Agentes dentales y bucales Agentes dermatológicos Dispositivos Reemplazo de enzimas/modificadores Agentes para los ojos, los

Transcripción

1 Índice Analgésicos... Anestésicos... 8 Agentes antiadicciones/para el tratamiento del abuso de sustancias... 9 Ansiolíticos Antibacterianos Antineoplásicos Agentes anticolinérgicos... 7 Antiepilépticos... 7 Agentes contra la demencia... 0 Antidepresivos... 1 Agentes antidiabéticos... 4 Antimicóticos... 7 Agentes antigotosos... 9 Antihistamínicos... 9 Antiinfecciosos (piel y membrana mucosa)... 9 Antijaquecosos... 9 Antimicobacterianos Antieméticos Antiparasitarios... 4 Antiparkinsonianos... 4 Antipsicóticos Antivíricos (General) Derivados hematológicos/modificadores/aumentadores de volumen... 5 Agentes calóricos Agentes cardiovasculares Agentes del sistema nervioso central Anticonceptivos

2 Agentes dentales y bucales Agentes dermatológicos Dispositivos Reemplazo de enzimas/modificadores Agentes para los ojos, los oídos, la nariz y la garganta Agentes gastrointestinales Agentes genitourinarios Antagonistas de metales pesados Agentes hormonales, estimulantes/sustituyentes/modificadores Agentes inmunológicos Agentes para la enfermedad inflamatoria intestinal Soluciones para irrigación Agentes para enfermedades óseas metabólicas Agentes terapéuticos varios Agentes oftálmicos Preparaciones de reemplazo Agentes para las vías respiratorias Miorrelajantes... 1 Agentes para trastornos del sueño... 1 Agentes vasodilatadores... 1 Vitaminas y minerales... 14

3 Nombre del Analgésicos Analgésicos, varios acetaminophen-codeine oral solution 10- QL (700 cada 0 días) 1 /5 ml acetaminophen-codeine oral tablet QL (60 cada 0 días) acetaminophen-codeine oral tablet 00-0 (Tylenol-Codeine #) QL (60 cada 0 días) acetaminophen-codeine oral tablet (Tylenol-Codeine #4) QL (180 cada 0 días) ALLZITAL ORAL TABLET 5-5 MG QL (60 cada 0 días) ascomp with codeine oral capsule QL (180 cada 0 días) 5-40 BELBUCA BUCCAL FILM 150 MCG, QL (60 cada 0 días) 00 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0. (Buprenex) /ml buprenorphine transdermal patch weekly (Butrans) QL (4 cada 8 días) 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral QL (180 cada 0 días) capsule butalbital-acetaminop-caf-cod oral QL (180 cada 0 días) capsule , butalbital-acetaminophen oral tablet 50- (Marten-Tab) QL (180 cada 0 días) 5 butalbital-acetaminophen-caff oral (Capacet) QL (180 cada 0 días) capsule butalbital-acetaminophen-caff oral tablet (Esgic) QL (180 cada 0 días) butalbital-aspirin-caffeine oral capsule (Fiorinal) QL (180 cada 0 días) BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 0 MCG/HOUR, 5 QL (4 cada 8 días) MCG/HOUR, 7.5 MCG/HOUR capacet oral capsule QL (180 cada 0 días) codeine sulfate oral tablet 15, 0, QL (180 cada 0 días) 60 endocet oral tablet 10-5 QL (40 cada 0 días) endocet oral tablet.5-5, 5-5 QL (60 cada 0 días)

4 Nombre del endocet oral tablet QL (00 cada 0 días) endodan oral tablet QL (60 cada 0 días) fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, (Actiq) ; QL (10 cada 0 días) 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 (Duragesic) QL (10 cada 0 días) mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour 7.5 QL (10 cada 0 días) mcg/hour fentanyl transdermal patch 7 hour 6.5 mcg/hour, 87.5 mcg/hour ; QL (10 cada 0 días) hydrocodone-acetaminophen oral solution QL (700 cada 0 días), /5 ml, 5-16 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (700 cada 0 días) /15 ml hydrocodone-acetaminophen oral tablet (Xodol 10/00) QL (90 cada 0 días) hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (60 cada 0 días) 10-5 hydrocodone-acetaminophen oral tablet (Verdrocet) QL (60 cada 0 días).5-5 hydrocodone-acetaminophen oral tablet 5- (Xodol 5/00) QL (90 cada 0 días) 00 hydrocodone-acetaminophen oral tablet 5- (Norco) QL (60 cada 0 días) 5 hydrocodone-acetaminophen oral tablet (Xodol 7.5/00) QL (90 cada 0 días) hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (60 cada 0 días) hydrocodone-ibuprofen oral tablet (Ibudone) QL (150 cada 0 días), 5-00 hydrocodone-ibuprofen oral tablet QL (150 cada 0 días) hydromorphone (pf) injection solution 10 (/ml) (5 ml) hydromorphone (pf) injection solution 10 /ml hydromorphone 10 /ml vial p/f,sdv,latex-f 10 /ml hydromorphone injection solution /ml, 4 /ml 4

5 Nombre del hydromorphone injection syringe /ml, (Dilaudid) 4 /ml hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 cada 0 días) hydromorphone oral tablet, 4, 8 (Dilaudid) QL (180 cada 0 días) HYSINGLA ER ORAL TABLET,ORAL QL (0 cada 0 días) ONLY,EXT.REL.4 HR 100 MG, 10 MG, 0 MG, 0 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 ; QL (0 cada 0 días) MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-5 QL (60 cada 0 días) lorcet hd oral tablet 10-5 QL (60 cada 0 días) lorcet plus oral tablet QL (60 cada 0 días) margesic oral capsule QL (180 cada 0 días) methadone injection solution 10 /ml methadone oral solution 10 /5 ml, 5 QL (1800 cada 0 días) /5 ml methadone oral tablet 10 (Dolophine) QL (60 cada 0 días) methadone oral tablet 5 (Dolophine) QL (180 cada 0 días) methadose oral tablet,soluble 40 QL (90 cada 0 días) morphine 10 /ml carpuject outer, p/f, l/f, suv 10 /ml morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml syringe p/f, latex-free, suv 4 /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 100 QL (180 cada 0 días) /5 ml (0 /ml) morphine intramuscular pen injector 10 /0.7 ml morphine intravenous cartridge 15 /ml morphine intravenous syringe 10 /ml, /ml, 4 /ml, 8 /ml morphine oral solution 10 /5 ml QL (700 cada 0 días) morphine oral solution 0 /5 ml (4 QL (00 cada 0 días) /ml) MORPHINE ORAL TABLET 15 MG 4 QL (180 cada 0 días) MORPHINE ORAL TABLET 0 MG 4 QL (10 cada 0 días) 5

6 Nombre del morphine oral tablet extended release 100 (MS Contin) QL (60 cada 0 días), 00, 60 morphine oral tablet extended release 15 (MS Contin) QL (180 cada 0 días) morphine oral tablet extended release 0 (MS Contin) QL (10 cada 0 días) NUCYNTA ER ORAL TABLET QL (60 cada 0 días) EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 QL (181 cada 0 días) MG, 75 MG oxycodone oral concentrate 0 /ml QL (10 cada 0 días) oxycodone oral solution 5 /5 ml QL (100 cada 0 días) oxycodone oral tablet 10 QL (180 cada 0 días) oxycodone oral tablet 15, 0 (Roxicodone) QL (10 cada 0 días) oxycodone oral tablet 0 QL (10 cada 0 días) oxycodone oral tablet 5 (Roxicodone) QL (180 cada 0 días) oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 cada 0 días) hr 10, 15, 0, 0, 40, 60 oxycodone oral tablet,oral only,ext.rel.1 hr 80 (OxyContin) ; QL (10 cada 0 días) oxycodone-acetaminophen oral solution 5- QL (1800 cada 0 días) 5 /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (40 cada 0 días) 5 oxycodone-acetaminophen oral tablet.5- (Endocet) QL (60 cada 0 días) 5, 5-5 oxycodone-acetaminophen oral tablet 7.5- (Endocet) QL (00 cada 0 días) 5 oxycodone-aspirin oral tablet QL (60 cada 0 días) OXYCONTIN ORAL TABLET,ORAL QL (60 cada 0 días) ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (10 cada 0 días) ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 (Opana) QL (10 cada 0 días) oxymorphone oral tablet 5 (Opana) QL (180 cada 0 días) oxymorphone oral tablet extended release 1 hr 10, 15, 0, 0, 40, 5, 7.5 QL (60 cada 0 días) 6

7 Nombre del reprexain oral tablet 10-00,.5-00 QL (150 cada 0 días), 5-00 tencon oral tablet 50-5 QL (180 cada 0 días) tramadol oral tablet 50 (Ultram) QL (40 cada 0 días) tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (40 cada 0 días) 5 vicodin es oral tablet QL (90 cada 0 días) vicodin hp oral tablet QL (90 cada 0 días) vicodin oral tablet 5-00 QL (90 cada 0 días) XTAMPZA ER ORAL QL (60 cada 0 días) CAPSULE,SPRINKLE,ER 1HR TMPRR 1.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (10 cada 0 días) CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG XTAMPZA ER ORAL QL (40 cada 0 días) CAPSULE,SPRINKLE,ER 1HR TMPRR 6 MG xylon 10 oral tablet QL (150 cada 0 días) zebutal oral capsule QL (180 cada 0 días) Medicamentos antiinflamatorios no esteroideos CALDOLOR INTRAVENOUS RECON 4 SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100, 00, (Celebrex) QL (60 cada 0 días) 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical gel 1 % (Voltaren) diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 etodolac oral capsule 00, 00 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 7

8 Nombre del etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 FLECTOR TRANSDERMAL PATCH 1 PA HOUR 1. % flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml (Children's Advil) ibuprofen oral tablet 400, 600, indomethacin oral capsule 5 1 QL (40 cada 0 días) indomethacin oral capsule 50 1 QL (10 cada 0 días) indomethacin oral capsule, extended QL (60 cada 0 días) release 75 indomethacin sodium intravenous recon soln 1 ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac oral tablet 10 QL (0 cada 0 días) mefenamic acid oral capsule 50 (Ponstel) meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) 1 nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 1 naproxen oral tablet 500 (Naprosyn) 1 naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75, 500 naproxen sodium oral tablet 75 naproxen sodium oral tablet 550 (Anaprox DS) piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet 150, 00 tolmetin oral capsule 400 tolmetin oral tablet 00, 600 VOLTAREN TOPICAL GEL 1 % Anestésicos Anestésicos locales glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 15 /ml (1.5 %), 0 /ml ( %), 5 /ml (0.5 %) (Xylocaine-MPF) 8

9 Nombre del lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 10 /ml (Xylocaine) (1 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive (Lidoderm) PA patch,medicated 5 % lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Agentes antiadicciones/para el tratamiento del abuso de sustancias Agentes antiadicciones/para el tratamiento del abuso de sustancias acamprosate oral tablet,delayed release (dr/ec) BUNAVAIL BUCCAL FILM.1-0. MG QL (0 cada 0 días) BUNAVAIL BUCCAL FILM QL (60 cada 0 días) MG, 6.-1 MG buprenorphine hcl sublingual tablet, PA; QL (90 cada 0 días) 8 buprenorphine-naloxone sublingual tablet QL (90 cada 0 días) -0.5, 8- buproban oral tablet extended release 1 hr 150 bupropion hcl (smoking deter) oral tablet extended release 1 hr 150 (Zyban) CHANTIX CONTINUING MONTH QL (168 cada 84 días) BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (168 cada 84 días) MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) QL (5 cada 8 días) disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, 1 /ml 9

10 Nombre del naltrexone oral tablet 50 (Revia) NARCAN NASAL SPRAY,NON- QL (4 cada 0 días) AEROSOL MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION 4 QL (1008 cada 90 días) CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 1- QL (60 cada 0 días) MG, 8- MG SUBOXONE SUBLINGUAL FILM -0.5 QL (0 cada 0 días) MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET 0.7- QL (0 cada 0 días) 0.18 MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET 8.6- QL (60 cada 0 días).1 MG Ansiolíticos Benzodiacepinas alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 QL (10 cada 0 días) alprazolam oral tablet (Xanax) 1 QL (150 cada 0 días) chlordiazepoxide hcl oral capsule 10, 1 QL (10 cada 0 días) 5, 5 clonazepam oral tablet 0.5, 1 (Klonopin) 1 QL (90 cada 0 días) clonazepam oral tablet (Klonopin) 1 QL (00 cada 0 días) clonazepam oral tablet,disintegrating QL (90 cada 0 días) 0.15, 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 cada 0 días) clorazepate dipotassium oral tablet 15,.75 QL (180 cada 0 días) clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (180 cada 0 días) diazepam injection solution 5 /ml QL (10 cada 8 días) diazepam intensol oral concentrate 5 QL (100 cada 0 días) /ml diazepam oral solution 5 /5 ml (1 /ml) QL (100 cada 0 días) diazepam oral tablet 10,, 5 (Valium) 1 QL (10 cada 0 días) diazepam rectal kit , 5- (Diastat AcuDial) diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml (Ativan) QL ( cada 0 días) lorazepam oral tablet 0.5, 1 (Ativan) 1 QL (90 cada 0 días) 10

11 Nombre del lorazepam oral tablet (Ativan) 1 QL (150 cada 0 días) ONFI ORAL SUSPENSION.5 MG/ML 5 Autorización previa solo para miembros nuevos (Prior Authorization for New Starts Only, PA NSO); NDS; QL (480 cada 0 días) ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NDS; QL (60 cada 0 días) Antibacterianos Aminoglucósidos BETHKIS INHALATION SOLUTION 5 PA BvD; NDS FOR NEBULIZATION 00 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 40 /ml gentamicin ped 0 / ml vial latex-free, sdv 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml neomycin oral tablet 500 streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 40 /ml Antibacterianos, varios bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram 11 ; QL (4 cada 8 días) (Tobi) 5 PA BvD; NDS (BACiiM) clindamycin 75 /5 ml soln 75 /5 ml (CleocinPediatric) clindamycin hcl oral capsule 150, 00 (Cleocin HCl), 75

12 Nombre del clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution 150 /ml clindamycin phosphate intravenous solution 600 /4 ml colistin (colistimethate na) injection recon soln 150 daptomycin intravenous recon soln 500 linezolid intravenous parenteral solution 600 /00 ml linezolid oral suspension for reconstitution 100 /5 ml (Cleocin in 5 % dextrose) (Cleocin) (Cleocin) (Coly-Mycin M Parenteral) (Cubicin) (Zyvox) (Zyvox) linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /100 ml metronidazole oral capsule 75 (Flagyl) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin) QL (10 cada 0 días) 100, 5, 50 nitrofurantoin monohyd/m-cryst oral (Macrobid) QL (60 cada 0 días) capsule 100 polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 vancomycin hcl 1g/00 ml bag 1 gram/00 ml vancomycin intravenous recon soln 1,000, 10 gram, 750 vancomycin intravenous recon soln 500 vancomycin oral capsule 15, 50 (Vancocin) 1

13 Nombre del XIFAXAN ORAL TABLET 00 MG ; QL (9 cada 0 días) XIFAXAN ORAL TABLET 550 MG Cefalosporinas cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 (Spectracef) CEFEPIME 1 GM INJECTION 1 4 GRAM/50 ML cefepime hcl 1 gm vial 10's, sdv 1 gram (Maxipime) cefepime hcl gram vial latex/f, sdv, outer (Maxipime) gram CEFEPIME INJECTION RECON SOLN (Maxipime) 4 1 GRAM, GRAM CEFEPIME-DEXTROSE GM/50 ML 4 GRAM/50 ML cefotaxime injection recon soln 1 gram, 10 (Claforan) gram, gram cefotaxime injection recon soln 500 cefoxitin gm piggyback bag gram/50 ml cefoxitin gm vial l/f, sdv outer gram cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 1

14 Nombre del cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 400 (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 180 /5 ml ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml ceftriaxone gm piggyback l/f, single use gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 50, 500 ceftriaxone intravenous recon soln 1 gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln (Zinacef) 750 cefuroxime sodium intravenous recon soln (Zinacef) 1.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) 1 cephalexin oral capsule 750 (Keflex) cephalexin oral suspension for 1 reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, MEFOXIN IN DEXTROSE (ISO-OSM) 4 INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 4 SUPRAX ORAL TABLET,CHEWABLE MG, 00 MG tazicef injection recon soln gram, 6 gram TEFLARO INTRAVENOUS RECON 4 SOLN 400 MG, 600 MG Macrólidos azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) 14

15 Nombre del azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (Zithromax Z-Pak) azithromycin oral tablet 50 (6 pack), 500 ( pack) azithromycin oral tablet 500 (Zithromax TRI-PAK) azithromycin oral tablet 600 (Zithromax) clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50 clarithromycin oral tablet, 500 (Biaxin) clarithromycin oral tablet extended release 4 hr 500 DIFICID ORAL TABLET 00 MG ; QL (0 cada 10 días) e.e.s. 400 oral tablet 400 e.e.s. granules oral suspension for reconstitution 00 /5 ml ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED 4 RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG 4 erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Antibióticos betalactámicos varios aztreonam injection recon soln 1 gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 LA; NDS imipenem-cilastatin intravenous recon (Primaxin IV) soln 50, 500 INVANZ INJECTION RECON SOLN 1 GRAM 4 15

16 Nombre del meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicilinas amoxicillin oral capsule 50, amoxicillin oral suspension for 1 reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, amoxicillin oral tablet,chewable 15, 1 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, ampicillin oral suspension for 1 reconstitution 15 /5 ml, 50 /5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram BICILLIN C-R INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) 16

17 Nombre del BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML 17 4 dicloxacillin oral capsule 50, 500 nafcillin gm vial 10's, latex-free gram nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 10 gram, gram oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin gk 0 million unit 0 million unit (Pfizerpen-G) penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous recon (Zosyn) soln.5 gram,.75 gram, 4.5 gram, 40.5 gram Quinolonas ciprofloxacin hcl oral tablet 100, ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml

18 Nombre del ciprofloxacin oral suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml (Cipro) levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50, 500, (Levaquin) moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 00, 400 Sulfonamidas sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) sulfasalazine oral tablet 500 (Sulfazine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 500 sulfatrim oral suspension /5 ml Tetraciclinas doxy-100 intravenous recon soln 100 doxycycline hyclate intravenous recon (Doxy-100) soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline monohydrate oral capsule 100 (Monodox), 50, 75 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral suspension for reconstitution 5 /5 ml (Vibramycin) 18

19 Nombre del doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 150, 50, 75 minocycline oral capsule 100, 50, (Minocin) 75 minocycline oral tablet 100, 50, 75 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) TYGACIL INTRAVENOUS RECON SOLN 50 MG Antineoplásicos Antineoplásicos ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG 5 PA NSO; NDS; QL (4 cada 1 días) adriamycin intravenous solution /ml, PA BvD 0 /10 ml adrucil,500 /50 ml vial outer, latexfree PA BvD.5 gram/50 ml adrucil intravenous solution 500 /10 ml PA BvD AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG 5 PA NSO; NDS; QL (11 cada 8 días) AFINITOR ORAL TABLET 10 MG 5 PA NSO; NDS; QL (56 cada 8 días) AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; NDS; QL (8 cada 8 días) ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (40 cada 0 días) ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALUNBRIG ORAL TABLET 0 MG 5 PA NSO; NDS; QL (180 cada 0 días) anastrozole oral tablet 1 (Arimidex) AVASTIN INTRAVENOUS SOLUTION 5 PA NSO; NDS 5 MG/ML, 5 MG/ML (16 ML) azacitidine injection recon soln 100 (Vidaza) BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML 5 PA NSO; NDS 19

20 Nombre del BELEODAQ INTRAVENOUS RECON 5 PA NSO; NDS SOLN 500 MG BENDEKA INTRAVENOUS 5 PA NSO; NDS SOLUTION 5 MG/ML bexarotene oral capsule 75 (Targretin) 5 PA NSO; NDS; QL (40 cada 0 días) bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 15 unit (Bleo 15K) PA BvD bleomycin injection recon soln 0 unit PA BvD BLINCYTO INTRAVENOUS KIT 5 MCG 5 PA NSO; NDS; QL (140 cada 65 días) BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; QL (10 cada 0 días) BOSULIF ORAL TABLET 500 MG 5 PA NSO; NDS; QL (0 cada 0 días) CABOMETYX ORAL TABLET 0 MG, 60 MG 5 PA NSO; NDS; QL (0 cada 0 días) CABOMETYX ORAL TABLET 40 MG 5 PA NSO; NDS; QL (60 cada 0 días) CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (60 cada 0 días) CAPRELSA ORAL TABLET 00 MG 5 PA NSO; NDS; QL (0 cada 0 días) clofarabine intravenous solution 0 (Clolar) /0 ml COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), 140 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) DARZALEX INTRAVENOUS 5 PA NSO; LA; NDS SOLUTION 0 MG/ML decitabine intravenous recon soln 50 (Dacogen) doxorubicin 00 /100 ml vial latex-free (Adriamycin) PA BvD /ml 0 5 PA NSO; NDS; QL (11 cada 8 días) COTELLIC ORAL TABLET 0 MG 5 PA NSO; LA; NDS; QL (6 cada 8 días) cyclophosphamide intravenous recon soln 5 PA BvD; NDS 1 gram, gram, 500 CYCLOPHOSPHAMIDE ORAL 4 PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) 5 PA NSO; NDS

21 Nombre del doxorubicin intravenous solution 50 (Adriamycin) PA BvD /5 ml doxorubicin, peg-liposomal intravenous (Lipodox) 5 PA BvD; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 400 MG ELIGARD ( MONTH) 4 QL (1 cada 84 días) SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) 4 QL (1 cada 11 días) SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) 4 QL (1 cada 168 días) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON 5 PA NSO; NDS SOLN 00 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (0 cada 0 días) ETOPOPHOS INTRAVENOUS RECON 4 SOLN 100 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 5 PA NSO; NDS MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil 5,000 /100 ml latex-free 5 (Adrucil) PA BvD gram/100 ml fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution.5 (Adrucil) PA BvD gram/50 ml, 500 /10 ml flutamide oral capsule 15 GAZYVA INTRAVENOUS SOLUTION 5 PA NSO; NDS 1,000 MG/40 ML GILOTRIF ORAL TABLET 0 MG, 0 MG, 40 MG 5 PA NSO; NDS; QL (0 cada 0 días) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG 4 1

22 Nombre del HERCEPTIN INTRAVENOUS RECON 5 PA NSO; NDS SOLN 150 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 5 PA NSO; NDS; QL (1 15 MG, 75 MG cada 8 días) ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NDS; QL (60 cada 0 días) ICLUSIG ORAL TABLET 45 MG 5 PA NSO; NDS; QL (0 cada 0 días) ifosfamide 1 gm/0 ml vial sdv,p/f,latexfree PA BvD 1 gram/0 ml ifosfamide intravenous recon soln 1 gram (Ifex) PA BvD ifosfamide-mesna intravenous kit PA BvD; NDS gram,,000-1,000 imatinib oral tablet 100 (Gleevec) 5 PA NSO; NDS; QL (90 cada 0 días) imatinib oral tablet 400 (Gleevec) 5 PA NSO; NDS; QL (60 cada 0 días) IMBRUVICA ORAL CAPSULE 140 MG 5 PA NSO; NDS IMFINZI INTRAVENOUS SOLUTION 5 PA NSO; NDS 50 MG/ML, 50 MG/ML (10 ML) IMLYGIC INJECTION SUSPENSION 5 PA NSO; NDS; QL (4 10EXP6 (1 MILLION) PFU/ML cada 65 días) IMLYGIC INJECTION SUSPENSION 5 PA NSO; NDS; QL (8 10EXP8 (100 MILLION) PFU/ML cada 8 días) INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; QL (180 cada 0 días) INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 cada 0 días) IRESSA ORAL TABLET 50 MG 5 PA NSO; NDS; QL (60 cada 0 días) IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 5 PA NSO; NDS; QL (60 0 MG, 5 MG, 5 MG cada 0 días) KEYTRUDA INTRAVENOUS RECON 5 PA NSO; NDS SOLN 50 MG KEYTRUDA INTRAVENOUS 5 PA NSO; NDS SOLUTION 100 MG/4 ML (5 MG/ML) KISQALI FEMARA CO-PACK ORAL 5 PA NSO; NDS; QL (49 TABLET 00 MG/DAY(00 MG X 1)- cada 8 días).5 MG

23 Nombre del KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 0 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X), 0 MG/DAY (10 MG X ), 4 MG/DAY(10 MG X -4 MG X 1), 8 MG/DAY (4 MG X ) 5 PA NSO; NDS; QL (70 cada 8 días) 5 PA NSO; NDS; QL (91 cada 8 días) 5 PA NSO; NDS; QL (6 cada 8 días) 5 PA NSO; NDS; QL (1 cada 8 días) 5 PA NSO; NDS; QL (6 cada 8 días) 5 PA NSO; LA; NDS 5 PA NSO; NDS letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG 4 leuprolide subcutaneous kit 1 /0. ml LONSURF ORAL TABLET MG 5 PA NSO; NDS; QL (100 cada 8 días) LONSURF ORAL TABLET MG 5 PA NSO; NDS; QL (80 cada 8 días) LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG ; QL (1 cada 84 días) ; QL (1 cada 84 días) ; QL (1 cada 168 días)

24 Nombre del LYNPARZA ORAL CAPSULE 50 MG 5 Autorización previa solo para miembros nuevos (Prior Authorization for New Starts Only, PA NSO); NDS; QL (480 cada 0 días) LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 40 MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NDS; QL (90 cada 0 días) MEKINIST ORAL TABLET MG 5 PA NSO; NDS; QL (0 cada 0 días) mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon PA BvD soln 1 gram methotrexate sodium (pf) injection PA BvD solution 5 /ml methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST mitoxantrone intravenous concentrate /ml NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NDS; QL (10 cada 0 días) nilutamide oral tablet 150 (Nilandron) NINLARO ORAL CAPSULE. MG, MG, 4 MG 5 PA NSO; NDS; QL ( cada 8 días) ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; LA; NDS ONCASPAR INJECTION SOLUTION 5 PA NSO; NDS 750 UNIT/ML ONIVYDE INTRAVENOUS 5 PA BvD; NDS DISPERSION 4. MG/ML OPDIVO INTRAVENOUS SOLUTION 5 PA NSO; NDS 100 MG/10 ML, 40 MG/4 ML POMALYST ORAL CAPSULE 1 MG, MG, MG, 4 MG 5 PA NSO; NDS; QL (1 cada 8 días) PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) 5 PA NSO; NDS; QL (100 cada 1 días) PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT 4

25 Nombre del PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 5 PA NSO; LA; NDS MG,.5 MG, 0 MG, 5 MG, 5 MG RITUXAN INTRAVENOUS 5 PA NSO; NDS CONCENTRATE 10 MG/ML RUBRACA ORAL TABLET 00 MG, 5 PA NSO; NDS; QL (10 50 MG, 00 MG cada 0 días) RYDAPT ORAL CAPSULE 5 MG 5 PA NSO; NDS; QL (4 cada 8 días) SOLTAMOX ORAL SOLUTION 10 4 MG/5 ML SPRYCEL ORAL TABLET 100 MG, PA NSO; NDS; QL (0 MG, 50 MG, 70 MG, 80 MG cada 0 días) SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NDS; QL (60 cada 0 días) STIVARGA ORAL TABLET 40 MG 5 PA NSO; NDS; QL (84 cada 8 días) SUTENT ORAL CAPSULE 1.5 MG, 5 5 PA NSO; NDS; QL (0 MG, 7.5 MG, 50 MG cada 0 días) SYLVANT INTRAVENOUS RECON 5 PA NSO; NDS SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON 5 PA NSO; NDS; QL (8 SOLN.5 MG cada 8 días) TABLOID ORAL TABLET 40 MG 4 TAFINLAR ORAL CAPSULE 50 MG, 75 5 PA NSO; NDS; QL (10 MG cada 0 días) TAGRISSO ORAL TABLET 40 MG, 80 5 PA NSO; LA; NDS; QL MG (0 cada 0 días) tamoxifen oral tablet 10, 0 TARCEVA ORAL TABLET 100 MG, 5 5 PA NSO; NDS; QL (60 MG cada 0 días) TARCEVA ORAL TABLET 150 MG 5 PA NSO; NDS; QL (90 cada 0 días) TARGRETIN ORAL CAPSULE 75 MG 5 PA NSO; NDS; QL (40 cada 0 días) TARGRETIN TOPICAL GEL 1 % 5 PA NSO; NDS; QL (60 cada 8 días) TASIGNA ORAL CAPSULE 150 MG, 5 PA NSO; NDS; QL (11 00 MG cada 8 días) TECENTRIQ INTRAVENOUS 5 PA NSO; NDS; QL (0 SOLUTION 1,00 MG/0 ML (60 cada 1 días) MG/ML) 5

26 Nombre del TEMODAR INTRAVENOUS RECON 5 PA NSO; NDS SOLN 100 MG thiotepa injection recon soln 15 (Tepadina) toposar intravenous solution 0 /ml TREANDA INTRAVENOUS RECON SOLN 100 MG TRELSTAR 11.5 MG VIAL INNER, SDV 11.5 MG ; QL (1 cada 84 días) TRELSTAR.75 MG VIAL INNER, SDV.75 MG TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION ; QL (1 cada 168 días).5 MG TRELSTAR INTRAMUSCULAR SYRINGE 11.5 MG/ ML ; QL (1 cada 84 días) TRELSTAR INTRAMUSCULAR SYRINGE.75 MG/ ML tretinoin (chemotherapy) oral capsule 10 TREXALL ORAL TABLET 10 MG, 15 4 PA BvD; ST MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 50 MG UNITUXIN INTRAVENOUS 5 PA NSO; NDS SOLUTION.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 5 PA NSO; NDS.5 MG VENCLEXTA ORAL TABLET 10 MG PA NSO; LA; QL (60 cada 0 días) VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; LA; NDS; QL (10 cada 0 días) VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (0 cada 0 días) VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinorelbine intravenous solution 10 /ml, (Navelbine) 50 /5 ml VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NDS; QL (10 cada 0 días) XALKORI ORAL CAPSULE 00 MG, 5 PA NSO; NDS; QL (60 50 MG cada 0 días) 6 5 PA NSO; LA; NDS; QL (4 cada 8 días)

27 Nombre del XATMEP ORAL SOLUTION.5 4 PA BvD; ST MG/ML XTANDI ORAL CAPSULE 40 MG 5 PA NSO; NDS; QL (10 cada 0 días) YERVOY INTRAVENOUS SOLUTION 5 PA NSO; NDS 00 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON 5 PA NSO; NDS SOLN 1 MG ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (90 cada 0 días) ZELBORAF ORAL TABLET 40 MG 5 PA NSO; NDS; QL (40 cada 0 días) ZOLADEX SUBCUTANEOUS 4 QL (1 cada 84 días) IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS 4 QL (1 cada 8 días) IMPLANT.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (60 cada 0 días) ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (140 cada 8 días) ZYTIGA ORAL TABLET 50 MG, 500 MG 5 PA NSO; NDS; QL (10 cada 0 días) Agentes anticolinérgicos Antimuscarinicos/Espasmolíticos atropine injection syringe 0.05 /ml, 0.1 /ml propantheline oral tablet 15 Antiepilépticos Antiepilépticos APTIOM ORAL TABLET 00 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 00 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML 5 ST; NDS 5 ST; NDS 5 ST; NDS 4 QL (80 cada 0 días) 4 QL (600 cada 0 días) 7

28 Nombre del BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG ; QL (60 cada 0 días) carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr 100, 00, 400 carbamazepine oral tablet,chewable 100 CELONTIN ORAL CAPSULE 00 MG DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 15 divalproex oral tablet extended release 4 (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 15, 50, 500 epitol oral tablet 00 ethosuximide oral capsule 50 (Zarontin) ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 400, 600 (Felbatol) fosphenytoin injection solution 100 pe/ ml, 500 pe/10 ml (Cerebyx) FYCOMPA ORAL SUSPENSION ST MG/ML FYCOMPA ORAL TABLET 10 MG, 1 MG, MG, 4 MG, 6 MG, 8 MG 4 ST gabapentin oral capsule 100, 00, (Neurontin) 400 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) GABITRIL ORAL TABLET 1 MG, 16 MG ST lamotrigine oral tablet 100, 150, (Lamictal) 00, 5 lamotrigine oral tablet extended release 4hr 100, 00, 5, 50, 00, 50 (Lamictal XR) 8

29 Nombre del lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 lamotrigine oral tablets,dose pack 5 (Lamictal Starter (5) (Blue) Kit) levetiracetam intravenous solution 500 (Keppra) /5 ml levetiracetam oral solution 100 /ml (Keppra) levetiracetam oral tablet 1,000, 50 (Keppra), 750 levetiracetam oral tablet 500 (Roweepra) levetiracetam oral tablet extended release 4 hr 500, 750 (Keppra XR) LYRICA ORAL CAPSULE 100 MG, 150 QL (90 cada 0 días) MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML QL (900 cada 0 días) oxcarbazepine oral suspension 00 /5 ml (60 /ml) (Trileptal) oxcarbazepine oral tablet 150, 00, (Trileptal) 600 OXTELLAR XR ORAL TABLET 4 ST EXTENDED RELEASE 4 HR 150 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml (4 QL (1500 cada 0 días) /ml) phenobarbital oral tablet 100, 15, QL (90 cada 0 días) 16.,.4, 60, 64.8, 97. phenobarbital oral tablet 0 QL (00 cada 0 días) phenytoin oral suspension 15 /5 ml (Dilantin-15) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 100 phenytoin sodium extended oral capsule (Phenytek) 00, 00 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml POTIGA ORAL TABLET 00 MG, 00 MG, 400 MG 5 ST; NDS; QL (90 cada 0 días) 9

30 Nombre del POTIGA ORAL TABLET 50 MG 5 ST; NDS; QL (70 cada 0 días) primidone oral tablet 50, 50 (Mysoline) ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR 4 ST; QL (60 cada 0 días) SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 50 MG, 500 MG, 750 MG 4 ST; QL (10 cada 0 días) tiagabine oral tablet, 4 (Gabitril) topiramate oral capsule, sprinkle 15, (Topamax) 5 topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) 100, 150, 00, 5, 50 topiramate oral tablet 100, 00, 5, 50 (Topamax) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 4HR 100 MG, 00 MG, 5 MG, 50 MG 4 ST valproate sodium intravenous solution 500 (Depacon) /5 ml (100 /ml) valproic acid (as sodium salt) oral (Depakene) solution 50 /5 ml valproic acid oral capsule 50 (Depakene) VIMPAT INTRAVENOUS SOLUTION 4 ST; QL (00 cada 5 días) 00 MG/0 ML VIMPAT ORAL SOLUTION 10 MG/ML 5 ST; NDS; QL (100 cada 0 días) VIMPAT ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG 4 ST; QL (60 cada 0 días) zonisamide oral capsule 100, 5 (Zonegran) zonisamide oral capsule 50 Agentes contra la demencia Agentes contra la demencia donepezil oral tablet 10,, 5 (Aricept) QL (0 cada 0 días) donepezil oral tablet,disintegrating 10, QL (0 cada 0 días) 5 0

31 Nombre del galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (0 cada 0 días) 4 hr 16, 4, 8 galantamine oral solution 4 /ml QL (00 cada 0 días) galantamine oral tablet 1, 4, 8 (Razadyne) QL (60 cada 0 días) memantine oral solution /ml QL (60 cada 0 días) memantine oral tablet 10, 5 (Namenda) QL (60 cada 0 días) memantine oral tablets,dose pack 5-10 (Namenda Titration QL (49 cada 8 días) Pak) NAMENDA XR ORAL QL (8 cada 8 días) CAP,SPRINKLE,ER 4HR DOSE PACK MG NAMENDA XR ORAL QL (0 cada 0 días) CAPSULE,SPRINKLE,ER 4HR 14 MG, 1 MG, 8 MG, 7 MG NAMZARIC ORAL CAP,SPRINKLE,ER QL (56 cada 65 días) 4HR DOSE PACK 7/14/1/8 MG-10 MG NAMZARIC ORAL QL (0 cada 0 días) CAPSULE,SPRINKLE,ER 4HR MG, 1-10 MG, 8-10 MG, 7-10 MG rivastigmine tartrate oral capsule 1.5,, 4.5, 6 QL (60 cada 0 días) rivastigmine transdermal patch 4 hour (Exelon) QL (0 cada 0 días) 1. /4 hour, 4.6 /4 hr, 9.5 /4 hr Antidepresivos Antidepresivos amitriptyline oral tablet 10, 100, 150, 5, 50, 75 amoxapine oral tablet 100, 150, 5, 50 BRINTELLIX ORAL TABLET 10 MG, 4 ST 0 MG, 5 MG bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release (Wellbutrin SR) 1 hr 100, 150, 00 bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr 150, 00 citalopram oral solution 10 /5 ml QL (600 cada 0 días) citalopram oral tablet 10, 0, 40 (Celexa) 1 QL (0 cada 0 días) 1

32 Nombre del clomipramine oral capsule 5, 50, (Anafranil) 75 desipramine oral tablet 10, 5 (Norpramin) desipramine oral tablet 100, 150, 50, 75 desvenlafaxine succinate oral tablet (Pristiq) ST; QL (0 cada 0 días) extended release 4 hr 100, 5, 50 doxepin oral capsule 10, 100, 150, 5, 50, 75 doxepin oral concentrate 10 /ml duloxetine oral capsule,delayed release(dr/ec) 0, 60 (Cymbalta) (Cymbalta); QL (60 cada 0 días) duloxetine oral capsule,delayed release(dr/ec) 0 (Cymbalta) (Cymbalta); QL (0 cada 0 días) duloxetine oral capsule,delayed release(dr/ec) 40 (Irenka) (Irenka); QL (0 cada 0 días) EMSAM TRANSDERMAL PATCH 4 HOUR 1 MG/4 HR, 6 MG/4 HR, 9 ; QL (0 cada 0 días) MG/4 HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 0 (Lexapro) 1, 5 FETZIMA ORAL CAPSULE,EXT REL 4 ST 4HR DOSE PACK 0 MG ()- 40 MG (6) FETZIMA ORAL 4 ST CAPSULE,EXTENDED RELEASE 4 HR 10 MG, 0 MG, 40 MG, 80 MG fluoxetine oral capsule 10, 0, 40 (Prozac) 1 fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) 90 fluoxetine oral solution 0 /5 ml (4 /ml) fluoxetine oral tablet 10, 0 (Sarafem) fluvoxamine oral capsule,extended release 4hr 100, 150 fluvoxamine oral tablet 100, 5, 50 imipramine hcl oral tablet 10, 5, 50 (Tofranil)

33 Nombre del imipramine pamoate oral capsule 100, 15, 150, 75 maprotiline oral tablet 5, 50, 75 MARPLAN ORAL TABLET 10 MG 4 mirtazapine oral tablet 15, 0, 45 (Remeron) mirtazapine oral tablet 7.5 mirtazapine oral tablet,disintegrating 15 (Remeron SolTab), 0, 45 nefazodone oral tablet 100, 150, 00, 50, 50 nortriptyline oral capsule 10, 5, (Pamelor) 50, 75 nortriptyline oral solution 10 /5 ml olanzapine-fluoxetine oral capsule 1-5 (Symbyax), 1-50, -5, 6-5, 6-50 paroxetine hcl oral tablet 10, 0, (Paxil) 1 40 paroxetine hcl oral tablet 0 (Paxil) paroxetine hcl oral tablet extended release (Paxil CR) 4 hr 1.5, 5, 7.5 PAXIL ORAL SUSPENSION 10 MG/5 4 ML perphenazine-amitriptyline oral tablet - 10, -5, 4-10, 4-5, 4-50 phenelzine oral tablet 15 (Nardil) PRISTIQ ORAL TABLET EXTENDED 4 ST; QL (0 cada 0 días) RELEASE 4 HR 100 MG, 5 MG, 50 MG protriptyline oral tablet 10, 5 sertraline oral concentrate 0 /ml (Zoloft) sertraline oral tablet 100, 5, 50 (Zoloft) 1 SURMONTIL ORAL CAPSULE MG, 5 MG, 50 MG tranylcypromine oral tablet 10 (Parnate) trazodone oral tablet 100, 150, 00 1, 50 trimipramine oral capsule 100, 5, 50 (Surmontil)

34 Nombre del TRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG venlafaxine oral capsule,extended release 4hr 150, 7.5, 75 venlafaxine oral tablet 100, 5, 7.5, 50, 75 venlafaxine oral tablet extended release 4hr 150, 7.5, 75 VIIBRYD ORAL TABLET 10 MG, 0 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG () Agentes antidiabéticos Agentes antidiabéticos, varios acarbose oral tablet 100, 5, 50 (Effexor XR) 4 4 ST (Precose) QL (90 cada 0 días) CYCLOSET ORAL TABLET 0.8 MG 4 QL (180 cada 0 días) GLYXAMBI ORAL TABLET 10-5 MG, ST; QL (0 cada 0 días) 5-5 MG INVOKAMET ORAL TABLET 150- ST; QL (60 cada 0 días) 1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG ST; QL (10 cada 0 días) INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 4HR 150-1,000 MG, MG, 50-1,000 MG, MG ST; QL (60 cada 0 días) INVOKANA ORAL TABLET 100 MG ST; QL (60 cada 0 días) INVOKANA ORAL TABLET 00 MG ST; QL (0 cada 0 días) JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 100-1,000 MG, 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 5 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 5 ST; QL (0 cada 0 días) MG JENTADUETO ORAL TABLET.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 4HR.5-1,000 MG, 5-1,000 MG 4 4

35 Nombre del KORLYM ORAL TABLET 00 MG ; QL (11 cada 8 días) metformin oral tablet 1,000 (Glucophage) 1 Primer Surtido Gratuito (Free First Fill, FF); QL (75 cada 0 días) metformin oral tablet 500 (Glucophage) 1 FF; QL (150 cada 0 días) metformin oral tablet 850 (Glucophage) 1 FF; QL (90 cada 0 días) metformin oral tablet extended release 4 hr 500 (Glucophage XR) FF; QL (10 cada 0 días) metformin oral tablet extended release 4 (Glucophage XR) FF; QL (90 cada 0 días) hr 750 metformin oral tablet extended release (Fortamet) ST; QL (60 cada 0 días) 4hr 1,000 metformin oral tablet extended release 4hr 500 (Fortamet) ST; QL (10 cada 0 días) miglitol oral tablet 100, 5, 50 (Glyset) QL (90 cada 0 días) nateglinide oral tablet 10, 60 (Starlix) QL (90 cada 0 días) pioglitazone oral tablet 15, 0, 45 (Actos) 1 QL (0 cada 0 días) pioglitazone-glimepiride oral tablet 0- (DUETACT) QL (0 cada 0 días), 0-4 pioglitazone-metformin oral tablet (Actoplus MET) QL (90 cada 0 días), repaglinide oral tablet 0.5 QL (40 cada 0 días) repaglinide oral tablet 1, (Prandin) QL (40 cada 0 días) repaglinide-metformin oral tablet QL (150 cada 0 días), -500 SYMLINPEN 10 SUBCUTANEOUS PEN INJECTOR,700 MCG/.7 ML ; QL (10.8 cada 8 días) SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML ; QL (6 cada 8 días) SYNJARDY ORAL TABLET 1.5-1,000 ST; QL (60 cada 0 días) MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR - ST; QL (0 cada 0 días) ER, BIPHASIC 4HR 10-1,000 MG, 5-1,000 MG SYNJARDY XR ORAL TABLET, IR - ST; QL (60 cada 0 días) ER, BIPHASIC 4HR 1.5-1,000 MG, 5-1,000 MG TRADJENTA ORAL TABLET 5 MG 5

36 Nombre del TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML 6 VICTOZA Insulinas HUMULIN R U-500 (CONC) KWIKPEN QL (4 cada 8 días) SUBCUTANEOUS INSULIN PEN 500 UNIT/ML ( ML) HUMULIN R U-500 QL (40 cada 8 días) (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR QL (0 cada 8 días) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LANTUS SUBCUTANEOUS QL (40 cada 8 días) SOLUTION 100 UNIT/ML NOVOLIN 70/0 SUBCUTANEOUS QL (40 cada 8 días) SUSPENSION 100 UNIT/ML (70-0) NOVOLIN N SUBCUTANEOUS QL (40 cada 8 días) SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION QL (40 cada 8 días) 100 UNIT/ML NOVOLOG FLEXPEN QL (0 cada 8 días) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX 70-0 FLEXPEN QL (0 cada 8 días) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) NOVOLOG MIX 70-0 QL (40 cada 8 días) SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-0) NOVOLOG PENFILL QL (0 cada 8 días) SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 cada 8 días) SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) Sulfonilureas glimepiride oral tablet 1, (Amaryl) 1 QL (0 cada 0 días) glimepiride oral tablet 4 (Amaryl) 1 QL (60 cada 0 días) glipizide oral tablet 10 (Glucotrol) 1 QL (10 cada 0 días)

37 Nombre del glipizide oral tablet 5 (Glucotrol) 1 QL (60 cada 0 días) glipizide oral tablet extended release 4hr (Glucotrol XL) QL (60 cada 0 días) 10 glipizide oral tablet extended release 4hr (Glucotrol XL) QL (0 cada 0 días).5, 5 glipizide-metformin oral tablet.5-50 QL (40 cada 0 días) glipizide-metformin oral tablet QL (10 cada 0 días), glyburide micronized oral tablet 1.5, (Glynase), 6 glyburide oral tablet 1.5,.5, 5 glyburide-metformin oral tablet glyburide-metformin oral tablet (Glucovance) 1 glyburide-metformin oral tablet (Glucovance) tolazamide oral tablet 50 QL (10 cada 0 días) tolazamide oral tablet 500 QL (60 cada 0 días) tolbutamide oral tablet 500 QL (180 cada 0 días) Antimicóticos Antimicóticos ABELCET INTRAVENOUS 5 PA BvD; NDS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS 5 PA BvD; NDS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 PA BvD CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Loprox (as olamine)) ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Ciclodan) ciclopirox topical suspension 0.77 % (Loprox (as olamine)) clotrimazole mucous membrane troche 10 clotrimazole topical cream 1 % (Lotrimin AF) clotrimazole topical solution 1 % clotrimazole-betamethasone topical cream % (Lotrisone) 7

38 Nombre del clotrimazole-betamethasone topical lotion % econazole topical cream 1 % fluconazole in nacl (iso-osm) intravenous piggyback 100 /50 ml, 00 /100 ml, 400 /00 ml fluconazole oral suspension for (Diflucan) reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 150, (Diflucan) 00, 50 flucytosine oral capsule 50, 500 (Ancobon) griseofulvin microsize oral tablet 500 itraconazole oral capsule 100 (Sporanox) ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical shampoo % (Nizoral) miconazole- vaginal suppository 00 NOXAFIL ORAL SUSPENSION 00 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram nyata topical powder 100,000 unit/gram nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram (Nystop) nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% nystop topical powder 100,000 unit/gram terbinafine hcl oral tablet 50 (Lamisil) 1 voriconazole intravenous solution 00 (Vfend IV) voriconazole oral suspension for (Vfend) reconstitution 00 /5 ml (40 /ml) voriconazole oral tablet 00, 50 (Vfend) 8

39 Nombre del Agentes antigotosos Agentes antigotosos, otros allopurinol oral tablet 100, 00 (Zyloprim) colchicine oral tablet 0.6 (Colcrys) COLCRYS ORAL TABLET 0.6 MG probenecid oral tablet 500 probenecid-colchicine oral tablet ULORIC ORAL TABLET 40 MG, 80 MG QL (0 cada 0 días) ZURAMPIC ORAL TABLET 00 MG ST; QL (0 cada 0 días) Antihistamínicos Antihistamínicos cyproheptadine oral syrup /5 ml cyproheptadine oral tablet 4 diphenhydramine hcl injection solution 50 /ml hydroxyzine hcl intramuscular solution 5 /ml, 50 /ml hydroxyzine hcl oral solution 10 /5 ml hydroxyzine hcl oral tablet 10, 5, 50 levocetirizine oral solution.5 /5 ml (Xyzal) levocetirizine oral tablet 5 (Xyzal) promethazine oral syrup 6.5 /5 ml Antiinfecciosos (piel y membrana mucosa) Antiinfecciosos (piel y membrana mucosa) AVC VAGINAL VAGINAL CREAM 15 % clindamycin phosphate vaginal cream % (Cleocin) metronidazole vaginal gel 0.75 % (Vandazole) terconazole vaginal cream 0.4 % (Terazol 7) terconazole vaginal cream 0.8 % terconazole vaginal suppository 80 Antijaquecosos Antijaquecosos dihydroergotamine injection solution 1 /ml dihydroergotamine nasal spray,nonaerosol 0.5 /pump act. (4 /ml) (D.H.E.45) ; QL (0 cada 8 días) (Migranal) ; QL (8 cada 8 días) 9