Farmacopea Hamaspik Medicare Select 2020 · 2020. 4. 6. · Cambios que no lo afectarán si...

Farmacopea HamaspikMedicare Select 2020

H0034_FORMUL_M

Hamaspik Medicare Select (HMO D-SNP) Farmacopea completa de la Parte D 2020

Hamaspik Medicare Select (HMO D-SNP)

Farmacopea 2020

Lista de medicamentos cubiertos

POR FAVOR, LEA: ESTE DOCUMENTO CONTIENE

INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE

CUBRIMOS EN ESTE PLAN

Esta farmacopea se actualizó el 01/03/2020

Para obtener información más reciente u otras preguntas, comuníquese

con Servicios para miembros al: 1-833-426-2774. Los usuarios de TTY,

deben llamar al 711. Nuestro horario es de 7 días a la semana, de 8:00 a.m. a 8:00

p.m., del 1.o de octubre de 2019 al 31 de marzo de 2020.

Desde abril de 2020 hasta septiembre de 2020, nuestro

personal de Servicios para miembros estará disponible de

lunes a viernes de 8:00 a.m. a 8:00 p.m.

O visite: www.hamaspik.com

H0034_FORMUL_M ID de entrega del archivo de Farmacopea aprobado de HPMS: 00020412, versión numero: 12


Nota para los miembros existentes:

Esta farmacopea ha cambiado desde el año pasado. Revise este documento para asegurarse de que

aún contenga los medicamentos que toma. Cuando esta lista de medicamentos (farmacopea) se

refiere a “nosotros”, “nos” o “nuestro”, significa Hamaspik Medicare Select. Cuando se refiere a

“plan” o “ nuestro plan”, significa Hamaspik Medicare Select. Este documento incluye una lista de

los medicamentos (farmacopea) para nuestro plan que está actualizada al 01/03/2020. Para obtener

una farmacopea actualizada, contáctenos. Nuestra información de contacto, junto con la fecha de la

última actualización de la farmacopea, aparece en la portada y contraportada.

En general, debe usar las farmacias de la red para usar su beneficio de medicamentos

recetados. Los beneficios, la farmacopea, la red de farmacias o los copagos/coseguros pueden

cambiar el 1.o de enero de 2020 y ocasionalmente durante el año.

¿Qué es la farmacopea de Hamaspik Medicare Select? Una farmacopea es una lista de medicamentos cubiertos seleccionados por Hamaspik Medicare

Select en consulta con un equipo de proveedores de atención médica, que representa las terapias

recetadas que se consideran parte necesaria de un programa de tratamiento de calidad. Hamaspik

Medicare Select generalmente cubrirá los medicamentos enumerados en nuestra farmacopea siempre

que el medicamento sea médicamente necesario, la receta se surta en una farmacia de la red

Hamaspik Medicare Select y se sigan otras reglas del plan. Para obtener más información sobre

cómo surtir sus recetas, revise su Evidencia de cobertura.

¿Puede cambiar la Farmacopea (lista de medicamentos)? La mayoría de los cambios en la cobertura de medicamentos ocurren el 1.o de enero, pero podemos agregar o eliminar medicamentos en la lista de medicamentos durante el año, moverlos a diferentes niveles de costo compartido o agregar nuevas restricciones.

Cambios que pueden afectarlo este año

En los siguientes casos, se verá afectado por los cambios de cobertura durante el

año:

• Nuevos medicamentos genéricos. Es posible que eliminemos de inmediato un medicamento de

marca en nuestra lista de medicamentos si lo reemplazamos con un nuevo medicamento genérico que

aparecerá en el mismo nivel de costo compartido o en uno más bajo y con las

mismas restricciones o menos. Además, al agregar el nuevo medicamento genérico, podemos decidir

mantener el medicamento de marca en nuestra lista de medicamentos, pero inmediatamente pasarlo a

un nivel de costo compartido diferente o agregar nuevas restricciones. Si actualmente está tomando

ese medicamento de marca, es posible que no le informemos con anticipación antes de realizar ese

cambio, pero luego le brindaremos información sobre los cambios específicos que hemos realizado.

o Si realizamos dicho cambio, usted o su médico pueden solicitarnos que

hagamos una excepción y continuar cubriendo el medicamento de marca para

usted. El aviso que le proporcionamos también incluirá información sobre cómo

solicitar una excepción, y también puede encontrar información en la sección a

continuación titulada “¿Cómo solicito una excepción a la Farmacopea de

Hamaspik Medicare Select?”.

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• Drogas retiradas del mercado. Si la Administración de Alimentos y Medicamentos considera

que un medicamento de nuestra farmacopea no es seguro o si el fabricante del medicamento elimina

el medicamento del mercado, eliminaremos inmediatamente el medicamento de nuestra farmacopea

y notificaremos a los miembros que lo toman.

• Otros cambios. Podemos hacer otros cambios que afecten a los miembros que actualmente toman

un medicamento. Por ejemplo, podemos agregar un medicamento genérico que no sea nuevo en el

mercado para reemplazar un medicamento de marca actualmente en la farmacopea o agregar nuevas

restricciones al medicamento de marca o moverlo a un nivel de costo compartido diferente. O

podemos hacer cambios basados en nuevas pautas clínicas. Si eliminamos medicamentos de nuestra

farmacopea, o agregamos autorización previa, límites de cantidad o restricciones de terapia

escalonada en un medicamento, debemos notificar a los miembros afectados del cambio al menos

30 días antes de que el cambio entre en vigencia, o en el momento en que el miembro solicita una

recarga del medicamento, momento en el cual el miembro recibirá un suministro de 30 días del

medicamento.

o Si hacemos estos otros cambios, usted o su médico pueden solicitarnos que

hagamos un excepción y continuar cubriendo el medicamento de marca para

usted. El aviso que le proporcionamos también incluirá información sobre cómo

solicitar una excepción, y también puede encontrar información en la sección a

continuación titulada “¿Cómo solicito una excepción a la Farmacopea de Hamaspik

Medicare Select?”.

Cambios que no lo afectarán si actualmente está tomando el medicamento.

En general, si está tomando un medicamento de nuestra farmacopea 2020 que estaba cubierto a

principios de año, no descontinuaremos ni reduciremos la cobertura del medicamento durante

el año de cobertura 2020, excepto como se describió anteriormente. Esto significa que estos

medicamentos permanecerán disponibles al mismo costo compartido y sin nuevas restricciones

para aquellos miembros que los toman por el resto del año de cobertura.

La farmacopea adjunta está actualizado al 01/03/2020. Para obtener información actualizada sobre

los medicamentos cubiertos por Hamaspik Medicare Select, contáctenos. Nuestra información de

contacto aparece en la portada y contraportada. Puede solicitar una copia actualizada de la

farmacopea en cualquier momento llamando a Servicios para miembros. Si actualizamos nuestra

farmacopea impresa con cambios en la farmacopea que no sean de mantenimiento, le enviaremos un

aviso que incluya esta información.

¿Cómo uso la farmacopea? Hay dos formas de encontrar su medicamento en la farmacopea:

Condición médica

La farmacopea comienza en la página 9. Los medicamentos en esta farmacopea se agrupan en

categorías según el tipo de uso que se le dé para tratar las afecciones médicas. Por ejemplo, los

medicamentos utilizados para tratar una afección cardíaca se enumeran en la categoría

“Cardiovascular”. Si usted sabe para qué se usa su medicamento, busque el nombre de la

categoría en la lista que comienza en la página 9. Luego busque debajo del nombre de la

categoría el de su medicamento.

Listado alfabético

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Si no está seguro en qué categoría buscar, debe buscar su medicamento en el Índice que

comienza en la página 121. El Índice proporciona una lista alfabética de todos los

medicamentos incluidos en este documento. Tanto los medicamentos de marca como los

genéricos se enumeran en el Índice. Mire en el índice y encuentre su medicamento. Al lado

de su medicamento, verá el número de página donde puede encontrar información de

cobertura. Vaya a la página que figura en el Índice y encuentre el nombre de su medicamento

en la primera columna de la lista.

¿Qué son las drogas genéricas? Hamaspik Medicare Select cubre tanto los medicamentos de marca como los genéricos. Un

medicamento genérico es aprobado por la FDA cuando tiene el mismo ingrediente activo que el

medicamento de marca. En general, los medicamentos genéricos cuestan menos que los de marca.

¿Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales en la

cobertura. Estos requisitos y límites pueden incluir:

• Autorización previa: Hamaspik Medicare Select requiere que usted o su médico obtengan

una autorización previa para ciertos medicamentos. Esto significa que deberá obtener la

aprobación de Hamaspik Medicare Select antes de surtir sus recetas. Si no obtiene la

aprobación, Hamaspik Medicare Select puede no cubrir el medicamento.

• Límites de cantidad: para ciertos medicamentos, Hamaspik Medicare Select limita la cantidad

del medicamento que cubrirá Hamaspik Medicare Select. Por ejemplo, Hamaspik Medicare

Select proporciona 30 unidades por receta para el comprimido de tartrato de zolpidem de 10

mg. Esto puede ser adicional a un suministro estándar de uno o tres meses.

• Terapia escalonada: en algunos casos, Hamaspik Medicare Select requiere que primero

pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro

medicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento B tratan su

afección médica, Hamaspik Medicare Select puede no cubrir el medicamento B a menos que

pruebe el medicamento A primero. Si el medicamento A no funciona para usted, Hamaspik

Medicare Select cubrirá el medicamento B.

Puede averiguar si su medicamento tiene requisitos o límites adicionales en la farmacopea que

comienza en la página 9. También puede obtener más información sobre las restricciones

aplicadas a medicamentos cubiertos específicos visitando nuestro sitio web

(www.hamaspik.com). Hemos publicado documentos en línea que explican nuestra autorización

previa y las restricciones de terapia escalonada. También puede pedirnos que le enviemos una

copia. Nuestra información de contacto, junto con la fecha en que actualizamos la farmacopea por

última vez, aparece en las páginas de portada y contraportada.

Puede pedirle a Hamaspik Medicare Select que haga una excepción a estas restricciones o límites o

puede solicitar una lista de otros medicamentos similares que puedan tratar su afección

médica. Consulte la sección, “¿Cómo solicito una excepción a la farmacopea de Hamaspik Medicare

Select ?” de la página 5 para obtener información sobre cómo solicitar una excepción.

¿Qué son los medicamentos de venta libre (OTC)?

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Los medicamentos de venta libre son medicamentos sin receta que normalmente no están cubiertos

por un plan de medicamentos con receta de Medicare. Hamaspik Medicare Select paga ciertos

medicamentos de venta libre como un beneficio suplementario. Este beneficio se describe en el

Capítulo 4 de su Evidencia de cobertura. Hamaspik Medicare Select le proporcionará estos

medicamentos de venta libre sin costo alguno para usted. El costo para Hamaspik Medicare Select de

estos medicamentos de venta libre no contará para sus costos totales de medicamentos de la Parte D

(es decir, el costo de los medicamentos de venta libre no cuenta para la brecha de

cobertura. Comuníquese con Servicios para miembros para obtener más información sobre sus

medicamentos de venta libre). El número de teléfono figura en la portada y contraportada de este

folleto.

¿Qué sucede si mi medicamento no está en la Farmacopea?

Si su medicamento no está incluido en esta farmacopea (lista de medicamentos

cubiertos), primero debe comunicarse con Servicios para miembros y preguntar si su

medicamento está cubierto.

Si se entera de que Hamaspik Medicare Select no cubre su medicamento, tiene dos opciones:

• Puede solicitar a Servicios para miembros una lista de medicamentos similares cubiertos por

Hamaspik Medicare Select. Cuando reciba la lista, muéstresela a su médico y pídale que le

recete un medicamento similar que esté cubierto por Hamaspik Medicare Select.

• Puede pedirle a Hamaspik Medicare Select que haga una excepción y cubra su

medicamento. Consulte a continuación para obtener información sobre cómo solicitar una

excepción.

¿Cómo solicito una excepción a la Farmacopea de Hamaspik

Medicare Select? Puede pedirle a Hamaspik Medicare Select que haga una excepción a nuestras reglas de

cobertura. Hay varios tipos de excepciones que puede solicitarnos que hagamos.

• Puede solicitarnos que cubramos un medicamento incluso si no está en nuestra

farmacopea. Si se aprueba, este medicamento estará cubierto a un nivel de costo compartido

predeterminado, y no podrá solicitarnos que proporcionemos el medicamento a un nivel de

costo compartido más bajo.

• Puede solicitarnos que no apliquemos restricciones o límites de cobertura a su

medicamento. Por ejemplo, para ciertos medicamentos, Hamaspik Medicare Select limita

la cantidad del medicamento que vamos a cubrir. Si su medicamento tiene un límite de

cantidad, puede solicitarnos que no apliquemos el límite y cubramos una cantidad mayor.

En general, Hamaspik Medicare Select solo aprobará su solicitud de excepción si los medicamentos

alternativos incluidos en la farmacopea del plan, el medicamento de costo compartido más bajo o las

restricciones de utilización adicionales no serían tan efectivos en el tratamiento de su afección o le

causarían tener efectos médicos adversos.

Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una

farmacopea o una excepción de restricción de uso. Cuando solicita una farmacopea o una

excepción de restricción de uso, debe presentar una declaración de su recetador o médico que

respalde su solicitud.

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En general, debemos tomar nuestra decisión dentro de las 72 horas de haber recibido la declaración

de respaldo de su médico. Puede solicitar una excepción acelerada (rápida) si usted o su

médico creen que su salud podría verse seriamente afectada si espera hasta 72 horas para tomar una

decisión. Si se otorga su solicitud de agilización, debemos darle una decisión a más tardar 24 horas

después de que recibamos una declaración de respaldo de su médico u otra persona que recete.

¿Qué debo hacer antes de poder hablar con mi médico acerca de

cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o permanente de nuestro plan, puede estar tomando medicamentos que no

están en nuestra farmacopea. O bien, puede estar tomando un medicamento que está en nuestra

farmacopea, pero su capacidad para obtenerlo es limitada. Por ejemplo, es posible que necesite una

autorización previa de nuestra parte antes de poder surtir su receta. Debe hablar con su médico para

decidir si debe cambiarse a un medicamento apropiado que cubramos o solicitar una excepción a la

farmacopea para que cubramos el medicamento que toma. Mientras habla 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 sea miembro de nuestro plan.

Para cada uno de sus medicamentos que no está en nuestra farmacopea o si su capacidad para

obtener sus medicamentos es limitada, cubriremos un suministro temporal de 30 días. Si su receta

está escrita por menos días, permitiremos surtidos para proporcionar un suministro máximo de

medicamentos para 30 días. Después de su primer suministro de 30 días, no pagaremos estos

medicamentos, incluso si ha sido miembro del plan por menos de 90 días.

Si es residente de un centro de atención a largo plazo y necesita un medicamento que no está en

nuestra farmacopea o si su capacidad para obtener sus medicamentos es limitada, pero ha pasado los

primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días

de ese medicamento mientras busca una excepción a la farmacopea.

También se proporcionará un suministro de receta de transición a los miembros actuales que: (1)

necesitan un suministro único en caso de emergencia, o (2) se les receta un medicamento que no

figura en la farmacopea como resultado de un cambio en el nivel de cuidado.

Para más información Para obtener información más detallada sobre su cobertura de medicamentos recetados por

Hamaspik Medicare Select, revise su Evidencia de cobertura y otro material del plan.

Si tiene preguntas sobre Hamaspik Medicare Select, contáctenos. Nuestra información de contacto,

junto con la fecha en que actualizamos la farmacopea por última vez, aparece en las páginas de

portada y contraportada.

Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a

Medicare al 1-800-MEDICARE (1-800-633-4227) las 24 horas del día, los 7 días de la semana. Los

usuarios de TTY deben llamar al 1-877-486-2048. O visite http://www.medicare.gov.

Farmacopea de Hamaspik Medicare Select

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La farmacopea que comienza en la página siguiente proporciona información de cobertura sobre

los medicamentos cubiertos por Hamaspik Medicare Select. Si tiene problemas para encontrar su

medicamento en la lista, consulte el Índice que comienza en la página 121.

La primera columna del cuadro enumera el nombre del medicamento. Los medicamentos de marca

aparecen en mayúscula (p. ej., METHADOSE 10 MG/ML ORAL CONCENTRADO) y los

medicamentos genéricos aparecen en minúscula y cursiva (p. ej., sulfato de albuterol).

La información en la columna Requisitos/límites le indica si Hamaspik Medicare Select tiene

algún requisito especial para la cobertura de su medicamento. Los símbolos que aparecen en la

página siguiente se utilizan para hacerle saber que un fármaco tiene uno o más requerimientos

especiales.

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CLAVE FORMULARIA DE ABREVIATURAS LA: Disponibilidad limitada. Esta receta puede estar disponible solo en

ciertas farmacias. Para obtener más información, consulte su Directorio de

farmacias o llame a Servicios para miembros al 1-833-426-2774, de lunes a

viernes, de 8:00 a.m. a 8:00 p.m. Los usuarios de TTY deben llamar al 711.

PA: Autorización previa. El plan requiere que usted o su médico obtengan

autorización previa para ciertos medicamentos. Esto significa que deberá

obtener la aprobación antes de surtir sus recetas. Si no obtiene la

aprobación, es posible que no cubramos el medicamento.

PA, determinación de la Parte B vs. Parte D. Este medicamento recetado

puede estar cubierto por las Partes B o D de Medicare, según las

circunstancias. Es posible que deba presentarse información que describa el

uso y la configuración del medicamento para tomar la determinación.

QL: Límite de cantidad. Para ciertos medicamentos, el plan limita la

cantidad del medicamento que cubriremos.

ST: Terapia escalonada. En algunos casos, el plan requiere que primero pruebe

ciertos medicamentos para tratar su afección médica antes de que cubramos otro

medicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento

B tratan su afección médica, es posible que no cubramos el medicamento B a menos

que primero pruebe el medicamento A. Si el medicamento A no funciona para usted,

cubriremos el medicamento B.

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2020 Hamaspik Medicare Select (Lista de medicamentos cubiertos)

NOMBRE DELMEDICAMENTO

NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Analgesics

Nonsteroidal Anti-inflammatory Drugsdiclofenac potassium 1

diclofenac sodium 1% gel 1 QL (1000 PER 30 DAYS)

diclofenac sodium (sod dr 25 mgtab, sod dr 50 mg tab, sod dr 75mg tab, sod ec 25 mg tab, sodec 50 mg tab, sod ec 75 mg tab,sodium 3% gel)

1

diclofenac sodium er 1

diflunisal 1

ec-naproxen 1

etodolac (200 mg capsule, 300mg capsule, 400 mg tablet, 500mg tablet)

1

fenoprofen 600 mg tablet 1

flurbiprofen (50 mg tablet, 100mg tablet)

1

ibu 1

ibuprofen (100 mg/5 ml susp,400 mg tablet, 600 mg tablet,800 mg tablet)

1

indomethacin (25 mg capsule,50 mg capsule)

1

ketoprofen 25 mg capsule 1

ketorolac tromethamine (15mg/ml syringe, 15 mg/ml vial, 30mg/ml isecure syr, 30 mg/ml vial,30 mg/ml syringe, 30 mg/mlcarpuject, 60 mg/2 ml syringe,60 mg/2 ml carpuject, 60 mg/2ml vial)

1

ketorolac 10 mg tablet 1 QL (20 PER 30 OVER TIME)

meclofenamate sodium (50 mgcapsule, 100 mg capsule)

1

Puede encontrar información sobre lo que significan los símbolosy las abreviaturas de esta tabla en la página 9.

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NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

mefenamic acid 250 mg capsule 1

meloxicam (7.5 mg tablet, 15 mgtablet)

1

nabumetone (500 mg tablet, 750mg tablet)

1

naproxen (125 mg/5 ml suspen,250 mg tablet, dr 375 mg tablet,375 mg tablet, 500 mg kit, 500mg tablet, dr 500 mg tablet)

1

naproxen sodium (275 mg tab,550 mg tab)

1

naproxen sodium ds 1

oxaprozin 1

piroxicam (10 mg capsule, 20mg capsule)

1

SPRIX 1 QL (5 PER 30 OVER TIME)

sulindac (150 mg tablet, 200 mgtablet)

1

tolmetin sodium (200 mg tab,400 mg cap, 600 mg tab)

1

Opioid Analgesics, Long-actingEMBEDA 1

fentanyl 1

hydromorphone er (er 16 mgtab, er 32 mg tab)

1

INFUMORPH 1

levorphanol 3 mg tablet 1

methadone hcl (hcl 5 mg tablet,5 mg/5 ml solution, 10 mg/5 mlsolution, hcl 10 mg/ml vial, 10mg/ml oral conc, hcl 10 mgtablet, hcl 200 mg/20 ml vl)

1

methadone intensol 1

METHADOSE 10 MG/ML ORALCONC

1


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NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

mitigo 1

morphine sulfate er (sulf er 15mg tablet, sulf er 30 mg tablet,sulf er 60 mg tablet, sulf er 100mg tablet, sulf er 200 mg tablet,sulfate er 10 mg cap, sulfate er20 mg cap, sulfate er 30 mg cap,sulfate er 40 mg cap, sulfate er50 mg cap, sulfate er 60 mg cap,sulfate er 80 mg cap, sulfate er100 mg cap)

1

oxymorphone hcl er 1

XTAMPZA ER 1

Opioid Analgesics, Short-actingABSTRAL 1 PA

acetaminophen-codeine(acetamin-codein 300-30mg/12.5, acetaminop-codeine120-12 mg/5, acetaminophen-cod #2 tablet, acetaminophen-cod #3 tablet, acetaminophen-cod #4 tablet)

1

butorphanol tartrate (1 mg/mlvial, 2 mg/ml vial, 4 mg/2 ml vial,10 mg/ml spray)

1

codeine sulfate 1

DURAMORPH 1

endocet 1

fentanyl citrate (50 mcg/ml vial,100 mcg/2 ml vial, 100 mcg/2 mlampul, 100 mcg/2 ml syringe,100 mcg/2 ml carpujct, 250mcg/5 ml ampul, 250 mcg/5 mlvial, 500 mcg/10 ml vial, 1,000mcg/20 ml ampul, 1,000 mcg/20ml vial, 2,500 mcg/50 ml vial)

1


11



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

fentanyl citrate (cit 100 mcgbuccal tb, cit 200 mcg buccal tb,cit 400 mcg buccal tb, cit 600mcg buccal tb, cit 800 mcgbuccal tb, cit otfc 1,200 mcg, citotfc 1,600 mcg, citrate otfc 200mcg, citrate otfc 400 mcg, citrateotfc 600 mcg, citrate otfc 800mcg)

1 PA

hydrocodone-acetaminophen(hydrocodone-acetamin 2.5-108/5, hydrocodone-acetamin 5-217/10, hydrocodone-acetamin5-300 mg, hydrocodone-acetamin 5-325 mg,hydrocodone-acetamin 7.5-325,hydrocodone-acetamin 7.5-300,hydrocodone-acetamin 10-325mg, hydrocodone-acetamin 10-300 mg, hydrocodone-acetamn7.5-325/15)

1

hydromorphone hcl (0.5 mg/0.5ml, hcl 1 mg/ml amp, 1 mg/mlcarpujct, 1 mg/ml vial, 1 mg/mlsyringe, 1 mg/ml solution, 2mg/ml carpujct, 2 mg/ml isecure,2 mg tablet, 4 mg/ml carpujct,hcl 4 mg/ml amp, 4 mg tablet, 5mg/5 ml soln, 8 mg tablet, 10mg/ml vial, 10 mg/ml ampule, 50mg/5 ml vial, 50 mg/5 ml amp,500 mg/50 ml vl)

1

LAZANDA 1 PA

lorcet 1

lorcet hd 1

lorcet plus 1


12



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

morphine sulfate (sulfate 2mg/ml vial, 2 mg/ml carpuject, 2mg/ml syringe, 2 mg/ml isecuresyr, 4 mg/ml carpuject, sulfate 4mg/ml vial, 4 mg/ml syringe, 4mg/ml isecure syr, 5 mg/ml vial,5 mg/ml syringe, sulf 100 mg/5ml conc, sulfate 5 mg/ml vial, 5mg/10 ml vial, 8 mg/ml carpuject,8 mg/ml isecure syrng, 10 mg/mlisecure syrg, sulf 10 mg/5 mlsoln, 10 mg/ml syringe, sulf 20mg/5 ml soln, sulfate 1 mg/mlvial, sulfate 8 mg/ml vial, 10mg/ml carpuject, sulfate 10mg/ml vial, 10 mg/10 ml vial,sulfate ir 15 mg tab, sulfate ir 30mg tab)

1

nalbuphine hcl (10 mg/ml ampul,20 mg/ml ampul, 100 mg/10 mlvial, 200 mg/10 ml vial)

1

OXAYDO 1

oxycodone hcl (5 mg/5 ml soln, 5mg capsule, 5 mg tablet, 10 mgtablet, 15 mg tablet, 20 mgtablet, 30 mg tablet, 100 mg/5 mlconc)

1

oxycodone hcl-aspirin 1

oxycodone hcl-ibuprofen 1

oxycodone-acetaminophen(oxycodon-acetaminophen 2.5-325, oxycodon-acetaminophen7.5-325, oxycodone-acetaminophen 5-325,oxycodone-acetaminophen 10-325)

1

ROXYBOND 1

tramadol hcl 50 mg tablet 1

tramadol hcl-acetaminophen 1

vicodin 1


13



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

vicodin es 1

vicodin hp 1

Anesthetics

Local Anestheticschloroprocaine hcl 1

glydo 1 QL (30 PER 30 DAYS)

lidocaine 5% patch 1 PA

lidocaine 5% ointment 1 PA, QL (150 PER 30 DAYS)

lidocaine hcl (0.5% vial, 1% 20mg/2 ml vl, 1% vial, 1% 50 mg/5ml, 1% 20 mg/2 ml, 1% 50 mg/5ml vl, 1% ampul, 1% 300 mg/30ml, 1.5% ampul, 2% ampul, 2%40 mg/2 ml, 2% 100 mg/5 ml,2% 40 mg/2 ml vl, 2% vial, 4%ampul)

1

lidocaine hcl 2% jelly 1 PA, QL (30 PER 30 DAYS)

lidocaine hcl 4% solution 1 PA, QL (250 PER 30 DAYS)

lidocaine-prilocaine 1 PA, QL (30 PER 30 DAYS)

liprozonepak 1 PA, QL (30 PER 30 DAYS)

medolor pak 1 PA, QL (30 PER 30 DAYS)

polocaine (1% vial, 2% vial) 1

polocaine-mpf 1

prilovix lite plus 1 QL (30 PER 30 DAYS)

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium 1

disulfiram (250 mg tablet, 500mg tablet)

1


14



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

VIVITROL 1

Opioid Dependence Treatmentsbuprenorphine hcl (2 mg tablet,8 mg tablet)

1

buprenorphine-naloxone(buprenor-nalox 12-3 mg film,buprenorp-nalox 4-1 mg film)

1 QL (60 PER 30 DAYS)

buprenorphine-naloxone(bupreno-nalox 2-0.5 mg film,buprenorp-nalox 8-2 mg film,buprenorphin-naloxon 8-2 mg)


buprenorphn-naloxn 2-0.5 mg sl 1 QL (360 PER 30 DAYS)

LUCEMYRA 1 QL (480 PER 30 DAYS)

naltrexone 50 mg tablet 1

Opioid Reversal Agentsnaloxone hcl (0.4 mg/mlcarpuject, 0.4 mg/ml vial, 2 mg/2ml syringe, 4 mg/10 ml vial)

1

NARCAN 1

Smoking Cessation Agentsbupropion hcl sr 150 mg tablet 1 QL (60 PER 30 DAYS)

CHANTIX (0.5 MG TABLET, 1MG CONT MONTH BOX, 1 MGTABLET, STARTING MONTHBOX)

1 QL (504 PER 365 OVER TIME)

NICOTROL 1 QL (2688 PER 365 OVER TIME)

NICOTROL NS 1 QL (360 PER 365 OVER TIME)

Anti-inflammatory Agents

Glucocorticoidsprocto-med hc 1

procto-pak 1


15



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

proctosol-hc 1

proctozone-hc 1

triamcinolone 0.147 mg/g spray 1

Antibacterials

Aminoglycosidesamikacin sulfate (sulf 1 gram/4ml vial, sulf 500 mg/2 ml vial, sulf1,000 mg/4 ml vl, sulfate 1,000mg/4 ml)

1

gentak 1

gentamicin sulfate (0.1%ointment, 0.1% cream, 0.3% eyedrop, 3 mg/ml eye drop, ped 20mg/2 ml vial, 40 mg/ml vial, 80mg/2 ml vial, 800 mg/20 ml vial)

1

gentamicin sulfate in ns (iso 100mg/100 ml, isoton 60 mg/50 ml,isoton 80 mg/100 ml, 80 mg/ns50 ml pb, isoton 80 mg/50 ml, 80mg/ns 100 ml pb, 100 mg/ns 100ml, isoton 100 mg/50 ml)

1

neomycin 500 mg tablet 1

neomycin-polymyxin b (40 mg/mlamp, 40 mg/ml vl)

1

paromomycin 250 mg capsule 1

streptomycin sulf 1 gm vial 1

tobramycin 0.3% eye drop 1

tobramycin sulfate (1.2 gm vial,1.2 gram/30 ml vial, 10 mg/mlvial, 40 mg/ml vial, 80 mg/2 mlvial, 1,200 mg/30 ml vial)

1

TOBREX 0.3% EYE OINTMENT 1


16



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Antibacterials, Otherbaciim 1

bacitracin (500 unit/gm ophth,50,000 unit vial)

1

BACTROBAN NASAL 1

chloramphenicol sod succinate 1

CLEOCIN 100 MG VAGINALOVULE

1

clindacin etz 1% pledget 1

clindacin p 1

clindamycin hcl (75 mg capsule,150 mg capsule, 300 mgcapsule)

1

clindamycin palmitate hcl 1

clindamycin pediatric 1

clindamycin phosphate (ph 1%solution, ph 1% gel, 2% vaginalcream, ph 9 g/60 ml vial, ph 300mg/2 ml vl, 300 mg/2 ml addvan,ph 600 mg/4 ml vl, ph 900 mg/6ml vl, phos 1% pledget, phosp1% lotion, phosphate 1% foam,phosphate 1% gel, 600 mg/4 mladdvan, 900 mg/6 ml addvan)

1

clindamycin phosphate-d5w 1

clindamycin-0.9% nacl 1

colistimethate 1

daptomycin 1

IMPAVIDO 1

linezolid 100 mg/5 ml susp 1 QL (1800 PER 28 DAYS)

linezolid 600 mg tablet 1 QL (56 PER 28 DAYS)

linezolid-d5w 1

mafenide acetate 1


17



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

methenamine hippurate 1

METRO IV 1

metronidazole (vaginal 0.75% gl,250 mg tablet, 375 mg capsule,500 mg/100 ml, 500 mg tablet)

1

mupirocin 2% ointment 1

nitrofurantoin (25 mg/5 ml susp,mcr 25 mg cap, mcr 50 mg cap,mcr 100 mg cap)

1

nitrofurantoin mono-macro 1

polymyxin b sulfate vial 1

silver sulfadiazine 1% cream 1

SIVEXTRO (200 MG VIAL, 200MG TABLET)


SSD 1

SYNERCID 1

tigecycline 1

trimethoprim 100 mg tablet 1

vancomycin hcl 125 mg capsule 1 QL (120 PER 30 DAYS)

vancomycin hcl 250 mg capsule 1 QL (240 PER 30 DAYS)

vancomycin hcl (1 gm vial, hcl1g/200 ml bag, 1 gm add-vanvial, hcl 1.25 gram vial, hcl 1.5gram vial, hcl 5 gm vial, hcl 10gm vial, hcl 100 gm smartpak,250 mg/5 ml soln, hcl 250 mgvial, 500 mg a-v vial, 500 mgvial, hcl 750 mg vial)

1

vancomycin-d5w 500 mg/100 ml 1

VANDAZOLE 1

VIBATIV 750 MG VIAL 1

XIFAXAN 1 PA


18



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Beta-lactam, CephalosporinsAVYCAZ 1

cefaclor (250 mg capsule, 500mg capsule)

1

cefaclor er 1

cefadroxil (1 gm tablet, 250 mg/5ml susp, 500 mg/5 ml susp, 500mg capsule)

1

cefazolin sodium (1 gm add-vanvial, 1 gm vial, 10 gm vial, 20 gmbulk vial, sod 100 gm bulk bag,sod 300 gm bulk bag, 500 mgvial)

1

cefazolin sodium-dextrose (1g/50, 2 g/50, 2 g/100)

1

cefdinir (125 mg/5 ml susp, 250mg/5 ml susp, 300 mg capsule)

1

cefepime hcl (1 gm vial, 2 gramvial)

1

cefixime (100 mg/5 ml susp, 200mg/5 ml susp, 400 mg capsule)

1

cefotaxime sodium 1

cefotetan 1

cefoxitin 1

cefpodoxime proxetil (50 mg/5ml susp, 100 mg tablet, 100mg/5 ml susp, 200 mg tablet)

1

cefprozil (125 mg/5 ml susp, 250mg/5 ml susp, 250 mg tablet,500 mg tablet)

1

ceftazidime (1 gm vial, 2 gm vial,6 gm vial)

1

ceftriaxone (1 gm add-vant vial,1 gm vial, 2 gm add vial, 2 gmvial, 10 gm vial, 100 gram bulkbag, 250 mg vial, 500 mg vial)

1


19



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

cefuroxime 1

cefuroxime sodium 1

cephalexin (125 mg/5 ml susp,250 mg tablet, 250 mg capsule,250 mg/5 ml susp, 500 mgtablet, 500 mg capsule, 750 mgcapsule)

1

SUPRAX (100 MG TABLETCHEWABLE, 200 MG TABLETCHEWABLE, 400 MGCAPSULE, 500 MG/5 MLSUSPENSION)

1

tazicef (1 gram vial, 1 gm add-vantage vial, 2 gm add-vantagevial, 2 gram vial, 6 gram vial)

1

TEFLARO 1

Beta-lactam, OtherAZACTAM 1

aztreonam 1

ertapenem 1

imipenem-cilastatin sodium 1

meropenem 1

meropenem-0.9% nacl 1gram/50

1

VABOMERE 1

Beta-lactam, Penicillinsamoxicillin (125 mg tab chew,125 mg/5 ml susp, 200 mg/5 mlsusp, 250 mg capsule, 250 mgtab chew, 250 mg/5 ml susp,400 mg/5 ml susp, 500 mgtablet, 500 mg capsule, 875 mgtablet)

1

amoxicillin-clavulanate pot er 1


20



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

amoxicillin-clavulanate potass(200-28.5 mg tab chew, 200-28.5 mg/5 ml sus, 250-62.5 mg/5ml sus, 250-125 mg tablet, 400-57 mg/5 ml susp, 400-57 mg tabchew, 500-125 mg tablet, 600-42.9 mg/5 ml sus, 875-125 mgtablet)

1

ampicillin sodium (1 gm add-vantage vl, 1 gm vial, 2 gm add-vantage vl, 2 gm vial, 10 gm vial,10 gm bottle, 125 mg vial, 250mg vial, 500 mg vial)

1

ampicillin 500 mg capsule 1

ampicillin-sulbactam (ampicillin-sulb 1.5 g add vial, ampicillin-sulb 3 gm add vial, ampicillin-sulbactam 1.5 gm vl, ampicillin-sulbactam 3 gm vial, ampicillin-sulbactam 15 gm vl)

1

AUGMENTIN 125-31.25 MG/5ML

1

BICILLIN C-R 1

BICILLIN L-A 1

dicloxacillin sodium 1

nafcillin 1

nafcillin sodium (1 gm vial, 2 gmvial, 2 gm add-vant vial, 10 gmbulk vial)

1

penicillin g potassium 1

penicillin g sodium 1

penicillin gk-iso-osm dextrose 1

penicillin v potassium (125 mg/5ml soln, 250 mg tablet, 250 mg/5ml soln, 500 mg tablet)

1


21



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

piperacillin-tazobactam(piperacil-tazo 2.25 gm add vl,piperacil-tazo 3.375 gm add vl,piperacil-tazo 4.5 gm add vial,piperacil-tazobact 2.25 gm vl,piperacil-tazobact 3.375 gm vl,piperacil-tazobact 4.5 gm vial,piperacil-tazobact 13.5 gm vl,piperacil-tazobact 40.5 gram)

1

ZOSYN (2.25 GM/50 ML BAG,3.375 GM/50 ML, 4.5 GM/100ML BAG)

1

Macrolidesazithromycin (1 gm pwd packet,100 mg/5 ml susp, 200 mg/5 mlsusp, 250 mg tablet, 500 mgadd-van vl, 500 mg tablet, 600mg tablet, i.v. 500 mg vial)

1

clarithromycin (125 mg/5 ml sus,250 mg tablet, 250 mg/5 ml sus,500 mg tablet)

1

clarithromycin er 1

DIFICID 1

ery 1

ERY-TAB 1

ERYPED 400 1

ERYTHROCIN LACTOBIONATE(LACT 500 MG VIAL, 500 MGADDVAN VIAL)

1

ERYTHROCIN STEARATE 1

erythromycin (0.5% eyeointment, 2% gel, 2% solution,2% pledgets, 250 mg filmtab, dr250 mg cap, dr 250 mg tablet, dr333 mg tablet, dr 500 mg tablet,500 mg filmtab)

1

erythromycin ethylsuccinate (200mg/5 ml susp, 400 mg/5 mlsusp, es 400 mg tab)

1


22



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

QuinolonesBAXDELA (300 MG VIAL, 450MG TABLET)

1

BESIVANCE 1

ciprofloxacin (200 mg/20 ml vl,250 mg/5 ml susp, 400 mg/40 mlvl, 500 mg/5 ml susp)

1

ciprofloxacin er 1

ciprofloxacin hcl (0.2% otic soln,0.3% eye drop, hcl 100 mg tab,hcl 250 mg tab, hcl 500 mg tab,hcl 750 mg tab)

1

ciprofloxacin-d5w 1

gatifloxacin 1

levofloxacin (0.5% eye drops, 25mg/ml solution, 250 mg/10 mlsoln, 250 mg tablet, 500 mg/20ml vial, 500 mg tablet, 500mg/20 ml soln, 750 mg/30 mlvial, 750 mg tablet)

1

levofloxacin-d5w 1

moxifloxacin (0.5% eye drops,400 mg/250 ml bag)

1

moxifloxacin hcl 400 mg tablet 1

ofloxacin (0.3% eye drops, 0.3%ear drops, 300 mg tablet, 400mg tablet)

1

Sulfonamidessulfacetamide sodium (drops,ointment)

1

sulfadiazine 500 mg tablet 1

sulfamethoxazole-trimethoprim(ds tablet, iv vial, ss tablet, susp)

1

SULFATRIM 1


23



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Tetracyclinesdemeclocycline hcl 1

DORYX MPC 1

doxy 100 1

doxycycline hyclate (hyc dr 50mg tab, 50 mg tablet, hyc dr 75mg tab, hyc dr 100 mg tab, hycdr 150 mg tab, hyc dr 200 mgtab, hyclate 20 mg tab, hyclate50 mg cap, hyclate 75 mg tab,hyclate 100 mg tab, hyclate 100mg vl, hyclate 100 mg cap,hyclate 150 mg tab)

1

doxycycline monohydrate (25mg/5 ml susp, mono 50 mg cap,mono 50 mg tablet, mono 75 mgtablet, mono 75 mg capsule,mono 100 mg tablet, mono 100mg cap, mono 150 mg cap,mono 150 mg tablet)

1

minocycline hcl (50 mg capsule,hcl 50 mg tablet, 75 mg capsule,hcl 75 mg tablet, 100 mgcapsule, hcl 100 mg tablet)

1

mondoxyne nl 1

morgidox (50 mg capsule, 100mg capsule)

1

NUZYRA (100 MG VIAL, 150MG TABLET-7 DAY, 150 MG-7DAY WITH LOAD, 150 MGTABLET)

1

okebo 100 mg capsule 1

soloxide 1

tetracycline hcl (250 mg capsule,500 mg capsule)

1

VIBRAMYCIN 50 MG/5 MLSYRUP

1


24



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Anticonvulsants

Anticonvulsants, OtherAPTIOM 1

BRIVIACT (10 MG TABLET, 25MG TABLET, 50 MG TABLET,75 MG TABLET, 100 MGTABLET)

1 PA - FOR NEW STARTS ONLY

BRIVIACT (10 MG/ML ORALSOLN, 50 MG/5 ML VIAL)

1

EPIDIOLEX 1 PA - FOR NEW STARTS ONLY

FYCOMPA (0.5 MG/ML ORALSUSP, 2 MG TABLET, 4 MGTABLET, 6 MG TABLET, 8 MGTABLET, 10 MG TABLET, 12MG TABLET)

1

levetiracetam (100 mg/ml soln,250 mg tablet, 500 mg/5 ml vial,500 mg tablet, 500 mg/5 ml soln,750 mg tablet, 1,000 mg tablet)

1

levetiracetam er 1

levetiracetam-nacl 1

NAYZILAM 1

phenobarbital (20 mg/5 ml soln,20 mg/5 ml elix)


roweepra 1

roweepra xr 1

SPRITAM 1

Calcium Channel Modifying AgentsCELONTIN 1

ethosuximide (250 mg/5 ml soln,250 mg capsule)

1


25



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

LYRICA (25 MG CAPSULE, 50MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE,150 MG CAPSULE, 200 MGCAPSULE, 225 MG CAPSULE)


LYRICA 300 MG CAPSULE 1 QL (60 PER 30 DAYS)

LYRICA 20 MG/ML ORALSOLUTION


pregabalin (25 mg capsule, 50mg capsule, 75 mg capsule, 100mg capsule, 150 mg capsule,200 mg capsule, 225 mgcapsule)


pregabalin 300 mg capsule 1 QL (60 PER 30 DAYS)

pregabalin 20 mg/ml solution 1 QL (900 PER 30 DAYS)

zonisamide (25 mg capsule, 50mg capsule, 100 mg capsule)

1

Gamma-aminobutyric Acid (GABA) Augmenting Agentsclobazam (2.5 mg/mlsuspension, 10 mg tablet, 20 mgtablet)

1

clonazepam (2 mg odt, 2 mgtablet)


clonazepam (0.125 mg odt,0.125 mg dis tab, 0.25 mg odt,0.5 mg dis tablet, 0.5 mg tablet,0.5 mg odt, 1 mg odt, 1 mgtablet, 1 mg dis tablet)


DIASTAT 1

DIASTAT ACUDIAL 1

diazepam (2.5 mg gel sys, 10mg gel syst, 20 mg gel syst)

1

divalproex sodium (dr 125 mgcap sprnk, sod dr 125 mg tab,sod dr 250 mg tab, sod dr 500mg tab)

1


26



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

divalproex sodium er 1

gabapentin (100 mg capsule,300 mg capsule)


gabapentin 400 mg capsule 1 QL (270 PER 30 DAYS)

gabapentin (250 mg/5 ml soln,300 mg/6 ml soln)

1 QL (2160 PER 30 DAYS)

gabapentin 600 mg tablet 1 QL (180 PER 30 DAYS)

gabapentin 800 mg tablet 1 QL (150 PER 30 DAYS)

phenobarbital (15 mg tablet,16.2 mg tablet, 30 mg tablet,32.4 mg tablet, 60 mg tablet,64.8 mg tablet, 97.2 mg tablet,100 mg tablet)


phenobarbital sodium (65 mg/mlvial, 130 mg/ml vial)


primidone (50 mg tablet, 250 mgtablet)

1

SYMPAZAN 1

tiagabine hcl 1

valproate sodium 1

valproic acid (250 mg capsule,250 mg/5 ml soln, 500 mg/10 mlsol)

1

vigabatrin (500 mg powderpackt, 500 mg tablet)


Glutamate Reducing Agentsfelbamate (400 mg tablet, 600mg tablet, 600 mg/5 ml susp)

1

lamotrigine (5 mg disper tablet,25 mg disper tab, 25 mg tablet,100 mg tablet, 150 mg tablet,200 mg tablet, tablet starter kit)

1

lamotrigine (blue) 1

lamotrigine (green) 1


27



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

lamotrigine (orange) 1

subvenite 1

subvenite (blue) 1

subvenite (green) 1

subvenite (orange) 1

topiramate (15 mg sprinkle cap,25 mg sprinkle cap, 25 mgtablet, 50 mg tablet, 100 mgtablet, 200 mg tablet)

1

Sodium Channel AgentsBANZEL (40 MG/MLSUSPENSION, 200 MGTABLET, 400 MG TABLET)

1

carbamazepine (100 mg tabchew, 100 mg/5 ml susp, 200mg tablet)

1

carbamazepine er (er 100 mgcap, er 100 mg tablet, er 200 mgtablet, er 200 mg cap, er 300 mgcap, er 400 mg tablet)

1

DILANTIN 30 MG CAPSULE 1

epitol 1

fosphenytoin sodium 1

oxcarbazepine (150 mg tablet,300 mg/5 ml susp, 300 mgtablet, 600 mg tablet)

1

PEGANONE 1

phenytoin (50 mg infatab, 50 mgtablet chew, 100 mg/4 ml susp,125 mg/5 ml susp)

1

phenytoin sodium extended 1

VIMPAT (10 MG/MLSOLUTION, 50 MG TABLET,100 MG TABLET, 150 MGTABLET, 200 MG/20 ML VIAL,200 MG TABLET)

1


28



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Antidementia Agents

Antidementia Agents, Otherergoloid mesylates 1 mg tab 1

Cholinesterase Inhibitorsdonepezil hcl (5 mg tablet, 10mg tablet)

1

donepezil hcl odt 1

galantamine er 1

galantamine hbr 1

galantamine hydrobromide 1

rivastigmine (1.5 mg capsule, 3mg capsule, 4.5 mg capsule, 4.6mg/24hr patch, 6 mg capsule,9.5 mg/24hr patch, 13.3 mg/24hrptch)

1

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl (hcl 2 mg/mlsolution, hcl 5 mg tablet, 5-10mg titration pk, hcl 10 mg tablet)

1

memantine hcl er 1 QL (30 PER 30 DAYS)

Antidepressants

Antidepressants, Otherbupropion hcl (75 mg tablet, 100mg tablet)

1

bupropion hcl sr (sr 100 mgtablet, sr 200 mg tablet)


bupropion hcl xl 150 mg tablet 1 QL (90 PER 30 DAYS)

bupropion hcl xl 300 mg tablet 1 QL (30 PER 30 DAYS)

mirtazapine (7.5 mg tablet, 15mg tablet, 15 mg odt, 30 mgtablet, 30 mg odt, 45 mg tablet,45 mg odt)

1


29



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Monoamine Oxidase InhibitorsEMSAM 1 ST, QL (30 PER 30 DAYS)

MARPLAN 1

phenelzine sulfate 15 mg tab 1

tranylcypromine sulfate 1

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin andNorepinephrine Reuptake Inhibitor

citalopram hbr (10 mg tablet, 10mg/5 ml soln, 20 mg tablet, 20mg/10 ml sol, 40 mg tablet)

1

desvenlafaxine suc er 100 mg 1 QL (120 PER 30 DAYS)

desvenlafaxine succinate er (er25 mg tb, er 50 mg tb)


DRIZALMA SPRINKLE (DR 20MG CAP, DR 60 MG CAP)


DRIZALMA SPRINKLE (DR 30MG CAP, DR 40 MG CAP)


duloxetine hcl (dr 20 mg cap, dr60 mg cap)


duloxetine hcl (dr 30 mg cap, dr40 mg cap)


escitalopram oxalate (oxalate 5mg/5 ml, 5 mg tablet, 10 mgtablet, 20 mg tablet)

1

FETZIMA 20-40 MG TITRATIONPAK

1 ST, QL (56 PER 365 OVER TIME)

FETZIMA (ER 20 MGCAPSULE, ER 40 MGCAPSULE, ER 80 MGCAPSULE, ER 120 MGCAPSULE)

1 ST, QL (30 PER 30 DAYS)

fluoxetine dr 1 QL (4 PER 28 DAYS)


30



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

fluoxetine hcl (hcl 10 mg tablet,hcl 10 mg capsule, hcl 20 mgtablet, hcl 20 mg capsule, 20mg/5 ml solution, hcl 40 mgcapsule, hcl 60 mg tablet)

1

fluvoxamine maleate 1

maprotiline hcl 1

nefazodone hcl 1

paroxetine cr 1

paroxetine er 1

paroxetine hcl 1

paroxetine mesylate 1 QL (30 PER 30 DAYS)

PAXIL 10 MG/5 MLSUSPENSION

1

sertraline hcl (20 mg/ml oralconc, hcl 25 mg tablet, hcl 50 mgtablet, hcl 100 mg tablet)

1

trazodone hcl (50 mg tablet, 100mg tablet, 150 mg tablet, 300 mgtablet)

1

TRINTELLIX 1 QL (30 PER 30 DAYS)

venlafaxine hcl 1

venlafaxine hcl er (er 37.5 mgcap, er 37.5 mg tab, er 75 mgcap, er 75 mg tab, er 150 mgcap, er 150 mg tab, er 225 mgtab)

1

VIIBRYD 10-20 MG STARTERPACK


VIIBRYD (10 MG TABLET, 20MG TABLET, 40 MG TABLET)


Tricyclicsamitriptyline hcl (10 mg tab, 25mg tab, 50 mg tab, 75 mg tab,100 mg tab, 150 mg tab)

1


31



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

amoxapine 1

chlordiazepoxide-amitriptyline 1 PA - FOR NEW STARTS ONLY

clomipramine hcl (25 mgcapsule, 50 mg capsule, 75 mgcapsule)

1

desipramine hcl (10 mg tablet,25 mg tablet, 50 mg tablet, 75mg tablet, 100 mg tablet, 150 mgtablet)

1

doxepin hcl (10 mg/ml oral conc,10 mg capsule, 25 mg capsule,50 mg capsule, 75 mg capsule,100 mg capsule, 150 mgcapsule)

1

imipramine hcl (10 mg tablet, 25mg tablet, 50 mg tablet)

1

nortriptyline hcl (hcl 10 mg cap,10 mg/5 ml soln, 20 mg/10 mlsoln, hcl 25 mg cap, hcl 50 mgcap, hcl 75 mg cap)

1

perphenazine-amitriptyline 1 PA - FOR NEW STARTS ONLY

protriptyline hcl 1

trimipramine maleate 1

Antiemetics

Antiemetics, OtherAKYNZEO 300-0.5 MGCAPSULE


compro 1

doxylamine succ-pyridoxine hcl 1 QL (120 PER 30 DAYS)

droperidol (2.5 mg/ml ampul, 5mg/2 ml vial)

1

meclizine hcl (12.5 mg tablet, 25mg tablet)

1

phenadoz 1 PA


32



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

prochlorperazine 1

prochlorperazine 10 mg/2 ml vl 1

prochlorperazine maleate (5 mgtablet, 10 mg tab)

1

promethazine hcl (6.25 mg/5 mlsyrp, 6.25 mg/5 ml soln, 12.5 mgtablet, 12.5 mg suppos, 25mg/ml vial, 25 mg suppository,25 mg tablet, 25 mg/ml ampul,50 mg/ml vial, 50 mgsuppository, 50 mg/ml ampul, 50mg tablet)

1 PA

promethegan 1 PA

scopolamine 1

Emetogenic Therapy AdjunctsANZEMET 1 QL (5 PER 30 OVER TIME)

aprepitant 125-80-80 mg pack 1 PA - Part B vs D Determination,QL (6 PER 30 OVER TIME)

aprepitant 125 mg capsule 1 PA - Part B vs D Determination,QL (2 PER 30 OVER TIME)



CINVANTI 1

dronabinol 1 PA, QL (60 PER 30 OVER TIME)

EMEND 125 MG POWDERPACKET

1 PA - Part B vs D Determination,QL (6 PER 30 OVER TIME)

granisetron hcl 1 mg tablet 1 PA - Part B vs D Determination,QL (30 PER 30 OVER TIME)

granisetron hcl (1 mg/ml vial, 4mg/4 ml vial)

1

ondansetron hcl (hcl 4 mg/2 mlvial, hcl 4 mg/2 ml syr, hcl 4mg/2 ml amp, 4 mg/2 ml isecure,40 mg/20 ml vial)

1


33



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ondansetron 4 mg/5 ml solution 1 PA - Part B vs D Determination,QL (450 PER 30 DAYS)

ondansetron hcl (4 mg tablet, 8mg tablet)

1 PA - Part B vs D Determination

ondansetron hcl 24 mg tablet 1 PA - Part B vs D Determination,QL (14 PER 28 OVER TIME)

ondansetron odt 1 PA - Part B vs D Determination

palonosetron hcl (0.25 mg/5 mlvial, 0.25 mg/2 ml vial)

1

SANCUSO 1 QL (2 PER 30 OVER TIME)

SYNDROS 1 PA, QL (120 PER 30 DAYS)

Antifungals

ABELCET 1 PA - Part B vs D Determination

AMBISOME 1 PA - Part B vs D Determination

amphotericin b 50 mg vial 1 PA - Part B vs D Determination

caspofungin acetate 1

ciclodan 8% solution 1 PA

ciclopirox (0.77% gel, 0.77%cream, 0.77% topical susp, 1%shampoo)

1

ciclopirox 8% solution 1 PA

clotrimazole (1% solution, 1%topical cream, 10 mg troche)

1

clotrimazole-betamethasone(crm, lot)

1

CRESEMBA (186 MGCAPSULE, 372 MG VIAL)

1

econazole nitrate 1% cream 1

EXELDERM (CREAM,SOLUTION)

1

fluconazole (10 mg/ml susp, 40mg/ml susp, 50 mg tablet, 100mg tablet, 150 mg tablet, 200 mgtablet)

1


34



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

fluconazole in saline (200mg/100 ml, 400 mg/200 ml)

1

fluconazole-nacl (200 mg/100ml, 400 mg/200 ml)

1

flucytosine (250 mg capsule, 500mg capsule)

1

griseofulvin (125 mg/5 ml susp,micro 500 mg tab)

1

griseofulvin ultramicrosize 1

itraconazole (10 mg/ml solution,100 mg capsule)

1 PA

JUBLIA 1

ketoconazole (2% foam, 2%shampoo, 2% cream, 200 mgtablet)

1

ketodan 2% foam 1

miconazole 3 1

naftifine hcl (1% gel, 1% cream,2% cream)

1

NATACYN 1

NOXAFIL (40 MG/MLSUSPENSION, DR 100 MGTABLET, 300 MG/16.7 ML VIAL)

1

nyamyc 1

nystatin (100,000 unit/gm cream,100,000 unit/ml susp, 100,000unit/gm oint, 100,000 unit/gmpowd, 500,000 unit oral tab,500,000 unit/5 ml sus)

1

nystatin-triamcinolone (cream,ointm)

1

nystop 1

oxiconazole nitrate 1

OXISTAT 1% LOTION 1


35



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

posaconazole dr 100 mg tablet 1

terbinafine hcl 250 mg tablet 1 QL (84 PER 180 OVER TIME)

terconazole (0.4% cream, 0.8%cream, 80 mg suppository)

1

TOLSURA 1 PA

voriconazole (40 mg/ml susp, 50mg tablet, 200 mg tablet, 200 mgvial)

1

Antigout Agents

allopurinol (100 mg tablet, 300mg tablet)

1

allopurinol sodium 1

colchicine (0.6 mg capsule, 0.6mg tablet)

1

febuxostat 1

KRYSTEXXA 1 PA

probenecid 1

probenecid-colchicine 1

ULORIC 1 ST

Antimigraine Agents

Ergot Alkaloidsdihydroergotamine 1 mg/ml amp 1

dihydroergotamine 4 mg/ml spry 1 QL (8 PER 30 OVER TIME)

ERGOMAR 1

ergotamine-caffeine 1

migergot suppository 1

ProphylacticAIMOVIG 140 MG/MLAUTOINJECTOR

1 PA, QL (1 PER 30 DAYS)


36



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

AIMOVIG 70 MG/MLAUTOINJECTOR


EMGALITY PEN 1 PA, QL (1 PER 30 DAYS)

EMGALITY 120 MG/MLSYRINGE


EMGALITY SYRINGE (100MG/ML SYR(1 OF 3), 300 MG(100 MG X3SYR))


timolol maleate (5 mg tablet, 10mg tablet, 20 mg tablet)

1

Serotonin (5-HT) 1b/1d Receptor Agonistseletriptan hbr 1 QL (12 PER 30 OVER TIME)

frovatriptan succinate 1 QL (12 PER 30 OVER TIME)

naratriptan hcl 1 QL (9 PER 30 OVER TIME)

rizatriptan (5 mg tablet, 5 mgodt, 10 mg odt, 10 mg tablet)


sumatriptan (5 mg spray, 20 mgspray)


sumatriptan succ-naproxen sod 1 QL (9 PER 30 OVER TIME)

sumatriptan succinate (4 mg/0.5ml cart, 4 mg/0.5 ml inject)


sumatriptan succinate (25 mgtablet, 50 mg tablet, 100 mgtablet)


sumatriptan succinate (6 mg/0.5ml vial, 6 mg/0.5 ml refill, 6mg/0.5 ml inject, 6 mg/0.5 mlsyrng)


TOSYMRA 1 QL (12 PER 30 OVER TIME)

zolmitriptan (2.5 mg tablet, 5 mgtablet)



37



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Antimyasthenic Agents

Parasympathomimeticsguanidine hcl 1

MESTINON 60 MG/5 MLSYRUP

1

pyridostigmine bromide (br 60mg tablet, 60 mg/5 ml soln)

1

pyridostigmine bromide er 1

REGONOL 1

Antimycobacterials

Antimycobacterials, Otherdapsone (25 mg tablet, 100 mgtablet)

1

rifabutin 1

AntitubercularsCAPASTAT SULFATE 1

cycloserine 250 mg capsule 1

ethambutol hcl 1

isoniazid (50 mg/5 ml solution,100 mg/ml vial, 100 mg tablet,300 mg tablet)

1

PASER 1

PRIFTIN 1

pyrazinamide 500 mg tablet 1

rifampin (150 mg capsule, 300mg capsule, iv 600 mg vial)

1

RIFATER 1

SIRTURO 1


38



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

TRECATOR 1

Antineoplastics

Alkylating AgentsBENDEKA 1

BICNU 1

busulfan 1

carboplatin (50 mg/5 ml vial, 150mg/15 ml vial, 450 mg/45 ml vial,600 mg/60 ml vial)

1

carmustine 1

cisplatin (50 mg/50 ml vial, 100mg/100 ml vial, 200 mg/200 mlvial)

1

cyclophosphamide (25 mgcapsule, 50 mg capsule)


cyclophosphamide (1 gm vial, 2gm vial, 500 mg vial)

1

dacarbazine 1

EVOMELA 1

GLEOSTINE (10 MG CAPSULE,40 MG CAPSULE, 100 MGCAPSULE)

1

HEXALEN 1

ifosfamide (1 gm/20 ml vial, 1gm vial, 3 gm vial, 3 gm/60 mlvial)

1

KISQALI FEMARA CO-PACK 1 PA - FOR NEW STARTS ONLY

LEUKERAN 1

MATULANE 1

melphalan hcl 1

oxaliplatin (50 mg vial, 50 mg/10ml vial, 100 mg vial, 100 mg/20ml vial)

1


39



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

TEMODAR 100 MG VIAL 1

thiotepa 15 mg vial 1

TREANDA 1

VALCHLOR 1 PA - FOR NEW STARTS ONLY

YONDELIS 1

ZANOSAR 1

Antiandrogensabiraterone acetate 1 PA - FOR NEW STARTS ONLY

bicalutamide 1

ERLEADA 1 PA - FOR NEW STARTS ONLY

flutamide 1

nilutamide 1

NUBEQA 1 PA - FOR NEW STARTS ONLY

XTANDI 1 PA - FOR NEW STARTS ONLY

YONSA 1 PA - FOR NEW STARTS ONLY

ZYTIGA 500 MG TABLET 1 PA - FOR NEW STARTS ONLY

Antiangiogenic AgentsPOMALYST 1 PA - FOR NEW STARTS ONLY

REVLIMID 1 PA - FOR NEW STARTS ONLY

THALOMID 1 PA - FOR NEW STARTS ONLY

Antiestrogens/ModifiersEMCYT 1

FASLODEX 1

fulvestrant 1

SOLTAMOX 1

tamoxifen citrate (10 mg tablet,20 mg tablet)

1

toremifene citrate 1


40



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Antimetabolitesadrucil 1

ALIMTA 1

ARRANON 1

cladribine 1

clofarabine 1

cytarabine 1

DROXIA 1

floxuridine 500 mg vial 1

fluorouracil (0.5% cream, 2%topical soln, 2.5 gm/50 ml btl, 2.5gm/50 ml vial, 5% cream, 5gm/100 ml btl, 5 gm/100 ml vial,5% topical soln, 500 mg/10 mlvial, 1,000 mg/20 ml vl, 2,500mg/50 ml vl, 5,000 mg/100 ml)

1

FOLOTYN 1 PA - FOR NEW STARTS ONLY

gemcitabine hcl (hcl 1 gram vial,hcl 1 gram/10 ml, 1 gram/26.3 mlvl, hcl 1.5 gram/15 ml, hcl 2gram/20 ml, 2 gram/52.6 ml vl,hcl 2 gram vial, hcl 200 mg vial,hcl 200 mg/2 ml vl, 200 mg/5.26ml vl)

1

hydroxyurea 500 mg capsule 1

INFUGEM (1,200 MG/120 MLBAG, 1,300 MG/130 ML BAG,1,400 MG/140 ML BAG, 1,500MG/150 ML BAG, 1,600 MG/160ML BAG, 1,700 MG/170 MLBAG, 1,800 MG/180 ML BAG,2,000 MG/200 ML BAG, 2,200MG/220 ML BAG)

1

LONSURF 1 PA - FOR NEW STARTS ONLY

mercaptopurine 50 mg tablet 1

NIPENT 1


41



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

PURIXAN 1

SIKLOS 1 PA

TABLOID 1

VYXEOS 1 PA - FOR NEW STARTS ONLY

Antineoplastics, OtherABRAXANE 1

adriamycin (10 mg vial, 10 mg/5ml vial, 20 mg/10 ml vial, 50mg/25 ml vial, 50 mg vial, 200mg/100 ml vial)

1

arsenic trioxide 10 mg/10ml vl 1

azacitidine 1

BCG (TICE STRAIN) 1

BELEODAQ 1 PA - FOR NEW STARTS ONLY

bleomycin sulfate 1

bortezomib 1 PA - FOR NEW STARTS ONLY

BRAFTOVI 1 PA - FOR NEW STARTS ONLY

COPIKTRA 1 PA - FOR NEW STARTS ONLY

COTELLIC 1 PA - FOR NEW STARTS ONLY

dactinomycin 1

daunorubicin hcl (20 mg/4 mlvial, 50 mg/10 ml vial)

1

DAURISMO 1 PA - FOR NEW STARTS ONLY

decitabine 1 PA - FOR NEW STARTS ONLY

dexrazoxane 1

docetaxel 1

doxorubicin hcl (10 mg/5 ml vial,20 mg/10 ml vial, 50 mg vial, 50mg/25 ml vial, 150 mg/75 ml vial,200 mg/100 ml vial)

1

doxorubicin hcl liposome 1


42



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

epirubicin hcl (50 mg/25 ml vial,200 mg/100 ml vial)

1

ERWINAZE 1

FARYDAK 1 PA - FOR NEW STARTS ONLY

fludarabine 50 mg vial 1

HALAVEN 1 PA - FOR NEW STARTS ONLY

IBRANCE (75 MG CAPSULE,100 MG CAPSULE, 125 MGCAPSULE)


idarubicin hcl 1

INREBIC 1 PA - FOR NEW STARTS ONLY

ISTODAX 1 PA - FOR NEW STARTS ONLY

IXEMPRA (45 MG KIT, 45 MGVIAL)

1

JEVTANA 1 PA - FOR NEW STARTS ONLY

KISQALI 1 PA - FOR NEW STARTS ONLY

leucovorin calcium (cal 100mg/10 ml vl, cal 500 mg/50 ml vl,calcium 5 mg tab, calcium 10 mgtab, calcium 15 mg tab, calcium25 mg tab, calcium 50 mg vial,calcium 100 mg vial, calcium200 mg vial, calcium 350 mgvial, calcium 500 mg vl)

1

levoleucovorin calcium (50 mgvial, 175 mg/17.5 ml, 250 mg/25ml vl)

1

LORBRENA 1 PA - FOR NEW STARTS ONLY

LYNPARZA (50 MG CAPSULE,100 MG TABLET, 150 MGTABLET)


MARQIBO 1

MEKTOVI 1 PA - FOR NEW STARTS ONLY

mitomycin (5 mg vial, 20 mg vial,40 mg vial)

1


43



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

mitoxantrone hcl 1 PA - FOR NEW STARTS ONLY

MUTAMYCIN 1

NERLYNX 1 PA - FOR NEW STARTS ONLY,QL (180 PER 30 DAYS)

NINLARO 1 PA - FOR NEW STARTS ONLY

ONCASPAR 1

paclitaxel 1

PIQRAY 1 PA - FOR NEW STARTS ONLY

PROLEUKIN 1

romidepsin 1 PA - FOR NEW STARTS ONLY

ROZLYTREK 1 PA - FOR NEW STARTS ONLY

RYDAPT 1 PA - FOR NEW STARTS ONLY

SYLATRON 1 PA - FOR NEW STARTS ONLY

SYLATRON 4-PACK 1 PA - FOR NEW STARTS ONLY

SYNRIBO 1 PA - FOR NEW STARTS ONLY

TALZENNA 1 PA - FOR NEW STARTS ONLY

TRISENOX 1

valrubicin 1

VALSTAR 1

VELCADE 1 PA - FOR NEW STARTS ONLY

VERZENIO 1 PA - FOR NEW STARTS ONLY

vinblastine sulfate 1

vincasar pfs 1 mg/ml vial 1

vincristine sulfate 1

vinorelbine tartrate 1

VITRAKVI (20 MG/MLSOLUTION, 25 MG CAPSULE,100 MG CAPSULE)


XPOVIO 1 PA - FOR NEW STARTS ONLY


44



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ZALTRAP 1 PA - FOR NEW STARTS ONLY

ZOLINZA 1 PA - FOR NEW STARTS ONLY

ZYKADIA 150 MG TABLET 1 PA - FOR NEW STARTS ONLY

Aromatase Inhibitors, 3rd Generationanastrozole 1 mg tablet 1

exemestane 1

letrozole 2.5 mg tablet 1

Enzyme InhibitorsBALVERSA 1 PA - FOR NEW STARTS ONLY

etoposide (100 mg/5 ml vial, 500mg/25 ml vial, 1,000 mg/50 mlvial)

1

irinotecan hcl (40 mg/2 ml vial,100 mg/5 ml vl, 500 mg/25 ml vl)

1

KYPROLIS 1 PA - FOR NEW STARTS ONLY

ONIVYDE 1

toposar 1

topotecan hcl (4 mg/4 ml vial, 4mg vial)

1

ZYDELIG 1 PA - FOR NEW STARTS ONLY

Molecular Target InhibitorsAFINITOR 1 PA - FOR NEW STARTS ONLY,

QL (30 PER 30 DAYS)

AFINITOR DISPERZ 1 PA - FOR NEW STARTS ONLY

ALECENSA 1 PA - FOR NEW STARTS ONLY

ALIQOPA 1 PA - FOR NEW STARTS ONLY

ALUNBRIG 90 MG-180 MG TABPACK

1 PA - FOR NEW STARTS ONLY,QL (60 PER 365 OVER TIME)

ALUNBRIG (90 MG TABLET,180 MG TABLET)

1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)


45



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ALUNBRIG 30 MG TABLET 1 PA - FOR NEW STARTS ONLY,QL (120 PER 30 DAYS)

BOSULIF 1 PA - FOR NEW STARTS ONLY

BRUKINSA 1 PA - FOR NEW STARTS ONLY

CABOMETYX 1 PA - FOR NEW STARTS ONLY

CALQUENCE 1 PA - FOR NEW STARTS ONLY

CAPRELSA 100 MG TABLET 1 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

CAPRELSA 300 MG TABLET 1 PA - FOR NEW STARTS ONLY

COMETRIQ 1 PA - FOR NEW STARTS ONLY

ERIVEDGE 1 PA - FOR NEW STARTS ONLY

erlotinib hcl 1 PA - FOR NEW STARTS ONLY

everolimus 1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

GILOTRIF 1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

ICLUSIG 15 MG TABLET 1 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

ICLUSIG 45 MG TABLET 1 PA - FOR NEW STARTS ONLY

IDHIFA 1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

imatinib mesylate 1 PA - FOR NEW STARTS ONLY

IMBRUVICA (70 MG CAPSULE,140 MG CAPSULE, 140 MGTABLET, 280 MG TABLET, 420MG TABLET, 560 MG TABLET)


INLYTA 1 PA - FOR NEW STARTS ONLY

IRESSA 1 PA - FOR NEW STARTS ONLY

JAKAFI (10 MG TABLET, 15 MGTABLET)

1 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

JAKAFI (5 MG TABLET, 20 MGTABLET, 25 MG TABLET)


LENVIMA 1 PA - FOR NEW STARTS ONLY


46



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

MEKINIST 1 PA - FOR NEW STARTS ONLY

NEXAVAR 1 PA - FOR NEW STARTS ONLY

ODOMZO 1 PA - FOR NEW STARTS ONLY

RUBRACA 1 PA - FOR NEW STARTS ONLY

SPRYCEL 1 PA - FOR NEW STARTS ONLY

STIVARGA 1 PA - FOR NEW STARTS ONLY

SUTENT 1 PA - FOR NEW STARTS ONLY

TAFINLAR 1 PA - FOR NEW STARTS ONLY

TAGRISSO 40 MG TABLET 1 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

TAGRISSO 80 MG TABLET 1 PA - FOR NEW STARTS ONLY

TASIGNA 1 PA - FOR NEW STARTS ONLY

temsirolimus 1

TIBSOVO 1 PA - FOR NEW STARTS ONLY

TORISEL 1

TURALIO 1 PA - FOR NEW STARTS ONLY

TYKERB 1 PA - FOR NEW STARTS ONLY

VENCLEXTA 1 PA - FOR NEW STARTS ONLY

VENCLEXTA STARTING PACK 1 PA - FOR NEW STARTS ONLY

VIZIMPRO 1 PA - FOR NEW STARTS ONLY

VOTRIENT 1 PA - FOR NEW STARTS ONLY

XALKORI 1 PA - FOR NEW STARTS ONLY

XOSPATA 1 PA - FOR NEW STARTS ONLY

ZEJULA 1 PA - FOR NEW STARTS ONLY

ZELBORAF 1 PA - FOR NEW STARTS ONLY

ZYKADIA 150 MG CAPSULE 1 PA - FOR NEW STARTS ONLY

Monoclonal Antibody/Antibody-Drug ConjugateAVASTIN 1


47



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

BAVENCIO 1 PA - FOR NEW STARTS ONLY

BESPONSA 1 PA - FOR NEW STARTS ONLY

BLINCYTO 35MCGVIAL+STABILIZER


CYRAMZA 1 PA - FOR NEW STARTS ONLY

DARZALEX 1 PA - FOR NEW STARTS ONLY

EMPLICITI 1 PA - FOR NEW STARTS ONLY

ERBITUX 1 PA - FOR NEW STARTS ONLY

GAZYVA 1 PA - FOR NEW STARTS ONLY

HERCEPTIN 1 PA - FOR NEW STARTS ONLY

IMFINZI 1 PA - FOR NEW STARTS ONLY

KADCYLA 1 PA - FOR NEW STARTS ONLY

KEYTRUDA 1 PA - FOR NEW STARTS ONLY

LARTRUVO 1 PA - FOR NEW STARTS ONLY

MYLOTARG 1 PA - FOR NEW STARTS ONLY

OPDIVO 1 PA - FOR NEW STARTS ONLY

PERJETA 1 PA - FOR NEW STARTS ONLY

PORTRAZZA 1 PA - FOR NEW STARTS ONLY

RITUXAN 1 PA - FOR NEW STARTS ONLY

RITUXAN HYCELA 1 PA - FOR NEW STARTS ONLY

TECENTRIQ 1 PA - FOR NEW STARTS ONLY

UNITUXIN 1

VECTIBIX 1

YERVOY 1 PA - FOR NEW STARTS ONLY

ZEVALIN 1

Retinoidsbexarotene 1 PA - FOR NEW STARTS ONLY

PANRETIN 1


48



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

TARGRETIN 1% GEL 1 PA - FOR NEW STARTS ONLY

tretinoin 10 mg capsule 1

Treatment AdjunctsKHAPZORY 1

mesna 1

MESNEX 400 MG TABLET 1

Antiparasitics

Anthelminticsalbendazole 200 mg tablet 1

benznidazole 1

ivermectin 3 mg tablet 1

praziquantel 600 mg tablet 1

AntiprotozoalsALINIA (100 MG/5 MLSUSPENSION, 500 MGTABLET)

1

atovaquone 1

atovaquone-proguanil hcl 1

chloroquine phosphate (250 mgtablet, 500 mg tablet)

1

COARTEM 1

DARAPRIM 1 PA

hydroxychloroquine 200 mg tab 1

mefloquine hcl 1

NEBUPENT 1 PA - Part B vs D Determination

PENTAM 300 1

pentamidine 300 mg vial 1

pentamidine 300 mg inhal powdr 1 PA - Part B vs D Determination


49



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

primaquine 1

quinine sulfate 324 mg capsule 1 PA

tinidazole (250 mg tablet, 500mg tablet)

1

Pediculicides/Scabicidescrotan 1

EURAX (CREAM, LOTION) 1

lindane 1% shampoo 1

malathion 1

permethrin 5% cream 1

Antiparkinson Agents

Anticholinergicsbenztropine mesylate (mes 0.5mg tab, mes 1 mg tablet, mes 2mg tablet, 2 mg/2 ml vial, 2 mg/2ml ampule)

1

trihexyphenidyl hcl (2 mg tablet,2 mg/5 ml elx, 5 mg tablet)

1

Antiparkinson Agents, Otherentacapone 1

GOCOVRI 1 PA

tolcapone 1

Dopamine AgonistsAPOKYN 1 PA, QL (90 PER 30 DAYS)

bromocriptine mesylate (2.5 mgtablet, 5 mg capsule)

1

INBRIJA 1 PA

NEUPRO 1 ST

pramipexole dihydrochloride 1


50



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ropinirole hcl 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 25 mg tablet 1

carbidopa-levodopa (carbidopa-levo 10-100 mg odt, carbidopa-levo 25-250 mg odt, carbidopa-levo 25-100 mg odt, carbidopa-levodopa 10-100 tab, carbidopa-levodopa 25-250 tab, carbidopa-levodopa 25-100 tab)

1

carbidopa-levodopa er 1

RYTARY 1 ST

Monoamine Oxidase B (MAO-B) Inhibitorsrasagiline mesylate (0.5 mg tab,1 mg tab)

1

selegiline hcl (5 mg tablet, 5 mgcapsule)

1

Antipsychotics

1st Generation/Typicalchlorpromazine hcl (10 mgtablet, 25 mg tablet, 25 mg/mlamp, 50 mg tablet, 100 mgtablet, 200 mg tablet)

1

fluphenazine dec 125 mg/5 ml 1

fluphenazine hcl (1 mg tablet,2.5 mg/ml vial, 2.5 mg tablet, 2.5mg/5 ml elix, 5 mg/ml conc, 5 mgtablet, 10 mg tablet)

1

haloperidol (0.5 mg tablet, 1 mgtablet, 2 mg tablet, 5 mg tablet,10 mg tablet, 20 mg tablet)

1


51



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

haloperidol decanoate (dec 50mg/ml vial, dec 100 mg/ml vial,dec 100 mg/ml amp, dec 250mg/5 ml vl, dec 500 mg/5 ml vl,decan 50 mg/ml amp)

1

haloperidol decanoate 100 1

haloperidol lactate (2 mg/mlconc, 5 mg/ml ampul, 5 mg/mlvial, 50 mg/10 ml vl)

1

loxapine 1

molindone hcl 1

perphenazine (2 mg tablet, 4 mgtablet, 8 mg tablet, 16 mg tablet)

1

pimozide 1

thioridazine hcl 1 PA - FOR NEW STARTS ONLY

thiothixene 1

trifluoperazine hcl 1

2nd Generation/AtypicalABILIFY MAINTENA (ER 300MG SYR, ER 300 MG VL, ER400 MG VL, ER 400 MG SYR)

1

ABILIFY MYCITE 1 ST, QL (30 PER 30 DAYS)

aripiprazole 1 mg/ml solution 1 QL (750 PER 30 DAYS)

aripiprazole (2 mg tablet, 5 mgtablet, 10 mg tablet, 15 mgtablet, 20 mg tablet, 30 mgtablet)


aripiprazole odt 1 QL (60 PER 30 DAYS)

ARISTADA 1

ARISTADA INITIO 1

FANAPT TITRATION PACK 1 ST, QL (8 PER 180 OVER TIME)

FANAPT (1 MG TABLET, 2 MGTABLET, 4 MG TABLET, 6 MGTABLET, 8 MG TABLET, 10 MGTABLET, 12 MG TABLET)



52



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

GEODON 20 MG/ML VIAL 1 QL (60 PER 30 DAYS)

INVEGA SUSTENNA 1

INVEGA TRINZA 1

LATUDA (20 MG TABLET, 40MG TABLET, 60 MG TABLET,120 MG TABLET)


LATUDA 80 MG TABLET 1 QL (60 PER 30 DAYS)

NUPLAZID (10 MG TABLET, 17MG TABLET, 34 MG CAPSULE)


olanzapine (2.5 mg tablet, 5 mgtablet, 7.5 mg tablet, 10 mgtablet, 15 mg tablet, 20 mgtablet)


olanzapine 10 mg vial 1

olanzapine odt 1 QL (30 PER 30 DAYS)

paliperidone er (er 1.5 mg tablet,er 3 mg tablet, er 9 mg tablet)


paliperidone er 6 mg tablet 1 QL (60 PER 30 DAYS)

PERSERIS 1

quetiapine fumarate (25 mg tab,50 mg tab, 100 mg tab, 200 mgtab)


quetiapine fumarate (300 mgtab, 400 mg tab)


quetiapine er 200 mg tablet 1 QL (90 PER 30 DAYS)

quetiapine fumarate er (er 50 mgtablet, er 150 mg tablet, er 300mg tablet, er 400 mg tablet)


REXULTI 1 QL (30 PER 30 DAYS)

RISPERDAL CONSTA 1

risperidone 1 mg/ml solution 1 QL (240 PER 30 DAYS)

risperidone (0.25 mg tablet, 0.5mg tablet, 1 mg tablet, 2 mgtablet, 3 mg tablet, 4 mg tablet)



53



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

risperidone odt 1 QL (60 PER 30 DAYS)

SAPHRIS 1 QL (60 PER 30 DAYS)

VRAYLAR 1.5 MG-3 MG PACK 1 ST, QL (14 PER 365 OVER TIME)

VRAYLAR (1.5 MG CAPSULE, 3MG CAPSULE, 4.5 MGCAPSULE, 6 MG CAPSULE)


ziprasidone hcl 1 QL (60 PER 30 DAYS)

ZYPREXA RELPREVV 1

Treatment-Resistantclozapine (25 mg tablet, 100 mgtablet)


clozapine 200 mg tablet 1 QL (120 PER 30 DAYS)

clozapine 50 mg tablet 1 QL (180 PER 30 DAYS)

clozapine odt (odt 25 mg tablet,odt 100 mg tablet)


clozapine odt 12.5 mg tablet 1 QL (90 PER 30 DAYS)

clozapine odt 150 mg tablet 1 QL (180 PER 30 DAYS)

clozapine odt 200 mg tablet 1 QL (120 PER 30 DAYS)

VERSACLOZ 1 QL (540 PER 30 DAYS)

Antispasticity Agents

baclofen (5 mg tablet, 10 mgtablet, 10 mg/20 ml vial, 20 mgtablet, 40 mg/20 ml vial, 20,000mcg/20 ml vial)

1

BOTOX 1 PA

dantrolene sodium (25 mg cap,50 mg cap, 100 mg cap)

1

LIORESAL INTRATHECAL 1

tizanidine hcl (2 mg tablet, 4 mgtablet)

1

XEOMIN 200 UNIT VIAL 1 PA


54



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Antivirals

Anti-HIV Agents, Integrase Inhibitors (INSTI)BIKTARVY 1 QL (30 PER 30 DAYS)

DELSTRIGO 1 QL (30 PER 30 DAYS)

DOVATO 1 QL (30 PER 30 DAYS)

GENVOYA 1 QL (30 PER 30 DAYS)

ISENTRESS (25 MG TABLETCHEW, 100 MG POWDERPACKET, 100 MG TABLETCHEW)

1

JULUCA 1 QL (30 PER 30 DAYS)

STRIBILD 1 QL (30 PER 30 DAYS)

TIVICAY 1

TRIUMEQ 1 QL (30 PER 30 DAYS)

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)ATRIPLA 1 QL (30 PER 30 DAYS)

COMPLERA 1 QL (30 PER 30 DAYS)

EDURANT 1

efavirenz (50 mg capsule, 200mg capsule, 600 mg tablet)

1

INTELENCE 1

nevirapine (50 mg/5 ml susp,200 mg tablet)

1

nevirapine er 1

ODEFSEY 1 QL (30 PER 30 DAYS)

PIFELTRO 1

RESCRIPTOR 200 MG TABLET 1

SUSTIVA 600 MG TABLET 1

SYMFI 1 QL (30 PER 30 DAYS)


55



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

SYMFI LO 1 QL (30 PER 30 DAYS)

VIRAMUNE 50 MG/5 ML SUSP 1

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors(NRTI)

abacavir (20 mg/ml solution, 300mg tablet)

1

abacavir-lamivudine 1 QL (30 PER 30 DAYS)

abacavir-lamivudine-zidovudine 1 QL (60 PER 30 DAYS)

CIMDUO 1 QL (30 PER 30 DAYS)

DESCOVY 1 QL (30 PER 30 DAYS)

didanosine (dr 200 mg capsule,dr 250 mg capsule, dr 400 mgcapsule)

1

EMTRIVA (10 MG/MLSOLUTION, 200 MG CAPSULE)

1

lamivudine (10 mg/ml oral soln,150 mg tablet, 300 mg tablet)

1

lamivudine-zidovudine 1 QL (60 PER 30 DAYS)

RETROVIR 200 MG/20 ML VIAL 1

stavudine 1

tenofovir disoproxil fumarate 1

TRUVADA 1 QL (30 PER 30 DAYS)

VIDEX 1

VIDEX EC 125 MG CAPSULE 1

VIREAD (150 MG TABLET, 200MG TABLET, 250 MG TABLET,POWDER)

1

ZERIT 1 MG/ML SOLUTION 1

zidovudine (50 mg/5 ml syrup,100 mg capsule, 300 mg tablet)

1


56



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Anti-HIV Agents, OtherFUZEON 1 QL (60 PER 30 DAYS)

ISENTRESS 400 MG TABLET 1

ISENTRESS HD 1

SELZENTRY (20 MG/ML ORALSOLN, 25 MG TABLET, 75 MGTABLET, 150 MG TABLET, 300MG TABLET)

1

TROGARZO 1

TYBOST 1

Anti-HIV Agents, Protease InhibitorsAPTIVUS (100 MG/MLSOLUTION, 250 MG CAPSULE)

1

atazanavir sulfate 1

CRIXIVAN 1

EVOTAZ 1 QL (30 PER 30 DAYS)

fosamprenavir calcium 1

INVIRASE (200 MG CAPSULE,500 MG TABLET)

1

KALETRA (100-25 MG TABLET,200-50 MG TABLET)

1

LEXIVA 50 MG/MLSUSPENSION

1

lopinavir-ritonavir 1

NORVIR (80 MG/MLSOLUTION, 100 MG POWDERPACKET)

1

PREZCOBIX 1 QL (30 PER 30 DAYS)

PREZISTA (75 MG TABLET,100 MG/ML SUSPENSION, 150MG TABLET, 600 MG TABLET,800 MG TABLET)

1

REYATAZ 50 MG POWDERPACKET

1


57



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ritonavir 1

SYMTUZA 1 QL (30 PER 30 DAYS)

VIRACEPT (250 MG TABLET,625 MG TABLET)

1

Anti-cytomegalovirus (CMV) Agentscidofovir 375 mg/5 ml vial 1

ganciclovir sodium (500 mg/10ml vial, 500 mg vial)

1

PREVYMIS (240 MG/12 MLVIAL, 240 MG TABLET, 480 MGTABLET, 480 MG/24 ML VIAL)

1

valganciclovir hcl (hcl 50 mg/ml,450 mg tablet)

1

ZIRGAN 1

Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 1

BARACLUDE 0.05 MG/MLSOLUTION


entecavir 1 QL (30 PER 30 DAYS)

EPIVIR HBV 25 MG/5 ML SOLN 1

INTRON A (10 MILLION UNITSVIL, 18 MILLION UNIT/3 ML, 18MILLION UNITS VIL, 25MILLION UNIT/2.5ML, 50MILLION UNITS VIL)


lamivudine 100 mg tablet 1

lamivudine hbv 1

VEMLIDY 1

Anti-hepatitis C (HCV) Agents, Direct Acting AgentsEPCLUSA 1 PA, QL (84 PER 365 OVER TIME)

HARVONI 90-400 MG TABLET 1 PA, QL (168 PER 365 OVERTIME)


58



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ledipasvir-sofosbuvir 1 PA, QL (168 PER 365 OVERTIME)

MAVYRET 1 PA, QL (336 PER 365 OVERTIME)

sofosbuvir-velpatasvir 1 PA, QL (84 PER 365 OVER TIME)

VOSEVI 1 PA, QL (84 PER 365 OVER TIME)

Anti-hepatitis C (HCV) Agents, OtherPEGASYS (180 MCG/ML VIAL,180 MCG/0.5 ML SYRINGE)

1 PA

PEGASYS PROCLICK 180MCG/0.5

1 PA

PEGINTRON 50 MCG KIT 1 PA

ribasphere (200 mg tablet, 200mg capsule, 400 mg tablet, 600mg tablet)

1

RIBASPHERE RIBAPAK 1

ribavirin (200 mg capsule, 200mg tablet)

1

Anti-influenza Agentsamantadine (50 mg/5 mlsolution, 100 mg tablet, 100mg/10 ml soln, 100 mg capsule)

1

oseltamivir phos 30 mg capsule 1 QL (168 PER 365 OVER TIME)



oseltamivir 6 mg/ml suspension 1 QL (1080 PER 365 OVER TIME)

RELENZA 1 QL (240 PER 365 OVER TIME)

rimantadine hcl 1

XOFLUZA 20 MG TAB (40 MGDOSE)



59



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Antiherpetic Agentsacyclovir (5% cream, 5%ointment, 200 mg capsule, 200mg/5 ml susp, 400 mg tablet,800 mg tablet)

1

acyclovir sodium (500 mg/10 mlvial, 1,000 mg/20 ml vial)


DENAVIR 1

famciclovir 1

trifluridine 1% eye drops 1

valacyclovir 1 QL (120 PER 30 DAYS)

Anxiolytics

Anxiolytics, Otherbuspirone hcl (5 mg tablet, 7.5mg tablet, 10 mg tablet, 15 mgtablet, 30 mg tablet)

1

dexmedetomidine 80 mcg/20ml-ns

1

meprobamate 1

Benzodiazepinesalprazolam (0.25 mg tablet, 0.5mg tablet, 1 mg tablet)


alprazolam 2 mg tablet 1 PA, QL (150 PER 30 DAYS)

alprazolam er (er 0.5 mg tablet,er 1 mg tablet)


alprazolam er 2 mg tablet 1 PA, QL (150 PER 30 DAYS)

alprazolam er 3 mg tablet 1 PA, QL (90 PER 30 DAYS)

alprazolam xr (0.5 mg tablet, 1mg tablet)


alprazolam xr 2 mg tablet 1 PA, QL (150 PER 30 DAYS)

alprazolam xr 3 mg tablet 1 PA, QL (90 PER 30 DAYS)


60



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

chlordiazepoxide 10 mg capsule 1 PA, QL (900 PER 30 DAYS)



clorazepate 15 mg tablet 1 QL (180 PER 30 DAYS)

clorazepate 3.75 mg tablet 1 QL (720 PER 30 DAYS)

clorazepate 7.5 mg tablet 1 QL (360 PER 30 DAYS)

diazepam (5 mg/5 ml solution, 5mg/ml oral conc, 10 mg/2 mlcarpuject, 10 mg/2 ml syringe,50 mg/10 ml vial)

1

diazepam 10 mg tablet 1 QL (120 PER 30 DAYS)



estazolam 1 PA, QL (30 PER 30 DAYS)

lorazepam (0.5 mg tablet, 1 mgtablet)


lorazepam 2 mg tablet 1 PA, QL (150 PER 30 DAYS)

lorazepam (2 mg/ml syringe, 2mg/ml oral concent, 2 mg/ml vial,2 mg/ml carpuject, 4 mg/mlcarpuject, 4 mg/ml vial, 20mg/10 ml vial, 40 mg/10 ml vial)

1 PA

lorazepam intensol 1 PA

midazolam hcl 2 mg/ml syrup 1

temazepam 1 PA, QL (30 PER 30 DAYS)

Bipolar Agents

Mood StabilizersEQUETRO 1

lithium 1

lithium carbonate (150 mg cap,300 mg tab, 300 mg cap, 600mg cap)

1


61



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

lithium carbonate er 1

Blood Glucose Regulators

Antidiabetic Agentsacarbose 1

CYCLOSET 1

glimepiride 1

glipizide (5 mg tablet, 10 mgtablet)

1

glipizide er 1

glipizide xl 1

glipizide-metformin 1

glyburide (1.25 mg tablet, 2.5 mgtablet, 5 mg tablet)

1

glyburide micronized 1

glyburide-metformin hcl 1

GLYXAMBI 1 ST

INVOKAMET 1 ST

INVOKAMET XR 1 ST

INVOKANA 1 ST

JANUMET 1 ST

JANUMET XR 1 ST

JANUVIA 1 ST

JARDIANCE 1 ST

JENTADUETO 1 ST

JENTADUETO XR 1 ST

metformin hcl (500 mg tablet,850 mg tablet, 1,000 mg tablet)

1

metformin hcl er 1


62



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

nateglinide 1

OZEMPIC 0.25-0.5 MG DOSEPEN

1 QL (1.5 PER 28 DAYS)

OZEMPIC 1 MG DOSE PEN 1 QL (3 PER 28 DAYS)

pioglitazone hcl 1

pioglitazone-glimepiride 1

pioglitazone-metformin 1

repaglinide 1

repaglinide-metformin hcl 1

RIOMET 1

SYMLINPEN 120 1 PA

SYMLINPEN 60 1 PA

SYNJARDY 1 ST

SYNJARDY XR 1 ST

tolazamide 1

tolbutamide 1

TRADJENTA 1 ST

TRULICITY 1 QL (2 PER 28 DAYS)

VICTOZA 2-PAK 1 QL (9 PER 30 DAYS)

VICTOZA 3-PAK 1 QL (9 PER 30 DAYS)

Glycemic AgentsGLUCAGEN 1

GLUCAGON EMERGENCY KIT 1

PROGLYCEM 1

InsulinsHUMALOG (100 UNITS/MLCARTRIDGE, 100 UNIT/MLVIAL)

1

HUMALOG JUNIOR KWIKPEN 1


63



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

HUMALOG KWIKPEN U-100 1

HUMALOG KWIKPEN U-200 1

HUMALOG MIX 50-50 1

HUMALOG MIX 50-50KWIKPEN

1

HUMALOG MIX 75-25 1

HUMALOG MIX 75-25KWIKPEN

1

HUMULIN R U-500 1

HUMULIN R U-500 KWIKPEN 1

insulin lispro 1

insulin lispro kwikpen u-100 1

LANTUS 1

LANTUS SOLOSTAR 1

LEVEMIR 1

LEVEMIR FLEXTOUCH 1

TOUJEO MAX SOLOSTAR 1

TOUJEO SOLOSTAR 1

TRESIBA 1

TRESIBA FLEXTOUCH U-100 1

TRESIBA FLEXTOUCH U-200 1

Blood Products/Modifiers/Volume Expanders

Anticoagulantsargatroban 1

argatroban-0.9% nacl (50mg/50ml-0.9%nacl, 125 mg/125-0.9%nacl)

1

argatroban-sodium chloride 1

ELIQUIS DVT-PE TREATSTART 5MG



64



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ELIQUIS 2.5 MG TABLET 1 QL (60 PER 30 DAYS)

ELIQUIS 5 MG TABLET 1 QL (90 PER 30 DAYS)

enoxaparin 30 mg/0.3 ml syr 1 QL (10.5 PER 90 OVER TIME)

enoxaparin 40 mg/0.4 ml syr 1 QL (14 PER 90 OVER TIME)

enoxaparin 60 mg/0.6 ml syr 1 QL (21 PER 90 OVER TIME)

enoxaparin sodium (100 mg/mlsyringe, 150 mg/ml syringe)


enoxaparin sodium (80 mg/0.8ml syr, 120 mg/0.8 ml syr)


enoxaparin 300 mg/3 ml vial 1 QL (105 PER 90 OVER TIME)

fondaparinux 10 mg/0.8 ml syr 1 QL (28 PER 90 OVER TIME)

fondaparinux 2.5 mg/0.5 ml syr 1 QL (17.5 PER 90 OVER TIME)

fondaparinux 5 mg/0.4 ml syr 1 QL (14 PER 90 OVER TIME)

fondaparinux 7.5 mg/0.6 ml syr 1 QL (21 PER 90 OVER TIME)

FRAGMIN (2,500 UNITS/0.2 MLSYR, 5,000 UNITS/0.2 ML SYR)


FRAGMIN 10,000 UNITS/MLSYRING


FRAGMIN 12,500 UNITS/0.5 ML 1 QL (17.5 PER 90 OVER TIME)

FRAGMIN 15,000 UNITS/0.6 ML 1 QL (21 PER 90 OVER TIME)

FRAGMIN 18,000 UNITS/0.72ML

1 QL (25.3 PER 90 OVER TIME)

FRAGMIN 7,500 UNITS/0.3 MLSYR


FRAGMIN 95,000 UNITS/3.8 MLVL



65



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

heparin sodium (sod 1,000unit/ml vial, sod 5,000 unit/0.5ml, 5,000 unit/ml carpujct, sod5,000 unit/ml vial, sod 5,000 unit/0.5 ml, sod 10,000 unit/ml vl,10,000 unit/10 ml vial, sod20,000 unit/ml vl, 30,000 unit/30ml vial, 40,000 unit/4 ml vial,50,000 unit/10 ml vial, 50,000unit/5 ml vial)

1

heparin sodium in 0.45% nacl 1

heparin sodium-0.45% nacl(heparin-12,500 unit/250-1/2,heparin 25,000 unit/500-1/2,heparin 25,000 unit/250-1/2)

1

heparin sodium-0.9% nacl(1,000 unit/500, 2,000unit/1,000)

1

heparin 20,000 unit/500 ml-d5w 1

jantoven 1

PRADAXA 1 QL (60 PER 30 DAYS)

warfarin sodium (1 mg tablet, 2mg tablet, 2.5 mg tablet, 3 mgtablet, 4 mg tablet, 5 mg tablet, 6mg tablet, 7.5 mg tablet, 10 mgtablet)

1

XARELTO STARTER PACK 1 QL (102 PER 365 OVER TIME)

XARELTO (10 MG TABLET, 20MG TABLET)


XARELTO (2.5 MG TABLET, 15MG TABLET)


Blood Formation Modifiersanagrelide hcl 1


66



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ARANESP (10 MCG/0.4 MLSYRINGE, 25 MCG/ML VIAL, 25MCG/0.42 ML SYRING, 40MCG/ML VIAL, 40 MCG/0.4 MLSYRINGE, 60 MCG/0.3 MLSYRINGE, 60 MCG/ML VIAL,100 MCG/ML VIAL, 100MCG/0.5 ML SYRINGE, 150MCG/0.3 ML SYRINGE, 200MCG/0.4 ML SYRINGE, 200MCG/ML VIAL, 300 MCG/0.6 MLSYRINGE, 300 MCG/ML VIAL,500 MCG/1 ML SYRINGE)

1 PA

FULPHILA 1 PA

GRANIX (300 MCG/ML VIAL,480 MCG/1.6 ML VIAL)

1 ST

LEUKINE 1 PA

MOZOBIL 1 PA, QL (38.4 PER 365 OVERTIME)

MULPLETA 1 PA

NEULASTA (6 MG/0.6 MLSYRINGE, ONPRO 6 MG/0.6ML KIT)

1 PA

NEUPOGEN (300 MCG/MLVIAL, 300 MCG/0.5 ML SYR,480 MCG/1.6 ML VIAL, 480MCG/0.8 ML SYR)

1 ST

NIVESTYM (300 MCG/ML VIAL,300 MCG/0.5 ML SYRING, 480MCG/0.8 ML SYRING, 480MCG/1.6 ML VIAL)

1 ST

NPLATE (250 MCG VIAL, 500MCG VIAL)

1 PA

OXBRYTA 1 PA, QL (90 PER 30 DAYS)

PROMACTA (12.5 MG SUSPENPACKET, 12.5 MG TABLET, 25MG TABLET, 50 MG TABLET,75 MG TABLET)

1 PA

UDENYCA 1 PA


67



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ZARXIO 1

ZIEXTENZO 1 PA

SOLIRIS 1 PA

ULTOMIRIS 1 PA

Hemostasis Agentsaminocaproic acid (5 g/20 ml vl,500 mg tab, 1,000 mg tab)

1

RETACRIT 1 PA

TAVALISSE 1 PA

tranexamic acid (650 mg tablet,1,000 mg/10 ml)

1

Platelet Modifying Agentsaspirin-dipyridamole er 1

BRILINTA 1

CABLIVI (11 MG VIAL, 11 MGKIT)


cilostazol 1

clopidogrel 1

prasugrel hcl 1

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine 1

clonidine hcl (0.1 mg tablet, 0.2mg tablet, 0.3 mg tablet)

1

guanfacine hcl 1

methyldopa 1

methyldopa-hydrochlorothiazide 1

midodrine hcl 1


68



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

phenylephrine hcl (10 mg/ml vial,50 mg/5 ml vial, 100 mg/10 mlvl)

1

Alpha-adrenergic Blocking Agentsphenoxybenzamine hcl 10 mgcap

1

prazosin hcl (1 mg capsule, 2mg capsule, 5 mg capsule)

1

Angiotensin II Receptor Antagonistscandesartan cilexetil 1

candesartan-hydrochlorothiazid 1

eprosartan mesylate 1

irbesartan 1

irbesartan-hydrochlorothiazide 1

losartan potassium 1

losartan-hydrochlorothiazide 1

olmesartan medoxomil 1

olmesartan-hydrochlorothiazide 1

telmisartan 1

telmisartan-hydrochlorothiazid 1

valsartan 1

valsartan-hydrochlorothiazide 1

Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl (5 mg tablet, 10mg tablet, 20 mg tablet, 40 mgtablet)

1

benazepril-hydrochlorothiazide 1

captopril (12.5 mg tablet, 25 mgtablet, 50 mg tablet, 100 mgtablet)

1

captopril-hydrochlorothiazide 1


69



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

enalapril maleate (2.5 mg tab, 5mg tablet, 10 mg tab, 20 mg tab)

1

enalapril-hydrochlorothiazide 1

EPANED 1 MG/ML ORALSOLUTION

1

fosinopril sodium 1

fosinopril-hydrochlorothiazide 1

lisinopril (2.5 mg tablet, 5 mgtablet, 10 mg tablet, 20 mgtablet, 30 mg tablet, 40 mgtablet)

1

lisinopril-hydrochlorothiazide 1

moexipril hcl 1

moexipril-hydrochlorothiazide 1

perindopril erbumine 1

quinapril hcl 1

quinapril-hydrochlorothiazide 1

ramipril 1

trandolapril 1

trandolapril-verapamil er 1

Antiarrhythmicsamiodarone hcl (hcl 100 mgtablet, 150 mg/3 ml syringe, 150mg/3 ml vial, hcl 200 mg tablet,hcl 400 mg tablet, 450 mg/9 mlvial, 900 mg/18 ml vial)

1

disopyramide phosphate 1

dofetilide 1

flecainide acetate 1

ibutilide fumarate 1

lidocaine hcl (1% abboject, 1%syringe, 2% syringe, 2%abboject, 2% luer-jet)

1


70



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

mexiletine hcl (150 mg capsule,200 mg capsule, 250 mgcapsule)

1

NORPACE CR 1

pacerone (100 mg tablet, 200mg tablet, 400 mg tablet)

1

procainamide hcl (procainamid1,000 mg/10 ml syr,procainamide 500 mg/ml vial,procainamide 1,000 mg/2 ml vl,procainamide 1,000 mg/10 ml vl)

1

propafenone hcl 1

propafenone hcl er 1

quinidine gluconate (80 mg/mlvial, er 324 mg tab)

1

quinidine sulfate (200 mg tab,300 mg tab)

1

sorine 1

sotalol 1

sotalol af 1

Beta-adrenergic Blocking Agentsacebutolol hcl (200 mg capsule,400 mg capsule)

1

atenolol (25 mg tablet, 50 mgtablet, 100 mg tablet)

1

atenolol-chlorthalidone 1

betaxolol hcl (10 mg tablet, 20mg tablet)

1

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide 1

BREVIBLOC (2,000 MG/100 MLBAG, 2,500 MG/250 ML BAG)

1

BYSTOLIC 1


71



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

carvedilol 1

carvedilol er 1

esmolol hcl 100 mg/10 ml vial 1

esmolol hcl-sodium chloride 1

labetalol hcl (100 mg tablet, 200mg tablet, 300 mg tablet)

1

metoprolol succinate 1

metoprolol tartrate (25 mg tab,50 mg tab, 100 mg tab)

1

metoprolol-hydrochlorothiazide 1

nadolol (20 mg tablet, 40 mgtablet, 80 mg tablet)

1

pindolol 1

propranolol hcl (1 mg/ml vial, 10mg tablet, 20 mg/5 ml soln, 20mg tablet, 40 mg tablet, 40 mg/5ml soln, 60 mg tablet, 80 mgtablet)

1

propranolol hcl er 1

propranolol-hydrochlorothiazid 1

Calcium Channel Blocking Agentsamlodipine besylate (2.5 mg tab,5 mg tab, 10 mg tab)

1

amlodipine besylate-benazepril 1

amlodipine-atorvastatin 1

amlodipine-valsartan 1

cartia xt 1

dilt-xr 1

diltiazem 12hr er 1

diltiazem 24hr er 1

diltiazem 24hr er (cd) 1


72



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

diltiazem 24hr er (la) 1

diltiazem 24hr er (xr) 1

diltiazem hcl (25 mg/5 ml vial, 30mg tablet, 50 mg/10 ml vial, 60mg tablet, 90 mg tablet, 100 mgadd-van vial, 120 mg tablet, 125mg/25 ml vial)

1

felodipine er 1

matzim la 1

nicardipine hcl (20 mg capsule,25 mg/10 ml ampule, 25 mg/10ml vial, 30 mg capsule)

1

nifedipine er 1

nimodipine 1

nisoldipine 1

NYMALIZE 1

taztia xt 1

verapamil er (er 120 mg capsule,er 120 mg tablet, er 180 mgtablet, er 180 mg capsule, er 240mg capsule, er 240 mg tablet)

1

verapamil er pm 1

verapamil hcl (5 mg/2 ml vial, 5mg/2 ml ampul, 10 mg/4 mlsyringe, 10 mg/4 ml vial, 40 mgtablet, 80 mg tablet, 120 mgtablet, 360 mg cap pellet)

1

verapamil sr 1

Cardiovascular Agents, Otheraliskiren 1

atropine sulfate (0.4 mg/ml vial,8 mg/20 ml vial)

1

CORLANOR 5 MG/5 ML ORALSOLN



73



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

CORLANOR (5 MG TABLET,7.5 MG TABLET)


DEMSER 1

digitek 1

digox 1

digoxin (0.05 mg/ml solution,0.125 mg tablet, 0.25 mg tablet,125 mcg tablet, 250 mcg tablet,500 mcg/2 ml ampule)

1

dobutamine hcl 1

dobutamine hcl in dextrose 1

dopamine hcl (200 mg/5 ml vial,400 mg/10 ml vial)

1

dopamine hcl in 5% dextrose 1

ENTRESTO 1 QL (60 PER 30 DAYS)

LANOXIN 62.5 MCG TABLET 1

mannitol (20% iv solution, 25%vial)

1

milrinone in 5% dextrose 1

milrinone lactate 1

norepinephrine bitartrate (4 mg/4ml vial, 4 mg/4 ml ampul)

1

NORTHERA 1 PA

OSMITROL 1

pentoxifylline er 400 mg tab 1

ranolazine er 1

REPATHA PUSHTRONEX 1 PA, QL (3.5 PER 28 DAYS)

REPATHA SURECLICK 1 PA, QL (3 PER 28 DAYS)

REPATHA SYRINGE 1 PA, QL (3 PER 28 DAYS)

TAKHZYRO 1 PA

tiadylt er 360 mg capsule 1


74



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

VYNDAMAX 1 PA, QL (30 PER 30 DAYS)

VYNDAQEL 1 PA, QL (120 PER 30 DAYS)

Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide sodium 1

Diuretics, Loopbumetanide (0.25 mg/ml vial, 0.5mg tablet, 1 mg/4 ml vial, 1 mgtablet, 2 mg tablet, 2.5 mg/10 mlvial)

1

ethacrynic acid 1

furosemide (10 mg/ml solution,20 mg tablet, 20 mg/2 ml vial, 40mg/4 ml vial, 40 mg/4 ml syringe,40 mg/5 ml soln, 40 mg tablet,80 mg tablet, 100 mg/10 mlsyring, 100 mg/10 ml vial)

1

torsemide 1

Diuretics, Potassium-sparingALDACTAZIDE 50-50 TABLET 1

amiloride hcl 5 mg tablet 1

amiloride-hydrochlorothiazide 1

DYRENIUM 1

eplerenone 1

spironolactone (25 mg tablet, 50mg tablet, 100 mg tablet)

1

spironolactone-hctz 1

triamterene (50 mg capsule, 100mg capsule)

1

triamterene-hydrochlorothiazid(37.5-25 mg cp, 37.5-25 mg tb,75-50 mg tab)

1


75



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Diuretics, Thiazidechlorothiazide 1

chlorothiazide sodium 1

chlorthalidone 1

DIURIL 1

hydrochlorothiazide (12.5 mg tb,12.5 mg cp, 25 mg tab, 50 mgtab)

1

indapamide 1

methyclothiazide 1

metolazone 1

Dyslipidemics, Fibric Acid Derivativesfenofibrate (40 mg tablet, 43 mgcapsule, 48 mg tablet, 54 mgtablet, 67 mg capsule, 120 mgtablet, 130 mg capsule, 134 mgcapsule, 145 mg tablet, 160 mgtablet, 200 mg capsule)

1

fenofibric acid (dr 45 mg cap, dr135 mg cap)

1

gemfibrozil 600 mg tablet 1

Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1

fluvastatin er 1

fluvastatin sodium 1

LIVALO 1 ST

lovastatin 1

pravastatin sodium 1

rosuvastatin calcium 1

simvastatin (5 mg tablet, 10 mgtablet, 20 mg tablet, 40 mgtablet, 80 mg tablet)

1


76



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Dyslipidemics, Othercholestyramine (packet, powder) 1

cholestyramine light (packet,powder)

1

colesevelam 625 mg tablet 1

colestipol hcl (hcl 1 gm tablet,hcl granules, hcl granulespacket, micronized 1 gm tab)

1

ezetimibe 1

ezetimibe-simvastatin 1

JUXTAPID 1 PA, QL (30 PER 30 DAYS)

KYNAMRO 1 PA, QL (4 PER 28 DAYS)

niacin 500 mg tablet 1

niacin er 1

niacor 1

omega-3 acid ethyl esters 1

prevalite (packet, powder) 1

triklo 1

VASCEPA 1

Vasodilators, Direct-acting Arterialhydralazine hcl (10 mg tablet, 25mg tablet, 50 mg tablet, 100 mgtablet)

1

minoxidil (2.5 mg tablet, 10 mgtablet)

1

Vasodilators, Direct-acting Arterial/VenousDILATRATE-SR 1

ISORDIL 1

isosorbide dinitrate (5 mg tab, 10mg tab, 20 mg tab, 30 mg tab)

1


77



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

isosorbide dinitrate er 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

minitran 1

NITRO-BID 1

NITRO-DUR (0.3 MG/HRPATCH, 0.8 MG/HR PATCH)

1

nitroglycerin (0.3 mg tablet, 0.4mg tablet, 0.6 mg tablet)

1

nitroglycerin in d5w (0.2 mg/mlin, 25 mg/250 ml in, 100 mg/250ml in)

1

nitroglycerin patch 1

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetaminesdextroamphetamine 5 mg/5 ml 1 PA, QL (1800 PER 30 DAYS)

dextroamphetamine 10 mg tab 1 PA, QL (180 PER 30 DAYS)

dextroamphetamine 5 mg tab 1 PA, QL (90 PER 30 DAYS)

dextroamphetamine er 10 mgcap


dextroamphetamine er 15 mgcap


dextroamphetamine er 5 mg cap 1 PA, QL (60 PER 30 DAYS)

dextroamphetamine-amphet er 1 PA, QL (30 PER 30 DAYS)

dextroamphetamine-amphetamine


zenzedi 10 mg tablet 1 PA, QL (180 PER 30 DAYS)

zenzedi 5 mg tablet 1 PA, QL (90 PER 30 DAYS)


78



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesatomoxetine hcl (18 mg capsule,25 mg capsule, 40 mg capsule,60 mg capsule, 80 mg capsule,100 mg capsule)


atomoxetine hcl 10 mg capsule 1 QL (60 PER 30 DAYS)

clonidine hcl er 1

dexmethylphenidate hcl 1 PA, QL (60 PER 30 DAYS)

dexmethylphenidate hcl er 1 PA, QL (30 PER 30 DAYS)

guanfacine hcl er 1

metadate er 1 PA, QL (90 PER 30 DAYS)

methylphenidate er (er 18 mgtab, er 27 mg tab, er 54 mg tab,er 72 mg tab)


methylphenidate er 36 mg tab 1 PA, QL (60 PER 30 DAYS)



methylphenidate er (la) 1 PA, QL (30 PER 30 DAYS)

methylphenidate hcl (5 mg/5 mlsoln, 10 mg/5 ml sol)

1 PA

methylphenidate 10 mg chewtab


methylphenidate hcl (2.5 mgchew tb, 5 mg tablet, 5 mg chewtab, 10 mg tablet, 20 mg tablet)


methylphenidate hcl cd 1 PA, QL (30 PER 30 DAYS)

methylphenidate hcl er (cd) 1 PA, QL (30 PER 30 DAYS)

methylphenidate la 1 PA, QL (30 PER 30 DAYS)

relexxii 1 PA, QL (30 PER 30 DAYS)

Central Nervous System, OtherAUSTEDO 1 PA, QL (120 PER 30 DAYS)


79



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

caffeine citrate (60 mg/3 ml vial,60 mg/3 ml oral)

1

clonidine hcl (1,000 mcg/10 mlvial, 5,000 mcg/10 ml vial)

1

INGREZZA 40 MG CAPSULE 1 PA, QL (60 PER 30 DAYS)

INGREZZA 80 MG CAPSULE 1 PA, QL (30 PER 30 DAYS)

INGREZZA INITIATION PACK 1 PA, QL (56 PER 365 OVER TIME)

NUEDEXTA 1 PA

RADICAVA 1 PA

riluzole 1 PA

tetrabenazine 1 PA

TIGLUTIK 1 PA

Fibromyalgia AgentsSAVELLA TITRATION PACK 1 QL (110 PER 365 OVER TIME)

SAVELLA (12.5 MG TABLET, 25MG TABLET, 50 MG TABLET,100 MG TABLET)


Multiple Sclerosis AgentsAMPYRA 1 PA, QL (60 PER 30 DAYS)

AUBAGIO 1 PA, QL (30 PER 30 DAYS)

AVONEX (30 MCG VIAL KIT,PREFILLED SYR 30 MCG KT)


AVONEX PEN 1 PA, QL (4 PER 28 DAYS)

BETASERON 0.3 MG KIT 1 PA, QL (15 PER 30 DAYS)

dalfampridine er 1 PA, QL (60 PER 30 DAYS)

EXTAVIA (0.3 MG VIAL, 0.3 MGKIT)


GILENYA 0.25 MG CAPSULE 1 PA, QL (30 PER 30 DAYS)

GILENYA 0.5 MG CAPSULE 1 PA, QL (30 PER 30 DAYS)

glatiramer 20 mg/ml syringe 1 PA, QL (30 PER 30 DAYS)


80



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

glatiramer 40 mg/ml syringe 1 PA, QL (12 PER 28 DAYS)

glatopa 20 mg/ml syringe 1 PA, QL (30 PER 30 DAYS)

glatopa 40 mg/ml syringe 1 PA, QL (12 PER 28 DAYS)

MAVENCLAD 1 PA

MAYZENT 0.25 MG TABLET 1 PA, QL (120 PER 30 DAYS)

MAYZENT 2 MG TABLET 1 PA, QL (30 PER 30 DAYS)

OCREVUS 1 PA, QL (40 PER 365 OVER TIME)

PLEGRIDY 125 MCG/0.5 MLSYRING


PLEGRIDY SYRINGESTARTER PACK

1 PA, QL (4 PER 365 OVER TIME)

PLEGRIDY 125 MCG/0.5 MLPEN


PLEGRIDY PEN INJ STARTERPACK


REBIF (22 MCG/0.5 MLSYRINGE, 44 MCG/0.5 MLSYRINGE)


REBIF TITRATION PACK 1 PA, QL (8.4 PER 365 OVERTIME)

REBIF REBIDOSE (22 MCG/0.5ML, 44 MCG/0.5 ML)


REBIF REBIDOSE TITRATIONPACK

1 PA, QL (8.4 PER 365 OVERTIME)

TECFIDERA (DR 120 MGCAPSULE, DR 240 MGCAPSULE)


TECFIDERA STARTER PACK 1 PA, QL (120 PER 365 OVERTIME)

TYSABRI 1 PA

VUMERITY 1 PA, QL (120 PER 30 DAYS)

Dental and Oral Agents

chlorhexidine 0.12% rinse 1


81



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

lidocaine hcl viscous 1

oralone 1

paroex 1

periogard 1

pilocarpine hcl (5 mg tablet, 7.5mg tablet)

1

triamcinolone 0.1% paste 1

Dermatological Agents

acitretin 1

adapalene (0.1% gel, 0.1%cream, 0.3% gel pump, 0.3%gel)

1

adapalene-benzoyl peroxide 1

ammonium lactate (cream,lotion)

1

amnesteem 1 PA

AVITA (CREAM, GEL) 1 PA

azelaic acid 15% gel 1

calcipotriene (cream, ointment) 1 QL (120 PER 30 DAYS)

calcipotriene 0.005% solution 1 QL (60 PER 30 DAYS)

calcitrene 1 QL (120 PER 30 DAYS)

claravis 1 PA

clind ph-benzoyl perox 1.2-5% 1

clindamycin phos-tretinoin 1

clindamycin-benzoyl peroxide(clinda-benzoyl 1-5% pump,clindamycin-benzoyl 1-5%)

1

CONDYLOX 0.5% GEL 1

COSENTYX (2 SYRINGES) 1 PA

COSENTYX PEN 1 PA


82



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

COSENTYX PEN (2 PENS) 1 PA

COSENTYX SYRINGE 1 PA

dapsone 5% gel 1

diclofenac 1.5% topical soln 1 PA

doxepin 5% cream 1 PA, QL (90 PER 30 DAYS)

doxycycline ir-dr 1

DUOBRII 1 PA

DUPIXENT 300 MG/2 MLSYRINGE


erythromycin-benzoyl peroxide 1

EUCRISA 1

FINACEA 15% FOAM 1

hydrocort-pramoxine 1%-1% crm 1

ILUMYA 1 PA

imiquimod (3.75% cream pump,5% cream packet)

1

isotretinoin (10 mg capsule, 20mg capsule, 30 mg capsule, 40mg capsule)

1 PA

ivermectin 1% cream 1

klofensaid ii 1 PA

methoxsalen (10 mg softgel, 10mg capsule)

1

metronidazole (0.75% cream,topical 0.75% gl, 0.75% lotion,top 1% gel pump, topical 1% gel)

1

MIRVASO (GEL, GEL PUMP) 1 PA

myorisan 1 PA

neuac gel 1

PICATO 1

pimecrolimus 1


83



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

podofilox 0.5% topical soln 1

RECTIV 1

rosadan (cream, gel) 1

SANTYL 1

selenium sulfide 2.5% lotion 1

SILIQ 1 PA

STELARA (45 MG/0.5 ML VIAL,45 MG/0.5 ML SYRINGE, 90MG/ML SYRINGE, 130 MG/26ML VIAL)

1 PA

tacrolimus (0.03%, 0.1%) 1

TALTZ AUTOINJECTOR 1 PA

TALTZ AUTOINJECTOR (2PACK)

1 PA

TALTZ AUTOINJECTOR (3PACK)

1 PA

TALTZ SYRINGE 1 PA

TALTZ SYRINGE (2 PACK) 1 PA

tazarotene 0.1% cream 1

TREMFYA (100 MG/MLINJECTOR, 100 MG/MLSYRINGE)

1 PA

tretinoin (0.01% gel, 0.025% gel,0.025% cream, 0.05% gel,0.05% cream, 0.1% cream)

1 PA

tretinoin microsphere (gel 0.04%tube, gel 0.04% pump, gel 0.1%tube, gel 0.1% pump)

1 PA

UVADEX 1

zenatane 1 PA

ZYCLARA (2.5% CREAMPUMP, 3.75% CREAM PUMP,3.75% CREAM)

1


84



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacementcalcium gluconate (gluc 1,000mg/10 ml vl, gluc 5,000 mg/50ml vl, gluc 10,000 mg/100 ml,gluconate 10% vial)

1

CARBAGLU 1

CLINIMIX (4.25%-5%SOLUTION, 4.25%-10%SOLUTION, 5%-20%SOLUTION, 5%-15%SOLUTION)


CLINIMIX E (2.75%-5%SOLUTION, 4.25%-10%SOLUTION, 4.25%-5%SOLUTION, 5%-15%SOLUTION, 5%-20%SOLUTION)


dextrose 10%-0.2% nacl 1


dextrose 2.5%-0.45% nacl 1


dextrose 5%-0.2% nacl-kcl 1











85



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

dextrose 5%-1/2ns-kcl 1

dextrose 5%-ns-kcl 1

dextrose 5%-potassium chloride(20 in solution, 40 in solution)

1

dextrose in lactated ringers 1

dextrose in water (5%-water 50ml, 5%-water vial, 5%-water 100ml, 5%-water iv soln, 10%-wateriv solution, 20%-water iv soln,25%-water syringe, 30%-water ivsoln, 40%-water iv soln, 50%-water abboject, 50%-watersyringe, 50%-water iv soln, 50%-water vial, 70%-water iv soln)

1

fluoride 1

FLUORITAB (0.5 MG TABLETCHEW, 1 MG TABLET CHEW)

1

glucose in water 1

IONOSOL MB-DEXTROSE 5% 1

ISOLYTE P WITH DEXTROSE 1

ISOLYTE S IV SOLUTION-EXCEL

1

klor-con 20 meq packet 1

KLOR-CON 10 1

KLOR-CON 8 1

klor-con m10 1

KLOR-CON M15 1

klor-con m20 1

klor-con sprinkle 1

lactated ringers injection 1

ludent fluoride 1


86



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

magnesium sulfate (sulf 2 g/50ml bag, sulf 4 g/100 ml bag, sulf4 g/50 ml bag, sulf 20 g/500 mlbag, sulf 40 g/1,000 ml, sulfate50% vial, sulfate 50% syringe)

1

magnesium sulf 1 g/100 ml-d5w 1

NORMOSOL-M ANDDEXTROSE

1

NORMOSOL-R ANDDEXTROSE

1

NORMOSOL-R PH 7.4 1

PLASMA-LYTE 148 1

PLASMA-LYTE A PH 7.4 1

potassium chl-normal saline 1

potassium chloride (2 meq/mlconc, er 8 meq capsule, er 8meq tablet, er 10 meq tablet,10% (20 meq/15ml), 10 meq/50ml sol, 10 meq/100 ml sol, er 10meq capsule, 10% (40meq/30ml), 10 meq/5 ml conc,20 meq packet, 20 meq/10 mlconc, 20 meq/50 ml sol, 20% (40meq/15ml), er 20 meq tablet, 20meq/100 ml sol, 40 meq/20 mlconc, 40 meq/100 ml sol, 60meq/30 ml conc)

1

potassium chloride in d5lr 1

potassium chloride proamp 1

potassium chloride-nacl 1

potassium citrate er (er 5 tab, er10 tb)

1

PROCALAMINE 1 PA - Part B vs D Determination

ringers injection 1

sodium acetate (40 meq/20 mlvl, 100 meq/50 ml, 200 meq/100ml)

1


87



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

sodium chloride (saline 0.45%soln-excel con, sodium chloride0.45% soln, sodium chloride0.9% syringe, sodium chloride0.9% 250 ml, sodium chloride0.9% 50 ml, sodium chloride0.9% sol-excel, sodium chloride0.9% vial, sodium chloride 0.9%solution, sodium chloride 0.9%carpuject, sodium chloride 0.9%soln, sodium chloride 0.9% 500ml, sodium chloride 0.9% 1,000ml, sodium chloride 0.9% 100ml, sodium chloride 3% iv soln,sodium chloride 5% iv soln,sodium chloride 50 meq/20 ml,sodium chloride 100 meq/40 ml)

1

sodium fluoride (0.25 (0.55) mg,0.5 mg(1.1 mg), 1 mg (2.2 mg))

1

sodium lactate 1

Electrolyte/Mineral/Metal Modifiersdeferasirox (90 mg tablet, 125mg tb for susp, 250 mg tb forsusp, 360 mg tablet, 500 mg tbfor susp)

1 PA

DEPEN 1

EXJADE 1 PA

FERRIPROX (100 MG/MLSOLUTION, 500 MG TABLET,1,000 MG TABLET)

1 PA

JADENU 1 PA

JADENU SPRINKLE 1 PA

JYNARQUE 15 MG TABLET 1 QL (60 PER 30 DAYS)

JYNARQUE 30 MG TABLET 1 QL (30 PER 30 DAYS)

JYNARQUE (45 MG-15 MGTABLET, 60 MG-30 MGTABLET, 90 MG-30 MGTABLET)



88



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

kionex 15 gm/60 ml suspension 1

sodium polystyrene sulfonate(sod polystyren sulf 15 g/60 ml,sodium polystyrene sulf powder,sps 15 gm/60 ml suspension,sps 30 gm/120 ml enema, sps50 gm/200 ml enema)

1

SPS 15 GM/60 MLSUSPENSION

1

trientine hcl 1 PA

VELTASSA 1

Phosphate BindersAURYXIA 1 PA

calcium acetate (667 mgcapsule, 667 mg tablet, 667 mggelcap)

1

lanthanum carbonate 1

sevelamer carbonate (0.8 gmpowder packet, 2.4 gm powderpacket, carbonate 800 mg tab)

1

sevelamer hcl 1

VELPHORO 1

Vitaminsprenatal vitamins 1

RAYALDEE 1

Gastrointestinal Agents

Antispasmodics, GastrointestinalCUVPOSA 1

dicyclomine hcl (10 mg capsule,10 mg/5 ml soln, 20 mg/2 ml vial,20 mg/2 ml ampul, 20 mg tablet)

1

GLYCATE 1


89



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

glycopyrrolate (0.2 mg/ml syrng,0.4 mg/2 ml syr, 1 mg tablet, 1.5mg tablet, 2 mg tablet)

1

methscopolamine bromide (2.5mg tb, 5 mg tab)

1

Gastrointestinal Agents, OtherCHENODAL 1

CHOLBAM 1 PA

cromolyn 100 mg/5 ml oral conc 1

diphenoxylate-atrop 2.5-0.025 1

GATTEX 1 PA

loperamide 2 mg capsule 1

metoclopramide hcl (5 mg tablet,5 mg/5 ml soln, 10 mg/2 ml vial,10 mg tablet, 10 mg/2 ml syr, 10mg/10 ml sol)

1

OCALIVA 1 PA, QL (30 PER 30 DAYS)

opium tincture 1

RELISTOR (12 MG/0.6 MLSYRINGE, 12 MG/0.6 ML VIAL)


RELISTOR 8 MG/0.4 MLSYRINGE


RELISTOR 150 MG TABLET 1 ST, QL (90 PER 30 DAYS)

ursodiol (250 mg tablet, 500 mgtablet)

1

XERMELO 1 PA, QL (90 PER 30 DAYS)

Histamine2 (H2) Receptor Antagonistscimetidine (200 mg tablet, 300mg tablet, 300 mg/5 ml soln, 400mg tablet, 800 mg tablet)

1

famotidine (20 mg tablet, 20mg/2 ml vial, 40 mg/5 ml susp,40 mg/4 ml vial, 40 mg tablet,200 mg/20 ml vial, 500 mg/50 mlvial)

1


90



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

nizatidine (15 mg/ml solution,150 mg capsule, 300 mgcapsule)

1

ranitidine hcl (15 mg/ml syrup,hcl 50 mg/2 ml vial, 150 mg/10ml syrup, hcl 150 mg/6 ml vl, 150mg tablet, 150 mg capsule, 300mg capsule, 300 mg tablet,1,000 mg/40 ml vial)

1

Irritable Bowel Syndrome Agentsalosetron hcl 1 PA

AMITIZA 1 QL (60 PER 30 DAYS)

LINZESS 1 QL (30 PER 30 DAYS)

LaxativesCLENPIQ 1

constulose 1

enulose 1

gavilyte-c 1

gavilyte-g 1

gavilyte-n 1

generlac 1

KRISTALOSE 1

lactulose (10 gm/15 ml solution,10 gm packet, 20 gm/30 mlsolution)

1

peg 3350-electrolyte 1

peg-3350 and electrolytes 1

polyethylene glycol 3350 1

SUPREP 1

trilyte with flavor packets 1


91



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Protectantsmisoprostol (100 mcg tablet, 200mcg tablet)

1

sucralfate (1 gm tablet, 1 gm/10ml susp)

1

Proton Pump Inhibitorsesomeprazole mag dr 20 mg cap 1 QL (60 PER 30 DAYS)

esomeprazole mag dr 40 mg cap 1 QL (60 PER 30 DAYS)

esomeprazole sodium 1

lansoprazole (dr 15 mg capsule,dr 30 mg capsule, odt 15 mgtablet, odt 30 mg tablet)


omeprazole (dr 10 mg capsule,dr 20 mg capsule, dr 40 mgcapsule)


omeprazole-sodium bicarbonate(20-1,680 pkt, 40-1,680 pkt)


pantoprazole sodium (dr 20 mgtab, dr 40 mg tab)


pantoprazole sodium 40 mg vial 1

rabeprazole sod dr 20 mg tab 1 QL (60 PER 30 DAYS)

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

ADAGEN 1

ALDURAZYME 1 PA

CERDELGA 1 PA

CEREZYME 400 UNIT VIAL 1 PA

CREON 1

CYSTAGON 1

ELAPRASE 1 PA

EXONDYS-51 1 PA


92



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

FABRAZYME 35 MG VIAL 1 PA

GALAFOLD 1 PA, QL (14 PER 28 DAYS)

KANUMA 1 PA

KUVAN (100 MG TABLET, 100MG POWDER PACKET, 500MG POWDER PACKET)

1 PA

LUMIZYME 1 PA

miglustat 1 PA

NAGLAZYME 1 PA

NITYR 1

ONPATTRO 1 PA

ORFADIN (2 MG CAPSULE, 4MG/ML SUSPENSION, 5 MGCAPSULE, 10 MG CAPSULE,20 MG CAPSULE)

1

PROCYSBI (DR 25 MGCAPSULE, DR 75 MGCAPSULE)

1 PA

RAVICTI 1 PA

REVCOVI 1 PA

sodium phenylbutyrate powder 1

STRENSIQ 1 PA

TEGSEDI 1 PA

VIMIZIM 1 PA

VPRIV 1 PA

XIAFLEX 1 PA

XURIDEN 1 PA, QL (120 PER 30 DAYS)

ZENPEP 1


93



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Genitourinary Agents

Antispasmodics, Urinarydarifenacin er 1

flavoxate hcl 1

MYRBETRIQ 1

oxybutynin chloride (5 mg/5 mlsyrup, 5 mg tablet)

1

oxybutynin chloride er 1

solifenacin succinate 1

tolterodine tartrate 1

tolterodine tartrate er 1

trospium chloride 1

trospium chloride er 1

Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 1

doxazosin mesylate (1 mg tab, 2mg tab, 4 mg tab, 8 mg tab)

1

dutasteride 0.5 mg capsule 1

finasteride 5 mg tablet 1

RAPAFLO 1

silodosin 1

tamsulosin hcl 1

terazosin hcl 1

Genitourinary Agents, Otheracetic acid 0.25% irrig soln 1

bethanechol chloride (5 mgtablet, 10 mg tablet, 25 mgtablet, 50 mg tablet)

1


94



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ELMIRON 1

THIOLA EC 1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

ala-cort 2.5% cream 1

alclometasone dipropionate (diproint, dipro crm)

1

amcinonide (cream, lotion,ointment)

1

apexicon e 1

beser 1

betamethasone dipropaugmented (crm, gel, lot, oin)

1

betamethasone dipropionate(crm, lot, oint)

1

betamethasone sod phos-acetate

1

betamethasone valer 0.12%foam


betamethasone valerate (vacream, va lotion, valer ointm)

1

clobetasol emollient (emollientcrm, emollnt foam)

1

clobetasol emulsion 1

clobetasol propionate (cream,gel, ointment, prop foam, propspray, shampoo, solution, topicallotn)

1

clocortolone pivalate 1

clodan 0.05% shampoo 1

CORTIFOAM 1

cortisone 25 mg tablet 1

DELTASONE 1


95



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

DEPO-MEDROL 20 MG/MLVIAL

1

desonide (cream, lotion,ointment)

1

desoximetasone (0.05% gel,0.05% ointment, 0.05% cream,0.25% cream, 0.25% ointment,0.25% spray)

1

dexamethasone (0.5 mg tablet,0.5 mg/5 ml elx, 0.5 mg/5 ml liq,0.75 mg tablet, 1 mg tablet, 1.5mg tablet, 2 mg tablet, 4 mgtablet, 6 mg tablet, 6 day 1.5 mgtab, 10 day 1.5 mg tb, 13 day 1.5mg tb)

1

dexamethasone intensol 1

dexamethasone sodiumphosphate (4 mg/ml vial, 4mg/ml syringe, 10 mg/ml vial, 20mg/5 ml vial, 100 mg/10 ml vl,120 mg/30 ml vl)

1

diflorasone 0.05% cream 1

diflorasone 0.05% ointment 1 QL (60 PER 30 DAYS)

EMFLAZA (6 MG TABLET, 18MG TABLET, 22.75 MG/MLORAL SUSP, 30 MG TABLET,36 MG TABLET)

1 PA

fludrocortisone 0.1 mg tablet 1

fluocinolone acetonide (0.01%solution, 0.01% cream, 0.025%cream, 0.025% ointment)

1

fluocinonide (cream, gel,ointment, solution)

1

fluocinonide 0.1% cream 1 QL (120 PER 30 DAYS)

fluocinonide-e 1

flurandrenolide (cream,ointment)

1


96



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

fluticasone propionate (0.005%oint, 0.05% cream, 0.05% lotion)

1

halcinonide 1

halobetasol propionate (cream,foam, ointmnt)

1

hydrocortisone (2.5% cream,2.5% ointment, 2.5% lotion, 5mg tablet, 10 mg tablet, 20 mgtablet)

1

hydrocortisone butyrate (butycream, butyr lotn, butyr oint,butyr soln)

1

hydrocortisone val 0.2% cream 1 QL (60 PER 30 DAYS)

hydrocortisone val 0.2% ointmt 1

KENALOG-10 1

LEXETTE 1

methylprednisolone (4 mg tablet,4 mg dosepk, 8 mg tab, 16 mgtab, 32 mg tab)

1

methylprednisolone acetate (40mg/ml vl, 80 mg/ml vl)

1

methylprednisolone sodium succ(1 gm vl, 40 mg vl, 125 mg)

1

mifepristone 1

millipred 5 mg tablet 1

mometasone furoate (cream,oint, soln)

1

nolix 0.05% cream 1

PANDEL 1

prednicarbate (cream, ointment) 1

prednisolone (15 mg/5 ml syrup,15 mg/5 ml soln)

1

prednisolone sodium phosphate(5 mg/5 ml soln, 10 mg/5 mlsoln, 20 mg/5 ml soln, sod ph 25mg/5 ml)

1


97



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

prednisone (1 mg tablet, 2.5 mgtablet, 5 mg tab dose pack, 5 mgtablet, 5 mg/5 ml solution, 10 mgtab dose pack, 10 mg tablet, 20mg tablet, 50 mg tablet)

1

prednisone intensol 1

RAYOS 1

SOLU-CORTEF 1

SOLU-MEDROL 2,000 MG VIAL 1

tovet emollient 1

triamcinolone acetonide (0.025%lotion, 0.025% oint, 0.025%cream, 0.1% ointment, 0.1%cream, 0.1% lotion, 0.5%ointment, 0.5% cream, acet 40mg/ml vl, acet 40mg/ml vl, acet200 mg/5 ml, acet 400 mg/10ml)

1

triderm 1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

ACTHAR 1 PA

chorionic gonad 10,000 unit vl 1 PA

desmopressin acetate (0.01%spray, 0.01% solution, ac 4mcg/ml vial, ac 4 mcg/ml ampul,acetate 0.1 mg tb, acetate 0.2mg tb, 40 mcg/10 ml vial)

1

GENOTROPIN (MINIQUICK 0.2MG, MINIQUICK 0.4 MG,MINIQUICK 0.6 MG,MINIQUICK 0.8 MG,MINIQUICK 1 MG, MINIQUICK1.2 MG, MINIQUICK 1.4 MG,MINIQUICK 1.6 MG,MINIQUICK 1.8 MG,MINIQUICK 2 MG, 5 MGCARTRIDGE, 12 MGCARTRIDGE)

1 PA


98



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

INCRELEX 1 PA

NOVAREL 5,000 UNIT VIAL 1 PA

NUTROPIN AQ NUSPIN 1 PA

PREGNYL 1 PA

SEROSTIM 1 PA

STIMATE 1

ZORBTIVE 1 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

KORLYM 1 PA, QL (120 PER 30 DAYS)

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic SteroidsANADROL-50 1 PA

oxandrolone 10 mg tablet 1 PA, QL (60 PER 30 DAYS)

oxandrolone 2.5 mg tablet 1 PA, QL (240 PER 30 DAYS)

AndrogensANDRODERM 1 PA

danazol (50 mg capsule, 100 mgcapsule, 200 mg capsule)

1

testosterone (1.62% (2.5 g) pkt,1.62%(1.25 g) pkt, 1.62% gelpump, 12.5 mg/1.25 gram, 25mg/2.5 gm pkt, 30 mg/1.5 mlpump, 50 mg/5 gram gel, 50mg/5 gram pkt)

1 PA

testosterone cypionate(testosteron 1,000 mg/10 ml,testosteron 2,000 mg/10 ml,testosterone 100 mg/ml,testosterone 200 mg/ml,testosterone 500 mg/5 ml,testosterone 6,000 mg/30ml)

1 PA


99



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

testosterone enanthate(testosteron 1,000 mg/5 ml,testosterone 200 mg/ml)

1 PA

Estrogensaltavera 1

alyacen 1

amabelz 1

amethia 1 QL (91 PER 91 DAYS)

amethia lo 1 QL (91 PER 91 DAYS)

amethyst 1

apri 1

aranelle 1

ashlyna 1 QL (91 PER 91 DAYS)

aubra 1

aubra eq 1

aurovela 24 fe 1

aviane 1

azurette 1

balziva 1

bekyree 1

blisovi 24 fe 1

blisovi fe 1.5-30 tablet 1

briellyn 1

camrese 1 QL (91 PER 91 DAYS)

camrese lo 1 QL (91 PER 91 DAYS)

caziant 1

chateal 1

CLIMARA PRO 1

cryselle 1


100



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

cyclafem 1

cyred 1

cyred eq 1

dasetta 1

daysee 1 QL (91 PER 91 DAYS)

delyla 1

desogestr-eth estrad eth estra 1

desogestrel-ethinyl estradiol 1

dotti 1

drospirenone-eth estra-levomef 1

drospirenone-ethinyl estradiol 1

ELESTRIN 1

elinest 1

emoquette 1

enpresse 1

enskyce 1

estarylla 1

estradiol (0.01% cream, tds0.025 mg/day, 0.025 mg patch,0.0375 mg/day patch, tds 0.0375mg/day, 0.0375 mg patch, 0.05mg patch, tds 0.05 mg/day, 0.06mg/day patch, tds 0.06 mg/day,tds 0.075 mg/day, 0.075 mgpatch, 0.075 mg/day patch, 0.1mg patch, tds 0.1 mg/day, 0.5mg tablet, 1 mg tablet, 2 mgtablet, 10 mcg vaginal insrt)

1

estradiol valerate (20 mg/ml vl,40 mg/ml vl)

1

estradiol-norethindrone acetat 1

ESTRING 1 QL (1 PER 90 OVER TIME)

ethynodiol-ethinyl estradiol 1


101



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

falmina 1

fayosim 1 QL (91 PER 91 DAYS)

femynor 1

fyavolv 1

gianvi 1

hailey 24 fe 1

introvale 1 QL (91 PER 91 DAYS)

isibloom 1

jasmiel 1

jinteli 1

jolessa 1 QL (91 PER 91 DAYS)

juleber 1

junel 1

junel fe 1

junel fe 24 1

kaitlib fe 1

kariva 1

kelnor 1-35 1

kelnor 1-50 1

kimidess 1

kurvelo 1

larin 1

larin 24 fe 1

larin fe 1

larissia 1

LAYOLIS FE 1

leena 1

lessina 1


102



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

levonest 1

levonorg-eth estrad eth estrad 1 QL (91 PER 91 DAYS)

levonorgestrel-eth estradiol 1

levora-28 1

LO LOESTRIN FE 1

lopreeza 1

loryna 1

low-ogestrel 1

lutera 1

marlissa 1

melodetta 24 fe 1

MENEST 1

mibelas 24 fe 1

microgestin 1

microgestin fe 1

mili 1

mimvey 1

mimvey lo 1

mono-linyah 1

mononessa 1

necon 0.5-35-28 tablet 1

nikki 1

norethin-eth estra-ferrous fum(noret-estr-fe 0.4-0.035(21)-75,noreth-estrad-fe 1-0.02(21)-75,noreth-estrad-fe 1-0.02(24)-75,norethin-estra-fe 0.8-0.025 mg)

1

norethindron-ethinyl estradiol(norethin-eth 1 mg-5 mcg,norethind-eth 0.5-2.5, norethind-eth 1-0.02 mg)

1


103



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

norgestimate-ethinyl estradiol 1

norlyda 1

nortrel 1

ocella 1

ogestrel 1

orsythia 1

philith 1

pimtrea 1

pirmella 1

portia 1

PREMARIN (0.3 MG TABLET,0.45 MG TABLET, 0.625 MGTABLET, 0.9 MG TABLET, 1.25MG TABLET, VAGINALCREAM-APPL)

1

PREMPHASE 1

PREMPRO 1

previfem 1

reclipsen 1

rivelsa 1 QL (91 PER 91 DAYS)

setlakin 1 QL (91 PER 91 DAYS)

sprintec 1

sronyx 1

syeda 1

tarina 24 fe 1

tarina fe 1

tarina fe 1-20 eq 1

tilia fe 1

tri-estarylla 1

tri-legest fe 1


104



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-sprintec 1

tri-mili 1

tri-previfem 1

tri-sprintec 1

tri-vylibra 1

tri-vylibra lo 1

trivora-28 1

tydemy 1

velivet 1

vestura 1

vienva 1

viorele 1

vyfemla 1

vylibra 1

wera 1

wymzya fe 1

xulane 1

yuvafem 1

zarah 1

zovia 1-35e 1

zumandimine 1

Progesterone Agonists/AntagonistsELLA 1

MAKENA 275 MG/1.1 MLAUTOINJCT

1 PA


105



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Progestinscamila 1

CRINONE 1 PA

deblitane 1

DEPO-PROVERA 400 MG/MLVIAL


DEPO-SUBQ PROVERA 104 1 QL (0.65 PER 90 OVER TIME)

errin 1

heather 1

hydroxyprogesterone 1.25 g/5ml 1 PA - FOR NEW STARTS ONLY

hydroxyprogesterone caproate(250 mg/ml vial, 1,250 mg/5 ml)

1 PA

incassia 1

jencycla 1

jolivette 1

lyza 1

medroxyprogesterone 150mg/ml


medroxyprogesterone acetate(2.5 mg tab, 5 mg tab, 10 mgtab)

1

megestrol acetate (20 mg tablet,acet 40 mg/ml susp, 40 mgtablet, acet 400 mg/10 ml, 625mg/5 ml susp)


nora-be 1

norethindrone 0.35 mg tablet 1

norethindrone ac (lupaneta) 1

norethindrone 5 mg tablet 1

norlyroc 1

progesterone (100 mg capsule,200 mg capsule, 500 mg/10 mlvial)

1


106



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

sharobel 1

tulana 1

Selective Estrogen Receptor Modifying AgentsOSPHENA 1 PA, QL (30 PER 30 DAYS)

raloxifene hcl 1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium (25 mcgtablet, 50 mcg tablet, 75 mcgtablet, 88 mcg tablet, 100 mcgvial, 100 mcg tablet, 100 mcg/5ml vl, 112 mcg tablet, 125 mcgtablet, 137 mcg tablet, 150 mcgtablet, 175 mcg tablet, 200 mcgtablet, 200 mcg/5 ml vl, 200 mcgvial, 300 mcg tablet, 500 mcg/5ml vl, 500 mcg vial)

1

LEVOXYL 1

liothyronine sodium (5 mcg tab,10 mcg/ml vl, 25 mcg tab, 50mcg tab)

1

TIROSINT (175 MCGCAPSULE, 200 MCGCAPSULE)

1

UNITHROID 1

Hormonal Agents, Suppressant (Adrenal)

LYSODREN 1

Hormonal Agents, Suppressant (Pituitary)

cabergoline 1

FIRMAGON (2 X 120 MG KIT,120 MG VIAL)


FIRMAGON 80 MG KIT 1 PA - FOR NEW STARTS ONLY,QL (1 PER 28 OVER TIME)


107



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

leuprolide acetate (1 mg/0.2 mlkit, 14 mg/2.8 ml vl, 14 mg/2.8ml kt)


LUPANETA PK 11.25-5 MG3MO KIT


LUPANETA PK 3.75-5 MG 1MOKIT


LUPRON DEPOT (11.25 MG3MO KIT, 22.5 MG 3MO KIT)


LUPRON DEPOT (3.75 MG KIT,7.5 MG KIT)


LUPRON DEPOT 45 MG 6MOKIT


LUPRON DEPOT-4 MONTH KIT 1 PA - FOR NEW STARTS ONLY,QL (1 PER 112 OVER TIME)

LUPRON DEPO 11.25MG(LUPANETA)


LUPRON DEPOT 3.75MG(LUPANETA)


LUPRON DEPOT-PED (11.25MG KIT, 15 MG KIT)


LUPRON DEPOT-PED 7.5 MGKIT


LUPRON DEPOT-PED 11.25MG 3MO

1 PA, PA - FOR NEW STARTSONLY, QL (1 PER 84 OVERTIME)

LUPRON DEPOT-PED 30 MG3MO KIT


octreotide acetate (acet 0.05mg/ml vl, acet 50 mcg/ml amp,acet 50 mcg/ml vial, acet 100mcg/ml vl, acet 100 mcg/ml amp,acet 200 mcg/ml vl, acet 500mcg/ml vl, acet 500 mcg/ml amp,1,000 mcg/5 ml vial, 1,000mcg/ml vial, 5,000 mcg/5 ml vial)

1 PA

ORILISSA 150 MG TABLET 1 PA, QL (30 PER 30 DAYS)


108



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ORILISSA 200 MG TABLET 1 PA, QL (60 PER 30 DAYS)

SANDOSTATIN LAR DEPOT 1 PA

SIGNIFOR 1 PA, QL (60 PER 30 DAYS)

SIGNIFOR LAR 1 PA, QL (1 PER 28 DAYS)

SOMATULINE DEPOT (60MG/0.2 ML, 90 MG/0.3 ML)

1 PA

SOMATULINE DEPOT 120MG/0.5 ML


SOMAVERT 1 PA

SUPPRELIN LA 1 PA, QL (1 PER 365 OVER TIME)

SYNAREL 1

TRELSTAR 11.25 MG VIAL 1 PA - FOR NEW STARTS ONLY,QL (1 PER 84 OVER TIME)



TRIPTODUR 1 PA, QL (1 PER 168 OVER TIME)

ZOLADEX 3.6 MG IMPLANTSYRN


Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole (5 mg tablet, 10 mgtablet)

1

propylthiouracil 50 mg tablet 1

Immunological Agents

Angioedema AgentsBERINERT (500 UNIT VIAL, 500UNIT KIT)

1 PA


109



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

FIRAZYR 1 PA

icatibant 1 PA

RUCONEST 1 PA

Immune SuppressantsAZASAN 1 PA - Part B vs D Determination

azathioprine 50 mg tablet 1 PA - Part B vs D Determination

azathioprine sodium 1

BENLYSTA (120 MG VIAL, 200MG/ML SYRINGE, 200 MG/MLAUTOINJECT, 400 MG VIAL)

1 PA

CIMZIA (2X200 MG/MLSYRINGE KIT, 2X200MG/ML(X3)START KT, 200 MGVIAL KIT)

1 PA

cyclosporine 250 mg/5 ml ampul 1

cyclosporine (25 mg capsule,100 mg capsule)


cyclosporine modified (25 mg,50 mg, 100 mg, 100mg/ml)


ENBREL (25 MG KIT, 25MG/0.5 ML SYRINGE, 50MG/ML SYRINGE)

1 PA

ENBREL MINI 1 PA

ENBREL SURECLICK 1 PA

gengraf (25 mg capsule, 100mg/ml solution, 100 mg capsule)


HUMIRA 1 PA

HUMIRA PEDIATRIC CROHN'S 1 PA

HUMIRA PEN 1 PA

HUMIRA PEN CROHN'S-UC-HS 1 PA

HUMIRA PEN PSOR-UVEITS-ADOL HS

1 PA


110



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

HUMIRA(CF) 1 PA

HUMIRA(CF) PEDIATRICCROHN'S

1 PA

HUMIRA(CF) PEN 40 MG/0.4ML

1 PA

HUMIRA(CF) PEN CROHN'S-UC-HS

1 PA

HUMIRA(CF) PEN PSOR-UV-ADOL HS

1 PA

INFLECTRA 1 PA

KINERET 1 PA

methotrexate (1 gm vial, 2.5 mgtablet, 50 mg/2 ml vial, 250mg/10 ml vial)

1

methotrexate sodium 1

mycophenolate mofetil (200mg/ml susp, 250 mg capsule,500 mg tablet)


mycophenolate 500 mg vial 1

mycophenolic acid 1 PA - Part B vs D Determination

NULOJIX 1 PA - FOR NEW STARTS ONLY

ORENCIA (50 MG/0.4 MLSYRINGE, 87.5 MG/0.7 MLSYRINGE, 125 MG/MLSYRINGE, 250 MG VIAL)

1 PA

ORENCIA CLICKJECT 1 PA, QL (4 PER 28 DAYS)

PROGRAF 5 MG/ML AMPULE 1

PROGRAF (0.2 MG GRANULEPACKET, 1 MG GRANULEPACKET)


RASUVO 10 MG/0.2 MLAUTOINJ

1 PA, QL (0.8 PER 28 DAYS)

RASUVO 12.5 MG/0.25 MLAUTOINJ



111



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES















REMICADE 1 PA

RENFLEXIS 1 PA

SANDIMMUNE 100 MG/MLSOLN


sirolimus (0.5 mg tablet, 1 mgtablet, 1 mg/ml solution, 2 mgtablet)


SKYRIZI (2 SYRINGES) KIT 1 PA

tacrolimus (0.5 mg capsule, 1mg capsule, 5 mg capsule)


TREXALL 1

XATMEP 1

ZORTRESS 1 PA - FOR NEW STARTS ONLY

Immunizing Agents, PassiveATGAM 1

BIVIGAM 10% VIAL 1

BIVIGAM LIQUID 10% VIAL 1 PA

CARIMUNE NFNANOFILTERED

1 PA


112



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

CUTAQUIG 1 PA

CUVITRU (1 GRAM/5 ML VIAL,2 GRAM/10 ML VIAL, 4GRAM/20 ML VIAL, 8 GRAM/ 40ML VIAL)

1 PA

FLEBOGAMMA DIF 1 PA

GAMASTAN 1 PA

GAMASTAN S-D 1 PA

GAMMAGARD LIQUID 1 PA

GAMMAGARD S-D 1 PA

GAMMAKED (1 GRAM/10 MLVIAL, 5 GRAM/50 ML VIAL, 10GRAM/100 ML VIAL, 20GRAM/200 ML VIAL)

1 PA

GAMMAKED 2.5 GRAM/25 MLVIAL

1

GAMMAPLEX 1 PA

GAMUNEX-C 1 PA

HEPAGAM B 1

HYPERHEP B S-D (NEONATALSYRIN., SYRINGE, VIAL)

1

HYPERRAB 1

HYPERRHO S-D 1

MICRHOGAM ULTRA-FILTERED PLUS

1

NABI-HB 1

OCTAGAM 1 PA

PANZYGA 1 PA

PRIVIGEN 1 PA

RHOGAM ULTRA-FILTEREDPLUS

1

RHOPHYLAC 1


113



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

SYNAGIS 1 PA

ImmunomodulatorsACTEMRA (80 MG/4 ML VIAL,200 MG/10 ML VIAL, 400 MG/20ML VIAL)

1 PA

ACTEMRA ACTPEN 1 PA

ACTIMMUNE 1 PA - FOR NEW STARTS ONLY

ARCALYST 1 PA

ENTYVIO 1 PA

ILARIS 1 PA, QL (2 PER 28 DAYS)

KEVZARA (150 MG/1.14 MLPEN INJ, 150 MG/1.14 MLSYRINGE, 200 MG/1.14 MLPEN INJ, 200 MG/1.14 MLSYRINGE)

1 PA

leflunomide 1

LEMTRADA 1 PA

OLUMIANT 1 PA

OTEZLA 30 MG TABLET 1 PA

RIDAURA 1

RINVOQ ER 1 PA

SIMPONI ARIA 1 PA

SYLVANT 1 PA - FOR NEW STARTS ONLY

XELJANZ 1 PA

XELJANZ XR 11 MG TABLET 1 PA

VaccinesACTHIB 1

ADACEL TDAP (SYRINGE,VIAL)

1

BCG VACCINE (TICE STRAIN) 1

BEXSERO 1


114



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

BOOSTRIX TDAP (SYRINGE,VIAL)

1

DAPTACEL DTAP 1

DIPHTHERIA-TETANUSTOXOIDS-PED

1

ENGERIX-B 20 MCG/ML SYRN 1 PA - Part B vs D Determination

ENGERIX-B PEDIATRIC-ADOLESCENT


GARDASIL 9 (9 VIAL, 9SYRINGE)

1

HAVRIX (720 UNITS/0.5 MLVIAL, 720 UNIT/0.5 MLSYRINGE, 1,440 UNITS/MLVIAL, 1,440 UNITS/MLSYRINGE)

1

HIBERIX 1

IMOVAX RABIES VACCINE 1 PA - Part B vs D Determination

INFANRIX DTAP VIAL 1

IPOL 1

IXIARO 1

KINRIX (TIP-LOK SYRINGE,VIAL)

1

M-M-R II VACCINE 1

MENACTRA 1

MENVEO A-C-Y-W-135-DIP 1

PEDIARIX 1

PEDVAXHIB 1

PENTACEL 1

PROQUAD 1

QUADRACEL DTAP-IPV 1

RABAVERT 1 PA - Part B vs D Determination

RECOMBIVAX HB (5 MCG/0.5ML SYR, 10 MCG/ML VIAL, 10MCG/ML SYR, 40 MCG/MLVIAL)



115



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ROTARIX 1

ROTATEQ 1

SHINGRIX 1

TDVAX 1

TENIVAC SYRINGE 1

TRUMENBA 1

TWINRIX 1

TYPHIM VI (25 MCG/0.5 MLSYRNG, 25 MCG/0.5 ML AL)

1

VAQTA (25 UNITS/0.5 MLSYRINGE, 25 UNITS/0.5 MLVIAL, 50 UNITS/ML SYRINGE,50 UNITS/ML VIAL)

1

VARIVAX VACCINE 1

VARIZIG 125 UNIT/1.2 ML VIAL 1 PA

YF-VAX 1

ZOSTAVAX 1

Inflammatory Bowel Disease Agents

AminosalicylatesAPRISO 1

balsalazide disodium 1

mesalamine (dr 1.2 gm tablet, 4gm/60 ml enema, 800 mg drtablet, 1,000 mg supp)

1

mesalamine er 1

Glucocorticoidsbudesonide ec 1

budesonide er 1

colocort 1


116



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

hydrocortisone 100 mg/60 ml 1

Sulfonamidessulfasalazine 500 mg tablet 1

sulfasalazine dr 1

Metabolic Bone Disease Agents

alendronate sodium (sod 70mg/75 ml, sodium 5 mg tablet,sodium 10 mg tab, sodium 35mg tab, sodium 40 mg tab)

1

alendronate sodium 70 mg tab 1 QL (4 PER 28 DAYS)

calcitonin-salmon 1 QL (3.7 PER 30 DAYS)

calcitriol (0.25 mcg capsule, 0.5mcg capsule, 1 mcg/ml solution,1 mcg/ml ampul)

1

cinacalcet hcl 1

doxercalciferol (0.5 mcg cap, 1mcg capsule, 2.5 mcg cap)

1

EVENITY (2 SYRINGES) 1 PA, QL (2.34 PER 28 DAYS)

FORTEO 1 PA

ibandronate sodium 150 mg tab 1 QL (1 PER 28 DAYS)

MIACALCIN (200 UNIT/MLVIAL, 400 UNIT/2 ML VIAL)

1

NATPARA 1 PA, QL (2 PER 28 DAYS)

pamidronate disodium (disod 30mg vial, 30 mg/10 ml vial, 60mg/10 ml vial, 90 mg/10 ml vial,disod 90 mg vial)

1

paricalcitol (1 mcg capsule, 2mcg/ml vial, 2 mcg capsule, 4mcg capsule, 5 mcg/ml vial, 10mcg/2 ml vial)

1

PROLIA 1 QL (2 PER 365 OVER TIME)


117



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

TYMLOS 1 PA

XGEVA 1 PA

zoledronic acid (4 mg/5 ml vial, 4mg/100 ml, 5 mg/100 ml)

1

Miscellaneous Therapeutic Agents

afirmelle 1

AMINOSYN II 10% IVSOLUTION


AMINOSYN-PF 1 PA - Part B vs D Determination

aurovela 1

aurovela fe 1-20 tablet 1

chateal eq 1

CINRYZE 1 PA

deferoxamine mesylate 1

ENDARI 1 PA

FIRDAPSE 1 PA, QL (240 PER 30 DAYS)

FREAMINE HBC 1 PA - Part B vs D Determination

FREAMINE III 10% IV SOLN. 1

HAEGARDA 1 PA

HEPATAMINE 1 PA - Part B vs D Determination

insulin pen needles 1 QL (200 PER 30 DAYS)

insulin syringe 1 QL (200 PER 30 DAYS)

INTRALIPID 20% IV FAT EMUL 1 PA - Part B vs D Determination

KALBITOR 1 PA

KEVEYIS 1 PA, QL (120 PER 30 DAYS)

lactated ringers irrigation 1

levocarnitine (1 g/10 ml soln,330 mg tablet)

1

lillow 1


118



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

lo-zumandimine 1

methergine 1

methylergonovine 0.2 mg tablet 1

MYALEPT 1 PA

NEPHRAMINE 1 PA - Part B vs D Determination

NUTRILIPID 1 PA - Part B vs D Determination

PHYSIOLYTE 1

PHYSIOSOL 1

PREMASOL 1 PA - Part B vs D Determination

PROSOL 1 PA - Part B vs D Determination

ringers irrigation 1

RUZURGI 1 PA, QL (300 PER 30 DAYS)

simliya 1

simpesse 1 QL (91 PER 91 DAYS)

sodium chloride (irrig., prcss sol) 1

sodium phenylacet-sodbenzoate

1

SPINRAZA 1 PA

TIS-U-SOL PENTALYTE 1

TRAVASOL 1 PA - Part B vs D Determination

tri femynor 1

tri-lo-mili 1

TROPHAMINE 10% IVSOLUTION


v-go 20 1

v-go 30 1

v-go 40 1

vgo 20 1

vgo 30 1


119



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

vgo 40 1

VISTOGARD 1

sterile water for irrigation 1

Ophthalmic Agents

Ophthalmic Agents, Otheratropine 1% eye drops 1

bacitracin-polymyxin 1

cyclopentolate hcl (0.5% eyedrops, 1% eye drops, 1% eyedrop, hcl 2% drops)

1

CYSTARAN 1 PA, QL (60 PER 28 OVER TIME)

EYLEA 2 MG/0.05 ML VIAL 1 PA

LACRISERT 1

neo-polycin 1

neomycin-bacitracin-polymyxin 1

neomycin-polymyxin-gramicidin 1

OXERVATE 1 PA, QL (56 PER 28 DAYS)

polycin 1

polymyxin b sul-trimethoprim 1

proparacaine 0.5% eye drops 1

RESTASIS 1

RESTASIS MULTIDOSE 1

RHOPRESSA 1 ST, QL (2.5 PER 25 DAYS)

XIIDRA 1 QL (60 PER 30 DAYS)

Ophthalmic Anti-allergy Agentsazelastine hcl 0.05% drops 1

BEPREVE 1

cromolyn 4% eye drops 1


120



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

epinastine hcl 1

olopatadine hcl (0.1% drops,0.2% drop)

1

Ophthalmic Anti-inflammatoriesALREX 1

BLEPHAMIDE 1

BLEPHAMIDE S.O.P. 1

bromfenac sodium 0.09% eyedrp

1

dexamethasone 0.1% eye drop 1

diclofenac 0.1% eye drops 1

DUREZOL 1

FLAREX 1

flurbiprofen sodium 1

FML FORTE 1

INVELTYS 1

ketorolac tromethamine (0.4%solution, 0.5% solution)

1

LOTEMAX 0.5% OPHTHALMICGEL


LOTEMAX 0.5% EYEOINTMENT


LOTEMAX SM 1 QL (20 PER 365 OVER TIME)

loteprednol etabonate 1

neo-polycin hc 1

neomycin-bacitracin-poly-hc 1

neomycin-polymyxin-dexameth(neomyc-polym-dexamet ointm,neomyc-polym-dexameth drop)

1

neomycin-poly-hc eye drops 1

PRED-G (1% DROPS, S.O.P.OINTMENT)

1


121



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

prednisolone ac 1% eye drop 1

prednisolone sod 1% eye drop 1

PROLENSA 1 QL (12 PER 365 OVER TIME)

sulfacetamide-prednisolone 1

TOBRADEX EYE OINTMENT 1

TOBRADEX ST 1

tobramycin-dexamethasone 1

TRIESENCE 1

ZYLET 1

Ophthalmic Antiglaucoma Agentsacetazolamide (125 mg tablet,250 mg tablet)

1

acetazolamide er 1

ALPHAGAN P 0.1% DROPS 1

apraclonidine hcl 1

AZOPT 1

betaxolol hcl 0.5% eye drop 1

BETIMOL 1

brimonidine tartrate (tartrate0.15% drp, 0.2% eye drop)

1

carteolol hcl 1

dorzolamide hcl 1

dorzolamide-timolol (2%-0.5%,eye drops)

1

IOPIDINE 1% EYE DROPS 1

levobunolol hcl 1

methazolamide (25 mg tablet, 50mg tablet)

1

PHOSPHOLINE IODIDE 1

pilocarpine hcl (1% drops, 2%drops, 4% drops)

1


122



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ROCKLATAN 1 QL (2.5 PER 25 DAYS)

SIMBRINZA 1

timolol maleate (0.25% gfs gel-solution, 0.25% gel-solution,maleate 0.25% eye drop, 0.5%eye drop, 0.5% gfs gel-solution,0.5% gel-solution, maleate 0.5%eye drops)

1

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost 0.03% eye drops 1 QL (5 PER 30 DAYS)

COMBIGAN 1

latanoprost 0.005% eye drops 1

LUMIGAN 0.01% EYE DROPS 1 QL (2.5 PER 25 DAYS)

VYZULTA 1 QL (5 PER 25 DAYS)

Otic Agents

acetic acid 2% ear solution 1

CIPRODEX 1

flac otic oil 1

fluocinolone acetonide oil 1

hydrocortisone-acetic acid 1

neomycin-polymyxin-hc ear susp 1

neomycin-polymyxin-hydrocort 1

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled CorticosteroidsASMANEX (110 MCG #7, 220MCG #14)


ASMANEX (TWISTHALER 110MCG #30, TWISTHALER 220MCG #60, TWISTHALER 220MCG #30, TWISTHALR 220MCG #120)



123



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ASMANEX HFA (HFA 100 MCGINHALER, HFA 200 MCGINHALER)


BREO ELLIPTA 1 QL (60 PER 30 DAYS)

budesonide (0.25 mg/2 ml susp,0.5 mg/2 ml susp, 1 mg/2 ml inhsusp)

1 PA - Part B vs D Determination,QL (120 PER 30 DAYS)

FLOVENT 250 MCG DISKUS 1 QL (240 PER 30 DAYS)

FLOVENT DISKUS (50 MCG,100 MCG)


FLOVENT HFA (HFA 110 MCGINHALER, HFA 220 MCGINHALER)


FLOVENT HFA 44 MCGINHALER

1 QL (21.2 PER 30 DAYS)

flunisolide 0.025% spray 1 QL (50 PER 30 DAYS)

fluticasone prop 50 mcg spray 1

mometasone furoate 50 mcgspry


NUCALA 100 MG VIAL 1 PA, QL (3 PER 28 DAYS)

QVAR REDIHALER 1 QL (21.2 PER 30 DAYS)

Antihistaminesazelastine hcl (0.1% (137 mcg)spry, 0.15% nasal spray)


cetirizine hcl 1

cyproheptadine 4 mg tablet 1 PA

desloratadine 5 mg tablet 1

dexchlorpheniramine maleate(dexchlorphen 2 mg/5 ml syrup,dexchlorpheniramine 2 mg/5 ml)

1 PA

diphenhydramine hcl (50 mg/mlsyrng, 50 mg/ml vial, 50 mg/mlcrpjt)

1

DYMISTA 1 QL (23 PER 30 DAYS)


124



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

hydroxyzine hcl (hcl 10 mgtablet, 10 mg/5 ml syrup, 10mg/5 ml soln, 25 mg/ml vial, hcl25 mg tablet, 50 mg/ml vial, 50mg/25 ml syrup, hcl 50 mgtablet, 100 mg/2 ml vial, 500mg/10 ml vial)

1 PA

hydroxyzine pamoate (25 mgcap, 50 mg cap, 100 mg cap)

1 PA

levocetirizine 5 mg tablet 1

olopatadine 665 mcg nasal spry 1 QL (30.5 PER 30 DAYS)

Antileukotrienesmontelukast sodium (4 mggranules, 4 mg tab chew, 5 mgtab chew, 10 mg tablet)

1

zafirlukast 1

zileuton er 1 ST

ZYFLO 1 ST

Bronchodilators, AnticholinergicATROVENT HFA 1 QL (25.8 PER 30 DAYS)

COMBIVENT RESPIMAT 1 QL (8 PER 30 DAYS)

ipratropium br 0.02% soln 1 PA - Part B vs D Determination,QL (312.5 PER 30 DAYS)

ipratropium bromide (0.03%spray, 0.06% spray)

1

ipratropium-albuterol 1 PA - Part B vs D Determination,QL (540 PER 30 DAYS)

LONHALA MAGNAIR REFILL 1 QL (60 PER 30 DAYS)

SPIRIVA 1 QL (30 PER 30 DAYS)

SPIRIVA RESPIMAT 1 QL (8 PER 28 DAYS)

YUPELRI 1 PA - Part B vs D Determination,QL (90 PER 30 DAYS)


125



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Bronchodilators, Sympathomimeticalbuterol sulfate (15 mg/3 mlsolution, 20 mg/4 ml solution)


albuterol sulfate (2.5 mg/0.5 mlsol, 5 mg/ml solution)


albuterol sulfate (sulf 2 mg/5 mlsyrup, sulfate 2 mg tab, sulfate 4mg tab)

1

albuterol sul 2.5 mg/3 ml soln 1 PA - Part B vs D Determination,QL (525 PER 30 DAYS)

albuterol sulfate (0.63 mg/3 mlsol, 1.25 mg/3 ml sol)


epinephrine (0.15 mg auto-injct,0.3 mg auto-inject)

1 ST

EPIPEN 2-PAK 1

EPIPEN JR 2-PAK 1

isoproterenol hcl (0.2 mg/mlampul, 0.2 mg/ml vial, 1 mg/5 mlvial, 1 mg/5 ml ampul)

1

levalbuterol concentrate 1 PA - Part B vs D Determination,QL (90 PER 30 DAYS)

levalbuterol 1.25 mg/3 ml sol 1 PA - Part B vs D Determination,QL (270 PER 30 DAYS)

levalbuterol hcl (0.31 mg/3 mlsol, 0.63 mg/3 ml sol)


levalbuterol tartrate hfa 1 QL (30 PER 30 DAYS)

metaproterenol sulfate (10 mgtablet, 10 mg/5 ml syr, 20 mgtablet)

1

PERFOROMIST 1 PA - Part B vs D Determination,QL (120 PER 30 DAYS)

PROAIR DIGIHALER 1 QL (2 PER 30 DAYS)

PROAIR HFA 1 QL (17 PER 30 DAYS)

PROAIR RESPICLICK 1 QL (2 PER 30 DAYS)


126



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

SEREVENT DISKUS 1 QL (60 PER 30 DAYS)

terbutaline sulfate (sulf 1 mg/mlvial, sulfate 2.5 mg tab, sulfate 5mg tab)

1

Cystic Fibrosis AgentsBETHKIS 1 PA - Part B vs D Determination

CAYSTON 1 PA

KALYDECO (25 MGGRANULES PACKET, 50 MGGRANULES PACKET, 75 MGGRANULES PACKET, 150 MGTABLET)

1 PA

ORKAMBI (100-125 MGGRANULE PKT, 150-188 MGGRANULE PKT)


ORKAMBI (100 MG TABLET,200 MG TABLET)


PULMOZYME 1 PA

SYMDEKO 100/150 MG-150MG TABS


SYMDEKO 50/75 MG-75 MGTABLETS


TOBI PODHALER 1 QL (224 PER 56 OVER TIME)

tobramycin 300 mg/5 ml ampule 1 PA - Part B vs D Determination

Mast Cell Stabilizerscromolyn 20 mg/2 ml neb soln 1 PA - Part B vs D Determination

Phosphodiesterase Inhibitors, Airways Diseaseaminophylline (250 mg/10 ml vl,500 mg/20 ml vl)

1

DALIRESP 1 PA

theophylline (er 400 mg tablet, er600 mg tablet)

1

theophylline anhydrous (er 100mg tablet, er 200 mg tablet, er300 mg tab, er 450 mg tab)

1


127



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

theophylline 400 mg/500 ml d5w 1

Pulmonary AntihypertensivesADEMPAS 1 PA, QL (90 PER 30 DAYS)

alyq 1 PA, QL (60 PER 30 DAYS)

ambrisentan 1 PA, QL (30 PER 30 DAYS)

bosentan 1 PA, QL (60 PER 30 DAYS)

epoprostenol sodium 1 PA

LETAIRIS 1 PA, QL (30 PER 30 DAYS)

OPSUMIT 1 PA, QL (30 PER 30 DAYS)

ORENITRAM ER 1 PA

REMODULIN 1 PA

sildenafil 1 PA, QL (90 PER 30 DAYS)

sildenafil 20 mg tablet 1 PA, QL (90 PER 30 DAYS)

sildenafil citrate (10 mg/ml oralsusp, 10 mg/12.5 ml vial)

1 PA

tadalafil 20 mg tablet 1 PA, QL (60 PER 30 DAYS)

treprostinil 1 PA

UPTRAVI 200-800 TITRATIONPACK

1 PA, QL (400 PER 365 OVERTIME)

UPTRAVI (200 MCG TABLET,400 MCG TABLET, 600 MCGTABLET, 800 MCG TABLET,1,000 MCG TABLET, 1,200MCG TABLET, 1,400 MCGTABLET, 1,600 MCG TABLET)


VELETRI 1 PA

VENTAVIS 1 PA, QL (270 PER 30 DAYS)

Pulmonary Fibrosis AgentsESBRIET (267 MG TABLET,801 MG TABLET)

1 PA


128



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

Respiratory Tract Agents, Otheracetylcysteine (10% vial, 20%vial)


ADVAIR DISKUS 1 QL (60 PER 30 DAYS)

ADVAIR HFA 1 QL (24 PER 30 DAYS)

ANORO ELLIPTA 1 QL (60 PER 30 DAYS)

ARALAST NP 1 PA

DULERA (100 MCG INHALER,200 MCG INHALER)

1 QL (17.6 PER 30 DAYS)

DUPIXENT 200 MG/1.14 MLSYRING


ESBRIET 267 MG CAPSULE 1 PA

FASENRA 1 PA

FASENRA PEN 1 PA

fluticasone-salmeterol (100-50,250-50, 500-50)


GLASSIA 1 PA

NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/MLSYRINGE)


OFEV 1 PA

PROLASTIN C 1 PA

ribavirin 6 gm inhalation vial 1

STIOLTO RESPIMAT 1 QL (24 PER 30 DAYS)

SYMBICORT 160-4.5 MCGINHALER


SYMBICORT 80-4.5 MCGINHALER

1 QL (13.8 PER 30 DAYS)

TRELEGY ELLIPTA 1 QL (60 PER 30 DAYS)

wixela inhub 1 QL (60 PER 30 DAYS)

XOLAIR (75 MG/0.5 MLSYRINGE, 150 MG/MLSYRINGE, 150 MG VIAL)

1 PA


129



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

ZEMAIRA 1 PA

Skeletal Muscle Relaxants

carisoprodol (250 mg tablet, 350mg tablet)

1 PA

chlorzoxazone (250 mg tablet,500 mg tablet)

1 PA

cyclobenzaprine hcl (5 mg tablet,10 mg tablet)

1 PA

methocarbamol (500 mg tablet,750 mg tablet)

1 PA

succinylcholine 200 mg/10 ml 1

Sleep Disorder Agents

GABA Receptor Modulatorszaleplon 10 mg capsule 1 QL (60 PER 30 DAYS)

zaleplon 5 mg capsule 1 QL (30 PER 30 DAYS)

zolpidem tartrate (5 mg tablet,10 mg tablet)


zolpidem tartrate er 1 QL (30 PER 30 DAYS)

Sleep Disorders, OtherBELSOMRA 1 QL (30 PER 30 DAYS)

doxepin hcl (3 mg tablet, 6 mgtablet)


HETLIOZ 1 PA, QL (30 PER 30 DAYS)

modafinil 1 PA, QL (30 PER 30 DAYS)

pentobarbital sodium (1,000mg/20 ml, 2,500 mg/50 ml)


ramelteon 1 QL (30 PER 30 DAYS)

SILENOR 1 QL (30 PER 30 DAYS)

WAKIX 1 PA, QL (60 PER 30 DAYS)


130



NIVEL DEMEDICAMENTO

REQUISITOS/ LIMITES

XYREM 1 PA, QL (540 PER 30 DAYS)

Uncategorized

Unclassifiedsodium chloride 0.9% ampule 1


131

Lista en orden alfabético

Aabacavir 56abacavir-lamivudine 56abacavir-lamivudine-zidovudine 56ABELCET 34ABILIFY MAINTENA 52ABILIFY MYCITE 52abiraterone acetate 40ABRAXANE 42ABSTRAL 11acamprosate calcium 14acarbose 62acebutolol hcl 71acetaminophen-codeine 11acetazolamide 122acetazolamide er 122acetazolamide sodium 75acetic acid 94,123acetylcysteine 129acitretin 82ACTEMRA 114ACTEMRA ACTPEN 114ACTHAR 98ACTHIB 114ACTIMMUNE 114acyclovir 60acyclovir sodium 60ADACEL TDAP 114ADAGEN 92adapalene 82adapalene-benzoyl peroxide 82adefovir dipivoxil 58ADEMPAS 128adriamycin 42adrucil 41ADVAIR DISKUS 129ADVAIR HFA 129AFINITOR 45AFINITOR DISPERZ 45afirmelle 118

AIMOVIG AUTOINJECTOR 36,37AKYNZEO 32ala-cort 95albendazole 49albuterol sulfate 126alclometasone dipropionate 95ALDACTAZIDE 75ALDURAZYME 92ALECENSA 45alendronate sodium 117alfuzosin hcl er 94ALIMTA 41ALINIA 49ALIQOPA 45aliskiren 73allopurinol 36allopurinol sodium 36alosetron hcl 91ALPHAGAN P 122alprazolam 60alprazolam er 60alprazolam xr 60ALREX 121altavera 100ALUNBRIG 45,46alyacen 100alyq 128amabelz 100amantadine 59AMBISOME 34ambrisentan 128amcinonide 95amethia 100amethia lo 100amethyst 100amikacin sulfate 16amiloride hcl 75amiloride-hydrochlorothiazide 75aminocaproic acid 68aminophylline 127AMINOSYN II 118

132

AMINOSYN-PF 118amiodarone hcl 70AMITIZA 91amitriptyline hcl 31amlodipine besylate 72amlodipine besylate-benazepril 72amlodipine-atorvastatin 72amlodipine-valsartan 72ammonium lactate 82amnesteem 82amoxapine 32amoxicillin 20amoxicillin-clavulanate pot er 20amoxicillin-clavulanate potass 21amphotericin b 34ampicillin sodium 21ampicillin trihydrate 21ampicillin-sulbactam 21AMPYRA 80ANADROL-50 99anagrelide hcl 66anastrozole 45ANDRODERM 99ANORO ELLIPTA 129ANZEMET 33apexicon e 95APOKYN 50apraclonidine hcl 122aprepitant 33apri 100APRISO 116APTIOM 25APTIVUS 57ARALAST NP 129aranelle 100ARANESP 67ARCALYST 114argatroban 64argatroban-0.9% nacl 64argatroban-sodium chloride 64aripiprazole 52

aripiprazole odt 52ARISTADA 52ARISTADA INITIO 52ARRANON 41arsenic trioxide 42ashlyna 100ASMANEX 123ASMANEX HFA 124aspirin-dipyridamole er 68atazanavir sulfate 57atenolol 71atenolol-chlorthalidone 71ATGAM 112atomoxetine hcl 79atorvastatin calcium 76atovaquone 49atovaquone-proguanil hcl 49ATRIPLA 55atropine sulfate 73,120ATROVENT HFA 125AUBAGIO 80aubra 100aubra eq 100AUGMENTIN 21aurovela 118aurovela 24 fe 100aurovela fe 118AURYXIA 89AUSTEDO 79AVASTIN 47aviane 100AVITA 82AVONEX 80AVONEX PEN 80AVYCAZ 19azacitidine 42AZACTAM 20AZASAN 110azathioprine 110azathioprine sodium 110azelaic acid 82

133

azelastine hcl 120,124azithromycin 22AZOPT 122aztreonam 20azurette 100

Bbaciim 17bacitracin 17bacitracin-polymyxin 120baclofen 54BACTROBAN NASAL 17balsalazide disodium 116BALVERSA 45balziva 100BANZEL 28BARACLUDE 58BAVENCIO 48BAXDELA 23BCG (TICE STRAIN) 42BCG VACCINE (TICE STRAIN) 114bekyree 100BELEODAQ 42BELSOMRA 130benazepril hcl 69benazepril-hydrochlorothiazide 69BENDEKA 39BENLYSTA 110benznidazole 49benztropine mesylate 50BEPREVE 120BERINERT 109beser 95BESIVANCE 23BESPONSA 48betamethasone diprop augmented 95betamethasone dipropionate 95betamethasone sod phos-acetate 95betamethasone valerate 95BETASERON 80betaxolol hcl 71,122

bethanechol chloride 94BETHKIS 127BETIMOL 122bexarotene 48BEXSERO 114bicalutamide 40BICILLIN C-R 21BICILLIN L-A 21BICNU 39BIKTARVY 55bimatoprost 123bisoprolol fumarate 71bisoprolol-hydrochlorothiazide 71BIVIGAM 112bleomycin sulfate 42BLEPHAMIDE 121BLEPHAMIDE S.O.P. 121BLINCYTO 48blisovi 24 fe 100blisovi fe 100BOOSTRIX TDAP 115bortezomib 42bosentan 128BOSULIF 46BOTOX 54BRAFTOVI 42BREO ELLIPTA 124BREVIBLOC 71briellyn 100BRILINTA 68brimonidine tartrate 122BRIVIACT 25bromfenac sodium 121bromocriptine mesylate 50BRUKINSA 46budesonide 124budesonide ec 116budesonide er 116bumetanide 75buprenorphine hcl 15buprenorphine-naloxone 15

134

bupropion hcl 29bupropion hcl sr 15,29bupropion xl 29buspirone hcl 60busulfan 39butorphanol tartrate 11BYSTOLIC 71

Ccabergoline 107CABLIVI 68CABOMETYX 46caffeine citrate 80calcipotriene 82calcitonin-salmon 117calcitrene 82calcitriol 117calcium acetate 89calcium gluconate 85CALQUENCE 46camila 106camrese 100camrese lo 100candesartan cilexetil 69candesartan-hydrochlorothiazid 69CAPASTAT SULFATE 38CAPRELSA 46captopril 69captopril-hydrochlorothiazide 69CARBAGLU 85carbamazepine 28carbamazepine er 28carbidopa 51carbidopa-levodopa 51carbidopa-levodopa er 51carboplatin 39CARIMUNE NF NANOFILTERED 112carisoprodol 130carmustine 39carteolol hcl 122cartia xt 72

carvedilol 72carvedilol er 72caspofungin acetate 34CAYSTON 127caziant 100cefaclor 19cefaclor er 19cefadroxil 19cefazolin sodium 19cefazolin sodium-dextrose 19cefdinir 19cefepime hcl 19cefixime 19cefotaxime sodium 19cefotetan 19cefoxitin 19cefpodoxime proxetil 19cefprozil 19ceftazidime 19ceftriaxone 19cefuroxime 20cefuroxime sodium 20CELONTIN 25cephalexin 20CERDELGA 92CEREZYME 92cetirizine hcl 124CHANTIX 15chateal 100chateal eq 118CHENODAL 90chloramphenicol sod succinate 17chlordiazepoxide hcl 61chlordiazepoxide-amitriptyline 32chlorhexidine gluconate 81chloroprocaine hcl 14chloroquine phosphate 49chlorothiazide 76chlorothiazide sodium 76chlorpromazine hcl 51chlorthalidone 76

135

chlorzoxazone 130CHOLBAM 90cholestyramine 77cholestyramine light 77chorionic gonadotropin 98ciclodan 34ciclopirox 34cidofovir 58cilostazol 68CIMDUO 56cimetidine 90CIMZIA 110cinacalcet hcl 117CINRYZE 118CINVANTI 33CIPRODEX 123ciprofloxacin 23ciprofloxacin er 23ciprofloxacin hcl 23ciprofloxacin-d5w 23cisplatin 39citalopram hbr 30cladribine 41claravis 82clarithromycin 22clarithromycin er 22CLENPIQ 91CLEOCIN 17CLIMARA PRO 100clindacin etz 17clindacin p 17clindamycin hcl 17clindamycin palmitate hcl 17clindamycin pediatric 17clindamycin phos-benzoyl perox 82clindamycin phos-tretinoin 82clindamycin phosphate 17clindamycin phosphate-d5w 17clindamycin-0.9% nacl 17clindamycin-benzoyl peroxide 82CLINIMIX 85

CLINIMIX E 85clobazam 26clobetasol emollient 95clobetasol emulsion 95clobetasol propionate 95clocortolone pivalate 95clodan 95clofarabine 41clomipramine hcl 32clonazepam 26clonidine 68clonidine hcl 68,80clonidine hcl er 79clopidogrel 68clorazepate dipotassium 61clotrimazole 34clotrimazole-betamethasone 34clozapine 54clozapine odt 54COARTEM 49codeine sulfate 11colchicine 36colesevelam hcl 77colestipol hcl 77colistimethate 17colocort 116COMBIGAN 123COMBIVENT RESPIMAT 125COMETRIQ 46COMPLERA 55compro 32CONDYLOX 82constulose 91COPIKTRA 42CORLANOR 73,74CORTIFOAM 95cortisone acetate 95COSENTYX (2 SYRINGES) 82COSENTYX PEN 82COSENTYX PEN (2 PENS) 83COSENTYX SYRINGE 83

136

COTELLIC 42CREON 92CRESEMBA 34CRINONE 106CRIXIVAN 57cromolyn sodium 90,120,127crotan 50cryselle 100CUTAQUIG 113CUVITRU 113CUVPOSA 89cyclafem 101cyclobenzaprine hcl 130cyclopentolate hcl 120cyclophosphamide 39cycloserine 38CYCLOSET 62cyclosporine 110cyclosporine modified 110cyproheptadine hcl 124CYRAMZA 48cyred 101cyred eq 101CYSTAGON 92CYSTARAN 120cytarabine 41

Ddacarbazine 39dactinomycin 42dalfampridine er 80DALIRESP 127danazol 99dantrolene sodium 54dapsone 38,83DAPTACEL DTAP 115daptomycin 17DARAPRIM 49darifenacin er 94DARZALEX 48dasetta 101

daunorubicin hcl 42DAURISMO 42daysee 101deblitane 106decitabine 42deferasirox 88deferoxamine mesylate 118DELSTRIGO 55DELTASONE 95delyla 101demeclocycline hcl 24DEMSER 74DENAVIR 60DEPEN 88DEPO-MEDROL 96DEPO-PROVERA 106DEPO-SUBQ PROVERA 104 106DESCOVY 56desipramine hcl 32desloratadine 124desmopressin acetate 98desogestr-eth estrad eth estra 101desogestrel-ethinyl estradiol 101desonide 96desoximetasone 96desvenlafaxine succinate er 30dexamethasone 96dexamethasone intensol 96dexamethasone sodium phosphate 96,121dexchlorpheniramine maleate 124dexmedetomidine-0.9% nacl 60dexmethylphenidate hcl 79dexmethylphenidate hcl er 79dexrazoxane 42dextroamphetamine sulfate 78dextroamphetamine sulfate er 78dextroamphetamine-amphet er 78dextroamphetamine-amphetamine 78dextrose 10%-0.2% nacl 85dextrose 10%-0.45% nacl 85dextrose 2.5%-0.45% nacl 85

137

dextrose 5%-0.2% nacl 85dextrose 5%-0.2% nacl-kcl 85dextrose 5%-0.225% nacl 85dextrose 5%-0.225% nacl-kcl 85dextrose 5%-0.3% nacl 85dextrose 5%-0.3% nacl-kcl 85dextrose 5%-0.33% nacl 85dextrose 5%-0.33% nacl-kcl 85dextrose 5%-0.45% nacl 85dextrose 5%-0.45% nacl-kcl 85dextrose 5%-0.9% nacl 85dextrose 5%-1/2ns-kcl 86dextrose 5%-ns-kcl 86dextrose 5%-potassium chloride 86dextrose in lactated ringers 86dextrose in water 86DIASTAT 26DIASTAT ACUDIAL 26diazepam 26,61diclofenac potassium 9diclofenac sodium 9,83,121diclofenac sodium er 9dicloxacillin sodium 21dicyclomine hcl 89didanosine 56DIFICID 22diflorasone diacetate 96diflunisal 9digitek 74digox 74digoxin 74dihydroergotamine mesylate 36DILANTIN 28DILATRATE-SR 77dilt-xr 72diltiazem 12hr er 72diltiazem 24hr er 72diltiazem 24hr er (cd) 72diltiazem 24hr er (la) 73diltiazem 24hr er (xr) 73diltiazem hcl 73

diphenhydramine hcl 124diphenoxylate-atropine 90DIPHTHERIA-TETANUS TOXOIDS-PED 115disopyramide phosphate 70disulfiram 14DIURIL 76divalproex sodium 26divalproex sodium er 27dobutamine hcl 74dobutamine hcl in dextrose 74docetaxel 42dofetilide 70donepezil hcl 29donepezil hcl odt 29dopamine hcl 74dopamine hcl in 5% dextrose 74DORYX MPC 24dorzolamide hcl 122dorzolamide-timolol 122dotti 101DOVATO 55doxazosin mesylate 94doxepin hcl 32,83,130doxercalciferol 117doxorubicin hcl 42doxorubicin hcl liposome 42doxy 100 24doxycycline hyclate 24doxycycline ir-dr 83doxycycline monohydrate 24doxylamine succ-pyridoxine hcl 32DRIZALMA SPRINKLE 30dronabinol 33droperidol 32drospirenone-eth estra-levomef 101drospirenone-ethinyl estradiol 101DROXIA 41DULERA 129duloxetine hcl 30DUOBRII 83DUPIXENT 83,129

138

DURAMORPH 11DUREZOL 121dutasteride 94DYMISTA 124DYRENIUM 75

Eec-naproxen 9econazole nitrate 34EDURANT 55efavirenz 55ELAPRASE 92ELESTRIN 101eletriptan hbr 37elinest 101ELIQUIS 64,65ELLA 105ELMIRON 95EMBEDA 10EMCYT 40EMEND 33EMFLAZA 96EMGALITY PEN 37EMGALITY SYRINGE 37emoquette 101EMPLICITI 48EMSAM 30EMTRIVA 56enalapril maleate 70enalapril-hydrochlorothiazide 70ENBREL 110ENBREL MINI 110ENBREL SURECLICK 110ENDARI 118endocet 11ENGERIX-B ADULT 115ENGERIX-B PEDIATRIC-ADOLESCENT 115enoxaparin sodium 65enpresse 101enskyce 101entacapone 50

entecavir 58ENTRESTO 74ENTYVIO 114enulose 91EPANED 70EPCLUSA 58EPIDIOLEX 25epinastine hcl 121epinephrine 126EPIPEN 2-PAK 126EPIPEN JR 2-PAK 126epirubicin hcl 43epitol 28EPIVIR HBV 58eplerenone 75epoprostenol sodium 128eprosartan mesylate 69EQUETRO 61ERBITUX 48ergoloid mesylates 29ERGOMAR 36ergotamine-caffeine 36ERIVEDGE 46ERLEADA 40erlotinib hcl 46errin 106ertapenem 20ERWINAZE 43ery 22ERY-TAB 22ERYPED 400 22ERYTHROCIN LACTOBIONATE 22ERYTHROCIN STEARATE 22erythromycin 22erythromycin ethylsuccinate 22erythromycin-benzoyl peroxide 83ESBRIET 128,129escitalopram oxalate 30esmolol hcl 72esmolol hcl-sodium chloride 72esomeprazole magnesium 92

139

esomeprazole sodium 92estarylla 101estazolam 61estradiol 101estradiol valerate 101estradiol-norethindrone acetat 101ESTRING 101ethacrynic acid 75ethambutol hcl 38ethosuximide 25ethynodiol-ethinyl estradiol 101etodolac 9etoposide 45EUCRISA 83EURAX 50EVENITY (2 SYRINGES) 117everolimus 46EVOMELA 39EVOTAZ 57EXELDERM 34exemestane 45EXJADE 88EXONDYS-51 92EXTAVIA 80EYLEA 120ezetimibe 77ezetimibe-simvastatin 77

FFABRAZYME 93falmina 102famciclovir 60famotidine 90FANAPT 52FARYDAK 43FASENRA 129FASENRA PEN 129FASLODEX 40fayosim 102febuxostat 36felbamate 27

felodipine er 73femynor 102fenofibrate 76fenofibric acid 76fenoprofen calcium 9fentanyl 10fentanyl citrate 11,12FERRIPROX 88FETZIMA 30FINACEA 83finasteride 94FIRAZYR 110FIRDAPSE 118FIRMAGON 107flac otic oil 123FLAREX 121flavoxate hcl 94FLEBOGAMMA DIF 113flecainide acetate 70FLOVENT DISKUS 124FLOVENT HFA 124floxuridine 41fluconazole 34fluconazole in saline 35fluconazole-nacl 35flucytosine 35fludarabine phosphate 43fludrocortisone acetate 96flunisolide 124fluocinolone acetonide 96fluocinolone acetonide oil 123fluocinonide 96fluocinonide-e 96fluoride 86FLUORITAB 86fluorouracil 41fluoxetine dr 30fluoxetine hcl 31fluphenazine decanoate 51fluphenazine hcl 51flurandrenolide 96

140

flurbiprofen 9flurbiprofen sodium 121flutamide 40fluticasone propionate 97,124fluticasone-salmeterol 129fluvastatin er 76fluvastatin sodium 76fluvoxamine maleate 31FML FORTE 121FOLOTYN 41fondaparinux sodium 65FORTEO 117fosamprenavir calcium 57fosinopril sodium 70fosinopril-hydrochlorothiazide 70fosphenytoin sodium 28FRAGMIN 65FREAMINE HBC 118FREAMINE III 118frovatriptan succinate 37FULPHILA 67fulvestrant 40furosemide 75FUZEON 57fyavolv 102FYCOMPA 25

Ggabapentin 27GALAFOLD 93galantamine er 29galantamine hbr 29galantamine hydrobromide 29GAMASTAN 113GAMASTAN S-D 113GAMMAGARD LIQUID 113GAMMAGARD S-D 113GAMMAKED 113GAMMAPLEX 113GAMUNEX-C 113ganciclovir sodium 58

GARDASIL 9 115gatifloxacin 23GATTEX 90gavilyte-c 91gavilyte-g 91gavilyte-n 91GAZYVA 48gemcitabine hcl 41gemfibrozil 76generlac 91gengraf 110GENOTROPIN 98gentak 16gentamicin sulfate 16gentamicin sulfate in ns 16GENVOYA 55GEODON 53gianvi 102GILENYA 80GILOTRIF 46GLASSIA 129glatiramer acetate 80,81glatopa 81GLEOSTINE 39glimepiride 62glipizide 62glipizide er 62glipizide xl 62glipizide-metformin 62GLUCAGEN 63GLUCAGON EMERGENCY KIT 63glucose in water 86glyburide 62glyburide micronized 62glyburide-metformin hcl 62GLYCATE 89glycopyrrolate 90glydo 14GLYXAMBI 62GOCOVRI 50granisetron hcl 33

141

GRANIX 67griseofulvin 35griseofulvin ultramicrosize 35guanfacine hcl 68guanfacine hcl er 79guanidine hcl 38

HHAEGARDA 118hailey 24 fe 102HALAVEN 43halcinonide 97halobetasol propionate 97haloperidol 51haloperidol decanoate 52haloperidol decanoate 100 52haloperidol lactate 52HARVONI 58HAVRIX 115heather 106HEPAGAM B 113heparin sodium 66heparin sodium in 0.45% nacl 66heparin sodium-0.45% nacl 66heparin sodium-0.9% nacl 66heparin sodium-d5w 66HEPATAMINE 118HERCEPTIN 48HETLIOZ 130HEXALEN 39HIBERIX 115HUMALOG 63HUMALOG JUNIOR KWIKPEN 63HUMALOG KWIKPEN U-100 64HUMALOG KWIKPEN U-200 64HUMALOG MIX 50-50 64HUMALOG MIX 50-50 KWIKPEN 64HUMALOG MIX 75-25 64HUMALOG MIX 75-25 KWIKPEN 64HUMIRA 110HUMIRA PEDIATRIC CROHN'S 110

HUMIRA PEN 110HUMIRA PEN CROHN'S-UC-HS 110HUMIRA PEN PSOR-UVEITS-ADOL HS 110HUMIRA(CF) 111HUMIRA(CF) PEDIATRIC CROHN'S 111HUMIRA(CF) PEN 111HUMIRA(CF) PEN CROHN'S-UC-HS 111HUMIRA(CF) PEN PSOR-UV-ADOL HS 111HUMULIN R U-500 64HUMULIN R U-500 KWIKPEN 64hydralazine hcl 77hydrochlorothiazide 76hydrocodone-acetaminophen 12hydrocortisone 97,117hydrocortisone butyrate 97hydrocortisone valerate 97hydrocortisone-acetic acid 123hydrocortisone-pramoxine 83hydromorphone er 10hydromorphone hcl 12hydroxychloroquine sulfate 49hydroxyprogesterone caproate 106hydroxyurea 41hydroxyzine hcl 125hydroxyzine pamoate 125HYPERHEP B S-D 113HYPERRAB 113HYPERRHO S-D 113

Iibandronate sodium 117IBRANCE 43ibu 9ibuprofen 9ibutilide fumarate 70icatibant 110ICLUSIG 46idarubicin hcl 43IDHIFA 46ifosfamide 39ILARIS 114

142

ILUMYA 83imatinib mesylate 46IMBRUVICA 46IMFINZI 48imipenem-cilastatin sodium 20imipramine hcl 32imiquimod 83IMOVAX RABIES VACCINE 115IMPAVIDO 17INBRIJA 50incassia 106INCRELEX 99indapamide 76indomethacin 9INFANRIX DTAP 115INFLECTRA 111INFUGEM 41INFUMORPH 10INGREZZA 80INGREZZA INITIATION PACK 80INLYTA 46INREBIC 43insulin lispro 64insulin lispro kwikpen u-100 64insulin pen needles 118insulin syringe 118INTELENCE 55INTRALIPID 118INTRON A 58introvale 102INVEGA SUSTENNA 53INVEGA TRINZA 53INVELTYS 121INVIRASE 57INVOKAMET 62INVOKAMET XR 62INVOKANA 62IONOSOL MB-DEXTROSE 5% 86IOPIDINE 122IPOL 115ipratropium bromide 125

ipratropium-albuterol 125irbesartan 69irbesartan-hydrochlorothiazide 69IRESSA 46irinotecan hcl 45ISENTRESS 55,57ISENTRESS HD 57isibloom 102ISOLYTE P WITH DEXTROSE 86ISOLYTE S 86isoniazid 38isoproterenol hcl 126ISORDIL 77isosorbide dinitrate 77isosorbide dinitrate er 78isosorbide mononitrate 78isosorbide mononitrate er 78isotretinoin 83ISTODAX 43itraconazole 35ivermectin 49,83IXEMPRA 43IXIARO 115

JJADENU 88JADENU SPRINKLE 88JAKAFI 46jantoven 66JANUMET 62JANUMET XR 62JANUVIA 62JARDIANCE 62jasmiel 102jencycla 106JENTADUETO 62JENTADUETO XR 62JEVTANA 43jinteli 102jolessa 102jolivette 106

143

JUBLIA 35juleber 102JULUCA 55junel 102junel fe 102junel fe 24 102JUXTAPID 77JYNARQUE 88

KKADCYLA 48kaitlib fe 102KALBITOR 118KALETRA 57KALYDECO 127KANUMA 93kariva 102kelnor 1-35 102kelnor 1-50 102KENALOG-10 97ketoconazole 35ketodan 35ketoprofen 9ketorolac tromethamine 9,121KEVEYIS 118KEVZARA 114KEYTRUDA 48KHAPZORY 49kimidess 102KINERET 111KINRIX 115kionex 89KISQALI 43KISQALI FEMARA CO-PACK 39klofensaid ii 83klor-con 86KLOR-CON 10 86KLOR-CON 8 86klor-con m10 86KLOR-CON M15 86klor-con m20 86

klor-con sprinkle 86KORLYM 99KRISTALOSE 91KRYSTEXXA 36kurvelo 102KUVAN 93KYNAMRO 77KYPROLIS 45

Llabetalol hcl 72LACRISERT 120lactated ringers 86,118lactulose 91lamivudine 56,58lamivudine hbv 58lamivudine-zidovudine 56lamotrigine 27lamotrigine (blue) 27lamotrigine (green) 27lamotrigine (orange) 28LANOXIN 74lansoprazole 92lanthanum carbonate 89LANTUS 64LANTUS SOLOSTAR 64larin 102larin 24 fe 102larin fe 102larissia 102LARTRUVO 48latanoprost 123LATUDA 53LAYOLIS FE 102LAZANDA 12ledipasvir-sofosbuvir 59leena 102leflunomide 114LEMTRADA 114LENVIMA 46lessina 102

144

LETAIRIS 128letrozole 45leucovorin calcium 43LEUKERAN 39LEUKINE 67leuprolide acetate 108levalbuterol concentrate 126levalbuterol hcl 126levalbuterol tartrate hfa 126LEVEMIR 64LEVEMIR FLEXTOUCH 64levetiracetam 25levetiracetam er 25levetiracetam-nacl 25levobunolol hcl 122levocarnitine 118levocetirizine dihydrochloride 125levofloxacin 23levofloxacin-d5w 23levoleucovorin calcium 43levonest 103levonorg-eth estrad eth estrad 103levonorgestrel-eth estradiol 103levora-28 103levorphanol tartrate 10levothyroxine sodium 107LEVOXYL 107LEXETTE 97LEXIVA 57lidocaine 14lidocaine hcl 14,70lidocaine hcl viscous 82lidocaine-prilocaine 14lillow 118lindane 50linezolid 17linezolid-d5w 17LINZESS 91LIORESAL INTRATHECAL 54liothyronine sodium 107liprozonepak 14

lisinopril 70lisinopril-hydrochlorothiazide 70lithium 61lithium carbonate 61lithium carbonate er 62LIVALO 76LO LOESTRIN FE 103lo-zumandimine 119LONHALA MAGNAIR REFILL 125LONSURF 41loperamide 90lopinavir-ritonavir 57lopreeza 103lorazepam 61lorazepam intensol 61LORBRENA 43lorcet 12lorcet hd 12lorcet plus 12loryna 103losartan potassium 69losartan-hydrochlorothiazide 69LOTEMAX 121LOTEMAX SM 121loteprednol etabonate 121lovastatin 76low-ogestrel 103loxapine 52LUCEMYRA 15ludent fluoride 86LUMIGAN 123LUMIZYME 93LUPANETA PACK 108LUPRON DEPOT 108LUPRON DEPOT (LUPANETA) 108LUPRON DEPOT-PED 108lutera 103LYNPARZA 43LYRICA 26LYSODREN 107lyza 106

145

MM-M-R II VACCINE 115mafenide acetate 17magnesium sulfate 87magnesium sulfate-d5w 87MAKENA 105malathion 50mannitol 74maprotiline hcl 31marlissa 103MARPLAN 30MARQIBO 43MATULANE 39matzim la 73MAVENCLAD 81MAVYRET 59MAYZENT 81meclizine hcl 32meclofenamate sodium 9medolor pak 14medroxyprogesterone acetate 106mefenamic acid 10mefloquine hcl 49megestrol acetate 106MEKINIST 47MEKTOVI 43melodetta 24 fe 103meloxicam 10melphalan hcl 39memantine hcl 29memantine hcl er 29MENACTRA 115MENEST 103MENVEO A-C-Y-W-135-DIP 115meprobamate 60mercaptopurine 41meropenem 20meropenem-0.9% nacl 20mesalamine 116mesalamine er 116

mesna 49MESNEX 49MESTINON 38metadate er 79metaproterenol sulfate 126metformin hcl 62metformin hcl er 62methadone hcl 10methadone intensol 10METHADOSE 10methazolamide 122methenamine hippurate 18methergine 119methimazole 109methocarbamol 130methotrexate 111methotrexate sodium 111methoxsalen 83methscopolamine bromide 90methyclothiazide 76methyldopa 68methyldopa-hydrochlorothiazide 68methylergonovine maleate 119methylphenidate er 79methylphenidate er (la) 79methylphenidate hcl 79methylphenidate hcl cd 79methylphenidate hcl er (cd) 79methylphenidate la 79methylprednisolone 97methylprednisolone acetate 97methylprednisolone sodium succ 97metoclopramide hcl 90metolazone 76metoprolol succinate 72metoprolol tartrate 72metoprolol-hydrochlorothiazide 72METRO IV 18metronidazole 18,83mexiletine hcl 71MIACALCIN 117

146

mibelas 24 fe 103miconazole 3 35MICRHOGAM ULTRA-FILTERED PLUS 113microgestin 103microgestin fe 103midazolam hcl 61midodrine hcl 68mifepristone 97migergot 36miglustat 93mili 103millipred 97milrinone in 5% dextrose 74milrinone lactate 74mimvey 103mimvey lo 103minitran 78minocycline hcl 24minoxidil 77mirtazapine 29MIRVASO 83misoprostol 92mitigo 11mitomycin 43mitoxantrone hcl 44modafinil 130moexipril hcl 70moexipril-hydrochlorothiazide 70molindone hcl 52mometasone furoate 97,124mondoxyne nl 24mono-linyah 103mononessa 103montelukast sodium 125morgidox 24morphine sulfate 13morphine sulfate er 11moxifloxacin 23moxifloxacin hcl 23MOZOBIL 67MULPLETA 67

mupirocin 18MUTAMYCIN 44MYALEPT 119mycophenolate mofetil 111mycophenolic acid 111MYLOTARG 48myorisan 83MYRBETRIQ 94

NNABI-HB 113nabumetone 10nadolol 72nafcillin 21nafcillin sodium 21naftifine hcl 35NAGLAZYME 93nalbuphine hcl 13naloxone hcl 15naltrexone hcl 15naproxen 10naproxen sodium 10naproxen sodium ds 10naratriptan hcl 37NARCAN 15NATACYN 35nateglinide 63NATPARA 117NAYZILAM 25NEBUPENT 49necon 103nefazodone hcl 31neo-polycin 120neo-polycin hc 121neomycin sulfate 16neomycin-bacitracin-poly-hc 121neomycin-bacitracin-polymyxin 120neomycin-polymyxin b 16neomycin-polymyxin-dexameth 121neomycin-polymyxin-gramicidin 120neomycin-polymyxin-hc 121,123

147

neomycin-polymyxin-hydrocort 123NEPHRAMINE 119NERLYNX 44neuac 83NEULASTA 67NEUPOGEN 67NEUPRO 50nevirapine 55nevirapine er 55NEXAVAR 47niacin 77niacin er 77niacor 77nicardipine hcl 73NICOTROL 15NICOTROL NS 15nifedipine er 73nikki 103nilutamide 40nimodipine 73NINLARO 44NIPENT 41nisoldipine 73NITRO-BID 78NITRO-DUR 78nitrofurantoin 18nitrofurantoin mono-macro 18nitroglycerin 78nitroglycerin in d5w 78nitroglycerin patch 78NITYR 93NIVESTYM 67nizatidine 91nolix 97nora-be 106norepinephrine bitartrate 74norethin-eth estra-ferrous fum 103norethindron-ethinyl estradiol 103norethindrone 106norethindrone ac (lupaneta) 106norethindrone acetate 106

norgestimate-ethinyl estradiol 104norlyda 104norlyroc 106NORMOSOL-M AND DEXTROSE 87NORMOSOL-R AND DEXTROSE 87NORMOSOL-R PH 7.4 87NORPACE CR 71NORTHERA 74nortrel 104nortriptyline hcl 32NORVIR 57NOVAREL 99NOXAFIL 35NPLATE 67NUBEQA 40NUCALA 124,129NUEDEXTA 80NULOJIX 111NUPLAZID 53NUTRILIPID 119NUTROPIN AQ NUSPIN 99NUZYRA 24nyamyc 35NYMALIZE 73nystatin 35nystatin-triamcinolone 35nystop 35

OOCALIVA 90ocella 104OCREVUS 81OCTAGAM 113octreotide acetate 108ODEFSEY 55ODOMZO 47OFEV 129ofloxacin 23ogestrel 104okebo 24olanzapine 53

148

olanzapine odt 53olmesartan medoxomil 69olmesartan-hydrochlorothiazide 69olopatadine hcl 121,125OLUMIANT 114omega-3 acid ethyl esters 77omeprazole 92omeprazole-sodium bicarbonate 92ONCASPAR 44ondansetron hcl 33,34ondansetron odt 34ONIVYDE 45ONPATTRO 93OPDIVO 48opium tincture 90OPSUMIT 128oralone 82ORENCIA 111ORENCIA CLICKJECT 111ORENITRAM ER 128ORFADIN 93ORILISSA 108,109ORKAMBI 127orsythia 104oseltamivir phosphate 59OSMITROL 74OSPHENA 107OTEZLA 114oxaliplatin 39oxandrolone 99oxaprozin 10OXAYDO 13OXBRYTA 67oxcarbazepine 28OXERVATE 120oxiconazole nitrate 35OXISTAT 35oxybutynin chloride 94oxybutynin chloride er 94oxycodone hcl 13oxycodone hcl-aspirin 13

oxycodone hcl-ibuprofen 13oxycodone-acetaminophen 13oxymorphone hcl er 11OZEMPIC 63

Ppacerone 71paclitaxel 44paliperidone er 53palonosetron hcl 34pamidronate disodium 117PANDEL 97PANRETIN 48pantoprazole sodium 92PANZYGA 113paricalcitol 117paroex 82paromomycin sulfate 16paroxetine cr 31paroxetine er 31paroxetine hcl 31paroxetine mesylate 31PASER 38PAXIL 31PEDIARIX 115PEDVAXHIB 115peg 3350-electrolyte 91peg-3350 and electrolytes 91PEGANONE 28PEGASYS 59PEGASYS PROCLICK 59PEGINTRON 59penicillin g potassium 21penicillin g sodium 21penicillin gk-iso-osm dextrose 21penicillin v potassium 21PENTACEL 115PENTAM 300 49pentamidine isethionate 49pentobarbital sodium 130pentoxifylline 74

149

PERFOROMIST 126perindopril erbumine 70periogard 82PERJETA 48permethrin 50perphenazine 52perphenazine-amitriptyline 32PERSERIS 53phenadoz 32phenelzine sulfate 30phenobarbital 25,27phenobarbital sodium 27phenoxybenzamine hcl 69phenylephrine hcl 69phenytoin 28phenytoin sodium extended 28philith 104PHOSPHOLINE IODIDE 122PHYSIOLYTE 119PHYSIOSOL 119PICATO 83PIFELTRO 55pilocarpine hcl 82,122pimecrolimus 83pimozide 52pimtrea 104pindolol 72pioglitazone hcl 63pioglitazone-glimepiride 63pioglitazone-metformin 63piperacillin-tazobactam 22PIQRAY 44pirmella 104piroxicam 10PLASMA-LYTE 148 87PLASMA-LYTE A PH 7.4 87PLEGRIDY 81PLEGRIDY PEN 81podofilox 84polocaine 14polocaine-mpf 14

polycin 120polyethylene glycol 3350 91polymyxin b sul-trimethoprim 120polymyxin b sulfate 18POMALYST 40portia 104PORTRAZZA 48posaconazole 36potassium chl-normal saline 87potassium chloride 87potassium chloride in d5lr 87potassium chloride proamp 87potassium chloride-nacl 87potassium citrate er 87PRADAXA 66pramipexole dihydrochloride 50prasugrel hcl 68pravastatin sodium 76praziquantel 49prazosin hcl 69PRED-G 121prednicarbate 97prednisolone 97prednisolone acetate 122prednisolone sodium phosphate 97,122prednisone 98prednisone intensol 98pregabalin 26PREGNYL 99PREMARIN 104PREMASOL 119PREMPHASE 104PREMPRO 104prenatal vitamins 89prevalite 77previfem 104PREVYMIS 58PREZCOBIX 57PREZISTA 57PRIFTIN 38prilovix lite plus 14

150

primaquine 50primidone 27PRIVIGEN 113PROAIR DIGIHALER 126PROAIR HFA 126PROAIR RESPICLICK 126probenecid 36probenecid-colchicine 36procainamide hcl 71PROCALAMINE 87prochlorperazine 33prochlorperazine edisylate 33prochlorperazine maleate 33procto-med hc 15procto-pak 15proctosol-hc 16proctozone-hc 16PROCYSBI 93progesterone 106PROGLYCEM 63PROGRAF 111PROLASTIN C 129PROLENSA 122PROLEUKIN 44PROLIA 117PROMACTA 67promethazine hcl 33promethegan 33propafenone hcl 71propafenone hcl er 71proparacaine hcl 120propranolol hcl 72propranolol hcl er 72propranolol-hydrochlorothiazid 72propylthiouracil 109PROQUAD 115PROSOL 119protriptyline hcl 32PULMOZYME 127PURIXAN 42pyrazinamide 38

pyridostigmine bromide 38pyridostigmine bromide er 38

QQUADRACEL DTAP-IPV 115quetiapine fumarate 53quetiapine fumarate er 53quinapril hcl 70quinapril-hydrochlorothiazide 70quinidine gluconate 71quinidine sulfate 71quinine sulfate 50QVAR REDIHALER 124

RRABAVERT 115rabeprazole sodium 92RADICAVA 80raloxifene hcl 107ramelteon 130ramipril 70ranitidine hcl 91ranolazine er 74RAPAFLO 94rasagiline mesylate 51RASUVO 111,112RAVICTI 93RAYALDEE 89RAYOS 98REBIF 81REBIF REBIDOSE 81reclipsen 104RECOMBIVAX HB 115RECTIV 84REGONOL 38RELENZA 59relexxii 79RELISTOR 90REMICADE 112REMODULIN 128RENFLEXIS 112

151

repaglinide 63repaglinide-metformin hcl 63REPATHA PUSHTRONEX 74REPATHA SURECLICK 74REPATHA SYRINGE 74RESCRIPTOR 55RESTASIS 120RESTASIS MULTIDOSE 120RETACRIT 68RETROVIR 56REVCOVI 93REVLIMID 40REXULTI 53REYATAZ 57RHOGAM ULTRA-FILTERED PLUS 113RHOPHYLAC 113RHOPRESSA 120ribasphere 59RIBASPHERE RIBAPAK 59ribavirin 59,129RIDAURA 114rifabutin 38rifampin 38RIFATER 38riluzole 80rimantadine hcl 59ringers injection 87ringers irrigation 119RINVOQ ER 114RIOMET 63RISPERDAL CONSTA 53risperidone 53risperidone odt 54ritonavir 58RITUXAN 48RITUXAN HYCELA 48rivastigmine 29rivelsa 104rizatriptan 37ROCKLATAN 123romidepsin 44

ropinirole hcl 51rosadan 84rosuvastatin calcium 76ROTARIX 116ROTATEQ 116roweepra 25roweepra xr 25ROXYBOND 13ROZLYTREK 44RUBRACA 47RUCONEST 110RUZURGI 119RYDAPT 44RYTARY 51

SSANCUSO 34SANDIMMUNE 112SANDOSTATIN LAR DEPOT 109SANTYL 84SAPHRIS 54SAVELLA 80scopolamine 33selegiline hcl 51selenium sulfide 84SELZENTRY 57SEREVENT DISKUS 127SEROSTIM 99sertraline hcl 31setlakin 104sevelamer carbonate 89sevelamer hcl 89sharobel 107SHINGRIX 116SIGNIFOR 109SIGNIFOR LAR 109SIKLOS 42sildenafil 128sildenafil citrate 128SILENOR 130SILIQ 84

152

silodosin 94silver sulfadiazine 18SIMBRINZA 123simliya 119simpesse 119SIMPONI ARIA 114simvastatin 76sirolimus 112SIRTURO 38SIVEXTRO 18SKYRIZI (2 SYRINGES) KIT 112sodium acetate 87sodium chloride 88,119,131sodium fluoride 88sodium lactate 88sodium phenylacet-sod benzoate 119sodium phenylbutyrate 93sodium polystyrene sulfonate 89sofosbuvir-velpatasvir 59solifenacin succinate 94SOLIRIS 68soloxide 24SOLTAMOX 40SOLU-CORTEF 98SOLU-MEDROL 98SOMATULINE DEPOT 109SOMAVERT 109sorine 71sotalol 71sotalol af 71SPINRAZA 119SPIRIVA 125SPIRIVA RESPIMAT 125spironolactone 75spironolactone-hctz 75sprintec 104SPRITAM 25SPRIX 10SPRYCEL 47SPS 89sronyx 104

SSD 18stavudine 56STELARA 84STIMATE 99STIOLTO RESPIMAT 129STIVARGA 47STRENSIQ 93streptomycin sulfate 16STRIBILD 55subvenite 28subvenite (blue) 28subvenite (green) 28subvenite (orange) 28succinylcholine chloride 130sucralfate 92sulfacetamide sodium 23sulfacetamide-prednisolone 122sulfadiazine 23sulfamethoxazole-trimethoprim 23sulfasalazine 117sulfasalazine dr 117SULFATRIM 23sulindac 10sumatriptan 37sumatriptan succ-naproxen sod 37sumatriptan succinate 37SUPPRELIN LA 109SUPRAX 20SUPREP 91SUSTIVA 55SUTENT 47syeda 104SYLATRON 44SYLATRON 4-PACK 44SYLVANT 114SYMBICORT 129SYMDEKO 127SYMFI 55SYMFI LO 56SYMLINPEN 120 63SYMLINPEN 60 63

153

SYMPAZAN 27SYMTUZA 58SYNAGIS 114SYNAREL 109SYNDROS 34SYNERCID 18SYNJARDY 63SYNJARDY XR 63SYNRIBO 44

TTABLOID 42tacrolimus 84,112tadalafil 128TAFINLAR 47TAGRISSO 47TAKHZYRO 74TALTZ AUTOINJECTOR 84TALTZ AUTOINJECTOR (2 PACK) 84TALTZ AUTOINJECTOR (3 PACK) 84TALTZ SYRINGE 84TALTZ SYRINGE (2 PACK) 84TALZENNA 44tamoxifen citrate 40tamsulosin hcl 94TARGRETIN 49tarina 24 fe 104tarina fe 104tarina fe 1-20 eq 104TASIGNA 47TAVALISSE 68tazarotene 84tazicef 20taztia xt 73TDVAX 116TECENTRIQ 48TECFIDERA 81TEFLARO 20TEGSEDI 93telmisartan 69telmisartan-hydrochlorothiazid 69

temazepam 61TEMODAR 40temsirolimus 47TENIVAC 116tenofovir disoproxil fumarate 56terazosin hcl 94terbinafine hcl 36terbutaline sulfate 127terconazole 36testosterone 99testosterone cypionate 99testosterone enanthate 100tetrabenazine 80tetracycline hcl 24THALOMID 40theophylline 127theophylline anhydrous 127theophylline in 5% dextrose 128THIOLA EC 95thioridazine hcl 52thiotepa 40thiothixene 52tiadylt er 74tiagabine hcl 27TIBSOVO 47tigecycline 18TIGLUTIK 80tilia fe 104timolol maleate 37,123tinidazole 50TIROSINT 107TIS-U-SOL PENTALYTE 119TIVICAY 55tizanidine hcl 54TOBI PODHALER 127TOBRADEX 122TOBRADEX ST 122tobramycin 16,127tobramycin sulfate 16tobramycin-dexamethasone 122TOBREX 16

154

tolazamide 63tolbutamide 63tolcapone 50tolmetin sodium 10TOLSURA 36tolterodine tartrate 94tolterodine tartrate er 94topiramate 28toposar 45topotecan hcl 45toremifene citrate 40TORISEL 47torsemide 75TOSYMRA 37TOUJEO MAX SOLOSTAR 64TOUJEO SOLOSTAR 64tovet emollient 98TRADJENTA 63tramadol hcl 13tramadol hcl-acetaminophen 13trandolapril 70trandolapril-verapamil er 70tranexamic acid 68tranylcypromine sulfate 30TRAVASOL 119trazodone hcl 31TREANDA 40TRECATOR 39TRELEGY ELLIPTA 129TRELSTAR 109TREMFYA 84treprostinil 128TRESIBA 64TRESIBA FLEXTOUCH U-100 64TRESIBA FLEXTOUCH U-200 64tretinoin 49,84tretinoin microsphere 84TREXALL 112tri femynor 119tri-estarylla 104tri-legest fe 104

tri-linyah 105tri-lo-estarylla 105tri-lo-marzia 105tri-lo-mili 119tri-lo-sprintec 105tri-mili 105tri-previfem 105tri-sprintec 105tri-vylibra 105tri-vylibra lo 105triamcinolone acetonide 16,82,98triamterene 75triamterene-hydrochlorothiazid 75triderm 98trientine hcl 89TRIESENCE 122trifluoperazine hcl 52trifluridine 60trihexyphenidyl hcl 50triklo 77trilyte with flavor packets 91trimethoprim 18trimipramine maleate 32TRINTELLIX 31TRIPTODUR 109TRISENOX 44TRIUMEQ 55trivora-28 105TROGARZO 57TROPHAMINE 119trospium chloride 94trospium chloride er 94TRULICITY 63TRUMENBA 116TRUVADA 56tulana 107TURALIO 47TWINRIX 116TYBOST 57tydemy 105TYKERB 47

155

TYMLOS 118TYPHIM VI 116TYSABRI 81

UUDENYCA 67ULORIC 36ULTOMIRIS 68UNITHROID 107UNITUXIN 48UPTRAVI 128ursodiol 90UVADEX 84

Vv-go 20 119v-go 30 119v-go 40 119VABOMERE 20valacyclovir 60VALCHLOR 40valganciclovir hcl 58valproate sodium 27valproic acid 27valrubicin 44valsartan 69valsartan-hydrochlorothiazide 69VALSTAR 44vancomycin hcl 18vancomycin hcl-d5w 18VANDAZOLE 18VAQTA 116VARIVAX VACCINE 116VARIZIG 116VASCEPA 77VECTIBIX 48VELCADE 44VELETRI 128velivet 105VELPHORO 89VELTASSA 89

VEMLIDY 58VENCLEXTA 47VENCLEXTA STARTING PACK 47venlafaxine hcl 31venlafaxine hcl er 31VENTAVIS 128verapamil er 73verapamil er pm 73verapamil hcl 73verapamil sr 73VERSACLOZ 54VERZENIO 44vestura 105vgo 20 119vgo 30 119vgo 40 120VIBATIV 18VIBRAMYCIN 24vicodin 13vicodin es 14vicodin hp 14VICTOZA 2-PAK 63VICTOZA 3-PAK 63VIDEX 56VIDEX EC 56vienva 105vigabatrin 27VIIBRYD 31VIMIZIM 93VIMPAT 28vinblastine sulfate 44vincasar pfs 44vincristine sulfate 44vinorelbine tartrate 44viorele 105VIRACEPT 58VIRAMUNE 56VIREAD 56VISTOGARD 120VITRAKVI 44VIVITROL 15

156

VIZIMPRO 47voriconazole 36VOSEVI 59VOTRIENT 47VPRIV 93VRAYLAR 54VUMERITY 81vyfemla 105vylibra 105VYNDAMAX 75VYNDAQEL 75VYXEOS 42VYZULTA 123

WWAKIX 130warfarin sodium 66water 120wera 105wixela inhub 129wymzya fe 105

XXALKORI 47XARELTO 66XATMEP 112XELJANZ 114XELJANZ XR 114XEOMIN 54XERMELO 90XGEVA 118XIAFLEX 93XIFAXAN 18XIIDRA 120XOFLUZA 59XOLAIR 129XOSPATA 47XPOVIO 44XTAMPZA ER 11XTANDI 40xulane 105

XURIDEN 93XYREM 131

YYERVOY 48YF-VAX 116YONDELIS 40YONSA 40YUPELRI 125yuvafem 105

Zzafirlukast 125zaleplon 130ZALTRAP 45ZANOSAR 40zarah 105ZARXIO 68ZEJULA 47ZELBORAF 47ZEMAIRA 130zenatane 84ZENPEP 93zenzedi 78ZERIT 56ZEVALIN 48zidovudine 56ZIEXTENZO 68zileuton er 125ziprasidone hcl 54ZIRGAN 58ZOLADEX 109zoledronic acid 118ZOLINZA 45zolmitriptan 37zolpidem tartrate 130zolpidem tartrate er 130zonisamide 26ZORBTIVE 99ZORTRESS 112ZOSTAVAX 116

157

ZOSYN 22zovia 1-35e 105zumandimine 105ZYCLARA 84ZYDELIG 45ZYFLO 125ZYKADIA 45,47ZYLET 122ZYPREXA RELPREVV 54ZYTIGA 40

158

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Farmacopea Hamaspik Medicare Select 2020 · 2020. 4. 6. · Cambios que no lo afectarán si...

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Transcript of Farmacopea Hamaspik Medicare Select 2020 · 2020. 4. 6. · Cambios que no lo afectarán si...