FORMULARIO DE MEDICAMENTOS EMPLEADOS ELA RUBÍ

Transcription

1 FORMULARIO DE MEDICAMENTOS EMPLEADOS ELA RUBÍ 208

2 Programa de Farmacia de Triple-S Salud TRIPLE-S SALUD, INC. Pharmacy Program from Triple-S Salud TRIPLE-S SALUD, INC. Lista de Medicamentos o Formulario ELA Rubi 208 ELA Rubi Drug List or Formulary 208 Revisado Noviembre 207 / Revised November 207 ELA Rubi

3 PARTE II - MEDICAMENTOS POR CLASIFICACION TERAPEUTICA / PART II DRUGS BY THERAPEUTIC CLASSIFICATION Medicamentos genéricos = letras minúsculas en negrillas / Generic Drugs = lowercase bold Medicamentos originales = letras mayúsculas / Brand name drugs = UPPERCASE Medicamentos (Drugs) Nivel (Level) Instrucciones (Instructions) Analgesics [Analgésicos] Nonsteroidal Anti-Inflammatory Drugs [Anti-Inflamatorios No Esteroidales] celecoxib oral capsule 00, 200, 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 00 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 00 etodolac oral tablet 400, 500 flurbiprofen oral tablet 00, 50 ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25, 50 ketorolac tromethamine injection solution 5 /ml ketorolac tromethamine injection solution 0 /ml, 00 /0ml, 60 /2ml ketorolac tromethamine intramuscular solution 60 /2ml meloxicam oral tablet 5, 7.5 nabumetone oral tablet 500, 750 naproxen oral suspension 25 /5ml naproxen oral tablet 250, 75, 500 naproxen sodium oral tablet 275, 550 salsalate oral tablet 500, 750 ST QL (40 ML per 5 days) QL (20 ML per 5 days) QL (20 ML per 5 days) ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

4 sulindac oral tablet 50, 200 Opioid Analgesics, Long-Acting [Analgésicos Opiodes, Larga Duración] fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr morphine sulfate er oral tablet extended release 00, 5, 200, 0, 60 oxycodone hcl er oral tablet er 2 hour abusedeterrent 0, 5, 20, 0, 40, 60, 80 PA Opioid Analgesics, Short-Acting [Analgésicos Opiodes, Corta Duración] acetaminophen-codeine #2 oral tablet 00-5 acetaminophen-codeine # oral tablet 00-0 acetaminophen-codeine #4 oral tablet acetaminophen-codeine oral solution 20-2 /5ml butalbital-apap-caff-cod oral capsule , butalbital-apap-caffeine oral capsule , butalbital-apap-caffeine oral tablet butalbital-asa-caff-codeine oral capsule CAPITAL/CODEINE ORAL SUSPENSION 20-2 MG/5ML DEMEROL INJECTION SOLUTION 00 MG/2ML, 25 MG/0.5ML fentanyl citrate buccal lozenge on a handle 200 mcg, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg hydrocodone-acetaminophen oral tablet 0-00, 0-25, , 5-00, 5-25, , ELA Rubi 208 / ELA Rubi 208 Rev. Noviembre 207 / November 207

5 hydrocodone-ibuprofen oral tablet 0-200, , 5-200, hydromorphone hcl injection solution /ml, 2 /ml, 4 /ml hydromorphone hcl pf injection solution 0 /ml meperidine hcl injection solution 0 /ml, 25 /ml meperidine hcl injection solution 00 /ml, 50 /ml morphine sulfate (concentrate) oral solution 00 /5ml morphine sulfate (pf) injection solution 0.5 /ml, /ml morphine sulfate oral solution 0 /5ml, 20 /5ml morphine sulfate oral tablet 5, 0 oxycodone hcl oral tablet 0, 5, 20, 0, 5 oxycodone-acetaminophen oral tablet 0-25, , 5-25, tramadol hcl oral tablet 50 tramadol-acetaminophen oral tablet Anesthetics [Anestésicos] Local Anesthetics [Anestésico Local] lidocaine external ointment 5 % lidocaine external patch 5 % PA lidocaine hcl (pf) injection solution 0.5 %, %,.5 %, 2 % lidocaine hcl external gel 2 % lidocaine hcl external solution 4 % lidocaine hcl injection solution 0.5 %, %,.5 %, 2 % lidocaine viscous mouth/throat solution 2 % ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207 QL (200 ML per 0 days) QL (200 ML per 0 days)

6 Anti-Addiction/Substance Abuse Treatment Agents [Tratamiento De Abuso De Sustancias/Contra La Addición] Alcohol Deterrents/Anti-Craving [Disuasivos De Alcohol/Anti-Ansiedad] acamprosate calcium oral tablet delayed release SL disulfiram oral tablet 250, 500 SL naltrexone hcl oral tablet 50 Opioid Dependence Treatment [Tratamiento Contra La Dependencia A Opiodes] buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 PA; SL PA; SL; QL (2 SL TABS per day) PA; SL; QL ( SL TABS per day) SUBOXONE SUBLINGUAL FILM 2- MG PA; SL; QL (2 SL FILMS per day) SUBOXONE SUBLINGUAL FILM MG PA; SL; QL (2 SL FILMS per day) SUBOXONE SUBLINGUAL FILM 4- MG, 8-2 MG Opioid Reversal Agent [Reversión De Efecto Opioide] naloxone hcl injection solution 0.4 /ml, /ml, 4 /0ml naloxone hcl injection solution cartridge 0.4 /ml naloxone hcl injection solution prefilled syringe 2 /2ml Smoking Cessation Agents [Cesación De Fumar] bupropion hcl er (smoking det) oral tablet extended release 2 hour 50 NICOTROL INHALATION INHALER 0 MG Antibacterials [Antibacterianos] Aminoglycosides [Aminoglicósidos] amikacin sulfate injection solution gm/4ml, 500 /2ml gentamicin sulfate external cream 0. % gentamicin sulfate external ointment 0. % PA; SL; QL ( SL FILMS per day) ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

7 gentamicin sulfate injection solution 0 /ml, 40 /ml gentamicin sulfate intravenous solution 0 /ml gentamicin sulfate ophthalmic ointment 0. % gentamicin sulfate ophthalmic solution 0. % neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 tobramycin ophthalmic solution 0. % tobramycin sulfate injection solution.2 gm/0ml, 0 /ml, 2 gm/50ml, 80 /2ml tobramycin-dexamethasone ophthalmic suspension % TOBREX OPHTHALMIC OINTMENT 0. % Antibacterials, Other [Antibacterianos, Otros] acetic acid otic solution 2 % acetic acid-aluminum acetate otic solution 2 % bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm clindamycin hcl oral capsule 50, 00, 75 clindamycin phosphate injection solution 00 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml clindamycin phosphate intravenous solution 50 /ml, 600 /4ml, 900 /6ml clindamycin phosphate vaginal cream 2 % colistimethate sodium injection solution reconstituted 50 daptomycin intravenous solution reconstituted 500 hydrocortisone-acetic acid otic solution -2 % lincomycin hcl injection solution 00 /ml methenamine hippurate oral tablet gm ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

8 metronidazole external cream 0.75 % metronidazole external gel 0.75 % metronidazole external lotion 0.75 % metronidazole oral capsule 75 metronidazole oral tablet 250, 500 metronidazole vaginal gel 0.75 % mupirocin external ointment 2 % neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-gramicidin ophthalmic solution neomycin-polymyxin-hc ophthalmic suspension neomycin-polymyxin-hc otic solution neomycin-polymyxin-hc otic suspension nitrofurantoin macrocrystal oral capsule 00, 25 nitrofurantoin macrocrystal oral capsule 50 nitrofurantoin monohyd macro oral capsule 00 polymyxin b-trimethoprim ophthalmic solution unit/ml-% silver sulfadiazine external cream % SIVEXTRO ORAL TABLET 200 MG PA; SL tigecycline intravenous solution reconstituted 50 trimethoprim oral tablet 00 vancomycin hcl intravenous solution reconstituted 000, 500, 750 vancomycin hcl oral capsule 25, 250 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

9 XIFAXAN ORAL TABLET 200 MG, 550 MG Beta-Lactam, Cephalosporins [Cefalosporinas, Beta-Lactámicas] cefaclor oral capsule 250, 500 cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet gm cefazolin sodium injection solution reconstituted gm, 0 gm, 00 gm, 20 gm, 00 gm, 500 cefazolin sodium intravenous solution reconstituted gm cefdinir oral capsule 00 cefdinir oral suspension reconstituted 25 /5ml, 250 /5ml cefepime hcl injection solution reconstituted gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 00 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 00, 200 cefprozil oral suspension reconstituted 25 /5ml, 250 /5ml cefprozil oral tablet 250, 500 ceftazidime injection solution reconstituted gm, 2 gm ceftriaxone sodium injection solution reconstituted gm, 2 gm, 250, 500 cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection solution reconstituted.5 gm, 7.5 gm, 750 cephalexin oral capsule 250, 500, 750 cephalexin oral suspension reconstituted 25 /5ml, 250 /5ml ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

10 FORTAZ INJECTION SOLUTION RECONSTITUTED 500 MG ZINACEF INTRAVENOUS SOLUTION RECONSTITUTED 750 MG Beta-Lactam, Other [Beta-Lactámicos, Otros] imipenem-cilastatin intravenous solution reconstituted 250, 500 INVANZ INJECTION SOLUTION RECONSTITUTED GM Beta-Lactam, Penicillins [Penicilinas, Beta-Lactámicas] amoxicillin oral capsule 250, 500 amoxicillin oral suspension reconstituted 25 /5ml, 200 /5ml, 250 /5ml, 400 /5ml amoxicillin oral tablet 500, 875 amoxicillin-pot clavulanate er oral tablet extended release 2 hour amoxicillin-pot clavulanate oral suspension reconstituted /5ml, /5ml, /5ml, /5ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet chewable , ampicillin oral capsule 250, 500 ampicillin oral suspension reconstituted 25 /5ml, 250 /5ml ampicillin sodium injection solution reconstituted gm, 25, 2 gm, 250, 500 AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML BICILLIN C-R 900/00 INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

11 dicloxacillin sodium oral capsule 250, 500 oxacillin sodium injection solution reconstituted gm, 0 gm, 2 gm penicillin g procaine intramuscular suspension unit/ml penicillin v potassium oral solution reconstituted 25 /5ml, 250 /5ml penicillin v potassium oral tablet 250, 500 piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm,.75 (- 0.75) gm, 4.5 (4-0.5) gm, 40.5 (6-4.5) gm TIMENTIN INTRAVENOUS SOLUTION RECONSTITUTED. GM, GM Macrolides [Macrólidos] azithromycin oral packet gm azithromycin oral suspension reconstituted 00 /5ml, 200 /5ml azithromycin oral tablet 250, 500, 600 clarithromycin oral suspension reconstituted 25 /5ml, 250 /5ml clarithromycin oral tablet 250, 500 E.S.P. oral suspension reconstituted /5ml ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, MG, 500 MG ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 000 MG, 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG erythromycin base oral capsule delayed release particles 250 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

12 erythromycin base oral tablet 250, 500 erythromycin ethylsuccinate oral suspension reconstituted 200 /5ml erythromycin ethylsuccinate oral tablet 400 erythromycin ophthalmic ointment 5 /gm Quinolones [Quinolonas] CIPRO HC OTIC SUSPENSION 0.2- % CIPRODEX OTIC SUSPENSION % 2 ciprofloxacin hcl ophthalmic solution 0. % ciprofloxacin hcl oral tablet 00, 250, 500, 750 ciprofloxacin intravenous solution 200 /20ml ciprofloxacin intravenous solution 400 /40ml ciprofloxacin oral suspension reconstituted 250 /5ml (5%), 500 /5ml (0%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 000 ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 500 levofloxacin oral tablet 250, 500, 750 MOXEZA OPHTHALMIC SOLUTION 0.5 % 2 moxifloxacin hcl ophthalmic solution 0.5 % moxifloxacin hcl oral tablet 400 ofloxacin ophthalmic solution 0. % ofloxacin otic solution 0. % VIGAMOX OPHTHALMIC SOLUTION 0.5 % 2 Sulfonamides [Sulfonamidas] BLEPHAMIDE OPHTHALMIC SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % sulfacetamide-prednisolone ophthalmic solution % sulfadiazine oral tablet 500 QL (4 TABS per 0 days) QL ( TABS per 0 days) ELA Rubi 208 / ELA Rubi 208 Rev. Noviembre 207 / November 207

13 sulfamethoxazole-trimethoprim intravenous solution /5ml sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet , Tetracyclines [Tetraciclinas] demeclocycline hcl oral tablet 50, 00 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00 doxycycline hyclate oral tablet 20 doxycycline monohydrate oral suspension reconstituted 25 /5ml minocycline hcl oral capsule 00, 50, 75 tetracycline hcl oral capsule 250, 500 VIBRAMYCIN ORAL SYRUP 50 MG/5ML Anticonvulsants [Anticonvulsivantes] Anticonvulsants, Other [Anticonvulsivantes, Otros] levetiracetam intravenous solution 500 /5ml levetiracetam oral solution 00 /ml levetiracetam oral tablet 000, 250, 500, 750 POTIGA ORAL TABLET 200 MG, 00 MG, 400 MG, 50 MG Calcium Channel Modifying Agents [Modificadores De Canales De Calcio] CELONTIN ORAL CAPSULE 00 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml LYRICA ORAL CAPSULE 00 MG, 50 MG, 225 MG, 25 MG, 00 MG, 50 MG, 75 MG,200 MG ST LYRICA ORAL SOLUTION 20 MG/ML ST ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

14 zonisamide oral capsule 00, 25, 50 Gamma-Aminobutyric Acid (GABA) Augmenting Agents [Aumentadores Del Ácido Gamma- Aminobutírico] clonazepam oral tablet 0.5,, 2 AL (Greater than 8 years) divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral capsule delayed release sprinkle 25 divalproex sodium oral tablet delayed release 25, 250, 500 gabapentin oral capsule 00, 00, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET 2 MG, 6 MG ONFI ORAL TABLET 0 MG, 20 MG PA phenobarbital oral elixir 20 /5ml phenobarbital oral tablet 00, 5, 6.2, 0, 2.4, 60, 64.8, 97.2 primidone oral tablet 250, 50 tiagabine hcl oral tablet 2, 4 valproate sodium intravenous solution 500 /5ml valproic acid oral capsule 250 valproic acid oral solution 250 /5ml valproic acid oral syrup 250 /5ml Glutamate Reducing Agents [Reductores De Glutamato] felbamate oral suspension 600 /5ml felbamate oral tablet 400, 600 lamotrigine oral tablet 00, 50, 200, 25 lamotrigine oral tablet chewable 25, 5 topiramate oral capsule sprinkle 5, 25 topiramate oral tablet 00, 200, 25, 50 ELA Rubi 208 / ELA Rubi 208 Rev. Noviembre 207 / November 207

15 Sodium Channel Agents [Canales De Sodio] BANZEL ORAL SUSPENSION 40 MG/ML PA; SL BANZEL ORAL TABLET 200 MG, 400 MG PA; SL carbamazepine er oral tablet extended release 2 hour 00, 200, 400 carbamazepine oral suspension 00 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 00 DILANTIN ORAL CAPSULE 0 MG oxcarbazepine oral suspension 00 /5ml oxcarbazepine oral tablet 50, 00, 600 PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 25 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 00, 200, 00 phenytoin sodium injection solution 50 /ml VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG Antidementia Agents [Antidemencia] Antidementia Agents, Other [Antidemencia, Otros] ergoloid mesylates oral tablet Cholinesterase Inhibitors [Inhibidores De Colinesterasa] donepezil hcl oral tablet 0, 5 donepezil hcl oral tablet dispersible 0, 5 galantamine hydrobromide er oral capsule extended release 24 hour 6, 24, 8 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

16 galantamine hydrobromide oral solution 4 /ml galantamine hydrobromide oral tablet 2, 4, 8 memantine hcl oral tablet 0, 5 (28)-0 (2), 5 NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 4 & 2 &28-0 MG NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4-0 MG, 2-0 MG, 28-0 MG, 7-0 MG rivastigmine tartrate oral capsule.5,, 4.5, 6 rivastigmine transdermal patch 24 hour. /24hr, 4.6 /24hr, 9.5 /24hr ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November PA; QL ( EA per day) N-Methyl-D-Aspartate (NMDA) Receptor Antagonist [Antagonista Del Receptor NMDA] memantine hcl oral solution 2 /ml NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 MG, 2 MG, 28 MG, 7 MG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 4 & 2 &28 MG Antidepressants [Antidepresivos] Antidepressants, Other [Antidepresivos, Otros] bupropion hcl er (sr) oral tablet extended release 2 hour 00, 50, ST 2 ST SL bupropion hcl oral tablet 00, 75 SL mirtazapine oral tablet 5, 0, 45, 7.5 mirtazapine oral tablet dispersible 5, 0, 45 SL SL Monoamine Oxidase Inhibitors [Inhibidores De Monoamino Oxidasa] EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 6 MG/24HR, 9 MG/24HR PA; SL MARPLAN ORAL TABLET 0 MG SL phenelzine sulfate oral tablet 5 SL

17 tranylcypromine sulfate oral tablet 0 SL SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors / Serotonin And Norepinephrine Reuptake Inhibitors) [SSRIs/SNRIs (Inhibidores De La Recaptación Selectiva De Serotonina / Inhibidores De La Recaptación De Serotonina Y Norepinefrina)] citalopram hydrobromide oral solution 0 /5ml citalopram hydrobromide oral tablet 0, 20, 40 duloxetine hcl oral capsule delayed release particles 20, 0, 60 SL SL escitalopram oxalate oral solution 5 /5ml SL escitalopram oxalate oral tablet 0, 20, 5 QL (2 CAPS per day) SL fluoxetine hcl oral capsule 0, 20, 40 SL fluoxetine hcl oral solution 20 /5ml SL fluvoxamine maleate oral tablet 00, 25, 50 SL maprotiline hcl oral tablet 25, 50, 75 SL paroxetine hcl er oral tablet extended release 24 hour 2.5, 25, 7.5 paroxetine hcl oral tablet 0, 20, 0, 40 SL SL PAXIL ORAL SUSPENSION 0 MG/5ML SL sertraline hcl oral concentrate 20 /ml SL sertraline hcl oral tablet 00, 25, 50 SL trazodone hcl oral tablet 00, 50, 00, 50 venlafaxine hcl er oral capsule extended release 24 hour 50, 7.5, 75 venlafaxine hcl oral tablet 00, 25, 7.5, 50, 75 Tricyclics [Tricíclicos] amitriptyline hcl oral tablet 0, 00, 50, 25, 50, 75 SL SL SL SL ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

18 amoxapine oral tablet 00, 50, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 0, 00, 50, 25, 50, 75 doxepin hcl oral capsule 0, 00, 50, 25, 50, 75 SL SL SL SL doxepin hcl oral concentrate 0 /ml SL imipramine hcl oral tablet 0, 25, 50 SL nortriptyline hcl oral capsule 0, 25, 50, 75 trimipramine maleate oral capsule 00, 25, 50 Antiemetics [Antieméticos] Antiemetics, Other [Antieméticos, Otros] diphenhydramine hcl injection solution 50 /ml meclizine hcl oral tablet 2.5, 25 metoclopramide hcl oral solution 5 /5ml metoclopramide hcl oral tablet 0, 5 pharbedryl oral capsule 50 promethazine hcl injection solution 25 /ml, 50 /ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 2.5, 25, 50 promethazine hcl rectal suppository 2.5, 25, 50 trimethobenzamide hcl oral capsule 00 SL SL Emetogenic Therapy Adjuncts [Adjuvantes Para Terapia Emetogénica] aprepitant oral capsule 25, 80 & 25, 80 dronabinol oral capsule 0, 2.5, 5 EMEND ORAL CAPSULE 25 MG, 80 & 25 MG, 80 MG ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207 PA; SL PA; SL

19 EMEND TRI-PACK ORAL CAPSULE 80 & 25 MG ondansetron hcl injection solution 4 /2ml, 40 /20ml ondansetron hcl oral tablet 4, 8 ondansetron oral tablet dispersible 4, 8 Antifungals [Antifungales] Antifungals [Antifungales] caspofungin acetate intravenous solution reconstituted 50, 70 ciclopirox external solution 8 % clotrimazole external cream % clotrimazole external solution % clotrimazole mouth/throat troche 0 clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % econazole nitrate external cream % ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG fluconazole oral suspension reconstituted 0 /ml, 40 /ml fluconazole oral tablet 00, 50, 200, 50 flucytosine oral capsule 250, 500 griseofulvin ultramicrosize oral tablet 25, 250 itraconazole oral capsule 00 ketoconazole external cream 2 % ketoconazole external shampoo 2 % ketoconazole oral tablet 200 MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG PA; SL ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

20 NATACYN OPHTHALMIC SUSPENSION 5 % nystatin external cream unit/gm nystatin external ointment unit/gm nystatin mouth/throat suspension unit/ml nystatin oral tablet unit nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% terbinafine hcl oral tablet 250 QL (84 TABS per 65 days) terconazole vaginal cream 0.4 % QL (45 GM per 5 days) terconazole vaginal cream 0.8 % QL (20 GM per 5 days) terconazole vaginal suppository 80 QL ( SUPP per 5 days) voriconazole oral tablet 200, 50 PA; SL Antigout Agents [Antigota] Antigout Agents [Antigota] allopurinol oral tablet 00, 00 colchicine oral tablet 0.6 colchicine-probenecid oral tablet probenecid oral tablet 500 Anti-Inflammatory Agents [Anti-Inflamatorios] Glucocorticoids [Glucocorticoides] A-HYDROCORT INJECTION SOLUTION RECONSTITUTED 00 MG budesonide oral capsule delayed release particles cortisone acetate oral tablet 25 DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML DEXAMETHASONE INTENSOL ORAL CONCENTRATE MG/ML dexamethasone oral elixir 0.5 /5ml dexamethasone oral solution 0.5 /5ml ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207 PA

21 dexamethasone oral tablet 0.5, 0.75,,.5, 2, 4, 6 dexamethasone sodium phosphate injection solution 0 /ml, 00 /0ml, 20 /0ml, 20 /5ml, 4 /ml hydrocortisone oral tablet 0, 20, 5 MEDROL ORAL TABLET 2 MG methylprednisolone acetate injection suspension 40 /ml, 80 /ml methylprednisolone oral tablet 6, 2, 4, 8 methylprednisolone sodium succ injection solution reconstituted 000, 25, 40 MILLIPRED ORAL TABLET 5 MG prednisone oral tablet, 0, 2.5, 20, 5, 50 SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 00 MG, 000 MG, 250 MG, 500 MG SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 2 GM, 500 MG Antimigraine Agents [Antimigraña] Ergot Alkaloids [Alcaloides De Ergotamina] dihydroergotamine mesylate nasal solution 4 /ml ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG Serotonin (5-HT) B/D Receptor Agonists [Agonistas Del Receptor De Serotonina] eletriptan hydrobromide oral tablet 20, 40 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207 ST; QL (6 TABS per 0 days) sumatriptan succinate oral tablet 00 QL (9 TABS per 0 days) sumatriptan succinate oral tablet 25, 50 QL (8 TABS per 0 days) sumatriptan succinate subcutaneous solution 6 /0.5ml Antimyasthenic Agents [Antimiasténicos] QL (5 ML per 0 days)

22 Parasympathomimetics [Parasimpatomiméticos] MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide er oral tablet extended release 80 pyridostigmine bromide oral tablet 60 Antimycobacterials [Antimicobacterianos] Antimycobacterials, Other [Antimicobacterianos, Otros] dapsone oral tablet 00, 25 rifabutin oral capsule 50 Antituberculars [Antituberculosos] CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED GM cycloserine oral capsule 250 ethambutol hcl oral tablet 00, 400 isoniazid oral syrup 50 /5ml isoniazid oral tablet 00, 00 PASER ORAL PACKET 4 GM PRIFTIN ORAL TABLET 50 MG rifampin intravenous solution reconstituted 600 rifampin oral capsule 50, 00 RIFATER ORAL TABLET MG TRECATOR ORAL TABLET 250 MG Antineoplastics [Antineoplásicos] Alkylating Agents [Alquilantes] GLEOSTINE ORAL CAPSULE 5 MG HEXALEN ORAL CAPSULE 50 MG LEUKERAN ORAL TABLET 2 MG lomustine oral capsule 0, 00, 40 MATULANE ORAL CAPSULE 50 MG Antiandrogens [Antiandrógenos] bicalutamide oral tablet 50 Co-aseguro Co-aseguro Co-aseguro Co-aseguro Co-aseguro Co-aseguro ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

23 flutamide oral capsule 25 nilutamide oral tablet 50 Co-aseguro Co-aseguro XTANDI ORAL CAPSULE 40 MG Co-aseguro PA; SL ZYTIGA ORAL TABLET 250 MG, 500 MG Co-aseguro PA; SL Antiangiogenic Agents [Antiangiogénicos] POMALYST ORAL CAPSULE MG, 2 MG, MG, 4 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG Co-aseguro Co-aseguro Co-aseguro Antiestrogens/Modifiers [Antiestrógenos/Modificadores] EMCYT ORAL CAPSULE 40 MG FARESTON ORAL TABLET 60 MG Co-aseguro Co-aseguro tamoxifen citrate oral tablet 0, 20 Co-aseguro PA Antimetabolites [Antimetabólitos] hydroxyurea oral capsule 500 mercaptopurine oral tablet 50 TABLOID ORAL TABLET 40 MG Antineoplastics, Others [Antineoplásicos, Otros] leucovorin calcium oral tablet 0, 5, 25, 5 LONSURF ORAL TABLET MG, MG MESNEX ORAL TABLET 400 MG Co-aseguro Co-aseguro Co-aseguro Co-aseguro Co-aseguro Co-aseguro PA; SL PA; SL PA; SL ZOLINZA ORAL CAPSULE 00 MG Co-aseguro PA; SL Aromatase Inhibitors, Rd Generation [Inhibidores De Aromatasa, Ra Generación] anastrozole oral tablet exemestane oral tablet 25 letrozole oral tablet 2.5 Co-aseguro Co-aseguro Co-aseguro Molecular Target Inhibitors [Inhibidores Del Blanco Molecular] PA ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

24 AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, MG, 5 MG AFINITOR ORAL TABLET 0 MG, 2.5 MG, 5 MG, 7.5 MG Co-aseguro Co-aseguro PA; SL PA; SL BOSULIF ORAL TABLET 00 MG, 500 MG Co-aseguro PA; SL CAPRELSA ORAL TABLET 00 MG, 00 MG Co-aseguro PA; SL COMETRIQ (00 MG DAILY DOSE) ORAL KIT X 80 & X 20 MG COMETRIQ (40 MG DAILY DOSE) ORAL KIT X 80 & X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG Co-aseguro Co-aseguro Co-aseguro PA; SL PA; SL PA; SL ERIVEDGE ORAL CAPSULE 50 MG Co-aseguro PA; SL ICLUSIG ORAL TABLET 5 MG, 45 MG Co-aseguro PA; SL imatinib mesylate oral tablet 00, 400 Co-aseguro PA; SL INLYTA ORAL TABLET MG, 5 MG Co-aseguro PA; SL JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG Co-aseguro PA; SL NEXAVAR ORAL TABLET 200 MG Co-aseguro PA; SL SPRYCEL ORAL TABLET 00 MG, 40 MG, 20 MG, 50 MG, 70 MG, 80 MG Co-aseguro PA; SL STIVARGA ORAL TABLET 40 MG Co-aseguro PA; SL SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 7.5 MG, 50 MG TARCEVA ORAL TABLET 00 MG, 50 MG, 25 MG Co-aseguro Co-aseguro PA; SL PA; SL TASIGNA ORAL CAPSULE 50 MG, 200 MG Co-aseguro PA; SL TYKERB ORAL TABLET 250 MG Co-aseguro PA; SL VOTRIENT ORAL TABLET 200 MG Co-aseguro PA; SL XALKORI ORAL CAPSULE 200 MG, 250 MG Co-aseguro PA; SL ZELBORAF ORAL TABLET 240 MG Co-aseguro PA; SL Monoclonal Antibodies [Anticuerpos Monoclonales] RITUXAN INTRAVENOUS SOLUTION 00 MG/0ML, 500 MG/50ML Retinoids [Retinoides] ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

25 bexarotene oral capsule 75 Co-aseguro PANRETIN EXTERNAL GEL 0. % 5 QL (60 GM per 5 days) TARGRETIN EXTERNAL GEL % 5 QL (60 GM per 5 days) tretinoin oral capsule 0 Antiparasitics [Antiparasitarios] Anthelmintics [Antihelmínticos] Co-aseguro ALBENZA ORAL TABLET 200 MG BILTRICIDE ORAL TABLET 600 MG ivermectin oral tablet Antiprotozoals [Antiprotozoarios] ALINIA ORAL SUSPENSION RECONSTITUTED 00 MG/5ML QL (60 ML per days) ALINIA ORAL TABLET 500 MG QL (6 TABS per days) atovaquone oral suspension 750 /5ml atovaquone-proguanil hcl oral tablet atovaquone-proguanil hcl oral tablet chloroquine phosphate oral tablet 250, 500 QL (2 TABS per 65 days) QL (48 TABS per 65 days) COARTEM ORAL TABLET MG QL (24 TABS per 65 days) DARAPRIM ORAL TABLET 25 MG 5 PA hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 NEBUPENT INHALATION SOLUTION RECONSTITUTED 00 MG PENTAM INJECTION SOLUTION RECONSTITUTED 00 MG primaquine phosphate oral tablet 26. quinine sulfate oral capsule 24 QL (42 CAPS per 65 days) Pediculicides/Scabicides [Pediculicidas/Escabicidas] EURAX EXTERNAL CREAM 0 % ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

26 EURAX EXTERNAL LOTION 0 % lindane external lotion % ST; QL (60 ML per 0 days) lindane external shampoo % QL (60 ML per 0 days) permethrin external cream 5 % Antiparkinson Agents [Antiparkinson] Anticholinergics [Anticolinérgicos] benztropine mesylate oral tablet 0.5,, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 Antiparkinson Agents, Others [Antiparkinson, Otros] amantadine hcl oral capsule 00 carbidopa-levodopa-entacapone oral tablet , , , , , entacapone oral tablet 200 tolcapone oral tablet 00 Dopamine Agonist [Agonistas De Dopamina] APOKYN SUBCUTANEOUS SOLUTION 0 MG/ML APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 0 MG/ML bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24HR, 2 MG/24HR, MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR pramipexole dihydrochloride oral tablet 0.25, 0.25, 0.5, 0.75,,.5 ropinirole hcl oral tablet 0.25, 0.5,, 2,, 4, 5 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November ST Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors [Precursores De Dopamina/Inhibidores Del L-Amino Acid Decarboxylase] carbidopa oral tablet 25

27 carbidopa-levodopa er oral tablet extended release 25-00, carbidopa-levodopa oral tablet 0-00, 25-00, Monoamine Oxidase B (MAO-B) Inhibitors [Inhibidores De MAO-B] rasagiline mesylate oral tablet 0.5, ST selegiline hcl oral capsule 5 Antipsychotics [Antipsicóticos] St Generation/Typical [Ra Generación/Típicos] chlorpromazine hcl injection solution 25 /ml, 50 /2ml chlorpromazine hcl oral tablet 0, 00, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml PA; SL SL PA; SL fluphenazine hcl injection solution 2.5 /ml PA; SL fluphenazine hcl oral concentrate 5 /ml SL fluphenazine hcl oral elixir 2.5 /5ml SL fluphenazine hcl oral tablet, 0, 2.5, 5 haloperidol decanoate intramuscular solution 00 /ml, 50 /ml SL PA; SL haloperidol lactate injection solution 5 /ml PA; SL haloperidol lactate oral concentrate 2 /ml SL haloperidol oral tablet 0.5,, 0, 2, 20, 5 loxapine succinate oral capsule 0, 25, 5, 50 perphenazine oral tablet 6, 2, 4, 8 pimozide oral tablet, 2 prochlorperazine edisylate injection solution 5 /ml SL SL SL PA; SL ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

28 prochlorperazine maleate oral tablet 0, 5 SL prochlorperazine rectal suppository 25 SL thioridazine hcl oral tablet 0, 00, 25, 50 thiothixene oral capsule, 0, 2, 5 trifluoperazine hcl oral tablet, 0, 2, 5 2Nd Generation/Atypical [2Da Generación/Atípicos] ABILIFY INTRAMUSCULAR SOLUTION 9.75 MG/.ML aripiprazole oral tablet 0, 5, 2, 20, 0, 5 olanzapine oral tablet 0, 5, 2.5, 20, 5, 7.5 PA; SL SL SL PA; SL ST; SL; QL ( TABS per day) SL; QL ( TABS per day) quetiapine fumarate oral tablet 00, 200 SL; QL ( TABS per day) quetiapine fumarate oral tablet 25, 50 PA; SL; QL ( TABS per day) quetiapine fumarate oral tablet 00, 400 SL; QL (2 TABS per day) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 2.5 MG, 25 MG, 7.5 MG, 50 MG 4 PA; SL risperidone oral solution /ml SL risperidone oral tablet 0.25, 0.5,, 2,, 4 risperidone oral tablet dispersible 0.25, 0.5,, 2,, 4 ziprasidone hcl oral capsule 20, 40, 60, 80 Treatment-Resistant [Resistentes A Tratamiento] clozapine oral tablet 00, 200, 25, 50 Antispasticity Agents [Antiespasticidad] Antispasticity [Antiespasticidad] baclofen oral tablet 0, 20 SL; QL (2 TABS per day) SL; QL (2 TABS per day) SL; QL (2 CAPS per day) SL ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

29 dantrolene sodium oral capsule 00, 25, 50 tizanidine hcl oral tablet 2, 4 Antivirals [Antivirales] Anti-Cytomegalovirus (CMV) Agents [Anti-Citomegalovirus] FOSCAVIR INTRAVENOUS SOLUTION 6000 MG/250ML ganciclovir sodium intravenous solution reconstituted 500 valganciclovir hcl oral tablet Anti-Hepatitis B (HBV) Agents [Anti-Hepatitis B] adefovir dipivoxil oral tablet 0 BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, EPIVIR HBV ORAL SOLUTION 5 MG/ML lamivudine oral tablet 00 PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 5 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/0.5ML, 80 MCG/ML 5 5 TYZEKA ORAL TABLET 600 MG Anti-Hepatitis C (HCV) Agents [Anti- Hepatitis C] EPCLUSA ORAL TABLET MG 4 PA HARVONI ORAL TABLET MG 4 PA; SL; AL (Greater than or equal to 8 years) PEG-INTRON REDIPEN SUBCUTANEOUS KIT 20 MCG/0.5ML, 50 MCG/0.5ML PEG-INTRON SUBCUTANEOUS KIT 50 MCG/0.5ML, 80 MCG/0.5ML ribavirin oral capsule ribavirin oral tablet SOVALDI ORAL TABLET 400 MG 4 PA; SL; AL (Greater than or equal to 8 years) ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

30 ZEPATIER ORAL TABLET MG 4 PA Antiherpetic Agents [Antiherpéticos] acyclovir oral capsule 200 acyclovir oral suspension 200 /5ml acyclovir oral tablet 400, 800 acyclovir sodium intravenous solution reconstituted 000, 500 famciclovir oral tablet 25, 500 QL (2 TABS per 7 days) famciclovir oral tablet 250 QL (2 TABS per day) trifluridine ophthalmic solution % valacyclovir hcl oral tablet gm, 500 Anti-HIV Agents, Integrase Inhibitors (Insti) [Anti-VIH, Inhibidor De Integrasa] ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 00 MG, 25 MG STRIBILD ORAL TABLET MG Anti-HIV Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) [Anti-VIH, Inhibidores No Nucleósidos De La Transciptasa Reversa] abacavir-lamivudine-zidovudine oral tablet ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EDURANT ORAL TABLET 25 MG INTELENCE ORAL TABLET 00 MG, 200 MG, 25 MG nevirapine er oral tablet extended release 24 hour 00, 400 nevirapine oral suspension 50 /5ml nevirapine oral tablet 200 RESCRIPTOR ORAL TABLET 00 MG, 200 MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

31 SUSTIVA ORAL TABLET 600 MG TRIUMEQ ORAL TABLET MG Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) [Anti- VIH, Inhibidores Nucleósidos Y Nucleótidos De La Transcriptasa Reversa] abacavir sulfate oral solution 20 /ml abacavir sulfate oral tablet 00 abacavir sulfate-lamivudine oral tablet didanosine oral capsule delayed release 25, 200, 250, 400 EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML EVOTAZ ORAL TABLET MG lamivudine oral solution 0 /ml lamivudine oral tablet 50, 00 lamivudine-zidovudine oral tablet PREZCOBIX ORAL TABLET MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML stavudine oral capsule 5, 20, 0, 40 stavudine oral solution reconstituted /ml TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG, 00 MG zidovudine oral capsule 00 zidovudine oral syrup 50 /5ml zidovudine oral tablet 00 Anti-HIV Agents, Others [Anti-VIH, Otros] ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

32 FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG SELZENTRY ORAL SOLUTION 20 MG/ML PA; SL SELZENTRY ORAL TABLET 50 MG, 25 MG, 00 MG, 75 MG TYBOST ORAL TABLET 50 MG PA; SL Anti-HIV Agents, Protease Inhibitors [Anti-VIH, Inhibidores De La Proteasa] APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 00 MG/ML CRIXIVAN ORAL CAPSULE 200 MG, 400 MG fosamprenavir calcium oral tablet 700 INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG KALETRA ORAL TABLET MG, MG LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution /5ml NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG REYATAZ ORAL CAPSULE 50 MG, 200 MG, 00 MG VIRACEPT ORAL TABLET 250 MG, 625 MG Anti-Influenza Agents [Antiinfluenza] oseltamivir phosphate oral capsule 0, 45, 75 oseltamivir phosphate oral suspension reconstituted 6 /ml RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 00 ELA Rubi 208 / ELA Rubi 208 Rev. Noviembre 207 / November 207

33 Anxiolytics [Ansiolíticos] Anxiolytics, Other [Ansiolíticos, Otros] buspirone hcl oral tablet 0, 5, 0, 5, 7.5 hydroxyzine pamoate oral capsule 00, 25, 50 Benzodiazepines [Benzodiazepinas] SL SL alprazolam oral tablet 0.25, 0.5, SL; AL (Greater than 8 years) clorazepate dipotassium oral tablet 5,.75, 7.5 SL; AL (Greater than 8 years) diazepam oral tablet 0, 2, 5 SL; AL (Greater than 8 years) lorazepam oral tablet 0.5,, 2 SL; AL (Greater than 8 years) oxazepam oral capsule 0, 5, 0 SL; AL (Greater than 8 years) Bipolar Agents [Bipolaridad] Mood Stabilizers [Estabilizadores Del Ánimo] lithium carbonate er oral tablet extended release 00, 450 lithium carbonate oral capsule 50, 00, 600 SL SL lithium oral solution 8 meq/5ml SL Blood Glucose Regulators [Reguladores De Glucosa En Sangre] Antidiabetic Agents [Antidiabéticos] acarbose oral tablet 00, 25, 50 BYDUREON BCISE SUBCUTANEOUS AUTO- INJECTOR 2 MG/0.85ML BYDUREON SUBCUTANEOUS PEN- INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG BYETTA 0 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 0 MCG/0.04ML BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML 2 ST; QL (.4 EA per 28 days) 2 ST; QL (4 EA per 28 days) 2 ST; QL (4 EA per 28 days) 2 ST; QL (2.4 ML per 0 days) 2 ST; QL (.2 ML per 0 days) ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

34 glimepiride oral tablet, 2, 4 glipizide er oral tablet extended release 24 hour 0, 2.5, 5 glipizide oral tablet 0, 5 glipizide-metformin hcl oral tablet , , glyburide micronized oral tablet.5,, 6 glyburide oral tablet.25, 2.5, 5 glyburide-metformin oral tablet , , GLYXAMBI ORAL TABLET 0-5 MG, 25-5 MG JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG ST JARDIANCE ORAL TABLET 0 MG, 25 MG 2 ST JENTADUETO ORAL TABLET MG, MG, MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 000, 500, 850 miglitol oral tablet 00, 25, 50 ST nateglinide oral tablet 20, 60 pioglitazone hcl oral tablet 5, 0, 45 repaglinide oral tablet 0.5,, 2 ST SYMLINPEN 20 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML PA; SL; QL (.5 ML per 0 days) ELA Rubi 208 / ELA Rubi 208 Rev. Noviembre 207 / November 207

35 SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 MCG/.5ML SYNJARDY ORAL TABLET MG, MG, MG, MG SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG, MG TRADJENTA ORAL TABLET 5 MG VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR 8 MG/ML Glycemic Agents [Glicémicos] GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED MG PROGLYCEM ORAL SUSPENSION 50 MG/ML Insulins [Insulinas] PA; SL; QL (.5 ML per 0 days) 2 ST 2 ST 2 ST; QL (9 ML per 0 days) APIDRA INJECTION SOLUTION 00 UNIT/ML QL (20 ML per 90 days) HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 00 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 00 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 00 UNIT/ML HUMULIN 70/0 SUBCUTANEOUS SUSPENSION (70-0) 00 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML HUMULIN R INJECTION SOLUTION 00 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML Blood Products/Modifiers/Volume Expanders [Productos Para La Sangre/Modificadores/Expansores De Volumen] Anticoagulants [Anticoagulantes] 2 QL (20 ML per 90 days) 2 QL (20 ML per 90 days) 2 QL (20 ML per 90 days) 2 QL (20 ML per 90 days) 2 QL (20 ML per 90 days) 2 QL (20 ML per 90 days) 2 QL (20 ML per 90 days) 2 QL (20 ML per 90 days) ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

36 enoxaparin sodium injection solution 00 /ml enoxaparin sodium subcutaneous solution 00 /ml, 20 /0.8ml, 50 /ml, 0 /0.ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml fondaparinux sodium subcutaneous solution 0 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml heparin sodium (porcine) injection solution 000 unit/ml, 0000 unit/ml, unit/ml, 5000 unit/ml PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG warfarin sodium oral tablet, 0, 2, 2.5,, 4, 5, 6, 7.5 XARELTO ORAL TABLET 0 MG 2 PA XARELTO ORAL TABLET 5 MG, 20 MG 2 PA XARELTO STARTER PACK ORAL TABLET THERAPY PACK 5 & 20 MG Antihemophilics [Antihemofílicos] ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 500 UNIT, 2000 UNIT, 250 UNIT, 000 UNIT, 4000 UNIT, 500 UNIT ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT, 750 UNIT ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT AFSTYLA INTRAVENOUS KIT 000 UNIT, 500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 000 UNIT, 500 UNIT ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT 2 PA 4 PA; SL 4 PA; SL ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

37 ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 2000 UNIT, 250 UNIT, 000 UNIT, 4000 UNIT, 500 UNIT BEBULIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT BENEFIX INTRAVENOUS KIT 000 UNIT, 2000 UNIT, 250 UNIT, 000 UNIT, 500 UNIT COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 500 UNIT, 2000 UNIT, 250 UNIT, 000 UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT FEIBA INTRAVENOUS SOLUTION RECONSTITUTED FEIBA NF INTRAVENOUS SOLUTION RECONSTITUTED HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, UNIT, 700 UNIT, UNIT, 250 UNIT, UNIT, 500 UNIT, UNIT HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED UNIT, UNIT, UNIT IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 500 UNIT IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 250 UNIT, 500 UNIT KOGENATE FS INTRAVENOUS KIT 000 UNIT, 2000 UNIT, 250 UNIT, 000 UNIT, 500 UNIT 4 PA; SL 4 PA; SL ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

38 KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 2000 UNIT, 250 UNIT, 000 UNIT, 500 UNIT MONOCLATE-P INTRAVENOUS KIT 000 UNIT, 500 UNIT, 250 UNIT, 500 UNIT MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 250 UNIT, 500 UNIT NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 500 UNIT, 2000 UNIT, 250 UNIT, 000 UNIT, 500 UNIT NOVOSEVEN INTRAVENOUS SOLUTION RECONSTITUTED 2400 MCG NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED MG, 2 MG, 5 MG, 8 MG NUWIQ INTRAVENOUS KIT 000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 000 UNIT, 4000 UNIT, 500 UNIT NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 000 UNIT, 4000 UNIT, 500 UNIT OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 500 UNIT, 500 UNIT RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED UNIT, UNIT, UNIT, UNIT, UNIT RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 000 UNIT, 2000 UNIT, 250 UNIT, 000 UNIT, 500 UNIT VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 00 UNIT, 650 UNIT WILATE INTRAVENOUS KIT UNIT, UNIT 4 PA; SL 4 PA; SL ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

39 WILATE INTRAVENOUS SOLUTION RECONSTITUTED UNIT, UNIT XYNTHA INTRAVENOUS KIT 000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT XYNTHA SOLOFUSE INTRAVENOUS KIT 000 UNIT Blood Formation Modifiers [Modificadores De La Formación De Sangre] EPOGEN INJECTION SOLUTION 0000 UNIT/ML, 2000 UNIT/ML, UNIT/ML, 000 UNIT/ML, 4000 UNIT/ML LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG NEUMEGA SUBCUTANEOUS SOLUTION RECONSTITUTED 5 MG NEUPOGEN INJECTION SOLUTION 00 MCG/ML, 480 MCG/.6ML NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 00 MCG/0.5ML, 480 MCG/0.8ML PROCRIT INJECTION SOLUTION 0000 UNIT/ML, 2000 UNIT/ML, UNIT/ML, 000 UNIT/ML, 4000 UNIT/ML, UNIT/ML PROMACTA ORAL TABLET 2.5 MG, 25 MG, 50 MG, 75 MG Coagulants [Coagulantes] tranexamic acid intravenous solution 000 /0ml Platelet Modifying Agents [Modificadores De Plaquetas] anagrelide hcl oral capsule 0.5, aspirin-dipyridamole er oral capsule extended release 2 hour PA 4 PA BRILINTA ORAL TABLET 60 MG, 90 MG PA; SL cilostazol oral tablet 00, 50 clopidogrel bisulfate oral tablet 75 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207 5

40 prasugrel hcl oral tablet 0, 5 PA; SL ticlopidine hcl oral tablet 250 Cardiovascular Agents [Cardiovasculares] Alpha-Adrenergic Agonists [Agonistas Alfa Adrenérgicos] clonidine hcl oral tablet 0., 0.2, 0. clonidine hcl transdermal patch weekly 0. /24hr, 0.2 /24hr, 0. /24hr guanfacine hcl oral tablet, 2 methyldopa oral tablet 250, 500 midodrine hcl oral tablet 0, 2.5, 5 Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos] doxazosin mesylate oral tablet, 2, 4, 8 prazosin hcl oral capsule, 2, 5 terazosin hcl oral capsule, 0, 2, 5 Angiotensin II Receptor Antagonists [Antagonistas Del Receptor Angiotensina II] irbesartan oral tablet 50, 00, 75 irbesartan-hydrochlorothiazide oral tablet , losartan potassium oral tablet 00, 25, 50 losartan potassium-hctz oral tablet , 00-25, valsartan oral tablet 60, 20, 40, 80 valsartan-hydrochlorothiazide oral tablet , 60-25, , 20-25, Angiotensin-Converting Enzyme (ACE) Inhibitors [Inhibidores De La Enzima Convertidora De Angiotensina] amlodipine besy-benazepril hcl oral capsule 0-20, 0-40, 2.5-0, 5-0, 5-20, 5-40 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

41 benazepril hcl oral tablet 0, 20, 40, 5 benazepril-hydrochlorothiazide oral tablet 0-2.5, , 20-25, captopril oral tablet 00, 2.5, 25, 50 captopril-hydrochlorothiazide oral tablet 25-5, 25-25, 50-5, enalapril maleate oral tablet 0, 2.5, 20, 5 enalapril-hydrochlorothiazide oral tablet 0-25, fosinopril sodium oral tablet 0, 20, 40 fosinopril sodium-hctz oral tablet 0-2.5, lisinopril oral tablet 0, 2.5, 20, 0, 40, 5 lisinopril-hydrochlorothiazide oral tablet 0-2.5, , moexipril hcl oral tablet 5, 7.5 moexipril-hydrochlorothiazide oral tablet 5-2.5, 5-25, perindopril erbumine oral tablet 2, 4, 8 quinapril hcl oral tablet 0, 20, 40, 5 quinapril-hydrochlorothiazide oral tablet 0-2.5, , ramipril oral capsule.25, 0, 2.5, 5 trandolapril oral tablet, 2, 4 Antiarrhythmics [Antiarrítmicos] amiodarone hcl oral tablet 00, 200, 400 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

42 disopyramide phosphate oral capsule 00, 50 dofetilide oral capsule 25 mcg, 250 mcg, 500 mcg flecainide acetate oral tablet 00, 50, 50 mexiletine hcl oral capsule 50, 200, 250 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 2 HOUR 00 MG, 50 MG propafenone hcl oral tablet 50, 225, 00 quinidine gluconate er oral tablet extended release 24 quinidine sulfate er oral tablet extended release 00 quinidine sulfate oral tablet 200, 00 Beta-Adrenergic Blocking Agents [Bloqueadores Beta Adrenérgicos] acebutolol hcl oral capsule 200, 400 atenolol oral tablet 00, 25, 50 atenolol-chlorthalidone oral tablet 00-25, betaxolol hcl oral tablet 0, 20 bisoprolol fumarate oral tablet 0, 5 bisoprolol-hydrochlorothiazide oral tablet , , carvedilol oral tablet 2.5, 25,.25, 6.25 labetalol hcl oral tablet 00, 200, 00 metoprolol succinate er oral tablet extended release 24 hour 00, 200, 25, 50 metoprolol tartrate oral tablet 00, 25, 50 metoprolol-hydrochlorothiazide oral tablet 00-25, 00-50, nadolol oral tablet 20, 40, 80 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

43 nadolol-bendroflumethiazide oral tablet 40-5, 80-5 pindolol oral tablet 0, 5 propranolol hcl er oral capsule extended release 24 hour 20, 60, 60, 80 propranolol hcl oral tablet 0, 20, 40, 60, 80 propranolol-hctz oral tablet 40-25, sotalol hcl (af) oral tablet 20, 60, 80 sotalol hcl oral tablet 20, 60, 240, 80 timolol maleate oral tablet 0, 20, 5 Calcium Channel Blocking Agents [Bloqueadores De Canales De Calcio] amlodipine besylate oral tablet 0, 2.5, 5 diltiazem hcl er beads oral capsule extended release 24 hour 20, 80, 240, 00, 60, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 20, 80, 240, 00, 60 diltiazem hcl er oral capsule extended release 2 hour 20, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 20, 80, 240 diltiazem hcl oral tablet 20, 0, 60, 90 nicardipine hcl oral capsule 20, 0 nifedipine er oral tablet extended release 24 hour 0, 60, 90 nifedipine er osmotic release oral tablet extended release 24 hour 0, 60, 90 nimodipine oral capsule 0 verapamil hcl er oral tablet extended release 20, 80, 240 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207

44 verapamil hcl oral tablet 20, 40, 80 Cardiovascular Agents, Other [Cardiovasculares, Otros] digoxin oral tablet 25 mcg, 250 mcg pentoxifylline er oral tablet extended release 400 phenoxybenzamine hcl oral capsule 0 RANEXA ORAL TABLET EXTENDED RELEASE 2 HOUR 000 MG, 500 MG Combinations, Others [Combinaciones, Otros] ENTRESTO ORAL TABLET MG, 49-5 MG, 97-0 MG ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207 PA; SL 2 PA; SL Diuretics, Carbonic Anhydrase Inhibitors [Diuréticos Inhibidores De Anhidrasa Carbónica] acetazolamide oral tablet 25, 250 methazolamide oral tablet 25, 50 Diuretics, Loop [Diuréticos Del Asa] bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5,, 2 furosemide injection solution 0 /ml furosemide oral solution 0 /ml, 8 /ml furosemide oral tablet 20, 40, 80 torsemide oral tablet 0, 00, 20, 5 Diuretics, Potassium-Sparing [Diuréticos Conservadores De Potasio] ALDACTAZIDE ORAL TABLET MG ST amiloride hcl oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 eplerenone oral tablet 25, 50 ST spironolactone oral tablet 00, 25, 50 spironolactone-hctz oral tablet triamterene-hctz oral capsule , triamterene-hctz oral tablet , 75-50

45 Diuretics, Thiazide [Diuréticos Tiazidas] chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 00, 25, 50 hydrochlorothiazide oral capsule 2.5 hydrochlorothiazide oral tablet 25, 50 indapamide oral tablet.25, 2.5 metolazone oral tablet 0, 2.5, 5 Dyslipidemics, Fibric Acid Derivatives [Dislipidémicos, Derivados De Ácido Fíbrico] fenofibrate micronized oral capsule 0, 4, 200, 4, 67 fenofibrate oral tablet 45, 60, 48, 54 fenofibric acid oral capsule delayed release 5, 45 gemfibrozil oral tablet 600 Dyslipidemics, HMG-CoA Reductase Inhibitors [Dislipidémicos, Inhibidores De La Reductasa De HMG-CoA] atorvastatin calcium oral tablet 0, 20, 40, 80 ezetimibe-simvastatin oral tablet 0-0, 0-20, 0-40 ST ezetimibe-simvastatin oral tablet 0-80 PA pravastatin sodium oral tablet 0, 20, 40, 80 simvastatin oral tablet 0, 20, 40, 5 simvastatin oral tablet 80 PA VYTORIN ORAL TABLET 0-0 MG, 0-20 MG, 0-40 MG VYTORIN ORAL TABLET 0-80 MG 2 PA Dyslipidemics, Other [Dislipidémicos, Otros] cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose 2 ELA Rubi 208 / ELA Rubi Rev. Noviembre 207 / November 207