AvMed Medicare Choice

Transcripción

1 AvMed Medicare Choice Formulario 2017 (Lista de s Cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN Nota para los afiliados: Este formulario ha cambiado desde el año pasado. Por favor revise este documento para asegurarse de que todavía contiene los medicamentos que toma. Este formulario ha sido actualizado para el 08/01/2017. Para obtener información más reciente o respuestas a sus preguntas, por favor llame al Departamento de Servicios a los Afiliados de AvMed Choice al desde el 1ro de octubre al 14 de febrero: 8:00 am a 8:00 pm, los 7 días de la semana. Y del 15 de febrero al 30 de septiembre: 8:00 am a 8:00 pm, de lunes a viernes, y 9:00 am a 1:00 pm los sábados (para los usuarios de TTY, 711 o el , los 7 días a la semana y las 24 horas del día) o visite Este documento incluye una lista de los medicamentos (el formulario) de nuestro plan cuya actualización parte del 1 de agosto de Para un formulario actualizado, por favor póngase en contacto con nosotros. La información para comunicarse con nosotros, junto con la fecha de la última vez que actualizamos el formulario, aparece aquí en la portada y la contraportada. Por lo general debe usar las farmacias de la red para tener derecho a su beneficio de medicamentos por receta. Los beneficios, el formulario, la red de farmacias, la prima o los copagos y coaseguros pueden cambiar el 1 de enero de 2018 Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro Departamento de Servicios para Afiliados al número que aparece arriba. HPMS Approved Formulary File Submission ID , Version 16 AvMed Medicare Choice es un plan de HMO con contrato de Medicare. Inscripción en AvMed depende de la renovación del contrato. H1016_PH SP accepted_final_1

2 AvMed cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. AvMed no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo. AvMed: Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes: o Interpretes 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 Servicios al Cliente a: AvMed Member Engagement, P.O. Box 749, Gainesville, FL 32627, por teléfono (TTY 711), vía fax , o por correo electrónico a [email protected]. Si considera que AvMed 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 por escrito a AvMed s Regulatory Correspondence Coordinator (Coordinador de Correspondencia), P.O. Box 749, Gainesville, FL 32627, por teléfono (TTY 711), vía fax , o por correo electrónico a [email protected]. Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, el Coordinador de Correspondencia esta a su disposición para brindársela. También puede presentar un reclamo de derechos civiles ante la Oficina de Derechos Civiles (Office for Civil Rights por sus siglas en inglés) del Departamento de Salud y Servicios Humanos de EE.UU. (U.S. Department of Health and Human Services) a través del portal electrónico para reclamos en el sitio web o por correo o por teléfono a: U.S. Department of Health and Human Services, 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC , (TDD). Puede obtener los formularios de reclamo en el sitio web ii

3 En qué consiste el formulario completo de AvMed Medicare Choice? Un formulario es una lista de medicamentos cubiertos y seleccionados por AvMed para sus planes Medicare Choice en consulta con un equipo de profesionales médicos. Representa las terapias de medicamentos recetados que se consideran parte necesaria de un programa de tratamiento de calidad. AvMed Medicare Choice generalmente cubrirán los medicamentos incluidos en nuestro formulario siempre y cuando los medicamentos sean médicamente necesarios; las recetas se despachen en una farmacia de AvMed Medicare Choice y se siguen otras reglas del plan. Para obtener más información sobre cómo presentar sus recetas, por favor revise su Constancia El formulario (lista de medicamentos) puede cambiar? En general, si usted está tomando un medicamento que aparece en nuestro formulario del 2017 y que estaba cubierto a principios de año, no vamos a interrumpir o reducir la cobertura del medicamento durante el año de cobertura 2017, excepto cuando un medicamento genérico nuevo y menos costoso esté disponible o cuando nueva información adversa sobre la seguridad o eficacia de un fármaco se dé a conocer. Otros tipos de cambios en el formulario, como la eliminación de un medicamento de nuestro formulario, no afectarán a los afiliados que actualmente están tomando el medicamento. Seguirá disponible al mismo costo compartido para esos afiliados que lo tomen durante el resto del año de cobertura. Creemos que es importante que usted tenga acceso continuo durante el resto del año de cobertura a los medicamentos que estaban disponibles cuando escogió nuestro plan, excepto en los casos en los que usted puede ahorrar dinero adicional o podemos garantizar su seguridad. Si eliminamos medicamentos de nuestro formulario, añadimos el requisito de autorización previa, límites en las cantidades o restricciones de terapias escalonadas para un medicamento, o elevamos un medicamento a un nivel de costo compartido más alto, entonces debemos notificar a los afiliados afectados al menos 60 días antes de que el cambio entre en vigor, o en el momento en que el afiliado solicite una repetición del medicamento; en ese momento el afiliado recibirá un suministro de 60 días del medicamento. Si la Administración de Alimentos y s (del Gobierno Federal) menciona que un medicamento de nuestro formulario puede ser peligroso o el fabricante del medicamento retira el medicamento del mercado, entonces procederemos a eliminar inmediatamente el medicamento de nuestro formulario y avisaremos a los afiliados que toman el medicamento. Este nuevo formulario está vigente a partir del 1 de agosto de Para obtener información actualizada sobre los medicamentos cubiertos por AvMed Medicare Choice, comuníquese con nosotros. Nuestro teléfono y demás información para contactarnos aparece en la portada y contraportada de este formulario. Cómo uso este formulario? Hay dos formas de encontrar su medicamento en el formulario: Problema Médico El formulario comienza en la página 2. Los medicamentos en este formulario están agrupados por categoría, según su aplicación a una enfermedad o problema médico. Por ejemplo, los medicamentos utilizados para tratar una enfermedad del corazón se encuentran dentro de la categoría Cardiovascular, Hipertensión/Lípidos. Si usted sabe para lo que se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página 2, y bajo esa categoría busque el nombre de su medicamento. Índice Alfabético Si no está seguro de la categoría, debe buscar su medicamento en el índice que comienza en la página 71. En el índice verá una lista alfabética de todos los medicamentos en este formulario. Tanto los medicamentos de marca como los medicamentos genéricos aparecen en el índice. Busque en el índice y encuentre su medicamento. Al lado de su medicamento, usted verá el número de la página donde se puede encontrar iii

4 información sobre la cobertura. Vaya a la página indicada en el índice y busque el nombre de su medicamento en la primera columna de la lista. Qué es un medicamento genérico? AvMed Medicare Choice cubre tanto los medicamentos de marca como los medicamentos genéricos. Un medicamento genérico es aprobado por la agencia federal FDA al comprobar que tiene el mismo ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los medicamentos de marca. Hay alguna restricción en la cobertura? Algunos medicamentos cubiertos pueden estar sujetos a requisitos adicionales o límites en la cobertura. Estos requisitos y límites pueden incluir lo siguiente: Autorización Previa: AvMed Medicare Choice t requiere que usted [o su médico] obtenga autorización previa para ciertos medicamentos. Esto significa que usted tendrá que obtener la aprobación de AvMed Medicare Choice t para que le despachen su receta o recetas. Si no obtiene la aprobación, AvMed Medicare Choice y pudiera no cubrir el medicamento. Límites en las Cantidades: Para ciertos medicamentos, AvMed Medicare Choice y limita la cantidad. Por ejemplo, AvMed Medicare Choice proporciona 30 unidades por receta de Zetia. Esto puede ser después de un mes o tres meses de suministro estándar. Terapia Escalonada: En algunos casos, AvMed Medicare Choice t requiere que usted pruebe primero ciertos medicamentos para el problema médico que padece antes de cubrir otro medicamento para ese mismo problema. Por ejemplo, si el medicamento A y el medicamento B son indicados para su situación médica, AvMed Medicare Choice puede no cubrir el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no le da resultado, entonces AvMed Medicare Choice cubrirá el medicamento B. Usted puede verificar si su medicamento tiene requisitos adicionales o límites buscando en el formulario que comienza en la página 2. También en nuestro sitio Web puede obtener más información acerca de las restricciones a los medicamentos cubiertos. Nuestra información de contacto, junto con la fecha de la última vez que se actualizó el formulario, aparece en la portada y la contraportada de este formulario. Usted puede pedirles al Medicare Choice AvMed que haga una excepción a estas restricciones o límites, o que le faciliten una lista de otros medicamentos similares que estén indicados para su padecimiento. Consulte la sección " Cómo puedo pedir una excepción al formulario de AvMed Medicare Choice " en la página iv para obtener información sobre cómo solicitar este tipo de excepción. Qué pasa si mi medicamento no aparece en el formulario? Si su medicamento no aparece en este formulario (lista de medicamentos cubiertos), primero debe llamar al Departamento de Servicios a los Afiliados y preguntar si su medicamento está cubierto. Si le informan que AvMed Medicare Choice no cubre su medicamento, usted tiene dos opciones: Puede pedir al Departamento de Servicios a los Afiliados una lista de medicamentos similares que estén cubiertos por AvMed Medicare Choice t. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por AvMed Medicare Choice. iv

5 Puede pedir al Medicare Choice AvMed que haga una excepción y cubra su medicamento. Vea más abajo la información sobre cómo solicitar una excepción. Cómo puedo pedir una excepción al formulario de AvMed Medicare Choice? Puede solicitar que AvMed Medicare Choice haga una excepción a nuestras reglas de cobertura. Hay varios tipos de excepciones que usted puede pedirnos que hagamos: Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro formulario. Si se aprueba, este medicamento será cubierto en un nivel de costo compartido predeterminado, y usted no podría pedirnos que le proporcionemos el medicamento a un nivel más bajo de costo compartido. Usted puede pedirnos que cubramos un medicamento del formulario en un nivel de costo compartido más bajo si este medicamento no está en el nivel de especialidad. Si se aprueba, esto reduciría la cantidad que debe pagar por su medicamento. Puede solicitarnos que no apliquemos a su medicamento las restricciones o los límites de cobertura. Por ejemplo, para ciertos medicamentos, AvMed Medicare Choice limita la cantidad del medicamento que cubrimos. Si su medicamento tiene un límite en la cantidad, puede solicitarnos que no apliquemos el límite y cubramos una mayor cantidad. Por lo general, AvMed Medicare Choice sólo aprobará su solicitud para una excepción si los medicamentos alternativos incluidos en el formulario del plan, o el medicamento de costo compartido más bajo o las restricciones de utilización adicionales no resultaran ser tan efectivos para tratar su problema médico o causaran efectos médicos adversos. Usted debe comunicarse con nosotros para solicitar una decisión inicial de cobertura para una excepción a la restricción ya sea de formulario, de niveles o de utilización. Cuando usted solicita una excepción a una restricción de formulario, de niveles o de utilización, debe presentar una declaración del que prescribe o del médico que respalde su solicitud. Por lo general, debemos tomar nuestra decisión dentro de las 72 horas de haber recibido la declaración de apoyo de su médico. Usted puede solicitar una excepción acelerada (rápida) si usted o su médico creen que su salud podría verse seriamente afectada si espera hasta el límite de 72 horas para tomar una decisión. Si se aprueba su solicitud de acelerar el trámite, debemos darle una decisión a lo sumo 24 horas después de recibir una declaración de apoyo de su médico u otro proveedor. Qué debo hacer antes de que pueda hablar con mi médico para cambiar mis medicamentos o pedir una excepción? Como afiliado nuevo de nuestro plan, usted puede estar tomando medicamentos que no están en nuestro formulario. O, usted puede estar tomando un medicamento que está en nuestro formulario pero su capacidad para obtener el medicamento es limitada. Por ejemplo, es posible que necesite una autorización previa de nosotros antes de que pueda obtener el medicamento recetado. Usted debe hablar con su médico para decidir si debe cambiar a un medicamento apropiado que nosotros cubramos o solicitar una excepción al formulario para que podamos cubrir el medicamento que usted toma. Mientras usted consulta con su médico para determinar el curso de acción correcto para usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días que ser afiliado de nuestro plan. Para cada uno de los medicamentos que no esté en nuestro formulario o si le resulta difícil obtener sus medicamentos, cubriremos un suministro temporal para 31 días (a menos que tenga una receta para menos días) cuando vaya a una farmacia de la red. Después de su primer suministro de 31 días, no pagaremos esos medicamentos, incluso si usted ha sido afiliado del plan por menos de 90 días. v

6 Si usted es residente de un centro de atención a largo plazo, le permitiremos que repita su receta hasta que le hayamos proporcionado un suministro de transición para 91 días, de acuerdo con el incremento de dispensación (a menos que tenga una receta por menos días). Le cubriremos más de una repetición de esos medicamentos durante los primeros 90 días de usted pertenecer a nuestro plan. Si necesita un medicamento que no está en nuestro formulario o si su habilidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90 días de su afiliación a nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento (a menos que usted tenga una receta para menos días) mientras solicita una excepción al formulario. Para más información Para obtener información más detallada acerca de la cobertura de los medicamentos por receta de AvMed Medicare Choice, por favor consulte su Constancia de Cobertura y otros materiales informativos del plan. Si usted tiene preguntas acerca de AvMed Medicare Choice, por favor póngase en contacto con nosotros. Nuestro teléfono y la fecha de la última vez que se actualizó el formulario, aparecen en la portada y la contraportada. Si usted tiene preguntas en general sobre la cobertura de los medicamentos por receta del Medicare, llame al Medicare al MEDICARE ( ) las 24 horas del día y los 7 días de la semana. Los usuarios de TTY deben llamar al O visite vi

7 Formulario del AvMed Medicare Choice En este formulario completo que aparece a continuación encontrará la cobertura de los medicamentos cubiertos por AvMed Medicare Choice. Si tiene problemas para encontrar su medicamento en la lista, consulte el índice que comienza en la página 71. La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca aparecen en letras mayúsculas (por ejemplo, ZETIA) y los medicamentos genéricos aparecen en cursiva y en minúsculas (por ejemplo, amoxicilina). La información contenida en la columna de Requisitos/Límites le dice si AvMed Medicare Choice tiene algún requisito especial para la cobertura de su medicamento. Lista de Abreviaturas y Su Significado B/D : Este medicamento por receta puede estar cubierto bajo la Parte B o la D del Medicare, dependiendo de las circunstancias. Para tomar una determinación, puede ser que se necesite presentar información que describa el uso y las circunstancias del medicamento. EX : s Realzado. Este medicamento por receta normalmente no está cubierto por ningún plan de Medicare para recetas médicas. La cantidad que usted paga cuando le despachan la receta de este medicamento no cuenta para sus costos totales de medicamentos (es decir, la cantidad que usted paga no le ayuda a calificar para la cobertura catastrófica). Además, si está recibiendo ayuda adicional para pagar sus medicamentos por receta, usted no conseguirá ningún tipo de ayuda adicional para costear este medicamento. GC : Cobertura de Brecha. Proporcionamos cobertura para este medicamento por receta en la Etapa de Falta Por favor consulte su Constancia de Cobertura para detalles sobre esta cobertura. LA : Disponibilidad Limitada. Este medicamento por receta puede estar disponible sólo en ciertas farmacias. Para obtener más información, por favor llame al Departamento de Servicios a los Afiliados. MO : Encargo por Correo. Este medicamento por receta está disponible a través de nuestro servicio de pedidos por correo, así como a través de nuestra red de farmacias. Considere usar esta opción de envíos por correo para sus medicamentos a largo plazo (de mantenimiento, como las medicinas para la presión arterial). Las farmacias de la red pueden ser más apropiadas para las recetas sin varias repeticiones (como los antibióticos). PA : Autorización Previa. El Plan requiere que usted o su médico obtenga autorización previa para ciertos medicamentos. Esto significa que usted tendrá que obtener la aprobación antes de que le despachen sus recetas. Si no obtiene la aprobación, es posible que el plan no cubra el medicamento. QL : Límite de Cantidad. Para ciertos medicamentos, el Plan limita la cantidad del medicamento que cubrimos. ST : Terapia Escalonada. En algunos casos, el Plan requiere que usted pruebe primero ciertos medicamentos para su problema médico antes de cubrir otro medicamento. Por ejemplo, si el medicamento A y el medicamento B son indicados para su problema médico, es posible que no cubramos el medicamento B a menos que usted primero pruebe el medicamento A. Si el medicamento A no le funciona, entonces le cubriremos el medicamento B. 1

8 AvMed Medicare Choice 08/01/2017 Analgésicos Gota allopurinol tab GC allopurinol tab GC colchicine w/ probenecid tab COLCRYS TAB 0.6MG QL (120 tabs / 30 probenecid tab ULORIC TAB 40MG 3 ST ULORIC TAB 80MG 3 ST Antiinflamatorios no esteroideos celecoxib cap 50 QL (240 caps / 30 celecoxib cap 100 QL (120 caps / 30 celecoxib cap 200 QL (60 caps / 30 celecoxib cap 400 QL (30 caps / 30 diclofenac potassium tab 50 QL (120 tabs / 30 diclofenac sodium tab delayed 2 GC release 25 diclofenac sodium tab delayed 2 GC release 50 diclofenac sodium tab delayed 2 GC release 75 diclofenac sodium tab er 24hr 2 GC 100 diflunisal tab etodolac cap etodolac cap etodolac tab etodolac tab etodolac tab er 24hr etodolac tab er 24hr etodolac tab er 24hr flurbiprofen tab 50 3 flurbiprofen tab ibuprofen susp 100 /5ml 3 ibuprofen tab 400 ibuprofen tab 600 ibuprofen tab 800 indomethacin cap 25 2 GC indomethacin cap 50 2 GC indomethacin cap er 75 2 GC ketoprofen cap 50 3 ketoprofen cap 75 3 MELOXICAM SUSP MG/5ML meloxicam tab 7.5 meloxicam tab 15 nabumetone tab GC nabumetone tab GC naproxen dr tab GC naproxen dr tab GC naproxen sodium tab naproxen sodium tab naproxen susp 125 /5ml 3 naproxen tab 250 naproxen tab 375 naproxen tab 500 piroxicam cap 10 4 piroxicam cap 20 4 sulindac tab GC sulindac tab GC Analgésicos opiáceos acetaminophen w/ codeine soln /5ml QL (5000 ml / 30 acetaminophen w/ codeine tab QL (400 tabs / 30 acetaminophen w/ codeine tab QL (400 tabs / 30 acetaminophen w/ codeine tab QL (400 tabs / 30 butorphanol tartrate inj 1 4 /ml butorphanol tartrate inj 2 4 /ml nalbuphine hcl inj 10 /ml 4 nalbuphine hcl inj 20 /ml 4 2 GC QL 2 GC QL 2 GC QL 2 GC QL ED - Excluido GC - Cobertura de Brecha 2

9 tramadol hcl tab 50 2 GC QL QL (240 tabs / 30 tramadol-acetaminophen tab QL (240 tabs / 30 Analgésicos opiáceos, CII DURAMORPH INJ 0.5MG/ML 3 B/D DURAMORPH INJ 1MG/ML 3 B/D endocet tab QL (360 tabs / 30 endocet tab QL (360 tabs / 30 endocet tab QL (360 tabs / 30 fentanyl citrate lozenge on a 5 QL PA handle 200 mcg QL (120 lozenges / 30 fentanyl citrate lozenge on a 5 QL PA handle 400 mcg QL (120 lozenges / 30 fentanyl citrate lozenge on a 5 QL PA handle 600 mcg QL (120 lozenges / 30 fentanyl citrate lozenge on a 5 QL PA handle 800 mcg QL (120 lozenges / 30 fentanyl citrate lozenge on a 5 QL PA handle 1200 mcg QL (120 lozenges / 30 fentanyl citrate lozenge on a 5 QL PA handle 1600 mcg QL (120 lozenges / 30 fentanyl td patch 72hr 12 mcg/hr QL (10 patches / 30 fentanyl td patch 72hr 25 mcg/hr QL (10 patches / 30 fentanyl td patch 72hr 50 mcg/hr QL (10 patches / 30 fentanyl td patch 72hr 75 mcg/hr QL (10 patches / 30 fentanyl td patch 72hr 100 mcg/hr QL (10 patches / 30 FENTORA TAB 100MCG QL (120 tabs / 30 FENTORA TAB 200MCG QL (120 tabs / 30 FENTORA TAB 400MCG QL (120 tabs / 30 FENTORA TAB 600MCG QL (120 tabs / 30 FENTORA TAB 800MCG QL (120 tabs / 30 hydrocodone-acetaminophen soln /15ml QL (5400 ml / 30 hydrocodone-acetaminophen tab QL (360 tabs / 30 hydrocodone-acetaminophen tab QL (360 tabs / 30 hydrocodone-acetaminophen tab QL (360 tabs / 30 hydrocodone-ibuprofen tab QL (150 tabs / 30 hydromorphone hcl liqd 1 /ml hydromorphone hcl preservative free (pf) inj 10 /ml hydromorphone hcl tab 2 QL (270 tabs / 30 hydromorphone hcl tab 4 QL (270 tabs / 30 PA PA PA 5 QL PA 5 QL PA 5 QL PA 5 QL PA 5 QL PA 2 GC QL 2 GC QL 2 GC QL 3 4 B/D ED - Excluido GC - Cobertura de Brecha 3

10 hydromorphone hcl tab 8 QL (270 tabs / 30 meperidine hcl oral soln 50 2 GC /5ml meperidine hcl tab 50 2 GC meperidine hcl tab GC methadone con 10/ml QL (120 ml / 30 methadone hcl soln 5 /5ml QL (600 ml / 30 methadone hcl soln 10 /5ml QL (600 ml / 30 methadone hcl tab 5 QL (240 tabs / 30 methadone hcl tab 10 QL (240 tabs / 30 MORPHINE SUL INJ 3 B/D 2MG/ML MORPHINE SUL INJ 3 B/D 4MG/ML MORPHINE SUL INJ 3 B/D 8MG/ML MORPHINE SUL INJ 3 B/D 150/30ML morphine sulfate inj pf B/D /ml morphine sulfate inj pf 1 3 B/D /ml MORPHINE SULFATE IV 3 B/D SOLN 1 MG/ML morphine sulfate iv soln pf 4 3 B/D /ml morphine sulfate iv soln pf 8 3 B/D /ml MORPHINE SULFATE IV 3 B/D SOLN PF 10 MG/ML MORPHINE SULFATE IV 3 B/D SOLN PF 15 MG/ML MORPHINE SULFATE ORAL 3 SOLN 10 MG/5ML MORPHINE SULFATE ORAL 3 SOLN 20 MG/5ML MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) 3 MORPHINE SULFATE TAB 15 MG QL (180 tabs / 30 MORPHINE SULFATE TAB 30 MG QL (180 tabs / 30 morphine sulfate tab er 15 QL (90 tabs / 30 morphine sulfate tab er 30 QL (90 tabs / 30 morphine sulfate tab er 60 QL (90 tabs / 30 morphine sulfate tab er 100 QL (90 tabs / 30 morphine sulfate tab er 200 oxycodone hcl cap 5 QL (180 caps / 30 oxycodone hcl conc 100 /5ml (20 /ml) OXYCODONE HCL SOLN 5 MG/5ML oxycodone hcl tab 5 QL (180 tabs / 30 oxycodone hcl tab 10 QL (180 tabs / 30 oxycodone hcl tab 15 QL (180 tabs / 30 oxycodone hcl tab 20 QL (180 tabs / 30 oxycodone hcl tab 30 QL (180 tabs / 30 oxycodone w/ acetaminophen soln /5ml QL (1800 ml / 30 oxycodone w/ acetaminophen tab QL (360 tabs / 30 oxycodone w/ acetaminophen tab QL (360 tabs / 30 oxycodone w/ acetaminophen tab QL (360 tabs / ED - Excluido GC - Cobertura de Brecha 4

11 oxycodone w/ acetaminophen tab QL (360 tabs / 30 Anestésicos Anestésicos locales lidocaine hcl local inj 0.5% 2 GC B/D lidocaine hcl local inj 1% 2 GC B/D lidocaine hcl local inj 1.5% 2 GC B/D lidocaine hcl local inj 2% 2 GC B/D lidocaine hcl local 2 GC B/D preservative free (pf) inj 0.5% lidocaine hcl local 2 GC B/D preservative free (pf) inj 1% Contra infecciones Antibacterianos, misceláneos amikacin sulfate inj 1 gm/4ml 3 (250 /ml) amikacin sulfate inj /2ml (250 /ml) gentam/nacl inj 0.9/ml 2 GC gentam/nacl inj 1.4/ml 2 GC gentamicin in saline inj GC /ml gentamicin in saline inj 1 2 GC /ml gentamicin in saline inj GC /ml gentamicin in saline inj GC /ml gentamicin in saline inj 2 2 GC /ml gentamicin sulfate inj 10 2 GC /ml gentamicin sulfate inj 40 2 GC /ml gentamicin sulfate iv soln 10 2 GC /ml neomycin sulfate tab paromomycin sulfate cap streptomycin sulfate for inj 1 4 gm sulfadiazine tab tobramycin nebu soln 300 /5ml 5 PA tobramycin sulfate for inj gm tobramycin sulfate inj gm/30ml (40 /ml) (base equiv) tobramycin sulfate inj 2 3 gm/50ml (40 /ml) (base equiv) tobramycin sulfate inj 10 3 /ml (base equivalent) tobramycin sulfate inj 80 3 /2ml (40 /ml) (base equiv) Contra infecciones, misceláneos ALBENZA TAB 200MG 5 ALINIA SUS 100/5ML 4 ALINIA TAB 500MG 4 atovaquone susp 750 /5ml 5 AZACTAM/DEX INJ 1GM 4 AZACTAM/DEX INJ 2GM 4 aztreonam for inj 1 gm 3 aztreonam for inj 2 gm 3 BILTRICIDE TAB 600MG 3 CAYSTON INH 75MG 5 LA PA clindamycin hcl cap 75 clindamycin hcl cap 150 clindamycin hcl cap 300 clindamycin palmitate hcl for 4 soln 75 /5ml (base equiv) clindamycin phosphate in d5w 3 iv soln 300 /50ml clindamycin phosphate in d5w 3 iv soln 600 /50ml clindamycin phosphate in d5w 3 iv soln 900 /50ml clindamycin phosphate inj 9 2 GC gm/60ml clindamycin phosphate inj GC /2ml clindamycin phosphate inj GC /4ml clindamycin phosphate inj GC /6ml clindamycin phosphate iv soln 300 /2ml 2 GC ED - Excluido GC - Cobertura de Brecha 5

12 clindamycin phosphate iv soln 2 GC 900 /6ml colistimethate sodium for inj CUBICIN SOL 500MG 5 dapsone tab 25 3 dapsone tab daptomycin for iv soln emverm chw imipenem-cilastatin 4 intravenous for soln 250 imipenem-cilastatin 4 intravenous for soln 500 INVANZ INJ 1GM 4 ivermectin tab 3 3 LINEZOLID FOR SUSP MG/5ML LINEZOLID IN SODIUM 5 CHLORIDE IV SOLN 600 MG/300ML-0.9% linezolid iv soln 600 /300ml 5 (2 /ml) LINEZOLID TAB 600 MG 5 meropenem iv for soln 1 gm 4 meropenem iv for soln methenamine hippurate tab 1 4 gm metronidazole in nacl 0.79% 2 GC iv soln 500 /100ml metronidazole tab GC metronidazole tab GC NEBUPENT INH 300MG 4 B/D nitrofurantoin macrocrystalline 3 cap 50 nitrofurantoin macrocrystalline 2 GC cap 100 nitrofurantoin monohydrate 2 GC macrocrystalline cap 100 PENTAM 300 INJ 300MG 4 SIVEXTRO INJ 200MG 5 SIVEXTRO TAB 200MG 5 sulfamethoxazoletrimethoprim iv soln /5ml 4 sulfamethoxazoletrimethoprim susp /5ml sulfamethoxazoletrimethoprim tab sulfamethoxazole- 4 trimethoprim tab SYNERCID INJ 500MG 5 TIGECYCLINE INJ 50MG 5 trimethoprim tab GC TYGACIL INJ 50MG 5 vancomycin hcl cap vancomycin hcl cap vancomycin hcl for inj 10 gm 3 vancomycin hcl for inj vancomycin hcl for inj vancomycin hcl for inj vancomycin hcl for inj VANCOMYCIN INJ 1 GM 4 VANCOMYCIN INJ 500MG 4 VANCOMYCIN INJ 750MG 4 Fungicidas ABELCET INJ 5MG/ML 5 B/D AMBISOME INJ 50MG 4 B/D amphotericin b for inj 50 4 B/D CANCIDAS INJ 50MG 5 CANCIDAS INJ 70MG 5 fluconazole for susp 10 /ml 3 fluconazole for susp 40 /ml 3 fluconazole in dextrose inj /100ml fluconazole in dextrose inj /200ml fluconazole in nacl 0.9% inj /100ml fluconazole in nacl 0.9% inj /200ml fluconazole tab 50 2 GC fluconazole tab GC fluconazole tab GC fluconazole tab GC fluconazole/ inj nacl ED - Excluido GC - Cobertura de Brecha 6

13 flucytosine cap flucytosine cap griseofulvin microsize susp /5ml griseofulvin microsize tab griseofulvin ultramicrosize tab griseofulvin ultramicrosize tab itraconazole cap PA ketoconazole tab PA MYCAMINE INJ 50MG 5 MYCAMINE INJ 100MG 5 NOXAFIL SUS 40MG/ML 5 NOXAFIL TAB 100MG 5 nystatin tab unit 3 terbinafine hcl tab GC QL QL (90 tabs / 365 voriconazole for inj voriconazole for susp 40 5 /ml voriconazole tab 50 5 voriconazole tab Antipalúdicos atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab chloroquine phosphate tab chloroquine phosphate tab COARTEM TAB MG 4 mefloquine hcl tab PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap PA Agentes antirretrovirales abacavir sulfate tab 300 (base equiv) APTIVUS CAP 250MG 5 APTIVUS SOL 5 CRIXIVAN CAP 200MG 4 CRIXIVAN CAP 400MG 4 3 didanosine delayed release 4 capsule 125 didanosine delayed release 4 capsule 200 didanosine delayed release 4 capsule 250 didanosine delayed release 4 capsule 400 EDURANT TAB 25MG 5 EMTRIVA CAP 200MG 3 EMTRIVA SOL 10MG/ML 3 FUZEON INJ 90MG 5 INTELENCE TAB 25MG 4 INTELENCE TAB 100MG 5 INTELENCE TAB 200MG 5 INVIRASE CAP 200MG 5 INVIRASE TAB 500MG 5 ISENTRESS CHW 25MG 3 ISENTRESS CHW 100MG 5 ISENTRESS POW 100MG 5 ISENTRESS TAB 400MG 5 lamivudine oral soln 10 /ml 3 lamivudine tab lamivudine tab LEXIVA SUS 50MG/ML 4 LEXIVA TAB 700MG 5 NEVIRAPINE SUSP 50 4 MG/5ML nevirapine tab nevirapine tab er 24hr nevirapine tab er 24hr NORVIR CAP 100MG 3 NORVIR SOL 80MG/ML 3 NORVIR TAB 100MG 3 PREZISTA SUS 100MG/ML 5 PREZISTA TAB 75MG 3 PREZISTA TAB 150MG 3 PREZISTA TAB 600MG 5 PREZISTA TAB 800MG 5 RESCRIPTOR TAB 100 MG 4 RESCRIPTOR TAB 200MG 4 RETROVIR INJ 10MG/ML 4 ED - Excluido GC - Cobertura de Brecha 7

14 REYATAZ CAP 150MG 5 REYATAZ CAP 200MG 5 REYATAZ CAP 300MG 5 REYATAZ POW 50MG 5 SELZENTRY TAB 25MG 4 SELZENTRY TAB 75MG 5 SELZENTRY TAB 150MG 5 SELZENTRY TAB 300MG 5 stavudine cap 15 4 stavudine cap 20 4 stavudine cap 30 4 stavudine cap 40 4 SUSTIVA CAP 50MG 3 SUSTIVA CAP 200MG 5 SUSTIVA TAB 600MG 5 TIVICAY TAB 10MG 3 TIVICAY TAB 25MG 5 TIVICAY TAB 50MG 5 TYBOST TAB 150MG 3 VIDEX SOL 2GM 4 VIDEX SOL 4GM 4 VIRACEPT TAB 250MG 5 VIRACEPT TAB 625MG 5 VIREAD POW 40MG/GM 5 VIREAD TAB 150MG 5 VIREAD TAB 200MG 5 VIREAD TAB 250MG 5 VIREAD TAB 300MG 5 ZERIT SOL 1MG/ML 5 ZIAGEN SOL 20MG/ML 3 zidovudine cap zidovudine syrup 10 /ml 4 zidovudine tab GC Agentes antirretrovirales mixtos ABACAVIR SULFATE- 5 LAMIVUDINE TAB MG abacavir sulfate-lamivudinezidovudine 5 tab ATRIPLA TAB 5 COMPLERA TAB 5 DESCOVY TAB 200/25 5 EVOTAZ TAB GENVOYA TAB 5 KALETRA SOL 5 KALETRA TAB MG 3 KALETRA TAB MG 5 lamivudine-zidovudine tab lopinavir-ritonavir soln /5ml (80-20 /ml) ODEFSEY TAB 5 PREZCOBIX TAB STRIBILD TAB 5 TRIUMEQ TAB 5 TRUVADA TAB QL TRUVADA TAB QL TRUVADA TAB QL TRUVADA TAB QL Agentes antituberculosos CAPASTAT SUL INJ 1GM 4 cycloserine cap ethambutol hcl tab ethambutol hcl tab isoniazid inj 100 /ml 3 isoniazid syrup 50 /5ml 4 isoniazid tab 100 isoniazid tab 300 paser gra 4gm 3 PRIFTIN TAB 150MG 4 pyrazinamide tab rifabutin cap rifampin cap rifampin cap rifampin for inj RIFATER TAB 4 SIRTURO TAB 100MG 5 LA PA TRECATOR TAB 250MG 4 Antivirales acyclovir cap GC ED - Excluido GC - Cobertura de Brecha 8

15 acyclovir sodium for inj B/D acyclovir sodium iv soln 50 4 B/D /ml acyclovir susp 200 /5ml 4 acyclovir tab GC acyclovir tab GC adefovir dipivoxil tab 10 5 BARACLUDE SOL.05MG/ML 5 DAKLINZA TAB 30MG 5 PA DAKLINZA TAB 60MG 5 PA DAKLINZA TAB 90MG 5 PA entecavir tab entecavir tab 1 5 EPIVIR HBV SOL 5MG/ML 4 famciclovir tab famciclovir tab famciclovir tab ganciclovir sodium for inj B/D lamivudine tab 100 (hbv) 4 oseltamivir phosphate cap 30 3 (base equiv) oseltamivir phosphate cap 45 3 (base equiv) oseltamivir phosphate cap 75 3 (base equiv) PEGASYS INJ 5 PA PEGASYS INJ 180MCG/M 5 PA PEGASYS INJ PROCLICK 5 PA REBETOL SOL 40MG/ML 5 RELENZA MIS DISKHALE 3 ribasphere cap ribasphere tab ribasphere tab ribasphere tab ribavirin cap ribavirin tab rimantadine hydrochloride tab SOVALDI TAB 400MG 5 PA TAMIFLU SUS 6MG/ML 3 TYZEKA TAB 600MG 5 valacyclovir hcl tab 1 gm 3 valacyclovir hcl tab VALCYTE SOL 50MG/ML 5 valganciclovir hcl for soln 50 5 /ml (base equiv) valganciclovir hcl tab (base equivalent) VEMLIDY TAB 25MG 5 ZEPATIER TAB MG 5 PA Cefalosporinas cefaclor cap cefaclor cap cefaclor er tab cefaclor for susp 125 /5ml 4 cefaclor for susp 250 /5ml 4 cefaclor for susp 375 /5ml 4 cefadroxil cap GC cefadroxil for susp /5ml cefadroxil for susp /5ml cefadroxil tab 1 gm 4 cefazolin inj 1gm/50ml 3 cefazolin sodium for inj 1 gm 3 cefazolin sodium for inj 10 gm 3 cefazolin sodium for inj 20 gm 3 cefazolin sodium for inj cefazolin sodium for iv soln 1 3 gm CEFAZOLIN SOL 3 cefdinir cap cefdinir for susp 125 /5ml 4 cefdinir for susp 250 /5ml 4 cefepime hcl for inj 1 gm 4 cefepime hcl for inj 2 gm 4 cefixime for susp 100 /5ml 4 cefixime for susp 200 /5ml 4 cefotaxime sodium for inj 1 4 gm cefotaxime sodium for inj 2 4 gm ED - Excluido GC - Cobertura de Brecha 9

16 cefotaxime sodium for inj cefoxitin sodium for inj 10 gm 4 cefoxitin sodium for iv soln 1 4 gm cefoxitin sodium for iv soln 2 4 gm cefpodoxime proxetil for susp 4 50 /5ml cefpodoxime proxetil for susp /5ml cefpodoxime proxetil tab cefpodoxime proxetil tab cefprozil for susp 125 /5ml 4 cefprozil for susp 250 /5ml 4 cefprozil tab cefprozil tab ceftazidime for inj 1 gm 4 ceftazidime for inj 2 gm 4 ceftazidime for inj 6 gm 4 CEFTAZIDIME/ SOL D5W 4 1GM CEFTAZIDIME/ SOL D5W 4 2GM ceftriaxone sodium for inj 1 3 gm ceftriaxone sodium for inj 2 3 gm ceftriaxone sodium for inj 10 3 gm ceftriaxone sodium for inj ceftriaxone sodium for inj ceftriaxone sodium for iv soln 3 1 gm ceftriaxone sodium for iv soln 3 2 gm cefuroxime axetil tab cefuroxime axetil tab cefuroxime sodium for inj gm cefuroxime sodium for inj gm cefuroxime sodium for inj cefuroxime sodium for iv soln gm cephalexin cap 250 cephalexin cap 500 cephalexin for susp /5ml cephalexin for susp /5ml SUPRAX CAP 400MG 3 suprax chw suprax chw SUPRAX SUS 500/5ML 3 tazicef inj 1gm 4 tazicef inj 2gm 4 tazicef inj 6gm 4 TEFLARO INJ 400MG 5 TEFLARO INJ 600MG 5 Eritromicinas/macrólidos azithromycin for susp /5ml azithromycin for susp /5ml azithromycin iv for soln AZITHROMYCIN POWD 3 PACK FOR SUSP 1 GM azithromycin tab 250 azithromycin tab 500 azithromycin tab 600 clarithromycin for susp /5ml clarithromycin for susp /5ml clarithromycin tab clarithromycin tab clarithromycin tab er 24hr DIFICID TAB 200MG 5 ery-tab tab 250 ec 4 ery-tab tab 333 ec 4 ED - Excluido GC - Cobertura de Brecha 10

17 ery-tab tab 500 ec 4 erythrocin inj erythrocin tab erythromycin ethylsuccinate 4 tab 400 erythromycin tab erythromycin tab erythromycin w/ delayed 4 release particles cap 250 Fluoroquinolonas ciprofloxacin 200 /100ml in 4 d5w ciprofloxacin 400 /200ml in 4 d5w ciprofloxacin for oral susp /5ml (5%) (5 gm/100ml) ciprofloxacin for oral susp /5ml (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 (base equiv) ciprofloxacin hcl tab 250 (base equiv) ciprofloxacin hcl tab 500 (base equiv) ciprofloxacin hcl tab 750 (base equiv) ciprofloxacin iv soln /20ml (1%) ciprofloxacin iv soln /40ml (1%) ciprofloxacin-ciprofloxacin hcl 4 tab er 24hr 500 (base eq) ciprofloxacin-ciprofloxacin hcl 4 tab er 24hr 1000 (base eq) levofloxacin in d5w iv soln /50ml levofloxacin in d5w iv soln /100ml levofloxacin in d5w iv soln /150ml levofloxacin iv soln 25 /ml 4 levofloxacin oral soln 25 4 /ml levofloxacin tab 250 levofloxacin tab 500 levofloxacin tab 750 moxifloxacin hcl tab GC (base equiv) Penicilinas amoxicillin & k clavulanate 3 chew tab amoxicillin & k clavulanate 3 chew tab amoxicillin & k clavulanate for 3 susp /5ml amoxicillin & k clavulanate for 3 susp /5ml amoxicillin & k clavulanate for 3 susp /5ml amoxicillin & k clavulanate for 3 susp /5ml amoxicillin & k clavulanate tab 2 GC amoxicillin & k clavulanate tab 2 GC amoxicillin & k clavulanate tab 2 GC amoxicillin & k clavulanate tab 4 er 12hr amoxicillin (trihydrate) cap 250 amoxicillin (trihydrate) cap 500 amoxicillin (trihydrate) chew 2 GC tab 125 amoxicillin (trihydrate) chew 2 GC tab 250 amoxicillin (trihydrate) for susp 125 /5ml amoxicillin (trihydrate) for susp 200 /5ml amoxicillin (trihydrate) for susp 250 /5ml amoxicillin (trihydrate) for susp 400 /5ml amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm 4 ED - Excluido GC - Cobertura de Brecha 11

18 ampicillin & sulbactam sodium 4 for inj 3 (2-1) gm ampicillin & sulbactam sodium 4 for inj 15 (10-5) gm ampicillin & sulbactam sodium 4 for iv soln 15 (10-5) gm ampicillin cap 250 ampicillin cap 500 ampicillin for susp 125 /5ml 3 ampicillin for susp 250 /5ml 3 ampicillin sodium for inj 1 gm 4 ampicillin sodium for inj 2 gm 4 ampicillin sodium for inj 10 gm 4 ampicillin sodium for inj ampicillin sodium for inj ampicillin sodium for inj ampicillin sodium for iv soln 1 4 gm ampicillin sodium for iv soln 2 4 gm ampicillin sodium for iv soln 4 10 gm BICILLIN L-A INJ BICILLIN L-A INJ BICILLIN L-A INJ dicloxacillin sodium cap GC dicloxacillin sodium cap GC nafcillin sodium for inj 1 gm 4 nafcillin sodium for inj 2 gm 4 nafcillin sodium for inj 10 gm 4 nafcillin sodium for iv soln 1 4 gm nafcillin sodium for iv soln 2 4 gm oxacillin sodium for inj 1 gm 4 oxacillin sodium for inj 2 gm 4 oxacillin sodium for inj 10 gm 5 pen g proc inj PENICILL GK/ INJ DEX 2MU 4 PENICILL GK/ INJ DEX 3MU 4 penicillin g potassium for inj unit penicillin g potassium for inj unit penicillin g sodium for inj unit penicillin v potassium for soln 125 /5ml penicillin v potassium for soln 250 /5ml penicillin v potassium tab 250 penicillin v potassium tab 500 piper/tazoba inj gm 4 piperacillin sod-tazobactam 4 na for inj gm ( gm) piperacillin sod-tazobactam 4 sod for inj 2.25 gm ( gm) piperacillin sod-tazobactam 4 sod for inj 4.5 gm (4-0.5 gm) piperacillin sod-tazobactam 4 sod for inj 40.5 gm ( gm) Tetraciclinas doxy 100 inj doxycycline hyclate cap 50 3 doxycycline hyclate cap doxycycline hyclate for inj doxycycline hyclate tab 20 4 doxycycline hyclate tab doxycycline monohydrate cap 2 GC 50 doxycycline monohydrate cap 2 GC 100 doxycycline monohydrate tab 3 50 doxycycline monohydrate tab 75 3 ED - Excluido GC - Cobertura de Brecha 12

19 doxycycline monohydrate tab doxycycline monohydrate tab minocycline hcl cap 50 2 GC minocycline hcl cap 75 2 GC minocycline hcl cap GC Agentes antineoplásicos Agentes alquilantes BENDEKA INJ 100/4ML 5 B/D BICNU INJ 100MG 5 B/D busulfan inj 6 /ml 5 B/D BUSULFEX INJ 6MG/ML 5 B/D CYCLOPHOSPH CAP 25MG 4 B/D CYCLOPHOSPH CAP 50MG 4 B/D cyclophosphamide for inj 1 5 B/D gm cyclophosphamide for inj 2 5 B/D gm cyclophosphamide for inj B/D dacarbazine for inj B/D dacarbazine for inj B/D EMCYT CAP 140MG 4 GLEOSTINE CAP 5MG 4 GLEOSTINE CAP 10MG 4 GLEOSTINE CAP 40MG 4 GLEOSTINE CAP 100MG 4 HEXALEN CAP 50MG 5 IFEX INJ 3GM 4 B/D ifosfamide for inj 1 gm 4 B/D IFOSFAMIDE INJ 3GM 4 B/D ifosfamide iv inj 1 gm/20ml 3 B/D (50 /ml) ifosfamide iv inj 3 gm/60ml 3 B/D (50 /ml) LEUKERAN TAB 2MG 4 melphalan hcl for inj 50 5 B/D (base equiv) MUSTARGEN INJ 10MG 5 B/D TREANDA INJ 25MG 5 B/D TREANDA INJ 100MG 5 B/D Antraciclinas adriamycin inj 20 3 B/D daunorubicin hcl inj 5 /ml 3 B/D (base equiv) doxorubicin hcl for inj 50 3 B/D doxorubicin hcl inj 2 /ml 3 B/D doxorubicin hcl liposomal inj 5 B/D (for iv infusion) 2 /ml epirubicin hcl iv soln 50 4 B/D /25ml (2 /ml) epirubicin hcl iv soln B/D /100ml (2 /ml) idarubicin hcl iv inj 5 /5ml 5 B/D (1 /ml) idarubicin hcl iv inj 10 5 B/D /10ml (1 /ml) idarubicin hcl iv inj 20 5 B/D /20ml (1 /ml) Antibióticos bleomycin sulfate for inj 15 3 B/D unit bleomycin sulfate for inj 30 3 B/D unit mitomycin for iv soln 5 5 B/D mitomycin for iv soln 20 5 B/D mitomycin for iv soln 40 5 B/D Antimetabolitos adrucil inj 500/10ml 3 B/D ALIMTA INJ 100MG 5 B/D ALIMTA INJ 500MG 5 B/D azacitidine for inj B/D cladribine iv soln 10 /10ml 5 B/D (1 /ml) cytarabine inj 20 /ml 3 B/D fludarabine phosphate for inj 4 B/D 50 fludarabine phosphate inj 25 4 B/D /ml fluorouracil inj 1 gm/20ml (50 3 B/D /ml) fluorouracil inj 2.5 gm/50ml 3 B/D (50 /ml) fluorouracil inj 5 gm/100ml (50 /ml) 3 B/D ED - Excluido GC - Cobertura de Brecha 13

20 fluorouracil inj 500 /10ml 3 B/D (50 /ml) gemcitabine hcl for inj 1 gm 5 B/D gemcitabine hcl for inj 2 gm 5 B/D gemcitabine hcl for inj B/D GEMCITABINE HCL INJ 1 5 B/D GM/26.3ML (38 MG/ML) (BASE EQUIV) GEMCITABINE HCL INJ 2 5 B/D GM/52.6ML (38 MG/ML) (BASE EQUIV) GEMCITABINE HCL INJ B/D MG/5.26ML (38 MG/ML) (BASE EQUIV) mercaptopurine tab 50 4 methotrexate sodium for inj 1 2 GC B/D gm METHOTREXATE SODIUM 2 GC B/D INJ 50 MG/2ML (25 MG/ML) methotrexate sodium inj GC B/D /10ml (25 /ml) methotrexate sodium inj pf 50 2 GC B/D /2ml (25 /ml) methotrexate sodium inj pf 2 GC B/D 100 /4ml (25 /ml) methotrexate sodium inj pf 2 GC B/D 200 /8ml (25 /ml) methotrexate sodium inj pf 2 GC B/D 250 /10ml (25 /ml) methotrexate sodium inj pf 2 GC B/D 1000 /40ml (25 /ml) NIPENT INJ 10MG 5 B/D PURIXAN SUS 20MG/ML 5 TABLOID TAB 40MG 4 Antimitótico, taxoides ABRAXANE INJ 100MG 5 B/D DOCEFREZ INJ 20MG 5 B/D DOCETAXEL FOR INJ CONC 5 B/D 20 MG/ML docetaxel for inj conc 80 5 B/D /4ml (20 /ml) DOCETAXEL INJ 20MG/2ML 5 B/D DOCETAXEL INJ 80MG/4ML 5 B/D DOCETAXEL INJ 80MG/8ML 5 B/D DOCETAXEL INJ 160/8ML 5 B/D DOCETAXEL INJ 160/16ML 5 B/D docetaxel inj 200/10 5 B/D paclitaxel iv conc 30 /5ml 4 B/D (6 /ml) paclitaxel iv conc B/D /16.7ml (6 /ml) paclitaxel iv conc B/D /25ml (6 /ml) paclitaxel iv conc B/D /50ml (6 /ml) TAXOTERE INJ 80MG/4ML 5 B/D Antimitóticos, alcaloides de la vinca vinblastine sulfate inj 1 /ml 3 B/D vincasar pfs inj 1/ml 2 GC B/D vincristine sulfate iv soln 1 /ml vinorelbine tartrate inj 10 /ml (base equiv) vinorelbine tartrate inj 50 /5ml (10 /ml) (base equiv) 2 GC B/D 3 B/D 3 B/D Modificadores de la reacción biológica AVASTIN INJ 5 LA PA AVASTIN INJ 400/16ML 5 LA PA BELEODAQ INJ 500MG 5 PA ERIVEDGE CAP 150MG 5 LA PA FARYDAK CAP 10MG 5 LA PA FARYDAK CAP 15MG 5 LA PA FARYDAK CAP 20MG 5 LA PA HERCEPTIN INJ 150MG 5 PA HERCEPTIN INJ 440MG 5 PA IBRANCE CAP 75MG 5 LA PA IBRANCE CAP 100MG 5 LA PA IBRANCE CAP 125MG 5 LA PA ISTODAX OVR INJ 10MG 5 B/D KADCYLA INJ 100MG 5 B/D KADCYLA INJ 160MG 5 B/D KEYTRUDA INJ 100MG/4M 5 PA KEYTRUDA SOL 50MG 5 PA KISQALI 200 PAK FEMARA 5 PA KISQALI 400 PAK FEMARA 5 PA KISQALI 600 PAK FEMARA 5 PA KISQALI TAB 200DOSE 5 PA KISQALI TAB 400DOSE 5 PA KISQALI TAB 600DOSE 5 PA ED - Excluido GC - Cobertura de Brecha 14

21 LYNPARZA CAP 50MG 5 LA PA NINLARO CAP 2.3MG 5 PA NINLARO CAP 3MG 5 PA NINLARO CAP 4MG 5 PA PROLEUKIN INJ 22MU 5 B/D RITUXAN INJ 100MG 5 LA PA RITUXAN INJ 500MG 5 LA PA RUBRACA TAB 200MG 5 LA PA RUBRACA TAB 250MG 5 LA PA RUBRACA TAB 300MG 5 LA PA TECENTRIQ INJ 1200/20 5 LA PA VELCADE INJ 3.5MG 5 PA VENCLEXTA TAB 10MG 4 LA PA VENCLEXTA TAB 50MG 4 LA PA VENCLEXTA TAB 100MG 5 LA PA VENCLEXTA TAB START PK 5 LA PA YERVOY INJ 50MG 5 PA YERVOY INJ 200MG 5 PA ZEJULA CAP 100MG 5 LA PA ZOLINZA CAP 100MG 5 PA Agentes antineoplásicos hormonales anastrozole tab 1 2 GC bicalutamide tab 50 3 DEPO-PROVERA INJ 400/ML 4 B/D exemestane tab 25 4 FARESTON TAB 60MG 5 FASLODEX INJ 250MG 5 B/D flutamide cap hydroxyprogesterone 4 B/D caproate im in oil 1.25 gm/5ml letrozole tab leuprolide acetate inj kit 5 3 PA /ml LUPRON DEPOT INJ 5 PA 3.75MG LUPRON DEPOT INJ 5 PA 11.25MG LYSODREN TAB 500MG 3 megestrol acetate susp 40 2 GC /ml MEGESTROL ACETATE 4 PA SUSP 625 MG/5ML megestrol acetate tab 20 2 GC megestrol acetate tab 40 2 GC nilutamide tab SOLTAMOX SOL 10MG/5ML 4 tamoxifen citrate tab 10 (base equivalent) tamoxifen citrate tab 20 (base equivalent) TRELSTAR MIX INJ 3.75MG 5 PA TRELSTAR MIX INJ 11.25MG 5 PA XTANDI CAP 40MG 5 LA PA ZYTIGA TAB 250MG 5 LA PA ZYTIGA TAB 500MG 5 LA PA Inhibidores de la cinasa AFINITOR DIS TAB 2MG 5 PA AFINITOR DIS TAB 3MG 5 PA AFINITOR DIS TAB 5MG 5 PA AFINITOR TAB 2.5MG 5 PA AFINITOR TAB 5MG 5 PA AFINITOR TAB 7.5MG 5 PA AFINITOR TAB 10MG 5 PA ALECENSA CAP 150MG 5 LA PA ALUNBRIG TAB 30MG 5 LA PA BOSULIF TAB 100MG 5 PA BOSULIF TAB 500MG 5 PA CABOMETYX TAB 20MG 5 LA PA CABOMETYX TAB 40MG 5 LA PA CABOMETYX TAB 60MG 5 LA PA CAPRELSA TAB 100MG 5 LA PA CAPRELSA TAB 300MG 5 LA PA COMETRIQ KIT 60MG 5 LA PA COMETRIQ KIT 100MG 5 LA PA COMETRIQ KIT 140MG 5 LA PA COTELLIC TAB 20MG 5 LA PA GILOTRIF TAB 20MG 5 LA PA GILOTRIF TAB 30MG 5 LA PA GILOTRIF TAB 40MG 5 LA PA GLEEVEC TAB 100MG 5 QL PA QL (90 tabs / 30 GLEEVEC TAB 400MG 5 QL PA ICLUSIG TAB 15MG 5 LA PA ICLUSIG TAB 45MG 5 LA PA imatinib mesylate tab 100 (base equivalent) QL (90 tabs / 30 5 QL PA ED - Excluido GC - Cobertura de Brecha 15

22 imatinib mesylate tab QL PA (base equivalent) IMBRUVICA CAP 140MG 5 LA PA INLYTA TAB 1MG 5 LA PA INLYTA TAB 5MG 5 LA PA IRESSA TAB 250MG 5 LA PA JAKAFI TAB 5MG 5 LA PA JAKAFI TAB 10MG 5 LA PA JAKAFI TAB 15MG 5 LA PA JAKAFI TAB 20MG 5 LA PA JAKAFI TAB 25MG 5 LA PA LENVIMA CAP 8 MG 5 LA PA LENVIMA CAP 10 MG 5 LA PA LENVIMA CAP 14 MG 5 LA PA LENVIMA CAP 18 MG 5 LA PA LENVIMA CAP 20 MG 5 LA PA LENVIMA CAP 24 MG 5 LA PA MEKINIST TAB 0.5MG 5 LA PA MEKINIST TAB 2MG 5 LA PA NEXAVAR TAB 200MG 5 LA PA RYDAPT CAP 25MG 5 PA SPRYCEL TAB 20MG 5 PA SPRYCEL TAB 50MG 5 PA SPRYCEL TAB 70MG 5 PA SPRYCEL TAB 80MG 5 PA SPRYCEL TAB 100MG 5 PA SPRYCEL TAB 140MG 5 PA STIVARGA TAB 40MG 5 LA PA SUTENT CAP 12.5MG 5 PA SUTENT CAP 25MG 5 PA SUTENT CAP 37.5MG 5 PA SUTENT CAP 50MG 5 PA TAFINLAR CAP 50MG 5 LA PA TAFINLAR CAP 75MG 5 LA PA TAGRISSO TAB 40MG 5 LA PA TAGRISSO TAB 80MG 5 LA PA TARCEVA TAB 25MG 5 LA PA TARCEVA TAB 100MG 5 LA PA TARCEVA TAB 150MG 5 LA PA TASIGNA CAP 150MG 5 PA TASIGNA CAP 200MG 5 PA TYKERB TAB 250MG 5 LA PA VOTRIENT TAB 200MG 5 LA PA XALKORI CAP 200MG 5 LA PA XALKORI CAP 250MG 5 LA PA ZELBORAF TAB 240MG 5 LA PA ZYDELIG TAB 100MG 5 LA PA ZYDELIG TAB 150MG 5 LA PA ZYKADIA CAP 150MG 5 LA PA Misceláneos bexarotene cap 75 5 PA DROXIA CAP 200MG 3 DROXIA CAP 300MG 3 DROXIA CAP 400MG 3 hydroxyurea cap LONSURF TAB PA LONSURF TAB PA MATULANE CAP 50MG 5 LA mitoxantrone hcl inj conc 20 3 B/D /10ml (2 /ml) mitoxantrone hcl inj conc 25 3 B/D /12.5ml (2 /ml) mitoxantrone hcl inj conc 30 3 B/D /15ml (2 /ml) ODOMZO CAP 200MG 5 LA PA SYLATRON KIT 200MCG 5 PA SYLATRON KIT 300MCG 5 PA SYLATRON KIT 600MCG 5 PA SYNRIBO INJ 3.5MG 5 PA tretinoin cap 10 5 TRISENOX SOL 10MG/10M 5 B/D Agentes a base de platino carboplatin iv soln 50 /5ml 4 B/D carboplatin iv soln B/D /15ml carboplatin iv soln B/D /45ml carboplatin iv soln B/D /60ml cisplatin inj 50 /50ml (1 3 B/D /ml) cisplatin inj 100 /100ml (1 3 B/D /ml) cisplatin inj 200 /200ml (1 3 B/D /ml) oxaliplatin for iv inj 50 4 B/D oxaliplatin for iv inj B/D oxaliplatin iv soln 50 /10ml 4 B/D ED - Excluido GC - Cobertura de Brecha 16

23 oxaliplatin iv soln 100 /20ml Agentes protectores AMIFOSTINE FOR INJ 500 MG 4 B/D 5 B/D dexrazoxane for inj B/D dexrazoxane for inj B/D ELITEK INJ 1.5MG 5 B/D ELITEK INJ 7.5MG 5 B/D FUSILEV INJ 50MG 5 B/D leucovorin calcium for inj 50 leucovorin calcium for inj 100 leucovorin calcium for inj 200 leucovorin calcium for inj 350 leucovorin calcium for inj 500 leucovorin calcium tab 5 3 leucovorin calcium tab 10 3 leucovorin calcium tab 15 3 leucovorin calcium tab B/D 4 B/D 4 B/D 4 B/D 4 B/D LEVOLEUCOVOR INJ 5 B/D 175MG levoleucovor sol 250/25 5 B/D levoleucovorin calcium for iv 5 B/D inj 50 (base equiv) levoleucovorin calcium inj B/D /17.5ml (base equiv) mesna inj 100 /ml 4 B/D MESNEX TAB 400MG 5 Inhibidores de la topoisomerasa etoposide inj 100 /5ml (20 3 B/D /ml) etoposide inj 500 /25ml (20 3 B/D /ml) irinotecan hcl inj 40 /2ml 4 B/D (20 /ml) irinotecan hcl inj 100 /5ml 4 B/D (20 /ml) irinotecan hcl inj 500 /25ml 4 B/D (20 /ml) toposar inj 1gm/50ml 3 B/D toposar inj 100/5ml 3 B/D topotecan hcl for inj 4 5 B/D TOPOTECAN INJ 4MG/4ML 5 B/D Cardiovascular Combinaciones del inhibidor de la ECA amlodipine besylatebenazepril hcl cap amlodipine besylatebenazepril hcl cap 5-10 amlodipine besylatebenazepril hcl cap 5-20 amlodipine besylatebenazepril hcl cap 5-40 amlodipine besylatebenazepril hcl cap amlodipine besylatebenazepril hcl cap benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab ED - Excluido GC - Cobertura de Brecha 17

24 enalapril maleate & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab Inhibidores de la ECA benazepril hcl tab 5 benazepril hcl tab 10 benazepril hcl tab 20 benazepril hcl tab 40 captopril tab 12.5 captopril tab 25 captopril tab 50 captopril tab 100 enalapril maleate tab 2.5 enalapril maleate tab 5 enalapril maleate tab 10 enalapril maleate tab 20 fosinopril sodium tab 10 fosinopril sodium tab 20 fosinopril sodium tab 40 lisinopril tab 2.5 lisinopril tab 5 lisinopril tab 10 lisinopril tab 20 lisinopril tab 30 lisinopril tab 40 moexipril hcl tab 7.5 moexipril hcl tab 15 perindopril erbumine tab 2 perindopril erbumine tab 4 perindopril erbumine tab 8 quinapril hcl tab 5 quinapril hcl tab 10 quinapril hcl tab 20 quinapril hcl tab 40 ramipril cap 1.25 ramipril cap 2.5 ramipril cap 5 ramipril cap 10 trandolapril tab 1 trandolapril tab 2 trandolapril tab 4 Antagonistas del receptor de aldosterona eplerenone tab 25 4 eplerenone tab 50 4 spironolactone tab 25 spironolactone tab 50 spironolactone tab 100 Alfa bloqueadores doxazosin mesylate tab 1 doxazosin mesylate tab 2 doxazosin mesylate tab 4 doxazosin mesylate tab 8 3 prazosin hcl cap 1 3 prazosin hcl cap 2 3 prazosin hcl cap 5 3 terazosin hcl cap 1 terazosin hcl cap 2 terazosin hcl cap 5 terazosin hcl cap 10 ED - Excluido GC - Cobertura de Brecha 18

25 Combinaciones de antagonista del receptor de la angiotensina II amlodipine besylateolmesartan medoxomil tab 5-20 amlodipine besylateolmesartan medoxomil tab 5-40 amlodipine besylateolmesartan medoxomil tab amlodipine besylateolmesartan medoxomil tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine-valsartanhydrochlorothiazide tab amlodipine-valsartanhydrochlorothiazide tab amlodipine-valsartanhydrochlorothiazide tab amlodipine-valsartanhydrochlorothiazide tab amlodipine-valsartanhydrochlorothiazide tab AZOR TAB 5-20MG 4 AZOR TAB 5-40MG 4 AZOR TAB 10-20MG 4 AZOR TAB 10-40MG 4 candesartan cilexetilhydrochlorothiazide tab candesartan cilexetilhydrochlorothiazide tab candesartan cilexetilhydrochlorothiazide tab ENTRESTO TAB 24-26MG 3 ENTRESTO TAB 49-51MG 3 ENTRESTO TAB MG 3 irbesartan-hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab losartan potassium & hydrochlorothiazide tab losartan potassium & hydrochlorothiazide tab losartan potassium & hydrochlorothiazide tab olmesartan medoxomilhydrochlorothiazide tab olmesartan medoxomilhydrochlorothiazide tab olmesartan medoxomilhydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab ED - Excluido GC - Cobertura de Brecha 19

26 telmisartanhydrochlorothiazide tab telmisartanhydrochlorothiazide tab telmisartanhydrochlorothiazide tab GC QL 2 GC QL 2 GC QL valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab Antagonistas del receptor de la angiotensina candesartan cilexetil tab 4 candesartan cilexetil tab 8 candesartan cilexetil tab 16 candesartan cilexetil tab 32 irbesartan tab 75 irbesartan tab 150 irbesartan tab 300 losartan potassium tab 25 losartan potassium tab 50 losartan potassium tab 100 olmesartan medoxomil tab 5 olmesartan medoxomil tab 20 olmesartan medoxomil tab 40 telmisartan tab 20 2 GC QL telmisartan tab 40 2 GC QL telmisartan tab 80 2 GC QL valsartan tab 40 valsartan tab 80 valsartan tab 160 valsartan tab 320 Antiarrítmicos amiodarone hcl inj GC /3ml (50 /ml) amiodarone hcl inj GC /9ml (50 /ml) amiodarone hcl inj GC /18ml (50 /ml) amiodarone hcl tab amiodarone hcl tab 200 amiodarone hcl tab disopyramide phosphate cap 2 GC 100 disopyramide phosphate cap 2 GC 150 DOFETILIDE CAP 125 MCG 4 (0.125 MG) DOFETILIDE CAP 250 MCG 4 (0.25 MG) DOFETILIDE CAP 500 MCG 4 (0.5 MG) flecainide acetate tab 50 3 flecainide acetate tab flecainide acetate tab mexiletine hcl cap mexiletine hcl cap mexiletine hcl cap MULTAQ TAB 400MG 4 NORPACE CAP 100MG CR 4 NORPACE CAP 150MG CR 4 pacerone tab pacerone tab 200 pacerone tab propafenone hcl cap er 12hr propafenone hcl cap er 12hr ED - Excluido GC - Cobertura de Brecha 20

27 propafenone hcl cap er 12hr propafenone hcl tab propafenone hcl tab propafenone hcl tab quinidine gluconate tab er quinidine sulfate tab GC quinidine sulfate tab GC sorine tab 80 2 GC sorine tab GC sorine tab GC sorine tab GC sotalol hcl (afib/afl) tab 80 3 sotalol hcl (afib/afl) tab sotalol hcl (afib/afl) tab sotalol hcl tab 80 2 GC sotalol hcl tab GC sotalol hcl tab GC sotalol hcl tab GC Antilipémicos, los inhibidores de la HMG- CoA reductasa atorvastatin calcium tab 10 (base equivalent) atorvastatin calcium tab 20 (base equivalent) atorvastatin calcium tab 40 (base equivalent) atorvastatin calcium tab 80 (base equivalent) ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab lovastatin tab 10 lovastatin tab 20 lovastatin tab 40 pravastatin sodium tab 10 pravastatin sodium tab 20 pravastatin sodium tab 40 pravastatin sodium tab 80 rosuvastatin calcium tab 5 QL rosuvastatin calcium tab 10 QL rosuvastatin calcium tab 20 QL rosuvastatin calcium tab 40 QL simvastatin tab 5 simvastatin tab 10 simvastatin tab 20 simvastatin tab 40 simvastatin tab 80 QL VYTORIN TAB 10-10MG 4 VYTORIN TAB 10-20MG 4 VYTORIN TAB 10-40MG 4 VYTORIN TAB 10-80MG 4 Antilipémicos, misceláneos cholestyramine light powder 4 4 gm/dose cholestyramine light powder 4 packets 4 gm cholestyramine powder 4 4 gm/dose cholestyramine powder 4 packets 4 gm choline fenofibrate cap dr 45 (fenofibric acid equiv) QL (30 caps / 30 choline fenofibrate cap dr 135 (fenofibric acid equiv) QL (30 caps / 30 colestipol hcl granule packets 4 5 gm colestipol hcl granules 5 gm 4 colestipol hcl tab 1 gm 4 ezetimibe tab 10 3 fenofibrate micronized cap 67 3 ED - Excluido GC - Cobertura de Brecha 21

28 fenofibrate micronized cap fenofibrate micronized cap fenofibrate tab 48 4 fenofibrate tab 54 4 fenofibrate tab fenofibrate tab gemfibrozil tab GC JUXTAPID CAP 5MG 5 LA PA JUXTAPID CAP 10MG 5 LA PA JUXTAPID CAP 20MG 5 LA PA JUXTAPID CAP 30MG 5 LA PA JUXTAPID CAP 40MG 5 LA PA JUXTAPID CAP 60MG 5 LA PA KYNAMRO INJ 200MG/ML 5 PA niacin tab er 500 (antihyperlipidemic) QL (90 tabs / 30 niacin tab er (antihyperlipidemic) niacin tab er (antihyperlipidemic) niacor tab omega-3-acid ethyl esters cap 4 1 gm PRALUENT INJ 75MG/ML 5 PA PRALUENT INJ 75MG/ML 5 PA PRALUENT INJ 150MG/ML 5 PA prevalite pow 4gm 4 prevalite pow 4gm pk 4 VASCEPA CAP 0.5GM 4 VASCEPA CAP 1GM 4 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 Betabloqueante / Diurético Cominaciones atenolol & chlorthalidone tab atenolol & chlorthalidone tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab metoprolol & 3 hydrochlorothiazide tab metoprolol & 3 hydrochlorothiazide tab metoprolol & 3 hydrochlorothiazide tab propranolol & 3 hydrochlorothiazide tab propranolol & 3 hydrochlorothiazide tab Betabloqueante acebutolol hcl cap GC acebutolol hcl cap GC atenolol tab 25 atenolol tab 50 atenolol tab 100 bisoprolol fumarate tab 5 2 GC bisoprolol fumarate tab 10 2 GC BYSTOLIC TAB 2.5MG 4 BYSTOLIC TAB 5MG 4 BYSTOLIC TAB 10MG 4 BYSTOLIC TAB 20MG 4 carvedilol tab carvedilol tab 6.25 carvedilol tab 12.5 carvedilol tab 25 COREG CR CAP 10MG 4 COREG CR CAP 20MG 4 COREG CR CAP 40MG 4 COREG CR CAP 80MG 4 labetalol hcl tab labetalol hcl tab labetalol hcl tab ED - Excluido GC - Cobertura de Brecha 22

29 metoprolol succinate tab er 3 24hr 25 (tartrate equiv) metoprolol succinate tab er 3 24hr 50 (tartrate equiv) metoprolol succinate tab er 3 24hr 100 (tartrate equiv) metoprolol succinate tab er 3 24hr 200 (tartrate equiv) metoprolol tartrate iv soln 5 3 /5ml metoprolol tartrate iv soln cart 3 inj 5 /5ml (1 /ml) metoprolol tartrate tab 25 metoprolol tartrate tab 50 metoprolol tartrate tab 100 nadolol tab 20 4 nadolol tab 40 4 nadolol tab 80 4 pindolol tab 5 4 pindolol tab 10 4 propranolol hcl cap er 24hr 60 4 propranolol hcl cap er 24hr 80 4 propranolol hcl cap er 24hr propranolol hcl cap er 24hr propranolol hcl inj 1 /ml 3 propranolol hcl oral soln 20 3 /5ml propranolol hcl oral soln 40 3 /5ml propranolol hcl tab 10 3 propranolol hcl tab 20 3 propranolol hcl tab 40 3 propranolol hcl tab 60 3 propranolol hcl tab 80 3 timolol maleate tab 5 4 timolol maleate tab 10 4 timolol maleate tab 20 4 Bloqueantes de los Canales de Calcio afeditab tab 30 cr 3 afeditab tab 60 cr 3 amlodipine besylate tab 2.5 amlodipine besylate tab 5 amlodipine besylate tab 10 diltiazem hcl cap er 12hr 60 4 diltiazem hcl cap er 12hr 90 4 diltiazem hcl cap er 12hr diltiazem hcl cap er 24hr diltiazem hcl cap er 24hr diltiazem hcl cap er 24hr diltiazem hcl coated beads 3 cap er 24hr 120 diltiazem hcl coated beads 3 cap er 24hr 180 diltiazem hcl coated beads 3 cap er 24hr 240 diltiazem hcl coated beads 3 cap er 24hr 300 diltiazem hcl coated beads 3 cap er 24hr 360 DILTIAZEM HCL COATED 3 BEADS CAP ER 24HR 360 MG diltiazem hcl extended release 3 beads cap er 24hr 120 diltiazem hcl extended release 3 beads cap er 24hr 180 diltiazem hcl extended release 3 beads cap er 24hr 240 diltiazem hcl extended release 3 beads cap er 24hr 300 diltiazem hcl extended release 3 beads cap er 24hr 360 diltiazem hcl extended release 3 beads cap er 24hr 420 diltiazem hcl iv soln 25 2 GC /5ml (5 /ml) diltiazem hcl iv soln 50 /10ml (5 /ml) 2 GC ED - Excluido GC - Cobertura de Brecha 23

30 diltiazem hcl iv soln GC /25ml (5 /ml) diltiazem hcl tab 30 2 GC diltiazem hcl tab 60 2 GC diltiazem hcl tab 90 2 GC diltiazem hcl tab GC felodipine tab er 24hr felodipine tab er 24hr 5 3 felodipine tab er 24hr 10 3 isradipine cap isradipine cap 5 4 nicardipine hcl cap 20 4 nicardipine hcl cap 30 4 nifedipine cap 10 2 GC nifedipine cap 20 2 GC nifedipine tab er 24hr 30 3 nifedipine tab er 24hr 60 3 nifedipine tab er 24hr 90 3 nifedipine tab er 24hr osmotic 3 release 30 nifedipine tab er 24hr osmotic 3 release 60 nifedipine tab er 24hr osmotic 3 release 90 nimodipine cap 30 5 NYMALIZE SOL 60/20ML 5 verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr VERAPAMIL HCL CAP ER 4 24HR 360 MG verapamil hcl iv soln /ml verapamil hcl tab 40 verapamil hcl tab 80 verapamil hcl tab 120 verapamil hcl tab er GC verapamil hcl tab er GC verapamil hcl tab er GC Bloqueante del canal de calcio /hipolipemiante combinaciones amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab 5-10 amlodipine besylateatorvastatin calcium tab 5-20 amlodipine besylateatorvastatin calcium tab 5-40 amlodipine besylateatorvastatin calcium tab 5-80 amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL ED - Excluido GC - Cobertura de Brecha 24

31 amlodipine besylateatorvastatin 2 GC QL calcium tab CADUET TAB 5-10MG CADUET TAB 5-20MG CADUET TAB 5-40MG CADUET TAB 5-80MG CADUET TAB 10-10MG CADUET TAB 10-20MG CADUET TAB 10-40MG CADUET TAB 10-80MG Glucósidos digitálicos digitek tab GC digitek tab digoxin inj 0.25 /ml 3 DIGOXIN ORAL SOLN GC MG/ML digoxin tab 125 mcg (0.125 ) digoxin tab 250 mcg ( GC ) Diuréticos acetazolamide cap er 12hr acetazolamide tab acetazolamide tab amiloride & 2 GC hydrochlorothiazide tab 5-50 amiloride hcl tab 5 3 bumetanide inj 0.25 /ml 3 bumetanide tab bumetanide tab 1 3 bumetanide tab 2 3 chlorothiazide tab chlorothiazide tab chlorthalidone tab 25 3 chlorthalidone tab 50 3 furosemide inj 10 /ml 2 GC FUROSEMIDE INJ 10 MG/ML 2 GC furosemide oral soln 8 /ml 2 GC furosemide oral soln 10 /ml 2 GC furosemide tab 20 furosemide tab 40 furosemide tab 80 hydrochlorothiazide cap 12.5 hydrochlorothiazide tab 12.5 hydrochlorothiazide tab 25 hydrochlorothiazide tab 50 indapamide tab GC indapamide tab GC methazolamide tab 25 4 methazolamide tab 50 4 methyclothiazide tab 5 3 metolazone tab metolazone tab 5 3 metolazone tab 10 3 spironolactone & 3 hydrochlorothiazide tab torsemide tab 5 2 GC torsemide tab 10 2 GC torsemide tab 20 2 GC torsemide tab GC triamterene & hydrochlorothiazide cap triamterene & hydrochlorothiazide tab triamterene & hydrochlorothiazide tab Inhibidores directos de la renina/combinaciones ED - Excluido GC - Cobertura de Brecha 25

32 TEKTURNA HCT TAB TEKTURNA HCT TAB MG TEKTURNA HCT TAB TEKTURNA HCT TAB MG TEKTURNA TAB 150MG TEKTURNA TAB 300MG Misceláneos clonidine hcl tab 0.1 clonidine hcl tab 0.2 clonidine hcl tab 0.3 clonidine hcl td patch weekly /24hr clonidine hcl td patch weekly /24hr clonidine hcl td patch weekly /24hr DEMSER CAP 250MG 5 hydralazine hcl inj 20 /ml 3 hydralazine hcl tab 10 2 GC hydralazine hcl tab 25 2 GC hydralazine hcl tab 50 2 GC hydralazine hcl tab GC methyldopa tab GC methyldopa tab GC midodrine hcl tab midodrine hcl tab 5 4 midodrine hcl tab 10 4 minoxidil tab GC minoxidil tab 10 2 GC NORTHERA CAP 100MG 5 LA PA NORTHERA CAP 200MG 5 LA PA NORTHERA CAP 300MG 5 LA PA RANEXA TAB 500MG 3 RANEXA TAB 1000MG 3 Nitratos ISORDIL TAB 5MG 4 ISORDIL TAB 40MG 4 isosorbide dinitrate tab 5 3 isosorbide dinitrate tab 10 3 isosorbide dinitrate tab 20 3 isosorbide dinitrate tab 30 3 isosorbide dinitrate tab er 40 4 isosorbide mononitrate tab 10 2 GC isosorbide mononitrate tab 20 2 GC isosorbide mononitrate tab er 2 GC 24hr 30 isosorbide mononitrate tab er 2 GC 24hr 60 isosorbide mononitrate tab er 2 GC 24hr 120 minitran dis 0.1/hr 3 minitran dis 0.2/hr 3 minitran dis 0.4/hr 3 minitran dis 0.6/hr 3 nitro-bid oin 2% 3 NITRO-DUR DIS 0.3MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 nitroglycerin sl tab nitroglycerin sl tab nitroglycerin sl tab nitroglycerin td patch 24hr /hr nitroglycerin td patch 24hr /hr nitroglycerin td patch 24hr /hr nitroglycerin td patch 24hr 0.6 /hr 3 Hipertensión Arterial Pulmonar ADCIRCA TAB 20MG 5 PA ADEMPAS TAB 0.5MG 5 QL LA PA QL (90 tabs / 30 ADEMPAS TAB 1.5MG 5 QL LA PA QL (90 tabs / 30 ADEMPAS TAB 1MG QL (90 tabs / 30 5 QL LA PA ED - Excluido GC - Cobertura de Brecha 26

33 ADEMPAS TAB 2.5MG 5 QL LA PA QL (90 tabs / 30 ADEMPAS TAB 2MG 5 QL LA PA QL (90 tabs / 30 LETAIRIS TAB 5MG 5 QL LA PA LETAIRIS TAB 10MG 5 QL LA PA OPSUMIT TAB 10MG 5 LA PA REMODULIN INJ 1MG/ML 5 LA PA REMODULIN INJ 2.5MG/ML 5 LA PA REMODULIN INJ 5MG/ML 5 LA PA REMODULIN INJ 10MG/ML 5 LA PA REVATIO SUS 10MG/ML 5 QL PA QL (224 ml / 30 sildenafil citrate tab 20 PA QL (90 tabs / 30 TRACLEER TAB 62.5MG 5 PA TRACLEER TAB 125MG 5 PA UPTRAVI TAB 200/800 5 LA PA UPTRAVI TAB 200MCG 5 QL LA PA QL (480 tabs / 30 UPTRAVI TAB 400MCG 5 QL LA PA QL (240 tabs / 30 UPTRAVI TAB 600MCG 5 QL LA PA QL (150 tabs / 30 UPTRAVI TAB 800MCG 5 QL LA PA QL (120 tabs / 30 UPTRAVI TAB 1000MCG 5 QL LA PA QL (90 tabs / 30 UPTRAVI TAB 1200MCG 5 QL LA PA UPTRAVI TAB 1400MCG 5 QL LA PA UPTRAVI TAB 1600MCG 5 QL LA PA VENTAVIS SOL 10MCG/ML 5 PA VENTAVIS SOL 20MCG/ML 5 PA Sistema nervioso central Contra la ansiedad alprazolam tab 0.5 QL (240 tabs / 30 alprazolam tab 0.25 QL (480 tabs / 30 alprazolam tab 1 QL (120 tabs / 30 QL QL QL alprazolam tab 2 QL QL (150 tabs / 30 buspirone hcl tab 5 2 GC buspirone hcl tab GC buspirone hcl tab 10 2 GC buspirone hcl tab 15 2 GC buspirone hcl tab 30 2 GC chlordiazepoxide hcl cap 5 2 GC QL QL (120 caps / 30 chlordiazepoxide hcl cap 10 2 GC QL QL (120 caps / 30 chlordiazepoxide hcl cap 25 2 GC QL QL (120 caps / 30 fluvoxamine maleate tab 25 QL (45 tabs / 30 fluvoxamine maleate tab 50 QL (45 tabs / 30 fluvoxamine maleate tab lorazepam con 2/ml QL (150 ml / 30 lorazepam inj 2 /ml 2 GC lorazepam inj 4 /ml 2 GC lorazepam tab 0.5 QL QL (150 tabs / 30 lorazepam tab 1 QL QL (150 tabs / 30 lorazepam tab 2 QL QL (150 tabs / 30 Anticonvulsivos APTIOM TAB 200MG QL (180 tabs / 30 APTIOM TAB 400MG 5 QL QL (90 tabs / 30 APTIOM TAB 600MG 5 QL APTIOM TAB 800MG 5 QL BANZEL SUS 40MG/ML 5 PA BANZEL TAB 200MG 5 PA BANZEL TAB 400MG 5 PA BRIVIACT INJ 50MG/5ML 4 PA ED - Excluido GC - Cobertura de Brecha 27

34 BRIVIACT SOL 10MG/ML 5 PA BRIVIACT TAB 10MG 5 PA BRIVIACT TAB 25MG 5 PA BRIVIACT TAB 50MG 5 PA BRIVIACT TAB 75MG 5 PA BRIVIACT TAB 100MG 5 PA carbamazepine cap er 12hr carbamazepine cap er 12hr carbamazepine cap er 12hr carbamazepine chew tab carbamazepine susp /5ml carbamazepine tab carbamazepine tab er 12hr carbamazepine tab er 12hr carbamazepine tab er 12hr CELONTIN CAP 300MG 4 clonazepam orally disintegrating tab 0.5 QL (240 tabs / 30 clonazepam orally disintegrating tab 0.25 QL (480 tabs / 30 clonazepam orally disintegrating tab QL (960 tabs / 30 clonazepam orally disintegrating tab 1 QL (120 tabs / 30 clonazepam orally disintegrating tab 2 QL (300 tabs / 30 clonazepam tab 0.5 QL (240 tabs / 30 clonazepam tab 1 QL (120 tabs / 30 clonazepam tab 2 QL (300 tabs / 30 QL QL QL clorazepate dipotassium tab 3.75 QL (120 tabs / 30 clorazepate dipotassium tab 7.5 QL (120 tabs / 30 clorazepate dipotassium tab 15 QL (180 tabs / 30 diazepam con 5/ml QL (240 ml / 30 diazepam inj 5 /ml 3 diazepam oral soln 1 /ml QL (1200 ml / 30 DIAZEPAM RECTAL GEL 4 DELIVERY SYSTEM 2.5 MG DIAZEPAM RECTAL GEL 4 DELIVERY SYSTEM 10 MG DIAZEPAM RECTAL GEL 4 DELIVERY SYSTEM 20 MG diazepam tab 2 QL QL (120 tabs / 30 diazepam tab 5 QL QL (120 tabs / 30 diazepam tab 10 QL QL (120 tabs / 30 dilantin cap 30 3 dilantin cap dilantin chw 50 3 DILANTIN-125 SUS 125/5ML 3 divalproex sodium cap 4 delayed release sprinkle 125 divalproex sodium tab 2 GC delayed release 125 divalproex sodium tab 2 GC delayed release 250 divalproex sodium tab 2 GC delayed release 500 divalproex sodium tab er 24 hr divalproex sodium tab er 24 hr epitol tab ethosuximide cap ED - Excluido GC - Cobertura de Brecha 28

35 ethosuximide soln /5ml felbamate susp 600 /5ml 5 felbamate tab felbamate tab FYCOMPA SUS 0.5MG/ML PA QL (720 ml / 30 FYCOMPA TAB 2MG PA QL (180 tabs / 30 FYCOMPA TAB 4MG PA QL (90 tabs / 30 FYCOMPA TAB 6MG PA FYCOMPA TAB 8MG PA FYCOMPA TAB 10MG PA FYCOMPA TAB 12MG PA gabapentin cap GC QL QL (1080 caps / 30 gabapentin cap GC QL QL (360 caps / 30 gabapentin cap GC QL QL (270 caps / 30 gabapentin oral soln 250 /5ml QL (2160 ml / 30 gabapentin tab 600 QL (180 tabs / 30 gabapentin tab 800 QL (120 tabs / 30 GABITRIL TAB 12MG 4 GABITRIL TAB 16MG 4 lamotrigine tab 25 2 GC lamotrigine tab GC lamotrigine tab GC lamotrigine tab GC lamotrigine tab chewable 3 dispersible 5 lamotrigine tab chewable 3 dispersible 25 lamotrigine tab er 24hr 25 4 lamotrigine tab er 24hr 50 4 lamotrigine tab er 24hr lamotrigine tab er 24hr lamotrigine tab er 24hr lamotrigine tab er 24hr LEVETIRACETA INJ 5MG/ML 4 LEVETIRACETA INJ 4 10MG/ML LEVETIRACETA INJ 4 15MG/ML levetiracetam in sodium 4 chloride iv soln 500 /100ml levetiracetam in sodium 4 chloride iv soln 1000 /100ml levetiracetam in sodium 4 chloride iv soln 1500 /100ml levetiracetam inj 500 /5ml 4 (100 /ml) levetiracetam oral soln /ml levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab er 24hr levetiracetam tab er 24hr LYRICA CAP 25MG QL (120 caps / 30 LYRICA CAP 50MG QL (120 caps / 30 LYRICA CAP 75MG QL (120 caps / 30 LYRICA CAP 100MG QL (120 caps / 30 LYRICA CAP 150MG QL (120 caps / 30 LYRICA CAP 200MG QL (90 caps / 30 ED - Excluido GC - Cobertura de Brecha 29

36 LYRICA CAP 225MG QL (60 caps / 30 LYRICA CAP 300MG QL (60 caps / 30 LYRICA SOL 20MG/ML QL (946 ml / 30 ONFI SUS 2.5MG/ML 5 PA ONFI TAB 10MG 4 PA ONFI TAB 20MG 5 PA oxcarbazepine susp /5ml (60 /ml) oxcarbazepine tab oxcarbazepine tab oxcarbazepine tab PEGANONE TAB 250MG 4 PHENOBARB INJ 65MG/ML 4 phenobarbital elixir 20 /5ml 2 GC phenobarbital sodium inj GC /ml phenobarbital tab 15 2 GC phenobarbital tab GC phenobarbital tab 30 2 GC phenobarbital tab GC phenobarbital tab 60 2 GC phenobarbital tab GC phenobarbital tab GC phenobarbital tab GC phenytek cap phenytek cap phenytoin chew tab 50 3 phenytoin sodium extended 3 cap 100 phenytoin sodium extended 3 cap 200 phenytoin sodium extended 3 cap 300 phenytoin sodium inj 50 3 /ml phenytoin susp 125 /5ml 3 POTIGA TAB 50MG 4 POTIGA TAB 200MG 5 QL QL (180 tabs / 30 POTIGA TAB 300MG QL (90 tabs / 30 5 QL POTIGA TAB 400MG 5 QL QL (90 tabs / 30 primidone tab 50 2 GC primidone tab GC roweepra tab roweepra tab roweepra tab SABRIL POW 500MG 5 QL LA PA QL (180 packets / 30 SABRIL TAB 500MG 5 QL LA PA QL (180 tabs / 30 SPRITAM TAB 250MG 4 SPRITAM TAB 500MG 4 SPRITAM TAB 750MG 4 SPRITAM TAB 1000MG 4 TEGRETOL SUS 100/5ML 4 TEGRETOL TAB 200MG 4 TEGRETOL-XR TAB 100MG 4 TEGRETOL-XR TAB 200MG 4 TEGRETOL-XR TAB 400MG 4 tiagabine hcl tab 2 4 tiagabine hcl tab 4 4 topiramate sprinkle cap 15 4 topiramate sprinkle cap 25 4 topiramate tab 25 2 GC topiramate tab 50 2 GC topiramate tab GC topiramate tab GC valproate sodium inj /ml valproate sodium oral soln 2 GC 250 /5ml (base equiv) valproic acid cap VIMPAT INJ 200MG/20 4 VIMPAT SOL 10MG/ML QL (1200 ml / 30 VIMPAT TAB 50MG QL (180 tabs / 30 VIMPAT TAB 100MG VIMPAT TAB 150MG ED - Excluido GC - Cobertura de Brecha 30

37 VIMPAT TAB 200MG zonisamide cap 25 3 zonisamide cap 50 3 zonisamide cap Contra la demencia donepezil hydrochloride orally disintegrating tab 5 donepezil hydrochloride orally 3 disintegrating tab 10 donepezil hydrochloride tab 5 2 GC QL donepezil hydrochloride tab 2 GC 10 donepezil hydrochloride tab 4 23 galantamine hydrobromide cap er 24hr 8 QL (30 caps / 30 galantamine hydrobromide cap er 24hr 16 QL (30 caps / 30 galantamine hydrobromide 4 cap er 24hr 24 galantamine hydrobromide 4 oral soln 4 /ml galantamine hydrobromide tab 4 QL (180 tabs / 30 galantamine hydrobromide tab 8 QL (90 tabs / 30 galantamine hydrobromide 4 tab 12 memantine hcl oral solution 2 3 PA /ml PA if < 30 yrs memantine hcl tab 5 4 PA PA if < 30 yrs MEMANTINE HCL TAB 10 4 PA MG PA if < 30 yrs NAMENDA XR CAP 7MG PA if < 30 yrs 4 PA NAMENDA XR CAP 14MG 4 PA PA if < 30 yrs NAMENDA XR CAP 21MG 4 PA PA if < 30 yrs NAMENDA XR CAP 28MG 4 PA PA if < 30 yrs NAMENDA XR CAP 4 PA TITRATIO PA if < 30 yrs NAMZARIC CAP 4 NAMZARIC CAP 7-10MG 4 NAMZARIC CAP 14-10MG 4 NAMZARIC CAP 21-10MG 4 NAMZARIC CAP 28-10MG 4 rivastigmine tartrate cap rivastigmine tartrate cap 3 4 rivastigmine tartrate cap rivastigmine tartrate cap 6 4 rivastigmine td patch 24hr 4.6 /24hr QL (30 patches / 30 rivastigmine td patch 24hr 9.5 /24hr QL (30 patches / 30 rivastigmine td patch 24hr 13.3 /24hr QL (30 patches / 30 Antidepresivos amitriptyline hcl tab 10 2 GC amitriptyline hcl tab 25 2 GC amitriptyline hcl tab 50 2 GC amitriptyline hcl tab 75 2 GC amitriptyline hcl tab GC amitriptyline hcl tab GC amoxapine tab 25 3 amoxapine tab 50 3 amoxapine tab amoxapine tab bupropion hcl tab 75 3 bupropion hcl tab ED - Excluido GC - Cobertura de Brecha 31

38 bupropion hcl tab er 12hr GC bupropion hcl tab er 12hr GC bupropion hcl tab er 12hr GC bupropion hcl tab er 24hr 150 QL (90 tabs / 30 bupropion hcl tab er 24hr 300 citalopram hydrobromide oral 4 soln 10 /5ml citalopram hydrobromide tab QL 10 (base equiv) QL (45 tabs / 30 citalopram hydrobromide tab QL 20 (base equiv) QL (45 tabs / 30 citalopram hydrobromide tab QL 40 (base equiv) clomipramine hcl cap 25 2 GC clomipramine hcl cap 50 2 GC clomipramine hcl cap 75 2 GC desipramine hcl tab 10 4 desipramine hcl tab 25 4 desipramine hcl tab 50 4 desipramine hcl tab 75 4 desipramine hcl tab desipramine hcl tab desvenlafaxine succinate tab er 24hr 25 (base equiv) desvenlafaxine succinate tab er 24hr 50 (base equiv) desvenlafaxine succinate tab er 24hr 100 (base equiv) doxepin hcl cap 10 2 GC doxepin hcl cap 25 2 GC doxepin hcl cap 50 2 GC doxepin hcl cap 75 2 GC doxepin hcl cap GC doxepin hcl cap GC doxepin hcl conc 10 /ml 2 GC duloxetine hcl enteric coated pellets cap 20 QL (180 caps / 30 duloxetine hcl enteric coated pellets cap 30 QL (120 caps / 30 duloxetine hcl enteric coated pellets cap 60 QL (60 caps / 30 EMSAM DIS 6MG/24HR 5 QL PA QL (30 patches / 30 EMSAM DIS 9MG/24HR 5 QL PA QL (30 patches / 30 EMSAM DIS 12MG/24H 5 QL PA QL (30 patches / 30 escitalopram oxalate soln 5 /5ml (base equiv) QL (600 ml / 30 escitalopram oxalate tab 5 2 GC QL (base equiv) QL (45 tabs / 30 escitalopram oxalate tab 10 2 GC QL (base equiv) QL (45 tabs / 30 escitalopram oxalate tab 20 2 GC QL (base equiv) FETZIMA CAP 20MG QL (180 caps / 30 FETZIMA CAP 40MG QL (90 caps / 30 FETZIMA CAP 80MG QL (30 caps / 30 FETZIMA CAP 120MG QL (30 caps / 30 FETZIMA CAP TITRATIO 4 fluoxetine hcl cap 10 QL QL (30 caps / 30 fluoxetine hcl cap 20 QL (120 caps / 30 QL ED - Excluido GC - Cobertura de Brecha 32

39 fluoxetine hcl cap 40 fluoxetine hcl solution 20 3 /5ml fluoxetine hcl tab 10 QL (45 tabs / 30 fluoxetine hcl tab 20 4 imipramine hcl tab 10 2 GC imipramine hcl tab 25 2 GC imipramine hcl tab 50 2 GC maprotiline hcl tab 25 4 maprotiline hcl tab 50 4 maprotiline hcl tab 75 4 MARPLAN TAB 10MG QL (180 tabs / 30 mirtazapine orally disintegrating tab 15 mirtazapine orally 3 disintegrating tab 30 mirtazapine orally 3 disintegrating tab 45 mirtazapine tab GC QL QL (45 tabs / 30 mirtazapine tab 15 2 GC QL QL (45 tabs / 30 mirtazapine tab 30 2 GC mirtazapine tab 45 2 GC nefazodone hcl tab 50 4 nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab nortriptyline hcl cap 10 nortriptyline hcl cap 25 nortriptyline hcl cap 50 nortriptyline hcl cap 75 nortriptyline hcl soln 10 4 /5ml paroxetine hcl tab 10 QL QL (45 tabs / 30 paroxetine hcl tab 20 QL QL (45 tabs / 30 paroxetine hcl tab 30 QL paroxetine hcl tab 40 QL QL (45 tabs / 30 PAXIL SUS 10MG/5ML QL (900 ml / 30 phenelzine sulfate tab 15 3 PRISTIQ TAB 25MG PRISTIQ TAB 50MG PRISTIQ TAB 100MG protriptyline hcl tab 5 4 protriptyline hcl tab 10 4 sertraline hcl oral conc 20 4 /ml sertraline hcl tab 25 QL QL (45 tabs / 30 sertraline hcl tab 50 QL QL (45 tabs / 30 sertraline hcl tab 100 tranylcypromine sulfate tab 10 4 trazodone hcl tab 50 trazodone hcl tab 100 trazodone hcl tab 150 trimipramine maleate cap 25 2 GC QL QL (240 caps / 30 trimipramine maleate cap 50 2 GC QL QL (120 caps / 30 trimipramine maleate cap GC QL QL (60 caps / 30 TRINTELLIX TAB 5MG QL (120 tabs / 30 TRINTELLIX TAB 10MG TRINTELLIX TAB 20MG venlafaxine hcl cap er 24hr 2 GC QL 37.5 (base equivalent) QL (30 caps / 30 venlafaxine hcl cap er 24hr 75 (base equivalent) QL (90 ea / 30 2 GC QL ED - Excluido GC - Cobertura de Brecha 33

40 venlafaxine hcl cap er 24hr 150 (base equivalent) QL (60 caps / 30 venlafaxine hcl tab 25 3 venlafaxine hcl tab venlafaxine hcl tab 50 3 venlafaxine hcl tab 75 3 venlafaxine hcl tab VIIBRYD KIT STARTER 4 2 GC QL VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG Antiparkinsonianos amantadine hcl cap 100 QL (120 caps / 30 amantadine hcl syrup 50 2 GC /5ml amantadine hcl tab APOKYN INJ 10MG/ML 5 LA PA AZILECT TAB 0.5MG 3 AZILECT TAB 1MG 3 BENZTROPINE MESYLATE 3 INJ 1 MG/ML benztropine mesylate tab GC benztropine mesylate tab 1 2 GC benztropine mesylate tab 2 2 GC bromocriptine mesylate cap 5 4 (base equivalent) bromocriptine mesylate tab (base equivalent) carbidopa & levodopa orally 4 disintegrating tab carbidopa & levodopa orally 4 disintegrating tab carbidopa & levodopa orally 4 disintegrating tab carbidopa & levodopa tab GC carbidopa & levodopa tab 25-2 GC 100 carbidopa & levodopa tab 25-2 GC 250 carbidopa & levodopa tab er carbidopa & levodopa tab er carbidopa tab 25 2 GC CARBIDOPA-LEVODOPA- 4 ENTACAPONE TABS MG CARBIDOPA-LEVODOPA- 4 ENTACAPONE TABS MG CARBIDOPA-LEVODOPA- 4 ENTACAPONE TABS MG CARBIDOPA-LEVODOPA- 4 ENTACAPONE TABS MG CARBIDOPA-LEVODOPA- 4 ENTACAPONE TABS MG CARBIDOPA-LEVODOPA- 4 ENTACAPONE TABS MG ENTACAPONE TAB 200 MG 4 NEUPRO DIS 1MG/24HR 4 NEUPRO DIS 2MG/24HR 4 NEUPRO DIS 3MG/24HR 4 NEUPRO DIS 4MG/24HR 4 NEUPRO DIS 6MG/24HR 4 NEUPRO DIS 8MG/24HR 4 pramipexole dihydrochloride 2 GC tab 0.5 pramipexole dihydrochloride 2 GC tab 0.25 pramipexole dihydrochloride 2 GC tab 0.75 pramipexole dihydrochloride 2 GC tab pramipexole dihydrochloride tab 1 2 GC ED - Excluido GC - Cobertura de Brecha 34

41 pramipexole dihydrochloride 2 GC tab 1.5 rasagiline mesylate tab (base equiv) rasagiline mesylate tab 1 3 (base equiv) ropinirole hydrochloride tab 2 GC 0.5 ropinirole hydrochloride tab 2 GC 0.25 ropinirole hydrochloride tab 1 2 GC ropinirole hydrochloride tab 2 2 GC ropinirole hydrochloride tab 3 2 GC ropinirole hydrochloride tab 4 2 GC ropinirole hydrochloride tab 5 2 GC selegiline hcl cap 5 4 selegiline hcl tab 5 4 trihexyphenidyl hcl elixir GC /ml trihexyphenidyl hcl tab 2 2 GC trihexyphenidyl hcl tab 5 2 GC Antipsicóticos ABILIFY MAIN INJ 300MG 5 QL QL (1 syringe / 28 ABILIFY MAIN INJ 300MG 5 QL QL (1 vial / 28 ABILIFY MAIN INJ 400MG 5 QL QL (1 syringe / 28 ABILIFY MAIN INJ 400MG 5 QL QL (1 vial / 28 aripiprazole oral solution 1 5 QL /ml QL (900 ml / 30 aripiprazole orally 5 QL disintegrating tab 10 aripiprazole orally 5 QL disintegrating tab 15 aripiprazole tab 2 aripiprazole tab 5 aripiprazole tab 10 aripiprazole tab 15 aripiprazole tab 20 5 QL aripiprazole tab 30 5 QL ARISTADA INJ 441MG/1. 5 QL QL (1 syringe / 28 ARISTADA INJ 662MG/2 5 QL QL (1 syringe / 28 ARISTADA INJ 882MG/3 5 QL QL (1 syringe / 28 chlorpromaz inj 25/ml 4 chlorpromaz inj 50/2ml 4 chlorpromazine hcl tab 10 4 chlorpromazine hcl tab 25 4 chlorpromazine hcl tab 50 4 chlorpromazine hcl tab chlorpromazine hcl tab CLOZAPINE ORALLY 4 PA DISINTEGRATING TAB 12.5 MG CLOZAPINE ORALLY 4 PA DISINTEGRATING TAB 25 MG CLOZAPINE ORALLY PA DISINTEGRATING TAB 100 MG QL (270 tabs / 30 CLOZAPINE ORALLY PA DISINTEGRATING TAB 150 MG QL (180 tabs / 30 CLOZAPINE ORALLY 5 QL PA DISINTEGRATING TAB 200 MG QL (135 tabs / 30 clozapine tab 25 3 clozapine tab 50 3 ED - Excluido GC - Cobertura de Brecha 35

42 clozapine tab 100 QL (270 tabs / 30 clozapine tab 200 QL (135 tabs / 30 FANAPT PAK 4 FANAPT TAB 1MG FANAPT TAB 2MG FANAPT TAB 4MG FANAPT TAB 6MG 5 QL FANAPT TAB 8MG 5 QL FANAPT TAB 10MG 5 QL FANAPT TAB 12MG 5 QL fluphenazine decanoate inj 25 4 /ml fluphenazine hcl elixir /5ml fluphenazine hcl inj 2.5 /ml 4 fluphenazine hcl oral conc 5 4 /ml fluphenazine hcl tab 1 2 GC fluphenazine hcl tab GC fluphenazine hcl tab 5 2 GC fluphenazine hcl tab 10 2 GC GEODON INJ 20MG QL (6 ml / 3 haloperidol decanoate im soln 3 50 /ml haloperidol decanoate im soln /ml haloperidol lactate inj 5 /ml 3 haloperidol lactate oral conc 2 3 /ml haloperidol tab haloperidol tab 1 3 haloperidol tab 2 3 haloperidol tab 5 3 haloperidol tab 10 3 haloperidol tab 20 3 INVEGA SUST INJ 39/0.25 QL (1 injection / 28 INVEGA SUST INJ 78/0.5ML QL (1 injection / 28 INVEGA SUST INJ 117/0.75 QL (1 injection / 28 INVEGA SUST INJ 156MG/ML QL (1 injection / 28 INVEGA SUST INJ 234/1.5 QL (1 injection / 28 INVEGA TRINZ INJ 273MG QL (1 syringe / 90 INVEGA TRINZ INJ 410MG QL (1 syringe / 90 INVEGA TRINZ INJ 546MG QL (1 syringe / 90 INVEGA TRINZ INJ 819MG QL (1 syringe / 90 LATUDA TAB 20MG QL (240 tabs / 30 LATUDA TAB 40MG LATUDA TAB 60MG LATUDA TAB 80MG LATUDA TAB 120MG loxapine succinate cap 5 3 loxapine succinate cap 10 3 loxapine succinate cap 25 3 loxapine succinate cap 50 3 molindone hcl tab 5 4 molindone hcl tab 10 4 molindone hcl tab 25 4 NUPLAZID TAB 17MG olanzapine for im inj 10 QL (3 vials / 1 day) 5 QL 5 QL 5 QL 5 QL 5 QL 5 QL 5 QL 5 QL 5 QL LA PA ED - Excluido GC - Cobertura de Brecha 36

43 olanzapine orally disintegrating tab 5 olanzapine orally disintegrating tab 10 olanzapine orally disintegrating tab 15 olanzapine orally disintegrating tab 20 olanzapine tab 2.5 QL (240 tabs / 30 olanzapine tab 5 QL (120 tabs / 30 olanzapine tab 7.5 olanzapine tab 10 olanzapine tab 15 olanzapine tab 20 paliperidone tab er 24hr 1.5 paliperidone tab er 24hr 3 paliperidone tab er 24hr 6 paliperidone tab er 24hr 9 perphenazine tab 2 4 perphenazine tab 4 4 perphenazine tab 8 4 perphenazine tab 16 4 pimozide tab 1 4 pimozide tab 2 4 quetiapine fumarate tab 25 QL (90 tabs / 30 quetiapine fumarate tab 50 QL (90 tabs / 30 5 QL 5 QL 5 QL 5 QL quetiapine fumarate tab 100 QL (90 tabs / 30 quetiapine fumarate tab 200 QL (90 tabs / 30 quetiapine fumarate tab 300 QL (90 tabs / 30 quetiapine fumarate tab 400 QL (90 tabs / 30 quetiapine fumarate tab er 24hr 50 QL (120 tabs / 30 quetiapine fumarate tab er 24hr 150 quetiapine fumarate tab er 24hr 200 quetiapine fumarate tab er 24hr 300 quetiapine fumarate tab er 24hr 400 REXULTI TAB 0.5MG QL (180 tabs / 30 REXULTI TAB 0.25MG QL (360 tabs / 30 REXULTI TAB 1MG QL (90 tabs / 30 REXULTI TAB 2MG REXULTI TAB 3MG REXULTI TAB 4MG RISPERDAL INJ 12.5MG QL (2 injections / 28 RISPERDAL INJ 25MG QL (2 injections / 28 5 QL 5 QL 5 QL 5 QL 5 QL 5 QL ED - Excluido GC - Cobertura de Brecha 37

44 RISPERDAL INJ 37.5MG QL (2 injections / 28 RISPERDAL INJ 50MG QL (2 injections / 28 risperidone orally disintegrating tab 0.5 QL (90 tabs / 30 risperidone orally disintegrating tab 0.25 QL (90 tabs / 30 risperidone orally disintegrating tab 1 risperidone orally disintegrating tab 2 risperidone orally disintegrating tab 3 risperidone orally disintegrating tab 4 QL (120 tabs / 30 risperidone soln 1 /ml QL (240 ml / 30 risperidone tab 0.5 QL (90 tabs / 30 risperidone tab 0.25 QL (90 tabs / 30 risperidone tab 1 risperidone tab 2 risperidone tab 3 risperidone tab 4 QL (120 tabs / 30 SAPHRIS SUB 2.5MG QL (240 tabs / 30 SAPHRIS SUB 5MG QL (120 tabs / 30 SAPHRIS SUB 10MG SEROQUEL XR TAB 200MG 5 QL 5 QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL 2 GC QL SEROQUEL XR TAB 300MG thioridazine hcl tab 10 2 GC thioridazine hcl tab 25 2 GC thioridazine hcl tab 50 2 GC thioridazine hcl tab GC thiothixene cap 1 4 thiothixene cap 2 4 thiothixene cap 5 4 thiothixene cap 10 4 trifluoperazine hcl tab 1 4 trifluoperazine hcl tab 2 4 trifluoperazine hcl tab 5 4 trifluoperazine hcl tab 10 4 VERSACLOZ SUS 50MG/ML 5 QL PA QL (600 ml / 30 VRAYLAR CAP 1.5-3MG 4 VRAYLAR CAP 1.5MG 5 QL QL (120 caps / 30 VRAYLAR CAP 3MG 5 QL QL (60 caps / 30 VRAYLAR CAP 4.5MG 5 QL QL (30 caps / 30 VRAYLAR CAP 6MG 5 QL QL (30 caps / 30 ziprasidone hcl cap 20 QL (60 caps / 30 ziprasidone hcl cap 40 QL (60 caps / 30 ziprasidone hcl cap 60 QL (90 caps / 30 ziprasidone hcl cap 80 QL (90 caps / 30 ZYPREXA RELP INJ 210MG PA QL (2 vials / 28 ZYPREXA RELP INJ 300MG 5 QL PA QL (2 vials / 28 ZYPREXA RELP INJ 405MG QL (1 vial / 28 5 QL PA Trastorno por déficit de atención e hiperactividad amphetaminedextroamphetamine cap er 24hr 5 QL (90 caps / 30 ED - Excluido GC - Cobertura de Brecha 38

45 amphetaminedextroamphetamine cap er 24hr 10 QL (90 caps / 30 amphetaminedextroamphetamine cap er 24hr 15 QL (30 caps / 30 amphetaminedextroamphetamine cap er 24hr 20 QL (30 caps / 30 amphetaminedextroamphetamine cap er 24hr 25 QL (30 caps / 30 amphetaminedextroamphetamine cap er 24hr 30 QL (30 caps / 30 amphetaminedextroamphetamine tab 5 QL (360 tabs / 30 amphetaminedextroamphetamine tab 7.5 QL (240 tabs / 30 amphetaminedextroamphetamine tab 10 QL (180 tabs / 30 amphetaminedextroamphetamine tab 12.5 QL (144 tabs / 30 amphetaminedextroamphetamine tab 15 QL (120 tabs / 30 amphetaminedextroamphetamine tab 20 QL (90 tabs / 30 amphetaminedextroamphetamine tab 30 atomoxetine hcl cap 10 (base equiv) QL (120 caps / 30 atomoxetine hcl cap 18 (base equiv) QL (120 caps / 30 atomoxetine hcl cap 25 (base equiv) QL (120 caps / 30 atomoxetine hcl cap 40 (base equiv) QL (60 caps / 30 atomoxetine hcl cap 60 (base equiv) QL (30 caps / 30 atomoxetine hcl cap 80 (base equiv) QL (30 caps / 30 atomoxetine hcl cap 100 (base equiv) QL (30 caps / 30 dextroamphetamine sulfate cap er 24hr 5 QL (180 caps / 30 dextroamphetamine sulfate cap er 24hr 10 QL (180 caps / 30 dextroamphetamine sulfate cap er 24hr 15 QL (120 caps / 30 dextroamphetamine sulfate tab 5 QL (180 tabs / 30 dextroamphetamine sulfate tab 10 QL (180 tabs / 30 guanfacine hcl tab er 24hr 1 (base equiv) guanfacine hcl tab er 24hr 2 (base equiv) guanfacine hcl tab er 24hr 3 (base equiv) guanfacine hcl tab er 24hr 4 (base equiv) 2 GC 2 GC 2 GC 2 GC ED - Excluido GC - Cobertura de Brecha 39

46 methylphenidate hcl soln 5 /5ml QL (1800 ml / 30 methylphenidate hcl soln 10 /5ml QL (900 ml / 30 methylphenidate hcl tab 5 QL (180 tabs / 30 methylphenidate hcl tab 10 QL (180 tabs / 30 methylphenidate hcl tab 20 QL (90 tabs / 30 methylphenidate hcl tab er 10 QL (90 tabs / 30 methylphenidate hcl tab er 20 QL (90 tabs / 30 STRATTERA CAP 10MG QL (120 caps / 30 STRATTERA CAP 18MG QL (120 caps / 30 STRATTERA CAP 25MG QL (120 caps / 30 STRATTERA CAP 40MG QL (60 caps / 30 STRATTERA CAP 60MG QL (30 caps / 30 STRATTERA CAP 80MG QL (30 caps / 30 STRATTERA CAP 100MG QL (30 caps / 30 Hipnóticos estazolam tab 1 2 GC estazolam tab 2 2 GC eszopiclone tab 1 2 GC QL QL (90 tabs / 30 eszopiclone tab 2 2 GC QL eszopiclone tab 3 2 GC QL HETLIOZ CAP 20MG 5 LA PA SILENOR TAB 3MG SILENOR TAB 6MG temazepam cap GC QL QL (30 caps / 30 temazepam cap 15 2 GC QL QL (60 caps / 30 temazepam cap 30 2 GC QL QL (30 caps / 30 zaleplon cap 5 2 GC zaleplon cap 10 2 GC zolpidem tartrate tab 5 2 GC QL zolpidem tartrate tab 10 2 GC QL zolpidem tartrate tab er GC QL zolpidem tartrate tab er GC QL Migraña dihydroergotamine mesylate 3 inj 1 /ml ergotamine w/ caffeine tab migergot sup 2/100 5 naratriptan hcl tab 1 (base equiv) QL (12 tabs / 30 naratriptan hcl tab 2.5 (base equiv) QL (12 tabs / 30 RELPAX TAB 20MG QL (12 tabs / 30 RELPAX TAB 40MG QL (12 tabs / 30 rizatriptan benzoate oral disintegrating tab 5 (base eq) QL (18 tabs / 30 rizatriptan benzoate oral disintegrating tab 10 (base eq) QL (18 tabs / 30 ED - Excluido GC - Cobertura de Brecha 40

47 rizatriptan benzoate tab 5 (base equivalent) QL (18 tabs / 30 rizatriptan benzoate tab 10 (base equivalent) QL (18 tabs / 30 SUMATRIPTAN NASAL SPRAY 5 MG/ACT QL (24 inhalers / 30 SUMATRIPTAN NASAL SPRAY 20 MG/ACT QL (12 inhalers / 30 sumatriptan succinate inj 6 /0.5ml QL (12 injections / 30 SUMATRIPTAN SUCCINATE SOLUTION AUTO- INJECTOR 4 MG/0.5ML QL (18 injections / 30 sumatriptan succinate solution auto-injector 6 /0.5ml QL (12 injections / 30 SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML QL (18 injections / 30 sumatriptan succinate solution cartridge 6 /0.5ml QL (12 injections / 30 sumatriptan succinate solution prefilled syringe 6 /0.5ml QL (12 injections / 30 sumatriptan succinate tab 25 2 GC QL QL (12 tabs / 30 sumatriptan succinate tab 50 QL (12 tabs / 30 2 GC QL sumatriptan succinate tab GC QL QL (12 tabs / 30 zolmitriptan orally disintegrating tab 2.5 QL (12 tabs / 30 zolmitriptan orally disintegrating tab 5 QL (12 tabs / 30 zolmitriptan tab 2.5 QL (12 tabs / 30 zolmitriptan tab 5 QL (12 tabs / 30 Misceláneos lithium carbonate cap 150 lithium carbonate cap 300 lithium carbonate cap 600 lithium carbonate tab GC lithium carbonate tab er GC lithium carbonate tab er GC LITHIUM SOL 8MEQ/5ML 3 NUEDEXTA CAP 20-10MG 4 PA pyridostigmine bromide tab 60 3 riluzole tab 50 3 TETRABENAZINE TAB QL PA MG QL (240 tabs / 30 TETRABENAZINE TAB 25 MG QL (120 tabs / 30 5 QL PA Agentes para la esclerosis múltiple AMPYRA TAB 10MG 5 LA PA AVONEX KIT 30MCG 5 PA AVONEX PEN KIT 30MCG 5 PA AVONEX PREFL KIT 30MCG 5 PA BETASERON INJ 0.3MG 5 QL PA QL (14 syringes / 28 COPAXONE INJ 20MG/ML QL (30 syringes / 30 5 QL PA ED - Excluido GC - Cobertura de Brecha 41

48 COPAXONE INJ 40MG/ML QL (12 syringes / 28 GILENYA CAP 0.5MG QL (28 caps / 28 glatopa inj 20/ml QL (30 syringes / 30 5 QL PA 5 QL PA 5 QL PA REBIF INJ 22/0.5 5 PA REBIF INJ 44/0.5 5 PA REBIF REBIDO INJ 44/0.5 5 PA REBIF TITRTN INJ PACK 5 PA TYSABRI INJ 300/15ML 5 LA PA Agentes para la terapia musculoesqueletal baclofen tab 10 2 GC baclofen tab 20 2 GC carisoprodol tab GC chlorzoxazone tab GC cyclobenzaprine hcl tab 5 2 GC cyclobenzaprine hcl tab 10 2 GC dantrolene sodium cap 25 4 dantrolene sodium cap 50 4 dantrolene sodium cap metaxalone tab GC metaxalone tab GC methocarbamol tab GC methocarbamol tab GC orphenadrine citrate tab er 12hr 100 tizanidine hcl cap 2 (base equivalent) tizanidine hcl cap 4 (base equivalent) tizanidine hcl cap 6 (base equivalent) tizanidine hcl tab 2 (base equivalent) tizanidine hcl tab 4 (base equivalent) Narcolepsia/cataplejía armodafinil tab 50 QL (150 tabs / 30 2 GC armodafinil tab 150 PA ARMODAFINIL TAB 200 MG PA armodafinil tab 250 PA XYREM SOL 500MG/ML QL (540 ml / 30 5 QL LA PA Psicoterapéuticos / Misceláneos acamprosate calcium tab 4 delayed release 333 buprenorphine hcl sl tab 2 3 PA (base equiv) buprenorphine hcl sl tab 8 3 PA (base equiv) buprenorphine hcl-naloxone PA hcl sl tab (base equiv) QL (120 tabs / 30 buprenorphine hcl-naloxone PA hcl sl tab 8-2 (base equiv) QL (120 tabs / 30 bupropion hcl (smoking 3 deterrent) tab er 12hr 150 butalbital-acetaminophen tab 2 GC butalbital-acetaminophen-caff 2 GC w/ cod cap butalbital-acetaminophen-caff 2 GC w/ cod cap butalbital-acetaminophencaffeine 2 GC cap butalbital-acetaminophencaffeine 2 GC cap butalbital-acetaminophencaffeine 2 GC tab butalbital-aspirin-caffeine cap 2 GC GC CHANTIX PAK 0.5& 1MG 4 PA CHANTIX PAK 1MG 4 PA 2 GC CHANTIX TAB 0.5MG 4 PA CHANTIX TAB 1MG 4 PA disulfiram tab PA disulfiram tab naloxone hcl inj 0.4 /ml 3 naloxone hcl inj 4 /10ml 3 ED - Excluido GC - Cobertura de Brecha 42

49 naloxone hcl soln cartridge /ml naloxone hcl soln prefilled 3 syringe 2 /2ml naltrexone hcl tab 50 3 NICOTROL INH 4 NICOTROL NS SPR 4 10MG/ML perphenazine-amitriptyline tab 2 GC 2-10 perphenazine-amitriptyline tab 2 GC 2-25 perphenazine-amitriptyline tab 2 GC 4-10 perphenazine-amitriptyline tab 2 GC 4-25 perphenazine-amitriptyline tab 2 GC 4-50 SUBOXONE MIS 2-0.5MG PA QL (120 SL films / 30 SUBOXONE MIS 4-1MG PA QL (120 SL films / 30 SUBOXONE MIS 8-2MG PA QL (120 SL films / 30 SUBOXONE MIS 12-3MG PA QL (60 SL films / 30 Endocrino y metabólico Andrógenos ANADROL-50 TAB 50MG 5 PA ANDRODERM DIS PA 2MG/24HR QL (30 patches / 30 ANDRODERM DIS PA 4MG/24HR QL (30 patches / 30 AXIRON SOL 30MG/ACT PA QL (440 ml / 30 oxandrolone tab PA oxandrolone tab 10 3 PA testosterone cypionate im inj 3 PA in oil 100 /ml testosterone cypionate im inj 3 PA in oil 200 /ml testosterone enanthate im inj 3 PA in oil 200 /ml Antidiabéticos, inyectables ALCOHOL SWABS 3 BYDUREON INJ 2MG QL (4 vials / 28 BYDUREON PEN INJ 2MG QL (4 pens / 28 BYETTA INJ 5MCG QL (1 pen / 30 BYETTA INJ 10MCG QL (1 pen / 30 GAUZE PADS 2" X 2" 3 HUMULIN R INJ U HUMULIN R INJ U B/D INSULIN PEN NEEDLE 3 INSULIN SAFETY NEEDLES 3 INSULIN SYRINGE 3 LANTUS INJ 100/ML 3 LANTUS INJ SOLOSTAR 3 LEVEMIR INJ 3 LEVEMIR INJ FLEXTOUC 3 NOVOLIN INJ 70/30 3 (brand RELION not covered) NOVOLIN N INJ U (brand RELION not covered) NOVOLIN R INJ U (brand RELION not covered) NOVOLOG INJ 100/ML 3 NOVOLOG INJ FLEXPEN 3 NOVOLOG INJ PENFILL 3 NOVOLOG MIX INJ 70/30 3 NOVOLOG MIX INJ 3 FLEXPEN SYMLINPEN 60 INJ 1000MCG QL (8 pens / 30 5 QL PA ED - Excluido GC - Cobertura de Brecha 43

50 SYMLNPEN 120 INJ 1000MCG QL (4 pens / 30 TOUJEO SOLO INJ 300IU/ML 5 QL PA TRESIBA FLEX INJ 100UNIT 3 TRESIBA FLEX INJ 200UNIT 3 TRULICITY INJ 0.75/0.5 QL (4 pens / 28 TRULICITY INJ 1.5/0.5 QL (4 pens / 28 VICTOZA INJ 18MG/3ML QL (3 pens / 30 Antidiabéticos, orales acarbose tab 25 3 acarbose tab 50 3 acarbose tab AVANDIA TAB 2MG AVANDIA TAB 4MG FARXIGA TAB 5MG FARXIGA TAB 10MG glimepiride tab 1 QL (240 tabs / 30 glimepiride tab 2 QL (120 tabs / 30 glimepiride tab 4 glipizide tab 5 QL (240 tabs / 30 glipizide tab 10 QL (120 tabs / 30 glipizide tab er 24hr 2.5 QL (240 tabs / 30 GLIPIZIDE TAB ER 24HR 2.5 MG QL (240 tabs / 30 glipizide tab er 24hr 5 QL (120 tabs / 30 glipizide tab er 24hr 10 3 QL QL QL QL QL QL QL QL QL GLIPIZIDE XL TAB 5MG QL QL (120 tabs / 30 glipizide-metformin hcl tab QL QL (240 tabs / 30 glipizide-metformin hcl tab QL QL (120 tabs / 30 glipizide-metformin hcl tab 5- QL 500 QL (120 tabs / 30 glyburide micronized tab GC QL QL (240 tabs / 30 glyburide micronized tab 3 2 GC QL QL (120 tabs / 30 glyburide micronized tab 6 2 GC QL glyburide tab GC QL QL (480 tabs / 30 glyburide tab GC QL QL (240 tabs / 30 glyburide tab 5 2 GC QL QL (120 tabs / 30 glyburide-metformin tab GC QL 250 QL (240 tabs / 30 glyburide-metformin tab GC QL 500 QL (120 tabs / 30 glyburide-metformin tab GC QL QL (120 tabs / 30 INVOKAMET TAB MG QL (120 tabs / 30 INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB INVOKAMET XR TAB MG QL (120 tabs / 30 ED - Excluido GC - Cobertura de Brecha 44

51 INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB INVOKANA TAB 100MG QL (90 tabs / 30 INVOKANA TAB 300MG JANUMET TAB MG JANUMET TAB JANUMET XR TAB MG JANUMET XR TAB JANUMET XR TAB JANUVIA TAB 25MG JANUVIA TAB 50MG JANUVIA TAB 100MG JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB XR JENTADUETO TAB XR metformin hcl tab 500 QL (150 tabs / 30 metformin hcl tab 850 QL (90 tabs / 30 metformin hcl tab 1000 QL (75 tabs / 30 QL QL QL metformin hcl tab er 24hr 500 QL QL (120 tabs / 30 (generic of GLUCOPHAGE XR) metformin hcl tab er 24hr 750 QL (generic of GLUCOPHAGE XR) nateglinide tab 60 QL QL (90 tabs / 30 nateglinide tab 120 QL QL (90 tabs / 30 ONGLYZA TAB 2.5MG ONGLYZA TAB 5MG pioglitazone hcl tab 15 QL (base equiv) pioglitazone hcl tab 30 QL (base equiv) pioglitazone hcl tab 45 QL (base equiv) pioglitazone hcl-metformin hcl 4 tab pioglitazone hcl-metformin hcl 4 tab repaglinide tab 0.5 QL QL (120 tabs / 30 repaglinide tab 1 QL QL (120 tabs / 30 repaglinide tab 2 QL QL (240 tabs / 30 TRADJENTA TAB 5MG XIGDUO XR TAB 5-500MG XIGDUO XR TAB MG XIGDUO XR TAB MG ED - Excluido GC - Cobertura de Brecha 45

52 XIGDUO XR TAB Bifosfonatos ACTONEL TAB 5MG 4 ACTONEL TAB 30MG 4 ACTONEL TAB 35MG 4 ACTONEL TAB 150MG 4 alendronate sodium tab 5 alendronate sodium tab 10 alendronate sodium tab 35 QL QL (4 tabs / 28 alendronate sodium tab 40 alendronate sodium tab 70 QL QL (4 tabs / 28 ibandronate sodium tab GC (base equivalent) pamidronate disodium for inj 3 B/D 30 pamidronate disodium for inj 3 B/D 90 pamidronate disodium iv soln 3 B/D 3 /ml pamidronate disodium iv soln 3 B/D 9 /ml pamidronate inj 6/ml 3 B/D risedronate sodium tab 5 2 GC risedronate sodium tab 30 2 GC risedronate sodium tab 35 2 GC risedronate sodium tab GC risedronate sodium tab 2 GC delayed release 35 zoledronic acid inj conc for iv 4 B/D infusion 4 /5ml zoledronic acid iv soln 5 4 B/D /100ml zoledronic inj 4 4 B/D Agonistas de los receptores de calcio SENSIPAR TAB 30MG QL (120 tabs / 30 SENSIPAR TAB 60MG 5 QL SENSIPAR TAB 90MG 5 QL QL (120 tabs / 30 Agentes quelantes CHEMET CAP 100MG 4 DEPEN TITRA TAB 250MG 5 EXJADE TAB 125MG 5 LA PA EXJADE TAB 250MG 5 LA PA EXJADE TAB 500MG 5 LA PA FERRIPROX SOL 100MG/ML 5 LA PA FERRIPROX TAB 500MG 5 LA PA sodium polystyrene sulfonate 3 oral susp 15 gm/60ml sodium polystyrene sulfonate powder 4 SYPRINE CAP 250MG 5 Anticonceptivos alyacen tab 1/35 3 apri tab 2 GC aranelle tab 2 GC aubra tab GC aviane tab 2 GC balziva tab 3 bekyree tab 3 blisovi fe tab 1.5/30 2 GC blisovi fe tab 1/20 2 GC briellyn tab 3 camila tab GC cryselle-28 tab 28 tabs 2 GC cyclafem tab 1/35 3 cyclafem tab 7/7/7 2 GC deblitane tab GC delyla tab GC desogest-eth estrad & eth estrad tab /0.01 (21/5) desogest-ethin est tab / / desogestrel & ethinyl estradiol tab mcg drospirenone-ethinyl estradiol tab GC 3 ED - Excluido GC - Cobertura de Brecha 46

53 DROSPIRENONE-ETHINYL 3 ESTRADIOL TAB MG drospirenone-ethinyl estradiol 3 tab DROSPIRENONE-ETHINYL 3 ESTRADIOL TAB MG ELLA TAB 30MG 4 emoquette tab 2 GC enpresse-28 tab 2 GC errin tab GC ethynodiol diacetate & ethinyl 3 estradiol tab 1-50 mcg falmina tab 2 GC femynor tab GC gildagia tab introvale tab 3 JOLIVETTE TAB 0.35MG 2 GC juleber tab 2 GC junel 1.5/30 tab 2 GC junel 1/20 tab 2 GC junel fe tab 1.5/30 2 GC junel fe tab 1/20 2 GC kariva tab 28 day 3 kelnor tab 1/35 3 kimidess tab 3 larin fe tab 1.5/30 2 GC larin fe tab 1/20 2 GC larin tab 1.5/30 2 GC larin tab 1/20 2 GC lessina tab 2 GC levonest tab 2 GC levonorgestrel & ethinyl 3 estradiol (91-day) tab LEVONORGESTREL & 3 ETHINYL ESTRADIOL (91- DAY) TAB MG levonorgestrel & ethinyl 2 GC estradiol tab mcg levonorgestrel & ethinyl 2 GC estradiol tab mcg levonorgestrel tab levonorgestrel-eth estra tab / / mcg 2 GC levora-28 tab 0.15/30 2 GC loryna tab lutera tab 2 GC lyza tab GC marlissa tab 0.15/30 2 GC medroxyprogesterone acetate 2 GC im susp 150 /ml MEDROXYPROGESTERON 2 GC E ACETATE IM SUSP PREFILLED SYR 150 MG/ML MONONESSA TAB 2 GC myzilra tab 2 GC necon tab 0.5/35 3 NECON TAB 1/ NECON TAB 7/7/7 2 GC necon tab 10/ nikki tab norelgestromin-ethinyl 4 estradiol td ptwk mcg/24hr norethindrone & ethinyl 3 estradiol tab 1-35 mcg NORETHINDRONE AC- 3 ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG norethindrone ace & ethinyl 2 GC estradiol tab 1-20 mcg NORETHINDRONE ACE & 2 GC ETHINYL ESTRADIOL TAB 1 MG-20 MCG norethindrone ace & ethinyl 2 GC estradiol tab mcg NORETHINDRONE ACE & 2 GC ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG NORETHINDRONE ACE & 2 GC ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG NORETHINDRONE ACE & 2 GC ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG norethindrone tab GC NORETHINDRONE TAB 0.35 MG 2 GC ED - Excluido GC - Cobertura de Brecha 47

54 NORETHINDRONE-ETH ESTRADIOL TAB /1-35/ MG-MCG norgestimate & ethinyl estradiol tab mcg norgestimate-eth estrad tab / / mcg norgestimate-eth estrad tab / / mcg 2 GC 2 GC 3 2 GC norgestrel & ethinyl estradiol 2 GC tab mcg norlyroc tab GC nortrel tab 0.5/35 3 nortrel tab 1/35 3 nortrel tab 7/7/7 2 GC NUVARING MIS 4 orsythia tab 2 GC philith tab pimtrea tab 3 pirmella tab 1/35 3 portia-28 tab 2 GC previfem tab 2 GC quasense tab 3 reclipsen tab 2 GC sharobel tab GC sprintec 28 tab 28 day 2 GC tarina fe tab 1/20 2 GC tri-legest tab fe 3 tri-lo- tab sprintec 3 tri-previfem tab 2 GC tri-sprintec tab 2 GC TRINESSA LO TAB 3 TRINESSA TAB 2 GC trivora-28 tab 2 GC velivet pak 3 vienva tab GC viorele tab 3 vyfemla tab zenchent tab 3 zovia 1/35e tab 3 zovia 1/50e tab 3 Endometriosis danazol cap 50 4 danazol cap danazol cap SYNAREL SOL 2MG/ML 5 Reemplazo enzimático ADAGEN INJ 250/ML 5 LA PA ALDURAZYME INJ 5 LA PA 2.9MG/5M BUPHENYL TAB 500MG 5 LA PA CARBAGLU TAB 200MG 5 LA PA CERDELGA CAP 84MG 5 PA CEREZYME INJ 400UNIT 5 LA PA CYSTADANE POW 5 LA CYSTAGON CAP 50MG 4 LA PA CYSTAGON CAP 150MG 4 LA PA FABRAZYME INJ 5MG 5 LA PA FABRAZYME INJ 35MG 5 LA PA KUVAN POW 100MG 5 LA PA KUVAN POW 500MG 5 LA PA KUVAN TAB 100MG 5 LA PA levocarnitine inj 200 /ml 3 B/D levocarnitine oral soln 1 4 B/D gm/10ml (10%) levocarnitine tab B/D LUMIZYME INJ 50MG 5 LA PA NAGLAZYME INJ 1MG/ML 5 LA PA ORFADIN CAP 2MG 5 LA PA ORFADIN CAP 5MG 5 LA PA ORFADIN CAP 10MG 5 LA PA ORFADIN CAP 20MG 5 LA PA ORFADIN SUS 4MG/ML 5 LA PA RAVICTI LIQ 1.1GM/ML 5 PA sodium phenylbutyrate oral 5 PA powder 3 gm/teaspoonful ZAVESCA CAP 100MG 5 LA PA Estrógenos ALORA DIS 0.1MG QL (8 patches / 28 ALORA DIS 0.05MG QL (8 patches / 28 ALORA DIS 0.025MG QL (8 patches / 28 ALORA DIS 0.075MG QL (8 patches / 28 ED - Excluido GC - Cobertura de Brecha 48

55 COMBIPATCH DIS.05/.14 QL (8 patches / 28 COMBIPATCH DIS.05/.25 QL (8 patches / 28 DELESTROGEN INJ 4 10MG/ML DIVIGEL GEL 0.5MG QL (30 packets / 30 estrace vag cre 0.1/gm 4 estradiol & norethindrone 2 GC acetate tab estradiol & norethindrone 2 GC acetate tab estradiol tab GC estradiol tab 1 2 GC estradiol tab 2 2 GC estradiol td patch twice 2 GC QL weekly 0.1 /24hr QL (8 patches / 28 estradiol td patch twice 2 GC QL weekly 0.05 /24hr QL (8 patches / 28 estradiol td patch twice 2 GC QL weekly /24hr QL (8 patches / 28 estradiol td patch twice 2 GC QL weekly /24hr QL (8 patches / 28 estradiol td patch twice 2 GC QL weekly /24hr QL (8 patches / 28 estradiol td patch weekly GC /24hr estradiol td patch weekly GC /24hr estradiol td patch weekly GC /24hr estradiol td patch weekly 2 GC /24hr estradiol td patch weekly 2 GC /24hr estradiol td patch weekly 2 GC /24hr (37.5 mcg/24hr) estradiol vaginal tab 10 mcg 4 estradiol valerate im in oil 20 3 /ml estradiol valerate im in oil 40 3 /ml ESTRING MIS 2MG QL (1 ring / 84 estropipate tab GC estropipate tab GC estropipate tab 3 2 GC FEMRING MIS 0.1MG/24 QL (1 ring / 84 FEMRING MIS 0.05/24H QL (1 ring / 84 jinteli tab 1-5mcg 2 GC menest tab menest tab menest tab mimvey lo tab GC mimvey tab GC norethindrone acetate-ethinyl 2 GC estradiol tab 1-5 mcg PREMARIN INJ 25MG 3 PREMARIN TAB 0.3MG 3 PREMARIN TAB 0.9MG 3 PREMARIN TAB 0.45MG 3 PREMARIN TAB 0.625MG 3 PREMARIN TAB 1.25MG 3 PREMARIN VAG CRE MG PREMPHASE TAB 3 PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB VIVELLE-DOT DIS 0.1MG QL (8 patches / 28 VIVELLE-DOT DIS 0.05MG QL (8 patches / 28 VIVELLE-DOT DIS 0.075MG QL (8 patches / 28 VIVELLE-DOT DIS MG QL (8 patches / 28 Glucocorticoides cortisone acetate tab 25 4 ED - Excluido GC - Cobertura de Brecha 49

56 dexamethason con 1/ml 3 dexamethasone elixir /5ml dexamethasone sod 2 GC phosphate preservative free inj 10 /ml dexamethasone sodium 2 GC phosphate inj 4 /ml dexamethasone sodium 2 GC phosphate inj 10 /ml dexamethasone sodium 2 GC phosphate inj 20 /5ml dexamethasone sodium 2 GC phosphate inj 100 /10ml dexamethasone sodium 2 GC phosphate inj 120 /30ml dexamethasone soln /5ml dexamethasone tab GC dexamethasone tab GC dexamethasone tab 1 2 GC dexamethasone tab GC dexamethasone tab 2 2 GC dexamethasone tab 4 2 GC dexamethasone tab 6 2 GC fludrocortisone acetate tab GC hydrocortisone tab 5 3 hydrocortisone tab 10 3 hydrocortisone tab 20 3 methylprednisolone acetate 2 GC B/D inj susp 40 /ml methylprednisolone acetate 2 GC B/D inj susp 80 /ml methylprednisolone sodium 3 B/D succinate for inj 40 methylprednisolone sodium 3 B/D succinate for inj 125 methylprednisolone sodium 3 B/D succinate for inj 1000 methylprednisolone tab 4 3 B/D methylprednisolone tab 8 3 B/D methylprednisolone tab 16 3 B/D methylprednisolone tab 32 3 B/D methylprednisolone tab 2 GC therapy pack 4 (21) prednisolone sod phosph oral 3 B/D soln 6.7 /5ml (5 /5ml base) prednisolone sod phosphate 3 B/D oral soln 15 /5ml (base equiv) prednisolone sodium 3 B/D phosphate oral soln 25 /5ml (base eq) prednisolone syrup 15 /5ml 2 GC B/D (usp solution equivalent) prednisone con 5/ml 3 B/D prednisone oral soln 5 /5ml 3 B/D prednisone tab 1 B/D prednisone tab 2.5 B/D prednisone tab 5 B/D prednisone tab 10 B/D prednisone tab 20 B/D prednisone tab 50 B/D prednisone tab therapy pack 5 2 GC (21) prednisone tab therapy pack 5 2 GC (48) prednisone tab therapy pack 2 GC 10 (21) prednisone tab therapy pack 2 GC 10 (48) SOLU-CORTEF INJ 250MG 4 Agentes para elevar los niveles de glucosa GLUCAGEN INJ HYPOKIT 3 GLUCAGON KIT 1MG 3 PROGLYCEM SUS 50MG/ML 4 Hormonas de crecimiento humano GENOTROPIN INJ 0.2MG 4 PA GENOTROPIN INJ 0.4MG 5 PA GENOTROPIN INJ 0.6MG 5 PA GENOTROPIN INJ 0.8MG 5 PA GENOTROPIN INJ 1.2MG 5 PA GENOTROPIN INJ 1.4MG 5 PA GENOTROPIN INJ 1.6MG 5 PA GENOTROPIN INJ 1.8MG 5 PA GENOTROPIN INJ 1MG 5 PA ED - Excluido GC - Cobertura de Brecha 50

57 GENOTROPIN INJ 2MG 5 PA GENOTROPIN INJ 5MG 5 PA GENOTROPIN INJ 12MG 5 PA NORDITROPIN INJ 5/1.5ML 5 PA NORDITROPIN INJ 10/1.5ML 5 PA NORDITROPIN INJ 15/1.5ML 5 PA NORDITROPIN INJ 30/3ML 5 PA Misceláneos cabergoline tab calcitonin (salmon) nasal soln 3 B/D 200 unit/act FORTICAL SPR 200/ACT 3 B/D INCRELEX INJ 40MG/4ML 5 LA PA KORLYM TAB 300MG 5 LA PA LUPR DEP-PED INJ 3M 5 PA 30MG LUPR DEP-PED INJ 7.5MG 5 PA LUPR DEP-PED INJ 5 PA 11.25MG LUPR DEP-PED INJ 15MG 5 PA methergine tab methylergonovine maleate tab MIACALCIN INJ 200/ML 5 B/D octreotide acetate inj 50 4 PA mcg/ml (0.05 /ml) octreotide acetate inj PA mcg/ml (0.1 /ml) octreotide acetate inj PA mcg/ml (0.2 /ml) octreotide acetate inj PA mcg/ml (0.5 /ml) octreotide acetate inj PA mcg/ml (1 /ml) PROLIA SOL 60MG/ML QL (1 syringe / 180 raloxifene hcl tab 60 3 SANDOSTATIN KIT LAR 5 PA 10MG SANDOSTATIN KIT LAR 5 PA 20MG SANDOSTATIN KIT LAR 5 PA 30MG SIGNIFOR INJ 0.3MG/ML 5 LA PA SIGNIFOR INJ 0.6MG/ML 5 LA PA SIGNIFOR INJ 0.9MG/ML 5 LA PA SOMATULINE INJ 60/0.2ML 5 PA SOMATULINE INJ 90/0.3ML 5 PA SOMATULINE INJ 120/.5ML 5 PA SOMAVERT INJ 10MG 5 LA PA SOMAVERT INJ 15MG 5 LA PA SOMAVERT INJ 20MG 5 LA PA SOMAVERT INJ 25MG 5 LA PA SOMAVERT INJ 30MG 5 LA PA XGEVA INJ 5 PA Hormonas paratiroideas FORTEO SOL 600/2.4 QL (1 pen / 28 5 QL PA NATPARA INJ 25MCG 5 PA NATPARA INJ 50MCG 5 PA NATPARA INJ 75MCG 5 PA NATPARA INJ 100MCG 5 PA Agentes aglutinantes de fosfato AURYXIA TAB 210MG 5 calcium acetate (phosphate 3 binder) cap 667 (169 ca) calcium acetate (phosphate 3 binder) tab 667 RENVELA PAK 0.8GM 3 RENVELA PAK 2.4GM 3 RENVELA TAB 800MG 3 Progestinas medroxyprogesterone acetate tab 2.5 medroxyprogesterone acetate tab 5 medroxyprogesterone acetate tab 10 norethindrone acetate tab 5 3 Agentes tiroideos CYTOMEL TAB 5MCG 4 CYTOMEL TAB 25MCG 4 CYTOMEL TAB 50MCG 4 levothyroxine sodium tab 25 mcg 2 GC ED - Excluido GC - Cobertura de Brecha 51

58 levothyroxine sodium tab 50 2 GC mcg LEVOTHYROXINE SODIUM 2 GC TAB 75 MCG levothyroxine sodium tab 88 2 GC mcg levothyroxine sodium tab GC mcg levothyroxine sodium tab GC mcg levothyroxine sodium tab GC mcg levothyroxine sodium tab GC mcg levothyroxine sodium tab GC mcg levothyroxine sodium tab GC mcg levothyroxine sodium tab GC mcg LEVOTHYROXINE SODIUM 2 GC TAB 300 MCG LEVOXYL TAB 25MCG 2 GC LEVOXYL TAB 50MCG 2 GC LEVOXYL TAB 75MCG 2 GC LEVOXYL TAB 88MCG 2 GC LEVOXYL TAB 100MCG 2 GC LEVOXYL TAB 112MCG 2 GC LEVOXYL TAB 125MCG 2 GC LEVOXYL TAB 137MCG 2 GC LEVOXYL TAB 150MCG 2 GC LEVOXYL TAB 175MCG 2 GC LEVOXYL TAB 200MCG 2 GC liothyronine sodium tab 5 mcg 3 liothyronine sodium tab 25 3 mcg liothyronine sodium tab 50 3 mcg methimazole tab 5 2 GC methimazole tab 10 2 GC propylthiouracil tab 50 3 SYNTHROID TAB 25MCG 4 SYNTHROID TAB 50MCG 4 SYNTHROID TAB 75MCG 4 SYNTHROID TAB 88MCG 4 SYNTHROID TAB 100MCG 4 SYNTHROID TAB 112MCG 4 SYNTHROID TAB 125MCG 4 SYNTHROID TAB 137MCG 4 SYNTHROID TAB 150MCG 4 SYNTHROID TAB 175MCG 4 SYNTHROID TAB 200MCG 4 SYNTHROID TAB 300MCG 4 UNITHROID TAB 25MCG 2 GC UNITHROID TAB 50MCG 2 GC UNITHROID TAB 75MCG 2 GC UNITHROID TAB 88MCG 2 GC UNITHROID TAB 100MCG 2 GC UNITHROID TAB 112MCG 2 GC UNITHROID TAB 125MCG 2 GC UNITHROID TAB 150MCG 2 GC UNITHROID TAB 175MCG 2 GC UNITHROID TAB 200MCG 2 GC UNITHROID TAB 300MCG 2 GC Vasopresinas desmopressin acetate inj 4 mcg/ml DESMOPRESSIN ACETATE NASAL SOLN 0.01% (REFRIGERATED) desmopressin acetate nasal spray soln 0.01% desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab desmopressin acetate tab STIMATE SOL 1.5MG/ML 4 Gastrointestinal Antieméticos aprepitant capsule 40 4 B/D aprepitant capsule 80 4 B/D aprepitant capsule B/D aprepitant capsule therapy pack 80 & 125 dronabinol cap 2.5 QL (60 caps / B/D 4 B/D QL ED - Excluido GC - Cobertura de Brecha 52

59 dronabinol cap 5 4 B/D QL QL (60 caps / 30 dronabinol cap 10 4 B/D QL QL (60 caps / 30 EMEND CAP 40MG 4 B/D EMEND CAP 80MG 4 B/D EMEND CAP 125MG 4 B/D EMEND SUS 125MG 4 B/D EMEND TRIPAC PAK 80 & 4 B/D 125 granisetron hcl inj 0.1 /ml 3 granisetron hcl inj 1 /ml 3 granisetron hcl inj 4 /4ml (1 3 /ml) granisetron hcl tab 1 4 B/D meclizine hcl tab GC meclizine hcl tab 25 2 GC metoclopramide hcl inj 5 2 GC /ml metoclopramide hcl soln 5 /5ml (10 /10ml) metoclopramide hcl tab 5 metoclopramide hcl tab 10 ondansetron hcl inj 4 /2ml 3 (2 /ml) ondansetron hcl inj 40 3 /20ml (2 /ml) ondansetron hcl oral soln 4 3 B/D /5ml ondansetron hcl tab 4 3 B/D ondansetron hcl tab 8 3 B/D ondansetron hcl tab 24 3 B/D ondansetron orally 2 GC B/D disintegrating tab 4 ondansetron orally 2 GC B/D disintegrating tab 8 phenadoz sup GC phenergan sup GC phenergan sup 25 2 GC phenergan sup 50 2 GC prochlorperazine edisylate inj 3 5 /ml prochlorperazine maleate tab 5 (base equivalent) prochlorperazine maleate tab 10 (base equivalent) prochlorperazine suppos 25 4 promethazine hcl inj 25 /ml 2 GC promethazine hcl inj 50 /ml 2 GC promethazine hcl suppos GC promethazine hcl suppos 25 2 GC promethazine hcl suppos 50 2 GC promethazine hcl syrup GC /5ml promethazine hcl tab GC promethazine hcl tab 25 2 GC promethazine hcl tab 50 2 GC promethegan sup 25 2 GC promethegan sup 50 2 GC TRANSDERM-SC DIS 1.5MG QL (10 patches / 30 Antiespasmódicos dicyclomine hcl cap 10 dicyclomine hcl oral soln 10 4 /5ml dicyclomine hcl tab 20 glycopyrrolate inj 4 /20ml 4 (0.2 /ml) glycopyrrolate tab 1 3 glycopyrrolate tab 2 3 Antagonista de los receptores de la H2 famotidine for susp 40 /5ml 4 famotidine in nacl 0.9% iv soln 2 GC 20 /50ml famotidine inj 20 /2ml 2 GC famotidine inj 40 /4ml 2 GC famotidine inj 200 /20ml 2 GC famotidine tab 20 famotidine tab 40 ranitidine hcl inj 50 /2ml 2 GC (25 /ml) ranitidine hcl inj 150 /6ml (25 /ml) 3 ED - Excluido GC - Cobertura de Brecha 53

60 ranitidine hcl syrup 15 /ml 3 (75 /5ml) ranitidine hcl tab 150 ranitidine hcl tab 300 Enfermedad inflamatoria intestinal APRISO CAP 0.375GM 3 balsalazide disodium cap budesonide delayed release 5 particles cap 3 CANASA SUP 1000MG 5 DELZICOL CAP 400MG 4 DIPENTUM CAP 250MG 5 hydrocortisone enema /60ml HYDROCORTISONE ENEMA MG/60ML mesalamine enema 4 gm 4 mesalamine rectal enema 4 4 gm & cleanser wipe kit MESALAMINE TAB 4 DELAYED RELEASE 800 MG sulfasalazine tab sulfasalazine tab delayed 3 release 500 Lasantes bisacodyl tab & peg 3350-kclsod 3 bicarb-nacl for soln kit constulose sol 10gm/15 2 GC enulose sol 10gm/15 2 GC gavilyte-c sol 2 GC gavilyte-g sol 2 GC gavilyte-n sol flav pk 2 GC generlac sol 10gm/15 2 GC GOLYTELY SOL 3 lactulose (encephalopathy) 2 GC solution 10 gm/15ml lactulose solution 10 gm/15ml 2 GC MOVIPREP SOL 4 NULYTELY SOL FLAV PKS 3 PEG 3350-KCL-NA BICARB- NACL-NA SULFATE FOR SOLN 236 GM 2 GC PEG 3350-KCL-NA BICARB- 2 GC NACL-NA SULFATE FOR SOLN 240 GM peg 3350-kcl-sod bicarb-nacl 2 GC for soln 420 gm polyethylene glycol 3350 oral 2 GC packet polyethylene glycol 3350 oral 2 GC powder SUPREP BOWEL SOL PREP 4 KIT trilyte sol 2 GC Misceláneos alosetron hcl tab 0.5 (base 5 PA equiv) alosetron hcl tab 1 (base 5 PA equiv) AMITIZA CAP 8MCG QL (60 caps / 30 AMITIZA CAP 24MCG QL (60 caps / 30 cromolyn sodium oral conc /5ml diphenoxylate w/ atropine liq /5ml diphenoxylate w/ atropine tab GATTEX KIT 5MG 5 LA PA LINZESS CAP 72MCG QL (30 caps / 30 LINZESS CAP 145MCG QL (60 caps / 30 LINZESS CAP 290MCG QL (30 caps / 30 loperamide hcl cap 2 2 GC misoprostol tab 100 mcg 3 misoprostol tab 200 mcg 3 MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG RELISTOR INJ 8/0.4ML 5 PA RELISTOR INJ 12/0.6ML 5 PA SUCRAID SOL 8500/ML 5 LA sucralfate tab 1 gm 3 ED - Excluido GC - Cobertura de Brecha 54

61 ursodiol cap ursodiol tab ursodiol tab XIFAXAN TAB 550MG 5 PA Enzimas pancreáticas CREON CAP 3000UNIT 3 CREON CAP 6000UNIT 3 CREON CAP 12000UNT 3 CREON CAP 24000UNT 3 CREON CAP 36000UNT 3 ZENPEP CAP 3000UNIT 4 ZENPEP CAP 5000UNIT 4 ZENPEP CAP 10000UNT 4 ZENPEP CAP 15000UNT 4 ZENPEP CAP 20000UNT 4 ZENPEP CAP 25000UNT 4 ZENPEP CAP 40000UNT 4 Inhipidores de la Bomba de Protones DEXILANT CAP 30MG DR QL (30 caps / 30 DEXILANT CAP 60MG DR QL (30 caps / 30 esomeprazole magnesium cap delayed release 20 (base eq) esomeprazole magnesium cap delayed release 40 (base eq) esomeprazole sodium for intravenous soln 20 (base equiv) esomeprazole sodium for intravenous soln 40 (base equiv) lansoprazole cap delayed 2 GC release 15 lansoprazole cap delayed 2 GC release 30 NEXIUM GRA 2.5MG DR 3 NEXIUM GRA 5MG DR 3 NEXIUM GRA 10MG DR QL (30 packets / NEXIUM GRA 20MG DR QL (30 packets / 30 NEXIUM GRA 40MG DR QL (30 packets / 30 omeprazole cap delayed release 10 omeprazole cap delayed release 20 omeprazole cap delayed release 40 pantoprazole sodium ec tab 20 (base equiv) pantoprazole sodium ec tab 40 (base equiv) 2 GC 2 GC PRILOSEC POW 2.5MG 4 PRILOSEC POW 10MG 4 rabeprazole sodium ec tab 20 4 Genitourinarias Hiperplasia Prostática Benigna alfuzosin hcl tab er 24hr 10 2 GC QL dutasteride cap 0.5 QL (30 caps / 30 dutasteride-tamsulosin hcl cap QL (30 caps / 30 finasteride tab 5 2 GC tamsulosin hcl cap Misceláneos bethanechol chloride tab 5 3 bethanechol chloride tab 10 3 bethanechol chloride tab 25 3 bethanechol chloride tab 50 3 ELMIRON CAP 100MG 4 POTASSIUM CITRATE TAB 4 ER 5 MEQ (540 MG) POTASSIUM CITRATE TAB 4 ER 10 MEQ (1080 MG) ED - Excluido GC - Cobertura de Brecha 55

62 potassium citrate tab er 15 4 meq (1620 ) Antiespansmódicos Urinario ENABLEX TAB 7.5MG ENABLEX TAB 15MG MYRBETRIQ TAB 25MG MYRBETRIQ TAB 50MG oxybutynin chloride syrup 5 /5ml oxybutynin chloride tab 5 3 oxybutynin chloride tab er 24hr 5 oxybutynin chloride tab er 24hr 10 oxybutynin chloride tab er 24hr 15 tolterodine tartrate cap er 24hr 2 QL (30 caps / 30 tolterodine tartrate cap er 24hr 4 QL (30 caps / 30 tolterodine tartrate tab 1 4 tolterodine tartrate tab 2 4 TOVIAZ TAB 4MG TOVIAZ TAB 8MG trospium chloride tab 20 VESICARE TAB 5MG VESICARE TAB 10MG Antiinfecciosos vaginales clindamycin phosphate 4 vaginal cream 2% metronidazole vaginal gel 0.75% 4 3 terconazole vaginal cream 0.4% terconazole vaginal cream 3 0.8% TERCONAZOLE VAGINAL 3 CREAM 0.8% terconazole vaginal suppos 4 80 VANDAZOLE GEL 0.75% 4 Hematológicos Anticoagulantes COUMADIN TAB 1MG 4 COUMADIN TAB 2.5MG 4 COUMADIN TAB 2MG 4 COUMADIN TAB 3MG 4 COUMADIN TAB 4MG 4 COUMADIN TAB 5MG 4 COUMADIN TAB 6MG 4 COUMADIN TAB 7.5MG 4 COUMADIN TAB 10MG 4 ELIQUIS TAB 2.5MG 4 PA ELIQUIS TAB 5MG 4 PA enoxaparin sodium inj 30 /0.3ml enoxaparin sodium inj 40 /0.4ml enoxaparin sodium inj 60 /0.6ml enoxaparin sodium inj 80 /0.8ml enoxaparin sodium inj 100 /ml enoxaparin sodium inj 120 /0.8ml enoxaparin sodium inj 150 /ml ENOXAPARIN SODIUM INJ 300 MG/3ML fondaparinux sodium subcutaneous inj 2.5 /0.5ml fondaparinux sodium subcutaneous inj 5 /0.4ml ED - Excluido GC - Cobertura de Brecha

63 fondaparinux sodium subcutaneous inj 7.5 /0.6ml fondaparinux sodium subcutaneous inj 10 /0.8ml HEP SOD/NACL INJ 25000UNT HEPARIN SODIUM (PORCINE) 40 UNIT/ML IN D5W HEPARIN SODIUM (PORCINE) 50 UNIT/ML IN D5W 5 heparin sodium (porcine) unit/ml in d5w heparin sodium (porcine) inj 3 B/D 1000 unit/ml heparin sodium (porcine) inj 3 B/D 5000 unit/ml heparin sodium (porcine) inj 3 B/D unit/ml heparin sodium (porcine) inj 3 B/D unit/ml jantoven tab 1 jantoven tab 2.5 jantoven tab 2 jantoven tab 3 jantoven tab 4 jantoven tab 5 jantoven tab 6 jantoven tab 7.5 jantoven tab 10 PRADAXA CAP 75MG 3 PRADAXA CAP 110MG 3 PRADAXA CAP 150MG 3 warfarin sodium tab 1 warfarin sodium tab 2 warfarin sodium tab 2.5 warfarin sodium tab 3 warfarin sodium tab 4 warfarin sodium tab 5 warfarin sodium tab 6 warfarin sodium tab 7.5 warfarin sodium tab XARELTO STAR TAB 15/20MG XARELTO TAB 10MG 3 XARELTO TAB 15MG 3 XARELTO TAB 20MG 3 Factores de crecimiento hematopoyéticos GRANIX INJ 300/0.5 5 PA GRANIX INJ 480/0.8 5 PA LEUKINE INJ 250MCG 5 PA MOZOBIL INJ 5 PA NEUPOGEN INJ 300/0.5 5 PA NEUPOGEN INJ 300MCG 5 PA NEUPOGEN INJ 480/0.8 5 PA NEUPOGEN INJ 480MCG 5 PA PROCRIT INJ 2000/ML 3 PA PROCRIT INJ 3000/ML 3 PA PROCRIT INJ 4000/ML 3 PA PROCRIT INJ 10000/ML 3 PA PROCRIT INJ 20000/ML 5 PA PROCRIT INJ 40000/ML 5 PA Misceláneos anagrelide hcl cap anagrelide hcl cap 1 4 cilostazol tab 50 2 GC cilostazol tab GC CINRYZE SOL 500 UNIT 5 LA PA dipyridamole tab 25 2 GC dipyridamole tab 50 2 GC dipyridamole tab 75 2 GC FIRAZYR INJ 30MG/3ML 5 PA pentoxifylline tab er PROMACTA TAB 12.5MG 5 QL LA PA QL (360 tabs / 30 PROMACTA TAB 25MG 5 QL LA PA QL (180 tabs / 30 PROMACTA TAB 50MG 5 QL LA PA QL (90 tabs / 30 PROMACTA TAB 75MG 5 QL LA PA tranexamic acid iv soln /10ml (100 /ml) tranexamic acid tab Inhibidores de la agregación plaquetaria ED - Excluido GC - Cobertura de Brecha 57

64 AGGRENOX CAP MG 4 ASPIRIN-DIPYRIDAMOLE 4 CAP ER 12HR MG BRILINTA TAB 60MG 3 BRILINTA TAB 90MG 3 clopidogrel bisulfate tab 75 (base equiv) EFFIENT TAB 5MG 4 EFFIENT TAB 10MG 4 ZONTIVITY TAB 2.08MG 4 Agentes inmunológicos Fármacos antirreumáticos modificadores de la enfermedad (DMARD) ENBREL INJ 25/0.5ML 5 PA ENBREL INJ 25MG 5 PA ENBREL INJ 50MG/ML 5 PA ENBREL SRCLK INJ 50MG/ML HUMIRA INJ 10MG/0.2 QL (2 syringes / 28 HUMIRA KIT 20MG/0.4 QL (2 syringes / 28 HUMIRA KIT 40MG/0.8 QL (6 syringes / 28 5 PA 5 QL PA 5 QL PA 5 QL PA HUMIRA PEDIA INJ 5 PA CROHNS HUMIRA PEN INJ 40MG/0.8 5 QL PA QL (6 pens / 28 HUMIRA PEN INJ CROHNS 5 PA HUMIRA PEN INJ PSORIASI 5 PA hydroxychloroquine sulfate 4 tab 200 leflunomide tab 10 3 leflunomide tab 20 3 methotrexate sodium tab (base equiv) REMICADE INJ 100MG 5 PA XATMEP SOL 2.5MG/ML 4 B/D XELJANZ TAB 5MG 5 QL PA XELJANZ XR TAB 11MG 5 QL PA Inmunoglobulinas BIVIGAM INJ 10% 5 PA CARIMUNE NF INJ 6GM 5 PA CARIMUNE NF INJ 12GM 5 PA FLEBOGAMMA INJ 5 PA 5GM/50ML FLEBOGAMMA INJ 5 PA 10/100ML FLEBOGAMMA INJ 5 PA 10/200ML FLEBOGAMMA INJ 5 PA 20/200ML FLEBOGAMMA INJ 5 PA 20/400ML FLEBOGAMMA INJ DIF 5% 5 PA GAMASTAN S/D INJ 3 B/D GAMMAGARD INJ 5 PA 1GM/10ML GAMMAGARD INJ 2.5GM/25 5 PA GAMMAGARD INJ 5GM/50ML 5 PA GAMMAGARD INJ 10GM/100 5 PA GAMMAGARD INJ 20GM/200 5 PA GAMMAGARD INJ 30GM/300 5 PA GAMMAGARD SD INJ 5GM 5 PA HU GAMMAGARD SD INJ 10GM 5 PA HU GAMMAKED INJ 1GM/10ML 5 PA GAMMAKED INJ 2.5GM/25 5 PA GAMMAKED INJ 5GM/50ML 5 PA GAMMAKED INJ 10GM/100 5 PA GAMMAKED INJ 20GM/200 5 PA GAMMAPLEX INJ 5% 5 PA GAMMAPLEX INJ 10% 5 PA GAMUNEX-C INJ 1GM/10ML 5 PA GAMUNEX-C INJ 2.5GM/25 5 PA GAMUNEX-C INJ 5GM/50ML 5 PA GAMUNEX-C INJ 10GM/100 5 PA GAMUNEX-C INJ 20GM/200 5 PA GAMUNEX-C INJ 40/400ML 5 PA OCTAGAM INJ 1GM 5 PA OCTAGAM INJ 2.5GM 5 PA OCTAGAM INJ 2GM/20ML 5 PA OCTAGAM INJ 5GM 5 PA ED - Excluido GC - Cobertura de Brecha 58

65 OCTAGAM INJ 10GM 5 PA OCTAGAM INJ 25GM 5 PA PRIVIGEN INJ 5 GRAMS 5 PA PRIVIGEN INJ 10GRAMS 5 PA PRIVIGEN INJ 20GRAMS 5 PA PRIVIGEN INJ 40GRAMS 5 PA Inmunomoduladores ACTIMMUNE INJ 2MU/0.5 5 LA PA ARCALYST INJ 220MG 5 PA INTRON A INJ 10MU 5 B/D INTRON A INJ 18MU 5 B/D INTRON A INJ 25MU 5 B/D INTRON A INJ 50MU 5 B/D POMALYST CAP 1MG 5 LA PA POMALYST CAP 2MG 5 LA PA POMALYST CAP 3MG 5 LA PA POMALYST CAP 4MG 5 LA PA REVLIMID CAP 2.5MG 5 LA PA REVLIMID CAP 5MG 5 LA PA REVLIMID CAP 10MG 5 LA PA REVLIMID CAP 15MG 5 LA PA REVLIMID CAP 20MG 5 LA PA REVLIMID CAP 25MG 5 LA PA THALOMID CAP 50MG 5 PA THALOMID CAP 100MG 5 PA THALOMID CAP 150MG 5 PA THALOMID CAP 200MG 5 PA Inmunosupresores azathioprine inj B/D azathioprine tab 50 3 B/D BENLYSTA INJ 120MG 5 PA BENLYSTA INJ 400MG 5 PA cyclosporine cap 25 4 B/D cyclosporine cap B/D cyclosporine iv soln 50 /ml 4 B/D cyclosporine modified cap 25 4 B/D cyclosporine modified cap 50 4 B/D cyclosporine modified cap B/D cyclosporine modified oral 4 B/D soln 100 /ml gengraf cap 25 4 B/D gengraf cap 50 4 B/D gengraf cap B/D gengraf sol 100/ml 4 B/D mycophenolate mofetil cap 4 B/D 250 mycophenolate mofetil for oral 5 B/D susp 200 /ml mycophenolate mofetil tab 4 B/D 500 mycophenolate sodium tab dr 4 B/D 180 (mycophenolic acid equiv) mycophenolate sodium tab dr 4 B/D 360 (mycophenolic acid equiv) NEORAL CAP 25MG 3 B/D NEORAL CAP 100MG 3 B/D NEORAL SOL 100MG/ML 3 B/D NULOJIX INJ 250MG 5 B/D PROGRAF CAP 0.5MG 4 B/D PROGRAF CAP 1MG 4 B/D PROGRAF CAP 5MG 5 B/D RAPAMUNE SOL 1MG/ML 5 B/D SANDIMMUNE SOL 3 B/D 100MG/ML sirolimus tab B/D sirolimus tab 1 4 B/D sirolimus tab 2 5 B/D tacrolimus cap B/D tacrolimus cap 1 4 B/D tacrolimus cap 5 4 B/D ZORTRESS TAB 0.5MG 5 B/D ZORTRESS TAB 0.25MG 3 B/D ZORTRESS TAB 0.75MG 5 B/D Vacunas ACTHIB INJ 3 ADACEL INJ 3 BCG VACCINE INJ 3 BEXSERO INJ 3 BOOSTRIX INJ 3 DAPTACEL INJ 3 DIP/TET PED INJ 25-5LFU 3 B/D ENGERIX-B INJ 10/0.5ML 3 B/D ENGERIX-B INJ 20MCG/ML 3 B/D GARDASIL 9 INJ 3 ED - Excluido GC - Cobertura de Brecha 59

66 GARDASIL INJ 3 HAVRIX INJ 720UNIT 3 HAVRIX INJ 1440UNIT 3 HIBERIX SOL 10MCG 3 IMOVAX RABIE INJ 2.5/ML 3 INFANRIX INJ 3 IPOL INJ INACTIVE 3 IXIARO INJ 3 KINRIX INJ 3 M-M-R II INJ 3 MENACTRA INJ 3 MENHIBRIX INJ 3 MENOMUNE INJ A/C/Y/W 3 MENVEO INJ 3 PEDIARIX INJ 0.5ML 3 PEDVAX HIB INJ 3 PENTACEL INJ 3 PROQUAD INJ 3 QUADRACEL INJ 3 RABAVERT INJ 3 RECOMBIVA HB INJ 3 B/D 5MCG/0.5 RECOMBIVA HB INJ 3 B/D 10MCG/ML RECOMBIVA-HB INJ 3 B/D 40MCG/ML ROTARIX SUS 3 ROTATEQ SOL 3 SYNAGIS INJ 50MG 5 SYNAGIS INJ 100MG/ML 5 TENIVAC INJ 5-2LF 3 B/D TET/DIP TOX INJ 2-2 LF 3 B/D TRUMENBA INJ 3 TWINRIX INJ 3 TYPHIM VI INJ 3 VAQTA INJ 25/0.5ML 3 VAQTA INJ 50UNT/ML 3 VARIVAX INJ 3 YF-VAX INJ 3 ZOSTAVAX INJ QL (1 vial per lifetime) Suplementos alimenticios Electrolitos KLOR-CON 8 TAB 8MEQ ER 2 GC KLOR-CON 10 TAB 10MEQ 2 GC ER klor-con m15 tab 15meq er 2 GC MAGNESIUM SU INJ 3 2GM/50ML MAGNESIUM SU INJ 3 4G/100ML MAGNESIUM SU INJ 3 20/500ML MAGNESIUM SU INJ 3 40G/1000 MAGNESIUM SU INJ 3 80MG/ML magnesium sulfate in 3 dextrose 5% iv soln 1 gm/100ml magnesium sulfate inj 50% 2 GC MAGNESIUM SULFATE INJ 2 GC 50% magnesium sulfate iv soln 2 2 GC gm/50ml (40 /ml) MG SO4/D5W INJ 10MG/ML 3 MG SO4/D5W INJ 20MG/ML 3 potassium chloride cap er 8 3 meq potassium chloride cap er 10 3 meq potassium chloride 2 GC microencapsulated crys er tab 10 meq potassium chloride 2 GC microencapsulated crys er tab 20 meq POTASSIUM CHLORIDE 4 ORAL SOLN 10% (20 MEQ/15ML) POTASSIUM CHLORIDE 4 ORAL SOLN 20% (40 MEQ/15ML) POTASSIUM CHLORIDE 4 POWDER PACKET 20 MEQ potassium chloride tab er 8 meq (600 ) 2 GC ED - Excluido GC - Cobertura de Brecha 60

67 potassium chloride tab er 10 2 GC meq potassium chloride tab er 20 2 GC meq (1500 ) SODIUM CHLORIDE INJ GC MEQ/ML (14.6%) sodium fluoride chew; tab; 1.1 (0.5 f) /ml soln 2 GC TPN ELECTROL INJ 4 B/D Nutrición IV amino acid infusion 6% 2 GC B/D AMINOSYN 7% INJ /LYTES 4 B/D AMINOSYN II INJ 8.5% 4 B/D AMINOSYN II INJ 8.5/LYTE 4 B/D AMINOSYN II INJ 10% 4 B/D AMINOSYN INJ 8.5% 4 B/D AMINOSYN INJ 8.5/LYTE 4 B/D AMINOSYN INJ 10% 4 B/D AMINOSYN M INJ 3.5% 4 B/D AMINOSYN-HBC INJ 7% 4 B/D AMINOSYN-PF INJ 7% 4 B/D AMINOSYN-PF INJ 10% 4 B/D AMINOSYN-RF INJ 5.2% 4 B/D CLINIMIX INJ 2.75/D5W 4 B/D CLINIMIX INJ 4.25/D5W 4 B/D CLINIMIX INJ 4.25/D10 4 B/D CLINIMIX INJ 4.25/D20 4 B/D CLINIMIX INJ 4.25/D25 4 B/D CLINIMIX INJ 5%/D15W 4 B/D CLINIMIX INJ 5%/D20W 4 B/D CLINIMIX INJ 5%/D25W 4 B/D fat emulsion iv soln 20% 4 B/D FREAMINE HBC INJ 6.9% 4 B/D FREAMINE III INJ 10% 4 B/D HEPATAMINE SOL 8% 4 B/D INTRALIPID INJ 20% 4 B/D INTRALIPID INJ 30% 4 B/D NEPHRAMINE INJ 5.4% 4 B/D premasol sol 10% 4 B/D PROCALAMINE INJ 3% 4 B/D PROSOL INJ 20% 4 B/D TRAVASOL INJ 10% 4 B/D TROPHAMINE INJ 10% 4 B/D Soluciones de reemplazo IV D5W/LYTES INJ #48 3 D5W/NACL INJ 0.3% 2 GC D10W/NACL INJ 0.2% 3 DEXTROSE 2.5% W/ 2 GC SODIUM CHLORIDE 0.45% DEXTROSE 5% IN 2 GC LACTATED RINGERS DEXTROSE 5% W/ SODIUM 2 GC CHLORIDE 0.2% DEXTROSE 5% W/ SODIUM 2 GC CHLORIDE 0.9% DEXTROSE 5% W/ SODIUM 2 GC CHLORIDE 0.33% DEXTROSE 5% W/ SODIUM 2 GC CHLORIDE 0.45% DEXTROSE 5% W/ SODIUM 2 GC CHLORIDE 0.225% DEXTROSE 10% W/ 2 GC SODIUM CHLORIDE 0.45% DEXTROSE INJ 5% 2 GC DEXTROSE INJ 10% 2 GC DEXTROSE INJ 50% 2 GC DEXTROSE INJ 70% 2 GC IONOSOL-B/ INJ D5W 4 IONOSOL-MB INJ /D5W 4 ISOLYTE-P INJ /D5W 4 ISOLYTE-S INJ 4 KCL 10 MEQ/L (0.075%) IN 2 GC DEXTROSE 5% & NACL 0.45% INJ KCL 20 MEQ/L (0.15%) IN 2 GC DEXTROSE 5% & NACL 0.2% INJ KCL 20 MEQ/L (0.15%) IN 2 GC DEXTROSE 5% & NACL 0.9% INJ KCL 20 MEQ/L (0.15%) IN 2 GC DEXTROSE 5% & NACL 0.33% INJ KCL 20 MEQ/L (0.15%) IN 2 GC DEXTROSE 5% & NACL 0.45% INJ KCL 20 MEQ/L (0.15%) IN 2 GC NACL 0.9% INJ kcl 20 meq/l (0.15%) in nacl 0.45% inj 2 GC ED - Excluido GC - Cobertura de Brecha 61

68 KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ KCL 30 MEQ/L (0.224%) IN DEXTROSE 5% & NACL 0.45% INJ KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & NACL 0.45% INJ 2 GC 2 GC 2 GC KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ 2 GC KCL/D5W/NACL INJ 0.3/0.9% 2 GC KCL/D5W/NACL INJ 0.15/0.2 3 LACTATED RINGER'S 2 GC SOLUTION NORMOSOL -M INJ /D5W 4 NORMOSOL -R INJ /D5W 4 NORMOSOL-R INJ PH PLASMA-LYTE INJ PLASMA-LYTE INJ -A 4 POTASSIUM CHLORIDE 20 2 GC MEQ/L (0.15%) IN DEXTROSE 5% INJ POTASSIUM CHLORIDE 40 2 GC MEQ/L (0.3%) IN DEXTROSE 5% INJ potassium chloride inj 2 2 GC meq/ml POTASSIUM CHLORIDE INJ 2 GC 10 MEQ/50ML POTASSIUM CHLORIDE INJ 2 GC 10 MEQ/100ML POTASSIUM CHLORIDE INJ 2 GC 20 MEQ/50ML POTASSIUM CHLORIDE INJ 2 GC 20 MEQ/100ML POTASSIUM CHLORIDE INJ 2 GC 40 MEQ/100ML RINGER'S SOLUTION 2 GC SODIUM CHLORIDE INJ 2 GC 0.45% SODIUM CHLORIDE INJ 3% 2 GC SODIUM CHLORIDE INJ 5% 2 GC SODIUM CHLORIDE IV 2 GC SOLN 0.9% Vitaminas calcitriol cap 0.5 mcg 3 B/D calcitriol cap 0.25 mcg 3 B/D calcitriol inj 1 mcg/ml 4 B/D calcitriol oral soln 1 mcg/ml 4 B/D paricalcitol cap 1 mcg 4 B/D paricalcitol cap 2 mcg 4 B/D paricalcitol cap 4 mcg 4 B/D prenatal vitamin/folic acid > 2 GC 0.8 (generic) Oftálmico Contra infecciones/ antiinflamatorios bacitracin-polymyxinneomycin-hc 3 ophth oint 1% blephamide oin s.o.p. 4 neomycin-polymyxindexamethasone 2 GC ophth oint 0.1% neomycin-polymyxindexamethasone 2 GC ophth susp 0.1% neomycin-polymyxin-hc ophth 4 susp sulfacetamide sodiumprednisolone 2 GC ophth soln (0.25)% TOBRADEX OIN % 3 TOBRADEX ST SUS tobramycin-dexamethasone 4 ophth susp % ZYLET SUS % 3 Contra infecciones bacitracin ophth oint unit/gm bacitracin-polymyxin b ophth 2 GC oint BESIVANCE SUS 0.6% 3 CILOXAN OIN 0.3% OP 3 ciprofloxacin hcl ophth soln 2 GC 0.3% erythromycin ophth oint 5 2 GC /gm gatifloxacin ophth soln 0.5% 4 gentak oin 0.3% op 2 GC gentamicin sulfate ophth oint 0.3% 2 GC ED - Excluido GC - Cobertura de Brecha 62

69 gentamicin sulfate ophth soln 2 GC 0.3% MOXEZA SOL 0.5% 3 NATACYN SUS 5% OP 4 neomycin-bacitrac zn-polymyx 3 5(3.5)-400unt-10000unt op oin neomycin-polymy-gramicid op 3 sol unt/ml ofloxacin ophth soln 0.3% 2 GC polymyxin b-trimethoprim 2 GC ophth soln unit/ml- 0.1% sulfacetamide sodium ophth 3 oint 10% sulfacetamide sodium ophth 3 soln 10% tobramycin ophth soln 0.3% 2 GC TOBREX OIN 0.3% OP 4 trifluridine ophth soln 1% 4 VIGAMOX DRO 0.5% 3 ZIRGAN GEL 0.15% 4 Antiinflamatorios ALREX SUS 0.2% 3 bromfenac sodium ophth soln % (base equiv) (oncedaily) bromfenac sodium ophth soln % (base equivalent) BROMSITE DRO 0.075% 4 dexamethasone sodium 3 phosphate ophth soln 0.1% diclofenac sodium ophth soln 3 0.1% DUREZOL EMU 0.05% 3 FLUOROMETHOLONE 4 OPHTH SUSP 0.1% flurbiprofen sodium ophth soln 0.03% ILEVRO DRO 0.3% OP 3 ketorolac tromethamine ophth 3 soln 0.4% ketorolac tromethamine ophth soln 0.5% 3 LOTEMAX GEL 0.5% 3 LOTEMAX OIN 0.5% 3 LOTEMAX SUS 0.5% 3 MAXIDEX SUS 0.1% OP 3 NEVANAC SUS 0.1% 4 pred sod pho sol 1% op 3 PREDNISOLONE ACETATE 3 OPHTH SUSP 1% Antialérgicos azelastine hcl ophth soln % BEPREVE DRO 1.5% 3 cromolyn sodium ophth soln 4% LASTACAFT SOL 0.25% 4 olopatadine hcl ophth soln 3 0.2% (base equivalent) PATADAY SOL 0.2% 3 PATANOL SOL 0.1% OP 4 PAZEO DRO 0.7% 3 Contra el glaucoma ALPHAGAN P SOL 0.1% 3 AZOPT SUS 1% OP 3 betaxolol hcl ophth soln 0.5% 4 BETOPTIC-S SUS 0.25% OP 3 brimonidine tartrate ophth 2 GC soln 0.2% BRIMONIDINE TARTRATE 4 OPHTH SOLN 0.15% carteolol hcl ophth soln 1% 2 GC COMBIGAN SOL 0.2/0.5% 3 dorzolamide hcl ophth soln 3 2% dorzolamide hcl-timolol 3 maleate ophth soln /ml ISTALOL SOL 0.5% OP 3 latanoprost ophth soln 2 GC 0.005% levobunolol hcl ophth soln 2 GC 0.5% LUMIGAN SOL 0.01% 3 metipranolol ophth soln 0.3% 3 ED - Excluido GC - Cobertura de Brecha 63

70 PHOSPHOLINE SOL %OP PILOCARPINE HCL OPHTH 4 SOLN 1% PILOCARPINE HCL OPHTH 4 SOLN 2% PILOCARPINE HCL OPHTH 4 SOLN 4% SIMBRINZA SUS 1-0.2% 3 TIMOLOL MALEATE OPHTH 4 GEL FORMING SOLN 0.5% TIMOLOL MALEATE OPHTH 4 GEL FORMING SOLN 0.25% timolol maleate ophth soln 0.5% timolol maleate ophth soln 0.25% TRAVATAN Z DRO 0.004% 3 Misceláneos CYSTARAN SOL 0.44% 5 LA PA naphazoline hcl ophth soln 0.1% PROLENSA SOL 0.07% 3 proparacaine hcl ophth soln 2 GC 0.5% RESTASIS EMU 0.05% QL (64 vials / 30 Inhibidores de la fosfodiesterasa tipo 5 Inhibidores de la fosfodiesterasa tipo 5 CIALIS TAB 10MG 3 ED QL QL (4 tabs / 30 CIALIS TAB 20MG 3 ED QL QL (4 tabs / 30 VIAGRA TAB 25MG 4 ED QL QL (4 tabs / 30 VIAGRA TAB 50MG 4 ED QL QL (4 tabs / 30 VIAGRA TAB 100MG 4 ED QL QL (4 tabs / 30 Respiratorio Combinaciones de anticolinérgico/beta agonista ANORO ELLIPT AER QL (60 blisters / 30 BEVESPI AER 9-4.8MCG QL (1 inhaler / 30 COMBIVENT AER QL (2 inhalers / 30 ipratropium-albuterol nebu 3 B/D soln (3) /3ml Anticolinérgicos ATROVENT HFA AER 17MCG QL (2 inhalers / 30 INCRUSE ELPT INH 62.5MCG QL (1 inhaler / 30 ipratropium bromide inhal soln 2 GC B/D 0.02% ipratropium bromide nasal 3 soln 0.03% (21 mcg/spray) ipratropium bromide nasal 3 soln 0.06% (42 mcg/spray) SPIRIVA AER 1.25MCG QL (1 inhaler / 30 SPIRIVA CAP HANDIHLR QL (30 caps / 30 SPIRIVA SPR 2.5MCG QL (1 inhaler / 30 Antihistamínicos azelastine hcl nasal spray 3 0.1% (137 mcg/spray) azelastine hcl nasal spray % (205.5 mcg/spray) cetirizine hcl oral soln 1 /ml 3 (5 /5ml) cyproheptadine hcl syrup 2 2 GC /5ml cyproheptadine hcl tab 4 2 GC diphenhydramine hcl elixir 2 GC 12.5 /5ml diphenhydramine hcl inj 50 2 GC /ml hydroxyzine hcl im soln 25 2 GC /ml hydroxyzine hcl im soln 50 2 GC /ml hydroxyzine hcl syrup 10 2 GC /5ml hydroxyzine hcl tab 10 2 GC ED - Excluido GC - Cobertura de Brecha 64

71 hydroxyzine hcl tab 25 2 GC hydroxyzine hcl tab 50 2 GC hydroxyzine pamoate cap 25 2 GC hydroxyzine pamoate cap 50 2 GC hydroxyzine pamoate cap GC levocetirizine dihydrochloride 4 soln 2.5 /5ml (0.5 /ml) levocetirizine dihydrochloride 2 GC tab 5 Beta agonistas albuterol sulfate soln nebu 2 GC B/D 0.5% (5 /ml) albuterol sulfate soln nebu 2 GC B/D 0.63 /3ml (base equiv) albuterol sulfate soln nebu 2 GC B/D 0.083% (2.5 /3ml) albuterol sulfate soln nebu 2 GC B/D 1.25 /3ml (base equiv) albuterol sulfate syrup 2 /5ml albuterol sulfate tab 2 4 albuterol sulfate tab 4 4 albuterol sulfate tab er 12hr 4 4 albuterol sulfate tab er 12hr 8 4 levalbuterol hcl soln nebu 4 B/D 1.25 /3ml (base equiv) levalbuterol hcl soln nebu 4 B/D conc 1.25 /0.5ml (base equiv) LEVALBUTEROL TARTRATE INHAL AEROSOL 45 MCG/ACT (BASE EQUIV) QL (2 inhalers / 30 PROAIR HFA AER QL (2 inhalers / 30 PROAIR RESPI AER QL (2 boxes / 30 PROVENTIL AER HFA QL (2 inhalers / 30 SEREVENT DIS AER 50MCG QL (60 inhalations / 30 terbutaline sulfate inj 1 /ml 5 terbutaline sulfate tab terbutaline sulfate tab 5 4 VENTOLIN HFA AER QL (2 inhalers / 30 Moduladores de los leucotrienos montelukast sodium chew tab 3 4 (base equiv) montelukast sodium chew tab 3 5 (base equiv) montelukast sodium oral 4 granules packet 4 (base equiv) montelukast sodium tab 10 3 (base equiv) zafirlukast tab 10 4 zafirlukast tab 20 4 Estabilizadores de los mastocitos cromolyn sodium soln nebu 3 B/D 20 /2ml Misceláneos acetylcysteine inhal soln 10% 3 B/D acetylcysteine inhal soln 20% 3 B/D ARALAST NP INJ 500MG 5 LA PA ARALAST NP INJ 1000MG 5 LA PA DALIRESP TAB 500MCG 4 EPIPEN 2-PAK INJ 0.3MG 3 EPIPEN-JR INJ 2-PAK 3 ESBRIET CAP 267MG 5 PA ESBRIET TAB 267MG 5 PA ESBRIET TAB 801MG 5 PA KALYDECO PAK 50MG 5 PA KALYDECO PAK 75MG 5 PA KALYDECO TAB 150MG 5 PA OFEV CAP 100MG 5 PA OFEV CAP 150MG 5 PA ORKAMBI TAB PA ORKAMBI TAB PA PROLASTIN-C INJ 1000MG 5 LA PA PULMOZYME SOL 1MG/ML 5 PA XOLAIR SOL 150MG 5 LA PA ED - Excluido GC - Cobertura de Brecha 65

72 ZEMAIRA INJ 1000MG 5 LA PA Esteroides nasales flunisolide nasal soln 25 mcg/act (0.025%) QL (2 bottles / 30 fluticasone propionate nasal 2 GC QL susp 50 mcg/act QL (1 bottle / 30 NASONEX SPR 50MCG/AC QL (2 inhalers / 30 QVAR AER 40MCG 4 QVAR AER 80MCG 4 Esteroides inhalados ARNUITY ELPT INH 100MCG QL (30 inhalations / 30 ARNUITY ELPT INH 200MCG QL (30 inhalations / 30 ASMANEX 30 AER 110MCG 4 ASMANEX 30 AER 220MCG 4 ASMANEX 60 AER 220MCG 4 ASMANEX 120 AER 220MCG 4 ASMANEX HFA AER MCG ASMANEX HFA AER MCG budesonide inhalation susp 4 B/D 0.5 /2ml budesonide inhalation susp 4 B/D 0.25 /2ml FLOVENT DISK AER 50MCG QL (120 inhalations / 30 FLOVENT DISK AER 100MCG QL (120 inhalations / 30 FLOVENT DISK AER 250MCG QL (240 inhalations / 30 FLOVENT HFA AER 44MCG QL (2 inhalers / 30 FLOVENT HFA AER 110MCG QL (2 inhalers / 30 FLOVENT HFA AER 220MCG QL (2 inhalers / 30 PULMICORT INH 90MCG QL (2 inhalers / 30 PULMICORT INH 180MCG QL (2 inhalers / 30 Combinaciones de esteroides/beta agonista ADVAIR DISKU AER 100/50 QL (60 inhalations / 30 ADVAIR DISKU AER 250/50 QL (60 inhalations / 30 ADVAIR DISKU AER 500/50 QL (60 inhalations / 30 ADVAIR HFA AER 45/21 QL (1 inhaler / 30 ADVAIR HFA AER 115/21 QL (1 inhaler / 30 ADVAIR HFA AER 230/21 QL (1 inhaler / 30 BREO ELLIPTA INH QL (60 blisters / 30 BREO ELLIPTA INH QL (60 blisters / 30 SYMBICORT AER QL (1 inhaler / 30 SYMBICORT AER QL (1 inhaler / 30 Xantinas aminophylline inj 25 /ml 3 elixophyllin elx 80/15ml 4 theo-24 cap 100 cr 4 theo-24 cap 200 cr 4 theo-24 cap 300 cr 4 theo-24 cap 400 er 4 theophylline soln 80 /15ml 4 ED - Excluido GC - Cobertura de Brecha 66

73 theophylline tab er 12hr tretinoin cream 0.1% 4 PA tretinoin cream 0.05% 4 PA theophylline tab er 12hr tretinoin cream 0.025% 4 PA TRETINOIN GEL 0.01% 4 PA theophylline tab er 12hr tretinoin gel 0.025% 4 PA zenatane cap 30 4 PA theophylline tab er 12hr Dermatología, antibióticos gentamicin sulfate cream 3 theophylline tab er 24hr % gentamicin sulfate oint 0.1% 3 theophylline tab er 24hr mupirocin oint 2% 2 GC SILVER SULFADIAZINE 2 GC De uso tópico CREAM 1% Dermatología, Acné SSD CRE 1% 2 GC adapalene cream 0.1% 4 SULFAMYLON CRE 4 adapalene gel 0.1% 4 85MG/GM AVITA CRE 0.025% 4 PA SULFAMYLON PAK 5% 5 AVITA GEL 0.025% 4 PA Dermatología, fungicidas benzoyl peroxideerythromycin gel 5-3% 4 ciclopirox gel 0.77% 4 ciclopirox olamine cream 3 claravis cap 10 4 PA 0.77% (base equiv) claravis cap 20 4 PA ciclopirox olamine susp 0.77% 3 claravis cap 30 4 PA (base equiv) claravis cap 40 4 PA ciclopirox shampoo 1% 4 clindamax gel 1% 4 ciclopirox solution 8% 2 GC clindamycin phosphate gel 4 clotrimazole cream 1% 3 1% clotrimazole soln 1% 3 clindamycin phosphate lotion 4 ketoconazole cream 2% 3 1% clindamycin phosphate soln 3 nyamyc pow % nyata pow clindamycin phosphate swab 3 nystatin cream % unit/gm erythromycin gel 2% 4 nystatin oint unit/gm 3 erythromycin pads 2% 4 nystatin topical powder 3 erythromycin soln 2% unit/gm isotretinoin cap 10 4 PA nystop pow isotretinoin cap 20 4 PA Dermatología, antipruriginosos isotretinoin cap 40 4 PA DOXEPIN HCL CREAM 5% 4 myorisan cap 10 4 PA hydrocortisone rectal cream 4 myorisan cap 20 4 PA 2.5% myorisan cap 30 4 PA procto-med cre hc 2.5% 4 myorisan cap 40 4 PA procto-pak cre 1% 4 sulfacetamide sodium lotion 4 proctozone cre -hc 2.5% 4 10% (acne) Dermatología, antipsoriásicos 67 ED - Excluido GC - Cobertura de Brecha

74 acitretin cap 10 5 PA acitretin cap PA acitretin cap 25 5 PA calcipotriene cream 0.005% 4 calcipotriene soln 0.005% (50 4 mcg/ml) 8-MOP CAP 10MG 4 tazarotene cream 0.1% 4 PA TAZORAC CRE 0.1% 4 PA TAZORAC CRE 0.05% 4 PA Dermatología, contra la seborreica ketoconazole shampoo 2% 2 GC selenium sulfide lotion 2.5% 2 GC Dermatología, corticosteroides ala-cort cre 1% ala-cort cre 2.5% alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05% betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented gel 0.05% betamethasone dipropionate augmented lotion 0.05% BETAMETHASONE DIPROPIONATE AUGMENTED OINT 0.05% betamethasone dipropionate 4 cream 0.05% betamethasone dipropionate 3 lotion 0.05% betamethasone dipropionate 4 oint 0.05% betamethasone valerate 3 cream 0.1% betamethasone valerate lotion 3 0.1% betamethasone valerate oint 3 0.1% desoximetasone cream 0.05% 4 desoximetasone cream 0.25% 4 desoximetasone gel 0.05% DESOXIMETASONE OINT % desoximetasone oint 0.25% 4 fluocin acet oil body 4 fluocin acet oil scalp 4 fluocinolone acetonide cream % fluocinolone acetonide cream % fluocinolone acetonide oint % fluocinolone acetonide soln % fluocinonide cream 0.05% 4 fluocinonide emulsified base 4 cream 0.05% fluocinonide gel 0.05% 4 fluocinonide soln 0.05% 4 fluticasone propionate cream 2 GC 0.05% fluticasone propionate oint 2 GC 0.005% halobetasol propionate cream % halobetasol propionate oint % hydrocortisone butyrate 4 cream 0.1% hydrocortisone butyrate oint 4 0.1% hydrocortisone butyrate soln 4 0.1% hydrocortisone cream 1% hydrocortisone cream 2.5% hydrocortisone lotion 2.5% 3 hydrocortisone oint 1% hydrocortisone oint 2.5% hydrocortisone valerate cream 4 0.2% hydrocortisone valerate oint 4 0.2% mometasone furoate cream 3 0.1% mometasone furoate oint 0.1% 3 ED - Excluido GC - Cobertura de Brecha 68

75 mometasone furoate solution 3 0.1% (lotion) texacort sol 2.5% 4 triamcinolone acetonide 2 GC cream 0.1% triamcinolone acetonide 2 GC cream 0.5% triamcinolone acetonide 2 GC cream 0.025% triamcinolone acetonide lotion 3 0.1% triamcinolone acetonide lotion % triamcinolone acetonide oint 2 GC 0.1% triamcinolone acetonide oint 2 GC 0.5% triamcinolone acetonide oint 0.025% 2 GC triderm cre 0.1% 2 GC Dermatología, anestésicos locales lidocaine hcl gel 2% 3 PA lidocaine hcl soln 4% PA lidocaine oint 5% 4 PA lidocaine patch 5% PA QL (3 patches / 1 day) lidocaine-prilocaine cream % 4 PA Dermatología, misceláneos de la piel y las membranas mucosas diclofenac sodium gel 1% 3 PA FLECTOR DIS 1.3% QL (60 patches / 30 fluorouracil cream 5% 4 fluorouracil soln 2% 4 fluorouracil soln 5% 4 imiquimod cream 5% 4 PA lactic acid (ammonium 3 lactate) cream 12% lactic acid (ammonium 2 GC lactate) lotion 12% metronidazole cream 0.75% 4 metronidazole gel 0.75% 4 metronidazole lotion 0.75% 4 PANRETIN GEL 0.1% 5 podofilox soln 0.5% 3 tacrolimus oint 0.1% 4 tacrolimus oint 0.03% 4 TARGRETIN GEL 1% 5 PA VALCHLOR GEL 0.016% 5 LA PA Dermatología, Escabicidas y contra la pediculosis EURAX CRE 10% 4 EURAX LOT 10% 4 malathion lotion 0.5% 4 permethrin cream 5% 3 Dermatología, agentes para el cuidad de heridas ACETIC ACID IRRIGATION SOLN 0.25% 2 GC REGRANEX GEL 0.01% 5 PA SANTYL OIN 250/GM 4 SODIUM CHLORIDE IRRIGATION SOLN 0.9% WATER FOR IRRIGATION, STERILE IRRIGATION SOLN 2 GC Agentes para la boca/garganta/dentales cevimeline hcl cap 30 4 chlorhexidine gluconate soln 0.12% clotrimazole troche 10 4 lidocaine hcl viscous soln 2% nystatin susp unit/ml 3 periogard sol 0.12% PILOCARPINE HCL TAB 5 4 MG pilocarpine hcl tab triamcinolone acetonide 3 dental paste 0.1% Ótico acetic acid 2% in aluminum 3 acetate otic soln ACETIC ACID Ótico SOLN 3 2% CIPRODEX SUS % 3 fluocinolone acetonide (otic) 4 oil 0.01% ED - Excluido GC - Cobertura de Brecha 69

76 neomycin-polymyxin-hc otic 3 soln 1% neomycin-polymyxin-hc otic 3 susp 3.5 /ml unit/ml- 1% ofloxacin otic soln 0.3% 4 Vitaminas Complejo de vitamina B cyanocobalamin inj 1000 mcg/ml 2 ED folic acid tab 1 1 ED GC QL FOLIC ACID TAB 1 MG 1 ED GC QL Vitamina D ergocalciferol cap unit 2 ED GC QL QL (4 caps / 28 Actividad de la vitamina K MEPHYTON TAB 5MG 4 ED QL ED - Excluido GC - Cobertura de Brecha 70

77 Index 8 8-MOP CAP 10MG A abacavir sulfate tab 300 (base equiv)...7 ABACAVIR SULFATE- LAMIVUDINE TAB MG...8 abacavir sulfate-lamivudinezidovudine tab ABELCET INJ 5MG/ML...6 ABILIFY MAIN INJ 300MG 35 ABILIFY MAIN INJ 400MG 35 ABRAXANE INJ 100MG acamprosate calcium tab delayed release acarbose tab acarbose tab acarbose tab acebutolol hcl cap acebutolol hcl cap acetaminophen w/ codeine soln /5ml...2 acetaminophen w/ codeine tab acetaminophen w/ codeine tab acetaminophen w/ codeine tab acetazolamide cap er 12hr acetazolamide tab acetazolamide tab acetic acid 2% in aluminum acetate otic soln ACETIC ACID IRRIGATION SOLN 0.25% ACETIC ACID OTIC SOLN 2% acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% acitretin cap acitretin cap acitretin cap ACTHIB INJ ACTIMMUNE INJ 2MU/ ACTONEL TAB 150MG ACTONEL TAB 30MG ACTONEL TAB 35MG ACTONEL TAB 5MG acyclovir cap acyclovir sodium for inj acyclovir sodium iv soln 50 /ml... 9 acyclovir susp 200 /5ml.. 9 acyclovir tab acyclovir tab ADACEL INJ ADAGEN INJ 250/ML adapalene cream 0.1% adapalene gel 0.1% ADCIRCA TAB 20MG adefovir dipivoxil tab 10 9 ADEMPAS TAB 0.5MG ADEMPAS TAB 1.5MG ADEMPAS TAB 1MG ADEMPAS TAB 2.5MG ADEMPAS TAB 2MG adriamycin inj adrucil inj 500/10ml ADVAIR DISKU AER 100/ ADVAIR DISKU AER 250/ ADVAIR DISKU AER 500/ ADVAIR HFA AER 115/21 66 ADVAIR HFA AER 230/21 66 ADVAIR HFA AER 45/ afeditab tab 30 cr afeditab tab 60 cr AFINITOR DIS TAB 2MG. 15 AFINITOR DIS TAB 3MG. 15 AFINITOR DIS TAB 5MG. 15 AFINITOR TAB 10MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG AGGRENOX CAP MG ala-cort cre 1% ala-cort cre 2.5% ALBENZA TAB 200MG... 5 albuterol sulfate soln nebu 0.083% (2.5 /3ml) albuterol sulfate soln nebu 0.5% (5 /ml) albuterol sulfate soln nebu 0.63 /3ml (base equiv). 65 albuterol sulfate soln nebu 1.25 /3ml (base equiv). 65 albuterol sulfate syrup 2 /5ml albuterol sulfate tab albuterol sulfate tab albuterol sulfate tab er 12hr albuterol sulfate tab er 12hr alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05% ALCOHOL SWABS ALDURAZYME INJ 2.9MG/5M ALECENSA CAP 150MG. 15 alendronate sodium tab alendronate sodium tab alendronate sodium tab alendronate sodium tab alendronate sodium tab alfuzosin hcl tab er 24hr ALIMTA INJ 100MG ALIMTA INJ 500MG ALINIA SUS 100/5ML... 5 ALINIA TAB 500MG... 5 allopurinol tab allopurinol tab ALORA DIS 0.025MG ALORA DIS 0.05MG ALORA DIS 0.075MG ALORA DIS 0.1MG

78 alosetron hcl tab 0.5 (base equiv) alosetron hcl tab 1 (base equiv) ALPHAGAN P SOL 0.1%.. 63 alprazolam tab alprazolam tab alprazolam tab alprazolam tab ALREX SUS 0.2% ALUNBRIG TAB 30MG alyacen tab 1/ amantadine hcl cap amantadine hcl syrup 50 /5ml amantadine hcl tab AMBISOME INJ 50MG...6 AMIFOSTINE FOR INJ 500 MG amikacin sulfate inj 1 gm/4ml (250 /ml)...5 amikacin sulfate inj 500 /2ml (250 /ml)...5 amiloride & hydrochlorothiazide tab amiloride hcl tab amino acid infusion 6% aminophylline inj 25 /ml 66 AMINOSYN 7% INJ /LYTES AMINOSYN II INJ 10% AMINOSYN II INJ 8.5% AMINOSYN II INJ 8.5/LYTE AMINOSYN INJ 10% AMINOSYN INJ 8.5% AMINOSYN INJ 8.5/LYTE. 61 AMINOSYN M INJ 3.5% AMINOSYN-HBC INJ 7%.. 61 AMINOSYN-PF INJ 10% AMINOSYN-PF INJ 7% AMINOSYN-RF INJ 5.2%. 61 amiodarone hcl inj 150 /3ml (50 /ml) amiodarone hcl inj 450 /9ml (50 /ml) amiodarone hcl inj 900 /18ml (50 /ml) amiodarone hcl tab amiodarone hcl tab amiodarone hcl tab AMITIZA CAP 24MCG AMITIZA CAP 8MCG amitriptyline hcl tab amitriptyline hcl tab amitriptyline hcl tab amitriptyline hcl tab amitriptyline hcl tab amitriptyline hcl tab amlodipine besylate tab amlodipine besylate tab amlodipine besylate tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylateatorvastatin calcium tab amlodipine besylatebenazepril hcl cap amlodipine besylatebenazepril hcl cap amlodipine besylatebenazepril hcl cap amlodipine besylatebenazepril hcl cap amlodipine besylatebenazepril hcl cap amlodipine besylatebenazepril hcl cap amlodipine besylateolmesartan medoxomil tab amlodipine besylateolmesartan medoxomil tab amlodipine besylateolmesartan medoxomil tab amlodipine besylateolmesartan medoxomil tab amlodipine besylatevalsartan tab amlodipine besylatevalsartan tab amlodipine besylatevalsartan tab amlodipine besylatevalsartan tab amlodipine-valsartanhydrochlorothiazide tab amlodipine-valsartanhydrochlorothiazide tab

79 amlodipine-valsartanhydrochlorothiazide tab amlodipine-valsartanhydrochlorothiazide tab amlodipine-valsartanhydrochlorothiazide tab amoxapine tab amoxapine tab amoxapine tab amoxapine tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate for susp /5ml. 11 amoxicillin & k clavulanate for susp /5ml. 11 amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml. 11 amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab er 12hr amoxicillin (trihydrate) cap amoxicillin (trihydrate) cap amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) for susp 125 /5ml amoxicillin (trihydrate) for susp 200 /5ml amoxicillin (trihydrate) for susp 250 /5ml amoxicillin (trihydrate) for susp 400 /5ml amoxicillin (trihydrate) tab amoxicillin (trihydrate) tab amphetaminedextroamphetamine cap er 24hr amphetaminedextroamphetamine cap er 24hr amphetaminedextroamphetamine cap er 24hr amphetaminedextroamphetamine cap er 24hr amphetaminedextroamphetamine cap er 24hr amphetaminedextroamphetamine cap er 24hr amphetaminedextroamphetamine tab amphetaminedextroamphetamine tab amphetaminedextroamphetamine tab amphetaminedextroamphetamine tab amphetaminedextroamphetamine tab amphetaminedextroamphetamine tab amphetaminedextroamphetamine tab amphotericin b for inj 50 6 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ampicillin & sulbactam sodium for inj 15 (10-5) gm ampicillin & sulbactam sodium for inj 3 (2-1) gm ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ampicillin cap ampicillin cap ampicillin for susp 125 /5ml ampicillin for susp 250 /5ml ampicillin sodium for inj 1 gm ampicillin sodium for inj 10 gm ampicillin sodium for inj ampicillin sodium for inj 2 gm ampicillin sodium for inj ampicillin sodium for inj ampicillin sodium for iv soln 1 gm ampicillin sodium for iv soln 10 gm ampicillin sodium for iv soln 2 gm AMPYRA TAB 10MG ANADROL-50 TAB 50MG 43 anagrelide hcl cap anagrelide hcl cap anastrozole tab ANDRODERM DIS 2MG/24HR ANDRODERM DIS 4MG/24HR ANORO ELLIPT AER APOKYN INJ 10MG/ML aprepitant capsule aprepitant capsule aprepitant capsule aprepitant capsule therapy pack 80 & apri tab APRISO CAP 0.375GM APTIOM TAB 200MG APTIOM TAB 400MG APTIOM TAB 600MG

80 APTIOM TAB 800MG APTIVUS CAP 250MG...7 APTIVUS SOL...7 ARALAST NP INJ 1000MG ARALAST NP INJ 500MG. 65 aranelle tab ARCALYST INJ 220MG aripiprazole oral solution 1 /ml aripiprazole orally disintegrating tab aripiprazole orally disintegrating tab aripiprazole tab aripiprazole tab aripiprazole tab aripiprazole tab aripiprazole tab aripiprazole tab ARISTADA INJ 441MG/ ARISTADA INJ 662MG/ ARISTADA INJ 882MG/ armodafinil tab ARMODAFINIL TAB 200 MG armodafinil tab armodafinil tab ARNUITY ELPT INH 100MCG ARNUITY ELPT INH 200MCG ASMANEX 120 AER 220MCG ASMANEX 30 AER 110MCG ASMANEX 30 AER 220MCG ASMANEX 60 AER 220MCG ASMANEX HFA AER 100 MCG ASMANEX HFA AER 200 MCG ASPIRIN-DIPYRIDAMOLE CAP ER 12HR MG 58 atenolol & chlorthalidone tab atenolol & chlorthalidone tab atenolol tab atenolol tab atenolol tab atomoxetine hcl cap 10 (base equiv) atomoxetine hcl cap 100 (base equiv) atomoxetine hcl cap 18 (base equiv) atomoxetine hcl cap 25 (base equiv) atomoxetine hcl cap 40 (base equiv) atomoxetine hcl cap 60 (base equiv) atomoxetine hcl cap 80 (base equiv) atorvastatin calcium tab 10 (base equivalent) atorvastatin calcium tab 20 (base equivalent) atorvastatin calcium tab 40 (base equivalent) atorvastatin calcium tab 80 (base equivalent) atovaquone susp 750 /5ml... 5 atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab ATRIPLA TAB... 8 ATROVENT HFA AER 17MCG aubra tab AURYXIA TAB 210MG AVANDIA TAB 2MG AVANDIA TAB 4MG AVASTIN INJ AVASTIN INJ 400/16ML aviane tab AVITA CRE 0.025% AVITA GEL 0.025% AVONEX KIT 30MCG AVONEX PEN KIT 30MCG AVONEX PREFL KIT 30MCG AXIRON SOL 30MG/ACT. 43 azacitidine for inj AZACTAM/DEX INJ 1GM... 5 AZACTAM/DEX INJ 2GM... 5 azathioprine inj azathioprine tab azelastine hcl nasal spray 0.1% (137 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 mcg/spray).. 64 azelastine hcl ophth soln 0.05% AZILECT TAB 0.5MG AZILECT TAB 1MG azithromycin for susp 100 /5ml azithromycin for susp 200 /5ml azithromycin iv for soln AZITHROMYCIN POWD PACK FOR SUSP 1 GM azithromycin tab azithromycin tab azithromycin tab AZOPT SUS 1% OP AZOR TAB 10-20MG AZOR TAB 10-40MG AZOR TAB 5-20MG AZOR TAB 5-40MG aztreonam for inj 1 gm... 5 aztreonam for inj 2 gm... 5 B bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint bacitracin-polymyxinneomycin-hc ophth oint 1% baclofen tab baclofen tab balsalazide disodium cap balziva tab BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG BARACLUDE SOL.05MG/ML... 9 BCG VACCINE INJ bekyree tab

81 BELEODAQ INJ 500MG benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril hcl tab benazepril hcl tab benazepril hcl tab benazepril hcl tab BENDEKA INJ 100/4ML BENLYSTA INJ 120MG BENLYSTA INJ 400MG benzoyl peroxideerythromycin gel 5-3% BENZTROPINE MESYLATE INJ 1 MG/ML benztropine mesylate tab benztropine mesylate tab benztropine mesylate tab BEPREVE DRO 1.5% BESIVANCE SUS 0.6% betamethasone dipropionate augmented cream 0.05%.. 68 betamethasone dipropionate augmented gel 0.05% betamethasone dipropionate augmented lotion 0.05% BETAMETHASONE DIPROPIONATE AUGMENTED OINT 0.05% betamethasone dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% betamethasone valerate cream 0.1% betamethasone valerate lotion 0.1% betamethasone valerate oint 0.1% BETASERON INJ 0.3MG.. 41 betaxolol hcl ophth soln 0.5% bethanechol chloride tab bethanechol chloride tab bethanechol chloride tab bethanechol chloride tab BETOPTIC-S SUS 0.25% OP BEVESPI AER 9-4.8MCG. 64 bexarotene cap BEXSERO INJ bicalutamide tab BICILLIN L-A INJ BICILLIN L-A INJ BICILLIN L-A INJ BICNU INJ 100MG BILTRICIDE TAB 600MG... 5 bisacodyl tab & peg kcl-sod bicarb-nacl for soln kit bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab bisoprolol fumarate tab bisoprolol fumarate tab BIVIGAM INJ 10% bleomycin sulfate for inj 15 unit bleomycin sulfate for inj 30 unit blephamide oin s.o.p blisovi fe tab 1.5/ blisovi fe tab 1/ BOOSTRIX INJ BOSULIF TAB 100MG BOSULIF TAB 500MG BREO ELLIPTA INH BREO ELLIPTA INH briellyn tab BRILINTA TAB 60MG BRILINTA TAB 90MG BRIMONIDINE TARTRATE OPHTH SOLN 0.15% brimonidine tartrate ophth soln 0.2% BRIVIACT INJ 50MG/5ML 27 BRIVIACT SOL 10MG/ML 28 BRIVIACT TAB 100MG BRIVIACT TAB 10MG BRIVIACT TAB 25MG BRIVIACT TAB 50MG BRIVIACT TAB 75MG bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) bromfenac sodium ophth soln 0.09% (base equivalent) bromocriptine mesylate cap 5 (base equivalent) bromocriptine mesylate tab 2.5 (base equivalent).. 34 BROMSITE DRO 0.075%. 63 budesonide delayed release particles cap budesonide inhalation susp 0.25 /2ml budesonide inhalation susp 0.5 /2ml bumetanide inj 0.25 /ml 25 bumetanide tab bumetanide tab bumetanide tab BUPHENYL TAB 500MG.. 48 buprenorphine hcl sl tab 2 (base equiv) buprenorphine hcl sl tab 8 (base equiv) buprenorphine hcl-naloxone hcl sl tab (base equiv)

82 buprenorphine hcl-naloxone hcl sl tab 8-2 (base equiv) bupropion hcl (smoking deterrent) tab er 12hr bupropion hcl tab bupropion hcl tab bupropion hcl tab er 12hr bupropion hcl tab er 12hr bupropion hcl tab er 12hr bupropion hcl tab er 24hr bupropion hcl tab er 24hr buspirone hcl tab buspirone hcl tab buspirone hcl tab buspirone hcl tab buspirone hcl tab busulfan inj 6 /ml BUSULFEX INJ 6MG/ML.. 13 butalbital-acetaminophen tab butalbital-acetaminophencaff w/ cod cap butalbital-acetaminophencaff w/ cod cap butalbital-acetaminophencaffeine cap butalbital-acetaminophencaffeine cap butalbital-acetaminophencaffeine tab butalbital-aspirin-caffeine cap butorphanol tartrate inj 1 /ml...2 butorphanol tartrate inj 2 /ml...2 BYDUREON INJ 2MG BYDUREON PEN INJ 2MG BYETTA INJ 10MCG BYETTA INJ 5MCG BYSTOLIC TAB 10MG BYSTOLIC TAB 2.5MG BYSTOLIC TAB 20MG BYSTOLIC TAB 5MG C cabergoline tab CABOMETYX TAB 20MG. 15 CABOMETYX TAB 40MG. 15 CABOMETYX TAB 60MG. 15 CADUET TAB 10-10MG CADUET TAB 10-20MG CADUET TAB 10-40MG CADUET TAB 10-80MG CADUET TAB 5-10MG CADUET TAB 5-20MG CADUET TAB 5-40MG CADUET TAB 5-80MG calcipotriene cream 0.005% calcipotriene soln 0.005% (50 mcg/ml) calcitonin (salmon) nasal soln 200 unit/act calcitriol cap 0.25 mcg calcitriol cap 0.5 mcg calcitriol inj 1 mcg/ml calcitriol oral soln 1 mcg/ml calcium acetate (phosphate binder) cap 667 (169 ca) calcium acetate (phosphate binder) tab camila tab CANASA SUP 1000MG CANCIDAS INJ 50MG... 6 CANCIDAS INJ 70MG... 6 candesartan cilexetil tab candesartan cilexetil tab candesartan cilexetil tab candesartan cilexetil tab candesartan cilexetilhydrochlorothiazide tab candesartan cilexetilhydrochlorothiazide tab candesartan cilexetilhydrochlorothiazide tab CAPASTAT SUL INJ 1GM.. 8 CAPRELSA TAB 100MG.. 15 CAPRELSA TAB 300MG.. 15 captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril tab captopril tab captopril tab captopril tab CARBAGLU TAB 200MG. 48 carbamazepine cap er 12hr carbamazepine cap er 12hr carbamazepine cap er 12hr carbamazepine chew tab carbamazepine susp 100 /5ml carbamazepine tab carbamazepine tab er 12hr carbamazepine tab er 12hr carbamazepine tab er 12hr carbidopa & levodopa orally disintegrating tab carbidopa & levodopa orally disintegrating tab

83 carbidopa & levodopa orally disintegrating tab carbidopa & levodopa tab carbidopa & levodopa tab carbidopa & levodopa tab carbidopa & levodopa tab er carbidopa & levodopa tab er carbidopa tab CARBIDOPA-LEVODOPA- ENTACAPONE TABS MG CARBIDOPA-LEVODOPA- ENTACAPONE TABS MG CARBIDOPA-LEVODOPA- ENTACAPONE TABS MG CARBIDOPA-LEVODOPA- ENTACAPONE TABS MG CARBIDOPA-LEVODOPA- ENTACAPONE TABS MG CARBIDOPA-LEVODOPA- ENTACAPONE TABS MG carboplatin iv soln 150 /15ml carboplatin iv soln 450 /45ml carboplatin iv soln 50 /5ml carboplatin iv soln 600 /60ml CARIMUNE NF INJ 12GM 58 CARIMUNE NF INJ 6GM.. 58 carisoprodol tab carteolol hcl ophth soln 1% carvedilol tab carvedilol tab carvedilol tab carvedilol tab CAYSTON INH 75MG...5 cefaclor cap cefaclor cap cefaclor er tab cefaclor for susp 125 /5ml... 9 cefaclor for susp 250 /5ml... 9 cefaclor for susp 375 /5ml... 9 cefadroxil cap cefadroxil for susp 250 /5ml... 9 cefadroxil for susp 500 /5ml... 9 cefadroxil tab 1 gm... 9 cefazolin inj 1gm/50ml... 9 cefazolin sodium for inj 1 gm... 9 cefazolin sodium for inj 10 gm... 9 cefazolin sodium for inj 20 gm... 9 cefazolin sodium for inj cefazolin sodium for iv soln 1 gm... 9 CEFAZOLIN SOL... 9 cefdinir cap cefdinir for susp 125 /5ml... 9 cefdinir for susp 250 /5ml... 9 cefepime hcl for inj 1 gm... 9 cefepime hcl for inj 2 gm... 9 cefixime for susp 100 /5ml... 9 cefixime for susp 200 /5ml... 9 cefotaxime sodium for inj 1 gm... 9 cefotaxime sodium for inj 2 gm... 9 cefotaxime sodium for inj cefoxitin sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln 2 gm cefpodoxime proxetil for susp 100 /5ml cefpodoxime proxetil for susp 50 /5ml cefpodoxime proxetil tab cefpodoxime proxetil tab cefprozil for susp 125 /5ml cefprozil for susp 250 /5ml cefprozil tab cefprozil tab ceftazidime for inj 1 gm ceftazidime for inj 2 gm ceftazidime for inj 6 gm CEFTAZIDIME/ SOL D5W 1GM CEFTAZIDIME/ SOL D5W 2GM ceftriaxone sodium for inj 1 gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 2 gm ceftriaxone sodium for inj ceftriaxone sodium for inj ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm cefuroxime axetil tab cefuroxime axetil tab cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj cefuroxime sodium for iv soln 1.5 gm celecoxib cap celecoxib cap celecoxib cap

84 celecoxib cap CELONTIN CAP 300MG cephalexin cap cephalexin cap cephalexin for susp 125 /5ml cephalexin for susp 250 /5ml CERDELGA CAP 84MG CEREZYME INJ 400UNIT 48 cetirizine hcl oral soln 1 /ml (5 /5ml) cevimeline hcl cap CHANTIX PAK 0.5& 1MG. 42 CHANTIX PAK 1MG CHANTIX TAB 0.5MG CHANTIX TAB 1MG CHEMET CAP 100MG chlordiazepoxide hcl cap chlordiazepoxide hcl cap chlordiazepoxide hcl cap chlorhexidine gluconate soln 0.12% chloroquine phosphate tab chloroquine phosphate tab chlorothiazide tab chlorothiazide tab chlorpromaz inj 25/ml chlorpromaz inj 50/2ml. 35 chlorpromazine hcl tab chlorpromazine hcl tab chlorpromazine hcl tab chlorpromazine hcl tab chlorpromazine hcl tab chlorthalidone tab chlorthalidone tab chlorzoxazone tab cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm choline fenofibrate cap dr 135 (fenofibric acid equiv) choline fenofibrate cap dr 45 (fenofibric acid equiv).. 21 CIALIS TAB 10MG CIALIS TAB 20MG ciclopirox gel 0.77% ciclopirox olamine cream 0.77% (base equiv) ciclopirox olamine susp 0.77% (base equiv) ciclopirox shampoo 1% ciclopirox solution 8% cilostazol tab cilostazol tab CILOXAN OIN 0.3% OP CINRYZE SOL 500 UNIT.. 57 CIPRODEX SUS % 69 ciprofloxacin 200 /100ml in d5w ciprofloxacin 400 /200ml in d5w ciprofloxacin for oral susp 250 /5ml (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 /5ml (10%) (10 gm/100ml) ciprofloxacin hcl ophth soln 0.3% ciprofloxacin hcl tab 100 (base equiv) ciprofloxacin hcl tab 250 (base equiv) ciprofloxacin hcl tab 500 (base equiv) ciprofloxacin hcl tab 750 (base equiv) ciprofloxacin iv soln 200 /20ml (1%) ciprofloxacin iv soln 400 /40ml (1%) ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 (base eq) cisplatin inj 100 /100ml (1 /ml) cisplatin inj 200 /200ml (1 /ml) cisplatin inj 50 /50ml (1 /ml) citalopram hydrobromide oral soln 10 /5ml citalopram hydrobromide tab 10 (base equiv) citalopram hydrobromide tab 20 (base equiv) citalopram hydrobromide tab 40 (base equiv) cladribine iv soln 10 /10ml (1 /ml) claravis cap claravis cap claravis cap claravis cap clarithromycin for susp 125 /5ml clarithromycin for susp 250 /5ml clarithromycin tab clarithromycin tab clarithromycin tab er 24hr clindamax gel 1% clindamycin hcl cap clindamycin hcl cap clindamycin hcl cap clindamycin palmitate hcl for soln 75 /5ml (base equiv)... 5 clindamycin phosphate gel 1% clindamycin phosphate in d5w iv soln 300 /50ml... 5 clindamycin phosphate in d5w iv soln 600 /50ml... 5 clindamycin phosphate in d5w iv soln 900 /50ml... 5 clindamycin phosphate inj 300 /2ml... 5 clindamycin phosphate inj 78

85 600 /4ml...5 clindamycin phosphate inj 9 gm/60ml...5 clindamycin phosphate inj 900 /6ml...5 clindamycin phosphate iv soln 300 /2ml...5 clindamycin phosphate iv soln 900 /6ml...6 clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate swab 1% clindamycin phosphate vaginal cream 2% CLINIMIX INJ 2.75/D5W CLINIMIX INJ 4.25/D CLINIMIX INJ 4.25/D CLINIMIX INJ 4.25/D CLINIMIX INJ 4.25/D5W CLINIMIX INJ 5%/D15W CLINIMIX INJ 5%/D20W CLINIMIX INJ 5%/D25W clomipramine hcl cap clomipramine hcl cap clomipramine hcl cap clonazepam orally disintegrating tab clonazepam orally disintegrating tab clonazepam orally disintegrating tab clonazepam orally disintegrating tab clonazepam orally disintegrating tab clonazepam tab clonazepam tab clonazepam tab clonidine hcl tab clonidine hcl tab clonidine hcl tab clonidine hcl td patch weekly 0.1 /24hr clonidine hcl td patch weekly 0.2 /24hr clonidine hcl td patch weekly 0.3 /24hr clopidogrel bisulfate tab 75 (base equiv) clorazepate dipotassium tab clorazepate dipotassium tab clorazepate dipotassium tab clotrimazole cream 1% clotrimazole soln 1% clotrimazole troche CLOZAPINE ORALLY DISINTEGRATING TAB 100 MG CLOZAPINE ORALLY DISINTEGRATING TAB 12.5 MG CLOZAPINE ORALLY DISINTEGRATING TAB 150 MG CLOZAPINE ORALLY DISINTEGRATING TAB 200 MG CLOZAPINE ORALLY DISINTEGRATING TAB 25 MG clozapine tab clozapine tab clozapine tab clozapine tab COARTEM TAB MG 7 colchicine w/ probenecid tab COLCRYS TAB 0.6MG... 2 colestipol hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm colistimethate sodium for inj COMBIGAN SOL 0.2/0.5% COMBIPATCH DIS.05/ COMBIPATCH DIS.05/ COMBIVENT AER COMETRIQ KIT 100MG COMETRIQ KIT 140MG COMETRIQ KIT 60MG COMPLERA TAB... 8 constulose sol 10gm/ COPAXONE INJ 20MG/ML COPAXONE INJ 40MG/ML COREG CR CAP 10MG COREG CR CAP 20MG COREG CR CAP 40MG COREG CR CAP 80MG cortisone acetate tab COTELLIC TAB 20MG COUMADIN TAB 10MG COUMADIN TAB 1MG COUMADIN TAB 2.5MG.. 56 COUMADIN TAB 2MG COUMADIN TAB 3MG COUMADIN TAB 4MG COUMADIN TAB 5MG COUMADIN TAB 6MG COUMADIN TAB 7.5MG.. 56 CREON CAP 12000UNT.. 55 CREON CAP 24000UNT.. 55 CREON CAP 3000UNIT CREON CAP 36000UNT.. 55 CREON CAP 6000UNIT CRIXIVAN CAP 200MG... 7 CRIXIVAN CAP 400MG... 7 cromolyn sodium ophth soln 4% cromolyn sodium oral conc 100 /5ml cromolyn sodium soln nebu 20 /2ml cryselle-28 tab 28 tabs CUBICIN SOL 500MG... 6 cyanocobalamin inj 1000 mcg/ml cyclafem tab 1/ cyclafem tab 7/7/ cyclobenzaprine hcl tab cyclobenzaprine hcl tab

86 CYCLOPHOSPH CAP 25MG CYCLOPHOSPH CAP 50MG cyclophosphamide for inj 1 gm cyclophosphamide for inj 2 gm cyclophosphamide for inj cycloserine cap cyclosporine cap cyclosporine cap cyclosporine iv soln 50 /ml cyclosporine modified cap cyclosporine modified cap cyclosporine modified cap cyclosporine modified oral soln 100 /ml cyproheptadine hcl syrup 2 /5ml cyproheptadine hcl tab CYSTADANE POW CYSTAGON CAP 150MG. 48 CYSTAGON CAP 50MG CYSTARAN SOL 0.44% cytarabine inj 20 /ml CYTOMEL TAB 25MCG CYTOMEL TAB 50MCG CYTOMEL TAB 5MCG D D10W/NACL INJ 0.2% D5W/LYTES INJ # D5W/NACL INJ 0.3% dacarbazine for inj dacarbazine for inj DAKLINZA TAB 30MG...9 DAKLINZA TAB 60MG...9 DAKLINZA TAB 90MG...9 DALIRESP TAB 500MCG. 65 danazol cap danazol cap danazol cap dantrolene sodium cap dantrolene sodium cap dantrolene sodium cap dapsone tab dapsone tab DAPTACEL INJ daptomycin for iv soln daunorubicin hcl inj 5 /ml (base equiv) deblitane tab DELESTROGEN INJ 10MG/ML delyla tab DELZICOL CAP 400MG DEMSER CAP 250MG DEPEN TITRA TAB 250MG DEPO-PROVERA INJ 400/ML DESCOVY TAB 200/ desipramine hcl tab desipramine hcl tab desipramine hcl tab desipramine hcl tab desipramine hcl tab desipramine hcl tab desmopressin acetate inj 4 mcg/ml DESMOPRESSIN ACETATE NASAL SOLN 0.01% (REFRIGERATED) desmopressin acetate nasal spray soln 0.01% desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab desmopressin acetate tab desogest-eth estrad & eth estrad tab /0.01 (21/5) desogest-ethin est tab / / desogestrel & ethinyl estradiol tab mcg desoximetasone cream 0.05% desoximetasone cream 0.25% desoximetasone gel 0.05% DESOXIMETASONE OINT 0.05% desoximetasone oint 0.25% desvenlafaxine succinate tab er 24hr 100 (base equiv) desvenlafaxine succinate tab er 24hr 25 (base equiv) desvenlafaxine succinate tab er 24hr 50 (base equiv) dexamethason con 1/ml dexamethasone elixir 0.5 /5ml dexamethasone sod phosphate preservative free inj 10 /ml dexamethasone sodium phosphate inj 10 /ml dexamethasone sodium phosphate inj 100 /10ml dexamethasone sodium phosphate inj 120 /30ml dexamethasone sodium phosphate inj 20 /5ml dexamethasone sodium phosphate inj 4 /ml dexamethasone sodium phosphate ophth soln 0.1% dexamethasone soln 0.5 /5ml dexamethasone tab dexamethasone tab

87 dexamethasone tab dexamethasone tab dexamethasone tab dexamethasone tab dexamethasone tab DEXILANT CAP 30MG DR DEXILANT CAP 60MG DR dexrazoxane for inj dexrazoxane for inj dextroamphetamine sulfate cap er 24hr dextroamphetamine sulfate cap er 24hr dextroamphetamine sulfate cap er 24hr dextroamphetamine sulfate tab dextroamphetamine sulfate tab DEXTROSE 10% W/ SODIUM CHLORIDE 0.45% DEXTROSE 2.5% W/ SODIUM CHLORIDE 0.45% DEXTROSE 5% IN LACTATED RINGERS DEXTROSE 5% W/ SODIUM CHLORIDE 0.2% DEXTROSE 5% W/ SODIUM CHLORIDE 0.225% DEXTROSE 5% W/ SODIUM CHLORIDE 0.33% DEXTROSE 5% W/ SODIUM CHLORIDE 0.45% DEXTROSE 5% W/ SODIUM CHLORIDE 0.9% DEXTROSE INJ 10% DEXTROSE INJ 5% DEXTROSE INJ 50% DEXTROSE INJ 70% diazepam con 5/ml diazepam inj 5 /ml diazepam oral soln 1 /ml DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG diazepam tab diazepam tab diazepam tab diclofenac potassium tab diclofenac sodium gel 1%. 69 diclofenac sodium ophth soln 0.1% diclofenac sodium tab delayed release diclofenac sodium tab delayed release diclofenac sodium tab delayed release diclofenac sodium tab er 24hr dicloxacillin sodium cap dicloxacillin sodium cap dicyclomine hcl cap dicyclomine hcl oral soln 10 /5ml dicyclomine hcl tab didanosine delayed release capsule didanosine delayed release capsule didanosine delayed release capsule didanosine delayed release capsule DIFICID TAB 200MG diflunisal tab digitek tab digitek tab digoxin inj 0.25 /ml DIGOXIN ORAL SOLN 0.05 MG/ML digoxin tab 125 mcg (0.125 ) digoxin tab 250 mcg (0.25 ) dihydroergotamine mesylate inj 1 /ml dilantin cap dilantin cap dilantin chw DILANTIN-125 SUS 125/5ML diltiazem hcl cap er 12hr diltiazem hcl cap er 12hr diltiazem hcl cap er 12hr diltiazem hcl cap er 24hr diltiazem hcl cap er 24hr diltiazem hcl cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr DILTIAZEM HCL COATED BEADS CAP ER 24HR 360 MG diltiazem hcl extended release beads cap er 24hr diltiazem hcl extended release beads cap er 24hr diltiazem hcl extended release beads cap er 24hr diltiazem hcl extended release beads cap er 24hr 81

88 diltiazem hcl extended release beads cap er 24hr diltiazem hcl extended release beads cap er 24hr diltiazem hcl iv soln 125 /25ml (5 /ml) diltiazem hcl iv soln 25 /5ml (5 /ml) diltiazem hcl iv soln 50 /10ml (5 /ml) diltiazem hcl tab diltiazem hcl tab diltiazem hcl tab diltiazem hcl tab DIP/TET PED INJ 25-5LFU DIPENTUM CAP 250MG.. 54 diphenhydramine hcl elixir 12.5 /5ml diphenhydramine hcl inj 50 /ml diphenoxylate w/ atropine liq /5ml diphenoxylate w/ atropine tab dipyridamole tab dipyridamole tab dipyridamole tab disopyramide phosphate cap disopyramide phosphate cap disulfiram tab disulfiram tab divalproex sodium cap delayed release sprinkle divalproex sodium tab delayed release divalproex sodium tab delayed release divalproex sodium tab delayed release divalproex sodium tab er 24 hr divalproex sodium tab er 24 hr DIVIGEL GEL 0.5MG DOCEFREZ INJ 20MG DOCETAXEL FOR INJ CONC 20 MG/ML docetaxel for inj conc 80 /4ml (20 /ml) DOCETAXEL INJ 160/16ML DOCETAXEL INJ 160/8ML docetaxel inj 200/ DOCETAXEL INJ 20MG/2ML DOCETAXEL INJ 80MG/4ML DOCETAXEL INJ 80MG/8ML DOFETILIDE CAP 125 MCG (0.125 MG) DOFETILIDE CAP 250 MCG (0.25 MG) DOFETILIDE CAP 500 MCG (0.5 MG) donepezil hydrochloride orally disintegrating tab donepezil hydrochloride orally disintegrating tab donepezil hydrochloride tab donepezil hydrochloride tab donepezil hydrochloride tab dorzolamide hcl ophth soln 2% dorzolamide hcl-timolol maleate ophth soln /ml doxazosin mesylate tab doxazosin mesylate tab doxazosin mesylate tab doxazosin mesylate tab doxepin hcl cap doxepin hcl cap doxepin hcl cap doxepin hcl cap doxepin hcl cap doxepin hcl cap doxepin hcl conc 10 /ml 32 DOXEPIN HCL CREAM 5% doxorubicin hcl for inj doxorubicin hcl inj 2 /ml 13 doxorubicin hcl liposomal inj (for iv infusion) 2 /ml doxy 100 inj doxycycline hyclate cap doxycycline hyclate cap doxycycline hyclate for inj doxycycline hyclate tab doxycycline hyclate tab doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate tab doxycycline monohydrate tab doxycycline monohydrate tab doxycycline monohydrate tab dronabinol cap dronabinol cap dronabinol cap drospirenone-ethinyl estradiol tab DROSPIRENONE-ETHINYL ESTRADIOL TAB MG drospirenone-ethinyl estradiol tab DROSPIRENONE-ETHINYL ESTRADIOL TAB MG DROXIA CAP 200MG DROXIA CAP 300MG

89 DROXIA CAP 400MG duloxetine hcl enteric coated pellets cap duloxetine hcl enteric coated pellets cap duloxetine hcl enteric coated pellets cap DURAMORPH INJ 0.5MG/ML...3 DURAMORPH INJ 1MG/ML...3 DUREZOL EMU 0.05% dutasteride cap dutasteride-tamsulosin hcl cap E EDURANT TAB 25MG...7 EFFIENT TAB 10MG EFFIENT TAB 5MG ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG ELITEK INJ 1.5MG ELITEK INJ 7.5MG elixophyllin elx 80/15ml ELLA TAB 30MG ELMIRON CAP 100MG EMCYT CAP 140MG EMEND CAP 125MG EMEND CAP 40MG EMEND CAP 80MG EMEND SUS 125MG EMEND TRIPAC PAK 80 & emoquette tab EMSAM DIS 12MG/24H EMSAM DIS 6MG/24HR EMSAM DIS 9MG/24HR EMTRIVA CAP 200MG...7 EMTRIVA SOL 10MG/ML...7 emverm chw ENABLEX TAB 15MG ENABLEX TAB 7.5MG enalapril maleate & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab enalapril maleate tab enalapril maleate tab enalapril maleate tab enalapril maleate tab 5 18 ENBREL INJ 25/0.5ML ENBREL INJ 25MG ENBREL INJ 50MG/ML ENBREL SRCLK INJ 50MG/ML endocet tab endocet tab endocet tab ENGERIX-B INJ 10/0.5ML 59 ENGERIX-B INJ 20MCG/ML enoxaparin sodium inj 100 /ml enoxaparin sodium inj 120 /0.8ml enoxaparin sodium inj 150 /ml enoxaparin sodium inj 30 /0.3ml ENOXAPARIN SODIUM INJ 300 MG/3ML enoxaparin sodium inj 40 /0.4ml enoxaparin sodium inj 60 /0.6ml enoxaparin sodium inj 80 /0.8ml enpresse-28 tab ENTACAPONE TAB 200 MG entecavir tab entecavir tab ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB MG enulose sol 10gm/ EPIPEN 2-PAK INJ 0.3MG EPIPEN-JR INJ 2-PAK epirubicin hcl iv soln 200 /100ml (2 /ml) epirubicin hcl iv soln 50 /25ml (2 /ml) epitol tab EPIVIR HBV SOL 5MG/ML. 9 eplerenone tab eplerenone tab ergocalciferol cap unit ergotamine w/ caffeine tab ERIVEDGE CAP 150MG.. 14 errin tab ery-tab tab 250 ec ery-tab tab 333 ec ery-tab tab 500 ec erythrocin inj erythrocin tab erythromycin ethylsuccinate tab erythromycin gel 2% erythromycin ophth oint 5 /gm erythromycin pads 2% erythromycin soln 2% erythromycin tab erythromycin tab erythromycin w/ delayed release particles cap ESBRIET CAP 267MG ESBRIET TAB 267MG ESBRIET TAB 801MG escitalopram oxalate soln 5 /5ml (base equiv) escitalopram oxalate tab 10 (base equiv) escitalopram oxalate tab 20 (base equiv) escitalopram oxalate tab 5 (base equiv) esomeprazole magnesium cap delayed release 20 (base eq) esomeprazole magnesium cap delayed release 40 (base eq) esomeprazole sodium for intravenous soln 20 (base equiv) esomeprazole sodium for intravenous soln 40 83

90 (base equiv) estazolam tab estazolam tab estrace vag cre 0.1/gm. 49 estradiol & norethindrone acetate tab estradiol & norethindrone acetate tab estradiol tab estradiol tab estradiol tab estradiol td patch twice weekly /24hr estradiol td patch twice weekly /24hr estradiol td patch twice weekly 0.05 /24hr estradiol td patch twice weekly /24hr estradiol td patch twice weekly 0.1 /24hr estradiol td patch weekly /24hr estradiol td patch weekly /24hr (37.5 mcg/24hr) estradiol td patch weekly 0.05 /24hr estradiol td patch weekly 0.06 /24hr estradiol td patch weekly /24hr estradiol td patch weekly 0.1 /24hr estradiol vaginal tab 10 mcg estradiol valerate im in oil 20 /ml estradiol valerate im in oil 40 /ml ESTRING MIS 2MG estropipate tab estropipate tab estropipate tab eszopiclone tab eszopiclone tab eszopiclone tab ethambutol hcl tab ethambutol hcl tab ethosuximide cap ethosuximide soln 250 /5ml ethynodiol diacetate & ethinyl estradiol tab 1-50 mcg etodolac cap etodolac cap etodolac tab etodolac tab etodolac tab er 24hr etodolac tab er 24hr etodolac tab er 24hr etoposide inj 100 /5ml (20 /ml) etoposide inj 500 /25ml (20 /ml) EURAX CRE 10% EURAX LOT 10% EVOTAZ TAB exemestane tab EXJADE TAB 125MG EXJADE TAB 250MG EXJADE TAB 500MG ezetimibe tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab F FABRAZYME INJ 35MG FABRAZYME INJ 5MG falmina tab famciclovir tab famciclovir tab famciclovir tab famotidine for susp 40 /5ml famotidine in nacl 0.9% iv soln 20 /50ml famotidine inj 20 /2ml famotidine inj 200 /20ml famotidine inj 40 /4ml famotidine tab famotidine tab FANAPT PAK FANAPT TAB 10MG FANAPT TAB 12MG FANAPT TAB 1MG FANAPT TAB 2MG FANAPT TAB 4MG FANAPT TAB 6MG FANAPT TAB 8MG FARESTON TAB 60MG FARXIGA TAB 10MG FARXIGA TAB 5MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG FASLODEX INJ 250MG fat emulsion iv soln 20% felbamate susp 600 /5ml felbamate tab felbamate tab felodipine tab er 24hr felodipine tab er 24hr felodipine tab er 24hr FEMRING MIS 0.05/24H.. 49 FEMRING MIS 0.1MG/ femynor tab fenofibrate micronized cap fenofibrate micronized cap fenofibrate micronized cap fenofibrate tab fenofibrate tab fenofibrate tab fenofibrate tab fentanyl citrate lozenge on a handle 1200 mcg... 3 fentanyl citrate lozenge on a handle 1600 mcg... 3 fentanyl citrate lozenge on a handle 200 mcg... 3 fentanyl citrate lozenge on a handle 400 mcg... 3 fentanyl citrate lozenge on a 84

91 handle 600 mcg...3 fentanyl citrate lozenge on a handle 800 mcg...3 fentanyl td patch 72hr 100 mcg/hr...3 fentanyl td patch 72hr 12 mcg/hr...3 fentanyl td patch 72hr 25 mcg/hr...3 fentanyl td patch 72hr 50 mcg/hr...3 fentanyl td patch 72hr 75 mcg/hr...3 FENTORA TAB 100MCG...3 FENTORA TAB 200MCG...3 FENTORA TAB 400MCG...3 FENTORA TAB 600MCG...3 FENTORA TAB 800MCG...3 FERRIPROX SOL 100MG/ML FERRIPROX TAB 500MG 46 FETZIMA CAP 120MG FETZIMA CAP 20MG FETZIMA CAP 40MG FETZIMA CAP 80MG FETZIMA CAP TITRATIO. 32 finasteride tab FIRAZYR INJ 30MG/3ML.. 57 FLEBOGAMMA INJ 10/100ML FLEBOGAMMA INJ 10/200ML FLEBOGAMMA INJ 20/200ML FLEBOGAMMA INJ 20/400ML FLEBOGAMMA INJ 5GM/50ML FLEBOGAMMA INJ DIF 5% flecainide acetate tab flecainide acetate tab flecainide acetate tab FLECTOR DIS 1.3% FLOVENT DISK AER 100MCG FLOVENT DISK AER 250MCG FLOVENT DISK AER 50MCG FLOVENT HFA AER 110MCG FLOVENT HFA AER 220MCG FLOVENT HFA AER 44MCG fluconazole for susp 10 /ml... 6 fluconazole for susp 40 /ml... 6 fluconazole in dextrose inj 200 /100ml... 6 fluconazole in dextrose inj 400 /200ml... 6 fluconazole in nacl 0.9% inj 200 /100ml... 6 fluconazole in nacl 0.9% inj 400 /200ml... 6 fluconazole tab fluconazole tab fluconazole tab fluconazole tab fluconazole/ inj nacl flucytosine cap flucytosine cap fludarabine phosphate for inj fludarabine phosphate inj 25 /ml fludrocortisone acetate tab flunisolide nasal soln 25 mcg/act (0.025%) fluocin acet oil body fluocin acet oil scalp fluocinolone acetonide (otic) oil 0.01% fluocinolone acetonide cream 0.01% fluocinolone acetonide cream 0.025% fluocinolone acetonide oint 0.025% fluocinolone acetonide soln 0.01% fluocinonide cream 0.05%. 68 fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05% fluocinonide soln 0.05% FLUOROMETHOLONE OPHTH SUSP 0.1% fluorouracil cream 5% fluorouracil inj 1 gm/20ml (50 /ml) fluorouracil inj 2.5 gm/50ml (50 /ml) fluorouracil inj 5 gm/100ml (50 /ml) fluorouracil inj 500 /10ml (50 /ml) fluorouracil soln 2% fluorouracil soln 5% fluoxetine hcl cap fluoxetine hcl cap fluoxetine hcl cap fluoxetine hcl solution 20 /5ml fluoxetine hcl tab fluoxetine hcl tab fluphenazine decanoate inj 25 /ml fluphenazine hcl elixir 2.5 /5ml fluphenazine hcl inj 2.5 /ml fluphenazine hcl oral conc 5 /ml fluphenazine hcl tab fluphenazine hcl tab fluphenazine hcl tab fluphenazine hcl tab flurbiprofen sodium ophth soln 0.03% flurbiprofen tab flurbiprofen tab flutamide cap fluticasone propionate cream 0.05% fluticasone propionate nasal susp 50 mcg/act fluticasone propionate oint 0.005% fluvoxamine maleate tab

92 fluvoxamine maleate tab fluvoxamine maleate tab folic acid tab FOLIC ACID TAB 1 MG fondaparinux sodium subcutaneous inj 10 /0.8ml fondaparinux sodium subcutaneous inj 2.5 /0.5ml fondaparinux sodium subcutaneous inj 5 /0.4ml fondaparinux sodium subcutaneous inj 7.5 /0.6ml FORTEO SOL 600/ FORTICAL SPR 200/ACT. 51 fosinopril sodium & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab fosinopril sodium tab fosinopril sodium tab fosinopril sodium tab FREAMINE HBC INJ 6.9% FREAMINE III INJ 10% furosemide inj 10 /ml FUROSEMIDE INJ 10 MG/ML furosemide oral soln 10 /ml furosemide oral soln 8 /ml furosemide tab furosemide tab furosemide tab FUSILEV INJ 50MG FUZEON INJ 90MG...7 FYCOMPA SUS 0.5MG/ML FYCOMPA TAB 10MG FYCOMPA TAB 12MG FYCOMPA TAB 2MG FYCOMPA TAB 4MG FYCOMPA TAB 6MG FYCOMPA TAB 8MG G gabapentin cap gabapentin cap gabapentin cap gabapentin oral soln 250 /5ml gabapentin tab gabapentin tab GABITRIL TAB 12MG GABITRIL TAB 16MG galantamine hydrobromide cap er 24hr galantamine hydrobromide cap er 24hr galantamine hydrobromide cap er 24hr galantamine hydrobromide oral soln 4 /ml galantamine hydrobromide tab galantamine hydrobromide tab galantamine hydrobromide tab GAMASTAN S/D INJ GAMMAGARD INJ 10GM/ GAMMAGARD INJ 1GM/10ML GAMMAGARD INJ 2.5GM/ GAMMAGARD INJ 20GM/ GAMMAGARD INJ 30GM/ GAMMAGARD INJ 5GM/50ML GAMMAGARD SD INJ 10GM HU GAMMAGARD SD INJ 5GM HU GAMMAKED INJ 10GM/ GAMMAKED INJ 1GM/10ML GAMMAKED INJ 2.5GM/ GAMMAKED INJ 20GM/ GAMMAKED INJ 5GM/50ML GAMMAPLEX INJ 10% GAMMAPLEX INJ 5% GAMUNEX-C INJ 10GM/ GAMUNEX-C INJ 1GM/10ML GAMUNEX-C INJ 2.5GM/ GAMUNEX-C INJ 20GM/ GAMUNEX-C INJ 40/400ML GAMUNEX-C INJ 5GM/50ML ganciclovir sodium for inj GARDASIL 9 INJ GARDASIL INJ gatifloxacin ophth soln 0.5% GATTEX KIT 5MG GAUZE PADS gavilyte-c sol gavilyte-g sol gavilyte-n sol flav pk gemcitabine hcl for inj 1 gm gemcitabine hcl for inj 2 gm gemcitabine hcl for inj GEMCITABINE HCL INJ 1 GM/26.3ML (38 MG/ML) (BASE EQUIV) GEMCITABINE HCL INJ 2 GM/52.6ML (38 MG/ML) (BASE EQUIV) GEMCITABINE HCL INJ 200 MG/5.26ML (38 MG/ML) (BASE EQUIV) gemfibrozil tab generlac sol 10gm/ gengraf cap gengraf cap

93 gengraf cap gengraf sol 100/ml GENOTROPIN INJ 0.2MG 50 GENOTROPIN INJ 0.4MG 50 GENOTROPIN INJ 0.6MG 50 GENOTROPIN INJ 0.8MG 50 GENOTROPIN INJ 1.2MG 50 GENOTROPIN INJ 1.4MG 50 GENOTROPIN INJ 1.6MG 50 GENOTROPIN INJ 1.8MG 50 GENOTROPIN INJ 12MG. 51 GENOTROPIN INJ 1MG GENOTROPIN INJ 2MG GENOTROPIN INJ 5MG gentak oin 0.3% op gentam/nacl inj 0.9/ml...5 gentam/nacl inj 1.4/ml...5 gentamicin in saline inj 0.8 /ml...5 gentamicin in saline inj 1 /ml...5 gentamicin in saline inj 1.2 /ml...5 gentamicin in saline inj 1.6 /ml...5 gentamicin in saline inj 2 /ml...5 gentamicin sulfate cream 0.1% gentamicin sulfate inj 10 /ml...5 gentamicin sulfate inj 40 /ml...5 gentamicin sulfate iv soln 10 /ml...5 gentamicin sulfate oint 0.1% gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% GENVOYA TAB...8 GEODON INJ 20MG gildagia tab GILENYA CAP 0.5MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG glatopa inj 20/ml GLEEVEC TAB 100MG GLEEVEC TAB 400MG GLEOSTINE CAP 100MG 13 GLEOSTINE CAP 10MG.. 13 GLEOSTINE CAP 40MG.. 13 GLEOSTINE CAP 5MG glimepiride tab glimepiride tab glimepiride tab glipizide tab glipizide tab glipizide tab er 24hr glipizide tab er 24hr GLIPIZIDE TAB ER 24HR 2.5 MG glipizide tab er 24hr GLIPIZIDE XL TAB 5MG.. 44 glipizide-metformin hcl tab glipizide-metformin hcl tab glipizide-metformin hcl tab GLUCAGEN INJ HYPOKIT GLUCAGON KIT 1MG glyburide micronized tab glyburide micronized tab glyburide micronized tab glyburide tab glyburide tab glyburide tab glyburide-metformin tab glyburide-metformin tab glyburide-metformin tab glycopyrrolate inj 4 /20ml (0.2 /ml) glycopyrrolate tab glycopyrrolate tab GOLYTELY SOL granisetron hcl inj 0.1 /ml granisetron hcl inj 1 /ml 53 granisetron hcl inj 4 /4ml (1 /ml) granisetron hcl tab GRANIX INJ 300/ GRANIX INJ 480/ griseofulvin microsize susp 125 /5ml... 7 griseofulvin microsize tab griseofulvin ultramicrosize tab griseofulvin ultramicrosize tab guanfacine hcl tab er 24hr 1 (base equiv) guanfacine hcl tab er 24hr 2 (base equiv) guanfacine hcl tab er 24hr 3 (base equiv) guanfacine hcl tab er 24hr 4 (base equiv) H halobetasol propionate cream 0.05% halobetasol propionate oint 0.05% haloperidol decanoate im soln 100 /ml haloperidol decanoate im soln 50 /ml haloperidol lactate inj 5 /ml haloperidol lactate oral conc 2 /ml haloperidol tab haloperidol tab haloperidol tab haloperidol tab haloperidol tab haloperidol tab HAVRIX INJ 1440UNIT HAVRIX INJ 720UNIT HEP SOD/NACL INJ 25000UNT heparin sodium (porcine) 100 unit/ml in d5w HEPARIN SODIUM (PORCINE) 40 UNIT/ML IN D5W HEPARIN SODIUM (PORCINE) 50 UNIT/ML IN 87

94 D5W heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj 5000 unit/ml HEPATAMINE SOL 8% HERCEPTIN INJ 150MG.. 14 HERCEPTIN INJ 440MG.. 14 HETLIOZ CAP 20MG HEXALEN CAP 50MG HIBERIX SOL 10MCG HUMIRA INJ 10MG/ HUMIRA KIT 20MG/ HUMIRA KIT 40MG/ HUMIRA PEDIA INJ CROHNS HUMIRA PEN INJ 40MG/ HUMIRA PEN INJ CROHNS HUMIRA PEN INJ PSORIASI HUMULIN R INJ U hydralazine hcl inj 20 /ml hydralazine hcl tab hydralazine hcl tab hydralazine hcl tab hydralazine hcl tab hydrochlorothiazide cap hydrochlorothiazide tab hydrochlorothiazide tab hydrochlorothiazide tab hydrocodone-acetaminophen soln /15ml...3 hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-ibuprofen tab hydrocortisone butyrate cream 0.1% hydrocortisone butyrate oint 0.1% hydrocortisone butyrate soln 0.1% hydrocortisone cream 1%. 68 hydrocortisone cream 2.5% hydrocortisone enema 100 /60ml HYDROCORTISONE ENEMA 100 MG/60ML hydrocortisone lotion 2.5% 68 hydrocortisone oint 1% hydrocortisone oint 2.5%.. 68 hydrocortisone rectal cream 2.5% hydrocortisone tab hydrocortisone tab hydrocortisone tab hydrocortisone valerate cream 0.2% hydrocortisone valerate oint 0.2% hydromorphone hcl liqd 1 /ml... 3 hydromorphone hcl preservative free (pf) inj 10 /ml... 3 hydromorphone hcl tab hydromorphone hcl tab hydromorphone hcl tab hydroxychloroquine sulfate tab hydroxyprogesterone caproate im in oil 1.25 gm/5ml hydroxyurea cap hydroxyzine hcl im soln 25 /ml hydroxyzine hcl im soln 50 /ml hydroxyzine hcl syrup 10 /5ml hydroxyzine hcl tab hydroxyzine hcl tab hydroxyzine hcl tab hydroxyzine pamoate cap hydroxyzine pamoate cap hydroxyzine pamoate cap I ibandronate sodium tab 150 (base equivalent) IBRANCE CAP 100MG IBRANCE CAP 125MG IBRANCE CAP 75MG ibuprofen susp 100 /5ml 2 ibuprofen tab ibuprofen tab ibuprofen tab ICLUSIG TAB 15MG ICLUSIG TAB 45MG idarubicin hcl iv inj 10 /10ml (1 /ml) idarubicin hcl iv inj 20 /20ml (1 /ml) idarubicin hcl iv inj 5 /5ml (1 /ml) IFEX INJ 3GM ifosfamide for inj 1 gm IFOSFAMIDE INJ 3GM ifosfamide iv inj 1 gm/20ml (50 /ml) ifosfamide iv inj 3 gm/60ml (50 /ml) ILEVRO DRO 0.3% OP imatinib mesylate tab 100 (base equivalent) imatinib mesylate tab 400 (base equivalent) IMBRUVICA CAP 140MG. 16 imipenem-cilastatin intravenous for soln imipenem-cilastatin intravenous for soln imipramine hcl tab imipramine hcl tab imipramine hcl tab imiquimod cream 5% IMOVAX RABIE INJ 2.5/ML

95 INCRELEX INJ 40MG/4ML INCRUSE ELPT INH 62.5MCG indapamide tab indapamide tab indomethacin cap indomethacin cap indomethacin cap er 75.2 INFANRIX INJ INLYTA TAB 1MG INLYTA TAB 5MG INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE INTELENCE TAB 100MG...7 INTELENCE TAB 200MG...7 INTELENCE TAB 25MG...7 INTRALIPID INJ 20% INTRALIPID INJ 30% INTRON A INJ 10MU INTRON A INJ 18MU INTRON A INJ 25MU INTRON A INJ 50MU introvale tab INVANZ INJ 1GM...6 INVEGA SUST INJ 117/ INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234/ INVEGA SUST INJ 39/ INVEGA SUST INJ 78/0.5ML INVEGA TRINZ INJ 273MG INVEGA TRINZ INJ 410MG INVEGA TRINZ INJ 546MG INVEGA TRINZ INJ 819MG INVIRASE CAP 200MG...7 INVIRASE TAB 500MG...7 INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB MG INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB MG INVOKANA TAB 100MG INVOKANA TAB 300MG IONOSOL-B/ INJ D5W IONOSOL-MB INJ /D5W IPOL INJ INACTIVE ipratropium bromide inhal soln 0.02% ipratropium bromide nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray) ipratropium-albuterol nebu soln (3) /3ml irbesartan tab irbesartan tab irbesartan tab irbesartanhydrochlorothiazide tab irbesartanhydrochlorothiazide tab IRESSA TAB 250MG irinotecan hcl inj 100 /5ml (20 /ml) irinotecan hcl inj 40 /2ml (20 /ml) irinotecan hcl inj 500 /25ml (20 /ml) ISENTRESS CHW 100MG. 7 ISENTRESS CHW 25MG... 7 ISENTRESS POW 100MG. 7 ISENTRESS TAB 400MG... 7 ISOLYTE-P INJ /D5W ISOLYTE-S INJ isoniazid inj 100 /ml... 8 isoniazid syrup 50 /5ml.. 8 isoniazid tab isoniazid tab ISORDIL TAB 40MG ISORDIL TAB 5MG isosorbide dinitrate tab isosorbide dinitrate tab isosorbide dinitrate tab isosorbide dinitrate tab isosorbide dinitrate tab er isosorbide mononitrate tab isosorbide mononitrate tab isosorbide mononitrate tab er 24hr isosorbide mononitrate tab er 24hr isosorbide mononitrate tab er 24hr isotretinoin cap isotretinoin cap isotretinoin cap isradipine cap isradipine cap ISTALOL SOL 0.5% OP ISTODAX OVR INJ 10MG 14 itraconazole cap ivermectin tab IXIARO INJ J JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG JAKAFI TAB 5MG jantoven tab jantoven tab jantoven tab jantoven tab jantoven tab jantoven tab jantoven tab jantoven tab

96 jantoven tab JANUMET TAB JANUMET TAB MG JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG JANUVIA TAB 100MG JANUVIA TAB 25MG JANUVIA TAB 50MG JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB XR jinteli tab 1-5mcg JOLIVETTE TAB 0.35MG. 47 juleber tab junel 1.5/30 tab junel 1/20 tab junel fe tab 1.5/ junel fe tab 1/ JUXTAPID CAP 10MG JUXTAPID CAP 20MG JUXTAPID CAP 30MG JUXTAPID CAP 40MG JUXTAPID CAP 5MG JUXTAPID CAP 60MG K KADCYLA INJ 100MG KADCYLA INJ 160MG KALETRA SOL...8 KALETRA TAB MG..8 KALETRA TAB MG..8 KALYDECO PAK 50MG KALYDECO PAK 75MG KALYDECO TAB 150MG.. 65 kariva tab 28 day KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% & NACL 0.45% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.2% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.33% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.45% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.9% INJ kcl 20 meq/l (0.15%) in nacl 0.45% inj KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ KCL 20 MEQ/L (0.15%) IN NACL 0.9% INJ KCL 30 MEQ/L (0.224%) IN DEXTROSE 5% & NACL 0.45% INJ KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & NACL 0.45% INJ KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ KCL/D5W/NACL INJ 0.15/ KCL/D5W/NACL INJ 0.3/0.9% kelnor tab 1/ ketoconazole cream 2% ketoconazole shampoo 2% ketoconazole tab ketoprofen cap ketoprofen cap ketorolac tromethamine ophth soln 0.4% ketorolac tromethamine ophth soln 0.5% KEYTRUDA INJ 100MG/4M KEYTRUDA SOL 50MG kimidess tab KINRIX INJ KISQALI 200 PAK FEMARA KISQALI 400 PAK FEMARA KISQALI 600 PAK FEMARA KISQALI TAB 200DOSE KISQALI TAB 400DOSE KISQALI TAB 600DOSE KLOR-CON 10 TAB 10MEQ ER KLOR-CON 8 TAB 8MEQ ER klor-con m15 tab 15meq er KORLYM TAB 300MG KUVAN POW 100MG KUVAN POW 500MG KUVAN TAB 100MG KYNAMRO INJ 200MG/ML L labetalol hcl tab labetalol hcl tab labetalol hcl tab LACTATED RINGER'S SOLUTION lactic acid (ammonium lactate) cream 12% lactic acid (ammonium lactate) lotion 12% lactulose (encephalopathy) solution 10 gm/15ml lactulose solution 10 gm/15ml lamivudine oral soln 10 /ml... 7 lamivudine tab 100 (hbv)... 9 lamivudine tab lamivudine tab lamivudine-zidovudine tab lamotrigine tab lamotrigine tab lamotrigine tab lamotrigine tab lamotrigine tab chewable dispersible lamotrigine tab chewable dispersible lamotrigine tab er 24hr lamotrigine tab er 24hr lamotrigine tab er 24hr lamotrigine tab er 24hr

97 lamotrigine tab er 24hr lamotrigine tab er 24hr lansoprazole cap delayed release lansoprazole cap delayed release LANTUS INJ 100/ML LANTUS INJ SOLOSTAR. 43 larin fe tab 1.5/ larin fe tab 1/ larin tab 1.5/ larin tab 1/ LASTACAFT SOL 0.25%.. 63 latanoprost ophth soln 0.005% LATUDA TAB 120MG LATUDA TAB 20MG LATUDA TAB 40MG LATUDA TAB 60MG LATUDA TAB 80MG leflunomide tab leflunomide tab LENVIMA CAP 10 MG LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 20 MG LENVIMA CAP 24 MG LENVIMA CAP 8 MG lessina tab LETAIRIS TAB 10MG LETAIRIS TAB 5MG letrozole tab leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium tab leucovorin calcium tab leucovorin calcium tab leucovorin calcium tab LEUKERAN TAB 2MG LEUKINE INJ 250MCG leuprolide acetate inj kit 5 /ml levalbuterol hcl soln nebu 1.25 /3ml (base equiv). 65 levalbuterol hcl soln nebu conc 1.25 /0.5ml (base equiv) LEVALBUTEROL TARTRATE INHAL AEROSOL 45 MCG/ACT (BASE EQUIV) LEVEMIR INJ LEVEMIR INJ FLEXTOUC 43 LEVETIRACETA INJ 10MG/ML LEVETIRACETA INJ 15MG/ML LEVETIRACETA INJ 5MG/ML levetiracetam in sodium chloride iv soln 1000 /100ml levetiracetam in sodium chloride iv soln 1500 /100ml levetiracetam in sodium chloride iv soln 500 /100ml levetiracetam inj 500 /5ml (100 /ml) levetiracetam oral soln 100 /ml levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab er 24hr levetiracetam tab er 24hr levobunolol hcl ophth soln 0.5% levocarnitine inj 200 /ml 48 levocarnitine oral soln 1 gm/10ml (10%) levocarnitine tab levocetirizine dihydrochloride soln 2.5 /5ml (0.5 /ml) levocetirizine dihydrochloride tab levofloxacin in d5w iv soln 250 /50ml levofloxacin in d5w iv soln 500 /100ml levofloxacin in d5w iv soln 750 /150ml levofloxacin iv soln 25 /ml levofloxacin oral soln 25 /ml levofloxacin tab levofloxacin tab levofloxacin tab LEVOLEUCOVOR INJ 175MG levoleucovor sol 250/ levoleucovorin calcium for iv inj 50 (base equiv) levoleucovorin calcium inj 175 /17.5ml (base equiv) levonest tab levonorgestrel & ethinyl estradiol (91-day) tab LEVONORGESTREL & ETHINYL ESTRADIOL (91- DAY) TAB MG.. 47 levonorgestrel & ethinyl estradiol tab mcg levonorgestrel & ethinyl estradiol tab mcg levonorgestrel tab levonorgestrel-eth estra tab / / mcg levora-28 tab 0.15/ levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg

98 levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg levothyroxine sodium tab 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 25 mcg LEVOTHYROXINE SODIUM TAB 300 MCG levothyroxine sodium tab 50 mcg LEVOTHYROXINE SODIUM TAB 75 MCG levothyroxine sodium tab 88 mcg LEVOXYL TAB 100MCG.. 52 LEVOXYL TAB 112MCG.. 52 LEVOXYL TAB 125MCG.. 52 LEVOXYL TAB 137MCG.. 52 LEVOXYL TAB 150MCG.. 52 LEVOXYL TAB 175MCG.. 52 LEVOXYL TAB 200MCG.. 52 LEVOXYL TAB 25MCG LEVOXYL TAB 50MCG LEVOXYL TAB 75MCG LEVOXYL TAB 88MCG LEXIVA SUS 50MG/ML...7 LEXIVA TAB 700MG...7 lidocaine hcl gel 2% lidocaine hcl local inj 0.5%..5 lidocaine hcl local inj 1%...5 lidocaine hcl local inj 1.5%..5 lidocaine hcl local inj 2%...5 lidocaine hcl local preservative free (pf) inj 0.5%...5 lidocaine hcl local preservative free (pf) inj 1% 5 lidocaine hcl soln 4% lidocaine hcl viscous soln 2% lidocaine oint 5% lidocaine patch 5% lidocaine-prilocaine cream % LINEZOLID FOR SUSP 100 MG/5ML... 6 LINEZOLID IN SODIUM CHLORIDE IV SOLN 600 MG/300ML-0.9%... 6 linezolid iv soln 600 /300ml (2 /ml)... 6 LINEZOLID TAB 600 MG... 6 LINZESS CAP 145MCG LINZESS CAP 290MCG LINZESS CAP 72MCG liothyronine sodium tab 25 mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 50 mcg lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril tab lisinopril tab lisinopril tab lisinopril tab lisinopril tab lisinopril tab lithium carbonate cap lithium carbonate cap lithium carbonate cap lithium carbonate tab lithium carbonate tab er lithium carbonate tab er LITHIUM SOL 8MEQ/5ML 41 LONSURF TAB LONSURF TAB loperamide hcl cap lopinavir-ritonavir soln /5ml (80-20 /ml).. 8 lorazepam con 2/ml lorazepam inj 2 /ml lorazepam inj 4 /ml lorazepam tab lorazepam tab lorazepam tab loryna tab losartan potassium & hydrochlorothiazide tab losartan potassium & hydrochlorothiazide tab losartan potassium & hydrochlorothiazide tab losartan potassium tab losartan potassium tab losartan potassium tab LOTEMAX GEL 0.5% LOTEMAX OIN 0.5% LOTEMAX SUS 0.5% lovastatin tab lovastatin tab lovastatin tab loxapine succinate cap loxapine succinate cap loxapine succinate cap loxapine succinate cap LUMIGAN SOL 0.01% LUMIZYME INJ 50MG LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG LUPR DEP-PED INJ 3M 30MG LUPR DEP-PED INJ 7.5MG LUPRON DEPOT INJ 11.25MG LUPRON DEPOT INJ 3.75MG

99 lutera tab LYNPARZA CAP 50MG LYRICA CAP 100MG LYRICA CAP 150MG LYRICA CAP 200MG LYRICA CAP 225MG LYRICA CAP 25MG LYRICA CAP 300MG LYRICA CAP 50MG LYRICA CAP 75MG LYRICA SOL 20MG/ML LYSODREN TAB 500MG.. 15 lyza tab M MAGNESIUM SU INJ 20/500ML MAGNESIUM SU INJ 2GM/50ML MAGNESIUM SU INJ 40G/ MAGNESIUM SU INJ 4G/100ML MAGNESIUM SU INJ 80MG/ML magnesium sulfate in dextrose 5% iv soln 1 gm/100ml magnesium sulfate inj 50% MAGNESIUM SULFATE INJ 50% magnesium sulfate iv soln 2 gm/50ml (40 /ml) malathion lotion 0.5% maprotiline hcl tab maprotiline hcl tab maprotiline hcl tab marlissa tab 0.15/ MARPLAN TAB 10MG MATULANE CAP 50MG MAXIDEX SUS 0.1% OP.. 63 meclizine hcl tab meclizine hcl tab medroxyprogesterone acetate im susp 150 /ml MEDROXYPROGESTERON E ACETATE IM SUSP PREFILLED SYR 150 MG/ML medroxyprogesterone acetate tab medroxyprogesterone acetate tab medroxyprogesterone acetate tab mefloquine hcl tab megestrol acetate susp 40 /ml MEGESTROL ACETATE SUSP 625 MG/5ML megestrol acetate tab megestrol acetate tab MEKINIST TAB 0.5MG MEKINIST TAB 2MG MELOXICAM SUSP 7.5 MG/5ML... 2 meloxicam tab meloxicam tab melphalan hcl for inj 50 (base equiv) memantine hcl oral solution 2 /ml MEMANTINE HCL TAB 10 MG memantine hcl tab MENACTRA INJ menest tab menest tab menest tab MENHIBRIX INJ MENOMUNE INJ A/C/Y/W 60 MENVEO INJ meperidine hcl oral soln 50 /5ml... 4 meperidine hcl tab meperidine hcl tab MEPHYTON TAB 5MG mercaptopurine tab meropenem iv for soln 1 gm 6 meropenem iv for soln mesalamine enema 4 gm.. 54 mesalamine rectal enema 4 gm & cleanser wipe kit MESALAMINE TAB DELAYED RELEASE 800 MG mesna inj 100 /ml MESNEX TAB 400MG metaxalone tab metaxalone tab metformin hcl tab metformin hcl tab metformin hcl tab metformin hcl tab er 24hr metformin hcl tab er 24hr methadone con 10/ml... 4 methadone hcl soln 10 /5ml... 4 methadone hcl soln 5 /5ml... 4 methadone hcl tab methadone hcl tab methazolamide tab methazolamide tab methenamine hippurate tab 1 gm... 6 methergine tab methimazole tab methimazole tab methocarbamol tab methocarbamol tab methotrexate sodium for inj 1 gm methotrexate sodium inj 250 /10ml (25 /ml) METHOTREXATE SODIUM INJ 50 MG/2ML (25 MG/ML) methotrexate sodium inj pf 100 /4ml (25 /ml) methotrexate sodium inj pf 1000 /40ml (25 /ml). 14 methotrexate sodium inj pf 200 /8ml (25 /ml) methotrexate sodium inj pf 250 /10ml (25 /ml) methotrexate sodium inj pf 50 /2ml (25 /ml) methotrexate sodium tab 2.5 (base equiv) methyclothiazide tab 5 25 methyldopa tab

100 methyldopa tab methylergonovine maleate tab methylphenidate hcl soln 10 /5ml methylphenidate hcl soln 5 /5ml methylphenidate hcl tab methylphenidate hcl tab methylphenidate hcl tab methylphenidate hcl tab er methylphenidate hcl tab er methylprednisolone acetate inj susp 40 /ml methylprednisolone acetate inj susp 80 /ml methylprednisolone sodium succinate for inj methylprednisolone sodium succinate for inj methylprednisolone sodium succinate for inj methylprednisolone tab methylprednisolone tab methylprednisolone tab methylprednisolone tab methylprednisolone tab therapy pack 4 (21) metipranolol ophth soln 0.3% metoclopramide hcl inj 5 /ml metoclopramide hcl soln 5 /5ml (10 /10ml) metoclopramide hcl tab metoclopramide hcl tab metolazone tab metolazone tab metolazone tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol succinate tab er 24hr 100 (tartrate equiv) metoprolol succinate tab er 24hr 200 (tartrate equiv) metoprolol succinate tab er 24hr 25 (tartrate equiv) 23 metoprolol succinate tab er 24hr 50 (tartrate equiv) 23 metoprolol tartrate iv soln 5 /5ml metoprolol tartrate iv soln cart inj 5 /5ml (1 /ml) 23 metoprolol tartrate tab metoprolol tartrate tab metoprolol tartrate tab metronidazole cream 0.75% metronidazole gel 0.75%.. 69 metronidazole in nacl 0.79% iv soln 500 /100ml... 6 metronidazole lotion 0.75% metronidazole tab metronidazole tab metronidazole vaginal gel 0.75% mexiletine hcl cap mexiletine hcl cap mexiletine hcl cap MG SO4/D5W INJ 10MG/ML MG SO4/D5W INJ 20MG/ML MIACALCIN INJ 200/ML midodrine hcl tab midodrine hcl tab midodrine hcl tab migergot sup 2/ mimvey lo tab mimvey tab minitran dis 0.1/hr minitran dis 0.2/hr minitran dis 0.4/hr minitran dis 0.6/hr minocycline hcl cap minocycline hcl cap minocycline hcl cap minoxidil tab minoxidil tab mirtazapine orally disintegrating tab mirtazapine orally disintegrating tab mirtazapine orally disintegrating tab mirtazapine tab mirtazapine tab mirtazapine tab mirtazapine tab misoprostol tab 100 mcg misoprostol tab 200 mcg mitomycin for iv soln mitomycin for iv soln mitomycin for iv soln 5 13 mitoxantrone hcl inj conc 20 /10ml (2 /ml) mitoxantrone hcl inj conc 25 /12.5ml (2 /ml) mitoxantrone hcl inj conc 30 /15ml (2 /ml) M-M-R II INJ moexipril hcl tab moexipril hcl tab moexiprilhydrochlorothiazide tab moexiprilhydrochlorothiazide tab moexiprilhydrochlorothiazide tab molindone hcl tab

101 molindone hcl tab molindone hcl tab mometasone furoate cream 0.1% mometasone furoate oint 0.1% mometasone furoate solution 0.1% (lotion) MONONESSA TAB montelukast sodium chew tab 4 (base equiv) montelukast sodium chew tab 5 (base equiv) montelukast sodium oral granules packet 4 (base equiv) montelukast sodium tab 10 (base equiv) MORPHINE SUL INJ 150/30ML...4 MORPHINE SUL INJ 2MG/ML...4 MORPHINE SUL INJ 4MG/ML...4 MORPHINE SUL INJ 8MG/ML...4 morphine sulfate inj pf 0.5 /ml...4 morphine sulfate inj pf 1 /ml...4 MORPHINE SULFATE IV SOLN 1 MG/ML...4 MORPHINE SULFATE IV SOLN PF 10 MG/ML...4 MORPHINE SULFATE IV SOLN PF 15 MG/ML...4 morphine sulfate iv soln pf 4 /ml...4 morphine sulfate iv soln pf 8 /ml...4 MORPHINE SULFATE ORAL SOLN 10 MG/5ML...4 MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)...4 MORPHINE SULFATE ORAL SOLN 20 MG/5ML...4 MORPHINE SULFATE TAB 15 MG...4 MORPHINE SULFATE TAB 30 MG... 4 morphine sulfate tab er morphine sulfate tab er morphine sulfate tab er morphine sulfate tab er morphine sulfate tab er MOVANTIK TAB 12.5MG. 54 MOVANTIK TAB 25MG MOVIPREP SOL MOXEZA SOL 0.5% moxifloxacin hcl tab 400 (base equiv) MOZOBIL INJ MULTAQ TAB 400MG mupirocin oint 2% MUSTARGEN INJ 10MG.. 13 MYCAMINE INJ 100MG... 7 MYCAMINE INJ 50MG... 7 mycophenolate mofetil cap mycophenolate mofetil for oral susp 200 /ml mycophenolate mofetil tab mycophenolate sodium tab dr 180 (mycophenolic acid equiv) mycophenolate sodium tab dr 360 (mycophenolic acid equiv) myorisan cap myorisan cap myorisan cap myorisan cap MYRBETRIQ TAB 25MG.. 56 MYRBETRIQ TAB 50MG.. 56 myzilra tab N nabumetone tab nabumetone tab nadolol tab nadolol tab nadolol tab nafcillin sodium for inj 1 gm nafcillin sodium for inj 10 gm nafcillin sodium for inj 2 gm nafcillin sodium for iv soln 1 gm nafcillin sodium for iv soln 2 gm NAGLAZYME INJ 1MG/ML nalbuphine hcl inj 10 /ml 2 nalbuphine hcl inj 20 /ml 2 naloxone hcl inj 0.4 /ml 42 naloxone hcl inj 4 /10ml 42 naloxone hcl soln cartridge 0.4 /ml naloxone hcl soln prefilled syringe 2 /2ml naltrexone hcl tab NAMENDA XR CAP 14MG NAMENDA XR CAP 21MG NAMENDA XR CAP 28MG NAMENDA XR CAP 7MG. 31 NAMENDA XR CAP TITRATIO NAMZARIC CAP NAMZARIC CAP 14-10MG NAMZARIC CAP 21-10MG NAMZARIC CAP 28-10MG NAMZARIC CAP 7-10MG. 31 naphazoline hcl ophth soln 0.1% naproxen dr tab naproxen dr tab naproxen sodium tab naproxen sodium tab naproxen susp 125 /5ml 2 naproxen tab naproxen tab naproxen tab naratriptan hcl tab 1 (base equiv)

102 naratriptan hcl tab 2.5 (base equiv) NASONEX SPR 50MCG/AC NATACYN SUS 5% OP nateglinide tab nateglinide tab NATPARA INJ 100MCG NATPARA INJ 25MCG NATPARA INJ 50MCG NATPARA INJ 75MCG NEBUPENT INH 300MG...6 necon tab 0.5/ NECON TAB 1/ necon tab 10/ NECON TAB 7/7/ nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab neomycin sulfate tab neomycin-bacitrac znpolymyx 5(3.5)-400unt unt op oin neomycin-polymy-gramicid op sol unt-/ml neomycin-polymyxindexamethasone ophth oint 0.1% neomycin-polymyxindexamethasone ophth susp 0.1% neomycin-polymyxin-hc ophth susp neomycin-polymyxin-hc otic soln 1% neomycin-polymyxin-hc otic susp 3.5 /ml unit/ml-1% NEORAL CAP 100MG NEORAL CAP 25MG NEORAL SOL 100MG/ML 59 NEPHRAMINE INJ 5.4% NEUPOGEN INJ 300/ NEUPOGEN INJ 300MCG 57 NEUPOGEN INJ 480/ NEUPOGEN INJ 480MCG 57 NEUPRO DIS 1MG/24HR. 34 NEUPRO DIS 2MG/24HR. 34 NEUPRO DIS 3MG/24HR. 34 NEUPRO DIS 4MG/24HR. 34 NEUPRO DIS 6MG/24HR. 34 NEUPRO DIS 8MG/24HR. 34 NEVANAC SUS 0.1% NEVIRAPINE SUSP 50 MG/5ML... 7 nevirapine tab nevirapine tab er 24hr nevirapine tab er 24hr NEXAVAR TAB 200MG NEXIUM GRA 10MG DR.. 55 NEXIUM GRA 2.5MG DR. 55 NEXIUM GRA 20MG DR.. 55 NEXIUM GRA 40MG DR.. 55 NEXIUM GRA 5MG DR niacin tab er 1000 (antihyperlipidemic) niacin tab er 500 (antihyperlipidemic) niacin tab er 750 (antihyperlipidemic) niacor tab nicardipine hcl cap nicardipine hcl cap NICOTROL INH NICOTROL NS SPR 10MG/ML nifedipine cap nifedipine cap nifedipine tab er 24hr nifedipine tab er 24hr nifedipine tab er 24hr nifedipine tab er 24hr osmotic release nifedipine tab er 24hr osmotic release nifedipine tab er 24hr osmotic release nikki tab nilutamide tab nimodipine cap NINLARO CAP 2.3MG NINLARO CAP 3MG NINLARO CAP 4MG NIPENT INJ 10MG nitro-bid oin 2% NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.8MG/HR nitrofurantoin macrocrystalline cap nitrofurantoin macrocrystalline cap 50 6 nitrofurantoin monohydrate macrocrystalline cap nitroglycerin sl tab nitroglycerin sl tab nitroglycerin sl tab nitroglycerin td patch 24hr 0.1 /hr nitroglycerin td patch 24hr 0.2 /hr nitroglycerin td patch 24hr 0.4 /hr nitroglycerin td patch 24hr 0.6 /hr NORDITROPIN INJ 10/1.5ML NORDITROPIN INJ 15/1.5ML NORDITROPIN INJ 30/3ML NORDITROPIN INJ 5/1.5ML norelgestromin-ethinyl estradiol td ptwk mcg/24hr norethindrone & ethinyl estradiol tab 1-35 mcg 47 norethindrone ace & ethinyl estradiol tab 1-20 mcg 47 NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG norethindrone ace & ethinyl 96

103 estradiol tab mcg NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG norethindrone acetate tab norethindrone acetate-ethinyl estradiol tab 1-5 mcg.. 49 NORETHINDRONE AC- ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG.. 47 norethindrone tab NORETHINDRONE TAB 0.35 MG NORETHINDRONE-ETH ESTRADIOL TAB /1-35/ MG-MCG norgestimate & ethinyl estradiol tab mcg norgestimate-eth estrad tab / / mcg norgestimate-eth estrad tab / / mcg norgestrel & ethinyl estradiol tab mcg norlyroc tab NORMOSOL -M INJ /D5W 62 NORMOSOL -R INJ /D5W 62 NORMOSOL-R INJ PH NORPACE CAP 100MG CR NORPACE CAP 150MG CR NORTHERA CAP 100MG. 26 NORTHERA CAP 200MG. 26 NORTHERA CAP 300MG. 26 nortrel tab 0.5/ nortrel tab 1/ nortrel tab 7/7/ nortriptyline hcl cap nortriptyline hcl cap nortriptyline hcl cap nortriptyline hcl cap nortriptyline hcl soln 10 /5ml NORVIR CAP 100MG... 7 NORVIR SOL 80MG/ML... 7 NORVIR TAB 100MG... 7 NOVOLIN INJ 70/ NOVOLIN N INJ U NOVOLIN R INJ U NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN 43 NOVOLOG INJ PENFILL.. 43 NOVOLOG MIX INJ 70/30 43 NOVOLOG MIX INJ FLEXPEN NOXAFIL SUS 40MG/ML... 7 NOXAFIL TAB 100MG... 7 NUEDEXTA CAP 20-10MG NULOJIX INJ 250MG NULYTELY SOL FLAV PKS NUPLAZID TAB 17MG NUVARING MIS nyamyc pow nyata pow NYMALIZE SOL 60/20ML. 24 nystatin cream unit/gm nystatin oint unit/gm nystatin susp unit/ml nystatin tab unit... 7 nystatin topical powder unit/gm nystop pow O OCTAGAM INJ 10GM OCTAGAM INJ 1GM OCTAGAM INJ 2.5GM OCTAGAM INJ 25GM OCTAGAM INJ 2GM/20ML OCTAGAM INJ 5GM octreotide acetate inj 100 mcg/ml (0.1 /ml) octreotide acetate inj 1000 mcg/ml (1 /ml) octreotide acetate inj 200 mcg/ml (0.2 /ml) octreotide acetate inj 50 mcg/ml (0.05 /ml) octreotide acetate inj 500 mcg/ml (0.5 /ml) ODEFSEY TAB... 8 ODOMZO CAP 200MG OFEV CAP 100MG OFEV CAP 150MG ofloxacin ophth soln 0.3%. 63 ofloxacin otic soln 0.3% olanzapine for im inj olanzapine orally disintegrating tab olanzapine orally disintegrating tab olanzapine orally disintegrating tab olanzapine orally disintegrating tab olanzapine tab olanzapine tab olanzapine tab olanzapine tab olanzapine tab olanzapine tab olmesartan medoxomil tab olmesartan medoxomil tab olmesartan medoxomil tab olmesartan medoxomilhydrochlorothiazide tab olmesartan medoxomilhydrochlorothiazide tab olmesartan medoxomilhydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab 40-97

104 olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olopatadine hcl ophth soln 0.2% (base equivalent) omega-3-acid ethyl esters cap 1 gm omeprazole cap delayed release omeprazole cap delayed release omeprazole cap delayed release ondansetron hcl inj 4 /2ml (2 /ml) ondansetron hcl inj 40 /20ml (2 /ml) ondansetron hcl oral soln 4 /5ml ondansetron hcl tab ondansetron hcl tab ondansetron hcl tab ondansetron orally disintegrating tab ondansetron orally disintegrating tab ONFI SUS 2.5MG/ML ONFI TAB 10MG ONFI TAB 20MG ONGLYZA TAB 2.5MG ONGLYZA TAB 5MG OPSUMIT TAB 10MG ORFADIN CAP 10MG ORFADIN CAP 20MG ORFADIN CAP 2MG ORFADIN CAP 5MG ORFADIN SUS 4MG/ML ORKAMBI TAB ORKAMBI TAB orphenadrine citrate tab er 12hr orsythia tab oseltamivir phosphate cap 30 (base equiv)... 9 oseltamivir phosphate cap 45 (base equiv)... 9 oseltamivir phosphate cap 75 (base equiv)... 9 oxacillin sodium for inj 1 gm oxacillin sodium for inj 10 gm oxacillin sodium for inj 2 gm oxaliplatin for iv inj oxaliplatin for iv inj oxaliplatin iv soln 100 /20ml oxaliplatin iv soln 50 /10ml oxandrolone tab oxandrolone tab oxcarbazepine susp 300 /5ml (60 /ml) oxcarbazepine tab oxcarbazepine tab oxcarbazepine tab oxybutynin chloride syrup 5 /5ml oxybutynin chloride tab oxybutynin chloride tab er 24hr oxybutynin chloride tab er 24hr oxybutynin chloride tab er 24hr oxycodone hcl cap oxycodone hcl conc 100 /5ml (20 /ml)... 4 OXYCODONE HCL SOLN 5 MG/5ML... 4 oxycodone hcl tab oxycodone hcl tab oxycodone hcl tab oxycodone hcl tab oxycodone hcl tab oxycodone w/ acetaminophen soln /5ml... 4 oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab P pacerone tab pacerone tab pacerone tab paclitaxel iv conc 100 /16.7ml (6 /ml) paclitaxel iv conc 150 /25ml (6 /ml) paclitaxel iv conc 30 /5ml (6 /ml) paclitaxel iv conc 300 /50ml (6 /ml) paliperidone tab er 24hr paliperidone tab er 24hr paliperidone tab er 24hr paliperidone tab er 24hr pamidronate disodium for inj pamidronate disodium for inj pamidronate disodium iv soln 3 /ml pamidronate disodium iv soln 9 /ml pamidronate inj 6/ml PANRETIN GEL 0.1% pantoprazole sodium ec tab 20 (base equiv) pantoprazole sodium ec tab 40 (base equiv) paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg paromomycin sulfate cap paroxetine hcl tab paroxetine hcl tab

105 paroxetine hcl tab paroxetine hcl tab paser gra 4gm...8 PATADAY SOL 0.2% PATANOL SOL 0.1% OP.. 63 PAXIL SUS 10MG/5ML PAZEO DRO 0.7% PEDIARIX INJ 0.5ML PEDVAX HIB INJ PEG 3350-KCL-NA BICARB- NACL-NA SULFATE FOR SOLN 236 GM PEG 3350-KCL-NA BICARB- NACL-NA SULFATE FOR SOLN 240 GM peg 3350-kcl-sod bicarb-nacl for soln 420 gm PEGANONE TAB 250MG. 30 PEGASYS INJ...9 PEGASYS INJ 180MCG/M.9 PEGASYS INJ PROCLICK.9 pen g proc inj PENICILL GK/ INJ DEX 2MU PENICILL GK/ INJ DEX 3MU penicillin g potassium for inj unit penicillin g potassium for inj unit penicillin g sodium for inj unit penicillin v potassium for soln 125 /5ml penicillin v potassium for soln 250 /5ml penicillin v potassium tab penicillin v potassium tab PENTACEL INJ PENTAM 300 INJ 300MG...6 pentoxifylline tab er perindopril erbumine tab perindopril erbumine tab perindopril erbumine tab periogard sol 0.12% permethrin cream 5% perphenazine tab perphenazine tab perphenazine tab perphenazine tab perphenazine-amitriptyline tab perphenazine-amitriptyline tab perphenazine-amitriptyline tab perphenazine-amitriptyline tab perphenazine-amitriptyline tab phenadoz sup phenelzine sulfate tab phenergan sup phenergan sup phenergan sup PHENOBARB INJ 65MG/ML phenobarbital elixir 20 /5ml phenobarbital sodium inj 130 /ml phenobarbital tab phenobarbital tab phenobarbital tab phenobarbital tab phenobarbital tab phenobarbital tab phenobarbital tab phenobarbital tab phenytek cap phenytek cap phenytoin chew tab phenytoin sodium extended cap phenytoin sodium extended cap phenytoin sodium extended cap phenytoin sodium inj 50 /ml phenytoin susp 125 /5ml philith tab PHOSPHOLINE SOL 0.125%OP PILOCARPINE HCL OPHTH SOLN 1% PILOCARPINE HCL OPHTH SOLN 2% PILOCARPINE HCL OPHTH SOLN 4% PILOCARPINE HCL TAB 5 MG pilocarpine hcl tab pimozide tab pimozide tab pimtrea tab pindolol tab pindolol tab pioglitazone hcl tab 15 (base equiv) pioglitazone hcl tab 30 (base equiv) pioglitazone hcl tab 45 (base equiv) pioglitazone hcl-metformin hcl tab pioglitazone hcl-metformin hcl tab piper/tazoba inj gm. 12 piperacillin sod-tazobactam na for inj gm ( gm) piperacillin sod-tazobactam sod for inj 2.25 gm ( gm) piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 gm ( gm) pirmella tab 1/ piroxicam cap piroxicam cap PLASMA-LYTE INJ PLASMA-LYTE INJ -A podofilox soln 0.5% polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder polymyxin b-trimethoprim 99

106 ophth soln unit/ml- 0.1% POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG portia-28 tab POTASSIUM CHLORIDE 20 MEQ/L (0.15%) IN DEXTROSE 5% INJ POTASSIUM CHLORIDE 40 MEQ/L (0.3%) IN DEXTROSE 5% INJ potassium chloride cap er 10 meq potassium chloride cap er 8 meq POTASSIUM CHLORIDE INJ 10 MEQ/100ML POTASSIUM CHLORIDE INJ 10 MEQ/50ML potassium chloride inj 2 meq/ml POTASSIUM CHLORIDE INJ 20 MEQ/100ML POTASSIUM CHLORIDE INJ 20 MEQ/50ML POTASSIUM CHLORIDE INJ 40 MEQ/100ML potassium chloride microencapsulated crys er tab 10 meq potassium chloride microencapsulated crys er tab 20 meq POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML) POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML) POTASSIUM CHLORIDE POWDER PACKET 20 MEQ potassium chloride tab er 10 meq potassium chloride tab er 20 meq (1500 ) potassium chloride tab er 8 meq (600 ) POTASSIUM CITRATE TAB ER 10 MEQ (1080 MG) potassium citrate tab er 15 meq (1620 ) POTASSIUM CITRATE TAB ER 5 MEQ (540 MG) POTIGA TAB 200MG POTIGA TAB 300MG POTIGA TAB 400MG POTIGA TAB 50MG PRADAXA CAP 110MG PRADAXA CAP 150MG PRADAXA CAP 75MG PRALUENT INJ 150MG/ML PRALUENT INJ 75MG/ML 22 pramipexole dihydrochloride tab pramipexole dihydrochloride tab pramipexole dihydrochloride tab pramipexole dihydrochloride tab pramipexole dihydrochloride tab pramipexole dihydrochloride tab pravastatin sodium tab pravastatin sodium tab pravastatin sodium tab pravastatin sodium tab prazosin hcl cap prazosin hcl cap prazosin hcl cap pred sod pho sol 1% op PREDNISOLONE ACETATE OPHTH SUSP 1% prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base) prednisolone sod phosphate oral soln 15 /5ml (base equiv) prednisolone sodium phosphate oral soln 25 /5ml (base eq) prednisolone syrup 15 /5ml (usp solution equivalent) prednisone con 5/ml prednisone oral soln 5 /5ml prednisone tab prednisone tab prednisone tab prednisone tab prednisone tab prednisone tab prednisone tab therapy pack 10 (21) prednisone tab therapy pack 10 (48) prednisone tab therapy pack 5 (21) prednisone tab therapy pack 5 (48) PREMARIN INJ 25MG PREMARIN TAB 0.3MG PREMARIN TAB 0.45MG. 49 PREMARIN TAB 0.625MG PREMARIN TAB 0.9MG PREMARIN TAB 1.25MG. 49 PREMARIN VAG CRE 0.625MG premasol sol 10% PREMPHASE TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB prenatal vitamin/folic acid > 0.8 (generic) prevalite pow 4gm prevalite pow 4gm pk previfem tab PREZCOBIX TAB PREZISTA SUS 100MG/ML... 7 PREZISTA TAB 150MG... 7 PREZISTA TAB 600MG... 7 PREZISTA TAB 75MG... 7 PREZISTA TAB 800MG... 7 PRIFTIN TAB 150MG... 8 PRILOSEC POW 10MG

107 PRILOSEC POW 2.5MG.. 55 PRIMAQUINE TAB 26.3MG7 primidone tab primidone tab PRISTIQ TAB 100MG PRISTIQ TAB 25MG PRISTIQ TAB 50MG PRIVIGEN INJ 10GRAMS 59 PRIVIGEN INJ 20GRAMS 59 PRIVIGEN INJ 40GRAMS 59 PRIVIGEN INJ 5 GRAMS. 59 PROAIR HFA AER PROAIR RESPI AER probenecid tab PROCALAMINE INJ 3% prochlorperazine edisylate inj 5 /ml prochlorperazine maleate tab 10 (base equivalent) prochlorperazine maleate tab 5 (base equivalent) prochlorperazine suppos PROCRIT INJ 10000/ML.. 57 PROCRIT INJ 2000/ML PROCRIT INJ 20000/ML.. 57 PROCRIT INJ 3000/ML PROCRIT INJ 4000/ML PROCRIT INJ 40000/ML.. 57 procto-med cre hc 2.5% procto-pak cre 1% proctozone cre -hc 2.5% PROGLYCEM SUS 50MG/ML PROGRAF CAP 0.5MG PROGRAF CAP 1MG PROGRAF CAP 5MG PROLASTIN-C INJ 1000MG PROLENSA SOL 0.07% PROLEUKIN INJ 22MU PROLIA SOL 60MG/ML PROMACTA TAB 12.5MG 57 PROMACTA TAB 25MG PROMACTA TAB 50MG PROMACTA TAB 75MG promethazine hcl inj 25 /ml promethazine hcl inj 50 /ml promethazine hcl suppos promethazine hcl suppos promethazine hcl suppos promethazine hcl syrup 6.25 /5ml promethazine hcl tab promethazine hcl tab promethazine hcl tab promethegan sup promethegan sup propafenone hcl cap er 12hr propafenone hcl cap er 12hr propafenone hcl cap er 12hr propafenone hcl tab propafenone hcl tab propafenone hcl tab proparacaine hcl ophth soln 0.5% propranolol & hydrochlorothiazide tab propranolol & hydrochlorothiazide tab propranolol hcl cap er 24hr propranolol hcl cap er 24hr propranolol hcl cap er 24hr propranolol hcl cap er 24hr propranolol hcl inj 1 /ml 23 propranolol hcl oral soln 20 /5ml propranolol hcl oral soln 40 /5ml propranolol hcl tab propranolol hcl tab propranolol hcl tab propranolol hcl tab propranolol hcl tab propylthiouracil tab PROQUAD INJ PROSOL INJ 20% protriptyline hcl tab protriptyline hcl tab PROVENTIL AER HFA PULMICORT INH 180MCG PULMICORT INH 90MCG 66 PULMOZYME SOL 1MG/ML PURIXAN SUS 20MG/ML. 14 pyrazinamide tab pyridostigmine bromide tab Q QUADRACEL INJ quasense tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr quinapril hcl tab quinapril hcl tab quinapril hcl tab quinapril hcl tab quinapril-hydrochlorothiazide tab

108 quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinidine gluconate tab er quinidine sulfate tab quinidine sulfate tab quinine sulfate cap QVAR AER 40MCG QVAR AER 80MCG R RABAVERT INJ rabeprazole sodium ec tab raloxifene hcl tab ramipril cap ramipril cap ramipril cap ramipril cap RANEXA TAB 1000MG RANEXA TAB 500MG ranitidine hcl inj 150 /6ml (25 /ml) ranitidine hcl inj 50 /2ml (25 /ml) ranitidine hcl syrup 15 /ml (75 /5ml) ranitidine hcl tab ranitidine hcl tab RAPAMUNE SOL 1MG/ML rasagiline mesylate tab 0.5 (base equiv) rasagiline mesylate tab 1 (base equiv) RAVICTI LIQ 1.1GM/ML REBETOL SOL 40MG/ML..9 REBIF INJ 22/ REBIF INJ 44/ REBIF REBIDO INJ 44/ REBIF TITRTN INJ PACK. 42 reclipsen tab RECOMBIVA HB INJ 10MCG/ML RECOMBIVA HB INJ 5MCG/ RECOMBIVA-HB INJ 40MCG/ML REGRANEX GEL 0.01%.. 69 RELENZA MIS DISKHALE. 9 RELISTOR INJ 12/0.6ML.. 54 RELISTOR INJ 8/0.4ML RELPAX TAB 20MG RELPAX TAB 40MG REMICADE INJ 100MG REMODULIN INJ 10MG/ML REMODULIN INJ 1MG/ML REMODULIN INJ 2.5MG/ML REMODULIN INJ 5MG/ML RENVELA PAK 0.8GM RENVELA PAK 2.4GM RENVELA TAB 800MG repaglinide tab repaglinide tab repaglinide tab RESCRIPTOR TAB 100 MG... 7 RESCRIPTOR TAB 200MG 7 RESTASIS EMU 0.05% RETROVIR INJ 10MG/ML.. 7 REVATIO SUS 10MG/ML. 27 REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 2.5MG REVLIMID CAP 20MG REVLIMID CAP 25MG REVLIMID CAP 5MG REXULTI TAB 0.25MG REXULTI TAB 0.5MG REXULTI TAB 1MG REXULTI TAB 2MG REXULTI TAB 3MG REXULTI TAB 4MG REYATAZ CAP 150MG... 8 REYATAZ CAP 200MG... 8 REYATAZ CAP 300MG... 8 REYATAZ POW 50MG... 8 ribasphere cap ribasphere tab ribasphere tab ribasphere tab ribavirin cap ribavirin tab rifabutin cap rifampin cap rifampin cap rifampin for inj RIFATER TAB... 8 riluzole tab rimantadine hydrochloride tab RINGER'S SOLUTION risedronate sodium tab risedronate sodium tab risedronate sodium tab risedronate sodium tab risedronate sodium tab delayed release RISPERDAL INJ 12.5MG. 37 RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG. 38 RISPERDAL INJ 50MG risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone soln 1 /ml risperidone tab risperidone tab risperidone tab risperidone tab risperidone tab risperidone tab RITUXAN INJ 100MG RITUXAN INJ 500MG rivastigmine tartrate cap rivastigmine tartrate cap rivastigmine tartrate cap

109 rivastigmine tartrate cap rivastigmine td patch 24hr 13.3 /24hr rivastigmine td patch 24hr 4.6 /24hr rivastigmine td patch 24hr 9.5 /24hr rizatriptan benzoate oral disintegrating tab 10 (base eq) rizatriptan benzoate oral disintegrating tab 5 (base eq) rizatriptan benzoate tab 10 (base equivalent) rizatriptan benzoate tab 5 (base equivalent) ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab rosuvastatin calcium tab rosuvastatin calcium tab rosuvastatin calcium tab rosuvastatin calcium tab ROTARIX SUS ROTATEQ SOL roweepra tab roweepra tab roweepra tab RUBRACA TAB 200MG RUBRACA TAB 250MG RUBRACA TAB 300MG RYDAPT CAP 25MG S SABRIL POW 500MG SABRIL TAB 500MG SANDIMMUNE SOL 100MG/ML SANDOSTATIN KIT LAR 10MG SANDOSTATIN KIT LAR 20MG SANDOSTATIN KIT LAR 30MG SANTYL OIN 250/GM SAPHRIS SUB 10MG SAPHRIS SUB 2.5MG SAPHRIS SUB 5MG selegiline hcl cap selegiline hcl tab selenium sulfide lotion 2.5% SELZENTRY TAB 150MG.. 8 SELZENTRY TAB 25MG... 8 SELZENTRY TAB 300MG.. 8 SELZENTRY TAB 75MG... 8 SENSIPAR TAB 30MG SENSIPAR TAB 60MG SENSIPAR TAB 90MG SEREVENT DIS AER 50MCG SEROQUEL XR TAB 200MG SEROQUEL XR TAB 300MG sertraline hcl oral conc 20 /ml sertraline hcl tab sertraline hcl tab sertraline hcl tab sharobel tab SIGNIFOR INJ 0.3MG/ML 51 SIGNIFOR INJ 0.6MG/ML 51 SIGNIFOR INJ 0.9MG/ML 51 sildenafil citrate tab SILENOR TAB 3MG SILENOR TAB 6MG SILVER SULFADIAZINE CREAM 1% SIMBRINZA SUS 1-0.2%.. 64 simvastatin tab simvastatin tab simvastatin tab simvastatin tab simvastatin tab sirolimus tab sirolimus tab sirolimus tab SIRTURO TAB 100MG... 8 SIVEXTRO INJ 200MG... 6 SIVEXTRO TAB 200MG... 6 SODIUM CHLORIDE INJ 0.45% SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%) SODIUM CHLORIDE INJ 3% SODIUM CHLORIDE INJ 5% SODIUM CHLORIDE IRRIGATION SOLN 0.9%. 69 SODIUM CHLORIDE IV SOLN 0.9% sodium fluoride chew; tab; 1.1 (0.5 f) /ml soln sodium phenylbutyrate oral powder 3 gm/teaspoonful. 48 sodium polystyrene sulfonate oral susp 15 gm/60ml sodium polystyrene sulfonate powder SOLTAMOX SOL 10MG/5ML SOLU-CORTEF INJ 250MG SOMATULINE INJ 120/.5ML SOMATULINE INJ 60/0.2ML SOMATULINE INJ 90/0.3ML SOMAVERT INJ 10MG SOMAVERT INJ 15MG SOMAVERT INJ 20MG SOMAVERT INJ 25MG SOMAVERT INJ 30MG sorine tab sorine tab sorine tab sorine tab sotalol hcl (afib/afl) tab sotalol hcl (afib/afl) tab

110 sotalol hcl (afib/afl) tab sotalol hcl tab sotalol hcl tab sotalol hcl tab sotalol hcl tab SOVALDI TAB 400MG...9 SPIRIVA AER 1.25MCG SPIRIVA CAP HANDIHLR 64 SPIRIVA SPR 2.5MCG spironolactone & hydrochlorothiazide tab spironolactone tab spironolactone tab spironolactone tab sprintec 28 tab 28 day SPRITAM TAB 1000MG SPRITAM TAB 250MG SPRITAM TAB 500MG SPRITAM TAB 750MG SPRYCEL TAB 100MG SPRYCEL TAB 140MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG SPRYCEL TAB 80MG SSD CRE 1% stavudine cap stavudine cap stavudine cap stavudine cap STIMATE SOL 1.5MG/ML. 52 STIVARGA TAB 40MG STRATTERA CAP 100MG 40 STRATTERA CAP 10MG.. 40 STRATTERA CAP 18MG.. 40 STRATTERA CAP 25MG.. 40 STRATTERA CAP 40MG.. 40 STRATTERA CAP 60MG.. 40 STRATTERA CAP 80MG.. 40 streptomycin sulfate for inj 1 gm...5 STRIBILD TAB...8 SUBOXONE MIS 12-3MG 43 SUBOXONE MIS 2-0.5MG SUBOXONE MIS 4-1MG.. 43 SUBOXONE MIS 8-2MG.. 43 SUCRAID SOL 8500/ML sucralfate tab 1 gm sulfacetamide sodium lotion 10% (acne) sulfacetamide sodium ophth oint 10% sulfacetamide sodium ophth soln 10% sulfacetamide sodiumprednisolone ophth soln (0.25)% sulfadiazine tab sulfamethoxazoletrimethoprim iv soln /5ml... 6 sulfamethoxazoletrimethoprim susp /5ml... 6 sulfamethoxazoletrimethoprim tab sulfamethoxazoletrimethoprim tab SULFAMYLON CRE 85MG/GM SULFAMYLON PAK 5% sulfasalazine tab sulfasalazine tab delayed release sulindac tab sulindac tab SUMATRIPTAN NASAL SPRAY 20 MG/ACT SUMATRIPTAN NASAL SPRAY 5 MG/ACT sumatriptan succinate inj 6 /0.5ml SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 4 MG/0.5ML sumatriptan succinate solution auto-injector 6 /0.5ml SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML 41 sumatriptan succinate solution cartridge 6 /0.5ml sumatriptan succinate solution prefilled syringe 6 /0.5ml sumatriptan succinate tab sumatriptan succinate tab sumatriptan succinate tab SUPRAX CAP 400MG suprax chw suprax chw SUPRAX SUS 500/5ML SUPREP BOWEL SOL PREP KIT SUSTIVA CAP 200MG... 8 SUSTIVA CAP 50MG... 8 SUSTIVA TAB 600MG... 8 SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG SYLATRON KIT 200MCG 16 SYLATRON KIT 300MCG 16 SYLATRON KIT 600MCG 16 SYMBICORT AER SYMBICORT AER SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG SYNAGIS INJ 100MG/ML. 60 SYNAGIS INJ 50MG SYNAREL SOL 2MG/ML.. 48 SYNERCID INJ 500MG... 6 SYNRIBO INJ 3.5MG SYNTHROID TAB 100MCG SYNTHROID TAB 112MCG SYNTHROID TAB 125MCG SYNTHROID TAB 137MCG SYNTHROID TAB 150MCG SYNTHROID TAB 175MCG SYNTHROID TAB 200MCG 104

111 SYNTHROID TAB 25MCG 52 SYNTHROID TAB 300MCG SYNTHROID TAB 50MCG 52 SYNTHROID TAB 75MCG 52 SYNTHROID TAB 88MCG 52 SYPRINE CAP 250MG T TABLOID TAB 40MG tacrolimus cap tacrolimus cap tacrolimus cap tacrolimus oint 0.03% tacrolimus oint 0.1% TAFINLAR CAP 50MG TAFINLAR CAP 75MG TAGRISSO TAB 40MG TAGRISSO TAB 80MG TAMIFLU SUS 6MG/ML...9 tamoxifen citrate tab 10 (base equivalent) tamoxifen citrate tab 20 (base equivalent) tamsulosin hcl cap TARCEVA TAB 100MG TARCEVA TAB 150MG TARCEVA TAB 25MG TARGRETIN GEL 1% tarina fe tab 1/ TASIGNA CAP 150MG TASIGNA CAP 200MG TAXOTERE INJ 80MG/4ML tazarotene cream 0.1% tazicef inj 1gm tazicef inj 2gm tazicef inj 6gm TAZORAC CRE 0.05% TAZORAC CRE 0.1% TECENTRIQ INJ 1200/ TEFLARO INJ 400MG TEFLARO INJ 600MG TEGRETOL SUS 100/5ML TEGRETOL TAB 200MG.. 30 TEGRETOL-XR TAB 100MG TEGRETOL-XR TAB 200MG TEGRETOL-XR TAB 400MG TEKTURNA HCT TAB TEKTURNA HCT TAB MG TEKTURNA HCT TAB TEKTURNA HCT TAB MG TEKTURNA TAB 150MG.. 26 TEKTURNA TAB 300MG.. 26 telmisartan tab telmisartan tab telmisartan tab telmisartanhydrochlorothiazide tab telmisartanhydrochlorothiazide tab telmisartanhydrochlorothiazide tab temazepam cap temazepam cap temazepam cap TENIVAC INJ 5-2LF terazosin hcl cap terazosin hcl cap terazosin hcl cap terazosin hcl cap terbinafine hcl tab terbutaline sulfate inj 1 /ml terbutaline sulfate tab terbutaline sulfate tab terconazole vaginal cream 0.4% terconazole vaginal cream 0.8% TERCONAZOLE VAGINAL CREAM 0.8% terconazole vaginal suppos testosterone cypionate im inj in oil 100 /ml testosterone cypionate im inj in oil 200 /ml testosterone enanthate im inj in oil 200 /ml TET/DIP TOX INJ 2-2 LF.. 60 TETRABENAZINE TAB 12.5 MG TETRABENAZINE TAB 25 MG texacort sol 2.5% THALOMID CAP 100MG.. 59 THALOMID CAP 150MG.. 59 THALOMID CAP 200MG.. 59 THALOMID CAP 50MG theo-24 cap 100 cr theo-24 cap 200 cr theo-24 cap 300 cr theo-24 cap 400 er theophylline soln 80 /15ml theophylline tab er 12hr theophylline tab er 12hr theophylline tab er 12hr theophylline tab er 12hr theophylline tab er 24hr theophylline tab er 24hr thioridazine hcl tab thioridazine hcl tab thioridazine hcl tab thioridazine hcl tab thiothixene cap thiothixene cap thiothixene cap thiothixene cap tiagabine hcl tab tiagabine hcl tab TIGECYCLINE INJ 50MG... 6 TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25% TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.5% timolol maleate ophth soln 105

112 0.25% timolol maleate ophth soln 0.5% timolol maleate tab timolol maleate tab timolol maleate tab TIVICAY TAB 10MG...8 TIVICAY TAB 25MG...8 TIVICAY TAB 50MG...8 tizanidine hcl cap 2 (base equivalent) tizanidine hcl cap 4 (base equivalent) tizanidine hcl cap 6 (base equivalent) tizanidine hcl tab 2 (base equivalent) tizanidine hcl tab 4 (base equivalent) TOBRADEX OIN % 62 TOBRADEX ST SUS tobramycin nebu soln 300 /5ml...5 tobramycin ophth soln 0.3% tobramycin sulfate for inj 1.2 gm...5 tobramycin sulfate inj 1.2 gm/30ml (40 /ml) (base equiv)...5 tobramycin sulfate inj 10 /ml (base equivalent)...5 tobramycin sulfate inj 2 gm/50ml (40 /ml) (base equiv)...5 tobramycin sulfate inj 80 /2ml (40 /ml) (base equiv)...5 tobramycin-dexamethasone ophth susp % TOBREX OIN 0.3% OP tolterodine tartrate cap er 24hr tolterodine tartrate cap er 24hr tolterodine tartrate tab tolterodine tartrate tab topiramate sprinkle cap topiramate sprinkle cap topiramate tab topiramate tab topiramate tab topiramate tab toposar inj 100/5ml toposar inj 1gm/50ml topotecan hcl for inj TOPOTECAN INJ 4MG/4ML torsemide tab torsemide tab torsemide tab torsemide tab TOUJEO SOLO INJ 300IU/ML TOVIAZ TAB 4MG TOVIAZ TAB 8MG TPN ELECTROL INJ TRACLEER TAB 125MG.. 27 TRACLEER TAB 62.5MG. 27 TRADJENTA TAB 5MG tramadol hcl tab tramadol-acetaminophen tab trandolapril tab trandolapril tab trandolapril tab tranexamic acid iv soln 1000 /10ml (100 /ml) tranexamic acid tab TRANSDERM-SC DIS 1.5MG tranylcypromine sulfate tab TRAVASOL INJ 10% TRAVATAN Z DRO 0.004% trazodone hcl tab trazodone hcl tab trazodone hcl tab TREANDA INJ 100MG TREANDA INJ 25MG TRECATOR TAB 250MG... 8 TRELSTAR MIX INJ 11.25MG TRELSTAR MIX INJ 3.75MG TRESIBA FLEX INJ 100UNIT TRESIBA FLEX INJ 200UNIT tretinoin cap tretinoin cream 0.025% tretinoin cream 0.05% tretinoin cream 0.1% TRETINOIN GEL 0.01% tretinoin gel 0.025% triamcinolone acetonide cream 0.025% triamcinolone acetonide cream 0.1% triamcinolone acetonide cream 0.5% triamcinolone acetonide dental paste 0.1% triamcinolone acetonide lotion 0.025% triamcinolone acetonide lotion 0.1% triamcinolone acetonide oint 0.025% triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5% triamterene & hydrochlorothiazide cap triamterene & hydrochlorothiazide tab triamterene & hydrochlorothiazide tab triderm cre 0.1% trifluoperazine hcl tab trifluoperazine hcl tab trifluoperazine hcl tab trifluoperazine hcl tab trifluridine ophth soln 1%.. 63 trihexyphenidyl hcl elixir

113 /ml trihexyphenidyl hcl tab trihexyphenidyl hcl tab tri-legest tab fe tri-lo- tab sprintec trilyte sol trimethoprim tab trimipramine maleate cap trimipramine maleate cap trimipramine maleate cap TRINESSA LO TAB TRINESSA TAB TRINTELLIX TAB 10MG TRINTELLIX TAB 20MG TRINTELLIX TAB 5MG tri-previfem tab TRISENOX SOL 10MG/10M tri-sprintec tab TRIUMEQ TAB...8 trivora-28 tab TROPHAMINE INJ 10% trospium chloride tab TRULICITY INJ 0.75/ TRULICITY INJ 1.5/ TRUMENBA INJ TRUVADA TAB TRUVADA TAB TRUVADA TAB TRUVADA TAB TWINRIX INJ TYBOST TAB 150MG...8 TYGACIL INJ 50MG...6 TYKERB TAB 250MG TYPHIM VI INJ TYSABRI INJ 300/15ML TYZEKA TAB 600MG...9 U ULORIC TAB 40MG...2 ULORIC TAB 80MG...2 UNITHROID TAB 100MCG UNITHROID TAB 112MCG UNITHROID TAB 125MCG UNITHROID TAB 150MCG UNITHROID TAB 175MCG UNITHROID TAB 200MCG UNITHROID TAB 25MCG. 52 UNITHROID TAB 300MCG UNITHROID TAB 50MCG. 52 UNITHROID TAB 75MCG. 52 UNITHROID TAB 88MCG. 52 UPTRAVI TAB 1000MCG. 27 UPTRAVI TAB 1200MCG. 27 UPTRAVI TAB 1400MCG. 27 UPTRAVI TAB 1600MCG. 27 UPTRAVI TAB 200/ UPTRAVI TAB 200MCG UPTRAVI TAB 400MCG UPTRAVI TAB 600MCG UPTRAVI TAB 800MCG ursodiol cap ursodiol tab ursodiol tab V valacyclovir hcl tab 1 gm... 9 valacyclovir hcl tab VALCHLOR GEL 0.016%. 69 VALCYTE SOL 50MG/ML... 9 valganciclovir hcl for soln 50 /ml (base equiv)... 9 valganciclovir hcl tab 450 (base equivalent)... 9 valproate sodium inj 100 /ml valproate sodium oral soln 250 /5ml (base equiv).. 30 valproic acid cap valsartan tab valsartan tab valsartan tab valsartan tab valsartanhydrochlorothiazide tab valsartanhydrochlorothiazide tab valsartanhydrochlorothiazide tab valsartanhydrochlorothiazide tab valsartanhydrochlorothiazide tab vancomycin hcl cap vancomycin hcl cap vancomycin hcl for inj 10 gm... 6 vancomycin hcl for inj vancomycin hcl for inj vancomycin hcl for inj vancomycin hcl for inj VANCOMYCIN INJ 1 GM... 6 VANCOMYCIN INJ 500MG 6 VANCOMYCIN INJ 750MG 6 VANDAZOLE GEL 0.75%. 56 VAQTA INJ 25/0.5ML VAQTA INJ 50UNT/ML VARIVAX INJ VASCEPA CAP 0.5GM VASCEPA CAP 1GM VELCADE INJ 3.5MG velivet pak VEMLIDY TAB 25MG... 9 VENCLEXTA TAB 100MG 15 VENCLEXTA TAB 10MG.. 15 VENCLEXTA TAB 50MG.. 15 VENCLEXTA TAB START PK venlafaxine hcl cap er 24hr 150 (base equivalent). 34 venlafaxine hcl cap er 24hr 37.5 (base equivalent) 33 venlafaxine hcl cap er 24hr 75 (base equivalent) venlafaxine hcl tab venlafaxine hcl tab venlafaxine hcl tab venlafaxine hcl tab

114 venlafaxine hcl tab VENTAVIS SOL 10MCG/ML VENTAVIS SOL 20MCG/ML VENTOLIN HFA AER verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr VERAPAMIL HCL CAP ER 24HR 360 MG verapamil hcl iv soln 2.5 /ml verapamil hcl tab verapamil hcl tab verapamil hcl tab verapamil hcl tab er verapamil hcl tab er verapamil hcl tab er VERSACLOZ SUS 50MG/ML VESICARE TAB 10MG VESICARE TAB 5MG VIAGRA TAB 100MG VIAGRA TAB 25MG VIAGRA TAB 50MG VICTOZA INJ 18MG/3ML. 44 VIDEX SOL 2GM...8 VIDEX SOL 4GM...8 vienva tab VIGAMOX DRO 0.5% VIIBRYD KIT STARTER VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG VIMPAT INJ 200MG/ VIMPAT SOL 10MG/ML VIMPAT TAB 100MG VIMPAT TAB 150MG VIMPAT TAB 200MG VIMPAT TAB 50MG vinblastine sulfate inj 1 /ml vincasar pfs inj 1/ml vincristine sulfate iv soln 1 /ml vinorelbine tartrate inj 10 /ml (base equiv) vinorelbine tartrate inj 50 /5ml (10 /ml) (base equiv) viorele tab VIRACEPT TAB 250MG... 8 VIRACEPT TAB 625MG... 8 VIREAD POW 40MG/GM... 8 VIREAD TAB 150MG... 8 VIREAD TAB 200MG... 8 VIREAD TAB 250MG... 8 VIREAD TAB 300MG... 8 VIVELLE-DOT DIS MG VIVELLE-DOT DIS 0.05MG VIVELLE-DOT DIS 0.075MG VIVELLE-DOT DIS 0.1MG 49 voriconazole for inj voriconazole for susp 40 /ml... 7 voriconazole tab voriconazole tab VOTRIENT TAB 200MG VRAYLAR CAP 1.5-3MG.. 38 VRAYLAR CAP 1.5MG VRAYLAR CAP 3MG VRAYLAR CAP 4.5MG VRAYLAR CAP 6MG vyfemla tab VYTORIN TAB 10-10MG.. 21 VYTORIN TAB 10-20MG.. 21 VYTORIN TAB 10-40MG.. 21 VYTORIN TAB 10-80MG.. 21 W warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab WATER FOR IRRIGATION, STERILE IRRIGATION SOLN WELCHOL PAK 3.75GM.. 22 WELCHOL TAB 625MG X XALKORI CAP 200MG XALKORI CAP 250MG XARELTO STAR TAB 15/20MG XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG XATMEP SOL 2.5MG/ML. 58 XELJANZ TAB 5MG XELJANZ XR TAB 11MG. 58 XGEVA INJ XIFAXAN TAB 550MG XIGDUO XR TAB XIGDUO XR TAB MG XIGDUO XR TAB MG XIGDUO XR TAB 5-500MG XOLAIR SOL 150MG XTANDI CAP 40MG XYREM SOL 500MG/ML.. 42 Y YERVOY INJ 200MG YERVOY INJ 50MG YF-VAX INJ Z zafirlukast tab zafirlukast tab zaleplon cap zaleplon cap ZAVESCA CAP 100MG ZEJULA CAP 100MG ZELBORAF TAB 240MG.. 16 ZEMAIRA INJ 1000MG zenatane cap zenchent tab ZENPEP CAP 10000UNT

115 ZENPEP CAP 15000UNT. 55 ZENPEP CAP 20000UNT. 55 ZENPEP CAP 25000UNT. 55 ZENPEP CAP 3000UNIT.. 55 ZENPEP CAP 40000UNT. 55 ZENPEP CAP 5000UNIT.. 55 ZEPATIER TAB MG.9 ZERIT SOL 1MG/ML...8 ZIAGEN SOL 20MG/ML...8 zidovudine cap zidovudine syrup 10 /ml.8 zidovudine tab ziprasidone hcl cap ziprasidone hcl cap ziprasidone hcl cap ziprasidone hcl cap ZIRGAN GEL 0.15% zoledronic acid inj conc for iv infusion 4 /5ml zoledronic acid iv soln 5 /100ml zoledronic inj ZOLINZA CAP 100MG zolmitriptan orally disintegrating tab zolmitriptan orally disintegrating tab zolmitriptan tab zolmitriptan tab zolpidem tartrate tab zolpidem tartrate tab 5 40 zolpidem tartrate tab er zolpidem tartrate tab er zonisamide cap zonisamide cap zonisamide cap ZONTIVITY TAB 2.08MG. 58 ZORTRESS TAB 0.25MG 59 ZORTRESS TAB 0.5MG.. 59 ZORTRESS TAB 0.75MG 59 ZOSTAVAX INJ zovia 1/35e tab zovia 1/50e tab ZYDELIG TAB 100MG ZYDELIG TAB 150MG ZYKADIA CAP 150MG ZYLET SUS % ZYPREXA RELP INJ 210MG ZYPREXA RELP INJ 300MG ZYPREXA RELP INJ 405MG ZYTIGA TAB 250MG ZYTIGA TAB 500MG

116 Este formulario ha sido actualizado para el 08/01/2017. Para obtener información más reciente o respuestas a sus preguntas, por favor llame al Departamento de Servicios a los Afiliados de AvMed Choice al desde el 1ro de octubre al 14 de febrero: 8:00 am a 8:00 pm, los 7 días de la semana. Y del 15 de febrero al 30 de septiembre: 8:00 am a 8:00 pm, de lunes a viernes, y 9:00 am a 1:00 pm los sábados (para los usuarios de TTY, 711 o el , los 7 días a la semana y las 24 horas del día) o visite 110