Octubre de 2016 Blue Cross and Blue Shield of New Mexico (BCBSNM) Lista de medicamentos de Blue Cross Community CentennialSM

Los miembros de Blue Cross Community CentennialSM deben hablar con sus médicos sobre los medicamentos con receta médica que se incluyen en la Lista de medicamentos. La Lista de medicamentos se actualiza trimestralmente. Visite www. bcbsnm.com para conocer las actualizaciones recientes. Contenido Introducción .................................................... I Beneficios de las recetas médicas ................. I Sustitución genérica ...................................... II Cómo usar esta lista ..................................... III Autorización previa (Preauthorization, PA) ... IV Medicamentos de farmacias de especialidades (Specialty Pharmacy, SP) .. VI Terapia escalonada (Step Therapy, ST) ..... VIII Lista de medicamentos de venta libre (OTC) I .............................................. VIII Lista de medicamentos de venta libre (OTC) II ............................................. XIII Lista de medicamentos de venta libre (OTC) III ............................................ XV Lista de medicamentos de venta libre (OTC) IV .......................................... XVII Límites de despacho (Dispensing Limits, DL) ............................................... XXII Kits de rescate de naloxona .................. XXVIII Clave de abreviaturas/acrónimos ............ XXIX

Categorías farmacológicas y terapéuticas Medicamentos antiinfecciosos .................... 1 Medicamentos contra el cáncer ................. 7 Hormonas, diabetes y medicamentos relacionados ......................9 Medicamentos cardíacos y circulatorios ............................................. 16 Agentes respiratorios ................................ 26 Medicamentos gastrointestinales ............. 29 Medicamentos genitourinarios .................. 32 Medicamentos para el sistema nervioso central....................................... 34 Analgésicos .............................................. 45 Medicamentos neuromusculares .............. 51 Suplementos ............................................. 55 Medicamentos modificadores de la sangre ................................................. 58 Medicamentos tópicos .............................. 60 Categorías varias ..................................... 68 Índice ....................................................... 70

Para buscar un nombre de medicamento dentro del documento PDF, utilice las teclas Control y F en su teclado o vaya a Editar en el menú desplegable y seleccione Encontrar/Buscar. Escriba la palabra o frase que busca y haga clic en Buscar.

3497-F NM © Prime Therapeutics LLC 10/16

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Si tiene alguna pregunta con relación a la Lista de medicamentos de beneficios de las farmacias de BCBSNM o si tiene sugerencias que pueden mejorar la utilidad de esta publicación, envíelas a: Medicaid Pharmacy Programs Manager Blue Cross and Blue Shield of New Mexico P.O. Box 27630 Albuquerque, NM 87125-7630 Teléfono: 1.866.689.1523 Correo electrónico: Sitio web en www.bcbsnm.com TTY: 711

Introducción Blue Cross and Blue Shield of New Mexico (BCBSNM) presenta la Lista de medicamentos para los miembros de Blue Cross Community Centennial. La Lista de medicamentos incluye muchos medicamentos genéricos comunes y medicamentos de marca que cubre Blue Cross and Blue Shield of New Mexico. Lleve esta Lista de medicamentos con usted cuando visite a su médico. Pida a su médico que le escriba las recetas médicas para medicamentos genéricos o medicamentos de marca que se encuentran en la Lista de medicamentos, cuando sea posible. Los miembros de Blue Cross Community Centennial también tienen una lista selecta de productos de Venta libre (OTC) que están cubiertos con una receta médica del médico. Beneficios de las recetas médicas Tomando en cuenta las excepciones que se enumeran a continuación, todos los medicamentos genéricos están cubiertos para los asegurados de Blue Cross Community Centennial. La lista de medicamentos solo muestra los medicamentos genéricos de uso común. Los medicamentos de marca cubiertos están limitados a aquellos que se muestran en la Lista de medicamentos. No tienen cobertura los medicamentos para algunos usos (por ejemplo: para el crecimiento del cabello). Además, tampoco tienen cobertura los medicamentos que no han sido aprobados como eficaces por la Administración de Alimentos y Medicamentos (medicamentos DESI). Algunos ejemplos de medicamentos DESI incluyen: Midrin, Estratest y supositorios de hidrocortisona para hemorroides. Las combinaciones de los medicamentos para la tos y el resfriado están excluidas de la cobertura para los miembros de 4 años de edad o menores. Los medicamentos genéricos de venta libre están cubiertos para los asegurados de Blue Cross Community Centennial con una receta del médico. Los medicamentos de venta libre adicionales disponibles para los asegurados se incluyen en las listas de venta libre en las páginas VIII – XXVIII. Los medicamentos no incluidos aún pueden estar cubiertos, mediante autorización previa, para los asegurados que sean candidatos para su uso. Las recetas médicas que se surten en una farmacia minorista se limitan a un suministro de 30 días o 120 tabletas o cápsulas, lo que sea menor. Los miembros de Blue Cross Community Centennial que surtan un suministro de 30 días de un medicamento que toman regularmente (por ejemplo: para la presión arterial alta) pueden obtener un suministro de 90 días a través de nuestra farmacia de pedido por correo, PrimeMail. Si tiene un copago, ordenar su receta a una farmacia que envía pedidos por correo le puede ser más beneficioso, ya que solamente se le cobrarán dos copagos por un suministro de tres meses. Los miembros de Blue Cross Community Centennial que tienen cobertura doble bajo Medicare y Medicaid observarán que la mayoría de sus medicamentos estarán cubiertos por Medicare. Sin embargo, un número limitado de medicamentos estará cubierto bajo Blue Cross Community Centennial.

*Las farmacias de Indian Health Services pueden surtir un suministro de medicamentos de mantenimiento para 90 días para los miembros nativos americanos. Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

I

Sustitución genérica El beneficio de Blue Cross Community Centennial requiere que los medicamentos genéricos se sustituyan por medicamentos de marca, cuando sea posible. BCBSNM apoya esta regla debido a que los medicamentos genéricos están aprobados por la Administración de Medicamentos y Alimentos (Food and Drug Administration, FDA) y se producen bajo los mismos estándares estrictos de la FDA requeridos para los productos de marca. Un medicamento genérico es igual al medicamento de marca en lo siguiente: 

efectividad



seguridad



forma de dosis



concentración



calidad



la manera en la que funciona



la manera en que se debe usar

Es posible que los medicamentos genéricos no luzcan exactamente como el medicamento de marca. El color, sabor y forma de los medicamentos genéricos puede ser diferente, pero estas cosas no afectan la manera en la que funciona el medicamento. Los genéricos son igual de seguros y efectivos en comparación con los medicamentos de marca. Usualmente, los genéricos también son menos costosos. Si selecciona un medicamento de marca cuando existe un medicamento genérico disponible, es posible que deba hacer un copago. Este copago no aplicará a los medicamentos que tratan las condiciones de salud mental. El copago tampoco aplicará a los nativos estadounidenses.

II

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

Cómo usar esta lista Esta lista está organizada en amplias categorías terapéuticas. Por ejemplo, los Medicamentos contra la diabetes, hormonas y medicamentos relacionados es una amplia categoría. Dentro de la mayoría de las categorías, los medicamentos están subagrupados con base en la clase de medicamento, por ejemplo, bajo Medicamentos para la diabetes, hormonas y medicamentos relacionados, usted encontrará a los estrógenos. Todos los medicamentos que se indican, ya sea genéricos o de marca, son medicamentos preferidos.

La primera columna de la tabla muestra el nombre del medicamento. Los medicamentos genéricos se muestran en letra minúscula negrita. La mayoría de los medicamentos genéricos van seguidos de un medicamento de marca de referencia en (paréntesis). Algunos productos genéricos no tienen marca de referencia. Los medicamentos con receta de marca preferida se muestran en letras MAYÚSCULA seguidas por el nombre genérico. La segunda columna indica si el medicamento es un medicamento especializado. Nota: la información adicional sobre los medicamentos especializados se puede encontrar en este documento bajo el encabezado Medicamentos especializados. El resto de las columnas indican el programa de Administración de uso (UM) que aplica al medicamento con receta médica (por ejemplo, autorización previa, límites de suministro y terapia escalonada). Si un indicador se encuentra en la columna, entonces el programa de UM que se indica, posiblemente aplica a su beneficio. Algunos planes pueden tener UM en los medicamentos adicionales más allá de los que se indican en este documento.

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

III

Autorización previa (PA) Los siguientes productos requieren Autorización previa (PA). Por favor tenga en cuenta que todos los medicamentos especializados (página VI) también requieren de autorización previa. Para obtener las actualizaciones de los medicamentos que requieren PA, verifique su sitio web en www.bcbsnm.com. Para solicitar una PA, su médico deberá llamar al 1-855-457-0755. ABILIFY MAINTENA ABILIFY ORAL SOLUCIÓN adapalene crm, gel (Differin); para miembros mayores de 41 años de edad ADASUVE ALPRAZOLAM INTENSOL AMOXAPINE ANDRODERM APLENZIN APTIOM ARISTADA bupropion de liberación prolongada: 12 horas (Zyban) CHANTIX CHLORDIAZEPOXIDE/AMITRIPTYLENE CHLORPROMAZINE HCL iny CLOZAPINE ODT DARAPRIM DESVENLAFAXINE ER DESVENLAFAXINE FUMARATE ER diazepam concentr., tabletas DIAZEPAM inj, soln DORAL DOXEPIN HCL EMSAM Productos nutritivos enterales – OTC – para miembros hasta 21 años de edad EQUETRO FANAPT FAZACLO FETZIMA FLUOXETINE 60 mg FLUPHENAZINE conc, elixir, iny FORFIVO XL GEODON iny hydromorphone tabletas de liberación prolongada HYDROXYZINE HCL iny 25 mg/mL HYDROXYZINE PAMOATE 100 mg caps INVEGA INVEGA SUSTENNA itraconazole cápsulas (Sporanox) KHEDEZLA LAMICTAL tabletas masticables 2 mg

IV

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

LAMICTAL ODT LAMICTAL STARTER KIT LAMICTAL XR KIT LATUDA LITHIUM MAPROTILINE HCL MARPLAN NEFAZODONE HCL inhalador NICOTROL aerosol nasal NICOTROL NS NORTRIPTYLINE HCL oral soln NOXAFIL OLEPTRO OXTELLAR XR PAXIL oral susp PERPHENAZINE/AMITRIPTYLINE PEXEVA PRISTIQ prochlorperazine iny QUAZEPAM REXULTI RISPERDAL CONSTA SAPHRIS SEROQUEL XR sildenafil 20 mg (Revatio) STAVZOR SURMONTIL TAZORAC: para miembros mayores de 41 años de edad terbinafine tabletas (Lamisil) tretinoin (Retin-A): para miembros mayores de 41 años de edad VENLAFAXINE ext-release tabs 225 mg VERSACLOZ VIIBRYD/VIIBRYD STARTER KIT voriconazole (Vfend) ZYPREXA RELPREVV ZYVOX

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

V

Medicamentos de farmacias de especialidades (SP) Los medicamentos de farmacias especializadas se indican en la siguiente lista, la cual no es una lista que incluye todos los Medicamentos especializados y está sujeta a cambio sin previo aviso. Los medicamentos de Farmacia especializada requieren Autorización previa antes de que se pueda surtir la receta médica. Están limitados a un suministro de 30 días y debe surtirse en un proveedor de Farmacia de especialidades. Prime Specialty Pharmacy es el proveedor preferido de BCBSNM. Los medicamentos que se muestran en ROJO son medicamentos preferidos de farmacia especializada. TRASTORNOS INFLAMATORIOS AUTOINMUNES ACTEMRA** ARCALYST * BENLYSTA** CIMZIA COSENTYX ENBREL HUMIRA INFLECTRA ILARIS*(**) KINERET ORENCIA REMICADE** SIMPONI SIMPONI ARIA** STELARA XELJANZ MODIFICADORES HEMÁTICOS ARANESP EPOGEN IPRIVASK LEUKINE MOZOBIL** NEULASTA NEUMEGA NEUPOGEN NPLATE** PROCRIT PROMACTA*

VI

MEDICAMENTO INYECTABLE CONTRA EL CÁNCER ELIGARD FIRMAGON** SYLATRON TRELSTAR** TRELSTAR MIXJECT** ORAL CONTRA EL CÁNCER AFINITOR AFINITOR DISPERZ ALECENSA BOSULIF* CABOMETYX CAPRELSA* capecitabine COMETRIQ* COTELLIC ERIVEDGE* GILOTRIF* GLEEVEC HEXALEN HYCAMTIN* IBRANCE ICLUSIG* imatinib mesylate INLYTA* JAKAFI* LENVIMA LYNPARZA LYSODREN

MATULANE* MEKINIST* NEXAVAR NINLARO POMALYST* REVLIMID* SPRYCEL STIVARGA SUTENT TAFINLAR* TARCEVA TARGRETIN TARGRISSO TASIGNA TEMODAR temozolomide THALOMID tretinoin caps TYKERB* VENCLEXTA VOTRIENT* XALKORI* XELODA XTANDI* ZELBORAF ZOLINZA ZYTIGA FIBROSIS QUÍSTICA BETHKIS* CAYSTON* KALYDECO ORKAMBI

PULMOZYME TOBI TOBI PODHALER tobramycin solución para inhalación DEFICIENCIAS DE ENZIMAS ALDURAZYME** BUPHENYL CARBAGLU* CEREZYME** CINRYZE*(**) CYSTAGON* CYSTARAN* ELAPRASE** ELELYSO*(**) FABRAZYME** KUVAN* LUMIZYME** MYOZYME** NAGLAZYME*(**) ORFADIN* PROCYSBI* RAVICTI* sodium phenylbutyrate SOLIRIS*(**) SUCRAID* VPRIV** XURIDEN XENAZINE* ZAVESCA*

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

HORMONAS DEL CRECIMIENTO GENOTROPIN HUMATROPE INCRELEX* NORDITROPIN NUTROPIN NUTROPIN AQ OMNITROPE SAIZEN SEROSTIM* TEV-TROPIN ZORBTIVE HEMOFILIA‡ ADVATE ADYNOVATE ALPHANATE ALPHANINE SD ALPROLIX BEBULIN BEBULIN VH BENEFIX COAGADEX CORIFACT* FEIBA NF FEIBA VH HELIXATE FS HEMOFIL M HUMATE-P IDELVION IXINITY KOATE-DVI KOGENATE FS KOVALTRY MONOCLATE-P MONONINE NOVOSEVEN NOVOSEVEN RT NUWIQ PROFILNINE SD

RECOMBINATE RIXUBIS TRETTEN WILATE XYNTHA HEPATITIS C COPEGUS DAKLINZA HARVONI INFERGEN INTRON-A OLYSIO PEGASYS PEG-INTRON ribavirin SOVALDI ZEPATIER HIV EGRIFTA* FUZEON TRASTORNOS PULMONARES ACTIMMUNE* ARALAST NP** CINQAIR ESBRIET GLASSIA** OFEV PROLASTIN/C*(**) SYNAGIS** XOLAIR*(**) ZEMAIRA*(**) DEGENERACIÓN MACULAR EYLEA*(**) LUCENTIS*(**) MACUGEN*(**) VISUDYNE*(**)

ESCLEROSIS MÚLTIPLE AMPYRA AUBAGIO AVONEX BETASERON COPAXONE EXTAVIA GILENYA GLATOPA REBIF TECFIDERA TYSABRI*(**) HIPERTENSIÓN PULMONAR ADCIRCA ADEMPAS* epoprostenol sodium*(**) FLOLAN*(**) LETAIRIS* REMODULIN*(**) REVATIO sildenafil citrate TRACLEER* TYVASO* UPTRAVI VELETRI*(**) VENTAVIS* OTROS ALFERON N** APOKYN* BERINERT* CHENODAL* CUPRIMINE daraprim DEPEN TITRATABS EXJADE*

FERRIPROX* FIRAZYR FORTEO GATTEX* H.P. ACTHAR GEL* JETREA*(**) JUXTAPID* KALBITOR*(**) KANUMA KORLYM* KRYSTEXXA*(**) leuprolide acetate LUPRON DEPOT** LUPRON DEPOTPED** LUPANETA PACK NUCALA PRALUENT PROLIA REPATHA SABRIL SAMSCA SANDOSTATIN SANDOSTATIN LAR** SIGNIFOR SOMATULINE DEPOT** SOMAVERT* SYNAREL SPYRINE THROMBATE III** VALCHLOR* VICTRELIS VISTOGARD VIVITROL** XGEVA** XIAFLEX*(**) XYREM* zoledronic acid ZOMETA**

*Sujeto a canales exclusivos de distribución **Puede estar cubierto a través de beneficios médicos ‡

Se proporciona a través de Accredo 866.712.5007 o Prime Specialty Pharmacy 877.627.6337

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

VII

Terapia escalonada (ST) El programa de Terapia escalonada requiere usar un medicamento genérico primero cuando se empieza una nueva terapia de medicamentos. Los pacientes pueden recibir uno de los siguientes medicamentos de marca o un medicamento genérico alternativo si el genérico no proporciona los resultados esperados. BENICAR BENICAR HCT CELEBREX y celecoxib CRESTOR 40 mg VICTOZA

Lista de medicamentos de venta libre (OTC) I Los medicamentos de venta libre (OTC) en la Lista I están cubiertos para los asegurados de Blue Cross Community Centennial en el Plan estatal de Medicaid (menores de 21 años), el Plan de expansión estatal de Medicaid (menores de 21 años) y los asegurados del Plan de beneficios alternativos que tienen 19 y 20 años (EPSDT), solamente. La cobertura de OTC está limitada a los medicamentos específicos y es posible que apliquen límites de surtido. Los productos para problemas respiratorios (combinaciones de medicamentos para la tos y el resfriado) se excluyen de la cobertura para asegurados menores de 4 años. Los asegurados de Blue Cross Community Centennial que tienen una exención autodirigida o con base en la agencia de Medicaid pueden recibir artículos de venta libre de Boost y Ensure, cuando la receta está escrita por un médico, APLICAN LÍMITES DE CANTIDAD. Es importante que muestre esta lista de medicamentos de venta libre a su médico para que tenga conocimiento de qué medicamentos están disponibles para beneficio de medicamentos de venta libre. Los asegurados necesitan la receta de un médico para que un medicamento OTC tenga cobertura en la farmacia. El farmacéutico colaborará con su médico para escoger el paquete y la cantidad a usar cuando surta la receta del medicamento OTC. Blue Cross Community Centennial paga solo por los productos OTC genéricos cuando uno de marca está también disponible. Sin embargo, en las siguientes listas de OTC, puede que se enumere un medicamento común de marca para ayudar a los farmacéuticos a identificar el producto genérico correcto. Los siguientes medicamentos de venta libre están cubiertos en este programa. La Lista de medicamentos de venta libre indica los medicamentos que están disponibles como genéricos por su nombre genérico y en letra minúscula en negrita. Un medicamento de marca común se indica en paréntesis después del nombre genérico para muchos productos para ayudar a identificar el medicamento cubierto. Si un genérico está disponible, un genérico casi siempre se despachará en este programa. Los medicamentos que están disponibles únicamente como marcas se indican por el nombre de marca y se muestran en letra mayúscula.

VIII

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

Límites de suministro para 30 días* Sólidos orales (como cápsulas, tabletas) – 100

Ojos y oídos – 1 paquete

Productos nutritivos ENTERALES – necesita autorización previa

Condones – 12

Líquidos orales – 240 mL Productos disuasivos para el tabaquismo – necesita autorización previa**

Supositorios – 24 Soluciones orales de electrolitos – 2,000 mL Refuerzos y Ensure*** – 2 latas/día y 180 latas/año MÁXIMO***

Tópicos – cremas, ungüentos, lociones: 80 g o mL

*En algunos casos, solo se cubrirá 1 paquete por 30 días **Los productos disuasivos para el tabaquismo están limitados a 2 cursos de 90 días por año calendario *** Los miembros de Blue Cross Community Centennial que tienen una renuncia de responsabilidades según la agencia o auto dirigida pueden recibir artículos de Boost y Ensure de venta libre, cuando un médico emite una receta médica, aplican límites de cantidad. 1 lata = 237 mL. LISTA I DE PRODUCTOS OTC PARA ASEGURADOS DEL PLAN ESTATAL DE MEDICAID (menores de 21 años), PLAN DE EXPANSIÓN ESTATAL DE MEDICAID (menores de 21 años) Y ASEGURADOS DEL PLAN DE BENEFICIOS ALTERNO, SOLAMENTE LOS QUE TIENEN 19 O 20 AÑOS DE EDAD (EPSDT) Producto OTC Formas de dosis, concentraciónes 325 mg, 500 mg tabs, Analgésicos: acetaminophen (Tylenol) caps; 650 mg extReductores de la release tabs Fiebre 80 mg, 160 mg chew acetaminophen tabs 100 mg/mL, 160 mg/5 mL soln, drops 160 mg/5 mL elixir, acetaminophen (Tylenol) liquid, susp 80 mg/0.8 mL susp acetaminophen (Tylenol Infants) 120 mg, 325 mg, 650 acetaminophen mg supp 80 mg, 160 mg acetaminophen (Tylenol Children’s or Jr Meltaways) dispersible tab ACETAMINOPHEN 500 mg dispersible tabs 81 mg chew tabs aspirin (Bayer Chewable Low Dose, St Joseph Aspirin) Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

IX

aspirin aspirin buffered (Bufferin) aspirin enteric-coated (Ecotrin) aspirin enteric-coated (Bufferin Low Dose)

Infecciones Fúngicas: Vaginales

aspirin/acetaminophen/caffeine (Excedrin Migraine) ibuprofen (Advil, Motrin IB) ibuprofen (Advil Jr Strength, Children’s Motrin) ibuprofen (Children’s Motrin, Children’s Advil) ibuprofen (Motrin Infants, Infants Advil) naproxen sodium (Aleve) clotrimazole (Gyne-Lotrimin)

miconazole tioconazole (Vagistat-1) CONCEPTROL (nonoxynol-9) Anticonceptivos condoms, latex (lubricated, unlubricated) ENCARE (nonoxynol-9) GYNOL II (nonoxynol-9) levonorgestrel (Plan B) levonorgestrel (Plan B One-Step) SHUR-SEAL (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE FOAM (nonoxynol-9) Otorrinolaringología carbamide peroxide (Debrox) cromolyn sodium – nasal (Nasalcrom) sodium chloride sodium chloride (Ocean) MEDICAMENTOS GASTROINTESTINALES Acidez, indigestión aluminum/magnesium hydroxide aluminum/magnesium hydroxide/simethicone (Mylanta DoubleStrength) calcium carbonate (Children’s Mylanta) calcium carbonate calcium carbonate (Maalox) calcium carbonate (Tums, Tums E-X, Tums Ultra) CALCIUM CARBONATE

X

81 mg, 325 mg, 500 mg tabs 325 mg tabs 325 mg, 500 mg delrelease tabs 81 mg del-release tabs 250-250-65 mg tabs 200 mg caps, tabs 100 mg chew tabs 100 mg/5 mL susp 40 mg/mL susp 220 mg tabs 1% vaginal crm 2% vaginal crm 6.5% vaginal oint 4% gel 100 mg supp 3% gel 0.75 mg tablet 1.5 mg tablet 2% gel 12.5% foam 6.5% optic soln 5.2 mg/act nasal aerosol 0.9% inhal soln 0.65% nasal spray 225-200 mg/5 mL susp 200-200-20 mg/5 mL susp 400-400-40 mg 5 mL susp 400 mg chew tabs 420 mg chew tabs 600 mg chew tabs 500 mg, 750 mg, 1000 mg tabs 1177 mg chew tabs

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

Estreñimiento

Diarrea Gas

cimetidine (Tagamet HB) famotidine (Pepcid AC, Pepcid AC MaxStrength) OMEPRAZOLE (PRILOSEC OTC) ranitidine (Zantac, Zantac 150 Maximum Strength) bisacodyl (Dulcolax) docusate sodium (Colace) magnesium citrate sennosides (Senokot, Senokot Xtra) sennosides (Ex-Lax, Ex-Lax Maximum Strength) loperamide (Imodium A-D)

200 mg tabs 10 mg, 20 mg tabs 20 mg del-release tabs 75 mg, 150 mg tabs 5 mg del-release tabs 100 mg caps, 50 mg/5 mL liquid oral soln 8.6 mg, 17.2 mg tabs 15 mg chew tabs 15 mg, 25 mg tabs 1 mg/5 mL, 2 mg soln, tabs 40 mg/0.6 mL susp 0.5% ophth soln

simethicone (Mylicon) carboxymethylcellulose sodium (Refresh Plus) ketotifen (Zaditor) 0.025% ophth soln 1.4% ophth soln polyvinyl alcohol NO SE CUBREN LOS PRODUCTOS PARA GRIPE Y RESFRIADO PARA NIÑOS DE 4 AÑOS DE EDAD O MENORES Antihistamínicos/ ALLEGRA ALLERGY CHILDRENS 30 mg ODT, tabs, 30 descongestionantes (fexofenadine) mg/5 mL susp brompheniramine/phenylephrine (Dimetapp 1-2.5 mg/5 mL elixir Cold and Allergy) cetirizine (Zyrtec Children’s Allergy) 5 mg, 10 mg chew tabs, 5 mg/5 mL syrup cetirizine (Zyrtec Allergy, Zyrtec Hives Relief) 5 mg, 10 mg tabs chlorpheniramine (Chlor-Trimeton) 4 mg tabs clemastine fumarate (Tavist Allergy) 1.34 mg tabs diphenhydramine (Sominex, Benadryl) 25 mg tabs, caps, 50 mg tabs, caps diphenhydramine (Benadryl Allergy) 12.5 mg/5 mL elixir, liquid fexofenadine (Allegra Allergy) 60 mg, 180 mg tabs, susp loratadine (Claritin) 5 mg/5 mL syrup loratadine (Claritin, Claritin Reditabs) 10 mg ODT, tabs loratadine/pseudoephedrine (Claritin D 12 5-120 mg, 10-240 mg HR, Claritin D 24 HR) ext-release tabs phenylephrine (Sudafed PE) 10 mg tabs Antitusivos y 1-2.5-5 mg/5 mL elixir brompheniramine/phenylephrine/ expectorantes dextromethorphan CODEINE/PSEUDOEPHEDRINE/ 9-30-12.5 mg/5 mL Productos para los Ojos

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

XI

CHLORCYCLIZINE dextromethorphan/guaifenesin (Cheracol-D) dextromethorphan/guaifenesin (Robitussin DM) guaifenesin guaifenesin/codeine (various) guaifenesin/phenylephrine (Medifin PE) PHENYLEPHRINE/BROMPHENIRAMINE/ CODEINE

liquid 10-100 mg/5 mL liquid 10-100 mg/5 mL syrup 100 mg/5 mL liquid, syrup 100-10 mg/5 mL soln, syrup 400-10 mg tabs 3.33-1.33-6.33 mg/5 mL, 7.5-4-10 mg liquid

PHENYLEPHRINE/CHLORPHENIRAMINE/ CODEINE PHENYLEPHRINE/ DEXCHLORPHENIRAMINE/CODEINE PHENYLEPHRINE/PYRILAMINE/CODEINE

5-1-10 mg/5 mL, 5-1-9 mg/5 mL liquid, syrup 5-8.33-9 mg/5 mL syrup 10-1.33-6.33 mg/5 mL pseudoephedrine/brompheniramine/ liquid codeine PSEUDOEPHEDRINE/BROMPHENIRAMINE/ 30-2-7.5 mg/5 mL CODEINE liquid PSEUDOEPHEDRINE/CHLORPHENIRAMINE/ 30-2-8 mg/5 mL, 30-2CODEINE 10 mg/5 mL, 3.3330.222-1 mg/mL, 3.750.25-1 mg/mL, 4.2860.286-1 mg/mL, 50.333-1 mg/mL liquid, susp 30-10-100 mg/5 mL pseudoephedrine/codeine/guaifenesin (various) soln PSEUDOEPHEDRINE/ 20-0.667-6 mg/5 mL DEXBROMPHENIRAMINE/CODEINE liq PIEL Acné Antibacteriales: tópicos

Antipruríticos

XII

benzoyl peroxide

10% gel

bacitracin bacitracin/polymyxin B (Polysporin) neomycin/polymyxin B/bacitracin (Triple Antibiotic) clotrimazole (Lotrimin AF) miconazole (Micatin) miconazole powder (Desenex Shake Powder) terbinafine (Lamisil AT) tolnaftate (Tinactin) hydrocortisone hydrocortisone acetate

500 U/g oint oint oint 1% crm 2% crm 2% powder 1% crm 1% crm, soln 1% crm, oint 1% crm

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

Pediculosis

permethrin

SUPLEMENTOS Y VITAMINAS calcium carbonate Suplementos calcium carbonate (Caltrate 600) calcium carbonate calcium carbonate/vitamin D

calcium citrate calcium citrate/vitamin D ferrous gluconate ferrous sulfate (Fer-In-Sol) ferrous sulfate ferrous sulfate enteric-coated ferrous sulfate, dried (Slow Fe) folic acid

Otros Productos

niacin oral electrolytes – DL prenatal vitamins vitamin D CHEMSTRIP urine test strip ENTERAL NUTRITION – PA INSULIN SYRINGES (QL) KETO-DIASTIX urine test strips KETOSTIX urine test strips MCT Oil (medium chain triglycerides oil) nicotine – DL, PA

1% crm rinse, lotn 1250 mg (500 mg Ca) tabs 1500 mg (600 mg Ca) tabs 600 mg tabs 250 mg-125 U, 500 mg-125 U, 500 mg-200 U, 600 mg-125 U, 600 mg-200 U, 600 mg-400 U tabs 950 mg (200 mg Ca) tabs 315 mg-200 U tabs 325 mg tabs 75 mg/mL soln 324 mg, 325 mg tabs 324 mg, 325 mg delrelease tabs 160 mg ext-release tabs 400 mcg, 800 mcg, 1000 mcg tabs 500 mg tabs 1000 mL soln All tabs 400 units/mL liq/drops

gum, lozenges, patches

Lista de medicamentos de venta libre (OTC) II Los asegurados de Blue Cross Community Centennial en el plan estatal de Medicaid que tienen 21 años de edad o más, tienen cobertura para ciertos medicamentos de venta libre Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

XIII

(OTC), con los mismos límites de suministro que los límites que tiene la población completa de Medicaid. La lista de OTC para asegurados que tienen 21 años de edad o más, se muestra en la Lista II de OTC. Límites de suministro para 30 días* Sólidos orales (como cápsulas, tabletas) – 100 Productos nutritivos ENTERALES – necesita autorización previa Líquidos orales – 240 mL Productos disuasivos para el tabaquismo – necesita autorización previa**

Ojos y oídos – 1 paquete Supositorios – 24 Condones – 12 Soluciones orales de electrolitos – 2,000 mL Refuerzos y Ensure*** – 2 latas/día y 180 latas/año MÁXIMO***

Tópicos – cremas, ungüentos, lociones: 80 g o mL *En algunos casos, solo se cubrirá 1 paquete por 30 días **Los productos disuasivos para el tabaquismo están limitados a 2 cursos de 90 días por año calendario ***Los asegurados de Blue Cross Community Centennial que tienen una exoneración basada en la agencia o una exoneración auto dirigida de Medicaid podrían recibir los productos de venta libre Boost y Ensure, si un médico les escribe una receta, aplican restricciones de cantidad. 1 lata = 237 mL LISTA II DE PRODUCTOS OTC PARA ASEGURADOS DE MEDICAID DE 21 AÑOS DE EDAD Y MAYORES Producto OTC Formas de dosis, concentraciónes clotrimazole (Gyne-Lotrimin) 1% vaginal crm 1% Infecciones fúngicas vaginal crm 2% Miconazole vaginales tioconazole (Vagistat-1) 6.5% vaginal oint 6.5% Anticonceptivos CONCEPTROL (nonoxynol-9) gel, 4% condoms, latex lubricated unlubricated ENCARE (nonoxynol-9) supp,100 mg GYNOL II (nonoxynol-9) gel, 3% levonorgestrel (Plan B, One-Step) tabs, 0.75 mg, 1.5 mg SHUR-SEAL (nonoxynol-9) gel, 2% TODAY SPONGE (contraceptive sponge) VCF VAGINAL CONTRACEPTIVE foam, 12.5% FOAM inhal soln 0.9% Otorrinolasodium chloride ringología XIV

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

Productos para los carboxymethylcellulose sodium (Refresh Plus) Ojos Productos para la clotrimazole (Lotrimin AF) piel miconazole (Micatin) miconazole (Desenex Shake Powder) terbinafine (Lamisil AT) tolnaftate (Tinactin) hydrocortisone hydrocortisone acetate permethrin oral electrolytes – DL Otros productos prenatal vitamins CHEMSTRIP urine test strip INSULIN SYRINGES (QL) KETO-DIASTIX KETOSTIX nicotine – DL, PA

ophth soln, 0.5% crm, 1% crm, 2% crm, 2% powder, 1% crm, 1% crm, soln, 1% crm, oint, 1% crm rinse, lotn, 1% 1000 mL todos

urine test strips urine test strips gum, lozenges, patches

Lista de medicamentos de venta libre (OTC) III Los medicamentos de venta libre (OTC) están cubiertos únicamente para los miembros del Plan alternativo de beneficios que no tienen ni 19 ni 20 años de edad (EPSDT) y están limitados a medicamentos específicos; pueden aplicar límites de despacho. Es importante que muestre esta lista de medicamentos de venta libre a su médico para que tenga conocimiento de qué medicamentos están disponibles para el beneficio de medicamentos de venta libre para los miembros del Plan alternativo de beneficios que no tienen ni 19 ni 20 años de edad (EPSDT). Los miembros necesitan la receta médica de un médico para que un medicamento de venta libre esté cubierto en una farmacia. El farmacéutico elegirá el paquete (marca y cantidad) que utilizará cuando surta la receta médica con el medicamento de venta libre. Los siguientes medicamentos de venta libre están cubiertos en este programa. La Lista de medicamentos de venta libre presenta a los medicamentos que están disponibles como genéricos por su nombre genérico en letra minúscula y negrita. Un medicamento de marca común se indica en paréntesis después del nombre genérico para muchos productos para ayudar a identificar el medicamento cubierto. Si un genérico está disponible, este casi siempre se despachará en este programa. Los medicamentos que están disponibles únicamente como marcas se indican por el nombre de marca y se muestran en letra mayúscula. Límites de suministro para 30 días* Sólidos orales (como cápsulas, tabletas) – 100 Productos nutritivos ENTERALES – necesita autorización previa Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

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Líquidos orales – 240 ml Productos para dejar de fumar – necesita autorización previa** Supositorios – 24 Condones – 12 *En algunos casos, solo se cubrirá 1 paquete cada 30 días **Los productos para dejar de fumar están limitados a 2 cursos de 90 días por año calendario LISTA III DE PRODUCTOS OTC PARA PLANES DE BENEFICIOS ALTERNOS PARA PERSONAS QUE NO TIENEN 19-20 AÑOS DE EDAD Producto OTC Formas de dosis, concentraciónes Anticonceptivos CONCEPTROL (nonoxynol-9) gel 4% condoms, latex lubricated unlubricated ENCARE (nonoxynol-9) Supp,100 mg GYNOL II (nonoxynol-9) gel, 3% levonorgestrel (Plan B) tabs 0.75 levonorgestrel (Plan B, One-Step) 1.5 mg SHUR-SEAL (nonoxynol-9) gel 2% VCF VAGINAL CONTRACEPTIVE foam, 12.5% FOAM 325 mg tabs Suplementos ferrous gluconate ferrous sulfate (Fer-In-Sol) 75 mg/mL soln 324 mg, 325 mg tabs ferrous sulfate 324 mg, 325 mg del-release ferrous sulfate enteric-coated tabs ferrous sulfate, dried (Slow Fe) 160 mg ext-release tabs 400 mcg, 800 mcg, 1000 folic acid mcg tabs Todos tabs prenatal vitamins 30-10-100 mg/5 mL soln Antitusivos y pseudoephedrine/codeine/ guaifenesin (various) expectorantes 100/10 mg/5mL soln guaifenesin/codeine ALCOHOL SWABS-DL Otros productos 81 mg tab, 81 mg chew tab aspirin (Bayer Chewable Low Dose, St Joseph’s) delayed release tabs aspirin 81 mg delayed release tabs aspirin enteric-coated (Bufferin Low Dose) CHEMSTRIP urine test strip ENTERAL NUTRITION – PA KETO-DIASTIX urine test strips KETOSTIX urine test strips gum, lozenges, patches nicotine – DL, PA XVI

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

Lista de medicamentos de venta libre (OTC) IV para Planes Dobles de Medicare y Medicaid Blue Cross Community Centennial no cubre los medicamentos de un beneficiario que sea elegible para la parte D de Medicare en los casos en los que el medicamento cumpla con la definición federal de medicamento cubierto en la parte D de Medicare. Además, Blue Cross Community Centennial no cubre ningún copago de un reclamo que haya sido pagado por la Parte D de Medicare y no cubre los medicamentos cubiertos por la Parte D de Medicare cuando el beneficiario tiene una brecha en la cobertura de la Parte D de Medicare (debido al límite de cobertura de Medicare). Para los medicamentos cubiertos de la Parte B de Medicare, los miembros de Blue Cross Community Centennial que se inscriben tanto en Medicare como Medicaid pueden tener su coaseguro/copago cubierto bajo sus beneficios de Medicaid. Sin embargo, algunos medicamentos solo están cubiertos bajo la Parte B de Medicare si un miembro tiene una condición médica específica o recibió un tratamiento médico específico. Para estos medicamentos, será necesario revisar primero la información sobre el historial médico para cubrir el coaseguro/copago de un miembro. Los miembros deberán llamar al número de Servicio al cliente que se encuentra en la parte posterior de la tarjeta de Blue Cross Community Centennial para que se complete la determinación de esta cobertura. La siguiente lista de artículos de venta libre está cubierta para los miembros que están inscritos en Medicare y Medicaid, cuando una receta médica la escribe un médico para estos artículos. Límites de suministro para 30 días* Sólidos orales (como cápsulas, tabletas) – 100 Productos nutritivos ENTERALES – necesita autorización previa Líquidos orales – 240 ml Productos para dejar de fumar – necesita autorización previa** Supositorios – 24 Condones – 12 *En algunos casos, solo se cubrirá 1 paquete cada 30 días **Los productos para dejar de fumar están limitados a 2 cursos de 90 días por año calendario

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

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LISTA IV DE PRODUCTOS OTC PARA PLANES DOBLES DE MEDICARE Y MEDICAID Producto OTC Formas de dosis, concentraciónes Analgésicos: acetaminophen (Tylenol) 325 mg, 500 mg tabs, caps; Reductores de la 650 mg ext-release tabs Fiebre 80 mg, 160 mg chew tabs acetaminophen acetaminophen (Tylenol) 160mg/5 mL elixir, liqud, susp 100 mg/mL, 160 mg/5 mL soln, drops acetaminophen (Tylenol Infants) 80 mg/0.8 mL susp 120 mg, 325 mg, 650 mg acetaminophen supp acetaminophen (Tylenol Children’s 80 mg, 160 mg dispers tab or Jr Meltaways) ACETAMINOPHEN 500 mg dispersible tabs aspirin (Bayer Chewable Low Dose, 81 mg chew tabs St Joseph Aspirin) 81 mg, 325 mg, 500 mg tabs aspirin aspirin buffered (Bufferin) 325 mg tabs aspirin enteric-coated (Ecotrin) 325 mg, 500 mg delayedrelease tabs aspirin enteric-coated (Bufferin 81 mg delayed-release tabs Low Dose) 250-250-65 mg tabs aspirin/acetaminophen/caffeine (Excedrin Migraine) ibuprofen (Advil, Motrin IB) 200 mg caps tabs ibuprofen (Advil Jr Strength, 100 mg chew tabs Children’s Motrin) ibuprofen (Children’s Motrin, 100 mg/5 mL susp Children’s Advil) ibuprofen (Motrin Infants, Infants 40 mg/mL susp Advil) naproxen sodium (Aleve) 220 mg tabs clotrimazole (Gyne-Lotrimin) 1% vaginal crm Infecciones 2% vaginal crm Fúngicas: miconazole Vaginales tioconazole (Vagistat-1) 6.5% vaginal oint CONCEPTROL (nonoxynol-9) 4% gel Anticonceptivos condoms, latex lubricated unlubricated ENCARE (nonoxynol-9) 100 mg supp GYNOL II (nonoxynol-9) 3% gel levonorgestrel (Plan B) 0.75 mg tablet levonorgestrel (Plan B One-Step ) 1.5 mg tablet SHUR-SEAL (nonoxynol-9) 2% gel VCF VAGINAL CONTACEPTIVE 12.5% foam XVIII

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

FOAM (nonoxynol-9) Otorrinolaringología carbamide peroxide (Debrox) cromolyn sodium – nasal (Nasalcrom) sodium chloride sodium chloride (Ocean) Acidez, aluminum/magnesium hydroxide indigestión aluminum/magnesium hydroxide/simethicone (Mylanta/ Double-Strength) calcium carbonate (Children’s Mylanta) calcium carbonate calcium carbonate (Maalox) calcium carbonate (Tums, Tums EX, Tums Ultra) CALCIUM CARBONATE cimetidine (Tagamet HB) famotidine (Pepcid AC, Pepcid AC MaxStrength) OMEPRAZOLE (PRILOSEC OTC) ranitidine (Zantac, Zantac 150 Maximum Strength) bisacodyl (Dulcolax) Estreñimiento docusate sodium (Colace)

Diarrea Misceláneos Productos para los Ojos

Antihistamínicos/

magnesium citrate mineral oil, mineral oil (Fleet Oil) Peg 3350 oral powder (Miralax) psyllium (Metamucil) sennosides (Senokot, Senokot Xtra) sennosides (Ex-Lax /Lax Maximum Strength) bismuth subsalicylate loperamide (Imodium A-D) simethicone (Mylicon) artificial tears carboxymethylcellulose sodium (Refresh Plus) ketotifen (Zaditor) polyvinyl alcohol TEARS AGAIN NIGHT&DAY ALLEGRA ALLERGY CHILDRENS

6.5% otic soln 5.2 mg/act nasal aerosol 0.9% inhal soln 0.65% nasal spray 225-200 mg/5 mL susp 200-200-20 mg/5 mL susp 400-400-40 mg/5 mL susp 400 mg chew tabs 420 mg chew tabs 600 mg chew tabs 500 mg, 750 mg, 1000 mg tabs 1177 mg chew tabs 200 mg tabs 10 mg, 20 mg tabs 20 mg delayed-release tabs 75 mg, 150 mg tabs 5 mg delayed-release tabs 100 mg caps, 50 mg/5 mL liq oral soln oil, enema powder caps, powder, wafer 8.6 mg, 17.2 mg tabs 15 mg chew, 15 mg, 25 mg tabs chew tabs, susp, tabs 1 mg/5 mL, 2 mg soln, tabs 40 mg/0.6 mL susp ophth oint 0.5% ophth soln 0.025% ophth soln 1.4% ophth soln ophth gel 30 mg, ODT tabs 30 mg/5

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

XIX

descongestionantes

XX

(fexofenadine) brompheniramine/phenylephrine (Dimetapp Cold and Allergy) cetirizine (Zyrtec Children’s Allergy) cetirizine (Zyrtec Children’s Allergy cetirizine (Zyrtec Allergy, Zyrtec Hives Relief) chlorpheniramine (Chlor-Trimeton) clemastine fumarate (Tavist Allergy) diphenhydramine diphenhydramine (Sominex, Benadryl) diphenhydramine (Benadryl Allergy) fexofenadine (Allegra Allergy) loratadine (Claritin) loratadine (Claritin, Claritin Reditabs) loratadine/pseudoephedrine (Claritin D 12 HR, Claritin D 24 HR) phenylephrine (Sudafed PE) brompheniramine/phenylephrine/ dextromethorphan CODEINE/PSEUDOEPHEDRINE/ CHLORCYCLIZINE dextromethorphan/guaifenesin (Robitussin DM) Dextromethorphan polistirex (Delsym) guaifenesin (Robitussin Chest Congestion) guaifenesin/codeine (various) guaifenesin/phenylephrine (Medifin PE) PHENYLEPHRINE/ BROMPHENIRAMINE/CODEINE PHENYLEPHRINE/ CHLORPHENIRAMINE/CODEINE PHENYLEPHRINE/ DEXCHLORPHENIRAMINE/ CODEINE PHENYLEPHRINE/PYRILAMINE/ CODEINE pseudoephedrine/ brompheniramine/codeine

mL susp 1-2.5 mg/5 mL elixir 5 mg, 10 mg chew tabs 5 mg/5 mL syrup 5 mg, 10 mg tabs 4 mg tabs 1.34 mg tabs 50 mg tabs, caps 25 mg tabs, caps 12.5 mg/5 mL elixir, liquid 60 mg, 180 mg tabs, susp 5 mg/5 mL syrup 10 mg ODT, tabs 5-120 mg, 10-240 mg extrelease tabs 10 mg tabs 1-2.5-5 mg/5 mL elixir 9-30-12.5 mg/5 mL liquid 10-100 mg/5 mL liquid, syrup 30mg/5 mL liquid 100 mg/5 mL liquid, syrup 100-10 mg/5 mL soln, syrup 400-10 mg tabs 3.33-1.33-6.33 mg/5 mL,7.54-10 mg liquid 5-2-10 mg/5 mL syrup 5-1-10 mg/5 mL, 5-1-9 mg/5 mL liquid, syrup 5-8.33-9 mg/5 mL syrup 10-1.33-6.33 mg/5 mL liquid, 30-2-7.5 mg/5 mL liquid

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

PSEUDOEPHEDRINE/ CHLORPHENIRAMINE/CODEINE

Acné Antimicóticos: tópicos

Antipruríticos Pediculosis Suplementos

pseudoephedrine/codeine/ guaifenesin (various) PSEUDOEPHEDRINE/ DEXBROMPHENIRAMINE/ CODEINE benzoyl peroxide clotrimazole (Lotrimin AF)

30-2-8 mg/5 mL, 30-2-10 mg/5 mL, 3.333-0.222-1 mg/mL, 3.75-0.25-1 mg/mL, 4.286-0.286-1 mg/mL, 5-0.333-1 mg/mL liquid, susp 30-10-100 mg/5 mL soln 20-0.667-6 mg/5 mL liq

10% gel 1% crm

miconazole (Micatin) miconazole powder (Desenex Shake Powder) terbinafine (Lamisil AT) tolnaftate (Tinactin) hydrocortisone

2% crm 2% powder

hydrocortisone acetate

1% crm

permethrin calcium carbonate

1% crm rinse, lotn 1250 mg (500 mg Ca) tabs

calcium carbonate (Caltrate 600)

1500 mg (600 mg Ca) tabs

calcium carbonate

600 mg tabs

calcium carbonate/vitamin D

calcium citrate

250 mg-125 U, 500 mg-125 U, 500 mg-200 U, 600 mg-125 U, 600 mg-200 U, 600 mg-400 U tab 950 mg (200 mg Ca) tabs

calcium citrate/vitamin D

315 mg-200 U tabs

ferrous gluconate

325 mg tabs

ferrous sulfate (Fer-In-Sol)

75 mg/mL soln

ferrous sulfate ferrous sulfate enteric coated ferrous sulfate, dried (Slow Fe)

324 mg, 325 mg tabs delayed- release tabs 160 mg ext-release tabs

folic acid

400 mcg, 800 mcg, 1000 mcg tabs 250, 400, 500 mg tabs, caps

magnesium oxide

1% crm 1% crm, soln 1% crm, oint

multiple vitamins with and without tabs Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

XXI

Otros Productos

iron niacin

500 mg tabs

oral electrolytes – DL

1000 mL soln

prenatal vitamins (all)

tabs

pediatric multivitamins/ with iron

chew tabs, liquid

vitamin D

400 units/mL liq/drops

ENTERAL NUTRITION – PA GLUCOSE

chew tabs 4 mg

MCT Oil (medium chain triglycerides oil) nicotine – DL, PA

oral oil gum, lozenges, patches

Además de los productos de venta sin receta que se encuentran en la Lista IV de OTC, Blue Cross Community Centennial cubre los siguientes productos con receta para miembros inscritos en los Planes de Medicare y Medicaid: Lista de vitaminas con receta para Medicare y los Planes Medicaid Dual Suplementos cyanocobalamin (Vitamin B12) 1000 mcg/mL, inj ergocalciferol (Vitamin D2) 50,000 IU caps potassium chloride (MicroK, Klor-Con) 8 mEq, 10 mEq 20 mEq ext-release tabs and caps, liquid; granules; packs Vitamin K (Mephyton) 5 mg tabs Límites de despacho (DL) Los siguientes medicamentos están limitados a las cantidades que se muestran a continuación. Estas son las cantidades que pueden surtirse por receta médica en el período de tiempo especificado. Los límites apoyan el uso correcto del medicamento y garantizan la seguridad del miembro. Los límites se desarrollan con base en el uso aprobado del medicamento por la FDA. Esta lista está sujeta a cambios. Medicamentos ABILIFY inj ABILIFY tab ABILIFY DISCMELT ABILIFY MAINTENA ADASUVE ADVAIR DISKUS ADVAIR HFA albuterol inhal soln 0.63 mg/3 mL, 0.083%, 1.25 mg/3 mL albuterol inhal soln 0.5% alprazolam ext-release (Xanax XR) XXII

Límites de despacho 90 viales/30 días 30 tabletas/30 días 60 tabletas/30 días 1 vial/30 días 1 inhalador/receta médica 1 inhalador/30 días 1 inhalador/30 días 360 mL/30 días 40 mL/30 días 60 tabletas/30 días

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

Medicamentos amphetamine/dextroamphetamine 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 30 mg (Adderall)

Límites de despacho 60 tabletas/30 días

amphetamine/dextroamphetamine 20 mg (Adderall)

90 tabletas/30 días

amphetamine/dextroamphetamine ext-release (Adderall XR) APLENZIN ARISTADA ASMANEX TWISTHALER ATROVENT HFA azelastine (Astepro) azithromycin tabs (Zithromax)* BLOOD GLUCOSE TEST STRIPS

30 cápsulas/30 días

buprenorphine sublingual tab

30 tabletas/30 días 1 inyección/mes 1 inhalador/30 días 1 inhalador/30 días 2 botellas/30 días 12 tabletas/30 días 204 tiras reactivas para pruebas/30 días 30 tabletas/30 días 60 mL/30 días 90 tabletas/30 días 90 tabletas/30 días

bupropion tab, 75 mg (Wellbutrin) bupropion tab, 100 mg (Wellbutrin) bupropion ext-release – 12 hr (Wellbutrin SR)

60 tabletas/30 días 120 tabletas/30 días 60 tabletas/30 días

bupropion ext-release – 24 hr (Wellbutrin XL)

30 tabletas/30 días

bupropion ext-release – 12 hr (Zyban) celecoxib (Celebrex) CHANTIX ciclopirox soln ciprofloxacin ext-release tab, 500 mg ciprofloxacin ext-release tab, 1000 mg

2 cursos de 90 días/año calendario 60 cápsulas/30 días 2 cursos de 90 días/año calendario 2 botellas/30 días 3 tabletas/30 días 14 tabletas/30 días

citalopram oral soln citalopram tab (Celexa) CLOZAPINE ODT 12.5 mg, 100 mg CLOZAPINE ODT 25 mg

600 mL/30 días 30 tabletas/30 días 90 tabletas/30 días 9 tabletas/día hasta 120 tabletas por reclamo 90 tabletas/30 días 9 tabletas/día hasta 120 tabletas por reclamo 1 inhalador/30 días 240 mL/30 días 60 tabletas/30 días 30 tabletas/30 días

BRINTELLIX budesonide inhal soln (Pulmicort) buprenorphine/naloxone tab (Suboxone)

clozapine tab, 25 mg (Clozaril) clozapine tab, 100 mg (Clozaril) COMBIVENT cromolyn sodium inhal soln DARAPRIM DESVENLAFAXINE/FUMARATE ext-release tab

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

XXIII

Medicamentos dexmethylphenidate (Focalin) dextroamphetamine tab, 5 mg dextroamphetamine tab, 10 mg dextroamphetamine ext-release cap, 5 mg (Dexedrine Spansule) dextroamphetamine ext-release cap, 10 mg, 15 mg (Dexedrine Spansule) DORAL tab

Límites de despacho 60 tabletas/30 días 60 tabletas/30 días 6 tabletas/día hasta 120 tabletas por 90 cápsulas/30 días

dronabinol cap (Marinol)* DULERA duloxetine (Cymbalta) EMEND cap, 40 mg, 80 mg, 125 mg* enoxaparin (Lovenox) escitalopram soln (Lexapro) escitalopram tab, 5 mg, 10 mg (Lexapro) escitalopram tab, 20 mg (Lexapro) estazolam EVOTAZ FANAPT FANAPT TITRATION PACK FAZACLO tab, 12.5 mg, 100 mg FAZACLO tab, 25 mg FAZACLO tab, 150 mg FAZACLO tab, 200 mg fentanyl (Actiq) fentanyl (Duragesic) FETZIMA FETZIMA TITRATION PACK fluconazole (Diflucan) flunisolide nasal spray 0.025% fluticasone nasal spray (Flonase) FLOVENT DISKUS FLOVENT HFA fluoxetine cap, 10 mg (Prozac) fluoxetine cap, 20 mg (Prozac) fluoxetine cap, 40 mg (Prozac) fluoxetine del release cap, 90 mg (Prozac Weekly) fluoxetine oral soln FLUOXETINE tab, 60 mg flurazepam

60 cápsulas/30 días 1 inhalador/30 días 60 tabletas/30 días 6 cápsulas/30 días 30 unidades/68 días 600 mL/30 días 30 tabletas/30 días 60 tabletas/30 días 30 tabletas/30 días 30 tabletas/30 días 60 tabletas/30 días 1 cajetilla (8 tabletas)/4 días 90 tabletas/30 días 9 tabletas/día hasta 120 tabletas por 6 tabletas/día hasta 120 tabletas por 120 tabletas/30 días 120 comprimidos/30 días 10 parches/30 días 30 tabletas/30 días 1 paquete (28 tabletas)/28 días 14 tabletas o 35 mL/30 días 1 botella/30 días 1 botella/30 días 1 inhalador/30 días 1 inhalador/30 días 30 cápsulas/30 días 120 cápsulas/30 días 60 cápsulas/30 días 4 cápsulas/28 días

XXIV

120 cápsulas/30 días 30 tabletas/30 días

600 mL/30 días 30 tabletas/30 días 30 cápsulas/30 días

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

Medicamentos fluvoxamine tab, 25 mg, 50 mg fluvoxamine tab, 100 mg fluvoxamine ext release caps (Luvox CR)

Límites de despacho 30 tabletas/30 días 90 tabletas/30 días 60 cápsulas/30 días

FORADIL AEROLIZER FORFIVO XL GEODON inj granisetron tab* ibandronate tab, 150 mg (Boniva) imiquimod (Aldara)* IMITREX nasal spray, 5 mg/act, 20 mg/act

1 inhalador (60 dosis)/30 días 30 tabletas/30 días 60 viales/30 días 12 tabletas/30 días 1 tableta/30 días 48 unidades/365 días; 24 unidades/surtido 1 caja de 6/30 días

INCRUSE ELLIPTA Insulin (all) INTUNIV INVEGA tab, 1.5 mg, 3 mg, 9 mg INVEGA tab, 6 mg INVEGA SUSTENNA ipratropium inhal soln ipratropium nasal spray (Atrovent nasal)

1 inhaler/30 days 60 mL/30 days 30 tabletas/30 días 30 tabletas/30 días 60 tabletas/30 días 1 kit/30 días 300 mL/30 días 1 botella/30 días

JANUVIA ketorolac tab KHEDEZLA lansoprazole del release cap (Prevacid) LATUDA tab, 20 mg, 40 mg, 60 mg, 120 mg LATUDA tab, 80 mg levalbuterol inhal soln (Xopenex) levonorgestrel/ethinyl estradiol

30 tabletas/30 días 20 tabletas/30 días 30 tabletas/30 días 60 cápsulas/30 días 30 tabletas/30 días 60 tabletas/30 días 300 mL/30 días 1 cajetilla/90 días

lidocaine/prilocaine crm (Emla)* MAPROTILINE methamphetamine (Desoxyn)

30 g/60 días 90 tabletas/30 días 5 tabletas/día hasta 120 tabletas por reclamo 30 cápsulas/30 días

methylphenidate ext release cap (Metadate CD) methylphenidate ext release cap, 20 mg, 40 mg (Ritalin LA) methylphenidate ext release cap, 30 mg (Ritalin LA) METHYLPHENIDATE ext release tab, 10 mg

30 cápsulas/30 días

methylphenidate ext release tab, 20 mg (Ritalin SR)

90 tabletas/30 días

60 cápsulas/30 días 90 tabletas/30 días

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

XXV

Medicamentos METHYLPHENIDATE EXT-RELEASE OSM tab, 18 mg, 27 mg, 54 mg METHYLPHENIDATE EXT-RELEASE OSM tab, 36 mg (Concerta) methylphenidate oral soln, 5 mg/5 mL methylphenidate oral soln, 10 mg/5 mL

Límites de despacho 30 tabletas/30 días

methylphenidate tab (Ritalin) mirtazapine tab, ODT (Remeron, Remeron Soltab)

90 tabletas/30 días 30 tabletas/30 días

modafinil (Provigil) morphine sulfate ext release cap (Kadian, Avinza)

30 tabletas/30 días 90 cápsulas/30 días

morphine sulfate ext release tab (MS Contin)

90 tabletas/30 días

naratriptan (Amerge) NASONEX NICOTROL inhaler NICOTROL nasal spray olanzapine inj (Zyprexa) olanzapine tab, ODT (Zyprexa, Zyprexa Zydis)

9 tabletas/30 días 1 botella/30 días 2 cursos de 90 días/año calendario 2 cursos de 90 días/año calendario 90 viales/30 días 30 tabletas/30 días

olanzapine/fluoxetine (Symbyax) OLEPTRO tab, 150 mg OLEPTRO tab, 300 mg omeprazole del release cap, 10 mg (Prilosec)

30 cápsulas/30 días 45 tabletas/30 días 30 tabletas/30 días 30 cápsulas/30 días

60 tabletas/30 días 450 mL/30 días 900 mL/30 días

omeprazole del release cap, 20 mg, 40 mg (Prilosec) 60 cápsulas/30 días ondansetron oral soln (Zofran)* ondansetron tab, ODT (Zofran, Zofran ODT)*

100 mL/30 días 270 tabletas/365 días

ondansetron tab, 24 mg* pantoprazole del release (Protonix)

4 tabletas/30 días 60 tabletas/30 días

paroxetine tab, 10 mg, 20 mg, (Paxil)

30 tabletas/30 días

paroxetine tab, 40 mg (Paxil) paroxetine tab, 30 mg (Paxil) paroxetine ext release tab, 12.5 mg (Paxil CR) paroxetine ext release tab, 25 mg, 37.5 mg (Paxil CR) PAXIL susp PEXEVA tab, 10 mg, 20 mg, 40 mg PEXEVA tab, 30 mg PRISTIQ PREZCOBIX

45 tabletas/30 días 60 tabletas/30 días 30 tabletas/30 días 60 tabletas/30 días

XXVI

900 mL/30 días 30 tabletas/30 días 60 tabletas/30 días 30 tabletas/30 días 30 tabs/30 days

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

Medicamentos PROAIR HFA QUAZEPAM quetiapine tab, 25 mg, 50 mg, 100 mg, 200 mg (Seroquel) quetiapine tab, 300 mg, 400 mg (Seroquel)

Límites de despacho 2 inhaladores/30 días 30 tabletas/30 días 90 tabletas/30 días

QVAR

2 inhaladores/30 días

REXULTI risperidone oral soln (Risperdal) risperidone tab, 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg; ODT (Risperdal)

30 tabletas/30 días 480 mL/30 días 60 tabletas/30 días

rizatriptan tab, ODT (Maxalt, Maxalt MLT) SAPHRIS SEROQUEL XR tab, 50 mg, 300 mg, 400 mg SEROQUEL XR tab, 150 mg, 200 mg sertraline oral conc (Zoloft) sertraline tab, 25 mg, 50 mg (Zoloft) sertraline tab, 100 mg (Zoloft) SLEEP AIDS** SPIRIVA HANDIHALER SYMBICORT SUBOXONE sublingual film, 2-0.5 mg, 4-1 mg, 8-2 mg SUBOXONE sublingual film, 12-3 mg sumatriptan tab (Imitrex) sumatriptan inj (Imitrex) temazepam tizanidine cap, 2 mg tizanidine cap, 4 mg tizanidine cap, 6mg tramadol (Ultram) tramadol ext release (Ultram ER) triamcinolone nasal spray (Nasacort AQ)

18 tabletas/30 días 60 tabletas/30 días 60 tabletas/30 días 30 tabletas/30 días 300 mL/30 días 30 tabletas/30 días 60 tabletas/30 días 1 tableta/cápsula por día 1 inhalador/30 días 1 inhalador/30 días 90 películas/30 días 60 películas/30 días 18 tabletas/30 días 6 viales/30 días 30 cápsulas 30 días 18 cápsulas/día hasta 120 cápsulas 9 cápsulas/día hasta 120 cápsulas 6 cápsulas/día hasta 120 cápsulas 8 tabletas/día hasta 120 tabletas por 30 tabletas/30 días 1 botella/30 días

triazolam

30 tabletas/30 días

venlafaxine venlafaxine ext release cap, 37.5 mg, 150 mg (Effexor XR) venlafaxine ext release cap, 75 mg (Effexor XR)

90 tabletas/30 días 60 cápsulas/30 días

venlafaxine ext release tab, 37.5 mg, 150 mg

30 tabletas/30 días

venlafaxine ext release tab, 75 mg

90 tabletas/30 días

60 tabletas/30 días

90 cápsulas/30 días

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

XXVII

Medicamentos VENLAFAXINE ext release tab, 225 mg VENTOLIN HFA VERSACLOZ susp, 50 mg/mL VIIBRYD VIIBRYD starter kit VITEKTA VYVANSE zaleplon (Sonata) ziprasidone cap (Geodon) zolpidem (Ambien) zolpidem ext release (Ambien CR) ZYCLARA cream ZYPREXA RELPREVV iny, 210 mg, 300 mg ZYPREXA RELPREVV iny, 405 mg ZYVOX tab ZYVOX susp

Límites de despacho 30 tabletas/30 días 2 inhaladores/30 días 6 botellas /30 days 30 tabletas/30 días 1 kit/30 días 30 tabletas/30 días 30 cápsulas/30 días 30 cápsulas/30 días 60 cápsulas/30 días 30 tabletas/30 días 30 tabletas/30 días 48 gramos/365 días 2 viales/28 días 1 vial/28 días 20 tabs in 180 days 150 mL in 180 days

*No están disponibles a través de pedidos por correo **LAS PASTILLAS PARA DORMIR también están limitadas a un agente sedante cada 30 días Kits de rescate de naloxona Blue Cross Community Centennial proporciona cobertura para jeringas prellenadas de Naloxona HCl y un atomizador que forman un “Kit de rescate de naloxona”. Este kit es una parte importante de una estrategia para evitar las muertes por sobredosis de opioides. La cobertura del Kit de rescate de naloxona depende del plan de beneficios de la Persona cubierta bajo la póliza.

XXVIII

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

Clave de abreviaturas/acrónimos caps ................................................ cápsulas conc ........................................... concentrado CR ...................................liberación controlada crm ...................................................... crema DL .................................... límite de despacho DR .................................... liberación retrasada lib prol ........................ liberación prolongada inhal .............................................. inhalación iny ................................................... inyección líq ........................................................ líquido loc ........................................................ loción mast .............................................. masticable NF ... no en la lista de medicamentos cubiertos

ODT ............... tabletas de desintegración oral OSM ............................... liberación osmótica OTC ................. medicamentos de venta libre PA .................................... autorización previa SL .................................................. sublingual soln .................................................. solución SP .............................. farmacia especializada SR .................................... liberación sostenida ST .................................... terapia escalonada sup ............................................. supositorios susp ............................................ suspensión tabs .................................................. tabletas ung ................................................. ungüento

Esos servicios reciben financiamiento parcial del estado de New Mexico. Blue Cross and Blue Shield of New Mexico, una división de Health Care Service Corporation, una compañía mutua de reserva legal, un licenciatario independiente de Blue Cross and Blue Shield Association. Prime Therapeutics, LLC, es una compañía independiente y es el Administrador de beneficios de farmacias para Blue Cross Community Centennial.

Lista de medicamentos de Blue Cross Community Centennial, Octubre de 2016

XXIX

MEDICAMENTOS ANTIINFECCIOSOS PENICILINAS AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml

ampicillin cap 250 mg ampicillin cap 500 mg dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg

amoxicillin (trihydrate) tab 875 mg

cefaclor cap 250 mg

amoxicillin & k clavulanate chew tab 200-28.5 mg

cefaclor cap 500 mg

amoxicillin & k clavulanate chew tab 400-57 mg

cefadroxil for susp 250 mg/5ml

cefadroxil cap 500 mg cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm

amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)

cefdinir cap 300 mg

amoxicillin & k clavulanate for susp 400-57 mg/5ml

cefdinir for susp 250 mg/5ml

amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr) amoxicillin & k clavulanate tab 250-125 mg amoxicillin & k clavulanate tab 500-125 mg (Augmentin) amoxicillin & k clavulanate tab 875-125 mg (Augmentin)

Terapiaescalonada

AMOXICILLIN/CLAVULANATE P – amoxicillin & k clavulanate chew tab 400-57 mg

amoxicillin (trihydrate) tab 500 mg

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)

Límite de surtido

AMOXICILLIN/CLAVULANATE P – amoxicillin & k clavulanate chew tab 200-28.5 mg

penicillin v potassium tab 500 mg CEFALOSPORINAS

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

cefdinir for susp 125 mg/5ml cefixime for susp 100 mg/5ml (Suprax) cefixime for susp 200 mg/5ml (Suprax) cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 200 mg cefprozil for susp 125 mg/5ml

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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cefprozil for susp 250 mg/5ml cefprozil tab 500 mg

demeclocycline hcl tab 300 mg

cefuroxime axetil tab 500 mg (Ceftin)

doxycycline hyclate cap 50 mg

cephalexin cap 250 mg (Keflex)

doxycycline hyclate cap 100 mg (Vibramycin)

cephalexin cap 500 mg (Keflex) cephalexin cap 750 mg (Keflex)

doxycycline hyclate tab delayed release 50 mg (Doryx)

cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml MACROLIDOS

doxycycline hyclate tab delayed release 75 mg

AZITHROMYCIN – azithromycin powd pack for susp 1 gm

doxycycline hyclate tab delayed release 100 mg

azithromycin for susp 100 mg/5ml (Zithromax)

doxycycline hyclate tab delayed release 150 mg

azithromycin for susp 200 mg/5ml (Zithromax)

doxycycline hyclate tab 20 mg

azithromycin tab 600 mg (Zithromax) clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml (Biaxin) clarithromycin tab sr 24hr 500 mg clarithromycin tab 250 mg (Biaxin) clarithromycin tab 500 mg (Biaxin) E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg ERY-TAB – erythromycin tab delayed release 250 mg ERY-TAB – erythromycin tab delayed release 333 mg ERY-TAB – erythromycin tab delayed release 500 mg ERYTHROMYCIN ETHYLSUCCINA – erythromycin ethylsuccinate tab 400 mg

2

Terapiaescalonada

demeclocycline hcl tab 150 mg

cefuroxime axetil tab 250 mg

azithromycin tab 500 mg (Zithromax)

Límite de surtido

erythromycin w/ delayed release particles cap 250 mg TETRACICLINAS

cefprozil tab 250 mg

azithromycin tab 250 mg (Zithromax)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • •

doxycycline hyclate tab 100 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 75 mg (Monodox) doxycycline monohydrate cap 100 mg (Monodox) doxycycline monohydrate cap 150 mg (Adoxa) doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) doxycycline monohydrate tab 50 mg (Adoxa) doxycycline monohydrate tab 75 mg (Adoxa) doxycycline monohydrate tab 100 mg (Adoxa pak 1/100) doxycycline monohydrate tab 150 mg (Adoxa pak 1/150) minocycline hcl cap 50 mg (Minocin) minocycline hcl cap 75 mg (Minocin) minocycline hcl cap 100 mg (Minocin)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

minocycline hcl tab sr 24hr 45 mg

ofloxacin tab 300 mg

minocycline hcl tab sr 24hr 90 mg

AMINOGLUCÓSIDOS

minocycline hcl tab sr 24hr 135 mg

neomycin sulfate tab 500 mg

minocycline hcl tab 50 mg

paromomycin sulfate cap 250 mg

minocycline hcl tab 75 mg

tobramycin nebu soln 300 mg/5ml (Tobi)

minocycline hcl tab 100 mg

isoniazid tab 100 mg

tetracycline hcl cap 500 mg (Tetracycline hcl) FLUOROQUINOLONAS

isoniazid tab 300 mg

ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro)

rifabutin cap 150 mg (Mycobutin)

PRIFTIN – rifapentine tab 150 mg pyrazinamide tab 500 mg rifampin cap 150 mg (Rifadin) rifampin cap 300 mg (Rifadin)

ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro)

INFECCIONES MICÓTICAS

levofloxacin tab 500 mg (Levaquin) levofloxacin tab 750 mg (Levaquin) moxifloxacin hcl tab 400 mg (base equiv) (Avelox) OFLOXACIN – ofloxacin tab 400 mg

•

fluconazole for susp 40 mg/ml (Diflucan)

ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)

levofloxacin tab 250 mg (Levaquin)

•

fluconazole for susp 10 mg/ml (Diflucan)

ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)

levofloxacin oral soln 25 mg/ml

Terapiaescalonada

ethambutol hcl tab 400 mg (Myambutol)

tetracycline hcl cap 250 mg (Tetracycline hcl)

ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr)

Límite de surtido

ethambutol hcl tab 100 mg (Myambutol)

TETRACYCLINE HCL – tetracycline hcl cap 500 mg

ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr)

•

TUBERCULOSIS

TETRACYCLINE HCL – tetracycline hcl cap 250 mg

ciprofloxacin hcl tab 750 mg (base equiv)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • • •

fluconazole tab 50 mg (Diflucan) fluconazole tab 100 mg (Diflucan)

•

fluconazole tab 150 mg (Diflucan)

•

flucytosine cap 250 mg (Ancobon)

fluconazole tab 200 mg (Diflucan) flucytosine cap 500 mg (Ancobon) griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 125 mg (Gris-peg) griseofulvin ultramicrosize tab 250 mg (Gris-peg) itraconazole cap 100 mg (Sporanox)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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ketoconazole tab 200 mg NOXAFIL – posaconazole tab delayed release 100 mg NOXAFIL – posaconazole susp 40 mg/ ml

terbinafine hcl tab 250 mg (Lamisil) voriconazole for susp 40 mg/ml (Vfend) voriconazole tab 50 mg (Vfend) voriconazole tab 200 mg (Vfend)

•

acyclovir cap 200 mg (Zovirax)

• • • •

Terapiaescalonada

Límite de surtido

Autorización previa

acyclovir tab 800 mg (Zovirax) famciclovir tab 125 mg (Famvir) famciclovir tab 250 mg (Famvir) famciclovir tab 500 mg (Famvir) valacyclovir hcl tab 500 mg (Valtrex) valacyclovir hcl tab 1 gm (Valtrex) VIH/SIDA abacavir sulfate tab 300 mg (base equiv) (Ziagen) abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg (Trizivir)

valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) Hepatitis

APTIVUS – tipranavir cap 250 mg

adefovir dipivoxil tab 10 mg (Hepsera)

APTIVUS – tipranavir oral soln 100 mg/ ml

BARACLUDE – entecavir oral soln 0.05 mg/ml

ATRIPLA – efavirenz-emtricitabinetenofovir df tab 600-200-300 mg

DAKLINZA – daclatasvir dihydrochloride tab 30 mg (base equivalent)

COMPLERA – emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg CRIXIVAN – indinavir sulfate cap 200 mg

DAKLINZA – daclatasvir dihydrochloride tab 60 mg (base equivalent)

CRIXIVAN – indinavir sulfate cap 400 mg

DAKLINZA – daclatasvir dihydrochloride tab 90 mg (base equivalent)

DESCOVY – emtricitabine-tenofovir alafenamide fumarate tab 200-25 mg didanosine delayed release capsule 125 mg (Videx ec)

entecavir tab 0.5 mg (Baraclude) entecavir tab 1 mg (Baraclude)

4

Especialización

acyclovir tab 400 mg (Zovirax)

VALCYTE – valganciclovir hcl for soln 50 mg/ml (base equiv)

ribavirin tab 200 mg (Copegus)

Herpes acyclovir susp 200 mg/5ml (Zovirax)

Citomegalovirus

ribavirin cap 200 mg (Rebetol)

Terapiaescalonada

ZEPATIER – elbasvir-grazoprevir tab 50-100 mg

INFECCIONES VIRALES

lamivudine tab 100 mg (hbv) (Epivir hbv)

Nombre del medicamento

•

nystatin oral powder nystatin tab 500000 unit

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

didanosine delayed release capsule 200 mg (Videx ec)

• • • •

didanosine delayed release capsule 250 mg (Videx ec)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

didanosine delayed release capsule 400 mg (Videx ec)

• •

nevirapine tab sr 24hr 400 mg (Viramune xr) nevirapine tab 200 mg (Viramune) NORVIR – ritonavir cap 100 mg NORVIR – ritonavir tab 100 mg

INTELENCE – etravirine tab 100 mg

NORVIR – ritonavir oral soln 80 mg/ml

INTELENCE – etravirine tab 200 mg

ODEFSEY – emtricitabine-rilpivirinetenofovir af tab 200-25-25 mg

ISENTRESS – raltegravir potassium packet for susp 100 mg (base equiv) ISENTRESS – raltegravir potassium chew tab 25 mg (base equiv) ISENTRESS – raltegravir potassium chew tab 100 mg (base equiv) KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) KALETRA – lopinavir-ritonavir tab 100-25 mg KALETRA – lopinavir-ritonavir tab 200-50 mg lamivudine oral soln 10 mg/ml (Epivir) lamivudine tab 150 mg (Epivir)

Terapiaescalonada

nevirapine tab sr 24hr 100 mg (Viramune xr)

INTELENCE – etravirine tab 25 mg

ISENTRESS – raltegravir potassium tab 400 mg (base equiv)

Límite de surtido

NEVIRAPINE – nevirapine susp 50 mg/5ml

EPZICOM – abacavir sulfatelamivudine tab 600-300 mg

INVIRASE – saquinavir mesylate tab 500 mg

Autorización previa

LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv)

EPIVIR – lamivudine oral soln 10 mg/ml

INVIRASE – saquinavir mesylate cap 200 mg

Especialización

LEXIVA – fosamprenavir calcium tab 700 mg (base equiv)

EMTRIVA – emtricitabine soln 10 mg/ml

GENVOYA – elvitegrav-cobicemtricitab-tenofov af tab 150-150-200-10 mg

Terapiaescalonada

lamivudine-zidovudine tab 150-300 mg (Combivir)

EMTRIVA – emtricitabine caps 200 mg

FUZEON – enfuvirtide for inj 90 mg

Nombre del medicamento lamivudine tab 300 mg (Epivir)

EDURANT – rilpivirine hcl tab 25 mg (base equivalent)

EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg (base equiv)

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

PREZCOBIX – darunavir-cobicistat tab 800-150 mg PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) PREZISTA – darunavir ethanolate tab 75 mg (base equiv) PREZISTA – darunavir ethanolate tab 150 mg (base equiv) PREZISTA – darunavir ethanolate tab 600 mg (base equiv) PREZISTA – darunavir ethanolate tab 800 mg (base equiv) RESCRIPTOR – delavirdine mesylate tab 100 mg RESCRIPTOR – delavirdine mesylate tab 200 mg REYATAZ – atazanavir sulfate oral powder packet 50 mg (base equiv) REYATAZ – atazanavir sulfate cap 150 mg (base equiv)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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REYATAZ – atazanavir sulfate cap 200 mg (base equiv)

VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm

REYATAZ – atazanavir sulfate cap 300 mg (base equiv)

VIREAD – tenofovir disoproxil fumarate tab 150 mg

SELZENTRY – maraviroc tab 150 mg

VIREAD – tenofovir disoproxil fumarate tab 200 mg

SELZENTRY – maraviroc tab 300 mg stavudine cap 15 mg (Zerit) stavudine cap 20 mg (Zerit) stavudine cap 30 mg (Zerit) stavudine cap 40 mg (Zerit) stavudine for oral soln 1 mg/ml (Zerit) STRIBILD – elvitegrav-cobic-emtricitabtenofovdf tab 150-150-200-300 mg SUSTIVA – efavirenz tab 600 mg SUSTIVA – efavirenz cap 50 mg SUSTIVA – efavirenz cap 200 mg TIVICAY – dolutegravir sodium tab 50 mg (base equiv) TRIUMEQ – abacavir-dolutegravirlamivudine tab 600-50-300 mg TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 133-200 mg TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 167-250 mg TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg TYBOST – cobicistat tab 150 mg VIDEX – didanosine for soln 2 gm VIDEX – didanosine for soln 4 gm VIRACEPT – nelfinavir mesylate tab 250 mg VIRACEPT – nelfinavir mesylate tab 625 mg VIRAMUNE – nevirapine susp 50 mg/5ml

6

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

VIREAD – tenofovir disoproxil fumarate tab 250 mg VIREAD – tenofovir disoproxil fumarate tab 300 mg VITEKTA – elvitegravir tab 85 mg VITEKTA – elvitegravir tab 150 mg ZIAGEN – abacavir sulfate soln 20 mg/ ml (base equiv) zidovudine cap 100 mg (Retrovir) zidovudine syrup 10 mg/ml (Retrovir) zidovudine tab 300 mg Influenza RELENZA DISKHALER – zanamivir aero powder breath activated 5 mg/ blister rimantadine hydrochloride tab 100 mg (Flumadine) TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base equiv) TAMIFLU – oseltamivir phosphate cap 30 mg (base equiv) TAMIFLU – oseltamivir phosphate cap 45 mg (base equiv) TAMIFLU – oseltamivir phosphate cap 75 mg (base equiv) MALARIA atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) atovaquone-proguanil hcl tab 250-100 mg (Malarone) chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg (Aralen) Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

hydroxychloroquine sulfate tab 200 mg (Plaquenil)

metronidazole cap 375 mg (Flagyl)

mefloquine hcl tab 250 mg

metronidazole tab 500 mg (Flagyl)

RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 10 mcg/ml

ALBENZA – albendazole tab 200 mg BILTRICIDE – praziquantel tab 600 mg

RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 40 mcg/ml

ivermectin tab 3 mg (Stromectol) OTROS ANTIINFECCIOSOS

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)

• •

sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) tinidazole tab 250 mg (Tindamax)

clindamycin hcl cap 75 mg (Cleocin)

tinidazole tab 500 mg (Tindamax)

clindamycin hcl cap 150 mg (Cleocin)

trimethoprim tab 100 mg

clindamycin hcl cap 300 mg (Cleocin)

vancomycin hcl cap 125 mg (Vancocin hcl)

clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr)

vancomycin hcl cap 250 mg (Vancocin hcl)

dapsone tab 25 mg

XIFAXAN – rifaximin tab 550 mg

dapsone tab 100 mg ENGERIX-B – hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml

ZYVOX – linezolid for susp 100 mg/5ml MEDICAMENTOS CONTRA EL CÁNCER

ENGERIX-B – hepatitis b vaccine (recombinant) susp 20 mcg/ml

ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)

ENGERIX-B – hepatitis b vaccine (recombinant) 10 mcg/0.5ml

AFINITOR – everolimus tab 2.5 mg

ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ml

AFINITOR – everolimus tab 5 mg

IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdc inj

AFINITOR – everolimus tab 10 mg

IMPAVIDO – miltefosine cap 50 mg linezolid for susp 100 mg/5ml (Zyvox) linezolid tab 600 mg (Zyvox)

Terapiaescalonada

RABAVERT – rabies vaccine, pcec for inj

quinine sulfate cap 324 mg (Qualaquin) INFECCIONES PARASITARIAS

CAYSTON – aztreonam lysine for inhal soln 75 mg (base equivalent)

Límite de surtido

metronidazole tab 250 mg (Flagyl)

PRIMAQUINE PHOSPHATE – primaquine phosphate tab 26.3 mg (15 mg base)

atovaquone susp 750 mg/5ml (Mepron)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

AFINITOR – everolimus tab 7.5 mg

• • • •

AFINITOR DISPERZ – everolimus tab for oral susp 2 mg AFINITOR DISPERZ – everolimus tab for oral susp 3 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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AFINITOR DISPERZ – everolimus tab for oral susp 5 mg

GILOTRIF – afatinib dimaleate tab 40 mg (base equivalent)

ALKERAN – melphalan tab 2 mg

hydroxyurea cap 500 mg (Hydrea)

anastrozole tab 1 mg (Arimidex)

ICLUSIG – ponatinib hcl tab 15 mg (base equiv)

• •

bicalutamide tab 50 mg (Casodex) BOSULIF – bosutinib tab 100 mg CABOMETYX – cabozantinib s-malate tab 20 mg (base equivalent)

imatinib mesylate tab 400 mg (base equivalent) (Gleevec)

CABOMETYX – cabozantinib s-malate tab 40 mg (base equivalent) CABOMETYX – cabozantinib s-malate tab 60 mg (base equivalent) capecitabine tab 150 mg (Xeloda) capecitabine tab 500 mg (Xeloda) CAPRELSA – vandetanib tab 100 mg CAPRELSA – vandetanib tab 300 mg

ICLUSIG – ponatinib hcl tab 45 mg (base equiv) imatinib mesylate tab 100 mg (base equivalent) (Gleevec)

BOSULIF – bosutinib tab 500 mg

IRESSA – gefitinib tab 250 mg

• • • •

• • • •

JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent) JAKAFI – ruxolitinib phosphate tab 10 mg (base equivalent) JAKAFI – ruxolitinib phosphate tab 15 mg (base equivalent) JAKAFI – ruxolitinib phosphate tab 20 mg (base equivalent)

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit

JAKAFI – ruxolitinib phosphate tab 25 mg (base equivalent)

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit

LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy pack 10 mg (10 mg daily dose)

exemestane tab 25 mg (Aromasin) FARYDAK – panobinostat lactate cap 10 mg (base equivalent) FARYDAK – panobinostat lactate cap 15 mg (base equivalent) FARYDAK – panobinostat lactate cap 20 mg (base equivalent) flutamide cap 125 mg GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent)

8

Terapiaescalonada

• • • • • • • •

IMBRUVICA – ibrutinib cap 140 mg

COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit

ERIVEDGE – vismodegib cap 150 mg

Límite de surtido

GILOTRIF – afatinib dimaleate tab 30 mg (base equivalent)

ALECENSA – alectinib hcl cap 150 mg (base equivalent)

bexarotene cap 75 mg (Targretin)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

• •

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• •

• • • • • • • • • •

LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose) LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose) LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose) LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose)

POMALYST – pomalidomide cap 4 mg

letrozole tab 2.5 mg (Femara)

TAGRISSO – osimertinib mesylate tab 40 mg (base equivalent)

leucovorin calcium tab 25 mg

tamoxifen citrate tab 20 mg (base equivalent)

LEUKERAN – chlorambucil tab 2 mg

temozolomide cap 5 mg (Temodar)

LOMUSTINE – lomustine cap 10 mg

temozolomide cap 20 mg (Temodar)

LOMUSTINE – lomustine cap 40 mg LOMUSTINE – lomustine cap 100 mg

temozolomide cap 100 mg (Temodar)

LONSURF – trifluridine-tipiracil tab 15-6.14 mg

temozolomide cap 140 mg (Temodar) temozolomide cap 180 mg (Temodar)

LONSURF – trifluridine-tipiracil tab 20-8.19 mg

temozolomide cap 250 mg (Temodar)

megestrol acetate tab 20 mg megestrol acetate tab 40 mg mercaptopurine tab 50 mg methotrexate sodium tab 2.5 mg (base equiv) MYLERAN – busulfan tab 2 mg NINLARO – ixazomib citrate cap 2.3 mg (base equivalent) NINLARO – ixazomib citrate cap 3 mg (base equivalent) NINLARO – ixazomib citrate cap 4 mg (base equivalent) POMALYST – pomalidomide cap 1 mg POMALYST – pomalidomide cap 2 mg POMALYST – pomalidomide cap 3 mg

Terapiaescalonada

Límite de surtido

tamoxifen citrate tab 10 mg (base equivalent)

leucovorin calcium tab 5 mg

megestrol acetate susp 40 mg/ml (Megace oral)

• • • • • • •

TAGRISSO – osimertinib mesylate tab 80 mg (base equivalent)

LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg

MATULANE – procarbazine hcl cap 50 mg

• • • • • • •

PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml)

LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg

LYNPARZA – olaparib cap 50 mg

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

tretinoin cap 10 mg

• •

VENCLEXTA – venetoclax tab 10 mg VENCLEXTA – venetoclax tab 50 mg VENCLEXTA – venetoclax tab 100 mg VENCLEXTA STARTING PACK – venetoclax tab therapy starter pack 10 & 50 & 100 mg XTANDI – enzalutamide cap 40 mg

• •

ZYDELIG – idelalisib tab 100 mg ZYDELIG – idelalisib tab 150 mg ZYKADIA – ceritinib cap 150 mg HORMONAS, DIABETES Y MEDICAMENTOS RELACIONADOS

CORTICOSTEROIDES budesonide delayed release particles cap 3 mg (Entocort ec) CORTISONE ACETATE – cortisone acetate tab 25 mg DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml dexamethasone elixir 0.5 mg/5ml

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg dexamethasone tab 4 mg dexamethasone tab 6 mg fludrocortisone acetate tab 0.1 mg

PREDNISONE – prednisone tab therapy pack 10 mg (21)

hydrocortisone tab 10 mg (Cortef)

prednisone tab 1 mg

hydrocortisone tab 20 mg (Cortef)

prednisone tab 2.5 mg

methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak)

prednisone tab 5 mg

methylprednisolone tab 4 mg (Medrol)

prednisone tab 20 mg HORMONAS MASCULINAS

methylprednisolone tab 32 mg (Medrol) prednisolone sod phos orally disintegr tab 10 mg (base eq) (Orapred odt)

prednisone tab 10 mg

ANDRODERM – testosterone td patch 24hr 2 mg/24hr ANDRODERM – testosterone td patch 24hr 4 mg/24hr

danazol cap 100 mg

prednisolone sod phos orally disintegr tab 30 mg (base eq) (Orapred odt)

oxandrolone tab 2.5 mg (Oxandrin)

prednisolone syrup 15 mg/5ml (usp solution equivalent) PREDNISONE – prednisone tab 50 mg PREDNISONE – prednisone oral soln 5 mg/5ml

10

•

danazol cap 50 mg danazol cap 200 mg

prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)

•

ANDROXY – fluoxymesterone tab 10 mg

prednisolone sod phos orally disintegr tab 15 mg (base eq) (Orapred odt)

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred)

Terapiaescalonada

PREDNISONE – prednisone tab therapy pack 5 mg (48)

PREDNISONE – prednisone tab therapy pack 10 mg (48)

methylprednisolone tab 16 mg (Medrol)

Límite de surtido

PREDNISONE – prednisone tab therapy pack 5 mg (21)

hydrocortisone tab 5 mg (Cortef)

methylprednisolone tab 8 mg (Medrol)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

methyltestosterone cap 10 mg (Testred) oxandrolone tab 10 mg (Oxandrin) testosterone td gel 25 mg/2.5gm (1%) (Androgel) testosterone td gel 50 mg/5gm (1%) (Androgel) testosterone td gel 12.5 mg/act (1%) (Androgel pump) ESTRÓGENOS COMBIPATCH – estradiolnorethindrone ace td pttw 0.05-0.14 mg/day

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

COMBIPATCH – estradiolnorethindrone ace td pttw 0.05-0.25 mg/day

estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara)

DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)

estradiol td patch weekly 0.05 mg/24hr (Climara)

DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)

estradiol td patch weekly 0.06 mg/24hr (Climara)

DIVIGEL – estradiol td gel 1 mg/gm (0.1%)

estradiol td patch weekly 0.075 mg/24hr (Climara)

ENJUVIA – estrogens, conjugated synthetic b tab 0.3 mg

estradiol td patch weekly 0.1 mg/24hr (Climara)

ENJUVIA – estrogens, conjugated synthetic b tab 0.45 mg

ESTROPIPATE – estropipate tab 3 mg

ENJUVIA – estrogens, conjugated synthetic b tab 0.625 mg

estropipate tab 1.5 mg

ENJUVIA – estrogens, conjugated synthetic b tab 0.9 mg ENJUVIA – estrogens, conjugated synthetic b tab 1.25 mg estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) estradiol & norethindrone acetate tab 1-0.5 mg (Activella) estradiol tab 0.5 mg (Estrace) estradiol tab 1 mg (Estrace)

Terapiaescalonada

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose) norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg PROGESTINAS medroxyprogesterone acetate tab 2.5 mg (Provera) medroxyprogesterone acetate tab 5 mg (Provera) medroxyprogesterone acetate tab 10 mg (Provera)

estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot)

megestrol acetate susp 625 mg/5ml (Megace es)

estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot)

norethindrone acetate tab 5 mg (Aygestin)

estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot)

progesterone micronized cap 100 mg (Prometrium)

estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-dot)

progesterone micronized cap 200 mg (Prometrium) ANTICONCEPTIVOS

estradiol td patch weekly 0.025 mg/24hr (Climara)

Límite de surtido

estropipate tab 0.75 mg

estradiol tab 2 mg (Estrace)

estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

DIAPHRAGMS - VARIOUS ELLA – ulipristal acetate tab 30 mg LEVONORGESTREL – levonorgestrel tab 0.75 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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levonorgestrel tab 1.5 mg (Plan b one-step)

glyburide micronized tab 3 mg (Glynase)

NUVARING – etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr

glyburide micronized tab 6 mg (Glynase)

oral contraceptives - all generics

glyburide tab 1.25 mg

ORTHO EVRA – norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr

glyburide tab 2.5 mg

XULANE – norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr

glyburide-metformin tab 1.25-250 mg (Glucovance)

BRAVELLE – urofollitropin purified for inj 75 unit CETROTIDE – cetrorelix acetate for inj kit 0.25 mg DIABETES acarbose tab 25 mg (Precose) acarbose tab 50 mg (Precose) acarbose tab 100 mg (Precose) glimepiride tab 1 mg (Amaryl) glimepiride tab 2 mg (Amaryl) glimepiride tab 4 mg (Amaryl) glipizide tab sr 24hr 2.5 mg (Glucotrol xl) glipizide tab sr 24hr 5 mg (Glucotrol xl) glipizide tab sr 24hr 10 mg (Glucotrol xl)

glyburide-metformin tab 2.5-500 mg (Glucovance) glyburide-metformin tab 5-500 mg (Glucovance) JANUMET – sitagliptin-metformin hcl tab 50-500 mg JANUMET – sitagliptin-metformin hcl tab 50-1000 mg JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-500 mg JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-1000 mg JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 100-1000 mg

•

JANUVIA – sitagliptin phosphate tab 25 mg (base equiv)

•

JANUVIA – sitagliptin phosphate tab 50 mg (base equiv)

glipizide tab 5 mg (Glucotrol) glipizide tab 10 mg (Glucotrol)

KORLYM – mifepristone tab 300 mg

glipizide-metformin hcl tab 2.5-250 mg

metformin hcl tab sr 24hr 500 mg (Glucophage xr)

glipizide-metformin hcl tab 2.5-500 mg

metformin hcl tab sr 24hr 750 mg (Glucophage xr)

glipizide-metformin hcl tab 5-500 mg

metformin hcl tab sr 24hr osmotic 500 mg (Fortamet)

12

Terapiaescalonada

glyburide tab 5 mg

JANUVIA – sitagliptin phosphate tab 100 mg (base equiv)

GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg

Límite de surtido

glyburide micronized tab 1.5 mg (Glynase)

levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg

INFERTILITY

Autorización previa

Nombre del medicamento

Especialización

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • •

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

Terapiaescalonada

Límite de surtido

HUMALOG – insulin lispro (human) soln cartridge 100 unit/ml

metformin hcl tab sr 24hr modified release 500 mg (Glumetza)

HUMALOG – insulin lispro (human) inj 100 unit/ml

metformin hcl tab sr 24hr modified release 1000 mg (Glumetza)

HUMALOG KWIKPEN – insulin lispro (human) soln pen-injector 100 unit/ml

metformin hcl tab 500 mg (Glucophage)

HUMALOG KWIKPEN – insulin lispro (human) soln pen-injector 200 unit/ml

metformin hcl tab 850 mg (Glucophage)

NOVOLOG – insulin aspart inj 100 unit/ ml

metformin hcl tab 1000 mg (Glucophage)

NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/ml

miglitol tab 25 mg (Glyset) miglitol tab 50 mg (Glyset)

NOVOLOG PENFILL – insulin aspart soln cartridge 100 unit/ml Insulinas de acción breve

miglitol tab 100 mg (Glyset) nateglinide tab 60 mg (Starlix)

HUMULIN R – insulin regular (human) inj 100 unit/ml

nateglinide tab 120 mg (Starlix) pioglitazone hcl tab 15 mg (base equiv) (Actos)

HUMULIN R U-500 (CONCENTR – insulin regular (human) inj 500 unit/ml

pioglitazone hcl tab 30 mg (base equiv) (Actos)

HUMULIN R U-500 KWIKPEN – insulin regular (human) soln pen-injector 500 unit/ml

pioglitazone hcl tab 45 mg (base equiv) (Actos)

NOVOLIN R – insulin regular (human) inj 100 unit/ml

pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)

NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml

pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)

RELION R – insulin regular (human) inj 100 unit/ml Insulinas de acción intermedia

pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met) pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met)

HUMALOG MIX 50/50 – insulin lispro prot & lispro (human) inj 100 unit/ml (50-50)

repaglinide tab 0.5 mg (Prandin) repaglinide tab 1 mg (Prandin)

HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50)

repaglinide tab 2 mg (Prandin) VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) DIABETES - INSULINAS

Autorización previa

Insulinas de acción rápida

metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet)

tolazamide tab 250 mg

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

•

HUMALOG MIX 75/25 – insulin lispro prot & lispro (human) inj 100 unit/ml (75-25)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25) HUMULIN N – insulin nph (human) (isophane) inj 100 unit/ml HUMULIN N KWIKPEN – insulin nph (human) (isophane) susp pen-injector 100 unit/ml HUMULIN 70/30 – insulin nph isophane & regular human inj 100 unit/ml (70-30) HUMULIN 70/30 KWIKPEN – insulin nph & regular susp pen-inj 100 unit/ ml (70-30) NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml NOVOLIN N RELION – insulin nph (human) (isophane) inj 100 unit/ml NOVOLIN 70/30 – insulin nph isophane & regular human inj 100 unit/ml (70-30) NOVOLIN 70/30 RELION – insulin nph isophane & regular human inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & aspart sus peninj 100 unit/ml (70-30) Insulinas basales LANTUS – insulin glargine inj 100 unit/ ml LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml LEVEMIR – insulin detemir inj 100 unit/ ml LEVEMIR FLEXPEN – insulin detemir soln pen-injector 100 unit/ml LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector 100 unit/ml

14

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

TOUJEO SOLOSTAR – insulin glargine soln pen-injector 300 unit/ml REGULACIÓN TIROIDEA levothyroxine sodium tab 25 mcg (Synthroid) levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium tab 75 mcg (Synthroid) levothyroxine sodium tab 88 mcg (Synthroid) levothyroxine sodium tab 100 mcg (Synthroid) levothyroxine sodium tab 112 mcg (Synthroid) levothyroxine sodium tab 125 mcg (Synthroid) levothyroxine sodium tab 137 mcg (Synthroid) levothyroxine sodium tab 150 mcg (Synthroid) levothyroxine sodium tab 175 mcg (Synthroid) levothyroxine sodium tab 200 mcg (Synthroid) levothyroxine sodium tab 300 mcg (Synthroid) liothyronine sodium tab 5 mcg (Cytomel) liothyronine sodium tab 25 mcg (Cytomel) liothyronine sodium tab 50 mcg (Cytomel) methimazole tab 5 mg (Tapazole) methimazole tab 10 mg (Tapazole) propylthiouracil tab 50 mg thyroid tab 30 mg (1/2 grain) (Armour thyroid)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

thyroid tab 60 mg (1 grain) (Armour thyroid)

calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)

thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) HORMONAS DE CRECIMIENTO

calcitriol cap 0.25 mcg (Rocaltrol)

EGRIFTA – tesamorelin acetate for inj 1 mg (base equiv) EGRIFTA – tesamorelin acetate for inj 2 mg (base equiv) INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml) SEROSTIM – somatropin (nonrefrigerated) for subcutaneous inj 4 mg SEROSTIM – somatropin (nonrefrigerated) for subcutaneous inj 5 mg SEROSTIM – somatropin (nonrefrigerated) for subcutaneous inj 6 mg

calcitriol oral soln 1 mcg/ml (Rocaltrol)

• •

CARBAGLU – carglumic acid tab 200 mg

•

desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)

• •

desmopressin acetate nasal spray soln 0.01% (Ddavp)

• • • •

ACTONEL – risedronate sodium tab 5 mg

Terapiaescalonada

desmopressin acetate tab 0.1 mg (Ddavp) desmopressin acetate tab 0.2 mg (Ddavp) doxercalciferol cap 0.5 mcg (Hectorol) doxercalciferol cap 1 mcg (Hectorol)

ETIDRONATE DISODIUM – etidronate disodium tab 400 mg

ALENDRONATE SODIUM – alendronate sodium tab 40 mg

H.P. ACTHAR – corticotropin inj gel 80 unit/ml

alendronate sodium tab 5 mg

ibandronate sodium tab 150 mg (base equivalent) (Boniva)

alendronate sodium tab 10 mg alendronate sodium tab 35 mg

cabergoline tab 0.5 mg

desmopressin acetate nasal spray soln 0.01% (refrigerated)

ETIDRONATE DISODIUM – etidronate disodium tab 200 mg

ACTONEL – risedronate sodium tab 35 mg

BUPHENYL – sodium phenylbutyrate oral powder 3 gm/teaspoonful

• •

doxercalciferol cap 2.5 mcg (Hectorol)

ACTONEL – risedronate sodium tab 30 mg

BUPHENYL – sodium phenylbutyrate tab 500 mg

Límite de surtido

calcitriol cap 0.5 mcg (Rocaltrol)

OTRAS HORMONAS Y MEDICAMENTOS RELACIONADOS

alendronate sodium tab 70 mg (Fosamax)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

KUVAN – sapropterin dihydrochloride soluble tab 100 mg

• •

KUVAN – sapropterin dihydrochloride powder packet 100 mg

•

KUVAN – sapropterin dihydrochloride powder packet 500 mg

• • • • •

levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

15

levocarnitine tab 330 mg (Carnitor)

SIGNIFOR – pasireotide diaspartate inj 0.9 mg/ml (base equiv)

NATPARA – parathyroid hormone (recombinant) for inj cartridge 50 mcg

sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl)

NATPARA – parathyroid hormone (recombinant) for inj cartridge 75 mcg

ORFADIN – nitisinone cap 10 mg

SOMAVERT – pegvisomant for inj 10 mg (as protein)

• • • • • •

paricalcitol cap 1 mcg (Zemplar) paricalcitol cap 4 mcg RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml

SOMAVERT – pegvisomant for inj 15 mg (as protein) SOMAVERT – pegvisomant for inj 20 mg (as protein)

• • • • • •

SOMAVERT – pegvisomant for inj 25 mg (as protein)

• •

STIMATE – desmopressin acetate nasal soln 1.5 mg/ml STRENSIQ – asfotase alfa subcutaneous inj 18 mg/0.45ml

risedronate sodium tab delayed release 35 mg (Atelvia)

STRENSIQ – asfotase alfa subcutaneous inj 28 mg/0.7ml

risedronate sodium tab 5 mg (Actonel)

STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml

risedronate sodium tab 30 mg (Actonel)

STRENSIQ – asfotase alfa subcutaneous inj 80 mg/0.8ml

risedronate sodium tab 35 mg (Actonel)

XURIDEN – uridine triacetate oral granules packet 2 gm MEDICAMENTOS CARDÍACOS Y CIRCULATORIOS

risedronate sodium tab 150 mg (Actonel) SAMSCA – tolvaptan tab 15 mg SAMSCA – tolvaptan tab 30 mg SENSIPAR – cinacalcet hcl tab 30 mg (base equiv) SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)

16

Terapiaescalonada

Límite de surtido

Autorización previa

•

SOMAVERT – pegvisomant for inj 30 mg (as protein)

paricalcitol cap 2 mcg (Zemplar) raloxifene hcl tab 60 mg (Evista)

Especialización

SIGNIFOR – pasireotide diaspartate inj 0.6 mg/ml (base equiv)

NATPARA – parathyroid hormone (recombinant) for inj cartridge 25 mcg

ORFADIN – nitisinone cap 5 mg

Terapiaescalonada

SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base equiv)

MYALEPT – metreleptin for subcutaneous inj 11.3 mg

ORFADIN – nitisinone cap 2 mg

Nombre del medicamento SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)

methylergonovine maleate tab 0.2 mg

NATPARA – parathyroid hormone (recombinant) for inj cartridge 100 mcg

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • • •

INHIBIDORES DE LA ENZIMA CONVERTIDORA DE ANGIOTENSINA (ACE, POR SU SIGLA EN INGLÉS) YCOMBINACIONES

benazepril & hydrochlorothiazide tab 5-6.25 mg benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct)

fosinopril sodium tab 20 mg

benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct)

lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)

benazepril hcl tab 5 mg benazepril hcl tab 10 mg (Lotensin) benazepril hcl tab 20 mg (Lotensin) benazepril hcl tab 40 mg (Lotensin) captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg

lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) lisinopril tab 2.5 mg (Zestril) lisinopril tab 5 mg (Prinivil) lisinopril tab 10 mg (Prinivil)

CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-15 mg

lisinopril tab 30 mg (Zestril) lisinopril tab 40 mg (Zestril)

CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-25 mg

moexipril hcl tab 15 mg

moexipril hcl tab 7.5 mg moexipril-hydrochlorothiazide tab 7.5-12.5 mg moexipril-hydrochlorothiazide tab 15-12.5 mg

CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-25 mg

moexipril-hydrochlorothiazide tab 15-25 mg

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

perindopril erbumine tab 4 mg (Aceon)

enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)

perindopril erbumine tab 8 mg (Aceon)

enalapril maleate tab 2.5 mg (Vasotec)

quinapril hcl tab 10 mg (Accupril)

enalapril maleate tab 10 mg (Vasotec) enalapril maleate tab 20 mg (Vasotec) fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg fosinopril sodium tab 10 mg

Terapiaescalonada

lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic)

lisinopril tab 20 mg (Prinivil)

enalapril maleate tab 5 mg (Vasotec)

Límite de surtido

fosinopril sodium tab 40 mg

captopril tab 100 mg

CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-15 mg

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

perindopril erbumine tab 2 mg

quinapril hcl tab 5 mg (Accupril) quinapril hcl tab 20 mg (Accupril) quinapril hcl tab 40 mg (Accupril) quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) ramipril cap 1.25 mg (Altace)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

17

ramipril cap 2.5 mg (Altace)

trandolapril tab 1 mg (Mavik) trandolapril tab 2 mg (Mavik) trandolapril tab 4 mg ANTAGONISTAS RECEPTORES DE ANGIOTENSINA II (ARA-II) Y COMBINACIONES

candesartan cilexetil tab 32 mg (Atacand) candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg (Atacand hct)

amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg (Exforge hct)

candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg (Atacand hct)

amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg (Exforge hct)

candesartan cilexetilhydrochlorothiazide tab 32-25 mg (Atacand hct)

amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg (Exforge hct)

EPROSARTAN MESYLATE – eprosartan mesylate tab 600 mg

amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg (Exforge hct)

irbesartan tab 150 mg (Avapro)

BENICAR – olmesartan medoxomil tab 20 mg BENICAR – olmesartan medoxomil tab 40 mg BENICAR HCT – olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg BENICAR HCT – olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg BENICAR HCT – olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg candesartan cilexetil tab 4 mg (Atacand)

18

Terapiaescalonada

candesartan cilexetil tab 16 mg (Atacand)

ramipril cap 10 mg (Altace)

BENICAR – olmesartan medoxomil tab 5 mg

Límite de surtido

candesartan cilexetil tab 8 mg (Atacand)

ramipril cap 5 mg (Altace)

amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg (Exforge hct)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

irbesartan tab 75 mg (Avapro) irbesartan tab 300 mg (Avapro) irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide)

• • • • • •

irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar) losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar) losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar) losartan potassium tab 25 mg (Cozaar) losartan potassium tab 50 mg (Cozaar) losartan potassium tab 100 mg (Cozaar) telmisartan tab 20 mg (Micardis)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

telmisartan tab 40 mg (Micardis) telmisartan tab 80 mg (Micardis) telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct)

telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct)

carvedilol tab 3.125 mg (Coreg) carvedilol tab 6.25 mg (Coreg)

valsartan tab 40 mg (Diovan)

carvedilol tab 12.5 mg (Coreg)

valsartan tab 80 mg (Diovan)

carvedilol tab 25 mg (Coreg)

valsartan tab 160 mg (Diovan)

labetalol hcl tab 100 mg

valsartan tab 320 mg (Diovan)

labetalol hcl tab 200 mg

valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct)

labetalol hcl tab 300 mg

valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct) valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) BETA BLOQUEADORES Y COMBINACINES acebutolol hcl cap 200 mg (Sectral) acebutolol hcl cap 400 mg (Sectral) atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) atenolol tab 25 mg (Tenormin) atenolol tab 50 mg (Tenormin) atenolol tab 100 mg (Tenormin) betaxolol hcl tab 10 mg (Kerlone) betaxolol hcl tab 20 mg (Kerlone) bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)

Terapiaescalonada

bisoprolol fumarate tab 5 mg (Zebeta) bisoprolol fumarate tab 10 mg (Zebeta)

valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct)

Límite de surtido

bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac)

telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)

valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct) metoprolol & hydrochlorothiazide tab 100-50 mg metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) (Toprol xl) metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) (Toprol xl) metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) (Toprol xl) metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) (Toprol xl) metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg (Lopressor) metoprolol tartrate tab 100 mg (Lopressor) nadolol & bendroflumethiazide tab 40-5 mg (Corzide) nadolol & bendroflumethiazide tab 80-5 mg (Corzide) nadolol tab 20 mg (Corgard) nadolol tab 40 mg (Corgard)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

19

nadolol tab 80 mg (Corgard)

propranolol hcl cap sr 24hr 60 mg (Inderal la)

propranolol hcl tab 40 mg

amlodipine besylate-benazepril hcl cap 2.5-10 mg

propranolol hcl tab 60 mg

amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel)

propranolol hcl tab 80 mg PROPRANOLOL/HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 40-25 mg

amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel)

PROPRANOLOL/HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 80-25 mg BLOQUEADORES DE LOS CANALES DE CALCIO Y COMBINACIONES

20

Terapiaescalonada

amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet)

propranolol hcl tab 20 mg

amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet)

Límite de surtido

amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet)

propranolol hcl tab 10 mg

amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet)

Autorización previa

amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet)

propranolol hcl cap sr 24hr 160 mg (Inderal la)

amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet)

Especialización

amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet)

propranolol hcl cap sr 24hr 120 mg (Inderal la)

amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet)

Terapiaescalonada

amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet)

propranolol hcl cap sr 24hr 80 mg (Inderal la)

amlodipine besylate tab 10 mg (Norvasc)

Límite de surtido

amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet)

pindolol tab 10 mg

amlodipine besylate tab 5 mg (Norvasc)

Nombre del medicamento amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet)

pindolol tab 5 mg

amlodipine besylate tab 2.5 mg (Norvasc)

Autorización previa

Nombre del medicamento

Especialización

2016

amlodipine besylate-benazepril hcl cap 5-40 mg amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) amlodipine besylate-valsartan tab 5-160 mg (Exforge) amlodipine besylate-valsartan tab 5-320 mg (Exforge) amlodipine besylate-valsartan tab 10-160 mg (Exforge) amlodipine besylate-valsartan tab 10-320 mg (Exforge) diltiazem hcl cap sr 12hr 60 mg diltiazem hcl cap sr 12hr 90 mg diltiazem hcl cap sr 12hr 120 mg diltiazem hcl cap sr 24hr 120 mg diltiazem hcl cap sr 24hr 180 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

diltiazem hcl cap sr 24hr 240 mg

felodipine tab sr 24hr 10 mg

diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd)

isradipine cap 2.5 mg

diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd)

nicardipine hcl cap 20 mg

diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd) diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd) diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd) diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la) diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la) diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la) diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la) diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la)

nifedipine cap 10 mg (Procardia) nifedipine cap 20 mg nifedipine tab sr 24hr 30 mg (Adalat cc) nifedipine tab sr 24hr 60 mg (Adalat cc) nifedipine tab sr 24hr 90 mg (Adalat cc) nifedipine tab sr 24hr osmotic release 30 mg (Procardia xl) nifedipine tab sr 24hr osmotic release 60 mg (Procardia xl) nifedipine tab sr 24hr osmotic release 90 mg (Procardia xl) nimodipine cap 30 mg

diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac)

nisoldipine tab sr 24hr 34 mg (Sular)

diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac) diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac) diltiazem hcl tab 30 mg (Cardizem) diltiazem hcl tab 60 mg (Cardizem) diltiazem hcl tab 90 mg diltiazem hcl tab 120 mg (Cardizem) felodipine tab sr 24hr 2.5 mg

Terapiaescalonada

nicardipine hcl cap 30 mg

nisoldipine tab sr 24hr 8.5 mg (Sular)

diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac)

Límite de surtido

isradipine cap 5 mg

diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac)

diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

nisoldipine tab sr 24hr 17 mg (Sular) telmisartan-amlodipine tab 40-5 mg (Twynsta) telmisartan-amlodipine tab 40-10 mg (Twynsta) telmisartan-amlodipine tab 80-5 mg (Twynsta) telmisartan-amlodipine tab 80-10 mg (Twynsta) trandolapril-verapamil hcl tab cr 1-240 mg (Tarka) trandolapril-verapamil hcl tab cr 2-180 mg (Tarka) trandolapril-verapamil hcl tab cr 2-240 mg (Tarka)

felodipine tab sr 24hr 5 mg Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)

isosorbide mononitrate tab 10 mg

verapamil hcl cap sr 24hr 100 mg (Verelan pm)

nitroglycerin cap cr 2.5 mg

verapamil hcl cap sr 24hr 120 mg (Verelan) verapamil hcl cap sr 24hr 180 mg (Verelan) verapamil hcl cap sr 24hr 200 mg (Verelan pm) verapamil hcl cap sr 24hr 240 mg (Verelan) verapamil hcl cap sr 24hr 300 mg (Verelan pm) verapamil hcl cap sr 24hr 360 mg (Verelan) verapamil hcl tab cr 120 mg (Calan sr) verapamil hcl tab cr 180 mg (Calan sr) verapamil hcl tab cr 240 mg (Calan sr) verapamil hcl tab 40 mg verapamil hcl tab 80 mg (Calan) verapamil hcl tab 120 mg (Calan) DOLOR TORÁCICO ISOSORBIDE DINITRATE ER – isosorbide dinitrate tab cr 40 mg isosorbide dinitrate tab 5 mg (Isordil titradose) isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg isosorbide mononitrate tab sr 24hr 30 mg isosorbide mononitrate tab sr 24hr 60 mg isosorbide mononitrate tab sr 24hr 120 mg

22

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

isosorbide mononitrate tab 20 mg nitroglycerin cap cr 6.5 mg nitroglycerin cap cr 9 mg nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual pumpspr) NITROSTAT – nitroglycerin sl tab 0.3 mg NITROSTAT – nitroglycerin sl tab 0.4 mg NITROSTAT – nitroglycerin sl tab 0.6 mg REDUCTORES DEL COLESTEROL atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) cholestyramine light powder packets 4 gm cholestyramine light powder 4 gm/ dose (Questran light) cholestyramine powder packets 4 gm (Questran) cholestyramine powder 4 gm/dose (Questran) Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)

JUXTAPID – lomitapide mesylate cap 60 mg (base equiv)

choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix)

KYNAMRO – mipomersen sodium soln prefilled syringe 200 mg/ml

colestipol hcl granule packets 5 gm (Colestid flavored)

lovastatin tab 10 mg

colestipol hcl granules 5 gm (Colestid flavored)

lovastatin tab 40 mg (Mevacor)

•

CRESTOR – rosuvastatin calcium tab 40 mg fenofibrate micronized cap 43 mg

fenofibrate micronized cap 134 mg (Lofibra)

pravastatin sodium tab 20 mg (Pravachol) pravastatin sodium tab 40 mg (Pravachol)

fenofibrate tab 48 mg (Tricor) fenofibrate tab 54 mg (Lofibra)

pravastatin sodium tab 80 mg (Pravachol)

fenofibrate tab 145 mg (Tricor)

rosuvastatin calcium tab 5 mg (Crestor)

fenofibrate tab 160 mg (Lofibra) fluvastatin sodium cap 20 mg

rosuvastatin calcium tab 10 mg (Crestor)

fluvastatin sodium cap 40 mg fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)

JUXTAPID – lomitapide mesylate cap 30 mg (base equiv) JUXTAPID – lomitapide mesylate cap 40 mg (base equiv)

Terapiaescalonada

pravastatin sodium tab 10 mg

fenofibrate micronized cap 200 mg (Lofibra)

JUXTAPID – lomitapide mesylate cap 20 mg (base equiv)

niacin tab cr 750 mg (antihyperlipidemic) (Niaspan)

omega-3-acid ethyl esters cap 1 gm (Lovaza)

fenofibrate micronized cap 130 mg

JUXTAPID – lomitapide mesylate cap 10 mg (base equiv)

niacin tab cr 500 mg (antihyperlipidemic) (Niaspan)

niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan)

fenofibrate micronized cap 67 mg (Lofibra)

JUXTAPID – lomitapide mesylate cap 5 mg (base equiv)

Límite de surtido

lovastatin tab 20 mg

colestipol hcl tab 1 gm (Colestid)

gemfibrozil tab 600 mg (Lopid)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

rosuvastatin calcium tab 20 mg (Crestor)

• • • • • •

rosuvastatin calcium tab 40 mg (Crestor) simvastatin tab 5 mg (Zocor) simvastatin tab 10 mg (Zocor) simvastatin tab 20 mg (Zocor) simvastatin tab 40 mg (Zocor) simvastatin tab 80 mg (Zocor) WELCHOL – colesevelam hcl tab 625 mg WELCHOL – colesevelam hcl packet for susp 3.75 gm

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

23

RETENCIÓN DE LÍQUIDOS (EDEMA) ACETAZOLAMIDE – acetazolamide tab 125 mg

spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide)

acetazolamide cap sr 12hr 500 mg (Diamox)

spironolactone tab 25 mg (Aldactone) spironolactone tab 50 mg (Aldactone)

acetazolamide tab 250 mg

spironolactone tab 100 mg (Aldactone)

amiloride & hydrochlorothiazide tab 5-50 mg

torsemide tab 10 mg (Demadex)

bumetanide tab 0.5 mg (Bumex)

torsemide tab 20 mg (Demadex)

bumetanide tab 1 mg (Bumex)

torsemide tab 100 mg

bumetanide tab 2 mg (Bumex)

triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide)

chlorothiazide tab 500 mg CHLORTHALIDONE – chlorthalidone tab 50 mg chlorthalidone tab 25 mg furosemide oral soln 10 mg/ml furosemide tab 20 mg (Lasix) furosemide tab 40 mg (Lasix) furosemide tab 80 mg (Lasix) hydrochlorothiazide cap 12.5 mg (Microzide) hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg indapamide tab 2.5 mg methazolamide tab 25 mg (Neptazane) methazolamide tab 50 mg (Neptazane) metolazone tab 2.5 mg metolazone tab 5 mg metolazone tab 10 mg

24

Terapiaescalonada

Límite de surtido

torsemide tab 5 mg

amiloride hcl tab 5 mg

CHLOROTHIAZIDE – chlorothiazide tab 250 mg

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) TRIAMTERENE/HYDROCHLOROTH – triamterene & hydrochlorothiazide cap 50-25 mg RITMO CARDÍACO amiodarone hcl tab 100 mg amiodarone hcl tab 200 mg (Cordarone) amiodarone hcl tab 400 mg disopyramide phosphate cap 100 mg (Norpace) disopyramide phosphate cap 150 mg (Norpace) dofetilide cap 125 mcg (0.125 mg) (Tikosyn) dofetilide cap 250 mcg (0.25 mg) (Tikosyn) dofetilide cap 500 mcg (0.5 mg) (Tikosyn) flecainide acetate tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

mexiletine hcl cap 150 mg

ADEMPAS – riociguat tab 2.5 mg

mexiletine hcl cap 200 mg

clonidine hcl tab 0.1 mg (Catapres)

mexiletine hcl cap 250 mg

clonidine hcl tab 0.2 mg (Catapres)

MULTAQ – dronedarone hcl tab 400 mg (base equivalent)

clonidine hcl tab 0.3 mg (Catapres)

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1)

propafenone hcl cap sr 12hr 225 mg (Rythmol sr)

clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2)

propafenone hcl cap sr 12hr 325 mg (Rythmol sr)

clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3)

propafenone hcl cap sr 12hr 425 mg (Rythmol sr) propafenone hcl tab 150 mg

DIGOXIN – digoxin oral soln 0.05 mg/ ml

propafenone hcl tab 225 mg (Rythmol)

digoxin tab 125 mcg (0.125 mg) (Lanoxin)

propafenone hcl tab 300 mg

digoxin tab 250 mcg (0.25 mg) (Lanoxin)

quinidine gluconate tab cr 324 mg

doxazosin mesylate tab 1 mg (Cardura)

QUINIDINE SULFATE – quinidine sulfate tab 200 mg

doxazosin mesylate tab 2 mg (Cardura)

QUINIDINE SULFATE – quinidine sulfate tab 300 mg

doxazosin mesylate tab 4 mg (Cardura)

quinidine sulfate tab 300 mg sotalol hcl (afib/afl) tab 80 mg (Betapace af)

doxazosin mesylate tab 8 mg (Cardura)

sotalol hcl (afib/afl) tab 120 mg (Betapace af)

eplerenone tab 25 mg (Inspra)

sotalol hcl (afib/afl) tab 160 mg (Betapace af)

eplerenone tab 50 mg (Inspra)

sotalol hcl tab 80 mg (Betapace)

guanfacine hcl tab 2 mg (Tenex)

sotalol hcl tab 120 mg (Betapace)

hydralazine hcl tab 10 mg

sotalol hcl tab 160 mg (Betapace)

hydralazine hcl tab 25 mg

sotalol hcl tab 240 mg

hydralazine hcl tab 50 mg

OTROS MEDICAMENTOS RELACIONADOS AL CORAZÓN

hydralazine hcl tab 100 mg

ADCIRCA – tadalafil tab 20 mg (pah)

LETAIRIS – ambrisentan tab 5 mg

guanfacine hcl tab 1 mg (Tenex)

• •

ADEMPAS – riociguat tab 0.5 mg

LETAIRIS – ambrisentan tab 10 mg

ADEMPAS – riociguat tab 1 mg

methyldopa tab 250 mg

ADEMPAS – riociguat tab 1.5 mg

methyldopa tab 500 mg

ADEMPAS – riociguat tab 2 mg

midodrine hcl tab 2.5 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

• • • •

25

midodrine hcl tab 5 mg

UPTRAVI – selexipag tab 1200 mcg

midodrine hcl tab 10 mg

UPTRAVI – selexipag tab 1400 mcg

minoxidil tab 2.5 mg

UPTRAVI – selexipag tab 1600 mcg

minoxidil tab 10 mg

VENTAVIS – iloprost inhalation solution 10 mcg/ml

ORENITRAM – treprostinil diolamine tab cr 0.125 mg (base equiv) ORENITRAM – treprostinil diolamine tab cr 0.25 mg (base equiv)

VENTAVIS – iloprost inhalation solution 20 mcg/ml KIT PARA PICADURAS DE ABEJAS

ORENITRAM – treprostinil diolamine tab cr 1 mg (base equiv)

EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)

ORENITRAM – treprostinil diolamine tab cr 2.5 mg (base equiv) phenoxybenzamine hcl cap 10 mg (Dibenzyline)

EPIPEN-JR 2-PAK – epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) AGENTES RESPIRATORIOS

prazosin hcl cap 1 mg (Minipress)

ANTIHISTAMÍNICOS

prazosin hcl cap 2 mg (Minipress)

brompheniramine maleate tab sr 12hr 6 mg

prazosin hcl cap 5 mg (Minipress) sildenafil citrate tab 20 mg (Revatio)

• •

terazosin hcl cap 1 mg

TRACLEER – bosentan tab 125 mg TYVASO – treprostinil inhalation solution 0.6 mg/ml TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ml TYVASO STARTER – treprostinil inhalation solution 0.6 mg/ml UPTRAVI – selexipag tab therapy pack 200 mcg (140) & 800 mcg (60) UPTRAVI – selexipag tab 200 mcg UPTRAVI – selexipag tab 400 mcg UPTRAVI – selexipag tab 600 mcg UPTRAVI – selexipag tab 800 mcg UPTRAVI – selexipag tab 1000 mcg

26

Terapiaescalonada

Límite de surtido

• •

carbinoxamine maleate soln 4 mg/5ml cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)

terazosin hcl cap 5 mg TRACLEER – bosentan tab 62.5 mg

• •

carbinoxamine maleate tab 4 mg

terazosin hcl cap 2 mg terazosin hcl cap 10 mg

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • • • • • • • • •

clemastine fumarate tab 2.68 mg cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg desloratadine tab 5 mg (Clarinex) diphenhydramine hcl cap 50 mg diphenhydramine hcl elixir 12.5 mg/5ml levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal) levocetirizine dihydrochloride tab 5 mg (Xyzal) promethazine hcl suppos 12.5 mg promethazine hcl suppos 25 mg promethazine hcl suppos 50 mg promethazine hcl syrup 6.25 mg/5ml promethazine hcl tab 12.5 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

promethazine hcl tab 25 mg promethazine hcl tab 50 mg PRODUCTOS NASALES azelastine hcl nasal spray 0.1% (137 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro) budesonide nasal susp 32 mcg/act (Rhinocort aqua) flunisolide nasal soln 25 mcg/act (0.025%) fluticasone propionate nasal susp 50 mcg/act ipratropium bromide nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray) mometasone furoate nasal susp 50 mcg/act (Nasonex) olopatadine hcl nasal soln 0.6% (Patanase) triamcinolone acetonide nasal aerosol suspension 55 mcg/act TOS/RESFRÍO/ALERGIA acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% BENZONATATE – benzonatate cap 150 mg benzonatate cap 100 mg (Tessalon perles) benzonatate cap 200 mg brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg hydrocod polst-chlorphen polst er susp 10-8 mg/5ml (Tussionex pennkineti) hydrocodone w/ homatropine syrup 5-1.5 mg/5ml

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

hydrocodone w/ homatropine tab 5-1.5 mg

• •

• • • • •

•

phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml) phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml promethazine & phenylephrine syrup 6.25-5 mg/5ml promethazine w/ codeine syrup 6.25-10 mg/5ml promethazine-dm syrup 6.25-15 mg/5ml pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro) pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml sodium chloride soln nebu 0.9% sodium chloride soln nebu 3% sodium chloride soln nebu 7% (Hyper-sal) sodium chloride soln nebu 10% ASMA/ENFERMEDAD PULMONAR OBSTRUCTIVA CRÓNICA (EPOC)

ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 100-50 mcg/dose ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 250-50 mcg/dose ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 500-50 mcg/dose ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 mcg/act

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

• • • •

27

ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 mcg/act ADVAIR HFA – fluticasone-salmeterol inhal aerosol 230-21 mcg/act albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) albuterol sulfate soln nebu 0.5% (5 mg/ml) albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab sr 12hr 4 mg (Vospire er) albuterol sulfate tab sr 12hr 8 mg (Vospire er)

• • •

ATROVENT HFA – ipratropium bromide hfa inhal aerosol 17 mcg/act

•

budesonide inhalation susp 0.25 mg/2ml (Pulmicort)

•

budesonide inhalation susp 0.5 mg/2ml (Pulmicort)

• •

DULERA – mometasone furoateformoterol fumarate aerosol 200-5 mcg/act

ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activ 200 mcg/act

dyphylline-guaifenesin liqd 100-100 mg/5ml

ASMANEX HFA – mometasone furoate inhal aerosol suspension 100 mcg/act

ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 110 mcg/inh (breath activated) ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated) 28

COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol soln 20-100 mcg/act

DULERA – mometasone furoateformoterol fumarate aerosol 100-5 mcg/act

ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activ 100 mcg/act

ASMANEX TWISTHALER 14 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated)

budesonide inhalation susp 1 mg/2ml (Pulmicort)

CROMOLYN SODIUM – cromolyn sodium soln nebu 20 mg/2ml

albuterol sulfate tab 4 mg

ASMANEX TWISTHALER 120 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated)

ASMANEX TWISTHALER 60 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated) ASMANEX TWISTHALER 7 METE – mometasone furoate inhal powd 110 mcg/inh (breath activated)

albuterol sulfate tab 2 mg

ASMANEX HFA – mometasone furoate inhal aerosol suspension 200 mcg/act

FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/blister

•

FLOVENT DISKUS – fluticasone propionate aer pow ba 100 mcg/ blister

•

FLOVENT DISKUS – fluticasone propionate aer pow ba 250 mcg/ blister

•

FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)

•

FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • • • • • • • •

• • • • •

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/act (250/valve) FORADIL AEROLIZER – formoterol fumarate inhal cap 12 mcg INCRUSE ELLIPTA – umeclidinium br aero powd breath act 62.5 mcg/inh (base eq) ipratropium bromide inhal soln 0.02% ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate) levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex) levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex) levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex)

•

•

SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act

•

terbutaline sulfate tab 2.5 mg

theophylline tab sr 12hr 100 mg theophylline tab sr 12hr 200 mg

•

theophylline tab sr 12hr 450 mg

theophylline tab sr 12hr 300 mg theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600 mg

montelukast sodium tab 10 mg (base equiv) (Singulair)

OTRAS DROGAS RESPIRATORIAS

SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)

•

VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) zafirlukast tab 10 mg (Accolate)

SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv)

Terapiaescalonada

theophylline soln 80 mg/15ml

montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)

QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/valve)

•

terbutaline sulfate tab 5 mg

•

montelukast sodium chew tab 5 mg (base equiv) (Singulair)

QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/valve)

•

SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/ act

•

montelukast sodium chew tab 4 mg (base equiv) (Singulair)

Límite de surtido

SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act

SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/ act

•

Autorización previa

Nombre del medicamento

Especialización

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

zafirlukast tab 20 mg (Accolate)

•

ESBRIET – pirfenidone cap 267 mg

•

KALYDECO – ivacaftor packet 50 mg

KALYDECO – ivacaftor tab 150 mg

• •

KALYDECO – ivacaftor packet 75 mg OFEV – nintedanib esylate cap 100 mg (base equivalent)

•

OFEV – nintedanib esylate cap 150 mg (base equivalent) ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg MEDICAMENTOS GASTROINTESTINALES

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

29

LAXANTES

peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)

famotidine tab 20 mg (Pepcid) famotidine tab 40 mg (Pepcid)

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)

FIRST-OMEPRAZOLE – omeprazole susp 2 mg/ml (compound kit)

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyteflavor packs)

glycopyrrolate tab 2 mg (Robinul forte)

polyethylene glycol 3350 oral powder

hyoscyamine sulfate elixir 0.125 mg/5ml

ANTIDIARREICOS

hyoscyamine sulfate soln 0.125 mg/ ml

diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)

hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)

loperamide hcl cap 2 mg

hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)

opium tincture 1% (10 mg/ml) (morphine equiv) ÚLCERA/ENFERMEDAD POR REFLUJO GASTROESOFÁGICO (ERGE)

cimetidine tab 200 mg cimetidine tab 300 mg cimetidine tab 400 mg

hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid) hyoscyamine sulfate tab 0.125 mg (Levsin) lansoprazole cap delayed release 15 mg (Prevacid) lansoprazole cap delayed release 30 mg (Prevacid)

• •

methscopolamine bromide tab 2.5 mg (Pamine)

cimetidine tab 800 mg

methscopolamine bromide tab 5 mg (Pamine forte)

dicyclomine hcl cap 10 mg (Bentyl)

misoprostol tab 100 mcg (Cytotec)

dicyclomine hcl oral soln 10 mg/5ml

misoprostol tab 200 mcg (Cytotec)

dicyclomine hcl tab 20 mg (Bentyl)

nizatidine cap 150 mg

esomeprazole magnesium cap delayed release 20 mg (base eq) (Nexium)

nizatidine cap 300 mg

30

•

glycopyrrolate tab 1 mg (Robinul)

polyethylene glycol 3350 oral packet

cimetidine hcl soln 300 mg/5ml

Terapiaescalonada

famotidine for susp 40 mg/5ml (Pepcid)

lactulose solution 10 gm/15ml

chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg (Librax)

Límite de surtido

esomeprazole magnesium cap delayed release 40 mg (base eq) (Nexium)

bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit

amoxicillin cap-clarithro tablansopraz cap dr therapy pack (Prevpac)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

omeprazole cap delayed release 10 mg (Prilosec)

•

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

omeprazole cap delayed release 20 mg (Prilosec) omeprazole cap delayed release 40 mg (Prilosec)

•

pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)

• •

rabeprazole sodium ec tab 20 mg (Aciphex)

ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ranitidine hcl tab 150 mg (Zantac)

EMEND – aprepitant capsule therapy pack 80 & 125 mg EMEND – aprepitant capsule 40 mg EMEND – aprepitant capsule 80 mg EMEND – aprepitant capsule 125 mg granisetron hcl tab 1 mg

ondansetron hcl oral soln 4 mg/5ml (Zofran) ondansetron hcl tab 4 mg (Zofran) ondansetron hcl tab 8 mg (Zofran)

Terapiaescalonada

Límite de surtido

Autorización previa

CREON – pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit

• •

ZENPEP – pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit

• • • • • • • •

meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg

CREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit

SUCRAID – sacrosidase soln 8500 unit/ml

sucralfate tab 1 gm (Carafate)

dronabinol cap 10 mg (Marinol)

trimethobenzamide hcl cap 300 mg (Tigan) ENZIMAS DIGESTIVAS

CREON – pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit

ranitidine hcl tab 300 mg (Zantac)

dronabinol cap 5 mg (Marinol)

•

CREON – pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit

ranitidine hcl cap 300 mg

dronabinol cap 2.5 mg (Marinol)

ondansetron orally disintegrating tab 4 mg (Zofran odt)

• •

CREON – pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit

ranitidine hcl cap 150 mg

NÁUSEA Y VÓMITOS

ondansetron hcl tab 24 mg

ondansetron orally disintegrating tab 8 mg (Zofran odt)

omeprazole-sodium bicarbonate cap 20-1100 mg (Zegerid) omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid)

Nombre del medicamento

Especialización

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • •

ZENPEP – pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit OTROS MEDICAMENTOS GASTROINTESTINALES alosetron hcl tab 0.5 mg (base equiv) (Lotronex) alosetron hcl tab 1 mg (base equiv) (Lotronex)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

31

ASACOL HD – mesalamine tab delayed release 800 mg

metoclopramide hcl tab 10 mg (Reglan)

balsalazide disodium cap 750 mg (Colazal)

OCALIVA – obeticholic acid tab 5 mg

calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)

PENTASA – mesalamine cap cr 250 mg

CHENODAL – chenodiol tab 250 mg

CIMZIA – certolizumab pegol for inj kit 2 x 200 mg CIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200 mg/ml

• •

GATTEX – teduglutide (rdna) for inj kit 5 mg lactulose (encephalopathy) solution 10 gm/15ml MESALAMINE DR – mesalamine tab delayed release 800 mg mesalamine enema 4 gm mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa) metoclopramide hcl orally disintegrating tab 5 mg (Metozolv odt) metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 5 mg (Reglan)

32

sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) sulfasalazine tab 500 mg (Azulfidine) ursodiol cap 300 mg (Actigall)

• •

ursodiol tab 250 mg (Urso 250) ursodiol tab 500 mg (Urso forte)

• •

MEDICAMENTOS GENITOURINARIOS

• •

methenamine hippurate tab 1 gm (Hiprex)

INFECCIONES DEL TRACTO URINARIO

methenamine mandelate tab 1 gm

cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) DELZICOL – mesalamine cap dr 400 mg

Terapiaescalonada

PENTASA – mesalamine cap cr 500 mg

CHOLBAM – cholic acid cap 50 mg CHOLBAM – cholic acid cap 250 mg

Límite de surtido

OCALIVA – obeticholic acid tab 10 mg

calcium acetate (phosphate binder) tab 667 mg (Eliphos) CANASA – mesalamine suppos 1000 mg

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg

• •

methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg methenamine-hyosc-meth blue-sod phos-phen sal cap 118 mg methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg methenamine-hyosc-meth blue-sod phos-phen sal tab 81 mg methenamine-hyoscamine-meth blue-sod phos cap 120 mg methenamine-hyoscamine-meth blue-sod phos tab 81.6 mg (Urogesic-blue) nitrofurantoin macrocrystalline cap 25 mg (Macrodantin) nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)

clindamycin phosphate vaginal cream 2% (Cleocin)

nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)

metronidazole vaginal gel 0.75% (Metrogel-vaginal)

nitrofurantoin susp 25 mg/5ml (Furadantin) ESPASMOS EN EL TRACTO URINARIO bethanechol chloride tab 5 mg (Urecholine) bethanechol chloride tab 10 mg (Urecholine) bethanechol chloride tab 25 mg (Urecholine) bethanechol chloride tab 50 mg (Urecholine) darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) (Enablex) darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) (Enablex) flavoxate hcl tab 100 mg oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl) oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl) oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl) oxybutynin chloride tab 5 mg tolterodine tartrate cap sr 24hr 2 mg (Detrol la) tolterodine tartrate cap sr 24hr 4 mg (Detrol la) tolterodine tartrate tab 1 mg (Detrol) tolterodine tartrate tab 2 mg (Detrol)

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

terconazole vaginal cream 0.4% (Terazol 7) terconazole vaginal cream 0.8% (Terazol 3) terconazole vaginal suppos 80 mg VAGIFEM – estradiol vaginal tab 10 mcg OTROS MEDICAMENTOS GENITOURINARIOS acetic acid irrigation soln 0.25% alfuzosin hcl tab sr 24hr 10 mg (Uroxatral) CYSTAGON – cysteamine bitartrate cap 50 mg CYSTAGON – cysteamine bitartrate cap 150 mg

• •

dutasteride cap 0.5 mg (Avodart) dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn) finasteride tab 5 mg (Proscar) glycine irrigation soln 1.5% neomycin-polymyxin b gu irrigation soln (Neosporin gu irrigan) phenazopyridine hcl tab 100 mg (Pyridium) phenazopyridine hcl tab 200 mg (Pyridium) pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml potassium citrate & citric acid powder pack 3300-1002 mg

trospium chloride cap sr 24hr 60 mg

potassium citrate & citric acid soln 1100-334 mg/5ml

trospium chloride tab 20 mg PRODUCTOS VAGINALES

potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

33

potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10)

buspirone hcl tab 10 mg

potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15)

buspirone hcl tab 30 mg chlordiazepoxide hcl cap 10 mg chlordiazepoxide hcl cap 25 mg

sodium chloride irrigation soln 0.9%

clorazepate dipotassium tab 7.5 mg (Tranxene t)

clorazepate dipotassium tab 3.75 mg

sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi)

clorazepate dipotassium tab 15 mg DIAZEPAM – diazepam im solution auto-inj 10 mg/2ml

tamsulosin hcl cap 0.4 mg (Flomax) MEDICAMENTOS PARA EL SISTEMA NERVIOSO CENTRAL

•

DIAZEPAM – diazepam oral soln 1 mg/ ml diazepam tab 2 mg (Valium) diazepam tab 5 mg (Valium)

alprazolam orally disintegrating tab 0.5 mg

hydroxyzine hcl syrup 10 mg/5ml

diazepam tab 10 mg (Valium) hydroxyzine hcl tab 10 mg

alprazolam orally disintegrating tab 1 mg

alprazolam tab sr 24hr 0.5 mg (Xanax xr) alprazolam tab sr 24hr 1 mg (Xanax xr) alprazolam tab sr 24hr 2 mg (Xanax xr) alprazolam tab sr 24hr 3 mg (Xanax xr) alprazolam tab 0.25 mg (Xanax) alprazolam tab 0.5 mg (Xanax) alprazolam tab 1 mg (Xanax) alprazolam tab 2 mg (Xanax) buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg 34

•

diazepam conc 5 mg/ml

alprazolam orally disintegrating tab 0.25 mg

alprazolam orally disintegrating tab 2 mg

Terapiaescalonada

chlordiazepoxide hcl cap 5 mg

PROCYSBI – cysteamine bitartrate cap delayed release 75 mg (base equiv)

ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml

Límite de surtido

buspirone hcl tab 15 mg

PROCYSBI – cysteamine bitartrate cap delayed release 25 mg (base equiv)

ANSIEDAD

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg

• •

HYDROXYZINE PAMOATE – hydroxyzine pamoate cap 100 mg

•

hydroxyzine pamoate cap 25 mg (Vistaril)

•

hydroxyzine pamoate cap 50 mg (Vistaril)

•

lorazepam tab 0.5 mg (Ativan)

lorazepam conc 2 mg/ml lorazepam tab 1 mg (Ativan) lorazepam tab 2 mg (Ativan) meprobamate tab 200 mg meprobamate tab 400 mg oxazepam cap 10 mg oxazepam cap 15 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

oxazepam cap 30 mg

amitriptyline hcl tab 25 mg (Elavil) amitriptyline hcl tab 75 mg

AMOXAPINE – amoxapine tab 100 mg AMOXAPINE – amoxapine tab 150 mg APLENZIN – bupropion hbr tab sr 24hr 174 mg APLENZIN – bupropion hbr tab sr 24hr 348 mg APLENZIN – bupropion hbr tab sr 24hr 522 mg BRINTELLIX – vortioxetine hbr tab 5 mg (base equiv) BRINTELLIX – vortioxetine hbr tab 10 mg (base equiv) BRINTELLIX – vortioxetine hbr tab 20 mg (base equiv) bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr) bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr) bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr) bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl) bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl) bupropion hcl tab 75 mg bupropion hcl tab 100 mg citalopram hydrobromide oral soln 10 mg/5ml

Terapiaescalonada

Límite de surtido

Autorización previa

Especialización

clomipramine hcl cap 25 mg (Anafranil)

amitriptyline hcl tab 100 mg

AMOXAPINE – amoxapine tab 50 mg

•

citalopram hydrobromide tab 40 mg (base equiv) (Celexa)

amitriptyline hcl tab 50 mg

• •

citalopram hydrobromide tab 20 mg (base equiv) (Celexa)

amitriptyline hcl tab 10 mg

AMOXAPINE – amoxapine tab 25 mg

Nombre del medicamento citalopram hydrobromide tab 10 mg (base equiv) (Celexa)

DEPRESIÓN

amitriptyline hcl tab 150 mg

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • • • • • • •

clomipramine hcl cap 50 mg (Anafranil) clomipramine hcl cap 75 mg (Anafranil) desipramine hcl tab 10 mg (Norpramin) desipramine hcl tab 25 mg (Norpramin) desipramine hcl tab 50 mg

• •

desipramine hcl tab 75 mg

• •

desipramine hcl tab 150 mg

• • • • • • • • • • • •

desipramine hcl tab 100 mg DESVENLAFAXINE ER – desvenlafaxine tab sr 24hr 50 mg DESVENLAFAXINE ER – desvenlafaxine tab sr 24hr 100 mg DESVENLAFAXINE ER – desvenlafaxine fumarate tab sr 24hr 50 mg (base equiv) DESVENLAFAXINE ER – desvenlafaxine fumarate tab sr 24hr 100 mg (base equiv) DOXEPIN HCL – doxepin hcl cap 75 mg

• • • • • • • • •

doxepin hcl cap 10 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl conc 10 mg/ml

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta)

EMSAM – selegiline td patch 24hr 6 mg/24hr EMSAM – selegiline td patch 24hr 9 mg/24hr EMSAM – selegiline td patch 24hr 12 mg/24hr escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) escitalopram oxalate tab 5 mg (base equiv) (Lexapro) escitalopram oxalate tab 10 mg (base equiv) (Lexapro) escitalopram oxalate tab 20 mg (base equiv) (Lexapro) FETZIMA – levomilnacipran hcl cap sr 24hr 20 mg (base equivalent) FETZIMA – levomilnacipran hcl cap sr 24hr 40 mg (base equivalent) FETZIMA – levomilnacipran hcl cap sr 24hr 80 mg (base equivalent) FETZIMA – levomilnacipran hcl cap sr 24hr 120 mg (base equivalent) FETZIMA TITRATION PACK – levomilnacipran hcl cap sr 24hr 20 & 40 mg therapy pack FLUOXETINE HCL – fluoxetine hcl tab 60 mg fluoxetine hcl cap delayed release 90 mg (Prozac weekly) fluoxetine hcl cap 10 mg (Prozac) fluoxetine hcl cap 20 mg (Prozac) fluoxetine hcl cap 40 mg (Prozac) fluoxetine hcl solution 20 mg/5ml

36

• •

fluoxetine hcl tab 20 mg

fluvoxamine maleate cap sr 24hr 150 mg fluvoxamine maleate tab 50 mg

•

FORFIVO XL – bupropion hcl tab sr 24hr 450 mg

fluvoxamine maleate tab 100 mg

•

imipramine hcl tab 10 mg (Tofranil)

•

imipramine hcl tab 50 mg (Tofranil)

• •

Terapiaescalonada

imipramine pamoate cap 100 mg imipramine pamoate cap 125 mg imipramine pamoate cap 150 mg KHEDEZLA – desvenlafaxine tab sr 24hr 50 mg

• •

MAPROTILINE HCL – maprotiline hcl tab 25 mg

• •

MAPROTILINE HCL – maprotiline hcl tab 50 mg

• •

MAPROTILINE HCL – maprotiline hcl tab 75 mg

• • • •

• • • • •

imipramine pamoate cap 75 mg

KHEDEZLA – desvenlafaxine tab sr 24hr 100 mg

•

•

imipramine hcl tab 25 mg (Tofranil)

• •

• •

•

fluvoxamine maleate cap sr 24hr 100 mg

•

•

Límite de surtido

fluoxetine hcl tab 10 mg

fluvoxamine maleate tab 25 mg

•

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

• •

duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta) duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta)

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

MARPLAN – isocarboxazid tab 10 mg mirtazapine orally disintegrating tab 15 mg (Remeron soltab) mirtazapine orally disintegrating tab 30 mg (Remeron soltab) mirtazapine orally disintegrating tab 45 mg (Remeron soltab) mirtazapine tab 7.5 mg mirtazapine tab 15 mg (Remeron) mirtazapine tab 30 mg (Remeron)

• • • • • • • • • • •

• • • • • •

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

mirtazapine tab 45 mg (Remeron) NEFAZODONE HCL – nefazodone hcl tab 100 mg NEFAZODONE HCL – nefazodone hcl tab 150 mg NEFAZODONE HCL – nefazodone hcl tab 200 mg

•

NORTRIPTYLINE HCL – nortriptyline hcl soln 10 mg/5ml

PRISTIQ – desvenlafaxine succinate tab sr 24hr 50 mg (base equiv)

•

paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr) paroxetine hcl tab sr 24hr 25 mg (Paxil cr) paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr) paroxetine hcl tab 10 mg (Paxil) paroxetine hcl tab 20 mg (Paxil) paroxetine hcl tab 30 mg (Paxil) paroxetine hcl tab 40 mg (Paxil) PAXIL – paroxetine hcl oral susp 10 mg/5ml (base equiv) PEXEVA – paroxetine mesylate tab 10 mg (base equiv) PEXEVA – paroxetine mesylate tab 20 mg (base equiv) PEXEVA – paroxetine mesylate tab 30 mg (base equiv)

Terapiaescalonada

Límite de surtido

Autorización previa

Especialización

• •

sertraline hcl tab 25 mg (Zoloft) sertraline hcl tab 50 mg (Zoloft)

• • • • • •

sertraline hcl tab 100 mg (Zoloft)

• • •

trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg

• • • • • •

trimipramine maleate cap 50 mg (Surmontil)

• •

•

trazodone hcl tab 50 mg

trimipramine maleate cap 25 mg (Surmontil)

• •

• •

tranylcypromine sulfate tab 10 mg (Parnate)

•

• •

• •

protriptyline hcl tab 5 mg sertraline hcl oral conc 20 mg/ml (Zoloft)

nortriptyline hcl cap 50 mg (Pamelor)

OLEPTRO – trazodone hcl tab sr 24hr 300 mg

PRISTIQ – desvenlafaxine succinate tab sr 24hr 100 mg (base equiv) protriptyline hcl tab 10 mg

nortriptyline hcl cap 25 mg (Pamelor)

OLEPTRO – trazodone hcl tab sr 24hr 150 mg

PEXEVA – paroxetine mesylate tab 40 mg (base equiv) PRISTIQ – desvenlafaxine succinate tab sr 24hr 25 mg (base equiv)

nortriptyline hcl cap 10 mg (Pamelor)

nortriptyline hcl cap 75 mg (Pamelor)

Nombre del medicamento

phenelzine sulfate tab 15 mg (Nardil)

•

•

Terapiaescalonada

•

•

nefazodone hcl tab 50 mg nefazodone hcl tab 250 mg

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

trimipramine maleate cap 100 mg (Surmontil) venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr) venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr) venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr) VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 225 mg (base equivalent)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

• • • • •

37

venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er)

• •

venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er) venlafaxine hcl tab 25 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg venlafaxine hcl tab 100 mg

• • • •

VIIBRYD – vilazodone hcl tab 10 mg VIIBRYD – vilazodone hcl tab 20 mg VIIBRYD – vilazodone hcl tab 40 mg VIIBRYD – vilazodone hcl tab starter kit 10 (7) & 20 (7) & 40 (16) mg

• • • • • • • • •

TRASTORNOS PSICÓTICOS Y BIPOLARES

ABILIFY DISCMELT – aripiprazole orally disintegrating tab 10 mg ABILIFY DISCMELT – aripiprazole orally disintegrating tab 15 mg ABILIFY MAINTENA – aripiprazole im for extended release susp 300 mg ABILIFY MAINTENA – aripiprazole im for extended release susp 400 mg ADASUVE – loxapine aerosol powder breath activated 10 mg aripiprazole oral solution 1 mg/ml aripiprazole orally disintegrating tab 15 mg

38

aripiprazole tab 15 mg (Abilify) aripiprazole tab 20 mg (Abilify) aripiprazole tab 30 mg (Abilify)

ARISTADA – aripiprazole lauroxil im er susp prefilled syr 882 mg/3.2ml CHLORPROMAZINE HCL – chlorpromazine hcl inj 50 mg/2ml chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg

clozapine orally disintegrating tab 25 mg (Fazaclo)

•

clozapine orally disintegrating tab 100 mg (Fazaclo)

•

clozapine tab 25 mg (Clozaril)

•

clozapine tab 100 mg (Clozaril)

• • • •

Terapiaescalonada

ARISTADA – aripiprazole lauroxil im er susp prefilled syr 662 mg/2.4ml

•

•

• • • • • •

ARISTADA – aripiprazole lauroxil im er susp prefilled syr 441 mg/1.6ml

CLOZAPINE ODT – clozapine orally disintegrating tab 12.5 mg

•

Límite de surtido

Autorización previa

aripiprazole tab 10 mg (Abilify)

chlorpromazine hcl tab 200 mg

VIIBRYD STARTER PACK – vilazodone hcl tab starter kit 10 (7) & 20 (23) mg

ABILIFY – aripiprazole im inj 9.75 mg/1.3ml (7.5 mg/ml)

aripiprazole tab 2 mg (Abilify) aripiprazole tab 5 mg (Abilify)

venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er)

ABILIFY – aripiprazole oral solution 1 mg/ml

Nombre del medicamento

Especialización

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • • • •

clozapine tab 50 mg clozapine tab 200 mg EQUETRO – carbamazepine (antipsychotic) cap sr 12hr 100 mg EQUETRO – carbamazepine (antipsychotic) cap sr 12hr 200 mg EQUETRO – carbamazepine (antipsychotic) cap sr 12hr 300 mg FANAPT – iloperidone tab 1 mg FANAPT – iloperidone tab 2 mg

• • • • • • • •

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

FANAPT – iloperidone tab 4 mg FANAPT – iloperidone tab 6 mg FANAPT – iloperidone tab 8 mg FANAPT – iloperidone tab 10 mg FANAPT – iloperidone tab 12 mg FANAPT TITRATION PACK – iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak FAZACLO – clozapine orally disintegrating tab 12.5 mg FAZACLO – clozapine orally disintegrating tab 150 mg FAZACLO – clozapine orally disintegrating tab 200 mg FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml FLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ml

• • • • • • • • •

fluphenazine hcl tab 1 mg fluphenazine hcl tab 5 mg GEODON – ziprasidone mesylate for inj 20 mg (base equivalent)

• •

haloperidol tab 0.5 mg haloperidol tab 1 mg

INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 78 mg/0.5ml INVEGA SUSTENNA – paliperidone palmitate im extend-release susp 117 mg/0.75ml INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 156 mg/ml INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 234 mg/1.5ml

Terapiaescalonada

Límite de surtido

Autorización previa

• • • • • • • • • • • • • •

INVEGA TRINZA – paliperidone palmitate im extend-release susp 273 mg/0.875ml

INVEGA TRINZA – paliperidone palmitate im extend-release susp 546 mg/1.75ml

LATUDA – lurasidone hcl tab 40 mg

haloperidol tab 5 mg

LATUDA – lurasidone hcl tab 60 mg

haloperidol tab 10 mg

INVEGA – paliperidone tab sr 24hr 3 mg

INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 39 mg/0.25ml

LATUDA – lurasidone hcl tab 20 mg

haloperidol tab 2 mg

INVEGA – paliperidone tab sr 24hr 1.5 mg

INVEGA – paliperidone tab sr 24hr 9 mg

INVEGA TRINZA – paliperidone palmitate im extend-release susp 819 mg/2.625ml

haloperidol lactate oral conc 2 mg/ml

haloperidol tab 20 mg

INVEGA – paliperidone tab sr 24hr 6 mg

INVEGA TRINZA – paliperidone palmitate im extend-release susp 410 mg/1.315ml

fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 10 mg

Nombre del medicamento

Especialización

• • • • • •

Terapiaescalonada

• • • • • •

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

LATUDA – lurasidone hcl tab 80 mg

• • • •

LATUDA – lurasidone hcl tab 120 mg LITHIUM – lithium oral solution 8 meq/5ml

• • • • • •

• • • • •

lithium carbonate cap 150 mg (Lithium carbonate) lithium carbonate cap 300 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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lithium carbonate cap 600 mg (Lithium carbonate)

perphenazine tab 2 mg

lithium carbonate tab cr 300 mg (Lithobid)

perphenazine tab 8 mg perphenazine tab 16 mg

loxapine succinate cap 5 mg loxapine succinate cap 25 mg

olanzapine tab 5 mg (Zyprexa) olanzapine tab 7.5 mg (Zyprexa) olanzapine tab 10 mg (Zyprexa) olanzapine tab 15 mg (Zyprexa) olanzapine tab 20 mg (Zyprexa) paliperidone tab sr 24hr 1.5 mg (Invega) paliperidone tab sr 24hr 3 mg (Invega) paliperidone tab sr 24hr 6 mg (Invega) paliperidone tab sr 24hr 9 mg (Invega)

40

Terapiaescalonada

•

quetiapine fumarate tab 300 mg (Seroquel)

MOLINDONE HYDROCHLORIDE – molindone hcl tab 10 mg

olanzapine tab 2.5 mg (Zyprexa)

•

quetiapine fumarate tab 200 mg (Seroquel)

MOLINDONE HYDROCHLORIDE – molindone hcl tab 5 mg

olanzapine orally disintegrating tab 20 mg (Zyprexa zydis)

•

quetiapine fumarate tab 100 mg (Seroquel)

loxapine succinate cap 50 mg

olanzapine orally disintegrating tab 15 mg (Zyprexa zydis)

•

quetiapine fumarate tab 50 mg (Seroquel)

loxapine succinate cap 10 mg

olanzapine orally disintegrating tab 10 mg (Zyprexa zydis)

•

quetiapine fumarate tab 25 mg (Seroquel)

lithium carbonate tab 300 mg

olanzapine orally disintegrating tab 5 mg (Zyprexa zydis)

Límite de surtido

perphenazine tab 4 mg

lithium carbonate tab cr 450 mg

MOLINDONE HYDROCHLORIDE – molindone hcl tab 25 mg

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

•

quetiapine fumarate tab 400 mg (Seroquel)

•

REXULTI – brexpiprazole tab 0.25 mg

•

REXULTI – brexpiprazole tab 1 mg

• • • • • • • • •

REXULTI – brexpiprazole tab 0.5 mg REXULTI – brexpiprazole tab 2 mg REXULTI – brexpiprazole tab 3 mg REXULTI – brexpiprazole tab 4 mg RISPERDAL CONSTA – risperidone microspheres for inj 12.5 mg RISPERDAL CONSTA – risperidone microspheres for inj 25 mg RISPERDAL CONSTA – risperidone microspheres for inj 37.5 mg RISPERDAL CONSTA – risperidone microspheres for inj 50 mg risperidone orally disintegrating tab 0.25 mg

•

risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab)

•

risperidone orally disintegrating tab 1 mg (Risperdal m-tab)

•

risperidone orally disintegrating tab 2 mg (Risperdal m-tab)

• • • • • • • •

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

risperidone orally disintegrating tab 3 mg (Risperdal m-tab) risperidone orally disintegrating tab 4 mg (Risperdal m-tab) risperidone soln 1 mg/ml (Risperdal) risperidone tab 0.25 mg (Risperdal) risperidone tab 0.5 mg (Risperdal) risperidone tab 1 mg (Risperdal) risperidone tab 2 mg (Risperdal) risperidone tab 3 mg (Risperdal) risperidone tab 4 mg (Risperdal) SAPHRIS – asenapine maleate sl tab 2.5 mg (base equiv) SAPHRIS – asenapine maleate sl tab 5 mg (base equiv) SAPHRIS – asenapine maleate sl tab 10 mg (base equiv) SEROQUEL XR – quetiapine fumarate tab sr 24hr 50 mg SEROQUEL XR – quetiapine fumarate tab sr 24hr 150 mg SEROQUEL XR – quetiapine fumarate tab sr 24hr 200 mg SEROQUEL XR – quetiapine fumarate tab sr 24hr 300 mg SEROQUEL XR – quetiapine fumarate tab sr 24hr 400 mg thioridazine hcl tab 10 mg thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thioridazine hcl tab 100 mg thiothixene cap 1 mg thiothixene cap 2 mg thiothixene cap 5 mg thiothixene cap 10 mg trifluoperazine hcl tab 1 mg trifluoperazine hcl tab 2 mg

• • • • • • • • • •

trifluoperazine hcl tab 10 mg VERSACLOZ – clozapine susp 50 mg/ ml

VRAYLAR – cariprazine hcl cap 3 mg (base equivalent) VRAYLAR – cariprazine hcl cap 4.5 mg (base equivalent) VRAYLAR – cariprazine hcl cap 6 mg (base equivalent) ziprasidone hcl cap 20 mg (Geodon)

ziprasidone hcl cap 80 mg (Geodon)

• •

Terapiaescalonada

VRAYLAR – cariprazine hcl cap 1.5 mg (base equivalent)

• •

• •

• •

VRAYLAR – cariprazine hcl cap therapy pack 1.5 mg (1) & 3 mg (6)

ziprasidone hcl cap 40 mg (Geodon)

• •

Límite de surtido

trifluoperazine hcl tab 5 mg

• •

• •

Autorización previa

Nombre del medicamento

Especialización

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

ziprasidone hcl cap 60 mg (Geodon) ZYPREXA RELPREVV – olanzapine pamoate for extended rel im susp 210 mg (base eq) ZYPREXA RELPREVV – olanzapine pamoate for extended rel im susp 300 mg (base eq) ZYPREXA RELPREVV – olanzapine pamoate for extended rel im susp 405 mg (base eq) SOMNÍFEROS DORAL – quazepam tab 15 mg estazolam tab 1 mg estazolam tab 2 mg eszopiclone tab 1 mg (Lunesta) eszopiclone tab 2 mg (Lunesta) eszopiclone tab 3 mg (Lunesta) flurazepam hcl cap 15 mg flurazepam hcl cap 30 mg

• • • • • • • • • •

• • • • • • • • •

PHENOBARBITAL – phenobarbital tab 15 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

41

PHENOBARBITAL – phenobarbital tab 30 mg

amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr)

PHENOBARBITAL – phenobarbital tab 60 mg

amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr)

PHENOBARBITAL – phenobarbital tab 100 mg

amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall xr)

phenobarbital elixir 20 mg/5ml

amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall xr)

phenobarbital tab 16.2 mg

amphetamine-dextroamphetamine tab 5 mg (Adderall)

phenobarbital tab 32.4 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg QUAZEPAM – quazepam tab 15 mg temazepam cap 7.5 mg (Restoril) temazepam cap 15 mg (Restoril) temazepam cap 22.5 mg (Restoril) temazepam cap 30 mg (Restoril) TRIAZOLAM – triazolam tab 0.125 mg triazolam tab 0.125 mg triazolam tab 0.25 mg (Halcion) zaleplon cap 5 mg (Sonata) zaleplon cap 10 mg (Sonata) zolpidem tartrate sl tab 1.75 mg (Intermezzo) zolpidem tartrate sl tab 3.5 mg (Intermezzo) zolpidem tartrate tab cr 6.25 mg (Ambien cr) zolpidem tartrate tab cr 12.5 mg (Ambien cr) zolpidem tartrate tab 5 mg (Ambien) zolpidem tartrate tab 10 mg (Ambien) HIPERACTIVIDAD/NARCOLEPSIA amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr) amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr)

42

• • • • • • • • • • • • • • • • • • •

amphetamine-dextroamphetamine tab 7.5 mg (Adderall) amphetamine-dextroamphetamine tab 10 mg (Adderall) amphetamine-dextroamphetamine tab 12.5 mg (Adderall) amphetamine-dextroamphetamine tab 15 mg (Adderall) amphetamine-dextroamphetamine tab 20 mg (Adderall) amphetamine-dextroamphetamine tab 30 mg (Adderall)

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • • • • • • • • •

ARMODAFINIL – armodafinil tab 200 mg armodafinil tab 50 mg (Nuvigil) armodafinil tab 150 mg (Nuvigil) armodafinil tab 250 mg (Nuvigil) caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) clonidine hcl tab sr 12hr 0.1 mg (Kapvay) dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin xr)

• • • •

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr) dexmethylphenidate hcl tab 2.5 mg (Focalin) dexmethylphenidate hcl tab 5 mg (Focalin) dexmethylphenidate hcl tab 10 mg (Focalin) dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine) dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine) dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine) dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra) dextroamphetamine sulfate tab 5 mg dextroamphetamine sulfate tab 10 mg guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv) guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv) guanfacine hcl tab sr 24hr 3 mg (base equiv) (Intuniv) guanfacine hcl tab sr 24hr 4 mg (base equiv) (Intuniv) methamphetamine hcl tab 5 mg (Desoxyn) methylphenidate hcl cap cr 10 mg (cd) (Metadate cd) methylphenidate hcl cap cr 20 mg (cd) (Metadate cd) methylphenidate hcl cap cr 30 mg (cd) (Metadate cd) methylphenidate hcl cap cr 40 mg (cd) (Metadate cd)

• • • • • • • • • • • • • • • • • • •

methylphenidate hcl cap cr 50 mg (cd) (Metadate cd) methylphenidate hcl cap cr 60 mg (cd) (Metadate cd) methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin la) methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin la) methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin la) methylphenidate hcl chew tab 2.5 mg (Methylin) methylphenidate hcl chew tab 5 mg (Methylin) methylphenidate hcl chew tab 10 mg (Methylin) METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 18 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 27 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 36 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 54 mg

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • • • • • • • • • •

METHYLPHENIDATE HCL ER – methylphenidate hcl tab sr 24hr 18 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab sr 24hr 27 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab sr 24hr 36 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab sr 24hr 54 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

43

methylphenidate hcl soln 5 mg/5ml (Methylin)

• • •

methylphenidate hcl tab cr 10 mg methylphenidate hcl tab cr 20 mg methylphenidate hcl tab 5 mg (Ritalin)

•

methylphenidate hcl tab 10 mg (Ritalin) methylphenidate hcl tab 20 mg (Ritalin) modafinil tab 100 mg (Provigil) modafinil tab 200 mg (Provigil) VYVANSE – lisdexamfetamine dimesylate cap 10 mg

•

VYVANSE – lisdexamfetamine dimesylate cap 60 mg

•

VYVANSE – lisdexamfetamine dimesylate cap 70 mg

AUBAGIO – teriflunomide tab 7 mg AUBAGIO – teriflunomide tab 14 mg AVONEX – interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml AVONEX – interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial) AVONEX PEN – interferon beta-1a im auto-injector kit 30 mcg/0.5ml

44

• • • • • • • •

Terapiaescalonada

Límite de surtido

Autorización previa

Terapiaescalonada

Especialización

OTROS MEDICAMENTOS PARA EL SISTEMA NERVIOSO CENTRAL

acamprosate calcium tab delayed release 333 mg bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban)

CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg (base equiv)

•

VYVANSE – lisdexamfetamine dimesylate cap 50 mg

•

glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)

• • •

•

VYVANSE – lisdexamfetamine dimesylate cap 40 mg

BETASERON – interferon beta-1b for inj kit 0.3 mg

•

•

VYVANSE – lisdexamfetamine dimesylate cap 30 mg

Nombre del medicamento

CHANTIX – varenicline tartrate tab 0.5 mg (base equiv)

•

VYVANSE – lisdexamfetamine dimesylate cap 20 mg

AMPYRA – dalfampridine tab sr 12hr 10 mg

• •

methylphenidate hcl soln 10 mg/5ml (Methylin)

MULTIPLE SCLEROSIS

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

CHANTIX – varenicline tartrate tab 1 mg (base equiv)

CHANTIX STARTING MONTH PA – varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 5-12.5 mg CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxide-amitriptyline tab 10-25 mg

• • • • • • • • • • • •

disulfiram tab 250 mg (Antabuse) disulfiram tab 500 mg (Antabuse) donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride tab 5 mg (Aricept) donepezil hydrochloride tab 10 mg (Aricept) donepezil hydrochloride tab 23 mg (Aricept) ERGOLOID MESYLATES – ergoloid mesylates tab 1 mg ergoloid mesylates tab 1 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

GALANTAMINE HYDROBROMIDE – galantamine hydrobromide oral soln 4 mg/ml

PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 2-10 mg

galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er)

PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 2-25 mg

galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er)

PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 4-10 mg

galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er)

PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 4-25 mg

galantamine hydrobromide tab 4 mg (Razadyne) galantamine hydrobromide tab 8 mg (Razadyne)

PERPHENAZINE/AMITRIPTYLIN – perphenazine-amitriptyline tab 4-50 mg

galantamine hydrobromide tab 12 mg (Razadyne)

NUEDEXTA – dextromethorphan hbrquinidine sulfate cap 20-10 mg olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax) olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax) olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax) olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax) olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)

Terapiaescalonada

Límite de surtido

• • •

rivastigmine tartrate cap 1.5 mg (Exelon)

memantine hcl tab 10 mg (Namenda)

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray)

•

pimozide tab 2 mg (Orap)

memantine hcl tab 5 mg (Namenda)

NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg delivered)

•

pimozide tab 1 mg (Orap)

memantine hcl oral solution 2 mg/ml (Namenda)

memantine hcl tab 5 mg (28) & 10 mg (21) titration pak (Namenda titration pa)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

rivastigmine tartrate cap 3 mg (Exelon)

• • • •

• • • • •

rivastigmine tartrate cap 4.5 mg (Exelon) rivastigmine tartrate cap 6 mg (Exelon) rivastigmine td patch 24hr 4.6 mg/24hr (Exelon) rivastigmine td patch 24hr 9.5 mg/24hr (Exelon) rivastigmine td patch 24hr 13.3 mg/24hr (Exelon) tetrabenazine tab 12.5 mg (Xenazine) tetrabenazine tab 25 mg (Xenazine) XENAZINE – tetrabenazine tab 12.5 mg XENAZINE – tetrabenazine tab 25 mg XYREM – sodium oxybate oral solution 500 mg/ml ANALGÉSICOS

• • • • • • • • • •

MEDICAMENTOS NO NARCÓTICOS Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

45

acetaminophen-salicylamidephenyltoloxamine cap 300-200-20mg

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)

butalbital-acetaminophen tab 50-325 mg

butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/ codeine)

butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet)

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg

butalbital-acetaminophen-caffeine cap 50-325-40 mg

butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3)

butalbital-acetaminophen-caffeine soln 50-325-40 mg/15ml

codeine sulfate tab 60 mg (Codeine sulfate)

diflunisal tab 500 mg

fentanyl citrate lozenge on a handle 200 mcg (Actiq)

salsalate tab 500 mg (Disalcid) salsalate tab 750 mg (Disalcid)

fentanyl citrate lozenge on a handle 400 mcg (Actiq)

TENCON – butalbital-acetaminophen tab 50-325 mg MEDICAMENTOS NARCÓTICOS

fentanyl citrate lozenge on a handle 600 mcg (Actiq)

acetaminophen w/ codeine soln 120-12 mg/5ml

fentanyl citrate lozenge on a handle 800 mcg (Actiq)

acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine)

fentanyl citrate lozenge on a handle 1200 mcg (Actiq)

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3)

fentanyl citrate lozenge on a handle 1600 mcg (Actiq)

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4)

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)

46

Terapiaescalonada

codeine sulfate tab 30 mg (Codeine sulfate)

choline & magnesium salicylates liq 500 mg/5ml

buprenorphine hcl sl tab 8 mg (base equiv)

Límite de surtido

codeine sulfate tab 15 mg (Codeine sulfate)

butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)

buprenorphine hcl sl tab 2 mg (base equiv)

•

butorphanol tartrate nasal soln 10 mg/ml

butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)

acetaminophen-caffeinedihydrocodeine cap 320.5-30-16 mg (Trezix)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

fentanyl td patch 72hr 12 mcg/hr (Duragesic) fentanyl td patch 72hr 25 mcg/hr (Duragesic)

•

fentanyl td patch 72hr 50 mcg/hr (Duragesic)

•

fentanyl td patch 72hr 75 mcg/hr (Duragesic)

•

fentanyl td patch 72hr 100 mcg/hr (Duragesic)

• • • • • • • • • • •

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet)

meperidine hcl tab 50 mg

hydrocodone-acetaminophen soln 10-325 mg/15ml (Zamicet)

methadone hcl conc 10 mg/ml (Methadose)

methadone hcl soln 10 mg/5ml (Methadone hcl)

hydrocodone-acetaminophen tab 5-300 mg (Xodol)

methadone hcl tab for oral susp 40 mg

hydrocodone-acetaminophen tab 7.5-300 mg (Xodol)

methadone hcl tab 5 mg (Dolophine) methadone hcl tab 10 mg (Dolophine)

hydrocodone-acetaminophen tab 5-325 mg (Norco)

MORPHINE SULFATE – morphine sulfate tab 15 mg

hydrocodone-acetaminophen tab 7.5-325 mg (Norco)

MORPHINE SULFATE – morphine sulfate tab 30 mg

hydrocodone-acetaminophen tab 10-300 mg (Xodol)

MORPHINE SULFATE – morphine sulfate suppos 5 mg

hydrocodone-ibuprofen tab 2.5-200 mg

MORPHINE SULFATE – morphine sulfate suppos 10 mg

hydrocodone-ibuprofen tab 5-200 mg (Reprexain)

MORPHINE SULFATE – morphine sulfate suppos 20 mg

hydrocodone-ibuprofen tab 7.5-200 mg

MORPHINE SULFATE – morphine sulfate suppos 30 mg

hydrocodone-ibuprofen tab 10-200 mg (Ibudone)

hydromorphone hcl tab er 24hr deter 12 mg (Exalgo) hydromorphone hcl tab er 24hr deter 16 mg (Exalgo) hydromorphone hcl tab 2 mg (Dilaudid) hydromorphone hcl tab 4 mg (Dilaudid) hydromorphone hcl tab 8 mg (Dilaudid)

Terapiaescalonada

methadone hcl soln 5 mg/5ml (Methadone hcl)

hydrocodone-acetaminophen tab 10-325 mg (Norco)

hydromorphone hcl tab er 24hr deter 8 mg (Exalgo)

Límite de surtido

meperidine hcl tab 100 mg (Demerol)

hydrocodone-acetaminophen tab 2.5-325 mg

hydromorphone hcl liqd 1 mg/ml (Dilaudid)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

morphine sulfate cap sr 24hr 10 mg (Kadian)

• • •

morphine sulfate cap sr 24hr 20 mg (Kadian) morphine sulfate cap sr 24hr 30 mg (Kadian) morphine sulfate cap sr 24hr 50 mg (Kadian) morphine sulfate cap sr 24hr 60 mg (Kadian) morphine sulfate cap sr 24hr 80 mg (Kadian) morphine sulfate cap sr 24hr 100 mg (Kadian)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

• • • • • • •

47

MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 30 mg MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 45 mg MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 60 mg MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 75 mg MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 90 mg MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 120 mg

• • • • •

morphine sulfate oral soln 10 mg/5ml

oxycodone w/ acetaminophen tab 10-325 mg (Percocet) oxycodone-aspirin tab 4.8355-325 mg oxycodone-ibuprofen tab 5-400 mg OXYCODONE/ACETAMINOPHEN – oxycodone w/ acetaminophen soln 5-325 mg/5ml

morphine sulfate oral soln 100 mg/5ml (20 mg/ml)

oxymorphone hcl tab sr 12hr 7.5 mg

morphine sulfate tab cr 60 mg (Ms contin) morphine sulfate tab cr 100 mg (Ms contin) morphine sulfate tab cr 200 mg (Ms contin) oxycodone hcl cap 5 mg oxycodone hcl conc 100 mg/5ml (20 mg/ml) oxycodone hcl soln 5 mg/5ml oxycodone hcl tab 5 mg (Roxicodone) oxycodone hcl tab 10 mg oxycodone hcl tab 15 mg (Roxicodone) oxycodone hcl tab 20 mg

oxymorphone hcl tab sr 12hr 5 mg

• •

oxymorphone hcl tab sr 12hr 10 mg oxymorphone hcl tab sr 12hr 15 mg oxymorphone hcl tab sr 12hr 20 mg

•

oxymorphone hcl tab sr 12hr 30 mg

•

oxymorphone hcl tab 5 mg (Opana)

•

oxymorphone hcl tab sr 12hr 40 mg oxymorphone hcl tab 10 mg (Opana) pentazocine w/ naloxone tab 50-0.5 mg SUBOXONE – buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base equiv) SUBOXONE – buprenorphine hclnaloxone hcl sl film 4-1 mg (base equiv) SUBOXONE – buprenorphine hclnaloxone hcl sl film 8-2 mg (base equiv)

oxycodone hcl tab 30 mg (Roxicodone)

SUBOXONE – buprenorphine hclnaloxone hcl sl film 12-3 mg (base equiv)

oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)

tramadol hcl tab sr 24hr 200 mg

48

Terapiaescalonada

oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)

morphine sulfate oral soln 20 mg/5ml

morphine sulfate tab cr 30 mg (Ms contin)

Límite de surtido

oxycodone w/ acetaminophen tab 5-325 mg (Percocet)

OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab 5-400 mg

morphine sulfate tab cr 15 mg (Ms contin)

Autorización previa

Nombre del medicamento

Especialización

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

tramadol hcl tab sr 24hr 100 mg

• • • • • •

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

tramadol hcl tab sr 24hr 300 mg (Ultram er)

•

tramadol hcl tab sr 24hr biphasic release 100 mg tramadol hcl tab sr 24hr biphasic release 200 mg tramadol hcl tab sr 24hr biphasic release 300 mg

ARCALYST – rilonacept for inj 220 mg celecoxib cap 50 mg (Celebrex) celecoxib cap 100 mg (Celebrex) celecoxib cap 200 mg (Celebrex) celecoxib cap 400 mg (Celebrex) diclofenac potassium tab 50 mg diclofenac sod dr tab 75 mg & capsaicin cr 0.025% ther pack (Derma silkrx diclopa) diclofenac sodium tab delayed release 25 mg

•

flurbiprofen tab 50 mg

Terapiaescalonada

etodolac tab 500 mg flurbiprofen tab 100 mg HUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml HUMIRA – adalimumab prefilled syringe kit 20 mg/0.4ml HUMIRA – adalimumab prefilled syringe kit 40 mg/0.8ml

• •

• • • •

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe kit 40 mg/0.8ml HUMIRA PEN – adalimumab peninjector kit 40 mg/0.8ml HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit 40 mg/0.8ml HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit 40 mg/0.8ml ibuprofen susp 100 mg/5ml ibuprofen tab 400 mg

diclofenac sodium tab delayed release 75 mg

ibuprofen tab 800 mg

diclofenac sodium tab sr 24hr 100 mg

indomethacin cap 25 mg

ibuprofen tab 600 mg indomethacin cap cr 75 mg indomethacin cap 50 mg ketoprofen cap 50 mg ketoprofen cap 75 mg

diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75)

ketorolac tromethamine tab 10 mg

etodolac cap 200 mg

leflunomide tab 10 mg (Arava)

etodolac cap 300 mg

Límite de surtido

etodolac tab sr 24hr 600 mg

diclofenac sodium tab delayed release 50 mg

diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50)

Autorización previa

etodolac tab sr 24hr 500 mg etodolac tab 400 mg

tramadol-acetaminophen tab 37.5-325 mg (Ultracet) REUMATISMO Y OSTEOARTRITIS ACTEMRA – tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml

etodolac tab sr 24hr 400 mg

•

•

tramadol hcl tab 50 mg (Ultram)

Nombre del medicamento

Especialización

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

•

KINERET – anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml leflunomide tab 20 mg (Arava)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

49

mefenamic acid cap 250 mg (Ponstel)

naratriptan hcl tab 1 mg (base equiv) (Amerge)

meloxicam tab 15 mg (Mobic) nabumetone tab 500 mg

naratriptan hcl tab 2.5 mg (base equiv) (Amerge)

nabumetone tab 750 mg NAPROXEN – naproxen susp 125 mg/5ml

rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt)

naproxen sodium tab sr 24hr 375 mg (base equiv) (Naprelan)

rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt)

naproxen sodium tab sr 24hr 500 mg (base equiv) (Naprelan)

rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt)

naproxen sodium tab 275 mg naproxen sodium tab 550 mg (Anaprox ds)

rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt)

naproxen susp 125 mg/5ml (Naprosyn)

sumatriptan nasal spray 5 mg/act (Imitrex)

naproxen tab ec 375 mg (Ecnaprosyn)

sumatriptan nasal spray 20 mg/act (Imitrex)

naproxen tab ec 500 mg (Ecnaprosyn)

SUMATRIPTAN SUCCINATE – sumatriptan succinate solution prefilled syringe 6 mg/0.5ml

naproxen tab 250 mg naproxen tab 375 mg

sumatriptan succinate inj 6 mg/0.5ml (Imitrex)

naproxen tab 500 mg (Naprosyn) oxaprozin tab 600 mg (Daypro)

sumatriptan succinate solution autoinjector 4 mg/0.5ml (Imitrex statdose sys)

piroxicam cap 10 mg (Feldene) piroxicam cap 20 mg (Feldene)

sumatriptan succinate solution autoinjector 6 mg/0.5ml (Imitrex statdose sys)

sulindac tab 150 mg sulindac tab 200 mg tolmetin sodium cap 400 mg

sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref)

DOLOR DE CABEZA/MIGRAÑAS almotriptan malate tab 6.25 mg (Axert)

sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref)

almotriptan malate tab 12.5 mg (Axert)

IMITREX – sumatriptan nasal spray 5 mg/act 50

sumatriptan succinate tab 25 mg (Imitrex)

•

sumatriptan succinate tab 50 mg (Imitrex)

•

Terapiaescalonada

Límite de surtido

Autorización previa

Especialización

Nombre del medicamento IMITREX – sumatriptan nasal spray 20 mg/act

meloxicam tab 7.5 mg (Mobic)

frovatriptan succinate tab 2.5 mg (base equivalent) (Frova)

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • • • • • • • • • • • • • • •

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

sumatriptan succinate tab 100 mg (Imitrex) zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt)

clonazepam tab 1 mg (Klonopin)

probenecid tab 500 mg MEDICAMENTOS NEUROMUSCULARES

carbamazepine cap sr 12hr 300 mg (Carbatrol)

Terapiaescalonada

clonazepam tab 0.5 mg (Klonopin)

COLCRYS – colchicine tab 0.6 mg

carbamazepine cap sr 12hr 200 mg (Carbatrol)

Límite de surtido

clonazepam orally disintegrating tab 2 mg

colchicine w/ probenecid tab 0.5-500 mg

carbamazepine cap sr 12hr 100 mg (Carbatrol)

Autorización previa

clonazepam orally disintegrating tab 1 mg

allopurinol tab 300 mg (Zyloprim)

APTIOM – eslicarbazepine acetate tab 800 mg

Especialización

clonazepam orally disintegrating tab 0.5 mg

allopurinol tab 100 mg (Zyloprim)

APTIOM – eslicarbazepine acetate tab 600 mg

Terapiaescalonada

clonazepam orally disintegrating tab 0.25 mg

GOTA

APTIOM – eslicarbazepine acetate tab 400 mg

carbamazepine tab sr 12hr 400 mg (Tegretol-xr) clonazepam orally disintegrating tab 0.125 mg

zolmitriptan tab 2.5 mg (Zomig) zolmitriptan tab 5 mg (Zomig)

APTIOM – eslicarbazepine acetate tab 200 mg

•

Nombre del medicamento

carbamazepine tab 200 mg (Tegretol)

zolmitriptan orally disintegrating tab 5 mg (Zomig zmt)

CONVULSIONES

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

clonazepam tab 2 mg (Klonopin)

• • • •

DIASTAT ACUDIAL – diazepam rectal gel delivery system 10 mg DIASTAT ACUDIAL – diazepam rectal gel delivery system 20 mg DIASTAT PEDIATRIC – diazepam rectal gel delivery system 2.5 mg DILANTIN – phenytoin sodium extended cap 30 mg divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles) divalproex sodium tab delayed release 125 mg (Depakote) divalproex sodium tab delayed release 250 mg (Depakote)

carbamazepine chew tab 100 mg

divalproex sodium tab delayed release 500 mg (Depakote)

carbamazepine susp 100 mg/5ml (Tegretol)

divalproex sodium tab sr 24 hr 250 mg (Depakote er)

carbamazepine tab sr 12hr 100 mg (Tegretol-xr)

divalproex sodium tab sr 24 hr 500 mg (Depakote er)

carbamazepine tab sr 12hr 200 mg (Tegretol-xr)

ethosuximide cap 250 mg (Zarontin)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

51

ethosuximide soln 250 mg/5ml (Zarontin)

lamotrigine orally disintegrating tab 50 mg (Lamictal odt)

felbamate susp 600 mg/5ml (Felbatol)

lamotrigine orally disintegrating tab 100 mg (Lamictal odt)

felbamate tab 400 mg (Felbatol) gabapentin cap 100 mg (Neurontin) gabapentin cap 400 mg (Neurontin)

lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di)

gabapentin oral soln 250 mg/5ml (Neurontin)

lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit (Lamictal odt)

gabapentin tab 600 mg (Neurontin)

LAMICTAL ODT – lamotrigine orally disintegrating tab 25 mg LAMICTAL ODT – lamotrigine orally disintegrating tab 50 mg LAMICTAL ODT – lamotrigine orally disintegrating tab 100 mg LAMICTAL ODT – lamotrigine orally disintegrating tab 200 mg LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg (42) & 100 mg (7) starter kit LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg (84) & 100 mg (14) starter kit LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg (35) starter kit LAMICTAL XR – lamotrigine tab sr 24hr 25 mg (21) & 50 mg (7) titration kit LAMICTAL XR – lamotrigine tab sr 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit LAMICTAL XR – lamotrigine tab sr 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit lamotrigine orally disintegrating tab 25 mg (Lamictal odt)

52

Terapiaescalonada

lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di)

gabapentin cap 300 mg (Neurontin)

LAMICTAL – lamotrigine tab chewable dispersible 2 mg

Límite de surtido

lamotrigine orally disintegrating tab 200 mg (Lamictal odt)

felbamate tab 600 mg (Felbatol)

gabapentin tab 800 mg (Neurontin)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

•

lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit (Lamictal odt)

•

lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit (Lamictal odt)

•

lamotrigine tab sr 24hr 25 mg (Lamictal xr)

•

lamotrigine tab sr 24hr 50 mg (Lamictal xr)

•

lamotrigine tab sr 24hr 100 mg (Lamictal xr)

•

lamotrigine tab sr 24hr 200 mg (Lamictal xr)

•

lamotrigine tab sr 24hr 250 mg (Lamictal xr)

•

lamotrigine tab 25 mg (Lamictal)

• • •

lamotrigine tab sr 24hr 300 mg (Lamictal xr) lamotrigine tab 100 mg (Lamictal) lamotrigine tab 150 mg (Lamictal) lamotrigine tab 200 mg (Lamictal) levetiracetam oral soln 100 mg/ml (Keppra) levetiracetam tab sr 24hr 500 mg (Keppra xr) levetiracetam tab sr 24hr 750 mg (Keppra xr)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

levetiracetam tab 250 mg (Keppra)

levetiracetam tab 1000 mg (Keppra) LYRICA – pregabalin cap 25 mg

SPRITAM – levetiracetam tab disintegrating soluble 1000 mg

LYRICA – pregabalin cap 50 mg

STAVZOR – valproic acid cap delayed release 125 mg

LYRICA – pregabalin cap 75 mg LYRICA – pregabalin cap 100 mg

STAVZOR – valproic acid cap delayed release 250 mg

LYRICA – pregabalin cap 150 mg LYRICA – pregabalin cap 200 mg

STAVZOR – valproic acid cap delayed release 500 mg

LYRICA – pregabalin cap 225 mg LYRICA – pregabalin cap 300 mg

• • •

Terapiaescalonada

Límite de surtido

topiramate sprinkle cap 25 mg (Topamax sprinkle) topiramate tab 25 mg (Topamax) topiramate tab 50 mg (Topamax) topiramate tab 100 mg (Topamax) topiramate tab 200 mg (Topamax) valproate sodium syrup 250 mg/5ml (base equiv) (Depakene) valproic acid cap 250 mg (Depakene) zonisamide cap 25 mg (Zonegran) zonisamide cap 50 mg zonisamide

phenytoin sodium extended cap 300 mg (Phenytek)

cap 100 mg (Zonegran)

phenytoin susp 125 mg/5ml (Dilantin-125)

amantadine hcl cap 100 mg

primidone tab 250 mg (Mysoline)

Autorización previa

topiramate sprinkle cap 15 mg (Topamax sprinkle)

phenytoin sodium extended cap 200 mg (Phenytek)

primidone tab 50 mg (Mysoline)

•

tiagabine hcl tab 4 mg (Gabitril)

oxcarbazepine tab 300 mg (Trileptal)

phenytoin sodium extended cap 100 mg (Dilantin)

•

tiagabine hcl tab 2 mg (Gabitril)

oxcarbazepine tab 150 mg (Trileptal)

phenytoin chew tab 50 mg (Dilantin infatabs)

•

TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg

oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)

OXTELLAR XR – oxcarbazepine tab sr 24hr 600 mg

Especialización

SPRITAM – levetiracetam tab disintegrating soluble 750 mg

LYRICA – pregabalin soln 20 mg/ml

OXTELLAR XR – oxcarbazepine tab sr 24hr 300 mg

Terapiaescalonada

SPRITAM – levetiracetam tab disintegrating soluble 500 mg

levetiracetam tab 750 mg (Keppra)

OXTELLAR XR – oxcarbazepine tab sr 24hr 150 mg

Nombre del medicamento SPRITAM – levetiracetam tab disintegrating soluble 250 mg

levetiracetam tab 500 mg (Keppra)

oxcarbazepine tab 600 mg (Trileptal)

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

•

ENFERMEDAD DE PARKINSON amantadine hcl syrup 50 mg/5ml APOKYN – apomorphine hydrochloride inj 10 mg/ml

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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AZILECT – rasagiline mesylate tab 0.5 mg (base equiv)

pramipexole dihydrochloride tab sr 24hr 4.5 mg (Mirapex er)

AZILECT – rasagiline mesylate tab 1 mg (base equiv)

pramipexole dihydrochloride tab 0.125 mg (Mirapex)

benztropine mesylate tab 0.5 mg

pramipexole dihydrochloride tab 0.25 mg (Mirapex)

benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg bromocriptine mesylate cap 5 mg (Parlodel) bromocriptine mesylate tab 2.5 mg carbidopa & levodopa orally disintegrating tab 10-100 mg carbidopa & levodopa orally disintegrating tab 25-100 mg carbidopa & levodopa orally disintegrating tab 25-250 mg carbidopa & levodopa tab cr 25-100 mg (Sinemet cr) carbidopa & levodopa tab cr 50-200 mg (Sinemet cr) carbidopa & levodopa tab 10-100 mg (Sinemet) carbidopa & levodopa tab 25-100 mg (Sinemet) carbidopa & levodopa tab 25-250 mg (Sinemet) carbidopa tab 25 mg (Lodosyn) entacapone tab 200 mg (Comtan) pramipexole dihydrochloride tab sr 24hr 0.375 mg (Mirapex er) pramipexole dihydrochloride tab sr 24hr 0.75 mg (Mirapex er) pramipexole dihydrochloride tab sr 24hr 1.5 mg (Mirapex er) pramipexole dihydrochloride tab sr 24hr 2.25 mg (Mirapex er) pramipexole dihydrochloride tab sr 24hr 3 mg (Mirapex er)

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

pramipexole dihydrochloride tab 0.5 mg (Mirapex) pramipexole dihydrochloride tab 0.75 mg (Mirapex) pramipexole dihydrochloride tab 1 mg (Mirapex) pramipexole dihydrochloride tab 1.5 mg (Mirapex) ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab 0.25 mg (Requip) ropinirole hydrochloride tab 0.5 mg (Requip) ropinirole hydrochloride tab 1 mg (Requip) ropinirole hydrochloride tab 2 mg (Requip) ropinirole hydrochloride tab 3 mg (Requip) ropinirole hydrochloride tab 4 mg (Requip) ropinirole hydrochloride tab 5 mg (Requip) selegiline hcl cap 5 mg (Eldepryl) selegiline hcl tab 5 mg

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Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

tolcapone tab 100 mg (Tasmar)

RELAJANTES MUSCULARES baclofen tab 20 mg carisoprodol tab 250 mg (Soma)

Terapiaescalonada

SUPLEMENTOS

carisoprodol tab 350 mg (Soma)

VITAMINAS

carisoprodol w/ aspirin & codeine tab 200-325-16 mg

ergocalciferol cap 50000 unit MEPHYTON – phytonadione tab 5 mg

carisoprodol w/ aspirin tab 200-325 mg

COMPLEJO MULTIVITAMÍNICO b-complex w/ c & folic acid cap 1 mg (Nephrocaps)

chlorzoxazone tab 500 mg (Parafon forte dsc)

b-complex w/ c & folic acid tab

cyclobenzaprine hcl tab 5 mg

b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx)

cyclobenzaprine hcl tab 7.5 mg (Fexmid)

b-complex w/ c & folic acid tab 5 mg

cyclobenzaprine hcl tab 10 mg

CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg

dantrolene sodium cap 25 mg (Dantrium)

CVS PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg

dantrolene sodium cap 50 mg (Dantrium)

EQL PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg

dantrolene sodium cap 100 mg metaxalone tab 800 mg (Skelaxin)

FOLBEE PLUS CZ – b-complex w/ cbiotin-minerals & folic acid tab 5 mg

methocarbamol tab 500 mg (Robaxin) methocarbamol tab 750 mg (Robaxin-750)

tizanidine hcl tab 2 mg (base equivalent)

Límite de surtido

pyridostigmine bromide tab 60 mg (Mestinon) riluzole tab 50 mg (Rilutek)

baclofen tab 10 mg

tizanidine hcl cap 6 mg (base equivalent) (Zanaflex)

Autorización previa

pyridostigmine bromide tab cr 180 mg (Mestinon timespan)

trihexyphenidyl hcl tab 5 mg

tizanidine hcl cap 4 mg (base equivalent) (Zanaflex)

Especialización

OTROS MEDICAMENTOS NEUROMUSCULARES

trihexyphenidyl hcl tab 2 mg

tizanidine hcl cap 2 mg (base equivalent) (Zanaflex)

Nombre del medicamento tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)

trihexyphenidyl hcl elixir 0.4 mg/ml

orphenadrine citrate tab sr 12hr 100 mg

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg

•

GNP PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg

•

GOODSENSE PRENATAL VITAMI – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg

•

HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg KP PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab 0.25 mg

MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab 0.5 mg

multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite)

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab 1 mg

multiple vitamins w/ minerals cap

PRE-NATAL FORMULA – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg

multiple vitamins w/ minerals tab (Strovite forte) NAT-RUL PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg O-CAL FA – prenatal vit w/ fe fumaratefa tab 27-1 mg pediatric multiple vitamin w/ minerals & c drops 45 mg/ml pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml pediatric multiple vitamins w/ fluoride chew tab 0.25 mg pediatric multiple vitamins w/ fluoride chew tab 0.5 mg pediatric multiple vitamins w/ fluoride chew tab 1 mg pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml pediatric vitamins acd w/ fluoride soln 0.25 mg/ml pediatric vitamins acd w/ fluoride soln 0.5 mg/ml PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe fumarate-fa tab 27-1 mg PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe fumarate-fa tab 27-1 mg

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Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1 mg PRENATAL – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1 mg PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg PRENATAL AND IRON – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg PRENATAL FORTE – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg PRENATAL MULTI +DHA – prenatal vit w/ fe fum-fa-omega 3 cap 27-0.8-228 mg PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg PRENATAL PLUS DHA – prenatal mv & min w/fe carbonyl-fa-dha tab 7-0.4-100 mg Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

prenatal vit w/ fe fumarate-fa tab 28-0.8 mg

TRICARE – prenatal vit w/ fe fumaratefa tab 27-1 mg

PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg

TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1 mg

PRENATAL VITAMINS – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg

VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg

PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg PREPLUS – prenatal vit w/ fe fumaratefa tab 27-1 mg PX PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg QC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg RA PRENATAL FORMULA/FOLIC – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg speciality vitamin product tab STUART PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg TH PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg MINERALES Y ELECTROLITOS K-PHOS – potassium phosphate monobasic tab 500 mg pot bicarbonate & chloride effer tab 25 meq pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (Kphos neutral) potassium bicarbonate effer tab 25 meq potassium chloride cap cr 8 meq (Micro-k) potassium chloride cap cr 10 meq (Micro-k) POTASSIUM CHLORIDE ER – potassium chloride tab cr 8 meq (600 mg) potassium chloride microencapsulated crys cr tab 10 meq potassium chloride microencapsulated crys cr tab 20 meq potassium chloride oral soln 10% (20 meq/15ml) potassium chloride oral soln 20% (40 meq/15ml) potassium chloride powder packet 20 meq potassium chloride tab cr 8 meq (600 mg)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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potassium chloride tab cr 10 meq (Ktab)

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride)

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml

sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride)

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml

sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride) OTROS SUPLEMENTOS

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 500 mcg/ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 mcg/ml

acetylcysteine cap 600 mg amino acids cap

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40 mcg/ml

folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg 2-fucosyllactose & lacto-nneotetraose packet 2000-1000 mg (Ollizac) MEDICAMENTOS MODIFICADORES DE LA SANGRE FÁRMACOS MODIFICADORES DE LA SANGRE

anagrelide hcl cap 1 mg ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 25 mcg/0.42ml ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 40 mcg/0.4ml

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Terapiaescalonada

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride)

anagrelide hcl cap 0.5 mg (Agrylin)

Límite de surtido

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 100 mcg/0.5ml

SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mg naf)

aminocaproic acid tab 500 mg

Autorización previa

ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml

SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from 1.1 mg naf)

aminocaproic acid syrup 25%

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60 mcg/ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 100 mcg/ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 150 mcg/0.75ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 200 mcg/ml ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 300 mcg/ml BRILINTA – ticagrelor tab 60 mg BRILINTA – ticagrelor tab 90 mg CERDELGA – eliglustat tartrate cap 84 mg (base equivalent) cilostazol tab 50 mg cilostazol tab 100 mg clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)

folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg

cyanocobalamin inj 1000 mcg/ml

fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml (Arixtra)

dipyridamole tab 25 mg dipyridamole tab 75 mg

enoxaparin sodium inj 40 mg/0.4ml (Lovenox) enoxaparin sodium inj 60 mg/0.6ml (Lovenox) enoxaparin sodium inj 80 mg/0.8ml (Lovenox) enoxaparin sodium inj 100 mg/ml (Lovenox) enoxaparin sodium inj 120 mg/0.8ml (Lovenox) enoxaparin sodium inj 150 mg/ml (Lovenox) fe fum-iron polysacch complex-fab cmplx-c-zn-mn-cu cap (Tandem plus)

•

fondaparinux sodium subcutaneous inj 10 mg/0.8ml (Arixtra)

•

INFED – iron dextran inj 50 mg/ml (elemental iron)

• • • • •

iron combination cap iron polysacch complex-vit b12-fa cap 150-0.025-1 mg iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg (Hematron-af) iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150) iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg (Icar-c plus) pentoxifylline tab cr 400 mg TICLOPIDINE HCL – ticlopidine hcl tab 250 mg ticlopidine hcl tab 250 mg

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg

tranexamic acid tab 650 mg (Lysteda)

fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg

warfarin sodium tab 2 mg (Coumadin)

ferrous fumarate-fa-b complex-c-znmg-mn-cu tab 106-1 mg ferrous fumarate-folic acid tab 324-1 mg folic acid tab 1 mg folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx)

Terapiaescalonada

fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml (Arixtra)

ELIQUIS – apixaban tab 2.5 mg enoxaparin sodium inj 30 mg/0.3ml (Lovenox)

Límite de surtido

fondaparinux sodium subcutaneous inj 5 mg/0.4ml (Arixtra)

dipyridamole tab 50 mg

ELIQUIS – apixaban tab 5 mg

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

warfarin sodium tab 1 mg (Coumadin) warfarin sodium tab 2.5 mg (Coumadin) warfarin sodium tab 3 mg (Coumadin) warfarin sodium tab 4 mg (Coumadin) warfarin sodium tab 5 mg (Coumadin) warfarin sodium tab 6 mg (Coumadin) warfarin sodium tab 7.5 mg (Coumadin) warfarin sodium tab 10 mg (Coumadin)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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XARELTO – rivaroxaban tab 10 mg

Terapiaescalonada

Límite de surtido

DEXAMETHASONE SODIUM PHOS – dexamethasone sodium phosphate ophth soln 0.1%

XARELTO – rivaroxaban tab 15 mg XARELTO – rivaroxaban tab 20 mg

dexamethasone sodium phosphate ophth soln 0.1%

XARELTO STARTER PACK – rivaroxaban tab starter therapy pack 15 mg & 20 mg

• •

ZAVESCA – miglustat cap 100 mg MEDICAMENTOS TÓPICOS OJOS

fluorometholone ophth susp 0.1% (Fml liquifilm) LOTEMAX – loteprednol etabonate ophth susp 0.5% neomycin-polymyxindexamethasone ophth oint 0.1% (Maxitrol)

Antiinfecciosos BACITRACIN – bacitracin ophth oint 500 unit/gm

neomycin-polymyxindexamethasone ophth susp 0.1% (Maxitrol)

bacitracin-polymyxin b ophth oint ciprofloxacin hcl ophth soln 0.3% (Ciloxan)

prednisolone acetate ophth susp 1% (Pred forte)

erythromycin ophth oint 5 mg/gm

PREDNISOLONE SODIUM PHOSP – prednisolone sodium phosphate ophth soln 1%

gatifloxacin ophth soln 0.5% (Zymaxid) gentamicin sulfate ophth oint 0.3%

sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%

gentamicin sulfate ophth soln 0.3%

tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex)

levofloxacin ophth soln 0.5% NATACYN – natamycin ophth susp 5%

ZYLET – loteprednol etabonatetobramycin ophth susp 0.5-0.3%

neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin

Glaucoma

neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)

ALPHAGAN P – brimonidine tartrate ophth soln 0.1% apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine)

ofloxacin ophth soln 0.3% (Ocuflox) polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim)

AZOPT – brinzolamide ophth susp 1% betaxolol hcl ophth soln 0.5%

sulfacetamide sodium ophth soln 10% (Bleph-10) tobramycin ophth soln 0.3% (Tobrex)

brimonidine tartrate ophth soln 0.15% (Alphagan p)

trifluridine ophth soln 1% (Viroptic)

brimonidine tartrate ophth soln 0.2%

Productos esteroides y combinaciones

carteolol hcl ophth soln 1%

bacitracin-polymyxin-neomycin-hc ophth oint 1%

dorzolamide hcl ophth soln 2% (Trusopt)

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Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)

cyclopentolate hcl ophth soln 2% (Cyclogyl)

latanoprost ophth soln 0.005% (Xalatan)

CYSTARAN – cysteamine hcl ophth soln 0.44% (base equivalent)

levobunolol hcl ophth soln 0.5% (Betagan)

diclofenac sodium ophth soln 0.1%

METIPRANOLOL – metipranolol ophth soln 0.3% pilocarpine hcl ophth soln 1% (Isopto carpine) pilocarpine hcl ophth soln 2% (Isopto carpine) pilocarpine hcl ophth soln 4% (Isopto carpine) timolol maleate ophth gel forming soln 0.25% (Timoptic-xe) timolol maleate ophth gel forming soln 0.5% (Timoptic-xe) timolol maleate ophth soln 0.25% (Timoptic) timolol maleate ophth soln 0.5% (Timoptic) Otros productos oftálmicos ATROPINE SULFATE – atropine sulfate ophth soln 1% ATROPINE SULFATE – atropine sulfate ophth oint 1%

epinastine hcl ophth soln 0.05% (Elestat) EYLEA – aflibercept intravitreal inj 2 mg/0.05ml (40 mg/ml)

homatropine hbr ophth soln 5% JETREA – ocriplasmin intravitreal inj 0.5 mg/0.2ml (2.5 mg/ml)

ketorolac tromethamine ophth soln 0.5% (Acular) LUCENTIS – ranibizumab intravitreal inj 0.3 mg/0.05ml (6 mg/ml) LUCENTIS – ranibizumab intravitreal inj 0.5 mg/0.05ml (10 mg/ml)

Terapiaescalonada

Límite de surtido

• •

olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol)

phenylephrine hcl ophth soln 2.5%

bromfenac sodium ophth soln 0.09% (base equivalent)

phenylephrine hcl ophth soln 10%

cyclopentolate hcl ophth soln 1% (Cyclogyl)

• •

NAPHAZOLINE HCL – naphazoline hcl ophth soln 0.1%

azelastine hcl ophth soln 0.05%

cyclopentolate hcl ophth soln 0.5% (Cyclogyl)

• •

ketorolac tromethamine ophth soln 0.4% (Acular ls)

PATADAY – olopatadine hcl ophth soln 0.2% (base equivalent)

cromolyn sodium ophth soln 4%

• •

flurbiprofen sodium ophth soln 0.03% (Ocufen)

atropine sulfate ophth soln 1%

bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

proparacaine hcl ophth soln 0.5% (Alcaine) tetracaine hcl ophth soln 0.5% OÍDO acetic acid otic soln 2% antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097%

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CIPRODEX – ciprofloxacindexamethasone otic susp 0.3-0.1% fluocinolone acetonide (otic) oil 0.01% (Dermotic) hydrocortisone w/ acetic acid otic soln 1-2% neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%

hydrocortisone enema 100 mg/60ml (Cortenema)

ofloxacin otic soln 0.3% (Floxin otic)

hydrocortisone rectal cream 1% (Proctocort)

cevimeline hcl cap 30 mg (Evoxac) chlorhexidine gluconate soln 0.12% (Peridex) clotrimazole troche 10 mg lidocaine hcl viscous soln 2% nystatin susp 100000 unit/ml pilocarpine hcl tab 5 mg (Salagen) pilocarpine hcl tab 7.5 mg (Salagen) PREVIDENT FLUORIDE – sodium fluoride gel 1.1% (0.5% f)

hydrocortisone rectal cream 2.5% (Anusol-hc) lidocaine-hydrocortisone acetate rectal cream kit 2-2% lidocaine-hydrocortisone acetate rectal cream kit 3-0.5% lidocaine-hydrocortisone acetate rectal cream kit 3-1% lidocaine-hydrocortisone acetate rectal cream 3-0.5% lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% AFECCIONES DE LA PIEL/PRODUCTOS Acné

PREVIDENT 5000 BOOSTER PL – sodium fluoride paste 1.1%

ADAPALENE – adapalene lotion

sodium fluoride cream 1.1% (Prevident 5000 plus)

adapalene gel 0.1% (Differin)

sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) sodium fluoride paste 1.1% (Prevident 5000 boost) sodium fluoride rinse 0.2% sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi)

0.1% adapalene cream 0.1% (Differin) adapalene gel 0.3% (Differin)

• • • •

benzoyl peroxide cloth 6% benzoyl peroxide foam 5.3% (Benzefoam) benzoyl peroxide foam 9.8% (Benzefoam ultra) benzoyl peroxide gel 10%

stannous fluoride conc 0.63% (Gelkam oral care ri)

benzoyl peroxide liq 2.5%

stannous fluoride gel 0.4%

benzoyl peroxide liq 10%

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Terapiaescalonada

CORTIFOAM – hydrocortisone acetate rectal foam 10% (90 mg/dose) hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc)

benzocaine dental soln 20%

Límite de surtido

triamcinolone acetonide dental paste 0.1% AGENTES ANORRECTALES

neomycin-polymyxin-hc otic soln 1%

pramoxine-chloroxylenol otic liquid 1-0.1% BOCA Y GARGANTA (LOCAL)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

benzoyl peroxide liq 7%

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

benzoyl peroxide liq 5.25% benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)

sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin)

clindamycin phosphate swab 1% (Cleocin-t)

isotretinoin cap 10 mg isotretinoin cap 20 mg isotretinoin cap 30 mg isotretinoin cap 40 mg metronidazole cream 0.75% (Metrocream) metronidazole gel 0.75%

Terapiaescalonada

sulfacetamide sodium w/ sulfur cleansing cloth 10-5%

clindamycin phosphate soln 1% (Cleocin-t)

FINACEA – azelaic acid gel 15%

Límite de surtido

sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser)

clindamycin phosphate lotion 1% (Cleocin-t)

erythromycin soln 2%

Autorización previa

sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% (Plexion cleanser)

clindamycin phosphate gel 1% (Cleocin-t)

erythromycin pads 2%

Especialización

sulfacetamide sodium lotion 10% (acne) (Klaron)

clindamycin phosphate foam 1% (Evoclin)

erythromycin gel 2% (Erygel)

Terapiaescalonada

sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit (Sumadan xlt)

clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)

DIFFERIN – adapalene lotion 0.1%

Nombre del medicamento sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit (Sumadan kit)

benzoyl peroxide lotion 6%

clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin)

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

sulfacetamide sodium w/ sulfur cream 9.8-4.8% (Plexion)

•

sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls) sulfacetamide sodium w/ sulfur cream 10-5% sulfacetamide sodium w/ sulfur emulsion 10-1% sulfacetamide sodium w/ sulfur emulsion 10-5% sulfacetamide sodium w/ sulfur foam 10-5% sulfacetamide sodium w/ sulfur lotion 9.8-4.8% (Plexion) sulfacetamide sodium w/ sulfur lotion 10-5%

metronidazole gel 1% (Metrogel)

sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts)

metronidazole lotion 0.75% (Metrolotion)

sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash)

SSS 10-5 – sulfacetamide sodium w/ sulfur foam 10-5%

sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash) sulfacetamide sodium-sulfur in urea emulsion 10-4%

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TAZORAC – tazarotene cream 0.05% TAZORAC – tazarotene cream 0.1% TAZORAC – tazarotene gel 0.05% TAZORAC – tazarotene gel 0.1% tretinoin cream 0.025% (Retin-a) tretinoin cream 0.05% (Retin-a) tretinoin cream 0.1% (Retin-a) tretinoin gel 0.01% (Retin-a) tretinoin gel 0.025% (Retin-a) tretinoin gel 0.05% (Atralin) tretinoin microsphere gel 0.04% (Retin-a micro) tretinoin microsphere gel 0.1% (Retin-a micro) Antiinfecciosos

diclofenac sodium soln 1.5% econazole nitrate cream 1% GENTAMICIN SULFATE – gentamicin sulfate cream 0.1% GENTAMICIN SULFATE – gentamicin sulfate oint 0.1% ketoconazole cream 2% ketoconazole foam 2% (Extina) ketoconazole shampoo 2% (Nizoral)

•

mafenide acetate packet for topical soln 5% (50 gm) (Sulfamylon)

CENTANY – mupirocin oint 2%

mupirocin oint 2%

ciclopirox gel 0.77%

naftifine hcl cream 2% (Naftin)

ciclopirox olamine cream 0.77% (base equiv) (Loprox)

nystatin cream 100000 unit/gm

ciclopirox olamine susp 0.77% (base equiv)

nystatin topical powder

ciclopirox solution 8% (Penlac nail lacquer) CICLOPIROX TOPICAL SOLUTI – ciclopirox solution 8% & vitamin e 5% topical kit

nystatin oint 100000 unit/gm oxiconazole nitrate cream 1% (Oxistat)

• • •

salicylic acid cream 6% salicylic acid cream 6% & cleanser liqd kit (Salex cream) salicylic acid film forming liquid 27.5% (Virasal) salicylic acid foam 6% (Salvax) salicylic acid gel 6% (Keralyt)

clotrimazole cream 1%

salicylic acid lotion 6%

clotrimazole soln 1%

salicylic acid lotion 6% & cleanser liqd kit (Salex lotion)

clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) clotrimazole w/ betamethasone lotion 1-0.05%

Terapiaescalonada

diclofenac sodium gel 1% (Voltaren)

mupirocin calcium cream 2% (Bactroban)

ciclopirox solution kit 8% (Ciclodan solution ki)

Límite de surtido

diclofenac sod soln 1.5% & capsaicin cream 0.025% ther pack (Dermacinrx lexitral)

acyclovir oint 5% (Zovirax)

ciclopirox shampoo 1% (Loprox shampoo)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

• • • • • • • • • • •

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

salicylic acid shampoo 6% (Salex) silver sulfadiazine cream 1% (Silvadene) ZOVIRAX – acyclovir cream 5%

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Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

Corticosteroides alclometasone dipropionate cream 0.05% (Aclovate) alclometasone dipropionate oint 0.05% betamethasone dipropionate augmented cream 0.05% (Diprolene af)

clobetasol propionate soln 0.05% (Temovate) clobetasol propionate spray 0.05% (Clobex)

betamethasone dipropionate augmented lotion 0.05% (Diprolene)

desonide oint 0.05%

betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% betamethasone valerate aerosol foam 0.12% (Luxiq) betamethasone valerate cream 0.1% betamethasone valerate lotion 0.1% betamethasone valerate oint 0.1% calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex) clobetasol propionate cream 0.05% (Temovate) clobetasol propionate emollient base cream 0.05% (Temovate e) clobetasol propionate emulsion foam 0.05% (Olux-e)

desonide lotion 0.05% (Desowen) DESOXIMETASONE – desoximetasone cream 0.05% desoximetasone cream 0.25% (Topicort) desoximetasone gel 0.05% (Topicort) desoximetasone oint 0.25% (Topicort) fluocinolone acetonide cream 0.01% fluocinolone acetonide cream 0.025% (Synalar) fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod) fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca) fluocinolone acetonide oint 0.025% (Synalar) fluocinolone acetonide soln 0.01% (Synalar) fluocinonide cream 0.05% fluocinonide cream 0.1% (Vanos) fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05%

clobetasol propionate foam 0.05% (Olux)

fluocinonide oint 0.05%

clobetasol propionate gel 0.05% (Temovate)

flurandrenolide cream 0.05% (Cordran)

clobetasol propionate lotion 0.05% (Clobex)

Terapiaescalonada

clobetasol propionate shampoo 0.05% (Clobex)

desonide cream 0.05% (Desowen)

betamethasone dipropionate cream 0.05%

Límite de surtido

clobetasol propionate oint 0.05% (Temovate)

betamethasone dipropionate augmented gel 0.05%

betamethasone dipropionate augmented oint 0.05% (Diprolene)

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

fluocinonide soln 0.05%

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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fluticasone propionate cream 0.05% (Cutivate)

prednicarbate cream 0.1% (Dermatop)

fluticasone propionate lotion 0.05% (Cutivate)

prednicarbate oint 0.1% (Dermatop)

fluticasone propionate oint 0.005%

triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog)

halobetasol propionate cream 0.05% (Ultravate)

triamcinolone acetonide cream 0.025%

halobetasol propionate oint 0.05% (Ultravate)

triamcinolone acetonide cream 0.1%

hydrocortisone acetate-aloe vera gel 2%

triamcinolone acetonide lotion 0.025% triamcinolone acetonide lotion 0.1%

hydrocortisone butyrate hydrophilic lipo base cream 0.1% (Locoid lipocream)

triamcinolone acetonide oint 0.1% Otros productos para la piel acitretin cap 10 mg (Soriatane)

hydrocortisone butyrate soln 0.1% (Locoid)

acitretin cap 25 mg (Soriatane)

hydrocortisone lotion 2% (Ala scalp) hydrocortisone lotion 2.5%

acitretin cap 17.5 mg (Soriatane) aluminum chloride soln 20% calcipotriene cream 0.005% (Dovonex) calcipotriene oint 0.005%

hydrocortisone oint 1%

calcipotriene soln 0.005% (50 mcg/ ml)

hydrocortisone oint 2.5%

capsaicin-menthol disk 0.0375-5%

hydrocortisone valerate cream 0.2%

capsaicin-menthol topical patch 0.05-5%

hydrocortisone valerate oint 0.2% (Westcort) mometasone furoate cream 0.1% (Elocon) mometasone furoate oint 0.1% (Elocon) mometasone furoate solution 0.1% (lotion) (Elocon) nystatin-triamcinolone cream 100000-0.1 unit/gm-% nystatin-triamcinolone oint 100000-0.1 unit/gm-%

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Terapiaescalonada

triamcinolone acetonide oint 0.025%

hydrocortisone butyrate oint 0.1% (Locoid)

hydrocortisone cream 2.5%

Límite de surtido

triamcinolone acetonide cream 0.5%

hydrocortisone butyrate cream 0.1% (Locoid)

hydrocortisone cream 1%

Autorización previa

Nombre del medicamento

Especialización

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

CEM-UREA – urea soln 45% COSENTYX – secukinumab subcutaneous soln prefilled syringe 150 mg/ml COSENTYX SENSOREADY PEN – secukinumab subcutaneous soln auto-injector 150 mg/ml dermatological products misc cream diclofenac sodium (actinic keratoses) gel 3% (Solaraze) Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

fluorouracil cream 5% (Efudex) fluorouracil soln 2%

•

TALTZ – ixekizumab subcutaneous soln auto-injector 80 mg/ml TALTZ – ixekizumab subcutaneous soln prefilled syringe 80 mg/ml

lidocaine hcl cream 3%

urea cream 39% (Aluvea)

lidocaine hcl gel 2%

urea cream 40%

lidocaine hcl soln 4% (Xylocaine)

urea cream 45% (Uramaxin)

lidocaine oint 5%

urea cream 47% (Keralac)

lidocaine patch 5% (Lidoderm)

urea cream 50%

lidocaine-menthol patch 4-1%

lindane shampoo 1% malathion lotion 0.5% (Ovide) methoxsalen rapid cap 10 mg (Oxsoralen ultra) permethrin cream 5% (Elimite) podofilox soln 0.5% (Condylox) pramoxine hcl gel 1% scar treatment products - gel selenium sulfide lotion 2.5% selenium sulfide-pyrithione zinc in urea shampoo 2.25%

Terapiaescalonada

tacrolimus oint 0.1% (Protopic)

lactic acid w/ vitamin e cream 10%-3500 unit/30gm

lindane lotion 1%

Límite de surtido

tacrolimus oint 0.03% (Protopic)

lactic acid (ammonium lactate) lotion 12% (Lac-hydrin)

lidocaine-prilocaine cream 2.5-2.5%

sulfacetamide sodium liquid 10% (Ovace wash) sulfacetamide sodium shampoo 10% (Ovace plus)

lactic acid (ammonium lactate) lotion 10%

lidocaine-prilocaine cream kit 2.5-2.5%

Autorización previa

sulfacetamide sodium cleansing gel 10% (Ovace plus wash)

lactic acid (ammonium lactate) cream 12% (Lac-hydrin)

lidocaine-menthol patch 4-4%

Especialización

skin protectants misc - cream

fluorouracil soln 5%

imiquimod cream 5% (Aldara)

Nombre del medicamento silver nitrate-potassium nitrate applicator 75-25% (Arzol silver nitrate)

ELIDEL – pimecrolimus cream 1%

hyaluronate sodium (emollient) gel 0.2% (Hylira)

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

urea foam 40% (Hydro 40 foam)

•

urea gel 40%

•

urea in lactic acid vehicle foam 35% (Hydro 35)

urea gel 45% (Uramaxin)

urea in lactic acid-salicylic acid vehicle susp 50% urea in zinc undecylenate-lactic acid vehicle emulsion 50% urea lotion 40% urea lotion 45% (Uramaxin) urea suspension 40% (Umecta nail film) VALCHLOR – mechlorethamine hcl gel 0.016% (base equivalent) wound dressings - cream ZYCLARA – imiquimod cream 3.75%

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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ZYCLARA PUMP – imiquimod cream 2.5% ZYCLARA PUMP – imiquimod cream 3.75% CATEGORÍAS VARIAS

•

EVZIO – naloxone hcl solution autoinjector 0.4 mg/0.4ml FERRIPROX – deferiprone tab 500 mg

irrigation solution, physiological

BAYER Blood Glucose Monitoring System - BREEZE 2, CONTOUR, CONTOUR NEXT/EZ/LINK/USB

lactated ringer's for irrigation

CALIBRATION LIQUID - BAYER BREEZE 2, CONTOUR, CONTOUR NEXT

mycophenolate mofetil cap 250 mg (Cellcept)

ALCOHOL PREP PADS, SWABS – various INSULIN PEN NEEDLES – VARIOUS

• •

LANCETS - BAYER ASCENCIA DISPOSITIVOS ESPACIADORES PARA INHALADORES

BREATHERITE

mycophenolate mofetil tab 500 mg (Cellcept) mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic) NALOXONE HCL – naloxone hcl inj 1 mg/ml

azathioprine tab 50 mg (I muran)

naltrexone hcl tab 50 mg

CHEMET – succimer cap 100 mg

NARCAN – naloxone hcl nasal spray 4 mg/0.1ml REVLIMID – lenalidomide caps 2.5 mg

cyclosporine cap 100 mg (Sandimmune)

REVLIMID – lenalidomide cap 5 mg

CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg

REVLIMID – lenalidomide cap 15 mg

cyclosporine modified cap 25 mg (Neoral)

REVLIMID – lenalidomide cap 10 mg REVLIMID – lenalidomide cap 20 mg REVLIMID – lenalidomide cap 25 mg

cyclosporine modified cap 50 mg (Cyclosporine modifie)

ringer's solution for irrigation

cyclosporine modified cap 100 mg (Neoral)

sirolimus tab 1 mg (Rapamune)

cyclosporine modified oral soln 100 mg/ml (Neoral)

sodium polystyrene sulfonate oral susp 15 gm/60ml

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Terapiaescalonada

mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)

MEDICAMENTOS VARIOS

cyclosporine cap 25 mg (Sandimmune)

Límite de surtido

METHYLENE BLUE – methylene blue inj 1%

INSULIN SYRINGES - VARIOUS

AEROCHAMBER

• •

FERRIPROX – deferiprone oral soln 100 mg/ml

SUMINISTROS PARA DIABÉTICOS

TEST STRIPS – BAYER ASCENCIA

Autorización previa

Nombre del medicamento

Especialización

•

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

• • • •

• • • •

• •

sirolimus tab 0.5 mg (Rapamune) sirolimus tab 2 mg (Rapamune)

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

Terapiaescalonada

Límite de surtido

Autorización previa

Nombre del medicamento

Especialización

2016

sodium polystyrene sulfonate powder (Kayexalate) sodium polystyrene sulfonate rectal susp 30 gm/120ml tacrolimus cap 0.5 mg (Prograf) tacrolimus cap 1 mg (Prograf) tacrolimus cap 5 mg (Prograf) VISTOGARD – uridine triacetate oral granules packet 10 gm VIVITROL – naltrexone for im extended release susp 380 mg water for irrigation, sterile irrigation soln XIAFLEX – collagenase clostridium histolyticum for inj 0.9 mg

• •

• •

ZORTRESS – everolimus tab 0.25 mg ZORTRESS – everolimus tab 0.5 mg ZORTRESS – everolimus tab 0.75 mg

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2016 ÍNDICE A abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg (Trizivir).................................................. 4 abacavir sulfate tab 300 mg (base equiv) (Ziagen)......... 4 ABILIFY – aripiprazole im inj 9.75 mg/1.3ml (7.5 mg/ ml)...................................................................................... 38 ABILIFY – aripiprazole oral solution 1 mg/ml..................... 38 ABILIFY DISCMELT – aripiprazole orally disintegrating tab 10 mg................................................................................. 38 ABILIFY DISCMELT – aripiprazole orally disintegrating tab 15 mg................................................................................. 38 ABILIFY MAINTENA – aripiprazole im for extended release susp 300 mg........................................................ 38 ABILIFY MAINTENA – aripiprazole im for extended release susp 400 mg........................................................ 38 acamprosate calcium tab delayed release 333 mg....... 44 acarbose tab 25 mg (Precose)........................................ 12 acarbose tab 50 mg (Precose)........................................ 12 acarbose tab 100 mg (Precose)...................................... 12 acebutolol hcl cap 200 mg (Sectral)............................... 19 acebutolol hcl cap 400 mg (Sectral)............................... 19 acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg (Trezix)...................................................46 acetaminophen-salicylamide-phenyltoloxamine cap 300-200-20mg................................................................... 46 acetaminophen w/ codeine soln 120-12 mg/5ml........... 46 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine)............................................................................ 46 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ codeine #3)....................................................................... 46 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ codeine #4)....................................................................... 46 ACETAZOLAMIDE – acetazolamide tab 125 mg............... 24 acetazolamide cap sr 12hr 500 mg (Diamox)................ 24 acetazolamide tab 250 mg............................................... 24 acetic acid irrigation soln 0.25%.....................................33 acetic acid otic soln 2%................................................... 61 acetylcysteine cap 600 mg.............................................. 58 acetylcysteine inhal soln 10%......................................... 27 acetylcysteine inhal soln 20%......................................... 27 acitretin cap 10 mg (Soriatane)....................................... 66 acitretin cap 17.5 mg (Soriatane).................................... 66 acitretin cap 25 mg (Soriatane)....................................... 66 ACTEMRA – tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml........................................................ 49 ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)........................................................... 7 ACTONEL – risedronate sodium tab 5 mg........................ 15 ACTONEL – risedronate sodium tab 30 mg...................... 15 ACTONEL – risedronate sodium tab 35 mg...................... 15 acyclovir cap 200 mg (Zovirax)......................................... 4 acyclovir oint 5% (Zovirax).............................................. 64 70

acyclovir susp 200 mg/5ml (Zovirax)............................... 4 acyclovir tab 400 mg (Zovirax)..........................................4 acyclovir tab 800 mg (Zovirax)..........................................4 ADAPALENE – adapalene lotion 0.1%.............................. 62 adapalene cream 0.1% (Differin)..................................... 62 adapalene gel 0.1% (Differin).......................................... 62 adapalene gel 0.3% (Differin).......................................... 62 ADASUVE – loxapine aerosol powder breath activated 10 mg...................................................................................... 38 ADCIRCA – tadalafil tab 20 mg (pah)................................ 25 adefovir dipivoxil tab 10 mg (Hepsera)............................ 4 ADEMPAS – riociguat tab 0.5 mg...................................... 25 ADEMPAS – riociguat tab 1 mg......................................... 25 ADEMPAS – riociguat tab 1.5 mg...................................... 25 ADEMPAS – riociguat tab 2 mg......................................... 25 ADEMPAS – riociguat tab 2.5 mg...................................... 25 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 100-50 mcg/dose............................................................... 27 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 250-50 mcg/dose............................................................... 27 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 500-50 mcg/dose............................................................... 27 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 mcg/act............................................................................... 27 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 mcg/act............................................................................... 28 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 230-21 mcg/act.................................................................. 28 AEROCHAMBER................................................................ 68 AFINITOR DISPERZ – everolimus tab for oral susp 2 mg........................................................................................ 7 AFINITOR DISPERZ – everolimus tab for oral susp 3 mg........................................................................................ 7 AFINITOR DISPERZ – everolimus tab for oral susp 5 mg........................................................................................ 8 AFINITOR – everolimus tab 2.5 mg..................................... 7 AFINITOR – everolimus tab 5 mg........................................ 7 AFINITOR – everolimus tab 7.5 mg..................................... 7 AFINITOR – everolimus tab 10 mg...................................... 7 ALBENZA – albendazole tab 200 mg.................................. 7 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).......... 28 albuterol sulfate soln nebu 0.5% (5 mg/ml)................... 28 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)................................................................................. 28 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)................................................................................. 28 albuterol sulfate syrup 2 mg/5ml.................................... 28 albuterol sulfate tab 2 mg................................................ 28 albuterol sulfate tab 4 mg................................................ 28 albuterol sulfate tab sr 12hr 4 mg (Vospire er)..............28 albuterol sulfate tab sr 12hr 8 mg (Vospire er)..............28 alclometasone dipropionate cream 0.05% (Aclovate).......................................................................... 65 alclometasone dipropionate oint 0.05%......................... 65 ALCOHOL PREP PADS, SWABS – various...................... 68

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 ALECENSA – alectinib hcl cap 150 mg (base equivalent)............................................................................8 ALENDRONATE SODIUM – alendronate sodium tab 40 mg...................................................................................... 15 alendronate sodium tab 5 mg......................................... 15 alendronate sodium tab 10 mg....................................... 15 alendronate sodium tab 35 mg....................................... 15 alendronate sodium tab 70 mg (Fosamax).................... 15 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)................... 33 ALKERAN – melphalan tab 2 mg.........................................8 allopurinol tab 100 mg (Zyloprim).................................. 51 allopurinol tab 300 mg (Zyloprim).................................. 51 almotriptan malate tab 6.25 mg (Axert)..........................50 almotriptan malate tab 12.5 mg (Axert)..........................50 alosetron hcl tab 0.5 mg (base equiv) (Lotronex)......... 31 alosetron hcl tab 1 mg (base equiv) (Lotronex)............ 31 ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 60 ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ ml........................................................................................ 34 alprazolam orally disintegrating tab 0.25 mg................ 34 alprazolam orally disintegrating tab 0.5 mg.................. 34 alprazolam orally disintegrating tab 1 mg..................... 34 alprazolam orally disintegrating tab 2 mg..................... 34 alprazolam tab 0.25 mg (Xanax)......................................34 alprazolam tab 0.5 mg (Xanax)........................................34 alprazolam tab 1 mg (Xanax)...........................................34 alprazolam tab 2 mg (Xanax)...........................................34 alprazolam tab sr 24hr 0.5 mg (Xanax xr)...................... 34 alprazolam tab sr 24hr 1 mg (Xanax xr)......................... 34 alprazolam tab sr 24hr 2 mg (Xanax xr)......................... 34 alprazolam tab sr 24hr 3 mg (Xanax xr)......................... 34 aluminum chloride soln 20%........................................... 66 amantadine hcl cap 100 mg............................................ 53 amantadine hcl syrup 50 mg/5ml....................................53 amiloride & hydrochlorothiazide tab 5-50 mg............... 24 amiloride hcl tab 5 mg..................................................... 24 amino acids cap................................................................ 58 aminocaproic acid syrup 25%......................................... 58 aminocaproic acid tab 500 mg........................................ 58 amiodarone hcl tab 100 mg............................................. 24 amiodarone hcl tab 400 mg............................................. 24 amiodarone hcl tab 200 mg (Cordarone)....................... 24 amitriptyline hcl tab 10 mg.............................................. 35 amitriptyline hcl tab 50 mg.............................................. 35 amitriptyline hcl tab 75 mg.............................................. 35 amitriptyline hcl tab 100 mg............................................ 35 amitriptyline hcl tab 150 mg............................................ 35 amitriptyline hcl tab 25 mg (Elavil)................................. 35 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet)...................................................................... 20 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet)...................................................................... 20 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet)...................................................................... 20

amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet).............................................................................20 amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet).............................................................................20 amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet).............................................................................20 amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet).............................................................................20 amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet).............................................................................20 amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet).............................................................................20 amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet).............................................................................20 amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet).............................................................................20 amlodipine besylate-benazepril hcl cap 2.5-10 mg....... 20 amlodipine besylate-benazepril hcl cap 5-40 mg.......... 20 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel)............................................................................... 20 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel)............................................................................... 20 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel)............................................................................... 20 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel)............................................................................... 20 amlodipine besylate tab 2.5 mg (Norvasc).................... 20 amlodipine besylate tab 5 mg (Norvasc)....................... 20 amlodipine besylate tab 10 mg (Norvasc)..................... 20 amlodipine besylate-valsartan tab 5-160 mg (Exforge)........................................................................... 20 amlodipine besylate-valsartan tab 5-320 mg (Exforge)........................................................................... 20 amlodipine besylate-valsartan tab 10-160 mg (Exforge)........................................................................... 20 amlodipine besylate-valsartan tab 10-320 mg (Exforge)........................................................................... 20 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg (Exforge hct)........................................... 18 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg (Exforge hct)..............................................................18 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg (Exforge hct).........................................18 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg (Exforge hct)............................................ 18 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg (Exforge hct)............................................ 18 AMOXAPINE – amoxapine tab 25 mg............................... 35 AMOXAPINE – amoxapine tab 50 mg............................... 35 AMOXAPINE – amoxapine tab 100 mg............................. 35 AMOXAPINE – amoxapine tab 150 mg............................. 35 AMOXICILLIN/CLAVULANATE P – amoxicillin & k clavulanate chew tab 200-28.5 mg.....................................1 AMOXICILLIN/CLAVULANATE P – amoxicillin & k clavulanate chew tab 400-57 mg........................................1

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2016 amoxicillin & k clavulanate chew tab 200-28.5 mg......... 1 amoxicillin & k clavulanate chew tab 400-57 mg............ 1 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml................................................................................. 1 amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)........................................................................ 1 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)........................................................... 1 amoxicillin & k clavulanate tab 250-125 mg.................... 1 amoxicillin & k clavulanate tab 500-125 mg (Augmentin)........................................................................ 1 amoxicillin & k clavulanate tab 875-125 mg (Augmentin)........................................................................ 1 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr)................................................................... 1 AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg........................................................................................ 1 AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg........................................................................................ 1 amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack (Prevpac)................................................................. 30 amoxicillin (trihydrate) cap 250 mg.................................. 1 amoxicillin (trihydrate) cap 500 mg.................................. 1 amoxicillin (trihydrate) for susp 125 mg/5ml................... 1 amoxicillin (trihydrate) for susp 200 mg/5ml................... 1 amoxicillin (trihydrate) for susp 250 mg/5ml................... 1 amoxicillin (trihydrate) for susp 400 mg/5ml................... 1 amoxicillin (trihydrate) tab 500 mg................................... 1 amoxicillin (trihydrate) tab 875 mg................................... 1 amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr)..................................................................... 42 amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr)..................................................................... 42 amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr)..................................................................... 42 amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr)..................................................................... 42 amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall xr)..................................................................... 42 amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall xr)..................................................................... 42 amphetamine-dextroamphetamine tab 5 mg (Adderall).......................................................................... 42 amphetamine-dextroamphetamine tab 7.5 mg (Adderall).......................................................................... 42 amphetamine-dextroamphetamine tab 10 mg (Adderall).......................................................................... 42 amphetamine-dextroamphetamine tab 12.5 mg (Adderall).......................................................................... 42 amphetamine-dextroamphetamine tab 15 mg (Adderall).......................................................................... 42 amphetamine-dextroamphetamine tab 20 mg (Adderall).......................................................................... 42

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amphetamine-dextroamphetamine tab 30 mg (Adderall).......................................................................... 42 ampicillin cap 250 mg........................................................ 1 ampicillin cap 500 mg........................................................ 1 AMPYRA – dalfampridine tab sr 12hr 10 mg..................... 44 anagrelide hcl cap 1 mg.................................................. 58 anagrelide hcl cap 0.5 mg (Agrylin)............................... 58 anastrozole tab 1 mg (Arimidex).......................................8 ANDRODERM – testosterone td patch 24hr 2 mg/24hr.............................................................................. 10 ANDRODERM – testosterone td patch 24hr 4 mg/24hr.............................................................................. 10 ANDROXY – fluoxymesterone tab 10 mg.......................... 10 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%).......................................................................... 61 antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097%................................................................ 61 APLENZIN – bupropion hbr tab sr 24hr 174 mg................ 35 APLENZIN – bupropion hbr tab sr 24hr 348 mg................ 35 APLENZIN – bupropion hbr tab sr 24hr 522 mg................ 35 APOKYN – apomorphine hydrochloride inj 10 mg/ml........ 53 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine)........................................................................... 60 APTIOM – eslicarbazepine acetate tab 200 mg................ 51 APTIOM – eslicarbazepine acetate tab 400 mg................ 51 APTIOM – eslicarbazepine acetate tab 600 mg................ 51 APTIOM – eslicarbazepine acetate tab 800 mg................ 51 APTIVUS – tipranavir cap 250 mg....................................... 4 APTIVUS – tipranavir oral soln 100 mg/ml.......................... 4 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 mcg/ml................................................................................ 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40 mcg/ml................................................................................ 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60 mcg/ml................................................................................ 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 100 mcg/ml........................................................................ 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 150 mcg/0.75ml................................................................. 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 200 mcg/ml........................................................................ 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 300 mcg/ml........................................................................ 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml.......................................... 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 25 mcg/0.42ml........................................ 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 40 mcg/0.4ml.......................................... 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml.......................................... 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 100 mcg/0.5ml........................................ 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml........................................ 58

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml........................................ 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml........................................ 58 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 500 mcg/ml............................................. 58 ARCALYST – rilonacept for inj 220 mg.............................. 49 aripiprazole orally disintegrating tab 15 mg.................. 38 aripiprazole oral solution 1 mg/ml.................................. 38 aripiprazole tab 2 mg (Abilify)......................................... 38 aripiprazole tab 5 mg (Abilify)......................................... 38 aripiprazole tab 10 mg (Abilify)....................................... 38 aripiprazole tab 15 mg (Abilify)....................................... 38 aripiprazole tab 20 mg (Abilify)....................................... 38 aripiprazole tab 30 mg (Abilify)....................................... 38 ARISTADA – aripiprazole lauroxil im er susp prefilled syr 441 mg/1.6ml..................................................................... 38 ARISTADA – aripiprazole lauroxil im er susp prefilled syr 662 mg/2.4ml..................................................................... 38 ARISTADA – aripiprazole lauroxil im er susp prefilled syr 882 mg/3.2ml..................................................................... 38 ARMODAFINIL – armodafinil tab 200 mg.......................... 42 armodafinil tab 50 mg (Nuvigil).......................................42 armodafinil tab 150 mg (Nuvigil).....................................42 armodafinil tab 250 mg (Nuvigil).....................................42 ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activ 100 mcg/act.................................................. 28 ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath activ 200 mcg/act.................................................. 28 ASACOL HD – mesalamine tab delayed release 800 mg...................................................................................... 32 ASMANEX HFA – mometasone furoate inhal aerosol suspension 100 mcg/act................................................... 28 ASMANEX HFA – mometasone furoate inhal aerosol suspension 200 mcg/act................................................... 28 ASMANEX TWISTHALER 120 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 28 ASMANEX TWISTHALER 7 METE – mometasone furoate inhal powd 110 mcg/inh (breath activated)....................... 28 ASMANEX TWISTHALER 14 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 28 ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 110 mcg/inh (breath activated)....................... 28 ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 28 ASMANEX TWISTHALER 60 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 28 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)...................................................................................... 19 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100).................................................................................... 19 atenolol tab 25 mg (Tenormin)........................................ 19 atenolol tab 50 mg (Tenormin)........................................ 19 atenolol tab 100 mg (Tenormin)...................................... 19

atorvastatin calcium tab 10 mg (base equivalent) (Lipitor).............................................................................. 22 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor).............................................................................. 22 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor).............................................................................. 22 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor).............................................................................. 22 atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)........................................................................... 6 atovaquone-proguanil hcl tab 250-100 mg (Malarone)........................................................................... 6 atovaquone susp 750 mg/5ml (Mepron)...........................7 ATRIPLA – efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg.................................................................. 4 ATROPINE SULFATE – atropine sulfate ophth oint 1%...................................................................................... 61 ATROPINE SULFATE – atropine sulfate ophth soln 1%...................................................................................... 61 atropine sulfate ophth soln 1%....................................... 61 ATROVENT HFA – ipratropium bromide hfa inhal aerosol 17 mcg/act......................................................................... 28 AUBAGIO – teriflunomide tab 7 mg................................... 44 AUBAGIO – teriflunomide tab 14 mg................................. 44 AVONEX – interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial)......................................................... 44 AVONEX – interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml...........................................................................44 AVONEX PEN – interferon beta-1a im auto-injector kit 30 mcg/0.5ml...........................................................................44 azathioprine tab 50 mg (Imuran)..................................... 68 azelastine hcl nasal spray 0.1% (137 mcg/spray)......... 27 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro)........................................................................... 27 azelastine hcl ophth soln 0.05%..................................... 61 AZILECT – rasagiline mesylate tab 0.5 mg (base equiv)................................................................................. 54 AZILECT – rasagiline mesylate tab 1 mg (base equiv)......54 AZITHROMYCIN – azithromycin powd pack for susp 1 gm........................................................................................ 2 azithromycin for susp 100 mg/5ml (Zithromax).............. 2 azithromycin for susp 200 mg/5ml (Zithromax).............. 2 azithromycin tab 250 mg (Zithromax).............................. 2 azithromycin tab 500 mg (Zithromax).............................. 2 azithromycin tab 600 mg (Zithromax).............................. 2 AZOPT – brinzolamide ophth susp 1%.............................. 60 B BACITRACIN – bacitracin ophth oint 500 unit/gm............. 60 bacitracin-polymyxin b ophth oint..................................60 bacitracin-polymyxin-neomycin-hc ophth oint 1%....... 60 baclofen tab 10 mg........................................................... 55 baclofen tab 20 mg........................................................... 55 balsalazide disodium cap 750 mg (Colazal).................. 32 BARACLUDE – entecavir oral soln 0.05 mg/ml................... 4

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2016 BAYER Blood Glucose Monitoring System - BREEZE 2, CONTOUR, CONTOUR NEXT/EZ/LINK/USB.................. 68 b-complex w/ c & folic acid cap 1 mg (Nephrocaps).................................................................... 55 b-complex w/ c & folic acid tab...................................... 55 b-complex w/ c & folic acid tab 5 mg............................. 55 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx)....................................................................................... 55 benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 16 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct)................................................................... 16 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct)................................................................... 17 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct)................................................................... 17 benazepril hcl tab 5 mg................................................... 17 benazepril hcl tab 10 mg (Lotensin)............................... 17 benazepril hcl tab 20 mg (Lotensin)............................... 17 benazepril hcl tab 40 mg (Lotensin)............................... 17 BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................. 18 BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................. 18 BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 40-25 mg.................................... 18 BENICAR – olmesartan medoxomil tab 5 mg.................... 18 BENICAR – olmesartan medoxomil tab 20 mg.................. 18 BENICAR – olmesartan medoxomil tab 40 mg.................. 18 benzocaine dental soln 20%............................................ 62 BENZONATATE – benzonatate cap 150 mg......................27 benzonatate cap 200 mg.................................................. 27 benzonatate cap 100 mg (Tessalon perles)................... 27 benzoyl peroxide cloth 6%.............................................. 62 benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)....................................................................63 benzoyl peroxide foam 5.3% (Benzefoam).................... 62 benzoyl peroxide foam 9.8% (Benzefoam ultra)........... 62 benzoyl peroxide gel 10%................................................ 62 benzoyl peroxide liq 2.5%................................................ 62 benzoyl peroxide liq 5.25%.............................................. 63 benzoyl peroxide liq 7%................................................... 62 benzoyl peroxide liq 10%................................................. 62 benzoyl peroxide lotion 6%............................................. 63 benztropine mesylate tab 0.5 mg....................................54 benztropine mesylate tab 1 mg.......................................54 benztropine mesylate tab 2 mg.......................................54 betamethasone dipropionate augmented cream 0.05% (Diprolene af)................................................................... 65 betamethasone dipropionate augmented gel 0.05%................................................................................. 65 betamethasone dipropionate augmented lotion 0.05% (Diprolene)........................................................................ 65 betamethasone dipropionate augmented oint 0.05% (Diprolene)........................................................................ 65 betamethasone dipropionate cream 0.05%................... 65

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betamethasone dipropionate lotion 0.05%.................... 65 betamethasone dipropionate oint 0.05%....................... 65 betamethasone valerate aerosol foam 0.12% (Luxiq)............................................................................... 65 betamethasone valerate cream 0.1%............................. 65 betamethasone valerate lotion 0.1%.............................. 65 betamethasone valerate oint 0.1%................................. 65 BETASERON – interferon beta-1b for inj kit 0.3 mg.......... 44 betaxolol hcl ophth soln 0.5%.........................................60 betaxolol hcl tab 10 mg (Kerlone).................................. 19 betaxolol hcl tab 20 mg (Kerlone).................................. 19 bethanechol chloride tab 5 mg (Urecholine)................. 33 bethanechol chloride tab 10 mg (Urecholine)............... 33 bethanechol chloride tab 25 mg (Urecholine)............... 33 bethanechol chloride tab 50 mg (Urecholine)............... 33 bexarotene cap 75 mg (Targretin)..................................... 8 bicalutamide tab 50 mg (Casodex)................................... 8 BILTRICIDE – praziquantel tab 600 mg............................... 7 bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit....................................................................................... 30 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac).................................................................................. 19 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac).................................................................................. 19 bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac).................................................................................. 19 bisoprolol fumarate tab 5 mg (Zebeta)...........................19 bisoprolol fumarate tab 10 mg (Zebeta).........................19 BOSULIF – bosutinib tab 100 mg........................................ 8 BOSULIF – bosutinib tab 500 mg........................................ 8 BRAVELLE – urofollitropin purified for inj 75 unit...............12 BREATHERITE.................................................................... 68 BRILINTA – ticagrelor tab 60 mg....................................... 58 BRILINTA – ticagrelor tab 90 mg....................................... 58 brimonidine tartrate ophth soln 0.2%.............................60 brimonidine tartrate ophth soln 0.15% (Alphagan p)........................................................................................ 60 BRINTELLIX – vortioxetine hbr tab 5 mg (base equiv)...... 35 BRINTELLIX – vortioxetine hbr tab 10 mg (base equiv)................................................................................. 35 BRINTELLIX – vortioxetine hbr tab 20 mg (base equiv)................................................................................. 35 bromfenac sodium ophth soln 0.09% (base equivalent)........................................................................ 61 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)....................................................................... 61 bromocriptine mesylate cap 5 mg (Parlodel)................ 54 bromocriptine mesylate tab 2.5 mg................................ 54 brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg...................................................................................... 27 brompheniramine maleate tab sr 12hr 6 mg................. 26 budesonide delayed release particles cap 3 mg (Entocort ec)...................................................................... 9 budesonide inhalation susp 0.25 mg/2ml (Pulmicort)........................................................................ 28

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 budesonide inhalation susp 0.5 mg/2ml (Pulmicort)........................................................................ 28 budesonide inhalation susp 1 mg/2ml (Pulmicort)....... 28 budesonide nasal susp 32 mcg/act (Rhinocort aqua).................................................................................. 27 bumetanide tab 0.5 mg (Bumex)..................................... 24 bumetanide tab 1 mg (Bumex)........................................ 24 bumetanide tab 2 mg (Bumex)........................................ 24 BUPHENYL – sodium phenylbutyrate oral powder 3 gm/ teaspoonful........................................................................ 15 BUPHENYL – sodium phenylbutyrate tab 500 mg............ 15 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)................................................................................. 46 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)................................................................................. 46 buprenorphine hcl sl tab 2 mg (base equiv)................. 46 buprenorphine hcl sl tab 8 mg (base equiv)................. 46 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban).............................................................................. 44 bupropion hcl tab 75 mg................................................. 35 bupropion hcl tab 100 mg............................................... 35 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)......... 35 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)......... 35 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)......... 35 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 35 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 35 buspirone hcl tab 5 mg.................................................... 34 buspirone hcl tab 7.5 mg................................................. 34 buspirone hcl tab 10 mg.................................................. 34 buspirone hcl tab 15 mg.................................................. 34 buspirone hcl tab 30 mg.................................................. 34 butalbital-acetaminophen-caffeine cap 50-325-40 mg...................................................................................... 46 butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet)............................................................................ 46 butalbital-acetaminophen-caffeine soln 50-325-40 mg/15ml.............................................................................46 butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)............................................................................... 46 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg...................................................................................... 46 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/codeine)...................................................... 46 butalbital-acetaminophen tab 50-325 mg.......................46 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)............................................................................ 46 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3)....................................................... 46 butorphanol tartrate nasal soln 10 mg/ml..................... 46 C cabergoline tab 0.5 mg.................................................... 15 CABOMETYX – cabozantinib s-malate tab 20 mg (base equivalent)............................................................................8

CABOMETYX – cabozantinib s-malate tab 40 mg (base equivalent)............................................................................8 CABOMETYX – cabozantinib s-malate tab 60 mg (base equivalent)............................................................................8 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)................................................................................. 42 calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex)................................................. 65 calcipotriene cream 0.005% (Dovonex).......................... 66 calcipotriene oint 0.005%................................................. 66 calcipotriene soln 0.005% (50 mcg/ml).......................... 66 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)........................................................................ 15 calcitriol cap 0.25 mcg (Rocaltrol).................................. 15 calcitriol cap 0.5 mcg (Rocaltrol).................................... 15 calcitriol oral soln 1 mcg/ml (Rocaltrol)......................... 15 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)............................................................... 32 calcium acetate (phosphate binder) tab 667 mg (Eliphos)............................................................................ 32 CALIBRATION LIQUID - BAYER BREEZE 2, CONTOUR, CONTOUR NEXT.............................................................. 68 CANASA – mesalamine suppos 1000 mg......................... 32 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg (Atacand hct)............................................................. 18 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg (Atacand hct)............................................................. 18 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg (Atacand hct)............................................................. 18 candesartan cilexetil tab 4 mg (Atacand)...................... 18 candesartan cilexetil tab 8 mg (Atacand)...................... 18 candesartan cilexetil tab 16 mg (Atacand).................... 18 candesartan cilexetil tab 32 mg (Atacand).................... 18 capecitabine tab 150 mg (Xeloda).................................... 8 capecitabine tab 500 mg (Xeloda).................................... 8 CAPRELSA – vandetanib tab 100 mg................................. 8 CAPRELSA – vandetanib tab 300 mg................................. 8 capsaicin-menthol disk 0.0375-5%................................. 66 capsaicin-menthol topical patch 0.05-5%...................... 66 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-15 mg.................................... 17 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-25 mg.................................... 17 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-15 mg.................................... 17 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-25 mg.................................... 17 captopril tab 12.5 mg........................................................17 captopril tab 25 mg...........................................................17 captopril tab 50 mg...........................................................17 captopril tab 100 mg.........................................................17 CARBAGLU – carglumic acid tab 200 mg......................... 15 carbamazepine cap sr 12hr 100 mg (Carbatrol)............ 51 carbamazepine cap sr 12hr 200 mg (Carbatrol)............ 51 carbamazepine cap sr 12hr 300 mg (Carbatrol)............ 51

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2016 carbamazepine chew tab 100 mg................................... 51 carbamazepine susp 100 mg/5ml (Tegretol).................. 51 carbamazepine tab 200 mg (Tegretol)............................ 51 carbamazepine tab sr 12hr 100 mg (Tegretol-xr).......... 51 carbamazepine tab sr 12hr 200 mg (Tegretol-xr).......... 51 carbamazepine tab sr 12hr 400 mg (Tegretol-xr).......... 51 carbidopa & levodopa orally disintegrating tab 10-100 mg...................................................................................... 54 carbidopa & levodopa orally disintegrating tab 25-100 mg...................................................................................... 54 carbidopa & levodopa orally disintegrating tab 25-250 mg...................................................................................... 54 carbidopa & levodopa tab cr 25-100 mg (Sinemet cr)....................................................................................... 54 carbidopa & levodopa tab cr 50-200 mg (Sinemet cr)....................................................................................... 54 carbidopa & levodopa tab 10-100 mg (Sinemet)........... 54 carbidopa & levodopa tab 25-100 mg (Sinemet)........... 54 carbidopa & levodopa tab 25-250 mg (Sinemet)........... 54 carbidopa tab 25 mg (Lodosyn)...................................... 54 carbinoxamine maleate soln 4 mg/5ml.......................... 26 carbinoxamine maleate tab 4 mg....................................26 carisoprodol tab 250 mg (Soma).................................... 55 carisoprodol tab 350 mg (Soma).................................... 55 carisoprodol w/ aspirin & codeine tab 200-325-16 mg...................................................................................... 55 carisoprodol w/ aspirin tab 200-325 mg.........................55 carteolol hcl ophth soln 1%............................................ 60 carvedilol tab 3.125 mg (Coreg)...................................... 19 carvedilol tab 6.25 mg (Coreg)........................................ 19 carvedilol tab 12.5 mg (Coreg)........................................ 19 carvedilol tab 25 mg (Coreg)........................................... 19 CAYSTON – aztreonam lysine for inhal soln 75 mg (base equivalent)............................................................................7 cefaclor cap 250 mg........................................................... 1 cefaclor cap 500 mg........................................................... 1 cefadroxil cap 500 mg........................................................ 1 cefadroxil for susp 250 mg/5ml........................................ 1 cefadroxil for susp 500 mg/5ml........................................ 1 cefadroxil tab 1 gm............................................................. 1 cefdinir cap 300 mg............................................................ 1 cefdinir for susp 125 mg/5ml............................................ 1 cefdinir for susp 250 mg/5ml............................................ 1 cefixime for susp 100 mg/5ml (Suprax)........................... 1 cefixime for susp 200 mg/5ml (Suprax)........................... 1 cefpodoxime proxetil for susp 50 mg/5ml....................... 1 cefpodoxime proxetil for susp 100 mg/5ml..................... 1 cefpodoxime proxetil tab 100 mg..................................... 1 cefpodoxime proxetil tab 200 mg..................................... 1 cefprozil for susp 125 mg/5ml...........................................1 cefprozil for susp 250 mg/5ml...........................................2 cefprozil tab 250 mg........................................................... 2 cefprozil tab 500 mg........................................................... 2 cefuroxime axetil tab 250 mg............................................ 2 cefuroxime axetil tab 500 mg (Ceftin).............................. 2

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celecoxib cap 50 mg (Celebrex)......................................49 celecoxib cap 100 mg (Celebrex)....................................49 celecoxib cap 200 mg (Celebrex)....................................49 celecoxib cap 400 mg (Celebrex)....................................49 CEM-UREA – urea soln 45%............................................. 66 CENTANY – mupirocin oint 2%.......................................... 64 cephalexin cap 250 mg (Keflex)........................................ 2 cephalexin cap 500 mg (Keflex)........................................ 2 cephalexin cap 750 mg (Keflex)........................................ 2 cephalexin for susp 125 mg/5ml....................................... 2 cephalexin for susp 250 mg/5ml....................................... 2 CERDELGA – eliglustat tartrate cap 84 mg (base equivalent)......................................................................... 58 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)................... 26 CETROTIDE – cetrorelix acetate for inj kit 0.25 mg.......... 12 cevimeline hcl cap 30 mg (Evoxac)................................ 62 CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg (base equiv)............................................................. 44 CHANTIX STARTING MONTH PA – varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack............................. 44 CHANTIX – varenicline tartrate tab 0.5 mg (base equiv)................................................................................. 44 CHANTIX – varenicline tartrate tab 1 mg (base equiv)...... 44 CHEMET – succimer cap 100 mg......................................68 CHENODAL – chenodiol tab 250 mg.................................32 CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxideamitriptyline tab 5-12.5 mg............................................... 44 CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxideamitriptyline tab 10-25 mg................................................ 44 chlordiazepoxide hcl cap 5 mg....................................... 34 chlordiazepoxide hcl cap 10 mg..................................... 34 chlordiazepoxide hcl cap 25 mg..................................... 34 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg (Librax).............................................................................. 30 chlorhexidine gluconate soln 0.12% (Peridex).............. 62 chloroquine phosphate tab 250 mg..................................6 chloroquine phosphate tab 500 mg (Aralen)................... 6 CHLOROTHIAZIDE – chlorothiazide tab 250 mg.............. 24 chlorothiazide tab 500 mg............................................... 24 CHLORPROMAZINE HCL – chlorpromazine hcl inj 50 mg/2ml............................................................................... 38 chlorpromazine hcl tab 10 mg........................................ 38 chlorpromazine hcl tab 25 mg........................................ 38 chlorpromazine hcl tab 50 mg........................................ 38 chlorpromazine hcl tab 100 mg...................................... 38 chlorpromazine hcl tab 200 mg...................................... 38 CHLORTHALIDONE – chlorthalidone tab 50 mg.............. 24 chlorthalidone tab 25 mg................................................. 24 chlorzoxazone tab 500 mg (Parafon forte dsc)............. 55 CHOLBAM – cholic acid cap 50 mg.................................. 32 CHOLBAM – cholic acid cap 250 mg................................ 32 cholestyramine light powder 4 gm/dose (Questran light)...................................................................................22 cholestyramine light powder packets 4 gm.................. 22 cholestyramine powder 4 gm/dose (Questran)............. 22

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 cholestyramine powder packets 4 gm (Questran)........ 22 choline & magnesium salicylates liq 500 mg/5ml......... 46 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)................................................................. 23 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix)................................................................. 23 ciclopirox gel 0.77%......................................................... 64 ciclopirox olamine cream 0.77% (base equiv) (Loprox).............................................................................64 ciclopirox olamine susp 0.77% (base equiv)................. 64 ciclopirox shampoo 1% (Loprox shampoo).................. 64 ciclopirox solution kit 8% (Ciclodan solution ki).......... 64 ciclopirox solution 8% (Penlac nail lacquer)................. 64 CICLOPIROX TOPICAL SOLUTI – ciclopirox solution 8% & vitamin e 5% topical kit................................................. 64 cilostazol tab 50 mg......................................................... 58 cilostazol tab 100 mg....................................................... 58 cimetidine hcl soln 300 mg/5ml...................................... 30 cimetidine tab 200 mg...................................................... 30 cimetidine tab 300 mg...................................................... 30 cimetidine tab 400 mg...................................................... 30 cimetidine tab 800 mg...................................................... 30 CIMZIA – certolizumab pegol for inj kit 2 x 200 mg........... 32 CIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml............ 32 CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200 mg/ml..................................................................................32 CIPRODEX – ciprofloxacin-dexamethasone otic susp 0.3-0.1%............................................................................. 62 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr)..................................................... 3 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr)........................................................... 3 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro).............................................................. 3 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro).............................................................. 3 ciprofloxacin hcl ophth soln 0.3% (Ciloxan)................. 60 ciprofloxacin hcl tab 750 mg (base equiv).......................3 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro).......... 3 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro).......... 3 citalopram hydrobromide oral soln 10 mg/5ml............. 35 citalopram hydrobromide tab 10 mg (base equiv) (Celexa)............................................................................. 35 citalopram hydrobromide tab 20 mg (base equiv) (Celexa)............................................................................. 35 citalopram hydrobromide tab 40 mg (base equiv) (Celexa)............................................................................. 35 clarithromycin for susp 125 mg/5ml.................................2 clarithromycin for susp 250 mg/5ml (Biaxin).................. 2 clarithromycin tab 250 mg (Biaxin).................................. 2 clarithromycin tab 500 mg (Biaxin).................................. 2 clarithromycin tab sr 24hr 500 mg................................... 2 CLASSIC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...........................................................................55 clemastine fumarate tab 2.68 mg....................................26

clindamycin hcl cap 75 mg (Cleocin)............................... 7 clindamycin hcl cap 150 mg (Cleocin)............................. 7 clindamycin hcl cap 300 mg (Cleocin)............................. 7 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr)............................................ 7 clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin)........................................................................ 63 clindamycin phosphate foam 1% (Evoclin)................... 63 clindamycin phosphate gel 1% (Cleocin-t).................... 63 clindamycin phosphate lotion 1% (Cleocin-t)............... 63 clindamycin phosphate soln 1% (Cleocin-t).................. 63 clindamycin phosphate swab 1% (Cleocin-t)................ 63 clindamycin phosphate vaginal cream 2% (Cleocin)............................................................................ 33 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)....................................................................63 clobetasol propionate cream 0.05% (Temovate)........... 65 clobetasol propionate emollient base cream 0.05% (Temovate e)..................................................................... 65 clobetasol propionate emulsion foam 0.05% (Oluxe)........................................................................................ 65 clobetasol propionate foam 0.05% (Olux)......................65 clobetasol propionate gel 0.05% (Temovate)................ 65 clobetasol propionate lotion 0.05% (Clobex)................ 65 clobetasol propionate oint 0.05% (Temovate)............... 65 clobetasol propionate shampoo 0.05% (Clobex).......... 65 clobetasol propionate soln 0.05% (Temovate).............. 65 clobetasol propionate spray 0.05% (Clobex)................ 65 clomipramine hcl cap 25 mg (Anafranil)........................ 35 clomipramine hcl cap 50 mg (Anafranil)........................ 35 clomipramine hcl cap 75 mg (Anafranil)........................ 35 clonazepam orally disintegrating tab 0.125 mg............ 51 clonazepam orally disintegrating tab 0.25 mg.............. 51 clonazepam orally disintegrating tab 0.5 mg................ 51 clonazepam orally disintegrating tab 1 mg................... 51 clonazepam orally disintegrating tab 2 mg................... 51 clonazepam tab 0.5 mg (Klonopin)................................. 51 clonazepam tab 1 mg (Klonopin).................................... 51 clonazepam tab 2 mg (Klonopin).................................... 51 clonidine hcl tab 0.1 mg (Catapres)............................... 25 clonidine hcl tab 0.2 mg (Catapres)............................... 25 clonidine hcl tab 0.3 mg (Catapres)............................... 25 clonidine hcl tab sr 12hr 0.1 mg (Kapvay)..................... 42 clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)...................................................................................25 clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)...................................................................................25 clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)...................................................................................25 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix).............................................................................. 58 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix).............................................................................. 59 clorazepate dipotassium tab 3.75 mg............................ 34 clorazepate dipotassium tab 15 mg............................... 34

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2016 clorazepate dipotassium tab 7.5 mg (Tranxene t)......... 34 clotrimazole cream 1%..................................................... 64 clotrimazole soln 1%........................................................ 64 clotrimazole troche 10 mg............................................... 62 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone)........................................................................ 64 clotrimazole w/ betamethasone lotion 1-0.05%............. 64 CLOZAPINE ODT – clozapine orally disintegrating tab 12.5 mg.............................................................................. 38 clozapine orally disintegrating tab 25 mg (Fazaclo)..... 38 clozapine orally disintegrating tab 100 mg (Fazaclo)............................................................................38 clozapine tab 50 mg......................................................... 38 clozapine tab 200 mg....................................................... 38 clozapine tab 25 mg (Clozaril).........................................38 clozapine tab 100 mg (Clozaril).......................................38 codeine sulfate tab 15 mg (Codeine sulfate)................. 46 codeine sulfate tab 30 mg (Codeine sulfate)................. 46 codeine sulfate tab 60 mg (Codeine sulfate)................. 46 colchicine w/ probenecid tab 0.5-500 mg...................... 51 COLCRYS – colchicine tab 0.6 mg.................................... 51 colestipol hcl granule packets 5 gm (Colestid flavored)............................................................................ 23 colestipol hcl granules 5 gm (Colestid flavored).......... 23 colestipol hcl tab 1 gm (Colestid)...................................23 COMBIPATCH – estradiol-norethindrone ace td pttw 0.05-0.14 mg/day.............................................................. 10 COMBIPATCH – estradiol-norethindrone ace td pttw 0.05-0.25 mg/day.............................................................. 11 COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol soln 20-100 mcg/act............................................ 28 COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit......................................................................... 8 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit................................................................ 8 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit................................................................ 8 COMPLERA – emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg.................................................................... 4 CORTIFOAM – hydrocortisone acetate rectal foam 10% (90 mg/dose)..................................................................... 62 CORTISONE ACETATE – cortisone acetate tab 25 mg...... 9 COSENTYX – secukinumab subcutaneous soln prefilled syringe 150 mg/ml............................................................. 66 COSENTYX SENSOREADY PEN – secukinumab subcutaneous soln auto-injector 150 mg/ml..................... 66 CREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit....................................................... 31 CREON – pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit..................................................... 31 CREON – pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit................................................... 31 CREON – pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit................................................. 31

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CREON – pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit............................................... 31 CRESTOR – rosuvastatin calcium tab 40 mg.................... 23 CRIXIVAN – indinavir sulfate cap 200 mg........................... 4 CRIXIVAN – indinavir sulfate cap 400 mg........................... 4 CROMOLYN SODIUM – cromolyn sodium soln nebu 20 mg/2ml............................................................................... 28 cromolyn sodium ophth soln 4%....................................61 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom).................................................................... 32 CVS PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...........................................................................55 cyanocobalamin inj 1000 mcg/ml................................... 59 cyclobenzaprine hcl tab 5 mg......................................... 55 cyclobenzaprine hcl tab 10 mg....................................... 55 cyclobenzaprine hcl tab 7.5 mg (Fexmid)...................... 55 cyclopentolate hcl ophth soln 0.5% (Cyclogyl)............. 61 cyclopentolate hcl ophth soln 1% (Cyclogyl)................ 61 cyclopentolate hcl ophth soln 2% (Cyclogyl)................ 61 cyclosporine cap 25 mg (Sandimmune)........................ 68 cyclosporine cap 100 mg (Sandimmune)...................... 68 cyclosporine modified cap 50 mg (Cyclosporine modifie)............................................................................. 68 cyclosporine modified cap 25 mg (Neoral).................... 68 cyclosporine modified cap 100 mg (Neoral).................. 68 CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg................................................................................. 68 cyclosporine modified oral soln 100 mg/ml (Neoral)..............................................................................68 cyproheptadine hcl syrup 2 mg/5ml............................... 26 cyproheptadine hcl tab 4 mg.......................................... 26 CYSTAGON – cysteamine bitartrate cap 50 mg................ 33 CYSTAGON – cysteamine bitartrate cap 150 mg.............. 33 CYSTARAN – cysteamine hcl ophth soln 0.44% (base equivalent)......................................................................... 61 D DAKLINZA – daclatasvir dihydrochloride tab 30 mg (base equivalent)............................................................................4 DAKLINZA – daclatasvir dihydrochloride tab 60 mg (base equivalent)............................................................................4 DAKLINZA – daclatasvir dihydrochloride tab 90 mg (base equivalent)............................................................................4 danazol cap 50 mg............................................................10 danazol cap 100 mg..........................................................10 danazol cap 200 mg..........................................................10 dantrolene sodium cap 100 mg...................................... 55 dantrolene sodium cap 25 mg (Dantrium)..................... 55 dantrolene sodium cap 50 mg (Dantrium)..................... 55 dapsone tab 25 mg............................................................. 7 dapsone tab 100 mg........................................................... 7 darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) (Enablex)............................................................... 33 darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) (Enablex)............................................................... 33

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 DELZICOL – mesalamine cap dr 400 mg.......................... 32 demeclocycline hcl tab 150 mg........................................ 2 demeclocycline hcl tab 300 mg........................................ 2 dermatological products misc - cream.......................... 66 DESCOVY – emtricitabine-tenofovir alafenamide fumarate tab 200-25 mg..................................................................... 4 desipramine hcl tab 50 mg.............................................. 35 desipramine hcl tab 75 mg.............................................. 35 desipramine hcl tab 100 mg............................................ 35 desipramine hcl tab 150 mg............................................ 35 desipramine hcl tab 10 mg (Norpramin)........................ 35 desipramine hcl tab 25 mg (Norpramin)........................ 35 desloratadine tab 5 mg (Clarinex).................................. 26 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp).............................................................................. 15 desmopressin acetate nasal spray soln 0.01% (Ddavp).............................................................................. 15 desmopressin acetate nasal spray soln 0.01% (refrigerated).....................................................................15 desmopressin acetate tab 0.1 mg (Ddavp).................... 15 desmopressin acetate tab 0.2 mg (Ddavp).................... 15 desonide cream 0.05% (Desowen)................................. 65 desonide lotion 0.05% (Desowen).................................. 65 desonide oint 0.05%......................................................... 65 desoximetasone cream 0.25% (Topicort)....................... 65 DESOXIMETASONE – desoximetasone cream 0.05%..... 65 desoximetasone gel 0.05% (Topicort)............................ 65 desoximetasone oint 0.25% (Topicort)........................... 65 DESVENLAFAXINE ER – desvenlafaxine fumarate tab sr 24hr 50 mg (base equiv).................................................. 35 DESVENLAFAXINE ER – desvenlafaxine fumarate tab sr 24hr 100 mg (base equiv)................................................ 35 DESVENLAFAXINE ER – desvenlafaxine tab sr 24hr 50 mg...................................................................................... 35 DESVENLAFAXINE ER – desvenlafaxine tab sr 24hr 100 mg...................................................................................... 35 DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml..................................................................................9 dexamethasone elixir 0.5 mg/5ml..................................... 9 DEXAMETHASONE SODIUM PHOS – dexamethasone sodium phosphate ophth soln 0.1%................................. 60 dexamethasone sodium phosphate ophth soln 0.1%................................................................................... 60 dexamethasone tab 0.5 mg............................................. 10 dexamethasone tab 0.75 mg........................................... 10 dexamethasone tab 1.5 mg............................................. 10 dexamethasone tab 4 mg................................................ 10 dexamethasone tab 6 mg................................................ 10 dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin xr)....................................................................................... 42 dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin xr)....................................................................................... 42 dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr)....................................................................................... 42

dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin xr)....................................................................................... 42 dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr)....................................................................................... 43 dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr)....................................................................................... 43 dexmethylphenidate hcl tab 2.5 mg (Focalin)............... 43 dexmethylphenidate hcl tab 5 mg (Focalin).................. 43 dexmethylphenidate hcl tab 10 mg (Focalin)................ 43 dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine)....................................................................... 43 dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine)....................................................................... 43 dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine)....................................................................... 43 dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra)........................................................................ 43 dextroamphetamine sulfate tab 5 mg.............................43 dextroamphetamine sulfate tab 10 mg...........................43 DIAPHRAGMS - VARIOUS................................................ 11 DIASTAT ACUDIAL – diazepam rectal gel delivery system 10 mg................................................................................. 51 DIASTAT ACUDIAL – diazepam rectal gel delivery system 20 mg................................................................................. 51 DIASTAT PEDIATRIC – diazepam rectal gel delivery system 2.5 mg................................................................... 51 diazepam conc 5 mg/ml................................................... 34 DIAZEPAM – diazepam im solution auto-inj 10 mg/2ml............................................................................... 34 DIAZEPAM – diazepam oral soln 1 mg/ml......................... 34 diazepam tab 2 mg (Valium)............................................ 34 diazepam tab 5 mg (Valium)............................................ 34 diazepam tab 10 mg (Valium).......................................... 34 diclofenac potassium tab 50 mg.....................................49 diclofenac sod dr tab 75 mg & capsaicin cr 0.025% ther pack (Derma silkrx diclopa)................................... 49 diclofenac sodium (actinic keratoses) gel 3% (Solaraze).......................................................................... 66 diclofenac sodium gel 1% (Voltaren).............................. 64 diclofenac sodium ophth soln 0.1%............................... 61 diclofenac sodium soln 1.5%.......................................... 64 diclofenac sodium tab delayed release 25 mg.............. 49 diclofenac sodium tab delayed release 50 mg.............. 49 diclofenac sodium tab delayed release 75 mg.............. 49 diclofenac sodium tab sr 24hr 100 mg.......................... 49 diclofenac sod soln 1.5% & capsaicin cream 0.025% ther pack (Dermacinrx lexitral)...................................... 64 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50)............................................................ 49 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75)............................................................ 49 dicloxacillin sodium cap 250 mg...................................... 1 dicloxacillin sodium cap 500 mg...................................... 1 dicyclomine hcl cap 10 mg (Bentyl)............................... 30 dicyclomine hcl oral soln 10 mg/5ml............................. 30

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2016 dicyclomine hcl tab 20 mg (Bentyl)................................ 30 didanosine delayed release capsule 125 mg (Videx ec)........................................................................................ 4 didanosine delayed release capsule 200 mg (Videx ec)........................................................................................ 4 didanosine delayed release capsule 250 mg (Videx ec)........................................................................................ 4 didanosine delayed release capsule 400 mg (Videx ec)........................................................................................ 5 DIFFERIN – adapalene lotion 0.1%................................... 63 diflunisal tab 500 mg........................................................ 46 DIGOXIN – digoxin oral soln 0.05 mg/ml........................... 25 digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 25 digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 25 DILANTIN – phenytoin sodium extended cap 30 mg......... 51 diltiazem hcl cap sr 12hr 60 mg......................................20 diltiazem hcl cap sr 12hr 90 mg......................................20 diltiazem hcl cap sr 12hr 120 mg....................................20 diltiazem hcl cap sr 24hr 120 mg....................................20 diltiazem hcl cap sr 24hr 180 mg....................................20 diltiazem hcl cap sr 24hr 240 mg....................................21 diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd)................................................................... 21 diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd)................................................................... 21 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd)................................................................... 21 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd)................................................................... 21 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd)................................................................... 21 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la).................................................................... 21 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la).................................................................... 21 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la).................................................................... 21 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la).................................................................... 21 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la).................................................................... 21 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac)....................................................................... 21 diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac)....................................................................... 21 diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac)....................................................................... 21 diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac)....................................................................... 21 diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac)....................................................................... 21 diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac)....................................................................... 21 diltiazem hcl tab 90 mg.................................................... 21 diltiazem hcl tab 30 mg (Cardizem)................................ 21

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diltiazem hcl tab 60 mg (Cardizem)................................ 21 diltiazem hcl tab 120 mg (Cardizem).............................. 21 diphenhydramine hcl cap 50 mg.................................... 26 diphenhydramine hcl elixir 12.5 mg/5ml........................ 26 diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)............................................................................ 30 dipyridamole tab 25 mg................................................... 59 dipyridamole tab 50 mg................................................... 59 dipyridamole tab 75 mg................................................... 59 disopyramide phosphate cap 100 mg (Norpace).......... 24 disopyramide phosphate cap 150 mg (Norpace).......... 24 disulfiram tab 250 mg (Antabuse).................................. 44 disulfiram tab 500 mg (Antabuse).................................. 44 divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles)................................................ 51 divalproex sodium tab delayed release 125 mg (Depakote)........................................................................ 51 divalproex sodium tab delayed release 250 mg (Depakote)........................................................................ 51 divalproex sodium tab delayed release 500 mg (Depakote)........................................................................ 51 divalproex sodium tab sr 24 hr 250 mg (Depakote er)....................................................................................... 51 divalproex sodium tab sr 24 hr 500 mg (Depakote er)....................................................................................... 51 DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)........... 11 DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)............... 11 DIVIGEL – estradiol td gel 1 mg/gm (0.1%).......................11 dofetilide cap 125 mcg (0.125 mg) (Tikosyn).................24 dofetilide cap 250 mcg (0.25 mg) (Tikosyn)...................24 dofetilide cap 500 mcg (0.5 mg) (Tikosyn).....................24 donepezil hydrochloride orally disintegrating tab 5 mg...................................................................................... 44 donepezil hydrochloride orally disintegrating tab 10 mg...................................................................................... 44 donepezil hydrochloride tab 5 mg (Aricept).................. 44 donepezil hydrochloride tab 10 mg (Aricept)................ 44 donepezil hydrochloride tab 23 mg (Aricept)................ 44 DORAL – quazepam tab 15 mg......................................... 41 dorzolamide hcl ophth soln 2% (Trusopt)..................... 60 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)................................................................ 61 doxazosin mesylate tab 1 mg (Cardura)........................ 25 doxazosin mesylate tab 2 mg (Cardura)........................ 25 doxazosin mesylate tab 4 mg (Cardura)........................ 25 doxazosin mesylate tab 8 mg (Cardura)........................ 25 doxepin hcl cap 10 mg..................................................... 35 doxepin hcl cap 25 mg..................................................... 35 doxepin hcl cap 50 mg..................................................... 35 doxepin hcl cap 100 mg................................................... 35 doxepin hcl cap 150 mg................................................... 35 doxepin hcl conc 10 mg/ml............................................. 35 DOXEPIN HCL – doxepin hcl cap 75 mg.......................... 35 doxercalciferol cap 0.5 mcg (Hectorol).......................... 15 doxercalciferol cap 1 mcg (Hectorol)............................. 15

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 doxercalciferol cap 2.5 mcg (Hectorol).......................... 15 doxycycline hyclate cap 50 mg.........................................2 doxycycline hyclate cap 100 mg (Vibramycin)................ 2 doxycycline hyclate tab delayed release 75 mg............. 2 doxycycline hyclate tab delayed release 100 mg........... 2 doxycycline hyclate tab delayed release 150 mg........... 2 doxycycline hyclate tab delayed release 50 mg (Doryx)................................................................................. 2 doxycycline hyclate tab 20 mg......................................... 2 doxycycline hyclate tab 100 mg....................................... 2 doxycycline monohydrate cap 50 mg.............................. 2 doxycycline monohydrate cap 150 mg (Adoxa).............. 2 doxycycline monohydrate cap 75 mg (Monodox)........... 2 doxycycline monohydrate cap 100 mg (Monodox)......... 2 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin)....................................................................... 2 doxycycline monohydrate tab 50 mg (Adoxa)................ 2 doxycycline monohydrate tab 75 mg (Adoxa)................ 2 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100)................................................................................... 2 doxycycline monohydrate tab 150 mg (Adoxa pak 1/150)................................................................................... 2 dronabinol cap 2.5 mg (Marinol)..................................... 31 dronabinol cap 5 mg (Marinol)........................................ 31 dronabinol cap 10 mg (Marinol)...................................... 31 DULERA – mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act...................................................... 28 DULERA – mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act...................................................... 28 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta)........................................................................ 36 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta)........................................................................ 36 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta)........................................................................ 36 dutasteride cap 0.5 mg (Avodart)................................... 33 dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)....... 33 dyphylline-guaifenesin liqd 100-100 mg/5ml................. 28 E econazole nitrate cream 1%............................................ 64 EDURANT – rilpivirine hcl tab 25 mg (base equivalent)...... 5 E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........ 2 EGRIFTA – tesamorelin acetate for inj 1 mg (base equiv)................................................................................. 15 EGRIFTA – tesamorelin acetate for inj 2 mg (base equiv)................................................................................. 15 ELIDEL – pimecrolimus cream 1%.................................... 67 ELIQUIS – apixaban tab 2.5 mg........................................ 59 ELIQUIS – apixaban tab 5 mg........................................... 59 ELLA – ulipristal acetate tab 30 mg................................... 11 EMEND – aprepitant capsule 40 mg..................................31 EMEND – aprepitant capsule 80 mg..................................31 EMEND – aprepitant capsule 125 mg................................31

EMEND – aprepitant capsule therapy pack 80 & 125 mg...................................................................................... 31 EMSAM – selegiline td patch 24hr 6 mg/24hr................... 36 EMSAM – selegiline td patch 24hr 9 mg/24hr................... 36 EMSAM – selegiline td patch 24hr 12 mg/24hr................. 36 EMTRIVA – emtricitabine caps 200 mg............................... 5 EMTRIVA – emtricitabine soln 10 mg/ml............................. 5 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg...................................................................................... 17 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)......................................................................... 17 enalapril maleate tab 2.5 mg (Vasotec).......................... 17 enalapril maleate tab 5 mg (Vasotec)............................. 17 enalapril maleate tab 10 mg (Vasotec)........................... 17 enalapril maleate tab 20 mg (Vasotec)........................... 17 ENGERIX-B – hepatitis b vaccine (recombinant) 10 mcg/0.5ml.............................................................................7 ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/ ml.......................................................................................... 7 ENGERIX-B – hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml.............................................................................7 ENGERIX-B – hepatitis b vaccine (recombinant) susp 20 mcg/ml.................................................................................. 7 ENJUVIA – estrogens, conjugated synthetic b tab 0.3 mg...................................................................................... 11 ENJUVIA – estrogens, conjugated synthetic b tab 0.45 mg...................................................................................... 11 ENJUVIA – estrogens, conjugated synthetic b tab 0.625 mg...................................................................................... 11 ENJUVIA – estrogens, conjugated synthetic b tab 0.9 mg...................................................................................... 11 ENJUVIA – estrogens, conjugated synthetic b tab 1.25 mg...................................................................................... 11 enoxaparin sodium inj 30 mg/0.3ml (Lovenox)............. 59 enoxaparin sodium inj 40 mg/0.4ml (Lovenox)............. 59 enoxaparin sodium inj 60 mg/0.6ml (Lovenox)............. 59 enoxaparin sodium inj 80 mg/0.8ml (Lovenox)............. 59 enoxaparin sodium inj 100 mg/ml (Lovenox)................ 59 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........... 59 enoxaparin sodium inj 150 mg/ml (Lovenox)................ 59 entacapone tab 200 mg (Comtan)...................................54 entecavir tab 0.5 mg (Baraclude)...................................... 4 entecavir tab 1 mg (Baraclude)......................................... 4 epinastine hcl ophth soln 0.05% (Elestat)..................... 61 EPIPEN-JR 2-PAK – epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)..................................................... 26 EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................. 26 EPIVIR – lamivudine oral soln 10 mg/ml............................. 5 eplerenone tab 25 mg (Inspra)........................................ 25 eplerenone tab 50 mg (Inspra)........................................ 25 EPROSARTAN MESYLATE – eprosartan mesylate tab 600 mg............................................................................... 18 EPZICOM – abacavir sulfate-lamivudine tab 600-300 mg........................................................................................ 5

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2016 EQL PRENATAL FORMULA – prenatal vit w/ fe fumaratefa tab 28-0.8 mg................................................................ 55 EQUETRO – carbamazepine (antipsychotic) cap sr 12hr 100 mg............................................................................... 38 EQUETRO – carbamazepine (antipsychotic) cap sr 12hr 200 mg............................................................................... 38 EQUETRO – carbamazepine (antipsychotic) cap sr 12hr 300 mg............................................................................... 38 ergocalciferol cap 50000 unit.......................................... 55 ERGOLOID MESYLATES – ergoloid mesylates tab 1 mg...................................................................................... 44 ergoloid mesylates tab 1 mg........................................... 44 ERIVEDGE – vismodegib cap 150 mg................................ 8 ERY-TAB – erythromycin tab delayed release 250 mg........ 2 ERY-TAB – erythromycin tab delayed release 333 mg........ 2 ERY-TAB – erythromycin tab delayed release 500 mg........ 2 ERYTHROMYCIN ETHYLSUCCINA – erythromycin ethylsuccinate tab 400 mg.................................................. 2 erythromycin gel 2% (Erygel).......................................... 63 erythromycin ophth oint 5 mg/gm.................................. 60 erythromycin pads 2%..................................................... 63 erythromycin soln 2%...................................................... 63 erythromycin w/ delayed release particles cap 250 mg........................................................................................ 2 ESBRIET – pirfenidone cap 267 mg.................................. 29 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro)........................................................................... 36 escitalopram oxalate tab 5 mg (base equiv) (Lexapro)........................................................................... 36 escitalopram oxalate tab 10 mg (base equiv) (Lexapro)........................................................................... 36 escitalopram oxalate tab 20 mg (base equiv) (Lexapro)........................................................................... 36 esomeprazole magnesium cap delayed release 20 mg (base eq) (Nexium).......................................................... 30 esomeprazole magnesium cap delayed release 40 mg (base eq) (Nexium).......................................................... 30 estazolam tab 1 mg.......................................................... 41 estazolam tab 2 mg.......................................................... 41 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella).......................................................................... 11 estradiol & norethindrone acetate tab 1-0.5 mg (Activella).......................................................................... 11 estradiol tab 0.5 mg (Estrace)......................................... 11 estradiol tab 1 mg (Estrace)............................................ 11 estradiol tab 2 mg (Estrace)............................................ 11 estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).....................................................................................11 estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot)...................................................................... 11 estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).....................................................................................11 estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).....................................................................................11

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estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).....................................................................................11 estradiol td patch weekly 0.025 mg/24hr (Climara).......11 estradiol td patch weekly 0.05 mg/24hr (Climara).........11 estradiol td patch weekly 0.06 mg/24hr (Climara).........11 estradiol td patch weekly 0.075 mg/24hr (Climara).......11 estradiol td patch weekly 0.1 mg/24hr (Climara)...........11 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara).........................................................11 ESTROPIPATE – estropipate tab 3 mg..............................11 estropipate tab 0.75 mg................................................... 11 estropipate tab 1.5 mg..................................................... 11 eszopiclone tab 1 mg (Lunesta)......................................41 eszopiclone tab 2 mg (Lunesta)......................................41 eszopiclone tab 3 mg (Lunesta)......................................41 ethambutol hcl tab 100 mg (Myambutol)......................... 3 ethambutol hcl tab 400 mg (Myambutol)......................... 3 ethosuximide cap 250 mg (Zarontin)..............................51 ethosuximide soln 250 mg/5ml (Zarontin)..................... 52 ETIDRONATE DISODIUM – etidronate disodium tab 200 mg...................................................................................... 15 ETIDRONATE DISODIUM – etidronate disodium tab 400 mg...................................................................................... 15 etodolac cap 200 mg........................................................ 49 etodolac cap 300 mg........................................................ 49 etodolac tab 400 mg......................................................... 49 etodolac tab 500 mg......................................................... 49 etodolac tab sr 24hr 400 mg........................................... 49 etodolac tab sr 24hr 500 mg........................................... 49 etodolac tab sr 24hr 600 mg........................................... 49 EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg (base equiv)......................................................................... 5 EVZIO – naloxone hcl solution auto-injector 0.4 mg/0.4ml............................................................................ 68 exemestane tab 25 mg (Aromasin)................................... 8 EYLEA – aflibercept intravitreal inj 2 mg/0.05ml (40 mg/ ml)...................................................................................... 61 F famciclovir tab 125 mg (Famvir)....................................... 4 famciclovir tab 250 mg (Famvir)....................................... 4 famciclovir tab 500 mg (Famvir)....................................... 4 famotidine for susp 40 mg/5ml (Pepcid)........................ 30 famotidine tab 20 mg (Pepcid)........................................ 30 famotidine tab 40 mg (Pepcid)........................................ 30 FANAPT – iloperidone tab 1 mg........................................ 38 FANAPT – iloperidone tab 2 mg........................................ 38 FANAPT – iloperidone tab 4 mg........................................ 39 FANAPT – iloperidone tab 6 mg........................................ 39 FANAPT – iloperidone tab 8 mg........................................ 39 FANAPT – iloperidone tab 10 mg...................................... 39 FANAPT – iloperidone tab 12 mg...................................... 39 FANAPT TITRATION PACK – iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak............................................. 39

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 FARYDAK – panobinostat lactate cap 10 mg (base equivalent)............................................................................8 FARYDAK – panobinostat lactate cap 15 mg (base equivalent)............................................................................8 FARYDAK – panobinostat lactate cap 20 mg (base equivalent)............................................................................8 FAZACLO – clozapine orally disintegrating tab 12.5 mg...................................................................................... 39 FAZACLO – clozapine orally disintegrating tab 150 mg...................................................................................... 39 FAZACLO – clozapine orally disintegrating tab 200 mg...................................................................................... 39 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg...................................................................................... 59 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg...................................................................................... 59 fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap (Tandem plus)...........................................................59 felbamate susp 600 mg/5ml (Felbatol)........................... 52 felbamate tab 400 mg (Felbatol)..................................... 52 felbamate tab 600 mg (Felbatol)..................................... 52 felodipine tab sr 24hr 2.5 mg.......................................... 21 felodipine tab sr 24hr 5 mg............................................. 21 felodipine tab sr 24hr 10 mg........................................... 21 fenofibrate micronized cap 43 mg.................................. 23 fenofibrate micronized cap 130 mg................................ 23 fenofibrate micronized cap 67 mg (Lofibra).................. 23 fenofibrate micronized cap 134 mg (Lofibra)................ 23 fenofibrate micronized cap 200 mg (Lofibra)................ 23 fenofibrate tab 54 mg (Lofibra)....................................... 23 fenofibrate tab 160 mg (Lofibra)..................................... 23 fenofibrate tab 48 mg (Tricor)......................................... 23 fenofibrate tab 145 mg (Tricor)....................................... 23 fentanyl citrate lozenge on a handle 200 mcg (Actiq)................................................................................ 46 fentanyl citrate lozenge on a handle 400 mcg (Actiq)................................................................................ 46 fentanyl citrate lozenge on a handle 600 mcg (Actiq)................................................................................ 46 fentanyl citrate lozenge on a handle 800 mcg (Actiq)................................................................................ 46 fentanyl citrate lozenge on a handle 1200 mcg (Actiq)................................................................................ 46 fentanyl citrate lozenge on a handle 1600 mcg (Actiq)................................................................................ 46 fentanyl td patch 72hr 12 mcg/hr (Duragesic)............... 46 fentanyl td patch 72hr 25 mcg/hr (Duragesic)............... 46 fentanyl td patch 72hr 50 mcg/hr (Duragesic)............... 46 fentanyl td patch 72hr 75 mcg/hr (Duragesic)............... 46 fentanyl td patch 72hr 100 mcg/hr (Duragesic)............. 46 FERRIPROX – deferiprone oral soln 100 mg/ml............... 68 FERRIPROX – deferiprone tab 500 mg............................. 68 ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg........................................................................... 59 ferrous fumarate-folic acid tab 324-1 mg.......................59

FETZIMA – levomilnacipran hcl cap sr 24hr 20 mg (base equivalent)......................................................................... 36 FETZIMA – levomilnacipran hcl cap sr 24hr 40 mg (base equivalent)......................................................................... 36 FETZIMA – levomilnacipran hcl cap sr 24hr 80 mg (base equivalent)......................................................................... 36 FETZIMA – levomilnacipran hcl cap sr 24hr 120 mg (base equivalent)......................................................................... 36 FETZIMA TITRATION PACK – levomilnacipran hcl cap sr 24hr 20 & 40 mg therapy pack......................................... 36 FINACEA – azelaic acid gel 15%.......................................63 finasteride tab 5 mg (Proscar)........................................ 33 FIRST-OMEPRAZOLE – omeprazole susp 2 mg/ml (compound kit)................................................................... 30 flavoxate hcl tab 100 mg..................................................33 flecainide acetate tab 50 mg........................................... 24 flecainide acetate tab 100 mg......................................... 24 flecainide acetate tab 150 mg......................................... 24 FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/blister.................................................................... 28 FLOVENT DISKUS – fluticasone propionate aer pow ba 100 mcg/blister.................................................................. 28 FLOVENT DISKUS – fluticasone propionate aer pow ba 250 mcg/blister.................................................................. 28 FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)........................................................... 28 FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)........................................................... 29 FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)............................................................. 28 fluconazole for susp 10 mg/ml (Diflucan)........................ 3 fluconazole for susp 40 mg/ml (Diflucan)........................ 3 fluconazole tab 50 mg (Diflucan)...................................... 3 fluconazole tab 100 mg (Diflucan).................................... 3 fluconazole tab 150 mg (Diflucan).................................... 3 fluconazole tab 200 mg (Diflucan).................................... 3 flucytosine cap 250 mg (Ancobon)...................................3 flucytosine cap 500 mg (Ancobon)...................................3 fludrocortisone acetate tab 0.1 mg.................................10 flunisolide nasal soln 25 mcg/act (0.025%)................... 27 fluocinolone acetonide cream 0.01%............................. 65 fluocinolone acetonide cream 0.025% (Synalar)........... 65 fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).............................................................. 65 fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)............................................................... 65 fluocinolone acetonide oint 0.025% (Synalar)............... 65 fluocinolone acetonide (otic) oil 0.01% (Dermotic)....... 62 fluocinolone acetonide soln 0.01% (Synalar)................ 65 fluocinonide cream 0.05%............................................... 65 fluocinonide cream 0.1% (Vanos)................................... 65 fluocinonide emulsified base cream 0.05%................... 65 fluocinonide gel 0.05%..................................................... 65 fluocinonide oint 0.05%....................................................65 fluocinonide soln 0.05%................................................... 65

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2016 fluorometholone ophth susp 0.1% (Fml liquifilm)........ 60 fluorouracil cream 5% (Efudex)...................................... 67 fluorouracil soln 2%......................................................... 67 fluorouracil soln 5%......................................................... 67 fluoxetine hcl cap delayed release 90 mg (Prozac weekly).............................................................................. 36 fluoxetine hcl cap 10 mg (Prozac).................................. 36 fluoxetine hcl cap 20 mg (Prozac).................................. 36 fluoxetine hcl cap 40 mg (Prozac).................................. 36 FLUOXETINE HCL – fluoxetine hcl tab 60 mg.................. 36 fluoxetine hcl solution 20 mg/5ml.................................. 36 fluoxetine hcl tab 10 mg.................................................. 36 fluoxetine hcl tab 20 mg.................................................. 36 FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml............................................................................... 39 FLUPHENAZINE HCL – fluphenazine hcl inj 2.5 mg/ ml........................................................................................ 39 FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ ml........................................................................................ 39 fluphenazine hcl tab 1 mg............................................... 39 fluphenazine hcl tab 2.5 mg............................................ 39 fluphenazine hcl tab 5 mg............................................... 39 fluphenazine hcl tab 10 mg............................................. 39 flurandrenolide cream 0.05% (Cordran)......................... 65 flurazepam hcl cap 15 mg............................................... 41 flurazepam hcl cap 30 mg............................................... 41 flurbiprofen sodium ophth soln 0.03% (Ocufen)........... 61 flurbiprofen tab 50 mg......................................................49 flurbiprofen tab 100 mg................................................... 49 flutamide cap 125 mg......................................................... 8 fluticasone propionate cream 0.05% (Cutivate)............ 66 fluticasone propionate lotion 0.05% (Cutivate)............. 66 fluticasone propionate nasal susp 50 mcg/act............. 27 fluticasone propionate oint 0.005%................................ 66 fluvastatin sodium cap 20 mg......................................... 23 fluvastatin sodium cap 40 mg......................................... 23 fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl).........23 fluvoxamine maleate cap sr 24hr 100 mg...................... 36 fluvoxamine maleate cap sr 24hr 150 mg...................... 36 fluvoxamine maleate tab 25 mg...................................... 36 fluvoxamine maleate tab 50 mg...................................... 36 fluvoxamine maleate tab 100 mg.................................... 36 FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & folic acid tab 5 mg............................................................ 55 folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg...................................................................................... 58 folic acid tab 1 mg............................................................ 59 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..... 59 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg........ 59 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx)....................................................................... 59 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml (Arixtra)............................................................................. 59 fondaparinux sodium subcutaneous inj 5 mg/0.4ml (Arixtra)............................................................................. 59

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fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml (Arixtra)............................................................................. 59 fondaparinux sodium subcutaneous inj 10 mg/0.8ml (Arixtra)............................................................................. 59 FORADIL AEROLIZER – formoterol fumarate inhal cap 12 mcg.....................................................................................29 FORFIVO XL – bupropion hcl tab sr 24hr 450 mg............. 36 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg...................................................................................... 17 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg...................................................................................... 17 fosinopril sodium tab 10 mg........................................... 17 fosinopril sodium tab 20 mg........................................... 17 fosinopril sodium tab 40 mg........................................... 17 frovatriptan succinate tab 2.5 mg (base equivalent) (Frova)............................................................................... 50 2-fucosyllactose & lacto-n-neotetraose packet 2000-1000 mg (Ollizac)................................................... 58 furosemide oral soln 10 mg/ml....................................... 24 furosemide tab 20 mg (Lasix)......................................... 24 furosemide tab 40 mg (Lasix)......................................... 24 furosemide tab 80 mg (Lasix)......................................... 24 FUZEON – enfuvirtide for inj 90 mg.....................................5 G gabapentin cap 100 mg (Neurontin)............................... 52 gabapentin cap 300 mg (Neurontin)............................... 52 gabapentin cap 400 mg (Neurontin)............................... 52 gabapentin oral soln 250 mg/5ml (Neurontin)............... 52 gabapentin tab 600 mg (Neurontin)................................ 52 gabapentin tab 800 mg (Neurontin)................................ 52 galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er)................................................................... 45 galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er)................................................................... 45 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er)................................................................... 45 GALANTAMINE HYDROBROMIDE – galantamine hydrobromide oral soln 4 mg/ml....................................... 45 galantamine hydrobromide tab 4 mg (Razadyne)......... 45 galantamine hydrobromide tab 8 mg (Razadyne)......... 45 galantamine hydrobromide tab 12 mg (Razadyne)....... 45 gatifloxacin ophth soln 0.5% (Zymaxid).........................60 GATTEX – teduglutide (rdna) for inj kit 5 mg..................... 32 gemfibrozil tab 600 mg (Lopid)....................................... 23 GENTAMICIN SULFATE – gentamicin sulfate cream 0.1%................................................................................... 64 GENTAMICIN SULFATE – gentamicin sulfate oint 0.1%................................................................................... 64 gentamicin sulfate ophth oint 0.3%................................ 60 gentamicin sulfate ophth soln 0.3%............................... 60 GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10 mg............................................................. 5 GEODON – ziprasidone mesylate for inj 20 mg (base equivalent)......................................................................... 39

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent)............................................................................8 GILOTRIF – afatinib dimaleate tab 30 mg (base equivalent)............................................................................8 GILOTRIF – afatinib dimaleate tab 40 mg (base equivalent)............................................................................8 glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)....................................................................... 44 glimepiride tab 1 mg (Amaryl).........................................12 glimepiride tab 2 mg (Amaryl).........................................12 glimepiride tab 4 mg (Amaryl).........................................12 glipizide-metformin hcl tab 2.5-250 mg.......................... 12 glipizide-metformin hcl tab 2.5-500 mg.......................... 12 glipizide-metformin hcl tab 5-500 mg............................. 12 glipizide tab 5 mg (Glucotrol)..........................................12 glipizide tab 10 mg (Glucotrol)........................................12 glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 12 glipizide tab sr 24hr 5 mg (Glucotrol xl)........................ 12 glipizide tab sr 24hr 10 mg (Glucotrol xl)...................... 12 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg.............................................................................. 12 glyburide-metformin tab 1.25-250 mg (Glucovance).................................................................... 12 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 12 glyburide-metformin tab 5-500 mg (Glucovance)......... 12 glyburide micronized tab 1.5 mg (Glynase)................... 12 glyburide micronized tab 3 mg (Glynase)...................... 12 glyburide micronized tab 6 mg (Glynase)...................... 12 glyburide tab 1.25 mg.......................................................12 glyburide tab 2.5 mg.........................................................12 glyburide tab 5 mg............................................................12 glycine irrigation soln 1.5%............................................. 33 glycopyrrolate tab 1 mg (Robinul).................................. 30 glycopyrrolate tab 2 mg (Robinul forte)......................... 30 GNP PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...........................................................................55 GNP PRENATAL VITAMINS – prenatal vit w/ fe fumaratefa tab 28-0.8 mg................................................................ 55 GOODSENSE PRENATAL VITAMI – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg................................................ 55 granisetron hcl tab 1 mg................................................. 31 griseofulvin microsize susp 125 mg/5ml......................... 3 griseofulvin microsize tab 500 mg................................... 3 griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 3 griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 3 guanfacine hcl tab 1 mg (Tenex).................................... 25 guanfacine hcl tab 2 mg (Tenex).................................... 25 guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv)............................................................................. 43 guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv)............................................................................. 43 guanfacine hcl tab sr 24hr 3 mg (base equiv) (Intuniv)............................................................................. 43 guanfacine hcl tab sr 24hr 4 mg (base equiv) (Intuniv)............................................................................. 43

H halobetasol propionate cream 0.05% (Ultravate).......... 66 halobetasol propionate oint 0.05% (Ultravate).............. 66 haloperidol lactate oral conc 2 mg/ml............................39 haloperidol tab 0.5 mg..................................................... 39 haloperidol tab 1 mg........................................................ 39 haloperidol tab 2 mg........................................................ 39 haloperidol tab 5 mg........................................................ 39 haloperidol tab 10 mg...................................................... 39 haloperidol tab 20 mg...................................................... 39 HM PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...................................................................................... 55 homatropine hbr ophth soln 5%..................................... 61 H.P. ACTHAR – corticotropin inj gel 80 unit/ml.................. 15 HUMALOG – insulin lispro (human) inj 100 unit/ml........... 13 HUMALOG – insulin lispro (human) soln cartridge 100 unit/ml................................................................................. 13 HUMALOG KWIKPEN – insulin lispro (human) soln peninjector 100 unit/ml............................................................ 13 HUMALOG KWIKPEN – insulin lispro (human) soln peninjector 200 unit/ml............................................................ 13 HUMALOG MIX 50/50 – insulin lispro prot & lispro (human) inj 100 unit/ml (50-50)........................................ 13 HUMALOG MIX 75/25 – insulin lispro prot & lispro (human) inj 100 unit/ml (75-25)........................................ 13 HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50)............................... 13 HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25)............................... 14 HUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml............................................................................ 49 HUMIRA – adalimumab prefilled syringe kit 20 mg/0.4ml............................................................................ 49 HUMIRA – adalimumab prefilled syringe kit 40 mg/0.8ml............................................................................ 49 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe kit 40 mg/0.8ml..................................................... 49 HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml............................................................................ 49 HUMIRA PEN-CROHNS DISEASE – adalimumab peninjector kit 40 mg/0.8ml..................................................... 49 HUMIRA PEN-PSORIASIS STAR – adalimumab peninjector kit 40 mg/0.8ml..................................................... 49 HUMULIN 70/30 – insulin nph isophane & regular human inj 100 unit/ml (70-30)....................................................... 14 HUMULIN 70/30 KWIKPEN – insulin nph & regular susp pen-inj 100 unit/ml (70-30)................................................ 14 HUMULIN N – insulin nph (human) (isophane) inj 100 unit/ ml........................................................................................ 14 HUMULIN N KWIKPEN – insulin nph (human) (isophane) susp pen-injector 100 unit/ml............................................ 14 HUMULIN R – insulin regular (human) inj 100 unit/ml....... 13 HUMULIN R U-500 (CONCENTR – insulin regular (human) inj 500 unit/ml..................................................... 13

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2016 HUMULIN R U-500 KWIKPEN – insulin regular (human) soln pen-injector 500 unit/ml............................................. 13 hyaluronate sodium (emollient) gel 0.2% (Hylira)......... 67 hydralazine hcl tab 10 mg............................................... 25 hydralazine hcl tab 25 mg............................................... 25 hydralazine hcl tab 50 mg............................................... 25 hydralazine hcl tab 100 mg............................................. 25 hydrochlorothiazide cap 12.5 mg (Microzide)............... 24 hydrochlorothiazide tab 12.5 mg.................................... 24 hydrochlorothiazide tab 25 mg....................................... 24 hydrochlorothiazide tab 50 mg....................................... 24 hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet)............................................................................... 47 hydrocodone-acetaminophen soln 10-325 mg/15ml (Zamicet)........................................................................... 47 hydrocodone-acetaminophen tab 2.5-325 mg............... 47 hydrocodone-acetaminophen tab 7.5-325 mg (Norco).............................................................................. 47 hydrocodone-acetaminophen tab 5-325 mg (Norco).............................................................................. 47 hydrocodone-acetaminophen tab 10-325 mg (Norco).............................................................................. 47 hydrocodone-acetaminophen tab 7.5-300 mg (Xodol)............................................................................... 47 hydrocodone-acetaminophen tab 5-300 mg (Xodol)............................................................................... 47 hydrocodone-acetaminophen tab 10-300 mg (Xodol)............................................................................... 47 hydrocodone-ibuprofen tab 2.5-200 mg......................... 47 hydrocodone-ibuprofen tab 7.5-200 mg......................... 47 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 47 hydrocodone-ibuprofen tab 5-200 mg (Reprexain)....... 47 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml....... 27 hydrocodone w/ homatropine tab 5-1.5 mg................... 27 hydrocod polst-chlorphen polst er susp 10-8 mg/5ml (Tussionex pennkineti)................................................... 27 hydrocortisone acetate-aloe vera gel 2%...................... 66 hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc).........................................................62 hydrocortisone butyrate cream 0.1% (Locoid).............. 66 hydrocortisone butyrate hydrophilic lipo base cream 0.1% (Locoid lipocream).................................................66 hydrocortisone butyrate oint 0.1% (Locoid).................. 66 hydrocortisone butyrate soln 0.1% (Locoid)................. 66 hydrocortisone cream 1%................................................ 66 hydrocortisone cream 2.5%............................................. 66 hydrocortisone enema 100 mg/60ml (Cortenema)........ 62 hydrocortisone lotion 2.5%............................................. 66 hydrocortisone lotion 2% (Ala scalp)............................. 66 hydrocortisone oint 1%.................................................... 66 hydrocortisone oint 2.5%................................................. 66 hydrocortisone rectal cream 2.5% (Anusol-hc)............ 62 hydrocortisone rectal cream 1% (Proctocort)............... 62 hydrocortisone tab 5 mg (Cortef)................................... 10 hydrocortisone tab 10 mg (Cortef)................................. 10

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hydrocortisone tab 20 mg (Cortef)................................. 10 hydrocortisone valerate cream 0.2%.............................. 66 hydrocortisone valerate oint 0.2% (Westcort)............... 66 hydrocortisone w/ acetic acid otic soln 1-2%............... 62 hydromorphone hcl liqd 1 mg/ml (Dilaudid).................. 47 hydromorphone hcl tab er 24hr deter 8 mg (Exalgo)............................................................................. 47 hydromorphone hcl tab er 24hr deter 12 mg (Exalgo)............................................................................. 47 hydromorphone hcl tab er 24hr deter 16 mg (Exalgo)............................................................................. 47 hydromorphone hcl tab 2 mg (Dilaudid)........................ 47 hydromorphone hcl tab 4 mg (Dilaudid)........................ 47 hydromorphone hcl tab 8 mg (Dilaudid)........................ 47 hydroxychloroquine sulfate tab 200 mg (Plaquenil)....... 7 hydroxyurea cap 500 mg (Hydrea)................................... 8 hydroxyzine hcl syrup 10 mg/5ml...................................34 hydroxyzine hcl tab 10 mg.............................................. 34 hydroxyzine hcl tab 25 mg.............................................. 34 hydroxyzine hcl tab 50 mg.............................................. 34 hydroxyzine pamoate cap 25 mg (Vistaril).................... 34 hydroxyzine pamoate cap 50 mg (Vistaril).................... 34 HYDROXYZINE PAMOATE – hydroxyzine pamoate cap 100 mg............................................................................... 34 hyoscyamine sulfate elixir 0.125 mg/5ml....................... 30 hyoscyamine sulfate soln 0.125 mg/ml.......................... 30 hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 30 hyoscyamine sulfate tab 0.125 mg (Levsin).................. 30 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl).......... 30 hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)..... 30 I ibandronate sodium tab 150 mg (base equivalent) (Boniva)............................................................................. 15 ibuprofen susp 100 mg/5ml............................................. 49 ibuprofen tab 400 mg....................................................... 49 ibuprofen tab 600 mg....................................................... 49 ibuprofen tab 800 mg....................................................... 49 ICLUSIG – ponatinib hcl tab 15 mg (base equiv)................ 8 ICLUSIG – ponatinib hcl tab 45 mg (base equiv)................ 8 imatinib mesylate tab 100 mg (base equivalent) (Gleevec)............................................................................. 8 imatinib mesylate tab 400 mg (base equivalent) (Gleevec)............................................................................. 8 IMBRUVICA – ibrutinib cap 140 mg.....................................8 imipramine hcl tab 10 mg (Tofranil)............................... 36 imipramine hcl tab 25 mg (Tofranil)............................... 36 imipramine hcl tab 50 mg (Tofranil)............................... 36 imipramine pamoate cap 75 mg......................................36 imipramine pamoate cap 100 mg....................................36 imipramine pamoate cap 125 mg....................................36 imipramine pamoate cap 150 mg....................................36 imiquimod cream 5% (Aldara)......................................... 67 IMITREX – sumatriptan nasal spray 5 mg/act................... 50 IMITREX – sumatriptan nasal spray 20 mg/act................. 50

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdc inj.......................................................................................... 7 IMPAVIDO – miltefosine cap 50 mg..................................... 7 INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)......... 15 INCRUSE ELLIPTA – umeclidinium br aero powd breath act 62.5 mcg/inh (base eq)............................................... 29 indapamide tab 1.25 mg................................................... 24 indapamide tab 2.5 mg..................................................... 24 indomethacin cap cr 75 mg............................................. 49 indomethacin cap 25 mg................................................. 49 indomethacin cap 50 mg................................................. 49 INFED – iron dextran inj 50 mg/ml (elemental iron)........... 59 INSULIN PEN NEEDLES – VARIOUS............................... 68 INSULIN SYRINGES - VARIOUS...................................... 68 INTELENCE – etravirine tab 25 mg..................................... 5 INTELENCE – etravirine tab 100 mg................................... 5 INTELENCE – etravirine tab 200 mg................................... 5 INVEGA – paliperidone tab sr 24hr 1.5 mg....................... 39 INVEGA – paliperidone tab sr 24hr 3 mg.......................... 39 INVEGA – paliperidone tab sr 24hr 6 mg.......................... 39 INVEGA – paliperidone tab sr 24hr 9 mg.......................... 39 INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 39 mg/0.25ml.............................. 39 INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 78 mg/0.5ml................................ 39 INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 156 mg/ml................................... 39 INVEGA SUSTENNA – paliperidone palmitate im extended-release susp 234 mg/1.5ml.............................. 39 INVEGA SUSTENNA – paliperidone palmitate im extendrelease susp 117 mg/0.75ml............................................. 39 INVEGA TRINZA – paliperidone palmitate im extendrelease susp 273 mg/0.875ml.......................................... 39 INVEGA TRINZA – paliperidone palmitate im extendrelease susp 410 mg/1.315ml.......................................... 39 INVEGA TRINZA – paliperidone palmitate im extendrelease susp 546 mg/1.75ml............................................ 39 INVEGA TRINZA – paliperidone palmitate im extendrelease susp 819 mg/2.625ml.......................................... 39 INVIRASE – saquinavir mesylate cap 200 mg.................... 5 INVIRASE – saquinavir mesylate tab 500 mg..................... 5 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml...... 29 ipratropium bromide inhal soln 0.02%........................... 29 ipratropium bromide nasal soln 0.03% (21 mcg/ spray)................................................................................ 27 ipratropium bromide nasal soln 0.06% (42 mcg/ spray)................................................................................ 27 irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide)............................................................................ 18 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide)............................................................................ 18 irbesartan tab 75 mg (Avapro)........................................ 18 irbesartan tab 150 mg (Avapro)...................................... 18 irbesartan tab 300 mg (Avapro)...................................... 18 IRESSA – gefitinib tab 250 mg............................................ 8

iron combination cap....................................................... 59 iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg (Hematron-af)............................................................ 59 iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150)..................................................................... 59 iron polysacch complex-vit b12-fa cap 150-0.025-1 mg...................................................................................... 59 iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg (Icar-c plus)...................................................................... 59 irrigation solution, physiological.................................... 68 ISENTRESS – raltegravir potassium chew tab 25 mg (base equiv)......................................................................... 5 ISENTRESS – raltegravir potassium chew tab 100 mg (base equiv)......................................................................... 5 ISENTRESS – raltegravir potassium packet for susp 100 mg (base equiv).................................................................. 5 ISENTRESS – raltegravir potassium tab 400 mg (base equiv)....................................................................................5 isoniazid tab 100 mg.......................................................... 3 isoniazid tab 300 mg.......................................................... 3 ISOSORBIDE DINITRATE ER – isosorbide dinitrate tab cr 40 mg................................................................................. 22 isosorbide dinitrate tab 10 mg........................................ 22 isosorbide dinitrate tab 20 mg........................................ 22 isosorbide dinitrate tab 30 mg........................................ 22 isosorbide dinitrate tab 5 mg (Isordil titradose)........... 22 isosorbide mononitrate tab 10 mg................................. 22 isosorbide mononitrate tab 20 mg................................. 22 isosorbide mononitrate tab sr 24hr 30 mg.................... 22 isosorbide mononitrate tab sr 24hr 60 mg.................... 22 isosorbide mononitrate tab sr 24hr 120 mg.................. 22 isotretinoin cap 10 mg..................................................... 63 isotretinoin cap 20 mg..................................................... 63 isotretinoin cap 30 mg..................................................... 63 isotretinoin cap 40 mg..................................................... 63 isradipine cap 2.5 mg....................................................... 21 isradipine cap 5 mg.......................................................... 21 itraconazole cap 100 mg (Sporanox)................................3 ivermectin tab 3 mg (Stromectol)..................................... 7 J JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent)............................................................................8 JAKAFI – ruxolitinib phosphate tab 10 mg (base equivalent)............................................................................8 JAKAFI – ruxolitinib phosphate tab 15 mg (base equivalent)............................................................................8 JAKAFI – ruxolitinib phosphate tab 20 mg (base equivalent)............................................................................8 JAKAFI – ruxolitinib phosphate tab 25 mg (base equivalent)............................................................................8 JANUMET – sitagliptin-metformin hcl tab 50-500 mg........ 12 JANUMET – sitagliptin-metformin hcl tab 50-1000 mg...... 12 JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-500 mg......................................................................... 12

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2016 JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-1000 mg....................................................................... 12 JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 100-1000 mg..................................................................... 12 JANUVIA – sitagliptin phosphate tab 25 mg (base equiv)................................................................................. 12 JANUVIA – sitagliptin phosphate tab 50 mg (base equiv)................................................................................. 12 JANUVIA – sitagliptin phosphate tab 100 mg (base equiv)................................................................................. 12 JETREA – ocriplasmin intravitreal inj 0.5 mg/0.2ml (2.5 mg/ml)................................................................................ 61 JUXTAPID – lomitapide mesylate cap 5 mg (base equiv)................................................................................. 23 JUXTAPID – lomitapide mesylate cap 10 mg (base equiv)................................................................................. 23 JUXTAPID – lomitapide mesylate cap 20 mg (base equiv)................................................................................. 23 JUXTAPID – lomitapide mesylate cap 30 mg (base equiv)................................................................................. 23 JUXTAPID – lomitapide mesylate cap 40 mg (base equiv)................................................................................. 23 JUXTAPID – lomitapide mesylate cap 60 mg (base equiv)................................................................................. 23 K KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)...................................................................... 5 KALETRA – lopinavir-ritonavir tab 100-25 mg..................... 5 KALETRA – lopinavir-ritonavir tab 200-50 mg..................... 5 KALYDECO – ivacaftor packet 50 mg............................... 29 KALYDECO – ivacaftor packet 75 mg............................... 29 KALYDECO – ivacaftor tab 150 mg................................... 29 ketoconazole cream 2%................................................... 64 ketoconazole foam 2% (Extina).......................................64 ketoconazole shampoo 2% (Nizoral).............................. 64 ketoconazole tab 200 mg................................................... 4 ketoprofen cap 50 mg...................................................... 49 ketoprofen cap 75 mg...................................................... 49 ketorolac tromethamine ophth soln 0.5% (Acular)....... 61 ketorolac tromethamine ophth soln 0.4% (Acular ls)....................................................................................... 61 ketorolac tromethamine tab 10 mg.................................49 KHEDEZLA – desvenlafaxine tab sr 24hr 50 mg............... 36 KHEDEZLA – desvenlafaxine tab sr 24hr 100 mg............. 36 KINERET – anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml................................................................... 49 KORLYM – mifepristone tab 300 mg................................. 12 K-PHOS – potassium phosphate monobasic tab 500 mg...................................................................................... 57 KP PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg................................................ 55 KUVAN – sapropterin dihydrochloride powder packet 100 mg...................................................................................... 15

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KUVAN – sapropterin dihydrochloride powder packet 500 mg...................................................................................... 15 KUVAN – sapropterin dihydrochloride soluble tab 100 mg...................................................................................... 15 KYNAMRO – mipomersen sodium soln prefilled syringe 200 mg/ml.......................................................................... 23 L labetalol hcl tab 100 mg................................................... 19 labetalol hcl tab 200 mg................................................... 19 labetalol hcl tab 300 mg................................................... 19 lactated ringer's for irrigation......................................... 68 lactic acid (ammonium lactate) cream 12% (Lachydrin)............................................................................... 67 lactic acid (ammonium lactate) lotion 10%....................67 lactic acid (ammonium lactate) lotion 12% (Lachydrin)............................................................................... 67 lactic acid w/ vitamin e cream 10%-3500 unit/30gm..... 67 lactulose (encephalopathy) solution 10 gm/15ml......... 32 lactulose solution 10 gm/15ml........................................ 30 LAMICTAL – lamotrigine tab chewable dispersible 2 mg...................................................................................... 52 LAMICTAL ODT – lamotrigine orally disintegrating tab 25 mg...................................................................................... 52 LAMICTAL ODT – lamotrigine orally disintegrating tab 50 mg...................................................................................... 52 LAMICTAL ODT – lamotrigine orally disintegrating tab 100 mg...................................................................................... 52 LAMICTAL ODT – lamotrigine orally disintegrating tab 200 mg...................................................................................... 52 LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg (42) & 100 mg (7) starter kit............................................. 52 LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg (84) & 100 mg (14) starter kit........................................... 52 LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg (35) starter kit.................................................................... 52 LAMICTAL XR – lamotrigine tab sr 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit.......................................................... 52 LAMICTAL XR – lamotrigine tab sr 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit..................................................... 52 LAMICTAL XR – lamotrigine tab sr 24hr 25 mg (21) & 50 mg (7) titration kit.............................................................. 52 lamivudine oral soln 10 mg/ml (Epivir)............................ 5 lamivudine tab 150 mg (Epivir)......................................... 5 lamivudine tab 300 mg (Epivir)......................................... 5 lamivudine tab 100 mg (hbv) (Epivir hbv)........................ 4 lamivudine-zidovudine tab 150-300 mg (Combivir)........ 5 lamotrigine orally disintegrating tab 25 mg (Lamictal odt).....................................................................................52 lamotrigine orally disintegrating tab 50 mg (Lamictal odt).....................................................................................52 lamotrigine orally disintegrating tab 100 mg (Lamictal odt).....................................................................................52 lamotrigine orally disintegrating tab 200 mg (Lamictal odt).....................................................................................52

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di)..................................................................... 52 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di)..................................................................... 52 lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit (Lamictal odt)............................................................. 52 lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit (Lamictal odt)................................................................... 52 lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit (Lamictal odt)............................................................. 52 lamotrigine tab 25 mg (Lamictal).................................... 52 lamotrigine tab 100 mg (Lamictal).................................. 52 lamotrigine tab 150 mg (Lamictal).................................. 52 lamotrigine tab 200 mg (Lamictal).................................. 52 lamotrigine tab sr 24hr 25 mg (Lamictal xr).................. 52 lamotrigine tab sr 24hr 50 mg (Lamictal xr).................. 52 lamotrigine tab sr 24hr 100 mg (Lamictal xr)................ 52 lamotrigine tab sr 24hr 200 mg (Lamictal xr)................ 52 lamotrigine tab sr 24hr 250 mg (Lamictal xr)................ 52 lamotrigine tab sr 24hr 300 mg (Lamictal xr)................ 52 LANCETS - BAYER ASCENCIA........................................ 68 lansoprazole cap delayed release 15 mg (Prevacid).......................................................................... 30 lansoprazole cap delayed release 30 mg (Prevacid).......................................................................... 30 LANTUS – insulin glargine inj 100 unit/ml......................... 14 LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml......................................................................... 14 latanoprost ophth soln 0.005% (Xalatan)....................... 61 LATUDA – lurasidone hcl tab 20 mg.................................. 39 LATUDA – lurasidone hcl tab 40 mg.................................. 39 LATUDA – lurasidone hcl tab 60 mg.................................. 39 LATUDA – lurasidone hcl tab 80 mg.................................. 39 LATUDA – lurasidone hcl tab 120 mg................................ 39 leflunomide tab 10 mg (Arava)........................................ 49 leflunomide tab 20 mg (Arava)........................................ 49 LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose)................................... 8 LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose).............................. 8 LENVIMA 24 MG DAILY DOSE – lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose).............................. 8 LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy pack 10 mg (10 mg daily dose).......................................... 8 LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose).................................... 8 LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose)........................................ 9 LETAIRIS – ambrisentan tab 5 mg.................................... 25 LETAIRIS – ambrisentan tab 10 mg.................................. 25 letrozole tab 2.5 mg (Femara)........................................... 9 LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg........................................................................................ 9 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg........................................................................................ 9

leucovorin calcium tab 5 mg............................................. 9 leucovorin calcium tab 25 mg........................................... 9 LEUKERAN – chlorambucil tab 2 mg.................................. 9 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate)....................................... 29 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex).......................................................................... 29 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex).......................................................................... 29 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex).......................................................................... 29 LEVEMIR FLEXPEN – insulin detemir soln pen-injector 100 unit/ml......................................................................... 14 LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector 100 unit/ml......................................................................... 14 LEVEMIR – insulin detemir inj 100 unit/ml......................... 14 levetiracetam oral soln 100 mg/ml (Keppra)..................52 levetiracetam tab 250 mg (Keppra).................................53 levetiracetam tab 500 mg (Keppra).................................53 levetiracetam tab 750 mg (Keppra).................................53 levetiracetam tab 1000 mg (Keppra)...............................53 levetiracetam tab sr 24hr 500 mg (Keppra xr)............... 52 levetiracetam tab sr 24hr 750 mg (Keppra xr)............... 52 levobunolol hcl ophth soln 0.5% (Betagan).................. 61 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 15 levocarnitine tab 330 mg (Carnitor)................................ 16 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ ml) (Xyzal)......................................................................... 26 levocetirizine dihydrochloride tab 5 mg (Xyzal)............ 26 levofloxacin ophth soln 0.5%.......................................... 60 levofloxacin oral soln 25 mg/ml........................................ 3 levofloxacin tab 250 mg (Levaquin)................................. 3 levofloxacin tab 500 mg (Levaquin)................................. 3 levofloxacin tab 750 mg (Levaquin)................................. 3 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg.................................................................................... 12 LEVONORGESTREL – levonorgestrel tab 0.75 mg.......... 11 levonorgestrel tab 1.5 mg (Plan b one-step)................. 12 levothyroxine sodium tab 25 mcg (Synthroid).............. 14 levothyroxine sodium tab 50 mcg (Synthroid).............. 14 levothyroxine sodium tab 75 mcg (Synthroid).............. 14 levothyroxine sodium tab 88 mcg (Synthroid).............. 14 levothyroxine sodium tab 100 mcg (Synthroid)............ 14 levothyroxine sodium tab 112 mcg (Synthroid)............ 14 levothyroxine sodium tab 125 mcg (Synthroid)............ 14 levothyroxine sodium tab 137 mcg (Synthroid)............ 14 levothyroxine sodium tab 150 mcg (Synthroid)............ 14 levothyroxine sodium tab 175 mcg (Synthroid)............ 14 levothyroxine sodium tab 200 mcg (Synthroid)............ 14 levothyroxine sodium tab 300 mcg (Synthroid)............ 14 LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv)....................................................................................5 LEXIVA – fosamprenavir calcium tab 700 mg (base equiv)....................................................................................5 lidocaine hcl cream 3%.................................................... 67

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2016 lidocaine hcl gel 2%......................................................... 67 lidocaine hcl soln 4% (Xylocaine)...................................67 lidocaine hcl viscous soln 2%........................................ 62 lidocaine-hydrocortisone acetate rectal cream 3-0.5%................................................................................ 62 lidocaine-hydrocortisone acetate rectal cream kit 2-2%................................................................................... 62 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5%................................................................................ 62 lidocaine-hydrocortisone acetate rectal cream kit 3-1%................................................................................... 62 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%................................................................................ 62 lidocaine-menthol patch 4-1%......................................... 67 lidocaine-menthol patch 4-4%......................................... 67 lidocaine oint 5%...............................................................67 lidocaine patch 5% (Lidoderm)....................................... 67 lidocaine-prilocaine cream 2.5-2.5%............................... 67 lidocaine-prilocaine cream kit 2.5-2.5%......................... 67 lindane lotion 1%.............................................................. 67 lindane shampoo 1%........................................................ 67 linezolid for susp 100 mg/5ml (Zyvox)............................. 7 linezolid tab 600 mg (Zyvox)............................................. 7 liothyronine sodium tab 5 mcg (Cytomel)..................... 14 liothyronine sodium tab 25 mcg (Cytomel)................... 14 liothyronine sodium tab 50 mcg (Cytomel)................... 14 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)....................................................................... 17 lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic)....................................................................... 17 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic)....................................................................... 17 lisinopril tab 5 mg (Prinivil)............................................. 17 lisinopril tab 10 mg (Prinivil)........................................... 17 lisinopril tab 20 mg (Prinivil)........................................... 17 lisinopril tab 2.5 mg (Zestril)........................................... 17 lisinopril tab 30 mg (Zestril)............................................ 17 lisinopril tab 40 mg (Zestril)............................................ 17 lithium carbonate cap 300 mg.........................................39 lithium carbonate cap 150 mg (Lithium carbonate)...... 39 lithium carbonate cap 600 mg (Lithium carbonate)...... 40 lithium carbonate tab cr 450 mg..................................... 40 lithium carbonate tab cr 300 mg (Lithobid)................... 40 lithium carbonate tab 300 mg......................................... 40 LITHIUM – lithium oral solution 8 meq/5ml........................ 39 LOMUSTINE – lomustine cap 10 mg................................... 9 LOMUSTINE – lomustine cap 40 mg................................... 9 LOMUSTINE – lomustine cap 100 mg................................. 9 LONSURF – trifluridine-tipiracil tab 15-6.14 mg...................9 LONSURF – trifluridine-tipiracil tab 20-8.19 mg...................9 loperamide hcl cap 2 mg................................................. 30 lorazepam conc 2 mg/ml.................................................. 34 lorazepam tab 0.5 mg (Ativan)........................................ 34 lorazepam tab 1 mg (Ativan)........................................... 34 lorazepam tab 2 mg (Ativan)........................................... 34

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losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar)...................................................................... 18 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar)...................................................................... 18 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar)...................................................................... 18 losartan potassium tab 25 mg (Cozaar)......................... 18 losartan potassium tab 50 mg (Cozaar)......................... 18 losartan potassium tab 100 mg (Cozaar)....................... 18 LOTEMAX – loteprednol etabonate ophth susp 0.5%....... 60 lovastatin tab 10 mg......................................................... 23 lovastatin tab 20 mg......................................................... 23 lovastatin tab 40 mg (Mevacor).......................................23 loxapine succinate cap 5 mg.......................................... 40 loxapine succinate cap 10 mg........................................ 40 loxapine succinate cap 25 mg........................................ 40 loxapine succinate cap 50 mg........................................ 40 LUCENTIS – ranibizumab intravitreal inj 0.3 mg/0.05ml (6 mg/ml)................................................................................ 61 LUCENTIS – ranibizumab intravitreal inj 0.5 mg/0.05ml (10 mg/ml)................................................................................ 61 LYNPARZA – olaparib cap 50 mg........................................ 9 LYRICA – pregabalin cap 25 mg........................................ 53 LYRICA – pregabalin cap 50 mg........................................ 53 LYRICA – pregabalin cap 75 mg........................................ 53 LYRICA – pregabalin cap 100 mg...................................... 53 LYRICA – pregabalin cap 150 mg...................................... 53 LYRICA – pregabalin cap 200 mg...................................... 53 LYRICA – pregabalin cap 225 mg...................................... 53 LYRICA – pregabalin cap 300 mg...................................... 53 LYRICA – pregabalin soln 20 mg/ml.................................. 53 M mafenide acetate packet for topical soln 5% (50 gm) (Sulfamylon)..................................................................... 64 malathion lotion 0.5% (Ovide)......................................... 67 MAPROTILINE HCL – maprotiline hcl tab 25 mg.............. 36 MAPROTILINE HCL – maprotiline hcl tab 50 mg.............. 36 MAPROTILINE HCL – maprotiline hcl tab 75 mg.............. 36 MARPLAN – isocarboxazid tab 10 mg...............................36 MATULANE – procarbazine hcl cap 50 mg......................... 9 meclizine hcl tab 12.5 mg................................................ 31 meclizine hcl tab 25 mg................................................... 31 medroxyprogesterone acetate tab 2.5 mg (Provera)........................................................................... 11 medroxyprogesterone acetate tab 5 mg (Provera)....... 11 medroxyprogesterone acetate tab 10 mg (Provera)..... 11 mefenamic acid cap 250 mg (Ponstel)........................... 50 mefloquine hcl tab 250 mg................................................ 7 megestrol acetate susp 625 mg/5ml (Megace es)......... 11 megestrol acetate susp 40 mg/ml (Megace oral)............ 9 megestrol acetate tab 20 mg............................................. 9 megestrol acetate tab 40 mg............................................. 9 meloxicam tab 7.5 mg (Mobic)........................................ 50 meloxicam tab 15 mg (Mobic)......................................... 50

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 memantine hcl oral solution 2 mg/ml (Namenda)......... 45 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak (Namenda titration pa).................................................... 45 memantine hcl tab 5 mg (Namenda).............................. 45 memantine hcl tab 10 mg (Namenda)............................ 45 meperidine hcl tab 50 mg................................................ 47 meperidine hcl tab 100 mg (Demerol)............................ 47 MEPHYTON – phytonadione tab 5 mg.............................. 55 meprobamate tab 200 mg................................................ 34 meprobamate tab 400 mg................................................ 34 mercaptopurine tab 50 mg................................................ 9 MESALAMINE DR – mesalamine tab delayed release 800 mg...................................................................................... 32 mesalamine enema 4 gm................................................. 32 mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa)........................................................................... 32 metaxalone tab 800 mg (Skelaxin)..................................55 metformin hcl tab 500 mg (Glucophage)....................... 13 metformin hcl tab 850 mg (Glucophage)....................... 13 metformin hcl tab 1000 mg (Glucophage)..................... 13 metformin hcl tab sr 24hr 500 mg (Glucophage xr)...... 12 metformin hcl tab sr 24hr 750 mg (Glucophage xr)...... 12 metformin hcl tab sr 24hr modified release 500 mg (Glumetza)........................................................................ 13 metformin hcl tab sr 24hr modified release 1000 mg (Glumetza)........................................................................ 13 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet)......................................................................... 12 metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet)......................................................................... 13 methadone hcl conc 10 mg/ml (Methadose)................. 47 methadone hcl soln 5 mg/5ml (Methadone hcl)............ 47 methadone hcl soln 10 mg/5ml (Methadone hcl).......... 47 methadone hcl tab for oral susp 40 mg......................... 47 methadone hcl tab 5 mg (Dolophine)............................. 47 methadone hcl tab 10 mg (Dolophine)........................... 47 methamphetamine hcl tab 5 mg (Desoxyn)................... 43 methazolamide tab 25 mg (Neptazane).......................... 24 methazolamide tab 50 mg (Neptazane).......................... 24 methenamine hippurate tab 1 gm (Hiprex).................... 32 methenamine-hyoscamine-meth blue-sod phos cap 120 mg.............................................................................. 32 methenamine-hyoscamine-meth blue-sod phos tab 81.6 mg (Urogesic-blue)................................................. 32 methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg........................................................................ 32 methenamine-hyosc-meth blue-sod phos-phen sal cap 118 mg...............................................................................32 methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg.............................................................................. 32 methenamine-hyosc-meth blue-sod phos-phen sal tab 81 mg................................................................................ 32 methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg............................................................................. 32 methenamine mandelate tab 1 gm................................. 32

methimazole tab 5 mg (Tapazole)................................... 14 methimazole tab 10 mg (Tapazole)................................. 14 methocarbamol tab 750 mg (Robaxin-750).................... 55 methocarbamol tab 500 mg (Robaxin)........................... 55 methotrexate sodium tab 2.5 mg (base equiv)................ 9 methoxsalen rapid cap 10 mg (Oxsoralen ultra)........... 67 methscopolamine bromide tab 2.5 mg (Pamine).......... 30 methscopolamine bromide tab 5 mg (Pamine forte).................................................................................. 30 methyldopa tab 250 mg................................................... 25 methyldopa tab 500 mg................................................... 25 METHYLENE BLUE – methylene blue inj 1%................... 68 methylergonovine maleate tab 0.2 mg........................... 16 methylphenidate hcl cap cr 10 mg (cd) (Metadate cd)...................................................................................... 43 methylphenidate hcl cap cr 20 mg (cd) (Metadate cd)...................................................................................... 43 methylphenidate hcl cap cr 30 mg (cd) (Metadate cd)...................................................................................... 43 methylphenidate hcl cap cr 40 mg (cd) (Metadate cd)...................................................................................... 43 methylphenidate hcl cap cr 50 mg (cd) (Metadate cd)...................................................................................... 43 methylphenidate hcl cap cr 60 mg (cd) (Metadate cd)...................................................................................... 43 methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin la)....................................................................................... 43 methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin la)....................................................................................... 43 methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin la)....................................................................................... 43 methylphenidate hcl chew tab 2.5 mg (Methylin)......... 43 methylphenidate hcl chew tab 5 mg (Methylin)............ 43 methylphenidate hcl chew tab 10 mg (Methylin).......... 43 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 18 mg................................................................... 43 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 27 mg................................................................... 43 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 36 mg................................................................... 43 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 54 mg................................................................... 43 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sr 24hr 18 mg.................................................................... 43 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sr 24hr 27 mg.................................................................... 43 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sr 24hr 36 mg.................................................................... 43 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sr 24hr 54 mg.................................................................... 43 methylphenidate hcl soln 5 mg/5ml (Methylin)............. 44 methylphenidate hcl soln 10 mg/5ml (Methylin)........... 44 methylphenidate hcl tab cr 10 mg.................................. 44 methylphenidate hcl tab cr 20 mg.................................. 44 methylphenidate hcl tab 5 mg (Ritalin).......................... 44

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2016 methylphenidate hcl tab 10 mg (Ritalin)........................ 44 methylphenidate hcl tab 20 mg (Ritalin)........................ 44 methylprednisolone tab 4 mg (Medrol).......................... 10 methylprednisolone tab 8 mg (Medrol).......................... 10 methylprednisolone tab 16 mg (Medrol)........................ 10 methylprednisolone tab 32 mg (Medrol)........................ 10 methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak)............................................................. 10 methyltestosterone cap 10 mg (Testred)....................... 10 METIPRANOLOL – metipranolol ophth soln 0.3%............ 61 metoclopramide hcl orally disintegrating tab 5 mg (Metozolv odt).................................................................. 32 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)......... 32 metoclopramide hcl tab 5 mg (Reglan).......................... 32 metoclopramide hcl tab 10 mg (Reglan)........................ 32 metolazone tab 2.5 mg..................................................... 24 metolazone tab 5 mg........................................................ 24 metolazone tab 10 mg...................................................... 24 metoprolol & hydrochlorothiazide tab 100-50 mg........ 19 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)................................................................ 19 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct)................................................................ 19 metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) (Toprol xl)......................................................................... 19 metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) (Toprol xl)......................................................................... 19 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) (Toprol xl)............................................................. 19 metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) (Toprol xl)............................................................. 19 metoprolol tartrate tab 25 mg......................................... 19 metoprolol tartrate tab 50 mg (Lopressor).................... 19 metoprolol tartrate tab 100 mg (Lopressor).................. 19 metronidazole cap 375 mg (Flagyl).................................. 7 metronidazole cream 0.75% (Metrocream).................... 63 metronidazole gel 0.75%.................................................. 63 metronidazole gel 1% (Metrogel).................................... 63 metronidazole lotion 0.75% (Metrolotion)...................... 63 metronidazole tab 250 mg (Flagyl)................................... 7 metronidazole tab 500 mg (Flagyl)................................... 7 metronidazole vaginal gel 0.75% (Metrogelvaginal)..............................................................................33 mexiletine hcl cap 150 mg............................................... 25 mexiletine hcl cap 200 mg............................................... 25 mexiletine hcl cap 250 mg............................................... 25 midodrine hcl tab 2.5 mg................................................. 25 midodrine hcl tab 5 mg.................................................... 26 midodrine hcl tab 10 mg.................................................. 26 miglitol tab 25 mg (Glyset).............................................. 13 miglitol tab 50 mg (Glyset).............................................. 13 miglitol tab 100 mg (Glyset)............................................ 13 minocycline hcl cap 50 mg (Minocin).............................. 2 minocycline hcl cap 75 mg (Minocin).............................. 2 minocycline hcl cap 100 mg (Minocin)............................ 2

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minocycline hcl tab 50 mg................................................ 3 minocycline hcl tab 75 mg................................................ 3 minocycline hcl tab 100 mg.............................................. 3 minocycline hcl tab sr 24hr 45 mg................................... 3 minocycline hcl tab sr 24hr 90 mg................................... 3 minocycline hcl tab sr 24hr 135 mg................................. 3 minoxidil tab 2.5 mg......................................................... 26 minoxidil tab 10 mg.......................................................... 26 mirtazapine orally disintegrating tab 15 mg (Remeron soltab)............................................................................... 36 mirtazapine orally disintegrating tab 30 mg (Remeron soltab)............................................................................... 36 mirtazapine orally disintegrating tab 45 mg (Remeron soltab)............................................................................... 36 mirtazapine tab 7.5 mg..................................................... 36 mirtazapine tab 15 mg (Remeron).................................. 36 mirtazapine tab 30 mg (Remeron).................................. 36 mirtazapine tab 45 mg (Remeron).................................. 37 misoprostol tab 100 mcg (Cytotec)................................ 30 misoprostol tab 200 mcg (Cytotec)................................ 30 modafinil tab 100 mg (Provigil)....................................... 44 modafinil tab 200 mg (Provigil)....................................... 44 moexipril hcl tab 7.5 mg.................................................. 17 moexipril hcl tab 15 mg................................................... 17 moexipril-hydrochlorothiazide tab 7.5-12.5 mg.............17 moexipril-hydrochlorothiazide tab 15-12.5 mg..............17 moexipril-hydrochlorothiazide tab 15-25 mg.................17 MOLINDONE HYDROCHLORIDE – molindone hcl tab 5 mg...................................................................................... 40 MOLINDONE HYDROCHLORIDE – molindone hcl tab 10 mg...................................................................................... 40 MOLINDONE HYDROCHLORIDE – molindone hcl tab 25 mg...................................................................................... 40 mometasone furoate cream 0.1% (Elocon)................... 66 mometasone furoate nasal susp 50 mcg/act (Nasonex).......................................................................... 27 mometasone furoate oint 0.1% (Elocon)........................66 mometasone furoate solution 0.1% (lotion) (Elocon)............................................................................. 66 montelukast sodium chew tab 4 mg (base equiv) (Singulair)......................................................................... 29 montelukast sodium chew tab 5 mg (base equiv) (Singulair)......................................................................... 29 montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)............................................................. 29 montelukast sodium tab 10 mg (base equiv) (Singulair)......................................................................... 29 morphine sulfate cap sr 24hr 10 mg (Kadian)............... 47 morphine sulfate cap sr 24hr 20 mg (Kadian)............... 47 morphine sulfate cap sr 24hr 30 mg (Kadian)............... 47 morphine sulfate cap sr 24hr 50 mg (Kadian)............... 47 morphine sulfate cap sr 24hr 60 mg (Kadian)............... 47 morphine sulfate cap sr 24hr 80 mg (Kadian)............... 47 morphine sulfate cap sr 24hr 100 mg (Kadian)............. 47

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 30 mg.................................................................... 48 MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 45 mg.................................................................... 48 MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 60 mg.................................................................... 48 MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 75 mg.................................................................... 48 MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 90 mg.................................................................... 48 MORPHINE SULFATE ER – morphine sulfate beads cap sr 24hr 120 mg.................................................................. 48 MORPHINE SULFATE – morphine sulfate suppos 5 mg...................................................................................... 47 MORPHINE SULFATE – morphine sulfate suppos 10 mg...................................................................................... 47 MORPHINE SULFATE – morphine sulfate suppos 20 mg...................................................................................... 47 MORPHINE SULFATE – morphine sulfate suppos 30 mg...................................................................................... 47 MORPHINE SULFATE – morphine sulfate tab 15 mg....... 47 MORPHINE SULFATE – morphine sulfate tab 30 mg....... 47 morphine sulfate oral soln 10 mg/5ml........................... 48 morphine sulfate oral soln 20 mg/5ml........................... 48 morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...... 48 morphine sulfate tab cr 15 mg (Ms contin)................... 48 morphine sulfate tab cr 30 mg (Ms contin)................... 48 morphine sulfate tab cr 60 mg (Ms contin)................... 48 morphine sulfate tab cr 100 mg (Ms contin)................. 48 morphine sulfate tab cr 200 mg (Ms contin)................. 48 moxifloxacin hcl tab 400 mg (base equiv) (Avelox)........ 3 MULTAQ – dronedarone hcl tab 400 mg (base equivalent)......................................................................... 25 multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite)............................................................................ 56 multiple vitamins w/ minerals cap.................................. 56 multiple vitamins w/ minerals tab (Strovite forte)......... 56 MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg...........................................................................56 mupirocin calcium cream 2% (Bactroban).................... 64 mupirocin oint 2%............................................................. 64 M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg........... 56 MYALEPT – metreleptin for subcutaneous inj 11.3 mg...... 16 mycophenolate mofetil cap 250 mg (Cellcept).............. 68 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)........................................................................... 68 mycophenolate mofetil tab 500 mg (Cellcept)............... 68 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic)...................................................... 68 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic)...................................................... 68 MYLERAN – busulfan tab 2 mg........................................... 9 N nabumetone tab 500 mg.................................................. 50

nabumetone tab 750 mg.................................................. 50 nadolol & bendroflumethiazide tab 40-5 mg (Corzide)............................................................................19 nadolol & bendroflumethiazide tab 80-5 mg (Corzide)............................................................................19 nadolol tab 20 mg (Corgard)........................................... 19 nadolol tab 40 mg (Corgard)........................................... 19 nadolol tab 80 mg (Corgard)........................................... 20 naftifine hcl cream 2% (Naftin)........................................64 NALOXONE HCL – naloxone hcl inj 1 mg/ml.................... 68 naltrexone hcl tab 50 mg................................................. 68 NAPHAZOLINE HCL – naphazoline hcl ophth soln 0.1%................................................................................... 61 NAPROXEN – naproxen susp 125 mg/5ml....................... 50 naproxen sodium tab 275 mg......................................... 50 naproxen sodium tab 550 mg (Anaprox ds).................. 50 naproxen sodium tab sr 24hr 375 mg (base equiv) (Naprelan)......................................................................... 50 naproxen sodium tab sr 24hr 500 mg (base equiv) (Naprelan)......................................................................... 50 naproxen susp 125 mg/5ml (Naprosyn)......................... 50 naproxen tab ec 375 mg (Ec-naprosyn)......................... 50 naproxen tab ec 500 mg (Ec-naprosyn)......................... 50 naproxen tab 250 mg........................................................50 naproxen tab 375 mg........................................................50 naproxen tab 500 mg (Naprosyn)................................... 50 naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 50 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 50 NARCAN – naloxone hcl nasal spray 4 mg/0.1ml............. 68 NATACYN – natamycin ophth susp 5%............................. 60 nateglinide tab 60 mg (Starlix)........................................ 13 nateglinide tab 120 mg (Starlix)...................................... 13 NATPARA – parathyroid hormone (recombinant) for inj cartridge 25 mcg............................................................... 16 NATPARA – parathyroid hormone (recombinant) for inj cartridge 50 mcg............................................................... 16 NATPARA – parathyroid hormone (recombinant) for inj cartridge 75 mcg............................................................... 16 NATPARA – parathyroid hormone (recombinant) for inj cartridge 100 mcg............................................................. 16 NAT-RUL PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg................................................ 56 NEFAZODONE HCL – nefazodone hcl tab 100 mg...........37 NEFAZODONE HCL – nefazodone hcl tab 150 mg...........37 NEFAZODONE HCL – nefazodone hcl tab 200 mg...........37 nefazodone hcl tab 50 mg............................................... 37 nefazodone hcl tab 250 mg............................................. 37 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin..................................60 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)................ 60 neomycin-polymyxin b gu irrigation soln (Neosporin gu irrigan)......................................................................... 33 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)........................................................................... 60

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2016 neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol)................................................................. 60 neomycin-polymyxin-hc otic soln 1%............................ 62 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%......................................................................... 62 neomycin sulfate tab 500 mg............................................ 3 NEVIRAPINE – nevirapine susp 50 mg/5ml........................ 5 nevirapine tab 200 mg (Viramune).................................... 5 nevirapine tab sr 24hr 100 mg (Viramune xr).................. 5 nevirapine tab sr 24hr 400 mg (Viramune xr).................. 5 niacin tab cr 500 mg (antihyperlipidemic) (Niaspan)........................................................................... 23 niacin tab cr 750 mg (antihyperlipidemic) (Niaspan)........................................................................... 23 niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan)........................................................................... 23 nicardipine hcl cap 20 mg............................................... 21 nicardipine hcl cap 30 mg............................................... 21 NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg delivered)..................................................................... 45 NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/ spray)................................................................................. 45 nifedipine cap 20 mg........................................................ 21 nifedipine cap 10 mg (Procardia)....................................21 nifedipine tab sr 24hr 30 mg (Adalat cc)........................21 nifedipine tab sr 24hr 60 mg (Adalat cc)........................21 nifedipine tab sr 24hr 90 mg (Adalat cc)........................21 nifedipine tab sr 24hr osmotic release 30 mg (Procardia xl)....................................................................21 nifedipine tab sr 24hr osmotic release 60 mg (Procardia xl)....................................................................21 nifedipine tab sr 24hr osmotic release 90 mg (Procardia xl)....................................................................21 nimodipine cap 30 mg...................................................... 21 NINLARO – ixazomib citrate cap 2.3 mg (base equivalent)............................................................................9 NINLARO – ixazomib citrate cap 3 mg (base equivalent)............................................................................9 NINLARO – ixazomib citrate cap 4 mg (base equivalent)............................................................................9 nisoldipine tab sr 24hr 8.5 mg (Sular)............................ 21 nisoldipine tab sr 24hr 17 mg (Sular)............................. 21 nisoldipine tab sr 24hr 34 mg (Sular)............................. 21 nitrofurantoin macrocrystalline cap 25 mg (Macrodantin)................................................................... 32 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)................................................................... 32 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)................................................................... 33 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid).................................................................. 33 nitrofurantoin susp 25 mg/5ml (Furadantin)..................33 nitroglycerin cap cr 2.5 mg............................................. 22 nitroglycerin cap cr 6.5 mg............................................. 22 nitroglycerin cap cr 9 mg................................................ 22

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nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur).......... 22 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur).......... 22 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur).......... 22 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur).......... 22 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual pumpspr)................................................... 22 NITROSTAT – nitroglycerin sl tab 0.3 mg.......................... 22 NITROSTAT – nitroglycerin sl tab 0.4 mg.......................... 22 NITROSTAT – nitroglycerin sl tab 0.6 mg.......................... 22 NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg...................................................................................... 56 nizatidine cap 150 mg...................................................... 30 nizatidine cap 300 mg...................................................... 30 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg.................................................................................... 11 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose).................................................. 11 norethindrone acetate tab 5 mg (Aygestin)................... 11 nortriptyline hcl cap 10 mg (Pamelor)............................37 nortriptyline hcl cap 25 mg (Pamelor)............................37 nortriptyline hcl cap 50 mg (Pamelor)............................37 nortriptyline hcl cap 75 mg (Pamelor)............................37 NORTRIPTYLINE HCL – nortriptyline hcl soln 10 mg/5ml............................................................................... 37 NORVIR – ritonavir cap 100 mg.......................................... 5 NORVIR – ritonavir oral soln 80 mg/ml................................ 5 NORVIR – ritonavir tab 100 mg........................................... 5 NOVOLIN 70/30 – insulin nph isophane & regular human inj 100 unit/ml (70-30)....................................................... 14 NOVOLIN 70/30 RELION – insulin nph isophane & regular human inj 100 unit/ml (70-30)...........................................14 NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ ml........................................................................................ 14 NOVOLIN N RELION – insulin nph (human) (isophane) inj 100 unit/ml......................................................................... 14 NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 13 NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml................................................................................. 13 NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/ml......................................................................... 13 NOVOLOG – insulin aspart inj 100 unit/ml........................ 13 NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)........................................ 14 NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)..............................14 NOVOLOG PENFILL – insulin aspart soln cartridge 100 unit/ml................................................................................. 13 NOXAFIL – posaconazole susp 40 mg/ml........................... 4 NOXAFIL – posaconazole tab delayed release 100 mg...... 4 NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap 20-10 mg............................................................................45 NUVARING – etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr......................................................... 12 nystatin cream 100000 unit/gm....................................... 64 nystatin oint 100000 unit/gm........................................... 64

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2016 nystatin oral powder........................................................... 4 nystatin susp 100000 unit/ml.......................................... 62 nystatin tab 500000 unit..................................................... 4 nystatin topical powder....................................................64 nystatin-triamcinolone cream 100000-0.1 unit/gm%........................................................................................ 66 nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 66 O O-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1 mg..... 56 OCALIVA – obeticholic acid tab 5 mg................................ 32 OCALIVA – obeticholic acid tab 10 mg.............................. 32 ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg...................................................................... 5 OFEV – nintedanib esylate cap 100 mg (base equivalent)......................................................................... 29 OFEV – nintedanib esylate cap 150 mg (base equivalent)......................................................................... 29 OFLOXACIN – ofloxacin tab 400 mg................................... 3 ofloxacin ophth soln 0.3% (Ocuflox).............................. 60 ofloxacin otic soln 0.3% (Floxin otic)............................. 62 ofloxacin tab 300 mg.......................................................... 3 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)....... 45 olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)....... 45 olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)....... 45 olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)..... 45 olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)..... 45 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis)................................................................................. 40 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis)................................................................................. 40 olanzapine orally disintegrating tab 15 mg (Zyprexa zydis)................................................................................. 40 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis)................................................................................. 40 olanzapine tab 2.5 mg (Zyprexa).....................................40 olanzapine tab 5 mg (Zyprexa)........................................40 olanzapine tab 7.5 mg (Zyprexa).....................................40 olanzapine tab 10 mg (Zyprexa)......................................40 olanzapine tab 15 mg (Zyprexa)......................................40 olanzapine tab 20 mg (Zyprexa)......................................40 OLEPTRO – trazodone hcl tab sr 24hr 150 mg................. 37 OLEPTRO – trazodone hcl tab sr 24hr 300 mg................. 37 olopatadine hcl nasal soln 0.6% (Patanase).................. 27 olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol)............................................................................ 61 omega-3-acid ethyl esters cap 1 gm (Lovaza)...............23 omeprazole cap delayed release 10 mg (Prilosec)....... 30 omeprazole cap delayed release 20 mg (Prilosec)....... 31 omeprazole cap delayed release 40 mg (Prilosec)....... 31 omeprazole-sodium bicarbonate cap 20-1100 mg (Zegerid)............................................................................ 31 omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid)............................................................................ 31 ondansetron hcl oral soln 4 mg/5ml (Zofran)................ 31

ondansetron hcl tab 24 mg............................................. 31 ondansetron hcl tab 4 mg (Zofran).................................31 ondansetron hcl tab 8 mg (Zofran).................................31 ondansetron orally disintegrating tab 4 mg (Zofran odt).....................................................................................31 ondansetron orally disintegrating tab 8 mg (Zofran odt).....................................................................................31 opium tincture 1% (10 mg/ml) (morphine equiv)...........30 oral contraceptives - all generics................................... 12 ORENITRAM – treprostinil diolamine tab cr 0.125 mg (base equiv)....................................................................... 26 ORENITRAM – treprostinil diolamine tab cr 0.25 mg (base equiv)................................................................................. 26 ORENITRAM – treprostinil diolamine tab cr 1 mg (base equiv)................................................................................. 26 ORENITRAM – treprostinil diolamine tab cr 2.5 mg (base equiv)................................................................................. 26 ORFADIN – nitisinone cap 2 mg........................................ 16 ORFADIN – nitisinone cap 5 mg........................................ 16 ORFADIN – nitisinone cap 10 mg...................................... 16 ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg.............29 orphenadrine citrate tab sr 12hr 100 mg....................... 55 ORTHO EVRA – norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr............................................................... 12 oxandrolone tab 2.5 mg (Oxandrin)................................10 oxandrolone tab 10 mg (Oxandrin).................................10 oxaprozin tab 600 mg (Daypro).......................................50 oxazepam cap 10 mg........................................................34 oxazepam cap 15 mg........................................................34 oxazepam cap 30 mg........................................................35 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)........................................................................... 53 oxcarbazepine tab 150 mg (Trileptal)............................. 53 oxcarbazepine tab 300 mg (Trileptal)............................. 53 oxcarbazepine tab 600 mg (Trileptal)............................. 53 oxiconazole nitrate cream 1% (Oxistat)......................... 64 OXTELLAR XR – oxcarbazepine tab sr 24hr 150 mg........53 OXTELLAR XR – oxcarbazepine tab sr 24hr 300 mg........53 OXTELLAR XR – oxcarbazepine tab sr 24hr 600 mg........53 oxybutynin chloride syrup 5 mg/5ml..............................33 oxybutynin chloride tab 5 mg......................................... 33 oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)...... 33 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl)....................................................................................... 33 oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl)....................................................................................... 33 OXYCODONE/ACETAMINOPHEN – oxycodone w/ acetaminophen soln 5-325 mg/5ml.................................. 48 OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab 5-400 mg............................................................................48 oxycodone-aspirin tab 4.8355-325 mg........................... 48 oxycodone hcl cap 5 mg................................................. 48 oxycodone hcl conc 100 mg/5ml (20 mg/ml)................. 48 oxycodone hcl soln 5 mg/5ml......................................... 48 oxycodone hcl tab 10 mg................................................ 48

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2016 oxycodone hcl tab 20 mg................................................ 48 oxycodone hcl tab 5 mg (Roxicodone).......................... 48 oxycodone hcl tab 15 mg (Roxicodone)........................ 48 oxycodone hcl tab 30 mg (Roxicodone)........................ 48 oxycodone-ibuprofen tab 5-400 mg............................... 48 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)......................................................................... 48 oxycodone w/ acetaminophen tab 5-325 mg (Percocet)......................................................................... 48 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)......................................................................... 48 oxycodone w/ acetaminophen tab 10-325 mg (Percocet)......................................................................... 48 oxymorphone hcl tab 5 mg (Opana)...............................48 oxymorphone hcl tab 10 mg (Opana).............................48 oxymorphone hcl tab sr 12hr 5 mg................................ 48 oxymorphone hcl tab sr 12hr 7.5 mg............................. 48 oxymorphone hcl tab sr 12hr 10 mg.............................. 48 oxymorphone hcl tab sr 12hr 15 mg.............................. 48 oxymorphone hcl tab sr 12hr 20 mg.............................. 48 oxymorphone hcl tab sr 12hr 30 mg.............................. 48 oxymorphone hcl tab sr 12hr 40 mg.............................. 48 P paliperidone tab sr 24hr 1.5 mg (Invega)....................... 40 paliperidone tab sr 24hr 3 mg (Invega).......................... 40 paliperidone tab sr 24hr 6 mg (Invega).......................... 40 paliperidone tab sr 24hr 9 mg (Invega).......................... 40 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix).......................................................................... 31 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix).......................................................................... 31 paricalcitol cap 4 mcg...................................................... 16 paricalcitol cap 1 mcg (Zemplar).................................... 16 paricalcitol cap 2 mcg (Zemplar).................................... 16 paromomycin sulfate cap 250 mg.................................... 3 paroxetine hcl tab 10 mg (Paxil)..................................... 37 paroxetine hcl tab 20 mg (Paxil)..................................... 37 paroxetine hcl tab 30 mg (Paxil)..................................... 37 paroxetine hcl tab 40 mg (Paxil)..................................... 37 paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 37 paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 37 paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 37 PATADAY – olopatadine hcl ophth soln 0.2% (base equivalent)......................................................................... 61 PAXIL – paroxetine hcl oral susp 10 mg/5ml (base equiv)................................................................................. 37 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ ml....................................................................................... 56 pediatric multiple vitamins w/ fluoride chew tab 0.25 mg...................................................................................... 56 pediatric multiple vitamins w/ fluoride chew tab 0.5 mg...................................................................................... 56 pediatric multiple vitamins w/ fluoride chew tab 1 mg...................................................................................... 56

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pediatric multiple vitamins w/ fluoride soln 0.25 mg/ ml....................................................................................... 56 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ ml....................................................................................... 56 pediatric multiple vitamin w/ minerals & c drops 45 mg/ml................................................................................. 56 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml...... 56 pediatric vitamins acd w/ fluoride soln 0.5 mg/ml........ 56 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor packs)....................................................... 30 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)...........................................................................30 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)...................................................... 30 penicillin v potassium for soln 125 mg/5ml.....................1 penicillin v potassium for soln 250 mg/5ml.....................1 penicillin v potassium tab 250 mg....................................1 penicillin v potassium tab 500 mg....................................1 PENTASA – mesalamine cap cr 250 mg........................... 32 PENTASA – mesalamine cap cr 500 mg........................... 32 pentazocine w/ naloxone tab 50-0.5 mg.........................48 pentoxifylline tab cr 400 mg............................................ 59 perindopril erbumine tab 2 mg....................................... 17 perindopril erbumine tab 4 mg (Aceon)......................... 17 perindopril erbumine tab 8 mg (Aceon)......................... 17 permethrin cream 5% (Elimite)........................................67 PERPHENAZINE/AMITRIPTYLIN – perphenazineamitriptyline tab 2-10 mg.................................................. 45 PERPHENAZINE/AMITRIPTYLIN – perphenazineamitriptyline tab 2-25 mg.................................................. 45 PERPHENAZINE/AMITRIPTYLIN – perphenazineamitriptyline tab 4-10 mg.................................................. 45 PERPHENAZINE/AMITRIPTYLIN – perphenazineamitriptyline tab 4-25 mg.................................................. 45 PERPHENAZINE/AMITRIPTYLIN – perphenazineamitriptyline tab 4-50 mg.................................................. 45 perphenazine tab 2 mg.................................................... 40 perphenazine tab 4 mg.................................................... 40 perphenazine tab 8 mg.................................................... 40 perphenazine tab 16 mg.................................................. 40 PEXEVA – paroxetine mesylate tab 10 mg (base equiv)................................................................................. 37 PEXEVA – paroxetine mesylate tab 20 mg (base equiv)................................................................................. 37 PEXEVA – paroxetine mesylate tab 30 mg (base equiv)................................................................................. 37 PEXEVA – paroxetine mesylate tab 40 mg (base equiv)................................................................................. 37 phenazopyridine hcl tab 100 mg (Pyridium).................. 33 phenazopyridine hcl tab 200 mg (Pyridium).................. 33 phenelzine sulfate tab 15 mg (Nardil)............................ 37 phenobarbital elixir 20 mg/5ml........................................42 PHENOBARBITAL – phenobarbital tab 15 mg.................. 41 PHENOBARBITAL – phenobarbital tab 30 mg.................. 42 PHENOBARBITAL – phenobarbital tab 60 mg.................. 42

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 PHENOBARBITAL – phenobarbital tab 100 mg................ 42 phenobarbital tab 16.2 mg............................................... 42 phenobarbital tab 32.4 mg............................................... 42 phenobarbital tab 64.8 mg............................................... 42 phenobarbital tab 97.2 mg............................................... 42 phenoxybenzamine hcl cap 10 mg (Dibenzyline)......... 26 phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)............................................................................... 27 phenylephrine hcl ophth soln 2.5%................................ 61 phenylephrine hcl ophth soln 10%................................. 61 phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml............................................................. 27 phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml........... 27 phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml................ 27 phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............. 27 phenytoin chew tab 50 mg (Dilantin infatabs)...............53 phenytoin sodium extended cap 100 mg (Dilantin)...... 53 phenytoin sodium extended cap 200 mg (Phenytek)......................................................................... 53 phenytoin sodium extended cap 300 mg (Phenytek)......................................................................... 53 phenytoin susp 125 mg/5ml (Dilantin-125).................... 53 pilocarpine hcl ophth soln 1% (Isopto carpine)............ 61 pilocarpine hcl ophth soln 2% (Isopto carpine)............ 61 pilocarpine hcl ophth soln 4% (Isopto carpine)............ 61 pilocarpine hcl tab 5 mg (Salagen).................................62 pilocarpine hcl tab 7.5 mg (Salagen)..............................62 pimozide tab 1 mg (Orap)................................................ 45 pimozide tab 2 mg (Orap)................................................ 45 pindolol tab 5 mg.............................................................. 20 pindolol tab 10 mg............................................................ 20 pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)...... 13 pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)...... 13 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met)................................................................. 13 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met)................................................................. 13 pioglitazone hcl tab 15 mg (base equiv) (Actos)...........13 pioglitazone hcl tab 30 mg (base equiv) (Actos)...........13 pioglitazone hcl tab 45 mg (base equiv) (Actos)...........13 piroxicam cap 10 mg (Feldene).......................................50 piroxicam cap 20 mg (Feldene).......................................50 PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe fumarate-fa tab 27-1 mg................................................... 56 PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe fumarate-fa tab 27-1 mg................................................... 56 podofilox soln 0.5% (Condylox)...................................... 67 polyethylene glycol 3350 oral packet............................. 30 polyethylene glycol 3350 oral powder........................... 30 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)........................................................... 60 POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab 0.25 mg............................................................. 56 POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab 0.5 mg............................................................... 56

POLY-VI-FLOR – ped multiple vit w/ fluoride biphasic chew tab 1 mg.................................................................. 56 POMALYST – pomalidomide cap 1 mg............................... 9 POMALYST – pomalidomide cap 2 mg............................... 9 POMALYST – pomalidomide cap 3 mg............................... 9 POMALYST – pomalidomide cap 4 mg............................... 9 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml............................................................................... 33 potassium bicarbonate effer tab 25 meq....................... 57 potassium chloride cap cr 8 meq (Micro-k)................... 57 potassium chloride cap cr 10 meq (Micro-k)................. 57 POTASSIUM CHLORIDE ER – potassium chloride tab cr 8 meq (600 mg).................................................................... 57 potassium chloride microencapsulated crys cr tab 10 meq.................................................................................... 57 potassium chloride microencapsulated crys cr tab 20 meq.................................................................................... 57 potassium chloride oral soln 10% (20 meq/15ml)......... 57 potassium chloride oral soln 20% (40 meq/15ml)......... 57 potassium chloride powder packet 20 meq.................. 57 potassium chloride tab cr 10 meq (K-tab)..................... 58 potassium chloride tab cr 8 meq (600 mg).................... 57 potassium citrate & citric acid powder pack 3300-1002 mg...................................................................................... 33 potassium citrate & citric acid soln 1100-334 mg/5ml............................................................................... 33 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5)........................................................................................ 33 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10)...................................................................................... 34 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15)...................................................................................... 34 pot bicarbonate & chloride effer tab 25 meq................. 57 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral)................................... 57 pramipexole dihydrochloride tab 0.125 mg (Mirapex)........................................................................... 54 pramipexole dihydrochloride tab 0.25 mg (Mirapex)........................................................................... 54 pramipexole dihydrochloride tab 0.5 mg (Mirapex)...... 54 pramipexole dihydrochloride tab 0.75 mg (Mirapex)........................................................................... 54 pramipexole dihydrochloride tab 1 mg (Mirapex)......... 54 pramipexole dihydrochloride tab 1.5 mg (Mirapex)...... 54 pramipexole dihydrochloride tab sr 24hr 0.375 mg (Mirapex er)...................................................................... 54 pramipexole dihydrochloride tab sr 24hr 0.75 mg (Mirapex er)...................................................................... 54 pramipexole dihydrochloride tab sr 24hr 1.5 mg (Mirapex er)...................................................................... 54 pramipexole dihydrochloride tab sr 24hr 2.25 mg (Mirapex er)...................................................................... 54 pramipexole dihydrochloride tab sr 24hr 3 mg (Mirapex er)...................................................................... 54

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2016 pramipexole dihydrochloride tab sr 24hr 4.5 mg (Mirapex er)...................................................................... 54 pramoxine-chloroxylenol otic liquid 1-0.1%.................. 62 pramoxine hcl gel 1%....................................................... 67 pravastatin sodium tab 10 mg........................................ 23 pravastatin sodium tab 20 mg (Pravachol)....................23 pravastatin sodium tab 40 mg (Pravachol)....................23 pravastatin sodium tab 80 mg (Pravachol)....................23 prazosin hcl cap 1 mg (Minipress)................................. 26 prazosin hcl cap 2 mg (Minipress)................................. 26 prazosin hcl cap 5 mg (Minipress)................................. 26 prednicarbate cream 0.1% (Dermatop).......................... 66 prednicarbate oint 0.1% (Dermatop).............................. 66 prednisolone acetate ophth susp 1% (Pred forte)........ 60 PREDNISOLONE SODIUM PHOSP – prednisolone sodium phosphate ophth soln 1%.................................... 60 prednisolone sod phos orally disintegr tab 10 mg (base eq) (Orapred odt).................................................. 10 prednisolone sod phos orally disintegr tab 15 mg (base eq) (Orapred odt).................................................. 10 prednisolone sod phos orally disintegr tab 30 mg (base eq) (Orapred odt).................................................. 10 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)...................................................................... 10 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred).............................................. 10 prednisolone syrup 15 mg/5ml (usp solution equivalent)........................................................................ 10 PREDNISONE – prednisone oral soln 5 mg/5ml............... 10 PREDNISONE – prednisone tab 50 mg............................ 10 PREDNISONE – prednisone tab therapy pack 5 mg (21)..................................................................................... 10 PREDNISONE – prednisone tab therapy pack 5 mg (48)..................................................................................... 10 PREDNISONE – prednisone tab therapy pack 10 mg (21)..................................................................................... 10 PREDNISONE – prednisone tab therapy pack 10 mg (48)..................................................................................... 10 prednisone tab 1 mg........................................................ 10 prednisone tab 2.5 mg..................................................... 10 prednisone tab 5 mg........................................................ 10 prednisone tab 10 mg...................................................... 10 prednisone tab 20 mg...................................................... 10 PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg...................................................................................... 56 PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1 mg...................................................................................... 56 PRENATAL AND IRON – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg....................................... 56 PRE-NATAL FORMULA – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg....................................... 56 PRENATAL FORMULA – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...........................................................................56 PRENATAL FORTE – prenatal multivitamins & minerals w/ iron & fa tab 0.8 mg.......................................................... 56

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PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg...........................................................................56 PRENATAL MULTI +DHA – prenatal vit w/ fe fum-faomega 3 cap 27-0.8-228 mg............................................ 56 PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg.................................................................... 56 PRENATAL PLUS DHA – prenatal mv & min w/fe carbonyl-fa-dha tab 7-0.4-100 mg.................................... 56 PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg...................................................................................... 56 PRENATAL – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg......................................................................... 56 PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg..............................................................................57 PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg..............................................................................57 PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg...................................................................................... 56 PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1 mg...................................................................................... 56 PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...................................................................................... 56 PRENATAL VITAMIN – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg...........................................................................57 PRENATAL VITAMINS – prenatal multivitamins & minerals w/iron & fa tab 0.8 mg...................................................... 57 PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...........................................................................57 prenatal vit w/ fe fumarate-fa tab 28-0.8 mg.................. 57 PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg...................................................................................... 57 PREVIDENT 5000 BOOSTER PL – sodium fluoride paste 1.1%................................................................................... 62 PREVIDENT FLUORIDE – sodium fluoride gel 1.1% (0.5% f)......................................................................................... 62 PREZCOBIX – darunavir-cobicistat tab 800-150 mg........... 5 PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv)....................................................................................5 PREZISTA – darunavir ethanolate tab 75 mg (base equiv)....................................................................................5 PREZISTA – darunavir ethanolate tab 150 mg (base equiv)....................................................................................5 PREZISTA – darunavir ethanolate tab 600 mg (base equiv)....................................................................................5 PREZISTA – darunavir ethanolate tab 800 mg (base equiv)....................................................................................5 PRIFTIN – rifapentine tab 150 mg....................................... 3 PRIMAQUINE PHOSPHATE – primaquine phosphate tab 26.3 mg (15 mg base)........................................................ 7 primidone tab 50 mg (Mysoline)..................................... 53 primidone tab 250 mg (Mysoline)................................... 53 PRISTIQ – desvenlafaxine succinate tab sr 24hr 25 mg (base equiv)....................................................................... 37 PRISTIQ – desvenlafaxine succinate tab sr 24hr 50 mg (base equiv)....................................................................... 37

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 PRISTIQ – desvenlafaxine succinate tab sr 24hr 100 mg (base equiv)....................................................................... 37 probenecid tab 500 mg.................................................... 51 PROCYSBI – cysteamine bitartrate cap delayed release 25 mg (base equiv)........................................................... 34 PROCYSBI – cysteamine bitartrate cap delayed release 75 mg (base equiv)........................................................... 34 progesterone micronized cap 100 mg (Prometrium).................................................................... 11 progesterone micronized cap 200 mg (Prometrium).................................................................... 11 promethazine & phenylephrine syrup 6.25-5 mg/5ml............................................................................... 27 promethazine-dm syrup 6.25-15 mg/5ml........................27 promethazine hcl suppos 12.5 mg................................. 26 promethazine hcl suppos 25 mg.................................... 26 promethazine hcl suppos 50 mg.................................... 26 promethazine hcl syrup 6.25 mg/5ml............................. 26 promethazine hcl tab 12.5 mg......................................... 26 promethazine hcl tab 25 mg............................................ 27 promethazine hcl tab 50 mg............................................ 27 promethazine w/ codeine syrup 6.25-10 mg/5ml........... 27 propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 25 propafenone hcl cap sr 12hr 325 mg (Rythmol sr)....... 25 propafenone hcl cap sr 12hr 425 mg (Rythmol sr)....... 25 propafenone hcl tab 150 mg........................................... 25 propafenone hcl tab 300 mg........................................... 25 propafenone hcl tab 225 mg (Rythmol)......................... 25 proparacaine hcl ophth soln 0.5% (Alcaine)................. 61 PROPRANOLOL/HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 40-25 mg.................................... 20 PROPRANOLOL/HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 80-25 mg.................................... 20 propranolol hcl cap sr 24hr 60 mg (Inderal la).............. 20 propranolol hcl cap sr 24hr 80 mg (Inderal la).............. 20 propranolol hcl cap sr 24hr 120 mg (Inderal la)............ 20 propranolol hcl cap sr 24hr 160 mg (Inderal la)............ 20 propranolol hcl tab 10 mg............................................... 20 propranolol hcl tab 20 mg............................................... 20 propranolol hcl tab 40 mg............................................... 20 propranolol hcl tab 60 mg............................................... 20 propranolol hcl tab 80 mg............................................... 20 propylthiouracil tab 50 mg.............................................. 14 protriptyline hcl tab 5 mg................................................ 37 protriptyline hcl tab 10 mg.............................................. 37 pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro)............................................................. 27 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml............................................................................... 27 PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ ml)........................................................................................ 9 PX PRENATAL MULTIVITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg................................................ 57 pyrazinamide tab 500 mg................................................... 3

pyridostigmine bromide tab cr 180 mg (Mestinon timespan).......................................................................... 55 pyridostigmine bromide tab 60 mg (Mestinon)............. 55 Q QC PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...................................................................................... 57 QUAZEPAM – quazepam tab 15 mg................................. 42 quetiapine fumarate tab 25 mg (Seroquel).................... 40 quetiapine fumarate tab 50 mg (Seroquel).................... 40 quetiapine fumarate tab 100 mg (Seroquel).................. 40 quetiapine fumarate tab 200 mg (Seroquel).................. 40 quetiapine fumarate tab 300 mg (Seroquel).................. 40 quetiapine fumarate tab 400 mg (Seroquel).................. 40 quinapril hcl tab 5 mg (Accupril).................................... 17 quinapril hcl tab 10 mg (Accupril).................................. 17 quinapril hcl tab 20 mg (Accupril).................................. 17 quinapril hcl tab 40 mg (Accupril).................................. 17 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic)........................................................................ 17 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic)........................................................................ 17 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic)........................................................................ 17 quinidine gluconate tab cr 324 mg................................. 25 QUINIDINE SULFATE – quinidine sulfate tab 200 mg....... 25 QUINIDINE SULFATE – quinidine sulfate tab 300 mg....... 25 quinidine sulfate tab 300 mg........................................... 25 quinine sulfate cap 324 mg (Qualaquin).......................... 7 QVAR – beclomethasone diprop inhal aero soln 40 mcg/ act (50/valve)..................................................................... 29 QVAR – beclomethasone diprop inhal aero soln 80 mcg/ act (100/valve)................................................................... 29 R RABAVERT – rabies vaccine, pcec for inj........................... 7 rabeprazole sodium ec tab 20 mg (Aciphex)................. 31 raloxifene hcl tab 60 mg (Evista).................................... 16 ramipril cap 1.25 mg (Altace).......................................... 17 ramipril cap 2.5 mg (Altace)............................................ 18 ramipril cap 5 mg (Altace)............................................... 18 ramipril cap 10 mg (Altace)............................................. 18 ranitidine hcl cap 150 mg................................................ 31 ranitidine hcl cap 300 mg................................................ 31 ranitidine hcl syrup 15 mg/ml (75 mg/5ml).................... 31 ranitidine hcl tab 150 mg (Zantac).................................. 31 ranitidine hcl tab 300 mg (Zantac).................................. 31 RA PRENATAL FORMULA/FOLIC – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg................................................ 57 RA PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...................................................................................... 57 RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml.......... 16 RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml................................................................ 7

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2016 RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 10 mcg/ml................................................................... 7 RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp 40 mcg/ml................................................................... 7 RELENZA DISKHALER – zanamivir aero powder breath activated 5 mg/blister.......................................................... 6 RELION R – insulin regular (human) inj 100 unit/ml.......... 13 repaglinide tab 0.5 mg (Prandin).................................... 13 repaglinide tab 1 mg (Prandin)....................................... 13 repaglinide tab 2 mg (Prandin)....................................... 13 RESCRIPTOR – delavirdine mesylate tab 100 mg..............5 RESCRIPTOR – delavirdine mesylate tab 200 mg..............5 REVLIMID – lenalidomide cap 5 mg.................................. 68 REVLIMID – lenalidomide cap 10 mg................................ 68 REVLIMID – lenalidomide cap 15 mg................................ 68 REVLIMID – lenalidomide cap 20 mg................................ 68 REVLIMID – lenalidomide cap 25 mg................................ 68 REVLIMID – lenalidomide caps 2.5 mg............................. 68 REXULTI – brexpiprazole tab 0.25 mg.............................. 40 REXULTI – brexpiprazole tab 0.5 mg................................ 40 REXULTI – brexpiprazole tab 1 mg................................... 40 REXULTI – brexpiprazole tab 2 mg................................... 40 REXULTI – brexpiprazole tab 3 mg................................... 40 REXULTI – brexpiprazole tab 4 mg................................... 40 REYATAZ – atazanavir sulfate cap 150 mg (base equiv)....................................................................................5 REYATAZ – atazanavir sulfate cap 200 mg (base equiv)....................................................................................6 REYATAZ – atazanavir sulfate cap 300 mg (base equiv)....................................................................................6 REYATAZ – atazanavir sulfate oral powder packet 50 mg (base equiv)......................................................................... 5 ribavirin cap 200 mg (Rebetol).......................................... 4 ribavirin tab 200 mg (Copegus)........................................ 4 rifabutin cap 150 mg (Mycobutin)..................................... 3 rifampin cap 150 mg (Rifadin)........................................... 3 rifampin cap 300 mg (Rifadin)........................................... 3 RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg.................................................................... 57 riluzole tab 50 mg (Rilutek)............................................. 55 rimantadine hydrochloride tab 100 mg (Flumadine)...... 6 ringer's solution for irrigation......................................... 68 risedronate sodium tab delayed release 35 mg (Atelvia)............................................................................. 16 risedronate sodium tab 5 mg (Actonel)......................... 16 risedronate sodium tab 30 mg (Actonel)....................... 16 risedronate sodium tab 35 mg (Actonel)....................... 16 risedronate sodium tab 150 mg (Actonel)..................... 16 RISPERDAL CONSTA – risperidone microspheres for inj 12.5 mg.............................................................................. 40 RISPERDAL CONSTA – risperidone microspheres for inj 25 mg................................................................................. 40 RISPERDAL CONSTA – risperidone microspheres for inj 37.5 mg.............................................................................. 40

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RISPERDAL CONSTA – risperidone microspheres for inj 50 mg................................................................................. 40 risperidone orally disintegrating tab 0.25 mg............... 40 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab)................................................................................ 40 risperidone orally disintegrating tab 1 mg (Risperdal m-tab)................................................................................ 40 risperidone orally disintegrating tab 2 mg (Risperdal m-tab)................................................................................ 40 risperidone orally disintegrating tab 3 mg (Risperdal m-tab)................................................................................ 41 risperidone orally disintegrating tab 4 mg (Risperdal m-tab)................................................................................ 41 risperidone soln 1 mg/ml (Risperdal)............................. 41 risperidone tab 0.25 mg (Risperdal)............................... 41 risperidone tab 0.5 mg (Risperdal)................................. 41 risperidone tab 1 mg (Risperdal).................................... 41 risperidone tab 2 mg (Risperdal).................................... 41 risperidone tab 3 mg (Risperdal).................................... 41 risperidone tab 4 mg (Risperdal).................................... 41 rivastigmine tartrate cap 1.5 mg (Exelon)......................45 rivastigmine tartrate cap 3 mg (Exelon).........................45 rivastigmine tartrate cap 4.5 mg (Exelon)......................45 rivastigmine tartrate cap 6 mg (Exelon).........................45 rivastigmine td patch 24hr 4.6 mg/24hr (Exelon).......... 45 rivastigmine td patch 24hr 9.5 mg/24hr (Exelon).......... 45 rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)........ 45 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt)................................................................ 50 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt)..................................................... 50 rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt)..............................................................................50 rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt)..............................................................................50 ropinirole hydrochloride tab 0.25 mg (Requip)............. 54 ropinirole hydrochloride tab 0.5 mg (Requip)............... 54 ropinirole hydrochloride tab 1 mg (Requip).................. 54 ropinirole hydrochloride tab 2 mg (Requip).................. 54 ropinirole hydrochloride tab 3 mg (Requip).................. 54 ropinirole hydrochloride tab 4 mg (Requip).................. 54 ropinirole hydrochloride tab 5 mg (Requip).................. 54 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl)................................................... 54 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl)................................................... 54 ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl)................................................... 54 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl)................................................... 54 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl)................................................... 54 rosuvastatin calcium tab 5 mg (Crestor)....................... 23 rosuvastatin calcium tab 10 mg (Crestor)..................... 23 rosuvastatin calcium tab 20 mg (Crestor)..................... 23

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 rosuvastatin calcium tab 40 mg (Crestor)..................... 23 S salicylic acid cream 6%................................................... 64 salicylic acid cream 6% & cleanser liqd kit (Salex cream)............................................................................... 64 salicylic acid film forming liquid 27.5% (Virasal).......... 64 salicylic acid foam 6% (Salvax)...................................... 64 salicylic acid gel 6% (Keralyt)......................................... 64 salicylic acid lotion 6%.................................................... 64 salicylic acid lotion 6% & cleanser liqd kit (Salex lotion)................................................................................ 64 salicylic acid shampoo 6% (Salex)................................. 64 salsalate tab 500 mg (Disalcid)....................................... 46 salsalate tab 750 mg (Disalcid)....................................... 46 SAMSCA – tolvaptan tab 15 mg........................................ 16 SAMSCA – tolvaptan tab 30 mg........................................ 16 SAPHRIS – asenapine maleate sl tab 2.5 mg (base equiv)................................................................................. 41 SAPHRIS – asenapine maleate sl tab 5 mg (base equiv)................................................................................. 41 SAPHRIS – asenapine maleate sl tab 10 mg (base equiv)................................................................................. 41 scar treatment products - gel..........................................67 selegiline hcl cap 5 mg (Eldepryl).................................. 54 selegiline hcl tab 5 mg..................................................... 54 selenium sulfide lotion 2.5%........................................... 67 selenium sulfide-pyrithione zinc in urea shampoo 2.25%................................................................................. 67 SELZENTRY – maraviroc tab 150 mg................................. 6 SELZENTRY – maraviroc tab 300 mg................................. 6 SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg...................................................................................... 57 SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg..............................................................................57 SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)..........16 SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)..........16 SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)..........16 SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv)................................................ 29 SEROQUEL XR – quetiapine fumarate tab sr 24hr 50 mg...................................................................................... 41 SEROQUEL XR – quetiapine fumarate tab sr 24hr 150 mg...................................................................................... 41 SEROQUEL XR – quetiapine fumarate tab sr 24hr 200 mg...................................................................................... 41 SEROQUEL XR – quetiapine fumarate tab sr 24hr 300 mg...................................................................................... 41 SEROQUEL XR – quetiapine fumarate tab sr 24hr 400 mg...................................................................................... 41 SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj 4 mg...................................................... 15 SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj 5 mg...................................................... 15

SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj 6 mg...................................................... 15 sertraline hcl oral conc 20 mg/ml (Zoloft)......................37 sertraline hcl tab 25 mg (Zoloft)..................................... 37 sertraline hcl tab 50 mg (Zoloft)..................................... 37 sertraline hcl tab 100 mg (Zoloft)................................... 37 SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base equiv)................................................................................. 16 SIGNIFOR – pasireotide diaspartate inj 0.6 mg/ml (base equiv)................................................................................. 16 SIGNIFOR – pasireotide diaspartate inj 0.9 mg/ml (base equiv)................................................................................. 16 sildenafil citrate tab 20 mg (Revatio)............................. 26 silver nitrate-potassium nitrate applicator 75-25% (Arzol silver nitrate)........................................................ 67 silver sulfadiazine cream 1% (Silvadene)...................... 64 simvastatin tab 5 mg (Zocor).......................................... 23 simvastatin tab 10 mg (Zocor)........................................ 23 simvastatin tab 20 mg (Zocor)........................................ 23 simvastatin tab 40 mg (Zocor)........................................ 23 simvastatin tab 80 mg (Zocor)........................................ 23 sirolimus tab 0.5 mg (Rapamune)...................................68 sirolimus tab 1 mg (Rapamune)......................................68 sirolimus tab 2 mg (Rapamune)......................................68 skin protectants misc - cream........................................ 67 SM PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg.................................................................... 57 sodium chloride irrigation soln 0.9%............................. 34 sodium chloride soln nebu 0.9%.................................... 27 sodium chloride soln nebu 3%....................................... 27 sodium chloride soln nebu 10%..................................... 27 sodium chloride soln nebu 7% (Hyper-sal)................... 27 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi)................................................... 34 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride).............................................................................. 58 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride).............................................................................. 58 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride).............................................................................. 58 sodium fluoride cream 1.1% (Prevident 5000 plus)...... 62 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)............................................................................. 62 sodium fluoride paste 1.1% (Prevident 5000 boost)..... 62 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi).................................................... 62 sodium fluoride rinse 0.2%.............................................. 62 SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from 1.1 mg naf)........................................................................ 58 SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mg naf)........................................................................ 58 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf)..................................................................................... 58 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride).............................................................................. 58

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2016 sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl)........................................................................ 16 sodium polystyrene sulfonate oral susp 15 gm/60ml.............................................................................68 sodium polystyrene sulfonate powder (Kayexalate)...................................................................... 69 sodium polystyrene sulfonate rectal susp 30 gm/120ml...........................................................................69 SOMAVERT – pegvisomant for inj 10 mg (as protein)....... 16 SOMAVERT – pegvisomant for inj 15 mg (as protein)....... 16 SOMAVERT – pegvisomant for inj 20 mg (as protein)....... 16 SOMAVERT – pegvisomant for inj 25 mg (as protein)....... 16 SOMAVERT – pegvisomant for inj 30 mg (as protein)....... 16 sotalol hcl (afib/afl) tab 80 mg (Betapace af)................. 25 sotalol hcl (afib/afl) tab 120 mg (Betapace af)............... 25 sotalol hcl (afib/afl) tab 160 mg (Betapace af)............... 25 sotalol hcl tab 240 mg...................................................... 25 sotalol hcl tab 80 mg (Betapace).................................... 25 sotalol hcl tab 120 mg (Betapace).................................. 25 sotalol hcl tab 160 mg (Betapace).................................. 25 speciality vitamin product tab.........................................57 SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)................... 29 SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act................................................ 29 SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act.................................................. 29 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide).....................................................................24 spironolactone tab 25 mg (Aldactone)........................... 24 spironolactone tab 50 mg (Aldactone)........................... 24 spironolactone tab 100 mg (Aldactone)......................... 24 SPRITAM – levetiracetam tab disintegrating soluble 250 mg...................................................................................... 53 SPRITAM – levetiracetam tab disintegrating soluble 500 mg...................................................................................... 53 SPRITAM – levetiracetam tab disintegrating soluble 750 mg...................................................................................... 53 SPRITAM – levetiracetam tab disintegrating soluble 1000 mg...................................................................................... 53 SSS 10-5 – sulfacetamide sodium w/ sulfur foam 10-5%................................................................................. 63 stannous fluoride conc 0.63% (Gel-kam oral care ri)........................................................................................ 62 stannous fluoride gel 0.4%.............................................. 62 stavudine cap 15 mg (Zerit)...............................................6 stavudine cap 20 mg (Zerit)...............................................6 stavudine cap 30 mg (Zerit)...............................................6 stavudine cap 40 mg (Zerit)...............................................6 stavudine for oral soln 1 mg/ml (Zerit)............................ 6 STAVZOR – valproic acid cap delayed release 125 mg...................................................................................... 53 STAVZOR – valproic acid cap delayed release 250 mg...................................................................................... 53

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STAVZOR – valproic acid cap delayed release 500 mg...................................................................................... 53 STIMATE – desmopressin acetate nasal soln 1.5 mg/ ml........................................................................................ 16 STRENSIQ – asfotase alfa subcutaneous inj 18 mg/0.45ml.......................................................................... 16 STRENSIQ – asfotase alfa subcutaneous inj 28 mg/0.7ml............................................................................ 16 STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ ml........................................................................................ 16 STRENSIQ – asfotase alfa subcutaneous inj 80 mg/0.8ml............................................................................ 16 STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab 150-150-200-300 mg........................................................... 6 STUART PRENATAL – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg...........................................................................57 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)....................................................... 48 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)................................................................ 48 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)................................................................ 48 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)................................................................ 48 SUCRAID – sacrosidase soln 8500 unit/ml....................... 31 sucralfate tab 1 gm (Carafate).........................................31 sulfacetamide sodium cleansing gel 10% (Ovace plus wash)................................................................................. 67 sulfacetamide sodium liquid 10% (Ovace wash).......... 67 sulfacetamide sodium lotion 10% (acne) (Klaron)........ 63 sulfacetamide sodium ophth soln 10% (Bleph-10)....... 60 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%.................................................................. 60 sulfacetamide sodium shampoo 10% (Ovace plus)..... 67 sulfacetamide sodium-sulfur in urea emulsion 10-4%................................................................................. 63 sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser)....................................................................... 63 sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% (Plexion cleanser)............................................................ 63 sulfacetamide sodium w/ sulfur cleansing cloth 10-5%................................................................................. 63 sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin).......................................................................... 63 sulfacetamide sodium w/ sulfur cream 10-5%.............. 63 sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls)....................................................................................... 63 sulfacetamide sodium w/ sulfur cream 9.8-4.8% (Plexion)............................................................................ 63 sulfacetamide sodium w/ sulfur emulsion 10-1%......... 63 sulfacetamide sodium w/ sulfur emulsion 10-5%......... 63 sulfacetamide sodium w/ sulfur foam 10-5%................ 63 sulfacetamide sodium w/ sulfur lotion 10-5%............... 63 sulfacetamide sodium w/ sulfur lotion 9.8-4.8% (Plexion)............................................................................ 63

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts)....................................................................................... 63 sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash).............................................................. 63 sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash)................................................................................. 63 sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit (Sumadan kit)............................................................. 63 sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit (Sumadan xlt)................................................................... 63 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml................................................................................. 7 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)............................................................................. 7 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds)........................................................................ 7 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)............................................................................. 32 sulfasalazine tab 500 mg (Azulfidine)............................ 32 sulindac tab 150 mg......................................................... 50 sulindac tab 200 mg......................................................... 50 sumatriptan nasal spray 5 mg/act (Imitrex)................... 50 sumatriptan nasal spray 20 mg/act (Imitrex)................. 50 sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............. 50 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys).................................... 50 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys).................................... 50 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref)...................................................... 50 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref)...................................................... 50 SUMATRIPTAN SUCCINATE – sumatriptan succinate solution prefilled syringe 6 mg/0.5ml................................ 50 sumatriptan succinate tab 25 mg (Imitrex).................... 50 sumatriptan succinate tab 50 mg (Imitrex).................... 50 sumatriptan succinate tab 100 mg (Imitrex).................. 51 SUSTIVA – efavirenz cap 50 mg......................................... 6 SUSTIVA – efavirenz cap 200 mg....................................... 6 SUSTIVA – efavirenz tab 600 mg........................................ 6 SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act..................................................... 29 SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/act................................................... 29 T tacrolimus cap 0.5 mg (Prograf)..................................... 69 tacrolimus cap 1 mg (Prograf)........................................ 69 tacrolimus cap 5 mg (Prograf)........................................ 69 tacrolimus oint 0.03% (Protopic).................................... 67 tacrolimus oint 0.1% (Protopic)...................................... 67 TAGRISSO – osimertinib mesylate tab 40 mg (base equivalent)............................................................................9 TAGRISSO – osimertinib mesylate tab 80 mg (base equivalent)............................................................................9

TALTZ – ixekizumab subcutaneous soln auto-injector 80 mg/ml..................................................................................67 TALTZ – ixekizumab subcutaneous soln prefilled syringe 80 mg/ml............................................................................ 67 TAMIFLU – oseltamivir phosphate cap 30 mg (base equiv)....................................................................................6 TAMIFLU – oseltamivir phosphate cap 45 mg (base equiv)....................................................................................6 TAMIFLU – oseltamivir phosphate cap 75 mg (base equiv)....................................................................................6 TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base equiv)....................................................................................6 tamoxifen citrate tab 10 mg (base equivalent)................ 9 tamoxifen citrate tab 20 mg (base equivalent)................ 9 tamsulosin hcl cap 0.4 mg (Flomax).............................. 34 TAZORAC – tazarotene cream 0.05%............................... 64 TAZORAC – tazarotene cream 0.1%................................. 64 TAZORAC – tazarotene gel 0.05%.................................... 64 TAZORAC – tazarotene gel 0.1%...................................... 64 TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg...... 53 telmisartan-amlodipine tab 40-5 mg (Twynsta)............. 21 telmisartan-amlodipine tab 80-5 mg (Twynsta)............. 21 telmisartan-amlodipine tab 40-10 mg (Twynsta)........... 21 telmisartan-amlodipine tab 80-10 mg (Twynsta)........... 21 telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct)................................................................... 19 telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)................................................................... 19 telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct)................................................................... 19 telmisartan tab 20 mg (Micardis).................................... 18 telmisartan tab 40 mg (Micardis).................................... 19 telmisartan tab 80 mg (Micardis).................................... 19 temazepam cap 7.5 mg (Restoril)................................... 42 temazepam cap 15 mg (Restoril).................................... 42 temazepam cap 22.5 mg (Restoril)................................. 42 temazepam cap 30 mg (Restoril).................................... 42 temozolomide cap 5 mg (Temodar).................................. 9 temozolomide cap 20 mg (Temodar)................................ 9 temozolomide cap 100 mg (Temodar).............................. 9 temozolomide cap 140 mg (Temodar).............................. 9 temozolomide cap 180 mg (Temodar).............................. 9 temozolomide cap 250 mg (Temodar).............................. 9 TENCON – butalbital-acetaminophen tab 50-325 mg....... 46 terazosin hcl cap 1 mg..................................................... 26 terazosin hcl cap 2 mg..................................................... 26 terazosin hcl cap 5 mg..................................................... 26 terazosin hcl cap 10 mg................................................... 26 terbinafine hcl tab 250 mg (Lamisil)................................. 4 terbutaline sulfate tab 2.5 mg......................................... 29 terbutaline sulfate tab 5 mg............................................ 29 terconazole vaginal cream 0.4% (Terazol 7).................. 33 terconazole vaginal cream 0.8% (Terazol 3).................. 33 terconazole vaginal suppos 80 mg.................................33

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2016 testosterone td gel 12.5 mg/act (1%) (Androgel pump)................................................................................ 10 testosterone td gel 25 mg/2.5gm (1%) (Androgel)........ 10 testosterone td gel 50 mg/5gm (1%) (Androgel)........... 10 TEST STRIPS – BAYER ASCENCIA................................. 68 tetrabenazine tab 12.5 mg (Xenazine)............................ 45 tetrabenazine tab 25 mg (Xenazine)............................... 45 tetracaine hcl ophth soln 0.5%....................................... 61 tetracycline hcl cap 250 mg (Tetracycline hcl)................ 3 tetracycline hcl cap 500 mg (Tetracycline hcl)................ 3 TETRACYCLINE HCL – tetracycline hcl cap 250 mg.......... 3 TETRACYCLINE HCL – tetracycline hcl cap 500 mg.......... 3 theophylline soln 80 mg/15ml......................................... 29 theophylline tab sr 12hr 100 mg..................................... 29 theophylline tab sr 12hr 200 mg..................................... 29 theophylline tab sr 12hr 300 mg..................................... 29 theophylline tab sr 12hr 450 mg..................................... 29 theophylline tab sr 24hr 400 mg..................................... 29 theophylline tab sr 24hr 600 mg..................................... 29 thioridazine hcl tab 10 mg............................................... 41 thioridazine hcl tab 25 mg............................................... 41 thioridazine hcl tab 50 mg............................................... 41 thioridazine hcl tab 100 mg............................................. 41 thiothixene cap 1 mg........................................................ 41 thiothixene cap 2 mg........................................................ 41 thiothixene cap 5 mg........................................................ 41 thiothixene cap 10 mg...................................................... 41 TH PRENATAL VITAMINS – prenatal vit w/ fe fumarate-fa tab 28-0.8 mg.................................................................... 57 thyroid tab 30 mg (1/2 grain) (Armour thyroid)............. 14 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid).......... 15 thyroid tab 60 mg (1 grain) (Armour thyroid)................ 15 tiagabine hcl tab 2 mg (Gabitril)..................................... 53 tiagabine hcl tab 4 mg (Gabitril)..................................... 53 ticlopidine hcl tab 250 mg............................................... 59 TICLOPIDINE HCL – ticlopidine hcl tab 250 mg............... 59 timolol maleate ophth gel forming soln 0.25% (Timoptic-xe).................................................................... 61 timolol maleate ophth gel forming soln 0.5% (Timoptic-xe).................................................................... 61 timolol maleate ophth soln 0.25% (Timoptic)................ 61 timolol maleate ophth soln 0.5% (Timoptic).................. 61 tinidazole tab 250 mg (Tindamax)..................................... 7 tinidazole tab 500 mg (Tindamax)..................................... 7 TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 6 tizanidine hcl cap 2 mg (base equivalent) (Zanaflex).......................................................................... 55 tizanidine hcl cap 4 mg (base equivalent) (Zanaflex).......................................................................... 55 tizanidine hcl cap 6 mg (base equivalent) (Zanaflex).......................................................................... 55 tizanidine hcl tab 2 mg (base equivalent)...................... 55 tizanidine hcl tab 4 mg (base equivalent) (Zanaflex).......................................................................... 55

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tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex)......................................................................... 60 tobramycin nebu soln 300 mg/5ml (Tobi)........................ 3 tobramycin ophth soln 0.3% (Tobrex)............................ 60 tolazamide tab 250 mg..................................................... 13 tolcapone tab 100 mg (Tasmar)...................................... 55 tolmetin sodium cap 400 mg........................................... 50 tolterodine tartrate cap sr 24hr 2 mg (Detrol la)............33 tolterodine tartrate cap sr 24hr 4 mg (Detrol la)............33 tolterodine tartrate tab 1 mg (Detrol)............................. 33 tolterodine tartrate tab 2 mg (Detrol)............................. 33 topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 53 topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 53 topiramate tab 25 mg (Topamax).................................... 53 topiramate tab 50 mg (Topamax).................................... 53 topiramate tab 100 mg (Topamax).................................. 53 topiramate tab 200 mg (Topamax).................................. 53 torsemide tab 5 mg...........................................................24 torsemide tab 100 mg.......................................................24 torsemide tab 10 mg (Demadex)..................................... 24 torsemide tab 20 mg (Demadex)..................................... 24 TOUJEO SOLOSTAR – insulin glargine soln pen-injector 300 unit/ml......................................................................... 14 TRACLEER – bosentan tab 62.5 mg................................. 26 TRACLEER – bosentan tab 125 mg.................................. 26 tramadol-acetaminophen tab 37.5-325 mg (Ultracet)........................................................................... 49 tramadol hcl tab 50 mg (Ultram)..................................... 49 tramadol hcl tab sr 24hr biphasic release 100 mg........ 49 tramadol hcl tab sr 24hr biphasic release 200 mg........ 49 tramadol hcl tab sr 24hr biphasic release 300 mg........ 49 tramadol hcl tab sr 24hr 100 mg.....................................48 tramadol hcl tab sr 24hr 200 mg.....................................48 tramadol hcl tab sr 24hr 300 mg (Ultram er)................. 49 trandolapril tab 4 mg........................................................ 18 trandolapril tab 1 mg (Mavik).......................................... 18 trandolapril tab 2 mg (Mavik).......................................... 18 trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)....... 21 trandolapril-verapamil hcl tab cr 2-180 mg (Tarka)....... 21 trandolapril-verapamil hcl tab cr 2-240 mg (Tarka)....... 21 trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)....... 22 tranexamic acid tab 650 mg (Lysteda)........................... 59 tranylcypromine sulfate tab 10 mg (Parnate)................ 37 trazodone hcl tab 50 mg.................................................. 37 trazodone hcl tab 100 mg................................................ 37 trazodone hcl tab 150 mg................................................ 37 trazodone hcl tab 300 mg................................................ 37 tretinoin cap 10 mg.............................................................9 tretinoin cream 0.025% (Retin-a).....................................64 tretinoin cream 0.05% (Retin-a).......................................64 tretinoin cream 0.1% (Retin-a).........................................64 tretinoin gel 0.05% (Atralin)............................................. 64 tretinoin gel 0.01% (Retin-a)............................................ 64 tretinoin gel 0.025% (Retin-a).......................................... 64 tretinoin microsphere gel 0.04% (Retin-a micro).......... 64

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 tretinoin microsphere gel 0.1% (Retin-a micro)............ 64 triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog)...........................................................................66 triamcinolone acetonide cream 0.025%......................... 66 triamcinolone acetonide cream 0.1%............................. 66 triamcinolone acetonide cream 0.5%............................. 66 triamcinolone acetonide dental paste 0.1%.................. 62 triamcinolone acetonide lotion 0.025%.......................... 66 triamcinolone acetonide lotion 0.1%.............................. 66 triamcinolone acetonide nasal aerosol suspension 55 mcg/act..............................................................................27 triamcinolone acetonide oint 0.025%............................. 66 triamcinolone acetonide oint 0.1%................................. 66 TRIAMTERENE/HYDROCHLOROTH – triamterene & hydrochlorothiazide cap 50-25 mg................................... 24 triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide)........................................................................... 24 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)..................................................................... 24 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)........................................................................... 24 triazolam tab 0.125 mg..................................................... 42 triazolam tab 0.25 mg (Halcion)...................................... 42 TRIAZOLAM – triazolam tab 0.125 mg.............................. 42 TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg..... 57 trifluoperazine hcl tab 1 mg............................................ 41 trifluoperazine hcl tab 2 mg............................................ 41 trifluoperazine hcl tab 5 mg............................................ 41 trifluoperazine hcl tab 10 mg.......................................... 41 trifluridine ophth soln 1% (Viroptic)............................... 60 trihexyphenidyl hcl elixir 0.4 mg/ml............................... 55 trihexyphenidyl hcl tab 2 mg...........................................55 trihexyphenidyl hcl tab 5 mg...........................................55 trimethobenzamide hcl cap 300 mg (Tigan).................. 31 trimethoprim tab 100 mg................................................... 7 trimipramine maleate cap 25 mg (Surmontil)................ 37 trimipramine maleate cap 50 mg (Surmontil)................ 37 trimipramine maleate cap 100 mg (Surmontil).............. 37 TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1 mg...................................................................................... 57 TRIUMEQ – abacavir-dolutegravir-lamivudine tab 600-50-300 mg.................................................................... 6 TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml................................................. 57 trospium chloride cap sr 24hr 60 mg............................. 33 trospium chloride tab 20 mg........................................... 33 TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg................................................................... 6 TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 133-200 mg................................................................... 6 TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 167-250 mg................................................................... 6 TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg................................................................... 6 TYBOST – cobicistat tab 150 mg.........................................6

TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ ml........................................................................................ 26 TYVASO STARTER – treprostinil inhalation solution 0.6 mg/ml..................................................................................26 TYVASO – treprostinil inhalation solution 0.6 mg/ml......... 26 U UPTRAVI – selexipag tab 200 mcg.................................... 26 UPTRAVI – selexipag tab 400 mcg.................................... 26 UPTRAVI – selexipag tab 600 mcg.................................... 26 UPTRAVI – selexipag tab 800 mcg.................................... 26 UPTRAVI – selexipag tab 1000 mcg.................................. 26 UPTRAVI – selexipag tab 1200 mcg.................................. 26 UPTRAVI – selexipag tab 1400 mcg.................................. 26 UPTRAVI – selexipag tab 1600 mcg.................................. 26 UPTRAVI – selexipag tab therapy pack 200 mcg (140) & 800 mcg (60)..................................................................... 26 urea cream 40%.................................................................67 urea cream 50%.................................................................67 urea cream 39% (Aluvea)................................................. 67 urea cream 47% (Keralac)................................................ 67 urea cream 45% (Uramaxin)............................................ 67 urea foam 40% (Hydro 40 foam)..................................... 67 urea gel 40%...................................................................... 67 urea gel 45% (Uramaxin).................................................. 67 urea in lactic acid-salicylic acid vehicle susp 50%.......67 urea in lactic acid vehicle foam 35% (Hydro 35)........... 67 urea in zinc undecylenate-lactic acid vehicle emulsion 50%.................................................................................... 67 urea lotion 40%................................................................. 67 urea lotion 45% (Uramaxin)............................................. 67 urea suspension 40% (Umecta nail film)....................... 67 ursodiol cap 300 mg (Actigall)........................................ 32 ursodiol tab 250 mg (Urso 250)...................................... 32 ursodiol tab 500 mg (Urso forte).................................... 32 V VAGIFEM – estradiol vaginal tab 10 mcg.......................... 33 valacyclovir hcl tab 1 gm (Valtrex)................................... 4 valacyclovir hcl tab 500 mg (Valtrex)............................... 4 VALCHLOR – mechlorethamine hcl gel 0.016% (base equivalent)......................................................................... 67 VALCYTE – valganciclovir hcl for soln 50 mg/ml (base equiv)....................................................................................4 valganciclovir hcl tab 450 mg (base equivalent) (Valcyte).............................................................................. 4 valproate sodium syrup 250 mg/5ml (base equiv) (Depakene)........................................................................ 53 valproic acid cap 250 mg (Depakene)............................ 53 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct)..................................................................................... 19 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct)..................................................................................... 19 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct)..................................................................................... 19

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2016 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct)..................................................................................... 19 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct)..................................................................................... 19 valsartan tab 40 mg (Diovan).......................................... 19 valsartan tab 80 mg (Diovan).......................................... 19 valsartan tab 160 mg (Diovan)........................................ 19 valsartan tab 320 mg (Diovan)........................................ 19 vancomycin hcl cap 125 mg (Vancocin hcl).................... 7 vancomycin hcl cap 250 mg (Vancocin hcl).................... 7 VENCLEXTA STARTING PACK – venetoclax tab therapy starter pack 10 & 50 & 100 mg.......................................... 9 VENCLEXTA – venetoclax tab 10 mg.................................. 9 VENCLEXTA – venetoclax tab 50 mg.................................. 9 VENCLEXTA – venetoclax tab 100 mg................................ 9 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr)....................................................................... 37 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr)....................................................................... 37 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr)....................................................................... 37 VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 225 mg (base equivalent)........................................................ 37 venlafaxine hcl tab 25 mg................................................38 venlafaxine hcl tab 37.5 mg.............................................38 venlafaxine hcl tab 50 mg................................................38 venlafaxine hcl tab 75 mg................................................38 venlafaxine hcl tab 100 mg..............................................38 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er)......................................................... 38 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er)......................................................... 38 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er)......................................................... 38 VENTAVIS – iloprost inhalation solution 10 mcg/ml........... 26 VENTAVIS – iloprost inhalation solution 20 mcg/ml........... 26 VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv).......................................................... 29 verapamil hcl cap sr 24hr 120 mg (Verelan).................. 22 verapamil hcl cap sr 24hr 180 mg (Verelan).................. 22 verapamil hcl cap sr 24hr 240 mg (Verelan).................. 22 verapamil hcl cap sr 24hr 360 mg (Verelan).................. 22 verapamil hcl cap sr 24hr 100 mg (Verelan pm)............ 22 verapamil hcl cap sr 24hr 200 mg (Verelan pm)............ 22 verapamil hcl cap sr 24hr 300 mg (Verelan pm)............ 22 verapamil hcl tab cr 120 mg (Calan sr).......................... 22 verapamil hcl tab cr 180 mg (Calan sr).......................... 22 verapamil hcl tab cr 240 mg (Calan sr).......................... 22 verapamil hcl tab 40 mg.................................................. 22 verapamil hcl tab 80 mg (Calan)..................................... 22 verapamil hcl tab 120 mg (Calan)................................... 22 VERSACLOZ – clozapine susp 50 mg/ml..........................41 VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ ml)...................................................................................... 13 VIDEX – didanosine for soln 2 gm....................................... 6

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VIDEX – didanosine for soln 4 gm....................................... 6 VIIBRYD STARTER PACK – vilazodone hcl tab starter kit 10 (7) & 20 (23) mg.......................................................... 38 VIIBRYD – vilazodone hcl tab 10 mg................................. 38 VIIBRYD – vilazodone hcl tab 20 mg................................. 38 VIIBRYD – vilazodone hcl tab 40 mg................................. 38 VIIBRYD – vilazodone hcl tab starter kit 10 (7) & 20 (7) & 40 (16) mg......................................................................... 38 VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg...................................................................................... 57 VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg...................................................................................... 57 VIRACEPT – nelfinavir mesylate tab 250 mg...................... 6 VIRACEPT – nelfinavir mesylate tab 625 mg...................... 6 VIRAMUNE – nevirapine susp 50 mg/5ml........................... 6 VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm.................................................................................. 6 VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 6 VIREAD – tenofovir disoproxil fumarate tab 200 mg........... 6 VIREAD – tenofovir disoproxil fumarate tab 250 mg........... 6 VIREAD – tenofovir disoproxil fumarate tab 300 mg........... 6 VISTOGARD – uridine triacetate oral granules packet 10 gm...................................................................................... 69 VITEKTA – elvitegravir tab 85 mg........................................ 6 VITEKTA – elvitegravir tab 150 mg...................................... 6 VIVITROL – naltrexone for im extended release susp 380 mg...................................................................................... 69 VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg...................................................................................... 57 voriconazole for susp 40 mg/ml (Vfend).......................... 4 voriconazole tab 50 mg (Vfend)........................................ 4 voriconazole tab 200 mg (Vfend)...................................... 4 VRAYLAR – cariprazine hcl cap 1.5 mg (base equivalent)......................................................................... 41 VRAYLAR – cariprazine hcl cap 3 mg (base equivalent)......................................................................... 41 VRAYLAR – cariprazine hcl cap 4.5 mg (base equivalent)......................................................................... 41 VRAYLAR – cariprazine hcl cap 6 mg (base equivalent)......................................................................... 41 VRAYLAR – cariprazine hcl cap therapy pack 1.5 mg (1) & 3 mg (6)............................................................................. 41 VYVANSE – lisdexamfetamine dimesylate cap 10 mg...... 44 VYVANSE – lisdexamfetamine dimesylate cap 20 mg...... 44 VYVANSE – lisdexamfetamine dimesylate cap 30 mg...... 44 VYVANSE – lisdexamfetamine dimesylate cap 40 mg...... 44 VYVANSE – lisdexamfetamine dimesylate cap 50 mg...... 44 VYVANSE – lisdexamfetamine dimesylate cap 60 mg...... 44 VYVANSE – lisdexamfetamine dimesylate cap 70 mg...... 44 W warfarin warfarin warfarin warfarin

sodium sodium sodium sodium

tab 1 mg (Coumadin).......................... 59 tab 2 mg (Coumadin).......................... 59 tab 2.5 mg (Coumadin)....................... 59 tab 3 mg (Coumadin).......................... 59

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

2016 warfarin sodium tab 4 mg (Coumadin).......................... 59 warfarin sodium tab 5 mg (Coumadin).......................... 59 warfarin sodium tab 6 mg (Coumadin).......................... 59 warfarin sodium tab 7.5 mg (Coumadin)....................... 59 warfarin sodium tab 10 mg (Coumadin)........................ 59 water for irrigation, sterile irrigation soln...................... 69 WELCHOL – colesevelam hcl packet for susp 3.75 gm...................................................................................... 23 WELCHOL – colesevelam hcl tab 625 mg........................ 23 wound dressings - cream................................................ 67 X XARELTO – rivaroxaban tab 10 mg................................... 60 XARELTO – rivaroxaban tab 15 mg................................... 60 XARELTO – rivaroxaban tab 20 mg................................... 60 XARELTO STARTER PACK – rivaroxaban tab starter therapy pack 15 mg & 20 mg........................................... 60 XENAZINE – tetrabenazine tab 12.5 mg........................... 45 XENAZINE – tetrabenazine tab 25 mg.............................. 45 XIAFLEX – collagenase clostridium histolyticum for inj 0.9 mg...................................................................................... 69 XIFAXAN – rifaximin tab 550 mg......................................... 7 XTANDI – enzalutamide cap 40 mg..................................... 9 XULANE – norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr............................................................................ 12 XURIDEN – uridine triacetate oral granules packet 2 gm...................................................................................... 16 XYREM – sodium oxybate oral solution 500 mg/ml........... 45 Y Z zafirlukast tab 10 mg (Accolate)..................................... 29 zafirlukast tab 20 mg (Accolate)..................................... 29 zaleplon cap 5 mg (Sonata)............................................. 42 zaleplon cap 10 mg (Sonata)........................................... 42 ZAVESCA – miglustat cap 100 mg.................................... 60 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit..................................................... 31 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit..................................................... 31 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit................................................... 31 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit................................................... 31 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit................................................. 31 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit................................................. 31 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit............................................... 31 ZEPATIER – elbasvir-grazoprevir tab 50-100 mg................ 4 ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)...... 6 zidovudine cap 100 mg (Retrovir).....................................6 zidovudine syrup 10 mg/ml (Retrovir).............................. 6 zidovudine tab 300 mg....................................................... 6

ziprasidone hcl cap 20 mg (Geodon)............................. 41 ziprasidone hcl cap 40 mg (Geodon)............................. 41 ziprasidone hcl cap 60 mg (Geodon)............................. 41 ziprasidone hcl cap 80 mg (Geodon)............................. 41 zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt).................................................................................... 51 zolmitriptan orally disintegrating tab 5 mg (Zomig zmt).................................................................................... 51 zolmitriptan tab 2.5 mg (Zomig)...................................... 51 zolmitriptan tab 5 mg (Zomig)......................................... 51 zolpidem tartrate sl tab 1.75 mg (Intermezzo)............... 42 zolpidem tartrate sl tab 3.5 mg (Intermezzo)................. 42 zolpidem tartrate tab cr 6.25 mg (Ambien cr)................ 42 zolpidem tartrate tab cr 12.5 mg (Ambien cr)................ 42 zolpidem tartrate tab 5 mg (Ambien)..............................42 zolpidem tartrate tab 10 mg (Ambien)............................42 zonisamide cap 50 mg..................................................... 53 zonisamide cap 25 mg (Zonegran)................................. 53 zonisamide cap 100 mg (Zonegran)............................... 53 ZORTRESS – everolimus tab 0.25 mg.............................. 69 ZORTRESS – everolimus tab 0.5 mg................................ 69 ZORTRESS – everolimus tab 0.75 mg.............................. 69 ZOVIRAX – acyclovir cream 5%........................................ 64 ZYCLARA – imiquimod cream 3.75%................................ 67 ZYCLARA PUMP – imiquimod cream 2.5%...................... 68 ZYCLARA PUMP – imiquimod cream 3.75%.................... 68 ZYDELIG – idelalisib tab 100 mg......................................... 9 ZYDELIG – idelalisib tab 150 mg......................................... 9 ZYKADIA – ceritinib cap 150 mg......................................... 9 ZYLET – loteprednol etabonate-tobramycin ophth susp 0.5-0.3%............................................................................. 60 ZYPREXA RELPREVV – olanzapine pamoate for extended rel im susp 210 mg (base eq)...........................41 ZYPREXA RELPREVV – olanzapine pamoate for extended rel im susp 300 mg (base eq)...........................41 ZYPREXA RELPREVV – olanzapine pamoate for extended rel im susp 405 mg (base eq)...........................41 ZYVOX – linezolid for susp 100 mg/5ml.............................. 7 El Estado de Nuevo México financia parcialmente tales servicios. Blue Cross and Blue Shield of New Mexico es una división de Health Care Service Corporation, una compañía mutua de reserva legal, un concesionario independiente de Blue Cross and Blue Shield Association. Prime Therapeutics LLC es una empresa independiente y es el gestor de los beneficios de farmacia de Blue Cross Community Centennial .

Blue Cross y Blue Shield de New Mexico octubre de 2016 Lista de medicamentos de Blue Cross Community Centennial

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