone oral tablets, dose pack 4 (Medrol (Pak)) PA BvD mg methylprednisolone sodium succ injection recon soln 25 mg, 40 mg methylprednisolone sodium succ intravenous (Solu-Medrol) recon soln, 000 mg prednisolone sodium phosphate oral solution PA BvD 5 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml) prednisolone sodium phosphate oral solution 5 (Pediapred) PA BvD mg base/5 ml (6.7 mg/5 ml) prednisone oral solution 5 mg/5 ml PA BvD prednisone oral tablet mg, 2.5 mg, 5 mg, 50 PA BvD mg prednisone oral tablet 0 mg PA BvD prednisone oral tablet 20 mg (Deltasone) PA BvD prednisone oral tablets, dose pack 0 mg, 0 PA BvD mg (48 pack), 5 mg, 5 mg (48 pack) SOLU-CORTEF (PF) INJECTION RECON SOLN 00 MG/2 ML Pituitary desmopressin 0 mcg/0. ml spr 0 mcg/spray (DDAVP) (0. ml) desmopressin injection solution 4 mcg/ml (DDAVP) desmopressin nasal solution 0. mg/ml (DDAVP) (refrigerate) desmopressin nasal spray, non-aerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0. mg, 0.2 mg (DDAVP) GENOTROPIN MINIQUICK PA SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, MG/0.25 ML,.2 MG/0.25 ML,.4 MG/0.25 ML,.6 MG/0.25 ML,.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 2 MG/ML (36 UNIT/ML), 5 MG/ML (5 UNIT/ML) PA 88

96 Nombre del HUMATROPE INJECTION CARTRIDGE 2 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (8 UNIT) HUMATROPE INJECTION RECON SOLN 5 (5 UNIT) MG INCRELEX SUBCUTANEOUS SOLUTION 0 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT.25 MG, 5 MG, 7.5 MG (PED) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (0 MG/ML), 30 MG/3 ML (0 MG/ML), 5 MG/.5 ML (3.3 MG/ML) NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 0 MG/2 ML (5 MG/ML), 20 MG/2 ML (0 MG/ML), 5 MG/2 ML (2.5 MG/ML) octreotide acet 00 mcg/ml syr outer, singledose, 0 00 mcg/ml ( ml) octreotide acet 50 mcg/ml syr outer, singledose, 0 50 mcg/ml ( ml) octreotide acetate injection solution, 000 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 00 mcg/ml, 50 mcg/ml OMNITROPE SUBCUTANEOUS CARTRIDGE 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/.5 ML (FINAL CONC.) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION, EXTENDED REL RECON 0 MG, 20 MG, 30 MG PA PA PA PA (Sandostatin) (Sandostatin) PA PA PA PA 89

97 Nombre del SEROSTIM SUBCUTANEOUS RECON PA SOLN 4 MG, 5 MG, 6 MG SIGNIFOR SUBCUTANEOUS SOLUTION QL (60 per MG/ML ( ML), 0.6 MG/ML ( ML), 0.9 MG/ML ( ML) SOMATULINE DEPOT SUBCUTANEOUS QL ( per 28 SYRINGE 20 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 0 MG, 5 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 QL ( per 360 MCG/DAY) SYNAREL NASAL SPRAY, NON AEROSOL 2 MG/ML ZOMACTON SUBCUTANEOUS RECON PA SOLN 0 MG, 5 MG ZORBTIVE SUBCUTANEOUS RECON PA SOLN 8.8 MG Progestins DEPO-PROVERA INTRAMUSCULAR QL (0 per 28 SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular PA NSO oil 250 mg/ml medroxyprogesterone intramuscular (Depo-Provera) QL ( per 84 suspension 50 mg/ml medroxyprogesterone intramuscular syringe (Depo-Provera) QL ( per mg/ml medroxyprogesterone oral tablet 0 mg, 2.5 (Provera) mg, 5 mg megestrol oral suspension 400 mg/0 ml (40 mg/ml) PA-HRM; AGE (Max 64 Years) norethindrone acetate oral tablet 5 mg (Aygestin) progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 00 mg, (Prometrium) 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 00 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 00 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 75 mcg, 88 mcg (Levoxyl) 90

98 Nombre del levothyroxine oral tablet 2 mcg, 300 mcg, 50 mcg (Unithroid) liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Cytomel) methimazole oral tablet 0 mg, 5 mg (Tapazole) propylthiouracil oral tablet 50 mg Agentes inmunológicos Agentes inmunológicos ACTEMRA INTRAVENOUS SOLUTION PA 200 MG/0 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE PA 62 MG/0.9 ML ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE, PA BvD EXTENDED RELEASE 24HR 0.5 MG, MG, 5 MG azathioprine oral tablet 50 mg (Imuran) PA BvD azathioprine sodium injection recon soln 00 PA BvD mg CARIMUNE NF NANOFILTERED PA BvD INTRAVENOUS RECON SOLN 2 GRAM, 3 GRAM, 6 GRAM CIMZIA POWDER FOR RECONST PA SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) PA cyclosporine intravenous solution 250 mg/5 ml (Sandimmune) PA BvD cyclosporine modified oral capsule 00 mg, 25 (Neoral) PA BvD mg cyclosporine modified oral capsule 50 mg (Gengraf) PA BvD cyclosporine modified oral solution 00 mg/ml (Gengraf) PA BvD cyclosporine oral capsule 00 mg, 25 mg (Sandimmune) PA BvD ENBREL SUBCUTANEOUS RECON SOLN PA 25 MG ( ML) ENBREL SUBCUTANEOUS SYRINGE 25 PA MG/0.5ML (0.5), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) PA 9

99 Nombre del ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION 5-8 % RANGE, 5-8 % RANGE (0 ML), 5-8 % RANGE (2 ML) GAMMAGARD LIQUID INJECTION SOLUTION 0 % GAMMAGARD S-D (IGA < MCG/ML) INTRAVENOUS RECON SOLN 0 GRAM, 5 GRAM GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS SOLUTION 0 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD gengraf oral capsule 00 mg, 25 mg, 50 mg PA BvD gengraf oral solution 00 mg/ml PA BvD HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) PA HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML, 50 UNIT/ML (0 ML) HYQVIA SUBCUTANEOUS SOLUTION 0 GRAM /00 ML (0 %), 2.5 GRAM /25 ML (0 %), 20 GRAM /200 ML (0 %), 30 GRAM /300 ML (0 %), 5 GRAM /50 ML (0 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 80 MG/.2 ML (50 MG/ML) PA PA PA PA PA BvD PA 92

100 Nombre del ILARIS (PF) SUBCUTANEOUS SOLUTION PA 50 MG/ML IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML INFLECTRA INTRAVENOUS RECON PA SOLN 00 MG KEVZARA SUBCUTANEOUS SYRINGE PA; QL (2.28 per MG/.4 ML, 200 MG/.4 ML KINERET SUBCUTANEOUS SYRINGE 00 MG/0.67 ML PA; QL (8.76 per 28 leflunomide oral tablet 0 mg, 20 mg (Arava) mycophenolate mofetil hcl intravenous recon (CellCept PA BvD soln 500 mg Intravenous) mycophenolate mofetil oral capsule 250 mg (CellCept) PA BvD mycophenolate mofetil oral suspension for (CellCept) PA BvD reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg (CellCept) PA BvD mycophenolate sodium oral tablet, delayed (Myfortic) PA BvD release (dr/ec) 80 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN PA BvD 250 MG OCTAGAM INTRAVENOUS SOLUTION 0 PA BvD %, 5 % ORENCIA (WITH MALTOSE) PA INTRAVENOUS RECON SOLN 250 MG ORENCIA CLICKJECT SUBCUTANEOUS PA AUTO-INJECTOR 25 MG/ML ORENCIA SUBCUTANEOUS SYRINGE PA 25 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML OTEZLA ORAL TABLET 30 MG PA; QL (60 per 30 OTEZLA STARTER ORAL TABLETS, PA; QL (60 per 30 DOSE PACK 0 MG (4)-20 MG (4)-30 MG (47), 0 MG (4)-20 MG (4)-30 MG(9) OTREXUP (PF) SUBCUTANEOUS AUTO INJECTOR 0 MG/0.4 ML, 2.5 MG/0.4 ML, 5 MG/0.4 ML, 7.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML PRIVIGEN INTRAVENOUS SOLUTION 0 PA BvD % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML PA BvD 93

101 Nombre del RAPAMUNE ORAL SOLUTION MG/ML PA BvD RASUVO (PF) SUBCUTANEOUS AUTO INJECTOR 0 MG/0.2 ML, 2.5 MG/0.25 ML, 5 MG/0.3 ML, 7.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.5 ML REMICADE INTRAVENOUS RECON PA SOLN 00 MG RIDAURA ORAL CAPSULE 3 MG SIMPONI ARIA INTRAVENOUS PA SOLUTION 2.5 MG/ML SIMPONI SUBCUTANEOUS PEN PA INJECTOR 00 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 00 PA MG/ML, 50 MG/0.5 ML sirolimus oral tablet 0.5 mg, mg, 2 mg (Rapamune) PA BvD STELARA INTRAVENOUS SOLUTION 30 PA MG/26 ML STELARA SUBCUTANEOUS SYRINGE 45 PA MG/0.5 ML, 90 MG/ML tacrolimus oral capsule 0.5 mg, mg, 5 mg (Prograf) PA BvD TYSABRI INTRAVENOUS SOLUTION 300 MG/5 ML PA; LA; QL (5 per 28 XELJANZ ORAL TABLET 5 MG PA; QL (60 per 30 XELJANZ XR ORAL TABLET EXTENDED PA; QL (30 per 30 RELEASE 24 HR MG ZORTRESS ORAL TABLET 0.25 MG, 0.5 PA BvD MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF ( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PA BvD PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML 94

102 Nombre del BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 0 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION, 440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE, 440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML PA BvD PA BvD PA BvD PA BvD QL (.5 per 365 QL (.5 per 365 QL (.5 per 365 PA BvD 95

103 Nombre del IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-0 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-0 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-35 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-35 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN, 000-2, 500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-25LF-25 MCG-0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 5 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML PA BvD PA BvD PA BvD 96

104 Nombre del RECOMBIVAX HB 5 MCG/0.5 ML VL OUTER, P/F, SDV 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TENIVAC VIAL L/F, P/F, OUTER, SUV 5 LF UNIT- 2 LF UNIT/0.5ML TETANUS, DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT -20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION, 350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9, 400 UNIT/0.65 ML PA BvD PA BvD QL (2 per 365 QL ( per

105 Nombre del Agentes de enfermedad inflamatoria intestinal Agentes de enfermedad inflamatoria intestinal alosetron oral tablet 0.5 mg, mg (Lotronex) APRISO ORAL CAPSULE, EXTENDED RELEASE 24HR GRAM balsalazide oral capsule 750 mg (Colazal) budesonide oral capsule, delayed, (Entocort EC) extend.release 3 mg CANASA RECTAL SUPPOSITORY, 000 MG colocort rectal enema 00 mg/60 ml DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG ST hydrocortisone rectal enema 00 mg/60 ml (Colocort) LIALDA ORAL TABLET, DELAYED RELEASE (DR/EC).2 GRAM mesalamine oral tablet, delayed release (dr/ec) (Asacol HD) 800 mg sulfasalazine oral tablet 500 mg (Sulfazine) sulfasalazine oral tablet, delayed release (Azulfidine ENtabs) (dr/ec) 500 mg UCERIS RECTAL FOAM 2 MG/ACTUATION Suspensiones/sueros de irrigación Suspensiones/sueros de irrigación acetic acid irrigation solution 0.25 % LACTATED RINGERS IRRIGATION SOLUTION ringer's irrigation solution sodium chloride irrigation solution 0.9 % (Sterile Saline) sorbitol irrigation solution 3 %, 3.3 % sorbitol-mannitol urethral solution g/00 ml water for irrigation, sterile irrigation solution Agentes metabólicos de enfermedad ósea Agentes metabólicos de enfermedad ósea (Curity Sterile Water) 98

106 Nombre del alendronate oral solution 70 mg/75 ml QL (300 per 28 alendronate oral tablet 0 mg, 40 mg, 5 mg alendronate oral tablet 35 mg QL (4 per 28 alendronate oral tablet 70 mg (Fosamax) QL (4 per 28 calcitonin (salmon) nasal spray, non-aerosol QL (3.7 per unit/actuation calcitriol intravenous solution mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 mcg/2 (Hectorol) ml doxercalciferol oral capsule 0.5 mcg, mcg, (Hectorol) 2.5 mcg FORTEO SUBCUTANEOUS PEN PA; QL (2.4 per 28 INJECTOR 20 MCG/DOSE MCG/2.4 ML ibandronate intravenous solution 3 mg/3 ml QL (3 per 84 ibandronate intravenous syringe 3 mg/3 ml (Boniva) QL (3 per 84 ibandronate oral tablet 50 mg (Boniva) QL ( per 28 MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE PA; QL (2 per MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE PARICALCITOL 0 MCG/2 ML VIAL MDV, INNER, LATEX-FREE 5 MCG/ML paricalcitol hemodialysis port injection solution 2 mcg/ml paricalcitol intravenous solution 2 mcg/ml (Zemplar) PARICALCITOL INTRAVENOUS (Zemplar) SOLUTION 5 MCG/ML paricalcitol oral capsule mcg, 2 mcg (Zemplar) paricalcitol oral capsule 4 mcg PROLIA SUBCUTANEOUS SYRINGE 60 QL ( per 80 MG/ML RAYALDEE ORAL CAPSULE, EXTENDED QL (60 per 30 RELEASE 24 HR 30 MCG risedronate oral tablet 50 mg (Actonel) QL ( per 28 risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 30 SENSIPAR ORAL TABLET 30 MG, 60 MG QL (60 per 30 SENSIPAR ORAL TABLET 90 MG QL (20 per 30 99

107 Nombre del TYMLOS SUBCUTANEOUS PEN PA; QL (.56 per 30 INJECTOR 80 MCG (3, 20 MCG/.56 ML) zoledronic acid intravenous solution 4 mg/5 ml (Zometa) zoledronic acid-mannitol-water intravenous (Reclast) QL (00 per 300 piggyback 5 mg/00 ml ZOMETA INTRAVENOUS PIGGYBACK 4 MG/00 ML Agentes terapéuticos misceláneos Agentes terapéuticos misceláneos ACTIMMUNE SUBCUTANEOUS SOLUTION 00 MCG/0.5 ML amifostine crystalline intravenous recon soln (Ethyol) 500 mg BENLYSTA INTRAVENOUS RECON PA SOLN 20 MG, 400 MG CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG CYSTADANE ORAL POWDER GRAM/.7 ML droperidol injection solution 2.5 mg/ml ELMIRON ORAL CAPSULE 00 MG ergoloid oral tablet mg EXONDYS 5 INTRAVENOUS SOLUTION PA; LA 50 MG/ML, 50 MG/ML (0 ML) fomepizole intravenous solution gram/ml guanidine oral tablet 25 mg HAEGARDA SUBCUTANEOUS RECON PA SOLN 2, 000 UNIT, 3, 000 UNIT hydroxyzine pamoate oral capsule 00 mg PA-HRM; AGE (Max 64 Years) hydroxyzine pamoate oral capsule 25 mg, 50 mg (Vistaril) PA-HRM; AGE (Max 64 Years) KEVEYIS ORAL TABLET 50 MG PA; QL (20 per 30 leucovorin calcium 200 mg vial latex-free, p/f, sdv 200 mg leucovorin calcium injection recon soln 00 mg, 350 mg, 50 mg leucovorin calcium oral tablet 0 mg, 5 mg, 25 mg, 5 mg levocarnitine (with sugar) oral solution 00 (Carnitor) mg/ml levocarnitine oral tablet 330 mg (Carnitor) 00

108 Nombre del LEVOLEUCOVORIN INTRAVENOUS RECON SOLN 75 MG levoleucovorin intravenous recon soln 50 mg (Fusilev) mesna intravenous solution 00 mg/ml (Mesnex) MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML PROGLYCEM ORAL SUSPENSION 50 MG/ML pyridostigmine bromide oral tablet 60 mg (Mestinon) pyridostigmine bromide oral tablet extended release 80 mg (Mestinon Timespan) THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG PA NSO; QL (60 per 30 THIOLA ORAL TABLET 00 MG TYBOST ORAL TABLET 50 MG QL (30 per 30 Agentes oftálmicos Antiglaucoma Agents acetazolamide oral capsule, extended release (Diamox 500 mg Sequels) acetazolamide oral tablet 25 mg, 250 mg acetazolamide sodium injection recon soln 500 mg ALPHAGAN P OPHTHALMIC DROPS 0. % betaxolol ophthalmic drops 0.5 % brimonidine ophthalmic drops 0.2 % carteolol ophthalmic drops % COMBIGAN OPHTHALMIC DROPS % dorzolamide ophthalmic drops 2 % (Trusopt) dorzolamide-timolol ophthalmic drops (Cosopt) 6.8 mg/ml latanoprost ophthalmic drops % (Xalatan) levobunolol ophthalmic drops 0.5 % (Betagan) LUMIGAN OPHTHALMIC DROPS 0.0 % QL (2.5 per 25 methazolamide oral tablet 25 mg, 50 mg (Neptazane) metipranolol ophthalmic drops 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC DROPS 0.25 % pilocarpine hcl ophthalmic drops %, 2 %, 4 % (Isopto Carpine) 0

109 Nombre del SIMBRINZA OPHTHALMIC DROPS, SUSPENSION -0.2 % timolol maleate ophthalmic drops 0.25 %, 0.5 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS % ZIOPTAN (PF) OPHTHALMIC DROPPERETTE % Preparaciones de reemplazo Preparaciones de reemplazo calcium chloride intravenous syringe 00 mg/ml (0 %) d0 %-0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 0 % and 0.2 % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution % electrolyte-48 in d5w intravenous parenteral solution IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION (Timoptic) (Timoptic-XE) QL (2.5 per 25 QL (30 per 30 02

110 Nombre del klor-con m0 oral tablet, er particles/crystals 0 meq klor-con m5 oral tablet, er particles/crystals 5 meq klor-con m20 oral tablet, er particles/crystals 20 meq klor-con sprinkle oral capsule, extended release 0 meq, 8 meq magnesium sulfate in d5w intravenous piggyback gram/00 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/, 000 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 48 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution 2 meq/ml potassium chlorid-d5-0.45%nacl intravenous parenteral solution 0 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l 03

111 Nombre del potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 0 meq/00 ml, 0 meq/50 ml, 20 meq/00 ml, 20 meq/50 ml, 30 meq/00 ml, 40 meq/00 ml potassium chloride intravenous solution 2 % potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended (Klor-Con release 0 meq, 8 meq Sprinkle) potassium chloride oral liquid 20 meq/5 ml, 40 meq/5 ml potassium chloride oral tablet extended (Klor-Con 0) release 0 meq potassium chloride oral tablet extended (K-Tab) release 20 meq, 8 meq potassium chloride oral tablet, er (Klor-Con particles/crystals 0 meq M0) potassium chloride oral tablet, er (Klor-Con particles/crystals 20 meq M20) potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release (Urocit-K 0) 0 meq (, 080 mg) potassium citrate oral tablet extended release (Urocit-K 5) 5 meq potassium citrate oral tablet extended release (Urocit-K 5) 5 meq (540 mg) potassium citrate-citric acid oral packet 3, (Cytra K 300-, 002 mg Crystals) ringer's intravenous parenteral solution sodium acetate intravenous solution 2 meq/ml sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.9 % intravenous parenteral solution 0.9 % 04

112 Nombre del sodium chloride 00 meq/40 ml 25's, sdv 2.5 meq/ml sodium chloride intravenous parenteral solution 2.5 meq/ml sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml TPN ELECTROLYTES II IV SOLN 25'S, 20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML Agentes de la vía respiratoria Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER QL (60 per 30 WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA QL (2 per 28 AEROSOL INHALER 5-2 MCG/ACTUATION, MCG/ACTUATION, 45-2 MCG/ACTUATION ARNUITY ELLIPTA INHALATION QL (30 per 30 BLISTER WITH DEVICE 00 MCG/ACTUATION, 200 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER QL (60 per 30 WITH DEVICE MCG/DOSE, MCG/DOSE budesonide inhalation suspension for (Pulmicort) PA BvD nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, mg/2 ml FLOVENT DISKUS INHALATION QL (60 per 30 BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION QL (20 per 30 BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION QL (2 per 28 05

113 Nombre del FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION SYMBICORT MCG INHALER 60 INHALATIONS MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) montelukast oral tablet 0 mg (Singulair) montelukast oral tablet, chewable 4 mg, 5 mg (Singulair) zafirlukast oral tablet 0 mg, 20 mg (Accolate) Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml,.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml QL (24 per 28 QL (2.2 per 28 QL (7.4 per 25 QL (2 per 25 QL ( per 25 PA BvD albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet extended release 2 hr 4 mg, 8 mg ANORO ELLIPTA INHALATION BLISTER QL (60 per 30 WITH DEVICE MCG/ACTUATION ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION QL (25.8 per 28 COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE 2 MCG INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation QL (8 per 30 QL (60 per 30 PA BvD (Xopenex HFA) QL (30 per 30 06

114 Nombre del metaproterenol oral syrup 0 mg/5 ml metaproterenol oral tablet 0 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION QL (60 per 30 BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG STIOLTO RESPIMAT INHALATION MIST QL (4 per MCG/ACTUATION STRIVERDI RESPIMAT INHALATION QL (4 per 28 MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution mg/ml theophylline in dextrose 5 % intravenous parenteral solution 200 mg/00 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/5 ml theophylline oral tablet extended release 2 hr (Theochron) 00 mg, 200 mg, 300 mg theophylline oral tablet extended release 2 hr 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg Agentes de la vía respiratoria, Other acetylcysteine intravenous solution 200 mg/ml (Acetadote) PA BvD (20 %) acetylcysteine solution 00 mg/ml (0 %), 200 PA BvD mg/ml (20 %) CINQAIR INTRAVENOUS SOLUTION 0 PA MG/ML cromolyn inhalation solution for nebulization PA BvD 20 mg/2 ml DALIRESP ORAL TABLET 500 MCG QL (30 per 30 07

115 Nombre del ESBRIET ORAL CAPSULE 267 MG PA; QL (270 per 30 ESBRIET ORAL TABLET 267 MG PA; QL (270 per 30 ESBRIET ORAL TABLET 80 MG PA; QL (90 per 30 KALYDECO ORAL GRANULES IN PA; QL (60 per 30 PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 50 MG PA; QL (60 per 30 NUCALA SUBCUTANEOUS RECON SOLN PA; LA; QL ( per MG OFEV ORAL CAPSULE 00 MG, 50 MG PA; QL (60 per 30 ORKAMBI ORAL TABLET MG, PA; QL (20 per MG PROLASTIN-C INTRAVENOUS RECON SOLN, 000 MG XOLAIR SUBCUTANEOUS RECON SOLN PA 50 MG Relajantes del músculo esquelético Relajantes del músculo esquelético baclofen oral tablet 0 mg, 20 mg carisoprodol oral tablet 250 mg, 350 mg (Soma) PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) chlorzoxazone oral tablet 500 mg (Parafon Forte DSC) cyclobenzaprine oral tablet 0 mg, 5 mg PA-HRM; AGE (Max 64 Years) dantrolene oral capsule 00 mg dantrolene oral capsule 25 mg, 50 mg (Dantrium) methocarbamol oral tablet 500 mg (Robaxin) PA-HRM; AGE (Max 64 Years) methocarbamol oral tablet 750 mg (Robaxin-750) PA-HRM; AGE (Max 64 Years) revonto intravenous recon soln 20 mg tizanidine oral tablet 2 mg tizanidine oral tablet 4 mg (Zanaflex) Agentes contra el trastorno del sueño Agentes contra el trastorno del sueño armodafinil oral tablet 50 mg, 200 mg, 250 mg, 50 mg BELSOMRA ORAL TABLET 0 MG, 5 MG, 20 MG, 5 MG (Nuvigil) PA QL (30 per 30 08

116 Nombre del eszopiclone oral tablet mg, 2 mg, 3 mg (Lunesta) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) HETLIOZ ORAL CAPSULE 20 MG PA; QL (30 per 30 SILENOR ORAL TABLET 3 MG, 6 MG QL (30 per 30 XYREM ORAL SOLUTION 500 MG/ML LA; QL (540 per 30 zaleplon oral capsule 0 mg, 5 mg (Sonata) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 ; AGE (Max 64 Years) zolpidem oral tablet 0 mg, 5 mg (Ambien) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) Agentes vasodilatadores Agentes vasodilatadores ADCIRCA ORAL TABLET 20 MG PA; QL (60 per 30 ADEMPAS ORAL TABLET 0.5 MG, MG, PA; QL (90 per 30.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln (Flolan) PA 0.5 mg,.5 mg LETAIRIS ORAL TABLET 0 MG, 5 MG PA; QL (30 per 30 OPSUMIT ORAL TABLET 0 MG PA; QL (30 per 30 ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 0.25 MG, MG, 2.5 MG, 5 MG PA 09

117 Nombre del REMODULIN INJECTION SOLUTION PA MG/ML, 0 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 0 mg/2.5 ml (Revatio) PA; QL (37.5 per day) sildenafil oral tablet 20 mg (Revatio) PA; QL (90 per 30 TRACLEER ORAL TABLET 25 MG, 62.5 MG PA; LA; QL (60 per 30 TYVASO INHALATION SOLUTION FOR PA NEBULIZATION.74 MG/2.9 ML (0.6 MG/ML) UPTRAVI ORAL TABLET, 000 MCG,, PA; QL (60 per MCG,, 400 MCG,, 600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG PA; QL (240 per 30 UPTRAVI ORAL TABLETS, DOSE PACK PA; QL (400 per MCG (40)- 800 MCG (60) Vitaminas y minerales Vitaminas y minerales fluoride (sodium) oral tablet mg (2.2 mg sod. fluoride) pnv prenatal plus multivit tab s/f, gluten-free 27 mg iron- mg prenatal vitamin plus low iron oral tablet 27 mg iron- mg sodium fluoride 0.5 mg/ml drop d/f, s/f, glutenfree 0.5 mg (. mg sod.fluorid)/ml ALL RX PRENATAL VITAMINS COVERABLE UNDER PART D ALL RX PRENATAL VITAMINS COVERABLE UNDER PART D 0

118 INDEX A abacavir...45 abacavir-lamivudine...45 abacavir-lamivudine-zidovudine...45 ABELCET...34 ABILIFY MAINTENA...4 ABRAXANE...7 acamprosate...8 acarbose...3 acebutolol...56 acetaminophen-codeine...3 acetazolamide...0 acetazolamide sodium...0 acetic acid...79, 98 acetylcysteine...07 acitretin...72 ACTEMRA...9 ACTHIB (PF)...94 ACTIMMUNE...00 acyclovir...48, 72 acyclovir sodium...48 ADACEL(TDAP ADOLESN/ADULT)(PF)..94 ADAGEN...77 adapalene...76 ADCIRCA...09 adefovir...48 ADEMPAS...09 adriamycin...7 adrucil...7 ADVAIR DISKUS...05 ADVAIR HFA...05 afeditab cr...60 AFINITOR...7 AFINITOR DISPERZ...7 a-hydrocort...87 AKTEN (PF)...78 AKYNZEO ala-cort ALBENZA albuterol sulfate alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME ALECENSA... 7 alendronate alfuzosin ALIMTA... 8 ALINIA allopurinol alosetron ALPHAGAN P... 0 alprazolam... 9 ALREX altavera (28) ALUNBRIG... 8 alyacen /35 (28) alyacen 7/7/7 (28) amabelz amantadine hcl AMBISOME amethia amethia lo amifostine crystalline amiloride... 6 amiloride-hydrochlorothiazide... 6 AMINO ACIDS 5 %... 5 AMINOSYN 0 %... 5 AMINOSYN 7 % WITH ELECTROLYTES... 5 AMINOSYN 8.5 %... 5 AMINOSYN 8.5 % ELECTROLYTES... 5 AMINOSYN II 0 %...5 AMINOSYN II 5 %...5 AMINOSYN II 7 %... 5 AMINOSYN II 8.5 %... 5 AMINOSYN II 8.5 % ELECTROLYTES...5 AMINOSYN M 3.5 %... 5 AMINOSYN-HBC 7%...5 AMINOSYN-PF 0 %... 5 AMINOSYN-PF 7 % (SULFITE-FREE)... 5 AMINOSYN-RF 5.2 %... 5 amiodarone AMITIZA amitriptyline amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-olmesartan...60 amlodipine-valsartan...60 amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicillin... 5 amoxicillin-pot clavulanate... 5 amphotericin b ampicillin... 5 ampicillin sodium... 5 ampicillin-sulbactam... 5 AMPYRA ANADROL anagrelide anastrozole... 8 ANDRODERM ANDROGEL androxy ANORO ELLIPTA I-

119 APOKYN...40 apraclonidine...78 aprepitant...38 apri...67 APRISO...98 APTIOM...25 APTIVUS...45 aranelle (28)...67 ARCALYST...9 aripiprazole...4 ARISTADA...4, 42 armodafinil...08 ARNUITY ELLIPTA...05 ascomp with codeine...3 ashlyna...67 aspirin-dipyridamole...50 ASSURE ID INSULIN SAFETY...76 ASTAGRAF XL...9 atenolol...56 atenolol-chlorthalidone...56 atomoxetine...64 atorvastatin...62 atovaquone...40 atovaquone-proguanil...40 ATRIPLA...45 atropine...25, 78 ATROVENT HFA...06 AUBAGIO...64 aubra...67 AUSTEDO...64 AVASTIN...8 AVC VAGINAL...37 aviane...67 AVONEX...64 AVONEX (WITH ALBUMIN)...64 azacitidine...8 azathioprine...9 azathioprine sodium...9 azelastine...78 azithromycin...3, 4 aztreonam... 4 azurette (28) B bacitracin... 0, 79 bacitracin-polymyxin b baclofen balsalazide balziva (28) BANZEL BAVENCIO... 8 BCG VACCINE, LIVE (PF). 94 BD INSULIN SYRINGE ULTRA-FINE BD ULTRA-FINE NANO PEN NEEDLES bekyree (28) BELBUCA... 3 BELEODAQ... 8 BELSOMRA benazepril benazepril-hydrochlorothiazide BENDEKA... 8 BENLYSTA benztropine betamethasone acet,sod phos 87 betamethasone dipropionate.. 74 betamethasone valerate betamethasone, augmented , 75 BETASERON betaxolol... 57, 0 bethanechol chloride BETHKIS... 0 bexarotene... 8 BEXSERO bicalutamide... 8 BICILLIN C-R... 5 BICILLIN L-A... 5 BIDIL bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin... 8 bleph BLINCYTO... 8 blisovi 24 fe blisovi fe.5/30 (28) blisovi fe /20 (28) BOOSTRIX TDAP BOSULIF... 8 BREO ELLIPTA briellyn BRILINTA brimonidine... 0 BRIVIACT bromocriptine BROMSITE budesonide... 98, 05 bumetanide... 6 BUNAVAIL... 8 BUPHENYL buprenorphine... 3 buprenorphine hcl... 3, 8 buprenorphine-naloxone...8 bupropion hcl bupropion hcl (smoking deter).8 buspirone...9 butalbital compound w/codeine3 butalbital-acetaminop-caf-cod.3 butalbital-acetaminophen...3 butalbital-acetaminophen-caff. 3 butalbital-aspirin-caffeine...3 BUTRANS... 3 BYSTOLIC BYVALSON C cabergoline CABOMETYX... 8 caffeine citrate... 64, 65 calcipotriene calcitonin (salmon) calcitrene I-2

120 calcitriol...73, 99 calcium acetate...84 calcium chloride...02 CALDOLOR...6 camila...67 camrese...67 camrese lo...67 CANASA...98 CANCIDAS...34 candesartan...54 candesartan-hydrochlorothiazid...54 capacet...3 CAPASTAT...37 CAPRELSA...8 captopril...55 captopril-hydrochlorothiazide55 CARAFATE...8 CARBAGLU...82 carbamazepine...25, 26 carbidopa-levodopa...40 carbidopa-levodopa-entacapone...40, 4 CARIMUNE NF NANOFILTERED...9 carisoprodol...08 carteolol...0 cartia xt...58 carvedilol...57 CAYSTON...4 caziant (28)...67 cefaclor...2 cefadroxil...2 cefazolin...2 cefazolin in dextrose (iso-os)..2 cefdinir...2 cefditoren pivoxil...2 CEFEPIME...2 CEFEPIME IN DEXTROSE 5 %...2 CEFEPIME IN DEXTROSE,ISO-OSM...2 cefotaxime... 2 cefoxitin... 2 cefoxitin in dextrose, iso-osm 2 cefpodoxime... 3 cefprozil... 3 ceftazidime... 3 ceftibuten... 3 ceftriaxone... 3 ceftriaxone in dextrose,iso-os 3 cefuroxime axetil... 3 cefuroxime sodium... 3 celecoxib... 6 CELONTIN cephalexin... 3 CEPROTIN (BLUE BAR) CERDELGA CEREZYME CERVARIX VACCINE (PF) 95 CETYLEV cevimeline CHANTIX... 8 CHANTIX CONTINUING MONTH BOX... 8 CHANTIX STARTING MONTH BOX... 8 chloramphenicol sod succinate... 0 chlordiazepoxide hcl... 9 chlorhexidine gluconate chloroquine phosphate chlorothiazide... 6 chlorothiazide sodium... 6 chlorpromazine chlorthalidone... 6 chlorzoxazone cholestyramine (with sugar).. 62 cholestyramine light ciclopirox cilostazol cimetidine... 8 cimetidine hcl... 8 CIMZIA... 9 CIMZIA POWDER FOR RECONST... 9 CINQAIR CINRYZE CIPRODEX ciprofloxacin... 6 ciprofloxacin hcl... 6, 79 ciprofloxacin in 5 % dextrose 6 ciprofloxacin lactate... 6 citalopram clarithromycin... 4 CLEVIPREX clindamycin hcl... clindamycin in 5 % dextrose.. clindamycin palmitate hcl... 0 clindamycin pediatric... clindamycin phosphate......, 37, 74 CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5% D20W(SULFITE-FREE) CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D0W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE I-3

121 CLINIMIX E 4.25%/D5W SULF FREE...52 CLINIMIX E 5%/D5W SULFIT FREE...52 CLINIMIX E 5%/D20W SULFIT FREE...53 CLINIMIX E 5%/D25W SULFIT FREE...53 CLINISOL SF 5 %...53 clobetasol...75 clobetasol-emollient...75 clocortolone pivalate...75 clofarabine...8 clomipramine...29 clonazepam...9 clonidine...54 clonidine hcl...54 clopidogrel...5 clorazepate dipotassium...9 clotrimazole...35 clotrimazole-betamethasone...35 clozapine...42 COARTEM...40 codeine sulfate...3 COLCRYS...36 colestipol...62 colistin (colistimethate na)... colocort...98 COLY-MYCIN S...79 COMBIGAN...0 COMBIPATCH...86 COMBIVENT RESPIMAT.06 COMETRIQ...8 COMPLERA...45 compro...38 CONDYLOX...73 constulose...82 COPAXONE...65 CORLANOR...58 cormax...75 cortisone...87 COSENTYX (2 SYRINGES) 73 COSENTYX PEN (2 PENS). 73 COTELLIC... 8 CREON CRIXIVAN cromolyn... 78, 07 cryselle (28) CUPRIMINE cyclafem /35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide... 8, 9 CYCLOSET... 3 cyclosporine... 9 cyclosporine modified... 9 cyproheptadine CYRAMZA... 9 cyred CYSTADANE CYSTARAN D d0 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride DAKLINZA DALIRESP danazol dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin... DARAPRIM DARZALEX... 9 dasetta /35 (28) dasetta 7/7/7 (28) daysee deblitane...68 decitabine... 9 deferoxamine delyla (28) DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA DESCOVY desipramine desmopressin desog-e.estradiol/e.estradiol.. 68 desogestrel-ethinyl estradiol.. 68 desoximetasone desvenlafaxine succinate dexamethasone dexamethasone sodium phosphate... 80, 87 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextrose 0 % and 0.2 % nacl...02 dextrose 0 % in water (d0w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringer's dextrose 5 % in water (d5w).. 53 dextrose 5 %-lactated ringers...02 dextrose 5%-0.2 % sod chloride...02 dextrose 5%-0.3 % sod.chloride...02 dextrose 50 % in water (d50w) I-4

122 dextrose 70 % in water (d70w)...53 dextrose with sodium chloride...02 DIASTAT...9 DIASTAT ACUDIAL...9 diazepam...9 diazepam intensol...9 diclofenac potassium...6 diclofenac sodium...6, 73, 80 diclofenac-misoprostol...6 dicloxacillin...5 dicyclomine...82 didanosine...45 DIFICID...4 diflunisal...6 digitek...59 digoxin...59 dihydroergotamine...37 DILANTIN...26 diltiazem hcl...58 dilt-xr...58 dimenhydrinate...38 DIPENTUM...98 diphenhydramine hcl...36 diphenoxylate-atropine...82 dipyridamole...5 disopyramide phosphate...56 disulfiram...8 divalproex...26 dobutamine...59 dobutamine in d5w...59 dofetilide...56 donepezil...28 dopamine...60 dopamine in 5 % dextrose...59 dorzolamide...0 dorzolamide-timolol...0 doxazosin...54 doxepin...29 doxercalciferol...99 doxorubicin...9 doxorubicin, peg-liposomal... 9 doxy doxycycline hyclate... 7 doxycycline monohydrate... 7 dronabinol droperidol drospirenone-ethinyl estradiol DROXIA... 9 DUAVEE duloxetine DUPIXENT DUREZOL dutasteride dutasteride-tamsulosin E e.e.s e.e.s. granules... 4 econazole EDARBI EDARBYCLOR EDURANT EFFIENT... 5 ELAPRASE electrolyte-48 in d5w ELIDEL ELIGARD... 9 ELIGARD (3 MONTH)... 9 ELIGARD (4 MONTH)... 9 ELIGARD (6 MONTH)... 9 elinest eliphos ELIQUIS ELITEK ELLA ELMIRON EMCYT... 9 EMEND EMFLAZA emoquette EMPLICITI... 9 EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide55 ENBREL... 9 ENBREL SURECLICK... 9 endocet...3 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone... 4 entecavir...48 ENTRESTO enulose ENVARSUS XR EPCLUSA epinastine epinephrine epitol EPIVIR HBV eplerenone EPOGEN... 49, 50 epoprostenol (glycine)...09 ergoloid ERGOMAR ERIVEDGE... 9 errin ery pads ERYPED ERYPED ery-tab...4 ERYTHROCIN... 4 erythrocin (as stearate)...4 erythromycin... 4, 79 erythromycin ethylsuccinate.. 4 erythromycin with ethanol ESBRIET escitalopram oxalate esmolol I-5

123 esomeprazole sodium...8 estarylla...68 ESTRACE...86 estradiol...86 estradiol valerate...86 estradiol-norethindrone acet..86 estropipate...87 eszopiclone...09 ethambutol...38 ethosuximide...26 ethynodiol diac-eth estradiol..68 etodolac...6, 7 ETOPOPHOS...9 etoposide...9 EUCRISA...75 EVOTAZ...45 exemestane...9 EXJADE...85 EXONDYS EXTAVIA...65 ezetimibe...62 F FABRAZYME...77 falmina (28)...68 famciclovir...48 famotidine...8 famotidine (pf)...8 famotidine (pf)-nacl (iso-os)..8 FANAPT...42 FARESTON...9 FARYDAK...9 FASLODEX...9 felbamate...26 felodipine...6 FEMRING...87 femynor...68 fenofibrate...62 fenofibrate micronized...62 fenofibrate nanocrystallized...62 fenofibric acid...62 fenofibric acid (choline)...62 fenoprofen...7 fentanyl... 4 fentanyl citrate... 4 FERRIPROX FETZIMA finasteride FIRAZYR FLEBOGAMMA DIF flecainide FLECTOR FLOVENT DISKUS FLOVENT HFA... 05, 06 floxuridine... 9 fluconazole fluconazole in dextrose(iso-o) 35 fluconazole in nacl (iso-osm). 35 flucytosine fludrocortisone flumazenil flunisolide fluocinolone fluocinonide fluocinonide-e fluoride (sodium)... 0 fluorometholone fluorouracil... 9, 73 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen... 7 flurbiprofen sodium flutamide... 9 fluticasone... 75, 8 fluvoxamine fomepizole fondaparinux FORADIL AEROLIZER FORTEO foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 0 %...53 furosemide... 6 FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < MCG/ML) GAMMAPLEX GAMMAPLEX (WITH SORBITOL) ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GAZYVA gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK88 gentak gentamicin... 0, 74, 79 gentamicin in nacl (iso-osm).. 0 gentamicin sulfate (ped) (pf).. 0 gentamicin sulfate (pf)... 0 GENVOYA GEODON gianvi (28) gildagia GILENYA GILOTRIF I-6

124 glatopa...65 GLEOSTINE...20 glimepiride...34 glipizide...34 glipizide-metformin...34 GLUCAGEN HYPOKIT...3 GLUCAGON EMERGENCY KIT (HUMAN)...3 glyburide...34 glyburide micronized...34 glyburide-metformin...34 glycopyrrolate...82 glydo...7 GLYXAMBI...3 granisetron (pf)...38 granisetron hcl...38 GRANIX...50 griseofulvin microsize...35 guanfacine...54, 65 guanidine...00 H HAEGARDA...00 halobetasol propionate...75 haloperidol...42 haloperidol decanoate...42 haloperidol lactate...42 HARVONI...47 HAVRIX (PF)...95 heather...68 heparin (porcine)...49 heparin (porcine) in 5 % dex..49 heparin, porcine (pf)...49 heparin(porcine) in 0.45% nacl...49 HEPATAMINE 8%...53 HERCEPTIN...20 HETLIOZ...09 HEXALEN...20 HIBERIX (PF)...95 HUMATROPE...89 HUMIRA...92 HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC HS START HUMIRA PEN PSORIASIS UVEITIS HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide... 6 hydrocodone-acetaminophen... 4 hydrocodone-ibuprofen... 4 hydrocortisone... 75, 87, 98 hydromorphone... 4 hydromorphone (pf)... 4 hydroxychloroquine hydroxyprogesterone caproate hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERRAB S/D (PF) HYQVIA HYSINGLA ER... 4 I ibandronate IBRANCE ibuprofen... 7 ICLUSIG ifosfamide ifosfamide-mesna ILARIS (PF)... 92, 93 ILEVRO... 8 imatinib IMBRUVICA IMFINZI imipenem-cilastatin... 4 imipramine hcl imipramine pamoate imiquimod IMLYGIC IMOGAM RABIES-HT (PF) 93 IMOVAX RABIES VACCINE (PF)...95 IMPAVIDO INCRELEX INCRUSE ELLIPTA...06 indapamide... 6 indomethacin... 7 indomethacin sodium...7 INFANRIX (DTAP) (PF) INFLECTRA INGREZZA INLYTA...20 INSULIN SYRINGE-NEEDLE U , 77 INTELENCE INTRALIPID INTRON A introvale...68 INVANZ... 4 INVEGA SUSTENNA...42, 43 INVEGA TRINZA INVIRASE INVOKAMET... 3 INVOKAMET XR... 3 INVOKANA IONOSOL-B IN D5W...02 IONOSOL-MB IN D5W...02 IPOL...95, 96 ipratropium bromide...78, 06 IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRESSA ISENTRESS ISENTRESS HD isibloom ISOLYTE-P IN 5 % DEXTROSE I-7

125 ISOLYTE-S...02 isoniazid...38 isosorbide dinitrate...63 isosorbide mononitrate...63, 64 isradipine...6 itraconazole...35 ivermectin...40 IXEMPRA...20 IXIARO (PF)...96 J JADENU...85 JADENU SPRINKLE...85 JAKAFI...2 jantoven...49 JANUMET...32 JANUMET XR...32 JANUVIA...32 JARDIANCE...32 jencycla...68 JENTADUETO...32 JENTADUETO XR...32 jolessa...68 jolivette...68 juleber...68 junel.5/30 (2)...68 junel /20 (2)...68 junel fe.5/30 (28)...68 junel fe /20 (28)...69 junel fe JUXTAPID...62 K KABIVEN...53 KALETRA...45 KALYDECO...08 KANUMA...77 kariva (28)...69 kelnor /35 (28)...69 ketoconazole...35 ketoprofen...7 ketorolac...7, 8 KEVEYIS...00 KEVZARA...93 KEYTRUDA... 2 kimidess (28) KINERET KINRIX (PF) kionex kionex (with sorbitol) KISQALI... 2 KISQALI FEMARA CO-PACK... 2 klor-con m klor-con m klor-con m klor-con sprinkle KORLYM KRYSTEXXA kurvelo KUVAN KYNAMRO KYPROLIS... 2 L l norgest/e.estradiol-e.estrad. 69 labetalol LACRISERT LACTATED RINGERS lactulose lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin.5/30 (2) larin /20 (2) larin 24 fe larin fe.5/30 (28) larin fe /20 (28) larissia LARTRUVO... 2 latanoprost... 0 LATUDA LAZANDA... 4 leena leflunomide LEMTRADA LENVIMA... 2 lessina...69 LETAIRIS letrozole... 2 leucovorin calcium LEUKERAN... 2 LEUKINE leuprolide... 2 levalbuterol tartrate...06 levetiracetam levobunolol... 0 levocarnitine levocarnitine (with sugar)...00 levocetirizine levofloxacin... 6, 79 levofloxacin in d5w... 6 LEVOLEUCOVORIN...0 levonest (28) levonorgestrel-ethinyl estrad.69 levonorg-eth estrad triphasic.69 levora levothyroxine... 90, 9 LEXIVA... 45, 46 LIALDA...98 lidocaine...8 lidocaine (pf)... 7, 8, 56 lidocaine hcl... 8 lidocaine in 5 % dextrose (pf) 56 lidocaine viscous... 8 lidocaine-prilocaine...8 linezolid... LINZESS liothyronine... 9 lisinopril...56 lisinopril-hydrochlorothiazide56 lithium carbonate lithium citrate LIVALO...62 lomedia 24 fe I-8

126 LONSURF...2 loperamide...83 lopinavir-ritonavir...46 lopreeza...87 lorazepam...9 lorcet (hydrocodone)...4 lorcet hd...4 lorcet plus...4 loryna (28)...69 losartan...55 losartan-hydrochlorothiazide.55 LOTEMAX...8 lovastatin...62 low-ogestrel (28)...69 loxapine succinate...43 LUMIGAN...0 LUPRON DEPOT...22 LUPRON DEPOT (3 MONTH)...2 LUPRON DEPOT (4 MONTH)...2 LUPRON DEPOT (6 MONTH)...2 LUPRON DEPOT-PED...89 LUPRON DEPOT-PED (3 MONTH)...89 lutera (28)...69 LYNPARZA...22 LYRICA...27 LYSODREN...22 lyza...69 M magnesium sulfate...03 magnesium sulfate in d5w...03 magnesium sulfate in water..03 malathion...76 maprotiline...30 marlissa...70 MARPLAN...30 MATULANE...22 matzim la...58 meclizine...39 medroxyprogesterone mefenamic acid... 7 mefloquine MEFOXIN IN DEXTROSE (ISO-OSM)... 3 megestrol... 22, 90 MEKINIST meloxicam... 7 memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-35 (PF) MENVEO A-C-Y-W-35-DIP (PF) mercaptopurine meropenem... 4 mesalamine mesna... 0 MESNEX... 0 MESTINON... 0 metaproterenol metformin methadone... 4 methadose... 4 methazolamide... 0 methenamine hippurate... methimazole... 9 methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen methscopolamine methyclothiazide... 6 methylphenidate hcl... 65, 66 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol... 0 metoclopramide hcl metolazone... 6 metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole..., 37, 74 metronidazole in nacl (iso-os) mexiletine MIACALCIN miconazole microgestin.5/30 (2)...70 microgestin /20 (2)...70 microgestin fe.5/30 (28) microgestin fe /20 (28) midodrine miglitol milrinone milrinone in 5 % dextrose mimvey mimvey lo minitran minocycline... 7 minoxidil MIRCERA mirtazapine misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide molindone mometasone mono-linyah mononessa (28) montelukast morphine...5 morphine concentrate...5 MOVANTIK MOVIPREP I-9

127 MOXEZA...79 moxifloxacin...6, 79 MOZOBIL...50 MULTAQ...56 mupirocin...74 mupirocin calcium...74 mycophenolate mofetil...93 mycophenolate mofetil hcl...93 mycophenolate sodium...93 MYRBETRIQ...84 myzilra...70 N nabumetone...7 nadolol...57 nafcillin...5 NAGLAZYME...77 naloxone...8 naltrexone...8 NAMENDA XR...28 NAMZARIC...29 naproxen...7 naratriptan...37 NARCAN...8 NATACYN...79 nateglinide...32 NATPARA...99 NEBUPENT...40 necon 0.5/35 (28)...70 necon /50 (28)...70 necon 0/ (28)...70 necon 7/7/7 (28)...70 nefazodone...30 neomycin...0 neomycin-bacitracin-poly-hc.79 neomycin-bacitracin-polymyxin...79 neomycin-polymyxin b gu...74 neomycin-polymyxin b- dexameth...79 neomycin-polymyxin-gramicidin...79 neomycin-polymyxin-hc...79, 80 neo-polycin neo-polycin hc NEPHRAMINE 5.4 % NEULASTA NEUPOGEN NEUPRO... 4 nevirapine NEXAVAR niacin niacor nicardipine... 6 NICOTROL... 8 nifedipine... 6 nikki (28) nilutamide NINLARO NITRO-BID nitrofurantoin macrocrystal.. nitrofurantoin monohyd/m-cryst... nitroglycerin nitroglycerin in 5 % dextrose 64 nora-be NORDITROPIN FLEXPRO. 89 norepinephrine bitartrate norethindrone (contraceptive)70 norethindrone acetate norethindrone ac-eth estradiol norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol70 norlyda norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA NUCYNTA... 5 NUCYNTA ER... 5 NUEDEXTA NULOJIX NUPLAZID NUTRESTORE NUTRILIPID NUTROPIN AQ NUSPIN NUVARING... 7 nyamyc nyata...35 nystatin nystatin-triamcinolone... 35, 36 nystop O OCALIVA ocella... 7 OCREVUS OCTAGAM octreotide acetate ODEFSEY ODOMZO OFEV...08 ofloxacin... 6, 80 ogestrel (28)... 7 olanzapine olmesartan olmesartan-amlodipin-hcthiazid I-0

128 olmesartan-hydrochlorothiazide...55 olopatadine...78 OLYSIO...47 omega-3 acid ethyl esters...62 omeprazole...82 OMNITROPE...89 ONCASPAR...22 ondansetron...39 ondansetron hcl...39 ondansetron hcl (pf)...39 ONFI...9, 0 ONIVYDE...22 OPDIVO...22 OPSUMIT...09 oralone...72 ORENCIA...93 ORENCIA (WITH MALTOSE)...93 ORENCIA CLICKJECT...93 ORENITRAM...09 ORFADIN...77 ORKAMBI...08 orsythia...7 oseltamivir...47 OTEZLA...93 OTEZLA STARTER...93 OTOVEL...78 OTREXUP (PF)...93 oxacillin...6 oxacillin in dextrose(iso-osm) 5 oxandrolone...86 oxcarbazepine...27 OXTELLAR XR...27 oxybutynin chloride...84 oxycodone...5 oxycodone-acetaminophen...5 oxycodone-aspirin...5 OXYCONTIN...6 oxymorphone...6 P pacerone...56 paliperidone PANRETIN pantoprazole PARICALCITOL paromomycin paroxetine hcl PASER PAXIL PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC.. 77 penicillin g pot in dextrose... 6 penicillin g potassium... 6 penicillin g procaine... 6 penicillin v potassium... 6 PENTACEL (PF) PENTAM pentoxifylline... 5 PERIKABIVEN perindopril erbumine periogard permethrin perphenazine perphenazine-amitriptyline... 3 pfizerpen-g... 6 phenadoz phenelzine... 3 phenobarbital phenylephrine hcl... 54, 78 phenytoin phenytoin sodium phenytoin sodium extended philith... 7 PHOSLYRA PHOSPHOLINE IODIDE... 0 PICATO pilocarpine hcl... 72, 0 pimozide...43 pimtrea (28)... 7 pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin...32 piperacillin-tazobactam... 6 pirmella... 7 piroxicam...7 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podofilox polyethylene glycol polymyxin b sulfate... polymyxin b sulf-trimethoprim80 POMALYST portia... 7 PORTRAZZA potassium acetate potassium chlorid-d5-0.45%nacl...03 potassium chloride potassium chloride in 0.9%nacl...03 potassium chloride in 5 % dex...03 potassium chloride in lr-d5..04 potassium chloride-0.45 % nacl...04 potassium chloride-d5-0.2%nacl...04 potassium chloride-d5-0.3%nacl...04 potassium chloride-d5-0.9%nacl...04 potassium citrate potassium citrate-citric acid 04 POTIGA...27 I-

129 PRADAXA...49 PRALUENT PEN...63 pramipexole...4 pravastatin...63 prazosin...54 prednicarbate...75 prednisolone acetate...8 prednisolone sodium phosphate...8, 88 prednisone...88 PREMARIN...87 PREMASOL 0 %...54 PREMASOL 6 %...54 PREMPHASE...87 PREMPRO...87 prenatal plus (calcium carb) 0 prenatal vitamin plus low iron...0 prevalite...63 previfem...7 PREZCOBIX...46 PREZISTA...46 PRIFTIN...38 PRIMAQUINE...40 primidone...27 PRIVIGEN...93 PROAIR HFA...07 PROAIR RESPICLICK...07 probenecid...36 probenecid-colchicine...36 procainamide...56 PROCALAMINE 3%...54 prochlorperazine...39 prochlorperazine edisylate...39 prochlorperazine maleate...39 PROCRIT...50 procto-med hc...75 procto-pak...76 proctosol hc...76 proctozone-hc...76 PROCYSBI...77 progesterone in oil...90 progesterone micronized PROGLYCEM... 0 PROGRAF PROLASTIN-C PROLEUKIN PROLIA PROMACTA promethazine... 36, 39 promethazine vc promethegan propafenone propantheline proparacaine propranolol propranolol-hydrochlorothiazid propylthiouracil... 9 PROQUAD (PF) PROSOL 20 % protamine protriptyline... 3 PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide... 0 Q QUADRACEL (PF) quasense... 7 quetiapine... 43, 44 quinapril quinapril-hydrochlorothiazide56 quinidine sulfate quinine sulfate QVAR R RABAVERT (PF) RADICAVA raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE rasagiline... 4 RASUVO (PF) RAVICTI RAYALDEE REBIF (WITH ALBUMIN).. 66 REBIF REBIDOSE REBIF TITRATION PACK.. 66 reclipsen (28)... 7 RECOMBIVAX HB (PF) 96, 97 RELENZA DISKHALER RELISTOR REMICADE REMODULIN... 0 RENAGEL RENVELA repaglinide repaglinide-metformin REPATHA PUSHTRONEX.. 63 REPATHA SURECLICK REPATHA SYRINGE reprexain...6 RESCRIPTOR RESTASIS... 8 RESTASIS MULTIDOSE... 8 RETROVIR REVLIMID revonto...08 REXULTI REYATAZ ribasphere ribavirin...48 RIDAURA rifabutin rifampin RIFATER riluzole rimantadine ringer's... 98, 04 risedronate RISPERDAL CONSTA risperidone RITUXAN I-2

130 RITUXAN HYCELA...23 rivastigmine...29 rivastigmine tartrate...29 rizatriptan...37 ropinirole...4 rosadan...74 rosuvastatin...63 ROTARIX...97 ROTATEQ VACCINE...97 ROWEEPRA...27 RUBRACA...23 RYDAPT...23 S SABRIL...27 SAIZEN...89 SAIZEN CLICK.EASY...89 SANDOSTATIN LAR DEPOT...89 SANTYL...73 SAPHRIS (BLACK CHERRY)...44 SAVELLA...66 selegiline hcl...4 selenium sulfide...74 SELZENTRY...46 SENSIPAR...99 SEREVENT DISKUS...07 SEROSTIM...90 sertraline...3 setlakin...7 sevelamer carbonate...84 sharobel...7 SIGNIFOR...90 sildenafil...0 SILENOR...09 SILIQ...73 silver sulfadiazine...74 SIMBRINZA...02 SIMPONI...94 SIMPONI ARIA...94 simvastatin...63 sirolimus...94 SIRTURO smoflipid sodium acetate sodium chloride... 98, 05 sodium chloride 0.45 % sodium chloride 0.9 % sodium lactate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate. 83 SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT sorbitol sorbitol-mannitol sorine sotalol sotalol af SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone... 6 spironolacton-hydrochlorothiaz... 6 sprintec (28)... 7 SPRITAM SPRYCEL sps (with sorbitol) sronyx... 7 ssd stavudine STELARA STERILE GAUZE PAD STIOLTO RESPIMAT STIVARGA STRENSIQ streptomycin... 0 STRIBILD STRIVERDI RESPIMAT SUBOXONE... 9 sucralfate sulfacetamide sodium...80 sulfacetamide sodium (acne).. 74 sulfacetamide-prednisolone sulfadiazine... 6 sulfamethoxazole-trimethoprim... 6, 7 sulfasalazine sulfatrim...7 sulindac...7 sumatriptan sumatriptan succinate SUPPRELIN LA SUPRAX... 3 SUPREP BOWEL PREP KIT84 SURMONTIL... 3 SUSTIVA SUTENT syeda... 7 SYLATRON SYLVANT SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID... 2 SYNJARDY SYNJARDY XR SYNRIBO SYPRINE T TABLOID tacrolimus... 76, 94 TAFINLAR TAGRISSO TALTZ AUTOINJECTOR...73 TALTZ SYRINGE TAMIFLU tamoxifen tamsulosin I-3

131 TARCEVA...23 TARGRETIN...23 tarina fe /20 (28)...7 TASIGNA...23 tazarotene...76 tazicef...3 TAZORAC...76 taztia xt...58 TECENTRIQ...23 TECFIDERA...66 TECHNIVIE...47 TEFLARO...3 TEKAMLO...63 TEKTURNA...63 TEKTURNA HCT...63 telmisartan...55 temazepam...0 TEMODAR...23 tencon...6 TENIVAC (PF)...97 terazosin...85 terbinafine hcl...36 terbutaline...07 terconazole...37 testosterone...86 testosterone cypionate...86 testosterone enanthate...86 TETANUS,DIPHTHERIA TOX PED(PF)...97 TETANUS-DIPHTHERIA TOXOIDS-TD...97 tetrabenazine...66 THALOMID...0 theophylline...07 theophylline in dextrose 5 % 07 THIOLA...0 thioridazine...44 thiotepa...23 thiothixene...44 tiagabine...27 TICE BCG...97 tigecycline...7 tilia fe... 7 timolol maleate... 58, 02 TIVICAY tizanidine TOBI PODHALER... 0 TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl... 0 tobramycin in 0.9 % nacl... 0 tobramycin sulfate... 0 tobramycin-dexamethasone TOLAK tolazamide tolbutamide tolterodine topiramate toposar torsemide... 6 TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER... 0 TRADJENTA tramadol... 6 tramadol-acetaminophen... 6 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine... 3 TRAVASOL 0 % TRAVATAN Z trazodone... 3 TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) TREXALL tri femynor... 7 triamcinolone acetonide.. 72, 76 triamterene-hydrochlorothiazid... 6, 62 tri-estarylla... 7 trifluoperazine trifluridine trihexyphenidyl... 4 tri-legest fe... 7 tri-linyah... 7 tri-lo-estarylla... 7 tri-lo-marzia... 7 tri-lo-sprintec... 7 trilyte with flavor packets...84 trimethoprim... 2 trimipramine... 3 trinessa (28)... 7 TRINTELLIX... 3 tri-previfem (28) tri-sprintec (28) TRIUMEQ trivora (28) TROKENDI XR TROPHAMINE 0 % TROPHAMINE 6% trospium...85 TRULICITY TRUMENBA TRUVADA TWINRIX (PF) TYBOST... 0 TYKERB TYMLOS TYPHIM VI TYSABRI TYVASO... 0 U UCERIS...98 ULORIC...36 UNITUXIN UPTRAVI... 0 ursodiol V valacyclovir I-4

132 VALCHLOR...73 valganciclovir...48 valproate sodium...28 valproic acid...28 valproic acid (as sodium salt) 28 valsartan...55 valsartan-hydrochlorothiazide...55 VALSTAR...24 vancomycin...2 vancomycin in dextrose 5 %...2 VAQTA (PF)...97 VARIVAX (PF)...97 VASCEPA...63 VELCADE...24 velivet triphasic regimen (28) 72 VELPHORO...84 VELTASSA...83 VEMLIDY...46 VENCLEXTA...24 VENCLEXTA STARTING PACK...24 venlafaxine...3 verapamil...58 VERSACLOZ...44 VESICARE...85 vestura (28)...72 VGO VIBERZI...83 VICTOZA...33 VIDEX 2 GRAM PEDIATRIC...47 VIEKIRA PAK...47 VIEKIRA XR...47 vienva...72 VIGAMOX...80 VIIBRYD...3 VIMIZIM...78 VIMPAT...28 vinorelbine viorele (28) VIRACEPT VIREAD VOLTAREN voriconazole VOTRIENT VPRIV VRAYLAR vyfemla (28) W warfarin water for irrigation, sterile WELCHOL wera (28) X XADAGO... 4 XALKORI XARELTO XATMEP XELJANZ XELJANZ XR XERMELO XIFAXAN... 2 XOLAIR XTAMPZA ER... 6 XTANDI xulane XULTOPHY 00/ XYREM Y YERVOY YF-VAX (PF) YONDELIS yuvafem Z zafirlukast zaleplon zarah ZARXIO ZAVESCA zebutal...6 ZEJULA...25 ZELBORAF zenatane...73 zenchent (28) ZENPEP...78 ZEPATIER ZERIT...47 ZIAGEN...47 zidovudine ZINBRYTA ZIOPTAN (PF) ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water...00 ZOLINZA zolmitriptan zolpidem ZOMACTON ZOMETA zonisamide ZORBTIVE ZORTRESS ZOSTAVAX (PF) zovia /35e (28) zovia /50e (28) ZUBSOLV... 9 ZURAMPIC ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV...44 ZYTIGA...25 I-5

133 CUSTOMER CARE CENTER (877) Llamadas a este número son gratis. Horas de atención son de 8 a.m. a 8 p.m., 7 días de la semana. Nuestro Centro de Atención al Cliente también tiene servicios de intérprete de idiomas gratis disponible para las personas que no hablan inglés. LLAME TTY 7. Llamadas a este número son gratis. Horas de atención son las 24 horas del día, 7 días de la semana. TTY 270 E. Elvira Road Tucson, AZ CORREO WEB Este formulario fue actualizado el 0/08/207. Para información más reciente o si tiene otras preguntas, favor de comunicarse con University Care Advantage al (877) o, para los usuarios de TTY, 7, de 8 a.m. a 8 p.m., 7 días de la semana, o visite