Lista de medicamentos Blue Cross Community ICPSM. Este documento contiene información sobre los medicamentos que cubre este plan.

Transcripción

1 Blue Cross Community ICPSM Lista de medicamentos 2017 Este documento contiene información sobre los medicamentos que cubre este plan. Lista de medicamentos vigente al 01 de noviembre de 2017, fecha de su publicación. Favor de notificar errores en esta lista de medicamentos a Blue Cross Community ICP por escrito a ilmedicaidoperations@bcbsil.com o por teléfono al TTY/TDD

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3 Lista de medicamentos Qué es la lista de medicamentos de Blue Cross Community ICP Plan (el "plan")? La lista de medicamentos (a veces denominada "formulario") es una lista que enumera los medicamentos que pueden estar cubiertos por el plan. Para que los medicamentos enumerados estén cubiertos, usted debe cumplir con lo siguiente: tener la necesidad médica de obtenerlos; abastecer las recetas en una farmacia de la red; seguir otras normas del plan. Para obtener más información sobre cómo abastecer sus recetas, consulte el Manual para miembros. Cuánto tendré que pagar? No debe pagar nada por los medicamentos cubiertos. La lista de medicamentos puede cambiar? Sí, puede cambiar. La cobertura puede cambiar en los siguientes casos: cuando esté disponible un nuevo medicamento genérico; cuando nueva información sobre un medicamento demuestra que este no es seguro o que es menos eficaz. Cómo utilizo la lista de medicamentos? 1. Por categoría Los medicamentos se enumeran en categorías, o grupos, según el tipo de afección que tratan. (Por ejemplo, los medicamentos que se utilizan para tratar enfermedades cardíacas se enumeran en "Heart and Circulatory Drugs" [Medicamentos cardiovasculares]). Si sabe qué afección trata su medicamento, busque ese grupo en la lista. Luego, busque ntro de ese grupo. 2. Listado en orden alfabético Busque su medicamento en el índice. Al lado del medicamento verá el número de página donde puede encontrar la información de la cobertura. Qué son los medicamentos genéricos? Los medicamentos genéricos son aprobados por la Administración de Drogas y Alimentos (FDA) por tener el mismo ingrediente activo que marca, pero generalmente cuestan menos. El plan cubre medicamentos de marca y medicamentos genéricos. Cuando se realicen cambios en la lista de medicamentos, se lo notificaremos por escrito. i

4 Blue Cross Community Integrated Care Plan (ICP) Existe algún límite en mi cobertura? Las condiciones o los límites adicionales que tienen algunos medicamentos cubiertos pueden incluir los siguientes: Autorización previa: Es posible que usted o su médico deban obtener aprobación antes de abastecer las recetas. Si no obtiene la aprobación, es posible que el plan no cubra el medicamento. Límites de cantidad: El plan limita la cantidad que cubrirá de algunos medicamentos. Terapia escalonada: En algunos casos, el plan requiere que usted primero pruebe determinados medicamentos antes de cubrir otro. Por ejemplo, si el medicamento A y el medicamento B tratan su enfermedad, es posible que el plan no cubra el medicamento B, a menos que usted pruebe el medicamento A primero. Si el medicamento A no funciona en su caso, entonces el plan cubrirá el medicamento B. Puede averiguar si su medicamento tiene alguna condición o límite adicional consultando la lista que comienza en la página 1. El plan paga medicamentos de venta libre? Sí, el plan paga algunos medicamentos de venta libre si usted tiene una receta válida de su médico. Puede obtenerlos sin costo alguno. Qué sucede si mi medicamento no figura en la lista de medicamentos? Comuníquese con Atención al Cliente y pregunte si el medicamento está cubierto. Si le informan que el plan no cubre su medicamento, tiene dos opciones: Hable con su médico para determinar si debe probar primero otro medicamento de nuestra lista antes de solicitar una excepción. Pregunte en Atención al Cliente cómo solicitar una excepción para que cubramos su medicamento. Envíe una declaración de su médico para respaldar su solicitud. Debemos tomar una decisión dentro de los 24 horas de la recepción de la declaración de su médico. Por lo general, solo aprobamos las solicitudes de excepción si otros medicamentos incluidos en nuestra lista, o los límites adicionales de uso, harían que su tratamiento sea menos eficaz o serían perjudiciales para su salud. Qué categorías de medicamentos no están cubiertas en la lista de medicamentos del plan? Las siguientes categorías de medicamentos no están cubiertas por su plan: medicamentos para el tratamiento de la anorexia, la pérdida de peso o el aumento de peso; productos químicos a granel; medicamentos con fines cosméticos; agentes de diagnóstico; medicamentos clasificados como ineficaces por la Implementación del Estudio de la Eficacia de los Medicamentos (DESI); medicamentos experimentales y en investigación; medicamentos contra la disfunción eréctil para tratar la impotencia; medicamentos para la fertilidad; medicamentos anestésicos generales; medicamentos de venta libre no incluidos de otra manera en la lista de medicamentos del plan; suministros o equipos médicos quirúrgicos. ii

5 Lista de medicamentos Para obtener más información Para obtener más detalles sobre la cobertura de medicamentos de su plan, consulte el Manual para miembros y los demás materiales del plan. Si usted tuviese cualquier pregunta, por favor llame a Atención al Cliente al: (TTY/TDD 711). Estamos a su disposición las 24 horas del día, los siete (7) días de la semana. La llamada es gratuita. Asistencia lingüística Servicios de interpretación Podemos coordinar que alguien lo ayude a comunicarse con nosotros en su idioma. Estos servicios son gratuitos. Si su médico no habla su idioma, podemos coordinar para que un traductor lo ayude. Llame a Servicios para Miembros al número que figura más arriba. Problemas de audición y visión Para nuestros miembros con problemas de audición y visión, ofrecemos un servicio de TTY/TDD sin cargo. Llame al 711, la línea está disponible las 24 horas del día, los 7 días de la semana. Otros idiomas y formatos: Puede obtener una copia de este cuadernillo y del Manual para miembros en español en nuestro sitio web, También ofrecemos los materiales en otros idiomas, en letra grande, audio y braille a través de Atención al Cliente. Lista de medicamentos de venta libre de Blue Cross Community ICP Plan El plan cubre una amplia selección de productos de venta libre. Estos se enumeran a continuación y requieren una orden emitida por su médico. Se deben recetar y entregar medicamentos genéricos cuando estén disponibles. Los productos deben abastecerse en una farmacia de la red del plan por un suministro de hasta 30 días. Lista de medicamentos de venta libre Analgésicos* Antiácidos* Antibióticos* Antidiarreicos* Antieméticos* Antiflatulentos* Antihistamínicos* Antitusivos* Acetaminophen (genérico) Calcium carbonate (genérico); Aluminum/magnesium hydroxide (genérico) Bacitracin (genérico); Clotrimazole (genérico); Miconazole (genérico); Neomycin/Bacitracin/Polymyxin (genéricos); Tioconazole, Tolnaftate (genéricos) Loperamide (genérico); Pink bismuth (genérico) Meclizine (genérico) Simethicone (genérico) Chlorpheniramine (genérico); Clemastine (genérico); Diphenhydramine (genérico); Cetirizine (genérico); Fexofenadine (genérico); Loratadine (genérico) Guaifenesin con DM (genérico) iii

6 Blue Cross Community Integrated Care Plan (ICP) Medicamentos para la tos y el resfrío* Diluyentes* Productos para equipos médicos duraderos* Preparados para los oídos* Electrolitos* Expectorantes* Anticonceptivos* Antagonistas de los receptores H2* Laxantes* Descongestivos nasales* Antiinflamatorios no esteroides* Preparados oftálmicos* Pediculicidas* Hiedra venenosa* Protectores* Inhibidores de la bomba de protones* Para dejar de fumar* Vitaminas y minerales* Brompheniramine y phenylephrine, Chlorpheniramine y phenylephrine, Diphenhydramine y phenylephrine, Guaifenesin con PE (genérico); Guaifenesin con CF (genérico) Sodium chloride (genérico) Suministros para pruebas de diabetes, medidores de flujo máximo, espaciadores Carbamide peroxide (genérico) Electrolyte solution (genérico) Guaifenesin (genérico) Condones, Levonorgestrel (anticonceptivo oral de emergencia), Nonoxinol-9 Famotidine (genérico); Ranitidine (genérico) Bisacodyl (genérico); Docusate sodium (genérico); Magnesium citrate (genérico); Polyethylene Glycol 3350, Psyllium (genérico); Sennosides (genérico) Phenylephrine (genérico); Saline, aerosol nasal (genérico) Aspirin (genérico); Ibuprofen (genérico); Naproxen (genérico) Lágrimas artificiales (genéricas); Ketotifen (genérico); Naphazoline con pheniramine (genérico) Permethrin (genérico) Calamine (genérico); Hydrocortisone (genérico) Zinc oxide (genérico) Lansoprazole (genérico); Omeprazole (genérico) Goma de mascar con nicotine (genérica); parche de nicotine (genérico) Calcium carbonate con vitamin D (genérico); Calcium citrate con vitamin D (genérico); Ferrous gluconate (genérico); Ferrous sulfate (genérico); Folic acid (genérico); multivitaminas (genérico); multivitaminas con hierro (genérico); Nicotinic acid (genérico); multivitaminas para niños (genérico); multivitaminas prenatales (genérico); Vitamin C (genérico); Vitamin D (genérico) *Se deben recetar y entregar medicamentos genéricos cuando estén disponibles. iv

7 MEDICAMENTOS ANTIINFECCIOSOS PENICILINAS AMOXICILLIN amoxicillin (trihydrate) chew tab 125 mg $0 (2) AMOXICILLIN amoxicillin (trihydrate) chew tab 250 mg $0 (2) amoxicillin (trihydrate) cap 250 mg $0 (1) amoxicillin (trihydrate) cap 500 mg $0 (1) amoxicillin (trihydrate) for susp 125 mg/5ml $0 (1) amoxicillin (trihydrate) for susp 200 mg/5ml $0 (1) amoxicillin (trihydrate) for susp 250 mg/5ml $0 (1) amoxicillin (trihydrate) for susp 400 mg/5ml $0 (1) amoxicillin (trihydrate) tab 875 mg $0 (1) amoxicillin & k clavulanate for susp mg/5ml $0 (1) amoxicillin & k clavulanate for susp mg/5ml $0 (1) (Augmentin) amoxicillin & k clavulanate for susp mg/5ml $0 (1) amoxicillin & k clavulanate for susp mg/5ml (Augmentin $0 (1) es-600) amoxicillin & k clavulanate tab mg $0 (1) amoxicillin & k clavulanate tab mg (Augmentin) $0 (1) amoxicillin & k clavulanate tab mg (Augmentin) $0 (1) AMPICILLIN ampicillin cap 500 mg $0 (1) dicloxacillin sodium cap 250 mg $0 (1) dicloxacillin sodium cap 500 mg $0 (1) PENICILLIN V POTASSIUM penicillin v potassium for soln $0 (1) 125 mg/5ml PENICILLIN V POTASSIUM penicillin v potassium for soln $0 (1) 250 mg/5ml penicillin v potassium tab 250 mg $0 (1) penicillin v potassium tab 500 mg $0 (1) CEFALOSPORINAS cefaclor cap 250 mg $0 (1) cefaclor cap 500 mg $0 (1) cefadroxil cap 500 mg $0 (1) cefadroxil for susp 250 mg/5ml $0 (1) cefadroxil for susp 500 mg/5ml $0 (1) cefadroxil tab 1 gm $0 (1) 1

8 cefdinir cap 300 mg $0 (1) cefdinir for susp 125 mg/5ml $0 (1) cefdinir for susp 250 mg/5ml $0 (1) cefprozil for susp 125 mg/5ml $0 (1) cefprozil for susp 250 mg/5ml $0 (1) cefprozil tab 250 mg $0 (1) cefprozil tab 500 mg $0 (1) ceftriaxone sodium for inj 250 mg $0 (1) ceftriaxone sodium for inj 500 mg $0 (1) ceftriaxone sodium for inj 1 gm $0 (1) ceftriaxone sodium for inj 2 gm $0 (1) cefuroxime axetil tab 250 mg $0 (1) cefuroxime axetil tab 500 mg $0 (1) cephalexin cap 250 mg (Keflex) $0 (1) cephalexin cap 500 mg (Keflex) $0 (1) cephalexin for susp 125 mg/5ml $0 (1) cephalexin for susp 250 mg/5ml $0 (1) MACRÓLIDOS azithromycin for susp 100 mg/5ml (Zithromax) $0 (1) azithromycin for susp 200 mg/5ml (Zithromax) $0 (1) azithromycin tab 250 mg (Zithromax) $0 (1) QL (60 tablets/180 days) azithromycin tab 500 mg (Zithromax) $0 (1) QL (60 tablets/180 days) azithromycin tab 600 mg (Zithromax) $0 (1) QL (60 tablets/180 days) clarithromycin tab 250 mg $0 (1) clarithromycin tab 500 mg (Biaxin) $0 (1) TETRACICLINAS demeclocycline hcl tab 150 mg $0 (1) doxycycline hyclate cap 50 mg $0 (1) doxycycline hyclate cap 100 mg (Vibramycin) $0 (1) doxycycline hyclate tab 20 mg $0 (1) doxycycline hyclate tab 100 mg $0 (1) doxycycline monohydrate cap 50 mg $0 (1) doxycycline monohydrate cap 100 mg (Monodox) $0 (1) doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) $0 (1) doxycycline monohydrate tab 50 mg $0 (1) 2

9 doxycycline monohydrate tab 75 mg $0 (1) doxycycline monohydrate tab 100 mg $0 (1) minocycline hcl cap 50 mg (Minocin) $0 (1) minocycline hcl cap 75 mg $0 (1) minocycline hcl cap 100 mg (Minocin) $0 (1) minocycline hcl tab 50 mg $0 (1) minocycline hcl tab 75 mg $0 (1) minocycline hcl tab 100 mg $0 (1) FLUOROQUINOLONAS ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) $0 (1) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) $0 (1) (Cipro) ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) $0 (1) ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) $0 (1) ciprofloxacin hcl tab 750 mg (base equiv) $0 (1) LEVOFLOXACIN levofloxacin oral soln 25 mg/ml $0 (2) levofloxacin tab 250 mg (Levaquin) $0 (1) levofloxacin tab 500 mg (Levaquin) $0 (1) levofloxacin tab 750 mg (Levaquin) $0 (1) SULFADIAZINE sulfadiazine tab 500 mg $0 (1) AMINOGLUCÓSIDOS neomycin sulfate tab 500 mg $0 (1) paromomycin sulfate cap 250 mg $0 (1) tobramycin nebu soln 300 mg/5ml (Tobi) $0 (1) QL (56 ampules/56 TUBERCULOSIS ethambutol hcl tab 100 mg (Myambutol) $0 (1) ethambutol hcl tab 400 mg (Myambutol) $0 (1) isoniazid tab 100 mg $0 (1) 90 isoniazid tab 300 mg $0 (1) 90 PRIFTIN rifapentine tab 150 mg $0 (2) pyrazinamide tab 500 mg $0 (1) rifabutin cap 150 mg (Mycobutin) $0 (1) rifampin cap 150 mg (Rifadin) $0 (1) rifampin cap 300 mg $0 (1) 3

10 INFECCIONES FÚNGICAS fluconazole for susp 10 mg/ml (Diflucan) $0 (1) fluconazole for susp 40 mg/ml (Diflucan) $0 (1) fluconazole tab 50 mg (Diflucan) $0 (1) fluconazole tab 100 mg (Diflucan) $0 (1) fluconazole tab 150 mg (Diflucan) $0 (1) fluconazole tab 200 mg (Diflucan) $0 (1) flucytosine cap 250 mg (Ancobon) $0 (1) flucytosine cap 500 mg (Ancobon) $0 (1) griseofulvin microsize susp 125 mg/5ml $0 (1) griseofulvin microsize tab 500 mg $0 (1) griseofulvin ultramicrosize tab 125 mg (Gris-peg) $0 (1) griseofulvin ultramicrosize tab 250 mg (Gris-peg) $0 (1) itraconazole cap 100 mg (Sporanox) $0 (1) QL (120 capsules/30 days) ketoconazole tab 200 mg $0 (1) NOXAFIL posaconazole tab delayed release 100 mg $0 (2) PA, 90 NOXAFIL posaconazole susp 40 mg/ml $0 (2) PA, 90 nystatin tab unit $0 (1) terbinafine hcl tab 250 mg (Lamisil) $0 (1) voriconazole for susp 40 mg/ml (Vfend) $0 (1) PA voriconazole tab 50 mg (Vfend) $0 (1) PA voriconazole tab 200 mg (Vfend) $0 (1) PA INFECCIONES VIRALES Citomegalovirus valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) $0 (1) 90 Hepatitis BARACLUDE entecavir oral soln 0.05 mg/ml $0 (2) 90 entecavir tab 0.5 mg (Baraclude) $0 (1) 90 entecavir tab 1 mg (Baraclude) $0 (1) 90 EPCLUSA sofosbuvir-velpatasvir tab mg $0 (2) PA, SP lamivudine tab 100 mg (hbv) (Epivir hbv) $0 (1) 90 MAVYRET glecaprevir-pibrentasvir tab mg $0 (1) PA, SP ribavirin cap 200 mg (Rebetol) $0 (1) SP SOVALDI sofosbuvir tab 400 mg $0 (2) PA, SP 4

11 ZEPATIER elbasvir-grazoprevir tab mg $0 (2) PA, SP Herpes acyclovir cap 200 mg (Zovirax) $0 (1) acyclovir susp 200 mg/5ml (Zovirax) $0 (1) acyclovir tab 400 mg (Zovirax) $0 (1) acyclovir tab 800 mg (Zovirax) $0 (1) valacyclovir hcl tab 500 mg (Valtrex) $0 (1) valacyclovir hcl tab 1 gm (Valtrex) $0 (1) VIH/SIDA abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen) $0 (1) QL (960 mls/30 abacavir sulfate tab 300 mg (base equiv) (Ziagen) $0 (1) QL (60 tablets/30 days) abacavir sulfate-lamivudine tab mg (Epzicom) $0 (1) QL (30 tablets/30 days) abacavir sulfate-lamivudine-zidovudine tab mg $0 (1) QL (60 tablets/30 days) (Trizivir) APTIVUS tipranavir cap 250 mg $0 (2) QL (120 capsules/30 days) APTIVUS tipranavir oral soln 100 mg/ml $0 (2) QL (4 bottles/30 days) ATRIPLA efavirenz-emtricitabine-tenofovir df tab $0 (2) QL (30 tablets/30 days) mg CRIXIVAN indinavir sulfate cap 200 mg $0 (2) QL (270 capsules/30 days) CRIXIVAN indinavir sulfate cap 400 mg $0 (2) QL (180 capsules/30 days) DESCOVY emtricitabine-tenofovir alafenamide fumarate tab $0 (2) QL (30 tablets/30 days) mg didanosine delayed release capsule 125 mg (Videx ec) $0 (1) QL (30 capsules/30 days) didanosine delayed release capsule 200 mg (Videx ec) $0 (1) QL (30 capsules/30 days) didanosine delayed release capsule 250 mg (Videx ec) $0 (1) QL (30 capsules/30 days) didanosine delayed release capsule 400 mg (Videx ec) $0 (1) QL (30 capsules/30 days) EDURANT rilpivirine hcl tab 25 mg (base equivalent) $0 (2) QL (30 tablets/30 days) EMTRIVA emtricitabine caps 200 mg $0 (2) QL (30 capsules/30 days) EMTRIVA emtricitabine soln 10 mg/ml $0 (2) QL (720 mls/30 days) fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) $0 (1) QL (120 tablets/30 GENVOYA elvitegrav-cobic-emtricitab-tenofov af tab $0 (2) QL (30 tablets/30 days) mg INTELENCE etravirine tab 25 mg $0 (2) QL (120 tablets/30 days) 5

12 INTELENCE etravirine tab 100 mg $0 (2) QL (60 tablets/30 days) INTELENCE etravirine tab 200 mg $0 (2) QL (60 tablets/30 days) INVIRASE saquinavir mesylate cap 200 mg $0 (2) QL (300 capsules/30 days) INVIRASE saquinavir mesylate tab 500 mg $0 (2) QL (120 tablets/30 days) ISENTRESS raltegravir potassium packet for susp 100 mg $0 (2) QL (60 packets/30 days) (base equiv) ISENTRESS raltegravir potassium tab 400 mg (base equiv) $0 (2) QL (60 tablets/30 days) ISENTRESS raltegravir potassium chew tab 25 mg (base $0 (2) QL (180 tablets/30 days) equiv) ISENTRESS raltegravir potassium chew tab 100 mg (base $0 (2) QL (180 tablets/30 days) equiv) ISENTRESS HD raltegravir potassium tab 600 mg (base equiv) $0 (2) QL (60 tablets/30 days) KALETRA lopinavir-ritonavir tab mg $0 (2) QL (180 tablets/30 days) KALETRA lopinavir-ritonavir tab mg $0 (2) QL (120 tablets/30 days) lamivudine oral soln 10 mg/ml (Epivir) $0 (1) QL (4 bottles/30 days) lamivudine tab 150 mg (Epivir) $0 (1) QL (30 tablets/30 days) lamivudine tab 300 mg (Epivir) $0 (1) QL (30 tablets/30 days) lamivudine-zidovudine tab mg (Combivir) $0 (1) QL (60 tablets/30 days) LEXIVA fosamprenavir calcium susp 50 mg/ml (base equiv) $0 (2) QL (8 bottles/30 days) lopinavir-ritonavir soln mg/5ml (80-20 mg/ml) (Kaletra) $0 (1) QL (480 mls/30 days) nevirapine tab er 24hr 100 mg (Viramune xr) $0 (1) QL (90 tablets/30 days) nevirapine tab er 24hr 400 mg (Viramune xr) $0 (1) QL (30 tablets/30 days) nevirapine tab 200 mg (Viramune) $0 (1) QL (60 tablets/30 days) NORVIR ritonavir cap 100 mg $0 (2) QL (360 capsules/30 days) NORVIR ritonavir tab 100 mg $0 (2) QL (360 tablets/30 days) NORVIR ritonavir oral soln 80 mg/ml $0 (2) QL (2 bottles/30 days) PREZISTA darunavir ethanolate susp 100 mg/ml (base equiv) $0 (2) QL (2 bottles/30 days) PREZISTA darunavir ethanolate tab 75 mg (base equiv) $0 (2) QL (300 tablets/30 days) PREZISTA darunavir ethanolate tab 150 mg (base equiv) $0 (2) QL (180 tablets/30 days) PREZISTA darunavir ethanolate tab 600 mg (base equiv) $0 (2) QL (60 tablets/30 days) PREZISTA darunavir ethanolate tab 800 mg (base equiv) $0 (2) QL (30 tablets/30 days) RESCRIPTOR delavirdine mesylate tab 100 mg $0 (2) QL (90 tablets/30 days) RESCRIPTOR delavirdine mesylate tab 200 mg $0 (2) QL (180 tablets/30 days) REYATAZ atazanavir sulfate oral powder packet 50 mg (base equiv) 6 $0 (2) QL (240 packets/30 days)

13 REYATAZ atazanavir sulfate cap 150 mg (base equiv) $0 (2) QL (30 capsules/30 days) REYATAZ atazanavir sulfate cap 200 mg (base equiv) $0 (2) QL (60 capsules/30 days) REYATAZ atazanavir sulfate cap 300 mg (base equiv) $0 (2) QL (30 capsules/30 days) SELZENTRY maraviroc tab 25 mg $0 (2) QL (240 tablets/30 days) SELZENTRY maraviroc tab 75 mg $0 (2) QL (60 tablets/30 days) SELZENTRY maraviroc tab 300 mg $0 (2) QL (120 tablets/30 days) stavudine cap 15 mg (Zerit) $0 (1) QL (60 capsules/30 days) stavudine cap 20 mg (Zerit) $0 (1) QL (60 capsules/30 days) stavudine cap 30 mg (Zerit) $0 (1) QL (60 capsules/30 days) stavudine cap 40 mg (Zerit) $0 (1) QL (60 capsules/30 days) SUSTIVA efavirenz tab 600 mg $0 (2) QL (30 tablets/30 days) SUSTIVA efavirenz cap 50 mg $0 (2) QL (90 tablets/30 days) SUSTIVA efavirenz cap 200 mg $0 (2) QL (60 tablets/30 days) TIVICAY dolutegravir sodium tab 10 mg (base equiv) $0 (2) QL (60 tablets/30 days) TIVICAY dolutegravir sodium tab 25 mg (base equiv) $0 (2) QL (60 tablets/30 days) TIVICAY dolutegravir sodium tab 50 mg (base equiv) $0 (2) QL (60 tablets/30 days) TRUVADA emtricitabine-tenofovir disoproxil fumarate tab $0 (2) QL (30 tablets/30 days) mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab $0 (2) QL (30 tablets/30 days) mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab $0 (2) QL (30 tablets/30 days) mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab $0 (2) QL (30 tablets/30 days) mg VIDEX didanosine for soln 2 gm $0 (2) QL (1200 mls/30 days) VIDEX didanosine for soln 4 gm $0 (2) QL (1200 mls/30 days) VIRACEPT nelfinavir mesylate tab 250 mg $0 (2) QL (270 tablets/30 days) VIRACEPT nelfinavir mesylate tab 625 mg $0 (2) QL (120 tablets/30 days) VIRAMUNE nevirapine susp 50 mg/5ml $0 (2) QL (5 bottles/30 days) VIREAD tenofovir disoproxil fumarate oral powder 40 mg/gm $0 (2) QL (4 bottles/30 days) VIREAD tenofovir disoproxil fumarate tab 150 mg $0 (2) QL (30 tablets/30 days) VIREAD tenofovir disoproxil fumarate tab 200 mg $0 (2) QL (30 tablets/30 days) VIREAD tenofovir disoproxil fumarate tab 250 mg $0 (2) QL (30 tablets/30 days) VIREAD tenofovir disoproxil fumarate tab 300 mg $0 (2) QL (30 tablets/30 days) zidovudine cap 100 mg (Retrovir) $0 (1) QL (180 capsules/30 days) zidovudine syrup 10 mg/ml (Retrovir) $0 (1) QL (8 bottles/30 days) 7

14 zidovudine tab 300 mg $0 (1) QL (60 tablets/30 days) Influenza oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) $0 (1) QL (40 capsules/120 days) oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) $0 (1) QL (20 capsules/120 days) oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) $0 (1) QL (20 capsules/120 days) RELENZA DISKHALER zanamivir aero powder breath $0 (2) QL (20 disks/120 days) activated 5 mg/blister TAMIFLU oseltamivir phosphate for susp 6 mg/ml (base equiv) $0 (2) QL (360 mls/120 days) MALARIA atovaquone-proguanil hcl tab mg (Malarone) $0 (1) atovaquone-proguanil hcl tab mg (Malarone) $0 (1) CHLOROQUINE PHOSPHATE chloroquine phosphate tab $0 (2) mg chloroquine phosphate tab 500 mg $0 (1) 90 DARAPRIM pyrimethamine tab 25 mg $0 (2) hydroxychloroquine sulfate tab 200 mg (Plaquenil) $0 (1) 90 mefloquine hcl tab 250 mg $0 (1) 90 PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg (15 mg base) 8 $0 (2) INFECCIONES DE PARÁSITOS ALBENZA albendazole tab 200 mg $0 (2) BILTRICIDE praziquantel tab 600 mg $0 (2) ivermectin tab 3 mg (Stromectol) $0 (1) OTROS ANTIINFECCIOSOS atovaquone susp 750 mg/5ml (Mepron) $0 (1) clindamycin hcl cap 75 mg (Cleocin) $0 (1) clindamycin hcl cap 150 mg (Cleocin) $0 (1) clindamycin hcl cap 300 mg (Cleocin) $0 (1) clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) $0 (1) (Cleocin pediatric gr) dapsone tab 25 mg $0 (1) 90 dapsone tab 100 mg $0 (1) 90 linezolid for susp 100 mg/5ml (Zyvox) $0 (1) QL (600 mls/180 days) linezolid tab 600 mg (Zyvox) $0 (1) QL (56 tablets/180 days)

15 metronidazole cap 375 mg (Flagyl) $0 (1) metronidazole tab 250 mg (Flagyl) $0 (1) metronidazole tab 500 mg (Flagyl) $0 (1) sulfamethoxazole-trimethoprim susp mg/5ml $0 (1) sulfamethoxazole-trimethoprim tab mg (Bactrim) $0 (1) sulfamethoxazole-trimethoprim tab mg (Bactrim ds) $0 (1) trimethoprim tab 100 mg $0 (1) vancomycin hcl cap 125 mg (Vancocin hcl) $0 (1) vancomycin hcl cap 250 mg (Vancocin hcl) $0 (1) XIFAXAN rifaximin tab 200 mg $0 (2) PA, QL (9 tablets/30 days) XIFAXAN rifaximin tab 550 mg $0 (2) PA, QL (60 tablets/30 ZYVOX linezolid for susp 100 mg/5ml $0 (2) QL (4 bottles/180 days) AGENTES DE INMUNIZACIÓN AFLURIA PF influenza virus vaccine split pf susp $0 (2) pref syringe 0.5 ml AFLURIA QUADRIVALENT 2017 influenza virus vac split $0 (2) quadrivalent susp pref syr 0.5ml AFLURIA QUADRIVALENT 2017 influenza virus vaccine split $0 (2) quadrivalent im inj AFLURIA influenza virus vaccine split im susp $0 (2) FLUARIX QUADRIVALENT 2017 influenza virus vac split quadrivalent susp pref syr 0.5ml FLUCELVAX QUADRIVALENT 20 influenza vac tiss-cult subunt quad susp pref syr 0.5 ml FLUCELVAX QUADRIVALENT 20 influenza vac tissue-cultured subunit quadrivalent im susp FLULAVAL QUADRIVALENT 201 influenza virus vac split quadrivalent susp pref syr 0.5ml FLULAVAL QUADRIVALENT 201 influenza virus vaccine split quadrivalent im inj FLUVIRIN influenza vac type a&b surface antigen susp pref syr 0.5 ml FLUVIRIN influenza virus vaccine types a & b surface antigen im susp FLUZONE HIGH-DOSE PF 2017 influenza virus vac split highdose pf susp pref syr 0.5ml FLUZONE QUADRIVALENT 2017 influenza virus vac split quadrivalent susp pref syr 0.5ml $0 (2) $0 (2) $0 (1) $0 (2) $0 (2) $0 (2) $0 (2) $0 (2) AL $0 (2) 9

16 FLUZONE QUADRIVALENT 2017 influenza virus vaccine split $0 (2) quadrivalent im inj SYNAGIS palivizumab im soln 50 mg/0.5ml $0 (1) PA, SP SYNAGIS palivizumab im soln 100 mg/ml $0 (1) PA, SP MEDICAMENTOS PARA EL CÁNCER ACTIMMUNE interferon gamma-1b inj 100 mcg/0.5ml ( unit/0.5ml) $0 (2) PA, QL (12 vials/28 AFINITOR everolimus tab 2.5 mg $0 (2) PA, QL (30 tablets/30 AFINITOR everolimus tab 5 mg $0 (2) PA, QL (30 tablets/30 AFINITOR everolimus tab 7.5 mg $0 (2) PA, QL (30 tablets/30 AFINITOR everolimus tab 10 mg $0 (2) PA, QL (30 tablets/30 AFINITOR DISPERZ everolimus tab for oral susp 2 mg $0 (2) PA, QL (60 tablets/30 AFINITOR DISPERZ everolimus tab for oral susp 3 mg $0 (2) PA, QL (90 tablets/30 AFINITOR DISPERZ everolimus tab for oral susp 5 mg $0 (2) PA, QL (60 tablets/30 ALKERAN melphalan tab 2 mg $0 (2) SP anastrozole tab 1 mg (Arimidex) $0 (1) 90 bexarotene cap 75 mg (Targretin) $0 (1) PA, SP bicalutamide tab 50 mg (Casodex) $0 (1) SP capecitabine tab 150 mg (Xeloda) $0 (1) PA, SP capecitabine tab 500 mg (Xeloda) $0 (1) PA, SP COTELLIC cobimetinib fumarate tab 20 mg (base equivalent) $0 (2) PA, QL (63 tablets/28 CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg $0 (2) SP CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg $0 (2) SP CYTARABINE cytarabine inj 20 mg/ml $0 (2) exemestane tab 25 mg (Aromasin) $0 (1) 90 flutamide cap 125 mg $0 (1) SP hydroxyurea cap 500 mg (Hydrea) $0 (1) SP IBRANCE palbociclib cap 75 mg $0 (2) PA, QL (21 capsules/28 10

17 IBRANCE palbociclib cap 100 mg $0 (2) PA, QL (21 capsules/28 IBRANCE palbociclib cap 125 mg $0 (2) PA, QL (21 capsules/28 imatinib mesylate tab 100 mg (base equivalent) (Gleevec) $0 (1) PA, QL (90 tablets/30), SP imatinib mesylate tab 400 mg (base equivalent) (Gleevec) $0 (1) PA, QL (60 tablets/30 KISQALI ribociclib succinate tab 200 mg (base equiv) $0 (2) PA, QL (63 tablets/28 KISQALI FEMARA 200 DOSE ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack KISQALI FEMARA 400 DOSE ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack KISQALI FEMARA 600 DOSE ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack LENVIMA 10 MG DAILY DOSE lenvatinib cap therapy pack 10 mg (10 mg daily dose) LENVIMA 14 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose) LENVIMA 18 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose) LENVIMA 20 MG DAILY DOSE lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose) LENVIMA 24 MG DAILY DOSE lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose) LENVIMA 8 MG DAILY DOSE lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose) $0 (1) PA, QL (91 tablets/28 $0 (1) PA, QL (91 tablets/28 $0 (1) PA, QL (91 tablets/28 $0 (2) PA, QL (30 capsules/30 $0 (2) PA, QL (60 capsules/30 $0 (2) PA, QL (90 capsules/30 $0 (2) PA, QL (60 capsules/30 $0 (2) PA, QL (90 capsules/30 $0 (2) PA, QL (60 capsules/30 letrozole tab 2.5 mg (Femara) $0 (1) 90 LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg $0 (2) LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg $0 (2) leucovorin calcium tab 5 mg $0 (1) leucovorin calcium tab 25 mg $0 (1) LEUKERAN chlorambucil tab 2 mg $0 (2) SP LYNPARZA olaparib cap 50 mg $0 (2) PA, QL (480 capsules/30 megestrol acetate susp 40 mg/ml $0 (1) megestrol acetate tab 20 mg $0 (1) 11

18 megestrol acetate tab 40 mg $0 (1) MEKINIST trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent) MEKINIST trametinib dimethyl sulfoxide tab 2 mg (base equivalent) melphalan tab 2 mg (Alkeran) $0 (1) $0 (2) PA, QL (90 tablets/30 $0 (2) PA, QL (30 tablets/30 mercaptopurine tab 50 mg $0 (1) SP METHOTREXATE SODIUM methotrexate sodium inj $0 (2) 250 mg/10ml (25 mg/ml) methotrexate sodium tab 2.5 mg (base equiv) $0 (1) MYLERAN busulfan tab 2 mg $0 (2) SP NEXAVAR sorafenib tosylate tab 200 mg (base equivalent) $0 (2) PA, QL (120 tablets/30 RUBRACA rucaparib camsylate tab 200 mg (base equivalent) $0 (2) PA, QL (120 tablets/30 RUBRACA rucaparib camsylate tab 250 mg (base equivalent) $0 (2) PA, QL (120 tablets/30 RUBRACA rucaparib camsylate tab 300 mg (base equivalent) $0 (2) PA, QL (120 tablets/30 RYDAPT midostaurin cap 25 mg $0 (1) PA, QL (240 capsules/30 days) SPRYCEL dasatinib tab 20 mg $0 (2) PA, QL (60 tablets/30 SPRYCEL dasatinib tab 50 mg $0 (2) PA, QL (30 tablets/30 SPRYCEL dasatinib tab 70 mg $0 (2) PA, QL (30 tablets/30 SPRYCEL dasatinib tab 80 mg $0 (2) PA, QL (30 tablets/30 SPRYCEL dasatinib tab 100 mg $0 (2) PA, QL (30 tablets/30 SPRYCEL dasatinib tab 140 mg $0 (2) PA, QL (30 tablets/30 STIVARGA regorafenib tab 40 mg $0 (2) PA, QL (84 tablets/28 SUTENT sunitinib malate cap 12.5 mg (base equivalent) $0 (2) PA, QL (90 capsules/30 12

19 SUTENT sunitinib malate cap 25 mg (base equivalent) $0 (2) PA, QL (30 capsules/30 SUTENT sunitinib malate cap 37.5 mg (base equivalent) $0 (2) PA, QL (30 capsules/30 SUTENT sunitinib malate cap 50 mg (base equivalent) $0 (2) PA, QL (30 capsules/30 tamoxifen citrate tab 10 mg (base equivalent) $0 (1) 90 tamoxifen citrate tab 20 mg (base equivalent) $0 (1) 90 TARCEVA erlotinib hcl tab 25 mg (base equivalent) $0 (2) PA, QL (60 tablets/30 TARCEVA erlotinib hcl tab 100 mg (base equivalent) $0 (2) PA, QL (30 tablets/30 TARCEVA erlotinib hcl tab 150 mg (base equivalent) $0 (2) PA, QL (30 tablets/30 TASIGNA nilotinib hcl cap 150 mg (base equivalent) $0 (2) PA, QL (120 capsules/30 TASIGNA nilotinib hcl cap 200 mg (base equivalent) $0 (2) PA, QL (120 capsules/30 temozolomide cap 5 mg (Temodar) $0 (1) PA, SP temozolomide cap 20 mg (Temodar) $0 (1) PA, SP temozolomide cap 100 mg (Temodar) $0 (1) PA, SP temozolomide cap 140 mg (Temodar) $0 (1) PA, SP temozolomide cap 180 mg (Temodar) $0 (1) PA, SP temozolomide cap 250 mg (Temodar) $0 (1) PA, SP tretinoin cap 10 mg $0 (1) PA, SP VOTRIENT pazopanib hcl tab 200 mg (base equiv) $0 (2) PA, QL (120 tablets/30 XALKORI crizotinib cap 200 mg $0 (2) PA, QL (60 capsules/30 XALKORI crizotinib cap 250 mg $0 (2) PA, QL (60 capsules/30 XTANDI enzalutamide cap 40 mg $0 (2) PA, QL (120 capsules/30 ZELBORAF vemurafenib tab 240 mg $0 (2) PA, QL (240 tablets/30 ZYTIGA abiraterone acetate tab 250 mg $0 (2) PA, QL (120 tablets/30 13

20 ZYTIGA abiraterone acetate tab 500 mg $0 (2) PA, QL (60 tablets/30 HORMONAS, DIABETES Y MEDICAMENTOS RELACIONADOS CORTICOSTEROIDES budesonide delayed release particles cap 3 mg (Entocort ec) $0 (1) CORTISONE ACETATE cortisone acetate tab 25 mg $0 (2) DEXAMETHASONE dexamethasone soln 0.5 mg/5ml $0 (2) dexamethasone elixir 0.5 mg/5ml $0 (1) dexamethasone tab 0.5 mg $0 (1) dexamethasone tab 0.75 mg $0 (1) dexamethasone tab 1.5 mg $0 (1) dexamethasone tab 4 mg $0 (1) dexamethasone tab 6 mg $0 (1) fludrocortisone acetate tab 0.1 mg $0 (1) 90 hydrocortisone tab 5 mg (Cortef) $0 (1) hydrocortisone tab 10 mg (Cortef) $0 (1) hydrocortisone tab 20 mg (Cortef) $0 (1) methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) $0 (1) methylprednisolone tab 4 mg (Medrol) $0 (1) methylprednisolone tab 8 mg (Medrol) $0 (1) methylprednisolone tab 16 mg (Medrol) $0 (1) methylprednisolone tab 32 mg (Medrol) $0 (1) prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) $0 (1) (Pediapred) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) $0 (1) prednisolone syrup 15 mg/5ml (usp solution equivalent) $0 (1) PREDNISONE prednisone tab 50 mg $0 (2) PREDNISONE prednisone oral soln 5 mg/5ml $0 (2) prednisone tab 1 mg $0 (1) prednisone tab 2.5 mg $0 (1) prednisone tab 5 mg $0 (1) prednisone tab 10 mg $0 (1) prednisone tab 20 mg $0 (1) HORMONAS MASCULINAS danazol cap 50 mg $0 (1) 14

21 danazol cap 100 mg $0 (1) danazol cap 200 mg $0 (1) testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone) $0 (1) QL (10 mls/28 days) testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone) $0 (1) QL (10 mls/28 days) testosterone enanthate im inj in oil 200 mg/ml $0 (1) QL (1 vial/28 days) ESTRÓGENOS COMBIPATCH estradiol-norethindrone ace td pttw $0 (2) mg/day COMBIPATCH estradiol-norethindrone ace td pttw $0 (2) mg/day estradiol & norethindrone acetate tab mg (Activella) $0 (1) 90 estradiol & norethindrone acetate tab mg (Activella) $0 (1) 90 estradiol tab 0.5 mg (Estrace) $0 (1) 90 estradiol tab 1 mg (Estrace) $0 (1) 90 estradiol tab 2 mg (Estrace) $0 (1) 90 estradiol td patch twice weekly mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 estradiol td patch twice weekly mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 estradiol td patch twice weekly mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 estradiol td patch weekly mg/24hr (Climara) $0 (1) QL (4 patches/30 estradiol td patch weekly mg/24hr (37.5 mcg/24hr) (Climara) $0 (1) QL (4 patches/30 estradiol td patch weekly 0.05 mg/24hr (Climara) $0 (1) QL (4 patches/30 estradiol td patch weekly 0.06 mg/24hr (Climara) $0 (1) QL (4 patches/30 estradiol td patch weekly mg/24hr (Climara) $0 (1) QL (4 patches/30 estradiol td patch weekly 0.1 mg/24hr (Climara) $0 (1) QL (4 patches/30 15

22 ESTROPIPATE estropipate tab 0.75 mg $0 (2) 90 ESTROPIPATE estropipate tab 1.5 mg $0 (2) 90 ESTROPIPATE estropipate tab 3 mg $0 (2) 90 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg $0 (1) 90 PREMPRO conjugated estrogen-medroxyprogest acetate tab mg PREMPRO conjugated estrogen-medroxyprogest acetate tab mg PREMPRO conjugated estrogen-medroxyprogest acetate tab mg PROGESTINAS medroxyprogesterone acetate tab 2.5 mg (Provera) $0 (1) medroxyprogesterone acetate tab 5 mg (Provera) $0 (1) medroxyprogesterone acetate tab 10 mg (Provera) $0 (1) megestrol acetate susp 625 mg/5ml (Megace es) $0 (1) $0 (2) 90 $0 (2) 90 $0 (2) 90 norethindrone acetate tab 5 mg (Aygestin) $0 (1) 90 progesterone im in oil 50 mg/ml $0 (1) progesterone micronized cap 100 mg (Prometrium) $0 (1) 90 progesterone micronized cap 200 mg (Prometrium) $0 (1) 90 MÉTODOS ANTICONCEPTIVOS CONDOMS - various $0 (3) desogest-eth estrad & eth estrad tab /0.01 mg(21/5) (Mircette) $0 (1) QL (28 tablets/21 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) $0 (1) QL (28 tablets/21 DIAPHRAGMS - various $0 (2) drospirenone-ethinyl estradiol tab mg (Yasmin 28) $0 (1) QL (28 tablets/21 ELLA ulipristal acetate tab 30 mg $0 (2) QL (3 tablets/365 days) ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg $0 (1) QL (28 tablets/21 KYLEENA levonorgestrel releasing iud 17.5 mcg/day (19.5 mg $0 (2) total) levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg $0 (1) QL (28 tablets/21 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg $0 (1) QL (28 tablets/21 16

23 levonorgestrel tab 1.5 mg $0 (3) QL (3 tablets/365 days) levonorgestrel-eth estra tab / / mg-mcg $0 (1) QL (28 tablets/21 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera $0 (1) contrac) MIRENA levonorgestrel releasing iud 20 mcg/day (52 mg total) $0 (2) NECON 10/11-28 norethindrone-eth estradiol tab /1-35 mg-mcg (10/11) NEXPLANON etonogestrel subdermal implant 68 mg $0 (2) norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21) norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Orthocyclen) norgestimate-eth estrad tab / / mg-mcg (Ortho tri-cyclen lo) norgestimate-eth estrad tab / / mg-mcg (Ortho tri-cyclen) $0 (2) QL (28 tablets/21 $0 (1) QL (28 tablets/21 $0 (1) QL (28 tablets/21 $0 (1) QL (28 tablets/21 $0 (1) QL (28 tablets/21 $0 (1) QL (28 tablets/21 $0 (1) QL (28 tablets/21 NUVARING etonogestrel-ethinyl estradiol va ring $0 (2) QL (1 ring/ mg/24hr PARAGARD INTRAUTERINE COP copper iud $0 (2) PLAN B ONE-STEP levonorgestrel tab 1.5 mg $0 (3) QL (3 tablets/365 days) SKYLA levonorgestrel releasing iud 14 mcg/day (13.5 mg total) $0 (2) XULANE norelgestromin-ethinyl estradiol td ptwk mcg/24hr $0 (2) QL (4 patches/21 DIABETES acarbose tab 25 mg (Precose) $0 (1) QL (180 tablets/30 acarbose tab 50 mg (Precose) $0 (1) QL (180 tablets/30 acarbose tab 100 mg (Precose) $0 (1) QL (90 tablets/30 ALOGLIPTIN alogliptin benzoate tab 6.25 mg (base equiv) $0 (2) QL (30 tablets/30 days), ST, 90 17

24 ALOGLIPTIN alogliptin benzoate tab 12.5 mg (base equiv) $0 (2) QL (30 tablets/30 days), ST, 90 ALOGLIPTIN alogliptin benzoate tab 25 mg (base equiv) $0 (2) QL (30 tablets/30 days), ST, 90 ALOGLIPTIN/METFORMIN HCL alogliptin-metformin hcl tab mg ALOGLIPTIN/METFORMIN HCL alogliptin-metformin hcl tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg $0 (2) QL (60 tablets/30 days), ST, 90 $0 (2) QL (60 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 glimepiride tab 1 mg (Amaryl) $0 (1) QL (60 tablets/30 glimepiride tab 2 mg (Amaryl) $0 (1) QL (60 tablets/30 glimepiride tab 4 mg (Amaryl) $0 (1) QL (60 tablets/30 glipizide tab er 24hr 2.5 mg (Glucotrol xl) $0 (1) QL (60 tablets/30 glipizide tab er 24hr 5 mg (Glucotrol xl) $0 (1) QL (90 tablets/30 glipizide tab er 24hr 10 mg (Glucotrol xl) $0 (1) QL (60 tablets/30 glipizide tab 5 mg (Glucotrol) $0 (1) QL (120 tablets/30 glipizide tab 10 mg (Glucotrol) $0 (1) QL (120 tablets/30 GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg $0 (2) QL (6 pens/365 days) glyburide micronized tab 1.5 mg (Glynase) $0 (1) QL (120 tablets/30 18

25 glyburide micronized tab 3 mg (Glynase) $0 (1) QL (60 tablets/30 glyburide micronized tab 6 mg (Glynase) $0 (1) QL (60 tablets/30 glyburide tab 1.25 mg $0 (1) QL (60 tablets/30 glyburide tab 2.5 mg $0 (1) QL (60 tablets/30 glyburide tab 5 mg $0 (1) QL (120 tablets/30 glyburide-metformin tab mg $0 (1) QL (120 tablets/30 glyburide-metformin tab mg (Glucovance) $0 (1) QL (120 tablets/30 glyburide-metformin tab mg (Glucovance) $0 (1) QL (120 tablets/30 metformin hcl tab er 24hr 500 mg (Glucophage xr) $0 (1) QL (120 tablets/30 metformin hcl tab er 24hr 750 mg (Glucophage xr) $0 (1) QL (60 tablets/30 metformin hcl tab 500 mg (Glucophage) $0 (1) QL (120 tablets/30 metformin hcl tab 850 mg (Glucophage) $0 (1) QL (90 tablets/30 metformin hcl tab 1000 mg (Glucophage) $0 (1) QL (60 tablets/30 nateglinide tab 60 mg (Starlix) $0 (1) QL (120 tablets/30 nateglinide tab 120 mg (Starlix) $0 (1) QL (90 tablets/30 pioglitazone hcl tab 15 mg (base equiv) (Actos) $0 (1) QL (30 tablets/30 pioglitazone hcl tab 30 mg (base equiv) (Actos) $0 (1) QL (30 tablets/30 pioglitazone hcl tab 45 mg (base equiv) (Actos) $0 (1) QL (30 tablets/30 TOLAZAMIDE tolazamide tab 250 mg $0 (2) QL (90 tablets/30 19

26 VICTOZA liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) $0 (2) QL (3 pens/30 days), ST, 90 DIABETES - INSULINAS Insulinas de acción rápida HUMALOG insulin lispro soln cartridge 100 unit/ml $0 (2) QL (45 mls/30 HUMALOG insulin lispro inj 100 unit/ml $0 (2) QL (45 mls/30 HUMALOG JUNIOR KWIKPEN insulin lispro soln pen-injector $0 (2) QL (45 mls/ unit/ml HUMALOG KWIKPEN insulin lispro soln pen-injector 100 unit/ $0 (2) QL (45 mls/30 ml HUMALOG KWIKPEN insulin lispro soln pen-injector 200 unit/ $0 (2) QL (24 mls/30 ml NOVOLOG insulin aspart inj 100 unit/ml $0 (2) QL (45 mls/30 NOVOLOG FLEXPEN insulin aspart soln pen-injector 100 unit/ $0 (2) QL (45 mls/30 ml NOVOLOG PENFILL insulin aspart soln cartridge 100 unit/ml $0 (2) QL (45 mls/30 Insulinas de acción corta HUMULIN R insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 NOVOLIN R insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 NOVOLIN R RELION insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 Insulinas de acción intermedia HUMALOG MIX 50/50 insulin lispro protamine & lispro inj 100 $0 (2) QL (45 mls/30 unit/ml (50-50) HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus $0 (2) QL (45 mls/30 pen-inj 100 unit/ml (50-50) HUMALOG MIX 75/25 insulin lispro prot & lispro inj 100 unit/ml $0 (2) QL (45 mls/30 (75-25) HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus $0 (2) QL (45 mls/30 pen-inj 100 unit/ml (75-25) HUMULIN N insulin nph (human) (isophane) inj 100 unit/ml $0 (3) QL (45 mls/30 HUMULIN N KWIKPEN insulin nph (human) (isophane) susp $0 (3) QL (45 mls/30 pen-injector 100 unit/ml HUMULIN 70/30 insulin nph isophane & regular human inj 100 $0 (3) QL (45 mls/30 unit/ml (70-30) HUMULIN 70/30 KWIKPEN insulin nph & regular susp pen-inj $0 (3) QL (45 mls/ unit/ml (70-30) NOVOLIN N insulin nph (human) (isophane) inj 100 unit/ml $0 (3) QL (45 mls/30 NOVOLIN N RELION insulin nph (human) (isophane) inj 100 unit/ml $0 (3) QL (45 mls/30 20

27 NOVOLIN 70/30 insulin nph isophane & regular human inj 100 unit/ml (70-30) NOVOLIN 70/30 RELION insulin nph isophane & regular human inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30) Insulinas basales BASAGLAR KWIKPEN insulin glargine soln pen-injector 100 unit/ml $0 (3) QL (45 mls/30 $0 (3) QL (45 mls/30 $0 (2) QL (45 mls/30 $0 (2) QL (45 mls/30 $0 (2) QL (45 mls/30 REGULACIÓN DE LA TIROIDES levothyroxine sodium tab 25 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 50 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 75 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 88 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 100 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 112 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 125 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 137 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 150 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 175 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 200 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 300 mcg (Synthroid) $0 (1) 90 liothyronine sodium tab 5 mcg (Cytomel) $0 (1) 90 liothyronine sodium tab 25 mcg (Cytomel) $0 (1) 90 liothyronine sodium tab 50 mcg (Cytomel) $0 (1) 90 methimazole tab 5 mg (Tapazole) $0 (1) 90 methimazole tab 10 mg (Tapazole) $0 (1) 90 propylthiouracil tab 50 mg $0 (1) 90 thyroid tab 30 mg (1/2 grain) (Armour thyroid) $0 (1) 90 thyroid tab 60 mg (1 grain) (Armour thyroid) $0 (1) 90 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) $0 (1) 90 HORMONA DEL CRECIMIENTO OMNITROPE somatropin for inj 5.8 mg $0 (2) PA, SP OTRAS HORMONAS Y MEDICAMENTOS RELACIONADOS 21

28 ALENDRONATE SODIUM alendronate sodium tab 40 mg $0 (2) QL (30 tablets/30 days) alendronate sodium tab 5 mg $0 (1) QL (30 tablets/30 alendronate sodium tab 10 mg $0 (1) QL (30 tablets/30 alendronate sodium tab 35 mg $0 (1) QL (4 tablets/28 alendronate sodium tab 70 mg (Fosamax) $0 (1) QL (4 tablets/28 cabergoline tab 0.5 mg $0 (1) calcitonin (salmon) nasal soln 200 unit/act $0 (1) 90 calcitriol cap 0.25 mcg (Rocaltrol) $0 (1) 90 calcitriol cap 0.5 mcg (Rocaltrol) $0 (1) 90 calcitriol oral soln 1 mcg/ml (Rocaltrol) $0 (1) 90 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) $0 (1) 90 desmopressin acetate nasal spray soln 0.01% (Ddavp) $0 (1) 90 desmopressin acetate nasal spray soln 0.01% (refrigerated) $0 (1) 90 desmopressin acetate tab 0.1 mg (Ddavp) $0 (1) 90 desmopressin acetate tab 0.2 mg (Ddavp) $0 (1) 90 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) $0 (1) 90 levocarnitine tab 330 mg (Carnitor) $0 (1) 90 METHERGINE methylergonovine maleate tab 0.2 mg $0 (2) octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) $0 (1) PA, QL (90 mls/30, 90 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin) $0 (1) PA, QL (90 mls/30, 90 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin) $0 (1) PA, QL (90 mls/30, 90 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) $0 (1) PA, QL (30 vials/30 octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) $0 (1) PA, QL (30 vials/30 raloxifene hcl tab 60 mg (Evista) $0 (1) 90 STIMATE desmopressin acetate nasal soln 1.5 mg/ml $0 (2) 90 TYMLOS abaloparatide subcutaneous soln pen-injector 3120 mcg/1.56ml MEDICAMENTOS PARA EL CORAZÓN Y LA CIRCULACIÓN 22 $0 (1) PA, QL (1 pen/30, 90 INHIBIDORES DE LA ENZIMA CONVERTIDORA DE ANGIOTENSINA (ACE, POR SU SIGLA EN INGLÉS) Y COMBINACIONES

29 benazepril & hydrochlorothiazide tab mg $0 (1) 90 benazepril & hydrochlorothiazide tab mg (Lotensin hct) $0 (1) 90 benazepril & hydrochlorothiazide tab mg (Lotensin hct) $0 (1) 90 benazepril & hydrochlorothiazide tab mg (Lotensin hct) $0 (1) 90 benazepril hcl tab 5 mg $0 (1) 90 benazepril hcl tab 10 mg $0 (1) 90 benazepril hcl tab 20 mg (Lotensin) $0 (1) 90 benazepril hcl tab 40 mg (Lotensin) $0 (1) 90 captopril tab 12.5 mg $0 (1) 90 captopril tab 25 mg $0 (1) 90 captopril tab 50 mg $0 (1) 90 captopril tab 100 mg $0 (1) 90 CAPTOPRIL/HYDROCHLOROTHIA captopril & $0 (2) 90 hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & $0 (2) 90 hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & $0 (2) 90 hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & $0 (2) 90 hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg $0 (1) 90 enalapril maleate & hydrochlorothiazide tab mg (Vaseretic) $0 (1) 90 enalapril maleate tab 2.5 mg (Vasotec) $0 (1) 90 enalapril maleate tab 5 mg (Vasotec) $0 (1) 90 enalapril maleate tab 10 mg (Vasotec) $0 (1) 90 enalapril maleate tab 20 mg (Vasotec) $0 (1) 90 fosinopril sodium & hydrochlorothiazide tab mg $0 (1) 90 fosinopril sodium & hydrochlorothiazide tab mg $0 (1) 90 fosinopril sodium tab 10 mg $0 (1) 90 fosinopril sodium tab 20 mg $0 (1) 90 fosinopril sodium tab 40 mg $0 (1) 90 lisinopril & hydrochlorothiazide tab mg (Zestoretic) $0 (1) 90 lisinopril & hydrochlorothiazide tab mg (Zestoretic) $0 (1) 90 lisinopril & hydrochlorothiazide tab mg (Zestoretic) $0 (1) 90 lisinopril tab 2.5 mg (Zestril) $0 (1) 90 lisinopril tab 5 mg (Prinivil) $0 (1) 90 23

30 lisinopril tab 10 mg (Prinivil) $0 (1) 90 lisinopril tab 20 mg (Prinivil) $0 (1) 90 lisinopril tab 30 mg (Zestril) $0 (1) 90 lisinopril tab 40 mg (Zestril) $0 (1) 90 moexipril hcl tab 7.5 mg $0 (1) 90 moexipril hcl tab 15 mg $0 (1) 90 moexipril-hydrochlorothiazide tab mg $0 (1) 90 moexipril-hydrochlorothiazide tab mg $0 (1) 90 moexipril-hydrochlorothiazide tab mg $0 (1) 90 perindopril erbumine tab 2 mg $0 (1) 90 perindopril erbumine tab 4 mg (Aceon) $0 (1) 90 perindopril erbumine tab 8 mg (Aceon) $0 (1) 90 quinapril hcl tab 5 mg (Accupril) $0 (1) 90 quinapril hcl tab 10 mg (Accupril) $0 (1) 90 quinapril hcl tab 20 mg (Accupril) $0 (1) 90 quinapril hcl tab 40 mg (Accupril) $0 (1) 90 quinapril-hydrochlorothiazide tab mg (Accuretic) $0 (1) 90 quinapril-hydrochlorothiazide tab mg (Accuretic) $0 (1) 90 quinapril-hydrochlorothiazide tab mg (Accuretic) $0 (1) 90 ramipril cap 1.25 mg (Altace) $0 (1) 90 ramipril cap 2.5 mg (Altace) $0 (1) 90 ramipril cap 5 mg (Altace) $0 (1) 90 ramipril cap 10 mg (Altace) $0 (1) 90 trandolapril tab 1 mg $0 (1) 90 trandolapril tab 2 mg (Mavik) $0 (1) 90 trandolapril tab 4 mg $0 (1) 90 ANTAGONISTAS DE LOS RECEPTORES DE ANGIOTENSINA II (ARBS, POR SU SIGLA EN INGLÉS) Y COMBINACIONES irbesartan tab 75 mg (Avapro) $0 (1) QL (30 tablets/30 irbesartan tab 150 mg (Avapro) $0 (1) QL (30 tablets/30 irbesartan tab 300 mg (Avapro) $0 (1) QL (30 tablets/30 irbesartan-hydrochlorothiazide tab mg (Avalide) $0 (1) QL (30 tablets/30 24

31 irbesartan-hydrochlorothiazide tab mg (Avalide) $0 (1) QL (30 tablets/30 losartan potassium & hydrochlorothiazide tab mg (Hyzaar) losartan potassium & hydrochlorothiazide tab mg (Hyzaar) losartan potassium & hydrochlorothiazide tab mg (Hyzaar) $0 (1) QL (30 tablets/30 $0 (1) QL (30 tablets/30 $0 (1) QL (30 tablets/30 losartan potassium tab 25 mg (Cozaar) $0 (1) QL (60 tablets/30 losartan potassium tab 50 mg (Cozaar) $0 (1) QL (60 tablets/30 losartan potassium tab 100 mg (Cozaar) $0 (1) QL (30 tablets/30 valsartan tab 40 mg (Diovan) $0 (1) QL (60 tablets/30 valsartan tab 80 mg (Diovan) $0 (1) QL (60 tablets/30 valsartan tab 160 mg (Diovan) $0 (1) QL (60 tablets/30 valsartan tab 320 mg (Diovan) $0 (1) QL (30 tablets/30 valsartan-hydrochlorothiazide tab mg (Diovan hct) $0 (1) QL (30 tablets/30 valsartan-hydrochlorothiazide tab mg (Diovan hct) $0 (1) QL (30 tablets/30 valsartan-hydrochlorothiazide tab mg (Diovan hct) $0 (1) QL (30 tablets/30 valsartan-hydrochlorothiazide tab mg (Diovan hct) $0 (1) QL (30 tablets/30 valsartan-hydrochlorothiazide tab mg (Diovan hct) $0 (1) QL (30 tablets/30 BETA BLOQUEADORES Y COMBINACINES acebutolol hcl cap 200 mg $0 (1) 90 acebutolol hcl cap 400 mg $0 (1) 90 atenolol & chlorthalidone tab mg (Tenoretic 50) $0 (1) 90 atenolol & chlorthalidone tab mg (Tenoretic 100) $0 (1) 90 atenolol tab 25 mg (Tenormin) $0 (1) 90 25