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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 66-0555677
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 66-0500678.

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 (60th) 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, Conners 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 (4th) 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 http://www.medicaid.gov/
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 Juan
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.

 
39

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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.

 
40

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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 31st 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.

 
45

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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.

 
46

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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.

 
47

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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).

 
48

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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
30th, 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.
 
ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES)

 /s/ Angela M. Avila Marrero
       
12/26/2017
 
Ms. Angela M. Avila Marrero, Executive Director
 
Date
 
EIN: 66-0500678
                     
TRIPLE-S SALUD, INC.
           
 /s/ Madeline Hernandez Urquiza
       
12/26/2017
 
Ms. Madeline Hernandez Urquiza, President
 
 Date
 

EIN: 66-0555677
 
Account No.: 252-000-5010-5035
 
50

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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
[image00001.jpg]

 
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
[image00001.jpg]

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
[image00001.jpg]

 
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
[image00001.jpg]

 
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
[image00001.jpg]

 
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 300-150-300 mg tab
10
Non-Preferred
TRIZIVIR
 

 

--------------------------------------------------------------------------------

VIH-SIDA
[image00001.jpg]

 
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
[image00001.jpg]

 
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 troche
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
[image00001.jpg]

 
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
[image00001.jpg]

 
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
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--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

 
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
[image00001.jpg]

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

 
Página 3 de 14
Revisado 5/18/2017

--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

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

 
Página 4 de 14
Revisado 5/18/2017

--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

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 De Canales De Calcio]
amlodipine besylate 10 mg  tab, 2.5 mg tab, 5 mg tab
1
Preferred
NORVASC
 

 
Página 5 de 14
Revisado 5/18/2017

--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

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
TENORMIN
 

 
Página 6 de 14
Revisado 5/18/2017

--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

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
 

 
Página 7 de 14
Revisado 5/18/2017

--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

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
BENIGNA]
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

 
Página 8 de 14
Revisado 5/18/2017

--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

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
.
 

 
Página 9 de 14
Revisado 5/18/2017

--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

 
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

 
Página 10 de 14
Revisado 5/18/2017

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NEFROLOGIA
[image00001.jpg]

 
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

 
Página 11 de 14
Revisado 5/18/2017

--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

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
 

 
Página 12 de 14
Revisado 5/18/2017

--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

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
KAY-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
 

 
Página 13 de 14
Revisado 5/18/2017

--------------------------------------------------------------------------------

NEFROLOGIA
[image00001.jpg]

 
 
 
[image00001.jpg]

 

--------------------------------------------------------------------------------

[image00001.jpg]
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
MOTRIN
QL=15 días  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 días  No refills
naproxen dr 375 mg tab dr, 500 mg tab dr
1
Preferred
NAPROSYN
QL=15 días  No refills
sulindac 150 mg tab, 200 mg tab
1
Preferred
CLINORIL
 
meloxicam7.5 mg tab, 15 mg tab
1
Preferred
MOBIC
QL=15 días  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 días 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 días No refills
fentanyl 100 mcg/hr td patch 72 hr
4
Preferred
DURAGESIC
 

 
1 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
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 días No refills
acetaminophen-codeine #2 300-15 mg tab
1
Preferred
TYLENOL-CODEINE
QL=15 días No refills
acetaminophen-codeine #3 300-30 mg tab
1
Preferred
TYLENOL-CODEINE
QL=15 días No refills
acetaminophen-codeine #4 300-60 mg tab
1
Preferred
TYLENOL-CODEINE
QL=15 días 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 días 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 días 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]
 
Página 2 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
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 días 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]
 
Página 3 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
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]
 
Página 4 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
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]
 
Página 5 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA

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]
 
Página 6 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA

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]
 
Página 7 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA

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, P
NEUPOGEN 480 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]
 
Página 8 de 17

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Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA

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]
 
Página 9 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA

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
CEENU
 
ALKERAN 2 mg tab
4
Non-Preferred
   
temozolomide 5 mg cap
4
Non-Preferred
TEMODAR
PA
lomustine 40 mg cap
5
Non-Preferred
CEENU
 
LEUKERAN 2 mg tab
6
Non-Preferred
   
lomustine 100 mg cap
6
Non-Preferred
CEENU
 
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]
 
Página 10 de 17

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Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA
 
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]
 
Página 11 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA

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 troche
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]
 
Página 12 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA

DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]
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
 
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 días
omeprazole 40 mg cap dr
1
Preferred
PRILOSEC
QL=180 caps/ 365 días
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]
 
Página 13 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA

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]
 
Página 14 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA

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]
 
Página 15 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]
ONCOLOGIA
 
Página 16 de 17

--------------------------------------------------------------------------------

Revisado: 5 de mayo de 2017
[image00001.jpg]

 
ONCOLOGIA
 
 
[image00001.jpg]
 

--------------------------------------------------------------------------------

[image00001.jpg]
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 días No refills
oxycodone-acetaminophen 10-325 mg tab, 7.5-325 mg tab
3
Preferred
PERCOCET
QL=15 días 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
   

 
Página 1 de 15

--------------------------------------------------------------------------------

Revisado: 1 de mayo de 2017
[image00001.jpg]
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]
 
Página 2 de 15

--------------------------------------------------------------------------------

Revisado: 1 de mayo de 2017
[image00001.jpg]
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]
 
Página 3 de 15

--------------------------------------------------------------------------------

Revisado: 1 de mayo de 2017
[image00001.jpg]
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]
 
Página 4 de 15

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Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN

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]
 
Página 5 de 15

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Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN

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]
 
Página 6 de 15

--------------------------------------------------------------------------------

Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN
 
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]
 
Página 7 de 15

--------------------------------------------------------------------------------

Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN

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/ml iv 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]
 
Página 8 de 15

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Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN

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]
 
Página 9 de 15

--------------------------------------------------------------------------------

Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN
 
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]
 
Página 10 de 15

--------------------------------------------------------------------------------

Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN

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]
 
Página 11 de 15

--------------------------------------------------------------------------------

Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN

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]
 
Página 12 de 15

--------------------------------------------------------------------------------

Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN

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 pompa / 30 días, P
FLOVENT HFA 110 mcg/act inh aer, 44 mcg/act inh aer
3
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 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 13 de 15

--------------------------------------------------------------------------------

Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN

ADVAIR DISKUS 100-50 mcg/dose inh aer pwdr, 25050 mcg/dose inh aer pwdr
4
Preferred
 
QL = 1 pompa / 30 días, ST, P
ADVAIR HFA 115-21 mcg/act inh aer, 45-21 mcg/act inh aer
4
Preferred
 
QL = 1 pompa / 30 días, 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 pompa / 30 días, P
ADVAIR DISKUS 500-50 mcg/dose inh aer pwdr
5
Preferred
 
QL = 1 pompa / 30 días, ST, P
ADVAIR HFA 230-21 mcg/act inh aer
5
Preferred
 
QL = 1 pompa / 30 días, 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]
 
Página 14 de 15

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Revisado: 1 de mayo de 2017
[image00001.jpg]
OB-GYN
 
VENTOLIN HFA 108 (90 base) mcg/act inh aer
1
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 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 15 de 15

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 [ANA  LGÉSICOS]
Nonsteroidal Anti-Inflammatory Agents (NSAIDs) [Anti-Inflamatorios No
Esteroidales]
ibuprofen 400 mg tab, 600 mg tab, 800 mg tab
1
Preferred
MOTRIN
QL=15 días 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 días No refills
naproxen dr 375 mg tab dr, 500 mg tab dr
1
Preferred
NAPROSYN
QL=15 días 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 días 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 Página de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 días 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 días  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 días  No refills
tramadol hcl 50 mg tab
1
Preferred
ULTRAM
 
butalbital-apap-caffeine 50325-40 mg cap, 50-325-40 mg tab
2
Preferred
FIORICET
QL=15 días  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 Página 2 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 días  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 Página 3 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página 4 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
 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 Página 5 de 53  para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página 6 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página 7 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página 8 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página 9 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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
3
Preferred
 
ST, C
ONGLYZA 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 Página de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

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 de Canales 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 Página de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página de 53  para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 mg chew 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 Página de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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, 25-100-200 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 Página 20 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 600-200-300 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 Página 2 de 53  para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 300-150-300 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 Página 22 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
BENIGN PROSTATIC HYPERTROPHY AGENTS [AGENTES PARA HIPERTROFIA PROSTÁTICA
BENIGNA]
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/ml iv 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 Página 23 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página 24 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página 25 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página 26 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página 27 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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 Página 28 de 53 para rangos de costo neto mensual] • P –
Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
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
CEENU
 
ALKERAN 2 mg tab
4
Non-Preferred
   
temozolomide 5 mg cap
4
Non-Preferred
TEMODAR
PA
lomustine 40 mg cap
5
Non-Preferred
CEENU
 
LEUKERAN 2 mg tab
6
Non-Preferred
   
lomustine 100 mg cap
6
Non-Preferred
CEENU
 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
 
Page 52 of 53 
Revisado 5/18/2017
 

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

 
 
Page 53 of 53 
Revisado 5/18/2017
 

--------------------------------------------------------------------------------

[image00004.jpg]

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]
 

--------------------------------------------------------------------------------

[image00004.jpg]

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]
 
Page 2 of 11

--------------------------------------------------------------------------------

[image00004.jpg]

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]
 
Page 3 of 11

--------------------------------------------------------------------------------

[image00004.jpg]

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]
 
Page 4 of 11

--------------------------------------------------------------------------------

[image00004.jpg]

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]
 
Page 5 of 11

--------------------------------------------------------------------------------

[image00004.jpg]

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

--------------------------------------------------------------------------------

[image00004.jpg]

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]
 
Page 7 of 11

--------------------------------------------------------------------------------

[image00004.jpg]

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 susp.er 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]
 
Page 8 of 11

--------------------------------------------------------------------------------

[image00004.jpg]

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]
 
Page 9 of 11

--------------------------------------------------------------------------------

SALUD MENTAL
[image00004.jpg]

 
Page 10 of 11

--------------------------------------------------------------------------------

SALUD MENTAL
[image00004.jpg]

 
 
Page 11 of 11

--------------------------------------------------------------------------------

SALUD FÍSICA
[image00004.jpg]

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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

[image00006.jpg]

 

--------------------------------------------------------------------------------

SUB MENTAL
[image00004.jpg]

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
[image00004.jpg]

 
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
[image00004.jpg]

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
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
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

--------------------------------------------------------------------------------

[image00004.jpg]
 
[image00009.jpg]

 
Página 7 de 7

--------------------------------------------------------------------------------

DENTAL
[image00004.jpg]

 
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
[image00004.jpg]

 
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
[image00004.jpg]

 
 

--------------------------------------------------------------------------------

[image00004.jpg]
 
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

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[image00004.jpg]
 
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]
 
Página 2 de 28

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[image00004.jpg]
 
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]
 
Página 3 de 28

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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]
 
Página 6 de 28

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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]
 
Página 13 de 28

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 
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

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[image00004.jpg]
 

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[image00005.jpg]
[image00007.jpg]

 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.
 
Page 1

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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.

 
Page 2

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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.

 
Page 3

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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

 
Page 4

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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

 
Page 5

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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 1st, 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 1st, 2017.

 
Page 6

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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.

 
Page 7

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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 1st, 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
1st, 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

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 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 1st to December 31st of each year.  The January 1st, 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 1st to December 31s, 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 1st to December 31st 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.

 
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On January 1st, 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.

 
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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.
 
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 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
(https://www.medicaid.pr.gov/) or the ASES website (http://www.asespr.org/ or
http://ases.pr.gov/).

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 1st, 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 1st, 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 1st, 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 (https://www.medicaid.pr.gov/) or the ASES website
(http://www.asespr.org/ or http://ases.pr.gov/).

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 1st, 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 (https://www.medicaid.pr.gov/) or the
ASES website (http://www.asespr.org/ or http://ases.pr.gov/).

 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 1st,
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 1st,
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 1st, 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 1st, 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
(https://www.medicaid.pr.gov/) or the ASES website (http://www.asespr.org/ or
http://ases.pr.gov/).

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.
The consequences, if any, for a beneficiary who does not pay a copayment amount.

2.
Have provided a reasonable opportunity for stakeholder comments about the
Medicaid SPA for the New Cost Sharing Structure.

Effective Date

This Cost Sharing (Copagos) Policy is effective on July 1st, 2016.

 
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[image00008.jpg]

ENROLLMENT MANUAL
 

--------------------------------------------------------------------------------

Table of Contents

--------------------------------------------------------------------------------

 
TABLE OF CONTENTS
 

   
Page #
I.
INTRODUCTION
5        II.
DEFINITIONS
7        III.
ELIGIBILITY
16

         
1.  ELIGIBILITY CONCEPTS
17    
1.1 Eligibility Determination
     
1.2 MA-10
     
1.3 Eligibility Effective Date
     
1.4 Certification Date and its Relation with the Effective Date
     
1.5 Eligibility Effective Date in the Case of a Newborn
           
2.  MAGI ELIGIBILITY RULES
19    
2.1 Transfer of Eligibility Files from Medicaid
     
2.2 Medicaid Family Record Changes
     
2.3 Medicaid Member Record Changes
     
2.4 Eligibility Records Concerning Household
     
2.5 Additional Health Insurance Record
           
3.  MEDICAID/CHIP RETROACTIVE ELIGIBILITY
23    
3.1 Medicaid or CHIP’s Retroactive Eligibility Effective Date
     
3.2 Group of Records for Retroactive Periods
           
4.TERMINATION OF ELIGIBILITY AND RECERTIFICATION PROCESS
24
         
5. ELIGIBILITY PERIOD EXTENSION
23    
5.1 Appeals Process for Re-Certification
     
5.2 Appealing a Certification
   
5.3 Eligibility Extension Due to Pregnancy
           
6. ELIGIBILITY PERIOD TERMINATION..
26        
IV. ENROLLMENT PROCESSES
       
7. DATA EXCHANGE
27          
8. VALIDATION PROCESS
28          
9. ENROLLMENT FILES
30
 
 
9.1 Enrollment Files (.sus)
 
   
9.2 Eligibility Files (.ref)
     
9.3 Data Export Files (.exp)
     
9.4 Rejected Enrollment File (.rjc)
 

 

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9.5 Eligibility Query File (.query)
     
9.6 Eligibility Query Response File (.res)
           
10. GHIP PLAN BENEFICIARY ENROLLMENT
31    
10.1 Effective Date of Enrollment
     
10.2 Date of Enrollment in the Case of Newborns
     
10.3 Date of Re-enrollment of Dependent Children in Pregnancy Status
     
10.4 Date of Re-enrollment in Cases of Loss of Eligibility
     
10.5 PCP/PMG Change Enrollment Effective Date
     
10.6 Changes in Coverage Codes and Enrollment
     
10.7 Process Date
           
11. MEDICARE PLATINO ENROLLMENT PROCESS
32    
11.1 Eligibility Query Preceding a Medicare Platino Enrollment
     
11.2 Transfer of Beneficiaries to Platino Products
     
11.3 Effective Date of Medicare Platino Enrollment
     
11.4 Recovery of Eligibility and Prospective Enrollment
    12. RETROACTIVE ENROLLMENT 34    
12.1 Retroactive Enrollment for Federal and State Category
     
12.2 Retroactive Enrollment for Platino Plans
           
13. ENROLLMENT RECORD
36          
14. ENROLLMENT RECORD FIELDS
37          
15. REJECTION OF AN ENROLLMENT RECORD
43          
16. REJECTED ENROLLMENTS MANAGEMENT
43          
17. ERROR CODES
43          
18. NEW ERROR CODES UNDER MAGI
44          
19. ERROR CODES TABLE
44          
20. DISENROLLMENT
55    
20.1 Disenrollment under GHIP and Medicare Platino
     
20.2 Effective Date of Disenrollment
           
21. GHIP PLAN DISENROLLMENT
55    
21.1 Disenrollment Made by ASES or Medicaid
     
21.2 Effective Date of the Programmatic Disenrollment
           
22. MEDICARE PLATINO DISENROLLMENT
57    
22.1 Disenrollment by Beneficiary Request
     
22.2 Automatic Disenrollment
     
22.3 Retroactive Disenrollment
           
23. UPDATES TO NEW ENROLLMENT AND ENROLLING OMITTED BENEFICIARIE
58

 

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24. CARRIERS RESPONSIBILITIES IN THE ENROLLMENT PROCESSES
59        
V. PREMIUM PAYMENT
61          
25 PREMIUM PAYMENTS GENERAL
62          
26. TYPES OF PAYMENT
62    
26.1 Monthly Payments
     
26.2 Prorated Payments
     
26.3 Retroactive Payments
     
26.4 Prorated-retroactive payment
     
26.5 Adjustments
     
26.6 Special Adjustments
     
26.7 Reasons why ASES will not execute a premium payment
     
26.8 EDI 820 Payment File
         
VI. SYSPREM: ENROLLMENT IN HISTORICAL DATA
65          
27. ENROLLMENT IN HISTORICAL DATA
65    
27.1 SYSPREM Functionality
     
27.2 Carrier’s Eligibility File
     
27.3 Premium Payment for SYSPREM
     
27.4 SYSPREM Error Codes
 

 

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I. Introduction

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I.
INTRODUCTION

 
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I. Introduction

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I. INTRODUCTION

 
The Puerto Rico Health Insurance Administration, hereinafter known as PRHIA or
ASES, is a government corporation created in accordance with the Act No. 72 of
September 7, 1993 as amended, also known as the “Puerto Rico Health Insurance
Administration Act”. PRHIA is created with the purpose of management,
negotiation and contracting of health insurance plans that enable it to obtain,
for its beneficiaries, particularly the medically needy, quality hospital and
other medical services.

This document constitutes a reference manual, which establishes the requirements
in the development of the systems, between the Information Systems Office of
PRHIA and the contracted insurers, in the different products according to
contract. This includes processes of eligibility, subscription, premium
payment.  Any conflicts between this document and the applicable statutes,
regulations and guidance from the Centers for Medicare and Medicaid Services
(CMS) or Contracts for the Provision of Physical and Behavioral Health Services
Under the Government Health Plan Program as between PRHIA and the Managed
Medicaid managed care organizations shall be resolved in favor of CMS guidance
and such contracts, as amended.

Changes are incorporated as required by CMS for Modified Adjusted Gross Income
(MAGI) effective July 1, 2017.
 
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II Definitions

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II.
DEFINITIONS

 
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II. DEFINITIONS

Adjusted Payment
Reversal of a payment that has been adjudicated during the payment process of a
previous premium payment cycle.

ASES
Administración de Seguros de Salud de Puerto Rico (the Puerto Rico Health
Insurance Administration (PRHIA), the entity in the Commonwealth responsible for
oversight and administration of the Government Health Insurance Plan (GHIP) or
its Agent.

Auto-Assignment
The assignment of an Enrollee to a PMG and a PCP by the carrier, normally at the
same time that ASES or the carrier auto-enrolls the person in the GHIP.

Auto-Enrollment
The enrollment of a Potential Beneficiary in the GHIP by the carrier's database,
in compliance with Article 5 of the Contract between ASES and the carriers,
without any action by the Potential Beneficiary.

Beneficiary
A person who is eligible and receives services in the health plan, as
established in Section 1.3.1 of the contract between ASES and contracted
insurers.

Business Day
Traditional workdays, including Monday, Tuesday, Wednesday, Thursday and
Friday.  Puerto Rico Holidays are excluded.

Calendar Days
The seven days of the week.

Capitation
A contractual agreement through which a carrier or provider agrees to provide
specified health care services to members for a fixed payment per month.

Carrier
Provides Managed Care Services in an ASES region. It is responsible for
contracting with PMG’s, PCP’s and other providers.

Centers for Medicare and Medicaid Services (“CMS”)
The agency within the U.S. Department of Health and Human Services which is
responsible for the Medicare, Medicaid and the Children’s Health Insurance
Program (CHIP).

Certification
A decision by the Puerto Rico Medicaid Office, that a person is eligible for
services under the GHIP because the person is Medicaid Eligible, CHIP Eligible,
or a member of the Commonwealth Population.
 
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Certification Date
Date when the Medicaid Office completes a beneficiary’s evaluation of
eligibility for healthcare services.

Children's Health Insurance Program (“CHIP”)
The Children’s Health Insurance Program established pursuant to Title XXI of the
Social Security Act.

Copayment
A cost-sharing requirement that constitutes a fixed amount paid by the
beneficiary to a provider for the provision of medical services covered by the
health plan. Copayments are defined by ASES for each of the coverage codes.

Coverage Code
Code assigned by the Puerto Rico Medicaid Office to eligible beneficiaries,
according to Federal, CHIP and State indigence criteria. Under GHIP, the
coverage code will coincide with the Plan Version.

Daily Run Processes Date
It is the date of the day, when the eligibility process is received, received by
the Medicaid Office and the subscriptions submitted by the contracted insurers.
These processes are performed in the Office of Information Systems.

Deemed newborns
Are children born to a mother with Medicaid eligibility.

Disenrollment
The termination of an individual’s enrollment in the GHIP or carrier’s plan.

Dual Eligible Beneficiary
An Enrollee or potential enrollee eligible for both Medicaid and Medicare.

Effective Date of Disenrollment
The date on which an Enrollee ceases to be covered under the carrier’s plan.

Effective Date of Eligibility
The date of eligibility of the beneficiary in the GHIP, described in the
contract established with the corresponding insurer.

Enrollment Effective Date
The date when you subscribe to the eligible beneficiary in the contracted
insurer's database.

PCP Effective Date
Date on which a PCP1 or PCP2 change becomes effective.

Recertification Effective Date
Date the Medicaid Office reevaluates the eligibility of the beneficiary.
 
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II Definitions

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Eligibility
Eligibility is determined by the Medicaid Office of the Puerto Rico Department
of Health except for populations covered under code 400.

Eligible Person
A person who meets the requirements and standards established by the Medicaid
Office to be eligible for the GHIP. Eligibility for populations covered under
code 400 are not determined by the Medicaid Office of the Puerto Rico Department
of Health.

Enrollee
A person who is eligible and is enrolled in the GHIP.

Enrollment
The process by which an eligible person becomes an Enrollee.

Federal Category
Classification established by the Medicaid Office of the Puerto Rico Department
of Health for a beneficiary, according to established criteria of indigence
levels.

Government Health Insurance Plan (GHIP)
The Government Health Services Program (also known as “La Reforma” or “Mi
Salud”) offered by the Government of Puerto Rico, and administered by ASES,
which serves mixed population of Medicaid Eligible, CHIP Eligible, and other
Eligible Persons, and emphasizes integrated delivery of physical and behavioral
health services.

Health Insurance Claim Number (HICN)
Is a Medicare beneficiary’s identification number, appears in the beneficiary's
insurance card. All Medicare beneficiary claims are processed according to this
number.

Identification Card (ID)
A card bearing an Enrollee’s name, contract number, and co-payment amounts, and
a customer service telephone number, which is used to identify the Enrollee in
connection with the provision of services.

Managed Care Organization (MCO)
An entity that is organized for the purpose of providing health care and is
licensed as an insurer by Puerto Rico Commissioner of Insurance (“PRICO”), which
contracts with ASES for provision of Coverage Services and Benefits in
designated Service Regions on the basis of PMPM Payments, under the GHIP.

MA-10
Form issued by the Puerto Rico Medicaid Office, entitled “Notice of Action Taken
or Application and/or Recertification” containing the Certification decision
(whether a person was determined eligible or ineligible for Medicaid, CHIP, or
the Commonwealth Population).

MAGI
Modified Adjusted Gross Income is a method that is used to standardize the way
in which income is calculated to determine Medicaid/CHIP eligibility. This new
method introduces changes to the real structure of addressing and complying with
the specifications established by the Centers for Medicare & Medicaid Services
(CMS).
 
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II Definitions

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Master Patient Index (MPI)
Master Patient Index. Unique number which identifies a Member in ASES and the
Medicaid Office databases.

Medicaid Office
The medical assistance federal/state joint government program established by
Title XIX of the Social Security Act.

Medicare
The Federal Program of medical assistance for persons over sixty-five (65) and
certain disabled persons under Title XVIII of the Social Security Act.

Medicare Beneficiaries
People older than sixty-five (65) years of age or disabled or people who have
end state renal disease (ESRD), who are eligible for Medicare Part A coverage
which covers hospital services or Parts A and B, which cover hospital,
ambulatory and medical care services.

Medicare Part A
The part of the Medicare program that covers inpatient hospital stays, skilled
nursing facilities, home health and hospice care.

Medicare Part B
The part of the Medicare program that covers physician, laboratories,
outpatient, and preventive services.

Medicare Part C
The part of the Medicare program that permits Medicare recipients to select
coverage among various private insurance plans.

Medicare Part D
The Medicare prescription outpatient drug benefit.

Medicare Platino
A program administered by ASES for Dual Eligible Beneficiaries, in which MCOs or
other carriers under contract with ASES function as Part C plans to provide
services covered by Medicare, and also to provide a “wrap-around” Benefit of
Covered Services and Benefits under the GHIP.

Newborn
For purposes of the agreement, is a child born during the eligibility period of
his/her mother to the GHIP.

Participating Provider
All of the healthcare service providers contracted by the carriers to provide
healthcare services to the beneficiaries represented by ASES.
 
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II Definitions

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Plan Type
Code 01 to identify members with GHIP and code 02 to identify member with
Medicare Platino.

Plan Version
Product identification number that corresponds with the Plan Type. For GHIP, the
Plan Version will be the same as the coverage code assigned to the beneficiaries
by the Medicaid Office. For Platino Plans, ASES will assign a Plan Version code
for each contracted product.

Platino Health Plans
Specific health plans offered by Medicare Advantage Organizations contracted by
ASES that cover beneficiaries with dual eligibility (Medicaid and Medicare Part
A and Part B). ASES pays a monthly premium to these insurance companies to cover
the differential between Medicaid coverage and Medicare Advantage coverage.

Platino Plan Beneficiaries
Medicaid beneficiaries covered by Medicare Part A and Part B who are 65 years
old or older or disabled.  Commonwealth Beneficiaries funded solely through
state funds are not eligible to be enrolled in a Platino Plan.

PMPM Premium (“Per Member Per Month” Payment)
The fixed monthly amount that the Contracted Insurer is paid by ASES for each
Enrollee to ensure that benefits under this contract are provided. This payment
is made regardless of whether the enrollee receives benefits during the period
covered by the payment.

Potential Enrollee
A person who has been certified by the Puerto Rico Medicaid Office as eligible
to enroll in the GHIP (whether on the basis of Medicaid Eligibility, CHIP
eligibility or eligibility as a member of the Commonwealth Population, but who
has not yet enrolled with the Contracted Insurer.

Primary Care Physician (PCP)
A licensed medical doctor (MD) who is a Provider and who, within the scope of
practice and in accordance with Puerto Rico Certification and licensure
requirements, is responsible for providing all required care to Enrollees.  The
PCP is responsible for determining services required by Enrollees, provides
continuity of care, and provides Referrals for Enrollees when Medically
Necessary.  A PCP may be a general practitioner, family physician, internal
medicine physician, obstetrician/gynecologist, or pediatrician.

Primary Medical Group (PMG)
A grouping of associated Primary Care Physicians and other Providers for the
delivery of services to GHIP Enrollees using a coordinated care model. PMGs may
be organized as Provider care organizations, or as another group of Providers
who have contractually agreed to offer a coordinated care model to GHIP
Enrollees under the terms of the Contract. This Type of provider is contracted
by the Carrier on a PMPM basis.

Process Date
The date on which the beneficiary acquires the cover of services with the
contracted insurer.
 
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II Definitions

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Prorated Payment
A back payment that covers a fraction of the month prior to the month in which
the premium payment is made.

Provider
Any physician, hospital, facility, or other Health Care Provider who is licensed
or otherwise authorized to provide physical or Behavioral Health Services in the
jurisdiction in which they are furnished.

Puerto Rico Medicaid Office
The subdivision of the Health Department that conducts eligibility
determinations under GHP for Medicaid, CHIP, and the Commonwealth Population.

Re-enrollment
Refers to the process of re-enrollment for a beneficiary of Federal GHIP
populations (Medicaid or CHIP), state funded GHIP beneficiaries (Commonwealth),
or Platino beneficiaries who have lost eligibility for a period of two (2)
months.

Recertification
A determination by the Puerto Rico Medicaid Office that a person previously
enrolled in the GHIP is again eligible for services under the GHIP.

Redetermination
The periodic redetermination of eligibility of an individual for Medicaid, CHIP
or the Commonwealth Population, conducted by the Puerto Rico Medicaid Office.

Retroactive Payment
Refers to a payment that corresponds to a period prior to the month in which the
premium payment is made.

Retroactivity
Identifying a premium payment that corresponds to a period prior to the current
one.

Special PMG
The assignment of a PMG (“Primary Medical Group”) to a beneficiary who does not
belong with the PMG assigned to his family.

State/Commonwealth Population: A group eligible to participate in the GHIP as
well as other eligible individuals, who do not receive federal coverage, made up
by low income people and other groups listed in Section 1.3.1.2 of the contract
between ASES and carriers.

Suspension of Healthcare Services
The culmination of the eligibility period allowed by the Medicaid Office.
 
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II Definitions

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SYSPREM
System that provides for the enrollment of a beneficiary in historical data. It
allows the update and/or enrollment of data that corresponds to eligibility
periods prior to the cancellation period of the eligibility of a beneficiary or
before an enrollment to a different carrier comes into effect.
 

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III. Eligibility

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III.
ELIGIBILITY

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1. ELIGIBILITY CONCEPTS

1.1 Eligibility Determination

 The Medicaid Office, which administers the Puerto Rico Medical Assistance
Program, is the body with authority to determine whether a person is eligible to
receive medical services under the GHIP, either in the federal category
(Medicaid and CHIP) or in the Commonwealth Population. This includes
certification of beneficiaries with Medicare Platino coverage.

 The eligibility criteria for the beneficiaries are set by CMS requirements,
including their level of indigence. In Medicare Platino, the age of the
applicant (aged 65 or older) or the disability status as mentioned in Title
XVIII of the Social Security Act is considered.

Medicaid, CHIP and state funded Commonwealth beneficiaries are annually
certified for an eligibility period of twelve (12) months.   The Medicare or
Medicaid eligibility period may be less than twelve (12) months in situations
where:  the beneficiary notifies that his/her circumstances have changed and
adversely affect his/her eligibility, persons with medical expenses fail to
qualify under the "spend down" method, deceased or incarcerated persons, or
others as determined by the Medicaid Office. Children identified as Deemed
Newborn are certified until thirteen (13) months of age.

1.2 MA-10

The eligibility determination of the Puerto Rico Medicaid Office granted to an
applicant for the GHIP or Medicare Platino is contained in Form MA-10, and is
provided to the beneficiary on the day he/she is certified.

The beneficiary will continue to receive coverage for services based on the day
they were certified by the Medicaid Office, as written on the Form MA-10, until
the day they receive their health insurance card by regular mail. The MA-10 form
may be used for a period of 30 days from the date of certification for the
purpose of demonstrating eligibility and receiving services without an
identification card issued by an MCO.

We will have two (2) MA-10 models in force. The current (rev. 10/2015): These
are the MA-10 forms that were issued between July 1, 2016 and June 30, 2017,
which will continue to be valid until the beneficiary is re-evaluated and
recertified following the rules of MAGI. The new (Rev. 6/2017): These are the
MA-10 forms that will be issued after July 1, 2017, after the applicant or
beneficiary has been evaluated or recertified following the MAGI rules.
 
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1.3 Eligibility Effective Date

The Effective Date for purposes of a Medicaid or CHIP Enrollee is the first of
the month in which the Medicaid Office determines eligibility.  This should be
the same date indicated as the period of eligibility on the MA-10 form. For
purposes of a state funded Commonwealth beneficiary, it is the Date of
Certification.

When a re-certification is filed, and the person is again eligible for
Medicaid/CHIP, the eligibility date is generally the 1st of the month after
eligibility expires.  However, if the Enrollee’s eligibility was lost for less
than two (2) months, enrollment should be effective as of the eligibility period
specified on the MA-10, and the person should be automatically enrolled in its
previous PCP/PMG.

A person may apply for Medicaid/CHIP on behalf of a person who has died in the
same month in which they apply or up to three months retroactively in the event
the person would have been eligible in those months. The eligibility period will
be from the first (1st) day of the month of the application until the date of
death. This provision does not apply to state funded Commonwealth beneficiaries.

All pregnant women under both federal Medicaid/CHIP and State-funded) may have a
period of eligibility greater than twelve 12 months when adding the required 60
days of postpartum coverage. The expiration date will be the last day of the
month at the end of these 60 days.

Retroactivity on the effective date is granted when the applicant indicates that
he/she has medical expenses prior to the effective date, including any
Medicaid-covered service that has not been paid for. The effective date will be
within three (3) months before the month in which the Enrollee is applying. If
the applicant is Medicaid or CHIP eligible in the month in which the service was
eligible, the applicant will be granted retroactivity. This retroactive benefit
does not apply to eligible state category.

In a recertification for state funded Commonwealth beneficiaries in which the
person is eligible again, the effective date is the first day of the month after
the current eligibility expires.

The date of certification for state category will be when the evaluation is
completed.

No retroactive eligibility is contemplated in the state funded category for
Commonwealth beneficiaries.
 
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III. Eligibility

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1.4 Certification Date and its Relation with the Effective Date

The date when the Medicaid Office issued an eligibility determination is known
as the Certification Date. In the state funded category for Commonwealth
beneficiaries, the Effective Date will always coincide with the Date of
Certification and would mark the beginning of the eligibility period granted to
the beneficiary. In the Medicaid/CHIP category, the Effective Date will be the
first day of the month in which the beneficiary was certified by the Medicaid
Office. In both cases, the Certification Date is provided on Form MA-10.

1.5 Eligibility Effective Date in the Case of a Newborn

The eligibility to be granted to the child is the same as the mother’s at the
time of birth. A newborn born to a mother who is a Medicaid Enrollee shall have
an Eligibility Effective Date of the date of birth. In the event that the mother
is retroactively eligible as a federal Medicaid beneficiary at the time of the
newborn’s birth, the newborn’s eligibility shall also have an Eligibility
Effective Date retroactive to the date of birth.  All federally eligible
newborns are auto-enrolled into the program and provided coverage from the date
of birth. 1 If the mother was a state funded Commonwealth beneficiary, the
Eligibility Effective Date of the newborn shall be the Certification Date.

2. MAGI ELIGIBILITY RECORDS CHANGES

2.1 Transfer of Eligibility Files from Medicaid

Once eligibility processes are completed by the Medicaid Office, the data of
certified beneficiaries are received via FTP Server by ASES, where ASES, in
turn, completes a daily process of updating the data received in their systems.

ASES - "ASSIST" systems and Office of Medicaid - "MEDITI" systems currently
handle eligibility using the concept of FAMILY. For this purpose, they will be
kept in the same concept, in that each FAMILY will consist of a single member
and the suffix "01", a constant that will remain in each register of the member.
The FAMILY code will become the last 11 digits of the MPI number.

--------------------------------------------------------------------------------

1 See Sections 5.2.2.2 and 5.2.6.2 of the GHIP Contract.
 
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III. Eligibility

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As of the date of change to MAGI, ASES will convert the data from January 2010
to the present. Data prior to 2010 will be archived. This will be the
definition:

RECORD TYPE
CODE
A Family Record
(F)- Required
A Member Record
(M)-Required
A Household Record (A group of related members)
(O)-Required
One or several additional insurance records.
(I)- If applicable
One or several  Spend-Down Records
(S)- If applicable

2.2 Medicaid Family Record Changes since July 1st, 2017

There will be fields that will not be used. These are labeled in the layout
specification for the file and will remain as zeros or spaces. There will be a
family register per group. See the changes below in the family log design.
 
FIELD
DESCRIPTION
Record_type
It is labeled with the letter “F” in the Record_type column.
Family Code
The last 11 digits of the MPI Number will be included in the family code column.
Tran_id
New values (‘1’, ‘2’, ‘3’) were added to the Tran_id column to identify
retroactive eligibility periods. This will be explained further below, in the
MAGI Retroactive Eligibility Period Section.
Contact last name 1
Paternal surname of the contact person. Required.
Contact last name 2
Maternal surname of the contact person. Required.
Contact first name
First name of the contact person. Required.
Residence-zip
Postal zone of the physical address. Required.
Residence-zip4
Additional digits for the postal zone.
PCT-of-poverty-level
This field will not be used. It must be filled with zeroes.
Deductible-level-code
This field will not be used. It must be filled with zeroes.
ELA_errors
This field will not be used. It must be fill with zeroes.
Mancomunado
This field will not be used. It must be fill with zeroes.
Application Number [new field]
 This number corresponds to a unique number, linked to the way people fill out
in the Medicaid Office, when they request the GHIP or when a recertification
occurs. This number changes each time the "Family" group is to be re-certified.

 
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2.3 Medicaid Member Record Changes since July 1st, 2017

There is a member record per group. There are many fields in this record that
will no longer be in use. These are labeled in the layout specification for the
file and will remain as zeroes or spaces. See changes below to the member record
layout.

FIELD
DESCRIPTION
Record Type
 This record is identified with the letter "M" in this column.
Member suffix
The content of the Member suffix column will always be “01”.
Tran_id
New values (‘1’, ‘2’, ‘3’) were added to the Tran_id column to identify
retroactive eligibility periods. This will be explained further below.
Contact Member
New field. The MPI number of the contact member will be included in this field.
If the contact person or guardian does not belong to the medically indigent
population, Medicaid will assign him/her a number. This field is tied to the
contact name in the family record.
Relationship
This field will not be used. Its content will consist of zeroes or spaces.
Place-of-Birth
This field will not be used. Its content will consist of zeroes or spaces.
Category
This field will not be used. Its content will consist of zeroes or spaces.
Category-2
This field will not be used. Its content will consist of zeroes or spaces.
Condition
This field will not be used. Its content will consist of zeroes or spaces.
Med-ins-code
This field will not be used. Its content will consist of zeroes or spaces.
Policy
This field will not be used. Its content will consist of zeroes or spaces.
Class
This field will not be used. Its content will consist of zeroes or spaces.
Class-2
This field will not be used. Its content will consist of zeroes or spaces.
Denial-cat
This field will not be used. Its content will consist of zeroes or spaces.
Denial-cat 2
This field will not be used. Its content will consist of zeroes or spaces.
Pilot-cat
This field will not be used. Its content will consist of zeroes or spaces.
Pilot-class
This field will not be used. Its content will consist of zeroes or spaces.
Pilot-denial
This field will not be used. Its content will consist of zeroes or spaces.
Cost-Sharing Flag
New Field.  The accepted values are:
N = No exception,
C = Child,
P =  Pregnant,
A = American Indian,
I =   Institutionalized,
H = Hospice.  For the moment, this piece of information will remain
informational in nature.
Max-copay
New field. This is the maximum co-pay amount that a beneficiary can pay within a
given period. For the moment, this piece of information will remain
informational in nature.
Extension-Flag
New field. Its content will be:
N = Not undergoing an appeals process
A = Currently undergoing an appeals process
U = Close of the appeal
P = Extension due to pregnancy
X = Extension due to other reasons
The appeals process will be explained further below (See Section 8.1).
Spend Down Flag
New field. This field indicates whether or not “S” (“Spend-down”) records are
included. If it does not contain this type of record, this field will show the
letter “N”. If it does contain this type of record, it will show the letter “S”.

 
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2.4. Eligibility Records Concerning Household, new record since July 1st, 2017
A Household record will be included in each group of records. It contains all
the MPI’s related to the member at the time that his/her eligibility is
evaluated. See changes below to the household record layout.

FIELD
DESCRIPTION
Record_type
It is labeled with the letter “O”.
Tran_id
This field will have the same content as the Family and Member records.
Process_date
Will have the same date contained in the Family and Member records.
MPI_1 al MPI_18
These are the MPIs of each member related to the member in the Member_id field
at the time during which the eligibility evaluation is being carried out at
Medicaid’s Offices.

 
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2.5 Additional Health Insurance Record (Insurance Record)
There can be more than one additional health insurance record in the group. See
changes below to the additional health insurance record layout.

FIELD
DESCRIPTION
Record_type
It is labeled with the letter “I”.
Tran_id
New values (‘1’, ‘2’, ‘3’) were added to the Tran_id column to identify
retroactive eligibility periods. This will be explained further below in
Medicaid or CHIP Retroactive Eligibility Record.

NOTE:
The file layouts are in the Appendix 9 for GHIP contract and Appendix K for
Platino contract

3. MEDICAID /CHIP’S RETROACTIVE ELIGIBILITY

The new MAGI changes have implications for the treatment of enrollments and
payments related to periods of retroactive eligibility under the federal
Medicaid and CHIP category. The new rules applicable to this topic are described
below.

3.1 Medicaid/CHIP’s Retroactive Eligibility Effective Date

Under Medicaid or CHIP, the Effective Date of the Eligibility for the
enrollments that correspond to a retroactive period will be determined month by
month. Each retroactive period or record shall correspond to one (1) calendar
month. The Medicaid Office may grant up to four (4) eligibility periods for the
same beneficiary which may be comprised of three (3) retroactive periods and one
(1) record for the current period. Each record of retroactivity will mark the
beginning and end of the eligibility in relation to the period to which it
corresponds. That is, each of the retroactive periods of eligibility granted
will determine the start and completion of the Eligibility Effective Date for
that particular period.

3.2 Group of Records for Retroactive Periods – if applicable.

Each retroactive eligibility period involves a group of records. The beneficiary
labeled as Federal (Medicaid, CHIP) could have one (1) to three (3) retroactive
eligibility periods. Each retroactivity period runs from the first day of the
month until the last. Each retroactivity period is evaluated separately.
Therefore, there can be a change in coverage from one period to the next.

The evaluation of the retroactive eligibility period is independent from that of
the current period. A member can have retroactive eligibility periods and not be
currently eligible.
 
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Retroactive eligibility periods will be confirmed and sent to insurance carriers
in the daily eligibility file (.exp). Each period will have a group of records
labeled with the ‘1’, ‘2’, ‘3’ indicators in the Tran_id column. The indicators
are unrelated to the order of the periods; they are only used to unify the group
of records.

ASES could receive, for a single member, up to three (3) retroactive eligibility
enrollment records and one (1) current eligibility enrollment record in an
enrollments file. A member may be eligible for one (1) to three (3) retroactive
periods and not be eligible for the current term. In this case, sets of records
for the retroactive periods may be received but none for the current eligibility
period. Retroactive eligibility period will be from the first day of the month
of retroactive eligibility until the last day of the month of retroactivity.
 
4. TERMINATION OF ELIGIBILITY AND RECERTIFICATION PROCESS

After a period of eligibility is granted to a beneficiary, a Recertification
Process will be initiated whereby a new eligibility evaluation will be carried
out, which will allow the renewal of the health services for the corresponding
period. The Re-certification Effective Date refers to the date Medicaid
re-evaluates a beneficiary's eligibility. This date is provided on the MA-10
form. The Eligibility Expiration Date refers to the expiration date of the
eligibility period granted to the beneficiary by the Medicaid Office

A federal beneficiary of the GHIP (Medicaid or CHIP), or a beneficiary of the
GHIP whose coverage is funded solely through state funds (Commonwealth) who, as
a result of a Recertification Process, receives a negative eligibility
determination for GHIP, will continue to be eligible to receive services under
the GHIP until the date specified in the document titled Negative
Redetermination Decision on MA-10 issued by the Puerto Rico Medicaid Office. The
cancellation of health services transaction due to the expiration of the
eligibility period will be notified by the Medicaid Office and will be reflected
in the ASES databases on the last day of each month. Only the Medicaid Office
may cancel and provide notice of the cancellation of a beneficiary's
eligibility.

5. ELIGIBILITY PERIOD EXTENSION

5.1 Appeals Process for Re-Certification

When a beneficiary does not qualify during his/her re-certification process,
he/she has the right to appeal his/her eligibility within a term of fifteen (15)
days. If a previously eligible Medicaid or CHIP member appeals within fifteen
(15) days of an adverse eligibility determination, content “A” or “X” will be
sent to the insurance carrier in the Extension_flag field. The member may not be
cancelled during the appeals process even if the expiration date passes. When
the appeals process is completed, Medicaid will send an update of the member’s
status to ASES. If the appeal is presented after the first fifteen (15) days
after the adverse eligibility determination, no extension will be issued. In
this case, a cancellation will be received from Medicaid at the end of
eligibility period or fifteen (15) days after the evaluation for disenrollment
exceptions.
 
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(1) If the appeal finds in favor of the beneficiary: the expiration date will be
updated to the appropriate one. He/she will be identified as eligible and the
termination of the appeals process will be labeled with a “U” and a new
eligibility period. If there were to be a change in coverage, a new enrollment
with the new coverage must be sent, just as is currently done.

(2) If the appeal finds against the beneficiary: the Medicaid Office will send a
cancellation with the original expiration date. He/she will be identified as
ineligible and the termination of the appeals process will be labeled with a
“U”. The insurance carrier will keep offering services to the beneficiary until
it receives the cancellation in the eligibility file sent by ASES. ASES will
continue paying premiums until the cancellation is received from Medicaid
Office. Only Medicaid Office may cancel a beneficiary. The cancellation’s
effective date will reflect the date in which ASES receives said cancellation.

(3) If the appeal is resolved only after a cancellation, the insurance carrier
will receive the eligibility information only if the appeal is in favor of the
beneficiary and with updated dates with the new eligibility period.

5.2 Appealing a Certification (either new or not active at the time)

If a person who is not active in the Medicaid Program requests eligibility and
he/she does not qualify, he/she has the right to appeal the result of the
evaluation. This type of appeal is an internal Medicaid Office process. The
Medicaid Office will not send to ASES records of these processes unless the
appeal is decided in the person’s favor. In the case of Medicaid or CHIP
eligible beneficiaries, a group of records will arrive with an effective date
that may be retroactive to the first day of the month corresponding to the
certification date. If the beneficiary has used medical services, the insurance
carrier will treat the enrollment as an emergency (special enroll = ‘E’), since
the retroactivity could go back more than three (3) months. In the event the
person is certified as a state funded Commonwealth beneficiary, the date of
eligibility after a favorable appeal shall be prospective from the date of the
favorable determination.

5.3 Eligibility Extension Due to Pregnancy
 
If a pregnant woman is undergoing re-certification and she is determined to be
ineligible, she cannot be terminated until sixty (60) days after the date on
which she gives birth or loses the fetus.   These cases will be labeled with the
letter “P” in the Extension flag field. The Medicaid Office will send ASES
cancellation at the appropriate point.
 
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Important Note:
Neither ASES nor insurance carriers may cancel a beneficiary until Medicaid
Office sends a cancellation, even if the expiration date has already passed.

6. ELIGIBILITY PERIOD TERMINATION

In those cases where it is determined that a beneficiary of the GHIP is no
longer eligible to continue receiving services after a Recertification Process
has been performed by the Medicaid Office, the beneficiary will maintain his or
her eligibility until the date specified in the document entitled Negative
Redetermination on MA-10 issued by the Puerto Rico Medicaid Office.

On a daily basis, ASES receives a file with the eligibility status of the
beneficiaries, including the cases in which the eligibility period has ended. In
such cases, ASES will send to the carriers the contents of the files of those
beneficiaries who have received a Negative Redetermination Decision within a
period of twenty-four (24) hours from the time it receives the file from the
Medicaid Office. 2

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2 See Section 5.1.4 of the GHIP Contract.
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IV.
 ENROLLMENT PROCESSES

 
 
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 7. DATA EXCHANGE

The eligibility files described in the previous sections are entered into the
daily run cycle and are evaluated through an editing and verification program at
the Information Systems Office at ASES. After receiving and processing the
eligibility data of each beneficiary, ASES creates an electronic record that
includes information which the carrier can use to enroll the beneficiary, such
as information about the Plan Type [federally funded GHIP (Medicaid and CHIP),
state funded GHIP (Commonwealth), or Platino]and Plan Version along with their
respective effective dates and other related data elements. ASES sends accepted
enrollments, new eligibility, updates and cancellations data to carriers in a
file (.exp) that shows the activity generated in a daily manner.

Under the automatic assignment, carriers update their database, assign a Primary
Medical Group (PMG) and a Primary Care Physician (PCP) based on the
beneficiaries' physical address, and issue the plan identification cards for
each beneficiary. These cards are sent to the beneficiaries by postal mail in an
approximate period of five (5) days. The beneficiaries, in turn, have ninety
(90) days to request a change of the PMG or the PCP, if they so desire. The
carrier then produces the electronic enrollment record and submits it to ASES in
a file (.sus) that accounts for the enrollments made. 3

Generally, carriers have a twenty-four (24) hour period to remit membership
records to ASES. They must notify ASES of the information about the new
beneficiaries enrolled and send information about any changes performed on a
record previously enrolled. Such notification must be sent on the next business
day.

In the case that the carrier has to update the information previously sent to
ASES in relation to a new enrollment, or when it is appropriate to add a new
beneficiary that has been previously omitted, that update must occur the next
business day after the information has been updated or that a new beneficiary
has been added. In these cases, ASES reserves the right not to accept new
additions or corrections to the enrollment data after sixty (60) calendar days
after the Effective Date of the Enrollment indicated in the carrier's
notification to ASES. Likewise, the beneficiary’s PMG and/or PCP changes will
take effect as stated in Section 13.5. 4

Records that are accepted without changes or modifications during the editing
process are updated in the databases at ASES and the beneficiaries are duly
enrolled. Enrolled Medicaid and CHIP beneficiaries, beneficiaries of the GHIP
funded solely through state funds (Commonwealth), and Platino beneficiaries are
those that are listed as eligible in the ASES databases. Any record that is
accepted during the editing and verification processes will be stored in the
current and historical data tables.
 

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3 See Section 5.2.5 of the GHIP Contract.
4 See Section Sec. 5.4.1.3 of the GHIP Contract.
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The records that are rejected are returned to the carrier with the applicable
reject codes in a file (.rjc). The carrier must correct any errors in the
enrollment record and send the information back to ASES in a file (.sus) within
24 hours. ASES will only pay the premiums related to those beneficiaries who are
enrolled in the databases at ASES. Therefore, the execution of the payment of
the corresponding premium for these rejected records will be stopped until they
are sent back with the correction of the indicated errors.

The exchange of data regarding eligibility and enrollment processes between the
Medicaid Office, ASES and the contracted carriers occurs on a daily basis. In
Figure 1, which is provided below, the information exchange processes described
in the previous subsections are presented.

Figure 1 ASES Information Flow

[image00010.jpg]

This process of information exchange is quite similar in both the GHIP and the
Platino Medicare programs with the exception of the need to comply with the
additional requirements applicable in the case of the latter. Before a
beneficiary of a Platino Plan can be enrolled, the carrier must perform the
procedures described later in this document.
 
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8. VALIDATION PROCESS

Carriers are responsible for transmitting enrollment files of their
beneficiaries to ASES on a daily basis. For proper processing of the enrollment
transactions, carriers must keep the eligibility information of the
beneficiaries who are referred to ASES daily updated in their respective
databases. To that end, they should use the following conventions related to the
file submission process.

9. ENROLLMENT FILES

Definition of the nomenclature of the data files to be exchanged between
Medicaid, ASES and carriers

9.1 ENROLLMENT FILE [CCYYMMDD.sus]
a.          CC =    Carrier Code
b.          YY =   Year
c.          MM =  Month
d.          DD =   Day
e.          .SUS = Identifies the file as an enrollment file. The enrollment
file may contain records
belonging to any of the regions contracted by the carrier.
Notes:
✓ Files received at 9:00 am are entered in the ASES daily cycle.
✓ If a file is received after 9:00 am, it will be entered in the next day's
cycle.

9.2 ELIGIBILITY FILE [VYYMMDD.ref]
a. V = indicates that it is an eligibility file
b. YY =  Year
c. MM = Month
d. DD =  Day
e. .ref = Indicates that it is a file containing the records of the
beneficiaries’ eligibility.

9.3 DATA EXPORT FILE [RRCCYYMMDD.exp]
a. RR = region code
b. CC = carrier code
c. YY =  Year
d. MM = Month
e. DD =  Day
f. .exp = Indicates that it is a file containing all the eligibility and
enrollment transactions processed during the daily run.

 
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9.4 REJECTED ENROLLMENTS FILE [*.rjc]
a. CC=   Carrier Code
b. YY =  Year
c. MM = Month
d. DD =  Day
e. .rjc= Indicates that it is a file containing the records of the beneficiaries
who have been rejected.
Notes: ASES runs a separate edition and update cycle for each contracted region.
Enrollments are filtered through various editing and verification programs and
identified as valid or rejected. This process produces a file (.rjc) that
contains all the records that are rejected.

9.5 ELIGIBILITY QUERY FILE [CCYYMMDD.qry]
a. CC= Carrier Code
b. YY=Year
c. MM=Month
d. DD=Day
e. .qry =Indicates that is a file for eligibility verification.
Notes: A '.query' file is submitted by the carriers to verify a person's
eligibility for the Medicare Platino Plan and the GHIP if necessary.
Consequently, ASES generates a response in a '.res' (response) file with the
requested information.

9.6 ELIGIBILITY QUERY RESPONSE FILE [CCYYMMDD.res]
a. CC=Carrier Code
b. YY=Year
c. MM=Month
d. DD=Day
e. .res = Indicates that it is a query response file.
Notes: This file is sent by ASES in response to a query file.

10. GHIP BENEFICIARY ENROLLMENT

In order for an enrollment record to be accepted during the editing and
validation processes, it is important to take into account the following
considerations regarding concepts related to the enrollment processes:

10.1 Effective Date of Enrollment

The Effective Date of an Enrollment refers to the date that a carrier
establishes as the beginning of the coverage period for a beneficiary.
Generally, this date concurs with the beginning of the eligibility period as
defined by the Medicaid Office for the Federal and State categories. For the
federal population, this date will be the first of the month in which the
beneficiary applied for health services coverage. For the Commonwealth
population, this date will be the same as the Certification Date. Also, this
date refers to the date on which a change of PMG, PCP or Plan Version will be
effective. The Effective Date of the Enrollment of these changes will fall as
described in Section 13.5.
 
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10.2 Date of Enrollment in the Case of Newborns

In newborns, the Effective Date of the Enrollment will be on the day of birth
for babies of federal mom and Certification Date for state mom, unless in the
newborn evaluation turns to be CHIP. In this case, the newborn could have
retroactive periods if there were utilization 5

10.3 Date of Re-enrollment in Cases of Loss of Eligibility

In the cases of re-enrollment of federal beneficiaries (Medicaid and CHIP),
state funded Commonwealth beneficiaries, or beneficiaries who have lost
eligibility for a period not exceeding two (2) months, the beneficiary will be
auto-assigned to the same PMG as previously assigned to.  The Effective Date of
the Enrollment will fall on the same eligibility period specified in the MA-10.
6

10.4 PCP/PMG Change Enrollment Effective Date

If an enrollee changes PCP/PMG during the first five (5) days of the month, the
change will be effective in the next subsequent month. If an enrollee changes
PCP/PMG after the fifth (5th) day of the month, the change will be effective in
the second subsequent month of the change. The enrollees can still receive
services until the change is effective through the original PCP/PMG assigned by
the contractor during the Auto-Enrollment process. 7

10.5 Changes in Coverage Codes and Enrollment
If the coverage code of a GHIP beneficiary changes, the insurer must send a
subscription with the new plan version (that is equal to the coverage code) with
the effective date of the first day of the next month. For Platino
beneficiaries, the insurer must send the plan version corresponding to the
product that the beneficiary has. The effective date is also the first day of
the next month,

10.6 Process Date

The Process Date has relevance both in cases of new enrollment of a beneficiary
and in cases of changes of PMG, PCP or Plan Version in relation to a record of
enrollment of a beneficiary. This is a date provided by the carrier that
identifies the day on which a new enrollment or a change in the record of a
beneficiary's enrollment was processed in its databases. For GHIP beneficiaries,
the Process Date must be equal to or before the Effective Date, but after the
three (3) months preceding the Effective Date.

In the case of a new enrollment under a Platino Plan, it refers to the date on
which the beneficiary contracted the coverage services with the corresponding
carrier. In Platino plans, the Process Date must be prior to the Effective Date
of the new enrollment or the change in question, but subsequent to the three (3)
months prior to the Effective Date of the new enrollment or change.
 

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5 See Section 5.2.2.2 of the GHIP Contract.
6 See Section 5.2.2.4 of the GHIP Contract.
7 See Section 5.4.1.4 of the 2015 Contract Amendment.
 
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11. MEDICARE PLATINO ENROLLMENT PROCESS

ASES is able to employ a variety of methods for the purpose of subscribing
persons who are eligible to receive coverage under Medicare Platino plans. This
includes enrollment assisted by Platino carriers, enrollment by ASES or a
combination of both. The procedure used for the enrollment under the Platino
Medicare Program is described in the Appendix F which accompanies the contract
entered into between ASES and the Platino carriers8. Relevant considerations are
highlighted throughout this manual.

11.1 Eligibility Query Preceding a Medicare Platino Enrollment

(1)
Query: through a file (".query"), the carrier requests a verification of a
beneficiary’s eligibility for the Medicaid Office.

(2)
Response: ASES processes this query file and sends a response to the request in
a file (.res). This file includes information regarding the beneficiary’s
eligibility for the Medicaid Office, Medicaid Office specification for which the
beneficiary is eligible (federal or local), and the data that identifies the
beneficiary in the database, both at Medicaid Office and ASES.

(3)
Platino Product Enrollment: If the beneficiary is eligible for Medicaid coverage
and has Medicare Part A and Part B benefits (dual-eligible beneficiary), the
carrier will complete an enrollment record that will include data corresponding
to the health plan under which the beneficiary is to be enrolled.

(4)
Enrollment Update: Subsequently, ASES will edit and update the data in the
electronic enrollment record to identify the individual as a Platino Medicare
beneficiary using CMS data file in monthly based. A daily eligibility file is
then sent to the carrier that contains the data that shows the beneficiary's
enrollment to Medicare Platino.

(5)
Rejected Enrollments: The enrollment records sended by carriers, are evaluated.
If the enrolment file contain errors will be returned to the carriers for
corresponding corrections.

 

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8 See Section 6.1.1 of the Platino Contract.
 
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11.2 Transfer of Beneficiaries to Platino Products

Medicare Advantage beneficiaries who are granted Medicaid coverage may elect to
transfer to the Medicare Platino products offered by their preferred carrier or
may enroll to Medicare Platino products available to dual eligible individuals.
In these cases, the carrier must process a new enrollment for the purpose of
transferring the beneficiary of the Medicare Advantage product to Medicare
Platino. To the extent possible, such enrollments will be effective on the first
day of the month in which the beneficiary's Medicaid coverage is effective. 9

11.3 Effective Date of Medicare Platino Enrollment

The Effective Date for a beneficiary’s Enrollment under a Platino Medicare Plan
will fall on the first day of the month in which the name of the beneficiary
appears on the CMS Prepaid Premium Plans List and on the first day of the month
in which it appears enrolled in the Platino Medicare plan of the carrier in
question. 10

11.4 Recovery of Eligibility and Prospective Enrollment

In those cases in which the enrollment of a Platino Medicare beneficiary is
canceled due to the loss of eligibility as a Medicaid beneficiary, but recovers
that eligibility within a period of two (2) consecutive months, the beneficiary
may be enrolled automatically and prospectively under the Platino Medicare plan
of the carrier in question. 11

12. RETROACTIVE ENROLLMENT

The retroactive enrollment processes involve the processing of an enrollment in
the ASES databases for a period prior to the current eligibility period. It is
important to distinguish between the terms granted for the retroactive
enrollment processes and the periods of retroactive eligibility granted by the
Medicaid Office, as they represent retroactivity in different contexts.
 

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9 See Section 6.8.1 of the Platino Contract.
10 See Section 6.4 of the Platino Contract.
11 See Section 6.6.1 of the GHIP Contract.
 
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12.1 Retroactive Enrollment for Federal and State Category

Under the federal Medicaid and CHIP programs, and the state funded Commonwealth
population, this date may be extended retroactively up to three (3) months prior
to the date the enrollment is processed at ASES, provided that the period to be
enrolled falls within the period of eligibility granted by Medicaid Office.

In the same subscription file, no more than one subscriber may be included for
the same member unless it is a subscription for a current eligibility period and
one to three subscriptions for retroactive eligibility periods.

The letters “E” or “C” will be included for retroactive eligibility period
enrollments, just like in SYSPREM cases. Retroactive period enrollments will be
labeled with the letter “T” in the Special_enroll field.

Each enrollment with retroactive eligibility period will be validated against
the member’s eligibility history. Therefore, the insurance carrier’s effective
date for each enrollment must correspond to the date of each retroactive period
in ASES’s member history.

12.2 Retroactive Enrollment for Platino Plans

For Platino plans, the enrollment may be extended retroactively from six (6) to
eighteen (18) months prior to the date on which the beneficiary's enrollment is
processed at ASES. That is, the Information Systems Office of ASES may accept an
enrollment of a beneficiary of the Platino Plan for up to eighteen (18)
retroactive months as long as the limits of the period to be enrolled fall
within the period of eligibility granted by the Medicaid Office.

For a better understanding of the concept of retroactivity in eligibility and
retroactivity in enrollment as discussed in the preceding sections, Table 1 is
provided with the applicable periods granted.
 
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Table 1: Retroactivity in Eligibility and Retroactivity in Enrollment

 
PLAN
RETROACTIVITY
 Eligibility
      Enrollment
Yes
No
Yes
No
Federal GHIP
(Medicaid and CHIP)
✓
(Up to Three (3) months)
 
✓
(3)
months
 
State GHIP
(State Population)
 
   ✓
✓
(3)
months
 
Platino
(65 years old, disabled, dual)
✓
(3)
months
 
✓
(6-18)
months
 

13. ENROLLMENT RECORD

The enrollment record that is used by carriers to notify ASES of the enrollment
of a beneficiary contains a series of data that are used for the purpose of
informing the details of the enrollment made and to verify their accuracy and
certainty. A beneficiary can be enrolled in one of two (2) types of plans
available:

Table 2: Plan Types

Code
Plan
01
State (Commonwealth Population) y Federal (Medicaid or CHIP).
02
Platino SNP (Special Needs Plan).

Under this diversity of plans, the carriers can offer different products that
are identified by their Plan Version number. ASES assigns a Plan Version number
for each contracted Platino product. In the cases that fall under any of the
GHIP, the Plan Version must be equal to the coverage code assigned to the
beneficiaries by the Medicaid Office.

Some of the plans contracted with ASES may require the assignment of Primary
Medical Group (PMGs) and/or Primary Care Physicians (PCPs) to beneficiaries by
the carriers. The enrollment record includes these fields as well as the Plan
Type and Plan Version noted above. The enrollment record also reports the date a
beneficiary has been processed by the carrier and the Effective Date of
Enrollment.
 
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14. ENROLLMENT RECORD FIELDS

The record of each beneficiary's enrollment contains the following information
that must be provided by the carrier:

1. RECORD_TYPE – In every case, and regardless of the transaction in question,
this field requires the insertion of code "E" that identifies the entry as an
enrollment record for both new enrollments of beneficiaries and changes on
records of beneficiaries previously enrolled.

2. TRAN_ID - This field allows the ASES systems to identify the action to take
on the record submitted. It can contain one of the values listed below:

a.     E = New Enrollment. This value identifies that the record is a new
enrollment for a beneficiary who has not been previously enrolled or that is
currently inactive. It could also imply that this is a retroactive enrollment
record for transactions not previously enrolled. For transactions previously
enrolled, either by the same or one that is different from the previous
enrollment, a "C" would be inserted.

b.    C = Carrier Change. Used when the beneficiary has selected a different
carrier than the one in which he/she is presently enrolled. It is also used for
initial enrollment in Platino Plans when the beneficiaries were previously
enrolled in a GHIP and they opt to change to Platino. It could also identify a
retroactive enrollment record in cases that are carried out by a carrier
different than that arising from the ASES database or by the same carrier if it
has to make a change on a previous enrollment.

c.     P = Changes in the Plan Type. It is used when a member enrolled under a
particular carrier changes from a product the carrier offers to one which is
identified under a different Plan Type under the same carrier.

d.    V = Plan Version Change. For GHIP carriers, it implies a change from a
product the carrier offers to one which is identified under the same Plan Type.
This transaction code is also used when a GHIP beneficiary’s coverage code
changes. In these cases, the carrier must reissue a health plan ID card
displaying the new benefits, and submit a version change enrollment record to
ASES where the Version number should be equal to the new coverage code. Failure
to submit said information to ASES, will trigger an automatic disenroll of the
beneficiary from the carrier that omits the timely submission. While in these
circumstances the beneficiary continues being eligible to receive the medical
services, the carrier will remain unable to claim a premium payment for said
beneficiary until a submission of the required information is performed.

e.     I = PMG (Primary Medical Group) Change. It is used to register, in ASES,
a change in the beneficiaries’ selected PMG under the same carrier, Plan Type
and Version.
 
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f.     1 = PCP1 change. It is used to register, in ASES, a change in the
beneficiaries’ selected PCP1 under the same carrier, Plan Type, Version and PMG.

g.    2 = PCP2 change. It is used to register, in ASES, a change in the
beneficiaries’ selected PCP2 under the same carrier, Plan Type, Version and PMG.

h.    3 = PCP1 and PCP2 change. It is used to register, in ASES, a change in the
beneficiaries’ selected PCP1 and PCP2 under the same carrier, Plan Type, Version
and PMG.

As we have seen, the content of the Tran_id field determines what type of
transaction is going to be executed through the enrollment record sent to ASES.
Some of the authorized transactions are broken down below. Table 3 below
identifies the information that each change will require and states the fields
that will be impacted by each one.

Table 3: Hierarchy Table

TRAN_ID
CARRIER
Plan_Type
VERSION
Primary
Center
PCP1
PCP2
E - New Enrollment
Y
Y
Y
Y
Y
O
C - Change Carrier
Must be different from ASES DB
Y
Y
Y
Y
O
P - Plan Change
Must be the same as in ASES DB
Must be different from ASES DB
Y
Y
Y
O
 V - Version Change
Must be the same as in ASES DB
Must be the same as in ASES DB
Must be different from ASES DB
Y
Y
O
I - Change Primary Medical Group
Must be the same as in ASES DB
Must be the same as in ASES DB
Must be the same as in ASES DB
Must be different from ASES DB
Y
O
1 - Change PCP1
Must be the same as in ASES DB
Must be the same as in ASES DB
Must be the same as in ASES DB
Must be the same as in ASES DB
Y
N
2 - Change PCP2
Must be the same as in ASES DB
Must be the same as in ASES DB
Must be the same as in ASES DB
Must be the same as in ASES DB
N
Y
3 - Change PCP1 & PCP2
Must be the same as in ASES DB
Must be the same as in ASES DB
Must be the same as in ASES DB
Must be the same as in ASES DB
Y
Y

 
Legend:
Y = Information required for the transaction type specified.
O = Optional information.
N = Information that should not be sent for the transaction type specified.
 
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(A) New enrollment ("E"): The system will require all fields related to
information about the Carrier, Plan Type, Plan Version, Primary Medical Group
and PCP1 to be completed. The PCP2 information will remain as optional
information for some cases.

(B) Change of Carrier ("C"): The system will require registering the name of the
new carrier and inserting information regarding the Plan Type, Plan Version,
Primary Medical Group, PCP1 and PCP2 (optional).

(C) Change of Plan Type ("P"): It will be necessary to insert the same code of
the carrier that submits the change with the new information of the Type of Plan
that corresponds to the beneficiary. Also, the information of Plan Version,
Primary Medical Group and PCP (optional) must be included.

(D) Plan Version Change ("V"): The carrier code and Plan Type information
provided must match the information in the ASES databases. Only information
regarding the new assigned Plan Version will be provided. Information should
also be provided in relation to the Primary Medical Group and PCP1 Center.

(E) Primary Medical Group Change ("I"): Information regarding the Carrier, Plan
Type and Plan Version must match the information contained in the ASES
databases. Only new information will be sent to ASES regarding the new Primary
Medical Group (PMG) that corresponds to the beneficiary.

(F) Change of PCP1 ("1"): It will be necessary that the information of Carrier,
Plan Type, Plan Version and Primary Medical Group provided coincide with the
information contained in the ASES databases. It will be necessary to submit the
new information regarding the change in PCP1 and it will not be necessary to
provide information on the PCP2.

(G) Change of PCP2 ("2"): It will not be necessary to provide information about
the PCP1. The only information allowed to differ with the one contained in the
ASES records will be the one related to the PCP2.

(H) Change of PCP1 and PCP2 ("3"): It will be necessary to submit new
information regarding the assigned PCP1 and PCP2. The information provided
regarding the other fields should remain unchanged.
 
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3. PROCESS_DATE – Process Date. Refers to the date on which the beneficiary
contracted the coverage services with the corresponding carrier. It also refers
to the date on which the carrier processed a change in PMG, Plan Version, Plan
Type or PCP.

4. REGION – Contains the region code assigned by ASES. This code must correspond
to the region assigned to the beneficiary in the ASES database. ASES is
responsible for assigning this code to Platino carriers. The Platino Plan
carriers obtain this code directly from ASES after a request process initiated
for these purposes. See Table 4 below for more information about the Region
Codes.

Table 4: Region Codes

Region Name
 
Region Codes
Used in the Data
Region Codes
Used for the Filenames
North
A
AR
Metro-North
B
BA
East
E
ES
Northeast
F
FA
San Juan
J
SJ
Southeast
G
GU
Southwest
S
SO
Special
P
PX
West
Z
MA

5. CARRIER – Two digit carrier code assigned by ASES to each of the carriers
with the purpose of identification.

6. MEMBER_PRIMARY_CENTER – Up to four digits code assigned by carrier to
identify their Primary Medical Groups (PMGs). Not required for some Plan
Types/Versions.

7. ODSI_FAMILY_ID – Eleven digit family identification code assigned by the
Medicaid Office. This is the first part of the identifier for the beneficiaries
in the ASES database. Platino carriers obtain this code from the ASES query
response.

8. MEMBER_SSN - Social Security number of the member. It is required that this
number matches with the one for the member in the ASES database.

9. MEMBER_SUFFIX – Two digit number which identifies a member within a family.
This is the second part of the identifier for the beneficiaries in the ASES
database.
 
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10. EFFECTIVE_DATE – Date in which the carriers start providing coverage for the
beneficiary under the enrolled Plan or the change for which the enrollment
record was submitted becomes effective. For the Federal GHIP population, this
date will be on the first of the month that the beneficiary applied for services
coverage. For the GHIP population funded solely through state funds, this date
will concur with the Certification Date. This date also refers to the date in
which the PMG, PCP or Plan Version change becomes effective. For Tran_Id’s other
than “E” in GHIP enrollment the Effective Date must be 1st of the month
following the enrollment.

11. PLAN_TYPE – Plan Type code that identifies the one under which the member is
enrolled.

12. PLAN_VERSION – Plan version code that identifies the one under which the
member is enrolled.

13. MPI- Master Patient Index. It is a unique number that identifies a member in
the ASES and Medicaid Office’s databases.

14. PCP1 – Fifteen digit number assigned by carriers. It is used to identify the
PCP1 selected by the beneficiaries.

15. PCP1_EFFECTIVE_DATE – Date in which the PCP1 assignment became effective. If
there is a change of PCP1, the initial PCP1 Effective Date will be kept until
the Effective Date of the PCP1 Change has been reached.

16. PCP2 – Fifteen digit number assigned by carriers. It is used to identify the
PCP2 selected by the beneficiaries.

17. PCP2_EFFECTIVE_DATE – Date in which the PCP2 assignment was effective. If
there is a change of PCP2, the initial PCP2 Effective Date will be kept until
the Effective Date of the PCP2 Change has been reached.

18. FAMILY_PRIMARY_CENTER – PMG assigned by the carrier to the beneficiary.

19. FAM_PRIMARY_CENTER_EFF_DATE – Date in which the assignment of the
beneficiary’s PMG became effective.

20. IPA_PCP_CHANGE_REASON – Not in use currently.

21. INDICADOR MEDICARE – Required for Platino enrollments only. (01=A&B, 03=A,
09=B).

22. NÚMERO HIC – Medicare Health Insurance Claim Number. It is required for
Platino beneficiaries’ enrollment.
 
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23. IPA_ESPECIAL – A code “1” indicates that the member is assigned to a special
IPA which is not the family IPA. Used for GHIP enrollment.

24. CONTRACT NUMBER – Contract number assigned by the carrier. It should be the
number by which the member is identified in the carriers’ ID card and internally
in their database.

25.  SPECIAL ENROLL – It is used to identify (1) the enrollment for newborns
that are beneficiaries of the Federal CHIP Program; (2) to process the cases of
utilization before the Certification Date (emergencies) for the federal
population and (3) to identify the cases of retroactive periods under MAGI. The
inclusion of an “N” in this field will allow the enrollment of the newborn from
his/her birthdate. The inclusion of an “E” will allow the enrollment of
emergency cases from the Eligibility Effective Date notified by the Medicaid
Office and the insertion of a “T” will allow the enrollment on a retroactive
period under MAGI.

26. Other data elements complimented by ASES – When a beneficiary’s record is
validated, the ASES system enters the following data in the enrollment record:

a.
Reject Identifier - As a result of the validations, the record could be accepted
or rejected. This field contains the codes that specify the result of said
validation.

"A" = Accepted;
"M" = Accepted Retroactively;
“T” = Retroactive Eligibility Period Enrollment
"R" = Rejected;

Identifier = “A”
Identifies an accepted enrollment that will be applied on a current or future
effective date. In this case, the update process moves the enrollment fields of
the carrier, Plan Type, Plan Version, PMG and PCP to the fields intended for new
enrollments in the beneficiary record. Until such time as the new Effective Date
is reached, the beneficiary will remain under the current enrollment condition
(same carrier, Plan, Version, PMG and PCP). During the end-of-month cycle, the
new fields are moved to the current fields and the enrollment becomes effective.

Identifier = “M”
Indicates a retroactive enrollment. In these cases, Enrollment data (Carrier,
Plan Type, Plan Version, PMG and PCP) are updated directly in the beneficiary's
historical record.

Identifier = “T”
Under MAGI, it identifies a successfully processed retroactive enrollment.

Identifier "R"
In cases when an enrollment record is not successfully processed because an
error has been identified, it indicates a record returned for correction.
 
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b. Record Key – Internal number assigned by the ASES system.

c. Error Codes one (1) to ten (10) – It is possible to record up to ten error
codes.

d. Update Date – Date for which the validation is run. Corresponds to the date
of the daily cycle the validation run was a part of.

e. Update User – ASES internal user code.

15. REJECTION OF AN ENROLLMENT RECORD

An enrollment record related to any type of enrollment, modification or update
transaction could be rejected if it does not pass the validation tests at the
ASES systems. As mentioned above, rejected enrollments are sent daily to
carriers in a file (.rjc) that includes error codes for records that have not
successfully passed the validation process. Carriers must correct identified
errors and resubmit the corrected records to ASES with the next file submission,
meaning the next business day. For the adequate correction of these errors
please refer to the Error Codes Table provided in Section 22.

16. REJECTED ENROLLMENTS MANAGEMENT

The daily process of carriers in relation to rejected enrollments should
include:

 
(1)
Receipt of rejected enrollment records;

 
(2)
Evaluation of rejection codes received;

 
(3)
Identification of situations in which rejection is not clear for consultation
with ASES;

 
(4)
Timely correction of identified errors;

 
(5)
Transfer of the corrected records to ASES in a 24 hour period.

 17. ERROR CODES

This section addresses the error codes produced by the ASES validation process.
In addition to the error codes known so far and as a result of the new changes
involved in the implementation of MAGI, two (2) new error codes have been
introduced and could appear as the result of the processes of validation and
verification of the enrollment records.
 
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18. NEW ERROR CODES UNDER MAGI

Code 023: If code "T", corresponding to a retroactive transaction, has been
entered in the "Special Enroll" field, the field “Tran_ID” should be filled with
code “E” or “C”, accordingly.

Code 109: In the 'Special Enroll' field it is necessary to insert a 'T' code
when dealing with transactions for retroactive eligibility periods (1, 2 or 3).
The notification of this error suggests that the "T" code was not found in the
field 'Special Enroll' for an enrollment corresponding to retroactive
eligibility periods on eligibility history files.

19. ERROR CODES TABLE

The following table contains the error codes produced by the validation program.
Additional descriptions and possible corrective actions have been included to
assist in the correction process.

Table 5: ErrorCodes
 
Error Code
Error Message
Additional Description
Possible Corrective Actions
011
(Record Type)
Invalid Record Type Code.
This field is required to be filled with code “E” in every case.
Fill with code “E”.
021
(Tran_ID)
Tran_ID field is blank.
This field is required to be filled with information about the type of
transaction being processed.
Fill this field with the corresponding code.
022
(Tran_ID)
Invalid “Tran ID”.
An invalid transaction code has been identified.
Fill this field with a valid transaction code.
023
MAGI
If the field “Special Enroll” has been filled with code “T”, then the field
“Tran_ID” should contain code “E” for new enrollments or code “C” if the
transaction is about a carrier change.
For retroactive transactions (“T”), the field Tran_ID should be filled with code
“E” or “C”, accordingly.
 
Verify and correct the information contained in the field.
 
 
031
(Process_ Date)
Process date field is blank.
   
032
(Process_Date)
Invalid process date.
   
033
(Process_Date)
Except for the cases about newborns, for GHIP transactions, the process date
should be lesser or equal to the effective date of the new enrollment or the
change that is notified and greater or equal to three months before the
effective date.
For GHIP (Plan Type = 01) the process date should be lesser or equal to the
effective date of the new enrollment or the change notified. The process date
should fall within three (3) months before the effective date.
Compare the process date with the effective date of the new subscription or the
change about the record notified.

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034
(Process_Date)
For GHIP transactions with Tran_Id = “E” and process date greater or equal to
‘11/16/2006’, the effective date cannot be equal to ‘11/01/2006’.
Special code for the coverage code conversion of November 2006.
Verify the effective date.
035
(Process_Date)
For Platino transactions, the process date should be within three (3) months
before the effective date.
For Platino (Plan Type = 02 or 03) the process date should be before the
effective date. The process date of the new enrollment or change in the
enrollment record should fall within three months before the effective date.
Compare the process date to the effective date and correct.
 
 
041
(Region)
Region code field is blank.
 
Fill the field with the corresponding region code.
042
(Region)
Invalid region code.
 
Verify and fill the field with the corresponding region code.
051
(Carrier)
Carrier code field is blank.
 
Verify and fill the field with the corresponding carrier code.
052
(Carrier)
Invalid carrier code provided.
 
Verify and fill the field with the corresponding carrier code.
053
(Carrier)
The carrier has notified that a change of carrier has been performed but the
carrier notifying the change is the same as the one registered in ASES’s
database.
The enrollment has code “C” (carrier change) in the “Tran_ID” field and the
carrier is the same as the one identified in the beneficiary’s record in ASES.
Verify if the record should have been sent with another “Tran_ID” (V or I, for
example). If that’s not the case, the beneficiary is already enrolled in the
database with the submitting carrier and no further action is required.
054
(Carrier)
If the “Plan Type” = 01, the “Tran_ID” is “C” or “D” and the enrollment
effective date (“Effective Date”) is in the future, this date should on or
before the first of the month three months in the future from the current date.
The future disenrollment or carrier change transactions should have effective
dates on or before the first of the month three months in the future from the
current date.
The effective date of the future disenrollment or carrier change transactions
should fall on or before the first of the month three months in the future from
the current date.
061
(IPA o PHO code)
It has been identified that the “Tran_ID” is “E”, “C”, “P”, “V” or “I”. These
changes require that the Primary Medical Group (PMG) field contains PMG
information.
Specifying the Primary Medical Group is required when the enrollment for a GHIP
carrier, or a Platino carrier for which the PMG is required,  has a “Tran_ID”
“E”, “C”, “P”, “V” or “I”.
Provide the corresponding PMG code.

 
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062
(IPA o PHO Code)
The “Tran_ID” is “1”, “2” or “3” and the specified PMG is different from the PMG
enrolled in the ASES databases.
 
The enrollment is about a PCP change but the transaction contains a PMG
different from the one that is currently enrolled in the ASES records.
The PCP changes are accepted in the ASES databases if the record concurs with
the carrier code, Plan Type, Version and PMG that is registered in the current
data. Verify if the intention is to change both the PMG and the PCP and submit a
PMG change (Tran_ID=I) with new PMG and PCP codes. If that is not the case, then
correct the PMG field.
063
(IPA o PHO Code)
The “Tran_ID” is “I” and the Primary Medical Group (PMG) specified is equal to
the Primary Medical Group stated in the current data from the ASES databases.
 
The carrier has sent a PMG change related to a beneficiary but the PMG stated in
the current data from ASES databases concurs with the one sent.
Verify if the record should have been sent with another “Tran_ID”. If that is
not the case, the beneficiary is already enrolled in the databases with the
corresponding PMG and no further action is required
064
(IPA o PHO Code)
If the transaction is about a disenrollment (Tran_ID=”D”), the field “Member
Primary Center” should be blank.
 
Verify if the transaction is about a disenrollment. If that is the case, remove
the PMG information.
071
(ODSI_Family_ID)
 “Family ID” information is required and the corresponding field is blank.
 
 
Include the eleven (11) characters code corresponding to the “Family ID”
assigned by ASES.
072
(ODSI_Family_ID)
The “Family ID” code provided does not contain eleven (11) characters.
 
Include the eleven (11) characters code corresponding to the “Family ID”
assigned by ASES.
073
(ODSI_Family_ID)
The “Family ID” was not found at the region specified.
The “Family_ID” was not found under the corresponding region in the ASES
eligibility records.
Verify if the “Family ID” sent is the correct one. Verify if the region code
corresponds with the beneficiary.
081
(Member_SSN)
The beneficiary’s social security number is required and the field is blank.
 
 
Include the beneficiary’s social security number.

082
(Member_SSN)
The beneficiary’s social security number does not contain nine (9) characters.
 
 
Verify this information and provide the beneficiary’s social security number.

 
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091
(Member_Suffix)
The information related to the suffix that identifies the beneficiary is
required and the corresponding field is blank.
 
Provide the suffix that identifies the beneficiary.
092
(Member_Suffix)
The suffix that identifies the beneficiary that was provided by the carrier does
not contain two (2) characters.
 
Provide the two (2) characters suffix that identifies the beneficiary.
093
(Member_Suffix)
The suffix that identifies the beneficiary was not found in the ASES eligibility
records databases under the region and family identifier specified.
A record for the beneficiary’s suffix was not found, under the region and family
identifier specified, in the ASES database.
 
Verify that the suffix assigned in the carrier’s database concurs with the one
registered in the ASES database. If the “Family_ID” contains an error this error
code will appear.
101
(Effective_Date)
The effective date information is required and the field is blank.
 
Provide the effective date.
102
(Effective_Date)
Invalid Effective Date.
 
Provide a valid effective date.
 
103
(Effective_Date)
For new enrollments under a GHIP plan, the effective date should be before the
daily run date (“Run Process Date”) at ASES.
 
For a new enrollment under the GHIP plan (Plan Type=01) and Tran_ID=E the
effective date should be before the daily run date at ASES. It is presumed that
a beneficiary has been enrolled with the carrier before the enrollment record
has been sent to ASES. The new enrollments should not be sent with future
effective dates.
Verify the dates and proceed to correct.
104
(Effective_Date)
For transactions related to the GHIP plan (Plan Type=01) which  “Tran_ID” is not
“1”, “2”, “3”, “E”, “O” o “D”, the effective date should be after the enrollment
process date and it should be on the first of the following month.
 
Only applies to GHIP plans and only when the transaction is not about a PCP
change, a new enrollment or a disenroll (“D”).
For transactions related to the GHIP plan (Plan Type=01) which  “Tran_ID” is not
“1”, “2”, “3”, “E”, “O” o “D”, the effective date should be after the process
date and it should be on the first of the following month after the process date
at ASES.
Verify the dates and proceed to correct.
105
(Effective_Date)
The Platino plans enrollment effective date that does not have Tran_ID “1”, “2”,
“3" or "D", should be on the first of the month of the beneficiary’s enrollment.
 
Verify that the Platino enrollment effective date is on the first of the month
of the beneficiary’s enrollment.
106
(Effective_Date)
For a disenrollment transaction (TRAN_ID=”D”), the transaction effective date
should be on the first of the following month.
   
107
(Effective_Date)
The enrollment effective date of the transaction sent should fall within the
family group’s last eligibility period.
The eligibility of the family, to which the beneficiary corresponds, was
cancelled after the effective date of the enrollment sent.
These cases will be submitted as candidates for enrollment in the historical
data under the enrollment system (SYSPREM).

 
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109
MAGI
 
(Effective_Date)
A code ‘T’ was not included in the ‘Special Enroll’ field and a SYSRETRO record,
specifying an eligibility period that covers the enrollment effective date sent
by the carrier, has been identified.
A code ‘T’ was not included in the ‘Special Enroll’ field for an enrollment that
corresponds to a SYSRETRO period.
Verify if the transaction is about a retroactive enrollment under MAGI. If that
is the case, include code “T” in the “Special Enroll” field.
10A
(Effective_Date)
Emergencias
If the field “Special_Enroll” =”E”, then, for GHIP beneficiaries funded through
state funds, the effective date should be greater or equal than the
Certification Date. For federally funded GHIP beneficiaries (Medicaid and CHIP),
the Effective Date should be greater or equal than the Eligibility Effective
Date.
For emergency cases the effective date cannot be before the certification date
(State funded GHIP) or the eligibility effective date (Federally GHIP, Medicaid
and CHIP).
Verify the effective dates and certification date and proceed to correct.
 
 
10B
(Effective_Date)
If the field “Special_Enroll” =”N”, the effective date should be greater or
equal than the beneficiary’s birth date and it should not surpass the period of
a year calculated from the birth date.
The newborn enrollments’ effective date cannot be before the birth date nor can
it extend for more than one (1) year calculated from the birth date.
Verify that the effective date concurs with the birth date and that it does not
surpass the period of one (1) year calculated from the birth date.
111
(Plan_Type)
The Plan Type code is required and the field is blank.
 
Include the required information related to the Plan Type.
112
(Plan _Type)
The provided Plan Type code does not contain two (2) characters.
 
Verify and provide the corresponding Plan Type code.
113
(Plan_Type)
The provided Plan Type, Carrier Code and Plan Version are incorrect.
The enrollment records are required to correspond with the Plan Type and Plan
Version contracted with ASES by the carrier.
 
The Plan Version code, for Platino plans, should concur with the Plan Version
code assigned by ASES; for GHIP plans, this code should equate to the coverage
code assigned by the Medicaid Office.
Verify this information and correct.
 
 
 
 
 
114
(Plan_Type)
For disenrollment transactions (Tran_ID =”D”), code “01” (GHIP) should be
included in the “Plan Type” field.
 
Verify the transaction type and include code 01 (GHIP) in the Plan Type field.
121
(Plan_Version)
The Plan Version code is required and the field is blank.
 
Include the information corresponding with the Plan Version.
122
(Plan_Version)
The Plan Version code does not contain three (3) characters.
 
Verify the information and provide the three (3) characters code corresponding
to the Plan Version.

 
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123
(Plan_Version)
The provided Plan Version code is invalid for the specified Effective Date.
The Plan Version code should be one that is active at the Effective Date
indicated.
Verify the Plan Version code and/or Effective Date.
 
124
(Plan_Version)
Invalid Plan Version code. If the transaction is about a disenrollment
(Tran_ID=”D”), the plan version code should be 001.
If the transaction is about a disenrollment (Tran_ID =D), then the Plan Version
field should contain the code “001”.
Verify the transaction type and include the corresponding code.
131
(MPI)
The provided “MPI Number” does not contain thirteen (13) characters.
 
Verify the included code. Provide the thirteen (13) characters code of the
corresponding MPI Number.
132
(MPI)
The “MPI Number” does not concur with the ASES records for the region specified.
 
 
 
Verify that the correct MPI Number has been provided. Verify if the region code
sent corresponds with the region to which the beneficiary corresponds.
141
(PCP1)
The PCP1 field is blank and the transaction is not type “2” or “D” (which
require this field to be blank).
The PCP1 field should not be blank if the PCP1 is required and the transaction
is not type “2” or “D”.
Verify the transaction type and include the corresponding PCP1 code.
142
(PCP1)
The PCP1 should be blank when the Tran ID is “2” or “D”.
If the transaction is about a PCP2 change or a disenrollment, the PCP1 field
should be blank.
Verify the transaction type. If the transaction is about a PCP2 change, remove
the information included in the PCP1 field.
151
(PCP1_Effective Date)
 
The PCP1 field is blank and the Tran_ID is neither “2” nor “D”.
 
 
The PCP1 field is blank or the provided date is invalid in a transaction for
which the PCP1 information was required.
Verify and correct.
152
(PCP1_Effective Date)
An invalid effective date was provided for the PCP1 Effective Date and this
information was required.
The PCP1 effective date field is blank or the provided date is invalid.
Verify the error and correct.
153
(PCP1_Effective Date)
 
There is information in the PCP1 effective date field and the transaction is not
about a PCP2 change or a disenrollment and the PCP1 is not required.
The PCP1 effective date should be blank when the enrollment does not imply a
PCP2 change and the PCP1 is not required.
Verify and correct.
154
(PCP1_Effective Date)
The field corresponding with the PCP1 effective date should be blank when the
transaction is about a PCP2 change or a disenrollment.
The PCP1 effective date should be blank when the transaction is about a PCP2
change or a disenrollment.
Verify and correct.

 
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155
(PCP1_Effective Date)
For transactions of new enrollment, the PCP1 effective date should be before the
daily run process date at ASES.
For the GHIP plan (“Plan Type=01”) the date for a new enrollment should be
before the daily run process date at ASES. It is presumed that the beneficiary
was enrolled before the enrollment record was sent to ASES. New enrollment
records are not performed with future dates.
Verify and correct.
156
(PCP1_Effective Date)
Barring new enrollment transactions, the PCP1 effective date should concur with
the first day of the following month.
For transactions about a PCP1 change, the PCP1 effective date should be on the
first day of the month following the notification of the change.
Verify the effective date provided for the PCP1 change.
157
(PCP1_Effective Date)
If the PCP1 field is not blank, the field corresponding with the PCP1 effective
date should not be blank.
When there is data in the PCP1 field, there should be a valid date in the PCP1
effective date field and vice versa.
If the transaction is about the PCP1, verify and include the information in the
appropriated field.
158
(PCP1_Effective Date)
 
For enrollments having Tran_ID 'E','C' or 'I', in which the PCP1 field is not
blank, the PCP1 effective date should be equal to the effective date of the
enrollment to be applied. For enrollments having Tran_ID 'P','V','1','3', in
which the PCP1 field is not blank, the PCP1 effective date  should be greater or
equal than the existing enrollment effective date.
For enrollments having Tran_ID 'E','C' or 'I', in which the PCP1 field is not
blank, the PCP1 effective date should be equal to the effective date of the
enrollment to be applied. For enrollments having Tran_ID 'P','V','1','3', in
which the PCP1 field is not blank, the PCP1 effective date  should be greater or
equal than the existing enrollment effective date.
Verify the provided PCP1 effective date.
161
(PCP2)
The PCP2 field is blank and the transaction is about a PCP2 change or a PCP1 and
PCP2 change (Tran_ID= “2” or “3”).
The transactions about a PCP2 change or a PCP1 and PCP2 change require
information in the PCP2 field.
Verify and include the information missing in the PCP2 field.
162
(PCP2_Effective Date)
 
The PCP2 field should be blank when the transaction is not about a PCP2 change
or a PCP1 and PCP2 change (Tran_ID= “2” or “3”).
If the transaction is about a PCP1 change or a disenrollment (Tran_ID=“1” or
“D”) the PCP2 field should be blank.
 
Verify if the transaction is about a PCP1 change or a disenrollment. If that is
the case, remove the information from the PCP2 field.
171
(PCP2_Effective Date)
The PCP2 effective date field is blank and the transaction is about a PCP2
change or a PCP1 and PCP2 change (Tran_ID “2” or “3”).
The transactions about a PCP2 change or a PCP1 and PCP2 change (Tran_ID “2” or
“3”) require a valid effective date in the PCP2 effective date field.
Verify and correct.
172
(PCP2_Effective Date)
Invalid PCP2 effective date.
An invalid date has been found in the PCP2 effective date field.
Verify the PCP2 effective date and correct.
173
(PCP2_Effective Date)
For transactions of new enrollment in which the PCP1 field is not blank, the
PCP2 effective date should be before the daily run process date at ASES.
 
 
For new enrollments (Tran_ID=E) under a GHIP plan (“Plan Type=01) the PCP2
effective date should be before the daily run process date at ASES. It is
presumed that the beneficiary was enrolled before the enrollment record was sent
to ASES. The system will not be able to process new enrollments with future
dates in this field.
Verify these dates and proceed to correct.
 

 
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174
(PCP2_Effective Date)
 
Barring new enrollment transactions, the PCP2 effective date should concur with
the first day of the month following the notification of the change.
 
For transactions about a PCP2 change, the PCP2 effective date should be on the
first day of the month following the notification of the change.
Verify that the PCP2 effective date is on the first day of the month following
the notification of the change.
175
(PCP2_Effective Date)
If the PCP2 field is not blank, the field corresponding with the PCP1 effective
date should not be blank and vice versa.
When there is data in the PCP2 field, there should be a valid date in the PCP2
effective date field and vice versa.
Verify the related fields and proceed to include the missing information.
176
(PCP2_Effective Date)
If the transaction is about a disenrollment (Tran_ID=”D”), then the PCP2
effective date field should be blank.
 
Verify the transaction type and remove any PCP2 information that is not
required.
177
(PCP2_Effective Date)
It has been identified that the beneficiary is already enrolled with another
carrier for a date equal or after the Effective Date of the enrollment sent.
This error applies to cases of new enrollment and carrier change.
The beneficiary is already enrolled at ASES with another carrier for a date
equal or after the effective date of the enrollment sent.
 
Verify that the effective date sent to ASES corresponds with the appropriated
date.
178
(PCP2_Effective Date)
 
For enrollments having Tran_ID 'E','C' or 'I', in which the PCP2 field is not
blank, the PCP2 effective date should be equal to the effective date of the
enrollment to be applied. For enrollments having Tran_ID 'P','V','2','3', in
which the PCP2 field is not blank, the PCP2 effective date  should be greater or
equal than the existing enrollment effective date.
For enrollments having Tran_ID 'E','C' or 'I', in which the PCP2 field is not
blank, the PCP2 effective date should be equal to the effective date of the
enrollment to be applied. For enrollments having Tran_ID 'P','V','2','3', in
which the PCP2 field is not blank, the PCP2 effective date  should be greater or
equal than the existing enrollment effective date.
Verify the provided PCP2 effective date.
181
(Family_Primary_
Center)
For GHIP plans, it is required to provide information about the Family Primary
Medical Group.
 
For GHIP plans, the information about the Family Primary Medical Group is
required.
 
Include the corresponding Primary Medical Group code for the corresponding
Family.
182
(Family_Primary_
Center)
The transaction did not require information about the Family Primary Medical
Group and information was provided for said field.
 
Verify the transaction type and remove the information not required from the
corresponding field.
183
(Family_Primary_
Center)
If the transaction is about a disenrollment (Tran_ID=”D”), the Primary Medical
Group field should be blank.
The transaction is about a disenrollment “D” and there is information in the
Primary Medical Group field.
Verify the transaction type and remove the information not required from the PMG
field.

 
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191
(Family_Primary_
Center Effective _Date)
The effective date for the Family Primary Medical Group is clank and the
information in this field is required.
 
Include a valid effective date in the Family Primary Medical Group field.
192
(Family_Primary_
Center Effective _Date)
The Family Primary Medical Group effective date included is not valid.
 
An invalid date was found in the Family Primary Medical Group effective date
field.
Verify the PMG effective date and provide the corresponding date.
193
(Family_Primary_
Center Effective _Date)
The information for the Family Primary Medical Group is not required and there
should be no information in this field.
The information for the Family Primary Medical Group is not required and there
is information in this field.
If this information should not be sent, remove the information provided in this
field.
194
(Family_Primary_
Center Effective _Date)
If the transaction is about a disenrollment (Tran_ID=”D”) this field should be
blank.
 
If the transaction is about a disenrollment, remove the information provided in
this field.
200
200
(IPA PCP Change Reason)
If the transaction is about a disenrollment (Tran_ID=”D”), then the PMG or PCP
Change Reason field should be blank.
If the transaction is about a disenrollment, then the PMG or PCP Change Reason
field should be blank.
If the transaction is about a disenrollment, remove the information provided in
the PMG or PCP Change Reason field should be blank.
211
Medicaid_IND
The Plan Version and Type are incorrect. The beneficiary does not receive
medical services under Federal Medicaid.
 
The Plan Version and Type codes provided by the carrier require that the
beneficiary is eligible to receive services under Federal Medicaid and the ASES
database states that the beneficiary is not eligible for that coverage.
Verify and submit the corresponding information.
221
(Relationship Edit)
Duplicate enrollment.
 
Two or more enrollment records with the same Family_ID and suffix were
identified in the same daily run process cycle at ASES.
Verify this information.
222
The transaction is about a new enrollment and the beneficiary is already
enrolled under the same carrier trying to enroll it through this transaction.
The transaction is about a new enrollment and it has been identified that the
beneficiary is already enrolled under the same carrier as the one sending the
enrollment.
Verify if the record should have been sent with another “Tran_ID” like, for
example, “V” or “I”. If that is not the case, the beneficiary is already
enrolled and no further action is required.
223
The transaction is about a new enrollment and the beneficiary is already
enrolled with another carrier.
The transaction is about a new enrollment (Tran_ID = “E”) and beneficiary
records of enrollment under another carrier have been found at the ASES
database.
Verify if the enrollment record should have been sent with a carrier change code
included in the “Tran_ID”.
224
The beneficiary was not eligible for the effective date indicated by the
carrier.
 
Verify the effective date.
225
(Member_SSN)
The social security number provided was not found in the ASES databases current
data.
 
Verify and correct the social security number.
 
226
(MPI)
The MPI Number sent was not found in the ASES databases current data.
 
Verify and correct the MPI Number.

 
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227
(Plan Type change)
The transaction is about a Plan Type change and the carrier sending it is
different from the carrier currently enrolled in the ASES databases.
Only the carrier registered in the ASES database at the moment a Plan Type
change is submitted may submit a Plan Type change in the enrollment record.
Verify if the record should have been sent with another Tran_ID.
228
(Plan Version change)
The transaction is about a plan version change (Trans_ID= “V”) and the carrier
or plan type submitted do not concur with the data found in the ASES database.
 
 
 
The plan type changes are accepted by the system if they are sent by the same
carrier and under the same plan type registered in the current data at ASES.
 
Only the carrier registered in the ASES database at the moment a Plan Version
change is submitted may submit a Plan Version change in the enrollment record.
Verify if the record should have been sent with another Tran_ID.
 
 
 
229
(IPA change)
The transaction is about a PMG change (Trans_ID= “I”) and the carrier, plan type
or plan version submitted do not concur with the data found in the ASES
database.
 
 
 
The PMG changes are permitted if they are sent by the carrier, plan type and
plan version registered in the current data at ASES.
 
Only the carrier registered in the ASES database at the moment a PMG change is
submitted may submit a PMG change in the enrollment record.
Verify if the record should have been sent with another Tran_ID.
 
22A
(PCP1, PCP2 o PCP1 y PCP2 Change)
The transaction is about a PCP1, PCP2 or PCP1 and PCP2 change (“Tran_ID” =“1”,
“2” o “3”) and the carrier, Plan Type, Plan Version and PMG do not concur with
the current data in the ASES databases.
 
The PCP changes are permitted under the same carrier, Plan Type, Plan Version
and PMG as stated by the beneficiary’s current data at ASES. This error suggests
that the beneficiary is currently enrolled under another carrier, Plan Type,
Plan Version or PMG in the ASES database.
Verify if the record should have been sent with another Tran_ID.
22B
(PCP1 Effective Date; PCP2_Effective_Date)
If the transaction is about a PCP1 and PCP2 change (Tran ID=3), both the PCP1
and PCP2 effective dates should be future or retroactive dates.
Both the PCP1 and PCP2 effective dates should be future or retroactive dates.
Verify the dates for PCP1 and PCP2 and correct.
22D
Invalid date values for enrollments of future effect. This error applies to all
the transactions that are not of type “D”.
The PCP, PMG, Plan Version and carrier changes cannot be sent with dates more
than four (4) months into the future. This error applies to all the transactions
that are not of type “D”.
 
22E
If the plan type is GHIP (“Plan Type” =01), then the plan version should be
equal to the “Coverage Code”.
For the GHIP enrollment record (“Plan Type” 01) the plan version code should
concur with the coverage code registered in ASES database for the beneficiary
being enrolled.
Verify and correct.

 
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22F
All GHIP beneficiaries from a same family group will be rejected if a record
corresponding to any of them is marked with an error code.
 
 
When a GHIP beneficiary’s enrollment record contains an error, every record from
beneficiaries belonging to the same family group receives a 22F error code. This
has the effect of maintaining all the beneficiary records under a same family
record and avoids the partial processing of the family in a same daily run
process cycle at ASES.
Verify and correct every additional error identified other than the 22F codes
for every GHIP beneficiary in the family.
250
(HIC Number)
If the transaction is about a disenrollment (Tran_ID=”D”) the HIC Number field
should be blank.
There should be no information in the “HIC Number” field if the transaction is
about a disenrollment (“D”).
If the transaction is about a disenrollment (“D”), remove the information
provided in the HIC Number field.
260
(IPA_Special)
If the transaction is about a disenrollment (Tran_ID=”D”) the IPA_SPECIAL field
should be blank.
There should be no information in the IPA_SPECIAL field if the transaction is
about a disenrollment (“D”).
If the transaction is about a disenrollment (“D”), remove the information
provided in the IPA_SPECIAL field.
270
(Medicare Indicator)
If the transaction is about a disenrollment (“Tran_ID” = “D”) the “Medicare
Indicator” field should be blank.
 
There should be no information in the Medicare Indicator field if the
transaction is about a disenrollment (“D”).
If the transaction is about a disenrollment “D”, remove the information provided
in the Medicare Indicator field.
280
The family should be eligible at the moment the record is being processed.
Family not eligible at the moment the record is being processed.
 
281
The beneficiary should be eligible at the moment the record is being processed.
Beneficiary not eligible at the moment the record is being processed.
 
998
Record number is blank.
Transaction without Record Number. Does not constitute an error. No further
action required.
No action required.
999
The record number sent does not concur with a previous record number from a
previous transfer.
The record number sent does not concur with a record number from a previous
transfer. Does not constitute an error. No further action required.
No action required.
 

 
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20. DISENROLLMENT (Cancellation)

20.1 Disenrollment under GHIP and Medicare Platino

The process of a disenrollment occurs only when the Medicaid Office determines
that a beneficiary is no longer eligible for GHIP or Medicare Platino or in
those cases where a disenrollment from the plan is requested by the Carrier or
the beneficiary and has been approved by ASES. 12

Medicaid will notify the disenrollment to ASES, and ASES will notify the carrier
of the disenrollment. Such notification shall be effected by means of a daily
transfer of files to the carrier together with files containing information on
new beneficiaries to be enrolled. This will be done within five (5) calendar
days after a final determination on the disenrollment. 13
Only the Medicaid Office may notify and cancel eligibility. However, both ASES
and the carriers may continue to process disaffiliations that do not have the
effect of cancelling the eligibility of a beneficiary to receive medical
services.

20.2 Effective Date of Disenrollment:

This is the date, as defined in Section 5.3.3 of the contract signed between
ASES and the carriers, in which the coverage of a beneficiary under a contracted
carrier ends. The effective date of the cancellation is the date ASES notifies
to carriers.

21. GHIP DISENROLLMENT (Cancellation)

21.1 Disenrollment Made by Medicaid Office

A GHIP disenrollment occurs when the Medicaid Office determines that (1) a
beneficiary has lost eligibility to receive medical services coverage under the
GHIP; (2) the eligibility period granted by the Medicaid Office has expired or
(3) a request for re-enrollment has been received from a beneficiary or a new
carrier as set forth in Sections 5.3.4 and 5.3.5 of the agreement signed between
ASES and the carriers.
In general, a disenrollment will be  notified to the carriers by ASES Any
disenrollment shall take effect as of its Effective Date specified in the notice
issued by ASES to the carrier in that respect.

In cases where ASES notifies the carrier of the disenrollment on or before the
last working day of the month in which the beneficiary's eligibility expires,
said disenrollment shall be effective on the first day of the following month.
 

--------------------------------------------------------------------------------

12 See sections 5.3.4 y 5.3.5 of the GHIP contract between ASES and the
carriers.
13 See section 5.3.2 of the contract between ASES and the carriers.
 
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When the disenrollment is made at the request of the carrier or the beneficiary,
as provided in Sections 5.3.4 and 5.3.5 of the contract signed between ASES and
carriers, the disenrollment shall take effect no later than the first day of the
second month following the month in which the request was made.
Table 6: Examples of GHIP Effective Dates of Disenrollment

GHIP Disenrollment Reason
GHIP Disenrollment Effective Date
Notified by ASES (not notified on the last business day of the month).
Date Specified in the ASES Disenrollment Notification.
Notified by ASES (on the last business day of the month).
First day of the following month.
Requested by Beneficiary or Carrier.
No later than the first day of the second month in which the Carrier or
Beneficiary has requested disenrollment.
Death of the Beneficiary
Federal and state funded Commonwealth beneficiaries are disenrolled from the
first day after death.
Move of the Beneficiary.
 
Since the contract covers all regions on the island any move within the island
has no impact. If the move causes a change of region, then the effective date is
the date notified by Medicaid.
Beneficiary moved outside of Puerto Rico.
Federal and state funded Commonwealth beneficiaries will be disenrolled as of
the first day of ineligibility as notified by the Medicaid Office.
Incarceration of the Beneficiary
Federal and state funded Commonwealth beneficiaries will be disenrolled as of
the first day of ineligibility as notified by the Medicaid Office.
After completing the pregnancy and post-natal care eligibility extension
If at re-certification a woman becomes ineligible for GHIP and is pregnant, the
eligibility is extended for 60 days after the baby is born or after a pregnancy
loss.

21.2 Effective Date of the Programmatic Disenrollment (Disaffiliation)

For programmatic purposes of the ASES Information Systems Office, this
Disenrollment Effective Date also refers to the day on which a beneficiary
ceases to be enrolled under a particular carrier in the ASES databases. This
disenrollment takes place in those cases in which the Medicaid Office has sent a
change of coverage code for a beneficiary and the carrier has not submitted an
enrollment with the new plan version related to the change of coverage.

Although in cases of programmatic disenrollment the eligibility period will
continue for the beneficiaries who are disenrolled, the premium payment cannot
be processed until a new beneficiary enrollment is sent by the carrier with the
information of the new plan version related to the change of coverage.
 
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22. MEDICARE PLATINO DISENROLLMENT

22.1 Disenrollment by Beneficiary Request

Platino Medicare beneficiaries may under certain circumstances require the
termination of the enrollment agreement that covers their services. The
Effective Date of these disenrollment will fall on the first day of the month
following the disenrollment request. However, in spite of the above, the
Effective Date of the Disenrollment shall in no case fall on a date after the
first day of the following month after the one in which the beneficiary has made
the disenrollment request.

22.2 Automatic Disenrollment

The carrier shall automatically process disenrollment in cases of death of a
beneficiary, loss of eligibility, for the causes outlined in Schedule F of the
Draft Agreement between ASES and Platino carriers, termination of the
eligibility period Granted by Medicaid, or in case of disenrollment of the
Medicare Platino product it offers. The Effective Date of the Disenrollment in
these cases will fall on the last day of the month in which any of the events
mentioned above takes place.

22.3 Retroactive Disenrollment
Retroactive disenrollment occurs exceptionally and only if a beneficiary has
been enrollment and is ineligible to receive medical services, in circumstances
in which he or she has been retroactively deprived of the Advantage product of
the carrier in question and in Cases of incarceration or death of the
beneficiary, etc. The Effective Date in these cases is discussed in Table 7
below.
 
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Table 7: Medicare Platino Effective Dates of Disenrollment'
 
Reason for Disenrollment
Effective Date of Disenrollment
Death of the Beneficiary
First day after death.
Incarceration of the Beneficiary
First day of ineligibility as notified by Medicaid.
Beneficiary enters or stated in a residential institution under circumstances
which rendered the individual ineligible for enrollment in Medicare Advantage,
including when an enrollee is admitted to the hospital that (1) is certified by
Medicare as a long term care hospital and (2) has an average stay for all
patients greater than ninety-five (95) days.
First day of ineligibility as notified by Medicaid.
Beneficiary enrollment while being eligible
Effective Date of Enrollment in the Platino Plan Carriers.
Move of the Beneficiary.
Since the contract covers all regions on the island any move within the island
has no impact.
Beneficiary moved outside of Puerto Rico.
First day of ineligibility as notified by Medicaid.
Expedite Disenrollment: - Urgent Medical Need
First day of the next month after determination except where medical need
requires an earlier disenrollment.
Expedite Disenrollment: - Non-consensual enrollment
Retroactive to the first day of the month
Expedite Disenrollment: - Disenrollment from the carrier Medicare Platino
Concurrent with the Effective Date of Disenrollment from the carrier Medicare
Advantage Product.

23. UPDATES TO NEW ENROLLMENTS AND ENROLLING OMITTED BENEFICIARIES

In cases in which the carrier must update the information previously sent to
ASES on a new enrollment, or that it must add a new beneficiary previously
omitted, that update must occur on the next Business Day after the information
has been updated or a new beneficiary has been added. ASES reserves the
discretion of not accepting new additions or corrections to the enrollment data
sixty (60) calendar days after the Enrollment Effective Date indicated in the
carrier's notification to ASES.
 
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24. CARRIERS RESPONSIBILITIES IN THE ENROLLMENT PROCESSES

In summary, as part of the enrollment process, it will be the responsibility of
the carriers to ensure compliance with the duties described in Table 8 below.

Table 8: Carriers Responsibilities about an Enrollment Transaction
 
Change or Modification
Action Required
1. Transfer of Daily Eligibility Files.
Daily Update of Eligibility Files in the carrier’s databases.
2. New Enrollments.
 
GHIP carriers should start the enrollment process with the beneficiary and
verify each of the enrollments made including the enrollment of newborns and
emergency cases. They must also enroll beneficiaries who have an Effective Date
prior to a cancellation period.
3. Carrier Change.
Identify the beneficiaries who have requested a change of carrier and take
action on behalf of these. The carrier that lost the beneficiary must identify
the loss of the beneficiary in the corresponding file.
4. Changes to the enrollment data. (Change of Plan Type, Plan Version, PMG
and/or PCP).
 
Identify beneficiaries who have changed coverage code, Plan Type, Plan Version,
PMG or PCP (1 or 2) and notify these changes. The carrier's system must be
updated in accordance with these modifications as failure to do so may lead to
the rejection of the enrollment record in future transactions.
5. Change in the demographic data of a beneficiary. This information is received
from the Medicaid Office but does not cause a change in the enrollment.
The carrier must update the beneficiary’s record with the new data in its
database.
6. Rejected Records
Correct the rejected records.
7. Cancellation of Beneficiary:
Only the Medicaid Office may cancel the eligibility of a beneficiary, having the
effect that until such notice of Medicaid is received the beneficiary will
remain active in the databases of both ASES and the carriers even when the
period of eligibility granted has expired.
Identify the cases of beneficiaries canceled or denied coverage and take action
on behalf of these.
 
The carriers must perform follow-up to the beneficiaries in case the
cancellation is caused by the expiration of the Certification Date.
8. Programmatic Disenrollment: Change in the coverage code.
 
 
Carriers should identify when a record received has a different coverage code
than is recorded in their databases.
 
In these cases, carriers must assess whether the new coverage code requires the
beneficiary to be enrolled in a different "Plan Version". If so, they must
re-enroll these beneficiaries under the new "Plan Version" to correspond with
the new coverage code. Subsequently, a change of "Plan Version" must be sent to
ASES before the end of the current month.
 
Beneficiaries who are not registered with a "Plan Version" that corresponds with
the coverage code will be disenrolled in the run of the end-of-month cycle in
the ASES databases.
 
The carrier should enroll the beneficiaries that have been disenrolled.
9. Beneficiary Disenrollment.
 
End of Month: When a record of a beneficiary is received with the field
corresponding to the carrier empty and it is identified that the beneficiary was
previously enrolled in the ASES databases it should be understood that a process
of disaffiliation of this beneficiary has been carried out in response to the
fact that no information has been received in response to a change of coverage
in ASES.
 
Carrier change: When a beneficiary's data is received with a different carrier
code from the one that appears in the carrier’s database, it means that the
beneficiary has been enrolled with a different carrier (this usually applies to
Platino plans). In this case, the previous carrier must disenroll the
beneficiary in its database.

 
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V.  
PREMIUM PAYMENT

 
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25. PREMIUM PAYMENT

The premium payment system operates under the concept that premiums are
calculated and paid only in relation to beneficiaries who are already enrolled
before the first day of the month to which the payment corresponds.
Beneficiaries enrolled after that date will be considered for the next payment
of the corresponding premium.

On a monthly basis, the system performs an automatic execution of payment in
which the payment that corresponds to each one of the carriers is calculated by
region according to the beneficiaries that are enrolled under each one of the
regions in the ASES databases.

Premium payments will be made on the first day of the month following the
acceptance of the enrollment by ASES. ASES is not obligated to pay premiums on
beneficiaries who are not duly enrolled according to ASES’s databases nor for
beneficiaries whose records contain transactions that have been rejected in the
ASES databases and have not been corrected within the periods established by
contract.

The payment system calculates several payment categories as listed below:

The reconciliation processes carried out with the insurers must be based on the
payment file for a given month and must take into consideration the status of
the subscriptions of the beneficiaries in ASES. Premium payments will be made on
the first day of the month following the acceptance of the ASES subscription.
 
The payment system calculates several payment categories as listed below:

26. TYPES OF PAYMENT

26.1 Monthly payments

In this case the system produces a payment for those beneficiaries whose
enrollment has already taken effect before the first day of the month for which
the payment transaction is executed. The execution of premium payment is made on
the first day of the month.

26.2 Prorated Payments

Prorated payments are specifically calculated for beneficiaries of the GHIP
funded solely through state funds (Commonwealth) who have been enrolled at some
point in a month prior to the month in which the premium payments are to be
made. The payment in these cases will satisfy a portion of the month and not a
month in its entirety. Under the state-funded GHIP a daily prorated premium is
calculated from the certification date of the enrollment that falls on that
previous month. This type of payment is not made for federal beneficiaries of
the GHIP (Medicaid or CHIP) or Platino Plan because under these plans, payments
are made based on full monthly periods. The only scenario in which a prorated
payment will occur for the federal population will be in cases of a region
change.
 
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However, in the event of a deceased or incarcerated beneficiary, loss of
eligibility by exceptions or one that has moved from Puerto Rico’s jurisdiction,
all populations including Medicaid, CHIP, and state funded Commonwealth
beneficiaries will be subject to the rule of proration regarding effective dates
of eligibility and disenrollment.

26.3 Retroactive Payments

These payments are calculated when the Effective Date of the Enrollment falls on
a period prior to the month for which the payment transaction is being executed.
In other words, this type of payment is executed when payments are identified
corresponding to months prior to the month in which a premium payment is made.
The retroactive payments will be computed based on the Enrollment Effective
Date. GHIP retroactive payments are always made for periods of up to three (3)
months before the month of payment. The system will process the premiums for
enrolled beneficiaries with an Effective Date prior to the payment date in the
case of monthly premiums or prorated premiums that have not been previously paid
within the time limits for retroactive payments. Retroactive payments may result
in an adjusted payment if they are the result of a carrier's cancelation of a
previous enrollment or a region change due to move.

Premiums are paid retroactively when a carrier has submitted a late enrollment
in relation to newborn beneficiaries and to cases of utilization prior to the
MA-10 Certification Date (emergencies) under the federal portion of the GHIP
(Medicaid and CHIP). In the first case the payment can only extend retroactively
for up to three (3) months. For the case of emergencies, this payment can only
extend retroactively for up to twelve (12) months.

Deemed Newborns- newborns born to a Medicaid-eligible mother shall be provided
coverage from the date of birth. The Medicaid identification number of the
mother serves as the child's identification number, and all claims for covered
services provided to the child may be submitted and paid under such number,
unless and until the state issues the child a separate identification number.

26.4 Prorated-retroactive payment

The prorated retroactive payment is calculated taking into consideration the
cases in which the Enrollment Effective Date falls on the first month considered
for a retroactive payment. This is a partial payment of the first month that
starts a series of months of pending payments. Usually, this type of payment is
used for GHIP State funded Commonwealth beneficiaries.
 
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V. Premium Payment

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26.5 Adjustments

A payment adjustment is calculated when there is a need to reverse a payment
that was awarded to a carrier during a previous premium payment process. It
occurs when, as a result of a retroactive payment calculation, a payment made in
relation to the same beneficiary is identified within the same period that has
been effected under a different carrier, type of plan or Plan Version. The
adjustments are calculated for those cases where a beneficiary changes carrier
retroactively after ASES had disbursed payment to the first carrier in a
previous payment transaction. In these cases an adjustment of premium paid to
the first carrier is made.

26.6 Special Adjustments

Generally, the special adjustments are carried out as a result of internal audit
processes that reveal that a wrongly adjudicated payment (like for example,
deceased beneficiaries or duplicate payments, etc.) must be reverted or that, on
the contrary, an omitted payment must be adjudicated.

26.7 Reasons why ASES will not execute a premium payment:

A premium payment will not be executed in favor of a carrier in the following
circumstances:

 
(1)
If the beneficiary is not enrolled in the ASES databases on the first day of the
month for which the payment transaction is being executed;

 
(2)
If the beneficiary is enrolled on a date after the date of payment;

 
(3)
If the enrollment had been rejected by ASES and a new enrollment was not
submitted by the carrier with the relevant corrections  (4) If from of the ASES
eligibility data arises that the beneficiary had a cancellation or changed the
carrier

26.8 EDI 820 Payment File

The reconciliation process carried out between ASES and the carriers in relation
to the payment of premiums must take into account the content of the EDI 820
files. This file is produced monthly by region, carrier and Plan Type. It
includes details of the types of payment that correspond to each of the
beneficiaries assigned to the carriers contracted for the month in question.

In this file, a distinction is not made about if the payment corresponds to an
adjustment from a regular premium payment process or a special adjustment. Thus,
in cases when special adjustments proceed, ASES will provide a separated file
for the special adjustments to the carrier.
 
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63

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VI. SYSPREM

--------------------------------------------------------------------------------

VI. 
 SYSPREM ENROLLMENT IN HISTORICAL DATA

 
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64

--------------------------------------------------------------------------------

VI. SYSPREM

--------------------------------------------------------------------------------

27. SYSPREM: ENROLLMENT IN HISTORICAL DATA

Generally, enrollments are applied to the current eligibility data contained in
the ASES databases. That is transactions related to federal beneficiaries of the
GHIP (Medicaid and CHIP), GHIP beneficiaries covered solely through state funds
(Commonwealth) and Medicare Platino are only processed based on a beneficiary's
current eligibility period. The eligibility period starts from the first
notification of eligibility in ASES, as the first record received about a
beneficiary or after a cancellation period in cases of beneficiaries who have
been canceled and then re-certified, and extends until a cancellation that is
related to say eligibility is made.

When a carrier does not send an enrollment on time or a record is not corrected
in a timely manner, the beneficiary's enrollment data will remain unregistered
in the ASES databases, which will prevent the processing of the corresponding
premium payment. This is due to the fact that the payment system does not make
premium payments for beneficiaries who are not enrolled at the moment in which
it corresponds to process the premium payment. As an example, in these cases, if
a beneficiary is canceled or is enrolled by a second carrier, the first carrier
will be prevented, during the validation phase of the system, from enrolling the
beneficiary in a period previous to the cancellation or the enrollment from the
second carrier. The main function of SYSPREM will be to allow the registration
of the beneficiary’s enrollment in historical data in those cases that cannot be
processed as current enrollments.

27.1 SYSPREM Functionality

Among the main functions of this system is the identification of enrollment
records that are candidates for processing in historical data because they are
enrollments that do not correspond to a current period of eligibility.

27.2 Carriers Eligibility File

The carrier's daily eligibility file will include beneficiary information
updated in historical data by the SYSPREM subsystem. In these transactions, the
Tran_id field will contain an "H" to identify the historical data. Carriers must
modify their systems so that the SYSPREM data is not included as current data
when processing the eligibility file. Once a transaction is received, which must
be processed through SYSPREM, a process of verification and validation of the
information that is contained in the record is carried out. Once the validation
tests have been passed, the record, in the database, containing the information
corresponding to historical transactions is updated. Those records that do not
successfully complete the verification processes will be sent in a file of
rejected enrollments to the corresponding carrier for correction.

The figure below shows the validation process performed for the purpose of
processing a candidate record for SYSPREM.
 
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65

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VI. SYSPREM

--------------------------------------------------------------------------------

Figure 2: Validation Process under SYSPREM

[image00011.jpg]

27.3 Premium Payment for SYSPREM

The run for the monthly premium payment will include all SYSPREM records that
have been processed during the previous month. The payment for these
transactions is calculated based on monthly periods from the Enrollment
Effective Date of the SYSPREM to:

(1)
The month in which the beneficiary was enrolled with a different carrier,

(2)
The month in which the beneficiary is cancelled or

(3)
Until the date of current billing.

27.4 SYSPREM Error Codes
 
The following is a breakdown of the Error Codes that will trigger an evaluation
under SYSPREM:

Table 9: Primary Error Codes for SYSPREM
 
Code
Primary Error Description
107
Effective Date prior to the current family eligibility period.
108
Effective date prior to the current beneficiary eligibility period.
280
The family must be eligible in the current eligibility data.
281
The beneficiary must be eligible in the current eligibility data.
177
Enrolled with another carrier on or after the effective date.

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VI. SYSPREM

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Table 10: Secondary Error Codes for SYSPREM
 
Code
Secondary Error Description
083
Social Security Number Not Found.
093
Suffix not found.
132
MPI Not Found.
222
Currently enrolled with the same carrier
223
Currently enrolled with another carrier
225
Incorrect Social Security Number
226
Incorrect MPI Number
22F
Error found in other beneficiaries of the family (GHIP).

The following is a breakdown of the Error Codes that could appear during an
evaluation under SYSPREM:

Table 11: SYSPREM Error Codes
 
Code
New Error Codes Description
996
Sysprem record successfully inserted in history.
980
The Process Date of the enrollment record must be greater than the Process Date
of the previous enrollment record for the beneficiary who appears previously
enrolled for the month corresponding to the Effective Date of the enrollment.
981
The beneficiary must not have beneficiaries of his family with errors not
acceptable by SYSPREM in the same enrollment file.
982
The enrollment record must not have an Effective Date prior to 01/01/2006.
983
Enrolled in history for the Effective Date of the enrollment record.
984
It is a New Enrollment, the Effective Date is not first of the month and the
beneficiary is already subscribed in another carrier at the Effective Date
specified.
985
It is a New Enrollment and the Effective Date should be at least as recent as
the beneficiary’s Certification Date at the specified Effective Date.
986
For SYSPREM processing, the Enrollment Effective Date should be before the
Effective Date of the current enrolled record at the ASES databases.

In summary, SYSPREM will process and/or enroll transactions in history in those
cases in which the enrollment cannot be applied to current data or to current
periods of eligibility. Some beneficiaries will not appear as enrolled in
history because they are not eligible for the Effective Date or because they are
enrolled with a different carrier. Carriers need to evaluate the cases rejected
by SYSPREM in order to identify errors in the assigned Effective Date and the
correctness of the beneficiaries' data included in the enrollment record.
 
Enrollment Manual
67

 
 

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--------------------------------------------------------------------------------

ATTACHMENT 11
Per Member Per Month Payments per Region
 
Region
 
Contracted PMPM
 
Metro-North
 
$
183.38
 
West
 
$
148.99
 

 

--------------------------------------------------------------------------------

[image00012.jpg]
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
COMMONWEALTH OF PUERTO RICO
PLANNING AND QUALITY AFFAIRS OFFICE
[image00013.jpg]

 
QUALITY INCENTIVE PROGRAM

--------------------------------------------------------------------------------

 
FY 2017
 
[image00014.jpg]

--------------------------------------------------------------------------------

TABLE OF CONTENTS

 
Contents
 
I.
INTRODUCTION
1
II.
REPORTING TIMEFRAMES
2
III.
EVALUATION & POINT DISTRIBUTION
2
IV.
RETENTION FUND & COMPLIANCE PERCENTAGE
3
V.
DEFINITIONS
4
VI.
PERFORMANCE MEASURES
5
VII.
PREVENTIVE CLINICAL PROGRAMS
12
A.
DISEASE MANAGEMENT PROGRAM
12
B.
PHYSICIAN INCENTIVE PLAN
16
VIII.
ER QUALITY INITIATIVE PROGRAM
16
IX.
CONCLUSION
17
X.
APPENDIX A
18

 

--------------------------------------------------------------------------------

I.
INTRODUCTION

 
The Puerto Rico Government Health Plan (GHP) is focus on providing quality care
services that are patient centered aimed at increasing appropriate use of
screening and prevention delivered in a timely manner to all Medicaid,
Children’s Health Insurance Program (CHIP) and Medicare-Medicaid Dual Eligible
enrollees in Puerto Rico.

 This Quality Improvement Procedure Manual has the sole purpose of providing the
necessary guidelines for attaining the required performance indicators for each
of the categories measured under the Quality Incentive Program (QIP), as
described in Article 12 of the contract executed between the MCO and the Puerto
Rico Health Insurance Administration (ASES, by its acronym in Spanish). ASES
shall maintain a Retention Fund of the Per Member per Month (PMPM) each month as
part of the QIP described in Section 12.5.3. A portion of the retained amount
shall be associated with each of the QIP initiatives outlined below:

•
Performance measures (Section 12.5.4.1)

•
Preventive Clinical Programs (Section 12.5.4.2)

✓
Physician Incentive Program

✓
Disease Management Program

•
Emergency Room Use Indicators (Section 12.5.4.3)

 ASES will reimburse the MCO according to compliance with each of the categories
of performance indicators in section 12.5.  The Planning and Quality Affairs
Office will audit the results of the data in the timeframes stated in Section
12.5 of the Contract for the performance indicators in the following categories:
Performance measures, Preventive clinical program measures, and ER Utilization
measures. This Manual describes in detail the requirements and the specific
metrics for each category of the Quality Incentive Program. The Quality
Improvement Procedure Manual will enter in effect the Effective Date of the
Contract and will be revised every contract year at ASES’ discretion unless
required in another timeframe by law or regulation.
 
Page 1
Definition reference in this manual are from the Puerto Rico Health Insurance
Administration Contract and NCQA (National Committee for Quality Assurance)

--------------------------------------------------------------------------------

II.
REPORTING TIMEFRAMES

Quarter
Incurred Service Time Period
Payment as of:
Submission Date
 
Baseline Data Analysis: Calendar Year 2016*
August 30, 2017
Q1
7/1/2017 through 9/30/2017
December 31, 2017
January 30, 2018
Q2
10/1/2017 through 12/31/2017
March 31, 2018
April 30, 2018
Q3
1/1/2018 through 3/30/2018
June 30, 2018
July 30, 2018
Q4
4/1/2018 through 6/30/2018
September 30, 2018
October 30, 2018

*For Performance Measures, the baseline may be adjusted removing members that
have reach compliance
 
from January 1st to June 30, 2017.

III.
EVALUATION & POINT DISTRIBUTION

The evaluation process of the QIP is divided in three categories; Performance
Measures, Preventive Clinical Programs and Emergency Room Quality Incentive
Program. This evaluation methodology has been developed to meet the requirements
established in section 23.1 of the GHP Contract. The scale of values per
indicator as determined by ASES, is divided in three levels as follows:

For metrics with a value of two (2) points:

  •
2 Points = Full compliance with expected goal, meets or exceeds (90%-100%)
expected goal as define in the QIP Manual.

 

•
1 point = Partial compliance, results reported are 70% or over  but less than
90% (70.00% - 89.99%) of the established goal.

 

•
0 point = Fails; results reported are less than 70% (0% - 69.99%) of the
established goal.

 
For metrics with a value of 1 (1) point:
 

•
1 Points = Full compliance with expected goal, meets or exceeds (90% - 100%)
expected goal as define in the QIP Manual.

 

•
O.5 point = Partial compliance, results reported are 70% or over  but less than
90% (70.00% - 89.99%) of the established goal.

 

•
0 point = Fails; results reported are less than 70% (0% - 69.99%) of the
established goal.

 
The point distribution by program is as follows:
 
Program
Points
Performance Measures
16
Preventive Clinical Programs
31
ER Quality Incentive Program
5

 
Page 2
Definition reference in this manual are from the Puerto Rico Health Insurance
Administration Contract and NCQA (National Committee for Quality Assurance)

--------------------------------------------------------------------------------

IV.
RETENTION FUND & COMPLIANCE PERCENTAGE

 
ASES will withhold a portion of the PMPM otherwise payable to the MCO in order
to incent the MCO to meet performance targets under the Quality Incentive
Program. The retention fund will be reimbursed to the MCO when a determination
is made by ASES that the MCO has complied with the quality standards and
criteria established by ASES in accordance with 23.1 of the contract. On a
quarterly basis the MCO will submit a quarterly Retention Fund Report in
accordance to 18.2.9.4 of the contract.

On a monthly basis, ASES will withhold a retention fund equivalent to two (2)
percent of the total PM/PM of each region. A portion of the retained amount will
be associated with each of the Quality Incentive initiatives outlined below for
each of the specified timeframes as per section 22.4.1 of the contract:
Time Period (Incurred service from Contract Term)
Monthly Retention Fund Percentage
7/1/2017 through 6/30/2018
2%
QIP Initiative
Retention Fund Breakdown
Performance Measures
40%
Clinical Programs
30%
Emergency Room Use Indicators
30%

No later than thirty (30) calendar days after receipt of the Contractor’s
quarterly reports, ASES shall determine if the MCO has met the applicable
performance objectives for each quality incentive initiative for that period.
The evaluation result and compliance will determine the percent to be disbursed
to the MCO as described in the following table:
Compliance Percent
Disbursement Percentage of Monthly PM/PM
100-90%
100%
89.9-80%
75%
79.9-70%
50%
69.9 and below %
0%

For the first quarter (July 1st to September 30, 2017), ASES will reimburse
corresponding period retention fund subject to the submission of the required
reporting templates regardless of the compliance with the established goals.
This waiver is provided to allow the MCOs to finish the programming, population
identification, develop strategies, communication to providers, start
interventions with identified members and all other activities related to this
QIP necessary to comply with its requirements.
 
Page 3
Definition reference in this manual are from the Puerto Rico Health Insurance
Administration Contract and NCQA (National Committee for Quality Assurance)

--------------------------------------------------------------------------------

V.
DEFINITIONS

 
The following definitions apply to measures of the Quality Improvement Manual:
 

  1.
Disease Management: An administrative function comprised of a set of
Enrollee-centered steps to provide coordinated care to Enrollees suffering from
diseases listed in Section [7.8.3] of the Contract.

 

2.
Hot Spotting: The ability to identify in a timely manner heavy users of the
systems and their patterns of utilization to provide targeted interventions and
care through mapping data.

 

3.
Incurred date: Is the date in which the service was provided.

 

4.
Intervention: activities targeted at the achievement of client stability,
wellness, and autonomy through advocacy, assessment, planning, communication,
education, resource management, care coordination, collaboration, and service
facilitation.

 

5.
Performance measures:  periodic measurement of outcomes and results used to
assess the effectiveness and efficiency of quality initiatives on selected
indicators.

 

6.
Per member per month payment (PMPM): The fixed monthly amount that the MCO is
paid by ASES for each enrollee to ensure that benefits under the Contract are
provided.  This payment is made regardless of whether the enrollee receives
benefits during the period covered by the payment.

 

7.
Preventive Services:  Health care services provided by a physician or other
provider within the scope of his or her practice under Puerto Rico law to detect
or prevent disease, disability, behavioral health conditions, or other health
conditions; and to promote physical and behavioral health and efficiency.

 

8.
Primary Care Physician: A licensed medical doctor (MD) who is a provider and
who, within the scope of practice and in accordance with Puerto Rico
Certification and licensure requirements, is responsible for providing all
required primary care to enrollees. The PCP is responsible for determining
services required by enrollees, provides continuity of care, and provides
referrals for enrollees when medically necessary.  A PCP may be a general
practitioner, family physician, internal medicine physician,
obstetrician/gynecologist, or pediatrician.

 

9.
Retention Fund: The amount of withhold by ASES of the monthly Per Member per
Month Payments otherwise payable to the MCO in order to incentivize the MCO to
meet performance targets under the Quality Incentive Program described in
Section [12.5.3].  This amount shall be equal to the percent of that portion of
the total Per Member per Month Payment that is determined to be attributable to
the MCO’s administration of the Quality Incentive Program described in Sections
[12.5 and 22.3]. Amounts withheld will be reimbursed to the MCO in whole or in
part (as set forth in Sections [12.5 and 22.3]) in the event of a determination
by ASES that the MCO has complied with the quality standards and criteria
established by Section [12.5].

 

10.
Special Coverage: A component of Covered Services provided by the MCO, described
in Section [7.7], which are more extensive than the Basic Coverage services, and
for which Enrollees are eligible only by “registering.” Registration for Special
Coverage is based on intensive medical needs occasioned by serious illness.

 

11.
Quality Incentive Program:  mechanism to improve the quality of services
provided to Enrollees. The program shall consist of three (3) categories of
performance indicators: performance measures, preventive clinical program
measures and ER Utilization measures.

 

12.
Active Member: GHP member with continuous enrollment during the measurement
quarter.

 
Page 4
Definition reference in this manual are from the Puerto Rico Health Insurance
Administration Contract and NCQA (National Committee for Quality Assurance)

--------------------------------------------------------------------------------

VI.
PERFORMANCE MEASURES

 
The reporting templates for each of the performance measures mentioned below
will be provided to the MCO through the ASES ShareFile site. Each reporting
template will be in Excel format. ASES shall reimburse the MCO the percent
applicable of the Retention Fund, as shown on page 3, in accordance with Section
22.3 of the contract for successful compliance with the performance measures
below based upon quarterly evaluation of this criterion.  The MCO shall
demonstrate an increase in the measurement year as described in the next table,
for the following performance measures:

PM1. Breast Cancer Screening
PM2. Cervical Cancer Screening
PM3. Cholesterol Management
PM4. Diabetes Care Management
PM5. Access to Preventive Care Visits
PM6. Asthma Management
PM7. Follow up after Hospitalization for Mental Health

The Performance Measures reports are based on claims incurred in the measurement
period for each region. The MCO shall provide data for each region.

For each reported submission, the MCO shall use the same template that was
submitted in previous quarter(s). The MCO may not update data submitted for
previous reporting periods.

The MCO will report the amounts individually for each quarter. For evaluation
purposes, to determine compliance, ASES will consider cumulative percentages by
quarter (roll over). In the event that the MCO achieve the annual goal before
the last quarter of the year, the MCO must demonstrate at least any increase in
the percentage during the remaining quarter(s).

Definition Requirements by Performance Measure
(Codes are subject to continuous update revision)

PM1. Breast Cancer
Breast Cancer
Definition for Baseline
Total women 50–74 years of age who has not have a mammogram to screen for breast
cancer any time on the year prior the measurement year.
Numerator
The number of active women with a Breast Cancer Screening during the measurement
period.
Denominator
Indicate the number of active women without a Breast Cancer screening the year
prior to the measurement period for whom the screening has not been performed
during previous quarters.
Codes
 
ICD-10-CM Diagnosis:
Z12.31
CPT CODES: 77055,77056, 77057
HCPCS: G0202, G0204, G0206

 
Page 5
Definition reference in this manual are from the Puerto Rico Health Insurance
Administration Contract and NCQA (National Committee for Quality Assurance)

--------------------------------------------------------------------------------

PM2.  Cervical Cancer Screening

Cervical Cancer
Definition for Baseline
Total of women 21–64 years of age who were not screened for cervical cancer the
year prior to the measurement year.
Numerator
The number of active women in the denominator with a cervical cancer screening
during the measurement year.
Denominator
Indicate the number of active women without a Cervical cancer screening the year
prior to the measurement period for whom the screening has not been performed
during previous quarters.
Codes
 
ICD-10-CM  Diagnosis: Z12.4
 
CPT CODES: 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174,
88175
HCPCS:  G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091

 
M3. Cholesterol Management
Cholesterol Management
Definition for Baseline
Total members 18-75 years with a high risk diagnose who have not had a LDL-C
test during year prior to the measurement period.
Numerator
Numerator 1: Indicate the number of active members in the denominator with
Diabetes Mellitus and a LDL-C test done during the measurement period.
Numerator 2: Indicate the number of active members in the denominator with a
Cardiovascular Condition and a LDL-C test done during the measurement period.
Numerator 3: Indicate the number of active members in the denominator with
Arterial Hypertension and a LDL-C test done during the measurement year.
Denominator
Denominator 1: Indicate the number of active members with Diabetes Mellitus and
without a LDL-C test done the year prior to the measurement year for whom the
screening has not been performed during previous quarters.
Denominator 2: Indicate the number of active members with a Cardiovascular
Condition and without a LDL-C test done the year prior to the measurement year
for whom the screening has not been performed during previous quarters.
Denominator 3: Indicate the number of active members with Hypertension and
without a LDL-C test done the year prior to the measurement year for whom the
screening has not been performed during previous quarters.
Codes
ICD-10-CM Diagnosis:       Z13.220 & Codes for DM (E10 y E11), CVD (I70, II75),
HBP (I10, I11,  I12, I13, I15)
 
CPT CODES: 80061 - Lipid Panel,  82465 Cholesterol,  83718 HDL Cholesterol,
83719 LDL, 83721 VLDL, 84478 Triglycerides , 83698 Lipoprotein Associated
Phospholipase A2, 83700 Lipoprotein, blood; electrophoretic, 83704 quantitation
of lipoprotein particle numbers and lipoprotein subclasses when measured.

 
Page 6
Definition reference in this manual are from the Puerto Rico Health Insurance
Administration Contract and NCQA (National Committee for Quality Assurance)

--------------------------------------------------------------------------------

PM4. Diabetes Care Management
Diabetes Care Management
Definition for Baseline
Total members 18-75 years of age with Diabetes Mellitus (E10 Type 1 Diabetes
Mellitus  or E11 Type 2 Diabetes Mellitus ) who have not had each of the
following the year prior the measurement period: Comprehensive Diabetes Care
(CDC):
•          Hemoglobin A1c (HbA1c) testing
•          Eye exam (retinal) performed by an eye care provider ( Z01.01
Encounter Examination of eye)
•          Medical attention for nephropathy – either evidence of nephrology
medical evaluation or a nephropathy screening test
Numerator
The number of active members in the denominator who have had a HgA1c Test, Eye
Exam and Nephropathy Screening Test during the measurement period.
Denominator
HgA1c Test Denominator: Indicate the number of active members without a HgA1c
test the year prior to the measurement year for whom the screening has not been
performed during previous quarters.
Eye Exam Denominator: Indicate the number of active members without an Eye Exam
the year prior to the measurement year for whom the screening has not been
performed during previous quarters. Nephropathy screening test (Urine
Microalbumin Testing) Denominator: Indicate the number of active members without
a Microalbumin test the year prior to the measurement year for whom the
screening has not been performed during previous quarters.
Codes
ICD-10-CM Diagnosis Diabetes: Use the appropriate code family: E10, E11
 
HbA1C Testing
CPT CODES 83036, 83037,  CPT II Codes 3044F (<7.0%), 3045F (7.0-9.0), 3046F
(>9%)
 
Nephropathy Screening
CPT CODES: 3060F, 3061F, 3062F, 3066F, 4010F
Nephropathy Screening test:82042, 82043, 82044, 84156
 
Nephropathy Exclusion: CKD stages 4  and 5
 
Retinal Eye Exam
CPT CODES:   67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107,
67108, 67110, 67112,
67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228,
92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235,
92240,92250, 92260, 99203-99205, 9921399215, 99242-99245
CPT II: 2022F, 2024F, 2026F, 3072F
HCPCS S0620, S0621, S0625, S3000

 
Page 7
Definition reference in this manual are from the Puerto Rico Health Insurance
Administration Contract and NCQA (National Committee for Quality Assurance)

--------------------------------------------------------------------------------

PM5. Access to Preventive Care Visits

Access to Preventive Care Visits
Definition for Baseline
Total members who have not had at least one preventive care visit with a PCP the
year prior during the measurement period.
Numerator
The number of active members in the denominator with a preventive care visit
with a PCP during the measurement period.
Denominator
Indicate the number of active members without a preventive care visit with a PCP
the year prior to the measurement period for whom the screening has not been
performed during previous quarters.
Codes
ICD-10-CM Diagnosis
"General Medical Exam:Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8,
Z02.0-Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9 "
ICD-10-CM Procedure Other Exams: Z00.5, Z00.8, Z02.0, Z02.2, Z02.3, Z02.4,
Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9
CPT CODES: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350,
9938199387, 99391-99397, 99401-99404, 99411, 99412, 99214, 99304-99310, 99315,
99316, 99318, 99324-99328, 99334-99337
HCPCS G0402, G0438, G0439, G0463, T1015

 
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PM6. Asthma Management
Asthma Management
Definition for Baseline
Percentage of members with at least one monthly prescription of drugs use for
prevention of bronchial asthma, of all members identified with a reported
medical evaluation with a diagnosis of Persistent Moderate or Severe Bronchial
Asthma during the baseline year 2016.
Numerator
The amount of members with at least one monthly prescriptions of drugs used for
Bronchial Asthma prevention, on active members identified on baseline, with
Moderate or Severe Persistent Bronchial Asthma diagnosis during the reporting
period.
Denominator
The number of active members on baseline, who are identify with Moderate and
Severe persistent Bronchial Asthma for the reporting period.
Codes
ICD-10-CM Diagnosis: J45.4; J45.5
Drugs for prevention of Bronchial Asthma to be provided  with the NDC codes.

 
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PM7. Follow up after Hospitalization for Mental Health
Follow up after Hospitalization for Mental Health
Definition for Baseline
Percent of members who were discharge of acute mental health care facility and
were seen on an outpatient basis by a psychiatrist or a physician within thirty
days after discharge.
Numerator
The number of discharges in the denominator followed by an outpatient encounter
with a psychiatrist or a physician within thirty days after discharge. (This
amount shall include visits performed 30 days after the end of the quarter.)
Denominator
The number of discharges from an acute mental health care facility during the
quarter.
Codes
ICD-10 F32.0 – F32.4, F32.9, F33.0-F33.3, F33.41, F33.9

 
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The point distribution for each of the measure is as follows:
Program: Performance Measures
Improvement Rate Target FY 2017/2018
 
Points
PM1. Breast Cancer Screening
Calendar year 2016: Baseline
Q2-Q4: Incurred services by quarter
Goal: 15%  improvement
Quarterly reimbursement will be based on achieving a minimum of 5% of the
established goal on each trimester.
2 points
PM2. Cervical Cancer Screening
Calendar year 2016: Baseline
Q2-Q4: Incurred services by quarter
Goal: 15% improvement
Quarterly reimbursement will be based on achieving a minimum of 5% of the
established goal on each trimester.
2 points
PM3. Cholesterol Management
Calendar year 2016: Baseline
Q2-Q4: Incurred services by quarter
Goal: 30% improvement
Quarterly reimbursement will be based on achieving a minimum of 10% of the
established goal on each trimester.
3 points
PM4. Diabetes Care Management
Calendar year 2016: Baseline
Q2-Q4: Incurred services by quarter
Goal: 30% improvement
Quarterly reimbursement will be based on achieving a minimum of 10% of the
established goal on each trimester.
3 points
PM5. Access to Preventive Care Visits
Calendar year 2016: Baseline
Q2-Q4: Incurred services by quarter
Goal: 15% improvement
Quarterly reimbursement will be based on achieving a minimum of 5% of the
established goal on each trimester.
2 points
PM6. Asthma Management
Calendar year 2016: Baseline
Q2-Q4: Incurred services by quarter
Goal: 7.5 % improvement
Quarterly reimbursement will be based on achieving a minimum increment of
2.5% of the established goal on each trimester.
2 points
PM7. Follow up after Hospitalization for Mental Health
Calendar year 2016: Baseline
Q2-Q4: Incurred services by quarter
Goal: 9% improvement
Quarterly reimbursement will be based on achieving a minimum of 3% of the
established goal each trimester.
2 points
Total points
 
16 points

 
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VII.
PREVENTIVE CLINICAL PROGRAMS

 
The MCO shall comply with the objectives of each of the following Preventive
Clinical Programs as stated in the GHP Contract in section 12.5.4.2. The
Preventive Clinical Programs are:

 
A.
DISEASE MANAGEMENT PROGRAM (7.8.3 OF THE CONTRACT)

Disease Management is an approach that aims to provide better care while
reducing the costs of caring for the chronically ill. The MCO shall develop a
Disease Management Program designed to:
 

  a.
Improve the health of persons with specific chronic conditions and

  b.
Reduce health care service use and costs associated with avoidable
complications, such as emergency room visits and hospitalizations.

As a first step, the MCOs Disease Management Program needs to identify the
population that will be enrolled in each of the selected conditions. Through a
Hot Spotting technique the MCO will provide ASES the demographic characteristics
and PMG information of identified members who will benefit from a disease
management program.

The second step of the MCO’s DM Program is the design of disease management
interventions that improve the overall health status of the identified members.
The MCO shall develop interventions that impact the following areas: a) Member
related (education and patient coaching), b) PCP related (Care Plan discussion
and revision) and c) Clinical related measures (UM Review).

For purpose of the Quality Incentive Program Retention Fund, ASES will consider
the UM Review metrics described below for compliance and release to the
applicable percent of the retained amount for this particular program.
 
Rule: Report unique patients by category. Patients with multiple conditions will
be include only in one Program using the MCO established hierarchy process.

1. Physical Health DM Metrics  A. Percent of Active Severe Members by DM
condition
 
Formula: Total number (cumulative) of active severe members who are participants
in DM by condition during the measurement year/ Total number of severe members
identified by DM condition on the baseline.

Baseline for FY 2017: Calendar year 2016 members identified as DM Candidate in
the category of severe. (Candidate is a members diagnose with a DM condition and
categorized as severe that is not a participant in the DM Program.)

The following table defines the baselines, numerator and denominators for the
Disease Management conditions to be measured.
 
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DM Condition
Baseline
Numerator
Denominator
DM1. Asthma (Bronchial Asthma)
 
Calendar year 2016  Members with the diagnosis of Asthma in the category of
severe
Total number of active members with the diagnosis of Asthma in the category of
severe who are  participants of the DM Program in the measurement period.
Number of active members with the diagnosis of Asthma in the category of severe
as identified in the baseline.
DM2. Diabetes Mellitus (Type 1 or 2)
 
Calendar year 2016  Members with the diagnosis of Diabetes Mellitus (Type 1 or
2) in the category of severe
Total number of active members with the diagnosis of Diabetes Mellitus (Type 1
or 2) in the category of severe who are participants of the DM Program in the
measurement period
Number of active members with the diagnosis of Diabetes Mellitus (Type 1 or 2)
in the category of severe as identified in the baseline.
DM3. Congestive Heart Failure
 
Calendar year 2016  Members with the diagnosis of Congestive Heart Failure in
the category of severe
Total number of active members with the diagnosis of Congestive Heart Failure in
the category of severe who are participants of the DM Program in the measurement
period
Number of active members with the diagnosis of Congestive Heart Failure in the
category of severe as identified in the baseline.
DM4. Arterial Hypertension
Calendar year 2016  Members with the diagnosis of Arterial Hypertension  in the
category of severe
Total number of active members with the diagnosis of Arterial Hypertension in
the category of severe who are participants of the DM Program in the measurement
period
Number of active members with the diagnosis of Arterial Hypertension in the
category of severe as identified in the baseline.
DM5. Major Depression (DEP)
Calendar year 2016  Members with the diagnosis of Major Depression in the
category of severe
Total number of active members with the diagnosis of Major Depression in the
category of severe who are participants of the DM Program in the measurement
period.
Number of active members with the diagnosis of Major Depression in the category
of severe as identified in the baseline.

Note: Reference definition for the numerator:
 
☐Participants = Member contacted by the MCO who have a care plan developed.

Goal: To enroll and maintain in DM program at least 22.5% of active severe
members by condition at the end of the year. Quarterly reimbursement will be
based on achieving at minimum 7.5% of the established goal by quarter.

Note: The MCO will report the amount of members enrolled each quarter. For
evaluation purposes, ASES will add any percentage in excess of the goal on the
previous quarter to the next quarter (roll over). Minimum goal per quarter must
be achieved.
 
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Score: 2 points by condition
 

 
B.
UM Metrics

 
Note: ER Visits and Hospital admissions to be included are those related to or a
complication of the DM condition being reported.

1. ER Visit Metrics by region and condition for each Physical Health DM
 
Formula:  Number of ER Visits of severe identified  DM members  annualized /   
x 1,000
Number of DM members with severe  classification

Baseline for FY 2017:  Rate of ER visits of members identified as DM candidate
from calendar year 2016

Goal by 2017-2018  Q1-Q4: At least 2 % decrease of active severe members ER
visits by condition in each quarter.

Score: 2 points by condition
 
2. Hospital Admission Metrics by region and condition for Physical Health (2
points)
 
Formula: Number of hospital admissions of severe DM members  annualized /    x
1,000
Number of hospital admissions of DM members with severe classification

Baseline for FY 2017:  Rate of Hospital Admissions of members identified as DM
candidate from calendar year 2016

Goal by 2017-2018 Q1-Q4: At least 2% decrease of active severe members hospital
admission by condition in each quarter

Score: 2 points by condition
 
2. For Mental Health DM Metrics are as follows: A.
 
Percent of participants with Major Depression
 
Formula:  Total number of active members with the diagnosis of Major Depression
in the category of severe who are participants of the DM Program in the
measurement period / Number of active members with the diagnosis of Major
Depression in the category of severe as identified in the baseline.

Baseline for FY 2017: Calendar year 2016 members with diagnosis of Major
Depression identified as DM Candidate in the category of severe
 
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Goal by 2017-2018  Q2-Q4: To enroll and maintain in DM program at least 22.5% of
active severe members by condition at the end of the year. Quarterly
reimbursement will be based on achieving at minimum 7.5% of the established goal
by quarter.

Note: The MCO will report the amount of members enrolled each quarter.For
evaluation purposes, ASES will add any percentage in excess of the goal on the
previous quarter to the next quarter (roll over).

Score: 2 points
 
B. UM Metric

Note: Hospital admissions to be included are those related to or a complication
of the DM condition being reported.

1. Hospital Admission
 
Formula: Number of hospital admissions of severe Major Depression in DM 
annualized /    x 1000
Number of hospital admissions of members with severe Major Depression
 
Goal by 2017-2018 Q1-Q4: At least 2% decrease of hospital admissions  of members
with severe Major Depression
 
Score: 2 points

2. Timely and Accurate Hot Spotting Report:
Submit a timely and accurate Hot Spotting Report by region, PMG number, PMG
name, PMG population and municipality of residence of members identified as
severe in the following conditions:
 
Physical and Mental Health DM
DM1. Asthma (Bronchial Asthma)
DM2. Diabetes Mellitus (Type 1 or 2)
DM3. Congestive Heart Failure
DM4. Arterial Hypertension
DM5. Major Depression

This report will include for each condition: number of members, percent of the
PMGs population, number of active cases and number of interventions.

Score: 1point
 
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B.PHYSICIAN INCENTIVE PLAN
 
Physician Incentive Programs are designed to recognize and reward Primary Care
Providers who are committed to Preventive Services and improving the quality of
the services to all their members.  The MCO shall design a Physician Incentive
Program that addresses the following key objectives:
 

  •
Improve the delivery of care to members for preventive services and chronic
conditions • Align with national quality measures such as those of the Centers
for Medicare & Medicaid       Services (CMS) and National Committee for Quality
Assurance (NCQA).

•
Improve patient Care coordination

•
Electronic Health Record (EHR)

For purpose of the Quality Incentive Program Retention Fund, ASES will consider
the process outcomes described by the MCOs’ Incentive Plan and ASES’s
requirements described below for compliance and release to the applicable
percent of the retained amount for this particular program Process outcome(s)
requirements from ASES:

  1.
Evaluate 100% of the PCPs (with 100 lives as minimum) through Medical Record
Review for compliance with clinical and administrative performance measures
identified by the Health Plan.

  §
The MCO will submit quarterly the reports on the number of PCP eligible by
region  and those  scores obtained on the reported quarter.

Score: 1 points
 

2.
The MCO shall ensure at a minimum seventy percent (70%) of PCP will be in
compliance with eighty percent (80%) scorecard on those indicators approved by
ASES and included in the  Health Plan Audit during the Contract year.

§
MCO will provide a list by PMG and by region of the certified PCP eligible for
the financial incentive that received the preventive services auditing with the
percentage of compliance for each PCP evaluated during the reporting period.

              Score: 1 points

Total points for this program 2 points.

VIII.
ER QUALITY INITIATIVE PROGRAM

The ER Quality Initiative Program shall be design to identify high users of
Emergency Services (including behavioral health) to allow for early
interventions of members and physician (PCP) in order to ensure appropriate
utilization of services and resources. The program design required by ASES for
the ER Quality Initiative will be based on the “Hot Spotting Model of the Camden
Coalition of Health Providers”. The MCO will submit to ASES for approval a work
plan with detailed activities and interventions aimed to High ER Utilizers.  The
activities and interventions of work plan shall include, but not limited to, the
following:
 

1.
Educational campaign to educate consumers about healthcare options available to
them when a primary care physician isn’t available. The intent of the campaign
is to let consumers know the emergency room is not the only alternative when
seeking treatment. Options include retail health clinics, walk-in doctor's
offices and urgent care centers – all of which, officials say, can provide the
same care in less time and less out-of-pocket expense than an ER visit.

 
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2.
One on One Care management interventions

 

3.
PCPs interventions on identifying high users or potential high users of ER
services.

 

4.
Changes on access to urgent care at PCP offices with extended hours or urgent
clinics.

 
For purpose of the Quality Incentive Program Retention fund, ASES will consider
the ER Report and UM Metrics described below for compliance and release to the
applicable percent of the retained amount for this particular program.
 

1.
Through a timely and accurate Hot Spotting Report all MCOs will provide ASES the
demographic characteristics and PMG information of identified High ER Utilizers
by severity level (1 point):

 
Member identification will be as follows:
 
Severity  Criteria ER Visits
Level 1: Mild          
3-6 visits a year
Level 2: Moderate
7-11 visits a year
Level 3: Severe
12 or more visits a year

          

2.
Ambulatory Visits Rate (2 points):

•
Total Number of Non-Emergency  Ambulatory Visits incurred by Active Severe ER
Utilizers  / Total members on Active Severe ER Utilizers

Baseline: Calendar year 2016: Rate of ambulatory visits per severe ER Utilizers
Goal:     3% quarterly increase in the rate of non-emergency ambulatory visits
per severe ER utilizers (Each quarter will be evaluated independently and roll
over does not appy to this metric.)
 

3.
Annualized ER Rate on frequent ER users (2 points):

•
Total Number of ER Visits incurred by members with 7 or more ER Visits / Total
members with 7 or more ER Visits  x 1,000

•
Baseline: Calendar year 2016: Annual rate per thousand of ER visits of members
in moderate and severe categories

Goal:   3% quarterly decrease in number of annualized ER Visits incurred by
members with 7 or more ER Visits (Each quarter will be evaluated independently
and roll over does not appy to this metric.) Total points in this program 5
points
 
IX
CONCLUSION

 
The compliance with the quality categories established in this Manual will be
measured and shall be accomplished by the MCO on a quarterly basis. MCO shall
comply with the required quarterly metrics in order to receive the reimbursement
of the amount retained by ASES for each quarter as defined in Section 23.1 of
the Contract.
 
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X
APPENDIX A

Disease Management Member Identification and Severity Criteria
 
Reminder: Events must be related to the DM Condition (based on the diagnosis
code)
 

1.
Asthma (Bronchial Asthma) Member Identification Criteria:

 
Diagnostic Code:
Medical encounters with any of the following ICD10:  J45
Age
 5-56
With at least one of the following events:
Medications
4 or more  asthma medications
ER
At least one visits (CPT:  99281-99285,  99288)
Hospital Admission
At least one hospital admission (CPT:  99221-99223, 99231-99233,
99238-99239, 99251-99255,  99261-99263, 99261-99263,
99291,99292)
Outpatient visits
At least four (4) outpatient encounters (CPT: 99201-99205, 99211-
99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350,
999382-99386, 99392-99396, 99401-99404, 99411, 99412, 99420, 99429.)

 
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Severity  Criteria:
Severity
Hospital
Admissions
ER Visits
Outpatient
Pharmacy
(Therapeutic categories)
Mild: Comply with all of the following:
0
1
0-3
1
Moderate: Comply with two of the following:
1
2
4-5
2
Severe: Comply with at least one of the following:
≥2
≥3
≥6
≥3 combined categories at least any three months during the baseline year

Exclusions
 
Patients with emphysema, COPD, Chronic Bronchitis, Cystic Fibrosis and Acute
Respiratory Failure

 

2.
Diabetes Mellitus (Type 1 and 2) Member Identification Criteria

 
Diagnostic Codes
Medical encounters with any of the following ICD10:   E10,  E11, E13
Age
0-75
With at least one of the following events:
Medications
1 or more
ER Visits
1 or more
Hospital Admission
At least one hospital admission
Outpatient Visits
2 or more

 
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Severity Criteria: At least one of the following
Severity
Hospital
Admissions
ER Visits
Pharmacy
(Therapeutic categories)
Complications*
Mild: Comply with all of the following:
0
0
1
0
Moderate: Comply with two of the following:
0
1 o  2
2
1-2
Severe: Comply with at least two of the following:
≥1
≥3
≥3
≥ 3

*Diabetes related complications including ophthalmic, renal, cardiovascular,
skin and neurological.
 

3.
Congestive Heart Failure Member Identification:

 
Diagnostic Code
Medical encounters with any of the following ICD10:
I50, I11.0,  I13.0,  I13.2
Age
≥18
Medications
1 or more
With at least one of the following events:
ER Visit
1 visit or more
Hospital Admission
1 admission or more
Outpatient Visit
1 or more

 
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Severity Criteria: At least one of the following
Severity
Hospital
Admissions
ER Visits
Pharmacy
(Therapeutic categories)
Complications*
Mild: Comply with all of the following:
0
0-1
0-1
0
Moderate: Comply with two of the following:
1
2
2
1-2
Severe: Comply with at least two of the following:
≥ 2
≥ 3
≥3
≥ 3

*CHF related complications including Renal Failure, Heart Valve Disease, Heart
Arrhythmia and Liver Disease
 
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4.
Arterial Hypertension Member Identification

Diagnostic
Codes
Medical encounters with any of the following ICD10:
I10, I11,  I12, I13, I15,
Age
18+
Medications
1 or more
With at least one of the following events:
ER Visits
1 or more
Hospital Admissions
1 admission
Outpatient visits
1 or more

 
Severity Criteria: At least one of the following
Severity
Hospital
Admissions
ER Visits
Pharmacy
(Therapeutic
Categories)
Complications*
Mild: Comply with all of the following:
0
0-1
0-2
0
Moderate: Comply with two of the following:
1
1 -4
3
1-3
Severe: Comply with at least one of the following:
≥ 2
≥ 5
≥ 4
≥ 4

*Arterial Hypertension related conditions including Myocardial Infarct,
Cerebrovascular Accidents, Arterial Aneurism, Renal Disease, Hyperlipidemia and
Metabolic Syndrome
 
Exclusions
 
Patients with I11.0, I13.0, I13.2

 
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5.
Major Depression

 
Diagnostic Codes
Medical encounters with any of the following ICD10:   F33, F32
Age
≥ 12
Medications
1 or more
With at least one of the following events:
ER Visits
1 or more
Hospital Admission
1 or more
Outpatient Visits
1 or more

Severity Criteria: At least one of the following
Severity
Hospital
Admissions
ER
Visits
Pharmacy
(Therapeutic
Categories)
Complications*
Mild: Comply with all of the following:
0
1
1
0
Moderate: Comply with two of the following:
1
2
2
1-2
Severe: Comply with at least one of the following:
≥ 2
≥ 3
≥3
≥ 3

*Complications including chronic pain, chronic physical illness, alcohol or drug
abuse, anxiety, panic disorder or social phobias, self-mutilation, suicidal
attempts, antisocial disorders
 
 
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