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Lista de medicamentos
cubiertos para 2015
(Formulario)
PARA PEDIR INFORMACIÓN
ADICIONAL, llame a Servicios para
afiliados al 1-877-941-0482 de 8 a.m.
a 8 p.m., siete días a la semana.
Usuarios de TTY deben llamar al 711.
Los fines de semana y feriados
federales, se le puede pedir que
deje un mensaje. Su llamada
será devuelta dentro del
próximo día hábil.
http://mmp.illinicare.com.com
00015549, Número de versión 21
Actualizado 10/01/2015
H0281_ListOfDrugs15C_SP_Approved 09182014
IlliniCare Health | Lista de medicamentos cubiertos para 2015
(Formulario)
Esta Lista de medicamentos se actualizó el 1 de octubre, 2015.
Ésta es una lista de medicamentos que los afiliados pueden obtener en IlliniCare Health.
� IlliniCare Health es un plan de salud que tiene contrato con Medicare y Medicaid de Illinois
para proporcionar los beneficios de los dos programas a los afiliados.
� Los beneficios, la Lista de medicamentos cubiertos, y las redes de farmacias y proveedores
y/o copagos pueden cambiar el 1º de enero de cada año.
� Usted siempre puede revisar la Lista de medicamentos cubiertos actualizada de IlliniCare
Health en internet en http://mmp.illinicare.com.
� Usted puede pedir esta información en otros formatos, como Braille o letra grande. Llame al
(877) 941-0482. La llamada es gratuita.
� Se pueden aplicar limitaciones, copagos, y restricciones. Para obtener más información, llame
a Servicios para Afiliados de IlliniCare Health o lea el Manual del afiliado de IlliniCare Health.
� Los copagos de medicamentos de receta podrían variar de acuerdo con el nivel de Ayuda
adicional que usted reciba. Comuníquese con el plan para conocer más detalles.
� You can get this document in English, or speak with someone about this information in other
languages for free. Call (877) 941-0482. TTY users call 711. The call is free.
� Usted puede obtener este documento en español, o hablar con alguien acerca de esta
información en otros idiomas de forma gratuita. Llame al (877) 941-0482. Usuarios de TTY
deben llamar al 711. La llamada es gratuita.
00015549, 1~PHURGHYHUVLyQ 21
$FWXDOL]DGR1 0/01/2015
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Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
1
Preguntas frecuentes (FAQ)
Encuentre aquí las respuestas a las preguntas que usted tenga sobre esta Lista de medicamentos
cubiertos. Usted puede leer todas las Preguntas frecuentes para saber más o buscar preguntas y
respuestas.
1. ¿Qué medicamentos de receta se encuentran en la Lista de
medicamentos cubiertos? (Llamamos "Lista de medicamentos"
a la Lista de medicamentos cubiertos, para abreviar.)
Los medicamentos de la Lista de medicamentos cubiertos que comienza en la página 12 son los
medicamentos cubiertos por IlliniCare Health. Los medicamentos están disponibles en las
farmacias dentro de nuestra red. Una farmacia está en nuestra red si tenemos un acuerdo con
ellos, para trabajar con nosotros y proporcionarle servicios a usted. Nos referimos a estas
farmacias como “farmacias de la red”
- IlliniCare Health cubrirá todos los medicamentos médicamente necesarios de la Lista, si:
• Su médico u otro proveedor médico dice que usted los necesita para mejorar o para seguir
sano y,
• Usted surte la receta en una farmacia de la red de IlliniCare Health.
- IlliniCare Health podría tener pasos adicionales para tener acceso a ciertos tipos de
medicamentos (lea en el pregunta #5 de abajo).
Usted puede también leer una lista actualizada de los medicamentos que cubrimos en nuestro
sitio web en http://mmp.illinicare.com o llame a Servicios al afiliado al (877) 941-0482.
2. ¿La Lista de medicamentos cambia alguna vez?
Sí. IlliniCare Health podría agregar o quitar medicamentos de la Lista de medicamentos durante el
año. De manera general, la Lista de medicamentos sólo cambiará si:
• Aparece un medicamento más barato, que funcione tan bien como algún medicamento que
se encuentre actualmente en la Lista de medicamentos o
• Nos enteramos que algún medicamento no es seguro.
También podemos cambiar nuestras reglas sobre algunos medicamentos. Por ejemplo,
podríamos:
?
Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
2
• Decidir si exigir o no aprobación previa para algún medicamento. (Aprobación previa es el
permiso de IlliniCare Health antes que usted puede obtener un medicamento.)
• Aumentar o reducir la cantidad de un medicamento que usted puede obtener (llamado
"límite de cantidad”).
• Agregar o cambiar restricciones de tratamiento progresivo de un medicamento. (Terapia
progresiva significa que usted podría tener que probar un medicamento antes que
cubramos otro medicamento.)
(Para obtener más información acerca de estas restricciones, lea la página 4.)
Le avisaremos cuando quitemos de la Lista de Medicamento algún medicamento que usted esté
tomando. También le diremos cuando cambiemos nuestras reglas para cubrir algún medicamento.
Las preguntas 3, 4 y 7 de abajo tienen más información sobre lo que sucederá cuando cambie la
Lista de medicamentos.
- Usted siempre puede leer la Lista de medicamentos actualizada de IlliniCare Health en
internet, en http://mmp.illinicare.com. También puede llamar a Servicios para Afiliados para
revisar la Lista de medicamentos actual, al (877) 941-0482.
3. ¿Qué sucederá cuando aparezca un medicamento más barato que
funcione tan bien como algún medicamento que se encuentre
actualmente en la Lista de medicamentos?
Si usted toma algún medicamento que hayamos quitado de la lista porque hay un medicamento
más barato que funcione tan bien, le avisaremos. Le avisaremos por lo menos 60 días antes de
sacarlo de la Lista de medicamentos o la próxima vez que pida un resurtido. En ese momento,
usted podrá obtener un suministro de 60 días del medicamento antes de que se haga el cambio
en la Lista de medicamentos.
Le enviaremos un aviso si cambiamos nuestras reglas para la cobertura de algún medicamento
que usted esté tomando. Recibirá este aviso por correo por lo menos 60 días antes que
cambiemos las reglas del medicamento o lo saquemos de nuestra Lista de medicamento
cubiertos. Por ejemplo, si añadimos autorización previa (aprobación) o un límite de cantidad a
algún medicamento que esté tomando, el aviso que reciba explicará las nuevas reglas. Debemos
notificarle del cambio al menos 60 días antes de que entre en vigor. O debemos notificarle en el
momento en que solicite que se le repita la receta del medicamento. Si le notificamos en el
momento en que solicite una recarga de su medicamento, recibirá un suministro de 60 días del
?
Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
3
medicamento. Para mayor información acerca de estas reglas de medicamentos, vea la página 4.
Si tiene preguntas sobre el aviso que recibirá de IlliniCare Health, comuníquese con Servicios
para Afiliado llamando al (877) 941-0482. Los usuarios de TTY deben llamar al 711 (Illinois State
Relay). Del 1 de octubre al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM.
Del 15 de febrero al 30 de septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM.
4. ¿Qué sucederá cuándo averigüemos que algún medicamento no es
seguro?
Si la Administración de alimentos y medicamentos (FDA) dice que algún medicamento no es
seguro, lo quitaremos inmediatamente de la Lista de medicamentos. También le enviaremos una
carta avisándole. Si tiene alguna pregunta después de recibir el aviso sobre el cambio, debería
comunicarse con el doctor que le recetó el medicamento.
5. ¿La cobertura de medicamentos tiene alguna restricción o límite?
¿O hay que hacer algo en particular para poder obtener ciertos
medicamentos?
Sí, algunos medicamentos tienen reglas de cobertura o tienen límites en la cantidad que usted
puede obtener. En algunos casos, tendrá que hacer algo antes de poder obtener el medicamento.
Por ejemplo:
• Aprobación previa (o autorización previa): Para algunos medicamentos, usted, su
médico u otro profesional de la salud deben obtener una aprobación de IlliniCare Health
antes de surtir su receta. Y si usted no consigue la aprobación, IlliniCare Health podría no
cubrir el medicamento.
• Límites de cantidad: A veces IlliniCare Health limita la cantidad de un medicamento que
usted puede obtener.
• Tratamiento progresivo: A veces IlliniCare Health exige que usted siga un tratamiento
progresivo. Esto significa que usted tendrá que probar los medicamentos en un cierto
orden para su enfermedad. Usted podría tener que probar un medicamento antes de que
cubramos otro medicamento. Si a su médico le parece que el primer medicamento no
funciona para usted, entonces cubriremos el segundo.
Usted puede averiguar si su medicamento tiene algún requisito o límite adicional, leyendo los
cuadros de las páginas 12 a 142. Usted también puede obtener más información en nuestro sitio
?
Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
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web en http://mmp.illinicare.com. Hemos publicado en línea un documento que explica nuestra
restricción de autorización previa o restricción de tratamiento progresivo o restricciones de
autorización previa y de tratamiento progresivo. También puede pedirnos que le enviemos una
copia.
Usted también puede pedir una "excepción" a esos límites. Por favor lea en la pregunta 11 más
información sobre las excepciones.
- Si usted está en un hogar para personas mayores u otra institución de cuidados a largo plazo
y necesita algún medicamento que no esté en la Lista de medicamentos o si no puede obtener
el medicamento que necesite fácilmente, podemos ayudarle. Cubriremos un suministro de
emergencia de 31 días del medicamento que usted necesite (a menos que tenga una receta
para menos días), sin importar que usted sea o no un afiliado nuevo de IlliniCare Health. Esto
le dará tiempo para hablar con su médico u otro proveedor médico. Ellos podrán ayudarle a
decidir si hay algún otro medicamento similar en la Lista de medicamentos que usted pueda
tomar en su lugar o si tiene que pedir una excepción. Por favor lea en la pregunta 11 más
información sobre las excepciones.
6.
¿Cómo sabrá si el medicamento que usted quiere tiene limitaciones
o si tiene que hacer algo para obtenerlo?
La Lista de medicamentos cubiertos de la página 12 tiene una columna llamada “Acciones
necesarias, restricciones o límites en el uso”
7. ¿Qué sucederá si cambiamos nuestras reglas sobre cómo cubrimos
algunos medicamentos? Por ejemplo, si agregamos requisitos de
autorización (aprobación) previa, límites de cantidad o restricciones
de tratamiento progresivo a algún medicamento.
Le avisaremos si agregamos requisitos de aprobación previa, límites de cantidad y restricciones
de tratamiento progresivo a un medicamento. Le avisaremos por lo menos 60 días antes de
agregar la restricción o cuando pida su siguiente resurtido. En ese momento, usted podrá obtener
un suministro de 60 días del medicamento antes de que se haga el cambio en la Lista de
medicamentos. Esto le dará tiempo para hablar con su médico u otro profesional de la salud sobre
qué hacer después.
?
Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
5
8. ¿Cómo puede encontrar un medicamento en la Lista de
medicamentos?
Hay dos maneras de encontrar un medicamento:
•
Puede buscar por orden alfabético (si usted sabe cómo se escribe el nombre del
medicamento) o
•
Puede buscar por enfermedad.
Para buscar por orden alfabético, vaya a la sección alfabética de la lista. Usted
puede encontrarla revisando el índice de medicamentos que comienza en la 121.
Para buscar por enfermedad, busque la sección titulada “Lista de medicamentos por
enfermedad” de la página 12. Luego, busque su enfermedad. Por ejemplo, si usted tiene una
enfermedad del corazón, usted debe buscar en esa categoría. Ahí encontrará los medicamentos
que traten enfermedades del corazón.
9. ¿Qué pasará si el medicamento que usted quiere tomar no está en
la Lista de medicamentos?
Si usted no encuentra su medicamento en la Lista de medicamentos, llame a Servicios al afiliado
al (877) 941-0482 > y pregunte por él. Si se entera que IlliniCare Health no cubrirá el
medicamento, usted puede hacer algo de lo siguiente:
• Pida a Servicios al afiliado una lista de medicamentos similar al que quiera tomar. Luego,
muestre la lista a su médico u otro proveedor médico. Éste podrá recetarle un
medicamento similar al de la Lista de medicamentos que usted quiere tomar. O,
• Usted también puede pedir al plan que haga una excepción para cubrir su medicamento.
Por favor lea en la pregunta 11 más información sobre las excepciones.
10. Qué pasará si usted es un afiliado nuevo de IlliniCare Health y no
puede encontrar su medicamento en la Lista o tiene problemas para
obtener su medicamento?
Podemos ayudarle. Podríamos cubrir temporariamente un suministro de 30 días de su
medicamento durante los primeros 90 días que usted sea afiliado de IlliniCare Health. Esto le dará
tiempo para hablar con su médico u otro proveedor médico. Ellos podrán ayudarle a decidir si hay
?
Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
6
algún otro medicamento similar en la Lista de medicamentos que usted pueda tomar en su lugar o
si tiene que pedir una excepción.
Cubriremos un suministro de 30 días de su medicamento si:
• Usted está tomando algún medicamento que no esté en nuestra Lista de medicamentos o
• Las reglas del plan de salud no le permiten obtener la cantidad recetada por su proveedor
médico o
• El medicamento requiere aprobación previa de IlliniCare Health o
• Usted toma algún medicamento que forme parte de una restricción de tratamiento
progresivo.
Si usted vive en un hogar para personas mayores u otra institución de cuidados a largo plazo,
usted puede resurtir su receta hasta por días por tanto tiempo como 91 a 98 días. Usted podrá
resurtir el medicamento varias veces durante los 91 a 98 días. Esto le dará tiempo a su proveedor
médico para cambiar su medicamento por alguno que esté en la Lista de medicamentos o para
pedir una excepción.
En determinadas circunstancias, el plan puede ofrecerle un suministro temporal de un
medicamento cuando el suyo no está incluido en la Lista de medicamentos o cuando está
restringido de alguna forma. Este suministro temporal le da más tiempo para hablar con su médico
sobre un medicamento o dosis diferente que esté cubierto dentro de las pautas del plan.
Para ser elegible para una provisión temporaria, debe cumplir con los dos requisitos siguientes:
1. El medicamento que ha estado tomando ya no está incluido en la Lista de
medicamentos de IlliniCare Health o el medicamento que ha estado tomando ahora
está restringido de alguna forma.
2. Usted debe estar en alguna de las situaciones que se describen a continuación:
• Para los afiliados nuevos del plan y que no se encuentran en un centro de cuidado
a largo plazo: Cubriremos un suministro temporal de su medicamento durante los
primeros 90 días como afiliado de IlliniCare Health. Este suministro temporal será
para un máximo de 30 días, o menos si su receta dispone una cantidad menor de
días. La receta se debe presentar en una farmacia de la red.
• Para los afiliados nuevos del plan y que se encuentran en un centro de cuidado a
largo plazo: Cubriremos un suministro temporal de su medicamento durante los
primeros 90 días como afiliado del plan. El primer suministro será por un máximo
?
Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
7
de 31 días, , o menos si su receta dispone una cantidad menor de días. Si es
necesario, cubriremos recargas adicionales durante sus primeros 90 días en
IlliniCare Health hasta un suministro máximo de 91 a 98 días.
• Para los afiliados que han permanecido en el plan durante más de 90 días y
residen en un centro de cuidado a largo plazo (LTC) y necesitan un suministro de
inmediato; Cubriremos un suministro único de 31 días, o menos si su receta
dispone una cantidad menor de días. Esto se suma al suministro de transición de
cuidado a largo plazo mencionado anteriormente. Debería también solicitar una
excepción o autorización previa en el momento de recargar la receta médica.
11. ¿Puede pedir al plan que haga una excepción para cubrir su
medicamento?
Sí. Usted puede pedirle a IlliniCare Health que haga una excepción para cubrir su medicamento si éste no está en la Lista de medicamentos. Usted también puede pedirnos un cambio a las reglas de su medicamento. • Por ejemplo, IlliniCare Health podría limitar la cantidad que cubriremos de un
medicamento. Si su medicamento tiene un límite, usted puede pedirnos que quitemos el
límite y que cubramos más.
• Otros ejemplos: Usted puede pedirnos que quitemos las restricciones de tratamiento
progresivo o los requisitos de aprobación previa.
12. ¿Cuánto tiempo toma obtener una excepción?
Primero, debemos recibir una declaración de su proveedor médico apoyando su pedido de una
excepción. Después de recibir la declaración, le daremos una decisión sobre su pedido de
excepción a más tardar en 72 horas.
Si usted o su proveedor médico piensan que su salud podría deteriorarse si tiene que esperar 72
horas para obtener una decisión, entonces usted puede pedir una excepción acelerada. Ésta es
una decisión más rápida. Si su proveedor médico apoya su pedido, le daremos una decisión a
más tardar 24 horas después de recibir la declaración de apoyo de su proveedor médico.
?
Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
8
13. ¿Cómo puede pedir una excepción?
Para pedir un excepción, llame a Servicios para Afiliados al (877) 941-0482, usuarios de TTY
deben llamar al 711 (Illinois State Relay). Un representante de Servicios para Afiliados trabajará
con usted y su proveedor para ayudarle a pedir una excepción.
14. ¿Qué son los medicamentos genéricos?
Los medicamentos genéricos están hechos con los mismos ingredientes que los medicamentos
de marca. Generalmente cuestan menos que los medicamentos de marca y no tienen marcas
tan conocidas. Los medicamentos genéricos son aprobados por la Administración de
alimentos y medicamentos (FDA).
IlliniCare Health cubre tanto medicamentos de marca como medicamentos genéricos.
15. ¿Qué son los medicamentos de venta libre (OTC)?
OTC quiere decir "medicamentos que se venden sin receta". Usted puede comprar medicamentos de venta libre con receta de su médico. Usted puede leer la Lista de medicamentos de IlliniCare Health para ver qué medicamentos de venta libre están cubiertos. 16. ¿Cuánto es su copago?
Usted puede leer la Lista de medicamentos de IlliniCare Health para enterarse de los copagos de
cada medicamento.
Los afiliados de IlliniCare Health que vivan en hogares para personas mayores u otras
instituciones de atención a largo plazo, no tendrán copagos. Tampoco tendrán copagos algunos
afiliados que reciban atención a largo plazo en la comunidad
Los copagos están organizados por niveles. Los niveles son grupos de medicamentos con los
mismos copagos.
?
Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
9
• Los medicamentos de Nivel 1 tienen el copago más bajo. Son medicamentos genéricos. El
Copago es de $0.
• Los medicamentos de Nivel 2 tienen un copago intermedio. Son medicamentos de marca.
El Copago será de $0 a $6.60, dependiendo de su nivel de elegibilidad para Medicaid.
• Los medicamentos de Nivel 3 tienen un copago de $0. La mayoría de estos medicamentos
son medicamentos OTC.
Lista de medicamentos cubiertos
La lista de medicamentos cubiertos que comienza en la página siguiente le da información sobre
los medicamentos cubiertos por IlliniCare Health. Si usted tiene problemas para encontrar su
medicamento en la lista, lea el Índice que comienza en la página 121.
La primera columna del cuadro contiene el nombre del medicamento. Los medicamentos de
marca están escritos en mayúsculas (por ejemplo, HUMALOG) y los medicamentos genéricos
están escritos en cursivas minúsculas (por ejemplo, amoxicillin).
La información de la columna titulada "Acciones necesarias, restricciones o límites en el uso", le
indica si IlliniCare Health tiene alguna regla para cubrir su medicamento.
Abreviaciones
B/D
DP
LA
PA
QL
?
Descripciones
Este medicamento de receta tiene un requisito de autorización previa de la
Parte B o la Parte D. Este medicamento puede estar cubierto bajo Medicare
Parte B o D según las circunstancias. Puede que se tenga que presentar
información que describa el uso y contexto del medicamento para tomar la
determinación.
El medicamento no es un medicamento de la Parte D
Disponibilidad limitada. Esta receta médica podría estar disponible solo en
farmacias determinadas. Para obtener mayor información, llame a Servicios
para Afiliados al (877) 941-0482. Usuarios de TTY/TDD deben llamar al 711
(Illinois State Relay).
Autorización previa. IlliniCare Health requiere que usted o su médico obtenga
autorización previa para ciertos medicamentos. Esto significa que tendrá que
obtener aprobación de IlliniCare Health antes de surtir sus recetas médicas. Si
no obtiene aprobación, IlliniCare Health podría no cubrir el medicamento.
Límite de cantidad. Para ciertos medicamentos, IlliniCare Health limita la
cantidad del medicamento que cubrirá. Por ejemplo, solo 30 tabletas de
ABILIFY cada 30 días. Esto podría ser en suma a un suministro estándar de
uno o tres meses.
Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
10
MO
Medicamento de mantenimiento. Este medicamento recetado es elegible para
un suministro de 90 días a través de nuestro servicio de pedido por correo, así
como a través de ciertas farmacias de venta al detalle de la red. Considere el
uso de pedidos por correo para sus medicamentos a largo plazo
(mantenimiento, tales como medicamentos para la presión alta). Las farmacias
minoristas de la red podrían ser más apropiadas para recetas a corto plazo
(como antibióticos).
Nota: El “DP” junto a un medicamento significa que el medicamento no es un “medicamento de la
Parte D”. El monto que paga al despachar una receta por este medicamento no cuenta hacia el
total de sus costos de medicamentos (es decir, el monto que paga no le ayuda hacia su
elegibilidad para cobertura catastrófica). Además, si usted se encuentra recibiendo ayuda
adicional para pagar sus recetas médicas, no recibirá ninguna ayuda adicional para pagar por
estos medicamentos. Estos medicamentos tienen también diferentes reglamentos de apelaciones.
Un apelación es una manera formal de solicitarnos que revisemos una decisión de cobertura y
que la cambiemos, si cree que hemos cometido un error. Por ejemplo, podríamos decidir que un
medicamento que usted toma no está cubierto o ya no está cubierto por Medicare o Medicaid. Si
usted o su doctor no está de acuerdo con nuestra decisión, puede apelar. Para pedir instrucciones
acerca de cómo apelar, llame Servicios para Afiliados al (877) 941-0482. Puede además leer la
Guía para Afiliados para informarse sobre cómo apelar una decisión.
?
Si tiene alguna pregunta, por favor llame a IlliniCare Health al (877) 941-0482. Del 1 de octubre
al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del15 de febrero al 30 de
septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM. Usuarios de TTY/TDD deben
llamar al 711 (Illinois State Relay). La llamada es gratuita. Para obtener más información, visite
http://mmp.illinicare.com.
11
Nombre del medicamento
Analgesics
Analgesics
APAP 500 LIQUID 500MG/5ML
butalbital/acetaminophen/caffeine/codeine capsule 325mg;
50mg; 40mg; 30mg
butalbital/acetaminophen/caffeine capsule 325mg; 50mg;
40mg
butalbital/acetaminophen/caffeine tablet 325mg; 50mg; 40mg
butalbital/acetaminophen tablet 325mg; 50mg
butalbital/aspirin/caffeine capsule 325mg; 50mg; 40mg
butalbital/aspirin/caffeine tablet 325mg; 50mg; 40mg
feverall suppository 325mg
GRALISE STARTER MISCELLANEOUS 0
GRALISE TABLET 300MG
GRALISE TABLET 600MG
tencon tablet 325mg; 50mg
TYLENOL ARTHRITIS PAIN TABLET EXTENDED
RELEASE 650MG
TYLENOL EXTRA STRENGTH TABLET 500MG
TYLENOL SORE THROAT DÍATIME LIQUID
500MG/15ML
Nonsteroidal Anti-inflammatory Drugs
all día pain relief tablet 220mg
aspirin suppository 600mg
aspirin tablet chewable 81mg
aspirin tablet 325mg
BUFFERIN TABLET 325MG; 158MG; 34MG; 63MG
diclofenac potassium tablet 50mg
diclofenac sodium dr tablet delayed release 25mg
diclofenac sodium dr tablet delayed release 50mg
diclofenac sodium dr tablet delayed release 75mg
diclofenac sodium er tablet extended release 24 hour 100mg
diflunisal tablet 500mg
etodolac er tablet extended release 24 hour 400mg
etodolac er tablet extended release 24 hour 500mg
etodolac er tablet extended release 24 hour 600mg
etodolac capsule 200mg
etodolac capsule 300mg
etodolac tablet 400mg
etodolac tablet 500mg
EXCEDRIN EXTRA STRENGTH TABLET 250MG;
250MG; 65MG
fenoprofen calcium tablet 600mg
flurbiprofen tablet 100mg
flurbiprofen tablet 50mg
ibuprofen capsule 200mg
ibuprofen suspension 100mg/5ml
Página 1 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
$0(Nivel 1)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
DP
DP
DP
DP
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 1)
DP
DP
Nombre del medicamento
ibuprofen tablet 400mg
ibuprofen tablet 600mg
ibuprofen tablet 800mg
indomethacin er capsule extended release 75mg
indomethacin capsule 25mg
indomethacin capsule 50mg
ketoprofen er capsule extended release 24 hour 200mg
ketoprofen capsule 50mg
ketoprofen capsule 75mg
ketorolac tromethamine injection 15mg/ml
ketorolac tromethamine injection 30mg/ml
meclofenamate sodium capsule 100mg
meclofenamate sodium capsule 50mg
meloxicam suspension 7.5mg/5ml
meloxicam tablet 15mg
meloxicam tablet 7.5mg
nabumetone tablet 500mg
nabumetone tablet 750mg
naproxen dr tablet delayed release 375mg
naproxen dr tablet delayed release 500mg
naproxen sodium tablet 275mg
naproxen sodium tablet 550mg
naproxen suspension 125mg/5ml
naproxen tablet 250mg
naproxen tablet 375mg
naproxen tablet 500mg
oxaprozin tablet 600mg
piroxicam capsule 10mg
piroxicam capsule 20mg
sulindac tablet 150mg
sulindac tablet 200mg
tolmetin sodium capsule 400mg
tolmetin sodium tablet 200mg
tolmetin sodium tablet 600mg
Opioid Analgesics, Long-acting
fentanyl patch 72 hour 100mcg/hr
fentanyl patch 72 hour 12mcg/hr
fentanyl patch 72 hour 25mcg/hr
fentanyl patch 72 hour 37.5mcg/hr
fentanyl patch 72 hour 50mcg/hr
fentanyl patch 72 hour 62.5mcg/hr
fentanyl patch 72 hour 75mcg/hr
fentanyl patch 72 hour 87.5mcg/hr
levorphanol tartrate tablet 2mg
METHADONE HCL INJECTION 10MG/ML
Página 2 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
PA (Agentes
anti-inflamatorios)
$0(Nivel 1)
PA (Agentes
anti-inflamatorios)
$0(Nivel 1)
PA (Agentes
anti-inflamatorios)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
QL (10 EA cada 30 días)
QL (10 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (10 EA cada 30 días)
$0(Nivel 1)
QL (10 EA cada 30 días)
$0(Nivel 1)
QL (10 EA cada 30 días)
$0(Nivel 1)
QL (10 EA cada 30 días)
$0(Nivel 1)
QL (10 EA cada 30 días)
$0(Nivel 1)
QL (10 EA cada 30 días)
$0(Nivel 1)
QL (240 EA cada 30 días)
$0-$6.60(Nivel 2)
Nombre del medicamento
methadone hcl solution 10mg/5ml
methadone hcl solution 5mg/5ml
methadone hcl tablet 10mg
methadone hcl tablet 5mg
methadose tablet 10mg
morphine sulfate er tablet extended release 100mg
morphine sulfate er tablet extended release 15mg
morphine sulfate er tablet extended release 200mg
morphine sulfate er tablet extended release 30mg
morphine sulfate er tablet extended release 60mg
Opioid Analgesics, Short-acting
acetaminophen/codeine #3 tablet 300mg; 30mg
acetaminophen/codeine tablet 300mg; 15mg
acetaminophen/codeine tablet 300mg; 60mg
ascomp/codeine capsule 325mg; 50mg; 40mg; 30mg
butorphanol tartrate injection 1mg/ml
butorphanol tartrate injection 2mg/ml
butorphanol tartrate solution 10mg/ml
DEMEROL INJECTION 50MG/ML
duramorph injection 0.5mg/ml
duramorph injection 1mg/ml
endocet tablet 325mg; 10mg
endocet tablet 325mg; 5mg
endocet tablet 325mg; 7.5mg
Citrato de fentanilo por víatransmucosa oral lozenge on a
handle 1200mcg
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (180 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (390 EA cada 30 días)
$0(Nivel 1)
QL (390 EA cada 30 días)
$0(Nivel 1)
QL (390 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (360 EA cada 30 días)
$0(Nivel 1)
QL (360 EA cada 30 días)
$0(Nivel 1)
QL (360 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
PA (Citrato de fentanilo
por víatransmucosa oral)
QL (120 EA cada 30 días)
Citrato de fentanilo por víatransmucosa oral lozenge on a
$0(Nivel 1)
handle 1600mcg
PA (Citrato de fentanilo
por víatransmucosa oral)
Citrato de fentanilo por víatransmucosa oral lozenge on a
$0(Nivel 1)
QL (120 EA cada 30 días)
handle 200mcg
PA (Citrato de fentanilo
por víatransmucosa oral)
Citrato de fentanilo por víatransmucosa oral lozenge on a
$0(Nivel 1)
QL (120 EA cada 30 días)
handle 400mcg
PA (Citrato de fentanilo
por víatransmucosa oral)
Citrato de fentanilo por víatransmucosa oral lozenge on a
$0(Nivel 1)
QL (120 EA cada 30 días)
handle 600mcg
PA (Citrato de fentanilo
por víatransmucosa oral)
Citrato de fentanilo por víatransmucosa oral lozenge on a
$0(Nivel 1)
QL (120 EA cada 30 días)
handle 800mcg
PA (Citrato de fentanilo
por víatransmucosa oral)
hydrocodone bitartrate/acetaminophen tablet 325mg; 2.5mg $0(Nivel 1)
QL (360 EA cada 30 días)
hydrocodone bitartrate/acetaminophen tablet 750mg; 10mg $0(Nivel 1)
QL (150 EA cada 30 días)
hydrocodone/acetaminophen tablet 325mg; 10mg
$0(Nivel 1)
QL (360 EA cada 30 días)
hydrocodone/acetaminophen tablet 325mg; 5mg
$0(Nivel 1)
QL (360 EA cada 30 días)
hydrocodone/acetaminophen tablet 325mg; 7.5mg
$0(Nivel 1)
QL (360 EA cada 30 días)
hydrocodone/acetaminophen tablet 500mg; 10mg
$0(Nivel 1)
QL (240 EA cada 30 días)
Página 3 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
hydrocodone/acetaminophen tablet 500mg; 5mg
$0(Nivel 1)
QL (240 EA cada 30 días)
hydrocodone/acetaminophen tablet 500mg; 7.5mg
$0(Nivel 1)
QL (240 EA cada 30 días)
$0(Nivel 1)
hydrocodone/acetaminophen tablet 650mg; 10mg
hydrocodone/acetaminophen tablet 650mg; 7.5mg
$0(Nivel 1)
QL (180 EA cada 30 días)
hydrocodone/acetaminophen tablet 660mg; 10mg
$0(Nivel 1)
QL (180 EA cada 30 días)
$0(Nivel 1)
QL (150 EA cada 30 días)
hydrocodone/acetaminophen tablet 750mg; 7.5mg
hydromorphone hcl injection 500mg/50ml
$0(Nivel 1)
hydromorphone hcl tablet 2mg
$0(Nivel 1)
hydromorphone hcl tablet 4mg
$0(Nivel 1)
hydromorphone hcl tablet 8mg
$0(Nivel 1)
LAZANDA SOLUTION 100MCG/ACT
$0-$6.60(Nivel 2) QL (600 EA cada 30 días)
PA (Lazanda)
LAZANDA SOLUTION 400MCG/ACT
$0-$6.60(Nivel 2) QL (150 EA cada 30 días)
PA (Lazanda)
meperidine hcl injection 100mg/ml
$0(Nivel 1)
meperidine hcl injection 25mg/ml
$0(Nivel 1)
meperidine hcl injection 50mg/ml
$0(Nivel 1)
morphine sulfate solution 10mg/5ml
$0(Nivel 1)
morphine sulfate solution 20mg/5ml
$0(Nivel 1)
morphine sulfate solution 20mg/ml
$0(Nivel 1)
morphine sulfate tablet 15mg
$0(Nivel 1)
morphine sulfate tablet 30mg
$0(Nivel 1)
nalbuphine hcl injection 10mg/ml
$0(Nivel 1)
nalbuphine hcl injection 20mg/ml
$0(Nivel 1)
oxycodone hcl tablet 10mg
$0(Nivel 1)
oxycodone hcl tablet 15mg
$0(Nivel 1)
oxycodone hcl tablet 20mg
$0(Nivel 1)
oxycodone hcl tablet 30mg
$0(Nivel 1)
oxycodone hcl tablet 5mg
$0(Nivel 1)
oxycodone/acetaminophen capsule 500mg; 5mg
$0(Nivel 1)
oxycodone/acetaminophen tablet 325mg; 10mg
$0(Nivel 1)
QL (360 EA cada 30 días)
oxycodone/acetaminophen tablet 325mg; 5mg
$0(Nivel 1)
QL (360 EA cada 30 días)
oxycodone/acetaminophen tablet 325mg; 7.5mg
$0(Nivel 1)
QL (360 EA cada 30 días)
$0(Nivel 1)
QL (240 EA cada 30 días)
oxycodone/acetaminophen tablet 500mg; 7.5mg
oxycodone/acetaminophen tablet 650mg; 10mg
$0(Nivel 1)
roxicet tablet 325mg; 5mg
$0(Nivel 1)
QL (360 EA cada 30 días)
stagesic capsule 500mg; 5mg
$0(Nivel 1)
QL (240 EA cada 30 días)
TALWIN INJECTION 30MG/ML
$0-$6.60(Nivel 2)
tramadol hcl tablet 50mg
$0(Nivel 1)
QL (240 EA cada 30 días)
tramadol hydrochloride/acetaminophen tablet 325mg; 37.5mg $0(Nivel 1)
QL (240 EA cada 30 días)
Anesthetics
Local Anesthetics
lidocaine hcl jelly gel 2%
$0(Nivel 1)
lidocaine hcl jelly gel 2%
$0(Nivel 1)
lidocaine hcl injection 0.5%
$0(Nivel 1)
lidocaine hcl injection 1%
$0(Nivel 1)
lidocaine hcl solution 4%
$0(Nivel 1)
lidocaine viscous solution 2%
$0(Nivel 1)
Página 4 de 143
Nombre del medicamento
lidocaine/prilocaine cream 2.5%; 2.5%
lidocaine ointment 5%
lidocaine patch 5%
lidocream cream 4%
XYLOCAINE-MPF INJECTION 1%
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium dr tablet delayed release 333mg
disulfiram tablet 250mg
disulfiram tablet 500mg
Opioid Dependence Treatments
buprenorphine hcl injection 0.3mg/ml
buprenorphine hcl tablet sublingual 2mg
buprenorphine hcl tablet sublingual 8mg
naltrexone hcl tablet 50mg
SUBOXONE FILM 12MG; 3MG
SUBOXONE FILM 2MG; 0.5MG
SUBOXONE FILM 4MG; 1MG
SUBOXONE FILM 8MG; 2MG
ZUBSOLV TABLET SUBLINGUAL 1.4MG; 0.36MG
ZUBSOLV TABLET SUBLINGUAL 5.7MG; 1.4MG
ZUBSOLV TABLET SUBLINGUAL 8.6MG; 2.1MG
Opioid Reversal Agents
naloxone hcl injection 1mg/ml
Smoking Cessation Agents
buproban tablet extended release 12 hour 150mg
CHANTIX CONTINUING MONTH PAK TABLET 1MG
CHANTIX STARTING MONTH PAK TABLET 0
CHANTIX TABLET 0.5MG
CHANTIX TABLET 1MG
gnp nicotine polacrilex gum 2mg
gnp nicotine polacrilex gum 2mg
gnp nicotine polacrilex gum 2mg
gnp nicotine polacrilex gum 4mg
gnp nicotine polacrilex gum 4mg
gnp nicotine polacrilex gum 4mg
gnp nicotine polacrilex lozenge 2mg
gnp nicotine polacrilex lozenge 4mg
NICODERM CQ PATCH 24 HOUR 14MG/24HR
NICODERM CQ PATCH 24 HOUR 21MG/24HR
NICODERM CQ PATCH 24 HOUR 21MG/24HR
NICODERM CQ PATCH 24 HOUR 21MG/24HR
NICODERM CQ PATCH 24 HOUR 7MG/24HR
nicorelief gum 2mg
nicorelief gum 2mg
nicorelief gum 2mg
nicorelief gum 4mg
Página 5 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
PA (Anestésicos)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (56 EA cada 28 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (56 EA cada 28 días)
$0-$6.60(Nivel 2) QL (56 EA cada 28 días)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
nicorelief gum 4mg
nicorelief gum 4mg
nicorelief gum 4mg
NICORETTE MINI LOZENGE 2MG
NICORETTE STARTER KIT GUM 2MG
NICORETTE STARTER KIT GUM 2MG
NICORETTE STARTER KIT GUM 4MG
NICORETTE GUM 2MG
NICORETTE GUM 2MG
NICORETTE GUM 2MG
NICORETTE GUM 2MG
NICORETTE GUM 2MG
NICORETTE GUM 4MG
NICORETTE GUM 4MG
NICORETTE GUM 4MG
NICORETTE GUM 4MG
NICORETTE GUM 4MG
NICORETTE GUM 4MG
NICORETTE LOZENGE 2MG
NICORETTE LOZENGE 2MG
NICORETTE LOZENGE 2MG
NICORETTE LOZENGE 2MG
NICORETTE LOZENGE 4MG
NICORETTE LOZENGE 4MG
NICORETTE LOZENGE 4MG
NICORETTE LOZENGE 4MG
NICORETTE LOZENGE 4MG
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 2mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
nicotine polacrilex gum 4mg
NICOTINE TRANSDERMAL SYSTEM KIT 0
Página 6 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
nicotine transdermal system patch 24 hour 14mg/24hr
nicotine transdermal system patch 24 hour 14mg/24hr
nicotine transdermal system patch 24 hour 21mg/24hr
nicotine transdermal system patch 24 hour 21mg/24hr
nicotine transdermal system patch 24 hour 7mg/24hr
nicotine transdermal system patch 24 hour 7mg/24hr
nicotine transdermal system patch 24 hour 7mg/24hr
nicotine patch 24 hour 14mg/24hr
nicotine patch 24 hour 14mg/24hr
nicotine patch 24 hour 21mg/24hr
nicotine patch 24 hour 21mg/24hr
nicotine patch 24 hour 21mg/24hr
nicotine patch 24 hour 7mg/24hr
nicotine patch 24 hour 7mg/24hr
NICOTROL NS SOLUTION 10MG/ML
sm nicotine polacrilex gum 2mg
sm nicotine polacrilex gum 4mg
sm nicotine polacrilex lozenge 4mg
sm nicotine gum 4mg
sm nicotine gum 4mg
sm nicotine gum 4mg
sm nicotine patch 24 hour 14mg/24hr
sm nicotine patch 24 hour 21mg/24hr
sm nicotine patch 24 hour 7mg/24hr
thrive gum 2mg
thrive gum 4mg
Antibacterials
Aminoglycosides
amikacin sulfate injection 500mg/2ml
gentak ointment 0.3%
GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE
INJECTION 0.9MG/ML; 0.9%
GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE
INJECTION 1.4MG/ML; 0.9%
gentamicin sulfate/0.9% sodium chloride injection 1.6mg/ml;
0.9%
gentamicin sulfate/0.9% sodium chloride injection 1mg/ml;
0.9%
gentamicin sulfate cream 0.1%
gentamicin sulfate injection 10mg/ml
gentamicin sulfate injection 40mg/ml
gentamicin sulfate ointment 0.1%
gentamicin sulfate ointment 0.3%
gentamicin sulfate solution 0.3%
isotonic gentamicin injection 0.8mg/ml; 0.9%
isotonic gentamicin injection 1.2mg/ml; 0.9%
neomycin sulfate tablet 500mg
Página 7 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
neomycin/polymyxin b sulfates solution 40mg/ml;
200000unit/ml
paromomycin sulfate capsule 250mg
STREPTOMYCIN SULFATE INJECTION 1GM
TOBRAMYCIN SULFATE/SODIUM CHLORIDE
INJECTION 0.9%; 0.8MG/ML
tobramycin sulfate injection 10mg/ml
tobramycin sulfate injection 80mg/2ml
tobramycin sulfate solution 0.3%
Antibacterials, Other
alcohol prep pads pad 70%
baciim injection 50000unit
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin zinc ointment 500unit/gm
bacitracin/neomycin/polymyxin ointment 400unit/gm;
5mg/gm; 5000unit/gm
bacitracin/neomycin/polymyxin ointment 400unit/gm;
5mg/gm; 5000unit/gm
BACITRACIN INJECTION 50000UNIT
bacitracin ointment 500unit/gm
bacitracin ointment 500unit/gm
bacitracin ointment 500unit/gm
BETADINE SKIN CLEANSER SOLUTION 7.5%
BETADINE SURGICAL SCRUB SOLUTION 7.5%
BETADINE SURGICAL SCRUB SOLUTION 7.5%
BETADINE SURGICAL SCRUB SOLUTION 7.5%
BETADINE SWAB AID SWAB 10%
BETADINE SWABSTICKS SWAB 10%
BETADINE SOLUTION 10%
BETADINE SOLUTION 10%
BETADINE SOLUTION 10%
BETADINE SOLUTION 10%
CHLORAMPHENICOL SODIUM SUCCINATE
INJECTION 1GM
CLEOCIN IN D5W INJECTION 300MG/50ML; 5%
CLEOCIN IN D5W INJECTION 600MG/50ML; 5%
CLEOCIN IN D5W INJECTION 900MG/50ML; 5%
CLEOCIN PEDIATRIC GRANULES SOLUTION
RECONSTITUTED 75MG/5ML
clindamax gel 1%
clindamycin hcl capsule 150mg
clindamycin hcl capsule 300mg
Página 8 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
clindamycin hcl capsule 75mg
clindamycin palmitate hcl solution reconstituted 75mg/5ml
clindamycin phosphate add-vantage injection 150mg/ml
clindamycin phosphate in d5w injection 300mg/50ml; 5%
clindamycin phosphate in d5w injection 600mg/50ml; 5%
clindamycin phosphate in d5w injection 900mg/50ml; 5%
clindamycin phosphate cream 2%
clindamycin phosphate gel 1%
clindamycin phosphate lotion 1%
clindamycin phosphate solution 1%
clindamycin phosphate swab 1%
colistimethate sodium injection 150mg
CUBICIN INJECTION 500MG
double antibiotic ointment 500unit/gm; 10000unit/gm
double antibiotic ointment 500unit/gm; 10000unit/gm
gnp antibiotic plus pramoxine cream 3.5mg/gm;
10000unit/gm; 10mg/gm
gnp bacitracin zinc ointment 500unit/gm
gnp povidone-iodine solution 10%
gnp triple antibiotic ointment 400unit/gm; 3.5mg/gm;
5000unit/gm
gnp triple antibiotic ointment 400unit/gm; 3.5mg/gm;
5000unit/gm
hm bacitracin ointment 500unit/gm
hm double antibiotic ointment 500unit/gm; 100000unit/gm
hm povidone-iodine solution 10%
HYDROGEN PEROXIDE SOLUTION 3%
LINCOCIN INJECTION 300MG/ML
linezolid injection 2mg/ml
linezolid tablet 600mg
methenamine hippurate tablet 1gm
metronidazole in nacl 0.79% injection 500mg/100ml; 0.79%
metronidazole vaginal gel 0.75%
metronidazole cream 0.75%
metronidazole gel 0.75%
metronidazole lotion 0.75%
metronidazole tablet 250mg
metronidazole tablet 500mg
mupirocin ointment 2%
neomycin/polymyxin/bacitracin/hydrocortisone ointment
400unit/gm; 1%; 0.5%; 10000unit/gm
neomycin/polymyxin/hydrocortisone suspension 1%;
3.5mg/ml; 10000unit/ml
nitrofurantoin macrocrystals capsule 100mg
nitrofurantoin macrocrystals capsule 50mg
nitrofurantoin monohydrate capsule 100mg
polymyxin b sulfate injection 500000unit
povidone-iodine ointment 10%
Página 9 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
B/D
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
QL (20 EA cada 10 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
PA (Antibacterianos)
PA (Antibacterianos)
PA (Antibacterianos)
DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
Nombre del medicamento
povidone-iodine ointment 10%
povidone-iodine solution 10%
povidone-iodine solution 10%
povidone-iodine solution 10%
povidone-iodine solution 10%
PRIMSOL SOLUTION 50MG/5ML
sb triple antibiotic ointment 400unit/gm; 3.5mg/gm;
5000unit/gm
silver sulfadiazine cream 1%
$0(Nivel 1)
sm double antibiotic ointment 500unit/gm; 100000unit/gm
$0(Nivel 3)
DP
sm first aid antibiotic ointment 500unit/gm
$0(Nivel 3)
DP
sm povidone-iodine solution 10%
$0(Nivel 3)
DP
sm povidone-iodine solution 10%
$0(Nivel 3)
DP
sm triple antibiotic ointment 400unit/gm; 3.5mg/gm;
$0(Nivel 3)
DP
5000unit/gm
ssd cream 1%
$0(Nivel 1)
summers eve medicated solution 0.3%
$0(Nivel 3)
DP
SYNERCID INJECTION 350MG; 150MG
$0-$6.60(Nivel 2)
$0(Nivel 1)
trimethoprim tablet 100mg
triple antibiotic plus ointment 500unit/gm; 5mg/gm;
$0(Nivel 3)
DP
10000unit/gm; 10mg/gm
triple antibiotic ointment 400unit/gm; 3.5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 3.5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 3.5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 3.5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 3.5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm $0(Nivel 3)
DP
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm $0(Nivel 3)
DP
TYGACIL INJECTION 50MG
$0-$6.60(Nivel 2)
vancomycin hcl capsule 125mg
$0(Nivel 1)
vancomycin hcl capsule 250mg
$0(Nivel 1)
vancomycin hcl injection 1000mg
$0(Nivel 1)
vancomycin hcl injection 10gm
$0(Nivel 1)
vancomycin hcl injection 500mg
$0(Nivel 1)
vandazole gel 0.75%
$0(Nivel 1)
XIFAXAN TABLET 200MG
$0-$6.60(Nivel 2)
ZYVOX INJECTION 2MG/ML
$0-$6.60(Nivel 2)
ZYVOX SUSPENSION RECONSTITUTED 100MG/5ML $0-$6.60(Nivel 2) QL (600 ML cada 10 días)
ZYVOX TABLET 600MG
$0-$6.60(Nivel 2) QL (20 EA cada 10 días)
Beta-lactam, Cephalosporins
cefaclor er tablet extended release 12 hour 500mg
$0(Nivel 1)
cefaclor capsule 250mg
$0(Nivel 1)
cefaclor capsule 500mg
$0(Nivel 1)
Página 10 de 143
Nombre del medicamento
cefadroxil capsule 500mg
cefadroxil suspension reconstituted 250mg/5ml
cefadroxil suspension reconstituted 500mg/5ml
cefadroxil tablet 1gm
cefazolin sodium injection 10gm
cefazolin sodium injection 1gm
CEFAZOLIN SODIUM INJECTION 1GM; 5%
cefazolin sodium injection 500mg
cefdinir capsule 300mg
cefdinir suspension reconstituted 125mg/5ml
cefdinir suspension reconstituted 250mg/5ml
cefepime injection 1gm
cefepime injection 2gm
cefixime suspension reconstituted 100mg/5ml
cefixime suspension reconstituted 200mg/5ml
cefotaxime sodium injection 10gm
cefotaxime sodium injection 1gm
cefotaxime sodium injection 2gm
cefotaxime sodium injection 500mg
cefoxitin sodium injection 10gm
cefoxitin sodium injection 1gm
cefoxitin sodium injection 2gm
cefpodoxime proxetil tablet 100mg
cefpodoxime proxetil tablet 200mg
cefprozil suspension reconstituted 125mg/5ml
cefprozil suspension reconstituted 250mg/5ml
cefprozil tablet 250mg
cefprozil tablet 500mg
ceftazidime injection 1gm
ceftazidime injection 2gm
ceftazidime injection 6gm
ceftriaxone sodium injection 10gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
Página 11 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
ceftriaxone sodium injection 1gm
$0(Nivel 1)
ceftriaxone sodium injection 1gm
$0(Nivel 1)
$0(Nivel 1)
ceftriaxone sodium injection 1gm
$0(Nivel 1)
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
$0(Nivel 1)
$0(Nivel 1)
ceftriaxone sodium injection 250mg
ceftriaxone sodium injection 2gm
$0(Nivel 1)
$0(Nivel 1)
ceftriaxone sodium injection 2gm
$0(Nivel 1)
ceftriaxone sodium injection 2gm
ceftriaxone sodium injection 2gm
$0(Nivel 1)
$0(Nivel 1)
ceftriaxone sodium injection 2gm
ceftriaxone sodium injection 2gm
$0(Nivel 1)
ceftriaxone sodium injection 2gm
$0(Nivel 1)
$0(Nivel 1)
ceftriaxone sodium injection 2gm
ceftriaxone sodium injection 2gm
$0(Nivel 1)
$0(Nivel 1)
ceftriaxone sodium injection 2gm
ceftriaxone sodium injection 2gm
$0(Nivel 1)
ceftriaxone sodium injection 2gm
$0(Nivel 1)
$0(Nivel 1)
ceftriaxone sodium injection 2gm
ceftriaxone sodium injection 2gm
$0(Nivel 1)
ceftriaxone sodium injection 2gm
$0(Nivel 1)
ceftriaxone sodium injection 2gm
$0(Nivel 1)
ceftriaxone sodium injection 2gm
$0(Nivel 1)
$0(Nivel 1)
ceftriaxone sodium injection 2gm
ceftriaxone sodium injection 2gm
$0(Nivel 1)
ceftriaxone sodium injection 2gm
$0(Nivel 1)
ceftriaxone sodium injection 500mg
$0(Nivel 1)
cefuroxime axetil tablet 250mg
$0(Nivel 1)
$0(Nivel 1)
cefuroxime axetil tablet 500mg
cefuroxime sodium injection 1.5gm
$0(Nivel 1)
cefuroxime sodium injection 7.5gm
$0(Nivel 1)
cefuroxime sodium injection 750mg
$0(Nivel 1)
cephalexin capsule 250mg
$0(Nivel 1)
$0(Nivel 1)
cephalexin capsule 500mg
cephalexin suspension reconstituted 125mg/5ml
$0(Nivel 1)
cephalexin suspension reconstituted 250mg/5ml
$0(Nivel 1)
cephalexin tablet 250mg
$0(Nivel 1)
cephalexin tablet 500mg
$0(Nivel 1)
CLAFORAN INJECTION 10GM
$0-$6.60(Nivel 2)
CLAFORAN INJECTION 1GM
$0-$6.60(Nivel 2)
CLAFORAN INJECTION 2GM
$0-$6.60(Nivel 2)
CLAFORAN INJECTION 500MG
$0-$6.60(Nivel 2)
FORTAZ INJECTION 1GM
$0-$6.60(Nivel 2)
FORTAZ INJECTION 2GM
$0-$6.60(Nivel 2)
SUPRAX CAPSULE 400MG
$0-$6.60(Nivel 2)
SUPRAX SUSPENSION RECONSTITUTED 100MG/5ML $0-$6.60(Nivel 2)
SUPRAX SUSPENSION RECONSTITUTED 200MG/5ML $0-$6.60(Nivel 2)
SUPRAX SUSPENSION RECONSTITUTED 500MG/5ML $0-$6.60(Nivel 2)
Página 12 de 143
Nombre del medicamento
SUPRAX TABLET CHEWABLE 100MG
SUPRAX TABLET CHEWABLE 200MG
SUPRAX TABLET 400MG
TEFLARO INJECTION 400MG
TEFLARO INJECTION 600MG
Beta-lactam, Other
AZACTAM IN ISO-OSMOTIC DEXTROSE INJECTION
1GM; 0
AZACTAM IN ISO-OSMOTIC DEXTROSE INJECTION
2GM; 0
AZACTAM INJECTION 1GM
aztreonam injection 1gm
imipenem/cilastatin injection 250mg; 250mg
imipenem/cilastatin injection 500mg; 500mg
INVANZ INJECTION 1GM
meropenem injection 500mg
Beta-lactam, Penicillins
amoxicillin/clavulanate potassium er tablet extended release
12 hour 1000mg; 62.5mg
amoxicillin/clavulanate potassium suspension reconstituted
200mg/5ml; 28.5mg/5ml
amoxicillin/clavulanate potassium suspension reconstituted
250mg/5ml; 62.5mg/5ml
amoxicillin/clavulanate potassium suspension reconstituted
400mg/5ml; 57mg/5ml
amoxicillin/clavulanate potassium suspension reconstituted
600mg/5ml; 42.9mg/5ml
amoxicillin/clavulanate potassium tablet chewable 200mg;
28.5mg
amoxicillin/clavulanate potassium tablet chewable 400mg;
57mg
amoxicillin/clavulanate potassium tablet 250mg; 125mg
amoxicillin/clavulanate potassium tablet 500mg; 125mg
amoxicillin/clavulanate potassium tablet 875mg; 125mg
amoxicillin capsule 250mg
amoxicillin capsule 500mg
amoxicillin suspension reconstituted 125mg/5ml
amoxicillin suspension reconstituted 200mg/5ml
amoxicillin suspension reconstituted 250mg/5ml
amoxicillin suspension reconstituted 400mg/5ml
amoxicillin tablet chewable 125mg
amoxicillin tablet chewable 250mg
amoxicillin tablet 500mg
amoxicillin tablet 875mg
ampicillin sodium injection 10gm
AMPICILLIN SODIUM INJECTION 125MG
ampicillin sodium injection 1gm
ampicillin-sulbactam injection 10gm; 5gm
Página 13 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
ampicillin-sulbactam injection 1gm; 0.5gm
ampicillin-sulbactam injection 2gm; 1gm
ampicillin capsule 250mg
ampicillin capsule 500mg
ampicillin suspension reconstituted 125mg/5ml
ampicillin suspension reconstituted 250mg/5ml
BACTOCILL IN DEXTROSE INJECTION 0; 1GM/50ML
BACTOCILL IN DEXTROSE INJECTION 0; 2GM/50ML
BICILLIN C-R INJECTION 300000UNIT/ML;
300000UNIT/ML
BICILLIN C-R INJECTION 900000UNIT/2ML;
300000UNIT/2ML
BICILLIN L-A INJECTION 1200000UNIT/2ML
BICILLIN L-A INJECTION 2400000UNIT/4ML
BICILLIN L-A INJECTION 600000UNIT/ML
dicloxacillin sodium capsule 250mg
dicloxacillin sodium capsule 500mg
nafcillin sodium injection 10gm
nafcillin sodium injection 1gm
NALLPEN/DEXTROSE INJECTION 0; 1GM/50ML
oxacillin sodium injection 10gm
oxacillin sodium injection 2gm
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE INJECTION 0; 40000UNIT/ML
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE INJECTION 0; 60000UNIT/ML
penicillin g potassium injection 5000000unit
PENICILLIN G PROCAINE INJECTION 600000UNIT/ML
PENICILLIN G SODIUM INJECTION 5000000UNIT
penicillin v potassium solution reconstituted 125mg/5ml
penicillin v potassium solution reconstituted 250mg/5ml
penicillin v potassium tablet 250mg
penicillin v potassium tablet 500mg
PFIZERPEN-G INJECTION 5000000UNIT
piperacillin sodium/tazobactam sodium injection 4gm; 0.5gm
TIMENTIN INJECTION 0.1GM; 3GM
ZOSYN INJECTION 3GM; 0.375GM
ZOSYN INJECTION 5%; 2GM/50ML; 0.25GM/50ML
ZOSYN INJECTION 5%; 3GM/50ML; 0.375GM/50ML
Macrolides
azithromycin injection 500mg
azithromycin suspension reconstituted 100mg/5ml
azithromycin suspension reconstituted 200mg/5ml
azithromycin tablet 250mg
azithromycin tablet 500mg
azithromycin tablet 600mg
clarithromycin er tablet extended release 24 hour 500mg
clarithromycin suspension reconstituted 125mg/5ml
Página 14 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (15 ML cada 5 días)
QL (22.5 ML cada 5 días)
QL (6 EA cada 5 días)
QL (3 EA cada 3 días)
QL (8 EA cada 28 días)
Nombre del medicamento
clarithromycin suspension reconstituted 250mg/5ml
clarithromycin tablet 250mg
clarithromycin tablet 500mg
e.e.s. 400 tablet 400mg
e.e.s. granules suspension reconstituted 200mg/5ml
ERY-TAB TABLET DELAYED RELEASE 250MG
ERY-TAB TABLET DELAYED RELEASE 333MG
ERY-TAB TABLET DELAYED RELEASE 500MG
ERYPED 400 SUSPENSION RECONSTITUTED
400MG/5ML
ERYTHROCIN LACTOBIONATE INJECTION 500MG
erythrocin stearate tablet 250mg
erythromycin base tablet 250mg
erythromycin base tablet 500mg
erythromycin ointment 5mg/gm
erythromycin solution 2%
KETEK TABLET 300MG
KETEK TABLET 400MG
ZMAX SUSPENSION RECONSTITUTED 2GM
Quinolones
AVELOX INJECTION 400MG/250ML; 0.8%
ciprofloxacin hcl solution 0.3%
ciprofloxacin hcl tablet 100mg
ciprofloxacin hcl tablet 250mg
ciprofloxacin hcl tablet 500mg
ciprofloxacin hcl tablet 750mg
ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5%
ciprofloxacin injection 400mg/40ml
LEVAQUIN INJECTION 5%; 750MG/150ML
levofloxacin in d5w injection 5%; 500mg/100ml
levofloxacin injection 25mg/ml
levofloxacin solution 25mg/ml
levofloxacin tablet 250mg
levofloxacin tablet 500mg
levofloxacin tablet 750mg
moxifloxacin hcl injection 400mg/250ml
ofloxacin solution 0.3%
ofloxacin solution 0.3%
ofloxacin tablet 200mg
ofloxacin tablet 300mg
ofloxacin tablet 400mg
Sulfonamides
sodium sulfacetamide solution 10%
sulfacetamide sodium suspension 10%
sulfadiazine tablet 500mg
sulfamethoxazole/trimethoprim ds tablet 800mg; 160mg
SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION
400MG/5ML; 80MG/5ML
Página 15 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
QL (28 EA cada 14 días)
$0(Nivel 1)
QL (42 EA cada 21 días)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (20 EA cada 10 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (10 EA cada 10 días)
$0(Nivel 1)
QL (14 EA cada 14 días)
$0(Nivel 1)
QL (14 EA cada 14 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
Nombre del medicamento
sulfamethoxazole/trimethoprim suspension 200mg/5ml;
40mg/5ml
sulfamethoxazole/trimethoprim tablet 400mg; 80mg
Tetracyclines
demeclocycline hcl tablet 150mg
demeclocycline hcl tablet 300mg
doxycycline hyclate capsule 100mg
doxycycline hyclate capsule 50mg
doxycycline hyclate tablet 100mg
doxycycline hyclate tablet 20mg
doxycycline monohydrate capsule 100mg
doxycycline monohydrate capsule 50mg
minocycline hcl capsule 100mg
minocycline hcl capsule 50mg
minocycline hcl capsule 75mg
Anticonvulsants
Anticonvulsants, Other
APTIOM TABLET 200MG
APTIOM TABLET 400MG
APTIOM TABLET 600MG
APTIOM TABLET 800MG
FYCOMPA TABLET 10MG
FYCOMPA TABLET 12MG
FYCOMPA TABLET 2MG
FYCOMPA TABLET 4MG
FYCOMPA TABLET 6MG
FYCOMPA TABLET 8MG
levetiracetam injection 1000mg/100ml; 750mg/100ml
levetiracetam injection 1500mg/100ml; 540mg/100ml
levetiracetam injection 500mg/100ml; 820mg/100ml
levetiracetam injection 500mg/5ml
levetiracetam solution 100mg/ml
levetiracetam tablet 1000mg
levetiracetam tablet 250mg
levetiracetam tablet 500mg
levetiracetam tablet 750mg
POTIGA TABLET 200MG
Página 16 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (180 EA cada 30 días)
MO
$0(Nivel 1)
QL (180 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
Nombre del medicamento
POTIGA TABLET 300MG
POTIGA TABLET 400MG
POTIGA TABLET 50MG
Calcium Channel Modifying Agents
CELONTIN CAPSULE 300MG
ethosuximide capsule 250mg
ethosuximide solution 250mg/5ml
LYRICA CAPSULE 100MG
LYRICA CAPSULE 150MG
LYRICA CAPSULE 200MG
LYRICA CAPSULE 225MG
LYRICA CAPSULE 25MG
LYRICA CAPSULE 300MG
LYRICA CAPSULE 50MG
LYRICA CAPSULE 75MG
LYRICA SOLUTION 20MG/ML
zonisamide capsule 100mg
zonisamide capsule 25mg
zonisamide capsule 50mg
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam odt tablet dispersible 0.125mg
clonazepam odt tablet dispersible 0.25mg
clonazepam odt tablet dispersible 0.5mg
clonazepam odt tablet dispersible 1mg
clonazepam odt tablet dispersible 2mg
clonazepam tablet 0.5mg
clonazepam tablet 1mg
clonazepam tablet 2mg
diazepam gel 10mg
diazepam gel 2.5mg
diazepam gel 20mg
divalproex sodium dr tablet delayed release 125mg
divalproex sodium dr tablet delayed release 250mg
divalproex sodium dr tablet delayed release 500mg
divalproex sodium er tablet extended release 24 hour 250mg
divalproex sodium er tablet extended release 24 hour 500mg
divalproex sodium capsule sprinkle 125mg
gabapentin capsule 100mg
gabapentin capsule 300mg
gabapentin capsule 400mg
gabapentin solution 250mg/5ml
gabapentin tablet 600mg
gabapentin tablet 800mg
GABITRIL TABLET 12MG
GABITRIL TABLET 16MG
ONFI SUSPENSION 2.5MG/ML
ONFI TABLET 10MG
Página 17 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (180 EA cada 30 días)
MO
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (150 EA cada 30 días)
$0(Nivel 1)
QL (150 EA cada 30 días)
$0(Nivel 1)
QL (150 EA cada 30 días)
$0(Nivel 1)
QL (150 EA cada 30 días)
$0(Nivel 1)
QL (300 EA cada 30 días)
$0(Nivel 1)
QL (150 EA cada 30 días)
$0(Nivel 1)
QL (150 EA cada 30 días)
QL (300 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (50 EA cada 30 días)
$0(Nivel 1)
QL (24.9 EA cada 30 días)
$0(Nivel 1)
QL (100 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) MO
$0-$6.60(Nivel 2)
Nombre del medicamento
ONFI TABLET 20MG
ONFI TABLET 5MG
phenobarbital elixir 20mg/5ml
phenobarbital tablet 100mg
phenobarbital tablet 15mg
phenobarbital tablet 16.2mg
phenobarbital tablet 30mg
phenobarbital tablet 32.4mg
phenobarbital tablet 60mg
phenobarbital tablet 64.8mg
phenobarbital tablet 97.2mg
primidone tablet 250mg
primidone tablet 50mg
SABRIL PACKET 500MG
SABRIL TABLET 500MG
tiagabine hydrochloride tablet 2mg
tiagabine hydrochloride tablet 4mg
valproate sodium injection 500mg/5ml
valproic acid capsule 250mg
valproic acid syrup 250mg/5ml
Glutamate Reducing Agents
felbamate suspension 600mg/5ml
felbamate tablet 400mg
felbamate tablet 600mg
lamotrigine odt tablet dispersible 100mg
lamotrigine odt tablet dispersible 200mg
lamotrigine odt tablet dispersible 25mg
lamotrigine odt tablet dispersible 50mg
lamotrigine tablet chewable 25mg
lamotrigine tablet chewable 5mg
lamotrigine tablet 100mg
lamotrigine tablet 150mg
lamotrigine tablet 200mg
lamotrigine tablet 25mg
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 100MG
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 150MG
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 200MG
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 25MG
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 50MG
topiramate er capsule er 24 hour sprinkle 100mg
topiramate er capsule er 24 hour sprinkle 150mg
Página 18 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (360 EA cada 30 días)
$0-$6.60(Nivel 2) QL (360 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
$0(Nivel 1)
QL (60 EA cada 30 días)
MO
Nombre del medicamento
topiramate er capsule er 24 hour sprinkle 200mg
topiramate er capsule er 24 hour sprinkle 25mg
topiramate er capsule er 24 hour sprinkle 50mg
topiramate capsule sprinkle 15mg
topiramate capsule sprinkle 25mg
topiramate tablet 100mg
topiramate tablet 200mg
topiramate tablet 25mg
topiramate tablet 50mg
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 100MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 200MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 25MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 50MG
Sodium Channel Agents
BANZEL SUSPENSION 40MG/ML
BANZEL TABLET 200MG
BANZEL TABLET 400MG
carbamazepine er capsule extended release 12 hour 100mg
carbamazepine er capsule extended release 12 hour 200mg
carbamazepine er capsule extended release 12 hour 300mg
carbamazepine er tablet extended release 12 hour 200mg
carbamazepine er tablet extended release 12 hour 400mg
carbamazepine suspension 100mg/5ml
carbamazepine tablet chewable 100mg
carbamazepine tablet 200mg
CARBATROL CAPSULE EXTENDED RELEASE 12
HOUR 100MG
CARBATROL CAPSULE EXTENDED RELEASE 12
HOUR 200MG
CARBATROL CAPSULE EXTENDED RELEASE 12
HOUR 300MG
CEREBYX INJECTION 500MG PE/10ML
DILANTIN INFATABS TABLET CHEWABLE 50MG
DILANTIN-125 SUSPENSION 125MG/5ML
DILANTIN CAPSULE 100MG
DILANTIN CAPSULE 30MG
epitol tablet 200mg
fosphenytoin sodium injection 100mg pe/2ml
oxcarbazepine suspension 300mg/5ml
oxcarbazepine tablet 150mg
oxcarbazepine tablet 300mg
Página 19 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (60 EA cada 30 días)
MO
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (240 EA cada 30 días)
$0-$6.60(Nivel 2) QL (240 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
oxcarbazepine tablet 600mg
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 150MG
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 300MG
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 600MG
PEGANONE TABLET 250MG
PHENYTEK CAPSULE 200MG
PHENYTEK CAPSULE 300MG
phenytoin infatabs tablet chewable 50mg
phenytoin sodium extended capsule 100mg
phenytoin sodium extended capsule 200mg
phenytoin sodium extended capsule 300mg
phenytoin sodium injection 50mg/ml
phenytoin suspension 125mg/5ml
phenytoin tablet chewable 50mg
TEGRETOL-XR TABLET EXTENDED RELEASE 12
HOUR 100MG
TEGRETOL-XR TABLET EXTENDED RELEASE 12
HOUR 200MG
TEGRETOL-XR TABLET EXTENDED RELEASE 12
HOUR 400MG
TEGRETOL SUSPENSION 100MG/5ML
TEGRETOL TABLET 200MG
VIMPAT INJECTION 200MG/20ML
VIMPAT SOLUTION 10MG/ML
VIMPAT TABLET 100MG
VIMPAT TABLET 150MG
VIMPAT TABLET 200MG
VIMPAT TABLET 50MG
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates tablet 1mg
Cholinesterase Inhibitors
donepezil hcl tablet dispersible 10mg
donepezil hcl tablet dispersible 5mg
donepezil hcl tablet 10mg
donepezil hcl tablet 5mg
galantamine hydrobromide capsule extended release 24 hour
16mg
galantamine hydrobromide capsule extended release 24 hour
24mg
galantamine hydrobromide capsule extended release 24 hour
8mg
galantamine hydrobromide solution 4mg/ml
galantamine hydrobromide tablet 12mg
galantamine hydrobromide tablet 4mg
Página 20 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (60 EA cada 30 días)
QL (180 EA cada 30 días)
Nombre del medicamento
galantamine hydrobromide tablet 8mg
rivastigmine tartrate capsule 1.5mg
rivastigmine tartrate capsule 3mg
rivastigmine tartrate capsule 4.5mg
rivastigmine tartrate capsule 6mg
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl titration pak tablet 0
memantine hcl tablet 10mg
memantine hcl tablet 5mg
NAMENDA TITRATION PAK TABLET 0
NAMENDA SOLUTION 10MG/5ML
NAMENDA TABLET 10MG
NAMENDA TABLET 5MG
Antidepressants
Antidepressants, Other
BRINTELLIX TABLET 10MG
BRINTELLIX TABLET 20MG
BRINTELLIX TABLET 5MG
budeprion sr tablet extended release 12 hour 100mg
budeprion sr tablet extended release 12 hour 150mg
bupropion hcl sr tablet extended release 12 hour 100mg
bupropion hcl sr tablet extended release 12 hour 150mg
bupropion hcl sr tablet extended release 12 hour 200mg
bupropion hcl xl tablet extended release 24 hour 150mg
bupropion hcl xl tablet extended release 24 hour 300mg
bupropion hcl tablet 100mg
bupropion hcl tablet 75mg
maprotiline hcl tablet 25mg
maprotiline hcl tablet 50mg
maprotiline hcl tablet 75mg
mirtazapine odt tablet dispersible 15mg
mirtazapine odt tablet dispersible 30mg
mirtazapine odt tablet dispersible 45mg
mirtazapine tablet 15mg
mirtazapine tablet 30mg
mirtazapine tablet 45mg
mirtazapine tablet 7.5mg
nefazodone hcl tablet 100mg
nefazodone hcl tablet 150mg
nefazodone hcl tablet 200mg
nefazodone hcl tablet 250mg
nefazodone hcl tablet 50mg
trazodone hcl tablet 100mg
trazodone hcl tablet 150mg
trazodone hcl tablet 300mg
trazodone hcl tablet 50mg
Página 21 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
QL (60 EA cada 30 días)
MO
QL (60 EA cada 30 días)
MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (360 ML cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) MO
$0-$6.60(Nivel 2) MO
$0-$6.60(Nivel 2) MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
Nombre del medicamento
Monoamine Oxidase Inhibitors
EMSAM PATCH 24 HOUR 12MG/24HR
$0-$6.60(Nivel 2)
EMSAM PATCH 24 HOUR 6MG/24HR
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
EMSAM PATCH 24 HOUR 9MG/24HR
MARPLAN TABLET 10MG
$0-$6.60(Nivel 2)
$0(Nivel 1)
phenelzine sulfate tablet 15mg
tranylcypromine sulfate tablet 10mg
$0(Nivel 1)
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin
and Norepinephrine Reuptake Inhibitor
citalopram hydrobromide solution 10mg/5ml
$0(Nivel 1)
citalopram hydrobromide tablet 10mg
$0(Nivel 1)
citalopram hydrobromide tablet 20mg
$0(Nivel 1)
citalopram hydrobromide tablet 40mg
$0(Nivel 1)
desvenlafaxine er tablet extended release 24 hour 100mg
$0(Nivel 1)
QL (30 EA cada 30 días)
desvenlafaxine er tablet extended release 24 hour 50mg
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
duloxetine hcl capsule delayed release particles 20mg
MO
duloxetine hcl capsule delayed release particles 30mg
$0(Nivel 1)
QL (60 EA cada 30 días)
MO
duloxetine hcl capsule delayed release particles 40mg
$0(Nivel 1)
QL (60 EA cada 30 días)
MO
duloxetine hcl capsule delayed release particles 60mg
$0(Nivel 1)
QL (60 EA cada 30 días)
MO
escitalopram oxalate solution 5mg/5ml
$0(Nivel 1)
escitalopram oxalate tablet 10mg
$0(Nivel 1)
QL (30 EA cada 30 días)
escitalopram oxalate tablet 20mg
$0(Nivel 1)
QL (30 EA cada 30 días)
escitalopram oxalate tablet 5mg
$0(Nivel 1)
QL (30 EA cada 30 días)
FETZIMA TITRATION PACK CAPSULE ER 24 HOUR
$0-$6.60(Nivel 2)
THERAPY PACK 0
$0-$6.60(Nivel 2) MO
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR
120MG
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR
$0-$6.60(Nivel 2) MO
20MG
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR
$0-$6.60(Nivel 2) MO
40MG
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR
$0-$6.60(Nivel 2) MO
80MG
fluoxetine hcl capsule 10mg
$0(Nivel 1)
fluoxetine hcl capsule 20mg
$0(Nivel 1)
fluoxetine hcl capsule 40mg
$0(Nivel 1)
fluoxetine hcl solution 20mg/5ml
$0(Nivel 1)
fluoxetine hcl tablet 10mg
$0(Nivel 1)
fluvoxamine maleate tablet 100mg
$0(Nivel 1)
fluvoxamine maleate tablet 25mg
$0(Nivel 1)
fluvoxamine maleate tablet 50mg
$0(Nivel 1)
KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR $0-$6.60(Nivel 2) QL (120 EA cada 30 días)
100MG
MO
Página 22 de 143
Nombre del medicamento
KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR
50MG
paroxetine hcl er tablet extended release 24 hour 37.5mg
paroxetine hcl tablet 10mg
paroxetine hcl tablet 20mg
paroxetine hcl tablet 30mg
paroxetine hcl tablet 40mg
PAXIL SUSPENSION 10MG/5ML
PRISTIQ TABLET EXTENDED RELEASE 24 HOUR
25MG
sertraline hcl concentrate 20mg/ml
sertraline hcl tablet 100mg
sertraline hcl tablet 25mg
sertraline hcl tablet 50mg
venlafaxine hcl er capsule extended release 24 hour 150mg
venlafaxine hcl er capsule extended release 24 hour 37.5mg
venlafaxine hcl er capsule extended release 24 hour 75mg
venlafaxine hcl er tablet extended release 24 hour 150mg
venlafaxine hcl er tablet extended release 24 hour 225mg
venlafaxine hcl er tablet extended release 24 hour 37.5mg
venlafaxine hcl er tablet extended release 24 hour 75mg
venlafaxine hcl tablet 100mg
venlafaxine hcl tablet 25mg
venlafaxine hcl tablet 37.5mg
venlafaxine hcl tablet 50mg
venlafaxine hcl tablet 75mg
VIIBRYD KIT 0
VIIBRYD TABLET 10MG
VIIBRYD TABLET 20MG
VIIBRYD TABLET 40MG
Tricyclics
amitriptyline hcl tablet 100mg
amitriptyline hcl tablet 10mg
amitriptyline hcl tablet 150mg
amitriptyline hcl tablet 25mg
amitriptyline hcl tablet 50mg
amitriptyline hcl tablet 75mg
amoxapine tablet 100mg
amoxapine tablet 150mg
amoxapine tablet 25mg
amoxapine tablet 50mg
chlordiazepoxide/amitriptyline tablet 12.5mg; 5mg
chlordiazepoxide/amitriptyline tablet 25mg; 10mg
clomipramine hcl capsule 25mg
clomipramine hcl capsule 50mg
clomipramine hcl capsule 75mg
desipramine hcl tablet 100mg
desipramine hcl tablet 10mg
Página 23 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
desipramine hcl tablet 150mg
desipramine hcl tablet 25mg
desipramine hcl tablet 50mg
desipramine hcl tablet 75mg
doxepin hcl capsule 100mg
doxepin hcl capsule 10mg
doxepin hcl capsule 25mg
doxepin hcl capsule 50mg
doxepin hcl capsule 75mg
doxepin hcl concentrate 10mg/ml
imipramine hcl tablet 10mg
imipramine hcl tablet 25mg
imipramine hcl tablet 50mg
imipramine pamoate capsule 100mg
imipramine pamoate capsule 125mg
imipramine pamoate capsule 150mg
imipramine pamoate capsule 75mg
nortriptyline hcl capsule 10mg
nortriptyline hcl capsule 25mg
nortriptyline hcl capsule 50mg
nortriptyline hcl capsule 75mg
nortriptyline hcl solution 10mg/5ml
perphenazine/amitriptyline tablet 10mg; 2mg
perphenazine/amitriptyline tablet 10mg; 4mg
perphenazine/amitriptyline tablet 25mg; 2mg
perphenazine/amitriptyline tablet 25mg; 4mg
perphenazine/amitriptyline tablet 50mg; 4mg
protriptyline hcl tablet 10mg
protriptyline hcl tablet 5mg
SURMONTIL CAPSULE 100MG
SURMONTIL CAPSULE 25MG
SURMONTIL CAPSULE 50MG
trimipramine maleate capsule 100mg
trimipramine maleate capsule 25mg
trimipramine maleate capsule 50mg
Antiemetics
Antiemetics, Other
dimenhydrinate tablet 50mg
driminate tablet 50mg
meclizine hcl tablet 12.5mg
meclizine hcl tablet 25mg
phenadoz suppository 12.5mg
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) MO
$0-$6.60(Nivel 2) MO
$0-$6.60(Nivel 2) MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
phenadoz suppository 25mg
$0(Nivel 1)
promethazine hcl injection 25mg/ml
$0(Nivel 1)
Página 24 de 143
DP
DP
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
Nombre del medicamento
promethazine hcl injection 50mg/ml
promethazine hcl suppository 12.5mg
promethazine hcl suppository 25mg
promethazine hcl suppository 50mg
promethazine hcl syrup 6.25mg/5ml
promethazine hcl tablet 12.5mg
promethazine hcl tablet 25mg
promethazine hcl tablet 50mg
promethegan suppository 25mg
TRANSDERM-SCOP PATCH 72 HOUR 1MG/3DAYS
travel sickness tablet chewable 25mg
travel sickness tablet chewable 25mg
trimethobenzamide hcl capsule 300mg
Emetogenic Therapy Adjuncts
dronabinol capsule 10mg
dronabinol capsule 2.5mg
dronabinol capsule 5mg
EMEND CAPSULE 0
EMEND CAPSULE 40MG
granisetron hcl injection 0.1mg/ml
granisetron hcl injection 1mg/ml
ondansetron hcl injection 4mg/2ml
ondansetron hcl injection 4mg/2ml
ondansetron hcl solution 4mg/5ml
ondansetron hcl tablet 24mg
ondansetron hcl tablet 4mg
ondansetron hcl tablet 8mg
ondansetron odt tablet dispersible 4mg
ondansetron odt tablet dispersible 8mg
Antifungals
Antifungals
ABELCET INJECTION 5MG/ML
AMBISOME INJECTION 50MG
AMPHOTERICIN B INJECTION 50MG
antifungal cream 2%
antifungal cream 2%
Página 25 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
$0(Nivel 1)
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0-$6.60(Nivel 2) QL (10 EA cada 30 días)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0-$6.60(Nivel 2) QL (3 EA cada 14 días)
B/D
$0-$6.60(Nivel 2) QL (1 EA cada 14 días)
B/D
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
baza antifungal cream 2%
CANCIDAS INJECTION 50MG
CANCIDAS INJECTION 70MG
castellani paint modified/color liquid 1.5%
ciclopirox olamine cream 0.77%
ciclopirox suspension 0.77%
clotrimazole anti-fungal cream 1%
clotrimazole cream 1%
clotrimazole cream 1%
clotrimazole cream 1%
clotrimazole cream 1%
clotrimazole cream 1%
clotrimazole cream 1%
clotrimazole solution 1%
clotrimazole troche 10mg
desenex shake powder powder 2%
desenex shake powder powder 2%
desenex spray powder aerosol powder 2%
desenex cream 1%
desenex cream 1%
econazole nitrate cream 1%
fluconazole in dextrose injection 56mg/ml; 400mg/200ml
fluconazole suspension reconstituted 10mg/ml
fluconazole suspension reconstituted 40mg/ml
fluconazole tablet 100mg
fluconazole tablet 150mg
fluconazole tablet 200mg
fluconazole tablet 50mg
flucytosine capsule 250mg
flucytosine capsule 500mg
FUNGOID TINCTURE KIT 2%
FUNGOID TINCTURE SOLUTION 2%
GENTIAN VIOLET SOLUTION 1%
gnp clotrimazole 3 cream 2%
gnp miconazole 3 kit 0
gnp miconazole 7 cream 2%
gnp terbinafine hydrochloride cream 1%
gnp terbinafine hydrochloride cream 1%
griseofulvin microsize tablet 500mg
griseofulvin ultramicrosize tablet 125mg
griseofulvin ultramicrosize tablet 250mg
itraconazole capsule 100mg
jock itch spray aerosol powder 1%
ketoconazole cream 2%
ketoconazole shampoo 2%
ketoconazole tablet 200mg
LAMISIL AT SPRAY SOLUTION 1%
LAMISIL AT CREAM 1%
Página 26 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (1 EA cada 10 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
LAMISIL AT CREAM 1%
LAMISIL AT CREAM 1%
miconazole 3 combo pack kit 0
miconazole 3 suppository 200mg
miconazole 7 cream 2%
miconazole 7 cream 2%
miconazole 7 cream 2%
miconazole 7 cream 2%
miconazole 7 suppository 100mg
miconazole nitrate cream 2%
miconazole nitrate cream 2%
miconazole nitrate cream 2%
miconazole nitrate cream 2%
miconazole nitrate suppository 100mg
miconazole cream 2%
micro guard powder 2%
mitrazol powder 2%
MYCAMINE INJECTION 100MG
MYCAMINE INJECTION 50MG
naftifine hcl cream 1%
NAFTIN CREAM 1%
NAFTIN GEL 1%
NATACYN SUSPENSION 5%
NOXAFIL SUSPENSION 40MG/ML
NOXAFIL TABLET DELAYED RELEASE 100MG
nyamyc powder 100000unit/gm
nystatin/triamcinolone cream 100000unit/gm; 0.1%
nystatin/triamcinolone ointment 100000unit/gm; 0.1%
nystatin cream 100000unit/gm
nystatin ointment 100000unit/gm
nystatin powder 100000unit/gm
nystatin suspension 100000unit/ml
nystatin tablet 500000unit
nystop powder 100000unit/gm
pedi-dri powder 100000unit/gm
remedy antifungal cream 2%
remedy antifungal powder 2%
sm 3-day vaginal cream 2%
sm antifungal miconazole cream 2%
sm athletes foot cream 1%
sm clotrimazole vaginal cream 1%
sm miconazole 3 kit 0
sm miconazole 7 cream 2%
sm miconazole 7 cream 2%
sm miconazole 7 suppository 100mg
SPORANOX SOLUTION 10MG/ML
terbinafine hcl cream 1%
terbinafine hcl cream 1%
Página 27 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
QL (12 EA cada 30 días)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
terbinafine hcl tablet 250mg
terconazole cream 0.4%
terconazole cream 0.8%
terconazole suppository 80mg
tolnaftate solution 1%
VAGISTAT-1 OINTMENT 6.5%
vagistat-3 kit 0
voriconazole injection 200mg
voriconazole tablet 200mg
voriconazole tablet 50mg
zeasorb-af powder 2%
Antigout Agents
Antigout Agents
allopurinol tablet 100mg
allopurinol tablet 300mg
ALOPRIM INJECTION 500MG
colchicine capsule 0.6mg
COLCRYS TABLET 0.6MG
mitigare capsule 0.6mg
probenecid/colchicine tablet 0.5mg; 500mg
probenecid tablet 500mg
Antimigraine Agents
Antimigraine Agents
BOTOX INJECTION 100UNIT
Ergot Alkaloids
dihydroergotamine mesylate injection 1mg/ml
ERGOMAR TABLET SUBLINGUAL 2MG
migergot suppository 100mg; 2mg
Serotonin (5-HT) 1b/1d Receptor Agonists
IMITREX STATDOSE REFILL INJECTION 4MG/0.5ML
IMITREX SOLUTION 20MG/ACT
IMITREX SOLUTION 5MG/ACT
naratriptan hcl tablet 1mg
naratriptan hcl tablet 2.5mg
rizatriptan benzoate odt tablet dispersible 10mg
rizatriptan benzoate odt tablet dispersible 5mg
rizatriptan benzoate tablet 10mg
rizatriptan benzoate tablet 5mg
sumatriptan succinate refill injection 4mg/0.5ml
sumatriptan succinate refill injection 6mg/0.5ml
sumatriptan succinate injection 6mg/0.5ml
sumatriptan succinate injection 6mg/0.5ml
sumatriptan succinate injection 6mg/0.5ml
sumatriptan succinate tablet 100mg
sumatriptan succinate tablet 25mg
sumatriptan succinate tablet 50mg
Antimyasthenic Agents
Página 28 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
QL (90 GM cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (3 EA cada 30 días)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
MO
$0-$6.60(Nivel 2)
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
$0-$6.60(Nivel 2) PA (Agentes terapéuticos
misceláneos - Botox)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
Parasympathomimetics
GUANIDINE HCL TABLET 125MG
MESTINON TIMESPAN TABLET EXTENDED RELEASE
180MG
MESTINON SYRUP 60MG/5ML
pyridostigmine bromide tablet extended release 180mg
pyridostigmine bromide tablet 60mg
Antimycobacterials
Antimycobacterials, Other
DAPSONE TABLET 100MG
DAPSONE TABLET 25MG
MYCOBUTIN CAPSULE 150MG
rifabutin capsule 150mg
Antituberculars
CAPASTAT SULFATE INJECTION 1GM
ethambutol hcl tablet 100mg
ethambutol hcl tablet 400mg
ISONIAZID INJECTION 100MG/ML
isoniazid syrup 50mg/5ml
isoniazid tablet 100mg
isoniazid tablet 300mg
PASER PACKET 4GM
PRIFTIN TABLET 150MG
pyrazinamide tablet 500mg
rifampin capsule 150mg
rifampin capsule 300mg
rifampin injection 600mg
RIFATER TABLET 50MG; 300MG; 120MG
SEROMYCIN CAPSULE 250MG
TRECATOR TABLET 250MG
Antineoplastics
Alkylating Agents
ALKERAN INJECTION 50MG
BICNU INJECTION 100MG
BUSULFEX INJECTION 6MG/ML
cyclophosphamide capsule 25mg
cyclophosphamide capsule 50mg
cyclophosphamide tablet 25mg
cyclophosphamide tablet 50mg
dacarbazine injection 200mg
HEXALEN CAPSULE 50MG
IFEX INJECTION 1GM
ifosfamide injection 1gm
LEUKERAN TABLET 2MG
lomustine capsule 100mg
lomustine capsule 10mg
lomustine capsule 40mg
MATULANE CAPSULE 50MG
Página 29 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
MO
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
Nombre del medicamento
melphalan hydrochloride injection 50mg
MUSTARGEN INJECTION 10MG
thiotepa injection 15mg
TREANDA INJECTION 100MG
TREANDA INJECTION 45MG/0.5ML
VALCHLOR GEL 0.016%
ZANOSAR INJECTION 1GM
Antiandrogens
bicalutamide tablet 50mg
flutamide capsule 125mg
NILANDRON TABLET 150MG
XTANDI CAPSULE 40MG
ZYTIGA TABLET 250MG
Antiangiogenic Agents
POMALYST CAPSULE 1MG
POMALYST CAPSULE 2MG
POMALYST CAPSULE 3MG
POMALYST CAPSULE 4MG
REVLIMID CAPSULE 10MG
REVLIMID CAPSULE 15MG
REVLIMID CAPSULE 2.5MG
REVLIMID CAPSULE 20MG
REVLIMID CAPSULE 25MG
REVLIMID CAPSULE 5MG
THALOMID CAPSULE 100MG
THALOMID CAPSULE 150MG
THALOMID CAPSULE 200MG
THALOMID CAPSULE 50MG
Antiestrogens/Modifiers
EMCYT CAPSULE 140MG
FARESTON TABLET 60MG
FASLODEX INJECTION 250MG/5ML
SOLTAMOX SOLUTION 10MG/5ML
tamoxifen citrate tablet 10mg
tamoxifen citrate tablet 20mg
Antimetabolites
adrucil injection 500mg/10ml
ALIMTA INJECTION 500MG
ARRANON INJECTION 5MG/ML
cladribine injection 1mg/ml
CLOLAR INJECTION 1MG/ML
cytarabine aqueous injection 100mg/ml
cytarabine aqueous injection 20mg/ml
cytarabine injection 500mg
DROXIA CAPSULE 200MG
DROXIA CAPSULE 300MG
DROXIA CAPSULE 400MG
ELITEK INJECTION 1.5MG
Página 30 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) LA
$0-$6.60(Nivel 2) LA
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) LA
$0-$6.60(Nivel 2) LA
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Nombre del medicamento
fluorouracil injection 2.5gm/50ml
FOLOTYN INJECTION 40MG/2ML
gemcitabine hcl injection 1gm
hydroxyurea capsule 500mg
mercaptopurine tablet 50mg
pentostatin injection 10mg
PURIXAN SUSPENSION 2000MG/100ML
TABLOID TABLET 40MG
Antineoplastics, Other
ABRAXANE INJECTION 900MG; 100MG
adriamycin injection 2mg/ml
amifostine injection 500mg
azacitidine injection 100mg
BELEODAQ INJECTION 500MG
bleomycin sulfate injection 30unit
CAMPTOSAR INJECTION 100MG/5ML
carboplatin injection 150mg/15ml
cisplatin injection 100mg/100ml
COSMEGEN INJECTION 0.5MG
DACOGEN INJECTION 50MG
dactinomycin injection 0.5mg
DAUNORUBICIN HCL INJECTION 5MG/ML
decitabine injection 50mg
dexrazoxane injection 250mg
DOCEFREZ INJECTION 20MG
DOCEFREZ INJECTION 80MG
DOCETAXEL INJECTION 80MG/4ML
DOCETAXEL INJECTION 80MG/8ML
DOXIL INJECTION 2MG/ML
doxorubicin hcl injection 2mg/ml
ELLENCE INJECTION 200MG/100ML
epirubicin hcl injection 50mg/25ml
fludarabine phosphate injection 50mg
FUSILEV INJECTION 50MG
GILOTRIF TABLET 20MG
GILOTRIF TABLET 30MG
GILOTRIF TABLET 40MG
HALAVEN INJECTION 1MG/2ML
IDAMYCIN PFS INJECTION 20MG/20ML
idarubicin hcl injection 10mg/10ml
irinotecan injection 100mg/5ml
ISTODAX INJECTION 10MG
IXEMPRA KIT INJECTION 45MG
JEVTANA INJECTION 60MG/1.5ML
leucovorin calcium injection 100mg
leucovorin calcium injection 350mg
leucovorin calcium tablet 10mg
leucovorin calcium tablet 15mg
Página 31 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
leucovorin calcium tablet 25mg
leucovorin calcium tablet 5mg
levoleucovorin calcium injection 175mg/17.5ml
lipodox 50 injection 2mg/ml
lipodox injection 2mg/ml
LYNPARZA CAPSULE 50MG
mesna injection 100mg/ml
MESNEX INJECTION 100MG/ML
MESNEX TABLET 400MG
mitomycin injection 20mg
mitoxantrone hcl injection 2mg/ml
ONCASPAR INJECTION 750UNIT/ML
oxaliplatin injection 100mg/20ml
paclitaxel injection 300mg/50ml
PROLEUKIN INJECTION 22000000UNIT
SYLATRON INJECTION 200MCG
SYLATRON INJECTION 300MCG
SYLATRON INJECTION 600MCG
SYNRIBO INJECTION 3.5MG
TRISENOX INJECTION 10MG/10ML
VELCADE INJECTION 3.5MG
VINBLASTINE SULFATE INJECTION 1MG/ML
vincristine sulfate injection 1mg/ml
vinorelbine tartrate injection 50mg/5ml
ZINECARD INJECTION 250MG
ZOLINZA CAPSULE 100MG
Antineoplastics
ZALTRAP INJECTION 100MG/4ML
ZYKADIA CAPSULE 150MG
Aromatase Inhibitors, 3rd Generation
anastrozole tablet 1mg
exemestane tablet 25mg
letrozole tablet 2.5mg
Enzyme Inhibitors
ETOPOPHOS INJECTION 100MG
etoposide injection 500mg/25ml
toposar injection 1gm/50ml
topotecan hcl injection 4mg
ZYDELIG TABLET 100MG
ZYDELIG TABLET 150MG
Molecular Target Inhibitors
AFINITOR DISPERZ TABLET SOLUBLE 2MG
AFINITOR DISPERZ TABLET SOLUBLE 3MG
AFINITOR DISPERZ TABLET SOLUBLE 5MG
AFINITOR TABLET 10MG
AFINITOR TABLET 2.5MG
AFINITOR TABLET 5MG
AFINITOR TABLET 7.5MG
Página 32 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (480 EA cada 30 días)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (150 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Nombre del medicamento
BOSULIF TABLET 100MG
BOSULIF TABLET 500MG
CAPRELSA TABLET 100MG
CAPRELSA TABLET 300MG
COMETRIQ KIT 0
COMETRIQ KIT 0
COMETRIQ KIT 20MG
ERIVEDGE CAPSULE 150MG
GLEEVEC TABLET 100MG
GLEEVEC TABLET 400MG
ICLUSIG TABLET 15MG
ICLUSIG TABLET 45MG
IMBRUVICA CAPSULE 140MG
INLYTA TABLET 1MG
INLYTA TABLET 5MG
JAKAFI TABLET 10MG
JAKAFI TABLET 15MG
JAKAFI TABLET 20MG
JAKAFI TABLET 25MG
JAKAFI TABLET 5MG
LENVIMA 10MG DAILY DOSE CAPSULE THERAPY
PACK 10MG
LENVIMA 14MG DAILY DOSE CAPSULE THERAPY
PACK 0
LENVIMA 20MG DAILY DOSE CAPSULE THERAPY
PACK 10MG
LENVIMA 24MG DAILY DOSE CAPSULE THERAPY
PACK 0
MEKINIST TABLET 0.5MG
MEKINIST TABLET 2MG
NEXAVAR TABLET 200MG
SPRYCEL TABLET 100MG
SPRYCEL TABLET 140MG
SPRYCEL TABLET 20MG
SPRYCEL TABLET 50MG
SPRYCEL TABLET 70MG
SPRYCEL TABLET 80MG
STIVARGA TABLET 40MG
SUTENT CAPSULE 12.5MG
SUTENT CAPSULE 25MG
SUTENT CAPSULE 37.5MG
SUTENT CAPSULE 50MG
TAFINLAR CAPSULE 50MG
TAFINLAR CAPSULE 75MG
TARCEVA TABLET 100MG
TARCEVA TABLET 150MG
TARCEVA TABLET 25MG
TASIGNA CAPSULE 150MG
Página 33 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Nombre del medicamento
TASIGNA CAPSULE 200MG
TYKERB TABLET 250MG
VOTRIENT TABLET 200MG
XALKORI CAPSULE 200MG
XALKORI CAPSULE 250MG
ZELBORAF TABLET 240MG
Monoclonal Antibodies
ARZERRA INJECTION 100MG/5ML
AVASTIN INJECTION 100MG/4ML
AVASTIN INJECTION 400MG/16ML
CYRAMZA INJECTION 100MG/10ML
CYRAMZA INJECTION 500MG/50ML
ERBITUX INJECTION 100MG/50ML
HERCEPTIN INJECTION 440MG
KADCYLA INJECTION 100MG
KEYTRUDA INJECTION 100MG/4ML
KEYTRUDA INJECTION 50MG
OPDIVO INJECTION 40MG/4ML
PERJETA INJECTION 420MG/14ML
RITUXAN INJECTION 10MG/ML
SYLVANT INJECTION 100MG
VECTIBIX INJECTION 100MG/5ML
YERVOY INJECTION 50MG/10ML
Retinoids
bexarotene capsule 75mg
PANRETIN GEL 0.1%
TARGRETIN CAPSULE 75MG
TARGRETIN GEL 1%
tretinoin capsule 10mg
Antiparasitics
Anthelmintics
ALBENZA TABLET 200MG
ivermectin tablet 3mg
STROMECTOL TABLET 3MG
Antiprotozoals
ALINIA SUSPENSION RECONSTITUTED 100MG/5ML
ALINIA TABLET 500MG
atovaquone/proguanil hcl tablet 250mg; 100mg
atovaquone suspension 750mg/5ml
chloroquine phosphate tablet 250mg
chloroquine phosphate tablet 500mg
COARTEM TABLET 20MG; 120MG
DARAPRIM TABLET 25MG
hydroxychloroquine sulfate tablet 200mg
mefloquine hcl tablet 250mg
MEPRON SUSPENSION 750MG/5ML
NEBUPENT SOLUTION RECONSTITUTED 300MG
PENTAM 300 INJECTION 300MG
Página 34 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2)
Nombre del medicamento
PRIMAQUINE PHOSPHATE TABLET 26.3MG
quinine sulfate capsule 324mg
tinidazole tablet 250mg
tinidazole tablet 500mg
Pediculicides/Scabicides
complete lice treatment kit kit 0.5%; 4%; 0.33%
gnp lice treatment shampoo 4%; 0.33%
lice killing maximum strength shampoo 4%; 0.33%
lindane lotion 1%
malathion lotion 0.5%
permethrin cream 5%
permethrin lotion 1%
sb lice treatment liquid 1%
Antiparkinson Agents
Anticholinergics
benztropine mesylate injection 1mg/ml
benztropine mesylate tablet 0.5mg
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0(Nivel 1)
QL (80 EA cada 365 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
benztropine mesylate tablet 1mg
$0(Nivel 1)
benztropine mesylate tablet 2mg
$0(Nivel 1)
trihexyphenidyl hcl elixir 0.4mg/ml
$0(Nivel 1)
trihexyphenidyl hcl tablet 2mg
$0(Nivel 1)
trihexyphenidyl hcl tablet 5mg
$0(Nivel 1)
Antiparkinson Agents, Other
entacapone tablet 200mg
TASMAR TABLET 100MG
tolcapone tablet 100mg
Dopamine Agonists
APOKYN INJECTION 10MG/ML
bromocriptine mesylate capsule 5mg
bromocriptine mesylate tablet 2.5mg
NEUPRO PATCH 24 HOUR 1MG/24HR
NEUPRO PATCH 24 HOUR 2MG/24HR
NEUPRO PATCH 24 HOUR 3MG/24HR
NEUPRO PATCH 24 HOUR 4MG/24HR
NEUPRO PATCH 24 HOUR 6MG/24HR
NEUPRO PATCH 24 HOUR 8MG/24HR
pramipexole dihydrochloride tablet 0.125mg
pramipexole dihydrochloride tablet 0.25mg
pramipexole dihydrochloride tablet 0.5mg
pramipexole dihydrochloride tablet 0.75mg
pramipexole dihydrochloride tablet 1.5mg
pramipexole dihydrochloride tablet 1mg
Página 35 de 143
DP
DP
DP
DP
DP
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
QL (240 EA cada 30 días)
$0-$6.60(Nivel 2)
$0(Nivel 1)
MO
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
ropinirole hcl tablet 0.25mg
ropinirole hcl tablet 0.5mg
ropinirole hcl tablet 1mg
ropinirole hcl tablet 2mg
ropinirole hcl tablet 3mg
ropinirole hcl tablet 4mg
ropinirole hcl tablet 5mg
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa/levodopa er tablet extended release 25mg; 100mg
carbidopa/levodopa er tablet extended release 50mg; 200mg
carbidopa/levodopa odt tablet dispersible 10mg; 100mg
carbidopa/levodopa odt tablet dispersible 25mg; 100mg
carbidopa/levodopa odt tablet dispersible 25mg; 250mg
carbidopa/levodopa tablet 10mg; 100mg
carbidopa/levodopa tablet 25mg; 100mg
carbidopa/levodopa tablet 25mg; 250mg
STALEVO 100 TABLET 25MG; 200MG; 100MG
STALEVO 125 TABLET 31.25MG; 200MG; 125MG
STALEVO 150 TABLET 37.5MG; 200MG; 150MG
STALEVO 200 TABLET 50MG; 200MG; 200MG
STALEVO 50 TABLET 12.5MG; 200MG; 50MG
STALEVO 75 TABLET 18.75MG; 200MG; 75MG
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT TABLET 0.5MG
AZILECT TABLET 1MG
ELDEPRYL CAPSULE 5MG
selegiline hcl capsule 5mg
selegiline hcl tablet 5mg
ZELAPAR TABLET DISPERSIBLE 1.25MG
Antipsychotics
1st Generation/Typical
CHLORPROMAZINE HCL INJECTION 25MG/ML
chlorpromazine hcl tablet 100mg
chlorpromazine hcl tablet 10mg
chlorpromazine hcl tablet 200mg
chlorpromazine hcl tablet 25mg
chlorpromazine hcl tablet 50mg
compro suppository 25mg
FLUPHENAZINE DECANOATE INJECTION 25MG/ML
fluphenazine hcl concentrate 5mg/ml
fluphenazine hcl elixir 2.5mg/5ml
FLUPHENAZINE HCL INJECTION 2.5MG/ML
fluphenazine hcl tablet 10mg
fluphenazine hcl tablet 1mg
fluphenazine hcl tablet 2.5mg
fluphenazine hcl tablet 5mg
haloperidol decanoate injection 100mg/ml
haloperidol decanoate injection 50mg/ml
Página 36 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
haloperidol lactate injection 5mg/ml
haloperidol concentrate 2mg/ml
haloperidol tablet 0.5mg
haloperidol tablet 10mg
haloperidol tablet 1mg
haloperidol tablet 20mg
haloperidol tablet 2mg
haloperidol tablet 5mg
loxapine succinate capsule 10mg
loxapine succinate capsule 25mg
loxapine succinate capsule 50mg
loxapine succinate capsule 5mg
ORAP TABLET 1MG
ORAP TABLET 2MG
perphenazine tablet 16mg
perphenazine tablet 2mg
perphenazine tablet 4mg
perphenazine tablet 8mg
PROCHLORPERAZINE EDISYLATE INJECTION
5MG/ML
prochlorperazine maleate tablet 10mg
prochlorperazine maleate tablet 5mg
thioridazine hcl tablet 100mg
thioridazine hcl tablet 10mg
thioridazine hcl tablet 25mg
thioridazine hcl tablet 50mg
thiothixene capsule 10mg
thiothixene capsule 1mg
thiothixene capsule 2mg
thiothixene capsule 5mg
trifluoperazine hcl tablet 10mg
trifluoperazine hcl tablet 1mg
trifluoperazine hcl tablet 2mg
trifluoperazine hcl tablet 5mg
2nd Generation/Atypical
ABILIFY DISCMELT TABLET DISPERSIBLE 10MG
ABILIFY DISCMELT TABLET DISPERSIBLE 15MG
ABILIFY MAINTENA INJECTION 300MG
ABILIFY INJECTION 9.75MG/1.3ML
ABILIFY SOLUTION 1MG/ML
ABILIFY TABLET 10MG
ABILIFY TABLET 15MG
ABILIFY TABLET 20MG
ABILIFY TABLET 2MG
ABILIFY TABLET 30MG
ABILIFY TABLET 5MG
aripiprazole tablet 10mg
aripiprazole tablet 15mg
Página 37 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (1 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
Nombre del medicamento
aripiprazole tablet 20mg
aripiprazole tablet 2mg
aripiprazole tablet 30mg
aripiprazole tablet 5mg
FANAPT TITRATION PACK TABLET 0
FANAPT TABLET 10MG
FANAPT TABLET 12MG
FANAPT TABLET 1MG
FANAPT TABLET 2MG
FANAPT TABLET 4MG
FANAPT TABLET 6MG
FANAPT TABLET 8MG
GEODON INJECTION 20MG
INVEGA SUSTENNA INJECTION 117MG/0.75ML
INVEGA SUSTENNA INJECTION 156MG/ML
INVEGA SUSTENNA INJECTION 234MG/1.5ML
INVEGA SUSTENNA INJECTION 39MG/0.25ML
INVEGA SUSTENNA INJECTION 78MG/0.5ML
INVEGA TABLET EXTENDED RELEASE 24 HOUR
1.5MG
INVEGA TABLET EXTENDED RELEASE 24 HOUR 3MG
INVEGA TABLET EXTENDED RELEASE 24 HOUR 6MG
INVEGA TABLET EXTENDED RELEASE 24 HOUR 9MG
LATUDA TABLET 120MG
LATUDA TABLET 20MG
LATUDA TABLET 40MG
LATUDA TABLET 60MG
LATUDA TABLET 80MG
olanzapine odt tablet dispersible 10mg
olanzapine odt tablet dispersible 15mg
olanzapine odt tablet dispersible 20mg
olanzapine odt tablet dispersible 5mg
olanzapine injection 10mg
olanzapine tablet 10mg
olanzapine tablet 15mg
olanzapine tablet 2.5mg
olanzapine tablet 20mg
olanzapine tablet 5mg
olanzapine tablet 7.5mg
quetiapine fumarate tablet 100mg
quetiapine fumarate tablet 200mg
quetiapine fumarate tablet 25mg
quetiapine fumarate tablet 300mg
quetiapine fumarate tablet 400mg
quetiapine fumarate tablet 50mg
Página 38 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (0.75 ML cada 28
días)
$0-$6.60(Nivel 2) QL (1 ML cada 28 días)
$0-$6.60(Nivel 2) QL (1.5 ML cada 28 días)
$0-$6.60(Nivel 2) QL (0.25 ML cada 28
días)
$0-$6.60(Nivel 2) QL (0.5 ML cada 28 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
REXULTI TABLET 0.25MG
REXULTI TABLET 0.5MG
REXULTI TABLET 1MG
rexulti tablet 2mg
REXULTI TABLET 3MG
REXULTI TABLET 4MG
RISPERDAL CONSTA INJECTION 12.5MG
RISPERDAL CONSTA INJECTION 25MG
RISPERDAL CONSTA INJECTION 37.5MG
RISPERDAL CONSTA INJECTION 50MG
risperidone odt tablet dispersible 0.25mg
risperidone odt tablet dispersible 0.5mg
risperidone odt tablet dispersible 1mg
risperidone odt tablet dispersible 2mg
risperidone odt tablet dispersible 3mg
risperidone odt tablet dispersible 4mg
risperidone solution 1mg/ml
risperidone tablet 0.25mg
risperidone tablet 0.5mg
risperidone tablet 1mg
risperidone tablet 2mg
risperidone tablet 3mg
risperidone tablet 4mg
SAPHRIS TABLET SUBLINGUAL 10MG
SAPHRIS TABLET SUBLINGUAL 2.5MG
SAPHRIS TABLET SUBLINGUAL 5MG
ziprasidone hcl capsule 20mg
ziprasidone hcl capsule 40mg
ziprasidone hcl capsule 60mg
ziprasidone hcl capsule 80mg
ZYPREXA RELPREVV INJECTION 210MG
Treatment-Resistant
clozapine odt tablet dispersible 100mg
clozapine odt tablet dispersible 12.5mg
clozapine odt tablet dispersible 150mg
clozapine odt tablet dispersible 200mg
clozapine odt tablet dispersible 25mg
clozapine tablet 100mg
clozapine tablet 200mg
clozapine tablet 25mg
clozapine tablet 50mg
FAZACLO TABLET DISPERSIBLE 100MG
Página 39 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (480 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (240 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (40 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (2 EA cada 28 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (180 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
Nombre del medicamento
FAZACLO TABLET DISPERSIBLE 12.5MG
FAZACLO TABLET DISPERSIBLE 150MG
FAZACLO TABLET DISPERSIBLE 200MG
FAZACLO TABLET DISPERSIBLE 25MG
VERSACLOZ SUSPENSION 50MG/ML
Antispasticity Agents
Antispasticity Agents
baclofen tablet 10mg
baclofen tablet 20mg
dantrolene sodium capsule 100mg
dantrolene sodium capsule 25mg
dantrolene sodium capsule 50mg
tizanidine hcl tablet 2mg
tizanidine hcl tablet 4mg
Antivirals
Anti-cytomegalovirus (CMV) Agents
cidofovir injection 75mg/ml
ganciclovir injection 500mg
VALCYTE SOLUTION RECONSTITUTED 50MG/ML
VALCYTE TABLET 450MG
valganciclovir tablet 450mg
VISTIDE INJECTION 75MG/ML
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil tablet 10mg
BARACLUDE SOLUTION 0.05MG/ML
BARACLUDE TABLET 0.5MG
BARACLUDE TABLET 1MG
entecavir tablet 0.5mg
entecavir tablet 1mg
EPIVIR HBV SOLUTION 5MG/ML
INTRON A W/DILUENT INJECTION 10MU
INTRON A INJECTION 18MU
INTRON A INJECTION 50MU
INTRON A INJECTION 6000000UNIT/ML
lamivudine tablet 100mg
TYZEKA TABLET 600MG
Anti-hepatitis C (HCV) Agents
INCIVEK TABLET 375MG
INFERGEN INJECTION 15MCG/0.5ML
OLYSIO CAPSULE 150MG
PEG-INTRON REDIPEN INJECTION 120MCG/0.5ML
Página 40 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (180 EA cada 30 días)
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
MO
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos - Infergen)
$0-$6.60(Nivel 2) QL (28 EA cada 28 días)
PA (Agentes
inmunológicos - Olysio)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
Nombre del medicamento
PEG-INTRON REDIPEN INJECTION 150MCG/0.5ML
PEG-INTRON REDIPEN INJECTION 50MCG/0.5ML
PEG-INTRON REDIPEN INJECTION 80MCG/0.5ML
PEG-INTRON INJECTION 50MCG/0.5ML
PEGASYS PROCLICK INJECTION 135MCG/0.5ML
PEGASYS PROCLICK INJECTION 180MCG/0.5ML
PEGASYS INJECTION 180MCG/0.5ML
PEGASYS INJECTION 180MCG/ML
PEGINTRON INJECTION 120MCG/0.5ML
PEGINTRON INJECTION 150MCG/0.5ML
PEGINTRON INJECTION 80MCG/0.5ML
REBETOL SOLUTION 40MG/ML
ribasphere ribapak tablet 0
ribasphere ribapak tablet 400mg
ribasphere ribapak tablet 600mg
ribasphere tablet 200mg
ribasphere tablet 400mg
ribasphere tablet 600mg
ribavirin capsule 200mg
ribavirin tablet 200mg
SOVALDI TABLET 400MG
VICTRELIS CAPSULE 200MG
VIRAZOLE SOLUTION RECONSTITUTED 6GM
Anti-HIV Agents, Integrase Inhibitors (INSTI)
Página 41 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos Peg-Intron, Pegasys)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (28 EA cada 28 días)
PA (Agentes
inmunológicos - Sovaldi)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Nombre del medicamento
ISENTRESS PACKET 100MG
ISENTRESS TABLET CHEWABLE 100MG
ISENTRESS TABLET CHEWABLE 25MG
ISENTRESS TABLET 400MG
TIVICAY TABLET 50MG
VITEKTA TABLET 150MG
VITEKTA TABLET 85MG
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA TABLET 200MG; 25MG; 300MG
$0-$6.60(Nivel 2)
EDURANT TABLET 25MG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
INTELENCE TABLET 100MG
INTELENCE TABLET 200MG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) MO
INTELENCE TABLET 25MG
nevirapine er tablet extended release 24 hour 400mg
$0(Nivel 1)
MO
nevirapine suspension 50mg/5ml
$0(Nivel 1)
nevirapine tablet 200mg
$0(Nivel 1)
RESCRIPTOR TABLET 100MG
$0-$6.60(Nivel 2)
RESCRIPTOR TABLET 200MG
$0-$6.60(Nivel 2)
STRIBILD TABLET 150MG; 150MG; 200MG; 300MG
$0-$6.60(Nivel 2)
SUSTIVA CAPSULE 200MG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
SUSTIVA CAPSULE 50MG
SUSTIVA TABLET 600MG
$0-$6.60(Nivel 2)
VIRAMUNE XR TABLET EXTENDED RELEASE 24
$0-$6.60(Nivel 2)
HOUR 100MG
VIRAMUNE XR TABLET EXTENDED RELEASE 24
$0-$6.60(Nivel 2)
HOUR 400MG
VIRAMUNE SUSPENSION 50MG/5ML
$0-$6.60(Nivel 2)
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir sulfate/lamivudine/zidovudine tablet 300mg; 150mg; $0(Nivel 1)
MO
300mg
abacavir tablet 300mg
$0(Nivel 1)
didanosine capsule delayed release 125mg
$0(Nivel 1)
didanosine capsule delayed release 200mg
$0(Nivel 1)
didanosine capsule delayed release 250mg
$0(Nivel 1)
didanosine capsule delayed release 400mg
$0(Nivel 1)
EMTRIVA CAPSULE 200MG
$0-$6.60(Nivel 2)
EMTRIVA SOLUTION 10MG/ML
$0-$6.60(Nivel 2)
EPIVIR SOLUTION 10MG/ML
$0-$6.60(Nivel 2)
EPZICOM TABLET 600MG; 300MG
$0-$6.60(Nivel 2)
lamivudine/zidovudine tablet 150mg; 300mg
$0(Nivel 1)
lamivudine solution 10mg/ml
$0(Nivel 1)
MO
lamivudine tablet 150mg
$0(Nivel 1)
lamivudine tablet 300mg
$0(Nivel 1)
RETROVIR IV INFUSION INJECTION 10MG/ML
$0-$6.60(Nivel 2)
Página 42 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
stavudine capsule 15mg
$0(Nivel 1)
stavudine capsule 20mg
$0(Nivel 1)
stavudine capsule 30mg
$0(Nivel 1)
stavudine capsule 40mg
$0(Nivel 1)
stavudine solution reconstituted 1mg/ml
$0(Nivel 1)
$0-$6.60(Nivel 2) MO
TRIUMEQ TABLET 600MG; 50MG; 300MG
TRUVADA TABLET 200MG; 300MG
$0-$6.60(Nivel 2)
VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM $0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
VIREAD POWDER 40MG/GM
VIREAD TABLET 150MG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
VIREAD TABLET 200MG
VIREAD TABLET 250MG
$0-$6.60(Nivel 2)
VIREAD TABLET 300MG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
ZIAGEN SOLUTION 20MG/ML
zidovudine capsule 100mg
$0(Nivel 1)
zidovudine syrup 50mg/5ml
$0(Nivel 1)
zidovudine tablet 300mg
$0(Nivel 1)
Anti-HIV Agents, Other
FUZEON INJECTION 90MG
$0-$6.60(Nivel 2)
SELZENTRY TABLET 150MG
$0-$6.60(Nivel 2)
SELZENTRY TABLET 300MG
$0-$6.60(Nivel 2)
TYBOST TABLET 150MG
$0-$6.60(Nivel 2) MO
Anti-HIV Agents, Protease Inhibitors
APTIVUS CAPSULE 250MG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
APTIVUS SOLUTION 100MG/ML
CRIXIVAN CAPSULE 200MG
$0-$6.60(Nivel 2)
CRIXIVAN CAPSULE 400MG
$0-$6.60(Nivel 2)
EVOTAZ TABLET 300MG; 150MG
$0-$6.60(Nivel 2) QL (300 EA cada 30 días)
MO
$0-$6.60(Nivel 2)
INVIRASE CAPSULE 200MG
INVIRASE TABLET 500MG
$0-$6.60(Nivel 2)
KALETRA SOLUTION 400MG/5ML; 100MG/5ML
$0-$6.60(Nivel 2)
KALETRA TABLET 100MG; 25MG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
KALETRA TABLET 200MG; 50MG
LEXIVA SUSPENSION 50MG/ML
$0-$6.60(Nivel 2)
LEXIVA TABLET 700MG
$0-$6.60(Nivel 2)
NORVIR CAPSULE 100MG
$0-$6.60(Nivel 2)
NORVIR SOLUTION 80MG/ML
$0-$6.60(Nivel 2)
NORVIR TABLET 100MG
$0-$6.60(Nivel 2)
PREZCOBIX TABLET 150MG; 800MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
PREZISTA SUSPENSION 100MG/ML
$0-$6.60(Nivel 2)
PREZISTA TABLET 150MG
$0-$6.60(Nivel 2)
PREZISTA TABLET 400MG
$0-$6.60(Nivel 2)
PREZISTA TABLET 600MG
$0-$6.60(Nivel 2)
PREZISTA TABLET 75MG
$0-$6.60(Nivel 2)
PREZISTA TABLET 800MG
$0-$6.60(Nivel 2)
REYATAZ CAPSULE 150MG
$0-$6.60(Nivel 2)
Página 43 de 143
Nombre del medicamento
REYATAZ CAPSULE 200MG
REYATAZ CAPSULE 300MG
REYATAZ PACKET 50MG
VIRACEPT TABLET 250MG
VIRACEPT TABLET 625MG
Anti-influenza Agents
amantadine hcl capsule 100mg
amantadine hcl syrup 50mg/5ml
amantadine hcl tablet 100mg
RELENZA DISKHALER AEROSOL POWDER BREATH
ACTIVATED 5MG/BLISTER
rimantadine hcl tablet 100mg
TAMIFLU CAPSULE 30MG
TAMIFLU CAPSULE 45MG
TAMIFLU CAPSULE 75MG
TAMIFLU SUSPENSION RECONSTITUTED 6MG/ML
Antiherpetic Agents
acyclovir sodium injection 50mg/ml
acyclovir capsule 200mg
acyclovir suspension 200mg/5ml
acyclovir tablet 400mg
acyclovir tablet 800mg
DENAVIR CREAM 1%
famciclovir tablet 125mg
famciclovir tablet 250mg
famciclovir tablet 500mg
trifluridine solution 1%
valacyclovir hcl tablet 1000mg
valacyclovir hcl tablet 500mg
ZOVIRAX CREAM 5%
ZOVIRAX OINTMENT 5%
Antivirals
ABREVA CREAM 10%
ATRIPLA TABLET 600MG; 200MG; 300MG
Anxiolytics
Anxiolytics, Other
buspirone hcl tablet 10mg
buspirone hcl tablet 15mg
buspirone hcl tablet 30mg
buspirone hcl tablet 5mg
buspirone hcl tablet 7.5mg
meprobamate tablet 200mg
meprobamate tablet 400mg
Benzodiazepines
ALPRAZOLAM INTENSOL CONCENTRATE 1MG/ML
Página 44 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (56 EA cada 180 días)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (84 EA cada 180 días)
$0-$6.60(Nivel 2) QL (42 EA cada 180 días)
$0-$6.60(Nivel 2) QL (28 EA cada 180 días)
$0-$6.60(Nivel 2) QL (540 ML cada 180
días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 GM cada 30 días)
$0-$6.60(Nivel 2) QL (30 GM cada 30 días)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
Nombre del medicamento
alprazolam tablet 0.25mg
alprazolam tablet 0.5mg
alprazolam tablet 1mg
alprazolam tablet 2mg
clorazepate dipotassium tablet 15mg
clorazepate dipotassium tablet 3.75mg
clorazepate dipotassium tablet 7.5mg
DIAZEPAM INTENSOL CONCENTRATE 5MG/ML
diazepam tablet 10mg
diazepam tablet 2mg
diazepam tablet 5mg
LORAZEPAM INTENSOL CONCENTRATE 2MG/ML
lorazepam tablet 0.5mg
lorazepam tablet 1mg
lorazepam tablet 2mg
triazolam tablet 0.125mg
triazolam tablet 0.25mg
Bipolar Agents
Mood Stabilizers
lithium carbonate er tablet extended release 300mg
lithium carbonate er tablet extended release 450mg
lithium carbonate capsule 150mg
lithium carbonate capsule 300mg
lithium carbonate capsule 600mg
lithium carbonate tablet 300mg
lithium solution 8meq/5ml
LITHOBID TABLET EXTENDED RELEASE 300MG
Blood Glucose Regulators
Antidiabetic Agents
acarbose tablet 100mg
acarbose tablet 25mg
acarbose tablet 50mg
AVANDARYL TABLET 1MG; 4MG
AVANDARYL TABLET 2MG; 4MG
AVANDARYL TABLET 2MG; 8MG
AVANDARYL TABLET 4MG; 4MG
AVANDARYL TABLET 4MG; 8MG
BYETTA INJECTION 10MCG/0.04ML
BYETTA INJECTION 5MCG/0.02ML
CYCLOSET TABLET 0.8MG
DUETACT TABLET 2MG; 30MG
DUETACT TABLET 4MG; 30MG
FARXIGA TABLET 10MG
Página 45 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (150 EA cada 30 días)
QL (150 EA cada 30 días)
$0(Nivel 1)
QL (150 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0-$6.60(Nivel 2)
QL (120 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (120 EA cada 30 días)
QL (120 EA cada 30 días)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
QL (120 EA cada 30 días)
QL (150 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (150 EA cada 30 días)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
QL (90 EA cada 30 días)
QL (90 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (2.4 ML cada 30 días)
PA (Reguladores de
glucosa en sangre)
$0-$6.60(Nivel 2) PA (Reguladores de
glucosa en sangre)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
Nombre del medicamento
FARXIGA TABLET 5MG
glimepiride tablet 1mg
glimepiride tablet 2mg
glimepiride tablet 4mg
glipizide er tablet extended release 24 hour 10mg
glipizide er tablet extended release 24 hour 2.5mg
glipizide er tablet extended release 24 hour 5mg
glipizide/metformin hcl tablet 2.5mg; 250mg
glipizide/metformin hcl tablet 2.5mg; 500mg
glipizide/metformin hcl tablet 5mg; 500mg
glipizide tablet 10mg
glipizide tablet 5mg
glyburide micronized tablet 1.5mg
glyburide micronized tablet 3mg
glyburide micronized tablet 6mg
glyburide/metformin hcl tablet 1.25mg; 250mg
glyburide/metformin hcl tablet 2.5mg; 500mg
glyburide/metformin hcl tablet 5mg; 500mg
glyburide tablet 1.25mg
glyburide tablet 2.5mg
glyburide tablet 5mg
GLYSET TABLET 100MG
GLYSET TABLET 25MG
GLYSET TABLET 50MG
JANUVIA TABLET 100MG
JANUVIA TABLET 25MG
JANUVIA TABLET 50MG
JENTADUETO TABLET 2.5MG; 1000MG
JENTADUETO TABLET 2.5MG; 500MG
JENTADUETO TABLET 2.5MG; 850MG
Página 46 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
PA (Medicamento de alto
riesgo - Glyburide)
$0(Nivel 1)
QL (30 EA cada 30 días)
PA (Medicamento de alto
riesgo - Glyburide)
$0(Nivel 1)
QL (60 EA cada 30 días)
PA (Medicamento de alto
riesgo - Glyburide)
$0(Nivel 1)
QL (120 EA cada 30 días)
PA (Medicamento de alto
riesgo - Glyburide)
$0(Nivel 1)
QL (120 EA cada 30 días)
PA (Medicamento de alto
riesgo - Glyburide)
$0(Nivel 1)
QL (120 EA cada 30 días)
PA (Medicamento de alto
riesgo - Glyburide)
$0(Nivel 1)
QL (30 EA cada 30 días)
PA (Medicamento de alto
riesgo - Glyburide)
$0(Nivel 1)
QL (30 EA cada 30 días)
PA (Medicamento de alto
riesgo - Glyburide)
$0(Nivel 1)
PA (Medicamento de alto
riesgo - Glyburide)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
Nombre del medicamento
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 2.5MG
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 5MG
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 500MG; 5MG
metformin hcl er tablet extended release 24 hour 500mg
metformin hcl er tablet extended release 24 hour 750mg
metformin hcl tablet 1000mg
metformin hcl tablet 500mg
metformin hcl tablet 850mg
nateglinide tablet 120mg
nateglinide tablet 60mg
ONGLYZA TABLET 2.5MG
ONGLYZA TABLET 5MG
pioglitazone hcl/metformin hcl tablet 500mg; 15mg
pioglitazone hcl/metformin hcl tablet 850mg; 15mg
pioglitazone hcl tablet 15mg
pioglitazone hcl tablet 30mg
pioglitazone hcl tablet 45mg
repaglinide tablet 0.5mg
repaglinide tablet 1mg
repaglinide tablet 2mg
SYMLINPEN 120 INJECTION 2700MCG/2.7ML
SYMLINPEN 60 INJECTION 1500MCG/1.5ML
tolbutamide tablet 500mg
TRADJENTA TABLET 5MG
Glycemic Agents
GLUCAGEN HYPOKIT INJECTION 1MG
GLUCAGON EMERGENCY KIT INJECTION 1MG
GLUCOSE TABLET CHEWABLE 4GM
glutose 15 gel 40%
glutose 15 gel 40%
HM GLUCOSE TABLET CHEWABLE 6MG; 4GM
INSTA-GLUCOSE GEL 77.4%
PROGLYCEM SUSPENSION 50MG/ML
SM GLUCOSE TABLET CHEWABLE 4GM
SM GLUCOSE TABLET CHEWABLE 6MG; 4GM
SM GLUCOSE TABLET CHEWABLE 6MG; 4GM
SM GLUCOSE TABLET CHEWABLE 6MG; 4GM
Insulins
APIDRA SOLOSTAR INJECTION 100UNIT/ML
APIDRA INJECTION 100UNIT/ML
HUMALOG KWIKPEN INJECTION 100UNIT/ML
Página 47 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0(Nivel 1)
QL (120 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
QL (60 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (120 EA cada 30 días)
QL (90 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0-$6.60(Nivel 2) PA (Reguladores de
glucosa en sangre Amylinomimetics)
$0-$6.60(Nivel 2) PA (Reguladores de
glucosa en sangre Amylinomimetics)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2) QL (30 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
Nombre del medicamento
HUMALOG KWIKPEN INJECTION 100UNIT/ML
HUMALOG KWIKPEN INJECTION 200UNIT/ML
HUMALOG MIX 50/50 KWIKPEN INJECTION
50UNIT/ML; 50UNIT/ML
HUMALOG MIX 50/50 INJECTION 50UNIT/ML;
50UNIT/ML
HUMALOG MIX 75/25 KWIKPEN INJECTION
25UNIT/ML; 75UNIT/ML
HUMALOG MIX 75/25 INJECTION 25UNIT/ML;
75UNIT/ML
HUMALOG INJECTION 100UNIT/ML
HUMALOG INJECTION 100UNIT/ML
HUMULIN 70/30 KWIKPEN INJECTION 30UNIT/ML;
70UNIT/ML
HUMULIN 70/30 INJECTION 30UNIT/ML; 70UNIT/ML
HUMULIN N KWIKPEN INJECTION 100UNIT/ML
HUMULIN N INJECTION 100UNIT/ML
HUMULIN R U-500 (CONCENTRATED) INJECTION
500UNIT/ML
HUMULIN R INJECTION 100UNIT/ML
LANTUS SOLOSTAR INJECTION 100UNIT/ML
LANTUS INJECTION 100UNIT/ML
LEVEMIR FLEXTOUCH INJECTION 100UNIT/ML
LEVEMIR INJECTION 100UNIT/ML
NOVOLIN 70/30 INJECTION 30UNIT/ML; 70UNIT/ML
NOVOLIN N INJECTION 100UNIT/ML
NOVOLIN R INJECTION 100UNIT/ML
NOVOLOG FLEXPEN INJECTION 100UNIT/ML
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
INJECTION 30UNIT/ML; 70UNIT/ML
NOVOLOG MIX 70/30 INJECTION 30UNIT/ML;
70UNIT/ML
NOVOLOG PENFILL INJECTION 100UNIT/ML
NOVOLOG INJECTION 100UNIT/ML
Blood Products/Modifiers/Volume Expanders
Anticoagulants
COUMADIN INJECTION 5MG
COUMADIN TABLET 10MG
COUMADIN TABLET 1MG
COUMADIN TABLET 2.5MG
COUMADIN TABLET 2MG
COUMADIN TABLET 3MG
COUMADIN TABLET 4MG
COUMADIN TABLET 5MG
Página 48 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (45 ML cada 30 días)
MO
$0-$6.60(Nivel 2) QL (45 ML cada 30 días)
MO
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (45 ML cada 30 días)
MO
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (30 ML cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (30 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2) QL (45 ML cada 30 días)
MO
$0-$6.60(Nivel 2) QL (40 ML cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Nombre del medicamento
COUMADIN TABLET 6MG
COUMADIN TABLET 7.5MG
enoxaparin sodium injection 100mg/ml
enoxaparin sodium injection 120mg/0.8ml
enoxaparin sodium injection 150mg/ml
enoxaparin sodium injection 300mg/3ml
enoxaparin sodium injection 30mg/0.3ml
enoxaparin sodium injection 40mg/0.4ml
enoxaparin sodium injection 60mg/0.6ml
enoxaparin sodium injection 80mg/0.8ml
fondaparinux sodium injection 10mg/0.8ml
fondaparinux sodium injection 2.5mg/0.5ml
fondaparinux sodium injection 5mg/0.4ml
fondaparinux sodium injection 7.5mg/0.6ml
FRAGMIN INJECTION 10000UNIT/ML
FRAGMIN INJECTION 12500UNIT/0.5ML
FRAGMIN INJECTION 15000UNIT/0.6ML
FRAGMIN INJECTION 18000UNT/0.72ML
FRAGMIN INJECTION 25000UNIT/ML
FRAGMIN INJECTION 2500UNIT/0.2ML
FRAGMIN INJECTION 5000UNIT/0.2ML
FRAGMIN INJECTION 7500UNIT/0.3ML
FRAGMIN INJECTION 95000UNIT/3.8ML
heparin sodium/d5w injection 5%; 100unit/ml
heparin sodium/d5w injection 5%; 40unit/ml
heparin sodium/d5w injection 5%; 50unit/ml
heparin sodium/nacl 0.9% injection 2unit/ml; 0.9%
heparin sodium injection 10000unit/ml
heparin sodium injection 1000unit/ml
heparin sodium injection 20000unit/ml
heparin sodium injection 5000unit/ml
jantoven tablet 10mg
jantoven tablet 1mg
jantoven tablet 2.5mg
jantoven tablet 2mg
jantoven tablet 3mg
jantoven tablet 4mg
jantoven tablet 5mg
jantoven tablet 6mg
jantoven tablet 7.5mg
PRADAXA CAPSULE 150MG
PRADAXA CAPSULE 75MG
warfarin sodium tablet 10mg
warfarin sodium tablet 1mg
warfarin sodium tablet 2.5mg
warfarin sodium tablet 2mg
warfarin sodium tablet 3mg
warfarin sodium tablet 4mg
Página 49 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
warfarin sodium tablet 5mg
$0(Nivel 1)
warfarin sodium tablet 6mg
$0(Nivel 1)
$0(Nivel 1)
warfarin sodium tablet 7.5mg
XARELTO STARTER PACK TABLET THERAPY PACK 0 $0-$6.60(Nivel 2)
XARELTO TABLET 10MG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
XARELTO TABLET 15MG
XARELTO TABLET 20MG
$0-$6.60(Nivel 2)
Blood Formation Modifiers
anagrelide hydrochloride capsule 0.5mg
$0(Nivel 1)
anagrelide hydrochloride capsule 1mg
$0(Nivel 1)
ARANESP ALBUMIN FREE INJECTION 100MCG/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
ARANESP ALBUMIN FREE INJECTION 10MCG/0.4ML $0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
ARANESP ALBUMIN FREE INJECTION 150MCG/0.3ML $0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
ARANESP ALBUMIN FREE INJECTION 200MCG/0.4ML $0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
ARANESP ALBUMIN FREE INJECTION 200MCG/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
ARANESP ALBUMIN FREE INJECTION 25MCG/0.42ML $0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
ARANESP ALBUMIN FREE INJECTION 25MCG/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
ARANESP ALBUMIN FREE INJECTION 300MCG/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
ARANESP ALBUMIN FREE INJECTION 40MCG/0.4ML $0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
Página 50 de 143
Nombre del medicamento
ARANESP ALBUMIN FREE INJECTION 40MCG/ML
ARANESP ALBUMIN FREE INJECTION 500MCG/ML
ARANESP ALBUMIN FREE INJECTION 60MCG/ML
EPOGEN INJECTION 10000UNIT/ML
EPOGEN INJECTION 20000UNIT/ML
EPOGEN INJECTION 2000UNIT/ML
EPOGEN INJECTION 3000UNIT/ML
EPOGEN INJECTION 4000UNIT/ML
GRANIX INJECTION 300MCG/0.5ML
GRANIX INJECTION 480MCG/0.8ML
LEUKINE INJECTION 250MCG
NEULASTA INJECTION 6MG/0.6ML
NEUMEGA INJECTION 5MG
NEUPOGEN INJECTION 300MCG/0.5ML
NEUPOGEN INJECTION 300MCG/ML
NEUPOGEN INJECTION 480MCG/0.8ML
NEUPOGEN INJECTION 480MCG/1.6ML
PROCRIT INJECTION 10000UNIT/ML
Página 51 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
Nombre del medicamento
PROCRIT INJECTION 20000UNIT/ML
PROCRIT INJECTION 2000UNIT/ML
PROCRIT INJECTION 3000UNIT/ML
PROCRIT INJECTION 40000UNIT/ML
PROCRIT INJECTION 4000UNIT/ML
PROMACTA TABLET 25MG
PROMACTA TABLET 50MG
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
PA
(Productos/modificadores/
expansores del volumen
de sangre - Promacta)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
PA
(Productos/modificadores/
expansores del volumen
de sangre - Promacta)
Coagulants
tranexamic acid injection 100mg/ml
$0(Nivel 1)
tranexamic acid tablet 650mg
$0(Nivel 1)
Platelet Modifying Agents
AGGRENOX CAPSULE EXTENDED RELEASE 12 HOUR $0-$6.60(Nivel 2) QL (60 EA cada 30 días)
25MG; 200MG
aspirin/dipyridamole capsule extended release 12 hour 25mg; $0(Nivel 1)
QL (60 EA cada 30 días)
200mg
MO
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
BRILINTA TABLET 90MG
cilostazol tablet 100mg
$0(Nivel 1)
cilostazol tablet 50mg
$0(Nivel 1)
clopidogrel tablet 300mg
$0(Nivel 1)
clopidogrel tablet 75mg
$0(Nivel 1)
QL (30 EA cada 30 días)
dipyridamole tablet 25mg
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
dipyridamole tablet 50mg
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
Página 52 de 143
Nombre del medicamento
dipyridamole tablet 75mg
EFFIENT TABLET 10MG
EFFIENT TABLET 5MG
ticlopidine hcl tablet 250mg
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl er tablet extended release 12 hour 0.1mg
clonidine hcl tablet 0.1mg
clonidine hcl tablet 0.2mg
clonidine hcl tablet 0.3mg
guanfacine hcl tablet 1mg
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
guanfacine hcl tablet 2mg
$0(Nivel 1)
methyldopa/hydrochlorothiazide tablet 15mg; 250mg
methyldopa/hydrochlorothiazide tablet 25mg; 250mg
methyldopa tablet 250mg
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
methyldopa tablet 500mg
$0(Nivel 1)
METHYLDOPATE HCL INJECTION 250MG/5ML
midodrine hcl tablet 10mg
midodrine hcl tablet 2.5mg
midodrine hcl tablet 5mg
Alpha-adrenergic Blocking Agents
prazosin hcl capsule 1mg
prazosin hcl capsule 2mg
prazosin hcl capsule 5mg
reserpine tablet 0.25mg
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Angiotensin II Receptor Antagonists
candesartan cilexetil/hydrochlorothiazide tablet 16mg;
$0(Nivel 1)
12.5mg
candesartan cilexetil/hydrochlorothiazide tablet 32mg;
$0(Nivel 1)
12.5mg
candesartan cilexetil/hydrochlorothiazide tablet 32mg; 25mg $0(Nivel 1)
candesartan cilexetil tablet 16mg
$0(Nivel 1)
candesartan cilexetil tablet 32mg
$0(Nivel 1)
candesartan cilexetil tablet 4mg
$0(Nivel 1)
candesartan cilexetil tablet 8mg
$0(Nivel 1)
Página 53 de 143
MO
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo) MO
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
eprosartan mesylate tablet 600mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
irbesartan/hydrochlorothiazide tablet 12.5mg; 150mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
$0(Nivel 1)
QL (30 EA cada 30 días)
irbesartan/hydrochlorothiazide tablet 12.5mg; 300mg
MO
irbesartan tablet 150mg
$0(Nivel 1)
QL (30 EA cada 30 días)
irbesartan tablet 300mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
irbesartan tablet 75mg
$0(Nivel 1)
QL (30 EA cada 30 días)
losartan potassium/hydrochlorothiazide tablet 12.5mg; 100mg $0(Nivel 1)
QL (30 EA cada 30 días)
losartan potassium/hydrochlorothiazide tablet 12.5mg; 50mg $0(Nivel 1)
QL (30 EA cada 30 días)
losartan potassium/hydrochlorothiazide tablet 25mg; 100mg $0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
losartan potassium tablet 100mg
$0(Nivel 1)
losartan potassium tablet 25mg
$0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
losartan potassium tablet 50mg
$0(Nivel 1)
telmisartan/hydrochlorothiazide tablet 12.5mg; 40mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
telmisartan/hydrochlorothiazide tablet 12.5mg; 80mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
telmisartan/hydrochloroth tablet 25mg; 80mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
telmisartan tablet 20mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
telmisartan tablet 40mg
$0(Nivel 1)
MO
telmisartan tablet 80mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
valsartan/hydrochlorothiazide tablet 12.5mg; 160mg
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
valsartan/hydrochlorothiazide tablet 12.5mg; 320mg
valsartan/hydrochlorothiazide tablet 12.5mg; 80mg
$0(Nivel 1)
QL (30 EA cada 30 días)
valsartan/hydrochlorothiazide tablet 25mg; 160mg
$0(Nivel 1)
QL (30 EA cada 30 días)
valsartan/hydrochlorothiazide tablet 25mg; 320mg
$0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
valsartan tablet 160mg
$0(Nivel 1)
MO
valsartan tablet 320mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
valsartan tablet 40mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
valsartan tablet 80mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide tablet 10mg; 12.5mg
$0(Nivel 1)
benazepril hcl/hydrochlorothiazide tablet 20mg; 12.5mg
$0(Nivel 1)
benazepril hcl/hydrochlorothiazide tablet 20mg; 25mg
$0(Nivel 1)
benazepril hcl/hydrochlorothiazide tablet 5mg; 6.25mg
$0(Nivel 1)
benazepril hcl tablet 10mg
$0(Nivel 1)
QL (30 EA cada 30 días)
benazepril hcl tablet 20mg
$0(Nivel 1)
QL (30 EA cada 30 días)
Página 54 de 143
Nombre del medicamento
benazepril hcl tablet 40mg
benazepril hcl tablet 5mg
captopril/hydrochlorothiazide tablet 25mg; 15mg
captopril/hydrochlorothiazide tablet 25mg; 25mg
captopril/hydrochlorothiazide tablet 50mg; 15mg
captopril/hydrochlorothiazide tablet 50mg; 25mg
captopril tablet 100mg
captopril tablet 12.5mg
captopril tablet 25mg
captopril tablet 50mg
enalapril maleate/hydrochlorothiazide tablet 10mg; 25mg
enalapril maleate/hydrochlorothiazide tablet 5mg; 12.5mg
enalapril maleate tablet 10mg
enalapril maleate tablet 2.5mg
enalapril maleate tablet 20mg
enalapril maleate tablet 5mg
fosinopril sodium/hydrochlorothiazide tablet 10mg; 12.5mg
fosinopril sodium/hydrochlorothiazide tablet 20mg; 12.5mg
fosinopril sodium tablet 10mg
fosinopril sodium tablet 20mg
fosinopril sodium tablet 40mg
lisinopril/hydrochlorothiazide tablet 12.5mg; 10mg
lisinopril/hydrochlorothiazide tablet 12.5mg; 20mg
lisinopril/hydrochlorothiazide tablet 25mg; 20mg
lisinopril tablet 10mg
lisinopril tablet 2.5mg
lisinopril tablet 20mg
lisinopril tablet 30mg
lisinopril tablet 40mg
lisinopril tablet 5mg
quinapril hcl tablet 10mg
quinapril hcl tablet 20mg
quinapril hcl tablet 40mg
quinapril hcl tablet 5mg
quinapril/hydrochlorothiazide tablet 12.5mg; 10mg
quinapril/hydrochlorothiazide tablet 12.5mg; 20mg
quinapril/hydrochlorothiazide tablet 25mg; 20mg
ramipril capsule 1.25mg
ramipril capsule 10mg
ramipril capsule 2.5mg
ramipril capsule 5mg
trandolapril tablet 1mg
trandolapril tablet 2mg
trandolapril tablet 4mg
Antiarrhythmics
amiodarone hcl injection 50mg/ml
amiodarone hcl tablet 200mg
amiodarone hcl tablet 400mg
Página 55 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
disopyramide phosphate capsule 100mg
disopyramide phosphate capsule 150mg
flecainide acetate tablet 100mg
flecainide acetate tablet 150mg
flecainide acetate tablet 50mg
mexiletine hcl capsule 150mg
mexiletine hcl capsule 200mg
mexiletine hcl capsule 250mg
MULTAQ TABLET 400MG
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
pacerone tablet 100mg
pacerone tablet 200mg
pacerone tablet 400mg
PROCAINAMIDE HCL INJECTION 100MG/ML
PROCAINAMIDE HCL INJECTION 500MG/ML
propafenone hcl tablet 150mg
propafenone hcl tablet 225mg
propafenone hcl tablet 300mg
quinidine gluconate cr tablet extended release 324mg
QUINIDINE GLUCONATE INJECTION 80MG/ML
quinidine sulfate er tablet extended release 300mg
quinidine sulfate tablet 200mg
quinidine sulfate tablet 300mg
sorine tablet 120mg
sorine tablet 160mg
sorine tablet 240mg
sorine tablet 80mg
sotalol hcl (af) tablet 120mg
sotalol hcl tablet 160mg
sotalol hcl tablet 240mg
sotalol hcl tablet 80mg
TIKOSYN CAPSULE 125MCG
TIKOSYN CAPSULE 250MCG
TIKOSYN CAPSULE 500MCG
Beta-adrenergic Blocking Agents
acebutolol hcl capsule 200mg
$0(Nivel 1)
acebutolol hcl capsule 400mg
$0(Nivel 1)
atenolol/chlorthalidone tablet 100mg; 25mg
$0(Nivel 1)
atenolol/chlorthalidone tablet 50mg; 25mg
$0(Nivel 1)
atenolol tablet 100mg
$0(Nivel 1)
atenolol tablet 25mg
$0(Nivel 1)
atenolol tablet 50mg
$0(Nivel 1)
betaxolol hcl tablet 10mg
$0(Nivel 1)
betaxolol hcl tablet 20mg
$0(Nivel 1)
bisoprolol fumarate/hydrochlorothiazide tablet 10mg; 6.25mg $0(Nivel 1)
bisoprolol fumarate/hydrochlorothiazide tablet 2.5mg; 6.25mg$0(Nivel 1)
bisoprolol fumarate/hydrochlorothiazide tablet 5mg; 6.25mg $0(Nivel 1)
bisoprolol fumarate tablet 10mg
$0(Nivel 1)
Página 56 de 143
Nombre del medicamento
bisoprolol fumarate tablet 5mg
carvedilol tablet 12.5mg
carvedilol tablet 25mg
carvedilol tablet 3.125mg
carvedilol tablet 6.25mg
labetalol hcl injection 5mg/ml
labetalol hcl tablet 100mg
labetalol hcl tablet 200mg
labetalol hcl tablet 300mg
metoprolol succinate er tablet extended release 24 hour
100mg
metoprolol succinate er tablet extended release 24 hour
200mg
metoprolol succinate er tablet extended release 24 hour 25mg
metoprolol succinate er tablet extended release 24 hour 50mg
metoprolol tartrate injection 1mg/ml
metoprolol tartrate tablet 100mg
metoprolol tartrate tablet 25mg
metoprolol tartrate tablet 50mg
metoprolol/hydrochlorothiazide tablet 25mg; 100mg
metoprolol/hydrochlorothiazide tablet 25mg; 50mg
metoprolol/hydrochlorothiazide tablet 50mg; 100mg
nadolol/bendroflumethiazide tablet 5mg; 40mg
nadolol/bendroflumethiazide tablet 5mg; 80mg
nadolol tablet 20mg
nadolol tablet 40mg
nadolol tablet 80mg
pindolol tablet 10mg
pindolol tablet 5mg
propranolol hcl er capsule extended release 24 hour 120mg
propranolol hcl er capsule extended release 24 hour 160mg
propranolol hcl er capsule extended release 24 hour 60mg
propranolol hcl er capsule extended release 24 hour 80mg
propranolol hcl injection 1mg/ml
propranolol hcl solution 20mg/5ml
propranolol hcl solution 40mg/5ml
propranolol hcl tablet 10mg
propranolol hcl tablet 20mg
propranolol hcl tablet 40mg
propranolol hcl tablet 60mg
propranolol hcl tablet 80mg
propranolol/hydrochlorothiazide tablet 25mg; 40mg
propranolol/hydrochlorothiazide tablet 25mg; 80mg
timolol maleate tablet 10mg
timolol maleate tablet 20mg
timolol maleate tablet 5mg
Calcium Channel Blocking Agents
afeditab cr tablet extended release 24 hour 30mg
Página 57 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
afeditab cr tablet extended release 24 hour 60mg
$0(Nivel 1)
QL (30 EA cada 30 días)
amlodipine besylate/benazepril hcl capsule 10mg; 40mg
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
amlodipine besylate/benazepril hcl capsule 5mg; 40mg
QL (30 EA cada 30 días)
amlodipine besylate/benazepril hydrochloride capsule 10mg; $0(Nivel 1)
20mg
amlodipine besylate/benazepril hydrochloride capsule 2.5mg; $0(Nivel 1)
QL (30 EA cada 30 días)
10mg
amlodipine besylate/benazepril hydrochloride capsule 5mg; $0(Nivel 1)
QL (30 EA cada 30 días)
10mg
QL (30 EA cada 30 días)
amlodipine besylate/benazepril hydrochloride capsule 5mg; $0(Nivel 1)
20mg
amlodipine besylate/valsartan tablet 10mg; 160mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
amlodipine besylate/valsartan tablet 10mg; 320mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
amlodipine besylate/valsartan tablet 5mg; 160mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
amlodipine besylate/valsartan tablet 5mg; 320mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
amlodipine besylate tablet 10mg
$0(Nivel 1)
QL (30 EA cada 30 días)
amlodipine besylate tablet 2.5mg
$0(Nivel 1)
QL (30 EA cada 30 días)
amlodipine besylate tablet 5mg
$0(Nivel 1)
QL (30 EA cada 30 días)
amlodipine/valsartan/hctz tablet 10mg; 12.5mg; 160mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
$0(Nivel 1)
QL (30 EA cada 30 días)
amlodipine/valsartan/hctz tablet 10mg; 25mg; 160mg
MO
amlodipine/valsartan/hctz tablet 10mg; 25mg; 320mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
amlodipine/valsartan/hctz tablet 5mg; 12.5mg; 160mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
amlodipine/valsartan/hctz tablet 5mg; 25mg; 160mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
cartia xt capsule extended release 24 hour 120mg
$0(Nivel 1)
QL (30 EA cada 30 días)
cartia xt capsule extended release 24 hour 180mg
$0(Nivel 1)
QL (30 EA cada 30 días)
cartia xt capsule extended release 24 hour 240mg
$0(Nivel 1)
QL (30 EA cada 30 días)
cartia xt capsule extended release 24 hour 300mg
$0(Nivel 1)
QL (30 EA cada 30 días)
dilt-cd capsule extended release 24 hour 300mg
$0(Nivel 1)
QL (30 EA cada 30 días)
dilt-xr capsule extended release 24 hour 120mg
$0(Nivel 1)
QL (60 EA cada 30 días)
dilt-xr capsule extended release 24 hour 180mg
$0(Nivel 1)
QL (90 EA cada 30 días)
dilt-xr capsule extended release 24 hour 240mg
$0(Nivel 1)
QL (60 EA cada 30 días)
diltiazem cd capsule extended release 24 hour 240mg
$0(Nivel 1)
QL (30 EA cada 30 días)
diltiazem hcl er capsule extended release 12 hour 120mg
$0(Nivel 1)
diltiazem hcl er capsule extended release 12 hour 60mg
$0(Nivel 1)
diltiazem hcl er capsule extended release 12 hour 90mg
$0(Nivel 1)
diltiazem hcl er capsule extended release 24 hour 120mg
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
diltiazem hcl er capsule extended release 24 hour 180mg
diltiazem hcl er capsule extended release 24 hour 300mg
$0(Nivel 1)
QL (30 EA cada 30 días)
diltiazem hcl er capsule extended release 24 hour 360mg
$0(Nivel 1)
QL (30 EA cada 30 días)
Página 58 de 143
Nombre del medicamento
diltiazem hcl er capsule extended release 24 hour 420mg
DILTIAZEM HCL INJECTION 100MG
diltiazem hcl injection 50mg/10ml
diltiazem hcl tablet 120mg
diltiazem hcl tablet 30mg
diltiazem hcl tablet 60mg
diltiazem hcl tablet 90mg
felodipine er tablet extended release 24 hour 10mg
felodipine er tablet extended release 24 hour 2.5mg
felodipine er tablet extended release 24 hour 5mg
matzim la tablet extended release 24 hour 180mg
matzim la tablet extended release 24 hour 240mg
matzim la tablet extended release 24 hour 300mg
matzim la tablet extended release 24 hour 360mg
matzim la tablet extended release 24 hour 420mg
nicardipine hcl capsule 20mg
nicardipine hcl capsule 30mg
nifedical xl tablet extended release 24 hour 30mg
nifedical xl tablet extended release 24 hour 60mg
nifedipine er tablet extended release 24 hour 30mg
nifedipine er tablet extended release 24 hour 60mg
nifedipine er tablet extended release 24 hour 90mg
taztia xt capsule extended release 24 hour 120mg
taztia xt capsule extended release 24 hour 180mg
taztia xt capsule extended release 24 hour 240mg
taztia xt capsule extended release 24 hour 300mg
taztia xt capsule extended release 24 hour 360mg
verapamil hcl er capsule extended release 24 hour 100mg
verapamil hcl er capsule extended release 24 hour 120mg
verapamil hcl er capsule extended release 24 hour 180mg
verapamil hcl er capsule extended release 24 hour 200mg
verapamil hcl er capsule extended release 24 hour 240mg
verapamil hcl er capsule extended release 24 hour 300mg
verapamil hcl er tablet extended release 180mg
verapamil hcl er tablet extended release 240mg
verapamil hcl sr capsule extended release 24 hour 360mg
verapamil hcl injection 2.5mg/ml
verapamil hcl tablet 120mg
verapamil hcl tablet 40mg
verapamil hcl tablet 80mg
Cardiovascular Agents, Other
DEMSER CAPSULE 250MG
digitek tablet 0.125mg
digitek tablet 0.25mg
digoxin injection 0.25mg/ml
Página 59 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (30 EA cada 30 días)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
PA (Medicamento de alto
riesgo - Digoxin) MO
$0(Nivel 1)
PA (Medicamento de alto
riesgo - Digoxin) MO
$0(Nivel 1)
PA (Medicamento de alto
riesgo - Digoxin)
Nombre del medicamento
digoxin solution 0.05mg/ml
digoxin tablet 125mcg
digoxin tablet 250mcg
LANOXIN INJECTION 0.25MG/ML
LANOXIN TABLET 125MCG
LANOXIN TABLET 250MCG
pentoxifylline er tablet extended release 400mg
RANEXA TABLET EXTENDED RELEASE 12 HOUR
1000MG
RANEXA TABLET EXTENDED RELEASE 12 HOUR
500MG
TEKTURNA HCT TABLET 150MG; 12.5MG
TEKTURNA HCT TABLET 150MG; 25MG
TEKTURNA HCT TABLET 300MG; 12.5MG
TEKTURNA HCT TABLET 300MG; 25MG
TEKTURNA TABLET 150MG
TEKTURNA TABLET 300MG
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide sodium injection 500mg
acetazolamide tablet 125mg
acetazolamide tablet 250mg
Diuretics, Loop
bumetanide injection 0.25mg/ml
bumetanide tablet 0.5mg
bumetanide tablet 1mg
bumetanide tablet 2mg
furosemide injection 10mg/ml
furosemide injection 10mg/ml
furosemide solution 10mg/ml
furosemide solution 8mg/ml
furosemide tablet 20mg
furosemide tablet 40mg
furosemide tablet 80mg
TORSEMIDE INJECTION 20MG/2ML
torsemide tablet 100mg
torsemide tablet 10mg
torsemide tablet 20mg
torsemide tablet 5mg
Diuretics, Potassium-sparing
amiloride hcl tablet 5mg
amiloride/hydrochlorothiazide tablet 5mg; 50mg
eplerenone tablet 25mg
Página 60 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
PA (Medicamento de alto
riesgo - Digoxin)
$0(Nivel 1)
PA (Medicamento de alto
$0(Nivel 1)
riesgo - Digoxin)
$0-$6.60(Nivel 2) PA (Medicamento de alto
riesgo - Digoxin)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) PA (Medicamento de alto
riesgo - Digoxin)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
PA (Agentes
cardiovasculares) MO
$0-$6.60(Nivel 2) QL (90 EA cada 30 días)
PA (Agentes
cardiovasculares) MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
eplerenone tablet 50mg
spironolactone/hydrochlorothiazide tablet 25mg; 25mg
spironolactone tablet 100mg
spironolactone tablet 25mg
spironolactone tablet 50mg
triamterene/hydrochlorothiazide capsule 25mg; 37.5mg
triamterene/hydrochlorothiazide capsule 25mg; 50mg
triamterene/hydrochlorothiazide tablet 25mg; 37.5mg
triamterene/hydrochlorothiazide tablet 50mg; 75mg
Diuretics, Thiazide
chlorothiazide sodium injection 500mg
chlorothiazide tablet 250mg
chlorothiazide tablet 500mg
chlorthalidone tablet 25mg
chlorthalidone tablet 50mg
hydrochlorothiazide capsule 12.5mg
hydrochlorothiazide tablet 12.5mg
hydrochlorothiazide tablet 25mg
hydrochlorothiazide tablet 50mg
indapamide tablet 1.25mg
indapamide tablet 2.5mg
methyclothiazide tablet 5mg
metolazone tablet 10mg
metolazone tablet 2.5mg
metolazone tablet 5mg
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized capsule 134mg
fenofibrate micronized capsule 200mg
fenofibrate micronized capsule 67mg
fenofibrate capsule 130mg
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (60 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (60 EA cada 30 días)
fenofibrate capsule 43mg
$0(Nivel 1)
fenofibrate tablet 120mg
$0(Nivel 1)
fenofibrate tablet 145mg
fenofibrate tablet 160mg
fenofibrate tablet 48mg
fenofibrate tablet 54mg
gemfibrozil tablet 600mg
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium tablet 10mg
atorvastatin calcium tablet 20mg
atorvastatin calcium tablet 40mg
atorvastatin calcium tablet 80mg
lovastatin tablet 10mg
lovastatin tablet 20mg
lovastatin tablet 40mg
Página 61 de 143
Nombre del medicamento
pravastatin sodium tablet 10mg
pravastatin sodium tablet 20mg
pravastatin sodium tablet 40mg
pravastatin sodium tablet 80mg
simvastatin tablet 10mg
simvastatin tablet 20mg
simvastatin tablet 40mg
simvastatin tablet 5mg
simvastatin tablet 80mg
Dyslipidemics, Other
cholestyramine light packet 4gm
colestipol hcl granules 5gm
colestipol hcl tablet 1gm
niacin er tablet extended release 1000mg
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
niacin er tablet extended release 500mg
$0(Nivel 1)
niacin er tablet extended release 750mg
$0(Nivel 1)
niacin tablet 100mg
niacin tablet 50mg
niacor tablet 500mg
omega-3-acid ethyl esters capsule 375mg; 465mg; 1gm
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
prevalite powder 4gm/dose
WELCHOL PACKET 3.75GM
WELCHOL TABLET 625MG
ZETIA TABLET 10MG
Vasodilators, Direct-acting Arterial/Venous
BIDIL TABLET 37.5MG; 20MG
isosorbide dinitrate er tablet extended release 40mg
isosorbide dinitrate tablet sublingual 2.5mg
isosorbide dinitrate tablet 10mg
isosorbide dinitrate tablet 20mg
isosorbide dinitrate tablet 30mg
isosorbide dinitrate tablet 5mg
isosorbide mononitrate er tablet extended release 24 hour
120mg
isosorbide mononitrate er tablet extended release 24 hour
30mg
isosorbide mononitrate er tablet extended release 24 hour
60mg
isosorbide mononitrate tablet 10mg
isosorbide mononitrate tablet 20mg
NITRO-DUR PATCH 24 HOUR 0.3MG/HR
NITRO-DUR PATCH 24 HOUR 0.8MG/HR
nitroglycerin transdermal patch 24 hour 0.1mg/hr
NITROGLYCERIN INJECTION 5MG/ML
Página 62 de 143
QL (60 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
QL (60 EA cada 30 días)
MO
DP
DP
QL (120 EA cada 30 días)
MO
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (180 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Nombre del medicamento
nitroglycerin patch 24 hour 0.2mg/hr
nitroglycerin patch 24 hour 0.4mg/hr
nitroglycerin patch 24 hour 0.6mg/hr
NITROSTAT TABLET SUBLINGUAL 0.3MG
NITROSTAT TABLET SUBLINGUAL 0.4MG
NITROSTAT TABLET SUBLINGUAL 0.6MG
Vasodilators, Direct-acting Arterial
hydralazine hcl injection 20mg/ml
$0(Nivel 1)
hydralazine hcl tablet 100mg
$0(Nivel 1)
hydralazine hcl tablet 10mg
$0(Nivel 1)
hydralazine hcl tablet 25mg
$0(Nivel 1)
hydralazine hcl tablet 50mg
$0(Nivel 1)
minoxidil tablet 10mg
$0(Nivel 1)
minoxidil tablet 2.5mg
$0(Nivel 1)
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg;
$0(Nivel 1)
1.25mg; 1.25mg
amphetamine/dextroamphetamine tablet 1.875mg; 1.875mg; $0(Nivel 1)
1.875mg; 1.875mg
amphetamine/dextroamphetamine tablet 2.5mg; 2.5mg;
$0(Nivel 1)
2.5mg; 2.5mg
amphetamine/dextroamphetamine tablet 3.125mg; 3.125mg; $0(Nivel 1)
3.125mg; 3.125mg
$0(Nivel 1)
amphetamine/dextroamphetamine tablet 3.75mg; 3.75mg;
3.75mg; 3.75mg
amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg; 5mg $0(Nivel 1)
amphetamine/dextroamphetamine tablet 7.5mg; 7.5mg;
$0(Nivel 1)
7.5mg; 7.5mg
$0(Nivel 1)
dextroamphetamine sulfate tablet 10mg
dextroamphetamine sulfate tablet 5mg
$0(Nivel 1)
Attention Deficit Hyperactivity Disorder Agents,
Non-amphetamines
guanfacine er tablet extended release 24 hour 1mg
$0(Nivel 1)
QL (90 EA cada 30 días)
QL (90 EA cada 30 días)
QL (90 EA cada 30 días)
QL (90 EA cada 30 días)
QL (90 EA cada 30 días)
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
QL (30 EA cada 30 días)
MO
guanfacine er tablet extended release 24 hour 2mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
guanfacine er tablet extended release 24 hour 3mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
guanfacine er tablet extended release 24 hour 4mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
INTUNIV TABLET EXTENDED RELEASE 24 HOUR 1MG$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
INTUNIV TABLET EXTENDED RELEASE 24 HOUR 2MG$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
INTUNIV TABLET EXTENDED RELEASE 24 HOUR 3MG$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
INTUNIV TABLET EXTENDED RELEASE 24 HOUR 4MG$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
METADATE CD CAPSULE EXTENDED RELEASE 20MG $0-$6.60(Nivel 2) QL (60 EA cada 30 días)
METADATE CD CAPSULE EXTENDED RELEASE 30MG $0-$6.60(Nivel 2)
methylphenidate hcl cd capsule extended release 10mg
$0(Nivel 1)
QL (30 EA cada 30 días)
Página 63 de 143
Nombre del medicamento
methylphenidate hcl cd capsule extended release 20mg
methylphenidate hcl cd capsule extended release 20mg
methylphenidate hcl cd capsule extended release 30mg
methylphenidate hcl cd capsule extended release 30mg
methylphenidate hcl cd capsule extended release 40mg
methylphenidate hcl cd capsule extended release 40mg
methylphenidate hcl cd capsule extended release 50mg
methylphenidate hcl cd capsule extended release 60mg
methylphenidate hcl er tablet extended release 20mg
methylphenidate hcl tablet 10mg
methylphenidate hcl tablet 20mg
methylphenidate hcl tablet 5mg
STRATTERA CAPSULE 100MG
STRATTERA CAPSULE 10MG
STRATTERA CAPSULE 18MG
STRATTERA CAPSULE 25MG
STRATTERA CAPSULE 40MG
STRATTERA CAPSULE 60MG
STRATTERA CAPSULE 80MG
Central Nervous System, Other
NUEDEXTA CAPSULE 20MG; 10MG
riluzole tablet 50mg
XENAZINE TABLET 12.5MG
XENAZINE TABLET 25MG
Fibromyalgia Agents
SAVELLA TITRATION PACK MISCELLANEOUS 0
SAVELLA TABLET 100MG
SAVELLA TABLET 12.5MG
SAVELLA TABLET 25MG
SAVELLA TABLET 50MG
Multiple Sclerosis Agents
AUBAGIO TABLET 14MG
AUBAGIO TABLET 7MG
AVONEX PEN INJECTION 30MCG/0.5ML
AVONEX INJECTION 30MCG/0.5ML
AVONEX INJECTION 30MCG/VIAL
BETASERON INJECTION 0.3MG
COPAXONE INJECTION 20MG/ML
GILENYA CAPSULE 0.5MG
glatopa injection 20mg/ml
REBIF REBIDOSE TITRATION PACK INJECTION 0
REBIF REBIDOSE INJECTION 22MCG/0.5ML
REBIF REBIDOSE INJECTION 44MCG/0.5ML
REBIF TITRATION PACK INJECTION 0
Página 64 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (180 EA cada 30 días)
PA (Agentes terapéuticos
misceláneos - Xenazine)
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
PA (Agentes terapéuticos
misceláneos - Xenazine)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Nombre del medicamento
REBIF INJECTION 22MCG/0.5ML
REBIF INJECTION 44MCG/0.5ML
TYSABRI INJECTION 300MG/15ML
Dental and Oral Agents
Dental and Oral Agents
chlorhexidine gluconate oral rinse solution 0.12%
GEL-KAM GEL 0.4%
KEPIVANCE INJECTION 6.25MG
periogard solution 0.12%
pilocarpine hcl tablet 7.5mg
pilocarpine hydrochloride tablet 5mg
triamcinolone in orabase paste 0.1%
Dermatological Agents
Dermatological Agents
A-MANTLE CREAM 0
ABSORBASE OINTMENT 0; 0; 0; 0
acne medication 10 gel 10%
acne medication 5 gel 5%
ACNE MEDICATION 5 LOTION 5%
ACNE MEDICATION LOTION 10%
adapalene cream 0.1%
adapalene gel 0.1%
ALOE VESTA SKIN CONDITIONER LOTION 3%
aluminum acetate astringent packet 1347mg; 952mg
amlactin lotion 12%
ammonium lactate cream 12%
ammonium lactate lotion 12%
anti-dandruff shampoo shampoo 1%
anti-itch maximum strength solution 2%
ATRAC-TAIN CREAM 10%
BALNETAR LIQUIM EMULSION 2.5%
baza protect cream 0; 0
BENZOIN COMPOUND TINCTURE TINCTURE 0
betasept surgical scrub liquid 4%
betasept surgical scrub liquid 4%
betasept surgical scrub liquid 4%
betasept surgical scrub liquid 4%
betasept surgical scrub liquid 4%
calcipotriene cream 0.005%
calcipotriene solution 0.005%
capsaicin cream 0.025%
CETAPHIL MOISTURIZING CREAM 0; 0; 0; 0
CETAPHIL MOISTURIZING LOTION 0; 0; 0
CETAPHIL CREAM 0; 0; 0; 0
claravis capsule 10mg
claravis capsule 20mg
claravis capsule 30mg
claravis capsule 40mg
Página 65 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
QL (240 GM cada 30 días)
QL (60 ML cada 30 días)
DP
DP
DP
DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
clindamycin/benzoyl peroxide gel 5%; 1%
$0(Nivel 1)
clotrimazole/betamethasone dipropionate cream 0.05%; 1% $0(Nivel 1)
clotrimazole/betamethasone dipropionate lotion 0.05%; 1% $0(Nivel 1)
DP
CRITIC-AID CLEAR MOISTUREBARRIER OINTMENT $0(Nivel 3)
71.5%
CRITIC-AID THICK MOISTUREBARRIER PASTE 51%; $0(Nivel 3)
DP
20%
curity gauze pads 2"x2" pad
$0(Nivel 1)
QL (204 EA cada 30 días)
$0(Nivel 3)
DP
DHS SAL SHAMPOO 3%
DHS TAR SHAMPOO 0.5%
$0(Nivel 3)
DP
dibucaine ointment 1%
$0(Nivel 3)
DP
dml lotion 0; 0; 0; 0; 0; 0; 0; 0; 0; 0
$0(Nivel 3)
DP
DR SMITHS DIAPER OINTMENT 10%
$0(Nivel 3)
DP
ELIDEL CREAM 1%
$0-$6.60(Nivel 2) QL (60 GM cada 30 días)
PA (Agentes
dermatológicos)
erythromycin/benzoyl peroxide gel 5%; 3%
$0(Nivel 1)
fluorouracil cream 5%
$0(Nivel 1)
fluorouracil solution 2%
$0(Nivel 1)
fluorouracil solution 5%
$0(Nivel 1)
GNP CALAMINE PHENOLATED LOTION 8%; 1%; 8% $0(Nivel 3)
DP
gnp caldyphen lotion 8%; 1%
$0(Nivel 3)
DP
gnp hygienic cleansing pads pad 50%
$0(Nivel 3)
DP
$0(Nivel 3)
DP
gnp soothing bath treatment packet 0
gnp therapeutic blue gel gel 2%
$0(Nivel 3)
DP
gnp vitamin a & d ointment 0; 0
$0(Nivel 3)
DP
hemorrhoidal cream 14.4%; 15%; 0.25%; 1%
$0(Nivel 3)
DP
HEMORRHOIDAL OINTMENT 14%; 71.9%; 0.25%; 3% $0(Nivel 3)
DP
$0(Nivel 3)
DP
hydrisalic gel 17%
imiquimod cream 5%
$0(Nivel 1)
QL (24 EA cada 30 días)
itch relief extra strength cream 2%; 0.1%
$0(Nivel 3)
DP
ITCH-X GEL 10%; 1%
$0(Nivel 3)
DP
lac-hydrin five lotion 5%
$0(Nivel 3)
DP
laclotion lotion 12%
$0(Nivel 1)
methoxsalen capsule 10mg
$0(Nivel 1)
NUPERCAINAL OINTMENT 1%
$0(Nivel 3)
DP
NUTRADERM LOTION 2.5%; 0; 2.5%; 2.5%; 2.5%; 2.5% $0(Nivel 3)
DP
OXSORALEN LOTION 1%
$0-$6.60(Nivel 2)
pain relieving rub cream 10%; 15%
$0(Nivel 3)
DP
panoxyl bar 10%
$0(Nivel 3)
DP
pedi-boro soak paks packet 839mg; 1191mg
$0(Nivel 3)
DP
pedi-boro soak paks packet 839mg; 1191mg
$0(Nivel 3)
DP
PEN-KERA CREAM
$0(Nivel 3)
DP
periguard ointment 0
$0(Nivel 3)
DP
PICATO GEL 0.015%
$0-$6.60(Nivel 2)
PICATO GEL 0.05%
$0-$6.60(Nivel 2)
podofilox solution 0.5%
$0(Nivel 1)
pramegel gel 1%
$0(Nivel 3)
DP
Página 66 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
PROSHIELD PLUS SKIN PROTECTANT CREAM 0
$0(Nivel 3)
DP
PROSHIELD PROTECTIVE HANDCREAM CREAM 0; 0; $0(Nivel 3)
DP
0
$0-$6.60(Nivel 2) QL (60 GM cada 30 días)
PROTOPIC OINTMENT 0.03%
PA (Agentes
dermatológicos)
PROTOPIC OINTMENT 0.1%
$0-$6.60(Nivel 2) QL (60 GM cada 30 días)
PA (Agentes
dermatológicos)
QC CALAMINE LOTION 0
$0(Nivel 3)
DP
$0(Nivel 3)
DP
salactic film solution 17%
SANTYL OINTMENT 250UNIT/GM
$0-$6.60(Nivel 2)
SARNA LOTION 0.5%; 0.5%
$0(Nivel 3)
DP
SEA-CLENS WOUND CLEANSER LIQUID 0
$0(Nivel 3)
DP
sebex shampoo 2%; 2%
$0(Nivel 3)
DP
selenium sulfide lotion 2.5%
$0(Nivel 1)
SENSI-CARE PROTECTIVE BARRIER OINTMENT 49%; $0(Nivel 3)
DP
15%
SILVERMED GEL 0; 0; 0; 0
$0(Nivel 3)
DP
SM CALAMINE PHENOLATED LOTION 0; 0
$0(Nivel 3)
DP
SM CALAMINE LOTION 0; 0
$0(Nivel 3)
DP
sodium chloride tablet 1gm
$0(Nivel 3)
DP
SORIATANE CAPSULE 10MG
$0-$6.60(Nivel 2)
SORIATANE CAPSULE 17.5MG
$0-$6.60(Nivel 2)
SORIATANE CAPSULE 25MG
$0-$6.60(Nivel 2)
SWEEN CREAM CREAM 0; 0
$0(Nivel 3)
DP
tacrolimus ointment 0.03%
$0(Nivel 1)
QL (60 GM cada 30 días)
PA (Agentes
dermatológicos)
tacrolimus ointment 0.1%
$0(Nivel 1)
QL (60 GM cada 30 días)
PA (Agentes
dermatológicos)
TAZORAC CREAM 0.05%
$0-$6.60(Nivel 2)
TAZORAC CREAM 0.1%
$0-$6.60(Nivel 2)
TAZORAC GEL 0.05%
$0-$6.60(Nivel 2)
TAZORAC GEL 0.1%
$0-$6.60(Nivel 2)
thera-derm bath oil oil 5%; 5%; 0; 5%
$0(Nivel 3)
DP
thera-derm lotion 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0
$0(Nivel 3)
DP
thera-gesic cream 1%; 15%
$0(Nivel 3)
DP
TRANS-VER-SAL PEDIAPATCH PATCH 15%
$0(Nivel 3)
DP
tretinoin cream 0.025%
$0(Nivel 1)
tretinoin cream 0.05%
$0(Nivel 1)
tretinoin cream 0.1%
$0(Nivel 1)
tretinoin gel 0.01%
$0(Nivel 1)
QL (90 GM cada 30 días)
tretinoin gel 0.025%
$0(Nivel 1)
QL (90 GM cada 30 días)
trixaicin hp cream 0.075%
$0(Nivel 3)
DP
ureacin-20 cream 20%
$0(Nivel 3)
DP
UVADEX INJECTION 20MCG/ML
$0-$6.60(Nivel 2)
Página 67 de 143
Nombre del medicamento
VELVACHOL CREAM 0; 0
VEREGEN OINTMENT 15%
vitamin a & d ointment 0; 0
vitamin a & d ointment 0; 0
vitamin a & d ointment 0; 0
vitamin a & d ointment 0; 0
vitamin a & d ointment 15.5%; 53.4%
VOLTAREN GEL 1%
WIBI LOTION 0; 0; 0; 0; 0; 0
zinc oxide ointment 20%
zinc oxide ointment 20%
zinc oxide ointment 20%
zinc oxide ointment 20%
ZONALON CREAM 5%
ZOSTRIX DIABETIC FOOT PAIN CREAM 0.075%
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN INJECTION 250UNIT/ML
ALDURAZYME INJECTION 2.9MG/5ML
BUPHENYL TABLET 500MG
CEREZYME INJECTION 400UNIT
CREON CAPSULE DELAYED RELEASE PARTICLES
120000UNIT; 24000UNIT; 76000UNIT
CREON CAPSULE DELAYED RELEASE PARTICLES
15000UNIT; 3000UNIT; 9500UNIT
CREON CAPSULE DELAYED RELEASE PARTICLES
180000UNIT; 36000UNIT; 114000UNIT
CREON CAPSULE DELAYED RELEASE PARTICLES
30000UNIT; 6000UNIT; 19000UNIT
CREON CAPSULE DELAYED RELEASE PARTICLES
60000UNIT; 12000UNIT; 38000UNIT
CYSTADANE POWDER 0
CYSTAGON CAPSULE 150MG
CYSTAGON CAPSULE 50MG
ELAPRASE INJECTION 6MG/3ML
ELELYSO INJECTION 200UNIT
FABRAZYME INJECTION 35MG
KUVAN PACKET 500MG
KUVAN TABLET SOLUBLE 100MG
lac-dose tablet 3000unit
lactose fast acting relief tablet chewable 9000unit
lactose fast acting relief tablet 9000unit
LACTRASE CAPSULE 250MG
LUMIZYME INJECTION 50MG
Página 68 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0-$6.60(Nivel 2) QL (15 GM cada 30 días)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) PA
(Modificadores/Reemplaz
os para enzimas - Kuvan)
$0-$6.60(Nivel 2) PA
(Modificadores/Reemplaz
os para enzimas - Kuvan)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
Nombre del medicamento
NAGLAZYME INJECTION 1MG/ML
PANCREAZE CAPSULE DELAYED RELEASE
PARTICLES 17500UNIT; 4200UNIT; 10000UNIT
PANCREAZE CAPSULE DELAYED RELEASE
PARTICLES 43750UNIT; 10500UNIT; 25000UNIT
PANCREAZE CAPSULE DELAYED RELEASE
PARTICLES 61000UNIT; 21000UNIT; 37000UNIT
PANCREAZE CAPSULE DELAYED RELEASE
PARTICLES 70000UNIT; 16800UNIT; 40000UNIT
sodium phenylbutyrate powder 3gm/tsp
SUCRAID SOLUTION 8500UNIT/ML
VPRIV INJECTION 400UNIT
ZAVESCA CAPSULE 100MG
ZENPEP CAPSULE DELAYED RELEASE PARTICLES
109000UNIT; 20000UNIT; 68000UNIT
ZENPEP CAPSULE DELAYED RELEASE PARTICLES
136000UNIT; 25000UNIT; 85000UNIT
ZENPEP CAPSULE DELAYED RELEASE PARTICLES
16000UNIT; 3000UNIT; 10000UNIT
ZENPEP CAPSULE DELAYED RELEASE PARTICLES
218000UNIT; 40000UNIT; 136000UNIT
ZENPEP CAPSULE DELAYED RELEASE PARTICLES
27000UNIT; 5000UNIT; 17000UNIT
ZENPEP CAPSULE DELAYED RELEASE PARTICLES
55000UNIT; 10000UNIT; 34000UNIT
ZENPEP CAPSULE DELAYED RELEASE PARTICLES
82000UNIT; 15000UNIT; 51000UNIT
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
ATROPINE SULFATE INJECTION 0.05MG/ML
atropine sulfate injection 0.1mg/ml
dicyclomine hcl capsule 10mg
dicyclomine hcl solution 10mg/5ml
dicyclomine hcl tablet 20mg
glycopyrrolate injection 4mg/20ml
glycopyrrolate tablet 1mg
glycopyrrolate tablet 2mg
KONSYL PACKET 100%
KONSYL PACKET 28.3%
methscopolamine bromide tablet 2.5mg
Gastrointestinal Agents, Other
acid gone suspension 95mg/15ml; 358mg/15ml
almacone double strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
almacone suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
ALUMINUM HYDROXIDE SUSPENSION 320MG/5ML
antacid plus anti-gas relief maximum strength suspension
400mg/5ml; 400mg/5ml; 40mg/5ml
Página 69 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
Nombre del medicamento
antacid plus anti-gas relief suspension 200mg/5ml;
200mg/5ml; 20mg/5ml
antacid suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
antacid tablet chewable 500mg
anti-diarrheal tablet 2mg
anti-diarrheal tablet 2mg
anti-diarrheal tablet 2mg
anti-diarrheal tablet 2mg
anti-diarrheal tablet 2mg
ASCRIPTIN TABLET 0; 325MG; 0; 0; 0
BENEFIBER POWDER 0
BENEFIBER POWDER 0
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisac-evac suppository 10mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl ec tablet delayed release 5mg
bisacodyl suppository 10mg
biscolax suppository 10mg
biscolax suppository 10mg
bismatrol maximum strength suspension 525mg/15ml
bismatrol suspension 262mg/15ml
bismatrol tablet chewable 262mg
cal-gest antacid tablet chewable 500mg
calcium antacid extra strength tablet chewable 750mg
calcium antacid extra strength tablet chewable 750mg
calcium antacid tablet chewable 500mg
calcium antacid tablet chewable 500mg
calcium antacid tablet chewable 500mg
calcium antacid tablet chewable 500mg
CALCIUM CARBONATE TABLET 648MG
CALCIUM TABLET CHEWABLE 500MG; 100UNIT
chewable antacid tablet chewable 500mg
CITRUCEL FIBER LAXATIVE POWDER 0
CITRUCEL FIBER LAXATIVE POWDER 0
CITRUCEL FIBER LAXATIVE POWDER 0
CITRUCEL TABLET 500MG
COLACE CAPSULE 50MG
cromolyn sodium concentrate 100mg/5ml
cvs antacid ultra strength tablet chewable 1000mg
Página 70 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Nombre del medicamento
diocto liquid 50mg/5ml
diphenoxylate/atropine tablet 0.025mg; 2.5mg
docqlace capsule 100mg
docu liquid 50mg/5ml
docusate sodium capsule 100mg
docusate sodium capsule 100mg
docusate sodium liquid 50mg/5ml
docusil capsule 100mg
docusil capsule 100mg
dok capsule 100mg
dok capsule 100mg
dok capsule 100mg
dok capsule 100mg
dok capsule 250mg
dok tablet 100mg
ducodyl tablet delayed release 5mg
EX-LAX MAXIMUM STRENGTH TABLET 25MG
EX-LAX TABLET CHEWABLE 15MG
EX-LAX TABLET 15MG
EX-LAX TABLET 15MG
fiber tabs tablet 625mg
fiber-lax tablet 625mg
fiber-lax tablet 625mg
fiber-lax tablet 625mg
FIBERCON TABLET 625MG
FIBERCON TABLET 625MG
FLEET BISACODYL ENEMA 10MG/30ML
FLEET LIQUID GLYCERIN SUPPOSITORIES ENEMA
5.6GM/DOSE
FLEET OIL ENEMA 0
gas-x extra strength capsule 125mg
GAS-X EXTRA STRENGTH TABLET CHEWABLE
125MG
gas-x ultra strength capsule 180mg
GAS-X TABLET CHEWABLE 80MG
GAVISCON EXTRA STRENGTH RELIEF FORMULA
SUSPENSION 508MG/10ML; 475MG/10ML
GAVISCON EXTRA STRENGTH TABLET CHEWABLE
160MG; 105MG
GAVISCON SUSPENSION 95MG/15ML; 358MG/15ML
GAVISCON TABLET CHEWABLE 80MG; 14.2MG
glycerin adult suppository 2.1gm
glycerin adult suppository 2.1gm
GLYCERIN ADULT SUPPOSITORY 2GM
GLYCERIN ADULT SUPPOSITORY 2GM
gnp antacid extra strength tablet chewable 750mg
gnp antacid ultra strength tablet chewable 1000mg
gnp antacid tablet chewable 500mg
Página 71 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
gnp antacid tablet chewable 500mg
$0(Nivel 3)
DP
gnp anti-diarrheal tablet 2mg
$0(Nivel 3)
DP
$0(Nivel 3)
DP
gnp anti-diarrheal tablet 2mg
$0(Nivel 3)
DP
gnp anti-diarrheal tablet 2mg
gnp glycerin adult suppository 2.1gm
$0(Nivel 3)
DP
$0(Nivel 3)
DP
gnp glycerin adult suppository 2.1gm
gnp k-pec suspension 262mg/15ml
$0(Nivel 3)
DP
$0(Nivel 3)
DP
gnp loperamide hcl suspension 1mg/7.5ml
$0(Nivel 3)
DP
gnp natural fiber powder 28.3%
gnp natural fiber powder 28.3%
$0(Nivel 3)
DP
DP
gnp natural fiber powder 48.57%
$0(Nivel 3)
gnp pink bismuth tablet chewable 262mg
$0(Nivel 3)
DP
gnp senna-lax tablet 8.6mg
$0(Nivel 3)
DP
DP
gnp stomach relief maximum strength suspension 525mg/15ml $0(Nivel 3)
gnp stomach relief suspension 262mg/15ml
$0(Nivel 3)
DP
$0(Nivel 3)
DP
hemorrhoidal suppository 88.7%; 0.25%
hm anti-diarrheal tablet 2mg
$0(Nivel 3)
DP
hm anti-diarrheal tablet 2mg
$0(Nivel 3)
DP
hm fiber powder 48.57%
$0(Nivel 3)
DP
$0(Nivel 3)
DP
hm loperamide hcl suspension 1mg/7.5ml
hm stomach relief tablet chewable 262mg
$0(Nivel 3)
DP
kao-tin capsule 240mg
$0(Nivel 3)
DP
kao-tin suspension 262mg/15ml
$0(Nivel 3)
DP
$0(Nivel 3)
DP
kao-tin suspension 262mg/15ml
KONSYL-D POWDER 52.3%
$0(Nivel 3)
DP
konsyl capsule 520mg
$0(Nivel 3)
DP
KONSYL POWDER 100%
$0(Nivel 3)
DP
konsyl powder 30.9%
$0(Nivel 3)
DP
KONSYL POWDER 60.3%
$0(Nivel 3)
DP
laxative suppository 10mg
$0(Nivel 3)
DP
loperamide hcl capsule 2mg
$0(Nivel 1)
loperamide hcl liquid 1mg/5ml
$0(Nivel 3)
DP
loperamide hcl suspension 1mg/7.5ml
$0(Nivel 3)
DP
loperamide hcl suspension 1mg/7.5ml
$0(Nivel 3)
DP
maalox advanced maximum strength suspension 400mg/5ml; $0(Nivel 3)
DP
400mg/5ml; 40mg/5ml
maalox max suspension 400mg/5ml; 400mg/5ml; 40mg/5ml $0(Nivel 3)
DP
MAALOX TABLET CHEWABLE 600MG
$0(Nivel 3)
DP
magnesium oxide tablet 400mg
$0(Nivel 3)
DP
magnesium oxide tablet 420mg
$0(Nivel 3)
DP
magnesium tablet 250mg
$0(Nivel 3)
DP
magnesium tablet 500mg
$0(Nivel 3)
DP
metamucil smooth texture powder 28.3%
$0(Nivel 3)
DP
metamucil smooth texture powder 28.3%
$0(Nivel 3)
DP
metamucil smooth texture powder 58.6%
$0(Nivel 3)
DP
$0(Nivel 3)
DP
metamucil smooth texture powder 58.6%
metoclopramide hcl injection 5mg/ml
$0(Nivel 1)
metoclopramide hcl solution 5mg/5ml
$0(Nivel 1)
Página 72 de 143
Nombre del medicamento
metoclopramide hcl tablet 10mg
metoclopramide hcl tablet 5mg
mi-acid maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
mi-acid suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
mi-acid tablet chewable 700mg; 300mg
MILK DE MAGNESIA CONCENTRATE SUSPENSION
2400MG/10ML
milk of magnesia suspension 1200mg/15ml
milk of magnesia suspension 1200mg/15ml
milk of magnesia suspension 400mg/5ml
milk of magnesia suspension 400mg/5ml
milk of magnesia suspension 7.75%
milk of magnesia suspension 7.75%
milk of magnesia suspension 7.75%
milk of magnesia suspension 7.75%
milk of magnesia suspension 7.75%
mintox maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
mintox plus tablet chewable 200mg; 200mg; 25mg
mintox suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
natural fiber therapy powder 30.9%
natural fiber therapy powder 30.9%
natural fiber therapy powder 48.57%
PEDIA-LAX SUPPOSITORY 1GM
PEDIA-LAX SUPPOSITORY 2.8GM
peptic relief tablet chewable 262mg
PEPTO-BISMOL MAX STRENGTH SUSPENSION
525MG/15ML
PEPTO-BISMOL SUSPENSION 524MG/30ML
PEPTO-BISMOL SUSPENSION 524MG/30ML
PEPTO-BISMOL SUSPENSION 524MG/30ML
pink bismuth tablet chewable 262mg
pink bismuth tablet chewable 262mg
qc pink bismuth tablet chewable 262mg
qc stool softener capsule 100mg
reguloid capsule 0.52gm
reguloid powder 28.3%
reguloid powder 28.3%
reguloid powder 48.57%
reguloid powder 48.57%
reguloid powder 58.6%
reguloid powder 58.6%
reguloid powder 58.6%
reguloid powder 58.6%
RELISTOR INJECTION 12MG/0.6ML
rulox suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
sb docusate sodium capsule 100mg
Página 73 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
senexon tablet 8.6mg
senna laxative tablet 8.6mg
senna lax tablet 8.6mg
senna lax tablet 8.6mg
senna syrup 8.8mg/5ml
senna tablet 8.6mg
senna tablet 8.6mg
senna tablet 8.6mg
silace liquid 150mg/15ml
silace syrup 60mg/15ml
sm anti-diarrheal tablet 2mg
sm anti-diarrheal tablet 2mg
sm anti-diarrheal tablet 2mg
sm calcium antacid tablet chewable 500mg
sm fiber powder 28.3%
sm fiber powder 28.3%
sm fiber powder 48.57%
sm fiber powder 58.6%
sm gentle laxative tablet delayed release 5mg
sm senna laxative tablet 8.6mg
sm stomach relief suspension 262mg/15ml
sm stool softener capsule 100mg
sm stool softener capsule 100mg
sodium bicarbonate tablet 325mg
sodium bicarbonate tablet 650mg
sodium bicarbonate tablet 650mg
soluble fiber powder 0
stimulant laxative tablet delayed release 5mg
stimulant laxative tablet delayed release 5mg
stomach relief maximum strength suspension 525mg/15ml
stomach relief suspension 262mg/15ml
stomach relief suspension 262mg/15ml
stomach relief suspension 262mg/15ml
stool softener extra strength capsule 250mg
stool softener extra strength capsule 250mg
stool softener laxative dc capsule 240mg
stool softener laxative dc capsule 240mg
stool softener laxative dc capsule 240mg
stool softener capsule 100mg
stool softener capsule 100mg
stool softener capsule 100mg
stool softener capsule 100mg
stool softener capsule 100mg
TUMS E-X 750 TABLET CHEWABLE 750MG
TUMS E-X 750 TABLET CHEWABLE 750MG
TUMS ULTRA 1000 TABLET CHEWABLE 1000MG
ursodiol capsule 300mg
ursodiol tablet 250mg
Página 74 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
ursodiol tablet 500mg
Histamine2 (H2) Receptor Antagonists
acid reducer tablet 10mg
AXID AR TABLET 75MG
cimetidine hcl solution 300mg/5ml
cimetidine tablet 200mg
cimetidine tablet 300mg
cimetidine tablet 400mg
cimetidine tablet 800mg
FAMOTIDINE PREMIXED INJECTION 0.4MG/ML; 0.9%
famotidine injection 20mg/2ml
famotidine tablet 10mg
famotidine tablet 10mg
famotidine tablet 10mg
famotidine tablet 20mg
famotidine tablet 40mg
heartburn relief tablet 10mg
kls acid reducer maximum strength tablet 150mg
ranitidine 75 tablet 75mg
ranitidine hcl capsule 150mg
ranitidine hcl capsule 300mg
ranitidine hcl injection 150mg/6ml
ranitidine hcl syrup 15mg/ml
ranitidine hcl tablet 150mg
ranitidine hcl tablet 300mg
sm acid reducer tablet 10mg
ZANTAC INJECTION 25MG/ML
ZANTAC INJECTION 25MG/ML
Irritable Bowel Syndrome Agents
alosetron hydrochloride tablet 0.5mg
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
QL (60 EA cada 30 días)
PA (Agentes para
síndrome de colon
irritable) MO
QL (60 EA cada 30 días)
PA (Agentes para
síndrome de colon
irritable) MO
alosetron hydrochloride tablet 1mg
$0(Nivel 1)
AMITIZA CAPSULE 24MCG
AMITIZA CAPSULE 8MCG
LOTRONEX TABLET 0.5MG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
PA (Agentes para
síndrome de colon
irritable)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
PA (Agentes para
síndrome de colon
irritable)
LOTRONEX TABLET 1MG
Laxatives
Página 75 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
constulose solution 10gm/15ml
doc-q-lax tablet 50mg; 8.6mg
doc-q-lax tablet 50mg; 8.6mg
docqlace capsule 100mg
docusate sodium & senna stimulant laxative/stool softener
tablet 50mg; 8.6mg
docusate sodium & senna stimulant laxative/stool softener
$0(Nivel 3)
DP
tablet 50mg; 8.6mg
enulose solution 10gm/15ml
$0(Nivel 1)
gavilyte-c solution reconstituted 240gm; 2.98gm; 6.72gm;
$0(Nivel 1)
5.84gm; 22.72gm
gavilyte-g solution reconstituted 236gm; 2.97gm; 6.74gm;
$0(Nivel 1)
5.86gm; 22.74gm
gavilyte-n/flavor pack solution reconstituted 420gm; 1.48gm; $0(Nivel 1)
5.72gm; 11.2gm
generlac solution 10gm/15ml
$0(Nivel 1)
gnp fiber therapy tablet 500mg
$0(Nivel 3)
DP
gnp milk of magnesia suspension 1200mg/15ml
$0(Nivel 3)
DP
gnp milk of magnesia suspension 1200mg/15ml
$0(Nivel 3)
DP
gnp milk of magnesia suspension 1200mg/15ml
$0(Nivel 3)
DP
gnp senna plus tablet 50mg; 8.6mg
$0(Nivel 3)
DP
lactulose solution 10gm/15ml
$0(Nivel 1)
magnesium citrate solution 1.745gm/30ml
$0(Nivel 3)
DP
milk of magnesia suspension 1200mg/15ml
$0(Nivel 3)
DP
milk of magnesia suspension 400mg/5ml
$0(Nivel 3)
DP
milk of magnesia suspension 7.75%
$0(Nivel 3)
DP
NULYTELY/FLAVOR PACKS SOLUTION
$0-$6.60(Nivel 2)
RECONSTITUTED 420GM; 1.48GM; 5.72GM; 11.2GM
$0(Nivel 3)
DP
NUTRISOURCE FIBER POWDER 0
peri-colace tablet 50mg; 8.6mg
$0(Nivel 3)
DP
polyethylene glycol 3350 powder 0
$0(Nivel 1)
RELISTOR INJECTION 12MG/0.6ML
$0-$6.60(Nivel 2)
RELISTOR INJECTION 8MG/0.4ML
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
sb milk of magnesia suspension 400mg/5ml
senna plus tablet 50mg; 8.6mg
$0(Nivel 3)
DP
sennalax-s tablet 50mg; 8.6mg
$0(Nivel 3)
DP
sm fiber laxative tablet 500mg
$0(Nivel 3)
DP
sm milk of magnesia suspension 1200mg/15ml
$0(Nivel 3)
DP
sm natural laxative plus stool softener tablet 50mg; 8.6mg
$0(Nivel 3)
DP
sm stool softener plus laxative tablet 50mg; 8.6mg
$0(Nivel 3)
DP
sm stool softener plus laxative tablet 50mg; 8.6mg
$0(Nivel 3)
DP
stool softener laxative tablet 50mg; 8.6mg
$0(Nivel 3)
DP
trilyte solution reconstituted 420gm; 1.48gm; 5.72gm; 11.2gm $0(Nivel 1)
Protectants
misoprostol tablet 100mcg
$0(Nivel 1)
misoprostol tablet 200mcg
$0(Nivel 1)
sucralfate tablet 1gm
$0(Nivel 1)
Proton Pump Inhibitors
Página 76 de 143
Nombre del medicamento
esomeprazole sodium injection 20mg
esomeprazole sodium injection 40mg
omeprazole capsule delayed release 10mg
omeprazole capsule delayed release 20mg
omeprazole capsule delayed release 40mg
OMEPRAZOLE TABLET DELAYED RELEASE 20MG
pantoprazole sodium tablet delayed release 20mg
pantoprazole sodium tablet delayed release 40mg
PRILOSEC OTC TABLET DELAYED RELEASE 20MG
PROTONIX INJECTION 40MG
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl tablet 100mg
oxybutynin chloride er tablet extended release 24 hour 10mg
oxybutynin chloride er tablet extended release 24 hour 15mg
oxybutynin chloride er tablet extended release 24 hour 5mg
oxybutynin chloride tablet 5mg
tolterodine tartrate er capsule extended release 24 hour 2mg
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 1)
QL (90 EA cada 30 días)
$0(Nivel 3)
DP
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
MO
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
tolterodine tartrate er capsule extended release 24 hour 4mg $0(Nivel 1)
tolterodine tartrate tablet 1mg
tolterodine tartrate tablet 2mg
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er tablet extended release 24 hour 10mg
AVODART CAPSULE 0.5MG
doxazosin mesylate tablet 1mg
doxazosin mesylate tablet 2mg
doxazosin mesylate tablet 4mg
doxazosin mesylate tablet 8mg
finasteride tablet 5mg
tamsulosin hcl capsule 0.4mg
terazosin hcl capsule 10mg
terazosin hcl capsule 1mg
terazosin hcl capsule 2mg
terazosin hcl capsule 5mg
Genitourinary Agents, Other
bethanechol chloride tablet 10mg
bethanechol chloride tablet 25mg
bethanechol chloride tablet 50mg
bethanechol chloride tablet 5mg
ELMIRON CAPSULE 100MG
lubricating jelly gel 0
surgilube gel 0
Phosphate Binders
calcium acetate capsule 667mg
calcium acetate tablet 667mg
Página 77 de 143
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
ELIPHOS TABLET 667MG
FOSRENOL TABLET CHEWABLE 1000MG
FOSRENOL TABLET CHEWABLE 500MG
FOSRENOL TABLET CHEWABLE 750MG
MAGNEBIND 300 TABLET 250MG; 300MG
RENVELA TABLET 800MG
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
a-hydrocort injection 100mg
alclometasone dipropionate cream 0.05%
alclometasone dipropionate ointment 0.05%
amcinonide cream 0.1%
amcinonide lotion 0.1%
amcinonide ointment 0.1%
aquanil hc lotion 1%
augmented betamethasone dipropionate cream 0.05%
augmented betamethasone dipropionate gel 0.05%
augmented betamethasone dipropionate lotion 0.05%
augmented betamethasone dipropionate ointment 0.05%
betamethasone dipropionate cream 0.05%
betamethasone dipropionate lotion 0.05%
betamethasone dipropionate ointment 0.05%
betamethasone valerate cream 0.1%
betamethasone valerate lotion 0.1%
betamethasone valerate ointment 0.1%
budesonide capsule extended release 24 hour 3mg
clobetasol propionate e cream 0.05%
clobetasol propionate gel 0.05%
clobetasol propionate ointment 0.05%
clobetasol propionate shampoo 0.05%
clobetasol propionate solution 0.05%
clodan shampoo 0.05%
cortisone acetate tablet 25mg
DEPO-MEDROL INJECTION 20MG/ML
desonide cream 0.05%
desonide lotion 0.05%
desonide ointment 0.05%
desoximetasone cream 0.05%
desoximetasone cream 0.25%
desoximetasone gel 0.05%
desoximetasone ointment 0.05%
desoximetasone ointment 0.25%
dexamethasone sodium phosphate injection 120mg/30ml
dexamethasone elixir 0.5mg/5ml
dexamethasone tablet 0.5mg
dexamethasone tablet 0.75mg
dexamethasone tablet 1.5mg
dexamethasone tablet 1mg
Página 78 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
dexamethasone tablet 2mg
dexamethasone tablet 4mg
dexamethasone tablet 6mg
fludrocortisone acetate tablet 0.1mg
fluocinolone acetonide cream 0.01%
fluocinolone acetonide cream 0.025%
fluocinolone acetonide oil 0.01%
fluocinolone acetonide ointment 0.025%
fluocinolone acetonide solution 0.01%
fluocinonide-e cream 0.05%
fluocinonide gel 0.05%
fluocinonide ointment 0.05%
fluocinonide solution 0.05%
fluticasone propionate cream 0.05%
fluticasone propionate ointment 0.005%
gnp hydrocortisone cream 0.5%
halobetasol propionate cream 0.05%
halobetasol propionate ointment 0.05%
hydro skin maximum strength lotion 1%
hydrocortisone butyrate cream 0.1%
hydrocortisone butyrate ointment 0.1%
hydrocortisone butyrate solution 0.1%
hydrocortisone valerate cream 0.2%
hydrocortisone valerate ointment 0.2%
hydrocortisone/aloe cream 0; 0.5%
HYDROCORTISONE/ALOE OINTMENT 0; 1%
hydrocortisone cream 0.5%
hydrocortisone cream 1%
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone enema 100mg/60ml
hydrocortisone lotion 1%
hydrocortisone lotion 2.5%
hydrocortisone ointment 0.5%
hydrocortisone ointment 1%
hydrocortisone ointment 2.5%
hydrocortisone tablet 10mg
hydrocortisone tablet 20mg
hydrocortisone tablet 5mg
medi-cortisone cream 1%
methylprednisolone acetate injection 40mg/ml
methylprednisolone acetate injection 80mg/ml
methylprednisolone dose pack tablet 4mg
methylprednisolone sodiumsuccinate injection 125mg
methylprednisolone sodiumsuccinate injection 1gm
methylprednisolone sodiumsuccinate injection 40mg
methylprednisolone tablet 16mg
methylprednisolone tablet 32mg
Página 79 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
methylprednisolone tablet 4mg
methylprednisolone tablet 8mg
mometasone furoate cream 0.1%
mometasone furoate ointment 0.1%
prednicarbate cream 0.1%
prednisolone sodium phosphate solution 15mg/5ml
prednisolone sodium phosphate solution 25mg/5ml
prednisolone sodium phosphate solution 5mg/5ml
prednisone solution 5mg/5ml
prednisone tablet 10mg
prednisone tablet 1mg
prednisone tablet 2.5mg
prednisone tablet 20mg
prednisone tablet 50mg
prednisone tablet 5mg
preparation h hydrocortisone cream 1%
PROCTO-PAK CREAM 1%
proctosol hc cream 2.5%
proctozone-hc cream 2.5%
sm hydrocortisone cream 0.5%
sm hydrocortisone cream 1%
SOLU-CORTEF INJECTION 100MG
SOLU-CORTEF INJECTION 250MG
SOLU-MEDROL INJECTION 125MG
SOLU-MEDROL INJECTION 2GM
SOLU-MEDROL INJECTION 40MG
SOLU-MEDROL INJECTION 500MG
triamcinolone acetonide cream 0.025%
triamcinolone acetonide cream 0.1%
triamcinolone acetonide cream 0.5%
triamcinolone acetonide lotion 0.025%
triamcinolone acetonide lotion 0.1%
triamcinolone acetonide ointment 0.025%
triamcinolone acetonide ointment 0.1%
triamcinolone acetonide ointment 0.5%
triderm cream 0.1%
u-cort cream 1%; 10%
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
chorionic gonadotropin injection 10000unit
desmopressin acetate injection 4mcg/ml
desmopressin acetate tablet 0.1mg
desmopressin acetate tablet 0.2mg
INCRELEX INJECTION 40MG/4ML
NORDITROPIN FLEXPRO INJECTION 15MG/1.5ML
Página 80 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario))
Nombre del medicamento
NORDITROPIN FLEXPRO INJECTION 30MG/3ML
NORDITROPIN FLEXPRO INJECTION 5MG/1.5ML
NUTROPIN INJECTION 10MG
pregnyl w/diluent benzyl alcohol/nacl injection 10000unit
SAIZEN CLICK.EASY INJECTION 8.8MG
SAIZEN INJECTION 5MG
SAIZEN INJECTION 8.8MG
SEROSTIM INJECTION 4MG
SEROSTIM INJECTION 5MG
SEROSTIM INJECTION 6MG
STIMATE SOLUTION 1.5MG/ML
TEV-TROPIN INJECTION 5MG
ZORBTIVE INJECTION 8.8MG
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
KORLYM TABLET 300MG
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers)
Anabolic Steroids
oxandrolone tablet 10mg
Página 81 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario))
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario))
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario))
$0(Nivel 1)
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario))
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario))
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario))
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario)
- Serostim)
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario)
- Serostim)
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario)
- Serostim)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario))
$0-$6.60(Nivel 2) PA (Agentes hormonales,
estimulantes/ reemplazos/
modificadores (Pituitario)
- Zorbtive)
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
$0(Nivel 1)
Nombre del medicamento
oxandrolone tablet 2.5mg
Androgens
ANDRODERM PATCH 24 HOUR 2MG/24HR
ANDRODERM PATCH 24 HOUR 4MG/24HR
ANDROXY TABLET 10MG
danazol capsule 100mg
danazol capsule 200mg
danazol capsule 50mg
METHITEST TABLET 10MG
testosterone cypionate injection 100mg/ml
testosterone cypionate injection 200mg/ml
testosterone enanthate injection 200mg/ml
Estrogens
ALORA PATCH TWICE WEEKLY 0.025MG/24HR
ALORA PATCH TWICE WEEKLY 0.05MG/24HR
ALORA PATCH TWICE WEEKLY 0.075MG/24HR
ALORA PATCH TWICE WEEKLY 0.1MG/24HR
apri tablet 0.15mg; 30mcg
aranelle tablet 0; 0
aubra tablet 20mcg; 0.1mg
aviane tablet 20mcg; 0.1mg
balziva tablet 35mcg; 0.4mg
CLIMARA PRO PATCH WEEKLY 0.045MG/DAY;
0.015MG/DAY
cryselle-28 tablet 30mcg; 0.3mg
cyclafem 1/35 tablet 35mcg; 1mg
delyla tablet 20mcg; 0.1mg
DEPO-ESTRADIOL INJECTION 5MG/ML
desogestrel/ethinyl estradiol tablet 0; 0
enpresse-28 tablet 0; 0
ESTRACE CREAM 0.1MG/GM
estradiol valerate injection 20mg/ml
estradiol valerate injection 40mg/ml
estradiol patch weekly 0.025mg/24hr
estradiol patch weekly 0.05mg/24hr
Página 82 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (8 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
$0-$6.60(Nivel 2) QL (8 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
$0-$6.60(Nivel 2) QL (8 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
$0-$6.60(Nivel 2) QL (8 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (4 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0-$6.60(Nivel 2)
$0(Nivel 1)
MO
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (4 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
QL (4 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
Nombre del medicamento
estradiol patch weekly 0.06mg/24hr
estradiol patch weekly 0.075mg/24hr
estradiol patch weekly 0.1mg/24hr
estradiol patch weekly 37.5mcg/24hr
estradiol tablet 0.5mg
estradiol tablet 1mg
estradiol tablet 2mg
estropipate tablet 0.75mg
estropipate tablet 1.5mg
estropipate tablet 3mg
falmina tablet 20mcg; 0.1mg
gildess 1.5/30 tablet 30mcg; 1.5mg
introvale tablet 0.03mg; 0.15mg
junel 1.5/30 tablet 30mcg; 1.5mg
junel 1/20 tablet 20mcg; 1mg
junel fe 1.5/30 tablet 30mcg; 75mg; 1.5mg
junel fe 1/20 tablet 20mcg; 75mg; 1mg
junel fe 24 tablet 20mcg; 75mg; 1mg
kariva tablet 0; 0
kelnor 1/35 tablet 35mcg; 1mg
kimidess tablet 0; 0
larin 1.5/30 tablet 30mcg; 1.5mg
leena tablet 0; 0
lessina tablet 20mcg; 0.1mg
levonorgestrel and ethinyl estradiol tablet 20mcg; 90mcg
levonorgestrel/ethinyl estradiol tablet 0; 0
levonorgestrel/ethinyl estradiol tablet 20mcg; 0.1mg
levora 0.15/30-28 tablet 30mcg; 0.15mg
loestrin 24 fe tablet 20mcg; 75mg; 1mg
low-ogestrel tablet 30mcg; 0.3mg
lutera tablet 20mcg; 0.1mg
marlissa tablet 0.03mg; 0.15mg
MENEST TABLET 0.3MG
Página 83 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (4 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
QL (4 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
QL (4 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
QL (4 EA cada 28 días)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) PA (Medicamentos de alto
riesgo)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
MENEST TABLET 0.625MG
$0-$6.60(Nivel 2) PA (Medicamentos de alto
riesgo)
MENEST TABLET 1.25MG
$0-$6.60(Nivel 2) PA (Medicamentos de alto
riesgo)
MENEST TABLET 2.5MG
$0-$6.60(Nivel 2) PA (Medicamentos de alto
riesgo)
microgestin 1.5/30 tablet 30mcg; 1.5mg
$0(Nivel 1)
microgestin 1/20 tablet 20mcg; 1mg
$0(Nivel 1)
microgestin fe 1.5/30 tablet 30mcg; 75mg; 1.5mg
$0(Nivel 1)
microgestin fe tablet 20mcg; 75mg; 1mg
$0(Nivel 1)
mononessa tablet 35mcg; 0.25mg
$0(Nivel 1)
necon 0.5/35-28 tablet 35mcg; 0.5mg
$0(Nivel 1)
necon 1/35 tablet 35mcg; 1mg
$0(Nivel 1)
necon 10/11-28 tablet 35mcg; 0
$0(Nivel 1)
necon 7/7/7 tablet 0; 0
$0(Nivel 1)
norethindrone acetate/ethinyl estradiol tablet 2.5mcg; 0.5mg $0(Nivel 1)
MO
norethindrone acetate/ethinyl estradiol tablet 5mcg; 1mg
$0(Nivel 1)
MO
nortrel 0.5/35 (28) tablet 35mcg; 0.5mg
$0(Nivel 1)
nortrel 1/35 tablet 35mcg; 1mg
$0(Nivel 1)
nortrel 1/35 tablet 35mcg; 1mg
$0(Nivel 1)
nortrel 7/7/7 tablet 0; 0
$0(Nivel 1)
OGESTREL TABLET 50MCG; 0.5MG
$0-$6.60(Nivel 2)
portia-28 tablet 0.03mg; 0.15mg
$0(Nivel 1)
$0-$6.60(Nivel 2)
PREMARIN CREAM 0.625MG/GM
PREMARIN INJECTION 25MG
$0-$6.60(Nivel 2)
PREMARIN TABLET 0.3MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
PREMARIN TABLET 0.45MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
PREMARIN TABLET 0.625MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
PREMARIN TABLET 0.9MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
PREMARIN TABLET 1.25MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
PREMPHASE TABLET 0.625MG; 5MG
$0-$6.60(Nivel 2) PA (Medicamentos de alto
riesgo)
PREMPRO TABLET 0.3MG; 1.5MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
PREMPRO TABLET 0.45MG; 1.5MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
Página 84 de 143
Nombre del medicamento
PREMPRO TABLET 0.625MG; 2.5MG
PREMPRO TABLET 0.625MG; 5MG
previfem tablet 35mcg; 0.25mg
quasense tablet 0.03mg; 0.15mg
sprintec 28 tablet 35mcg; 0.25mg
sronyx tablet 20mcg; 0.1mg
tri-previfem tablet 0; 0
tri-sprintec tablet 0; 0
trinessa tablet 0; 0
trivora-28 tablet 0; 0
velivet tablet 0; 0
xulane patch weekly 35mcg/24hr; 150mcg/24hr
zovia 1/35e tablet 35mcg; 1mg
zovia 1/50e tablet 50mcg; 1mg
Progesterone Agonists/Antagonists
ELLA TABLET 30MG
Progestins
camila tablet 0.35mg
deblitane tablet 0.35mg
DEPO-SUBQ PROVERA 104 INJECTION 104MG/0.65ML
errin tablet 0.35mg
jolivette tablet 0.35mg
lyza tablet 0.35mg
medroxyprogesterone acetate injection 150mg/ml
medroxyprogesterone acetate tablet 10mg
medroxyprogesterone acetate tablet 2.5mg
medroxyprogesterone acetate tablet 5mg
megestrol acetate suspension 40mg/ml
megestrol acetate tablet 20mg
megestrol acetate tablet 40mg
nora-be tablet 0.35mg
norethindrone acetate tablet 5mg
norethindrone tablet 0.35mg
norlyroc tablet 0.35mg
progesterone capsule 100mg
progesterone capsule 200mg
PROMETRIUM CAPSULE 100MG
PROMETRIUM CAPSULE 200MG
sharobel tablet 0.35mg
Selective Estrogen Receptor Modifying Agents
EVISTA TABLET 60MG
Página 85 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
$0(Nivel 1)
QL (91 EA cada 91 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (3 EA cada 28 días)
MO
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
MO
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
Nombre del medicamento
raloxifene hydrochloride tablet 60mg
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
CYTOMEL TABLET 25MCG
CYTOMEL TABLET 50MCG
CYTOMEL TABLET 5MCG
levothyroxine sodium tablet 100mcg
levothyroxine sodium tablet 112mcg
levothyroxine sodium tablet 125mcg
levothyroxine sodium tablet 137mcg
levothyroxine sodium tablet 150mcg
levothyroxine sodium tablet 175mcg
levothyroxine sodium tablet 200mcg
levothyroxine sodium tablet 25mcg
levothyroxine sodium tablet 300mcg
levothyroxine sodium tablet 50mcg
levothyroxine sodium tablet 75mcg
levothyroxine sodium tablet 88mcg
levoxyl tablet 100mcg
levoxyl tablet 112mcg
levoxyl tablet 125mcg
levoxyl tablet 137mcg
levoxyl tablet 150mcg
levoxyl tablet 175mcg
levoxyl tablet 200mcg
levoxyl tablet 25mcg
levoxyl tablet 50mcg
levoxyl tablet 75mcg
levoxyl tablet 88mcg
liothyronine sodium injection 10mcg/ml
liothyronine sodium tablet 25mcg
liothyronine sodium tablet 50mcg
liothyronine sodium tablet 5mcg
SYNTHROID TABLET 100MCG
SYNTHROID TABLET 112MCG
SYNTHROID TABLET 125MCG
SYNTHROID TABLET 137MCG
SYNTHROID TABLET 150MCG
SYNTHROID TABLET 175MCG
SYNTHROID TABLET 200MCG
SYNTHROID TABLET 25MCG
SYNTHROID TABLET 300MCG
SYNTHROID TABLET 50MCG
SYNTHROID TABLET 75MCG
SYNTHROID TABLET 88MCG
THYROLAR-1/2 TABLET 30MG
THYROLAR-1/4 TABLET 15MG
Página 86 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Nombre del medicamento
THYROLAR-1 TABLET 60MG
THYROLAR-2 TABLET 120MG
THYROLAR-3 TABLET 180MG
unithroid tablet 100mcg
unithroid tablet 112mcg
unithroid tablet 125mcg
unithroid tablet 137mcg
unithroid tablet 150mcg
unithroid tablet 175mcg
unithroid tablet 200mcg
unithroid tablet 25mcg
unithroid tablet 300mcg
unithroid tablet 50mcg
unithroid tablet 75mcg
unithroid tablet 88mcg
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN TABLET 500MG
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABLET 30MG
SENSIPAR TABLET 60MG
SENSIPAR TABLET 90MG
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline tablet 0.5mg
ELIGARD INJECTION 22.5MG
ELIGARD INJECTION 30MG
ELIGARD INJECTION 45MG
ELIGARD INJECTION 7.5MG
FIRMAGON INJECTION 120MG
FIRMAGON INJECTION 80MG
leuprolide acetate injection 1mg/0.2ml
LUPRON DEPOT-PED INJECTION 11.25MG
LUPRON DEPOT-PED INJECTION 15MG
LUPRON DEPOT INJECTION 11.25MG
LUPRON DEPOT INJECTION 22.5MG
LUPRON DEPOT INJECTION 3.75MG
LUPRON DEPOT INJECTION 30MG
LUPRON DEPOT INJECTION 7.5MG
octreotide acetate injection 1000mcg/ml
octreotide acetate injection 100mcg/ml
octreotide acetate injection 200mcg/ml
octreotide acetate injection 500mcg/ml
octreotide acetate injection 50mcg/ml
SOMATULINE DEPOT INJECTION 120MG/0.5ML
SOMATULINE DEPOT INJECTION 90MG/0.3ML
Página 87 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Nombre del medicamento
SOMAVERT INJECTION 10MG
SOMAVERT INJECTION 15MG
SOMAVERT INJECTION 20MG
SOMAVERT INJECTION 25MG
SOMAVERT INJECTION 30MG
SYNAREL SOLUTION 2MG/ML
TRELSTAR MIXJECT INJECTION 11.25MG
TRELSTAR MIXJECT INJECTION 22.5MG
TRELSTAR MIXJECT INJECTION 3.75MG
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole tablet 10mg
methimazole tablet 5mg
propylthiouracil tablet 50mg
Immunological Agents
Angioedema (HAE) Agents
CINRYZE INJECTION 500UNIT
FIRAZYR INJECTION 30MG/3ML
Immune Suppressants
azathioprine tablet 50mg
CELLCEPT INTRAVENOUS INJECTION 500MG
CELLCEPT SUSPENSION RECONSTITUTED 200MG/ML
cyclosporine modified capsule 100mg
cyclosporine modified capsule 25mg
cyclosporine modified capsule 50mg
cyclosporine modified solution 100mg/ml
cyclosporine capsule 100mg
cyclosporine capsule 25mg
cyclosporine injection 50mg/ml
ENBREL SURECLICK INJECTION 50MG/ML
ENBREL INJECTION 25MG/0.5ML
Página 88 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) PA (Agentes hormonales,
supresor (Pituitario) Somavert)
$0-$6.60(Nivel 2) PA (Agentes hormonales,
supresor (Pituitario) Somavert)
$0-$6.60(Nivel 2) PA (Agentes hormonales,
supresor (Pituitario) Somavert)
$0-$6.60(Nivel 2) PA (Agentes hormonales,
supresor (Pituitario) Somavert)
$0-$6.60(Nivel 2) PA (Agentes hormonales,
supresor (Pituitario) Somavert)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (100 EA cada 30 días)
PA
(Productos/modificadores/
expansores del volumen
de sangre - Cinryze)
$0-$6.60(Nivel 2) QL (270 ML cada 30 días)
PA (Firazyr)
$0(Nivel 1)
B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
ENBREL INJECTION 25MG
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
ENBREL INJECTION 50MG/ML
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
gengraf capsule 100mg
$0(Nivel 1)
B/D
gengraf capsule 25mg
$0(Nivel 1)
B/D
gengraf solution 100mg/ml
$0(Nivel 1)
B/D
HUMIRA PEN-CROHNS DISEASESTARTER INJECTION $0-$6.60(Nivel 2) PA (Agentes
40MG/0.8ML
inmunológicos)
HUMIRA INJECTION 10MG/0.2ML
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
HUMIRA INJECTION 20MG/0.4ML
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
HUMIRA INJECTION 40MG/0.8ML
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
KINERET INJECTION 100MG/0.67ML
$0-$6.60(Nivel 2) QL (28 ML cada 28 días)
PA (Agentes
inmunológicos)
methotrexate sodium injection 1gm
$0(Nivel 1)
methotrexate tablet 2.5mg
$0(Nivel 1)
mycophenolate mofetil capsule 250mg
$0(Nivel 1)
B/D
mycophenolate mofetil suspension reconstituted 200mg/ml
$0(Nivel 1)
B/D
mycophenolate mofetil tablet 500mg
$0(Nivel 1)
B/D
NULOJIX INJECTION 250MG
$0-$6.60(Nivel 2) B/D
ORENCIA INJECTION 125MG/ML
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
ORENCIA INJECTION 250MG
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
PROGRAF CAPSULE 0.5MG
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
PROGRAF CAPSULE 1MG
PROGRAF CAPSULE 5MG
$0-$6.60(Nivel 2) B/D
PROGRAF INJECTION 5MG/ML
$0-$6.60(Nivel 2) B/D
RAPAMUNE SOLUTION 1MG/ML
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
RAPAMUNE TABLET 0.5MG
RAPAMUNE TABLET 1MG
$0-$6.60(Nivel 2) B/D
RAPAMUNE TABLET 2MG
$0-$6.60(Nivel 2) B/D
REMICADE INJECTION 100MG
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
sirolimus tablet 0.5mg
$0(Nivel 1)
B/D
sirolimus tablet 1mg
$0(Nivel 1)
B/D
sirolimus tablet 2mg
$0(Nivel 1)
B/D
tacrolimus capsule 0.5mg
$0(Nivel 1)
B/D
tacrolimus capsule 1mg
$0(Nivel 1)
B/D
tacrolimus capsule 5mg
$0(Nivel 1)
B/D
TORISEL INJECTION 25MG/ML
$0-$6.60(Nivel 2)
ZORTRESS TABLET 0.25MG
$0-$6.60(Nivel 2) B/D
ZORTRESS TABLET 0.5MG
$0-$6.60(Nivel 2) B/D
ZORTRESS TABLET 0.75MG
$0-$6.60(Nivel 2) B/D
Página 89 de 143
Nombre del medicamento
Immunizing Agents, Passive
CARIMUNE NANOFILTERED INJECTION 6GM
GAMASTAN S/D INJECTION 0
GAMMAGARD LIQUID INJECTION 2.5GM/25ML
GAMUNEX-C INJECTION 1GM/10ML
THYMOGLOBULIN INJECTION 25MG
Immunomodulators
ACTIMMUNE INJECTION 2000000UNIT/0.5ML
ARCALYST INJECTION 220MG
ILARIS INJECTION 180MG
leflunomide tablet 10mg
leflunomide tablet 20mg
SIMULECT INJECTION 20MG
SYNAGIS INJECTION 50MG/0.5ML
Vaccines
ACTHIB INJECTION 0
ADACEL INJECTION 15.5MCG/0.5ML; 2LF/0.5ML;
5LF/0.5ML
BEXSERO INJECTION 0
BOOSTRIX INJECTION 18.5MCG/0.5ML; 2.5LF/0.5ML;
5LF/0.5ML
BOOSTRIX INJECTION 18.5MCG/0.5ML; 2.5LF/0.5ML;
5LF/0.5ML
CERVARIX INJECTION 0
COMVAX INJECTION 7.5MCG/0.5ML; 5MCG/0.5ML
DAPTACEL INJECTION 10MCG/0.5ML; 15LF/0.5ML;
5LF/0.5ML
DECAVAC INJECTION 2LFU; 5LFU
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC INJECTION 25LFU/0.5ML; 5LFU/0.5ML
ENGERIX-B INJECTION 10MCG/0.5ML
ENGERIX-B INJECTION 10MCG/0.5ML
ENGERIX-B INJECTION 20MCG/ML
GARDASIL 9 INJECTION 0
GARDASIL 9 INJECTION 0
GARDASIL INJECTION 0
GARDASIL INJECTION 0
HAVRIX INJECTION 1440ELU/ML
HAVRIX INJECTION 720ELU/0.5ML
IMOVAX RABIES (H.D.C.V.) INJECTION 2.5UNIT/ML
INFANRIX INJECTION 58MCG/0.5ML; 25LFU/0.5ML;
10LFU/0.5ML
IPOL INACTIVATED IPV INJECTION 0
IPOL INACTIVATED IPV INJECTION 0
IXIARO INJECTION 0
M-M-R II INJECTION 0; 0; 0
Página 90 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (1 EA cada 28 días)
PA (Agentes
inmunológicos - Ilaris)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
MENACTRA INJECTION 0
$0-$6.60(Nivel 2)
MENOMUNE-A/C/Y/W-135 INJECTION 0
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
MENVEO INJECTION 0
$0-$6.60(Nivel 2)
PEDVAX HIB INJECTION 7.5MCG/0.5ML
PROQUAD INJECTION 0; 0; 0; 0
$0-$6.60(Nivel 2)
QUADRACEL INJECTION 48MCG/0.5ML; 15LFU/0.5ML; $0-$6.60(Nivel 2)
0; 5LFU/0.5ML
RABAVERT INJECTION 0
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) B/D
RECOMBIVAX HB INJECTION 10MCG/ML
RECOMBIVAX HB INJECTION 10MCG/ML
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
RECOMBIVAX HB INJECTION 40MCG/ML
RECOMBIVAX HB INJECTION 5MCG/0.5ML
$0-$6.60(Nivel 2) B/D
ROTARIX SUSPENSION RECONSTITUTED 0
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
ROTATEQ SOLUTION 0
TENIVAC INJECTION 2LFU; 5LFU
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
TETANUS TOXOID ADSORBED INJECTION 5LFU
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT $0-$6.60(Nivel 2)
INJECTION 2LF/0.5ML; 2LF/0.5ML
TRUMENBA INJECTION 0
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
TWINRIX INJECTION 720ELU/ML; 20MCG/ML
TYPHIM VI INJECTION 25MCG/0.5ML
$0-$6.60(Nivel 2)
TYPHIM VI INJECTION 25MCG/0.5ML
$0-$6.60(Nivel 2)
VAQTA INJECTION 25UNIT/0.5ML
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
VAQTA INJECTION 25UNIT/0.5ML
VAQTA INJECTION 50UNIT/ML
$0-$6.60(Nivel 2)
VARIVAX INJECTION 1350PFU/0.5ML
$0-$6.60(Nivel 2)
VARIZIG INJECTION 125UNIT/1.2ML
$0-$6.60(Nivel 2)
YF-VAX INJECTION 0
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
ZOSTAVAX INJECTION 19400UNT/0.65ML
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium capsule 750mg
$0(Nivel 1)
MO
DELZICOL CAPSULE DELAYED RELEASE 400MG
$0-$6.60(Nivel 2) QL (180 EA cada 30 días)
$0-$6.60(Nivel 2)
DIPENTUM CAPSULE 250MG
mesalamine kit 4gm
$0(Nivel 1)
Sulfonamides
sulfasalazine tablet 500mg
$0(Nivel 1)
sulfazine ec tablet delayed release 500mg
$0(Nivel 1)
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium tablet 10mg
$0(Nivel 1)
QL (30 EA cada 30 días)
alendronate sodium tablet 40mg
$0(Nivel 1)
QL (30 EA cada 30 días)
alendronate sodium tablet 5mg
$0(Nivel 1)
QL (30 EA cada 30 días)
alendronate sodium tablet 70mg
$0(Nivel 1)
QL (4 EA cada 28 días)
calcitonin-salmon solution 200unit/act
$0(Nivel 1)
QL (4 ML cada 30 días)
calcitriol capsule 0.25mcg
$0(Nivel 1)
calcitriol capsule 0.5mcg
$0(Nivel 1)
calcitriol injection 1mcg/ml
$0(Nivel 1)
Página 91 de 143
Nombre del medicamento
calcitriol solution 1mcg/ml
etidronate disodium tablet 200mg
etidronate disodium tablet 400mg
FORTEO INJECTION 600MCG/2.4ML
fortical solution 200unit/act
HECTOROL CAPSULE 0.5MCG
HECTOROL CAPSULE 2.5MCG
HECTOROL INJECTION 4MCG/2ML
ibandronate sodium tablet 150mg
MIACALCIN INJECTION 200UNIT/ML
pamidronate disodium injection 30mg/10ml
PAMIDRONATE DISODIUM INJECTION 6MG/ML
pamidronate disodium injection 90mg/10ml
PROLIA INJECTION 60MG/ML
risedronate sodium tablet 30mg
risedronate sodium tablet 35mg
risedronate sodium tablet 35mg
risedronate sodium tablet 5mg
XGEVA INJECTION 120MG/1.7ML
zoledronic acid injection 4mg/5ml
zoledronic acid injection 5mg/100ml
ZOMETA INJECTION 4MG/100ML
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
arginine tablet 500mg
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"
MISCELLANEOUS
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16"
MISCELLANEOUS
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"
MISCELLANEOUS
bd insulin syringe ultrafine/1ml/30g x 1/2" miscellaneous
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"
MISCELLANEOUS
bd insulin syringe/detachable needle/u-100/1ml/25g x 5/8"
miscellaneous
bd pen needle/mini/ultrafine/31g x 3/16" miscellaneous
bd pen needle/mini/ultrafine/31g x 3/16" miscellaneous
Página 92 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) PA (Agentes metabólicos
de enfermedad ósea - IV
osteoporosis)
$0(Nivel 1)
QL (4 ML cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
QL (1 EA cada 30 días)
$0(Nivel 1)
MO
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (1 ML cada 180 días)
PA (Agentes metabólicos
de enfermedad ósea Prolia)
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
$0(Nivel 1)
QL (4 EA cada 28 días)
MO
$0(Nivel 1)
QL (4 EA cada 28 días)
MO
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (200 EA cada 30 días)
$0-$6.60(Nivel 2) QL (200 EA cada 30 días)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (200 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
bd pen needle/short/ultrafine/31g x 5/16" miscellaneous
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
MISCELLANEOUS
bd pen needles short/ultrafine/31g x 5/16" miscellaneous
BOTOX INJECTION 200UNIT
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (200 EA cada 30 días)
$0(Nivel 1)
$0-$6.60(Nivel 2) PA (Agentes terapéuticos
misceláneos - Botox)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
easy touch pen needles 31gx5/16" miscellaneous
easy touch pen needles/31g x 3/16" miscellaneous
exel comfort point insulin pen needles 31g x 8mm
miscellaneous
gnp fish oil capsule delayed release 0; 0; 1200mg
$0(Nivel 3)
DP
insupen ultrafin 31gx8mm miscellaneous
$0(Nivel 1)
intralipid injection 20gm/100ml
$0(Nivel 1)
B/D
INTRALIPID INJECTION 30GM/100ML
$0-$6.60(Nivel 2) B/D
$0(Nivel 1)
lactated ringers irrigation solution 3meq/l; 109meq/l;
28meq/l; 4meq/l; 130meq/l
levocarnitine injection 200mg/ml
$0(Nivel 1)
levocarnitine solution 1gm/10ml
$0(Nivel 1)
levocarnitine tablet 330mg
$0(Nivel 1)
liposyn iii injection 2.5%; 30%
$0(Nivel 1)
B/D
lite touch pen needles/31g x 3/16" miscellaneous
$0(Nivel 1)
methylergonovine maleate tablet 0.2mg
$0(Nivel 1)
monoject insulin syringe/detach needle/1ml/25g x 5/8"
$0(Nivel 1)
miscellaneous
novofine 32gx6mm miscellaneous
$0(Nivel 1)
nutrilipid injection 20gm/100ml
$0(Nivel 1)
B/D
nutrilipid injection 20gm/100ml
$0(Nivel 1)
B/D
physiolyte solution 27meq/1000ml; 98meq/1000ml;
$0(Nivel 1)
23meq/1000ml; 3meq/1000ml; 5meq/1000ml; 140meq/1000ml
physiosol irrigation solution 30mg/100ml; 37mg/100ml;
$0(Nivel 1)
222mg/100ml; 526mg/100ml; 502mg/100ml
prodigy insulin mini pen needles/31g x 3/16" miscellaneous $0(Nivel 1)
prodigy insulin short penneedles/31g x 5/16" miscellaneous $0(Nivel 1)
ringers irrigation solution 4.5meq/l; 156meq/l; 4meq/l;
$0(Nivel 1)
147meq/l
sterile water irrigation solution 0
$0(Nivel 1)
sure-fine pen needles 31gx3/16" 5mm miscellaneous
$0(Nivel 1)
sure-fine pen needles 31gx5/16" 8mm miscellaneous
$0(Nivel 1)
ulticare short pen needles 31gx8mm miscellaneous
$0(Nivel 1)
ulticare short pen needles 31gx8mm miscellaneous
$0(Nivel 1)
ulticare short pen needles ulti-fine iv miscellaneous
$0(Nivel 1)
ulticare short pen needles ulti-fine iv miscellaneous
$0(Nivel 1)
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
COMBIGAN SOLUTION 0.2%; 0.5%
$0-$6.60(Nivel 2)
latanoprost solution 0.005%
$0(Nivel 1)
LUMIGAN SOLUTION 0.01%
$0-$6.60(Nivel 2)
Ophthalmic Agents, Other
Página 93 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
Nombre del medicamento
akwa tears ointment 2%; 15%; 83%
artificial tears ointment 15%; 83%
artificial tears solution 1.4%
artificial tears solution 1.4%
bacitracin/polymyxin b ointment 500unit/gm; 10000unit/gm
ENUCLENE SOLUTION 0.25%
GENTEAL MILD TO MODERATE SOLUTION 0.3%
GENTEAL MILD TO MODERATE SOLUTION 0.3%
GENTEAL MILD SOLUTION 0.2%
GENTEAL SEVERE GEL 0.3%
GENTEAL SEVERE GEL 0.3%
ISOPTO TEARS SOLUTION 0.5%
liquitears solution 1.4%
lubrifresh p.m. ointment 15%; 83%
MURO 128 OINTMENT 5%
MURO 128 OINTMENT 5%
MURO 128 SOLUTION 2%
MURO 128 SOLUTION 5%
MURO 128 SOLUTION 5%
naphazoline hcl solution 0.1%
natural balance tears solution 0.4%
natures tears solution 0.4%
neomycin/bacitracin/polymyxin ointment 400unit/gm;
5mg/gm; 10000unit/gm
$0(Nivel 1)
neomycin/polymyxin/gramicidin solution 0.025mg/ml;
1.75mg/ml; 10000unit/ml
polymyxin b sulfate/trimethoprim sulfate solution
$0(Nivel 1)
10000unit/ml; 0.1%
REFRESH CELLUVISC SOLUTION 1%
$0(Nivel 3)
DP
$0(Nivel 3)
DP
refresh lacri-lube ointment 42.5%; 56.8%
refresh lacri-lube ointment 42.5%; 56.8%
$0(Nivel 3)
DP
REFRESH LIQUIGEL SOLUTION 1%
$0(Nivel 3)
DP
REFRESH LIQUIGEL SOLUTION 1%
$0(Nivel 3)
DP
$0(Nivel 3)
DP
REFRESH PLUS SOLUTION 0.5%
REFRESH TEARS SOLUTION 0.5%
$0(Nivel 3)
DP
REFRESH SOLUTION 1.4%; 0.6%
$0(Nivel 3)
DP
RESTASIS EMULSION 0.05%
$0-$6.60(Nivel 2)
sm artificial tears solution 0.01%; 0; 0.05%; 0.3%
$0(Nivel 3)
DP
sodium chloride ointment 5%
$0(Nivel 3)
DP
sodium chloride ointment 5%
$0(Nivel 3)
DP
sodium chloride solution 5%
$0(Nivel 3)
DP
sodium chloride solution 5%
$0(Nivel 3)
DP
systane nighttime ointment 3%; 94%
$0(Nivel 3)
DP
SYSTANE PRESERVATIVE FREE SOLUTION 0.4%; 0.3% $0(Nivel 3)
DP
SYSTANE SOLUTION 0.4%; 0.3%
$0(Nivel 3)
DP
tears naturale forte solution 0.1%; 0.2%; 0.3%
$0(Nivel 3)
DP
tears naturale ii solution 0.01%; 0; 0.05%; 0.3%
$0(Nivel 3)
DP
tears naturale ii solution 0.01%; 0; 0.05%; 0.3%
$0(Nivel 3)
DP
Página 94 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
tears naturale solution 0.1%; 0.3%
tears pure solution 0.1%; 0.3%
Ophthalmic Anti-allergy Agents
cromolyn sodium solution 4%
$0(Nivel 1)
PATANOL SOLUTION 0.1%
$0-$6.60(Nivel 2)
Ophthalmic Anti-inflammatories
dexamethasone sodium phosphate solution 0.1%
$0(Nivel 1)
diclofenac sodium solution 0.1%
$0(Nivel 1)
fluorometholone suspension 0.1%
$0(Nivel 1)
flurbiprofen sodium solution 0.03%
$0(Nivel 1)
ketorolac tromethamine solution 0.4%
$0(Nivel 1)
QL (5 ML cada 15 días)
ketorolac tromethamine solution 0.5%
$0(Nivel 1)
QL (5 ML cada 15 días)
LOTEMAX SUSPENSION 0.5%
$0-$6.60(Nivel 2)
$0(Nivel 1)
neomycin/polymyxin/dexamethasone ointment 0.1%;
3.5mg/gm; 10000unit/gm
neomycin/polymyxin/dexamethasone suspension 0.1%;
$0(Nivel 1)
3.5mg/ml; 10000unit/ml
PRED-G S.O.P. OINTMENT 0.3%; 0.6%
$0-$6.60(Nivel 2)
PRED-G SUSPENSION 0.3%; 1%
$0-$6.60(Nivel 2)
prednisolone acetate suspension 1%
$0(Nivel 1)
prednisolone sodium phosphate solution 1%
$0(Nivel 1)
sulfacetamide sodium/prednisolone sodium phosphate solution$0(Nivel 1)
0.23%; 10%
TOBRADEX OINTMENT 0.1%; 0.3%
$0-$6.60(Nivel 2)
tobramycin/dexamethasone suspension 0.1%; 0.3%
$0(Nivel 1)
Ophthalmic Antiglaucoma Agents
acetazolamide er capsule extended release 12 hour 500mg
$0(Nivel 1)
ALPHAGAN P SOLUTION 0.1%
$0-$6.60(Nivel 2)
betaxolol hcl solution 0.5%
$0(Nivel 1)
brimonidine tartrate solution 0.15%
$0(Nivel 1)
brimonidine tartrate solution 0.2%
$0(Nivel 1)
carteolol hcl solution 1%
$0(Nivel 1)
dorzolamide hcl/timolol maleate solution 22.3mg/ml;
$0(Nivel 1)
QL (20 ML cada 30 días)
6.8mg/ml
dorzolamide hcl solution 2%
$0(Nivel 1)
QL (20 ML cada 30 días)
levobunolol hcl solution 0.25%
$0(Nivel 1)
levobunolol hcl solution 0.25%
$0(Nivel 1)
QL (30 ML cada 30 días)
levobunolol hcl solution 0.5%
$0(Nivel 1)
methazolamide tablet 25mg
$0(Nivel 1)
methazolamide tablet 50mg
$0(Nivel 1)
metipranolol solution 0.3%
$0(Nivel 1)
PHOSPHOLINE IODIDE SOLUTION RECONSTITUTED $0-$6.60(Nivel 2)
0.125%
PILOPINE HS GEL 4%
$0-$6.60(Nivel 2)
timolol maleate ophthalmic gel forming gel forming solution $0(Nivel 1)
0.25%
timolol maleate ophthalmic gel forming gel forming solution $0(Nivel 1)
0.5%
Página 95 de 143
Nombre del medicamento
timolol maleate solution 0.25%
timolol maleate solution 0.5%
Otic Agents
Otic Agents
acetasol hc solution 2%; 1%
acetic acid solution 2%
CIPRODEX SUSPENSION 0.3%; 0.1%
ear wax removal drops solution 6.5%
ear wax remover solution 6.5%
earwax treatment drops solution 6.5%
gnp ear drops solution 6.5%
gnp ear systems solution 6.5%
hm earwax removal aid solution 6.5%
hydrocortisone/acetic acid solution 2%; 1%
neomycin/polymyxin/hc solution 1%; 3.5mg/ml; 10000unit/ml
neomycin/polymyxin/hydrocortisone suspension 1%;
3.5mg/ml; 10000unit/ml
sb ear wax remover solution 6.5%
SWIM EAR LIQUID 95%
Respiratory Tract/Pulmonary Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS AEROSOL POWDER BREATH
ACTIVATED 100MCG/DOSE; 50MCG/DOSE
ADVAIR DISKUS AEROSOL POWDER BREATH
ACTIVATED 250MCG/DOSE; 50MCG/DOSE
ADVAIR DISKUS AEROSOL POWDER BREATH
ACTIVATED 500MCG/DOSE; 50MCG/DOSE
ADVAIR HFA AEROSOL 115MCG/ACT; 21MCG/ACT
ADVAIR HFA AEROSOL 230MCG/ACT; 21MCG/ACT
ADVAIR HFA AEROSOL 45MCG/ACT; 21MCG/ACT
ASMANEX HFA AEROSOL 100MCG/ACT
ASMANEX HFA AEROSOL 200MCG/ACT
ASMANEX TWISTHALER 120 METERED DOSES
AEROSOL POWDER BREATH ACTIVATED
220MCG/INH
ASMANEX TWISTHALER 14 METERED DOSES
AEROSOL POWDER BREATH ACTIVATED
220MCG/INH
ASMANEX TWISTHALER 30 METERED DOSES
AEROSOL POWDER BREATH ACTIVATED
110MCG/INH
ASMANEX TWISTHALER 30 METERED DOSES
AEROSOL POWDER BREATH ACTIVATED
220MCG/INH
ASMANEX TWISTHALER 60 METERED DOSES
AEROSOL POWDER BREATH ACTIVATED
220MCG/INH
budesonide suspension 32mcg/act
Página 96 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (12 GM cada 30 días)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) MO
$0-$6.60(Nivel 2) MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
MO
Nombre del medicamento
DULERA AEROSOL 5MCG/ACT; 100MCG/ACT
DULERA AEROSOL 5MCG/ACT; 200MCG/ACT
FLOVENT DISKUS AEROSOL POWDER BREATH
ACTIVATED 100MCG/BLIST
FLOVENT DISKUS AEROSOL POWDER BREATH
ACTIVATED 250MCG/BLIST
FLOVENT DISKUS AEROSOL POWDER BREATH
ACTIVATED 50MCG/BLIST
FLOVENT HFA AEROSOL 110MCG/ACT
FLOVENT HFA AEROSOL 220MCG/ACT
FLOVENT HFA AEROSOL 44MCG/ACT
flunisolide solution 0.025%
fluticasone propionate suspension 50mcg/act
SYMBICORT AEROSOL 160MCG/ACT; 4.5MCG/ACT
SYMBICORT AEROSOL 80MCG/ACT; 4.5MCG/ACT
triamcinolone acetonide aerosol 55mcg/act
Antihistamines
allergy relief capsule 25mg
allergy relief tablet 25mg
allergy/congestion relief tablet extended release 24 hour
10mg; 240mg
azelastine hcl solution 0.1%
azelastine hcl solution 0.15%
cetirizine hcl tablet 5mg
cyproheptadine hcl syrup 2mg/5ml
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (24 GM cada 30 días)
$0-$6.60(Nivel 2) QL (24 GM cada 30 días)
$0-$6.60(Nivel 2) QL (21.2 GM cada 30
días)
$0(Nivel 1)
MO
$0(Nivel 1)
QL (32 GM cada 30 días)
$0-$6.60(Nivel 2) QL (10.2 GM cada 30
días)
$0-$6.60(Nivel 2) QL (10.2 GM cada 30
días)
$0(Nivel 1)
QL (33 GM cada 30 días)
MO
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 1)
QL (30 ML cada 30 días)
MO
DP
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
DP
cyproheptadine hcl tablet 4mg
$0(Nivel 1)
diphenhydramine hcl capsule 50mg
diphenhydramine hcl injection 50mg/ml
ed a-hist pse tablet 60mg; 2.5mg
goodsense all día allergy tablet 10mg
HYDROXYZINE HCL INJECTION 25MG/ML
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2) PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
hydroxyzine hcl injection 50mg/ml
hydroxyzine hcl solution 10mg/5ml
hydroxyzine hcl tablet 10mg
hydroxyzine hcl tablet 25mg
hydroxyzine hcl tablet 50mg
Página 97 de 143
Nombre del medicamento
hydroxyzine pamoate capsule 100mg
hydroxyzine pamoate capsule 25mg
hydroxyzine pamoate capsule 50mg
levocetirizine dihydrochloride solution 2.5mg/5ml
levocetirizine dihydrochloride tablet 5mg
loratadine tablet 10mg
olopatadine hcl solution 0.6%
rynex pse liquid 1mg/5ml; 15mg/5ml
TAVIST ALLERGY TABLET 1.34MG
Antileukotrienes
montelukast sodium packet 4mg
montelukast sodium tablet chewable 4mg
montelukast sodium tablet chewable 5mg
montelukast sodium tablet 10mg
zafirlukast tablet 10mg
zafirlukast tablet 20mg
ZYFLO CR TABLET EXTENDED RELEASE 12 HOUR
600MG
Bronchodilators, Anticholinergic
ATROVENT HFA AEROSOL SOLUTION 17MCG/ACT
COMBIVENT RESPIMAT AEROSOL SOLUTION
100MCG/ACT; 20MCG/ACT
ipratropium bromide/albuterol sulfate solution 2.5mg/3ml;
0.5mg/3ml
ipratropium bromide solution 0.02%
ipratropium bromide solution 0.03%
ipratropium bromide solution 0.06%
SPIRIVA HANDIHALER CAPSULE 18MCG
SPIRIVA RESPIMAT AEROSOL SOLUTION
2.5MCG/ACT
Bronchodilators, Sympathomimetic
albuterol sulfate er tablet extended release 12 hour 4mg
albuterol sulfate er tablet extended release 12 hour 8mg
albuterol sulfate nebulization solution 0.083%
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
DP
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
$0-$6.60(Nivel 2) QL (39 GM cada 30 días)
$0-$6.60(Nivel 2) QL (8 GM cada 30 días)
MO
$0(Nivel 1)
QL (540 ML cada 30 días)
B/D
$0(Nivel 1)
QL (300 ML cada 30 días)
B/D
$0(Nivel 1)
QL (30 ML cada 30 días)
$0(Nivel 1)
QL (15 ML cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (8 GM cada 30 días)
MO
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
albuterol sulfate nebulization solution 0.5%
$0(Nivel 1)
albuterol sulfate nebulization solution 0.63mg/3ml
$0(Nivel 1)
albuterol sulfate nebulization solution 1.25mg/3ml
$0(Nivel 1)
albuterol sulfate syrup 2mg/5ml
albuterol sulfate tablet 2mg
albuterol sulfate tablet 4mg
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Página 98 de 143
QL (1170 ML cada 30
días) B/D
QL (200 ML cada 30 días)
B/D
QL (1200 ML cada 30
días) B/D
QL (1200 ML cada 30
días) B/D
Nombre del medicamento
EPIPEN 2-PAK INJECTION 0.3MG/0.3ML
EPIPEN-JR 2-PAK INJECTION 0.15MG/0.3ML
levalbuterol hcl nebulization solution 0.31mg/3ml
levalbuterol hcl nebulization solution 0.63mg/3ml
metaproterenol sulfate syrup 10mg/5ml
metaproterenol sulfate tablet 10mg
metaproterenol sulfate tablet 20mg
PROAIR HFA AEROSOL SOLUTION 108MCG/ACT
PROAIR RESPICLICK AEROSOL POWDER BREATH
ACTIVATED 108MCG/ACT
SEREVENT DISKUS AEROSOL POWDER BREATH
ACTIVATED 50MCG/DOSE
terbutaline sulfate injection 1mg/ml
terbutaline sulfate tablet 2.5mg
terbutaline sulfate tablet 5mg
VENTOLIN HFA AEROSOL SOLUTION 108MCG/ACT
XOPENEX HFA AEROSOL 45MCG/ACT
XOPENEX NEBULIZATION SOLUTION 1.25MG/3ML
Cystic Fibrosis Agents
CAYSTON SOLUTION RECONSTITUTED 75MG
PULMOZYME SOLUTION 1MG/ML
TOBI PODHALER CAPSULE 28MG
tobramycin nebulization solution 300mg/5ml
Mast Cell Stabilizers
cromolyn sodium aerosol solution 5.2mg/act
cromolyn sodium nebulization solution 20mg/2ml
Phosphodiesterase Inhibitors, Airways Disease
aminophylline injection 25mg/ml
DALIRESP TABLET 500MCG
ELIXOPHYLLIN ELIXIR 80MG/15ML
LUFYLLIN TABLET 200MG
LUFYLLIN TABLET 400MG
THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR 0;
100MG
THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR
200MG
THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR
300MG
THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR
400MG
theophylline cr tablet extended release 12 hour 100mg
theophylline cr tablet extended release 12 hour 200mg
theophylline er tablet extended release 12 hour 300mg
theophylline er tablet extended release 12 hour 450mg
theophylline er tablet extended release 24 hour 400mg
Página 99 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (2 EA cada 10 días)
$0-$6.60(Nivel 2) QL (2 EA cada 10 días)
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (36 GM cada 30 días)
$0-$6.60(Nivel 2) QL (2 EA cada 30 días)
MO
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (36 GM cada 30 días)
$0-$6.60(Nivel 2) QL (45 GM cada 30 días)
$0-$6.60(Nivel 2) QL (450 ML cada 30 días)
B/D
$0-$6.60(Nivel 2) PA (Antibacterianos Beta lactam, Other)
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2)
$0(Nivel 1)
B/D
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
DP
QL (305 ML cada 30 días)
B/D
Nombre del medicamento
theophylline er tablet extended release 24 hour 600mg
theophylline solution 80mg/15ml
Pulmonary Antihypertensives
LETAIRIS TABLET 10MG
LETAIRIS TABLET 5MG
ORENITRAM TABLET EXTENDED RELEASE 0.125MG
ORENITRAM TABLET EXTENDED RELEASE 0.25MG
ORENITRAM TABLET EXTENDED RELEASE 1MG
ORENITRAM TABLET EXTENDED RELEASE 2.5MG
sildenafil tablet 20mg
TRACLEER TABLET 125MG
TRACLEER TABLET 62.5MG
TYVASO SOLUTION 0.6MG/ML
Respiratory Tract Agents, Other
acetylcysteine solution 10%
acetylcysteine solution 20%
ARALAST NP INJECTION 400MG
AYR NASAL DROPS SOLUTION 0.65%
ayr saline nasal gel 0
ayr solution 0.65%
bromfed dm syrup 2mg/5ml; 10mg/5ml; 30mg/5ml
cheratussin dac solution 10mg/5ml; 100mg/5ml; 30mg/5ml
CODITUSS DM SYRUP 10MG/5ML; 5MG/5ML;
8.33MG/5ML
cold head congestion severe díatime tablet 325mg; 10mg;
200mg; 5mg
CONGESTAC TABLET 400MG; 60MG
decongestant 12hour maximum strength tablet extended
release 12 hour 120mg
deep sea nasal spray solution 0.65%
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
DRISTAN SPRAY SOLUTION 0.05%
gnp nose drops extra strength solution 1%
guaifenesin/codeine solution 10mg/5ml; 100mg/5ml
hydrocodone bitartrate/homatropine methylbromide syrup
1.5mg/5ml; 5mg/5ml
hydrocodone bitartrate/homatropine methylbromide tablet
1.5mg; 5mg
hydrocodone polistirex/chlorpheniramine polistirex liquid
extended release 8mg/5ml; 10mg/5ml
lohist-dm syrup 2mg/5ml; 10mg/5ml; 5mg/5ml
m-end dm liquid 2mg/5ml; 15mg/5ml; 15mg/5ml
MUCINEX D TABLET EXTENDED RELEASE 12 HOUR
600MG; 60MG
Página 100 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
MO
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
QL (90 EA cada 30 días)
PA (sildenafil - PAH)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
LA
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
LA
$0-$6.60(Nivel 2) B/D
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
DP
DP
DP
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
Nombre del medicamento
nasal spray extra moisturizing 12 hour solution 0.05%
OCEAN NASAL SPRAY SOLUTION 0.65%
OCEAN NASAL SPRAY SOLUTION 0.65%
organ-i nr tablet 200mg
PHENYLHISTINE DH LIQUID 2MG/5ML; 10MG/5ML;
30MG/5ML
PROLASTIN-C INJECTION 1000MG
$0-$6.60(Nivel 2)
promethazine vc plain syrup 5mg/5ml; 6.25mg/5ml
$0(Nivel 1)
robitussin maximum strength syrup 15mg/5ml
$0(Nivel 3)
DP
robitussin peak cold cough+ chest congestion dm liquid
$0(Nivel 3)
DP
10mg/5ml; 100mg/5ml
saline mist solution 0.65%
$0(Nivel 3)
DP
saline nasal mist solution 0.65%
$0(Nivel 3)
DP
saline nasal spray solution 0.65%
$0(Nivel 3)
DP
sb saline nose solution 0.65%
$0(Nivel 3)
DP
sea soft nasal mist solution 0.65%
$0(Nivel 3)
DP
silphen dm cough syrup 10mg/5ml
$0(Nivel 3)
DP
sm nasal spray saline solution 0.65%
$0(Nivel 3)
DP
sm nasal spray saline solution 0.65%
$0(Nivel 3)
DP
TUSNEL PEDIATRIC LIQUID 5MG/5ML; 50MG/5ML;
$0(Nivel 3)
DP
15MG/5ML
TUSNEL-DM PEDIATRIC LIQUID 2.5MG/ML; 25MG/ML; $0(Nivel 3)
DP
7.5MG/ML
TUSNEL CAPSULE 2MG; 15MG; 200MG
$0(Nivel 3)
DP
TUSNEL LIQUID 15MG/5ML; 200MG/5ML; 30MG/5ML $0(Nivel 3)
DP
TYZINE PEDIATRIC NASAL DROPS SOLUTION 0.05% $0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) PA (Agentes de la vía
XOLAIR INJECTION 150MG
respiratoria)
ZEMAIRA INJECTION 1000MG
$0-$6.60(Nivel 2)
zinc gluconate tablet 50mg
$0(Nivel 3)
DP
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
chlorzoxazone tablet 500mg
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
QL (90 EA cada 30 días)
cyclobenzaprine hcl tablet 10mg
PA (Medicamentos de alto
riesgo)
cyclobenzaprine hcl tablet 5mg
$0(Nivel 1)
QL (90 EA cada 30 días)
PA (Medicamentos de alto
riesgo)
methocarbamol tablet 500mg
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
methocarbamol tablet 750mg
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
orphenadrine citrate er tablet extended release 12 hour
$0(Nivel 1)
PA (Medicamentos de alto
100mg
riesgo)
orphenadrine citrate injection 30mg/ml
$0(Nivel 1)
Sleep Disorder Agents
Página 101 de 143
Nombre del medicamento
GABA Receptor Modulators
flurazepam hcl capsule 15mg
flurazepam hcl capsule 30mg
temazepam capsule 15mg
temazepam capsule 30mg
zaleplon capsule 10mg
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
zaleplon capsule 5mg
$0(Nivel 1)
zolpidem tartrate er tablet extended release 12.5mg
$0(Nivel 1)
zolpidem tartrate er tablet extended release 6.25mg
$0(Nivel 1)
zolpidem tartrate tablet 10mg
$0(Nivel 1)
zolpidem tartrate tablet 5mg
$0(Nivel 1)
Sleep Disorders, Other
modafinil tablet 200mg
ROZEREM TABLET 8MG
XYREM SOLUTION 500MG/ML
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
CHEMET CAPSULE 100MG
DEPEN TITRATABS TABLET 250MG
EXJADE TABLET SOLUBLE 125MG
EXJADE TABLET SOLUBLE 250MG
Página 102 de 143
$0(Nivel 1)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
QL (30 EA cada 30 días)
PA (Agentes del sistema
central nervioso)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (540 ML cada 30 días)
LA
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
Nombre del medicamento
EXJADE TABLET SOLUBLE 500MG
kionex powder 0
SODIUM LACTATE INJECTION 167MEQ/L
SODIUM LACTATE INJECTION 5MEQ/ML
sodium polystyrene sulfonate suspension 15gm/60ml
SYPRINE CAPSULE 250MG
Electrolyte/Mineral Replacement
AMINOSYN 7%/ELECTROLYTES INJECTION
$0-$6.60(Nivel 2) B/D
124MEQ/L; 900MG/100ML; 690MG/100ML; 96MEQ/L;
900MG/100ML; 210MG/100ML; 510MG/100ML;
660MG/100ML; 510MG/100ML; 10MEQ/L; 280MG/100ML;
310MG/100ML; 30MMOLE/L; 65MEQ/L; 610MG/100ML;
300MG/100ML; 65MEQ/L; 370MG/100ML; 120MG/100ML;
44MG/100ML; 560MG/100ML
$0(Nivel 1)
B/D
aminosyn 8.5%/electrolytes injection 142meq/l;
1100mg/100ml; 850mg/100ml; 98meq/l; 1100mg/100ml;
260mg/100ml; 620mg/100ml; 810mg/100ml; 624mg/100ml;
10meq/l; 340mg/100ml; 380mg/100ml; 30meq/l; 65meq/l;
750mg/100ml; 370mg/100ml; 65meq/l; 460mg/100ml;
150mg/100ml; 44mg/100ml; 680mg/100ml
aminosyn ii 8.5%/electrolytes injection 61meq/l;
$0(Nivel 1)
B/D
844mg/100ml; 865mg/100ml; 595mg/100ml; 86meq/l;
627mg/100ml; 425mg/100ml; 255mg/100ml; 561mg/100ml;
850mg/100ml; 893mg/100ml; 10meq/l; 146mg/100ml;
253mg/100ml; 30mmole/l; 66meq/l; 614mg/100ml;
450mg/100ml; 80meq/l; 340mg/100ml; 170mg/100ml;
230mg/100ml; 425mg/100ml
AMINOSYN II INJECTION 107.6MEQ/L; 1490MG/100ML; $0-$6.60(Nivel 2) B/D
1527MG/100ML; 1050MG/100ML; 1107MG/100ML;
750MG/100ML; 450MG/100ML; 990MG/100ML;
1500MG/100ML; 1575MG/100ML; 258MG/100ML;
447MG/100ML; 1083MG/100ML; 795MG/100ML;
50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML;
750MG/100ML
AMINOSYN II INJECTION 50.3MEQ/L; 695MG/100ML; $0-$6.60(Nivel 2) B/D
713MG/100ML; 490MG/100ML; 517MG/100ML;
350MG/100ML; 210MG/100ML; 462MG/100ML;
700MG/100ML; 735MG/100ML; 120MG/100ML;
209MG/100ML; 505MG/100ML; 371MG/100ML;
31.3MEQ/L; 280MG/100ML; 140MG/100ML;
189MG/100ML; 350MG/100ML
AMINOSYN II INJECTION 61.1MEQ/L; 844MG/100ML; $0-$6.60(Nivel 2) B/D
865MG/100ML; 595MG/100ML; 627MG/100ML;
425MG/100ML; 255MG/100ML; 561MG/100ML;
850MG/100ML; 893MG/100ML; 146MG/100ML;
253MG/100ML; 614MG/100ML; 450MG/100ML;
33.3MEQ/L; 340MG/100ML; 170MG/100ML;
230MG/100ML; 425MG/100ML
Página 103 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) B/D
Nombre del medicamento
AMINOSYN II INJECTION 71.8MEQ/L; 993MG/100ML;
1018MG/100ML; 700MG/100ML; 738MG/100ML;
500MG/100ML; 300MG/100ML; 660MG/100ML;
1000MG/100ML; 1050MG/100ML; 172MG/100ML;
298MG/100ML; 722MG/100ML; 530MG/100ML;
45.3MEQ/L; 400MG/100ML; 200MG/100ML;
270MG/100ML; 500MG/100ML
AMINOSYN M INJECTION 65MEQ/L; 448MG/100ML;
$0-$6.60(Nivel 2) B/D
343MG/100ML; 40MEQ/L; 448MG/100ML; 105MG/100ML;
252MG/100ML; 329MG/100ML; 252MG/100ML; 3MEQ/L;
140MG/100ML; 154MG/100ML; 3.5MMOLE/L; 13MEQ/L;
300MG/100ML; 147MG/100ML; 40MEQ/L; 182MG/100ML;
56MG/100ML; 31MG/100ML; 280MG/100ML
AMINOSYN-HBC INJECTION 7.1MEQ/100ML;
$0-$6.60(Nivel 2) B/D
660MG/100ML; 507MG/100ML; 4MEQ/100ML;
660MG/100ML; 154MG/100ML; 789MG/100ML;
1576MG/100ML; 265MG/100ML; 206MG/100ML;
1.12GM/100ML; 228MG/100ML; 448MG/100ML;
221MG/100ML; 272MG/100ML; 88MG/100ML;
33MG/100ML; 789MG/100ML
AMINOSYN-PF 7% INJECTION 32.5MEQ/L;
$0-$6.60(Nivel 2) B/D
490MG/100ML; 861MG/100ML; 370MG/100ML;
576MG/100ML; 270MG/100ML; 220MG/100ML;
534MG/100ML; 831MG/100ML; 475MG/100ML;
125MG/100ML; 10.69GM/L; 300MG/100ML;
570MG/100ML; 70GM/L; 347MG/100ML; 50MG/100ML;
360MG/100ML; 125MG/100ML; 44MG/100ML;
452MG/100ML
AMINOSYN-PF INJECTION 46MEQ/L; 698MG/100ML; $0-$6.60(Nivel 2) B/D
1227MG/100ML; 527MG/100ML; 820MG/100ML;
385MG/100ML; 312MG/100ML; 760MG/100ML;
1200MG/100ML; 677MG/100ML; 180MG/100ML;
427MG/100ML; 812MG/100ML; 495MG/100ML;
3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML;
44MG/100ML; 673MG/100ML
AMINOSYN-RF INJECTION 113MEQ/L; 600MG/100ML; $0-$6.60(Nivel 2) B/D
429MG/100ML; 462MG/100ML; 726MG/100ML;
535MG/100ML; 726MG/100ML; 726MG/100ML;
330MG/100ML; 165MG/100ML; 528MG/100ML
AMMONIUM CHLORIDE INJECTION 5MEQ/ML
$0-$6.60(Nivel 2)
CALCI-CHEW TABLET CHEWABLE 1250MG
$0(Nivel 3)
DP
CALCI-MIX CAPSULE 1250MG
$0(Nivel 3)
DP
calcium & magnesium + zinc tablet 334mg; 134mg; 5mg
$0(Nivel 3)
DP
calcium + d3 tablet 600mg; 200unit
$0(Nivel 3)
DP
calcium carbonate suspension 1250mg/5ml
$0(Nivel 3)
DP
calcium carbonate tablet 1250mg
$0(Nivel 3)
DP
calcium citrate+ d tablet 250mg; 200unit
$0(Nivel 3)
DP
CALCIUM GLUCONATE TABLET 500MG
$0(Nivel 3)
DP
Página 104 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
CALCIUM LACTATE TABLET 648MG
CALTRATE 600+D PLUS MINERALS TABLET
CHEWABLE 600MG; 800UNIT; 1MG; 50MG; 0; 0; 1.8MG;
250MCG; 7.5MG
DP
CALTRATE 600+D PLUS MINERALS TABLET 600MG; $0(Nivel 3)
800UNIT; 1MG; 50MG; 1.8MG; 250MCG; 7.5MG
CALTRATE 600+D TABLET 600MG; 800UNIT
$0(Nivel 3)
DP
caltrate 600 tablet 1500mg
$0(Nivel 3)
DP
$0(Nivel 3)
DP
citrus calcium/vitamin d tablet 200mg; 250unit
CLINIMIX 2.75%/DEXTROSE 5% INJECTION
$0-$6.60(Nivel 2) B/D
24MEQ/1000ML; 570MG/100ML; 316MG/100ML;
11MEQ/1000ML; 5GM/100ML; 283MG/100ML;
132MG/100ML; 165MG/100ML; 201MG/100ML;
159MG/100ML; 110MG/100ML; 154MG/100ML;
187MG/100ML; 138MG/100ML; 116MG/100ML;
50MG/100ML; 11MG/100ML; 160MG/100ML
CLINIMIX 4.25%/DEXTROSE 10% INJECTION 37MEQ/L; $0-$6.60(Nivel 2) B/D
880MG/100ML; 489MG/100ML; 17MEQ/L; 10GM/100ML;
438MG/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 170MG/100ML;
238MG/100ML; 289MG/100ML; 213MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
CLINIMIX 4.25%/DEXTROSE 20% INJECTION 37MEQ/L; $0-$6.60(Nivel 2) B/D
880MG/100ML; 489MG/100ML; 17MEQ/L; 20GM/100ML;
438MG/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 170MG/100ML;
238MG/100ML; 289MG/100ML; 213MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
CLINIMIX 4.25%/DEXTROSE 25% INJECTION 37MEQ/L; $0-$6.60(Nivel 2) B/D
880MG/100ML; 489MG/100ML; 17MEQ/L; 25GM/100ML;
438MG/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 170MG/100ML;
238MG/100ML; 289MG/100ML; 213MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
CLINIMIX 4.25%/DEXTROSE 5% INJECTION 37MEQ/L; $0-$6.60(Nivel 2) B/D
880MG/100ML; 489MG/100ML; 17MEQ/L; 5GM/100ML;
438MG/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 170MG/100ML;
238MG/100ML; 289MG/100ML; 213MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
Página 105 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) B/D
Nombre del medicamento
CLINIMIX 5%/DEXTROSE 15% INJECTION
42MEQ/1000ML; 1035MG/100ML; 575MG/100ML;
20MEQ/1000ML; 15GM/100ML; 515MG/100ML;
240MG/100ML; 300MG/100ML; 365MG/100ML;
290MG/100ML; 200MG/100ML; 280MG/100ML;
340MG/100ML; 250MG/100ML; 210MG/100ML;
90MG/100ML; 20MG/100ML; 290MG/100ML
CLINIMIX 5%/DEXTROSE 20% INJECTION 42MEQ/L; $0-$6.60(Nivel 2) B/D
1035MG/100ML; 575MG/100ML; 20MEQ/L; 20GM/100ML;
515MG/100ML; 240MG/100ML; 300MG/100ML;
365MG/100ML; 290MG/100ML; 200MG/100ML;
280MG/100ML; 340MG/100ML; 250MG/100ML;
210MG/100ML; 90MG/100ML; 20MG/100ML;
290MG/100ML
CLINIMIX 5%/DEXTROSE 25% INJECTION 42MEQ/L; $0-$6.60(Nivel 2) B/D
1035MG/100ML; 575MG/100ML; 20MEQ/L; 25GM/100ML;
515MG/100ML; 240MG/100ML; 300MG/100ML;
365MG/100ML; 290MG/100ML; 200MG/100ML;
280MG/100ML; 340MG/100ML; 250MG/100ML;
210MG/100ML; 90MG/100ML; 20MG/100ML;
290MG/100ML
CLINIMIX E 2.75%/DEXTROSE 10% INJECTION
$0-$6.60(Nivel 2) B/D
570MG/100ML; 316MG/100ML; 33MG/100ML;
10GM/100ML; 132MG/100ML; 165MG/100ML;
201MG/100ML; 159MG/100ML; 51MG/100ML;
110MG/100ML; 454MG/100ML; 154MG/100ML;
261MG/100ML; 187MG/100ML; 138MG/100ML;
217MG/100ML; 112MG/100ML; 116MG/100ML;
50MG/100ML; 11MG/100ML; 160MG/100ML
CLINIMIX E 2.75%/DEXTROSE 5% INJECTION
$0-$6.60(Nivel 2) B/D
570MG/100ML; 316MG/100ML; 33MG/100ML;
5GM/100ML; 132MG/100ML; 165MG/100ML;
201MG/100ML; 159MG/100ML; 51MG/100ML;
110MG/100ML; 454MG/100ML; 154MG/100ML;
261MG/100ML; 187MG/100ML; 138MG/100ML;
217MG/100ML; 112MG/100ML; 116MG/100ML;
50MG/100ML; 11MG/100ML; 160MG/100ML
CLINIMIX E 4.25%/DEXTROSE 10% INJECTION
$0-$6.60(Nivel 2) B/D
880MG/100ML; 489MG/100ML; 33MG/100ML;
10GM/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 51MG/100ML;
170MG/100ML; 702MG/100ML; 238MG/100ML;
261MG/100ML; 289MG/100ML; 213MG/100ML;
297MG/100ML; 77MG/100ML; 179MG/100ML;
77MG/100ML; 17MG/100ML; 247MG/100ML
Página 106 de 143
Nombre del medicamento
CLINIMIX E 4.25%/DEXTROSE 25% INJECTION
880MG/100ML; 489MG/100ML; 33MG/100ML;
25GM/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 51MG/100ML;
170MG/100ML; 702MG/100ML; 238MG/100ML;
261MG/100ML; 289MG/100ML; 213MG/100ML;
297MG/100ML; 77MG/100ML; 179MG/100ML;
77MG/100ML; 17MG/100ML; 247MG/100ML
CLINIMIX E 4.25%/DEXTROSE 5% INJECTION
880MG/100ML; 489MG/100ML; 33MG/100ML;
5GM/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 51MG/100ML;
170MG/100ML; 702MG/100ML; 238MG/100ML;
261MG/100ML; 289MG/100ML; 213MG/100ML;
297MG/100ML; 77MG/100ML; 179MG/100ML;
77MG/100ML; 17MG/100ML; 247MG/100ML
CLINIMIX E 5%/DEXTROSE 15% INJECTION
1035MG/100ML; 575MG/100ML; 33MG/100ML;
15GM/100ML; 240MG/100ML; 300MG/100ML;
365MG/100ML; 290MG/100ML; 51MG/100ML;
200MG/100ML; 826MG/100ML; 280MG/100ML;
261MG/100ML; 340MG/100ML; 250MG/100ML;
340MG/100ML; 59MG/100ML; 210MG/100ML;
90MG/100ML; 20MG/100ML; 290MG/100ML
CLINIMIX E 5%/DEXTROSE 20% INJECTION
1035MG/100ML; 575MG/100ML; 33MG/100ML;
20GM/100ML; 240MG/100ML; 300MG/100ML;
365MG/100ML; 290MG/100ML; 51MG/100ML;
200MG/100ML; 826MG/100ML; 280MG/100ML;
261MG/100ML; 340MG/100ML; 250MG/100ML;
340MG/100ML; 59MG/100ML; 210MG/100ML;
90MG/100ML; 20MG/100ML; 290MG/100ML
CLINIMIX E 5%/DEXTROSE 25% INJECTION
1035MG/100ML; 575MG/100ML; 33MG/100ML;
25GM/100ML; 240MG/100ML; 300MG/100ML;
365MG/100ML; 290MG/100ML; 51MG/100ML;
200MG/100ML; 826MG/100ML; 280MG/100ML;
261MG/100ML; 340MG/100ML; 250MG/100ML;
340MG/100ML; 59MG/100ML; 210MG/100ML;
90MG/100ML; 20MG/100ML; 290MG/100ML
cvs electrolyte solution solution 35meq/l; 30meq/l; 20gm/l;
5gm/l; 20meq/l; 45meq/l
cvs iron tablet 325mg
cvs iron tablet 325mg
dexferrum injection 50mg/ml
DEXTROSE 10%/NACL 0.45% INJECTION 10%; 0.45%
dextrose 10% flex container injection 10%
DEXTROSE 10%/NACL 0.2% INJECTION 10%; 0.2%
Página 107 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
dextrose 2.5%/sodium chloride 0.45% injection 2.5%; 0.45% $0(Nivel 1)
dextrose 5%/nacl 0.2% injection 5%; 0.2%
$0(Nivel 1)
DEXTROSE 5%/NACL 0.225% INJECTION 5%; 0.225% $0-$6.60(Nivel 2)
$0(Nivel 1)
dextrose 5%/nacl 0.33% injection 5%; 0.33%
dextrose 5%/nacl 0.45% injection 5%; 0.45%
$0(Nivel 1)
dextrose 5%/nacl 0.9% injection 5%; 0.9%
$0(Nivel 1)
dextrose 5%/potassium chloride 0.15% injection 5%; 20meq/l $0(Nivel 1)
dextrose 5% injection 5%
$0(Nivel 1)
eql iron supplement therapy tablet 200mg
$0(Nivel 3)
DP
eql iron supplement therapy tablet 325mg
$0(Nivel 3)
DP
FEOSOL TABLET 200MG
$0(Nivel 3)
DP
FEOSOL TABLET 45MG
$0(Nivel 3)
DP
fer-iron solution 15mg/ml
$0(Nivel 3)
DP
FERATE TABLET 256MG
$0(Nivel 3)
DP
ferosul elixir 220mg/5ml
$0(Nivel 3)
DP
ferretts tablet 325mg
$0(Nivel 3)
DP
FERROUS FUMARATE TABLET 90MG
$0(Nivel 3)
DP
FERROUS GLUCONATE TABLET 324MG
$0(Nivel 3)
DP
ferrous gluconate tablet 324mg
$0(Nivel 3)
DP
ferrous sulfate elixir 220mg/5ml
$0(Nivel 3)
DP
ferrous sulfate elixir 220mg/5ml
$0(Nivel 3)
DP
ferrous sulfate elixir 220mg/5ml
$0(Nivel 3)
DP
FERROUS SULFATE LIQUID 220MG/5ML
$0(Nivel 3)
DP
$0(Nivel 3)
DP
FERROUS SULFATE SYRUP 300MG/5ML
FERROUS SULFATE TABLET DELAYED RELEASE
$0(Nivel 3)
DP
324MG
FERROUS SULFATE TABLET DELAYED RELEASE
$0(Nivel 3)
DP
324MG
FERROUS SULFATE TABLET DELAYED RELEASE
$0(Nivel 3)
DP
324MG
ferrous sulfate tablet delayed release 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet delayed release 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet delayed release 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
$0(Nivel 3)
DP
ferrous sulfate tablet 325mg
Página 108 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2) B/D
Nombre del medicamento
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
ferrous sulfate tablet 325mg
FREAMINE HBC 6.9% INJECTION 59.3MEQ/L;
400MG/100ML; 580MG/100ML; 3MEQ/L; 14MG/100ML;
330MG/100ML; 160MG/100ML; 760MG/100ML;
1370MG/100ML; 410MG/100ML; 250MG/100ML;
320MG/100ML; 630MG/100ML; 330MG/100ML; 10MEQ/L;
200MG/100ML; 90MG/100ML; 880MG/100ML
GALZIN CAPSULE 25MG
$0(Nivel 3)
DP
GALZIN CAPSULE 50MG
$0(Nivel 3)
DP
gnp iron tablet 200mg
$0(Nivel 3)
DP
gnp pediatric electrolyte solution 35meq/l; 20gm/l; 5gm/l;
$0(Nivel 3)
DP
20meq/l; 45meq/l
gnp pediatric electrolyte solution 35meq/l; 20gm/l; 5gm/l;
$0(Nivel 3)
DP
20meq/l; 45meq/l
gnp pediatric electrolyte solution 35meq/l; 25gm/l; 20meq/l; $0(Nivel 3)
DP
45meq/l
hepatamine injection 62meq/l; 770mg/100ml; 600mg/100ml; $0(Nivel 1)
B/D
3meq/l; 20mg/100ml; 900mg/100ml; 240mg/100ml;
900mg/100ml; 1100mg/100ml; 610mg/100ml; 100mg/100ml;
100mg/100ml; 115mg/100ml; 800mg/100ml; 500mg/100ml;
100mg/100ml; 450mg/100ml; 66mg/100ml; 840mg/100ml
IONOSOL-B/DEXTROSE 5% INJECTION 49MEQ/L; 5%; $0-$6.60(Nivel 2)
25MEQ/L; 5MEQ/L; 13MEQ/L; 25MEQ/L; 57MEQ/L
IONOSOL-MB/DEXTROSE 5% INJECTION 22MEQ/L;
$0-$6.60(Nivel 2)
5%; 23MEQ/L; 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L
ISOLYTE-P/DEXTROSE 5% INJECTION 23MEQ/L;
$0-$6.60(Nivel 2)
23MEQ/L; 5%; 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L
ISOLYTE-S INJECTION 27MEQ/L; 98MEQ/L; 23MEQ/L; $0-$6.60(Nivel 2)
3MEQ/L; 5MEQ/L; 140MEQ/L
kcl 0.075%/d5w/nacl 0.45% injection 5%; 10meq/l; 0.45%
$0(Nivel 1)
KCL 0.15%/D5W/LR INJECTION 3MEQ/L; 149MEQ/L;
$0-$6.60(Nivel 2)
5%; 28MEQ/L; 24MEQ/L; 130MEQ/L
kcl 0.15%/d5w/nacl 0.2% injection 5%; 20meq/l; 0.2%
$0(Nivel 1)
KCL 0.15%/D5W/NACL 0.225% INJECTION 5%;
$0-$6.60(Nivel 2)
20MEQ/L; 0.225%
kcl 0.15%/d5w/nacl 0.9% injection 5%; 20meq/l; 0.9%
$0(Nivel 1)
Página 109 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0-$6.60(Nivel 2)
Nombre del medicamento
kcl 0.3%/d5w/nacl 0.45% injection 5%; 40meq/l; 0.45%
KCL 0.3%/D5W/NACL 0.9% INJECTION 5%; 40MEQ/L;
0.9%
klor-con 10 tablet extended release 10meq
$0(Nivel 1)
klor-con 8 tablet extended release 8meq
$0(Nivel 1)
klor-con m10 tablet extended release 10meq
$0(Nivel 1)
klor-con m10 tablet extended release 10meq
$0(Nivel 1)
klor-con m15 tablet extended release 15meq
$0(Nivel 1)
klor-con m20 tablet extended release 20meq
$0(Nivel 1)
kp ferrous sulfate tablet 325mg
$0(Nivel 3)
DP
lactated ringers dextrose 5% viaflex injection 2.7meq/l;
$0(Nivel 1)
109meq/l; 5%; 28meq/l; 4meq/l; 130meq/l
lactated ringers viaflex injection 3meq/l; 109meq/l; 28meq/l; $0(Nivel 1)
4meq/l; 130meq/l
mag-delay tablet extended release 64mg
$0(Nivel 3)
DP
magnesium gluconate tablet 500mg
$0(Nivel 3)
DP
magnesium sulfate injection 50%
$0(Nivel 1)
magnesium sulfate injection 50%
$0(Nivel 1)
MAGONATE LIQUID 1000MG/5ML
$0(Nivel 3)
DP
magonate tablet 500mg
$0(Nivel 3)
DP
MOZOBIL INJECTION 24MG/1.2ML
$0-$6.60(Nivel 2) PA (Mozobil)
$0-$6.60(Nivel 2) B/D
NEPHRAMINE INJECTION 44MEQ/L; 20MG/100ML;
250MG/100ML; 560MG/100ML; 880MG/100ML;
640MG/100ML; 880MG/100ML; 880MG/100ML; 6MEQ/L;
400MG/100ML; 200MG/100ML; 640MG/100ML
normosol-m in d5w injection 16meq/l; 40meq/l; 5%; 3meq/l; $0(Nivel 1)
13meq/l; 40meq/l
NORMOSOL-R IN D5W INJECTION 27MEQ/L; 98MEQ/L; $0-$6.60(Nivel 2)
5%; 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L
$0-$6.60(Nivel 2)
NORMOSOL-R INJECTION 27MEQ/L; 98MEQ/L;
23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L
nu-iron 150 capsule 150mg
$0(Nivel 3)
DP
oralyte solution 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l $0(Nivel 3)
DP
oralyte solution 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l $0(Nivel 3)
DP
oralyte solution 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l $0(Nivel 3)
DP
oralyte solution 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l $0(Nivel 3)
DP
os-cal calcium + d3 tablet 500mg; 200unit
$0(Nivel 3)
DP
oysco d tablet 250mg; 125unit; 0
$0(Nivel 3)
DP
oyster shell/vitamin d tablet 600mg; 125unit
$0(Nivel 3)
DP
PEDIALYTE SOLUTION 35MEQ/L; 20GM/L; 5GM/L;
$0(Nivel 3)
DP
20MEQ/L; 45MEQ/L
PEDIALYTE SOLUTION 35MEQ/L; 30MEQ/L; 25GM/L; $0(Nivel 3)
DP
20MEQ/L; 45MEQ/L
PEDIALYTE SOLUTION 35MEQ/L; 30MEQ/L; 25GM/L; $0(Nivel 3)
DP
20MEQ/L; 45MEQ/L
PEDIALYTE SOLUTION 35MEQ/L; 30MEQ/L; 25GM/L; $0(Nivel 3)
DP
20MEQ/L; 45MEQ/L
Página 110 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
Nombre del medicamento
PEDIALYTE SOLUTION 35MEQ/L; 30MEQ/L; 25GM/L;
20MEQ/L; 45MEQ/L
PEDIALYTE SOLUTION 35MEQ/L; 30MEQ/L; 25GM/L; $0(Nivel 3)
DP
20MEQ/L; 45MEQ/L
DP
PEDIALYTE SOLUTION 35MEQ/L; 30MEQ/L; 25GM/L; $0(Nivel 3)
20MEQ/L; 45MEQ/L
pediatric electrolyte solution 35meq/l; 20gm/l; 20meq/l;
$0(Nivel 3)
DP
45meq/l
pediatric electrolyte solution 35meq/l; 20gm/l; 5gm/l;
$0(Nivel 3)
DP
20meq/l; 45meq/l
pediatric electrolyte solution 35meq/l; 30meq/l; 25gm/l;
$0(Nivel 3)
DP
20meq/l; 45meq/l
pediatric electrolyte solution 35meq/l; 30meq/l; 25gm/l;
$0(Nivel 3)
DP
20meq/l; 45meq/l
DP
PHOS-NAK POWDER CONCENTRATE PACKET 250MG; $0(Nivel 3)
280MG; 160MG
PLASMA-LYTE A INJECTION 27MEQ/L; 98MEQ/L;
$0-$6.60(Nivel 2)
23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L
PLASMA-LYTE-148 INJECTION 27MEQ/L; 98MEQ/L;
$0-$6.60(Nivel 2)
23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L
PLASMA-LYTE-56/D5W INJECTION 16MEQ/L;
$0-$6.60(Nivel 2)
40MEQ/L; 5%; 3MEQ/L; 13MEQ/L; 40MEQ/L
potassium chloride 0.15% /nacl 0.45% viaflex injection
$0(Nivel 1)
20meq/l; 0.45%
potassium chloride 0.15% d5w/nacl 0.33% injection 5%;
$0(Nivel 1)
20meq/l; 0.33%
potassium chloride 0.15% d5w/nacl 0.45% injection 5%;
$0(Nivel 1)
20meq/l; 0.45%
potassium chloride 0.15%/nacl 0.9% injection 20meq/l; 0.9% $0(Nivel 1)
potassium chloride 0.22% d5w/nacl 0.45% injection 5%;
$0(Nivel 1)
30meq/l; 0.45%
POTASSIUM CHLORIDE 0.3%/ NACL 0.9% INJECTION $0-$6.60(Nivel 2)
40MEQ/L; 0.9%
potassium chloride 0.3%/d5w injection 5%; 40meq/l
$0(Nivel 1)
potassium chloride er capsule extended release 10meq
$0(Nivel 1)
potassium chloride er capsule extended release 8meq
$0(Nivel 1)
potassium chloride er tablet extended release 10meq
$0(Nivel 1)
potassium chloride er tablet extended release 20meq
$0(Nivel 1)
potassium chloride er tablet extended release 8meq
$0(Nivel 1)
MO
potassium chloride sr tablet extended release 8meq
$0(Nivel 1)
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML
$0-$6.60(Nivel 2)
POTASSIUM CHLORIDE INJECTION 20MEQ/100ML
$0-$6.60(Nivel 2)
potassium chloride injection 2meq/ml
$0(Nivel 1)
POTASSIUM CHLORIDE INJECTION 30MEQ/100ML
$0-$6.60(Nivel 2)
POTASSIUM CHLORIDE INJECTION 40MEQ/100ML
$0-$6.60(Nivel 2)
potassium chloride liquid 10%
$0(Nivel 1)
MO
potassium chloride liquid 20%
$0(Nivel 1)
MO
potassium citrate er tablet extended release 1080mg
$0(Nivel 1)
Página 111 de 143
Nombre del medicamento
potassium citrate er tablet extended release 15meq
potassium citrate er tablet extended release 540mg
PREMASOL INJECTION 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
premasol injection 56meq/l; 320mg/100ml; 730mg/100ml;
190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml;
490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml;
230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml;
120mg/100ml; 140mg/100ml; 470mg/100ml
PROCALAMINE INJECTION 47MEQ/L; 210MG/100ML;
290MG/100ML; 3MEQ/L; 41MEQ/L; 20MG/100ML;
420MG/100ML; 85MG/100ML; 210MG/100ML;
270MG/100ML; 220MG/100ML; 5MEQ/L; 160MG/100ML;
170MG/100ML; 7MMOLE/L; 24MEQ/L; 340MG/100ML;
180MG/100ML; 35MEQ/L; 120MG/100ML; 46MG/100ML;
200MG/100ML
PROSOL INJECTION 2.76GM/100ML; 1.96GM/100ML;
600MG/100ML; 1.02GM/100ML; 2.06GM/100ML;
1.18GM/100ML; 1.08GM/100ML; 1.08GM/100ML;
1.35GM/100ML; 760MG/100ML; 1GM/100ML;
1.34GM/100ML; 1.02GM/100ML; 980MG/100ML;
320MG/100ML; 50MG/100ML; 1.44GM/100ML
px iron tablet 200mg
ringers injection injection 4.5meq/l; 156meq/l; 4meq/l;
147meq/l
SELENIUM TABLET EXTENDED RELEASE 200MCG
SLOW FE TABLET EXTENDED RELEASE 160MG
sm pediatric electrolyte solution 35meq/l; 30meq/l; 25gm/l;
20meq/l; 45meq/l
sm pediatric electrolyte solution 35meq/l; 30meq/l; 25gm/l;
20meq/l; 45meq/l
sodium chloride 0.45% viaflex injection 0.45%
sodium chloride 0.9% solution 0.9%
sodium chloride injection 0.9%
sodium chloride injection 2.5meq/ml
sodium chloride injection 3%
sodium chloride injection 5%
sodium fluoride tablet 1mg
TANDEM CAPSULE 162MG; 115.2MG
tpn electrolytes injection 29.5meq/20ml; 4.5meq/20ml;
35meq/20ml; 5meq/20ml; 20meq/20ml; 35meq/20ml
Página 112 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
MO
$0(Nivel 1)
$0-$6.60(Nivel 2) B/D
$0(Nivel 1)
B/D
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2) B/D
$0(Nivel 3)
$0(Nivel 1)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 1)
DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) B/D
Nombre del medicamento
TRAVASOL INJECTION 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
TROPHAMINE INJECTION 0; 0.32GM/100ML;
$0-$6.60(Nivel 2) B/D
0.73GM/100ML; 0.19GM/100ML; 0.014GM/100ML;
0.22GM/100ML; 0.29GM/100ML; 0.49GM/100ML;
0.3GM/100ML; 0.84GM/100ML; 0.49GM/100ML;
0.2GM/100ML; 0.29GM/100ML; 0.41GM/100ML;
0.23GM/100ML; 0.05GM/100ML; 0.015GM/100ML;
0.25GM/100ML; 0.12GM/100ML; 0.14GM/100ML;
0.47GM/100ML
TROPHAMINE INJECTION 97MEQ/L; 0.54GM/100ML; $0-$6.60(Nivel 2) B/D
1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML;
0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML;
1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML;
0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML;
5MEQ/L; 0.025GM/100ML; 0.42GM/100ML;
0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML
UROCIT-K 10 TABLET EXTENDED RELEASE 1080MG $0-$6.60(Nivel 2)
UROCIT-K 15 TABLET EXTENDED RELEASE 15MEQ $0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
UROCIT-K 5 TABLET EXTENDED RELEASE 540MG
VENOFER INJECTION 20MG/ML
$0(Nivel 3)
DP
VENOFER INJECTION 20MG/ML
$0(Nivel 3)
DP
VENOFER INJECTION 20MG/ML
$0(Nivel 3)
DP
zinc sulfate tablet 220mg
$0(Nivel 3)
DP
zinc tablet 50mg
$0(Nivel 3)
DP
Vitamins
acerola c-500 tablet chewable 500mg
$0(Nivel 3)
DP
ADVANCED AM/PM MISCELLANEOUS 0; 0; 0; 0; 0; 0; 0; $0(Nivel 3)
DP
10MG; 100MG; 650MG; 0; 50UNIT
AQUADEKS CAPSULE 10MG; 100MCG; 12MG;
$0(Nivel 3)
DP
800UNIT; 10MG; 12MCG; 200MCG; 10MG; 700MCG;
1.9MG; 1.7MG; 75MCG; 75MG; 1.5MG; 150UNIT;
18167UNIT; 80MG; 10MG
aquadeks liquid 45mg/ml; 3mg/ml; 15mcg/ml; 3mg/ml;
$0(Nivel 3)
DP
400unit/ml; 2mg/ml; 6mg/ml; 400mcg/ml; 0.6mg/ml;
0.6mg/ml; 10mcg/ml; 0.6mg/ml; 50unit/ml; 5751unit/ml;
15mg/ml; 5mg/ml
AQUASOL A PARENTERAL INJECTION 50000UNIT/ML $0(Nivel 3)
DP
aqueous vitamin e solution 15unit/0.3ml
$0(Nivel 3)
DP
b complex capsule 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg;
$0(Nivel 3)
DP
3mg; 60mg
b-100 tr tablet extended release 100mcg; 100mg; 100mcg;
$0(Nivel 3)
DP
400mcg; 100mg; 100mg; 100mg; 100mg
Página 113 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
Nombre del medicamento
b-complex/c tablet 500mg; 50mcg; 50mg; 50mcg; 400mcg;
50mg; 50mg; 50mg; 50mg
balanced b-100 tablet 100mcg; 100mg; 100mcg; 100mcg;
$0(Nivel 3)
100mg; 100mg; 100mg; 100mg; 100mg; 100mg; 100mg
balanced b-50 tablet 50mcg; 50mg; 50mcg; 100mcg; 50mg; $0(Nivel 3)
50mg; 50mg; 50mg; 50mg; 50mg; 50mg
beta carotene capsule 25000unit
$0(Nivel 3)
biotin tablet 300mcg
$0(Nivel 3)
c-500 tablet chewable 500mg; 0
$0(Nivel 3)
CENTRUM SILVER TABLET CHEWABLE 75MG; 0;
$0(Nivel 3)
45MCG; 200MG; 10MG; 400UNIT; 100MCG; 2MG;
25MCG; 500MCG; 250MCG; 50MG; 4.5MG; 12MG; 5MCG;
125MG; 100MCG; 7MG; 2.7MG; 4MG; 10MCG; 25MCG;
22.5MCG; 10MCG; 2.2MG; 70UNIT; 4000UNIT; 15MG
CENTRUM SILVER TABLET 60MG; 0; 30MCG; 150MCG; $0(Nivel 3)
200MG; 10MG; 72MG; 150MCG; 2MG; 25MCG; 400UNIT;
400MCG; 250MCG; 300MCG; 100MG; 2MG; 20MG;
5MCG; 48MG; 10MCG; 80MG; 150MCG; 3MG; 1.7MG;
2MG; 10MCG; 75MCG; 20MCG; 1.5MG; 45UNIT;
3500UNIT; 15MG
CENTRUM SILVER TABLET 60MG; 0; 30MCG; 220MG; $0(Nivel 3)
10MG; 72MG; 500UNIT; 45MCG; 0.5MG; 25MCG;
400MCG; 0; 0; 50MG; 2.3MG; 20MG; 5MCG; 20MG;
30MCG; 80MG; 150MCG; 3MG; 1.7MG; 2MG; 150MCG;
10MCG; 45MCG; 55MCG; 1.5MG; 50UNIT; 2500UNIT;
11MG
cerovite advanced formula liquid 60mg/15ml; 300mcg/15ml; $0(Nivel 3)
10mg/15ml; 25mcg/15ml; 6mcg/15ml; 9mg/15ml; 2mg/15ml;
20mg/15ml; 150mcg/15ml; 2mg/15ml; 1.7mg/15ml;
25mcg/15ml; 1.5mg/15ml; 30unit/15ml; 3mg/15ml
cerovite advanced formula tablet 60mg; 0; 0; 30mcg; 75mcg; $0(Nivel 3)
200mg; 10mg; 72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg;
400mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 25mcg; 80mg;
150mcg; 2mg; 1.7mg; 2mg; 0; 10mcg; 45mcg; 55mcg;
10mcg; 1.5mg; 30unit; 3500unit; 11mg
cerovite jr tablet chewable 60mg; 0; 45mcg; 108mg; 10mg; $0(Nivel 3)
400unit; 20mcg; 2mg; 6mcg; 18mg; 400mcg; 40mg; 1mg;
20mg; 50mg; 10mcg; 150mcg; 2mg; 1.7mg; 0; 20mcg; 1.5mg;
30unit; 3500unit; 15mg
cod liver oil capsule 0; 1250unit; 130unit
$0(Nivel 3)
compete tablet 90mg; 9mcg; 0.4mg; 27mg; 30mg; 20.6mg;
$0(Nivel 3)
2.6mg; 2mg; 5000unit; 400unit; 45unit; 22.5mg
corvita tablet 375mg; 750unit; 75mcg; 315unit; 150mcg;
$0(Nivel 3)
1mg; 70mcg; 125unit; 1.25mg; 13mg; 10mg; 7mg; 2.5mg;
35mg; 35mg; 5mg; 35mg; 3.4mg; 125mcg; 25mg; 35mg
cyanocobalamin injection 1000mcg/ml
$0(Nivel 3)
d 10000 capsule 10000unit
$0(Nivel 3)
Página 114 de 143
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
daily-vite/iron/beta-carotene tablet 60mg; 0; 10mg; 400unit; $0(Nivel 3)
DP
6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit;
5000unit
DRISDOL SOLUTION 8000UNIT/ML
$0(Nivel 3)
DP
DP
ear health formula tablet 100mg; 1.67mg; 29mg; 111.33mg; $0(Nivel 3)
1.67mcg; 111.33mg; 200mg; 3.33mg; 0.33mg; 1mg; 0.33mg
ELDERTONIC ELIXIR 13.5%; 2MCG/15ML; 3MG/15ML; $0(Nivel 3)
DP
0; 0.7MG/15ML; 7MG/15ML; 0.7MG/15ML; 0.6MG/15ML;
0.5MG/15ML; 5MG/15ML
FOLIC ACID INJECTION 5MG/ML
$0(Nivel 3)
DP
$0(Nivel 3)
DP
folic acid tablet 400mcg
folic acid tablet 800mcg
$0(Nivel 3)
DP
FOSFREE TABLET 50MG; 300MG; 2MG; 14.5MG; 10MG; $0(Nivel 3)
DP
1MG; 3MG; 2MG; 5MG; 1500UNIT; 200UNIT
geravim liquid 100mg/30ml; 1mcg/30ml; 15mg/30ml;
$0(Nivel 3)
DP
2mg/30ml; 2mg/30ml; 50mg/30ml; 10mg/30ml; 100mcg/30ml;
1mg/30ml; 2.5mg/30ml; 5mg/30ml; 2mg/30ml
gnp one daily mens health/lycopene tablet 90mg; 0; 30mcg; $0(Nivel 3)
DP
210mg; 5mg; 400unit; 120mcg; 2mg; 18mcg; 400mcg;
600mcg; 120mg; 2mg; 16mg; 20mcg; 100mg; 3mg; 1.7mg;
105mcg; 1.2mg; 45unit; 3500unit; 15mg
gnp therapeutic-m tablet 90mg; 0; 30mcg; 150mcg; 40mg;
$0(Nivel 3)
DP
10mg; 7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg; 400mcg;
100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg; 150mcg;
6mg; 3.4mg; 2mg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg;
60unit; 5000unit; 15mg
HYDROXOCOBALAMIN INJECTION 1000MCG/ML
$0(Nivel 3)
DP
i-vite tablet 200mg; 1000unit; 2mg; 2mg; 55mcg; 60unit;
$0(Nivel 3)
DP
40mg
ICAPS AREDS FORMULA TABLET 113MG; 7160UNIT; $0(Nivel 3)
DP
33MG; 0.4MG; 100UNIT; 17.4MG
ICAPS PLUS TABLET 200MG; 6000UNIT; 2MG; 5MG;
$0(Nivel 3)
DP
20MG; 20MCG; 60UNIT; 40MG
kids vitamins complete tablet chewable 60mg; 0; 40mcg;
$0(Nivel 3)
DP
130mg; 10mg; 2mg; 6mcg; 400unit; 18mg; 400mcg; 20mg;
13.5mg; 100mg; 150mcg; 2mg; 1.7mg; 0; 1.5mg; 30unit;
5000unit; 15mg
MULTI-DELYN/IRON LIQUID 60MG/5ML; 4.5MCG/5ML; $0(Nivel 3)
DP
10MG/5ML; 13.5MG/5ML; 1.05MG/5ML; 1.2MG/5ML;
1.05MG/5ML; 15UNIT/5ML; 2500UNIT/5ML;
400UNIT/5ML
multilex-t&m tablet 150mg; 10mg; 400unit; 1mg; 7.5mcg;
$0(Nivel 3)
DP
15mg; 5mg; 1mg; 100mg; 0.15mg; 2mg; 10mg; 15mg;
5.5unit; 10000unit; 1.5mg
multiple vitamin tablet 60mg; 6mcg; 400unit; 0.4mg; 20mg; $0(Nivel 3)
DP
2mg; 1.7mg; 1.5mg; 5000unit; 15unit
natural mixed tocopherols capsule 1000unit
$0(Nivel 3)
DP
natural mixed tocopherols capsule 400unit
$0(Nivel 3)
DP
Página 115 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
Nombre del medicamento
NEPHRO-VITE TABLET 60MG; 300MCG; 6MCG;
800MCG; 20MG; 10MG; 10MG; 1.7MG; 1.5MG
niacin er capsule extended release 250mg
$0(Nivel 3)
DP
$0(Nivel 3)
DP
NIACIN TR TABLET EXTENDED RELEASE 1000MG
niacin tr tablet extended release 750mg
$0(Nivel 3)
DP
DP
niacinamide tablet 100mg
$0(Nivel 3)
niacinamide tablet 500mg
$0(Nivel 3)
DP
DP
ocuvite extra tablet 200mg; 0; 2mg; 5mg; 5mg; 40mg; 3mg; $0(Nivel 3)
40mcg; 50unit; 6000unit; 40mg
ONCOVITE TABLET 500MG; 10000UNIT; 100UNIT;
$0(Nivel 3)
DP
1.5MCG; 0.1MG; 5MG; 2.5MG; 25MG; 0.425MG; 0.368MG;
8000UNIT; 100UNIT; 22.5MG
one daily for women tablet 60mg; 0; 30mcg; 450mg; 5mg;
$0(Nivel 3)
DP
1000unit; 120mcg; 2mg; 6mcg; 18mg; 400mcg; 50mg; 2mg;
10mg; 25mcg; 2mg; 1.7mg; 20mcg; 1.5mg; 30unit; 2500unit;
15mg
ONE-A-DAY WOMENS FORMULA TABLET 60MG; 0; $0(Nivel 3)
DP
30MCG; 450MG; 5MG; 800UNIT; 120MCG; 2MG; 6MCG;
18MG; 400MCG; 50MG; 2MG; 10MG; 25MCG; 2MG;
1.7MG; 20MCG; 1.5MG; 2500UNIT; 30UNIT; 15MG
POLY-VI-SOL/IRON SOLUTION 35MG/ML; 10MG/ML; $0(Nivel 3)
DP
8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.5MG/ML;
1500UNIT/ML; 400UNIT/ML; 5UNIT/ML
POLY-VI-SOL SOLUTION 35MG/ML; 2MCG/ML;
$0(Nivel 3)
DP
8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.5MG/ML;
1500UNIT/ML; 400UNIT/ML; 5UNIT/ML
PRENAPLUS TABLET 120MG; 0; 200MG; 400UNIT;
$0-$6.60(Nivel 2)
2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG;
22MG; 4000UNIT; 25MG
QL (30 EA cada 30 días)
prenatabs rx tablet 120mg; 4000unit; 30mcg; 200mg; 7mg; $0(Nivel 1)
400unit; 3mg; 8mcg; 1mg; 29mg; 100mg; 20mg; 150mcg;
3mg; 3mg; 0; 3mg; 30unit; 15mg
$0(Nivel 1)
QL (30 EA cada 30 días)
prenatal plus iron tablet 120mg; 0; 200mg; 400unit; 2mg;
12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22mg;
4000unit; 25mg
prenatal plus iron tablet 120mg; 0; 200mg; 400unit; 2mg;
$0(Nivel 1)
QL (30 EA cada 30 días)
12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22unit;
4000unit; 25mg
prenatal plus iron tablet 120mg; 0; 200mg; 400unit; 2mg;
$0(Nivel 1)
QL (30 EA cada 30 días)
12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22unit;
4000unit; 25mg
prenatal plus iron tablet 120mg; 0; 200mg; 400unit; 2mg;
$0(Nivel 1)
QL (30 EA cada 30 días)
12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22unit;
4000unit; 25mg
prosight tablet 60mg; 2mg; 40mcg; 5000unit; 30mg; 40mg
$0(Nivel 3)
DP
PYRIDOXINE HCL INJECTION 100MG/ML
$0(Nivel 3)
DP
ra vitamin e capsule 1000unit
$0(Nivel 3)
DP
slo-niacin tablet extended release 250mg
$0(Nivel 3)
DP
Página 116 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
sm ballanced b-100 tablet 100mcg; 100mg; 10mcg; 400mcg; $0(Nivel 3)
DP
100mg; 100mg; 100mg; 100mg
sm complete advanced formula tablet 60mg; 0; 30mcg;
$0(Nivel 3)
DP
162mg; 10mg; 72mg; 120mcg; 2mg; 6mcg; 400unit; 18mg;
400mcg; 150mcg; 250mcg; 300mcg; 100mg; 2mg; 20mg;
5mcg; 109mg; 80mg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg;
75mcg; 20mcg; 10mcg; 1.5mg; 3500unit; 30unit; 25mcg;
15mg
DP
sm complete senior formula tablet 60mg; 0; 30mcg; 150mcg; $0(Nivel 3)
200mg; 72mg; 130mcg; 2mg; 25mcg; 400mcg; 150mcg; 4mg;
100mg; 3.5mg; 160mcg; 20mg; 5mcg; 10mg; 46mg; 60mg;
3mg; 1.7mg; 20mcg; 2mg; 15mg; 10mcg; 5000unit; 400unit;
45unit; 10mcg; 15mg
sm pain reliever pm extra strength tablet 500mg; 25mg
$0(Nivel 3)
DP
$0(Nivel 3)
DP
THERA M PLUS TABLET 90MG; 0; 30MCG; 30MG;
10MG; 50MCG; 2MG; 12MCG; 400UNIT; 9MG; 400MCG;
100MG; 2MG; 20MG; 5MCG; 23MG; 28MCG; 7MG;
150MCG; 6MG; 3.4MG; 6MG; 150MCG; 10MCG; 75MCG;
70MCG; 10MCG; 3MG; 60UNIT; 5000UNIT; 15MG
$0(Nivel 3)
DP
THERA-M TABLET 90MG; 0; 30MCG; 30MG; 10MG;
50MCG; 2MG; 12MCG; 400UNIT; 9MG; 400MCG; 100MG;
2MG; 20MG; 5MCG; 23MG; 28MCG; 7.5MG; 7MG;
150MCG; 6MG; 3.4MG; 6MG; 150MCG; 10MCG; 75MCG;
70MCG; 10MCG; 3MG; 60UNIT; 5000UNIT; 15MG
therapeutic formula/hematinics tablet 11.7mg; 0.67mg;
$0(Nivel 3)
DP
50mcg; 66.7mg; 0.33mg; 41.7mg; 33.3mg; 3.3mg; 3.3mg;
100mg; 3.3mg; 5unit; 1400unit; 140unit
$0(Nivel 3)
DP
THEREMS-M TABLET 90MG; 0; 0; 30MCG; 40MG;
10MG; 2MG; 7.5MG; 400UNIT; 50MCG; 2MG; 12MCG;
9MG; 400MCG; 100MG; 2MG; 20MG; 5MCG; 31MG;
28MCG; 7.5MG; 150MCG; 6MG; 3.4MG; 0; 150MCG;
10MCG; 75MCG; 70MCG; 10MCG; 3MG; 60UNIT;
5000UNIT; 15MG
thiamine hcl injection 100mg/ml
$0(Nivel 3)
DP
VINATE ONE TABLET 80MG; 0; 0.03MG; 200MG;
$0-$6.60(Nivel 2)
400UNIT; 3MG; 2.5MCG; 60MG; 1MG; 100MG; 17MG;
7MG; 4MG; 1.6MG; 1.5MG; 15UNIT; 4000UNIT; 25MG
VITAMAX TABLET CHEWABLE 60MG; 0; 300MCG;
$0(Nivel 3)
DP
10MG; 400UNIT; 6MCG; 200MCG; 20MG; 2MG; 1.7MG;
1.5MG; 200UNIT; 5000UNIT; 200MCG; 7.5MG
vitamin a capsule 10000unit
$0(Nivel 3)
DP
vitamin b-12 tablet 100mcg
$0(Nivel 3)
DP
vitamin b-12 tablet 250mcg
$0(Nivel 3)
DP
vitamin b-12 tablet 500mcg
$0(Nivel 3)
DP
vitamin b-1 tablet 50mg
$0(Nivel 3)
DP
vitamin b-6 tablet 100mg
$0(Nivel 3)
DP
vitamin b-6 tablet 25mg
$0(Nivel 3)
DP
vitamin c cr tablet extended release 500mg
$0(Nivel 3)
DP
Página 117 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
vitamin c tablet chewable 250mg
$0(Nivel 3)
DP
vitamin c tablet 1000mg
$0(Nivel 3)
DP
$0(Nivel 3)
DP
vitamin c tablet 250mg
$0(Nivel 3)
DP
vitamin c tablet 500mg
vitamin d-1000 tablet 1000unit
$0(Nivel 3)
DP
$0(Nivel 3)
DP
vitamin d3 400 capsule 400unit
vitamin d3 tablet 400unit
$0(Nivel 3)
DP
vitamin e capsule 1000unit
$0(Nivel 3)
DP
vitamin e capsule 100unit
$0(Nivel 3)
DP
vitamin e capsule 200unit
$0(Nivel 3)
DP
vitamin e capsule 200unit
$0(Nivel 3)
DP
vitamin e capsule 400unit
$0(Nivel 3)
DP
vitamin e capsule 400unit
$0(Nivel 3)
DP
VITAMIN K1 INJECTION 10MG/ML
$0(Nivel 3)
DP
$0(Nivel 3)
DP
vitamin k1 injection 1mg/0.5ml
vitamins & minerals tablet 60mg; 60mg; 400unit; 2mg; 6mcg; $0(Nivel 3)
DP
400mcg; 150mcg; 16mg; 1mg; 20mg; 10mg; 45mg; 5mg;
2mg; 1.7mg; 1.5mg; 5000unit; 30unit; 15mg
vol-tab rx tablet 120mg; 4000unit; 30mcg; 200mg; 7mg;
$0(Nivel 1)
QL (30 EA cada 30 días)
400unit; 3mg; 8mcg; 1mg; 29mg; 100mg; 20mg; 150mcg;
3mg; 3mg; 3mg; 30unit; 15mg
VP-PNV-DHA CAPSULE 80MG; 50MG; 400UNIT; 1MG; $0-$6.60(Nivel 2)
12MCG; 200MG; 15.8MG; 28MG; 1MG; 30MG; 20MG;
16MG; 2.2MG; 6MG; 30UNIT; 2500UNIT; 20MG
womens daily formula/folic acid/calcium/iron tablet 60mg; 0; $0(Nivel 3)
DP
30mcg; 450mg; 10mg; 400unit; 120mcg; 2mg; 6mcg; 27mg;
400mcg; 2mg; 20mg; 25mcg; 2mg; 1.7mg; 20mcg; 1.5mg;
30unit; 5250unit; 15mg
Unclassified
No Classification
ABILIFY MAINTENA INJECTION 300MG
$0-$6.60(Nivel 2) QL (1 EA cada 30 días)
ABILIFY MAINTENA INJECTION 400MG
$0-$6.60(Nivel 2) QL (1 EA cada 30 días)
antacid fast acting suspension 200mg/5ml; 200mg/5ml;
$0(Nivel 3)
DP
20mg/5ml
antacid maximum strength suspension 400mg/5ml;
$0(Nivel 3)
DP
400mg/5ml; 40mg/5ml
antacid regular strength suspension 200mg/5ml; 200mg/5ml; $0(Nivel 3)
DP
20mg/5ml
CALCET PETITES TABLET 200MG; 250UNIT
$0(Nivel 3)
DP
CALCIONATE SYRUP 1.8GM/5ML
$0(Nivel 3)
DP
cvs fiber laxative tablet 625mg
$0(Nivel 3)
DP
CVS SLOW RELEASE IRON TABLET EXTENDED
$0(Nivel 3)
DP
RELEASE 143MG
dermamed ointment 0
$0(Nivel 3)
DP
dibucaine ointment 1%
$0(Nivel 3)
DP
eye drops allergy relief solution 0.05%; 0.25%
$0(Nivel 3)
DP
FARYDAK CAPSULE 10MG
$0-$6.60(Nivel 2) QL (9 EA cada 28 días)
$0-$6.60(Nivel 2) QL (9 EA cada 28 días)
FARYDAK CAPSULE 15MG
Página 118 de 143
Nombre del medicamento
FARYDAK CAPSULE 20MG
fiber laxative capsule 0.52gm
fiber laxative tablet 625mg
glycerin liquid 0
GLYCERIN LIQUID 99.5%
gnp 12 hour nasal spray solution 0.05%
gnp antacid anti-gas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
gnp antacid maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
gnp artificial tears solution 0.5%; 0.6%
gnp fiber-caps tablet 625mg
gnp masanti maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
gnp masanti regular strength suspension 200mg/5ml;
200mg/5ml; 20mg/5ml
gnp miconazorb af powder 2%
gnp suphedrin liquid 15mg/5ml
gnp vitamin b1 tablet 100mg
gnp zinc oxide ointment 20%
HEMORRHOIDAL OINTMENT 0; 3%
hm acid reducer tablet 75mg
hm antacid/antigas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
hm artificial tears solution 0.5%; 0.6%
hm saline nasal spray solution 0.65%
hm triple antibiotic plus maximum strength ointment
500unit/gm; 3.5mg/gm; 10000unit/gm; 10mg/gm
hm triple antibiotic ointment 400unit/gm; 3.5mg/gm;
5000unit/gm
IBRANCE CAPSULE 100MG
IBRANCE CAPSULE 125MG
IBRANCE CAPSULE 75MG
ICAR TABLET CHEWABLE 15MG
L-LYSINE ACETATE TABLET 500MG
metamucil smooth texture powder 58.6%
MYOFLEX CREAM 10%
PETROLATUM OINTMENT 0; 0
PROFERRIN ES TABLET 12MG
qc 3 día vaginal cream cream 4%
SLOW-MAG TABLET DELAYED RELEASE 119MG;
71.5MG
sm antacid anti-gas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
sm antacid/antigas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
sm fiber laxative capsule 0.52gm
sm fiber laxative tablet 625mg
Página 119 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (9 EA cada 28 días)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
DP
DP
DP
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
DP
DP
Nombre del medicamento
sm nasal decongestant pe tablet 10mg
sm redness relief solution 0.2%; 0.012%
TRIXAICIN CREAM 0.025%
VIACTIV TABLET CHEWABLE 500MG; 500UNIT;
40MCG
VICKS VAPORUB OINTMENT 0; 0; 0; 0; 0
ZINC TRACE METAL INJECTION 1MG/ML
Página 120 de 143
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
DP
DP
Índice
Nombre del medicamento
Nombre del medicamento
abacavir
abacavir sulfate/lamivudine/zidovudine
ABELCET
ABILIFY
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY MAINTENA
ABRAXANE
ABREVA
ABSORBASE
acamprosate calcium dr
acarbose
acebutolol hcl
acerola c-500
acetaminophen/codeine
acetaminophen/codeine #3
acetasol hc
acetazolamide
acetazolamide er
acetazolamide sodium
acetic acid
acetylcysteine
acid gone
acid reducer
ACNE MEDICATION
acne medication 10
acne medication 5
ACTHIB
ACTIMMUNE
acyclovir
acyclovir sodium
ADACEL
ADAGEN
adapalene
adefovir dipivoxil
adriamycin
adrucil
ADVAIR DISKUS
ADVAIR HFA
ADVANCED AM/PM
afeditab cr
AFINITOR
AFINITOR DISPERZ
AGGRENOX
a-hydrocort
akwa tears
Página 121 de 143
# de
página
42
42
25
37
37
118
37
31
44
65
5
45
56
113
3
3
96
60
95
60
96
100
69
75
65
65
65
90
90
44
44
90
68
65
40
31
30
96
96
113
57
32
32
52
78
94
ALBENZA
albuterol sulfate
albuterol sulfate er
alclometasone dipropionate
alcohol prep pads
ALDURAZYME
alendronate sodium
alfuzosin hcl er
ALIMTA
ALINIA
ALKERAN
all día pain relief
allergy relief
allergy/congestion relief
allopurinol
almacone
almacone double strength
ALOE VESTA SKIN CONDITIONER
ALOPRIM
ALORA
alosetron hydrochloride
ALPHAGAN P
alprazolam
ALPRAZOLAM INTENSOL
aluminum acetate astringent
ALUMINUM HYDROXIDE
amantadine hcl
A-MANTLE
AMBISOME
amcinonide
amifostine
amikacin sulfate
amiloride hcl
amiloride/hydrochlorothiazide
aminophylline
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
AMINOSYN II
aminosyn ii 8.5%/electrolytes
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
amiodarone hcl
AMITIZA
amitriptyline hcl
amlactin
amlodipine besylate
# de
página
34
98
98
78
8
68
91
77
30
34
29
1
97
97
28
69
69
65
28
82
75
95
45
44
65
69
44
65
25
78
31
7
60
60
99
103
103
103
103
104
104
104
104
104
55
75
23
65
58
Nombre del medicamento
amlodipine besylate/benazepril hcl
amlodipine besylate/benazepril
hydrochloride
amlodipine besylate/valsartan
amlodipine/valsartan/hctz
AMMONIUM CHLORIDE
ammonium lactate
amoxapine
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amphetamine/dextroamphetamine
AMPHOTERICIN B
ampicillin
ampicillin sodium
ampicillin-sulbactam
anagrelide hydrochloride
anastrozole
ANDRODERM
ANDROXY
antacid
antacid fast acting
antacid maximum strength
antacid plus anti-gas relief
antacid plus anti-gas relief maximum
strength
antacid regular strength
anti-dandruff shampoo
anti-diarrheal
antifungal
anti-itch maximum strength
APAP 500
APIDRA
APIDRA SOLOSTAR
APOKYN
apri
APTIOM
APTIVUS
AQUADEKS
aquanil hc
AQUASOL A PARENTERAL
aqueous vitamin e
ARALAST NP
aranelle
ARANESP ALBUMIN FREE
ARCALYST
arginine
aripiprazole
ARRANON
Página 122 de 143
# de
página
58
58
58
58
104
65
23
13
13
13
63
25
14
13
13
50
32
82
82
70
118
118
70
69
118
65
70
25
65
1
47
47
35
82
16
43
113
78
113
113
100
82
50
90
92
37
30
Nombre del medicamento
artificial tears
ARZERRA
ascomp/codeine
ASCRIPTIN
ASMANEX HFA
ASMANEX TWISTHALER 120
METERED DOSES
ASMANEX TWISTHALER 14 METERED
DOSES
ASMANEX TWISTHALER 30 METERED
DOSES
ASMANEX TWISTHALER 60 METERED
DOSES
aspirin
aspirin/dipyridamole
atenolol
atenolol/chlorthalidone
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRAC-TAIN
ATRIPLA
ATROPINE SULFATE
ATROVENT HFA
AUBAGIO
aubra
augmented betamethasone dipropionate
AVANDARYL
AVASTIN
AVELOX
aviane
AVODART
AVONEX
AVONEX PEN
AXID AR
ayr
AYR NASAL DROPS
ayr saline nasal
azacitidine
AZACTAM
AZACTAM IN ISO-OSMOTIC
DEXTROSE
azathioprine
azelastine hcl
AZILECT
azithromycin
aztreonam
b complex
b-100 tr
# de
página
94
34
3
70
96
96
96
96
96
1
52
56
56
61
34
34
65
44
69
98
64
82
78
45
34
15
82
77
64
64
75
100
100
100
31
13
13
88
97
36
14
13
113
113
Nombre del medicamento
baciim
BACITRACIN
bacitracin zinc
bacitracin/neomycin/polymyxin
bacitracin/polymyxin b
baclofen
BACTOCILL IN DEXTROSE
balanced b-100
balanced b-50
BALNETAR LIQUIM
balsalazide disodium
balziva
BANZEL
BARACLUDE
baza antifungal
baza protect
b-complex/c
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X 1/2"
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X 5/16"
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X 1/2"
bd insulin syringe ultrafine/1ml/30g x 1/2"
BD INSULIN SYRINGE
ULTRAFINE/1ML/31G X 5/16"
bd insulin syringe/detachable
needle/u-100/1ml/25g x 5/8"
bd pen needle/mini/ultrafine/31g x 3/16"
bd pen needle/short/ultrafine/31g x 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X
12.7MM
bd pen needles short/ultrafine/31g x 5/16"
BELEODAQ
benazepril hcl
benazepril hcl/hydrochlorothiazide
BENEFIBER
BENZOIN COMPOUND TINCTURE
benztropine mesylate
beta carotene
BETADINE
BETADINE SKIN CLEANSER
BETADINE SURGICAL SCRUB
BETADINE SWAB AID
BETADINE SWABSTICKS
betamethasone dipropionate
betamethasone valerate
betasept surgical scrub
BETASERON
Página 123 de 143
# de
página
8
8
8
8
94
40
14
114
114
65
91
82
19
40
26
65
114
92
92
92
92
92
92
92
93
93
93
31
54
54
70
65
35
114
8
8
8
8
8
78
78
65
64
Nombre del medicamento
betaxolol hcl
betaxolol hcl
bethanechol chloride
bexarotene
BEXSERO
bicalutamide
BICILLIN C-R
BICILLIN L-A
BICNU
BIDIL
biotin
bisac-evac
bisacodyl
bisacodyl ec
biscolax
bismatrol
bismatrol maximum strength
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
bleomycin sulfate
BOOSTRIX
BOSULIF
BOTOX
BOTOX
BRILINTA
brimonidine tartrate
BRINTELLIX
bromfed dm
bromocriptine mesylate
budeprion sr
budesonide
budesonide
BUFFERIN
bumetanide
BUPHENYL
buprenorphine hcl
buproban
bupropion hcl
bupropion hcl sr
bupropion hcl xl
buspirone hcl
BUSULFEX
butalbital/acetaminophen
butalbital/acetaminophen/caffeine
butalbital/acetaminophen/caffeine/codeine
butalbital/aspirin/caffeine
butorphanol tartrate
BYETTA
c-500
# de
página
56
95
77
34
90
30
14
14
29
62
114
70
70
70
70
70
70
56
56
31
90
33
28
93
52
95
21
100
35
21
78
96
1
60
68
5
5
21
21
21
44
29
1
1
1
1
3
45
114
Nombre del medicamento
cabergoline
CALCET PETITES
CALCI-CHEW
CALCI-MIX
CALCIONATE
calcipotriene
calcitonin-salmon
calcitriol
CALCIUM
calcium & magnesium + zinc
calcium + d3
calcium acetate
calcium antacid
calcium antacid extra strength
CALCIUM CARBONATE
calcium carbonate
calcium citrate+ d
CALCIUM GLUCONATE
CALCIUM LACTATE
cal-gest antacid
caltrate 600
CALTRATE 600+D
CALTRATE 600+D PLUS MINERALS
camila
CAMPTOSAR
CANCIDAS
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
CAPASTAT SULFATE
CAPRELSA
capsaicin
captopril
captopril/hydrochlorothiazide
carbamazepine
carbamazepine er
CARBATROL
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
carboplatin
CARIMUNE NANOFILTERED
carteolol hcl
cartia xt
carvedilol
castellani paint modified/color
CAYSTON
cefaclor
cefaclor er
cefadroxil
Página 124 de 143
# de
página
87
118
104
104
118
65
91
91
70
104
104
77
70
70
70
104
104
104
105
70
105
105
105
85
31
26
53
53
29
33
65
55
55
19
19
19
36
36
36
31
90
95
58
57
26
99
10
10
11
Nombre del medicamento
cefazolin sodium
cefdinir
cefepime
cefixime
cefotaxime sodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
CELLCEPT
CELLCEPT INTRAVENOUS
CELONTIN
CENTRUM SILVER
cephalexin
CEREBYX
CEREZYME
cerovite advanced formula
cerovite jr
CERVARIX
CETAPHIL
CETAPHIL MOISTURIZING
cetirizine hcl
CHANTIX
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CHEMET
cheratussin dac
chewable antacid
CHLORAMPHENICOL SODIUM
SUCCINATE
chlordiazepoxide/amitriptyline
chlorhexidine gluconate oral rinse
chloroquine phosphate
chlorothiazide
chlorothiazide sodium
CHLORPROMAZINE HCL
chlorthalidone
chlorzoxazone
cholestyramine light
chorionic gonadotropin
ciclopirox
ciclopirox olamine
cidofovir
cilostazol
cimetidine
cimetidine hcl
# de
página
11
11
11
11
11
11
11
11
11
11
12
12
88
88
17
114
12
19
68
114
114
90
65
65
97
5
5
5
102
100
70
8
23
65
34
61
61
36
61
101
62
80
26
26
40
52
75
75
Nombre del medicamento
CINRYZE
CIPRODEX
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
cisplatin
citalopram hydrobromide
CITRUCEL
CITRUCEL FIBER LAXATIVE
citrus calcium/vitamin d
cladribine
CLAFORAN
claravis
clarithromycin
clarithromycin er
CLEOCIN IN D5W
CLEOCIN PEDIATRIC GRANULES
CLIMARA PRO
clindamax
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate
clindamycin phosphate add-vantage
clindamycin phosphate in d5w
clindamycin/benzoyl peroxide
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 2.75%/DEXTROSE 10%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 4.25%/DEXTROSE 10%
CLINIMIX E 4.25%/DEXTROSE 25%
CLINIMIX E 4.25%/DEXTROSE 5%
CLINIMIX E 5%/DEXTROSE 15%
CLINIMIX E 5%/DEXTROSE 20%
CLINIMIX E 5%/DEXTROSE 25%
clobetasol propionate
clobetasol propionate e
clodan
CLOLAR
clomipramine hcl
clonazepam
clonazepam odt
clonidine hcl
Página 125 de 143
# de
página
88
96
15
15
15
31
22
70
70
105
30
12
65
14
14
8
8
82
8
8
9
9
9
9
66
105
105
105
105
105
106
106
106
106
106
106
107
107
107
107
107
78
78
78
30
23
17
17
53
Nombre del medicamento
clonidine hcl er
clopidogrel
clorazepate dipotassium
clotrimazole
clotrimazole anti-fungal
clotrimazole/betamethasone dipropionate
clozapine
clozapine odt
COARTEM
cod liver oil
CODITUSS DM
COLACE
colchicine
COLCRYS
cold head congestion severe díatime
colestipol hcl
colistimethate sodium
COMBIGAN
COMBIVENT RESPIMAT
COMETRIQ
compete
COMPLERA
complete lice treatment kit
compro
COMVAX
CONGESTAC
constulose
COPAXONE
cortisone acetate
corvita
COSMEGEN
COUMADIN
CREON
CRITIC-AID CLEAR
MOISTUREBARRIER
CRITIC-AID THICK
MOISTUREBARRIER
CRIXIVAN
cromolyn sodium
cromolyn sodium
cromolyn sodium
cryselle-28
CUBICIN
curity gauze pads 2"x2"
cvs antacid ultra strength
cvs electrolyte solution
cvs fiber laxative
cvs iron
CVS SLOW RELEASE IRON
# de
página
53
52
45
26
26
66
39
39
34
114
100
70
28
28
100
62
9
93
98
33
114
42
35
36
90
100
76
64
78
114
31
48
68
66
66
43
70
95
99
82
9
66
70
107
118
107
118
Nombre del medicamento
cyanocobalamin
cyclafem 1/35
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine modified
cyproheptadine hcl
CYRAMZA
CYSTADANE
CYSTAGON
cytarabine
cytarabine aqueous
CYTOMEL
d 10000
dacarbazine
DACOGEN
dactinomycin
daily-vite/iron/beta-carotene
DALIRESP
danazol
dantrolene sodium
DAPSONE
DAPTACEL
DARAPRIM
DAUNORUBICIN HCL
deblitane
DECAVAC
decitabine
decongestant 12hour maximum strength
deep sea nasal spray
DELSYM
delyla
DELZICOL
demeclocycline hcl
DEMEROL
DEMSER
DENAVIR
DEPEN TITRATABS
DEPO-ESTRADIOL
DEPO-MEDROL
DEPO-SUBQ PROVERA 104
dermamed
desenex
desenex shake powder
desenex spray powder
desipramine hcl
desmopressin acetate
desogestrel/ethinyl estradiol
Página 126 de 143
# de
página
114
82
101
29
45
88
88
97
34
68
68
30
30
86
114
29
31
31
115
99
82
40
29
90
34
31
85
90
31
100
100
100
82
91
16
3
59
44
102
82
78
85
118
26
26
26
23
80
82
Nombre del medicamento
desonide
desoximetasone
desvenlafaxine er
dexamethasone
dexamethasone sodium phosphate
dexamethasone sodium phosphate
dexferrum
dexrazoxane
dextroamphetamine sulfate
DEXTROSE 10%/NACL 0.45%
dextrose 10% flex container
DEXTROSE 10%/NACL 0.2%
dextrose 2.5%/sodium chloride 0.45%
dextrose 5%
dextrose 5%/nacl 0.2%
DEXTROSE 5%/NACL 0.225%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dextrose 5%/potassium chloride 0.15%
DHS SAL
DHS TAR
diazepam
diazepam
DIAZEPAM INTENSOL
dibucaine
dibucaine
diclofenac potassium
diclofenac sodium
diclofenac sodium dr
diclofenac sodium er
dicloxacillin sodium
dicyclomine hcl
didanosine
diflunisal
digitek
digoxin
dihydroergotamine mesylate
DILANTIN
DILANTIN INFATABS
DILANTIN-125
dilt-cd
diltiazem cd
DILTIAZEM HCL
diltiazem hcl er
dilt-xr
dimenhydrinate
diocto
DIPENTUM
# de
página
78
78
22
78
78
95
107
31
63
107
107
107
108
108
108
108
108
108
108
108
66
66
17
45
45
118
66
1
95
1
1
14
69
42
1
59
59
28
19
19
19
58
58
59
58
58
24
71
91
Nombre del medicamento
diphenhydramine hcl
diphenoxylate/atropine
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC
dipyridamole
disopyramide phosphate
disulfiram
divalproex sodium
divalproex sodium dr
divalproex sodium er
dml
DOCEFREZ
DOCETAXEL
docqlace
docqlace
doc-q-lax
docu
docusate sodium
docusate sodium & senna stimulant
laxative/stool softener
docusil
dok
donepezil hcl
dorzolamide hcl
dorzolamide hcl/timolol maleate
double antibiotic
doxazosin mesylate
doxepin hcl
DOXIL
doxorubicin hcl
doxycycline hyclate
doxycycline monohydrate
DR SMITHS DIAPER
driminate
DRISDOL
DRISTAN SPRAY
dronabinol
DROXIA
ducodyl
DUETACT
DULERA
duloxetine hcl
duramorph
e.e.s. 400
e.e.s. granules
ear health formula
ear wax removal drops
ear wax remover
earwax treatment drops
Página 127 de 143
# de
página
97
71
90
52
56
5
17
17
17
66
31
31
71
76
76
71
71
76
71
71
20
95
95
9
77
24
31
31
16
16
66
24
115
100
25
30
71
45
97
22
3
15
15
115
96
96
96
Nombre del medicamento
easy touch pen needles 31gx5/16"
easy touch pen needles/31g x 3/16"
econazole nitrate
ed a-hist pse
EDURANT
EFFIENT
ELAPRASE
ELDEPRYL
ELDERTONIC
ELELYSO
ELIDEL
ELIGARD
ELIPHOS
ELITEK
ELIXOPHYLLIN
ELLA
ELLENCE
ELMIRON
EMCYT
EMEND
EMSAM
EMTRIVA
enalapril maleate
enalapril maleate/hydrochlorothiazide
ENBREL
ENBREL SURECLICK
endocet
ENGERIX-B
enoxaparin sodium
enpresse-28
entacapone
entecavir
ENUCLENE
enulose
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epirubicin hcl
epitol
EPIVIR
EPIVIR HBV
eplerenone
EPOGEN
eprosartan mesylate
EPZICOM
eql iron supplement therapy
ERBITUX
ergoloid mesylates
ERGOMAR
ERIVEDGE
# de
página
93
93
26
97
42
53
68
36
115
68
66
87
78
30
99
85
31
77
30
25
22
42
55
55
88
88
3
90
49
82
35
40
94
76
99
99
31
19
42
40
60
51
54
42
108
34
20
28
33
Nombre del medicamento
errin
ERYPED 400
ERY-TAB
ERYTHROCIN LACTOBIONATE
erythrocin stearate
erythromycin
erythromycin base
erythromycin/benzoyl peroxide
escitalopram oxalate
esomeprazole sodium
ESTRACE
estradiol
estradiol valerate
estropipate
ethambutol hcl
ethosuximide
etidronate disodium
etodolac
etodolac er
ETOPOPHOS
etoposide
EVISTA
EVOTAZ
EXCEDRIN EXTRA STRENGTH
exel comfort point insulin pen needles 31g x
8mm
exemestane
EXJADE
EX-LAX
EX-LAX MAXIMUM STRENGTH
eye drops allergy relief
FABRAZYME
falmina
famciclovir
famotidine
FAMOTIDINE PREMIXED
FANAPT
FANAPT TITRATION PACK
FARESTON
FARXIGA
FARYDAK
FASLODEX
FAZACLO
felbamate
felodipine er
fenofibrate
fenofibrate micronized
fenoprofen calcium
fentanyl
Página 128 de 143
# de
página
85
15
15
15
15
15
15
66
22
77
82
82
82
83
29
17
92
1
1
32
32
85
43
1
93
32
102
71
71
118
68
83
44
75
75
38
38
30
45
118
30
39
18
59
61
61
1
2
Nombre del medicamento
Citrato de fentanilo por víatransmucosa
oral
FEOSOL
FERATE
fer-iron
ferosul
ferretts
FERROUS FUMARATE
FERROUS GLUCONATE
ferrous sulfate
FETZIMA
FETZIMA TITRATION PACK
feverall
fiber laxative
fiber tabs
FIBERCON
fiber-lax
finasteride
FIRAZYR
FIRMAGON
flavoxate hcl
flecainide acetate
FLEET BISACODYL
FLEET LIQUID GLYCERIN
SUPPOSITORIES
FLEET OIL
FLOVENT DISKUS
FLOVENT HFA
fluconazole
fluconazole in dextrose
flucytosine
fludarabine phosphate
fludrocortisone acetate
flunisolide
fluocinolone acetonide
fluocinonide
fluocinonide-e
fluorometholone
fluorouracil
fluorouracil
fluoxetine hcl
FLUPHENAZINE DECANOATE
fluphenazine hcl
flurazepam hcl
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
fluticasone propionate
# de
página
3
108
108
108
108
108
108
108
108
22
22
1
119
71
71
71
77
88
87
77
56
71
71
71
97
97
26
26
26
31
79
97
79
79
79
95
31
66
22
36
36
102
1
95
30
79
97
Nombre del medicamento
fluvoxamine maleate
FOLIC ACID
FOLOTYN
fondaparinux sodium
FORTAZ
FORTEO
fortical
FOSFREE
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FRAGMIN
FREAMINE HBC 6.9%
FUNGOID TINCTURE
furosemide
FUSILEV
FUZEON
FYCOMPA
gabapentin
GABITRIL
galantamine hydrobromide
GALZIN
GAMASTAN S/D
GAMMAGARD LIQUID
GAMUNEX-C
ganciclovir
GARDASIL
GARDASIL 9
GAS-X
gas-x extra strength
gas-x ultra strength
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
GAVISCON
GAVISCON EXTRA STRENGTH
GAVISCON EXTRA STRENGTH RELIEF
FORMULA
GEL-KAM
gemcitabine hcl
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate
GENTAMICIN SULFATE/0.9% SODIUM
CHLORIDE
GENTEAL MILD
Página 129 de 143
# de
página
22
115
31
49
12
92
92
115
55
55
19
78
49
109
26
60
31
43
16
17
17
20
109
90
90
90
40
90
90
71
71
71
76
76
76
71
71
71
65
31
61
76
89
7
7
7
94
Nombre del medicamento
GENTEAL MILD TO MODERATE
GENTEAL SEVERE
GENTIAN VIOLET
GEODON
geravim
gildess 1.5/30
GILENYA
GILOTRIF
glatopa
GLEEVEC
glimepiride
glipizide
glipizide er
glipizide/metformin hcl
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
GLUCOSE
glutose 15
glyburide
glyburide micronized
glyburide/metformin hcl
glycerin
glycerin adult
glycopyrrolate
GLYSET
gnp 12 hour nasal spray
gnp antacid
gnp antacid anti-gas
gnp antacid extra strength
gnp antacid maximum strength
gnp antacid ultra strength
gnp antibiotic plus pramoxine
gnp anti-diarrheal
gnp artificial tears
gnp bacitracin zinc
GNP CALAMINE PHENOLATED
gnp caldyphen
gnp clotrimazole 3
gnp ear drops
gnp ear systems
gnp fiber therapy
gnp fiber-caps
gnp fish oil
gnp glycerin adult
gnp hydrocortisone
gnp hygienic cleansing pads
gnp iron
gnp k-pec
gnp lice treatment
# de
página
94
94
26
38
115
83
64
31
64
33
46
46
46
46
47
47
47
47
46
46
46
119
71
69
46
119
71
119
71
119
71
9
72
119
9
66
66
26
96
96
76
119
93
72
79
66
109
72
35
Nombre del medicamento
gnp loperamide hcl
gnp masanti maximum strength
gnp masanti regular strength
gnp miconazole 3
gnp miconazole 7
gnp miconazorb af
gnp milk of magnesia
gnp natural fiber
gnp nicotine polacrilex
gnp nose drops extra strength
gnp one daily mens health/lycopene
gnp pediatric electrolyte
gnp pink bismuth
gnp povidone-iodine
gnp senna plus
gnp senna-lax
gnp soothing bath treatment
gnp stomach relief
gnp stomach relief maximum strength
gnp suphedrin
gnp terbinafine hydrochloride
gnp therapeutic blue gel
gnp therapeutic-m
gnp triple antibiotic
gnp vitamin a & d
gnp vitamin b1
gnp zinc oxide
goodsense all día allergy
GRALISE
GRALISE STARTER
granisetron hcl
GRANIX
griseofulvin microsize
griseofulvin ultramicrosize
guaifenesin/codeine
guanfacine er
guanfacine hcl
GUANIDINE HCL
HALAVEN
halobetasol propionate
haloperidol
haloperidol decanoate
haloperidol lactate
HAVRIX
heartburn relief
HECTOROL
HEMORRHOIDAL
hemorrhoidal
hemorrhoidal
Página 130 de 143
# de
página
72
119
119
26
26
119
76
72
5
100
115
109
72
9
76
72
66
72
72
119
26
66
115
9
66
119
119
97
1
1
25
51
26
26
100
63
53
29
31
79
37
36
37
90
75
92
119
66
72
Nombre del medicamento
heparin sodium
heparin sodium/d5w
heparin sodium/nacl 0.9%
hepatamine
HERCEPTIN
HEXALEN
hm acid reducer
hm antacid/antigas
hm anti-diarrheal
hm artificial tears
hm bacitracin
hm double antibiotic
hm earwax removal aid
hm fiber
HM GLUCOSE
hm loperamide hcl
hm povidone-iodine
hm saline nasal spray
hm stomach relief
hm triple antibiotic
hm triple antibiotic plus maximum strength
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMIRA
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500 (CONCENTRATED)
hydralazine hcl
hydrisalic
hydro skin maximum strength
hydrochlorothiazide
hydrocodone bitartrate/acetaminophen
hydrocodone bitartrate/homatropine
methylbromide
hydrocodone polistirex/chlorpheniramine
polistirex
hydrocodone/acetaminophen
hydrocortisone
hydrocortisone butyrate
hydrocortisone valerate
# de
página
49
49
49
109
34
29
119
119
72
119
9
9
96
72
47
72
9
119
72
119
119
48
47
48
48
48
48
89
89
48
48
48
48
48
48
63
66
79
61
3
100
100
3
79
79
79
Nombre del medicamento
hydrocortisone/acetic acid
hydrocortisone/aloe
HYDROGEN PEROXIDE
hydromorphone hcl
HYDROXOCOBALAMIN
hydroxychloroquine sulfate
hydroxyurea
HYDROXYZINE HCL
hydroxyzine pamoate
ibandronate sodium
IBRANCE
ibuprofen
ICAPS AREDS FORMULA
ICAPS PLUS
ICAR
ICLUSIG
IDAMYCIN PFS
idarubicin hcl
IFEX
ifosfamide
ILARIS
IMBRUVICA
imipenem/cilastatin
imipramine hcl
imipramine pamoate
imiquimod
IMITREX
IMITREX STATDOSE REFILL
IMOVAX RABIES (H.D.C.V.)
INCIVEK
INCRELEX
indapamide
indomethacin
indomethacin er
INFANRIX
INFERGEN
INLYTA
INSTA-GLUCOSE
insupen ultrafin 31gx8mm
INTELENCE
intralipid
INTRON A
INTRON A W/DILUENT
introvale
INTUNIV
INVANZ
INVEGA
INVEGA SUSTENNA
INVIRASE
Página 131 de 143
# de
página
96
79
9
4
115
34
31
97
98
92
119
1
115
115
119
33
31
31
29
29
90
33
13
24
24
66
28
28
90
40
80
61
2
2
90
40
33
47
93
42
93
40
40
83
63
13
38
38
43
Nombre del medicamento
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
IPOL INACTIVATED IPV
ipratropium bromide
ipratropium bromide/albuterol sulfate
irbesartan
irbesartan/hydrochlorothiazide
irinotecan
ISENTRESS
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
ISONIAZID
ISOPTO TEARS
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
isotonic gentamicin
ISTODAX
itch relief extra strength
ITCH-X
itraconazole
ivermectin
i-vite
IXEMPRA KIT
IXIARO
JAKAFI
jantoven
JANUVIA
JENTADUETO
JEVTANA
jock itch spray
jolivette
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
KADCYLA
KALETRA
kao-tin
kariva
kcl 0.075%/d5w/nacl 0.45%
KCL 0.15%/D5W/LR
kcl 0.15%/d5w/nacl 0.2%
KCL 0.15%/D5W/NACL 0.225%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
# de
página
109
109
90
98
98
54
54
31
42
109
109
29
94
62
62
62
62
7
31
66
66
26
34
115
31
90
33
49
46
46
31
26
85
83
83
83
83
83
34
43
72
83
109
109
109
109
109
110
110
Nombre del medicamento
kelnor 1/35
KEPIVANCE
KETEK
ketoconazole
ketoprofen
ketoprofen er
ketorolac tromethamine
ketorolac tromethamine
KEYTRUDA
KHEDEZLA
kids vitamins complete
kimidess
KINERET
kionex
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
kls acid reducer maximum strength
KOMBIGLYZE XR
KONSYL
konsyl
KONSYL-D
KORLYM
kp ferrous sulfate
KUVAN
labetalol hcl
lac-dose
lac-hydrin five
laclotion
lactated ringers dextrose 5% viaflex
lactated ringers irrigation
lactated ringers viaflex
lactose fast acting relief
LACTRASE
lactulose
LAMISIL AT
LAMISIL AT SPRAY
lamivudine
lamivudine
lamivudine/zidovudine
lamotrigine
lamotrigine odt
LANOXIN
LANTUS
LANTUS SOLOSTAR
larin 1.5/30
latanoprost
Página 132 de 143
# de
página
83
65
15
26
2
2
2
95
34
22
115
83
89
103
110
110
110
110
110
75
47
69
72
72
81
110
68
57
68
66
66
110
93
110
68
68
76
26
26
40
42
42
18
18
60
48
48
83
93
Nombre del medicamento
LATUDA
laxative
LAZANDA
leena
leflunomide
LENVIMA 10MG DAILY DOSE
LENVIMA 14MG DAILY DOSE
LENVIMA 20MG DAILY DOSE
LENVIMA 24MG DAILY DOSE
lessina
LETAIRIS
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide acetate
levalbuterol hcl
LEVAQUIN
LEVEMIR
LEVEMIR FLEXTOUCH
levetiracetam
levobunolol hcl
levocarnitine
levocetirizine dihydrochloride
levofloxacin
levofloxacin in d5w
levoleucovorin calcium
levonorgestrel and ethinyl estradiol
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
levorphanol tartrate
levothyroxine sodium
levoxyl
LEXIVA
lice killing maximum strength
lidocaine
lidocaine hcl
lidocaine hcl jelly
lidocaine viscous
lidocaine/prilocaine
lidocream
LINCOCIN
lindane
linezolid
liothyronine sodium
lipodox
lipodox 50
liposyn iii
liquitears
# de
página
38
72
4
83
90
33
33
33
33
83
100
32
31
29
51
87
99
15
48
48
16
95
93
98
15
15
32
83
83
83
2
86
86
43
35
5
4
4
4
5
5
9
35
9
86
32
32
93
94
Nombre del medicamento
lisinopril
lisinopril/hydrochlorothiazide
lite touch pen needles/31g x 3/16"
lithium
lithium carbonate
lithium carbonate er
LITHOBID
L-LYSINE ACETATE
loestrin 24 fe
lohist-dm
lomustine
loperamide hcl
loratadine
lorazepam
LORAZEPAM INTENSOL
losartan potassium
losartan potassium/hydrochlorothiazide
LOTEMAX
LOTRONEX
lovastatin
low-ogestrel
loxapine succinate
lubricating jelly
lubrifresh p.m.
LUFYLLIN
LUMIGAN
LUMIZYME
LUPRON DEPOT
LUPRON DEPOT-PED
lutera
LYNPARZA
LYRICA
LYSODREN
lyza
MAALOX
maalox advanced maximum strength
maalox max
mag-delay
MAGNEBIND 300
magnesium
magnesium citrate
magnesium gluconate
magnesium oxide
magnesium sulfate
MAGONATE
malathion
maprotiline hcl
marlissa
MARPLAN
Página 133 de 143
# de
página
55
55
93
45
45
45
45
119
83
100
29
72
98
45
45
54
54
95
75
61
83
37
77
94
99
93
68
87
87
83
32
17
87
85
72
72
72
110
78
72
76
110
72
110
110
35
21
83
22
Nombre del medicamento
MATULANE
matzim la
meclizine hcl
meclofenamate sodium
medi-cortisone
medroxyprogesterone acetate
mefloquine hcl
megestrol acetate
MEKINIST
meloxicam
melphalan hydrochloride
memantine hcl
memantine hcl titration pak
MENACTRA
m-end dm
MENEST
MENOMUNE-A/C/Y/W-135
MENVEO
meperidine hcl
meprobamate
MEPRON
mercaptopurine
meropenem
mesalamine
mesna
MESNEX
MESTINON
MESTINON TIMESPAN
METADATE CD
metamucil smooth texture
metamucil smooth texture
metaproterenol sulfate
metformin hcl
metformin hcl er
METHADONE HCL
methadose
methazolamide
methenamine hippurate
methimazole
METHITEST
methocarbamol
methotrexate
methotrexate sodium
methoxsalen
methscopolamine bromide
methyclothiazide
methyldopa
methyldopa/hydrochlorothiazide
METHYLDOPATE HCL
# de
página
29
59
24
2
79
85
34
85
33
2
30
21
21
91
100
83
91
91
4
44
34
31
13
91
32
32
29
29
63
119
72
99
47
47
2
3
95
9
88
82
101
89
89
66
69
61
53
53
53
Nombre del medicamento
methylergonovine maleate
methylphenidate hcl
methylphenidate hcl cd
methylphenidate hcl er
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone sodiumsuccinate
metipranolol
metoclopramide hcl
metolazone
metoprolol succinate er
metoprolol tartrate
metoprolol/hydrochlorothiazide
metronidazole
metronidazole in nacl 0.79%
metronidazole vaginal
mexiletine hcl
MIACALCIN
mi-acid
mi-acid maximum strength
miconazole
miconazole 3
miconazole 3 combo pack
miconazole 7
miconazole nitrate
micro guard
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
midodrine hcl
migergot
milk of magnesia
milk of magnesia
MILK DE MAGNESIA CONCENTRATE
minocycline hcl
minoxidil
mintox
mintox maximum strength
mintox plus
mirtazapine
mirtazapine odt
misoprostol
mitigare
mitomycin
mitoxantrone hcl
mitrazol
M-M-R II
Página 134 de 143
# de
página
93
64
63
64
79
79
79
79
95
72
61
57
57
57
9
9
9
56
92
73
73
27
27
27
27
27
27
84
84
84
84
53
28
73
76
73
16
63
73
73
73
21
21
76
28
32
32
27
90
Nombre del medicamento
modafinil
mometasone furoate
monoject insulin syringe/detach
needle/1ml/25g x 5/8"
mononessa
montelukast sodium
morphine sulfate
morphine sulfate er
moxifloxacin hcl
MOZOBIL
MUCINEX D
MULTAQ
MULTI-DELYN/IRON
multilex-t&m
multiple vitamin
mupirocin
MURO 128
MUSTARGEN
MYCAMINE
MYCOBUTIN
mycophenolate mofetil
MYOFLEX
nabumetone
nadolol
nadolol/bendroflumethiazide
nafcillin sodium
naftifine hcl
NAFTIN
NAGLAZYME
nalbuphine hcl
NALLPEN/DEXTROSE
naloxone hcl
naltrexone hcl
NAMENDA
NAMENDA TITRATION PAK
naphazoline hcl
naproxen
naproxen dr
naproxen sodium
naratriptan hcl
nasal spray extra moisturizing 12 hour
NATACYN
nateglinide
natural balance tears
natural fiber therapy
natural mixed tocopherols
natures tears
NEBUPENT
necon 0.5/35-28
# de
página
102
80
93
84
98
4
3
15
110
100
56
115
115
115
9
94
30
27
29
89
119
2
57
57
14
27
27
69
4
14
5
5
21
21
94
2
2
2
28
101
27
47
94
73
115
94
34
84
Nombre del medicamento
necon 1/35
necon 10/11-28
necon 7/7/7
nefazodone hcl
neomycin sulfate
neomycin/bacitracin/polymyxin
neomycin/polymyxin b sulfates
neomycin/polymyxin/bacitracin/hydrocortis
one
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone
neomycin/polymyxin/hydrocortisone
NEPHRAMINE
NEPHRO-VITE
NEULASTA
NEUMEGA
NEUPOGEN
NEUPRO
nevirapine
nevirapine er
NEXAVAR
niacin
niacin er
niacin er
NIACIN TR
niacinamide
niacor
nicardipine hcl
NICODERM CQ
nicorelief
NICORETTE
NICORETTE MINI
NICORETTE STARTER KIT
nicotine
nicotine polacrilex
NICOTINE TRANSDERMAL SYSTEM
NICOTROL NS
nifedical xl
nifedipine er
NILANDRON
NITRO-DUR
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
NITROGLYCERIN
nitroglycerin transdermal
NITROSTAT
nora-be
Página 135 de 143
# de
página
84
84
84
21
7
94
8
9
95
94
96
9
96
110
116
51
51
51
35
42
42
33
62
62
116
116
116
62
59
5
5
6
6
6
7
6
6
7
59
59
30
62
9
9
62
62
63
85
Nombre del medicamento
NORDITROPIN FLEXPRO
norethindrone
norethindrone acetate
norethindrone acetate/ethinyl estradiol
norlyroc
normosol-m in d5w
NORMOSOL-R
NORMOSOL-R IN D5W
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
nortriptyline hcl
NORVIR
novofine 32gx6mm
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN
NOVOLOG PENFILL
NOXAFIL
NUEDEXTA
nu-iron 150
NULOJIX
NULYTELY/FLAVOR PACKS
NUPERCAINAL
NUTRADERM
nutrilipid
NUTRISOURCE FIBER
NUTROPIN
nyamyc
nystatin
nystatin/triamcinolone
nystop
OCEAN NASAL SPRAY
octreotide acetate
ocuvite extra
ofloxacin
OGESTREL
olanzapine
olanzapine odt
olopatadine hcl
OLYSIO
omega-3-acid ethyl esters
omeprazole
ONCASPAR
# de
página
80
85
85
84
85
110
110
110
84
84
84
24
43
93
48
48
48
48
48
48
48
48
27
64
110
89
76
66
66
93
76
81
27
27
27
27
101
87
116
15
84
38
38
98
40
62
77
32
Nombre del medicamento
ONCOVITE
ondansetron hcl
ondansetron odt
one daily for women
ONE-A-DAY WOMENS FORMULA
ONFI
ONGLYZA
OPDIVO
oralyte
ORAP
ORENCIA
ORENITRAM
organ-i nr
orphenadrine citrate
orphenadrine citrate er
os-cal calcium + d3
oxacillin sodium
oxaliplatin
oxandrolone
oxaprozin
oxcarbazepine
OXSORALEN
OXTELLAR XR
oxybutynin chloride
oxybutynin chloride er
oxycodone hcl
oxycodone/acetaminophen
oysco d
oyster shell/vitamin d
pacerone
paclitaxel
pain relieving rub
pamidronate disodium
PANCREAZE
panoxyl
PANRETIN
pantoprazole sodium
paromomycin sulfate
paroxetine hcl
paroxetine hcl er
PASER
PATANOL
PAXIL
PEDIA-LAX
PEDIALYTE
pediatric electrolyte
pedi-boro soak paks
pedi-dri
PEDVAX HIB
Página 136 de 143
# de
página
116
25
25
116
116
17
47
34
110
37
89
100
101
101
101
110
14
32
81
2
19
66
20
77
77
4
4
110
110
56
32
66
92
69
66
34
77
8
23
23
29
95
23
73
110
111
66
27
91
Nombre del medicamento
PEGANONE
PEGASYS
PEGASYS PROCLICK
PEGINTRON
PEG-INTRON
PEG-INTRON REDIPEN
penicillin g potassium
PENICILLIN G POTASSIUM IN
ISO-OSMOTIC DEXTROSE
PENICILLIN G PROCAINE
PENICILLIN G SODIUM
penicillin v potassium
PEN-KERA
PENTAM 300
pentostatin
pentoxifylline er
peptic relief
PEPTO-BISMOL
PEPTO-BISMOL MAX STRENGTH
peri-colace
periguard
periogard
PERJETA
permethrin
perphenazine
perphenazine/amitriptyline
PETROLATUM
PFIZERPEN-G
phenadoz
phenelzine sulfate
phenobarbital
PHENYLHISTINE DH
PHENYTEK
phenytoin
phenytoin infatabs
phenytoin sodium
phenytoin sodium extended
PHOS-NAK POWDER CONCENTRATE
PHOSPHOLINE IODIDE
physiolyte
physiosol irrigation
PICATO
pilocarpine hcl
pilocarpine hydrochloride
PILOPINE HS
pindolol
pink bismuth
pioglitazone hcl
pioglitazone hcl/metformin hcl
# de
página
20
41
41
41
41
40
14
14
14
14
14
66
34
31
60
73
73
73
76
66
65
34
35
37
24
119
14
24
22
18
101
20
20
20
20
20
111
95
93
93
66
65
65
95
57
73
47
47
Nombre del medicamento
piperacillin sodium/tazobactam sodium
piroxicam
PLASMA-LYTE A
PLASMA-LYTE-148
PLASMA-LYTE-56/D5W
podofilox
polyethylene glycol 3350
polymyxin b sulfate
polymyxin b sulfate/trimethoprim sulfate
POLY-VI-SOL
POLY-VI-SOL/IRON
POMALYST
portia-28
POTASSIUM CHLORIDE
potassium chloride 0.15% /nacl 0.45%
viaflex
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45%
potassium chloride 0.15%/nacl 0.9%
potassium chloride 0.22% d5w/nacl 0.45%
POTASSIUM CHLORIDE 0.3%/ NACL
0.9%
potassium chloride 0.3%/d5w
potassium chloride er
potassium chloride sr
potassium citrate er
POTIGA
povidone-iodine
PRADAXA
pramegel
pramipexole dihydrochloride
pravastatin sodium
prazosin hcl
PRED-G
PRED-G S.O.P.
prednicarbate
prednisolone acetate
prednisolone sodium phosphate
prednisolone sodium phosphate
prednisone
pregnyl w/diluent benzyl alcohol/nacl
PREMARIN
PREMASOL
PREMPHASE
PREMPRO
PRENAPLUS
prenatabs rx
prenatal plus iron
preparation h hydrocortisone
Página 137 de 143
# de
página
14
2
111
111
111
66
76
9
94
116
116
30
84
111
111
111
111
111
111
111
111
111
111
111
16
9
49
66
35
62
53
95
95
80
95
80
95
80
81
84
112
84
84
116
116
116
80
Nombre del medicamento
prevalite
previfem
PREZCOBIX
PREZISTA
PRIFTIN
PRILOSEC OTC
PRIMAQUINE PHOSPHATE
primidone
PRIMSOL
PRISTIQ
PROAIR HFA
PROAIR RESPICLICK
probenecid
probenecid/colchicine
PROCAINAMIDE HCL
PROCALAMINE
PROCHLORPERAZINE EDISYLATE
prochlorperazine maleate
PROCRIT
PROCTO-PAK
proctosol hc
proctozone-hc
prodigy insulin mini pen needles/31g x
3/16"
prodigy insulin short penneedles/31g x
5/16"
PROFERRIN ES
progesterone
PROGLYCEM
PROGRAF
PROLASTIN-C
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
promethazine vc plain
promethegan
PROMETRIUM
propafenone hcl
propranolol hcl
propranolol hcl er
propranolol/hydrochlorothiazide
propylthiouracil
PROQUAD
PROSHIELD PLUS SKIN PROTECTANT
PROSHIELD PROTECTIVE
HANDCREAM
prosight
PROSOL
# de
página
62
85
43
43
29
77
35
18
10
23
99
99
28
28
56
112
37
37
51
80
80
80
93
93
119
85
47
89
101
32
92
52
24
101
25
85
56
57
57
57
88
91
67
67
116
112
Nombre del medicamento
PROTONIX
PROTOPIC
protriptyline hcl
PULMOZYME
PURIXAN
px iron
pyrazinamide
pyridostigmine bromide
PYRIDOXINE HCL
qc 3 día vaginal cream
QC CALAMINE
qc pink bismuth
qc stool softener
QUADRACEL
quasense
QUDEXY XR
quetiapine fumarate
quinapril hcl
quinapril/hydrochlorothiazide
QUINIDINE GLUCONATE
quinidine gluconate cr
quinidine sulfate
quinidine sulfate er
quinine sulfate
ra vitamin e
RABAVERT
raloxifene hydrochloride
ramipril
RANEXA
ranitidine 75
ranitidine hcl
RAPAMUNE
REBETOL
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
REBIF TITRATION PACK
RECOMBIVAX HB
REFRESH
REFRESH CELLUVISC
refresh lacri-lube
REFRESH LIQUIGEL
REFRESH PLUS
REFRESH TEARS
reguloid
RELENZA DISKHALER
RELISTOR
RELISTOR
remedy antifungal
Página 138 de 143
# de
página
77
67
24
99
31
112
29
29
116
119
67
73
73
91
85
18
38
55
55
56
56
56
56
35
116
91
86
55
60
75
75
89
41
65
64
64
64
91
94
94
94
94
94
94
73
44
73
76
27
Nombre del medicamento
REMICADE
RENVELA
repaglinide
RESCRIPTOR
reserpine
RESTASIS
RETROVIR IV INFUSION
REVLIMID
REXULTI
REYATAZ
ribasphere
ribasphere ribapak
ribavirin
rifabutin
rifampin
RIFATER
riluzole
rimantadine hcl
ringers injection
ringers irrigation
risedronate sodium
RISPERDAL CONSTA
risperidone
risperidone odt
RITUXAN
rivastigmine tartrate
rizatriptan benzoate
rizatriptan benzoate odt
robitussin maximum strength
robitussin peak cold cough+ chest
congestion dm
ropinirole hcl
ROTARIX
ROTATEQ
roxicet
ROZEREM
rulox
rynex pse
SABRIL
SAIZEN
SAIZEN CLICK.EASY
salactic film
saline mist
saline nasal mist
saline nasal spray
SANTYL
SAPHRIS
SARNA
SAVELLA
# de
página
89
78
47
42
53
94
42
30
39
43
41
41
41
29
29
29
64
44
112
93
92
39
39
39
34
21
28
28
101
101
36
91
91
4
102
73
98
18
81
81
67
101
101
101
67
39
67
64
Nombre del medicamento
SAVELLA TITRATION PACK
sb docusate sodium
sb ear wax remover
sb lice treatment
sb milk of magnesia
sb saline nose
sb triple antibiotic
sea soft nasal mist
SEA-CLENS WOUND CLEANSER
sebex
selegiline hcl
SELENIUM
selenium sulfide
SELZENTRY
senexon
senna
senna lax
senna laxative
senna plus
sennalax-s
SENSI-CARE PROTECTIVE BARRIER
SENSIPAR
SEREVENT DISKUS
SEROMYCIN
SEROSTIM
sertraline hcl
sharobel
silace
sildenafil
silphen dm cough
silver sulfadiazine
SILVERMED
SIMULECT
simvastatin
sirolimus
slo-niacin
SLOW FE
SLOW-MAG
sm 3-day vaginal
sm acid reducer
sm antacid anti-gas
sm antacid/antigas
sm anti-diarrheal
sm antifungal miconazole
sm artificial tears
sm athletes foot
sm ballanced b-100
SM CALAMINE
SM CALAMINE PHENOLATED
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página
64
73
96
35
76
101
10
101
67
67
36
112
67
43
74
74
74
74
76
76
67
87
99
29
81
23
85
74
100
101
10
67
90
62
89
116
112
119
27
75
119
119
74
27
94
27
117
67
67
Nombre del medicamento
sm calcium antacid
sm clotrimazole vaginal
sm complete advanced formula
sm complete senior formula
sm double antibiotic
sm fiber
sm fiber laxative
sm fiber laxative
sm first aid antibiotic
sm gentle laxative
SM GLUCOSE
sm hydrocortisone
sm miconazole 3
sm miconazole 7
sm milk of magnesia
sm nasal decongestant pe
sm nasal spray saline
sm natural laxative plus stool softener
sm nicotine
sm nicotine polacrilex
sm pain reliever pm extra strength
sm pediatric electrolyte
sm povidone-iodine
sm redness relief
sm senna laxative
sm stomach relief
sm stool softener
sm stool softener plus laxative
sm triple antibiotic
sodium bicarbonate
sodium chloride
sodium chloride
sodium chloride
sodium chloride 0.45% viaflex
sodium chloride 0.9%
sodium fluoride
SODIUM LACTATE
sodium phenylbutyrate
sodium polystyrene sulfonate
sodium sulfacetamide
SOLTAMOX
soluble fiber
SOLU-CORTEF
SOLU-MEDROL
SOMATULINE DEPOT
SOMAVERT
SORIATANE
sorine
sotalol hcl
# de
página
74
27
117
117
10
74
119
76
10
74
47
80
27
27
76
120
101
76
7
7
117
112
10
120
74
74
74
76
10
74
67
94
112
112
112
112
103
69
103
15
30
74
80
80
87
88
67
56
56
Nombre del medicamento
sotalol hcl (af)
SOVALDI
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
spironolactone
spironolactone/hydrochlorothiazide
SPORANOX
sprintec 28
SPRYCEL
sronyx
ssd
stagesic
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
stavudine
sterile water irrigation
STIMATE
stimulant laxative
STIVARGA
stomach relief
stomach relief maximum strength
stool softener
stool softener extra strength
stool softener laxative
stool softener laxative dc
STRATTERA
STREPTOMYCIN SULFATE
STRIBILD
STROMECTOL
SUBOXONE
SUCRAID
sucralfate
sulfacetamide sodium
sulfacetamide sodium/prednisolone sodium
phosphate
sulfadiazine
SULFAMETHOXAZOLE/TRIMETHOPRI
M
sulfamethoxazole/trimethoprim ds
sulfasalazine
sulfazine ec
sulindac
sumatriptan succinate
sumatriptan succinate refill
summers eve medicated
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# de
página
56
41
98
98
61
61
27
85
33
85
10
4
36
36
36
36
36
36
43
93
81
74
33
74
74
74
74
76
74
64
8
42
34
5
69
76
15
95
15
15
15
91
91
2
28
28
10
Nombre del medicamento
SUPRAX
sure-fine pen needles 31gx3/16" 5mm
sure-fine pen needles 31gx5/16" 8mm
surgilube
SURMONTIL
SUSTIVA
SUTENT
SWEEN CREAM
SWIM EAR
SYLATRON
SYLVANT
SYMBICORT
SYMLINPEN 120
SYMLINPEN 60
SYNAGIS
SYNAREL
SYNERCID
SYNRIBO
SYNTHROID
SYPRINE
SYSTANE
systane nighttime
SYSTANE PRESERVATIVE FREE
TABLOID
tacrolimus
tacrolimus
TAFINLAR
TALWIN
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TANDEM
TARCEVA
TARGRETIN
TASIGNA
TASMAR
TAVIST ALLERGY
TAZORAC
taztia xt
tears naturale
tears naturale forte
tears naturale ii
tears pure
TEFLARO
TEGRETOL
TEGRETOL-XR
TEKTURNA
TEKTURNA HCT
telmisartan
# de
página
12
93
93
77
24
42
33
67
96
32
34
97
47
47
90
88
10
32
86
103
94
94
94
31
67
89
33
4
44
30
77
112
33
34
33
35
98
67
59
95
94
94
95
13
20
20
60
60
54
Nombre del medicamento
telmisartan/hydrochloroth
telmisartan/hydrochlorothiazide
temazepam
tencon
TENIVAC
terazosin hcl
terbinafine hcl
terbutaline sulfate
terconazole
testosterone cypionate
testosterone enanthate
TETANUS TOXOID ADSORBED
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED ADULT
TEV-TROPIN
THALOMID
THEO-24
theophylline
theophylline cr
theophylline er
THERA M PLUS
thera-derm
thera-derm bath oil
thera-gesic
THERA-M
therapeutic formula/hematinics
THEREMS-M
thiamine hcl
thioridazine hcl
thiotepa
thiothixene
thrive
THYMOGLOBULIN
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
tiagabine hydrochloride
ticlopidine hcl
TIKOSYN
TIMENTIN
timolol maleate
timolol maleate
timolol maleate ophthalmic gel forming
tinidazole
TIVICAY
tizanidine hcl
TOBI PODHALER
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# de
página
54
54
102
1
91
77
27
99
28
82
82
91
91
81
30
99
100
99
99
117
67
67
67
117
117
117
117
37
30
37
7
90
87
86
86
87
87
18
53
56
14
57
96
95
35
42
40
99
Nombre del medicamento
TOBRADEX
tobramycin
tobramycin sulfate
TOBRAMYCIN SULFATE/SODIUM
CHLORIDE
tobramycin/dexamethasone
tolbutamide
tolcapone
tolmetin sodium
tolnaftate
tolterodine tartrate
tolterodine tartrate er
topiramate
topiramate er
toposar
topotecan hcl
TORISEL
TORSEMIDE
tpn electrolytes
TRACLEER
TRADJENTA
tramadol hcl
tramadol hydrochloride/acetaminophen
trandolapril
tranexamic acid
TRANSDERM-SCOP
TRANS-VER-SAL PEDIAPATCH
tranylcypromine sulfate
TRAVASOL
travel sickness
trazodone hcl
TREANDA
TRECATOR
TRELSTAR MIXJECT
tretinoin
tretinoin
triamcinolone acetonide
triamcinolone acetonide
triamcinolone in orabase
triamterene/hydrochlorothiazide
triazolam
triderm
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl
trilyte
trimethobenzamide hcl
trimethoprim
trimipramine maleate
# de
página
95
99
8
8
95
47
35
2
28
77
77
19
18
32
32
89
60
112
100
47
4
4
55
52
25
67
22
113
25
21
30
29
88
34
67
80
97
65
61
45
80
37
44
35
76
25
10
24
Nombre del medicamento
trinessa
triple antibiotic
triple antibiotic plus
tri-previfem
TRISENOX
tri-sprintec
TRIUMEQ
trivora-28
TRIXAICIN
trixaicin hp
TROKENDI XR
TROPHAMINE
TRUMENBA
TRUVADA
TUMS E-X 750
TUMS ULTRA 1000
TUSNEL
TUSNEL PEDIATRIC
TUSNEL-DM PEDIATRIC
TWINRIX
TYBOST
TYGACIL
TYKERB
TYLENOL ARTHRITIS PAIN
TYLENOL EXTRA STRENGTH
TYLENOL SORE THROAT DÍATIME
TYPHIM VI
TYSABRI
TYVASO
TYZEKA
TYZINE PEDIATRIC NASAL DROPS
u-cort
ulticare short pen needles 31gx8mm
ulticare short pen needles ulti-fine iv
unithroid
ureacin-20
UROCIT-K 10
UROCIT-K 15
UROCIT-K 5
ursodiol
UVADEX
VAGISTAT-1
vagistat-3
valacyclovir hcl
VALCHLOR
VALCYTE
valganciclovir
valproate sodium
valproic acid
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# de
página
85
10
10
85
32
85
43
85
120
67
19
113
91
43
74
74
101
101
101
91
43
10
34
1
1
1
91
65
100
40
101
80
93
93
87
67
113
113
113
74
67
28
28
44
30
40
40
18
18
Nombre del medicamento
valsartan
valsartan/hydrochlorothiazide
vancomycin hcl
vandazole
VAQTA
VARIVAX
VARIZIG
VECTIBIX
VELCADE
velivet
VELVACHOL
venlafaxine hcl
venlafaxine hcl er
VENOFER
VENTOLIN HFA
verapamil hcl
verapamil hcl er
verapamil hcl sr
VEREGEN
VERSACLOZ
VIACTIV
VICKS VAPORUB
VICTRELIS
VIDEX PEDIATRIC
VIIBRYD
VIMPAT
VINATE ONE
VINBLASTINE SULFATE
vincristine sulfate
vinorelbine tartrate
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIRAZOLE
VIREAD
VISTIDE
VITAMAX
vitamin a
vitamin a & d
vitamin b-1
vitamin b-12
vitamin b-6
vitamin c
vitamin c cr
vitamin d-1000
vitamin d3
vitamin d3 400
vitamin e
VITAMIN K1
# de
página
54
54
10
10
91
91
91
34
32
85
68
23
23
113
99
59
59
59
68
40
120
120
41
43
23
20
117
32
32
32
44
42
42
41
43
40
117
117
68
117
117
117
118
117
118
118
118
118
118
Nombre del medicamento
vitamins & minerals
VITEKTA
vol-tab rx
VOLTAREN
voriconazole
VOTRIENT
VP-PNV-DHA
VPRIV
warfarin sodium
WELCHOL
WIBI
womens daily formula/folic
acid/calcium/iron
XALKORI
XARELTO
XARELTO STARTER PACK
XENAZINE
XGEVA
XIFAXAN
XOLAIR
XOPENEX
XOPENEX HFA
XTANDI
xulane
XYLOCAINE-MPF
XYREM
YERVOY
YF-VAX
zafirlukast
zaleplon
ZALTRAP
ZANOSAR
ZANTAC
ZAVESCA
zeasorb-af
ZELAPAR
ZELBORAF
ZEMAIRA
ZENPEP
ZETIA
ZIAGEN
zidovudine
zinc
zinc gluconate
zinc oxide
zinc sulfate
ZINC TRACE METAL
ZINECARD
ziprasidone hcl
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# de
página
118
42
118
68
28
34
118
69
49
62
68
118
34
50
50
64
92
10
101
99
99
30
85
5
102
34
91
98
102
32
30
75
69
28
36
34
101
69
62
43
43
113
101
68
113
120
32
39
Nombre del medicamento
ZMAX
zoledronic acid
ZOLINZA
zolpidem tartrate
zolpidem tartrate er
ZOMETA
ZONALON
zonisamide
ZORBTIVE
ZORTRESS
ZOSTAVAX
ZOSTRIX DIABETIC FOOT PAIN
ZOSYN
zovia 1/35e
zovia 1/50e
ZOVIRAX
ZUBSOLV
ZYDELIG
ZYFLO CR
ZYKADIA
ZYPREXA RELPREVV
ZYTIGA
ZYVOX
# de
página
15
92
32
102
102
92
68
17
81
89
91
68
14
85
85
44
5
32
98
32
39
30
10
999 Oakmont Plaza Drive
Westmont, IL 60559
Teléfono: 877-941-0482
TTY: 711
http://mmp.illinicare.com
PARA PEDIR INFORMACIÓN
ADICIONAL, llame a Servicios
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de 8 a.m. a 8 p.m., siete días a la
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deje un mensaje. Su llamada será
devuelta dentro del próximo día
hábil.
00015549, Número de versión 21
Actualizado 10/01/2015
© 2015 IlliniCare HealthPlan. All rights reserved.