Formulario (Lista de medicamentos)

Transcripción

1 Formulario (Lista de medicamentos) CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) Condado de Los Ángeles, CA 2016 LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIS EN ESTE PLAN. Este formulario fue actualizado el 08/01/2016. Si tiene preguntas, llame a Servicios al Miembro de CareMore Cal MediConnect Plan al (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora del Pacífico. H6629_16_25137_T_001_SP CMS Approved 08/26/2015 Para obtener más información, ID del formulario: Versión: 9 ID del formulario: Versión: 20 visite duals.caremore.com. Publicado el 1/1/2016

2 H6629_16_25137_T_001_SP CMS Approved 09/01/2015 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) Lista de medicamentos cubiertos (Formulario) 2016 Esta es una lista de medicamentos que los miembros pueden obtener en CareMore Cal MediConnect Plan (Medicare-Medicaid Plan). CareMore Cal MediConnect Plan es un plan de salud que tiene contratos con ambos Medicare y Medi-Cal para proporcionar beneficios de ambos programas a los inscritos. CareMore administra el contrato a nombre de un afiliado de CareMore. CareMore es una marca comercial registrada de CareMore Health System. La lista de medicamentos cubiertos y/o las redes de farmacias y proveedores pueden cambiar a lo largo del año. Le enviaremos una notificación antes de hacer un cambio que le afecte. Los beneficios y/o los copagos pueden cambiar el 1 de enero de cada año. Siempre puede verificar la Lista de medicamentos cubiertos de CareMore Cal MediConnect Plan actualizada en línea en duals.caremore.com o llamando al (TTY 711). Puede obtener esta información gratuitamente en otros formatos, tales como letras grandes, braille o audio. Llame al (TTY 711). La llamada es gratuita. Pueden aplicar limitaciones y restricciones. Para obtener más información, llame a Servicios al Miembro de CareMore Cal MediConnect Plan o lea el manual del miembro de CareMore Cal MediConnect Plan. Puede recibir esta información sin cargo en otros idiomas. Llame al (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m. La llamada es gratuita. Դուք կարող եք ստանալ այս ձեռնարկն անվճար է այլ լեզուներով: Call երկուշաբթի - ուրբաթ `8:00 - ից 8:00 - ին: TTY օգտվողները պետք է զանգահարել 711. Կանչի ազատ է 您可以免費取得本手冊其他語言版本請致電, 週一至週五, 上午 8:00 至晚上 8:00 TTY 使用者可撥打 711 此為免費電話 الخط الخاص باالعضاء بإمكانك الحصول على هذه المعلومات مجانا بلغات أخرى. اتصل على الرقم 8 صباحا لغاية 8 من يوم االثنين لغاية يوم الجمعة ومن الساعة 711 TTY ممن لديهم ضعف في السمع أو النظر. مساءا. هذه المكالمة مجانية صبح تا 8:00 می توانید این دفترچه را به طور رایگان به سایر زبان ها دریافت کنید. از دوشنبه تا جمعه و از ساعت " تماس بگیرند. این تماس 711 باید با شماره TTY تماس بگیرید. کاربران شب با شماره 8:00 " رایگان است 귀하께서는이안내서를다른언어로무료로받아보실수있습니다. 주중 ( 월 - 금 ) 오전 8:00 시에서 오후 8:00 시사이에번으로전화해주십시오. TTY 사용자는 711 로전화해주십시오. 통화는무료 입니다. Этот справочник можно бесплатно получить в переводе на другие языки. Звоните по телефону, линия работает с понедельника по пятницу с 8:00 до 20:00. Если вы пользуетесь устройством TTY, звоните по телефону 711. Звонки бесплатные. Puedes recibir este manual en otros idiomas sin cargo. Llama al de lunes a viernes, de 8.00 a.m. a 8.00 p.m. Los usuarios de TTY deben llamar al 711. La llamada es gratuita. Makukuha ninyo nang libre ang handbook na ito sa ibang wika. Tawagan ang, Lunes hanggang Biyernes 8:00 a.m. hanggang 8:00 p.m. Ang mga gumagamit ng TTY ay dapat tawagan ang 711. Libre ang pagtawag. es gratuita. Para obtener más información, visite duals.caremore.com. 1

3 Quy vi co thê nhâṇ sô tay naỳ miêñ phi băǹg cać ngôn ngư khać. Haỹ goị sô, tư Thư Hai đêń Thư Saú, từ 8 giơ sańg đêń 8 giơ tôí. Ngươì duǹg TTY câǹ goị đêń sô 711. Cuô c goị được miêñ phi. es gratuita. Para obtener más información, visite duals.caremore.com. 2

4 Preguntas frecuentes (FAQ) Encuentre aquí respuestas a las preguntas que tenga sobre esta Lista de medicamentos cubiertos. Puede leer todas las preguntas frecuentes para aprender más o buscar una pregunta y respuesta. 1. Qué medicamentos recetados se encuentran en la lista de medicamentos cubiertos (Llamamos a la lista de medicamentos cubiertos la lista de medicamentos para abreviar). Los medicamentos en la Lista de medicamentos son los medicamentos que están cubiertos por CareMore Cal MediConnect Plan. Los medicamentos están disponibles en farmacias de nuestra red. Una farmacia se encuentra en nuestra red si tiene un acuerdo para trabajar con nosotros y proporcionarle sus servicios. Nos referimos a estas farmacias como farmacias de la red. CareMore Cal MediConnect Plan cubrirá todos los medicamentos necesarios por motivos médicos en la Lista de medicamentos si: su doctor u otro recetante afirma que los necesita para mejorarse o para estar sano y usted abastece la receta en una farmacia de la red de CareMore Cal MediConnect Plan. En algunos casos, usted debe realizar algo antes de poder recibir un medicamento (vea la pregunta No. 5 a continuación). Puede ver una lista actualizada de los medicamentos que cubrimos en nuestro sitio web en duals.caremore.com o llamar a Servicios al Miembro al (TTY 711). 2. Cambia alguna vez la lista de medicamentos Sí. CareMore Cal MediConnect Plan puede agregar o eliminar medicamentos de la Lista de medicamentos durante el año. Por lo general, la lista de medicamentos solo cambiará si: surge un medicamento más barato que funciona tan bien como el medicamento en la lista de medicamentos ahora, o nos enteramos de que un medicamento no es seguro. También podemos cambiar nuestras reglas sobre medicamentos. Por ejemplo, podríamos: Decidir la exigencia o no de aprobación previa para un medicamento. (Aprobación previa es permiso de CareMore Cal MediConnect Plan antes de que usted pueda recibir un medicamento). Agregar o cambiar la cantidad de un medicamento que puede recibir (llamado límites de cantidad ). Agregar o cambiar restricciones de terapia escalonada para un medicamento. (Terapia escalonada significa que debe probar un medicamento antes de que cubramos otro medicamento). (Para obtener más información sobre estas reglas de medicamentos, vea la página 4). es gratuita. Para obtener más información, visite duals.caremore.com. 3

5 Le informaremos cuando un medicamento que usted toma es retirado de la Lista de medicamentos. También le avisaremos cuando cambiemos nuestras reglas para cubrir un medicamento. Las preguntas 3, 4 y 7 a continuación tienen más información sobre lo que ocurre cuando cambia la lista de medicamentos. Siempre puede revisar la lista actualizada de medicamentos cubiertos en línea de CareMore Cal MediConnect Plan en duals.caremore.com. También puede llamar a Servicios al Miembro para revisar la Lista de medicamentos actual al (TTY 711). 3. Qué ocurre cuando surge un medicamento más barato que funciona tan bien como un medicamento en la lista de medicamentos ahora Si toma un medicamento que es retirado debido a la aparición de un medicamento más económico que funciona bien, le informaremos. Le avisaremos al menos 60 días antes de retirarlo de la lista de medicamentos o cuando usted solicite un reabastecimiento. Luego puede recibir un suministro de 60 días del medicamento antes de que el medicamento sea retirado de la lista de medicamentos. Le enviaremos una carta acerca de cualquier cambio que no sea de mantenimiento a la lista de medicamentos a lo largo del año. También publicaremos una copia de la carta en nuestro sitio web. 4. Qué ocurre cuando averiguamos que un medicamento no es seguro Si la Administración de Alimentos y Medicamentos (Food and Drug Administration (FDA)) informa que un medicamento que usted está tomando no es seguro, lo eliminaremos de la lista de medicamentos de inmediato. También le enviaremos una carta informándole esta situación. Si recibe un aviso acerca de un medicamento poco seguro, llame de inmediato a su doctor. Su doctor puede ayudarle a encontrar otro medicamento que le sea de utilidad. 5. Hay alguna restricción o límite en la cobertura de medicamentos O existen acciones requeridas que se deben realizar para obtener ciertos medicamentos Sí, algunos medicamentos tienen reglas de cobertura o límites en la cantidad que puede recibir. En algunos casos usted o su doctor u otro recetante debe realizar algo antes de poder recibir el medicamento. Por ejemplo: Aprobación previa (o autorización previa): Para algunos medicamentos, usted o su doctor u otro recetante deben obtener aprobación de CareMore Cal MediConnect Plan antes de abastecer su receta. Si no obtiene aprobación, puede que CareMore Cal MediConnect Plan no cubra el medicamento. Límites de cantidad: En ocasiones CareMore Cal MediConnect Plan limita la cantidad de un medicamento que usted puede recibir. es gratuita. Para obtener más información, visite duals.caremore.com. 4

6 Terapia escalonada: A veces CareMore Cal MediConnect Plan requiere que usted haga terapia escalonada. Esto significa que tendrá que probar los medicamentos en un cierto orden para su condición médica. Es posible que deba probar un medicamento antes de que cubramos otro medicamento. Si su doctor cree que el primer medicamento no funciona en su caso, entonces cubriremos el segundo. Usted puede saber si su medicamento tiene requisitos adicionales o límites buscando en las tablas en las páginas También puede obtener más información visitando nuestro sitio web en duals.caremore.com. Hemos publicado en línea un documento que explica nuestra restricción de autorización previa. También puede pedirnos que le enviemos una copia. Puede pedir una excepción de estos límites. Vea la pregunta 11 para obtener más información sobre las excepciones. Si se encuentra en un asilo de ancianos u otro centro de cuidado a largo plazo y necesita un medicamento que no está en la Lista de medicamentos o si no puede obtener con facilidad el medicamento que necesita, podemos ayudarlo. Cubriremos un suministro de emergencia de 31 días del medicamento que necesita (a menos que tenga una receta por menos días), aunque sea un nuevo miembro de CareMore Cal MediConnect Plan o no. Esto le dará tiempo para conversar con su doctor u otro recetante. Este profesional puede ayudarle a decidir si existe un medicamento similar en la lista de medicamentos que usted puede tomar o si solicita una excepción. Vea la pregunta 11 para obtener más información sobre las excepciones. 6. Cómo sabrá si el medicamento que desea tiene limitaciones o si existen acciones requeridas que realizar para obtener el medicamento La Lista de medicamentos cubiertos en la página 9 tiene una columna llamada Acciones necesarias, restricciones o límites de uso. 7. Qué ocurre si cambiamos nuestras reglas sobre cómo cubrimos algunos de los medicamentos Por ejemplo, si agregamos autorización (aprobación) previa, límites de cantidad y/o restricciones de terapia escalonada a un medicamento Le informaremos si agregamos aprobación previa, límites de cantidad y/o restricciones de terapia escalonada a un medicamento. Le diremos al menos 60 días antes de añadir la restricción o cuando solicite reabastecimiento a su farmacia. Luego, puede recibir un suministro de 60 días del medicamento antes de que se realice el cambio a las reglas de cobertura. Esto le permitirá contar con tiempo para conversar con su doctor u otro recetante acerca de lo que debe hacer a continuación. es gratuita. Para obtener más información, visite duals.caremore.com. 5

7 8. Cómo puede encontrar un medicamento en la lista de medicamentos Hay dos formas de encontrar un medicamento: Puede buscar en forma alfabética (si sabe cómo deletrear el medicamento) o Puede buscar por condición médica. Para buscar en forma alfabética, vaya a la sección Listado alfabético. Puede encontrarlo usando la primera letra del nombre del medicamento. Para buscar por condición médica, busque la sección llamada Lista de medicamentos por condición médica en la página 9. Los medicamentos en esta sección están agrupados en categorías, dependiendo del tipo de condiciones médicas para los que se utilizan. Por ejemplo, si tiene una condición cardiaca, debe buscar en la categoría, CARDIOVASCULAR, HIPERTENSIÓN / LÍPIDOS. Ahí es donde encontrará medicamentos para tratar condiciones cardiacas. 9. Qué pasa si el medicamento que desea tomar no está en la lista de medicamentos Si no encuentra su medicamento en la Lista de medicamentos, llame a Servicios al Miembro al (TTY 711) y pregunte por el mismo. Si se entera de que CareMore Cal MediConnect Plan no cubrirá el medicamento, puede seguir uno de estos dos pasos: Pida a Servicios al Miembro una lista de los medicamentos similares al que desea tomar. Luego muestre la lista a su doctor u otro recetante. Él o ella puede recetar un medicamento de la lista de medicamentos que sea similar al que usted desea tomar. O Puede pedirle al plan de salud que haga una excepción y cubra su medicamento. Vea la pregunta 11 para obtener más información sobre las excepciones. 10. Qué ocurre si usted es un nuevo miembro de CareMore Cal MediConnect Plan y no puede encontrar su medicamento en la Lista de medicamentos o tiene un problema para obtener su medicamento Podemos ayudar. Podemos cubrir un suministro temporal de 30 días de su medicamento durante los primeros 90 días en que usted es miembro de CareMore Cal MediConnect Plan. Esto le dará tiempo para conversar con su doctor u otro recetante. Este profesional puede ayudarle a decidir si existe un medicamento similar en la lista de medicamentos que usted puede tomar o si solicita una excepción. Cubriremos un suministro de 30 días de su medicamento si: usted toma un medicamento que no está en nuestra Lista de medicamentos, o las reglas del plan de salud no le permiten recibir la cantidad establecida por su recetante, o el medicamento requiere aprobación previa de CareMore Cal MediConnect Plan, o es gratuita. Para obtener más información, visite duals.caremore.com. 6

8 usted toma un medicamento que es parte de una restricción de terapia escalonada. Si vive en un asilo de ancianos u otro centro de cuidado a largo plazo, puede reabastecer su receta hasta por días. Puede reabastecer el medicamento múltiples veces durante sus primeros 90 días en el plan. Esto le brinda a su recetante tiempo para cambiar sus medicamentos a los que están en la Lista de medicamentos o pedir una excepción. Si experimenta un cambio en el nivel de cuidado que recibe, que le exige pasar de una instalación o centro de tratamiento a otro, puede ser elegible para un reabastecimiento temporal único de la receta que tiene actualmente. Por ejemplo, si recibe el alta del hospital y se le entrega una lista de medicamentos basada en el formulario del hospital, es posible que reciba un reabastecimiento único del medicamento. Puede recibir la excepción temporal única sin importar si se encuentra o no en sus primeros 90 días de inscripción en el programa. Pida a su recetante que nos llame para indicarnos los detalles. 11. Puede pedir una excepción para cubrir su medicamento Sí. Puede pedirle a CareMore Cal MediConnect Plan que haga una excepción para cubrir un medicamento que no está en la Lista de medicamentos. También nos puede pedir que cambiemos las reglas sobre su medicamento. Por ejemplo, CareMore Cal MediConnect Plan puede limitar la cantidad de un medicamento que cubriremos. Si su medicamento tiene un límite, puede pedirnos que cambiemos el límite y cubramos más. Otros ejemplos: Puede pedirnos que eliminemos las restricciones de terapia escalonada o requisitos de aprobación previa. 12. Cuánto tiempo toma obtener una excepción Primero, debemos recibir una declaración de su recetante que apoye su solicitud para una excepción. Después de recibir la declaración, le daremos una decisión sobre su solicitud de excepción dentro de 72 horas. Si usted o su recetante piensan que su salud se puede ver afectada si tiene que esperar 72 horas para recibir una decisión, puede solicitar una excepción acelerada. Esta es una decisión más rápida. Si su recetante apoya su solicitud, le daremos una decisión dentro de 24 horas de recibir la declaración de apoyo de su recetante. 13. Cómo puede pedir una excepción Para pedir una excepción, llame a Servicios al Miembro. Servicios al Miembro trabajará con usted y su proveedor para ayudarle a pedir una excepción es gratuita. Para obtener más información, visite duals.caremore.com. 7

9 14. Qué son medicamentos genéricos Los medicamentos genéricos están elaborados con los mismos ingredientes que los medicamentos de marca. Por lo general cuestan menos que el medicamento de marca y sus nombres son menos conocidos. Los medicamentos genéricos son aprobados por la Administración de Alimentos y Medicamentos (Food and Drug Administration (FDA)). CareMore Cal MediConnect Plan cubre medicamentos tanto de marca como genéricos. 15. Qué son medicamentos OTC OTC significa de venta libre. CareMore Cal MediConnect Plan cubre algunos medicamentos OTC, cuando están escritos como recetas por parte de su proveedor. Puede leer la Lista de medicamentos de CareMore Cal MediConnect Plan para ver qué OTC están cubiertos. 16. Cubre CareMore Cal MediConnect Plan productos OTC que no sean medicamentos Puede leer la Lista de medicamentos de CareMore Cal MediConnect Plan para ver qué productos OTC que no sean medicamentos están cubiertos. 17. Cuál es su copago Puede leer la Lista de medicamentos de CareMore Cal MediConnect Plan para conocer el copago de cada medicamento. Los miembros de CareMore Cal MediConnect Plan que viven en asilos de ancianos u otros centros de cuidado a largo plazo no tendrán copagos. Algunos miembros que reciben cuidado a largo plazo en la comunidad tampoco tendrán copagos. Los copagos están listados por niveles. Los niveles son grupos de medicamentos con el mismo copago. Los medicamentos del nivel 1 son medicamentos genéricos. El copago para medicamentos en este nivel es $0. Los medicamentos del nivel 2 son medicamentos de marca. El copago para medicamentos en este nivel es $0. Los medicamentos del nivel 3 son medicamentos recetados que están cubiertos por Medi-Cal. El copago por medicamentos en este nivel es $0. Los medicamentos del nivel 4 son medicamentos de venta libre (OTC) que están cubiertos por Medi-Cal. El copago por medicamentos en este nivel es $0. Lista de medicamentos cubiertos es gratuita. Para obtener más información, visite duals.caremore.com. 8

10 La lista de medicamentos cubiertos a continuación le da información sobre los medicamentos cubiertos por CareMore Cal MediConnect Plan. Si tiene problemas para encontrar su medicamento en la lista, vaya al Índice que empieza en la página 136. La primera columna del cuadro lista el nombre del medicamento. Los medicamentos de marca están en mayúsculas (por ejemplo: BRAND-NAME EXAMPLE) y los medicamentos genéricos están listados en minúsculas cursivas (por ejemplo: generic example). La información en la columna de le indica si CareMore Cal MediConnect Plan tiene alguna regla para cubrir su medicamento. Esta es una lista de las abreviaturas que usamos: Abreviatura B/D HI LA Descripción Determinación de Parte B vs. Parte D Infusión en el hogar Disponibilidad limitada Medicamento de pedido por correo Explicación Este medicamento recetado puede estar cubierto bajo Medicare Parte B o D dependiendo de las circunstancias. Tal vez se tenga que presentar información que describa el uso y entorno del medicamento para tomar la determinación. Este medicamento recetado puede ser cubierto bajo nuestro beneficio médico. Para obtener más información, llame a Servicios al Miembro al (TTY 711). Esta receta puede estar disponible solamente en ciertas farmacias. Para obtener más información, llame a Servicios al Miembro al (TTY 711). Este medicamento recetado está disponible a través de nuestro servicio de pedido por correo, como también a través de nuestras farmacias minoristas de la red. Considere el uso del pedido por correo para sus medicamentos a largo plazo (mantenimiento) (como medicamentos para la presión arterial alta). Las farmacias minoristas de la red pueden ser más adecuadas para recetas es gratuita. Para obtener más información, visite duals.caremore.com. 9

11 PAR QLL ST Se requiere autorización previa Límite de cantidad Terapia escalonada de corto plazo (como antibióticos). El Plan requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted tendrá que obtener aprobación antes de abastecer sus recetas. Si no obtiene aprobación, puede que no cubramos el medicamento. Para ciertos medicamentos, el Plan limita la cantidad del medicamento que cubriremos. Usted debe probar otros medicamentos antes de que pueda recibir este. Nota: El asterisco (*) junto a un medicamento significa que el medicamento no es un medicamento de la Parte D. No se le exigirá pagar un copago para estos medicamentos. Estos medicamentos también tienen reglas diferentes para las apelaciones. Una apelación es una manera formal de pedirnos que revisemos una decisión que tomamos sobre su cobertura y que la cambiemos si usted cree que cometimos un error. Por ejemplo, podríamos decidir que un medicamento que usted desea no está cubierto o ya no está cubierto por Medicare o Medi-Cal. Si usted o su doctor no está de acuerdo con nuestra decisión, puede apelar. Si alguna vez tiene una pregunta, llame a Servicios al Miembro al (TTY 711). También puede leer el manual del miembro para aprender cómo apelar a una decisión. es gratuita. Para obtener más información, visite duals.caremore.com. 10

12 Lista de medicamentos por condición médica Los medicamentos en esta sección están agrupados en categorías, dependiendo del tipo de condiciones médicas para los que se utilizan. Por ejemplo, si tiene una condición cardiaca, debe buscar en la categoría, CARDIOVASCULAR, HIPERTENSIÓN / LÍPIDOS. Ahí es donde encontrará medicamentos para tratar condiciones cardiacas. Nombre del medicamento ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET AMBISOME amphotericin b CANCIDAS clotrimazole mucous membrane ERAXIS(WATER DILUENT) fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 400 mg/200 ml fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml flucytosine griseofulvin microsize oral suspension griseofulvin ultramicrosize itraconazole ketoconazole oral NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet terbinafine hcl oral voriconazole intravenous B/D; ; HI B/D; B/D; B/D; PAR; ; QLL (630 per 30 days) ; QLL (30 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 11

13 voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg voriconazole oral tablet 50 mg ANTIVIRALS abacavir abacavir-lamivudine-zidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir amantadine hcl oral capsule amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION COMPLERA CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG DESCOVY didanosine oral capsule,delayed release (dr/ec) 125 mg didanosine oral capsule,delayed release (dr/ec) 200 mg didanosine oral capsule,delayed release (dr/ec) 250 mg, 400 mg EDURANT EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION PAR; ; QLL (300 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (60 per 30 days) B/D; ; QLL (120 per 30 days) QLL (390 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (600 per 30 days) ; QLL (30 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (870 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

14 entecavir EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM EVOTAZ famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium GENVOYA HARVONI INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET, CHEWABLE 100 MG ISENTRESS ORAL TABLET, CHEWABLE 25 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution lamivudine oral tablet 100 mg PAR; ; QLL (30 per 30 days) ; QLL (960 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (21 per 7 days) B/D ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (28 per 28 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (120 per 30 days) ; QLL (180 per 30 days) ; QLL (720 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (900 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 13

15 lamivudine oral tablet 150 mg lamivudine oral tablet 300 mg lamivudine-zidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET DERIBA nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY OLYSIO PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (1800 per 30 days) ; QLL (120 per 30 days) ; QLL (1200 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (360 per 30 days) ; QLL (480 per 30 days) ; QLL (360 per 30 days) QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (420 per 30 days) ; QLL (180 per 30 days) ; QLL (60 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 180 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

16 REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY SOVALDI stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg stavudine oral recon soln STRIBILD SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYNAGIS TAMIFLU TECHNIVIE TIVICAY ORAL TABLET 10 MG, 25 MG TIVICAY ORAL TABLET 50 MG TRIUMEQ TRIZIVIR TRUVADA ORAL TABLET MG, MG, MG TRUVADA ORAL TABLET MG TYBOST TYZEKA ; QLL (240 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (2400 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (360 per 30 days) ; QLL (30 per 30 days) PAR; ; LA PAR; ; QLL (56 per 28 days) QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 15

17 valacyclovir valganciclovir VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA ZEPATIER ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml ; QLL (30 per 2 days) ; QLL (1200 per 30 days) ; QLL (1200 per 30 days) PAR; ; QLL (300 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (960 per 30 days) ; QLL (180 per 30 days) ; QLL (1920 per 30 days) ; QLL (60 per 30 days) ; HI Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

18 cefazolin injection recon soln 1 gram cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g cefazolin injection recon soln 500 mg cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, 2 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium intravenous vial injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous vial intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral tablet HI ; HI ; HI HI ; HI HI ; HI HI ; HI HI ; HI ; HI HI es gratuita. Para obtener más información, visite duals.caremore.com. 17

19 TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 500 mg azithromycin intravenous recon soln 500 mg (2 mg/ml) azithromycin oral suspension for reconstitution azithromycin oral tablet clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml atovaquone atovaquone-proguanil oral tablet mg ; QLL (28 per 2 days) ; QLL (180 per 3 days) PAR; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

20 AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) baciim bacitracin intramuscular BILTRICIDE CAPASTAT CAYSTON chloramphenicol sod succinate chloroquine phosphate oral clindamycin hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) CUBICIN DAPSONE DARAPRIM ethambutol gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml ; HI HI PAR; ; LA ; HI es gratuita. Para obtener más información, visite duals.caremore.com. 19

21 hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid oral linezolid oral suspension for reconstitution linezolid oral tablet mefloquine meropenem metro i.v. metronidazole in nacl (iso-os) metronidazole oral MYCOBUTIN NEBUPENT neomycin paromomycin PASER PENTAM PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifampin RIFATER SIRTURO STREPTOMYCIN INTRAMUSCULAR STROMECTOL SYNERCID TOBI tobramycin sulfate injection recon soln ; HI ; HI PAR; ; QLL (1800 per 2 days) ; QLL (28 per 2 days) ; HI B/D; PAR; PAR; ; LA PAR; ; QLL (280 per 28 days) HI Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

22 tobramycin sulfate injection solution TRECATOR TYGACIL XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/ 100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/ 300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION PENICILLINS 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 ampicillin sodium intravenous recon soln 1 gram ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 1.5 gram ; HI ; HI PAR; ; QLL (84 per 28 days) HI ; HI PAR; ; QLL (1800 per 2 days) ; HI HI ; HI HI es gratuita. Para obtener más información, visite duals.caremore.com. 21

23 ampicillin-sulbactam intravenous recon soln 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/ 600K) dicloxacillin nafcillin injection recon soln 1 gram, 10 gram nafcillin injection recon soln 2 gram nafcillin intravenous recon soln 2 gram oxacillin injection recon soln 1 gram, 2 gram oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 1 gram oxacillin intravenous recon soln 2 gram PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 20 million unit penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium piperacillin-tazobactam ; HI ; HI HI HI ; HI ; HI ; HI Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

24 ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML, 4.5 GRAM/100 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML QUINOLONES ciprofloxacin er ciprofloxacin hcl oral ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin intravenous levofloxacin oral ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine oral sulfamethoxazole-trimethoprim TETRACYCLINES demeclocycline DOXY-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral tablet minocycline oral capsule HI ; HI es gratuita. Para obtener más información, visite duals.caremore.com. 23

25 minocycline oral tablet morgidox oral capsule 100 mg tetracycline URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 25 MG, 50 MG methenamine hippurate trimethoprim VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/ 100 ML, 750 MG/150 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/200 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/ 100 ML, 750 MG/150 ML vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg, 750 mg vancomycin intravenous recon soln 5 gram vancomycin oral capsule 125 mg vancomycin oral capsule 250 mg B/D ; HI B/D; ; HI ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 250 mg dexrazoxane hcl intravenous recon soln 500 mg ELITEK INTRAVENOUS RECON SOLN 1.5 MG elitek intravenous recon soln 7.5 mg PAR; ; QLL (40 per 2 days) PAR; ; QLL (80 per 2 days) PAR; PAR; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

26 FUSILEV KEPIVANCE leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral mesna MESNEX ORAL XGEVA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE AFINITOR AFINITOR DISPERZ ALECENSA ALIMTA anastrozole ARRANON ARZERRA ASTAGRAF XL AVASTIN azacitidine AZASAN azathioprine azathioprine sodium BELEODAQ BENDEKA bexarotene bicalutamide PAR; ; QLL (1.7 per 28 days) PAR; PAR; ; QLL (30 per 30 days) B/D; B/D; B/D; B/D PAR; ; QLL (4 per 30 days) PAR; ; QLL (300 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 25

27 BICNU bleomycin BLINCYTO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG BUSULFEX CABOMETYX ORAL TABLET 20 MG CABOMETYX ORAL TABLET 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/ DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/ DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/ DAY (20 MG X 3/DAY) COTELLIC cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine cytarabine (pf) injection solution 100 mg/ 5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ ml) PAR; PAR; ; QLL (120 per 30 days) PAR; ; QLL (30 per 30 days) B/D PAR; LA; QLL (90 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; ; LA; QLL (90 per 30 days) PAR; ; LA; QLL (30 per 30 days) B/D; PAR; ; QLL (56 per 28 days) PAR; ; QLL (112 per 28 days) PAR; ; QLL (84 per 28 days) PAR; ; LA; QLL (90 per 30 days) B/D; B/D B/D; B/D; PAR; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

28 cytarabine (pf) injection solution 20 mg/ ml dacarbazine DACOGEN DARZALEX daunorubicin intravenous solution decitabine DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous solution DROXIA EMCYT EMPLICITI epirubicin intravenous solution 200 mg/ 100 ml epirubicin intravenous solution 50 mg/25 ml ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane ; LA B/D; PAR; PAR; ; QLL (30 per 30 days) ; QLL (60 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 27

29 FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN GAZYVA gemcitabine intravenous recon soln 1 gram, 200 mg gemcitabine intravenous recon soln 2 gram gemcitabine intravenous solution 1 gram/ 26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gemcitabine intravenous solution 2 gram/ 52.6 ml (38 mg/ml) gengraf oral capsule 100 mg, 25 mg gengraf oral capsule 50 mg gengraf oral solution GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE HALAVEN HERCEPTIN HEXALEN ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; B/D; B/D B/D; PAR; ; QLL (30 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

30 hydroxyurea IBRANCE ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA irinotecan intravenous solution 100 mg/ 5 ml, 40 mg/2 ml irinotecan intravenous solution 500 mg/ 25 ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 15 MG JAKAFI ORAL TABLET 20 MG JAKAFI ORAL TABLET 25 MG JAKAFI ORAL TABLET 5 MG JEVTANA KADCYLA KEYTRUDA LENVIMA ORAL CAPSULE 10 MG/ DAY (10 MG X 1/DAY) PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (150 per 30 days) PAR; ; QLL (100 per 30 days) PAR; ; QLL (75 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (300 per 30 days) PAR; PAR; PAR; ; QLL (30 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 29

31 LENVIMA ORAL CAPSULE 14 MG/ DAY(10 MG X 1-4 MG X 1), 20 MG/ DAY (10 MG X 2) LENVIMA ORAL CAPSULE 18 MG/ DAY (10 MG X 1-4 MG X2) LENVIMA ORAL CAPSULE 24 MG/ DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 8 MG/ DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK) letrozole LEUKERAN leuprolide subcutaneous kit LONSURF LUPRON DEPOT (3 NTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG LYNPARZA LYSODREN MATULANE megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/20 ml (20 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl mercaptopurine methotrexate sodium PAR; ; QLL (60 per 30 days) PAR; QLL (90 per 30 days) PAR; ; QLL (90 per 30 days) PAR; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; PAR; PAR; ; QLL (1 per 28 days) PAR; PAR; ; QLL (480 per 30 days) PAR; QLL (90 per 30 days) PAR; QLL (30 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

32 methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil mycophenolate sodium NEXAVAR NILANDRON NINLARO NIPENT NULOJIX octreotide acetate ODOMZO ONCASPAR OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE 2 MG POMALYST ORAL CAPSULE 3 MG, 4 MG PORTRAZZA PROGRAF INTRAVENOUS B/D; B/D; PAR; ; LA; QLL (120 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (3 per 28 days) B/D; PAR; PAR; ; LA; QLL (30 per 30 days) PAR; PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) B/D; es gratuita. Para obtener más información, visite duals.caremore.com. 31

33 PURIXAN RAPAMUNE REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG RITUXAN SANDIMMUNE ORAL SOLUTION SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG SYNRIBO TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG TARGRETIN ORAL PAR; B/D; ; LA; QLL (60 per 30 days) ; LA; QLL (30 per 30 days) ; LA; QLL (150 per 30 days) PAR; B/D; B/D B/D; B/D; ; QLL (30 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) B/D; PAR; QLL (120 per 30 days) PAR; ; LA; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) PAR; ; QLL (300 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

34 TARGRETIN TOPICAL TASIGNA TECENTRIQ THALOMID ORAL CAPSULE 100 MG, 50 MG THALOMID ORAL CAPSULE 150 MG, 200 MG thiotepa toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML, 3.75 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML tretinoin (chemotherapy) TREXALL TRISENOX TYKERB UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG PAR; ; QLL (120 per 30 days) LA; QLL (20 per 21 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (1 per 168 days) ; QLL (1 per 168 days) ; LA; QLL (180 per 30 days) PAR; PAR; LA; QLL (60 per 30 days) PAR; LA; QLL (120 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 33

35 VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK vinblastine intravenous solution VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML vincasar pfs intravenous solution 2 mg/2 ml vincristine vinorelbine VOTRIENT XALKORI XTANDI YERVOY YONDELIS ZALTRAP ZANOSAR ZELBORAF ZOLINZA ZORTRESS ZYDELIG ZYKADIA ZYTIGA PAR; LA; QLL (30 per 30 days) PAR; LA; QLL (42 per 365 days) ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) PAR; PAR; ; QLL (240 per 30 days) ; QLL (120 per 30 days) B/D; AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG PAR; ; QLL (60 per 30 days) PAR; ; QLL (150 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (2400 per 30 days) PAR; ; QLL (480 per 30 days) PAR; ; QLL (240 per 30 days) PAR PAR; QLL (600 per 30 days) PAR; QLL (600 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

36 BRIVIACT ORAL TABLET 100 MG, 75 MG BRIVIACT ORAL TABLET 25 MG BRIVIACT ORAL TABLET 50 MG carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/ 5 ml carbamazepine oral suspension 200 mg/ 10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating mg clonazepam oral tablet,disintegrating 0.25 mg clonazepam oral tablet,disintegrating 0.5 mg clonazepam oral tablet,disintegrating 1 mg clonazepam oral tablet,disintegrating 2 mg diazepam rectal kit mg diazepam rectal kit 2.5 mg, mg PAR; QLL (60 per 30 days) PAR; QLL (240 per 30 days) PAR; QLL (120 per 30 days) ; QLL (1200 per 30 days) ; QLL (600 per 30 days) ; QLL (300 per 30 days) ; QLL (4800 per 30 days) ; QLL (2400 per 30 days) ; QLL (1200 per 30 days) ; QLL (600 per 30 days) ; QLL (300 per 30 days) ; QLL (2 per 2 days) es gratuita. Para obtener más información, visite duals.caremore.com. 35

37 DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS divalproex epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ethosuximide felbamate fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (180 per 30 days) QLL (720 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (45 per 30 days) ; QLL (1080 per 30 days) ; QLL (360 per 30 days) ; QLL (270 per 30 days) ; QLL (2160 per 30 days) QLL (2160 per 30 days) ; QLL (180 per 30 days) ; QLL (135 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

38 lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (720 per 30 days) ; QLL (360 per 30 days) ; QLL (240 per 30 days) ; QLL (900 per 30 days) PAR; ; QLL (480 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 37

39 PEGANONE phenobarbital oral elixir phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg phenobarbital oral tablet 16.2 mg phenobarbital oral tablet 30 mg phenobarbital oral tablet 32.4 mg phenobarbital oral tablet 60 mg phenobarbital oral tablet 64.8 mg phenobarbital oral tablet 97.2 mg phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG primidone roweepra SABRIL SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG tiagabine topiramate oral capsule, sprinkle topiramate oral tablet 100 mg topiramate oral tablet 200 mg topiramate oral tablet 25 mg ; QLL (3000 per 30 days) ; QLL (120 per 30 days) ; QLL (800 per 30 days) ; QLL (741 per 30 days) ; QLL (400 per 30 days) ; QLL (370 per 30 days) ; QLL (200 per 30 days) ; QLL (185 per 30 days) ; QLL (123 per 30 days) ; QLL (90 per 30 days) ; QLL (270 per 30 days) ; LA; QLL (180 per 30 days) QLL (60 per 30 days) QLL (120 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (1920 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

40 topiramate oral tablet 50 mg TRILEPTAL ORAL SUSPENSION valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG VIMPAT ORAL TABLET 200 MG VIMPAT ORAL TABLET 50 MG zonisamide ANTIPARKINSONISM AGENTS APOKYN AZILECT benztropine oral bromocriptine carbidopa-levodopa entacapone NEUPRO pramipexole oral tablet ropinirole oral tablet selegiline hcl tolcapone trihexyphenidyl ; QLL (960 per 30 days) QLL (1200 per 30 days) ; QLL (1200 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) PAR; ; LA PAR; ; QLL (30 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 39

41 MIGRAINE / CLUSTER HEADACHE THERAPY ERGOMAR MIGRANAL rizatriptan sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml zolmitriptan ZOMIG NASAL MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil oral tablet 10 mg donepezil oral tablet 5 mg donepezil oral tablet,disintegrating 10 mg donepezil oral tablet,disintegrating 5 mg EXELON TRANSDERMAL galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet GILENYA GLATOPA ; QLL (8 per 28 days) ; QLL (12 per 30 days) ; QLL (9 per 30 days) ; QLL (4 per 30 days) ; QLL (4 per 30 days) ; QLL (4 per 30 days) QLL (4 per 30 days) ; QLL (9 per 30 days) ; QLL (6 per 30 days) PAR; ; LA; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (12 per 28 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

42 memantine oral solution memantine oral tablet 10 mg memantine oral tablet 5 mg NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET 10 MG NAMENDA ORAL TABLET 5 MG NAMENDA TITRATION PAK NAMENDA XR ORAL CAP, SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE, SPRINKLE,ER 24HR NUEDEXTA rivastigmine rivastigmine tartrate tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg TYSABRI XENAZINE ORAL TABLET 12.5 MG XENAZINE ORAL TABLET 25 MG MUSCLE RELAXANTS / ANTISPASDIC THERAPY AMRIX baclofen dantrolene MESTINON ORAL SYRUP MESTINON TIMESPAN pyridostigmine bromide tizanidine oral tablet NARCOTIC ANALGESICS ABSTRAL ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (56 per 365 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; LA PAR; ; LA; QLL (240 per 30 days) PAR; ; LA; QLL (120 per 30 days) PAR; PAR; ; QLL (120 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 41

43 acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg / 10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg butalbital-acetaminop-caf-cod oral capsule mg duramorph (pf) injection solution 0.5 mg/ ml duramorph (pf) injection solution 1 mg/ ml endocet oral tablet mg, mg, mg fentanyl citrate fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg QLL (4500 per 30 days) ; QLL (4500 per 30 days) ; QLL (390 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (150 per 30 days) QLL (150 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (180 per 30 days) QLL (180 per 30 days) ; QLL (360 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (15 per 30 days) PAR; ; QLL (120 per 30 days) QLL (2700 per 30 days) ; QLL (2700 per 30 days) ; QLL (390 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

44 hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-ibuprofen oral tablet mg hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY LAZANDA NASAL SPRAY,NON- AEROSOL 300 MCG/SPRAY levorphanol tartrate LORCET (HYDROCODONE) LORCET HD LORCET PLUS ORAL TABLET MG LORTAB LORTAB LORTAB methadone injection methadone intensol methadone oral concentrate methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg methadose oral concentrate morphine (pf) injection solution 0.5 mg/ ml morphine (pf) injection solution 1 mg/ml ; QLL (360 per 30 days) ; QLL (480 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) PAR; ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) QLL (150 per 30 days) ; QLL (180 per 30 days) ; QLL (180 per 30 days) ; QLL (900 per 30 days) ; QLL (1800 per 30 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (180 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 43

45 morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine intravenous cartridge 2 mg/ml RPHINE INTRAVENOUS CARTRIDGE 8 MG/ML morphine intravenous solution 10 mg/ml, 50 mg/ml morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml RPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML morphine intravenous syringe 2 mg/ml, 4 mg/ml morphine oral capsule, er multiphase 24 hr 30 mg, 60 mg morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 10 mg/5 ml morphine oral solution 20 mg/5 ml (4 mg/ ml) morphine oral tablet 15 mg morphine oral tablet 30 mg morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg morphine oral tablet extended release 200 mg NORCO oxycodone oral capsule oxycodone oral concentrate oxycodone oral tablet 10 mg, 5 mg ; QLL (120 per 30 days) B/D; QLL (180 per 30 days) ; QLL (270 per 30 days) QLL (120 per 30 days) QLL (120 per 30 days) ; QLL (120 per 30 days) QLL (120 per 30 days) ; QLL (180 per 30 days) QLL (120 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (2700 per 30 days) ; QLL (1350 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

46 oxycodone oral tablet 15 mg oxycodone oral tablet 20 mg, 30 mg oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin SUBSYS vicodin vicodin es vicodin hp XODOL 10/300 XODOL 5/300 XODOL 7.5/300 NON-NARCOTIC ANALGESICS ACEPHEN RECTAL SUPPOSITORY 650 MG ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML ACETAMINOPHEN EXTRA STRENGTH ORAL SUSPENSION 160 MG/5 ML ACETAMINOPHEN LIQUID acetaminophen oral suspension 160 mg/ 5 ml acetaminophen oral tablet 500 mg ACETAMINOPHEN PAIN RELIEF acetaminophen rectal suppository 650 mg ; QLL (540 per 30 days) ; QLL (180 per 30 days) QLL (1800 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; QLL (390 per 30 days) ; ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 45

47 ADDED STRENGTH PAIN RELIEVER ADULT LOW DOSE ASPIRIN ALL DAY RELIEF ASPIR-LOW ASPIRIN LOW DOSE aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg BETATEMP buprenorphine-naloxone sublingual tablet mg buprenorphine-naloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal diclofenac potassium diclofenac sodium oral diflunisal ECOTRIN LOW STRENGTH ENTERIC COATED ASPIRIN etodolac fenoprofen oral tablet FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION FEVERALL RECTAL SUPPOSITORY 650 MG FLANAX (NAPROXEN) flurbiprofen ; ; ; ; ; ; ; PAR; ; QLL (360 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (5 per 28 days) ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

48 HEADACHE RELIEF (ASA-ACET- CAF) I-PRIN IBUPROFEN IB ORAL TABLET ibuprofen oral capsule ibuprofen oral suspension ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg MAPAP EXTRA STRENGTH MASOPHEN ORAL TABLET 500 MG meclofenamate oral MEDIPROXEN meloxicam oral suspension meloxicam oral tablet MENSTRUAL RELIEF MIGRAINE FORMULA MIGRAINE RELIEF nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone naltrexone naproxen naproxen sodium oral capsule naproxen sodium oral tablet 220 mg naproxen sodium oral tablet 275 mg, 550 mg NON-ASPIRIN ORAL SUSPENSION ; ; ; QLL (300 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; es gratuita. Para obtener más información, visite duals.caremore.com. 47

49 oxaprozin PAIN AND FEVER ORAL TABLET 500 MG PAIN RELIEF (ACETAMIN-ASP-CAF) PAIN RELIEF EXTRA STRENGTH PAIN RELIEF ORAL TABLET PAIN RELIEVER (ACETAM-ASPIRIN) PAIN RELIEVER EXTRA STRENGTH PAIN RELIEVER ORAL CAPSULE PAIN RELIEVER ORAL TABLET 500 MG PAIN RELIEVER PLUS PAIN-OFF PAMPRIN MAX PHARBETOL ORAL TABLET 500 MG piroxicam PROVIL Q-PAP EXTRA STRENGTH Q-PAP ORAL TABLET 500 MG sulindac oral SUPER PAIN RELIEF tolmetin tramadol oral tablet tramadol-acetaminophen VOLTAREN TOPICAL GEL 1 % PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ADASUVE alprazolam oral tablet amitriptyline amoxapine ; ; ; ; ; QLL (240 per 30 days) ; QLL (240 per 30 days) ; QLL (1000 per 30 days) ; QLL (1 per 28 days) ; QLL (90 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

50 aripiprazole oral solution aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg, 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet,disintegrating 10 mg aripiprazole oral tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg buspirone chlorpromazine citalopram oral solution ; QLL (900 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (450 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (1.6 per 30 days) PAR; ; QLL (2.4 per 30 days) PAR; ; QLL (3.2 per 30 days) ; QLL (135 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (600 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 49

51 citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg clomipramine clorazepate dipotassium clozapine oral tablet 100 mg clozapine oral tablet 200 mg clozapine oral tablet 25 mg clozapine oral tablet 50 mg clozapine oral tablet,disintegrating 100 mg clozapine oral tablet,disintegrating 12.5 mg clozapine oral tablet,disintegrating 150 mg clozapine oral tablet,disintegrating 200 mg clozapine oral tablet,disintegrating 25 mg desipramine oral DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (270 per 30 days) ; QLL (135 per 30 days) ; QLL (1080 per 30 days) ; QLL (540 per 30 days) QLL (270 per 30 days) QLL (2160 per 30 days) QLL (180 per 30 days) QLL (135 per 30 days) QLL (1080 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) QLL (120 per 30 days) QLL (240 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

52 dextroamphetamine oral capsule, extended release 10 mg, 5 mg dextroamphetamine oral capsule, extended release 15 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamine-amphetamine oral tablet 30 mg diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ ml) diazepam oral solution 5 mg/5 ml (1 mg/ ml, 5 ml) diazepam oral tablet 10 mg diazepam oral tablet 2 mg diazepam oral tablet 5 mg doxepin oral 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 EMSAM ; QLL (60 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (240 per 30 days) ; QLL (1200 per 30 days) QLL (1200 per 30 days) ; QLL (120 per 30 days) ; QLL (600 per 30 days) ; QLL (240 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 51

53 ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG FANAPT ORAL TABLET 12 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET, DISINTEGRATING 100 MG FAZACLO ORAL TABLET, DISINTEGRATING 12.5 MG FAZACLO ORAL TABLET, DISINTEGRATING 25 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 40 MG fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral solution ; QLL (600 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (720 per 30 days) QLL (72 per 30 days) ; QLL (60 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (16 per 365 days) QLL (270 per 30 days) QLL (2160 per 30 days) QLL (1080 per 30 days) PAR; ; QLL (56 per 365 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (600 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

54 fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg fluphenazine decanoate fluphenazine hcl fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULAR guanidine haloperidol haloperidol decanoate haloperidol lactate HETLIOZ imipramine hcl INTUNIV ER INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (2 per 28 days) ; QLL (0.875 per 90 days) ; QLL (1.315 per 90 days) ; QLL (1.75 per 90 days) es gratuita. Para obtener más información, visite duals.caremore.com. 53

55 INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG LATUDA ORAL TABLET 120 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG LATUDA ORAL TABLET 80 MG lithium carbonate lithium citrate oral solution 8 meq/5 ml LORAZEPAM INTENSOL lorazepam oral tablet loxapine succinate LUNESTA maprotiline oral tablet 25 mg maprotiline oral tablet 50 mg maprotiline oral tablet 75 mg MARPLAN METADATE ER methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule,er biphasic mg methylphenidate oral capsule,er biphasic mg methylphenidate oral tablet methylphenidate oral tablet extended release ; QLL (2.625 per 90 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (75 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) ; QLL (270 per 30 days) ; QLL (135 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (90 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

56 methylphenidate oral tablet extended release 24hr 18 mg mirtazapine oral tablet 15 mg mirtazapine oral tablet 30 mg mirtazapine oral tablet 45 mg mirtazapine oral tablet 7.5 mg mirtazapine oral tablet,disintegrating 15 mg mirtazapine oral tablet,disintegrating 30 mg mirtazapine oral tablet,disintegrating 45 mg modafinil oral tablet 100 mg modafinil oral tablet 200 mg molindone nefazodone oral tablet 100 mg nefazodone oral tablet 150 mg nefazodone oral tablet 200 mg nefazodone oral tablet 250 mg nefazodone oral tablet 50 mg nortriptyline NUPLAZID olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 20 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (72 per 30 days) ; QLL (360 per 30 days) PAR; LA; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (40 per 30 days) ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 55

57 olanzapine oral tablet,disintegrating 10 mg olanzapine oral tablet,disintegrating 15 mg olanzapine oral tablet,disintegrating 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapine-fluoxetine oral capsule mg, mg, 6-50 mg olanzapine-fluoxetine oral capsule 3-25 mg, 6-25 mg ORAP paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION perphenazine phenelzine ; QLL (60 per 30 days) ; QLL (40 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (45 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (900 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

58 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG REXULTI ORAL TABLET 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/ 2 ML risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.25 mg ; QLL (120 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (960 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (2 per 28 days) ; QLL (480 per 30 days) ; QLL (1920 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) ; QLL (1920 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 57

59 risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 1 mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ROZEREM SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg SLEEP AID (DOXYLAMINE) STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG ; QLL (960 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (150 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

60 STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG SURNTIL temazepam oral capsule 15 mg, 22.5 mg, 30 mg thioridazine thiothixene tranylcypromine trazodone trifluoperazine trintellix oral tablet 10 mg trintellix oral tablet 20 mg trintellix oral tablet 5 mg ULTRA SLEEP (DOXYLAMINE SUCC) venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 100 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg venlafaxine oral tablet 75 mg venlafaxine oral tablet extended release 24hr 150 mg venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg ; QLL (30 per 30 days) ; QLL (30 per 30 days) QLL (60 per 30 days) QLL (30 per 30 days) QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (113 per 30 days) ; QLL (450 per 30 days) ; QLL (300 per 30 days) ; QLL (225 per 30 days) ; QLL (150 per 30 days) ; QLL (60 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 59

61 VERSACLOZ VIIBRYD ORAL TABLET 10 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK XYREM zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg zenzedi oral tablet 10 mg zenzedi oral tablet 5 mg ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution amiodarone intravenous syringe amiodarone oral dofetilide flecainide lidocaine (pf) intravenous solution lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %) QLL (600 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) PAR; QLL (7 per 365 days) PAR; ; LA; QLL (540 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) QLL (2 per 28 days) ; QLL (2 per 28 days) B/D; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/ B/D

62 mexiletine MULTAQ pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ ml procainamide injection solution 500 mg/ ml propafenone oral tablet quinidine gluconate oral quinidine sulfate oral tablet sorine oral tablet 120 mg, 160 mg, 80 mg sorine oral tablet 240 mg sotalol af sotalol oral TIKOSYN ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr amiloride amiloride-hydrochlorothiazide amlodipine besylate oral tablet 10 mg, 2.5 mg amlodipine besylate oral tablet 5 mg amlodipine-benazepril atenolol atenolol-chlorthalidone benazepril benazepril-hydrochlorothiazide ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (45 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 61

63 betaxolol oral bisoprolol fumarate bisoprolol-hydrochlorothiazide bumetanide candesartan oral tablet 16 mg, 4 mg, 8 mg candesartan oral tablet 32 mg candesartan-hydrochlorothiazid oral tablet mg candesartan-hydrochlorothiazid oral tablet mg, mg captopril captopril-hydrochlorothiazide cartia xt carvedilol chlorothiazide chlorthalidone oral tablet 25 mg, 50 mg clonidine hcl oral tablet clonidine transdermal patch DEMSER dilt-xr diltiazem hcl intravenous solution diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (4 per 28 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

64 diltiazem hcl oral tablet extended release 24 hr doxazosin enalapril maleate enalapril-hydrochlorothiazide eplerenone eprosartan felodipine oral er fosinopril fosinopril-hydrochlorothiazide furosemide injection solution furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet hydralazine hydrochlorothiazide indapamide irbesartan labetalol intravenous solution labetalol oral lisinopril lisinopril-hydrochlorothiazide losartan oral tablet 100 mg losartan oral tablet 25 mg, 50 mg losartan-hydrochlorothiazide matzim la methyclothiazide methyldopa methyldopa-hydrochlorothiazide ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 63

65 methyldopate metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate intravenous solution metoprolol tartrate intravenous syringe metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg minoxidil oral nadolol nadolol-bendroflumethiazide nicardipine oral nifedical xl nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr pindolol prazosin oral propranolol intravenous propranolol oral propranolol-hydrochlorothiazid quinapril quinapril-hydrochlorothiazide ramipril spironolacton-hydrochlorothiaz spironolactone taztia xt telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg terazosin timolol maleate oral ; QLL (30 per 30 days) ; QLL (60 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

66 torsemide oral trandolapril triamterene-hydrochlorothiazid oral capsule mg triamterene-hydrochlorothiazid oral tablet valsartan oral tablet 160 mg valsartan oral tablet 320 mg valsartan oral tablet 40 mg, 80 mg valsartan-hydrochlorothiazide verapamil verapamil intravenous solution CARDIAC GLYCOSIDES digox oral tablet 125 mcg digoxin injection solution digoxin oral solution 50 mcg/ml digoxin oral tablet 125 mcg LANOXIN ORAL TABLET 125 MCG, 62.5 MCG COAGULATION THERAPY AGGRENOX BRILINTA cilostazol clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg EFFIENT ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG enoxaparin subcutaneous solution ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (1 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (74 per 30 days) ; QLL (84 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 65

67 enoxaparin subcutaneous syringe 100 mg/ ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/ 0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 mg/ 0.3 ml enoxaparin subcutaneous syringe 40 mg/ 0.4 ml enoxaparin subcutaneous syringe 60 mg/ 0.6 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/ 0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml (100 unit/ml), 25,000 unit/500 ml (50 unit/ ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2, 000 unit/1,000 ml heparin (porcine) injection cartridge heparin (porcine) injection solution HEPARIN FLUSH heparin lock flush intravenous kit 100 unit/ml $0 (Tier 3) $0 (Tier 3) ; QLL (28 per 30 days) ; QLL (22.4 per 30 days) ; QLL (8.4 per 30 days) ; QLL (11.2 per 30 days) ; QLL (16.8 per 30 days) ; QLL (24 per 30 days) ; QLL (15 per 30 days) ; QLL (12 per 30 days) ; QLL (18 per 30 days) B/D; HI B/D; ; HI B/D; HI B/D; ; HI B/D; ; HI ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

68 heparin lock flush intravenous solution 10 unit/ml, 100 unit/ml heparin lock flush intravenous syringe 10 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 100 UNIT/ ML HEPARIN LOCKFLUSH(PORCINE) (PF) HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/500 ml heparin, porcine (pf) injection solution heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml) HEPARIN, PORCINE (PF) INTRAVENOUS SYRINGE 1 UNIT/ML heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml jantoven MEPHYTON NOJECT PREFILL (PF) NOJECT PREFILL ADVANCED (PF) pentoxifylline PRADAXA ORAL CAPSULE 110 MG $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) B/D; ; B/D; B/D; ; B/D; ; B/D B/D B/D; B/D; B/D; B/D; B/D; ; ; B/D; B/D; ; es gratuita. Para obtener más información, visite duals.caremore.com. 67

69 PRADAXA ORAL CAPSULE 150 MG, 75 MG PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG PROMACTA ORAL TABLET 50 MG tranexamic acid intravenous warfarin XARELTO ORAL TABLET 10 MG, 20 MG XARELTO ORAL TABLET 15 MG XARELTO ORAL TABLETS,DOSE PACK LIPID/CHOLESTEROL LOWERING AGENTS atorvastatin cholestyramine (with sugar) cholestyramine light colestipol fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized 48 mg, 145 mg fenofibrate oral tablet 160 mg, 54 mg gemfibrozil oral JUXTAPID KYNAMRO lovastatin oral tablet 10 mg, 20 mg lovastatin oral tablet 40 mg niacin oral capsule, extended release 250 mg, 500 mg niacin oral tablet 100 mg, 50 mg, 500 mg NIACIN ORAL TABLET 250 MG niacin oral tablet extended release 24 hr 1,000 mg, 750 mg ; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) PAR; ; LA; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (42 per 30 days) ; QLL (102 per 365 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) PAR; ; LA PAR; ; LA ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; ; ; ; QLL (60 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

70 niacin oral tablet extended release 24 hr 500 mg niacin oral tablet extended release 250 mg, 750 mg NIACOR NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 1,000 MG, 750 MG NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 500 MG omega-3 acid ethyl esters PRALUENT PEN PRALUENT SYRINGE pravastatin prevalite REPATHA SURECLICK REPATHA SYRINGE simvastatin WELCHOL ZETIA MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA VECAMYL NITRATES isosorbide dinitrate oral isosorbide mononitrate nitro-bid nitroglycerin intravenous nitroglycerin transdermal patch 24 hour ; QLL (30 per 30 days) ; ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (2 per 28 days) PAR; ; QLL (2 per 28 days) ; QLL (30 per 30 days) PAR; ; QLL (3 per 28 days) PAR; ; QLL (3 per 28 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) B/D es gratuita. Para obtener más información, visite duals.caremore.com. 69

71 NITROSTAT DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC calcipotriene scalp calcipotriene topical selenium sulfide topical lotion SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG VECTICAL BURN THERAPY silver sulfadiazine ssd KERATOLYTICS SALICYLIC ACID TOPICAL LIQUID 3 % SCALP RELIEF HYDROCORTISONE TOPICAL LIQUID 3 % MISCELLANEOUS DERMATOLOGICALS 8-P AMLACTIN TOPICAL LOTION ammonium lactate AMNIUM LACTATE TOPICAL LOTION 12 % AMNIUM LACTATE TOPICAL LOTION 5 % calamine CALAMINE-ZINC OXIDE TOPICAL LOTION 8-8 % diclofenac sodium topical gel 3 % ELIDEL fluorouracil topical cream 5 % GORMEL TEN ; QLL (60 per 30 days) ; QLL (120 per 30 days) PAR; ; ; ; PAR; ; QLL (100 per 30 days) PAR; ; QLL (100 per 90 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

72 imiquimod methoxsalen rapid OXSORALEN PANRETIN PICATO podofilox PROTOPIC SKIN TREATMENT urea topical cream 10 %, 20 % urea topical lotion 10 % UREACIN-20 UVADEX VALCHLOR THERAPY FOR ACNE ACNE TREATMENT (BENZOYL PEROX) TOPICAL GEL ACNE-CLEAR benzoyl peroxide topical gel 10 %, 5 % BP clindamycin phosphate topical DIFFERIN TOPICAL GEL 0.3 % DIFFERIN TOPICAL GEL WITH PUMP ery pads erythromycin with ethanol erythromycin-benzoyl peroxide metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical lotion PERSA-GEL PAR; PAR; ; QLL (100 per 90 days) ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 71

73 rosadan topical cream TAZORAC tretinoin topical cream tretinoin topical gel 0.01 %, % TOPICAL ANESTHETICS lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 15 mg/ml (1.5 %) lidocaine hcl injection solution lidocaine hcl laryngotracheal lidocaine hcl mucous membrane lidocaine hcl urethral lidocaine topical adhesive patch, medicated lidocaine topical ointment lidocaine viscous lidocaine-prilocaine topical cream TOPICAL ANTIBACTERIALS ANTIBIOTIC (NEOMY-BACIT- POLYM) ANTIBIOTIC-PAIN RELIEF (BACIT) bacitracin topical ointment BACITRACIN TOPICAL PACKET BACITRACIN ZINC TOPICAL PACKET bacitracin-polymyxin b topical ointment bacitracin-polymyxin b topical packet BACITRAYCIN PLUS TOPICAL OINTMENT 500 UNIT/GRAM DOUBLE ANTIBIOTIC ; QLL (45 per 30 days) ; QLL (45 per 30 days) PAR; ; QLL (90 per 30 days) ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

74 gentamicin topical mupirocin topical ointment NEOSPORIN PLUS PAINRELIEF(BAC) POLY BACITRACIN sulfacetamide sodium (acne) SULFAMYLON TRI-BIOZENE TRIPLE ANTIBIOTIC (PRAM) EXTRA TRIPLE ANTIBIOTIC PLUS TRIPLE ANTIBIOTIC TOPICAL OINTMENT TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET TRIPLE ANTIBIOTIC-PAIN RELIEF TOPICAL ANTIFUNGALS ANTI-FUNGAL MICONAZOLE POWDER TOPICAL POWDER 2 % ANTIFUNGAL (CLOTRIMAZOLE) ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM ANTIFUNGAL MICONAZOLE CREAM ATHLETE'S FOOT (TERBINAFINE) ATHLETE'S FOOT (TOLNAFTATE) ATHLETE'S FOOT AF ciclodan topical solution ciclopirox topical cream ciclopirox topical gel ; ; PAR; es gratuita. Para obtener más información, visite duals.caremore.com. 73

75 ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension CLOTRIMAZOLE AF CLOTRIMAZOLE ANTIFUNGAL clotrimazole topical clotrimazole-betamethasone DESENEX TOPICAL POWDER econazole topical FUNGOID-D INZO ANTIFUNGAL JOCK ITCH JOCK ITCH (CLOTRIMAZOLE) JOCK ITCH (TERBINAFINE) ketoconazole topical LAMISIL AT TOPICAL CREAM LOTRIMIN AF TOPICAL CREAM LOTRIMIN AF TOPICAL POWDER MICATIN miconazole nitrate topical cream MICONAZORB AF MICRO-GUARD nyamyc nystatin topical nystatin-triamcinolone nystop ODOR CONTROL FOOT-SNEAKER RINGWORM SECURA ANTIFUNGAL PAR; ; ; ; ; ; ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

76 SECURA ANTIFUNGAL EXTRA THICK terbinafine hcl topical TINACTIN TOPICAL AEROSOL POWDER tolnaftate topical aerosol powder tolnaftate topical cream ZEASORB (MICONAZOLE) TOPICAL ANTIVIRALS acyclovir topical DENAVIR TOPICAL CORTICOSTEROIDS ala-cort topical cream alclometasone amcinonide ANTI-ITCH (HC) TOPICAL CREAM ANTI-ITCH (HC) TOPICAL OINTMENT BETA-HC betamethasone dipropionate betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical lotion betamethasone, augmented topical ointment CAPEX clobetasol scalp ; ; ; ; QLL (30 per 30 days) ; QLL (5 per 2 days) ; es gratuita. Para obtener más información, visite duals.caremore.com. 75

77 clobetasol topical cream clobetasol topical gel clobetasol topical ointment clobetasol-emollient topical cream cormax scalp CORTISONE (HYDROCORTISONE) TOPICAL CREAM CORTIZONE-10 PLUS CORTIZONE-10 TOPICAL CREAM CORTIZONE-10 TOPICAL OINTMENT desonide desoximetasone diflorasone ECZEMA ANTI-ITCH fluocinolone fluocinolone and shower cap fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e fluticasone topical cream fluticasone topical ointment halobetasol propionate HALOG hydrocortisone acetate topical HYDROCORTISONE PLUS hydrocortisone topical cream 0.5 % hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 1 % ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

78 hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 0.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate hydrocortisone-min oil-wht pet HYDROCREAM HYDROSKIN TOPICAL LOTION LOKARA mometasone topical NEOSPORIN ANTI-ITCH NOBLE FORMULA HC TOPICAL CREAM RECORT PLUS SCALP RELIEF HYDROCORTISONE TOPICAL SOLUTION 1 % SCALPICIN ANTI-ITCH SOOTHING CARE (HYDROCORTISONE) triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % trianex triderm topical cream TOPICAL ENZYMES SANTYL TOPICAL SCABICIDES / PEDICULICIDES COMPLETE LICE TREATMENT LICE BEDDING SPRAY ; ; ; ; QLL (30 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 77

79 LICE COMPLETE KIT LICE CREAM RINSE LICE KILLING LICE KILLING (PERMETHRIN) LICE PYRINYL SHAMPOO LICE SOLUTION LICE TREATMENT (PERMETHRIN) LICE TREATMENT TOPICAL LIQUID 1 % LICE TREATMENT TOPICAL SHAMPOO lindane topical shampoo permethrin topical cream permethrin topical liquid RID COMPLETE LICE ELIM KIT TOPICAL STOP LICE DIAGNOSTICS / MISCELLANEOUS AGENTS ANOREXIANTS benzphetamine oral tablet 50 mg phentermine ANTIDOTES acetylcysteine intravenous IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringers irrigation MISCELLANEOUS AGENTS acamprosate ADAGEN alendronate oral tablet 40 mg $0 (Tier 3) $0 (Tier 3) ; PAR; ; PAR; ; B/D; B/D; ; QLL (30 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

80 anagrelide ARALAST NP BUPHENYL ORAL TABLET CARBAGLU cevimeline CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride DEX4 GLUCOSE ORAL TABLET, CHEWABLE DEX4 GLUCOSE POUCH PACK DEX4 GLUCOSE QUICK DISSOLVE dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe PAR; ; LA PAR; PAR; ; LA B/D; HI B/D; HI B/D; HI HI HI ; HI ; HI ; HI ; HI ; HI ; HI HI HI es gratuita. Para obtener más información, visite duals.caremore.com. 79

81 dextrose 70 % in water (d70w) dextrose oral gel dextrose with sodium chloride disulfiram EXJADE FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET GLUCO BURST GLUCOSE GEL glucose oral tablet,chewable 4 gram GLUTOSE 15 GLUTOSE 45 INCRELEX INSTA-GLUCOSE kionex oral suspension levocarnitine (with sugar) levocarnitine oral tablet midodrine ORFADIN ORAL CAPSULE pilocarpine hcl oral RAVICTI RENAGEL RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM RENVELA ORAL TABLET riluzole sodium chloride 0.9 % intravenous sodium chloride irrigation sodium polystyrene (sorb free) B/D; HI PAR; ; LA PAR PAR; ; ; ; PAR; ; LA ; B/D; LA PAR; ; QLL (525 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (270 per 30 days) ; HI Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

82 sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal enema 30 gram/120 ml SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML sps oral sps rectal SYPRINE water for irrigation, sterile ZEMAIRA SKING DETERRENTS buproban CHANTIX CHANTIX CONTINUING NTH BOX CHANTIX STARTING NTH BOX NICORELIEF nicotine (polacrilex) NICOTINE TRANSDERMAL nicotine transdermal system transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr nicotine transdermal system transdermal patch, td daily, sequential mg/24 hr NICOTROL NS QUIT 2 QUIT 4 BUCCAL GUM PAR; ; LA QLL (60 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (56 per 28 days) PAR; ; QLL (106 per 365 days) ; ; ; ; ; QLL (120 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 81

83 STOP SKING AID EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTEPRO NASAL SPRAY,NON- AEROSOL azelastine nasal aerosol,spray chlorhexidine gluconate mucous membrane ipratropium bromide nasal NASAL MIST oralone paroex oral rinse periogard STERILE SALINE NASAL triamcinolone acetonide dental TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS acetic acid otic acetic acid-aluminum acetate fluocinolone acetonide oil hydrocortisone-acetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRODEX COLY-MYCIN S neomycin-polymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORNES ACTHAR H.P. cortisone ; QLL (30 per 25 days) ; QLL (30 per 25 days) ; QLL (30 per 30 days) PAR; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

84 dexamethasone dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection fludrocortisone hydrocortisone oral methylprednisolone acetate methylprednisolone oral tablets methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/ 5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating prednisone intensol prednisone oral triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg propylthiouracil DIABETES THERAPY acarbose oral tablet 100 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg ; QLL (90 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 83

85 alcohol pads BYDUREON BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ ML) 1.2 ML CONDOMS, LATEX, LUBRICATED CONDOMS, LATEX, NON- LUBRICATED DEVICE CYCLOSET FREESTYLE INSULINX STRIP FREESTYLE INSULINX TEST STRIPS FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE TEST GAUZE PADS 2 X 2 glimepiride oral tablet 1 mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg glipizide-metformin oral tablet mg, mg ; QLL (4 per 28 days) ; QLL (2.4 per 30 days) ; QLL (1.2 per 30 days) ; QLL (180 per 30 days) ; ; QLL (100 per 30 days) ; ; QLL (100 per 30 days) ; ; ; QLL (100 per 30 days) ; ; QLL (100 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

86 GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) insulin pen needle INSULIN SYRINGE (DISP) U ML, 1 ML, 1/2 ML INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG JANUMET JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG JANUVIA ORAL TABLET 25 MG JANUVIA ORAL TABLET 50 MG JARDIANCE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg PAR; ; QLL (90 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (76 per 30 days) ; QLL (153 per 30 days) ; QLL (90 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (75 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 85

87 nateglinide oral tablet 120 mg nateglinide oral tablet 60 mg needles, insulin disp.,safety NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL pioglitazone oral tablet 15 mg pioglitazone oral tablet 30 mg pioglitazone oral tablet 45 mg pioglitazone-metformin PROGLYCEM repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg repaglinide oral tablet 2 mg SYMLINPEN 120 SYMLINPEN 60 TOUJEO SOLOSTAR VICTOZA 2-PAK VICTOZA 3-PAK MISCELLANEOUS HORNES ALDURAZYME ANDRODERM ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ; QLL (90 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (11 per 30 days) ; QLL (6 per 30 days) ; QLL (9 per 30 days) ; QLL (9 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (150 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

88 ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) androxy AXIRON cabergoline calcitonin (salmon) calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule CEREZYME INTRAVENOUS RECON SOLN 400 UNIT danazol oral desmopressin injection desmopressin nasal aerosol,spray desmopressin nasal spray,non-aerosol desmopressin oral ELAPRASE FABRAZYME KORLYM KUVAN ORAL TABLET,SOLUBLE MIACALCIN INJECTION MYOZYME NAGLAZYME NATPARA ; QLL (225 per 30 days) ; QLL (300 per 30 days) ; QLL (112.5 per 30 days) ; QLL (150 per 30 days) PAR; ; QLL (180 per 30 days) ; QLL (4 per 30 days) B/D; B/D; PAR; PAR; PAR; PAR; PAR; B/D; PAR; ; LA PAR; ; LA es gratuita. Para obtener más información, visite duals.caremore.com. 87

89 oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg pamidronate SENSIPAR ORAL TABLET 30 MG, 60 MG SENSIPAR ORAL TABLET 90 MG SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON SOLN 25 MG, 30 MG STIMATE SYNAREL TESTIM testosterone cypionate testosterone enanthate VPRIV ZAVESCA zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML THYROID HORNES levothyroxine oral levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral SYNTHROID UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG ; QLL (60 per 30 days) ; QLL (120 per 30 days) B/D; ; QLL (60 per 30 days) ; QLL (120 per 30 days) PAR; ; LA PAR; PAR; ; QLL (300 per 30 days) PAR; PAR; ; LA Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

90 GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASDICS ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML atropine injection syringe 0.05 mg/ml, 0.1 mg/ml BISMATROL ORAL SUSPENSION 262 MG/15 ML BISMATROL ORAL SUSPENSION 525 MG/15 ML BISMATROL ORAL TABLET, CHEWABLE BISMUTH BISMUTH MAXIMUM STRENGTH DIARRHEA RELIEF (BISMUTH SUBS) dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet DIOTAME diphenoxylate-atropine glycopyrrolate oral K-PEC ANTIDIARRHEAL (BISM SUB) KAO-TIN (BISMUTH SUBSALICYLAT) KAOPECTATE (BISMUTH SUBSALICY) KAOPECTATE EX STR (BISMUTH SS) loperamide oral capsule loperamide oral liquid 1 mg/5 ml PEPTIC RELIEF ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 89

91 PEPTO-BISL ORAL TABLET, CHEWABLE PEPTO-BISL TO-GO PINK BISMUTH MAXIMUM STRENGTH PINK BISMUTH ORAL SUSPENSION PINK BISMUTH ORAL TABLET PINK BISMUTH ORAL TABLET, CHEWABLE SOOTHE (BISMUTH SUBSALICYLATE) SOOTHE REGULAR STRENGTH STOMACH RELIEF STOMACH RELIEF MAX STRENGTH STOMACH RELIEF ORIGINAL MISCELLANEOUS GASTROINTESTINAL AGENTS ACID GONE ANTACID E.STRENGTH ADVANCED ANTACID-ANTIGAS ALOPHEN alosetron ALUMINA AND MAGNESIUM ANTACID ORAL SUSPENSION MG/15 ML ALUMINA AND MAGNESIUM ANTACID ORAL TABLET, CHEWABLE MG ALUMINA, MAGNESIA, SIMETHICONE SUSPENSION ORAL SUSPENSION MG/5 ML, MG/5 ML aluminum hydroxide gel oral suspension 320 mg/5 ml aluminum hydroxide gel oral suspension 600 mg/5 ml ; ; ; QLL (60 per 30 days) ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

92 ANTACID ANTACID ANTI-GAS ANTACID ANTI-GAS DOUBLE STR ANTACID EXST (MAG CARB-AL HYD) ANTACID EXTRA-STRENGTH ORAL SUSPENSION MG/5 ML ANTACID LIQUID ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI-GAS ANTACID REGULAR STRENGTH ANTACID WITH SIMETHICONE ANTACID-ANTIGAS ANTACID-SIMETHICONE APRISO ASACOL HD balsalazide BISA-LAX BISAC-EVAC bisacodyl oral bisacodyl rectal BISCOLAX budesonide oral CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL SUSPENSION MG/5 ML, MG/5 ML CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL TABLET,CHEWABLE MG ; ; ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 91

93 CANASA CITRATE OF MAGNESIA CITROMA CLEARLAX COL-RITE colocort COMFORT GEL COMFORT GEL EXTRA STRENGTH compro constulose CREON CYSTADANE DELZICOL ORAL CAPSULE, DELAYED RELEASE(DR/EC) DIOCTO ORAL LIQUID DIOCTO ORAL SYRUP DIOCTYL DIPENTUM DOC-Q-LACE DOCU DOCUPRENE docusate calcium docusate sodium oral capsule 100 mg docusate sodium oral capsule 250 mg docusate sodium oral liquid docusate sodium oral tablet DOCUSIL DOK ORAL CAPSULE 100 MG DOK ORAL CAPSULE 250 MG DOK ORAL TABLET ; ; ; ; ; ; ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

94 DRAMAMINE LESS DROWSY dronabinol DSS DUCODYL DULCOLAX STOOL SOFTENER (DSS) EMEND ORAL CAPSULE 125 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE 80 MG EMEND ORAL CAPSULE,DOSE PACK enulose FLANAX ANTACID FLEET GLYCERIN (ADULT) FLEET LAXATIVE GAS RELIEF 80 GAS RELIEF ULTRA STRENGTH GATTEX 30-VIAL GATTEX ONE-VIAL GAVILAX ORAL POWDER gavilyte-c gavilyte-g gavilyte-n generlac GENTLE LAXATIVE GENTLELAX GERI-LANTA GERI-X ANTACID-ANTIGAS glycerin (adult) GLYCOLAX ORAL POWDER ; B/D; ; QLL (120 per 30 days) ; B/D; ; QLL (5 per 30 days) B/D; ; QLL (1 per 2 days) B/D; ; QLL (10 per 30 days) B/D; ; QLL (15 per 30 days) ; es gratuita. Para obtener más información, visite duals.caremore.com. 93

95 HEALTHYLAX HEARTBURN ANTACID HEARTBURN RELIEF hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema KAO-TIN (DOCUSATE CALCIUM) lactulose LAXA CLEAR LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/ EC) LAXATIVE (BISACODYL) RECTAL LAXATIVE PEG 3350 ORAL POWDER LINZESS LIQUID ANTACID MAALOX MAXIMUM STRENGTH MAG-AL PLUS MAG-AL PLUS EXTRA STRENGTH magnesium citrate oral solution MASANTI DOUBLE STRENGTH meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable MEDI-MECLIZINE mesalamine rectal mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl injection syringe metoclopramide hcl oral solution metoclopramide hcl oral tablet MI-ACID GAS RELIEF MILK OF MAGNESIA ; ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

96 MILK OF MAGNESIA CONCENTRATED MINERAL OIL EXTRA HEAVY MINERAL OIL HEAVY ORAL MINERAL OIL LAXATIVE mineral oil oral mineral oil rectal MINTOX MINTOX MAXIMUM STRENGTH MINTOX PLUS MIRALAX ORAL POWDER IN PACKET TION RELIEF (MECLIZINE) TION SICKNESS (MECLIZINE) TION SICKNESS RELIEF(MECLIZ) VIPREP MYTAB GAS MYTAB GAS MAXIMUM STRENGTH ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl intravenous ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron odt ORAL SALINE LAXATIVE ORAL LIQUID PANCREAZE peg 3350-electrolytes oral recon soln gram ; ; ; ; ; ; ; ; B/D; ; QLL (450 per 30 days) B/D; QLL (30 per 30 days) B/D; ; QLL (90 per 30 days) B/D; ; QLL (90 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 95

97 peg 3350-electrolytes oral recon soln gram peg-electrolyte soln PENTASA PHOSPHATE LAXATIVE ORAL LIQUID polyethylene glycol 3350 oral powder polyethylene glycol 3350 oral powder in packet POWDERLAX prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine maleate rectal procto-pak proctosol hc proctozone-hc PROLAXIN PURELAX READY-TO-USE ENEMA (MIN OIL) RELISTOR SUBCUTANEOUS SOLUTION REMICADE RI-GEL RI-GEL II RI-X SANI-SUPP (ADULT) SILACE ORAL LIQUID SILACE ORAL SYRUP SIMETHICONE ORAL CAPSULE 125 MG ; PAR; PAR; ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

98 simethicone oral capsule 180 mg simethicone oral tablet,chewable SOTHLAX SOF-LAX STOOL SOFTENER ORAL CAPSULE 100 MG, 240 MG, 250 MG STOOL SOFTENER ORAL CAPSULE 50 MG STOOL SOFTENER ORAL LIQUID STOOL SOFTENER ORAL SYRUP STOOL SOFTENER ORAL TABLET sulfasalazine SUPPOSITORY ADULT SUPREP BOWEL PREP KIT SURFAK THE MAGIC BULLET TRANSDERM-SCOP TRAVEL SICKNESS (MECLIZINE) ursodiol WOMAN'S LAXATIVE ORAL TABLET,DELAYED RELEASE (DR/ EC) WOMEN'S GENTLE LAXATIVE (BISAC) WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) ULCER THERAPY ACID CONTROL (RANITIDINE) ORAL TABLET 150 MG ACID REDUCER (FATIDINE) ; ; ; ; QLL (4 per 12 days) ; es gratuita. Para obtener más información, visite duals.caremore.com. 97

99 ACID REDUCER (RANITIDINE) DEXILANT famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine intravenous famotidine oral suspension famotidine oral tablet 10 mg famotidine oral tablet 20 mg, 40 mg HEARTBURN PREVENTION HEARTBURN RELIEF (FATIDINE) HEARTBURN RELIEF (RANITIDINE) lansoprazole oral capsule,delayed release (dr/ec) misoprostol omeprazole oral capsule,delayed release (dr/ec) OMEPRAZOLE ORAL TABLET, DELAYED RELEASE (DR/EC) pantoprazole PEPCID AC ORAL TABLET 20 MG PROTONIX INTRAVENOUS ranitidine hcl injection ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg ranitidine hcl oral tablet 75 mg sucralfate oral tablet IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, ; QLL (30 per 30 days) ; ; QLL (30 per 30 days) ; ; ; PAR; PAR; ; QLL (4 per 28 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

100 200 MCG/ML, 25 MCG/ML, 300 MCG/ ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 200 MCG/0.4 ML, 40 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0.3 ML, 60 MCG/0.3 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/0.42 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 300 MCG/0.6 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML ARCALYST AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE AVONEX INTRAMUSCULAR SYRINGE KIT BETASERON SUBCUTANEOUS KIT GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT) ILARIS (PF) PAR; ; QLL (1.6 per 28 days) PAR; ; QLL (2 per 28 days) PAR; ; QLL (1.2 per 28 days) PAR; ; QLL (1.68 per 28 days) PAR; ; QLL (2.4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; ; QLL (4 per 28 days) PAR; PAR; PAR; PAR; PAR; ; LA es gratuita. Para obtener más información, visite duals.caremore.com. 99

101 INTRON A INJECTION LEUKINE INJECTION RECON SOLN ZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUPOGEN NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) PEGINTRON PEGINTRON REDIPEN PROCRIT PROLEUKIN REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK SYLATRON VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT) (PF) ATGAM BCG VACCINE, LIVE (PF) BEXSERO (PF) BOOSTRIX TDAP CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM CERVARIX VACCINE (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) PAR; PAR; PAR; ; QLL (2 per 28 days) PAR; PAR; PAR; PAR; ; QLL (4 per 28 days) PAR; ; QLL (12 per 28 days) PAR; PAR; PAR; PAR; B/D PAR; B/D; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

102 ENGERIX-B PEDIATRIC (PF) FLEBOGAMMA DIF GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ ML) GAMUNEX-C GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML HIBERIX (PF) IVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION IPOL INJECTION SUSPENSION IXIARO (PF) M-M-R II (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENOMUNE - A/C/Y/W-135 MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) PEDVAX HIB (PF) PROQUAD (PF) QUADRACEL (PF) B/D; PAR; PAR; PAR; PAR; PAR; es gratuita. Para obtener más información, visite duals.caremore.com. 101

103 RABAVERT (PF) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/ 0.5 ML ROTARIX ROTATEQ VACCINE tetanus,diphtheria tox ped(pf) TETANUS-DIPHTHERIA TOXOIDS- TD THYGLOBULIN TICE BCG TRUMENBA TWINRIX (PF) TYPHIM VI INTRAMUSCULAR SOLUTION TYPHIM VI INTRAMUSCULAR SYRINGE VAQTA (PF) INTRAMUSCULAR SUSPENSION VAQTA (PF) INTRAMUSCULAR SYRINGE VARIVAX (PF) VARIZIG YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol B/D; B/D; B/D B/D Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

104 colchicine-probenecid COLCRYS probenecid OSTEOPOROSIS THERAPY alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg BONIVA INTRAVENOUS FORTEO ibandronate intravenous ibandronate oral PROLIA raloxifene OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS VIAL BENLYSTA DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN PSORIASIS STARTER ; QLL (30 per 30 days) ; QLL (4 per 28 days) B/D; PAR; ; QLL (3 per 28 days) B/D; ; QLL (1 per 28 days) PAR; ; QLL (2 per 365 days) ; QLL (30 per 30 days) PAR; PAR; PAR; ; QLL (8 per 28 days) PAR; ; QLL (4.08 per 28 days) PAR; ; QLL (8 per 28 days) PAR; ; QLL (8 per 28 days) PAR; ; QLL (4.8 per 365 days) PAR; ; QLL (3.2 per 28 days) PAR; ; QLL (9.6 per 365 days) PAR; ; QLL (3.2 per 28 days) es gratuita. Para obtener más información, visite duals.caremore.com. 103

105 HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML KINERET leflunomide ORENCIA ORENCIA (WITH MALTOSE) RIDAURA SAVELLA ORAL TABLET 100 MG SAVELLA ORAL TABLET 12.5 MG SAVELLA ORAL TABLET 25 MG SAVELLA ORAL TABLET 50 MG SAVELLA ORAL TABLETS,DOSE PACK OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila DEBLITANE DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML errin ESTRACE VAGINAL estradiol oral estradiol transdermal patch weekly ESTRING heather jencycla jolivette lyza medroxyprogesterone intramuscular PAR; ; QLL (2 per 28 days) PAR; ; QLL (3.2 per 28 days) PAR; ; QLL (28 per 28 days) PAR; ; QLL (4 per 28 days) PAR; ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (110 per 365 days) ; QLL (4 per 28 days) ; QLL (1 per 90 days) ; QLL (1 per 90 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

106 medroxyprogesterone oral MENEST nora-be norethindrone (contraceptive) norethindrone acetate NORLYROC PREMARIN PREMPHASE PREMPRO SHAROBEL VAGIFEM VIVELLE-DOT MISCELLANEOUS OB/GYN 3-DAY VAGINAL clindamycin phosphate vaginal CLOTRIMAZOLE 3 DAY clotrimazole vaginal cream CLOTRIMAZOLE-3 CLOTRIMAZOLE-7 metronidazole vaginal MICONAZOLE 3 DAY VAGINAL CREAM MICONAZOLE 7 miconazole nitrate vaginal comb pack, prefill appl, cream miconazole nitrate vaginal cream miconazole nitrate vaginal suppository MICONAZOLE-3 VAGINAL KIT miconazole-3 vaginal suppository ; QLL (8 per 28 days) ; ; ; ; ; QLL (6 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 105

107 NUVARING terconazole tranexamic acid oral VAGINAL CONTRACEPTIVE FOAM VAGISTAT-3 ORAL CONTRACEPTIVES / RELATED AGENTS AFTERA altavera (28) alyacen 1/35 (28) alyacen 7/7/7 (28) apri aranelle (28) AUBRA aviane azurette (28) balziva (28) briellyn caziant (28) cryselle (28) cyclafem 7/7/7 (28) dasetta 7/7/7 (28) DELYLA (28) desog-e.estradiol/e.estradiol drospirenone-ethinyl estradiol oral tablet mg ECONTRA EZ elinest ELLA enpresse FALLBACK SOLO Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

108 falmina (28) gildagia gildess 1.5/30 (21) gildess fe 1.5/30 (28) gildess fe 1/20 (28) jolessa junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) JUNEL FE 24 kariva (28) kelnor 1/35 (28) kurvelo LARIN 1.5/30 (21) LARIN FE 1/20 (28) lessina levonest (28) levonorg-eth estrad triphasic levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg levonorgestrel-ethinyl estrad oral tablets, dose pack,3 month low-ogestrel (28) lutera (28) marlissa MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) es gratuita. Para obtener más información, visite duals.caremore.com. 107

109 MICROGESTIN FE 1/20 (28) MIRCETTE (28) mono-linyah mononessa (28) MY WAY myzilra necon 0.5/35 (28) necon 1/35 (28) necon 10/11 (28) necon 7/7/7 (28) NEXT CHOICE ONE DOSE norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), mg-mcg nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) OPCICON ONE-STEP orsythia philith PIMTREA (28) pirmella portia previfem reclipsen (28) sprintec (28) sronyx Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

110 syeda TAKE ACTION TARINA FE 1/20 (28) tri-estarylla tri-linyah tri-previfem (28) tri-sprintec (28) trinessa (28) trivora (28) velivet triphasic regimen (28) viorele (28) VYFEMLA (28) zarah zenchent (28) zovia 1/35e (28) zovia 1/50e (28) OPHTHALLOGY ANTIBIOTICS bacitracin ophthalmic bacitracin-polymyxin b ophthalmic ciprofloxacin hcl ophthalmic erythromycin ophthalmic gentak ophthalmic ointment gentamicin ophthalmic NATACYN neo-polycin neomycin-bacitracin-polymyxin neomycin-polymyxin-gramicidin es gratuita. Para obtener más información, visite duals.caremore.com. 109

111 ofloxacin ophthalmic polycin polymyxin b sulf-trimethoprim tobramycin VIGAX ANTIVIRALS trifluridine ZIRGAN BETA-BLOCKERS betaxolol ophthalmic carteolol levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops MISCELLANEOUS OPHTHALLOGICS AKWA TEARS (POLYVINYL ALCOHOL) ALAWAY ALLERGY EYE (KETOTIFEN) ARTIFICIAL TEARS (PF) OPHTHALMIC DROPPERETTE % ARTIFICIAL TEARS (POLYVIN ALC) ARTIFICIAL TEARS OPHTHALMIC DROPS %, % ARTIFICIAL TEARS(GLYCERIN-PEG) azelastine ophthalmic ; ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

112 BION TEARS (PF) COLLYRIUM cromolyn ophthalmic DRY EYE RELIEF EYE DROP TEARS EYE IRRIGATING SOLUTION EYE ITCH RELIEF EYE STREAM EYE WASH EYE WASH STERILE ITCHY EYE DROPS KETOTIFEN FUM 0.025% EYE DROPS ketotifen fumarate LIQUITEARS LUBRICANT EYE (PG-PEG 400) LUBRICANT EYE DROPS LUBRICANT EYE DROPS (GLYC-PG) LUBRICATING PLUS MEDIWASH MEDIWASH EYE IRRIGANT ISTURE DROPS NATURAL TEARS (PF) OCUSOFT IRRIGATING OPHTH SOLN olopatadine ophthalmic PATADAY PATANOL PAZEO polyvinyl alcohol ; ; ; ; ; ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 111

113 RESTASIS REVIVE PLUS STERILE EYE WASH TEARS AGAIN (PVA) TEARS NATURALE FREE (PF) ULTRA FRESH NON-STEROIDAL ANTI-INFLAMMATORY AGENTS flurbiprofen ophthalmic drops ILEVRO ketorolac ophthalmic NEVANAC ORAL DRUGS FOR GLAUCOMA acetazolamide acetazolamide sodium methazolamide oral OTHER GLAUCOMA DRUGS AZOPT COMBIGAN dorzolamide dorzolamide-timolol latanoprost LUMIGAN OPHTHALMIC DROPS 0.01 % TRAVATAN Z travoprost (benzalkonium) STEROID-ANTIBIOTIC COMBINATIONS neo-polycin hc neomycin-bacitracin-poly-hc neomycin-polymyxin b-dexameth neomycin-polymyxin-hc ophthalmic ; QLL (60 per 30 days) ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

114 tobramycin-dexamethasone opthalmic suspension STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE S.O.P. sulfacetamide-prednisolone STEROIDS dexamethasone sodium phosphate ophthalmic DUREZOL fluorometholone prednisolone acetate prednisolone sodium phosphate ophthalmic SULFONAMIDES sulfacetamide sodium ophthalmic drops SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % apraclonidine brimonidine ophthalmic drops 0.2 % VASOCONSTRICTOR DECONGESTANTS LUBRICANT REDNESS RELIEVER OPHTHALMIC DROPS % MAXIMUM REDNESS RELIEF naphazoline REDNESS RELIEVER LUBRICANT STERILE EYE DROPS OPHTHALMIC DROPS %, % es gratuita. Para obtener más información, visite duals.caremore.com. 113

115 RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS ACTA-TABS PE ADULT TUSSIN CHEST CONGESTION ADULT TUSSIN COUGH CONGEST DM ALA-HIST DM ALAVERT ALKA-SELTZER PLUS ALLERGY ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET ALL DAY ALLERGY RELIEF(CETIR) ALLER-G-TIME ALLER-TEC ALLERGY (DIPHENHYDRAMINE) ALLERGY AND SINUS RELIEF ALLERGY RELIEF (CETIRIZINE) ORAL TABLET ALLERGY RELIEF (CLEMASTINE) ALLERGY RELIEF (LORATADINE) ORAL TABLET ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING ALLERGY RELIEF (DIPHENHYDRAMIN) AP-HIST DM APRODINE arbinoxa BANOPHEN ALLERGY BANOPHEN ORAL CAPSULE 25 MG BANOPHEN ORAL CAPSULE 50 MG ; ; ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; ; ; ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

116 BANOPHEN ORAL LIQUID BANOPHEN ORAL TABLET benzonatate oral capsule 100 mg, 200 mg BIOCOTRON brompheniramin-phenylephrin-dm oral liquid mg/5 ml cetirizine oral tablet CHERATUSSIN AC clemastine oral tablet 1.34 mg clemastine oral tablet 2.68 mg codeine-guaifenesin COLD AND ALLERGY COLD AND ALLERGY PE COMPLETE ALLERGY COMPLETE ALLERGY MEDICINE COUGH CONTROL (GUAIFENESIN) COUGH CONTROL DM ORAL LIQUID COUGH SYRUP cyproheptadine oral tablet DAYHIST ALLERGY DIABETIC SILTUSSIN DAS-NA DIABETIC SILTUSSIN-DM DIABETIC TUSSIN DM ORAL LIQUID MG/5 ML DIABETIC TUSSIN EX DIPHEDRYL ALLERGY DIPHEDRYL ORAL CAPSULE DIPHEDRYL ORAL LIQUID DIPHEDRYL ORAL TABLET $0 (Tier 3) ; ; ; ; QLL (30 per 30 days) ; ; ; ; ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 115

117 DIPHENHIST ORAL CAPSULE DIPHENHIST ORAL LIQUID DIPHENHIST ORAL TABLET 25 MG diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule diphenhydramine hcl oral elixir diphenhydramine hcl oral liquid diphenhydramine hcl oral syrup diphenhydramine hcl oral tablet 25 mg DIPHENHYDRAMINE ORAL CAPSULE 25 MG, 50 MG DIPHENHYDRAMINE ORAL ELIXIR 12.5 MG/5 ML DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/5 ML DIPHENHYDRAMINE ORAL SYRUP 12.5 MG/5 ML ED A-HIST ORAL TABLET ED A-HIST PSE ENTRE-HIST PSE epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK EPIPEN JR 2-PAK EXPECTORANT COUGH SYRUP EXPECTORANT ORAL LIQUID G-TRON GERI-TUSSIN GUAIFENESIN AC guaifenesin oral liquid GUAIFENESIN-DM ; ; ; ; ; QLL (2 per 2 days) ; QLL (2 per 2 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

118 hydrocodone-chlorpheniramine hydrocodone-homatropine oral syrup mg/5 ml HYDROCODONE-HOMATROPINE ORAL SYRUP MG/5 ML (5 ML) hydrocodone-homatropine oral tablet HYDROMET IOPHEN C-NR IOPHEN DM-NR IOPHEN-NR levocetirizine oral tablet LOHIST-DM LORADAMED loratadine oral tablet loratadine oral tablet,disintegrating M-CLEAR WC NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET EXTENDED RELEASE NIGHTIME SLEEP NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET NON-DROWSY ALLERGY phenadoz $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) ; ; ; ; ; ; ; ; QLL (30 per 30 days) ; ; ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 117

119 PHENYLEPHRINE HCL/ DIPHENHYDRAMINE HCL promethazine oral tablet PROMETHAZINE VC-CODEINE promethazine-codeine promethazine-dm promethazine-phenyleph-codeine promethegan rectal suppository 12.5 mg PSEUDOEPHEDRINE 120 MG ER pseudoephedrine hcl oral liquid pseudoephedrine hcl oral tablet 30 mg pseudoephedrine hcl oral tablet 60 mg pseudoephedrine hcl oral tablet extended release PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE ORAL TABLET 4-10 MG, 4-60 MG PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE TABLET PSEUDOEPHEDRINE HCL/ TRIPROLIDINE HCL ORAL TABLET Q-DRYL ORAL CAPSULE Q-DRYL ORAL LIQUID Q-TUSSIN QUENALIN RELCOF C REST SIMPLY NIGHTTIME SLEEP RESTFULLY SLEEP RI-TUSSIN ROBAFEN ROBAFEN DM COUGH $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) PAR; ; ; ; ; ; ; ; ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

120 RYDEX SCOT-TUSSIN EXPECTORANT SILADRYL SA SILTUSSIN DM DAS SILTUSSIN SA SINUS 12 HOUR SINUS AND ALLERGY PE SINUS-ALLERGY (PHENYLEPHRINE) SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET SLEEP AID MAX STR (DIPHENHYDR) SLEEP TABLET (DIPHENHYDRAMINE) SLEEP-TABS SUDOGEST SUDOGEST 12-HOUR SUDOGEST COLD AND ALLERGY SUDOGEST SINUS AND ALLERGY SUPHEDRIN SUPHEDRIN 12 HOUR SUPHEDRINE SUPHEDRINE 12 HOUR SUPHEDRINE PE COLD AND ALLERGY SUPHEDRINE PE SINUS ANDALLERGY TUSNEL DIABETIC ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 119

121 TUSSI PRES-B ORAL LIQUID MG/5 ML TUSSIGON TUSSIN CHEST CONGESTION TUSSIN COUGH-CHEST CONGESTION TUSSIN DM COUGH AND CHEST ORAL LIQUID MG/5 ML TUSSIN DM ORAL LIQUID TUSSIN EXPECTORANT TUSSIN HONEY TUSSIN ORAL LIQUID VALU-DRYL ALLERGY ORAL CAPSULE VIRTUSSIN AC PULNARY AGENTS acetylcysteine ADEMPAS ADVAIR DISKUS ADVAIR HFA albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral ATROVENT HFA budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml CINRYZE COMBIVENT RESPIMAT cromolyn inhalation DALIRESP $0 (Tier 3) ; ; B/D; PAR; ; LA ; QLL (60 per 30 days) ; QLL (12 per 30 days) B/D; ; QLL (360 per 30 days) B/D; ; QLL (60 per 30 days) ; QLL (26 per 30 days) B/D; ; QLL (120 per 30 days) PAR; ; QLL (8 per 30 days) B/D; ; QLL (240 per 30 days) PAR; ; QLL (30 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

122 DULERA ESBRIET FIRAZYR FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluticasone nasal FORADIL AEROLIZER ipratropium bromide inhalation ipratropium-albuterol KALYDECO ORAL TABLET LETAIRIS levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml metaproterenol montelukast ; QLL (13 per 30 days) PAR; QLL (270 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (12 per 30 days) ; QLL (24 per 30 days) ; QLL (11 per 30 days) ; QLL (75 per 30 days) ; QLL (16 per 30 days) ; QLL (60 per 30 days) B/D; B/D; ; QLL (540 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) B/D; ; QLL (270 per 30 days) B/D; ; QLL (540 per 30 days) ; QLL (30 per 30 days) es gratuita. Para obtener más información, visite duals.caremore.com. 121

123 PROAIR HFA PROAIR RESPICLICK PULZYME QVAR INHALATION AEROSOL 40 MCG/ACTUATION QVAR INHALATION AEROSOL 80 MCG/ACTUATION SEREVENT DISKUS sildenafil oral sodium chloride inhalation solution for nebulization 0.9 %, 3 % SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER SYMBICORT terbutaline oral terbutaline subcutaneous theophylline oral tablet extended release theophylline oral tablet extended release 12 hr TRACLEER TUDORZA PRESSAIR VENTAVIS VENTOLIN HFA VOSPIRE ER XOLAIR zafirlukast UROLOGICALS $0 (Tier 3) ANTICHOLINERGICS / ANTISPASDICS MYRBETRIQ oxybutynin chloride oral syrup oxybutynin chloride oral tablet ; QLL (18 per 30 days) ; QLL (2 per 30 days) B/D; ; QLL (9 per 30 days) ; QLL (18 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (90 per 30 days) ; ; QLL (4 per 30 days) ; QLL (30 per 30 days) ; QLL (11 per 30 days) PAR; ; LA; QLL (60 per 30 days) ; QLL (1 per 30 days) PAR; ; QLL (36 per 30 days) PAR; ; LA; QLL (6 per 28 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (600 per 30 days) ; QLL (120 per 30 days) Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

124 oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg tolterodine oral capsule,extended release 24hr tolterodine oral tablet TOVIAZ VESICARE BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin AVODART dutasteride dutasteride-tamsulosin finasteride oral tablet 5 mg JALYN tamsulosin CHOLINERGIC STIMULANTS bethanechol chloride MISCELLANEOUS UROLOGICALS CYSTAGON potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) URINARY ANESTHETICS URINARY PAIN RELIEF ORAL TABLET 95 MG URINARY TRACT ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; LA es gratuita. Para obtener más información, visite duals.caremore.com. 123

125 VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES ALCALAK ANTACID (CALCIUM CARBONATE) ANTACID EXT STR (CALCIUM CARB) ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 168 MG (420 MG), 300 MG (750 MG) CAL-GEST ANTACID CALCI-CHEW CALCIONATE CALCITRATE CALCIUM 500 CALCIUM D (D3) CALCIUM D ORAL TABLET 500 MG(1,250MG) -200 UNIT CALCIUM D ORAL TABLET 500 MG(1,250MG) -400 UNIT CALCIUM D ORAL TABLET, CHEWABLE CALCIUM 500 WITH D CALCIUM 600 CALCIUM D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG (1,500MG) -400 UNIT CALCIUM 600 WITH VITAMIN D3 ORAL TABLET calcium acetate oral capsule calcium acetate oral tablet 667 mg CALCIUM ANTACID ORAL TABLET, CHEWABLE 200 MG CALCIUM (500 MG) ; ; ; ; ; ; ; ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

126 CALCIUM ANTACID ORAL TABLET, CHEWABLE 300 MG (750 MG), 400 MG (1,000 MG) CALCIUM ANTACID TROPICAL CALCIUM ANTACID ULTRA MAX ST calcium carbonate - d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit calcium carbonate - d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonate - d3 oral tablet, chewable 500 mg(1,250mg) -400 unit CALCIUM CARBONATE - D3 ORAL TABLET,CHEWABLE MG- UNIT CALCIUM CARBONATE ANTACID ORAL TABLET,CHEWABLE 400 MG (1,000 MG) CALCIUM CARBONATE ORAL SUSPENSION calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 400 mg (1,000 mg), 500 mg calcium (1,250 mg) CALCIUM CITRATE + D calcium citrate oral tablet 200 mg (950 mg) CALCIUM CITRATE ORAL TABLET 250 MG CALCIUM ; ; ; ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 125

127 calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit calcium citrate-vitamin d3 oral tablet mg-unit, mg-unit CALCIUM GLUCONATE ORAL TABLET 45 MG (500 MG) CALCIUM GLUCONATE ORAL TABLET 60 MG (650 MG) CALCIUM LACTATE ORAL TABLET 84 MG (648 MG) CALCIUM WITH VITAMIN D calcium-magnesium-zinc oral tablet CALCIUM-MAGNESIUM-ZINC ORAL TABLET MG CERASPORT ORAL LIQUID CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT CITRUS CALCIUM ORAL TABLET MG-UNIT dextrose-kcl-nacl HI-CAL PLUS VIT D KLOR-CON 10 KLOR-CON 8 klor-con m10 KLOR-CON M15 KLOR-CON M20 lactated ringers intravenous MAGNESIUM OXIDE ORAL CAPSULE 500 MG magnesium sulfate in water intravenous parenteral solution ; ; ; ; ; B/D; ; HI ; HI Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

128 magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/ 50 ml (8 %) magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %) magnesium sulfate injection solution magnesium sulfate injection syringe NORSOL-R NORSOL-R IN 5 % DEXTROSE OYSCO 500/D ORAL TABLET OYSCO D OYSCO-500 OYST-CAL-500 OYSTER SHELL + D3 OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM 500 OYSTER SHELL CALCIUM-VIT D3 OYSTERCAL-D potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/ l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/ l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 30 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l HI HI ; ; ; ; ; ; HI ; HI HI HI ; HI es gratuita. Para obtener más información, visite duals.caremore.com. 127

129 potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/ 50 ml, 40 meq/100 ml potassium chloride intravenous piggyback 10 meq/50 ml potassium chloride intravenous piggyback 30 meq/100 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l ringers intravenous SOTH ANTACID sodium chloride 0.45 % intravenous parenteral solution sodium chloride 0.45 % intravenous piggyback sodium chloride 3 % sodium chloride 5 % HI ; HI ; HI HI ; HI HI ; HI HI B/D; HI ; HI HI ; HI Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/ HI

130 sodium chloride intravenous parenteral solution 2.5 meq/ml sodium chloride intravenous parenteral solution 4 meq/ml SUPER CALCIUM TPN ELECTROLYTES TUMS ULTRA ORAL TABLET, CHEWABLE 400 MG (1,000 MG) ULTRA STRENGTH ANTACID ULTRA STRENGTH CALCIUM ANTACID MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 5%-D20W(SULFITE-FREE) ; HI HI ; B/D B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI es gratuita. Para obtener más información, visite duals.caremore.com. 129

131 CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % freamine iii 10 % HEPATAMINE 8% intralipid intravenous emulsion 20 % NORSOL-M IN 5 % DEXTROSE NORSOL-R PH 7.4 PLASMA-LYTE 148 PLASMA-LYTE-56 IN 5 % DEXTROSE travasol 10 % TROPHAMINE 10 % TROPHAMINE 6% VITAMINS / HEMATINICS ascorbic acid (vitamin c) oral capsule, extended release ascorbic acid (vitamin c) oral tablet 1,000 mg B-12 DOTS C-500 ORAL TABLET C-500 ORAL TABLET,CHEWABLE CALCIUM MINERALS calcium carbonate-vit d3-min oral tablet CALCIUM CARBONATE-VIT D3-MIN ORAL TABLET,CHEWABLE 600 MG (1,500 MG)-400 UNIT CALCIUM FOR WOMEN CALCIUM SOFT CHEW ORAL TABLET,CHEWABLE MG- B/D; HI B/D; HI B/D; HI B/D; HI B/D; HI B/D; ; HI B/D B/D; HI B/D; HI HI HI HI B/D; ; HI B/D; ; HI B/D; HI ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

132 UNIT-MCG, MG-UNIT- MCG calcium-vitamin d3-vitamin k oral tablet, chewable mg-unit-mcg cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit cholecalciferol (vitamin d3) oral drops 400 unit/ml cholecalciferol (vitamin d3) oral tablet 1, 000 unit, 2,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral tablet 400 unit CLASSIC PRENATAL cyanocobalamin (vitamin b-12) injection cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 100 mcg, 500 mcg cyanocobalamin (vitamin b-12) oral tablet extended release cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg cyanocobalamin (vitamin b-12) sublingual tablet 2,500 mcg D-VI-SOL D-VITA D DAILY PRENATAL DELTA D3 DIALYVITE 800 DIALYVITE VITAMIN D ergocalciferol (vitamin d2) oral capsule $0 (Tier 3) $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 131

133 ergocalciferol (vitamin d2) oral tablet 400 unit EZFE 200 FEOSOL ORAL TABLET 325 MG (65 MG IRON) FERATE ORAL TABLET 240 MG (27 MG IRON) FEROSUL ORAL TABLET FERRETTS FERREX 150 FERRO-TIME ferrous gluconate oral tablet 240 mg (27 mg iron) ferrous gluconate oral tablet 256 mg (28 mg iron) FERROUS GLUCONATE ORAL TABLET 324 MG (36 MG IRON), 324 MG (37.5 MG IRON), 324 MG (38 MG IRON), 325 MG (36 MG IRON) ferrous sulfate oral tablet 325 mg (65 mg iron) FERROUS SULFATE ORAL TABLET, DELAYED RELEASE (DR/EC) 324 MG (65 MG IRON) ferrous sulfate oral tablet,delayed release (dr/ec) 325 mg (65 mg iron) FERROUSUL folic acid oral tablet 1 mg folic acid oral tablet 400 mcg, 800 mcg FULL SPECTRUM B-VITAMIN C HIGH POTENCY IRON IFEREX 150 IRON (DRIED) IRON (FERROUS SULFATE) $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

134 IRON HIGH POTENCY IRON ORAL TABLET 325 MG (65 MG IRON) KPN MYFERON 150 ONE DAILY PRENATAL ORAL COMBO PACK MG-MCG- MG OYSTER SHELL CALCIUM WITH D POLY-IRON POLY-VITA POLY-VITAMIN polysaccharide iron complex PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG PRENATAL ONE DAILY PRENATAL TABLET PRENATAL VITAMIN ORAL CAPSULE MG prenatal vitamin oral tablet PRENATAL VITAMIN ORAL TABLET, MG PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 800 MCG prenatal vitamin oral tablet 28 mg iron- 800 mcg pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg RENA-VITE RISACAL-D ; ; ; ; ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 133

135 SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 160 MG (50 MG IRON), 47.5 MG IRON sodium fluoride oral tablet sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg) STRAWBERRY C THERA-D thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg, 50 mg thiamine mononitrate (vit b1) VITAMIN A PALMITATE ORAL CAPSULE VITAMIN A PALMITATE ORAL TABLET 10,000 UNIT vitamin a palmitate oral tablet 15,000 unit VITAMIN B-1 VITAMIN B-1 (NONITRATE) VITAMIN B-12 ORAL TABLET 1,000 MCG, 100 MCG, 250 MCG, 500 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 1,000 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 2,000 MCG VITAMIN B-12 SUBLINGUAL TABLET 2,500 MCG VITAMIN B-2 VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG VITAMIN C ORAL CAPSULE, EXTENDED RELEASE VITAMIN C ORAL TABLET 1,000 MG, 250 MG, 500 MG VITAMIN C ORAL TABLET, CHEWABLE 250 MG, 500 MG ; ; ; ; ; ; ; ; ; Puede encontrar información sobre qué significan los símbolos y las abreviaturas en esta tabla yendo a la página 9. Updated 08/01/

136 VITAMIN C WITH ROSE HIPS ORAL TABLET VITAMIN D2 VITAMIN D3 ORAL CAPSULE 1,000 UNIT, 2,000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 1,000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 2,000 UNIT, 5,000 UNIT VITAMIN E (DL, ACETATE) ORAL CAPSULE 100 UNIT vitamin e oral capsule 1,000 unit, 200 unit, 400 unit vitamin e oral capsule 100 unit $0 (Tier 3) ; ; ; ; ; ; es gratuita. Para obtener más información, visite duals.caremore.com. 135

137 Índice 3 3-DAY VAGINAL P A abacavir abacavir-lamivudinezidovudine ABELCET ABILIFY MAINTENA ABRAXANE ABSTRAL acamprosate acarbose oral tablet 100 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg acebutolol ACEPHEN RECTAL SUPPOSITORY 650 MG ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML ACETAMINOPHEN EXTRA STRENGTH ORAL SUSPENSION 160 MG/5 ML ACETAMINOPHEN LIQUID acetaminophen oral suspension 160 mg/5 ml acetaminophen oral tablet 500 mg ACETAMINOPHEN PAIN RELIEF acetaminophen rectal suppository 650 mg acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg acetazolamide acetazolamide sodium acetic acid otic acetic acid-aluminum acetate acetylcysteine acetylcysteine intravenous ACID CONTROL (RANITIDINE) ORAL TABLET 150 MG ACID GONE ANTACID E.STRENGTH ACID REDUCER (FATIDINE) ACID REDUCER (RANITIDINE) ACNE TREATMENT (BENZOYL PEROX) TOPICAL GEL ACNE-CLEAR ACTA-TABS PE ACTEMRA INTRAVENOUS VIAL ACTHAR H.P ACTHIB (PF) ACTIMMUNE acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution acyclovir topical ADACEL(TDAP ADOLESN/ ADULT)(PF) ADAGEN ADASUVE ADDED STRENGTH PAIN RELIEVER adefovir ADEMPAS ADULT LOW DOSE ASPIRIN ADULT TUSSIN CHEST CONGESTION ADULT TUSSIN COUGH CONGEST DM ADVAIR DISKUS ADVAIR HFA ADVANCED ANTACID- ANTIGAS afeditab cr AFINITOR AFINITOR DISPERZ AFTERA AGGRENOX AKWA TEARS (POLYVINYL ALCOHOL) ala-cort topical cream ALA-HIST DM ALAVERT ALAWAY ALBENZA albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral ALCALAK alclometasone alcohol pads ALDURAZYME ALECENSA es gratuita. Para obtener más información, visite duals.caremore.com. 136

138 alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg alendronate oral tablet 40 mg alfuzosin ALIMTA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET ALKA-SELTZER PLUS ALLERGY ALL DAY ALLERGY RELIEF(CETIR) ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET ALL DAY RELIEF ALLER-G-TIME ALLER-TEC ALLERGY AND SINUS RELIEF ALLERGY EYE (KETOTIFEN) ALLERGY RELIEF (CETIRIZINE) ORAL TABLET ALLERGY RELIEF (CLEMASTINE) ALLERGY RELIEF (LORATADINE) ORAL TABLET ALLERGY RELIEF (LORATADINE) ORAL TABLET, DISINTEGRATING ALLERGY RELIEF (DIPHENHYDRAMIN) ALLERGY (DIPHENHYDRAMINE) allopurinol ALOPHEN alosetron ALPHAGAN P OPHTHALMIC DROPS 0.1 % alprazolam oral tablet altavera (28) ALUMINA AND MAGNESIUM ANTACID ORAL SUSPENSION MG/15 ML ALUMINA AND MAGNESIUM ANTACID ORAL TABLET,CHEWABLE MG ALUMINA, MAGNESIA, SIMETHICONE SUSPENSION ORAL SUSPENSION MG/5 ML, MG/5 ML aluminum hydroxide gel oral suspension 320 mg/5 ml aluminum hydroxide gel oral suspension 600 mg/5 ml alyacen 1/35 (28) alyacen 7/7/7 (28) amantadine hcl oral capsule amantadine hcl oral tablet AMBISOME amcinonide amifostine crystalline amikacin injection solution 1, 000 mg/4 ml, 500 mg/2 ml amiloride amiloridehydrochlorothiazide AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) amiodarone intravenous solution amiodarone intravenous syringe amiodarone oral amitriptyline AMLACTIN TOPICAL LOTION amlodipine besylate oral tablet 10 mg, 2.5 mg amlodipine besylate oral tablet 5 mg amlodipine-benazepril ammonium lactate AMNIUM LACTATE TOPICAL LOTION 12 % AMNIUM LACTATE TOPICAL LOTION 5 % amoxapine amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet, chewable 125 mg, 250 mg amoxicillin-pot clavulanate amphotericin b ampicillin ampicillin sodium injection ampicillin sodium intravenous recon soln 1 gram ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 1.5 gram es gratuita. Para obtener más información, visite duals.caremore.com. 137

139 ampicillin-sulbactam intravenous recon soln 3 gram AMPYRA AMRIX anagrelide anastrozole ANDRODERM ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/ 2.5GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/ 1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/ 2.5 GRAM) androxy ANTACID ANTACID ANTI-GAS ANTACID ANTI-GAS DOUBLE STR ANTACID EXST (MAG CARB-AL HYD) ANTACID EXT STR (CALCIUM CARB) ANTACID EXTRA- STRENGTH ORAL SUSPENSION MG/5 ML ANTACID EXTRA- STRENGTH ORAL TABLET, CHEWABLE 168 MG (420 MG), 300 MG (750 MG) ANTACID LIQUID ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI- GAS ANTACID REGULAR STRENGTH ANTACID WITH SIMETHICONE ANTACID (CALCIUM CARBONATE) ANTACID-ANTIGAS ANTACID- SIMETHICONE ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML ANTI-FUNGAL MICONAZOLE POWDER TOPICAL POWDER 2 % ANTI-ITCH (HC) TOPICAL CREAM ANTI-ITCH (HC) TOPICAL OINTMENT ANTIBIOTIC (NEOMY- BACIT-POLYM) ANTIBIOTIC-PAIN RELIEF (BACIT) ANTIFUNGAL MICONAZOLE CREAM ANTIFUNGAL (CLOTRIMAZOLE) ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM AP-HIST DM APOKYN apraclonidine apri APRISO APRODINE APTIOM APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 200 MCG/0.4 ML, 40 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0.3 ML, 60 MCG/0.3 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/0.42 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 300 MCG/0.6 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML arbinoxa ARCALYST aripiprazole oral solution aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg aripiprazole oral tablet 2 mg es gratuita. Para obtener más información, visite duals.caremore.com. 138

140 aripiprazole oral tablet 20 mg, 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet, disintegrating 10 mg aripiprazole oral tablet, disintegrating 15 mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML ARRANON ARTIFICIAL TEARS OPHTHALMIC DROPS %, % ARTIFICIAL TEARS (PF) OPHTHALMIC DROPPERETTE % ARTIFICIAL TEARS (POLYVIN ALC) ARTIFICIAL TEARS (GLYCERIN-PEG) ARZERRA ASACOL HD ascorbic acid (vitamin c) oral capsule, extended release ascorbic acid (vitamin c) oral tablet 1,000 mg ASPIR-LOW ASPIRIN LOW DOSE aspirin oral tablet aspirin oral tablet, chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg ASTAGRAF XL ASTEPRO NASAL SPRAY, NON-AEROSOL atenolol atenolol-chlorthalidone ATGAM ATHLETE'S FOOT AF ATHLETE'S FOOT (TERBINAFINE) ATHLETE'S FOOT (TOLNAFTATE) atorvastatin atovaquone atovaquone-proguanil oral tablet mg ATRIPLA atropine injection syringe 0.05 mg/ml, 0.1 mg/ml atropine ophthalmic drops ATROVENT HFA AUBRA AVASTIN aviane AVODART AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE AVONEX INTRAMUSCULAR SYRINGE KIT AVONEX (WITH ALBUMIN) AXIRON azacitidine AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) AZASAN azathioprine azathioprine sodium azelastine nasal aerosol, spray azelastine ophthalmic AZILECT azithromycin intravenous recon soln 500 mg azithromycin intravenous recon soln 500 mg (2 mg/ ml) azithromycin oral suspension for reconstitution azithromycin oral tablet AZOPT azurette (28) B B-12 DOTS baciim bacitracin intramuscular bacitracin ophthalmic bacitracin topical ointment BACITRACIN TOPICAL PACKET BACITRACIN ZINC TOPICAL PACKET bacitracin-polymyxin b ophthalmic bacitracin-polymyxin b topical ointment bacitracin-polymyxin b topical packet BACITRAYCIN PLUS TOPICAL OINTMENT 500 UNIT/GRAM baclofen balsalazide balziva (28) BANOPHEN ALLERGY BANOPHEN ORAL CAPSULE 25 MG BANOPHEN ORAL CAPSULE 50 MG BANOPHEN ORAL LIQUID BANOPHEN ORAL TABLET es gratuita. Para obtener más información, visite duals.caremore.com. 139

141 BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BARACLUDE ORAL SOLUTION BCG VACCINE, LIVE (PF) BELEODAQ benazepril benazeprilhydrochlorothiazide BENDEKA BENLYSTA benzonatate oral capsule 100 mg, 200 mg benzoyl peroxide topical gel 10 %, 5 % benzphetamine oral tablet 50 mg benztropine oral BETA-HC betamethasone dipropionate betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical lotion betamethasone, augmented topical ointment BETASERON SUBCUTANEOUS KIT BETATEMP betaxolol ophthalmic betaxolol oral bethanechol chloride bexarotene BEXSERO (PF) bicalutamide BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K) BICNU BILTRICIDE BIOCOTRON BION TEARS (PF) BISA-LAX BISAC-EVAC bisacodyl oral bisacodyl rectal BISCOLAX BISMATROL ORAL SUSPENSION 262 MG/15 ML BISMATROL ORAL SUSPENSION 525 MG/15 ML BISMATROL ORAL TABLET,CHEWABLE BISMUTH BISMUTH MAXIMUM STRENGTH bisoprolol fumarate bisoprololhydrochlorothiazide bleomycin BLEPHAMIDE S.O.P BLINCYTO BONIVA INTRAVENOUS BOOSTRIX TDAP BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG BP briellyn BRILINTA brimonidine ophthalmic drops 0.2 % BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 75 MG BRIVIACT ORAL TABLET 25 MG BRIVIACT ORAL TABLET 50 MG bromocriptine brompheniraminphenylephrin-dm oral liquid mg/5 ml budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml budesonide oral bumetanide BUPHENYL ORAL TABLET buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual tablet mg buprenorphine-naloxone sublingual tablet 8-2 mg buproban bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg buspirone es gratuita. Para obtener más información, visite duals.caremore.com. 140

142 BUSULFEX butalbital-acetaminop-caf-cod oral capsule mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal BYDUREON BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/ DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/ DOSE (250 MCG/ML) 1.2 ML C C-500 ORAL TABLET C-500 ORAL TABLET, CHEWABLE cabergoline CABOMETYX ORAL TABLET 20 MG CABOMETYX ORAL TABLET 40 MG, 60 MG CAL-GEST ANTACID calamine CALAMINE-ZINC OXIDE TOPICAL LOTION 8-8 % CALCI-CHEW CALCIONATE calcipotriene scalp calcipotriene topical calcitonin (salmon) CALCITRATE calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule CALCIUM CALCIUM D ORAL TABLET 500 MG(1,250MG) -200 UNIT CALCIUM D ORAL TABLET 500 MG(1,250MG) -400 UNIT CALCIUM D ORAL TABLET,CHEWABLE CALCIUM D (D3) CALCIUM 500 WITH D CALCIUM CALCIUM D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG(1, 500MG) -400 UNIT CALCIUM MINERALS CALCIUM 600 WITH VITAMIN D3 ORAL TABLET calcium acetate oral capsule calcium acetate oral tablet 667 mg CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG) CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG), 400 MG (1,000 MG) CALCIUM ANTACID TROPICAL CALCIUM ANTACID ULTRA MAX ST calcium carbonate - d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit calcium carbonate - d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonate - d3 oral tablet,chewable 500 mg(1, 250mg) -400 unit CALCIUM CARBONATE - D3 ORAL TABLET, CHEWABLE MG- UNIT CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL SUSPENSION MG/5 ML, MG/5 ML CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL TABLET,CHEWABLE MG CALCIUM CARBONATE ANTACID ORAL TABLET, CHEWABLE 400 MG (1,000 MG) CALCIUM CARBONATE ORAL SUSPENSION calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet, chewable 200 mg calcium (500 mg), 400 mg (1,000 mg), 500 mg calcium (1,250 mg) calcium carbonate-vit d3-min oral tablet CALCIUM CARBONATE- VIT D3-MIN ORAL TABLET,CHEWABLE 600 MG (1,500 MG)-400 UNIT CALCIUM CITRATE + D calcium citrate oral tablet 200 mg (950 mg) CALCIUM CITRATE ORAL TABLET 250 MG CALCIUM calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit es gratuita. Para obtener más información, visite duals.caremore.com. 141

143 calcium citrate-vitamin d3 oral tablet mg-unit, mg-unit CALCIUM FOR WOMEN CALCIUM GLUCONATE ORAL TABLET 45 MG (500 MG) CALCIUM GLUCONATE ORAL TABLET 60 MG (650 MG) CALCIUM LACTATE ORAL TABLET 84 MG (648 MG) CALCIUM SOFT CHEW ORAL TABLET,CHEWABLE MG-UNIT-MCG, MG-UNIT- MCG CALCIUM WITH VITAMIN D calcium-magnesium-zinc oral tablet CALCIUM-MAGNESIUM- ZINC ORAL TABLET MG calcium-vitamin d3-vitamin k oral tablet,chewable mg-unit-mcg camila CANASA CANCIDAS candesartan oral tablet 16 mg, 4 mg, 8 mg candesartan oral tablet 32 mg candesartanhydrochlorothiazid oral tablet mg candesartanhydrochlorothiazid oral tablet mg, mg CAPASTAT CAPEX CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG captopril captoprilhydrochlorothiazide CARBAGLU carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral suspension 200 mg/10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet, chewable carbidopa-levodopa carboplatin intravenous solution CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM carteolol cartia xt carvedilol CAYSTON caziant (28) cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/ 50 ml cefazolin injection recon soln 1 gram cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g cefazolin injection recon soln 500 mg cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, isoosm cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, 2 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,isoos ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium intravenous vial injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous vial intravenous recon soln 7.5 gram CELLCEPT INTRAVENOUS CELONTIN ORAL CAPSULE 300 MG cephalexin oral capsule 250 mg, 500 mg es gratuita. Para obtener más información, visite duals.caremore.com. 142

144 cephalexin oral suspension for reconstitution cephalexin oral tablet CERASPORT ORAL LIQUID CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CERVARIX VACCINE (PF) cetirizine oral tablet cevimeline CHANTIX CHANTIX CONTINUING NTH BOX CHANTIX STARTING NTH BOX CHERATUSSIN AC chloramphenicol sod succinate chlorhexidine gluconate mucous membrane chloroquine phosphate oral chlorothiazide chlorpromazine chlorthalidone oral tablet 25 mg, 50 mg cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit cholecalciferol (vitamin d3) oral drops 400 unit/ml cholecalciferol (vitamin d3) oral tablet 1,000 unit, 2,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral tablet 400 unit cholestyramine light cholestyramine (with sugar) ciclodan topical solution ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension cilostazol CINRYZE CIPRODEX ciprofloxacin er ciprofloxacin hcl ophthalmic ciprofloxacin hcl oral ciprofloxacin lactate intravenous solution 200 mg/ 20 ml ciprofloxacin lactate intravenous solution 400 mg/ 40 ml cisplatin citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg CITRATE OF MAGNESIA CITROMA CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT CITRUS CALCIUM ORAL TABLET MG- UNIT cladribine clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr CLASSIC PRENATAL CLEARLAX clemastine oral tablet 1.34 mg clemastine oral tablet 2.68 mg clindamycin hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml clindamycin phosphate topical clindamycin phosphate vaginal CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 5%-D20W (SULFITE-FREE) CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol scalp clobetasol topical cream es gratuita. Para obtener más información, visite duals.caremore.com. 143

145 clobetasol topical gel clobetasol topical ointment clobetasol-emollient topical cream CLOLAR clomipramine clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet, disintegrating mg clonazepam oral tablet, disintegrating 0.25 mg clonazepam oral tablet, disintegrating 0.5 mg clonazepam oral tablet, disintegrating 1 mg clonazepam oral tablet, disintegrating 2 mg clonidine hcl oral tablet clonidine transdermal patch clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg clorazepate dipotassium CLOTRIMAZOLE 3 DAY CLOTRIMAZOLE AF CLOTRIMAZOLE ANTIFUNGAL clotrimazole mucous membrane clotrimazole topical clotrimazole vaginal cream CLOTRIMAZOLE CLOTRIMAZOLE clotrimazolebetamethasone clozapine oral tablet 100 mg clozapine oral tablet 200 mg clozapine oral tablet 25 mg clozapine oral tablet 50 mg clozapine oral tablet, disintegrating 100 mg clozapine oral tablet, disintegrating 12.5 mg clozapine oral tablet, disintegrating 150 mg clozapine oral tablet, disintegrating 200 mg clozapine oral tablet, disintegrating 25 mg COARTEM codeine-guaifenesin COL-RITE colchicine-probenecid COLCRYS COLD AND ALLERGY COLD AND ALLERGY PE colestipol colistin (colistimethate na) COLLYRIUM colocort COLY-MYCIN S COMBIGAN COMBIVENT RESPIMAT COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COMFORT GEL COMFORT GEL EXTRA STRENGTH COMPLERA COMPLETE ALLERGY COMPLETE ALLERGY MEDICINE COMPLETE LICE TREATMENT compro CONDOMS, LATEX, LUBRICATED CONDOMS, LATEX, NON- LUBRICATED DEVICE constulose COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML cormax scalp cortisone CORTISONE (HYDROCORTISONE) TOPICAL CREAM CORTIZONE-10 PLUS CORTIZONE-10 TOPICAL CREAM CORTIZONE-10 TOPICAL OINTMENT COTELLIC COUGH CONTROL DM ORAL LIQUID COUGH CONTROL (GUAIFENESIN) COUGH SYRUP CREON CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG cromolyn inhalation cromolyn ophthalmic cryselle (28) CUBICIN cyanocobalamin (vitamin b- 12) injection es gratuita. Para obtener más información, visite duals.caremore.com. 144

146 cyanocobalamin (vitamin b- 12) oral tablet 1,000 mcg, 100 mcg, 500 mcg cyanocobalamin (vitamin b- 12) oral tablet extended release cyanocobalamin (vitamin b- 12) sublingual tablet 1,000 mcg cyanocobalamin (vitamin b- 12) sublingual tablet 2,500 mcg cyclafem 7/7/7 (28) cyclophosphamide oral capsule CYCLOSET cyclosporine intravenous cyclosporine modified cyclosporine oral capsule cyproheptadine oral tablet CYRAMZA CYSTADANE CYSTAGON cytarabine cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ ml), 2 gram/20 ml (100 mg/ ml) cytarabine (pf) injection solution 20 mg/ml D D-VI-SOL D-VITA d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride D d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine DACOGEN DAILY PRENATAL DALIRESP danazol oral dantrolene DAPSONE DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM DARZALEX dasetta 7/7/7 (28) daunorubicin intravenous solution DAYHIST ALLERGY DEBLITANE decitabine DELTA D DELYLA (28) DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) demeclocycline DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ ML DESCOVY DESENEX TOPICAL POWDER desipramine oral desmopressin injection desmopressin nasal aerosol, spray desmopressin nasal spray,nonaerosol desmopressin oral desog-e.estradiol/ e.estradiol desonide desoximetasone DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DEX4 GLUCOSE ORAL TABLET,CHEWABLE DEX4 GLUCOSE POUCH PACK DEX4 GLUCOSE QUICK DISSOLVE dexamethasone dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection dexamethasone sodium phosphate ophthalmic DEXILANT dexrazoxane hcl intravenous recon soln 250 mg dexrazoxane hcl intravenous recon soln 500 mg dextroamphetamine oral capsule, extended release 10 mg, 5 mg dextroamphetamine oral capsule, extended release 15 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamineamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg es gratuita. Para obtener más información, visite duals.caremore.com. 145

147 dextroamphetamineamphetamine oral tablet 30 mg dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) dextrose oral gel dextrose with sodium chloride dextrose-kcl-nacl DIABETIC SILTUSSIN DAS- NA DIABETIC SILTUSSIN- DM DIABETIC TUSSIN DM ORAL LIQUID MG/5 ML DIABETIC TUSSIN EX DIALYVITE DIALYVITE VITAMIN D DIARRHEA RELIEF (BISMUTH SUBS) diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml) diazepam oral tablet 10 mg diazepam oral tablet 2 mg diazepam oral tablet 5 mg diazepam rectal kit mg diazepam rectal kit 2.5 mg, mg diclofenac potassium diclofenac sodium oral diclofenac sodium topical gel 3 % dicloxacillin dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet didanosine oral capsule, delayed release(dr/ec) 125 mg didanosine oral capsule, delayed release(dr/ec) 200 mg didanosine oral capsule, delayed release(dr/ec) 250 mg, 400 mg DIFFERIN TOPICAL GEL 0.3 % DIFFERIN TOPICAL GEL WITH PUMP diflorasone diflunisal digox oral tablet 125 mcg digoxin injection solution digoxin oral solution 50 mcg/ ml digoxin oral tablet 125 mcg DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS dilt-xr diltiazem hcl intravenous solution diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule, extended release 12 hr diltiazem hcl oral capsule, extended release 24hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr DIOCTO ORAL LIQUID DIOCTO ORAL SYRUP DIOCTYL DIOTAME DIPENTUM DIPHEDRYL ALLERGY DIPHEDRYL ORAL CAPSULE DIPHEDRYL ORAL LIQUID DIPHEDRYL ORAL TABLET DIPHENHIST ORAL CAPSULE DIPHENHIST ORAL LIQUID DIPHENHIST ORAL TABLET 25 MG diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe es gratuita. Para obtener más información, visite duals.caremore.com. 146

148 diphenhydramine hcl oral capsule diphenhydramine hcl oral elixir diphenhydramine hcl oral liquid diphenhydramine hcl oral syrup diphenhydramine hcl oral tablet 25 mg DIPHENHYDRAMINE ORAL CAPSULE 25 MG, 50 MG DIPHENHYDRAMINE ORAL ELIXIR 12.5 MG/5 ML DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/5 ML DIPHENHYDRAMINE ORAL SYRUP 12.5 MG/5 ML diphenoxylate-atropine disulfiram divalproex DOC-Q-LACE DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ ml), 20 mg/2 ml (10 mg/ ml) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) DOCU DOCUPRENE docusate calcium docusate sodium oral capsule 100 mg docusate sodium oral capsule 250 mg docusate sodium oral liquid docusate sodium oral tablet DOCUSIL dofetilide DOK ORAL CAPSULE 100 MG DOK ORAL CAPSULE 250 MG DOK ORAL TABLET donepezil oral tablet 10 mg donepezil oral tablet 5 mg donepezil oral tablet, disintegrating 10 mg donepezil oral tablet, disintegrating 5 mg dorzolamide dorzolamide-timolol DOUBLE ANTIBIOTIC doxazosin doxepin oral doxorubicin intravenous recon soln doxorubicin intravenous solution DOXY doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline hyclate oral tablet, delayed release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral tablet DRAMAMINE LESS DROWSY dronabinol drospirenone-ethinyl estradiol oral tablet mg DROXIA DRY EYE RELIEF DSS DUCODYL DULCOLAX STOOL SOFTENER (DSS) DULERA 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 duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml DUREZOL dutasteride dutasteride-tamsulosin E econazole topical ECONTRA EZ ECOTRIN LOW STRENGTH ECZEMA ANTI-ITCH ED A-HIST ORAL TABLET ED A-HIST PSE EDURANT EFFIENT ELAPRASE ELIDEL elinest ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG ELITEK INTRAVENOUS RECON SOLN 1.5 MG elitek intravenous recon soln 7.5 mg ELLA EMCYT EMEND ORAL CAPSULE 125 MG es gratuita. Para obtener más información, visite duals.caremore.com. 147

149 EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE 80 MG EMEND ORAL CAPSULE, DOSE PACK EMPLICITI EMSAM EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION enalapril maleate enalaprilhydrochlorothiazide ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK endocet oral tablet mg, mg, mg ENGERIX-B PEDIATRIC (PF) ENGERIX-B (PF) enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/ 0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml enpresse entacapone entecavir ENTERIC COATED ASPIRIN ENTRE-HIST PSE enulose epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin intravenous solution 200 mg/100 ml epirubicin intravenous solution 50 mg/25 ml epitol EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION eplerenone eprosartan EPZICOM EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ERAXIS(WATER DILUENT) ERBITUX ergocalciferol (vitamin d2) oral capsule ergocalciferol (vitamin d2) oral tablet 400 unit ergoloid ERGOMAR ERIVEDGE errin ERWINAZE ery pads ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/ EC) 500 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral tablet erythromycin ophthalmic erythromycin oral tablet erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ESTRACE VAGINAL estradiol oral estradiol transdermal patch weekly ESTRING ethambutol ethosuximide etodolac ETOPOPHOS etoposide intravenous EVOMELA EVOTAZ EXELON TRANSDERMAL exemestane EXJADE EXPECTORANT COUGH SYRUP EXPECTORANT ORAL LIQUID EYE DROP TEARS EYE IRRIGATING SOLUTION EYE ITCH RELIEF EYE STREAM es gratuita. Para obtener más información, visite duals.caremore.com. 148

150 EYE WASH EYE WASH STERILE EZFE F FABRAZYME FALLBACK SOLO falmina (28) famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg famotidine intravenous famotidine oral suspension famotidine oral tablet 10 mg famotidine oral tablet 20 mg, 40 mg famotidine (pf) famotidine (pf)-nacl (isoos) FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG FANAPT ORAL TABLET 12 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS, DOSE PACK FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FAZACLO ORAL TABLET, DISINTEGRATING 100 MG FAZACLO ORAL TABLET, DISINTEGRATING 12.5 MG FAZACLO ORAL TABLET, DISINTEGRATING 25 MG felbamate felodipine oral er fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized 48 mg, 145 mg fenofibrate oral tablet 160 mg, 54 mg fenoprofen oral tablet fentanyl citrate fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/ hr FENTORA FEOSOL ORAL TABLET 325 MG (65 MG IRON) FERATE ORAL TABLET 240 MG (27 MG IRON) FEROSUL ORAL TABLET FERRETTS FERREX FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET FERRO-TIME ferrous gluconate oral tablet 240 mg (27 mg iron) ferrous gluconate oral tablet 256 mg (28 mg iron) FERROUS GLUCONATE ORAL TABLET 324 MG (36 MG IRON), 324 MG (37.5 MG IRON), 324 MG (38 MG IRON), 325 MG (36 MG IRON) ferrous sulfate oral tablet 325 mg (65 mg iron) FERROUS SULFATE ORAL TABLET,DELAYED RELEASE (DR/EC) 324 MG (65 MG IRON) ferrous sulfate oral tablet, delayed release (dr/ec) 325 mg (65 mg iron) FERROUSUL FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE, EXTENDED RELEASE 24 HR 40 MG FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION FEVERALL RECTAL SUPPOSITORY 650 MG finasteride oral tablet 5 mg FIRAZYR FIRMAGON KIT W DILUENT SYRINGE FLANAX ANTACID FLANAX (NAPROXEN) FLEBOGAMMA DIF flecainide FLEET GLYCERIN (ADULT) FLEET LAXATIVE FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ ACTUATION, 50 MCG/ ACTUATION es gratuita. Para obtener más información, visite duals.caremore.com. 149

151 FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION fluconazole fluconazole in dextrose(isoo) fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/ 50 ml, 400 mg/200 ml fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/ 100 ml flucytosine fludarabine intravenous recon soln fludarabine intravenous solution fludrocortisone flunisolide nasal spray,nonaerosol 25 mcg (0.025 %) fluocinolone fluocinolone acetonide oil fluocinolone and shower cap fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e fluorometholone fluorouracil intravenous fluorouracil topical cream 5 % fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen ophthalmic drops flutamide fluticasone nasal fluticasone topical cream fluticasone topical ointment fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg folic acid oral tablet 1 mg folic acid oral tablet 400 mcg, 800 mcg FOLOTYN fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml FORADIL AEROLIZER FORTEO foscarnet fosinopril fosinoprilhydrochlorothiazide fosphenytoin FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/ 0.2 ML freamine iii 10 % FREESTYLE INSULINX STRIP FREESTYLE INSULINX TEST STRIPS FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE TEST FULL SPECTRUM B- VITAMIN C FUNGOID-D furosemide injection solution furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ ml) furosemide oral tablet FUSILEV FUZEON SUBCUTANEOUS RECON SOLN FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG G G-TRON gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg es gratuita. Para obtener más información, visite duals.caremore.com. 150

152 gabapentin oral solution 250 mg/5 ml gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMUNEX-C ganciclovir sodium GARDASIL 9 (PF) GARDASIL (PF) GAS RELIEF GAS RELIEF ULTRA STRENGTH GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PADS 2 X GAVILAX ORAL POWDER gavilyte-c gavilyte-g gavilyte-n GAZYVA gemcitabine intravenous recon soln 1 gram, 200 mg gemcitabine intravenous recon soln 2 gram gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml) gemfibrozil oral generlac gengraf oral capsule 100 mg, 25 mg gengraf oral capsule 50 mg gengraf oral solution GENOTROPIN GENOTROPIN MINIQUICK gentak ophthalmic ointment gentamicin injection gentamicin ophthalmic gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/ 10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml gentamicin topical GENTLE LAXATIVE GENTLELAX GENVOYA GEODON INTRAMUSCULAR GERI-LANTA GERI-X ANTACID- ANTIGAS GERI-TUSSIN gildagia gildess 1.5/30 (21) gildess fe 1.5/30 (28) gildess fe 1/20 (28) GILENYA GILOTRIF GLATOPA GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE glimepiride oral tablet 1 mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) GLUCO BURST GLUCOSE GEL glucose oral tablet,chewable 4 gram GLUTOSE GLUTOSE glycerin (adult) GLYCOLAX ORAL POWDER glycopyrrolate oral GORMEL TEN griseofulvin microsize oral suspension griseofulvin ultramicrosize GUAIFENESIN AC guaifenesin oral liquid GUAIFENESIN-DM guanidine H HALAVEN halobetasol propionate HALOG haloperidol haloperidol decanoate haloperidol lactate es gratuita. Para obtener más información, visite duals.caremore.com. 151

153 HARVONI HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/ 0.5 ML HEADACHE RELIEF (ASA- ACET-CAF) HEALTHYLAX HEARTBURN ANTACID HEARTBURN PREVENTION HEARTBURN RELIEF HEARTBURN RELIEF (FATIDINE) HEARTBURN RELIEF (RANITIDINE) heather HEPARIN FLUSH heparin lock flush intravenous kit 100 unit/ml heparin lock flush intravenous solution 10 unit/ml, 100 unit/ ml heparin lock flush intravenous syringe 10 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 100 UNIT/ML HEPARIN LOCKFLUSH (PORCINE)(PF) heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml (100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2, 000 unit/1,000 ml heparin (porcine) injection cartridge heparin (porcine) injection solution heparin, porcine (pf) injection solution heparin, porcine (pf) intravenous solution 100 unit/ ml (1 ml) HEPARIN, PORCINE (PF) INTRAVENOUS SYRINGE 1 UNIT/ML heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/500 ml HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN HI-CAL PLUS VIT D HIBERIX (PF) HIGH POTENCY IRON HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT) HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S- UC-HS START HUMIRA PEN PSORIASIS STARTER HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML hydralazine hydrochlorothiazide hydrocodone-acetaminophen oral solution mg/15 ml (15 ml), mg/5 ml, mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodonechlorpheniramine hydrocodone-homatropine oral syrup mg/5 ml HYDROCODONE- HOMATROPINE ORAL SYRUP MG/5 ML (5 ML) hydrocodone-homatropine oral tablet hydrocodone-ibuprofen oral tablet mg hydrocortisone acetate topical hydrocortisone oral HYDROCORTISONE PLUS hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema hydrocortisone topical cream 0.5 % es gratuita. Para obtener más información, visite duals.caremore.com. 152

154 hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 1 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 0.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-min oil-wht pet HYDROCREAM HYDROMET hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg HYDROSKIN TOPICAL LOTION hydroxychloroquine oral hydroxyurea I I-PRIN ibandronate intravenous ibandronate oral IBRANCE IBUPROFEN IB ORAL TABLET ibuprofen oral capsule ibuprofen oral suspension ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin IFEREX ifosfamide intravenous recon soln ifosfamide intravenous solution ILARIS (PF) ILEVRO imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA imipenem-cilastatin imipramine hcl imiquimod IVAX RABIES VACCINE (PF) INCRELEX indapamide INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG INSTA-GLUCOSE insulin pen needle INSULIN SYRINGE (DISP) U ML, 1 ML, 1/2 ML INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG intralipid intravenous emulsion 20 % INTRON A INJECTION INTUNIV ER INVANZ INJECTION INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG INZO ANTIFUNGAL IOPHEN C-NR IOPHEN DM-NR IOPHEN-NR IPOL INJECTION SUSPENSION ipratropium bromide inhalation ipratropium bromide nasal ipratropium-albuterol irbesartan IRESSA irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml irinotecan intravenous solution 500 mg/25 ml es gratuita. Para obtener más información, visite duals.caremore.com. 153

155 IRON HIGH POTENCY IRON ORAL TABLET 325 MG (65 MG IRON) IRON (DRIED) IRON (FERROUS SULFATE) ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET, CHEWABLE 100 MG ISENTRESS ORAL TABLET, CHEWABLE 25 MG isoniazid oral isosorbide dinitrate oral isosorbide mononitrate ISTODAX ITCHY EYE DROPS itraconazole IXEMPRA IXIARO (PF) J JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 15 MG JAKAFI ORAL TABLET 20 MG JAKAFI ORAL TABLET 25 MG JAKAFI ORAL TABLET 5 MG JALYN jantoven JANUMET JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG JANUVIA ORAL TABLET 25 MG JANUVIA ORAL TABLET 50 MG JARDIANCE jencycla JEVTANA JOCK ITCH JOCK ITCH (CLOTRIMAZOLE) JOCK ITCH (TERBINAFINE) jolessa jolivette junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) JUNEL FE JUXTAPID K K-PEC ANTIDIARRHEAL (BISM SUB) KADCYLA KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG KALYDECO ORAL TABLET KAO-TIN (BISMUTH SUBSALICYLAT) KAO-TIN (DOCUSATE CALCIUM) KAOPECTATE EX STR (BISMUTH SS) KAOPECTATE (BISMUTH SUBSALICY) kariva (28) kelnor 1/35 (28) KEPIVANCE ketoconazole oral ketoconazole topical ketorolac ophthalmic KETOTIFEN FUM 0.025% EYE DROPS ketotifen fumarate KEYTRUDA KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG KINERET kionex oral suspension KLOR-CON KLOR-CON klor-con m KLOR-CON M KLOR-CON M KORLYM KPN kurvelo KUVAN ORAL TABLET, SOLUBLE KYNAMRO L labetalol intravenous solution labetalol oral lactated ringers intravenous lactated ringers irrigation lactulose LAMISIL AT TOPICAL CREAM lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg lamivudine oral tablet 300 mg lamivudine-zidovudine lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible LANOXIN ORAL TABLET 125 MCG, 62.5 MCG lansoprazole oral capsule, delayed release(dr/ec) LANTUS LANTUS SOLOSTAR LARIN 1.5/30 (21) es gratuita. Para obtener más información, visite duals.caremore.com. 154

156 LARIN FE 1/20 (28) latanoprost LATUDA ORAL TABLET 120 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG LATUDA ORAL TABLET 80 MG LAXA CLEAR LAXATIVE PEG 3350 ORAL POWDER LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) LAXATIVE (BISACODYL) RECTAL LAZANDA NASAL SPRAY, NON-AEROSOL 100 MCG/ SPRAY, 400 MCG/ SPRAY LAZANDA NASAL SPRAY, NON-AEROSOL 300 MCG/ SPRAY leflunomide LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/ DAY) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2) LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK) lessina LETAIRIS letrozole leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral LEUKERAN LEUKINE INJECTION RECON SOLN leuprolide subcutaneous kit levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml LEVEMIR LEVEMIR FLEXTOUCH levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg levobunolol ophthalmic drops 0.5 % levocarnitine oral tablet levocarnitine (with sugar) levocetirizine oral tablet levofloxacin intravenous levofloxacin oral levonest (28) levonorg-eth estrad triphasic levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month levorphanol tartrate levothyroxine oral levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET LICE BEDDING SPRAY LICE COMPLETE KIT LICE CREAM RINSE LICE KILLING LICE KILLING (PERMETHRIN) LICE PYRINYL SHAMPOO LICE SOLUTION LICE TREATMENT TOPICAL LIQUID 1 % LICE TREATMENT TOPICAL SHAMPOO LICE TREATMENT (PERMETHRIN) lidocaine hcl injection solution lidocaine hcl laryngotracheal lidocaine hcl mucous membrane lidocaine hcl urethral lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine viscous lidocaine (pf) injection solution 10 mg/ml (1 %), 20 es gratuita. Para obtener más información, visite duals.caremore.com. 155

157 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 15 mg/ml (1.5 %) lidocaine (pf) intravenous solution lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %) lidocaine-prilocaine topical cream lindane topical shampoo linezolid oral suspension for reconstitution linezolid oral tablet LINZESS liothyronine oral LIQUID ANTACID LIQUITEARS lisinopril lisinoprilhydrochlorothiazide lithium carbonate lithium citrate oral solution 8 meq/5 ml LOHIST-DM LOKARA LONSURF loperamide oral capsule loperamide oral liquid 1 mg/5 ml LORADAMED loratadine oral tablet loratadine oral tablet, disintegrating LORAZEPAM INTENSOL lorazepam oral tablet LORCET HD LORCET PLUS ORAL TABLET MG LORCET (HYDROCODONE) LORTAB LORTAB LORTAB losartan oral tablet 100 mg losartan oral tablet 25 mg, 50 mg losartanhydrochlorothiazide LOTRIMIN AF TOPICAL CREAM LOTRIMIN AF TOPICAL POWDER lovastatin oral tablet 10 mg, 20 mg lovastatin oral tablet 40 mg low-ogestrel (28) loxapine succinate LUBRICANT EYE DROPS LUBRICANT EYE DROPS (GLYC-PG) LUBRICANT EYE (PG-PEG 400) LUBRICANT REDNESS RELIEVER OPHTHALMIC DROPS % LUBRICATING PLUS LUMIGAN OPHTHALMIC DROPS 0.01 % LUNESTA LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG LUPRON DEPOT (3 NTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG lutera (28) LYNPARZA LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION LYSODREN lyza M M-CLEAR WC M-M-R II (PF) MAALOX MAXIMUM STRENGTH MACRODANTIN ORAL CAPSULE 25 MG, 50 MG MAG-AL PLUS MAG-AL PLUS EXTRA STRENGTH magnesium citrate oral solution MAGNESIUM OXIDE ORAL CAPSULE 500 MG magnesium sulfate in water intravenous parenteral solution magnesium sulfate in water intravenous piggyback 2 gram/ 50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water intravenous piggyback 4 gram/ 100 ml (4 %) magnesium sulfate injection solution magnesium sulfate injection syringe MAPAP EXTRA STRENGTH maprotiline oral tablet 25 mg maprotiline oral tablet 50 mg es gratuita. Para obtener más información, visite duals.caremore.com. 156

158 maprotiline oral tablet 75 mg marlissa MARPLAN MASANTI DOUBLE STRENGTH MASOPHEN ORAL TABLET 500 MG MATULANE matzim la MAXIMUM REDNESS RELIEF meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet, chewable meclofenamate oral MEDI-MECLIZINE MEDIPROXEN MEDIWASH MEDIWASH EYE IRRIGANT medroxyprogesterone intramuscular medroxyprogesterone oral mefloquine megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/20 ml (20 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG meloxicam oral suspension meloxicam oral tablet melphalan hcl memantine oral solution memantine oral tablet 10 mg memantine oral tablet 5 mg MENACTRA (PF) INTRAMUSCULAR SOLUTION MENEST MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-135 (PF) MENSTRUAL RELIEF MENVEO A-C-Y-W-135-DIP (PF) MEPHYTON mercaptopurine meropenem mesalamine rectal mesalamine with cleansing wipe mesna MESNEX ORAL MESTINON ORAL SYRUP MESTINON TIMESPAN METADATE ER metaproterenol metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg methadone injection methadone intensol methadone oral concentrate methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/ 5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg methadose oral concentrate methazolamide oral methenamine hippurate methimazole oral tablet 10 mg, 5 mg methotrexate sodium methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methoxsalen rapid methyclothiazide methyldopa methyldopahydrochlorothiazide methyldopate methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule, er biphasic mg methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr 18 mg methylprednisolone acetate methylprednisolone oral tablets methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous metipranolol metoclopramide hcl injection solution metoclopramide hcl injection syringe es gratuita. Para obtener más información, visite duals.caremore.com. 157

159 metoclopramide hcl oral solution metoclopramide hcl oral tablet metolazone metoprolol succinate metoprolol tahydrochlorothiaz metoprolol tartrate intravenous solution metoprolol tartrate intravenous syringe metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg metro i.v metronidazole in nacl (isoos) metronidazole oral metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical lotion metronidazole vaginal mexiletine MI-ACID GAS RELIEF MIACALCIN INJECTION MICATIN MICONAZOLE 3 DAY VAGINAL CREAM MICONAZOLE miconazole nitrate topical cream miconazole nitrate vaginal comb pack,prefill appl, cream miconazole nitrate vaginal cream miconazole nitrate vaginal suppository MICONAZOLE-3 VAGINAL KIT miconazole-3 vaginal suppository MICONAZORB AF MICRO-GUARD MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) MICROGESTIN FE 1/20 (28) midodrine MIGRAINE FORMULA MIGRAINE RELIEF MIGRANAL MILK OF MAGNESIA MILK OF MAGNESIA CONCENTRATED MINERAL OIL EXTRA HEAVY MINERAL OIL HEAVY ORAL MINERAL OIL LAXATIVE mineral oil oral mineral oil rectal minocycline oral capsule minocycline oral tablet minoxidil oral MINTOX MINTOX MAXIMUM STRENGTH MINTOX PLUS MIRALAX ORAL POWDER IN PACKET MIRCETTE (28) mirtazapine oral tablet 15 mg mirtazapine oral tablet 30 mg mirtazapine oral tablet 45 mg mirtazapine oral tablet 7.5 mg mirtazapine oral tablet, disintegrating 15 mg mirtazapine oral tablet, disintegrating 30 mg mirtazapine oral tablet, disintegrating 45 mg misoprostol mitomycin mitoxantrone modafinil oral tablet 100 mg modafinil oral tablet 200 mg DERIBA ISTURE DROPS molindone mometasone topical mono-linyah NOJECT PREFILL ADVANCED (PF) NOJECT PREFILL (PF) mononessa (28) montelukast morgidox oral capsule 100 mg morphine concentrate oral solution morphine intravenous cartridge 2 mg/ml RPHINE INTRAVENOUS CARTRIDGE 8 MG/ML morphine intravenous solution 10 mg/ml, 50 mg/ml morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml RPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ ML morphine intravenous syringe 2 mg/ml, 4 mg/ml morphine oral capsule, er multiphase 24 hr 30 mg, 60 mg morphine oral capsule, extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 10 mg/ 5 ml morphine oral solution 20 mg/ 5 ml (4 mg/ml) morphine oral tablet 15 mg es gratuita. Para obtener más información, visite duals.caremore.com. 158

160 morphine oral tablet 30 mg morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg morphine oral tablet extended release 200 mg morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ml morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml TION RELIEF (MECLIZINE) TION SICKNESS RELIEF(MECLIZ) TION SICKNESS (MECLIZINE) VIPREP ZOBIL MULTAQ mupirocin topical ointment MUSTARGEN MY WAY MYCOBUTIN mycophenolate mofetil mycophenolate sodium MYFERON MYOZYME MYRBETRIQ MYTAB GAS MYTAB GAS MAXIMUM STRENGTH myzilra N nabumetone nadolol nadololbendroflumethiazide nafcillin injection recon soln 1 gram, 10 gram nafcillin injection recon soln 2 gram nafcillin intravenous recon soln 2 gram NAGLAZYME nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone naltrexone NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET 10 MG NAMENDA ORAL TABLET 5 MG NAMENDA TITRATION PAK NAMENDA XR ORAL CAP, SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR naphazoline naproxen naproxen sodium oral capsule naproxen sodium oral tablet 220 mg naproxen sodium oral tablet 275 mg, 550 mg NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET EXTENDED RELEASE NASAL MIST NATACYN nateglinide oral tablet 120 mg nateglinide oral tablet 60 mg NATPARA NATURAL TEARS (PF) NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 10/11 (28) necon 7/7/7 (28) needles, insulin disp., safety nefazodone oral tablet 100 mg nefazodone oral tablet 150 mg nefazodone oral tablet 200 mg nefazodone oral tablet 250 mg nefazodone oral tablet 50 mg neo-polycin neo-polycin hc neomycin neomycin-bacitracin-polyhc neomycin-bacitracinpolymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc ophthalmic neomycin-polymyxin-hc otic NEOSPORIN ANTI- ITCH NEOSPORIN PLUS PAINRELIEF(BAC) NEULASTA SUBCUTANEOUS SYRINGE NEUPOGEN NEUPRO es gratuita. Para obtener más información, visite duals.caremore.com. 159

161 NEVANAC nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg NEXAVAR NEXT CHOICE ONE DOSE niacin oral capsule, extended release 250 mg, 500 mg niacin oral tablet 100 mg, 50 mg, 500 mg NIACIN ORAL TABLET 250 MG niacin oral tablet extended release 24 hr 1,000 mg, 750 mg niacin oral tablet extended release 24 hr 500 mg niacin oral tablet extended release 250 mg, 750 mg NIACOR NIASPAN EXTENDED- RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 1,000 MG, 750 MG NIASPAN EXTENDED- RELEASE ORAL TABLET EXTENDED RELEASE 24 HR 500 MG nicardipine oral NICORELIEF NICOTINE TRANSDERMAL nicotine transdermal system transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/ 24 hr nicotine transdermal system transdermal patch, td daily, sequential mg/24 hr nicotine (polacrilex) NICOTROL NS nifedical xl nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr NIGHTIME SLEEP NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET NILANDRON NINLARO NIPENT nitro-bid nitroglycerin intravenous nitroglycerin transdermal patch 24 hour NITROSTAT NOBLE FORMULA HC TOPICAL CREAM NON-ASPIRIN ORAL SUSPENSION NON-DROWSY ALLERGY nora-be NORCO NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) norethindrone acetate norethindrone (contraceptive) norethindrone-e.estradioliron norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg- 35 mcg (28), mgmcg NORLYROC NORSOL-M IN 5 % DEXTROSE NORSOL-R NORSOL-R IN 5 % DEXTROSE NORSOL-R PH nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL ORAL SUSPENSION NUEDEXTA NULOJIX NUPLAZID NUVARING nyamyc nystatin oral suspension nystatin oral tablet nystatin topical nystatin-triamcinolone nystop O ocella octreotide acetate OCUSOFT IRRIGATING OPHTH SOLN ODEFSEY ODOMZO ODOR CONTROL FOOT- SNEAKER ofloxacin ophthalmic ofloxacin oral tablet 400 mg ofloxacin otic ogestrel (28) es gratuita. Para obtener más información, visite duals.caremore.com. 160

162 olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 20 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet, disintegrating 10 mg olanzapine oral tablet, disintegrating 15 mg olanzapine oral tablet, disintegrating 20 mg olanzapine oral tablet, disintegrating 5 mg olanzapine-fluoxetine oral capsule mg, mg, 6-50 mg olanzapine-fluoxetine oral capsule 3-25 mg, 6-25 mg olopatadine ophthalmic OLYSIO omega-3 acid ethyl esters omeprazole oral capsule, delayed release(dr/ec) OMEPRAZOLE ORAL TABLET,DELAYED RELEASE (DR/EC) ONCASPAR ondansetron hcl intravenous ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron odt ONE DAILY PRENATAL ORAL COMBO PACK MG-MCG- MG ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG OPCICON ONE-STEP OPDIVO ORAL SALINE LAXATIVE ORAL LIQUID oralone ORAP ORENCIA ORENCIA (WITH MALTOSE) ORFADIN ORAL CAPSULE orsythia oxacillin injection recon soln 1 gram, 2 gram oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 1 gram oxacillin intravenous recon soln 2 gram oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg oxaprozin oxcarbazepine oral tablet OXSORALEN OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG oxybutynin chloride oral syrup oxybutynin chloride oral tablet oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral tablet 10 mg, 5 mg oxycodone oral tablet 15 mg oxycodone oral tablet 20 mg, 30 mg oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin OYSCO 500/D ORAL TABLET OYSCO D OYSCO OYST-CAL OYSTER SHELL + D OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM es gratuita. Para obtener más información, visite duals.caremore.com. 161

163 OYSTER SHELL CALCIUM WITH D OYSTER SHELL CALCIUM- VIT D OYSTERCAL-D P pacerone oral tablet 100 mg, 200 mg, 400 mg paclitaxel PAIN AND FEVER ORAL TABLET 500 MG PAIN RELIEF EXTRA STRENGTH PAIN RELIEF ORAL TABLET PAIN RELIEF (ACETAMIN- ASP-CAF) PAIN RELIEVER EXTRA STRENGTH PAIN RELIEVER ORAL CAPSULE PAIN RELIEVER ORAL TABLET 500 MG PAIN RELIEVER PLUS PAIN RELIEVER (ACETAM- ASPIRIN) PAIN-OFF paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg pamidronate PAMPRIN MAX PANCREAZE PANRETIN pantoprazole paroex oral rinse paromomycin paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PASER PATADAY PATANOL PAXIL ORAL SUSPENSION PAZEO PEDVAX HIB (PF) peg 3350-electrolytes oral recon soln gram peg 3350-electrolytes oral recon soln gram peg-electrolyte soln PEGANONE PEGINTRON PEGINTRON REDIPEN PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 20 million unit penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium PENTAM PENTASA pentoxifylline PEPCID AC ORAL TABLET 20 MG PEPTIC RELIEF PEPTO-BISL ORAL TABLET,CHEWABLE PEPTO-BISL TO- GO periogard PERJETA permethrin topical cream permethrin topical liquid perphenazine PERSA-GEL PHARBETOL ORAL TABLET 500 MG phenadoz phenelzine phenobarbital oral elixir phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg phenobarbital oral tablet 16.2 mg phenobarbital oral tablet 30 mg phenobarbital oral tablet 32.4 mg phenobarbital oral tablet 60 mg phenobarbital oral tablet 64.8 mg phenobarbital oral tablet 97.2 mg phentermine es gratuita. Para obtener más información, visite duals.caremore.com. 162

164 PHENYLEPHRINE HCL/ DIPHENHYDRAMINE HCL phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet, chewable phenytoin sodium extended phenytoin sodium intravenous solution philith PHOSPHATE LAXATIVE ORAL LIQUID PHOSPHOLINE IODIDE PICATO pilocarpine hcl oral PIMTREA (28) pindolol PINK BISMUTH MAXIMUM STRENGTH PINK BISMUTH ORAL SUSPENSION PINK BISMUTH ORAL TABLET PINK BISMUTH ORAL TABLET,CHEWABLE pioglitazone oral tablet 15 mg pioglitazone oral tablet 30 mg pioglitazone oral tablet 45 mg pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam PLASMA-LYTE PLASMA-LYTE-56 IN 5 % DEXTROSE podofilox POLY BACITRACIN POLY-IRON POLY-VITA POLY-VITAMIN polycin polyethylene glycol 3350 oral powder polyethylene glycol 3350 oral powder in packet polymyxin b sulftrimethoprim polysaccharide iron complex polyvinyl alcohol POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE 2 MG POMALYST ORAL CAPSULE 3 MG, 4 MG portia PORTRAZZA potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/ l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/ l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/ l potassium chloride in 5 % dex intravenous parenteral solution 30 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/ 100 ml, 20 meq/100 ml, 20 meq/50 ml, 40 meq/100 ml potassium chloride intravenous piggyback 10 meq/ 50 ml potassium chloride intravenous piggyback 30 meq/ 100 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral tablet extended release potassium chloride oral tablet, er particles/crystals potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/ l potassium chloride-d5-0.2%nacl intravenous parenteral solution 40 meq/ l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/ l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/ l potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/ l potassium citrate oral tablet extended release 10 meq (1, 080 mg), 5 meq (540 mg) POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG POWDERLAX PRADAXA ORAL CAPSULE 110 MG es gratuita. Para obtener más información, visite duals.caremore.com. 163

165 PRADAXA ORAL CAPSULE 150 MG, 75 MG PRALUENT PEN PRALUENT SYRINGE pramipexole oral tablet pravastatin prazosin oral prednisolone acetate prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate ophthalmic prednisolone sodium phosphate oral solution 15 mg/ 5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet, disintegrating prednisone intensol prednisone oral PREMARIN PREMPHASE PREMPRO PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG PRENATAL ONE DAILY PRENATAL TABLET PRENATAL VITAMIN ORAL CAPSULE MG prenatal vitamin oral tablet PRENATAL VITAMIN ORAL TABLET, MG PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 800 MCG prenatal vitamin oral tablet 28 mg iron- 800 mcg prevalite previfem PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG PRIFTIN PRIMAQUINE primidone PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG PROAIR HFA PROAIR RESPICLICK probenecid procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine maleate rectal PROCRIT procto-pak proctosol hc proctozone-hc PROGLYCEM PROGRAF INTRAVENOUS PROLEUKIN PROLIA PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG PROMACTA ORAL TABLET 50 MG promethazine oral tablet PROMETHAZINE VC- CODEINE promethazine-codeine promethazine-dm promethazine-phenylephcodeine promethegan rectal suppository 12.5 mg PROLAXIN propafenone oral tablet propranolol intravenous propranolol oral propranololhydrochlorothiazid propylthiouracil PROQUAD (PF) PROTONIX INTRAVENOUS PROTOPIC protriptyline PROVIL PSEUDOEPHEDRINE 120 MG ER pseudoephedrine hcl oral liquid pseudoephedrine hcl oral tablet 30 mg pseudoephedrine hcl oral tablet 60 mg pseudoephedrine hcl oral tablet extended release PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE ORAL TABLET 4-10 MG, 4-60 MG PSEUDOEPHEDRINE HCL/ CHLORPHENIRAMINE MALEATE TABLET PSEUDOEPHEDRINE HCL/ TRIPROLIDINE HCL ORAL TABLET PULZYME PURELAX PURIXAN pyrazinamide pyridostigmine bromide es gratuita. Para obtener más información, visite duals.caremore.com. 164

166 pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg Q Q-DRYL ORAL CAPSULE Q-DRYL ORAL LIQUID Q-PAP EXTRA STRENGTH Q-PAP ORAL TABLET 500 MG Q-TUSSIN QUADRACEL (PF) QUENALIN quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg quinapril quinaprilhydrochlorothiazide quinidine gluconate oral quinidine sulfate oral tablet quinine sulfate QUIT QUIT 4 BUCCAL GUM QVAR INHALATION AEROSOL 40 MCG/ ACTUATION QVAR INHALATION AEROSOL 80 MCG/ ACTUATION R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl injection ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg ranitidine hcl oral tablet 75 mg RAPAMUNE RAVICTI READY-TO-USE ENEMA (MIN OIL) REBIF REBIDOSE REBIF TITRATION PACK REBIF (WITH ALBUMIN) reclipsen (28) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML RECORT PLUS REDNESS RELIEVER LUBRICANT RELCOF C RELENZA DISKHALER RELISTOR SUBCUTANEOUS SOLUTION REMICADE RENA-VITE RENAGEL RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM RENVELA ORAL TABLET repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg repaglinide oral tablet 2 mg REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE REST SIMPLY NIGHTTIME SLEEP RESTASIS RESTFULLY SLEEP RETROVIR INTRAVENOUS REVIVE PLUS REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG REXULTI ORAL TABLET 3 MG, 4 MG REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET RI-GEL RI-GEL II RI-X RI-TUSSIN ribasphere oral capsule ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg RID COMPLETE LICE ELIM KIT TOPICAL RIDAURA es gratuita. Para obtener más información, visite duals.caremore.com. 165

167 rifampin RIFATER riluzole rimantadine ringers intravenous ringers irrigation RINGWORM RISACAL-D RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet, disintegrating 0.25 mg risperidone oral tablet, disintegrating 0.5 mg risperidone oral tablet, disintegrating 1 mg risperidone oral tablet, disintegrating 2 mg risperidone oral tablet, disintegrating 3 mg risperidone oral tablet, disintegrating 4 mg RITUXAN rivastigmine rivastigmine tartrate rizatriptan ROBAFEN ROBAFEN DM COUGH ropinirole oral tablet rosadan topical cream ROTARIX ROTATEQ VACCINE roweepra ROZEREM RYDEX S SABRIL SALICYLIC ACID TOPICAL LIQUID 3 % SANDIMMUNE ORAL SOLUTION SANI-SUPP (ADULT) SANTYL SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SAVELLA ORAL TABLET 100 MG SAVELLA ORAL TABLET 12.5 MG SAVELLA ORAL TABLET 25 MG SAVELLA ORAL TABLET 50 MG SAVELLA ORAL TABLETS, DOSE PACK SCALP RELIEF HYDROCORTISONE TOPICAL LIQUID 3 % SCALP RELIEF HYDROCORTISONE TOPICAL SOLUTION 1 % SCALPICIN ANTI- ITCH SCOT-TUSSIN EXPECTORANT SECURA ANTIFUNGAL SECURA ANTIFUNGAL EXTRA THICK selegiline hcl selenium sulfide topical lotion SELZENTRY SENSIPAR ORAL TABLET 30 MG, 60 MG SENSIPAR ORAL TABLET 90 MG SEREVENT DISKUS SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg SHAROBEL SIGNIFOR SILACE ORAL LIQUID SILACE ORAL SYRUP SILADRYL SA sildenafil oral SILTUSSIN DM DAS SILTUSSIN SA silver sulfadiazine es gratuita. Para obtener más información, visite duals.caremore.com. 166

168 SIMETHICONE ORAL CAPSULE 125 MG simethicone oral capsule 180 mg simethicone oral tablet, chewable SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG simvastatin SINUS 12 HOUR SINUS AND ALLERGY PE SINUS-ALLERGY (PHENYLEPHRINE) sirolimus SIRTURO SKIN TREATMENT SLEEP AID MAX STR (DIPHENHYDR) SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET SLEEP AID (DOXYLAMINE) SLEEP TABLET (DIPHENHYDRAMINE) SLEEP-TABS SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 160 MG (50 MG IRON), 47.5 MG IRON SOTH ANTACID SOTHLAX sodium chloride 0.45 % intravenous parenteral solution sodium chloride 0.45 % intravenous piggyback sodium chloride 0.9 % intravenous sodium chloride 3 % sodium chloride 5 % sodium chloride inhalation solution for nebulization 0.9 %, 3 % sodium chloride intravenous parenteral solution 2.5 meq/ ml sodium chloride intravenous parenteral solution 4 meq/ ml sodium chloride irrigation sodium fluoride oral tablet sodium fluoride oral tablet, chewable 1 mg fluoride (2.2 mg) sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal enema 30 gram/120 ml SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML sodium polystyrene (sorb free) SOF-LAX SOLTAX SOMATULINE DEPOT SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON SOLN 25 MG, 30 MG SOOTHE REGULAR STRENGTH SOOTHE (BISMUTH SUBSALICYLATE) SOOTHING CARE (HYDROCORTISONE) SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG sorine oral tablet 120 mg, 160 mg, 80 mg sorine oral tablet 240 mg sotalol af sotalol oral SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactonhydrochlorothiaz spironolactone sprintec (28) SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG SPRYCEL sps oral sps rectal sronyx ssd stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg stavudine oral recon soln STERILE EYE DROPS OPHTHALMIC DROPS %, % STERILE EYE WASH STERILE SALINE NASAL STIMATE STIVARGA STOMACH RELIEF STOMACH RELIEF MAX STRENGTH STOMACH RELIEF ORIGINAL STOOL SOFTENER ORAL CAPSULE 100 MG, 240 MG, 250 MG STOOL SOFTENER ORAL CAPSULE 50 MG es gratuita. Para obtener más información, visite duals.caremore.com. 167

169 STOOL SOFTENER ORAL LIQUID STOOL SOFTENER ORAL SYRUP STOOL SOFTENER ORAL TABLET STOP LICE STOP SKING AID STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG STRAWBERRY C STREPTOMYCIN INTRAMUSCULAR STRIBILD STROMECTOL SUBSYS sucralfate oral tablet SUDOGEST SUDOGEST 12-HOUR SUDOGEST COLD AND ALLERGY SUDOGEST SINUS AND ALLERGY sulfacetamide sodium ophthalmic drops sulfacetamide sodium (acne) sulfacetamideprednisolone sulfadiazine oral sulfamethoxazoletrimethoprim SULFAMYLON sulfasalazine sulindac oral sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml SUPER CALCIUM SUPER PAIN RELIEF SUPHEDRIN SUPHEDRIN 12 HOUR SUPHEDRINE SUPHEDRINE 12 HOUR SUPHEDRINE PE COLD AND ALLERGY SUPHEDRINE PE SINUS ANDALLERGY SUPPOSITORY ADULT SUPREP BOWEL PREP KIT SURFAK SURNTIL SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG syeda SYLATRON SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYNTHROID SYPRINE T TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG TAKE ACTION TAMIFLU tamoxifen tamsulosin TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG TARGRETIN ORAL TARGRETIN TOPICAL TARINA FE 1/20 (28) TASIGNA TAZORAC taztia xt TEARS AGAIN (PVA) TEARS NATURALE FREE (PF) TECENTRIQ TECHNIVIE TEFLARO telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg temazepam oral capsule 15 mg, 22.5 mg, 30 mg terazosin terbinafine hcl oral terbinafine hcl topical terbutaline oral terbutaline subcutaneous terconazole TESTIM testosterone cypionate testosterone enanthate tetanus,diphtheria tox ped (pf) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg es gratuita. Para obtener más información, visite duals.caremore.com. 168

170 tetracycline THALOMID ORAL CAPSULE 100 MG, 50 MG THALOMID ORAL CAPSULE 150 MG, 200 MG THE MAGIC BULLET theophylline oral tablet extended release theophylline oral tablet extended release 12 hr THERA-D thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg, 50 mg thiamine mononitrate (vit b1) thioridazine thiotepa thiothixene THYGLOBULIN tiagabine TICE BCG TIKOSYN timolol maleate ophthalmic timolol maleate oral TINACTIN TOPICAL AEROSOL POWDER TIVICAY ORAL TABLET 10 MG, 25 MG TIVICAY ORAL TABLET 50 MG tizanidine oral tablet TOBI tobramycin tobramycin sulfate injection recon soln tobramycin sulfate injection solution tobramycin-dexamethasone opthalmic suspension tolcapone tolmetin tolnaftate topical aerosol powder tolnaftate topical cream tolterodine oral capsule, extended release 24hr tolterodine oral tablet topiramate oral capsule, sprinkle topiramate oral tablet 100 mg topiramate oral tablet 200 mg topiramate oral tablet 25 mg topiramate oral tablet 50 mg toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL torsemide oral TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TRACLEER tramadol oral tablet tramadol-acetaminophen trandolapril tranexamic acid intravenous tranexamic acid oral TRANSDERM-SCOP tranylcypromine travasol 10 % TRAVATAN Z TRAVEL SICKNESS (MECLIZINE) travoprost (benzalkonium) trazodone TREANDA INTRAVENOUS RECON SOLN TRECATOR TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML, 3.75 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML tretinoin topical cream tretinoin topical gel 0.01 %, % tretinoin (chemotherapy) TREXALL TRI-BIOZENE tri-estarylla tri-linyah tri-previfem (28) tri-sprintec (28) triamcinolone acetonide dental triamcinolone acetonide injection suspension 10 mg/ ml triamcinolone acetonide injection suspension 40 mg/ ml triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % triamterenehydrochlorothiazid oral capsule mg triamterenehydrochlorothiazid oral tablet trianex triderm topical cream trifluoperazine trifluridine trihexyphenidyl TRILEPTAL ORAL SUSPENSION trimethoprim trinessa (28) es gratuita. Para obtener más información, visite duals.caremore.com. 169

171 trintellix oral tablet 10 mg trintellix oral tablet 20 mg trintellix oral tablet 5 mg TRIPLE ANTIBIOTIC PLUS TRIPLE ANTIBIOTIC TOPICAL OINTMENT TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET TRIPLE ANTIBIOTIC (PRAM) EXTRA TRIPLE ANTIBIOTIC-PAIN RELIEF TRISENOX TRIUMEQ trivora (28) TRIZIVIR TROPHAMINE 10 % TROPHAMINE 6% TRUMENBA TRUVADA ORAL TABLET MG, MG, MG TRUVADA ORAL TABLET MG TUDORZA PRESSAIR TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG (1,000 MG) TUSNEL DIABETIC TUSSI PRES-B ORAL LIQUID MG/5 ML TUSSIGON TUSSIN CHEST CONGESTION TUSSIN COUGH-CHEST CONGESTION TUSSIN DM COUGH AND CHEST ORAL LIQUID MG/5 ML TUSSIN DM ORAL LIQUID TUSSIN EXPECTORANT TUSSIN HONEY TUSSIN ORAL LIQUID TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI INTRAMUSCULAR SOLUTION TYPHIM VI INTRAMUSCULAR SYRINGE TYSABRI TYZEKA TYZINE NASAL DROPS 0.05 % U ULTRA FRESH ULTRA SLEEP (DOXYLAMINE SUCC) ULTRA STRENGTH ANTACID ULTRA STRENGTH CALCIUM ANTACID UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG UNITUXIN urea topical cream 10 %, 20 % urea topical lotion 10 % UREACIN URINARY PAIN RELIEF ORAL TABLET 95 MG URINARY TRACT ursodiol UVADEX V VAGIFEM VAGINAL CONTRACEPTIVE FOAM VAGISTAT valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) valsartan oral tablet 160 mg valsartan oral tablet 320 mg valsartan oral tablet 40 mg, 80 mg valsartanhydrochlorothiazide VALU-DRYL ALLERGY ORAL CAPSULE VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/200 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg, 750 mg vancomycin intravenous recon soln 5 gram vancomycin oral capsule 125 mg vancomycin oral capsule 250 mg es gratuita. Para obtener más información, visite duals.caremore.com. 170

172 VAQTA (PF) INTRAMUSCULAR SUSPENSION VAQTA (PF) INTRAMUSCULAR SYRINGE VARIVAX (PF) VARIZIG VECAMYL VECTIBIX VECTICAL VELCADE velivet triphasic regimen (28) VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK venlafaxine oral capsule, extended release 24hr 150 mg venlafaxine oral capsule, extended release 24hr 37.5 mg venlafaxine oral capsule, extended release 24hr 75 mg venlafaxine oral tablet 100 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg venlafaxine oral tablet 75 mg venlafaxine oral tablet extended release 24hr 150 mg venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg VENTAVIS VENTOLIN HFA verapamil verapamil intravenous solution VERSACLOZ VESICARE vicodin vicodin es vicodin hp VICTOZA 2-PAK VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIGAX VIIBRYD ORAL TABLET 10 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG VIMPAT ORAL TABLET 200 MG VIMPAT ORAL TABLET 50 MG vinblastine intravenous solution VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML vincasar pfs intravenous solution 2 mg/2 ml vincristine vinorelbine viorele (28) VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET VIRTUSSIN AC VITAMIN A PALMITATE ORAL CAPSULE VITAMIN A PALMITATE ORAL TABLET 10,000 UNIT vitamin a palmitate oral tablet 15,000 unit VITAMIN B VITAMIN B-1 (NONITRATE) VITAMIN B-12 ORAL TABLET 1,000 MCG, 100 MCG, 250 MCG, 500 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 1,000 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 2,000 MCG VITAMIN B-12 SUBLINGUAL TABLET 2, 500 MCG VITAMIN B VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG VITAMIN C ORAL CAPSULE, EXTENDED RELEASE VITAMIN C ORAL TABLET 1,000 MG, 250 MG, 500 MG es gratuita. Para obtener más información, visite duals.caremore.com. 171

173 VITAMIN C ORAL TABLET, CHEWABLE 250 MG, 500 MG VITAMIN C WITH ROSE HIPS ORAL TABLET VITAMIN D VITAMIN D3 ORAL CAPSULE 1,000 UNIT, 2,000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 1,000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 2,000 UNIT, 5,000 UNIT vitamin e oral capsule 1,000 unit, 200 unit, 400 unit vitamin e oral capsule 100 unit VITAMIN E (DL, ACETATE) ORAL CAPSULE 100 UNIT VITEKTA VIVELLE-DOT VOLTAREN TOPICAL GEL 1 % voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg voriconazole oral tablet 50 mg VOSPIRE ER VOTRIENT VPRIV VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK VYFEMLA (28) W warfarin water for irrigation, sterile WELCHOL WOMAN'S LAXATIVE ORAL TABLET,DELAYED RELEASE (DR/EC) WOMEN'S GENTLE LAXATIVE(BISAC) WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) X XALKORI XARELTO ORAL TABLET 10 MG, 20 MG XARELTO ORAL TABLET 15 MG XARELTO ORAL TABLETS, DOSE PACK XENAZINE ORAL TABLET 12.5 MG XENAZINE ORAL TABLET 25 MG XGEVA XIFAXAN ORAL TABLET 550 MG XODOL 10/ XODOL 5/ XODOL 7.5/ XOLAIR XTANDI XYREM Y YERVOY YF-VAX (PF) YONDELIS Z zafirlukast zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg ZALTRAP ZANOSAR zarah ZAVESCA ZEASORB (MICONAZOLE) ZELBORAF ZEMAIRA zenchent (28) zenzedi oral tablet 10 mg zenzedi oral tablet 5 mg ZEPATIER ZETIA ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg, 80 mg ZIRGAN zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml ZOLINZA zolmitriptan ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML ZOMIG NASAL zonisamide ZORTRESS ZOSTAVAX (PF) ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML, 4.5 GRAM/100 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/ 50 ML zovia 1/35e (28) zovia 1/50e (28) ZYDELIG ZYKADIA ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG es gratuita. Para obtener más información, visite duals.caremore.com. 172

174 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG ZYTIGA ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION es gratuita. Para obtener más información, visite duals.caremore.com. 173

175 Si tiene preguntas, llame a Servicios al Miembro de CareMore Cal MediConnect Plan al (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. hora del Pacífico. La lista de medicamentos cubiertos y/o las redes de farmacias y proveedores pueden cambiar a lo largo del año. Le enviaremos una notificación antes de hacer un cambio que le afecte. Los beneficios y/o los copagos pueden cambiar el 1 de enero de cada año. Siempre puede verificar la Lista de medicamentos cubiertos de CareMore Cal MediConnect Plan actualizada en línea en duals.caremore.com o llamando al (TTY 711). Pueden aplicar limitaciones y restricciones. Para obtener más información, llame a Servicios al Miembro de CareMore Cal MediConnect Plan o lea el manual del miembro de CareMore Cal MediConnect Plan. Los copagos para medicamentos recetados pueden variar con base en el nivel de Ayuda adicional (Extra Help) que usted recibe. Póngase en contacto con el plan para mayores detalles. CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) es un plan de salud que tiene contrato con ambos Medicare y Medi-Cal para proporcionar beneficios de ambos programas a los inscritos. CareMore administra el contrato a nombre de un afiliado de CareMore. CareMore es una marca comercial registrada de CareMore Health System. H6629_16_25137_T_001_SP CMS Approved 08/26/2015 ID del formulario: Versión: 20 Publicado el 1/1/2016 CCADMKT