AMENDMENT TO THE CONTRACT BETWEEN

Exhibit 10.1

AMENDMENT TO THE CONTRACT BETWEEN

ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES) and TRIPLE-S SALUD, INC.

to

ADMINISTER THE PROVISION OF PHYSICAL

AND BEHAVIORAL HEALTH SERVICES UNDER THE GOVERNMENT HEALTH

PLAN

CONTRACT NUMBER: 2015-000087I

THIS AMENDMENT TO THE CONTRACT BETWEEN ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES) AND TRIPLE-S SALUD, INC. FOR THE PROVISION OF PHYSICAL AND BEHAVIORAL HEALTH SERVICES UNDER THE GOVERNMENT

HEALTH PLAN WITHIN THE METRO NORTH AND WEST SERVICE REGIONS (the

“Amendment”) is by and between Triple-S Salud, Inc. (“the Contractor”), an insurance company duly organized and authorized to do business under the laws of the Commonwealth of Puerto Rico, with employer identification number 00-0000000 and the Puerto Rico Health Insurance

Administration (Administración de Seguros de Salud de Puerto Rico, hereinafter referred to as “ASES” or “the Administration”), a public corporation of the Commonwealth of Puerto Rico, with employer identification number 00-0000000.

WHEREAS, the Contractor and ASES executed a Contract for the provision of Physical Health and  Behavioral Health Services under the Government Health Plan within the Metro North and West Service Regions of the Commonwealth of Puerto Rico, on December 3rd, 2015 (hereinafter referred to as the “Contract”);

WHEREAS, the Contract provides, pursuant to Section 21.6, that ASES is granted the option to renew the Contract for an additional term of up to one (1) fiscal year, beginning on July 1, 2017 to June 30, 2018;

WHEREAS, ASES has exercised, through this Amendment and through previously executed agreements by the Parties to extend the Contract beyond its original expiration date of June 30, 2017 (the “Agreed Extensions”), the option to renew the Contract for an additional term of one (1) fiscal year;

WHEREAS, the Contract also provides, pursuant to Article 55, that the Parties may amend such Contract by mutual written consent; and

WHEREAS, all provisions of the Contract will remain in full force and effect as described therein, except as otherwise provided in this Amendment and the Agreed Extensions.

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NOW, THEREFORE, and in consideration of the mutual promises herein contained and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree to clarify and/or amend the Contract as follows:

I. RENEWAL OF CONTRACT

ASES has exercised its option to renew of the Contract for an additional one (1) fiscal year term, which shall begin on July 1, 2017 and end at midnight on June 30, 2018, in accordance with Section 21.6 of the Contract.

II. DISCONTINUATION OF HIGH UTILIZERS PROGRAM

The Parties agree that the High Utilizers Program operated by the Contractor will be discontinued for the July 1, 2017 to June 30, 2018 renewal term.

III. AMENDMENTS

1. Immediately following Section 1.1.6, a new Section 1.1.7 shall be inserted stating as follows:

1.1.7 Pursuant to 42 CFR 438.602(i), the Contractor shall not be located outside of the United States.

2. The following definitions in Article 2 shall be amended as follows:

Adverse Benefit Determination: The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service, requirements for medical necessity appropriateness, setting or effectiveness of a covered benefit; the denial, in whole or part, of payment for a service (including in circumstances in which an Enrollee is forced to pay for a service; the failure to provide services in a timely manner (within the timeframes established by this Contract or otherwise established by ASES); the failure of the Contractor to act within the timeframes provided in 42 CFR 438.408(b); or the denial of an Enrollee’s request to dispute a financial liability, including cost-sharing, co-payments, premiums, deductibles, coinsurance, and other Enrollee financial liabilities. For a resident of a rural area, the denial of an Enrollee's request to exercise his or her right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the network.

Emergency Medical Condition: As defined in 42 C.F.R. 438.114, a medical or Behavioral Health condition, regardless of diagnosis or symptoms, manifesting itself in acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairments of bodily functions, serious dysfunction of any bodily organ or part, serious harm to self or other due to an alcohol or drug abuse emergency, serious injury to self or bodily harm to others, or the lack of adequate time for a pregnant women having contractions to safely reach a another hospital before delivery.  The Contractor may not impose limits on what constitutes an Emergency Medical Condition based only, or exclusively, on diagnoses or symptoms.

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Emergency Services: As defined in 42 CFR 438.114, any Physical or Behavioral Health Covered Services (as described in Section 7.5.9) furnished by a qualified Provider in an emergency room that are needed to evaluate or stabilize an Emergency Medical Condition or a Psychiatric Emergency that is found to exist using the prudent layperson standard.

Excess Profit: The excess over two point five percent (2.5%) of the annual profit before income taxes as reported in the audited financial statements for the period of July 1, 2017 to June 30, 2018. Excess Profits are to be shared between the Contractor or the Subcontractors and ASES, as provided in Sections 22.1.18 and 22.1.19.

Overpayment: Any funds that a person or entity receives which that person or entity is not entitled to under Title XIX of the Social Security Act. Overpayments shall not include funds that have been subject to a payment suspension or that have been identified as a Third Party Liability as set forth in Section 23.4.

Performance Improvement Projects (PIPs): Projects consistent with 42 CFR 438.330.

Primary Care: All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by ASES, to the extent the furnishing of those services is legally authorized where the practitioner furnishes them.

Subcontractor: Any organization or person, including the Contractor’s parent, subsidiary or Affiliate, who has a contract or written arrangement with the Contractor to provide any function or service for the Contractor specifically related to securing or fulfilling the Contractor’s obligations to the Commonwealth under the terms of this Contract. Subcontractors do not include Providers unless the Provider is responsible for services other than providing Covered Services pursuant to a Provider participation agreement.

3. The following definitions in Article 2 shall be inserted as follows:

Formulary of Medications Covered (“FMC”):  A published subset of pharmaceutical products used for the treatment of physical and Behavioral Health conditions developed by the PPA after clinical recommendations from the Pharmacy and Therapeutics (P&T) Committee and financial review from the Pharmacy Benefits Financial Committee.

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List of Medications by Exception (“LME”):  List of medications that are not included in the FMC, but that have been evaluated and approved by ASES’s Pharmacy and Therapeutics (P&T) Committee to be covered only through an exception process if certain clinical criteria are met. Covered outpatient drugs that are not included on the LME may still be covered under an Exception Request in compliance with Section 7.5.12.10.1.2, unless statutorily excluded.

4. The definition of Preferred Drug List (“PDL”) in Article 2 shall be deleted in its entirety.  The acronym of PDL in Article 3 shall be deleted in its entirety.

5. The following acronyms in Article 3 shall be inserted as follows:

FMC	Formulary of Medications Covered
LME	List of Medications by Exception

6. The following acronyms in Article 3 shall be amended as follows:

QIP	Quality Incentive Program
US or USA	United States of America

7. All subsequent references within the Contract to the following defined terms and acronyms shall be replaced as follows, unless otherwise stated in this Amendment:

a. All references to the defined term “Action” shall be deleted and replaced with the defined term “Adverse Benefit Determination.”

b. All references to the defined term “Preferred Drug List” shall be deleted and replaced with the defined term “Formulary of Medications Covered.”  All references to the acronym “PDL” shall be deleted and replaced with the acronyms

“FMC.”

c. All references to the defined term “Master Formulary” shall be deleted and replaced with the defined term “List of Medications by Exception” or the acronym “LME.”

d. All references to the former “Quality Improvement Procedure” shall be deleted and replaced with “Quality Incentive Program.”

8. Section 4.5.1 shall be amended and replaced in its entirety as follows:

4.5.1 ASES shall conduct readiness reviews of the Contractor’s operations three (3) months before the start of a new managed care program and when the Contractor will provide or arrange for the provision of covered benefits to new eligibility groups.  Such review will include, at a minimum, one (1) on-site review, at dates and times to be determined by ASES.  These reviews may include, but are not limited to, desk and on-site reviews of documents provided by the Contractor, walk-through(s) of the Contractor’s facilities, Information System demonstrations, and interviews with the Contractor’s staff. ASES will conduct the readiness review to confirm that the Contractor is capable and prepared to perform all Administrative Functions and to provide high-quality services to GHP Enrollees.

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9. Section 4.5.3.12 shall be amended and replaced in its entirety as follows:

4.5.3.12 Financial management, including financial reporting and monitoring and financial solvency;

10. Section 4.5.3.14 shall be amended and replaced in its entirety as follows:

4.5.3.14 Information Systems management, including claims management, encounter data and enrollment information management, systems performance, interfacing capabilities, and security management functions and capabilities; and

11. Section 5.2.1.1 shall be amended and replaced in its entirety as follows:

5.2.1.1 The Contractor shall accept all Potential Enrollees into its Plan without restrictions.  The Contractor shall not discriminate against individuals eligible to enroll on the basis of religion, race, color, national origin, sex,  sexual orientation, gender identity, or disability, and will not use any policy or practice that has the effect of discriminating on the basis of religion, race, color, national origin, sex, sexual orientation, gender identity, or disability on the basis of health, health status, pre-existing condition, or need for health care services.

12. Section 5.2.2 shall be amended and replaced in its entirety as follows:

5.2.2 Effective Date of Enrollment

5.2.2.1 Except as provided below, Enrollment, whether chosen or automatic, will be effective (hereinafter referred to as the “Effective Date of Enrollment”) the same date as the period of eligibility specified on the MA-10.

5.2.2.2 Effective Date of Enrollment for Newborns. The Effective Date of Enrollment for Medicaid and CHIP Eligible newborns is the date of his or her birth. The Effective Date of Enrollment for Commonwealth Population newborns is the date the newborn is registered with the Puerto Rico Medicaid Program. A newborn shall be Auto-Enrolled pursuant to the procedures set forth in Section 5.2.6.

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5.2.2.3 Re-Enrollment Policy and Effective Date of Re-Enrollment for Mothers Who are Minor Dependents.  In the event that a female Enrollee who is included in a family group for coverage under the GHP as a Dependent child becomes pregnant, the Enrollee shall be referred to the Puerto Rico Medicaid Program.  She will effectively establish a new family with the diagnosis of her pregnancy and will become the Contact Member of the new family.  The eligibility period of the new family will begin on the date of the first diagnosis of the pregnancy, and the Enrollee shall be AutoEnrolled, effective as of this date.  The mother shall be Auto-Assigned to the PMG and PCP to which she was assigned before the Re-Enrollment.

5.2.2.4 Effective Date of Re-Enrollment for Enrollees Who Lose Eligibility. If an Enrollee who is a Medicaid- or - CHIP Eligible Person or member of the Commonwealth Population loses eligibility for the GHP for a period of two (2) months or less, Enrollment in the Contractor’s Plan shall be reinstated.  Upon notification from ASES of the Recertification, the Contractor shall Auto-Enroll the person, with Enrollment effective as of the eligibility period specified on the MA-10.

13. Section 5.2.4.2 shall be amended and replaced in its entirety as follows:

5.2.4.2 The Auto-Enrollment process will include Auto-Assignment of a PMG and a PCP (see Section 5.4 of this Contract).  A new Enrollee who is a Dependent of a current GHP Enrollee (the “Contact Member’) shall be automatically assigned to the same PMG as his or her Contact Member, as identified by the Contact Member number.

14. Section 5.2.5.2 shall be amended and replaced in its entirety as follows:

5.2.5.2 Once the Enrollee calls or visits the Contractor’s office to execute the right of changing the assigned PMG, PCP, or both, the Contractor shall request that the Enrollee select a new PMG and PCP.  During the visit or call, the Contractor shall issue to the Enrollee an Enrollee ID Card and a notice of Enrollment, as well as an Enrollee Handbook and Provider Directory either in paper or electronic form, subject to requirements of Sections 6.9.8 and 6.9.9; or, such notice of Enrollment, an ID Card, a Handbook, and a Provider Directory may be sent to the Enrollee via surface mail or electronically, subject to the requirements of Sections 6.9.8 and 6.9.9 within five (5) Business Days of the Enrollee’s request to change the Auto-Enrollment assignments.

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15. Immediately following Section 5.2.5.3, a new Section 5.2.2.3.1 shall be inserted stating as follows:

5.2.5.3.1 All Enrollees must also be notified at least annually of their disenrollment rights as set forth in Section 5.3 and 42 CFR 438.56.  Such notification must clearly explain the process for exercising this disenrollment right, as well as the alternatives available to the Enrollee based on their specific circumstance.

16. Section 5.2.6.4 shall be amended and replaced in its entirety as follows:

5.2.6.4 If the mother has not made a PCP and PMG selection at the time of the child’s birth, the Contractor shall, within one (1) Business Day of the birth, auto-assign the newborn to a PCP who is a pediatrician and to the Contact Member’s PMG.

17. Section 5.3.3.3 shall be amended and replaced in its entirety as follows:

5.3.3.3 If what would otherwise be the Effective Date of Disenrollment under this Section 5.3.3 falls:

5.3.3.3.1 When the Enrollee is an inpatient at a hospital, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the month in which the Enrollee is discharged from the hospital, or the last day of the month following the month in which Disenrollment would otherwise be effective, whichever occurs earlier;

5.3.3.3.2 During a month in which  a Medicaid, CHIP or Commonwealth Enrollee is pregnant, or on the date the pregnancy ends, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the month in which the 60-day post-partum period ends;

5.3.3.3.3 When the Enrollee is in the process of appealing a Disenrollment though either the Grievance System, ASES’s Administrative Law Hearing process, or the Puerto Rico Medicaid Department’s dedicated hearing process on Disenrollments, as applicable, then ASES shall postpone the Effective Date of Disenrollment until a decision is rendered after the hearing;  or

5.3.3.3.4 During a month in which an Enrollee is diagnosed with a Terminal Condition, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the following month. 

18. Immediately following Section 5.3.5, a new Section 5.3.5.1 shall be inserted stating as follows, and the remaining Section 5.3.5 shall be renumbered accordingly, including any references thereto:

5.3.5.1 All Enrollees must be notified at least annually of their disenrollment rights as set forth in Section 5.3 and 42 CFR 438.56.  Such notification must clearly explain the process for exercising this disenrollment right, as well as the coverage alternatives available to the Enrollee based on their specific circumstance.

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19. Original Section 5.3.5.2, renumbered by this Amendment as 5.3.5.3, shall be amended and replaced in its entirety as follows:

5.3.5.3 An Enrollee may request Disenrollment from the Contractor’s Plan without cause during the ninety (90) Calendar Days following the Effective Date of Enrollment with the Plan or the date that the Contractor sends the Enrollee notice of the Enrollment, whichever is later.  An Enrollee may request Disenrollment without cause every twelve (12) months thereafter or if, upon automatic re-enrollment of an Enrollee disenrolled solely because he or she loses eligibility for a period of two (2) months or less, the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity.  In addition, an Enrollee may request Disenrollment without cause in the event that ASES notifies the Enrollee that ASES has imposed or intends to impose on the Contractor the intermediate sanctions set forth in 42 CFR 438.702(a)(3).

20. Immediately following Original Section 5.3.5.3.1, renumbered by this Amendment as 5.3.5.4.1, a new Section 5.3.5.4.2 shall be inserted stating as follows, and the remaining Section 5.3.5.4 shall be renumbered accordingly, including any references thereto:

5.3.5.4.2 The Contractor’s Plan does not, due to moral or religious objections, cover the health service the Enrollee seeks.

21. Original Section 5.3.5.4, renumbered by this Amendment as 5.3.5.5, shall be amended and replaced in its entirety as follows:

5.3.5.5 If the Contractor fails to refer a Disenrollment request within the timeframe specified in Section 5.3.3, or if ASES fails to make a Disenrollment determination so that the Enrollee may be disenrolled by the first day of the second month following the month when the Disenrollment request was made, per Section 5.3.3, the Disenrollment shall be deemed approved for the effective date that would have been established had ASES or the Contractor complied with Section 5.3.3.

22. Section 5.3.8.2 shall be amended and replaced in its entirety as follows:

5.3.8.2 The Contractor shall notify the Puerto Rico Medicaid Program Immediately when the Enrollment database is updated to reflect a change in the place of residence of an Enrollee or an Enrollee’s death.

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23. Section 6.1.1 shall be amended and replaced in its entirety as follows:

6.1.1 The Contractor shall have policies and procedures, prior approved by ASES and submitted in accordance with Attachment 12, that explain how it will ensure that Enrollees and Potential Enrollees:

6.1.1.1 Are aware of their rights and responsibilities;

6.1.1.2 How to obtain physical and Behavioral Health Services;

6.1.1.3 What to do in an emergency or urgent medical situation;

6.1.1.4 How to request a Grievance, Appeal, or Administrative Law Hearing;

6.1.1.5 How to report suspected Incident of Fraud, Waste, and Abuse;

6.1.1.6 Have basic information on the basic features of managed care; and

6.1.1.7 Understand the MCO’s responsibilities to coordinate Enrollee care.

24. Section 6.1.2 shall be amended and replaced in its entirety as follows:

6.1.2 The Contractor’s informational materials must convey to Enrollees and Potential Enrollees that GHP is an integrated program that includes both physical and Behavioral Health Services, and must also explain the concepts of Primary Medical Groups and Preferred Provider Networks.

25. Immediately following Section 6.1.6, a new Section 6.1.7 shall be inserted stating as follows:

6.1.6 The Contractor shall use the definitions for managed care terminology set forth by ASES in all of its written and verbal communications with Enrollees, in accordance with 42 CFR 438.10(c)(4)(i).

26. Section 6.2.4.3 shall be amended and replaced in its entirety as follows:

6.2.4.3 Standard letters and notifications, such as the notice of Enrollment required in Section 5.2.5.3, the notice of Redetermination required in Section 5.2.7.1, and the notice of Disenrollment required in Section 5.3.2.  The Contractor shall use model Enrollee notices developed by ASES.

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27. Section 6.3.2 shall be amended and replaced in its entirety as follows:

6.3.2 The Contractor shall make all written materials available through auxiliary aids and services or alternative formats, and in a manner that takes into consideration the Enrollee’s or Potential Enrollee’s special needs, including Enrollees and Potential Enrollees who are visually impaired or have limited reading proficiency.  The Contractor shall notify all Enrollees and Potential Enrollees that Information is available in alternative formats, and shall instruct them on how to access those formats.  Consistent with Section 1557 of PPACA and 42 C.F.R. 438.10(d)(3), all written materials must also include taglines in the prevalent languages, as well as large print, with a font size of no smaller than 18 point, to explain the availability of written and oral translation to understand the Information provided and the toll-free and TTY/TDY telephone number of the GHP Service Line.

28. Section 6.3.3 shall be amended and replaced in its entirety as follows:

6.3.3 Once an Enrollee has requested a written material in an alternative format or language, the Contractor shall at no cost to the Enrollee or Potential Enrollee (i) make a notation of the Enrollee or Potential Enrollee’s preference in the Contractor’s system and (ii) provide all subsequent written materials to the Enrollee or Potential Enrollee in such format unless the Enrollee or Potential Enrollee requests otherwise.

29. Section 6.3.4 shall be amended and replaced in its entirety as follows:

6.3.4 Except as provided in Sections 1.1.5 and 6.4 (Enrollee Handbook) and subject to Section 6.3.8, the Contractor shall make all written information available in Spanish on other applicable Prevalent Non-English Language, as defined in Section 6.3.8 below, with a language block in English, explaining that (i) Enrollees may access an English translation of the Information if needed, and (ii) the Contractor will provide oral interpretation services into any language other than Spanish or English, if needed.  Such translation or interpretation shall be provided by the Contractor at no cost to the Enrollee. The language block and all other content shall comply with 42 CFR 438.10(d)(2) and Section 1557 of PPACA.

30. Section 6.3.5 shall be amended and replaced in its entirety as follows:

6.3.5 If oral interpretation services are required in order to explain the Benefits covered under the GHP to a Potential Enrollee who does not speak either English or Spanish, the Contractor must, at its own cost, make such services available in a third language, in compliance with 42 CFR 438.10(d)(4).

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31. Section 6.3.8 shall be amended and replaced in its entirety as follows:

6.3.8 Within ninety (90) Calendar Days of a notification from ASES that ASES has identified a Prevalent Non-English Language other than Spanish or English (with “Prevalent Non-English Language” defined as a language that is the primary language of more than five percent (5%) of the population of Puerto Rico), all written materials provided to Enrollees and Potential Enrollees shall be translated into and made available in such language.

32. Section 6.4.1 shall be amended and replaced in its entirety as follows:

6.4.1 The Contractor shall produce at its sole cost, and shall mail or make electronically available, subject to the requirements of Section 6.9.8 and 6.9.9, to all new Enrollees, an Enrollee Handbook including information on physical health, Behavioral Health, and all other Covered Services offered under the GHP.    The Contractor shall distribute the Handbook either simultaneously with the notice of Enrollment referenced in Section 5.2.5.3 or within five (5) Calendar Days of sending the notice of Enrollment via surface mail.

33. Section 6.4.3 shall be amended and replaced in its entirety as follows:

6.4.3 The Contractor shall either:

6.4.3.1 Mail or make electronically available, subject to the requirements of Sections 6.9.8 and 6.9.9, to all Enrollees an Enrollee Handbook on at least an annual basis, after the initial distribution of the Handbook at Enrollment; or

6.4.3.2 At least annually, as required by 42 CFR 438.10, mail or make electronically available, subject to the requirements of Sections 6.9.8 and 6.9.9, to all Enrollees a Handbook supplement that includes Information on the following:

6.4.3.2.1 The Contractor’s service area;

6.4.3.2.2 Benefits covered under the GHP;

6.4.3.2.3 Any cost-sharing imposed by the Contractor; and

6.4.3.2.4 To the extent available, quality and performance indicators, including Enrollee satisfaction.

6.4.3.3 The Contractor is not required to mail an Enrollee Handbook to an Enrollee who may have been disenrolled and subsequently reenrolled if Enrollee was provided a Enrollee Handbook within the past year.  The Contractor is also not required to mail an Enrollee Handbook to new Enrollees under the age of twenty-one (21) if an Enrollee Handbook has been mailed within the past year to a member of that Enrollee’s household.  However, this exception does not apply to pregnant Enrollees under the age of twenty-one (21).

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34. Section 6.4.5.9 shall be amended and replaced in its entirety as follows:

6.4.5.9 Information on the amount, duration and scope of Benefits and Covered Services, including how the scope of Benefits and services differs between Medicaid- and CHIP Eligibles and Other Eligible Persons.  This must include Information on the EPSDT Benefit and how Enrollees under the age of twentyone (21) and entitled to the EPSDT Benefit may access component services;

35. Section 6.4.5.12 shall be amended and replaced in its entirety as follows:

6.4.5.12 An explanation of any service limitations or exclusions from coverage, including any restrictions on the Enrollee’s freedom of choice among network Providers;

36. Section 6.4.5.27.3.2 shall be amended and replaced in its entirety as follows:

6.4.5.27.3.2 No Co-Payments shall be charged for Medicaid and CHIP children under twenty-one (21) years under any circumstances.

37. Section 6.4.5.29.9 shall be amended and replaced in its entirety as follows:

6.4.5.29.9 Information on the family planning services and supplies, including the extent to which, and how, Enrollees may obtain such services or supplies from out-of-network providers, and that an Enrollee cannot be required to obtain a referral before choosing a family planning Provider.

38. Immediately following Section 6.4.5.29.9, new Sections 6.4.5.29.10 and 6.4.5.29.11 shall be inserted stating as follows:

6.4.5.29.10 Information on non-coverage of counseling or referral services based on Contractor’s moral or religious objections, as specified in Section 7.13 and how to access these services from ASES; and

6.4.5.29.11 Instructions on how to access oral or written translation services, Information in alternative formats, and auxiliary aids and services, as specified in Sections 6.3 and 6.11.

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39. Section 6.5.1.16 shall be amended and replaced in its entirety as follows:

6.5.1.16 Only be responsible for cost-sharing in accordance with 42 CFR 447.50 through 42 CFR 447.82 and as permitted by the Puerto Rico Medicaid and CHIP State Plans and Puerto Rico law as applicable to the Enrollee.

40. Section 6.6.1 shall be amended and replaced in its entirety as follows:

6.6.1 The Contractor shall develop, maintain, and mail or make electronically available, subject to the requirements of Sections 6.9.8 and 6.9.9 to all new Enrollees a Provider Directory that includes Information on both physical and Behavioral Health Providers under the GHP.   The Contractor shall distribute the Provider Directory, within five (5) Calendar Days of sending the notice of Enrollment referenced in Section 5.2.5.3.

6.6.1.1 The Contractor is not required to mail a Provider Directory to an Enrollee who may have been disenrolled and subsequently reenrolled if Enrollee was provided a Provider Directory within the past year.  The Contractor is also not required to mail a Provider Directory to new Enrollees under the age of twenty-one (21) if a Provider Directory has been mailed within the past year to a member of that Enrollee’s household.  However, this exception does not apply to pregnant Enrollees under the age of twentyone (21).

41. Section 6.6.2 shall be amended and replaced in its entirety as follows:

6.6.2 The Contractor shall update the paper Provider Directory once a month and distribute it to Enrollees upon Enrollee request.

42. Section 6.6.3 shall be amended and replaced in its entirety as follows:

6.6.3 The Contractor shall make the Provider Directory available on its website in a machine readable file and format as specified by CMS.

43. Section 6.6.4 shall be amended and replaced in its entirety as follows:

6.6.4 The Provider Directory shall include the names, provider group affiliations, locations, office hours, telephone numbers, websites, cultural and linguistic capabilities, completion of Cultural Competency training, and accommodations for people with physical disabilities of current Network Providers.  This includes, at a minimum, Information sorted by Service Region on PCPs, specialists, dentists, FQHCs and RHCs, Behavioral Health Providers, and pharmacies in each Service Region, hospitals, including locations of emergency settings and Post-Stabilization Services, with the name, location, hours of operation, and telephone number of each facility/setting.  The Provider Directory shall also identify all Network Providers that are not accepting new patients. Any subcontractors of ASES, such as the PBM, will collaborate with the Contractor to provide information in a format mutually agreed upon for the generation of the Provider Directory.

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44. Section 6.7.2.10 shall be amended and replaced in its entirety as follows:

6.7.2.10 The applicable Co-Payment levels for various services outside the Enrollee’s PPN and the assurance that no Co-Payment will be charged for a Medicaid Eligible Person and for CHIP children under twenty-one (21) years under any circumstances;

45. Immediately following Section 6.9.7, new Sections 6.9.8 and 6.9.9 shall be inserted stating as follows:

6.9.8 Any Enrollee Information required under 42 CFR 438.10, including the Enrollee Handbook, Provider Directory, and Enrollee notices, may not be provided electronically or on the Contractor’s website unless such Information (1) is readily accessible, (2) is placed on the Contractor’s website in a prominent location, (3) is provided in a form that can be electronically retained and printed, and (4) includes notice to the Enrollee that the Information is available in paper form without charge and can be provided upon request within five (5) Business Days.

6.9.9 The Enrollee Handbook and Provider Directory may be provided electronically instead of paper form if all required elements of Section 6.9.8 are satisfied.  However, the Contractor must provide the Enrollee Handbook and Provider Directory in paper form upon request by the Enrollee at no charge and within five (5) Business Days.  If the Enrollee Handbook is provided by e-mail, the Contractor must first obtain the Enrollee’s agreement to receive the Enrollee Handbook by e-mail.  If the Enrollee Handbook is posted on the Contractor’s website, the Contractor must first advise the Enrollee in paper or electronic form that the information is available on the internet, and must include the applicable website address, provided that Enrollees with disabilities who cannot access this information online are provided auxiliary aids and services upon request and at no cost.

46. Section 6.10.1 shall be amended and replaced in its entirety as follows:

6.10.1 In accordance with 42 CFR 438.206, the Contractor shall have a comprehensive written Cultural Competency plan describing how the Contractor will ensure that services are provided in a culturally competent manner to all Enrollees.  The Cultural Competency plan must describe how the Providers, individuals, and systems within the Contractor’s Plan will effectively provide services to people of all diverse cultural and ethnic backgrounds, disabilities, and regardless of gender, sexual orientation, gender identity, or religion in a manner that recognizes values, affirms, and respects the worth of the individual Enrollees and protects and preserves the dignity of each individual.

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47. Section 6.11.1 shall be amended and replaced in its entirety as follows:

6.11.1 The Contractor shall provide oral interpreter services to any Enrollee or Potential Enrollee who speaks any language other than English or Spanish as his or her primary language, regardless of whether the Enrollee or Potential Enrollee speaks a language that meets the threshold of a Prevalent Non-English Language.  This also includes the use of auxiliary aids and services such as TTY/TDY and the use of American Sign Language. The Contractor is required to notify its Enrollees of the availability of oral interpretation services and to inform them of how to access oral interpretation services.  There shall be no charge to an Enrollee or Potential Enrollee for interpreter services or other auxiliary aids.

48. Section 6.14.1 shall be amended and replaced in its entirety as follows:

6.14.1 Prohibited Activities.  The Contractor is prohibited from engaging in the following activities:

6.14.1.1 Directly or indirectly engaging in door-to-door, telephone, e-mail, texting or other Cold-Call Marketing activities;

6.14.1.2 Offering any favors, inducements or gifts, promotions, or other insurance products that are designed to induce Enrollment in the Contractor’s Plan;

6.14.1.3 Distributing plans and materials that contain statements that ASES determines are inaccurate, false, or misleading.  Statements considered false or misleading include, but are not limited to, any assertion or statement (whether written or oral) that the Contractor’s plan is endorsed by the Federal Government or Commonwealth, or similar entity;

6.14.1.4 Distributing materials that, according to ASES, mislead or falsely describe

the Contractor’s Provider Network, the participation or availability of Network Providers, the qualifications and skills of Network Providers (including their bilingual skills); or the hours and location of network services;

6.14.1.5 Seeking to influence Enrollment in conjunction with the sale or offering of any private insurance; and

6.14.1.6 Asserting or stating in writing or verbally that the Enrollee or Potential Enrollee must enroll in the Contractor’s plan to obtain or retain Benefits.

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49. Section 7.1.4.1 shall be amended and replaced in its entirety as follows:

7.1.4.1 The Enrollee paid the Provider for the service. This rule does not apply in circumstances where a Medicaid or CHIP Eligible Enrollee incurs out-ofpocket expenses for Emergency Services provided in the other USA jurisdictions. In such a case, the expenses will be reimbursed under the GHP; or

50. Section 7.5.2.1.19 shall be amended and replaced in its entirety as follows:

7.5.2.1.19 Organ and tissue transplants, except skin, bone and corneal transplants.  Such skin, bone and corneal transplants shall be covered only in accordance with ASES’s written standards providing for similarly situated individuals to be treated alike, and, for any restriction on facilities or practitioners providing such services, to be consistent with the accessibility of high quality care to Enrollees; and

51. Section 7.5.7.11 shall be amended and replaced in its entirety as follows:

7.5.7.11 The Contractor shall be responsible for timely payment for emergency transportation services in the other USA jurisdictions for Enrollees who are Medicaid or CHIP Eligibles, if the emergency transportation is associated with an Emergency Service in the other USA jurisdictions covered under Section 7.5.9.3.1.2 of this Contract.  If, in an extenuating circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for emergency transportation services provided in the other USA jurisdictions, the Contractor shall reimburse the Enrollee for such expenses in a timely manner, and the reimbursement shall be considered a Covered Service.

52. Section 7.5.8.4.7 shall be amended and replaced in its entirety as follows:

7.5.8.4.7 Other FDA approved contraceptive medications or methods not covered by sections 7.5.8.4.5 or 7.5.8.4.6 of the Contract, when it is Medically Necessary and approved through a Prior Authorization or through an exception process and the prescribing Provider can demonstrate at least one of the following situations:

7.5.8.4.7.1 Contra-indication with drugs that are in the FMC or LME that the Enrollee is already taking, and no other methods available in the  FMC or LME  that can be  used  by the  Enrollee.

7.5.8.4.7.2 History of adverse reaction by the Enrollee to the contraceptive methods covered as specified by ASES; or

7.5.8.4.7.3 History of adverse reaction by the Enrollee to the contraceptive medications that are on the FMC or LME.

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53. Immediately following Section 7.5.8.4.7.3, a new Section 7.5.8.5 shall be inserted stating as follows:

7.5.8.5 Maternity services, including family planning and postpartum services, must be covered for a sixty (60) day period, beginning on the day the pregnancy ends.  These services will also be covered for any remaining days in the month in which the sixtieth (60^th) day falls.

54. Section 7.5.9.1 shall be amended and replaced in its entirety as follows:

7.5.9.1 The Contractor shall cover and pay for Emergency Services where necessary to treat an Emergency Medical Condition or a Psychiatric Emergency.  The Contractor shall ensure that Medical and Psychiatric Emergency Services are available twenty-four (24) hours a day, seven (7) days per Week.  The Contractor shall ensure that emergency rooms and other Providers qualified to furnish Emergency Services have appropriate personnel to provide physical and Behavioral Health Services. All Emergency Services must be billed appropriately to the Contractor based on the applicable treatment and site of care.  No Prior Authorization will be required for Emergency Services, and the Contractor shall not deny payment for treatment if a representative of the Contractor instructed the Enrollee to seek Emergency Services.

55. Section 7.5.9.2 shall be amended and replaced in its entirety as follows:

7.5.9.2 Emergency Services shall include, but are not limited to, the following:

7.5.9.2.1 Emergency room visits, including medical attention and routine and necessary services;

7.5.9.2.2 Trauma services;

7.5.9.2.3 Operating room use;

7.5.9.2.4 Respiratory therapy;

7.5.9.2.5 Specialist and sub-specialist treatment when required by the emergency room physician;

7.5.9.2.6 Anesthesia;

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7.5.9.2.7 Surgical material;

7.5.9.2.8 Laboratory tests and X-Rays;

7.5.9.2.9 Post-Stabilization Services, as provided in Section 7.5.9.4 below;

7.5.9.2.10 Care as necessary in the case of a Psychiatric Emergency in an emergency room setting;

7.5.9.2.11 Drugs, medicine and intravenous solutions used in the emergency room; and

7.5.9.2.12 Transfusion of blood and blood plasma services, without limitations, including:

7.5.9.2.12.1 Authologal and irradiated blood;

7.5.9.2.12.2 Monoclonal factor IX with a certified hematologist Referral;

7.5.9.2.12.3 Intermediate purity concentrated ant hemophilic factor (Factor VIII);

7.5.9.2.12.4 Monoclonal type anti-hemophilic factor with a certified hematologist’s authorization; and

7.5.9.2.12.5 Activated protrombine complex (Autoflex and Feiba) with a certified hematologist’s authorization.

56. Section 7.5.9.3 shall be amended and replaced in its entirety as follows:

7.5.9.3 Emergency Services Within and Outside Puerto Rico

7.5.9.3.1 The Contractor shall make Emergency Services available:

7.5.9.3.1.1 For all Enrollees, throughout Puerto Rico, including outside the Contractor’s Service Regions, and notwithstanding whether the Emergency Services Provider is a Network Provider; and

7.5.9.3.1.2 For Medicaid and CHIP Eligibles, in Puerto Rico or in the other USA jurisdictions, when the services are Medically Necessary and could not be anticipated, notwithstanding that Emergency Services Providers outside of Puerto Rico are not Network Providers.  The Contractor shall be responsible for fulfilling payment for Emergency Services rendered in the other USA jurisdictions in a timely manner.  If, in an extenuating circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for Emergency Services provided in the other USA jurisdictions, the Contractor shall reimburse the Enrollee for such expenses in a timely manner, and the reimbursement shall be considered a Covered Service.

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7.5.9.3.2 In covering Emergency Services provided by Puerto Rico Providers outside the Contractor’s Network, or by Providers in the other USA jurisdictions, the Contractor shall pay the Provider at least the average rate paid to Network Providers.

57. Section 7.5.9.4.2 shall be amended and replaced in its entirety as follows:

7.5.9.4.2 An Enrollee who has been treated for an Emergency Medical Condition or Psychiatric Emergency shall not be held liable for any subsequent screening or treatment necessary to stabilize or diagnose the specific condition in order to stabilize the Enrollee.

58. Immediately following Section 7.5.9.4.3.1, a new Section 7.5.9.4.3.2 shall be inserted stating as follows, and the remaining Section 7.5.9.4.3 shall be renumbered accordingly, including any references thereto:

7.5.9.4.3.2 The Contractor must limit cost-sharing for Post-Stabilization Services upon inpatient admission to Enrollees to amounts no greater than what the Contractor would charge Enrollee if services were obtained through the Contractor’s General Network.

59. Section 7.5.9.6.2 shall be amended and replaced in its entirety as follows:

7.5.9.6.2 No Co-Payments shall be charged for Medicaid and CHIP children under twenty-one (21) years of age under any circumstances.

60. Section 7.5.9.7.2 shall be amended and replaced in its entirety as follows:

7.5.9.7.2 The Contractor shall not refuse to cover an Emergency Medical Condition or a Psychiatric Emergency based on the emergency room Provider, hospital, or fiscal Agent not notifying the Enrollee’s PCP or the Contractor of the Enrollee’s screening or treatment within ten (10) Calendar Days following the Enrollee’s presentation for Emergency Services.

61. Section 7.5.12.1 shall be amended and replaced in its entirety as follows:

7.5.12.1 The Contractor shall provide in accordance with Section 1927 of the Social Security Act pharmacy services under the GHP, including the following:

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7.5.12.1.1 All costs related to prescribed medications for Enrollees, excluding the Enrollee’s Co-Payment where applicable;

7.5.12.1.2 Drugs on the Formulary of Medications Covered (FMC);

7.5.12.1.3 Drugs included on the LME, but not in the FMC (through the exceptions process explained in Section 7.5.12.10); and

7.5.12.1.4 In some instances, through the exceptions process, drugs that are not included on either the FMC or the LME.

62. Section 7.5.12.4.1 shall be amended and replaced in its entirety as follows:

7.5.12.4.1 Consistent with the requirements of Section 1927(d)(5) of the Social Security Act, some or all prescription drugs may be subject to Prior Authorization, which shall be implemented and managed by the PBM or the Contractor, according to policies and procedures established by the ASES Pharmacy and Therapeutic (“P&T”) Committee and decided upon in consultation with the Contractor when applicable.

63. Section 7.5.12.4.2.1 shall be amended and replaced in its entirety as follows:

7.5.12.4.2.1 The decision whether to grant a Prior Authorization of a prescription must not exceed twenty-four (24) hours from the receipt of the Enrollee’s Service Authorization Request and the standard information needed to make a determination is provided. Such standard information to make a determination includes the following:  the prescription, a supporting statement setting forth the clinical justification and medical necessity for the prescribed medication, and expected duration of treatment, as required by the protocol for the medication. The Contractor shall provide notice on a Prior Authorization request by telephone or other telecommunication device in the required timeframes. In circumstances where the Contractor or the Enrollee’s Provider determines that the Enrollee’s life or health could be endangered by a delay in accessing the prescription drug, the Contractor shall provide at least a seventy-two (72) hour supply of the prescription drug unless the drug is statutorily excluded from coverage under Section 1927(d)(2) of the Social Security Act. In such cases, Prior Authorization must be provided as expeditiously as the Enrollee’s health requires, and no later than within twenty-four (24) hours following the Service Authorization Request.

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64. Section 7.5.12.10.1.2 shall be amended and replaced in its entirety as follows:

7.5.12.10.1.2 The Contractor shall cover a drug that is not included on either the FMC or the LME, only as part of an exceptions process, provided that the drug is being prescribed for a use approved by the FDA or for a medically accepted indication, as defined in Section 1927(k)(6) of the Social Security Act for the treatment of the condition.

65. Section 7.5.12.10.2 shall be amended and replaced in its entirety as follows:

7.5.12.10.2 In addition to demonstrating that the drug is being prescribed for a medically accepted indication, as defined in Section 1927(k)(6) of the Social Security Act and as referenced in Section 7.5.12.10.1.2 above, a Provider prescribing a drug not on the FMC or LME must provide the Contractor with the necessary medical documentation to demonstrate that:

7.5.12.10.2.1 The drug does not have any bioequivalent on the market; and

7.5.12.10.2.2 The drug is clinically indicated because of:

7.5.12.10.2.2.1 Contra-indication with drugs that are in the FMC or LME that the Enrollee is already taking, and scientific literature’s indication of the possibility of serious adverse health effects related to the taking the drug;

7.5.12.10.2.2.2 History of adverse reaction by the Enrollee to drugs that are on the FMC or LME;

7.5.12.10.2.2.3 Therapeutic failure of all available alternatives on the FMC or LME; or

7.5.12.10.2.2.4 Other special circumstances.

66. Section 7.5.12.14 shall be amended and replaced in its entirety as follows:

7.5.12.14 Formulary Management Program

7.5.12.14.1 The Contractor shall select two (2) members of its staff to serve on a cross-functional committee, the Pharmacy Benefit Financial Committee, tasked with rebate maximization and/or evaluating recommendations regarding the FMC and LME from the P&T Committee and the PPA and PBM as applicable.  The Pharmacy Benefit Financial Committee will also review the FMC and LME from time to time and evaluate additional recommendations on potential cost-saving pharmacy initiatives, under the direction and approval of ASES.

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7.5.12.14.2 The Contractor shall select a member of its staff to serve on a crossfunctional subcommittee tasked with assisting in the evaluation of additional potential cost-saving pharmacy initiatives as needed.

67. Section 7.5.12.15 shall be amended and replaced in its entirety as follows:

7.5.12.15 Utilization Management and Reports.  The Contractor shall:

7.5.12.15.1 Perform drug Utilization reviews that meet the standards established by both ASES and Federal authorities, including the operation of a drug utilization review program as required in 42 CFR Part 456, Subpart K;

7.5.12.15.2 Develop and distribute protocols that will be subject to ASES approval, when necessary; and

7.5.12.15.3 Provide to ASES annually a detailed description of its drug utilization program activities.

68. Section 7.5.12.16.2 shall be amended and replaced in its entirety as follows:

7.5.12.16.2 The Contractor shall advise Providers that they may not outright deny medication because it is not included on ASES’s FMC or LME.  A medication not on the FMC or LME may be provided through the exceptions process described in Section 7.5.12.10.

69. Section 7.5.12.17 shall be amended and replaced in its entirety as follows:

7.5.12.17 Cooperation with the Pharmacy Program Administrator (“PPA”)

7.5.12.17.1 The Contractor shall receive updates to the FMC and LME from the PPA. The Contractor shall adhere to these updates.

7.5.12.17.2 Any rebates shall be negotiated by the PPA and retained in their entirety by ASES.  The Contractor shall neither negotiate, collect, nor retain any pharmacy rebate for Enrollee Utilization of brand drugs included on ASES’s FMC or LME.

70. Immediately following Section 7.5.12.17.2, a new Section 7.5.12.18 shall be inserted stating as follows:

7.5.12.18 Information on Pharmacy Benefits Coverage.  The Contractor shall provide Information on the FMC and LME in electronic or paper form, including which generic or brand medications are covered, and what formulary tier each medication is on.  Drug lists that are published on the Contractor’s website must be in a machine readable file and format as specified by CMS.

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71. Section 7.7.8 shall be amended and replaced in its entirety as follows:

7.7.8 The Contractor shall complete, monitor, and routinely update a treatment plan for each Enrollee who is registered for Special Coverage at least every twelve (12) months, or when the Enrollee’s circumstances or needs change significantly, or at the request of the Enrollee.

7.7.8.1 The treatment plan shall be developed by the Enrollee’s PCP, with the Enrollee’s participation, and in consultation with any specialists caring for the Enrollee.  The Contractor shall require, in its Provider Contracts with PCPs, that Special Coverage registration treatment plans be submitted to the Contractor for review and approval in a timely manner.

72. Section 7.8.2.3 shall be amended and replaced in its entirety as follows:

7.8.2.3 The Contractor’s Care Management system shall emphasize prevention, continuity of care, and coordination of care, including between settings of care and appropriate discharge planning for short- and long-term hospital and institutional stays.  The system will advocate for, and link Enrollees to, services as necessary across Providers, including community and social support Providers, and settings.  Care Management functions include:

7.8.2.3.1 Assignment of a specific Care Manager to each enrollee qualified for Care Management;

7.8.2.3.2 Management of Enrollee to Care Manager ratios that have been reviewed and approved by ASES;

7.8.2.3.3 Identification of Enrollees who have or may have chronic or severe Behavioral Health needs, including through use of the screening tools MCHAT for the detection of Autism, ASQ, ASQ-SE, Xxxxxxx Scale (ADHD screen), DAST-10, GAD, and PC-PTSD, and other tools available for diagnosis of Behavioral Health disorders;

7.8.2.3.4 Assessment of an Enrollee’s physical and Behavioral Health needs utilizing a standardized needs assessment within thirty (30) Calendar  Days of Referral to Care Management that has been reviewed and given written approval by ASES.  The Contractor shall also make its best efforts to perform this needs assessment for all new Enrollees within ninety (90) Calendar Days of the Effective Date of Enrollment, and to comply with all other requirements for such assessments set forth in 42 CFR 438.208(b);

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7.8.2.3.5 Development of a plan of care within sixty (60) Calendar Days of the needs assessment;

7.8.2.3.6 Referrals and assistance to ensure timely Access to Providers;

7.8.2.3.7 Coordination of care actively linking the Enrollee to Providers, medical services, residential, social, and other support services where deemed necessary;

7.8.2.3.8 Monitoring of the Enrollees needs for assistance and additional services via face-to-face or telephonic contact at least quarterly (based on high- or low-risk;

7.8.2.3.9 Continuity and transition of care; and

7.8.2.3.10 Follow-up and documentation, including the review and/or revision of a plan of care upon reassessment of need, at least every twelve (12) months, or when the Enrollee’s circumstances or needs change significantly, or at the request of the Enrollee. 

73. Section 7.10.1 shall be amended and replaced in its entirety as follows:

7.10.1 In compliance with 42 CFR 438.3 (j)(1) and (2), 42 CFR 422.128(a), 42 CFR 422.128(b), 42 CFR 489.102(a), and Law No. 160 of November 17, 2001, the Contractor shall maintain written policies and procedures for Advance Directives.  Such Advance Directives shall be included in each Enrollee’s Medical Record.  The Contractor shall provide these policies and procedures written at a fourth (4^th) grade reading level in English and Spanish to all Enrollees eighteen (18) years of age and older and shall advise Enrollees of:

7.10.1.1 Their rights under the laws of Puerto Rico, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives;

7.10.1.2 The Contractor’s written policies respecting the implementation of those rights, including a statement of any limitation that incorporates the requirements set forth under 42 CFR 422.128(b)(1)(ii) regarding the implementation of Advance Directives as a matter of conscience; and

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7.10.1.3 The Enrollee’s right to file Complaints concerning noncompliance with Advance Directive requirements directly with ASES or with the Puerto Rico Office of the Patient Advocate.

74. Section 7.11.4.2 shall be amended and replaced in its entirety as follows:

7.11.4.2 No Co-Payments shall be charged for Medicaid and CHIP children under twenty-one (21) years of age under any circumstances.

75. Immediately following Section 7.12.2, new Sections 7.12.3 and 7.12.3.1 shall be inserted stating as follows:

7.12.3 The Contractor must enter into a Coordination of Benefits Agreement with Medicare within sixty (60) days from the Effective Date of the Contract and participate in the automated claims crossover process in order to appropriately allocate reimbursement for Dual Eligible Beneficiaries. Any crossover claims not appropriately reimbursed by the applicable Medicaid program will be considered an Overpayment and shall be reported and returned in accordance with Section 22.1.19.

7.12.3.1 ASES may extend the sixty (60) day time frame set forth in Section 7.12.3 if the Contractor can provide evidence, satisfactory to ASES, that documents the Contractor’s reasonable efforts to enter into a Coordination of Benefits Agreement with Medicare.

76. Section 7.13.2 shall be amended and replaced in its entirety as follows:

7.13.2 The Contractor shall furnish information about the services it does not cover based on a moral or religious objection to ASES with its GHP Program application.  The Contractor acknowledges that such objections will be factored into the calculation of rates paid to the Contractor and, when made during the course of the Contract period, may serve as grounds for recalculation of the rates paid.

77. Section 10.3.1.22 shall be amended and replaced in its entirety as follows:

10.3.1.22 Specify that ASES, CMS, the Office of Inspector General, the Comptroller General, the Medicaid Fraud Control Unit, and their designees, shall have the right at any time to inspect, evaluate, and audit any pertinent records or documents, and may inspect the premises, physical facilities, and equipment where activities or work related to the GHP program is conducted.  The right to audit exists for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later;

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78. Section 10.4.3 shall be amended and replaced in its entirety as follows:

10.4.3 The Contractor shall, within fifteen (15) Calendar Days of issuance of a notice of termination to a Provider, provide written notice of the termination to Enrollees who received his or her Primary Care from, or was seen on a regular basis by, the terminated Provider, and shall assist the Enrollee as needed in finding a new Provider.

79. Section 10.5.1.5 shall be amended and replaced in its entirety as follows:

10.5.1.5 With the exceptions noted below, the Contractor shall negotiate rates with Providers, and such rates shall be specified in the Provider Contract.  Payment arrangements may take any form allowed under Federal law and the laws of Puerto Rico, including Capitation payments, Fee-for-Service payment, and salary, if any, subject to Section 10.6 concerning permitted risk arrangements.  However, the Contractor must consider the use of maximum provider reimbursement rates equaling eighty percent (80%) of the 2016 Medicare fee schedule for the reimbursement of non-facility professional services related to cardiology and nuclear medicine services, and seventy percent (70%) of the 2016 Medicare fee schedule for the reimbursement of non-facility professional services related to all other specialties except radiation oncology, hematology/oncology, urology, interventional radiology and dialysis services.  Any use of the 2016 Medicare fee schedule to set maximum provider reimbursement rates shall not obligate the Contractor to increase current provider reimbursement rates that have been previously negotiated. The Contractor shall inform ASES in writing when it enters any Provider payment arrangement other than Fee-for-Service.

80. Section 10.5.1.6 shall be amended and replaced in its entirety as follows:

10.5.1.6 Any Capitation payment made by the Contractor to Providers shall be based on sound actuarial methods in accordance with 42 C.F.R. 438.4. The Contractor shall submit data on the basis of which ASES will certify the actuarial soundness of Capitation payments, including the base data generated by the Contractor. All Provider payments by the Contractor shall be reasonable, and the amount paid shall not jeopardize or infringe upon the quality of the services provided.

81. Section 11.2.5 shall be amended and replaced in its entirety as follows:

11.2.5 If the Contractor delegates any of its utilization management responsibilities under this Section 11.2 or 11.4 to any delegated Utilization Management agent or Subcontractor, such agent or Subcontractor must also comply with written policies and procedures for processing requests for authorizations of services in accordance with 42 CFR 438.210(b)(1).

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82. Section 11.4.1.5 shall be amended and replaced in its entirety as follows:

11.4.1.5 Neither the Contractor nor any Provider or Subcontractor may impose a requirement that Referrals be submitted for the approval of committees, boards, Medical Directors, etc.  The Contractor shall strictly enforce this directive and shall issue Administrative Referrals (see Section 11.4.1.4) whenever it deems medically necessary.

83. Section 11.4.2.1.1 shall be amended and replaced in its entirety as follows:

11.4.2.1.1 With the exception of Prior Authorization of covered prescription drugs as described in Section 7.5.12.4.2, the decision to grant or deny a Prior Authorization must not exceed seventy-two (72) hours from the time of the Enrollee’s Service Authorization Request for all Covered Services; except that, where the Contractor or the Enrollee’s Provider determines that the Enrollee’s life or health could be endangered by a delay in accessing services, the Prior Authorization must be provided as expeditiously as the Enrollee’s health requires, and no later than twenty-four (24) hours from the Service Authorization Request.

84. Section 11.4.6.1 shall be amended and replaced in its entirety as follows:

11.4.6.1 Neither a Referral nor Prior Authorization shall be required for any Emergency Service, no matter whether the Provider is within the PPN, and notwithstanding whether there is ultimately a determination that the condition for which the Enrollee sought treatment  from an Emergency Services Provider was not an Emergency Medical Condition or Psychiatric Emergency.

85. Section 12.1.4 shall be amended and replaced in its entirety as follows:

12.1.4 ASES, in strict compliance with 42 CFR 438.340 and other Federal and Puerto Rico regulations, shall evaluate the delivery of health care by the Contractor. Such quality monitoring shall include monitoring of all the Contractor’s Quality Management/Quality Improvement (“QM/QI”) programs described in this Article 12 of this Contract.

86. Section 12.2.2 shall be amended and replaced in its entirety as follows:

12.2.2 For Medicaid and CHIP Eligibles, the QAPI program shall be in compliance with Federal requirements specified at 42 CFR 438.330.

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87. Section 12.2.3.1 shall be amended and replaced in its entirety as follows:

12.2.3.1 A method of monitoring, analyzing, evaluating, and improving the delivery, quality and appropriateness of health care furnished to all Enrollees (including over, under, and inappropriate Utilization of services) and including those with special health care needs, as defined by ASES in the quality strategy;

88. Immediately following Section 12.2.6, a new Section 12.2.7 shall be inserted stating as follows:

12.2.7 As per 42 CFR 438.332(a) and (b), the Contractor shall inform ASES as to whether it has been accredited by a private, independent accrediting entity, and if so, shall provide or authorize the accrediting entity to provide ASES, as applicable, a copy of its most recent accreditation review (including its accreditation status, expiration date of the accreditation, and survey type and level) recommended actions or improvements, corrective action plans, and summaries of findings.

89. Section 12.3.1 shall be amended and replaced in its entirety as follows:

12.3.1 At a minimum, the Contractor shall have a PIPs work plan and activities that are consistent with Federal and Puerto Rico statutes, regulations, and Quality Assessment and Performance Improvement Program requirements for pursuant to 42 C.F.R. 438.330. For more detailed information refer to the “EQR Managed Care Organization Protocol” available at xxxx://xxx.xxxxxxxx.xxx/ Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Quality-ofCare-External- Quality-Review.html.

90. Section 12.7.1 shall be amended and replaced in its entirety as follows:

12.7.1 In compliance with Federal requirements at 42 CFR 438.358, ASES will contract with an External Quality Review Organization (“EQRO”) to conduct annual, external, independent reviews of the quality outcomes, timeliness of, and Access to, the services covered in this Contract.  The Contractor shall collaborate with ASES’s EQRO to develop studies, surveys, and other analytic activities to assess the quality of care and services provided to Enrollees and to identify opportunities for program improvement.  To facilitate this process the Contractor shall supply Data, including but not limited to Claims Data and Medical Records, to the EQRO. Upon the request of ASES, the Contractor shall provide its protocols for providing Information, participating in review activities, and using the results of the reviews to improve the quality of the services and programs provided to Enrollees.

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91. Section 13.1.2 shall be amended and replaced in its entirety as follows:

13.1.2 For Medicaid and CHIP Eligibles, the Contractor’s internal controls, policies, and procedures shall comply with all Federal requirements regarding Fraud, Waste, and Abuse and program integrity, including but not limited to Sections 1128, 1128A, 1156, 1842(j)(2), and 1902(a)(68) of the Social Security Act, Section 6402(h) of PPACA, 42 CFR 438.608, the CMS Medicaid Integrity program, and the Deficit Reduction Act of 2005.  The Contractor shall exercise diligent efforts to ensure that no payments are made to any person or entity that has been excluded from participation in Federal health care programs.  (See State Medicaid Director Letter #09-001, January 16, 2009.)

92. Section 13.2.2.2 shall be amended and replaced in its entirety as follows:

13.2.2.2 Require the designation of a compliance officer and a compliance committee that are accountable to the Contractor’s senior management.  The compliance officer must have express authority to provide unfiltered reports directly to the Contractor’s most senior leader and governing body;

93. Section 13.2.3 shall be amended and replaced in its entirety as follows:

13.2.3 The Contractor, and any Subcontractors delegated the responsibility by the Contractor for coverage of services and payment of claims under this Contract, shall include in all employee handbooks a specific discussion of the False Claims Act and its Fraud, Waste, and Abuse policies and procedures, the rights of employees to be protected as whistleblowers, and the Contractor and Subcontractor’s procedures for detecting and preventing Fraud, Waste, and Abuse.

94. Section 13.4.1.2.3 shall be amended and replaced in its entirety as follows:

13.4.1.2.3 Any Subcontractor or other person with an employment, consulting, or other arrangement with the Contractor for the provision of items or services that are significant and material the Contractor’s obligations under this Contract.

95. Section 13.5.3 shall be amended and replaced in its entirety as follows:

13.5.3 The Contractor shall Immediately report to ASES the identity of any Provider or other person who is debarred, suspended, or otherwise prohibited from participating in procurement activities.  ASES shall promptly notify the Secretary of Health and Human Services of the noncompliance, as required by 42 CFR 438.610(d).

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96. Section 14.1.1 shall be amended and replaced in its entirety as follows:

14.1.1 In accordance with 42 CFR Part 438, Subpart F, the Contractor shall establish an internal Grievance System under which Enrollees, or Providers acting on their behalf, may express dissatisfaction with the Contractor or challenge the denial of coverage of, or payment for, Covered Services.

97. Section 14.1.10 shall be amended and replaced in its entirety as follows:

14.1.10 The Contractor shall include information regarding the Grievance System in the Provider Guidelines and upon joining the Contractor’s Network, all Providers and Subcontractors, as applicable shall receive training and education regarding the Contractor’s Grievance System, which includes but is not limited to:

14.1.10.1 The Enrollee’s right to file Complaints, Grievances and, Appeals and the requirements and timeframes for filing;

14.1.10.2 The Enrollee’s right to file a Complaint, Grievance, or Appeal with the Patient Advocate Office;

14.1.10.3 The Enrollee’s right to an Administrative Law Hearing, how to obtain an Administrative Law Hearing, and representation rules at an Administrative Law Hearing;

14.1.10.4 The availability of assistance in filing a Complaint, Grievance, or Appeal;

14.1.10.5 The toll-free numbers to file oral Complaints, Grievances, and Appeals;

14.1.10.6 The Enrollee’s right to request continuation of Benefits during an Appeal, or an Administrative Law Hearing filing,  and that  if the Contractor’s Adverse Benefit Determination is upheld in an Administrative Law Hearing, the Enrollee may be liable for the cost of any continued Benefits; and

14.1.10.7 Any Puerto Rico-determined Provider Appeal rights to challenge the failure of the Contractor to cover a service.

98. Section 14.1.14 shall be amended and replaced in its entirety as follows:

14.1.14 The Contractor shall ensure that the individuals who make decisions on Grievances and Appeals are individuals:

14.1.14.1 Who were not involved in any previous level of review or decisionmaking, or who were subordinates of any individual involved in a previous review or decision-making;

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14.1.14.2 Who, if deciding any of the following, are Providers who have the appropriate clinical expertise, as determined by ASES, in treating the Enrollee’s condition or disease if deciding any of the following:

14.1.14.2.1 An Appeal of a denial that is based on lack of Medical Necessity;

14.1.14.2.2 A Grievance regarding denial of expedited resolutions of Appeal; and

14.1.14.2.3 Any Grievance or Appeal that involves clinical issues; and

14.1.14.3 Who take into account all comments, documents, records and other information submitted by Enrollee without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination.

99. Section 14.1.16 shall be amended and replaced in its entirety as follows:

14.1.16 The Contractor and Subcontractors, as applicable, shall have a system in place to collect, analyze, and integrate Data regarding Complaints, Grievances, and Appeals. At a minimum, the record must be accessible to ASES and available upon request to CMS and include the following information:

14.1.16.1 Date Complaint, Grievance, or Appeal was received;

14.1.16.2 Enrollee’s name;

14.1.16.3 Enrollee’s Medicaid ID number, if applicable;

14.1.16.4 Name of the individual filing the Complaint, Grievance, or Appeal on behalf of the Enrollee;

14.1.16.5 Date of acknowledgement that receipt of Grievance or Appeal was mailed to the Enrollee;

14.1.16.6 Summary of Complaint, Grievance, or Appeal;

14.1.16.7 Date of each review or review meeting and resolution at each level, if applicable;

14.1.16.8 Date Notice of Disposition or Notice of Adverse Benefit Determination was mailed to the Enrollee;

14.1.16.9 Corrective Action required; and

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14.1.16.10 Date of resolution.

100. Section 14.2.3 shall be amended and replaced in its entirety as follows:

14.2.3 An Enrollee or Enrollee’s Authorized Representative shall file a Complaint within fifteen (15) Calendar Days after the date of occurrence that initiated the Complaint. If the Enrollee or Enrollee’s Authorized Representative attempts to file a Complaint beyond the fifteen (15) Calendar Days, the Contractor shall instruct the Enrollee or Enrollee’s Authorized Representative to file a Grievance.

101. Section 14.2.5 shall be amended and replaced in its entirety as follows:

14.2.5 The Contractor shall resolve each Complaint within seventy-two (72) hours of the time the Contractor received the initial Complaint, whether orally or in writing.  If the Complaint is not resolved within this timeframe, the Complaint shall be treated as a Grievance. The Contractor cannot require the Enrollee to file a separate Grievance before proceeding to Appeal.

102. Section 14.3.2 shall be amended and replaced in its entirety as follows:

14.3.2 An Enrollee may file a Grievance at any time.

103. Section 14.3.4 shall be amended and replaced in its entirety as follows:

14.3.4 The Contractor shall provide written notice of the disposition of the Grievance as expeditiously as the Enrollee’s health condition requires, but in any event, within ninety (90) Calendar Days from the day the Contractor receives the Grievance. If the Grievance originated from a Complaint that was not resolved within the seventy-two (72) hour timeframe set forth in Section 14.2.5, the time already spent by the Contractor to resolve the original Complaint must be deducted from this ninety (90) Calendar Day timeframe.

104. Section 14.3.6 shall be amended and replaced in its entirety as follows:

14.3.6 The Contractor may extend the timeframe to provide a written notice of disposition of a Grievance for up to fourteen (14) Calendar Days if the Enrollee requests the extension or the Contractor demonstrates (to the satisfaction of ASES, upon its request) that there is a need for additional Information and how the delay is in the Enrollee’s interest.  If the Contractor extends the timeframe, it shall, for any extension not requested by the Enrollee:

14.3.6.1 Make reasonable efforts to provide Enrollee prompt oral notice of the delay;

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14.3.6.2 Give the Enrollee written notice of the reason for the delay within two (2) Calendar Days; and

14.3.6.3 Inform the Enrollee of the right to file a Grievance if the Enrollee  disagrees with the decision to extend the timeframe; and .

105. Section 14.4.1 shall be amended and replaced in its entirety as follows:

14.4.1 Pursuant to 42 CFR 438.210(a), the Contractor shall provide written notice to the requesting Provider and the Enrollee of any decision by the Contractor to deny a Service Authorization Request, or to authorize a service in an amount, duration, or scope that is less than requested. The Contractor’s notices shall meet the requirements of 42 CFR 438.404.

106. Immediately following Section 14.4.3.2, a new Section 14.4.3.3 shall be inserted stating as follows, and the remaining Section 14.4.3 shall be renumbered accordingly, including any references thereto:

14.3.3.3 The right of Enrollee to be provided, upon request and at no expense to Enrollee, reasonable access to and copies of all documents, records and other information relevant to the Adverse Benefit Determination.

107. Section 14.4.4.4 shall be amended and replaced in its entirety as follows:

14.4.4.4 If the Contractor extends the timeframe for the authorization decision and issuance of Notice of Adverse Benefit Determination according to Section 14.4.3, the Contractor shall give the Enrollee written notice of the reasons for the decision to extend if he or she did not request the extension and the Enrollee’s right to file a Grievance if he or she disagrees with that decision. The Contractor shall issue and carry out its determination as expeditiously as the Enrollee’s health requires and no later than the date the extension expires.

108. Section 14.5.3 shall be amended and replaced in its entirety as follows:

14.5.3 The requirements of the Appeal process shall be binding for all types of Appeals, including expedited Appeals, unless otherwise established for expedited Appeals.  Only one (1) level of Appeal is permitted before proceeding to an Administrative Law Hearing.

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109. Section 14.5.7 shall be amended and replaced in its entirety as follows:

14.5.7 The Appeals process shall provide the Enrollee, the Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, opportunity, before and during the Appeals process, to examine the Enrollee’s case file, including Medical Records, and any other documents and records considered during the Appeals process and provide copies of documents contained therein without charge and sufficiently in advance of the resolution timeframe for the Appeal.

110. Section 14.5.9 shall be amended and replaced in its entirety as follows:

14.5.9 The Contractor shall resolve each standard Appeal and provide written notice of the disposition, as expeditiously as the Enrollee’s health condition requires but no more than  thirty (30) Calendar Days from the date the Contractor receives the Appeal.

111. Section 14.5.11 shall be amended and replaced in its entirety as follows:

14.5.11 The Contractor shall resolve each expedited Appeal and provide a written Notice of Disposition, as expeditiously as the Enrollee’s health condition requires, but no longer than seventy-two (72) hours after the Contractor receives the Appeal and make reasonable efforts to provide oral notice.

112. Section 14.5.12 shall be amended and replaced in its entirety as follows:

14.5.12 If the Contractor denies an Enrollee’s request for expedited review, it shall utilize the timeframe for standard Appeals specified herein and shall make reasonable efforts to give the Enrollee prompt oral notice of the denial, and follow-up within two (2) Calendar Days with a written notice. If the Enrollee disagrees with the decision to extend the prescribed timeframe, he or she shall be informed of the right to file a Grievance and the Grievance shall be resolved within twenty-four (24) hours.  The Contractor shall also make reasonable efforts to provide oral notice for resolution of an expedited review of an Appeal.

113. Section 14.5.13 shall be amended and replaced in its entirety as follows:

14.5.13 The Contractor may extend the timeframe for standard or expedited resolution of the Appeal by up to fourteen (14) Calendar Days if the Enrollee, Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, requests the extension or the Contractor demonstrates (to the satisfaction of ASES, upon its request) that there is need for additional information and how the delay is in the Enrollee’s interest.  If the Contractor extends the timeframe, it shall, for any extension not requested by the Enrollee:

14.5.13.1 Make reasonable efforts to provide Enrollee prompt oral notice of the delay;

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14.5.13.2 Give the Enrollee written notice of the reason for the delay within two (2) Calendar Days;

14.5.13.3 Inform the Enrollee of the right to file a Grievance if the Enrollee disagrees with the decision to extend the timeframe; and

14.5.13.4 Resolve the Appeal as expeditiously as the Enrollee’s health condition requires, and no later than the date the extension expires.

114. Section 14.5.15 shall be amended and replaced in its entirety as follows:

14.5.15 The written notice of Disposition shall be in a format and language that, at a minimum, meets applicable notification standards and shall include:

14.5.15.1 The results and date of the Appeal resolution; and

14.5.15.2 For decisions not wholly in the Enrollee’s favor:

14.5.15.3 The right to request an Administrative Law Hearing;

14.5.15.4 How to request an Administrative Law Hearing;

14.5.15.5 The right to continue to receive Benefits pending an Administrative Law Hearing;

14.5.15.6 How to request the continuation of Benefits; and

14.5.15.7 Notification that if the Contractor’s Adverse Benefit Determination is upheld in a hearing, the Enrollee may liable for the cost of any continued Benefits.

115. Section 14.6.1 shall be amended and replaced in its entirety as follows:

14.6.1 The Contractor is responsible for explaining the Enrollee’s right to and the procedures for an Administrative Law Hearing, including that the Enrollee must exhaust the Contractor’s Grievance, Complaints, and Appeals process before requesting an Administrative Law Hearing.  However, if the Contractor fails to adhere to all notice and timing requirements set forth in 42 CFR 438.408, the Enrollee is deemed to have exhausted the Contractor’s Appeals process and may proceed with initiating an Administrative Law Hearing.

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116. Section 14.6.4 shall be amended and replaced in its entirety as follows:

14.6.4 ASES shall permit the Enrollee to request an Administrative Law Hearing within one hundred and twenty (120) Calendar Days of the Notice of Resolution of the Appeal.

117. Section 14.7.2 shall be amended and replaced in its entirety as follows:

14.7.2 The Contractor shall continue the Enrollee’s Benefits if the Enrollee or the Enrollee’s Authorized Representative files the Appeal within sixty (60) Calendar Days following the date on the Adverse Benefit Determination notice; the Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; the services were ordered by an authorized Provider; the period covered by the original authorization has not expired; and the Enrollee timely files for continuation of the Benefits.

118. Section 14.7.5 shall be amended and replaced in its entirety as follows:

14.7.5 If the Contractor or ASES reverses a decision to deny, limit, or delay services that were not furnished while the Appeal / Administrative Law Hearing was pending, the Contractor shall authorize or provide the disputed services promptly and as expeditiously as the Enrollee’s health condition requires but no later than seventy-two (72) hours from the date the Contractor receives notice reversing the determination.

119. Section 16.4 shall be amended and replaced in its entirety as follows:

16.4 The Contractor shall not pay any Claim submitted by a Provider during the period of time when such Provider is excluded or suspended from the Medicare, Medicaid, CHIP or Title V Maternal and Child Health Services Block Grant programs for Fraud, Waste, or Abuse or otherwise included on the Department of Health and Human Services Office of the Inspector General exclusions list, or employs someone on this list, and when the Contractor knew, or had reason to know, of that exclusion, after a reasonable time period after reasonable notice has been furnished to the Contractor.  The Contractor shall not pay any Claim submitted by a Provider that is on Payment Hold.

120. Section 16.6 shall be amended and replaced in its entirety as follows:

16.6 Network Providers may not receive payment other than by the Contractor for services covered under this Agreement, except when such payments are specifically required to be made by ASES under Title XIX of the Social Security Act, or its implementing regulations, or when ASES makes direct payments to Network Providers for graduate medical education costs approved under the Medicaid State Plan. The Contractor is prohibited from making payment on any amount expended for any  item or service not covered under the Medicaid State Plan.

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121. Section 16.13.2 shall be amended and replaced in its entirety as follows:

16.13.2 The Provider will have a period of sixty (60) Calendar Days to make the requested payment, to agree to Contractor retention of said payment, or to dispute the recovery action following the process described in Section 16.11.6.

122. Section 17.2.4.6 shall be amended and replaced in its entirety as follows:

17.2.4.6 Be maintained for ten (10) years in either live and/or archival systems.  The duration of the retention period may be extended at the discretion of and as indicated to the Contractor by ASES as needed for ongoing audits or other purposes.

123. Section 17.3.3 shall be amended and replaced in its entirety as follows:

17.3.3 Each month the Contractor shall generate Encounter Data files from its Claims management system(s) and/or other sources. Such files must be submitted in standardized Accredited Standards Committee (ASC) X12N 837 and National Council for Prescription Drug Programs (NCPDP) formats, and the ASC X12N 835 format as appropriate. The files will contain settled Claims and Claim adjustments and Encounter Data from Providers for the most recent month for which all such transactions were completed.  The Contractor shall provide these files electronically to ASES and/or its Agent at a frequency and level of detail to be specified by CMS and ASES based on program administration, oversight, and program integrity needs, and in adherence to the procedure, content standards and format indicated in Attachment 9.  The Contractor shall make changes or corrections to any systems, processes or Data transmission formats as needed to comply with Encounter Data quality standards as originally defined or subsequently amended.

124. Immediately following Section 17.3.5, a new Section 17.3.6 shall be inserted stating as follows:

17.3.6 Revisions to the Modified Adjusted Gross Income (“MAGI”) are expected to be implemented on July 1, 2017.  To comply with MAGI requirements, Contractor must update its Information Systems in accordance with the procedures and timelines set forth in Attachment 9 and any other subsequent guidance issued by ASES.

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125. Section 18.1.1 shall be amended and replaced in its entirety as follows:

18.1.1 ASES may, at its discretion, require the Contractor to submit additional reports or any other data, documentation or information relating to the performance of the Contractor’s obligations both on an ad hoc and recurring basis as required by ASES or CMS. If ASES requests any revisions to the reports already submitted, the Contractor shall make the changes and re-submit the reports, according to the time period and format specified by ASES.

126. Immediately following Section 18.2.5.6, a new Section 18.2.5.7 shall be inserted stating as follows:

18.2.5.7 The Contractor shall submit a quarterly Provider Preventable Conditions Report describing any identified Provider preventable conditions as defined in Sections 7.1.1.1.1 and 7.1.1.1.2 of this Contract.  The report shall include but not be limited to, a description of each identified instance of a provider preventable condition, the name of the applicable Provider, and a summary of corrective actions taken by the Contractor or Provider to address any underlying causes of the provider preventable condition.

127. Section 19.1.4.3.3 shall be amended and replaced in its entirety as follows:

19.1.4.3.3 The Contractor has taken actions that have caused substantial risk to Enrollees’ health;

128. Section 19.4.1 shall be amended and replaced in its entirety as follows:

19.4.1 The Contractor has the right within fifteen (15) Calendar Days following receipt of the notice of imposition of intermediate sanctions to seek administrative review in writing of ASES’s determination and any such intermediate sanctions, pursuant to Act 72 or under any other applicable law or regulation. This time period can be extended for an additional fifteen (15) days if the Contractor submits a written request that includes a credible explanation of why it needs additional time, the request is received by ASES before the end of the initial period, and ASES has determined that the Contractor’s conduct does not pose a threat to an Enrollee’s health or safety.

129. Section 19.4.5 shall be amended and replaced in its entirety as follows:

19.4.5 In addition to the actions described under Section 19.4.3, the examining officer may recommend the delivery and implementation of a Corrective Action Plan with respect to Contractor’s failure to comply with the terms of this Contract as set forth in ASES’ notice of intermediate sanctions.

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130. Section 19.5 shall be amended and replaced in its entirety as follows:

19.5 Judicial Review - To the extent administrative review is sought by the Contractor pursuant to Section 19.4, the Contractor has the right to seek judicial review of ASES’s actions by the Puerto Rico Court of Appeals, San Xxxx Panel, within thirty (30) Calendar Days of the notice of final determination issued by ASES.

131. Section 22.1.2 shall be amended and replaced in its entirety as follows:

22.1.2 ASES will have the discretion to recoup payments made to the Contractor for ineligible Enrollees, including, but not limited to, the following:

22.1.2.1 Enrollees incorrectly enrolled with more than one Contractor;

22.1.2.2 Enrollees who die prior to the Enrollment month for which the payment was made;

22.1.2.3 Enrollees whom ASES later determines were not eligible for Medicaid during the Enrollment month for which payment was made.

22.1.2.4 Enrollees whom were not domiciled in Puerto Rico during the Enrollment month for which payment was made; or

22.1.2.5 Enrollees whom were incarcerated during the Enrollment month for which payment was made.

132. Section 22.1.5 shall be amended and replaced in its entirety as follows:

22.1.5 The PMPM Payment for Enrollees not enrolled for the full month shall be determined on a pro rata basis by dividing the monthly Capitation amount by the number of days in the month and multiplying the result by the number of days including and following the Effective Date of Enrollment or the number of days prior to and including the Effective Date of Disenrollment, as applicable.  The Contractor is entitled to a PMPM Payment for each Enrollee as of the Effective Date of Enrollment, including the period referred to in Section 5.2.2.  The Contractor is entitled to a PMPM Payment for each Enrollee up to the Effective Date of Disenrollment, including the period referred to in Section 5.3.

133. Section 22.1.17 shall be amended and replaced in its entirety as follows:

22.1.17 The profit of the Contractor and Subcontractors for each fiscal year of the Contract Term shall not exceed two point five percent (2.5 %) of the PMPM Payment (Excess Profit).  In the event that the profit exceeds this amount as a result of the positive impact the high quality services provided by the Contractor and Sub-Contractors had on the Enrollees Health, the Parties shall share the Excess Profit in proportions of fifty percent (50%) for the Contractor and Subcontractors, and fifty percent (50%) for ASES. For the purpose of this section high quality services will be measured on the Contractor’s compliance with eighty-five percent (85%) of the QIP quality metrics as established by ASES in Attachment 19. In the event ASES discovers the existence of Excess Profit by means of an audit during the Control and Supervision Plan or the Contractor does not meet the high quality services standard mentioned in this section, ASES is entitled to one hundred percent (100%) of the Excess Profit.

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22.1.17.1 Excess Profit and any other incentive arrangements between ASES and the Contractor must comply the requirements set forth by CMS in 42 CFR 438.6(b)(2).

134. Section 22.1.18 shall be amended and replaced in its entirety as follows:

22.1.18 The Contractor shall initially determine its Excess Profit for each fiscal year and shall submit a sworn certification annually to attest to the truth and accuracy of its Excess Profit and the assumptions on which it is calculated to ASES. After receipt of the Contractor’s sworn certification, ASES will audit the Contractor’s Excess Profit based on the Contractor’s sworn certification and the Contractor’s and Subcontractors’ audited financial statements submitted annually to ASES pursuant to Sections 23.1.3 and 18.2.9.8 of this Contract, and the validation of the IBNR reserve by ASES’s actuary.  The Excess Profit calculation will include the entire fiscal year (total aggregated earned premium for all Service Regions).  ASES will audit the Excess Profit certified by the Contractor using the actual medical expenses and the contracted administrative fee portion of the PMPM. ASES shall notify the Contractor of ASES’s determination of the Contractor’s Excess Profit within forty-five (45) Calendar Days of receipt by ASES of the Contractor’s audited financial statement.  The Contractor shall remit the portion of Excess Profit payable to ASES within fifteen (15) Calendar Days of receiving the notice of Excess Profit determination from ASES.  The same regulations shall apply to any and all Subcontractors.

135. Immediately following Section 22.1.18, a new Section 22.1.19 shall be inserted stating as follows, and the remaining Section 22.1 shall be renumbered accordingly, including any references thereto:

22.1.19 The Contractor shall include in its calculation of Excess Profit, as reported under this Section 22.1, all of the profit of its partially- or wholly-owned subsidiaries or Affiliates realized from services rendered in relation to this contract (the “Affiliated Profit”), unless the Contractor demonstrates and ASES agrees that the Affiliated Profit did not result from preferential contractual terms included in the Contractor’s contracts or arrangements with its partially- or wholly-owned subsidiaries and Affiliates.

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22.1.19.1 Preferential contractual terms are those that result in a cost or expense that exceeds fair market value, or those that exceed any other terms for the provisioning of same or similar goods and services as would be agreed to by a reasonable person under the same or similar circumstances prevailing at the time the decision was made for that same or similar good or service.  In determining whether preferential contract terms exist, consideration must be given to factors including “sound business practices,” “arm’slength bargaining” and “market prices for comparable goods and services for the geographical area.”  Contractual terms shall also be deemed preferential if the Contractor’s partially- or wholly-owned subsidiaries or Affiliates charge the Contractor a higher price for the same or similar goods or services than the lowest price charged by the Contractor’s partially- or wholly-owned subsidiaries or Affiliates to any and all other clients.

22.1.19.2 Notwithstanding the above, if a Contractor’s subsidiary or Affiliate charges the Contractor for goods or services provided under or associated with the GHP program, and such charges exceed 60% of the total revenue of the subsidiary or Affiliate, such charges must be at cost.  If such charges are not at cost, any excess amounts above cost must be included in the calculation of the Contractor’s Excess Profit.

22.1.19.3 Contractor shall report to ASES’s Office of Finance all related-party transactions within thirty (30) Calendar Days and provide a copy of the contract for each transaction detailing the amounts paid or to be paid, charged or transferred and goods or services to be provided under the contract.  A certification under penalty from criminal perjury from the Contractor’s President, Vice-President, Chief Financial Officer, or Treasurer specifying what are the “at cost” and/or “fair market value” amounts of the contract, as applicable, shall be included with each submission.

136. Original Section 22.1.18, renumbered by this Amendment as 22.1.20, shall be amended and replaced in its entirety as follows:

22.1.20 To comply with 42 CFR 438.608(d) and 433.312, the Contractor shall, consistent with the procedures set forth in Attachment 23, refund (i) the share of the Overpayment due to ASES within eleven (11) months of the discovery and (ii) the share of an Overpayment due to ASES within fifteen (15) Calendar Days from a final judgment on a Fraud, Waste, or Abuse Action.  The Contractor must also require and have a mechanism for a Provider to report to the Contractor when it has received an Overpayment, to return that Overpayment to the Contractor with a written reason for the Overpayment within sixty (60) Calendar Days after the date on which the Overpayment was identified.  The Contractor shall report annually to ASES on their recoveries of all Overpayments.

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137. Immediately following Section 22.1, a new Section 22.2 shall be inserted stating as follows, and the remaining Article 22 shall be renumbered accordingly, including any references thereto:

22.2 Medical Loss Ratio

22.2.1 The Contractor shall report a Medical Loss Ratio and related data, including the data on the basis of which ASES will determine the compliance of the Contractor with the Medical Loss Ratio Requirement, as required under 42 CFR 438.8(k) for each rating period.  Such reporting shall be provided to ASES no later than March 31^st of the following year.

22.2.2 The Contractor shall calculate its Medical Loss Ratio and related data based on the methodology set forth in 42 CFR 438.8 and any other instructions issued by CMS or ASES.  Effective July 1, 2017, the Contractor is expected to achieve a target medical loss ratio standard, as calculated under 42 CFR 438.8, of at least ninety-one percent (91%) for the contract year.

22.2.3 The calculation of administrative expenses for the purposes of determining the Medical Loss Ratio in accordance with 42 CFR 438.8 shall not be affected by the methodology used to calculate Excess Profit as set forth in Sections 22.1.18 and 22.1.19.

138. Original Section 22.3.1, renumbered by this Amendment as 22.4.1, shall be amended and replaced in its entirety as follows:

22.4.1 ASES shall maintain a Retention Fund of the PMPM Payment each month as part of the Quality Incentive Program described in Section 12.5 according to the following table:

Retention Fund Percentage (RFP) Breakdown
Baseline FY 2016
Time Period (Incurred service from Contract Term)	Retention Fund Percentage	Performance Measures	Preventive Clinical Programs	Emergency Room Use Indicators
7/1/2017 through 9/30/2017	2% of PMPM	40% of RFP	30% of RFP	30% of RFP
10/31/2017 through 12/31/2017	2% of PMPM	40% of RFP	30% of RFP	30% of RFP
1/31/2018 through 3/30/2018	2% of PMPM	40% of RFP	30% of RFP	30% of RFP
4/30/2018 through 6/30/2018	2% of PMPM	40% of RFP	30% of RFP	30% of RFP

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139. Original Section 22.3.2.1, renumbered by this Amendment as 22.4.2.1, shall be amended and replaced in its entirety as follows:

22.4.2.1 The Contractor shall submit a quarterly report no later than ninety (90) Calendar Days after the end of each quarter regarding each of the performance indicators to be evaluated, as determined by ASES (from those listed in Section 12.5);

140. Immediately following Original Section 22.3.2.3, renumbered by this Amendment as 22.4.2.3, a new Section 22.4.3 shall be inserted stating as follows:

22.4.3 The Quality Incentive Program and any other withhold incentive arrangements between ASES and the Contractor must comply the requirements set forth by CMS in 42 CFR 438.6(b)(3).

141. Section 23.1.4 shall be amended and replaced in its entirety as follows:

23.1.4 The Contractor shall provide to ASES a copy of its Annual Report required to be filed with the Puerto Rico Office of the Insurance Commissioner (OIC Report), as applicable, in the format agreed upon by the National Association of Insurance Commissioners (NAIC), for the year ended on December 31, 2014, and subsequently thereafter, during the Contract Term and any renewals, not later than March 31 of each year. The Contractor shall submit to ASES a reconciliation of the OIC Report with its annual audited financial statements filed pursuant to Section 23.1.3 and Section 18.2.9.8.

142. Section 23.2.3 shall be amended and replaced in its entirety as follows:

23.2.3 The Contractor shall provide assurances to ASES that its provision against the risk of insolvency is adequate, in compliance with the Federal standards set forth in 42 CFR 438.116, and shall submit data on the basis of which ASES will determine that the Contractor has made adequate provision against the risk of insolvency.  In particular, the Contractor shall, according to the timeframe specified in Attachment 12 to this Contract, furnish documentation, certified by a Certified Public Accountant, of:

23.2.3.1 The relationship between PMPM Payments and capital, with the optimal relationship being 10:1, in order to prove capacity to assume risk;

23.2.3.2 A debt level of less than seventy-five percent (75%).and

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23.2.3.3 Relationship of current assets to total liabilities shall be, at least, 80%.

143. Section 23.3.3 shall be amended and replaced in its entirety as follows:

23.3.3 The Contractor shall establish a stop-loss limit amount that is in compliance with the limits specified in 42 CFR 422.208(f).  The limit shall be activated when the expense of providing Covered Services to an Enrollee, including all outpatient and inpatient expenses, reaches this sum.  The Contractor shall have mechanisms in place to identify the stop loss once it is reached for an Enrollee, and shall establish monthly reports to inform PMGs of Enrollees who have reached the stop-loss limit.  The Contractor shall assume all losses exceeding the limit.

144. Section 23.6.1 shall be amended and replaced in its entirety as follows:

23.6.1 Any Physician Incentive Plans established by the Contractor shall comply with Federal and Puerto Rico regulations, including 42 CFR 422.208 and 422.210, and 42 CFR 438.3(i), and with the requirements in Section 10.7 of this Contract.

145. Section 23.7.4.1 shall be amended and replaced in its entirety as follows:

23.7.4.1 Definition of A Party in Interest – As defined in Section 1318(b) of the Public Health Service Act, a party in interest is:

23.7.4.1.1 (i) Any director, officer, partner, or employee responsible for management or administration of the Contractor; (ii) any person or legal entity that is directly or indirectly the beneficial owner of more than five percent (5%) of the equity of the Contractor; (iii) any person or legal entity that is the beneficial owner of a mortgage, deed of trust, note, or other interest secured by, and valuing more than five percent (5%) of the Contractor; or, (iv) in the case of a Contractor organized as a nonprofit corporation, an incorporator or enrollee of such corporation under applicable Commonwealth corporation law;

23.7.4.1.2 Any organization in which a person or a legal entity described in Section 23.7.4.1.1 is director, officer or partner; has directly or indirectly a beneficial interest of more than five percent (5%) of the equity of the Contractor; or has a mortgage, deed of trust, note, or other interest valuing more than five percent (5%) of the assets of the Contractor;

23.7.4.1.3 Any person directly or indirectly controlling, controlled by, or under common control with the Contractor; or

23.7.4.1.4 Any spouse, child, or parent of an individual described in Sections 23.7.4.1.1-23.7.4.1.3.

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146. Section 23.7.4.4 shall be amended and replaced in its entirety as follows:

23.7.4.4 As per 42 CFR 455.105 the Contractor, within thirty-five (35) Calendar Days  of the date of request by the HHS Secretary, ASES or the Commonwealth Medicaid agency, and on an annual basis to ASES and the Commonwealth Medicaid agency, shall report full and complete information about:

23.7.4.4.1 The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the day of the request; and

23.7.4.4.2 Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the five (5)-year period ending on the date of the request.

147. Immediately following Section 23.7.4.4.2, a new Section 23.7.4.5 shall be inserted stating as follows:

23.7.4.5 Disclosures of Information on Annual Business Transactions or other reports of transactions between the Contractor and parties in interest provided to ASES or other agencies must be made available to Enrollees upon reasonable request.

148. Section 29.1 shall be amended and replaced in its entirety as follows:

29.1 ASES is prohibited by law from entering into contracts with any person or entity that has been, or whose affiliated subsidiary companies, or any of its shareholders, partners, officers, principals, managing employees, subsidiaries, parent companies, officers, directors, board members, or ruling bodies have been, under investigation for, accused of, convicted of, or sentenced to imprisonment, in Puerto Rico, the other USA jurisdictions, or any other jurisdiction, for any crime involving corruption, fraud, embezzlement, or unlawful appropriation of public funds, pursuant to Act 458, as amended, and Act 84 of 2002.

149. Section 30.1.4 shall be amended and replaced in its entirety as follows:

30.1.4 All contracts between the Contractor and Subcontractors must be in writing, must comply with all applicable Medicaid laws and regulations, including subregulatory guidance and provisions set forth in this Agreement, as applicable, and must specify the activities and responsibilities delegated to the Subcontractor containing terms and conditions consistent with this Contract.  The contracts must also include provisions for revoking delegation or imposing other sanctions if the Subcontractor’s performance is inadequate. The Contractor and the Subcontractors must also make reference to a business associates agreement between the Parties.

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150. Section 30.1.8 shall be amended and replaced in its entirety as follows:

30.1.8 ASES shall have the right to review all financial or business transactions between the Contractor and a Subcontractor at any time upon request.  ASES, CMS, or Office of Inspector General may inspect, evaluate and audit the Subcontractor at any time if ASES, CMS or Office of Inspector General determines there is a reasonable possibility of fraud or similar risk.  ASES shall also retain the right to review all criminal background checks for all employees of the Subcontractor, as referenced in Article 29, as well as any past exclusions from Federal programs.

151. Immediately following Section 30.1.11, a new Section 30.1.12 shall be inserted stating as follows, and the remaining Article 30.1 shall be renumbered accordingly, including any references thereto:

30.1.12 Pursuant to the requirements of 42 CFR 438.230(c)(3)(i) and 42 CFR 438.3(k), ASES, CMS, the Office of Inspector General, the Comptroller General, and their respective designees shall have the right at any time to inspect, evaluate, and audit any books, records, contractors, computer or other electronic systems of the Subcontractor, or of the Subcontractor’s contractor, that pertain to any aspect of services and activities performed or determination of amounts payable under this Agreement.

152. Original Section 30.1.12, renumbered by this Amendment as 30.1.13, shall be amended and replaced in its entirety as follows:

30.1.13 All Subcontractors must fulfill the requirements of 42 CFR 438.3, 438.6 and 438.230 as appropriate. Subcontractors shall also retain, as applicable, enrollee grievance and appeal records as per 42 CFR 438.416, base data for setting actuarially sound capitation rates as per 42 CFR 438.5(c), Medical Loss Ratio reports as per 42 CFR 438.8(k), and the data, information and documentation specified in 42 CFR 438.604, 438.606, 438.608, and 610 for a period of no less than ten (10) years, as set forth in Section 33.1.1.

153. Original Section 30.1.12 shall be deleted in its entirety, including any references thereto.

154. Section 30.2.1 shall be amended and replaced in its entirety as follows:

30.2.1 The Contractor shall submit to ASES, and shall require any Subcontractors hereunder to submit to ASES, cost or pricing Data for any subcontract to this Contract prior to award.  The Contractor shall also certify that the information submitted by the Subcontractor is, to the best of the Contractor’s knowledge and belief, accurate, complete and current as of the date of agreement, or the date of the negotiated price of the Subcontract or amendment to the Contract.  The Contractor shall insert the substance of this Section in each Subcontract hereunder.

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155. Section 33.1.1 shall be amended and replaced in its entirety as follows:

33.1.1 The Contractor and its Subcontractors, if any, shall preserve and make available all of its records pertaining to the performance under this Contract for inspection or audit, as provided below, throughout the Contract Term, for a period of ten (10) years from the date of final payment under this Contract, and for such period, if any, as is required by applicable statute or by any other section of this Contract.  If the Contract is completely or partially terminated, the records relating to the work terminated shall be preserved and made available for period of  ten (10) years from the Termination Date of the Contract or of any resulting final settlement.  The Contractor is responsible to preserve all records pertaining to its performance under this Contract, and to have them available and accessible in a timely manner, and in a reasonable format that assures their integrity. Records that relate to Appeals, litigation, or the settlements of Claims arising out of the performance of this Contract, or costs and expenses of any such agreements as to which exception has been taken by the  Contractor or any of its duly Authorized Representatives, shall be retained by Contractor until such Appeals, litigation, Claims or exceptions have been disposed of.

156. Section 33.2.3 shall be amended and replaced in its entirety as follows:

33.2.3 Pursuant to the requirements of 42 CFR 434.6(a)(5) and 42 CFR 434.38, ASES, CMS, the Office of Inspector General, the Comptroller General, and their respective designees shall have the right at any time to inspect, evaluate, and audit any pertinent records or documents of the Contractor and Subcontractors, and may inspect the premises, physical facilities, equipment, computers or other electronic systems where activities or work related to the GHP program is conducted.  The right to audit exists for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later.  Any records requested hereunder shall be produced Immediately for on-site review or sent to the requesting authority by mail within fourteen (14) Calendar Days following a request.  All records shall be provided at the sole cost and expense of the Contractor.  ASES shall have unlimited rights to use, disclose, and duplicate all Information and Data in any way relating to this Contract in accordance with applicable Puerto Rico and Federal laws and regulations.

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157. Immediately following Section 38.2.2, a new Section 38.2.3 shall be inserted stating as follows, and the remaining Article 38 shall be renumbered accordingly, including any references thereto:

38.2.3 At the request of either party, ASES will evaluate any enacted Federal, state or local legislative or regulatory changes with applicability to the GHIP program that materially impact the PMPM Payment.  If after a process of actuarial evaluation, using credible data, ASES determines that the enacted legislative and/or regulatory changes materially impact the PMPM Payment, ASES will adjust the PMPM rates for Metro North and West Service Regions to reflect the above-referenced changes after the adjusted rates are approved by CMS.  Any revisions to the PMPM Payments under this Section would be applicable only from January 1, 2018 until June 30, 2018, or from the effective date of any new law or regulation, whichever is later.  “Materially impact” shall mean that a recalculation of current PMPM Payments is required in order to remain actuarially sound.

158. Section 40.1 shall be amended and replaced in its entirety as follows:

40.1 This Contract shall be governed in all respects by the laws of Puerto Rico.  Any lawsuit or other action brought against ASES or the Commonwealth based upon or arising from this Contract shall be brought in a court of competent jurisdiction in Puerto Rico.

159. Section 54.1 shall be amended and replaced in its entirety as follows:

54.1 The Contractor and Subcontractors shall disclose, and ASES shall review, financial statements for each person or corporation with an ownership or control interest of five percent (5%) or more of its entity.  For the purposes of this Section, a person or corporation with an ownership or control interest shall mean a person or corporation:

54.1.1 That owns directly or indirectly five percent (5%) or more of the Contractor’s/Subcontractor’s capital or stock or received five percent (5%) or more of its profits;

54.1.2 That has an interest in any mortgage, deed of trust, note, or other obligation secured in whole or in part by the Contractor/Subcontractor or by its property or assets, and that interest is equal to or exceeds five percent (5%) of the total property and assets of the Contractor/Subcontractor; and

54.1.3 That is an officer or director of the Contractor/Subcontractor (if it is organized as a corporation) or is a partner in the Contractor’s/ Subcontractor’s organization (if it is organized as a partnership).

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160. Section 55.2 shall be amended and replaced in its entirety as follows:

55.2 ASES reserves the authority to seek an amendment to this Contract at any time if such an amendment is necessary in order for the terms of this Contract to comply with Federal law, the laws of Puerto Rico or the Government of Puerto Rico Fiscal Plan as certified by the Financial Oversight and Management Board for Puerto Rico pursuant to the Puerto Rico Oversight, Management and Economic Stability Act of 2016. The Contractor shall consent to any such amendment.

161. The following amended attachments, copies of which are included, are substituted in this Agreement as follows:

a. ATTACHMENT 5:  FORMULARY OF MEDICATIONS COVERED AND LIST OF MEDICATIONS BY EXCEPTION

b. ATTACHMENT 8:  COST-SHARING

c. ATTACHMENT 9:  ENROLLMENT MANUAL

d. ATTACHMENT 11:  PER MEMBER PER MONTH PAYMENTS

e. ATTACHMENT 19:  QUALITY INCENTIVE PROGRAM MANUAL

IV. RATIFICATION

All other terms and provisions of the original Contract, as amended by Contracts Number 2015000087A, 2015-000087B, 2015-000087C, 2015-000087D, 2015-000087E, 2015-000087F, 2015000087G, and of any and all documents incorporated by reference therein, not specifically deleted or modified herein shall remain in full force and effect.  The parties hereby affirm their respective undertakings and representations as set forth therein, as of the date thereof. Capitalized terms used in this Amendment, if any, shall have the same meaning assigned to such terms in the Contract.

V. EFFECT;CMS APPROVAL

The Parties acknowledge that this Amendment is subject to approval by the United States Department of Health and Human Services Centers for Medicare and Medicaid Services (“CMS”), and ASES shall submit the Amendment for CMS approval.  Pending CMS approval, this Amendment shall serve as a binding letter of agreement between the Parties.

VI. AMENDMENT EFFECTIVE DATE

Unless a provision contained in this Amendment specifically indicates a different effective date, for purposes of the provisions contained herein, this Amendment shall become effective retroactively July 1, 2017 and end on June 30^th, 2018.

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VII. ENTIRE AGREEMENT

This Amendment constitutes the entire understanding and agreement of the parties with regards to the subject matter hereof, and the parties by their execution and delivery of this Seventh Amendment to the Contract hereby ratify all of the terms and conditions of the Contract, as amended by Contracts Number 2015-000087A, 2015-000087B, 2015-000087C, 2015-000087D, 2015-000087E, 2015-000087F, 2015-000087G, and as supplemented by this Agreement.

 The Parties agree that ASES will be responsible for the submission and registration of this Amendments in the Office of the Comptroller General of the Commonwealth, as required under law and applicable regulations.

IN WITNESS WHEREOF, the parties hereto execute this Amendment to the Contract by their duly authorized representatives as of the dates set out below and set their signatures.

XXXXXXXXXXXXXX XX XXXXXXX XX XXXXX XX XXXXXX XXXX (ASES)

/s/ Xxxxxx X. Xxxxx Xxxxxxx
		12/26/2017
Xx. Xxxxxx X. Xxxxx Xxxxxxx, Executive Director		Date
EIN: 00-0000000
TRIPLE-S SALUD, INC.
/s/ Xxxxxxxx Xxxxxxxxx Xxxxxxx
		12/26/2017
Xx. Xxxxxxxx Xxxxxxxxx Xxxxxxx, President		Date

EIN: 00-0000000

Account No.: 252-000-5010-5035

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ATTACHMENT 5:  FORMULARY OF MEDICATIONS COVERED AND LIST OF MEDICATIONS BY EXCEPTION

PLAN DE SALUD DEL GOBIERNO

Lista de Medicamentos por Excepción (LME)

2017

Therapeutic Category [Categoría Terapéutica]	Therapeutic Class [Clase Terapéutica]	Drug Description [Descripción de la Droga]	Preautorization [Preautorización] Y=Yes
ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS	Stimulants - Misc.	Modafinil Oral Tablet 100 MG	Y
ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS	Stimulants - Misc.	Modafinil Oral Tablet 200 MG	Y
ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS	Stimulants - Misc.	Provigil Oral Tablet 100 MG	Y
ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS	Stimulants - Misc.	Provigil Oral Tablet 200 MG	Y
ANALGESICS - ANTIINFLAMMATORY	Interleukin-1 Receptor Antagonist (IL-1Ra)	Kineret Subcutaneous Solution Prefilled Syringe 100 MG/0.67ML	Y
ANTHELMINTICS	ANTHELMINTICS	Albenza Oral Tablet 200 MG	Y
ANTHELMINTICS	ANTHELMINTICS	Ivermectin Oral Tablet 3 MG	Y
ANTHELMINTICS	ANTHELMINTICS	Stromectol Oral Tablet 3 MG	Y
ANTIDOTES AND SPECIFIC ANTAGONISTS	Antidotes - Chelating Agents	Exjade Oral Tablet Soluble 125 MG	Y
ANTIDOTES AND SPECIFIC ANTAGONISTS	Antidotes - Chelating Agents	Exjade Oral Tablet Soluble 250 MG	Y

ANTIDOTES AND SPECIFIC ANTAGONISTS	Antidotes - Chelating Agents	Exjade Oral Tablet Soluble 500 MG	Y
ANTIDOTES AND SPECIFIC ANTAGONISTS	Antidotes - Chelating Agents	Jadenu Oral Tablet 90 MG	Y
ANTIDOTES AND SPECIFIC ANTAGONISTS	Antidotes - Chelating Agents	Jadenu Oral Tablet 180 MG	Y
ANTIDOTES AND SPECIFIC ANTAGONISTS	Antidotes - Chelating Agents	Jadenu Oral Tablet 360 MG	Y
ANTIEMETICS	Substance P/Neurokinin 1 (NK1) Receptor Antagonists	Aprepitant Oral Capsule 80 MG	Y

Therapeutic Category [Categoría Terapéutica]	Therapeutic Class [Clase Terapéutica]	Drug Description [Descripción de la Droga]	Preautorization [Preautorización] Y=Yes
ANTIEMETICS	Substance P/Neurokinin 1 (NK1) Receptor Antagonists	Aprepitant Oral Capsule 125 MG	Y
ANTIEMETICS	Substance P/Neurokinin 1 (NK1) Receptor Antagonists	Emend Oral Capsule 80 MG	Y
ANTIEMETICS	Substance P/Neurokinin 1 (NK1) Receptor Antagonists	Emend Oral Capsule 125 MG	Y
ANTIEMETICS	Substance P/Neurokinin 1 (NK1) Receptor Antagonists	Aprepitant Oral Capsule 40 MG	Y
ANTIEMETICS	Substance P/Neurokinin 1 (NK1) Receptor Antagonists	Emend Oral Capsule 40 MG	Y

ANTIEMETICS	Substance P/Neurokinin 1 (NK1) Receptor Antagonists	Emend Oral Capsule 80 & 125 MG	Y
ANTIEMETICS	Substance P/Neurokinin 1 (NK1) Receptor Antagonists	Emend Oral Suspension Reconstituted 125 MG	Y
ANTIEMETICS	Substance P/Neurokinin 1 (NK1) Receptor Antagonists	Aprepitant Oral Capsule 80 & 125 MG	Y
ANTI-INFECTIVE AGENTS - MISC.	Antiprotozoal Agents	Mepron Oral Suspension 750 MG/5ML	Y
ANTI-INFECTIVE AGENTS - MISC.	Antiprotozoal Agents	Atovaquone Oral Suspension 750 MG/5ML	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Alkylating Agents	Cyclophosphamide Oral Capsule 25 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Alkylating Agents	Cyclophosphamide Oral Capsule 50 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Antibiotics	Novantrone Intravenous Concentrate 20 MG/10ML	Y

Therapeutic Category [Categoría Terapéutica]	Therapeutic Class [Clase Terapéutica]	Drug Description [Descripción de la Droga]	Preautorization [Preautorización] Y=Yes
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Antibiotics	Mitoxantrone HCl Intravenous Concentrate 25 MG/12.5ML	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Antibiotics	Mitoxantrone HCl Intravenous Concentrate 20 MG/10ML	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Antibiotics	Mitoxantrone HCl Intravenous Concentrate 30 MG/15ML	Y

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antimetabolites	Tabloid Oral Tablet 40 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic - Antibodies	Rituxan Intravenous Solution 100 MG/10ML	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic - Antibodies	Rituxan Intravenous Solution 500 MG/50ML	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic - Hedgehog Pathway Inhibitors	Erivedge Oral Capsule 150 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic - Hormonal and Related Agents	Xtandi Oral Capsule 40 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic - Hormonal and Related Agents	Lysodren Oral Tablet 500 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic - Hormonal and Related Agents	Fareston Oral Tablet 60 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Sutent Oral Capsule 37.5 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Votrient Oral Tablet 200 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Tykerb Oral Tablet 250 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Sutent Oral Capsule 12.5 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Sutent Oral Capsule 50 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Sutent Oral Capsule 25 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Tarceva Oral Tablet 25 MG	Y

Therapeutic Category [Categoría Terapéutica]	Therapeutic Class [Clase Terapéutica]	Drug Description [Descripción de la Droga]	Preautorization [Preautorización] Y=Yes
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Tarceva Oral Tablet 100 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Tarceva Oral Tablet 150 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Bosulif Oral Tablet 500 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Bosulif Oral Tablet 100 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Afinitor Disperz Oral Tablet Soluble 2 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Afinitor Disperz Oral Tablet Soluble 3 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Afinitor Disperz Oral Tablet Soluble 5 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Tafinlar Oral Capsule 50 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Tafinlar Oral Capsule 75 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Mekinist Oral Tablet 0.5 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Mekinist Oral Tablet 2 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Imbruvica Oral Capsule 140 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Zelboraf Oral Tablet 240 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Ibrance Oral Capsule 75 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Ibrance Oral Capsule 100 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Ibrance Oral Capsule 125 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Cotellic Oral Tablet 20 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Ninlaro Oral Capsule 2.3 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Ninlaro Oral Capsule 3 MG	Y
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES	Antineoplastic Enzyme Inhibitors	Ninlaro Oral Capsule 4 MG	Y

Therapeutic Category [Categoría Terapéutica]	Therapeutic Class [Clase Terapéutica]	Drug Description [Descripción de la Droga]	Preautorization [Preautorización] Y=Yes
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Benzisoxazoles	Risperdal Consta Intramuscular Suspension Reconstituted 12.5 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Benzisoxazoles	Risperdal Consta Intramuscular Suspension Reconstituted 37.5 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Benzisoxazoles	Risperdal Consta Intramuscular Suspension Reconstituted 50 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Benzisoxazoles	Risperdal Consta Intramuscular Suspension Reconstituted 25 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Dibenzapines	Quetiapine Fumarate ER Oral Tablet Extended Release 24 Hour 200 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Dibenzapines	Quetiapine Fumarate ER Oral Tablet Extended Release 24 Hour 300 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Dibenzapines	Quetiapine Fumarate ER Oral Tablet Extended Release 24 Hour 400 MG	Y

ANTIPSYCHOTICS/ANTIMANIC AGENTS	Dibenzapines	Quetiapine Fumarate ER Oral Tablet Extended Release 24 Hour 50 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Dibenzapines	Quetiapine Fumarate ER Oral Tablet Extended Release 24 Hour 150 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Dibenzapines	Clozaril Oral Tablet 100 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Dibenzapines	Clozaril Oral Tablet 25 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Dibenzapines	Clozapine Oral Tablet 100 MG	Y
ANTIPSYCHOTICS/ANTIMANIC AGENTS	Dibenzapines	Clozapine Oral Tablet 25 MG	Y
ANTIVIRALS	Hepatitis Agents	Hepsera Oral Tablet 10 MG	Y
ANTIVIRALS	Hepatitis Agents	Adefovir Dipivoxil Oral Tablet 10 MG	Y
ANTIVIRALS	Hepatitis Agents	Entecavir Oral Tablet 0.5 MG	Y

Therapeutic Category [Categoría Terapéutica]	Therapeutic Class [Clase Terapéutica]	Drug Description [Descripción de la Droga]	Preautorization [Preautorización] Y=Yes
ANTIVIRALS	Hepatitis Agents	Entecavir Oral Tablet 1 MG	Y
ANTIVIRALS	Hepatitis Agents	Baraclude Oral Tablet 0.5 MG	Y
ANTIVIRALS	Hepatitis Agents	Baraclude Oral Tablet 1 MG	Y
CORTICOSTEROIDS	Glucocorticosteroid s	Entocort EC Oral Capsule Delayed Release Particles 3 MG	Y
CORTICOSTEROIDS	Glucocorticosteroid s	Budesonide Oral Capsule Delayed Release Particles 3 MG	Y
DERMATOLOGICALS	Antipsoriatics	Tazorac External Gel 0.05 %	Y
DERMATOLOGICALS	Antipsoriatics	Tazorac External Gel 0.1 %	Y
DERMATOLOGICALS	Antipsoriatics	Tazorac External Cream 0.05 %	Y
DERMATOLOGICALS	Antipsoriatics	Tazorac External Cream 0.1 %	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Bone Density Regulators	Forteo Subcutaneous Solution 600 MCG/2.4ML	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Bone Density Regulators	Reclast Intravenous Solution 5 MG/100ML	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Bone Density Regulators	Zoledronic Acid Intravenous Solution 5 MG/100ML	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Bone Density Regulators	Pamidronate Disodium Intravenous Solution 30 MG/10ML	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Bone Density Regulators	Pamidronate Disodium Intravenous Solution 90 MG/10ML	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Bone Density Regulators	Pamidronate Disodium Intravenous Solution 6 MG/ML	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Bone Density Regulators	Alendronate Sodium Oral Tablet 40 MG	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Bone Density Regulators	Fosamax Oral Tablet 40 MG	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Bone Density Regulators	Prolia Subcutaneous Solution 60 MG/ML	Y

Therapeutic Category [Categoría Terapéutica]	Therapeutic Class [Clase Terapéutica]	Drug Description [Descripción de la Droga]	Preautorization [Preautorización] Y=Yes
ENDOCRINE AND METABOLIC AGENTS - MISC.	Hormone Receptor Modulators	Raloxifene HCl Oral Tablet 60 MG	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Hormone Receptor Modulators	Evista Oral Tablet 60 MG	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Growth Hormone Receptor Antagonists	Somavert Subcutaneous Solution Reconstituted 10 MG	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Growth Hormone Receptor Antagonists	Somavert Subcutaneous Solution Reconstituted 15 MG	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Growth Hormone Receptor Antagonists	Somavert Subcutaneous Solution Reconstituted 20 MG	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Growth Hormone Receptor Antagonists	Somavert Subcutaneous Solution Reconstituted 25 MG	Y
ENDOCRINE AND METABOLIC AGENTS - MISC.	Growth Hormone Receptor Antagonists	Somavert Subcutaneous Solution Reconstituted 30 MG	Y
HEMATOLOGICAL AGENTS - MISC.	Antihemophilic Products	Feiba NF Intravenous Solution Reconstituted	Y
HEMATOLOGICAL AGENTS - MISC.	Antihemophilic Products	Feiba VH Immuno Intravenous Solution Reconstituted	Y
HEMATOLOGICAL AGENTS - MISC.	Antihemophilic Products	Feiba Intravenous Solution Reconstituted	Y
HEMATOLOGICAL AGENTS - MISC.	Antihemophilic Products	Eloctate Intravenous Solution Reconstituted 250 UNIT	Y

HEMATOLOGICAL AGENTS - MISC.	Antihemophilic Products	Eloctate Intravenous Solution Reconstituted 500 UNIT	Y
HEMATOLOGICAL AGENTS - MISC.	Antihemophilic Products	Eloctate Intravenous Solution Reconstituted 750 UNIT	Y
HEMATOLOGICAL AGENTS - MISC.	Antihemophilic Products	Eloctate Intravenous Solution Reconstituted 1000 UNIT	Y
HEMATOLOGICAL AGENTS - MISC.	Antihemophilic Products	Eloctate Intravenous Solution Reconstituted 1500 UNIT	Y

Therapeutic Category [Categoría Terapéutica]	Therapeutic Class [Clase Terapéutica]	Drug Description [Descripción de la Droga]	Preautorization [Preautorización] Y=Yes
HEMATOLOGICAL AGENTS - MISC.	Antihemophilic Products	Eloctate Intravenous Solution Reconstituted 2000 UNIT	Y
HEMATOLOGICAL AGENTS - MISC.	Antihemophilic Products	Eloctate Intravenous Solution Reconstituted 3000 UNIT	Y
HEMATOLOGICAL AGENTS - MISC.	Platelet Aggregation Inhibitors	Effient Oral Tablet 5 MG	Y
HEMATOLOGICAL AGENTS - MISC.	Platelet Aggregation Inhibitors	Effient Oral Tablet 10 MG	Y
MISCELLANEOUS THERAPEUTIC CLASSES	Immunosuppressive Agents	Zortress Oral Tablet 0.25 MG	Y
MISCELLANEOUS THERAPEUTIC CLASSES	Immunosuppressive Agents	Zortress Oral Tablet 0.75 MG	Y
MISCELLANEOUS THERAPEUTIC CLASSES	Immunosuppressive Agents	Zortress Oral Tablet 0.5 MG	Y
MISCELLANEOUS THERAPEUTIC CLASSES	Systemic Lupus Erythematosus Agents	Benlysta Intravenous Solution Reconstituted 120 MG	Y

MISCELLANEOUS THERAPEUTIC CLASSES	Systemic Lupus Erythematosus Agents	Benlysta Intravenous Solution Reconstituted 400 MG	Y
NEUROMUSCULAR AGENTS	Neuromuscular Blocking Agent - Neurotoxins	Botox Injection Solution Reconstituted 200 UNIT	Y
NEUROMUSCULAR AGENTS	Neuromuscular Blocking Agent - Neurotoxins	Botox Injection Solution Reconstituted 100 UNIT	Y
OPHTHALMIC AGENTS	Ophthalmic Steroids	Tobradex Ophthalmic Suspension 0.3-0.1 %	Y
OPHTHALMIC AGENTS	Ophthalmic Steroids	Tobramycin- Dexamethasone Ophthalmic Suspension 0.3-0.1 %	Y
OPHTHALMIC AGENTS	Prostaglandins - Ophthalmic	Travatan Z Ophthalmic Solution 0.004 %	Y
OPHTHALMIC AGENTS	Prostaglandins - Ophthalmic	Lumigan Ophthalmic Solution 0.01 %	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammagard S/D Intravenous Solution Reconstituted 5 GM	Y

Therapeutic Category [Categoría Terapéutica]	Therapeutic Class [Clase Terapéutica]	Drug Description [Descripción de la Droga]	Preautorization [Preautorización] Y=Yes
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammagard S/D Intravenous Solution Reconstituted 10 GM	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammagard S/D Less IgA Intravenous Solution Reconstituted 5 GM	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammagard S/D Less IgA Intravenous Solution Reconstituted 10 GM	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gamunex-C Injection Solution 1 GM/10ML	Y

PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gamunex-C Injection Solution 2.5 GM/25ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gamunex-C Injection Solution 5 GM/50ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gamunex-C Injection Solution 20 GM/200ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gamunex-C Injection Solution 10 GM/100ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammaked Injection Solution 1 GM/10ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammaked Injection Solution 2.5 GM/25ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammaked Injection Solution 5 GM/50ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammaked Injection Solution 10 GM/100ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammaked Injection Solution 20 GM/200ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammagard Injection Solution 1 GM/10ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammagard Injection Solution 2.5 GM/25ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammagard Injection Solution 5 GM/50ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammagard Injection Solution 10 GM/100ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammagard Injection Solution 20 GM/200ML	Y
PASSIVE IMMUNIZING AND TREATMENT AGENTS	Immune Serums	Gammagard Injection Solution 30 GM/300ML	Y

Therapeutic Category [Categoría Terapéutica]	Therapeutic Class [Clase Terapéutica]	Drug Description [Descripción de la Droga]	Preautorization [Preautorización] Y=Yes
RESPIRATORY AGENTS - MISC.	Cystic Fibrosis Agents	Pulmozyme Inhalation Solution 1 MG/ML	Y
TETRACYCLINES	TETRACYCLINES	Tetracycline HCl Oral Capsule 250 MG	Y
TETRACYCLINES	TETRACYCLINES	Tetracycline HCl Oral Capsule 500 MG	Y
TETRACYCLINES	TETRACYCLINES	Demeclocycline HCl Oral Tablet 150 MG	Y
TETRACYCLINES	TETRACYCLINES	Demeclocycline HCl Oral Tablet 300 MG	Y
TETRACYCLINES	TETRACYCLINES	Declomycin Oral Tablet 300 MG	Y
VASOPRESSORS	Anaphylaxis Therapy Agents	Epinephrine Injection Solution Auto-injector 0.15 MG/0.3ML	Y
VASOPRESSORS	Anaphylaxis Therapy Agents	Epinephrine Injection Solution Auto-injector 0.15 MG/0.15ML	Y
VASOPRESSORS	Anaphylaxis Therapy Agents	Epinephrine Injection Solution Auto-injector 0.3 MG/0.3ML	Y

VIH-SIDA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase Terapéutica]
ANESTHETICS [ANEST ÉSICOS]
Local Anesthetics [Anestésicos Locales]
lidocaine viscous 2 % mouth/throat soln	1	Preferred	XYLOCAINE
ANTIBACTERIALS [ANTIBACTERIANOS]
Macrolides [Macrólidos]
azithromycin 250 mg tab, 500 mg tab	1	Preferred	ZITHROMAX
azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab	2	Preferred	ZITHROMAX
clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab	2	Preferred	BIAXIN
clarithromycin 250 mg/5ml susp	3	Preferred	BIAXIN
ERY-TAB 500 mg tab dr	3	Preferred
erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab	3	Preferred	ERY-TAB
erythromycin ethylsuccinate 400 mg tab	3	Preferred	E.E.S.
ERYTHROCIN STEARATE 250 mg tab	4	Non-Preferred
E.E.S. GRANULES 200 mg/5ml susp	5	Preferred
ERYPED 200 200 mg/5ml susp	5	Preferred
ERYPED 400 400 mg/5ml susp	6	Preferred

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización

Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado

Preferido]

 Página

VIH-SIDA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Miscellaneous Antibacterials [Antibacterianos Misceláneos]
clindamycin hcl 150 mg cap, 300 mg cap, 75 mg cap	1	Preferred	CLEOCIN
Penicillins [Penicilinas]
amoxicillin 125 mg/5ml susp , 200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab	1	Preferred	AMOXIL
amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 875-125 mg tab	1	Preferred	AUGMENTIN
ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap	1	Preferred	PRINCIPEN
penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab	1	Preferred	VEETIDS
amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp	3	Preferred	AUGMENTIN
BICILLIN L-A 600000 unit/ml im susp	3	Non-Preferred
penicillin g procaine 600000 unit/ml im susp	3	Non-Preferred	BICILLIN LA
BICILLIN L-A 1200000 unit/2ml im susp	4	Non-Preferred
BICILLIN L-A 2400000 unit/4ml im susp	5	Non-Preferred
Quinolones [Quinolonas]
ciprofloxacin hcl 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	CIPRO
levofloxacin 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	LEVAQUIN
ciprofloxacin 500 mg/5ml (10%) susp	3	Preferred	CIPRO

VIH-SIDA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ciprofloxacin 250 mg/5ml (5%) susp	4	Preferred	CIPRO
Sulfonamides [Sulfonamidas]
sulfamethoxazole -tmp ds 800-160 mg tab	1	Preferred	SEPTRA
sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab	1	Preferred	SEPTRA
sulfadiazine 500 mg tab	4	Preferred	SULFADIAZINE
Tetracyclines [Tetraciclinas]
minocycline hcl 100 mg cap, 50 mg cap, 75 mg cap	1	Preferred	MINOCIN
doxycycline monohydrate 50  mg cap, 100 mg cap	2	Non-Preferred	MONODOX
ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]
Antituberculars [Antituberculosos]
isoniazid 100 mg tab, 300 mg tab	1	Preferred	ISONIAZID
rifampin 150 mg cap	1	Preferred	RIFADIN
ethambutol hcl 100 mg tab	2	Non-Preferred	MYAMBUTOL
pyrazinamide 500 mg tab	2	Non-Preferred	PYRAZINAMIDE
rifampin 300 mg cap	2	Preferred	RIFADIN
ethambutol hcl 400 mg tab	3	Non-Preferred	MYAMBUTOL
isoniazid 50 mg/5ml syr	5	Non-Preferred	ISONIAZID
rifabutin 150 mg cap			MYCOBUTIN	Puerto Rico Health Department Tuberculosis Control Program
cycloserine 250 mg cap			SEROMYCIN
RIFAMATE 50-300 mg cap
TRECATOR 250 mg tab
CAPASTAT 1 gm inj

VIH-SIDA

Miscellaneous Antimycobacterials [Antimicobacterianos Misceláneos]
dapsone 100 mg tab, 25 mg tab	2	Preferred	DAPSONE
ANTIMYCOTIC AGENTS [ANTIMICÓTICOS]
Antifungals [Antifungales]
fluconazole 10 mg/ml susp, 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab	1	Preferred	DIFLUCAN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ketoconazole 200 mg tab	1	Preferred	NIZORAL
terbinafine hcl 250 mg tab	1	Preferred	LAMISIL
fluconazole 40 mg/ml susp	2	Preferred	DIFLUCAN
voriconazole 40 mg/ml susp	4	Preferred	VFEND
itraconazole 100 mg cap	5	Preferred	SPORANOX
SPORANOX 10 mg/ml soln	6	Preferred
voriconazole 50 mg tab	8	Preferred	VFEND
voriconazole 200 mg tab	10	Preferred	VFEND
ANTIPARASITICS [ANTIPARASITARIOS]
Anthelmintics [Antihelmínticos]
ALBENZA 200 mg tab	9	Preferred
Antimalarials [Antimaláricos]
DARAPRIM 25 mg tab	7	Non-Preferred		PA
Antiprotozoals - Non-Antimalarials [Antiprotozoarios No-Antimalaráricos]
NEBUPENT 300 mg inh soln	4	Preferred
atovaquone 750 mg/5ml susp	9	Non-Preferred	MEPRON
ANTIVIRALS [ANTIVIRALES]
Anti-Cytomegalovirus (CMV) Agents [Agentes Anti-Citomegalovirus]
valganciclovir hcl 450 mg tab	13	Non-Preferred	VALCYTE

VIH-SIDA

Antiherpetic Agents [Agentes Antiherpéticos]
acyclovir 200 mg cap, 400 mg tab, 800 mg tab	1	Preferred	ZOVIRAX
acyclovir 200 mg/5ml susp	2	Preferred	ZOVIRAX
Non-Nucleoside Reverse Transcriptase Inhibitors [Inhibidores No Nucleósidos De La Transciptasa Reversa]
nevirapine 200 mg tab	1	Preferred	VIRAMUNE
nevirapine 50 mg/5ml susp	5	Non-Preferred	VIRAMUNE
RESCRIPTOR 200 mg tab	6	Non-Preferred
SUSTIVA 200 mg cap	6	Preferred		P
nevirapine er 100 mg tab er 24 hr, 400 mg tab er 24 hr	7	Non-Preferred	VIRAMUNE XR
SUSTIVA 50 mg cap, 600 mg tab	7	Preferred		P
zidovudine 300 mg tab	2	Non-Preferred	RETROVIR

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Nucleoside/Nucleotide Reverse Transcriptase Inhibitors [Inhibidores Nucleósidos/Nucleótidos De La Transcriptasa Reversa]
stavudine 1 mg/ml soln, 15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap	3	Preferred	ZERIT
didanosine 125 mg cap dr, 200 mg cap dr, 250 mg cap dr	4	Non-Preferred	VIDEX EC
lamivudine 10 mg/ml soln	4	Preferred	EPIVIR
lamivudine 150 mg tab	4	Preferred	EPIVIR
zidovudine 100 mg cap, 50 mg/5ml syr	4	Non-Preferred	RETROVIR
abacavir sulfate 300 mg tab	5	Non-Preferred	ZIAGEN
didanosine 400 mg cap dr	5	Non-Preferred	VIDEX EC
lamivudine 300 mg tab	5	Preferred	EPIVIR
VIDEX 2 gm soln	5	Non-Preferred
lamivudine 100 mg tab	6	Preferred	EPIVIR	PA
lamivudine-zidovudine 150300 mg tab	6	Preferred	COMBIVIR
ZIAGEN 20 mg/ml soln	6	Non-Preferred

abacavir-lamivudinezidovudine 000-000-000 mg tab 10 Non-Preferred TRIZIVIR

VIH-SIDA

BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]
Erythropoiesis-Stimulating Agents [Agentes Estimulantes De Eritropoiesis]
ARANESP (ALBUMIN FREE) 100 mcg/0.5ml inj soln	1	Preferred		PA, P
PROCRIT 3000 unit/ml inj soln	5	Preferred		PA, P
ARANESP (ALBUMIN FREE) 25 mcg/0.42ml inj soln, 25 mcg/ml inj soln	6	Preferred		PA, P
PROCRIT 10000 unit/ml inj soln	6	Preferred		PA, P
ARANESP (ALBUMIN FREE) 40 mcg/0.4ml inj soln	7	Preferred		PA, P

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ARANESP (ALBUMIN FREE) 40 mcg/ml inj soln, 60 mcg/ml inj soln	8	Preferred		PA, P
ARANESP (ALBUMIN FREE) 150 mcg/0.3ml inj soln, 150 mcg/0.75ml inj soln, 200 mcg/0.4ml inj soln, 200 mcg/ml inj soln, 300 mcg/0.6ml inj soln, 300 mcg/ml inj soln, 500 mcg/ml inj soln, 60 mcg/0.3ml inj soln	9	Preferred		PA, P
ARANESP (ALBUMIN FREE) 100 mcg/ml inj soln	11	Preferred		PA, P
PROCRIT 40000 unit/ml inj soln	11	Preferred		PA, P
Iron [Hierro]
iron 325 (65 fe) mg tab	1	Preferred	IRON

VIH-SIDA

CHEMOTHERAPIES [QUIMIOTERAPIAS]
Antineoplastic Progestins [Antineoplásicos De Progestina]
megestrol acetate 20 mg tab, 40 mg tab	1	Preferred	MEGACE
megestrol acetate 40 mg/ml susp, 400 mg/10ml susp	2	Preferred	MEGACE
Folic Acid Antagonists Rescue Agents [Antagonistas De Ácido Fólico]
leucovorin calcium 5 mg tab	3	Preferred	LEUCOVORIN
leucovorin calcium 10 mg tab, 15 mg tab	4	Preferred	LEUCOVORIN
leucovorin calcium 25 mg tab	9	Preferred	LEUCOVORIN
leucovorin calcium 50 mg inj, 100 mg inj, 200 mg inj, 350 mg inj, 500 mg inj	9	Non-Preferred	LEUCOVORIN
DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]
Antifungals [Antifungales]
clotrimazole 10 mg mouth/throat lozenge, 10 mg mouth/throat xxxxxx	1	Preferred	MYCELEX

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
nystatin 100000 unit/ml mouth/throat susp	1	Preferred	MYCOSTATIN
HORMONAL AGENTS [AGENTES HORMONALES]
Mineralocorticoids [Mineralocorticoides]
fludrocortisone acetate 0.1 mg tab	1	Preferred	FLORINEF

VIH-SIDA

IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]
Glucocorticosteroids [Glucocorticoides]
dexamethasone 0.5 mg tab, 0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab	1	Preferred	DECADRON
MEDROL 2 mg tab	1	Preferred

methylprednisolone 32 mg tab, 4 mg tab	1	Preferred	MEDROL
methylprednisolone (pak) 4 mg tab	1	Preferred	MEDROL
prednisolone 15 mg/5ml soln, 15 mg/5ml syr	1	Preferred	PRELONE
prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab	1	Preferred	DELTASONE
prednisone (pak) 10 mg tab, 5 mg tab	1	Preferred	DELTASONE
hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab	2	Preferred	CORTEF
methylprednisolone 16 mg tab, 8 mg tab	2	Preferred	MEDROL

NEFROLOGIA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase Te rapéutica]
ANALGESICS [ANALGÉ SICOS]
Nonsteroidal Anti-Inflammatory Agents (Nsaids) [Anti-Inflamatorios No Esteroidales]
indomethacin 25 mg cap, 50 mg cap	1	Non-Preferred	INDOCIN
ANTIBACTERIALS [ANTIBACTERIANOS]
First Generation Cephalosporins [Cefalosporinas De Primera Generación]
cephalexin 125 mg/5ml susp, 250 mg cap, 500 mg cap	1	Preferred	KEFLEX
cefadroxil 250 mg/5ml susp	2	Non-Preferred	DURICEF	AL ≤ 12 años
cephalexin 250 mg/5ml susp	2		KEFLEX
cefadroxil 500 mg/5ml susp	3	Non-Preferred	DURICEF	AL≤ 12 años
Macrolides [Macrólidos]
azithromycin 250 mg tab, 500 mg tab	1	Preferred	ZITHROMAX
azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab	2	Preferred	ZITHROMAX
clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab	2	Preferred	BIAXIN
clarithromycin 250 mg/5ml susp	3	Preferred	BIAXIN
ERY-TAB 500 mg tab dr	3	Preferred
XI ycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab	3	Preferred	ERY-TAB
erythromycin ethylsuccinate 400 mg tab	3	Preferred	E.E.S.
ERYTHROCIN STEARATE 250 mg tab	4	Non-Preferred
E.E.S. GRANULES 200 mg/5ml susp	5	Preferred
ERYPED 200 200 mg/5ml susp	5	Preferred

Página 1 de 14

Revisado 5/18/2017

NEFROLOGIA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ERYPED 400 400 mg/5ml susp	6	Preferred
Penicillins [Penicilinas]
amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab	1	Preferred	AMOXIL
amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 875-125 mg tab	1	Preferred	AUGMENTIN
ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap	1	Preferred	PRINCIPEN
penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab	1	Preferred	VEETIDS
amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp	3	Preferred	AUGMENTIN
BICILLIN L-A 600000 unit/ml im susp	3	Non-Preferred
penicillin g procaine 600000 unit/ml im susp	3	Non-Preferred	BICILLIN LA
BICILLIN L-A 1200000 unit/2ml im susp	4	Non-Preferred
BICILLIN L-A 2400000 unit/4ml im susp	5	Non-Preferred
Quinolones [Quinolonas]
ciprofloxacin hcl 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	CIPRO
levofloxacin 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	LEVAQUIN
ciprofloxacin 500 mg/5ml (10%) susp	3	Preferred	CIPRO

Página 2 de 14

Revisado 5/18/2017

NEFROLOGIA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ciprofloxacin 250 mg/5ml (5%) susp	4	Preferred	CIPRO
Second Generation Cephalosporins [Cefalosporinas De Segunda Generación]
cefaclor 250 mg cap, 500 mg cap	2	Preferred	CECLOR
cefprozil 125 mg/5ml susp, 250 mg tab, 250 mg/5ml susp, 500 mg tab	2	Preferred	CEFZIL
Sulfonamides [Sulfonamidas]
sulfamethoxazole -tmp ds 800-160 mg tab	1	Preferred	SEPTRA
sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab	1	Preferred	SEPTRA
Third Generation Cephalosporins [Cefalosporinas De Tercera Generación]
cefdinir 125 mg/5ml susp, 300 mg cap	2	Preferred	OMNICEF
cefdinir 250 mg/5ml susp	3	Preferred	OMNICEF
ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]
Alpha-Glucosidase Inhibitors [Inhibidores De Alfa Glucosidasa]
acarbose 100 mg tab, 25 mg tab, 50 mg tab	2	Preferred	PRECOSE
Biguanides [Biguanidas]
metformin hcl 1000 mg tab, 500 mg tab, 850 mg tab	1	Preferred	GLUCOPHAGE
metformin hcl er 500 mg tab er 24 hr, 750 mg tab er 24 hr	1	Preferred	GLUCOPHAGE XR
Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors [Inhibidores De Dpp-4]
KOMBIGLYZE XR 2.5 -1000 mg tab er 24 hr, 5-1000 mg tab er 24 hr, 5-500 mg tab er 24 hr	3	Preferred		ST, P
ONGLYZA 2.5 mg tab, 5 mg tab	3	Preferred		ST, P
Insulin Mixtures [Mezclas De Insulinas]
HUMULIN 70/30 (70 -30) 100 unit/ml sc susp	2	Preferred		P

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NEFROLOGIA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
HUMALOG MIX 75/25 (7525) 100 unit/ml sc susp	3	Preferred		P
HUMALOG MIX 50/50 (5050) 100 unit/ml sc susp	4	Preferred		P
Insulin Sensitizing Agents [Agentes Sensibilizantes De Insulin]
pioglitazone hcl 15 mg tab, 30 mg tab, 45 mg tab	1	Preferred	ACTOS
Intermediate-Acting Insulins [Insulinas De Duración Intermedia]
HUMULIN N 100 unit/ml sc susp	2	Preferred		P
Long-Acting Insulins [Insulinas De Larga Duración]
LANTUS SOLOSTAR 100 unit/ml subcutaneous solution pen-injector	2	Preferred		P
LANTUS 100 unit/ml sc soln	3	Preferred		P
Rapid-Acting Insulins [Insulinas De Rápida Duración]
HUMALOG 100 unit/ml subcutaneous solution cartridge	2	Preferred		P
HUMALOG 100 unit/ml sc soln	3	Preferred		P
Short-Acting Insulins [Insulinas De Corta Duración]
HUMULIN R 100 unit/ml inj soln	2	Preferred		P

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NEFROLOGIA

Sulfonylureas [Sulfonilureas]
glimepiride 1 mg tab, 2 mg tab, 4 mg tab	1	Preferred	AMARYL
glipizide 10 mg tab, 5 mg tab	1	Preferred	GLUCOTROL
ANTIEMETICS [ANTIEMÉTICOS]
Miscellaneous Antiemetics [Antieméticos Misceláneos]
metoclopramide hcl 10 mg tab, 10 mg/10ml soln, 5 mg tab, 5 mg/5ml soln, 5 mg/ml inj soln	1	Preferred	REGLAN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ANTIHYPERTENSIVES [ANTIHIPERTENSIVOS]
Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]
terazosin hcl 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap	1	Preferred	HYTRIN
Angiotensin II Receptor Blockers (Arb) [Antagonistas Del Receptor Angiotensina II]
losartan potassium 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	COZAAR
losartan potassium-hctz 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab	1	Preferred	HYZAAR
Angiotensin-Converting Enzyme (Ace) Inhibitors [Inhibidores De La Enzima Convertidora De Angiotensin]
fosinopril sodium 10 mg tab, 20 mg tab, 40 mg tab	1	Preferred	MONOPRIL
lisinopril 10 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab	1	Preferred	ZESTRIL
lisinopril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab	1	Preferred	ZESTORETIC
Calcium Channel Blocking Agents [Bloqueadores Xx Xxxxxxx De Calcio]
amlodipine besylate 10 mg tab, 2.5 mg tab, 5 mg tab	1	Preferred	NORVASC

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NEFROLOGIA

diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab	1	Preferred	CARDIZEM
diltiazem hcl er 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr	1	Preferred	DILACOR XR
diltiazem hcl er beads 120 mg cap er 24 hr	1	Preferred	TIAZAC
diltiazem hcl er coated beads 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr	1	Preferred	CARDIZEM CD
dilt-xr 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr	1	Preferred	DILACOR XR

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
nifedipine er osmotic 30 mg tab er 24 hr	1	Preferred	PROCARDIA XL
verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab	1	Preferred	CALAN
verapamil hcl er 120 mg tab er, 180 mg tab er, 240 mg tab er	1	Preferred	CALAN SR
diltiazem hcl er beads 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr	2	Preferred	TIAZAC
diltiazem hcl er coated beads 300 mg cap er 24 hr	2	Preferred	CARDIZEM CD
nifedipine er osmotic 60 mg tab er 24 hr, 90 mg tab er 24 hr	2	Preferred	PROCARDIA XL
Cardioselective Beta Blocking Agents [Bloqueadores Beta Cardioselectivos]
atenolol 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	XXXXXXXX

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NEFROLOGIA

metoprolol succinate er 25 mg tab er 24 hr, 50 mg tab er 24 hr	1	Preferred	LOPRESSOR
metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	LOPRESSOR
metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr	2	Preferred	LOPRESSOR
Cardioselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos Cardioselectivos]
atenolol-chlorthalidone 10025 mg tab, 50-25 mg tab	1	Preferred	TENORETIC
metoprolol- hydrochlorothiazide 50-25 mg tab	2	Non-Preferred	LOPRESSOR HCT
metoprololhydrochlorothiazide 100-25 mg tab, 100-50 mg tab	3	Non-Preferred	LOPRESSOR HCT

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Loop Diuretics [Diuréticos Del Asa]
bumetanide 0.5 mg tab, 1 mg tab, 2 mg tab	1	Non-Preferred	BUMEX
furosemide 10 mg/ml soln, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	LASIX
Nonselective Beta Blocking Agents [Bloqueadores Beta No-Selectivos]
propranolol hcl 10 mg tab, 20 mg tab, 20 mg/5ml soln, 40 mg tab, 40 mg/5ml soln, 80 mg tab	1	Preferred	INDERAL
propranolol hcl 60 mg tab	2	Preferred	INDERAL
Nonselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos No- Selectivos]
Thiazide Diuretics [Diuréticos Tiazidas]
chlorothiazide 250 mg tab, 500 mg tab	1	Preferred	DIURIL

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NEFROLOGIA

chlorthalidone 25 mg tab, 50 mg tab	1	Non-Preferred	HYGROTON
DIURIL 250 mg/5ml susp	1	Preferred
hydrochlorothiazide 25 mg tab, 50 mg tab	1	Preferred	MICROZIDE
metolazone 2.5 mg tab, 5 mg tab	1	Non-Preferred	ZAROXOLYN
chlorthalidone 100 mg tab	2	Non-Preferred	HYGROTON
metolazone 10 mg tab	2	Non-Preferred	ZAROXOLYN
Vasodilator Beta Blockers [Bloqueadores Beta Vasodilatadores]
carvedilol 12.5 mg tab, 25 mg tab, 3.125 mg tab, 6.25 mg tab	1	Preferred	COREG
BENIGN PROSTATIC HYPERTROPHY AGENTS [AGENTES PARA HIPERTROFIA PROSTÁTICA XXXXXXX]
Alpha 1-Adrenoceptor Antagonists [Bloqueadores Alfa1-Adrenérgicos]
tamsulosin hcl 0.4 mg cap	1	Preferred	FLOMAX

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]
Cobalamins [Cobalaminas]
cyanocobalamin 1000 mcg/ml inj soln	1	Preferred	VIT B-12
Erythropoiesis-Stimulating Agents [Agentes Estimulantes De Eritropoiesis]
ARANESP (ALBUMIN FREE) 100 mcg/0.5ml inj soln	1	Preferred		PA, P
PROCRIT 2000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln	5	Preferred		PA, P
ARANESP (ALBUMIN FREE) 25 mcg/0.42ml inj soln, 25 mcg/ml inj soln	6	Preferred		PA, P
PROCRIT 10000 unit/ml inj soln	6	Preferred		PA, P

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NEFROLOGIA

ARANESP (ALBUMIN FREE) 40 mcg/0.4ml inj soln	7	Preferred		PA, P
ARANESP (ALBUMIN FREE) 40 mcg/ml inj soln, 60 mcg/ml inj soln	8	Preferred		PA, P
ARANESP (ALBUMIN FREE) 150 mcg/0.75ml inj soln, 200 mcg/0.4ml inj soln, 200 mcg/ml inj soln, 300 mcg/0.6ml inj soln, 300 mcg/ml inj soln, 500 mcg/ml inj soln, 60 mcg/0.3ml inj soln	9	Preferred		PA, P
PROCRIT 20000 unit/ml inj soln	9	Preferred		PA, P
ARANESP (ALBUMIN FREE) 100 mcg/ml inj soln	11	Preferred		PA, P
PROCRIT 40000 unit/ml inj soln	11	Preferred		PA, P
Folates [Folatos]
folic acid 1 mg tab, 400 mcg tab, 800 mcg tab	1	Preferred	FOLIC ACID	OTC

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Iron [Hierro]
iron 325 (65 fe) mg tab	1	Preferred	IRON
DEXFERRUM 50 mg/ml inj soln	5	Non-Preferred
INFED 50 mg/ml inj soln	5
CHEMOTHERAPIES [QUIMIOTERAPIAS]
Antineoplastic Progestins [Antineoplásicos De Progestina]
megestrol acetate 20 mg tab, 40 mg tab	1	Preferred	MEGACE
megestrol acetate 40 mg/ml susp, 400 mg/10ml susp	2	Preferred	MEGACE
DIABETES SUPPLIES [SUMINISTROS PARA DIABETES]
Needles & Syringes [Agujas Y Jeringuillas]
insulin syringe/needle	1	Preferred	.

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NEFROLOGIA

DYSLIPIDEMICS [DISLIPIDÉMICOS]
Bile Acid Sequestrants [Secuestradores De Acidos Biliares]
cholestyramine 4 gm pckt, 4 gm/dose oral pwdr	3	Preferred	QUESTRAN
Fibric Acid Derivatives [Derivados De Ácido Fíbrico]
gemfibrozil 600 mg tab	1	Preferred	LOPID
Hmg Coa Reductase Inhibitors [Inhibidores De La Reductasa De Hmg Coa]
atorvastatin calcium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	LIPITOR
pravastatin sodium 10 mg tab, 20 mg tab, 80 mg tab	1	Non-Preferred	PRAVACHOL
simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab, 80 mg tab	1	Preferred	ZOCOR
pravastatin sodium 40 mg tab	2	Non-Preferred	PRAVACHOL
GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]
Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De H2]
famotidine 20 mg tab, 40 mg tab	1	Preferred	PEPCID

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr	1	Preferred	ZANTAC
GENITOURINARY AGENTS [AGENTES GENITOURINARIOS]
Phosphate Binder Agents [Enlazadores De Fosfato]
RENVELA 0.8 gm pckt	6	Preferred		PA, P
RENVELA 2.4 gm pckt, 800 mg tab	7	Preferred		PA, P

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NEFROLOGIA

calcium acetate 667 mg cap.	3	Non-Preferred	PHOSLO
HORMONAL AGENTS [AGENTES HORMONALES]
Calcimimetics [Calcimiméticos]
SENSIPAR 30 mg tab	7	Preferred		PA
SENSIPAR 60 mg tab	9	Preferred		PA
SENSIPAR 90 mg tab	10	Preferred		PA
Mineralocorticoids [Mineralocorticoides]
fludrocortisone acetate 0.1 mg tab	1	Preferred	FLORINEF
Vasopressin Analogs [Análogos De Vasopresina]
desmopressin acetate 4 mcg/ml inj soln	2	Non-Preferred	DDAVP
desmopressin acetate 0.2 mg tab	3	Non-Preferred	DDAVP
desmopressin ace spray refrig 0.01 % nasal soln	4	Non-Preferred	DDAVP
desmopressin acetate 0.1 mg tab	4	Non-Preferred	DDAVP
desmopressin acetate spray 0.01 % nasal soln	4	Non-Preferred	DDAVP
STIMATE 1.5 mg/ml nasal soln	7	Non-Preferred		PA
IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]
Cyclosporine Analogs [Análogos De Ciclosporina]
cyclosporine modified 25 mg cap, 50 mg cap	3	Preferred	NEORAL	PA, P
cyclosporine modified 25 mg cap, 50 mg cap	3	Preferred	NEORAL	PA
NEORAL 25 mg cap	3	Preferred		PA, P

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
cyclosporine 25 mg cap	4	Preferred	SANDIMMUNE	PA
cyclosporine modified 100 mg cap, 100 mg/ml soln	4	Preferred	NEORAL	PA
cyclosporine 100 mg cap	5	Preferred	SANDIMMUNE	PA

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NEFROLOGIA

cyclosporine modified 100 mg cap	5	Preferred	NEORAL	PA, P
NEORAL 100 mg cap	5	Preferred		PA, P
cyclosporine 100 mg cap, 25 mg cap	6	Preferred	SANDIMMUNE	PA, P
SANDIMMUNE 100 mg cap, 100 mg/ml soln, 25 mg cap	6	Preferred		PA, P
cyclosporine modified 100 mg/ml soln	7	Preferred	NEORAL	PA, P
NEORAL 100 mg/ml soln	7	Preferred		PA, P
Glucocorticosteroids [Glucocorticoides]
dexamethasone 0.5 mg tab , 0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab	1	Preferred	DECADRON
MEDROL 2 mg tab	1	Preferred
methylprednisolone 32 mg tab, 4 mg tab	1	Preferred	MEDROL
methylprednisolone (pak) 4 mg tab	1	Preferred	MEDROL
prednisolone 15 mg/5ml soln, 15 mg/5ml syr	1	Preferred	PRELONE
prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab	1	Preferred	DELTASONE
prednisone (pak) 10 mg tab, 5 mg tab	1	Preferred	DELTASONE
hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab	2	Preferred	CORTEF
methylprednisolone 16 mg tab, 8 mg tab	2	Preferred	MEDROL
Organ Transplant Agents [Agentes Para Trasplantes]
azathioprine 50 mg tab	1	Preferred	IMURAN

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NEFROLOGIA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
mycophenolate mofetil 250 mg cap, 500 mg tab	2	Preferred	CELLCEPT	PA
tacrolimus 0.5 mg cap	3	Non-Preferred	PROGRAF	PA
MYFORTIC 180 mg tab dr	4	Preferred		PA, P
tacrolimus 1 mg cap	4	Non-Preferred	PROGRAF	PA
mycophenolic acid 180 mg tab dr	5	Preferred	MYFORTIC	PA
sirolimus 0.5 mg tab, 1 mg tab, 2 mg tab	5	Non-Preferred	RAPAMUNE	PA
MYFORTIC 360 mg tab dr	6			PA, P
tacrolimus 5 mg cap	6	Non-Preferred	PROGRAF	PA
mycophenolic acid 360 mg tab dr	7	Preferred	MYFORTIC	PA
RAPAMUNE 1 mg/ml soln	8	Non-Preferred		PA
MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]
Calcium Regulating Agents [Agentes Reguladores De Calcio]
calcitriol 0.25 mcg cap	1	Preferred	ROCALTROL
calcitriol 0.5 mcg cap	2	Preferred	ROCALTROL
calcitriol 1 mcg/ml soln	5	Preferred	ROCALTROL
Electrolytes/Minerals Replacement [Reemplazo De Electrolitos/Minerales]
potassium chloride 20 meq/15ml (10%) oral liquid, 20 meq/15ml (10%) soln	1	Preferred	XXX-CIEL
potassium chloride crys er 10 meq tab er, 20 meq tab er	1	Preferred	KLOR-CON
potassium chloride er 10 meq tab er, 8 meq tab er	1	Preferred	KLOR-CON
potassium chloride er 10 meq cap er, 8 meq cap er	2	Preferred	MICRO-K
potassium chloride 40 meq/15ml (20%) oral liquid	4	Preferred	KAON CL
Potassium Removing Resins [Resinas Removedoras De Potasio]
kalexate oral pwdr	3	Preferred	KAYEXALATE
sodium polystyrene sulfonate oral pwdr, 15 gm/60ml susp	3	Preferred	KAYEXALATE

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NEFROLOGIA

ONCOLOGIA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase Terapéutica]
ANALGESICS [ANALG ÉSICOS]
Nonsteroidal Anti-Inflammatory Agents (NSAIDS) [Anti-Inflamatorios No Esteroidales]
ibuprofen 400 mg tab, 600 mg tab, 800 mg tab	1	Preferred	XXXXXX	XXx00 xxxx  No refills
nabumetone 500 mg tab, 750 mg tab	1	Preferred	RELAFEN
naproxen 250 mg tab, 375 mg tab, 500 mg tab	1	Preferred	NAPROSYN	QL=15 xxxx  No refills
naproxen dr 375 mg tab dr, 500 mg tab dr	1	Preferred	NAPROSYN	QL=15 xxxx  No refills
sulindac 150 mg tab, 200 mg tab	1	Preferred	CLINORIL
meloxicam7.5 mg tab, 15 mg tab	1	Preferred	MOBIC	QL=15 xxxx  No refills
indomethacin 25 mg cap, 50 mg cap	1	Non-Preferred	INDOCIN
Opioid Analgesics, Long-Acting [Analgésicos Opiodes, Larga Duración]
fentanyl 25 mcg/hr td patch 72 hr	2	Preferred	DURAGESIC
oxycodone hcl 10 mg tab	2	Preferred	DAZIDOX	QL=15 xxxx No refills
fentanyl 50 mcg/hr td patch 72 hr, 75 mcg/hr td patch 72 hr	3	Preferred	DURAGESIC
morphine sulfate er 15 mg tab er	3	Preferred	MORPHINE
oxycodone hcl 20 mg tab	3	Preferred	DAZIDOX	QL=15 xxxx No refills
fentanyl 100 mcg/hr td patch 72 hr	4	Preferred	DURAGESIC

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ONCOLOGIA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
morphine sulfate er 30 mg tab er	4	Preferred	MORPHINE
morphine sulfate er 60 mg tab er	5	Preferred	MORPHINE
morphine sulfate er 100 mg tab er	6	Preferred	MORPHINE
Short-Acting Opioid Analgesics [Analgésicos Opiodes De Corta Duración]
acetaminophen  -codeine 120-12 mg/5ml soln, 300-15 mg tab, 300-30 mg tab, 300- 60 mg tab	1	Preferred	TYLENOL-CODEINE	QL=15 xxxx No refills
acetaminophen-codeine #2 300-15 mg tab	1	Preferred	TYLENOL-CODEINE	QL=15 xxxx No refills
acetaminophen-codeine #3 300-30 mg tab	1	Preferred	TYLENOL-CODEINE	QL=15 xxxx No refills
acetaminophen-codeine #4 300-60 mg tab	1	Preferred	TYLENOL-CODEINE	QL=15 xxxx No refills
hydrocodoneacetaminophen 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab, 7.5-500 mg/15ml soln	1	Preferred	VICODIN	QL=15 xxxx No refills
hydromorphone hcl 2 mg tab, 4 mg tab	1	Preferred	DILAUDID
meperidine hcl 50 mg/ml inj soln	1	Preferred	DEMEROL
morphine sulfate 15 mg tab, 30 mg tab	1	Preferred	MORPHINE
oxycodone-acetaminophen 5-325 mg tab	1	Preferred	PERCOCET	QL=15 xxxx No refills
tramadol hcl 50 mg tab	1	Preferred	ULTRAM
codeine sulfate 15 mg tab, 30 mg tab, 60 mg tab	2	Preferred	CODEINE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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ONCOLOGIA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
meperidine hcl 100 mg/ml inj soln	2	Preferred	DEMEROL
morphine sulfate 10 mg/5ml soln	2	Preferred	MORPHINE
morphine sulfate (concentrate) 100 mg/5ml soln, 20 mg/ml soln	2	Preferred	MORPHINE
hydromorphone hcl 8 mg tab	3	Preferred	DILAUDID
oxycodone-acetaminophen 10-325 mg tab, 7.5-325 mg tab	3	Preferred	PERCOCET	QL=15 xxxx No refills
hydromorphone hcl 1 mg/ml oral liquid	4	Preferred	DILAUDID
ANESTHETICS [ANESTÉSICOS]
Local Anesthetics [Anestésicos Locales]
lidocaine viscous 2 % mouth/throat soln 1 Preferred XYLOCAINE
ANTIBACTERIALS [ANTIBACTERIANOS]
Macrolides [Macrólidos]
azithromycin 250 mg tab, 500 mg tab	1	Preferred	ZITHROMAX
azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab	2	Preferred	ZITHROMAX

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Xxxxxx 0 xx 00

Xxxxxxxx: 0 xx xxxx xx 2017

ONCOLOGIA

clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab	2	Preferred	BIAXIN
clarithromycin 250 mg/5ml susp	3	Preferred	BIAXIN
ERY-TAB 500 mg tab dr	3	Preferred
erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab	3	Preferred	ERY-TAB

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
erythromycin ethylsuccinate 400 mg tab	3	Preferred	E.E.S.
ERYTHROCIN STEARATE 250 mg tab	4	Non-Preferred
E.E.S. GRANULES 200 mg/5ml susp	5	Preferred
ERYPED 200 200 mg/5ml susp	5	Preferred
ERYPED 400 400 mg/5ml susp	6	Preferred
Penicillins [Penicilinas]
amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab	1	Preferred	AMOXIL
amoxicillin-pot clavulanate, 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 875-125 mg tab	1	Preferred	AUGMENTIN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Xxxxxx 0 xx 00

Xxxxxxxx: 0 xx xxxx xx 2017

ONCOLOGIA

ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap	1	Preferred	PRINCIPEN
penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab	1	Preferred	VEETIDS
amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp	3	Preferred	AUGMENTIN
BICILLIN L-A 600000 unit/ml im susp	3	Non-Preferred
penicillin g procaine 600000 unit/ml im susp	3	Non-Preferred	BICILLIN LA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
BICILLIN L-A 1200000 unit/2ml im susp	4	Non-Preferred
BICILLIN L-A 2400000 unit/4ml im susp	5	Non-Preferred
Quinolones [Quinolonas]
ciprofloxacin hcl 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	CIPRO
levofloxacin 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	LEVAQUIN
ciprofloxacin 500 mg/5ml (10%) susp	3	Preferred	CIPRO
ciprofloxacin 250 mg/5ml (5%) susp	4	Preferred	CIPRO
Sulfonamides [Sulfonamidas]

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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sulfamethoxazole-tmp ds 800-160 mg tab	1	Preferred	SEPTRA
sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab	1	Preferred	SEPTRA
sulfadiazine 500 mg tab	4	Preferred	SULFADIAZINE
ANTICONVULSANTS [ANTICONVULSIVANTES]
Anticonvulsants [Anticonvulsivantes
gabapentin 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab	1	Preferred	NEURONTIN
DILANTIN 30 mg cap	2	Preferred
gabapentin 250 mg/5ml soln	2	Preferred	NEURONTIN
phenytoin 125 mg/5ml susp, 50 mg tab chew	2	Preferred	DILANTIN
phenytoin sodium extended 100 mg cap	2	Preferred	DILANTIN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ANTIEMETICS [ANTIEMÉTICOS]
5-Hydroxytryptamine 3 (5-HT3) Antagonists [Antagonistas De 5-HT3]
ondansetron 4 mg odt, 8 mg odt	1	Preferred	ZOFRAN ODT
ondansetron hcl 24 mg tab, 4 mg tab, 8 mg tab	1	Preferred	ZOFRAN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Miscellaneous Antiemetics [Antieméticos Misceláneos]
metoclopramide hcl 10 mg tab, 10 mg/10ml soln, 5 mg tab, 5 mg/5ml soln, 5 mg/ml inj soln	1	Preferred	REGLAN
promethazine hcl 25 mg/ml inj soln, 50 mg/ml inj soln	1	Preferred	PHENERGAN
promethazine hcl 12.5 mg tab, 25 mg tab, 50 mg tab, 6.25 mg/5ml soln, 6.25 mg/5ml syr	1	Preferred	PHENERGAN
trimethobenzamide hcl 300 mg cap	1	Preferred	TIGAN
Phenothiazines [Fenotiazinas]
prochlorperazine edisylate 5 mg/ml inj soln	1	Preferred	COMPAZINE
prochlorperazine maleate 10 mg tab, 5 mg tab	1	Preferred	COMPAZINE
prochlorperazine 25 mg rect supp	4	Non-Preferred	COMPAZINE
ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]
Miscellaneous Antimycobacterials [Antimicobacterianos Misceláneos]
dapsone 100 mg tab, 25 mg tab	2	Preferred	DAPSONE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ANTIMYCOTIC AGENTS [ANTIMICÓTICOS]
Antifungals [Antifungales]
fluconazole 10 mg/ml susp, 100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab	1	Preferred	DIFLUCAN
ketoconazole 200 mg tab	1	Preferred	NIZORAL
terbinafine hcl 250 mg tab	1	Preferred	LAMISIL
fluconazole 40 mg/ml susp	2	Preferred	DIFLUCAN
ANTIVIRALS [ANTIVIRALES]
Antiherpetic Agents [Agentes Antiherpéticos]
acyclovir 200 mg cap, 400 mg tab, 800 mg tab	1	Preferred	ZOVIRAX
acyclovir 200 mg/5ml susp	2	Preferred	ZOVIRAX
BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]
Cobalamins [Cobalaminas]
cyanocobalamin 1000 mcg/ml inj soln	1	Preferred	VIT B-12
Colony Stimulating Factors [Estimulantes Mieloides]
NEUPOGEN 300 mcg/0.5ml  inj soln, 300 mcg/ml inj soln, 480 mcg/1.6ml inj soln	10	Preferred		PA, P
NEULASTA 6 mg/0.6ml sc soln	12	Preferred		PA, X
XXXXXXXX 000 mcg/0.8ml inj soln	12	Preferred		PA, P
Erythropoiesis-Stimulating Agents [Agentes Estimulantes De Eritropoiesis]
ARANESP (ALBUMIN FREE) 100 mcg/0.5ml inj soln	1	Preferred		PA, P
PROCRIT 2000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln	5	Preferred		PA, P

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Drug Name [Nombre del Medicamento]	Net Cost [Cost Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ARANESP (ALBUMIN FREE) 25 mcg/0.42ml inj soln, 25 mcg/ml inj soln	6	Preferred		PA, P
PROCRIT 10000 unit/ml inj soln	6	Preferred		PA, P
ARANESP (ALBUMIN FREE) 40 mcg/0.4ml inj soln	7	Preferred		PA, P
ARANESP (ALBUMIN FREE) 40 mcg/ml inj soln, 60 mcg/ml inj soln	8	Preferred		PA, P
ARANESP (ALBUMIN FREE) 150 mcg/0.3ml inj soln, 150 mcg/0.75ml inj soln, 200 mcg/0.4ml inj soln, 200 mcg/ml inj soln, 300 mcg/0.6ml inj soln, 300 mcg/ml inj soln, 500 mcg/ml inj soln, 60 mcg/0.3ml inj soln	9	Preferred		PA, P
PROCRIT 20000 unit/ml inj soln	9	Preferred		PA, P
ARANESP (ALBUMIN FREE) 100 mcg/ml inj soln	11	Preferred		PA, P
PROCRIT 40000 unit/ml inj soln	11	Preferred		PA, P
Folates [Folatos]
folic acid 1 mg tab, 400 mcg tab, 800 mcg tab	1	Preferred	FOLIC ACID	OTC
Iron [Hierro]
iron 325 (65 fe) mg tab	1	Preferred	IRON
DEXFERRUM 50 mg/ml inj soln	5	Non-Preferred
INFED 50 mg/ml inj soln	5	Preferred

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
CHEMOTHERAPIES [QUIMIOTERAPIAS]
Alkylating Agents [Agentes Alquilantes]
lomustine 10 mg cap	3	Non-Preferred	XXXXX
ALKERAN 2 mg tab	4	Non-Preferred
temozolomide 5 mg cap	4	Non-Preferred	TEMODAR	PA
lomustine 40 mg cap	5	Non-Preferred	XXXXX
LEUKERAN 2 mg tab	6	Non-Preferred
lomustine 100 mg cap	6	Non-Preferred	XXXXX
MYLERAN 2 mg tab	7	Preferred
temozolomide 20 mg cap	9	Non-Preferred	TEMODAR	PA
temozolomide 250 mg cap	11	Non-Preferred	TEMODAR	PA
temozolomide 140 mg cap	13	Non-Preferred	TEMODAR	PA
temozolomide 100 mg cap, 180 mg cap	14	Non-Preferred	TEMODAR	PA
Angiogenesis Inhibitors [Inhibidores de Angiogénesis]
STIVARGA 40 mg tab	21	Preferred		PA, P
Antiandrogens [Antiandrógenos]
bicalutamide 50 mg tab	2	Preferred	CASODEX
flutamide 125 mg cap	4	Non-Preferred	EULEXIN	PA
Antiestrogens [Antiestrógenos]
tamoxifen citrate 10 mg tab, 20 mg tab	1	Preferred	NOLVADEX
Antimetabolites [Antimetabolitos]
hydroxyurea 500 mg cap	2	Preferred	HYDREA
mercaptopurine 50 mg tab	2	Preferred	PURINETHOL
methotrexate 2.5 mg tab	2	Preferred	METHOTREXATE
capecitabine 150 mg tab	7	Preferred	XELODA	PA
capecitabine 500 mg tab	11	Preferred	XELODA	PA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Antineoplastic Enzyme Inhibitors [Antineoplásicos Inhibidores De Enzimas]
SPRYCEL 20 mg tab	10	Preferred		PA, P
SPRYCEL 50 mg tab	13	Preferred		PA, P
imatinib 100 mg tab	13	Non-Preferred	GLEEVEC	PA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
SPRYCEL 70 mg tab	14	Preferred		PA, P
TASIGNA 200 mg cap	15	Preferred		PA, P
SPRYCEL 80 mg tab	17	Preferred		PA, P
TASIGNA 150 mg cap	18	Preferred		PA, P
SPRYCEL 100 mg tab	19	Preferred		PA, P
AFINITOR 2.5 mg tab	20	Preferred		PA, P
NEXAVAR 200 mg tab	20	Preferred		PA, P
SPRYCEL 140 mg tab	20	Preferred		PA, P
AFINITOR 10 mg tab, 5 mg tab, 7.5 mg tab	21	Preferred		PA, P
imatinib 400 mg tab	23	Non-Preferred	GLEEVEC	PA
Antineoplastic Progestins [Antineoplásicos De Progestina]
megestrol acetate 20 mg tab, 40 mg tab	1	Preferred	MEGACE
megestrol acetate 40 mg/ml susp, 400 mg/10ml susp	2	Preferred	MEGACE
Aromatase Inhibitors [Inhibidores De La Aromatasa]
anastrozole 1 mg tab	1	Preferred	ARIMIDEX
Folic Acid Antagonists Rescue Agents [Antagonistas De Ácido Fólico]
leucovorin calcium 5 mg tab	3	Preferred	LEUCOVORIN
leucovorin calcium 10 mg tab, 15 mg tab	4	Preferred	LEUCOVORIN

leucovorin calcium 25 mg tab 9 Preferred LEUCOVORIN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Luteinizing Hormone-Releasing (Lhrh) Analogs [Análogos De Lhrh]
LUPRON DEPOT 11.25 mg im kit, 3.75 mg im kit	6	Preferred		PA, P
LUPRON DEPOT-PED 11.25 mg im kit, 15 mg im kit, 7.5 mg im kit	8	Preferred		PA, P
LUPRON DEPOT 22.5 mg im kit, 30 mg im kit	9	Preferred		PA, P

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
leuprolide acetate 1 mg/ 0.2 ml inj kit		Non-preferred		PA
ZOLADEX 3.6 mg, 10.8 mg subcutaneous implant	7	Non-preferred		PA
Miscellaneous Antineoplastics [Antineoplásicos Misceláneos]
MATULANE 50 mg cap	10	Non-Preferred		PA
ACTIMMUNE 2000000 unit/0.5ml sc soln	25	Non-Preferred		PA
Mitotic Inhibitors [Inhibidores Mitóticos]
etoposide 50 mg cap	4	Non-Preferred	VEPESID
DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]
Antifungals [Antifungales]
clotrimazole 10 mg mouth/throat lozenge, 10 mg mouth/throat xxxxxx	1	Preferred	MYCELEX	OTC
nystatin 100000 unit/ml mouth/throat susp	1	Preferred	MYCOSTATIN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]
Dermatological Skin Cancer Agents [Dermatológicos Para Cáncer De Xx Xxxx]
fluorouracil 2 % soln, 5 % soln	3	Preferred	EFUDEX
fluorouracil 5 % crm	4	Non-Preferred	EFUDEX
GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]
Anti-Ulcer Agents [Agentes Anti-Ulceras]
misoprostol 100 mcg tab, 200 mcg tab	1	Preferred	CYTOTEC
sucralfate 1 gm tab	1	Preferred	CARAFATE
CARAFATE 1 gm/10ml susp	3	Non-Preferred
Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De H2]
famotidine 20 mg tab, 40 mg tab	1	Preferred	PEPCID

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr	1	Preferred	ZANTAC
Proton Pump Inhibitors [Inhibidores De La Bomba De Protones]
omeprazole 10 mg cap dr, 20 mg cap dr	1	Preferred	PRILOSEC	QL=180 caps/ 365 xxxx
omeprazole 40 mg cap dr	1	Preferred	PRILOSEC	QL=180 caps/ 365 xxxx
HORMONAL AGENTS [AGENTES HORMONALES]
Mineralocorticoids [Mineralocorticoides]
fludrocortisone acetate 0.1 mg tab	1	Preferred	FLORINEF

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]
Cyclosporine Analogs [Análogos De Ciclosporina]
NEORAL 25 mg cap	3	Preferred		PA, P
cyclosporine modified 25 mg cap, 50 mg cap	3	Preferred	NEORAL	PA
cyclosporine 25 mg cap	4	Preferred	SANDIMMUNE	PA
cyclosporine modified 100 mg cap, 100 mg/ml soln	4	Preferred	NEORAL	PA
cyclosporine 100 mg cap	5	Preferred	SANDIMMUNE	PA
NEORAL 100 mg cap	5	Preferred		PA, P
cyclosporine 100 mg cap, 25 mg cap	6	Preferred	SANDIMMUNE	PA
SANDIMMUNE 100 mg cap, 100 mg/ml soln, 25 mg cap	6	Preferred		PA, P
NEORAL 100 mg/ml soln	7	Preferred		PA, P

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Glucocorticosteroids [Glucocorticoides]
dexamethasone 0.5 mg tab, 0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab	1	Preferred	DECADRON
MEDROL 2 mg tab	1	Preferred
methylprednisolone 32 mg tab, 4 mg tab	1	Preferred	MEDROL
methylprednisolone (pak) 4 mg tab	1	Preferred	MEDROL
prednisolone 15 mg/5ml soln, 15 mg/5ml syr	1	Preferred	PRELONE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab	1	Preferred	DELTASONE
prednisone (pak) 10 mg tab, 5 mg tab	1	Preferred	DELTASONE
hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab	2	Preferred	CORTEF
methylprednisolone 16 mg tab, 8 mg tab	2	Preferred	MEDROL
Organ Transplant Agents [Agentes Para Trasplantes]
azathioprine 50 mg tab	1	Preferred	IMURAN
mycophenolate mofetil 200 mg/ml susp, 250 mg cap, 500 mg tab	2	Preferred	CELLCEPT	PA
tacrolimus 0.5 mg cap	3	Non-Preferred	PROGRAF	PA
MYFORTIC 180 mg tab dr	4	Preferred		PA, P
tacrolimus 1 mg cap	4	Non-Preferred	PROGRAF	PA
sirolimus 0.5 mg tab, 1 mg tab, 2 mg tab	5	Non-Preferred	RAPAMUNE	PA
MYFORTIC 360 mg tab dr	6	Preferred		PA, P

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
tacrolimus 5 mg cap	6	Non-Preferred	PROGRAF	PA
RAPAMUNE 1 mg/ml soln	8	Non-Preferred		PA
MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]
Calcium Regulating Agents [Agentes Reguladores De Calcio]
calcitriol 0.25 mcg cap	1	Preferred	ROCALTROL
calcitriol 0.5 mcg cap	2	Preferred	ROCALTROL

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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OB-GYN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase Terapéutica]
ANALGESICS [ANALGÉSICOS]
Short-Acting Opioid Analgesics [Analgésicos Opiodes De Corta Duración]
oxycodone-acetaminophen 5-325 mg tab	1	Preferred	PERCOCET	QL=15 xxxx No refills
oxycodone-acetaminophen 10-325 mg tab, 7.5-325 mg tab	3	Preferred	PERCOCET	QL=15 xxxx No refills
ANTIANXIETY AGENTS [AGENTES PARA LA ANXIEDAD]
Miscellaneous Anxiolytics [Ansiolíticos Misceláneos]
hydroxyzine pamoate 100 mg cap, 25 mg cap, 50 mg cap	1	Preferred	VISTARIL
ANTIBACTERIALS [ANTIBACTERIANOS]
First Generation Cephalosporins [Cefalosporinas De Primera Generación]
cephalexin 125 mg/5ml susp, 250 mg cap, 500 mg cap	1	Preferred	KEFLEX
cephalexin 250 mg/5ml susp	2	Preferred	KEFLEX
Macrolides [Macrólidos]
azithromycin 250 mg tab, 500 mg tab	1	Preferred	ZITHROMAX
azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab	2	Preferred	ZITHROMAX
ERY-TAB 500 mg tab dr	3	Preferred
erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab	3	Preferred	ERY-TAB
erythromycin ethylsuccinate 400 mg tab	3	Preferred	E.E.S.
ERYTHROCIN STEARATE 250 mg tab	4	Non-Preferred

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OB-GYN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
E.E.S. GRANULES 200 mg/5ml susp	5	Preferred
ERYPED 200 200 mg/5ml susp	5	Preferred
ERYPED 400 400 mg/5ml susp	6	Preferred
Miscellaneous Antibacterials [Antibacterianos Misceláneos]
clindamycin hcl 150 mg cap, 300 mg cap, 75 mg cap	1	Preferred	CLEOCIN
MACRODANTIN 25 mg cap	1	Preferred
metronidazole 250 mg tab, 500 mg tab	1	Preferred	FLAGYL
nitrofurantoin macrocrystal 50 mg cap	1	Preferred	MACRODANTIN
nitrofurantoin macrocrystal 100 mg cap	2	Preferred	MACRODANTIN
nitrofurantoin monohyd macro 100 mg cap	2	Preferred	MACROBID
nitrofurantoin oral suspension 25 MG/5ML	6	Non-Preferred	FURADANTIN
Penicillins [Penicilinas]
amoxicillin 125 mg/5ml susp          , 200 mg/5ml susp, 250 mg cap, , 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab	1	Preferred	AMOXIL
amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 875-125 mg tab	1	Preferred	AUGMENTIN
ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap	1	Preferred	PRINCIPEN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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OB-GYN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab	1	Preferred	VEETIDS
amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp	3	Preferred	AUGMENTIN
BICILLIN L-A 600000 unit/ml im susp	3	Non-Preferred
penicillin g procaine 600000 unit/ml im susp	3	Non-Preferred	BICILLIN LA
BICILLIN L-A 1200000 unit/2ml im susp	4	Non-Preferred
BICILLIN L-A 2400000 unit/4ml im susp	5	Non-Preferred
Second Generation Cephalosporins [Cefalosporinas De Segunda Generación]
cefaclor 250 mg cap, 500 mg cap	2	Preferred	CECLOR
cefprozil 125 mg/5ml susp, 250 mg tab, 250 mg/5ml susp, 500 mg tab	2	Preferred	CEFZIL
Sulfonamides [Sulfonamidas]
sulfamethoxazole -tmp ds 800-160 mg tab	1	Preferred	SEPTRA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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OB-GYN

sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab	1	Preferred	SEPTRA
Third Generation Cephalosporins [Cefalosporinas De Tercera Generación]
cefdinir 125 mg/5ml susp, 300 mg cap	2	Preferred	OMNICEF
cefdinir 250 mg/5ml susp	3	Preferred	OMNICEF
Vaginal Antibiotics [Antibióticos Vaginales]
metronidazole 0.75 % vag gel	2	Preferred	VANDAZOLE

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
clindamycin phosphate 2 % vag crm	3	Preferred	CLEOCIN
ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]
Insulin Mixtures [Mezclas De Insulinas]
HUMULIN 70/30 (70-30) 100 unit/ml sc susp	3	Preferred		P
HUMALOG MIX 75/25 (7525) 100 unit/ml sc susp	4	Preferred		P
HUMALOG MIX 50/50 (5050) 100 unit/ml sc susp	4	Preferred		P
Intermediate-Acting Insulins [Insulinas De Duración Intermedia]
HUMULIN N 100 unit/ml sc susp	2	Preferred		P
Long-Acting Insulins [Insulinas De Larga Duración]
LANTUS SOLOSTAR 100 unit/ml subcutaneous solution pen-injector	3	Preferred		P
LANTUS 100 unit/ml sc soln	3	Preferred		P

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Rapid-Acting Insulins [Insulinas De Rápida Duración]
HUMALOG 100 unit/ml sc soln	4	Preferred		P
Short-Acting Insulins [Insulinas De Corta Duración]
HUMULIN R 100 unit/ml inj soln	2	Preferred		P
ANTIEMETICS [ANTIEMÉTICOS]
Miscellaneous Antiemetics [Antieméticos Misceláneos]
metoclopramide hcl 10 mg tab, 10 mg/10ml soln, 5 mg tab, 5 mg/5ml soln, 5 mg/ml inj soln	1	Preferred	REGLAN
trimethobenzamide hcl 300 mg cap	1	Preferred	TIGAN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Phenothiazines [Fenotiazinas]
prochlorperazine edisylate 5 mg/ml inj soln	1	Preferred	COMPAZINE
prochlorperazine maleate 10 mg tab, 5 mg tab	1	Preferred	COMPAZINE
prochlorperazine 25 mg rect supp	4	Non-Preferred	COMPAZINE
ANTIHYPERTENSIVES [ANTIHIPERTENSIVOS]
Alpha-Adrenergic Agonists [Agonistas Alfa Adrenérgicos]
methyldopa 250 mg tab, 500 mg tab	1	Preferred	ALDOMET
Cardioselective Beta Blocking Agents [Bloqueadores Beta Cardioselectivos]
atenolol 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	TENORMIN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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metoprolol succinate er 25 mg tab er 24 hr, 50 mg tab er 24 hr	1	Preferred	LOPRESSOR
metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	LOPRESSOR
metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr	2	Preferred	LOPRESSOR
Cardioselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos Cardioselectivos]
atenolol-chlorthalidone 10025 mg tab, 50-25 mg tab	1	Preferred	TENORETIC
metoprolol-hydrochlorothiazide 50-25 mg tab	2	Non-Preferred	LOPRESSOR HCT
metoprololhydrochlorothiazide 100-25 mg tab, 100-50 mg tab	3	Non-Preferred	LOPRESSOR HCT

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Nonselective Beta Blocking Agents [Bloqueadores Beta No-Selectivos]
propranolol hcl 10 mg tab , 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	INDERAL
propranolol hcl 60 mg tab	2	Preferred	INDERAL
Vasodilator Beta Blockers [Bloqueadores Beta Vasodilatadores]
carvedilol 12.5 mg tab, 25 mg tab, 3.125 mg tab, 6.25 mg tab 1 Preferred COREG
Vasodilators [Vasodilatadores]
hydralazine hcl 10 mg tab, 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	APRESOLINE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]
Antituberculars [Antituberculosos]
isoniazid 100 mg tab, 300 mg tab	1	Preferred	ISONIAZID
rifampin 150 mg cap	1	Preferred	RIFADIN
ethambutol hcl 100 mg tab	2	Non-Preferred	MYAMBUTOL
rifampin 300 mg cap	2	Preferred	RIFADIN
ethambutol hcl 400 mg tab	3	Non-Preferred	MYAMBUTOL
isoniazid 50 mg/5ml syr	5	Non-Preferred	ISONIAZID
rifabutin 150 mg cap	6	Preferred	MYCOBUTIN	Puerto Rico Health Department Tuberculosis Control Program
RIFAMATE 50-300 mg cap
TRECATOR 250 mg tab
Miscellaneous Antimycobacterials [Antimicobacterianos Misceláneos]
dapsone 100 mg tab, 25 mg tab	2	Preferred	DAPSONE
ANTIMYCOTIC AGENTS [ANTIMICÓTICOS]
Vaginal Antifungals [Antifungales Vaginales]
terconazole 0.4 % vag crm, 0.8 % vag crm	2	Preferred	TERAZOL

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ANTIPARASITICS [ANTIPARASITARIOS]
Antiprotozoals - Non-Antimalarials [Antiprotozoarios No-Antimalaráricos]
NEBUPENT 300 mg inh soln	4	Preferred		PA
ANTIVIRALS [ANTIVIRALES]
Antiherpetic Agents [Agentes Antiherpéticos]

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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acyclovir 200 mg cap, 400 mg tab, 800 mg tab	1	Preferred	ZOVIRAX
acyclovir 200 mg/5ml susp	2	Preferred	ZOVIRAX
Anti-Influenza Agents [Agentes Antiinfluenza]
RELENZA DISKHALER 5 mg/blister inh aer pwdr	3	Preferred
oseltamivir phosphate 30 mg cap, 45 mg cap, 75 mg cap	4	Preferred	TAMIFLU
TAMIFLU 6 mg/ ml susp	5	Non-Preferred
Nucleoside/Nucleotide Reverse Transcriptase Inhibitors [Inhibidores Nucleósidos/Nucleótidos De La Transcriptasa Reversa]
zidovudine 300 mg tab	2	Non-Preferred	RETROVIR
zidovudine 100 mg cap, 50 mg/5ml syr	4	Non-Preferred	RETROVIR
BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]
Anticoagulants [Anticoagulantes]
heparin sodium (porcine) 1000 unit/ml inj soln	2	Preferred	HEPARIN
heparin sodium (porcine) 10000 unit/ml inj soln, 5000 unit/ml inj soln	3	Preferred	HEPARIN
heparin sodium (porcine) pf 5000 unit/0.5ml inj soln	3	Preferred	HEPARIN
heparin sodium (porcine) 2000 unit/xx xx soln	8	Preferred	HEPARIN
Cobalamins [Cobalaminas]
cyanocobalamin 1000 mcg/ml inj soln	1	Preferred	VIT B-12

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Folates [Folatos]
folic acid 1 mg tab, 400 mcg tab, 800 mcg tab	1	Preferred	FOLIC ACID	OTC
Iron [Hierro]
iron 325 (65 fe) mg tab	1	Preferred	IRON
DEXFERRUM 50 mg/ml inj soln	5	Non-Preferred
INFED 50 mg/ml inj soln	5	Preferred
BONE DENSITY REGULATORS [REGULADORES DE DENSIDAD ÓSEA]
Bisphosphonates [Bifosfonatos]
alendronate sodium 10 mg tab, 35 mg tab, 5 mg tab, 70 mg tab	1	Preferred	FOSAMAX
CHEMOTHERAPIES [QUIMIOTERAPIAS]
Folic Acid Antagonists Rescue Agents [Antagonistas De Ácido Fólico]
leucovorin calcium 5 mg tab	3	Preferred	LEUCOVORIN
leucovorin calcium 10 mg tab, 15 mg tab	4	Preferred	LEUCOVORIN
leucovorin calcium 25 mg tab	9	Preferred	LEUCOVORIN
leucovorin calcium 50 mg inj, 100 mg inj, 200 mg inj, 350 mg inj, 500 mg inj	9	Non-Preferred	LEUCOVORIN
Luteinizing Hormone-Releasing (Lhrh) Analogs [Análogos De Lhrh]
LUPRON DEPOT 11.25 mg im kit, 3.75 mg im kit	6	Preferred		PA, P
ZOLADEX 3.6 mg, 10.8 mg subcutaneous implant	7	Non-preferred		PA
DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]
Antihistamines [Antihistamínicos]
hydroxyzine hcl 10 mg tab, 10 mg/5ml soln, 10 mg/5ml syr, 25 mg tab, 50 mg tab	1	Preferred	ATARAX

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Topical Antifungals [Antifungales Tópicos]
clotrimazole 1 % crm	1	Preferred	LOTRIMIN	OTC (crm)
nystatin 100000 unit/gm oint	1	Preferred	MYCOSTATIN
DIABETES SUPPLIES [SUMINISTROS PARA DIABETES]
Needles & Syringes [Agujas Y Jeringuillas]
insulin syringe/needle	1	Preferred	.
GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]
Anti-Ulcer Agents [Agentes Anti-Ulceras]
sucralfate 1 gm tab	1	Preferred	CARAFATE
CARAFATE 1 gm/10ml susp	3	Non-Preferred
Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De H2]
famotidine 20 mg tab, 40 mg tab	1	Preferred	PEPCID
ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr	1	Preferred	ZANTAC
Rectal Anti-Inflammatories [Anti-Inflamatorios Rectales]
hydrocortisone ace pramoxine 1-1 % rect crm, 2.5-1 % rect crm	2	Preferred	ANALPRAM-HC
pramcort 1-1 % rect crm	2	Preferred	ANALPRAM-HC
HORMONAL AGENTS [AGENTES HORMONALES]
Dysmenorrhea Agents [Agentes Para La Dismenorrea]
medroxyprogesterone acetate 10 mg tab, 2.5 mg tab, 5 mg tab	1	Preferred	PROVERA
alyacen 1/35 1-35 mg-mcg tab	2	Preferred	ARANELLE	PA
CRYSELLE-28 0.3-30 mgmcg tab	2	Preferred		PA
ELINEST 0.3-30 mg-mcg tab	2	Preferred		PA
LOW-OGESTREL 0.3-30 mg-mcg tab	2	Preferred		PA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Estrogens [Estrógenos]
estradiol 1 mg tab, 2 mg tab	1	Preferred	ESTRACE
estropipate 0.75 mg tab, 1.5 mg tab	1	Preferred	ESTROPIPATE
estropipate 3 mg tab	2	Preferred	ESTROPIPATE
Estrogens and Progestins [Estrógenos y Progestinas]
estradiol -norethindrone acet 1-0.5 mg tab	4	Non-Preferred	ACTIVELLA
Glucocorticosteroids [Glucocorticoides]
betamethasone sod phos & acet 6 (3-3) mg/ml inj susp	2	Preferred	CELESTONE
Mineralocorticoids [Mineralocorticoides]
fludrocortisone acetate 0.1 mg tab	1	Preferred	FLORINEF
Thyroid Hormones [Hormona Tiroidea]
levothyroxine sodium 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab	1	Preferred	SYNTHROID
SYNTHROID 100 mcg tab, 112 mcg tab, 125 mcg tab,137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab	1	Preferred		P
Vaginal Estrogens [Estrógenos Vaginal]
VAGIFEM 10 mcg vag tab	3	Non-Preferred

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]
Glucocorticosteroids [Glucocorticoides]
dexamethasone 0.5 mg tab, 0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab	1	Preferred	DECADRON
dexamethasone sodium phosphate 120 mg/30ml inj soln, 20 mg/5ml inj soln, 4 mg/ml inj soln	1	Preferred	DECADRON
KENALOG 10 mg/ml inj susp	1	Non-Preferred
MEDROL 2 mg tab	1	Preferred
methylprednisolone 32 mg tab, 4 mg tab	1	Preferred	MEDROL
methylprednisolone (pak) 4 mg tab	1	Preferred	MEDROL
prednisolone 15 mg/5ml soln, 15 mg/5ml syr	1	Preferred	PRELONE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización

Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab	1	Preferred	DELTASONE
prednisone (pak) 10 mg tab, 5 mg tab	1	Preferred	DELTASONE
hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab	2	Preferred	CORTEF
methylprednisolone 16 mg tab, 8 mg tab	2	Preferred	MEDROL
KENALOG 40 mg/ml inj susp	5	Non-Preferred
Immune Globulins [Immunoglobulinas]
RHOGAM ultra-filtered plus im soln 1500 unit	4	Preferred

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]
Prenatal Vitamins [Vitaminas Prenatales]
prenatal tab	1	Preferred	PRENATAL VITAMINS
RESPIRATORY AGENTS [AGENTES RESPIRATORIOS]
Anticholinergic Bronchodilators [Broncodilatadores Anticolinérgicos]
ipratropium bromide 0.02 % inh soln	1	Non-Preferred	ATROVENT
Inhaled Corticosteroids [Corticosteroides Inhalados]
FLOVENT DISKUS 100 mcg/blist inh aer pwdr, 250 mcg/blist inh aer pwdr, 50 mcg/blist inh aer pwdr	3	Preferred		QL = 1 xxxxx / 30 xxxx, P
FLOVENT HFA 110 mcg/act inh aer, 44 mcg/act inh aer	3	Preferred		QL = 1 xxxxx / 30 xxxx, P

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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ADVAIR DISKUS 100-50 mcg/dose inh aer pwdr, 25050 mcg/dose inh aer pwdr	4	Preferred		QL = 1 xxxxx / 30 xxxx, ST, P
ADVAIR HFA 115-21 mcg/act inh aer, 45-21 mcg/act inh aer	4	Preferred		QL = 1 xxxxx / 30 xxxx, ST, P
budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp,	4	Non-Preferred	PULMICORT	AL ≤ 12 años
budesonide 1mg/2ml inh susp	8	Non-Preferred	PULMICORT	AL ≤ 12 años
FLOVENT HFA 220 mcg/act inh aer	4	Preferred		QL = 1 xxxxx / 30 xxxx, P
ADVAIR DISKUS 500-50 mcg/dose inh aer pwdr	5	Preferred		QL = 1 xxxxx / 30 xxxx, ST, P
ADVAIR HFA 230-21 mcg/act inh aer	5	Preferred		QL = 1 xxxxx / 30 xxxx, ST, P
Nonsedating Histamine1 Blocking Agents [Bloqueadores De Histamina1 No-Sedantes]
loratadine 10 mg tab	1	Preferred	CLARITIN	OTC

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Sedating Histamine1 Blocking Agents [Sedantes Bloqueadores Histamine1]
promethazine hcl 12.5 mg tab, 25 mg tab, 50 mg tab, 6.25 mg/5ml soln, 6.25 mg/5ml syr	1	Preferred	PHENERGAN
Sympathomimetic Bronchodilators [Broncodilatadores Simpatomiméticos]
albuterol sulfate (2.5 mg/3ml) 0.083% inh neb soln, (5 mg/ml) 0.5% inh neb soln	1	Preferred	ALBUTEROL
terbutaline sulfate 2.5 mg tab, 5 mg tab	1	Preferred	BRETHINE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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VENTOLIN HFA 108 (90 base) mcg/act inh aer 1 Preferred QL = 1 xxxxx / 30 xxxx, P

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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XXXXX XXXXXX

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase Terapéutica]
ANALGESICS [XXX  LGÉSICOS]
Nonsteroidal Anti-Inflammatory Agents (NSAIDs) [Anti-Inflamatorios No Esteroidales]
ibuprofen 400 mg tab, 600 mg tab, 800 mg tab	1	Preferred	XXXXXX	XXx00 xxxx No refills
indomethacin 25 mg cap, 50 mg cap	1	Non-Preferred	INDOCIN
nabumetone 500 mg tab, 750 mg tab	1	Preferred	RELAFEN
naproxen 250 mg tab, 375 mg tab, 500 mg tab	1	Preferred	NAPROSYN	QL=15 xxxx No refills
naproxen dr 375 mg tab dr, 500 mg tab dr	1	Preferred	NAPROSYN	QL=15 xxxx No refills
salsalate 500 mg tab, 750 mg tab	1	Preferred	DISALCID
sulindac 150 mg tab, 200 mg tab	1	Preferred	CLINORIL
meloxicam7.5 mg tab, 15 mg tab	1	Preferred	MOBIC	QL=15 xxxx No refills
Long-Acting Opioid Analgesics [Analgésicos Opiodes de Larga Duración]
fentanyl 25 mcg/hr td patch  72 hr	2	Preferred	DURAGESIC
fentanyl 50 mcg/hr td patch 72 hr, 75 mcg/hr td patch 72 hr	3	Preferred	DURAGESIC
morphine sulfate er 15 mg tab er	3	Preferred	MORPHINE
fentanyl 100 mcg/hr td patch 72 hr	4	Preferred	DURAGESIC
morphine sulfate er 30 mg tab er	4	Preferred	MORPHINE
morphine sulfate er 60 mg tab er	5	Preferred	MORPHINE
morphine sulfate er 100 mg tab er	6	Preferred	MORPHINE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
methadone hcl oral tablet 10 mg		Preferred	METHADONE	ASSMCA
methadone hcl oral solution 10 mg/ 5ml		Preferred	METHADONE	ASSMCA
Short-Acting Opioid Analgesics [Analgésicos Opiodes de Corta Duración]
test
acetaminophen-codeine 120-12 mg/5ml soln, 30015 mg tab, 300-30 mg tab, 300-60 mg tab	1	Preferred	TYLENOL-CODEINE	QL=15 xxxx No refills
hydrocodoneacetaminophen 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab, 7.5-500 mg/15ml soln	1	Preferred	VICODIN	QL=15 xxxx  No refills
hydromorphone hcl 2 mg tab, 4 mg tab	1	Preferred	DILAUDID
meperidine hcl 50 mg/ml inj soln	1	Preferred	DEMEROL
morphine sulfate 15 mg tab, 30 mg tab	1	Preferred	MORPHINE
oxycodone-acetaminophen 5-325 mg tab	1	Preferred	OXYCODONE APAP	QL=15 xxxx  No refills
tramadol hcl 50 mg tab	1	Preferred	ULTRAM
butalbital-apap-caffeine 50325-40 mg cap, 00-000-00 mg tab	2	Preferred	FIORICET	QL=15 xxxx  No refills
codeine sulfate 15 mg tab, 30 mg tab, 60 mg tab	2	Preferred	CODEINE
meperidine hcl 100 mg/ml inj soln	2	Preferred	DEMEROL
morphine sulfate 10 mg/5ml soln	2	Preferred	MORPHINE
morphine sulfate (concentrate) 100 mg/5ml soln, 20 mg/ml soln	2	Preferred	MORPHINE
hydromorphone hcl 8 mg tab	3	Preferred	DILAUDID

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 0 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
oxycodone-acetaminophen 10-325 mg tab, 7.5-325 mg tab	3	Preferred	OXYCODONE APAP	QL=15 xxxx  No refills
hydromorphone hcl 1 mg/ml oral liquid	4	Preferred	DILAUDID
ANESTHETICS [ANESTÉSICOS]
Local Anesthetics [Anestésicos Locales]
lidocaine viscous 2 % mouth/throat soln	1	Preferred	XYLOCAINE
ANTIANXIETY AGENTS [AGENTES PARA LA ANSIEDAD]
Benzodiazepines [Ben zodiazepinas]
clonazepam 0.5 mg tab, 1 mg tab, 2mg tab	1	Preferred	KLONOPIN
diazepam 1 mg/ml soln, 10 mg tab, 2 mg tab, 5 mg tab, 5 mg/ml oral conc	1	Preferred	VALIUM	MENTAL/SUBMENTAL QL=5días
flurazepam hcl 15 mg cap, 30 mg cap	1	Preferred	DALMANE	MENTAL/SUBMENTAL QL=5días
lorazepam 0.5 mg tab, 1 mg tab	1	Preferred	ATIVAN	MENTAL/SUBMENTAL QL=5días
midazolam hcl 10 mg/10ml inj soln, 2 mg/2ml inj soln, 5 mg/5ml inj soln, 5 mg/ml inj soln	1	Preferred	VERSED	QL 5ml / 30días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 0 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Miscellaneous Anxiolytics [Ansiolíticos Misceláneos]

hydroxyzine pamoate 100  mg cap, 25 mg cap, 50 mg cap	1	Preferred	VISTARIL
ANTIBACTERIALS [ANTIBACTERIANOS]
Aminoglycosides [Aminoglucósidos]
tobramycin 300 mg/5ml inh neb soln	18	Non-Preferred	TOBI	PA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
First Generation Cephalosporins [Cefalosporinas de Primera Generación]
cephalexin 125 mg/5ml  susp, 250 mg cap, 500 mg cap	1	Preferred	KEFLEX
cefadroxil 250 mg/5ml susp	2	Non-Preferred	DURICEF	AL ≤ 12 años
cephalexin 250 mg/5ml susp	2	Preferred	KEFLEX
cefadroxil 500 mg/5ml susp	3	Non-Preferred	DURICEF	AL ≤ 12 años
Macrolides [Macrólidos]
azithromycin 250 mg tab,  500 mg tab	1	Preferred	ZITHROMAX
azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab	2	Preferred	ZITHROMAX
clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab	2	Preferred	BIAXIN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 0 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

clarithromycin 250 mg/5ml susp	3	Preferred	BIAXIN
erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab	3	Preferred	ERY-TAB
erythromycin ethylsuccinate 400 mg tab	3	Preferred	E.E.S.
ERYTHROCIN STEARATE 250 mg tab	4	Non-Preferred
Miscellaneous Antibacterials [Antibacterianos Misceláneos]
clindamycin hcl 150 mg  cap, 300 mg cap, 75 mg cap	1	Preferred	CLEOCIN
MACRODANTIN 25 mg cap	1	Preferred
metronidazole 250 mg tab, 500 mg tab	1	Preferred	FLAGYL
nitrofurantoin macrocrystal 50 mg cap	1	Preferred	MACRODANTIN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
nitrofurantoin macrocrystal 100 mg cap	2	Preferred	MACRODANTIN
nitrofurantoin monohyd macro 100 mg cap	2	Preferred	MACROBID
nitrofurantoin oral suspension 25 MG/5ML	6	Non-Preferred	FURADANTIN
vancomycin hcl 125 mg cap	9	Non-Preferred	VANCOCIN
vancomycin hcl 250 mg cap	10	Non-Preferred	VANCOCIN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 0 xx 00  xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Penincillinis [Penicilinas]
amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab	1	Preferred	AMOXIL
amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 400-57 mg/5ml susp, 500125 mg tab, 600-42.9 mg/5ml susp, 875-125 mg tab	1	Preferred	AUGMENTIN
ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap	1	Preferred	PRINCIPEN
penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab	1	Preferred	VEETIDS
amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp	3	Preferred	AUGMENTIN
BICILLIN L-A 600000 unit/ml im susp	3	Non-Preferred
penicillin g procaine 600000 unit/ml im susp	3	Non-Preferred	BICILLIN LA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
BICILLIN L-A 1200000 unit/2ml im susp	4	Non-Preferred
BICILLIN L-A 2400000 unit/4ml im susp	5	Non-Preferred
Quinolones [Quinolonas]
ciprofloxacin hcl 250 mg  tab, 500 mg tab, 750 mg tab	1	Preferred	CIPRO

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 0 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

levofloxacin 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	LEVAQUIN
ciprofloxacin 500 mg/5ml (10%) susp	3	Preferred	CIPRO
ciprofloxacin 250 mg/5ml (5%) susp	4	Preferred	CIPRO
Second Generation Cephalosporins [Cefalosporinas de Segunda Generación]
cefaclor 250 mg cap, 500  mg cap	2	Preferred	CECLOR
cefprozil 125 mg/5ml susp, 250 mg tab, 250 mg/5ml susp, 500 mg tab	2	Preferred	CEFZIL
Sulfonamides [Sulfonamidas]
sulfamethoxazole  -tmp ds 800-160 mg tab	1	Preferred	SEPTRA
sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab	1	Preferred	SEPTRA
sulfadiazine 500 mg tab	4	Preferred	SULFADIAZINE
Tetracyclines [Tetraciclinas]
minocycline hcl 100 mg  cap, 50 mg cap, 75 mg cap	1	Preferred	MINOCIN
doxycycline monohydrate 50  mg cap, 100 mg cap	2	Non-Preferred	MONODOX
Third Generation Cephalosporins [Cefalosporinas de Tercera Generación]
cefdinir 125 mg/5ml susp,  300 mg cap	2	Preferred	OMNICEF
cefdinir 250 mg/5ml susp	3	Preferred	OMNICEF

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Vaginal Antibiotics [Antibióticos Vaginales]
metronidazole 0.75 % vag  gel	2	Preferred	VANDAZOLE

clindamycin phosphate 2 % vag crm 3 Non-Preferred CLEOCIN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 0 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

ANTICONVULSANTS [ANTICONVULSIVANTES]
Anticonvulsants [Anticonvulsivantes]
carbamazepine 100 mg tab  chew, 200 mg tab	1	Preferred	TEGRETOL
clonazepam 0.5 mg tab, 1 mg tab, 2 mg tab	1	Preferred	KLONOPIN
divalproex sodium 125 mg tab dr, 250 mg tab dr, 500 mg tab dr	1	Preferred	DEPAKOTE
gabapentin 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab	1	Preferred	NEURONTIN
lamotrigine 100 mg tab, 150 mg tab, 200 mg tab, 25 mg tab	1	Preferred	LAMICTAL
lamotrigine chew tab 5 mg, 25 mg	3	Non-Preferred	LAMICTAL
levetiracetam 250 mg tab, 500 mg tab	1	Preferred	KEPPRA
levetiracetam er 24 hrs 500 mg tab, 750 mg	3	Non-Preferred	KEPPRA XR
oxcarbazepine 150 mg tab	1	Preferred	TRILEPTAL
phenobarbital 100 mg tab, 15 mg tab, 16.2 mg tab, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab	1	Preferred	PHENOBARBITAL
primidone 250 mg tab, 50 mg tab	1	Preferred	MYSOLINE
topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab	1	Preferred	TOPAMAX

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 0 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
valproic acid 250 mg cap, 250 mg/5ml syr	1	Preferred	DEPAKENE
zonisamide 50 mg cap	1	Preferred	ZONEGRAN
DILANTIN 30 mg cap	2	Preferred
gabapentin 250 mg/5ml soln	2	Preferred	NEURONTIN
levetiracetam 100 mg/ml soln, 1000 mg tab, 750 mg tab	2	Preferred	KEPPRA
oxcarbazepine 300 mg tab, 600 mg tab	2	Preferred	TRILEPTAL
phenytoin 125 mg/5ml susp, 50 mg tab chew	2	Preferred	DILANTIN
phenytoin sodium extended 100 mg cap, 200 mg cap, 300 mg cap	2	Preferred	DILANTIN
zonisamide 100 mg cap, 25 mg cap	2	Preferred	ZONEGRAN
carbamazepine er 200 mg tab er 12 hr	3	Preferred	TEGRETOL
ethosuximide 250 mg cap, 250 mg/5ml soln	3	Preferred	ZARONTIN
phenobarbital 20 mg/5ml oral elix, 20 mg/5ml soln	3	Preferred	PHENOBARBITAL
carbamazepine 100 mg/5ml susp	4	Preferred	TEGRETOL
carbamazepine er 400 mg tab er 12 hr	4	Preferred	TEGRETOL
oxcarbazepine 300 mg/5ml susp	4	Preferred	TRILEPTAL
VIMPAT 10 mg/ml soln,100 mg tab, 150 mg tab,50 mg tab	5	Preferred		PA, C
VIMPAT 200 mg tab, 200 mg/20ml iv soln	6	Preferred		PA, C

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 0 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
ANTIDEMENTIA AGENTS [AGENTES ANTIDEMENCIA]
Antidementia Agents [Agen tes Antidemencia]
ergoloid mesylates 1 mg  tab	6	Non-Preferred	HYDERGINE
Cholinesterase Inhibitors [Inhibidores de Colinesterasa]
donepezil hcl 10 mg tab,  10 mg odt, 5 mg tab, 5 mg odt	1	Preferred	ARICEPT
rivastigmine tartrate 1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap	3	Preferred	EXELON
NMDA Receptor Antagonists [Antagonista del Receptor NMDA]
memantine 10 mg tab, 5 mg tab	1	Preferred	NAMENDA
memantine TITRATIONPAK 5 (28)-10 (21) mg tab	1	Preferred	NAMENDA
ANTIDEPRESSANTS [ANTIDEPRESIVOS]
Antidepressants [Antidepresivos]
amitriptyline hcl 10 mg tab,  100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab	1	Preferred	ELAVIL	MENTAL, SUB MENTAL
doxepin hcl 10 mg cap, 10 mg/ml oral conc, 25 mg cap, 50 mg cap, 75 mg cap	1	Preferred	SINEQUAN	MENTAL, SUB MENTAL
imipramine hcl 10 mg tab, 25 mg tab, 50 mg tab	1	Preferred	TOFRANIL	MENTAL, SUB MENTAL
nortriptyline hcl 10 mg cap, 10 mg/5ml soln, 25 mg cap, 50 mg cap, 75 mg cap	1	Preferred	PAMELOR	MENTAL, SUB MENTAL
doxepin hcl 100 mg cap, 150 mg cap	2	Preferred	SINEQUAN	MENTAL, SUB MENTAL
duloxetine 20 mg cap, 30 mg cap, 60 mg cap	2	Non-Preferred	CYMBALTA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]
Alpha-Glucosidase Inhibitors [Inhibidores de Alfa Glucosidasa]
acarbose 100 mg tab, 25  mg tab, 50 mg tab	2	Preferred	PRECOSE
Biguanides [Biguanidas]
metformin hcl 1000 mg tab,  500 mg tab, 850 mg tab	1	Preferred	GLUCOPHAGE
metformin hcl er 500 mg tab er 24 hr, 750 mg tab er 24 hr	1	Preferred	GLUCOPHAGE XR
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors [Inhibidores de DPP-4]
KOMBIGL YZE XR 2.51000 mg tab er 24 hr, 5-1000 mg tab er 24 hr, 5-500 mg tab er 24 hr	0	Xxxxxxxxx		XX, X
XXXXXXX 2.5 mg tab, 5 mg tab	3	Preferred		ST, C
Glycemic Agents [Agentes Glicémicos]
GLUCAGON EMERGENCY 1 mg inj kit	4	Preferred
Insulin Mixtures [Mezclas de Insulinas]
HUMULIN 70/30 (70 -30) 100 unit/ml sc susp	3	Preferred		C
HUMALOG MIX 75/25 (7525) 100 unit/ml sc susp	4	Preferred		C
HUMALOG MIX 50/50 (5050) 100 unit/ml sc susp	4	Preferred		C
Insulin Sensitizing Agents [Agentes Sensibilizantes de Insulin]
pioglitazone hcl 15 mg tab,  30 mg tab, 45 mg tab	1	Preferred	ACTOS

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Intermediate-Acting Insulins [Insulinas de Duración Intermedia]
HUMULIN N  100 unit/ml sc susp	2	Preferred		C
Long-Acting Insulins [Insulinas de Larga Duración]
LANTUS SOLOSTAR 100  unit/ml subcutaneous solution pen-injector	2	Preferred		C

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
LANTUS 100 unit/ml sc soln	3	Preferred		C
Rapid-Acting Insulins [Insulinas de Rápida Duración]
HUMALOG 100 unit/ml sc  soln	3	Preferred		C
Short-Acting Insulins [Insulinas de Corta Duración]
HUMULIN R 100 unit/ml inj soln 2 Preferred  C
Sulfonylureas [Sulfonilureas]
glimepiride 1 mg tab, 2 mg  tab, 4 mg tab	1	Preferred	AMARYL
glipizide 10 mg tab, 5 mg tab	1	Preferred	GLUCOTROL
DIABETES SUPPLIES [SUMINISTROS PARA DIABETES]
Needles & Syringes [Agujas y Jeringuillas]
insulin syringe/needle	1	Preferred
ANTIEMETICS [ANTIEMÉTICOS]
5-Hydroxytryptamine 3 (5-HT3) Antagonists [Antagonistas de 5-HT3]
ondansetron 4 mg odt, 8  mg odt	1	Preferred	ZOFRAN ODT
ondansetron hcl 24 mg tab, 4 mg tab, 8 mg tab	1	Preferred	ZOFRAN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Miscellaneous Antiemetics [Antieméticos Misceláneos]
metoclopramide hcl 10 mg  tab, 10 mg/10ml soln, 5 mg tab, 5 mg/5ml soln, 5 mg/ml inj soln	1	Preferred	REGLAN
promethazine hcl 12.5 mg tab, 25 mg tab, 50 mg tab, 6.25 mg/5ml soln, 6.25 mg/5ml syr, 25 mg/ml  inj soln, 50 mg/ml inj soln	1	Preferred	PHENERGAN
trimethobenzamide hcl 300 mg cap	1	Preferred	TIGAN
Phenothiazines [Fenotiazinas]
prochlorperazine edisylate  5 mg/ml inj soln	1	Preferred	COMPAZINE

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
prochlorperazine maleate 10 mg tab, 5 mg tab	1	Preferred	COMPAZINE
prochlorperazine 25 mg rect supp	4	Non-Preferred	COMPAZINE
ANTIGOUT AGENTS [AGENTES ANTIGOTA]
Antigout Agents [Agentes Antigota]
allopurinol 100 mg tab, 300  mg tab	1	Preferred	ZYLOPRIM
colchicine 0.6 mg cap	3	Preferred	MITIGARE	PA
colchicine 0.6 mg tab	3	Non-Preferred	COLCRYS	QL= 3 tab, 15días
Uricosurics [Uricosúricos]
probenecid 500 mg tab	1	Preferred	BENEMID
ANTIHYPERTENSIVES [ANTIHIPERTENSIVOS]
Alpha-Adrenergic Agonists [Agonistas Alfa Adrenérgicos]
clonidine hcl 0.1 mg tab, 0.2 mg tab, 0.3 mg tab	1	Preferred	CATAPRESS

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

methyldopa 250 mg tab, 500 mg tab 1 Preferred ALDOMET

Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]
terazosin hcl 1 mg cap, 10  mg cap, 2 mg cap, 5 mg cap	1	Preferred	HYTRIN
Angiotensin II Receptor Blockers (ARB) [Antagonistas Del Receptor Angiotensina II]
losartan potassium 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	COZAAR
losartan potassium-hctz 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab	1	Preferred	HYZAAR
Angiotensin-Converting Enzyme (ACE) Inhibitors [Inhibidores de la Enzima Convertidora de Angiotensin]
fosinopril sodium 10 mg  tab, 20 mg tab, 40 mg tab	1	Preferred	MONOPRIL
lisinopril 10 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab	1	Preferred	ZESTRIL

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
lisinopril-hydrochlorothiazide 1012.5 mg tab, 20-12.5 mg tab, 20-25 mg tab	1	Preferred	ZESTORETIC
Calcium Channel Blocking Agents [Bloqueadores xx Xxxxxxx de Calcio]
amlodipine besylate 10 mg  tab, 2.5 mg tab, 5 mg tab	1	Preferred	NORVASC
diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab	1	Preferred	CARDIZEM
diltiazem hcl er 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr	1	Preferred	DILACOR XR

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

diltiazem hcl er beads 120 mg cap er 24 hr	1	Preferred	TIAZAC
diltiazem hcl er coated beads 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr	1	Preferred	CARDIZEM CD
dilt-xr 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr	1	Preferred	DILACOR XR
nifedipine er osmotic 30 mg tab er 24 hr	1	Preferred	PROCARDIA XL
verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab	1	Preferred	CALAN
verapamil hcl er 120 mg tab er, 180 mg tab er, 240 mg tab er	1	Preferred	CALAN SR
diltiazem hcl er beads 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg er 24 hr	2	Preferred	TIAZAC
diltiazem hcl er coated beads 300 mg cap er 24 hr	2	Preferred	CARDIZEM CD

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
nifedipine er osmotic 60 mg tab er 24 hr, 90 mg tab er 24 hr	2	Preferred	PROCARDIA XL
Carbonic Anhydrase Inhibitors Diuretics [Diuréticos Inhibidores de Anhidrasa Carbónica]
acetazolamide 125 mg tab,  250 mg tab	3	Preferred	DIAMOX
Cardioselective Beta Blocking Agents [Bloqueadores Beta Cardioselectivos]
atenolol 100 mg tab, 25 mg  tab, 50 mg tab	1	Preferred	TENORMIN
metoprolol succinate er 25 mg tab er 24 hr, 50 mg tab er 24 hr	1	Preferred	TOPROL XL

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00  xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	LOPRESSOR
metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr	2	Non-Preferred	TOPROL XL

Cardioselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos Cardioselectivos]
atenolol -chlorthalidone100-25 mg tab, 50-25 mg tab	1	Preferred	TENORETIC
metoprolol-hydrochlorothiazide 50-25 mg tab	2	Non-Preferred	LOPRESSOR HCT
metoprolol-hydrochlorothiazide 100-25 mg tab, 100-50 mg tab	3	Non-Preferred	LOPRESSOR HCT
Loop Diuretics [Diuréticos del Asa]
bumetanide 0.5 mg tab, 1  mg tab, 2 mg tab	1	Non-Preferred	BUMEX
furosemide 10 mg/ml soln, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	LASIX

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
Nonselective Beta Blocking Agents [Bloqueadores Beta No-Selectivos]
propranolol hcl 10 mg tab,  20 mg tab, 20 mg/5ml soln,40 mg tab, 40 mg/5ml soln, 80 mg tab	1	Preferred	INDERAL
propranolol hcl 60 mg tab	2	Non-Preferred	INDERAL
Potassium-Sparing Diuretics [Diuréticos Conservadores de Potasio]
spironolactone 100 mg tab,  25 mg tab, 50 mg tab	1	Preferred	ALDACTONE
triamterene-hctz 37.5-25 mg cap, 37.5-25 mg tab, 75-50 mg tab	1	Preferred	MAXZIDE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Thiazide Diuretics [Diuréticos Tiazidas]
chlorothiazide 250 mg tab,  500 mg tab	1	Preferred	DIURIL
chlorthalidone 25 mg tab, 50 mg tab	1	Non-Preferred	HYGROTON
DIURIL 250 mg/5ml susp	1	Preferred
hydrochlorothiazide 12.5 mg tab, 25 mg tab, 50 mg tab	1	Preferred	MICROZIDE
indapamide 1.25 mg tab,2.5 mg tab	1	Preferred	LOZOL
metolazone 2.5 mg tab, 5 mg tab	1	Non-Preferred	ZAROXOLYN
chlorthalidone 100 mg tab	2	Non-Preferred	HYGROTON
metolazone 10 mg tab	2	Non-Preferred	ZAROXOLYN
Vasodilator Beta Blockers [Bloqueadores Beta Vasodilatadores]
carvedilol 12.5 mg tab, 25  mg tab, 3.125 mg tab, 6.25 mg tab	1	Preferred	COREG
Vasodilators [Vasodilatadores]
hydralazine hcl 10 mg tab,  100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	APRESOLINE
minoxidil 10 mg tab, 2.5 mg tab	1	Preferred	LONITEN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
ANTIMIGRAINE AGENTS [AGENTES ANTIMIGRAÑA]
Beta-Adrenergic Blocking Agents [Bloqueadores Beta Adrenérgicos]
divalproex sodium 125 mg  tab dr, 250 mg tab dr, 500 mg tab dr	1	Preferred	DEPAKOTE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 1 Preferred TOPAMAX

Serotonin (5-HT) Receptor Agonists [Agonistas Del Receptor De Serotonina]
sumatriptan succinate 100  mg tab, 25 mg tab, 50 mg tab	1	Preferred	IMITREX	QL= 6 tab
ANTIMYASTHENIC AGENTS [AGENTES ANTIMIASTÉNICOS]
Parasympathomimetics [Parasimpatomiméticos]
pyridostigmine  bromide 60 mg tab	2	Preferred	MESTINON
MESTINON 60 mg/5ml syr	4	Non-Preferred
pyridostigmine bromide 180 mg tab er	6	Non-Preferred	MESTINON
ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]
Antituberculars [Antituberculosos]
isoniazid 100 mg tab, 300  mg tab	1	Preferred	ISONIAZID
rifampin 150 mg cap	1	Preferred	RIFADIN
ethambutol hcl 100 mg tab	2	Non-Preferred	MYAMBUTOL
pyrazinamide 500 mg tab	2	Non-Preferred	PYRAZINAMIDE
rifampin 300 mg cap	2	Preferred	RIFADIN
ethambutol hcl 400 mg tab	3	Non-Preferred	MYAMBUTOL
isoniazid 50 mg/5ml syr	5	Non-Preferred	ISONIAZID
rifabutin 150 mg cap			MYCOBUTIN	Puerto Rico Health Department Tuberculosis Control Program
cycloserine 250 mg cap			SEROMYCIN
RIFAMATE 50-300 mg cap
TRECATOR 250 mg tab
CAPASTAT 1 gm inj
Miscellaneous Antimycobacterials [Antimicobacterianos Misceláneos]
dapsone 100 mg tab, 25  mg tab	2	Preferred	DAPSONE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
ANTIMYCOTIC AGENTS [ANTIMICÓTICOS]
Antifungals [Antifungales]
fluconazole 10 mg/ml susp, 100 mg tab, 150 mg tab,200 mg tab, 50 mg tab	1	Preferred	DIFLUCAN
ketoconazole 200 mg tab	1	Preferred	NIZORAL
nystatin 100000 unit/gm crm	1	Preferred	MYCOSTATIN
terbinafine hcl 250 mg tab	1	Preferred	LAMISIL
fluconazole 40 mg/ml susp	2	Preferred	DIFLUCAN
itraconazole 100 mg cap		Preferred	SPORANOX	SIDA
Vaginal Antifungals [Antifungales Vaginales]
terconazole 0.4 % vag crm, 0.8 % vag crm	2	Preferred	TERAZOL
Antimalarials [Antimaláricos]
chloroquine phosphate 250  mg tab, 500 mg tab	1	Preferred	ARALEN
hydroxychloroquine sulfate 200 mg tab	1	Preferred	PLAQUENIL
DARAPRIM 25 mg tab	19	Non-Preferred		PA
Antiprotozoals - Non-Antimalarials [Antiprotozoarios No-Antimalaráricos]
NEBUPENT 300 mg inh  soln	4	Non-Preferred		PA
ANTIPARASITICS [ANTIPARASITARIOS]
Anthelmintics [Antihelmínticos]
PIN-X 720.5 xx xxxx tab	1	Preferred		OTC
REESES PINWORM MEDICINE 144 mg/ml Susp	1	Preferred		OTC
BILTRICIDE 600 mg tab	7	Non-Preferred		PA
ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]
Anticholinergics [Anticolinérgicos]
benztropine mesylate 0.5  mg tab, 1 mg tab, 2 mg tab	1	Preferred	COGENTIN
Antiparkinson Dopaminergics [Dopaminérgicos Antiparkinson]
amantadine hcl 50 mg/5ml  syr	1	Preferred	SYMMETREL

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
pramipexoledihydrochloride 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab,1.5 mg tab	1	Preferred	MIRAPEX
ropinirole hcl 0.25 mg tab, 0.5 mg tab, 1 mg tab, 3 mg tab, 4 mg tab, 5 mg tab	1	Preferred	REQUIP
ropinirole hcl 2 mg tab	2	Preferred	REQUIP
amantadine hcl 100 mg cap	3	Preferred	SYMMETREL
bromocriptine mesylate 2.5 mg tab	3	Preferred	PARLODEL
carbidopa-levodopaentacapone 18.75-75-200 mg tab	4	Non-Preferred	STALEVO
carbidopa-levodopaentacapone 12.5-50-200 mg tab, 00-000-000 mg tab, 31.25-125-200 mg tab,37.5-150-200 mg tab, 50200-200 mg tab	5	Non-Preferred	STALEVO
Dopamine Precursors [Precursores de Dopamina]
carbidopa -levodopa 10-100 mg tab, 25-100 mg tab	1	Preferred	SINEMET
carbidopa-levodopa 25250 mg tab	2	Preferred	SINEMET
carbidopa-levodopa er 25100 mg tab er, 50-200 mg tab er	2	Preferred	SINEMET CR
Monoamine Oxidase B (MAO-B) Inhibitors [Inhibidores de MAO-B]
selegiline hcl 5 mg tab	3	Non-Preferred	CARBEX

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 00 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

ANTIVIRALS [ANTIVIRALES]
Anti-Influenza Agents [Age ntes Anti-Infuenza]
oseltamivir phosphate 30 mg cap, 45 mg cap, 75 mg cap	4	Preferred	TAMIFLU
TAMIFLU 6 mg/ ml susp	13	Non-Preferred

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
Anti-Cytomegalovirus (CMV) Agents [Agentes Anti-Citomegalovirus]
valganciclovir hcl 450 mg  tab	13	Non-Preferred	VALCYTE	PA
Antiherpetic Agents [Agentes Antiherpéticos]
acyclovir 200 mg cap, 400  mg tab, 800 mg tab	1	Preferred	ZOVIRAX
acyclovir 200 mg/5ml susp	2	Preferred	ZOVIRAX
Antiretroviral Combinations [Combinaciones Antiretrovirales]
EPZICOM 600-300 mg tab				CENTROS DE PREVENCIÓN Y TRATAMIENTO - CLÍNICAS DE IMMUNOLOGÍA
ATRIPLA 000-000-000 mg tab
Integrase Inhibitors [Inhibidores de la Integrasa]
ISENTRESS potassium 400 mg tab				CENTROS DE PREVENCIÓN Y TRATAMIENTO - CLÍNICAS DE IMMUNOLOGÍA
Miscellaneous Anti-HIV Agents [Agentes Anti-VIH Misceláneos]
SELZENTRY 300 mg tab				CENTROS DE PREVENCIÓN Y TRATAMIENTO - CLÍNICAS DE IMMUNOLOGÍA
FUZEON subcutaneous kit 90 mg
Non-Nucleoside Reverse Transcriptase Inhibitors [Inhibidores No Nucleósidos de la TransciptasaReversa]
nevirapine 200 mg tab	1	Preferred	VIRAMUNE
nevirapine 50 mg/5ml susp	5	Non-Preferred	VIRAMUNE
RESCRIPTOR 200 mg tab	6	Non-Preferred
SUSTIVA 50 mg cap, 200 mg cap	6	Preferred		C
nevirapine er, 100 mg tab er 24 hr, 400 mg tab er 24 hr	7	Non-Preferred	VIRAMUNE XR
SUSTIVA 600 mg tab	7	Preferred		C

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 0 xx 00  xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
INTELENCE 200 mg tab				CENTROS DE PREVENCIÓN Y TRATAMIENTO - CLÍNICAS DE IMMUNOLOGÍA
Nucleoside/Nucleotide Reverse Transcriptase Inhibitors [Inhibidores Nucleósidos/Nucleótidos de la Transcriptasa Reversa]
zidovudine 300 mg tab	2	Non-Preferred	RETROVIR
stavudine 1 mg/ml soln, 15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap	3	Preferred	ZERIT
didanosine 125 mg cap dr, 200 mg cap dr, 250 mg cap dr	4	Non-Preferred	ZIAGEN
lamivudine 10 mg/ml soln	5	Preferred	EPIVIR
lamivudine 150 mg tab	4	Preferred	EPIVIR
zidovudine 100 mg cap, 50 mg/5ml syr	4	Non-Preferred	RETROVIR
abacavir sulfate 300 mg tab	5	Preferred	ZIAGEN
didanosine 400 mg cap dr	5	Non-Preferred	ZIAGEN
lamivudine 300 mg tab	5	Preferred	EPIVIR
VIDEX 2 gm soln	5	Non-Preferred
lamivudine 100 mg tab	6	Preferred	EPIVIR	PA
lamivudine-zidovudine 150-300 mg tab	6	Preferred	COMBIVIR
abacavir-lamivudinezidovudine 000-000-000 mg tab	10	Non-Preferred	TRIZIVIR
EMTRIVA 200 mg cap				CENTROS DE PREVENCIÓN Y TRATAMIENTO - CLÍNICAS DE IMMUNOLOGÍA
VIREAD 300 mg tab
TRUVADA 200-300 mg tab			TRUVADA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 00 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

BENIGN PROSTATIC HYPERTROPHY AGENTS [AGENTES PARA HIPERTROFIA PROSTÁTICA XXXXXXX]
5-Alpha Reductase Inhibitors [Inhibidores de 5-Alfa Reductasa]
finasteride 5 mg tab	1	Preferred	PROSCAR

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]
tamsulosin hcl 0.4 mg cap	1	Preferred	FLOMAX
terazosin hcl 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap	1	Preferred	HYTRIN
BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]
Anticoagulants [Anticoagulantes]
warfarin sodium 1 mg tab,  10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab,7.5 mg tab	1	Preferred	COUMADIN
heparin sodium (porcine) 1000 unit/ml inj soln	2	Preferred	HEPARIN
heparin sodium (porcine)10000 unit/ml inj soln,5000 unit/ml inj soln	3	Preferred	HEPARIN
heparin sodium (porcine) pf 5000 unit/0.5ml inj soln	3	Preferred	HEPARIN
heparin sodium (porcine) 2000 unit/xx xx soln	8	Preferred	HEPARIN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 00 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Cobalamins [Cobalaminas]
cyanocobalamin 1000  mcg/ml inj soln	1	Preferred	VIT B-12
Colony Stimulating Factors [Estimulantes Mieloides]
NEUPOGEN 300 mcg/0.5ml inj soln, 300 mcg/ml inj soln, 480 mcg/1.6ml inj soln	10	Preferred		PA, C
NEULASTA 6 mg/0.6ml sc soln	15	Preferred		PA, C
NEULASTA DELIVERYKIT6 mg/0.6ml sc soln	15	Preferred		PA, C
NEUPOGEN 480mcg/0.8ml inj soln	12	Preferred		PA, C

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Erythropoiesis-Stimulating Agents [Agentes Estimulantes de Eritropoiesis]
ARANESP (ALBUMIN FREE) 100 mcg/0.5ml inj soln	1	Preferred		PA, C
PROCRIT 2000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln	6	Preferred		PA, C
ARANESP (ALBUMINFREE) 25 mcg/0.42ml inj soln, 25 mcg/ml inj soln	6	Preferred		PA, C
PROCRIT 10000 unit/ml inj soln	7	Preferred		PA, C
ARANESP (ALBUMINFREE) 40 mcg/0.4ml inj soln	7	Preferred		PA, C
ARANESP (ALBUMINFREE) 40 mcg/ml inj soln, 60 mcg/ml inj soln	8	Preferred		PA, C

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 00 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

ARANESP (ALBUMINFREE) 150 mcg/0.3ml inj soln, 150 mcg/0.75ml inj soln, 200 mcg/0.4ml inj soln, 200 mcg/ml inj soln, 300 mcg/0.6ml inj soln, 300 mcg/ml inj soln, 500 mcg/ml inj soln, 60 mcg/0.3ml inj soln	9	Preferred		PA, C
PROCRIT 20000 unit/ml inj soln	9	Preferred		PA, C
ARANESP (ALBUMIN FREE) 100 mcg/ml inj soln	11	Preferred		PA, C
PROCRIT 40000 unit/ml inj soln	10	Preferred		PA, C
Factor Xa Inhibitors [Inhibidores Del Factor Xa]
ELIQUIS 2.5 mg tab	4	Preferred		PA, C
ELIQUIS 5 mg tab	4	Preferred		PA, C

Drug Name [Nombre del Me dicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Folates [Folatos]
folic acid 1 mg tab, 400  mcg tab, 800 mcg tab	1	Preferred	FOLIC ACID	OTC
Iron [Hierro]
ferrous sulfate 325 (65 fe)  mg tab	1	Preferred	IRON	OTC
INFED 50 mg/ml inj soln	5	Non-Preferred
Low Molecular Weight Heparins [Heparinas de Bajo Peso Molecular]
enoxaparin sodium 30  mg/0.3ml sc soln, 40 mg/0.4ml sc soln	5	Non-Preferred	LOVENOX	PA
enoxaparin sodium 300 mg/3ml inj soln, 60 mg/0.6ml sc soln, 80 mg/0.8ml sc soln	7	Non-Preferred	LOVENOX	PA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 00 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

enoxaparin sodium 100 mg/ml sc soln	9	Non-Preferred	LOVENOX	PA
enoxaparin sodium 120 mg/0.8ml sc soln	10	Non-Preferred	LOVENOX	PA
enoxaparin sodium 150 mg/ml sc soln	14	Non-Preferred	LOVENOX	PA
Platelet Modifying Agents [Modificadores de Plaquetas]
aspirin 325 mg tab, 325 mg  tab dr, 81 mg tab dr	1	Preferred	ASPIRIN	OTC
aspirin low dose 81 mg tab, 81 mg tab dr	1	Preferred	ASPIRIN	OTC
cilostazol 100 mg tab, 50 mg tab	1	Preferred	PLETAL
clopidogrel bisulfate 75 mg tab	1	Preferred	PLAVIX
BONE DENSITY REGULATORS [REGULADORES DE DENSIDAD ÓSEA]
Bisphosphonates [Bifosfonatos]
alendronate sodium 10 mg  tab, 35 mg tab, 5 mg tab, 70 mg tab	1	Preferred	FOSAMAX

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
CARDIOVASCULAR AGENTS [AGENTES CARDIOVASCULARES]
Antiarrhythmics Class II [Antiarrítmicos Clase II]
propranolol hcl 10 mg tab,  20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	INDERAL
sotalol hcl 120 mg tab, 160 mg tab, 240 mg tab, 80 mg tab	1	Preferred	BETAPACE
propranolol hcl 60 mg tab	2	Preferred	INDERAL
Antiarrhythmics Type I-A [Antiarrítmicos Tipo I-A]
quinidine sulfate 200 mg  tab, 300 mg tab	1	Preferred	QUINIDINE SULFATE
quinidine gluconate er 324 mg tab er	2	Preferred	QUINAGLUTE
quinidine sulfate er 300 mg tab er	2	Preferred	QUINIDINE SULFATE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 00 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Antiarrhythmics Type I-B [Antiarrítmicos Tipo I-B]
mexiletine hcl 150 mg cap	2	Preferred	MEXITIL
mexiletine hcl 200 mg cap	3	Preferred	MEXITIL
Antiarrhythmics Type I-C [Antiarrítmicos Tipo I-C]
flecainide acetate 100 mg  tab, 50 mg tab	1	Preferred	TAMBOCOR
propafenone hcl 150 mg tab, 225 mg tab	1	Preferred	RYTHMOL
flecainide acetate 150 mg tab	2	Preferred	TAMBOCOR
propafenone hcl 300 mg tab	3	Preferred	RYTHMOL
Antiarrhythmics Type III [Antiarrítmicos Tipo III]
amiodarone hcl 200 mg tab	1	Preferred	CORDARONE
Intermittent Claudication Agents [Agentes Para La Claudicación Intermitente]
pentoxifylline er 400 mg  tab er	1	Preferred	TRENTAL
Miscellaneous Cardiovascular Agents [Agentes Cardiovasculares Misceláneos]
digox 125 mcg tab, 250  mcg tab	2	Preferred	LANOXIN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
digoxin 0.05 mg/ml soln, 125 mcg tab, 250 mcg tab	2	Preferred	LANOXIN
Pulmonary Hypertension Agents [Agentes Para Hipertensión Pulmonar]
sildenafil citrate 20 mg tab	3	Preferred	REVATIO	PA
ADEMPAS 0.5 mg tab	15	Preferred		PA, C
ADEMPAS 1 mg tab, 1.5 mg tab, 2 mg tab	18	Preferred		PA, C
ADEMPAS 2.5 mg tab	20	Preferred		PA, C

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 00 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Vasodilators [Vasodilatadores]
isosorbide mononitrate 10  mg tab, 20 mg tab	1	Preferred	IMDUR
isosorbide mononitrate er 120 mg tab er 24 hr, 30 mg tab er 24 hr, 60 mg tab er 24 hr	1	Preferred	IMDUR
nitroglycerin 0.2 mg/hr td patch 24hr	1	Preferred	NITRODUR
NITROSTAT 0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl	1	Preferred
nitroglycerin 0.1 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr	2	Non-Preferred	NITRODUR
CENTRAL NERVOUS SYSTEM AGENTS [AGENTES SISTEMA NERVIOSO CENTRAL]
Multiple Sclerosis Agents [Agentes para Esclerosis Múltiple]
AMPYRA  10 tab er 12hr	9	Preferred		PA, C
COPAXONE 20 mg/ml sc kit	17	Preferred		PA, C
COPAXONE 40 mg/ml subcutaneous solution prefilled syringe	14	Preferred		PA, C
AVONEX 30 mcg im kit	13	Preferred		PA, C
AVONEX PEN 30 mcg/0.5ml im kit	13	Preferred		PA, C
AVONEX PREFILLED 30 mcg/0.5ml im kit	13	Preferred		PA, C
GILENYA 0.5 mg cap	15	Preferred		PA, C

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Xxxxxx 00 xx 00 xxxx xxxxxx xx costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
TYSABRI intravenous concentrate 300 mg/15ml	15	Preferred		PA, C

TECFIDERA 120 mg cap dr	14	Preferred		PA, C
TECFIDERA 240 mg cap dr	14	Preferred		PA, C
TECFIDERA 120-240 MG misc	14	Preferred		PA, C
BETASERON 0.3 mg sc kit	13	Preferred		PA, C
CHEMOTHERAPIES [QUIMIOTERAPIAS]
Alkylating Agents [Agentes Alquilantes]
lomustine 10 mg cap	3	Non-Preferred	XXXXX
ALKERAN 2 mg tab	4	Non-Preferred
temozolomide 5 mg cap	4	Non-Preferred	TEMODAR	PA
lomustine 40 mg cap	5	Non-Preferred	XXXXX
LEUKERAN 2 mg tab	6	Non-Preferred
lomustine 100 mg cap	6	Non-Preferred	XXXXX
MYLERAN 2 mg tab	7	Non-Preferred
temozolomide 20 mg cap	9	Non-Preferred	TEMODAR	PA
temozolomide 250 mg cap	11	Non-Preferred	TEMODAR	PA
temozolomide 140 mg cap	13	Non-Preferred	TEMODAR	PA
temozolomide 100 mg cap, 180 mg cap	14	Non-Preferred	TEMODAR	PA
Angiogenesis Inhibitors [Inhibidores de Angiogénesis]
STIVARGA 40 mg tab	15	Preferred		PA, C
Antiandrogens [Antiandrógenos]
bicalutamide 50 mg tab	2	Preferred	CASODEX
flutamide 125 mg cap	4	Non-Preferred	EULEXIN
Antiestrogens [Antiestrógenos]
tamoxifen  citrate 10 mg tab, 20 mg tab	1	Preferred	NOLVADEX
Vaginal Estrogens [Estrógenos Vaginal]
VAGIFEM 10 mcg vag tab	3	Non-Preferred
Antimetabolites [Antimetabolitos]
hydroxyurea 500 mg cap	2	Preferred	HYDREA
mercaptopurine 50 mg tab	2	Preferred	PURINETHOL
methotrexate 2.5 mg tab	2	Preferred	METHOTREXATE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 29 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
capecitabine 150 mg tab	7	Non-Preferred	XELODA	PA
capecitabine 500 mg tab	11	Non-Preferred	XELODA	PA
Antineoplastic Enzyme Inhibitors [Antineoplásicos Inhibidores de Enzimas]
SPRYCEL 20 mg tab	14	Preferred		PA, C
SPRYCEL 50 mg tab	21	Preferred		PA, C
imatinib 100 mg tab	18	Non-Preferred	GLEEVEC	PA
SPRYCEL 70 mg tab	17	Preferred		PA, C
SPRYCEL 80 mg tab	25	Preferred		PA, C
TASIGNA 150 mg cap	22	Preferred		PA, C
SPRYCEL 100 mg tab	25	Preferred		PA, C
AFINITOR 2.5 mg tab	25	Preferred		PA, C
NEXAVAR 200 mg tab	25	Preferred		PA, C
SPRYCEL 140 mg tab	25	Preferred		PA, C
AFINITOR 10 mg tab, 5 mg tab, 7.5 mg tab	23	Preferred		PA, C
TASIGNA 200 mg cap	19	Preferred		PA, C
imatinib 400 mg tab	25	Non-Preferred	GLEEVEC	PA
Apetite Stimulants [Estimulantes de Apetito]
megestrol acetate 20 mg  tab, 40 mg tab	1	Preferred	MEGACE
megestrol acetate 40 mg/ml susp, 400 mg/10ml susp	2	Preferred	MEGACE
Aromatase Inhibitors [Inhibidores de la Aromatasa]
anastrozole 1 mg tab	1	Preferred	ARIMIDEX
Folic Acid Antagonists Rescue Agents [Antagonistas de Ácido Fólico]
leucovorin calcium 5 mg  tab	3	Preferred	LEUCOVORIN
leucovorin calcium 10 mg tab, 15 mg tab	4	Preferred	LEUCOVORIN
leucovorin calcium 25 mg tab	9	Preferred	LEUCOVORIN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 30 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Luteinizing Hormone-Releasing (LHRH) Analogs [Análogos De LHRH]
LUPRON DEPOT 45 mg  im kit	2	Preferred		PA, C
LUPRON DEPOT 11.25 mg im kit, 3.75 mg im kit	6	Preferred		PA, C

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
LUPRON DEPOT-PED 11.25 mg im kit, 15 mg im kit, 7.5 mg im kit	8	Preferred		PA, C
LUPRON DEPOT 22.5 mg im kit, 30 mg im kit	9	Preferred		PA, C
LUPRON DEPOT-PED 11.25 mg (ped) im kit	9	Preferred		PA, C
LUPRON DEPOT-PED 30 mg (ped) im kit	10	Preferred		PA, C
leuprolide acetate 1 mg/ 0.2 ml inj kit	7	Non-preferred		PA
ZOLADEX 3.6 mg, 10.8 mg subcutaneous implant	7	Non-preferred		PA
Miscellaneous Antineoplastics [Antineoplásicos Misceláneos]
MATULANE 50 mg cap	10	Non-Preferred		PA
ACTIMMUNE 2000000 unit/0.5ml sc soln	25	Non-Preferred		PA
INTRON A  6000000 unit/ml, 10000000 unit, 18000000 unit, 50000000 unit		Non-Preferred		PA
Mitotic Inhibitors [Inhibidores Mitóticos]
etoposide 50 mg cap	4	Non-Preferred	VEPESID

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 3 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]

Antifungals [Antifungales]
clotrimazole 10 mg  mouth/throat lozenge, 10 mg mouth/throat troche	1	Preferred	MYCELEX
nystatin 100000 unit/ml mouth/throat susp	1	Preferred	MYCOSTATIN
Oral Antiseptics [Antisépticos Orales]
chlorhexidine gluconate  0.12 % mouth/throat soln 1 Preferred PERIDEX
Xerostomia [Xerostomía]
pilocarpine 5 mg tab	3	Preferred	SALAGEN

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]
Acne Antibiotics [Antibióticos para Acné]
sulfacetamide sodium sulfur 10-5 % external emulsion	1	Preferred	SULFACET R
clindamycin phosphate 1 % soln	2	Preferred	CLEOCIN T
erythromycin 2 % gel, 2 % soln	2	Preferred	ERYGEL
Acne Products [Productos para el Acné]
tretinoin 0.05 % crm,	2	Preferred	RETIN A	AL < 21 años
isotretinoin 10 mg cap, 20 mg cap, 30 mg cap	6	Preferred	Zenatane
Antihistamines [Antihistamínicos]
hydroxyzine hcl 10 mg tab,  10 mg/5ml soln, 10 mg/5ml syr, 25 mg tab, 50 mg tab	1	Preferred	ATARAX
Antipsoriatics [Antipsoriáticos]
methoxsalen 10 m cap		Preferred	Oxsoralen
Antiseborrheic Products [Productos Antiseborrea]
selenium sulfide 2.5 % lot	1	Preferred	SELSUN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 32 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

nystatin 100000 unit/gm oint, crm	1	Preferred	MYCOSTATIN
Dermatological Skin Cancer Agents [Dermatológicos para Cáncer de la Piel]
fluorouracil 2 % soln, 5 %  soln	3	Preferred	EFUDEX
fluorouracil 5 % crm	4	Non-Preferred	EFUDEX
Very High Potency Topical Glucocorticoids [Glucocorticoides Tópicos de Muy Alta Potencia]
betamethasone dipropionate aug 0.05 % crm	3	Non-Preferred	DIPROLENE
betamethasone dipropionate aug 0.05 % oint	4	Non-Preferred	DIPROLENE
High Potency Topical Glucocorticoids [Glucocorticoides Tópicos de Alta Potencia]
mometasone furoate 0.1 % oint, 0.1% crm, 0.1% soln	1	Preferred	ELOCON

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
Medium Potency Topical Glucocorticoids [Glucocorticoides Tópicos de Mediana Potencia]
triamcinolone acetonide  0.1 % crm, 0.1 % oint, 0.5 % crm, 0.5 % oint	1	Preferred	KENALOG
betamethasone valerate 0.1 % crm, 0.1 % lot, 0.1 % oint	1	Preferred	DIPROLENE
Low Potency Topical Glucocorticoids [Glucocorticoides Tópicos de Baja Potencia]
hydrocortisone 2.5 % crm,  2.5 % lot, 2.5 % oint	1	Preferred	HYDROCORTISONE
Pediculicides and Scabicides [Pediculicidas y Escabicidas]
permethrin 5 % crm	3	Preferred	ELIMITE	QL= 60 gm.
lindane 1 % lot	4	Non-Preferred	LINDANE	QL = 60 cc, 30días,  ST
Topical Skin Antibiotics [Antibióticos Tópicos para la piel]
mupirocin 2 % oint	1	Preferred	BACTROBAN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 33 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

silver sulfadiazine 1 % crm	1	Preferred	SILVADENE
metronidazole 0.75 % crm, 0.75 % gel, 0.75 % lot	4	Non-Preferred	METROLOTION
Topical Antifungals [Antifungales Tópicos]
clotrimazole 1 % crm	1	Preferred	LOTRIMIN	OTC (crm)
nystatin 100000 unit/gm oint, crm	1	Preferred	MYCOSTATIN
Topical Antipsoriatics [Antipsoriáticos Tópicos]
calcipotriene 0.005 % crm	6	Non-Preferred	DOVONEX
acitretin 10 mg cap, 17.5 mg cap, 25 mg cap	7	Non-Preferred	SORIATANE
DYSLIPIDEMICS [DISLIPIDÉMICOS]
Bile Acid Sequestrants [Secuestradores de Acidos Biliares]
cholestyramine 4 gm pckt,  4 gm/dose oral pwdr	3	Preferred	QUESTRAN
Fibric Acid Derivatives [Derivados de Ácido Fíbrico]
gemfibrozil 600 mg tab	1	Preferred	LOPID
HMG-CoA Reductase Inhibitors [Inhibidores de la Reductasa De HMG-CoA]
atorvastatin calcium 10 mg  tab, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	LIPITOR

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
pravastatin sodium 10 mg tab, 20 mg tab, 80 mg tab	1	Non-Preferred	PRAVACHOL
simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab, 80 mg tab	1	Preferred	ZOCOR
pravastatin sodium 40 mg tab	2	Non-Preferred	PRAVACHOL
GASTROINTESTINAL AGENTS [AGENTESGASTROINTESTINALES]
Antispasmodics [Antiespasmódicos]
dicyclomine hcl 10 mg cap,  20 mg tab	1	Preferred	BENTYL

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 34 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

dicyclomine hcl 10 mg/5ml soln 2 Preferred BENTYL

Anti-Ulcer Agents [Agentes Anti-Ulceras]
misoprostol 100 mcg tab,  200 mcg tab	1	Preferred	CYTOTEC
sucralfate 1 gm tab	1	Preferred	CARAFATE
1 gm/10ml susp	3	Non-Preferred
Digestive Enzymes [Enzimas Digestivas]
CREON 12000 unit cap dr  prt, 6000 unit cap dr prt	3	Preferred		C
CREON 24000 unit cap dr prt, 36000 unit cap dr prt, 3000-9500 unit cap dr prt	5	Preferred		C
Histamine2 (H2) Receptor Antagonists [Antagonistas del Receptor de H2]
famotidine 20 mg tab, 40 mg tab	1	Preferred	PEPCID
ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr	1	Preferred	ZANTAC
Miscellaneous Gastrointestinal Agents [Agentes Gastrointestinales Misceláneos]
ursodiol 300 mg cap	4	Preferred	ACTIGALL	PA
cromolyn sodium 100 mg/5ml oral conc	6	Non-Preferred	GASTROCROM	PA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Proton Pump Inhibitors [Inhibidores de la Bomba de Protones]
omeprazole 10 mg cap dr, 20 mg cap dr,40 mg cap dr	1	Preferred	PRILOSEC	QL=180 caps/ 365 días
Rectal Anti-Inflammatories [Anti-Inflamatorios Rectales]
hydrocortisone ace pramoxine 1-1 % rect crm, 2.5-1 % rect crm	2	Preferred	ANALPRAM-HC

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 35 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

GENITOURINARY AGENTS [AGENTES GENITOURINARIOS]
Miscellaneous Genitourinary Agents [Agentes Genitourinarios Misceláneos]
phenazopyridine hcl 100  mg tab, 200 mg tab	1	Preferred	PYRIDIUM	QL= 6 tab.
Phosphate Binder Agents [Enlazadores de Fosfato]
RENVELA  0.8 gm pckt	8	Preferred		PA, C
RENVELA 2.4 gm pckt, 800 mg tab	8	Preferred		PA, C
calcium acetate 667 mg cap.	3	Non-Preferred	PHOSLO
Urinary Antibiotics [Antibióticos Urinarios]
ur n -c 81.6 mg tab	1	Preferred	URIN D/S
URETRON D/S tab	1	Preferred
URIMAR-T 120 mg tab	1	Preferred
urin ds tab	1	Preferred	URIN D/S
Urinary Antispasmodics [Antiespasmódicos Urinarios]
oxybutynin chloride 5 mg  tab, 5 mg/5ml syr	1	Preferred	DITROPAN
HEMATOLOGICAL AGENTS [AGENTES HEMATOLÓGICOS]
Antihemophilic Products [Productos Antithemofílicos]
ADVATE 250 unit iv soln,  500 unit iv soln, 1000 unit iv soln, 1500 unit iv soln, 2000 unit iv soln, 3000 unit iv soln, 4000 unit iv soln	25	Preferred		PA, C

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
ALPHANATE/VWF COMPLEX/HUMAN 250 unit iv soln, 500 unit iv soln, 1000 unit iv soln, 1500 unit iv soln, 2000 unit iv soln	25	Non-Preferred		PA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 36 de  53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

KOGENATE FS 1000 unit intravenous kit, 2000 unit intravenous kit, 250 unit intravenous kit, 3000 unit intravenous kit, 500 unit intravenous kit	25	Preferred		PA, C
KOGENATE FS BIO-SET 1000 unit intravenous kit, 2000 unit intravenous kit, 250 unit intravenous kit, 3000 unit intravenous kit, 500 unit intravenous kit	25	Preferred		PA, C
BENEFIX 250 unit intravenous kit, 500 unit intravenous kit, 1000 unit intravenous kit, 2000 unit intravenous kit, 3000 unit intravenous kit	25	Preferred		PA, C
ANTIINHIBITOR COAGULANT COMPLEX for inj	25	Non-Preferred		PA
ANTIHEMOPHILIC FACTOR VIII for inj.	25	Non-Preferred		PA
Hemostatics [Hemostáticos]
tranexamic acid  650 mg tab, 1000 mg/ ml IV soln	4	Non-Preferred	LYSTEDA	PA
AMICAR 500 mg tab, 0.25 gm/ml oral soln	5	Non-Preferred		PA
AMICAR 0.25 gm/ml oral soln	8	Non-Preferred		PA
tranexamic acid  100 mg/ml IV soln		Non-Preferred	CYKLOKAPRON	PA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 37 de  53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
HORMONAL AGENTS [AGENTES HORMONALES]
Androgens [Andrógenos]
testosterone cypionate 100  mg/ml im soln, 200 mg/ml im soln	2	Preferred	DEPO- TESTOSTERONE
Antithyroid Agents [Agentes Antitiroide]
methimazole 10 mg tab, 5  mg tab	1	Preferred	TAPAZOLE
propylthiouracil 50 mg tab	2	Preferred	PROPYLTHIOURACIL
Calcimimetics [Calcimiméticos]
SENSIPAR 30 mg tab	7	Preferred		PA, C
SENSIPAR 60 mg tab	9	Preferred		PA, C
SENSIPAR 90 mg tab	10	Preferred		PA, C
Dopamine Agonists [Agonistas de Dopamina]
bromocriptine mesylate 2.5  mg tab	3	Preferred	PARLODEL
cabergoline 0.5 mg tab	3	Preferred	DOSTINEX
Dysmenorrhea Agents [Agentes para la Dismenorrea]
medroxyprogesterone  acetate 10 mg tab, 2.5 mg tab, 5 mg tab	1	Preferred	PROVERA
alyacen 1/35 1-35 mg-mcg tab	2	Preferred	ARANELLE	PA
CRYSELLE-28 0.3-30 mgmcg tab	2	Preferred		PA
LOW-OGESTREL 0.3-30 mg-mcg tab	2	Preferred		PA
medroxyprogesterone acetate 150mg/ml susp	5	Preferred	DEPO-PROVERA	PA
Estrogens [Estrógenos]
estradiol 0.5 mg tab, 1 mg  tab, 2 mg tab	1	Preferred	ESTRACE
estropipate 0.75 mg tab, 1.5 mg tab	1	Preferred	ESTROPIPATE
estropipate 3 mg tab	2	Preferred	ESTROPIPATE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 38 de  53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Estrogens and Progestins [Estrógenos y Progestinas]
estradiol  -norethindrone acet 1-0.5 mg tab	4	Non-Preferred	ACTIVELLA
Growth Hormones Analogs [Análogos de Hormona de Crecimiento]
NORDITROPIN FLEXPRO 5 mg/1.5ml sc soln	5	Preferred		PA, C
NORDITROPIN FLEXPRO 30 mg/3ml sc soln	8	Preferred		PA, C
NORDITROPIN NORDIFLEX 30 mg/3ml sc soln	9	Preferred		PA, C
NORDITROPIN FLEXPRO 10 mg/1.5ml sc soln, 15 mg/1.5ml sc soln	8	Preferred		PA, C
Mineralocorticoids [Mineralocorticoides]
fludrocortisone acetate 0.1  mg tab	1	Preferred	FLORINEF
Prostaglandins [Prostaglandinas]
misoprostol 100 mcg tab,  200 mcg tab	1	Preferred	CYTOTEC
Somatostatic Analogs [Análogos de Somastatina]
octreotide acetate 50  mcg/ml inj soln	3	Preferred	SANDOSTATIN	PA
octreotide acetate 100 mcg/ml inj soln, 1000 mcg/5ml inj soln, 200 mcg/ml inj soln, 500 mcg/ml inj soln	6	Preferred	SANDOSTATIN	PA
octreotide acetate 1000 mcg/ml inj soln	8	Preferred	SANDOSTATIN	PA
SANDOSTATIN LAR DEPOT 10 mg im kit	11	Non-Preferred		PA
SANDOSTATIN LAR DEPOT 30 mg im kit	14	Non-Preferred		PA
SANDOSTATIN LAR DEPOT 20 mg im kit	16	Non-Preferred		PA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 39 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Thyroid Hormones [Hormona Tiroidea]
levothyroxine sodium 100  mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab	1	Preferred	SYNTHROID
SYNTHROID 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab	1	Preferred		C
Vasopressin Analogs [Análogos de Vasopresina]
desmopressin  acetate 4 mcg/ml inj soln	2	Non-Preferred	DDAVP
desmopressin acetate 0.2 mg tab	3	Non-Preferred	DDAVP
desmopressin ace rhinal tube 0.01 % nasal soln	4	Non-Preferred	DDAVP
desmopressin ace spray refrig 0.01 % nasal soln	4	Non-Preferred	DDAVP
desmopressin acetate 0.1 mg tab	4	Non-Preferred	DDAVP
desmopressin acetate spray 0.01 % nasal soln	4	Non-Preferred	DDAVP
STIMATE 1.5 mg/ml nasal soln	7	Non-Preferred

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 40 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

IMMUNOLOGICAL AGENTS [AGENTES INMUNOLÓGICOS]
Immunomodulators (TNF and Non-TNF) [Inmunomoduladores (TNF y No-TNF)]
ENBREL 25 mg sc kit, 25mg/0.5ml sc sol	9	Preferred		PA, C
ENBREL 50mg/ml sc soldermat	9	Preferred		PA, C

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
HUMIRA 10 mg/0.2ml sc kit, 20 mg/0.4ml sc kit, 40 mg/0.8ml sc kit	9	Preferred		PA, C
REMICADE 100 mg iv soln	16	Preferred		PA, C
IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]
Organ Transplant Agents
cyclosporine modified 25  mg cap, 50 mg cap	3	Preferred	NEORAL	aPA
cyclosporine modified 25 mg cap, 50 mg cap	3	Preferred	NEORAL	aPA
NEORAL 25 mg cap	4	Preferred		aPA, C
cyclosporine 25 mg cap	4	Preferred	SANDIMMUNE	aPA
cyclosporine modified 100 mg cap, 100 mg/ml soln	4	Preferred	NEORAL	aPA
cyclosporine 100 mg cap	5	Preferred	SANDIMMUNE	aPA
cyclosporine modified 100 mg cap	5	Preferred	NEORAL	aPA
NEORAL 100 mg cap	5	Preferred		aPA, C
cyclosporine 100 mg cap, 25 mg cap	6	Preferred	SANDIMMUNE	aPA
SANDIMMUNE 100 mg cap, 100 mg/ml soln, 25 mg cap	6	Preferred		aPA, C
cyclosporine modified 100 mg/ml soln	7	Preferred	NEORAL	aPA
NEORAL 100 mg/ml soln	8	Preferred		aPA, C

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 4 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Glucocorticosteroids [Glucocorticoides]
dexamethasone 0.5 mg  tab, 0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab	1	Preferred	DECADRON
dexamethasone sodium phosphate 120 mg/30ml inj soln, 20 mg/5ml inj soln, 4 mg/ml inj soln	1	Preferred	DECADRON	OB-GYN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 42 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
KENALOG 10 mg/ml inj susp	1	Preferred
MEDROL 2 mg tab	1	Preferred
methylprednisolone 32 mg tab, 4 mg tab	1	Preferred	MEDROL
methylprednisolone (pak) 4 mg tab	1	Preferred	MEDROL
prednisolone 15 mg/5ml soln, 15 mg/5ml syr	1	Preferred	PRELONE
prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab	1	Preferred	DELTASONE
prednisone (pak) 10 mg tab, 5 mg tab	1	Preferred	DELTASONE
hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab	2	Preferred	CORTEF
methylprednisolone 16 mg tab, 8 mg tab	2	Preferred	MEDROL
cortisone acetate 25 mg tab	3	Non-Preferred	CORTISONE
KENALOG 40 mg/ml inj susp	5	Non-Preferred
betamethasone sod phos & acet 6 mg/ml inj susp	2	Preferred	CELESTONE SOLUSPAN	OB-GYN
Organ Transplant Agents [Agentes para Trasplantes]
azathioprine 50 mg tab	1	Preferred	IMURAN
AZASAN 75 mg, 100 mg		Non-Preferred
mycophenolate mofetil 200 mg/ml susp, 250 mg cap, 500 mg tab	2	Preferred	CELLCEPT	aPA
tacrolimus 0.5 mg cap	3	Non-Preferred	PROGRAF	aPA
MYFORTIC 180 mg tab dr	4	Preferred		aPA, C
tacrolimus 1 mg cap	4	Non-Preferred	PROGRAF	aPA
sirolimus 0.5 mg tab, 1 mg tab, 2 mg tab	5	Non-Preferred	RAPAMUNE	aPA
MYFORTIC 360 mg tab dr	6	Preferred		aPA, C
tacrolimus 5 mg cap	6	Non-Preferred	PROGRAF	aPA
RAPAMUNE 1 mg/ml soln	8	Non-Preferred		aPA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 43 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
INFLAMMATORY BOWEL DISEASE [ENFERMEDAD INFLAMATORIA INTESTINAL]
Aminosalicylates [Aminosalicilatos]
mesalamine  rectal enema 4 gm	4	Preferred	ROWASA
DELZICOL 400 mg cap dr	5	Preferred		C
ASACOL HD 800 mg tab dr	6	Preferred		C
Immunomodulators (TNF and Non-TNF) [Inmunomoduladores (TNF y No-TNF)]
ENBREL 25 mg sc kit, 25mg/0.5ml sc sol	8	Preferred		PA, C
ENBREL 50mg/ml sc sol	9	Preferred		PA, C
HUMIRA 10 mg/0.2 ml sc kit, 20 mg/0.4ml sc kit, 40 mg/0.8ml sc kit	11	Preferred		PA, C
HUMIRA PEDIATRIC CROHNS START 40 mg/0.8ml sc kit	11	Preferred		PA, C
HUMIRA PEN 40 mg/0.8ml sc kit	11	Preferred		PA, C
HUMIRA PEN-CROHNS STARTER 40 mg/0.8ml sc kit	11	Preferred		PA, C
HUMIRA PEN-PSORIASIS STARTER 40 mg/0.8ml sc kit	11	Preferred		PA, C
REMICADE 100 mg iv soln	13	Preferred		PA, C

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 44 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Intrarectal Low Potency Glucocorticoids [Glucocorticoides Intrarectales de Baja Potencia]
hydrocortisone 100  mg/60ml rect enema	2	Preferred	COLOCORT
Sulfonamides [Sulfonamidas]
sulfasalazine 500 mg tab,  500 mg tab dr	1	Preferred	AZULFIDINE
MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]
Calcium Regulating Agents [Agentes Reguladores de Calcio]
calcitriol 0.25 mcg cap	1	Preferred	ROCALTROL
calcitriol 0.5 mcg cap	2	Preferred	ROCALTROL

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Carnitine Deficiency [Deficiencia de Carnitina]
levocarnitine 1 gm/10ml soln, 330 mg tab	3	Preferred	CARNITOR
Chelating Agents [Agentes Quelantes]
DEPEN TITRATABS  250 mg tab	25	Preferred		PA
Electrolytes/Minerals Replacement [Reemplazo de Electrolitos/Minerales]
potassium chloride 20  meq/15ml (10%) oral liquid, 20 meq/15ml (10%) soln	1	Preferred	KAY-CIEL
potassium chloride crys er 10 meq tab er, 20 meq tab er	1	Preferred	KLOR-CON
potassium chloride er 10 meq cap er, 8 meq cap er	2	Preferred	MICRO-K
potassium chloride 40 meq/15ml (20%) oral solution	4	Preferred	KAON CL
Potassium Removing Resins [Resinas Removedoras de Potasio]
sodium polystyrene  sulfonate 15 gm/60ml susp	3	Preferred	KAYEXALATE

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 45 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Prenatal Vitamins [Vitaminas Prenatales]
classic   prenatal 28-0.8 mg tab	1	Preferred	PRENATAL VITAMINS	OB-GYN
prenatal 27-0.8 mg tab, 271 mg tab, 28-0.8 mg tab	1	Preferred	PREPLUS	OB-GYN
prenatal 19 tab chew, tab, 29-1 mg tab chew, 29-1 mg tab	1	Preferred	PRENATAL VITAMINS	OB-GYN
prenatal formula 28-0.8 mg tab	1	Preferred	PRENATAL VITAMINS	OB-GYN
prenatal low iron 27-0.8 mg tab, 27-1 mg tab	1	Preferred	PREPLUS	OB-GYN
prenatal plus iron 29-1 mg tab	1	Preferred	PRENATABS	OB-GYN
prenatal vitamins 0.8 mg tab, 28-0.8 mg tab	1	Preferred	PRENATAL VITAMINS	OB-GYN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos  /Límites]
Vitamin K [Vitamina K]
MEPHYTOIN 5 mg tab	6	Non-Preferred
MUSCLE RELAXANTS [RELAJANTES MUSCULARES]
Antispasticity Agents [Agentes Antiespasticidad]
baclofen 10 mg tab, 20 mg  tab	1	Preferred	LIORESAL
dantrolene sodium 25 mg cap, 50 mg cap	2	Preferred	DANTRIUM
dantrolene sodium 100 mg cap	3	Preferred	DANTRIUM
Skeletal Muscle Relaxants [Relajantes Musculoesqueletales]
cyclobenzaprine hcl 10 mg  tab	1	Preferred	FLEXERIL
NASAL AGENTS [AGENTES NASALES]
Nasal Anticholinergics [Anticolinérgicos Nasales]
ipratropium bromide 0.03  % nasal soln	2	Non-Preferred	ATROVENT
Nasal Mast Cell Stabilizers [Estabilizadores Nasales de Mastocitos]
cromolyn sodium  5.2 mg/act nasal aerosol sol	1	Preferred	NASALCROM

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 46 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Nasal Steroids [Esteroides Nasales]
fluticasone propionate 50  mcg/act nasal susp	1	Preferred	FLONASE	QL = 1 pompa / 30 días
OPHTHALMIC AGENTS [AGENTES OFTÁLMICOS]
Antiglaucoma Agents [Agentes Antiglaucoma]
brimonidine tartrate 0.2 %  ophth soln	1	Preferred	ALPHAGAN
dorzolamide hcl 2 % ophth soln	1	Preferred	TRUSOPT
levobunolol hcl 0.25 % ophth soln, 0.5 % ophth soln	1	Preferred	BETAGAN
timolol maleate 0.25 % ophth soln, 0.5 % ophth soln	1	Preferred	TIMOPTIC
dorzolamide hcl-timolol mal ophth sol 22.3-6.8 mg/ml	1	Preferred	COSOPT

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
betaxolol hcl 0.5 % ophth soln	2	Non-Preferred	BETOPTIC
Miotics [Mióticos]
pilocarpine hcl 1 % ophth  soln, 2 % ophth soln, 4 % ophth soln	3	Preferred	ISOPTOCARPINE
Mydriatics [Midriáticos]
atropine sulfate 1 % ophth  oint, 1 % ophth soln	1	Preferred	ISO-ATROPINE
Nonsteroidal Anti-Inflammatory Agents (NSAIDs) [Anti-Inflamatorios No Esteroidales]
diclofenac sodium 0.1 %  ophth soln	1	Preferred	VOLTAREN	QL = max 30 días / 365 días
ketorolac tromethamine 0.5 % ophth soln	1	Preferred	ACULAR	QL = max 30 días / 365 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 47 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Ophthalmic Antibiotics [Antibióticos Oftálmicos]

ciprofloxacin hcl 0.3 %  ophth soln	1	Preferred	CILOXAN
gentamicin sulfate 0.3 % ophth oint, 0.3 % ophth soln	1	Preferred	GARAMYCIN
ofloxacin 0.3 % ophth soln	1	Preferred	OCUFLOX
polymyxin b-trimethoprim 10000-0.1 unit/ml-% ophth soln	1	Preferred	POLYTRIM
tobramycin 0.3 % ophth soln	1	Preferred	TOBREX
bacitracin 500 unit/gm ophth oint	3	Non-Preferred	BACITRACIN
Ophthalmic Antivirals [Antivirales Oftálmicos]
trifluridine 1 % ophth soln	4	Non-Preferred	VIROPTIC	PA
Ophthalmic Prostaglandins [Prostaglandinas Oftálmicas]
latanoprost 0.005 % ophth  soln	1	Preferred	XALATAN

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Ophthalmic Steroids [Esteroides Oftálmicos]
neomycin  -polymyxindexamethasone 3.5- 10000-0.1 ophth oint, 3.5- 10000-0.1 ophth susp	1	Preferred	MAXITROL
prednisolone acetate 1 % ophth susp	2	Preferred	PRED FORTE
prednisolone sodium phosphate 1 % ophth soln	2	Preferred	INFLAMASE
fluorometholone 0.1 % ophth susp	3	Preferred	FML LIQUIFILM

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 48 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

OTIC AGENTS [AGENTES OTICOS]
Miscellaneous Otic Agents [Agentes Oticos Misceláneos]
acetic acid 2 % otic soln	2	Preferred	VOSOL
Otic Antibiotics [Antibióticos Oticos]
neomycin  -polymyxin-hc 1 % otic soln, 3.5-10000-1 otic soln, 3.5-10000-1 otic susp	2	Preferred	CORTISPORIN
cipro hc  0.2-1 % otic susp	1	Preferred
RESPIRATORY AGENTS [AGENTES RESPIRATORIOS]
Anticholinergic Bronchodilators [Broncodilatadores Anticolinérgicos]
ipratropium bromide 0.02  % inh soln	1	Preferred	ATROVENT
Antileukotrienes [Antileukotrienos]
montelukast sodium 10 mg  tab, 4 mg tab chew, 5 mg tab chew	1	Preferred	SINGULAIR
Antitussive-Expectorant [Expectorantes Antitusivos]
benzonatate  100 mg cap	1	Preferred	TESSALON
guaifenesin-codeine 10010 mg/5ml soln	1	Preferred	CHERATUSSIN
Bronchiolitis Agents [Agentes para Bronquiolitis]
SYNAGIS 50 mg/0.5ml im  soln	9	Preferred		PA, C
SYNAGIS 100 mg/ml im soln	11	Preferred		PA, C

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Inhaled Corticosteroids [Corticosteroides Inhalados]
FLOVENT DISKUS 100  mcg/blist inh aer pwdr, 250 mcg/blist inh aer pwdr, 50 mcg/blist inh aer pwdr	3	Preferred		QL = 1 pompa / 30 días, C

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 49 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

FLOVENT HFA 110 mcg/act inh aer, 44 mcg/act inh aer	3	Preferred		QL = 1 pompa / 30 días, C
ADVAIR DISKUS 100-50 mcg/dose inh aer pwdr, 250-50 mcg/dose inh aer pwdr	4	Preferred		QL= 1 pompa / 30 días, ST, C
ADVAIR HFA 115-21 mcg/act inh aer, 45-21 mcg/act inh aer	4	Preferred		QL= 1 pompa / 30 días, ST, C
budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp	4	Non-Preferred	PULMICORT	AL ≤ 12 años
budesonide 1mg/2ml inh susp	8	Non-Preferred	PULMICORT	AL ≤ 12 años
FLOVENT HFA 220 mcg/act inh aer	4	Preferred		QL= 1 pompa / 30 días, C
ADVAIR DISKUS 500-50 mcg/dose inh aer pwdr	5	Preferred		QL= 1 pompa / 30 días, ST, C
ADVAIR HFA 230-21 mcg/act inh aer	5	Preferred		QL= 1 pompa / 30 días, ST, C
Nonsedating Histamine1 Blocking Agents [Bloqueadores de Histamina1 No-Sedantes]
cetirizine HCl oral soln 1 MG/ML (5 MG/5ML)	1	Preferred	ZYRTEC	OTC
loratadine 5 mg/5ml soln, 5 mg/5ml syr	1	Preferred	CLARITIN	OTC
loratadine 10 mg tab	1	Preferred	CLARITIN	OTC
Phosphodiesterase Inhibitors [Inhibidores de la Fosfodiesterasa]
theophylline er 100 mg tab  er 12 hr, 200 mg tab er 12 hr, 300 mg tab er 12 hr, 450 mg tab er 12 hr	1	Preferred	THEO-DUR

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 50 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos /Límites]
Sympathomimetic Bronchodilators [Broncodilatadores Simpatomiméticos]
albuterol sulfate (2.5  mg/3ml) 0.083% inh neb soln, (5 mg/ml) 0.5% inh neb soln, 2 mg/5ml syr	1	Preferred	ALBUTEROL
terbutaline sulfate 2.5 mg tab, 5 mg tab	1	Preferred	BRETHINE
VENTOLIN HFA 108 (90 base) mcg/act inh aer	2	Preferred		QL = 1 pompa / 30 días, C
RHEUMATOID ARTHRITIS AGENTS [AGENTES PARA ARTRITIS REUMATOIDE]
Immunomodulators (TNF And Non-TNF) [Inmunomoduladores (TNF Y No-TNF)]
ENBREL 25 mg sc kit, 25mg/0.5ml sc sol	8	Preferred		PA, C
ENBREL 50mg/ml sc sol	9	Preferred		PA, C
ORENCIA 125 mg/ml subcutaneous solution prefilled syringe, 125 mg/ml ClickJect sc sol Autoinjector	10	Preferred		PA, C
HUMIRA 10 mg/ 0.2ml sc kit, 20 mg/0.4ml sc kit, 40 mg/0.8ml sc kit	11	Preferred		PA, C
REMICADE 100 mg iv soln	13	Preferred		PA, C
Non-Biologic Agents [Agentes No-Biológicos]
methotrexate 2.5 mg tab	2	Preferred	METHOTREXATE
leflunomide 10 mg tab, 20 mg tab	4	Non-Preferred	ARAVA	PA
DEPEN TITRATABS 250 mg tab	25	Preferred		PA

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización  Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 51 de 53 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

SALUD FÍSICA

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SALUD FÍSICA

Page 53 of 53 

Revisado 5/18/2017

MENTAL HEALTH

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase  Terapéutica]
ANTI-ADDICTION AGENTS [AGENTES CONTRA LA ADDICIÓN]
Opioid Antagonist [Antagonistas De Opioides]
buprenorphine hcl 2 mg tab subl, 8 mg tab subl	3	Preferred	SUBUTEX	PA
SUBOXONE subl film 2-0.5 mg, 8-2 mg, 4-1 mg, 12-3 mg	4	Preferred		PA, C
Detox Treatment [Tratamiento De Detox]
b-1 100 mg tab	1	Preferred	THIAMINE	QL
clonidine hcl 0.1 mg tab	1	Preferred	CATAPRESS
folic acid 1 mg tab	1	Preferred	FOLIC ACID	QL
ibuprofen 800 mg tab	1	Preferred	MOTRIN	QL
loperamide hcl 2 mg cap	1	Preferred	IMODIUM	QL
ANTIANXIETY AGENTS [AGENTES PARA LA ANXIEDAD]
Benzodiazepines [Benzodiazepinas]
clonazepam 0.5 mg tab, 1 mg tab, 2mg tab	1	Preferred	KLONOPIN
diazepam 10 mg tab, 2 mg tab, 5 mg tab	1	Preferred	VALIUM
lorazepam 0.5 mg tab, 1 mg tab	1	Preferred	ATIVAN
diazepam 1 mg/ml soln	2	Non-Preferred	VALIUM
DIAZEPAM INTENSOL 5 mg/ml oral conc	2	Non-Preferred
lorazepam 2 mg/ml oral conc	2	Non-Preferred	ATIVAN
Sedating Histamine 1 Blocking Agents [Sedantes Bloqueadores Histamine 1]
hydroxyzine pamoate 100 mg cap, 25 mg cap, 50 mg cap	1	Preferred	VISTARIL

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

MENTAL HEALTH

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
ANTIDEPRESSANTS [ANTIDEPRESIVOS]
Miscellaneous Antidepressants [Antidepresivos Misceláneos]
bupropion hcl 75 mg tab	1	Preferred	WELLBUTRIN
bupropion hcl er (sr) 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr	1	Preferred	WELLBUTRIN SR
escitalopram oxalate 5mg tab, 10 mg tab, 20 mg tab	1	Preferred	LEXAPRO
mirtazapine 15 mg tab, 30 mg tab, 45 mg tab, 7.5 mg tab	1	Preferred	REMERON
trazodone hcl 100 mg tab, 150 mg tab, 50 mg tab	1	Preferred	DESYREL
bupropion hcl 100 mg tab	2	Non-Preferred	WELLBUTRIN
bupropion hcl er (xl) 150 mg tab er 24 hr, 300 mg tab er 24 hr	2	Non-Preferred	WELLBUTRIN XL
mirtazapine 15 mg odt, 30 mg odt, 45 mg odt	3	Non-Preferred	REMERON

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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MENTAL HEALTH

Serotonin and/or Norepinephrine Modulators [Moduladores De Serotonina y/o Norepinefrina]
citalopram hydrobromide 10 mg tab, 20 mg tab, 40 mg tab	1	Preferred	CELEXA
fluoxetine hcl 10 mg cap, 20 mg cap	1	Preferred	PROZAC
paroxetine hcl 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab	1	Preferred	PAXIL
sertraline hcl 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	ZOLOFT
sertraline hcl oral concentrate 20 mg/ml	2	Non-Preferred	ZOLOFT

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
venlafaxine hcl 100mg tab, 25mg tab, 37.5mg tab, 50mg tab, 75mg tab	1	Preferred	EFFEXOR
venlafaxine hcl er 150 mg cap er 24 hr, 37.5 mg cap er 24 hr, 75 mg cap er 24 hr	1	Preferred	EFFEXOR XR
duloxetine 20 mg cap, 30 mg cap, 60 mg cap	2	Non-Preferred	CYMBALTA
Tricyclic Agents [Tricíclicos]
amitriptyline hcl 10 mg tab, 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab	1	Preferred	ELAVIL
doxepin hcl 10 mg cap, 10 mg/ml oral conc, 25 mg cap, 50 mg cap, 75 mg cap	1	Preferred	SINEQUAN
imipramine hcl 10 mg tab, 25 mg tab, 50 mg tab	1	Preferred	TOFRANIL

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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MENTAL HEALTH

nortriptyline hcl 10 mg cap, 10 mg/5ml soln, 25 mg cap, 50 mg cap, 75 mg cap	1	Preferred	PAMELOR
doxepin hcl 100 mg cap, 150 mg cap	2	Preferred	SINEQUAN
ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]
Anticholinergics [Anticolinérgicos]
benztropine mesylate 0.5 mg tab, 1 mg tab, 2 mg tab	1	Preferred	COGENTIN
ANTIPSYCHOTICS [ANTIPSICÓTICOS]
Atypical - Second Generation [Atípicos - Segunda Generación]
olanzapine 10 mg tab, 15 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab	1	Preferred	ZYPREXA
quetiapine fumarate 25 mg tab	1	Preferred	SEROQUEL

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
risperidone 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab	1	Preferred	RISPERDAL
quetiapine fumarate 50 mg tab	2	Preferred	SEROQUEL
risperidone 1 mg/ml soln	2	Preferred	RISPERDAL
quetiapine fumarate 100 mg tab	3	Preferred	SEROQUEL
LATUDA 120 mg tab, 20 mg tab, 40 mg tab, 60 mg tab, 80 mg tab	4	Preferred	PA	PA, P

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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MENTAL HEALTH

quetiapine fumarate 200 mg tab	4	Preferred	SEROQUEL
quetiapine fumarate 300 mg tab	5	Preferred	SEROQUEL
quetiapine fumarate 400 mg tab	6	Preferred	SEROQUEL
aripriprazole 2 mg tab, 5 mg tab, 10 mg tab, 15 mg tab, 20 mg tab, 30 mg tab	7	Non-Preferred	ABILIFY	PA
aripiprazole 1 mg/ml soln	10	Non-Preferred	ABILIFY	PA
Typical - First Generation [Típicos - Primera Generación]
fluphenazine hcl 1 mg tab, 10 mg tab, 2.5 mg tab, 5 mg tab	1	Preferred	PROLIXIN
haloperidol 0.5 mg tab, 1 mg tab, 2 mg tab, 2 mg/ml oral conc	1	Preferred	HALDOL
thioridazine hcl 10 mg tab, 25 mg tab, 50 mg tab	1	Preferred	MELLARIL
thiothixene 1 mg cap, 2 mg cap, 5 mg cap	1	Preferred	NAVANE
trifluoperazine hcl mg tab, 2 mg tab, 5 mg tab, 10 mg tab	2	Preferred	STELAZINE

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
chlorpromazine hcl 25 mg tab	2	Preferred	THORAZINE
haloperidol 5 mg tab	2	Preferred	HALDOL
haloperidol decanoate 50 mg/ml im soln	2	Preferred	HALDOL DECANOATE

 • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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MENTAL HEALTH

thioridazine hcl 100 mg tab	2	Preferred	MELLARIL
thiothixene 10 mg cap	2	Preferred	NAVANE
chlorpromazine hcl 100 mg tab, 50 mg tab	3	Preferred	THORAZINE
haloperidol 10 mg tab	3	Preferred	HALDOL
haloperidol decanoate 100 mg/ml im soln	3	Preferred	HALDOL DECANOATE
chlorpromazine hcl 200 mg tab	4	Preferred	THORAZINE
haloperidol 20 mg tab	4	Preferred	HALDOL
MOOD STABILIZERS [ESTABILIZADORES DEL ÁNIMO]
Bipolar Agents [Agentes Para Bipolaridad]
divalproex sodium 125 mg tab dr, 250 mg tab dr, 500 mg tab dr	1	Preferred	DEPAKOTE
lamotrigine 100 mg tab, 150 mg tab, 200 mg tab, 25 mg tab	1	Preferred	LAMICTAL
lamotrigine chew tab 5 mg, 25 mg	3	Non-Preferred	LAMICTAL
lithium carbonate 150 mg cap, 300 mg cap, 300 mg tab, 600 mg cap	1	Preferred	LITHIUM
lithium carbonate er 300 mg tab er, 450 mg tab er	1	Preferred	LITHIUM
olanzapine 10 mg tab, 15 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab	1	Preferred	ZYPREXA
quetiapine fumarate 25 mg tab	1	Preferred	SEROQUEL

 • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Page 6 of 11

MENTAL HEALTH

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
risperidone 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab	1	Preferred	RISPERDAL
valproic acid 250 mg cap, 250 mg/5ml soln, 250 mg/5ml syr	1	Preferred	DEPAKENE
quetiapine fumarate 50 mg tab	2	Preferred	SEROQUEL
risperidone 1 mg/ml soln	2	Preferred	RISPERDAL
quetiapine fumarate 100 mg tab	3	Preferred	SEROQUEL
quetiapine fumarate 200 mg tab	4	Preferred	SEROQUEL
quetiapine fumarate 300 mg tab	5	Preferred	SEROQUEL
quetiapine fumarate 400 mg tab	6	Preferred	SEROQUEL
aripriprazole 10 mg tab, 15 mg tab, 2 mg tab, 5 mg tab, 20 mg tab, 30 mg tab	7	Non-Preferred	ABILIFY	PA
aripiprazole 1 mg/ml soln	10	Non-Preferred	ABILIFY	PA
PSYCHOSTIMULANTS [PSICOESTIMULANTES]
ADHD Amphetamines [Anfetaminas ADHD]
amphetamine  -dextroamphetamine 15 mg tab, 30 mg tab	2	Preferred	ADDERALL	AL 4-20años
amphetamine- dextroamphetamine 10 mg tab, 12.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab	3	Preferred	ADDERALL	AL 4-20 años
dextroamphetamine sulfate 10 mg tab, 5 mg tab	3	Preferred	DEXEDRINE	AL 4-20 años
dextroamphetamine sulfate er 5 mg cap er 24 hr, 10 mg cap er 24 hr	4	Non-Preferred	DEXEDRINE SR	AL 4-20 años

 • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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MENTAL HEALTH

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
dextroamphetamine sulfate er 15 mg cap er 24 hr	5	Non-Preferred	DEXEDRINE SR	AL 4-20 años
DYANAVEL XR oral xxxx.xx 2.5 mg/ mL	4	Non-Preferred	DYANAVEL XR	PA, AL 6-20 años
ADHD Non-Amphetamines [No-Anfetaminas ADHD]
clonidine hcl 0.1 mg tab	1	Preferred	CATAPRESS
dexmethylphenidate hcl 2.5 mg tab, 5 mg tab	2	Preferred	FOCALIN	AL 6-20 años
methylphenidate hcl 5 mg tab	2	Preferred	RITALIN	AL 6-20 años
dexmethylphenidate hcl 10 mg tab	3	Preferred	FOCALIN	AL 6-20 años
methylphenidate hcl 10 mg tab, 20 mg tab	3	Preferred	RITALIN	AL 6-20 años
methylphenidate soln 5mg/5ml, 10 mg/5ml		Non-Preferred	METHYLIN
STRATTERA 10 mg cap, 100 mg cap, 18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap	4	Preferred		PA, AL 6-20 años, P

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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MENTAL HEALTH

SLEEP DISORDER AGENTS [DESORDENES DEL SUEÑO]
Benzodiazepines [Benzodiazepinas]
flurazepam hcl 15 mg cap, 30 mg cap	1	Preferred	DALMANE
temazepam 15 mg cap, 30 mg cap	1	Preferred	RESTORIL
Miscellaneous Sleep Disorder Agents [Agentes Misceláneos Desordenes Del Sueño]
doxepin hcl 10 mg cap, 10  mg/ml oral conc, 25 mg cap, 50 mg cap, 75 mg cap	1	Preferred	SINEQUAN
zolpidem tartrate 10 mg tab, 5 mg tab	1	Preferred	AMBIEN

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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SALUD MENTAL

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SALUD MENTAL

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SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase Terapéutica]
ANALGESICS [ANALG ÉSICOS]
Nonsteroidal Anti-Inflammatory Agents (NSAIDs) [Anti-Inflamatorios No Esteroidales]
ibuprofen 400 mg tab, 600  mg tab	1	Preferred	MOTRIN	QL=5 días
nabumetone 500 mg tab, 750 mg tab	1	Preferred	RELAFEN	QL=5 días
naproxen 250 mg tab, 375 mg tab, 500 mg tab	1	Preferred	NAPROSYN	QL=15 días No repeticiones
salsalate 500 mg tab, 750 mg tab	1	Preferred	DISALCID	QL=5 días
indomethacin 25 mg cap, 50 mg cap	1	Non-Preferred	INDOCIN
Short-Acting Opioid Analgesics [Analgésicos Opiodes De Corta Duración]
acetaminophen -codeine 120-12 mg/5ml soln, 300-15 mg tab, 300-30 mg tab, 300- 60 mg tab	1	Preferred	TYLENOL-CODEINE	QL=5 días
acetaminophen-codeine #2 300-15 mg tab	1	Preferred	TYLENOL-CODEINE	QL=5 días
acetaminophen-codeine #3 300-30 mg tab	1	Preferred	TYLENOL-CODEINE	QL=5 días
acetaminophen-codeine #4 300-60 mg tab	1	Preferred	TYLENOL-CODEINE	QL=5 días
butalbital-apap-caffeine 50325-40 mg tab	1	Preferred	FIORICET	QL=5 días
tramadol hcl 50 mg tab	1	Preferred	ULTRAM	QL=5 días
butalbital-apap-caffeine 50325-40 mg cap	2	Preferred	FIORICET	QL=5 días
margesic 50-325-40 mg cap	2	Preferred	FIORICET	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 1 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ANESTHETICS [ANESTÉSICOS]
Local Anesthetics [Anestésicos Locales]
lidocaine viscous 2 % mouth/throat soln	1	Preferred	XYLOCAINE	QL=5 días
ANTIBACTERIALS [ANTIBACTERIANOS]
First Generation Cephalosporins [Cefalosporinas De Primera Generación]
cephalexin 125 mg/5ml susp, 250 mg cap, 500 mg cap	1	Preferred	KEFLEX	QL=5 días
cefadroxil 250 mg/5ml susp	2	Non-Preferred	DURICEF	QL=5 días, AL 012 años
cephalexin 250 mg/5ml susp	2	Preferred	KEFLEX	QL=5 días
cefadroxil 500 mg/5ml susp	3	Non-Preferred	DURICEF	QL=5 días, AL 0-12 años
Macrolides [Macrólidos]
azithromycin 250 mg tab, 500 mg tab	1	Preferred	ZITHROMAX	QL=5 días
azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab	2	Preferred	ZITHROMAX	QL=5 días
clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab	2	Preferred	BIAXIN	QL=5 días
clarithromycin 250 mg/5ml susp	3	Preferred	BIAXIN	QL=5 días
erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab	3	Preferred	ERY-TAB	QL=5 días
erythromycin ethylsuccinate 400 mg tab	3	Preferred	E.E.S.	QL=5 días
ERYTHROCIN STEARATE 250 mg tab	4	Non-Preferred		QL=5 días
Miscellaneous Antibacterials [Antibacterianos Misceláneos]
clindamycin hcl 150 mg cap, 300 mg cap, 75 mg cap	1	Preferred	CLEOCIN	QL=5 días
MACRODANTIN 25 mg cap	1	Preferred		QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 2 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

 

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
metronidazole 250 mg tab, 500 mg tab	1	Preferred	FLAGYL	QL=5 días
nitrofurantoin macrocrystal 50 mg cap	1	Preferred	MACRODANTIN	QL=5 días
nitrofurantoin macrocrystal 100 mg cap	2	Preferred	MACRODANTIN	QL=5 días
nitrofurantoin monohyd macro 100 mg cap	2	Preferred	MACROBID	QL=5 días
Penicillins [Penicilinas]
amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab	1	Preferred	AMOXIL	QL=5 días
amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 600-42.9 mg/5ml susp, 875-125 mg tab	1	Preferred	AUGMENTIN	QL=5 días
ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap	1	Preferred	PRINCIPEN	QL=5 días
penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab	1	Preferred	VEETIDS	QL=5 días
amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp	3	Preferred	AUGMENTIN	QL=5 días
Quinolones [Quinolonas]
ciprofloxacin hcl 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	CIPRO	QL=5 días
levofloxacin 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	LEVAQUIN	QL=5 días
ciprofloxacin 500 mg/5ml (10%) susp	3	Preferred	CIPRO	QL=5 días
ciprofloxacin 250 mg/5ml (5%) susp	4	Preferred	CIPRO	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 3 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
Second Generation Cephalosporins [Cefalosporinas De Segunda Generación]
cefaclor 250 mg cap, 500 mg cap	2	Preferred	CECLOR	QL=5 días
cefprozil 125 mg/5ml susp, 250 mg tab, 250 mg/5ml susp, 500 mg tab	2	Preferred	CEFZIL	QL=5 días
Sulfonamides [Sulfonamidas]
sulfamethoxazole-tmp ds 800-160 mg tab	1	Preferred	SEPTRA	QL=5 días
sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab	1	Preferred	SEPTRA	QL=5 días
Third Generation Cephalosporins [Cefalosporinas De Tercera Generación]
cefdinir 125 mg/5ml susp, 300 mg cap	2	Preferred	OMNICEF	QL=5 días
cefdinir 250 mg/5ml susp	3	Preferred	OMNICEF	QL=5 días
ANTICONVULSANTS [ANTICONVULSIVANTES]
Anticonvulsants [Anticonvulsivantes]
carbamazepine 100 mg tab chew, 200 mg tab	1	Preferred	TEGRETOL	QL=5 días
gabapentin 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab	1	Preferred	NEURONTIN	QL=5 días
levetiracetam 250 mg tab, 500 mg tab	1	Preferred	KEPPRA	QL=5 días
oxcarbazepine 150 mg tab	1	Preferred	TRILEPTAL	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 4 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

phenobarbital 100 mg tab, 15 mg tab, 16.2 mg tab, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab	1	Preferred	PHENOBARBITAL	QL=5 días
primidone 250 mg tab, 50 mg tab	1	Preferred	MYSOLINE	QL=5 días
topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab	1	Preferred	TOPAMAX	QL=5 días
DILANTIN 30 mg cap	2	Preferred		QL=5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
levetiracetam 1000 mg tab, 750 mg tab	2	Preferred	KEPPRA	QL=5 días
oxcarbazepine 300 mg tab, 600 mg tab	2	Preferred	TRILEPTAL	QL=5 días
phenytoin 125 mg/5ml susp, 50 mg tab chew	2	Preferred	DILANTIN	QL=5 días
phenytoin sodium extended 100 mg cap, 200 mg cap, 300 mg cap	2	Preferred	DILANTIN	QL=5 días
phenytoin sodium extended 100 mg cap, 200 mg cap, 300 mg cap	2	Preferred	DILANTIN	QL=5 días
ethosuximide 250 mg cap, 250 mg/5ml soln	3	Preferred	ZARONTIN	QL=5 días
phenobarbital 20 mg/5ml oral elix, 20 mg/5ml soln	3	Preferred	PHENOBARBITAL	QL=5 días

ANTIDEMENTIA AGENTS [AGENTES ANTIDEMENCIA]
Cholinesterase Inhibitors [Inhibidores De Colinesterasa]
donepezil hcl 10 mg tab, 5 mg tab	1	Preferred	ARICEPT	QL=5 días
rivastigmine tartrate 1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap	3	Preferred	EXELON	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 5 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

ANTIDEPRESSANTS [ANTIDEPRESIVOS]
Monoamine Oxidase (Mao) Inhibitors [Inhibidores De Mao]
selegiline hcl 5 mg tab	3	Non-Preferred	CARBEX	QL=5 días
ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]
Alpha-Glucosidase Inhibitors [Inhibidores De Alfa Glucosidasa]
acarbose 100 mg tab, 25 mg tab, 50 mg tab	2	Preferred	PRECOSE	QL=5 días
Biguanides [Biguanidas]
metformin hcl 1000 mg tab, 500 mg tab, 850 mg tab	1	Preferred	GLUCOPHAGE	QL=5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors [Inhibidores De Dpp-4]
KOMBIGLYZE XR 2.5 -1000 mg tab er 24 hr, 5-1000 mg tab er 24 hr, 5-500 mg tab er 24 hr	3	Preferred		QL=5 días, ST, P
ONGLYZA 2.5 mg tab, 5 mg tab	3	Preferred		QL=5 días, ST, P
Insulin Mixtures [Mezclas De Insulinas]
HUMULIN 70/30 (70  -30) 100 unit/ml sc susp	2	Preferred		QL= 1 vial / 30 días, P
Insulin Sensitizing Agents [Agentes Sensibilizantes De Insulin]
pioglitazone hcl 15 mg tab, 30 mg tab, 45 mg tab	1	Preferred	ACTOS	QL=5 días
Intermediate-Acting Insulins [Insulinas De Duración Intermedia]
HUMULIN N 100 unit/ml sc QL= 1 vial / susp 2 Preferred  30 días, P
Short-Acting Insulins [Insulinas De Corta Duración]
HUMULIN R 100 unit/ml inj soln	2	Preferred		QL= 1 vial / 30 días, P
Sulfonylureas [Sulfonilureas]
glimepiride 1 mg tab, 2 mg tab, 4 mg tab	1	Preferred	AMARYL	QL=5 días
glipizide 10 mg tab, 5 mg tab	1	Preferred	GLUCOTROL	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 6 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

ANTIEMETICS [ANTIEMÉTICOS]
Miscellaneous Antiemetics [Antieméticos Misceláneos]
metoclopramide hcl 10 mg tab, 5 mg tab, 5 mg/ml inj soln	1	Preferred	REGLAN	QL=5 días
trimethobenzamide hcl 300 mg cap	1	Preferred	TIGAN	QL=5 días
Phenothiazines [Fenotiazinas]
prochlorperazine maleate 10 mg tab, 5 mg tab	1	Preferred	COMPAZINE	QL=5 días
prochlorperazine 25 mg rect supp	4	Non-Preferred	COMPAZINE	QL=5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
ANTIGOUT AGENTS [AGENTES ANTIGOTA]
Antigout Agents [Agentes Antigota]
allopurinol 100 mg tab, 300 mg tab	1	Preferred	ZYLOPRIM	QL=5 días
colchicine 0.6 mg cap	3	Preferred	MITIGARE	PA
colchicine 0.6 mg tab	3	Non-Preferred	COLCRYS	QL= 3 tab, 15días
Uricosurics [Uricosúricos]
probenecid 500 mg tab	1	Preferred	BENEMID	QL=5 días
ANTIHYPERTENSIVES [ANTIHIPERTENSIVOS]
Alpha-Adrenergic Agonists [Agonistas Alfa Adrenérgicos]
clonidine hcl 0.2 mg tab, 0.3 mg tab	1	Preferred	CATAPRESS	QL=5 días
methyldopa 250 mg tab, 500 mg tab	1	Preferred	ALDOMET	QL=5 días
Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]
terazosin hcl 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap	1	Preferred	HYTRIN	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 7 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

Angiotensin II Receptor Blockers (Arb) [Antagonistas Del Receptor Angiotensina II]
losartan potassium 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	COZAAR	QL=5 días
losartan potassium-hctz 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab	1	Preferred	HYZAAR	QL=5 días
Angiotensin-Converting Enzyme (Ace) Inhibitors [Inhibidores De La Enzima Convertidora De Angiotensin]
lisinopril 10 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab	1	Preferred	ZESTRIL	QL=5 días
lisinopril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab	1	Preferred	ZESTORETIC	QL=5 días
Calcium Channel Blocking Agents [Bloqueadores De Canales De Calcio]
amlodipine besylate 10 mg tab, 2.5 mg tab, 5 mg tab	1	Preferred	NORVASC	QL=5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab	1	Preferred	CARDIZEM	QL=5 días
verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab	1	Preferred	CALAN	QL=5 días
Carbonic Anhydrase Inhibitors Diuretics [Diuréticos Inhibidores De Anhidrasa Carbónica]
acetazolamide 125 mg tab, 250 mg tab	3	Preferred	DIAMOX	QL=5 días
Cardioselective Beta Blocking Agents [Bloqueadores Beta Cardioselectivos]
atenolol 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	TENORMIN	QL=5 días
metoprolol succinate er 25 mg tab er 24 hr, 50 mg tab er 24 hr	1	Preferred	LOPRESSOR	QL=5 días
metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	LOPRESSOR	QL=5 días
metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr	2	Preferred	LOPRESSOR	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 8 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

Cardioselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos Cardioselectivos]
atenolol  -chlorthalidone 10025 mg tab, 50-25 mg tab	1	Preferred	TENORETIC	QL=5 días
metoprolol- hydrochlorothiazide 50-25 mg tab	2	Non-Preferred	LOPRESSOR HCT	QL=5 días
metoprolol- hydrochlorothiazide 100-25 mg tab, 100-50 mg tab	3	Non-Preferred	LOPRESSOR HCT	QL=5 días
Loop Diuretics [Diuréticos Del Asa]
furosemide 10 mg/ml soln, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	LASIX	QL=5 días
Nonselective Beta Blocking Agents [Bloqueadores Beta No-Selectivos]
propranolol hcl 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	INDERAL	QL=5 días
propranolol hcl 60 mg tab	2	Preferred	INDERAL	QL=5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
Potassium-Sparing Diuretics [Diuréticos Conservadores De Potasio]
spironolactone 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	ALDACTONE	QL=5 días
triamterene-hctz 37.5-25 mg cap, 37.5-25 mg tab, 75-50 mg tab	1	Preferred	MAXZIDE	QL=5 días
Thiazide Diuretics [Diuréticos Tiazidas]
chlorothiazide 250 mg tab, 500 mg tab	1	Preferred	DIURIL	QL=5 días
chlorthalidone 25 mg tab, 50 mg tab	1	Preferred	HYGROTON	QL=5 días
DIURIL 250 mg/5ml susp	1	Preferred		QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 9 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

hydrochlorothiazide 12.5 mg tab, 25 mg tab, 50 mg tab	1	Preferred	MICROZIDE	QL=5 días
indapamide 1.25 mg tab, 2.5 mg tab	1	Preferred	LOZOL	QL=5 días
metolazone 2.5 mg tab, 5 mg tab	1	Non-Preferred	ZAROXOLYN	QL=5 días
chlorthalidone 100 mg tab	2	Preferred	HYGROTON	QL=5 días
metolazone 10 mg tab	2	Non-Preferred	ZAROXOLYN	QL=5 días
Vasodilator Beta Blockers [Bloqueadores Beta Vasodilatadores]
carvedilol 12.5 mg tab, 25 mg tab, 3.125 mg tab, 6.25 mg tab	1	Preferred	COREG	QL=5 días
Vasodilators [Vasodilatadores]
hydralazine hcl 10 mg tab, 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	APRESOLINE	QL=5 días
ANTIMIGRAINE AGENTS [AGENTES ANTIMIGRAÑA]
Beta-Adrenergic Blocking Agents [Bloqueadores Beta Adrenérgicos]
topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab 1 Preferred TOPAMAX QL=5 días
ANTIMYASTHENIC AGENTS [AGENTES ANTIMIASTÉNICOS]
Parasympathomimetics [Parasimpatomiméticos]
pyridostigmine bromide 60 mg tab	2	Preferred	MESTINON	QL=5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
pyridostigmine bromide 180 mg tab er	6	Non-Preferred	MESTINON
ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]
Antituberculars [Antituberculosos]
isoniazid 100 mg tab, 300 mg tab	1	Preferred	ISONIAZID	QL=5 días
rifampin 150 mg cap	1	Preferred	RIFADIN	QL=5 días

 

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 10 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

pyrazinamide 500 mg tab	2	Non-Preferred	PYRAZINAMIDE	QL=5 días
rifampin 300 mg cap	2	Preferred	RIFADIN	QL=5 días
isoniazid 50 mg/5ml syr	5	Non-Preferred	ISONIAZID	QL=5 días
rifabutin 150 mg cap			MYCOBUTIN	Puerto Rico Health Department Tuberculosis Program
cycloserine 250 mg cap			SEROMYCIN
CAPASTAT SULFATE 1 gm inj
RIFAMATE 150-300 mg cap
TRECATOR 250 mg tab
ANTIPARASITICS [ANTIPARASITARIOS]
Antimalarials [Antimaláricos]
chloroquine phosphate 250 mg tab, 500 mg tab	1	Preferred	ARALEN	QL=5 días
hydroxychloroquine sulfate 200 mg tab	1	Preferred	PLAQUENIL	QL=5 días
DARAPRIM 25 mg tab	7	Non-Preferred		QL=5 días
ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]
Antiparkinson Dopaminergics [Dopaminérgicos Antiparkinson]
amantadine hcl 50 mg/5ml syr	1	Preferred	SYMMETREL	QL=5 días
pramipexole dihydrochloride 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab	1	Preferred	MIRAPEX	QL=5 días
ropinirole hcl 0.25 mg tab, 0.5 mg tab, 1 mg tab, 3 mg tab, 4 mg tab, 5 mg tab	1	Preferred	REQUIP	QL=5 días
ropinirole hcl 2 mg tab	2	Preferred	REQUIP	QL=5 días
amantadine hcl 100 mg cap	3	Preferred	SYMMETREL	QL=5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
bromocriptine mesylate 2.5 mg tab	3	Preferred	PARLODEL	QL=5 días

 

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 11 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

carbidopa-levodopaentacapone 18.75-75-200 mg tab	4	Non-Preferred	STALEVO	QL=5 días
carbidopa-levodopaentacapone 12.5-50-200 mg tab, 25-100-200 mg tab, 31.25-125-200 mg tab, 37.5150-200 mg tab, 50-200-200 mg tab	5	Non-Preferred	STALEVO	QL=5 días
Dopamine Precursors [Precursores De Dopamina]
carbidopa  -levodopa 10-100 mg tab, 25-100 mg tab	1	Preferred	SINEMET	QL=5 días
carbidopa-levodopa 25-250 mg tab	2	Preferred	SINEMET	QL=5 días
carbidopa-levodopa er 25100 mg tab er, 50-200 mg tab er	2	Preferred	SINEMET CR	QL=5 días
Monoamine Oxidase B (Mao-B) Inhibitors [Inhibidores De Mao-B]
selegiline hcl 5 mg tab	3	Preferred	CARBEX	QL=5 días
ANTIVIRALS [ANTIVIRALES]
Anti-Cytomegalovirus (Cmv) Agents [Agentes Anti-Citomegalovirus]
valganciclovir hcl 450 mg tab	13	Non-Preferred	VALCYTE	PA, QL=5 días
Antiherpetic Agents [Agentes Antiherpéticos]
acyclovir 200 mg cap, 400 mg tab, 800 mg tab	1	Preferred	ZOVIRAX	QL=5 días
acyclovir 200 mg/5ml susp	2	Preferred	ZOVIRAX	QL=5 días
Anti-Influenza Agents [Agentes Antiinfluenza]
amantadine hcl 50 mg/5ml syr	1	Preferred	SYMMETREL	QL=5 días
amantadine hcl 100 mg cap	3	Preferred	SYMMETREL	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 12 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
BENIGN PROSTATIC HYPERTROPHY AGENTS [AGENTES PARA HIPERTROFIA PROSTÁTICA BENIGNA]
Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]
terazosin hcl 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap	1	Preferred	HYTRIN	QL=5 días
BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]
Anticoagulants [Anticoagulantes]
warfarin sodium 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab	1	Preferred	COUMADIN	QL=5 días
heparin sodium (porcine) 1000 unit/ml inj soln	2	Preferred	HEPARIN	QL=5 días
heparin sodium (porcine) 10000 unit/ml inj soln, 5000 unit/ml inj soln	3	Preferred	HEPARIN	QL=5 días
heparin sodium (porcine) pf 5000 unit/0.5ml inj soln	3	Preferred	HEPARIN	QL=5 días
heparin sodium (porcine) 2000 unit/ml iv soln	8	Preferred	HEPARIN	QL=5 días
Colony Stimulating Factors [Estimulantes Mieloides]
NEULASTA 6 mg/0.6ml sc soln	12	Preferred		PA, QL=5 días, P
NEULASTA DELIVERY KIT 6 mg/0.6ml sc soln	12	Preferred		PA, QL=5 días, P
Platelet Modifying Agents [Modificadores De Plaquetas]
cilostazol 100           mg tab, 50 mg tab	1	Preferred	PLETAL	QL=5 días
clopidogrel bisulfate 75 mg tab	1	Preferred	PLAVIX	QL=5 días
CARDIOVASCULAR AGENTS [AGENTES CARDIOVASCULARES]
Antiarrhythmics Class II [Antiarrítmicos Clase II]
propranolol hcl 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	INDERAL	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 13 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
sotalol hcl 120 mg tab, 160 mg tab, 240 mg tab, 80 mg tab	1	Preferred	BETAPACE	QL=5 días
sotalol hcl (af) 120 mg tab, 160 mg tab, 80 mg tab	1	Preferred	BETAPACE	QL=5 días
propranolol hcl 60 mg tab	2	Preferred	INDERAL	QL=5 días
Antiarrhythmics Type I-A [Antiarrítmicos Tipo I-A]
quinidine sulfate 200           mg tab, 300 mg tab	1	Preferred	QUINIDINE SULFATE	QL=5 días
quinidine gluconate er 324 mg tab er	2	Preferred	QUINAGLUTE	QL=5 días
quinidine sulfate er 300 mg tab er	2	Preferred	QUINIDINE SULFATE	QL=5 días
Antiarrhythmics Type I-B [Antiarrítmicos Tipo I-B]
mexiletine hcl 150 mg cap	2	Preferred	MEXITIL	QL=5 días
mexiletine hcl 200 mg cap	3	Preferred	MEXITIL	QL=5 días
Antiarrhythmics Type I-C [Antiarrítmicos Tipo I-C]
flecainide acetate 100 mg tab, 50 mg tab	1	Preferred	TAMBOCOR	QL=5 días
propafenone hcl 150 mg tab, 225 mg tab	1	Preferred	RYTHMOL	QL=5 días
flecainide acetate 150 mg tab	2	Preferred	TAMBOCOR	QL=5 días
propafenone hcl 300 mg tab	3	Preferred	RYTHMOL	QL=5 días
Antiarrhythmics Type III [Antiarrítmicos Tipo III]
amiodarone hcl 200 mg tab	1	Preferred	CORDARONE	QL=5 días
Miscellaneous Cardiovascular Agents [Agentes Cardiovasculares Misceláneos]
digox 125 mcg tab, 250 mcg tab	2	Preferred	LANOXIN	QL=5 días
digoxin 125 mcg tab, 250 mcg tab	2	Preferred	LANOXIN	QL=5 días
Vasodilators [Vasodilatadores]
isosorbide mononitrate 10 mg tab, 20 mg tab	1	Preferred	ISORDIL	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 14 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
isosorbide mononitrate er 120 mg tab er 24 hr, 30 mg tab er 24 hr, 60 mg tab er 24 hr	1	Preferred	IMDUR	QL=5 días
NITROSTAT 0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl	1	Preferred		QL=5 días
DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]
Antifungals [Antifungales]
clotrimazole 10 mg mouth/throat lozenge, 10 mg mouth/throat troche	1	Preferred	MYCELEX	QL=5 días, OTC
nystatin 100000 unit/ml mouth/throat susp, 100000 unit/ml crm	1	Preferred	NYSTATIN	QL=5 días
DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]
Topical Antibiotics [Antibióticos Tópicos]
mupirocin 2 % oint	1	Preferred	BACTROBAN	QL=5 días
silver sulfadiazine 1 % crm	1	Preferred	SILVADENE	QL=5 días
gentamicin sulfate 0.1 % crm	2	Preferred	GARAMYCIN	QL=1 frasco / 5 días
gentamicin sulfate 0.1 % oint	2	Preferred	GARAMYCIN	QL=1 tubo / 5 días
DYSLIPIDEMICS [DISLIPIDÉMICOS]
Bile Acid Sequestrants [Secuestradores De Acidos Biliares]
cholestyramine 4 gm pckt, 4 gm/dose oral pwdr	3	Preferred	QUESTRAN	QL=5 días
cholestyramine light 4 gm pckt, 4 gm/dose oral pwdr	3	Preferred	QUESTRAN	QL=5 días
Fibric Acid Derivatives [Derivados De Ácido Fíbrico]
gemfibrozil 600 mg tab	1	Preferred	LOPID	QL=5 días
Hmg-Coa Reductase Inhibitors [Inhibidores De La Hmg-Coa Reductasa]
atorvastatin calcium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	LIPITOR	QL=5 días
simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab	1	Preferred	ZOCOR	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 15 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]
Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De H2]
famotidine           20 mg tab, 40 mg tab	1	Preferred	PEPCID	QL=5 días
ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr	1	Preferred	ZANTAC	QL=5 días
Miscellaneous Gastrointestinal Agents [Agentes Gastrointestinales Misceláneos]
ursodiol 300 mg cap	2	Preferred	ACTIGALL	PA, QL=5 días
Proton Pump Inhibitors [Inhibidores De La Bomba De Protones]
omeprazole 10 mg cap dr, 20 mg cap dr	1	Preferred	PRILOSEC	QL=5 días
GENITOURINARY AGENTS [AGENTES GENITOURINARIOS]
Miscellaneous Genitourinary Agents [Agentes Genitourinarios Misceláneos]
phenazopyridine hcl 100 mg tab, 200 mg tab	1	Preferred	PYRIDIUM	QL=3 días
HORMONAL AGENTS [AGENTES HORMONALES]
Antithyroid Agents [Agentes Antitiroide]
methimazole 10 mg tab, 5 mg tab	1	Preferred	TAPAZOLE	QL=5 días
propylthiouracil 50 mg tab	2	Preferred	PROPYLTHIOURA CIL	QL=5 días
Calcimimetic Agents [Agentes Calcimiméticos]
SENSIPAR 30 mg tab	7			PA, QL=5 días
SENSIPAR 60 mg tab	9			PA, QL=5 días
SENSIPAR 90 mg tab	10			PA, QL=5 días
Dopamine Agonists [Agonistas De Dopamina]
bromocriptine mesylate 2.5 mg tab	3	Preferred	PARLODEL	QL=5 días
Thyroid Hormones [Hormona Tiroidea]
levothyroxine sodium 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab	1	Preferred	SYNTHROID	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 16 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
SYNTHROID 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab	1	Preferred		QL=5 días
IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]
Glucocorticosteroids [Glucocorticoides]
dexamethasone 0.5 mg tab, 0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab	1	Preferred	DECADRON	QL=5 días
methylprednisolone 32 mg tab, 4 mg tab	1	Preferred	MEDROL	QL=5 días
prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab	1	Preferred	DELTASONE	QL=5 días
prednisone (pak) 10 mg tab, 5 mg tab	1	Preferred	DELTASONE	QL=5 días
methylprednisolone 16 mg tab, 8 mg tab	2	Preferred	MEDROL	QL=5 días

 

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 17 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

INFLAMMATORY BOWEL DISEASE [ENFERMEDAD INFLAMATORIA INTESTINAL]
Aminosalicylates [Aminosalicilatos]
DELZICOL 400 mg cap dr	5	Preferred		QL=5 días, P
ASACOL HD 800 mg tab dr	6	Preferred		QL=5 días, P
Sulfonamides [Sulfonamidas]
sulfasalazine 500 mg tab, 500 mg tab dr	1	Preferred	AZULFIDINE	QL=5 días
MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]
MUSCLE RELAXANTS [RELAJANTES MUSCULARES]
Antispasticity Agents [Agentes Antiespasticidad]
baclofen 10 mg tab, 20 mg tab	1	Preferred	LIORESAL	QL=5 días
dantrolene sodium 25 mg cap, 50 mg cap	2	Preferred	DANTRIUM	QL=5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
dantrolene sodium 100 mg cap	3	Preferred	DANTRIUM	QL=5 días
Skeletal Muscle Relaxants [Relajantes Musculoesqueletales]
cyclobenzaprine hcl 10 mg tab	1	Preferred	FLEXERIL	QL=5 días
OPHTHALMIC AGENTS [AGENTES OFTÁLMICOS]
Antiglaucoma Agents [Agentes Antiglaucoma]
brimonidine tartrate 0.2 % ophth soln	1	Preferred	ALPHAGAN	QL=1 frasco 5 ml / 15 días
dorzolamide hcl 2 % ophth soln	1	Preferred	TRUSOPT	QL=1 frasco / 30 días
levobunolol hcl 0.5 % ophth soln	1	Preferred	BETAGAN	QL=1 frasco / 15 días
levobunolol hcl 0.25 % ophth soln	1	Preferred	BETAGAN	QL=1 frasco / 15 días
timolol maleate 0.5 % ophth soln	1	Preferred	TIMOPTIC	QL=1 frasco / 30 días
timolol maleate 0.25 % ophth soln	1	Preferred	TIMOPTIC	QL=1 frasco / 25 días

 

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 18 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

dorzolamide hcl-timolol mal ophth sol 22.3-6.8 mg/ml	1	Preferred	COSOPT	QL=1 frasco / 30 días
betaxolol hcl 0.5 % ophth soln	2	Non-Preferred	BETOPTIC	QL=1 frasco / 15 días
Ophthalmic Antibiotics [Antibióticos Oftálmicos]
gentamicin sulfate 0.3 % ophth oint	1	Preferred	GARAMYCIN	QL=5 días
gentamicin sulfate 0.3 % ophth soln	1	Preferred	GARAMYCIN	QL=5 días
tobramycin 0.3 % ophth soln	1	Preferred	TOBREX	QL=1 frasco / 5 días
Ophthalmic Prostaglandins [Prostaglandinas Oftálmicas]
latanoprost 0.005 % ophth soln	1	Preferred	XALATAN	QL=1 frasco / 25 días
Ophthalmic Steroids [Esteroides Oftálmicos]
neomycin -polymyxindexamethasone 3.5-100000.1 ophth oint, 3.5-100000.1 ophth susp	1	Preferred	MAXITROL

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
prednisolone acetate 1 % ophth susp	2	Preferred	PRED FORTE	QL=1 frasco 5ml / 25 días
OTIC AGENTS [AGENTES OTICOS]
Miscellaneous Otic Agents [Agentes Oticos Misceláneos]
acetic acid 2 % otic soln	2	Preferred	VOSOL	QL= 1 frasco / 10 días
Otic Antibiotics [Antibióticos Oticos]
neomycin    -polymyxin-hc 1 % otic soln, 3.5-10000-1 otic soln, 3.5-10000-1 otic susp	2	Preferred	CORTISPORIN	QL=1 frasco / 10 días
RESPIRATORY AGENTS [AGENTES RESPIRATORIOS]
Anticholinergic Bronchodilators [Broncodilatadores Anticolinérgicos]

 • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 19 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

ipratropium bromide 0.02 % inh soln	1	Non-Preferred	ATROVENT	QL=5 días
Antileukotrienes [Antileukotrienos]
montelukast sodium 10 mg tab, 4 mg tab chew, 5 mg tab chew	1	Preferred	SINGULAIR	QL=5 días
Antitussive-Expectorant [Expectorantes Antitusivos]
guaifenesin -codeine 100-10 mg/5ml soln	1	Preferred	CHERATUSSIN	QL=5 días
Inhaled Corticosteroids [Corticosteroides Inhalados]
FLOVENT DISKUS 100  mcg/blist inh aer pwdr, 250 mcg/blist inh aer pwdr, 50 mcg/blist inh aer pwdr	3	Preferred		QL=1 pompa / 30 días, P
FLOVENT HFA 110 mcg/act inh aer	3	Preferred		QL=1 pompa / 30 días, P
FLOVENT HFA 44 mcg/act inh aer	3	Preferred		QL=1 pompa / 30 días, P
budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp,	4	Non-Preferred	PULMICORT	QL=5 días, AL 012 años
budesonide 1mg/2ml inh susp	8	Non-Preferred	PULMICORT	AL 0-12 años
FLOVENT HFA 220 mcg/act inh aer	4	Preferred		QL=1 pompa / 30 días, P

 • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 20 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
Sedating Histamine1 Blocking Agents [Sedantes Bloqueadores Histamine1]
promethazine hcl 12.5 mg tab, 25 mg tab, 50 mg tab, 6.25 mg/5ml soln, 6.25 mg/5ml syr	1	Preferred	PHENERGAN	QL=5 días
Sympathomimetic Bronchodilators [Broncodilatadores Simpatomiméticos]
albuterol sulfate (2.5 mg/3ml) 0.083% inh neb soln, (5 mg/ml) 0.5% inh neb soln, 2 mg/5ml syr	1	Preferred	PROVENTIL	QL=5 días
terbutaline sulfate 2.5 mg tab, 5 mg tab	1	Preferred	BRETHINE	QL=5 días
VENTOLIN HFA 108 (90 base) mcg/act inh aer	1	Preferred		QL=1 frasco / 30 días, P

 • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Página 21 de 22 Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  Revisado 5/12/2017 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

SALUD FÍSICA

SUB MENTAL

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase Terapéutica]
ANTIANXIETY AGENTS [AGENTES PARA LA ANXIEDAD]
Benzodiazepines [Benzodiazepinas]
diazepam 10 mg tab, 2 mg tab, 5 mg tab	1	Preferred	VALIUM	QL=5 días
lorazepam 0.5 mg tab, 1 mg tab	1	Preferred	ATIVAN	QL=5 días
Sedating Histamine 1 Blocking Agents [Sedantes Bloqueadores Histamine 1]
hydroxyzine pamoate 100 mg cap, 25 mg cap, 50 mg cap	1	Preferred	VISTARIL	QL=30 días
ANTIDEPRESSANTS [ANTIDEPRESIVOS]
Miscellaneous Antidepressants [Antidepresivos Misceláneos]
bupropion hcl 75 mg tab	1	Preferred	WELLBUTRIN	QL=30 días
bupropion hcl er (sr) 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr	1	Preferred	WELLBUTRIN SR	QL=30 días
mirtazapine 15 mg tab, 30 mg tab, 45 mg tab, 7.5 mg tab	1	Preferred	REMERON	QL=30 días
trazodone hcl 100 mg tab, 150 mg tab, 50 mg tab	1	Preferred	DESYREL	QL=30 días
bupropion hcl 100 mg tab	2	Non-Preferred	WELLBUTRIN	QL=30 días
bupropion hcl er (xl) 150 mg tab er 24 hr, 300 mg tab er 24 hr	2	Non-Preferred	WELLBUTRIN XL	QL=30 días
mirtazapine 15 mg odt, 30 mg odt, 45 mg odt	3	Non-Preferred	REMERON	QL=30 días

Página 1 de 7

SUB MENTAL

Serotonin and/or Norepinephrine Modulators [Moduladores De Serotonina y/o Norepinefrina]
citalopram hydrobromide 10 mg tab, 20 mg tab, 40 mg tab	1	Preferred	CELEXA	QL=30 días
fluoxetine hcl 10 mg cap, 20 mg cap	1	Preferred	PROZAC	QL=30 días

 Página

Página 2 de 7

SUB MENTAL

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
paroxetine hcl 20 mg tab, 30 mg tab, 40 mg tab	1	Preferred	PAXIL	QL=30 días
sertraline hcl 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	ZOLOFT	QL=30 días
venlafaxine hcl 100 mg tab, 25 mg tab, 37.5 mg tab, 50 mg tab, 75 mg tab	1	Preferred	EFFEXOR	QL=30 días
Tricyclic Agents [Tricíclicos]
amitriptyline hcl 10 mg tab, 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab	1	Preferred	ELAVIL	QL=30 días
doxepin hcl 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap	1	Preferred	SINEQUAN	QL=30 días
imipramine hcl 10 mg tab, 25 mg tab, 50 mg tab	1	Preferred	TOFRANIL	QL=30 días
nortriptyline hcl 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap	1	Preferred	PAMELOR	QL=30 días
doxepin hcl 100 mg cap, 150 mg cap	2	Preferred	SINEQUAN	QL=30 días
ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]
Anticholinergics [Anticolinérgicos]
benztropine mesylate 0.5 mg tab, 1 mg tab, 2 mg tab	1	Preferred	COGENTIN	QL=30 días
ANTIPSYCHOTICS [ANTIPSICÓTICOS]
Atypical - Second Generation [Atípicos - Segunda Generación]
risperidone 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab	1	Preferred	RISPERDAL	QL=5 días
Typical - First Generation [Típicos - Primera Generación]
haloperidol 0.5 mg tab, 1 mg tab, 2 mg tab	1	Preferred	HALDOL	QL=5 días
haloperidol 5 mg tab	2	Preferred	HALDOL	QL=5 días
haloperidol 10 mg tab	3	Preferred	HALDOL	QL=5 días
haloperidol 20 mg tab	4	Preferred	HALDOL	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 7 for monthly net cost range [Ver  Página 3 de 7 página 7 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/12/2017

Página 3 de 7

SUB MENTAL

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
DETOX TREATMENT [TRATAMIENTO DE DETOX]
Detox Treatment [Tratamiento De Detox]
clonidine hcl 0.1 mg tab	1	Preferred	CATAPRESS	QL=7 días
folic acid 1 mg tab	1	Preferred	FOLIC ACID	QL=7 días
ibuprofen 800 mg tab	1	Preferred	MOTRIN	QL=7 días
loperamide hcl 2 mg cap	1	Preferred	IMODIUM	QL=7 días
vitamin b-1 100 mg tab	1	Preferred	THIAMINE	QL=7 días
MOOD STABILIZERS [ESTABILIZADORES DEL ÁNIMO]
Bipolar Agents [Agentes Para Bipolaridad]
divalproex sodium 125 mg tab dr, 250 mg tab dr, 500 mg tab dr	1	Preferred	DEPAKOTE	QL=30 días
lamotrigine 100 mg tab, 150 mg tab, 200 mg tab, 25 mg tab	1	Preferred	LAMICTAL	QL=30 días
valproic acid 250 mg cap, 250 mg/5ml soln, 250 mg/5ml syr	1	Preferred	DEPAKENE	QL=30 días
PSYCHOSTIMULANTS [PSICOESTIMULANTES]
ADHD Amphetamines [Anfetaminas ADHD]
amphetamine- dextroamphetamine 15 mg tab, 30 mg tab	2	Preferred	ADDERALL	QL=30 días, AL 4-20 años, PA ≥ 21 años

 

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 7 for monthly net cost range [Ver  Página 4 de7 página 7 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/12/2017

Página 4 de 7

SUB MENTAL

amphetaminedextroamphetamine 10 mg tab, 12.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab	3	Preferred	ADDERALL	QL=30 días, AL 4-20 años, PA ≥ 21 años
dextroamphetamine sulfate 10 mg tab, 5 mg tab	3	Preferred	DEXEDRINE	QL=30 días, AL 4-20 años, PA ≥ 21 años
dextroamphetamine sulfate er 5 mg cap er 24 hr, 10 mg cap er 24 hr	4	Non-Preferred	DEXEDRINE SR	QL=30 días, AL 4-20 años, PA ≥ 21 años
dextroamphetamine sulfate er 15 mg cap er 24 hr	5	Non-Preferred	DEXEDRINE SR	QL=30 días, AL 4-20 años, PA ≥ 21 años
DYANAVEL XR oral susp. er 2.5 mg/ mL	4	Non-Preferred	DYANAVEL XR	PA, AL 6-20 años

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
ADHD Non-Amphetamines [No-Anfetaminas ADHD]
clonidine hcl 0.1 mg tab	1	Preferred	CATAPRESS	QL=7 días
dexmethylphenidate hcl 2.5 mg tab, 5 mg tab	2	Preferred	FOCALIN	QL=30 días, AL 6-20 años, PA ≥ 21 años
methylphenidate hcl 5 mg tab	2	Preferred	RITALIN	QL=30 días, AL 6-20 años, PA ≥ 21 años
dexmethylphenidate hcl 10 mg tab	3	Preferred	FOCALIN	QL=30 días, AL 6-20 años, PA ≥ 21 años
methylphenidate hcl 10 mg tab, 20 mg tab	3	Preferred	RITALIN	QL=30 días, AL 6-20 años, PA ≥ 21 años
STRATTERA 10 mg cap, 100 mg cap, 18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap	4	Preferred		PA, QL=30 días, AL 6-20 años, PA ≥ 21 años, P

 

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 7 for monthly net cost range [Ver  Página 5 de7 página 7 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/12/2017

Página 5 de 7

SUB MENTAL

SLEEP DISORDER AGENTS [DESORDENES DEL SUEÑO]
Benzodiazepines [Benzodiazepinas]
flurazepam hcl 15 mg cap, 30 mg cap	1	Preferred	DALMANE	QL=5 días
temazepam 15 mg cap, 30 mg cap	1	Preferred	RESTORIL	QL=5 días
Miscellaneous Sleep Disorder Agents [Agentes Misceláneos Desordenes Del Sueño]
zolpidem tartrate 10 mg tab, 5 mg tab	1	Preferred	AMBIEN	QL=5 días

• PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 7 for monthly net cost range [Ver  Página 6 de7 página 7 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/12/2017

Página 6 de 7

Página 7 de 7

DENTAL

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/  Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase Terapéutica]
ANALGESICS [ANALGÉSICOS]
Nonsteroidal Anti-Inflammatory Agents (Nsaids) [Anti-Inflamatorios No Esteroidales]
ibuprofen 400 mg tab, 600  mg tab, 800 mg tab	1	Preferred	MOTRIN	QL=7 días
naproxen 250 mg tab, 375 mg tab, 500 mg tab	1	Preferred	NAPROSYN	QL=7 días
naproxen dr 375 mg tab dr, 500 mg tab dr	1	Preferred	NAPROSYN	QL=7 días
Short-Acting Opioid Analgesics [Analgésicos Opiodes De Corta Duración]
acetaminophen -codeine 120-12 mg/5ml soln, 300-15 mg tab, 300-30 mg tab, 300- 60 mg tab	1	Preferred	TYLENOL- CODEINE	QL=7 días
acetaminophen-codeine #2 300-15 mg tab	1	Preferred	TYLENOL- CODEINE	QL=7 días
acetaminophen-codeine #3 300-30 mg tab	1	Preferred	TYLENOL- CODEINE	QL=7 días
acetaminophen-codeine #4 300-60 mg tab	1	Preferred	TYLENOL- CODEINE	QL=7 días
hydrocodone- acetaminophen 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab	1	Preferred	VICODIN	QL=7 días
ANTIBACTERIALS [ANTIBACTERIANOS]
First Generation Cephalosporins [Cefalosporinas De Primera Generación]
cephalexin 125 mg/5ml susp, 250 mg cap, 500 mg cap	1	Preferred	KEFLEX
cefadroxil 250 mg/5ml susp	2	Non-Preferred	DURICEF	AL ≤ 12 años
cephalexin 250 mg/5ml susp	2	Preferred	KEFLEX
cefadroxil 500 mg/5ml susp	3	Non-Preferred	DURICEF	AL ≤ 12 años
Macrolides [Macrólidos]
ERY -TAB 500 mg tab dr	3	Preferred

DENTAL

 

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos/ Límites]
erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab	3	Preferred	ERY-TAB
erythromycin ethylsuccinate 400 mg tab	3	Preferred	E.E.S.
ERYTHROCIN STEARATE 250 mg tab	4	Non-Preferred
E.E.S. GRANULES 200 mg/5ml susp	5	Preferred
ERYPED 200 200 mg/5ml susp	5	Preferred
ERYPED 400 400 mg/5ml susp	6	Preferred
Miscellaneous Antibacterials [Antibacterianos Misceláneos]
clindamycin hcl 150 mg cap, 300 mg cap, 75 mg cap	1	Preferred	CLEOCIN
Penicillins [Penicilinas]
amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab	1	Preferred	AMOXIL
ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap	1	Preferred	PRINCIPEN
penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab	1	Preferred	VEETIDS

DENTAL

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]
Therapeutic Class [Clase  Terapéutica]
ANALGESICS [ANALG ÉSICOS]
Nonsteroidal Anti-Inflammatory Agents (Nsaids) [ Anti-Inflamatorios No Esteroidales]
ibuprofen 400 mg tab, 600 mg tab, 800 mg tab	1	Preferred	MOTRIN	QL = 5 días
indomethacin 25 mg cap, 50 mg cap	1	Non-Preferred	INDOCIN	QL = 5 días
nabumetone 500 mg tab, 750 mg tab	1	Preferred	RELAFEN	QL = 5 días
naproxen 250 mg tab, 375 mg tab, 500 mg tab	1	Preferred	NAPROSYN	QL = 5 días
naproxen sodium 275 mg tab, 550 mg tab	1	Preferred	ANAPROX	QL = 5 días
salsalate 500 mg tab, 750 mg tab	1	Preferred	DISALCID	QL = 5 días
Short-Acting Opioid Analgesics [Analgésicos Opiodes De Corta Duración]
acetaminophen  -codeine 120-12 mg/5ml soln, 300-15 mg tab, 300-30 mg tab, 300- 60 mg tab	1	Preferred	TYLENOL- CODEINE	QL = 5 días
acetaminophen-codeine #2 300-15 mg tab	1	Preferred	TYLENOL- CODEINE	QL = 5 días
acetaminophen-codeine #3 300-30 mg tab	1	Preferred	TYLENOL- CODEINE	QL = 5 días
acetaminophen-codeine #4 300-60 mg tab	1	Preferred	TYLENOL- CODEINE	QL = 5 días
butalbital-apap-caffeine 50325-40 mg tab	1	Preferred	FIORICET	QL = 5 días
tramadol hcl 50 mg tab	1	Preferred	ULTRAM	QL = 5 días
butalbital-apap-caffeine 50325-40 mg cap	2	Preferred	FIORICET	QL = 5 días

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 1 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
ANESTHETICS [ANESTÉSICOS]
Local Anesthetics [Anestésicos Locales]
lidocaine viscous 2 % mouth/throat soln	1	Preferred	XYLOCAINE	QL = 5 días
ANTIANXIETY AGENTS [AGENTES PARA LA ANXIEDAD]
Benzodiazepines [Benzodiazepinas]
clonazepam 0.5 mg tab, 1 mg tab, 2mg tab	1	Preferred	KLONOPIN	QL = 5 días
diazepam 10 mg tab, 2 mg tab, 5 mg tab	1	Preferred	VALIUM	QL = 5 días
lorazepam 0.5 mg tab, 1 mg tab	1	Preferred	ATIVAN	QL = 5 días
temazepam 15 mg cap, 30 mg cap	1	Preferred	RESTORIL	QL = 5 días
Miscellaneous Anxiolytics [Ansiolíticos Misceláneos]
hydroxyzine pamoate 100 mg cap, 25 mg cap, 50 mg cap	1	Preferred	VISTARIL	QL = 5 días
ANTIBACTERIALS [ANTIBACTERIANOS]
First Generation Cephalosporins [Cefalosporinas De Primera Generación]
cephalexin 125 mg/5ml susp, 250 mg cap, 500 mg cap	1	Preferred	KEFLEX	QL = 5 días

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

cefadroxil 250 mg/5ml susp	2	Non-Preferred	DURICEF	QL = 5 días, AL ≤ 12
cephalexin 250 mg/5ml susp	2	Preferred	KEFLEX	QL = 5 días
cefadroxil 500 mg/5ml susp	3	Non-Preferred	DURICEF	QL = 5 días, AL ≤ 12
Macrolides [Macrólidos]
azithromycin 250 mg tab, 500 mg tab	1	Preferred	ZITHROMAX	QL = 5 días
azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab	2	Preferred	ZITHROMAX	QL = 5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab	2	Preferred	BIAXIN	QL = 5 días
clarithromycin 250 mg/5ml susp	3	Preferred	BIAXIN	QL = 5 días
erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab	3	Preferred	ERY-TAB	QL = 5 días
erythromycin ethylsuccinate 400 mg tab	3	Preferred	E.E.S.	QL = 5 días
ERYTHROCIN STEARATE 250 mg tab	4	Non-Preferred		QL = 5 días
Miscellaneous Antibacterials [Antibacterianos Misceláneos]
clindamycin hcl 150 mg cap, 300 mg cap, 75 mg cap	1	Preferred	CLEOCIN	QL = 5 días
MACRODANTIN 25 mg cap	1	Preferred		QL = 5 días

 • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

metronidazole 250 mg tab, 500 mg tab	1	Preferred	FLAGYL	QL = 5 días
nitrofurantoin macrocrystal 50 mg cap	1	Preferred	MACRODANTIN	QL = 5 días
nitrofurantoin macrocrystal 100 mg cap	2	Preferred	MACRODANTIN	QL = 5 días
nitrofurantoin oral suspension 25 MG/5ML	6	Non-Preferred	FURADANTIN
nitrofurantoin monohyd macro 100 mg cap	2	Preferred	MACROBID	QL = 5 días
Penicillins [Penicilinas]
amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab	1	Preferred	AMOXIL	QL = 5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 600-42.9 mg/5ml susp, 875-125 mg tab	1	Preferred	AUGMENTIN	QL = 5 días
ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap	1	Preferred	PRINCIPEN	QL = 5 días
penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab	1	Preferred	VEETIDS	QL = 5 días
amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp	3	Preferred	AUGMENTIN	QL = 5 días

 

 • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 4 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Quinolones [Quinolonas]
ciprofloxacin hcl 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	CIPRO	QL = 5 días
levofloxacin 250 mg tab, 500 mg tab, 750 mg tab	1	Preferred	LEVAQUIN	QL = 5 días
ciprofloxacin 500 mg/5ml (10%) susp	3	Preferred	CIPRO	QL = 5 días
ciprofloxacin 250 mg/5ml (5%) susp	4	Preferred	CIPRO	QL = 5 días
Second Generation Cephalosporins [Cefalosporinas De Segunda Generación]
cefaclor 250 mg cap, 500 mg cap	2	Preferred	CECLOR	QL = 5 días
cefprozil 125 mg/5ml susp, 250 mg tab, 250 mg/5ml susp, 500 mg tab	2	Preferred	CEFZIL	QL = 5 días
Sulfonamides [Sulfonamidas]
sulfamethoxazole  -tmp ds 800-160 mg tab	1	Preferred	SEPTRA	QL = 5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab	1	Preferred	SEPTRA	QL = 5 días
Third Generation Cephalosporins [Cefalosporinas De Tercera Generación]
cefdinir 125 mg/5ml susp, 300 mg cap	2	Preferred	OMNICEF	QL = 5 días
cefdinir 250 mg/5ml susp	3	Preferred	OMNICEF	QL = 5 días

 

 • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 5 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

ANTICONVULSANTS [ANTICONVULSIVANTES]
Anticonvulsants [Anticonvulsivantes]
carbamazepine 100 mg tab chew, 200 mg tab	1	Preferred	TEGRETOL	QL = 5 días
clonazepam 0.5 mg tab, 1 mg tab, 2mg tab	1	Preferred	KLONOPIN	QL = 5 días
divalproex sodium 125 mg tab dr, 250 mg tab dr, 500 mg tab dr	1	Preferred	DEPAKOTE	QL = 5 días
gabapentin 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab	1	Preferred	NEURONTIN	QL = 5 días
lamotrigine 100 mg tab, 150 mg tab, 200 mg tab, 25 mg tab	1	Preferred	LAMICTAL	QL = 5 días
lamotrigine chew tab 5 mg, 25 mg	3	Non-Preferred	LAMICTAL
levetiracetam 250 mg tab, 500 mg tab	1	Preferred	KEPPRA	QL = 5 días
levetiracetam er 24 hrs 500 mg tab, 750 mg	3	Non-Preferred	KEPPRA XR
oxcarbazepine 150 mg tab	1	Preferred	TRILEPTAL	QL = 5 días
phenobarbital 100 mg tab, 15 mg tab, 16.2 mg tab, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab	1	Preferred	PHENOBARBITAL	QL = 5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
primidone 250 mg tab, 50 mg tab	1	Preferred	MYSOLINE	QL = 5 días

 

 • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab	1	Preferred	TOPAMAX	QL = 5 días
valproic acid 250 mg cap, 250 mg/5ml soln, 250 mg/5ml syr	1	Preferred	DEPAKENE	QL = 5 días
zonisamide 50 mg cap	1	Preferred	ZONEGRAN	QL = 5 días
DILANTIN 30 mg cap	2	Preferred		QL = 5 días
levetiracetam 1000 mg tab, 750 mg tab	2	Preferred	KEPPRA	QL = 5 días
oxcarbazepine 300 mg tab, 600 mg tab	2	Preferred	TRILEPTAL	QL = 5 días
phenytoin 125 mg/5ml susp, 50 mg tab chew	2	Preferred	DILANTIN	QL = 5 días
phenytoin sodium extended 100 mg cap, 200 mg cap, 300 mg cap	2	Preferred	DILANTIN	QL = 5 días
zonisamide 100 mg cap, 25 mg cap	2	Preferred	ZONEGRAN	QL = 5 días
ethosuximide 250 mg cap, 250 mg/5ml soln	3	Preferred	ZARONTIN	QL = 5 días
phenobarbital 20 mg/5ml oral elix, 20 mg/5ml soln	3	Preferred	PHENOBARBITAL	QL = 5 días
ANTIDEMENTIA AGENTS [AGENTES ANTIDEMENCIA]
Cholinesterase Inhibitors [Inhibidores De Colinesterasa
donepezil hcl 10 mg tab, 5 mg tab	1	Preferred	ARICEPT	QL = 5 días
rivastigmine tartrate 1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap	3	Preferred	EXELON	QL = 5 días

 • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 7 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
ANTIDEPRESSANTS [ANTIDEPRESIVOS]
Miscellaneous Antidepressants [Antidepresivos Misceláneos]
trazodone hcl 100 mg tab, 150 mg tab, 50 mg tab	1	Preferred	DESYREL	QL = 5 días
Monoamine Oxidase (Mao) Inhibitors [Inhibidores De Mao]
selegiline hcl 5 mg tab	3	Non-Preferred	CARBEX	QL = 5 días
ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]
Alpha-Glucosidase Inhibitors [Inhibidores De Alfa Glucosidasa]
acarbose 100 mg tab, 25 mg tab, 50 mg tab	2	Preferred	PRECOSE	QL = 5 días
Biguanides [Biguanidas]
metformin hcl 1000 mg tab, 500 mg tab, 850 mg tab	1	Preferred	GLUCOPHAGE	QL = 5 días
Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors [Inhibidores De Dpp-4]
KOMBIGLYZE XR 2.5 -1000 mg tab er 24 hr, 5-1000 mg tab er 24 hr, 5-500 mg tab er 24 hr	3	Preferred		QL = 5 días, ST, P
ONGLYZA 2.5 mg tab, 5 mg tab	3	Preferred		QL = 5 días, ST, P
Insulin Mixtures [Mezclas De Insulinas]
HUMULIN 70/30 (70          -30) 100 unit/ml sc susp	2	Preferred		QL = 1 Vial 10 ML/30 días, P
Insulin Sensitizing Agents [Agentes Sensibilizantes De Insulin]
pioglitazone hcl 15 mg tab, 30 mg tab, 45 mg tab	1	Preferred	ACTOS	QL = 5 días
Intermediate-Acting Insulins [Insulinas De Duración Intermedia]
HUMULIN N 100 unit/ml sc susp	2	Preferred		QL = 1 Vial 10 ML/30 días, P
Short-Acting Insulins [Insulinas De Corta Duración]
HUMULIN R 100 unit/ml inj soln	2	Preferred		QL = 1 Vial 10 ML/30 días, P

 • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 8 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
Sulfonylureas [Sulfonilureas]
glimepiride 1 mg tab, 2 mg tab, 4 mg tab	1	Preferred	AMARYL	QL = 5 días
glipizide 10 mg tab, 5 mg tab	1	Preferred	GLUCOTROL	QL = 5 días
ANTIEMETICS [ANTIEMÉTICOS]
Miscellaneous Antiemetics [Antieméticos Misceláneos]
metoclopramide hcl 10 mg tab, 5 mg tab, 5 mg/ml inj soln	1	Preferred	REGLAN	QL = 5 días
ormir 50 mg cap	1	Preferred	BENADRYL	QL = 5 días
pharbedryl 50 mg cap	1	Preferred	BENADRYL	QL = 5 días
trimethobenzamide hcl 300 mg cap	1	Preferred	TIGAN	QL = 5 días
Phenothiazines [Fenotiazinas]
prochlorperazine maleate 10 mg tab, 5 mg tab	1	Preferred	COMPAZINE	QL = 5 días
prochlorperazine 25 mg rect supp	4	Non-Preferred	COMPAZINE	QL = 5 días

 

 • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 9 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

ANTIGOUT AGENTS [AGENTES ANTIGOTA]
Antigout Agents [Agentes Antigota]
allopurinol 100 mg tab, 300 mg tab	1	Preferred	ZYLOPRIM	QL = 5 días
colchicine 0.6 mg cap	3	Preferred	MITIGARE	PA
COLCRYS 0.6 mg tab	4	Non-Preferred		QL= 3 tab, 15días
Uricosurics [Uricosúricos]
probenecid 500 mg tab	1	Preferred	BENEMID	QL = 5 días
ANTIHYPERTENSIVES [ANTIHIPERTENSIVOS]
Alpha-Adrenergic Agonists [Agonistas Alfa Adrenérgicos]
clonidine hcl 0.1 mg tab, 0.2 mg tab, 0.3 mg tab	1	Preferred	CATAPRESS	QL = 5 días
methyldopa 250 mg tab, 500 mg tab	1	Preferred	ALDOMET	QL = 5 días

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]
terazosin hcl 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap	1	Preferred	HYTRIN	QL = 5 días
Angiotensin II Receptor Blockers (ARB) [Antagonistas Del Receptor Angiotensina II]
losartan potassium 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	COZAAR	QL = 5 días
losartan potassium-hctz 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab	1	Preferred	HYZAAR	QL = 5 días

 

 • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 10 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Angiotensin-Converting Enzyme (ACE) Inhibitors [Inhibidores De La Enzima Convertidora De Angiotensina]
lisinopril 10 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab	1	Preferred	ZESTRIL	QL = 5 días
lisinopril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab	1	Preferred	ZESTORETIC	QL = 5 días
Calcium Channel Blocking Agents [Bloqueadores De Canales De Calcio]
amlodipine besylate 10 mg tab, 2.5 mg tab, 5 mg tab	1	Preferred	NORVASC	QL = 5 días
diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab	1	Preferred	CARDIZEM	QL = 5 días
verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab	1	Preferred	CALAN	QL = 5 días
Carbonic Anhydrase Inhibitors Diuretics [Diuréticos Inhibidores De Anhidrasa Carbónica]
acetazolamide 125 mg tab, 250 mg tab	3	Preferred	DIAMOX	QL = 5 días
Cardioselective Beta Blocking Agents [Bloqueadores Beta Cardioselectivos]
atenolol 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	TENORMIN	QL = 5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
metoprolol succinate er 25 mg tab er 24 hr, 50 mg tab er 24 hr	1	Preferred	LOPRESSOR	QL = 5 días
metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	LOPRESSOR	QL = 5 días

 

 • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 11 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr	2	Preferred	LOPRESSOR	QL = 5 días
Cardioselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos Cardioselectivos]
atenolol -chlorthalidone 10025 mg tab, 50-25 mg tab	1	Preferred	TENORETIC	QL = 5 días
metoprolol- hydrochlorothiazide 50-25 mg tab	2	Non-Preferred	LOPRESSOR HCT	QL = 5 días
metoprololhydrochlorothiazide 100-25 mg tab, 100-50 mg tab	3	Non-Preferred	LOPRESSOR HCT	QL = 5 días
Loop Diuretics [Diuréticos Del Asa]
furosemide 10 mg/ml soln, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	LASIX	QL = 5 días
Nonselective Beta Blocking Agents [Bloqueadores Beta No-Selectivos]
propranolol hcl 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	INDERAL	QL = 5 días
propranolol hcl 60 mg tab	2	Preferred	INDERAL	QL = 5 días
Potassium-Sparing Diuretics [Diuréticos Conservadores De Potasio]
spironolactone 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	ALDACTONE	QL = 5 días
triamterene-hctz 37.5-25 mg cap, 37.5-25 mg tab, 75-50 mg tab	1	Preferred	MAXZIDE	QL = 5 días

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 12 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
Thiazide Diuretics [Diuréticos Tiazidas]
chlorothiazide 250 mg tab, 500 mg tab	1	Preferred	DIURIL	QL = 5 días
chlorthalidone 25 mg tab, 50 mg tab	1	Non-Preferred	HYGROTON	QL = 5 días
DIURIL 250 mg/5ml susp	1	Preferred		QL = 5 días
hydrochlorothiazide 12.5 mg tab, 25 mg tab, 50 mg tab	1	Preferred	MICROZIDE	QL = 5 días
indapamide 1.25 mg tab, 2.5 mg tab	1	Preferred	LOZOL	QL = 5 días
metolazone 2.5 mg tab, 5 mg tab	1	Non-Preferred	ZAROXOLYN	QL = 5 días
chlorthalidone 100 mg tab	2	Non-Preferred	HYGROTON	QL = 5 días
metolazone 10 mg tab	2	Non-Preferred	ZAROXOLYN	QL = 5 días
Vasodilator Beta Blockers [Bloqueadores Beta Vasodilatadores]
carvedilol 12.5 mg tab, 25 mg tab, 3.125 mg tab, 6.25 mg tab	1	Preferred	COREG	QL = 5 días
Vasodilators [Vasodilatadores]
hydralazine hcl 10 mg tab, 100 mg tab, 25 mg tab, 50 mg tab	1	Preferred	APRESOLINE	QL = 5 días
ANTIMIGRAINE AGENTS [AGENTES ANTIMIGRAÑA]
Beta-Adrenergic Blocking Agents [Bloqueadores Beta Adrenérgicos]
divalproex sodium 125 mg tab dr, 250 mg tab dr, 500 mg tab dr	1	Preferred	DEPAKOTE	QL = 5 días
topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab	1	Preferred	TOPAMAX	QL = 5 días, ST
ANTIMYASTHENIC AGENTS [AGENTES ANTIMIASTÉNICOS]
Parasympathomimetics [Parasimpatomiméticos]
pyridostigmine bromide 60 mg tab	2	Preferred	MESTINON	QL = 5 días

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

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FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
MESTINON 60 mg/5ml syr	4	Non-Preferred		QL = 5 días
pyridostigmine bromide 180 mg tab er	6	Non-Preferred	MESTINON	QL = 5 días
ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]
Antituberculars [Antituberculosos]
CAPASTAT SULFATE 1 gm inj soln				QL = 5 días Puerto Rico Department Tuberculosis Control Program
cycloserine 250 mg cap			SEROMYCIN
RIFAMATE 150-300 mg cap
TRECATOR 250 mg tab
rifabutin 150 mg cap	7		MYCOBUTIN
isoniazid 100 mg tab, 300 mg tab	1	Preferred	ISONIAZID	QL = 5 días
rifampin 150 mg cap	1	Preferred	RIFADIN	QL = 5 días
ethambutol hcl 100 mg tab	2	Non-Preferred	MYAMBUTOL	QL = 5 días
pyrazinamide 500 mg tab	2	Non-Preferred	PYRAZINAMIDE	QL = 5 días
rifampin 300 mg cap	2	Preferred	RIFADIN	QL = 5 días
ethambutol hcl 400 mg tab	3	Non-Preferred	MYAMBUTOL	QL = 5 días
isoniazid 50 mg/5ml syr	5	Non-Preferred	ISONIAZID	QL = 5 días
ANTIPARASITICS [ANTIPARASITARIOS]
Antimalarials [Antimaláricos]
chloroquine phosphate 250 mg tab, 500 mg tab	1	Preferred	ARALEN	QL = 5 días

 

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 14 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

hydroxychloroquine sulfate 200 mg tab	1	Preferred	PLAQUENIL	QL = 5 días
quinine sulfate 324 mg cap	4	Preferred	QUININE	QL = 5 días
DARAPRIM 25 mg tab	7	Non-Preferred		PA, QL = 5 días
ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]
Anticholinergics [Anticolinérgicos]
benztropine mesylate 0.5 mg tab, 1 mg tab, 2 mg tab	1	Preferred	COGENTIN	QL = 5 días
Antiparkinson Dopaminergics [Dopaminérgicos Antiparkinson]
amantadine hcl 50 mg/5ml syr	1	Preferred	SYMMETREL	QL = 5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
pramipexole dihydrochloride 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab	1	Preferred	MIRAPEX	QL = 5 días
ropinirole hcl 0.25 mg tab, 0.5 mg tab, 1 mg tab, 3 mg tab, 4 mg tab, 5 mg tab	1	Preferred	REQUIP	QL = 5 días
ropinirole hcl 2 mg tab	2	Preferred	REQUIP	QL = 5 días
amantadine hcl 100 mg cap	3	Preferred	SYMMETREL	QL = 5 días
bromocriptine mesylate 2.5 mg tab	3	Preferred	PARLODEL	QL = 5 días
carbidopa-levodopaentacapone 18.75-75-200 mg tab	4	Non-Preferred	STALEVO	QL = 5 días
carbidopa-levodopaentacapone 12.5-50-200 mg tab, 25-100-200 mg tab, 31.25-125-200 mg tab, 37.5150-200 mg tab, 50-200-200 mg tab	5	Non-Preferred	STALEVO	QL = 5 días

 

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 15 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Dopamine Precursors [Precursores De Dopamina]
carbidopa  -levodopa 10-100 mg tab, 25-100 mg tab	1	Preferred	SINEMET	QL = 5 días
carbidopa-levodopa 25-250 mg tab	2	Preferred	SINEMET	QL = 5 días
carbidopa-levodopa er 25100 mg tab er, 50-200 mg tab er	2	Preferred	SINEMET CR	QL = 5 días
ANTIPSYCHOTICS [ANTIPSICÓTICOS]
Atypical - Second Generation [Atípicos - Segunda Generación]
risperidone 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab	1	Preferred	RISPERDAL	QL = 5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
Typical - First Generation [Típicos - Primera Generación]
haloperidol 0.5 mg tab, 1 mg tab, 2 mg tab	1	Preferred	HALDOL	QL = 5 días
haloperidol 5 mg tab	2	Preferred	HALDOL	QL = 5 días
haloperidol 10 mg tab	3	Preferred	HALDOL	QL = 5 días
haloperidol 20 mg tab	4	Preferred	HALDOL	QL = 5 días

 

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 16 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

ANTIVIRALS [ANTIVIRALES]
Anti-Cytomegalovirus (Cmv) Agents [Agentes Anti-Citomegalovirus]
valganciclovir hcl 450 mg tab	13	Non-Preferred	VALCYTE	PA, QL = 5 días
Antiherpetic Agents [Agentes Antiherpéticos]
acyclovir 200 mg cap, 400 mg tab, 800 mg tab	1	Preferred	ZOVIRAX	QL = 5 días
acyclovir 200 mg/5ml susp	2	Preferred	ZOVIRAX	QL = 5 días
Anti-Influenza Agents [Agentes Antiinfluenza]
amantadine hcl 50 mg/5ml syr	1	Preferred	SYMMETREL	QL = 5 días
amantadine hcl 100 mg cap	3	Preferred	SYMMETREL	QL = 5 días
oseltamivir phosphate 30 mg cap, 45 mg cap, 75 mg	4	Preferred	TAMIFLU
TAMIFLU 6 mg/ ml susp	5	Non-Preferred
BENIGN PROSTATIC HYPERTROPHY AGENTS [AGENTES PARA HIPERTROFIA PROSTÁTICA BENIGNA]
Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]
terazosin hcl 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap	1	Preferred	HYTRIN	QL = 5 días
BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]
Anticoagulants [Anticoagulantes]
warfarin sodium 1 mg tab, 10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab	1	Preferred	COUMADIN	QL = 5 días
heparin sodium (porcine) 1000 unit/ml inj soln	2	Preferred	HEPARIN	QL = 5 días

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 17 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
heparin sodium (porcine) 10000 unit/ml inj soln, 5000 unit/ml inj soln	3	Preferred	HEPARIN	QL = 5 días
heparin sodium (porcine) pf 5000 unit/0.5ml inj soln	3	Preferred	HEPARIN	QL = 5 días
heparin sodium (porcine) 2000 unit/ml iv soln	8	Preferred	HEPARIN	QL = 5 días
Colony Stimulating Factors [Estimulantes Mieloides]
NEULASTA 6 mg/0.6ml sc soln	12	Preferred		PA, QL = 5 días, P
NEULASTA DELIVERY KIT 6 mg/0.6ml sc soln	12	Preferred		PA, QL = 5 días, P
Platelet Modifying Agents [Modificadores De Plaquetas]
cilostazol 100 mg tab, 50 mg tab	1	Preferred	PLETAL	QL = 5 días
clopidogrel bisulfate 75 mg tab	1	Preferred	PLAVIX	QL = 5 días
CARDIOVASCULAR AGENTS [AGENTES CARDIOVASCULARES]
Antiarrhythmics Class Ii [Antiar rítmicos Clase Ii]
propranolol hcl 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	INDERAL	QL = 5 días
sotalol hcl 120 mg tab, 160 mg tab, 240 mg tab, 80 mg tab	1	Preferred	BETAPACE	QL = 5 días
sotalol hcl (af) 120 mg tab, 160 mg tab, 80 mg tab	1	Preferred	BETAPACE	QL = 5 días
propranolol hcl 60 mg tab	2	Preferred	INDERAL	QL = 5 días
Antiarrhythmics Type I-A [Antiarrítmicos Tipo I-A]
quinidine sulfate 200 mg tab, 300 mg tab	1	Preferred	QUINIDINE SULFATE	QL = 5 días
quinidine gluconate er 324 mg tab er	2	Preferred	QUINAGLUTE	QL = 5 días
quinidine sulfate er 300 mg tab er	2	Preferred	QUINIDINE SULFATE	QL = 5 días

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 18 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
Antiarrhythmics Type I-B [Antiarrítmicos Tipo I-B]
mexiletine hcl 150 mg cap	2	Preferred	MEXITIL	QL = 5 días
mexiletine hcl 200 mg cap	3	Preferred	MEXITIL	QL = 5 días
Antiarrhythmics Type I-C [Antiarrítmicos Tipo I-C]
flecainide acetate 100 mg tab, 50 mg tab	1	Preferred	TAMBOCOR	QL = 5 días
propafenone hcl 150 mg tab, 225 mg tab	1	Preferred	RYTHMOL	QL = 5 días
flecainide acetate 150 mg tab	2	Preferred	TAMBOCOR	QL = 5 días
propafenone hcl 300 mg tab	3	Preferred	RYTHMOL	QL = 5 días
Antiarrhythmics Type Iii [Antiarrítmicos Tipo Iii]
amiodarone hcl 200 mg tab	1	Preferred	CORDARONE	QL = 5 días
Miscellaneous Cardiovascular Agents [Agentes Cardiovasculares Misceláneos]
digoxin 125           mcg tab, 250 mcg tab	2	Preferred	LANOXIN	QL = 5 días
Vasodilators [Vasodilatadores]
isosorbide mononitrate 10 mg tab, 20 mg tab	1	Preferred	ISORDIL	QL = 5 días

 

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 19 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

isosorbide mononitrate er 120 mg tab er 24 hr, 30 mg tab er 24 hr, 60 mg tab er 24 hr	1	Preferred	IMDUR	QL = 5 días
NITROSTAT 0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl	1	Preferred		QL = 5 días
DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]
Antifungals [Antifungales]
clotrimazole 10 mg mouth/throat lozenge, 10 mg mouth/throat troche	1	Preferred	MYCELEX	QL = 5 días
nystatin 100000 unit/ml mouth/throat susp, 100000 unit/ml crm	1	Preferred	NYSTATIN	QL = 5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]
Pediculicides And Scabicides [Pediculicidas Y Escabicidas]
permethrin 5 % crm	3	Preferred	ELIMITE	QL = 5 días
Topical Antibiotics [Antibióticos Tópicos]
mupirocin 2 % oint	1	Preferred	BACTROBAN	QL = 5 días
silver sulfadiazine 1 % crm	1	Preferred	SILVADENE	QL = 5 días
terbinafine 1% crm	1	Preferred	LAMISIL	OTC, QL = 5días
DYSLIPIDEMICS [DISLIPIDÉMICOS]
Bile Acid Sequestrants [Secuestradores De Ácidos Biliares]
cholestyramine 4 gm pckt, 4 gm/dose oral pwdr	3	Preferred	QUESTRAN	QL = 5 días

 

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 20 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

cholestyramine light 4 gm pckt, 4 gm/dose oral pwdr	3	Preferred	QUESTRAN	QL = 5 días
Fibric Acid Derivatives [Derivados De Ácido Fíbrico]
gemfibrozil 600 mg tab	1	Preferred	LOPID	QL = 5 días
Hmg-Coa Reductase Inhibitors [Inhibidores De La Hmg-Coa Reductasa]
atorvastatin  calcium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab	1	Preferred	LIPITOR	QL = 5 días
simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab	1	Preferred	ZOCOR	QL = 5 días
GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]
Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De H2]
famotidine 20 mg tab, 40 mg tab	1	Preferred	PEPCID	QL = 5 días
ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr	1	Preferred	ZANTAC	QL = 5 días
Miscellaneous Gastrointestinal Agents [Agentes Gastrointestinales Misceláneos]
ursodiol 300 mg cap	2	Preferred	ACTIGALL	PA, QL = 5 días

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
Proton Pump Inhibitors [Inhibidores De La Bomba De Protones]
omeprazole 10 mg cap dr, 20 mg cap dr, 40 mg cap dr	1	Preferred	PRILOSEC	QL=180 caps/ 365 días
GENITOURINARY AGENTS [AGENTES GENITOURINARIOS]
Miscellaneous Genitourinary Agents [Agentes Genitourinarios Misceláneos]

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 21 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

phenazopyridine hcl 100 mg tab, 200 mg tab	1	Preferred	PYRIDIUM	QL = 3 días
HORMONAL AGENTS [AGENTES HORMONALES]
Antithyroid Agents [Agentes Antitiroide]
methimazole 10 mg tab, 5 mg tab	1	Preferred	TAPAZOLE	QL = 5 días
propylthiouracil 50 mg tab	2	Preferred	PROPYLTHIOURA CIL	QL = 5 días
Calcimimetic Agents [Agentes Calcimiméticos]
SENSIPAR 30 mg tab	7	Preferred		PA, QL = 5 días
SENSIPAR 60 mg tab	9	Preferred		PA, QL = 5 días
SENSIPAR 90 mg tab	10	Preferred		PA, QL = 5 días
Dopamine Agonists [Agonistas De Dopamina]
bromocriptine mesylate 2.5 mg tab	3	Preferred	PARLODEL	QL = 5 días
Thyroid Hormones [Hormona Tiroidea]
SYNTHROID 100 mcg tab,  112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab	1	Preferred		QL = 5 días, P

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 22 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]
Glucocorticosteroids [Glucocorticoides]
dexamethasone 0.5 mg tab, 0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab	1	Preferred	DECADRON	QL = 5 días
methylprednisolone 32 mg tab, 4 mg tab	1	Preferred	MEDROL	QL = 5 días
prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab	1	Preferred	DELTASONE	QL = 5 días
prednisone (pak) 10 mg tab, 5 mg tab	1	Preferred	DELTASONE	QL = 5 días
methylprednisolone 16 mg tab, 8 mg tab	2	Preferred	MEDROL	QL = 5 días
Immune Globulins [Immunoglobulinas]
RHOGAM ultra-filtered plus im soln 1500 unit	4	Preferred
INFLAMMATORY BOWEL DISEASE [ENFERMEDAD INFLAMATORIA INTESTINAL]
Aminosalicylates [Aminosalicilatos]
DELZICOL 400 mg cap dr	5	Preferred		QL = 5 días, P
ASACOL HD 800 mg tab dr	6	Preferred		QL = 5 días, P
Sulfonamides [Sulfonamidas]
sulfasalazine 500 mg tab, 500 mg tab dr	1	Preferred	AZULFIDINE	QL = 5 días
MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]
Calcium Regulating Agents [Agentes Reguladores De Calcio]
vitamin d 400 unit cap	1	Preferred	VITAMIN D	QL = 5 días
MUSCLE RELAXANTS [RELAJANTES MUSCULARES]
Antispasticity Agents [Agentes Antiespasticidad]
baclofen 10 mg tab, 20 mg tab	1	Preferred	LIORESAL	QL = 5 días

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 23 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
dantrolene sodium 25 mg cap, 50 mg cap	2	Preferred	DANTRIUM	QL = 5 días
dantrolene sodium 100 mg cap	3	Preferred	DANTRIUM	QL = 5 días
Skeletal Muscle Relaxants [Relajantes Musculoesqueletales]
cyclobenzaprine hcl 10 mg tab	1	Preferred	FLEXERIL	QL = 5 días
OPHTHALMIC AGENTS [AGENTES OFTÁLMICOS]
Antiglaucoma Agents [Agentes Antiglaucoma]
brimonidine tartrate 0.2 % ophth soln	1	Preferred	ALPHAGAN	QL = 1 Frasco 5 ML/15 días
dorzolamide hcl 2 % ophth soln	1	Preferred	TRUSOPT	QL = Frasco 10 ML/30 días
levobunolol hcl 0.5 % ophth soln	1	Preferred	BETAGAN	QL = 1 Frasco 5 ML/25 días
levobunolol hcl 0.25 % ophth soln	1	Preferred	BETAGAN	QL = 1 Frasco 5 ML/15 días
timolol maleate 0.5 % ophth soln	1	Preferred	TIMOPTIC	QL = 1 Frasco 5 ML/30 días
dorzolamide hcl-timolol mal ophth sol 22.3-6.8 mg/ml	1	Preferred	COSOPT	QL = 1 Frasco 5 ML/30 días
timolol maleate 0.25 % ophth soln	1	Preferred	TIMOPTIC	QL = 1 Frasco 5 ML/25 días
betaxolol hcl 0.5 % ophth soln	2	Non-Preferred	BETOPTIC	QL = 1 Frasco 5 ML/15 días
Ophthalmic Antibiotics [Antibióticos Oftálmicos]
gentamicin sulfate 0.3 % ophth oint	1	Preferred	GARAMYCIN	QL = 1 Tubo 3.5 GM/5 días
gentamicin sulfate 0.3 % ophth soln	1	Preferred	GARAMYCIN	QL = 1 Frasco 5 ML/5 días
tobramycin 0.3 % ophth soln	1	Preferred	TOBREX	QL = 1 Frasco 5 ML/5 días
Ophthalmic Prostaglandins [Prostaglandinas Oftálmicas]
latanoprost 0.005 % ophth soln	1	Preferred	XALATAN	QL = 1 Frasco/25 días

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 24 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Drug Name [Nombre del Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
Ophthalmic Steroids [Esteroides Oftálmicos]
neomycin -polymyxindexamethasone 3.5-100000.1 ophth oint, 3.5-100000.1 ophth susp	1	Preferred	MAXITROL	QL = 1Frasco 5ML/5 días
prednisolone acetate 1 % ophth susp	2	Preferred	PRED FORTE	QL = 1 Frasco 5 ML/5 días
OTIC AGENTS [AGENTES OTICOS]
Miscellaneous Otic Agents [Agentes Oticos Misceláneos]
acetic acid 2 % otic soln	2	Preferred	VOSOL	QL = 1 Frasco 15 ML/10 días
Otic Antibiotics [Antibióticos Oticos]
neomycin   -polymyxin-hc 1 % otic soln, 3.5-10000-1 otic soln, 3.5-10000-1 otic susp	2	Preferred	CORTISPORIN	QL = 1 Frasco 10 ML/10 días
RESPIRATORY AGENTS [AGENTES RESPIRATORIOS]
Anticholinergic Bronchodilators [Broncodilatadores Anticolinérgicos]
ipratropium bromide 0.02 % inh soln	1	Non-Preferred	ATROVENT	QL = 5 días

 

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 25 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Antileukotrienes [Antileukotrienos]
montelukast sodium 10 mg tab, 4 mg tab chew, 5 mg tab chew 1 Preferred SINGULAIR QL = 5 días
Antitussive-Expectorant [Expectorantes Antitusivos]
benzonatate 100 mg cap	1	Preferred	TESSALON	QL = 5 días
guaifenesin-codeine 100-10 mg/5ml soln	1	Preferred	CHERATUSSIN	QL = 5 días
Inhaled Corticosteroids [Corticosteroides Inhalados]
FLOVENT DISKUS 100 mcg/blist inh aer pwdr, 250 mcg/blist inh aer pwdr, 50 mcg/blist inh aer pwdr	3	Preferred		QL = 1 Inh 60 EA/30 días, P

Drug Name [Nombre del  Medicamento]	Net Cost [Costo Neto]	Tier [Tier]	Reference Name  [Nombre de Referencia]	Requirements/ Limits [Requerimientos / Límites]
FLOVENT HFA 110 mcg/act inh aer	3	Preferred		QL = 1 Inh 12 EA/30 días, P
FLOVENT HFA 44 mcg/act  inh aer	3	Preferred		QL = 1 Inh 10.6 EA/30 días, P
budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp, 1mg/2ml inh susp	4	Non-Preferred	PULMICORT	AL </=12
budesonide 1mg/2ml inh susp	8	Non-Preferred	PULMICORT	AL </=12
FLOVENT HFA 220 mcg/act inh aer	4	Preferred		QL = 1 Inh 12EA/30 días, P

 

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 26 de 28

FORMULARIO DE EMERGENCIA INTEGRADO (FEI)

Sedating Histamine1 Blocking Agents [Sedantes Bloqueadores Histamine1]
promethazine hcl 12.5 mg tab, 25 mg tab, 50 mg tab, 6.25 mg/5ml soln, 6.25 mg/5ml syr	1	Preferred	PHENERGAN	QL = 5 días
Sympathomimetic Bronchodilators [Broncodilatadores Simpatomiméticos]
albuterol sulfate (2.5 mg/3ml) 0.083% inh neb soln, (5 mg/ml) 0.5% inh neb soln, 2 mg/5ml syr	1	Dl	ALBUTEROL	QL = 5 días
terbutaline sulfate 2.5 mg tab, 5 mg tab	1	Preferred	BRETHINE	QL = 5 días
VENTOLIN HFA 108 (90 base) mcg/act inh aer	1	Preferred		QL = 1 Inh 18 EA/30 días, P

• PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

Página 27 de 28

 PUERTO RICO MEDICAID PROGRAM

 Cost Sharing Policy (Copayments) for Medicaid and CHIP Beneficiaries

 Introduction

On July 15, 2013, the Centers for Medicare and Medicaid Services (CMS) published the final rule to update and simplify the Medicaid premium and cost sharing requirements, to promote the most effective use of services, and to assist states in identifying cost sharing flexibilities, (78 Federal Register page 42,100).

The federal regulation defines "cost sharing" as any copayment, coinsurance, deductible, or other similar charge.  Copayment is a fixed amount (for example, $1) that the beneficiary pays directly to a provider for each covered health care service, usually when he or she receives at the time of the service.

The Puerto Rico Medicaid State Plan dictates that Medicaid beneficiaries may pay cost sharing.  The Puerto Rico Department of Health (PRDoH), through the Puerto Rico Medicaid Program (Medicaid Program), and the Puerto Rico Health Insurance Administration (PRHIA, Administración de Seguros de Salud de Puerto Rico, or ASES, from its acronym in Spanish) have issued this "Cost Sharing Policy (Copayments) for Medicaid and CHIP Beneficiaries" to establish copayment rules, as required by:

1. The Social Security Act (SSA), Sections 1916 and 1916A.

2. The federal regulation, 42 CFR §§447.50-447.57 (excluding 42 CFR §447.55) of the federal regulation.

3. The Puerto Rico State Plan Amendment (SPA) for Cost Sharing.

4. The New Cost Sharing (Copayment) Structure for Medicaid and CHIP Beneficiaries.

The federal regulation addresses the following topics:

Medicaid Premiums and Cost Sharing

42 CFR §447.50 Premiums and cost sharing: Basis and purpose.

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42 CFR §447.51	Definitions.
42 CFR §447.52	Cost sharing.
42 CFR §447.53	Cost sharing for drugs.
42 CFR §447.54	Cost sharing for services furnished in a hospital emergency department.
42 CFR §447.55	Premiums.
42 CFR §447.56	Limitations on premiums and cost sharing.
42 CFR §447.57	Beneficiary and public notice requirements.

The Policy establishes the following copayments rules, among others:

1. Medicaid beneficiaries are only subject to copayments and to no other form of cost sharing, such as coinsurances or deductibles.

2. CHIP beneficiaries (Children Health Insurance Program or Medicaid Optional Targeted Low-Income Children) do not pay cost sharing or any other form of cost sharing, such as coinsurances or deductibles.

3. Certain beneficiaries and services are exempt from any cost sharing, which mean that no copayment will be charged in these instances.

4. Copayment amounts can vary by coverage codes and by the type of covered health care service.

5. This Policy does not apply to individuals eligible for the Government Health Plan (GHP) as State or Commonwealth beneficiary.

 Medicaid and CHIP Cost Sharing (Copayments) Structure Prior to July 1, 2016

Cost Sharing (Copayments) Policy for Medicaid and CHIP Beneficiaries:

1. The Cost Sharing (Copagos) Structure, coverage codes, and copayment amounts applied to all Medicaid and CHIP beneficiaries, were effective from November 1, 2011 through June 30, 2016.

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2. The coverage codes were determined on the basis of the beneficiary Eligibility Monthly Income and the number of Members in the Family Unit.  For example: if the Eligibility Income of a Medicaid beneficiary is $300 per month and the Members in the Family Unit is two (2), the coverage code assigned is 110.  The evaluation uses Table I as follows:

a. Eligibility Monthly Income = $300;

b. Members in Family Unit = 2;

c. Position on the row for Members in Family Unit of 2;

d. Determine in which column of Coverage Codes on the row the Eligibility Monthly Income of $300 fits;

e. The eligibility monthly income of $300 fits in range $249-UP which is under column 110; and

f. Therefore, the beneficiary is assigned coverage code 110.

3. It does not apply to anyone who is eligible as a State or Commonwealth beneficiary.

The following three (3) tables illustrate the Cost Sharing (Copayments) Structure for Medicaid and CHIP Beneficiaries prior July 1, 2016:

1. Table I - Medicaid Coverage Codes, determined on the basis of eligibility monthly income and the number of members in the beneficiary’s family unit.

2. Table II - CHIP Coverage Codes, determined on the basis of eligibility monthly income and the number of members in the beneficiary’s family unit.

3. Table III - Medicaid and CHIP Coverage Codes and the applicable copayment amounts for each service.

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TABLE I
Medicaid Cost Sharing (Copayments) Structure Prior to July 1st, 2016 Coverage Codes and Its Determination
Members in Family Unit	Eligibility Monthly Income Range by Coverage Code
	100	110
1	$0-$200	$201-UP
2	$0-$248	$249-UP
3	$0-$295	$296-UP
4	$0-$343	$344-UP
5	$0-$390	$391-UP
6	$0-$438	$439-UP
7	$0-$485	$486-UP
8	$0-$533	$534-UP
9	$0-$580	$581-UP
10	$0-$628	$629-UP
11	$0-$675	$676-UP
12	$0-$723	$724-UP
13	$0-$770	$771-UP
14	$0-$818	$819-UP
15	$0-$865	$866-UP

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TABLE II
CHIP Cost Sharing Structure (Copayments) Prior to July 1st, 2016 Coverage Codes and Its Determination
Members in Family Unit	Eligibility Monthly Income Range by Coverage Code
	230
1	$551-$1,100
2	$551-$1,300
3	$551-$1,500
4	$551-$1,700
5	$551-$1,900
6	$551-$2,100
7	$551-$2,300
8	$551-$2,500
9	$551-$2,700
10	$551-$2,900
11	$551-$3,100
12	$551-$3,300
13	$551-$3,500
14	$551-$3,700
15	$551-$3,900

TABLE III
Medicaid and CHIP Cost Sharing (Copayments) Structure Prior to July 1st, 2016 Applicable Copayment Amounts for Each Service by Coverage Code
Service	Coverage Codes and Copayments Amounts
	Medicaid		CHIP
	100	110	230
Hospital Admission, (per entire stay)	$0.00	$3.00	$0.00
Non-emergency Services Provided in a Hospital Emergency Room (ER), (per visit)	$3.80	$3.80	$0.00
Visit to Primary Care Physician (PCP), (per visit)	$0.00	$1.00	$0.00
Visit to Specialist, (per visit)	$0.00	$1.00	$0.00
Visit to Sub-Specialist, (per visit)	$0.00	$1.00	$0.00
High-Tech Laboratories, (per procedure)	$0.00	$0.50	$0.00

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TABLE III
Medicaid and CHIP Cost Sharing (Copayments) Structure Prior to July 1st, 2016 Applicable Copayment Amounts for Each Service by Coverage Code
Service	Coverage Codes and Copayments Amounts
	Medicaid		CHIP
	100	110	230
Clinical Laboratories, (per procedure)	$0.00	$0.50	$0.00
X-Rays, (per procedure)	$0.00	$0.50	$0.00
Special Diagnostic Test, (per procedure)	$0.00	$1.00	$0.00
Therapy - Physical, (per procedure)	$0.00	$1.00	$0.00
Therapy - Respiratory, (per procedure)	$0.00	$1.00	$0.00
Therapy - Occupational, (per procedure)	$0.00	$1.00	$0.00
Dental - Preventative, (per procedure)	$0.00	$1.00	$0.00
Dental - Restorative, (per procedure)	$0.00	$1.00	$0.00
Pharmacy - Generic, (per drug)	$1.00	$1.00	$0.00
Pharmacy - Brand, (per drug)	$3.00	$3.00	$0.00
All Other Services or Items Not Specified Above	$0.00	$0.00	$0.00

Medicaid and CHIP Cost Sharing (Copagos) Structure to be Effective On and After July 1, 2016

The New Cost Sharing Structure (Copayments) will apply to all Medicaid and CHIP beneficiaries and:

1. Be effective on July 1^st, 2016; except for those Medicaid dual beneficiaries with Medicare Part A and B and who are enrolled in a Medicare Advantage (MA) Plan contracted with ASES, commonly known as Platino Plan.  In Platino Plans, the New Cost Sharing Structure will be implemented on January 1^st, 2017.

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2. Assign the Medicaid and CHIP Coverage Codes on the basis of:

a. MAGI: Obamacare provides a new method for determining eligibility of individuals for Medicaid and CHIP, based on what is called Modified Adjusted Gross Income (MAGI).

b. At July 1, 2016 and until implementation of MAGI Methodologies for determining Medicaid and CHIP eligibility, the Medicaid Program will continue assigning Medicaid and CHIP Coverage Codes for a beneficiary on the basis of the eligibility monthly income and the number of members in the family unit of the beneficiary, as illustrates on Tables I and II.

c. On and after implementation of MAGI Methodologies for determining Medicaid and CHIP eligibility:

(1) The Medicaid Program will be assigned the Medicaid and CHIP Coverage Codes for an individual on the basis of MAGI Monthly Income and MAGI Household Size of the individual.

(2) Coverage Codes vary by household monthly income ranges.

(3) Medicaid and CHIP Coverage Codes are based on ranges of MAGI Monthly Income as a percentage of the Puerto Rico Poverty Level (PRPL) in effect.

(4) Example: if the MAGI Monthly Income of a Medicaid beneficiary is $300 per month with a MAGI household size of two (2) the coverage code assigned is 110.  The evaluation uses Table IV as follows:

(a) MAGI Monthly Income = 300;

(b) MAGI household size = 2;

(c) Position on the row for MAGI Household Size of 2;

(d) Determine in which column of Coverage Code 100, 110, 120 ó 130 on the row, the MAGI Monthly Income of $300 fits;

(e) MAGI Monthly Income of $300 fits in range $272-$542 which is under column 110; and,

(f) Therefore, the beneficiary is assigned coverage code 110.

3. Expand the number of coverage codes:

a. The new coverage codes 120, 130, and 220 and the copayments amounts associate with these codes will be implemented on and after MAGI eligibility evaluation system go-lives.

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b. The new coverage codes will be assigned on the basis of MAGI Monthly Income and MAGI Household Size of the individual.

4. Revise some copayments amounts on existing coverage codes, and establish copayment amounts on new coverage codes.

a. Starting on July 1^st, 2016:

(1) All Medicaid beneficiaries with the coverage codes 100 or 110 will pay the new the copayments amounts associate with these codes, as illustrate on Table VI.

(2) All CHIP beneficiaries with the coverage code 230 will continue paying the copayments amounts associate with this code, which remains as zero ($0) as illustrate on Table VI.

b. On and after the implementation of MAGI methodologies for determining Medicaid or CHIP eligibility:

(1) All Medicaid beneficiaries assigned the new coverage codes 120 and 130 will pay the copayment amounts associate with these codes, as illustrate on Table VI.

(2) All CHIP beneficiaries with the coverage code 220 will pay the copayments amounts associate with this codes, which is zero ($0) as illustrate on Table VI.

5. Copayment amount vary by coverage codes and by service.

The following three (3) tables illustrate the Cost Sharing (Coapyments) Structure for Medicaid or CHIP Beneficiaries to be effective on and after July 1^st, 2016:

1. Table IV - Medicaid Coverage Codes, determined on the basis of MAGI Monthly Income and the MAGI Household Size of the individual.  Coverage codes are assigned according to monthly income ranges defines as a percentage of the PRPL.

2. Table V - CHIP Coverage Codes, determined on the basis of MAGI Monthly Income and the MAGI Household Size of the individual.  Coverage codes are assigned according to income ranges defines as a percentage of the PRPL.

3. Table VI - Medicaid and CHIP Coverage Codes and the applicable copayment amounts for each service.

Page 8

TABLE IV
Medicaid Cost Sharing Structure (Copayments) to be Effective On and After July 1, 2016 Coverage Codes and Its Determination
MAGI  Household Size	Puerto Rico Poverty Level (PRPL)	MAGI Monthly Income Range by Coverage Code
		100	110	120	130
		Percentage of PRPL
		0%-50%	51%-100%	101%-150%	151%-UP
1	$0-$459	$0-$230	$231-$459	$460-$689	$690-UP
2	$0-$542	$0-$271	$272-$542	$543-$813	$814-UP
3	$0-$626	$0-$313	$314-$626	$627-$939	$940-UP
4	$0-$709	$0-$355	$356-$709	$710-$1,064	$1,065-UP
5	$0-$792	$0-$396	$397-$792	$793-$1,188	$1,189-UP
6	$0-$876	$0-$438	$438-$876	$877-$1,314	$1,315-UP
7	$0-$959	$0-$480	$481-$959	$960-$1,439	$1,440-UP
8	$0-$1,043	$0-$522	$523-$1,043	$1,044-$1,565	$1,566-UP
9	$0-$1,126	$0-$563	$564-$1,126	$1,127-$1,689	$1,690-UP
10	$0-$1,210	$0-$605	$606-$1,210	$1,211-$1,815	$1,816-UP
11	$0-$1,293	$0-$647	$648-$1,293	$1,294-$1,940	$1,941-UP
12	$0-$1,377	$0-$689	$690-$1,377	$1,378-$2,066	$2,067-UP
13	$0-$1,460	$0-$730	$731-$1,460	$1,461-$2,190	$2,191-UP
TABLE IV
Medicaid Cost Sharing Structure (Copayments) to be Effective On and After July 1, 2016 Coverage Codes and Its Determination
MAGI  Household Size	Puerto Rico Poverty Level (PRPL)	MAGI Monthly Income Range by Coverage Code
		100	110	120	130
		Percentage of PRPL
		0%-50%	51%-100%	101%-150%	151%-UP
14	$0-$1,544	$0-$772	$773-$1,544	$1,545-$2,316	$2,317-UP
15	$0-$1,627	$0-$814	$815-$1,627	$1,628-$2,441	$2,442-UP

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TABLE V
CHIP Cost Sharing Structure (Copayments) to be Effective On and After July 1, 2016 Coverage Codes and Its Determination
MAGI  Household Size	Puerto Rico Poverty Level (PRPL)	MAGI Monthly Income Range by  Coverage Code
		220	230
		Percentage of PRPL
		0%-150%	151%-UP
1	$0-$459	$0-$689	$690-UP
2	$0-$542	$0-$813	$814-UP
3	$0-$626	$0-$939	$940-UP
4	$0-$709	$0-$1,064	$1,065-UP
5	$0-$792	$0-$1,188	$1,189-UP
6	$0-$876	$0-$1,314	$1,315-UP
7	$0-$959	$0-$1,439	$1,440-UP
8	$0-$1,043	$0-$1,565	$1,566-UP
9	$0-$1,126	$0-$1,689	$1,690-UP
10	$0-$1,210	$0-$1,815	$1,816-UP
11	$0-$1,293	$0-$1,940	$1,941-UP
12	$0-$1,377	$0-$2,066	$2,067-UP
13	$0-$1,460	$0-$2,190	$2,191-UP
14	$0-$1,544	$0-$2,316	$2,317-UP
15	$0-$1,627	$0-$2,441	$2,442-UP

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TABLE VI
Medicaid and CHIP Cost Sharing Structure (Copayments) to be Effective On and After July 1, 2016 Applicable Copayment Amounts for Each Service by Coverage Code
Service	Coverage Codes and Copayments Amounts
	Medicaid				CHIP
	100	110	120	130	220	230
Hospital Admission, (per entire stay)	$0.00	$4.00	$5.00	$8.00	$0.00	$0.00
Non-Emergency Services Provided in a Hospital Emergency Room, (per visit)	$0.00	$4.00	$5.00	$8.00	$0.00	$0.00
Non-Emergency Services Provided in a non-Hospital / Freestanding Emergency Room, (per visit)	$0.00	$2.00	$3.00	$4.00	$0.00	$0.00
Visit to Primary Care Physician (PCP), (per visit)	$0.00	$1.00	$1.50	$2.00	$0.00	$0.00
Visit to Specialist, (per visit)	$0.00	$1.00	$1.50	$2.00	$0.00	$0.00
Visit to Sub-Specialist, (per visit)	$0.00	$1.00	$1.50	$2.00	$0.00	$0.00
High-Tech Laboratories, (per procedure)	$0.00	$0.50	$1.00	$1.50	$0.00	$0.00
Clinical Laboratories, (per procedure)	$0.00	$0.50	$1.00	$1.50	$0.00	$0.00
X-Rays, (per procedure)	$0.00	$0.50	$1.00	$1.50	$0.00	$0.00
Special Diagnostic Test, (per procedure)	$0.00	$1.00	$1.50	$2.00	$0.00	$0.00
Therapy - Physical, (per procedure)	$0.00	$1.00	$1.50	$2.00	$0.00	$0.00
Therapy - Respiratory, (per procedure)	$0.00	$1.00	$1.50	$2.00	$0.00	$0.00
Therapy - Occupational, (per procedure)	$0.00	$1.00	$1.50	$2.00	$0.00	$0.00
Dental - Preventative, (per procedure)	$0.00	$1.00	$1.50	$2.00	$0.00	$0.00
Dental - Restorative, (per procedure)	$0.00	$1.00	$1.50	$2.00	$0.00	$0.00
Pharmacy - Preferred Drugs, (per drug)	$0.00	$1.00	$2.00	$3.00	$0.00	$0.00
Pharmacy - Non-Preferred Drugs, (per drug)	$0.00	$3.00	$4.00	$6.00	$0.00	$0.00
All Other Services or Items Not Specified Above	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00

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Contracts between ASES and Managed Care Organizations (MCOs), Medicare Advantage Organizations (MAOs), Pharmacy Benefit Managers (PBMs), Managed Behavioral Healthcare Organizations (MBHOs), and Third Party Administrators (TPAs), among others, shall include this Cost Sharing Policy.  Each entity is required by contract to make this Cost Sharing (Copayments) Policy known to beneficiaries and providers.  Compliance with this Cost Sharing Policy will be monitored by ASES.

 Medicaid Beneficiaries Enrolled in a Platino Plan

The Medicaid dual beneficiaries with Medicare Part A and B have the option to be enrolled in a Medicare Advantage (MA) Plan contracted with ASES, commonly known as Platino Plan.  For Platino Plans, the New Cost Sharing Structure will be implemented on January 1, 2017.

MAO contracts, or Platino Plan contracts, are based on calendar year, from January 1^st to December 31^st of each year.  The January 1^st, 2017 implementation date will allow the changes in copayments to be incorporated under premiums and contract negotiation with each MAO, which will take effect in 2017.

Therefore, from July 1^st to December 31^s, 2016, MAOs will continue using the Cost Sharing Structure as indicated in Table I, II and III for the Platino Plans.  The beneficiary will continue using his/her Platino ID Card up to December 31, 2016.  If during the period from July 1^st to December 31^st 2016 the Medicaid Program:

1. Performs a Medicaid beneficiary determination or redetermination on a beneficiary who enrolls in, or is enrolled in, a Platino Plan, and

2. The beneficiary is assigned a coverage 120 or 130,

3. The MAO will treat that beneficiary as if the coverage code was assigned as 110.

Page 12

On January 1^st, 2017:

1. The MAOs will implement the New Cost Sharing Structure, as indicated in Tables IV, VI, and VI.

2. The MAOs will issue to each beneficiary a new ID Card with (i) the coverage code assigned by the Medicaid Program and (ii) copayments amount applicable to such code, as indicated in Table VI.

4. The beneficiary will discard the old ID Card and use the new ID Card.

5. The beneficiary will only be liable to pay the Table VI's copayments amount as a maximum.

A Platino beneficiary can submit a reimbursement request as soon as he/she believes he/she has exceeded the 5% limit per quarter as it is described under the section "Five Percent (5%) Limit or Cap Per Quarter on all Copayments".

MAOs cannot impose cost sharing requirements on specified Medicaid beneficiary with a Platino Plan that would exceed the amounts permitted under the Medicaid State Plan for Medicaid beneficiaries not enrolled in a Platino Plan.  Therefore, MAOs are not allowed to charge any other cost sharing for Medicaid covered services except for the copayment amounts establish in the Puerto Rico Medicaid State Plan, as described in this "Cost Sharing Policy for Medicaid and CHIP Beneficiaries".

Contracts between ASES and MAOs shall include this Cost Sharing Policy.  The MAOs are required by contract to make this Cost Sharing Policy knows to beneficiaries, providers, and any other person that provides health care services to beneficiaries.  Compliance with this Cost Sharing Policy will be monitored by ASES.

 Beneficiaries Copayments Exemptions

Pursuant to the federal regulation, 42 CFR §447.56(a)(1), Puerto Rico Medicaid State Plan states that certain groups of individuals are exempted from any copayments.  No copayment will be charged to the following Medicaid or CHIP beneficiaries:

1. Children from 0 to less than 21 years of age.

2. Pregnant women, during pregnancy and the post-partum period.  The post-partum period begins on the last day of pregnancy and extends through the end of the month in which a 60-day period following the last day of pregnancy ends.  Example: If March 3 is the last day of pregnancy, May 2 is the end of the 60-days, and May 31 is the last day of the month in which post-partum ends.

3. Institutionalized Individuals, such as a nursing home.

4. Beneficiaries receiving hospice care.  As defined in Section 1905(o) of the Social Security Act, hospice care means the care furnished by a hospice program to a terminally ill individual who has voluntarily elected to have payment made for hospice care.

Page 13

5. American Indians and Alaskan Natives (AI/AN).

Contracts between ASES and MCOs, MAOs and PBMs include the requirement to exempt these group of beneficiaries, as defined at 42 CFR §447.56(a)(1).  MCOs, MAOs, and PBMs are required by contract to make these exemptions known to beneficiaries, providers, and any other person that provides health care services to beneficiaries.  Compliance with these cost sharing exemptions will be monitored by ASES.

 Health Care Services Copayments Exemptions

Pursuant to the federal regulation, 42 CFR §447.56(a)(2), Puerto Rico Medicaid State Plan establishes that certain health care services are exempted from any copayments.  All Medicaid and CHIP beneficiaries are exempt from copayments for the following services:

1. Emergency services, (including ambulatory, hospital, and post-stabilization services), as defined at Section 1932(b)(2) of the Social Security Act and in the federal regulation, 42 CFR §438.114(a).

2. Family planning services and supplies as described in Section 1905(a)(4)(C) of the Social Security Act, including contraceptives and pharmaceuticals for which the Puerto Rico claims or could claim Federal match at the enhanced rate under Section 1903(a)(5) of the Social Security Act for family planning services and supplies.

3. Preventive services provided to children under 18 years of age, as described in the federal regulation at 42 CFR §457.520 of chapter D.

4. Pregnancy-related services, including those services as defined in the federal regulation, 42 CFR §440.210(a)(2) and 42 CFR §440.250(p), and counseling services and drugs for cessation of tobacco use.  All services provided to pregnant women, during pregnancy and the 60-day post-partum period, will be considered as pregnancy-related.

5. Provider-preventable services as defined in the federal regulation, 42 CFR §447.26(b).

Contracts between ASES and MCOs, MAOs and PBMs include the requirement to exempt these services, as defined in 42 CFR §447.56(a)(2).  MCOs, MAOs, and PBMs are required by contract to make these exemptions known to beneficiaries, providers, and any other person that provides health care services to beneficiaries.  Compliance with these cost sharing exemptions will be monitored by ASES.

Page 14

 Other Copayments Exemptions

Preferred Provider Network (PPN) Copayment Exemption:

1. The Preferred Provider Network is a subset of providers within the MCO General Network of Providers.  The objectives of the Preferred Provider model are to:

a. Increase access to Providers and needed services;

b. Improve timely receipt of services;

c. Improve the quality of beneficiary care;

d. Enhance continuity of care; and

e. Facilitate effective exchange of personal health information between providers and the MCO.

2. Copayments do not apply to any service provided to a Medicaid beneficiary by a provider participating in the Preferred Provider Network.

3. A provider who is a member of the Preferred Provider Network provides services to beneficiaries without the requirement for referrals and copayments.

4. The MCO’s contracts with a provider who is a member of the Preferred Provider Network shall prohibit the provider from collecting copayments from Medicaid beneficiary.

5. The Medicaid beneficiary is not required to use the Preferred Provider Network.  But, if the Medicaid beneficiary chooses a provider from the MCO General Network of Providers, he/she is subject to the applicable copayments amount.

6. If the Medicaid beneficiary needs a covered service and cannot have access to a specialist within the Preferred Provider Network within thirty (30) calendar days, the beneficiary shall have access to the specialist within the MCO General Network of Providers, without the imposition of copayments, but shall return to the PPN specialist once the PPN specialist is available to treat the beneficiary.

7. Dentists and Pharmacies are not part of the Preferred Provider Network.

8. For a Platino Plan, MAOs have to be in compliance with this exemption, if they operate a Preferred Provider Network model.

Medical Advice Service Line Copayment Exemption:

1. The Puerto Rico Medicaid State Plan does not allow charging copayment for non-emergency services provided in a hospital emergency room to a Medicaid or CHIP beneficiary when the beneficiary:

a. Calls the MCO Medical Advice Service Line, prior to visiting the hospital emergency room;

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b. Receives a code or an identification number;

c. Presents such number at the time of the visit to the hospital emergency room; and

d. The hospital emergency room will waive the beneficiary copayment for non-emergency services provided in a hospital emergency room.

2. Regardless of whether the beneficiary uses or does not use the MCO Medical Advice Service Line, under no circumstance will a copayment be imposed on a Medicaid or CHIP Beneficiary for the treatment of an Emergency Medical Condition or Psychiatric Emergency provided.

3. For a Platino Plan, MAOs will comply with the "Medical Advice Service Line Copayment Exemption", as described herein.

Preventive Services:

All Medicaid beneficiaries do not pay copayments for the following diagnostics tests when these services are required as part of a preventive service.

1. High-Tech Laboratories.

2. Clinical Laboratories.

3. X-Rays.

4. Special Diagnostic Test.

Contracts between ASES and MCOs, MAOs, and PBMs include the requirement to exempt Medicaid beneficiaries from these copayments when he/she complies with the rules as described under this section.  MCOs, MAOs, and PBMs are required by contract to make these exemptions known to beneficiaries, providers, and any other person that provides health care services to the beneficiaries.  Compliance with this Policy Cost Sharing section will be monitored by ASES.

 Copayment for Non-Emergency Services Provided in a Hospital Emergency Room (ER)

Pursuant the federal regulation, 42 CFR §447.51, Non-Emergency Services means any care or services that are not considered emergency services, as it concept is defined and described in 42 CFR §438.114 (Emergency and Post-Stabilization Services).  Non-Emergency Services do not include any services furnished in a hospital emergency department that are required to be provided as an appropriate medical screening examination or stabilizing examination and treatment under Section 1867 of the Social Security Act, (Examination and Treatment for Emergency Medical Conditions and Women In Labor, also known as EMTALA).

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Emergency and Post-Stabilization Services are defined as follows:

1. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:

a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

b. Serious impairment to bodily functions; and

c. Serious dysfunction of any bodily organ or part.

2. Emergency services means covered inpatient and outpatient services that are:

a. Furnished by a provider that is qualified to furnish these services under 42 CFR §438.114 and

b. Needed to evaluate or stabilize an emergency medical condition.

3. Post-Stabilization care services means covered services, related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition, or to improve or resolve the enrollee's condition.

The Puerto Rico Medicaid State Plan allows charging cost sharing for non-emergency services provided in the hospital emergency room.  It is expected that all participating hospital emergency rooms will charge the applicable copayment amount to all non-exempt Medicaid beneficiaries for the non-emergency services provided in a hospital emergency room.

The Puerto Rico Medicaid State Plan does not allow charging cost sharing for non-emergency services provided in the hospital emergency room in the following instances:

1. To Medicaid beneficiary when he/she:

a. Calls the MCO Medical Advice Service Line, previous to visit the hospital emergency room,

b. Receives a code or an identification number, and

c. Presents such number at the time of the visit to the hospital emergency room.  In this instance, the copayment is waived.

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2. To Medicaid exempted groups of individuals listed in this Cost Sharing Policy under section "Copayments Are Not Charged To The Following Beneficiaries".

3. Copayments do not apply to any service provided to a Medicaid beneficiary by a hospital emergency room participating in the Preferred Provider Network (PPN).

4. For Medicaid beneficiaries with a Platino Plan, MAOs have to be in compliance with the "Preferred Provider Network (PPN) Copayment Exemption" and the "Medical Advice Service Line Copayment Exemption", as described under section "Other Copayments Exemptions".

If the beneficiary does not follow the copayment exemption describes under section "Medical Advice Service Line Copayment Exemption" of this Cost Sharing Policy, the non-preferred hospital's emergency room may charge the applicable copayment for this service only if, before providing non-emergency services and imposing the applicable copayment for such services, the hospital's emergency room must complies with the following requirements:

1. First, conducts an appropriate medical screening to determine

a. Whether or not an emergency medical condition exists as required under 42 CFR §489.24 subpart G and  b. That the individual does not need emergency services.

2. Second, if not an emergency medical condition exists and before providing non-emergency services and imposing cost sharing for such services, the hospital's emergency room:

a. Informs the beneficiary of the amount of his or her copayment obligation for non-emergency services provided in the hospital emergency room;

b. Provides the beneficiary with the name and location of an available and accessible alternative non-emergency services provider;

c. Determines that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser copayment amount or no copayment if the beneficiary is otherwise exempt from copayment; and

d. Provides a referral to coordinate scheduling for treatment by the alternative provider.

3. The federal regulation, 42 CFR §447.51, defines Alternative Non-Emergency Services Provider as a Medicaid provider, such as a physician's office, health care clinic, community health center, hospital outpatient department, or similar provider that can provide clinically appropriate services in a timely manner.

4. Therefore, the hospital emergency room cannot charge the copayment if it does not follow and comply with the process as described herein.

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The Puerto Rico Medicaid Program and ASES ensure that:

1. Before providing non-emergency services and imposing the applicable copayment for such services the hospital's emergency room will comply with the above mentioned requirements.

2. There is a process in place to identify hospital emergency room services as non-emergency's room services for purposes of imposing cost sharing.  This process does not:

a. Limit hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Social Security Act (EMTALA); or

b. Modify any obligations under either state or federal standards relating to the application of a prudentlayperson standard for payment or coverage of emergency medical services by any MCO (MAO for a Platino Plan).

3. As part of the New Cost Sharing Structure, all participating hospital emergency rooms located in Puerto Rico will have their payments reduced by the copayment amount for non-emergency services provided at the hospital emergency room.

4. Contracts between ASES and MCOs and MAOs include the non-emergency hospital emergency room copayment rules.  MCOs and MAOs are required by contract to make these rules know to beneficiaries and providers.  Compliance with these cost sharing rules will be monitored by ASES.

The Puerto Rico Medicaid State Plan does not allow charging the copayment for "Non-Emergency Services Provided in a Hospital Emergency Room" when the non-emergency services is provided in a nonhospital/freestanding emergency room.  In non-hospital/freestanding emergency room facilities, the provider can only charge, per visit, the copayment applicable for "Non-Emergency Services Provided in a nonHospital/Freestanding Emergency Room", as indicated in "TABLE VI".

The List of Hospital Emergency Rooms by MCO, that may charge the copayment for non-emergency services provided in the hospital emergency room, is available in any of the Medicaid Local Offices throughout the Island or at the ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico  00926-2712).  Additionally, the list of MCO's Hospital Emergency Rooms can be downloaded, reviewed, and printed from the Medicaid Program website (xxxxx://xxx.xxxxxxxx.xx.xxx/) or the ASES website (xxxx://xxx.xxxxxx.xxx/ or xxxx://xxxx.xx.xxx/).

The List of Hospital Emergency Rooms by MCO may be changed to add or remove its participating Hospital Emergency Rooms at any time.  ASES will notify and post such changes through its ASES website.

Each MCO will post its Hospital Emergency Rooms List through its website, as well as any change to add or remove its participating Hospital Emergency Rooms at any time.

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Each MAO will post its Hospital Emergency Rooms List through its website not later than January 1^st, 2017, as well as any change to add or remove its participating Hospital Emergency Rooms at any time.

Contracts between ASES and MCOs, MAOs, and PBMs include these copayment rules.  MCOs, MAOs, and PBMs are required by contract to make these rules known to beneficiaries, providers, and any other person that provides health care services to the beneficiaries.  Compliance with these copayment rules will be monitored by ASES.

 Preferred Drug List

Pursuant to the federal regulation, 42 CFR §447.51, preferred drugs means drugs that the state has identified on a publicly available schedule as being determined by a pharmacy and therapeutics committee for clinical efficacy as the most cost effective drugs within each therapeutically equivalent or therapeutically similar class of drugs.

The Medicaid Program and ASES differentiate between preferred and non-preferred drugs.  The Preferred Drug List (PDL) was revised to produce a new Drugs Formulary (“Formulario de Medicamentos en Cubierta del Plan de Salud del Gobierno de PR”).  The review was performed by ASES’ Pharmacy Administrative Committee, composed of a clinical pharmacist, an epidemiology analyst, a medical doctor from the Pharmacy Program Administrator (PPA), two clinical pharmacists, a system implementation manager from the contracted PBM, ASES Clinical Medical Doctor Representative, and ASES Clinical Department Manager.  All drugs included have been previously approved by the ASES Pharmacy and Therapeutics Committee, composed of thirteen (13) voluntary community representatives, community medical doctors, and pharmacist representatives.  All decisions have been managed and documented under the contracted PBM for such purposes.

For the determination of which medication will be covered as preferred or non-preferred drug, the Pharmacy Administrative Committee evaluated each therapeutic category based on the amount of alternatives available with similar efficacy, utilization frequency, and total cost impact.  As a result of such analysis the majority of the generic drugs were considered as preferred drugs, with some exceptions where other more cost-effective drugs were available within the same therapeutic category.  All branded products with contracted rebates were considered preferred drugs, but depending on availability on a class category, some non-rebatable, branded drugs were also considered preferred drugs.

The drugs in the Formulary are divided into two categories (Tiers): Preferred and Non-preferred drugs, as permitted by the federal regulation applicable to Medicaid.  The criteria used for the drug classifications were based on their safety profile, established efficacy (cost-effectiveness), generic drug availability, and treatment cost.  The Medicaid Program and ASES define both categories as follows:

Preferred Drugs means:

1. All generic drugs, except for:

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a. Those with a significantly higher cost compared to their therapeutic alternatives, in which case they are classified as non-preferred drugs.

b. Those with a low safety profile compared to their therapeutic alternatives, in which case they are classified as non-preferred drugs.

2. Branded drugs that:

a. Have no generic available and their net cost does not exceed a certain limit, otherwise they are classified as non-preferred.

b. Their generic drug alternative is more expensive.

c. Are contracted by ASES.

3. Specialty drugs contracted by ASES.

Non-Preferred Drugs means:

1. Branded drugs, except for:

a. Those that have no generic drug available and their cost does not exceed a certain limit, in which case they are classified as preferred drug.

b. Those with a more expensive generic (net cost), in which case they are classified as preferred drug.

c. Are contracted by ASES, in which case they are classified as preferred drugs.

2. Generic drugs that their established safety, efficacy, and cost profile (cost-effectiveness) are low compared to their therapeutic alternatives.

3. Specialty drugs not contracted by ASES.

The Puerto Rico Medicaid State Plan allows charging copayments for preferred and non-preferred drugs.  However, the Medicaid State Plan does not allow charging those copayments in the following instances:

1. To Medicaid beneficiaries exempted groups of individuals listed in this Cost Sharing (Copayments) Policy under section Beneficiaries Copayments Exemptions

2. To Medicaid exempted services as described in this Cost Sharing (Copayments) Policy under section Health Care Services Copayments Exemptions, such as contraceptives for family planning services and drugs for cessation of tobacco use.

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3. For Platino Plans, MAOs will comply with this rule on January 1^st, 2017.

The Puerto Rico Medicaid State Plan requires charging the applicable copayment for preferred drug instead of the non-preferred drug copayment in the following instances:

1. The beneficiary's prescribing provider determines based on medical necessity that:

a. A Formulary non-preferred drug can be covered when a Formulary preferred drug for treatment of the same health condition either: (i) is less effective for the beneficiary health condition, (ii) has adverse effects for the beneficiary, or (iii) both.

b. A non-Formulary drug can be covered when a Formulary preferred or non-preferred drug for treatment of the same health condition either: (i) is less effective for the beneficiary health condition, (ii) has adverse effects for the beneficiary, or (iii) both.

2. The MCOs and the provider follow the usual pre-authorization procedure to consider these cases.

a. The exception process is utilized when there is an indication that there is a medically necessary reason to cover a non-preferred drug or non-Formulary drug.

b. When an exception is requested by the beneficiary, the MCO will do a clinical evaluation to consider and review the justification given by the prescribing provider, beneficiary's medical records, and any other relevant documentation to determine medical necessity based on the following criteria:

(1) Contraindications to the medication listed in the Formulary.

(2) History of adverse reactions to the medication listed in the Formulary.

(3) Therapeutic failure of all available alternatives in the Formulary.

(4) Non-existence of alternative therapy in the Formulary.

c. If the documents and information provided supports the exception, the preauthorization is granted.

d. The beneficiary has the right to file an appeal and request a fair hearing to review the determination that has been notified by the MCO.

3. If the authorization is granted, the Medicaid Program and ASES have a timely process in place in which the pharmacy only charges to the Medicaid beneficiary the copayment applicable to a preferred drug, which is: $1 to beneficiaries with coverage code 110, $2 with coverage code 120, and $3 with coverage code 130.

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4. According with the federal regulation, 42 CFR §447.53(e), the Medicaid Program and ASES certify that in such cases the reimbursement to the pharmacy is based on the appropriate copayment amount.

5. For Platino Plans, MAOs will comply with this rule on January 1^st, 2017.

In addition to, the Puerto Rico Medicaid State Plan indicates that:

1. In the event a beneficiary needs a drug or medicine that is not included in Puerto Rico Medicaid Formulary, the MCOs and providers will follow the usual pre-authorization procedure to allow beneficiaries to obtain drugs not included in the Formulary.

2. The use of bioequivalent medications and drugs approved by the FDA and local regulations is authorized, unless contraindicated for the beneficiary by the physician or dentist who prescribed the medication.

3. The absence of bioequivalent medications and drugs in stock does not exonerate the pharmacist from dispensing the medication nor does it entail the payment of additional surcharges by beneficiaries.

4. Brand name drugs will be dispensed if the bioequivalent is not available at the pharmacy.

5. All prescriptions shall be filled and dispensed at a participating pharmacy properly licensed under the laws of Puerto Rico freely chosen by the beneficiary.

6. Pharmacies and Dentists are not part of the Preferred Provider Network.

7. The MCO and/or provider cannot establish a different drug formulary nor limit in any way the drugs and medications included in the Puerto Rico Medicaid Formulary.

The Drugs Formulary is available in any of the Medicaid Local Offices throughout the Island or at ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico  00926-2712).  Additionally, the Drugs Formulary can be downloaded, reviewed, and printed from the Medicaid Program website (xxxxx://xxx.xxxxxxxx.xx.xxx/) or the ASES website (xxxx://xxx.xxxxxx.xxx/ or xxxx://xxxx.xx.xxx/).

The Drugs Formulary may be amended to add or remove drugs, as well as to classify a drug as a preferred or non-preferred, at any time according to the ASES' Pharmacy Administrative Committee.  ASES will notify and post such changes through its ASES website.

Each MCO and PBM will post the“Formulario de Medicamentos en Cubierta del Plan de Salud del Gobierno de PR”, as well as any amendment approved by the ASES' Pharmacy Administrative Committee to add or remove drugs or to classify a drug as a preferred or non-preferred, through its website.

Each MAO has its own drugs formulary that has to be in compliance with Medicare and Medicaid federal regulation.  The Medicaid beneficiaries with a Platino Plan will use the MAO's Drugs Formulary.  The MAO's Drugs Formulary, as well as any amendment, will be posted through the MAO's website.  Pursuant the federal regulation, each MAO must be in compliance with the copayment rules state under the Puerto Rico Medicaid State Plan and this Cost Sharing Policy.

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Contracts between ASES and MCOs, MAOs, and PBMs include these copayment rules.  MCOs, MAOs, and PBMs are required by contract to make these rules known to beneficiaries, providers, and any other person that provides health care services to the beneficiaries.  Compliance with these copayment rules will be monitored by ASES.

 Five Percent (5%) Limit or Cap Per Quarter on all Copayments

The federal regulation, 42 CFR §447.56(f), provides that Medicaid or CHIP copayments incurred by all eligible beneficiary in his/her Medicaid and CHIP household may not exceed an aggregate limit of five percent (5%) of the household's income applied on a quarterly basis.  The 5% cap on total copayments per quarter is determined on the basis of:

1. At July 1^st, 2016 and until implementation of MAGI Methodologies for determining Medicaid & CHIP eligibility, the Medicaid Program will continue determining the 5% cap on total copayments per quarter for a beneficiary on the basis of the eligibility monthly income and the number of members in the family unit of the beneficiary.

2. On and after implementation of MAGI Methodologies for determining Medicaid & CHIP eligibility, the Medicaid Program will determine the 5% cap on total copayments per quarter for a beneficiary on the basis of his/her MAGI Monthly Income and his/her MAGI Household Size.

3. For example: if a beneficiary Monthly Income is $300 per month, his/her quarterly copayment limit will be $45 ($300 x 3 months = $900 x 5% = $45).

Each beneficiary has his/her own quarters, which are based on the eligibility month.  For example, if the

Medicaid Program determines that the individual is eligible starting in February, he/she's quarters are: February, March, and April (first quarter); May, June, and July (second quarter); August, September and October (third quarter); and November, December, and January (fourth quarter).

Any Medicaid beneficiary can request to the Medicaid Program a reassessment of his/her aggregate limit of 5 percent (5%) if he/she has a change in circumstances, such as:

1. Increase or decrease in income.

2. Increase or decrease in household size.

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A beneficiary's 5% cap or limit will be reached, if copayments paid in a quarter by his/her family unit or MAGI household members who are Medicaid and CHIP are summed together and the result exceeds the calculated 5% cap amount per quarter.

The New Cost Sharing Structure does not place beneficiaries at risk of reaching the copayment aggregate limit of 5% per quarter of the family unit or MAGI household income applied on a quarterly basis.  The Medicaid Program and ASES have a "Process for Requesting Reimbursement of Excess Cost Sharing Payments" for individuals that believe they have incurred cost sharing over the aggregate limit for a quarterly cap period, which includes an explanation of his/her right to appeal any decision and request a fair hearing.

If, over the course of a period of Medicaid or CHIP eligibility, a Medicaid or CHIP beneficiary believes that copayments in a quarter have been paid in excess of the 5% cap, he/she can submit a Cost Sharing Reimbursement Request, which will be evaluated by ASES.  The Process for Requesting Reimbursement of Excess Cost Sharing Payments establishes that:

1. The reimbursement requests must be submitted no later than two (2) calendar months after the end of the quarter.

2. Reimbursement requests must include all minimum mandatory information, as instructed on the reimbursement request form, and can be submitted:

a. In person: at ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico 00926-2712) or in any of the Medicaid Local Offices throughout the Island;

b. By mail, to following postal address: ASES Client Services, PO Box 195661, San Juan, PR, 00919-5661; or

c. By Facsimile (Fax), to ASES Fax number: 787-474-3347.

3. ASES will conduct an investigation to evaluate reimbursement requests which will be completed no later than four (4) months from the end of the quarter for which the reimbursement request is made.  The results of the investigation of any reimbursement request will be notified to the beneficiary no later than fifteen (15) calendar days from the limit date for the investigation.  ASES will send a written communication to the beneficiary explaining the results of the reimbursement process investigation, and:

a. If the amount to be reimbursed is five dollars ($5) or more, ASES will issue a reimbursement and will send a written communication to the beneficiary explaining the results of the reimbursement process investigation.

b. If the amount to be reimbursed is less than five dollars ($5), the amount will be kept as a credit for a two

(2) years period and can be added to the result of reimbursement request for another quarter.

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4. The individual has the right to file an appeal and request a fair hearing to review the determination that has been notified by ASES.  The appeal must be presented in writing and within a period of thirty (30) days, counting from the date of the ASES' notice.  The appeal may be submitted:

a. In person: at the ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico, 00926-2712);

b. By mail, to following postal address: ASES Client Services, PO Box 195661, San Juan, PR, 00919-5661; or

c. By Facsimile (Fax), to ASES Fax number: 787-474-3347.

5. The determination will be final if the individual does not appeal within the term of thirty (30) days.

The "Process for Requesting Reimbursement of Excess Cost Sharing Payments" and the reimbursement request form (in English or Spanish) are available in any of the Medicaid Local Offices throughout the Island or at the ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico  00926-2712).  These documents can also be downloaded, reviewed, and printed from the Medicaid Program website (xxxxx://xxx.xxxxxxxx.xx.xxx/) or the ASES website (xxxx://xxx.xxxxxx.xxx/ or xxxx://xxxx.xx.xxx/).

 The Consequences for a Beneficiary Who Does Not Pay a Cost Sharing Charge

A Medicaid beneficiary is expected to pay a copayment at the time of receiving the health care service.  Therefore, the provider may request and collect the copayment amount each time a beneficiary receives a service.

A beneficiary does not have to pay copayments for any service provided by a provider participating in the Preferred Provider Network.  The MCO’s (MAO for a Platino Plan) contracts with a provider who is a member of the Preferred Provider Network shall prohibit the provider from collecting copayments from Medicaid beneficiary.

The Medicaid beneficiary, who chooses a provider from MCO's General Network of Providers (MAO for a Platino Plan) and with coverage code 110, 120 or 130, is subject to the applicable copayments amount.

Pursuant the federal regulation, 42 CFR §447.52(e), the Puerto Rico Medicaid State Plan dispone:

1. Beneficiaries with an eligibility monthly income at or below 100 percent (100%) of the PRPL:

a. When copayment charge is allowed or the beneficiary is not part of an otherwise exempt group, the provider, including a pharmacy or dentist, may request the applicable copayment amount, but cannot not deny services to a beneficiary on account of the his/her inability to pay the copayment amount at the time of receiving a service.

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b. The beneficiary will receive the health care service without paying the cost sharing at the time of receiving the service.

c. Although services may not be denied, the beneficiary is still obligated to pay the cost sharing unless it is waived by the provider.

d. If the copayment is not waived, the provider may ask the beneficiary for outstanding copayments amount the next time the beneficiary comes in for a service and/or send a bill to the beneficiary.

e. In these cases, a hospital can charge the applicable copayment for non-emergency services furnished in its emergency room, if the conditions under 42 CFR 447.54(d) and the copayment rules for this service have been satisfied.

f. Nothing prohibits a provider from choosing to reduce or to waive the copayment on a case-by-case basis.

g. Medicaid beneficiaries identified by coverage code 100:

(1) Prior MAGI Implementation and as illustrate on Table VII, all Medicaid beneficiaries identified by coverage code 100 have an Eligibility Monthly Income unit below 100% of the PRPL.

(2) On and After MAGI Implementation and as illustrate on Table VIII, all Medicaid beneficiaries identified by coverage code 100 have a MAGI household monthly income below 100% of the PRPL.

h. Medicaid beneficiaries identified by coverage code 110:

(1) Prior MAGI Implementation and as illustrate on Table VII, there are some Medicaid beneficiaries identified by coverage code 110 have an Eligibility Monthly Income at or below 100% of the PRPL.

(2) On and After MAGI Implementation and as illustrate on Table VIII, all Medicaid beneficiaries identified by coverage code 110 have a MAGI household monthly income at or below 100% of the PRPL.

2. Beneficiaries with MAGI household monthly income above 100 percent (100%) of the PRPL:

a. When copayment charge is allowed or the beneficiary is not part of an otherwise exempt group, the provider, including a pharmacy and a dentist, may request the applicable copayment amount as a condition for receiving the service.

b. In these cases, a hospital can charge the applicable copayment for non-emergency services furnished in its emergency room, if the conditions under 42 CFR 447.54(d) and the copayment rules for this service have been satisfied.

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c. Nothing prohibits a provider from choosing to reduce or to waive the copayment on a case-by-case basis.

d. Medicaid beneficiaries identified by coverage code 110: Prior MAGI Implementation and as illustrate on Table VII, there are some Medicaid beneficiaries identified by coverage code 110 have an Eligibility Monthly Income above 100% of the PRPL.

e. Medicaid beneficiaries identified by coverage code 120 or 130: On and After MAGI Implementation and as illustrate on Table VIII, all Medicaid beneficiaries identified by coverage code 120 or 130 have a MAGI household monthly income above 100% of the PRPL.

3. The following tables show Puerto Rico Poverty Level (PRPL) for Medicaid and CHIP and the coverage codes:

a. Table VII: Puerto Rico Poverty Level (PRPL) Prior MAGI Implementation.

b. Table VIII: Puerto Rico Poverty Level (PRPL) On and After MAGI Implementation.

TABLE VII
	Puerto Rico Poverty Level (PRPL) Prior MAGI Implementation
Member in Family Unit	Puerto Rico Poverty Level (PRPL)	Eligibility Monthly Income Ranges by Coverage Codes
		At or Below 100% of the PRPL		Above 100% of the PRPL
		100	110	Ranges Above 100% PRPL	110
1	$0-$413.53	$0-$200	$201-$413.53	$413.54-UP	$413.54-$550
2	$0-$488.72	$0-$248	$249-$488.72	$488.73-UP	$488.73-$650
3	$0-$563.91	$0-$295	$296-$563.91	$563.92-UP	$563.92-$750
4	$0-$639.10	$0-$343	$344-$639.10	$639.11-UP	$639.11-$850
5	$0-$714.29	$0-$390	$391-$714.29P	$714.30-UP	$714.30-$950
6	$0-$789.47	$0-$438	$439-$789.47	$789.48-UP	$789.48-$1,050
7	$0-$864.66	$0-$485	$486-$864.66	$864.67-UP	$864.67-$1,150
8	$0-$939.85	$0-$533	$534-$939.85	$939.86-UP	$939.86-$1,250
9	$0-$1,015.04	$0-$580	$581-$1,015.04	$1,015.05-UP	$1,015.05-$1,350
10	$0-$1,090.23	$0-$628	$629-$1,090.23	$1,090.24-UP	$1,090.24-$1,450
11	$0-$1,165.41	$0-$675	$676-$1,165.41	$1,165.42-UP	$1,165.42-$1,550
12	$0-$1,240.60	$0-$723	$724-$1,240.60	$1,240.61-UP	$1,240.61-$1,650
13	$0-$1,315.79	$0-$770	$771-$1,315.79	$1,315.79-UP	$1,315.79-$1,750
14	$0-$1,390.98	$0-$818	$819-$1,390.98	$1,390.98-UP	$1,390.98-$1,850
15	$0-$1,466.17	$0-$865	$866-$1,466.17	$1,466.17-UP	$1,466.17-$1,950

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TABLE VIII
Puerto Rico Poverty Level (PRPL) To Be Effective Implemented On and After MAGI Implementation
MAGI Household Size	Puerto Rico Poverty Level (PRPL)	MAGI Monthly Income Range by Coverage Code
		100	110	120	130
		At or Below 100% of the PRPL		Above 100% of the PRPL
		0%-50%	51%-100%	101%-150%	151%-UP
1	$0-$459	$0-$230	$231-$459	$460-$689	$690-UP
2	$0-$542	$0-$271	$272-$542	$543-$813	$814-UP
3	$0-$626	$0-$313	$314-$626	$627-$939	$940-UP
TABLE VIII
Puerto Rico Poverty Level (PRPL) To Be Effective Implemented On and After MAGI Implementation
MAGI Household Size	Puerto Rico Poverty Level (PRPL)	MAGI Monthly Income Range by Coverage Code
		100	110	120	130
		At or Below 100% of the PRPL		Above 100% of the PRPL
		0%-50%	51%-100%	101%-150%	151%-UP
4	$0-$709	$0-$355	$356-$709	$710-$1,064	$1,065-UP
5	$0-$792	$0-$396	$397-$792	$793-$1,188	$1,189-UP
6	$0-$876	$0-$438	$438-$876	$877-$1,314	$1,315-UP
7	$0-$959	$0-$480	$481-$959	$960-$1,439	$1,440-UP
8	$0-$1,043	$0-$522	$523-$1,043	$1,044-$1,565	$1,566-UP
9	$0-$1,126	$0-$563	$564-$1,126	$1,127-$1,689	$1,690-UP
10	$0-$1,210	$0-$605	$606-$1,210	$1,211-$1,815	$1,816-UP
11	$0-$1,293	$0-$647	$648-$1,293	$1,294-$1,940	$1,941-UP
12	$0-$1,377	$0-$689	$690-$1,377	$1,378-$2,066	$2,067-UP
13	$0-$1,460	$0-$730	$731-$1,460	$1,461-$2,190	$2,191-UP
14	$0-$1,544	$0-$772	$773-$1,544	$1,545-$2,316	$2,317-UP
15	$0-$1,627	$0-$814	$815-$1,627	$1,628-$2,441	$2,442-UP

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 ASES requires that the MCOs, MAOs, and PBMs inform providers whether the copayment for a specific service may be imposed on a beneficiary and whether the provider may require the beneficiary to pay the copayment, as a condition for receiving the service, through an indicator:

1. In the Eligibility and Enrollment System;

2. In the Eligibility Verification System; and

3. On the Beneficiary Identification Card.

Contracts between ASES and MCOs, MAOs, and PBMs include this copayment rule.  MCOs, MAOs, and PBMs are required by contract to make these rules known to beneficiaries, providers, and any other person that provides health care services to the beneficiaries.  Compliance with these copayment rules will be monitored by ASES.

 Mechanisms for Required Cost Sharing Charges and Payments to Providers

The MCOs, MAOs, and PBMs contracted by ASES may impose copayments on beneficiaries up to the amounts specified under the Puerto Rico Medicaid State Plan, and the requirements set forth in 42 CFR 447.50 through 447.57”as presented in this Policy.

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Therefore, the ASES' contract with these entities will provide that any copayment charges the MCO, MAO or PBM impose on Medicaid and CHIP beneficiaries are implemented and administered in accordance with:

1. The Social Security Act (SSA), Sections 1916 and 1916A.

2. The federal regulation, 42 CFR §§447.50-447.57 (excluding 42 CFR §447.55) of the federal regulation.

3. The Puerto Rico Medicaid and CHIP State Plans.

El Plan Estatal Medicaid y el de CHIP de Puerto Rico.

4. Cost Sharing Policy (Copayments) for Medicaid and CHIP Beneficiaries.

5. The New Cost Sharing (Copayment) Structure for Medicaid and CHIP Beneficiaries.

Payments to MCOs and MAOs:

1. ASES has contracted with more than one MCO (MAO for a Platino Plan) to deliver the health care services establish under Puerto Rico Medicaid State Plan.

2. ASES provides assurance that it calculates the payments to MCOs (MAOs for a Platino Plan) to take into account the copayments established under the Medicaid State Plan for beneficiaries or services not exempt from copayment, regardless of whether the MCO (MAO for a Platino Plan) imposes the copayment or the copayment is collected by the providers.

3. Any MCO, MAO, or PBM contracted by ASES is allowed to impose copayments on beneficiaries up to the amounts specified in this Cost Sharing (Copagos) Policy, but such MCO, MAO, or PBM cannot exceed the copayment amounts established under the Puerto Rico Medicaid State Plan, as shown in this Policy.

4. Contracts between ASES and MCOs, MAOs, and PBMs shall include this Cost Sharing Policy.

5. MCOs and PBMs are required by contract:

a. To make these rules know to beneficiaries and providers.

b. To comply with this Cost Sharing Policy and the Puerto Rico Medicaid State Plan.

6. For Platino Plans, MAOs have to be in compliance with this rule on January 1^st, 2017.

7. ASES will monitor the compliance with this Cost Sharing Policy.

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Payments to Providers:

1. Except as provided under federal regulation 42 CFR §§447.56(c)(2) and (c)(3), each MCO must reduce the payment it makes to a provider by the amount of a beneficiary's copayment obligation, regardless of whether the provider has collected the copayment or has waived the copayment.  Where the MCO contracts a provider on a capitated basis, the beneficiary’s copayment obligation is taken into account in calculating capitated rates.

2. Contracts between ASES and MCOs shall include this Cost Sharing (Copagos) Policy.  ASES will monitor the MCOs compliance with this Cost Sharing Policy's requirement.

3. Contracts between ASES and MCOs and providers shall include this Cost Sharing Policy.  MCOs will monitor the providers' compliance with this Cost Sharing Policy's requirement.

4. For Platino Plans, MAOs have to be in compliance with this rule on January 1^st, 2017.  ASES will monitor the MCOs compliance with this Cost Sharing Policy's requirement.

Notice of the Results of Coverage Code and Cost Sharing (Copayments) Determination

The Medicaid or CHIP Beneficiary is notified to his/her coverage code and copayments amount through:

1. The Medicaid Program notifies the beneficiary the "Results of Cost Sharing Determination" through the MA-10 Form (Notification of Action Taken on Application and/or Recertification), which is provided after a determination or redetermination of eligibility or when the Results of Cost Sharing Determination is revised.

2. ASES notifies to the beneficiary the assign coverage code and the copayments amounts through the ID Card, which is provided by the MCO (MAO for a Platino Plan).

Before July 1^st, 2016, each MCO contracted by ASES will send a certification coverage letter to the beneficiary to notify the coverage code assigned by the Medicaid Program and the copayments amount applicable to such code for each service.  The beneficiary will use said letter as his/her ID Card up to his/her eligibility redetermination, when the MCO will issue a new ID Card.  ASES will monitor the MCOs compliance with this Cost Sharing Policy's requirement.

For Platino Plans, the MAOs will implement the New Cost Sharing (Copayments) Structure on January 1^st, 2017.

The MAOs will issue to each beneficiary a new ID Card with the coverage code assigned by the Medicaid Program and copayments amount, as applicable to such code.  The beneficiary will discard the old ID Card and use the new ID Card.  ASES will monitor the MCOs compliance with this Cost Sharing Policy's requirement.

ASES requires that the MCOs, MAOs, and PBMs inform providers whether the copayment for a specific service may be imposed on a beneficiary and whether the provider may require the beneficiary to pay the copayment, as a condition for receiving the service, through an indicator:

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1. In the Eligibility and Enrollment System;

2. In the Eligibility Verification System; and

3. On the Beneficiary Identification Card.

 Right to Appeal Coverage Code and Cost Sharing (Copayments) Determination

The beneficiary is entitled to file an appeal and to request a fair hearing to the Medicaid Program to review the "Results of Cost Sharing Determination" that it is notified through the MA-10 Form (Notification of Action Taken on Application and/or Recertification) when he/she is not in agreement with the decision made in his/her case.

The request for review must be presented in writing and within a period of thirty (30) days, counting from the Certification Date shown on the MA-10.  This request for review can be submitted:

1. In person: at any Puerto Rico Medicaid Program Local Office throughout the Island;

2. By mail, to the following postal address: Medicaid Program, Puerto Rico Department of Health, P.O. Box 70184, San Juan, P.R.  00936-8184; or

3. By Facsimile (Fax) to: (787) 759-8361.

Access to the Cost Sharing (Copayment) Policy

The Medicaid and CHIP Beneficiaries have access to the New Cost Sharing Structure (Copayments) through the Enrollee Handbook or Guide, which is provided by the MCO (MAO for a Platino Plan).

The Cost Sharing Policy and the Puerto Rico Medicaid SPA for a New Cost Sharing Structure are available in any of the Medicaid Local Offices throughout the Island or at the ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico, 00926-2712).  These documents can also be downloaded, reviewed, and printed from the Medicaid Program website (xxxxx://xxx.xxxxxxxx.xx.xxx/) or the ASES website (xxxx://xxx.xxxxxx.xxx/ or xxxx://xxxx.xx.xxx/).

In compliance with the federal regulation, 42 CFR §435.905(b), the Medicaid Program will provided access to this Policy, upon request, to individuals living with disabilities through the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act.

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Attestation The Medicaid Program and ASES assure that:

1. They administer the Medicaid and CHIP Cost Sharing (Copagos) Policy in accordance with:

a. The Social Security Act (SSA), Sections 1916 and 1916A

b. The federal regulation, 42 CFR §§447.50-447.57 (excluding 42 CFR §447.55) of the federal regulation,

c. The Puerto Rico Medicaid and CHIP State Plan.

2. The cost sharing amount established for each service is always less than the amount that is paid for the service.

3. The contracts with the MCOs, MAOs, and PBMs provide that any copayment charges imposes on Medicaid or CHIP beneficiaries are in accordance with the Puerto Rico Medicaid State Plan and this Cost Sharing (Copayments) Policy.

The Medicaid Program and ASES, as required by the federal regulation (42 CFR 447.57):

1. Issued a Public Notice, in English and Spanish, to inform the beneficiaries, applicants, providers, and general public of the Cost Sharing SPA that specifies, among other topics:

a. The copayment amounts for each service by coverage code.

b. The beneficiaries who are subject to the copayment charges.

c.