Formulario FIDA Lista de medicamentos cubiertos

Transcripción

1 2015 Plan FIDA de CenterLight Healthcare (plan de Medicare y Medicaid) Formulario FIDA Lista de medicamentos cubiertos Del 1 de enero al 31 de diciembre de 2015 Si tiene preguntas, comuníquese con el plan FIDA de CenterLight Healthcare al , los 7 días de la semana, de 8:00 a. m. a 8:00 p. m. Los usuarios de TTY deben llamar al 711. La llamada es gratuita. Para obtener más información, visite Este formulario se actualizó el 10/15. HPMS approved Formulary File Submission ID , version 21. H8420_2015 FIDA Formulary Approved _SPA

2 A continuación figura una lista de abreviaturas que pueden aparecer en las próximas páginas en la columna Requisitos/Límites y que le indican si hay algún requisito especial para cubrir su medicamento. Lista de abreviaturas *: medicamentos de la Parte D no cubiertos por Medicare o artículos de venta libre cubiertos por Medicaid DL: disponibilidad limitada. Esta receta puede estar disponible sólo en ciertas farmacias. Para obtener más información, llame al Servicio de atención al cliente. AP: autorización previa. El plan exige que usted o su médico obtengan autorización previa para ciertos medicamentos. Lo que significa que necesitará obtener la aprobación antes de completar sus recetas. Si no recibe la aprobación, es posible que no cubramos el medicamento. LC: límites de cantidad. Para algunos medicamentos, el plan limita la cantidad de medicamento que cubre. TE: tratamiento escalonado. En algunos casos, el plan exige que pruebe algunos medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si ambos medicamentos, A y B, sirven para tratar su afección médica, es posible que no cubramos el medicamento B a menos que usted pruebe el medicamento A primero. Si el medicamento A no le da resultado, entonces cubriremos el medicamento B. 1

3 NOMBRE D MEDICA NIV LO QUE LE ANTIBIÓTICOS AGENTES ANTIMICÓTICOS ABCET 2 $0 PA AMBISOME 2 $0 PA amphotericin b PA CANCIDAS 2 $0 PA clotrimazole mucous membrane CRESEMBA INTRAVENOUS 2 $0 ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG 2 $0 fluconazole fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml flucytosine griseofulvin microsize griseofulvin ultramicrosize LÍMITES SOBRE USO itraconazole QL (120 per 30 days) ketoconazole oral LAMISIL ORAL GRANULES IN PACKET 2 $0 MYCAMINE 2 $0 NOXAFIL ORAL SUSPENSION 2 $0 nystatin oral suspension nystatin oral tablet SPORANOX ORAL SOLUTION 2 $0 terbinafine hcl oral voriconazole intravenous voriconazole oral tablet ANTIVIRALES gratuita. Para obtener más información, visite 2

4 NOMBRE D MEDICA NIV LO QUE LE abacavir abacavir-lamivudine-zidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution PA adefovir amantadine hcl APTIVUS 2 $0 ATRIPLA 2 $0 BARACLUDE 2 $0 cidofovir PA COMPLERA 2 $0 CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 $0 LÍMITES SOBRE USO DAKLINZA ORAL TABLET 30 MG 2 $0 PA; QL (84 per 28 days) DAKLINZA ORAL TABLET 60 MG 2 $0 PA; QL (28 per 28 days) didanosine EDURANT 2 $0 EMTRIVA 2 $0 entecavir EPIVIR HBV ORAL SOLUTION 2 $0 EPIVIR ORAL SOLUTION 2 $0 EPZICOM 2 $0 EVOTAZ 2 $0 famciclovir FUZEON SUBCUTANEOUS RECON SOLN 2 $0 ganciclovir sodium HARVONI 2 $0 PA; QL (28 per 28 days) gratuita. Para obtener más información, visite 3

5 NOMBRE D MEDICA NIV LO QUE LE INTENCE 2 $0 INVIRASE 2 $0 isentress oral powder in packet ISENTRESS ORAL TABLET 2 $0 ISENTRESS ORAL TABLET,CHEWABLE 2 $0 KALETRA 2 $0 lamivudine lamivudine-zidovudine LEXIVA 2 $0 moderiba moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) nevirapine NORVIR 2 $0 OLYSIO 2 $0 PA PREZCOBIX 2 $0 PREZISTA ORAL SUSPENSION 2 $0 PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 2 $0 LÍMITES SOBRE USO RENZA DISKHALER 2 $0 QL (60 per 180 days) RESCRIPTOR 2 $0 RETROVIR INTRAVENOUS 2 $0 REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 2 $0 REYATAZ ORAL POWDER IN PACKET 2 $0 ribasphere oral capsule ribasphere oral tablet 200 mg RIBASPHERE ORAL TABLET 400 MG, 600 MG 2 $0 gratuita. Para obtener más información, visite 4

6 NOMBRE D MEDICA NIV LO QUE LE RIBASPHERE RIBAPAK ORAL TABLETS,DOSE PACK MG (28)-MG (28), MG (28)-MG (28), MG (28)-MG (28) 2 $0 ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SZENTRY 2 $0 SOVALDI 2 $0 PA stavudine STRIBILD 2 $0 SUSTIVA 2 $0 SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML 2 $0 LA LÍMITES SOBRE USO TAMIFLU ORAL CAPSULE 30 MG 2 $0 QL (84 per 180 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG 2 $0 QL (42 per 180 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 2 $0 QL (600 per 180 days) TECHNIVIE 2 $0 PA; QL (56 per 28 days) TIVICAY 2 $0 TRIUMEQ 2 $0 TRUVADA 2 $0 TYZEKA 2 $0 valacyclovir QL (30 per 30 days) VALCYTE 2 $0 valganciclovir VIDEX 2 GRAM PEDIATRIC 2 $0 VIEKIRA PAK 2 $0 PA; QL (112 per 28 days) VIRACEPT ORAL TABLET 2 $0 gratuita. Para obtener más información, visite 5

7 NOMBRE D MEDICA NIV LO QUE LE VIRAZOLE 2 $0 VIREAD 2 $0 VITEKTA 2 $0 ZIAGEN ORAL SOLUTION 2 $0 zidovudine CEFALOSPORINAS cefaclor oral capsule cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml cefazolin injection recon soln 1 gram, 500 mg cefdinir cefepime cefixime cefotaxime injection recon soln 1 gram, 2 gram, 500 mg cefotetan injection cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil ceftazidime ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln cefuroxime axetil oral tablet LÍMITES SOBRE USO gratuita. Para obtener más información, visite 6

8 NOMBRE D MEDICA NIV LO QUE LE cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous cephalexin SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML 2 $0 TEFLARO 2 $0 ERITROMICIINAS/OTROS MACRÓLIDOS azithromycin clarithromycin e.e.s. 400 oral tablet E.E.S. GRANULES 2 $0 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DAYED REASE (DR/EC) 500 MG 2 $0 erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG 2 $0 erythromycin ethylsuccinate oral tablet erythromycin oral tablet ANTIBIÓTICOS MISCÁNEOS ALBENZA 2 $0 ALINIA 2 $0 amikacin injection solution 500 mg/2 ml atovaquone atovaquone-proguanil aztreonam injection recon soln 1 gram LÍMITES SOBRE USO gratuita. Para obtener más información, visite 7

9 NOMBRE D MEDICA NIV LO QUE LE CAPASTAT 2 $0 LÍMITES SOBRE USO CAYSTON 2 $0 LA; QL (84 per 28 days) chloramphenicol sod succinate chloroquine phosphate oral clindamycin hcl clindamycin in 5 % dextrose clindamycin pediatric clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM 2 $0 colistin (colistimethate na) CUBICIN 2 $0 DAPSONE 2 $0 DARAPRIM 2 $0 ethambutol gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION 2 $0 isoniazid oral ivermectin oral linezolid mefloquine MEPRON 2 $0 gratuita. Para obtener más información, visite 8

10 NOMBRE D MEDICA NIV LO QUE LE meropenem intravenous recon soln 500 mg metronidazole in nacl (iso-os) metronidazole oral LÍMITES SOBRE USO NEBUPENT 2 $0 PA; QL (6 per 28 days) neomycin paromomycin PASER 2 $0 PENTAM 2 $0 PRIFTIN 2 $0 PRIMAQUINE 2 $0 pyrazinamide quinine sulfate rifabutin rifampin intravenous rifampin oral SIRTURO 2 $0 STREPTOMYCIN INTRAMUSCULAR 2 $0 STROMECTOL 2 $0 SYNERCID 2 $0 tinidazole tobramycin in % nacl PA; QL (280 per 28 days) tobramycin in 0.9 % nacl intravenous piggyback 80 mg/100 ml tobramycin sulfate injection solution TRECATOR 2 $0 TYGACIL 2 $0 XIFAXAN 2 $0 gratuita. Para obtener más información, visite 9

11 NOMBRE D MEDICA NIV LO QUE LE ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML 2 $0 ZYVOX ORAL 2 $0 PENICILINAS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin-sulbactam injection recon soln 15 gram, 3 gram ampicillin-sulbactam intravenous recon soln 1.5 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML 2 $0 BICILLIN C-R 2 $0 BICILLIN L-A 2 $0 dicloxacillin nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml nafcillin injection recon soln 1 gram, 10 gram oxacillin intravenous recon soln 2 gram penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g sodium LÍMITES SOBRE USO gratuita. Para obtener más información, visite 10

12 NOMBRE D MEDICA NIV LO QUE LE penicillin v potassium pfizerpen-g injection recon soln 5 million unit piperacillin-tazobactam intravenous recon soln gram, 4.5 gram QUINOLONAS CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 2 $0 ciprofloxacin ciprofloxacin hcl oral ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml levofloxacin intravenous levofloxacin oral moxifloxacin MOXIFLOXACIN-SOD.ACE,SUL-WATER 2 $0 ofloxacin oral tablet 400 mg SULFAMIDAS/AGENTES sulfadiazine oral sulfamethoxazole-trimethoprim TETRACICLINAS demeclocycline oral doxy-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 75 mg LÍMITES SOBRE USO gratuita. Para obtener más información, visite 11

13 NOMBRE D MEDICA NIV LO QUE LE doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral URINARY TRACT AGENTS FURADANTIN 2 $0 methenamine hippurate nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst nitrofurantoin oral trimethoprim VANCOMICINA vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg vancomycin oral capsule MEDICAS INMUNOSUPRESORES/ ANTINEOPLÁSICOS AGENTES COADYUVANTE AMIFOSTINE CRYSTALLINE 2 $0 dexrazoxane hcl intravenous recon soln 250 mg ITEK INTRAVENOUS RECON SOLN 1.5 MG 2 $0 FUSILEV 2 $0 KEPIVANCE 2 $0 leucovorin calcium injection recon soln 100 mg, 350 mg LÍMITES SOBRE USO gratuita. Para obtener más información, visite 12

14 NOMBRE D MEDICA NIV LO QUE LE leucovorin calcium oral LEVOLEUCOVORIN CALCIUM 2 $0 mesna MESNEX ORAL 2 $0 XGEVA 2 $0 MEDICAS INMUNOSUPRESORES/ANTINEOPLÁSICO S ABRAXANE 2 $0 adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ 2 $0 PA LÍMITES SOBRE USO AFINITOR ORAL TABLET 10 MG 2 $0 PA; QL (60 per 30 days) AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG 2 $0 PA 2 $0 anastrozole ARRANON 2 $0 ARZERRA INTRAVENOUS SOLUTION 100 MG/5 ML 2 $0 PA AVASTIN 2 $0 azacitidine AZASAN 2 $0 PA azathioprine PA BEODAQ 2 $0 bexarotene bicalutamide BICNU 2 $0 bleomycin injection recon soln 30 unit gratuita. Para obtener más información, visite 13

15 NOMBRE D MEDICA NIV LO QUE LE BOSULIF ORAL TABLET 100 MG 2 $0 PA LÍMITES SOBRE USO BOSULIF ORAL TABLET 500 MG 2 $0 PA; QL (30 per 30 days) BUSULFEX 2 $0 CAPRSA ORAL TABLET 100 MG 2 $0 LA CAPRSA ORAL TABLET 300 MG 2 $0 LA; QL (30 per 30 days) carboplatin intravenous solution CLCEPT INTRAVENOUS 2 $0 PA CLCEPT ORAL SUSPENSION FOR RECONSTITUTION 2 $0 PA cisplatin cladribine CLOLAR 2 $0 COMETRIQ 2 $0 PA COSMEGEN 2 $0 CYCLOPHOSPHAMIDE ORAL CAPSULE 2 $0 PA cyclosporine intravenous cyclosporine modified PA cyclosporine oral capsule PA CYRAMZA 2 $0 PA cytarabine cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) dacarbazine intravenous recon soln 200 mg daunorubicin intravenous solution DAUNOXOME 2 $0 decitabine DOCEFREZ INTRAVENOUS RECON SOLN 20 MG 2 $0 gratuita. Para obtener más información, visite 14

16 NOMBRE D MEDICA NIV LO QUE LE docetaxel intravenous solution 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) DOXIL 2 $0 doxorubicin intravenous solution 50 mg/25 ml DROXIA 2 $0 IGARD 2 $0 PA EMCYT 2 $0 epirubicin intravenous solution 50 mg/25 ml LÍMITES SOBRE USO ERIVEDGE 2 $0 PA; QL (30 per 30 days) ERWINAZE 2 $0 ETOPOPHOS 2 $0 etoposide intravenous exemestane FARESTON 2 $0 FARYDAK ORAL CAPSULE 10 MG 2 $0 PA; QL (12 per 21 days) FARYDAK ORAL CAPSULE 15 MG, 20 MG 2 $0 PA; QL (6 per 21 days) FASLODEX 2 $0 FIRMAGON KIT W DILUENT SYRINGE 2 $0 fludarabine intravenous recon soln fluorouracil intravenous solution 2.5 gram/50 ml flutamide GEMCITABINE INTRAVENOUS RECON SOLN 1 GRAM 2 $0 gengraf PA GILOTRIF ORAL TABLET 20 MG 2 $0 PA; QL (60 per 30 days) GILOTRIF ORAL TABLET 30 MG 2 $0 PA; QL (40 per 30 days) GILOTRIF ORAL TABLET 40 MG 2 $0 PA; QL (30 per 30 days) GLEEVEC ORAL TABLET 100 MG 2 $0 PA gratuita. Para obtener más información, visite 15

17 NOMBRE D MEDICA NIV LO QUE LE LÍMITES SOBRE USO GLEEVEC ORAL TABLET 400 MG 2 $0 PA; QL (60 per 30 days) HALAVEN 2 $0 HERCEPTIN 2 $0 HEXALEN 2 $0 hydroxyurea IBRANCE 2 $0 PA; QL (21 per 28 days) ICLUSIG ORAL TABLET 15 MG 2 $0 PA; QL (90 per 30 days) ICLUSIG ORAL TABLET 45 MG 2 $0 PA; QL (30 per 30 days) idarubicin ifosfamide intravenous recon soln 1 gram IMBRUVICA 2 $0 PA; QL (120 per 30 days) INLYTA ORAL TABLET 1 MG 2 $0 PA INLYTA ORAL TABLET 5 MG 2 $0 PA; QL (120 per 30 days) IRINOTECAN INTRAVENOUS SOLUTION 100 MG/5 ML 2 $0 ISTODAX 2 $0 IXEMPRA INTRAVENOUS RECON SOLN 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG 2 $0 2 $0 PA JAKAFI ORAL TABLET 25 MG 2 $0 PA; QL (60 per 30 days) JEVTANA 2 $0 KEYTRUDA 2 $0 LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY), 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4 MG[1])/DAY letrozole LEUKERAN 2 $0 2 $0 PA; QL (60 per 30 days) 2 $0 PA; QL (90 per 30 days) gratuita. Para obtener más información, visite 16

18 NOMBRE D MEDICA NIV LO QUE LE leuprolide LOMUSTINE 2 $0 LUPRON DEPOT 2 $0 PA LUPRON DEPOT (3 MONTH) 2 $0 PA LUPRON DEPOT (4 MONTH) 2 $0 PA LUPRON DEPOT (6 MONTH) 2 $0 PA LUPRON DEPOT-PED INTRAMUSCULAR KIT MG, 15 MG 2 $0 PA LYNPARZA 2 $0 PA LYSODREN 2 $0 MATULANE 2 $0 megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml megestrol oral tablet LÍMITES SOBRE USO MEKINIST ORAL TABLET 0.5 MG 2 $0 PA; QL (120 per 30 days) MEKINIST ORAL TABLET 2 MG 2 $0 PA; QL (30 per 30 days) melphalan hcl mercaptopurine METHOTREXATE SODIUM (PF) INJECTION RECON SOLN 2 $0 PA methotrexate sodium (pf) injection solution PA methotrexate sodium oral PA mitomycin intravenous recon soln 20 mg mitoxantrone MUSTARGEN 2 $0 mycophenolate mofetil PA mycophenolate sodium PA NEXAVAR 2 $0 PA; LA NILANDRON 2 $0 gratuita. Para obtener más información, visite 17

19 NOMBRE D MEDICA NIV LO QUE LE NULOJIX 2 $0 PA OCTREOTIDE ACETATE INJECTION SOLUTION 1,000 MCG/ML octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml 2 $0 ONCASPAR 2 $0 OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML OXALIPLATIN INTRAVENOUS SOLUTION 100 MG/20 ML 2 $0 2 $0 paclitaxel PERJETA 2 $0 POMALYST 2 $0 PROGRAF INTRAVENOUS 2 $0 PA PURIXAN 2 $0 RAPAMUNE ORAL SOLUTION 2 $0 PA RAPAMUNE ORAL TABLET 1 MG, 2 MG 2 $0 PA REVLIMID 2 $0 PA; LA RITUXAN 2 $0 PA SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 2 $0 SIGNIFOR 2 $0 PA SIMULECT INTRAVENOUS RECON SOLN 20 MG 2 $0 PA sirolimus PA SOLTAMOX 2 $0 SOMATULINE DEPOT 2 $0 SPRYC ORAL TABLET 100 MG, 20 MG, 50 MG, 80 MG 2 $0 PA LÍMITES SOBRE USO SPRYC ORAL TABLET 140 MG 2 $0 PA; QL (30 per 30 days) gratuita. Para obtener más información, visite 18

20 NOMBRE D MEDICA NIV LO QUE LE LÍMITES SOBRE USO SPRYC ORAL TABLET 70 MG 2 $0 PA; QL (60 per 30 days) STIVARGA 2 $0 PA; QL (84 per 28 days) SUTENT ORAL CAPSULE 12.5 MG 2 $0 PA SUTENT ORAL CAPSULE 25 MG, 37.5 MG 2 $0 PA; QL (60 per 30 days) SUTENT ORAL CAPSULE 50 MG 2 $0 PA; QL (30 per 30 days) SYLVANT INTRAVENOUS RECON SOLN 100 MG 2 $0 SYNRIBO 2 $0 TABLOID 2 $0 tacrolimus oral PA TAFINLAR ORAL CAPSULE 50 MG 2 $0 PA; QL (180 per 30 days) TAFINLAR ORAL CAPSULE 75 MG 2 $0 PA; QL (120 per 30 days) tamoxifen TARCEVA ORAL TABLET 100 MG, 25 MG 2 $0 PA TARCEVA ORAL TABLET 150 MG 2 $0 PA; QL (30 per 30 days) TARGRETIN ORAL 2 $0 TASIGNA ORAL CAPSULE 150 MG 2 $0 PA TASIGNA ORAL CAPSULE 200 MG 2 $0 PA; QL (112 per 28 days) THALOMID 2 $0 PA THIOTEPA 2 $0 toposar topotecan intravenous recon soln TORIS 2 $0 TREANDA INTRAVENOUS RECON SOLN 100 MG TREANDA INTRAVENOUS SOLUTION 45 MG/0.5 ML TRSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2 $0 2 $0 2 $0 gratuita. Para obtener más información, visite 19

21 NOMBRE D MEDICA NIV LO QUE LE TRSTAR INTRAMUSCULAR SYRINGE MG/2 ML, 3.75 MG/2 ML 2 $0 tretinoin (chemotherapy) TRISENOX 2 $0 LÍMITES SOBRE USO TYKERB 2 $0 PA; LA; QL (180 per 30 days) VCADE 2 $0 vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml vincristine intravenous solution 1 mg/ml vinorelbine intravenous solution 50 mg/5 ml VOTRIENT 2 $0 PA; QL (120 per 30 days) XALKORI ORAL CAPSULE 200 MG 2 $0 PA XALKORI ORAL CAPSULE 250 MG 2 $0 PA; QL (60 per 30 days) XTANDI 2 $0 PA; QL (120 per 30 days) ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) 2 $0 ZANOSAR 2 $0 ZBORAF 2 $0 PA; QL (240 per 30 days) ZOLINZA 2 $0 ZORTRESS 2 $0 PA ZYDIG 2 $0 PA ZYKADIA 2 $0 PA; QL (150 per 30 days) ZYTIGA 2 $0 PA; QL (120 per 30 days) MEDICAS AUTÓNOMOS/PARA SISTEMA NERVIOSO CENTRAL, NEUROLOGÍA/PSIQUIATRÍA ANTICONVULSIVOS APTIOM 2 $0 gratuita. Para obtener más información, visite 20

22 NOMBRE D MEDICA NIV LO QUE LE BANZ 2 $0 carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CONTIN ORAL CAPSULE 300 MG 2 $0 CEREBYX INJECTION SOLUTION 500 MG PE/10 ML 2 $0 clonazepam PA diazepam rectal PA DILANTIN 30 MG 2 $0 DILANTIN EXTENDED 100 MG 2 $0 DILANTIN INFATABS 50 MG 2 $0 DILANTIN MG/5 ML 2 $0 divalproex epitol ethosuximide felbamate fosphenytoin injection solution 100 mg pe/2 ml FYCOMPA ORAL TABLET 2 $0 gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG 2 $0 LAMICTAL XR 2 $0 LAMICTAL XR STARTER (BLUE) 2 $0 LAMICTAL XR STARTER (GREEN) 2 $0 LÍMITES SOBRE USO gratuita. Para obtener más información, visite 21

23 NOMBRE D MEDICA NIV LO QUE LE LAMICTAL XR STARTER (ORANGE) 2 $0 lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating LEVETIRACETAM IN NACL (ISO-OS) 2 $0 levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA 2 $0 PA ONFI ORAL SUSPENSION 2 $0 PA ONFI ORAL TABLET 10 MG, 20 MG 2 $0 PA oxcarbazepine PEGANONE 2 $0 phenobarbital phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution POTIGA 2 $0 primidone QUDEXY XR 2 $0 PA SABRIL 2 $0 LA TEGRETOL XR ORAL TABLET EXTENDED REASE 12 HR 100 MG 2 $0 tiagabine topiramate oral capsule, sprinkle PA LÍMITES SOBRE USO gratuita. Para obtener más información, visite 22

24 NOMBRE D MEDICA NIV LO QUE LE topiramate oral tablet PA valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml VIMPAT INTRAVENOUS 2 $0 VIMPAT ORAL SOLUTION 2 $0 VIMPAT ORAL TABLET 2 $0 zonisamide PA AGENTES ANTIPARKINSONIANOS APOKYN 2 $0 LA AZILECT 2 $0 benztropine bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone entacapone LODOSYN 2 $0 NEUPRO 2 $0 pramipexole oral tablet ropinirole selegiline hcl tolcapone TRATAMIENTO PARA MIGRAÑA/CEFALEA EN BROTES LÍMITES SOBRE USO almotriptan malate oral tablet 12.5 mg QL (24 per 28 days) almotriptan malate oral tablet 6.25 mg QL (18 per 28 days) gratuita. Para obtener más información, visite 23

25 NOMBRE D MEDICA NIV LO QUE LE dihydroergotamine injection LÍMITES SOBRE USO dihydroergotamine nasal QL (8 per 28 days) migergot naratriptan QL (18 per 28 days) rizatriptan QL (36 per 28 days) sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation QL (18 per 28 days) QL (36 per 28 days) sumatriptan succinate oral QL (18 per 28 days) sumatriptan succinate subcutaneous cartridge QL (16 per 28 days) sumatriptan succinate subcutaneous pen injector QL (16 per 28 days) sumatriptan succinate subcutaneous solution QL (16 per 28 days) zolmitriptan QL (18 per 28 days) TRATAMIENTOS NEUROLÓGICOS VARIOS AMPYRA 2 $0 PA; LA COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML donepezil 2 $0 PA; QL (30 per 30 days) EXON TRANSDERMAL 2 $0 ST galantamine GILENYA 2 $0 PA glatopa PA; QL (30 per 30 days) memantine oral tablet PA MEMANTINE ORAL TABLETS,DOSE PACK 2 $0 PA NAMENDA 2 $0 PA NAMENDA TITRATION PAK 2 $0 PA NAMENDA XR 2 $0 gratuita. Para obtener más información, visite 24

26 NOMBRE D MEDICA NIV LO QUE LE NUEDEXTA 2 $0 rivastigmine tartrate TECFIDERA 2 $0 PA tetrabenazine PA TYSABRI 2 $0 PA; LA XENAZINE 2 $0 PA; LA RAJANTES MUSCULARES/ TRATAMIENTO ANTIESPASMÓDICO baclofen cyclobenzaprine oral tablet PA dantrolene LIORESAL 2 $0 PA MESTINON ORAL SYRUP 2 $0 MESTINON TIMESPAN 2 $0 pyridostigmine bromide tizanidine oral tablet ANALGÉSICOS OPIOIDES acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg LÍMITES SOBRE USO QL (4500 per 30 days) QL (360 per 30 days) acetaminophen-codeine oral tablet mg QL (180 per 30 days) buprenorphine hcl injection syringe QL (267 per 30 days) buprenorphine hcl sublingual tablet 2 mg QL (300 per 30 days) buprenorphine hcl sublingual tablet 8 mg QL (75 per 30 days) butalbital-acetaminophen-caff oral capsule mg codeine sulfate oral tablet QL (180 per 30 days) duramorph (pf) injection solution 0.5 mg/ml QL (4000 per 30 days) gratuita. Para obtener más información, visite 25

27 NOMBRE D MEDICA NIV LO QUE LE LÍMITES SOBRE USO duramorph (pf) injection solution 1 mg/ml QL (2000 per 30 days) endocet oral tablet mg, mg, mg FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 1,200 MCG FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 1,600 MCG fentanyl citrate buccal lozenge on a handle 200 mcg FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 400 MCG FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 600 MCG FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 800 MCG QL (360 per 30 days) 2 $0 PA; QL (39 per 30 days) 2 $0 PA; QL (29 per 30 days) PA; QL (120 per 30 days) 2 $0 PA; QL (116 per 30 days) 2 $0 PA; QL (77 per 30 days) 2 $0 PA; QL (58 per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr QL (9 per 30 days) fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg QL (10 per 30 days) QL (5550 per 30 days) QL (360 per 30 days) hydrocodone-ibuprofen oral tablet mg QL (50 per 30 days) hydromorphone (pf) injection solution 10 mg/ml QL (120 per 30 days) hydromorphone oral liquid QL (300 per 30 days) hydromorphone oral tablet QL (180 per 30 days) hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 8 mg hydromorphone oral tablet extended release 24 hr 32 mg QL (60 per 30 days) QL (47 per 30 days) levorphanol tartrate QL (120 per 30 days) gratuita. Para obtener más información, visite 26

28 NOMBRE D MEDICA NIV LO QUE LE LÍMITES SOBRE USO lorcet (hydrocodone) QL (360 per 30 days) lorcet hd QL (360 per 30 days) lorcet plus oral tablet mg QL (360 per 30 days) lortab QL (360 per 30 days) lortab QL (360 per 30 days) lortab QL (360 per 30 days) methadone injection QL (160 per 30 days) methadone oral solution 10 mg/5 ml QL (600 per 30 days) methadone oral solution 5 mg/5 ml QL (1200 per 30 days) methadone oral tablet 10 mg QL (120 per 30 days) methadone oral tablet 5 mg QL (240 per 30 days) morphine concentrate oral solution QL (300 per 30 days) morphine intravenous syringe 2 mg/ml QL (1000 per 30 days) morphine intravenous syringe 4 mg/ml QL (500 per 30 days) morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.release pellets 100 mg morphine oral capsule,extend.release pellets 80 mg QL (50 per 30 days) QL (60 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (75 per 30 days) morphine oral solution QL (900 per 30 days) morphine oral tablet QL (180 per 30 days) morphine oral tablet extended release 100 mg QL (60 per 30 days) morphine oral tablet extended release 15 mg, 30 mg QL (120 per 30 days) morphine oral tablet extended release 200 mg QL (30 per 30 days) gratuita. Para obtener más información, visite 27

29 NOMBRE D MEDICA NIV LO QUE LE LÍMITES SOBRE USO morphine oral tablet extended release 60 mg QL (100 per 30 days) oxycodone oral capsule QL (360 per 30 days) oxycodone oral concentrate QL (180 per 30 days) oxycodone oral solution QL (1200 per 30 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg QL (180 per 30 days) oxycodone oral tablet 30 mg QL (134 per 30 days) oxycodone oral tablet 5 mg QL (360 per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (360 per 30 days) oxycodone-aspirin QL (360 per 30 days) oxymorphone oral tablet 10 mg QL (200 per 30 days) oxymorphone oral tablet 5 mg QL (180 per 30 days) oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 30 mg oxymorphone oral tablet extended release 12 hr 40 mg QL (90 per 30 days) QL (67 per 30 days) QL (50 per 30 days) reprexain oral tablet mg QL (50 per 30 days) ANALGÉSICOS NO OPIOIDES ACEPHEN * acetaminophen oral liquid 500 mg/5 ml * acetaminophen oral solution 325 mg/10.15 ml * acetaminophen oral tablet * acetaminophen oral tablet extended release * ASPIR-81 * aspirin oral tablet 325 mg * aspirin oral tablet,chewable * aspirin oral tablet,delayed release (dr/ec) 325 mg * gratuita. Para obtener más información, visite 28

30 NOMBRE D MEDICA NIV LO QUE LE aspirin rectal * LÍMITES SOBRE USO bunavail buccal film mg, mg PA; QL (90 per 30 days) bunavail buccal film mg PA; QL (60 per 30 days) buprenorphine-naloxone PA; QL (90 per 30 days) butorphanol tartrate injection solution 1 mg/ml QL (720 per 30 days) butorphanol tartrate injection solution 2 mg/ml QL (360 per 30 days) butorphanol tartrate nasal QL (40 per 30 days) CEBREX 2 $0 celecoxib CHILDREN'S MAPAP * CHILDREN'S PAIN & FEVER RIEF ORAL IXIR CHILDREN'S PAIN & FEVER RIEF ORAL SUSPENSION CHILDREN'S PAIN & FEVER RIEF ORAL TABLET,CHEWABLE CHILDREN'S PAIN RIEF ORAL SUSPENSION * 2 $0 * * * diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac-misoprostol diflunisal etodolac FENOPROFEN ORAL CAPSULE 2 $0 fenoprofen oral tablet flurbiprofen glucosamine sulfate oral capsule 500 mg * ibuprofen oral suspension gratuita. Para obtener más información, visite 29

31 NOMBRE D MEDICA NIV LO QUE LE ibuprofen oral tablet 200 mg * ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg MAPAP (ACETAMINOPHEN) ORAL CAPSULE * meclofenamate oral mefenamic acid meloxicam oral suspension meloxicam oral tablet 15 mg LÍMITES SOBRE USO meloxicam oral tablet 7.5 mg QL (30 per 30 days) nabumetone naloxone injection syringe 1 mg/ml naltrexone oral naproxen naproxen sodium oral tablet 220 mg * naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr 375 mg oxaprozin piroxicam tolmetin tramadol oral tablet QL (240 per 30 days) tramadol oral tablet extended release 24 hr 100 mg, 200 mg QL (30 per 30 days) tramadol-acetaminophen QL (240 per 30 days) TRI-BUFFERED ASPIRIN * VOLTAREN G TOPICAL G 1 % 2 $0 gratuita. Para obtener más información, visite 30

32 NOMBRE D MEDICA NIV LO QUE LE MEDICAS PSICOTERAPÉUTICOS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED R RECON 300 MG abilify maintena intramuscular suspension,extended rel syring 2 $0 LÍMITES SOBRE USO ABILIFY ORAL TABLET 10 MG 2 $0 QL (90 per 30 days) ABILIFY ORAL TABLET 15 MG, 20 MG 2 $0 QL (60 per 30 days) ABILIFY ORAL TABLET 2 MG 2 $0 QL (450 per 30 days) ABILIFY ORAL TABLET 30 MG 2 $0 QL (30 per 30 days) ABILIFY ORAL TABLET 5 MG 2 $0 QL (180 per 30 days) alprazolam oral tablet amitriptyline PA amitriptyline-chlordiazepoxide amoxapine amphetamine salt combo aripiprazole oral tablet 10 mg QL (90 per 30 days) aripiprazole oral tablet 15 mg, 20 mg QL (60 per 30 days) aripiprazole oral tablet 2 mg QL (450 per 30 days) aripiprazole oral tablet 30 mg QL (30 per 30 days) aripiprazole oral tablet 5 mg QL (180 per 30 days) BRINTLIX ORAL TABLET 10 MG 2 $0 QL (60 per 30 days) BRINTLIX ORAL TABLET 20 MG 2 $0 QL (30 per 30 days) BRINTLIX ORAL TABLET 5 MG 2 $0 QL (120 per 30 days) bupropion hcl oral tablet bupropion hcl oral tablet extended release 100 mg QL (120 per 30 days) bupropion hcl oral tablet extended release 150 mg QL (90 per 30 days) bupropion hcl oral tablet extended release 200 mg QL (60 per 30 days) gratuita. Para obtener más información, visite 31

33 NOMBRE D MEDICA NIV LO QUE LE bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg buspirone chlorpromazine citalopram oral solution LÍMITES SOBRE USO QL (90 per 30 days) QL (60 per 30 days) citalopram oral tablet 10 mg QL (120 per 30 days) citalopram oral tablet 20 mg QL (60 per 30 days) clomipramine PA clonidine hcl oral tablet extended release 12 hr clorazepate dipotassium PA clozapine oral tablet clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG 2 $0 desipramine oral dexedrine dexmethylphenidate oral capsule,er biphasic dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamine-amphetamine oral capsule,extended release 24hr diazepam intensol PA diazepam oral solution 5 mg/5 ml PA diazepam oral tablet PA doxepin oral PA gratuita. Para obtener más información, visite 32

34 NOMBRE D MEDICA NIV LO QUE LE duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg LÍMITES SOBRE USO QL (180 per 30 days) QL (120 per 30 days) EMSAM 2 $0 ergoloid escitalopram oxalate oral solution QL (60 per 30 days) escitalopram oxalate oral tablet 10 mg QL (60 per 30 days) escitalopram oxalate oral tablet 20 mg QL (30 per 30 days) escitalopram oxalate oral tablet 5 mg QL (120 per 30 days) eszopiclone ST; QL (30 per 30 days) FANAPT ORAL TABLET 1 MG 2 $0 QL (720 per 30 days) FANAPT ORAL TABLET 10 MG, 8 MG 2 $0 QL (90 per 30 days) FANAPT ORAL TABLET 12 MG 2 $0 QL (60 per 30 days) FANAPT ORAL TABLET 2 MG 2 $0 QL (360 per 30 days) FANAPT ORAL TABLET 4 MG 2 $0 QL (180 per 30 days) FANAPT ORAL TABLET 6 MG 2 $0 QL (120 per 30 days) FANAPT ORAL TABLETS,DOSE PACK 2 $0 QL (8 per 28 days) FAZACLO 2 $0 FETZIMA ORAL CAPSULE,EXT R 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED REASE 24 HR 120 MG FETZIMA ORAL CAPSULE,EXTENDED REASE 24 HR 20 MG 2 $0 ST; QL (28 per 28 days) 2 $0 ST; QL (30 per 30 days) 2 $0 ST; QL (180 per 30 days) gratuita. Para obtener más información, visite 33

35 NOMBRE D MEDICA NIV LO QUE LE FETZIMA ORAL CAPSULE,EXTENDED REASE 24 HR 40 MG FETZIMA ORAL CAPSULE,EXTENDED REASE 24 HR 80 MG LÍMITES SOBRE USO 2 $0 ST; QL (90 per 30 days) 2 $0 ST; QL (45 per 30 days) fluoxetine oral capsule 10 mg QL (240 per 30 days) fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg QL (60 per 30 days) fluoxetine oral capsule,delayed release(dr/ec) QL (4 per 28 days) fluoxetine oral solution fluoxetine oral tablet 10 mg QL (240 per 30 days) fluoxetine oral tablet 20 mg fluphenazine decanoate fluphenazine hcl fluvoxamine oral capsule,extended release 24hr 100 mg fluvoxamine oral capsule,extended release 24hr 150 mg QL (90 per 30 days) QL (60 per 30 days) fluvoxamine oral tablet 100 mg QL (90 per 30 days) fluvoxamine oral tablet 25 mg QL (360 per 30 days) fluvoxamine oral tablet 50 mg QL (180 per 30 days) GEODON INTRAMUSCULAR 2 $0 haloperidol haloperidol decanoate haloperidol lactate imipramine hcl PA imipramine pamoate PA INVEGA ORAL TABLET EXTENDED REASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED REASE 24HR 3 MG 2 $0 QL (240 per 30 days) 2 $0 QL (120 per 30 days) gratuita. Para obtener más información, visite 34

36 NOMBRE D MEDICA NIV LO QUE LE INVEGA ORAL TABLET EXTENDED REASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED REASE 24HR 9 MG INVEGA SUSTENNA 2 $0 LÍMITES SOBRE USO 2 $0 QL (60 per 30 days) 2 $0 QL (41 per 30 days) IRENKA 2 $0 ST LATUDA ORAL TABLET 120 MG 2 $0 QL (30 per 30 days) LATUDA ORAL TABLET 20 MG 2 $0 QL (240 per 30 days) LATUDA ORAL TABLET 40 MG 2 $0 QL (120 per 30 days) LATUDA ORAL TABLET 60 MG, 80 MG 2 $0 QL (60 per 30 days) lithium carbonate lithium citrate oral solution 8 meq/5 ml lorazepam intensol PA lorazepam oral tablet PA loxapine succinate maprotiline MARPLAN 2 $0 methylphenidate oral capsule, er biphasic mg, 60 mg methylphenidate oral capsule,er biphasic methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet extended release 24hr 18 mg, 36 mg, 54 mg methylphenidate oral tablet,chewable mirtazapine modafinil PA nefazodone nortriptyline gratuita. Para obtener más información, visite 35

37 NOMBRE D MEDICA NIV LO QUE LE olanzapine intramuscular LÍMITES SOBRE USO olanzapine oral tablet 10 mg QL (60 per 30 days) olanzapine oral tablet 15 mg, 20 mg QL (30 per 30 days) olanzapine oral tablet 2.5 mg QL (240 per 30 days) olanzapine oral tablet 5 mg QL (120 per 30 days) olanzapine oral tablet 7.5 mg QL (81 per 30 days) olanzapine oral tablet,disintegrating 10 mg QL (60 per 30 days) olanzapine oral tablet,disintegrating 15 mg, 20 mg QL (30 per 30 days) olanzapine oral tablet,disintegrating 5 mg QL (120 per 30 days) olanzapine-fluoxetine ORAP 2 $0 paroxetine hcl oral tablet 10 mg QL (180 per 30 days) paroxetine hcl oral tablet 20 mg QL (90 per 30 days) paroxetine hcl oral tablet 30 mg QL (60 per 30 days) paroxetine hcl oral tablet 40 mg QL (45 per 30 days) paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION 2 $0 perphenazine QL (180 per 30 days) QL (90 per 30 days) QL (60 per 30 days) perphenazine-amitriptyline PA phenelzine PRISTIQ ORAL TABLET EXTENDED REASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED REASE 24 HR 25 MG 2 $0 ST; QL (120 per 30 days) 2 $0 ST gratuita. Para obtener más información, visite 36

38 NOMBRE D MEDICA NIV LO QUE LE PRISTIQ ORAL TABLET EXTENDED REASE 24 HR 50 MG protriptyline LÍMITES SOBRE USO 2 $0 ST; QL (240 per 30 days) quetiapine oral tablet 100 mg QL (240 per 30 days) quetiapine oral tablet 200 mg QL (120 per 30 days) quetiapine oral tablet 25 mg QL (902 per 30 days) quetiapine oral tablet 300 mg QL (81 per 30 days) quetiapine oral tablet 400 mg QL (60 per 30 days) quetiapine oral tablet 50 mg QL (480 per 30 days) REXULTI ORAL TABLET 0.25 MG 2 $0 QL (480 per 30 days) REXULTI ORAL TABLET 0.5 MG 2 $0 QL (240 per 30 days) REXULTI ORAL TABLET 1 MG 2 $0 QL (120 per 30 days) REXULTI ORAL TABLET 2 MG 2 $0 QL (60 per 30 days) REXULTI ORAL TABLET 3 MG 2 $0 QL (40 per 30 days) REXULTI ORAL TABLET 4 MG 2 $0 QL (30 per 30 days) RISPERDAL CONSTA 2 $0 risperidone oral solution QL (480 per 30 days) risperidone oral tablet 0.25 mg QL (1920 per 30 days) risperidone oral tablet 0.5 mg QL (960 per 30 days) risperidone oral tablet 1 mg QL (480 per 30 days) risperidone oral tablet 2 mg QL (240 per 30 days) risperidone oral tablet 3 mg QL (161 per 30 days) risperidone oral tablet 4 mg QL (120 per 30 days) risperidone oral tablet,disintegrating 0.25 mg QL (1920 per 30 days) risperidone oral tablet,disintegrating 0.5 mg QL (960 per 30 days) risperidone oral tablet,disintegrating 1 mg QL (480 per 30 days) risperidone oral tablet,disintegrating 2 mg QL (240 per 30 days) risperidone oral tablet,disintegrating 3 mg QL (161 per 30 days) gratuita. Para obtener más información, visite 37

39 NOMBRE D MEDICA NIV LO QUE LE LÍMITES SOBRE USO risperidone oral tablet,disintegrating 4 mg QL (120 per 30 days) ROZEREM 2 $0 QL (30 per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQU XR ORAL TABLET EXTENDED REASE 24 HR 150 MG SEROQU XR ORAL TABLET EXTENDED REASE 24 HR 200 MG SEROQU XR ORAL TABLET EXTENDED REASE 24 HR 300 MG SEROQU XR ORAL TABLET EXTENDED REASE 24 HR 400 MG SEROQU XR ORAL TABLET EXTENDED REASE 24 HR 50 MG 2 $0 QL (60 per 30 days) 2 $0 sertraline oral concentrate 2 $0 QL (120 per 30 days) 2 $0 QL (161 per 30 days) 2 $0 QL (120 per 30 days) 2 $0 QL (81 per 30 days) 2 $0 QL (60 per 30 days) 2 $0 QL (480 per 30 days) sertraline oral tablet 100 mg QL (60 per 30 days) sertraline oral tablet 25 mg QL (240 per 30 days) sertraline oral tablet 50 mg QL (120 per 30 days) STRATTERA 2 $0 SURMONTIL 2 $0 PA temazepam PA thioridazine thiothixene tranylcypromine trazodone trifluoperazine gratuita. Para obtener más información, visite 38

40 NOMBRE D MEDICA NIV LO QUE LE venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg LÍMITES SOBRE USO QL (60 per 30 days) QL (180 per 30 days) QL (90 per 30 days) venlafaxine oral tablet 100 mg, 75 mg QL (90 per 30 days) venlafaxine oral tablet 25 mg QL (270 per 30 days) venlafaxine oral tablet 37.5 mg QL (180 per 30 days) venlafaxine oral tablet 50 mg QL (150 per 30 days) venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VERSACLOZ 2 $0 VIIBRYD ORAL TABLET 10 MG 2 $0 QL (120 per 30 days) VIIBRYD ORAL TABLET 20 MG 2 $0 QL (60 per 30 days) VIIBRYD ORAL TABLET 40 MG 2 $0 QL (30 per 30 days) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16) 2 $0 QL (30 per 30 days) XYREM 2 $0 LA zaleplon oral capsule 10 mg ST; QL (60 per 30 days) zaleplon oral capsule 5 mg ST; QL (30 per 30 days) ziprasidone hcl oral capsule 20 mg QL (240 per 30 days) ziprasidone hcl oral capsule 40 mg QL (120 per 30 days) ziprasidone hcl oral capsule 60 mg QL (80 per 30 days) ziprasidone hcl oral capsule 80 mg QL (60 per 30 days) zolpidem ST; QL (30 per 30 days) ZYPREXA RPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG 2 $0 gratuita. Para obtener más información, visite 39

41 NOMBRE D MEDICA NIV LO QUE LE AFECCIONES, CARDIOVASCULARES, HIPERTENSIÓN/LÍPIDOS AGENTES ANTIARRÍTMICOS amiodarone intravenous solution PA amiodarone oral tablet 200 mg, 400 mg flecainide mexiletine pacerone oral tablet 100 mg, 200 mg procainamide injection propafenone quinidine gluconate quinidine sulfate oral tablet sorine sotalol af oral tablet 120 mg sotalol oral tablet 160 mg, 240 mg, 80 mg SOTYLIZE 2 $0 TIKOSYN 2 $0 TRATAMIENTO ANTIHIPERTENSIVO acebutolol afeditab cr amiloride oral amiloride-hydrochlorothiazide amlodipine amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid atenolol LÍMITES SOBRE USO gratuita. Para obtener más información, visite 40

42 NOMBRE D MEDICA NIV LO QUE LE atenolol-chlorthalidone benazepril benazepril-hydrochlorothiazide betaxolol oral BIDIL 2 $0 bisoprolol fumarate bisoprolol-hydrochlorothiazide bumetanide candesartan candesartan-hydrochlorothiazid captopril captopril-hydrochlorothiazide cartia xt carvedilol chlorothiazide chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg LÍMITES SOBRE USO clonidine QL (4 per 28 days) clonidine hcl oral tablet DEMSER 2 $0 DIBENZYLINE 2 $0 diltiazem hcl intravenous diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral tablet gratuita. Para obtener más información, visite 41

43 NOMBRE D MEDICA NIV LO QUE LE dilt-xr LÍMITES SOBRE USO doxazosin oral tablet 1 mg, 2 mg, 4 mg QL (30 per 30 days) doxazosin oral tablet 8 mg QL (60 per 30 days) DUTOPROL 2 $0 enalapril maleate enalapril-hydrochlorothiazide eplerenone eprosartan ethacrynate sodium felodipine fosinopril fosinopril-hydrochlorothiazide furosemide injection furosemide oral solution 10 mg/ml, 40 mg/5 ml furosemide oral tablet hydralazine hydrochlorothiazide indapamide irbesartan irbesartan-hydrochlorothiazide isradipine labetalol intravenous solution labetalol oral lisinopril lisinopril-hydrochlorothiazide losartan losartan-hydrochlorothiazide matzim la gratuita. Para obtener más información, visite 42

44 NOMBRE D MEDICA NIV LO QUE LE methyclothiazide methyldopa metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate intravenous solution metoprolol tartrate oral minoxidil oral moexipril moexipril-hydrochlorothiazide nadolol nadolol-bendroflumethiazide nicardipine oral nifedical xl nifedipine oral tablet extended release 24hr nimodipine nisoldipine perindopril erbumine phenoxybenzamine pindolol prazosin oral propranolol propranolol-hydrochlorothiazid quinapril quinapril-hydrochlorothiazide ramipril REMODULIN 2 $0 PA; LA spironolactone LÍMITES SOBRE USO gratuita. Para obtener más información, visite 43

45 NOMBRE D MEDICA NIV LO QUE LE spironolacton-hydrochlorothiaz taztia xt telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid LÍMITES SOBRE USO terazosin oral capsule 1 mg, 2 mg, 5 mg QL (30 per 30 days) terazosin oral capsule 10 mg QL (60 per 30 days) timolol maleate oral torsemide oral trandolapril trandolapril-verapamil triamterene-hydrochlorothiazid valsartan valsartan-hydrochlorothiazide verapamil intravenous solution verapamil oral GLUCÓSIDOS CARDÍACOS digitek digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN ORAL 2 $0 TRATAMIENTO ANTICOAGULANTE AGGRENOX 2 $0 aspirin-dipyridamole BRILINTA ORAL TABLET 90 MG 2 $0 cilostazol clopidogrel COUMADIN ORAL 2 $0 gratuita. Para obtener más información, visite 44

46 NOMBRE D MEDICA NIV LO QUE LE dipyridamole oral EFFIENT 2 $0 IQUIS 2 $0 enoxaparin subcutaneous solution ENOXAPARIN SUBCUTANEOUS SYRINGE 100 MG/ML, 120 MG/0.8 ML, 150 MG/ML enoxaparin subcutaneous syringe 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml 2 $0 fondaparinux heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) injection solution jantoven pentoxifylline PERSANTINE 2 $0 PROMACTA 2 $0 PA; LA tranexamic acid intravenous VITAMIN K INJECTION * VITAMIN K1 INJECTION * warfarin XARTO 2 $0 AGENTES PARA REDUCIR LÍPIDOS/COLESTEROL LÍMITES SOBRE USO amlodipine-atorvastatin QL (30 per 30 days) atorvastatin QL (30 per 30 days) cholestyramine light oral powder in packet colestipol oral granules gratuita. Para obtener más información, visite 45

47 NOMBRE D MEDICA NIV LO QUE LE colestipol oral tablet CRESTOR 2 $0 ST fenofibrate micronized fenofibrate nanocrystallized FENOFIBRATE ORAL TABLET 120 MG 2 $0 fenofibrate oral tablet 160 mg, 54 mg fenofibric acid (choline) LÍMITES SOBRE USO fluvastatin oral capsule 20 mg QL (30 per 30 days) fluvastatin oral capsule 40 mg QL (60 per 30 days) gemfibrozil oral JUXTAPID 2 $0 LA lovastatin oral tablet 10 mg QL (30 per 30 days) lovastatin oral tablet 20 mg, 40 mg QL (60 per 30 days) LOVAZA 2 $0 PA niacin oral capsule, extended release 500 mg * niacin oral tablet 100 mg, 50 mg, 500 mg * niacin oral tablet extended release 24 hr niacin oral tablet extended release 500 mg * niacinamide oral tablet 500 mg * omega-3 acid ethyl esters PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 75 MG/ML 2 $0 PA; QL (2 per 28 days) 2 $0 PA; QL (4 per 28 days) 2 $0 PA; QL (2 per 28 days) 2 $0 PA; QL (4 per 28 days) pravastatin QL (30 per 30 days) gratuita. Para obtener más información, visite 46

48 NOMBRE D MEDICA NIV LO QUE LE prevalite oral powder LÍMITES SOBRE USO simvastatin QL (30 per 30 days) WCHOL 2 $0 ZETIA 2 $0 AGENTES CARDIOVASCULARES VARIOS CORLANOR 2 $0 PA ENTRESTO 2 $0 PA; QL (60 per 30 days) RANEXA 2 $0 VECAMYL 2 $0 NITRATOS isosorbide dinitrate oral isosorbide mononitrate nitro-bid nitroglycerin intravenous PA nitroglycerin transdermal patch 24 hour nitroglycerin translingual spray,non-aerosol NITROSTAT 2 $0 TRATAMIENTOS DERMATOLÓGICOS/TÓPICOS ANTIPSORIÁSICOS/ANTISEBORREICOS acitretin calcipotriene calcipotriene-betamethasone calcitriol topical NEUTROGENA T-G 2 $0 * selenium sulfide topical suspension TERA-G TAR SHAMPOO * gratuita. Para obtener más información, visite 47

49 NOMBRE D MEDICA NIV LO QUE LE TRATAMIENTO PARA QUEMADURAS silver sulfadiazine ssd TRATAMIENTOS DERMATOLÓGICOS VARIOS 8-MOP 2 $0 ammonium lactate topical ANTI-ITCH(DIPHENHYD) WITH ZINC TOPICAL CREAM % * AQUAPHOR 2 $0 * calamine * capsaicin topical cream % * CARAC 2 $0 CETAPHIL GENTLE CLEANSER 2 $0 * DERMAMED (ALUMINUM HYDROXIDE) * diclofenac sodium topical gel PA fluorouracil topical cream 5 % fluorouracil topical solution HIBICLENS 2 $0 * HYDROPHOR * imiquimod ITCH RIEF TOPICAL CREAM % * methoxsalen rapid OXSORALEN ULTRA 2 $0 PANRETIN 2 $0 podofilox PROTOPIC 2 $0 PA tacrolimus topical PA LÍMITES SOBRE USO gratuita. Para obtener más información, visite 48

50 NOMBRE D MEDICA NIV LO QUE LE THERA-DERM * THERA-GESIC TOPICAL CREAM 15-1 % * UVADEX 2 $0 VALCHLOR 2 $0 VEREGEN 2 $0 vits a and d-white pet-lanolin topical ointment * white petrolatum topical gel * zinc oxide topical ointment 20 % * ZOSTRIX-HP 2 $0 * ZYCLARA TOPICAL CREAM IN METERED- DOSE PUMP 2.5 % 2 $0 ZYCLARA TOPICAL CREAM IN PACKET 2 $0 TRATAMIENTO CONTRA ACNÉ adapalene topical cream PA adapalene topical gel PA amnesteem avita topical cream PA benzoyl peroxide topical gel 10 %, 5 % * benzoyl peroxide topical lotion 10 % * claravis oral capsule 10 mg, 20 mg, 40 mg CLARAVIS ORAL CAPSULE 30 MG 2 $0 clindamycin phosphate topical clindamycin-benzoyl peroxide topical gel 1-5 % ery pads erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycin-benzoyl peroxide metronidazole topical cream LÍMITES SOBRE USO gratuita. Para obtener más información, visite 49

51 NOMBRE D MEDICA NIV LO QUE LE metronidazole topical gel metronidazole topical lotion neuac TAZORAC TOPICAL CREAM 2 $0 PA tretinoin microspheres topical gel with pump PA tretinoin topical cream PA tretinoin topical gel 0.01 %, % PA ANESTÉSICOS TÓPICOS lidocaine (pf) injection solution 5 mg/ml (0.5 %) lidocaine hcl injection solution 20 mg/ml (2 %) lidocaine hcl mucous membrane lidocaine hcl urethral lidocaine topical adhesive patch,medicated PA lidocaine topical ointment lidocaine-prilocaine topical cream ANTIBACTERIANOS TÓPICOS bacitracin topical ointment * bacitracin zinc topical packet * gentamicin topical iodine strong * mupirocin mupirocin calcium sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM 2 $0 TRIPLE ANTIBIOTIC TOPICAL OINTMENT * ANTIMICÓTICOS TÓPICOS ANTIFUNGAL CREAM * ATHLETE'S FOOT (TERBINAFINE) * LÍMITES SOBRE USO gratuita. Para obtener más información, visite 50

52 NOMBRE D MEDICA NIV LO QUE LE ciclopirox clotrimazole topical clotrimazole-betamethasone econazole topical ketoconazole topical nyamyc nystatin topical nystatin-triamcinolone nystop tolnaftate topical cream * tolnaftate topical powder * tolnaftate topical solution * ANTIVIRALES TÓPICOS ABREVA * acyclovir topical DENAVIR 2 $0 ZOVIRAX TOPICAL CREAM 2 $0 CORTICOSTEROIDES TÓPICOS ala-cort topical cream alclometasone amcinonide apexicon e betamethasone dipropionate betamethasone valerate betamethasone, augmented topical cream betamethasone, augmented topical lotion betamethasone, augmented topical ointment clobetasol topical foam LÍMITES SOBRE USO gratuita. Para obtener más información, visite 51

53 NOMBRE D MEDICA NIV LO QUE LE clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution clobetasol topical spray,non-aerosol clobetasol-emollient topical cream clodan cormax topical solution desonide desoximetasone diflorasone fluocinolone fluocinonide topical cream 0.1 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e fluticasone topical cream fluticasone topical ointment halobetasol propionate hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone butyr-emollient hydrocortisone topical cream 0.5 % * hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 0.5 % * LÍMITES SOBRE USO gratuita. Para obtener más información, visite 52