1. No category

H6870_ListOfDrugs15_TX_2015_102214-GO_S_Approved_02112015
STAR+PLUS MEDICARE-MEDICAID PLAN
Lista de medicamentos
cubiertos para 2015
(Formulario)
PARA PEDIR INFORMACIÓN
ADICIONAL, llame a Servicios para
afiliados al 1-866-896-1844 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.SuperiorHealthPlan.com
00015552, Número de versión 20
Actualizado 10/01/2015
H6870_ListOfDrugs15_TX_2015_102214-GO_S_Approved_02112015
Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan
(MMP) | Lista de medicamentos cubiertos (Formulario) para 2015
Esta Lista de medicamentos se actualizó el 1 de octubre, 2015. Para obtener información más
reciente o si tiene alguna pregunta, llame a Superior HealthPlan (Superior) STAR+PLUS MMP
al 1-866-896-1844 de 8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados
federales, es posible que le pidan que deje un mensaje. Su llamada será devuelta dentro del
próximo día hábil. Usuarios de TTY llamen al 711. La llamada es gratuita. Para obtener más
información, visite http://mmp.SuperiorHealthPlan.com
Ésta es una lista de medicamentos que los afiliados pueden obtener en Superior STAR+PLUS
MMP.
 Superior STAR+PLUS MMP es un plan de salud que tiene contrato con Medicare y
Texas Medicaid para proporcionar los beneficios de los dos programas a los afiliados.
 Los beneficios, la Lista de medicamentos cubiertos, 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
Superior STAR+PLUS MMP en internet en http://mmp.SuperiorHealthPlan.com.
 Se pueden aplicar limitaciones, copagos y restricciones. Para obtener más
información, llame a Servicios para afiliados de Superior STAR+PLUS MMP o lea el
Manual del afiliado de Superior STAR+PLUS MMP.
 Los copagos de medicamentos de receta podrían variar de acuerdo con el nivel de
Ayuda adicional que reciba. Comuníquese con el plan para conocer más detalles.
 Usted puede pedir esta información en otros formatos, como Braille o letra grande.
Llame al 1-866-896-1844. La llamada es gratuita
 You can get this information for free in other languages. Call 1-866-896-1844. The call
is free. Hours are from 8 a.m. to 8 p.m., seven days a week. On weekends and
Federal holidays, you may be asked to leave a message. Your call will be returned
within the next business day. TTY users call 711. The call is free.
 Usted puede obtener esta información de forma gratuita en otros idiomas. Llamar 1866-896-1844. La llamada es gratuita. Horario es de 8 am a 8 pm los siete días de la
semana. Los fines de semana y días feriados federales, se le puede pedir que deje un
mensaje. Su llamada será devuelta dentro del siguiente día hábil. Usuarios de TTY
deben llamar al 711. La llamada es gratuita
000015552, Número de versión 20
Actualizado 10/01/2015
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Si tiene alguna pregunta, por favor llame a Superior HealthPlan STAR+PLUS MMP al 1-866896-1844, de 8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales,
es posible que le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día
hábil. Usuarios de TTY llamen al 711. La llamada es gratuita. Para obtener más información,
visite http://mmp.SuperiorHealthPlan.com.
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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 13 son los
medicamentos cubiertos por Superior STAR+PLUS MMP. 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”.
 Superior STAR+PLUS MMP 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 Superior STAR+PLUS MMP.
 Superior STAR+PLUS MMP 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.SuperiorHealthPlan.com o llame a Servicios para Afiliados al 1-866-8961844.
2. ¿La Lista de medicamentos cambia alguna vez?
Sí. Superior STAR+PLUS MMP 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.
?
Si tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
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También podemos cambiar nuestras reglas sobre algunos medicamentos. Por ejemplo,
podríamos:
 Decidir si exigir o no aprobación previa para algún medicamento. (Aprobación
previa es el permiso de Superior STAR+PLUS MMP 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 medicamentos algún medicamento de la Parte D
que usted esté tomando. También le diremos cuando cambiemos nuestras reglas para cubrir
algún medicamento de la Parte D. 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 Superior
STAR+PLUS MMP en internet, en http://mmp.SuperiorHealthPlan.com. También
puede llamar a Servicios para Afiliados para revisar la Lista de medicamentos actual,
al 1-866-896-1844.
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 de la Parte D 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 medicamentos
cubiertos. Por ejemplo, si añadimos autorización previa (aprobación) y/o un límite de cantidad, el
?
Si tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
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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 una recarga del
medicamento. Si le notificamos en el momento en que solicite una recarga de su medicamento,
recibirá un suministro de 60 días del medicamento. Para mayor información acerca de estas
reglas de medicamentos, vea la página 4. Si tiene preguntas sobre el aviso que recibirá de
Superior STAR+PLUS MMP, comuníquese con Servicios para Afiliados llamando al 1-866-8961844 de 8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es
posible que le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil.
Usuarios de TTY llamen al 711.
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 haber recibido aviso sobre el cambio,
comuníquese con el médico que le haya recetado.
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 Superior
STAR+PLUS MMP antes de surtir su receta. Y si usted no consigue la aprobación,
Superior STAR+PLUS MMP podría no cubrir el medicamento.
 Límites de cantidad: A veces Superior STAR+PLUS MMP limita la cantidad de un
medicamento que usted puede obtener.
 Tratamiento progresivo: A veces Superior STAR+PLUS MMP 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
?
Si tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
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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 la página 11. Usted también puede obtener más información en nuestro sitio web en
http://mmp.SuperiorHealthPlan.com. Tenemos en internet un documento explicando nuestra
restricción de aprobación previa. 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 Superior STAR+PLUS MMP. 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 13 tiene una columna llamada “Medidas
necesarias, restricciones o límites de 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
?
Si tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
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medicamentos. Esto le dará tiempo para hablar con su médico u otro profesional de la salud
sobre qué hacer después.
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 página 125.
Para buscar por enfermedad, busque la sección titulada “Lista de medicamentos por
enfermedad” de la página 13. 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 para
Afiliados al 1-866-896-1844 y pregunte por él. Si se entera que Superior STAR+PLUS MMP no
cubrirá el medicamento, usted puede hacer algo de lo siguiente:
 Pida a Servicios para Afiliados 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.
?
Si tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
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10. ¿Qué pasará si usted es un afiliado nuevo de Superior STAR+PLUS
MMP y no puede encontrar su medicamento en la Lista o tiene
problemas para obtener su medicamento?
Podemos ayudarle. Puede que cubramos un suministro temporario de 30 días de su
medicamento durante los primeros 90 días que usted sea afiliado de Superior STAR+PLUS
MMP. Esto le dará tiempo para hablar con su médico u otro proveedor médico. Ellos pueden
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.
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 Superior STAR+PLUS MMP 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 98 días. Usted puede resurtir
el medicamento varias veces durante los 90 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.
Puede que durante el año del plan, usted tenga un cambio en el ambiente de su tratamiento (el
lugar en el cual obtiene y toma su medicamento), debido al nivel de cuidado que requiere. Tales
transiciones pueden incluir, pero no se limitan a:

Afiliados que son dados de alta de un hospital o centro de enfermería
especializada a un ambiente de hogar

Afiliados que son ingresados a un hospital o centro de enfermería
especializada desde un ambiente de hogar

Afiliados que se transfieren de una centro de enfermería especializada a otro y
que son servidos por otra farmacia
?
Si tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
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
Afiliados que terminan su estadía de Medicare Parte A en un centro de
enfermería especializada (donde los pagos incluyen todos los cargos de
farmacia) y que ahora tienen que recurrir a su beneficio Parte D del plan

Afiliados que renuncian a su estado de hospicio y vuelven a la cobertura
estándar de Medicare Parte A y B

Afiliados dados de alta de hospitales psiquiátricos crónicos con regímenes de
medicamentos altamente individualizados
Para estos cambios en ambientes de tratamiento, Superior STAR+PLUS MMP cubrirá un
suministro temporal de hasta 31 días de un medicamento cubierto por la Parte D cuando
despache su receta en una farmacia de la red. Si usted cambia de ambiente de
tratamiento varias veces dentro del mismo mes, tal vez tenga que solicitar una excepción
o autorización previa y obtener aprobación para una cobertura continua de su
medicamento. Revisaremos estas solicitudes para continuación de terapia caso por caso
cuando se encuentre en un régimen de medicamentos estable que es conocido por
conllevar riesgos al ser cambiado. Para pedir un suministro temporal de un medicamento,
llame a Servicios para Afiliados.
11. ¿Puede pedir al plan que haga una excepción para cubrir su
medicamento?
Sí. Usted puede pedirle a Superior STAR+PLUS MMP 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, Superior STAR+PLUS MMP 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 tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
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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.
13. ¿Cómo puede pedir una excepción?
Para pedir un excepción, llame Servicios para Afiliados al 1-866-896-1844 de 8 a.m. a 8 p.m.,
siete días a la semana. Los fines de semana y feriados federales, es posible que le pidan que
deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios de TTY llamen
al 711. 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 activos 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).
Superior STAR+PLUS MMP 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". Superior STAR+PLUS MMP cubre
algunos medicamentos de venta libre cuando su proveedor los escriba en forma de receta
médica.
Usted puede leer la Lista de medicamentos de Superior STAR+PLUS MMP para ver qué
medicamentos de venta libre están cubiertos.
?
Si tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
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16. ¿Superior STAR+PLUS MMP cubre algún producto de venta libre
que no sea un medicamento?
Superior STAR+PLUS MMP cubre algunos productos de venta libre que no son medicamentos
cuando su proveedor los escriba en forma de receta médica.
Usted puede leer la Lista de medicamentos de Superior STAR+PLUS MMP para ver qué
productos de venta libre, que no son medicamentos, están cubiertos.
17. ¿Cuánto es su copago?
Usted puede leer la Lista de medicamentos de Superior STAR+PLUS MMP para enterarse de los
copagos de cada medicamento.
Los afiliados de Superior STAR+PLUS MMP 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.
 Los medicamentos de Nivel 1 tienen el copago más bajo. Son medicamentos
genéricos. El Copago será 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 son medicamentos de venta libre de Superior
STAR+PLUS MMP que no son de Medicare Rx/OTC. El copago será de $0..
?
Si tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
10
Lista de medicamentos cubiertos
La lista de medicamentos cubiertos que comienza en la página siguiente le da información sobre
los medicamentos cubiertos por Superior STAR+PLUS MMP. Si usted tiene problemas para
encontrar su medicamento en la lista, lea el Índice que comienza en la página 125.
La primera columna del cuadro contiene el nombre del medicamento. Los medicamentos de
marca están escritos en mayúsculas (p.ej.: HUMALOG) y los medicamentos genéricos están
escritos en cursivas minúsculas (p.ej.: amoxicillin). La información de la columna titulada
"Medidas necesarias, restricciones o límites de uso", le indica si Superior STAR+PLUS MMP
tiene alguna regla para cubrir su medicamento.
Abreviaciones
B/D
DP
LA
PA
QL
MO
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
LA: Disponibilidad limitada. Esta receta médica podría estar disponible solo
en farmacias determinadas. Para obtener mayor información, consulte su
Directorio de farmacias o llame a Servicios para Afiliados al 1-866-896-1844
de 8 a.m. a 8 p.m., siete días a la semana. Usuarios de TTY/TDD deben
llamar al 711.
Esta receta requiere que usted o su médico obtenga autorización previa.
Esto significa que tendrá que obtener aprobación de Superior STAR+PLUS
MMP antes de surtir sus recetas médicas. Si no obtiene aprobación, nuestro
plan podría no cubrir el medicamento.
Para ciertos medicamentos, nuestro plan limita la cantidad del medicamento
que cubrirá. Por ejemplo, Superior STAR+PLUS MMP proporciona 30
tabletas por cada receta de Januvia. Esto podría ser en suma a un suministro
estándar de uno o tres meses.
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 minoristas 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 símbolo "DP" junto a un medicamento significa que el medicamento no es un
“medicamento Parte D”. La cantidad que usted paga cuándo surta una receta de este medicamento
no cuenta hacia el costo total de sus medicamentos (o sea, la cantidad que usted paga no le ayuda
para ser elegible para cobertura catastrófica). Además, si recibe Ayuda adicional para pagar sus
?
Si tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
11
recetas, usted no recibirá ninguna Ayuda adicional para pagar estos medicamentos. Estos
medicamentos también tienen reglas diferentes para las apelaciones. Una apelación es una
manera formal de pedirnos que revisemos alguna decisión de cobertura y que la cambiemos, si le
parece que hemos cometido un error. Por ejemplo, podríamos decidir que un medicamento que
usted quiere ya no está cubierto por Medicare o Medicaid. Si usted o su médico no están de
acuerdo con nuestra decisión, usted puede apelar. Para pedir instrucciones sobre cómo apelar,
llame a Servicios para Afiliados, al 1-866-896-1844. Usted también puede enterarse de cómo
apelar una decisión leyendo el Manual del afiliado.
?
Si tiene alguna pregunta, por favor llame a Superior STAR+PLUS MMP al 1-855-735-4398, de
8 a.m. a 8 p.m., siete días a la semana. Los fines de semana y feriados federales, es posible que
le pidan que deje un mensaje. Su llamada será devuelta dentro del próximo día hábil. Usuarios
de TTY llamen al 711. La llamada es gratuita. Para obtener más información, visite
http://mmp.SuperiorHealthPlan.com.
12
Nombre del medicamento
Analgesics
Analgesics
acephen suppository 120mg
acephen suppository 120mg
acephen suppository 120mg
acephen suppository 325mg
acephen suppository 650mg
acephen suppository 650mg
acephen suppository 650mg
acetaminophen/diphenhydramine tablet 500mg; 25mg
acetaminophen tablet 325mg
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
childrens mapap rapid tabs tablet dispersible 80mg
childrens pain reliever tablet dispersible 80mg
childrens silapap liquid 160mg/5ml
childrens silapap liquid 160mg/5ml
childrens silapap liquid 160mg/5ml
ed-apap liquid 160mg/5ml
ELIXSURE FEVER/PAIN GEL 160MG/5ML
ELIXSURE FEVER/PAIN GEL 160MG/5ML
ELIXSURE FEVER/PAIN GEL 160MG/5ML
gnp arthritis pain relief tablet extended release 650mg
gnp pain relief extra strength tablet 500mg
gnp pain relief extra strength tablet 500mg
gnp pain relief extra strength tablet 500mg
gnp pain relief extra strength tablet 500mg
gnp pain relief tablet 325mg
GRALISE STARTER MISCELLANEOUS 0
GRALISE TABLET 300MG
GRALISE TABLET 600MG
infants silapap solution 100mg/ml
infants silapap solution 100mg/ml
junior mapap tablet dispersible 160mg
mapap arthritis pain tablet extended release 650mg
mapap childrens suspension 160mg/5ml
mapap childrens tablet dispersible 80mg
mapap infants suspension 160mg/5ml
mapap pm tablet 500mg; 25mg
mapap capsule 500mg
mapap liquid 160mg/5ml
Página 1 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
DP
DP
DP
DP
DP
DP
DP
DP
DP
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 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(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
mapap liquid 160mg/5ml
mapap tablet chewable 80mg
mapap tablet 500mg
mapap tablet 500mg
mapap tablet 500mg
mapap tablet 500mg
mapap tablet 500mg
medi-tabs extra strength tablet 500mg
medi-tabs pm extra strength tablet 500mg; 25mg
medi-tabs tablet 325mg
non-aspirin childrens suspension 160mg/5ml
non-aspirin pain relief extra strength tablet 500mg
non-aspirin pain relief extra strength tablet 500mg
nortemp infants suspension 80mg/0.8ml
nortemp suspension 160mg/5ml
pain & fever childrens solution 160mg/5ml
pain & fever childrens solution 160mg/5ml
pain & fever childrens suspension 160mg/5ml
pain & fever childrens suspension 160mg/5ml
pain & fever childrens suspension 160mg/5ml
pain & fever childrens suspension 160mg/5ml
pain & fever extra strength tablet 500mg
pain & fever extra strength tablet 500mg
pain & fever extra strength tablet 500mg
pain & fever extra strength tablet 500mg
pain & fever tablet 325mg
pain & fever tablet 325mg
pain relief childrens suspension 160mg/5ml
pain relief extra strength tablet 500mg
pain relief extra strength tablet 500mg
pain reliever pm extra strength tablet 500mg; 25mg
q-pap childrens suspension 160mg/5ml
q-pap childrens suspension 160mg/5ml
q-pap childrens suspension 160mg/5ml
q-pap extra strength tablet 500mg
q-pap extra strength tablet 500mg
q-pap infants solution 80mg/0.8ml
q-pap liquid 160mg/5ml
q-pap liquid 160mg/5ml
q-pap liquid 160mg/5ml
q-pap tablet 325mg
q-pap tablet 325mg
qc arthritis pain relief tablet extended release 650mg
qc arthritis pain relief tablet extended release 650mg
qc non-aspirin childrens suspension 160mg/5ml
qc non-aspirin extra strength tablet 500mg
qc non-aspirin extra strength tablet 500mg
qc non-aspirin pm tablet 500mg; 25mg
Página 2 de 148
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(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)
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
DP
$0(Nivel 3)
$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
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
Nombre del medicamento
sm pain reliever childrens suspension 160mg/5ml
sm pain reliever extra strength tablet 500mg
sm pain reliever extra strength tablet 500mg
sm pain reliever pm extra strength tablet 500mg; 25mg
sm pain reliever tablet 325mg
tencon tablet 325mg; 50mg
Nonsteroidal Anti-inflammatory Drugs
added strength headache relief tablet 250mg; 250mg; 65mg
added strength headache relief tablet 250mg; 250mg; 65mg
adult aspirin ec low strength tablet delayed release 81mg
all día pain relief tablet 220mg
all día pain relief tablet 220mg
all día relief tablet 220mg
all día relief tablet 220mg
aspir-low tablet delayed release 81mg
aspir-low tablet delayed release 81mg
aspir-low tablet delayed release 81mg
aspirin adult low strength tablet chewable 81mg
aspirin childrens tablet chewable 81mg
aspirin ec lo-dose tablet delayed release 81mg
aspirin ec lo-dose tablet delayed release 81mg
aspirin ec low dose tablet delayed release 81mg
aspirin ec low dose tablet delayed release 81mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 325mg
aspirin ec tablet delayed release 81mg
aspirin ec tablet delayed release 81mg
aspirin ec tablet delayed release 81mg
aspirin ec tablet delayed release 81mg
aspirin low strength tablet chewable 81mg
aspirin tablet chewable 81mg
aspirin tablet chewable 81mg
aspirin tablet chewable 81mg
aspirin tablet delayed release 325mg
aspirin tablet delayed release 325mg
aspirin tablet delayed release 325mg
aspirin tablet delayed release 325mg
aspirin tablet 325mg
aspirin tablet 325mg
aspirin tablet 325mg
aspirin tablet 325mg
aspirin tablet 325mg
aspirin tablet 325mg
childrens aspirin tablet chewable 81mg
childrens aspirin tablet chewable 81mg
childrens aspirin tablet chewable 81mg
childrens aspirin tablet chewable 81mg
Página 3 de 148
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(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 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)
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
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
diclofenac potassium tablet 50mg
$0(Nivel 1)
MO
diclofenac sodium dr tablet delayed release 25mg
$0(Nivel 1)
diclofenac sodium dr tablet delayed release 50mg
$0(Nivel 1)
diclofenac sodium dr tablet delayed release 75mg
$0(Nivel 1)
diclofenac sodium er tablet extended release 24 hour 100mg $0(Nivel 1)
diflunisal tablet 500mg
$0(Nivel 1)
effervescent pain relief tablet effervescent 325mg; 1000mg; $0(Nivel 3)
DP
1916mg
enteric coated aspirin tablet delayed release 325mg
$0(Nivel 3)
DP
enteric coated aspirin tablet delayed release 325mg
$0(Nivel 3)
DP
etodolac er tablet extended release 24 hour 400mg
$0(Nivel 1)
etodolac er tablet extended release 24 hour 500mg
$0(Nivel 1)
etodolac er tablet extended release 24 hour 600mg
$0(Nivel 1)
etodolac capsule 200mg
$0(Nivel 1)
etodolac capsule 300mg
$0(Nivel 1)
etodolac tablet 400mg
$0(Nivel 1)
etodolac tablet 500mg
$0(Nivel 1)
fenoprofen calcium tablet 600mg
$0(Nivel 1)
flurbiprofen tablet 100mg
$0(Nivel 1)
flurbiprofen tablet 50mg
$0(Nivel 1)
gnp adult aspirin low strength tablet chewable 81mg
$0(Nivel 3)
DP
gnp aspirin tablet 325mg
$0(Nivel 3)
DP
gnp ibuprofen junior strength tablet chewable 100mg
$0(Nivel 3)
DP
gnp ibuprofen junior strength tablet chewable 100mg
$0(Nivel 3)
DP
gnp ibuprofen tablet 200mg
$0(Nivel 3)
DP
gnp ibuprofen tablet 200mg
$0(Nivel 3)
DP
gnp ibuprofen tablet 200mg
$0(Nivel 3)
DP
gnp ibuprofen tablet 200mg
$0(Nivel 3)
DP
headache formula added strength tablet 250mg; 250mg; 65mg $0(Nivel 3)
DP
ibu-drops infants suspension 50mg/1.25ml
$0(Nivel 3)
DP
ibu-drops suspension 40mg/ml
$0(Nivel 3)
DP
ibu-profen cold/sinus tablet 200mg; 30mg
$0(Nivel 3)
DP
ibuprofen junior strength tablet chewable 100mg
$0(Nivel 3)
DP
ibuprofen capsule 200mg
$0(Nivel 3)
DP
ibuprofen suspension 100mg/5ml
$0(Nivel 1)
ibuprofen tablet 200mg
$0(Nivel 3)
DP
ibuprofen tablet 200mg
$0(Nivel 3)
DP
ibuprofen tablet 200mg
$0(Nivel 3)
DP
ibuprofen tablet 200mg
$0(Nivel 3)
DP
ibuprofen tablet 200mg
$0(Nivel 3)
DP
ibuprofen tablet 200mg
$0(Nivel 3)
DP
ibuprofen tablet 200mg
$0(Nivel 3)
DP
ibuprofen tablet 200mg
$0(Nivel 3)
DP
ibuprofen tablet 200mg
$0(Nivel 3)
DP
ibuprofen tablet 200mg
$0(Nivel 3)
DP
$0(Nivel 3)
DP
ibuprofen tablet 200mg
ibuprofen tablet 200mg
$0(Nivel 3)
DP
ibuprofen tablet 200mg
$0(Nivel 3)
DP
Página 4 de 148
Nombre del medicamento
ibuprofen tablet 200mg
ibuprofen tablet 200mg
ibuprofen tablet 200mg
ibuprofen tablet 200mg
ibuprofen tablet 400mg
ibuprofen tablet 600mg
ibuprofen tablet 800mg
indomethacin er capsule extended release 75mg
indomethacin capsule 25mg
indomethacin capsule 50mg
infants ibuprofen suspension 50mg/1.25ml
infants ibuprofen suspension 50mg/1.25ml
infants ibuprofen suspension 50mg/1.25ml
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
medi-profen tablet 200mg
medi-profen tablet 200mg
medi-profen tablet 200mg
meloxicam suspension 7.5mg/5ml
meloxicam tablet 15mg
meloxicam tablet 7.5mg
migraine formula tablet 250mg; 250mg; 65mg
migraine formula tablet 250mg; 250mg; 65mg
nabumetone tablet 500mg
nabumetone tablet 750mg
naproxen dr tablet delayed release 375mg
naproxen dr tablet delayed release 500mg
naproxen sodium tablet 220mg
naproxen sodium tablet 220mg
naproxen sodium tablet 220mg
naproxen sodium tablet 220mg
naproxen sodium tablet 220mg
naproxen sodium tablet 220mg
naproxen sodium tablet 275mg
naproxen sodium tablet 550mg
naproxen suspension 125mg/5ml
naproxen tablet 250mg
naproxen tablet 375mg
naproxen tablet 500mg
oxaprozin tablet 600mg
Página 5 de 148
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 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 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$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 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$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 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 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
piroxicam capsule 10mg
piroxicam capsule 20mg
qc aspirin low dose tablet delayed release 81mg
qc aspirin tablet delayed release 325mg
qc aspirin tablet 325mg
qc aspirin tablet 325mg
qc childrens aspirin tablet chewable 81mg
qc headache relief tablet 250mg; 250mg; 65mg
qc ibuprofen capsule 200mg
qc ibuprofen tablet 200mg
qc ibuprofen tablet 200mg
qc naproxen sodium tablet 220mg
qc naproxen sodium tablet 220mg
sm aspirin ec low strength tablet delayed release 81mg
sm aspirin tablet 325mg
sm childrens aspirin tablet chewable 81mg
sm childrens aspirin tablet chewable 81mg
sm headache added strength tablet 250mg; 250mg; 65mg
sm ibuprofen tablet 200mg
sm ibuprofen tablet 200mg
sm ibuprofen tablet 200mg
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
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
Página 6 de 148
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)
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)
$0(Nivel 1)
$0(Nivel 1)
MO
$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 (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)
$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)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
acetaminophen/codeine #3 tablet 300mg; 30mg
$0(Nivel 1)
QL (390 EA cada 30 días)
acetaminophen/codeine tablet 300mg; 15mg
$0(Nivel 1)
QL (390 EA cada 30 días)
$0(Nivel 1)
QL (390 EA cada 30 días)
acetaminophen/codeine tablet 300mg; 60mg
$0(Nivel 1)
ascomp/codeine capsule 325mg; 50mg; 40mg; 30mg
butorphanol tartrate injection 1mg/ml
$0(Nivel 1)
butorphanol tartrate injection 2mg/ml
$0(Nivel 1)
butorphanol tartrate solution 10mg/ml
$0(Nivel 1)
DEMEROL INJECTION 50MG/ML
$0-$6.60(Nivel 2)
duramorph injection 0.5mg/ml
$0(Nivel 1)
duramorph injection 1mg/ml
$0(Nivel 1)
endocet tablet 325mg; 10mg
$0(Nivel 1)
QL (360 EA cada 30 días)
endocet tablet 325mg; 5mg
$0(Nivel 1)
QL (360 EA cada 30 días)
endocet tablet 325mg; 7.5mg
$0(Nivel 1)
QL (360 EA cada 30 días)
Citrato de fentanilo por víatransmucosa oral lozenge on a
$0(Nivel 1)
QL (120 EA cada 30 días)
handle 1200mcg
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 1600mcg
PA (Citrato de fentanilo
por víatransmucosa oral)
$0(Nivel 1)
QL (120 EA cada 30 días)
Citrato de fentanilo por víatransmucosa oral lozenge on a
handle 200mcg
PA (Citrato de fentanilo
por víatransmucosa oral)
$0(Nivel 1)
QL (120 EA cada 30 días)
Citrato de fentanilo por víatransmucosa oral lozenge on a
PA (Citrato de fentanilo
handle 400mcg
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)
$0(Nivel 1)
QL (360 EA cada 30 días)
hydrocodone/acetaminophen tablet 325mg; 10mg
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)
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)
hydrocodone/acetaminophen tablet 650mg; 10mg
$0(Nivel 1)
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)
hydrocodone/acetaminophen tablet 750mg; 7.5mg
$0(Nivel 1)
QL (150 EA cada 30 días)
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)
Página 7 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
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)
$0(Nivel 1)
QL (240 EA cada 30 días)
tramadol hcl tablet 50mg
tramadol hydrochloride/acetaminophen tablet 325mg; 37.5mg $0(Nivel 1)
QL (240 EA cada 30 días)
Anesthetics
Local Anesthetics
azo tabs tablet 95mg
$0(Nivel 3)
DP
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)
lidocaine/prilocaine cream 2.5%; 2.5%
$0(Nivel 1)
lidocaine ointment 5%
$0(Nivel 1)
lidocaine patch 5%
$0(Nivel 1)
QL (90 EA cada 30 días)
PA (Anestésicos)
XYLOCAINE-MPF INJECTION 1%
$0-$6.60(Nivel 2)
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium dr tablet delayed release 333mg
$0(Nivel 1)
disulfiram tablet 250mg
$0(Nivel 1)
Página 8 de 148
Nombre del medicamento
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
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 7MG/24HR
nicorelief gum 2mg
nicorelief gum 2mg
nicorelief gum 4mg
nicorelief gum 4mg
NICORETTE MINI LOZENGE 2MG
NICORETTE MINI LOZENGE 4MG
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 4MG
NICORETTE GUM 4MG
NICORETTE GUM 4MG
NICORETTE GUM 4MG
NICORETTE LOZENGE 2MG
NICORETTE LOZENGE 2MG
NICORETTE LOZENGE 2MG
NICORETTE LOZENGE 4MG
NICORETTE LOZENGE 4MG
NICORETTE LOZENGE 4MG
nicotine polacrilex gum 2mg
Página 9 de 148
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)
$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
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
Nombre del medicamento
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 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
NICOTROL NS SOLUTION 10MG/ML
Antibacterials
Aminoglycosides
amikacin sulfate injection 500mg/2ml
AMIKACIN SULFATE INJECTION 50MG/ML
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
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%
Página 10 de 148
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(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 1)
$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(Nivel 1)
$0(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)
Nombre del medicamento
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/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
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
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
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%
Página 11 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
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-$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)
B/D
$0-$6.60(Nivel 2)
$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)
Nombre del medicamento
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%
povidone-iodine ointment 10%
povidone-iodine solution 10%
povidone-iodine solution 10%
povidone-iodine solution 10%
PRIMSOL SOLUTION 50MG/5ML
qc povidone iodine solution 10%
silver sulfadiazine cream 1%
ssd cream 1%
SYNERCID INJECTION 350MG; 150MG
trimethoprim tablet 100mg
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm
triple antibiotic ointment 400unit/gm; 5mg/gm; 5000unit/gm
TYGACIL INJECTION 50MG
vancomycin hcl capsule 125mg
vancomycin hcl capsule 250mg
vancomycin hcl injection 1000mg
vancomycin hcl injection 10gm
vancomycin hcl injection 500mg
vandazole gel 0.75%
XIFAXAN TABLET 200MG
ZYVOX INJECTION 2MG/ML
ZYVOX SUSPENSION RECONSTITUTED 100MG/5ML
ZYVOX TABLET 600MG
Beta-lactam, Cephalosporins
cefaclor er tablet extended release 12 hour 500mg
cefaclor capsule 250mg
cefaclor capsule 500mg
cefadroxil capsule 500mg
cefadroxil suspension reconstituted 250mg/5ml
cefadroxil suspension reconstituted 500mg/5ml
cefadroxil tablet 1gm
cefazolin sodium injection 10gm
Página 12 de 148
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)
PA (Antibacterianos)
$0(Nivel 1)
PA (Antibacterianos)
$0(Nivel 1)
PA (Antibacterianos)
$0(Nivel 1)
$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 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 3)
DP
$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-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (600 ML cada 10 días)
$0-$6.60(Nivel 2) 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)
Nombre del medicamento
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
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
ceftriaxone sodium injection 1gm
Página 13 de 148
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(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$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 250mg
$0(Nivel 1)
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)
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)
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)
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)
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)
ceftriaxone sodium injection 500mg
$0(Nivel 1)
cefuroxime axetil tablet 250mg
$0(Nivel 1)
cefuroxime axetil tablet 500mg
$0(Nivel 1)
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)
cephalexin capsule 500mg
$0(Nivel 1)
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)
SUPRAX TABLET CHEWABLE 100MG
$0-$6.60(Nivel 2)
SUPRAX TABLET CHEWABLE 200MG
$0-$6.60(Nivel 2)
SUPRAX TABLET 400MG
$0-$6.60(Nivel 2)
TEFLARO INJECTION 400MG
$0-$6.60(Nivel 2)
TEFLARO INJECTION 600MG
$0-$6.60(Nivel 2)
Página 14 de 148
Nombre del medicamento
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
ampicillin-sulbactam injection 1gm; 0.5gm
ampicillin-sulbactam injection 2gm; 1gm
ampicillin capsule 250mg
ampicillin capsule 500mg
ampicillin suspension reconstituted 125mg/5ml
Página 15 de 148
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-$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)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
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
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
Página 16 de 148
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-$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)
$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)
QL (28 EA cada 14 días)
QL (42 EA cada 21 días)
Nombre del medicamento
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
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
sulfamethoxazole/trimethoprim suspension 200mg/5ml;
40mg/5ml
sulfamethoxazole/trimethoprim tablet 400mg; 80mg
Tetracyclines
demeclocycline hcl tablet 150mg
demeclocycline hcl tablet 300mg
Página 17 de 148
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(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-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
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
POTIGA TABLET 300MG
POTIGA TABLET 400MG
POTIGA TABLET 50MG
Calcium Channel Modifying Agents
CELONTIN CAPSULE 300MG
Página 18 de 148
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-$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)
$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)
Nombre del medicamento
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
ONFI TABLET 20MG
ONFI TABLET 5MG
phenobarbital elixir 20mg/5ml
phenobarbital tablet 100mg
phenobarbital tablet 15mg
phenobarbital tablet 16.2mg
Página 19 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
$0(Nivel 1)
QL (300 EA cada 30 días)
$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)
$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
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
topiramate er capsule er 24 hour sprinkle 200mg
topiramate er capsule er 24 hour sprinkle 25mg
topiramate er capsule er 24 hour sprinkle 50mg
Página 20 de 148
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-$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
$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
Nombre del medicamento
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
oxcarbazepine tablet 600mg
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 150MG
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 300MG
Página 21 de 148
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) 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)
$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
Nombre del medicamento
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
galantamine hydrobromide tablet 8mg
rivastigmine tartrate capsule 1.5mg
rivastigmine tartrate capsule 3mg
rivastigmine tartrate capsule 4.5mg
rivastigmine tartrate capsule 6mg
Página 22 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (60 EA cada 30 días)
QL (180 EA cada 30 días)
QL (90 EA cada 30 días)
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
Nombre del medicamento
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA TITRATION PAK TABLET 0
$0-$6.60(Nivel 2)
NAMENDA SOLUTION 10MG/5ML
$0-$6.60(Nivel 2) QL (360 ML cada 30 días)
NAMENDA TABLET 10MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
NAMENDA TABLET 5MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
Antidepressants
Antidepressants, Other
BRINTELLIX TABLET 10MG
$0-$6.60(Nivel 2) MO
BRINTELLIX TABLET 20MG
$0-$6.60(Nivel 2) MO
BRINTELLIX TABLET 5MG
$0-$6.60(Nivel 2) MO
$0(Nivel 1)
budeprion sr tablet extended release 12 hour 100mg
budeprion sr tablet extended release 12 hour 150mg
$0(Nivel 1)
bupropion hcl sr tablet extended release 12 hour 100mg
$0(Nivel 1)
bupropion hcl sr tablet extended release 12 hour 150mg
$0(Nivel 1)
bupropion hcl sr tablet extended release 12 hour 200mg
$0(Nivel 1)
bupropion hcl xl tablet extended release 24 hour 150mg
$0(Nivel 1)
QL (30 EA cada 30 días)
bupropion hcl xl tablet extended release 24 hour 300mg
$0(Nivel 1)
QL (30 EA cada 30 días)
bupropion hcl tablet 100mg
$0(Nivel 1)
bupropion hcl tablet 75mg
$0(Nivel 1)
maprotiline hcl tablet 25mg
$0(Nivel 1)
maprotiline hcl tablet 50mg
$0(Nivel 1)
maprotiline hcl tablet 75mg
$0(Nivel 1)
mirtazapine odt tablet dispersible 15mg
$0(Nivel 1)
mirtazapine odt tablet dispersible 30mg
$0(Nivel 1)
mirtazapine odt tablet dispersible 45mg
$0(Nivel 1)
mirtazapine tablet 15mg
$0(Nivel 1)
mirtazapine tablet 30mg
$0(Nivel 1)
mirtazapine tablet 45mg
$0(Nivel 1)
mirtazapine tablet 7.5mg
$0(Nivel 1)
nefazodone hcl tablet 100mg
$0(Nivel 1)
nefazodone hcl tablet 150mg
$0(Nivel 1)
nefazodone hcl tablet 200mg
$0(Nivel 1)
nefazodone hcl tablet 250mg
$0(Nivel 1)
nefazodone hcl tablet 50mg
$0(Nivel 1)
trazodone hcl tablet 100mg
$0(Nivel 1)
trazodone hcl tablet 150mg
$0(Nivel 1)
trazodone hcl tablet 300mg
$0(Nivel 1)
trazodone hcl tablet 50mg
$0(Nivel 1)
Monoamine Oxidase Inhibitors
EMSAM PATCH 24 HOUR 12MG/24HR
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
EMSAM PATCH 24 HOUR 6MG/24HR
EMSAM PATCH 24 HOUR 9MG/24HR
$0-$6.60(Nivel 2)
MARPLAN TABLET 10MG
$0-$6.60(Nivel 2)
phenelzine sulfate tablet 15mg
$0(Nivel 1)
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)
Página 23 de 148
Nombre del medicamento
citalopram hydrobromide tablet 10mg
citalopram hydrobromide tablet 20mg
citalopram hydrobromide tablet 40mg
desvenlafaxine er tablet extended release 24 hour 100mg
desvenlafaxine er tablet extended release 24 hour 50mg
duloxetine hcl capsule delayed release particles 20mg
duloxetine hcl capsule delayed release particles 30mg
duloxetine hcl capsule delayed release particles 40mg
duloxetine hcl capsule delayed release particles 60mg
escitalopram oxalate solution 5mg/5ml
escitalopram oxalate tablet 10mg
escitalopram oxalate tablet 20mg
escitalopram oxalate tablet 5mg
FETZIMA TITRATION PACK CAPSULE ER 24 HOUR
THERAPY PACK 0
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR
120MG
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR
20MG
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR
40MG
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR
80MG
fluoxetine hcl capsule 10mg
fluoxetine hcl capsule 20mg
fluoxetine hcl capsule 40mg
fluoxetine hcl solution 20mg/5ml
fluoxetine hcl tablet 10mg
fluvoxamine maleate tablet 100mg
fluvoxamine maleate tablet 25mg
fluvoxamine maleate tablet 50mg
KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR
100MG
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
Página 24 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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 (60 EA cada 30 días)
MO
$0(Nivel 1)
QL (60 EA cada 30 días)
MO
$0(Nivel 1)
QL (60 EA cada 30 días)
MO
$0(Nivel 1)
QL (60 EA cada 30 días)
MO
$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-$6.60(Nivel 2)
$0-$6.60(Nivel 2) MO
$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)
$0(Nivel 1)
$0(Nivel 1)
$0-$6.60(Nivel 2) QL (120 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-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
MO
$0(Nivel 1)
Nombre del medicamento
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
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
Página 25 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$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
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
dimenhydrinate 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)
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)
promethazine hcl injection 50mg/ml
$0(Nivel 1)
promethazine hcl suppository 12.5mg
$0(Nivel 1)
promethazine hcl suppository 25mg
$0(Nivel 1)
promethazine hcl suppository 50mg
$0(Nivel 1)
promethazine hcl syrup 6.25mg/5ml
$0(Nivel 1)
promethazine hcl tablet 12.5mg
$0(Nivel 1)
Página 26 de 148
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)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
Nombre del medicamento
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 50mg
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
anti-fungal powder powder 1%
antifungal aerosol 1%
antifungal cream 1%
antifungal cream 2%
antifungal cream 2%
antifungal cream 2%
CANCIDAS INJECTION 50MG
CANCIDAS INJECTION 70MG
ciclopirox olamine cream 0.77%
ciclopirox suspension 0.77%
clotrimazole cream 1%
clotrimazole cream 1%
clotrimazole cream 1%
clotrimazole cream 1%
Página 27 de 148
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-$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
$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(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
clotrimazole solution 1%
clotrimazole troche 10mg
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 SOLUTION 2%
griseofulvin microsize tablet 500mg
griseofulvin ultramicrosize tablet 125mg
griseofulvin ultramicrosize tablet 250mg
itraconazole capsule 100mg
ketoconazole cream 2%
ketoconazole shampoo 2%
ketoconazole tablet 200mg
miconazole 3 suppository 200mg
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 cream 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
qc tolnaftate cream 1%
sm miconazole 7 cream 2%
Página 28 de 148
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)
QL (1 EA cada 10 días)
$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)
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-$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
Nombre del medicamento
SPORANOX SOLUTION 10MG/ML
terbinafine hcl cream 1%
terbinafine hcl cream 1%
terbinafine hcl tablet 250mg
terconazole cream 0.4%
terconazole cream 0.8%
terconazole suppository 80mg
tioconazole-1 ointment 6.5%
tolnaftate cream 1%
tolnaftate cream 1%
tolnaftate cream 1%
tolnaftate powder 1%
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 injection 6mg/0.5ml
sumatriptan succinate injection 6mg/0.5ml
sumatriptan succinate tablet 100mg
sumatriptan succinate tablet 25mg
Página 29 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$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 3)
$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)
Nombre del medicamento
sumatriptan succinate tablet 50mg
Antimyasthenic Agents
Parasympathomimetics
GUANIDINE HCL TABLET 125MG
MESTINON TIMESPAN TABLET EXTENDED RELEASE
180MG
MESTINON SYRUP 60MG/5ML
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
Página 30 de 148
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-$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)
Nombre del medicamento
MATULANE CAPSULE 50MG
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
Página 31 de 148
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(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)
Nombre del medicamento
ELITEK INJECTION 1.5MG
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
Página 32 de 148
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(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)
Nombre del medicamento
leucovorin calcium tablet 15mg
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
Página 33 de 148
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) 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)
Nombre del medicamento
AFINITOR TABLET 7.5MG
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
Página 34 de 148
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)
$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)
Nombre del medicamento
TASIGNA CAPSULE 150MG
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
ERBITUX INJECTION 100MG/50ML
HERCEPTIN INJECTION 440MG
KADCYLA INJECTION 100MG
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
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/proguanil hcl tablet 62.5mg; 25mg
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
PRIMAQUINE PHOSPHATE TABLET 26.3MG
quinine sulfate capsule 324mg
tinidazole tablet 250mg
Página 35 de 148
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) 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(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-$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)
$0-$6.60(Nivel 2)
$0(Nivel 1)
QL (80 EA cada 365 días)
$0(Nivel 1)
Nombre del medicamento
tinidazole tablet 500mg
Pediculicides/Scabicides
lindane lotion 1%
malathion lotion 0.5%
permethrin cream 5%
permethrin lotion 1%
permethrin lotion 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(Nivel 1)
$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
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
Página 36 de 148
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)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
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
haloperidol lactate injection 5mg/ml
haloperidol concentrate 2mg/ml
haloperidol tablet 0.5mg
haloperidol tablet 10mg
haloperidol tablet 1mg
haloperidol tablet 20mg
Página 37 de 148
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-$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)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
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
aripiprazole tablet 20mg
aripiprazole tablet 2mg
aripiprazole tablet 30mg
aripiprazole tablet 5mg
FANAPT TITRATION PACK TABLET 0
FANAPT TABLET 10MG
Página 38 de 148
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(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)
$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)
Nombre del medicamento
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
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
Página 39 de 148
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 (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)
$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
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
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
FOSCARNET SODIUM INJECTION 24MG/ML
ganciclovir injection 500mg
Página 40 de 148
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-$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)
$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-$6.60(Nivel 2)
$0(Nivel 1)
Nombre del medicamento
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
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 INJECTION 180MCG/0.5ML
Página 41 de 148
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)
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)
$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)
Nombre del medicamento
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)
ISENTRESS PACKET 100MG
ISENTRESS TABLET CHEWABLE 100MG
ISENTRESS TABLET CHEWABLE 25MG
ISENTRESS TABLET 400MG
TIVICAY TABLET 50MG
VITEKTA TABLET 150MG
VITEKTA TABLET 85MG
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA TABLET 200MG; 25MG; 300MG
EDURANT TABLET 25MG
INTELENCE TABLET 100MG
INTELENCE TABLET 200MG
INTELENCE TABLET 25MG
nevirapine er tablet extended release 24 hour 400mg
nevirapine suspension 50mg/5ml
nevirapine tablet 200mg
RESCRIPTOR TABLET 100MG
RESCRIPTOR TABLET 200MG
Página 42 de 148
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)
$0(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)
$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
$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(Nivel 1)
MO
$0(Nivel 1)
$0(Nivel 1)
$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-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Nombre del medicamento
STRIBILD TABLET 150MG; 150MG; 200MG; 300MG
SUSTIVA CAPSULE 200MG
SUSTIVA CAPSULE 50MG
SUSTIVA TABLET 600MG
VIRAMUNE XR TABLET EXTENDED RELEASE 24
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)
$0-$6.60(Nivel 2)
EMTRIVA SOLUTION 10MG/ML
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)
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)
TRIUMEQ TABLET 600MG; 50MG; 300MG
$0-$6.60(Nivel 2) MO
TRUVADA TABLET 200MG; 300MG
$0-$6.60(Nivel 2)
VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM $0-$6.60(Nivel 2)
VIREAD POWDER 40MG/GM
$0-$6.60(Nivel 2)
VIREAD TABLET 150MG
$0-$6.60(Nivel 2)
VIREAD TABLET 200MG
$0-$6.60(Nivel 2)
VIREAD TABLET 250MG
$0-$6.60(Nivel 2)
VIREAD TABLET 300MG
$0-$6.60(Nivel 2)
ZIAGEN SOLUTION 20MG/ML
$0-$6.60(Nivel 2)
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)
Página 43 de 148
Nombre del medicamento
TYBOST TABLET 150MG
Anti-HIV Agents, Protease Inhibitors
APTIVUS CAPSULE 250MG
APTIVUS SOLUTION 100MG/ML
CRIXIVAN CAPSULE 200MG
CRIXIVAN CAPSULE 400MG
EVOTAZ TABLET 300MG; 150MG
INVIRASE CAPSULE 200MG
INVIRASE TABLET 500MG
KALETRA SOLUTION 400MG/5ML; 100MG/5ML
KALETRA TABLET 100MG; 25MG
KALETRA TABLET 200MG; 50MG
LEXIVA SUSPENSION 50MG/ML
LEXIVA TABLET 700MG
NORVIR CAPSULE 100MG
NORVIR SOLUTION 80MG/ML
NORVIR TABLET 100MG
PREZCOBIX TABLET 150MG; 800MG
PREZISTA SUSPENSION 100MG/ML
PREZISTA TABLET 150MG
PREZISTA TABLET 400MG
PREZISTA TABLET 600MG
PREZISTA TABLET 75MG
PREZISTA TABLET 800MG
REYATAZ CAPSULE 150MG
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
Página 44 de 148
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)
$0-$6.60(Nivel 2) QL (300 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-$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)
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-$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) 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)
Nombre del medicamento
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
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
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
Página 45 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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-$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)
PA (Medicamentos de alto
riesgo)
PA (Medicamentos de alto
riesgo)
$0-$6.60(Nivel 2)
$0(Nivel 1)
QL (120 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 (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(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-$6.60(Nivel 2)
$0(Nivel 1)
QL (120 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 (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
lithium carbonate capsule 300mg
lithium carbonate capsule 600mg
lithium carbonate tablet 300mg
lithium solution 8meq/5ml
LITHOBID TABLET EXTENDED RELEASE 300MG
Reguladores de glucosa en sangre
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
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
Página 46 de 148
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 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 (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
$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)
Nombre del medicamento
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
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
Página 47 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
$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)
$0(Nivel 1)
QL (60 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 (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
Nombre del medicamento
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
glutose 15 gel 40%
glutose 15 gel 40%
glutose 45 gel 40%
PROGLYCEM SUSPENSION 50MG/ML
Insulins
APIDRA SOLOSTAR INJECTION 100UNIT/ML
APIDRA INJECTION 100UNIT/ML
HUMALOG KWIKPEN INJECTION 100UNIT/ML
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
Página 48 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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-$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 (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)
Nombre del medicamento
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
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
Página 49 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
$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)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
heparin sodium injection 1000unit/ml
$0(Nivel 1)
heparin sodium injection 20000unit/ml
$0(Nivel 1)
heparin sodium injection 5000unit/ml
$0(Nivel 1)
jantoven tablet 10mg
$0(Nivel 1)
jantoven tablet 1mg
$0(Nivel 1)
jantoven tablet 2.5mg
$0(Nivel 1)
jantoven tablet 2mg
$0(Nivel 1)
jantoven tablet 3mg
$0(Nivel 1)
jantoven tablet 4mg
$0(Nivel 1)
jantoven tablet 5mg
$0(Nivel 1)
jantoven tablet 6mg
$0(Nivel 1)
jantoven tablet 7.5mg
$0(Nivel 1)
PRADAXA CAPSULE 150MG
$0-$6.60(Nivel 2)
PRADAXA CAPSULE 75MG
$0-$6.60(Nivel 2)
warfarin sodium tablet 10mg
$0(Nivel 1)
warfarin sodium tablet 1mg
$0(Nivel 1)
warfarin sodium tablet 2.5mg
$0(Nivel 1)
warfarin sodium tablet 2mg
$0(Nivel 1)
warfarin sodium tablet 3mg
$0(Nivel 1)
warfarin sodium tablet 4mg
$0(Nivel 1)
warfarin sodium tablet 5mg
$0(Nivel 1)
warfarin sodium tablet 6mg
$0(Nivel 1)
warfarin sodium tablet 7.5mg
$0(Nivel 1)
XARELTO STARTER PACK TABLET THERAPY PACK 0 $0-$6.60(Nivel 2)
XARELTO TABLET 10MG
$0-$6.60(Nivel 2)
XARELTO TABLET 15MG
$0-$6.60(Nivel 2)
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)
Página 50 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
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)
ARANESP ALBUMIN FREE INJECTION 40MCG/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
ARANESP ALBUMIN FREE INJECTION 500MCG/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
ARANESP ALBUMIN FREE INJECTION 60MCG/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
EPOGEN INJECTION 10000UNIT/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
EPOGEN INJECTION 20000UNIT/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
EPOGEN INJECTION 2000UNIT/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
EPOGEN INJECTION 3000UNIT/ML
$0-$6.60(Nivel 2) PA
(Productos/modificadores/
expansores del volumen
de sangre)
Página 51 de 148
Nombre del medicamento
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
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
Coagulants
Página 52 de 148
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)
$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)
$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)
Nombre del medicamento
tranexamic acid injection 100mg/ml
tranexamic acid tablet 650mg
Platelet Modifying Agents
AGGRENOX CAPSULE EXTENDED RELEASE 12 HOUR
25MG; 200MG
BRILINTA TABLET 90MG
cilostazol tablet 100mg
cilostazol tablet 50mg
clopidogrel tablet 300mg
clopidogrel tablet 75mg
dipyridamole tablet 25mg
dipyridamole tablet 50mg
dipyridamole tablet 75mg
EFFIENT TABLET 10MG
EFFIENT TABLET 5MG
ticlopidine hcl tablet 250mg
Agentes cardiovasculares
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)
$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(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (30 EA cada 30 días)
$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-$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
Angiotensin II Receptor Antagonists
Página 53 de 148
$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)
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
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
candesartan cilexetil/hydrochlorothiazide tablet 16mg;
$0(Nivel 1)
QL (30 EA cada 30 días)
12.5mg
MO
candesartan cilexetil/hydrochlorothiazide tablet 32mg;
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
12.5mg
candesartan cilexetil/hydrochlorothiazide tablet 32mg; 25mg $0(Nivel 1)
QL (30 EA cada 30 días)
MO
candesartan cilexetil tablet 16mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
candesartan cilexetil tablet 32mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
candesartan cilexetil tablet 4mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
candesartan cilexetil tablet 8mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
$0(Nivel 1)
QL (30 EA cada 30 días)
eprosartan mesylate tablet 600mg
MO
irbesartan/hydrochlorothiazide tablet 12.5mg; 150mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
irbesartan/hydrochlorothiazide tablet 12.5mg; 300mg
$0(Nivel 1)
QL (30 EA cada 30 días)
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)
QL (30 EA cada 30 días)
losartan potassium/hydrochlorothiazide tablet 12.5mg; 100mg $0(Nivel 1)
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)
losartan potassium tablet 100mg
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
losartan potassium tablet 25mg
losartan potassium tablet 50mg
$0(Nivel 1)
QL (30 EA cada 30 días)
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
$0(Nivel 1)
QL (30 EA cada 30 días)
telmisartan/hydrochloroth tablet 25mg; 80mg
MO
telmisartan tablet 20mg
$0(Nivel 1)
QL (30 EA cada 30 días)
MO
$0(Nivel 1)
QL (30 EA cada 30 días)
telmisartan tablet 40mg
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)
Página 54 de 148
Nombre del medicamento
valsartan tablet 160mg
valsartan tablet 320mg
valsartan tablet 40mg
valsartan tablet 80mg
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide tablet 10mg; 12.5mg
benazepril hcl/hydrochlorothiazide tablet 20mg; 12.5mg
benazepril hcl/hydrochlorothiazide tablet 20mg; 25mg
benazepril hcl/hydrochlorothiazide tablet 5mg; 6.25mg
benazepril hcl tablet 10mg
benazepril hcl tablet 20mg
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
Página 55 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (30 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)
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(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$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 (60 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 (30 EA cada 30 días)
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
Nombre del medicamento
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
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
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
Página 56 de 148
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)
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)
$0(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)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
Nombre del medicamento
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)
bisoprolol fumarate tablet 5mg
$0(Nivel 1)
carvedilol tablet 12.5mg
$0(Nivel 1)
$0(Nivel 1)
carvedilol tablet 25mg
$0(Nivel 1)
carvedilol tablet 3.125mg
carvedilol tablet 6.25mg
$0(Nivel 1)
labetalol hcl injection 5mg/ml
$0(Nivel 1)
labetalol hcl tablet 100mg
$0(Nivel 1)
labetalol hcl tablet 200mg
$0(Nivel 1)
labetalol hcl tablet 300mg
$0(Nivel 1)
metoprolol succinate er tablet extended release 24 hour
$0(Nivel 1)
100mg
metoprolol succinate er tablet extended release 24 hour
$0(Nivel 1)
200mg
metoprolol succinate er tablet extended release 24 hour 25mg $0(Nivel 1)
metoprolol succinate er tablet extended release 24 hour 50mg $0(Nivel 1)
metoprolol tartrate injection 1mg/ml
$0(Nivel 1)
metoprolol tartrate tablet 100mg
$0(Nivel 1)
metoprolol tartrate tablet 25mg
$0(Nivel 1)
metoprolol tartrate tablet 50mg
$0(Nivel 1)
metoprolol/hydrochlorothiazide tablet 25mg; 100mg
$0(Nivel 1)
metoprolol/hydrochlorothiazide tablet 25mg; 50mg
$0(Nivel 1)
metoprolol/hydrochlorothiazide tablet 50mg; 100mg
$0(Nivel 1)
nadolol/bendroflumethiazide tablet 5mg; 40mg
$0(Nivel 1)
nadolol/bendroflumethiazide tablet 5mg; 80mg
$0(Nivel 1)
nadolol tablet 20mg
$0(Nivel 1)
nadolol tablet 40mg
$0(Nivel 1)
nadolol tablet 80mg
$0(Nivel 1)
pindolol tablet 10mg
$0(Nivel 1)
pindolol tablet 5mg
$0(Nivel 1)
propranolol hcl er capsule extended release 24 hour 120mg $0(Nivel 1)
propranolol hcl er capsule extended release 24 hour 160mg $0(Nivel 1)
$0(Nivel 1)
propranolol hcl er capsule extended release 24 hour 60mg
propranolol hcl er capsule extended release 24 hour 80mg
$0(Nivel 1)
Página 57 de 148
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
QL (60 EA cada 30 días)
Nombre del medicamento
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
afeditab cr tablet extended release 24 hour 60mg
amlodipine besylate/benazepril hcl capsule 10mg; 40mg
amlodipine besylate/benazepril hcl capsule 5mg; 40mg
amlodipine besylate/benazepril hydrochloride capsule 10mg;
20mg
amlodipine besylate/benazepril hydrochloride capsule 2.5mg;
10mg
amlodipine besylate/benazepril hydrochloride capsule 5mg;
10mg
amlodipine besylate/benazepril hydrochloride capsule 5mg;
20mg
amlodipine besylate/valsartan tablet 10mg; 160mg
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)
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)
QL (30 EA cada 30 días)
$0(Nivel 1)
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)
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)
MO
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
amlodipine besylate/valsartan tablet 10mg; 320mg
$0(Nivel 1)
amlodipine besylate/valsartan tablet 5mg; 160mg
$0(Nivel 1)
amlodipine besylate/valsartan tablet 5mg; 320mg
$0(Nivel 1)
amlodipine besylate tablet 10mg
amlodipine besylate tablet 2.5mg
amlodipine besylate tablet 5mg
amlodipine/valsartan/hctz tablet 10mg; 12.5mg; 160mg
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
amlodipine/valsartan/hctz tablet 10mg; 25mg; 160mg
$0(Nivel 1)
amlodipine/valsartan/hctz tablet 10mg; 25mg; 320mg
$0(Nivel 1)
amlodipine/valsartan/hctz tablet 5mg; 12.5mg; 160mg
$0(Nivel 1)
amlodipine/valsartan/hctz tablet 5mg; 25mg; 160mg
$0(Nivel 1)
cartia xt capsule extended release 24 hour 120mg
$0(Nivel 1)
Página 58 de 148
Nombre del medicamento
cartia xt capsule extended release 24 hour 180mg
cartia xt capsule extended release 24 hour 240mg
cartia xt capsule extended release 24 hour 300mg
dilt-cd capsule extended release 24 hour 300mg
dilt-xr capsule extended release 24 hour 120mg
dilt-xr capsule extended release 24 hour 180mg
dilt-xr capsule extended release 24 hour 240mg
diltiazem cd capsule extended release 24 hour 240mg
diltiazem hcl er capsule extended release 12 hour 120mg
diltiazem hcl er capsule extended release 12 hour 60mg
diltiazem hcl er capsule extended release 12 hour 90mg
diltiazem hcl er capsule extended release 24 hour 120mg
diltiazem hcl er capsule extended release 24 hour 180mg
diltiazem hcl er capsule extended release 24 hour 300mg
diltiazem hcl er capsule extended release 24 hour 360mg
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
nifediac cc tablet extended release 24 hour 90mg
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
Página 59 de 148
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 (60 EA cada 30 días)
$0(Nivel 1)
QL (90 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)
$0(Nivel 1)
$0(Nivel 1)
$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 (30 EA cada 30 días)
$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)
Nombre del medicamento
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
Agentes cardiovasculares, Other
DEMSER CAPSULE 250MG
digitek tablet 0.125mg
digitek tablet 0.25mg
digoxin injection 0.25mg/ml
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
Página 60 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
$0(Nivel 1)
PA (Medicamento de alto
riesgo - Digoxin)
$0(Nivel 1)
$0(Nivel 1)
PA (Medicamento de alto
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)
Nombre del medicamento
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
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
Página 61 de 148
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-$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)
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)
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
Nombre del medicamento
fenofibrate capsule 43mg
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
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)
MO
$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)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$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)
niacor tablet 500mg
omega-3-acid ethyl esters capsule 375mg; 465mg; 1gm
$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
Página 62 de 148
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)
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 (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (30 EA cada 30 días)
QL (60 EA cada 30 días)
MO
QL (30 EA cada 30 días)
MO
QL (60 EA cada 30 días)
MO
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)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
isosorbide dinitrate tablet 5mg
isosorbide mononitrate er tablet extended release 24 hour
120mg
isosorbide mononitrate er tablet extended release 24 hour
$0(Nivel 1)
30mg
isosorbide mononitrate er tablet extended release 24 hour
$0(Nivel 1)
60mg
isosorbide mononitrate tablet 10mg
$0(Nivel 1)
isosorbide mononitrate tablet 20mg
$0(Nivel 1)
NITRO-DUR PATCH 24 HOUR 0.3MG/HR
$0-$6.60(Nivel 2)
NITRO-DUR PATCH 24 HOUR 0.8MG/HR
$0-$6.60(Nivel 2)
nitroglycerin transdermal patch 24 hour 0.1mg/hr
$0(Nivel 1)
NITROGLYCERIN INJECTION 5MG/ML
$0-$6.60(Nivel 2)
nitroglycerin patch 24 hour 0.2mg/hr
$0(Nivel 1)
nitroglycerin patch 24 hour 0.4mg/hr
$0(Nivel 1)
nitroglycerin patch 24 hour 0.6mg/hr
$0(Nivel 1)
NITROSTAT TABLET SUBLINGUAL 0.3MG
$0-$6.60(Nivel 2)
NITROSTAT TABLET SUBLINGUAL 0.4MG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
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)
Agentes del sistema central nervioso
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg;
$0(Nivel 1)
QL (90 EA cada 30 días)
1.25mg; 1.25mg
QL (90 EA cada 30 días)
amphetamine/dextroamphetamine tablet 1.875mg; 1.875mg; $0(Nivel 1)
1.875mg; 1.875mg
amphetamine/dextroamphetamine tablet 2.5mg; 2.5mg;
$0(Nivel 1)
QL (90 EA cada 30 días)
2.5mg; 2.5mg
amphetamine/dextroamphetamine tablet 3.125mg; 3.125mg; $0(Nivel 1)
QL (90 EA cada 30 días)
3.125mg; 3.125mg
amphetamine/dextroamphetamine tablet 3.75mg; 3.75mg;
$0(Nivel 1)
QL (90 EA cada 30 días)
3.75mg; 3.75mg
amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg; 5mg $0(Nivel 1)
QL (60 EA cada 30 días)
amphetamine/dextroamphetamine tablet 7.5mg; 7.5mg;
$0(Nivel 1)
QL (60 EA cada 30 días)
7.5mg; 7.5mg
dextroamphetamine sulfate tablet 10mg
$0(Nivel 1)
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 (30 EA cada 30 días)
MO
Página 63 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
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)
$0(Nivel 1)
QL (30 EA cada 30 días)
methylphenidate hcl cd capsule extended release 20mg
methylphenidate hcl cd capsule extended release 20mg
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
methylphenidate hcl cd capsule extended release 30mg
methylphenidate hcl cd capsule extended release 30mg
$0(Nivel 1)
QL (30 EA cada 30 días)
methylphenidate hcl cd capsule extended release 40mg
$0(Nivel 1)
QL (30 EA cada 30 días)
$0(Nivel 1)
QL (30 EA cada 30 días)
methylphenidate hcl cd capsule extended release 40mg
methylphenidate hcl cd capsule extended release 50mg
$0(Nivel 1)
QL (30 EA cada 30 días)
methylphenidate hcl cd capsule extended release 60mg
$0(Nivel 1)
QL (30 EA cada 30 días)
methylphenidate hcl er tablet extended release 20mg
$0(Nivel 1)
QL (90 EA cada 30 días)
QL (90 EA cada 30 días)
methylphenidate hcl tablet 10mg
$0(Nivel 1)
methylphenidate hcl tablet 20mg
$0(Nivel 1)
QL (90 EA cada 30 días)
methylphenidate hcl tablet 5mg
$0(Nivel 1)
QL (90 EA cada 30 días)
STRATTERA CAPSULE 100MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
STRATTERA CAPSULE 10MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
STRATTERA CAPSULE 18MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
STRATTERA CAPSULE 25MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
STRATTERA CAPSULE 40MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
STRATTERA CAPSULE 60MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
STRATTERA CAPSULE 80MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
Central Nervous System, Other
NUEDEXTA CAPSULE 20MG; 10MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
riluzole tablet 50mg
$0(Nivel 1)
XENAZINE TABLET 12.5MG
$0-$6.60(Nivel 2) QL (180 EA cada 30 días)
PA (Agentes terapéuticos
misceláneos - Xenazine)
XENAZINE TABLET 25MG
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
PA (Agentes terapéuticos
misceláneos - Xenazine)
Fibromyalgia Agents
SAVELLA TITRATION PACK MISCELLANEOUS 0
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
SAVELLA TABLET 100MG
SAVELLA TABLET 12.5MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
SAVELLA TABLET 25MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
SAVELLA TABLET 50MG
$0-$6.60(Nivel 2) QL (60 EA cada 30 días)
Multiple Sclerosis Agents
Página 64 de 148
Nombre del medicamento
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
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%
KEPIVANCE INJECTION 6.25MG
periogard solution 0.12%
pilocarpine hcl tablet 7.5mg
pilocarpine hydrochloride tablet 5mg
triamcinolone in orabase paste 0.1%
Agentes dermatológicos
Agentes dermatológicos
acne medication 5 gel 5%
adapalene cream 0.1%
adapalene gel 0.1%
ammonium lactate cream 12%
ammonium lactate lotion 12%
anti-itch maximum strength solution 2%
anti-itch cream 2%; 0.1%
AQUABASE OINTMENT 0
benzoyl peroxide gel 10%
benzoyl peroxide gel 10%
BENZOYL PEROXIDE GEL 2.5%
benzoyl peroxide gel 5%
benzoyl peroxide gel 5%
calcipotriene cream 0.005%
calcipotriene solution 0.005%
caldyphen lotion 8%; 1%
CARMOL 10 LOTION 10%
CARMOL 20 CREAM 20%
claravis capsule 10mg
claravis capsule 20mg
claravis capsule 30mg
claravis capsule 40mg
Página 65 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
$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(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
$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 1)
$0(Nivel 1)
$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
QL (240 GM cada 30 días)
QL (60 ML cada 30 días)
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)
COATS ALOE VERA LINIMENT LIQUID 0
$0(Nivel 3)
DP
COATS ALOE VERA LINIMENT LIQUID 0
$0(Nivel 3)
DP
COATS ALOE VERA CREAM 0
$0(Nivel 3)
DP
COATS ALOE VERA CREAM 0
$0(Nivel 3)
DP
COATS ALOE VERA GEL 90%
$0(Nivel 3)
DP
COATS ALOE VERA GEL 90%
$0(Nivel 3)
DP
COATS ALOE VERA LIQUID 0
$0(Nivel 3)
DP
COATS ALOE VERA LOTION 0
$0(Nivel 3)
DP
COATS ALOE VERA LOTION 0
$0(Nivel 3)
DP
COATS ALOE VERA LOTION 0
$0(Nivel 3)
DP
curity gauze pads 2"x2" pad
$0(Nivel 1)
QL (204 EA cada 30 días)
DERMABASE OIL IN WATER CREAM 2.5%; 0; 0; 0; 0; $0(Nivel 3)
DP
2.5%; 2.5%; 2.5%; 2.5%; 2.5%
diaper rash ointment 40%
$0(Nivel 3)
DR SMITHS DIAPER OINTMENT 10%
$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)
FATTIBASE OINTMENT 0
$0(Nivel 3)
DP
fluorouracil cream 5%
$0(Nivel 1)
fluorouracil solution 2%
$0(Nivel 1)
fluorouracil solution 5%
$0(Nivel 1)
hemorrhoidal ointment 14%; 71.9%; 0.25%; 3%
$0(Nivel 3)
DP
HEMORRHOIDAL OINTMENT 14%; 71.9%; 0.25%; 3% $0(Nivel 3)
DP
$0(Nivel 3)
DP
hemorrhoid suppository 85.5%; 0.25%; 3%
HYDROCREAM BASE WATER IN OIL CREAM 2.5%; 0; $0(Nivel 3)
DP
0; 0; 0; 2.5%; 2.5%; 2.5%; 2.5%; 2.5%
hydrophilic ointment 0
$0(Nivel 3)
imiquimod cream 5%
$0(Nivel 1)
QL (24 EA cada 30 días)
ITCH-X GEL 10%; 1%
$0(Nivel 3)
DP
laclotion lotion 12%
$0(Nivel 1)
methoxsalen capsule 10mg
$0(Nivel 1)
MOISTUREL LOTION 0; 0; 0
$0(Nivel 3)
DP
MOISTUREL LOTION 0; 0; 0
$0(Nivel 3)
DP
OXSORALEN LOTION 1%
$0-$6.60(Nivel 2)
pain relieving gel gel 3.5%
$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)
POLYBASE OINTMENT 0
$0(Nivel 3)
DP
POLYBASE OINTMENT 0
$0(Nivel 3)
DP
Página 66 de 148
Nombre del medicamento
PROTOPIC OINTMENT 0.03%
PROTOPIC OINTMENT 0.1%
sal-acid plasters pad 40%
SANTYL OINTMENT 250UNIT/GM
SARNA LOTION 0.5%; 0.5%
selenium sulfide lotion 2.5%
sm hemorrhoidal ointment 14%; 71.9%; 0.25%; 3%
sm hemorrhoidal suppository 85.5%; 0.25%; 3%
SORIATANE CAPSULE 10MG
SORIATANE CAPSULE 17.5MG
SORIATANE CAPSULE 25MG
tacrolimus ointment 0.03%
tacrolimus ointment 0.1%
TAZORAC CREAM 0.05%
TAZORAC CREAM 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
thera-gesic cream 1%; 15%
tretinoin cream 0.025%
tretinoin cream 0.05%
tretinoin cream 0.1%
tretinoin gel 0.01%
tretinoin gel 0.025%
trixaicin hp cream 0.075%
ureacin-10 lotion 10%
ureacin-20 cream 20%
UVADEX INJECTION 20MCG/ML
VEREGEN OINTMENT 15%
vitamin a & d ointment 15.5%; 53.4%
VOLTAREN GEL 1%
WHITE PETROLATUM GEL 0
zinc oxide ointment 20%
zinc oxide ointment 20%
zinc oxide ointment 20%
zinc oxide ointment 20%
zinc oxide ointment 20%
zinc oxide ointment 20%
zinc oxide ointment 20%
ZONALON CREAM 5%
Enzyme Replacement/Modifiers
Página 67 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (60 GM cada 30 días)
PA (Agentes
dermatológicos)
$0-$6.60(Nivel 2) QL (60 GM cada 30 días)
PA (Agentes
dermatológicos)
$0(Nivel 3)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$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(Nivel 1)
QL (60 GM cada 30 días)
PA (Agentes
dermatológicos)
$0(Nivel 1)
QL (60 GM cada 30 días)
PA (Agentes
dermatológicos)
$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(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (90 GM cada 30 días)
$0(Nivel 1)
QL (90 GM cada 30 días)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2) QL (15 GM cada 30 días)
$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)
$0(Nivel 3)
$0(Nivel 3)
$0-$6.60(Nivel 2)
Nombre del medicamento
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
LACTRASE CAPSULE 250MG
LUMIZYME INJECTION 50MG
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
Página 68 de 148
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)
$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-$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)
Nombre del medicamento
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
methscopolamine bromide tablet 2.5mg
Gastrointestinal Agents, Other
acid gone suspension 95mg/15ml; 358mg/15ml
actidose/sorbitol liquid 50gm/240ml; 0
almacone double strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
almacone suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
ALUMINUM HYDROXIDE SUSPENSION 320MG/5ML
antacid extra strength tablet chewable 750mg
antacid plus anti-gas relief 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
anu-med suppository 88.7%; 0.25%
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
biscolax suppository 10mg
biscolax suppository 10mg
bismatrol maximum strength suspension 525mg/15ml
bismatrol suspension 262mg/15ml
bismatrol tablet chewable 262mg
Página 69 de 148
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)
$0(Nivel 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)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
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)
$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
DP
DP
DP
DP
DP
DP
DP
DP
DP
Nombre del medicamento
cal-gest antacid tablet chewable 500mg
calcium antacid extra strength tablet chewable 750mg
calcium antacid ultra maximum strength tablet chewable
1000mg
calcium antacid tablet chewable 500mg
calcium antacid tablet chewable 500mg
calcium antacid tablet chewable 500mg
chewable antacid tablet chewable 500mg
chewable antacid tablet chewable 500mg
COATS ALOE VERA JUICE DRINK LIQUID 0
COLACE CAPSULE 100MG
COLACE CAPSULE 100MG
cromolyn sodium concentrate 100mg/5ml
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 capsule 100mg
dok capsule 100mg
dok capsule 100mg
dok capsule 100mg
dok capsule 250mg
dok tablet 100mg
enemeez mini enema 283mg
enemeez plus enema 20mg; 283mg
fiber tabs tablet 625mg
fiber-lax tablet 625mg
fiber-lax tablet 625mg
fiber-lax tablet 625mg
FLEET PEDIATRIC ENEMA 3.5GM/59ML; 9.5GM/59ML
gas relief extra strength capsule 125mg
gas relief extra strength capsule 125mg
gas relief suspension 20mg/0.3ml
gas relief tablet chewable 80mg
gentle laxative tablet delayed release 5mg
glycerin adult suppository 2.1gm
glycerin adult suppository 2.1gm
glycerin adult suppository 2.1gm
glycerin adult suppository 2.1gm
glycerin adult suppository 3gm
glycerin adult suppository 3gm
glycerin child suppository 1.5gm
glycerin pediatric suppository 1.2gm
glycerin pediatric suppository 1.2gm
gnp natural fiber powder 48.57%
infants gas relief suspension 20mg/0.3ml
Página 70 de 148
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)
$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)
$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 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)
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
infants gas relief suspension 20mg/0.3ml
infants simethicone suspension 20mg/0.3ml
kao-tin capsule 240mg
kao-tin suspension 262mg/15ml
kao-tin suspension 262mg/15ml
KONSYL POWDER 100%
KONSYL POWDER 100%
konsyl powder 28.3%
laxative with senna tablet 25mg
laxative suppository 10mg
laxative suppository 10mg
laxative tablet 25mg
loperamide hcl capsule 2mg
loperamide hcl liquid 1mg/5ml
loperamide hcl suspension 1mg/7.5ml
loperamide hcl suspension 1mg/7.5ml
magnesium oxide tablet 241.3mg
magnesium oxide tablet 241.3mg
magnesium oxide tablet 241.3mg
magnesium oxide tablet 241.3mg
magnesium oxide tablet 400mg
medi-bismuth tablet chewable 262mg
medi-natural tablet 8.6mg
metoclopramide hcl injection 5mg/ml
metoclopramide hcl solution 5mg/5ml
metoclopramide hcl tablet 10mg
metoclopramide hcl tablet 5mg
mi-acid gas relief tablet chewable 80mg
mi-acid maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
mi-acid suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
MILK DE MAGNESIA CONCENTRATE SUSPENSION
2400MG/10ML
MILK DE MAGNESIA CONCENTRATE SUSPENSION
2400MG/10ML
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%
MINERAL OIL OIL 0
mintox maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
mytab gas max str tablet chewable 125mg
mytab gas tablet chewable 80mg
natural fiber therapy powder 30.9%
natural fiber therapy powder 30.9%
natural fiber therapy powder 48.57%
Página 71 de 148
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(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 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(Nivel 1)
$0(Nivel 1)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
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)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
DP
DP
Nombre del medicamento
natural fiber therapy powder 48.57%
pink bismuth maximum strength suspension 525mg/15ml
pink bismuth tablet chewable 262mg
pink bismuth tablet chewable 262mg
qc antacid extra strength tablet chewable 750mg
qc anti-diarrheal tablet 2mg
qc anti-diarrheal tablet 2mg
qc gas relief tablet chewable 80mg
qc gentle laxative tablet delayed release 5mg
qc pink bismuth suspension 262mg/15ml
qc pink bismuth tablet chewable 262mg
qc pink bismuth tablet 262mg
qc senna tablet 8.6mg
qc stool softener capsule 100mg
reguloid capsule 0.52gm
RELISTOR INJECTION 12MG/0.6ML
rulox suspension 200mg/5ml; 200mg/5ml; 20mg/5ml
senexon liquid 8.8mg/5ml
senexon tablet 8.6mg
senexon 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
silace liquid 150mg/15ml
silace syrup 60mg/15ml
simethicone capsule 180mg
simethicone suspension 40mg/0.6ml
simethicone suspension 40mg/0.6ml
simethicone tablet chewable 125mg
simethicone tablet chewable 80mg
simethicone tablet chewable 80mg
sm anti-diarrheal liquid 1mg/5ml
sm anti-diarrheal tablet 2mg
sm calcium antacid extra strength tablet chewable 750mg
sm calcium antacid tablet chewable 500mg
sm calcium antacid tablet chewable 500mg
sm fiber powder 28.3%
sm fiber powder 48.57%
sm fiber powder 58.6%
sm glycerin adult suppository 80.7%
sm glycerin pediatric suppository 80.7%
sm stomach relief max st suspension 525mg/15ml
sm stomach relief suspension 527mg/30ml
sm stomach relief tablet chewable 262mg
sodium bicarbonate tablet 650mg
stimulant laxative tablet delayed release 5mg
Página 72 de 148
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(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
$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
stimulant laxative tablet delayed release 5mg
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
sur-q-lax capsule 240mg
ursodiol capsule 300mg
ursodiol tablet 250mg
ursodiol tablet 500mg
womans laxative tablet delayed release 5mg
Histamine2 (H2) Receptor Antagonists
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 20mg
famotidine tablet 40mg
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
ranitidine hcl tablet 75mg
ranitidine hcl tablet 75mg
ZANTAC INJECTION 25MG/ML
ZANTAC INJECTION 25MG/ML
Agentes para síndrome de colon irritable
alosetron hydrochloride tablet 0.5mg
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(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)
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 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 3)
DP
$0(Nivel 3)
DP
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
alosetron hydrochloride tablet 1mg
$0(Nivel 1)
AMITIZA CAPSULE 24MCG
AMITIZA CAPSULE 8MCG
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
Página 73 de 148
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
Nombre del medicamento
LOTRONEX TABLET 0.5MG
LOTRONEX TABLET 1MG
Laxatives
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
tablet 50mg; 8.6mg
dok plus tablet 50mg; 8.6mg
enema enema 7gm/118ml; 19gm/118ml
enema enema 7gm/118ml; 19gm/118ml
enulose solution 10gm/15ml
gavilyte-c solution reconstituted 240gm; 2.98gm; 6.72gm;
5.84gm; 22.72gm
gavilyte-g solution reconstituted 236gm; 2.97gm; 6.74gm;
5.86gm; 22.74gm
gavilyte-n/flavor pack solution reconstituted 420gm; 1.48gm;
5.72gm; 11.2gm
generlac solution 10gm/15ml
gnp enema enema 7gm/118ml; 19gm/118ml
gnp milk of magnesia suspension 1200mg/15ml
gnp milk of magnesia suspension 1200mg/15ml
lactulose solution 10gm/15ml
milk of magnesia suspension 1200mg/15ml
milk of magnesia suspension 400mg/5ml
milk of magnesia suspension 400mg/5ml
NULYTELY/FLAVOR PACKS SOLUTION
RECONSTITUTED 420GM; 1.48GM; 5.72GM; 11.2GM
polyethylene glycol 3350 powder 0
qc docusate calcium capsule 240mg
qc enema enema 16gm/133ml; 6gm/133ml
qc milk of magnesia suspension 400mg/5ml
qc milk of magnesia suspension 400mg/5ml
qc senna-s tablet 50mg; 8.6mg
qc stool softener plus laxative tablet 50mg; 8.6mg
RELISTOR INJECTION 12MG/0.6ML
RELISTOR INJECTION 8MG/0.4ML
senna-s tablet 50mg; 8.6mg
sennalax-s tablet 50mg; 8.6mg
Página 74 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
DP
$0(Nivel 3)
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
$0(Nivel 1)
DP
DP
DP
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$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-$6.60(Nivel 2)
$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-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
sennalax-s tablet 50mg; 8.6mg
$0(Nivel 3)
DP
sm milk of magnesia suspension 400mg/5ml
$0(Nivel 3)
DP
sm milk of magnesia suspension 400mg/5ml
$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
esomeprazole sodium injection 20mg
$0(Nivel 1)
MO
esomeprazole sodium injection 40mg
$0(Nivel 1)
GNP OMEPRAZOLE TABLET DELAYED RELEASE
$0(Nivel 3)
DP
20MG
GNP OMEPRAZOLE TABLET DELAYED RELEASE
$0(Nivel 3)
DP
20MG
GNP OMEPRAZOLE TABLET DELAYED RELEASE
$0(Nivel 3)
DP
20MG
omeprazole capsule delayed release 10mg
$0(Nivel 1)
QL (30 EA cada 30 días)
omeprazole capsule delayed release 20mg
$0(Nivel 1)
QL (90 EA cada 30 días)
omeprazole capsule delayed release 40mg
$0(Nivel 1)
QL (90 EA cada 30 días)
OMEPRAZOLE TABLET DELAYED RELEASE 20MG
$0(Nivel 3)
DP
OMEPRAZOLE TABLET DELAYED RELEASE 20MG
$0(Nivel 3)
DP
OMEPRAZOLE TABLET DELAYED RELEASE 20MG
$0(Nivel 3)
DP
pantoprazole sodium tablet delayed release 20mg
$0(Nivel 1)
QL (30 EA cada 30 días)
pantoprazole sodium tablet delayed release 40mg
$0(Nivel 1)
QL (60 EA cada 30 días)
MO
PRILOSEC OTC TABLET DELAYED RELEASE 20MG
$0(Nivel 3)
DP
PRILOSEC OTC TABLET DELAYED RELEASE 20MG
$0(Nivel 3)
DP
PRILOSEC OTC TABLET DELAYED RELEASE 20MG
$0(Nivel 3)
DP
PROTONIX INJECTION 40MG
$0-$6.60(Nivel 2)
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl tablet 100mg
$0(Nivel 1)
oxybutynin chloride er tablet extended release 24 hour 10mg $0(Nivel 1)
oxybutynin chloride er tablet extended release 24 hour 15mg $0(Nivel 1)
oxybutynin chloride er tablet extended release 24 hour 5mg $0(Nivel 1)
oxybutynin chloride tablet 5mg
$0(Nivel 1)
tolterodine tartrate er capsule extended release 24 hour 2mg $0(Nivel 1)
QL (30 EA cada 30 días)
MO
QL (30 EA cada 30 días)
tolterodine tartrate er capsule extended release 24 hour 4mg $0(Nivel 1)
MO
tolterodine tartrate tablet 1mg
$0(Nivel 1)
QL (60 EA cada 30 días)
$0(Nivel 1)
QL (60 EA cada 30 días)
tolterodine tartrate tablet 2mg
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er tablet extended release 24 hour 10mg
$0(Nivel 1)
QL (30 EA cada 30 días)
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
AVODART CAPSULE 0.5MG
doxazosin mesylate tablet 1mg
$0(Nivel 1)
Página 75 de 148
Nombre del medicamento
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
Phosphate Binders
calcium acetate capsule 667mg
calcium acetate tablet 667mg
ELIPHOS TABLET 667MG
FOSRENOL TABLET CHEWABLE 1000MG
FOSRENOL TABLET CHEWABLE 500MG
FOSRENOL TABLET CHEWABLE 750MG
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%
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%
Página 76 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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 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(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$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
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
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%
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 cream 0.5%
hydrocortisone cream 1%
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone enema 100mg/60ml
hydrocortisone lotion 2.5%
hydrocortisone ointment 0.5%
hydrocortisone ointment 1%
hydrocortisone ointment 2.5%
Página 77 de 148
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(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 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 1)
$0(Nivel 1)
$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 3)
DP
$0(Nivel 1)
$0(Nivel 1)
Nombre del medicamento
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
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
PROCTO-PAK CREAM 1%
proctosol hc cream 2.5%
proctozone-hc cream 2.5%
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 (Pituitario)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitario)
Página 78 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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(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-$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)
Nombre del medicamento
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
NORDITROPIN FLEXPRO INJECTION 5MG/1.5ML
NORDITROPIN NORDIFLEX PEN INJECTION
30MG/3ML
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
Página 79 de 148
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-$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))
$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)
Nombre del medicamento
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
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 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
Página 80 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (120 EA cada 30 días)
$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(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)
Nombre del medicamento
estradiol valerate injection 20mg/ml
estradiol valerate injection 40mg/ml
estradiol patch weekly 0.025mg/24hr
estradiol patch weekly 0.05mg/24hr
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
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
Página 81 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
$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)
$0(Nivel 1)
$0(Nivel 1)
MO
$0(Nivel 1)
MO
$0(Nivel 1)
MO
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
levora 0.15/30-28 tablet 30mcg; 0.15mg
$0(Nivel 1)
loestrin 24 fe tablet 20mcg; 75mg; 1mg
$0(Nivel 1)
low-ogestrel tablet 30mcg; 0.3mg
$0(Nivel 1)
lutera tablet 20mcg; 0.1mg
$0(Nivel 1)
marlissa tablet 0.03mg; 0.15mg
$0(Nivel 1)
MENEST TABLET 0.3MG
$0-$6.60(Nivel 2) PA (Medicamentos de alto
riesgo)
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)
$0(Nivel 1)
portia-28 tablet 0.03mg; 0.15mg
PREMARIN CREAM 0.625MG/GM
$0-$6.60(Nivel 2)
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)
Página 82 de 148
Nombre del medicamento
PREMPHASE TABLET 0.625MG; 5MG
PREMPRO TABLET 0.3MG; 1.5MG
PREMPRO TABLET 0.45MG; 1.5MG
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
Página 83 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) PA (Medicamentos de alto
riesgo)
$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-$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
Nombre del medicamento
progesterone capsule 100mg
progesterone capsule 200mg
PROMETRIUM CAPSULE 100MG
PROMETRIUM CAPSULE 200MG
sharobel tablet 0.35mg
Selective Estrogen Receptor Modifying Agents
EVISTA TABLET 60MG
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
Página 84 de 148
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)
MO
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
$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)
Nombre del medicamento
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
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
Agentes hormonales, supresor (Adrenal)
Agentes hormonales, supresor (Adrenal)
LYSODREN TABLET 500MG
Agentes hormonales, supresor (Parathyroid)
Agentes hormonales, supresor (Parathyroid)
SENSIPAR TABLET 30MG
SENSIPAR TABLET 60MG
SENSIPAR TABLET 90MG
Agentes hormonales, supresor (Pituitario)
Agentes hormonales, supresor (Pituitario)
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
Página 85 de 148
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(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(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)
Nombre del medicamento
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
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
Agentes hormonales, supresor (Thyroid)
Antithyroid Agents
methimazole tablet 10mg
methimazole tablet 5mg
propylthiouracil tablet 50mg
Agentes inmunológicos
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
Página 86 de 148
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-$6.60(Nivel 2)
$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
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
cyclosporine capsule 25mg
$0(Nivel 1)
B/D
cyclosporine injection 50mg/ml
$0(Nivel 1)
B/D
ENBREL SURECLICK INJECTION 50MG/ML
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
ENBREL INJECTION 25MG/0.5ML
$0-$6.60(Nivel 2) PA (Agentes
inmunológicos)
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
inmunológicos)
40MG/0.8ML
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
PROGRAF CAPSULE 1MG
$0-$6.60(Nivel 2) B/D
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
RAPAMUNE TABLET 0.5MG
$0-$6.60(Nivel 2) B/D
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
Página 87 de 148
Nombre del medicamento
tacrolimus capsule 1mg
tacrolimus capsule 5mg
TORISEL INJECTION 25MG/ML
ZORTRESS TABLET 0.25MG
ZORTRESS TABLET 0.5MG
ZORTRESS TABLET 0.75MG
Immunizing Agents, Passive
CARIMUNE NANOFILTERED INJECTION 6GM
GAMASTAN S/D INJECTION 0
GAMMAGARD LIQUID INJECTION 0
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
Página 88 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
B/D
$0(Nivel 1)
B/D
$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) 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)
Nombre del medicamento
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
MENACTRA INJECTION 0
MENOMUNE-A/C/Y/W-135 INJECTION 0
MENVEO INJECTION 0
PEDVAX HIB INJECTION 7.5MCG/0.5ML
PROQUAD INJECTION 0; 0; 0; 0
QUADRACEL INJECTION 48MCG/0.5ML; 15LFU/0.5ML;
0; 5LFU/0.5ML
RABAVERT INJECTION 0
RECOMBIVAX HB INJECTION 10MCG/ML
RECOMBIVAX HB INJECTION 10MCG/ML
RECOMBIVAX HB INJECTION 40MCG/ML
RECOMBIVAX HB INJECTION 5MCG/0.5ML
ROTARIX SUSPENSION RECONSTITUTED 0
ROTATEQ SOLUTION 0
TENIVAC INJECTION 2LFU; 5LFU
TETANUS TOXOID ADSORBED INJECTION 5LFU
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT
INJECTION 2LF/0.5ML; 2LF/0.5ML
TRUMENBA INJECTION 0
TWINRIX INJECTION 720ELU/ML; 20MCG/ML
TYPHIM VI INJECTION 25MCG/0.5ML
TYPHIM VI INJECTION 25MCG/0.5ML
VAQTA INJECTION 25UNIT/0.5ML
VAQTA INJECTION 25UNIT/0.5ML
VAQTA INJECTION 50UNIT/ML
VARIVAX INJECTION 1350PFU/0.5ML
VARIZIG INJECTION 125UNIT/1.2ML
YF-VAX INJECTION 0
ZOSTAVAX INJECTION 19400UNT/0.65ML
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium capsule 750mg
DELZICOL CAPSULE DELAYED RELEASE 400MG
DIPENTUM CAPSULE 250MG
mesalamine kit 4gm
Sulfonamides
sulfasalazine tablet 500mg
sulfazine ec tablet delayed release 500mg
Agentes metabólicos de enfermedad ósea
Agentes metabólicos de enfermedad ósea
alendronate sodium tablet 10mg
alendronate sodium tablet 40mg
Página 89 de 148
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)
$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) 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)
$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) QL (180 EA cada 30 días)
$0-$6.60(Nivel 2)
$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)
Nombre del medicamento
alendronate sodium tablet 5mg
alendronate sodium tablet 70mg
calcitonin-salmon solution 200unit/act
calcitriol capsule 0.25mcg
calcitriol capsule 0.5mcg
calcitriol injection 1mcg/ml
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
Agentes terapéuticos misceláneos
Agentes terapéuticos misceláneos
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
Página 90 de 148
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 (4 EA cada 28 días)
$0(Nivel 1)
QL (4 ML cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$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)
$0(Nivel 1)
QL (1 EA cada 30 días)
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-$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)
Nombre del medicamento
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
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-$6.60(Nivel 2) QL (200 EA cada 30 días)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$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
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
lactated ringers irrigation solution 3meq/l; 109meq/l;
$0(Nivel 1)
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
Página 91 de 148
Nombre del medicamento
Ophthalmic Prostaglandin and Prostamide Analogs
COMBIGAN SOLUTION 0.2%; 0.5%
latanoprost solution 0.005%
LUMIGAN SOLUTION 0.01%
Ophthalmic Agents, Other
akwa tears ointment 2%; 15%; 83%
artificial tears ointment 0; 0; 0
artificial tears ointment 15%; 83%
artificial tears solution 1.4%
artificial tears solution 1.4%
bacitracin/polymyxin b ointment 500unit/gm; 10000unit/gm
FRESHKOTE SOLUTION 2.7%; 2%
ISOPTO TEARS SOLUTION 0.5%
lubrifresh p.m. ointment 15%; 83%
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
neomycin/polymyxin/gramicidin solution 0.025mg/ml;
1.75mg/ml; 10000unit/ml
polymyxin b sulfate/trimethoprim sulfate solution
10000unit/ml; 0.1%
REFRESH CELLUVISC SOLUTION 1%
refresh lacri-lube ointment 42.5%; 56.8%
refresh lacri-lube ointment 42.5%; 56.8%
REFRESH PLUS SOLUTION 0.5%
RESTASIS EMULSION 0.05%
sodium chloride ointment 5%
sodium chloride solution 5%
tears renewed ointment 0; 0
Ophthalmic Anti-allergy Agents
cromolyn sodium solution 4%
PATANOL SOLUTION 0.1%
Ophthalmic Anti-inflammatories
dexamethasone sodium phosphate solution 0.1%
diclofenac sodium solution 0.1%
fluorometholone suspension 0.1%
flurbiprofen sodium solution 0.03%
ketorolac tromethamine solution 0.4%
ketorolac tromethamine solution 0.5%
LOTEMAX SUSPENSION 0.5%
neomycin/polymyxin/dexamethasone ointment 0.1%;
3.5mg/gm; 10000unit/gm
Página 92 de 148
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(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$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 3)
$0(Nivel 3)
$0(Nivel 1)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Nivel 1)
$0(Nivel 1)
$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)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
$0(Nivel 1)
QL (5 ML cada 15 días)
$0(Nivel 1)
QL (5 ML cada 15 días)
$0-$6.60(Nivel 2)
$0(Nivel 1)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
Nombre del medicamento
neomycin/polymyxin/dexamethasone suspension 0.1%;
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)
$0(Nivel 1)
betaxolol hcl solution 0.5%
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%
timolol maleate solution 0.25%
$0(Nivel 1)
timolol maleate solution 0.5%
$0(Nivel 1)
Otic Agents
Otic Agents
acetasol hc solution 2%; 1%
$0(Nivel 1)
acetic acid solution 2%
$0(Nivel 1)
CIPRODEX SUSPENSION 0.3%; 0.1%
$0-$6.60(Nivel 2)
ear drops earwax removal aid solution 6.5%
$0(Nivel 3)
DP
ear drops solution 6.5%
$0(Nivel 3)
DP
ear wax remover solution 6.5%
$0(Nivel 3)
DP
earwax treatment drops solution 6.5%
$0(Nivel 3)
DP
hydrocortisone/acetic acid solution 2%; 1%
$0(Nivel 1)
neomycin/polymyxin/hc solution 1%; 3.5mg/ml; 10000unit/ml $0(Nivel 1)
neomycin/polymyxin/hydrocortisone suspension 1%;
$0(Nivel 1)
3.5mg/ml; 10000unit/ml
Página 93 de 148
Nombre del medicamento
qc ear wax removal drops solution 6.5%
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
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%
flunisolide solution 29mcg/act
fluticasone propionate suspension 50mcg/act
SYMBICORT AEROSOL 160MCG/ACT; 4.5MCG/ACT
Página 94 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
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
$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 (50 ML cada 30 días)
$0(Nivel 1)
QL (32 GM cada 30 días)
$0-$6.60(Nivel 2) QL (10.2 GM cada 30
días)
Nombre del medicamento
SYMBICORT AEROSOL 80MCG/ACT; 4.5MCG/ACT
triamcinolone acetonide aerosol 55mcg/act
Antihistamines
aceta-gesic tablet 325mg; 12.5mg
alavert allergy/sinus tablet extended release 12 hour 5mg;
120mg
alavert tablet 10mg
ALDEX AN TABLET CHEWABLE 5MG
all día allergy childrens tablet chewable 10mg
all día allergy childrens tablet chewable 5mg
all día allergy-d tablet extended release 12 hour 5mg; 120mg
all día allergy tablet 10mg
all día allergy tablet 10mg
all día allergy tablet 10mg
all día allergy tablet 10mg
all día allergy tablet 10mg
aller-chlor syrup 2mg/5ml
aller-chlor tablet 4mg
allergy relief child syrup 5mg/5ml
allergy relief d-24 tablet extended release 24 hour 10mg;
240mg
allergy relief tablet 10mg
allergy relief tablet 10mg
allergy/congestion relief tablet extended release 24 hour
10mg; 240mg
allergy tablet dispersible 10mg
allergy tablet 10mg
allergy tablet 10mg
allergy tablet 4mg
allergy tablet 4mg
allerhist-1 tablet 1.34mg
azelastine hcl solution 0.1%
azelastine hcl solution 0.15%
banophen capsule 50mg
banophen liquid 12.5mg/5ml
banophen liquid 12.5mg/5ml
brotapp liquid 1mg/5ml; 15mg/5ml
brotapp liquid 1mg/5ml; 15mg/5ml
BROVEX PEB LIQUID 4MG/5ML; 10MG/5ML
BROVEX PSB LIQUID 4MG/5ML; 20MG/5ML
cardec liquid 1mg/ml; 3.5mg/ml
cetirizine hcl/pseudoephedrine hcl er tablet extended release
12 hour 5mg; 120mg
cetirizine hcl tablet chewable 10mg
cetirizine hcl tablet chewable 10mg
cetirizine hcl tablet chewable 5mg
Página 95 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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)
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)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
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 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
QL (30 ML cada 30 días)
MO
DP
DP
DP
DP
DP
DP
DP
DP
DP
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
cetirizine hcl tablet chewable 5mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 10mg
$0(Nivel 3)
DP
cetirizine hcl tablet 5mg
$0(Nivel 3)
DP
cetirizine hcl tablet 5mg
$0(Nivel 3)
DP
cetirizine hcl tablet 5mg
$0(Nivel 3)
DP
childrens loratadine solution 5mg/5ml
$0(Nivel 3)
DP
childrens loratadine syrup 5mg/5ml
$0(Nivel 3)
DP
childrens loratadine syrup 5mg/5ml
$0(Nivel 3)
DP
chlorpheniramine maleate tablet extended release 12mg
$0(Nivel 3)
DP
CLARITIN REDITABS TABLET DISPERSIBLE 10MG
$0(Nivel 3)
DP
CLARITIN-D 12 HOUR TABLET EXTENDED RELEASE $0(Nivel 3)
DP
12 HOUR 5MG; 120MG
CLARITIN-D 24 HOUR TABLET EXTENDED RELEASE $0(Nivel 3)
DP
24 HOUR 10MG; 240MG
CLARITIN SYRUP 5MG/5ML
$0(Nivel 3)
DP
CLARITIN TABLET 10MG
$0(Nivel 3)
DP
complete allergy medicine capsule 25mg
$0(Nivel 3)
DP
complete allergy capsule 25mg
$0(Nivel 3)
DP
complete allergy tablet 25mg
$0(Nivel 3)
DP
cyproheptadine hcl syrup 2mg/5ml
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
cyproheptadine hcl tablet 4mg
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
DALLERGY SYRUP 12.5MG/5ML; 5MG/5ML
$0(Nivel 3)
DP
dimaphen childrens elixir 1mg/5ml; 2.5mg/5ml
$0(Nivel 3)
DP
dimaphen childrens elixir 1mg/5ml; 2.5mg/5ml
$0(Nivel 3)
DP
diphenhist liquid 12.5mg/5ml
$0(Nivel 3)
DP
diphenhist liquid 12.5mg/5ml
$0(Nivel 3)
DP
diphenhist tablet 25mg
$0(Nivel 3)
DP
diphenhydramine hcl capsule 25mg
$0(Nivel 3)
DP
diphenhydramine hcl capsule 25mg
$0(Nivel 3)
DP
diphenhydramine hcl capsule 25mg
$0(Nivel 3)
DP
diphenhydramine hcl capsule 25mg
$0(Nivel 3)
DP
diphenhydramine hcl capsule 50mg
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
Página 96 de 148
Nombre del medicamento
diphenhydramine hcl capsule 50mg
diphenhydramine hcl capsule 50mg
diphenhydramine hcl capsule 50mg
diphenhydramine hcl capsule 50mg
diphenhydramine hcl injection 50mg/ml
ed a-hist pse tablet 60mg; 2.5mg
ED A-HIST LIQUID 4MG/5ML; 10MG/5ML
ed a-hist tablet 4mg; 10mg
ED CHLORPED D LIQUID 2MG/ML; 5MG/ML
ed chlorped jr syrup 2mg/5ml
ed chlorped jr syrup 2mg/5ml
ED CHLORPED LIQUID 2MG/ML
ed-chlortan tablet 4mg
fexofenadine hcl tablet 180mg
fexofenadine hcl tablet 180mg
fexofenadine hcl tablet 180mg
fexofenadine hcl tablet 180mg
fexofenadine hcl tablet 180mg
fexofenadine hcl tablet 60mg
gnp all día allergy tablet 10mg
gnp all día allergy tablet 10mg
gnp allergy tablet 4mg
gnp díahist allergy tablet 1.34mg
gnp loratadine-d 24 hour tablet extended release 24 hour
10mg; 240mg
gnp loratadine syrup 5mg/5ml
gnp loratadine syrup 5mg/5ml
gnp loratadine tablet 10mg
gnp loratadine tablet 10mg
HYDROXYZINE HCL INJECTION 25MG/ML
hydroxyzine hcl injection 50mg/ml
hydroxyzine hcl solution 10mg/5ml
hydroxyzine hcl tablet 10mg
hydroxyzine hcl tablet 25mg
hydroxyzine hcl tablet 50mg
hydroxyzine pamoate capsule 100mg
hydroxyzine pamoate capsule 25mg
hydroxyzine pamoate capsule 50mg
J-TAN D PD LIQUID 1MG/ML; 7.5MG/ML
Página 97 de 148
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
$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)
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)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
DP
$0(Nivel 3)
Nombre del medicamento
J-TAN PD LIQUID 1MG/ML
levocetirizine dihydrochloride solution 2.5mg/5ml
levocetirizine dihydrochloride tablet 5mg
LODRANE D CAPSULE 4MG; 60MG
LOHIST-D LIQUID 2MG/5ML; 30MG/5ML
lohist-peb liquid 4mg/5ml; 10mg/5ml
loratadine allergy relief tablet dispersible 10mg
loratadine childrens solution 5mg/5ml
loratadine childrens syrup 5mg/5ml
loratadine hives relief solution 5mg/5ml
loratadine-d 12hr tablet extended release 12 hour 5mg;
120mg
loratadine-d 24hr tablet extended release 24 hour 10mg;
240mg
loratadine-d 24hr tablet extended release 24 hour 10mg;
240mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
loratadine tablet 10mg
medi-phedryl capsule 25mg
medi-sleep tablet 25mg
nasohist liquid 1mg/ml; 2mg/ml
night time sleep aid tablet 25mg
nohist-lq liquid 4mg/5ml; 10mg/5ml
olopatadine hcl solution 0.6%
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
q-dryl capsule 25mg
qc chlor-pheniramine tablet 4mg
qc complete allergy medicine tablet 25mg
qc loratadine allergy relief tablet 10mg
qc loratadine-d tablet extended release 24 hour 10mg; 240mg
qc rest simply tablet 25mg
RESCON TABLET 2MG; 60MG
restfully sleep tablet 25mg
RYMED TABLET 2MG; 10MG
rynex pe elixir 1mg/5ml; 2.5mg/5ml
rynex pse liquid 1mg/5ml; 15mg/5ml
siladryl allergy liquid 12.5mg/5ml
siladryl allergy liquid 12.5mg/5ml
Página 98 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 1)
$0(Nivel 1)
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)
$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)
$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)
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
siladryl allergy liquid 12.5mg/5ml
sm allergy 4 hour tablet 4mg
sm allergy relief capsule 25mg
sm allergy relief tablet 1.34mg
sm allergy relief tablet 25mg
sm lorata-dine d tablet extended release 24 hour 10mg;
240mg
sm loratadine syrup 5mg/5ml
sm sinus & allergy maximum strength tablet 4mg; 60mg
sm sleep aid tablet 25mg
sudogest sinus & allergy tablet 4mg; 60mg
virdec liquid 1mg/ml; 3.5mg/ml
VITUZ SOLUTION 4MG/5ML; 5MG/5ML
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 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)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$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)
$0(Nivel 1)
QL (60 EA cada 30 días)
$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
$0(Nivel 1)
$0(Nivel 1)
Página 99 de 148
DP
DP
DP
DP
DP
DP
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
albuterol sulfate tablet 4mg
EPHEDRINE SULFATE CAPSULE 25MG
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
S2 NEBULIZATION SOLUTION 2.25%
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 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
Página 100 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
$0(Nivel 3)
DP
$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(Nivel 3)
DP
$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, otro)
$0-$6.60(Nivel 2) B/D
$0-$6.60(Nivel 2)
$0(Nivel 1)
B/D
$0(Nivel 3)
$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)
DP
DP
QL (305 ML cada 30 días)
B/D
Nombre del medicamento
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
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%
AEROKID SYRUP 4MG/5ML; 1.25MG/5ML; 10MG/5ML
AEROKID SYRUP 4MG/5ML; 1.25MG/5ML; 10MG/5ML
ALAHIST DM LIQUID 4MG/5ML; 15MG/5ML;
7.5MG/5ML
ALDEX GS DM TABLET 15MG; 190MG; 30MG
ALDEX GS TABLET 190MG; 30MG
ALDEX-CT TABLET CHEWABLE 12.5MG; 5MG
all-nite multi-symptom cold/flu relief liquid 325mg/15ml;
15mg/15ml; 6.25mg/15ml
ALLRES PD SUSPENSION 7.5MG/5ML; 30MG/5ML
amdry-d tablet extended release 12 hour 2.5mg; 120mg
ap-hist dm liquid 4mg/5ml; 15mg/5ml; 7.5mg/5ml
aprodine tablet 60mg; 2.5mg
aprodine tablet 60mg; 2.5mg
ARALAST NP INJECTION 400MG
AYR NASAL DROPS SOLUTION 0.65%
ayr saline nasal gel 0
ayr solution 0.65%
baby ayr saline solution 0.65%
BALAMINE DM SYRUP 2MG/5ML; 10MG/5ML;
5MG/5ML
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
Página 101 de 148
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)
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)
$0(Nivel 1)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
B/D
B/D
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
DP
DP
$0(Nivel 3)
$0(Nivel 3)
$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(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
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
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
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
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
Nombre del medicamento
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 100mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
benzonatate capsule 200mg
BICLORA LIQUID 12.5MG/5ML; 12.5MG/5ML
BICLORA TABLET 25MG; 25MG
BP 8 COUGH LIQUID 15MG/5ML; 175MG/5ML;
30MG/5ML
brom/pse/dm syrup 2mg/5ml; 10mg/5ml; 30mg/5ml
$0(Nivel 3)
bromfed dm syrup 2mg/5ml; 10mg/5ml; 30mg/5ml
$0(Nivel 3)
bromfed dm syrup 2mg/5ml; 10mg/5ml; 30mg/5ml
$0(Nivel 3)
brotapp dm liquid 1mg/5ml; 5mg/5ml; 15mg/5ml
$0(Nivel 3)
brotapp dm liquid 1mg/5ml; 5mg/5ml; 15mg/5ml
$0(Nivel 3)
BROVEX PEB DM LIQUID 4MG/5ML; 20MG/5ML;
$0(Nivel 3)
10MG/5ML
BROVEX PSB DM LIQUID 4MG/5ML; 20MG/5ML;
$0(Nivel 3)
20MG/5ML
cardec dm liquid 1mg/ml; 3mg/ml; 3.5mg/ml
$0(Nivel 3)
cheratussin ac syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
cheratussin ac syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
cheratussin ac syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
cheratussin dac solution 10mg/5ml; 100mg/5ml; 30mg/5ml $0(Nivel 3)
chest congestion relief tablet 400mg
$0(Nivel 3)
childrens silfedrine liquid 15mg/5ml
$0(Nivel 3)
childrens silfedrine liquid 15mg/5ml
$0(Nivel 3)
CHLO TUSS EX LIQUID 12.5MG/5ML; 100MG/5ML
$0(Nivel 3)
chlor-mes tablet extended release 12 hour 12mg; 2.5mg;
$0(Nivel 3)
20mg
chlorpheniramine/codeine liquid 2mg/5ml; 10mg/5ml
$0(Nivel 3)
CLOFERA LIQUID 12.5MG/5ML; 30MG/5ML
$0(Nivel 3)
codeine phosphate/guaifenesin liquid 10mg/5ml; 300mg/5ml $0(Nivel 3)
codeine/guaifenesin tablet 10mg; 300mg
$0(Nivel 3)
cold/cough dm childrens elixir 1mg/5ml; 5mg/5ml; 2.5mg/5ml $0(Nivel 3)
coldamine tablet extended release 12 hour 8mg; 2.5mg; 90mg $0(Nivel 3)
coldcough syrup 2mg/5ml; 7.5mg/5ml; 15mg/5ml
$0(Nivel 3)
corfen-dm liquid 4mg/5ml; 15mg/5ml; 10mg/5ml
$0(Nivel 3)
cough dm liquid extended release 30mg/5ml
$0(Nivel 3)
cough syrup syrup 100mg/5ml
$0(Nivel 3)
Página 102 de 148
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DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
Nombre del medicamento
cpm 8/pe 20/msc 1.25 tablet extended release 12 hour 8mg;
1.25mg; 20mg
d-hist d tablet extended release 12 hour 3.5mg; 1mg; 45mg $0(Nivel 3)
DAY TIME MULTI-SYMPTOM COLD/FLU RELIEF
$0(Nivel 3)
CAPSULE 325MG; 10MG; 5MG
DECONEX DMX TABLET 15MG; 380MG; 10MG
$0(Nivel 3)
DECONSAL DM TABLET CHEWABLE 15MG; 10MG;
$0(Nivel 3)
16MG
deep sea nasal spray solution 0.65%
$0(Nivel 3)
delsym childrens night time cough/cold liquid 12.5mg/5ml;
$0(Nivel 3)
5mg/5ml
delsym night time cough/cold childrens liquid 6.25mg/5ml;
$0(Nivel 3)
2.5mg/5ml
delsym night time cough/cold liquid 500mg/15ml; 15mg/15ml; $0(Nivel 3)
6.25mg/15ml
delsym night time cough/cold liquid 6.25mg/5ml; 2.5mg/5ml $0(Nivel 3)
delsym night time multi-symptom liquid 325mg/15ml;
$0(Nivel 3)
10mg/15ml; 6.25mg/15ml; 5mg/15ml
delsym night time multi-symptom liquid 325mg/15ml;
$0(Nivel 3)
15mg/15ml; 6.25mg/15ml
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
$0(Nivel 3)
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
$0(Nivel 3)
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
$0(Nivel 3)
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
$0(Nivel 3)
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
$0(Nivel 3)
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
$0(Nivel 3)
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
$0(Nivel 3)
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
$0(Nivel 3)
DELSYM LIQUID EXTENDED RELEASE 30MG/5ML
$0(Nivel 3)
dex-tuss dm liquid 10mg/5ml; 300mg/5ml
$0(Nivel 3)
dextromethorphan polistirex liquid extended release
$0(Nivel 3)
30mg/5ml
dimaphen dm cold/cough childrens elixir 1mg/5ml; 5mg/5ml; $0(Nivel 3)
2.5mg/5ml
DONATUSSIN SYRUP 12.5MG/5ML; 120MG/5ML;
$0(Nivel 3)
5MG/5ML
DUOHIST DH LIQUID 2MG/5ML; 7.25MG/5ML;
$0(Nivel 3)
5MG/5ML
duradryl sr tablet extended release 12 hour 8mg; 2.5mg;
$0(Nivel 3)
20mg
DURAHIST D TABLET EXTENDED RELEASE 12 HOUR $0(Nivel 3)
3.5MG; 1MG; 45MG
DURAHIST PE TABLET EXTENDED RELEASE 12 HOUR $0(Nivel 3)
8MG; 1.25MG; 20MG
DURAHIST TABLET EXTENDED RELEASE 12 HOUR $0(Nivel 3)
8MG; 1.25MG; 60MG
ed a-hist dm liquid 4mg/5ml; 15mg/5ml; 10mg/5ml
$0(Nivel 3)
ed bron gp liquid 100mg/5ml; 5mg/5ml
$0(Nivel 3)
Página 103 de 148
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Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
endacof-c liquid 2mg/5ml; 10mg/5ml
$0(Nivel 3)
DP
endacof-dm liquid 1mg/5ml; 5mg/5ml; 2.5mg/5ml
$0(Nivel 3)
DP
ENTSOL NASAL GEL GEL 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0 $0(Nivel 3)
DP
extra action cough syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
gnp tussin dm liquid 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
gnp tussin dm liquid 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
gnp tussin syrup 100mg/5ml
$0(Nivel 3)
DP
guaiatussin ac syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
guaiatussin ac syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
guaifenesin ac syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
guaifenesin er tablet extended release 12 hour 600mg
$0(Nivel 3)
DP
guaifenesin er tablet extended release 12 hour 600mg
$0(Nivel 3)
DP
guaifenesin er tablet extended release 12 hour 600mg
$0(Nivel 3)
DP
guaifenesin/codeine solution 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
guaifenesin/codeine solution 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
guaifenesin tablet 400mg
$0(Nivel 3)
HEXAFLU TABLET 650MG; 2MG; 45MG
$0(Nivel 3)
hist-pse liquid 10mg/ml; 0.938mg/ml
$0(Nivel 3)
DP
histade mx tablet extended release 12 hour 8mg; 2.5mg;
$0(Nivel 3)
120mg
histatab d tablet extended release 12 hour 3.5mg; 1mg; 45mg $0(Nivel 3)
histatab ph tablet extended release 12 hour 8mg; 1.25mg;
$0(Nivel 3)
20mg
histatab tablet extended release 12 hour 8mg; 1.25mg; 60mg $0(Nivel 3)
hydrocodone bitartrate/homatropine methylbromide syrup
$0(Nivel 3)
DP
1.5mg/5ml; 5mg/5ml
hydrocodone bitartrate/homatropine methylbromide tablet
$0(Nivel 3)
DP
1.5mg; 5mg
hydrocodone bitartrate/homatropine methylbromide tablet
$0(Nivel 3)
DP
1.5mg; 5mg
hydrocodone polistirex/chlorpheniramine polistirex liquid
$0(Nivel 3)
DP
extended release 8mg/5ml; 10mg/5ml
hydrocodone polistirex/chlorpheniramine polistirex liquid
$0(Nivel 3)
DP
extended release 8mg/5ml; 10mg/5ml
hydrocodone polistirex/chlorpheniramine polistirex liquid
$0(Nivel 3)
DP
extended release 8mg/5ml; 10mg/5ml
hydrocodone polistirex/chlorpheniramine polistirex liquid
$0(Nivel 3)
DP
extended release 8mg/5ml; 10mg/5ml
hydrocodone/homatropine syrup 1.5mg/5ml; 5mg/5ml
$0(Nivel 3)
DP
hydromet syrup 1.5mg/5ml; 5mg/5ml
$0(Nivel 3)
DP
iophen c-nr liquid 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
iophen dm-nr liquid 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
iophen-nr liquid 100mg/5ml
$0(Nivel 3)
DP
DP
J-MAX SYRUP 200MG/5ML; 5MG/5ML
$0(Nivel 3)
J-MAX TABLET EXTENDED RELEASE 12 HOUR
$0(Nivel 3)
1200MG; 35MG
kidkare cough/cold liquid 1mg/5ml; 5mg/5ml; 15mg/5ml
$0(Nivel 3)
DP
l-all 12 nf suspension 30mg/5ml; 25mg/5ml
$0(Nivel 3)
Página 104 de 148
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
Nombre del medicamento
liquibid tablet 400mg
lohist-dm syrup 2mg/5ml; 10mg/5ml; 5mg/5ml
lohist-peb-dm liquid 4mg/5ml; 20mg/5ml; 10mg/5ml
LUSAIR LIQUID 200MG/5ML; 7.5MG/5ML
M-END DMX LIQUID 0.667MG/5ML; 10MG/5ML;
20MG/5ML
M-END MAX D LIQUID 6MG/5ML; 0.667MG/5ML;
$0(Nivel 3)
20MG/5ML
m-end wc liquid 1.33mg/5ml; 6.33mg/5ml; 10mg/5ml
$0(Nivel 3)
mapap cold formula multi-symptom tablet 325mg; 10mg; 5mg $0(Nivel 3)
mapap sinus maximum strength congestion and pain tablet
$0(Nivel 3)
325mg; 5mg
medi-tussin dm diabetic liquid 10mg/5ml; 100mg/5ml
$0(Nivel 3)
medi-tussin dm syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
medi-tussin syrup 100mg/5ml
$0(Nivel 3)
mucaphed tablet 400mg; 10mg
$0(Nivel 3)
MUCINEX CHILDRENS MULTI-SYMPTOM COLD &
$0(Nivel 3)
FEVER LIQUID 325MG/10ML; 10MG/10ML;
200MG/10ML; 5MG/10ML
MUCINEX CHILDRENS MULTI-SYMPTOM COLD
$0(Nivel 3)
LIQUID 5MG/5ML; 100MG/5ML; 2.5MG/5ML
MUCINEX COLD FOR KIDS LIQUID 100MG/5ML;
$0(Nivel 3)
2.5MG/5ML
mucinex cough for kids liquid 5mg/5ml; 100mg/5ml
$0(Nivel 3)
MUCINEX COUGH FOR KIDS PACKET 5MG; 100MG
$0(Nivel 3)
MUCINEX DM MAXIMUM STRENGTH TABLET
$0(Nivel 3)
EXTENDED RELEASE 12 HOUR 60MG; 1200MG
MUCINEX DM MAXIMUM STRENGTH TABLET
$0(Nivel 3)
EXTENDED RELEASE 12 HOUR 60MG; 1200MG
MUCINEX DM TABLET EXTENDED RELEASE 12 HOUR$0(Nivel 3)
30MG; 600MG
MUCINEX DM TABLET EXTENDED RELEASE 12 HOUR$0(Nivel 3)
30MG; 600MG
MUCINEX D TABLET EXTENDED RELEASE 12 HOUR $0(Nivel 3)
1200MG; 120MG
MUCINEX D TABLET EXTENDED RELEASE 12 HOUR $0(Nivel 3)
600MG; 60MG
MUCINEX D TABLET EXTENDED RELEASE 12 HOUR $0(Nivel 3)
600MG; 60MG
MUCINEX FAST-MAX COLD & SINUS LIQUID
$0(Nivel 3)
650MG/20ML; 400MG/20ML; 10MG/20ML
MUCINEX FAST-MAX COLD FLU& SORE THROAT
$0(Nivel 3)
LIQUID 650MG/20ML; 20MG/20ML; 400MG/20ML;
10MG/20ML
mucinex fast-max dm max liquid 20mg/20ml; 400mg/20ml
$0(Nivel 3)
MUCINEX FAST-MAX SEVERE CONGESTION &
$0(Nivel 3)
COUGH LIQUID 20MG/20ML; 400MG/20ML;
10MG/20ML
Página 105 de 148
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Nombre del medicamento
mucinex for kids liquid 100mg/5ml
MUCINEX FOR KIDS PACKET 100MG
MUCINEX FOR KIDS PACKET 50MG
MUCINEX MAXIMUM STRENGTH TABLET
EXTENDED RELEASE 12 HOUR 1200MG
MUCINEX MAXIMUM STRENGTH TABLET
EXTENDED RELEASE 12 HOUR 1200MG
mucinex nasal spray full force solution 0.05%
MUCINEX TABLET EXTENDED RELEASE 12 HOUR
600MG
MUCINEX TABLET EXTENDED RELEASE 12 HOUR
600MG
MUCINEX TABLET EXTENDED RELEASE 12 HOUR
600MG
MUCINEX TABLET EXTENDED RELEASE 12 HOUR
600MG
MUCINEX TABLET EXTENDED RELEASE 12 HOUR
600MG
mucus relief tablet 400mg
mucus relief tablet 400mg
mucus-er tablet extended release 12 hour 600mg
mucus-er tablet extended release 12 hour 600mg
mucusrelief sinus tablet 400mg; 10mg
nasal decongestant spray solution 0.05%
nasal decongestant spray solution 0.05%
nasal decongestant spray solution 0.05%
nasal decongestant spray solution 0.05%
nasal decongestant solution 1%
NASAL DECONGESTANT SYRUP 30MG/5ML
NASOHIST DM LIQUID 1MG/ML; 3MG/ML; 2MG/ML
night time multi-symptom cold/flu relief capsule 325mg;
15mg; 6.25mg
nohist-dm liquid 4mg/5ml; 15mg/5ml; 10mg/5ml
NOREL AD TABLET 325MG; 4MG; 10MG
NOREL CS LIQUID 4MG/5ML; 12.5MG/5ML; 10MG/5ML
NOREL DM SOLUTION 4MG/5ML; 15MG/5ML;
10MG/5ML
nrs nasal relief solution 0.05%
OCEAN NASAL SPRAY SOLUTION 0.65%
OCEAN NASAL SPRAY SOLUTION 0.65%
organ-i nr tablet 200mg
p-hist dm liquid 1mg/ml; 5mg/ml; 12mg/ml
p-hist syrup 1.25mg/5ml; 5mg/5ml; 5mg/5ml; 5mg/5ml
pcm allergy tablet extended release 12 hour 12mg; 2.5mg;
20mg
pcm la tablet extended release 12 hour 8mg; 1.25mg; 60mg
PEDIATEX TD LIQUID 10MG/ML; 0.938MG/ML
Página 106 de 148
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(Nivel 3)
$0(Nivel 3)
DP
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)
$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
DP
DP
DP
$0(Nivel 3)
$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)
DP
DP
DP
DP
$0(Nivel 3)
$0(Nivel 3)
DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
Nombre del medicamento
PEDIATEX TDM SUSPENSION 4MG/ML; 10MG/ML;
0.938MG/ML
pediatric cough/cold liquid 1mg/5ml; 5mg/5ml; 15mg/5ml
$0(Nivel 3)
DP
phenylephrine hcl/pyrilamine maleate tablet 10mg; 25mg
$0(Nivel 3)
DP
PHENYLHISTINE DH LIQUID 2MG/5ML; 10MG/5ML;
$0(Nivel 3)
DP
30MG/5ML
PHENYLHISTINE DH LIQUID 2MG/5ML; 10MG/5ML;
$0(Nivel 3)
DP
30MG/5ML
POLY-TUSSIN AC LIQUID 4MG/5ML; 10MG/5ML;
$0(Nivel 3)
DP
7.5MG/5ML
PROHIST DM LIQUID 1MG/ML; 5MG/ML; 12MG/ML
$0(Nivel 3)
PROHIST SYRUP 1.25MG/5ML; 5MG/5ML; 5MG/5ML;
$0(Nivel 3)
5MG/5ML
PROLASTIN-C INJECTION 1000MG
$0-$6.60(Nivel 2)
$0(Nivel 1)
promethazine vc plain syrup 5mg/5ml; 6.25mg/5ml
PROMETHAZINE VC/CODEINE SYRUP 10MG/5ML;
$0(Nivel 3)
DP
5MG/5ML; 6.25MG/5ML
promethazine-dm syrup 15mg/5ml; 6.25mg/5ml
$0(Nivel 3)
DP
promethazine-dm syrup 15mg/5ml; 6.25mg/5ml
$0(Nivel 3)
DP
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
$0(Nivel 3)
DP
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
$0(Nivel 3)
DP
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
$0(Nivel 3)
DP
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
$0(Nivel 3)
DP
promethazine/dextromethorphan syrup 15mg/5ml; 6.25mg/5ml$0(Nivel 3)
DP
promethazine/dextromethorphan syrup 15mg/5ml; 6.25mg/5ml$0(Nivel 3)
DP
promethazine/dextromethorphan syrup 15mg/5ml; 6.25mg/5ml$0(Nivel 3)
DP
PSEUDACARB TABLET CHEWABLE 25MG; 75MG
$0(Nivel 3)
pseudoephedrine hcl tablet 30mg
$0(Nivel 3)
DP
pseudoephedrine/codeine liquid 10mg/5ml; 30mg/5ml
$0(Nivel 3)
PYRIL DM SUSPENSION 15MG/5ML; 5MG/5ML;
$0(Nivel 3)
DP
16MG/5ML
q-tussin dm syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
DP
q-tussin dm syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
q-tussin dm syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
DP
q-tussin syrup 100mg/5ml
$0(Nivel 3)
DP
q-tussin syrup 100mg/5ml
$0(Nivel 3)
DP
DP
q-tussin syrup 100mg/5ml
$0(Nivel 3)
qc cough/sore throat nighttime liquid 1000mg/30ml;
$0(Nivel 3)
DP
30mg/30ml; 12.5mg/30ml
qc díatime multi-symptom cold/flu capsule 325mg; 10mg; 5mg $0(Nivel 3)
DP
qc nighttime cough liquid 15mg/15ml; 6.25mg/15ml
$0(Nivel 3)
DP
qc nighttime cough liquid 15mg/15ml; 6.25mg/15ml
$0(Nivel 3)
DP
qc nighttime multi-symptom cold/flu capsule 325mg; 15mg; $0(Nivel 3)
DP
6.25mg
quad tann tablet 60mg; 5mg; 10mg; 10mg
$0(Nivel 3)
RESCON DM SYRUP 2MG/5ML; 10MG/5ML; 30MG/5ML $0(Nivel 3)
DP
RESCON DM SYRUP 2MG/5ML; 10MG/5ML; 30MG/5ML $0(Nivel 3)
DP
RESCON-GG LIQUID 100MG/5ML; 5MG/5ML
$0(Nivel 3)
DP
Página 107 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 3)
DP
$0(Nivel 3)
Nombre del medicamento
RESCON-GG LIQUID 100MG/5ML; 5MG/5ML
RESCON TABLET EXTENDED RELEASE 12 HOUR
12MG; 2MG; 40MG
RESPAIRE-30 CAPSULE 150MG; 30MG
$0(Nivel 3)
resperal syrup 1.25mg/5ml; 5mg/5ml; 5mg/5ml; 5mg/5ml
$0(Nivel 3)
REZIRA SOLUTION 5MG/5ML; 60MG/5ML
$0(Nivel 3)
RHINARIS SOLUTION 0.2%
$0(Nivel 3)
robafen cf cough & cold syrup 10mg/5ml; 100mg/5ml;
$0(Nivel 3)
5mg/5ml
robafen dm cough clear syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
robafen dm syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
robafen dm syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
robafen syrup 100mg/5ml
$0(Nivel 3)
robafen syrup 100mg/5ml
$0(Nivel 3)
ROBITUSSIN CHEST CONGESTION SYRUP 100MG/5ML $0(Nivel 3)
rynex dm liquid 1mg/5ml; 5mg/5ml; 2.5mg/5ml
$0(Nivel 3)
saline nasal spray solution 0.65%
$0(Nivel 3)
sea soft nasal mist solution 0.65%
$0(Nivel 3)
sil-tex syrup 100mg/5ml; 7.5mg/5ml
$0(Nivel 3)
silphen dm cough syrup 10mg/5ml
$0(Nivel 3)
siltussin das liquid 100mg/5ml
$0(Nivel 3)
siltussin dm das liquid 10mg/5ml; 100mg/5ml
$0(Nivel 3)
siltussin sa syrup 100mg/5ml
$0(Nivel 3)
siltussin sa syrup 100mg/5ml
$0(Nivel 3)
siltussin sa syrup 100mg/5ml
$0(Nivel 3)
siltussin-dm syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
siltussin-dm syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
siltussin-dm syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
SINA-12X SUSPENSION 100MG/5ML; 5MG/5ML
$0(Nivel 3)
sm cold & cough childrens elixir 1mg/5ml; 5mg/5ml;
$0(Nivel 3)
15mg/5ml
sm nasal spray saline solution 0.65%
$0(Nivel 3)
sm tussin dm cough/chest congestion syrup 10mg/5ml;
$0(Nivel 3)
100mg/5ml
sm tussin dm syrup 10mg/5ml; 100mg/5ml
$0(Nivel 3)
sm tussin syrup 100mg/5ml
$0(Nivel 3)
su-tuss dm elixir 20mg/5ml; 200mg/5ml
$0(Nivel 3)
sudogest 12 hour tablet extended release 12 hour 120mg
$0(Nivel 3)
sudogest pe tablet 10mg
$0(Nivel 3)
sudogest tablet 30mg
$0(Nivel 3)
sudogest tablet 30mg
$0(Nivel 3)
sudogest tablet 60mg
$0(Nivel 3)
$0(Nivel 3)
TANDUR DM SUSPENSION 3MG/5ML; 27.5MG/5ML;
50MG/5ML
trip-pse liquid 10mg/ml; 0.938mg/ml
$0(Nivel 3)
trital sr tablet extended release 12 hour 325mg; 8mg; 40mg; $0(Nivel 3)
50mg
tusscough dhc syrup 5mg/5ml; 3mg/5ml; 20mg/5ml
$0(Nivel 3)
Página 108 de 148
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
tussin dm clear liquid 10mg/5ml; 100mg/5ml
tussin dm liquid 10mg/5ml; 100mg/5ml
tussin dm syrup 10mg/5ml; 100mg/5ml
tussin dm syrup 10mg/5ml; 100mg/5ml
tussin dm syrup 10mg/5ml; 100mg/5ml
tussin dm syrup 10mg/5ml; 100mg/5ml
tussin mucus + chest congestion syrup 100mg/5ml
tussin mucus + chest congestion syrup 100mg/5ml
tussin syrup 100mg/5ml
tussin syrup 100mg/5ml
TUSSIONEX PENNKINETIC EXTENDED RELEASE
LIQUID EXTENDED RELEASE 8MG/5ML; 10MG/5ML
tussizone-12 rf tablet 60mg; 5mg
TYZINE PEDIATRIC NASAL DROPS SOLUTION 0.05%
viratan-dm suspension 25mg/5ml; 12.5mg/5ml; 30mg/5ml
virdec dm liquid 1mg/ml; 3mg/ml; 3.5mg/ml
XOLAIR INJECTION 150MG
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(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-$6.60(Nivel 2)
$0(Nivel 3)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2) PA (Respiratory Tract
Agents)
$0(Nivel 3)
DP
$0(Nivel 3)
DP
z-cof 12dm liquid 15mg/5ml; 175mg/5ml; 30mg/5ml
Z-COF I SUSPENSION 15MG/5ML; 211MG/5ML;
30MG/5ML
ZEMAIRA INJECTION 1000MG
$0-$6.60(Nivel 2)
ZONATUSS CAPSULE 150MG
$0(Nivel 3)
DP
ZUTRIPRO SOLUTION 4MG/5ML; 5MG/5ML; 60MG/5ML $0(Nivel 3)
DP
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
chlorzoxazone tablet 500mg
$0(Nivel 1)
PA (Medicamentos de alto
riesgo)
cyclobenzaprine hcl tablet 10mg
$0(Nivel 1)
QL (90 EA cada 30 días)
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
GABA Receptor Modulators
flurazepam hcl capsule 15mg
$0(Nivel 1)
QL (30 EA cada 30 días)
flurazepam hcl capsule 30mg
$0(Nivel 1)
QL (30 EA cada 30 días)
temazepam capsule 15mg
$0(Nivel 1)
QL (30 EA cada 30 días)
temazepam capsule 30mg
$0(Nivel 1)
QL (30 EA cada 30 días)
Página 109 de 148
Nombre del medicamento
zaleplon capsule 10mg
zaleplon capsule 5mg
zolpidem tartrate er tablet extended release 12.5mg
zolpidem tartrate er tablet extended release 6.25mg
zolpidem tartrate tablet 10mg
zolpidem tartrate tablet 5mg
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
EXJADE TABLET SOLUBLE 500MG
kionex powder 0
SODIUM LACTATE INJECTION 167MEQ/L
SODIUM LACTATE INJECTION 5MEQ/ML
sodium polystyrene sulfonate suspension 15gm/60ml
Página 110 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0(Nivel 1)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
$0(Nivel 1)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
$0(Nivel 1)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
$0(Nivel 1)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
$0(Nivel 1)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
$0(Nivel 1)
QL (90 EA cada 365 días)
PA (Medicamento de alto
riesgo Nonbenzodiazepine
Hipnóticos)
$0(Nivel 1)
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)
$0-$6.60(Nivel 2)
$0(Nivel 1)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 1)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2)
Nombre del medicamento
SYPRINE CAPSULE 250MG
Electrolyte/Mineral Replacement
$0-$6.60(Nivel 2) B/D
AMINOSYN 7%/ELECTROLYTES INJECTION
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
aminosyn 8.5%/electrolytes injection 142meq/l;
$0(Nivel 1)
B/D
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 111 de 148
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
$0-$6.60(Nivel 2) B/D
AMINOSYN M INJECTION 65MEQ/L; 448MG/100ML;
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)
calcium carbonate suspension 1250mg/5ml
$0(Nivel 3)
DP
calcium carbonate suspension 1250mg/5ml
$0(Nivel 3)
DP
CALTRATE 600+D SOFT CHEWS TABLET CHEWABLE $0(Nivel 3)
DP
600MG; 800UNIT
caltrate 600+d tablet chewable 600mg; 400unit
$0(Nivel 3)
DP
Página 112 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) B/D
Nombre del medicamento
CLINIMIX 2.75%/DEXTROSE 5% INJECTION
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
CLINIMIX 5%/DEXTROSE 15% INJECTION
$0-$6.60(Nivel 2) B/D
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
Página 113 de 148
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 20% INJECTION 42MEQ/L;
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
CLINIMIX E 4.25%/DEXTROSE 25% INJECTION
$0-$6.60(Nivel 2) B/D
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
Página 114 de 148
Nombre del medicamento
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
DEXTROSE 10%/NACL 0.45% INJECTION 10%; 0.45%
dextrose 10% flex container injection 10%
DEXTROSE 10%/NACL 0.2% INJECTION 10%; 0.2%
dextrose 2.5%/sodium chloride 0.45% injection 2.5%; 0.45%
dextrose 5%/nacl 0.2% injection 5%; 0.2%
DEXTROSE 5%/NACL 0.225% INJECTION 5%; 0.225%
dextrose 5%/nacl 0.33% injection 5%; 0.33%
dextrose 5%/nacl 0.45% injection 5%; 0.45%
dextrose 5%/nacl 0.9% injection 5%; 0.9%
dextrose 5%/potassium chloride 0.15% injection 5%; 20meq/l
dextrose 5% injection 5%
Página 115 de 148
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)
$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)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) B/D
Nombre del medicamento
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
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
$0-$6.60(Nivel 2)
IONOSOL-MB/DEXTROSE 5% INJECTION 22MEQ/L;
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)
kcl 0.3%/d5w/nacl 0.45% injection 5%; 40meq/l; 0.45%
$0(Nivel 1)
KCL 0.3%/D5W/NACL 0.9% INJECTION 5%; 40MEQ/L; $0-$6.60(Nivel 2)
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)
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
mag-g tablet 500mg
$0(Nivel 3)
DP
mag-sr plus calcium tablet delayed release 106mg; 64mg
$0(Nivel 3)
DP
mag-sr tablet extended release 535mg
$0(Nivel 3)
DP
magnesium sulfate injection 50%
$0(Nivel 1)
magnesium sulfate injection 50%
$0(Nivel 1)
MOZOBIL INJECTION 24MG/1.2ML
$0-$6.60(Nivel 2) PA (Mozobil)
Página 116 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) B/D
Nombre del medicamento
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
NOVAFERRUM 125 LIQUID 100UNIT/5ML; 125MG/5ML $0(Nivel 3)
DP
NOVAFERRUM 50 CAPSULE 50MG
$0(Nivel 3)
DP
DP
NOVAFERRUM PEDIATRIC DROPS LIQUID 15MG/ML $0(Nivel 3)
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)
potassium citrate er tablet extended release 15meq
$0(Nivel 1)
MO
potassium citrate er tablet extended release 540mg
$0(Nivel 1)
Página 117 de 148
Nombre del medicamento
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
ringers injection injection 4.5meq/l; 156meq/l; 4meq/l;
147meq/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
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
Página 118 de 148
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$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 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)
$0(Nivel 1)
DP
$0-$6.60(Nivel 2) B/D
Nombre del medicamento
TROPHAMINE INJECTION 0; 0.32GM/100ML;
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;
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
UROCIT-K 15 TABLET EXTENDED RELEASE 15MEQ
UROCIT-K 5 TABLET EXTENDED RELEASE 540MG
Vitamins
ADVANCED CARE PLUS TABLET 50MG; 250MG; 0;
240UNIT; 2MG; 12MCG; 50MG; 30MG; 1MG; 25MG;
20MG; 50MG; 3.4MG; 35MG; 3MG; 3.5UNIT; 15MG
aqueous vitamin d infants liquid 400unit/ml
centrum kids complete tablet chewable 60mg; 0; 45mcg;
108mg; 10mg; 20mcg; 2mg; 6mcg; 400unit; 400mcg; 18mg;
40mg; 1mg; 20mg; 50mg; 10mcg; 150mcg; 2mg; 1.7mg;
20mcg; 1.5mg; 30unit; 3500unit; 15mg
centrum kids complete tablet chewable 60mg; 0; 45mcg;
108mg; 10mg; 20mcg; 2mg; 6mcg; 400unit; 400mcg; 18mg;
40mg; 1mg; 20mg; 50mg; 10mcg; 150mcg; 2mg; 1.7mg;
20mcg; 1.5mg; 30unit; 3500unit; 15mg
DIALYVITE 800/ZINC 15 TABLET 80MG; 300MCG;
10MG; 800MCG; 6MCG; 20MG; 10MG; 1.7MG; 1.5MG;
15MG
DIALYVITE 800/ZINC TABLET 60MG; 0.3MG; 0.006MG;
0.8MG; 20MG; 10MG; 10MG; 1.7MG; 1.5MG; 50MG
DRISDOL CAPSULE 50000UNIT
ergocalciferol solution 8000unit/ml
EZFE FORTE CAPSULE 45MG; 150MCG; 10MG;
1000MCG; 1000MCG; 20MG; 155MG; 25MG; 1.7MG;
1.5MG
FOLIC ACID INJECTION 5MG/ML
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
Página 119 de 148
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)
$0-$6.60(Nivel 2)
$0-$6.60(Nivel 2)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
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)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
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
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
DP
$0(Nivel 3)
Nombre del medicamento
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
folic acid tablet 1mg
FOLTABS 90 PLUS DHA MISCELLANEOUS 120MG;
200MG; 400UNIT; 2MG; 250MG; 50MG; 1MG; 90MG;
20MG; 150MCG; 20MG; 3.4MG; 3MG; 30UNIT; 25MG
FOLTABS PRENATAL PLUS DHA MISCELLANEOUS
$0(Nivel 3)
120MG; 125MG; 400UNIT; 2MG; 30UNIT; 250MG; 50MG;
1MG; 27MG; 20MG; 150MCG; 20MG; 3.4MG; 3MG; 25MG
FOLTABS PRENATAL TABLET 120MG; 125MG;
$0(Nivel 3)
400UNIT; 2MG; 50MG; 1MG; 27MG; 20MG; 150MCG;
20MG; 3.4MG; 3MG; 30UNIT; 25MG
ICAPS AREDS FORMULA TABLET 113MG; 7160UNIT; $0(Nivel 3)
33MG; 0.4MG; 100UNIT; 17.4MG
MEPHYTON TABLET 5MG
$0(Nivel 3)
NATACHEW TABLET CHEWABLE 120MG; 1000UNIT; $0(Nivel 3)
400UNIT; 12MCG; 29MG; 1MG; 20MG; 10MG; 3MG;
2MG; 11UNIT
natalcare glosstabs tablet 120mg; 0; 200mg; 400unit; 2mg; $0(Nivel 3)
12mcg; 50mg; 1mg; 90mg; 30mg; 20mg; 20mg; 3.4mg; 3mg;
30unit; 2700unit; 25mg
natalcare pic forte tablet 80mg; 250mg; 2mg; 12mcg;
$0(Nivel 3)
400unit; 1mg; 60mg; 10mg; 20mg; 0.2mg; 4mg; 3.4mg; 3mg;
5000unit; 30unit; 25mg
natalcare pic tablet 125mg; 3mcg; 1mg; 10mg; 60mg; 2mg; $0(Nivel 3)
3mg; 50mg; 3mg; 4000unit; 400unit; 18mcg
natalcare plus tablet 120mg; 0; 200mg; 400unit; 2mg; 12mcg;$0(Nivel 3)
27mg; 1mg; 20mg; 10mg; 3mg; 1.84mg; 22mg; 4000unit;
25mg
natalcare three tablet 120mg; 3000unit; 200mg; 400unit;
$0(Nivel 3)
2mg; 12mcg; 28mg; 1mg; 25mg; 20mg; 25mg; 4mg; 1.8mg;
22mg; 25mg
natatab fa tablet 120mg; 0; 200mg; 8mcg; 29mg; 1mg; 20mg; $0(Nivel 3)
150mcg; 3mg; 3mg; 3mg; 30unit; 4000unit; 400unit; 15mg
natatab rx tablet 120mg; 4000unit; 30mcg; 200mg; 400unit; $0(Nivel 3)
3mg; 8mcg; 1mg; 29mg; 100mg; 20mg; 7mg; 150mcg; 3mg;
3mg; 3mg; 30unit; 15mg
NATELLE PLUS W/DHA MISCELLANEOUS 120MG; 0; $0(Nivel 3)
30MCG; 100MG; 8MG; 420UNIT; 60MG; 2MG; 12MCG;
200MG; 26MG; 1MG; 50MG; 20MG; 30MG; 3.5MG;
50MCG; 3MG; 20UNIT; 2600UNIT; 15MG
nutrinate tablet chewable 120mg; 0; 400unit; 12mcg; 29mg; $0(Nivel 3)
1mg; 20mg; 10mg; 3mg; 2mg; 11unit; 1000unit
Página 120 de 148
DP
DP
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
Nombre del medicamento
(nivel)
uso
nutrispire tablet 120mg; 200mg; 400unit; 8mcg; 1mg; 29mg; $0(Nivel 3)
20mg; 150mcg; 3mg; 3mg; 3mg; 30unit; 15mg
PREFERA OB + DHA MISCELLANEOUS 30MCG; 10MG; $0(Nivel 3)
400UNIT; 0.8MG; 12MCG; 10UNIT; 200MG; 1MG; 6MG;
17MG; 22MG; 175MCG; 50MG; 1.6MG; 65MCG; 1.5MG;
15MG
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 3)
prenatal mr 90 fe tablet extended release 120mg; 250mg;
2mg; 12mcg; 50mg; 1mg; 0.15mg; 90mg; 20mg; 20mg;
3.4mg; 3mg; 4000unit; 400unit; 30unit; 25mg
prenatal mtr/selenium tablet 120mg; 0; 30mcg; 200mg;
$0(Nivel 3)
25mcg; 2mg; 12mcg; 27mg; 1mg; 25mg; 5mg; 25mcg; 20mg;
10mg; 150mcg; 10mg; 3.4mg; 20mcg; 3mg; 30unit; 5000unit;
400unit; 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; 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
$0(Nivel 3)
prenatal rx 1 tablet 80mg; 0.03mg; 200mg; 3mg; 2.5mcg;
400unit; 1mg; 60mg; 100mg; 17mg; 7mg; 4mg; 1.6mg;
1.5mg; 4000unit; 15unit; 25mg
DP
PRENATAL VITAMINS TABLET 100MG; 200MG; 4MCG; $0(Nivel 3)
800MCG; 27MG; 18MG; 2.6MG; 1.7MG; 1.84MG;
4000UNIT; 400UNIT; 11UNIT; 25MG
prenatal z tablet 70mg; 200mg; 400unit; 2.2mcg; 65mg; 1mg; $0(Nivel 3)
175mcg; 100mg; 17mg; 2.2mg; 1.6mg; 1.5mg; 3000unit;
10unit; 15mg
PRENATAL TABLET 120MG; 4000UNIT; 200MG;
$0(Nivel 3)
DP
400UNIT; 8MCG; 28MG; 800MCG; 20MG; 2.6MG; 1.7MG;
1.8MG; 30UNIT; 25MG
PROFE FORTE CAPSULE 45MG; 150MCG; 10MG;
$0(Nivel 3)
DP
1000MCG; 1000MCG; 20MG; 155MG; 25MG; 1.7MG;
1.5MG
Página 121 de 148
Nombre del medicamento
qc childrens chewable complete tablet chewable 60mg; 0;
40mcg; 100mg; 10mg; 400unit; 2mg; 6mcg; 18mg; 400mcg;
20mg; 15mg; 100mg; 150mcg; 2mg; 1.7mg; 1.5mg; 30unit;
3000unit; 12mg
STRONGSTART TABLET CHEWABLE 50MG; 250MG;
6MCG; 2MG; 35MG; 1MG; 40MG; 50MG; 3.5MG; 15MG
ultra natalcare tablet 120mg; 0; 200mg; 400unit; 2mg;
12mcg; 50mg; 1mg; 90mg; 20mg; 150mcg; 20mg; 3.4mg;
3mg; 2700unit; 30unit; 25mg
vinatal forte tablet 120mg; 0; 400unit; 12mcg; 1mg; 60mg;
20mg; 10mg; 3mg; 2mg; 11unit; 1000unit
VINATE ONE TABLET 80MG; 0; 0.03MG; 200MG;
400UNIT; 3MG; 2.5MCG; 60MG; 1MG; 100MG; 17MG;
7MG; 4MG; 1.6MG; 1.5MG; 15UNIT; 4000UNIT; 25MG
vitamin d capsule 50000unit
vitamin d capsule 50000unit
vitamin d capsule 50000unit
vitamin d capsule 50000unit
vitamin d capsule 50000unit
VITAMIN K1 INJECTION 10MG/ML
vol-tab rx tablet 120mg; 4000unit; 30mcg; 200mg; 7mg;
400unit; 3mg; 8mcg; 1mg; 29mg; 100mg; 20mg; 150mcg;
3mg; 3mg; 3mg; 30unit; 15mg
VP-PNV-DHA CAPSULE 80MG; 50MG; 400UNIT; 1MG;
12MCG; 200MG; 15.8MG; 28MG; 1MG; 30MG; 20MG;
16MG; 2.2MG; 6MG; 30UNIT; 2500UNIT; 20MG
Unclassified
No Classification
12 hour decongestant tablet extended release 12 hour 120mg
ABILIFY MAINTENA INJECTION 300MG
ABILIFY MAINTENA INJECTION 400MG
ALA-HIST IR TABLET 2MG
ALA-HIST PE TABLET 2MG; 10MG
antacid maximum strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
antacid w/simethicone suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
antacid/simethicone double strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
chest congestion relief pe tablet 400mg; 10mg
de-chlor dm liquid 2mg/5ml; 15mg/5ml; 10mg/5ml
DECONEX IR TABLET 380MG; 10MG
DEX-TUSS LIQUID 10MG/5ML; 300MG/5ML
dibucaine ointment 1%
DURAFLU TABLET 500MG; 20MG; 200MG; 60MG
duratan pe suspension 2mg/5ml; 1.5mg/5ml; 10mg/5ml
exefen-ir tablet 400mg; 60mg
FARYDAK CAPSULE 10MG
Página 122 de 148
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-$6.60(Nivel 2)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 1)
DP
DP
DP
DP
DP
DP
QL (30 EA cada 30 días)
$0-$6.60(Nivel 2)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2) QL (1 EA cada 30 días)
$0-$6.60(Nivel 2) QL (1 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)
$0(Nivel 3)
DP
$0-$6.60(Nivel 2) QL (9 EA cada 28 días)
Cuánto le costaráMedidas necesarias,
el medicamento restricciones o límites de
(nivel)
uso
$0-$6.60(Nivel 2) QL (9 EA cada 28 días)
$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
Nombre del medicamento
FARYDAK CAPSULE 15MG
FARYDAK CAPSULE 20MG
fiber laxative capsule 0.52gm
fiber laxative tablet 625mg
fiber laxative tablet 625mg
gas relief capsule 180mg
gnp 12 hour nasal spray solution 0.05%
gnp antacid anti-gas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
gnp masanti maximum strength suspension 400mg/5ml;
$0(Nivel 3)
DP
400mg/5ml; 40mg/5ml
gnp masanti regular strength suspension 200mg/5ml;
$0(Nivel 3)
DP
200mg/5ml; 20mg/5ml
HEMORRHOIDAL OINTMENT 0; 3%
$0(Nivel 3)
DP
IBRANCE CAPSULE 100MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
IBRANCE CAPSULE 125MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
IBRANCE CAPSULE 75MG
$0-$6.60(Nivel 2) QL (30 EA cada 30 días)
long acting nasal spray solution 0.05%
$0(Nivel 3)
DP
LORTUSS DM LIQUID 15MG/5ML; 6.25MG/5ML;
$0(Nivel 3)
DP
30MG/5ML
LORTUSS EX LIQUID 10MG/5ML; 100MG/5ML;
$0(Nivel 3)
DP
22.5MG/5ML
LORTUSS LQ LIQUID 6.25MG/5ML; 30MG/5ML
$0(Nivel 3)
DP
medi-phedrine tablet 30mg
$0(Nivel 3)
DP
medi-phedrine tablet 30mg
$0(Nivel 3)
DP
MOBISYL CREAM 10%
$0(Nivel 3)
DP
nasal decongestant pe tablet 10mg
$0(Nivel 3)
DP
nasal spray x-moist solution 0.05%
$0(Nivel 3)
DP
NASOPEN PE LIQUID 10MG/15ML; 50MG/15ML
$0(Nivel 3)
DP
neutrahist solution 0.8mg/ml; 9mg/ml
$0(Nivel 3)
DP
pain relief sinus pe díatime tablet 325mg; 5mg
$0(Nivel 3)
DP
POLY-HIST DM LIQUID 10MG/5ML; 5MG/5ML;
$0(Nivel 3)
DP
25MG/5ML
POLY-HIST PD LIQUID 6.25MG/ML; 6.25MG/ML
$0(Nivel 3)
DP
PRO-CHLO LIQUID 12.5MG/5ML; 5MG/5ML;
$0(Nivel 3)
DP
12.5MG/5ML
PRO-CLEAR AC SYRUP 9MG/5ML; 8.33MG/5ML
$0(Nivel 3)
DP
PROPYLENE GLYCOL SOLUTION 0
$0(Nivel 3)
DP
pseudoephedrine hcl tablet 30mg
$0(Nivel 3)
DP
qc antacid/anti-gas maximum strength suspension 400mg/5ml; $0(Nivel 3)
DP
400mg/5ml; 40mg/5ml
qc anti-gas ultra strength capsule 180mg
$0(Nivel 3)
DP
qc fiber laxative capsule 0.52gm
$0(Nivel 3)
DP
qc heartburn antacid tablet chewable 160mg; 105mg
$0(Nivel 3)
DP
qc no drip nasal relief solution 0.05%
$0(Nivel 3)
DP
qc sore throat lozenge 6mg; 10mg
$0(Nivel 3)
DP
qc suphedrine pe tablet 10mg
$0(Nivel 3)
DP
Página 123 de 148
Nombre del medicamento
sm antacid anti-gas extr a strength suspension 400mg/5ml;
400mg/5ml; 40mg/5ml
sm antacid anti-gas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
sm antacid/antigas suspension 200mg/5ml; 200mg/5ml;
20mg/5ml
sm nasal decongestant maximum strength tablet 30mg
sm nasal spray 12 hour solution 0.05%
sm nasal spray pump mist solution 0.05%
sm pain reliever sinus maximum strength tablet 500mg; 30mg
sm sinus maximum strength tablet 500mg; 30mg
SUSPENDOL-S LIQUID 0; 0
TRIXAICIN CREAM 0.025%
VANACOF DM LIQUID 18MG/15ML; 200MG/15ML;
10MG/15ML
VANACOF-8 LIQUID 25MG/15ML; 50MG/15ML
VANACOF LIQUID 12.5MG/5ML; 1MG/5ML; 30MG/5ML
VANAHIST PD LIQUID 0.625MG/ML
VINATE III TABLET 120MG; 3000UNIT; 200MG;
400UNIT; 2MG; 12MCG; 1MG; 29MG; 25MG; 20MG;
25MG; 4MG; 1.8MG; 30MG; 25MG
Página 124 de 148
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)
$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
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
$0(Nivel 3)
DP
DP
DP
Nombre del medicamento
Índice
Nombre del medicamento
12 hour decongestant
abacavir
abacavir sulfate/lamivudine/zidovudine
ABELCET
ABILIFY
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY MAINTENA
ABRAXANE
acamprosate calcium dr
acarbose
acebutolol hcl
acephen
aceta-gesic
acetaminophen
acetaminophen/codeine
acetaminophen/codeine #3
acetaminophen/diphenhydramine
acetasol hc
acetazolamide
acetazolamide er
acetazolamide sodium
acetic acid
acetylcysteine
acid gone
acne medication 5
ACTHIB
actidose/sorbitol
ACTIMMUNE
acyclovir
acyclovir sodium
ADACEL
ADAGEN
adapalene
added strength headache relief
adefovir dipivoxil
adriamycin
adrucil
adult aspirin ec low strength
ADVAIR DISKUS
ADVAIR HFA
ADVANCED CARE PLUS
AEROKID
afeditab cr
AFINITOR
AFINITOR DISPERZ
Página 125 de 148
# de
página
122
43
43
27
38
38
122
38
32
8
46
57
1
95
1
7
7
1
93
60
93
60
93
101
69
65
88
69
88
44
44
88
68
65
3
41
32
31
3
94
94
119
101
58
33
33
AGGRENOX
a-hydrocort
akwa tears
ALAHIST DM
ALA-HIST IR
ALA-HIST PE
alavert
alavert allergy/sinus
ALBENZA
albuterol sulfate
albuterol sulfate er
alclometasone dipropionate
alcohol prep pads
ALDEX AN
ALDEX GS
ALDEX GS DM
ALDEX-CT
ALDURAZYME
alendronate sodium
alfuzosin hcl er
ALIMTA
ALINIA
ALKERAN
all día allergy
all día allergy childrens
all día allergy-d
all día pain relief
all día relief
aller-chlor
allergy
allergy relief
allergy relief child
allergy relief d-24
allergy/congestion relief
allerhist-1
all-nite multi-symptom cold/flu relief
allopurinol
ALLRES PD
almacone
almacone double strength
ALOPRIM
ALORA
alosetron hydrochloride
ALPHAGAN P
alprazolam
ALPRAZOLAM INTENSOL
ALUMINUM HYDROXIDE
amantadine hcl
AMBISOME
# de
página
53
76
92
101
122
122
95
95
35
99
99
76
11
95
101
101
101
68
89
75
31
35
30
95
95
95
3
3
95
95
95
95
95
95
95
101
29
101
69
69
29
80
73
93
45
45
69
44
27
Nombre del medicamento
amcinonide
amdry-d
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
amlodipine besylate
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 extra strength
antacid maximum strength
antacid plus anti-gas relief
antacid w/simethicone
antacid/simethicone double strength
anti-diarrheal
antifungal
anti-fungal powder
Página 126 de 148
# de
página
76
101
32
10
61
61
100
111
111
111
111
112
112
112
112
112
56
73
25
58
58
58
58
58
112
65
25
15
15
15
63
27
15
15
15
50
33
80
80
69
69
122
69
122
122
69
27
27
Nombre del medicamento
anti-itch
anti-itch maximum strength
anu-med
APAP 500
ap-hist dm
APIDRA
APIDRA SOLOSTAR
APOKYN
apri
aprodine
APTIOM
APTIVUS
AQUABASE
aqueous vitamin d infants
ARALAST NP
aranelle
ARANESP ALBUMIN FREE
ARCALYST
aripiprazole
ARRANON
artificial tears
ARZERRA
ascomp/codeine
ASMANEX HFA
ASMANEX TWISTHALER 120
METERED DOSES
ASMANEX TWISTHALER 14 METERED
DOSES
ASMANEX TWISTHALER 30 METERED
DOSES
ASMANEX TWISTHALER 60 METERED
DOSES
aspirin
aspirin adult low strength
aspirin childrens
aspirin ec
aspirin ec lo-dose
aspirin ec low dose
aspirin low strength
aspir-low
atenolol
atenolol/chlorthalidone
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRIPLA
ATROPINE SULFATE
ATROVENT HFA
AUBAGIO
# de
página
65
65
69
1
101
48
48
36
80
101
18
44
65
119
101
80
50
88
38
31
92
35
7
94
94
94
94
94
3
3
3
3
3
3
3
3
57
57
62
35
35
45
69
99
65
Nombre del medicamento
aubra
augmented betamethasone dipropionate
AVANDARYL
AVASTIN
AVELOX
aviane
AVODART
AVONEX
AVONEX PEN
ayr
AYR NASAL DROPS
ayr saline nasal
azacitidine
AZACTAM
AZACTAM IN ISO-OSMOTIC
DEXTROSE
azathioprine
azelastine hcl
AZILECT
azithromycin
azo tabs
aztreonam
baby ayr saline
baciim
BACITRACIN
bacitracin zinc
bacitracin/neomycin/polymyxin
bacitracin/polymyxin b
baclofen
BACTOCILL IN DEXTROSE
BALAMINE DM
balsalazide disodium
balziva
banophen
BANZEL
BARACLUDE
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"
Página 127 de 148
# de
página
80
76
46
35
17
80
75
65
65
101
101
101
32
15
15
86
95
37
16
8
15
101
11
11
11
11
92
40
16
101
89
80
95
21
41
90
90
90
90
91
91
91
91
Nombre del medicamento
BD PEN NEEDLE/ULTRAFINE/29G X
12.7MM
bd pen needles short/ultrafine/31g x 5/16"
BELEODAQ
benazepril hcl
benazepril hcl/hydrochlorothiazide
benzonatate
benzoyl peroxide
benztropine mesylate
betamethasone dipropionate
betamethasone valerate
BETASERON
betaxolol hcl
betaxolol hcl
bethanechol chloride
BEXSERO
bicalutamide
BICILLIN C-R
BICILLIN L-A
BICLORA
BICNU
BIDIL
bisac-evac
bisacodyl ec
biscolax
bismatrol
bismatrol maximum strength
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
bleomycin sulfate
BOOSTRIX
BOSULIF
BOTOX
BOTOX
BP 8 COUGH
BRILINTA
brimonidine tartrate
BRINTELLIX
brom/pse/dm
bromfed dm
bromocriptine mesylate
brotapp
brotapp dm
BROVEX PEB
BROVEX PEB DM
BROVEX PSB
BROVEX PSB DM
budeprion sr
budesonide
# de
página
91
91
32
55
55
101
65
36
76
76
65
57
93
76
88
31
16
16
102
30
62
69
69
69
69
69
57
57
32
88
34
29
91
102
53
93
23
102
102
36
95
102
95
102
95
102
23
76
Nombre del medicamento
budesonide
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
cabergoline
calcipotriene
calcitonin-salmon
calcitriol
calcium acetate
calcium antacid
calcium antacid extra strength
calcium antacid ultra maximum strength
calcium carbonate
caldyphen
cal-gest antacid
caltrate 600+d
CALTRATE 600+D SOFT CHEWS
camila
CAMPTOSAR
CANCIDAS
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
CAPASTAT SULFATE
CAPRELSA
captopril
captopril/hydrochlorothiazide
carbamazepine
carbamazepine er
CARBATROL
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
carboplatin
cardec
cardec dm
CARIMUNE NANOFILTERED
CARMOL 10
Página 128 de 148
# de
página
94
60
68
9
9
23
23
23
45
30
1
1
1
1
7
46
85
65
90
90
76
70
70
70
112
65
70
112
112
83
32
27
54
54
30
34
55
55
21
21
21
37
37
37
32
95
102
88
65
Nombre del medicamento
CARMOL 20
carteolol hcl
cartia xt
carvedilol
CAYSTON
cefaclor
cefaclor er
cefadroxil
cefazolin sodium
cefdinir
cefepime
cefixime
cefotaxime sodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
CELLCEPT
CELLCEPT INTRAVENOUS
CELONTIN
centrum kids complete
cephalexin
CEREBYX
CEREZYME
CERVARIX
cetirizine hcl
cetirizine hcl/pseudoephedrine hcl er
CHANTIX
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CHEMET
cheratussin ac
cheratussin dac
chest congestion relief
chest congestion relief pe
chewable antacid
childrens aspirin
childrens loratadine
childrens mapap rapid tabs
childrens pain reliever
childrens silapap
childrens silfedrine
CHLO TUSS EX
CHLORAMPHENICOL SODIUM
SUCCINATE
chlordiazepoxide/amitriptyline
# de
página
65
93
58
57
100
12
12
12
12
13
13
13
13
13
13
13
13
13
14
14
86
86
18
119
14
21
68
88
95
95
9
9
9
110
102
102
102
122
70
3
96
1
1
1
102
102
11
25
Nombre del medicamento
chlorhexidine gluconate oral rinse
chlor-mes
chloroquine phosphate
chlorothiazide
chlorothiazide sodium
chlorpheniramine maleate
chlorpheniramine/codeine
CHLORPROMAZINE HCL
chlorthalidone
chlorzoxazone
cholestyramine light
chorionic gonadotropin
ciclopirox
ciclopirox olamine
cidofovir
cilostazol
cimetidine
cimetidine hcl
CINRYZE
CIPRODEX
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
cisplatin
citalopram hydrobromide
cladribine
CLAFORAN
claravis
clarithromycin
clarithromycin er
CLARITIN
CLARITIN REDITABS
CLARITIN-D 12 HOUR
CLARITIN-D 24 HOUR
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%
Página 129 de 148
# de
página
65
102
35
61
61
96
102
37
61
109
62
79
27
27
40
53
73
73
86
93
17
17
17
32
23
31
14
65
16
16
96
96
96
96
11
11
80
11
11
11
11
11
11
66
113
113
113
113
113
Nombre del medicamento
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
CLOFERA
CLOLAR
clomipramine hcl
clonazepam
clonazepam odt
clonidine hcl
clonidine hcl er
clopidogrel
clorazepate dipotassium
clotrimazole
clotrimazole/betamethasone dipropionate
clozapine
clozapine odt
COARTEM
COATS ALOE VERA
COATS ALOE VERA JUICE DRINK
COATS ALOE VERA LINIMENT
codeine phosphate/guaifenesin
codeine/guaifenesin
COLACE
colchicine
COLCRYS
cold/cough dm childrens
coldamine
coldcough
colestipol hcl
colistimethate sodium
COMBIGAN
COMBIVENT RESPIMAT
COMETRIQ
COMPLERA
complete allergy
complete allergy medicine
compro
COMVAX
# de
página
113
114
114
114
114
114
114
115
115
115
115
76
76
76
102
31
25
19
19
53
53
53
45
27
66
40
40
35
66
70
66
102
102
70
29
29
102
102
102
62
11
92
99
34
42
96
96
37
88
Nombre del medicamento
constulose
COPAXONE
corfen-dm
cortisone acetate
COSMEGEN
cough dm
cough syrup
COUMADIN
cpm 8/pe 20/msc 1.25
CREON
CRIXIVAN
cromolyn sodium
cromolyn sodium
cromolyn sodium
cryselle-28
CUBICIN
curity gauze pads 2"x2"
cyclafem 1/35
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine modified
cyproheptadine hcl
CYSTADANE
CYSTAGON
cytarabine
cytarabine aqueous
CYTOMEL
dacarbazine
DACOGEN
dactinomycin
DALIRESP
DALLERGY
danazol
dantrolene sodium
DAPSONE
DAPTACEL
DARAPRIM
DAUNORUBICIN HCL
DAY TIME MULTI-SYMPTOM
COLD/FLU RELIEF
deblitane
DECAVAC
de-chlor dm
decitabine
DECONEX DMX
DECONEX IR
DECONSAL DM
Página 130 de 148
# de
página
74
65
102
77
32
102
102
49
103
68
44
70
92
100
80
11
66
80
109
30
46
86
86
96
68
68
31
31
84
30
32
32
100
96
80
40
30
88
35
32
103
83
88
122
32
103
122
103
Nombre del medicamento
deep sea nasal spray
DELSYM
delsym childrens night time cough/cold
delsym night time cough/cold
delsym night time cough/cold childrens
delsym night time multi-symptom
delyla
DELZICOL
demeclocycline hcl
DEMEROL
DEMSER
DENAVIR
DEPEN TITRATABS
DEPO-ESTRADIOL
DEPO-MEDROL
DEPO-SUBQ PROVERA 104
DERMABASE OIL IN WATER
desipramine hcl
desmopressin acetate
desogestrel/ethinyl estradiol
desonide
desoximetasone
desvenlafaxine er
dexamethasone
dexamethasone sodium phosphate
dexamethasone sodium phosphate
dexrazoxane
dextroamphetamine sulfate
dextromethorphan polistirex
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%
DEX-TUSS
dex-tuss dm
d-hist d
DIALYVITE 800/ZINC
DIALYVITE 800/ZINC 15
diaper rash
diazepam
diazepam
DIAZEPAM INTENSOL
# de
página
103
103
103
103
103
103
80
89
17
7
60
45
110
80
77
83
66
25
79
80
77
77
24
77
77
92
32
63
103
115
115
115
115
115
115
115
115
115
115
115
122
103
103
119
119
66
19
45
45
Nombre del medicamento
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
dimaphen childrens
dimaphen dm cold/cough childrens
dimenhydrinate
diocto
DIPENTUM
diphenhist
diphenhydramine hcl
diphenoxylate/atropine
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC
dipyridamole
disopyramide phosphate
disulfiram
divalproex sodium
divalproex sodium dr
divalproex sodium er
DOCEFREZ
DOCETAXEL
docqlace
docqlace
doc-q-lax
docu
docusate sodium
docusate sodium & senna stimulant
laxative/stool softener
dok
dok plus
DONATUSSIN
donepezil hcl
Página 131 de 148
# de
página
122
4
92
4
4
16
69
43
4
60
60
29
21
21
21
59
59
59
59
59
96
103
26
70
89
96
96
70
88
53
56
8
19
19
19
32
32
70
74
74
70
70
74
70
74
103
22
Nombre del medicamento
dorzolamide hcl
dorzolamide hcl/timolol maleate
doxazosin mesylate
doxepin hcl
DOXIL
doxorubicin hcl
doxycycline hyclate
doxycycline monohydrate
DR SMITHS DIAPER
DRISDOL
dronabinol
DROXIA
DUETACT
DULERA
duloxetine hcl
DUOHIST DH
duradryl sr
DURAFLU
DURAHIST
DURAHIST D
DURAHIST PE
duramorph
duratan pe
e.e.s. 400
e.e.s. granules
ear drops
ear drops earwax removal aid
ear wax remover
earwax treatment drops
easy touch pen needles 31gx5/16"
easy touch pen needles/31g x 3/16"
econazole nitrate
ED A-HIST
ed a-hist dm
ed a-hist pse
ed bron gp
ED CHLORPED
ED CHLORPED D
ed chlorped jr
ed-apap
ed-chlortan
EDURANT
effervescent pain relief
EFFIENT
ELAPRASE
ELDEPRYL
ELELYSO
ELIDEL
ELIGARD
# de
página
93
93
75
25
32
32
18
18
66
119
27
31
46
94
24
103
103
122
103
103
103
7
122
16
16
93
93
93
93
91
91
28
97
103
97
103
97
97
97
1
97
42
4
53
68
37
68
66
85
Nombre del medicamento
ELIPHOS
ELITEK
ELIXOPHYLLIN
ELIXSURE FEVER/PAIN
ELLA
ELLENCE
ELMIRON
EMCYT
EMEND
EMSAM
EMTRIVA
enalapril maleate
enalapril maleate/hydrochlorothiazide
ENBREL
ENBREL SURECLICK
endacof-c
endacof-dm
endocet
enema
enemeez mini
enemeez plus
ENGERIX-B
enoxaparin sodium
enpresse-28
entacapone
entecavir
enteric coated aspirin
ENTSOL NASAL GEL
enulose
EPHEDRINE SULFATE
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epirubicin hcl
epitol
EPIVIR
EPIVIR HBV
eplerenone
EPOGEN
eprosartan mesylate
EPZICOM
ERBITUX
ergocalciferol
ergoloid mesylates
ERGOMAR
ERIVEDGE
errin
ERYPED 400
ERY-TAB
ERYTHROCIN LACTOBIONATE
Página 132 de 148
# de
página
76
32
100
1
83
32
76
31
27
23
43
55
55
87
87
104
104
7
74
70
70
88
49
80
36
41
4
104
74
100
100
100
32
21
43
41
61
51
54
43
35
119
22
29
34
83
17
17
17
Nombre del medicamento
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
exefen-ir
exel comfort point insulin pen needles 31g x
8mm
exemestane
EXJADE
extra action cough
EZFE FORTE
FABRAZYME
falmina
famciclovir
famotidine
FAMOTIDINE PREMIXED
FANAPT
FANAPT TITRATION PACK
FARESTON
FARXIGA
FARYDAK
FASLODEX
FATTIBASE
FAZACLO
felbamate
felodipine er
fenofibrate
fenofibrate micronized
fenoprofen calcium
fentanyl
Citrato de fentanilo por víatransmucosa
oral
FETZIMA
FETZIMA TITRATION PACK
# de
página
17
17
17
66
24
75
80
81
81
81
30
19
90
4
4
33
33
84
44
122
91
33
110
104
119
68
81
45
73
73
38
38
31
46
122
31
66
40
20
59
61
61
4
6
7
24
24
Nombre del medicamento
fexofenadine hcl
fiber laxative
fiber tabs
fiber-lax
finasteride
FIRAZYR
FIRMAGON
flavoxate hcl
flecainide acetate
FLEET PEDIATRIC
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
fluvoxamine maleate
FOLIC ACID
FOLOTYN
FOLTABS 90 PLUS DHA
FOLTABS PRENATAL
FOLTABS PRENATAL PLUS DHA
fondaparinux sodium
FORTAZ
FORTEO
fortical
FOSCARNET SODIUM
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FRAGMIN
Página 133 de 148
# de
página
97
123
70
70
76
86
85
75
56
70
94
94
28
28
28
32
77
94
77
77
77
92
32
66
24
37
37
109
4
92
31
77
94
24
119
32
120
120
120
49
14
90
90
40
55
55
21
76
49
Nombre del medicamento
FREAMINE HBC 6.9%
FRESHKOTE
FUNGOID TINCTURE
furosemide
FUSILEV
FUZEON
FYCOMPA
gabapentin
GABITRIL
galantamine hydrobromide
GAMASTAN S/D
GAMMAGARD LIQUID
GAMUNEX-C
ganciclovir
GARDASIL
GARDASIL 9
gas relief
gas relief
gas relief extra strength
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
gemcitabine hcl
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate
GENTAMICIN SULFATE/0.9% SODIUM
CHLORIDE
gentle laxative
GEODON
gildess 1.5/30
GILENYA
GILOTRIF
glatopa
GLEEVEC
glimepiride
glipizide
glipizide er
glipizide/metformin hcl
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
glutose 15
glutose 45
glyburide
glyburide micronized
glyburide/metformin hcl
glycerin adult
# de
página
116
92
28
61
32
43
18
19
19
22
88
88
88
40
88
88
123
70
70
74
74
74
32
62
74
87
10
10
10
70
39
81
65
32
65
34
46
46
46
46
48
48
48
48
47
46
47
70
Nombre del medicamento
glycerin child
glycerin pediatric
glycopyrrolate
GLYSET
gnp 12 hour nasal spray
gnp adult aspirin low strength
gnp all día allergy
gnp allergy
gnp antacid anti-gas
gnp arthritis pain relief
gnp aspirin
gnp díahist allergy
gnp enema
gnp ibuprofen
gnp ibuprofen junior strength
gnp loratadine
gnp loratadine-d 24 hour
gnp masanti maximum strength
gnp masanti regular strength
gnp milk of magnesia
gnp natural fiber
GNP OMEPRAZOLE
gnp pain relief
gnp pain relief extra strength
gnp tussin
gnp tussin dm
GRALISE
GRALISE STARTER
granisetron hcl
GRANIX
griseofulvin microsize
griseofulvin ultramicrosize
guaiatussin ac
guaifenesin
guaifenesin ac
guaifenesin er
guaifenesin/codeine
guanfacine er
guanfacine hcl
GUANIDINE HCL
HALAVEN
halobetasol propionate
haloperidol
haloperidol decanoate
haloperidol lactate
HAVRIX
headache formula added strength
HECTOROL
hemorrhoid
Página 134 de 148
# de
página
70
70
69
47
123
4
97
97
123
1
4
97
74
4
4
97
97
123
123
74
70
75
1
1
104
104
1
1
27
52
28
28
104
104
104
104
104
63
53
30
32
77
37
37
37
88
4
90
66
Nombre del medicamento
HEMORRHOIDAL
hemorrhoidal
heparin sodium
heparin sodium/d5w
heparin sodium/nacl 0.9%
hepatamine
HERCEPTIN
HEXAFLU
HEXALEN
histade mx
histatab
histatab d
histatab ph
hist-pse
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
hydro skin maximum strength
hydrochlorothiazide
hydrocodone bitartrate/acetaminophen
hydrocodone bitartrate/homatropine
methylbromide
hydrocodone polistirex/chlorpheniramine
polistirex
hydrocodone/acetaminophen
hydrocodone/homatropine
hydrocortisone
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone/acetic acid
HYDROCREAM BASE WATER IN OIL
hydromet
hydromorphone hcl
hydrophilic
hydroxychloroquine sulfate
hydroxyurea
# de
página
123
66
49
49
49
116
35
104
30
104
104
104
104
104
48
48
48
48
48
48
87
87
48
48
48
48
48
48
63
77
61
7
104
104
7
104
77
77
77
93
66
104
7
66
35
32
Nombre del medicamento
HYDROXYZINE HCL
hydroxyzine pamoate
ibandronate sodium
IBRANCE
ibu-drops
ibu-drops infants
ibuprofen
ibu-profen cold/sinus
ibuprofen junior strength
ICAPS AREDS FORMULA
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
infants gas relief
infants ibuprofen
infants silapap
infants simethicone
INFERGEN
INLYTA
insupen ultrafin 31gx8mm
INTELENCE
intralipid
INTRON A
INTRON A W/DILUENT
introvale
INTUNIV
INVANZ
INVEGA
INVEGA SUSTENNA
INVIRASE
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
Página 135 de 148
# de
página
97
97
90
123
4
4
4
4
4
120
34
32
32
30
30
88
34
15
25
26
66
29
29
88
41
79
61
5
5
89
70
5
1
71
41
34
91
42
91
41
41
81
64
15
39
39
44
116
116
Nombre del medicamento
iophen c-nr
iophen dm-nr
iophen-nr
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-X
itraconazole
ivermectin
IXEMPRA KIT
IXIARO
JAKAFI
jantoven
JANUVIA
JENTADUETO
JEVTANA
J-MAX
jolivette
J-TAN D PD
J-TAN PD
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
junior mapap
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%
# de
página
104
104
104
89
99
99
54
54
32
42
116
116
30
92
62
62
63
63
10
32
66
28
35
32
89
34
50
47
47
32
104
83
97
98
81
81
81
81
81
1
35
44
71
81
116
116
116
116
116
Nombre del medicamento
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
kelnor 1/35
KEPIVANCE
KETEK
ketoconazole
ketoprofen
ketoprofen er
ketorolac tromethamine
ketorolac tromethamine
KEYTRUDA
KHEDEZLA
kidkare cough/cold
KINERET
kionex
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
KOMBIGLYZE XR
KONSYL
KORLYM
KUVAN
labetalol hcl
laclotion
lactated ringers dextrose 5% viaflex
lactated ringers irrigation
lactated ringers viaflex
LACTRASE
lactulose
l-all 12 nf
lamivudine
lamivudine
lamivudine/zidovudine
lamotrigine
lamotrigine odt
LANOXIN
LANTUS
LANTUS SOLOSTAR
larin 1.5/30
latanoprost
LATUDA
laxative
laxative with senna
LAZANDA
leena
leflunomide
LENVIMA 10MG DAILY DOSE
Página 136 de 148
# de
página
116
116
81
65
17
28
5
5
5
92
35
24
104
87
110
116
116
116
116
116
47
71
80
68
57
66
116
91
116
68
74
104
41
43
43
20
20
60
48
48
81
92
39
71
71
8
81
88
34
Nombre del medicamento
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
lidocaine
lidocaine hcl
lidocaine hcl jelly
lidocaine viscous
lidocaine/prilocaine
LINCOCIN
lindane
linezolid
liothyronine sodium
lipodox
lipodox 50
liposyn iii
liquibid
lisinopril
lisinopril/hydrochlorothiazide
lite touch pen needles/31g x 3/16"
lithium
lithium carbonate
lithium carbonate er
LITHOBID
LODRANE D
# de
página
34
34
34
81
101
33
32
30
52
85
100
17
48
48
18
93
91
98
17
17
33
81
81
82
6
84
84
44
8
8
8
8
8
11
36
11
84
33
33
91
105
55
55
91
46
45
45
46
98
Nombre del medicamento
loestrin 24 fe
LOHIST-D
lohist-dm
lohist-peb
lohist-peb-dm
lomustine
long acting nasal spray
loperamide hcl
loratadine
loratadine allergy relief
loratadine childrens
loratadine hives relief
loratadine-d 12hr
loratadine-d 24hr
lorazepam
LORAZEPAM INTENSOL
LORTUSS DM
LORTUSS EX
LORTUSS LQ
losartan potassium
losartan potassium/hydrochlorothiazide
LOTEMAX
LOTRONEX
lovastatin
low-ogestrel
loxapine succinate
lubrifresh p.m.
LUFYLLIN
LUMIGAN
LUMIZYME
LUPRON DEPOT
LUPRON DEPOT-PED
LUSAIR
lutera
LYNPARZA
LYRICA
LYSODREN
lyza
mag-delay
mag-g
magnesium oxide
magnesium sulfate
mag-sr
mag-sr plus calcium
malathion
mapap
mapap arthritis pain
mapap childrens
mapap cold formula multi-symptom
Página 137 de 148
# de
página
82
98
105
98
105
30
123
71
98
98
98
98
98
98
45
45
123
123
123
54
54
92
74
62
82
38
92
100
92
68
85
85
105
82
33
19
85
83
116
116
71
116
116
116
36
1
1
1
105
Nombre del medicamento
mapap infants
mapap pm
mapap sinus maximum strength congestion
and pain
maprotiline hcl
marlissa
MARPLAN
MATULANE
matzim la
meclizine hcl
meclofenamate sodium
medi-bismuth
medi-cortisone
medi-natural
medi-phedrine
medi-phedryl
medi-profen
medi-sleep
medi-tabs
medi-tabs extra strength
medi-tabs pm extra strength
medi-tussin
medi-tussin dm
medi-tussin dm diabetic
medroxyprogesterone acetate
mefloquine hcl
megestrol acetate
MEKINIST
meloxicam
melphalan hydrochloride
MENACTRA
M-END DMX
M-END MAX D
m-end wc
MENEST
MENOMUNE-A/C/Y/W-135
MENVEO
meperidine hcl
MEPHYTON
meprobamate
MEPRON
mercaptopurine
meropenem
mesalamine
mesna
MESNEX
MESTINON
MESTINON TIMESPAN
METADATE CD
# de
página
1
1
105
23
82
23
31
59
26
5
71
78
71
123
98
5
98
2
2
2
105
105
105
83
35
83
34
5
31
89
105
105
105
82
89
89
8
120
45
35
32
15
89
33
33
30
30
64
Nombre del medicamento
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
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 gas relief
mi-acid maximum strength
miconazole
miconazole 3
miconazole 7
miconazole nitrate
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
midodrine hcl
Página 138 de 148
# de
página
100
47
47
6
6
93
11
86
80
109
87
87
66
69
61
53
53
53
91
64
64
64
78
78
78
78
93
71
61
57
57
57
11
11
11
56
90
71
71
71
28
28
28
28
82
82
82
82
53
Nombre del medicamento
migergot
migraine formula
milk of magnesia
milk of magnesia
MILK DE MAGNESIA CONCENTRATE
MINERAL OIL
minocycline hcl
minoxidil
mintox maximum strength
mirtazapine
mirtazapine odt
misoprostol
mitigare
mitomycin
mitoxantrone hcl
M-M-R II
MOBISYL
modafinil
MOISTUREL
mometasone furoate
monoject insulin syringe/detach
needle/1ml/25g x 5/8"
mononessa
montelukast sodium
morphine sulfate
morphine sulfate er
MOZOBIL
mucaphed
MUCINEX
MUCINEX CHILDRENS
MULTI-SYMPTOM COLD
MUCINEX CHILDRENS
MULTI-SYMPTOM COLD & FEVER
MUCINEX COLD FOR KIDS
mucinex cough for kids
MUCINEX D
MUCINEX DM
MUCINEX DM MAXIMUM STRENGTH
MUCINEX FAST-MAX COLD & SINUS
MUCINEX FAST-MAX COLD FLU&
SORE THROAT
mucinex fast-max dm max
MUCINEX FAST-MAX SEVERE
CONGESTION & COUGH
mucinex for kids
MUCINEX MAXIMUM STRENGTH
mucinex nasal spray full force
mucus relief
mucus-er
# de
página
29
5
71
74
71
71
18
63
71
23
23
75
29
33
33
89
123
110
66
78
91
82
99
8
6
116
105
106
105
105
105
105
105
105
105
105
105
105
105
106
106
106
106
106
Nombre del medicamento
mucusrelief sinus
MULTAQ
mupirocin
MURO 128
MUSTARGEN
MYCAMINE
MYCOBUTIN
mycophenolate mofetil
mytab gas
mytab gas max str
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 decongestant
nasal decongestant pe
nasal decongestant spray
nasal spray x-moist
nasohist
NASOHIST DM
NASOPEN PE
NATACHEW
NATACYN
natalcare glosstabs
natalcare pic
natalcare pic forte
natalcare plus
natalcare three
natatab fa
natatab rx
nateglinide
NATELLE PLUS W/DHA
natural balance tears
natural fiber therapy
natures tears
Página 139 de 148
# de
página
106
56
12
92
31
28
30
87
71
71
5
57
57
16
28
28
68
8
16
9
9
23
23
92
5
5
5
29
106
123
106
123
98
106
123
120
28
120
120
120
120
120
120
120
47
120
92
71
92
Nombre del medicamento
NEBUPENT
necon 0.5/35-28
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
NEULASTA
NEUMEGA
NEUPOGEN
NEUPRO
neutrahist
nevirapine
nevirapine er
NEXAVAR
niacin er
niacor
nicardipine hcl
NICODERM CQ
nicorelief
NICORETTE
NICORETTE MINI
NICORETTE STARTER KIT
nicotine polacrilex
nicotine transdermal system
NICOTROL NS
nifediac cc
nifedical xl
nifedipine er
night time multi-symptom cold/flu relief
night time sleep aid
NILANDRON
NITRO-DUR
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
NITROGLYCERIN
nitroglycerin transdermal
NITROSTAT
nohist-dm
# de
página
35
82
82
82
82
23
10
92
10
12
92
92
93
12
93
117
52
52
52
36
123
42
42
34
62
62
59
9
9
9
9
9
9
10
10
59
59
59
106
98
31
63
12
12
63
63
63
106
Nombre del medicamento
nohist-lq
non-aspirin childrens
non-aspirin pain relief extra strength
nora-be
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX PEN
NOREL AD
NOREL CS
NOREL DM
norethindrone
norethindrone acetate
norethindrone acetate/ethinyl estradiol
norlyroc
normosol-m in d5w
NORMOSOL-R
NORMOSOL-R IN D5W
nortemp
nortemp infants
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
nortriptyline hcl
NORVIR
NOVAFERRUM 125
NOVAFERRUM 50
NOVAFERRUM PEDIATRIC DROPS
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
nrs nasal relief
NUEDEXTA
NULOJIX
NULYTELY/FLAVOR PACKS
nutrilipid
nutrinate
nutrispire
NUTROPIN
nyamyc
nystatin
nystatin/triamcinolone
nystop
Página 140 de 148
# de
página
98
2
2
83
79
79
106
106
106
83
83
82
83
117
117
117
2
2
82
82
82
26
44
117
117
117
91
48
49
49
49
49
49
49
49
28
106
64
87
74
91
120
121
79
28
28
28
28
Nombre del medicamento
OCEAN NASAL SPRAY
octreotide acetate
ofloxacin
OGESTREL
olanzapine
olanzapine odt
olopatadine hcl
OLYSIO
omega-3-acid ethyl esters
omeprazole
ONCASPAR
ondansetron hcl
ondansetron odt
ONFI
ONGLYZA
OPDIVO
ORAP
ORENCIA
ORENITRAM
organ-i nr
orphenadrine citrate
orphenadrine citrate er
oxacillin sodium
oxaliplatin
oxandrolone
oxaprozin
oxcarbazepine
OXSORALEN
OXTELLAR XR
oxybutynin chloride
oxybutynin chloride er
oxycodone hcl
oxycodone/acetaminophen
pacerone
paclitaxel
pain & fever
pain & fever childrens
pain & fever extra strength
pain relief childrens
pain relief extra strength
pain relief sinus pe díatime
pain reliever pm extra strength
pain relieving gel
pamidronate disodium
PANCREAZE
PANRETIN
pantoprazole sodium
paromomycin sulfate
paroxetine hcl
# de
página
106
85
17
82
39
39
98
41
62
75
33
27
27
19
47
35
38
87
101
106
109
109
16
33
80
5
21
66
21
75
75
8
8
56
33
2
2
2
2
2
123
2
66
90
68
35
75
10
24
Nombre del medicamento
paroxetine hcl er
PASER
PATANOL
PAXIL
pcm allergy
pcm la
PEDIATEX TD
PEDIATEX TDM
pediatric cough/cold
pedi-dri
PEDVAX HIB
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
PENTAM 300
pentostatin
pentoxifylline er
periogard
PERJETA
permethrin
perphenazine
perphenazine/amitriptyline
PFIZERPEN-G
phenadoz
phenelzine sulfate
phenobarbital
phenylephrine hcl/pyrilamine maleate
PHENYLHISTINE DH
PHENYTEK
phenytoin
phenytoin infatabs
phenytoin sodium
phenytoin sodium extended
p-hist
p-hist dm
PHOSPHOLINE IODIDE
physiolyte
physiosol irrigation
PICATO
pilocarpine hcl
Página 141 de 148
# de
página
24
30
92
24
106
106
106
107
107
28
89
22
41
41
42
41
41
16
16
16
16
16
35
32
60
65
35
36
38
26
16
26
23
19
107
107
22
22
22
22
22
106
106
93
91
91
66
65
Nombre del medicamento
pilocarpine hydrochloride
PILOPINE HS
pindolol
pink bismuth
pink bismuth maximum strength
pioglitazone hcl
pioglitazone hcl/metformin hcl
piperacillin sodium/tazobactam sodium
piroxicam
PLASMA-LYTE A
PLASMA-LYTE-148
PLASMA-LYTE-56/D5W
podofilox
POLYBASE
polyethylene glycol 3350
POLY-HIST DM
POLY-HIST PD
polymyxin b sulfate
polymyxin b sulfate/trimethoprim sulfate
POLY-TUSSIN AC
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
pramipexole dihydrochloride
pravastatin sodium
prazosin hcl
PRED-G
PRED-G S.O.P.
prednicarbate
prednisolone acetate
prednisolone sodium phosphate
prednisolone sodium phosphate
prednisone
PREFERA OB + DHA
# de
página
65
93
57
72
72
47
47
16
6
117
117
117
66
66
74
123
123
12
92
107
31
82
117
117
117
117
117
117
117
117
117
117
117
18
12
50
36
62
53
93
93
78
93
78
93
78
121
Nombre del medicamento
pregnyl w/diluent benzyl alcohol/nacl
PREMARIN
PREMASOL
PREMPHASE
PREMPRO
PRENAPLUS
prenatabs rx
PRENATAL
prenatal mr 90 fe
prenatal mtr/selenium
prenatal plus iron
prenatal rx 1
PRENATAL VITAMINS
prenatal z
prevalite
previfem
PREZCOBIX
PREZISTA
PRIFTIN
PRILOSEC OTC
PRIMAQUINE PHOSPHATE
primidone
PRIMSOL
PRISTIQ
PROAIR HFA
PROAIR RESPICLICK
probenecid
probenecid/colchicine
PROCAINAMIDE HCL
PROCALAMINE
PRO-CHLO
PROCHLORPERAZINE EDISYLATE
prochlorperazine maleate
PRO-CLEAR AC
PROCRIT
PROCTO-PAK
proctosol hc
proctozone-hc
prodigy insulin mini pen needles/31g x
3/16"
prodigy insulin short penneedles/31g x
5/16"
PROFE FORTE
progesterone
PROGLYCEM
PROGRAF
PROHIST
PROHIST DM
PROLASTIN-C
Página 142 de 148
# de
página
79
82
118
83
83
121
121
121
121
121
121
121
121
121
62
83
44
44
30
75
35
20
12
24
100
100
29
29
56
118
123
38
38
123
52
78
78
78
91
91
121
84
48
87
107
107
107
Nombre del medicamento
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
promethazine vc plain
PROMETHAZINE VC/CODEINE
promethazine/codeine
promethazine/codeine
promethazine/dextromethorphan
promethazine-dm
promethegan
PROMETRIUM
propafenone hcl
propranolol hcl
propranolol hcl er
propranolol/hydrochlorothiazide
PROPYLENE GLYCOL
propylthiouracil
PROQUAD
PROSOL
PROTONIX
PROTOPIC
protriptyline hcl
PSEUDACARB
pseudoephedrine hcl
pseudoephedrine hcl
pseudoephedrine/codeine
PULMOZYME
PURIXAN
pyrazinamide
pyridostigmine bromide
PYRIL DM
qc antacid extra strength
qc antacid/anti-gas maximum strength
qc anti-diarrheal
qc anti-gas ultra strength
qc arthritis pain relief
qc aspirin
qc aspirin low dose
qc childrens aspirin
qc childrens chewable complete
qc chlor-pheniramine
qc complete allergy medicine
qc cough/sore throat nighttime
qc díatime multi-symptom cold/flu
qc docusate calcium
qc ear wax removal drops
qc enema
qc fiber laxative
# de
página
33
90
52
26
107
107
98
107
107
107
27
84
56
58
57
58
123
86
89
118
75
67
26
107
123
107
107
100
32
30
30
107
72
123
72
123
2
6
6
6
122
98
98
107
107
74
94
74
123
Nombre del medicamento
qc gas relief
qc gentle laxative
qc headache relief
qc heartburn antacid
qc ibuprofen
qc loratadine allergy relief
qc loratadine-d
qc milk of magnesia
qc naproxen sodium
qc nighttime cough
qc nighttime multi-symptom cold/flu
qc no drip nasal relief
qc non-aspirin childrens
qc non-aspirin extra strength
qc non-aspirin pm
qc pink bismuth
qc povidone iodine
qc rest simply
qc senna
qc senna-s
qc sore throat
qc stool softener
qc stool softener plus laxative
qc suphedrine pe
qc tolnaftate
q-dryl
q-pap
q-pap childrens
q-pap extra strength
q-pap infants
q-tussin
q-tussin dm
quad tann
QUADRACEL
quasense
QUDEXY XR
quetiapine fumarate
quinapril hcl
quinapril/hydrochlorothiazide
QUINIDINE GLUCONATE
quinidine gluconate cr
quinidine sulfate
quinidine sulfate er
quinine sulfate
RABAVERT
raloxifene hydrochloride
ramipril
RANEXA
ranitidine 75
Página 143 de 148
# de
página
72
72
6
123
6
98
98
74
6
107
107
123
2
2
2
72
12
98
72
74
123
72
74
123
28
98
2
2
2
2
107
107
107
89
83
20
39
55
56
56
56
56
56
35
89
84
56
60
73
Nombre del medicamento
ranitidine hcl
RAPAMUNE
REBETOL
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
REBIF TITRATION PACK
RECOMBIVAX HB
REFRESH CELLUVISC
refresh lacri-lube
REFRESH PLUS
reguloid
RELENZA DISKHALER
RELISTOR
RELISTOR
REMICADE
RENVELA
repaglinide
RESCON
RESCON
RESCON DM
RESCON-GG
RESCRIPTOR
reserpine
RESPAIRE-30
resperal
RESTASIS
restfully sleep
RETROVIR IV INFUSION
REVLIMID
REYATAZ
REZIRA
RHINARIS
ribasphere
ribasphere ribapak
ribavirin
rifabutin
rifampin
RIFATER
riluzole
rimantadine hcl
ringers injection
ringers irrigation
risedronate sodium
RISPERDAL CONSTA
risperidone
risperidone odt
RITUXAN
rivastigmine tartrate
# de
página
73
87
42
65
65
65
65
89
92
92
92
72
44
72
74
87
76
47
98
108
107
107
42
53
108
108
92
98
43
31
44
108
108
42
42
42
30
30
30
64
44
118
91
90
39
40
39
35
22
Nombre del medicamento
rizatriptan benzoate
rizatriptan benzoate odt
robafen
robafen cf cough & cold
robafen dm
robafen dm cough clear
ROBITUSSIN CHEST CONGESTION
ropinirole hcl
ROTARIX
ROTATEQ
roxicet
ROZEREM
rulox
RYMED
rynex dm
rynex pe
rynex pse
S2
SABRIL
SAIZEN
SAIZEN CLICK.EASY
sal-acid plasters
saline nasal spray
SANTYL
SAPHRIS
SARNA
SAVELLA
SAVELLA TITRATION PACK
sea soft nasal mist
selegiline hcl
selenium sulfide
SELZENTRY
senexon
senna
senna lax
sennalax-s
senna-s
SENSIPAR
SEREVENT DISKUS
SEROMYCIN
SEROSTIM
sertraline hcl
sharobel
silace
siladryl allergy
sildenafil
silphen dm cough
sil-tex
siltussin das
Página 144 de 148
# de
página
29
29
108
108
108
108
108
36
89
89
8
110
72
98
108
98
98
100
20
79
79
67
108
67
40
67
64
64
108
37
67
43
72
72
72
74
74
85
100
30
79
24
84
72
98
101
108
108
108
Nombre del medicamento
siltussin dm das
siltussin sa
siltussin-dm
silver sulfadiazine
simethicone
SIMULECT
simvastatin
SINA-12X
sirolimus
sm allergy 4 hour
sm allergy relief
sm antacid anti-gas
sm antacid anti-gas extr a strength
sm antacid/antigas
sm anti-diarrheal
sm aspirin
sm aspirin ec low strength
sm calcium antacid
sm calcium antacid extra strength
sm childrens aspirin
sm cold & cough childrens
sm fiber
sm glycerin adult
sm glycerin pediatric
sm headache added strength
sm hemorrhoidal
sm ibuprofen
sm loratadine
sm lorata-dine d
sm miconazole 7
sm milk of magnesia
sm nasal decongestant maximum strength
sm nasal spray 12 hour
sm nasal spray pump mist
sm nasal spray saline
sm pain reliever
sm pain reliever childrens
sm pain reliever extra strength
sm pain reliever pm extra strength
sm pain reliever sinus maximum strength
sm sinus & allergy maximum strength
sm sinus maximum strength
sm sleep aid
sm stomach relief
sm stomach relief max st
sm tussin
sm tussin dm
sm tussin dm cough/chest congestion
sodium bicarbonate
# de
página
108
108
108
12
72
88
62
108
87
99
99
124
124
124
72
6
6
72
72
6
108
72
72
72
6
67
6
99
99
28
75
124
124
124
108
3
3
3
3
124
99
124
99
72
72
108
108
108
72
Nombre del medicamento
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
SOLU-CORTEF
SOLU-MEDROL
SOMATULINE DEPOT
SOMAVERT
SORIATANE
sorine
sotalol hcl
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
stool softener
stool softener extra strength
stool softener laxative
stool softener laxative dc
STRATTERA
STREPTOMYCIN SULFATE
STRIBILD
STROMECTOL
STRONGSTART
Página 145 de 148
# de
página
92
118
118
118
118
110
68
110
17
31
78
78
86
86
67
56
56
56
42
99
99
61
61
29
83
34
83
12
8
37
37
37
37
37
37
43
91
79
72
34
73
73
75
73
64
10
43
35
122
Nombre del medicamento
SUBOXONE
SUCRAID
sucralfate
sudogest
sudogest 12 hour
sudogest pe
sudogest sinus & allergy
sulfacetamide sodium
sulfacetamide sodium/prednisolone sodium
phosphate
sulfadiazine
SULFAMETHOXAZOLE/TRIMETHOPRI
M
sulfamethoxazole/trimethoprim ds
sulfasalazine
sulfazine ec
sulindac
sumatriptan succinate
SUPRAX
sure-fine pen needles 31gx3/16" 5mm
sure-fine pen needles 31gx5/16" 8mm
SURMONTIL
sur-q-lax
SUSPENDOL-S
SUSTIVA
SUTENT
su-tuss dm
SYLATRON
SYLVANT
SYMBICORT
SYMLINPEN 120
SYMLINPEN 60
SYNAGIS
SYNAREL
SYNERCID
SYNRIBO
SYNTHROID
SYPRINE
TABLOID
tacrolimus
tacrolimus
TAFINLAR
TALWIN
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TANDEM
TANDUR DM
TARCEVA
# de
página
9
68
75
108
108
108
99
17
93
17
17
17
89
89
6
29
14
91
91
26
73
124
43
34
108
33
35
94
48
48
88
86
12
33
84
111
32
67
87
34
8
44
31
76
118
108
34
Nombre del medicamento
TARGRETIN
TASIGNA
TASMAR
TAZORAC
taztia xt
tears renewed
TEFLARO
TEGRETOL
TEGRETOL-XR
TEKTURNA
TEKTURNA HCT
telmisartan
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-gesic
thioridazine hcl
thiotepa
thiothixene
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
Página 146 de 148
# de
página
35
35
36
67
59
92
14
22
22
60
60
54
54
54
109
3
89
76
29
100
29
80
80
89
89
79
31
100
101
100
101
67
38
31
38
88
85
85
85
85
85
20
53
56
16
58
93
93
Nombre del medicamento
tinidazole
tioconazole-1
TIVICAY
tizanidine hcl
TOBI PODHALER
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
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
# de
página
35
29
42
40
100
93
100
10
10
93
48
36
6
29
75
75
21
20
33
33
88
61
118
101
48
8
8
56
53
27
23
118
27
23
31
30
86
35
67
78
95
65
61
45
78
38
45
36
Nombre del medicamento
trilyte
trimethobenzamide hcl
trimethoprim
trimipramine maleate
trinessa
triple antibiotic
trip-pse
tri-previfem
TRISENOX
tri-sprintec
trital sr
TRIUMEQ
trivora-28
TRIXAICIN
trixaicin hp
TROKENDI XR
TROPHAMINE
TRUMENBA
TRUVADA
tusscough dhc
tussin
tussin dm
tussin dm clear
tussin mucus + chest congestion
TUSSIONEX PENNKINETIC
EXTENDED RELEASE
tussizone-12 rf
TWINRIX
TYBOST
TYGACIL
TYKERB
TYPHIM VI
TYSABRI
TYVASO
TYZEKA
TYZINE PEDIATRIC NASAL DROPS
u-cort
ulticare short pen needles 31gx8mm
ulticare short pen needles ulti-fine iv
ultra natalcare
unithroid
ureacin-10
ureacin-20
UROCIT-K 10
UROCIT-K 15
UROCIT-K 5
ursodiol
UVADEX
valacyclovir hcl
Página 147 de 148
# de
página
75
27
12
26
83
12
108
83
33
83
108
43
83
124
67
21
119
89
43
108
109
109
109
109
109
109
89
44
12
35
89
65
101
41
109
78
91
91
122
85
67
67
119
119
119
73
67
45
Nombre del medicamento
VALCHLOR
VALCYTE
valganciclovir
valproate sodium
valproic acid
valsartan
valsartan/hydrochlorothiazide
VANACOF
VANACOF DM
VANACOF-8
VANAHIST PD
vancomycin hcl
vandazole
VAQTA
VARIVAX
VARIZIG
VECTIBIX
VELCADE
velivet
venlafaxine hcl
venlafaxine hcl er
VENTOLIN HFA
verapamil hcl
verapamil hcl er
verapamil hcl sr
VEREGEN
VERSACLOZ
VICTRELIS
VIDEX PEDIATRIC
VIIBRYD
VIMPAT
vinatal forte
VINATE III
VINATE ONE
VINBLASTINE SULFATE
vincristine sulfate
vinorelbine tartrate
VIRACEPT
VIRAMUNE
VIRAMUNE XR
viratan-dm
VIRAZOLE
virdec
virdec dm
VIREAD
VISTIDE
vitamin a & d
vitamin d
VITAMIN K1
# de
página
31
41
41
20
20
55
54
124
124
124
124
12
12
89
89
89
35
33
83
25
25
100
60
59
60
67
40
42
43
25
22
122
124
122
33
33
33
44
43
43
109
42
99
109
43
41
67
122
122
Nombre del medicamento
VITEKTA
VITUZ
vol-tab rx
VOLTAREN
voriconazole
VOTRIENT
VP-PNV-DHA
VPRIV
warfarin sodium
WELCHOL
WHITE PETROLATUM
womans laxative
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
z-cof 12dm
Z-COF I
zeasorb-af
ZELAPAR
ZELBORAF
ZEMAIRA
ZENPEP
ZETIA
ZIAGEN
zidovudine
zinc oxide
ZINECARD
ziprasidone hcl
ZMAX
zoledronic acid
ZOLINZA
Página 148 de 148
# de
página
42
99
122
67
29
35
122
68
50
62
67
73
35
50
50
64
90
12
109
100
100
31
83
8
110
35
89
99
110
33
31
73
68
109
109
29
37
35
109
68
62
43
43
67
33
40
17
90
33
Nombre del medicamento
zolpidem tartrate
zolpidem tartrate er
ZOMETA
ZONALON
ZONATUSS
zonisamide
ZORBTIVE
ZORTRESS
ZOSTAVAX
ZOSYN
zovia 1/35e
zovia 1/50e
ZOVIRAX
ZUBSOLV
ZUTRIPRO
ZYDELIG
ZYFLO CR
ZYKADIA
ZYPREXA RELPREVV
ZYTIGA
ZYVOX
# de
página
110
110
90
67
109
19
79
88
89
16
83
83
45
9
109
33
99
33
40
31
12
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Suite 200
Austin, TX 78704
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