FORMULARIO COMPRENSIVO

Transcripción

1 FORMULARIO COMPRENSIVO (Lista de medicamentos cubiertos) 1ro de enero - 31 de diciembre POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN ID del formulario 18088, Versión 9 Este formulario se actualizó el 1 de agosto del Para obtener información más reciente o hacer preguntas, comuníquese con el Departamento de Servicios a los Miembros de Leon Medical Centers Health Plans al ó al número gratuito ó, los usuarios de TTY, 711, los siete días de la semana de 8:00 am a 8:00 pm o visite Leon Medical Centers Health Plans es un plan HMO con un contrato Medicare. La inscripción en Leon Medical Centers Health Plans depende de la renovación de contrato. H5410_18_56769_Final_1S Alternate Format

2 Nota para los miembros actuales: Este formulario ha cambiado con respecto al año pasado. Por favor revise este documento para asegurarse de que todavía se incluyen los medicamentos que usted toma. Cuando esta lista de medicamentos (formulario) indica nosotros nos o nuestro, se está haciendo referencia a Leon Medical Centers Health Plans. Cuando indica plan o nuestro plan, se está haciendo referencia a Leon Medical Centers Health Plans Leon Cares. Este documento incluye una lista de medicamentos (formulario) para nuestro plan que esta vigente a partir de agosto del Comuníquese con nosotros para obtener un formulario actualizado. Nuestra información de contacto, junto con la fecha en la que actualizamos el formulario por última vez, aparecen en la portada y en la contraportada. Por lo general, usted debe utilizar las farmacias de la red para recibir su beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias, y/o los copagos /coseguros pueden cambiar a partir del 1 de enero del 2019 y en ocasiones durante el año. Qué es el formulario de Leon Medical Centers Health Plans Leon Cares? Un formulario es una lista de medicamentos con cobertura seleccionados por nuestro plan en colaboración con un equipo de proveedores de atención médica el cual representa los tratamientos de medicamentos recetados considerados como una parte necesaria de un programa que ofrece tratamiento de calidad. En general, cubrimos los medicamentos que aparecen en el formulario, siempre y cuando sean médicamente necesarios, las recetas sean surtidas en una farmacia de la red de Leon Medical Centers Health Plans Leon Cares y se sigan otras reglas del plan. Si desea obtener más información sobre cómo adquirir medicamentos recetados, consulte la Evidencia de cobertura. Puede cambiar el formulario (lista de medicamentos)? Por lo general, si usted toma un medicamento que se encuentra en el formulario del 2018 el cual estaba cubierto al inicio del año, no suspenderemos ni reduciremos la cobertura durante el año de cobertura 2017, salvo que haya un nuevo medicamento genérico menos costoso o se publique información negativa acerca de la seguridad o efectividad del medicamento. Otros tipos de cambios en el formulario, como la eliminación de un medicamento, no afectarán a los miembros que tomen el medicamento actualmente. El medicamento seguirá estando disponible durante el resto del año de cobertura para los miembros que lo tomen, y con el mismo costo compartido. Creemos que es importante que, durante el resto del año de cobertura, usted siga teniendo acceso a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan. Con la excepción de los casos en los que usted puede ahorrar dinero o en los que podemos garantizar su seguridad. Ya sea que eliminemos medicamentos de nuestro formulario, que agreguemos requisitos de autorización previa, límites de cantidad y/o restricciones a la terapia escalonada para un medicamento, o que traslademos un medicamento a un nivel de costo compartido más alto, debemos notificarle a los miembros que se verán afectados por estos cambios al menos 60 días antes de que el cambio entre en vigencia, o al momento en que el miembro solicite un reabastecimiento del medicamento, en cuyo caso el miembro recibirá un suministro del medicamento por 60 días. Si la Administración de Drogas y Alimentos (Food and Drug Administration, FDA) considera que un medicamento del formulario no es seguro, o si el fabricante retira un medicamento del mercado, lo quitaremos de inmediato del formulario y notificaremos a los miembros que lo toman. El formulario que se adjunta esta vigente a partir de agosto del Comuníquese con nosotros para obtener información actualizada sobre los medicamentos cubiertos por el plan. Nuestra información de contacto aparece en la portada y la contraportada. Los formularios que se encuentran en nuestro sitio web se revisan y actualizan todos los meses. Si hubiera cambios importantes en el formulario impreso durante el año de cobertura, recibirá una notificación por correo postal en la que se identificarán los cambios. 1

3 Cómo uso el formulario? Hay dos maneras de encontrar un medicamento en el formulario: Condición médica El formulario comienza en la página 8. Los medicamentos de este formulario se agrupan en categorías, según el tipo de afección médica que traten. Por ejemplo, los medicamentos que se utilizan para tratar afecciones del corazón se enumeran en la categoría Agentes Cardiovasculaers Si sabe que afección trata el medicamento, busque el nombre de la categoría en la lista que comienza en la página 8. Luego, busque el medicamento en esa categoría. Listado alfabético Si no está seguro en qué categoría se encuentra el medicamento, debe buscarlo en el índice que comienza en la página 144. En el índice encontrará una lista ordenada alfabéticamente de todos los medicamentos que figuran en este documento. Se incluyen los medicamentos de marca y los genéricos. Consulte el índice para encontrar el medicamento que desea. Junto al nombre del medicamento, verá el número de la página donde se encuentra la información sobre la cobertura del mismo. Diríjase a la página que aparece en el índice y busque el nombre del medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Leon Medical Centers Health Plans - Leon Cares cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico tiene la aprobación de la FDA la cual se certifica que contiene el mismo ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos son más económicos que los medicamentos de marca. Existen restricciones en la cobertura? Existen algunos requisitos o límites adicionales para algunos medicamentos cubiertos. Por ejemplo: Autorización previa: Leon Medical Centers Health Plans - Leon Cares exige que usted o su médico solicite una autorización previa para obtener ciertos medicamentos. Esto significa que usted tendrá que obtener nuestra aprobación antes de surtir sus recetas. Si no obtiene la aprobación, es posible que no cubramos el medicamento. Límites de cantidad: En el caso de determinados medicamentos, Leon Medical Centers Health Plans - Leon Cares limita la cantidad que tendrá cobertura. Por ejemplo, nuestro plan proporciona 30 unidades de EDARBI por receta. Esto podría ser adicional al suministro estándar de un mes o de tres meses. Terapia escalonada: En algunos casos, Leon Medical Centers Health Plans - Leon Cares exige que usted primero pruebe determinados medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento B se usan para tratar su afección, es posible que no cubramos el medicamento B, a menos que pruebe antes el medicamento A. Si el medicamento A no funciona para usted, entonces cubriremos el medicamento B. 2

4 En el formulario comenzando en la página 8, puede saber si el medicamento que necesita está sujeto a requisitos o límites adicionales. También puede obtener más información acerca de las restricciones que se aplican a medicamentos específicos cubiertos visitando nuestro sitio web. Hemos publicado en Internet los documentos que explican los detalles de nuestras restricciones de autorización previa y terapia escalonada. Usted también puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha en la que actualizamos el formulario por última vez, aparece en la portada y en la contraportada. Puede solicitarle a Leon Medical Centers Health Plans Leon Cares que haga una excepción respecto a estas restricciones o límites, o pedir una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección Cómo solicito una excepción al formulario de Leon Medical Centers Health Plans Leon Cares? en la página 4, para obtener más información sobre cómo solicitar una excepción. Qué son los medicamentos de venta libre (Over-the counter, OTC)? Los OTC son medicamentos no recetados que normalmente no cubre un plan de medicamentos recetados de Medicare. Leon Medical Centers Health Plans Leon Cares paga algunos medicamentos OTC. Le proporcionaremos estos medicamentos OTC sin costo alguno. El costo de estos medicamentos OTC en nuestro plan no cuenta para los costos totales de los medicamentos de la Parte D (es decir, el monto que usted paga no cuenta para el período sin cobertura). OTC Covered Drugs 3 DAY VAGINL CRE 2% DIPHENHIST LIQ 12.5/5ML ALAWAY DRO 0.025%OP HYDROCORT CRE 0.5% ALLERGY RELF TAB 10MG KETOTIF FUM DRO 0.025%OP AMMONIUM LAC CRE 12% LORATADINE TAB 10MG AMMONIUM LAC LOT 12% MECLIZINE TAB 12.5MG ANTIFUNGAL CRE 2% MI-ACID SUS CETIRIZINE TAB MICONAZOLE CRE 2% CLOTRIMAZOLE CRE 1% REMEDY POW ANTIFUNG CLOTRIMAZOLE CRE 1% VAG SLO-NIACIN TAB CR CLOTRIMAZOLE SOL 1% TRAVEL SICK CHW 25MG Qué sucede si el medicamento que necesito no está incluido en el formulario? Si su medicamento no está en este formulario (lista de medicamentos cubiertos), comuníquese primero con el Departamento de Servicios a los Miembros y pregunte si su medicamento está cubierto. Si le informan que Leon Medical Centers Health Plans no cubre el medicamento, tiene dos opciones: Puede pedir a Servicios a los Miembros que le proporcione una lista de medicamentos similares que están cubiertos por Leon Medical Centers Health Plans. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que cubra nuestro plan. Puede solicitar que hagamos una excepción y cubramos su medicamento. Consulte la información que se brinda a continuación sobre cómo solicitar una excepción. 3

5 Cómo solicito una excepción al formulario de Leon Medical Centers Health Plans Leon Cares? Puede solicitarle a Leon Medical Centers Health Plans que haga una excepción a nuestras reglas de cobertura. Existen varios tipos de excepciones que puede solicitarnos. Puede pedirnos que cubramos el medicamento, incluso si no está incluido en nuestro formulario. Si se aprueba, este medicamento será cubierto en un nivel predeterminado del costo compartido, de esta forma, usted no podrá solicitar el medicamento a un nivel más bajo del costo compartido. Puede pedirnos que cubramos un medicamento del formulario a un nivel más bajo de costo compartido si este medicamento no está en el nivel de especialidad. Si se aprueba, esto reduciría la cantidad que debe pagar usted por su medicamento. Puede solicitarnos que no apliquemos las restricciones o límites de la cobertura a su medicamento. Por ejemplo, Leon Medical Centers Health Plans cubre una cantidad limitada de determinados medicamentos. Si existe un límite de cantidad para el medicamento, puede pedirnos que no apliquemos el límite y que cubramos una mayor cantidad. Por lo general, Leon Medical Centers Health Plans solamente aprobará su solicitud de una excepción si los medicamentos alternativos incluidos en el formulario del plan o las restricciones adicionales de utilización no fuesen tan eficaces para tratar su afección y/o le provocasen efectos secundarios. Si desea solicitar una excepción al formulario, al nivel o a las restricciones de utilización, debe comunicarse con nosotros para que tomemos una decisión de cobertura inicial. Cuando solicite una excepción al formulario, al nivel o de restricciones de utilización, debe presentar una declaración de su recetador o médico apoyando su solicitud. Por lo general, debemos tomar una decisión antes de transcurridas las 72 horas de haber recibido la declaración de la persona que emitió la receta. Puede solicitar una excepción acelerada (rápida) si usted o su médico creen que su salud podría verse seriamente afectada si espera 72 horas para que tomemos una decisión. Si se acepta su solicitud acelerada, debemos informarle la decisión, a más tardar, 24 horas después de recibir la declaración de su médico u otra persona que emita la receta. Qué debo hacer antes de consultar con mi médico la posibilidad de que me cambie los medicamentos o de que solicite una excepción? Como miembro nuevo o permanente de nuestro plan, usted puede estar tomando medicamentos que no se encuentran en nuestro formulario. O quizá tome un medicamento que está en el formulario, pero existen limitaciones para conseguirlo. Por ejemplo, podría necesitar nuestra autorización previa para poder adquirir su medicamento recetado. Debe hablar con su médico para decidir si debe cambiar a un medicamento adecuado que cubramos o si debe solicitar una excepción al formulario, de modo que cubramos el medicamento que usted toma. Mientras decide junto a su médico lo más conveniente para usted, podemos cubrir el medicamento en algunos casos durante los primeros 90 días de membrecía en nuestro plan. Para cada uno de sus medicamentos que no se encuentre en nuestro formulario o en el caso de que su capacidad para adquirir los medicamentos sea limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta emitida por menos días) cuando los adquiera en una farmacia de la red. Después de su primer suministro para 30 días, no continuaremos pagando esos medicamentos, aun cuando haya sido miembro del plan durante menos de 90 días. 4

6 Si reside en un centro de atención a largo plazo, le permitiremos que reabastezca su receta hasta que le hayamos otorgado un suministro de transición de 91 días de acuerdo con el aumento de preparación (a menos que la receta se indique por menos días). Cubriremos más de un reabastecimiento de estos medicamentos durante los primeros 90 días de su membrecía en el plan. Si necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada y ya han pasado 90 días desde que se hizo miembro del plan, cubriremos un suministro de emergencia de 31 días de ese medicamento (a menos que tenga una receta médica por menos días) mientras solicita una excepción al formulario. Si el plan recibe un cambio en el nivel de atención según la definición de Medicare, se permitirá una anulación. El plan identificará a los miembros afectados para asegurar la continuidad de la atención y los guiará en la dirección correcta. Información adicional Para obtener información más detallada acerca de la cobertura de los medicamentos recetados de Leon Medical Centers Health Plans, consulte la Evidencia de cobertura y otros materiales del plan. Si tiene preguntas acerca de Leon Medical Centers Health Plans, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en la que actualizamos el formulario por última vez, aparece en la portada y en la contraportada. Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, comuníquese con Medicare al MEDICARE ( ), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al O bien, visite el sitio web Formulario de Leon Medical Centers Health Plans El formulario a continuación proporciona información sobre la cobertura de los medicamentos que están cubiertos por Leon Medical Centers Health Plans. Si tiene problemas para encontrar su medicamento en la lista, debe buscarlo en el Índice que comienza en la página 144. En la primera columna de la tabla se encuentra el nombre del medicamento. Los medicamentos de marca aparecen en mayúsculas (p. ej., EDARBI) y los genéricos, en cursiva minúscula (p. ej., atenolol). La información que figura en la columna Requisitos/Límites le indica si Leon Medical Centers Health Plans tiene 5

7 Lista de abreviaturas #: Este medicamento recetado no está cubierto normalmente en un plan de medicamentos recetados de Medicare. El monto que usted paga cuando abastece una receta de este medicamento no cuenta para sus costos totales de medicamentos (es decir, el monto que paga no le ayuda a calificar para la cobertura catastrófica). Además, si usted recibe ayuda adicional para pagar sus medicamentos recetados, no obtendrá ningún tipo de ayuda adicional para pagar este medicamento. B: De marca (Brand) B/D: Este medicamento recetado tiene un requisito de autorización administrativa previa de la Parte B frente a la Parte D. Este medicamento puede estar cubierto por la Parte B o D de Medicare, según las circunstancias. Quizás sea necesario proporcionar información que describa el uso y el contexto del medicamento para tomar la determinación. G: Genéricos : Proporcionamos cobertura adicional de este medicamento recetado en el período sin cobertura. Consulte la Evidencia de cobertura para obtener más información acerca de esta cobertura. HI: LA: PA: QL: Este medicamento recetado puede estar cubierto por nuestro beneficio médico. Para obtener más información, llame a Servicios a los Miembros al , los siete días de la semana de 8:00 a. m. a 8:00 p. m. Los usuarios de TTY deben llamar al 711. Es posible que este medicamento recetado esté disponible únicamente en determinadas farmacias. Para obtener más información, consulte el Directorio de proveedores y farmacias o llame a Servicios a los Miembros al , los siete días de la semana de 8:00 a. m. a 8 p. m. Los usuarios de TTY deben llamar al 711. Autorización previa (Prior Authorization). Leon Medical Centers Health Plans - Leon Cares exige que usted o su médico solicite una autorización previa para obtener ciertos medicamentos. Esto significa que usted tendrá que obtener la aprobación de Leon Medical Centers Health Plans Leon Cares antes de abastecer sus recetas. Si no obtiene la aprobación, es posible que Leon Medical Centers Health Plans Leon Cares no cubra el medicamento. Límite de cantidad (Quantity Limit). En el caso de determinados medicamentos, Leon Medical Centers Health Plans - Leon Cares limita la cantidad que tendrá cobertura del plan. Por ejemplo, Leon Medical Centers Health Plans Leon Cares proporciona 30 unidades de EDARBI por receta. Es posible que esto se sume al suministro estándar para un mes o para tres meses. S: Medicamentos especiales (Specialty) ST: Terapia escalonada (Step Therapy). En algunos casos, Leon Medical Centers Health Plans - Leon Cares exige que usted primero pruebe determinados medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento B se usan para tratar su afección, es posible que no cubramos el medicamento B, a menos que pruebe antes el medicamento A. Si el medicamento A no funciona para usted, entonces cubriremos el medicamento B. 6

8 Tabla de nivel de medicamentos y costos compartidos Costo compartido en una farmacia minorista preferida (dentro de la red) (hasta un suministro para 30 días) Costo compartido en una farmacia minorista estándar (dentro de la red) (hasta un suministro para 30 días) Costo compartido en una farmacia minorista preferida (dentro de la red) (hasta un suministro para 90 días) Costo compartido en una farmacia minorista estándar (dentro de la red) (hasta un suministro para 90 días) Costo Compartido Nivel 1 (medicamentos genéricos y algunos de marca) Costo Compartido Nivel 2 (medicamentos de marca) Copago de $0 Copago de $5 Copago de $0 Copago de $15 Copago de $0 Copago de $10 Copago de $0 Copago de $30 Costo Compartido Nivel 3 (medicamentos especiales) Coseguro del 33 % Coseguro del 33 % Un suministro a largo plazo no está disponible para los medicamentos en el nivel 3 Un suministro a largo plazo no está disponible para los medicamentos en el nivel 3 La red de farmacias de Leon Medical Centers Health Plans ofrece acceso limitado a las farmacias con costos compartidos preferido en las zonas urbanas y suburbanas del Condado Miami-Dade, FL. Los costos más bajos anunciados en nuestros materiales del plan de estas farmacias podrían no estar disponibles en la farmacia que usted utiliza. Para información actualizada sobre nuestras farmacias de la red, incluyendo las farmacias con costos compartidos preferidos, por favor llame al , usuarios de TTY deben llamar al 711 o consultar el directorio de farmacias en nuestro sitio web 7

9 Agentes antidemencia donepezil hcl tabs 10mg 1 G donepezil hcl tabs 23mg 1 G QL (30 EA por 30 días) donepezil hcl tabs 5mg 1 G donepezil hcl tbdp 10mg 1 G donepezil hcl tbdp 5mg 1 G ergoloid mesylates tabs 1mg 1 G galantamine hydrobromide er cp24 16mg 1 G galantamine hydrobromide er cp24 24mg 1 G galantamine hydrobromide er cp24 8mg 1 G galantamine hydrobromide soln 4mg/ml 1 G galantamine hydrobromide tabs 12mg 1 G galantamine hydrobromide tabs 4mg 1 G galantamine hydrobromide tabs 8mg 1 G memantine hcl titration pak tabs 0 1 G QL (49 EA por 28 días) PA memantine hcl tabs 10mg 1 G QL (60 EA por 30 días) PA memantine hcl tabs 5mg 1 G QL (90 EA por 30 días) PA memantine hydrochloride soln 2mg/ml 1 G QL (300 ML por 30 días) PA rivastigmine tartrate caps 1.5mg 1 G rivastigmine tartrate caps 3mg 1 G rivastigmine tartrate caps 4.5mg 1 G rivastigmine tartrate caps 6mg 1 G rivastigmine transdermal system pt mg/24hr 1 G rivastigmine transdermal system pt24 4.6mg/24hr 1 G rivastigmine transdermal system pt24 9.5mg/24hr 1 G Agentes antiespásticos baclofen tabs 10mg 1 G baclofen tabs 20mg 1 G dantrolene sodium caps 100mg 1 G dantrolene sodium caps 25mg 1 G dantrolene sodium caps 50mg 1 G GABLOFEN INJ 10000MCG/20ML B/D GABLOFEN INJ 20000MCG/20ML B/D GABLOFEN INJ 40000MCG/20ML B/D GABLOFEN INJ 50MCG/ML B/D LIORESAL INTRATHECAL INJ 0.05MG/ML B/D LIORESAL INTRATHECAL INJ 10MG/20ML B/D LIORESAL INTRATHECAL INJ 10MG/5ML B/D LIORESAL INTRATHECAL INJ 40MG/20ML B/D tizanidine hcl caps 2mg 1 G tizanidine hcl caps 4mg 1 G Página 8

10 tizanidine hcl caps 6mg 1 G tizanidine hcl tabs 2mg 1 G tizanidine hcl tabs 4mg 1 G XEOMIN INJ 200UNIT PA Agentes antiinflamatorios hydrocortisone acetate/pramoxine crea 2.5%; 1% 1 G # pramosone lotn 1%; 1% 1 G pramosone lotn 2.5%; 1% 1 G Agentes antijaquecosos almotriptan malate tabs 12.5mg 1 G QL (8 EA por 30 días) almotriptan malate tabs 6.25mg 1 G QL (8 EA por 30 días) dihydroergotamine mesylate inj 1mg/ml 1 G dihydroergotamine mesylate soln 4mg/ml 1 G ERGOMAR SUBL 2MG ergotamine tartrate/caffeine tabs 100mg; 1mg 1 G frovatriptan succinate tabs 2.5mg 1 G QL (12 EA por 30 días) migergot supp 100mg; 2mg 1 G naratriptan hcl tabs 1mg 1 G QL (9 EA por 30 días) naratriptan hcl tabs 2.5mg 1 G QL (9 EA por 30 días) RELPAX TABS 20MG QL (12 EA por 30 días) RELPAX TABS 40MG QL (12 EA por 30 días) rizatriptan benzoate odt tbdp 10mg 1 G QL (12 EA por 30 días) rizatriptan benzoate odt tbdp 5mg 1 G QL (12 EA por 30 días) rizatriptan benzoate tabs 10mg 1 G QL (12 EA por 30 días) rizatriptan benzoate tabs 5mg 1 G QL (12 EA por 30 días) sumatriptan succinate refill inj 4mg/0.5ml 1 G QL (9 ML por 30 días) sumatriptan succinate refill inj 6mg/0.5ml 1 G QL (9 ML por 30 días) sumatriptan succinate inj 6mg/0.5ml 1 G QL (9 ML por 30 días) sumatriptan succinate inj 6mg/0.5ml 1 G QL (9 ML por 30 días) sumatriptan succinate inj 6mg/0.5ml 1 G QL (9 ML por 30 días) sumatriptan succinate tabs 100mg 1 G QL (9 EA por 30 días) sumatriptan succinate tabs 25mg 1 G QL (9 EA por 30 días) sumatriptan succinate tabs 50mg 1 G QL (9 EA por 30 días) sumatriptan soln 20mg/act 1 G QL (12 EA por 30 días) sumatriptan soln 5mg/act 1 G QL (12 EA por 30 días) SUMAVEL DOSEPRO INJ 4MG/0.5ML QL (9 ML por 30 días) SUMAVEL DOSEPRO INJ 6MG/0.5ML QL (9 ML por 30 días) TREXIMET TABS 500MG; 85MG TREXIMET TABS 60MG; 10MG Página 9

11 zolmitriptan odt tbdp 2.5mg 1 G QL (8 EA por 30 días) zolmitriptan odt tbdp 5mg 1 G QL (8 EA por 30 días) zolmitriptan tabs 2.5mg 1 G QL (8 EA por 30 días) zolmitriptan tabs 5mg 1 G QL (8 EA por 30 días) ZOMIG SOLN 2.5MG QL (12 EA por 30 días) ZOMIG SOLN 5MG QL (12 EA por 30 días) Agentes antimiasténicos GUANIDINE HCL TABS 125MG 1 B MESTINON SYRP 60MG/5ML pyridostigmine bromide er tbcr 180mg 1 G pyridostigmine bromide tabs 60mg 1 G REGONOL INJ 10MG/2ML B/D Agentes antiparkinsonianos amantadine hcl caps 100mg 1 G amantadine hcl syrp 50mg/5ml 1 G amantadine hcl tabs 100mg 1 G APOKYN INJ 30MG/3ML B/D benztropine mesylate inj 1mg/ml 1 G benztropine mesylate tabs 0.5mg 1 G benztropine mesylate tabs 1mg 1 G benztropine mesylate tabs 2mg 1 G bromocriptine mesylate caps 5mg 1 G bromocriptine mesylate tabs 2.5mg 1 G carbidopa/levodopa er tbcr 25mg; 100mg 1 G carbidopa/levodopa er tbcr 50mg; 200mg 1 G carbidopa/levodopa odt tbdp 10mg; 100mg 1 G carbidopa/levodopa odt tbdp 25mg; 100mg 1 G carbidopa/levodopa odt tbdp 25mg; 250mg 1 G carbidopa/levodopa/entacapone tabs 12.5mg; 200mg; 50mg 1 G carbidopa/levodopa/entacapone tabs 18.75mg; 200mg; 75mg 1 G carbidopa/levodopa/entacapone tabs 25mg; 200mg; 100mg 1 G carbidopa/levodopa/entacapone tabs 31.25mg; 200mg; 125mg 1 G carbidopa/levodopa/entacapone tabs 37.5mg; 200mg; 150mg 1 G carbidopa/levodopa/entacapone tabs 50mg; 200mg; 200mg 1 G carbidopa/levodopa tabs 10mg; 100mg 1 G carbidopa/levodopa tabs 25mg; 100mg 1 G carbidopa/levodopa tabs 25mg; 250mg 1 G carbidopa tabs 25mg 1 G DUOPA SUSP 4.63MG/ML; 20MG/ML entacapone tabs 200mg 1 G NEUPRO PT24 1MG/24HR NEUPRO PT24 2MG/24HR NEUPRO PT24 3MG/24HR NEUPRO PT24 4MG/24HR NEUPRO PT24 6MG/24HR Página 10

12 NEUPRO PT24 8MG/24HR pramipexole dihydrochloride er tb mg 1 G pramipexole dihydrochloride er tb mg 1 G pramipexole dihydrochloride er tb24 1.5mg 1 G pramipexole dihydrochloride er tb mg 1 G pramipexole dihydrochloride er tb mg 1 G pramipexole dihydrochloride er tb24 3mg 1 G pramipexole dihydrochloride er tb24 4.5mg 1 G pramipexole dihydrochloride tabs 0.125mg 1 G pramipexole dihydrochloride tabs 0.25mg 1 G pramipexole dihydrochloride tabs 0.5mg 1 G pramipexole dihydrochloride tabs 0.75mg 1 G pramipexole dihydrochloride tabs 1.5mg 1 G pramipexole dihydrochloride tabs 1mg 1 G rasagiline mesylate tabs 0.5mg 1 G rasagiline mesylate tabs 1mg 1 G ropinirole er tb24 12mg 1 G ropinirole er tb24 2mg 1 G ropinirole er tb24 4mg 1 G ropinirole er tb24 6mg 1 G ropinirole er tb24 8mg 1 G ropinirole hcl tabs 0.25mg 1 G ropinirole hcl tabs 0.5mg 1 G ropinirole hcl tabs 1mg 1 G ropinirole hcl tabs 2mg 1 G ropinirole hcl tabs 3mg 1 G ropinirole hcl tabs 4mg 1 G ropinirole hcl tabs 5mg 1 G RYTARY CPCR 23.75MG; 95MG RYTARY CPCR 36.25MG; 145MG RYTARY CPCR 48.75MG; 195MG RYTARY CPCR 61.25MG; 245MG selegiline hcl caps 5mg 1 G selegiline hcl tabs 5mg 1 G tolcapone tabs 100mg trihexyphenidyl hcl elix 0.4mg/ml 1 G trihexyphenidyl hcl tabs 2mg 1 G trihexyphenidyl hcl tabs 5mg 1 G ZELAPAR TBDP 1.25MG Agentes cardiovasculares acebutolol hcl caps 200mg 1 G acebutolol hcl caps 400mg 1 G acetazolamide sodium inj 500mg 1 G HI acetazolamide tabs 125mg 1 G acetazolamide tabs 250mg 1 G afeditab cr tb24 30mg 1 G Página 11

13 afeditab cr tb24 60mg 1 G ALDACTAZIDE TABS 50MG; 50MG ALTOPREV TB24 20MG QL (30 EA por 30 días) ALTOPREV TB24 40MG QL (30 EA por 30 días) amiloride hcl tabs 5mg 1 G amiloride/hydrochlorothiazide tabs 5mg; 50mg 1 G amiodarone hcl inj 50mg/ml 1 G B/D amiodarone hcl inj 50mg/ml 1 G B/D amiodarone hcl inj 900mg/18ml 1 G B/D amiodarone hcl tabs 100mg 1 G amiodarone hcl tabs 200mg 1 G amiodarone hcl tabs 400mg 1 G amlodipine besylate/atorvastatin calcium tabs 10mg; 10mg 1 G amlodipine besylate/atorvastatin calcium tabs 10mg; 20mg 1 G amlodipine besylate/atorvastatin calcium tabs 10mg; 40mg 1 G amlodipine besylate/atorvastatin calcium tabs 10mg; 80mg 1 G amlodipine besylate/atorvastatin calcium tabs 2.5mg; 10mg 1 G amlodipine besylate/atorvastatin calcium tabs 2.5mg; 20mg 1 G amlodipine besylate/atorvastatin calcium tabs 2.5mg; 40mg 1 G amlodipine besylate/atorvastatin calcium tabs 5mg; 10mg 1 G amlodipine besylate/atorvastatin calcium tabs 5mg; 20mg 1 G amlodipine besylate/atorvastatin calcium tabs 5mg; 40mg 1 G amlodipine besylate/atorvastatin calcium tabs 5mg; 80mg 1 G amlodipine besylate/benazepril hydrochloride caps 10mg; 1 G 20mg amlodipine besylate/benazepril hydrochloride caps 10mg; 1 G 40mg amlodipine besylate/benazepril hydrochloride caps 2.5mg; 1 G 10mg amlodipine besylate/benazepril hydrochloride caps 5mg; 1 G 10mg amlodipine besylate/benazepril hydrochloride caps 5mg; 1 G 20mg amlodipine besylate/benazepril hydrochloride caps 5mg; 1 G 40mg amlodipine besylate/valsartan tabs 10mg; 160mg 1 G QL (30 EA por 30 días) amlodipine besylate/valsartan tabs 10mg; 320mg 1 G QL (30 EA por 30 días) amlodipine besylate/valsartan tabs 5mg; 160mg 1 G QL (30 EA por 30 días) amlodipine besylate/valsartan tabs 5mg; 320mg 1 G QL (30 EA por 30 días) amlodipine besylate tabs 10mg 1 G amlodipine besylate tabs 2.5mg 1 G amlodipine besylate tabs 5mg 1 G Página 12

14 amlodipine/olmesartan medoxomil tabs 10mg; 20mg 1 G amlodipine/olmesartan medoxomil tabs 10mg; 40mg 1 G amlodipine/olmesartan medoxomil tabs 5mg; 20mg 1 G amlodipine/olmesartan medoxomil tabs 5mg; 40mg 1 G amlodipine/valsartan/hctz tabs 10mg; 12.5mg; 160mg 1 G QL (30 EA por 30 días) amlodipine/valsartan/hctz tabs 10mg; 25mg; 160mg 1 G QL (30 EA por 30 días) amlodipine/valsartan/hctz tabs 10mg; 25mg; 320mg 1 G QL (30 EA por 30 días) amlodipine/valsartan/hctz tabs 5mg; 12.5mg; 160mg 1 G QL (30 EA por 30 días) amlodipine/valsartan/hctz tabs 5mg; 25mg; 160mg 1 G QL (30 EA por 30 días) ANTARA CAPS 30MG ST ANTARA CAPS 90MG ST atenolol/chlorthalidone tabs 100mg; 25mg 1 G atenolol/chlorthalidone tabs 50mg; 25mg 1 G atenolol tabs 100mg 1 G atenolol tabs 25mg 1 G atenolol tabs 50mg 1 G atorvastatin calcium tabs 10mg 1 G atorvastatin calcium tabs 20mg 1 G atorvastatin calcium tabs 40mg 1 G atorvastatin calcium tabs 80mg 1 G atropine sulfate inj 0.5mg/5ml 1 G benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg 1 G benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg 1 G benazepril hcl/hydrochlorothiazide tabs 20mg; 25mg 1 G benazepril hcl/hydrochlorothiazide tabs 5mg; 6.25mg 1 G benazepril hcl tabs 10mg 1 G benazepril hcl tabs 20mg 1 G benazepril hcl tabs 40mg 1 G benazepril hcl tabs 5mg 1 G betaxolol hcl tabs 10mg 1 G betaxolol hcl tabs 20mg 1 G BIDIL TABS 37.5MG; 20MG bisoprolol fumarate/hydrochlorothiazide tabs 10mg; 6.25mg 1 G bisoprolol fumarate/hydrochlorothiazide tabs 2.5mg; 6.25mg 1 G bisoprolol fumarate/hydrochlorothiazide tabs 5mg; 6.25mg 1 G bisoprolol fumarate tabs 10mg 1 G bisoprolol fumarate tabs 5mg 1 G bumetanide inj 0.25mg/ml 1 G HI bumetanide tabs 0.5mg 1 G bumetanide tabs 1mg 1 G bumetanide tabs 2mg 1 G Página 13

15 Nombre del medicamento medicamento BYSTOLIC TABS 10MG BYSTOLIC TABS 2.5MG BYSTOLIC TABS 20MG BYSTOLIC TABS 5MG BYVALSON TABS 5MG; 80MG candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg 1 G Página 14 candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg 1 G Requisitos/Límites QL (30 EA por 30 días) QL (30 EA por 30 días) candesartan cilexetil/hydrochlorothiazide tabs 32mg; 25mg 1 G QL (30 EA por 30 días) candesartan cilexetil tabs 16mg 1 G QL (30 EA por 30 días) candesartan cilexetil tabs 32mg 1 G QL (30 EA por 30 días) candesartan cilexetil tabs 4mg 1 G QL (30 EA por 30 días) candesartan cilexetil tabs 8mg 1 G QL (30 EA por 30 días) captopril/hydrochlorothiazide tabs 25mg; 15mg 1 G captopril/hydrochlorothiazide tabs 25mg; 25mg 1 G captopril/hydrochlorothiazide tabs 50mg; 15mg 1 G captopril/hydrochlorothiazide tabs 50mg; 25mg 1 G captopril tabs 100mg 1 G captopril tabs 12.5mg 1 G captopril tabs 25mg 1 G captopril tabs 50mg 1 G CARDENE IV INJ 20MG/200ML; 0.86% CARDENE IV INJ 40MG/200ML; 0.83% CARDENE IV INJ 5%; 40MG/200ML B/D CARDIZEM LA TB24 120MG CARDURA XL TB24 4MG CARDURA XL TB24 8MG cartia xt cp24 120mg 1 G cartia xt cp24 180mg 1 G cartia xt cp24 240mg 1 G cartia xt cp24 300mg 1 G carvedilol tabs 12.5mg 1 G carvedilol tabs 25mg 1 G carvedilol tabs 3.125mg 1 G carvedilol tabs 6.25mg 1 G chlorothiazide sodium inj 500mg 1 G HI chlorothiazide tabs 250mg 1 G chlorothiazide tabs 500mg 1 G chlorthalidone tabs 25mg 1 G chlorthalidone tabs 50mg 1 G

16 cholestyramine light pack 4gm 1 G cholestyramine light powd 4gm/dose 1 G cholestyramine pack 4gm 1 G cholestyramine powd 4gm/dose 1 G clonidine hcl ptwk 0.1mg/24hr 1 G clonidine hcl ptwk 0.2mg/24hr 1 G clonidine hcl ptwk 0.3mg/24hr 1 G clonidine hcl tabs 0.1mg 1 G clonidine hcl tabs 0.2mg 1 G clonidine hcl tabs 0.3mg 1 G clorpres tabs 15mg; 0.1mg 1 G clorpres tabs 15mg; 0.2mg 1 G clorpres tabs 15mg; 0.3mg 1 G colestipol hcl gran 5gm 1 G colestipol hcl tabs 1gm 1 G COREG CR CP24 10MG ST COREG CR CP24 20MG ST COREG CR CP24 40MG ST COREG CR CP24 80MG ST CORLANOR TABS 5MG CORLANOR TABS 7.5MG DEMSER CAPS 250MG digitek tabs 0.125mg 1 G digitek tabs 0.25mg 1 G digoxin inj 0.25mg/ml 1 G digoxin soln 0.05mg/ml 1 G digoxin tabs 125mcg 1 G digoxin tabs 250mcg 1 G digox tabs 125mcg 1 G digox tabs 250mcg 1 G dilt-cd cp24 180mg 1 G dilt-cd cp24 240mg 1 G dilt-xr cp24 120mg 1 G dilt-xr cp24 180mg 1 G dilt-xr cp24 240mg 1 G diltiazem cd cp24 120mg 1 G diltiazem cd cp24 120mg 1 G diltiazem cd cp24 180mg 1 G diltiazem cd cp24 240mg 1 G diltiazem cd cp24 300mg 1 G diltiazem hcl cd cp24 360mg 1 G diltiazem hcl er cp12 120mg 1 G diltiazem hcl er cp12 60mg 1 G diltiazem hcl er cp12 90mg 1 G diltiazem hcl er cp24 120mg 1 G diltiazem hcl er cp24 120mg 1 G Página 15

17 diltiazem hcl er cp24 120mg 1 G diltiazem hcl er cp24 180mg 1 G diltiazem hcl er cp24 180mg 1 G diltiazem hcl er cp24 180mg 1 G diltiazem hcl er cp24 240mg 1 G diltiazem hcl er cp24 240mg 1 G diltiazem hcl er cp24 240mg 1 G diltiazem hcl er cp24 300mg 1 G diltiazem hcl er cp24 300mg 1 G diltiazem hcl er cp24 360mg 1 G diltiazem hcl er cp24 360mg 1 G diltiazem hcl er cp24 420mg 1 G diltiazem hcl er tb24 180mg 1 G diltiazem hcl er tb24 240mg 1 G diltiazem hcl er tb24 300mg 1 G diltiazem hcl er tb24 360mg 1 G diltiazem hcl er tb24 420mg 1 G diltiazem hcl inj 100mg 1 G B/D diltiazem hcl inj 125mg/25ml 1 G B/D diltiazem hcl inj 25mg/5ml 1 G B/D diltiazem hcl inj 50mg/10ml 1 G B/D diltiazem hcl tabs 120mg 1 G diltiazem hcl tabs 30mg 1 G diltiazem hcl tabs 60mg 1 G diltiazem hcl tabs 90mg 1 G diltzac cp24 300mg 1 G diltzac cp24 360mg 1 G disopyramide phosphate caps 100mg 1 G disopyramide phosphate caps 150mg 1 G DIURIL SUSP 250MG/5ML dofetilide caps 125mcg 1 G dofetilide caps 250mcg 1 G dofetilide caps 500mcg 1 G DUTOPROL TB MG; 100MG DUTOPROL TB MG; 25MG DUTOPROL TB MG; 50MG DYRENIUM CAPS 0; 100MG DYRENIUM CAPS 50MG EDARBI TABS 40MG QL (30 EA por 30 días) EDARBI TABS 80MG QL (30 EA por 30 días) EDARBYCLOR TABS 40MG; 12.5MG EDARBYCLOR TABS 40MG; 25MG enalapril maleate/hydrochlorothiazide tabs 10mg; 25mg 1 G enalapril maleate/hydrochlorothiazide tabs 5mg; 12.5mg 1 G enalapril maleate tabs 10mg 1 G enalapril maleate tabs 2.5mg 1 G Página 16

18 enalapril maleate tabs 20mg 1 G enalapril maleate tabs 5mg 1 G ENTRESTO TABS 24MG; 26MG ENTRESTO TABS 49MG; 51MG ENTRESTO TABS 97MG; 103MG EPANED SOLN 1MG/ML EPANED SOLR 1MG/ML eplerenone tabs 25mg 1 G eplerenone tabs 50mg 1 G eprosartan mesylate tabs 600mg 1 G ethacrynate sodium inj 50mg HI ethacrynic acid tabs 25mg 1 G ezetimibe/simvastatin tabs 10mg; 10mg 1 G ezetimibe/simvastatin tabs 10mg; 20mg 1 G ezetimibe/simvastatin tabs 10mg; 40mg 1 G ezetimibe/simvastatin tabs 10mg; 80mg 1 G ezetimibe tabs 10mg 1 G QL (30 EA por 30 días) felodipine er tb24 10mg 1 G felodipine er tb24 2.5mg 1 G felodipine er tb24 5mg 1 G fenofibrate micronized caps 134mg 1 G fenofibrate micronized caps 200mg 1 G fenofibrate micronized caps 67mg 1 G fenofibrate caps 130mg 1 G fenofibrate caps 150mg 1 G fenofibrate caps 43mg 1 G fenofibrate caps 50mg 1 G fenofibrate tabs 120mg 1 G ST fenofibrate tabs 145mg 1 G fenofibrate tabs 160mg 1 G fenofibrate tabs 40mg 1 G ST fenofibrate tabs 48mg 1 G fenofibrate tabs 54mg 1 G fenofibric acid dr cpdr 135mg 1 G fenofibric acid dr cpdr 45mg 1 G fenofibric acid tabs 105mg 1 G fenofibric acid tabs 35mg 1 G flecainide acetate tabs 100mg 1 G flecainide acetate tabs 150mg 1 G flecainide acetate tabs 50mg 1 G fluvastatin sodium er tb24 80mg 1 G fluvastatin caps 20mg 1 G fluvastatin caps 40mg 1 G fosinopril sodium/hydrochlorothiazide tabs 10mg; 12.5mg 1 G fosinopril sodium/hydrochlorothiazide tabs 20mg; 12.5mg 1 G Página 17

19 fosinopril sodium tabs 10mg 1 G fosinopril sodium tabs 20mg 1 G fosinopril sodium tabs 40mg 1 G furosemide inj 10mg/ml 1 G HI furosemide inj 10mg/ml 1 G HI furosemide soln 10mg/ml 1 G furosemide soln 8mg/ml 1 G furosemide tabs 20mg 1 G furosemide tabs 40mg 1 G furosemide tabs 80mg 1 G gemfibrozil tabs 600mg 1 G guanfacine hcl tabs 1mg 1 G guanfacine hcl tabs 2mg 1 G hydralazine hcl inj 20mg/ml 1 G B/D hydralazine hcl tabs 100mg 1 G hydralazine hcl tabs 10mg 1 G hydralazine hcl tabs 25mg 1 G hydralazine hcl tabs 50mg 1 G hydrochlorothiazide caps 12.5mg 1 G hydrochlorothiazide tabs 12.5mg 1 G hydrochlorothiazide tabs 25mg 1 G hydrochlorothiazide tabs 50mg 1 G indapamide tabs 1.25mg 1 G indapamide tabs 2.5mg 1 G irbesartan/hydrochlorothiazide tabs 12.5mg; 150mg 1 G irbesartan/hydrochlorothiazide tabs 12.5mg; 300mg 1 G irbesartan tabs 150mg 1 G irbesartan tabs 300mg 1 G irbesartan tabs 75mg 1 G ISORDIL TITRADOSE TABS 40MG isosorbide dinitrate er tbcr 40mg 1 G isosorbide dinitrate tabs 10mg 1 G isosorbide dinitrate tabs 20mg 1 G isosorbide dinitrate tabs 30mg 1 G isosorbide dinitrate tabs 5mg 1 G isosorbide mononitrate er tb24 120mg 1 G isosorbide mononitrate er tb24 30mg 1 G isosorbide mononitrate er tb24 60mg 1 G isosorbide mononitrate tabs 10mg 1 G isosorbide mononitrate tabs 20mg 1 G isradipine caps 2.5mg 1 G isradipine caps 5mg 1 G KYNAMRO INJ 200MG/ML PA labetalol hcl inj 5mg/ml 1 G B/D labetalol hcl tabs 100mg 1 G labetalol hcl tabs 200mg 1 G Página 18

20 labetalol hcl tabs 300mg 1 G LANOXIN PEDIATRIC INJ 0.1MG/ML 1 B LANOXIN TABS 187.5MCG 1 B LANOXIN TABS 62.5MCG 1 B LEVATOL TABS 20MG lidocaine hcl inj 10mg/ml 1 G B/D lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg 1 G lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg 1 G lisinopril/hydrochlorothiazide tabs 25mg; 20mg 1 G lisinopril tabs 10mg 1 G lisinopril tabs 2.5mg 1 G lisinopril tabs 20mg 1 G lisinopril tabs 30mg 1 G lisinopril tabs 40mg 1 G lisinopril tabs 5mg 1 G LIVALO TABS 1MG LIVALO TABS 2MG LIVALO TABS 4MG losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg 1 G losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg 1 G losartan potassium/hydrochlorothiazide tabs 25mg; 100mg 1 G losartan potassium tabs 100mg 1 G losartan potassium tabs 25mg 1 G losartan potassium tabs 50mg 1 G lovastatin tabs 10mg 1 G lovastatin tabs 20mg 1 G lovastatin tabs 40mg 1 G matzim la tb24 180mg 1 G matzim la tb24 240mg 1 G matzim la tb24 300mg 1 G matzim la tb24 360mg 1 G matzim la tb24 420mg 1 G methazolamide tabs 25mg 1 G methazolamide tabs 50mg 1 G methyclothiazide tabs 5mg 1 G methyldopa/hydrochlorothiazide tabs 15mg; 250mg 1 G methyldopa/hydrochlorothiazide tabs 25mg; 250mg 1 G methyldopa tabs 250mg 1 G methyldopa tabs 500mg 1 G methyldopate hcl inj 250mg/5ml 1 G B/D metolazone tabs 10mg 1 G metolazone tabs 2.5mg 1 G metolazone tabs 5mg 1 G metoprolol succinate er/hydrochlorothiazide tb mg; 100mg 1 G Página 19

21 metoprolol succinate er/hydrochlorothiazide tb mg; 1 G 25mg metoprolol succinate er/hydrochlorothiazide tb mg; 1 G 50mg metoprolol succinate er tb24 100mg 1 G metoprolol succinate er tb24 200mg 1 G metoprolol succinate er tb24 25mg 1 G metoprolol succinate er tb24 50mg 1 G metoprolol tartrate inj 5mg/5ml 1 G B/D metoprolol tartrate inj 5mg/5ml 1 G B/D metoprolol tartrate tabs 100mg 1 G metoprolol tartrate tabs 25mg 1 G metoprolol tartrate tabs 37.5mg 1 G metoprolol tartrate tabs 37.5mg 1 G metoprolol tartrate tabs 50mg 1 G metoprolol tartrate tabs 75mg 1 G metoprolol tartrate tabs 75mg 1 G metoprolol/hydrochlorothiazide tabs 25mg; 100mg 1 G metoprolol/hydrochlorothiazide tabs 25mg; 50mg 1 G metoprolol/hydrochlorothiazide tabs 50mg; 100mg 1 G mexiletine hcl caps 150mg 1 G mexiletine hcl caps 200mg 1 G mexiletine hcl caps 250mg 1 G midodrine hcl tabs 10mg 1 G midodrine hcl tabs 2.5mg 1 G midodrine hcl tabs 5mg 1 G minitran pt24 0.1mg/hr 1 G minitran pt24 0.2mg/hr 1 G minitran pt24 0.4mg/hr 1 G minitran pt24 0.6mg/hr 1 G minoxidil tabs 10mg 1 G minoxidil tabs 2.5mg 1 G moexipril hcl tabs 15mg 1 G moexipril hcl tabs 7.5mg 1 G moexipril/hydrochlorothiazide tabs 12.5mg; 15mg 1 G moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg 1 G moexipril/hydrochlorothiazide tabs 25mg; 15mg 1 G MULTAQ TABS 400MG nadolol/bendroflumethiazide tabs 5mg; 40mg 1 G nadolol/bendroflumethiazide tabs 5mg; 80mg 1 G nadolol tabs 20mg 1 G nadolol tabs 40mg 1 G nadolol tabs 80mg 1 G NEXTERONE INJ 150MG/100ML; 42.1MG/ML NEXTERONE INJ 360MG/200ML; 41.4MG/ML niacin er tbcr 1000mg 1 G Página 20

22 niacin er tbcr 500mg 1 G niacin er tbcr 750mg 1 G niacor tabs 500mg 1 G nicardipine hcl caps 20mg 1 G nicardipine hcl caps 30mg 1 G nicardipine hcl inj 2.5mg/ml 1 G nifedical xl tb24 30mg 1 G nifedical xl tb24 60mg 1 G nifedipine er tb24 30mg 1 G nifedipine er tb24 30mg 1 G nifedipine er tb24 60mg 1 G nifedipine er tb24 60mg 1 G nifedipine er tb24 90mg 1 G nifedipine er tb24 90mg 1 G nifedipine caps 10mg 1 G nifedipine caps 20mg 1 G nimodipine caps 30mg 1 G nisoldipine er tb24 17mg 1 G nisoldipine er tb24 20mg 1 G nisoldipine er tb mg 1 G nisoldipine er tb24 30mg 1 G nisoldipine er tb24 34mg 1 G nisoldipine er tb24 40mg 1 G nisoldipine er tb24 8.5mg 1 G NITRO-BID OINT 2% NITRO-DUR PT24 0.3MG/HR NITRO-DUR PT24 0.8MG/HR nitro-time cpcr 2.5mg 1 G # nitro-time cpcr 6.5mg 1 G # nitroglycerin er cpcr 6.5mg 1 G # nitroglycerin lingual aers 400mcg/spray 1 G nitroglycerin lingual soln 0.4mg/spray 1 G nitroglycerin transdermal pt24 0.1mg/hr 1 G nitroglycerin transdermal pt24 0.2mg/hr 1 G nitroglycerin transdermal pt24 0.4mg/hr 1 G nitroglycerin transdermal pt24 0.6mg/hr 1 G nitroglycerin inj 5mg/ml 1 G B/D nitroglycerin subl 0.3mg 1 G nitroglycerin subl 0.4mg 1 G nitroglycerin subl 0.6mg 1 G NITROMIST AERS 400MCG/SPRAY NORPACE CR CP12 100MG NORPACE CR CP12 150MG NORTHERA CAPS 100MG QL (90 EA por 30 días) PA Página 21

23 NORTHERA CAPS 200MG QL (180 EA por 30 días) PA NORTHERA CAPS 300MG QL (180 EA por 30 días) PA olmesartan medoxomil/amlodipine/hydrochlorothiazide tabs 1 G 10mg; 12.5mg; 40mg olmesartan medoxomil/amlodipine/hydrochlorothiazide tabs 1 G 10mg; 25mg; 40mg olmesartan medoxomil/amlodipine/hydrochlorothiazide tabs 1 G 5mg; 12.5mg; 20mg olmesartan medoxomil/amlodipine/hydrochlorothiazide tabs 1 G 5mg; 12.5mg; 40mg olmesartan medoxomil/amlodipine/hydrochlorothiazide tabs 1 G 5mg; 25mg; 40mg olmesartan medoxomil/hydrochlorothiazide tabs 12.5mg; 1 G 20mg olmesartan medoxomil/hydrochlorothiazide tabs 12.5mg; 40mg 1 G olmesartan medoxomil/hydrochlorothiazide tabs 25mg; 40mg 1 G olmesartan medoxomil tabs 20mg 1 G olmesartan medoxomil tabs 40mg 1 G olmesartan medoxomil tabs 5mg 1 G omega-3-acid ethyl esters caps 375mg; 465mg; 1gm 1 G QL (120 EA por 30 días) pacerone tabs 100mg 1 G pacerone tabs 200mg 1 G pacerone tabs 400mg 1 G pentoxifylline er tbcr 400mg 1 G perindopril erbumine tabs 2mg 1 G perindopril erbumine tabs 4mg 1 G perindopril erbumine tabs 8mg 1 G phenoxybenzamine hydrochloride caps 10mg pindolol tabs 10mg 1 G pindolol tabs 5mg 1 G pravastatin sodium tabs 10mg 1 G pravastatin sodium tabs 20mg 1 G pravastatin sodium tabs 40mg 1 G pravastatin sodium tabs 80mg 1 G prazosin hcl caps 1mg 1 G prazosin hcl caps 2mg 1 G prazosin hcl caps 5mg 1 G prevalite pack 4gm 1 G prevalite powd 4gm/dose 1 G procainamide hcl inj 100mg/ml 1 G B/D procainamide hcl inj 500mg/ml 1 G propafenone hcl er cp12 225mg 1 G Página 22

24 propafenone hcl er cp12 325mg 1 G propafenone hcl er cp12 425mg 1 G propafenone hcl tabs 150mg 1 G propafenone hcl tabs 225mg 1 G propafenone hcl tabs 300mg 1 G propranolol hcl er cp24 120mg 1 G propranolol hcl er cp24 160mg 1 G propranolol hcl er cp24 60mg 1 G propranolol hcl er cp24 80mg 1 G propranolol hcl inj 1mg/ml 1 G B/D propranolol hcl soln 20mg/5ml 1 G propranolol hcl soln 40mg/5ml 1 G propranolol hcl tabs 10mg 1 G propranolol hcl tabs 20mg 1 G propranolol hcl tabs 40mg 1 G propranolol hcl tabs 60mg 1 G propranolol hcl tabs 80mg 1 G propranolol/hydrochlorothiazide tabs 25mg; 40mg 1 G propranolol/hydrochlorothiazide tabs 25mg; 80mg 1 G quinapril hcl tabs 10mg 1 G quinapril hcl tabs 20mg 1 G quinapril hcl tabs 40mg 1 G quinapril hcl tabs 5mg 1 G quinapril/hydrochlorothiazide tabs 12.5mg; 10mg 1 G quinapril/hydrochlorothiazide tabs 12.5mg; 20mg 1 G quinapril/hydrochlorothiazide tabs 25mg; 20mg 1 G quinidine gluconate cr tbcr 324mg 1 G quinidine gluconate er tbcr 324mg 1 G quinidine gluconate inj 80mg/ml 1 G quinidine sulfate er tbcr 300mg 1 G quinidine sulfate tabs 200mg 1 G quinidine sulfate tabs 300mg 1 G ramipril caps 1.25mg 1 G ramipril caps 10mg 1 G ramipril caps 2.5mg 1 G ramipril caps 5mg 1 G RANEXA TB MG RANEXA TB12 500MG RECTIV OINT 0.4% REPATHA PUSHTRONEX SYSTEM INJ 420MG/3.5ML QL (3.5 ML por 30 días) PA REPATHA SURECLICK INJ 140MG/ML QL (3 ML por 30 días) PA REPATHA INJ 140MG/ML QL (3 ML por 30 días) PA reserpine tabs 0.1mg 1 G reserpine tabs 0.25mg 1 G rosuvastatin calcium tabs 10mg 1 G Página 23

25 rosuvastatin calcium tabs 20mg 1 G rosuvastatin calcium tabs 40mg 1 G rosuvastatin calcium tabs 5mg 1 G SIMCOR TB MG; 20MG SIMCOR TB MG; 40MG SIMCOR TB24 500MG; 20MG SIMCOR TB24 500MG; 40MG SIMCOR TB24 750MG; 20MG simvastatin tabs 10mg 1 G simvastatin tabs 20mg 1 G simvastatin tabs 40mg 1 G simvastatin tabs 5mg 1 G simvastatin tabs 80mg 1 G sorine tabs 120mg 1 G sorine tabs 160mg 1 G sorine tabs 240mg 1 G sorine tabs 80mg 1 G sotalol hcl (af) tabs 120mg 1 G sotalol hcl (af) tabs 160mg 1 G sotalol hcl (af) tabs 80mg 1 G sotalol hcl tabs 120mg 1 G sotalol hcl tabs 160mg 1 G sotalol hcl tabs 240mg 1 G sotalol hcl tabs 80mg 1 G SOTYLIZE SOLN 5MG/ML spironolactone/hydrochlorothiazide tabs 25mg; 25mg 1 G spironolactone tabs 100mg 1 G spironolactone tabs 25mg 1 G spironolactone tabs 50mg 1 G taztia xt cp24 120mg 1 G taztia xt cp24 180mg 1 G taztia xt cp24 240mg 1 G taztia xt cp24 300mg 1 G taztia xt cp24 360mg 1 G TEKTURNA HCT TABS 150MG; 12.5MG TEKTURNA HCT TABS 150MG; 25MG TEKTURNA HCT TABS 300MG; 12.5MG TEKTURNA HCT TABS 300MG; 25MG TEKTURNA TABS 150MG TEKTURNA TABS 300MG telmisartan/amlodipine tabs 10mg; 40mg 1 G telmisartan/amlodipine tabs 10mg; 80mg 1 G telmisartan/amlodipine tabs 5mg; 40mg 1 G telmisartan/amlodipine tabs 5mg; 80mg 1 G telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg 1 G QL (30 EA por 30 días) Página 24

26 telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg 1 G QL (30 EA por 30 días) telmisartan/hydrochlorothiazide tabs 25mg; 80mg 1 G QL (30 EA por 30 días) telmisartan tabs 20mg 1 G QL (30 EA por 30 días) telmisartan tabs 40mg 1 G QL (30 EA por 30 días) telmisartan tabs 80mg 1 G QL (30 EA por 30 días) TEVETEN HCT TABS 600MG; 25MG QL (30 EA por 30 días) timolol maleate tabs 10mg 1 G timolol maleate tabs 20mg 1 G timolol maleate tabs 5mg 1 G torsemide inj 20mg/2ml 1 G torsemide tabs 100mg 1 G torsemide tabs 10mg 1 G torsemide tabs 20mg 1 G torsemide tabs 5mg 1 G trandolapril/verapamil hcl er tbcr 1mg; 240mg 1 G trandolapril/verapamil hcl er tbcr 2mg; 180mg 1 G trandolapril/verapamil hcl er tbcr 2mg; 240mg 1 G trandolapril/verapamil hcl er tbcr 4mg; 240mg 1 G trandolapril tabs 1mg 1 G trandolapril tabs 2mg 1 G trandolapril tabs 4mg 1 G triamterene/hydrochlorothiazide caps 25mg; 37.5mg 1 G triamterene/hydrochlorothiazide caps 25mg; 50mg 1 G triamterene/hydrochlorothiazide tabs 25mg; 37.5mg 1 G triamterene/hydrochlorothiazide tabs 50mg; 75mg 1 G valsartan/hydrochlorothiazide tabs 12.5mg; 160mg 1 G QL (30 EA por 30 días) valsartan/hydrochlorothiazide tabs 12.5mg; 320mg 1 G QL (30 EA por 30 días) valsartan/hydrochlorothiazide tabs 12.5mg; 80mg 1 G QL (30 EA por 30 días) valsartan/hydrochlorothiazide tabs 25mg; 160mg 1 G QL (30 EA por 30 días) valsartan/hydrochlorothiazide tabs 25mg; 320mg 1 G QL (30 EA por 30 días) valsartan tabs 160mg 1 G QL (30 EA por 30 días) valsartan tabs 320mg 1 G QL (30 EA por 30 días) valsartan tabs 40mg 1 G QL (30 EA por 30 días) Página 25

27 valsartan tabs 80mg 1 G QL (30 EA por 30 días) VASCEPA CAPS 0.5GM VASCEPA CAPS 1GM VECAMYL TABS 2.5MG verapamil hcl er cp24 100mg 1 G verapamil hcl er cp24 120mg 1 G verapamil hcl er cp24 180mg 1 G verapamil hcl er cp24 200mg 1 G verapamil hcl er cp24 240mg 1 G verapamil hcl er cp24 300mg 1 G verapamil hcl er tbcr 120mg 1 G verapamil hcl er tbcr 180mg 1 G verapamil hcl er tbcr 240mg 1 G verapamil hcl sr cp24 360mg 1 G verapamil hcl inj 2.5mg/ml 1 G B/D verapamil hcl tabs 120mg 1 G verapamil hcl tabs 40mg 1 G verapamil hcl tabs 80mg 1 G WELCHOL PACK 3.75GM WELCHOL TABS 625MG Agentes de antigout allopurinol sodium inj 500mg 1 G allopurinol tabs 100mg 1 G allopurinol tabs 300mg 1 G colchicine caps 0.6mg 1 G colchicine tabs 0.6mg 1 G MITIGARE CAPS 0.6MG probenecid/colchicine tabs 0.5mg; 500mg 1 G probenecid tabs 500mg 1 G ULORIC TABS 40MG QL (30 EA por 30 días) ST ULORIC TABS 80MG QL (30 EA por 30 días) ST Agentes de la enfermedad inflamatoria intestinal APRISO CP GM ASACOL HD TBEC 800MG balsalazide disodium caps 750mg 1 G budesonide cpep 3mg 1 G CANASA SUPP 1000MG colocort enem 100mg/60ml 1 G DELZICOL CPDR 400MG DIPENTUM CAPS 250MG GIAZO TABS 1.1GM hydrocortisone enem 100mg/60ml 1 G LIALDA TBEC 1.2GM Página 26

28 mesalamine dr tbec 1.2gm 1 G mesalamine dr tbec 800mg 1 G mesalamine enem 4gm 1 G mesalamine kit 4gm 1 G PENTASA CPCR 250MG PENTASA CPCR 500MG sulfasalazine tabs 500mg 1 G sulfasalazine tbec 500mg 1 G Agentes de las enfermedades óseas metabólicas alendronate sodium soln 70mg/75ml 1 G alendronate sodium tabs 10mg 1 G alendronate sodium tabs 35mg 1 G alendronate sodium tabs 40mg 1 G alendronate sodium tabs 5mg 1 G alendronate sodium tabs 70mg 1 G BINOSTO TBEF 70MG ST calcitonin-salmon soln 200unit/act 1 G calcitriol caps 0.25mcg 1 G calcitriol caps 0.5mcg 1 G calcitriol inj 1mcg/ml 1 G calcitriol soln 1mcg/ml 1 G doxercalciferol caps 0.5mcg 1 G doxercalciferol caps 1mcg 1 G doxercalciferol caps 2.5mcg doxercalciferol inj 4mcg/2ml 1 G B/D etidronate disodium tabs 200mg 1 G etidronate disodium tabs 400mg 1 G FORTEO INJ 600MCG/2.4ML PA FOSAMAX PLUS D TABS 70MG; 2800UNIT ST FOSAMAX PLUS D TABS 70MG; 5600UNIT ST ibandronate sodium inj 3mg/3ml 1 G PA ibandronate sodium tabs 150mg 1 G MIACALCIN INJ 200UNIT/ML pamidronate disodium inj 30mg/10ml 1 G B/D pamidronate disodium inj 30mg 1 G B/D pamidronate disodium inj 6mg/ml 1 G B/D pamidronate disodium inj 90mg/10ml 1 G B/D pamidronate disodium inj 90mg 1 G B/D paricalcitol caps 1mcg 1 G paricalcitol caps 2mcg 1 G paricalcitol caps 4mcg 1 G paricalcitol inj 2mcg/ml 1 G B/D paricalcitol inj 5mcg/ml 1 G B/D PROLIA INJ 60MG/ML B/D risedronate sodium dr tbec 35mg 1 G QL (4 EA por 28 días) ST Página 27

29 risedronate sodium tabs 150mg 1 G QL (1 EA por 30 días) ST risedronate sodium tabs 30mg 1 G QL (30 EA por 30 días) ST risedronate sodium tabs 35mg 1 G QL (4 EA por 28 días) ST risedronate sodium tabs 35mg 1 G QL (4 EA por 28 días) ST risedronate sodium tabs 35mg 1 G QL (4 EA por 28 días) ST risedronate sodium tabs 5mg 1 G QL (30 EA por 30 días) ST SENSIPAR TABS 30MG SENSIPAR TABS 60MG SENSIPAR TABS 90MG XGEVA INJ 120MG/1.7ML B/D zoledronic acid inj 4mg/100ml 1 G B/D zoledronic acid inj 4mg/5ml 1 G B/D zoledronic acid inj 4mg 1 G B/D zoledronic acid inj 5mg/100ml 1 G B/D Agentes del sistema nervioso central ADZENYS XR-ODT TBED 12.5MG ADZENYS XR-ODT TBED 15.7MG ADZENYS XR-ODT TBED 18.8MG ADZENYS XR-ODT TBED 3.1MG ADZENYS XR-ODT TBED 6.3MG ADZENYS XR-ODT TBED 9.4MG amphetamine/dextroamphetamine cp mg; 1.25mg; 1.25mg; 1.25mg 1 G amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 1 G 2.5mg amphetamine/dextroamphetamine cp mg; 3.75mg; 3.75mg; 3.75mg 1 G amphetamine/dextroamphetamine cp24 5mg; 5mg; 5mg; 5mg 1 G amphetamine/dextroamphetamine cp mg; 6.25mg; 6.25mg; 6.25mg 1 G amphetamine/dextroamphetamine cp24 7.5mg; 7.5mg; 7.5mg; 1 G 7.5mg amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1 G 1.25mg; 1.25mg amphetamine/dextroamphetamine tabs 1.875mg; 1.875mg; 1.875mg; 1.875mg 1 G amphetamine/dextroamphetamine tabs 2.5mg; 2.5mg; 2.5mg; 1 G 2.5mg amphetamine/dextroamphetamine tabs 3.125mg; 3.125mg; 3.125mg; 3.125mg 1 G Página 28

30 amphetamine/dextroamphetamine tabs 3.75mg; 3.75mg; 3.75mg; 3.75mg 1 G amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg 1 G amphetamine/dextroamphetamine tabs 7.5mg; 7.5mg; 7.5mg; 1 G 7.5mg AMPYRA TB12 10MG APTENSIO XR CP24 10MG APTENSIO XR CP24 15MG APTENSIO XR CP24 20MG APTENSIO XR CP24 30MG APTENSIO XR CP24 40MG APTENSIO XR CP24 50MG APTENSIO XR CP24 60MG atomoxetine caps 100mg 1 G atomoxetine caps 10mg 1 G atomoxetine caps 18mg 1 G atomoxetine caps 25mg 1 G atomoxetine caps 40mg 1 G atomoxetine caps 60mg 1 G atomoxetine caps 80mg 1 G AVONEX PEN INJ 30MCG/0.5ML QL (4 EA por 28 días) PA AVONEX INJ 30MCG/0.5ML QL (4 EA por 28 días) PA AVONEX INJ 30MCG/VIAL QL (4 EA por 28 días) PA BETASERON INJ 0.3MG QL (15 EA por 30 días) PA clonidine hcl er tb12 0.1mg 1 G COPAXONE INJ 20MG/ML QL (30 ML por 30 días) PA COPAXONE INJ 40MG/ML QL (12 ML por 28 días) PA DAYTRANA PTCH 10MG/9HR DAYTRANA PTCH 15MG/9HR DAYTRANA PTCH 20MG/9HR DAYTRANA PTCH 30MG/9HR dexmethylphenidate hcl er cp24 10mg 1 G dexmethylphenidate hcl er cp24 15mg 1 G dexmethylphenidate hcl er cp24 20mg 1 G dexmethylphenidate hcl er cp24 25mg 1 G dexmethylphenidate hcl er cp24 30mg 1 G dexmethylphenidate hcl er cp24 35mg 1 G dexmethylphenidate hcl er cp24 40mg 1 G dexmethylphenidate hcl er cp24 5mg 1 G dexmethylphenidate hcl tabs 10mg 1 G dexmethylphenidate hcl tabs 2.5mg 1 G dexmethylphenidate hcl tabs 5mg 1 G dextroamphetamine sulfate er cp24 10mg 1 G Página 29

31 dextroamphetamine sulfate er cp24 15mg 1 G dextroamphetamine sulfate er cp24 5mg 1 G dextroamphetamine sulfate soln 5mg/5ml 1 G dextroamphetamine sulfate tabs 10mg 1 G dextroamphetamine sulfate tabs 5mg 1 G EVEKEO TABS 10MG EVEKEO TABS 5MG GILENYA CAPS 0.5MG QL (30 EA por 30 días) PA guanfacine er tb24 1mg 1 G guanfacine er tb24 2mg 1 G guanfacine er tb24 3mg 1 G guanfacine er tb24 4mg 1 G HETLIOZ CAPS 20MG QL (30 EA por 30 días) PA HORIZANT TBCR 300MG HORIZANT TBCR 600MG metadate er tbcr 20mg 1 G methamphetamine hcl tabs 5mg 1 G PA methylphenidate hcl cd cpcr 10mg 1 G methylphenidate hcl cd cpcr 20mg 1 G methylphenidate hcl cd cpcr 40mg 1 G methylphenidate hcl cd cpcr 50mg 1 G methylphenidate hcl cd cpcr 60mg 1 G methylphenidate hcl er (la) cp24 60mg 1 G methylphenidate hcl er cp24 20mg 1 G methylphenidate hcl er cp24 40mg 1 G methylphenidate hcl er cpcr 20mg 1 G methylphenidate hcl er cpcr 30mg 1 G methylphenidate hcl er cpcr 40mg 1 G methylphenidate hcl er tb24 18mg 1 G methylphenidate hcl er tb24 27mg 1 G methylphenidate hcl er tb24 36mg 1 G methylphenidate hcl er tb24 54mg 1 G methylphenidate hcl er tbcr 10mg 1 G methylphenidate hcl er tbcr 18mg 1 G methylphenidate hcl er tbcr 20mg 1 G methylphenidate hcl er tbcr 27mg 1 G methylphenidate hcl er tbcr 36mg 1 G methylphenidate hcl er tbcr 54mg 1 G methylphenidate hcl chew 10mg 1 G methylphenidate hcl chew 2.5mg 1 G methylphenidate hcl chew 5mg 1 G methylphenidate hcl tabs 10mg 1 G methylphenidate hcl tabs 20mg 1 G methylphenidate hcl tabs 5mg 1 G Página 30

32 methylphenidate hydrochloride soln 10mg/5ml 1 G methylphenidate hydrochloride soln 5mg/5ml 1 G NUEDEXTA CAPS 20MG; 10MG QUILLIVANT XR SUSR 25MG/5ML riluzole tabs 50mg 1 G RITALIN LA CP24 10MG RITALIN LA CP24 60MG SAVELLA TITRATION PACK MISC 0 SAVELLA TABS 100MG SAVELLA TABS 12.5MG SAVELLA TABS 25MG SAVELLA TABS 50MG TECFIDERA STARTER PACK MISC 0 QL (120 EA por 365 días) PA TECFIDERA CPDR 120MG QL (14 EA por 30 días) PA TECFIDERA CPDR 240MG QL (60 EA por 30 días) PA tetrabenazine tabs 12.5mg PA tetrabenazine tabs 25mg PA TYSABRI INJ 300MG/15ML B/D VYVANSE CAPS 10MG VYVANSE CAPS 20MG VYVANSE CAPS 30MG VYVANSE CAPS 40MG VYVANSE CAPS 50MG VYVANSE CAPS 60MG VYVANSE CAPS 70MG VYVANSE CHEW 10MG VYVANSE CHEW 20MG VYVANSE CHEW 30MG VYVANSE CHEW 40MG VYVANSE CHEW 50MG VYVANSE CHEW 60MG zenzedi tabs 10mg 1 G ZENZEDI TABS 15MG ZENZEDI TABS 2.5MG ZENZEDI TABS 20MG ZENZEDI TABS 30MG zenzedi tabs 5mg 1 G ZENZEDI TABS 7.5MG Agentes del trastorno del sueño armodafinil tabs 150mg 1 G PA armodafinil tabs 200mg 1 G PA armodafinil tabs 250mg 1 G PA armodafinil tabs 50mg 1 G PA Página 31

33 BELSOMRA TABS 10MG BELSOMRA TABS 15MG BELSOMRA TABS 20MG BELSOMRA TABS 5MG EDLUAR SUBL 10MG EDLUAR SUBL 5MG eszopiclone tabs 1mg 1 G eszopiclone tabs 2mg 1 G eszopiclone tabs 3mg 1 G modafinil tabs 100mg 1 G PA modafinil tabs 200mg 1 G PA ROZEREM TABS 8MG SECONAL SODIUM CAPS 100MG SILENOR TABS 3MG SILENOR TABS 6MG temazepam caps 15mg 1 G temazepam caps 22.5mg 1 G temazepam caps 30mg 1 G temazepam caps 7.5mg 1 G XYREM SOLN 500MG/ML zaleplon caps 10mg 1 G zaleplon caps 5mg 1 G zolpidem tartrate er tbcr 12.5mg 1 G zolpidem tartrate er tbcr 6.25mg 1 G zolpidem tartrate subl 1.75mg 1 G zolpidem tartrate subl 3.5mg 1 G zolpidem tartrate tabs 10mg 1 G zolpidem tartrate tabs 5mg 1 G ZOLPIMIST SOLN 5MG/ACT Agentes dentales y orales cevimeline hcl caps 30mg 1 G chlorhexidine gluconate oral rinse soln 0.12% 1 G chlorhexidine gluconate soln 0.12% 1 G KEPIVANCE INJ 6.25MG B/D oralone pste 0.1% 1 G paroex soln 0.12% 1 G periogard soln 0.12% 1 G pilocarpine hcl tabs 7.5mg 1 G pilocarpine hydrochloride tabs 5mg 1 G triamcinolone acetonide pste 0.1% 1 G triamcinolone in orabase pste 0.1% 1 G Agentes dermatológicos 8-MOP CAPS 10MG ABSORICA CAPS 10MG PA ABSORICA CAPS 20MG PA ABSORICA CAPS 25MG PA Página 32

34 ABSORICA CAPS 30MG PA ABSORICA CAPS 35MG PA ABSORICA CAPS 40MG PA ACANYA GEL 2.5%; 1.2% acitretin caps 10mg 1 G acitretin caps 17.5mg 1 G acitretin caps 25mg 1 G ACZONE GEL 5% ACZONE GEL 7.5% adapalene crea 0.1% 1 G PA adapalene gel 0.1% 1 G PA adapalene gel 0.3% 1 G PA adapalene lotn 0.1% 1 G PA ammonium lactate crea 12% 1 G ammonium lactate lotn 12% 1 G amnesteem caps 10mg 1 G PA amnesteem caps 20mg 1 G PA amnesteem caps 40mg 1 G PA AVITA CREA 0.025% 1 B PA avita gel 0.025% 1 G PA AZELEX CREA 20% calcipotriene/betamethasone dipropionate oint 0.064%; 1 G 0.005% calcipotriene crea 0.005% 1 G QL (120 GM por 30 días) calcipotriene oint 0.005% 1 G QL (120 GM por 30 días) calcipotriene soln 0.005% 1 G QL (60 ML por 30 días) calcitrene oint 0.005% 1 G QL (120 GM por 30 días) calcitrene oint 0.005% 1 G QL (120 GM por 30 días) calcitriol oint 3mcg/gm 1 G QL (800 GM por 30 días) claravis caps 10mg 1 G PA claravis caps 20mg 1 G PA claravis caps 30mg 1 G PA claravis caps 40mg 1 G PA CLINDACIN PAC KIT 0; 1% clindacin-p swab 1% 1 G clindamycin phosphate/tretinoin gel 1.2%; 0.025% 1 G PA clindamycin/benzoyl peroxide gel 5%; 1% 1 G clindamycin/benzoyl peroxide gel 5%; 1.2% 1 G CONDYLOX GEL 0.5% COSENTYX SENSOREADY PEN INJ 150MG/ML PA Página 33

35 COSENTYX INJ 150MG/ML PA curity gauze pads 2"x2" pads 1 G diclofenac sodium gel 3% 1 G PA diclofenac sodium soln 1.5% 1 G DIFFERIN LOTN 0.1% PA doxepin hydrochloride crea 5% 1 G doxycycline cpdr 40mg 1 G ELIDEL CREA 1% QL (100 GM por 30 días) PA EPIDUO FORTE GEL 0.3%; 2.5% EPIDUO GEL 0.1%; 2.5% erythromycin/benzoyl peroxide gel 5%; 3% 1 G FABIOR FOAM 0.1% FINACEA FOAM 15% FINACEA GEL 15% FLUOROPLEX CREA 1% fluorouracil crea 0.5% 1 G fluorouracil crea 5% 1 G fluorouracil soln 2% 1 G fluorouracil soln 5% 1 G imiquimod crea 5% 1 G lactic acid lotn 10% 1 G methoxsalen caps 10mg MIRVASO GEL 0.33% myorisan caps 10mg 1 G PA myorisan caps 20mg 1 G PA myorisan caps 30mg 1 G PA myorisan caps 40mg 1 G PA NEO-SYNALAR CREA 0.025%; 0.5% 1 B neuac gel 5%; 1.2% 1 G ORACEA CPDR 40MG OXSORALEN LOTN 1% PICATO GEL 0.015% PICATO GEL 0.05% podofilox soln 0.5% 1 G REGRANEX GEL 0.01% QL (15 GM por 30 días) PA RETIN-A MICRO PUMP GEL 0.08% PA salacyn crea 6% 1 G salicylic acid crea 6% 1 G salicylic acid crea 6% 1 G salicylic acid crea 6% 1 G salicylic acid sham 6% 1 G # SANTYL OINT 250UNIT/GM selenium sulfide lotn 2.5% 1 G SORILUX FOAM 0.005% Página 34

36 STELARA INJ 45MG/0.5ML STELARA INJ 90MG/ML SYNALAR CREAM KIT KIT 0.025% SYNALAR OINTMENT KIT KIT 0.025% SYNALAR CREA 0.025% tacrolimus oint 0.03% 1 G QL (100 GM por 30 días) PA tacrolimus oint 0.1% 1 G QL (100 GM por 30 días) PA tazarotene crea 0.1% 1 G QL (120 GM por 30 días) TAZORAC CREA 0.05% QL (120 GM por 30 días) TAZORAC CREA 0.1% QL (120 GM por 30 días) TAZORAC GEL 0.05% QL (100 GM por 30 días) TAZORAC GEL 0.1% QL (100 GM por 30 días) tretinoin microsphere pump gel 0.04% 1 G PA tretinoin microsphere pump gel 0.04% 1 G PA tretinoin microsphere pump gel 0.1% 1 G PA tretinoin microsphere gel 0.04% 1 G PA tretinoin microsphere gel 0.1% 1 G PA tretinoin crea 0.025% 1 G PA tretinoin crea 0.05% 1 G PA tretinoin crea 0.1% 1 G PA tretinoin gel 0.01% 1 G PA tretinoin gel 0.025% 1 G PA tretinoin gel 0.05% 1 G PA UVADEX INJ 20MCG/ML B/D VECTICAL OINT 3MCG/GM QL (800 GM por 30 días) VELTIN GEL 1.2%; 0.025% PA VEREGEN OINT 15% zenatane caps 10mg 1 G PA zenatane caps 20mg 1 G PA zenatane caps 30mg 1 G PA zenatane caps 40mg 1 G PA ZYCLARA PUMP CREA 2.5% PA ZYCLARA CREA 3.75% PA Agentes gastrointestinales ACIPHEX SPRINKLE CPSP 10MG ST ACIPHEX SPRINKLE CPSP 5MG ST alosetron hydrochloride tabs 0.5mg 1 G alosetron hydrochloride tabs 1mg 1 G AMITIZA CAPS 24MCG QL (60 EA por 30 días) AMITIZA CAPS 8MCG QL (60 EA por 30 días) anaspaz tbdp 0.125mg 1 G atropine sulfate inj 0.25mg/5ml 1 G atropine sulfate inj 0.4mg/0.5ml 1 G B/D Página 35

37 atropine sulfate inj 0.5mg/5ml 1 G atropine sulfate inj 1mg/ml 1 G B/D atropine sulfate inj 8mg/20ml 1 G B/D CANTIL TABS 25MG CARAFATE SUSP 1GM/10ML CHENODAL TABS 250MG chlordiazepoxide hcl/clidinium bromide caps 5mg; 2.5mg 1 G # chlordiazepoxide hcl/clidinium bromide caps 5mg; 2.5mg 1 G # cimetidine hcl soln 300mg/5ml 1 G cimetidine tabs 200mg 1 G cimetidine tabs 300mg 1 G cimetidine tabs 400mg 1 G cimetidine tabs 800mg 1 G constulose soln 10gm/15ml 1 G cromolyn sodium conc 100mg/5ml 1 G CUVPOSA SOLN 1MG/5ML DEXILANT CPDR 30MG ST DEXILANT CPDR 60MG ST dicyclomine hcl caps 10mg 1 G dicyclomine hcl inj 10mg/ml 1 G dicyclomine hcl soln 10mg/5ml 1 G dicyclomine hcl tabs 20mg 1 G diphenoxylate/atropine liqd 0.025mg/5ml; 2.5mg/5ml 1 G diphenoxylate/atropine tabs 0.025mg; 2.5mg 1 G ed-spaz tbdp 0.125mg 1 G enulose soln 10gm/15ml 1 G esomeprazole magnesium cpdr 20mg 1 G esomeprazole magnesium cpdr 40mg 1 G esomeprazole sodium inj 20mg 1 G B/D esomeprazole sodium inj 40mg 1 G B/D famotidine premixed inj 0.4mg/ml; 0.9% 1 G famotidine inj 200mg/20ml 1 G famotidine inj 20mg/2ml 1 G famotidine inj 40mg/4ml 1 G famotidine inj 500mg/50ml 1 G famotidine susr 40mg/5ml 1 G famotidine tabs 20mg 1 G famotidine tabs 40mg 1 G FULYZAQ TBEC 125MG GATTEX INJ 5MG GAVILYTE-C SOLR 240GM; 2.98GM; 6.72GM; 5.84GM; 22.72GM gavilyte-g solr 236gm; 2.97gm; 6.74gm; 5.86gm; 22.74gm 1 G gavilyte-h kit 5mg; 210gm; 0.74gm; 2.86gm; 5.6gm 1 G gavilyte-n/flavor pack solr 420gm; 1.48gm; 5.72gm; 11.2gm 1 G generlac soln 10gm/15ml 1 G Página 36

38 glycopyrrolate inj 0.2mg/ml 1 G glycopyrrolate inj 0.4mg/2ml 1 G glycopyrrolate inj 1mg/5ml 1 G glycopyrrolate inj 4mg/20ml 1 G glycopyrrolate tabs 1mg 1 G glycopyrrolate tabs 2mg 1 G HELIDAC MISC 0; 0; 0 hyoscyamine sulfate er tb mg 1 G hyoscyamine sulfate er tb mg 1 G hyoscyamine sulfate odt tbdp 0.125mg 1 G hyoscyamine sulfate sr tb mg 1 G hyoscyamine sulfate elix 0.125mg/5ml 1 G hyoscyamine sulfate subl 0.125mg 1 G hyoscyamine sulfate tabs 0.125mg 1 G hyoscyamine sulfate tbdp 0.125mg 1 G hyosyne elix 0.125mg/5ml 1 G KRISTALOSE PACK 10GM KRISTALOSE PACK 20GM lactulose soln 10gm/15ml 1 G lactulose soln 10gm/15ml 1 G lansoprazole cpdr 15mg 1 G lansoprazole cpdr 30mg 1 G LINZESS CAPS 145MCG LINZESS CAPS 290MCG LINZESS CAPS 72MCG loperamide hcl caps 2mg 1 G methscopolamine bromide tabs 2.5mg 1 G methscopolamine bromide tabs 5mg 1 G metoclopramide hcl inj 5mg/ml 1 G metoclopramide hcl soln 5mg/5ml 1 G metoclopramide hcl tabs 10mg 1 G metoclopramide hcl tabs 5mg 1 G metoclopramide odt tbdp 10mg 1 G metoclopramide odt tbdp 5mg 1 G misoprostol tabs 100mcg 1 G misoprostol tabs 200mcg 1 G MOTOFEN TABS 0.025MG; 1MG MOVIPREP SOLR 4.7GM; 100GM; 1.015GM; 5.9GM; 2.691GM; 7.5GM MYTESI TBEC 125MG nizatidine caps 150mg 1 G nizatidine caps 300mg 1 G nizatidine soln 15mg/ml 1 G nulev tbdp 0.125mg 1 G omeprazole/sodium bicarbonate caps 20mg; 1100mg 1 G omeprazole/sodium bicarbonate caps 40mg; 1100mg 1 G Página 37

39 omeprazole/sodium bicarbonate pack 20mg; 1680mg 1 G ST omeprazole/sodium bicarbonate pack 40mg; 1680mg 1 G ST omeprazole cpdr 10mg 1 G omeprazole cpdr 20mg 1 G omeprazole cpdr 40mg 1 G oscimin sr tb mg 1 G oscimin subl 0.125mg 1 G oscimin tabs 0.125mg 1 G oscimin tbdp 0.125mg 1 G pantoprazole sodium inj 40mg 1 G B/D pantoprazole sodium tbec 20mg 1 G pantoprazole sodium tbec 40mg 1 G PAREGORIC TINC 2MG/5ML PEG 3350/ELECTROLYTES SOLR 240GM; 2.98GM; 6.72GM; 5.84GM; 22.72GM peg-3350/electrolytes solr 236gm; 2.97gm; 6.74gm; 5.86gm; 1 G 22.74gm peg-3350/nacl/na bicarbonate/kcl solr 420gm; 1.48gm; 1 G 5.72gm; 11.2gm polyethylene glycol 3350 pack 0 1 G polyethylene glycol 3350 powd 0 1 G propantheline bromide tabs 15mg 1 G PROTONIX PACK 40MG QL (30 EA por 30 días) ST PYLERA CAPS 140MG; 125MG; 125MG rabeprazole sodium tbec 20mg 1 G ranitidine hcl caps 150mg 1 G ranitidine hcl caps 300mg 1 G ranitidine hcl inj 150mg/6ml 1 G ranitidine hcl inj 50mg/2ml 1 G ranitidine hcl syrp 75mg/5ml 1 G ranitidine hcl tabs 150mg 1 G ranitidine hcl tabs 300mg 1 G RELISTOR INJ 12MG/0.6ML RELISTOR INJ 12MG/0.6ML RELISTOR INJ 8MG/0.4ML sucralfate tabs 1gm 1 G SUPREP BOWEL PREP KIT SOLN 1.6GM/180ML; 3.13GM/180ML; 17.5GM/180ML symax-sl subl 0.125mg 1 G symax-sr tb mg 1 G trilyte solr 420gm; 1.48gm; 5.72gm; 11.2gm 1 G ursodiol caps 300mg 1 G ursodiol tabs 250mg 1 G ursodiol tabs 500mg 1 G VIMOVO TBEC 20MG; 375MG Página 38

40 VIMOVO TBEC 20MG; 500MG XENICAL CAPS 120MG PA Agentes genitourinarios alfuzosin hcl er tb24 10mg 1 G bethanechol chloride tabs 10mg 1 G bethanechol chloride tabs 25mg 1 G bethanechol chloride tabs 50mg 1 G bethanechol chloride tabs 5mg 1 G darifenacin hydrobromide er tb24 15mg 1 G darifenacin hydrobromide er tb24 7.5mg 1 G doxazosin mesylate tabs 1mg 1 G doxazosin mesylate tabs 2mg 1 G doxazosin mesylate tabs 8mg 1 G doxazosin tabs 4mg 1 G dutasteride/tamsulosin hydrochloride caps 0.5mg; 0.4mg 1 G dutasteride caps 0.5mg 1 G ELMIRON CAPS 100MG finasteride tabs 5mg 1 G flavoxate hcl tabs 100mg 1 G GELNIQUE GEL 10% GELNIQUE GEL 3% hyophen tabs 9mg; 0.12mg; 81.6mg; 10.8mg; 36.2mg 1 G # LITHOSTAT TABS 250MG MYRBETRIQ TB24 25MG MYRBETRIQ TB24 50MG oxybutynin chloride er tb24 10mg 1 G oxybutynin chloride er tb24 15mg 1 G oxybutynin chloride er tb24 5mg 1 G oxybutynin chloride syrp 5mg/5ml 1 G oxybutynin chloride tabs 5mg 1 G OXYTROL PTTW 3.9MG/24HR phenazopyridine hcl tabs 100mg 1 G phenazopyridine hcl tabs 200mg 1 G tamsulosin hcl caps 0.4mg 1 G terazosin hcl caps 10mg 1 G terazosin hcl caps 1mg 1 G terazosin hcl caps 2mg 1 G terazosin hcl caps 5mg 1 G tolterodine tartrate er cp24 2mg 1 G tolterodine tartrate er cp24 4mg 1 G tolterodine tartrate tabs 1mg 1 G tolterodine tartrate tabs 2mg 1 G TOVIAZ TB24 4MG TOVIAZ TB24 8MG trospium chloride er cp24 60mg 1 G trospium chloride tabs 20mg 1 G Página 39

41 urin d/s tabs 0.12mg; 81.6mg; 10.8mg; 36.2mg; 40.8mg 1 G urophen mb tabs 9mg; 0.12mg; 81.6mg; 10.8mg; 36.2mg 1 G # VIAGRA TABS 100MG 1 B QL (4 EA por 30 días) # VIAGRA TABS 25MG 1 B QL (4 EA por 30 días) # VIAGRA TABS 50MG 1 B QL (4 EA por 30 días) # Agentes hormonales, estimulación/sustitución/modificación (hipófisis) chorionic gonadotropin inj 10000unit 1 G PA desmopressin acetate inj 4mcg/ml 1 G desmopressin acetate soln 0.01% 1 G desmopressin acetate soln 0.01% 1 G desmopressin acetate soln 0.01% 1 G desmopressin acetate soln 0.01% 1 G desmopressin acetate tabs 0.1mg 1 G desmopressin acetate tabs 0.2mg 1 G EGRIFTA INJ 1MG EGRIFTA INJ 2MG GENOTROPIN MINIQUICK INJ 0.2MG PA GENOTROPIN MINIQUICK INJ 0.4MG PA GENOTROPIN MINIQUICK INJ 0.6MG PA GENOTROPIN MINIQUICK INJ 0.8MG PA GENOTROPIN MINIQUICK INJ 1.2MG PA GENOTROPIN MINIQUICK INJ 1.4MG PA GENOTROPIN MINIQUICK INJ 1.6MG PA GENOTROPIN MINIQUICK INJ 1.8MG PA GENOTROPIN MINIQUICK INJ 1MG PA GENOTROPIN MINIQUICK INJ 2MG PA GENOTROPIN INJ 12MG PA GENOTROPIN INJ 5MG PA H.P. ACTHAR INJ 80UNIT/ML B/D HUMATROPE COMBO PACK INJ 5MG PA HUMATROPE INJ 12MG PA HUMATROPE INJ 24MG PA HUMATROPE INJ 5MG PA HUMATROPE INJ 6MG PA INCRELEX INJ 40MG/4ML NORDITROPIN FLEXPRO INJ 10MG/1.5ML PA NORDITROPIN FLEXPRO INJ 15MG/1.5ML PA NORDITROPIN FLEXPRO INJ 30MG/3ML PA NORDITROPIN FLEXPRO INJ 5MG/1.5ML PA NOVAREL INJ 10000UNIT PA NUTROPIN AQ NUSPIN 5 INJ 5MG/2ML PA NUTROPIN AQ PEN INJ 10MG/2ML PA Página 40

42 NUTROPIN AQ PEN INJ 20MG/2ML PA OMNITROPE INJ 10MG/1.5ML PA OMNITROPE INJ 5.8MG PA OMNITROPE INJ 5MG/1.5ML PA PREGNYL W/DILUENT BENZYL ALCOHOL/NACL INJ PA 10000UNIT SAIZEN CLICK.EASY INJ 8.8MG PA SAIZEN INJ 5MG PA SAIZEN INJ 8.8MG PA SEROSTIM INJ 4MG PA SEROSTIM INJ 5MG PA SEROSTIM INJ 6MG PA STIMATE SOLN 1.5MG/ML TEV-TROPIN INJ 5MG PA ZOMACTON INJ 10MG PA ZOMACTON INJ 5MG PA ZORBTIVE INJ 8.8MG PA Agentes hormonales, estimulación/sustitución/modificación (hormonas sexuales/modificadores) ALORA PTTW 0.025MG/24HR ALORA PTTW 0.05MG/24HR ALORA PTTW 0.075MG/24HR ALORA PTTW 0.1MG/24HR altavera tabs 0.03mg; 0.15mg 1 G alyacen 1/35 tabs 35mcg; 1mg 1 G alyacen 7/7/7 tabs 0; 0 1 G amabelz tabs 0.5mg; 0.1mg 1 G amabelz tabs 1mg; 0.5mg 1 G amethia lo tabs 0; 0 1 G amethia tabs 0; 0 1 G amethyst tabs 20mcg; 90mcg 1 G ANADROL-50 TABS 50MG ANDRODERM PT24 2MG/24HR ANDRODERM PT24 4MG/24HR ANDROGEL PUMP GEL 1.62% ANDROGEL GEL 20.25MG/1.25GM ANDROGEL GEL 40.5MG/2.5GM ANDROXY TABS 10MG ANGELIQ TABS 0.25MG; 0.5MG ANGELIQ TABS 0.5MG; 1MG apri tabs 0.15mg; 30mcg 1 G aranelle tabs 0; 0 1 G ashlyna tabs 0; 0 1 G aubra tabs 20mcg; 0.1mg 1 G AVEED INJ 750MG/3ML aviane tabs 20mcg; 0.1mg 1 G Página 41

43 AXIRON SOLN 30MG/ACT azurette tabs 0; 0 1 G balziva tabs 35mcg; 0.4mg 1 G bekyree tabs 0; 0 1 G BEYAZ TABS 3MG; 0.02MG; 0.451MG blisovi 24 fe tabs 20mcg; 75mg; 1mg 1 G blisovi fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 G blisovi fe 1/20 tabs 20mcg; 75mg; 1mg 1 G briellyn tabs 35mcg; 0.4mg 1 G camila tabs 0.35mg 1 G camrese lo tabs 0; 0 1 G camrese tabs 0; 0 1 G caziant tabs 0; 0 1 G cesia tabs 0; 0 1 G chateal tabs 0.03mg; 0.15mg 1 G CLIMARA PRO PTWK 0.045MG/DAY; 0.015MG/DAY COMBIPATCH PTTW 0.05MG/DAY; 0.14MG/DAY COMBIPATCH PTTW 0.05MG/DAY; 0.25MG/DAY CRINONE GEL 4% PA CRINONE GEL 8% PA cryselle-28 tabs 30mcg; 0.3mg 1 G cyclafem 1/35 tabs 35mcg; 1mg 1 G cyclafem 7/7/7 tabs 0; 0 1 G cyred tabs 0.15mg; 30mcg 1 G danazol caps 100mg 1 G danazol caps 200mg 1 G danazol caps 50mg 1 G dasetta 1/35 tabs 35mcg; 1mg 1 G dasetta 7/7/7 tabs 0; 0 1 G daysee tabs 0; 0 1 G deblitane tabs 0.35mg 1 G delyla tabs 20mcg; 0.1mg 1 G DEPO-ESTRADIOL INJ 5MG/ML DEPO-PROVERA INJ 400MG/ML B/D DEPO-SUBQ PROVERA 104 INJ 104MG/0.65ML desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg 1 G desogestrel/ethinyl estradiol tabs 0; 0 1 G DIVIGEL GEL 0.25MG/0.25GM DIVIGEL GEL 0.5MG/0.5GM DIVIGEL GEL 1MG/GM drospirenone/ethinyl estradiol/levomefolate calcium tabs 3mg; 1 G 0.02mg; 0.451mg drospirenone/ethinyl estradiol tabs 3mg; 0.02mg 1 G drospirenone/ethinyl estradiol tabs 3mg; 0.03mg 1 G DUAVEE TABS 20MG; 0.45MG ELESTRIN GEL 0.06% Página 42

44 elinest tabs 30mcg; 0.3mg 1 G emoquette tabs 0.15mg; 30mcg 1 G enpresse-28 tabs 0; 0 1 G enskyce tabs 0.15mg; 30mcg 1 G errin tabs 0.35mg 1 G estarylla tabs 35mcg; 0.25mg 1 G ESTRACE CREA 0.1MG/GM estradiol valerate inj 10mg/ml 1 G estradiol valerate inj 20mg/ml 1 G estradiol valerate inj 40mg/ml 1 G estradiol/norethindrone acetate tabs 0.5mg; 0.1mg 1 G estradiol/norethindrone acetate tabs 1mg; 0.5mg 1 G estradiol pttw 0.025mg/24hr 1 G estradiol pttw mg/24hr 1 G estradiol pttw 0.05mg/24hr 1 G estradiol pttw 0.075mg/24hr 1 G estradiol pttw 0.1mg/24hr 1 G estradiol ptwk 0.025mg/24hr 1 G estradiol ptwk 0.05mg/24hr 1 G estradiol ptwk 0.06mg/24hr 1 G estradiol ptwk 0.075mg/24hr 1 G estradiol ptwk 0.1mg/24hr 1 G estradiol ptwk 37.5mcg/24hr 1 G estradiol tabs 0.5mg 1 G estradiol tabs 1mg 1 G estradiol tabs 2mg 1 G ESTRING RING 2MG ESTROGEL GEL 0.06% 1 B estropipate tabs 0.75mg 1 G estropipate tabs 1.5mg 1 G estropipate tabs 3mg 1 G ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg 1 G EVAMIST SOLN 1.53MG/SPRAY falmina tabs 20mcg; 0.1mg 1 G fayosim tabs 0; 0 1 G FEMRING RING 0.05MG/24HR FEMRING RING 0.1MG/24HR femynor tabs 35mcg; 0.25mg 1 G fyavolv tabs 2.5mcg; 0.5mg 1 G fyavolv tabs 5mcg; 1mg 1 G GENERESS FE CHEW 25MCG; 75MG; 0.8MG gianvi tabs 3mg; 0.02mg 1 G gildagia tabs 35mcg; 0.4mg 1 G gildess 1.5/30 tabs 30mcg; 1.5mg 1 G gildess 1/20 tabs 20mcg; 1mg 1 G gildess 24 fe tabs 20mcg; 75mg; 1mg 1 G Página 43

45 gildess fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 G gildess fe 1/20 tabs 20mcg; 75mg; 1mg 1 G heather tabs 0.35mg 1 G hydroxyprogesterone caproate inj 1.25gm/5ml introvale tabs 0.03mg; 0.15mg 1 G jencycla tabs 0.35mg 1 G jevantique lo tabs 2.5mcg; 0.5mg 1 G jinteli tabs 5mcg; 1mg 1 G jolessa tabs 0.03mg; 0.15mg 1 G jolivette tabs 0.35mg 1 G juleber tabs 0.15mg; 30mcg 1 G junel 1.5/30 tabs 30mcg; 1.5mg 1 G junel 1/20 tabs 20mcg; 1mg 1 G junel fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 G junel fe 1/20 tabs 20mcg; 75mg; 1mg 1 G junel fe 24 tabs 20mcg; 75mg; 1mg 1 G kaitlib fe chew 25mcg; 75mg; 0.8mg 1 G kariva tabs 0; 0 1 G kelnor 1/35 tabs 35mcg; 1mg 1 G kimidess tabs 0; 0 1 G kurvelo tabs 0.03mg; 0.15mg 1 G larin 1.5/30 tabs 30mcg; 1.5mg 1 G larin 1/20 tabs 20mcg; 1mg 1 G larin 24 fe tabs 20mcg; 75mg; 1mg 1 G larin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 G larin fe 1/20 tabs 20mcg; 75mg; 1mg 1 G larissia tabs 20mcg; 0.1mg 1 G layolis fe chew 25mcg; 75mg; 0.8mg 1 G leena tabs 0; 0 1 G lessina tabs 20mcg; 0.1mg 1 G levonest tabs 0; 0 1 G levonorgestrel and ethinyl estradiol tabs 0; 0 1 G levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg 1 G levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg 1 G levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg 1 G levonorgestrel/ethinyl estradiol tabs 0; 0 1 G levonorgestrel/ethinyl estradiol tabs 0; 0 1 G levonorgestrel/ethinyl estradiol tabs 20mcg; 0.1mg 1 G levonorgestrel tabs 0.75mg 1 G levonorgestrel tabs 1.5mg 1 G levora 0.15/30-28 tabs 0.03mg; 0.15mg 1 G LO LOESTRIN FE TABS 10MCG; 75MG; 1MG LO MINASTRIN FE THPK 10MCG; 75MG; 1MG lomedia 24 fe tabs 20mcg; 75mg; 1mg 1 G lopreeza tabs 0.5mg; 0.1mg 1 G lopreeza tabs 1mg; 0.5mg 1 G Página 44

46 loryna tabs 3mg; 0.02mg 1 G low-ogestrel tabs 30mcg; 0.3mg 1 G lutera tabs 20mcg; 0.1mg 1 G lyza tabs 0.35mg 1 G MAKENA INJ 250MG/ML marlissa tabs 0.03mg; 0.15mg 1 G medroxyprogesterone acetate inj 150mg/ml 1 G medroxyprogesterone acetate inj 150mg/ml 1 G medroxyprogesterone acetate inj 150mg/ml 1 G medroxyprogesterone acetate tabs 10mg 1 G medroxyprogesterone acetate tabs 2.5mg 1 G medroxyprogesterone acetate tabs 5mg 1 G megestrol acetate susp 40mg/ml 1 G megestrol acetate susp 625mg/5ml 1 G megestrol acetate tabs 20mg 1 G megestrol acetate tabs 40mg 1 G MENEST TABS 0.3MG MENEST TABS 0.625MG MENEST TABS 1.25MG MENEST TABS 2.5MG MENOSTAR PTWK 14MCG/24HR METHITEST TABS 10MG methyltestosterone caps 10mg 1 G mibelas 24 fe chew 20mcg; 75mg; 1mg 1 G microgestin 1.5/30 tabs 30mcg; 1.5mg 1 G microgestin 1/20 tabs 20mcg; 1mg 1 G microgestin 24 fe tabs 20mcg; 75mg; 1mg 1 G microgestin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 G microgestin fe tabs 20mcg; 75mg; 1mg 1 G mimvey lo tabs 0.5mg; 0.1mg 1 G mimvey tabs 1mg; 0.5mg 1 G MINASTRIN 24 FE CHEW 20MCG; 75MG; 1MG MINIVELLE PTTW 0.025MG/24HR MINIVELLE PTTW MG/24HR MINIVELLE PTTW 0.05MG/24HR MINIVELLE PTTW 0.075MG/24HR MINIVELLE PTTW 0.1MG/24HR mono-linyah tabs 35mcg; 0.25mg 1 G mononessa tabs 35mcg; 0.25mg 1 G myzilra tabs 0; 0 1 G NATAZIA TABS 0; 0 NATESTO GEL 5.5MG/ACT necon 0.5/35-28 tabs 35mcg; 0.5mg 1 G necon 1/35 tabs 35mcg; 1mg 1 G necon 1/50-28 tabs 50mcg; 1mg 1 G necon 10/11-28 tabs 35mcg; 0 1 G Página 45

47 necon 7/7/7 tabs 0; 0 1 G nikki tabs 3mg; 0.02mg 1 G nora-be tabs 0.35mg 1 G norethindrone & ethinyl estradiol ferrous fumarate chew 25mcg; 75mg; 0.8mg 1 G norethindrone acetate/ethinyl estradiol/ferrous fumarate chew 1 G 20mcg; 75mg; 1mg norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs 1 G 20mcg; 75mg; 1mg norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs 1 G 20mcg; 75mg; 1mg norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg 1 G norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg 1 G norethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg 1 G norethindrone acetate tabs 5mg 1 G norethindrone/ethinyl estradiol/ferrous fumarate chew 35mcg; 1 G 0; 0.4mg norethindrone tabs 0.35mg 1 G norgestimate/ethinyl estradiol tabs 0; 0 1 G norgestimate/ethinyl estradiol tabs 0; 0 1 G norgestimate/ethinyl estradiol tabs 35mcg; 0.25mg 1 G norlyroc tabs 0.35mg 1 G nortrel 0.5/35 (28) tabs 35mcg; 0.5mg 1 G nortrel 1/35 tabs 35mcg; 1mg 1 G nortrel 1/35 tabs 35mcg; 1mg 1 G nortrel 7/7/7 tabs 0; 0 1 G NUVARING RING 0.015MG/24HR; 0.12MG/24HR ocella tabs 3mg; 0.03mg 1 G ogestrel tabs 50mcg; 0.5mg 1 G orsythia tabs 20mcg; 0.1mg 1 G ortho-est tabs 0.75mg 1 G ortho-est tabs 1.5mg 1 G oxandrolone tabs 10mg 1 G oxandrolone tabs 2.5mg 1 G philith tabs 35mcg; 0.4mg 1 G pimtrea tabs 0; 0 1 G pirmella 1/35 tabs 35mcg; 1mg 1 G pirmella 7/7/7 tabs 0; 0 1 G portia-28 tabs 0.03mg; 0.15mg 1 G PREFEST TABS 0; 0 PREMARIN CREA 0.625MG/GM PREMARIN INJ 25MG PREMARIN TABS 0.3MG PREMARIN TABS 0.45MG PREMARIN TABS 0.625MG PREMARIN TABS 0.9MG Página 46

48 PREMARIN TABS 1.25MG PREMPHASE TABS 0.625MG; 5MG PREMPRO TABS 0.3MG; 1.5MG PREMPRO TABS 0.45MG; 1.5MG PREMPRO TABS 0.625MG; 2.5MG PREMPRO TABS 0.625MG; 5MG previfem tabs 35mcg; 0.25mg 1 G progesterone caps 100mg 1 G progesterone caps 200mg 1 G QUARTETTE TABS 0; 0 quasense tabs 0.03mg; 0.15mg 1 G raloxifene hydrochloride tabs 60mg 1 G QL (30 EA por 30 días) reclipsen tabs 0.15mg; 30mcg 1 G rivelsa tabs 0; 0 1 G SAFYRAL TABS 3MG; 0.03MG; 0.451MG setlakin tabs 0.03mg; 0.15mg 1 G sharobel tabs 0.35mg 1 G solia tabs 0.15mg; 30mcg 1 G sprintec 28 tabs 35mcg; 0.25mg 1 G sronyx tabs 20mcg; 0.1mg 1 G STRIANT MISC 30MG syeda tabs 3mg; 0.03mg 1 G tarina fe 1/20 tabs 20mcg; 75mg; 1mg 1 G testosterone cypionate inj 100mg/ml 1 G testosterone cypionate inj 200mg/ml 1 G testosterone enanthate inj 200mg/ml 1 G testosterone pump gel 1% 1 G testosterone gel 10mg/act 1 G testosterone gel 25mg/2.5gm 1 G testosterone gel 50mg/5gm 1 G testosterone soln 30mg/act 1 G tilia fe tabs 0; 75mg; 1mg 1 G tri-estarylla tabs 0; 0 1 G tri-legest fe tabs 0; 75mg; 1mg 1 G tri-linyah tabs 0; 0 1 G tri-lo-estarylla tabs 0; 0 1 G tri-lo-marzia tabs 0; 0 1 G tri-lo-sprintec tabs 0; 0 1 G tri-previfem tabs 0; 0 1 G tri-sprintec tabs 0; 0 1 G trinessa lo tabs 0; 0 1 G trinessa tabs 0; 0 1 G trivora-28 tabs 0; 0 1 G velivet tabs 0; 0 1 G vestura tabs 3mg; 0.02mg 1 G Página 47

49 vienva tabs 20mcg; 0.1mg 1 G viorele tabs 0; 0 1 G vyfemla tabs 35mcg; 0.4mg 1 G wera tabs 35mcg; 0.5mg 1 G wymzya fe chew 35mcg; 0; 0.4mg 1 G xulane ptwk 35mcg/24hr; 150mcg/24hr 1 G yuvafem tabs 10mcg 1 G zarah tabs 3mg; 0.03mg 1 G zenchent fe chew 35mcg; 0; 0.4mg 1 G zenchent tabs 35mcg; 0.4mg 1 G zovia 1/35e tabs 35mcg; 1mg 1 G zovia 1/50e tabs 50mcg; 1mg 1 G Agentes hormonales, estimulación/sustitución/modificación (suprarrenal) a-hydrocort inj 100mg 1 G a-methapred inj 40mg 1 G HI ala-cort crea 1% 1 G alclometasone dipropionate crea 0.05% 1 G alclometasone dipropionate oint 0.05% 1 G amcinonide crea 0.1% 1 G amcinonide lotn 0.1% 1 G amcinonide oint 0.1% 1 G anucort-hc supp 25mg 1 G # APEXICON E CREA 0.05% augmented betamethasone dipropionate crea 0.05% 1 G augmented betamethasone dipropionate gel 0.05% 1 G augmented betamethasone dipropionate lotn 0.05% 1 G augmented betamethasone dipropionate oint 0.05% 1 G baycadron elix 0.5mg/5ml 1 G betamethasone dipropionate crea 0.05% 1 G betamethasone dipropionate lotn 0.05% 1 G betamethasone dipropionate oint 0.05% 1 G betamethasone valerate crea 0.1% 1 G betamethasone valerate foam 0.12% 1 G betamethasone valerate lotn 0.1% 1 G betamethasone valerate oint 0.1% 1 G CAPEX SHAM 0.01% clobetasol propionate e crea 0.05% 1 G clobetasol propionate emollient foam 0.05% 1 G clobetasol propionate crea 0.05% 1 G clobetasol propionate foam 0.05% 1 G clobetasol propionate foam 0.05% 1 G clobetasol propionate gel 0.05% 1 G clobetasol propionate liqd 0.05% 1 G clobetasol propionate lotn 0.05% 1 G clobetasol propionate oint 0.05% 1 G Página 48

50 clobetasol propionate sham 0.05% 1 G clobetasol propionate soln 0.05% 1 G clocortolone pivalate pump crea 0.1% 1 G clocortolone pivalate crea 0.1% 1 G clodan sham 0.05% 1 G CORDRAN TAPE TAPE 4MCG/SQCM CORDRAN TAPE 4MCG/SQCM cormax scalp application soln 0.05% 1 G CORTIFOAM FOAM 10% cortisone acetate tabs 25mg 1 G DEPO-MEDROL INJ 20MG/ML DESONATE GEL 0.05% desonide crea 0.05% 1 G desonide lotn 0.05% 1 G desonide oint 0.05% 1 G desoximetasone crea 0.05% 1 G ST desoximetasone crea 0.25% 1 G ST desoximetasone gel 0.05% 1 G ST desoximetasone oint 0.05% 1 G ST desoximetasone oint 0.25% 1 G ST dexamethasone intensol conc 1mg/ml 1 G dexamethasone sodium phosphate inj 100mg/10ml 1 G dexamethasone sodium phosphate inj 10mg/ml 1 G dexamethasone sodium phosphate inj 10mg/ml 1 G dexamethasone sodium phosphate inj 120mg/30ml 1 G dexamethasone sodium phosphate inj 20mg/5ml 1 G dexamethasone sodium phosphate inj 4mg/ml 1 G dexamethasone elix 0.5mg/5ml 1 G dexamethasone soln 0.5mg/5ml 1 G dexamethasone tabs 0.5mg 1 G dexamethasone tabs 0.75mg 1 G dexamethasone tabs 1.5mg 1 G dexamethasone tabs 1mg 1 G dexamethasone tabs 2mg 1 G dexamethasone tabs 4mg 1 G dexamethasone tabs 6mg 1 G diflorasone diacetate crea 0.05% 1 G diflorasone diacetate oint 0.05% 1 G fludrocortisone acetate tabs 0.1mg 1 G fluocinolone acetonide body oil 0.01% 1 G fluocinolone acetonide scalp oil 0.01% 1 G fluocinolone acetonide crea 0.01% 1 G fluocinolone acetonide crea 0.025% 1 G fluocinolone acetonide oint 0.025% 1 G fluocinolone acetonide soln 0.01% 1 G fluocinonide emulsified base crea 0.05% 1 G Página 49

51 fluocinonide crea 0.05% 1 G fluocinonide crea 0.1% 1 G fluocinonide gel 0.05% 1 G fluocinonide oint 0.05% 1 G fluocinonide soln 0.05% 1 G flurandrenolide crea 0.05% 1 G flurandrenolide lotn 0.05% 1 G fluticasone propionate crea 0.05% 1 G fluticasone propionate lotn 0.05% 1 G fluticasone propionate oint 0.005% 1 G halobetasol propionate crea 0.05% 1 G halobetasol propionate oint 0.05% 1 G HALOG CREA 0.1% HALOG OINT 0.1% hemmorex-hc supp 25mg 1 G # hemmorex-hc supp 30mg 1 G # hydrocortisone acetate/pramoxine crea 1%; 1% 1 G # hydrocortisone acetate/pramoxine crea 2.5%; 1% 1 G # hydrocortisone acetate supp 25mg 1 G # hydrocortisone acetate supp 30mg 1 G # hydrocortisone butyrate (lipid) crea 0.1% 1 G hydrocortisone butyrate (lipophilic) crea 0.1% 1 G hydrocortisone butyrate crea 0.1% 1 G hydrocortisone butyrate oint 0.1% 1 G hydrocortisone butyrate soln 0.1% 1 G hydrocortisone valerate crea 0.2% 1 G hydrocortisone valerate oint 0.2% 1 G hydrocortisone crea 1% 1 G hydrocortisone crea 2.5% 1 G hydrocortisone crea 1% 1 G hydrocortisone crea 2.5% 1 G hydrocortisone lotn 2.5% 1 G hydrocortisone oint 1% 1 G hydrocortisone oint 2.5% 1 G hydrocortisone tabs 10mg 1 G hydrocortisone tabs 20mg 1 G hydrocortisone tabs 5mg 1 G LOCOID LOTN 0.1% lokara lotn 0.05% 1 G MEDROL TABS 2MG methylprednisolone acetate inj 40mg/ml 1 G methylprednisolone acetate inj 80mg/ml 1 G methylprednisolone dose pack tbpk 4mg 1 G methylprednisolone sodiumsuccinate inj 1000mg 1 G HI methylprednisolone sodiumsuccinate inj 125mg 1 G HI methylprednisolone sodiumsuccinate inj 40mg 1 G HI Página 50

52 methylprednisolone tabs 16mg 1 G methylprednisolone tabs 32mg 1 G methylprednisolone tabs 4mg 1 G methylprednisolone tabs 8mg 1 G MILLIPRED TABS 5MG mometasone furoate crea 0.1% 1 G mometasone furoate oint 0.1% 1 G mometasone furoate soln 0.1% 1 G nolix lotn 0.05% 1 G pramcort crea 1%; 1% 1 G # prednicarbate crea 0.1% 1 G prednicarbate oint 0.1% 1 G prednisolone sodium phosphate odt tbdp 10mg 1 G prednisolone sodium phosphate odt tbdp 15mg 1 G prednisolone sodium phosphate odt tbdp 30mg 1 G prednisolone sodium phosphate soln 10mg/5ml 1 G prednisolone sodium phosphate soln 15mg/5ml 1 G prednisolone sodium phosphate soln 20mg/5ml 1 G prednisolone sodium phosphate soln 25mg/5ml 1 G prednisolone sodium phosphate soln 5mg/5ml 1 G prednisolone soln 15mg/5ml 1 G prednisone intensol conc 5mg/ml 1 G prednisone soln 5mg/5ml 1 G prednisone tabs 10mg 1 G prednisone tabs 1mg 1 G prednisone tabs 2.5mg 1 G prednisone tabs 20mg 1 G prednisone tabs 50mg 1 G prednisone tabs 5mg 1 G prednisone tbpk 10mg 1 G prednisone tbpk 10mg 1 G prednisone tbpk 5mg 1 G prednisone tbpk 5mg 1 G procto-med hc crea 2.5% 1 G procto-pak crea 1% 1 G PROCTOFOAM HC FOAM 1%; 1% 1 B proctosol hc crea 2.5% 1 G proctozone-hc crea 2.5% 1 G RAYOS TBEC 1MG RAYOS TBEC 2MG RAYOS TBEC 5MG SOLU-CORTEF INJ 1000MG HI SOLU-CORTEF INJ 100MG HI SOLU-CORTEF INJ 250MG HI SOLU-CORTEF INJ 500MG HI SOLU-MEDROL INJ 2GM HI Página 51

53 TACLONEX SUSP 0.064%; 0.005% texacort soln 2.5% 1 G TOPICORT LIQD 0.25% triamcinolone acetonide aers 0.147mg/gm 1 G triamcinolone acetonide crea 0.025% 1 G triamcinolone acetonide crea 0.1% 1 G triamcinolone acetonide crea 0.5% 1 G triamcinolone acetonide lotn 0.025% 1 G triamcinolone acetonide lotn 0.1% 1 G triamcinolone acetonide oint 0.025% 1 G triamcinolone acetonide oint 0.1% 1 G triamcinolone acetonide oint 0.5% 1 G trianex oint 0.05% triderm crea 0.1% 1 G UCERIS FOAM 2MG/ACT UCERIS TB24 9MG VERDESO FOAM 0.05% Agentes hormonales, estimulación/sustitución/modificación (tiroides) ARMOUR THYROID TABS 120MG ARMOUR THYROID TABS 15MG ARMOUR THYROID TABS 180MG ARMOUR THYROID TABS 240MG ARMOUR THYROID TABS 300MG ARMOUR THYROID TABS 30MG ARMOUR THYROID TABS 60MG ARMOUR THYROID TABS 90MG levothyroxine sodium inj 100mcg 1 G levothyroxine sodium inj 200mcg 1 G B/D levothyroxine sodium inj 500mcg 1 G B/D levothyroxine sodium tabs 100mcg 1 G levothyroxine sodium tabs 112mcg 1 G levothyroxine sodium tabs 125mcg 1 G levothyroxine sodium tabs 137mcg 1 G levothyroxine sodium tabs 150mcg 1 G levothyroxine sodium tabs 175mcg 1 G levothyroxine sodium tabs 200mcg 1 G levothyroxine sodium tabs 25mcg 1 G levothyroxine sodium tabs 300mcg 1 G levothyroxine sodium tabs 50mcg 1 G levothyroxine sodium tabs 75mcg 1 G levothyroxine sodium tabs 88mcg 1 G levoxyl tabs 100mcg 1 G levoxyl tabs 112mcg 1 G levoxyl tabs 125mcg 1 G levoxyl tabs 137mcg 1 G Página 52

54 levoxyl tabs 150mcg 1 G levoxyl tabs 175mcg 1 G levoxyl tabs 200mcg 1 G levoxyl tabs 25mcg 1 G levoxyl tabs 50mcg 1 G levoxyl tabs 75mcg 1 G levoxyl tabs 88mcg 1 G liothyronine sodium inj 10mcg/ml 1 G liothyronine sodium tabs 25mcg 1 G liothyronine sodium tabs 50mcg 1 G liothyronine sodium tabs 5mcg 1 G np thyroid 15 tabs 15mg 1 G np thyroid 30 tabs 30mg 1 G np thyroid 60 tabs 60mg 1 G np thyroid 90 tabs 90mg 1 G np thyroid tabs 120mg 1 G np thyroid tabs 30mg 1 G np thyroid tabs 60mg 1 G np thyroid tabs 90mg 1 G THYROLAR-1/2 TABS 30MG THYROLAR-1/4 TABS 15MG THYROLAR-1 TABS 60MG THYROLAR-2 TABS 120MG THYROLAR-3 TABS 180MG TIROSINT CAPS 100MCG TIROSINT CAPS 112MCG TIROSINT CAPS 125MCG TIROSINT CAPS 137MCG TIROSINT CAPS 13MCG TIROSINT CAPS 150MCG TIROSINT CAPS 25MCG TIROSINT CAPS 50MCG TIROSINT CAPS 75MCG TIROSINT CAPS 88MCG unithroid tabs 100mcg 1 G unithroid tabs 112mcg 1 G unithroid tabs 125mcg 1 G unithroid tabs 137mcg 1 G unithroid tabs 150mcg 1 G unithroid tabs 175mcg 1 G unithroid tabs 200mcg 1 G unithroid tabs 25mcg 1 G unithroid tabs 300mcg 1 G unithroid tabs 50mcg 1 G unithroid tabs 75mcg 1 G unithroid tabs 88mcg 1 G Página 53

55 Agentes hormonales, inhibidor (hipófisis) cabergoline tabs 0.5mg 1 G ELIGARD INJ 22.5MG B/D ELIGARD INJ 30MG B/D ELIGARD INJ 45MG B/D ELIGARD INJ 7.5MG B/D FIRMAGON INJ 120MG B/D FIRMAGON INJ 80MG B/D leuprolide acetate inj 1mg/0.2ml 1 G B/D LUPANETA PACK KIT 11.25MG; 5MG B/D LUPANETA PACK KIT 3.75MG; 5MG B/D LUPRON DEPOT (1-MONTH) INJ 3.75MG B/D LUPRON DEPOT (1-MONTH) INJ 7.5MG B/D LUPRON DEPOT (3-MONTH) INJ 11.25MG B/D LUPRON DEPOT (3-MONTH) INJ 22.5MG B/D LUPRON DEPOT (4-MONTH) INJ 30MG B/D LUPRON DEPOT (6-MONTH) INJ 45MG B/D LUPRON DEPOT-PED (1-MONTH) INJ 11.25MG B/D LUPRON DEPOT-PED (1-MONTH) INJ 15MG B/D LUPRON DEPOT-PED (1-MONTH) INJ 7.5MG B/D LUPRON DEPOT-PED (3-MONTH) INJ 11.25MG B/D LUPRON DEPOT-PED (3-MONTH) INJ 30MG B/D octreotide acetate inj 1000mcg/ml 1 G PA octreotide acetate inj 100mcg/ml 1 G PA octreotide acetate inj 200mcg/ml 1 G PA octreotide acetate inj 500mcg/ml PA octreotide acetate inj 50mcg/ml 1 G PA SANDOSTATIN LAR DEPOT INJ 10MG PA SANDOSTATIN LAR DEPOT INJ 20MG PA SANDOSTATIN LAR DEPOT INJ 30MG PA SIGNIFOR LAR INJ 20MG PA SIGNIFOR LAR INJ 40MG PA SIGNIFOR LAR INJ 60MG PA SIGNIFOR INJ 0.3MG/ML SIGNIFOR INJ 0.6MG/ML SIGNIFOR INJ 0.9MG/ML SOMATULINE DEPOT INJ 120MG/0.5ML PA SOMATULINE DEPOT INJ 60MG/0.2ML PA SOMATULINE DEPOT INJ 90MG/0.3ML PA SOMAVERT INJ 10MG B/D SOMAVERT INJ 15MG B/D SOMAVERT INJ 20MG B/D SOMAVERT INJ 25MG B/D SOMAVERT INJ 30MG B/D SYNAREL SOLN 2MG/ML TRELSTAR MIXJECT INJ 11.25MG B/D Página 54

56 TRELSTAR MIXJECT INJ 22.5MG B/D TRELSTAR MIXJECT INJ 3.75MG B/D TRELSTAR INJ 11.25MG B/D TRELSTAR INJ 3.75MG B/D Agentes hormonales, inhibidor (suprarrenal) LYSODREN TABS 500MG Agentes hormonales, inhibidor (tiroides) methimazole tabs 10mg 1 G methimazole tabs 5mg 1 G propylthiouracil tabs 50mg 1 G Agentes inmunológicos ACTEMRA INJ 162MG/0.9ML PA ACTEMRA INJ 200MG/10ML B/D ACTEMRA INJ 400MG/20ML B/D ACTEMRA INJ 80MG/4ML B/D ACTHIB INJ 0 ACTIMMUNE INJ UNIT/0.5ML PA ADACEL INJ 15.5MCG/0.5ML; 2LF/0.5ML; 5LF/0.5ML ARCALYST INJ 220MG PA ASTAGRAF XL CP24 0.5MG PA ASTAGRAF XL CP24 1MG PA ASTAGRAF XL CP24 5MG PA ATGAM INJ 50MG/ML PA AZASAN TABS 100MG PA AZASAN TABS 75MG PA azathioprine inj 100mg 1 G PA azathioprine tabs 50mg 1 G PA BCG VACCINE INJ 0 B/D BENLYSTA INJ 120MG PA BENLYSTA INJ 400MG QL (9 EA por 28 días) PA BERINERT INJ 500UNIT B/D BEXSERO INJ 0 BIVIGAM INJ 10GM/100ML B/D BIVIGAM INJ 5GM/50ML B/D BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML; 5LF/0.5ML BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML; 5LF/0.5ML CARIMUNE NANOFILTERED INJ 6GM B/D CERVARIX INJ 0 CIMZIA INJ 200MG/ML PA CIMZIA INJ 200MG PA CINRYZE INJ 500UNIT B/D COMVAX INJ 7.5MCG/0.5ML; 5MCG/0.5ML CUVITRU INJ 1GM/5ML B/D CUVITRU INJ 2GM/10ML B/D Página 55

57 CUVITRU INJ 4GM/20ML B/D cyclosporine modified caps 100mg 1 G PA cyclosporine modified caps 25mg 1 G PA cyclosporine modified caps 50mg 1 G PA cyclosporine modified soln 100mg/ml 1 G PA cyclosporine caps 100mg 1 G PA cyclosporine caps 25mg 1 G PA cyclosporine inj 50mg/ml 1 G PA DAPTACEL INJ 10MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC INJ 25LFU/0.5ML; 5LFU/0.5ML ENBREL SURECLICK INJ 50MG/ML PA ENBREL INJ 25MG/0.5ML PA ENBREL INJ 25MG PA ENBREL INJ 50MG/ML PA ENGERIX-B INJ 10MCG/0.5ML B/D ENGERIX-B INJ 10MCG/0.5ML B/D ENGERIX-B INJ 20MCG/ML B/D ENVARSUS XR TB MG PA ENVARSUS XR TB24 1MG PA ENVARSUS XR TB24 4MG PA FIRAZYR INJ 30MG/3ML FLEBOGAMMA DIF INJ 0.5GM/10ML B/D FLEBOGAMMA DIF INJ 10% B/D FLEBOGAMMA DIF INJ 10% B/D FLEBOGAMMA DIF INJ 10% B/D FLEBOGAMMA DIF INJ 10GM/200ML B/D FLEBOGAMMA DIF INJ 2.5GM/50ML B/D FLEBOGAMMA DIF INJ 20GM/400ML B/D FLEBOGAMMA DIF INJ 5GM/100ML B/D GAMASTAN S/D INJ 0 B/D GAMASTAN S/D INJ 0 B/D GAMMAGARD LIQUID INJ 2.5GM/25ML B/D GAMMAGARD LIQUID INJ 30GM/300ML B/D GAMMAKED INJ 10GM/100ML B/D GAMMAKED INJ 1GM/10ML B/D GAMMAKED INJ 2.5GM/25ML B/D GAMMAKED INJ 20GM/200ML B/D GAMMAKED INJ 5GM/50ML B/D GAMMAPLEX INJ 10GM/100ML; 0 B/D GAMMAPLEX INJ 10GM/200ML B/D GAMMAPLEX INJ 20GM/200ML B/D GAMMAPLEX INJ 20GM/400ML B/D GAMMAPLEX INJ 20GM/400ML B/D GAMMAPLEX INJ 5GM/100ML B/D GAMMAPLEX INJ 5GM/50ML B/D Página 56

58 GAMUNEX-C INJ 10GM/100ML B/D GAMUNEX-C INJ 1GM/10ML B/D GAMUNEX-C INJ 2.5GM/25ML B/D GAMUNEX-C INJ 20GM/200ML B/D GAMUNEX-C INJ 40GM/400ML B/D GAMUNEX-C INJ 5GM/50ML B/D GARDASIL 9 INJ 0 GARDASIL 9 INJ 0 GARDASIL INJ 0 GARDASIL INJ 0 gengraf caps 100mg 1 G PA gengraf caps 25mg 1 G PA gengraf caps 50mg 1 G PA gengraf soln 100mg/ml 1 G PA HAVRIX INJ 1440ELU/ML HAVRIX INJ 720ELU/0.5ML hecoria caps 0.5mg 1 G PA hecoria caps 1mg 1 G PA hecoria caps 5mg 1 G PA HIBERIX INJ 10MCG HIZENTRA INJ 10GM/50ML B/D HIZENTRA INJ 1GM/5ML B/D HIZENTRA INJ 2GM/10ML B/D HIZENTRA INJ 4GM/20ML B/D HUMIRA PEDIATRIC CROHNS DISEASE STARTER PA PACK INJ 40MG/0.8ML HUMIRA PEDIATRIC CROHNS DISEASE STARTER PA PACK INJ 40MG/0.8ML HUMIRA PEN-CROHNS DISEASESTARTER INJ PA 40MG/0.8ML HUMIRA PEN-PSORIASIS STARTER INJ 40MG/0.8ML PA HUMIRA PEN INJ 40MG/0.8ML PA HUMIRA INJ 10MG/0.2ML PA HUMIRA INJ 20MG/0.4ML PA HUMIRA INJ 40MG/0.8ML PA ILARIS INJ 150MG/ML B/D ILARIS INJ 180MG B/D IMOVAX RABIES (H.D.C.V.) INJ 2.5UNIT/ML B/D INFANRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 10LFU/0.5ML IPOL INACTIVATED IPV INJ 0 IXIARO INJ 0 KINERET INJ 100MG/0.67ML PA KINRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 0; 10LFU/0.5ML Página 57

59 KINRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 0; 10LFU/0.5ML leflunomide tabs 10mg 1 G leflunomide tabs 20mg 1 G M-M-R II INJ 0; 0; 0 MENACTRA INJ 0 MENHIBRIX INJ 2.5MCG; 5MCG; 5MCG MENOMUNE-A/C/Y/W-135 INJ 0 MENVEO INJ 0 methotrexate sodium inj 100mg/4ml 1 G methotrexate sodium inj 1gm/40ml 1 G methotrexate sodium inj 1gm 1 G methotrexate sodium inj 200mg/8ml 1 G methotrexate sodium inj 250mg/10ml 1 G methotrexate sodium inj 250mg/10ml 1 G methotrexate sodium inj 50mg/2ml 1 G methotrexate tabs 2.5mg 1 G mycophenolate mofetil caps 250mg 1 G PA mycophenolate mofetil inj 500mg 1 G PA mycophenolate mofetil susr 200mg/ml 1 G PA mycophenolate mofetil tabs 500mg 1 G PA mycophenolic acid dr tbec 180mg 1 G PA mycophenolic acid dr tbec 360mg 1 G PA NULOJIX INJ 250MG PA OCTAGAM INJ 10GM/100ML B/D OCTAGAM INJ 10GM/200ML B/D OCTAGAM INJ 1GM/20ML B/D OCTAGAM INJ 2.5GM/50ML B/D OCTAGAM INJ 20GM/200ML B/D OCTAGAM INJ 25GM/500ML B/D OCTAGAM INJ 2GM/20ML B/D OCTAGAM INJ 5GM/100ML B/D OCTAGAM INJ 5GM/50ML B/D ORENCIA CLICKJECT INJ 125MG/ML PA ORENCIA INJ 125MG/ML PA ORENCIA INJ 250MG PA ORENCIA INJ 50MG/0.4ML PA ORENCIA INJ 87.5MG/0.7ML PA OTEZLA TABS 30MG QL (60 EA por 30 días) PA OTEZLA TBPK 0 QL (55 EA por 28 días) PA OTREXUP INJ 10MG/0.4ML PA OTREXUP INJ 12.5MG/0.4ML PA OTREXUP INJ 15MG/0.4ML PA OTREXUP INJ 17.5MG/0.4ML PA Página 58

60 OTREXUP INJ 20MG/0.4ML PA OTREXUP INJ 22.5MG/0.4ML PA OTREXUP INJ 25MG/0.4ML PA OTREXUP INJ 7.5MG/0.4ML PA PEDIARIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 10MCG/0.5ML; 0; 10LFU/0.5ML PEDVAX HIB INJ 7.5MCG/0.5ML PRIVIGEN INJ 10GM/100ML B/D PRIVIGEN INJ 20GM/200ML B/D PRIVIGEN INJ 5GM/50ML B/D PROGRAF INJ 5MG/ML PA PROQUAD INJ 0; 0; 0; 0 QUADRACEL INJ 48MCG/0.5ML; 15LFU/0.5ML; 0; 5LFU/0.5ML RABAVERT INJ 0 B/D RAPAMUNE SOLN 1MG/ML PA RASUVO INJ 10MG/0.2ML PA RASUVO INJ 12.5MG/0.25ML PA RASUVO INJ 15MG/0.3ML PA RASUVO INJ 17.5MG/0.35ML PA RASUVO INJ 20MG/0.4ML PA RASUVO INJ 22.5MG/0.45ML PA RASUVO INJ 25MG/0.5ML PA RASUVO INJ 27.5MG/0.55ML PA RASUVO INJ 30MG/0.6ML PA RASUVO INJ 7.5MG/0.15ML PA RECOMBIVAX HB INJ 10MCG/ML B/D RECOMBIVAX HB INJ 10MCG/ML B/D RECOMBIVAX HB INJ 40MCG/ML B/D RECOMBIVAX HB INJ 5MCG/0.5ML B/D REMICADE INJ 100MG PA RHEUMATREX TABS 2.5MG B/D RHEUMATREX TABS 2.5MG B/D RHEUMATREX TABS 2.5MG B/D RHEUMATREX TABS 2.5MG B/D RHEUMATREX TABS 2.5MG B/D RIDAURA CAPS 3MG ROTARIX SUSR 0 ROTATEQ SOLN 0 RUCONEST INJ 2100UNIT PA SANDIMMUNE SOLN 100MG/ML PA SIMPONI ARIA INJ 50MG/4ML B/D SIMPONI INJ 100MG/ML PA SIMPONI INJ 100MG/ML PA SIMPONI INJ 50MG/0.5ML PA SIMPONI INJ 50MG/0.5ML PA Página 59

61 SIMULECT INJ 10MG B/D SIMULECT INJ 20MG B/D sirolimus tabs 0.5mg 1 G PA sirolimus tabs 1mg 1 G PA sirolimus tabs 2mg 1 G PA STAMARIL INJ 0 QL (1 EA por 999 días) STELARA INJ 130MG/26ML B/D SYNAGIS INJ 100MG/ML B/D SYNAGIS INJ 50MG/0.5ML B/D tacrolimus caps 0.5mg 1 G PA tacrolimus caps 1mg 1 G PA tacrolimus caps 5mg 1 G PA TENIVAC INJ 2LFU; 5LFU TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT INJ 2LF/0.5ML; 2LF/0.5ML TETANUS/DIPHTHERIA TOXOIDS-ADSORBED INJ 2LF/0.5ML; 2LF/0.5ML THYMOGLOBULIN INJ 25MG B/D TORISEL INJ 25MG/ML HI TREXALL TABS 10MG B/D TREXALL TABS 15MG B/D TREXALL TABS 5MG B/D TREXALL TABS 7.5MG B/D TRUMENBA INJ 0 TWINRIX INJ 720ELU/ML; 20MCG/ML TYPHIM VI INJ 25MCG/0.5ML TYPHIM VI INJ 25MCG/0.5ML VAQTA INJ 25UNIT/0.5ML VAQTA INJ 50UNIT/ML VARIVAX INJ 1350PFU/0.5ML VARIZIG INJ 125UNIT/1.2ML VARIZIG INJ 125UNIT VAXCHORA SUSR 0 XATMEP SOLN 2.5MG/ML PA XELJANZ XR TB24 11MG QL (30 EA por 30 días) PA XELJANZ TABS 5MG QL (60 EA por 30 días) PA YF-VAX INJ 0 ZORTRESS TABS 0.25MG PA ZORTRESS TABS 0.5MG PA ZORTRESS TABS 0.75MG PA ZOSTAVAX INJ 19400UNT/0.65ML Agentes oftálmicos acetazolamide er cp12 500mg 1 G ALOCRIL SOLN 2% ST Página 60

62 ALOMIDE SOLN 0.1% ALPHAGAN P SOLN 0.1% ALREX SUSP 0.2% altafrin soln 2.5% 1 G apraclonidine soln 0.5% 1 G atropine sulfate soln 1% 1 G azelastine hcl soln 0.05% 1 G ST AZOPT SUSP 1% ST betaxolol hcl soln 0.5% 1 G BETIMOL SOLN 0.25% BETIMOL SOLN 0.5% BETOPTIC-S SUSP 0.25% bimatoprost soln 0.03% 1 G brimonidine tartrate soln 0.15% 1 G brimonidine tartrate soln 0.2% 1 G bromfenac soln 0.09% 1 G bromfenac soln 0.09% 1 G carteolol hcl soln 1% 1 G COMBIGAN SOLN 0.2%; 0.5% COSOPT PF SOLN 22.3MG/ML; 6.8MG/ML cromolyn sodium soln 4% 1 G CYSTARAN SOLN 0.44% dexamethasone sodium phosphate soln 0.1% 1 G diclofenac sodium soln 0.1% 1 G dorzolamide hcl/timolol maleate soln 22.3mg/ml; 6.8mg/ml 1 G dorzolamide hcl soln 2% 1 G DUREZOL EMUL 0.05% EMADINE SOLN 0.05% ST epinastine hcl soln 0.05% 1 G ST fluorometholone susp 0.1% 1 G flurbiprofen sodium soln 0.03% 1 G FML FORTE SUSP 0.25% FML OINT 0.1% ILEVRO SUSP 0.3% IOPIDINE SOLN 1% ketorolac tromethamine soln 0.4% 1 G ketorolac tromethamine soln 0.5% 1 G LACRISERT INST 5MG latanoprost soln 0.005% 1 G levobunolol hcl soln 0.5% 1 G LOTEMAX GEL 0.5% LOTEMAX OINT 0.5% LOTEMAX SUSP 0.5% LUMIGAN SOLN 0.01% MAXIDEX SUSP 0.1% metipranolol soln 0.3% 1 G Página 61

63 mydral soln 0.5% 1 G mydral soln 1% 1 G naphazoline hcl soln 0.1% 1 G neofrin soln 2.5% 1 G neomycin/polymyxin/dexamethasone oint 0.1%; 3.5mg/gm; 1 G 10000unit/gm neomycin/polymyxin/dexamethasone susp 0.1%; 3.5mg/ml; 1 G 10000unit/ml olopatadine hcl soln 0.1% 1 G olopatadine hydrochloride soln 0.2% 1 G PAZEO SOLN 0.7% ST phenylephrine hcl soln 10% 1 G phenylephrine hcl soln 2.5% 1 G PHOSPHOLINE IODIDE SOLR 0.125% pilocarpine hcl soln 1% 1 G pilocarpine hcl soln 2% 1 G pilocarpine hcl soln 4% 1 G PRED MILD SUSP 0.12% PRED-G S.O.P. OINT 0.3%; 0.6% PRED-G SUSP 0.3%; 1% prednisolone acetate susp 1% 1 G prednisolone sodium phosphate soln 1% 1 G PROCYSBI CPDR 25MG PA PROCYSBI CPDR 75MG PA PROLENSA SOLN 0.07% proparacaine hcl soln 0.5% 1 G RESCULA SOLN 0.15% RESTASIS EMUL 0.05% QL (60 EA por 30 días) SIMBRINZA SUSP 0.2%; 1% timolol maleate ophthalmic gel forming solg 0.25% 1 G timolol maleate ophthalmic gel forming solg 0.5% 1 G timolol maleate soln 0.25% 1 G timolol maleate soln 0.5% 1 G TIMOPTIC OCUDOSE SOLN 0.5% TOBRADEX OINT 0.1%; 0.3% tobramycin/dexamethasone susp 0.1%; 0.3% 1 G TRAVATAN Z SOLN 0.004% travoprost soln 0.004% 1 G tropicamide soln 0.5% 1 G tropicamide soln 1% 1 G VEXOL SUSP 1% XIIDRA SOLN 5% ZIOPTAN SOLN 0.015MG/ML Agentes para la bipolaridad lithium carbonate er tbcr 300mg 1 G lithium carbonate er tbcr 450mg 1 G Página 62

64 lithium carbonate caps 150mg 1 G lithium carbonate caps 300mg 1 G lithium carbonate caps 600mg 1 G lithium carbonate tabs 300mg 1 G lithium soln 8meq/5ml 1 G Agentes para tratamientos antiadicción/contra la drogadicción acamprosate calcium dr tbec 333mg 1 G buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg 1 G QL (90 EA por 30 días) buprenorphine hcl/naloxone hcl subl 8mg; 2mg 1 G QL (90 EA por 30 días) buprenorphine hcl subl 2mg 1 G buprenorphine hcl subl 8mg 1 G buproban tb12 150mg 1 G QL (60 EA por 30 días) bupropion hcl sr tb12 150mg 1 G QL (60 EA por 30 días) CHANTIX CONTINUING MONTH PAK TABS 1MG CHANTIX STARTING MONTH PAK TABS 0 CHANTIX TABS 0.5MG CHANTIX TABS 1MG disulfiram tabs 250mg 1 G disulfiram tabs 500mg 1 G EVZIO INJ 0.4MG/0.4ML EVZIO INJ 2MG/0.4ML naloxone hcl inj 0.4mg/ml 1 G naloxone hcl inj 2mg/2ml 1 G naloxone hcl inj 4mg/10ml 1 G naltrexone hcl tabs 50mg 1 G NARCAN LIQD 4MG/0.1ML QL (4 EA por 30 días) NICOTROL INHALER INHA 10MG NICOTROL NS SOLN 10MG/ML SUBOXONE FILM 12MG; 3MG QL (90 EA por 30 días) SUBOXONE FILM 2MG; 0.5MG QL (90 EA por 30 días) SUBOXONE FILM 4MG; 1MG QL (90 EA por 30 días) SUBOXONE FILM 8MG; 2MG QL (90 EA por 30 días) VIVITROL INJ 380MG B/D ZUBSOLV SUBL 0.7MG; 0.18MG QL (30 EA por 30 días) ZUBSOLV SUBL 1.4MG; 0.36MG QL (90 EA por 30 días) ZUBSOLV SUBL 11.4MG; 2.9MG QL (30 EA por 30 días) ZUBSOLV SUBL 2.9MG; 0.71MG QL (90 EA por 30 días) ZUBSOLV SUBL 5.7MG; 1.4MG QL (90 EA por 30 días) ZUBSOLV SUBL 8.6MG; 2.1MG QL (90 EA por 30 días) Agentes para vías respiratorias/pulmonares acetylcysteine soln 10% 1 G B/D acetylcysteine soln 20% 1 G B/D Página 63

65 ADCIRCA TABS 20MG PA ADEMPAS TABS 0.5MG QL (90 EA por 30 días) PA ADEMPAS TABS 1.5MG QL (90 EA por 30 días) PA ADEMPAS TABS 1MG QL (90 EA por 30 días) PA ADEMPAS TABS 2.5MG QL (90 EA por 30 días) PA ADEMPAS TABS 2MG QL (90 EA por 30 días) PA AEROSPAN AERS 80MCG/ACT albuterol sulfate er tb12 4mg 1 G albuterol sulfate er tb12 8mg 1 G albuterol sulfate nebu 0.083% 1 G B/D albuterol sulfate nebu 0.5% 1 G B/D albuterol sulfate nebu 0.63mg/3ml 1 G B/D albuterol sulfate nebu 1.25mg/3ml 1 G B/D albuterol sulfate syrp 2mg/5ml 1 G albuterol sulfate tabs 2mg 1 G albuterol sulfate tabs 4mg 1 G albuterol tabs 4mg 1 G ALVESCO AERS 160MCG/ACT ALVESCO AERS 80MCG/ACT aminophylline inj 25mg/ml 1 G ANORO ELLIPTA AEPB 62.5MCG/INH; 25MCG/INH ARALAST NP INJ 1000MG B/D ARALAST NP INJ 500MG B/D ARALAST NP INJ 800MG B/D arbinoxa soln 4mg/5ml 1 G arbinoxa tabs 4mg 1 G ARCAPTA NEOHALER CAPS 75MCG ARNUITY ELLIPTA AEPB 100MCG/ACT ARNUITY ELLIPTA AEPB 200MCG/ACT ASMANEX HFA AERO 100MCG/ACT ASMANEX HFA AERO 200MCG/ACT ASMANEX TWISTHALER 120 METERED DOSES AEPB 220MCG/INH ASMANEX TWISTHALER 14 METERED DOSES AEPB 220MCG/INH ASMANEX TWISTHALER 30 METERED DOSES AEPB 110MCG/INH ASMANEX TWISTHALER 30 METERED DOSES AEPB 220MCG/INH ASMANEX TWISTHALER 60 METERED DOSES AEPB 220MCG/INH Página 64

66 ASMANEX TWISTHALER 7 METERED DOSES AEPB 110MCG/INH ATROVENT HFA AERS 17MCG/ACT AUVI-Q INJ 0.15MG/0.15ML QL (2 EA por 30 días) AUVI-Q INJ 0.3MG/0.3ML QL (2 EA por 30 días) azelastine hcl soln 0.1% 1 G azelastine hcl soln 0.15% 1 G BECONASE AQ SUSP 42MCG/SPRAY QL (50 GM por 30 días) benzonatate caps 100mg 1 G # benzonatate caps 200mg 1 G # BETHKIS NEBU 300MG/4ML B/D BREO ELLIPTA AEPB 100MCG/INH; 25MCG/INH BREO ELLIPTA AEPB 200MCG/INH; 25MCG/INH BROVANA NEBU 15MCG/2ML B/D budesonide nasal spray susp 32mcg/act 1 G QL (17.2 GM por 30 días) budesonide susp 0.25mg/2ml 1 G B/D budesonide susp 0.5mg/2ml 1 G B/D budesonide susp 1mg/2ml 1 G B/D carbinoxamine maleate soln 4mg/5ml 1 G carbinoxamine maleate tabs 4mg 1 G CAYSTON SOLR 75MG cetirizine hcl syrp 1mg/ml 1 G CLARINEX-D 12 HOUR TB12 2.5MG; 120MG QL (60 EA por 30 días) CLARINEX SYRP 0.5MG/ML clemastine fumarate syrp 0.67mg/5ml 1 G clemastine fumarate tabs 2.68mg 1 G COMBIVENT RESPIMAT AERS 100MCG/ACT; 20MCG/ACT cromolyn sodium nebu 20mg/2ml 1 G B/D cyproheptadine hcl syrp 2mg/5ml 1 G cyproheptadine hcl tabs 4mg 1 G DALIRESP TABS 500MCG desloratadine tabs 5mg 1 G dexchlorpheniramine maleate syrp 2mg/5ml 1 G diphenhydramine hcl elix 12.5mg/5ml 1 G diphenhydramine hcl inj 50mg/ml 1 G DULERA AERO 5MCG/ACT; 100MCG/ACT DULERA AERO 5MCG/ACT; 200MCG/ACT DYMISTA SUSP 137MCG/ACT; 50MCG/ACT ELIXOPHYLLIN ELIX 80MG/15ML epinephrine hcl inj 0.1mg/ml 1 G epinephrine hcl inj 1mg/ml 1 G epinephrine inj 0.15mg/0.15ml 1 G QL (2 EA por 30 días) epinephrine inj 0.15mg/0.3ml 1 G QL (2 EA por 30 días) epinephrine inj 0.3mg/0.3ml 1 G QL (2 EA por 30 días) Página 65

67 epinephrine inj 0.3mg/0.3ml 1 G QL (2 EA por 30 días) EPIPEN 2-PAK INJ 0.3MG/0.3ML QL (2 EA por 30 días) EPIPEN-JR 2-PAK INJ 0.15MG/0.3ML QL (2 EA por 30 días) ESBRIET CAPS 267MG PA ESBRIET TABS 267MG PA ESBRIET TABS 801MG PA FLOVENT DISKUS AEPB 100MCG/BLIST FLOVENT DISKUS AEPB 250MCG/BLIST FLOVENT DISKUS AEPB 50MCG/BLIST FLOVENT HFA AERO 110MCG/ACT FLOVENT HFA AERO 220MCG/ACT FLOVENT HFA AERO 44MCG/ACT flunisolide soln 0.025% 1 G fluticasone propionate/salmeterol aepb 113mcg/act; 1 G 14mcg/act fluticasone propionate/salmeterol aepb 232mcg/act; 14mcg/act 1 G fluticasone propionate/salmeterol aepb 55mcg/act; 14mcg/act 1 G fluticasone propionate susp 50mcg/act 1 G GLASSIA INJ 1000MG/50ML B/D hydrocodone bitartrate/homatropine methylbromide syrp 1 G # 1.5mg/5ml; 5mg/5ml hydrocodone polistirex/chlorpheniramine polistirex suer 1 G # 8mg/5ml; 10mg/5ml hydrocodone/homatropine syrp 1.5mg/5ml; 5mg/5ml 1 G # hydromet syrp 1.5mg/5ml; 5mg/5ml 1 G # hydroxyzine hcl inj 25mg/ml 1 G hydroxyzine hcl inj 50mg/ml 1 G hydroxyzine hcl syrp 10mg/5ml 1 G hydroxyzine hcl tabs 10mg 1 G hydroxyzine hcl tabs 25mg 1 G hydroxyzine hcl tabs 50mg 1 G hydroxyzine pamoate caps 100mg 1 G hydroxyzine pamoate caps 25mg 1 G hydroxyzine pamoate caps 50mg 1 G INCRUSE ELLIPTA AEPB 62.5MCG/INH ipratropium bromide/albuterol sulfate soln 2.5mg/3ml; 1 G B/D 0.5mg/3ml ipratropium bromide soln 0.02% 1 G B/D ipratropium bromide soln 0.03% 1 G ipratropium bromide soln 0.06% 1 G KALYDECO PACK 50MG PA KALYDECO PACK 75MG PA KALYDECO TABS 150MG PA KARBINAL ER SUER 4MG/5ML LETAIRIS TABS 10MG PA Página 66

68 LETAIRIS TABS 5MG PA levalbuterol hcl nebu 0.31mg/3ml 1 G B/D levalbuterol hcl nebu 0.63mg/3ml 1 G B/D levalbuterol hcl nebu 1.25mg/3ml 1 G B/D levalbuterol tartrate hfa aero 45mcg/act 1 G levalbuterol nebu 1.25mg/0.5ml 1 G B/D levocetirizine dihydrochloride soln 2.5mg/5ml 1 G levocetirizine dihydrochloride tabs 5mg 1 G LUFYLLIN TABS 200MG metaproterenol sulfate syrp 10mg/5ml 1 G metaproterenol sulfate tabs 10mg 1 G metaproterenol sulfate tabs 20mg 1 G mometasone furoate susp 50mcg/act 1 G montelukast sodium chew 4mg 1 G montelukast sodium chew 5mg 1 G montelukast sodium pack 4mg 1 G montelukast sodium tabs 10mg 1 G OFEV CAPS 100MG PA OFEV CAPS 150MG PA olopatadine hcl soln 0.6% 1 G OPSUMIT TABS 10MG QL (30 EA por 30 días) PA ORENITRAM TBCR 0.125MG PA ORENITRAM TBCR 0.25MG PA ORENITRAM TBCR 1MG PA ORENITRAM TBCR 2.5MG PA ORENITRAM TBCR 5MG PA ORKAMBI TABS 125MG; 100MG ORKAMBI TABS 125MG; 200MG PERFOROMIST NEBU 20MCG/2ML QL (120 ML por 30 días) B/D PROAIR HFA AERS 108MCG/ACT PROAIR RESPICLICK AEPB 108MCG/ACT PROLASTIN-C INJ 1000MG B/D promethazine hcl plain syrp 6.25mg/5ml 1 G promethazine hcl inj 25mg/ml 1 G promethazine hcl inj 50mg/ml 1 G promethazine hcl syrp 6.25mg/5ml 1 G promethazine hcl tabs 12.5mg 1 G promethazine hcl tabs 25mg 1 G promethazine hcl tabs 50mg 1 G promethazine vc plain soln 5mg/5ml; 6.25mg/5ml 1 G promethazine vc/codeine syrp 10mg/5ml; 5mg/5ml; 1 G # 6.25mg/5ml promethazine/codeine syrp 10mg/5ml; 6.25mg/5ml 1 G # promethazine/dextromethorphan syrp 15mg/5ml; 6.25mg/5ml 1 G # Página 67

69 promethazine/phenylephrine/codeine syrp 10mg/5ml; 1 G # 5mg/5ml; 6.25mg/5ml promethazine/phenylephrine syrp 5mg/5ml; 6.25mg/5ml 1 G PULMICORT FLEXHALER AEPB 180MCG/ACT PULMICORT FLEXHALER AEPB 90MCG/ACT PULMOZYME SOLN 1MG/ML QL (150 ML por 30 días) PA QNASL CHILDRENS AERS 40MCG/ACT QNASL AERS 80MCG/ACT QVAR AERS 40MCG/ACT QVAR AERS 80MCG/ACT REMODULIN INJ 10MG/ML B/D REMODULIN INJ 1MG/ML B/D REMODULIN INJ 2.5MG/ML B/D REMODULIN INJ 5MG/ML B/D ribavirin solr 6gm B/D SEMPREX-D CAPS 8MG; 60MG SEREVENT DISKUS AEPB 50MCG/DOSE sildenafil inj 10mg/12.5ml 1 G PA sildenafil tabs 20mg 1 G QL (90 EA por 30 días) PA SPIRIVA HANDIHALER CAPS 18MCG QL (30 EA por 30 días) SPIRIVA RESPIMAT AERS 1.25MCG/ACT QL (4 GM por 30 días) SPIRIVA RESPIMAT AERS 2.5MCG/ACT QL (4 GM por 30 días) STIOLTO RESPIMAT AERS 2.5MCG/ACT; 2.5MCG/ACT STRIVERDI RESPIMAT AERS 2.5MCG/ACT SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT terbutaline sulfate inj 1mg/ml 1 G terbutaline sulfate tabs 2.5mg 1 G terbutaline sulfate tabs 5mg 1 G THEO-24 CP24 0; 100MG THEO-24 CP24 200MG THEO-24 CP24 300MG THEO-24 CP24 400MG theochron tb12 100mg 1 G theochron tb12 200mg 1 G theochron tb12 300mg 1 G theophylline cr tb12 100mg 1 G theophylline cr tb12 200mg 1 G theophylline er tb12 100mg 1 G theophylline er tb12 200mg 1 G theophylline er tb12 300mg 1 G theophylline er tb12 450mg 1 G theophylline er tb24 400mg 1 G theophylline er tb24 600mg 1 G Página 68

70 theophylline soln 80mg/15ml 1 G TOBI PODHALER CAPS 28MG tobramycin nebu 300mg/5ml 1 G B/D TRACLEER TABS 125MG QL (90 EA por 30 días) PA TRACLEER TABS 62.5MG QL (90 EA por 30 días) PA triamcinolone acetonide aero 55mcg/act 1 G TUDORZA PRESSAIR AEPB 400MCG/ACT TUDORZA PRESSAIR AEPB 400MCG/ACT TYVASO REFILL SOLN 0.6MG/ML B/D TYVASO STARTER SOLN 0.6MG/ML B/D TYVASO SOLN 0.6MG/ML B/D TYZINE PEDIATRIC NASAL DROPS SOLN 0.05% VENTAVIS SOLN 10MCG/ML B/D VENTAVIS SOLN 20MCG/ML B/D XOLAIR INJ 150MG PA zafirlukast tabs 10mg 1 G zafirlukast tabs 20mg 1 G ZEMAIRA INJ 1000MG B/D zileuton er tb12 600mg 1 G ZYFLO CR TB12 600MG ZYFLO TABS 600MG Agentes Terapéuticos, Misceláneos argyle sterile saline 100ml soln 0.9% 1 G bd insulin syringe safetyglide/1ml/29g x 1/2" misc 1 G bd insulin syringe ultrafine/0.3ml/31g x 5/16" misc 1 G bd insulin syringe ultrafine/0.5ml/30g x 1/2" misc 1 G bd insulin syringe ultrafine/1ml/31g x 5/16" misc 1 G bd pen needle/ultrafine/29g x 12.7mm misc 1 G BOTOX INJ 100UNIT PA BOTOX INJ 200UNIT PA CARNITOR INJ 200MG/ML HI curity sterile saline soln 0.9% 1 G DYSPORT INJ 300UNIT PA DYSPORT INJ 500UNIT PA FERRIPROX SOLN 100MG/ML FERRIPROX TABS 500MG fomepizole inj 1gm/ml 1 G B/D INTRALIPID INJ 20GM/100ML HI INTRALIPID INJ 30GM/100ML HI KORLYM TABS 300MG PA LACTATED RINGERS IRRIGATION SOLN 3MEQ/L; 1 B 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L levocarnitine inj 200mg/ml 1 G HI levocarnitine soln 1gm/10ml 1 G Página 69

71 levocarnitine tabs 330mg 1 G LIPOSYN III INJ 1.2GM/100ML; 2.5GM/100ML; HI 10GM/100ML LIPOSYN III INJ 1.2GM/100ML; 2.5GM/100ML; HI 20GM/100ML LIPOSYN III INJ 2.5%; 30% HI methylergonovine maleate tabs 0.2mg 1 G MYALEPT INJ 11.3MG PA NATPARA INJ 100MCG PA NATPARA INJ 25MCG PA NATPARA INJ 50MCG PA NATPARA INJ 75MCG PA NUTRILIPID INJ 20GM/100ML HI PHYSIOLYTE SOLN 27MEQ/1000ML; 98MEQ/1000ML; 23MEQ/1000ML; 3MEQ/1000ML; 5MEQ/1000ML; 140MEQ/1000ML PHYSIOSOL IRRIGATION SOLN 30MG/100ML; 37MG/100ML; 222MG/100ML; 526MG/100ML; 502MG/100ML RINGERS IRRIGATION SOLN 4.5MEQ/L; 156MEQ/L; 4MEQ/L; 147MEQ/L sodium chloride 0.9% soln 0.9% 1 G sterile water irrigation soln 0 1 G TIS-U-SOL SOLN 4.5MEQ/L; 156MEQ/L; 4MEQ/L; 147MEQ/L XEOMIN INJ 100UNIT PA XEOMIN INJ 50UNIT PA Agentes óticos acetasol hc soln 2%; 1% 1 G acetic acid/aluminum acetate soln 2%; 0 1 G acetic acid soln 2% 1 G antipyrine/benzocaine soln 54mg/ml; 14mg/ml 1 G # COLY-MYCIN S SUSP 3MG/ML; 10MG/ML; 3.3MG/ML; 0.5MG/ML CORTISPORIN-TC SUSP 3MG/ML; 10MG/ML; 3.3MG/ML; 0.5MG/ML fluocinolone acetonide ear drops oil 0.01% 1 G fluocinolone acetonide oil 0.01% 1 G hydrocortisone/acetic acid soln 2%; 1% 1 G neomycin/polymyxin/hc soln 1%; 3.5mg/ml; 10000unit/ml 1 G neomycin/polymyxin/hydrocortisone soln 1%; 3.5mg/ml; 1 G 10000unit/ml neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml; 1 G 10000unit/ml Analgésicos ABSTRAL SUBL 100MCG PA Página 70

72 ABSTRAL SUBL 200MCG PA ABSTRAL SUBL 300MCG PA ABSTRAL SUBL 400MCG PA ABSTRAL SUBL 600MCG PA ABSTRAL SUBL 800MCG PA acetaminophen/caffeine/dihydrocodeine caps 320.5mg; 30mg; 1 G 16mg acetaminophen/codeine phosphate tabs 300mg; 30mg 1 G acetaminophen/codeine soln 120mg/5ml; 12mg/5ml 1 G acetaminophen/codeine tabs 300mg; 15mg 1 G acetaminophen/codeine tabs 300mg; 30mg 1 G acetaminophen/codeine tabs 300mg; 60mg 1 G ascomp/codeine caps 325mg; 50mg; 40mg; 30mg 1 G aspirin-caffeine-dihydrocodeine caps 356.4mg; 30mg; 16mg 1 G bupap tabs 300mg; 50mg 1 G buprenorphine hcl inj 0.3mg/ml 1 G B/D buprenorphine hcl inj 0.3mg/ml 1 G B/D buprenorphine ptwk 10mcg/hr 1 G buprenorphine ptwk 15mcg/hr 1 G buprenorphine ptwk 20mcg/hr 1 G buprenorphine ptwk 5mcg/hr 1 G buprenorphine ptwk 7.5mcg/hr 1 G butalbital/acetaminophen/caffeine/codeine caps 300mg; 1 G 50mg; 40mg; 30mg butalbital/acetaminophen/caffeine/codeine caps 325mg; 50mg; 40mg; 30mg 1 G butalbital/acetaminophen/caffeine caps 300mg; 50mg; 40mg 1 G butalbital/acetaminophen/caffeine caps 325mg; 50mg; 40mg 1 G butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg 1 G butalbital/acetaminophen tabs 300mg; 50mg 1 G butalbital/acetaminophen tabs 325mg; 50mg 1 G butalbital/aspirin/caffeine/codeine caps 325mg; 50mg; 40mg; 1 G 30mg butalbital/aspirin/caffeine caps 325mg; 50mg; 40mg 1 G butorphanol tartrate inj 1mg/ml 1 G butorphanol tartrate inj 2mg/ml 1 G butorphanol tartrate soln 10mg/ml 1 G BUTRANS PTWK 7.5MCG/HR CAMBIA PACK 50MG capacet caps 325mg; 50mg; 40mg 1 G CAPITAL/CODEINE SUSP 120MG/5ML; 12MG/5ML carisoprodol/aspirin/codeine tabs 325mg; 200mg; 16mg 1 G PA celecoxib caps 100mg 1 G celecoxib caps 200mg 1 G celecoxib caps 400mg 1 G celecoxib caps 50mg 1 G Página 71

73 codeine sulfate tabs 15mg 1 G codeine sulfate tabs 30mg 1 G codeine sulfate tabs 60mg 1 G diclofenac potassium tabs 50mg 1 G diclofenac sodium dr tbec 25mg 1 G diclofenac sodium dr tbec 50mg 1 G diclofenac sodium dr tbec 75mg 1 G diclofenac sodium er tb24 100mg 1 G diclofenac sodium/misoprostol tbec 50mg; 200mcg 1 G diclofenac sodium/misoprostol tbec 75mg; 200mcg 1 G diflunisal tabs 500mg 1 G DUEXIS TABS 26.6MG; 800MG DURAMORPH INJ 0.5MG/ML HI DURAMORPH INJ 1MG/ML HI EMBEDA CPCR 100MG; 4MG EMBEDA CPCR 20MG; 0.8MG EMBEDA CPCR 30MG; 1.2MG EMBEDA CPCR 50MG; 2MG EMBEDA CPCR 60MG; 2.4MG EMBEDA CPCR 80MG; 3.2MG endocet tabs 325mg; 10mg 1 G endocet tabs 325mg; 2.5mg 1 G endocet tabs 325mg; 5mg 1 G endocet tabs 325mg; 7.5mg 1 G endodan tabs 325mg; 4.835mg 1 G esgic caps 325mg; 50mg; 40mg 1 G etodolac er tb24 400mg 1 G etodolac er tb24 500mg 1 G etodolac er tb24 600mg 1 G etodolac caps 200mg 1 G etodolac caps 300mg 1 G etodolac tabs 400mg 1 G etodolac tabs 500mg 1 G fenoprofen calcium caps 400mg 1 G fenoprofen calcium tabs 600mg 1 G fentanyl citrate oral transmucosal lpop 1200mcg PA fentanyl citrate oral transmucosal lpop 1600mcg PA fentanyl citrate oral transmucosal lpop 200mcg 1 G PA fentanyl citrate oral transmucosal lpop 400mcg 1 G PA fentanyl citrate oral transmucosal lpop 600mcg 1 G PA fentanyl citrate oral transmucosal lpop 800mcg PA fentanyl citrate inj 1000mcg/20ml 1 G B/D fentanyl citrate inj 100mcg/2ml 1 G B/D fentanyl citrate inj 2500mcg/50ml 1 G B/D fentanyl citrate inj 250mcg/5ml 1 G B/D fentanyl citrate inj 500mcg/10ml 1 G B/D Página 72

74 fentanyl pt72 100mcg/hr 1 G fentanyl pt72 12mcg/hr 1 G fentanyl pt72 25mcg/hr 1 G fentanyl pt mcg/hr 1 G fentanyl pt72 50mcg/hr 1 G fentanyl pt mcg/hr 1 G fentanyl pt72 75mcg/hr 1 G fentanyl pt mcg/hr 1 G FENTORA TABS 100MCG PA FENTORA TABS 200MCG PA FENTORA TABS 400MCG PA FENTORA TABS 600MCG PA FENTORA TABS 800MCG PA FLECTOR PTCH 1.3% PA flurbiprofen tabs 100mg 1 G flurbiprofen tabs 50mg 1 G GRALISE STARTER MISC 0 GRALISE TABS 300MG GRALISE TABS 600MG hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 10mg/15ml 1 G QL (2700 ML por 30 días) hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 7.5mg/15ml 1 G QL (2700 ML por 30 días) hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg 1 G QL (180 EA por 30 días) hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg 1 G QL (390 EA por 30 días) hydrocodone bitartrate/acetaminophen tabs 300mg; 7.5mg 1 G QL (390 EA por 30 días) hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg 1 G QL (360 EA por 30 días) hydrocodone/acetaminophen soln 500mg/15ml; 7.5mg/15ml 1 G QL (3600 ML por 30 días) hydrocodone/acetaminophen tabs 325mg; 10mg 1 G QL (360 EA por 30 días) hydrocodone/acetaminophen tabs 325mg; 5mg 1 G QL (360 EA por 30 días) hydrocodone/acetaminophen tabs 325mg; 7.5mg 1 G QL (360 EA por 30 días) hydrocodone/ibuprofen tabs 10mg; 200mg 1 G hydrocodone/ibuprofen tabs 2.5mg; 200mg 1 G hydrocodone/ibuprofen tabs 5mg; 200mg 1 G hydrocodone/ibuprofen tabs 7.5mg; 200mg 1 G hydromorphone hcl dosette inj 2mg/ml 1 G B/D hydromorphone hcl er t24a 12mg 1 G hydromorphone hcl er t24a 16mg 1 G Página 73

75 hydromorphone hcl er t24a 8mg 1 G hydromorphone hcl inj 10mg/ml 1 G B/D hydromorphone hcl inj 1mg/ml 1 G B/D hydromorphone hcl inj 2mg/ml 1 G B/D hydromorphone hcl inj 4mg/ml 1 G B/D hydromorphone hcl inj 50mg/5ml 1 G B/D hydromorphone hcl liqd 1mg/ml 1 G QL (1200 ML por 30 días) hydromorphone hcl tabs 2mg 1 G hydromorphone hcl tabs 4mg 1 G hydromorphone hcl tabs 8mg 1 G hydromorphone hydrochloride er t24a 32mg 1 G hydromorphone hydrochloride t24a 32mg 1 G ibudone tabs 5mg; 200mg 1 G ibuprofen susp 100mg/5ml 1 G ibuprofen tabs 400mg 1 G ibuprofen tabs 600mg 1 G ibuprofen tabs 800mg 1 G INDOCIN SUSP 25MG/5ML indomethacin er cpcr 75mg 1 G indomethacin caps 25mg 1 G indomethacin caps 50mg 1 G INFUMORPH 200 INJ 10MG/ML B/D INFUMORPH 500 INJ 25MG/ML B/D KADIAN CP24 200MG KADIAN CP24 40MG ketoprofen er cp24 200mg 1 G ketoprofen caps 50mg 1 G ketoprofen caps 75mg 1 G ketorolac tromethamine inj 15mg/ml 1 G B/D ketorolac tromethamine inj 300mg/10ml 1 G B/D ketorolac tromethamine inj 30mg/ml 1 G B/D ketorolac tromethamine inj 30mg/ml 1 G ketorolac tromethamine inj 30mg/ml 1 G B/D ketorolac tromethamine tabs 10mg 1 G LAZANDA SOLN 100MCG/ACT PA LAZANDA SOLN 300MCG/ACT PA LAZANDA SOLN 400MCG/ACT PA levorphanol tartrate tabs 2mg lorcet hd tabs 325mg; 10mg 1 G QL (360 EA por 30 días) lorcet plus tabs 325mg; 7.5mg 1 G QL (360 EA por 30 días) lorcet tabs 325mg; 5mg 1 G QL (360 EA por 30 días) Página 74

76 lortab tabs 325mg; 10mg 1 G QL (360 EA por 30 días) lortab tabs 325mg; 5mg 1 G QL (360 EA por 30 días) lortab tabs 325mg; 7.5mg 1 G QL (360 EA por 30 días) margesic caps 325mg; 50mg; 40mg 1 G marten-tab tabs 325mg; 50mg 1 G meclofenamate sodium caps 100mg 1 G meclofenamate sodium caps 50mg 1 G mefenamic acid caps 250mg 1 G meloxicam susp 7.5mg/5ml 1 G meloxicam tabs 15mg 1 G meloxicam tabs 7.5mg 1 G meperidine hcl inj 100mg/ml 1 G B/D meperidine hcl inj 10mg/ml 1 G B/D meperidine hcl inj 25mg/ml 1 G B/D meperidine hcl inj 50mg/ml 1 G B/D meperidine hcl soln 50mg/5ml 1 G meperidine hcl tabs 100mg 1 G meperidine hcl tabs 50mg 1 G methadone hcl intensol conc 10mg/ml 1 G methadone hcl conc 10mg/ml 1 G methadone hcl inj 10mg/ml 1 G B/D methadone hcl soln 10mg/5ml 1 G methadone hcl soln 5mg/5ml 1 G methadone hcl tabs 10mg 1 G methadone hcl tabs 5mg 1 G morphine sulfate add-vantage inj 25mg/ml 1 G HI morphine sulfate er cp24 100mg 1 G morphine sulfate er cp24 10mg 1 G morphine sulfate er cp24 120mg 1 G morphine sulfate er cp24 20mg 1 G morphine sulfate er cp24 30mg 1 G morphine sulfate er cp24 30mg 1 G morphine sulfate er cp24 45mg 1 G morphine sulfate er cp24 50mg 1 G morphine sulfate er cp24 60mg 1 G morphine sulfate er cp24 60mg 1 G morphine sulfate er cp24 75mg 1 G morphine sulfate er cp24 80mg 1 G morphine sulfate er cp24 90mg 1 G morphine sulfate er tbcr 100mg 1 G morphine sulfate er tbcr 15mg 1 G morphine sulfate er tbcr 200mg 1 G morphine sulfate er tbcr 30mg 1 G Página 75

77 morphine sulfate er tbcr 60mg 1 G morphine sulfate inj 0.5mg/ml 1 G HI morphine sulfate inj 10mg/ml 1 G HI morphine sulfate inj 10mg/ml 1 G HI morphine sulfate inj 150mg/30ml 1 G HI morphine sulfate inj 15mg/ml 1 G HI morphine sulfate inj 15mg/ml 1 G HI morphine sulfate inj 1mg/ml 1 G HI morphine sulfate inj 1mg/ml 1 G HI morphine sulfate inj 25mg/ml 1 G HI morphine sulfate inj 2mg/ml 1 G HI morphine sulfate inj 2mg/ml 1 G HI morphine sulfate inj 4mg/ml 1 G HI morphine sulfate inj 4mg/ml 1 G HI morphine sulfate inj 50mg/ml 1 G HI morphine sulfate inj 5mg/ml 1 G HI morphine sulfate inj 8mg/ml 1 G HI morphine sulfate inj 8mg/ml 1 G HI morphine sulfate soln 100mg/5ml 1 G morphine sulfate soln 10mg/5ml 1 G morphine sulfate soln 20mg/5ml 1 G morphine sulfate tabs 15mg 1 G morphine sulfate tabs 30mg 1 G nabumetone tabs 500mg 1 G nabumetone tabs 750mg 1 G nalbuphine hcl inj 10mg/ml 1 G B/D nalbuphine hcl inj 20mg/ml 1 G B/D NAPRELAN TB24 750MG naproxen dr tbec 375mg 1 G naproxen dr tbec 500mg 1 G naproxen sodium er tb24 375mg 1 G naproxen sodium tabs 275mg 1 G naproxen sodium tabs 550mg 1 G naproxen sodium tb24 500mg 1 G naproxen susp 125mg/5ml 1 G naproxen tabs 250mg 1 G naproxen tabs 375mg 1 G naproxen tabs 500mg 1 G NUCYNTA ER TB12 100MG NUCYNTA ER TB12 150MG NUCYNTA ER TB12 200MG NUCYNTA ER TB12 250MG NUCYNTA ER TB12 50MG NUCYNTA TABS 100MG NUCYNTA TABS 50MG NUCYNTA TABS 75MG Página 76

78 OPANA ER (CRUSH RESISTANT) T12A 10MG QL (60 EA por 30 días) OPANA ER (CRUSH RESISTANT) T12A 15MG QL (60 EA por 30 días) OPANA ER (CRUSH RESISTANT) T12A 20MG QL (60 EA por 30 días) OPANA ER (CRUSH RESISTANT) T12A 30MG QL (60 EA por 30 días) OPANA ER (CRUSH RESISTANT) T12A 40MG QL (120 EA por 30 días) OPANA ER (CRUSH RESISTANT) T12A 5MG QL (60 EA por 30 días) OPANA ER (CRUSH RESISTANT) T12A 7.5MG QL (60 EA por 30 días) oxaprozin tabs 600mg 1 G oxycodone hcl er t12a 10mg 1 G QL (60 EA por 30 días) oxycodone hcl er t12a 15mg 1 G QL (60 EA por 30 días) oxycodone hcl er t12a 20mg 1 G QL (60 EA por 30 días) oxycodone hcl er t12a 30mg 1 G QL (60 EA por 30 días) oxycodone hcl er t12a 40mg 1 G QL (60 EA por 30 días) oxycodone hcl er t12a 60mg 1 G QL (60 EA por 30 días) oxycodone hcl er t12a 80mg 1 G QL (60 EA por 30 días) oxycodone hcl caps 5mg 1 G oxycodone hcl conc 100mg/5ml 1 G oxycodone hcl soln 5mg/5ml 1 G oxycodone hcl tabs 10mg 1 G oxycodone hcl tabs 15mg 1 G oxycodone hcl tabs 20mg 1 G oxycodone hcl tabs 30mg 1 G oxycodone hcl tabs 5mg 1 G oxycodone/acetaminophen soln 325mg/5ml; 5mg/5ml 1 G oxycodone/acetaminophen tabs 325mg; 10mg 1 G oxycodone/acetaminophen tabs 325mg; 2.5mg 1 G oxycodone/acetaminophen tabs 325mg; 5mg 1 G oxycodone/acetaminophen tabs 325mg; 7.5mg 1 G oxycodone/aspirin tabs 325mg; 4.835mg 1 G oxycodone/ibuprofen tabs 400mg; 5mg 1 G OXYCONTIN T12A 15MG QL (60 EA por 30 días) OXYCONTIN T12A 30MG QL (60 EA por 30 días) OXYCONTIN T12A 60MG QL (60 EA por 30 días) oxymorphone hydrochloride er tb12 10mg 1 G QL (60 EA por 30 días) oxymorphone hydrochloride er tb12 15mg 1 G QL (60 EA por 30 días) oxymorphone hydrochloride er tb12 20mg 1 G QL (60 EA por 30 días) Página 77

79 oxymorphone hydrochloride er tb12 30mg 1 G QL (60 EA por 30 días) oxymorphone hydrochloride er tb12 40mg 1 G QL (120 EA por 30 días) oxymorphone hydrochloride er tb12 5mg 1 G QL (60 EA por 30 días) oxymorphone hydrochloride er tb12 7.5mg 1 G QL (60 EA por 30 días) oxymorphone hydrochloride tabs 10mg 1 G QL (180 EA por 30 días) oxymorphone hydrochloride tabs 5mg 1 G QL (180 EA por 30 días) pentazocine/acetaminophen tabs 650mg; 25mg 1 G pentazocine/naloxone hcl tabs 0.5mg; 50mg 1 G PHRENILIN FORTE CAPS 650MG; 50MG piroxicam caps 10mg 1 G piroxicam caps 20mg 1 G PRIMLEV TABS 300MG; 10MG QL (360 EA por 30 días) PRIMLEV TABS 300MG; 5MG QL (360 EA por 30 días) PRIMLEV TABS 300MG; 7.5MG QL (360 EA por 30 días) reprexain tabs 10mg; 200mg 1 G salsalate tabs 500mg 1 G salsalate tabs 750mg 1 G SPRIX SOLN 15.75MG/SPRAY SUBSYS LIQD 100MCG PA SUBSYS LIQD 1200MCG PA SUBSYS LIQD 1600MCG PA SUBSYS LIQD 200MCG PA SUBSYS LIQD 400MCG PA SUBSYS LIQD 600MCG PA SUBSYS LIQD 800MCG PA sulindac tabs 150mg 1 G sulindac tabs 200mg 1 G SYNALGOS-DC CAPS 356.4MG; 30MG; 16MG TALWIN INJ 30MG/ML tencon tabs 325mg; 50mg 1 G tencon tabs 650mg; 50mg 1 G TIVORBEX CAPS 20MG TIVORBEX CAPS 40MG tolmetin sodium caps 400mg 1 G tolmetin sodium tabs 200mg 1 G tolmetin sodium tabs 600mg 1 G tramadol hcl er cp24 100mg 1 G tramadol hcl er cp24 150mg 1 G tramadol hcl er cp24 200mg 1 G tramadol hcl er cp24 300mg 1 G Página 78

80 tramadol hcl er tb24 100mg 1 G tramadol hcl er tb24 100mg 1 G tramadol hcl er tb24 200mg 1 G tramadol hcl er tb24 200mg 1 G tramadol hcl er tb24 300mg 1 G tramadol hcl er tb24 300mg 1 G tramadol hcl tabs 50mg 1 G tramadol hydrochloride/acetaminophen tabs 325mg; 37.5mg 1 G VANATOL LQ SOLN 325MG/15ML; 50MG/15ML; 40MG/15ML vicodin es tabs 300mg; 7.5mg 1 G QL (390 EA por 30 días) vicodin hp tabs 300mg; 10mg 1 G QL (180 EA por 30 días) vicodin tabs 300mg; 5mg 1 G QL (390 EA por 30 días) XARTEMIS XR TBCR 325MG; 7.5MG QL (120 EA por 30 días) xylon tabs 10mg; 200mg 1 G xylon tabs 10mg; 200mg 1 G zebutal caps 325mg; 50mg; 40mg 1 G ZIPSOR CAPS 25MG ZOHYDRO ER C12A 10MG QL (60 EA por 30 días) PA ZOHYDRO ER C12A 15MG QL (60 EA por 30 días) PA ZOHYDRO ER C12A 20MG QL (60 EA por 30 días) PA ZOHYDRO ER C12A 30MG QL (60 EA por 30 días) PA ZOHYDRO ER C12A 40MG QL (60 EA por 30 días) PA ZOHYDRO ER C12A 50MG QL (60 EA por 30 días) PA ZORVOLEX CAPS 18MG ZORVOLEX CAPS 35MG ZYDONE TABS 400MG; 10MG QL (180 EA por 30 días) ZYDONE TABS 400MG; 5MG QL (300 EA por 30 días) ZYDONE TABS 400MG; 7.5MG QL (210 EA por 30 días) Anestésicos glydo gel 2% 1 G lidocaine hcl jelly gel 2% 1 G lidocaine hcl viscous soln 2% 1 G lidocaine hcl gel 2% 1 G lidocaine hcl inj 0.5% 1 G B/D lidocaine hcl inj 0.5% 1 G B/D lidocaine hcl inj 1% 1 G B/D Página 79

81 lidocaine hcl inj 1% 1 G B/D lidocaine hcl inj 1.5% 1 G B/D lidocaine hcl inj 2% 1 G B/D lidocaine hcl inj 2% 1 G B/D lidocaine hcl inj 4% 1 G B/D lidocaine hcl soln 4% 1 G lidocaine hcl soln 4% 1 G lidocaine pak oint 5% 1 G lidocaine viscous soln 2% 1 G lidocaine/prilocaine crea 2.5%; 2.5% 1 G lidocaine oint 5% 1 G lidocaine ptch 5% 1 G PA premium lidocaine oint 5% 1 G SYNERA PTCH 70MG; 70MG Ansiolíticos alprazolam er tb24 0.5mg 1 G alprazolam er tb24 1mg 1 G alprazolam er tb24 2mg 1 G alprazolam er tb24 3mg 1 G ALPRAZOLAM INTENSOL CONC 1MG/ML alprazolam odt tbdp 0.25mg 1 G alprazolam odt tbdp 0.5mg 1 G alprazolam odt tbdp 1mg 1 G alprazolam odt tbdp 2mg 1 G alprazolam xr tb24 1mg 1 G alprazolam xr tb24 2mg 1 G alprazolam xr tb24 3mg 1 G alprazolam tabs 0.25mg 1 G alprazolam tabs 0.5mg 1 G alprazolam tabs 1mg 1 G alprazolam tabs 2mg 1 G buspirone hcl tabs 10mg 1 G buspirone hcl tabs 15mg 1 G buspirone hcl tabs 30mg 1 G buspirone hcl tabs 5mg 1 G buspirone hcl tabs 7.5mg 1 G chlordiazepoxide hcl caps 10mg 1 G chlordiazepoxide hcl caps 25mg 1 G chlordiazepoxide hcl caps 5mg 1 G clorazepate dipotassium tabs 15mg 1 G clorazepate dipotassium tabs 3.75mg 1 G clorazepate dipotassium tabs 7.5mg 1 G diazepam intensol conc 5mg/ml 1 G diazepam conc 5mg/ml 1 G diazepam inj 5mg/ml 1 G DIAZEPAM SOLN 1MG/ML Página 80

82 diazepam tabs 10mg 1 G diazepam tabs 2mg 1 G diazepam tabs 5mg 1 G estazolam tabs 1mg 1 G estazolam tabs 2mg 1 G flurazepam hcl caps 15mg 1 G flurazepam hcl caps 30mg 1 G lorazepam intensol conc 2mg/ml 1 G lorazepam conc 2mg/ml 1 G lorazepam inj 2mg/ml 1 G lorazepam inj 4mg/ml 1 G lorazepam tabs 0.5mg 1 G lorazepam tabs 1mg 1 G lorazepam tabs 2mg 1 G meprobamate tabs 200mg 1 G meprobamate tabs 400mg 1 G oxazepam caps 10mg 1 G oxazepam caps 15mg 1 G oxazepam caps 30mg 1 G triazolam tabs 0.125mg 1 G triazolam tabs 0.25mg 1 G Antibacterianos ak-poly-bac oint 500unit/gm; 10000unit/gm 1 G alcohol prep pads pads 70% 1 G ALTABAX OINT 1% amikacin sulfate inj 1gm/4ml 1 G HI amikacin sulfate inj 500mg/2ml 1 G HI amoxicillin er tb24 775mg 1 G amoxicillin/clavulanate potassium er tb mg; 62.5mg 1 G amoxicillin/clavulanate potassium chew 200mg; 28.5mg 1 G amoxicillin/clavulanate potassium chew 400mg; 57mg 1 G amoxicillin/clavulanate potassium susr 200mg/5ml; 1 G 28.5mg/5ml amoxicillin/clavulanate potassium susr 250mg/5ml; 62.5mg/5ml 1 G amoxicillin/clavulanate potassium susr 400mg/5ml; 57mg/5ml 1 G amoxicillin/clavulanate potassium susr 600mg/5ml; 1 G 42.9mg/5ml amoxicillin/clavulanate potassium tabs 250mg; 125mg 1 G amoxicillin/clavulanate potassium tabs 500mg; 125mg 1 G amoxicillin/clavulanate potassium tabs 875mg; 125mg 1 G amoxicillin caps 250mg 1 G amoxicillin caps 500mg 1 G amoxicillin chew 125mg 1 G amoxicillin chew 250mg 1 G amoxicillin susr 125mg/5ml 1 G Página 81

83 amoxicillin susr 200mg/5ml 1 G amoxicillin susr 250mg/5ml 1 G amoxicillin susr 400mg/5ml 1 G amoxicillin tabs 500mg 1 G amoxicillin tabs 875mg 1 G ampicillin sodium inj 10gm 1 G HI ampicillin sodium inj 10gm 1 G HI ampicillin sodium inj 125mg 1 G HI ampicillin sodium inj 1gm 1 G HI ampicillin sodium inj 1gm 1 G HI ampicillin sodium inj 1gm 1 G HI ampicillin sodium inj 250mg 1 G HI ampicillin sodium inj 2gm 1 G HI ampicillin sodium inj 2gm 1 G HI ampicillin sodium inj 500mg 1 G HI ampicillin-sulbactam inj 10gm; 5gm 1 G HI ampicillin-sulbactam inj 10gm; 5gm 1 G HI ampicillin-sulbactam inj 1gm; 0.5gm 1 G HI ampicillin-sulbactam inj 1gm; 0.5gm 1 G HI ampicillin-sulbactam inj 2gm; 1gm 1 G HI ampicillin caps 250mg 1 G ampicillin caps 500mg 1 G ampicillin susr 125mg/5ml 1 G ampicillin susr 250mg/5ml 1 G AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML AVELOX INJ 400MG/250ML; 0.8% HI AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM; 0 HI AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 2GM; 0 HI AZASITE SOLN 1% azithromycin inj 500mg 1 G HI azithromycin pack 1gm 1 G azithromycin susr 100mg/5ml 1 G azithromycin susr 200mg/5ml 1 G azithromycin tabs 250mg 1 G azithromycin tabs 250mg 1 G azithromycin tabs 500mg 1 G azithromycin tabs 500mg 1 G azithromycin tabs 600mg 1 G aztreonam inj 1gm 1 G HI aztreonam inj 2gm 1 G HI baciim inj 50000unit 1 G bacitracin/polymyxin b oint 500unit/gm; 10000unit/gm 1 G bacitracin inj 50000unit 1 G bacitracin oint 500unit/gm 1 G bactocill in dextrose inj 0; 1gm/50ml 1 G HI bactocill in dextrose inj 0; 2gm/50ml 1 G HI Página 82

84 BACTROBAN NASAL OINT 2% BESIVANCE SUSP 0.6% BICILLIN C-R INJ UNIT/ML; UNIT/ML BICILLIN C-R INJ UNIT/2ML; UNIT/2ML BICILLIN L-A INJ UNIT/2ML BICILLIN L-A INJ UNIT/4ML BICILLIN L-A INJ UNIT/ML BLEPHAMIDE S.O.P. OINT 0.2%; 10% BLEPHAMIDE SUSP 0.2%; 10% cefaclor er tb12 500mg 1 G cefaclor caps 250mg 1 G cefaclor caps 500mg 1 G cefaclor susr 125mg/5ml 1 G cefaclor susr 250mg/5ml 1 G cefaclor susr 375mg/5ml 1 G cefadroxil caps 500mg 1 G cefadroxil susr 250mg/5ml 1 G cefadroxil susr 500mg/5ml 1 G cefadroxil tabs 1gm 1 G cefazolin sodium/dextrose inj 1gm; 4% 1 G HI cefazolin sodium/dextrose inj 2gm; 3% 1 G HI cefazolin sodium inj 100gm 1 G HI cefazolin sodium inj 10gm 1 G HI cefazolin sodium inj 1gm 1 G HI cefazolin sodium inj 1gm 1 G HI cefazolin sodium inj 1gm; 5% 1 G HI cefazolin sodium inj 300gm 1 G HI cefazolin sodium inj 500mg 1 G HI cefazolin inj 2gm/100ml; 4% 1 G HI cefdinir caps 300mg 1 G cefdinir susr 125mg/5ml 1 G cefdinir susr 250mg/5ml 1 G cefditoren pivoxil tabs 200mg 1 G cefditoren pivoxil tabs 400mg 1 G cefepime/dextrose inj 1gm/50ml; 5% 1 G HI cefepime/dextrose inj 2gm/50ml; 5% 1 G HI cefepime inj 1gm/50ml 1 G HI cefepime inj 1gm 1 G HI cefepime inj 2gm/100ml 1 G HI cefepime inj 2gm 1 G HI cefixime susr 100mg/5ml 1 G cefixime susr 200mg/5ml 1 G cefotaxime sodium inj 10gm 1 G HI cefotaxime sodium inj 1gm 1 G HI cefotaxime sodium inj 2gm 1 G HI cefotaxime sodium inj 500mg 1 G HI Página 83

85 cefotetan/dextrose inj 1gm; 3.58% 1 G HI cefotetan/dextrose inj 2gm; 2.08% 1 G HI cefotetan inj 10gm 1 G HI cefotetan inj 1gm 1 G HI cefotetan inj 2gm 1 G HI cefoxitin sodium inj 10gm 1 G HI cefoxitin sodium inj 1gm 1 G HI cefoxitin sodium inj 1gm; 4% 1 G HI cefoxitin sodium inj 2gm 1 G HI cefoxitin sodium inj 2gm; 2.2% 1 G HI cefpodoxime proxetil susr 100mg/5ml 1 G cefpodoxime proxetil susr 50mg/5ml 1 G cefpodoxime proxetil tabs 100mg 1 G cefpodoxime proxetil tabs 200mg 1 G cefprozil susr 125mg/5ml 1 G cefprozil susr 250mg/5ml 1 G cefprozil tabs 250mg 1 G cefprozil tabs 500mg 1 G ceftazidime/dextrose inj 1gm/50ml; 5% 1 G HI ceftazidime/dextrose inj 2gm/50ml; 5% 1 G HI ceftazidime inj 1gm 1 G HI ceftazidime inj 2gm 1 G HI ceftazidime inj 6gm 1 G HI ceftibuten caps 400mg 1 G ceftibuten susr 180mg/5ml 1 G CEFTIN SUSR 125MG/5ML CEFTIN SUSR 250MG/5ML ceftriaxone in iso-osmotic dextrose inj 20mg/ml; 0 1 G HI ceftriaxone in iso-osmotic dextrose inj 40mg/ml; 0 1 G HI ceftriaxone sodium inj 100gm 1 G HI ceftriaxone sodium inj 10gm 1 G HI ceftriaxone sodium inj 1gm 1 G HI ceftriaxone sodium inj 1gm 1 G HI ceftriaxone sodium inj 250mg 1 G HI ceftriaxone sodium inj 2gm 1 G HI ceftriaxone sodium inj 2gm 1 G HI ceftriaxone sodium inj 500mg 1 G HI ceftriaxone/dextrose inj 1gm; 3.74% 1 G HI ceftriaxone/dextrose inj 2gm; 2.22% 1 G HI cefuroxime axetil tabs 250mg 1 G cefuroxime axetil tabs 500mg 1 G cefuroxime sodium inj 1.5gm 1 G HI cefuroxime sodium inj 1.5gm 1 G HI cefuroxime sodium inj 7.5gm 1 G HI cefuroxime sodium inj 7.5gm 1 G HI cefuroxime sodium inj 750mg 1 G HI Página 84

86 cefuroxime sodium inj 75gm 1 G HI cefuroxime/dextrose inj 750mg; 4.1% 1 G HI cephalexin caps 250mg 1 G cephalexin caps 500mg 1 G cephalexin caps 750mg 1 G cephalexin susr 125mg/5ml 1 G cephalexin susr 250mg/5ml 1 G cephalexin tabs 250mg 1 G cephalexin tabs 500mg 1 G chloramphenicol sodium succinate inj 1gm 1 G HI CILOXAN OINT 0.3% CIPRO HC SUSP 0.2%; 1% CIPRODEX SUSP 0.3%; 0.1% ciprofloxacin er tb mg; 0 1 G ciprofloxacin er tb24 500mg; 0 1 G ciprofloxacin hcl soln 0.3% 1 G ciprofloxacin hcl tabs 100mg 1 G ciprofloxacin hcl tabs 250mg 1 G ciprofloxacin hcl tabs 500mg 1 G ciprofloxacin hcl tabs 750mg 1 G ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% 1 G HI ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5% 1 G HI ciprofloxacin inj 200mg/20ml 1 G HI ciprofloxacin inj 400mg/40ml 1 G HI ciprofloxacin susr 250mg/5ml 1 G ciprofloxacin susr 500mg/5ml 1 G CLAFORAN/D5W INJ 1GM/50ML; 5% HI CLAFORAN/D5W INJ 2GM/50ML; 5% HI CLAFORAN INJ 1GM HI CLAFORAN INJ 2GM HI clarithromycin er tb24 500mg 1 G clarithromycin susr 125mg/5ml 1 G clarithromycin susr 250mg/5ml 1 G clarithromycin tabs 250mg 1 G clarithromycin tabs 500mg 1 G CLEOCIN SUPP 100MG clindacin etz pledgets swab 1% 1 G clindamax gel 1% 1 G clindamycin hcl caps 150mg 1 G clindamycin hcl caps 300mg 1 G clindamycin hcl caps 75mg 1 G clindamycin palmitate hcl solr 75mg/5ml 1 G clindamycin phosphate add-vantage inj 900mg/6ml 1 G HI clindamycin phosphate in d5w inj 300mg/50ml; 5% 1 G clindamycin phosphate in d5w inj 600mg/50ml; 5% 1 G clindamycin phosphate in d5w inj 900mg/50ml; 5% 1 G Página 85

87 clindamycin phosphate pharmacy bulk package inj 150mg/ml 1 G HI clindamycin phosphate crea 2% 1 G clindamycin phosphate foam 1% 1 G clindamycin phosphate gel 1% 1 G clindamycin phosphate inj 150mg/ml 1 G HI clindamycin phosphate inj 300mg/2ml 1 G HI clindamycin phosphate inj 600mg/4ml 1 G HI clindamycin phosphate inj 900mg/6ml 1 G HI clindamycin phosphate lotn 1% 1 G clindamycin phosphate soln 1% 1 G clindamycin phosphate swab 1% 1 G clindamycin/sodium chloride inj 300mg/50ml; 0.9% 1 G HI clindamycin/sodium chloride inj 600mg/50ml; 0.9% 1 G clindamycin/sodium chloride inj 900mg/50ml; 0.9% 1 G HI clindamycin inj 900mg/6ml 1 G HI CLINDESSE CREA 2% colistimethate sodium inj 150mg 1 G HI CORTISPORIN CREA 0.5%; 3.5MG/GM; 10000UNIT/GM DALVANCE INJ 500MG HI daptomycin inj 500mg HI demeclocycline hcl tabs 150mg 1 G demeclocycline hcl tabs 300mg 1 G dicloxacillin sodium caps 250mg 1 G dicloxacillin sodium caps 500mg 1 G DIFICID TABS 200MG DORIBAX INJ 250MG HI DORIBAX INJ 500MG HI doripenem inj 250mg 1 G HI doripenem inj 500mg 1 G HI doxy 100 inj 100mg 1 G HI doxycycline hyclate dr tbec 100mg 1 G doxycycline hyclate dr tbec 150mg 1 G doxycycline hyclate dr tbec 75mg 1 G doxycycline hyclate caps 100mg 1 G doxycycline hyclate caps 50mg 1 G doxycycline hyclate inj 100mg 1 G HI doxycycline hyclate tabs 100mg 1 G doxycycline hyclate tabs 20mg 1 G doxycycline monohydrate caps 100mg 1 G doxycycline monohydrate caps 150mg 1 G doxycycline monohydrate caps 50mg 1 G doxycycline monohydrate caps 75mg 1 G doxycycline monohydrate tabs 100mg 1 G doxycycline monohydrate tabs 150mg 1 G doxycycline monohydrate tabs 50mg 1 G doxycycline monohydrate tabs 75mg 1 G Página 86

88 doxycycline susr 25mg/5ml 1 G e.e.s. 400 tabs 400mg 1 G ERY-TAB TBEC 250MG ERY-TAB TBEC 333MG ERY-TAB TBEC 500MG ery pads 2% 1 G ERYPED 400 SUSR 400MG/5ML ERYTHROCIN LACTOBIONATE INJ 500MG HI erythrocin stearate tabs 250mg 1 G erythromycin base tabs 250mg 1 G erythromycin base tabs 500mg 1 G erythromycin ethylsuccinate susr 200mg/5ml 1 G erythromycin ethylsuccinate tabs 400mg 1 G erythromycin gel 2% 1 G erythromycin oint 5mg/gm 1 G erythromycin pads 2% 1 G erythromycin soln 2% 1 G FACTIVE TABS 320MG FLAGYL ER TB24 750MG gatifloxacin soln 0.5% 1 G gentak oint 0.3% 1 G gentamicin sulfate pediatric inj 10mg/ml 1 G HI gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9% 1 G HI gentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml; 0.9% 1 G HI gentamicin sulfate/0.9% sodium chloride inj 1.4mg/ml; 0.9% 1 G HI gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 0.9% 1 G HI gentamicin sulfate/0.9% sodium chloride inj 1mg/ml; 0.9% 1 G HI gentamicin sulfate/0.9% sodium chloride inj 2mg/ml; 0.9% 1 G HI gentamicin sulfate crea 0.1% 1 G gentamicin sulfate inj 10mg/ml 1 G HI gentamicin sulfate inj 10mg/ml 1 G HI gentamicin sulfate inj 40mg/ml 1 G HI gentamicin sulfate oint 0.1% 1 G gentamicin sulfate oint 0.3% 1 G gentamicin sulfate soln 0.3% 1 G ilotycin oint 5mg/gm 1 G imipenem/cilastatin inj 250mg; 250mg 1 G HI imipenem/cilastatin inj 500mg; 500mg 1 G HI INVANZ INJ 1GM HI INVANZ INJ 1GM HI isotonic gentamicin inj 0.8mg/ml; 0.9% 1 G HI KETEK TABS 300MG KETEK TABS 400MG lansoprazole/amoxicillin/clarithromycin misc 0; 0; 0 1 G levofloxacin in 5% dextrose inj 5%; 250mg/50ml 1 G HI levofloxacin in d5w inj 5%; 250mg/50ml 1 G HI Página 87

89 levofloxacin in d5w inj 5%; 500mg/100ml 1 G HI levofloxacin in d5w inj 5%; 750mg/150ml 1 G HI levofloxacin inj 25mg/ml 1 G levofloxacin soln 0.5% 1 G levofloxacin soln 25mg/ml 1 G levofloxacin tabs 250mg 1 G levofloxacin tabs 500mg 1 G levofloxacin tabs 750mg 1 G lincomycin hcl inj 300mg/ml 1 G HI linezolid inj 600mg/300ml 1 G HI linezolid inj 600mg/300ml; 0.9% 1 G HI linezolid inj 600mg/300ml; 0.9% 1 G HI linezolid susr 100mg/5ml linezolid tabs 600mg mafenide acetate pack 5% 1 G meropenem/sodium chloride inj 1gm/50ml; 0.9% 1 G HI meropenem/sodium chloride inj 500mg/50ml; 0.9% 1 G HI meropenem inj 1gm 1 G HI meropenem inj 500mg 1 G HI methenamine hippurate tabs 1gm 1 G metronidazole in nacl 0.79% inj 500mg/100ml; 0.79% 1 G HI metronidazole vaginal gel 0.75% 1 G metronidazole caps 375mg 1 G metronidazole crea 0.75% 1 G metronidazole gel 0.75% 1 G metronidazole gel 1% 1 G metronidazole inj 500mg/100ml; 0.79% 1 G HI metronidazole lotn 0.75% 1 G metronidazole tabs 250mg 1 G metronidazole tabs 500mg 1 G minocycline hcl er tb24 135mg 1 G minocycline hcl er tb24 45mg 1 G minocycline hcl er tb24 90mg 1 G minocycline hcl caps 100mg 1 G minocycline hcl caps 50mg 1 G minocycline hcl caps 75mg 1 G minocycline hcl tabs 100mg 1 G minocycline hcl tabs 50mg 1 G minocycline hcl tabs 75mg 1 G mondoxyne nl caps 100mg 1 G mondoxyne nl caps 50mg 1 G mondoxyne nl caps 75mg 1 G MONUROL PACK 5.631GM morgidox 1x100mg caps 100mg 1 G morgidox 1x50mg caps 50mg 1 G morgidox 2x100mg caps 100mg 1 G Página 88

90 MOXEZA SOLN 0.5% moxifloxacin hcl inj 400mg/250ml 1 G HI moxifloxacin hcl soln 0.5% 1 G moxifloxacin hcl tabs 400mg 1 G mupirocin calcium crea 2% 1 G mupirocin crea 2% 1 G mupirocin oint 2% 1 G nafcillin sodium inj 10gm 1 G HI nafcillin sodium inj 1gm 1 G HI nafcillin sodium inj 1gm 1 G HI nafcillin sodium inj 2gm 1 G HI nafcillin sodium inj 2gm 1 G HI NAFCILLIN INJ 0; 1GM/50ML 1 B HI NAFCILLIN INJ 0; 2GM/100ML 1 B HI neo-polycin hc oint 400unit/gm; 1%; 3.5mg/gm; 10000unit/gm 1 G neo-polycin oint 400unit/gm; 3.5mg/gm; 10000unit/gm 1 G neomycin sulfate tabs 500mg 1 G neomycin/bacitracin/polymyxin oint 400unit/gm; 5mg/gm; 10000unit/gm 1 G neomycin/polymyxin b sulfates soln 40mg/ml; unit/ml 1 G neomycin/polymyxin/bacitracin/hydrocortisone oint 400unit/gm; 1%; 0.5%; 10000unit/gm 1 G neomycin/polymyxin/gramicidin soln 0.025mg/ml; 1.75mg/ml; 1 G 10000unit/ml neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml; 1 G 10000unit/ml nitrofurantoin macrocrystals caps 100mg 1 G nitrofurantoin macrocrystals caps 25mg 1 G nitrofurantoin macrocrystals caps 50mg 1 G nitrofurantoin monohydrate/macrocrystals caps 100mg 1 G nitrofurantoin monohydrate caps 100mg 1 G nitrofurantoin susp 25mg/5ml 1 G NORITATE CREA 1% NOROXIN TABS 400MG NUVESSA GEL 1.3% ofloxacin soln 0.3% 1 G ofloxacin soln 0.3% 1 G ofloxacin tabs 300mg 1 G ofloxacin tabs 400mg 1 G OMECLAMOX-PAK MISC 500MG; 500MG; 20MG oxacillin sodium inj 10gm 1 G HI oxacillin sodium inj 1gm 1 G HI oxacillin sodium inj 2gm 1 G HI paromomycin sulfate caps 250mg 1 G penicillin g potassium in iso-osmotic dextrose inj 0; 20000unit/ml 1 G HI Página 89

91 penicillin g potassium in iso-osmotic dextrose inj 0; 1 G HI 40000unit/ml penicillin g potassium in iso-osmotic dextrose inj 0; 1 G HI 60000unit/ml penicillin g potassium inj unit 1 G HI penicillin g potassium inj unit 1 G HI penicillin g procaine inj unit/ml 1 G penicillin g sodium inj unit 1 G HI penicillin v potassium solr 125mg/5ml 1 G penicillin v potassium solr 250mg/5ml 1 G penicillin v potassium tabs 250mg 1 G penicillin v potassium tabs 500mg 1 G piperacillin sodium/ tazobactam sodium inj 36gm; 4.5gm 1 G HI piperacillin sodium/tazobactam sodium inj 2gm; 0.25gm 1 G HI piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm 1 G HI piperacillin/tazobactam inj 12gm; 1.5gm 1 G HI piperacillin/tazobactam inj 2gm; 0.25gm 1 G HI piperacillin/tazobactam inj 36gm; 4.5gm 1 G HI piperacillin/tazobactam inj 4gm; 0.5gm 1 G HI polycin oint 500unit/gm; 10000unit/gm 1 G polymyxin b sulfate/trimethoprim sulfate soln 10000unit/ml; 1 G 0.1% polymyxin b sulfate inj unit 1 G HI PRIMSOL SOLN 50MG/5ML rosadan crea 0.75% 1 G rosadan gel 0.75% 1 G silver sulfadiazine crea 1% 1 G SIVEXTRO INJ 200MG HI SIVEXTRO TABS 200MG PA sodium sulfacetamide soln 10% 1 G SOLODYN TB24 105MG SOLODYN TB24 115MG SOLODYN TB24 55MG SOLODYN TB24 65MG SOLODYN TB24 80MG ssd crea 1% 1 G streptomycin sulfate inj 1gm 1 G sulfacetamide sodium/prednisolone sodium phosphate soln 1 G 0.23%; 10% sulfacetamide sodium lotn 10% 1 G sulfacetamide sodium oint 10% 1 G sulfadiazine tabs 500mg 1 G sulfamethoxazole/trimethoprim ds tabs 800mg; 160mg 1 G sulfamethoxazole/trimethoprim inj 400mg/5ml; 80mg/5ml 1 G HI sulfamethoxazole/trimethoprim susp 200mg/5ml; 40mg/5ml 1 G sulfamethoxazole/trimethoprim tabs 400mg; 80mg 1 G Página 90

92 sulfamylon crea 85mg/gm 1 G sulfatrim pediatric susp 200mg/5ml; 40mg/5ml 1 G SUPRAX CAPS 400MG SUPRAX CHEW 100MG SUPRAX CHEW 200MG SUPRAX SUSR 500MG/5ML SYNERCID INJ 350MG; 150MG HI tazicef inj 1gm 1 G HI tazicef inj 1gm 1 G HI tazicef inj 2gm 1 G HI tazicef inj 6gm 1 G HI TEFLARO INJ 400MG HI TEFLARO INJ 600MG HI tetracycline hydrochloride caps 250mg 1 G tetracycline hydrochloride caps 500mg 1 G TIGECYCLINE INJ 50MG HI tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml 1 G HI tobramycin sulfate/sodium chloride inj 0.9%; 1.2mg/ml 1 G HI tobramycin sulfate inj 1.2gm/30ml 1 G HI tobramycin sulfate inj 1.2gm 1 G HI tobramycin sulfate inj 10mg/ml 1 G HI tobramycin sulfate inj 40mg/ml 1 G HI tobramycin sulfate inj 80mg/2ml 1 G HI tobramycin sulfate soln 0.3% 1 G TOBREX OINT 0.3% trimethoprim sulfate/polymyxin b sulfate soln 10000unit/ml; 1 G 0.1% trimethoprim tabs 100mg 1 G TYGACIL INJ 50MG HI vancomycin hcl in dextrose inj 5%; 1gm/200ml 1 G HI vancomycin hcl in dextrose inj 5%; 500mg/100ml 1 G HI vancomycin hcl in dextrose inj 5%; 750mg/150ml 1 G HI vancomycin hcl caps 125mg 1 G vancomycin hcl caps 250mg 1 G vancomycin hcl inj 0.9%; 1gm/200ml 1 G HI vancomycin hcl inj 1000mg 1 G HI vancomycin hcl inj 10gm 1 G HI vancomycin hcl inj 5000mg 1 G HI vancomycin hcl inj 500mg 1 G HI vancomycin hcl inj 750mg 1 G HI vancomycin inj 0.9%; 500mg/100ml 1 G HI vancomycin inj 0.9%; 750mg/150ml 1 G HI VANDAZOLE GEL 0.75% 1 B VIBRAMYCIN SYRP 50MG/5ML VIGAMOX SOLN 0.5% XIFAXAN TABS 200MG Página 91

93 XIFAXAN TABS 550MG ZERBAXA INJ 1GM; 0.5GM HI ZMAX SUSR 2GM ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML HI ZOSYN INJ 5%; 3GM/50ML; 0.375GM/50ML HI ZOSYN INJ 5%; 4GM/100ML; 0.5GM/100ML HI ZYLET SUSP 0.5%; 0.3% Anticonvulsivos APTIOM TABS 200MG QL (30 EA por 30 días) APTIOM TABS 400MG QL (30 EA por 30 días) APTIOM TABS 600MG QL (60 EA por 30 días) APTIOM TABS 800MG QL (30 EA por 30 días) BANZEL SUSP 40MG/ML BANZEL TABS 200MG BANZEL TABS 400MG BRIVIACT INJ 50MG/5ML QL (600 ML por 30 días) BRIVIACT SOLN 10MG/ML QL (1200 ML por 30 días) BRIVIACT TABS 100MG QL (120 EA por 30 días) BRIVIACT TABS 10MG QL (60 EA por 30 días) BRIVIACT TABS 25MG QL (60 EA por 30 días) BRIVIACT TABS 50MG QL (60 EA por 30 días) BRIVIACT TABS 75MG QL (60 EA por 30 días) carbamazepine er cp12 100mg 1 G carbamazepine er cp12 200mg 1 G carbamazepine er cp12 300mg 1 G carbamazepine er tb12 100mg 1 G carbamazepine er tb12 200mg 1 G carbamazepine er tb12 400mg 1 G carbamazepine chew 100mg 1 G carbamazepine susp 100mg/5ml 1 G carbamazepine tabs 200mg 1 G CELONTIN CAPS 300MG clonazepam odt tbdp 0.125mg 1 G clonazepam odt tbdp 0.25mg 1 G clonazepam odt tbdp 0.5mg 1 G clonazepam odt tbdp 1mg 1 G clonazepam odt tbdp 2mg 1 G clonazepam tabs 0.5mg 1 G clonazepam tabs 1mg 1 G clonazepam tabs 2mg 1 G DIASTAT ACUDIAL GEL 10MG DIASTAT ACUDIAL GEL 20MG DIASTAT PEDIATRIC GEL 2.5MG DIAZEPAM GEL 10MG DIAZEPAM GEL 2.5MG DIAZEPAM GEL 20MG Página 92

94 DILANTIN CAPS 30MG divalproex sodium dr tbec 125mg 1 G divalproex sodium dr tbec 250mg 1 G divalproex sodium dr tbec 500mg 1 G divalproex sodium er tb24 250mg 1 G divalproex sodium er tb24 500mg 1 G divalproex sodium csdr 125mg 1 G epitol tabs 200mg 1 G EQUETRO CP12 100MG 1 B EQUETRO CP12 200MG 1 B EQUETRO CP12 300MG 1 B ethosuximide caps 250mg 1 G ethosuximide soln 250mg/5ml 1 G felbamate susp 600mg/5ml felbamate tabs 400mg 1 G felbamate tabs 600mg 1 G fosphenytoin sodium inj 100mg pe/2ml 1 G fosphenytoin sodium inj 500mg pe/10ml 1 G FYCOMPA SUSP 0.5MG/ML FYCOMPA TABS 10MG FYCOMPA TABS 12MG FYCOMPA TABS 2MG FYCOMPA TABS 4MG FYCOMPA TABS 6MG FYCOMPA TABS 8MG gabapentin caps 100mg 1 G gabapentin caps 300mg 1 G gabapentin caps 400mg 1 G gabapentin soln 250mg/5ml 1 G gabapentin tabs 600mg 1 G gabapentin tabs 800mg 1 G GABITRIL TABS 12MG GABITRIL TABS 16MG LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE KIT 0 LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE KIT 0 LAMICTAL STARTER/TAKING VALPROATE KIT 25MG LAMICTAL XR KIT 0 LAMICTAL XR KIT 0 LAMICTAL XR KIT 0 lamotrigine er tb24 100mg 1 G lamotrigine er tb24 200mg 1 G lamotrigine er tb24 250mg 1 G lamotrigine er tb24 25mg 1 G lamotrigine er tb24 300mg 1 G Página 93

95 lamotrigine er tb24 50mg 1 G lamotrigine odt tbdp 100mg 1 G lamotrigine odt tbdp 200mg 1 G lamotrigine odt tbdp 25mg 1 G lamotrigine odt tbdp 50mg 1 G lamotrigine titration kit 0 1 G lamotrigine titration kit 0 1 G lamotrigine titration kit 0 1 G lamotrigine chew 25mg 1 G lamotrigine chew 5mg 1 G lamotrigine tabs 100mg 1 G lamotrigine tabs 150mg 1 G lamotrigine tabs 200mg 1 G lamotrigine tabs 25mg 1 G levetiracetam er tb24 500mg 1 G levetiracetam er tb24 750mg 1 G levetiracetam inj 1000mg/100ml; 750mg/100ml 1 G levetiracetam inj 1500mg/100ml; 540mg/100ml 1 G levetiracetam inj 500mg/100ml; 820mg/100ml 1 G levetiracetam inj 500mg/5ml 1 G B/D levetiracetam soln 100mg/ml 1 G levetiracetam tabs 1000mg 1 G levetiracetam tabs 250mg 1 G levetiracetam tabs 500mg 1 G levetiracetam tabs 750mg 1 G LYRICA CAPS 100MG LYRICA CAPS 150MG LYRICA CAPS 200MG LYRICA CAPS 225MG LYRICA CAPS 25MG LYRICA CAPS 300MG LYRICA CAPS 50MG LYRICA CAPS 75MG LYRICA SOLN 20MG/ML magnesium sulfate in d5w inj 5%; 10gm/500ml 1 G HI magnesium sulfate in d5w inj 5%; 1gm/100ml 1 G HI magnesium sulfate in d5w inj 5%; 1gm/100ml 1 G HI ONFI SUSP 2.5MG/ML ONFI TABS 10MG ONFI TABS 20MG ONFI TABS 5MG oxcarbazepine susp 300mg/5ml 1 G oxcarbazepine tabs 150mg 1 G oxcarbazepine tabs 300mg 1 G oxcarbazepine tabs 600mg 1 G OXTELLAR XR TB24 150MG Página 94

96 OXTELLAR XR TB24 300MG OXTELLAR XR TB24 600MG PEGANONE TABS 250MG phenobarbital elix 20mg/5ml 1 G phenobarbital tabs 100mg 1 G phenobarbital tabs 15mg 1 G phenobarbital tabs 16.2mg 1 G phenobarbital tabs 30mg 1 G phenobarbital tabs 32.4mg 1 G phenobarbital tabs 60mg 1 G phenobarbital tabs 64.8mg 1 G phenobarbital tabs 97.2mg 1 G phenytoin infatabs chew 50mg 1 G phenytoin sodium extended caps 100mg 1 G phenytoin sodium extended caps 200mg 1 G phenytoin sodium extended caps 300mg 1 G phenytoin sodium inj 50mg/ml 1 G phenytoin chew 50mg 1 G phenytoin susp 125mg/5ml 1 G POTIGA TABS 200MG POTIGA TABS 300MG POTIGA TABS 400MG POTIGA TABS 50MG primidone tabs 250mg 1 G primidone tabs 50mg 1 G QUDEXY XR CS24 100MG QUDEXY XR CS24 150MG QUDEXY XR CS24 200MG QUDEXY XR CS24 25MG QUDEXY XR CS24 50MG roweepra tabs 1000mg 1 G roweepra tabs 500mg 1 G roweepra tabs 750mg 1 G SABRIL PACK 500MG SABRIL TABS 500MG SPRITAM TB3D 1000MG QL (60 EA por 30 días) SPRITAM TB3D 250MG QL (60 EA por 30 días) SPRITAM TB3D 500MG QL (60 EA por 30 días) SPRITAM TB3D 750MG QL (120 EA por 30 días) STAVZOR CPDR 125MG STAVZOR CPDR 250MG STAVZOR CPDR 500MG tiagabine hydrochloride tabs 2mg 1 G tiagabine hydrochloride tabs 4mg 1 G topiramate er cs24 100mg 1 G topiramate er cs24 150mg 1 G Página 95

97 topiramate er cs24 200mg 1 G topiramate er cs24 25mg 1 G topiramate er cs24 50mg 1 G topiramate cpsp 15mg 1 G topiramate cpsp 25mg 1 G topiramate tabs 100mg 1 G topiramate tabs 200mg 1 G topiramate tabs 25mg 1 G topiramate tabs 50mg 1 G TROKENDI XR CP24 100MG QL (30 EA por 30 días) TROKENDI XR CP24 200MG QL (60 EA por 30 días) TROKENDI XR CP24 25MG QL (30 EA por 30 días) TROKENDI XR CP24 50MG QL (30 EA por 30 días) valproate sodium inj 100mg/ml 1 G valproic acid caps 250mg 1 G valproic acid soln 250mg/5ml 1 G VIMPAT INJ 200MG/20ML VIMPAT SOLN 10MG/ML VIMPAT TABS 100MG VIMPAT TABS 150MG VIMPAT TABS 200MG VIMPAT TABS 50MG zonisamide caps 100mg 1 G zonisamide caps 25mg 1 G zonisamide caps 50mg 1 G Antidepresivos amitriptyline hcl tabs 100mg 1 G amitriptyline hcl tabs 10mg 1 G amitriptyline hcl tabs 150mg 1 G amitriptyline hcl tabs 25mg 1 G amitriptyline hcl tabs 50mg 1 G amitriptyline hcl tabs 75mg 1 G amoxapine tabs 100mg 1 G amoxapine tabs 150mg 1 G amoxapine tabs 25mg 1 G amoxapine tabs 50mg 1 G APLENZIN TB24 174MG APLENZIN TB24 348MG APLENZIN TB24 522MG bupropion hcl er tb12 150mg 1 G bupropion hcl er tb12 200mg 1 G bupropion hcl sr tb12 100mg 1 G bupropion hcl sr tb12 150mg 1 G bupropion hcl sr tb12 200mg 1 G bupropion hcl xl tb24 150mg 1 G bupropion hcl xl tb24 300mg 1 G Página 96

98 bupropion hcl tabs 100mg 1 G bupropion hcl tabs 75mg 1 G chlordiazepoxide/amitriptyline tabs 12.5mg; 5mg 1 G chlordiazepoxide/amitriptyline tabs 25mg; 10mg 1 G clomipramine hcl caps 25mg 1 G clomipramine hcl caps 50mg 1 G clomipramine hcl caps 75mg 1 G desipramine hcl tabs 100mg 1 G desipramine hcl tabs 10mg 1 G desipramine hcl tabs 150mg 1 G desipramine hcl tabs 25mg 1 G desipramine hcl tabs 50mg 1 G desipramine hcl tabs 75mg 1 G doxepin hcl caps 100mg 1 G doxepin hcl caps 10mg 1 G doxepin hcl caps 150mg 1 G doxepin hcl caps 25mg 1 G doxepin hcl caps 50mg 1 G doxepin hcl caps 75mg 1 G doxepin hcl conc 10mg/ml 1 G EMSAM PT24 12MG/24HR EMSAM PT24 6MG/24HR EMSAM PT24 9MG/24HR FORFIVO XL TB24 450MG imipramine hcl tabs 10mg 1 G imipramine hcl tabs 25mg 1 G imipramine hcl tabs 50mg 1 G imipramine pamoate caps 100mg 1 G imipramine pamoate caps 125mg 1 G imipramine pamoate caps 150mg 1 G imipramine pamoate caps 75mg 1 G maprotiline hcl tabs 25mg 1 G maprotiline hcl tabs 50mg 1 G maprotiline hcl tabs 75mg 1 G MARPLAN TABS 10MG mirtazapine odt tbdp 15mg 1 G mirtazapine odt tbdp 30mg 1 G mirtazapine odt tbdp 45mg 1 G mirtazapine tabs 15mg 1 G mirtazapine tabs 30mg 1 G mirtazapine tabs 45mg 1 G mirtazapine tabs 7.5mg 1 G nefazodone hcl tabs 100mg 1 G nefazodone hcl tabs 150mg 1 G nefazodone hcl tabs 200mg 1 G nefazodone hcl tabs 250mg 1 G Página 97

99 nefazodone hcl tabs 50mg 1 G nortriptyline hcl caps 10mg 1 G nortriptyline hcl caps 25mg 1 G nortriptyline hcl caps 50mg 1 G nortriptyline hcl caps 75mg 1 G nortriptyline hcl soln 10mg/5ml 1 G OLEPTRO TB24 150MG OLEPTRO TB24 300MG perphenazine/amitriptyline tabs 10mg; 2mg 1 G perphenazine/amitriptyline tabs 10mg; 4mg 1 G perphenazine/amitriptyline tabs 25mg; 2mg 1 G perphenazine/amitriptyline tabs 25mg; 4mg 1 G perphenazine/amitriptyline tabs 50mg; 4mg 1 G phenelzine sulfate tabs 15mg 1 G protriptyline hcl tabs 10mg 1 G protriptyline hcl tabs 5mg 1 G tranylcypromine sulfate tabs 10mg 1 G trazodone hcl tabs 100mg 1 G trazodone hcl tabs 150mg 1 G trazodone hcl tabs 300mg 1 G trazodone hcl tabs 50mg 1 G trimipramine maleate caps 100mg 1 G trimipramine maleate caps 25mg 1 G trimipramine maleate caps 50mg 1 G TRINTELLIX TABS 10MG QL (30 EA por 30 días) ST TRINTELLIX TABS 20MG QL (30 EA por 30 días) ST TRINTELLIX TABS 5MG QL (30 EA por 30 días) ST Antidepressants BRISDELLE CAPS 7.5MG QL (30 EA por 30 días) citalopram hydrobromide soln 10mg/5ml 1 G citalopram hydrobromide tabs 10mg 1 G citalopram hydrobromide tabs 20mg 1 G citalopram hydrobromide tabs 40mg 1 G desvenlafaxine er tb24 100mg 1 G ST desvenlafaxine er tb24 100mg 1 G ST desvenlafaxine er tb24 25mg 1 G ST desvenlafaxine er tb24 50mg 1 G ST desvenlafaxine er tb24 50mg 1 G ST duloxetine hcl cpep 20mg 1 G duloxetine hcl cpep 30mg 1 G duloxetine hcl cpep 40mg 1 G duloxetine hcl cpep 60mg 1 G escitalopram oxalate soln 5mg/5ml 1 G Página 98

100 escitalopram oxalate tabs 10mg 1 G escitalopram oxalate tabs 20mg 1 G escitalopram oxalate tabs 5mg 1 G FETZIMA TITRATION PACK C4PK 0 QL (56 EA por 365 días) ST FETZIMA CP24 120MG QL (30 EA por 30 días) ST FETZIMA CP24 20MG QL (30 EA por 30 días) ST FETZIMA CP24 40MG QL (30 EA por 30 días) ST FETZIMA CP24 80MG QL (30 EA por 30 días) ST fluoxetine dr cpdr 90mg 1 G fluoxetine hcl caps 10mg 1 G fluoxetine hcl caps 20mg 1 G fluoxetine hcl caps 40mg 1 G fluoxetine hcl soln 20mg/5ml 1 G fluoxetine hcl tabs 10mg 1 G fluoxetine hcl tabs 10mg 1 G fluoxetine hcl tabs 20mg 1 G fluoxetine hcl tabs 20mg 1 G fluoxetine hcl tabs 60mg 1 G fluoxetine caps 10mg 1 G fluoxetine caps 20mg 1 G fluvoxamine maleate er cp24 100mg 1 G QL (60 EA por 30 días) fluvoxamine maleate er cp24 150mg 1 G QL (60 EA por 30 días) fluvoxamine maleate tabs 100mg 1 G QL (90 EA por 30 días) fluvoxamine maleate tabs 25mg 1 G QL (30 EA por 30 días) fluvoxamine maleate tabs 50mg 1 G QL (60 EA por 30 días) KHEDEZLA TB24 100MG ST KHEDEZLA TB24 50MG ST olanzapine/fluoxetine caps 25mg; 12mg 1 G olanzapine/fluoxetine caps 25mg; 3mg 1 G olanzapine/fluoxetine caps 25mg; 6mg 1 G olanzapine/fluoxetine caps 50mg; 12mg 1 G olanzapine/fluoxetine caps 50mg; 6mg 1 G paroxetine hcl er tb mg 1 G paroxetine hcl er tb24 25mg 1 G paroxetine hcl er tb mg 1 G paroxetine hcl tabs 10mg 1 G Página 99

101 paroxetine hcl tabs 20mg 1 G paroxetine hcl tabs 30mg 1 G paroxetine hcl tabs 40mg 1 G PAXIL SUSP 10MG/5ML ST PEXEVA TABS 10MG PEXEVA TABS 20MG PEXEVA TABS 30MG PEXEVA TABS 40MG PRISTIQ TB24 100MG ST PRISTIQ TB24 25MG ST PRISTIQ TB24 50MG ST sertraline hcl conc 20mg/ml 1 G sertraline hcl tabs 100mg 1 G sertraline hcl tabs 25mg 1 G sertraline hcl tabs 50mg 1 G venlafaxine hcl er cp24 150mg 1 G venlafaxine hcl er cp mg 1 G venlafaxine hcl er cp24 75mg 1 G venlafaxine hcl er tb24 150mg 1 G venlafaxine hcl er tb24 225mg 1 G venlafaxine hcl er tb mg 1 G venlafaxine hcl er tb24 75mg 1 G venlafaxine hcl tabs 100mg 1 G venlafaxine hcl tabs 25mg 1 G venlafaxine hcl tabs 37.5mg 1 G venlafaxine hcl tabs 50mg 1 G venlafaxine hcl tabs 75mg 1 G VIIBRYD STARTER PACK KIT 0 QL (30 EA por 30 días) ST VIIBRYD KIT 0 QL (30 EA por 30 días) ST VIIBRYD TABS 10MG QL (30 EA por 30 días) ST VIIBRYD TABS 20MG QL (30 EA por 30 días) ST VIIBRYD TABS 40MG QL (30 EA por 30 días) ST Antieméticos AKYNZEO CAPS 300MG; 0.5MG PA ALOXI INJ 0.25MG/5ML HI ANZEMET INJ 20MG/ML PA ANZEMET TABS 100MG QL (5 EA por 30 días) PA ANZEMET TABS 50MG QL (5 EA por 30 días) PA aprepitant caps 0 1 G B/D aprepitant caps 125mg 1 G B/D aprepitant caps 40mg 1 G B/D Página 100

102 aprepitant caps 80mg 1 G B/D CESAMET CAPS 1MG PA dronabinol caps 10mg 1 G B/D dronabinol caps 2.5mg 1 G B/D dronabinol caps 5mg 1 G B/D EMEND SUSR 125MG B/D granisetron hcl inj 0.1mg/ml 1 G HI granisetron hcl inj 1mg/ml 1 G HI granisetron hcl inj 1mg/ml 1 G HI granisetron hcl tabs 1mg 1 G PA meclizine hcl tabs 12.5mg 1 G meclizine hcl tabs 25mg 1 G ondansetron hcl inj 40mg/20ml 1 G B/D ondansetron hcl inj 4mg/2ml 1 G B/D ondansetron hcl inj 4mg/2ml 1 G B/D ondansetron hcl soln 4mg/5ml 1 G B/D ondansetron hcl tabs 24mg 1 G B/D ondansetron hcl tabs 4mg 1 G B/D ondansetron hcl tabs 8mg 1 G B/D ondansetron odt tbdp 4mg 1 G B/D ondansetron odt tbdp 8mg 1 G B/D phenadoz supp 12.5mg 1 G phenadoz supp 25mg 1 G phenergan supp 12.5mg 1 G phenergan supp 25mg 1 G phenergan supp 50mg 1 G promethazine hcl supp 12.5mg 1 G promethazine hcl supp 25mg 1 G promethazine hcl supp 50mg 1 G promethegan supp 12.5mg 1 G promethegan supp 25mg 1 G promethegan supp 50mg 1 G SANCUSO PTCH 3.1MG/24HR PA TRANSDERM-SCOP PT72 1MG/3DAYS trimethobenzamide hcl caps 300mg 1 G PA ZUPLENZ FILM 4MG B/D ZUPLENZ FILM 8MG B/D Antimicobacterianos CAPASTAT SULFATE INJ 1GM B/D cycloserine caps 250mg 1 G dapsone tabs 100mg 1 G dapsone tabs 25mg 1 G ethambutol hcl tabs 100mg 1 G ethambutol hcl tabs 400mg 1 G isoniazid inj 100mg/ml 1 G isoniazid syrp 50mg/5ml 1 G Página 101

103 isoniazid tabs 100mg 1 G isoniazid tabs 300mg 1 G PASER PACK 4GM PRIFTIN TABS 150MG pyrazinamide tabs 500mg 1 G rifabutin caps 150mg 1 G rifampin caps 150mg 1 G rifampin caps 300mg 1 G rifampin inj 600mg 1 G B/D RIFATER TABS 50MG; 300MG; 120MG SIRTURO TABS 100MG TRECATOR TABS 250MG Antimicóticos ABELCET INJ 5MG/ML HI AMBISOME INJ 50MG HI amphotericin b inj 50mg 1 G HI CANCIDAS INJ 50MG HI CANCIDAS INJ 70MG HI ciclodan crea 0.77% 1 G ciclodan soln 8% 1 G ciclopirox nail lacquer soln 8% 1 G ciclopirox olamine crea 0.77% 1 G ciclopirox gel 0.77% 1 G ST ciclopirox sham 1% 1 G ST ciclopirox susp 0.77% 1 G clotrimazole/betamethasone dipropionate crea 0.05%; 1% 1 G clotrimazole/betamethasone dipropionate lotn 0.05%; 1% 1 G clotrimazole crea 1% 1 G clotrimazole lozg 10mg 1 G clotrimazole soln 1% 1 G CRESEMBA CAPS 186MG CRESEMBA INJ 372MG econazole nitrate crea 1% 1 G ERAXIS INJ 100MG HI ERAXIS INJ 50MG HI ERTACZO CREA 2% ST EXELDERM CREA 1% EXELDERM SOLN 1% fluconazole in dextrose inj 56mg/ml; 200mg/100ml 1 G HI fluconazole in dextrose inj 56mg/ml; 400mg/200ml 1 G HI fluconazole in nacl inj 100mg/50ml; 0.9% 1 G HI fluconazole in nacl inj 200mg/100ml; 0.9% 1 G HI fluconazole in nacl inj 400mg/200ml; 0.9% 1 G HI fluconazole susr 10mg/ml 1 G fluconazole susr 40mg/ml 1 G fluconazole tabs 100mg 1 G Página 102

104 fluconazole tabs 150mg 1 G fluconazole tabs 200mg 1 G fluconazole tabs 50mg 1 G flucytosine caps 250mg 1 G flucytosine caps 500mg 1 G griseofulvin microsize susp 125mg/5ml 1 G griseofulvin microsize tabs 500mg 1 G griseofulvin ultramicrosize tabs 125mg 1 G griseofulvin ultramicrosize tabs 250mg 1 G GYNAZOLE-1 CREA 2% itraconazole caps 100mg 1 G KERYDIN SOLN 5% ketoconazole crea 2% 1 G ketoconazole foam 2% 1 G ketoconazole sham 2% 1 G ketoconazole tabs 200mg 1 G KETODAN KIT KIT 2%; 0; 0 ketodan foam 2% 1 G LAMISIL PACK 125MG QL (60 EA por 30 días) LAMISIL PACK 187.5MG QL (30 EA por 30 días) LUZU CREA 1% ST MENTAX CREA 1% miconazole 3 supp 200mg 1 G MYCAMINE INJ 100MG HI MYCAMINE INJ 50MG HI naftifine hcl crea 1% 1 G ST naftifine hydrochloride crea 2% 1 G ST NATACYN SUSP 5% NOXAFIL SUSP 40MG/ML NOXAFIL TBEC 100MG nyamyc powd unit/gm 1 G nystatin/triamcinolone crea unit/gm; 0.1% 1 G nystatin/triamcinolone oint unit/gm; 0.1% 1 G nystatin crea unit/gm 1 G nystatin oint unit/gm 1 G nystatin powd unit/gm 1 G nystatin susp unit/ml 1 G nystatin tabs unit 1 G nystop powd unit/gm 1 G ONMEL TABS 200MG ORAVIG TABS 50MG oxiconazole nitrate crea 1% 1 G ST OXISTAT LOTN 1% ST SPORANOX SOLN 10MG/ML terbinafine hcl tabs 250mg 1 G terconazole crea 0.4% 1 G Página 103

105 terconazole crea 0.8% 1 G terconazole supp 80mg 1 G voriconazole inj 200mg PA voriconazole susr 40mg/ml 1 G PA voriconazole tabs 200mg 1 G PA voriconazole tabs 50mg 1 G PA zazole crea 0.4% 1 G zazole crea 0.8% 1 G zazole supp 80mg 1 G Antineoplásicos ABRAXANE INJ 900MG; 100MG HI adrucil inj 2.5gm/50ml 1 G HI adrucil inj 500mg/10ml 1 G HI adrucil inj 5gm/100ml 1 G HI AFINITOR DISPERZ TBSO 2MG PA AFINITOR DISPERZ TBSO 3MG PA AFINITOR DISPERZ TBSO 5MG PA AFINITOR TABS 10MG PA AFINITOR TABS 2.5MG PA AFINITOR TABS 5MG PA AFINITOR TABS 7.5MG PA ALECENSA CAPS 150MG QL (240 EA por 30 días) PA ALIMTA INJ 100MG HI ALIMTA INJ 500MG HI ALUNBRIG TABS 30MG PA amifostine inj 500mg 1 G HI anastrozole tabs 1mg 1 G ARRANON INJ 5MG/ML HI ARZERRA INJ 1000MG/50ML B/D ARZERRA INJ 100MG/5ML B/D AVASTIN INJ 100MG/4ML HI AVASTIN INJ 400MG/16ML HI azacitidine inj 100mg 1 G HI BAVENCIO INJ 200MG/10ML HI BELEODAQ INJ 500MG HI BENDEKA INJ 100MG/4ML HI bexarotene caps 75mg bicalutamide tabs 50mg 1 G BICNU INJ 100MG HI bleomycin sulfate inj 15unit 1 G HI bleomycin sulfate inj 30unit 1 G HI BOSULIF TABS 100MG PA BOSULIF TABS 500MG PA busulfan inj 6mg/ml 1 G HI BUSULFEX INJ 6MG/ML HI Página 104

106 CABOMETYX TABS 20MG PA CABOMETYX TABS 40MG PA CABOMETYX TABS 60MG PA CAPRELSA TABS 100MG QL (60 EA por 30 días) PA CAPRELSA TABS 300MG QL (30 EA por 30 días) PA carboplatin inj 150mg/15ml 1 G HI carboplatin inj 450mg/45ml 1 G HI carboplatin inj 50mg/5ml 1 G HI carboplatin inj 600mg/60ml 1 G HI cisplatin inj 100mg/100ml 1 G HI cisplatin inj 200mg/200ml 1 G HI cisplatin inj 50mg/50ml 1 G HI cladribine inj 10mg/10ml 1 G HI clofarabine inj 1mg/ml 1 G HI COMETRIQ KIT 0 PA COMETRIQ KIT 0 PA COMETRIQ KIT 20MG PA COSMEGEN INJ 0.5MG B/D COTELLIC TABS 20MG QL (63 EA por 28 días) PA cyclophosphamide caps 25mg 1 G B/D cyclophosphamide caps 50mg 1 G B/D cyclophosphamide inj 1gm 1 G HI cyclophosphamide inj 2gm 1 G HI cyclophosphamide inj 500mg 1 G HI CYRAMZA INJ 100MG/10ML B/D CYRAMZA INJ 500MG/50ML B/D cytarabine aqueous inj 100mg/ml 1 G HI cytarabine aqueous inj 20mg/ml 1 G HI cytarabine aqueous inj 20mg/ml 1 G HI cytarabine aqueous inj 20mg/ml 1 G HI dacarbazine inj 100mg 1 G HI dacarbazine inj 200mg 1 G HI DARZALEX INJ 100MG/5ML HI DARZALEX INJ 400MG/20ML HI daunorubicin hcl inj 5mg/ml 1 G HI decitabine inj 50mg HI dexrazoxane inj 250mg 1 G HI dexrazoxane inj 500mg 1 G HI DOCEFREZ INJ 20MG B/D docetaxel inj 140mg/7ml B/D docetaxel inj 160mg/16ml B/D docetaxel inj 160mg/8ml B/D docetaxel inj 160mg/8ml B/D Página 105

107 docetaxel inj 160mg/8ml B/D docetaxel inj 200mg/10ml B/D docetaxel inj 200mg/20ml B/D docetaxel inj 20mg/0.5ml B/D docetaxel inj 20mg/2ml B/D docetaxel inj 20mg/ml B/D docetaxel inj 80mg/2ml B/D docetaxel inj 80mg/4ml B/D docetaxel inj 80mg/8ml B/D doxorubicin hcl liposome inj 2mg/ml B/D doxorubicin hcl inj 10mg 1 G HI doxorubicin hcl inj 2mg/ml 1 G HI doxorubicin hcl inj 50mg 1 G HI DROXIA CAPS 200MG DROXIA CAPS 300MG DROXIA CAPS 400MG ELITEK INJ 1.5MG HI ELITEK INJ 7.5MG HI EMCYT CAPS 140MG EMPLICITI INJ 300MG PA EMPLICITI INJ 400MG PA epirubicin hcl inj 200mg/100ml 1 G HI epirubicin hcl inj 50mg/25ml 1 G HI ERBITUX INJ 100MG/50ML HI ERBITUX INJ 200MG/100ML HI ERIVEDGE CAPS 150MG QL (30 EA por 30 días) PA ERWINAZE INJ 10000UNIT B/D ETHYOL INJ 500MG HI ETOPOPHOS INJ 100MG HI etoposide inj 100mg/5ml 1 G HI etoposide inj 1gm/50ml 1 G HI etoposide inj 500mg/25ml 1 G HI EVOMELA INJ 50MG HI exemestane tabs 25mg 1 G FARESTON TABS 60MG FARYDAK CAPS 10MG PA FARYDAK CAPS 15MG PA FARYDAK CAPS 20MG PA FASLODEX INJ 250MG/5ML B/D fludarabine phosphate inj 50mg/2ml 1 G HI fludarabine phosphate inj 50mg 1 G HI fluorouracil inj 1gm/20ml 1 G HI fluorouracil inj 2.5gm/50ml 1 G HI fluorouracil inj 500mg/10ml 1 G HI fluorouracil inj 5gm/100ml 1 G HI Página 106

108 flutamide caps 125mg 1 G FOLOTYN INJ 20MG/ML B/D FOLOTYN INJ 40MG/2ML B/D FUSILEV INJ 50MG B/D GAZYVA INJ 1000MG/40ML B/D gemcitabine hcl inj 1gm 1 G HI gemcitabine hcl inj 200mg 1 G HI gemcitabine hcl inj 2gm 1 G HI gemcitabine inj 1gm/26.3ml 1 G HI gemcitabine inj 200mg/5.26ml 1 G HI gemcitabine inj 2gm/52.6ml 1 G HI GILOTRIF TABS 20MG PA GILOTRIF TABS 30MG PA GILOTRIF TABS 40MG PA GLEOSTINE CAPS 100MG GLEOSTINE CAPS 10MG GLEOSTINE CAPS 40MG GLEOSTINE CAPS 5MG HALAVEN INJ 1MG/2ML B/D HERCEPTIN INJ 150MG HI HERCEPTIN INJ 440MG HI HEXALEN CAPS 50MG hydroxyurea caps 500mg 1 G IBRANCE CAPS 100MG QL (21 EA por 28 días) PA IBRANCE CAPS 125MG QL (21 EA por 28 días) PA IBRANCE CAPS 75MG QL (21 EA por 28 días) PA ICLUSIG TABS 15MG PA ICLUSIG TABS 45MG PA idarubicin hcl inj 10mg/10ml 1 G HI idarubicin hcl inj 20mg/20ml 1 G HI idarubicin hcl inj 5mg/5ml 1 G HI ifosfamide inj 1gm/20ml 1 G HI ifosfamide inj 1gm 1 G HI ifosfamide inj 3gm/60ml 1 G HI ifosfamide inj 3gm 1 G HI imatinib mesylate tabs 100mg PA imatinib mesylate tabs 400mg PA IMBRUVICA CAPS 140MG QL (120 EA por 30 días) PA IMFINZI INJ 120MG/2.4ML B/D IMFINZI INJ 500MG/10ML B/D INLYTA TABS 1MG QL (240 EA por 30 días) PA Página 107

109 INLYTA TABS 5MG QL (120 EA por 30 días) PA IRESSA TABS 250MG QL (30 EA por 30 días) PA irinotecan hcl inj 100mg/5ml 1 G HI irinotecan inj 100mg/5ml 1 G HI irinotecan inj 40mg/2ml 1 G HI ISTODAX (OVERFILL) INJ 10MG HI ISTODAX INJ 10MG HI IXEMPRA KIT INJ 15MG HI IXEMPRA KIT INJ 45MG HI JAKAFI TABS 10MG QL (60 EA por 30 días) PA JAKAFI TABS 15MG QL (60 EA por 30 días) PA JAKAFI TABS 20MG QL (60 EA por 30 días) PA JAKAFI TABS 25MG QL (60 EA por 30 días) PA JAKAFI TABS 5MG QL (60 EA por 30 días) PA JEVTANA INJ 60MG/1.5ML B/D KADCYLA INJ 100MG B/D KADCYLA INJ 160MG B/D KEYTRUDA INJ 100MG/4ML HI KEYTRUDA INJ 50MG HI KISQALI FEMARA 200 DOSE TBPK 2.5MG; 200MG QL (49 EA por 28 días) PA KISQALI FEMARA 400 DOSE TBPK 2.5MG; 200MG QL (70 EA por 28 días) PA KISQALI FEMARA 600 DOSE TBPK 2.5MG; 200MG QL (91 EA por 28 días) PA KISQALI TABS 200MG QL (63 EA por 28 días) PA KISQALI TABS 200MG QL (63 EA por 28 días) PA KISQALI TABS 200MG QL (63 EA por 28 días) PA KYPROLIS INJ 30MG B/D KYPROLIS INJ 60MG B/D LARTRUVO INJ 190MG/19ML B/D LARTRUVO INJ 500MG/50ML B/D LENVIMA 10 MG DAILY DOSE CPPK 10MG PA LENVIMA 14 MG DAILY DOSE CPPK 0 PA LENVIMA 18 MG DAILY DOSE CPPK 0 PA LENVIMA 20 MG DAILY DOSE CPPK 10MG PA Página 108

110 LENVIMA 24 MG DAILY DOSE CPPK 0 PA LENVIMA 8 MG DAILY DOSE CPPK 4MG PA letrozole tabs 2.5mg 1 G QL (30 EA por 30 días) leucovorin calcium inj 100mg 1 G HI leucovorin calcium inj 200mg 1 G HI leucovorin calcium inj 350mg 1 G HI leucovorin calcium inj 500mg 1 G HI leucovorin calcium inj 50mg 1 G HI leucovorin calcium tabs 10mg 1 G leucovorin calcium tabs 15mg 1 G leucovorin calcium tabs 25mg 1 G leucovorin calcium tabs 5mg 1 G LEUKERAN TABS 2MG levoleucovorin calcium inj 175mg/17.5ml B/D levoleucovorin inj 175mg/17.5ml B/D levoleucovorin inj 250mg/25ml B/D levoleucovorin inj 50mg B/D LIPODOX 50 INJ 2MG/ML B/D LIPODOX INJ 2MG/ML B/D LOMUSTINE CAPS 100MG LOMUSTINE CAPS 10MG LOMUSTINE CAPS 40MG LONSURF TABS 6.14MG; 15MG QL (100 EA por 28 días) PA LONSURF TABS 8.19MG; 20MG QL (80 EA por 28 días) PA LYNPARZA CAPS 50MG QL (480 EA por 30 días) PA MATULANE CAPS 50MG MEKINIST TABS 0.5MG PA MEKINIST TABS 2MG PA melphalan hydrochloride inj 50mg 1 G HI mercaptopurine tabs 50mg 1 G mesna inj 100mg/ml 1 G HI MESNEX TABS 400MG mitomycin inj 20mg 1 G HI mitomycin inj 40mg 1 G HI mitomycin inj 5mg 1 G HI mitoxantrone hcl inj 2mg/ml 1 G HI mitoxantrone hcl inj 2mg/ml 1 G HI mitoxantrone hcl inj 2mg/ml 1 G HI MUSTARGEN INJ 10MG HI NERLYNX TABS 40MG PA NEXAVAR TABS 200MG PA nilutamide tabs 150mg Página 109

111 NINLARO CAPS 2.3MG QL (3 EA por 28 días) PA NINLARO CAPS 3MG QL (3 EA por 28 días) PA NINLARO CAPS 4MG QL (3 EA por 28 días) PA NIPENT INJ 10MG HI ODOMZO CAPS 200MG QL (30 EA por 30 días) PA ONCASPAR INJ 750UNIT/ML B/D ONIVYDE INJ 43MG/10ML PA OPDIVO INJ 100MG/10ML B/D OPDIVO INJ 40MG/4ML B/D oxaliplatin inj 100mg/20ml 1 G HI oxaliplatin inj 100mg 1 G HI oxaliplatin inj 50mg/10ml 1 G HI oxaliplatin inj 50mg 1 G HI paclitaxel inj 100mg/16.7ml 1 G HI paclitaxel inj 150mg/25ml 1 G HI paclitaxel inj 300mg/50ml 1 G HI paclitaxel inj 30mg/5ml 1 G HI PANRETIN GEL 0.1% PERJETA INJ 420MG/14ML B/D POMALYST CAPS 1MG QL (21 EA por 28 días) PA POMALYST CAPS 2MG QL (21 EA por 28 días) PA POMALYST CAPS 3MG QL (21 EA por 28 días) PA POMALYST CAPS 4MG QL (21 EA por 28 días) PA PORTRAZZA INJ 800MG/50ML B/D PROLEUKIN INJ UNIT HI PURIXAN SUSP 2000MG/100ML REVLIMID CAPS 10MG PA REVLIMID CAPS 15MG PA REVLIMID CAPS 2.5MG PA REVLIMID CAPS 20MG PA REVLIMID CAPS 25MG PA REVLIMID CAPS 5MG PA RITUXAN HYCELA INJ 23400UNT/11.7ML; HI 1400MG/11.7ML RITUXAN HYCELA INJ 26800UNT/13.4ML; HI 1600MG/13.4ML RITUXAN INJ 100MG/10ML HI RITUXAN INJ 500MG/50ML HI RUBRACA TABS 200MG QL (120 EA por 30 días) PA Página 110

112 RUBRACA TABS 250MG QL (120 EA por 30 días) PA RUBRACA TABS 300MG QL (120 EA por 30 días) PA RYDAPT CAPS 25MG PA SOLTAMOX SOLN 10MG/5ML SPRYCEL TABS 100MG PA SPRYCEL TABS 140MG PA SPRYCEL TABS 20MG PA SPRYCEL TABS 50MG PA SPRYCEL TABS 70MG PA SPRYCEL TABS 80MG PA STIVARGA TABS 40MG PA SUTENT CAPS 12.5MG PA SUTENT CAPS 25MG PA SUTENT CAPS 37.5MG PA SUTENT CAPS 50MG PA SYLATRON INJ 200MCG PA SYLATRON INJ 300MCG PA SYLATRON INJ 300MCG PA SYLATRON INJ 600MCG PA SYLATRON INJ 600MCG PA SYNRIBO INJ 3.5MG PA TABLOID TABS 40MG TAFINLAR CAPS 50MG PA TAFINLAR CAPS 75MG PA TAGRISSO TABS 40MG QL (30 EA por 30 días) PA TAGRISSO TABS 80MG QL (30 EA por 30 días) PA tamoxifen citrate tabs 10mg 1 G tamoxifen citrate tabs 20mg 1 G TARCEVA TABS 100MG PA TARCEVA TABS 150MG PA TARCEVA TABS 25MG PA TARGRETIN GEL 1% QL (60 GM por 30 días) TASIGNA CAPS 150MG PA TASIGNA CAPS 200MG PA TECENTRIQ INJ 1200MG/20ML B/D TEMODAR INJ 100MG HI TEPADINA INJ 100MG TEPADINA INJ 15MG THALOMID CAPS 100MG PA THALOMID CAPS 150MG PA THALOMID CAPS 200MG PA THALOMID CAPS 50MG PA Página 111

113 thiotepa inj 15mg 1 G toposar inj 100mg/5ml 1 G HI toposar inj 1gm/50ml 1 G HI toposar inj 500mg/25ml 1 G HI toposar inj 500mg/25ml 1 G HI topotecan hcl inj 4mg/4ml HI topotecan hcl inj 4mg HI TREANDA INJ 100MG HI TREANDA INJ 180MG/2ML HI TREANDA INJ 25MG HI TREANDA INJ 45MG/0.5ML HI tretinoin caps 10mg TRISENOX INJ 10MG/10ML B/D TYKERB TABS 250MG PA UNITUXIN INJ 17.5MG/5ML B/D VALCHLOR GEL 0.016% PA VECTIBIX INJ 100MG/5ML HI VECTIBIX INJ 400MG/20ML HI VELCADE INJ 3.5MG HI VENCLEXTA STARTING PACK TBPK 0 QL (84 EA por 365 días) PA VENCLEXTA TABS 100MG QL (120 EA por 30 días) PA VENCLEXTA TABS 10MG QL (60 EA por 30 días) PA VENCLEXTA TABS 50MG QL (30 EA por 30 días) PA vinblastine sulfate inj 1mg/ml 1 G HI vincasar pfs inj 1mg/ml 1 G HI vincristine sulfate inj 1mg/ml 1 G HI vinorelbine tartrate inj 10mg/ml 1 G HI vinorelbine tartrate inj 50mg/5ml 1 G HI VOTRIENT TABS 200MG PA XALKORI CAPS 200MG QL (60 EA por 30 días) PA XALKORI CAPS 250MG QL (60 EA por 30 días) PA XTANDI CAPS 40MG QL (120 EA por 30 días) PA YERVOY INJ 200MG/40ML B/D YERVOY INJ 50MG/10ML B/D YONDELIS INJ 1MG PA ZALTRAP INJ 100MG/4ML B/D ZALTRAP INJ 200MG/8ML B/D ZANOSAR INJ 1GM B/D Página 112

114 ZEJULA CAPS 100MG QL (90 EA por 30 días) PA ZELBORAF TABS 240MG QL (240 EA por 30 días) PA ZOLINZA CAPS 100MG ZYDELIG TABS 100MG PA ZYDELIG TABS 150MG PA ZYKADIA CAPS 150MG PA ZYTIGA TABS 250MG PA ZYTIGA TABS 500MG PA Antiparasitarios ALBENZA TABS 200MG ALINIA SUSR 100MG/5ML ALINIA TABS 500MG atovaquone/proguanil hcl tabs 250mg; 100mg 1 G atovaquone/proguanil hcl tabs 62.5mg; 25mg 1 G ATOVAQUONE SUSP 750MG/5ML BILTRICIDE TABS 600MG chloroquine phosphate tabs 250mg 1 G chloroquine phosphate tabs 500mg 1 G COARTEM TABS 20MG; 120MG DARAPRIM TABS 25MG EURAX CREA 10% EURAX LOTN 10% hydroxychloroquine sulfate tabs 200mg 1 G ivermectin tabs 3mg 1 G lindane lotn 1% 1 G lindane sham 1% 1 G malathion lotn 0.5% 1 G mefloquine hcl tabs 250mg 1 G NEBUPENT SOLR 300MG B/D PENTAM 300 INJ 300MG B/D permethrin crea 5% 1 G PRIMAQUINE PHOSPHATE TABS 26.3MG 1 B quinine sulfate caps 324mg 1 G SKLICE LOTN 0.5% spinosad susp 0.9% 1 G tinidazole tabs 250mg 1 G tinidazole tabs 500mg 1 G ULESFIA LOTN 5% Antipsicóticos aripiprazole odt tbdp 10mg 1 G aripiprazole odt tbdp 15mg 1 G aripiprazole soln 1mg/ml 1 G aripiprazole tabs 10mg 1 G aripiprazole tabs 15mg 1 G Página 113

115 aripiprazole tabs 20mg 1 G aripiprazole tabs 2mg 1 G aripiprazole tabs 30mg 1 G aripiprazole tabs 5mg 1 G ARISTADA INJ 1064MG/3.9ML QL (3.9 ML por 60 días) ARISTADA INJ 441MG/1.6ML QL (1.6 ML por 30 días) ARISTADA INJ 662MG/2.4ML QL (2.4 ML por 30 días) ARISTADA INJ 882MG/3.2ML QL (3.2 ML por 30 días) chlorpromazine hcl inj 25mg/ml 1 G chlorpromazine hcl inj 50mg/2ml 1 G chlorpromazine hcl tabs 100mg 1 G chlorpromazine hcl tabs 10mg 1 G chlorpromazine hcl tabs 200mg 1 G chlorpromazine hcl tabs 25mg 1 G chlorpromazine hcl tabs 50mg 1 G clozapine odt tbdp 100mg 1 G clozapine odt tbdp 12.5mg 1 G clozapine odt tbdp 150mg 1 G clozapine odt tbdp 200mg 1 G clozapine odt tbdp 25mg 1 G clozapine tabs 100mg 1 G clozapine tabs 200mg 1 G clozapine tabs 25mg 1 G clozapine tabs 50mg 1 G compro supp 25mg 1 G FANAPT TITRATION PACK TABS 0 FANAPT TABS 10MG FANAPT TABS 12MG FANAPT TABS 1MG FANAPT TABS 2MG FANAPT TABS 4MG FANAPT TABS 6MG FANAPT TABS 8MG fluphenazine decanoate inj 25mg/ml 1 G fluphenazine hcl conc 5mg/ml 1 G fluphenazine hcl elix 2.5mg/5ml 1 G fluphenazine hcl inj 2.5mg/ml 1 G fluphenazine hcl tabs 10mg 1 G fluphenazine hcl tabs 1mg 1 G fluphenazine hcl tabs 2.5mg 1 G fluphenazine hcl tabs 5mg 1 G GEODON INJ 20MG haloperidol decanoate inj 100mg/ml 1 G haloperidol decanoate inj 50mg/ml 1 G haloperidol lactate inj 5mg/ml 1 G haloperidol conc 2mg/ml 1 G Página 114

116 haloperidol tabs 0.5mg 1 G haloperidol tabs 10mg 1 G haloperidol tabs 1mg 1 G haloperidol tabs 20mg 1 G haloperidol tabs 2mg 1 G haloperidol tabs 5mg 1 G INVEGA SUSTENNA INJ 117MG/0.75ML QL (0.75 ML por 28 días) INVEGA SUSTENNA INJ 156MG/ML QL (1 ML por 28 días) INVEGA SUSTENNA INJ 234MG/1.5ML QL (1.5 ML por 28 días) INVEGA SUSTENNA INJ 39MG/0.25ML QL (0.25 ML por 28 días) INVEGA SUSTENNA INJ 78MG/0.5ML QL (0.5 ML por 28 días) INVEGA TRINZA INJ 273MG/0.875ML QL (0.88 ML por 90 días) INVEGA TRINZA INJ 410MG/1.315ML QL (1.32 ML por 90 días) INVEGA TRINZA INJ 546MG/1.75ML QL (1.75 ML por 90 días) INVEGA TRINZA INJ 819MG/2.625ML QL (2.63 ML por 90 días) LATUDA TABS 120MG LATUDA TABS 20MG LATUDA TABS 40MG LATUDA TABS 60MG LATUDA TABS 80MG loxapine succinate caps 10mg 1 G loxapine succinate caps 25mg 1 G loxapine succinate caps 50mg 1 G loxapine succinate caps 5mg 1 G loxapine caps 10mg 1 G loxapine caps 25mg 1 G loxapine caps 50mg 1 G loxapine caps 5mg 1 G molindone hydrochloride tabs 10mg 1 G molindone hydrochloride tabs 25mg 1 G molindone hydrochloride tabs 5mg 1 G NUPLAZID TABS 17MG QL (60 EA por 30 días) PA olanzapine odt tbdp 10mg 1 G olanzapine odt tbdp 15mg 1 G olanzapine odt tbdp 20mg 1 G olanzapine odt tbdp 5mg 1 G olanzapine inj 10mg 1 G olanzapine tabs 10mg 1 G olanzapine tabs 15mg 1 G olanzapine tabs 2.5mg 1 G olanzapine tabs 20mg 1 G olanzapine tabs 5mg 1 G olanzapine tabs 7.5mg 1 G paliperidone er tb24 1.5mg 1 G paliperidone er tb24 3mg 1 G Página 115

117 paliperidone er tb24 6mg 1 G paliperidone er tb24 9mg 1 G perphenazine tabs 16mg 1 G perphenazine tabs 2mg 1 G perphenazine tabs 4mg 1 G perphenazine tabs 8mg 1 G pimozide tabs 1mg 1 G pimozide tabs 2mg 1 G prochlorperazine edisylate inj 5mg/ml 1 G prochlorperazine maleate tabs 10mg 1 G prochlorperazine maleate tabs 5mg 1 G prochlorperazine supp 25mg 1 G quetiapine fumarate er tb24 150mg 1 G quetiapine fumarate er tb24 200mg 1 G quetiapine fumarate er tb24 300mg 1 G quetiapine fumarate er tb24 400mg 1 G quetiapine fumarate er tb24 50mg 1 G quetiapine fumarate tabs 100mg 1 G quetiapine fumarate tabs 200mg 1 G quetiapine fumarate tabs 25mg 1 G quetiapine fumarate tabs 300mg 1 G quetiapine fumarate tabs 400mg 1 G quetiapine fumarate tabs 50mg 1 G REXULTI TABS 0.25MG REXULTI TABS 0.5MG REXULTI TABS 1MG REXULTI TABS 2MG REXULTI TABS 3MG REXULTI TABS 4MG RISPERDAL CONSTA INJ 12.5MG QL (2 EA por 28 días) RISPERDAL CONSTA INJ 25MG QL (2 EA por 28 días) RISPERDAL CONSTA INJ 37.5MG QL (2 EA por 28 días) RISPERDAL CONSTA INJ 50MG QL (2 EA por 28 días) risperidone m-tab tbdp 0.5mg 1 G risperidone m-tab tbdp 2mg 1 G risperidone odt tbdp 0.25mg 1 G risperidone odt tbdp 0.5mg 1 G risperidone odt tbdp 1mg 1 G risperidone odt tbdp 2mg 1 G risperidone odt tbdp 3mg 1 G risperidone odt tbdp 4mg 1 G risperidone soln 1mg/ml 1 G risperidone tabs 0.25mg 1 G risperidone tabs 0.5mg 1 G risperidone tabs 1mg 1 G risperidone tabs 2mg 1 G Página 116

118 risperidone tabs 3mg 1 G risperidone tabs 4mg 1 G SAPHRIS SUBL 10MG QL (60 EA por 30 días) SAPHRIS SUBL 2.5MG QL (60 EA por 30 días) SAPHRIS SUBL 5MG QL (60 EA por 30 días) thioridazine hcl tabs 100mg 1 G thioridazine hcl tabs 10mg 1 G thioridazine hcl tabs 25mg 1 G thioridazine hcl tabs 50mg 1 G thiothixene caps 10mg 1 G thiothixene caps 1mg 1 G thiothixene caps 2mg 1 G thiothixene caps 5mg 1 G trifluoperazine hcl tabs 10mg 1 G trifluoperazine hcl tabs 1mg 1 G trifluoperazine hcl tabs 2mg 1 G trifluoperazine hcl tabs 5mg 1 G VERSACLOZ SUSP 50MG/ML VRAYLAR CAPS 1.5MG VRAYLAR CAPS 3MG VRAYLAR CAPS 4.5MG VRAYLAR CAPS 6MG VRAYLAR CPPK 0 ziprasidone hcl caps 20mg 1 G ziprasidone hcl caps 40mg 1 G ziprasidone hcl caps 60mg 1 G ziprasidone hcl caps 80mg 1 G ZYPREXA RELPREVV INJ 210MG QL (2 EA por 28 días) ZYPREXA RELPREVV INJ 300MG QL (2 EA por 28 días) ZYPREXA RELPREVV INJ 405MG QL (1 EA por 28 días) Antivírico abacavir sulfate/lamivudine/zidovudine tabs 300mg; 150mg; 300mg abacavir/lamivudine tabs 600mg; 300mg abacavir tabs 300mg 1 G acyclovir sodium inj 50mg/ml 1 G B/D acyclovir caps 200mg 1 G acyclovir oint 5% 1 G acyclovir susp 200mg/5ml 1 G acyclovir tabs 400mg 1 G acyclovir tabs 800mg 1 G adefovir dipivoxil tabs 10mg 1 G PA APTIVUS CAPS 250MG APTIVUS SOLN 100MG/ML ATRIPLA TABS 600MG; 200MG; 300MG BARACLUDE SOLN 0.05MG/ML Página 117

119 cidofovir inj 75mg/ml 1 G B/D COMPLERA TABS 200MG; 25MG; 300MG CRIXIVAN CAPS 200MG CRIXIVAN CAPS 400MG DENAVIR CREA 1% DESCOVY TABS 200MG; 25MG QL (30 EA por 30 días) didanosine cpdr 125mg 1 G didanosine cpdr 200mg 1 G didanosine cpdr 250mg 1 G didanosine cpdr 400mg 1 G EDURANT TABS 25MG EMTRIVA CAPS 200MG EMTRIVA SOLN 10MG/ML entecavir tabs 0.5mg 1 G entecavir tabs 1mg 1 G EPCLUSA TABS 400MG; 100MG QL (28 EA por 28 días) PA EPIVIR HBV SOLN 5MG/ML EVOTAZ TABS 300MG; 150MG famciclovir tabs 125mg 1 G famciclovir tabs 250mg 1 G famciclovir tabs 500mg 1 G FUZEON INJ 90MG QL (60 EA por 30 días) ganciclovir inj 500mg 1 G B/D GENVOYA TABS 150MG; 150MG; 200MG; 10MG HARVONI TABS 90MG; 400MG QL (28 EA por 28 días) PA INTELENCE TABS 100MG INTELENCE TABS 200MG INTELENCE TABS 25MG INTRON A W/DILUENT INJ 10MU PA INTRON A W/DILUENT INJ 18MU PA INTRON A W/DILUENT INJ 50MU PA INTRON A INJ 10MU/ML PA INTRON A INJ 10MU PA INTRON A INJ 18MU PA INTRON A INJ 50MU PA INTRON A INJ UNIT/ML PA INVIRASE CAPS 200MG INVIRASE TABS 500MG ISENTRESS HD TABS 600MG ISENTRESS CHEW 100MG ISENTRESS CHEW 25MG ISENTRESS PACK 100MG ISENTRESS TABS 400MG KALETRA SOLN 400MG/5ML; 100MG/5ML Página 118

120 KALETRA TABS 100MG; 25MG KALETRA TABS 200MG; 50MG lamivudine/zidovudine tabs 150mg; 300mg 1 G lamivudine soln 10mg/ml 1 G lamivudine tabs 100mg 1 G lamivudine tabs 150mg 1 G lamivudine tabs 300mg 1 G LEXIVA SUSP 50MG/ML LEXIVA TABS 700MG lopinavir/ritonavir soln 400mg/5ml; 100mg/5ml 1 G nevirapine er tb24 100mg 1 G nevirapine er tb24 400mg 1 G nevirapine susp 50mg/5ml 1 G nevirapine tabs 200mg 1 G NORVIR CAPS 100MG NORVIR SOLN 80MG/ML NORVIR TABS 100MG ODEFSEY TABS 200MG; 25MG; 25MG QL (30 EA por 30 días) OLYSIO CAPS 150MG QL (28 EA por 28 días) PA oseltamivir phosphate caps 30mg 1 G oseltamivir phosphate caps 45mg 1 G oseltamivir phosphate caps 75mg 1 G PEGASYS PROCLICK INJ 135MCG/0.5ML QL (4 ML por 28 días) PA PEGASYS PROCLICK INJ 180MCG/0.5ML QL (4 ML por 28 días) PA PEGASYS INJ 180MCG/0.5ML QL (4 ML por 28 días) PA PEGASYS INJ 180MCG/ML QL (4 ML por 28 días) PA PREZCOBIX TABS 150MG; 800MG PREZISTA SUSP 100MG/ML PREZISTA TABS 150MG PREZISTA TABS 600MG PREZISTA TABS 75MG PREZISTA TABS 800MG RELENZA DISKHALER AEPB 5MG/BLISTER RESCRIPTOR TABS 100MG RESCRIPTOR TABS 200MG RETROVIR IV INFUSION INJ 10MG/ML REYATAZ CAPS 150MG REYATAZ CAPS 200MG REYATAZ CAPS 300MG REYATAZ PACK 50MG ribavirin caps 200mg 1 G ribavirin tabs 200mg 1 G rimantadine hcl tabs 100mg 1 G SELZENTRY SOLN 20MG/ML SELZENTRY TABS 150MG Página 119

121 SELZENTRY TABS 25MG SELZENTRY TABS 300MG SELZENTRY TABS 75MG stavudine caps 15mg 1 G stavudine caps 20mg 1 G stavudine caps 30mg 1 G stavudine caps 40mg 1 G stavudine solr 1mg/ml 1 G STRIBILD TABS 150MG; 150MG; 200MG; 300MG SUSTIVA CAPS 200MG SUSTIVA CAPS 50MG SUSTIVA TABS 600MG TAMIFLU SUSR 6MG/ML TIVICAY TABS 10MG TIVICAY TABS 25MG TIVICAY TABS 50MG trifluridine soln 1% 1 G TRIUMEQ TABS 600MG; 50MG; 300MG QL (30 EA por 30 días) TRUVADA TABS 100MG; 150MG TRUVADA TABS 133MG; 200MG TRUVADA TABS 167MG; 250MG TRUVADA TABS 200MG; 300MG TYBOST TABS 150MG TYZEKA TABS 600MG valacyclovir hcl tabs 1gm 1 G valacyclovir hcl tabs 500mg 1 G valganciclovir hydrochlorde solr 50mg/ml valganciclovir tabs 450mg VIDEX PEDIATRIC SOLR 2GM VIDEX PEDIATRIC SOLR 4GM VIRACEPT TABS 250MG VIRACEPT TABS 625MG VIREAD POWD 40MG/GM VIREAD TABS 150MG VIREAD TABS 200MG VIREAD TABS 250MG VIREAD TABS 300MG VITEKTA TABS 150MG VITEKTA TABS 85MG XERESE CREA 5%; 1% ZERIT SOLR 1MG/ML ZIAGEN SOLN 20MG/ML zidovudine caps 100mg 1 G zidovudine syrp 50mg/5ml 1 G zidovudine tabs 300mg 1 G ZIRGAN GEL 0.15% Página 120

122 ZOVIRAX CREA 5% Electrolitos/minerales/metales/vitaminas AMINOSYN 7%/ELECTROLYTES INJ 124MEQ/L; 900MG/100ML; 690MG/100ML; 96MEQ/L; 900MG/100ML; 210MG/100ML; 510MG/100ML; 660MG/100ML; 510MG/100ML; 10MEQ/L; 280MG/100ML; 310MG/100ML; 30MMOLE/L; 65MEQ/L; 610MG/100ML; 300MG/100ML; 65MEQ/L; 370MG/100ML; 120MG/100ML; 44MG/100ML; 560MG/100ML AMINOSYN 8.5%/ELECTROLYTES INJ 142MEQ/L; 1100MG/100ML; 850MG/100ML; 98MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML; 10MEQ/L; 340MG/100ML; 380MG/100ML; 30MEQ/L; 65MEQ/L; 750MG/100ML; 370MG/100ML; 65MEQ/L; 460MG/100ML; 150MG/100ML; 44MG/100ML; 680MG/100ML AMINOSYN II 8.5%/ELECTROLYTES INJ 61MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 86MEQ/L; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 10MEQ/L; 146MG/100ML; 253MG/100ML; 30MMOLE/L; 66MEQ/L; 614MG/100ML; 450MG/100ML; 80MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML AMINOSYN II INJ 107.6MEQ/L; 1490MG/100ML; 1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML; 447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML AMINOSYN II INJ 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML medicamento HI HI HI HI HI HI Requisitos/Límites Página 121

123 AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; HI 298MG/100ML; 722MG/100ML; 530MG/100ML; 38MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML AMINOSYN M INJ 65MEQ/L; 448MG/100ML; HI 343MG/100ML; 40MEQ/L; 448MG/100ML; 105MG/100ML; 252MG/100ML; 329MG/100ML; 252MG/100ML; 3MEQ/L; 140MG/100ML; 154MG/100ML; 3.5MMOLE/L; 13MEQ/L; 300MG/100ML; 147MG/100ML; 40MEQ/L; 182MG/100ML; 56MG/100ML; 31MG/100ML; 280MG/100ML AMINOSYN-HBC INJ 7.1MEQ/100ML; 660MG/100ML; HI 507MG/100ML; 4MEQ/100ML; 660MG/100ML; 154MG/100ML; 789MG/100ML; 1576MG/100ML; 265MG/100ML; 206MG/100ML; 1.12GM/100ML; 228MG/100ML; 448MG/100ML; 221MG/100ML; 272MG/100ML; 88MG/100ML; 33MG/100ML; 789MG/100ML AMINOSYN-PF 7% INJ 32.5MEQ/L; 490MG/100ML; HI 861MG/100ML; 370MG/100ML; 576MG/100ML; 270MG/100ML; 220MG/100ML; 534MG/100ML; 831MG/100ML; 475MG/100ML; 125MG/100ML; 10.69GM/L; 300MG/100ML; 570MG/100ML; 70GM/L; 347MG/100ML; 50MG/100ML; 360MG/100ML; 125MG/100ML; 44MG/100ML; 452MG/100ML AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML; HI 1227MG/100ML; 527MG/100ML; 820MG/100ML; 385MG/100ML; 312MG/100ML; 760MG/100ML; 1200MG/100ML; 677MG/100ML; 180MG/100ML; 427MG/100ML; 812MG/100ML; 495MG/100ML; 3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML; 44MG/100ML; 673MG/100ML AMINOSYN-RF INJ 113MEQ/L; 600MG/100ML; HI 429MG/100ML; 462MG/100ML; 726MG/100ML; 535MG/100ML; 726MG/100ML; 726MG/100ML; 330MG/100ML; 165MG/100ML; 528MG/100ML AMINOSYN INJ 148MEQ/L; 1280MG/100ML; 980MG/100ML; 1280MG/100ML; 300MG/100ML; 720MG/100ML; 940MG/100ML; 720MG/100ML; 400MG/100ML; 440MG/100ML; 5.4MEQ/L; 860MG/100ML; 420MG/100ML; 520MG/100ML; 160MG/100ML; 44MG/100ML; 800MG/100ML HI Página 122

124 AMINOSYN INJ 90MEQ/L; 1100MG/100ML; HI 850MG/100ML; 35MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML; 340MG/100ML; 380MG/100ML; 5.4MEQ/L; 750MG/100ML; 370MG/100ML; 460MG/100ML; 150MG/100ML; 44MG/100ML; 680MG/100ML ammonium chloride inj 5meq/ml 1 G HI AURYXIA TABS 210MG bp folinatal plus b tabs 200mg; 12mcg; 1mg; 75mg 1 G bp multinatal plus chew 50mg; 0; 250mg; 0; 6mcg; 2mg; 1 G 40mg; 1mg; 50mg; 2mg; 3.5unit; 15mg bp multinatal plus tabs 60mg; 0; 200mg; 0; 2mg; 12mcg; 1 G 30mg; 1mg; 100mg; 20mg; 50mg; 3.4mg; 3mg; 30unit; 15mg c-nate dha caps 100mg; 400unit; 1mg; 15mcg; 28mg; 1mg; 1 G 30mg; 200mg; 20mg; 3mg; 3mg; 30unit; 20mg calcium acetate caps 667mg 1 G calcium acetate tabs 667mg 1 G CARBAGLU TABS 200MG PA CHEMET CAPS 100MG CLINIMIX 2.75%/DEXTROSE 5% INJ 24MEQ/1000ML; HI 570MG/100ML; 316MG/100ML; 11MEQ/1000ML; 5GM/100ML; 283MG/100ML; 132MG/100ML; 165MG/100ML; 201MG/100ML; 159MG/100ML; 110MG/100ML; 154MG/100ML; 187MG/100ML; 138MG/100ML; 116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML CLINIMIX 4.25%/DEXTROSE 10% INJ 37MEQ/L; HI 880MG/100ML; 489MG/100ML; 17MEQ/L; 10GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX 4.25%/DEXTROSE 20% INJ 37MEQ/L; 880MG/100ML; 489MG/100ML; 17MEQ/L; 20GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML HI Página 123

125 CLINIMIX 4.25%/DEXTROSE 25% INJ 37MEQ/L; HI 880MG/100ML; 489MG/100ML; 17MEQ/L; 25GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX 4.25%/DEXTROSE 5% INJ 37MEQ/L; HI 880MG/100ML; 489MG/100ML; 17MEQ/L; 5GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX 5%/DEXTROSE 15% INJ 42MEQ/1000ML; HI 1035MG/100ML; 575MG/100ML; 20MEQ/1000ML; 15GM/100ML; 515MG/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML CLINIMIX 5%/DEXTROSE 20% INJ 42MEQ/L; HI 1035MG/100ML; 575MG/100ML; 20MEQ/L; 20GM/100ML; 515MG/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML CLINIMIX 5%/DEXTROSE 25% INJ 42MEQ/L; HI 1035MG/100ML; 575MG/100ML; 20MEQ/L; 25GM/100ML; 515MG/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML CLINIMIX E 2.75%/DEXTROSE 10% INJ 570MG/100ML; HI 316MG/100ML; 33MG/100ML; 10GM/100ML; 132MG/100ML; 165MG/100ML; 201MG/100ML; 159MG/100ML; 51MG/100ML; 110MG/100ML; 454MG/100ML; 154MG/100ML; 261MG/100ML; 187MG/100ML; 138MG/100ML; 217MG/100ML; 112MG/100ML; 116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML Página 124

126 CLINIMIX E 2.75%/DEXTROSE 5% INJ 570MG/100ML; 316MG/100ML; 33MG/100ML; 5GM/100ML; 132MG/100ML; 165MG/100ML; 201MG/100ML; 159MG/100ML; 51MG/100ML; 110MG/100ML; 454MG/100ML; 154MG/100ML; 261MG/100ML; 187MG/100ML; 138MG/100ML; 217MG/100ML; 112MG/100ML; 116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML CLINIMIX E 4.25%/DEXTROSE 10% INJ 880MG/100ML; 489MG/100ML; 33MG/100ML; 10GM/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 51MG/100ML; 170MG/100ML; 702MG/100ML; 238MG/100ML; 261MG/100ML; 289MG/100ML; 213MG/100ML; 297MG/100ML; 77MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX E 4.25%/DEXTROSE 25% INJ 880MG/100ML; 489MG/100ML; 33MG/100ML; 25GM/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 51MG/100ML; 170MG/100ML; 702MG/100ML; 238MG/100ML; 261MG/100ML; 289MG/100ML; 213MG/100ML; 297MG/100ML; 77MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX E 4.25%/DEXTROSE 5% INJ 880MG/100ML; 489MG/100ML; 33MG/100ML; 5GM/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 51MG/100ML; 170MG/100ML; 702MG/100ML; 238MG/100ML; 261MG/100ML; 289MG/100ML; 213MG/100ML; 297MG/100ML; 77MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX E 5%/DEXTROSE 15% INJ 1035MG/100ML; 575MG/100ML; 33MG/100ML; 15GM/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 51MG/100ML; 200MG/100ML; 826MG/100ML; 280MG/100ML; 261MG/100ML; 340MG/100ML; 250MG/100ML; 340MG/100ML; 59MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML HI HI HI HI HI Página 125

127 CLINIMIX E 5%/DEXTROSE 20% INJ 1035MG/100ML; HI 575MG/100ML; 33MG/100ML; 20GM/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 51MG/100ML; 200MG/100ML; 826MG/100ML; 280MG/100ML; 261MG/100ML; 340MG/100ML; 250MG/100ML; 340MG/100ML; 59MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML CLINIMIX E 5%/DEXTROSE 25% INJ 1035MG/100ML; HI 575MG/100ML; 33MG/100ML; 25GM/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 51MG/100ML; 200MG/100ML; 826MG/100ML; 280MG/100ML; 261MG/100ML; 340MG/100ML; 250MG/100ML; 340MG/100ML; 59MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML CLINISOL SF 15% INJ 151MEQ/L; 2170MG/100ML; HI 1470MG/100ML; 434MG/100ML; 749MG/100ML; 1040MG/100ML; 894MG/100ML; 749MG/100ML; 1040MG/100ML; 1180MG/100ML; 749MG/100ML; 1040MG/100ML; 894MG/100ML; 592MG/100ML; 749MG/100ML; 250MG/100ML; 39MG/100ML; 960MG/100ML complete natal dha misc 120mg; 0; 200mg; 400unit; 2mg; 1 G 12mcg; 200mg; 0; 1mg; 29mg; 0; 25mg; 20mg; 250mg; 25mg; 4mg; 1.8mg; 30mg; 3000unit; 25mg CUPRIMINE CAPS 250MG cyanocobalamin inj 1000mcg/ml 1 G # cytra k crystals pack 1002mg; 3300mg 1 G DEPEN TITRATABS TABS 250MG dextrose 10%/nacl 0.45% inj 10%; 0.45% 1 G HI dextrose 5% /electrolyte #48 viaflex inj 24meq/l; 5%; 1 G HI 23meq/l; 3meq/l; 3meq/l; 20meq/l; 25meq/l dextrose 10%/nacl 0.2% inj 10%; 0.2% 1 G HI dextrose 10%/nacl 0.225% inj 10%; 0.225% 1 G HI DEXTROSE 10% INJ 10% HI dextrose 2.5%/nacl 0.45% inj 2.5%; 0.45% 1 G HI DEXTROSE 20% INJ 20% HI DEXTROSE 25% INJ 250MG/ML HI DEXTROSE 30% INJ 30% HI DEXTROSE 40% INJ 40% HI dextrose 5%/lactated ringers inj 2.7meq/l; 109meq/l; 5%; 1 G HI 28meq/l; 4meq/l; 130meq/l dextrose 5%/nacl 0.2% inj 5%; 0.2% 1 G HI dextrose 5%/nacl 0.225% inj 5%; 0.225% 1 G HI dextrose 5%/nacl 0.3% inj 5%; 0.3% 1 G HI Página 126

128 dextrose 5%/nacl 0.33% inj 5%; 0.33% 1 G HI dextrose 5%/nacl 0.45% inj 5%; 0.45% 1 G HI dextrose 5%/nacl 0.9% inj 5%; 0.9% 1 G HI DEXTROSE 5% INJ 5% HI DEXTROSE 50% INJ 50% HI DEXTROSE 70% INJ 70% HI fluor-a-day soln 0.125mg/drop 1 G fluoride chew 0.25mg 1 G fluoride chew 0.5mg 1 G fluoride chew 1mg 1 G fluoritab chew 0.5mg 1 G fluoritab chew 1mg 1 G fluoritab soln 0.125mg/drop 1 G flura-drops soln 0.125mg/drop 1 G folbecal tabs 200mg; 12mcg; 1mg; 75mg 1 G folcaps omega 3 caps 25mg; 150mg; 0; 0; 170unit; 260mg; 1 G 40mg; 7mg; 1mg; 20mg; 30mg; 30mg; 330mg; 25mg; 30unit folic acid tabs 1mg 1 G # FOSRENOL CHEW 1000MG FOSRENOL CHEW 500MG FOSRENOL CHEW 750MG FOSRENOL PACK 1000MG FOSRENOL PACK 750MG FREAMINE HBC 6.9% INJ 59.3MEQ/L; 400MG/100ML; 580MG/100ML; 3MEQ/L; 14MG/100ML; 330MG/100ML; 160MG/100ML; 760MG/100ML; 1370MG/100ML; 410MG/100ML; 250MG/100ML; 320MG/100ML; HI 630MG/100ML; 330MG/100ML; 10MEQ/L; 200MG/100ML; 90MG/100ML; 880MG/100ML FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; HI 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML HEPATAMINE INJ 62MEQ/L; 770MG/100ML; HI 600MG/100ML; 3MEQ/L; 20MG/100ML; 900MG/100ML; 240MG/100ML; 900MG/100ML; 1100MG/100ML; 610MG/100ML; 100MG/100ML; 100MG/100ML; 115MG/100ML; 800MG/100ML; 500MG/100ML; 100MG/100ML; 450MG/100ML; 66MG/100ML; 840MG/100ML IONOSOL-B/DEXTROSE 5% INJ 49MEQ/L; 5%; 25MEQ/L; 5MEQ/L; 13MEQ/L; 25MEQ/L; 57MEQ/L HI Página 127

129 IONOSOL-MB/DEXTROSE 5% INJ 22MEQ/L; 5%; 23MEQ/L; 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L HI ISOLYTE-P/DEXTROSE 5% INJ 23MEQ/L; 23MEQ/L; 5%; HI 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L ISOLYTE-S INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 3MEQ/L; HI 5MEQ/L; 140MEQ/L JADENU SPRINKLE PACK 180MG JADENU SPRINKLE PACK 360MG JADENU SPRINKLE PACK 90MG JADENU TABS 180MG JADENU TABS 360MG JADENU TABS 90MG k-sol soln 10% 1 G k-sol soln 20% 1 G K-TAB TBCR 20MEQ KABIVEN INJ 467MG/100ML; 330MG/100ML; B/D 99MG/100ML; 29MG/100ML; 9.8GM/100ML; 164MG/100ML; 231MG/100ML; 199MG/100ML; 164MG/100ML; 263MG/100ML; 231MG/100ML; 96MG/100ML; 164MG/100ML; 231MG/100ML; 174MG/100ML; 199MG/100ML; 131MG/100ML; 239MG/100ML; 147MG/100ML; 164MG/100ML; 55MG/100ML; 6.7MG/100ML; 213MG/100ML karidium soln 0.125mg/drop 1 G kcl 0.075%/d5w/nacl 0.45% inj 5%; 10meq/l; 0.45% 1 G HI kcl 0.15%/d5w/ nacl 0.3% inj 5%; 20meq/l; 0.33% 1 G HI kcl 0.15%/d5w/nacl 0.2% inj 5%; 20meq/l; 0.2% 1 G HI kcl 0.15%/d5w/nacl 0.225% inj 5%; 20meq/l; 0.225% 1 G HI kcl 0.15%/d5w/nacl 0.9% inj 5%; 20meq/l; 0.9% 1 G HI kcl 0.3%/d5w/nacl 0.45% inj 5%; 40meq/l; 0.45% 1 G HI kcl 0.3%/d5w/nacl 0.9% inj 5%; 40meq/l; 0.9% 1 G HI kionex powd 0 1 G kionex susp 15gm/60ml 1 G kionex susp 15gm/60ml 1 G KLOR-CON 10 TBCR 10MEQ klor-con 8 tbcr 8meq 1 G klor-con m10 tbcr 10meq 1 G KLOR-CON M15 TBCR 15MEQ klor-con m20 tbcr 20meq 1 G klor-con sprinkle cpcr 10meq 1 G klor-con sprinkle cpcr 8meq 1 G klor-con pack 20meq 1 G klor-con pack 20meq 1 G LACTATED RINGERS VIAFLEX INJ 3MEQ/L; 1 B HI 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L ludent chew 0.25mg 1 G Página 128

130 ludent chew 0.5mg 1 G ludent chew 1mg 1 G macnatal cn dha caps 100mg; 400unit; 250mg; 50mg; 0; 1 G 1mg; 28mg; 25mg; 30unit magnesium sulfate inj 20gm/500ml 1 G B/D magnesium sulfate inj 20gm/500ml 1 G B/D magnesium sulfate inj 2gm/50ml 1 G B/D magnesium sulfate inj 2gm/50ml 1 G B/D magnesium sulfate inj 40gm/1000ml 1 G B/D magnesium sulfate inj 40gm/1000ml 1 G B/D magnesium sulfate inj 4gm/100ml 1 G B/D magnesium sulfate inj 4gm/100ml 1 G B/D magnesium sulfate inj 4gm/50ml 1 G B/D magnesium sulfate inj 4gm/50ml 1 G B/D magnesium sulfate inj 50% 1 G B/D magnesium sulfate inj 50% 1 G B/D mephyton tabs 5mg 1 G # multivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg; 1 G 13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit; 400unit; 15unit multivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg; 1 G 13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit; 400unit; 15unit multivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg; 1 G 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 2500unit; 400unit; 15unit mynate 90 plus tbcr 120mg; 250mg; 2mg; 12mcg; 50mg; 400unit; 90mg; 1mg; 20mg; 0.15mg; 20mg; 3.4mg; 3mg; 4000unit; 30unit; 25mg 1 G mynephrocaps caps 100mg; 150mcg; 5mg; 6mcg; 1mg; 20mg; 1 G # 10mg; 1.7mg; 1.5mg mynephron caps 100mg; 150mcg; 5mg; 6mcg; 1mg; 20mg; 1 G # 10mg; 1.7mg; 1.5mg nafrinse drops soln 0.125mg/drop 1 G NEPHRAMINE INJ 44MEQ/L; 20MG/100ML; HI 250MG/100ML; 560MG/100ML; 880MG/100ML; 640MG/100ML; 880MG/100ML; 880MG/100ML; 6MEQ/L; 400MG/100ML; 200MG/100ML; 640MG/100ML NORMOSOL -R INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; HI 3MEQ/L; 5MEQ/L; 140MEQ/L NORMOSOL-M IN D5W INJ 16MEQ/L; 40MEQ/L; 5%; HI 3MEQ/L; 13MEQ/L; 40MEQ/L NORMOSOL-R IN D5W INJ 27MEQ/L; 98MEQ/L; 5%; HI 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L NORMOSOL-R INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L HI Página 129

131 NUTRILYTE II INJ 1.475MEQ/ML; 0.225MEQ/ML; HI 1.75MEQ/ML; 0.25MEQ/ML; 1MEQ/ML; 1.75MEQ/ML NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; HI 1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ ob-natal one caps 150mg; 25mg; 170unit; 260mg; 40mg; 1 G 7mg; 1mg; 20mg; 30mg; 30mg; 330mg; 25mg; 30unit PERIKABIVEN INJ 333MG/100ML; 235MG/100ML; B/D 71MG/100ML; 20MG/100ML; 6.8GM/100ML; 116MG/100ML; 164MG/100ML; 141MG/100ML; 116MG/100ML; 164MG/100ML; 187MG/100ML; 68MG/100ML; 116MG/100ML; 164MG/100ML; 124MG/100ML; 141MG/100ML; 94MG/100ML; 170MG/100ML; 105MG/100ML; 116MG/100ML; 40MG/100ML; 4.8MG/100ML; 152MG/100ML PHOSLYRA SOLN 667MG/5ML PLASMA-LYTE A INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; HI 3MEQ/L; 5MEQ/L; 140MEQ/L PLASMA-LYTE-148 INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; HI 3MEQ/L; 5MEQ/L; 140MEQ/L PLASMA-LYTE-56/D5W INJ 16MEQ/L; 40MEQ/L; 5%; HI 3MEQ/L; 13MEQ/L; 40MEQ/L PLENAMINE INJ 151MEQ/L; 2170MG/100ML; 1470MG/100ML; 434MG/100ML; 749MG/100ML; 1040MG/100ML; 894MG/100ML; 749MG/100ML; 1040MG/100ML; 1180MG/100ML; 749MG/100ML; 1040MG/100ML; 894MG/100ML; 592MG/100ML; 749MG/100ML; 250MG/100ML; 39MG/100ML; 960MG/100ML HI pnv-dha caps 85mg; 140mg; 200unit; 12mcg; 300mg; 27mg; 1 G 400mcg; 600mcg; 45mg; 25mg; 10unit pnv-select tabs 80mg; 2500unit; 300mcg; 120mg; 6mg; 400unit; 2mg; 12mcg; 27mg; 400mcg; 600mcg; 30mg; 20mg; 150mcg; 20mg; 3.4mg; 3mg; 10unit; 15mg 1 G potassium chloride /sodium chloride inj 30meq/100ml; 0.9% 1 G HI potassium chloride 0.15% d5w/nacl 0.33% inj 5%; 20meq/l; 1 G HI 0.33% potassium chloride 0.15% d5w/nacl 0.45% viaflex inj 5%; 1 G HI 20meq/l; 0.45% potassium chloride 0.15% d5w/nacl 0.45% inj 5%; 20meq/l; 1 G HI 0.45% potassium chloride 0.22% d5w/nacl 0.45% inj 5%; 30meq/l; 1 G HI 0.45% potassium chloride cr tbcr 10meq 1 G potassium chloride cr tbcr 10meq 1 G potassium chloride er cpcr 10meq 1 G Página 130

132 potassium chloride er cpcr 8meq 1 G potassium chloride er tbcr 10meq 1 G potassium chloride er tbcr 10meq 1 G potassium chloride er tbcr 20meq 1 G potassium chloride er tbcr 20meq 1 G potassium chloride er tbcr 8meq 1 G potassium chloride sr tbcr 8meq 1 G potassium chloride sr tbcr 8meq 1 G potassium chloride/dextrose/lactated ringers inj 3meq/l; 1 G HI 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l potassium chloride/dextrose/lactated ringers inj 3meq/l; 1 G HI 149meq/l; 5%; 28meq/l; 44meq/l; 130meq/l potassium chloride/dextrose inj 5%; 20meq/l 1 G HI potassium chloride/dextrose inj 5%; 40meq/l 1 G HI potassium chloride/sodium chloride inj 20meq/l; 0.45% 1 G HI potassium chloride/sodium chloride inj 20meq/l; 0.9% 1 G HI potassium chloride/sodium chloride inj 40meq/l; 0.9% 1 G HI potassium chloride inj 0.4meq/ml 1 G HI potassium chloride inj 10meq/100ml 1 G HI potassium chloride inj 10meq/50ml 1 G HI potassium chloride inj 20meq/100ml 1 G HI potassium chloride inj 2meq/ml 1 G HI potassium chloride inj 40meq/100ml 1 G HI potassium chloride pack 20meq 1 G potassium chloride soln 10% 1 G potassium chloride soln 20% 1 G potassium citrate er tbcr 1080mg 1 G potassium citrate er tbcr 15meq 1 G potassium citrate er tbcr 540mg 1 G potassium citrate-citric acid crystals pack 1002mg; 3300mg 1 G pr natal 400 ec misc 120mg; 3000unit; 200mg; 400unit; 2mg; 1 G 12mcg; 275mg; 0; 1mg; 29mg; 25mg; 20mg; 400mg; 25mg; 4mg; 1.8mg; 3mg; 25mg pr natal 400 misc 120mg; 3000unit; 200mg; 400unit; 2mg; 12mcg; 275mg; 0; 0; 1mg; 29mg; 0; 25mg; 20mg; 400mg; 25mg; 4mg; 1.8mg; 30mg; 25mg 1 G pr natal 430 ec misc 120mg; 3000unit; 200mg; 400unit; 2mg; 1 G 12mcg; 295mg; 0; 0; 1mg; 29mg; 0; 25mg; 20mg; 430mg; 25mg; 4mg; 1.8mg; 3mg; 25mg pr natal 430 misc 120mg; 3000unit; 200mg; 400unit; 2mg; 12mcg; 295mg; 0; 0; 1mg; 29mg; 0; 25mg; 20mg; 430mg; 25mg; 4mg; 1.8mg; 30mg; 25mg 1 G Página 131

133 PREMASOL INJ 52MEQ/L; 1760MG/100ML; HI 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML; 230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML; 120MG/100ML; 140MG/100ML; 470MG/100ML HI prenaissance plus caps 100mg; 400unit; 250mg; 50mg; 1mg; 1 G 28mg; 25mg; 30unit prenata chew 120mg; 400unit; 12mcg; 29mg; 1mg; 20mg; 1 G 10mg; 3mg; 0; 2mg; 11unit prenate dha caps 90mg; 145mg; 220unit; 13mcg; 300mg; 1 G 28mg; 400mcg; 600mcg; 50mg; 26mg; 10unit prenate elite tabs 75mg; 2600unit; 330mcg; 100mg; 6mg; 450unit; 1.5mg; 13mcg; 26mg; 400mcg; 150mcg; 600mcg; 25mg; 21mg; 21mg; 3.5mg; 3mg; 10unit; 15mg 1 G prenate enhance caps 85mg; 500mcg; 155mg; 0; 0; 1000unit; 1 G 12mcg; 400mg; 28mg; 400mcg; 600mcg; 50mg; 150mcg; 25mg; 10unit prenate restore caps 85mg; 10mg; 500mcg; 155mg; 0; 0; 1 G 1000unit; 12mcg; 400mg; 27mg; 400mcg; 600mcg; 45mg; 25mg; 10unit PROCALAMINE INJ 47MEQ/L; 210MG/100ML; HI 290MG/100ML; 3MEQ/L; 41MEQ/L; 20MG/100ML; 420MG/100ML; 85MG/100ML; 210MG/100ML; 270MG/100ML; 220MG/100ML; 5MEQ/L; 160MG/100ML; 170MG/100ML; 7MMOLE/L; 24MEQ/L; 340MG/100ML; 180MG/100ML; 35MEQ/L; 120MG/100ML; 46MG/100ML; 200MG/100ML PROSOL INJ 2.76GM/100ML; 1.96GM/100ML; HI 600MG/100ML; 1.02GM/100ML; 2.06GM/100ML; 1.18GM/100ML; 1.08GM/100ML; 1.08GM/100ML; 1.35GM/100ML; 760MG/100ML; 1GM/100ML; 1.34GM/100ML; 1.02GM/100ML; 980MG/100ML; 320MG/100ML; 50MG/100ML; 1.44GM/100ML relnate dha caps 100mg; 400unit; 1mg; 15mcg; 28mg; 1mg; 1 G 30mg; 200mg; 20mg; 3mg; 3mg; 30unit; 20mg RENAGEL TABS 400MG RENAGEL TABS 800MG Página 132

134 renal caps caps 100mg; 150mcg; 5mg; 6mcg; 1mg; 20mg; 1 G # 10mg; 1.7mg; 1.5mg reno caps caps 100mg; 150mcg; 5mg; 6mcg; 1mg; 20mg; 1 G # 10mg; 1.7mg; 1.5mg RENVELA PACK 0.8GM RENVELA PACK 2.4GM RENVELA TABS 800MG RINGERS INJECTION INJ 4.5MEQ/L; 156MEQ/L; HI 4MEQ/L; 147MEQ/L rulavite dha caps 85mg; 140mg; 200unit; 12mcg; 300mg; 1 G 27mg; 330mg; 400mcg; 600mcg; 45mg; 25mg; 0; 10unit SAMSCA TABS 15MG SAMSCA TABS 30MG sevelamer carbonate pack 0.8gm 1 G sevelamer carbonate pack 2.4gm 1 G sodium bicarbonate partial fill inj 4.2% 1 G B/D sodium bicarbonate inj 4.2% 1 G B/D sodium bicarbonate inj 7.5% 1 G B/D sodium bicarbonate inj 8.4% 1 G B/D sodium chloride 0.45% inj 0.45% 1 G HI sodium chloride inj 0.9% 1 G HI sodium chloride inj 0.9% 1 G HI sodium chloride inj 0.9% 1 G HI sodium chloride inj 2.5meq/ml 1 G HI sodium chloride inj 3% 1 G HI sodium chloride inj 4meq/ml 1 G HI sodium chloride inj 5% 1 G HI sodium fluoride chew 0.25mg 1 G sodium fluoride chew 0.5mg 1 G sodium fluoride chew 0.5mg 1 G sodium fluoride chew 1mg 1 G sodium fluoride soln 0.5mg/ml 1 G sodium fluoride tabs 1mg 1 G sodium lactate inj 5meq/ml 1 G HI sodium polystyrene sulfonate powd 0 1 G sodium polystyrene sulfonate susp 15gm/60ml 1 G sodium polystyrene sulfonate susp 30gm/120ml 1 G sps susp 15gm/60ml 1 G SYPRINE CAPS 250MG taron-crystals pack 1002mg; 3300mg 1 G tl folate tabs 80mg; 4000unit; 300mcg; 120mg; 6mg; 400unit; 1 G 2mg; 12mcg; 27mg; 500mcg; 500mcg; 90mg; 20mg; 150mcg; 20mg; 3.4mg; 3mg; 30unit; 15mg TPN ELECTROLYTES INJ 29.5MEQ/20ML; 4.5MEQ/20ML; 35MEQ/20ML; 5MEQ/20ML; 20MEQ/20ML; 35MEQ/20ML HI Página 133

135 TRAVASOL INJ 52MEQ/L; 1760MG/100ML; HI 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML triphrocaps caps 100mg; 150mcg; 5mg; 6mcg; 1mg; 20mg; 10mg; 1.7mg; 1.5mg 1 G # triveen-duo dha misc 120mg; 3000unit; 200mg; 400unit; 2mg; 1 G 12mcg; 275mg; 0; 0; 1mg; 29mg; 0; 25mg; 20mg; 400mg; 25mg; 4mg; 1.8mg; 30mg; 25mg TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; HI 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML ultimatecare one caps 25mg; 150mg; 0; 0; 170unit; 260mg; 1 G 40mg; 7mg; 1mg; 20mg; 30mg; 30mg; 330mg; 25mg; 30unit VELPHORO CHEW 500MG VELTASSA PACK 16.8GM VELTASSA PACK 25.2GM VELTASSA PACK 8.4GM vinate c tabs 60mg; 200mg; 0; 2mg; 12mcg; 30mg; 1mg; 1 G 100mg; 20mg; 50mg; 3.4mg; 3mg; 30unit; 15mg virt-caps caps 100mg; 150mcg; 5mg; 6mcg; 1mg; 20mg; 1 G # 10mg; 1.7mg; 1.5mg virt-care one caps 25mg; 150mg; 0; 170unit; 260mg; 40mg; 7mg; 1mg; 20mg; 30mg; 30mg; 330mg; 25mg; 30unit 1 G virt-nate dha caps 100mg; 400unit; 1mg; 15mcg; 0; 0; 28mg; 1 G 1mg; 30mg; 200mg; 20mg; 3mg; 3mg; 30unit; 20mg virt-pn dha caps 85mg; 140mg; 200unit; 12mcg; 300mg; 27mg; 330mg; 400mcg; 600mcg; 45mg; 25mg; 10unit 1 G virt-pn tabs 80mg; 2500unit; 300mcg; 120mg; 6mg; 400unit; 1 G 2mg; 12mcg; 27mg; 400mcg; 600mcg; 30mg; 20mg; 150mcg; 20mg; 3.4mg; 3mg; 10unit; 15mg virt-pn tabs 80mg; 2500unit; 300mcg; 120mg; 6mg; 400unit; 1 G 2mg; 12mcg; 27mg; 400mcg; 600mcg; 30mg; 20mg; 150mcg; 20mg; 3.4mg; 3mg; 10unit; 15mg vital-d rx tabs 60mg; 300mcg; 1750unit; 6mg; 1mg; 20mg; 1 G # 10mg; 10mg; 1.7mg; 1.5mg; 12.5mg vitamedmd one rx/quatrefolic caps 60mg; 300mcg; 10mg; 1 G 400unit; 8mcg; 200mg; 30mg; 400mcg; 600mcg; 20mg; 25mg; 1.7mg; 1.5mg; 21unit; 7.5mg vitamin d caps 50000unit 1 G # Página 134

136 vp-ch plus caps 650mg; 104mg; 400unit; 265mg; 50mg; 1mg; 1 G 29mg; 25mg; 30unit vp-ch-pnv caps 104mg; 400unit; 260mg; 50mg; 0; 1mg; 1 G 30mg; 25mg; 30unit VP-PNV-DHA CAPS 80MG; 50MG; 400UNIT; 1MG; 1 B 12MCG; 200MG; 15.8MG; 28MG; 1MG; 30MG; 20MG; 16MG; 2.2MG; 6MG; 30UNIT; 2500UNIT; 20MG zatean-ch caps 100mg; 400unit; 250mg; 50mg; 1mg; 27mg; 1 G 25mg; 30unit zatean-pn dha caps 85mg; 140mg; 200unit; 12mcg; 300mg; 1 G 27mg; 400mcg; 600mcg; 45mg; 25mg; 10unit Productos/modificadores/expansores de volumen plasmático anagrelide hydrochloride caps 0.5mg 1 G anagrelide hydrochloride caps 1mg 1 G ARANESP ALBUMIN FREE INJ 100MCG/0.5ML PA ARANESP ALBUMIN FREE INJ 100MCG/ML PA ARANESP ALBUMIN FREE INJ 10MCG/0.4ML PA ARANESP ALBUMIN FREE INJ 150MCG/0.3ML PA ARANESP ALBUMIN FREE INJ 200MCG/0.4ML PA ARANESP ALBUMIN FREE INJ 200MCG/ML PA ARANESP ALBUMIN FREE INJ 25MCG/0.42ML PA ARANESP ALBUMIN FREE INJ 25MCG/ML PA ARANESP ALBUMIN FREE INJ 300MCG/0.6ML PA ARANESP ALBUMIN FREE INJ 300MCG/ML PA ARANESP ALBUMIN FREE INJ 40MCG/0.4ML PA ARANESP ALBUMIN FREE INJ 40MCG/ML PA ARANESP ALBUMIN FREE INJ 500MCG/ML PA ARANESP ALBUMIN FREE INJ 60MCG/0.3ML PA ARANESP ALBUMIN FREE INJ 60MCG/ML PA ARGATROBAN INJ 125MG/125ML; 0.9% B/D ARGATROBAN INJ 250MG/2.5ML B/D ARGATROBAN INJ 250MG/250ML; 0.9% B/D aspirin/dipyridamole cp12 25mg; 200mg 1 G QL (60 EA por 30 días) BRILINTA TABS 60MG BRILINTA TABS 90MG cilostazol tabs 100mg 1 G cilostazol tabs 50mg 1 G clopidogrel tabs 300mg 1 G clopidogrel tabs 75mg 1 G dipyridamole tabs 25mg 1 G dipyridamole tabs 50mg 1 G dipyridamole tabs 75mg 1 G enoxaparin sodium inj 100mg/ml 1 G enoxaparin sodium inj 120mg/0.8ml 1 G enoxaparin sodium inj 150mg/ml 1 G Página 135

137 enoxaparin sodium inj 300mg/3ml 1 G enoxaparin sodium inj 30mg/0.3ml 1 G enoxaparin sodium inj 40mg/0.4ml 1 G enoxaparin sodium inj 60mg/0.6ml 1 G enoxaparin sodium inj 80mg/0.8ml 1 G EPOGEN INJ 10000UNIT/ML PA EPOGEN INJ 20000UNIT/ML PA EPOGEN INJ 2000UNIT/ML PA EPOGEN INJ 3000UNIT/ML PA EPOGEN INJ 4000UNIT/ML PA fondaparinux sodium inj 10mg/0.8ml 1 G fondaparinux sodium inj 2.5mg/0.5ml 1 G fondaparinux sodium inj 5mg/0.4ml 1 G fondaparinux sodium inj 7.5mg/0.6ml 1 G FRAGMIN INJ 10000UNIT/ML FRAGMIN INJ 12500UNIT/0.5ML FRAGMIN INJ 15000UNIT/0.6ML FRAGMIN INJ 18000UNT/0.72ML FRAGMIN INJ 2500UNIT/0.2ML FRAGMIN INJ 5000UNIT/0.2ML FRAGMIN INJ 7500UNIT/0.3ML FRAGMIN INJ 95000UNIT/3.8ML GRANIX INJ 300MCG/0.5ML PA GRANIX INJ 480MCG/0.8ML PA heparin sodium/d5w inj 5%; 100unit/ml 1 G HI heparin sodium/d5w inj 5%; 40unit/ml 1 G HI heparin sodium/d5w inj 5%; 50unit/ml 1 G HI heparin sodium/nacl 0.45% inj 100unit/ml; 0.45% 1 G HI heparin sodium/nacl 0.45% inj 50unit/ml; 0.45% 1 G HI heparin sodium/nacl 0.9% inj 2unit/ml; 0.9% 1 G HI heparin sodium/sodium chloride 0.9% premix inj 2unit/ml; 1 G HI 0.9% heparin sodium/sodium chloride 0.9% inj 2unit/ml; 0.9% 1 G HI heparin sodium/sodium chloride 0.9% inj 2unit/ml; 0.9% 1 G HI heparin sodium inj 10000unit/ml 1 G HI heparin sodium inj 1000unit/ml 1 G HI heparin sodium inj 20000unit/ml 1 G HI heparin sodium inj 2000unit/ml 1 G HI heparin sodium inj 2500unit/ml 1 G HI heparin sodium inj 5000unit/0.5ml 1 G HI heparin sodium inj 5000unit/ml 1 G HI jantoven tabs 10mg 1 G jantoven tabs 1mg 1 G jantoven tabs 2.5mg 1 G jantoven tabs 2mg 1 G jantoven tabs 3mg 1 G Página 136

138 jantoven tabs 4mg 1 G jantoven tabs 5mg 1 G jantoven tabs 6mg 1 G jantoven tabs 7.5mg 1 G LEUKINE INJ 250MCG PA MIRCERA INJ 100MCG/0.3ML PA MIRCERA INJ 200MCG/0.3ML PA MIRCERA INJ 50MCG/0.3ML PA MIRCERA INJ 75MCG/0.3ML PA MOZOBIL INJ 24MG/1.2ML B/D NEUMEGA INJ 5MG QL (21 EA por 30 días) B/D PRADAXA CAPS 110MG QL (60 EA por 30 días) PRADAXA CAPS 150MG QL (60 EA por 30 días) PRADAXA CAPS 75MG QL (60 EA por 30 días) PROCRIT INJ 10000UNIT/ML PA PROCRIT INJ 20000UNIT/ML PA PROCRIT INJ 2000UNIT/ML PA PROCRIT INJ 3000UNIT/ML PA PROCRIT INJ 40000UNIT/ML PA PROCRIT INJ 4000UNIT/ML PA PROMACTA TABS 12.5MG PA PROMACTA TABS 25MG PA PROMACTA TABS 50MG PA PROMACTA TABS 75MG PA tranexamic acid inj 1000mg/10ml 1 G tranexamic acid tabs 650mg 1 G warfarin sodium tabs 10mg 1 G warfarin sodium tabs 1mg 1 G warfarin sodium tabs 2.5mg 1 G warfarin sodium tabs 2mg 1 G warfarin sodium tabs 3mg 1 G warfarin sodium tabs 4mg 1 G warfarin sodium tabs 5mg 1 G warfarin sodium tabs 6mg 1 G warfarin sodium tabs 7.5mg 1 G XARELTO STARTER PACK TBPK 0 QL (102 EA por 365 días) XARELTO TABS 10MG QL (30 EA por 30 días) XARELTO TABS 15MG QL (60 EA por 30 días) XARELTO TABS 20MG QL (30 EA por 30 días) ZONTIVITY TABS 2.08MG Reguladores de la glucemia acarbose tabs 100mg 1 G acarbose tabs 25mg 1 G acarbose tabs 50mg 1 G ACTOPLUS MET XR TB MG; 15MG Página 137

139 ACTOPLUS MET XR TB MG; 30MG AFREZZA POWD 0 AFREZZA POWD 0 AFREZZA POWD 0 AFREZZA POWD 0 AFREZZA POWD 0 AFREZZA POWD 12UNIT AFREZZA POWD 4UNIT AFREZZA POWD 8UNIT AVANDAMET TABS 1000MG; 2MG AVANDAMET TABS 500MG; 4MG AVANDARYL TABS 1MG; 4MG AVANDARYL TABS 2MG; 4MG AVANDARYL TABS 4MG; 8MG AVANDIA TABS 2MG QL (60 EA por 30 días) AVANDIA TABS 4MG QL (60 EA por 30 días) AVANDIA TABS 8MG QL (30 EA por 30 días) BYDUREON PEN INJ 2MG QL (4 EA por 28 días) BYDUREON INJ 2MG QL (4 EA por 28 días) BYETTA INJ 10MCG/0.04ML BYETTA INJ 5MCG/0.02ML chlorpropamide tabs 100mg 1 G chlorpropamide tabs 250mg 1 G CYCLOSET TABS 0.8MG glimepiride tabs 1mg 1 G glimepiride tabs 2mg 1 G glimepiride tabs 4mg 1 G glipizide er tb24 10mg 1 G glipizide er tb24 2.5mg 1 G glipizide er tb24 5mg 1 G glipizide xl tb24 10mg 1 G glipizide xl tb24 2.5mg 1 G glipizide xl tb24 5mg 1 G glipizide/metformin hcl tabs 2.5mg; 250mg 1 G glipizide/metformin hcl tabs 2.5mg; 500mg 1 G glipizide/metformin hcl tabs 5mg; 500mg 1 G glipizide tabs 10mg 1 G glipizide tabs 5mg 1 G GLUCAGEN HYPOKIT INJ 1MG GLUCAGON EMERGENCY KIT INJ 1MG glyburide micronized tabs 1.5mg 1 G glyburide micronized tabs 3mg 1 G glyburide micronized tabs 6mg 1 G glyburide/metformin hcl tabs 1.25mg; 250mg 1 G glyburide/metformin hcl tabs 2.5mg; 500mg 1 G glyburide/metformin hcl tabs 5mg; 500mg 1 G Página 138

140 glyburide tabs 1.25mg 1 G glyburide tabs 2.5mg 1 G glyburide tabs 5mg 1 G GLYXAMBI TABS 10MG; 5MG GLYXAMBI TABS 25MG; 5MG HUMALOG KWIKPEN INJ 100UNIT/ML HUMALOG KWIKPEN INJ 200UNIT/ML HUMALOG MIX 50/50 KWIKPEN INJ 50UNIT/ML; 50UNIT/ML HUMALOG MIX 50/50 INJ 50UNIT/ML; 50UNIT/ML HUMALOG MIX 75/25 KWIKPEN INJ 25UNIT/ML; 75UNIT/ML HUMALOG MIX 75/25 INJ 25UNIT/ML; 75UNIT/ML HUMALOG INJ 100UNIT/ML HUMALOG INJ 100UNIT/ML HUMULIN 70/30 KWIKPEN INJ 30UNIT/ML; 70UNIT/ML HUMULIN 70/30 INJ 30UNIT/ML; 70UNIT/ML HUMULIN N KWIKPEN INJ 100UNIT/ML HUMULIN N INJ 100UNIT/ML HUMULIN R U-500 (CONCENTRATED) INJ 500UNIT/ML HUMULIN R U-500 KWIKPEN INJ 500UNIT/ML HUMULIN R INJ 100UNIT/ML INVOKAMET XR TB24 150MG; 1000MG INVOKAMET XR TB24 150MG; 500MG INVOKAMET XR TB24 50MG; 1000MG INVOKAMET XR TB24 50MG; 500MG INVOKAMET TABS 150MG; 1000MG INVOKAMET TABS 150MG; 500MG INVOKAMET TABS 50MG; 1000MG INVOKAMET TABS 50MG; 500MG INVOKANA TABS 100MG INVOKANA TABS 300MG JANUMET XR TB MG; 100MG JANUMET XR TB MG; 50MG JANUMET XR TB24 500MG; 50MG JANUMET TABS 1000MG; 50MG JANUMET TABS 500MG; 50MG JANUVIA TABS 100MG JANUVIA TABS 25MG JANUVIA TABS 50MG JARDIANCE TABS 10MG JARDIANCE TABS 25MG JENTADUETO XR TB24 2.5MG; 1000MG JENTADUETO XR TB24 5MG; 1000MG JENTADUETO TABS 2.5MG; 1000MG JENTADUETO TABS 2.5MG; 500MG Página 139

141 JENTADUETO TABS 2.5MG; 850MG KAZANO TABS 12.5MG; 1000MG KAZANO TABS 12.5MG; 500MG LANTUS SOLOSTAR INJ 100UNIT/ML LANTUS INJ 100UNIT/ML LEVEMIR FLEXTOUCH INJ 100UNIT/ML LEVEMIR INJ 100UNIT/ML metformin hcl er tb mg 1 G metformin hcl er tb mg 1 G metformin hcl er tb24 500mg 1 G metformin hcl er tb24 500mg 1 G metformin hcl er tb24 500mg 1 G metformin hcl er tb24 750mg 1 G metformin hcl tabs 1000mg 1 G metformin hcl tabs 500mg 1 G metformin hcl tabs 850mg 1 G miglitol tabs 100mg 1 G miglitol tabs 25mg 1 G miglitol tabs 50mg 1 G nateglinide tabs 120mg 1 G nateglinide tabs 60mg 1 G NESINA TABS 12.5MG NESINA TABS 25MG NESINA TABS 6.25MG NOVOLIN 70/30 RELION INJ 30UNIT/ML; 70UNIT/ML NOVOLIN N RELION INJ 100UNIT/ML NOVOLIN R RELION INJ 100UNIT/ML OSENI TABS 12.5MG; 15MG OSENI TABS 12.5MG; 30MG OSENI TABS 12.5MG; 45MG OSENI TABS 25MG; 15MG OSENI TABS 25MG; 30MG OSENI TABS 25MG; 45MG pioglitazone hcl-glimepiride tabs 2mg; 30mg 1 G pioglitazone hcl-glimepiride tabs 4mg; 30mg 1 G pioglitazone hcl/metformin hcl tabs 500mg; 15mg 1 G pioglitazone hcl/metformin hcl tabs 850mg; 15mg 1 G pioglitazone hcl tabs 15mg 1 G pioglitazone hcl tabs 30mg 1 G pioglitazone hcl tabs 45mg 1 G PROGLYCEM SUSP 50MG/ML repaglinide/metformin hydrochloride tabs 500mg; 1mg 1 G repaglinide/metformin hydrochloride tabs 500mg; 2mg 1 G repaglinide tabs 0.5mg 1 G repaglinide tabs 1mg 1 G repaglinide tabs 2mg 1 G Página 140

142 RIOMET SOLN 500MG/5ML SYMLINPEN 120 INJ 2700MCG/2.7ML SYMLINPEN 60 INJ 1500MCG/1.5ML SYNJARDY XR TB24 10MG; 1000MG SYNJARDY XR TB MG; 1000MG SYNJARDY XR TB24 25MG; 1000MG SYNJARDY XR TB24 5MG; 1000MG SYNJARDY TABS 12.5MG; 1000MG SYNJARDY TABS 12.5MG; 500MG SYNJARDY TABS 5MG; 1000MG SYNJARDY TABS 5MG; 500MG TANZEUM INJ 30MG TANZEUM INJ 50MG tolazamide tabs 250mg 1 G tolazamide tabs 500mg 1 G tolbutamide tabs 500mg 1 G TOUJEO SOLOSTAR INJ 300UNIT/ML TRADJENTA TABS 5MG TRESIBA FLEXTOUCH INJ 100UNIT/ML TRESIBA FLEXTOUCH INJ 200UNIT/ML TRULICITY INJ 0.75MG/0.5ML TRULICITY INJ 1.5MG/0.5ML VICTOZA INJ 18MG/3ML Relajantes musculares esqueléticos carisoprodol/aspirin tabs 325mg; 200mg 1 G PA carisoprodol tabs 250mg 1 G PA carisoprodol tabs 350mg 1 G PA chlorzoxazone tabs 500mg 1 G cyclobenzaprine hcl tabs 10mg 1 G PA cyclobenzaprine hcl tabs 5mg 1 G PA cyclobenzaprine hcl tabs 7.5mg 1 G PA LORZONE TABS 375MG LORZONE TABS 750MG metaxall tabs 800mg 1 G metaxalone tabs 400mg 1 G metaxalone tabs 800mg 1 G methocarbamol inj 1000mg/10ml 1 G B/D methocarbamol tabs 500mg 1 G methocarbamol tabs 750mg 1 G orphenadrine citrate er tb12 100mg 1 G orphenadrine citrate inj 30mg/ml 1 G B/D Therapeutic Nutrients/Minerals/ Electrolytes ISOLYTE-S PH 7.4 INJ 27MEQ/1000ML; 98MEQ/1000ML; HI 23MEQ/1000ML; 3MEQ/1000ML; 1MEQ/1000ML; 5MEQ/1000ML; 141MEQ/1000ML Página 141

143 Trastorno genético o enzimático: Reemplazo, modificadores, tratamiento ADAGEN INJ 250UNIT/ML B/D ALDURAZYME INJ 2.9MG/5ML B/D BUPHENYL TABS 500MG PA CEREZYME INJ 400UNIT B/D CREON CPEP UNIT; 24000UNIT; 76000UNIT CREON CPEP 15000UNIT; 3000UNIT; 9500UNIT CREON CPEP UNIT; 36000UNIT; UNIT CREON CPEP 30000UNIT; 6000UNIT; 19000UNIT CREON CPEP 60000UNIT; 12000UNIT; 38000UNIT CYSTADANE POWD 0 CYSTAGON CAPS 150MG CYSTAGON CAPS 50MG ELAPRASE INJ 6MG/3ML HI ELELYSO INJ 200UNIT B/D FABRAZYME INJ 35MG B/D FABRAZYME INJ 5MG B/D KUVAN PACK 100MG KUVAN PACK 500MG KUVAN TBSO 100MG LUMIZYME INJ 50MG B/D MYOZYME INJ 50MG B/D NAGLAZYME INJ 1MG/ML B/D ORFADIN CAPS 10MG ORFADIN CAPS 20MG ORFADIN CAPS 2MG ORFADIN CAPS 5MG ORFADIN SUSP 4MG/ML RAVICTI LIQD 1.1GM/ML PA sodium phenylbutyrate powd 3gm/tsp PA SUCRAID SOLN 8500UNIT/ML VPRIV INJ 400UNIT B/D ZAVESCA CAPS 100MG ZENPEP CPEP UNIT; 20000UNIT; 68000UNIT ZENPEP CPEP UNIT; 25000UNIT; 85000UNIT ZENPEP CPEP 16000UNIT; 3000UNIT; 10000UNIT ZENPEP CPEP UNIT; 40000UNIT; UNIT ZENPEP CPEP 27000UNIT; 5000UNIT; 17000UNIT ZENPEP CPEP 55000UNIT; 10000UNIT; 34000UNIT ZENPEP CPEP 82000UNIT; 15000UNIT; 51000UNIT Página 142

144 Productos de venta libre Nombre del medicament Agentes dermatológicos ammonium lactate crea 12% 1 G ammonium lactate lotn 12% 1 G Agentes gastrointestinales mi-acid susp 200mg/5ml; 200mg/5ml; 20mg/5ml 1 G Agentes hormonales, estimulación/sustitución/modificación (suprarrenal) hydrocortisone crea 0.5% 1 G Agentes oftálmicos alaway soln 0.025% 1 G ketotifen fumarate soln 0.025% 1 G sodium chloride oint 5% 1 G sodium chloride soln 5% 1 G Agentes para vías respiratorias/pulmonares allergy relief tabs 10mg 1 G cetirizine hcl tabs 10mg 1 G cetirizine hcl tabs 5mg 1 G cheratussin dac soln 10mg/5ml; 100mg/5ml; 30mg/5ml 1 G diphenhist liqd 12.5mg/5ml 1 G guaifenesin dac soln 10mg/5ml; 100mg/5ml; 30mg/5ml 1 G loratadine tabs 10mg 1 G loratadine tabs 10mg 1 G virtussin a/c soln 10mg/5ml; 100mg/5ml 1 G Antieméticos meclizine hcl tabs 12.5mg 1 G travel sickness chew 25mg 1 G Antimicóticos 3 day vaginal crea 2% 1 G antifungal crea 2% 1 G clotrimazole crea 1% 1 G clotrimazole crea 1% 1 G clotrimazole soln 1% 1 G miconazole crea 2% 1 G remedy antifungal powd 2% 1 G sm 3-day vaginal crea 2% 1 G Electrolitos/minerales/metales/vitaminas slo-niacin tbcr 250mg 1 G slo-niacin tbcr 500mg 1 G slo-niacin tbcr 750mg 1 G vinate care chew 50mg; 0; 250mg; 0; 6mcg; 2mg; 40mg; 1mg; 50mg; 2mg; 3.5unit; 15mg 1 G Página 143

145 Índice Nombre del medicamento Página 3 day vaginal MOP 32 abacavir 117 abacavir sulfate/lamivudine/zidovudine 117 abacavir/lamivudine 117 ABELCET 102 ABRAXANE 104 ABSORICA 32 ABSTRAL 70 acamprosate calcium dr 63 ACANYA 33 acarbose 137 acebutolol hcl 11 acetaminophen/caffeine/dihydrocodeine 71 acetaminophen/codeine 71 acetaminophen/codeine phosphate 71 acetasol hc 70 acetazolamide 11 acetazolamide er 60 acetazolamide sodium 11 acetic acid 70 acetic acid/aluminum acetate 70 acetylcysteine 63 ACIPHEX SPRINKLE 35 acitretin 33 ACTEMRA 55 ACTHIB 55 ACTIMMUNE 55 ACTOPLUS MET XR 137 acyclovir 117 acyclovir sodium 117 ACZONE 33 ADACEL 55 ADAGEN 142 adapalene 33 ADCIRCA 64 adefovir dipivoxil 117 ADEMPAS 64 adrucil 104 ADZENYS XR-ODT 28 AEROSPAN 64 afeditab cr 11 AFINITOR 104 AFINITOR DISPERZ 104 AFREZZA 138 a-hydrocort 48 Página 144 Nombre del medicamento Página ak-poly-bac 81 AKYNZEO 100 ala-cort 48 alaway 143 ALBENZA 113 albuterol 64 albuterol sulfate 64 albuterol sulfate er 64 alclometasone dipropionate 48 alcohol prep pads 81 ALDACTAZIDE 12 ALDURAZYME 142 ALECENSA 104 alendronate sodium 27 alfuzosin hcl er 39 ALIMTA 104 ALINIA 113 allergy relief 143 allopurinol 26 allopurinol sodium 26 almotriptan malate 9 ALOCRIL 60 ALOMIDE 61 ALORA 41 alosetron hydrochloride 35 ALOXI 100 ALPHAGAN P 61 alprazolam 80 alprazolam er 80 ALPRAZOLAM INTENSOL 80 alprazolam odt 80 alprazolam xr 80 ALREX 61 ALTABAX 81 altafrin 61 altavera 41 ALTOPREV 12 ALUNBRIG 104 ALVESCO 64 alyacen 1/35 41 alyacen 7/7/7 41 amabelz 41 amantadine hcl 10 AMBISOME 102 amcinonide 48 a-methapred 48 amethia 41 amethia lo 41 amethyst 41 amifostine 104

146 Página amikacin sulfate 81 amiloride hcl 12 amiloride/hydrochlorothiazide 12 aminophylline 64 AMINOSYN 122 AMINOSYN 7%/ELECTROLYTES 121 AMINOSYN 8.5%/ELECTROLYTES 121 AMINOSYN II 121 AMINOSYN II 8.5%/ELECTROLYTES 121 AMINOSYN M 122 AMINOSYN-HBC 122 AMINOSYN-PF 122 AMINOSYN-PF 7% 122 AMINOSYN-RF 122 amiodarone hcl 12 AMITIZA 35 amitriptyline hcl 96 amlodipine besylate 12 amlodipine besylate/atorvastatin calcium 12 amlodipine besylate/benazepril 12 hydrochloride amlodipine besylate/valsartan 12 amlodipine/olmesartan medoxomil 13 amlodipine/valsartan/hctz 13 ammonium chloride 123 ammonium lactate 33 ammonium lactate 143 amnesteem 33 amoxapine 96 amoxicillin 81 amoxicillin er 81 amoxicillin/clavulanate potassium 81 amoxicillin/clavulanate potassium er 81 amphetamine/dextroamphetamine 28 amphotericin b 102 ampicillin 82 ampicillin sodium 82 ampicillin-sulbactam 82 AMPYRA 29 ANADROL anagrelide hydrochloride 135 anaspaz 35 anastrozole 104 ANDRODERM 41 ANDROGEL 41 ANDROGEL PUMP 41 ANDROXY 41 ANGELIQ 41 ANORO ELLIPTA 64 ANTARA 13 Página 145 Nombre del medicamento Página antifungal 143 antipyrine/benzocaine 70 anucort-hc 48 ANZEMET 100 APEXICON E 48 APLENZIN 96 APOKYN 10 apraclonidine 61 aprepitant 100 apri 41 APRISO 26 APTENSIO XR 29 APTIOM 92 APTIVUS 117 ARALAST NP 64 aranelle 41 ARANESP ALBUMIN FREE 135 arbinoxa 64 ARCALYST 55 ARCAPTA NEOHALER 64 ARGATROBAN 135 argyle sterile saline 100ml 69 aripiprazole 113 aripiprazole odt 113 ARISTADA 114 armodafinil 31 ARMOUR THYROID 52 ARNUITY ELLIPTA 64 ARRANON 104 ARZERRA 104 ASACOL HD 26 ascomp/codeine 71 ashlyna 41 ASMANEX HFA 64 ASMANEX TWISTHALER METERED DOSES ASMANEX TWISTHALER 14 METERED 64 DOSES ASMANEX TWISTHALER 30 METERED 64 DOSES ASMANEX TWISTHALER 60 METERED 64 DOSES ASMANEX TWISTHALER 7 METERED 65 DOSES aspirin/dipyridamole 135 aspirin-caffeine-dihydrocodeine 71 ASTAGRAF XL 55 atenolol 13 atenolol/chlorthalidone 13 ATGAM 55

147 Página atomoxetine 29 atorvastatin calcium 13 ATOVAQUONE 113 atovaquone/proguanil hcl 113 ATRIPLA 117 atropine sulfate 13 atropine sulfate 35 atropine sulfate 61 ATROVENT HFA 65 aubra 41 augmented betamethasone dipropionate 48 AUGMENTIN 82 AURYXIA 123 AUVI-Q 65 AVANDAMET 138 AVANDARYL 138 AVANDIA 138 AVASTIN 104 AVEED 41 AVELOX 82 aviane 41 AVITA 33 AVONEX 29 AVONEX PEN 29 AXIRON 42 azacitidine 104 AZACTAM IN ISO-OSMOTIC 82 DEXTROSE AZASAN 55 AZASITE 82 azathioprine 55 azelastine hcl 61 azelastine hcl 65 AZELEX 33 azithromycin 82 AZOPT 61 aztreonam 82 azurette 42 baciim 82 bacitracin 82 bacitracin/polymyxin b 82 baclofen 8 bactocill in dextrose 82 BACTROBAN NASAL 83 balsalazide disodium 26 balziva 42 BANZEL 92 BARACLUDE 117 BAVENCIO 104 baycadron 48 Página 146 Nombre del medicamento Página BCG VACCINE 55 bd insulin syringe safetyglide/1ml/29g x 69 1/2" bd insulin syringe ultrafine/0.3ml/31g x 69 5/16" bd insulin syringe ultrafine/0.5ml/30g x 1/2" 69 bd insulin syringe ultrafine/1ml/31g x 5/16" 69 bd pen needle/ultrafine/29g x 12.7mm 69 BECONASE AQ 65 bekyree 42 BELEODAQ 104 BELSOMRA 32 benazepril hcl 13 benazepril hcl/hydrochlorothiazide 13 BENDEKA 104 BENLYSTA 55 benzonatate 65 benztropine mesylate 10 BERINERT 55 BESIVANCE 83 betamethasone dipropionate 48 betamethasone valerate 48 BETASERON 29 betaxolol hcl 13 betaxolol hcl 61 bethanechol chloride 39 BETHKIS 65 BETIMOL 61 BETOPTIC-S 61 bexarotene 104 BEXSERO 55 BEYAZ 42 bicalutamide 104 BICILLIN C-R 83 BICILLIN L-A 83 BICNU 104 BIDIL 13 BILTRICIDE 113 bimatoprost 61 BINOSTO 27 bisoprolol fumarate 13 bisoprolol fumarate/hydrochlorothiazide 13 BIVIGAM 55 bleomycin sulfate 104 BLEPHAMIDE 83 BLEPHAMIDE S.O.P. 83 blisovi 24 fe 42 blisovi fe 1.5/30 42 blisovi fe 1/20 42 BOOSTRIX 55

148 Página BOSULIF 104 BOTOX 69 bp folinatal plus b 123 bp multinatal plus 123 BREO ELLIPTA 65 briellyn 42 BRILINTA 135 brimonidine tartrate 61 BRISDELLE 98 BRIVIACT 92 bromfenac 61 bromocriptine mesylate 10 BROVANA 65 budesonide 26 budesonide 65 budesonide nasal spray 65 bumetanide 13 bupap 71 BUPHENYL 142 buprenorphine 71 buprenorphine hcl 63 buprenorphine hcl 71 buprenorphine hcl/naloxone hcl 63 buproban 63 bupropion hcl 97 bupropion hcl er 96 bupropion hcl sr 63 bupropion hcl sr 96 bupropion hcl xl 96 buspirone hcl 80 busulfan 104 BUSULFEX 104 butalbital/acetaminophen 71 butalbital/acetaminophen/caffeine 71 butalbital/acetaminophen/caffeine/codeine 71 butalbital/aspirin/caffeine 71 butalbital/aspirin/caffeine/codeine 71 butorphanol tartrate 71 BUTRANS 71 BYDUREON 138 BYDUREON PEN 138 BYETTA 138 BYSTOLIC 14 BYVALSON 14 cabergoline 54 CABOMETYX 105 calcipotriene 33 calcipotriene/betamethasone dipropionate 33 calcitonin-salmon 27 calcitrene 33 Página 147 Nombre del medicamento Página calcitriol 27 calcitriol 33 calcium acetate 123 CAMBIA 71 camila 42 camrese 42 camrese lo 42 CANASA 26 CANCIDAS 102 candesartan cilexetil 14 candesartan cilexetil/hydrochlorothiazide 14 CANTIL 36 capacet 71 CAPASTAT SULFATE 101 CAPEX 48 CAPITAL/CODEINE 71 CAPRELSA 105 captopril 14 captopril/hydrochlorothiazide 14 CARAFATE 36 CARBAGLU 123 carbamazepine 92 carbamazepine er 92 carbidopa 10 carbidopa/levodopa 10 carbidopa/levodopa er 10 carbidopa/levodopa odt 10 carbidopa/levodopa/entacapone 10 carbinoxamine maleate 65 carboplatin 105 CARDENE IV 14 CARDIZEM LA 14 CARDURA XL 14 CARIMUNE NANOFILTERED 55 carisoprodol 141 carisoprodol/aspirin 141 carisoprodol/aspirin/codeine 71 CARNITOR 69 carteolol hcl 61 cartia xt 14 carvedilol 14 CAYSTON 65 caziant 42 cefaclor 83 cefaclor er 83 cefadroxil 83 cefazolin 83 cefazolin sodium 83 cefazolin sodium/dextrose 83 cefdinir 83

149 Página cefditoren pivoxil 83 cefepime 83 cefepime/dextrose 83 cefixime 83 cefotaxime sodium 83 cefotetan 84 cefotetan/dextrose 84 cefoxitin sodium 84 cefpodoxime proxetil 84 cefprozil 84 ceftazidime 84 ceftazidime/dextrose 84 ceftibuten 84 CEFTIN 84 ceftriaxone in iso-osmotic dextrose 84 ceftriaxone sodium 84 ceftriaxone/dextrose 84 cefuroxime axetil 84 cefuroxime sodium 84 cefuroxime/dextrose 85 celecoxib 71 CELONTIN 92 cephalexin 85 CEREZYME 142 CERVARIX 55 CESAMET 101 cesia 42 cetirizine hcl 65 cetirizine hcl 143 cevimeline hcl 32 CHANTIX 63 CHANTIX CONTINUING MONTH PAK 63 CHANTIX STARTING MONTH PAK 63 chateal 42 CHEMET 123 CHENODAL 36 cheratussin dac 143 chloramphenicol sodium succinate 85 chlordiazepoxide hcl 80 chlordiazepoxide hcl/clidinium bromide 36 chlordiazepoxide/amitriptyline 97 chlorhexidine gluconate 32 chlorhexidine gluconate oral rinse 32 chloroquine phosphate 113 chlorothiazide 14 chlorothiazide sodium 14 chlorpromazine hcl 114 chlorpropamide 138 chlorthalidone 14 chlorzoxazone 141 Página 148 Nombre del medicamento Página cholestyramine 15 cholestyramine light 15 chorionic gonadotropin 40 ciclodan 102 ciclopirox 102 ciclopirox nail lacquer 102 ciclopirox olamine 102 cidofovir 118 cilostazol 135 CILOXAN 85 cimetidine 36 cimetidine hcl 36 CIMZIA 55 CINRYZE 55 CIPRO HC 85 CIPRODEX 85 ciprofloxacin 85 ciprofloxacin er 85 ciprofloxacin hcl 85 ciprofloxacin i.v.-in d5w 85 cisplatin 105 citalopram hydrobromide 98 cladribine 105 CLAFORAN 85 CLAFORAN/D5W 85 claravis 33 CLARINEX 65 CLARINEX-D 12 HOUR 65 clarithromycin 85 clarithromycin er 85 clemastine fumarate 65 CLEOCIN 85 CLIMARA PRO 42 clindacin etz pledgets 85 CLINDACIN PAC 33 clindacin-p 33 clindamax 85 clindamycin 86 clindamycin hcl 85 clindamycin palmitate hcl 85 clindamycin phosphate 86 clindamycin phosphate add-vantage 85 clindamycin phosphate in d5w 85 clindamycin phosphate pharmacy bulk 86 package clindamycin phosphate/tretinoin 33 clindamycin/benzoyl peroxide 33 clindamycin/sodium chloride 86 CLINDESSE 86 CLINIMIX 2.75%/DEXTROSE 5% 123

150 Página CLINIMIX 4.25%/DEXTROSE 10% 123 CLINIMIX 4.25%/DEXTROSE 20% 123 CLINIMIX 4.25%/DEXTROSE 25% 124 CLINIMIX 4.25%/DEXTROSE 5% 124 CLINIMIX 5%/DEXTROSE 15% 124 CLINIMIX 5%/DEXTROSE 20% 124 CLINIMIX 5%/DEXTROSE 25% 124 CLINIMIX E 2.75%/DEXTROSE 10% 124 CLINIMIX E 2.75%/DEXTROSE 5% 125 CLINIMIX E 4.25%/DEXTROSE 10% 125 CLINIMIX E 4.25%/DEXTROSE 25% 125 CLINIMIX E 4.25%/DEXTROSE 5% 125 CLINIMIX E 5%/DEXTROSE 15% 125 CLINIMIX E 5%/DEXTROSE 20% 126 CLINIMIX E 5%/DEXTROSE 25% 126 CLINISOL SF 15% 126 clobetasol propionate 48 clobetasol propionate e 48 clobetasol propionate emollient 48 clocortolone pivalate 49 clocortolone pivalate pump 49 clodan 49 clofarabine 105 clomipramine hcl 97 clonazepam 92 clonazepam odt 92 clonidine hcl 15 clonidine hcl er 29 clopidogrel 135 clorazepate dipotassium 80 clorpres 15 clotrimazole 102 clotrimazole 143 clotrimazole/betamethasone dipropionate 102 clozapine 114 clozapine odt 114 c-nate dha 123 COARTEM 113 codeine sulfate 72 colchicine 26 colestipol hcl 15 colistimethate sodium 86 colocort 26 COLY-MYCIN S 70 COMBIGAN 61 COMBIPATCH 42 COMBIVENT RESPIMAT 65 COMETRIQ 105 COMPLERA 118 complete natal dha 126 Página 149 Nombre del medicamento Página compro 114 COMVAX 55 CONDYLOX 33 constulose 36 COPAXONE 29 CORDRAN 49 CORDRAN TAPE 49 COREG CR 15 CORLANOR 15 cormax scalp application 49 CORTIFOAM 49 cortisone acetate 49 CORTISPORIN 86 CORTISPORIN-TC 70 COSENTYX 34 COSENTYX SENSOREADY PEN 33 COSMEGEN 105 COSOPT PF 61 COTELLIC 105 CREON 142 CRESEMBA 102 CRINONE 42 CRIXIVAN 118 cromolyn sodium 36 cromolyn sodium 61 cromolyn sodium 65 cryselle CUPRIMINE 126 curity gauze pads 2"x2" 34 curity sterile saline 69 CUVITRU 55 CUVPOSA 36 cyanocobalamin 126 cyclafem 1/35 42 cyclafem 7/7/7 42 cyclobenzaprine hcl 141 cyclophosphamide 105 cycloserine 101 CYCLOSET 138 cyclosporine 56 cyclosporine modified 56 cyproheptadine hcl 65 CYRAMZA 105 cyred 42 CYSTADANE 142 CYSTAGON 142 CYSTARAN 61 cytarabine aqueous 105 cytra k crystals 126 dacarbazine 105

151 Página 150 Nombre del medicamento Página DALIRESP 65 DALVANCE 86 danazol 42 dantrolene sodium 8 dapsone 101 DAPTACEL 56 daptomycin 86 DARAPRIM 113 darifenacin hydrobromide er 39 DARZALEX 105 dasetta 1/35 42 dasetta 7/7/7 42 daunorubicin hcl 105 daysee 42 DAYTRANA 29 deblitane 42 decitabine 105 delyla 42 DELZICOL 26 demeclocycline hcl 86 DEMSER 15 DENAVIR 118 DEPEN TITRATABS 126 DEPO-ESTRADIOL 42 DEPO-MEDROL 49 DEPO-PROVERA 42 DEPO-SUBQ PROVERA DESCOVY 118 desipramine hcl 97 desloratadine 65 desmopressin acetate 40 desogestrel/ethinyl estradiol 42 DESONATE 49 desonide 49 desoximetasone 49 desvenlafaxine er 98 dexamethasone 49 dexamethasone intensol 49 dexamethasone sodium phosphate 49 dexamethasone sodium phosphate 61 dexchlorpheniramine maleate 65 DEXILANT 36 dexmethylphenidate hcl 29 dexmethylphenidate hcl er 29 dexrazoxane 105 dextroamphetamine sulfate 30 dextroamphetamine sulfate er 29 dextrose 10%/nacl 0.45% 126 dextrose 5% /electrolyte #48 viaflex 126 DEXTROSE 10% 126 Nombre del medicamento Página dextrose 10%/nacl 0.2% 126 dextrose 10%/nacl 0.225% 126 dextrose 2.5%/nacl 0.45% 126 DEXTROSE 20% 126 DEXTROSE 25% 126 DEXTROSE 30% 126 DEXTROSE 40% 126 DEXTROSE 5% 127 dextrose 5%/lactated ringers 126 dextrose 5%/nacl 0.2% 126 dextrose 5%/nacl 0.225% 126 dextrose 5%/nacl 0.3% 126 dextrose 5%/nacl 0.33% 127 dextrose 5%/nacl 0.45% 127 dextrose 5%/nacl 0.9% 127 DEXTROSE 50% 127 DEXTROSE 70% 127 DIASTAT ACUDIAL 92 DIASTAT PEDIATRIC 92 diazepam 80 DIAZEPAM 92 diazepam intensol 80 diclofenac potassium 72 diclofenac sodium 34 diclofenac sodium 61 diclofenac sodium dr 72 diclofenac sodium er 72 diclofenac sodium/misoprostol 72 dicloxacillin sodium 86 dicyclomine hcl 36 didanosine 118 DIFFERIN 34 DIFICID 86 diflorasone diacetate 49 diflunisal 72 digitek 15 digox 15 digoxin 15 dihydroergotamine mesylate 9 DILANTIN 93 dilt-cd 15 diltiazem cd 15 diltiazem hcl 16 diltiazem hcl cd 15 diltiazem hcl er 15 dilt-xr 15 diltzac 16 DIPENTUM 26 diphenhist 143 diphenhydramine hcl 65

152 Página diphenoxylate/atropine 36 DIPHTHERIA/TETANUS TOXOIDS 56 ADSORBED PEDIATRIC dipyridamole 135 disopyramide phosphate 16 disulfiram 63 DIURIL 16 divalproex sodium 93 divalproex sodium dr 93 divalproex sodium er 93 DIVIGEL 42 DOCEFREZ 105 docetaxel 105 dofetilide 16 donepezil hcl 8 DORIBAX 86 doripenem 86 dorzolamide hcl 61 dorzolamide hcl/timolol maleate 61 doxazosin 39 doxazosin mesylate 39 doxepin hcl 97 doxepin hydrochloride 34 doxercalciferol 27 doxorubicin hcl 106 doxorubicin hcl liposome 106 doxy doxycycline 34 doxycycline 87 doxycycline hyclate 86 doxycycline hyclate dr 86 doxycycline monohydrate 86 dronabinol 101 drospirenone/ethinyl estradiol 42 drospirenone/ethinyl estradiol/levomefolate 42 calcium DROXIA 106 DUAVEE 42 DUEXIS 72 DULERA 65 duloxetine hcl 98 DUOPA 10 DURAMORPH 72 DUREZOL 61 dutasteride 39 dutasteride/tamsulosin hydrochloride 39 DUTOPROL 16 DYMISTA 65 DYRENIUM 16 DYSPORT 69 Página 151 Nombre del medicamento Página e.e.s econazole nitrate 102 EDARBI 16 EDARBYCLOR 16 EDLUAR 32 ed-spaz 36 EDURANT 118 EGRIFTA 40 ELAPRASE 142 ELELYSO 142 ELESTRIN 42 ELIDEL 34 ELIGARD 54 elinest 43 ELITEK 106 ELIXOPHYLLIN 65 ELMIRON 39 EMADINE 61 EMBEDA 72 EMCYT 106 EMEND 101 emoquette 43 EMPLICITI 106 EMSAM 97 EMTRIVA 118 enalapril maleate 16 enalapril maleate/hydrochlorothiazide 16 ENBREL 56 ENBREL SURECLICK 56 endocet 72 endodan 72 ENGERIX-B 56 enoxaparin sodium 135 enpresse enskyce 43 entacapone 10 entecavir 118 ENTRESTO 17 enulose 36 ENVARSUS XR 56 EPANED 17 EPCLUSA 118 EPIDUO 34 EPIDUO FORTE 34 epinastine hcl 61 epinephrine 65 epinephrine hcl 65 EPIPEN 2-PAK 66 EPIPEN-JR 2-PAK 66 epirubicin hcl 106

153 Página 152 Nombre del medicamento Página epitol 93 EPIVIR HBV 118 eplerenone 17 EPOGEN 136 eprosartan mesylate 17 EQUETRO 93 ERAXIS 102 ERBITUX 106 ergoloid mesylates 8 ERGOMAR 9 ergotamine tartrate/caffeine 9 ERIVEDGE 106 errin 43 ERTACZO 102 ERWINAZE 106 ery 87 ERYPED ERY-TAB 87 ERYTHROCIN LACTOBIONATE 87 erythrocin stearate 87 erythromycin 87 erythromycin base 87 erythromycin ethylsuccinate 87 erythromycin/benzoyl peroxide 34 ESBRIET 66 escitalopram oxalate 98 esgic 72 esomeprazole magnesium 36 esomeprazole sodium 36 estarylla 43 estazolam 81 ESTRACE 43 estradiol 43 estradiol valerate 43 estradiol/norethindrone acetate 43 ESTRING 43 ESTROGEL 43 estropipate 43 eszopiclone 32 ethacrynate sodium 17 ethacrynic acid 17 ethambutol hcl 101 ethosuximide 93 ethynodiol diacetate/ethinyl estradiol 43 ETHYOL 106 etidronate disodium 27 etodolac 72 etodolac er 72 ETOPOPHOS 106 etoposide 106 Nombre del medicamento Página EURAX 113 EVAMIST 43 EVEKEO 30 EVOMELA 106 EVOTAZ 118 EVZIO 63 EXELDERM 102 exemestane 106 ezetimibe 17 ezetimibe/simvastatin 17 FABIOR 34 FABRAZYME 142 FACTIVE 87 falmina 43 famciclovir 118 famotidine 36 famotidine premixed 36 FANAPT 114 FANAPT TITRATION PACK 114 FARESTON 106 FARYDAK 106 FASLODEX 106 fayosim 43 felbamate 93 felodipine er 17 FEMRING 43 femynor 43 fenofibrate 17 fenofibrate micronized 17 fenofibric acid 17 fenofibric acid dr 17 fenoprofen calcium 72 fentanyl 73 fentanyl citrate 72 fentanyl citrate oral transmucosal 72 FENTORA 73 FERRIPROX 69 FETZIMA 99 FETZIMA TITRATION PACK 99 FINACEA 34 finasteride 39 FIRAZYR 56 FIRMAGON 54 FLAGYL ER 87 flavoxate hcl 39 FLEBOGAMMA DIF 56 flecainide acetate 17 FLECTOR 73 FLOVENT DISKUS 66 FLOVENT HFA 66

154 Página 153 Nombre del medicamento Página fluconazole 102 fluconazole in dextrose 102 fluconazole in nacl 102 flucytosine 103 fludarabine phosphate 106 fludrocortisone acetate 49 flunisolide 66 fluocinolone acetonide 49 fluocinolone acetonide 70 fluocinolone acetonide body 49 fluocinolone acetonide ear drops 70 fluocinolone acetonide scalp 49 fluocinonide 50 fluocinonide emulsified base 49 fluor-a-day 127 fluoride 127 fluoritab 127 fluorometholone 61 FLUOROPLEX 34 fluorouracil 34 fluorouracil 106 fluoxetine 99 fluoxetine dr 99 fluoxetine hcl 99 fluphenazine decanoate 114 fluphenazine hcl 114 flura-drops 127 flurandrenolide 50 flurazepam hcl 81 flurbiprofen 73 flurbiprofen sodium 61 flutamide 107 fluticasone propionate 50 fluticasone propionate 66 fluticasone propionate/salmeterol 66 fluvastatin 17 fluvastatin sodium er 17 fluvoxamine maleate 99 fluvoxamine maleate er 99 FML 61 FML FORTE 61 folbecal 127 folcaps omega folic acid 127 FOLOTYN 107 fomepizole 69 fondaparinux sodium 136 FORFIVO XL 97 FORTEO 27 FOSAMAX PLUS D 27 Nombre del medicamento Página fosinopril sodium 18 fosinopril sodium/hydrochlorothiazide 17 fosphenytoin sodium 93 FOSRENOL 127 FRAGMIN 136 FREAMINE HBC 6.9% 127 FREAMINE III 127 frovatriptan succinate 9 FULYZAQ 36 furosemide 18 FUSILEV 107 FUZEON 118 fyavolv 43 FYCOMPA 93 gabapentin 93 GABITRIL 93 GABLOFEN 8 galantamine hydrobromide 8 galantamine hydrobromide er 8 GAMASTAN S/D 56 GAMMAGARD LIQUID 56 GAMMAKED 56 GAMMAPLEX 56 GAMUNEX-C 57 ganciclovir 118 GARDASIL 57 GARDASIL 9 57 gatifloxacin 87 GATTEX 36 GAVILYTE-C 36 gavilyte-g 36 gavilyte-h 36 gavilyte-n/flavor pack 36 GAZYVA 107 GELNIQUE 39 gemcitabine 107 gemcitabine hcl 107 gemfibrozil 18 GENERESS FE 43 generlac 36 gengraf 57 GENOTROPIN 40 GENOTROPIN MINIQUICK 40 gentak 87 gentamicin sulfate 87 gentamicin sulfate pediatric 87 gentamicin sulfate/0.9% sodium chloride 87 GENVOYA 118 GEODON 114 gianvi 43

155 Página 154 Nombre del medicamento Página GIAZO 26 gildagia 43 gildess 1.5/30 43 gildess 1/20 43 gildess 24 fe 43 gildess fe 1.5/30 44 gildess fe 1/20 44 GILENYA 30 GILOTRIF 107 GLASSIA 66 GLEOSTINE 107 glimepiride 138 glipizide 138 glipizide er 138 glipizide xl 138 glipizide/metformin hcl 138 GLUCAGEN HYPOKIT 138 GLUCAGON EMERGENCY KIT 138 glyburide 139 glyburide micronized 138 glyburide/metformin hcl 138 glycopyrrolate 37 glydo 79 GLYXAMBI 139 GRALISE 73 GRALISE STARTER 73 granisetron hcl 101 GRANIX 136 griseofulvin microsize 103 griseofulvin ultramicrosize 103 guaifenesin dac 143 guanfacine er 30 guanfacine hcl 18 GUANIDINE HCL 10 GYNAZOLE H.P. ACTHAR 40 HALAVEN 107 halobetasol propionate 50 HALOG 50 haloperidol 114 haloperidol decanoate 114 haloperidol lactate 114 HARVONI 118 HAVRIX 57 heather 44 hecoria 57 HELIDAC 37 hemmorex-hc 50 heparin sodium 136 heparin sodium/d5w 136 Nombre del medicamento Página heparin sodium/nacl 0.45% 136 heparin sodium/nacl 0.9% 136 heparin sodium/sodium chloride 0.9% 136 heparin sodium/sodium chloride 0.9% 136 premix HEPATAMINE 127 HERCEPTIN 107 HETLIOZ 30 HEXALEN 107 HIBERIX 57 HIZENTRA 57 HORIZANT 30 HUMALOG 139 HUMALOG KWIKPEN 139 HUMALOG MIX 50/ HUMALOG MIX 50/50 KWIKPEN 139 HUMALOG MIX 75/ HUMALOG MIX 75/25 KWIKPEN 139 HUMATROPE 40 HUMATROPE COMBO PACK 40 HUMIRA 57 HUMIRA PEDIATRIC CROHNS 57 DISEASE STARTER PACK HUMIRA PEN 57 HUMIRA PEN-CROHNS 57 DISEASESTARTER HUMIRA PEN-PSORIASIS STARTER 57 HUMULIN 70/ HUMULIN 70/30 KWIKPEN 139 HUMULIN N 139 HUMULIN N KWIKPEN 139 HUMULIN R 139 HUMULIN R U-500 (CONCENTRATED) 139 HUMULIN R U-500 KWIKPEN 139 hydralazine hcl 18 hydrochlorothiazide 18 hydrocodone bitartrate/acetaminophen 73 hydrocodone bitartrate/homatropine 66 methylbromide hydrocodone polistirex/chlorpheniramine 66 polistirex hydrocodone/acetaminophen 73 hydrocodone/homatropine 66 hydrocodone/ibuprofen 73 hydrocortisone 26 hydrocortisone 50 hydrocortisone 143 hydrocortisone acetate 50 hydrocortisone acetate/pramoxine 9 hydrocortisone acetate/pramoxine 50

156 Página 155 Nombre del medicamento Página hydrocortisone butyrate 50 hydrocortisone butyrate (lipid) 50 hydrocortisone butyrate (lipophilic) 50 hydrocortisone valerate 50 hydrocortisone/acetic acid 70 hydromet 66 hydromorphone hcl 74 hydromorphone hcl dosette 73 hydromorphone hcl er 73 hydromorphone hydrochloride 74 hydromorphone hydrochloride er 74 hydroxychloroquine sulfate 113 hydroxyprogesterone caproate 44 hydroxyurea 107 hydroxyzine hcl 66 hydroxyzine pamoate 66 hyophen 39 hyoscyamine sulfate 37 hyoscyamine sulfate er 37 hyoscyamine sulfate odt 37 hyoscyamine sulfate sr 37 hyosyne 37 ibandronate sodium 27 IBRANCE 107 ibudone 74 ibuprofen 74 ICLUSIG 107 idarubicin hcl 107 ifosfamide 107 ILARIS 57 ILEVRO 61 ilotycin 87 imatinib mesylate 107 IMBRUVICA 107 IMFINZI 107 imipenem/cilastatin 87 imipramine hcl 97 imipramine pamoate 97 imiquimod 34 IMOVAX RABIES (H.D.C.V.) 57 INCRELEX 40 INCRUSE ELLIPTA 66 indapamide 18 INDOCIN 74 indomethacin 74 indomethacin er 74 INFANRIX 57 INFUMORPH INFUMORPH INLYTA 107 Nombre del medicamento Página INTELENCE 118 INTRALIPID 69 INTRON A 118 INTRON A W/DILUENT 118 introvale 44 INVANZ 87 INVEGA SUSTENNA 115 INVEGA TRINZA 115 INVIRASE 118 INVOKAMET 139 INVOKAMET XR 139 INVOKANA 139 IONOSOL-B/DEXTROSE 5% 127 IONOSOL-MB/DEXTROSE 5% 128 IOPIDINE 61 IPOL INACTIVATED IPV 57 ipratropium bromide 66 ipratropium bromide/albuterol sulfate 66 irbesartan 18 irbesartan/hydrochlorothiazide 18 IRESSA 108 irinotecan 108 irinotecan hcl 108 ISENTRESS 118 ISENTRESS HD 118 ISOLYTE-P/DEXTROSE 5% 128 ISOLYTE-S 128 ISOLYTE-S PH isoniazid 101 ISORDIL TITRADOSE 18 isosorbide dinitrate 18 isosorbide dinitrate er 18 isosorbide mononitrate 18 isosorbide mononitrate er 18 isotonic gentamicin 87 isradipine 18 ISTODAX 108 ISTODAX (OVERFILL) 108 itraconazole 103 ivermectin 113 IXEMPRA KIT 108 IXIARO 57 JADENU 128 JADENU SPRINKLE 128 JAKAFI 108 jantoven 136 JANUMET 139 JANUMET XR 139 JANUVIA 139 JARDIANCE 139

157 Página 156 Nombre del medicamento Página jencycla 44 JENTADUETO 139 JENTADUETO XR 139 jevantique lo 44 JEVTANA 108 jinteli 44 jolessa 44 jolivette 44 juleber 44 junel 1.5/30 44 junel 1/20 44 junel fe 1.5/30 44 junel fe 1/20 44 junel fe KABIVEN 128 KADCYLA 108 KADIAN 74 kaitlib fe 44 KALETRA 118 KALYDECO 66 KARBINAL ER 66 karidium 128 kariva 44 KAZANO 140 kcl 0.075%/d5w/nacl 0.45% 128 kcl 0.15%/d5w/ nacl 0.3% 128 kcl 0.15%/d5w/nacl 0.2% 128 kcl 0.15%/d5w/nacl 0.225% 128 kcl 0.15%/d5w/nacl 0.9% 128 kcl 0.3%/d5w/nacl 0.45% 128 kcl 0.3%/d5w/nacl 0.9% 128 kelnor 1/35 44 KEPIVANCE 32 KERYDIN 103 KETEK 87 ketoconazole 103 ketodan 103 KETODAN KIT 103 ketoprofen 74 ketoprofen er 74 ketorolac tromethamine 61 ketorolac tromethamine 74 ketotifen fumarate 143 KEYTRUDA 108 KHEDEZLA 99 kimidess 44 KINERET 57 KINRIX 57 kionex 128 KISQALI 108 Nombre del medicamento Página KISQALI FEMARA 200 DOSE 108 KISQALI FEMARA 400 DOSE 108 KISQALI FEMARA 600 DOSE 108 klor-con 128 KLOR-CON klor-con klor-con m KLOR-CON M klor-con m klor-con sprinkle 128 KORLYM 69 KRISTALOSE 37 k-sol 128 K-TAB 128 kurvelo 44 KUVAN 142 KYNAMRO 18 KYPROLIS 108 labetalol hcl 18 LACRISERT 61 LACTATED RINGERS IRRIGATION 69 LACTATED RINGERS VIAFLEX 128 lactic acid 34 lactulose 37 LAMICTAL STARTER/NOT TAKING 93 CARBAMAZEPINE LAMICTAL STARTER/TAKING 93 CARBAMAZEPINE/NOT TAKING VALPROATE LAMICTAL STARTER/TAKING 93 VALPROATE LAMICTAL XR 93 LAMISIL 103 lamivudine 119 lamivudine/zidovudine 119 lamotrigine 94 lamotrigine er 93 lamotrigine odt 94 lamotrigine titration 94 LANOXIN 19 LANOXIN PEDIATRIC 19 lansoprazole 37 lansoprazole/amoxicillin/clarithromycin 87 LANTUS 140 LANTUS SOLOSTAR 140 larin 1.5/30 44 larin 1/20 44 larin 24 fe 44 larin fe 1.5/30 44 larin fe 1/20 44

158 Página 157 Nombre del medicamento Página larissia 44 LARTRUVO 108 latanoprost 61 LATUDA 115 layolis fe 44 LAZANDA 74 leena 44 leflunomide 58 LENVIMA 10 MG DAILY DOSE 108 LENVIMA 14 MG DAILY DOSE 108 LENVIMA 18 MG DAILY DOSE 108 LENVIMA 20 MG DAILY DOSE 108 LENVIMA 24 MG DAILY DOSE 109 LENVIMA 8 MG DAILY DOSE 109 lessina 44 LETAIRIS 66 letrozole 109 leucovorin calcium 109 LEUKERAN 109 LEUKINE 137 leuprolide acetate 54 levalbuterol 67 levalbuterol hcl 67 levalbuterol tartrate hfa 67 LEVATOL 19 LEVEMIR 140 LEVEMIR FLEXTOUCH 140 levetiracetam 94 levetiracetam er 94 levobunolol hcl 61 levocarnitine 69 levocetirizine dihydrochloride 67 levofloxacin 88 levofloxacin in 5% dextrose 87 levofloxacin in d5w 87 levoleucovorin 109 levoleucovorin calcium 109 levonest 44 levonorgestrel 44 levonorgestrel and ethinyl estradiol 44 levonorgestrel/ethinyl estradiol 44 levora 0.15/ levorphanol tartrate 74 levothyroxine sodium 52 levoxyl 52 LEXIVA 119 LIALDA 26 lidocaine 80 lidocaine hcl 19 lidocaine hcl 79 Nombre del medicamento Página lidocaine hcl jelly 79 lidocaine hcl viscous 79 lidocaine pak 80 lidocaine viscous 80 lidocaine/prilocaine 80 lincomycin hcl 88 lindane 113 linezolid 88 LINZESS 37 LIORESAL INTRATHECAL 8 liothyronine sodium 53 LIPODOX 109 LIPODOX LIPOSYN III 70 lisinopril 19 lisinopril/hydrochlorothiazide 19 lithium 63 lithium carbonate 63 lithium carbonate er 62 LITHOSTAT 39 LIVALO 19 LO LOESTRIN FE 44 LO MINASTRIN FE 44 LOCOID 50 lokara 50 lomedia 24 fe 44 LOMUSTINE 109 LONSURF 109 loperamide hcl 37 lopinavir/ritonavir 119 lopreeza 44 loratadine 143 lorazepam 81 lorazepam intensol 81 lorcet 74 lorcet hd 74 lorcet plus 74 lortab 75 loryna 45 LORZONE 141 losartan potassium 19 losartan potassium/hydrochlorothiazide 19 LOTEMAX 61 lovastatin 19 low-ogestrel 45 loxapine 115 loxapine succinate 115 ludent 128 LUFYLLIN 67 LUMIGAN 61

159 Página 158 Nombre del medicamento Página LUMIZYME 142 LUPANETA PACK 54 LUPRON DEPOT (1-MONTH) 54 LUPRON DEPOT (3-MONTH) 54 LUPRON DEPOT (4-MONTH) 54 LUPRON DEPOT (6-MONTH) 54 LUPRON DEPOT-PED (1-MONTH) 54 LUPRON DEPOT-PED (3-MONTH) 54 lutera 45 LUZU 103 LYNPARZA 109 LYRICA 94 LYSODREN 55 lyza 45 macnatal cn dha 129 mafenide acetate 88 magnesium sulfate 129 magnesium sulfate in d5w 94 MAKENA 45 malathion 113 maprotiline hcl 97 margesic 75 marlissa 45 MARPLAN 97 marten-tab 75 MATULANE 109 matzim la 19 MAXIDEX 61 meclizine hcl 101 meclizine hcl 143 meclofenamate sodium 75 MEDROL 50 medroxyprogesterone acetate 45 mefenamic acid 75 mefloquine hcl 113 megestrol acetate 45 MEKINIST 109 meloxicam 75 melphalan hydrochloride 109 memantine hcl 8 memantine hcl titration pak 8 memantine hydrochloride 8 MENACTRA 58 MENEST 45 MENHIBRIX 58 MENOMUNE-A/C/Y/W MENOSTAR 45 MENTAX 103 MENVEO 58 meperidine hcl 75 Nombre del medicamento Página mephyton 129 meprobamate 81 mercaptopurine 109 meropenem 88 meropenem/sodium chloride 88 mesalamine 27 mesalamine dr 27 mesna 109 MESNEX 109 MESTINON 10 metadate er 30 metaproterenol sulfate 67 metaxall 141 metaxalone 141 metformin hcl 140 metformin hcl er 140 methadone hcl 75 methadone hcl intensol 75 methamphetamine hcl 30 methazolamide 19 methenamine hippurate 88 methimazole 55 METHITEST 45 methocarbamol 141 methotrexate 58 methotrexate sodium 58 methoxsalen 34 methscopolamine bromide 37 methyclothiazide 19 methyldopa 19 methyldopa/hydrochlorothiazide 19 methyldopate hcl 19 methylergonovine maleate 70 methylphenidate hcl 30 methylphenidate hcl cd 30 methylphenidate hcl er 30 methylphenidate hcl er (la) 30 methylphenidate hydrochloride 31 methylprednisolone 51 methylprednisolone acetate 50 methylprednisolone dose pack 50 methylprednisolone sodiumsuccinate 50 methyltestosterone 45 metipranolol 61 metoclopramide hcl 37 metoclopramide odt 37 metolazone 19 metoprolol succinate er 20 metoprolol succinate er/hydrochlorothiazide 19 metoprolol tartrate 20

160 Página 159 Nombre del medicamento Página metoprolol/hydrochlorothiazide 20 metronidazole 88 metronidazole in nacl 0.79% 88 metronidazole vaginal 88 mexiletine hcl 20 MIACALCIN 27 mi-acid 143 mibelas 24 fe 45 miconazole 143 miconazole microgestin 1.5/30 45 microgestin 1/20 45 microgestin 24 fe 45 microgestin fe 45 microgestin fe 1.5/30 45 midodrine hcl 20 migergot 9 miglitol 140 MILLIPRED 51 mimvey 45 mimvey lo 45 MINASTRIN 24 FE 45 minitran 20 MINIVELLE 45 minocycline hcl 88 minocycline hcl er 88 minoxidil 20 MIRCERA 137 mirtazapine 97 mirtazapine odt 97 MIRVASO 34 misoprostol 37 MITIGARE 26 mitomycin 109 mitoxantrone hcl 109 M-M-R II 58 modafinil 32 moexipril hcl 20 moexipril/hydrochlorothiazide 20 molindone hydrochloride 115 mometasone furoate 51 mometasone furoate 67 mondoxyne nl 88 mono-linyah 45 mononessa 45 montelukast sodium 67 MONUROL 88 morgidox 1x100mg 88 morgidox 1x50mg 88 morgidox 2x100mg 88 Nombre del medicamento Página morphine sulfate 76 morphine sulfate add-vantage 75 morphine sulfate er 75 MOTOFEN 37 MOVIPREP 37 MOXEZA 89 moxifloxacin hcl 89 MOZOBIL 137 MULTAQ 20 multivitamin with fluoride 129 mupirocin 89 mupirocin calcium 89 MUSTARGEN 109 MYALEPT 70 MYCAMINE 103 mycophenolate mofetil 58 mycophenolic acid dr 58 mydral 62 mynate 90 plus 129 mynephrocaps 129 mynephron 129 myorisan 34 MYOZYME 142 MYRBETRIQ 39 MYTESI 37 myzilra 45 nabumetone 76 nadolol 20 nadolol/bendroflumethiazide 20 NAFCILLIN 89 nafcillin sodium 89 nafrinse drops 129 naftifine hcl 103 naftifine hydrochloride 103 NAGLAZYME 142 nalbuphine hcl 76 naloxone hcl 63 naltrexone hcl 63 naphazoline hcl 62 NAPRELAN 76 naproxen 76 naproxen dr 76 naproxen sodium 76 naproxen sodium er 76 naratriptan hcl 9 NARCAN 63 NATACYN 103 NATAZIA 45 nateglinide 140 NATESTO 45

161 Página NATPARA 70 NEBUPENT 113 necon 0.5/ necon 1/35 45 necon 1/ necon 10/ necon 7/7/7 46 nefazodone hcl 97 neofrin 62 neomycin sulfate 89 neomycin/bacitracin/polymyxin 89 neomycin/polymyxin b sulfates 89 neomycin/polymyxin/bacitracin/hydrocortis 89 one neomycin/polymyxin/dexamethasone 62 neomycin/polymyxin/gramicidin 89 neomycin/polymyxin/hc 70 neomycin/polymyxin/hydrocortisone 70 neomycin/polymyxin/hydrocortisone 89 neo-polycin 89 neo-polycin hc 89 NEO-SYNALAR 34 NEPHRAMINE 129 NERLYNX 109 NESINA 140 neuac 34 NEUMEGA 137 NEUPRO 10 nevirapine 119 nevirapine er 119 NEXAVAR 109 NEXTERONE 20 niacin er 20 niacor 21 nicardipine hcl 21 NICOTROL INHALER 63 NICOTROL NS 63 nifedical xl 21 nifedipine 21 nifedipine er 21 nikki 46 nilutamide 109 nimodipine 21 NINLARO 110 NIPENT 110 nisoldipine er 21 NITRO-BID 21 NITRO-DUR 21 nitrofurantoin 89 nitrofurantoin macrocrystals 89 Página 160 Nombre del medicamento Página nitrofurantoin monohydrate 89 nitrofurantoin monohydrate/macrocrystals 89 nitroglycerin 21 nitroglycerin er 21 nitroglycerin lingual 21 nitroglycerin transdermal 21 NITROMIST 21 nitro-time 21 nizatidine 37 nolix 51 nora-be 46 NORDITROPIN FLEXPRO 40 norethindrone 46 norethindrone & ethinyl estradiol ferrous 46 fumarate norethindrone acetate 46 norethindrone acetate/ethinyl estradiol 46 norethindrone acetate/ethinyl 46 estradiol/ferrous fumarate norethindrone/ethinyl estradiol/ferrous 46 fumarate norgestimate/ethinyl estradiol 46 NORITATE 89 norlyroc 46 NORMOSOL -R 129 NORMOSOL-M IN D5W 129 NORMOSOL-R 129 NORMOSOL-R IN D5W 129 NOROXIN 89 NORPACE CR 21 NORTHERA 21 nortrel 0.5/35 (28) 46 nortrel 1/35 46 nortrel 7/7/7 46 nortriptyline hcl 98 NORVIR 119 NOVAREL 40 NOVOLIN 70/30 RELION 140 NOVOLIN N RELION 140 NOVOLIN R RELION 140 NOXAFIL 103 np thyroid 53 np thyroid np thyroid np thyroid np thyroid NUCYNTA 76 NUCYNTA ER 76 NUEDEXTA 31 nulev 37

162 Página NULOJIX 58 NUPLAZID 115 NUTRILIPID 70 NUTRILYTE 130 NUTRILYTE II 130 NUTROPIN AQ NUSPIN 5 40 NUTROPIN AQ PEN 40 NUVARING 46 NUVESSA 89 nyamyc 103 nystatin 103 nystatin/triamcinolone 103 nystop 103 ob-natal one 130 ocella 46 OCTAGAM 58 octreotide acetate 54 ODEFSEY 119 ODOMZO 110 OFEV 67 ofloxacin 89 ogestrel 46 olanzapine 115 olanzapine odt 115 olanzapine/fluoxetine 99 OLEPTRO 98 olmesartan medoxomil 22 olmesartan 22 medoxomil/amlodipine/hydrochlorothiazide olmesartan medoxomil/hydrochlorothiazide 22 olopatadine hcl 62 olopatadine hcl 67 olopatadine hydrochloride 62 OLYSIO 119 OMECLAMOX-PAK 89 omega-3-acid ethyl esters 22 omeprazole 38 omeprazole/sodium bicarbonate 37 OMNITROPE 41 ONCASPAR 110 ondansetron hcl 101 ondansetron odt 101 ONFI 94 ONIVYDE 110 ONMEL 103 OPANA ER (CRUSH RESISTANT) 77 OPDIVO 110 OPSUMIT 67 ORACEA 34 oralone 32 Página 161 Nombre del medicamento Página ORAVIG 103 ORENCIA 58 ORENCIA CLICKJECT 58 ORENITRAM 67 ORFADIN 142 ORKAMBI 67 orphenadrine citrate 141 orphenadrine citrate er 141 orsythia 46 ortho-est 46 oscimin 38 oscimin sr 38 oseltamivir phosphate 119 OSENI 140 OTEZLA 58 OTREXUP 58 oxacillin sodium 89 oxaliplatin 110 oxandrolone 46 oxaprozin 77 oxazepam 81 oxcarbazepine 94 oxiconazole nitrate 103 OXISTAT 103 OXSORALEN 34 OXTELLAR XR 94 oxybutynin chloride 39 oxybutynin chloride er 39 oxycodone hcl 77 oxycodone hcl er 77 oxycodone/acetaminophen 77 oxycodone/aspirin 77 oxycodone/ibuprofen 77 OXYCONTIN 77 oxymorphone hydrochloride 78 oxymorphone hydrochloride er 77 OXYTROL 39 pacerone 22 paclitaxel 110 paliperidone er 115 pamidronate disodium 27 PANRETIN 110 pantoprazole sodium 38 PAREGORIC 38 paricalcitol 27 paroex 32 paromomycin sulfate 89 paroxetine hcl 99 paroxetine hcl er 99 PASER 102

163 Página 162 Nombre del medicamento Página PAXIL 100 PAZEO 62 PEDIARIX 59 PEDVAX HIB 59 PEG 3350/ELECTROLYTES 38 peg-3350/electrolytes 38 peg-3350/nacl/na bicarbonate/kcl 38 PEGANONE 95 PEGASYS 119 PEGASYS PROCLICK 119 penicillin g potassium 90 penicillin g potassium in iso-osmotic 89 dextrose penicillin g procaine 90 penicillin g sodium 90 penicillin v potassium 90 PENTAM PENTASA 27 pentazocine/acetaminophen 78 pentazocine/naloxone hcl 78 pentoxifylline er 22 PERFOROMIST 67 PERIKABIVEN 130 perindopril erbumine 22 periogard 32 PERJETA 110 permethrin 113 perphenazine 116 perphenazine/amitriptyline 98 PEXEVA 100 phenadoz 101 phenazopyridine hcl 39 phenelzine sulfate 98 phenergan 101 phenobarbital 95 phenoxybenzamine hydrochloride 22 phenylephrine hcl 62 phenytoin 95 phenytoin infatabs 95 phenytoin sodium 95 phenytoin sodium extended 95 philith 46 PHOSLYRA 130 PHOSPHOLINE IODIDE 62 PHRENILIN FORTE 78 PHYSIOLYTE 70 PHYSIOSOL IRRIGATION 70 PICATO 34 pilocarpine hcl 32 pilocarpine hcl 62 Nombre del medicamento Página pilocarpine hydrochloride 32 pimozide 116 pimtrea 46 pindolol 22 pioglitazone hcl 140 pioglitazone hcl/metformin hcl 140 pioglitazone hcl-glimepiride 140 piperacillin sodium/ tazobactam sodium 90 piperacillin sodium/tazobactam sodium 90 piperacillin/tazobactam 90 pirmella 1/35 46 pirmella 7/7/7 46 piroxicam 78 PLASMA-LYTE A 130 PLASMA-LYTE PLASMA-LYTE-56/D5W 130 PLENAMINE 130 pnv-dha 130 pnv-select 130 podofilox 34 polycin 90 polyethylene glycol polymyxin b sulfate 90 polymyxin b sulfate/trimethoprim sulfate 90 POMALYST 110 portia PORTRAZZA 110 potassium chloride 131 potassium chloride /sodium chloride 130 potassium chloride 0.15% d5w/nacl 0.33% 130 potassium chloride 0.15% d5w/nacl 0.45% 130 potassium chloride 0.15% d5w/nacl 0.45% 130 viaflex potassium chloride 0.22% d5w/nacl 0.45% 130 potassium chloride cr 130 potassium chloride er 130 potassium chloride sr 131 potassium chloride/dextrose 131 potassium chloride/dextrose/lactated 131 ringers potassium chloride/sodium chloride 131 potassium citrate er 131 potassium citrate-citric acid crystals 131 POTIGA 95 pr natal pr natal 400 ec 131 pr natal pr natal 430 ec 131 PRADAXA 137 pramcort 51

164 Página 163 Nombre del medicamento Página pramipexole dihydrochloride 11 pramipexole dihydrochloride er 11 pramosone 9 pravastatin sodium 22 prazosin hcl 22 PRED MILD 62 PRED-G 62 PRED-G S.O.P. 62 prednicarbate 51 prednisolone 51 prednisolone acetate 62 prednisolone sodium phosphate 51 prednisolone sodium phosphate 62 prednisolone sodium phosphate odt 51 prednisone 51 prednisone intensol 51 PREFEST 46 PREGNYL W/DILUENT BENZYL 41 ALCOHOL/NACL PREMARIN 46 PREMASOL 132 premium lidocaine 80 PREMPHASE 47 PREMPRO 47 prenaissance plus 132 prenata 132 prenate dha 132 prenate elite 132 prenate enhance 132 prenate restore 132 prevalite 22 previfem 47 PREZCOBIX 119 PREZISTA 119 PRIFTIN 102 PRIMAQUINE PHOSPHATE 113 primidone 95 PRIMLEV 78 PRIMSOL 90 PRISTIQ 100 PRIVIGEN 59 PROAIR HFA 67 PROAIR RESPICLICK 67 probenecid 26 probenecid/colchicine 26 procainamide hcl 22 PROCALAMINE 132 prochlorperazine 116 prochlorperazine edisylate 116 prochlorperazine maleate 116 Nombre del medicamento Página PROCRIT 137 PROCTOFOAM HC 51 procto-med hc 51 procto-pak 51 proctosol hc 51 proctozone-hc 51 PROCYSBI 62 progesterone 47 PROGLYCEM 140 PROGRAF 59 PROLASTIN-C 67 PROLENSA 62 PROLEUKIN 110 PROLIA 27 PROMACTA 137 promethazine hcl 67 promethazine hcl 101 promethazine hcl plain 67 promethazine vc plain 67 promethazine vc/codeine 67 promethazine/codeine 67 promethazine/dextromethorphan 67 promethazine/phenylephrine 68 promethazine/phenylephrine/codeine 68 promethegan 101 propafenone hcl 23 propafenone hcl er 22 propantheline bromide 38 proparacaine hcl 62 propranolol hcl 23 propranolol hcl er 23 propranolol/hydrochlorothiazide 23 propylthiouracil 55 PROQUAD 59 PROSOL 132 PROTONIX 38 protriptyline hcl 98 PULMICORT FLEXHALER 68 PULMOZYME 68 PURIXAN 110 PYLERA 38 pyrazinamide 102 pyridostigmine bromide 10 pyridostigmine bromide er 10 QNASL 68 QNASL CHILDRENS 68 QUADRACEL 59 QUARTETTE 47 quasense 47 QUDEXY XR 95

165 Página 164 Nombre del medicamento Página quetiapine fumarate 116 quetiapine fumarate er 116 QUILLIVANT XR 31 quinapril hcl 23 quinapril/hydrochlorothiazide 23 quinidine gluconate 23 quinidine gluconate cr 23 quinidine gluconate er 23 quinidine sulfate 23 quinidine sulfate er 23 quinine sulfate 113 QVAR 68 RABAVERT 59 rabeprazole sodium 38 raloxifene hydrochloride 47 ramipril 23 RANEXA 23 ranitidine hcl 38 RAPAMUNE 59 rasagiline mesylate 11 RASUVO 59 RAVICTI 142 RAYOS 51 reclipsen 47 RECOMBIVAX HB 59 RECTIV 23 REGONOL 10 REGRANEX 34 RELENZA DISKHALER 119 RELISTOR 38 relnate dha 132 RELPAX 9 remedy antifungal 143 REMICADE 59 REMODULIN 68 RENAGEL 132 renal caps 133 reno caps 133 RENVELA 133 repaglinide 140 repaglinide/metformin hydrochloride 140 REPATHA 23 REPATHA PUSHTRONEX SYSTEM 23 REPATHA SURECLICK 23 reprexain 78 RESCRIPTOR 119 RESCULA 62 reserpine 23 RESTASIS 62 RETIN-A MICRO PUMP 34 Nombre del medicamento Página RETROVIR IV INFUSION 119 REVLIMID 110 REXULTI 116 REYATAZ 119 RHEUMATREX 59 ribavirin 68 ribavirin 119 RIDAURA 59 rifabutin 102 rifampin 102 RIFATER 102 riluzole 31 rimantadine hcl 119 RINGERS INJECTION 133 RINGERS IRRIGATION 70 RIOMET 141 risedronate sodium 28 risedronate sodium dr 27 RISPERDAL CONSTA 116 risperidone 116 risperidone m-tab 116 risperidone odt 116 RITALIN LA 31 RITUXAN 110 RITUXAN HYCELA 110 rivastigmine tartrate 8 rivastigmine transdermal system 8 rivelsa 47 rizatriptan benzoate 9 rizatriptan benzoate odt 9 ropinirole er 11 ropinirole hcl 11 rosadan 90 rosuvastatin calcium 23 ROTARIX 59 ROTATEQ 59 roweepra 95 ROZEREM 32 RUBRACA 110 RUCONEST 59 rulavite dha 133 RYDAPT 111 RYTARY 11 SABRIL 95 SAFYRAL 47 SAIZEN 41 SAIZEN CLICK.EASY 41 salacyn 34 salicylic acid 34 salsalate 78

166 Página 165 Nombre del medicamento Página SAMSCA 133 SANCUSO 101 SANDIMMUNE 59 SANDOSTATIN LAR DEPOT 54 SANTYL 34 SAPHRIS 117 SAVELLA 31 SAVELLA TITRATION PACK 31 SECONAL SODIUM 32 selegiline hcl 11 selenium sulfide 34 SELZENTRY 119 SEMPREX-D 68 SENSIPAR 28 SEREVENT DISKUS 68 SEROSTIM 41 sertraline hcl 100 setlakin 47 sevelamer carbonate 133 sharobel 47 SIGNIFOR 54 SIGNIFOR LAR 54 sildenafil 68 SILENOR 32 silver sulfadiazine 90 SIMBRINZA 62 SIMCOR 24 SIMPONI 59 SIMPONI ARIA 59 SIMULECT 60 simvastatin 24 sirolimus 60 SIRTURO 102 SIVEXTRO 90 SKLICE 113 slo-niacin 143 sm 3-day vaginal 143 sodium bicarbonate 133 sodium bicarbonate partial fill 133 sodium chloride 143 sodium chloride 133 sodium chloride 0.45% 133 sodium chloride 0.9% 70 sodium fluoride 133 sodium lactate 133 sodium phenylbutyrate 142 sodium polystyrene sulfonate 133 sodium sulfacetamide 90 solia 47 SOLODYN 90 Nombre del medicamento Página SOLTAMOX 111 SOLU-CORTEF 51 SOLU-MEDROL 51 SOMATULINE DEPOT 54 SOMAVERT 54 SORILUX 34 sorine 24 sotalol hcl 24 sotalol hcl (af) 24 SOTYLIZE 24 spinosad 113 SPIRIVA HANDIHALER 68 SPIRIVA RESPIMAT 68 spironolactone 24 spironolactone/hydrochlorothiazide 24 SPORANOX 103 sprintec SPRITAM 95 SPRIX 78 SPRYCEL 111 sps 133 sronyx 47 ssd 90 STAMARIL 60 stavudine 120 STAVZOR 95 STELARA 35 STELARA 60 sterile water irrigation 70 STIMATE 41 STIOLTO RESPIMAT 68 STIVARGA 111 streptomycin sulfate 90 STRIANT 47 STRIBILD 120 STRIVERDI RESPIMAT 68 SUBOXONE 63 SUBSYS 78 SUCRAID 142 sucralfate 38 sulfacetamide sodium 90 sulfacetamide sodium/prednisolone sodium 90 phosphate sulfadiazine 90 sulfamethoxazole/trimethoprim 90 sulfamethoxazole/trimethoprim ds 90 sulfamylon 91 sulfasalazine 27 sulfatrim pediatric 91 sulindac 78

167 Página 166 Nombre del medicamento Página sumatriptan 9 sumatriptan succinate 9 sumatriptan succinate refill 9 SUMAVEL DOSEPRO 9 SUPRAX 91 SUPREP BOWEL PREP KIT 38 SUSTIVA 120 SUTENT 111 syeda 47 SYLATRON 111 symax-sl 38 symax-sr 38 SYMBICORT 68 SYMLINPEN SYMLINPEN SYNAGIS 60 SYNALAR 35 SYNALAR CREAM KIT 35 SYNALAR OINTMENT KIT 35 SYNALGOS-DC 78 SYNAREL 54 SYNERA 80 SYNERCID 91 SYNJARDY 141 SYNJARDY XR 141 SYNRIBO 111 SYPRINE 133 TABLOID 111 TACLONEX 52 tacrolimus 35 tacrolimus 60 TAFINLAR 111 TAGRISSO 111 TALWIN 78 TAMIFLU 120 tamoxifen citrate 111 tamsulosin hcl 39 TANZEUM 141 TARCEVA 111 TARGRETIN 111 tarina fe 1/20 47 taron-crystals 133 TASIGNA 111 tazarotene 35 tazicef 91 TAZORAC 35 taztia xt 24 TECENTRIQ 111 TECFIDERA 31 TECFIDERA STARTER PACK 31 Nombre del medicamento Página TEFLARO 91 TEKTURNA 24 TEKTURNA HCT 24 telmisartan 25 telmisartan/amlodipine 24 telmisartan/hydrochlorothiazide 24 temazepam 32 TEMODAR 111 tencon 78 TENIVAC 60 TEPADINA 111 terazosin hcl 39 terbinafine hcl 103 terbutaline sulfate 68 terconazole 103 testosterone 47 testosterone cypionate 47 testosterone enanthate 47 testosterone pump 47 TETANUS/DIPHTHERIA TOXOIDS- 60 ADSORBED TETANUS/DIPHTHERIA TOXOIDS- 60 ADSORBED ADULT tetrabenazine 31 tetracycline hydrochloride 91 TEVETEN HCT 25 TEV-TROPIN 41 texacort 52 THALOMID 111 THEO theochron 68 theophylline 69 theophylline cr 68 theophylline er 68 thioridazine hcl 117 thiotepa 112 thiothixene 117 THYMOGLOBULIN 60 THYROLAR-1 53 THYROLAR-1/2 53 THYROLAR-1/4 53 THYROLAR-2 53 THYROLAR-3 53 tiagabine hydrochloride 95 TIGECYCLINE 91 tilia fe 47 timolol maleate 25 timolol maleate 62 timolol maleate ophthalmic gel forming 62 TIMOPTIC OCUDOSE 62

168 Página tinidazole 113 TIROSINT 53 TIS-U-SOL 70 TIVICAY 120 TIVORBEX 78 tizanidine hcl 8 tl folate 133 TOBI PODHALER 69 TOBRADEX 62 tobramycin 69 tobramycin sulfate 91 tobramycin sulfate/sodium chloride 91 tobramycin/dexamethasone 62 TOBREX 91 tolazamide 141 tolbutamide 141 tolcapone 11 tolmetin sodium 78 tolterodine tartrate 39 tolterodine tartrate er 39 TOPICORT 52 topiramate 96 topiramate er 95 toposar 112 topotecan hcl 112 TORISEL 60 torsemide 25 TOUJEO SOLOSTAR 141 TOVIAZ 39 TPN ELECTROLYTES 133 TRACLEER 69 TRADJENTA 141 tramadol hcl 79 tramadol hcl er 78 tramadol hydrochloride/acetaminophen 79 trandolapril 25 trandolapril/verapamil hcl er 25 tranexamic acid 137 TRANSDERM-SCOP 101 tranylcypromine sulfate 98 TRAVASOL 134 TRAVATAN Z 62 travel sickness 143 travoprost 62 trazodone hcl 98 TREANDA 112 TRECATOR 102 TRELSTAR 55 TRELSTAR MIXJECT 54 TRESIBA FLEXTOUCH 141 Página 167 Nombre del medicamento Página tretinoin 35 tretinoin 112 tretinoin microsphere 35 tretinoin microsphere pump 35 TREXALL 60 TREXIMET 9 triamcinolone acetonide 32 triamcinolone acetonide 52 triamcinolone acetonide 69 triamcinolone in orabase 32 triamterene/hydrochlorothiazide 25 trianex 52 triazolam 81 triderm 52 tri-estarylla 47 trifluoperazine hcl 117 trifluridine 120 trihexyphenidyl hcl 11 tri-legest fe 47 tri-linyah 47 tri-lo-estarylla 47 tri-lo-marzia 47 tri-lo-sprintec 47 trilyte 38 trimethobenzamide hcl 101 trimethoprim 91 trimethoprim sulfate/polymyxin b sulfate 91 trimipramine maleate 98 trinessa 47 trinessa lo 47 TRINTELLIX 98 triphrocaps 134 tri-previfem 47 TRISENOX 112 tri-sprintec 47 TRIUMEQ 120 triveen-duo dha 134 trivora TROKENDI XR 96 TROPHAMINE 134 tropicamide 62 trospium chloride 39 trospium chloride er 39 TRULICITY 141 TRUMENBA 60 TRUVADA 120 TUDORZA PRESSAIR 69 TWINRIX 60 TYBOST 120 TYGACIL 91

169 Página TYKERB 112 TYPHIM VI 60 TYSABRI 31 TYVASO 69 TYVASO REFILL 69 TYVASO STARTER 69 TYZEKA 120 TYZINE PEDIATRIC NASAL DROPS 69 UCERIS 52 ULESFIA 113 ULORIC 26 ultimatecare one 134 unithroid 53 UNITUXIN 112 urin d/s 40 urophen mb 40 ursodiol 38 UVADEX 35 valacyclovir hcl 120 VALCHLOR 112 valganciclovir 120 valganciclovir hydrochlorde 120 valproate sodium 96 valproic acid 96 valsartan 25 valsartan/hydrochlorothiazide 25 VANATOL LQ 79 vancomycin 91 vancomycin hcl 91 vancomycin hcl in dextrose 91 VANDAZOLE 91 VAQTA 60 VARIVAX 60 VARIZIG 60 VASCEPA 26 VAXCHORA 60 VECAMYL 26 VECTIBIX 112 VECTICAL 35 VELCADE 112 velivet 47 VELPHORO 134 VELTASSA 134 VELTIN 35 VENCLEXTA 112 VENCLEXTA STARTING PACK 112 venlafaxine hcl 100 venlafaxine hcl er 100 VENTAVIS 69 verapamil hcl 26 Página 168 Nombre del medicamento Página verapamil hcl er 26 verapamil hcl sr 26 VERDESO 52 VEREGEN 35 VERSACLOZ 117 vestura 47 VEXOL 62 VIAGRA 40 VIBRAMYCIN 91 vicodin 79 vicodin es 79 vicodin hp 79 VICTOZA 141 VIDEX PEDIATRIC 120 vienva 48 VIGAMOX 91 VIIBRYD 100 VIIBRYD STARTER PACK 100 VIMOVO 38 VIMPAT 96 vinate c 134 vinate care 143 vinblastine sulfate 112 vincasar pfs 112 vincristine sulfate 112 vinorelbine tartrate 112 viorele 48 VIRACEPT 120 VIREAD 120 virt-caps 134 virt-care one 134 virt-nate dha 134 virt-pn 134 virt-pn dha 134 virtussin a/c 143 vital-d rx 134 vitamedmd one rx/quatrefolic 134 vitamin d 134 VITEKTA 120 VIVITROL 63 voriconazole 104 VOTRIENT 112 vp-ch plus 135 vp-ch-pnv 135 VP-PNV-DHA 135 VPRIV 142 VRAYLAR 117 vyfemla 48 VYVANSE 31 warfarin sodium 137

170 Página 169 Nombre del medicamento Página WELCHOL 26 wera 48 wymzya fe 48 XALKORI 112 XARELTO 137 XARELTO STARTER PACK 137 XARTEMIS XR 79 XATMEP 60 XELJANZ 60 XELJANZ XR 60 XENICAL 39 XEOMIN 9 XEOMIN 70 XERESE 120 XGEVA 28 XIFAXAN 91 XIIDRA 62 XOLAIR 69 XTANDI 112 xulane 48 xylon 79 XYREM 32 YERVOY 112 YF-VAX 60 YONDELIS 112 yuvafem 48 zafirlukast 69 zaleplon 32 ZALTRAP 112 ZANOSAR 112 zarah 48 zatean-ch 135 zatean-pn dha 135 ZAVESCA 142 zazole 104 zebutal 79 ZEJULA 113 ZELAPAR 11 ZELBORAF 113 ZEMAIRA 69 zenatane 35 zenchent 48 zenchent fe 48 ZENPEP 142 zenzedi 31 ZERBAXA 92 ZERIT 120 ZIAGEN 120 zidovudine 120 zileuton er 69 Nombre del medicamento Página ZIOPTAN 62 ziprasidone hcl 117 ZIPSOR 79 ZIRGAN 120 ZMAX 92 ZOHYDRO ER 79 zoledronic acid 28 ZOLINZA 113 zolmitriptan 10 zolmitriptan odt 10 zolpidem tartrate 32 zolpidem tartrate er 32 ZOLPIMIST 32 ZOMACTON 41 ZOMIG 10 zonisamide 96 ZONTIVITY 137 ZORBTIVE 41 ZORTRESS 60 ZORVOLEX 79 ZOSTAVAX 60 ZOSYN 92 zovia 1/35e 48 zovia 1/50e 48 ZOVIRAX 121 ZUBSOLV 63 ZUPLENZ 101 ZYCLARA 35 ZYCLARA PUMP 35 ZYDELIG 113 ZYDONE 79 ZYFLO 69 ZYFLO CR 69 ZYKADIA 113 ZYLET 92 ZYPREXA RELPREVV 117 ZYTIGA 113

171 Notificación Contra la Discriminación: La Discriminación es Contra la Ley Leon Medical Centers Health Plans cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Leon Medical Centers Health Plans no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo. Leon Medical Centers Health Plans: Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes: o Intérpretes de lenguaje de señas capacitados. o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos). Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes: o Intérpretes capacitados. o Información escrita en otros idiomas. Si necesita recibir estos servicios, comuníquese con el Departamento de Servicio al Miembro al , 8 a.m. 8 p.m., 7 días de la semana. Si considera que Leon Medical Centers Health Plans no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo al: Departamento de Quejas 8600 NW 41st Street, Suite 201 Doral, FL Teléfono: , TTY 711, Fax: (305) Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, el Departamento de Servicio al Miembro está a su disposición para brindársela. También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Puede obtener los formularios de reclamo en el sitio web Todos los productos y servicios de Cigna se brindan exclusivamente por o a través de subsidiarias operativas de Cigna Corporation. El nombre de Cigna, los logotipos, y otras marcas de Cigna son propiedad de Cigna Intellectual Property, Inc. Leon Medical Centers es una marca comercial registrada de Leon Medical Centers. Leon Medical Centers Health Plans es un plan HMO con contrato con Medicare. La inscripción en Leon Medical Centers Health Plans depende de la renovación de contrato. INT_17_50238S