PIANO AETNA BETTER HEALTH FIDA
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Elenco dei farmaci coperti / Prontuario per il 2016
Il piano FIDA Aetna Better Health è un piano di cure gestite che stipula contratti sia con Medicare, sia con il Dipartimento di Sanità dello Stato di New York (Medicaid) per fornire i benefici di entrambi i programmi ai partecipanti tramite la dimostrazione denominata
FIDA (Fully Integrated Duals Advantage).
www.aetnabetterhealth.com/newyork
H8056_16_004_DRG_LST_ITA ACCEPTED
Informazioni utili
Servizi per i partecipanti (Participant Services)
1-855-494-9945 (non udenti: 711)
Trasporti non di emergenza
Gestione dei trasporti medici (MTM)
1-866-334-8919
Servizi per iscritti audiolesi (non udenti)
711
Indirizzo
FIDA Aetna Better Health Plan
55 W. 125th St., Suite 1300
New York, NY 10027
Informazioni personali
Il mio numero identificativo
Il mio fornitore di cure di base (PCP)
Il numero di telefono del mio fornitore di cure di base (PCP)
Il nome e il numero di telefono del mio gestore delle cure
www.aetnabetterhealth.com/newyork
Piano Aetna Better Health FIDA | Elenco dei farmaci coperti per il 2016
(Prontuario)
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Questo è un elenco dei farmaci che i Partecipanti possono ricevere nell'ambito del piano Aetna Better
Health FIDA.
❖ Il piano Aetna Better Health FIDA è un piano di cure gestite che stipula contratti sia con Medicare, sia con il
Dipartimento di Sanità dello Stato di New York (Medicaid) per fornire i benefici di entrambi i programmi ai
partecipanti tramite la dimostrazione denominata FIDA (Fully Integrated Duals Advantage).
❖ L'Elenco dei farmaci coperti e/o delle reti di fornitori e farmacie possono cambiare nel corso dell'anno.
Le invieremo un avviso prima di apportare qualsiasi cambiamento che possa influire su di Lei.
❖ I benefici possono cambiare a partire dal 1° gennaio di ogni anno.
Lei può sempre consultare l'Elenco dei farmaci aggiornato per il piano Aetna Better Health FIDA all'indirizzo
www.aetnabetterhealth.com/newyork o chiamando il reparto Servizi per i Partecipanti (Participant
Services) del piano Aetna Better Health FIDA al numero 1‑855‑494‑9945 (non udenti: 711).
❖ Potrebbero essere applicate limitazioni e restrizioni. Per maggiori informazioni, chiami il reparto Servizi
per i Partecipanti (Participant Services) del piano Aetna Better Health FIDA o legga il Manuale del
partecipante del piano Aetna Better Health FIDA.
❖ Non c'è alcun ticket da pagare per i farmaci coperti.
❖ È possibile ricevere gratuitamente queste informazioni in altri formati, quali ad esempio Braille, stampa
a caratteri grandi o audio. Chiami il numero 1‑855‑494‑9945 (servizio TTY/TTD per non udenti: 711),
24 ore su 24, 7 giorni su 7. La chiamata è gratuita.
❖ È possibile ricevere gratuitamente queste informazioni in altre lingue. Contattare il numero
1‑855‑494‑9945 e il servizio TTY/TTD per non udenti al numero 711, 24 ore su 24, 7 giorni su 7.
La chiamata è gratuita.
❖ Lo Stato di New York ha creato un programma con difensori civici denominato "Independent Consumer
Advocacy Network" (ICAN) per fornire ai Partecipanti un'assistenza gratuita e riservata su qualsiasi servizio
offerto dal piano Aetna Better Health FIDA. Può contattare l'ICAN al numero verde 1-844-614-8800
oppure online all'indirizzo www.icannys.org.
In caso di dubbi o domande, è possibile contattare il piano Aetna Better Health FIDA al numero
1-855-494-9945 (servizio TTY/TDD per i non udenti: 711), 24 ore su 24, 7 giorni su 7. La chiamata è gratuita.
Per ulteriori informazioni, visitare il sito www.aetnabetterhealth.com/newyork.
NY-15-08-05 H8056_16_004_DRG_LST_ITA ACCEPTED
I
II
In caso di dubbi o domande, è possibile contattare il piano Aetna Better Health FIDA al numero
1-855-494-9945 (servizio TTY/TDD per i non udenti: 711), 24 ore su 24, 7 giorni su 7. La chiamata è gratuita.
Per ulteriori informazioni, visitare il sito www.aetnabetterhealth.com/newyork.
NY-15-08-05 H8056_16_004_DRG_LST_ITA ACCEPTED
Domande più frequenti (FAQ)
Qui può trovare le risposte alle domande riguardanti il presente Elenco dei farmaci coperti. Può leggere
tutte le FAQ per saperne di più, oppure cercare una domanda e una risposta specifiche.
1. Quali farmaci prescrivibili sono presenti nell'Elenco dei farmaci
coperti? (Da qui in poi, l'Elenco dei farmaci coperti sarà abbreviato
in "Elenco dei farmaci")
I farmaci presenti nell'Elenco dei farmaci che inizia a pagina 1 sono i farmaci coperti dal piano Aetna Better
Health FIDA. Tali farmaci sono disponibili presso le farmacie incluse nella nostra rete convenzionata. Una
farmacia fa parte della nostra rete nel caso abbia accettato di lavorare con noi e di fornirle servizi. Tali
farmacie sono indicate con il termine "farmacie della rete".
➨ Il piano Aetna Better Health FIDA coprirà tutti i farmaci inclusi nell'Elenco dei farmaci se:
• il Suo medico o un altro fornitore sanitario afferma che Lei ha bisogno di tali farmaci per sentirsi
meglio o restare in salute;
• il farmaco è necessario per le Sue condizioni dal punto di vista medico; e
• compila la prescrizione in una farmacia della rete convenzionata del piano Aetna Better Health FIDA.
➨ Il piano Aetna Better Health FIDA può prevedere ulteriori requisiti per accedere a determinati farmaci
(consulti la domanda 5 a seguire). In alcuni casi, Lei potrebbe dover fare qualcosa prima di poter ricevere
un farmaco, ad esempio provare prima altri farmaci.
Può inoltre consultare un elenco aggiornato dei farmaci da noi coperti sul nostro sito web, all'indirizzo
www.aetnabetterhealth.com/newyork oppure può chiamare il reparto Servizi per i Partecipanti
(Participant Services) al numero 1‑855‑494‑9945 (non udenti: 711).
2. L'Elencodeifarmacièsoggettoamodifiche?
Sì. Il piano Aetna Better Health FIDA può aggiungere o togliere farmaci dall'Elenco dei farmaci durante
l'anno. In genere, le modifiche all'Elenco dei farmaci sono apportate soltanto se:
• diventa disponibile un nuovo farmaco che funziona con la stessa efficacia di un farmaco attualmente incluso nell'Elenco dei farmaci; oppure
• scopriamo che un farmaco non è sicuro.
Potremmo anche modificare le nostre regole sui farmaci. Ad esempio, potremmo:
• Decidere di richiedere o meno l'approvazione preliminare per un farmaco. (Il termine Approvazione
preliminare indica un permesso che deve essere rilasciato dal piano Aetna Better Health FIDA o dal
Suo team interdisciplinare prima che Lei possa ricevere un farmaco);
• Aggiungere o modificare la quantità di un farmaco che Lei può ricevere (i cosiddetti "limiti quantitativi");
• Aggiungere o modificare le restrizioni della terapia a gradini su un farmaco. (Il termine Terapia a gradini
indica una terapia in base a cui Lei deve provare un farmaco prima che copriamo un altro farmaco).
(Per ulteriori informazioni su queste regole per i farmaci, consulti la pagina V)
Nel caso che un farmaco che sta assumendo venga tolto dall'Elenco dei farmaci, La informeremo quanto prima.
Le segnaleremo inoltre tutti i casi in cui modificheremo le regole per la copertura di un farmaco. Le domande 3,
4 e 7 a seguire contengono informazioni su ciò che avviene quando l'Elenco dei farmaci viene modificato.
➨ Lei può sempre consultare l'Elenco dei farmaci aggiornato per il piano Aetna Better Health FIDA all'indirizzo
www.aetnabetterhealth.com/newyork. Può inoltre chiamare il reparto Servizi per i Partecipanti (Participant
Services) per verificare l'Elenco dei farmaci in vigore al numero 1‑855‑494‑9945 (non udenti: 711).
In caso di dubbi o domande, è possibile contattare il piano Aetna Better Health FIDA al numero
1-855-494-9945 (servizio TTY/TDD per i non udenti: 711), 24 ore su 24, 7 giorni su 7. La chiamata è gratuita.
Per ulteriori informazioni, visitare il sito www.aetnabetterhealth.com/newyork.
NY-15-08-05 H8056_16_004_DRG_LST_ITA ACCEPTED
III
3. Cosa succede quando diventa disponibile un farmaco meno costoso
chefunzionaconlastessaefficaciadiunfarmacoattualmenteincluso
nell'Elenco dei farmaci?
Se diventa disponibile un farmaco meno costoso che funziona con la stessa efficacia di un farmaco
attualmente incluso nell'Elenco dei farmaci:
• Il Suo farmacista potrebbe fornirle il farmaco meno costoso in occasione della Sua prossima
prescrizione. Se Lei e il Suo fornitore sanitario decidete che il farmaco meno costoso non fa al caso Suo,
il Suo fornitore può segnalare al farmacista di continuare con il farmaco che Lei sta assumendo adesso.
• Il piano Aetna Better Health FIDA potrebbe decidere di togliere il farmaco più costoso dall'Elenco
dei farmaci. Se sta assumendo un farmaco che viene tolto dall'Elenco dei farmaci perché diventa
disponibile un farmaco meno costoso che funziona con la stessa efficacia, La avviseremo almeno
60 giorni prima della rimozione di tale farmaco dall'elenco oppure quando Lei chiede un rinnovo.
A quel punto Lei può ottenere una fornitura del farmaco per 60 giorni prima che venga apportata la
modifica all'Elenco dei farmaci. Riceverà un'email in cui Le verrà comunicato se la variazione nell'elenco
dei farmaci La riguarda. Potrà anche cercare il Suo farmaco con lo strumento di prontuario online
interattivo che viene costantemente aggiornato con la copertura attualmente in vigore.
4. Cosa succede se si scopre che un farmaco non è sicuro?
Qualora la Food and Drug Administration (FDA) affermi che un farmaco che Lei sta assumendo non è
sicuro, toglieremo immediatamente tale farmaco dall'Elenco dei farmaci. Le invieremo inoltre una lettera,
oltre a contattarla telefonicamente, per avvisarla che il farmaco non sicuro è stato tolto dall'Elenco dei
farmaci. Se riceve questa lettera, La invitiamo a contattare il medico che Le ha prescritto il farmaco.
5. Vi sono restrizioni o limitazioni sulla copertura dei farmaci? Oppure vi
sono azioni necessarie da intraprendere per ricevere determinati farmaci?
Sì, alcuni farmaci presentano regole sulla loro copertura o limitazioni sulla quantità che Lei può ricevere.
In alcuni casi Lei, il Suo medico o un altro fornitore sanitario deve far qualcosa prima di poter ricevere il
farmaco. Ad esempio:
• Approvazione preliminare (o autorizzazione preliminare): Per alcuni farmaci, Lei, o il Suo medico o
altra persona che esegue le prescrizioni, deve ottenere un'approvazione da parte del piano Aetna Better
Health FIDA o del Suo team interdisciplinare (IDT) prima che venga compilata la prescrizione. Qualora
non ricevesse tale approvazione, il piano Aetna Better Health FIDA potrebbe non coprire il farmaco.
• Limiti quantitativi: Talvolta, il piano Aetna Better Health FIDA limita la quantità di farmaco che Lei
può ricevere.
• Terapia a gradini: A volte il piano Aetna Better Health FIDA La obbliga a seguire una terapia a
gradini. Ciò significa che dovrà provare i farmaci in un determinato ordine per le Sue condizioni
mediche. Potrebbe dover provare un farmaco prima che copriamo un altro farmaco. Se il Suo medico
ritiene che il primo farmaco non faccia al caso Suo, allora copriremo il secondo.
Può scoprire se il Suo farmaco presenta requisiti o limiti aggiuntivi consultando le tabelle a pagina 1-86.
Lei può inoltre reperire ulteriori informazioni visitando il nostro sito web, all'indirizzo
www.aetnabetterhealth.com/newyork. Abbiamo pubblicato online alcuni documenti che spiegano come
funziona la nostra autorizzazione preliminare e le restrizioni della terapia a gradini. Lei può inoltre chiederci
di inviarle una copia.
Lei può chiedere un' "eccezione" a tali limiti. Consulti la domanda 11 per ulteriori informazioni sulle eccezioni.
IV
In caso di dubbi o domande, è possibile contattare il piano Aetna Better Health FIDA al numero
1-855-494-9945 (servizio TTY/TDD per i non udenti: 711), 24 ore su 24, 7 giorni su 7. La chiamata è gratuita.
Per ulteriori informazioni, visitare il sito www.aetnabetterhealth.com/newyork.
NY-15-08-05 H8056_16_004_DRG_LST_ITA ACCEPTED
➨ Se si trova in una casa di riposo o in un'altra struttura per cure a lungo termine e Le servisse un farmaco
che non è incluso nell'Elenco dei farmaci, oppure se non potesse procurarsi con facilità il farmaco
che Le serve, possiamo aiutarla. Copriremo una fornitura d'emergenza del farmaco che Le serve per
31 giorni (a meno che la Sua prescrizione non indichi un numero minore di giorni), che Lei sia o meno un
nuovo Partecipante del piano Aetna Better Health FIDA. Ciò Le darà il tempo di parlare con il Suo medico
(o con altra persona che esegue le prescrizioni), che potrà aiutarla a decidere se esiste, nell'Elenco dei
farmaci, un farmaco simile che Lei può assumere al posto di quello attuale oppure se richiedere o meno
un'eccezione. Consulti la domanda 11 per ulteriori informazioni sulle eccezioni.
6. Come può scoprire se il farmaco da Lei desiderato presenta delle
limitazioni oppure se è necessario intraprendere determinate azioni
per ricevere tale farmaco?
L'Elenco dei farmaci a pagina 1 presenta una colonna denominata "Azioni necessarie, restrizioni o
limitazioni all'uso".
7. Cosasuccedesemodifichiamoleregolesulmodoincuicopriamo
determinati farmaci? Ad esempio, se aggiungiamo l'autorizzazione
(approvazione) preliminare, limiti quantitativi e/o restrizioni alla
terapia a gradini su un farmaco.
Se aggiungiamo l'approvazione preliminare, limiti quantitativi e/o restrizioni alla terapia a gradini su un
farmaco, La avviseremo almeno 60 giorni prima che la restrizione venga aggiunta oppure quando chiede il
prossimo rinnovo. A quel punto Lei può ottenere una fornitura del farmaco per 60 giorni prima che venga
apportata la modifica all'Elenco dei farmaci. Ciò Le darà il tempo di parlare con il Suo medico (o con altra
persona che esegue le prescrizioni) per decidere cosa fare in seguito.
8. Come posso trovare un farmaco nell'Elenco dei farmaci?
Esistono due modi per trovare un farmaco:
• Lei può cercarlo in ordine alfabetico (se sa come si trascrive il nome del farmaco), oppure
• può cercarlo in base alla condizione medica.
Per cercarlo in ordine alfabetico, consulti la sezione Elenco alfabetico a pagina 87. In seguito, cerchi il
nome del Suo farmaco nell'elenco.
Per eseguire ricerche in base alla condizione medica, trovi la sezione denominata "Elenco dei farmaci in base
alla condizione medica" a pagina 1. I farmaci in questa sezione sono raggruppati in categorie in base al tipo di
condizione medica per cui vengono utilizzati come trattamento. Ad esempio, se soffre di disturbi cardiaci, deve
cercare in quella categoria, ossia Agenti cardiovascolari. Lì troverà i farmaci che curano i disturbi cardiaci.
9. Cosa succede se il farmaco da Lei desiderato non è incluso nell'Elenco
dei farmaci?
Se non trova il Suo farmaco nell'Elenco dei farmaci, chiami il reparto Servizi per i Partecipanti (Participant
Services) al numero 1‑855‑494‑9945 (non udenti: 771) e chieda informazioni in merito. Se scopre che il
piano Aetna Better Health FIDA non coprirà il farmaco, può decidere di fare quanto segue:
In caso di dubbi o domande, è possibile contattare il piano Aetna Better Health FIDA al numero
1-855-494-9945 (servizio TTY/TDD per i non udenti: 711), 24 ore su 24, 7 giorni su 7. La chiamata è gratuita.
Per ulteriori informazioni, visitare il sito www.aetnabetterhealth.com/newyork.
NY-15-08-05 H8056_16_004_DRG_LST_ITA ACCEPTED
V
• Chiedere al reparto Servizi per i Partecipanti (Participant Services) un elenco di farmaci simili a
quello che desidera assumere, quindi mostrare l'elenco al Suo medico (o altra persona che esegue le
prescrizioni) che potrà prescrivere un farmaco, presente nell'Elenco dei farmaci, simile a quello che
desidera assumere. Oppure
• Chiedere al piano o al Suo team interdisciplinare (IDT) di fare un'eccezione per coprire il Suo farmaco.
Consulti la domanda 11 per ulteriori informazioni sulle eccezioni.
10. Cosa succede se Lei è un nuovo Partecipante al piano Aetna Better
Health FIDA e non riesce a trovare il Suo farmaco nell'Elenco dei
farmaci oppure ha problemi nell'ottenere il Suo farmaco?
Possiamo aiutarla. Abbiamo l'obbligo di coprire fino a 90 giorni di forniture temporanee del Suo farmaco,
secondo necessità, durante i Suoi primi 90 giorni di partecipazione al piano Aetna Better Health FIDA. Ciò
Le darà il tempo di parlare con il Suo medico (o con altra persona che esegue le prescrizioni), che potrà
aiutarla a decidere se esiste, nell'Elenco dei farmaci, un farmaco simile che Lei può assumere al posto di
quello attuale oppure se richiedere o meno un'eccezione.
Copriremo fino a 90 giorni di forniture temporanee del Suo farmaco se:
• Lei sta assumendo un farmaco che non è incluso nel nostro Elenco dei farmaci; oppure
• le regole del piano sanitario non Le permettono di ricevere la quantità ordinata da chi esegue le prescrizioni; oppure • il farmaco richiede un'approvazione preliminare da parte del piano Aetna Better Health FIDA oppure
del Suo team interdisciplinare; oppure
• Lei sta assumendo un farmaco che fa parte di una restrizione alla terapia a gradini.
Se risiede in una casa di riposo o in un'altra struttura per cure a lungo termine, Lei può rinnovare la Sua
prescrizione fino a 91 giorni, con possibile estensione a 98 giorni. Lei può farsi erogare il farmaco diverse
volte durante i primi 90 giorni dall'iscrizione al piano. Ciò dà il tempo a chi esegue le prescrizioni di
cambiare i Suoi farmaci e passare a quelli presenti nell'Elenco dei farmaci, oppure di chiedere un'eccezione.
Se Lei risulta attualmente partecipante e ha cambiato il Suo livello di cure (ad es. è stato/a dimesso/a
dall'ospedale, ricoverato/a o dimesso/a da struttura per cure a lungo termine), la Sua farmacia può ottenere
un'estensione della fornitura fino a 90 giorni dal piano Aetna Better Health FIDA.
Durante il periodo in cui riceve una fornitura temporanea di un farmaco, Lei deve parlare con il Suo
fornitore per decidere cosa fare una volta esaurita tale fornitura. Lei può passare a un diverso farmaco
coperto dal piano oppure chiedere al piano di fare un'eccezione per Lei e coprire il Suo farmaco attuale.
11. Può chiedere un'eccezione per coprire il Suo farmaco?
Sì. Lei può chiedere al piano Aetna Better Health FIDA oppure al Suo team interdisciplinare (IDT) di fare
un'eccezione per coprire un farmaco che non è incluso nell'Elenco dei farmaci.
Lei può inoltre chiedere al piano Aetna Better Health FIDA o al Suo team interdisciplinare di modificare le
regole sul Suo farmaco.
• Ad esempio, il piano Aetna Better Health FIDA potrebbe limitare la quantità di farmaco che coprirà.
Se il Suo farmaco presenta un limite, può chiederci, oppure chiedere al Suo team interdisciplinare,
di modificare il limite e coprirne una quantità maggiore.
• Altri esempi: Lei può chiederci, oppure chiedere al Suo team interdisciplinare, di ridurre le restrizioni
alla terapia a gradini o i requisiti per l'approvazione preliminare.
VI
In caso di dubbi o domande, è possibile contattare il piano Aetna Better Health FIDA al numero
1-855-494-9945 (servizio TTY/TDD per i non udenti: 711), 24 ore su 24, 7 giorni su 7. La chiamata è gratuita.
Per ulteriori informazioni, visitare il sito www.aetnabetterhealth.com/newyork.
NY-15-08-05 H8056_16_004_DRG_LST_ITA ACCEPTED
12. Quanto tempo serve per ricevere un'eccezione?
Per prima cosa, il piano Aetna Better Health FIDA o il Suo team interdisciplinare (IDT) devono ricevere una
dichiarazione da parte di chi esegue le prescrizioni a supporto della Sua richiesta di eccezione. Dopo che
avremo ricevuto la dichiarazione, Lei riceverà una decisione sulla Sua richiesta di eccezione entro 72 ore.
Se Lei, o chi esegue le prescrizioni, ritiene che la Sua salute potrebbe essere pregiudicata nel caso dovesse
attendere 72 ore per una decisione, può richiedere un'eccezione urgente. Si tratta di una decisione più
rapida. Se chi esegue le prescrizioni supporta la Sua richiesta, Lei riceverà una decisione entro 24 ore dal
ricevimento della dichiarazione di supporto.
13. Come può chiedere un'eccezione?
Per chiedere un'eccezione, contatti il Suo gestore delle cure. Il Suo gestore delle cure lavorerà con Lei e con
il Suo fornitore sanitario per aiutarla a chiedere un'eccezione.
14. Che cosa sono i farmaci equivalenti?
I farmaci equivalenti (detti anche generici) sono composti dagli stessi ingredienti dei farmaci di marca.
In genere, costano meno dei farmaci di marca corrispondenti e non hanno nomi conosciuti. I farmaci
equivalenti sono approvati dalla Food and Drug Administration (FDA).
Il piano Aetna Better Health FIDA copre sia farmaci di marca, sia farmaci equivalenti.
15. Che cosa sono i farmaci da banco?
La sigla inglese OTC indica i farmaci "da banco". Il piano Aetna Better Health FIDA copre alcuni farmaci da
banco quando vengono prescritti dal Suo fornitore.
Può consultare l'Elenco dei farmaci del piano Aetna Better Health FIDA per verificare quali farmaci da banco
sono coperti.
16. Il piano Aetna Better Health FIDA copre i prodotti non farmaceutici
da banco?
Il piano Aetna Better Health FIDA copre alcuni farmaci da banco quando vengono prescritti dal Suo fornitore.
Può consultare l'Elenco dei farmaci del piano Aetna Better Health FIDA per verificare quali prodotti non
farmaceutici da banco sono coperti.
17. Quanto deve pagare di ticket?
Non Le verrà addebitato alcun ticket per i farmaci inclusi nell'Elenco dei farmaci.
18. Quali sono le classi di farmaci?
Le classi sono gruppi di farmaci soggetti allo stesso ticket.
• I farmaci di Classe 1 sono farmaci equivalenti prescrivibili da Parte D.
• I farmaci di Classe 2 sono farmaci di marca prescrivibili da Parte D.
• I farmaci di Classe 3 sono farmaci prescrivibili non da Parte D e farmaci da banco.
Nessuna delle classi prevede il ticket
In caso di dubbi o domande, è possibile contattare il piano Aetna Better Health FIDA al numero
1-855-494-9945 (servizio TTY/TDD per i non udenti: 711), 24 ore su 24, 7 giorni su 7. La chiamata è gratuita.
Per ulteriori informazioni, visitare il sito www.aetnabetterhealth.com/newyork.
NY-15-08-05 H8056_16_004_DRG_LST_ITA ACCEPTED
VII
Elenco dei farmaci coperti
L'Elenco dei farmaci coperti presente alla pagina successiva Le fornisce informazioni sui farmaci coperti
dal piano Aetna Better Health FIDA. Qualora avesse problemi a reperire il Suo farmaco nell'elenco, faccia
riferimento all'Indice che inizia a pagina 87.
La prima colonna della tabella elenca il nome del farmaco. I farmaci di marca sono scritti in lettere
maiuscole (ad esempio, CRESTOR) mentre i farmaci equivalenti sono scritti in lettere minuscole e in corsivo
(ad esempio, amoxicillina).
Le informazioni nella colonna Azioni necessarie, restrizioni o limitazioni all'uso indicano se il piano Aetna
Better Health FIDA presenta eventuali regole per la copertura del farmaco.
Diseguitosonoriportateledefinizionideicodiciutilizzatinellacolonna"Azioninecessarie,
restrizioni o limitazioni all'uso":
(*) = Farmaci non Parte D o articoli da banco coperti da Medicaid
B/D = coperti da Medicare B o D
PA = autorizzazione preliminare
MO = disponibile per corrispondenza
QL = limiti quantitativi
ST = terapia a gradini
LA = accesso limitato
Nota: L'asterisco (*) accanto al farmaco indica che esso non è un "farmaco Parte D". Questi farmaci
presentano regole differenti per i ricorsi. Un ricorso è un modo formale con cui chiedere il riesame e
l'eventuale modifica di una decisione sulla copertura, qualora Lei ritenesse che si sia verificato un errore.
Ad esempio, il piano Aetna Better Health FIDA o il Suo team interdisciplinare (IDT) potrebbero decidere che
un farmaco da Lei desiderato non è coperto o non è più coperto da Medicare o Medicaid. Se Lei (o il Suo
medico, o chi esegue le prescrizioni) non è d'accordo con la decisione, può presentare ricorso. Per ricevere
istruzioni su come presentare un ricorso, contatti il reparto Servizi per i Partecipanti (Participant Services), al
numero 1‑855‑494‑9945 (non udenti: 711) oppure l'ICAN (Independent Consumer Advocacy Network) al
numero 1-844-614-8800. Per sapere come ricorrere contro una decisione può inoltre leggere il Manuale
del Partecipante.
VIII
In caso di dubbi o domande, è possibile contattare il piano Aetna Better Health FIDA al numero
1-855-494-9945 (servizio TTY/TDD per i non udenti: 711), 24 ore su 24, 7 giorni su 7. La chiamata è gratuita.
Per ulteriori informazioni, visitare il sito www.aetnabetterhealth.com/newyork.
NY-15-08-05 H8056_16_004_DRG_LST_ITA ACCEPTED
Piano Medicare‑Medicaid NY in vigore dal 01/01/2016
Elenco dei farmaci per condizione medica
I farmaci in questa sezione sono raggruppati in categorie in base al tipo di condizione medica per cui
vengono utilizzati come trattamento. Ad esempio, se soffre di disturbi cardiaci, deve cercare in quella
categoria, ossia Agenti cardiovascolari. Lì troverà i farmaci che curano i disturbi cardiaci.
Costo
Livello a Suo
Nome del farmaco
di
carico
Classe
per il
farmaco
ANALGESICI: FARMACI PER IL TRATTAMENTO
DI STATI DOLOROSI ED INFIAMMATORI
Analgesici
ACETAMINOPHEN 8 HOUR
3
$0
APAP 500
3
$0
butalbital/acetaminophen/caffeine/co1
$0
deine
butalbital/acetaminophen/caffeine caps
1
$0
butalbital/acetaminophen/caffeine tabs
1
$0
325mg; 50mg; 40mg
butalbital/apap/caffeine
1
$0
butalbital/aspirin/caffeine/codeine
1
$0
butalbital/aspirin/caffeine caps
1
$0
capacet
1
$0
childrens non-aspirin chew
3
$0
esgic caps
1
$0
FEBROL
3
$0
feverall adults
3
$0
feverall childrens
3
$0
feverall junior strength
3
$0
infants pain relief susp 80mg/0.8ml
3
$0
margesic
1
$0
pain relief 8 hour
3
$0
pain relief childrens
3
$0
pain relief extra strength tabs
3
$0
pain reliever tabs
3
$0
q-pap infants
3
$0
TRIAMINIC FEVER REDUCER PAIN
3
$0
RELIEVER INFANTS
zebutal caps 325mg; 50mg; 40mg
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
*
*
QL (180 CAD per 30 giorni) PA MO
QL (180 CAD per 30 giorni) PA MO
QL (180 CAD per 30 giorni) PA MO
QL (180 CAD per 30 giorni) PA MO
QL (180 CAD per 30 giorni) PA MO
QL (180 CAD per 30 giorni) PA MO
QL (180 CAD per 30 giorni) PA
*
QL (180 CAD per 30 giorni) PA MO
*
*
*
*
*
QL (180 CAD per 30 giorni) PA MO
*
*
*
*
*
*
QL (180 CAD per 30 giorni) PA MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
1
Nome del farmaco
Farmaci Antinfiammatori
Non Steroidei (FANS)
aspir-low
aspirin tabs
aspirin supp 300mg, 600mg
aspirin tbec 325mg
bayer chewable low dose
celecoxib caps 400mg
celecoxib caps 100mg, 200mg, 50mg
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diflunisal tabs
etodolac er
etodolac caps, tabs
flurbiprofen tabs
ibuprofen susp
ibuprofen tabs 400mg, 600mg, 800mg
ketoprofen er
ketoprofen caps
meclofenamate sodium caps
meloxicam susp, tabs
motrin ib
nabumetone
naproxen dr
naproxen sodium tabs 275mg, 550mg
naproxen susp, tabs
oxaprozin
piroxicam caps
ra ibuprofen childrens
sulindac tabs
tolmetin sodium
VOLTAREN
Analgesici oppiacei, a lunga
durata d'azione
fentanyl pt72 37.5mcg/hr, 62.5mcg/hr,
87.5mcg/hr
2
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
Azioni necessarie,
restrizioni o
limitazioni all'uso
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
3
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
*
*
*
*
*
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
*
MO
MO
MO
MO
MO
MO
*
MO
MO
QL (1020 GM per 30 giorni) MO
1
$0
QL (15 CAD per 30 giorni)
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
fentanyl pt72 100mcg/hr, 12mcg/hr,
25mcg/hr, 50mcg/hr, 75mcg/hr
methadone hcl inj
methadone hcl tabs
methadone hcl oral soln
methadone hcl conc
methadone hcl tbso
methadose sugar-free
methadose conc
methadose tbso
morphine sulfate er cp24 120mg
morphine sulfate er cp24 45mg, 75mg,
90mg
morphine sulfate er cp24 100mg, 10mg,
20mg, 30mg, 50mg, 60mg, 80mg
morphine sulfate er tbcr
Analgesici oppiacei, a breve durata d'azione
acetaminophen/codeine #3
acetaminophen/codeine soln
acetaminophen/codeine tabs 300mg;
15mg, 300mg; 60mg
butalbital compound/codeine
codeine sulfate tabs
duramorph
endocet tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
fentanyl citrate oral transmucosal
hydrocodone bitartrate/acetaminophen
soln
hydrocodone bitartrate/acetaminophen
tabs 325mg; 2.5mg
hydrocodone bitartrate/acetaminophen
tabs 300mg; 10mg, 300mg; 5mg,
300mg; 7.5mg
hydrocodone/acetaminophen soln
325mg/15ml; 10mg/15ml
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
1
$0
QL (15 CAD per 30 giorni) MO
1
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
QL (240 CAD per 30 giorni) MO
QL (3000 ML per 30 giorni) MO
QL (360 ML per 30 giorni) MO
QL (90 CAD per 30 giorni)
QL (360 ML per 30 giorni) MO
QL (360 ML per 30 giorni) MO
QL (90 CAD per 30 giorni)
QL (180 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
1
$0
QL (60 CAD per 30 giorni) MO
1
QL (90 CAD per 30 giorni) MO
1
1
1
$0
$0
$0
$0
1
1
1
1
$0
$0
$0
$0
QL (180 CAD per 30 giorni) PA
QL (180 CAD per 30 giorni) MO
B/D
QL (360 CAD per 30 giorni)
1
1
$0
$0
QL (120 CAD per 30 giorni) PA MO
QL (5550 ML per 30 giorni) MO
1
$0
QL (360 CAD per 30 giorni)
1
$0
QL (390 CAD per 30 giorni) MO
1
$0
QL (5550 ML per 30 giorni)
QL (390 CAD per 30 giorni) MO
QL (4500 ML per 30 giorni) MO
QL (390 CAD per 30 giorni) MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
3
Nome del farmaco
hydrocodone/acetaminophen tabs
325mg; 10mg, 325mg; 5mg, 325mg;
7.5mg
hydrocodone/ibuprofen
hydromorphone hcl liqd
hydromorphone hcl inj 1mg/ml, 2mg/ml,
4mg/ml, 500mg/50ml
hydromorphone hcl tabs 4mg, 8mg
hydromorphone hcl tabs 2mg
ibudone tabs 5mg; 200mg
lorcet
lorcet hd
lorcet plus tabs 325mg; 7.5mg
morphine sulfate inj
morphine sulfate tabs
morphine sulfate oral soln 20mg/5ml
morphine sulfate oral soln 20mg/ml
morphine sulfate oral soln 10mg/5ml
nalbuphine hcl inj
oxycodone hcl conc
oxycodone hcl caps
oxycodone hcl soln
oxycodone hcl tabs 10mg, 15mg, 20mg,
30mg
oxycodone hcl tabs 5mg
oxycodone/acetaminophen tabs 325mg;
10mg, 325mg; 2.5mg, 325mg; 5mg,
325mg; 7.5mg
oxycodone/aspirin
oxycodone/ibuprofen
ROXICET SOLN
roxicet tabs 325mg; 5mg
tramadol hcl tabs
tramadol hydrochloride/acetaminophen
vicodin es tabs 300mg; 7.5mg
vicodin tabs 300mg; 5mg
4
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
1
$0
QL (360 CAD per 30 giorni) MO
1
1
1
$0
$0
$0
QL (150 CAD per 30 giorni) MO
QL (2400 ML per 30 giorni) MO
B/D MO
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
QL (240 CAD per 30 giorni) MO
QL (480 CAD per 30 giorni) MO
QL (150 CAD per 30 giorni)
QL (360 CAD per 30 giorni)
QL (360 CAD per 30 giorni)
QL (360 CAD per 30 giorni)
B/D
QL (180 CAD per 30 giorni) MO
QL (1020 ML per 30 giorni) MO
QL (180 ML per 30 giorni) MO
QL (1800 ML per 30 giorni) MO
MO
QL (180 ML per 30 giorni) MO
QL (360 CAD per 30 giorni) MO
QL (5400 ML per 30 giorni) MO
QL (180 CAD per 30 giorni) MO
1
1
$0
$0
QL (360 CAD per 30 giorni) MO
QL (360 CAD per 30 giorni) MO
1
1
2
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
QL (360 CAD per 30 giorni) MO
QL (120 CAD per 30 giorni) MO
QL (1800 ML per 30 giorni) MO
QL (360 CAD per 30 giorni)
QL (240 CAD per 30 giorni) MO
QL (240 CAD per 30 giorni) MO
QL (390 CAD per 30 giorni)
QL (390 CAD per 30 giorni)
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
zamicet
ANESTETICI: FARMACI CHE INDUCONO
LO STATO DI TORPORE
Anestetici locali
glydo
lidocaine hcl jelly
lidocaine hcl gel 2%
lidocaine hcl inj 0.5%, 1.5%
lidocaine hcl inj 1%, 2%, 4%
lidocaine hcl external soln 4%
lidocaine hcl mouth/throat soln 4%
lidocaine viscous
lidocaine/prilocaine kit
lidocaine/prilocaine crea
lidocaine oint
lidocaine ptch
AGENTI ANTI‑DIPENDENZE: AGENTI PER IL
TRATTAMENTO DELL'ABUSO DI SOSTANZE
Deterrenti nei confronti
dell'alcol/Anti-craving
acamprosate calcium dr
disulfiram tabs
naltrexone hcl tabs
Trattamenti per la dipendenza da oppioidi
buprenorphine hcl/naloxone hcl
buprenorphine hcl subl
SUBOXONE FILM 12MG; 3MG
SUBOXONE FILM 2MG; 0.5MG, 4MG;
1MG, 8MG; 2MG
Agenti antagonisti degli oppioidi
EVZIO
naloxone hcl inj
Agenti per smettere di fumare
buproban
bupropion hcl sr tb12 150mg
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
1
$0
QL (5550 ML per 30 giorni)
1
1
1
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0 $0
$0
$0 $0
$0
$0
$0
$0
MO
MO
MO
MO
MO
MO
MO
QL (90 CAD per 30 giorni) PA MO
1
1
1
1
1
2
2
2
1
1
1
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
MO
MO
QL (90 CAD per 30 giorni) PA MO
QL (90 CAD per 30 giorni) PA MO
QL (60 CAD per 30 giorni) PA MO
QL (90 CAD per 30 giorni) PA MO
PA MO
QL (60 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (336 CAD per 365 giorni) MO
QL (106 CAD per 365 giorni) MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
5
Nome del farmaco
CHANTIX TABS 0.5MG, 1MG
NICODERM CQ PT24 14MG/24HR,
7MG/24HR
nicotine polacrilex gum 4mg
nicotine polacrilex lozg 4mg
nicotine transdermal system pt24
nicotine lozg 2mg
nicotine pt24 21mg/24hr
NICOTROL NS
ANTIBATTERICI: FARMACI PER IL
TRATTAMENTO DELLE INFEZIONI
Aminoglicosidi
amikacin sulfate inj 1gm/4ml,
500mg/2ml
gentamicin sulfate pediatric
gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/
ml; 0.9%
gentamicin sulfate/0.9% sodium chloride
inj 0.8mg/ml; 0.9%
gentamicin sulfate inj 10mg/ml
gentamicin sulfate inj 40mg/ml
isotonic gentamicin inj 1.2mg/ml; 0.9%,
2mg/ml; 0.9%
isotonic gentamicin inj 0.8mg/ml; 0.9%
neomycin sulfate
paromomycin sulfate
streptomycin sulfate inj
tobramycin sulfate/sodium chloride inj
0.9%; 0.8mg/ml
tobramycin sulfate inj 1.2gm, 10mg/ml,
40mg/ml
tobramycin sulfate inj 1.2gm/30ml,
40mg/ml, 80mg/2ml
Antibatterici, altro
baciim
bacitracin inj 50000unit
6
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
2
$0
QL (336 CAD per 365 giorni) MO
3
$0
*
3
3
3
3
3
2
$0
$0
$0
$0
$0
$0
*
*
*
*
*
QL (40 ML per 30 giorni) MO
1
$0
1
1
$0
$0 MO
1
$0
MO
1
1
1
$0 $0
$0
MO
1
1
1
1
1
$0
$0
$0
$0
$0
1
$0
1
$0
MO
1
1
$0
$0
MO
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
chloramphenicol sodium succinate
clindamax gel
clindamycin hcl caps
clindamycin palmitate hcl
clindamycin phosphate add-vantage
clindamycin phosphate in d5w
clindamycin phosphate crea 2%
clindamycin phosphate inj 150mg/ml,
300mg/2ml, 9000mg/60ml
clindamycin phosphate inj 600mg/4ml,
900mg/6ml
colistimethate sodium
CUBICIN
DALVANCE
ISOPROPYL ALCOHOL WIPES
linezolid inj
linezolid tabs
methenamine hippurate
METRO IV
metronidazole in nacl 0.79%
metronidazole vaginal
metronidazole caps 375mg
metronidazole tabs 250mg, 500mg
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
nitrofurantoin susp
SIVEXTRO INJ
SIVEXTRO TABS
SYNERCID
tinidazole
trimethoprim tabs
TYGACIL
vancomycin hcl in dextrose
vancomycin hcl caps
vancomycin hcl inj 1000mg, 10gm,
5000mg, 750mg
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0 1
$0
1
$0
MO
1
$0
MO
1
$0 1
$0 1
$0
MO
1
$0
1
$0
MO
1
2
2
2
1
1
1
2
1
1
1
1
1
1
1
2
2
2
1
1
2
1
1
1
$0
$0 $0 $0 $0
$0
$0
$0 $0
$0
$0
$0
$0
$0
$0
$0 $0
$0 $0
$0
$0 $0 $0
$0
PA MO
Azioni necessarie,
restrizioni o
limitazioni all'uso
PA
QL (56 CAD per 28 giorni) PA
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
7
Nome del farmaco
vancomycin hcl inj 500mg
vandazole
ZYVOX INJ
ZYVOX SUSR
Beta-lattamici, Cefalosporine
cefaclor er
cefaclor caps
cefaclor susr 125mg/5ml, 375mg/5ml
cefaclor susr 250mg/5ml
cefadroxil
cefazolin sodium/dextrose
cefazolin sodium inj 100gm, 1gm; 5%,
1gm, 20gm, 300gm
cefazolin sodium inj 10gm, 1gm, 500mg
cefdinir
cefditoren pivoxil tabs 200mg
cefditoren pivoxil tabs 400mg
cefepime inj 1gm/50ml; 5%, 1gm/50ml,
2gm/100ml, 2gm/50ml; 5%
cefepime inj 1gm, 2gm
cefotaxime sodium inj 10gm, 500mg
cefotaxime sodium inj 1gm, 2gm
cefotetan
cefotetan/dextrose
cefoxitin sodium inj 10gm, 1gm; 4%,
2gm; 2.2%
cefoxitin sodium inj 1gm, 2gm
cefpodoxime proxetil
cefprozil
ceftazidime/dextrose
ceftazidime inj 6gm
ceftazidime inj 1gm, 2gm
ceftriaxone in iso-osmotic dextrose
ceftriaxone sodium inj 1gm
ceftriaxone sodium inj 10gm, 1gm,
250mg, 2gm, 500mg
8
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
2
$0
2
$0
1
$0
1
$0
1
$0 1
$0
1
$0
1
$0 1
$0
1
1
1
1
1
$0
$0
$0 $0
$0
1
1
1
1
1
1
$0
$0 $0
$0
$0 $0
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0 $0 $0
$0 $0 $0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
PA
QL (1800 ML per 28 giorni) PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
ceftriaxone/dextrose
cefuroxime axetil tabs
cefuroxime sodium inj 1.5gm, 7.5gm,
75gm
cefuroxime sodium inj 750mg
cefuroxime/dextrose inj 750mg; 4.1%
cephalexin
SUPRAX CAPS
SUPRAX CHEW 100MG
SUPRAX CHEW 200MG
SUPRAX SUSR 500MG/5ML
SUPRAX SUSR 100MG/5ML,
200MG/5ML
tazicef inj 1gm, 2gm, 6gm
TEFLARO
Beta-lattamici, altro
aztreonam inj 2gm
aztreonam inj 1gm
imipenem/cilastatin
INVANZ INJ 1GM
INVANZ INJ 1GM
meropenem
Beta-lattamici, Penicilline
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
ampicillin sodium inj 10gm, 125mg,
1gm, 250mg, 2gm
ampicillin sodium inj 1gm, 2gm, 500mg
ampicillin-sulbactam
ampicillin caps
ampicillin susr 125mg/5ml
ampicillin susr 250mg/5ml
BICILLIN L-A
dicloxacillin sodium
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0 1
$0
MO
1
$0
1
1
1
2
2
2
2
2
$0
$0 $0
$0
$0 $0
$0 $0
1
2
1
1
1
1
$0 $0 $0
$0
$0
$0 $0
$0
$0
$0
$0
$0
1
1
1
1
1
2
1
$0
$0 $0
$0 $0
$0
$0
1
1
1
2
2
1
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
9
Nome del farmaco
NALLPEN ISO-OSMOTIC IN DEXTROSE
NALLPEN/DEXTROSE INJ 0;
1GM/50ML
oxacillin sodium inj 10gm, 1gm
oxacillin sodium inj 2gm
penicillin g potassium inj 20000000unit,
5000000unit
penicillin g procaine
penicillin g sodium
penicillin v potassium
piperacillin sodium/ tazobactam sodium
piperacillin sodium/tazobactam sodium
inj 2gm; 0.25gm
piperacillin sodium/tazobactam sodium
inj 3gm; 0.375gm, 4gm; 0.5gm
Macrolidi
azithromycin pack, susr, tabs
azithromycin inj 500mg
clarithromycin susr, tabs
DIFICID
ERYTHROCIN LACTOBIONATE INJ
500MG
erythromycin base tabs
erythromycin ethylsuccinate tabs
erythromycin stearate tabs
erythromycin cpep 250mg
Chinoloni
ciprofloxacin er
ciprofloxacin hcl tabs 100mg, 250mg,
500mg, 750mg
ciprofloxacin i.v.-in d5w inj
200mg/100ml; 5%
ciprofloxacin i.v.-in d5w inj
400mg/200ml; 5%
ciprofloxacin inj, otic soln, susr
levofloxacin in d5w
10
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
2
$0
1
1
1
$0 $0
$0
1
1
1
1
1
$0
$0 $0
$0 $0
MO
1
$0
MO
1
1
1
2
2
$0
$0
$0
$0
$0
MO
MO
MO
MO
1
1
1
1
MO
MO
MO
1
1
$0
$0
$0
$0
$0
$0
MO
MO
MO
MO
1
$0
1
$0
MO
1
1
$0
$0 MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
levofloxacin inj 25mg/ml
levofloxacin oral soln 25mg/ml
levofloxacin tabs 250mg, 500mg,
750mg
ofloxacin tabs 400mg
Sulfonamidi
sulfadiazine tabs
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
Tetracicline
doxy 100
doxycycline hyclate dr
doxycycline hyclate caps, inj, tabs
doxycycline monohydrate caps
doxycycline monohydrate tabs 50mg
doxycycline monohydrate tabs 100mg,
150mg, 50mg, 75mg
doxycycline caps, susr
minocycline hcl caps
morgidox 1x100mg caps
morgidox 2x100mg caps
tetracycline hcl caps
ANTICONVULSIVANTI: FARMACI PER IL
TRATTAMENTO DELLE CONVULSIONI
Anticonvulsivanti, altro
APTIOM TABS 200MG, 400MG,
800MG
APTIOM TABS 600MG
FYCOMPA TABS 10MG, 12MG, 4MG,
6MG, 8MG
FYCOMPA TABS 2MG
levetiracetam oral soln, tabs
levetiracetam inj 1000mg/100ml;
750mg/100ml, 1500mg/100ml; 540mg/100ml, 500mg/100ml; 820mg/100ml
levetiracetam inj 500mg/5ml
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0 1
$0
MO
1
$0
MO
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0 $0
$0
$0
$0 $0 $0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
$0
QL (30 CAD per 30 giorni) PA MO
2
2
$0
$0
QL (60 CAD per 30 giorni) PA MO
QL (30 CAD per 30 giorni) PA MO
2
1
1
$0
$0
$0 QL (60 CAD per 30 giorni) PA MO
MO
1
$0
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
11
Nome del farmaco
POTIGA TABS 50MG
POTIGA TABS 200MG, 300MG,
400MG
Agenti che modificano i canali del calcio CELONTIN
ethosuximide
LYRICA SOLN
LYRICA CAPS 225MG, 300MG
LYRICA CAPS 100MG, 150MG,
200MG, 25MG, 50MG, 75MG
zonisamide
Agenti che aumentano l'acido gamma­
aminobutirrico (GABA)
clonazepam odt tbdp 1mg
clonazepam odt tbdp 2mg
clonazepam odt tbdp 0.125mg, 0.25mg,
0.5mg
clonazepam tabs 1mg
clonazepam tabs 2mg
clonazepam tabs 0.5mg
diazepam gel 10mg, 2.5mg, 20mg
divalproex sodium
divalproex sodium dr
divalproex sodium er
gabapentin caps, soln, tabs
GABITRIL TABS 12MG, 16MG
ONFI SUSP
ONFI TABS 10MG, 20MG
phenobarbital tabs
phenobarbital elix
primidone tabs
SABRIL
tiagabine hydrochloride
valproate sodium inj
valproic acid caps, syrp
Agenti che riducono il glutammato
12
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
2
$0
QL (270 CAD per 30 giorni) MO
2
$0
QL (90 CAD per 30 giorni) MO
2
1
2
2
2
$0
$0
$0
$0
$0
MO
MO
QL (900 ML per 30 giorni) PA MO
QL (60 CAD per 30 giorni) PA MO
QL (90 CAD per 30 giorni) PA MO
1
$0
MO
1
1
1
$0
$0
$0
QL (120 CAD per 30 giorni) MO
QL (300 CAD per 30 giorni) MO
QL (90 CAD per 30 giorni) MO
1
1
1
1
1
1
1
1
2
2
2
1
1
1
2
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
QL (120 CAD per 30 giorni) MO
QL (300 CAD per 30 giorni) MO
QL (90 CAD per 30 giorni) MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (120 CAD per 30 giorni) PA MO
QL (1500 ML per 30 giorni) PA MO
MO
PA LA
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Costo
Livello a Suo
Nome del farmaco
di
carico
Classe
per il
farmaco
felbamate
1
$0
lamotrigine chew, tabs
1
$0
topiramate cpsp, tabs
1
$0
Agenti per i canali del sodio
BANZEL
2
$0
carbamazepine er
1
$0
carbamazepine chew, susp, tabs
1
$0
DILANTIN CAPS 30MG
2
$0
epitol
1
$0
fosphenytoin sodium inj 100mg pe/2ml
1
$0 fosphenytoin sodium inj 500mg pe/10ml
1
$0
oxcarbazepine
1
$0
PEGANONE
2
$0
phenytoin sodium extended
1
$0
phenytoin sodium inj
1
$0 phenytoin chew, susp
1
$0
TEGRETOL-XR TB12 100MG
2
$0
VIMPAT INJ
2
$0 VIMPAT ORAL SOLN
2
$0
VIMPAT TABS 50MG
2
$0
VIMPAT TABS 100MG, 150MG,
2
$0
200MG
AGENTI ANTIDEMENZA: FARMACI PER
IL TRATTAMENTO DELLA DEMENZA
E DELL'AMNESIA
Agenti antidemenza, altro
ergoloid mesylates tabs
1
$0
Inibitori della colinesterasi
donepezil hcl tbdp
1
$0
donepezil hcl tabs 23mg, 5mg
1
$0
donepezil hcl tabs 10mg
1
$0
EXELON PT24
2
$0
galantamine hydrobromide soln
1
$0
galantamine hydrobromide cp24
1
$0
galantamine hydrobromide tabs
1
$0
rivastigmine tartrate
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (180 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
PA MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (200 ML per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
13
Nome del farmaco
Antagonista del recettore N-metil-D­
aspartato (NMDA)
NAMENDA TITRATION PAK
NAMENDA XR
NAMENDA XR TITRATION PACK
NAMENDA SOLN
NAMENDA TABS
ANTIDEPRESSIVI: FARMACI PER IL
TRATTAMENTO DELLA DEPRESSIONE
Antidepressivi, altro
bupropion hcl er
bupropion hcl sr tb12 100mg, 150mg,
200mg
bupropion hcl xl
bupropion hcl tabs
mirtazapine odt
mirtazapine tabs
Inibitori della monoamino ossidasi
EMSAM
MARPLAN
phenelzine sulfate tabs
tranylcypromine sulfate
SSRI/SNRI (Inibitori selettivi della
ricaptazione della serotonina/ Inibitore
della ricaptazione della serotonina
e della norepinefrina)
BRINTELLIX
citalopram hydrobromide soln
citalopram hydrobromide tabs 10mg
citalopram hydrobromide tabs 40mg
citalopram hydrobromide tabs 20mg
desvenlafaxine er tb24 100mg, 50mg
desvenlafaxine er tb24 100mg, 50mg
duloxetine hcl cpep 20mg, 60mg
duloxetine hcl cpep 30mg
escitalopram oxalate soln
escitalopram oxalate tabs 20mg
14
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
2
2
2
2
1
1
1
1
1
1
2
2
1
1
2
1
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (49 CAD per 28 giorni) PA MO
QL (30 CAD per 30 giorni) PA MO
QL (30 CAD per 30 giorni) PA MO
QL (360 ML per 30 giorni) PA MO
QL (60 CAD per 30 giorni) PA MO
QL (60 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (180 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
MO
QL (30 CAD per 30 giorni) ST MO
MO
MO
MO
QL (30 CAD per 30 giorni) ST MO
QL (600 ML per 30 giorni) MO
QL (120 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) ST
QL (30 CAD per 30 giorni) ST MO
QL (60 CAD per 30 giorni) MO
QL (90 CAD per 30 giorni) MO
QL (600 ML per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
escitalopram oxalate tabs 10mg, 5mg
FETZIMA
FETZIMA TITRATION PACK
fluoxetine
fluoxetine dr
fluoxetine hcl caps, soln, tabs
fluvoxamine maleate
maprotiline hcl
nefazodone hcl
olanzapine/fluoxetine
paroxetine hcl
PAXIL SUSP
PRISTIQ TB24 25MG
sertraline hcl conc, tabs
trazodone hcl
venlafaxine hcl
venlafaxine hcl er cp24 37.5mg, 75mg
venlafaxine hcl er cp24 150mg
venlafaxine hcl er tb24 225mg, 37.5mg,
75mg
venlafaxine hcl er tb24 150mg
VIIBRYD TABS
VIIBRYD KIT
Triciclici
amitriptyline hcl tabs
amoxapine
clomipramine hcl caps
desipramine hcl tabs
doxepin hcl caps, conc
imipramine hcl tabs
nortriptyline hcl caps, soln
perphenazine/amitriptyline
protriptyline hcl
SURMONTIL
ANTIEMETICI: FARMACI PER LA NAUSEA
E IL VOMITO
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
2
2
1
1
1
1
1
1
1
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (45 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) ST MO
QL (30 CAD per 30 giorni) ST MO
MO
QL (4 CAD per 28 giorni) MO
MO
MO
MO
MO
QL (30 CAD per 30 giorni) MO
MO
MO
QL (120 CAD per 30 giorni) ST
MO
MO
MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 365 giorni) MO
PA MO
MO
PA MO
MO
PA MO
PA MO
MO
MO
MO
PA MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
15
Nome del farmaco
Antiemetici, altro
meclizine hcl tabs
phenadoz supp 25mg
phenadoz supp 12.5mg
phenergan supp
promethazine hcl supp 12.5mg, 25mg,
50mg
promethegan supp 12.5mg, 25mg
promethegan supp 50mg
TRANSDERM-SCOP
Aggiunte alla terapia emetogenica
dronabinol
EMEND CAPS 40MG
EMEND CAPS 0, 125MG, 80MG
granisetron hcl tabs
ondansetron hcl oral soln
ondansetron hcl inj 40mg/20ml,
4mg/2ml
ondansetron hcl tabs 24mg
ondansetron hcl tabs 4mg, 8mg
ondansetron odt
ANTIMICOTICI: FARMACI PER IL
TRATTAMENTO DELLE INFEZIONI FUNGINE
Antimicotici
ABELCET
AMBISOME
amphotericin b
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
ciclodan
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine crea
clotrimazole/betamethasone dipropionate
clotrimazole external crea 1%
16
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
2
1
2
2
1
1
1
1
1
1
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
PA
PA MO
PA
PA MO
$0
$0
$0
$0
$0
$0
$0
$0
$0
PA
PA MO
MO
$0
$0
$0
B/D
B/D MO
B/D MO
QL (60 CAD per 30 giorni) PA MO
QL (1 CAD per 30 giorni) B/D MO
QL (6 CAD per 30 giorni) B/D MO
QL (60 CAD per 30 giorni) B/D MO
QL (900 ML per 30 giorni) B/D MO
MO
2
2
1
2
2
1
1
1
1
1
$0
$0
$0
$0 $0
$0
$0
$0
$0
$0
MO
MO
MO
MO
1
$0
MO
B/D
B/D MO
B/D MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
clotrimazole soln 1%
clotrimazole troc 10mg
econazole nitrate crea
ERAXIS
fluconazole in dextrose
fluconazole in nacl
fluconazole susr, tabs
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole caps
ketoconazole crea, sham, tabs
NOXAFIL INJ
NOXAFIL SUSP, TBEC
nyamyc
nystatin crea, oint, powd, susp, tabs
nystop
SPORANOX SOLN
terbinafine hcl tabs
terconazole
voriconazole inj
voriconazole susr, tabs
AGENTI ANTIGOTTOSI: FARMACI PER IL
TRATTAMENTO DELLA GOTTA
Agenti antigottosi
allopurinol tabs
colchicine caps, tabs
COLCRYS
probenecid/colchicine
probenecid tabs
AGENTI ANTIEMICRANICI: FARMACI PER IL
TRATTAMENTO DELLE CEFALEE GRAVI
Alcaloidi dell'ergot
dihydroergotamine mesylate inj
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
2
$0
1
$0 1
$0 1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
PA
MO
MO
MO
MO
PA MO
MO
PA
PA MO
MO
MO
PA MO
MO
MO
MO
1
1
2
1
1
1
$0
$0 $0
$0
$0
$0
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
17
Nome del farmaco
MIGERGOT
Antagonisti del recettore della serotonina
(5-HT) 1b/1d
naratriptan hcl
rizatriptan benzoate
rizatriptan benzoate odt
sumatriptan succinate refill inj
6mg/0.5ml
sumatriptan succinate refill inj
4mg/0.5ml
sumatriptan succinate tabs
sumatriptan succinate inj 6mg/0.5ml
sumatriptan succinate inj 4mg/0.5ml,
6mg/0.5ml
sumatriptan soln
AGENTI ANTIMIASTENICI: FARMACI PER IL
TRATTAMENTO DELLA MIASTENIA GRAVIS
Parasimpaticomimetici
guanidine hcl
MESTINON TIMESPAN
MESTINON SYRP
pyridostigmine bromide tabs
ANTIMICOBATTERICI: FARMACI PER IL
TRATTAMENTO DELLA TUBERCOLOSI
Antimicobatterici, altro
dapsone tabs
rifabutin
Antitubercolari
CAPASTAT SULFATE
cycloserine
ethambutol hcl tabs
isoniazid inj
isoniazid syrp, tabs
PASER
PRIFTIN
pyrazinamide tabs
18
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
2
$0
QL (20 CAD per 28 giorni) MO
1
1
1
1
$0
$0
$0
$0
QL (9 CAD per 30 giorni) MO
QL (12 CAD per 30 giorni) MO
QL (12 CAD per 30 giorni) MO
QL (4 ML per 30 giorni)
1
$0
QL (4 ML per 30 giorni) MO
1
1
1
$0
$0
$0
QL (9 CAD per 30 giorni) MO
QL (4 ML per 30 giorni)
QL (4 ML per 30 giorni) MO
1
$0
QL (6 CAD per 30 giorni) MO
1
2
2
1
1
1
2
1
1
1
1
2
2
1
$0
$0
$0
$0
$0
$0
$0 $0 $0
$0 $0
$0
$0
$0
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
rifampin caps, inj
RIFATER
SIRTURO
TRECATOR
ANTINEOPLASTICI: FARMACI PER IL
TRATTAMENTO DEI TUMORI
Agenti alchilanti
ALKERAN TABS
BUSULFEX
cyclophosphamide inj
cyclophosphamide caps
HEXALEN
ifosfamide/mesna
LEUKERAN
lomustine
MATULANE
melphalan hydrochloride
MUSTARGEN
TEMODAR INJ
TREANDA
VALCHLOR
Antiandrogeni
bicalutamide
flutamide
NILANDRON
XTANDI
ZYTIGA
Agenti antiangiogenici
POMALYST
REVLIMID
THALOMID CAPS 100MG, 150MG,
50MG
THALOMID CAPS 200MG
Antiestrogeni/Modificanti EMCYT
FARESTON
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
2
$0
2
$0
2
$0
2
2
1
1
2
1
2
1
2
1
2
2
2
2
1
1
2
2
2
2
2
2
2
2
2
$0
$0 $0 $0
$0
$0 $0
$0 $0 $0
$0 $0
$0 $0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
QL (188 CAD per 365 giorni) PA
MO
B/D MO
B/D MO
MO
MO
B/D
PA
MO
MO
MO
QL (120 CAD per 30 giorni) PA LA
QL (120 CAD per 30 giorni) PA
QL (21 CAD per 28 giorni) PA LA
QL (30 CAD per 30 giorni) PA LA
QL (28 CAD per 28 giorni) PA
QL (56 CAD per 28 giorni) PA
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
19
Nome del farmaco
SOLTAMOX
tamoxifen citrate tabs
Antimetaboliti
DEPOCYT
DROXIA
hydroxyurea caps
mercaptopurine tabs
PURIXAN
TABLOID
Antineoplastici, altro
ABRAXANE
adrucil
ALIMTA
amifostine
ARRANON
AVASTIN
azacitidine
BELEODAQ
BICNU
bleomycin sulfate
carboplatin inj 150mg/15ml,
450mg/45ml, 50mg/5ml, 600mg/60ml
cisplatin
cladribine
CLOLAR
COSMEGEN
cytarabine aqueous
dacarbazine
daunorubicin hcl inj 5mg/ml
DAUNOXOME
decitabine
dexrazoxane
DOCEFREZ
docetaxel inj 140mg/7ml, 160mg/16ml,
200mg/20ml, 20mg/2ml, 20mg/ml,
80mg/4ml, 80mg/8ml
20
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
1
$0
2
$0 2
$0
1
$0 1
$0
2
$0
2
$0
2
$0 1
$0
2
$0
1
$0 2
$0 2
$0
1
$0
2
$0
2
$0 1
$0
1
$0
1
1
2
2
1
1
1
2
1
1
2
1
$0 $0
$0 $0 $0
$0
$0
$0 $0
$0
$0 $0
Azioni necessarie,
restrizioni o
limitazioni all'uso
PA MO
MO
MO
MO
PA
MO
B/D
PA
PA
PA
PA LA
B/D
B/D
B/D
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
doxorubicin hcl
doxorubicin hcl liposome
ELITEK
epirubicin hcl inj 200mg/100ml,
50mg/25ml
ERBITUX
ERWINAZE
FARYDAK
FASLODEX
floxuridine
fludarabine phosphate
fluorouracil inj 1gm/20ml, 2.5gm/50ml,
500mg/10ml, 5gm/100ml
FOLOTYN
FUSILEV
gemcitabine
gemcitabine hcl
HALAVEN
HERCEPTIN
IBRANCE
idarubicin hcl
ifosfamide
INTRON A W/DILUENT
INTRON A INJ 10MU/ML,
6000000UNIT/ML
irinotecan
ISTODAX
IXEMPRA KIT
JEVTANA
KADCYLA
leucovorin calcium tabs
leucovorin calcium inj 100mg, 200mg,
350mg, 500mg, 50mg
levoleucovorin calcium
LYNPARZA
mesna
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
B/D
1
$0 2
$0
PA
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
2
2
2
2
1
1
1
$0
$0
$0
$0
$0
$0 $0
PA
PA
QL (6 CAD per 21 giorni) PA LA
PA
B/D
2
2
1
1
2
2
2
1
1
2
2
$0 $0 $0
$0
$0
$0
$0
$0
$0 $0
$0
PA
PA
QL (21 CAD per 28 giorni) PA LA
1
2
2
2
2
1
1
$0
$0
$0
$0
$0
$0
$0
PA
PA
PA
PA
MO
1
2
1
$0
$0
$0 QL (448 CAD per 28 giorni) PA
B/D
PA
PA
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
21
Nome del farmaco
MESNEX TABS
mitomycin
mitoxantrone hcl
NIPENT
ONCASPAR
oxaliplatin
paclitaxel
PERJETA
PROLEUKIN
SYLATRON INJ 200MCG, 300MCG,
600MCG
SYLATRON INJ 200MCG, 300MCG
SYNRIBO
THERACYS
TICE BCG
TRISENOX
UVADEX
VALSTAR
VECTIBIX
VELCADE
vinblastine sulfate inj 1mg/ml
vincasar pfs
vincristine sulfate
vinorelbine tartrate
YERVOY
ZALTRAP INJ 100MG/4ML
ZALTRAP INJ 200MG/8ML
ZANOSAR
ZOLINZA
Inibitori dell'aromatasi, 3° generazione
anastrozole tabs
exemestane
letrozole
Inibitori enzimatici
etoposide inj
toposar
22
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
2
$0
MO
1
$0
1
$0
2
$0 2
$0 1
$0
1
$0
2
$0
PA LA
2
$0 2
$0
PA
2
2
2
2
2
2
2
2
2
1
1
1
1
2
2
2
2
2
1
1
1
1
1
$0
$0
$0 $0 $0
$0 $0 $0
$0
$0
$0
$0
$0
$0
$0
$0
$0 $0
$0
$0
$0
$0 $0 PA LA
PA
PA
PA
PA
B/D
B/D
B/D
PA
PA
PA LA
QL (120 CAD per 30 giorni) PA
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
topotecan hcl
ZYDELIG
Inibitori bersaglio molecolare
AFINITOR
AFINITOR DISPERZ
BOSULIF
CAPRELSA TABS 300MG
CAPRELSA TABS 100MG
COMETRIQ KIT 0, 20MG
COMETRIQ KIT 0
ERIVEDGE
GILOTRIF
GLEEVEC TABS 400MG
GLEEVEC TABS 100MG
ICLUSIG TABS 45MG
ICLUSIG TABS 15MG
IMBRUVICA
INLYTA TABS 5MG
INLYTA TABS 1MG
JAKAFI
LENVIMA 10MG DAILY DOSE
LENVIMA 14MG DAILY DOSE
LENVIMA 20MG DAILY DOSE
LENVIMA 24MG DAILY DOSE
MEKINIST TABS 0.5MG
MEKINIST TABS 2MG
NEXAVAR
SPRYCEL TABS 100MG, 140MG
SPRYCEL TABS 20MG, 50MG, 70MG,
80MG
STIVARGA
SUTENT CAPS 25MG, 37.5MG, 50MG
SUTENT CAPS 12.5MG
TAFINLAR CAPS 75MG
TAFINLAR CAPS 50MG
TARCEVA TABS 25MG
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (60 CAD per 30 giorni) PA
QL (30 CAD per 30 giorni) PA
QL (60 CAD per 30 giorni) PA
PA
QL (30 CAD per 30 giorni) PA
QL (60 CAD per 30 giorni) PA
PA
PA MO
QL (30 CAD per 30 giorni) PA LA
QL (30 CAD per 30 giorni) PA
QL (60 CAD per 30 giorni) PA
QL (90 CAD per 30 giorni) PA
QL (30 CAD per 30 giorni) PA
QL (60 CAD per 30 giorni) PA
QL (120 CAD per 30 giorni) PA
QL (120 CAD per 30 giorni) PA LA
QL (240 CAD per 30 giorni) PA LA
QL (60 CAD per 30 giorni) PA LA
PA
PA
PA
PA
QL (120 CAD per 30 giorni) PA LA
QL (30 CAD per 30 giorni) PA LA
QL (120 CAD per 30 giorni) PA LA
QL (30 CAD per 30 giorni) PA
QL (60 CAD per 30 giorni) PA
QL (120 CAD per 30 giorni) PA LA
QL (30 CAD per 30 giorni) PA
QL (90 CAD per 30 giorni) PA
QL (120 CAD per 30 giorni) PA LA
QL (180 CAD per 30 giorni) PA LA
QL (60 CAD per 30 giorni) PA LA
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
23
Nome del farmaco
TARCEVA TABS 100MG, 150MG
TASIGNA
TORISEL
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYKADIA
Anticorpi monoclonali
ARZERRA
BLINCYTO
CYRAMZA
GAZYVA
KEYTRUDA
OPDIVO
RITUXAN
SYLVANT
Retinoidi
PANRETIN
TARGRETIN
tretinoin caps 10mg
ANTIPARASSITARI: FARMACI PER IL
TRATTAMENTO DELLA MALARIA E DEI
PIDOCCHI
Antielmintici
ALBENZA
ivermectin tabs
STROMECTOL
Antiprotozoari
ALINIA
atovaquone
atovaquone/proguanil hcl
chloroquine phosphate tabs
COARTEM
DARAPRIM
hydroxychloroquine sulfate tabs
24
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
2
$0 2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
1
2
2
1
1
1
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (90 CAD per 30 giorni) PA LA
QL (120 CAD per 30 giorni) PA
QL (180 CAD per 30 giorni) PA LA
QL (120 CAD per 30 giorni) PA LA
QL (60 CAD per 30 giorni) PA LA
QL (240 CAD per 30 giorni) PA LA
QL (150 CAD per 30 giorni) PA LA
PA LA
PA LA
PA
PA LA
PA LA
PA LA
PA
PA
MO
PA
MO
MO
MO
MO
MO
PA MO
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
mefloquine hcl
MEPRON
NEBUPENT
PENTAM 300
primaquine phosphate tabs
quinine sulfate
Pediculicidi/Scabicidi
lindane lotn, sham
malathion lotn
permethrin crea 5%
AGENTI ANTIPARKINSONIANI: FARMACI
UTILIZZATI PER IL TRATTAMENTO DEL
MORBO DI PARKINSON
Anticolinergici
benztropine mesylate inj, tabs
trihexyphenidyl hcl
Agenti antiparkinsoniani, altro
amantadine hcl caps, syrp, tabs
entacapone
Agonisti della dopamina
APOKYN
bromocriptine mesylate caps, tabs
NEUPRO
pramipexole dihydrochloride
ropinirole hcl
Precursori della dopamina/inibitori della
decarbossilasi degli L-aminoacidi
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
carbidopa/levodopa/entacapone
carbidopa tabs
Inibitori della monoamino ossidasi B (MAO-B)
AZILECT
selegiline hcl caps, tabs
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
1
2
1
2
1
1
1
1
1
1
1
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
PA MO
B/D MO
MO
MO
PA MO
MO
MO
MO
PA MO
PA MO
MO
MO
PA LA
MO
QL (30 CAD per 30 giorni) MO
MO
MO
MO
MO
MO
MO
MO
QL (30 CAD per 30 giorni) MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
25
Costo
Livello a Suo
Nome del farmaco
di
carico
Classe
per il
farmaco
ANTIPSICOTICI: FARMACI PER IL TRATTAMENTO
DELLE PSICOSI E DELLA SCHIZOFRENIA
1° Generazione/tipici
ADASUVE
2
$0 1
$0
chlorpromazine hcl inj, tabs
compazine supp
1
$0 1
$0
compro
fluphenazine decanoate inj
1
$0
fluphenazine hcl conc, elix, inj, tabs
1
$0
haloperidol decanoate
1
$0
haloperidol lactate
1
$0
haloperidol conc, tabs
1
$0
loxapine succinate caps
1
$0
ORAP
2
$0
perphenazine tabs
1
$0
prochlorperazine
1
$0
prochlorperazine edisylate inj
1
$0
prochlorperazine maleate tabs
1
$0
thioridazine hcl tabs
1
$0
thiothixene caps
1
$0
trifluoperazine hcl tabs
1
$0
2° Generazione/atipici
2
$0
ABILIFY DISCMELT
ABILIFY MAINTENA INJ 300MG,
2
$0
400MG
ABILIFY MAINTENA INJ 300MG
2
$0
ABILIFY INJ
2
$0
ABILIFY ORAL SOLN
2
$0
aripiprazole
1
$0
FANAPT
2
$0
FANAPT TITRATION PACK
2
$0
GEODON INJ
2
$0
INVEGA SUSTENNA INJ
2
$0
39MG/0.25ML
INVEGA SUSTENNA INJ 78MG/0.5ML
2
$0
INVEGA SUSTENNA INJ
2
$0
117MG/0.75ML
26
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
MO
MO
QL (60 CAD per 30 giorni) MO
MO
MO
QL (900 ML per 30 giorni) MO
QL (30 CAD per 30 giorni)
QL (60 CAD per 30 giorni) ST MO
QL (16 CAD per 365 giorni) ST
MO
QL (0,25 ML per 28 giorni) MO
QL (0,5 ML per 28 giorni) MO
QL (0,75 ML per 28 giorni) MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
INVEGA SUSTENNA INJ 156MG/ML
INVEGA SUSTENNA INJ
234MG/1.5ML
INVEGA TB24 1.5MG, 3MG, 9MG
INVEGA TB24 6MG
LATUDA
olanzapine odt
olanzapine inj
olanzapine tabs 10mg, 15mg, 20mg,
5mg, 7.5mg
olanzapine tabs 2.5mg
quetiapine fumarate tabs 200mg
quetiapine fumarate tabs 25mg
quetiapine fumarate tabs 300mg,
400mg
quetiapine fumarate tabs 100mg, 50mg
RISPERDAL CONSTA
risperidone odt tbdp 4mg
risperidone odt tbdp 1mg, 2mg
risperidone odt tbdp 0.25mg, 0.5mg,
3mg
risperidone soln
risperidone tabs 4mg
risperidone tabs 1mg, 2mg
risperidone tabs 0.25mg, 0.5mg, 3mg
SAPHRIS SUBL 2.5MG
SAPHRIS SUBL 10MG, 5MG
ziprasidone hcl
ZYPREXA RELPREVV INJ 405MG
ZYPREXA RELPREVV INJ 210MG,
300MG
Resistenti al trattamento
clozapine
clozapine odt
FAZACLO
VERSACLOZ
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
2
$0
QL (1 ML per 28 giorni) MO
2
$0
QL (1,5 ML per 28 giorni) MO
2
2
2
1
1
1
$0
$0
$0
$0
$0
$0
QL (30 CAD per 30 giorni) ST MO
QL (60 CAD per 30 giorni) ST MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
MO
QL (30 CAD per 30 giorni) MO
1
1
1
1
$0
$0
$0
$0
QL (60 CAD per 30 giorni) MO
QL (120 CAD per 30 giorni) MO
QL (180 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
1
2
1
1
1
$0
$0
$0
$0
$0
QL (90 CAD per 30 giorni) MO
MO
QL (120 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (90 CAD per 30 giorni) MO
1
1
1
1
2
2
1
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
QL (120 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (90 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni)
QL (60 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (1 CAD per 28 giorni)
QL (2 CAD per 28 giorni)
1
1
2
2
$0
$0
$0
$0
ST
ST
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
27
Nome del farmaco
AGENTI ANTISPASTICI: FARMACI PER IL
TRATTAMENTO DEGLI SPASMI MUSCOLARI
Agenti antispastici
baclofen tabs
dantrolene sodium caps
tizanidine hcl tabs
ANTIVIRALI: FARMACI PER IL TRATTAMENTO
DELLE INFEZIONI VIRALI, DELL'EPATITE E
DELLE INFEZIONI HIV/AIDS
Agenti anti-Citomegalovirus (CMV)
foscarnet sodium
ganciclovir inj
VALCYTE
valganciclovir
Agenti anti-epatite B (HBV)
adefovir dipivoxil
BARACLUDE TABS
BARACLUDE SOLN
entecavir
EPIVIR HBV SOLN
INTRON A INJ 18MU, 50MU
lamivudine tabs 100mg
TYZEKA
Agenti anti-epatite C (HCV)
HARVONI
moderiba tabs
PEG-INTRON REDIPEN
PEG-INTRON INJ 50MCG/0.5ML
PEGINTRON INJ 120MCG/0.5ML,
150MCG/0.5ML, 80MCG/0.5ML
ribavirin
SOVALDI
Agenti anti-HIV, inibitori dell'integrasi
(INSTI)
ATRIPLA
ISENTRESS TABS
28
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
1
1
1
1
2
1
1
2
2
1
2
2
1
2
2
1
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
B/D
B/D
MO
MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (630 ML per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
MO
PA LA
MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) PA
PA
PA
PA
PA
1
2
$0
$0
PA
QL (28 CAD per 28 giorni) PA
2
2
$0
$0
QL (30 CAD per 30 giorni) MO
QL (120 CAD per 30 giorni) MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
ISENTRESS CHEW
ISENTRESS PACK
TIVICAY
VITEKTA
Agenti anti-HIV, inibitori non-nucleosidici
della trascrittasi inversa (NNRTI)
COMPLERA
EDURANT
INTELENCE TABS 25MG
INTELENCE TABS 100MG, 200MG
nevirapine
nevirapine er
RESCRIPTOR
STRIBILD
SUSTIVA
VIRAMUNE XR TB24 100MG
VIRAMUNE SUSP
Agenti anti-HIV, inibitori nucleosidici
e nucleotidici della trascrittasi
inversa (NRTI)
abacavir
abacavir sulfate/lamivudine/zidovudine
didanosine
EMTRIVA
EPIVIR SOLN
EPZICOM
lamivudine/zidovudine
lamivudine soln 10mg/ml
lamivudine tabs 150mg, 300mg
RETROVIR IV INFUSION
stavudine
TRIUMEQ
TRUVADA
VIDEX PEDIATRIC
VIREAD POWD
VIREAD TABS 200MG, 250MG
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
2
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (180 CAD per 30 giorni) MO
QL (300 CAD per 30 giorni)
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni)
2
2
2
2
1
1
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0 $0
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (180 CAD per 30 giorni)
QL (60 CAD per 30 giorni) MO
MO
MO
MO
QL (30 CAD per 30 giorni) MO
MO
1
1
1
2
2
2
1
1
1
2
1
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0 $0
$0 $0
$0
$0
$0
$0
$0 MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
29
Nome del farmaco
VIREAD TABS 150MG, 300MG
ZIAGEN SOLN
zidovudine
Agenti anti-HIV, altro
FUZEON
SELZENTRY TABS 300MG
SELZENTRY TABS 150MG
TYBOST
Agenti anti-HIV, Inibitori della proteasi
APTIVUS SOLN
APTIVUS CAPS
CRIXIVAN
EVOTAZ
INVIRASE
KALETRA SOLN
KALETRA TABS 200MG; 50MG
KALETRA TABS 100MG; 25MG
LEXIVA
NORVIR
PREZCOBIX
PREZISTA SUSP
PREZISTA TABS 75MG
PREZISTA TABS 150MG, 600MG,
800MG
REYATAZ PACK
REYATAZ CAPS 150MG, 200MG,
300MG
VIRACEPT
Agenti anti-influenzali RELENZA DISKHALER
rimantadine hcl
TAMIFLU SUSR
TAMIFLU CAPS 30MG
TAMIFLU CAPS 45MG, 75MG
Agenti anti-erpetici
acyclovir sodium inj 1000mg, 50mg/ml
30
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0 2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0 2
$0
2
2
$0 $0
2
$0
$0
$0
$0
$0
$0
$0
2
1
2
2
2
1
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
QL (60 CAD per 30 giorni)
QL (120 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
MO
MO
QL (30 CAD per 30 giorni)
MO
QL (390 ML per 30 giorni) MO
QL (120 CAD per 30 giorni) MO
QL (240 CAD per 30 giorni) MO
MO
MO
QL (30 CAD per 30 giorni)
MO
MO
MO
MO
QL (120 CAD per 365 giorni) MO
MO
QL (1080 ML per 365 giorni) MO
QL (168 CAD per 365 giorni) MO
QL (84 CAD per 365 giorni) MO
B/D
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Costo
Livello a Suo
Nome del farmaco
di
carico
Classe
per il
farmaco
acyclovir sodium inj 500mg
1
$0
acyclovir caps, oint, susp, tabs
1
$0
DENAVIR
2
$0
famciclovir tabs 125mg, 250mg
1
$0
famciclovir tabs 500mg
1
$0
valacyclovir hcl
1
$0
Antivirali
VIRAZOLE
2
$0 ANSIOLITICI: FARMACI PER IL TRATTAMENTO
DELL'ANSIA
Ansiolitici, altro
buspirone hcl tabs
1
$0
Benzodiazepine
alprazolam tabs 0.25mg, 0.5mg
1
$0
alprazolam tabs 1mg, 2mg
1
$0
clorazepate dipotassium tabs 15mg
1
$0
clorazepate dipotassium tabs 3.75mg,
1
$0
7.5mg
diazepam intensol
1
$0
diazepam inj 5mg/ml
1
$0
diazepam oral soln 1mg/ml
1
$0
diazepam tabs 10mg, 2mg, 5mg
1
$0
lorazepam intensol
1
$0
lorazepam tabs
1
$0
lorazepam inj 4mg/ml
1
$0
lorazepam inj 2mg/ml
1
$0
SSRI/SNRI (Inibitori selettivi della ricap­
tazione della serotonina/ Inibitore della
ricaptazione della serotonina e della
norepinefrina)
duloxetine hcl cpep 40mg
1
$0
AGENTI BIPOLARI: FARMACI PER IL
TRATTAMENTO DEL DISTURBO BIPOLARE
Stabilizzatori dell'umore
EQUETRO
2
$0
lithium
1
$0
lithium carbonate er
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
B/D MO
MO
MO
QL (60 CAD per 30 giorni) MO
QL (90 CAD per 30 giorni) MO
MO
MO
QL (120 CAD per 30 giorni) MO
QL (150 CAD per 30 giorni) MO
QL (180 CAD per 30 giorni) MO
QL (90 CAD per 30 giorni) MO
MO
QL (240 ML per 30 giorni) PA MO
QL (1200 ML per 30 giorni) PA MO
QL (120 CAD per 30 giorni) PA MO
QL (150 ML per 30 giorni) MO
QL (90 CAD per 30 giorni) MO
QL (120 ML per 30 giorni)
QL (120 ML per 30 giorni) MO
QL (60 CAD per 30 giorni)
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
31
Nome del farmaco
lithium carbonate caps, tabs
REGOLATORI DELLA GLICEMIA: FARMACI
PER IL TRATTAMENTO DEL DIABETE
Agenti antidiabetici
acarbose
glimepiride
glipizide er
glipizide xl
glipizide/metformin hcl
glipizide tabs
glyburide micronized
glyburide/metformin hcl
glyburide tabs
INVOKAMET
INVOKANA TABS 300MG
INVOKANA TABS 100MG
JANUMET
JANUMET XR TB24 1000MG; 100MG,
500MG; 50MG
JANUMET XR TB24 1000MG; 50MG
JANUVIA
JENTADUETO
KORLYM
metformin hcl er
metformin hcl tabs
nateglinide
pioglitazone hcl
pioglitazone hcl-glimepiride
pioglitazone hcl/metformin hcl
repaglinide tabs 0.5mg, 1mg
repaglinide tabs 2mg
SYMLINPEN 120
SYMLINPEN 60
tolazamide
tolbutamide
TRADJENTA
32
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
MO
Azioni necessarie,
restrizioni o
limitazioni all'uso
1
1
1
1
1
1
1
1
1
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA MO
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
2
2
2
2
1
1
1
1
1
1
1
1
2
2
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
MO
QL (120 CAD per 30 giorni) PA
MO
MO
MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (90 CAD per 30 giorni) MO
QL (120 CAD per 30 giorni) MO
QL (240 CAD per 30 giorni) MO
QL (10,8 ML per 30 giorni) MO
QL (6 ML per 30 giorni) MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
TRULICITY
VICTOZA
Agenti glicemici
GLUCAGEN DIAGNOSTIC
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM
Insuline
LEVEMIR
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN
NOVOLOG PENFILL
PRODOTTI EMATICI / MODIFICATORI /
DILATATORI DEL VOLUME DEL SANGUE:
FARMACI PER IL TRATTAMENTO DEI
DISTURBI EMATICI; ANTICOAGULANTI:
FARMACI PER FLUIDIFICARE IL SANGUE
Anticoagulanti
ELIQUIS
enoxaparin sodium
fondaparinux sodium
heparin sodium/d5w
heparin sodium/nacl 0.45%
heparin sodium/nacl 0.9%
heparin sodium/sodium chloride 0.9%
heparin sodium/sodium chloride 0.9%
premix
heparin sodium inj 10000unit/
ml, 1000unit/ml, 20000unit/ml,
5000unit/0.5ml, 5000unit/ml
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (2 ML per 28 giorni) MO
QL (9 ML per 30 giorni) MO
QL (4 CAD per 30 giorni) MO
QL (4 CAD per 30 giorni) MO
QL (4 CAD per 30 giorni) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (60 CAD per 30 giorni) MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
33
Nome del farmaco
jantoven
PRADAXA
warfarin sodium tabs
XARELTO STARTER PACK
XARELTO TABS 10MG, 20MG
XARELTO TABS 15MG
Modificatori delle formazioni ematiche
anagrelide hydrochloride
ARANESP ALBUMIN FREE INJ
500MCG/ML
ARANESP ALBUMIN FREE INJ
150MCG/0.3ML, 60MCG/0.3ML
ARANESP ALBUMIN FREE INJ
200MCG/0.4ML, 40MCG/0.4ML
ARANESP ALBUMIN FREE INJ
25MCG/0.42ML
ARANESP ALBUMIN FREE INJ
100MCG/0.5ML
ARANESP ALBUMIN FREE INJ
300MCG/0.6ML
ARANESP ALBUMIN FREE INJ
150MCG/0.75ML
ARANESP ALBUMIN FREE INJ
10MCG/0.4ML
ARANESP ALBUMIN FREE INJ
100MCG/ML, 200MCG/ML, 25MCG/
ML, 300MCG/ML, 40MCG/ML,
60MCG/ML
LEUKINE INJ 250MCG
NEUMEGA
NEUPOGEN
PROCRIT INJ 10000UNIT/ML,
20000UNIT/ML, 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/ML
PROCRIT INJ 40000UNIT/ML
PROMACTA
Coagulanti
tranexamic acid inj
34
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
2
$0
1
$0
2
$0
2
$0
2
$0
1
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (60 CAD per 30 giorni) MO
MO
QL (51 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
MO
QL (1 ML per 21 giorni) PA
2
$0
QL (1,2 ML per 28 giorni) PA
2
$0
QL (1,6 ML per 28 giorni) PA
2
$0
QL (1,68 ML per 28 giorni) PA
2
$0
QL (2 ML per 28 giorni) PA
2
$0
QL (2,4 ML per 28 giorni) PA
2
$0
QL (3 ML per 28 giorni) PA
2
$0
QL (3,2 ML per 28 giorni) PA
2
$0
QL (4 ML per 28 giorni) PA
2
2
2
2
$0
$0
$0
$0
PA
PA
PA
QL (12 ML per 28 giorni) PA
2
2
$0
$0
$0
QL (8 ML per 28 giorni) PA
QL (30 CAD per 30 giorni) PA LA
1
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
tranexamic acid tabs
Agenti che modificano le piastrine
AGGRENOX
BRILINTA
cilostazol
clopidogrel tabs 300mg
clopidogrel tabs 75mg
ticlopidine hcl
AGENTI CARDIOVASCOLARI: FARMACI PER
IL TRATTAMENTO DEI DISTURBI CARDIACI
E CIRCOLATORI, PRESSIONE/FREQUENZA
CARDIACA ALTA, COLESTEROLO ALTO
Agonisti alfa-andrenergici
clonidine hcl tabs
clonidine hcl ptwk
midodrine hcl
Agenti per il blocco degli alfa-adrenergici
doxazosin mesylate
prazosin hcl
terazosin hcl
Antagonisti del recettore dell'angiotensina II
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
tabs 32mg; 12.5mg, 32mg; 25mg
candesartan cilexetil/hydrochlorothiazide
tabs 16mg; 12.5mg
eprosartan mesylate
irbesartan
irbesartan/hydrochlorothiazide
losartan potassium/hydrochlorothiazide
losartan potassium tabs 100mg
losartan potassium tabs 25mg, 50mg
telmisartan
telmisartan/amlodipine
telmisartan/hydrochloroth
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (30 CAD per 5 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
MO
QL (2 CAD per 365 giorni)
QL (30 CAD per 30 giorni) MO
PA MO
1
1
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
QL (60 CAD per 30 giorni) MO
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
1
1
1
1
1
1
MO
QL (8 CAD per 28 giorni) MO
MO
MO
MO
MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
35
Nome del farmaco
telmisartan/hydrochlorothiazide
valsartan
valsartan/hydrochlorothiazide
Inibitori dell'enzima convertitore dell'an­
giotensina (ACE)
benazepril hcl/hydrochlorothiazide
benazepril hcl tabs
captopril/hydrochlorothiazide
captopril tabs
enalapril maleate/hydrochlorothiazide
enalapril maleate tabs
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
lisinopril
lisinopril/hydrochlorothiazide
moexipril hcl
moexipril/hydrochlorothiazide
perindopril erbumine
quinapril hcl
quinapril/hydrochlorothiazide
ramipril
trandolapril
trandolapril/verapamil hcl
trandolapril/verapamil hcl er
Antiaritmici
amiodarone hcl tabs
disopyramide phosphate caps
flecainide acetate
lidocaine hcl inj 10mg/ml, 20mg/ml
mexiletine hcl
MULTAQ
pacerone
propafenone hcl
propafenone hcl er
quinidine gluconate cr
quinidine gluconate er
36
Costo
Azioni necessarie,
Livello a Suo
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
1
$0
QL (30 CAD per 30 giorni) MO
1
$0
MO
1
$0
QL (30 CAD per 30 giorni) MO
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
MO
MO
MO
QL (60 CAD per 30 giorni) MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Costo
Livello a Suo
Nome del farmaco
di
carico
Classe
per il
farmaco
quinidine sulfate
1
$0
quinidine sulfate er
1
$0
sorine
1
$0
sotalol hcl
1
$0
sotalol hcl (af)
1
$0
TIKOSYN
2
$0
Agenti per il blocco dei beta-adrenergici
acebutolol hcl caps
1
$0
atenolol/chlorthalidone
1
$0
atenolol tabs
1
$0
betaxolol hcl tabs 10mg, 20mg
1
$0
bisoprolol fumarate
1
$0
bisoprolol fumarate/hydrochlorothiazide
1
$0
carvedilol
1
$0
labetalol hcl inj
1
$0
labetalol hcl tabs
1
$0
metoprolol succinate er
1
$0
metoprolol tartrate inj, tabs
1
$0
metoprolol/hydrochlorothiazide
1
$0
nadolol/bendroflumethiazide
1
$0
nadolol tabs
1
$0
pindolol
1
$0
propranolol hcl er
1
$0
propranolol hcl inj
1
$0
propranolol hcl oral soln, tabs
1
$0
propranolol/hydrochlorothiazide
1
$0
timolol maleate tabs 10mg, 20mg, 5mg
1
$0
Agenti che bloccano i canali del calcio
amlodipine besylate/atorvastatin calcium
1
$0
amlodipine besylate/benazepril hcl
1
$0
amlodipine besylate/benazepril hydroch1
$0
loride
amlodipine besylate/valsartan
1
$0
amlodipine besylate tabs
1
$0
amlodipine/valsartan/hctz
1
$0
cartia xt
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
MO
QL (30 CAD per 30 giorni) MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
37
Nome del farmaco
dilt-xr
diltiazem cd cp24 120mg
diltiazem cd cp24 180mg, 240mg,
300mg
diltiazem hcl cd
diltiazem hcl er
diltiazem hcl inj
diltiazem hcl tabs
isradipine
matzim la
nicardipine hcl caps
nisoldipine
nisoldipine er
taztia xt cp24 180mg, 300mg
taztia xt cp24 120mg, 240mg, 360mg
verapamil hcl er
verapamil hcl sr cp24
verapamil hcl sr tbcr 240mg
verapamil hcl inj, tabs
Agenti cardiovascolari, altro
CORLANOR
digitek
digox
digoxin inj, oral soln, tabs
NORTHERA
pentoxifylline cr
pentoxifylline er
Diuretici, inibitori dell'anidrasi carbonica
acetazolamide er
acetazolamide tabs
methazolamide
Diuretici, Ansa
bumetanide inj, tabs
furosemide inj, oral soln, tabs
torsemide tabs
38
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
MO
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
2
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA
MO
PA LA
MO
MO
MO
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
Diuretici, risparmiatori di potassio
amiloride hcl tabs
amiloride/hydrochlorothiazide
eplerenone
spironolactone/hydrochlorothiazide
spironolactone tabs
triamterene/hydrochlorothiazide
Diuretici, tiazide
chlorothiazide
chlorthalidone tabs 25mg, 50mg
hydrochlorothiazide caps, tabs
indapamide tabs
methyclothiazide tabs
metolazone
Dislipidemici, derivati dell'acido fibrico
fenofibrate micronized
fenofibrate caps
fenofibrate tabs 145mg, 160mg, 48mg,
54mg
fenofibric acid
fenofibric acid dr
gemfibrozil tabs
Dislipidemici, inibitori della HMG CoA
reduttasi
atorvastatin calcium
CRESTOR
fluvastatin
lovastatin
pravastatin sodium
simvastatin tabs 10mg, 20mg, 40mg,
5mg
simvastatin tabs 80mg
Dislipidemici, altro
cholestyramine light
cholestyramine pack, powd
colestipol hcl
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
1
1
$0
$0
$0
MO
MO
MO
1
2
1
1
1
1
$0
$0
$0
$0
$0
$0
MO
QL (30 CAD per 30 giorni) MO
MO
MO
MO
MO
1
$0
$0
$0
$0
QL (30 CAD per 30 giorni) MO
1
1
1
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
39
Nome del farmaco
colestipol hcl for oral suspension
KYNAMRO
LOVAZA
micronized colestipol hcl
niacin er tbcr 1000mg, 500mg, 750mg
omega-3-acid ethyl esters
prevalite
VASCEPA
ZETIA
Vasodilatatori, arteriosi/venosi
ad azione diretta
isosorbide dinitrate er
isosorbide dinitrate tabs
isosorbide mononitrate
isosorbide mononitrate er
minitran
nitroglycerin lingual
nitroglycerin transdermal pt24 0.1mg/
hr, 0.6mg/hr
nitroglycerin inj
nitroglycerin pt24 0.2mg/hr, 0.4mg/hr,
0.6mg/hr
NITROSTAT
Vasodilatatori, arteriosi/venosi
ad azione diretta
hydralazine hcl inj, tabs
minoxidil tabs
AGENTI DEL SISTEMA NERVOSO CENTRALE:
FARMACI PER IL TRATTAMENTO DI ADHD,
SCLEROSI MULTIPLA, COREA ASSOCIATA
A MALATTIA DI HUNTINGTON
Agenti per il disturbo da deficit
dell'attenzione/iperattività, anfetamine
40
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
PA LA
QL (120 CAD per 30 giorni) ST MO
MO
MO
QL (120 CAD per 30 giorni) MO
MO
MO
QL (30 CAD per 30 giorni) MO
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
MO
MO
MO
MO
MO
MO
1
1
$0
$0
MO
2
$0
MO
1
1
$0
$0
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg;
1.25mg, 1.875mg; 1.875mg; 1.875mg;
1.875mg, 2.5mg; 2.5mg; 2.5mg;
2.5mg, 3.125mg; 3.125mg; 3.125mg;
3.125mg, 3.75mg; 3.75mg; 3.75mg;
3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg
amphetamine/dextroamphetamine tabs
5mg; 5mg; 5mg; 5mg
dextroamphetamine sulfate tabs
dextroamphetamine sulfate soln
Agenti per il disturbo da deficit
dell'attenzione/iperattività, non-anfetamine
guanfacine er
INTUNIV
metadate er
methylphenidate hcl er tbcr 10mg,
20mg
methylphenidate hcl sr
methylphenidate hcl tabs
Agenti del sistema nervoso centrale, altro
NUEDEXTA
riluzole
XENAZINE TABS 25MG
XENAZINE TABS 12.5MG
Agenti per la sclerosi multipla
AMPYRA
COPAXONE INJ 40MG/ML
COPAXONE INJ 20MG/ML
EXTAVIA
glatopa
AGENTI DENTALI E ORALI
Agenti dentali e orali
chlorhexidine gluconate oral rinse
oralone
paroex
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
1
$0
QL (60 CAD per 30 giorni) PA MO
1
$0
QL (90 CAD per 30 giorni) PA MO
1
1
$0
$0
QL (180 CAD per 30 giorni) PA MO
QL (1800 ML per 30 giorni) PA MO
1
2
1
1
$0
$0
$0
$0
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (90 CAD per 30 giorni) PA MO
QL (90 CAD per 30 giorni) PA MO
1
1
$0
$0
$0
$0
$0
$0
QL (90 CAD per 30 giorni) PA MO
PA MO
2
1
2
2
2
2
2
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
QL (60 CAD per 30 giorni) MO
MO
QL (120 CAD per 30 giorni) PA LA
QL (90 CAD per 30 giorni) PA LA
QL (60 CAD per 30 giorni) PA LA
QL (12 ML per 28 giorni) PA
QL (30 ML per 30 giorni) PA
QL (15 CAD per 30 giorni) PA
QL (30 ML per 30 giorni) PA
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
41
Nome del farmaco
periogard
pilocarpine hcl tabs 7.5mg
pilocarpine hydrochloride
triamcinolone acetonide pste 0.1%
triamcinolone in orabase
AGENTI DERMATOLOGICI: ANTIPSORIATICI,
VARI AGENTI PER MEMBRANA MUCO­
CUTANEA, ACNE, LESIONI CUTANEE,
ANTIBIOTICI
Agenti dermatologici
8-MOP
ABREVA
acitretin
ACNE MEDICATION
ACNE MEDICATION 5 LOTN
ALTABAX
ammonium lactate crea, lotn
amnesteem
antifungal
avita crea
avita gel
bacitracin zinc
bacitracin external oint 500unit/gm
calcipotriene
calcitrene
castellani paint modified/color
CLARAVIS CAPS 30MG
claravis caps 10mg, 20mg, 40mg
clindamycin phosphate foam 1%
clindamycin phosphate gel 1%
clindamycin phosphate lotn 1%
clindamycin phosphate external soln 1%
clindamycin phosphate swab 1%
clindamycin/benzoyl peroxide
desenex
desenex jock itch spray powder
42
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
1
$0
1
$0
2
3
1
3
3
2
1
1
3
1
1
3
3
1
1
3
2
1
1
1
1
1
1
1
3
3
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
*
PA MO
*
*
MO
MO
*
PA
PA MO
*
*
MO
MO
*
MO
MO
MO
MO
MO
MO
*
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Costo
Livello a Suo
Nome del farmaco
di
carico
Classe
per il
farmaco
ELIDEL
2
$0
ery
1
$0
erythromycin/benzoyl peroxide
1
$0
erythromycin gel 2%
1
$0
erythromycin pads 2%
1
$0
erythromycin soln 2%
1
$0
fluorouracil crea 0.5%
1
$0
fluorouracil crea 5%
1
$0
fluorouracil external soln 2%, 5%
1
$0
FUNGOID TINCTURE
3
$0
gentamicin sulfate crea 0.1%
1
$0
gentamicin sulfate external oint 0.1%
1
$0
hydrocortisone/aloe crea 0; 1%
3
$0
imiquimod crea
1
$0
kp benzoyl peroxide
3
$0
kp terbinafine hydrochloride
3
$0
lamisil af defense
3
$0
lice killing maximum strength
3
$0
lice treatment
3
$0
LOTRIMIN ULTRA
3
$0
methoxsalen caps
1
$0
metronidazole crea 0.75%
1
$0
metronidazole gel 0.75%, 1%
1
$0
metronidazole lotn 0.75%
1
$0
mupirocin
1
$0
mupirocin calcium
1
$0
myorisan
1
$0
OXSORALEN
2
$0
permethrin lotn 1%
3
$0
podofilox soln
1
$0
pyrethins/piperonyl buto xide
3
$0
REGRANEX
2
$0
RID ESSENTIAL LICE ELIMINATION KIT
3
$0
rosadan
1
$0
SANTYL
2
$0
sb lice treatment
3
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (60 GM per 30 giorni) ST MO
MO
MO
MO
MO
MO
MO
MO
*
MO
MO
*
MO
*
*
*
*
*
*
MO
MO
MO
MO
MO
MO
MO
*
MO
*
QL (15 GM per 30 giorni) PA MO
*
MO
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
43
Nome del farmaco
selenium sulfide lotn
silver sulfadiazine
sodium sulfacetamide lotn 10%
ssd
sulfacetamide sodium susp 10%
SULFAMYLON
TAZORAC
tolnaftate
tretinoin crea 0.025%, 0.05%, 0.1%
tretinoin gel 0.01%, 0.025%
ZENATANE CAPS 30MG
zenatane caps 10mg, 20mg, 40mg
zinc oxide oint 20%
ZONALON
SOSTITUTIVI/MODIFICATORI ENZIMATICI:
FARMACI PER IL TRATTAMENTO DI DEFICIENZE
ENZIMATICHE, ENZIMI PANCREATICI
Sostitutivi/modificatori enzimatici
ADAGEN
ALDURAZYME
BUPHENYL TABS
CARBAGLU
CEREZYME INJ 400UNIT
CREON
CYSTADANE
CYSTAGON
FABRAZYME
KUVAN TBSO
KUVAN PACK 500MG
KUVAN PACK 100MG
LUMIZYME
NAGLAZYME
ORFADIN
pancrelipase
RAVICTI
sodium phenylbutyrate powd
44
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
3
$0
1
$0
1
$0
2
$0
1
$0
3
$0
2
$0
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
*
PA MO
PA MO
*
MO
PA
PA LA
PA
PA LA
MO
PA LA
PA LA
PA LA
PA
PA LA
LA
PA LA
PA
MO
PA LA
PA
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
VPRIV
ZAVESCA
ZENPEP CPEP 218000UNIT;
40000UNIT; 136000UNIT
ZENPEP CPEP 109000UNIT;
20000UNIT; 68000UNIT, 136000UNIT; 25000UNIT; 85000UNIT, 16000UNIT; 3000UNIT; 10000UNIT, 27000UNIT; 5000UNIT;
17000UNIT, 55000UNIT; 10000UNIT;
34000UNIT, 82000UNIT; 15000UNIT;
51000UNIT
AGENTI GASTROINTESTINALI: FARMACI PER
IL TRATTAMENTO DI DISTURBI INTESTINALI
E DELLO STOMACO, ANTIDIARROICI,
LASSATIVI, ULCERE E ACIDITÀ DI STOMACO
Antispasmodici, gastrointestinali
dicyclomine hcl
glycopyrrolate inj, tabs
methscopolamine bromide
Agenti gastrointestinali, altro
acid gone susp
aluminum hydroxide
antacid maximum strength
anti-diarrheal liqd, tabs
calcium antacid
calcium antacid ultra maximum strength
cromolyn sodium conc 100mg/5ml
diphenoxylate/atropine
DRAMAMINE
dramamine less drowsy
GATTEX
GAVISCON EXTRA STRENGTH RELIEF
FORMULA
GAVISCON CHEW
gnp antacid & anti-gas maximum
strength
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
PA
2
$0
PA
2
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
3
3
3
3
3
3
1
1
3
3
2
3
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
3
3
$0
$0
1
1
1
PA MO
MO
MO
*
*
*
*
*
*
MO
PA MO
*
*
PA LA
*
*
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
45
Nome del farmaco
gnp foaming antacid
kaopectate
loperamide hcl caps
maalox childrens
maalox regular strength
magnesium oxide tabs 400mg, 420mg
metoclopramide hcl inj, oral soln, tabs
mi-acid chew
mintox plus
motion sickness
motion sickness relief
peptic relief chew 262mg
RELISTOR INJ 12MG/0.6ML
RELISTOR INJ 8MG/0.4ML
SODIUM BICARBONATE POWD 0
sodium bicarbonate tabs 650mg
soothe tabs
titralac
ursodiol caps, tabs
Antagonisti del recettore dell'istamina2 (H2)
acid reducer tabs 10mg
AXID AR
cimetidine hcl soln
cimetidine tabs 200mg, 300mg, 400mg,
800mg
cimetidine tabs 200mg
famotidine premixed
famotidine inj 200mg/20ml, 40mg/4ml
famotidine inj 20mg/2ml
famotidine susr 40mg/5ml
famotidine tabs 20mg, 40mg
kls acid reducer maximum strength
PEPCID AC CHEW
ranitidine 75
ranitidine hcl caps, syrp
46
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
3
$0
3
$0
1
$0
3
$0
3
$0
3
$0
1
$0
3
$0
3
$0
3
$0
3
$0
3
$0
2
$0
2
$0
3
$0
3
$0
3
$0
3
$0
1
$0
3
3
1
1
$0
$0
$0
$0
3
1
1
1
1
1
3
3
3
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
*
*
MO
*
*
*
MO
*
*
*
*
*
PA
PA MO
*
*
*
*
MO
*
*
MO
MO
*
MO
MO
MO
*
*
*
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
3
$0
3
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
ranitidine hcl inj 150mg/6ml
ranitidine hcl inj 50mg/2ml
MO
ranitidine hcl tabs 150mg, 300mg
MO
wal-itin d
*
wal-phed sinus/allergy
*
Agenti per la sindrome
dell'intestino irritabile
alosetron hydrochloride
1
$0
QL (60 CAD per 30 giorni)
AMITIZA
2
$0
QL (60 CAD per 30 giorni) MO
Lassativi
constulose
1
$0
cvs laxative dietary supplement
3
$0
*
docusate sodium liqd
3
$0
*
dok tabs
3
$0
*
enema ready-to-use
3
$0
*
enemeez mini
3
$0
*
enemeez plus
3
$0
*
enulose
1
$0
ex-lax ultra
3
$0
*
fiber laxative tabs
3
$0
*
FLEET BISACODYL
3
$0
*
gavilyte-c
1
$0
gavilyte-g
1
$0
MO
gavilyte-n/flavor pack
1
$0
MO
generlac
1
$0
MO
gnp stool softener syrp
3
$0
*
HYDROCIL INSTANT PACK
3
$0
*
KONSYL-D POWD
3
$0
*
KONSYL PACK 100%
3
$0
*
KONSYL POWD 60.3%, 71.67%
3
$0
*
konsyl powd 30.9%
3
$0
*
lactulose soln
1
$0
MO
METAMUCIL MULTIHEALTH FIBER
3
$0
*
POWD 63%
milk of magnesia susp 1200mg/15ml
3
$0
*
MIRALAX
3
$0
*
natural fiber therapy powd 48.57%
3
$0
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
47
Nome del farmaco
peg 3350/electrolytes
peg-3350/electrolytes
peg-3350/nacl/na bicarbonate/kcl
polyethylene glycol 3350 pack, powd
psyldex
reguloid powd 48.57%, 58.6%
sb fib lax orange powd 33%
sb natural fiber laxative
senna syrp
soluble fiber
sorbulax
stool softener caps 100mg
SUPREP BOWEL PREP
trilyte
Protettivi
misoprostol
sucralfate susp, tabs
Inibitori della pompa protonica
dual action complete
esomeprazole sodium
omeprazole cpdr 20mg
omeprazole cpdr 10mg
omeprazole cpdr 40mg
omeprazole tbec
pantoprazole sodium inj
pantoprazole sodium tbec 20mg
pantoprazole sodium tbec 40mg
PRILOSEC OTC
ra lansoprazole
AGENTI GENITOURINARI: ANTI‑INFETTIVI
VAGINALI
Antispasmodici, urinari
MYRBETRIQ
oxybutynin chloride er tb24 5mg
oxybutynin chloride er tb24 10mg,
15mg
48
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
1
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
2
$0
1
$0
1
$0
1
$0
3
$0
1
$0
1
$0
1
$0
1
$0
3
$0
1
$0
1
$0
1
$0
3
$0
3
$0
2
1
1
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
*
*
*
*
*
*
*
*
MO
MO
MO
MO
*
MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
*
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
*
*
QL (30 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
oxybutynin chloride tabs
oxybutynin chloride syrp
tolterodine tartrate
VESICARE
Agenti per l'ipertrofia prostatica benigna
finasteride tabs 5mg
tamsulosin hcl
Agenti genitourinari, altro
bethanechol chloride
clotrimazole vaginal crea 1%
methylergonovine maleate
miconazole 3
miconazole 3 combination pack
miconazole 3 combo pack
miconazole 7
sodium chloride 0.9%
THIOLA
tioconazole-1
vagistat-3
Leganti del fosfato
AURYXIA
calcium acetate caps
calcium acetate tabs 667mg
FOSRENOL PACK
FOSRENOL CHEW
RENVELA
VELPHORO
AGENTI ORMONALI, STIMOLANTI /
SOSTITUTIVI / MODIFICATORI (SURRENALI):
FARMACI CORTICOSTEROIDI UTILIZZABILI
NEL TRATTAMENTO DI DIVERSE CONDIZIONI,
AD ES. INFIAMMAZIONI
Agenti ormonali, stimolanti / sostitutivi /
modificatori (surrenali)
a-hydrocort
alclometasone dipropionate
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
1
$0
3
$0
1
$0
3
$0
3
$0
3
$0
3
$0
1
$0
2
$0
3
$0
3
$0
2
$0
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (120 CAD per 30 giorni) MO
QL (600 ML per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (30 CAD per 30 giorni) MO
MO
MO
MO
*
MO
*
*
*
*
MO
MO
*
*
ST
MO
MO
MO
MO
MO
1
1
$0
$0
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
49
Costo
Livello a Suo
Nome del farmaco
di
carico
Classe
per il
farmaco
amcinonide
1
$0
MO
augmented betamethasone dipropionate
1
$0
MO
betamethasone dipropionate crea, lotn,
1
$0
MO
oint
betamethasone valerate crea, foam, lotn,
1
$0
MO
oint
budesonide cp24 3mg
1
$0
MO
clobetasol propionate e
1
$0
MO
clobetasol propionate emollient foam
1
$0
MO
clobetasol propionate liqd
1
$0
clobetasol propionate crea, foam, gel,
1
$0
MO
lotn, oint, sham, soln
colocort
1
$0
cormax scalp application
1
$0
cortisone acetate tabs
1
$0
MO
desonide crea, lotn, oint
1
$0
MO
desoximetasone crea, gel, oint
1
$0
MO
DEXAMETHASONE INTENSOL
2
$0
MO
dexamethasone sodium phosphate inj
1
$0
10mg/ml, 120mg/30ml, 20mg/5ml,
4mg/ml
dexamethasone sodium phosphate inj
1
$0
MO
100mg/10ml, 10mg/ml
dexamethasone elix, soln, tabs
1
$0
MO
diflorasone diacetate crea, oint
1
$0
MO
fludrocortisone acetate tabs
1
$0
MO
fluocinolone acetonide body
1
$0
MO
fluocinolone acetonide scalp
1
$0
MO
fluocinolone acetonide crea 0.01%,
1
$0
MO
0.025%
fluocinolone acetonide oint 0.025%
1
$0
MO
fluocinolone acetonide soln 0.01%
1
$0
MO
fluocinonide-e
1
$0
MO
fluocinonide crea, gel, oint, soln
1
$0
MO
fluticasone propionate crea 0.05%
1
$0
MO
fluticasone propionate lotn 0.05%
1
$0
MO
fluticasone propionate oint 0.005%
1
$0
MO
50
Azioni necessarie,
restrizioni o
limitazioni all'uso
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
halobetasol propionate
hydrocortisone butyrate (lipophilic)
hydrocortisone butyrate crea, oint, soln
hydrocortisone in absorbase
hydrocortisone valerate
hydrocortisone crea 2.5%
hydrocortisone enem, tabs
hydrocortisone lotn 2.5%
hydrocortisone oint 1%, 2.5%
methylprednisolone acetate inj
methylprednisolone dose pack
methylprednisolone sodiumsuccinate inj
1000mg, 125mg, 40mg
methylprednisolone tabs
MILLIPRED
MILLIPRED DP
mometasone furoate crea, oint, soln
prednicarbate
prednisolone sodium phosphate oral soln
15mg/5ml, 25mg/5ml, 5mg/5ml
prednisolone soln, syrp
PREDNISONE INTENSOL
prednisone soln, tabs
procto-pak
proctosol hc
proctozone-hc
triamcinolone acetonide aers 0
triamcinolone acetonide crea 0.025%,
0.1%, 0.5%
triamcinolone acetonide lotn 0.025%,
0.1%
triamcinolone acetonide oint 0.025%,
0.1%, 0.5%
triderm
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
2
2
1
1
1
$0
$0
$0
$0
$0
$0
MO
MO
MO
MO
MO
MO
1
2
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
MO
MO
MO
MO
MO
MO
1
$0
MO
1
$0
MO
1
$0
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
51
Nome del farmaco
AGENTI ORMONALI, STIMOLANTI /
SOSTITUTIVI / MODULATORI (GHIANDOLA
PITUITARIA): FARMACI PER REGOLARE GLI
ORMONI DELLA GHIANDOLA PITUITARIA,
DELLA CRESCITA
Agenti ormonali, stimolanti / sostitutivi /
modificatori (ghiandola pituitaria)
desmopressin acetate inj, nasal soln, tabs
EGRIFTA INJ 2MG
EGRIFTA INJ 1MG
INCRELEX
NORDITROPIN FLEXPRO INJ
10MG/1.5ML, 15MG/1.5ML,
5MG/1.5ML
NORDITROPIN NORDIFLEX PEN
VASOSTRICT
AGENTI ORMONALI, STIMOLANTI /
SOSTITUTIVI / MODIFICATORI (ORMONI
SESSUALI / MODIFICATORI): CONTROLLO
DELLE NASCITE, ENDOMETRIOSI,
ESTROGENI, ORMONI MASCHILI
Steroidi anabolici
ANADROL-50
oxandrolone tabs 2.5mg
oxandrolone tabs 10mg
Androgeni
ANDROGEL PUMP GEL 1.62%
ANDROGEL PUMP GEL 1%
ANDROGEL GEL 20.25MG/1.25GM,
40.5MG/2.5GM
ANDROGEL GEL 25MG/2.5GM,
50MG/5GM
danazol caps
testosterone cypionate inj
testosterone enanthate inj
testosterone gel 25mg/2.5gm
Estrogeni
altavera
52
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
Azioni necessarie,
restrizioni o
limitazioni all'uso
1
2
2
2
2
$0
$0
$0
$0
$0
MO
QL (30 CAD per 30 giorni) PA LA
QL (60 CAD per 30 giorni) PA LA
PA LA
PA
2
2
$0
$0
PA
2
2
2
$0
$0
$0
$0
$0
$0
PA MO
QL (300 GM per 30 giorni) PA MO
PA MO
2
$0
QL (300 GM per 30 giorni) PA MO
1
1
1
1
$0
$0
$0
$0
$0
MO
PA MO
PA MO
QL (300 GM per 30 days) PA
2
1
1
1
MO
QL (120 CAD per 30 giorni) PA MO
QL (60 CAD per 30 giorni) PA MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
alyacen 1/35
alyacen 7/7/7
amethia
amethia lo
amethyst
apri
aranelle
ashlyna
aubra
aviane
azurette
balziva
briellyn
camrese
camrese lo
caziant
chateal
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
dasetta 1/35
dasetta 7/7/7
daysee
delyla
DEPO-ESTRADIOL
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
elinest
emoquette
enpresse-28
enskyce
estarylla
ESTRACE CREA
estradiol/norethindrone acetate
estradiol tabs
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
53
Nome del farmaco
estradiol ptwk
estradiol pttw
falmina
gianvi
gildagia
gildess 1.5/30
gildess 1/20
gildess 24 fe
gildess fe 1.5/30
gildess fe 1/20
introvale
jinteli
jolessa
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
kariva
kelnor 1/35
kurvelo
larin 1.5/30
larin 1/20
larin fe 1.5/30
larin fe 1/20
leena
lessina
levonest
levonorgestrel and ethinyl estradiol tabs
0; 0
levonorgestrel/ethinyl estradiol tabs 0; 0
levonorgestrel/ethinyl estradiol tabs
0.03mg; 0.15mg, 20mcg; 0.1mg
levora 0.15/30-28
lomedia 24 fe
lopreeza
54
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (4 CAD per 28 giorni) PA MO
QL (8 CAD per 28 giorni) PA
MO
MO
PA MO
MO
MO
MO
MO
MO
1
1
$0
$0
MO
1
1
1
$0
$0
$0
MO
PA
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
loryna
low-ogestrel
lutera
marlissa
MENEST
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
mimvey
mimvey lo
mono-linyah
mononessa
myzilra
necon 0.5/35-28
necon 1/35
NECON 1/50-28
NECON 10/11-28
necon 7/7/7
nikki
norethindrone & ethinyl estradiol ferrous
fumarate
norethindrone acetate/ethinyl estradiol/
ferrous fumarate tabs 20mcg; 75mg;
1mg
norethindrone acetate/ethinyl estradiol/
ferrous fumarate tabs 20mcg; 75mg;
1mg
norethindrone acetate/ethinyl estradiol
tabs 20mcg; 1mg
norethindrone acetate/ethinyl estradiol
tabs 5mcg; 1mg
norgestimate/ethinyl estradiol
NORINYL 1+50
nortrel 0.5/35 (28)
nortrel 1/35
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
1
$0
1
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
PA MO
PA MO
PA MO
MO
MO
MO
1
$0
1
$0
MO
1
$0
MO
1
$0
PA
1
2
1
1
$0
$0
$0
$0
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
55
Nome del farmaco
nortrel 7/7/7
ocella
OGESTREL
orsythia
philith
pimtrea
pirmella 1/35
pirmella 7/7/7
portia-28
previfem
quasense
reclipsen
sprintec 28
sronyx
syeda
tarina fe 1/20
tilia fe
tri-estarylla
tri-legest fe
tri-linyah
tri-previfem
tri-sprintec
trinessa
trivora-28
VAGIFEM
velivet
vestura
viorele
vyfemla
wera
wymzya fe
zarah
zenchent
zenchent fe
zovia 1/35e
56
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
ZOVIA 1/50E
Agonisti/antagonisti progesterone
ELLA
Progestinici
camila
deblitane
DEPO-PROVERA
econtra ez
errin
heather
jencycla
jolivette
levonorgestrel
lyza
medroxyprogesterone acetate inj, tabs
megestrol acetate tabs
megestrol acetate susp 40mg/ml
my way
next choice one dose
nora-be
norethindrone acetate tabs
norethindrone tabs
norlyroc
progesterone caps, inj
sharobel
Agenti modificatori selettivi del recettore
degli estrogeni
raloxifene hydrochloride
AGENTI ORMONALI, STIMOLANTI /
SOSTITUTIVI / MODULATORI (TIROIDE):
FARMACI PER REGOLARE I LIVELLI TIROIDEI
Agenti ormonali, stimolanti / sostitutivi /
modificatori (tiroide)
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
1
$0
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
3
$0
3
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
PA MO
PA MO
*
*
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
57
Nome del farmaco
levothyroxine sodium tabs
levothyroxine sodium inj 200mcg
levothyroxine sodium inj 100mcg,
500mcg
levoxyl
liothyronine sodium tabs
SYNTHROID
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
unithroid tabs 100mcg, 112mcg,
125mcg, 150mcg, 175mcg, 200mcg,
25mcg, 300mcg, 50mcg, 75mcg, 88mcg
AGENTI ORMONALI, SOPPRESSORI
(SURRENALI): FARMACI PER IL
TRATTAMENTO DEL TUMORE
CORTICO‑SURRENALICO
Agenti ormonali, soppressori (surrenali)
LYSODREN
AGENTI ORMONALI, SOPPRESSORI
(PARATIROIDEI): FARMACI PER IL
TRATTAMENTO DI LIVELLI ELEVATI DI
CALCIO IN PAZIENTI CON INSUFFICIENZA
RENALE CRONICA
Agenti ormonali, soppressori (paratiroidei)
SENSIPAR TABS 90MG
SENSIPAR TABS 30MG, 60MG
AGENTI ORMONALI, SOPPRESSORI
(PITUITARI): FARMACI PER IL TRATTAMENTO
DEL TUMORE ALLA PROSTATA E ALTRE
CONDIZIONI ASSOCIATE A UN'IPERATTIVITÀ
DELLA GHIANDOLA PITUITARIA
Agenti ormonali, soppressori (pituitari)
cabergoline
FIRMAGON
58
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
MO
1
$0
1
$0
MO
1
1
2
2
2
2
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
MO
2
$0
MO
2
2
$0
$0
QL (120 CAD per 30 giorni)
QL (60 CAD per 30 giorni)
1
2
$0
$0
MO
PA
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
leuprolide acetate inj
LUPRON DEPOT
LUPRON DEPOT-PED
octreotide acetate
SIGNIFOR
SOMATULINE DEPOT INJ
60MG/0.2ML
SOMATULINE DEPOT INJ
90MG/0.3ML
SOMATULINE DEPOT INJ
120MG/0.5ML
SOMAVERT
SYNAREL
TRELSTAR MIXJECT
VANTAS
ZOLADEX
AGENTI ORMONALI, SOPPRESSORI
(TIROIDEI). FARMACI PER ABBASSARE
I LIVELLI TIROIDEI
Agenti antitiroidei
methimazole tabs
propylthiouracil tabs
AGENTI IMMUNOLOGICI: VACCINI, ARTRITE
REUMATOIDE, IMMUNOGLOBULINE,
IMMUNOMODULATORI,
IMMUNOSOPPRESSORI
Agenti angioedema (HAE)
CINRYZE
FIRAZYR
Immunosoppressori
azathioprine tabs
CELLCEPT INTRAVENOUS
CELLCEPT SUSR
CIMZIA
CIMZIA STARTER KIT
cyclosporine modified
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
2
$0
2
$0
1
$0
2
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
PA
PA
PA
PA
QL (60 ML per 30 giorni) PA
QL (0,2 ML per 28 giorni) PA
2
$0
QL (0,3 ML per 28 giorni) PA
2
$0
QL (0,5 ML per 28 giorni) PA
2
2
2
2
2
$0
$0
$0
$0
$0
PA LA
MO
PA
1
1
2
2
1
2
2
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
MO
PA LA
QL (270 ML per 30 days) PA LA
B/D MO
PA
PA MO
QL (6 CAD per 28 giorni) PA
QL (6 CAD per 28 giorni) PA
PA MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
59
Nome del farmaco
cyclosporine inj
cyclosporine caps
gengraf caps
gengraf soln
hecoria
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK
HUMIRA PEN
HUMIRA PEN-CROHNS DISEASESTARTER
HUMIRA PEN-PSORIASIS STARTER
HUMIRA INJ 10MG/0.2ML,
20MG/0.4ML
HUMIRA INJ 40MG/0.8ML
methotrexate sodium inj 1gm/40ml,
1gm
methotrexate sodium inj 25mg/ml
methotrexate tabs
mycophenolate mofetil
NULOJIX
PROGRAF INJ
RAPAMUNE SOLN
REMICADE
SANDIMMUNE SOLN
SIMULECT
sirolimus tabs
tacrolimus caps
ZORTRESS
Agenti immunizzanti, passivi
ATGAM
GAMASTAN S/D
GAMMAPLEX INJ 10GM/200ML
GAMMAPLEX INJ 2.5GM/50ML,
20GM/400ML, 5GM/100ML
THYMOGLOBULIN
Immunomodulatori
60
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
PA
PA MO
PA
PA MO
PA
QL (6 CAD per 28 giorni) PA
2
2
$0
$0
QL (6 CAD per 28 giorni) PA
QL (6 CAD per 28 giorni) PA
2
2
$0
$0
QL (6 CAD per 28 giorni) PA
QL (2 CAD per 28 giorni) PA
2
1
$0
$0
QL (6 CAD per 28 giorni) PA
1
1
1
2
2
2
2
2
2
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
MO
PA MO
PA MO
PA
PA MO
PA
PA MO
B/D
PA MO
PA MO
PA MO
$0
B/D
2
2
2
2
2
PA
PA
PA
PA LA
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
ACTIMMUNE
ARCALYST
BENLYSTA
ILARIS
leflunomide
SYNAGIS
Vaccini
ACTHIB
ADACEL
bcg vaccine
BEXSERO
BOOSTRIX
CERVARIX
COMVAX
DAPTACEL
diphtheria/tetanus toxoids adsorbed
pediatric
ENGERIX-B
GARDASIL 9
GARDASIL INJ 0
GARDASIL INJ 0
HAVRIX
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II
MENACTRA
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB
PENTACEL
PROQUAD
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
2
$0
2
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
PA LA
PA LA
PA
QL (2 CAD per 28 giorni) PA LA
MO
PA
B/D
MO
B/D
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
61
Nome del farmaco
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TENIVAC
tetanus/diphtheria toxoids-adsorbed
adult
TRUMENBA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
AGENTI PER I DISTURBI INTESTINALI
INFIAMMATORI: FARMACI PER LA GESTIONE
DEI DISTURBI DEL COLON E/O INTESTINALI
Aminosalicilati
APRISO
balsalazide disodium
mesalamine enem, kit
Sulfonamidi
sulfasalazine tabs, tbec
sulfazine
sulfazine ec
AGENTI PER DISTURBI DEL METABOLISMO
OSSEO: FARMACI PER IL TRATTAMENTO
DELLA PERDITA OSSEA
Agenti per disturbi del metabolismo osseo
alendronate sodium soln
alendronate sodium tabs 10mg, 40mg,
5mg
alendronate sodium tabs 35mg, 70mg
calcitonin-salmon
calcitriol inj
calcitriol caps, oral soln
62
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
B/D
2
$0
B/D
2
$0
2
$0
2
$0
1
$0
2
2
2
2
2
2
2
2
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
1
$0
$0
1
1
1
1
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (1 CAD per 365 giorni)
MO
MO
MO
MO
MO
MO
QL (30 CAD per 30 giorni) MO
QL (4 CAD per 28 giorni) MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
doxercalciferol caps
etidronate disodium
FORTEO
MIACALCIN INJ
pamidronate disodium inj 30mg,
90mg/10ml, 90mg
pamidronate disodium inj 30mg/10ml,
6mg/ml
paricalcitol inj
paricalcitol caps
PROLIA
risedronate sodium dr
risedronate sodium tabs 150mg
risedronate sodium tabs 35mg
risedronate sodium tabs 30mg, 5mg
XGEVA
zoledronic acid inj 4mg/5ml, 4mg,
5mg/100ml
AGENTI TERAPEUTICI VARI
Agenti terapeutici vari
ALCOHOL PREP PADS
GAUZE PADS 2”X2”
INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X 1/2”
INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X 5/16”
INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X 1/2”
INSULIN SYRINGE
ULTRAFINE/1ML/31G X 5/16”
INSUPEN 33GX4MM
NATPARA
PEN NEEDLE/ULTRAFINE/29G X
12.7MM
V-GO 20
V-GO 30
V-GO 40
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
2
$0
2
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
QL (2,4 ML per 28 giorni) PA
MO
1
$0
MO
1
1
2
1
1
1
1
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
QL (1 ML per 180 giorni)
QL (4 CAD per 28 giorni)
QL (1 CAD per 28 giorni) MO
QL (12 CAD per 84 giorni)
QL (30 CAD per 30 giorni)
PA
2
2
2
$0
$0
$0
MO
2
$0
ST MO
2
$0
ST MO
2
$0
ST MO
2
2
2
$0
$0
$0
ST
QL (2 CAD per 28 giorni) PA
ST MO
2
2
2
$0
$0
$0
ST MO
ST MO
ST MO
ST MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
63
Nome del farmaco
AGENTI OFTALMICI: FARMACI PER IL
TRATTAMENTO DI ALLERGIE, INFEZIONI E
INFIAMMAZIONI OCULARI E DEL GLAUCOMA
Agenti oftalmici, analoghi delle
prostaglandine e delle prostamidi
COMBIGAN
latanoprost
LUMIGAN SOLN 0.01%
TRAVATAN Z
travoprost
Agenti oftalmici, altro
ak-poly-bac
artificial tears soln 1.4%
atropine sulfate soln
AZASITE
bacitracin/neomycin/polymyxin
bacitracin/polymyxin b
bacitracin ophthalmic oint 500unit/gm
BESIVANCE
ciprofloxacin hcl soln 0.3%
cvs lubricating eye drops/dry eye
CYSTARAN
erythromycin oint 5mg/gm
gentak
gentamicin sulfate ophthalmic oint 0.3%
gentamicin sulfate ophthalmic soln 0.3%
gnp artificial tears soln 0.5%; 0.6%
HYPOTEARS SOLN
ISOPTO TEARS
levofloxacin ophthalmic soln 0.5%
MURO 128 SOLN 2%
muro 128 soln 5%
naphazoline hcl
natures tears soln 0.4%
neo-polycin
neomycin/bacitracin/polymyxin
64
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
Azioni necessarie,
restrizioni o
limitazioni all'uso
2
1
2
2
1
1
3
1
2
1
1
1
2
1
3
2
1
1
1
1
3
3
3
1
3
3
1
3
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
MO
MO
MO
MO
*
MO
MO
MO
MO
MO
MO
*
QL (60 ML per 28 giorni)
MO
MO
MO
MO
*
*
*
MO
*
*
MO
*
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 3.5mg/ml;
10000unit/ml
ofloxacin ophthalmic soln 0.3%
polycin
polymyxin b sulfate/trimethoprim sulfate
proparacaine hcl
pure & gentle lubricant soln 0.3%
ra lubricant eye drops soln 0.4%; 0.3%
REFRESH CELLUVISC
refresh p.m.
RESTASIS
sodium chloride oint 5%
sodium sulfacetamide soln 10%
STERILE LUBRICANT DROPS
sulfacetamide sodium/prednisolone
sodium phosphate
sulfacetamide sodium oint 10%
sulfacetamide sodium soln 10%
SYSTANE OVERNIGHT THERAPY LUBRICANT EYE
TEARS AGAIN NIGHT & DAY
THERATEARS SOLN
tobramycin sulfate ophthalmic soln 0.3%
tobramycin/dexamethasone
TOBREX
trifluridine
trimethoprim sulfate/polymyxin b sulfate
triple antibiotic
ZIRGAN
Agenti oftalmici, anti-allergici
azelastine hcl ophthalmic soln 0.05%
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
MO
1
1
1
$0
$0
$0
MO
MO
MO
1
1
1
1
3
3
3
3
2
3
1
3
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
MO
MO
*
*
*
*
MO
*
MO
*
MO
1
1
3
$0
$0
$0
MO
MO
*
3
3
1
1
2
1
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
*
*
MO
MO
MO
MO
MO
1
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
65
Nome del farmaco
cromolyn sodium soln 4%
epinastine hcl
PATADAY
PATANOL
PAZEO
Antinfiammatori oftalmici
ACUVAIL
dexamethasone sodium phosphate
ophthalmic soln 0.1%
DUREZOL
fluorometholone
flurbiprofen sodium
ILEVRO
ketorolac tromethamine
NEVANAC
prednisolone acetate
prednisolone sodium phosphate
ophthalmic soln 1%
PROLENSA
Agenti oftalmici, anti-glaucoma
ALPHAGAN P SOLN 0.1%
apraclonidine
betaxolol hcl soln 0.5%
brimonidine tartrate
carteolol hcl
dorzolamide hcl
dorzolamide hcl/timolol maleate
ISOPTO CARPINE
levobunolol hcl
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl soln 1%, 2%, 4%
SIMBRINZA
timolol maleate ophthalmic gel forming
timolol maleate soln 0.25%, 0.5%
66
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
1
$0
2
$0
2
$0
2
$0
2
$0
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
2
1
1
2
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
$0
MO
MO
MO
MO
MO
MO
MO
MO
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
2
1
1
1
1
1
1
2
1
1
2
1
2
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
AGENTI OTICI: FARMACI PER IL TRATTAMENTO
DELLE CONDIZIONI DELL'ORECCHIO
Agenti otici
acetasol hc
acetic acid
acetic acid/aluminum acetate
antibiotic ear
fluocinolone acetonide oil 0.01%
hydrocortisone/acetic acid
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone otic
susp 1%; 3.5mg/ml; 10000unit/ml
ofloxacin otic soln 0.3%
AGENTI DEL TRATTO RESPIRATORIO/
POLMONARI: FARMACI PER IL
TRATTAMENTO DI ALLERGIE, ASMA,
BPCO, IPERTENSIONE POLMONARE
Antinfiammatori, corticosteroidi inalabili
ADVAIR DISKUS
ADVAIR HFA
ASMANEX HFA
ASMANEX TWISTHALER 120 METERED DOSES
ASMANEX TWISTHALER 14 METERED
DOSES
ASMANEX TWISTHALER 30 METERED
DOSES
ASMANEX TWISTHALER 60 METERED
DOSES
ASMANEX TWISTHALER 7 METERED
DOSES
BREO ELLIPTA AEPB 200MCG/INH;
25MCG/INH
BREO ELLIPTA AEPB 100MCG/INH;
25MCG/INH
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
MO
MO
MO
MO
2
2
2
2
$0
$0
$0
$0
QL (60 CAD per 30 giorni) MO
QL (12 GM per 30 giorni) MO
QL (13 GM per 30 days)
QL (1 CAD per 30 giorni) MO
2
$0
QL (2 CAD per 28 giorni) MO
2
$0
QL (1 CAD per 30 giorni) MO
2
$0
QL (1 CAD per 30 giorni) MO
2
$0
QL (4 CAD per 28 giorni)
2
$0
QL (60 CAD per 30 giorni)
2
$0
QL (60 CAD per 30 giorni) MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
67
Nome del farmaco
budesonide inhalation susp
0.25mg/2ml, 0.5mg/2ml
budesonide nasal susp 32mcg/act
flunisolide soln 0.025%
fluticasone propionate susp 50mcg/act
QVAR
triamcinolone acetonide aero 55mcg/act
Antistaminici
ALLEGRA ALLERGY CHILDRENS SUSP,
TABS
aller-ease tabs 60mg
allergy relief tabs 10mg
altaryl elix
azelastine hcl nasal soln 0.15%
azelastine hcl nasal soln 0.1%
cetirizine hcl chew
cetirizine hcl tabs 5mg
childrens complete allergy
CLARITIN REDITABS TBDP 5MG
CLARITIN CHEW
clemastine fumarate syrp
clemastine fumarate tabs 2.68mg
diphenhydramine hcl caps 50mg
diphenhydramine hcl inj
ed chlorped jr
fexofenadine hcl tabs 180mg
goodsense all day allergy
hydroxyzine hcl inj
J-TAN PD
levocetirizine dihydrochloride tabs
levocetirizine dihydrochloride soln
loratadine tabs
olopatadine hcl
promethazine hcl tabs 12.5mg, 25mg,
50mg
TRIAMINIC COUGH & RUNNY NOSE
68
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
1
$0
B/D MO
1
1
1
2
1
MO
MO
MO
QL (17,4 GM per 30 giorni) MO
MO
3
$0
$0
$0
$0
$0
$0
3
3
3
1
1
3
3
3
3
3
1
1
3
1
3
3
3
1
3
1
1
3
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
*
*
*
MO
QL (30 ML per 25 giorni) MO
*
*
*
*
*
PA MO
PA MO
*
PA MO
*
*
*
PA MO
*
QL (30 CAD per 30 giorni) MO
QL (300 ML per 30 giorni) MO
*
QL (30,5 GM per 30 giorni) MO
PA MO
3
$0
*
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
wal-itin syrp
ZYRTEC ALLERGY TABS
ZYRTEC CHILDRENS ALLERGY SYRP
1MG/ML
Antileucotrienici
montelukast sodium
zafirlukast
Broncodilatatori, anticolinergici
ANORO ELLIPTA
COMBIVENT RESPIMAT
ipratropium bromide/albuterol sulfate
ipratropium bromide inhalation soln
ipratropium bromide nasal soln
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
Broncodilatatori, simpaticomimetici
albuterol sulfate er
albuterol sulfate nebu
albuterol sulfate syrp, tabs
ARCAPTA NEOHALER
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
FORADIL AEROLIZER
levalbuterol hcl nebu
levalbuterol nebu
metaproterenol sulfate syrp, tabs
PROAIR HFA
PROAIR RESPICLICK
terbutaline sulfate tabs
VENTOLIN HFA
Agenti per la fibrosi cistica
CAYSTON
KALYDECO PACK
KALYDECO TABS
PULMOZYME
tobramycin
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
3
$0
*
3
$0
*
3
$0
*
1
1
2
2
1
1
1
2
2
1
1
1
2
2
2
2
1
1
1
2
2
1
2
2
2
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
QL (30 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) ST MO
QL (8 GM per 30 giorni) MO
B/D MO
B/D MO
MO
QL (30 CAD per 30 giorni) MO
QL (4 GM per 30 giorni) MO
MO
B/D MO
MO
QL (30 CAD per 30 giorni) MO
QL (2 CAD per 30 giorni) MO
QL (2 CAD per 30 giorni) MO
QL (60 CAD per 30 giorni) MO
B/D MO
B/D MO
MO
QL (17 GM per 30 giorni) MO
QL (2 CAD per 30 giorni)
MO
QL (36 GM per 30 giorni) MO
QL (84 ML per 56 giorni)
QL (56 CAD per 28 giorni) PA
QL (60 CAD per 30 giorni) PA
B/D
QL (280 ML per 56 giorni) B/D
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
69
Nome del farmaco
Stabilizzatori dei mastociti
cromolyn sodium nebu 20mg/2ml
Inibitori della fosfodiesterasi, disturbi
delle vie aeree
aminophylline
DALIRESP
theophylline cr tb12 100mg, 200mg
theophylline er
theophylline elix
theophylline soln
Anti-ipertensivi polmonari
ADEMPAS
epoprostenol sodium
OPSUMIT
REMODULIN
sildenafil tabs
TRACLEER
Agenti del tratto respiratorio, altro
acetylcysteine inj
acetylcysteine inhalation soln
afrin childrens
AFRIN MENTHOL
afrin saline nasal mist soln 0; 0.002%;
0.65%; 0; 0
all day allergy-d
altarussin-pe
AYR NASAL DROPS
benzonatate caps 100mg, 200mg
childrens cold & allergy
CODITUSS DM
cold/cough childrens
comtrex severe cold & sinus maximum
strength day/night
coricidin hbp chest congestion & cough
cough & cold
70
Costo
Livello a Suo
Azioni necessarie,
di
carico
restrizioni o
Classe
per il
limitazioni all'uso
farmaco
1
$0
B/D MO
1
2
1
1
1
1
1
1
3
3
3
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
3
3
3
3
3
3
3
3
$0
$0
$0
$0
$0
$0
$0
$0
*
*
*
*
*
*
*
*
3
3
$0
$0
*
*
2
1
2
2
1
2
MO
QL (30 CAD per 30 giorni) MO
MO
MO
MO
QL (90 CAD per 30 giorni) PA LA
PA LA
QL (30 CAD per 30 giorni) PA LA
PA LA
QL (90 CAD per 30 giorni) PA
QL (60 CAD per 30 giorni) PA LA
B/D MO
*
*
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
DIMETAPP LONG ACTING COUGH
PLUS COLD
dimetapp nighttime cold &congestion
DRISTAN SPRAY
ESBRIET
exefen-ir
gnp cold multi-symptom day/night
gnp cold multi-symptom nighttime
kidkare cough/cold
LITTLE NOSES DECONGESTANTNOSE
DROPS
loratadine/pseudoephedrine
mapap cold formula multi-symptom
mucaphed
MUCINEX FOR KIDS PACK 100MG
mucus relief
mucus relief cough childrens
mucus-dm
nasal decongestant pe maximum strength
NASAL DECONGESTANT LIQD, SYRP
nasal decongestant tabs 30mg
nasal spray extra moisturizing 12 hour
pediacare childrens long-acting cough
PROLASTIN-C
ra multi-symptom cold relief/daytime/
nighttime
RHINARIS
robafen cf cough & cold
ROBITUSSIN CHILDRENS COUGH/
COLD LONG-ACTING
robitussin maximum strength
robitussin mucus+chest congestion
rynex pse
sb cough control dm max
scot-tussin dm
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
3
$0
*
Azioni necessarie,
restrizioni o
limitazioni all'uso
3
3
2
3
3
3
3
3
$0
$0
$0
$0
$0
$0
$0
$0
*
*
QL (270 CAD per 30 giorni) PA LA
*
*
*
*
*
3
3
3
3
3
3
3
3
$0
$0
$0
$0
$0
$0
$0
$0
*
*
*
*
*
*
*
*
3
3
3
3
2
3
$0
$0
$0
$0
$0
$0
*
*
*
*
PA MO
*
3
3
3
$0
$0
$0
*
*
*
3
3
3
3
3
$0
$0
$0
$0
$0
*
*
*
*
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
71
Nome del farmaco
sm adult nasal decongestant
sm tussin cf liqd 10mg/5ml;
100mg/5ml; 30mg/5ml
STIOLTO RESPIMAT
TESSALON PERLES
triacting day time cold/cough childrens
TRIAMINIC NIGHT TIME COLD &
COUGH
tussin cf cough & cold
tussin dm syrp
TYZINE PEDIATRIC NASAL DROPS
wal-act
wal-fex d 12 hour allergy& congestion
wal-phed pe sinus/allergy
XOLAIR
ZONATUSS
MIORILASSANTI SCHELETRICI: FARMACI PER
IL TRATTAMENTO DEGLI SPASMI MUSCOLARI
Miorilassanti scheletrici
chlorzoxazone tabs
cyclobenzaprine hcl tabs
AGENTI PER DISTURBI DEL SONNO: FARMACI
PER IL TRATTAMENTO DELL'INSONNIA O DEI
DISTURBI DEL SONNO
Modulatori del recettore dell'acido gam­
ma-aminobutirrico (GABA)
zaleplon caps 5mg
zaleplon caps 10mg
zolpidem tartrate
Disturbi del sonno, altro
HETLIOZ
modafinil tabs 100mg
modafinil tabs 200mg
ROZEREM
XYREM
NUTRIENTI / MINERALI / ELETTROLITI
TERAPEUTICI, VITAMINE, NUTRIZIONE EV
72
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
3
$0
*
3
$0
*
Azioni necessarie,
restrizioni o
limitazioni all'uso
2
3
3
3
$0
$0
$0
$0
QL (4 GM per 30 days)
*
*
*
3
3
2
3
3
3
2
3
$0
$0
$0
$0
$0
$0
$0
$0
*
*
1
1
$0
$0
*
*
*
QL (6 CAD per 28 giorni) PA LA
*
QL (180 CAD per 30 giorni) PA MO
QL (90 CAD per 30 giorni) PA MO
1
1
1
2
1
1
2
2
$0
$0
$0
$0
$0
$0
$0
$0
QL (30 CAD per 30 giorni) PA MO
QL (60 CAD per 30 giorni) PA MO
QL (30 CAD per 30 giorni) PA MO
QL (30 CAD per 30 giorni) PA
QL (30 CAD per 30 giorni) PA MO
QL (60 CAD per 30 giorni) PA MO
QL (30 CAD per 30 giorni) MO
QL (540 ML per 30 giorni) PA
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
Modificatori di elettroliti / minerali
CUPRIMINE
DEPEN TITRATABS
eql iron supplement therapy
EXJADE
fer-iron
ferretts
FERRIPROX
FERROUS FUMARATE
ferrous gluconate
ferrous sulfate
foltabs 800
fomepizole
iron 100 plus
kionex powd
kionex susp
kp ferrous sulfate
levocarnitine
MYKIDZ IRON 10
nu-iron 150
ra slow release iron
SAMSCA TABS 15MG
SAMSCA TABS 30MG
sodium bicarbonate partial fill
sodium bicarbonate inj 8.4%
sodium polystyrene sulfonate rectal susp
sodium polystyrene sulfonate powd, oral
susp
SYPRINE
Sostituzione elettroliti/minerali
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
AMINOSYN II
aminosyn ii 8.5%/electrolytes
AMINOSYN M
AMINOSYN-HBC
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
3
$0
2
$0
3
$0
3
$0
2
$0
3
$0
3
$0
3
$0
3
$0
1
$0
3
$0
1
$0
1
$0
3
$0
1
$0
3
$0
3
$0
3
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
2
2
1
2
1
2
2
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
*
PA LA
*
*
PA
*
*
*
*
*
MO
*
MO
*
*
*
QL (30 CAD per 30 giorni) PA
QL (60 CAD per 30 giorni) PA
MO
MO
MO
MO
B/D
B/D
B/D
B/D
B/D
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
73
Nome del farmaco
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
AMINOSYN INJ 148MEQ/L;
1280MG/100ML; 980MG/100ML;
1280MG/100ML; 300MG/100ML;
720MG/100ML; 940MG/100ML;
720MG/100ML; 400MG/100ML;
440MG/100ML; 5.4MEQ/L;
860MG/100ML; 420MG/100ML;
520MG/100ML; 160MG/100ML;
44MG/100ML; 800MG/100ML,
90MEQ/L; 1100MG/100ML;
850MG/100ML; 35MEQ/L;
1100MG/100ML; 260MG/100ML;
620MG/100ML; 810MG/100ML;
624MG/100ML; 340MG/100ML;
380MG/100ML; 5.4MEQ/L;
750MG/100ML; 370MG/100ML;
460MG/100ML; 150MG/100ML;
44MG/100ML; 680MG/100ML
BEELITH
CALCI-MIX
CALCIONATE
calcium + d3
calcium 500+d high potency
calcium 500/vitamin d3
calcium 600+d plus minerals chew
600mg; 400unit; 1mg; 50mg; 1.8mg;
250mcg; 7.5mg
calcium 600 tabs 600mg
calcium carbonate susp
calcium carbonate tabs 1250mg
calcium chloride
calcium citrate + d tabs 315mg; 200unit
calcium citrate+ d
calcium gluconate inj
calcium lactate tabs 648mg
74
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
2
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
B/D
B/D
B/D
B/D
3
3
3
3
3
3
3
$0
$0
$0
$0
$0
$0
$0
*
*
*
*
*
*
*
3
3
3
1
3
3
1
3
$0
$0
$0
$0
$0
$0
$0
$0
*
*
*
*
*
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
calcium/vitamin d tabs 600mg; 200unit,
600mg; 400unit
calcium tabs 500mg
CALTRATE 600+D PLUS MINERALS
CHEW
citrus calcium +d
citrus calcium/vitamin d
clinisol sf 15%
dextrose 10%/nacl 0.45%
dextrose 5% /electrolyte #48 viaflex
dextrose 10% flex container
dextrose 10%/nacl 0.2%
dextrose 2.5%/sodium chloride 0.45%
dextrose 20%
dextrose 25%
dextrose 30%
dextrose 40%
dextrose 5%
dextrose 5%/lactated ringers
dextrose 5%/nacl 0.2%
dextrose 5%/nacl 0.225%
dextrose 5%/nacl 0.3%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dextrose 5%/potassium chloride 0.15%
dextrose 50%
dextrose 70%
FLORIVA
fluoritab chew 0.5mg, 1mg
FLURA-DROPS SOLN 0.25MG/DROP
gnp calcium 1200
gnp calcium 500 +d3
hepatamine
INTRALIPID INJ 30GM/100ML
intralipid inj 20gm/100ml
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
3
$0
*
3
3
$0
$0
*
*
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
3
3
1
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
*
*
B/D
Azioni necessarie,
restrizioni o
limitazioni all'uso
B/D
B/D
B/D
B/D
B/D
MO
MO
B/D
B/D
MO
*
*
B/D
B/D
B/D
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
75
Costo
Livello a Suo
Nome del farmaco
di
carico
Classe
per il
farmaco
KABIVEN
2
$0
kcl 0.075%/d5w/nacl 0.45%
1
$0
1
$0
kcl 0.15%/d5w/lr
1
$0
kcl 0.15%/d5w/nacl 0.2%
1
$0
kcl 0.15%/d5w/nacl 0.225%
1
$0
kcl 0.15%/d5w/nacl 0.45%
1
$0
kcl 0.15%/d5w/nacl 0.9%
1
$0
kcl 0.3%/d5w/lr iv lac ring
1
$0
kcl 0.3%/d5w/nacl 0.45%
1
$0
kcl 0.3%/d5w/nacl 0.9%
klor-con 10
1
$0
1
$0
klor-con 8
klor-con m10
1
$0
klor-con m20
1
$0
3
$0
kp calcium 600+d tabs
1
$0
lactated ringers dextrose 5% viaflex
1
$0
lactated ringers viaflex
LIPOSYN III
2
$0
mag-delay
3
$0
MAGNEBIND 200
3
$0
MAGNEBIND 300
3
$0
magnesium oxide tabs 241,3mg, 400mg
3
$0
magnesium sulfate inj 40mg/ml, 50%,
1
$0
80mg/ml
magnesium sulfate inj 50%
1
$0
magnesium tabs 500mg
3
$0
NEPHRAMINE
2
$0
oysco 500
3
$0
oyster shell calcium/vitamin d tabs
3
$0
500mg; 400unit
PEDIALYTE SOLN 35MEQ/L;
3
$0
30MEQ/L; 25GM/L; 20MEQ/L;
45MEQ/L
PERIKABIVEN
2
$0
PHOS-NAK POWDER CONCENTRATE
3
$0
76
Azioni necessarie,
restrizioni o
limitazioni all'uso
B/D
MO
MO
MO
*
MO
B/D
*
*
*
*
MO
*
B/D
*
*
*
B/D
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
potassium chloride 0.15% /nacl 0.45%
viaflex
potassium chloride 0.15% d5w/nacl
0.33%
potassium chloride 0.15% d5w/nacl
0.45%
potassium chloride 0.15% d5w/nacl
0.45% viaflex
potassium chloride 0.15% nacl 0.9%
potassium chloride 0.15%/nacl 0.9%
potassium chloride 0.22% d5w/nacl
0.45%
potassium chloride 0.224%d5w/nacl
0.45% viaflex
potassium chloride 0.3%/ nacl 0.9%
potassium chloride 0.3%/d5w
potassium chloride cr tbcr 10meq,
20meq
potassium chloride er
potassium chloride sr tbcr 8meq
potassium chloride liqd
potassium chloride inj 10meq/50ml,
20meq/100ml, 40meq/100ml
potassium chloride inj 0.4meq/ml,
10meq/100ml, 2meq/ml
potassium citrate er
PREMASOL INJ 52MEQ/L;
1760MG/100ML; 880MG/100ML;
34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML;
526MG/100ML; 492MG/100ML;
492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML;
390MG/100ML; 34MG/100ML;
152MG/100ML
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
1
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
1
1
$0
$0
$0
1
1
1
1
$0
$0
$0
$0
MO
MO
1
$0
MO
1
2
$0
$0
MO
B/D
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
77
Nome del farmaco
premasol inj 56meq/l; 320mg/100ml;
730mg/100ml; 190mg/100ml;
3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml;
490mg/100ml; 840mg/100ml;
490mg/100ml; 200mg/100ml;
290mg/100ml; 410mg/100ml;
230mg/100ml; 5meq/l; 15mg/100ml;
250mg/100ml; 120mg/100ml;
140mg/100ml; 470mg/100ml
pronutrients calcium+d3
rehydralyte
ringers injection
SLOW-MAG
SM CORAL CALCIUM
sm magnesium
sodium chloride 0.45% viaflex
sodium chloride inj 0.9%, 2.5meq/ml,
3%, 5%
sodium fluoride chew 0.5mg, 1.1mg
sterile water irrigation
tpn electrolytes
vitamins a/d/c/fluoride
Vitamine
A-25
ANTIOXIDANT FORMULA SG
aquadeks liqd
b complex caps 5mg; 1mcg; 60mg;
20mg; 0.5mg; 3mg; 3mg; 60mg
b-complex plus vitamin c
b-complex tabs 0.1mg; 5mcg; 20mg;
1mg; 2mg; 3mg
BAL-CARE DHA
bee zee
c-500 chew 500mg; 0
calciferol
CALCIUM PNV
78
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
B/D
3
3
1
3
3
3
1
1
$0
$0
$0
$0
$0
$0
$0
$0
1
1
1
1
MO
MO
3
3
3
3
$0
$0
$0
$0
$0
$0
$0
$0
3
3
$0
$0
*
*
2
3
3
3
2
$0
$0
$0
$0
$0
MO
*
*
*
Azioni necessarie,
restrizioni o
limitazioni all'uso
*
*
*
*
*
MO
*
*
*
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
centrum kids complete
CENTRUM SILVER CHEW
cerovite advanced formula liqd
chewable vite childrens
chewable vite with iron/childrens
CITRANATAL 90 DHA MISC 120MG;
159MG; 400UNIT; 2MG; 300MG; 50MG; 0.75MG; 0; 1MG; 90MG; 0; 20MG; 150MCG; 20MG; 3.4MG; 3MG;
30UNIT; 25MG
CITRANATAL ASSURE MISC 120MG;
124MG; 400UNIT; 2MG; 300MG; 50MG; 0.75MG; 0; 1MG; 35MG; 0; 20MG; 150MCG; 25MG; 3.4MG; 3MG;
30UNIT; 25MG
CITRANATAL B-CALM
CITRANATAL DHA MISC 625MG;
120MG; 0; 124MG; 400UNIT; 2MG;
250MG; 50MG; 0.625MG; 0; 1MG; 27MG; 0; 20MG; 150MCG; 20MG; 3.4MG; 3MG; 30UNIT; 25MG
CITRANATAL RX TABS 120MG;
125MG; 400UNIT; 2MG; 30UNIT;
50MG; 1MG; 27MG; 20MG; 150MCG;
20MG; 3.4MG; 3MG; 25MG
complete natal dha
completenate
CONCEPT DHA
CONCEPT OB
cyanocobalamin inj
daily-vite/iron/beta-carotene
DIALYVITE 800/ZINC 15
DIALYVITE VITAMIN D3 MAX
DRISDOL CAPS
ecee plus
ELDERTONIC
ESCAVITE
ESCAVITE D
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
3
$0
3
$0
3
$0
3
$0
3
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
*
*
*
*
*
MO
2
$0
MO
2
2
$0
$0
MO
MO
2
$0
MO
1
1
2
2
3
3
3
3
3
3
3
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
MO
MO
MO
*
*
*
*
*
*
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
79
Nome del farmaco
ESCAVITE LQ
EXTRA-VIRT PLUS DHA
FOCALGIN-B
FOLCAL DHA
FOLCAPS OMEGA 3
FOLET DHA
FOLET ONE
folic acid inj
folic acid tabs 1mg, 400mcg
FOLIVANE-OB
FOLIVANE-PRX DHA NF
geravim
HEMENATAL OB
HEMENATAL OB + DHA
hydroxocobalamin
icaps mv
inatal advance
inatal ultra
iromin-g
kp folic acid
MEPHYTON
meribin
MISSION PRENATAL
MISSION PRENATAL HP
mult-vitamin/fluoride chew 60mg;
400unit; 4.5mcg; 0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg;
2500unit; 15unit
multi vitamin/fluoride chew 60mg;
400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 15unit;
2500unit
multi-delyn
MULTI-DELYN/IRON
80
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
3
$0
3
$0
2
$0
2
$0
3
$0
2
$0
2
$0
3
$0
3
$0
1
$0
1
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
1
$0
1
$0
3
3
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
*
*
MO
MO
*
MO
MO
*
*
*
*
*
*
*
*
MO
*
*
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
multi-vit/fluoride soln 35mg/ml;
400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/
ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml
multi-vit/iron/fluoride soln 35mg/ml;
400unit/ml; 10mg/ml; 8mg/ml; 0.4mg/
ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml
multi-vitamin/fluoride/iron soln 35mg/
ml; 400unit/ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/
ml; 0.5mg/ml; 1500unit/ml
multi-vitamin/fluoride soln 35mg/ml;
400unit/ml; 2mcg/ml; 5unit/ml; 8mg/
ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml
multivitamin with fluoride chew 60mg;
4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit; 400unit; 15unit, 60mg; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit; 400unit; 15unit
mvc-fluoride
MYKIDZ IRON
NATACHEW CHEW 120MG;
2700UNIT; 400UNIT; 12MCG; 0; 0;
1MG; 28MG; 20MG; 10MG; 3MG; 0;
2MG; 20UNIT
NATALVIRT 90 DHA
NATALVIRT CA
NESTABS
NESTABS DHA
NEXA PLUS CAPS 28MG; 0; 250MCG;
660MG; 160MG; 0; 800UNIT; 350MG;
55MG; 29MG; 1.25MG; 25MG; 30UNIT
niacin er cpcr 500mg
niacin tr tbcr 500mg
niacinamide tabs 500mg
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
1
$0
MO
1
$0
MO
1
$0
MO
1
$0
MO
1
$0
MO
1
3
2
$0
$0
$0
MO
*
2
2
2
2
2
$0
$0
$0
$0
$0
MO
MO
MO
MO
MO
3
3
3
$0
$0
$0
*
*
*
Azioni necessarie,
restrizioni o
limitazioni all'uso
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
81
Nome del farmaco
niacin tabs 100mg, 50mg
NUTRICION PORVIDA
O-CAL PRENATAL
OB COMPLETE ONE
OB COMPLETE PETITE
OB COMPLETE PREMIER
OB COMPLETE/DHA
PAIRE OB
PERRY PRENATAL
PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID
PNV FOLIC ACID + IRON MULTIVITAMIN
PNV OB+DHA
PNV PRENATAL PLUS MULTIVITAMIN
PNV TABS 29-1
pnv-dha
pnv-select
PNV-VP-U
poly-vitamin/fluoride chew
poly-vitamin/fluoride soln 35mg/ml;
50mcg/ml; 2mcg/ml; 0.25mg/ml; 8mg/
ml; 3mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml
polyvitamin/iron soln 35mg/ml;
400unit/ml; 10mg/ml; 8mg/ml; 0.4mg/
ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml
polyvitamin soln 35mg/ml; 400unit/ml;
2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.5mg/ml; 5unit/ml; 1500unit/ml
pr natal 400
pr natal 400 ec
pr natal 430
pr natal 430 ec
PREFERA OB
82
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
3
$0
3
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
3
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
*
*
MO
MO
MO
MO
MO
MO
*
MO
2
$0
MO
2
2
2
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
$0
3
$0
*
3
$0
*
1
1
1
1
2
$0
$0
$0
$0
$0
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
PREFERA OB + DHA MISC 30MCG;
10MG; 400UNIT; 0.8MG; 12MCG;
200MG; 2.5MG; 1MG; 6MG; 0.5MG;
17MG; 203MG; 28MG; 250MCG;
50MG; 1.6MG; 65MCG; 1.5MG;
10UNIT; 4.5MG
PREFERAOB ONE
PRENAISSANCE
PRENAISSANCE PLUS
PRENATA
prenatabs fa
prenatal 19 chew 100mg; 1000unit;
200mg; 7mg; 400unit; 12mcg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit;
20mg
prenatal 19 tabs 100mg; 1000unit;
200mg; 7mg; 400unit; 12mcg; 25mg;
29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg
PRENATAL PLUS IRON TABS 120MG;
0; 200MG; 400UNIT; 2MG; 12MCG;
1MG; 29MG; 20MG; 10MG; 3MG;
1.84MG; 22UNIT; 4000UNIT; 25MG
PRENATAL PLUS TABS 120MG; 0;
200MG; 400UNIT; 2MG; 12MCG;
27MG; 1MG; 20MG; 10MG; 3MG;
1.84MG; 22MG; 4000UNIT; 25MG
prenatal plus tabs 120mg; 0; 200mg;
400unit; 2mg; 12mcg; 27mg; 1mg; 20mg; 10mg; 3mg; 1.84mg; 22mg; 4000unit; 25mg
PRENATAL TABS 100MG; 0; 0;
263MG; 400UNIT; 4MCG; 27MG; 0.8MG; 18MG; 2.6MG; 1.7MG; 1.5MG; 11UNIT; 4000UNIT; 25MG
PRENATE AM
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
MO
2
2
2
2
1
1
$0
$0
$0
$0
$0
$0
MO
MO
MO
MO
MO
MO
1
$0
MO
2
$0
2
$0
1
$0
MO
3
$0
*
2
$0
MO
Azioni necessarie,
restrizioni o
limitazioni all'uso
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
83
Nome del farmaco
PRENATE DHA CAPS 90MG; 145MG;
220UNIT; 13MCG; 300MG; 28MG;
400MCG; 600MCG; 50MG; 26MG;
10UNIT
PRENATE ELITE TABS 75MG;
2600UNIT; 330MCG; 100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG; 400MCG; 150MCG; 600MCG; 25MG;
21MG; 21MG; 3.5MG; 3MG; 10UNIT;
15MG
PRENATE ESSENTIAL CAPS 90MG;
280MCG; 145MG; 220UNIT; 13MCG;
300MG; 40MG; 29MG; 0; 400MCG; 600MCG; 50MG; 150MCG; 26MG;
10UNIT
PRENATE ESSENTIAL CAPS 600MCG;
90MG; 280MCG; 155MG; 220UNIT; 13MCG; 300MG; 40MG; 18MG; 400MCG; 50MG; 150MCG; 26MG;
10UNIT
PRENATE MINI
PRENATE PIXIE
PREPLUS
PREQUE 10
PRETAB
PUREFE OB PLUS
pyridoxine hcl inj
QUFLORA PEDIATRIC SOLN
RELNATE DHA
SCOOBY-DOO ONE A DAY
se-natal 19
se-tan dha
SELECT-OB CHEW 60MG; 0;
400UNIT; 5MCG; 0.4MG; 0.6MG;
25MG; 15MG; 29MG; 2.5MG; 1.8MG;
0; 1.6MG; 30UNIT; 1700UNIT; 15MG
SETON ET-EC
setonet
84
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
2
$0
2
$0
2
$0
MO
2
2
2
2
2
2
3
2
2
3
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
MO
2
1
$0
$0
MO
MO
*
MO
*
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome del farmaco
sm vitamin b12 tr
super b-100 tabs 100mcg; 100mg;
100mcg; 400mcg; 100mg; 100mg;
100mg; 50mg; 100mg; 100mg
TARON-PREX
THERA/BETA-CAROTENE TABS
90MG; 0; 30MCG; 23MG; 10MG; 9MCG; 400UNIT; 400MCG; 20MG; 18MG; 3MG; 3.4MG; 3MG; 30UNIT;
5000UNIT
thiamine hcl inj
TL FOLATE
TL-CARE DHA
TL-SELECT
total b/c
TRI-VI-SOL
tri-vit/fluoride
tri-vit/fluoride/iron
tri-vita
tri-vitamin/fluoride
tri-vitamin soln 35mg/ml; 400unit/ml;
1500unit/ml
triadvance
tricare
TRICARE PRENATAL COMPLEAT
TRICARE PRENATAL DHA ONE
TRINATAL GT
trinatal rx 1
triple-vitamin/fluoride
TRIVEEN-DUO DHA
TRIVEEN-PRX RNF
ultimatecare one nf
VEMAVITE-PRX 2
VENA-BAL DHA
VIRT-ADVANCE
VIRT-CARE ONE
VIRT-PN
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
3
$0
*
3
$0
*
2
3
$0
$0
MO
*
3
2
2
2
3
3
1
1
3
1
3
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
*
1
1
2
2
2
1
1
2
2
1
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
*
*
MO
MO
*
MO
*
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
85
Nome del farmaco
VIRT-PN DHA
VIRT-PN PLUS
VIRT-SELECT
VITA-MAG
VITAFOL-ONE
VITAMEDMD ONE RX/QUATREFOLIC
VITAMEDMD PLUS RX/QUATRE FOLIC
vitamin a caps 10000unit
vitamin a tabs 1000unit; 10000unit
vitamin b-12 tabs 100mcg
vitamin b-1 tabs 100mg, 50mg
vitamin b-6 tabs 100mg, 25mg, 50mg
vitamin c chew 250mg
vitamin c syrp
vitamin c tabs 100mg, 250mg, 500mg
vitamin d-1000
vitamin d3 liqd 400unit/ml
VITAMIN D3 TABS 3000UNIT
vitamin d3 tabs 400unit
vitamin k1 inj 10mg/ml, 1mg/0.5ml
vitamins a/c/d/fluoride
vitatrum chew
VOL-NATE
VOL-PLUS
VP CH ULTRA
VP-CH-PNV
VP-HEME OB
VP-PNV-DHA
yl folic acid
ZATEAN-CH
ZATEAN-PN
ZATEAN-PN DHA
ZATEAN-PN PLUS
86
Costo
Livello a Suo
di
carico
Classe
per il
farmaco
2
$0
2
$0
2
$0
3
$0
2
$0
2
$0
2
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
3
$0
1
$0
3
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
3
$0
2
$0
2
$0
2
$0
2
$0
Azioni necessarie,
restrizioni o
limitazioni all'uso
MO
MO
MO
*
MO
MO
MO
*
*
*
*
*
*
*
*
*
*
*
*
*
MO
*
MO
MO
MO
MO
MO
*
MO
MO
MO
MO
PA - Autorizzazione preliminare QL - Limiti quantitativi ST - Terapia a gradini MO - Disponibili per
corrispondenza B/D - Coperti da Medicare B o D LA - Accesso limitato * - Farmaci non Parte D o farmaci
da banco che sono coperti da Medicaid.
NY-15-08-05
H8056_16_004_DRG_LST_ITA ACCEPTED
Nome farmaco
Pagina n.
Indice dei farmaci
8-MOP.............................................................................. 42
A-25.................................................................................. 78
abacavir ....................................................................................29
abacavir sulfate/lamivudine/zidovudine ..........................29
ABELCET .......................................................................... 16
ABILIFY DISCMELT.......................................................... 26
ABILIFY INJ ....................................................................... 26
ABILIFY MAINTENA INJ 300MG .................................. 26
ABILIFY MAINTENA INJ 300MG, 400MG .................. 26
ABILIFY ORAL SOLN ...................................................... 26
ABRAXANE ...................................................................... 20
ABREVA ............................................................................ 42
acamprosate calcium dr ......................................................... 5
acarbose ...................................................................................32
acebutolol hcl caps.................................................................37
ACETAMINOPHEN 8 HOUR ........................................... 1
acetaminophen/codeine #3 .................................................. 3
acetaminophen/codeine soln ................................................ 3
acetaminophen/codeine tabs 300mg; 15mg, 300mg; 60mg ........................................................................................... 3
acetasol hc ...............................................................................67
acetazolamide er ....................................................................38
acetazolamide tabs ................................................................38
acetic acid.................................................................................67
acetic acid/aluminum acetate .............................................67
acetylcysteine inhalation soln .............................................70
acetylcysteine inj.....................................................................70
acid gone susp.........................................................................45
acid reducer tabs 10mg ........................................................46
acitretin .....................................................................................42
ACNE MEDICATION ....................................................... 42
ACNE MEDICATION 5 LOTN ........................................ 42
ACTHIB ............................................................................. 61
ACTIMMUNE ................................................................... 61
ACUVAIL ........................................................................... 66
acyclovir caps, oint, susp, tabs.............................................31
acyclovir sodium inj 500mg ................................................31
acyclovir sodium inj 1000mg, 50mg/ml..........................30
ADACEL ............................................................................ 61
ADAGEN ........................................................................... 44
ADASUVE ......................................................................... 26
adefovir dipivoxil .....................................................................28
ADEMPAS ......................................................................... 70
adrucil........................................................................................20
ADVAIR DISKUS............................................................... 67
ADVAIR HFA ..................................................................... 67
AFINITOR.......................................................................... 23
AFINITOR DISPERZ ......................................................... 23
afrin childrens .........................................................................70
AFRIN MENTHOL ........................................................... 70
afrin saline nasal mist soln 0; 0.002%; 0.65%; 0; 0 .....70
AGGRENOX...................................................................... 35
a-hydrocort..............................................................................49
ak-poly-bac .............................................................................64
ALBENZA ......................................................................... 24
albuterol sulfate er .................................................................69
albuterol sulfate nebu............................................................69
albuterol sulfate syrp, tabs ...................................................69
alclometasone dipropionate ................................................49
ALCOHOL PREP PADS ................................................... 63
ALDURAZYME ................................................................. 44
alendronate sodium soln ......................................................62
alendronate sodium tabs 10mg, 40mg, 5mg.................62
alendronate sodium tabs 35mg, 70mg ...........................62
ALIMTA ............................................................................. 20
ALINIA............................................................................... 24
ALKERAN TABS ............................................................... 19
all day allergy-d ......................................................................70
ALLEGRA ALLERGY CHILDRENS SUSP, TABS ........... 68
aller-ease tabs 60mg ............................................................68
allergy relief tabs 10mg ........................................................68
allopurinol tabs .......................................................................17
alosetron hydrochloride .......................................................47
ALPHAGAN P SOLN 0.1% ............................................ 66
alprazolam tabs 0.25mg, 0.5mg .......................................31
alprazolam tabs 1mg, 2mg..................................................31
ALTABAX........................................................................... 42
altarussin-pe ...........................................................................70
altaryl elix..................................................................................68
altavera .....................................................................................52
aluminum hydroxide ..............................................................45
alyacen 1/35 ...........................................................................53
alyacen 7/7/7..........................................................................53
amantadine hcl caps, syrp, tabs ..........................................25
AMBISOME ...................................................................... 16
amcinonide ..............................................................................50
amethia .....................................................................................53
amethia lo ................................................................................53
amethyst ...................................................................................53
amifostine ................................................................................20
87
Nome farmaco
Pagina n.
amikacin sulfate inj 1gm/4ml, 500mg/2ml...................... 6
amiloride hcl tabs ...................................................................39
amiloride/hydrochlorothiazide ...........................................39
aminophylline..........................................................................70
AMINOSYN 7%/ELECTROLYTES ................................. 73
aminosyn 8.5%/electrolytes ................................................73
AMINOSYN-HBC ............................................................ 73
AMINOSYN II ................................................................... 73
aminosyn ii 8.5%/electrolytes .............................................73
AMINOSYN INJ 148MEQ/L; 1280MG/100ML;
980MG/100ML; 1280MG/100ML; 300MG/100ML;
720MG/100ML; 940MG/100ML; 720MG/100ML;
400MG/100ML; 440MG/100ML; 5.4MEQ/L;
860MG/100ML; 420MG/100ML; 520MG/100ML; 160MG/100ML; 44MG/100ML; 800MG/100ML, 90MEQ/L; 1100MG/100ML; 850MG/100ML; 35MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML; 340MG/100ML; 380MG/100ML; 5.4MEQ/L; 750MG/100ML; 370MG/100ML; 460MG/100ML; 150MG/100ML; 44MG/100ML; 680MG/100ML ..74
AMINOSYN M.................................................................. 73
AMINOSYN-PF................................................................ 74
AMINOSYN-PF 7% ........................................................ 74
AMINOSYN-RF................................................................ 74
amiodarone hcl tabs ..............................................................36
AMITIZA ........................................................................... 47
amitriptyline hcl tabs .............................................................15
amlodipine besylate/atorvastatin calcium .......................37
amlodipine besylate/benazepril hcl ...................................37
amlodipine besylate/benazepril hydrochloride ..............37
amlodipine besylate tabs ......................................................37
amlodipine besylate/valsartan ............................................37
amlodipine/valsartan/hctz...................................................37
ammonium lactate crea, lotn ..............................................42
amnesteem ..............................................................................42
amoxapine ................................................................................15
amoxicillin .................................................................................. 9
amoxicillin/clavulanate potassium ....................................... 9
amoxicillin/clavulanate potassium er .................................. 9
amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg ........................................................................................41
amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 88
Nome farmaco
Pagina n.
5mg............................................................................................41
amphotericin b ........................................................................16
ampicillin caps........................................................................... 9
ampicillin sodium inj 1gm, 2gm, 500mg ........................... 9
ampicillin sodium inj 10gm, 125mg, 1gm, 250mg, 2gm
9
ampicillin-sulbactam .............................................................. 9
ampicillin susr 125mg/5ml ................................................... 9
ampicillin susr 250mg/5ml ................................................... 9
AMPYRA ........................................................................... 41
ANADROL-50 ................................................................. 52
anagrelide hydrochloride .....................................................34
anastrozole tabs......................................................................22
ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM
52
ANDROGEL GEL 25MG/2.5GM, 50MG/5GM .......... 52
ANDROGEL PUMP GEL 1%.......................................... 52
ANDROGEL PUMP GEL 1.62%.................................... 52
ANORO ELLIPTA ............................................................. 69
antacid maximum strength .................................................45
antibiotic ear............................................................................67
anti-diarrheal liqd, tabs ........................................................45
antifungal .................................................................................42
ANTIOXIDANT FORMULA SG ...................................... 78
APAP 500 ........................................................................... 1
APOKYN ........................................................................... 25
apraclonidine...........................................................................66
apri .............................................................................................53
APRISO ............................................................................. 62
APTIOM TABS 200MG, 400MG, 800MG .................. 11
APTIOM TABS 600MG .................................................. 11
APTIVUS CAPS ................................................................ 30
APTIVUS SOLN ............................................................... 30
aquadeks liqd ..........................................................................78
aranelle .....................................................................................53
ARANESP ALBUMIN FREE INJ 10MCG/0.4ML ......... 34
ARANESP ALBUMIN FREE INJ 25MCG/0.42ML ...... 34
ARANESP ALBUMIN FREE INJ 100MCG/0.5ML ...... 34
ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 25MCG/ML, 300MCG/ML, 40MCG/
ML, 60MCG/ML .............................................................. 34
ARANESP ALBUMIN FREE INJ 150MCG/0.3ML, 60MCG/0.3ML................................................................ 34
ARANESP ALBUMIN FREE INJ 150MCG/0.75ML .... 34
ARANESP ALBUMIN FREE INJ 200MCG/0.4ML, 40MCG/0.4ML................................................................ 34
ARANESP ALBUMIN FREE INJ 300MCG/0.6ML ...... 34
Nome farmaco
Pagina n.
ARANESP ALBUMIN FREE INJ 500MCG/ML ............ 34
ARCALYST ........................................................................ 61
ARCAPTA NEOHALER.................................................... 69
aripiprazole ..............................................................................26
ARRANON........................................................................ 20
artificial tears soln 1.4% .......................................................64
ARZERRA .......................................................................... 24
ashlyna ......................................................................................53
ASMANEX HFA ................................................................ 67
ASMANEX TWISTHALER 7 METERED DOSES .......... 67
ASMANEX TWISTHALER 14 METERED DOSES........ 67
ASMANEX TWISTHALER 30 METERED DOSES........ 67
ASMANEX TWISTHALER 60 METERED DOSES........ 67
ASMANEX TWISTHALER 120 METERED DOSES ..... 67
aspirin supp 300mg, 600mg ................................................ 2
aspirin tabs................................................................................. 2
aspirin tbec 325mg ................................................................. 2
aspir-low..................................................................................... 2
atenolol/chlorthalidone ........................................................37
atenolol tabs ............................................................................37
ATGAM.............................................................................. 60
atorvastatin calcium ..............................................................39
atovaquone ..............................................................................24
atovaquone/proguanil hcl ....................................................24
ATRIPLA ............................................................................ 28
atropine sulfate soln ..............................................................64
aubra .........................................................................................53
augmented betamethasone dipropionate .......................50
AURYXIA ........................................................................... 49
AVASTIN ........................................................................... 20
aviane ........................................................................................53
avita crea ..................................................................................42
avita gel .....................................................................................42
AXID AR ............................................................................ 46
AYR NASAL DROPS ........................................................ 70
azacitidine ................................................................................20
AZASITE............................................................................ 64
azathioprine tabs ....................................................................59
azelastine hcl nasal soln 0.1% ............................................68
azelastine hcl nasal soln 0.15%..........................................68
azelastine hcl ophthalmic soln 0.05% ..............................65
AZILECT ............................................................................ 25
azithromycin inj 500mg .......................................................10
azithromycin pack, susr, tabs...............................................10
aztreonam inj 1gm................................................................... 9
aztreonam inj 2gm................................................................... 9
azurette .....................................................................................53
Nome farmaco
Pagina n.
baciim .......................................................................................... 6
bacitracin external oint 500unit/gm .................................42
bacitracin inj 50000unit ........................................................ 6
bacitracin/neomycin/polymyxin .........................................64
bacitracin ophthalmic oint 500unit/gm ..........................64
bacitracin/polymyxin b..........................................................64
bacitracin zinc .........................................................................42
baclofen tabs ...........................................................................28
BAL-CARE DHA .............................................................. 78
balsalazide disodium .............................................................62
balziva .......................................................................................53
BANZEL ............................................................................ 13
BARACLUDE SOLN ........................................................ 28
BARACLUDE TABS.......................................................... 28
bayer chewable low dose ........................................................ 2
bcg vaccine...............................................................................61
b complex caps 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg; 3mg; 60mg ..............................................................................78
b-complex plus vitamin c......................................................78
b-complex tabs 0.1mg; 5mcg; 20mg; 1mg; 2mg; 3mg78
BEELITH ............................................................................ 74
bee zee.......................................................................................78
BELEODAQ ...................................................................... 20
benazepril hcl/hydrochlorothiazide ...................................36
benazepril hcl tabs .................................................................36
BENLYSTA......................................................................... 61
benzonatate caps 100mg, 200mg ....................................70
benztropine mesylate inj, tabs .............................................25
BESIVANCE ...................................................................... 64
betamethasone dipropionate crea, lotn, oint ..................50
betamethasone valerate crea, foam, lotn, oint ...............50
betaxolol hcl soln 0.5% .........................................................66
betaxolol hcl tabs 10mg, 20mg ..........................................37
bethanechol chloride.............................................................49
BEXSERO .......................................................................... 61
bicalutamide ............................................................................19
BICILLIN L-A ...................................................................... 9
BICNU ............................................................................... 20
bisoprolol fumarate ...............................................................37
bisoprolol fumarate/hydrochlorothiazide ........................37
bleomycin sulfate....................................................................20
BLINCYTO ........................................................................ 24
BOOSTRIX ........................................................................ 61
BOSULIF ........................................................................... 23
BREO ELLIPTA AEPB 100MCG/INH; 25MCG/INH .. 67
BREO ELLIPTA AEPB 200MCG/INH; 25MCG/INH .. 67
briellyn.......................................................................................53
89
Nome farmaco
Pagina n.
BRILINTA .......................................................................... 35
brimonidine tartrate ..............................................................66
BRINTELLIX ...................................................................... 14
bromocriptine mesylate caps, tabs ....................................25
budesonide cp24 3mg ..........................................................50
budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml68
budesonide nasal susp 32mcg/act ....................................68
bumetanide inj, tabs ..............................................................38
BUPHENYL TABS ............................................................ 44
buprenorphine hcl/naloxone hcl........................................... 5
buprenorphine hcl subl ........................................................... 5
buproban .................................................................................... 5
bupropion hcl er......................................................................14
bupropion hcl sr tb12 100mg, 150mg, 200mg ...........14
bupropion hcl sr tb12 150mg .............................................. 5
bupropion hcl tabs .................................................................14
bupropion hcl xl ......................................................................14
buspirone hcl tabs ..................................................................31
BUSULFEX........................................................................ 19
butalbital/acetaminophen/caffeine caps............................ 1
butalbital/acetaminophen/caffeine/codeine ..................... 1
butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg ........................................................................................... 1
butalbital/apap/caffeine ......................................................... 1
butalbital/aspirin/caffeine caps ............................................ 1
butalbital/aspirin/caffeine/codeine ...................................... 1
butalbital compound/codeine ............................................... 3
c-500 chew 500mg; 0 .........................................................78
cabergoline ..............................................................................58
calciferol ...................................................................................78
CALCI-MIX ....................................................................... 74
CALCIONATE ................................................................... 74
calcipotriene ............................................................................42
calcitonin-salmon ..................................................................62
calcitrene ..................................................................................42
calcitriol caps, oral soln .........................................................62
calcitriol inj ...............................................................................62
calcium 500+d high potency ..............................................74
calcium 500/vitamin d3 .......................................................74
calcium 600+d plus minerals chew 600mg; 400unit; 1mg; 50mg; 1.8mg; 250mcg; 7.5mg ..............................74
calcium 600 tabs 600mg ....................................................74
calcium acetate caps .............................................................49
calcium acetate tabs 667mg ...............................................49
calcium antacid .......................................................................45
calcium antacid ultra maximum strength ........................45
calcium carbonate susp ........................................................74
90
Nome farmaco
Pagina n.
calcium carbonate tabs 1250mg ......................................74
calcium chloride......................................................................74
calcium citrate+ d...................................................................74
calcium citrate + d tabs 315mg; 200unit ........................74
calcium + d3 ............................................................................74
calcium gluconate inj.............................................................74
calcium lactate tabs 648mg ................................................74
CALCIUM PNV................................................................. 78
calcium tabs 500mg .............................................................75
calcium/vitamin d tabs 600mg; 200unit, 600mg; 400unit .....................................................................................75
CALTRATE 600+D PLUS MINERALS CHEW .............. 75
camila ........................................................................................57
camrese.....................................................................................53
camrese lo ................................................................................53
CANCIDAS INJ 50MG..................................................... 16
CANCIDAS INJ 70MG..................................................... 16
candesartan cilexetil ..............................................................35
candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg .....................................................................................35
candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg, 32mg; 25mg ..........................................................35
capacet........................................................................................ 1
CAPASTAT SULFATE ....................................................... 18
CAPRELSA TABS 100MG .............................................. 23
CAPRELSA TABS 300MG .............................................. 23
captopril/hydrochlorothiazide ............................................36
captopril tabs ...........................................................................36
CARBAGLU ...................................................................... 44
carbamazepine chew, susp, tabs.........................................13
carbamazepine er...................................................................13
carbidopa/levodopa ..............................................................25
carbidopa/levodopa/entacapone.......................................25
carbidopa/levodopa er..........................................................25
carbidopa/levodopa odt .......................................................25
carbidopa tabs ........................................................................25
carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml, 600mg/60ml ..........................................................................20
carteolol hcl..............................................................................66
cartia xt .....................................................................................37
carvedilol ..................................................................................37
castellani paint modified/color............................................42
CAYSTON ......................................................................... 69
caziant .......................................................................................53
cefaclor caps .............................................................................. 8
cefaclor er................................................................................... 8
cefaclor susr 125mg/5ml, 375mg/5ml ............................ 8
Nome farmaco
Pagina n.
cefaclor susr 250mg/5ml ...................................................... 8
cefadroxil .................................................................................... 8
cefazolin sodium/dextrose...................................................... 8
cefazolin sodium inj 10gm, 1gm, 500mg.......................... 8
cefazolin sodium inj 100gm, 1gm; 5%, 1gm, 20gm, 300gm ........................................................................................ 8
cefdinir ........................................................................................ 8
cefditoren pivoxil tabs 200mg .............................................. 8
cefditoren pivoxil tabs 400mg .............................................. 8
cefepime inj 1gm, 2gm ........................................................... 8
cefepime inj 1gm/50ml; 5%, 1gm/50ml, 2gm/100ml, 2gm/50ml; 5% ......................................................................... 8
cefotaxime sodium inj 1gm, 2gm ......................................... 8
cefotaxime sodium inj 10gm, 500mg................................. 8
cefotetan ..................................................................................... 8
cefotetan/dextrose ................................................................... 8
cefoxitin sodium inj 1gm, 2gm.............................................. 8
cefoxitin sodium inj 10gm, 1gm; 4%, 2gm; 2.2% ........... 8
cefpodoxime proxetil ............................................................... 8
cefprozil ...................................................................................... 8
ceftazidime/dextrose ............................................................... 8
ceftazidime inj 1gm, 2gm ...................................................... 8
ceftazidime inj 6gm ................................................................. 8
ceftriaxone/dextrose ................................................................ 9
ceftriaxone in iso-osmotic dextrose..................................... 8
ceftriaxone sodium inj 1gm ................................................... 8
ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg ........................................................................................ 8
cefuroxime axetil tabs .............................................................. 9
cefuroxime/dextrose inj 750mg; 4.1% ............................... 9
cefuroxime sodium inj 1.5gm, 7.5gm, 75gm ................... 9
cefuroxime sodium inj 750mg .............................................. 9
celecoxib caps 100mg, 200mg, 50mg .............................. 2
celecoxib caps 400mg ............................................................ 2
CELLCEPT INTRAVENOUS ............................................ 59
CELLCEPT SUSR.............................................................. 59
CELONTIN ........................................................................ 12
centrum kids complete..........................................................79
CENTRUM SILVER CHEW .............................................. 79
cephalexin .................................................................................. 9
CEREZYME INJ 400UNIT ............................................... 44
cerovite advanced formula liqd...........................................79
CERVARIX ......................................................................... 61
cetirizine hcl chew ..................................................................68
cetirizine hcl tabs 5mg ..........................................................68
CHANTIX CONTINUING MONTH PAK ......................... 5
CHANTIX STARTING MONTH PAK................................ 5
Nome farmaco
Pagina n.
CHANTIX TABS 0.5MG, 1MG ......................................... 6
chateal.......................................................................................53
chewable vite childrens .........................................................79
chewable vite with iron/childrens .......................................79
childrens cold & allergy .........................................................70
childrens complete allergy ...................................................68
childrens non-aspirin chew ................................................... 1
chloramphenicol sodium succinate ..................................... 7
chlorhexidine gluconate oral rinse .....................................41
chloroquine phosphate tabs ................................................24
chlorothiazide..........................................................................39
chlorpromazine hcl inj, tabs.................................................26
chlorthalidone tabs 25mg, 50mg......................................39
chlorzoxazone tabs.................................................................72
cholestyramine light ..............................................................39
cholestyramine pack, powd .................................................39
ciclodan.....................................................................................16
ciclopirox...................................................................................16
ciclopirox nail lacquer ............................................................16
ciclopirox olamine crea .........................................................16
cilostazol ...................................................................................35
cimetidine hcl soln..................................................................46
cimetidine tabs 200mg ........................................................46
cimetidine tabs 200mg, 300mg, 400mg, 800mg .......46
CIMZIA .............................................................................. 59
CIMZIA STARTER KIT...................................................... 59
CINRYZE ........................................................................... 59
ciprofloxacin er ........................................................................10
ciprofloxacin hcl soln 0.3% ..................................................64
ciprofloxacin hcl tabs 100mg, 250mg, 500mg, 750mg..
10
ciprofloxacin inj, otic soln, susr............................................10
ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% .............10
ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5% .............10
cisplatin .....................................................................................20
citalopram hydrobromide soln............................................14
citalopram hydrobromide tabs 10mg...............................14
citalopram hydrobromide tabs 20mg...............................14
citalopram hydrobromide tabs 40mg...............................14
CITRANATAL 90 DHA MISC 120MG; 159MG; 400UNIT; 2MG; 300MG; 50MG; 0.75MG; 0; 1MG; 90MG; 0; 20MG; 150MCG; 20MG; 3.4MG; 3MG; 30UNIT; 25MG ............................................................... 79
CITRANATAL ASSURE MISC 120MG; 124MG; 400UNIT; 2MG; 300MG; 50MG; 0.75MG; 0; 1MG; 35MG; 0; 20MG; 150MCG; 25MG; 3.4MG; 3MG; 30UNIT; 25MG ............................................................... 79
91
Nome farmaco
Pagina n.
CITRANATAL B-CALM................................................... 79
CITRANATAL DHA MISC 625MG; 120MG; 0; 124MG; 400UNIT; 2MG; 250MG; 50MG; 0.625MG; 0; 1MG;
27MG; 0; 20MG; 150MCG; 20MG; 3.4MG; 3MG; 30UNIT; 25MG ............................................................... 79
CITRANATAL RX TABS 120MG; 125MG; 400UNIT; 2MG; 30UNIT; 50MG; 1MG; 27MG; 20MG; 150MCG; 20MG; 3.4MG; 3MG; 25MG ........................................ 79
citrus calcium +d ....................................................................75
citrus calcium/vitamin d .......................................................75
cladribine ..................................................................................20
claravis caps 10mg, 20mg, 40mg.....................................42
CLARAVIS CAPS 30MG ................................................. 42
clarithromycin susr, tabs.......................................................10
CLARITIN CHEW ............................................................. 68
CLARITIN REDITABS TBDP 5MG ................................. 68
clemastine fumarate syrp ....................................................68
clemastine fumarate tabs 2.68mg ....................................68
clindamax gel............................................................................. 7
clindamycin/benzoyl peroxide .............................................42
clindamycin hcl caps................................................................ 7
clindamycin palmitate hcl ...................................................... 7
clindamycin phosphate add-vantage.................................. 7
clindamycin phosphate crea 2% .......................................... 7
clindamycin phosphate external soln 1%.........................42
clindamycin phosphate foam 1% ......................................42
clindamycin phosphate gel 1% ...........................................42
clindamycin phosphate in d5w ............................................. 7
clindamycin phosphate inj 150mg/ml, 300mg/2ml, 9000mg/60ml ......................................................................... 7
clindamycin phosphate inj 600mg/4ml, 900mg/6ml ... 7
clindamycin phosphate lotn 1% .........................................42
clindamycin phosphate swab 1%.......................................42
clinisol sf 15% .........................................................................75
clobetasol propionate crea, foam, gel, lotn, oint, sham, soln .............................................................................................50
clobetasol propionate e ........................................................50
clobetasol propionate emollient foam ..............................50
clobetasol propionate liqd ....................................................50
CLOLAR ............................................................................ 20
clomipramine hcl caps ..........................................................15
clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg .........12
clonazepam odt tbdp 1mg...................................................12
clonazepam odt tbdp 2mg...................................................12
clonazepam tabs 0.5mg .......................................................12
clonazepam tabs 1mg...........................................................12
clonazepam tabs 2mg...........................................................12
92
Nome farmaco
Pagina n.
clonidine hcl ptwk...................................................................35
clonidine hcl tabs ....................................................................35
clopidogrel tabs 75mg ..........................................................35
clopidogrel tabs 300mg .......................................................35
clorazepate dipotassium tabs 3.75mg, 7.5mg...............31
clorazepate dipotassium tabs 15mg .................................31
clotrimazole/betamethasone dipropionate.....................16
clotrimazole external crea 1%.............................................16
clotrimazole soln 1% .............................................................17
clotrimazole troc 10mg ........................................................17
clotrimazole vaginal crea 1% ..............................................49
clozapine ...................................................................................27
clozapine odt ...........................................................................27
COARTEM ........................................................................ 24
codeine sulfate tabs ................................................................. 3
CODITUSS DM ................................................................ 70
colchicine caps, tabs ..............................................................17
COLCRYS .......................................................................... 17
cold/cough childrens .............................................................70
colestipol hcl ............................................................................39
colestipol hcl for oral suspension .......................................40
colistimethate sodium ............................................................. 7
colocort .....................................................................................50
COMBIGAN ..................................................................... 64
COMBIVENT RESPIMAT ................................................ 69
COMETRIQ KIT 0 ............................................................ 23
COMETRIQ KIT 0, 20MG............................................... 23
compazine supp ......................................................................26
COMPLERA ...................................................................... 29
complete natal dha ................................................................79
completenate...........................................................................79
compro ......................................................................................26
comtrex severe cold & sinus maximum strength day/night
70
COMVAX........................................................................... 61
CONCEPT DHA ............................................................... 79
CONCEPT OB .................................................................. 79
constulose ................................................................................47
COPAXONE INJ 20MG/ML............................................ 41
COPAXONE INJ 40MG/ML............................................ 41
coricidin hbp chest congestion & cough...........................70
CORLANOR ..................................................................... 38
cormax scalp application ......................................................50
cortisone acetate tabs ...........................................................50
COSMEGEN ..................................................................... 20
cough & cold ............................................................................70
CREON .............................................................................. 44
Nome farmaco
Pagina n.
CRESTOR .......................................................................... 39
CRIXIVAN ......................................................................... 30
cromolyn sodium conc 100mg/5ml .................................45
cromolyn sodium nebu 20mg/2ml ...................................70
cromolyn sodium soln 4%....................................................66
cryselle-28 ...............................................................................53
CUBICIN ............................................................................. 7
CUPRIMINE ...................................................................... 73
cvs laxative dietary supplement ..........................................47
cvs lubricating eye drops/dry eye .......................................64
cyanocobalamin inj................................................................79
cyclafem 1/35 .........................................................................53
cyclafem 7/7/7 .......................................................................53
cyclobenzaprine hcl tabs ......................................................72
cyclophosphamide caps .......................................................19
cyclophosphamide inj ...........................................................19
cycloserine ...............................................................................18
cyclosporine caps ...................................................................60
cyclosporine inj .......................................................................60
cyclosporine modified ...........................................................59
CYRAMZA ........................................................................ 24
CYSTADANE..................................................................... 44
CYSTAGON ...................................................................... 44
CYSTARAN ....................................................................... 64
cytarabine aqueous ...............................................................20
dacarbazine .............................................................................20
daily-vite/iron/beta-carotene .............................................79
DALIRESP ......................................................................... 70
DALVANCE ......................................................................... 7
danazol caps ............................................................................52
dantrolene sodium caps .......................................................28
dapsone tabs ...........................................................................18
DAPTACEL ........................................................................ 61
DARAPRIM ....................................................................... 24
dasetta 1/35............................................................................53
dasetta 7/7/7 ..........................................................................53
daunorubicin hcl inj 5mg/ml ...............................................20
DAUNOXOME .................................................................. 20
daysee .......................................................................................53
deblitane ...................................................................................57
decitabine .................................................................................20
delyla .........................................................................................53
DENAVIR........................................................................... 31
DEPEN TITRATABS ......................................................... 73
DEPOCYT ......................................................................... 20
DEPO-ESTRADIOL ......................................................... 53
DEPO-PROVERA ............................................................ 57
Nome farmaco
Pagina n.
desenex .....................................................................................42
desenex jock itch spray powder...........................................42
desipramine hcl tabs..............................................................15
desmopressin acetate inj, nasal soln, tabs .......................52
desogestrel/ethinyl estradiol ...............................................53
desonide crea, lotn, oint........................................................50
desoximetasone crea, gel, oint ............................................50
desvenlafaxine er tb24 100mg, 50mg.............................14
desvenlafaxine er tb24 100mg, 50mg.............................14
dexamethasone elix, soln, tabs ............................................50
DEXAMETHASONE INTENSOL.................................... 50
dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml ..................................50
dexamethasone sodium phosphate inj 100mg/10ml, 10mg/ml...................................................................................50
dexamethasone sodium phosphate ophthalmic soln 0.1% ..........................................................................................66
dexrazoxane .............................................................................20
dextroamphetamine sulfate soln ........................................41
dextroamphetamine sulfate tabs........................................41
dextrose 2.5%/sodium chloride 0.45% ............................75
dextrose 5% .............................................................................75
dextrose 5% /electrolyte #48 viaflex ................................75
dextrose 5%/lactated ringers ..............................................75
dextrose 5%/nacl 0.2% .........................................................75
dextrose 5%/nacl 0.3% .........................................................75
dextrose 5%/nacl 0.9% .........................................................75
dextrose 5%/nacl 0.33% ......................................................75
dextrose 5%/nacl 0.45% ......................................................75
dextrose 5%/nacl 0.225% ...................................................75
dextrose 5%/potassium chloride 0.15% ..........................75
dextrose 10% flex container ................................................75
dextrose 10%/nacl 0.2% ......................................................75
dextrose 10%/nacl 0.45% ..................................................75
dextrose 20% ..........................................................................75
dextrose 25% ..........................................................................75
dextrose 30% ..........................................................................75
dextrose 40% ..........................................................................75
dextrose 50% ..........................................................................75
dextrose 70% ..........................................................................75
DIALYVITE 800/ZINC 15 ............................................... 79
DIALYVITE VITAMIN D3 MAX ....................................... 79
diazepam gel 10mg, 2.5mg, 20mg ...................................12
diazepam inj 5mg/ml ............................................................31
diazepam intensol ..................................................................31
diazepam oral soln 1mg/ml .................................................31
diazepam tabs 10mg, 2mg, 5mg .......................................31
93
Nome farmaco
Pagina n.
diclofenac potassium .............................................................. 2
diclofenac sodium dr ............................................................... 2
diclofenac sodium er ............................................................... 2
dicloxacillin sodium .................................................................. 9
dicyclomine hcl .......................................................................45
didanosine ................................................................................29
DIFICID.............................................................................. 10
diflorasone diacetate crea, oint...........................................50
diflunisal tabs............................................................................. 2
digitek ........................................................................................38
digox...........................................................................................38
digoxin inj, oral soln, tabs......................................................38
dihydroergotamine mesylate inj .........................................17
DILANTIN CAPS 30MG ................................................. 13
diltiazem cd cp24 120mg ....................................................38
diltiazem cd cp24 180mg, 240mg, 300mg ...................38
diltiazem hcl cd .......................................................................38
diltiazem hcl er ........................................................................38
diltiazem hcl inj .......................................................................38
diltiazem hcl tabs ....................................................................38
dilt-xr .........................................................................................38
DIMETAPP LONG ACTING COUGH PLUS COLD ...... 71
dimetapp nighttime cold &congestion .............................71
diphenhydramine hcl caps 50mg ......................................68
diphenhydramine hcl inj .......................................................68
diphenoxylate/atropine .........................................................45
diphtheria/tetanus toxoids adsorbed pediatric...............61
disopyramide phosphate caps ............................................36
disulfiram tabs........................................................................... 5
divalproex sodium ..................................................................12
divalproex sodium dr .............................................................12
divalproex sodium er..............................................................12
DOCEFREZ ....................................................................... 20
docetaxel inj 140mg/7ml, 160mg/16ml, 200mg/20ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml ..............20
docusate sodium liqd.............................................................47
dok tabs.....................................................................................47
donepezil hcl tabs 10mg ......................................................13
donepezil hcl tabs 23mg, 5mg ...........................................13
donepezil hcl tbdp ..................................................................13
dorzolamide hcl ......................................................................66
dorzolamide hcl/timolol maleate .......................................66
doxazosin mesylate ................................................................35
doxepin hcl caps, conc ...........................................................15
doxercalciferol caps................................................................63
doxorubicin hcl ........................................................................21
doxorubicin hcl liposome ......................................................21
94
Nome farmaco
Pagina n.
doxy 100 ...................................................................................11
doxycycline caps, susr............................................................11
doxycycline hyclate caps, inj, tabs.......................................11
doxycycline hyclate dr............................................................11
doxycycline monohydrate caps ...........................................11
doxycycline monohydrate tabs 50mg ...............................11
doxycycline monohydrate tabs 100mg, 150mg, 50mg, 75mg .........................................................................................11
DRAMAMINE ................................................................... 45
dramamine less drowsy ........................................................45
DRISDOL CAPS ............................................................... 79
DRISTAN SPRAY .............................................................. 71
dronabinol ................................................................................16
drospirenone/ethinyl estradiol ............................................53
DROXIA ............................................................................. 20
dual action complete .............................................................48
duloxetine hcl cpep 20mg, 60mg ......................................14
duloxetine hcl cpep 30mg ....................................................14
duloxetine hcl cpep 40mg ....................................................31
duramorph ................................................................................. 3
DUREZOL ......................................................................... 66
ecee plus ...................................................................................79
econazole nitrate crea ...........................................................17
econtra ez .................................................................................57
ed chlorped jr ...........................................................................68
EDURANT......................................................................... 29
EGRIFTA INJ 1MG ............................................................ 52
EGRIFTA INJ 2MG ............................................................ 52
ELDERTONIC ................................................................... 79
ELIDEL............................................................................... 43
elinest ........................................................................................53
ELIQUIS ............................................................................ 33
ELITEK ............................................................................... 21
ELLA .................................................................................. 57
EMCYT .............................................................................. 19
EMEND CAPS 0, 125MG, 80MG ................................. 16
EMEND CAPS 40MG...................................................... 16
emoquette ................................................................................53
EMSAM ............................................................................. 14
EMTRIVA........................................................................... 29
enalapril maleate/hydrochlorothiazide ............................36
enalapril maleate tabs ...........................................................36
endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg .......................................................................................... 3
enema ready-to-use..............................................................47
enemeez mini ..........................................................................47
enemeez plus ...........................................................................47
Nome farmaco
Pagina n.
ENGERIX-B ...................................................................... 61
enoxaparin sodium.................................................................33
enpresse-28 ............................................................................53
enskyce......................................................................................53
entacapone ..............................................................................25
entecavir ...................................................................................28
enulose ......................................................................................47
epinastine hcl ..........................................................................66
EPIPEN 2-PAK ................................................................. 69
EPIPEN-JR 2-PAK............................................................ 69
epirubicin hcl inj 200mg/100ml, 50mg/25ml ..............21
epitol ..........................................................................................13
EPIVIR HBV SOLN ........................................................... 28
EPIVIR SOLN .................................................................... 29
eplerenone ...............................................................................39
epoprostenol sodium .............................................................70
eprosartan mesylate ..............................................................35
EPZICOM .......................................................................... 29
eql iron supplement therapy................................................73
EQUETRO ......................................................................... 31
ERAXIS .............................................................................. 17
ERBITUX............................................................................ 21
ergoloid mesylates tabs ........................................................13
ERIVEDGE......................................................................... 23
errin............................................................................................57
ERWINAZE ....................................................................... 21
ery...............................................................................................43
ERYTHROCIN LACTOBIONATE INJ 500MG............... 10
erythromycin base tabs ........................................................10
erythromycin/benzoyl peroxide ..........................................43
erythromycin cpep 250mg ..................................................10
erythromycin ethylsuccinate tabs ......................................10
erythromycin gel 2% .............................................................43
erythromycin oint 5mg/gm .................................................64
erythromycin pads 2% ..........................................................43
erythromycin soln 2% ...........................................................43
erythromycin stearate tabs ..................................................10
ESBRIET ............................................................................ 71
ESCAVITE ......................................................................... 79
ESCAVITE D...................................................................... 79
ESCAVITE LQ ................................................................... 80
escitalopram oxalate soln .....................................................14
escitalopram oxalate tabs 10mg, 5mg .............................15
escitalopram oxalate tabs 20mg ........................................14
esgic caps ................................................................................... 1
esomeprazole sodium ...........................................................48
estarylla.....................................................................................53
Nome farmaco
Pagina n.
ESTRACE CREA ............................................................... 53
estradiol/norethindrone acetate ........................................53
estradiol pttw...........................................................................54
estradiol ptwk ..........................................................................54
estradiol tabs ...........................................................................53
ethambutol hcl tabs ...............................................................18
ethosuximide ...........................................................................12
etidronate disodium...............................................................63
etodolac caps, tabs ................................................................... 2
etodolac er.................................................................................. 2
etoposide inj.............................................................................22
EVOTAZ............................................................................. 30
EVZIO .................................................................................. 5
exefen-ir....................................................................................71
EXELON PT24.................................................................. 13
exemestane ..............................................................................22
EXJADE.............................................................................. 73
ex-lax ultra................................................................................47
EXTAVIA ............................................................................ 41
EXTRA-VIRT PLUS DHA ................................................ 80
FABRAZYME..................................................................... 44
falmina ......................................................................................54
famciclovir tabs 125mg, 250mg .......................................31
famciclovir tabs 500mg .......................................................31
famotidine inj 20mg/2ml.....................................................46
famotidine inj 200mg/20ml, 40mg/4ml ........................46
famotidine premixed..............................................................46
famotidine susr 40mg/5ml .................................................46
famotidine tabs 20mg, 40mg.............................................46
FANAPT ............................................................................ 26
FANAPT TITRATION PACK ............................................ 26
FARESTON........................................................................ 19
FARYDAK .......................................................................... 21
FASLODEX ........................................................................ 21
FAZACLO .......................................................................... 27
FEBROL ............................................................................... 1
felbamate .................................................................................13
fenofibrate caps ......................................................................39
fenofibrate micronized ..........................................................39
fenofibrate tabs 145mg, 160mg, 48mg, 54mg ............39
fenofibric acid..........................................................................39
fenofibric acid dr.....................................................................39
fentanyl citrate oral transmucosal ....................................... 3
fentanyl pt72 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr ... 2
fentanyl pt72 100mcg/hr, 12mcg/hr, 25mcg/hr, 50mcg/
hr, 75mcg/hr ............................................................................. 3
fer-iron ......................................................................................73
95
Nome farmaco
Pagina n.
ferretts.......................................................................................73
FERRIPROX ....................................................................... 73
FERROUS FUMARATE .................................................... 73
ferrous gluconate ...................................................................73
ferrous sulfate .........................................................................73
FETZIMA ........................................................................... 15
FETZIMA TITRATION PACK........................................... 15
feverall adults ............................................................................ 1
feverall childrens....................................................................... 1
feverall junior strength ............................................................ 1
fexofenadine hcl tabs 180mg .............................................68
fiber laxative tabs ....................................................................47
finasteride tabs 5mg ..............................................................49
FIRAZYR ............................................................................ 59
FIRMAGON ...................................................................... 58
flecainide acetate....................................................................36
FLEET BISACODYL.......................................................... 47
FLORIVA............................................................................ 75
floxuridine .................................................................................21
fluconazole in dextrose..........................................................17
fluconazole in nacl..................................................................17
fluconazole susr, tabs.............................................................17
flucytosine ................................................................................17
fludarabine phosphate ..........................................................21
fludrocortisone acetate tabs ................................................50
flunisolide soln 0.025% ........................................................68
fluocinolone acetonide body ...............................................50
fluocinolone acetonide crea 0.01%, 0.025% .................50
fluocinolone acetonide oil 0.01% ......................................67
fluocinolone acetonide oint 0.025%.................................50
fluocinolone acetonide scalp ...............................................50
fluocinolone acetonide soln 0.01% ...................................50
fluocinonide crea, gel, oint, soln .........................................50
fluocinonide-e .........................................................................50
fluoritab chew 0.5mg, 1mg .................................................75
fluorometholone.....................................................................66
fluorouracil crea 0.5%...........................................................43
fluorouracil crea 5% ..............................................................43
fluorouracil external soln 2%, 5% ......................................43
fluorouracil inj 1gm/20ml, 2.5gm/50ml, 500mg/10ml, 5gm/100ml .............................................................................21
fluoxetine ..................................................................................15
fluoxetine dr .............................................................................15
fluoxetine hcl caps, soln, tabs...............................................15
fluphenazine decanoate inj ..................................................26
fluphenazine hcl conc, elix, inj, tabs ...................................26
FLURA-DROPS SOLN 0.25MG/DROP ....................... 75
96
Nome farmaco
Pagina n.
flurbiprofen sodium ...............................................................66
flurbiprofen tabs ....................................................................... 2
flutamide...................................................................................19
fluticasone propionate crea 0.05% ...................................50
fluticasone propionate lotn 0.05% ....................................50
fluticasone propionate oint 0.005% .................................50
fluticasone propionate susp 50mcg/act ...........................68
fluvastatin .................................................................................39
fluvoxamine maleate..............................................................15
FOCALGIN-B ................................................................... 80
FOLCAL DHA ................................................................... 80
FOLCAPS OMEGA 3 ....................................................... 80
FOLET DHA ...................................................................... 80
FOLET ONE ...................................................................... 80
folic acid inj ..............................................................................80
folic acid tabs 1mg, 400mcg...............................................80
FOLIVANE-OB ................................................................. 80
FOLIVANE-PRX DHA NF................................................ 80
FOLOTYN.......................................................................... 21
foltabs 800...............................................................................73
fomepizole ................................................................................73
fondaparinux sodium ............................................................33
FORADIL AEROLIZER ..................................................... 69
FORTEO ............................................................................ 63
foscarnet sodium ....................................................................28
fosinopril sodium ....................................................................36
fosinopril sodium/hydrochlorothiazide ............................36
fosphenytoin sodium inj 100mg pe/2ml .........................13
fosphenytoin sodium inj 500mg pe/10ml.......................13
FOSRENOL CHEW .......................................................... 49
FOSRENOL PACK ............................................................ 49
FUNGOID TINCTURE ..................................................... 43
furosemide inj, oral soln, tabs..............................................38
FUSILEV ............................................................................ 21
FUZEON ............................................................................ 30
FYCOMPA TABS 2MG .................................................... 11
FYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG ... 11
gabapentin caps, soln, tabs..................................................12
GABITRIL TABS 12MG, 16MG ..................................... 12
galantamine hydrobromide cp24 ......................................13
galantamine hydrobromide soln ........................................13
galantamine hydrobromide tabs ........................................13
GAMASTAN S/D ............................................................. 60
GAMMAPLEX INJ 2.5GM/50ML, 20GM/400ML,
5GM/100ML ................................................................... 60
GAMMAPLEX INJ 10GM/200ML ................................ 60
ganciclovir inj...........................................................................28
Nome farmaco
Pagina n.
GARDASIL 9 ..................................................................... 61
GARDASIL INJ 0............................................................... 61
GARDASIL INJ 0............................................................... 61
GATTEX............................................................................. 45
GAUZE PADS 2”X2” ....................................................... 63
gavilyte-c ..................................................................................47
gavilyte-g..................................................................................47
gavilyte-n/flavor pack ...........................................................47
GAVISCON CHEW .......................................................... 45
GAVISCON EXTRA STRENGTH RELIEF FORMULA... 45
GAZYVA ............................................................................ 24
gemcitabine .............................................................................21
gemcitabine hcl.......................................................................21
gemfibrozil tabs.......................................................................39
generlac ....................................................................................47
gengraf caps ............................................................................60
gengraf soln .............................................................................60
gentak........................................................................................64
gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml; 0.9% ............................................................................................ 6
gentamicin sulfate/0.9% sodium chloride inj 0.9mg/
ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9% ............................................................... 6
gentamicin sulfate crea 0.1%..............................................43
gentamicin sulfate external oint 0.1% ..............................43
gentamicin sulfate inj 10mg/ml ........................................... 6
gentamicin sulfate inj 40mg/ml ........................................... 6
gentamicin sulfate ophthalmic oint 0.3%........................64
gentamicin sulfate ophthalmic soln 0.3% .......................64
gentamicin sulfate pediatric .................................................. 6
GEODON INJ .................................................................... 26
geravim .....................................................................................80
gianvi .........................................................................................54
gildagia......................................................................................54
gildess 1.5/30 .........................................................................54
gildess 1/20 .............................................................................54
gildess 24 fe .............................................................................54
gildess fe 1.5/30.....................................................................54
gildess fe 1/20 ........................................................................54
GILOTRIF........................................................................... 23
glatopa ......................................................................................41
GLEEVEC TABS 100MG ................................................. 23
GLEEVEC TABS 400MG ................................................. 23
glimepiride ...............................................................................32
glipizide er ................................................................................32
glipizide/metformin hcl .........................................................32
glipizide tabs ............................................................................32
Nome farmaco
Pagina n.
glipizide xl .................................................................................32
GLUCAGEN DIAGNOSTIC............................................. 33
GLUCAGEN HYPOKIT .................................................... 33
GLUCAGON EMERGENCY KIT ..................................... 33
glyburide/metformin hcl.......................................................32
glyburide micronized .............................................................32
glyburide tabs ..........................................................................32
glycopyrrolate inj, tabs ..........................................................45
glydo ............................................................................................ 5
gnp antacid & anti-gas maximum strength ....................45
gnp artificial tears soln 0.5%; 0.6%...................................64
gnp calcium 500 +d3............................................................75
gnp calcium 1200..................................................................75
gnp cold multi-symptom day/night ...................................71
gnp cold multi-symptom nighttime...................................71
gnp foaming antacid .............................................................46
gnp stool softener syrp..........................................................47
goodsense all day allergy......................................................68
granisetron hcl tabs ...............................................................16
griseofulvin microsize............................................................17
griseofulvin ultramicrosize ...................................................17
guanfacine er...........................................................................41
guanidine hcl ...........................................................................18
HALAVEN ......................................................................... 21
halobetasol propionate .........................................................51
haloperidol conc, tabs ...........................................................26
haloperidol decanoate ..........................................................26
haloperidol lactate .................................................................26
HARVONI ......................................................................... 28
HAVRIX ............................................................................. 61
heather......................................................................................57
hecoria ......................................................................................60
HEMENATAL OB ............................................................. 80
HEMENATAL OB + DHA ................................................ 80
heparin sodium/d5w .............................................................33
heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml.............33
heparin sodium/nacl 0.9% ..................................................33
heparin sodium/nacl 0.45% ................................................33
heparin sodium/sodium chloride 0.9% ............................33
heparin sodium/sodium chloride 0.9% premix ..............33
hepatamine ..............................................................................75
HERCEPTIN ...................................................................... 21
HETLIOZ ........................................................................... 72
HEXALEN ......................................................................... 19
HIBERIX............................................................................. 61
HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML ................ 60
97
Nome farmaco
Pagina n.
HUMIRA INJ 40MG/0.8ML ........................................... 60
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK.................................................................................. 60
HUMIRA PEN ................................................................... 60
HUMIRA PEN-CROHNS DISEASESTARTER............... 60
HUMIRA PEN-PSORIASIS STARTER ........................... 60
hydralazine hcl inj, tabs .........................................................40
hydrochlorothiazide caps, tabs ...........................................39
HYDROCIL INSTANT PACK ........................................... 47
hydrocodone/acetaminophen soln 325mg/15ml; 10mg/15ml ............................................................................... 3
hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg .............................................. 4
hydrocodone bitartrate/acetaminophen soln ................... 3
hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg................................. 3
hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg .......................................................................................... 3
hydrocodone/ibuprofen.......................................................... 4
hydrocortisone/acetic acid ...................................................67
hydrocortisone/aloe crea 0; 1%..........................................43
hydrocortisone butyrate crea, oint, soln ...........................51
hydrocortisone butyrate (lipophilic)...................................51
hydrocortisone crea 2.5% ....................................................51
hydrocortisone enem, tabs ..................................................51
hydrocortisone in absorbase ...............................................51
hydrocortisone lotn 2.5%.....................................................51
hydrocortisone oint 1%, 2.5% ............................................51
hydrocortisone valerate ........................................................51
hydromorphone hcl inj 1mg/ml, 2mg/ml, 4mg/ml, 500mg/50ml ............................................................................ 4
hydromorphone hcl liqd ......................................................... 4
hydromorphone hcl tabs 2mg .............................................. 4
hydromorphone hcl tabs 4mg, 8mg ................................... 4
hydroxocobalamin..................................................................80
hydroxychloroquine sulfate tabs.........................................24
hydroxyurea caps....................................................................20
hydroxyzine hcl inj ..................................................................68
HYPOTEARS SOLN ......................................................... 64
IBRANCE .......................................................................... 21
ibudone tabs 5mg; 200mg .................................................... 4
ibuprofen susp........................................................................... 2
ibuprofen tabs 400mg, 600mg, 800mg ........................... 2
icaps mv ....................................................................................80
ICLUSIG TABS 15MG ..................................................... 23
ICLUSIG TABS 45MG ..................................................... 23
idarubicin hcl ...........................................................................21
98
Nome farmaco
Pagina n.
ifosfamide.................................................................................21
ifosfamide/mesna ..................................................................19
ILARIS................................................................................ 61
ILEVRO .............................................................................. 66
IMBRUVICA...................................................................... 23
imipenem/cilastatin ................................................................. 9
imipramine hcl tabs ...............................................................15
imiquimod crea .......................................................................43
IMOVAX RABIES (H.D.C.V.) ............................................ 61
inatal advance .........................................................................80
inatal ultra ................................................................................80
INCRELEX ......................................................................... 52
indapamide tabs .....................................................................39
INFANRIX .......................................................................... 61
infants pain relief susp 80mg/0.8ml................................... 1
INLYTA TABS 1MG .......................................................... 23
INLYTA TABS 5MG .......................................................... 23
INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2” 63
INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16”63
INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2” . 63
INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16” .. 63
INSUPEN 33GX4MM ..................................................... 63
INTELENCE TABS 25MG ............................................... 29
INTELENCE TABS 100MG, 200MG ............................ 29
intralipid inj 20gm/100ml ...................................................75
INTRALIPID INJ 30GM/100ML .................................... 75
INTRON A INJ 10MU/ML, 6000000UNIT/ML .......... 21
INTRON A INJ 18MU, 50MU ........................................ 28
INTRON A W/DILUENT.................................................. 21
introvale ....................................................................................54
INTUNIV ........................................................................... 41
INVANZ INJ 1GM............................................................... 9
INVANZ INJ 1GM............................................................... 9
INVEGA SUSTENNA INJ 39MG/0.25ML .................... 26
INVEGA SUSTENNA INJ 78MG/0.5ML....................... 26
INVEGA SUSTENNA INJ 117MG/0.75ML.................. 26
INVEGA SUSTENNA INJ 156MG/ML .......................... 27
INVEGA SUSTENNA INJ 234MG/1.5ML .................... 27
INVEGA TB24 1.5MG, 3MG, 9MG .............................. 27
INVEGA TB24 6MG ........................................................ 27
INVIRASE .......................................................................... 30
INVOKAMET .................................................................... 32
INVOKANA TABS 100MG ............................................. 32
INVOKANA TABS 300MG ............................................. 32
IPOL INACTIVATED IPV ................................................. 61
ipratropium bromide/albuterol sulfate .............................69
ipratropium bromide inhalation soln ................................69
Nome farmaco
Pagina n.
ipratropium bromide nasal soln .........................................69
irbesartan .................................................................................35
irbesartan/hydrochlorothiazide..........................................35
irinotecan .................................................................................21
iromin-g ....................................................................................80
iron 100 plus ...........................................................................73
ISENTRESS CHEW .......................................................... 29
ISENTRESS PACK ............................................................ 29
ISENTRESS TABS............................................................. 28
isoniazid inj...............................................................................18
isoniazid syrp, tabs .................................................................18
ISOPROPYL ALCOHOL WIPES ....................................... 7
ISOPTO CARPINE ........................................................... 66
ISOPTO TEARS ................................................................ 64
isosorbide dinitrate er............................................................40
isosorbide dinitrate tabs .......................................................40
isosorbide mononitrate.........................................................40
isosorbide mononitrate er ....................................................40
isotonic gentamicin inj 0.8mg/ml; 0.9% ............................ 6
isotonic gentamicin inj 1.2mg/ml; 0.9%, 2mg/ml; 0.9% 6
isradipine ..................................................................................38
ISTODAX ........................................................................... 21
itraconazole caps....................................................................17
ivermectin tabs........................................................................24
IXEMPRA KIT ................................................................... 21
IXIARO .............................................................................. 61
JAKAFI ............................................................................... 23
jantoven ....................................................................................34
JANUMET ......................................................................... 32
JANUMET XR TB24 1000MG; 50MG ......................... 32
JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG
32
JANUVIA ........................................................................... 32
jencycla .....................................................................................57
JENTADUETO ................................................................... 32
JEVTANA ........................................................................... 21
jinteli ..........................................................................................54
jolessa ........................................................................................54
jolivette ......................................................................................57
J-TAN PD........................................................................... 68
junel 1.5/30 .............................................................................54
junel 1/20.................................................................................54
junel fe 1.5/30 ........................................................................54
junel fe 1/20 ............................................................................54
junel fe 24.................................................................................54
KABIVEN........................................................................... 76
KADCYLA ......................................................................... 21
Nome farmaco
Pagina n.
KALETRA SOLN .............................................................. 30
KALETRA TABS 100MG; 25MG ................................... 30
KALETRA TABS 200MG; 50MG ................................... 30
KALYDECO PACK............................................................. 69
KALYDECO TABS ............................................................. 69
kaopectate ................................................................................46
kariva .........................................................................................54
kcl 0.3%/d5w/lr iv lac ring ....................................................76
kcl 0.3%/d5w/nacl 0.9% ......................................................76
kcl 0.3%/d5w/nacl 0.45%....................................................76
kcl 0.15%/d5w/lr ....................................................................76
kcl 0.15%/d5w/nacl 0.2%....................................................76
kcl 0.15%/d5w/nacl 0.9%....................................................76
kcl 0.15%/d5w/nacl 0.45% .................................................76
kcl 0.15%/d5w/nacl 0.225% ..............................................76
kcl 0.075%/d5w/nacl 0.45% ..............................................76
kelnor 1/35 ..............................................................................54
ketoconazole crea, sham, tabs ............................................17
ketoprofen caps ........................................................................ 2
ketoprofen er ............................................................................. 2
ketorolac tromethamine.......................................................66
KEYTRUDA ....................................................................... 24
kidkare cough/cold .................................................................71
KINRIX ............................................................................... 61
kionex powd .............................................................................73
kionex susp ...............................................................................73
klor-con 8.................................................................................76
klor-con 10 ..............................................................................76
klor-con m10 ..........................................................................76
klor-con m20 ..........................................................................76
kls acid reducer maximum strength ..................................46
KONSYL-D POWD .......................................................... 47
KONSYL PACK 100% ..................................................... 47
konsyl powd 30.9% ...............................................................47
KONSYL POWD 60.3%, 71.67% ................................. 47
KORLYM ............................................................................ 32
kp benzoyl peroxide ................................................................43
kp calcium 600+d tabs .........................................................76
kp ferrous sulfate ....................................................................73
kp folic acid ..............................................................................80
kp terbinafine hydrochloride ...............................................43
kurvelo.......................................................................................54
KUVAN PACK 100MG .................................................... 44
KUVAN PACK 500MG .................................................... 44
KUVAN TBSO................................................................... 44
KYNAMRO........................................................................ 40
labetalol hcl inj ........................................................................37
99
Nome farmaco
Pagina n.
labetalol hcl tabs .....................................................................37
lactated ringers dextrose 5% viaflex ..................................76
lactated ringers viaflex ..........................................................76
lactulose soln ...........................................................................47
lamisil af defense ....................................................................43
lamivudine soln 10mg/ml ....................................................29
lamivudine tabs 100mg .......................................................28
lamivudine tabs 150mg, 300mg .......................................29
lamivudine/zidovudine ..........................................................29
lamotrigine chew, tabs ..........................................................13
larin 1.5/30 .............................................................................54
larin 1/20 .................................................................................54
larin fe 1.5/30 .........................................................................54
larin fe 1/20.............................................................................54
latanoprost...............................................................................64
LATUDA ............................................................................ 27
leena ..........................................................................................54
leflunomide ..............................................................................61
LENVIMA 10MG DAILY DOSE ...................................... 23
LENVIMA 14MG DAILY DOSE ...................................... 23
LENVIMA 20MG DAILY DOSE ...................................... 23
LENVIMA 24MG DAILY DOSE ...................................... 23
lessina........................................................................................54
letrozole ....................................................................................22
leucovorin calcium inj 100mg, 200mg, 350mg, 500mg, 50mg .........................................................................................21
leucovorin calcium tabs ........................................................21
LEUKERAN ....................................................................... 19
LEUKINE INJ 250MCG.................................................... 34
leuprolide acetate inj..............................................................59
levalbuterol hcl nebu .............................................................69
levalbuterol nebu ....................................................................69
LEVEMIR ........................................................................... 33
LEVEMIR FLEXTOUCH ................................................... 33
levetiracetam inj 500mg/5ml .............................................11
levetiracetam inj 1000mg/100ml; 750mg/100ml, 1500mg/100ml; 540mg/100ml, 500mg/100ml; 820mg/100ml .......................................................................11
levetiracetam oral soln, tabs ................................................11
levobunolol hcl ........................................................................66
levocarnitine ............................................................................73
levocetirizine dihydrochloride soln ....................................68
levocetirizine dihydrochloride tabs ....................................68
levofloxacin in d5w .................................................................10
levofloxacin inj 25mg/ml ......................................................11
levofloxacin ophthalmic soln 0.5% ....................................64
levofloxacin oral soln 25mg/ml ..........................................11
100
Nome farmaco
Pagina n.
levofloxacin tabs 250mg, 500mg, 750mg .....................11
levoleucovorin calcium..........................................................21
levonest .....................................................................................54
levonorgestrel..........................................................................57
levonorgestrel and ethinyl estradiol tabs 0; 0 .................54
levonorgestrel/ethinyl estradiol tabs 0; 0 .........................54
levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 20mcg; 0.1mg ........................................................................54
levora 0.15/30-28 ................................................................54
levothyroxine sodium inj 100mcg, 500mcg ...................58
levothyroxine sodium inj 200mcg......................................58
levothyroxine sodium tabs....................................................58
levoxyl ........................................................................................58
LEXIVA .............................................................................. 30
lice killing maximum strength .............................................43
lice treatment ..........................................................................43
lidocaine hcl external soln 4% ............................................... 5
lidocaine hcl gel 2% ................................................................. 5
lidocaine hcl inj 0.5%, 1.5% .................................................. 5
lidocaine hcl inj 1%, 2%, 4% ................................................. 5
lidocaine hcl inj 10mg/ml, 20mg/ml .................................36
lidocaine hcl jelly ....................................................................... 5
lidocaine hcl mouth/throat soln 4% .................................... 5
lidocaine oint ............................................................................. 5
lidocaine/prilocaine crea ........................................................ 5
lidocaine/prilocaine kit ............................................................ 5
lidocaine ptch ............................................................................ 5
lidocaine viscous ....................................................................... 5
lindane lotn, sham..................................................................25
linezolid inj.................................................................................. 7
linezolid tabs .............................................................................. 7
liothyronine sodium tabs ......................................................58
LIPOSYN III ....................................................................... 76
lisinopril ....................................................................................36
lisinopril/hydrochlorothiazide .............................................36
lithium .......................................................................................31
lithium carbonate caps, tabs ...............................................32
lithium carbonate er ..............................................................31
LITTLE NOSES DECONGESTANTNOSE DROPS........ 71
lomedia 24 fe ..........................................................................54
lomustine ..................................................................................19
loperamide hcl caps ...............................................................46
lopreeza.....................................................................................54
loratadine/pseudoephedrine ...............................................71
loratadine tabs ........................................................................68
lorazepam inj 2mg/ml ...........................................................31
lorazepam inj 4mg/ml ...........................................................31
Nome farmaco
Pagina n.
lorazepam intensol.................................................................31
lorazepam tabs........................................................................31
lorcet ............................................................................................ 4
lorcet hd ...................................................................................... 4
lorcet plus tabs 325mg; 7.5mg ............................................ 4
loryna ........................................................................................55
losartan potassium/hydrochlorothiazide .........................35
losartan potassium tabs 25mg, 50mg .............................35
losartan potassium tabs 100mg ........................................35
LOTRIMIN ULTRA............................................................ 43
lovastatin ..................................................................................39
LOVAZA ............................................................................ 40
low-ogestrel .............................................................................55
loxapine succinate caps.........................................................26
LUMIGAN SOLN 0.01% ................................................ 64
LUMIZYME ....................................................................... 44
LUPRON DEPOT ............................................................. 59
LUPRON DEPOT-PED .................................................... 59
lutera..........................................................................................55
LYNPARZA ........................................................................ 21
LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG .................................................................. 12
LYRICA CAPS 225MG, 300MG .................................... 12
LYRICA SOLN ................................................................... 12
LYSODREN ....................................................................... 58
lyza .............................................................................................57
maalox childrens.....................................................................46
maalox regular strength .......................................................46
mag-delay ................................................................................76
MAGNEBIND 200 ........................................................... 76
MAGNEBIND 300 ........................................................... 76
magnesium oxide tabs 241.3mg, 400mg .......................76
magnesium oxide tabs 400mg, 420mg...........................46
magnesium sulfate inj 40mg/ml, 50%, 80mg/ml .........76
magnesium sulfate inj 50% .................................................76
magnesium tabs 500mg ......................................................76
malathion lotn.........................................................................25
mapap cold formula multi-symptom ................................71
maprotiline hcl ........................................................................15
margesic ..................................................................................... 1
marlissa.....................................................................................55
MARPLAN ........................................................................ 14
MATULANE ...................................................................... 19
matzim la ..................................................................................38
meclizine hcl tabs ...................................................................16
meclofenamate sodium caps ................................................ 2
medroxyprogesterone acetate inj, tabs .............................57
Nome farmaco
Pagina n.
mefloquine hcl.........................................................................25
megestrol acetate susp 40mg/ml ......................................57
megestrol acetate tabs ..........................................................57
MEKINIST TABS 0.5MG ................................................. 23
MEKINIST TABS 2MG..................................................... 23
meloxicam susp, tabs ............................................................... 2
melphalan hydrochloride .....................................................19
MENACTRA ..................................................................... 61
MENEST............................................................................ 55
MENOMUNE-A/C/Y/W-135 ....................................... 61
MENVEO........................................................................... 61
MEPHYTON ..................................................................... 80
MEPRON .......................................................................... 25
mercaptopurine tabs .............................................................20
meribin ......................................................................................80
meropenem ............................................................................... 9
mesalamine enem, kit ...........................................................62
mesna ........................................................................................21
MESNEX TABS ................................................................. 22
MESTINON SYRP ............................................................ 18
MESTINON TIMESPAN .................................................. 18
metadate er..............................................................................41
METAMUCIL MULTIHEALTH FIBER POWD 63% ...... 47
metaproterenol sulfate syrp, tabs .......................................69
metformin hcl er .....................................................................32
metformin hcl tabs .................................................................32
methadone hcl conc ................................................................ 3
methadone hcl inj..................................................................... 3
methadone hcl oral soln ......................................................... 3
methadone hcl tabs ................................................................. 3
methadone hcl tbso ................................................................. 3
methadose conc ....................................................................... 3
methadose sugar-free ............................................................ 3
methadose tbso ........................................................................ 3
methazolamide .......................................................................38
methenamine hippurate ......................................................... 7
methimazole tabs ...................................................................59
methotrexate sodium inj 1gm/40ml, 1gm ......................60
methotrexate sodium inj 25mg/ml ....................................60
methotrexate tabs ..................................................................60
methoxsalen caps ...................................................................43
methscopolamine bromide..................................................45
methyclothiazide tabs ...........................................................39
methylergonovine maleate ..................................................49
methylphenidate hcl er tbcr 10mg, 20mg.......................41
methylphenidate hcl sr..........................................................41
methylphenidate hcl tabs .....................................................41
101
Nome farmaco
Pagina n.
methylprednisolone acetate inj ...........................................51
methylprednisolone dose pack ...........................................51
methylprednisolone sodiumsuccinate inj 1000mg, 125mg, 40mg ........................................................................51
methylprednisolone tabs ......................................................51
metipranolol ............................................................................66
metoclopramide hcl inj, oral soln, tabs .............................46
metolazone ..............................................................................39
metoprolol/hydrochlorothiazide ........................................37
metoprolol succinate er ........................................................37
metoprolol tartrate inj, tabs .................................................37
METRO IV ........................................................................... 7
metronidazole caps 375mg .................................................. 7
metronidazole crea 0.75% ..................................................43
metronidazole gel 0.75%, 1% ............................................43
metronidazole in nacl 0.79% ................................................ 7
metronidazole lotn 0.75% ...................................................43
metronidazole tabs 250mg, 500mg................................... 7
metronidazole vaginal............................................................. 7
mexiletine hcl ...........................................................................36
MIACALCIN INJ................................................................ 63
mi-acid chew ...........................................................................46
miconazole 3 ...........................................................................49
miconazole 3 combination pack ........................................49
miconazole 3 combo pack ...................................................49
miconazole 7 ...........................................................................49
microgestin 1.5/30................................................................55
microgestin 1/20 ...................................................................55
microgestin fe..........................................................................55
microgestin fe 1.5/30 ...........................................................55
micronized colestipol hcl ......................................................40
midodrine hcl ..........................................................................35
MIGERGOT....................................................................... 18
milk of magnesia susp 1200mg/15ml.............................47
MILLIPRED ....................................................................... 51
MILLIPRED DP ................................................................. 51
mimvey......................................................................................55
mimvey lo .................................................................................55
minitran ....................................................................................40
minocycline hcl caps..............................................................11
minoxidil tabs...........................................................................40
mintox plus ...............................................................................46
MIRALAX .......................................................................... 47
mirtazapine odt.......................................................................14
mirtazapine tabs .....................................................................14
misoprostol ..............................................................................48
MISSION PRENATAL ...................................................... 80
102
Nome farmaco
Pagina n.
MISSION PRENATAL HP ................................................ 80
mitomycin ................................................................................22
mitoxantrone hcl.....................................................................22
M-M-R II........................................................................... 61
modafinil tabs 100mg ..........................................................72
modafinil tabs 200mg ..........................................................72
moderiba tabs .........................................................................28
moexipril hcl.............................................................................36
moexipril/hydrochlorothiazide............................................36
mometasone furoate crea, oint, soln ................................51
mono-linyah ............................................................................55
mononessa...............................................................................55
montelukast sodium ..............................................................69
morgidox 1x100mg caps .....................................................11
morgidox 2x100mg caps .....................................................11
morphine sulfate er cp24 45mg, 75mg, 90mg ............... 3
morphine sulfate er cp24 100mg, 10mg, 20mg, 30mg, 50mg, 60mg, 80mg................................................................ 3
morphine sulfate er cp24 120mg ....................................... 3
morphine sulfate er tbcr ......................................................... 3
morphine sulfate inj ................................................................. 4
morphine sulfate oral soln 10mg/5ml ............................... 4
morphine sulfate oral soln 20mg/5ml ............................... 4
morphine sulfate oral soln 20mg/ml .................................. 4
morphine sulfate tabs ............................................................. 4
motion sickness ......................................................................46
motion sickness relief ............................................................46
motrin ib ..................................................................................... 2
mucaphed ................................................................................71
MUCINEX FOR KIDS PACK 100MG ............................. 71
mucus-dm ................................................................................71
mucus relief..............................................................................71
mucus relief cough childrens ...............................................71
MULTAQ ........................................................................... 36
multi-delyn...............................................................................80
MULTI-DELYN/IRON ...................................................... 80
multi vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 15unit; 2500unit ..................................................................................80
multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/
ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 1500unit/ml ...............................81
multi-vitamin/fluoride soln 35mg/ml; 400unit/ml; 2mcg/
ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml .......................................................81
multivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit; Nome farmaco
Pagina n.
400unit; 15unit, 60mg; 4.5mcg; 0.3mg; 13.5mg;
1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit; 400unit;
15unit........................................................................................81
multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml;
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml;
5unit/ml; 1500unit/ml .........................................................81
multi-vit/iron/fluoride soln 35mg/ml; 400unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml ....................................81
mult-vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg; 2500unit; 15unit ...................................................................80
mupirocin .................................................................................43
mupirocin calcium..................................................................43
MURO 128 SOLN 2% .................................................... 64
muro 128 soln 5% .................................................................64
MUSTARGEN ................................................................... 19
mvc-fluoride ............................................................................81
mycophenolate mofetil .........................................................60
MYKIDZ IRON .................................................................. 81
MYKIDZ IRON 10 ............................................................ 73
myorisan ...................................................................................43
MYRBETRIQ ..................................................................... 48
my way ......................................................................................57
myzilra .......................................................................................55
nabumetone .............................................................................. 2
nadolol/bendroflumethiazide .............................................37
nadolol tabs .............................................................................37
NAGLAZYME ................................................................... 44
nalbuphine hcl inj ..................................................................... 4
NALLPEN/DEXTROSE INJ 0; 1GM/50ML .................. 10
NALLPEN ISO-OSMOTIC IN DEXTROSE ................... 10
naloxone hcl inj ......................................................................... 5
naltrexone hcl tabs ................................................................... 5
NAMENDA SOLN ........................................................... 14
NAMENDA TABS............................................................. 14
NAMENDA TITRATION PAK.......................................... 14
NAMENDA XR ................................................................. 14
NAMENDA XR TITRATION PACK ................................. 14
naphazoline hcl .......................................................................64
naproxen dr ................................................................................ 2
naproxen sodium tabs 275mg, 550mg ............................. 2
naproxen susp, tabs.................................................................. 2
naratriptan hcl ........................................................................18
NASAL DECONGESTANT LIQD, SYRP ........................ 71
nasal decongestant pe maximum strength .....................71
nasal decongestant tabs 30mg ..........................................71
Nome farmaco
Pagina n.
nasal spray extra moisturizing 12 hour ............................71
NATACHEW CHEW 120MG; 2700UNIT; 400UNIT; 12MCG; 0; 0; 1MG; 28MG; 20MG; 10MG; 3MG; 0; 2MG; 20UNIT .................................................................. 81
NATALVIRT 90 DHA........................................................ 81
NATALVIRT CA ................................................................. 81
nateglinide................................................................................32
NATPARA ......................................................................... 63
natural fiber therapy powd 48.57% ..................................47
natures tears soln 0.4% ........................................................64
NEBUPENT ...................................................................... 25
necon 0.5/35-28 ...................................................................55
necon 1/35 ..............................................................................55
NECON 1/50-28 ............................................................ 55
necon 7/7/7 ............................................................................55
NECON 10/11-28 .......................................................... 55
nefazodone hcl ........................................................................15
neomycin/bacitracin/polymyxin .........................................64
neomycin/polymyxin/bacitracin/hydrocortisone ...........65
neomycin/polymyxin/dexamethasone ..............................65
neomycin/polymyxin/gramicidin ........................................65
neomycin/polymyxin/hc .......................................................67
neomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 3.5mg/ml; 10000unit/ml............................................65
neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; 10000unit/ml ....................................................67
neomycin sulfate....................................................................... 6
neo-polycin ..............................................................................64
NEPHRAMINE ................................................................. 76
NESTABS .......................................................................... 81
NESTABS DHA................................................................. 81
NEUMEGA ........................................................................ 34
NEUPOGEN ..................................................................... 34
NEUPRO ........................................................................... 25
NEVANAC......................................................................... 66
nevirapine.................................................................................29
nevirapine er ............................................................................29
NEXA PLUS CAPS 28MG; 0; 250MCG; 660MG; 160MG; 0; 800UNIT; 350MG; 55MG; 29MG; 1.25MG; 25MG; 30UNIT .............................................. 81
NEXAVAR.......................................................................... 23
next choice one dose..............................................................57
niacinamide tabs 500mg .....................................................81
niacin er cpcr 500mg ............................................................81
niacin er tbcr 1000mg, 500mg, 750mg .........................40
niacin tabs 100mg, 50mg ...................................................82
niacin tr tbcr 500mg .............................................................81
103
Nome farmaco
Pagina n.
nicardipine hcl caps ...............................................................38
NICODERM CQ PT24 14MG/24HR, 7MG/24HR....... 6
nicotine lozg 2mg ..................................................................... 6
nicotine polacrilex gum 4mg ................................................. 6
nicotine polacrilex lozg 4mg .................................................. 6
nicotine pt24 21mg/24hr ..................................................... 6
nicotine transdermal system pt24 ....................................... 6
NICOTROL NS ................................................................... 6
nikki ............................................................................................55
NILANDRON .................................................................... 19
NIPENT ............................................................................. 22
nisoldipine ................................................................................38
nisoldipine er ...........................................................................38
nitrofurantoin macrocrystals ................................................ 7
nitrofurantoin monohydrate ................................................. 7
nitrofurantoin susp .................................................................. 7
nitroglycerin inj .......................................................................40
nitroglycerin lingual ...............................................................40
nitroglycerin pt24 0.2mg/hr, 0.4mg/hr, 0.6mg/hr .......40
nitroglycerin transdermal pt24 0.1mg/hr, 0.6mg/hr ...40
NITROSTAT....................................................................... 40
nora-be .....................................................................................57
NORDITROPIN FLEXPRO INJ 10MG/1.5ML,
15MG/1.5ML, 5MG/1.5ML.......................................... 52
NORDITROPIN NORDIFLEX PEN ................................. 52
norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs 20mcg; 75mg; 1mg .....................................................55
norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs 20mcg; 75mg; 1mg .....................................................55
norethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg
55
norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg............................................................................................55
norethindrone acetate tabs .................................................57
norethindrone & ethinyl estradiol ferrous fumarate .....55
norethindrone tabs ................................................................57
norgestimate/ethinyl estradiol ............................................55
NORINYL 1+50 ............................................................... 55
norlyroc .....................................................................................57
NORTHERA ...................................................................... 38
nortrel 0.5/35 (28) ................................................................55
nortrel 1/35 .............................................................................55
nortrel 7/7/7 ...........................................................................56
nortriptyline hcl caps, soln ...................................................15
NORVIR............................................................................. 30
NOVOLIN 70/30 ............................................................. 33
NOVOLIN N ..................................................................... 33
104
Nome farmaco
Pagina n.
NOVOLIN R ...................................................................... 33
NOVOLOG........................................................................ 33
NOVOLOG FLEXPEN...................................................... 33
NOVOLOG MIX 70/30 ................................................... 33
NOVOLOG MIX 70/30 PREFILLED FLEXPEN ............ 33
NOVOLOG PENFILL ....................................................... 33
NOXAFIL INJ ..................................................................... 17
NOXAFIL SUSP, TBEC..................................................... 17
NUEDEXTA ....................................................................... 41
nu-iron 150 .............................................................................73
NULOJIX ............................................................................ 60
NUTRICION PORVIDA ................................................... 82
nyamyc ......................................................................................17
nystatin crea, oint, powd, susp, tabs ..................................17
nystop ........................................................................................17
OB COMPLETE/DHA ..................................................... 82
OB COMPLETE ONE ...................................................... 82
OB COMPLETE PETITE .................................................. 82
OB COMPLETE PREMIER .............................................. 82
O-CAL PRENATAL .......................................................... 82
ocella .........................................................................................56
octreotide acetate ..................................................................59
ofloxacin ophthalmic soln 0.3% .........................................65
ofloxacin otic soln 0.3% ........................................................67
ofloxacin tabs 400mg ...........................................................11
OGESTREL ....................................................................... 56
olanzapine/fluoxetine ............................................................15
olanzapine inj ..........................................................................27
olanzapine odt.........................................................................27
olanzapine tabs 2.5mg .........................................................27
olanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg......27
olopatadine hcl .......................................................................68
omega-3-acid ethyl esters ..................................................40
omeprazole cpdr 10mg ........................................................48
omeprazole cpdr 20mg ........................................................48
omeprazole cpdr 40mg ........................................................48
omeprazole tbec .....................................................................48
ONCASPAR ...................................................................... 22
ondansetron hcl inj 40mg/20ml, 4mg/2ml....................16
ondansetron hcl oral soln .....................................................16
ondansetron hcl tabs 4mg, 8mg ........................................16
ondansetron hcl tabs 24mg ................................................16
ondansetron odt .....................................................................16
ONFI SUSP ....................................................................... 12
ONFI TABS 10MG, 20MG ............................................. 12
OPDIVO ............................................................................ 24
OPSUMIT.......................................................................... 70
Nome farmaco
Pagina n.
oralone ......................................................................................41
ORAP................................................................................. 26
ORFADIN .......................................................................... 44
orsythia .....................................................................................56
oxacillin sodium inj 2gm .......................................................10
oxacillin sodium inj 10gm, 1gm..........................................10
oxaliplatin .................................................................................22
oxandrolone tabs 2.5mg ......................................................52
oxandrolone tabs 10mg .......................................................52
oxaprozin .................................................................................... 2
oxcarbazepine .........................................................................13
OXSORALEN .................................................................... 43
oxybutynin chloride er tb24 5mg .......................................48
oxybutynin chloride er tb24 10mg, 15mg ......................48
oxybutynin chloride syrp.......................................................49
oxybutynin chloride tabs.......................................................49
oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg................................ 4
oxycodone/aspirin .................................................................... 4
oxycodone hcl caps .................................................................. 4
oxycodone hcl conc .................................................................. 4
oxycodone hcl soln ................................................................... 4
oxycodone hcl tabs 5mg ......................................................... 4
oxycodone hcl tabs 10mg, 15mg, 20mg, 30mg ............. 4
oxycodone/ibuprofen .............................................................. 4
oysco 500.................................................................................76
oyster shell calcium/vitamin d tabs 500mg; 400unit ...76
pacerone ...................................................................................36
paclitaxel ...................................................................................22
pain relief 8 hour ...................................................................... 1
pain relief childrens .................................................................. 1
pain relief extra strength tabs................................................ 1
pain reliever tabs....................................................................... 1
PAIRE OB .......................................................................... 82
pamidronate disodium inj 30mg/10ml, 6mg/ml ..........63
pamidronate disodium inj 30mg, 90mg/10ml, 90mg 63
pancrelipase.............................................................................44
PANRETIN ........................................................................ 24
pantoprazole sodium inj .......................................................48
pantoprazole sodium tbec 20mg .......................................48
pantoprazole sodium tbec 40mg .......................................48
paricalcitol caps ......................................................................63
paricalcitol inj ..........................................................................63
paroex ........................................................................................41
paromomycin sulfate............................................................... 6
paroxetine hcl ..........................................................................15
PASER................................................................................ 18
Nome farmaco
Pagina n.
PATADAY ........................................................................... 66
PATANOL .......................................................................... 66
PAXIL SUSP ...................................................................... 15
PAZEO ............................................................................... 66
pediacare childrens long-acting cough ............................71
PEDIALYTE SOLN 35MEQ/L; 30MEQ/L; 25GM/L;
20MEQ/L; 45MEQ/L ...................................................... 76
PEDIARIX .......................................................................... 61
PEDVAX HIB ..................................................................... 61
peg 3350/electrolytes ...........................................................48
peg-3350/electrolytes ..........................................................48
peg-3350/nacl/na bicarbonate/kcl ..................................48
PEGANONE...................................................................... 13
PEG-INTRON INJ 50MCG/0.5ML ................................ 28
PEGINTRON INJ 120MCG/0.5ML, 150MCG/0.5ML, 80MCG/0.5ML................................................................ 28
PEG-INTRON REDIPEN ................................................. 28
penicillin g potassium inj 20000000unit, 5000000unit
10
penicillin g procaine ...............................................................10
penicillin g sodium .................................................................10
penicillin v potassium ............................................................10
PEN NEEDLE/ULTRAFINE/29G X 12.7MM................ 63
PENTACEL ........................................................................ 61
PENTAM 300 ................................................................... 25
pentoxifylline cr .......................................................................38
pentoxifylline er.......................................................................38
PEPCID AC CHEW .......................................................... 46
peptic relief chew 262mg ....................................................46
PERIKABIVEN .................................................................. 76
perindopril erbumine.............................................................36
periogard ..................................................................................42
PERJETA ............................................................................ 22
permethrin crea 5%...............................................................25
permethrin lotn 1% ...............................................................43
perphenazine/amitriptyline .................................................15
perphenazine tabs ..................................................................26
PERRY PRENATAL ........................................................... 82
phenadoz supp 12.5mg .......................................................16
phenadoz supp 25mg ...........................................................16
phenelzine sulfate tabs..........................................................14
phenergan supp ......................................................................16
phenobarbital elix ...................................................................12
phenobarbital tabs .................................................................12
phenytoin chew, susp.............................................................13
phenytoin sodium extended.................................................13
phenytoin sodium inj .............................................................13
105
Nome farmaco
Pagina n.
philith.........................................................................................56
PHOS-NAK POWDER CONCENTRATE ...................... 76
PHOSPHOLINE IODIDE ................................................. 66
pilocarpine hcl soln 1%, 2%, 4% ........................................66
pilocarpine hcl tabs 7.5mg ..................................................42
pilocarpine hydrochloride ....................................................42
pimtrea......................................................................................56
pindolol .....................................................................................37
pioglitazone hcl .......................................................................32
pioglitazone hcl-glimepiride................................................32
pioglitazone hcl/metformin hcl...........................................32
piperacillin sodium/ tazobactam sodium .........................10
piperacillin sodium/tazobactam sodium inj 2gm; 0.25gm
10
piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm, 4gm; 0.5gm .........................................................10
pirmella 1/35 ..........................................................................56
pirmella 7/7/7 ........................................................................56
piroxicam caps .......................................................................... 2
pnv-dha ....................................................................................82
PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID..
82
PNV FOLIC ACID + IRON MULTIVITAMIN .................. 82
PNV OB+DHA.................................................................. 82
PNV PRENATAL PLUS MULTIVITAMIN........................ 82
pnv-select .................................................................................82
PNV TABS 29-1...............................................................82
PNV-VP-U........................................................................ 82
podofilox soln ..........................................................................43
polycin .......................................................................................65
polyethylene glycol 3350 pack, powd ..............................48
polymyxin b sulfate/trimethoprim sulfate ........................65
poly-vitamin/fluoride chew..................................................82
poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml; 2mcg/
ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml ............82
polyvitamin/iron soln 35mg/ml; 400unit/ml; 10mg/
ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml............................................................................82
polyvitamin soln 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml............................................................................82
POMALYST ....................................................................... 19
portia-28..................................................................................56
potassium chloride 0.3%/d5w ............................................77
potassium chloride 0.3%/ nacl 0.9% ................................77
potassium chloride 0.15% d5w/nacl 0.33% ..................77
106
Nome farmaco
Pagina n.
potassium chloride 0.15% d5w/nacl 0.45% ..................77
potassium chloride 0.15% d5w/nacl 0.45% viaflex .....77
potassium chloride 0.15% nacl 0.9% ...............................77
potassium chloride 0.15%/nacl 0.9% ..............................77
potassium chloride 0.15% /nacl 0.45% viaflex ..............77
potassium chloride 0.22% d5w/nacl 0.45% ..................77
potassium chloride 0.224%d5w/nacl 0.45% viaflex ...77
potassium chloride cr tbcr 10meq, 20meq .....................77
potassium chloride er ............................................................77
potassium chloride inj 0.4meq/ml, 10meq/100ml, 2meq/ml ...................................................................................77
potassium chloride inj 10meq/50ml, 20meq/100ml, 40meq/100ml ........................................................................77
potassium chloride liqd .........................................................77
potassium chloride sr tbcr 8meq........................................77
potassium citrate er ...............................................................77
POTIGA TABS 50MG...................................................... 12
POTIGA TABS 200MG, 300MG, 400MG ................... 12
PRADAXA ......................................................................... 34
pramipexole dihydrochloride...............................................25
pravastatin sodium ................................................................39
prazosin hcl ..............................................................................35
prednicarbate ..........................................................................51
prednisolone acetate .............................................................66
prednisolone sodium phosphate ophthalmic soln 1% .66
prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml ...........................................................51
prednisolone soln, syrp .........................................................51
PREDNISONE INTENSOL .............................................. 51
prednisone soln, tabs .............................................................51
PREFERA OB .................................................................... 82
PREFERA OB + DHA MISC 30MCG; 10MG; 400UNIT; 0.8MG; 12MCG; 200MG; 2.5MG; 1MG; 6MG; 0.5MG; 17MG; 203MG; 28MG; 250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 10UNIT; 4.5MG ............................... 83
PREFERAOB ONE ........................................................... 83
PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML.................................. 77
premasol inj 56meq/l; 320mg/100ml; 730mg/100ml;
190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml; 490mg/100ml;
840mg/100ml; 490mg/100ml; 200mg/100ml;
290mg/100ml; 410mg/100ml; 230mg/100ml;
Nome farmaco
Pagina n.
5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml ........................................78
PRENAISSANCE .............................................................. 83
PRENAISSANCE PLUS ................................................... 83
PRENATA .......................................................................... 83
prenatabs fa .............................................................................83
prenatal 19 chew 100mg; 1000unit; 200mg; 7mg; 400unit; 12mcg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg ..........................................................................83
prenatal 19 tabs 100mg; 1000unit; 200mg; 7mg; 400unit; 12mcg; 25mg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg ....................................................83
PRENATAL PLUS IRON TABS 120MG; 0; 200MG; 400UNIT; 2MG; 12MCG; 1MG; 29MG; 20MG; 10MG; 3MG; 1.84MG; 22UNIT; 4000UNIT; 25MG.............. 83
PRENATAL PLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG; 22MG; 4000UNIT; 25MG............................ 83
prenatal plus tabs 120mg; 0; 200mg; 400unit; 2mg; 12mcg; 27mg; 1mg; 20mg; 10mg; 3mg; 1.84mg; 22mg; 4000unit; 25mg .......................................................83
PRENATAL TABS 100MG; 0; 0; 263MG; 400UNIT; 4MCG; 27MG; 0.8MG; 18MG; 2.6MG; 1.7MG; 1.5MG; 11UNIT; 4000UNIT; 25MG ........................... 83
PRENATE AM ................................................................... 83
PRENATE DHA CAPS 90MG; 145MG; 220UNIT; 13MCG; 300MG; 28MG; 400MCG; 600MCG; 50MG; 26MG; 10UNIT ............................................................... 84
PRENATE ELITE TABS 75MG; 2600UNIT; 330MCG; 100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG; 400MCG; 150MCG; 600MCG; 25MG; 21MG; 21MG; 3.5MG; 3MG; 10UNIT; 15MG...................................... 84
PRENATE ESSENTIAL CAPS 90MG; 280MCG; 145MG; 220UNIT; 13MCG; 300MG; 40MG; 29MG; 0; 400MCG; 600MCG; 50MG; 150MCG; 26MG; 10UNIT
84
PRENATE ESSENTIAL CAPS 600MCG; 90MG; 280MCG; 155MG; 220UNIT; 13MCG; 300MG; 40MG; 18MG; 400MCG; 50MG; 150MCG; 26MG; 10UNIT ............................................................................. 84
PRENATE MINI ................................................................ 84
PRENATE PIXIE ................................................................ 84
PREPLUS........................................................................... 84
PREQUE 10 ...................................................................... 84
PRETAB ............................................................................. 84
prevalite ....................................................................................40
previfem ....................................................................................56
Nome farmaco
Pagina n.
PREZCOBIX ...................................................................... 30
PREZISTA SUSP ............................................................... 30
PREZISTA TABS 75MG ................................................... 30
PREZISTA TABS 150MG, 600MG, 800MG ................ 30
PRIFTIN ............................................................................. 18
PRILOSEC OTC ................................................................ 48
primaquine phosphate tabs.................................................25
primidone tabs ........................................................................12
PRISTIQ TB24 25MG ..................................................... 15
pr natal 400 .............................................................................82
pr natal 400 ec........................................................................82
pr natal 430 .............................................................................82
pr natal 430 ec........................................................................82
PROAIR HFA ..................................................................... 69
PROAIR RESPICLICK....................................................... 69
probenecid/colchicine ...........................................................17
probenecid tabs ......................................................................17
prochlorperazine ....................................................................26
prochlorperazine edisylate inj .............................................26
prochlorperazine maleate tabs ...........................................26
PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML ........ 34
PROCRIT INJ 40000UNIT/ML....................................... 34
procto-pak ...............................................................................51
proctosol hc .............................................................................51
proctozone-hc .........................................................................51
progesterone caps, inj ...........................................................57
PROGLYCEM .................................................................... 33
PROGRAF INJ ................................................................... 60
PROLASTIN-C ................................................................. 71
PROLENSA ....................................................................... 66
PROLEUKIN...................................................................... 22
PROLIA ............................................................................. 63
PROMACTA...................................................................... 34
promethazine hcl supp 12.5mg, 25mg, 50mg ..............16
promethazine hcl tabs 12.5mg, 25mg, 50mg ...............68
promethegan supp 12.5mg, 25mg...................................16
promethegan supp 50mg ....................................................16
pronutrients calcium+d3 .....................................................78
propafenone hcl......................................................................36
propafenone hcl er .................................................................36
proparacaine hcl .....................................................................65
propranolol hcl er ...................................................................37
propranolol hcl inj ..................................................................37
propranolol hcl oral soln, tabs .............................................37
propranolol/hydrochlorothiazide.......................................37
propylthiouracil tabs..............................................................59
107
Nome farmaco
Pagina n.
PROQUAD........................................................................ 61
protriptyline hcl.......................................................................15
psyldex .......................................................................................48
PULMOZYME................................................................... 69
PUREFE OB PLUS............................................................ 84
pure & gentle lubricant soln 0.3%......................................65
PURIXAN .......................................................................... 20
pyrazinamide tabs ..................................................................18
pyrethins/piperonyl buto xide ..............................................43
pyridostigmine bromide tabs ..............................................18
pyridoxine hcl inj .....................................................................84
q-pap infants ............................................................................. 1
QUADRACEL ................................................................... 62
quasense ...................................................................................56
quetiapine fumarate tabs 25mg ........................................27
quetiapine fumarate tabs 100mg, 50mg ........................27
quetiapine fumarate tabs 200mg......................................27
quetiapine fumarate tabs 300mg, 400mg .....................27
QUFLORA PEDIATRIC SOLN ........................................ 84
quinapril hcl .............................................................................36
quinapril/hydrochlorothiazide ............................................36
quinidine gluconate cr...........................................................36
quinidine gluconate er...........................................................36
quinidine sulfate .....................................................................37
quinidine sulfate er.................................................................37
quinine sulfate .........................................................................25
QVAR ................................................................................. 68
RABAVERT ....................................................................... 62
ra ibuprofen childrens ............................................................. 2
ra lansoprazole........................................................................48
raloxifene hydrochloride .......................................................57
ra lubricant eye drops soln 0.4%; 0.3% ............................65
ramipril......................................................................................36
ra multi-symptom cold relief/daytime/nighttime ..........71
ranitidine 75 ............................................................................46
ranitidine hcl caps, syrp ........................................................46
ranitidine hcl inj 50mg/2ml.................................................47
ranitidine hcl inj 150mg/6ml ..............................................47
ranitidine hcl tabs 150mg, 300mg ...................................47
RAPAMUNE SOLN .......................................................... 60
ra slow release iron ................................................................73
RAVICTI............................................................................. 44
reclipsen ....................................................................................56
RECOMBIVAX HB ............................................................ 62
REFRESH CELLUVISC ..................................................... 65
refresh p.m. ..............................................................................65
REGRANEX ....................................................................... 43
108
Nome farmaco
Pagina n.
reguloid powd 48.57%, 58.6% ..........................................48
rehydralyte ...............................................................................78
RELENZA DISKHALER.................................................... 30
RELISTOR INJ 8MG/0.4ML ............................................ 46
RELISTOR INJ 12MG/0.6ML ......................................... 46
RELNATE DHA ................................................................. 84
REMICADE ....................................................................... 60
REMODULIN .................................................................... 70
RENVELA .......................................................................... 49
repaglinide tabs 0.5mg, 1mg ..............................................32
repaglinide tabs 2mg.............................................................32
RESCRIPTOR .................................................................... 29
RESTASIS .......................................................................... 65
RETROVIR IV INFUSION................................................. 29
REVLIMID ......................................................................... 19
REYATAZ CAPS 150MG, 200MG, 300MG ................. 30
REYATAZ PACK................................................................. 30
RHINARIS ......................................................................... 71
ribavirin .....................................................................................28
RID ESSENTIAL LICE ELIMINATION KIT ..................... 43
rifabutin ....................................................................................18
rifampin caps, inj ....................................................................19
RIFATER ............................................................................. 19
riluzole .......................................................................................41
rimantadine hcl .......................................................................30
ringers injection ......................................................................78
risedronate sodium dr ...........................................................63
risedronate sodium tabs 30mg, 5mg................................63
risedronate sodium tabs 35mg ..........................................63
risedronate sodium tabs 150mg ........................................63
RISPERDAL CONSTA ...................................................... 27
risperidone odt tbdp 0.25mg, 0.5mg, 3mg ....................27
risperidone odt tbdp 1mg, 2mg .........................................27
risperidone odt tbdp 4mg ....................................................27
risperidone soln ......................................................................27
risperidone tabs 0.25mg, 0.5mg, 3mg ............................27
risperidone tabs 1mg, 2mg .................................................27
risperidone tabs 4mg ............................................................27
RITUXAN .......................................................................... 24
rivastigmine tartrate ..............................................................13
rizatriptan benzoate...............................................................18
rizatriptan benzoate odt .......................................................18
robafen cf cough & cold ........................................................71
ROBITUSSIN CHILDRENS COUGH/COLD LONG-ACTING .................................................................................. 71
robitussin maximum strength .............................................71
robitussin mucus+chest congestion..................................71
Nome farmaco
Pagina n.
ropinirole hcl ............................................................................25
rosadan .....................................................................................43
ROTARIX ........................................................................... 62
ROTATEQ .......................................................................... 62
ROXICET SOLN.................................................................. 4
roxicet tabs 325mg; 5mg ....................................................... 4
ROZEREM ......................................................................... 72
rynex pse ...................................................................................71
SABRIL .............................................................................. 12
SAMSCA TABS 15MG .................................................... 73
SAMSCA TABS 30MG .................................................... 73
SANDIMMUNE SOLN .................................................... 60
SANTYL............................................................................. 43
SAPHRIS SUBL 2.5MG................................................... 27
SAPHRIS SUBL 10MG, 5MG......................................... 27
sb cough control dm max .....................................................71
sb fib lax orange powd 33%.................................................48
sb lice treatment .....................................................................43
sb natural fiber laxative .........................................................48
SCOOBY-DOO ONE A DAY ........................................... 84
scot-tussin dm ........................................................................71
SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG; 0.4MG; 0.6MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 0; 1.6MG; 30UNIT; 1700UNIT; 15MG ........ 84
selegiline hcl caps, tabs .........................................................25
selenium sulfide lotn ..............................................................44
SELZENTRY TABS 150MG............................................. 30
SELZENTRY TABS 300MG............................................. 30
se-natal 19 ..............................................................................84
senna syrp ................................................................................48
SENSIPAR TABS 30MG, 60MG..................................... 58
SENSIPAR TABS 90MG .................................................. 58
sertraline hcl conc, tabs ........................................................15
se-tan dha ................................................................................84
setonet.......................................................................................84
SETON ET-EC .................................................................. 84
sharobel ....................................................................................57
SIGNIFOR.......................................................................... 59
sildenafil tabs ...........................................................................70
silver sulfadiazine ...................................................................44
SIMBRINZA ...................................................................... 66
SIMULECT ........................................................................ 60
simvastatin tabs 10mg, 20mg, 40mg, 5mg ...................39
simvastatin tabs 80mg .........................................................39
sirolimus tabs ..........................................................................60
SIRTURO ........................................................................... 19
SIVEXTRO INJ ..................................................................... 7
Nome farmaco
Pagina n.
SIVEXTRO TABS ................................................................ 7
SLOW-MAG ..................................................................... 78
sm adult nasal decongestant...............................................72
SM CORAL CALCIUM .................................................... 78
sm magnesium .......................................................................78
sm tussin cf liqd 10mg/5ml; 100mg/5ml; 30mg/5ml 72
sm vitamin b12 tr ...................................................................85
sodium bicarbonate inj 8.4% ..............................................73
sodium bicarbonate partial fill ............................................73
SODIUM BICARBONATE POWD 0 .............................. 46
sodium bicarbonate tabs 650mg.......................................46
sodium chloride 0.9% ...........................................................49
sodium chloride 0.45% viaflex ............................................78
sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5% ..............78
sodium chloride oint 5%.......................................................65
sodium fluoride chew 0.5mg, 1.1mg ................................78
sodium phenylbutyrate powd ..............................................44
sodium polystyrene sulfonate powd, oral susp ...............73
sodium polystyrene sulfonate rectal susp ........................73
sodium sulfacetamide lotn 10%.........................................44
sodium sulfacetamide soln 10% ........................................65
SOLTAMOX....................................................................... 20
soluble fiber..............................................................................48
SOMATULINE DEPOT INJ 60MG/0.2ML .................... 59
SOMATULINE DEPOT INJ 90MG/0.3ML .................... 59
SOMATULINE DEPOT INJ 120MG/0.5ML ................. 59
SOMAVERT ...................................................................... 59
soothe tabs...............................................................................46
sorbulax.....................................................................................48
sorine .........................................................................................37
sotalol hcl..................................................................................37
sotalol hcl (af) ..........................................................................37
SOVALDI ........................................................................... 28
SPIRIVA HANDIHALER................................................... 69
SPIRIVA RESPIMAT ......................................................... 69
spironolactone/hydrochlorothiazide .................................39
spironolactone tabs ...............................................................39
SPORANOX SOLN .......................................................... 17
sprintec 28 ...............................................................................56
SPRYCEL TABS 20MG, 50MG, 70MG, 80MG ........... 23
SPRYCEL TABS 100MG, 140MG ................................. 23
sronyx ........................................................................................56
ssd ..............................................................................................44
stavudine ..................................................................................29
STERILE LUBRICANT DROPS ....................................... 65
sterile water irrigation ...........................................................78
STIOLTO RESPIMAT ........................................................ 72
109
Nome farmaco
Pagina n.
STIVARGA ........................................................................ 23
stool softener caps 100mg ..................................................48
streptomycin sulfate inj ........................................................... 6
STRIBILD........................................................................... 29
STROMECTOL ................................................................. 24
SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG .................................................................................... 5
SUBOXONE FILM 12MG; 3MG ...................................... 5
sucralfate susp, tabs...............................................................48
sulfacetamide sodium oint 10%.........................................65
sulfacetamide sodium/prednisolone sodium phosphate ..
65
sulfacetamide sodium soln 10% ........................................65
sulfacetamide sodium susp 10% .......................................44
sulfadiazine tabs .....................................................................11
sulfamethoxazole/trimethoprim ........................................11
sulfamethoxazole/trimethoprim ds ...................................11
SULFAMYLON.................................................................. 44
sulfasalazine tabs, tbec .........................................................62
sulfazine ....................................................................................62
sulfazine ec ...............................................................................62
sulindac tabs .............................................................................. 2
sumatriptan soln ....................................................................18
sumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml ......18
sumatriptan succinate inj 6mg/0.5ml ..............................18
sumatriptan succinate refill inj 4mg/0.5ml .....................18
sumatriptan succinate refill inj 6mg/0.5ml .....................18
sumatriptan succinate tabs..................................................18
super b-100 tabs 100mcg; 100mg; 100mcg; 400mcg; 100mg; 100mg; 100mg; 50mg; 100mg; 100mg .......85
SUPRAX CAPS ................................................................... 9
SUPRAX CHEW 100MG .................................................. 9
SUPRAX CHEW 200MG .................................................. 9
SUPRAX SUSR 100MG/5ML, 200MG/5ML ................ 9
SUPRAX SUSR 500MG/5ML .......................................... 9
SUPREP BOWEL PREP ................................................... 48
SURMONTIL .................................................................... 15
SUSTIVA............................................................................ 29
SUTENT CAPS 12.5MG ................................................. 23
SUTENT CAPS 25MG, 37.5MG, 50MG ...................... 23
syeda ..........................................................................................56
SYLATRON INJ 200MCG, 300MCG ............................. 22
SYLATRON INJ 200MCG, 300MCG, 600MCG .......... 22
SYLVANT ........................................................................... 24
SYMLINPEN 60 ............................................................... 32
SYMLINPEN 120 ............................................................. 32
SYNAGIS ........................................................................... 61
110
Nome farmaco
Pagina n.
SYNAREL .......................................................................... 59
SYNERCID .......................................................................... 7
SYNRIBO........................................................................... 22
SYNTHROID ..................................................................... 58
SYPRINE............................................................................ 73
SYSTANE OVERNIGHT THERAPY LUBRICANT EYE . 65
TABLOID ........................................................................... 20
tacrolimus caps .......................................................................60
TAFINLAR CAPS 50MG ................................................. 23
TAFINLAR CAPS 75MG ................................................. 23
TAMIFLU CAPS 30MG ................................................... 30
TAMIFLU CAPS 45MG, 75MG...................................... 30
TAMIFLU SUSR ................................................................ 30
tamoxifen citrate tabs ............................................................20
tamsulosin hcl .........................................................................49
TARCEVA TABS 25MG ................................................... 23
TARCEVA TABS 100MG, 150MG ................................ 24
TARGRETIN ...................................................................... 24
tarina fe 1/20 ..........................................................................56
TARON-PREX .................................................................. 85
TASIGNA........................................................................... 24
tazicef inj 1gm, 2gm, 6gm ..................................................... 9
TAZORAC ......................................................................... 44
taztia xt cp24 120mg, 240mg, 360mg ...........................38
taztia xt cp24 180mg, 300mg ...........................................38
TEARS AGAIN NIGHT & DAY ........................................ 65
TEFLARO ............................................................................ 9
TEGRETOL-XR TB12 100MG ....................................... 13
telmisartan ...............................................................................35
telmisartan/amlodipine ........................................................35
telmisartan/hydrochloroth ..................................................35
telmisartan/hydrochlorothiazide........................................36
TEMODAR INJ .................................................................. 19
TENIVAC ........................................................................... 62
terazosin hcl .............................................................................35
terbinafine hcl tabs ................................................................17
terbutaline sulfate tabs..........................................................69
terconazole...............................................................................17
TESSALON PERLES ........................................................ 72
testosterone cypionate inj ....................................................52
testosterone enanthate inj ...................................................52
testosterone gel 25mg/2.5gm............................................52
tetanus/diphtheria toxoids-adsorbed adult .....................62
tetracycline hcl caps ..............................................................11
THALOMID CAPS 100MG, 150MG, 50MG............... 19
THALOMID CAPS 200MG ............................................ 19
theophylline cr tb12 100mg, 200mg...............................70
Nome farmaco
Pagina n.
theophylline elix ......................................................................70
theophylline er.........................................................................70
theophylline soln.....................................................................70
THERA/BETA-CAROTENE TABS 90MG; 0; 30MCG; 23MG; 10MG; 9MCG; 400UNIT; 400MCG; 20MG; 18MG; 3MG; 3.4MG; 3MG; 30UNIT; 5000UNIT ..... 85
THERACYS ....................................................................... 22
THERATEARS SOLN ....................................................... 65
thiamine hcl inj........................................................................85
THIOLA ............................................................................. 49
thioridazine hcl tabs...............................................................26
thiothixene caps ......................................................................26
THYMOGLOBULIN ......................................................... 60
THYROLAR-1 .................................................................. 58
THYROLAR-1/2 .............................................................. 58
THYROLAR-1/4 .............................................................. 58
THYROLAR-2 .................................................................. 58
THYROLAR-3 .................................................................. 58
tiagabine hydrochloride........................................................12
TICE BCG .......................................................................... 22
ticlopidine hcl ..........................................................................35
TIKOSYN ........................................................................... 37
tilia fe .........................................................................................56
timolol maleate ophthalmic gel forming ..........................66
timolol maleate soln 0.25%, 0.5% ....................................66
timolol maleate tabs 10mg, 20mg, 5mg .........................37
tinidazole .................................................................................... 7
tioconazole-1 ..........................................................................49
titralac .......................................................................................46
TIVICAY ............................................................................. 29
tizanidine hcl tabs ...................................................................28
TL-CARE DHA ................................................................. 85
TL FOLATE........................................................................ 85
TL-SELECT ....................................................................... 85
tobramycin ...............................................................................69
tobramycin/dexamethasone................................................65
tobramycin sulfate inj 1.2gm, 10mg/ml, 40mg/ml......... 6
tobramycin sulfate inj 1.2gm/30ml, 40mg/ml, 80mg/2ml.................................................................................. 6
tobramycin sulfate ophthalmic soln 0.3% .......................65
tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml6
TOBREX ............................................................................ 65
tolazamide................................................................................32
tolbutamide..............................................................................32
tolmetin sodium ........................................................................ 2
tolnaftate ..................................................................................44
tolterodine tartrate.................................................................49
Nome farmaco
Pagina n.
topiramate cpsp, tabs ............................................................13
toposar ......................................................................................22
topotecan hcl ...........................................................................23
TORISEL ............................................................................ 24
torsemide tabs.........................................................................38
total b/c .....................................................................................85
tpn electrolytes........................................................................78
TRACLEER ........................................................................ 70
TRADJENTA ...................................................................... 32
tramadol hcl tabs...................................................................... 4
tramadol hydrochloride/acetaminophen ........................... 4
trandolapril ..............................................................................36
trandolapril/verapamil hcl ...................................................36
trandolapril/verapamil hcl er...............................................36
tranexamic acid inj .................................................................34
tranexamic acid tabs..............................................................35
TRANSDERM-SCOP....................................................... 16
tranylcypromine sulfate ........................................................14
TRAVATAN Z .................................................................... 64
travoprost .................................................................................64
trazodone hcl ...........................................................................15
TREANDA ......................................................................... 19
TRECATOR........................................................................ 19
TRELSTAR MIXJECT ........................................................ 59
tretinoin caps 10mg ..............................................................24
tretinoin crea 0.025%, 0.05%, 0.1%................................44
tretinoin gel 0.01%, 0.025% ..............................................44
triacting day time cold/cough childrens ...........................72
triadvance.................................................................................85
triamcinolone acetonide aero 55mcg/act .......................68
triamcinolone acetonide aers 0 ..........................................51
triamcinolone acetonide crea 0.025%, 0.1%, 0.5%.....51
triamcinolone acetonide lotn 0.025%, 0.1% .................51
triamcinolone acetonide oint 0.025%, 0.1%, 0.5% .....51
triamcinolone acetonide pste 0.1%...................................42
triamcinolone in orabase .....................................................42
TRIAMINIC COUGH & RUNNY NOSE ......................... 68
TRIAMINIC FEVER REDUCER PAIN RELIEVER INFANTS
1
TRIAMINIC NIGHT TIME COLD & COUGH ................72
triamterene/hydrochlorothiazide.......................................39
tricare ........................................................................................85
TRICARE PRENATAL COMPLEAT................................. 85
TRICARE PRENATAL DHA ONE ................................... 85
triderm ......................................................................................51
tri-estarylla ..............................................................................56
trifluoperazine hcl tabs .........................................................26
111
Nome farmaco
Pagina n.
trifluridine .................................................................................65
trihexyphenidyl hcl .................................................................25
tri-legest fe ...............................................................................56
tri-linyah ...................................................................................56
trilyte..........................................................................................48
trimethoprim sulfate/polymyxin b sulfate ........................65
trimethoprim tabs .................................................................... 7
TRINATAL GT ................................................................... 85
trinatal rx 1...............................................................................85
trinessa......................................................................................56
triple antibiotic ........................................................................65
triple-vitamin/fluoride...........................................................85
tri-previfem..............................................................................56
TRISENOX......................................................................... 22
tri-sprintec ...............................................................................56
TRIUMEQ.......................................................................... 29
TRIVEEN-DUO DHA....................................................... 85
TRIVEEN-PRX RNF.......................................................... 85
TRI-VI-SOL ...................................................................... 85
tri-vita........................................................................................85
tri-vitamin/fluoride ................................................................85
tri-vitamin soln 35mg/ml; 400unit/ml; 1500unit/ml ..85
tri-vit/fluoride..........................................................................85
tri-vit/fluoride/iron.................................................................85
trivora-28 ................................................................................56
TRULICITY ........................................................................ 33
TRUMENBA ..................................................................... 62
TRUVADA ......................................................................... 29
tussin cf cough & cold ...........................................................72
tussin dm syrp .........................................................................72
TWINRIX ........................................................................... 62
TYBOST ............................................................................ 30
TYGACIL ............................................................................. 7
TYKERB ............................................................................. 24
TYPHIM VI ........................................................................ 62
TYZEKA ............................................................................. 28
TYZINE PEDIATRIC NASAL DROPS ............................. 72
ultimatecare one nf................................................................85
unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg .......................................................................................58
ursodiol caps, tabs ..................................................................46
UVADEX ............................................................................ 22
VAGIFEM .......................................................................... 56
vagistat-3 .................................................................................49
valacyclovir hcl ........................................................................31
VALCHLOR ....................................................................... 19
112
Nome farmaco
Pagina n.
VALCYTE ........................................................................... 28
valganciclovir...........................................................................28
valproate sodium inj ..............................................................12
valproic acid caps, syrp .........................................................12
valsartan ...................................................................................36
valsartan/hydrochlorothiazide............................................36
VALSTAR ........................................................................... 22
vancomycin hcl caps ................................................................ 7
vancomycin hcl in dextrose .................................................... 7
vancomycin hcl inj 500mg..................................................... 8
vancomycin hcl inj 1000mg, 10gm, 5000mg, 750mg. 7
vandazole ................................................................................... 8
VANTAS ............................................................................ 59
VAQTA ............................................................................... 62
VARIVAX ........................................................................... 62
VASCEPA .......................................................................... 40
VASOSTRICT.................................................................... 52
VECTIBIX........................................................................... 22
VELCADE .......................................................................... 22
velivet.........................................................................................56
VELPHORO ...................................................................... 49
VEMAVITE-PRX 2 ........................................................... 85
VENA-BAL DHA ............................................................. 85
venlafaxine hcl.........................................................................15
venlafaxine hcl er cp24 37.5mg, 75mg ...........................15
venlafaxine hcl er cp24 150mg..........................................15
venlafaxine hcl er tb24 150mg ..........................................15
venlafaxine hcl er tb24 225mg, 37.5mg, 75mg ...........15
VENTOLIN HFA ............................................................... 69
verapamil hcl er.......................................................................38
verapamil hcl inj, tabs ............................................................38
verapamil hcl sr cp24 ............................................................38
verapamil hcl sr tbcr 240mg ...............................................38
VERSACLOZ ..................................................................... 27
VESICARE ......................................................................... 49
vestura.......................................................................................56
V-GO 20 ........................................................................... 63
V-GO 30 ........................................................................... 63
V-GO 40 ........................................................................... 63
vicodin es tabs 300mg; 7.5mg ............................................. 4
vicodin tabs 300mg; 5mg ...................................................... 4
VICTOZA ........................................................................... 33
VIDEX PEDIATRIC............................................................ 29
VIIBRYD KIT ...................................................................... 15
VIIBRYD TABS .................................................................. 15
VIMPAT INJ ....................................................................... 13
VIMPAT ORAL SOLN ...................................................... 13
Nome farmaco
Pagina n.
VIMPAT TABS 50MG ...................................................... 13
VIMPAT TABS 100MG, 150MG, 200MG.................... 13
vinblastine sulfate inj 1mg/ml .............................................22
vincasar pfs ..............................................................................22
vincristine sulfate....................................................................22
vinorelbine tartrate ................................................................22
viorele ........................................................................................56
VIRACEPT ......................................................................... 30
VIRAMUNE SUSP ............................................................ 29
VIRAMUNE XR TB24 100MG ....................................... 29
VIRAZOLE......................................................................... 31
VIREAD POWD ................................................................ 29
VIREAD TABS 150MG, 300MG.................................... 30
VIREAD TABS 200MG, 250MG.................................... 29
VIRT-ADVANCE............................................................... 85
VIRT-CARE ONE.............................................................. 85
VIRT-PN ............................................................................ 85
VIRT-PN DHA .................................................................. 86
VIRT-PN PLUS ................................................................. 86
VIRT-SELECT ................................................................... 86
VITAFOL-ONE ................................................................. 86
VITA-MAG ........................................................................ 86
VITAMEDMD ONE RX/QUATREFOLIC ........................ 86
VITAMEDMD PLUS RX/QUATRE FOLIC ...................... 86
vitamin a caps 10000unit ...................................................86
vitamin a tabs 1000unit; 10000unit ................................86
vitamin b-1 tabs 100mg, 50mg ........................................86
vitamin b-6 tabs 100mg, 25mg, 50mg...........................86
vitamin b-12 tabs 100mcg .................................................86
vitamin c chew 250mg .........................................................86
vitamin c syrp ..........................................................................86
vitamin c tabs 100mg, 250mg, 500mg ..........................86
vitamin d3 liqd 400unit/ml .................................................86
vitamin d3 tabs 400unit .......................................................86
VITAMIN D3 TABS 3000UNIT ...................................... 86
vitamin d-1000 ......................................................................86
vitamin k1 inj 10mg/ml, 1mg/0.5ml ................................86
vitamins a/c/d/fluoride ..........................................................86
vitamins a/d/c/fluoride ..........................................................78
vitatrum chew..........................................................................86
VITEKTA ............................................................................ 29
VOL-NATE ........................................................................ 86
VOL-PLUS ........................................................................ 86
VOLTAREN.......................................................................... 2
voriconazole inj .......................................................................17
voriconazole susr, tabs ..........................................................17
VOTRIENT ........................................................................ 24
Nome farmaco
Pagina n.
VP-CH-PNV..................................................................... 86
VP CH ULTRA................................................................... 86
VP-HEME OB .................................................................. 86
VP-PNV-DHA .................................................................. 86
VPRIV ................................................................................ 45
vyfemla......................................................................................56
wal-act ......................................................................................72
wal-fex d 12 hour allergy& congestion .............................72
wal-itin d...................................................................................47
wal-itin syrp .............................................................................69
wal-phed pe sinus/allergy ....................................................72
wal-phed sinus/allergy ..........................................................47
warfarin sodium tabs.............................................................34
wera ...........................................................................................56
wymzya fe .................................................................................56
XALKORI ........................................................................... 24
XARELTO STARTER PACK .............................................. 34
XARELTO TABS 10MG, 20MG ...................................... 34
XARELTO TABS 15MG ................................................... 34
XENAZINE TABS 12.5MG ............................................. 41
XENAZINE TABS 25MG ................................................. 41
XGEVA ............................................................................... 63
XOLAIR.............................................................................. 72
XTANDI ............................................................................. 19
XYREM .............................................................................. 72
YERVOY............................................................................. 22
YF-VAX.............................................................................. 62
yl folic acid ................................................................................86
zafirlukast .................................................................................69
zaleplon caps 5mg .................................................................72
zaleplon caps 10mg...............................................................72
ZALTRAP INJ 100MG/4ML ........................................... 22
ZALTRAP INJ 200MG/8ML ........................................... 22
zamicet ........................................................................................ 5
ZANOSAR......................................................................... 22
zarah ..........................................................................................56
ZATEAN-CH .................................................................... 86
ZATEAN-PN ..................................................................... 86
ZATEAN-PN DHA ........................................................... 86
ZATEAN-PN PLUS .......................................................... 86
ZAVESCA .......................................................................... 45
zebutal caps 325mg; 50mg; 40mg ..................................... 1
ZELBORAF........................................................................ 24
zenatane caps 10mg, 20mg, 40mg ..................................44
ZENATANE CAPS 30MG................................................ 44
zenchent ...................................................................................56
zenchent fe ...............................................................................56
113
Nome farmaco
Pagina n.
ZENPEP CPEP 109000UNIT; 20000UNIT;
68000UNIT, 136000UNIT; 25000UNIT; 85000UNIT,
16000UNIT; 3000UNIT; 10000UNIT, 27000UNIT;
5000UNIT; 17000UNIT, 55000UNIT; 10000UNIT;
34000UNIT, 82000UNIT; 15000UNIT; 51000UNIT ...
45
ZENPEP CPEP 218000UNIT; 40000UNIT; 136000UNIT ................................................................... 45
ZETIA................................................................................. 40
ZIAGEN SOLN ................................................................. 30
zidovudine ................................................................................30
zinc oxide oint 20% ................................................................44
ziprasidone hcl ........................................................................27
ZIRGAN ............................................................................. 65
ZOLADEX.......................................................................... 59
zoledronic acid inj 4mg/5ml, 4mg, 5mg/100ml ...........63
ZOLINZA........................................................................... 22
zolpidem tartrate ....................................................................72
114
Nome farmaco
Pagina n.
ZONALON ........................................................................ 44
ZONATUSS ....................................................................... 72
zonisamide ...............................................................................12
ZORTRESS ........................................................................ 60
ZOSTAVAX ........................................................................ 62
zovia 1/35e ..............................................................................56
ZOVIA 1/50E ................................................................... 57
ZYDELIG ........................................................................... 23
ZYKADIA ........................................................................... 24
ZYPREXA RELPREVV INJ 210MG, 300MG ................. 27
ZYPREXA RELPREVV INJ 405MG ................................. 27
ZYRTEC ALLERGY TABS ................................................. 69
ZYRTEC CHILDRENS ALLERGY SYRP 1MG/ML ........ 69
ZYTIGA.............................................................................. 19
ZYVOX INJ ........................................................................... 8
ZYVOX SUSR ...................................................................... 8
Note:
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NY-15-08-05