formulario completo - SelectHealth Advantage

Transcrição

2016
FORMULARIO COMPLETO
Lista de Medicamentos Cubiertos
Este formulario fue actualizado el 01 de septiembre de 2016. Para la
información más reciente u otras preguntas, póngase en contacto con
SelectHealth Servicios para Miembros al número gratuito,
855-442-9900 o, para los usuarios de TTY, 711, durante las siguientes
fechas y horarios:
• El 1 de octubre al 14 de febrero: lunes a viernes 7:00 a.m. a 8:00
p.m., el sábado y el domingo de 8:00 a.m. a 8:00 p.m.
• El 15 de febrero al 30 de septiembre: lunes a viernes 7:00 a.m. a
8:00 p.m, el sábado 9:00 a.m. a 3:00 p.m., cerrado el domingo.
Fuera de estas horas de operación, por favor deje un mensaje.
Su llamada será devuelta dentro de un día hábil, o visite
selecthealthadvantage.org.
SelectHealth Advantage (HMO)
Formulario Completo de 2016
(Lista de Medicamentos Cubiertos)
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA
DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN.
SelectHealth es un patrocinador del plan HMO con un contrato de Medicare. La inscripción en
SelectHealth Advantage depende de renovación de contrato.
Esta información está disponible de forma gratuita en otros idiomas. Por favor llame a nuestra línea de
servicio para clientes al 855-442-9900 (línea gratuita), durante las fechas y horarios indicados en la portada y
contraportada de este libro. Los usuarios de TTY pueden llamar al 711.
H1994_4455R_FINAL_C_SP_v31 Aceptado
HPMS Aprobado Número de Identificación del Sumisión de Archivo 16001 Versión 31
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Nota para los miembros actuales: Este formulario cambió desde el año pasado. Por favor, revise este
documento para asegurarse de que aún contenga los medicamentos que usted toma.
Cuando este lista de medicamentos (formulario) se refiere a "nosotros", "nos" o "nuestro," quiere decir o
significa SelectHealth. Cuando se refiere a "plan" o "nuestro plan," quiere decir o significa SelectHealth
Advantage (HMO).
Este documento contiene una lista de medicamentos (el formulario) para nuestro plan que está
actualizado a partir del 01 de septiembre de 2016. Para obtener un formulario más actual, por favor
contacte con nosotros. Nuestra información de contacto, junto con la fecha en la que últimamente
actualizamos el formulario, aparece en la parte delantera y contraportada.
Generalmente, usted debe utilizar las farmacias de la red para acceder a su beneficio de medicamentos
recetados. Los beneficios, el formulario, la red de farmacias, las primas y/o los copagos/coseguro pueden
cambiar el 1 de enero de 2017 y de vez en cuando durante el año.
¿Qué es el Formulario de SelectHealth Advantage?
Un formulario es una lista de medicamentos cubiertos seleccionados por SelectHealth Advantage junto con
un equipo de proveedores de atención médica, que representa a las terapias recetadas que se consideran
parte necesaria de un programa de tratamiento de calidad. SelectHealth Advantage generalmente cubre los
medicamentos que se encuentran en nuestro formulario, siempre que tal medicamento sea médicamente
necesario, que la receta médica se presente en una farmacia de la red de SelectHealth Advantage y se sigan
otras reglas del plan. Para obtener más información sobre cómo llenar sus recetas, consulte su Evidencia de
Cobertura.
¿Puede cambiar el Formulario (Lista de Medicamentos)?
En general, si toma un medicamento de nuestro formulario del año 2016 que se cubría al inicio del
año, no vamos a descontinuar o reducir la cobertura del medicamento durante la cobertura del año
2016 a menos que esté disponible un nuevo medicamento genérico más económico, o cuando se
publique información nueva desfavorable respecto de la seguridad o la eficacia de un medicamento.
Otros tipos de cambios al formulario, como la eliminación de un medicamento de nuestro formulario,
no afectarán a los miembros que actualmente toman el medicamento. Éste seguirá disponible al
mismo costo compartido para esos miembros que lo toman durante el resto del año de cobertura.
Consideramos que es importante que tenga acceso continuo durante el resto del año de cobertura a
los medicamentos del formulario que se encontraban disponibles al momento de optar por el plan,
excepto por los casos en los que puede ahorrar dinero adicional o en los que podemos garantizar la
seguridad.
Si eliminamos medicamentos de nuestro formulario, agregamos autorización previa, los límites de cantidad
y/o las restricciones a la terapia en etapas, o se mueve un medicamento a un nivel de costo compartido
mayor, debemos notificar a los miembros afectados sobre el cambio al menos 60 días antes de que el
cambio entre en vigencia, o en el momento que el miembro solicite una receta de un medicamento, en cuyo
caso el miembro recibirá un suministro del medicamento para 60 días. Si la Administración de Drogas y
Alimentos de los Estados Unidos (FDA por sus siglas en inglés) considera que un medicamento de nuestro
formulario es inseguro o el fabricante del medicamento retira el medicamento del mercado, de inmediato lo
eliminaremos de nuestro formulario y proporcionaremos la notificación a los miembros que toman el
medicamento.
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El formulario adjunto está actualizado a partir de la fecha 01 de septiembre de 2016. Para obtener un
formulario más actual, por favor contacte con nosotros. Nuestra información de contacto, junto con la
fecha en la que últimamente actualizamos el formulario, aparece en la parte delantera y contraportada.
En caso de cambios que no sean de mantenimiento regular al formulario durante todo el año del plan,
SelectHealth puede hacer cambios a través de hojas de erratas que le enviaremos por correo. Además,
puede visitar nuestro sitio web para acceder a un vínculo a la hoja de erratas.
¿Cómo se utiliza el Formulario?
Hay dos formas de buscar su medicamento en el formulario
Condición Medical o Enfermedad
El formulario comienza en la página 7. Los medicamentos de este formulario están agrupados en
categorías según el tipo de enfermedad para la que se utilizan. Por ejemplo, los medicamentos que se
usan para tratar una enfermedad cardíaca se listan bajo la categoría, medicamentos
cariovasculares/agentes hipotensores. Si sabe para qué se usa su medicamento, busque el nombre de la
categoría en la lista que comienza en la página 7. Luego busque bajo el nombre de la categoría de su
medicamento.
Listado Alfabético
Si no está seguro en qué categoría buscar, debe buscar su medicamento en el Índice que comienza en la
página 122. El Índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en
este documento. Tanto los medicamentos de marca como los genéricos aparecen en la lista del Índice.
Para buscar su medicamento busque en el Índice. Junto al medicamento, verá el número de página en el
que puede buscar información sobre la cobertura. Vaya a la página que se indica en el Índice y busque el
nombre del medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
SelectHealth Advantage cubre tanto medicamentos de marca como genéricos. Un medicamento genérico
está aprobado por la Administración de Drogas y Alimentos de los Estados Unidos (FDA) por tener el
mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan
menos que los de marca.
¿Existen restricciones en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Estos
requisitos y límites pueden ser:
• Autorización previa: SelectHealth Advantage requiere que usted o su médico obtengan una
autorización previa para ciertos medicamentos. Esto significa que necesitará la aprobación de
SelectHealth Advantage antes de presentar sus recetas médicas. Si no obtiene la aprobación,
SelectHealth Advantage no puede cubrir el medicamento.
• Límites de cantidad: Para ciertos medicamentos, SelectHealth Advantage limita la cantidad de
medicamento que cubre SelectHealth Advantage. Por ejemplo, SelectHealth Advantage proporciona
60 tabletas por receta para Valsartan. Éste puede agregarse a un suministro estándar para uno o tres
meses.
• Terapia en etapas En algunos casos, SelectHealth Advantage requiere que primero pruebe con
ciertos medicamentos para tratar su enfermedad antes de cubrir otro medicamento para dicha
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enfermedad. Por ejemplo, si un Medicamento A y un Medicamento B tratan la misma enfermedad,
SelectHealth Advantage puede no cubrir el Medicamento B salvo que primero pruebe el
Medicamento A. Si el Medicamento A no funciona en usted, SelectHealth Advantage cubrirá el
Medicamento B.
Para averiguar si su medicamento tiene algún requisito o límite adicional, busque en el formulario que
comienza en la página 7. Además, para obtener más información acerca de las restricciones aplicadas a
medicamentos cubiertos específicos, visite nuestro sitio web. Nuestra información de contacto, junto con la
fecha en la que últimamente actualizamos el formulario, aparece en la parte delantera y contraportada.
Usted puede solicitar a SelectHealth Advantage que haga una excepción a estas restricciones o límites.
Consulte la sección, “¿Cómo solicitar una excepción al formulario de SelectHealth Advantage?” en la
página 4 para obtener información acerca de cómo solicitar una excepción.
¿Qué ocurre si mi medicamento no está en el Formulario?
Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe
comunicarse con Servicios para Miembros y confirmar que su medicamento no esté cubierto.
Si sabe que SelectHealth Advantage no cubre su medicamento, tiene dos opciones:
• Puede pedir a Servicios para Miembros una lista de medicamentos similares que cubre SelectHealth
Advantage. Cuando reciba la lista, preséntesela al médico y pídale que le recete algún medicamento
similar que cubra SelectHealth Advantage.
• O puede solicitar a SelectHealth Advantage que haga una excepción y cubra su medicamento.
Consulte a continuación para obtener información sobre cómo solicitar una excepción.
¿Cómo solicitar una excepción al Formulario de SelectHealth Advantage?
Puede solicitar a SelectHealth Advantage que haga una excepción a nuestras reglas de cobertura. Existen
diversos tipos de excepciones que nos puede solicitar.
• Puede solicitarnos que cubramos su medicamento aunque no esté en nuestro formulario. Si se
aprueba, esta droga se cubrirá en un nivel determinado de gastos, y no sería capaz de pedir nos
permite proporcionar la droga en un nivel más bajo de participación en los gastos.
• Usted puede pedirnos que cubramos un medicamento de formulario a un nivel menor de costo
compartido si este medicamento no está en el nivel de la especialidad. Si se aprueba, esto reduciría la
cantidad que debe pagar por sus medicamentos.
• Puede solicitarnos de renunciar a la cobertura restricciones o límites en su medicamento. Por
ejemplo, para ciertos medicamentos, SelectHealth ventaja limita la cantidad de medicamento que
cubriremos. Si su medicamento tiene un límite de cantidad, usted puede pedirnos que apliquemos el
límite y cubrir una mayor cantidad.
En general, SelectHealth Advantage solamente aprobará su solicitud de excepción si los medicamentos
alternativos incluidos en el formulario del plan, el medicamento de menor nivel o las restricciones
adicionales a la utilización no fueran tan eficaces para el tratamiento de su enfermedad y/o causaran un
efecto adverso en su salud.
Debe comunicarse con nosotros para que tomemos una decisión inicial de cobertura de un formulario,
nivel o excepción en restricción de utilización. Cuando solicita un formulario, nivel o excepción de
restricción de utilización, debe enviar una declaración de quien emite la receta o el médico para
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justificar su solicitud. En general, debemos tomar nuestra decisión en un plazo de 72 horas de recibida la
declaración de respaldo del médico que emite la receta. Puede solicitar una excepción urgente (rápida) si
usted o su médico consideran que su salud podría verse gravemente afectada si espera una decisión hasta 72
horas. Si se otorga su solicitud de excepción urgente, debemos comunicarle una decisión antes de las 24
horas tras la recepción de la declaración de respaldo de quien emite la receta o el médico.
¿Qué debo hacer antes de hablar con mi médico acerca de cambiar mis medicamentos o
solicitar una excepción?
Como miembro nuevo o permanente de nuestro plan puede que esté tomando medicamentos que no
formen parte de nuestro formulario. Por ejemplo, puede ser que esté tomando un medicamento que forma
parte de nuestro formulario pero que su capacidad para obtenerlo sea limitada. Por ejemplo, puede que
necesite nuestra autorización previa antes de poder presentar su receta. Debe hablar con su médico para
decidir si debe cambiar por un medicamento adecuado que cubrimos o solicitar una excepción al
formulario para que cubramos el medicamento que usted toma. Mientras habla con su médico para
determinar la medida indicada en su caso, puede que cubramos su medicamento en ciertos casos durante
los primeros 90 días que sea miembro de nuestro plan.
Para cada uno de sus medicamentos que no figure en nuestro formulario o si su capacidad para obtener sus
medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta
para menos días) cuando vaya a una farmacia de la red. Después del primer suministro para 30 días, no
pagaremos estos medicamentos, aunque haya sido miembro del plan menos de 90 días.
Si vive en un centro de cuidado a largo plazo, le permitiremos presentar su receta médica hasta que le
hayamos proporcionado un suministro de transición para 98 días, conforme al incremento de dispensación,
(a menos que tenga una receta para menos días). Cubriremos más de una reposición de estos
medicamentos durante los primeros 90 días de ser miembro en nuestro plan, cubriremos un suministro de
emergencia de ese medicamento para 90 días de ser miembro en nuestro plan, cubriremos un suministro de
emergencia de ese medicamento para 31 días (a menos que tenga una receta para menos días) mientras trata
de obtener una excepción al formulario.
Si usted experimenta un cambio en su nivel de atención, como un traslado de un hospital a un entorno de
hogar, y usted necesita un medicamento que no está en nuestro formulario o si su habilidad para obtener
sus medicamentos es limitada, cubriremos un suministro temporal de una sola vez por hasta 30 días (o 31
días si usted es un residente de cuidado a largo plazo) cuando utilice una farmacia de la red. Durante este
período, debe utilizar el proceso de excepción del plan si desea tener cobertura continuada del
medicamento después de que haya terminado el suministro temporal.
Para obtener más información
Para obtener más información detallada sobre la cobertura de medicamentos recetados de SelectHealth
Advantage, consulte su Evidencia de Cobertura y demás material del plan.
Si tiene preguntas acerca SelectHealth Advantage, por favor contacte con nosotros. Nuestra información de
contacto, junto con la fecha en la que últimamente actualizamos el formulario, aparece en la parte delantera
y contraportada.
Si tiene preguntas generales acerca de la cobertura de medicamentos recetados de Medicare, llame a
Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los
usuarios de TTY deben llamar al 1-877-486-2048. O, visite www.medicare.gov.
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Formulario de SelectHealth Advantage
El formulario que comienza en la proxima página proporciona información de cobertura acerca de algunos
de los medicamentos que cubre SelectHealth Advantage. Si tiene problemas para encontrar su
medicamento en la lista, vaya al Índice que comienza en la página 122.
En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca están
en mayúscula (por ejemplo, ADVAIR) y los medicamentos genéricos aparecen en letra cursiva minúscula
(por ejemplo, simvastatin).
La segunda columna de la tabla muestra el Nivel de medicamentos. La columna Nivel de medicamentos le
permite saber el tipo de copago o coseguro, por el que usted será responsable en la farmacia. Por favor,
consulte su Evidencia de Cobertura para obtener más información acerca de cuánto tendrá que pagar por sus
medicamentos recetados. La siguiente tabla le indica el monto del coseguro de copago para medicamentos
en cada nivel:
Cobertura para el Periodo Initial y los Niveles de Copagos/Coseguros
Nivel de Medicamento
Farmacia de la Red de Venta por Menor
(Hasta un suministro de 30 días)
Pedido por correo
(suministro de 90 días)
Nivel 1: Genérico Preferido
$3.00
$6.00
Nivel 2: Genérico
$15.00
$30.00
Nivel 3: Marca Preferida
$45.00
$135.00
Nivel 4: Marca No Preferida
$95.00
$285.00
Coaseguro de 33%
No Está Disponible
Nivel 5: Especialidad
La información en la columna Requisitos/Límites le indica si SelectHealth Advantage tiene algún
requisito especial de cobertura para su medicamento.
AP – Requerimos que usted o su médico obtenga una autorización previa para ciertos medicamentos
antes de surtir sus recetas.
LC – Limitamos la cantidad del medicamento en un período de tiempo específico.
TE – Requerimos que usted primero pruebe ciertos medicamentos para tratar su condición médica antes
de cubrir otro medicamento para esa afección.
AL – Este medicamento requiere manejo especial o tiene requisitos especiales de dispensación (acceso
limitado). Esta receta médica puede estar disponible sólo en ciertas farmacias. Para más
información, consulte su Directorio de Proveedores y Farmacias o llame a Servicios para Miembros al 855442-9900 (cobro revertido). Los usuarios de TTY deben llamar al 711.
NM – Este medicamento no está disponible a través de nuestra farmacia de pedido por correo.
BvsD – Este medicamento puede estar cubierto bajo los beneficio de Medicare Parte B o Parte D.
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Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
AGENTES ANTIINFECTIVOS
ANTIHELMÍNTICOS
ALBENZA TABLET 200MG
3
BILTRICIDE TABLET
4
600MG
ivermectin tablet 3mg
2
ANTIINFECTIVOS URINARIOS
methenamine hippurate tablet
2
1 gram
MONUROL PACKET 3
4
GRAM
nitrofurantoin capsule 100mg
2
2
2
nitrofurantoin mono-macro
2
capsule 100mg
nitrofurantoin suspension 25
2
mg/5 ml
trimethoprim tablet 100mg
2
ANTIMYCOBACTERIALES
AVELOX ABC PACK
4
TABLET 400MG
CAPASTAT SULFATE FOR
4
SOLUTION 1 GRAM
dapsone tablet 100mg
3
dapsone tablet 25mg
3
ethambutol hcl tablet 100mg
2
ethambutol hcl tablet 400mg
2
isoniazid solution 100 mg/ml
2
isoniazid tablet 100mg
2
isoniazid tablet 300mg
2
PASER PACKET 4 GRAM
4
pyrazinamide tablet 500mg
2
SIRTURO TABLET 100MG
4
LC 188 cada 30 dia(s)
/Límites
TRECATOR TABLET
250MG
ANTIONGO (SISTÉMICA)
AMBISOME FOR
SUSPENSION 50MG
amphotericin b for solution
50mg
CANCIDAS FOR
SOLUTION 50MG
CANCIDAS FOR
SOLUTION 70MG
CRESEMBA CAPSULE
186MG
CRESEMBA FOR
SOLUTION 372MG
fluconazole for suspension 10
mg/ml
fluconazole for suspension 40
mg/ml
fluconazole in dextrose
solution 400 mg/200 ml
fluconazole tablet 100mg
fluconazole-nacl solution 200
mg/100 ml
flucytosine capsule 250mg
flucytosine capsule 500mg
GRIS-PEG TABLET 125MG
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
AP; NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
4
NM
4
AP; NM
2
AP; NM
5
AP; NM
5
AP; NM
4
LC; AP; NM
4
LC; AP; NM
2
NM
2
NM
2
BvsD; NM
1
1
1
1
NM
NM
NM
NM
2
BvsD; NM
2
2
3
NM
NM
NM
LC; AP; NM
AP – Autorización Previa
LC – Límites de Cantidad
TE – Terapia en Etapas
AL – Acceso Limitado
NM – No-mantenimiento
BvsD - Este medicamento puede estar cubierto bajo la Parte B o Parte D.
Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por al ver la página 6.
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Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
GRIS-PEG TABLET 250MG
griseofulvin suspension 125
mg/5 ml
griseofulvin tablet 500mg
griseofulvin ultramicrosize
tablet 125mg
griseofulvin ultramicrosize
tablet 250mg
itraconazole capsule 100mg
ketoconazole tablet 200mg
LAMISIL PACKET 125MG
LAMISIL PACKET 187.5MG
NOXAFIL SUSPENSION
200 MG/5 ML (40 MG/ML)
NOXAFIL TABLET DR
100MG
nystatin suspension 100,000
unit/ml
nystatin tablet 500,000 unit
SPORANOX SOLUTION 10
MG/ML
terbinafine hcl tablet 250mg
voriconazole for solution
200mg
voriconazole for suspension
200 mg/5 ml (40 mg/ml)
LC 450 mililitro(s) cada 30
dia(s)
voriconazole tablet 200mg
3
NM
2
NM
2
NM
2
NM
2
NM
2
LC; NM
2
4
4
NM
NM
NM
4
AP; NM
4
LC; AP; NM
2
NM
2
NM
4
NM
1
LC; NM
2
AP; NM
2
LC; AP; NM
2
LC; AP; NM
/Límites
voriconazole tablet 50mg
ANTIPROTOZOALES
ALINIA FOR SUSPENSION
100 MG/5 ML
ALINIA TABLET 500MG
atovaquone suspension 750
mg/5 ml
atovaquone-proguanil hcl
tablet 250-100mg
atovaquone-proguanil hcl
tablet 62.5 mg-25 mg
(pediatric)
chloroquine phosphate tablet
250mg
chloroquine phosphate tablet
500mg
COARTEM TABLET 20120MG
hydroxychloroquine sulfate
tablet 200mg
mefloquine hcl tablet 250mg
LC 5 cada 30 dia(s)
metronidazole capsule 375mg
metronidazole tablet 250mg
metronidazole tablet 500mg
NEBUPENT FOR
SOLUTION 300MG
primaquine tablet 26.3mg
quinidine sulfate tablet 200mg
quinidine sulfate tablet 300mg
quinine sulfate capsule 324mg
tinidazole tablet 250mg
2
LC; AP; NM
4
NM
4
NM
2
NM
2
NM
2
NM
2
NM
2
NM
4
LC; NM
1
NM
2
LC; NM
2
1
1
NM
NM
NM
4
BvsD; NM
2
2
2
2
2
NM
NM
NM
NM
NM
8
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
tinidazole tablet 500mg
2
ANTIVIRALES (SISTÉMICAS)
abacavir tablet 300mg
2
abacavir-lamivudinezidovudine tablet 300-1502
300mg
acyclovir capsule 200mg
1
acyclovir sodium solution 50
2
mg/ml
acyclovir suspension 200 mg/5
2
ml
acyclovir tablet 400mg
1
acyclovir tablet 800mg
1
adefovir dipivoxil tablet 10mg
2
amantadine capsule 100mg
2
amantadine syrup 50 mg/5 ml
2
amantadine tablet 100mg
2
APTIVUS CAPSULE 250MG 3
APTIVUS SOLUTION 100
3
MG/ML
ATRIPLA TABLET 600-2003
300MG
BARACLUDE SOLUTION
4
0.05 MG/ML
cidofovir solution 75 mg/ml
2
COMPLERA TABLET 2003
25-300MG
CRIXIVAN CAPSULE
3
200MG
CRIXIVAN CAPSULE
3
400MG
DAKLINZA TABLET 30MG
5
5
/Límites
NM
DESCOVY TABLET 20025MG
didanosine capsule dr 125mg
EDURANT TABLET 25MG
EMTRIVA CAPSULE
200MG
EMTRIVA SOLUTION 10
MG/ML
entecavir tablet 0.5mg
entecavir tablet 1mg
EPIVIR HBV SOLUTION 25
MG/5 ML (5 MG/ML)
EPZICOM TABLET 600300MG
EVOTAZ TABLET 300150MG
famciclovir tablet 125mg
FUZEON FOR SOLUTION
90MG
ganciclovir sodium for
solution 500mg
GENVOYA TABLET 150150-200-10MG
NM
NM
NM
BvsD; NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
BvsD; NM
NM
NM
NM
LC; AP; NM
LC; AP; NM
5
LC; AP; NM
3
LC; NM
2
2
2
2
3
NM
NM
NM
NM
NM
3
NM
3
NM
2
2
NM
NM
3
NM
3
NM
4
LC; NM
2
2
2
NM
NM
NM
5
LC; NM
2
BvsD; NM
3
LC; NM
9
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
HARVONI TABLET 90400MG
INTELENCE TABLET
100MG
INTELENCE TABLET
200MG
INTELENCE TABLET
25MG
INTRON A FOR SOLUTION
10 MILLION UNIT (1 ML)
INTRON A SOLUTION 6
MILLION UNIT/ML
INVIRASE CAPSULE
200MG
INVIRASE TABLET 500MG
ISENTRESS PACKET
100MG
ISENTRESS TABLET
400MG
ISENTRESS TABLET
CHEWABLE 100MG
ISENTRESS TABLET
CHEWABLE 25MG
KALETRA SOLUTION 400
MG-100 MG/5 ML
KALETRA TABLET 10025MG
KALETRA TABLET 20050MG
5
LC; AP
3
NM
3
NM
3
NM
5
NM
/Límites
lamivudine hbv tablet 100mg
lamivudine solution 10 mg/ml
lamivudine tablet 150mg
lamivudine tablet 300mg
lamivudine-zidovudine tablet
150-300mg
LEXIVA SUSPENSION 50
MG/ML
LEXIVA TABLET 700MG
nevirapine er tablet er 24hr
100mg
nevirapine er tablet er 24hr
400mg
nevirapine suspension 50
mg/5 ml
nevirapine tablet 200mg
NORVIR CAPSULE 100MG
NORVIR SOLUTION 80
MG/ML
NORVIR TABLET 100MG
ODEFSEY TABLET 200-2525MG
OLYSIO CAPSULE 150MG
PEGASYS PROCLICK
SOLUTION 135 MCG/0.5
ML
dia(s)
PEGASYS PROCLICK
SOLUTION 180 MCG/0.5
ML
dia(s)
5
5
5
NM
3
NM
3
NM
3
NM
3
NM
3
NM
3
NM
3
NM
3
NM
3
NM
2
2
2
2
NM
NM
NM
NM
2
NM
3
NM
3
NM
2
NM
2
NM
2
NM
2
3
NM
NM
3
NM
3
NM
4
LC; NM
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP
10
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
PEGASYS SOLUTION 180
MCG/0.5 ML
dia(s)
PEGASYS SOLUTION 180
MCG/ML
dia(s)
PEGINTRON KIT 120
MCG/0.5 ML
LC 4 cada 30 dia(s)
PEGINTRON KIT 150
MCG/0.5 ML
LC 4 cada 30 dia(s)
PEGINTRON KIT 50
MCG/0.5 ML
LC 4 cada 30 dia(s)
PEGINTRON KIT 80
MCG/0.5 ML
LC 4 cada 30 dia(s)
PEGINTRON REDIPEN KIT
120 MCG/0.5 ML
LC 4 cada 30 dia(s)
150 MCG/0.5 ML
LC 4 cada 30 dia(s)
50 MCG/0.5 ML
LC 4 cada 30 dia(s)
80 MCG/0.5 ML
LC 4 cada 30 dia(s)
PREZCOBIX TABLET 800150MG
5
LC; AP; NM
5
LC; AP; NM
5
5
5
5
5
5
5
/Límites
PREZISTA SUSPENSION
100 MG/ML
PREZISTA TABLET 150MG
PURIXAN SUSPENSION 20
MG/ML
dia(s)
REBETOL SOLUTION 40
MG/ML
RELENZA AERO POW BR
ACT 5MG
RESCRIPTOR TABLET
100MG
RESCRIPTOR TABLET
200MG
RETROVIR SOLUTION 10
MG/ML
REYATAZ CAPSULE
150MG
REYATAZ CAPSULE
200MG
REYATAZ CAPSULE
300MG
LC; AP; NM
LC; AP; NM
LC; AP; NM
LC; AP; NM
LC; AP; NM
LC; AP; NM
LC; AP; NM
5
LC; AP; NM
4
LC; NM
3
NM
3
3
3
3
NM
NM
NM
NM
5
LC; AP
4
NM
4
LC; NM
3
NM
3
NM
3
NM
3
LC; NM
3
LC; NM
3
LC; NM
11
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
REYATAZ PACKET 50MG
ribasphere capsule 200mg
ribasphere tablet 200mg
ribavirin capsule 200mg
ribavirin tablet 200mg
SELZENTRY TABLET
150MG
SELZENTRY TABLET
300MG
SOVALDI TABLET 400MG
stavudine capsule 15mg
stavudine for solution 1 mg/ml
STRIBILD TABLET 150150-200-300MG
SUSTIVA CAPSULE 200MG
SUSTIVA CAPSULE 50MG
SUSTIVA TABLET 600MG
TAMIFLU CAPSULE 30MG
3
TAMIFLU FOR
SUSPENSION 6 MG/ML
dia(s)
TECHNIVIE TABLET 12.575-50MG
TIVICAY TABLET 10MG
TIVICAY TABLET 25MG
TIVICAY TABLET 50MG
TRIUMEQ TABLET 600-50300MG
TRUVADA TABLET 100150MG
TYBOST TABLET 150MG
TYZEKA TABLET 600MG
valacyclovir tablet 1,000mg
valacyclovir tablet 500mg
VALCHLOR GEL 0.016 %
LC 120 gram(s) cada 30 dia(s)
LC; NM
2
LC; NM
2
NM
2
LC; NM
2
NM
3
NM
3
/Límites
NM
5
LC; AP; NM
2
2
2
2
2
NM
NM
NM
NM
NM
5
NM
3
LC; NM
3
LC; NM
3
LC; NM
4
LC; NM
4
LC; NM
4
LC; NM
4
LC; NM
5
LC; AP; NM
3
LC; NM
3
LC; NM
3
LC; NM
4
LC; NM
3
NM
3
NM
3
NM
3
NM
3
LC
4
NM
2
LC; NM
2
LC; NM
5
LC; AP
12
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
VALCYTE FOR SOLUTION
50 MG/ML
valganciclovir hcl tablet
450mg
VIDEX FOR SOLUTION 10
MG/ML (FINAL
CONCENTRATION)
VIEKIRA PAK TAB THER
PACK 12.5 MG-75 MG-50
MG (2)/250 MG (2)
VIRACEPT TABLET 250MG
VIRACEPT TABLET 625MG
VIRAZOLE FOR SOLUTION
6 GRAM
VIREAD POWDER 40
MG/SCOOP (40 MG/GRAM)
VIREAD TABLET 150MG
VIREAD TABLET 200MG
VIREAD TABLET 250MG
VIREAD TABLET 300MG
VITEKTA TABLET 150MG
VITEKTA TABLET 85MG
ZEPATIER TABLET 50100MG
4
NM
2
NM
3
NM
5
LC; AP; NM
3
3
NM
NM
4
AP; NM
3
NM
3
LC; NM
3
LC; NM
3
LC; NM
3
LC; NM
4
LC; NM
4
LC; NM
5
LC; AP
/Límites
ZIAGEN SOLUTION 20
MG/ML
zidovudine capsule 100mg
zidovudine syrup 10 mg/ml
zidovudine tablet 300mg
BACTERICIDAS
amikacin sulfate solution 500
mg/2 ml
amoxicillin capsule 250mg
amoxicillin capsule 500mg
amoxicillin for suspension 125
mg/5 ml
mg/5 ml
mg/5 ml
mg/5 ml
amoxicillin tablet 500mg
amoxicillin tablet 875mg
amoxicillin tablet chewable
125mg
amoxicillin tablet chewable
250mg
amoxicillin-clavulanate pot er
tablet er 12hr 1,000-62.5mg
amoxicillin-clavulanate potass
for suspension 200 mg-28.5
mg/5 ml
mg/5 ml
for suspension 400 mg-57
mg/5 ml
3
NM
2
2
2
NM
NM
NM
2
BvsD; NM
2
2
NM
NM
2
NM
2
NM
2
NM
2
NM
2
2
NM
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
13
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
mg/5 ml
tablet 250-125mg
tablet 500-125mg
tablet 875-125mg
tablet chewable 200-28.5mg
tablet chewable 400-57mg
ampicillin sodium for solution
1 gram
10 gram
125mg
ampicillin trihydrate capsule
250mg
ampicillin trihydrate capsule
500mg
ampicillin trihydrate for
suspension 125 mg/5 ml
ampicillin trihydrate for
ampicillin-sulbactam for
solution 1.5 gram
solution 15 gram
solution 3 gram
azithromycin for solution
500mg
2
/Límites
azithromycin for suspension
100 mg/5 ml
azithromycin for suspension
200 mg/5 ml
azithromycin packet 1 gram
azithromycin tablet 250mg
aztreonam for solution 1 gram
BETHKIS 300 MG/4 ML
AMPULE
dia(s)
BICILLIN C-R
SUSPENSION 1,200,000
UNIT/2 ML
(600,000/600,000)
BICILLIN C-R
SUSPENSION 1,200,000
UNIT/2 ML
(900,000/300,000)
BICILLIN L-A
SUSPENSION 1.2 MILLION
UNIT/2 ML
BICILLIN L-A
SUSPENSION 2.4 MILLION
UNIT/4 ML
BICILLIN L-A
SUSPENSION 600,000
UNIT/ML
CAYSTON FOR SOLUTION
75 MG/ML
dia(s)
CEDAX CAPSULE 400MG
cefaclor capsule 250mg
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
NM
2
NM
2
NM
2
NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
NM
2
NM
2
2
2
2
2
NM
NM
NM
NM
NM
5
LC; AP; NM
4
NM
4
NM
4
NM
4
NM
4
NM
5
LC; AP; NM
4
2
NM
NM
14
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
cefaclor capsule 500mg
cefaclor er tablet er 12hr
500mg
cefadroxil capsule 500mg
cefadroxil for suspension 250
mg/5 ml
cefadroxil for suspension 500
mg/5 ml
cefadroxil tablet 1 gram
cefazolin sodium for solution 1
gram
cefazolin sodium for solution
10 gram
cefazolin sodium for solution
500mg
cefdinir capsule 300mg
cefdinir for suspension 125
mg/5 ml
cefdinir for suspension 250
mg/5 ml
cefepime hcl for solution 1
gram
cefepime hcl for solution 2
gram
cefepime-dextrose for solution
1 gram/50 ml
cefepime-dextrose for solution
2 gram/50 ml
cefixime for suspension 100
mg/5 ml
cefixime for suspension 200
mg/5 ml
cefotaxime sodium for solution
1 gram
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
NM
2
NM
2
2
BvsD; NM
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
2
2 gram
500mg
cefoxitin for solution 1 gram
cefoxitin sodium for solution 1
gram/50 ml
cefoxitin sodium for solution 2
gram/50 ml
cefpodoxime proxetil for
cefpodoxime proxetil for
cefpodoxime proxetil tablet
100mg
cefpodoxime proxetil tablet
200mg
cefprozil for suspension 125
mg/5 ml
cefprozil for suspension 250
mg/5 ml
cefprozil tablet 250mg
cefprozil tablet 500mg
ceftazidime for solution 1
gram/50 ml
ceftazidime for solution 2
gram/50 ml
CEFTIN FOR SUSPENSION
125 MG/5 ML
CEFTIN FOR SUSPENSION
250 MG/5 ML
ceftriaxone for solution 1
gram
NM
2
2
/Límites
NM
NM
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
2
2
BvsD; NM
BvsD; NM
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
2
NM
NM
2
NM
2
NM
4
NM
4
NM
2
BvsD; NM
15
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
gram
gram
ceftriaxone for solution 250mg
ceftriaxone for solution 500mg
cefuroxime sodium for
solution 1.5 gram
solution 7.5 gram
solution 750mg
cefuroxime tablet 250mg
cefuroxime tablet 500mg
cephalexin capsule 250mg
cephalexin capsule 500mg
cephalexin for suspension 125
mg/5 ml
cephalexin for suspension 250
mg/5 ml
cephalexin tablet 250mg
cephalexin tablet 500mg
chloramphenicol sod
succinate for solution 1 gram
ciprofloxacin er tablet er 24hr
1,000mg
ciprofloxacin er tablet er 24hr
500mg
ciprofloxacin for suspension
250 mg/5 ml
ciprofloxacin for suspension
500 mg/5 ml
ciprofloxacin hcl tablet 100mg
2
BvsD; NM
2
BvsD; NM
2
2
BvsD; NM
BvsD; NM
2
BvsD; NM
2
/Límites
ciprofloxacin solution 400
mg/40 ml
ciprofloxacin-d5w solution
200 mg/100 ml
clarithromycin er tablet er
24hr 500mg
clarithromycin for suspension
125 mg/5 ml
clarithromycin for suspension
250 mg/5 ml
clarithromycin tablet 250mg
clarithromycin tablet 500mg
clindamycin hcl capsule
150mg
clindamycin hcl capsule
300mg
clindamycin hcl capsule 75mg
clindamycin pediatric for
solution 75 mg/5 ml
clindamycin phosphate
clindamycin phosphate-d5w
colistimethate for solution
150mg
CUBICIN FOR SOLUTION
500MG
DALVANCE FOR
SOLUTION 500MG
BvsD; NM
2
BvsD; NM
2
2
2
2
NM
NM
NM
NM
2
NM
2
NM
2
2
NM
NM
2
BvsD; NM
2
NM
2
NM
2
NM
2
NM
2
2
2
NM
NM
NM
2
NM
2
BvsD; NM
2
BvsD; NM
2
NM
2
NM
2
NM
2
2
NM
NM
2
NM
2
NM
2
NM
2
NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
4
LC; AP; NM
4
LC; AP; NM
16
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
DARAPRIM TABLET 25MG
dicloxacillin sodium capsule
250mg
dicloxacillin sodium capsule
500mg
DIFICID TABLET 200MG
doxycycline hyclate capsule
100mg
doxycycline hyclate capsule
50mg
doxycycline hyclate for
solution 100mg
doxycycline hyclate tablet
100mg
doxycycline hyclate tablet
20mg
doxycycline hyclate tablet dr
100mg
150mg
75mg
doxycycline monohydrate
capsule 100mg
capsule 50mg
capsule 75mg
doxycycline monohydrate for
tablet 100mg
tablet 150mg
4
NM
1
NM
1
4
tablet 50mg
tablet 75mg
E.E.S. 200 FOR
SUSPENSION 200 MG/5 ML
ERY-TAB TABLET DR
250MG
ERY-TAB TABLET DR
333MG
ERY-TAB TABLET DR
500MG
ERYPED 200 FOR
ERYPED 400 FOR
ERYTHROCIN
LACTOBIONATE FOR
SOLUTION 500MG
ERYTHROCIN STEARATE
TABLET 250MG
erythromycin capsule dr part
250mg
erythromycin tablet 250mg
erythromycin tablet 500mg
gentamicin sulfate in ns
NM
LC; AP; NM
2
NM
2
NM
2
BvsD; NM
2
/Límites
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
3
NM
4
NM
4
NM
4
NM
4
NM
4
NM
2
BvsD; NM
3
NM
2
NM
2
2
NM
NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
17
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
gentamicin sulfate iv soln 10
mg/ml
gentamicin sulfate solution 40
mg/ml
imipenem-cilastatin sodium
for solution 250mg
imipenem-cilastatin sodium
for solution 500mg
INVANZ FOR SOLUTION 1
GRAM
KETEK TABLET 300MG
KETEK TABLET 400MG
lansoprazol-amoxicil-clarithro
levofloxacin solution 25 mg/ml
levofloxacin tablet 250mg
levofloxacin-d5w solution 500
mg/100 ml
levofloxacin-d5w solution 750
mg/150 ml
linezolid for suspension 100
mg/5 ml
linezolid solution 600 mg/300
ml
linezolid tab 600 mg
meropenem for solution
500mg
metronidazole solution 500
mg/100 ml
minocycline hcl capsule
100mg
minocycline hcl capsule 50mg
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
4
AP; NM
4
AP; NM
4
NM
4
4
2
2
2
2
2
NM
NM
NM
BvsD; NM
NM
NM
NM
2
BvsD; NM
2
BvsD; NM
2
NM
2
BvsD; NM
2
NM
2
NM
2
BvsD; NM
2
NM
2
NM
/Límites
minocycline hcl capsule 75mg
minocycline hcl er tablet er
24hr 135mg
24hr 45mg
24hr 90mg
minocycline hcl tablet 100mg
moxifloxacin hcl tablet 400mg
nafcillin sodium for solution 1
gram
nafcillin sodium for solution
10 gram
nafcillin solution 1 gram/50
ml
neomycin sulfate tablet 500mg
ofloxacin tablet 400mg
ORACEA CAPSULE DR
40MG
ORBACTIV FOR
SOLUTION 400MG
paromomycin sulfate capsule
250mg
PCE TABLET DR 333MG
PCE TABLET DR 500MG
penicillin g potassium for
solution 5 million unit
2
NM
2
LC; NM
2
LC; NM
2
LC; NM
2
2
2
2
NM
NM
NM
NM
2
AP; NM
2
AP; NM
2
AP; NM
2
2
NM
NM
4
NM
4
LC; AP; NM
2
NM
4
4
NM
NM
2
BvsD; NM
18
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
penicillin g procaine
suspension 1.2 million unit/2
ml
penicillin g sodium for
solution 5 million unit
penicillin gk-iso-osm dextrose
solution 2 million unit/50 ml
penicillin gk-iso-osm dextrose
solution 3 million unit/50 ml
penicillin v potassium for
penicillin v potassium for
penicillin v potassium tablet
250mg
penicillin v potassium tablet
500mg
PENTAM 300 FOR
SOLUTION 300MG
piperacillin-tazobactam for
solution 3.375 gram
piperacillin-tazobactam for
solution 4.5 gram
PYLERA CAPSULE 140125-125MG
rifabutin capsule 150mg
rifampin capsule 150mg
rifampin capsule 300mg
rifampin for solution 600mg
RIFATER TABLET 120-50300MG
SIVEXTRO FOR
SOLUTION 200MG
LC 6 cada 30 dia(s)
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
2
NM
2
NM
2
NM
2
NM
4
BvsD; NM
2
BvsD; NM
2
BvsD; NM
4
NM
2
2
2
2
NM
NM
NM
NM
4
NM
4
/Límites
SIVEXTRO TABLET 200MG
LC 6 cada 30 dia(s)
SOLODYN TABLET ER
24HR 105MG
SOLODYN TABLET ER
24HR 115MG
streptomycin sulfate for
solution 1 gram
sulfadiazine tablet 500mg
sulfamethoxazoletrimethoprim solution 80 mg16 mg/ml
sulfamethoxazoletrimethoprim suspension 200
mg-40 mg/5 ml
sulfamethoxazoletrimethoprim tablet 400-80mg
sulfamethoxazoletrimethoprim tablet 800160mg
SUPRAX CAPSULE 400MG
SUPRAX FOR
SUPRAX FOR
SUPRAX FOR
SUPRAX TABLET
CHEWABLE 100MG
SUPRAX TABLET
CHEWABLE 200MG
SYNAGIS SOLUTION 50
MG/0.5 ML
LC; AP; NM
4
LC; AP; NM
4
LC; NM
4
LC; NM
2
BvsD; NM
2
NM
2
BvsD; NM
2
NM
2
NM
2
NM
4
LC; NM
4
NM
4
NM
4
NM
4
LC; NM
4
LC; NM
4
AP; NM
19
Medicamento
Nivel Requisitos
Medicamento
/Límites
SYNERCID FOR
SOLUTION 500MG
TEFLARO FOR SOLUTION
400MG
TEFLARO FOR SOLUTION
600MG
TOBI PODHALER
CAPSULE 28MG
tobramycin 300 mg/5 ml
ampule
tobramycin sulfate solution 10
mg/ml
tobramycin sulfate solution 40
mg/ml
TYGACIL FOR SOLUTION
50MG
vancomycin hcl capsule
125mg
vancomycin hcl capsule
250mg
vancomycin hcl for solution 1
gram
vancomycin hcl for solution 10
gram
vancomycin hcl for solution
500mg
XIFAXAN TABLET 200MG
XIFAXAN TABLET 550MG
ZMAX FOR SUSPENSION 2
GRAM/60 ML
ZOSYN SOLUTION 2.25
GRAM/50 ML
4
LC; AP; NM
4
AP; NM
4
AP; NM
5
AP; NM
5
AP; NM
2
BvsD; NM
2
BvsD; NM
4
LC; AP; NM
2
LC; NM
2
LC; NM
2
BvsD; NM
2
BvsD; NM
2
BvsD; NM
4
LC; AP; NM
4
LC; AP; NM
4
NM
4
BvsD; NM
Nivel Requisitos
/Límites
ZOSYN SOLUTION 3.375
4 BvsD; NM
GRAM/50 ML
AGENTES ANTINEOPLASTICOS
AGENTES ANTINEOPLASTICOS
ABRAXANE FOR
5 AP
SUSPENSION 100MG
AFINITOR DISPERZ
TABLET SOLUBLE 2MG
5 LC; AP
AFINITOR DISPERZ
TABLET SOLUBLE 3MG
5 LC; AP
AFINITOR DISPERZ
TABLET SOLUBLE 5MG
5 LC; AP
AFINITOR TABLET 10MG
5 LC; AP
AFINITOR TABLET 2.5MG
5 LC; AP
AFINITOR TABLET 5MG
5 LC; AP
AFINITOR TABLET 7.5MG
5 LC; AP
ALECENSA CAPSULE
150MG
5 LC; AP
ALIMTA FOR SOLUTION
5 AP
500MG
anastrozole tablet 1mg
2 LC
ARRANON SOLUTION 250
5 BvsD
MG/50 ML
20
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
AVASTIN SOLUTION 25
MG/ML
azacitidine for suspension
100mg
BELEODAQ FOR
SOLUTION 500MG
bexarotene capsule 75mg
bicalutamide tablet 50mg
BICNU FOR SOLUTION
100MG
bleomycin sulfate for solution
30 unit
BOSULIF TABLET 100MG
BOSULIF TABLET 500MG
BUSULFEX SOLUTION 60
MG/10 ML
CABOMETYX TABLET
20MG
CABOMETYX TABLET
40MG
CABOMETYX TABLET
60MG
CAPRELSA TABLET
100MG
CAPRELSA TABLET
300MG
carboplatin solution 10 mg/ml
cisplatin solution 1 mg/ml
5
AP
5
BvsD
5
LC; AP
5
2
AP
4
BvsD
2
BvsD
5
5
AP
AP
5
BvsD
5
LC; AP
5
LC; AP
5
/Límites
cladribine solution 10 mg/10
ml
CLOLAR SOLUTION 20
MG/20 ML
COMETRIQ KIT 100
MG/DAY (80 MG X 1-20 MG
X 1/DAY)
COMETRIQ KIT 140
MG/DAY (80 MG X 1-20 MG
X 3/DAY)
COMETRIQ KIT 60
MG/DAY (20 MG X 3/DAY)
COTELLIC TABLET 20MG
cyclophosphamide capsule
25mg
cyclophosphamide capsule
50mg
CYRAMZA SOLUTION 100
MG/10 ML (10 MG/ML)
CYRAMZA SOLUTION 500
MG/50 ML (10 MG/ML)
cytarabine solution 2 gram/20
ml (100 mg/ml)
cytarabine solution 20 mg/ml
DARZALEX SOLUTION 100
MG/5 ML (20 MG/ML)
daunorubicin hcl injectable 5
mg/ml
decitabine for solution 50mg
docetaxel concentrate 80 mg/4
ml (20 mg/ml)
docetaxel solution 80 mg/8 ml
(10 mg/ml)
doxorubicin hcl liposome
injectable 2 mg/ml
LC; AP
4
LC; AP
4
LC; AP
2
2
BvsD
BvsD
5
BvsD
5
BvsD
5
AP
5
AP
5
AP
5
LC; AP; AL
2
BvsD
2
BvsD
5
AP
5
AP
2
BvsD
2
BvsD
5
AP; AL
2
BvsD
5
BvsD
5
BvsD
5
BvsD
2
BvsD
21
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
doxorubicin hcl solution 50
mg/25 ml
DROXIA CAPSULE 200MG
ELIGARD KIT 22.5 MG (3
MONTH)
ELIGARD KIT 30 MG (4
MONTH)
ELIGARD KIT 7.5 MG (1
MONTH)
EMCYT CAPSULE 140MG
EMPLICITI FOR SOLUTION
300MG
EMPLICITI FOR SOLUTION
400MG
epirubicin hcl solution 50
mg/25 ml
ERBITUX SOLUTION 100
MG/50 ML
ERIVEDGE CAPSULE
150MG
ERWINAZE FOR
SOLUTION 10,000 UNIT
etoposide solution 20 mg/ml
exemestane tablet 25mg
FARESTON TABLET 60MG
FARYDAK CAPSULE 10MG
2
/Límites
FASLODEX SOLUTION 250
MG/5 ML
FIRMAGON FOR
SOLUTION 120MG
FIRMAGON FOR
SOLUTION 80MG
fludarabine phosphate for
solution 50mg
fluorouracil solution 2 %
fluorouracil solution 2.5
gram/50 ml
fluorouracil solution 5 %
flutamide capsule 125mg
FOLOTYN SOLUTION 40
MG/2 ML (20 MG/ML)
GILOTRIF TABLET 20MG
GLEEVEC TABLET 100MG
GLEEVEC TABLET 400MG
GLEOSTINE CAPSULE
100MG
GLEOSTINE CAPSULE
10MG
GLEOSTINE CAPSULE
40MG
GLEOSTINE CAPSULE
5MG
BvsD
4
4
4
4
BvsD
4
BvsD
4
BvsD
3
5
5
2
5
AP
AP
BvsD
AP
5
LC; AP
5
AP
2
BvsD
2
LC
4
5
LC; AP
5
LC; AP
5
LC; AP
5
BvsD
5
BvsD
4
BvsD
2
BvsD
2
2
BvsD
2
2
5
AP
5
LC; AP
5
LC; AP
5
LC; AP
3
LC
3
LC
4
4
4
4
22
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
HALAVEN SOLUTION 1
MG/2 ML (0.5 MG/ML)
HERCEPTIN FOR
SOLUTION 440MG
HEXALEN CAPSULE 50MG
hydroxyurea capsule 500mg
IBRANCE CAPSULE
100MG
IBRANCE CAPSULE
125MG
IBRANCE CAPSULE 75MG
ICLUSIG TABLET 15MG
ICLUSIG TABLET 45MG
idarubicin hcl solution 1
mg/ml
ifosfamide for solution 1 gram
IMBRUVICA CAPSULE
140MG
INLYTA TABLET 1MG
INLYTA TABLET 5MG
IRESSA TABLET 250MG
irinotecan hcl solution 100
mg/5 ml
ISTODAX FOR SOLUTION
10 MG/2 ML
IXEMPRA FOR SOLUTION
45MG
JAKAFI TABLET 10MG
5
AP
5
BvsD
/Límites
JAKAFI TABLET 15MG
JAKAFI TABLET 20MG
JAKAFI TABLET 25MG
JAKAFI TABLET 5MG
JEVTANA SOLUTION 10
MG/ML (FIRST DILUTION)
KADCYLA FOR SOLUTION
100MG
KEYTRUDA FOR
SOLUTION 50MG
KEYTRUDA SOLUTION
100 MG/4 ML (25 MG/ML)
dia(s)
LENVIMA CAP THER
PACK 10 MG/DAY (10 MG
X 1/DAY)
LENVIMA CAP THER
X 1 AND 4 MG X 1)
LENVIMA CAP THER
X 1 AND 4 MG X 2)
LENVIMA CAP THER
X 2)
LENVIMA CAP THER
PACK 24 MG PER DAY (10
MG X 2 AND 4 MG X 1)
3
2
5
LC; AP
5
LC; AP
5
LC; AP
5
5
AP
AP
5
BvsD
2
BvsD
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
2
BvsD
5
AP
5
AP
4
AP
4
4
4
4
AP
AP
AP
AP
5
AP
5
AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
23
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
LENVIMA CAP THER
PACK 8 MG/DAY (4 MG X
2)
LENVIMA CAP THER
PACK 8 MG/DAY (4 MG X
2)
letrozole tablet 2.5mg
LEUKERAN TABLET 2MG
leuprolide acetate kit 1 mg/0.2
ml
levoleucovorin calcium
solution 10 mg/ml
LONSURF TABLET 156.14MG
LONSURF TABLET 208.19MG
LUPRON DEPOT KIT
11.25MG
LUPRON DEPOT KIT 22.5
MG (3 MONTH)
LUPRON DEPOT KIT
3.75MG
LUPRON DEPOT KIT 30
MG (4 MONTH)
LUPRON DEPOT KIT 45
MG (6 MONTH)
LUPRON DEPOT KIT 7.5
MG (1 MONTH)
LUPRON DEPOT-PED KIT
11.25MG
LUPRON DEPOT-PED KIT
15MG
5
/Límites
LYNPARZA CAPSULE
50MG
LYSODREN TABLET
500MG
MATULANE CAPSULE
50MG
megestrol acetate suspension
400 mg/10 ml (40 mg/ml)
megestrol acetate tablet 20mg
megestrol acetate tablet 40mg
MEKINIST TABLET 0.5MG
MEKINIST TABLET 2MG
melphalan hcl for solution
50mg
mercaptopurine tablet 50mg
methotrexate sodium solution
25 mg/ml
methotrexate tablet 2.5mg
mitomycin for solution 20mg
mitoxantrone hcl concentrate
2 mg/ml
MUSTARGEN FOR
SOLUTION 10MG
NEXAVAR TABLET 200MG
NILANDRON TABLET
150MG
NINLARO CAPSULE 2.3MG
LC 3 cada 28 dia(s)
LC; AP
5
LC; AP
2
LC
3
2
5
AP
5
LC; AP
5
LC; AP
5
BvsD
5
BvsD
5
BvsD
5
BvsD
5
BvsD
5
BvsD
5
BvsD
5
BvsD
5
LC; AP
3
3
2
2
2
5
LC; AP
5
LC; AP
5
BvsD
2
2
BvsD
2
2
BvsD
2
BvsD
4
BvsD
5
LC; AP
3
5
LC; AP
24
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
NINLARO CAPSULE 3MG
LC 3 cada 28 dia(s)
NINLARO CAPSULE 4MG
LC 3 cada 28 dia(s)
ODOMZO CAPSULE
200MG
ONCASPAR SOLUTION 750
UNIT/ML
OPDIVO SOLUTION 40
MG/4 ML
dia(s)
oxaliplatin solution 100 mg/20
ml (5 mg/ml)
paclitaxel concentrate 6
mg/ml
POMALYST CAPSULE
1MG
POMALYST CAPSULE
2MG
POMALYST CAPSULE
3MG
POMALYST CAPSULE
4MG
PROLEUKIN FOR
SOLUTION 22 MILLION
UNIT
RASUVO SOLN AUTO-INJ
10 MG/0.2 ML
LC 0.8 mililitro(s) cada 28
dia(s)
5
/Límites
12.5 MG/0.25 ML
dia(s)
15 MG/0.3 ML
dia(s)
17.5 MG/0.35 ML
dia(s)
20 MG/0.4 ML
dia(s)
22.5 MG/0.45 ML
dia(s)
25 MG/0.5 ML
dia(s)
27.5 MG/0.55 ML
dia(s)
30 MG/0.6 ML
dia(s)
7.5 MG/0.15 ML
dia(s)
REVLIMID CAPSULE
10MG
LC; AP
5
LC; AP
5
LC; AP; AL
5
AP
5
LC; AP
5
BvsD
2
BvsD
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
5
LC; AP; AL
25
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
REVLIMID CAPSULE
15MG
REVLIMID CAPSULE
2.5MG
REVLIMID CAPSULE
20MG
REVLIMID CAPSULE
25MG
REVLIMID CAPSULE 5MG
RHEUMATREX TABLET
2.5MG
RITUXAN SOLUTION 10
MG/ML
SOLTAMOX SOLUTION 10
MG/5 ML
SPRYCEL TABLET 100MG
SPRYCEL TABLET 140MG
SPRYCEL TABLET 20MG
SPRYCEL TABLET 50MG
SPRYCEL TABLET 70MG
SPRYCEL TABLET 80MG
STIVARGA TABLET 40MG
5
/Límites
SUTENT CAPSULE 12.5MG
SUTENT CAPSULE 25MG
SUTENT CAPSULE 37.5MG
SUTENT CAPSULE 50MG
SYLATRON KIT 200 MCG
SYNRIBO FOR SOLUTION
3.5MG
TABLOID TABLET 40MG
TAFINLAR 75 MG
CAPSULE
TAFINLAR CAPSULE
50MG
TAGRISSO TABLET 40MG
TAGRISSO TABLET 80MG
tamoxifen citrate tablet 10mg
tamoxifen citrate tablet 20mg
TARCEVA TABLET 100MG
TARCEVA TABLET 150MG
TARCEVA TABLET 25MG
TASIGNA CAPSULE
150MG
LC; AP; AL
5
LC; AP; AL
5
LC; AP; AL
5
LC; AP; AL
5
LC; AP; AL
4
5
BvsD
4
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
5
5
AP
AP
AP
5
AP
4
5
LC; AP
5
LC; AP
5
LC; AP; AL
5
LC; AP; AL
2
2
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
26
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
TASIGNA CAPSULE
200MG
thiotepa for solution 15mg
toposar solution 20 mg/ml
topotecan hcl for solution 4mg
TORISEL SOLUTION 30
MG/3 ML (10 MG/ML)
(FIRST DILUTION)
TREANDA FOR SOLUTION
100MG
TRELSTAR FOR
SUSPENSION 11.25 MG/2
ML
TRELSTAR FOR
ML
tretinoin capsule 10mg
TREXALL TABLET 10MG
TREXALL TABLET 15MG
TREXALL TABLET 5MG
TREXALL TABLET 7.5MG
TRIPTORELIN PAMOATE
FOR IM SUSP 22.5 MG
TRISENOX SOLUTION 10
MG/10 ML
TYKERB TABLET 250MG
VECTIBIX SOLUTION 100
MG/5 ML (20 MG/ML)
VELCADE FOR SOLUTION
3.5MG
VENCLEXTA STARTING
PACK TAB THER PACK 10
MG (14)-50 MG (7)-100 MG
(21)
5
LC; AP
5
4
5
AP
BvsD
BvsD
5
AP
5
AP
5
BvsD
5
BvsD
/Límites
VENCLEXTA TABLET
100MG
VENCLEXTA TABLET
10MG
VENCLEXTA TABLET
50MG
vinblastine sulfate solution 1
mg/ml
vincasar pfs solution 1 mg/ml
vincristine sulfate solution 1
mg/ml
vinorelbine tartrate solution
50 mg/5 ml
VOTRIENT TABLET
200MG
XALKORI CAPSULE
200MG
XALKORI CAPSULE
250MG
XTANDI CAPSULE 40MG
YERVOY SOLUTION 50
MG/10 ML (5 MG/ML)
ZANOSAR FOR SOLUTION
1 GRAM
ZELBORAF TABLET
240MG
ZOLINZA CAPSULE 100MG
2
3
3
3
3
5
BvsD
5
BvsD
5
LC; AP; AL
5
AP
5
AP
5
5
LC; AP
5
LC; AP
5
LC; AP
2
BvsD
4
BvsD
2
BvsD
2
BvsD
5
5
LC; AP
5
LC; AP
5
AP
5
AP
4
BvsD
5
LC; AP
3
LC; AP
LC; AP
27
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
ZYDELIG TABLET 100MG
5 LC; AP
ZYDELIG TABLET 150MG
5 LC; AP
ZYKADIA CAPSULE
150MG
5 LC; AP
ZYTIGA TABLET 250MG
5 LC; AP
AGENTES DE LA PIEL Y MEMBRANAS
MUCOSAS
AGENTES ANTIINFLAMATORIOS (de la PIEL
Y MUCOSAS)
alclometasone dipropionate
2
cream 0.05 %
alclometasone dipropionate
2
ointment 0.05 %
amcinonide cream 0.1 %
2
amcinonide lotion 0.1 %
2
amcinonide ointment 0.1 %
2
betamethasone dipropionate
2
cream 0.05 %
2
gel 0.05 %
2
lotion 0.05 %
2
ointment 0.05 %
betamethasone valerate cream
2
0.1 %
betamethasone valerate foam
2
0.12 %
betamethasone valerate lotion
2
0.1 %
betamethasone valerate
ointment 0.1 %
calcipotriene-betamethasone
dp ointment 0.005 %-0.064 %
CAPEX SHAMPOO
SHAMPOO 0.01 %
clobetasol emollient cream
0.05 %
clobetasol propionate foam
0.05 %
clobetasol propionate gel 0.05
%
clobetasol propionate liquid
0.05 %
clobetasol propionate lotion
0.05 %
clobetasol propionate
ointment 0.05 %
clobetasol propionate
shampoo 0.05 %
clobetasol propionate solution
0.05 %
CLODERM CREAM 0.1 %
colocort enema 100 mg/60 ml
CORDRAN TAPE 4
MCG/CM2
DESONATE GEL 0.05 %
desonide cream 0.05 %
desonide lotion 0.05 %
desonide lotion 0.05%
desonide ointment 0.05 %
desoximetasone cream 0.05 %
desoximetasone cream 0.25 %
desoximetasone gel 0.05 %
2
2
4
2
2
2
2
2
2
2
2
4
2
4
4
2
2
2
2
2
2
2
28
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
desoximetasone ointment 0.05
%
desoximetasone ointment 0.25
%
diflorasone diacetate cream
0.05 %
diflorasone diacetate ointment
0.05 %
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 cream 0.1 %
fluocinonide gel 0.05 %
fluocinonide ointment 0.05 %
fluocinonide solution 0.05 %
fluocinonide-e cream 0.05 %
fluticasone propionate cream
0.05 %
fluticasone propionate lotion
0.05 %
fluticasone propionate
ointment 0.005 %
halobetasol propionate cream
0.05 %
halobetasol propionate
ointment 0.05 %
HALOG CREAM 0.1 %
HALOG OINTMENT 0.1 %
hydrocortisone butyrate cream
0.1 %
/Límites
hydrocortisone butyrate
ointment 0.1 %
hydrocortisone butyrate
solution 0.1 %
hydrocortisone cream 1 %
hydrocortisone cream 2.5 %
hydrocortisone enema 100
mg/60 ml
hydrocortisone lotion 2.5 %
hydrocortisone ointment 1 %
hydrocortisone ointment 2.5 %
hydrocortisone valerate
ointment 0.2 %
KENALOG AEROSOL
SOLN 0.147 MG/GRAM
mometasone furoate cream 0.1
%
mometasone furoate ointment
0.1 %
mometasone furoate solution
0.1 %
OLUX FOAM 0.05 %
PANDEL CREAM 0.1 %
prednicarbate cream 0.1 %
prednicarbate ointment 0.1 %
procto-pak cream 1 %
proctozone-hc cream 2.5 %
TACLONEX SUSPENSION
0.005 %-0.064 %
triamcinolone acetonide
aerosol soln 0.147 mg/gram
cream 0.025 %
cream 0.1 %
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
1
2
1
2
2
2
1
2
2
4
2
2
2
4
4
2
2
2
2
4
2
1
1
1
29
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
1
cream 0.5 %
triamcinolone acetonide lotion
1
0.025 %
triamcinolone acetonide lotion
1
0.1 %
1
ointment 0.025 %
1
ointment 0.1 %
1
ointment 0.5 %
triamcinolone acetonide paste
2
0.1 %
AGENTES DE DESPIGMENTANTE Y
PIGMENTOGÉNICA
8-MOP CAPSULE 10MG
4
methoxsalen capsule 10mg
5
AGENTES DE LA PIEL Y MEMBRANAS
MUCOSAS, MISC.
acitretin capsule 10mg
2
acitretin capsule 17.5mg
2
acitretin capsule 25mg
2
ACZONE GEL 5 %
4
adapalene cream 0.1 %
2
adapalene gel 0.1 %
2
adapalene gel 0.3 %
2
AZELEX CREAM 20 %
4
calcipotriene cream 0.005 %
2
calcipotriene ointment 0.005
2
%
calcipotriene solution 0.005 % 2
calcitriol ointment 3
2
mcg/gram
claravis capsule 10mg
2
2
2
CONDYLOX GEL 0.5 %
COSENTYX PEN SOLN
AUTO-INJ 150 MG/ML
dia(s)
COSENTYX SYRINGE
SOLN PREF SYR 150
MG/ML
dia(s)
diclofenac sodium gel 3 %
DIFFERIN LOTION 0.1 %
ELIDEL CREAM 1 %
EPIDUO FORTE GEL 0.3 %2.5 %
EPIDUO GEL 0.1 %-2.5 %
FINACEA GEL 15 %
fluorouracil cream 0.5 %
fluorouracil cream 5 %
imiquimod cream 5 %
PANRETIN GEL 0.1 %
PICATO GEL 0.015 %
LC 3 cada 30 dia(s)
PICATO GEL 0.05 %
LC 2 cada 30 dia(s)
podofilox solution 0.5 %
SANTYL OINTMENT 250
UNIT/GRAM
STELARA SOLN PREF SYR
45 MG/0.5 ML
dia(s)
2
4
5
LC; AP
5
LC; AP
2
4
3
TE
4
4
4
2
2
2
4
4
LC
4
LC
2
4
5
LC; AP
30
Medicamento
Nivel Requisitos
Medicamento
/Límites
Nivel Requisitos
/Límites
STELARA SOLN PREF SYR
90 MG/ML
5 LC; AP
dia(s)
tacrolimus ointment 0.03 %
2 TE
tacrolimus ointment 0.1 %
2 TE
TARGRETIN GEL 1 %
3 AP
TAZORAC CREAM 0.05 %
3
TAZORAC CREAM 0.1 %
3
TAZORAC GEL 0.05 %
3
TAZORAC GEL 0.1 %
3
TOLAK CREAM 4 %
3 LC
ZYCLARA CREAM 2.5 %
4 LC
ZYCLARA CREAM 3.75 %
4
ANTIPRURIGINOSOS Y ANESTÉSICOS
LOCALES
doxepin hcl cream 5 %
2
lidocaine hcl gel 2 %
2
lidocaine ointment 5 %
2
lidocaine patch 5 %
2 AP
lidocaine-prilocaine cream
2
2.5 %-2.5 %
PRUDOXIN CREAM 5 %
4
PROLIFERANTS Y ESTIMULANTES DE LA
CÉLULA
avita cream 0.025 %
2
avita gel 0.025 %
2
KEPIVANCE FOR
5 AP
SOLUTION 6.25MG
RETIN-A MICRO PUMP
4
GEL 0.08 %
tretinoin cream 0.025 %
2
2
2
tretinoin gel 0.01 %
2
2
2
tretinoin microsphere gel 0.04
2
%
tretinoin microsphere gel 0.1
2
%
VELTIN GEL 1.2 %-0.025 %
4
AGENTES DE TRACTO RESPIRATORIO
AGENTES ANTIINFLAMATORIOS
(RESPIRATORIO)
ALOCRIL SOLUTION 2 %
4 LC
dia(s)
ALVESCO AEROSOL SOLN
160 MCG/ACTUATION
4 LC
LC 12.2 gram(s) cada 30
dia(s)
ALVESCO AEROSOL SOLN
80 MCG/ACTUATION
4 LC
LC 6.1 gram(s) cada 30 dia(s)
ASMANEX AERO POW BR
ACT 110 MCG (30 DOSES)
3 LC
LC 1 cada 30 dia(s)
ASMANEX AERO POW BR
3 LC
LC 1 cada 30 dia(s)
ASMANEX AERO POW BR
3 LC
LC 1 cada 30 dia(s)
31
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ASMANEX AERO POW BR
LC 1 cada 30 dia(s)
ASMANEX HFA AEROSOL
100 MCG/ACTUATION
ASMANEX HFA AEROSOL
200 MCG/ACTUATION
BECONASE AQ
SUSPENSION 42 MCG
budesonide suspension 0.25
mg/2 ml
budesonide suspension 0.5
mg/2 ml
budesonide suspension 1 mg/2
ml
budesonide suspension 32
mcg/actuation
cromolyn 20 mg/2 ml neb soln
cromolyn sodium solution 4 %
DYMISTA SUSPENSION
137 MCG-50 MCG/SPRAY
FLOVENT DISKUS AERO
POW BR ACT 100 MCG
FLOVENT DISKUS AERO
POW BR ACT 250 MCG
FLOVENT DISKUS AERO
POW BR ACT 50 MCG
FLOVENT HFA AEROSOL
110 MCG/ACTUATION
3
LC
3
LC
3
LC
/Límites
FLOVENT HFA AEROSOL
220 MCG
FLOVENT HFA AEROSOL
44 MCG
dia(s)
flunisolide solution 25 mcg
(0.025 %)
fluticasone propionate
suspension 50 mcg/actuation
mometasone furoate
suspension 50 mcg
montelukast sodium packet
4mg
montelukast sodium tablet
10mg
chewable 4mg
chewable 5mg
OMNARIS SUSPENSION 50
MCG
PULMICORT FLEXHALER
AERO POW BR ACT 180
MCG/ACTUATION (160
MCG DELIVERED)
LC 2 cada 30 dia(s)
PULMICORT FLEXHALER
AERO POW BR ACT 90
MCG/ACTUATION (80
MCG DELIVERED)
LC 2 cada 30 dia(s)
4
2
BvsD
2
BvsD
2
BvsD
2
2
2
BvsD
4
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
2
1
2
2
LC
2
LC
2
LC
2
LC
4
3
LC
3
LC
32
Medicamento
Nivel Requisitos
Medicamento
/Límites
Nivel Requisitos
/Límites
QNASL AEROSOL SOLN 80
MCG/ACTUATION
4 LC
QNASL CHILDREN
AEROSOL SOLN 40
4 LC
MCG/ACTUATION
QVAR AEROSOL SOLN 40
MCG/ACTUATION
3 LC
QVAR AEROSOL SOLN 80
MCG
3 LC
dia(s)
VERAMYST SUSPENSION
4
27.5 MCG/ACTUATION
zafirlukast tablet 10mg
2 LC
zafirlukast tablet 20mg
2 LC
ZETONNA AEROSOL SOLN
37 MCG/ACTUATION
4 LC
ZYFLO CR TABLET ER
12HR 600MG
4 LC
AGENTES DEL TRACTO RESPIRATORIO,
MISCELÁNEOS
ARALAST NP FOR
SOLUTION 500MG
5 LC; BvsD
ESBRIET CAPSULE 267MG
5 LC; AP
GLASSIA SOLUTION 1
GRAM/50 ML (2 %)
5 LC; BvsD
KALYDECO PACKET
5 AP
50MG
KALYDECO PACKET
5 AP
75MG
KALYDECO TABLET
5 AP
150MG
OFEV CAPSULE 100MG
5 LC; AP
OFEV CAPSULE 150MG
5 LC; AP
PROLASTIN C FOR
SOLUTION 1,000MG
5 LC; BvsD
XOLAIR FOR SOLUTION
5 AP
150MG
ZEMAIRA FOR SOLUTION
1,000MG
5 LC; BvsD
INHIBIDORES DE LA FOSFODIESTERASA
TIPO 4
DALIRESP TABLET 500
3
MCG
AGENTES DEL SISTEMA NERVIOSO
CENTRAL
AGENTES ANTIMÁNICOS
lithium carbonate capsule
1
150mg
1
300mg
1
600mg
lithium carbonate er tablet er
1
300mg
33
Medicamento
Nivel Requisitos
Medicamento
/Límites
lithium carbonate er tablet er
1
450mg
lithium carbonate tablet
1
300mg
lithium solution 8 meq/5 ml
2
AGENTES ANTIMIGRAÑOSOS
naratriptan hcl tablet 1mg
2
LC 9 cada 30 dia(s)
naratriptan hcl tablet 2.5mg
2
LC 9 cada 30 dia(s)
rizatriptan tablet 10mg
2
rizatriptan tablet 5mg
2
rizatriptan tablet disperse
10mg
2
rizatriptan tablet disperse 5mg
2
sumatriptan solution 20mg
2
sumatriptan solution 5mg
2
sumatriptan succinate soln
auto-inj 6 mg/0.5 ml
2
dia(s)
cartridge 4 mg/0.5 ml
2
dia(s)
cartridge 6 mg/0.5 ml
2
dia(s)
Nivel Requisitos
/Límites
sumatriptan succinate solution
6 mg/0.5 ml
2 LC
dia(s)
sumatriptan succinate tablet
100mg
2 LC
LC 9 cada 30 dia(s)
25mg
2 LC
LC 9 cada 30 dia(s)
50mg
2 LC
LC 9 cada 30 dia(s)
zolmitriptan odt tablet
disperse 2.5mg
2 LC
LC 9 cada 30 dia(s)
zolmitriptan odt tablet
disperse 5mg
2 LC
LC 9 cada 30 dia(s)
zolmitriptan tablet 2.5mg
2 LC
LC 9 cada 30 dia(s)
zolmitriptan tablet 5mg
2 LC
LC 9 cada 30 dia(s)
ZOMIG SOLUTION 2.5MG
4 LC
LC 6 cada 30 dia(s)
ZOMIG SOLUTION 5MG
4 LC
LC 6 cada 30 dia(s)
AGENTES ANTIPARKINSONIANOS (CNS)
APOKYN SOLUTION 10
5 AP
MG/ML
AZILECT TABLET 0.5MG
3
AZILECT TABLET 1MG
3
benztropine mesylate solution
2 BvsD
2 mg/2 ml
LC
LC
LC
LC
LC
LC
LC
LC
LC
LC
LC
34
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
benztropine mesylate tablet
0.5mg
1mg
2mg
bromocriptine mesylate
capsule 5mg
bromocriptine mesylate tablet
2.5mg
cabergoline tablet 0.5mg
carbidopa-levodopa er tablet
er 25-100mg
carbidopa-levodopa er tablet
er 50-200mg
carbidopa-levodopa tablet 10100mg
carbidopa-levodopa tablet
disperse 10-100mg
disperse 25-100mg
disperse 25-250mg
carbidopa-levodopaentacapone tablet 12.5-50200mg
carbidopa-levodopaentacapone tablet 25-100200mg
/Límites
carbidopa-levodopaentacapone tablet 50-200200mg
CYCLOSET TABLET 0.8MG
entacapone tablet 200mg
MIRAPEX ER TABLET ER
24HR 3.75MG
NEUPRO PATCH 24HR 1
MG/24 HOUR
NEUPRO PATCH 24HR 2
MG/24 HOUR
NEUPRO PATCH 24HR 3
MG/24 HOUR
NEUPRO PATCH 24HR 4
MG/24 HOUR
NEUPRO PATCH 24HR 6
MG/24 HOUR
NEUPRO PATCH 24HR 8
MG/24 HOUR
pramipexole dihydrochloride
tablet 0.125mg
tablet 0.25mg
tablet 0.5mg
tablet 0.75mg
tablet 1.5mg
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
LC
2
4
LC
4
4
4
4
4
4
1
1
1
1
1
35
Medicamento
Nivel Requisitos
Medicamento
/Límites
tablet 1mg
pramipexole er tablet er 24hr
0.375mg
0.75mg
1.5mg
2.25mg
3mg
4.5mg
ropinirole er tablet er 24hr
12mg
2mg
4mg
6mg
8mg
/Límites
ropinirole hcl tablet 0.25mg
1
ropinirole hcl tablet 0.5mg
1
ropinirole hcl tablet 1mg
1
1
1
1
1
RYTARY CAPSULE ER
23.75-95MG
4 LC; TE
RYTARY CAPSULE ER
36.25-145MG
4 LC; TE
RYTARY CAPSULE ER
48.75-195MG
4 LC; TE
RYTARY CAPSULE ER
61.25-245MG
4 LC; TE
tolcapone tablet 100mg
2
trihexyphenidyl hcl elixir 2
2
mg/5 ml
trihexyphenidyl hcl tablet 2mg
2
trihexyphenidyl hcl tablet 5mg
2
AGENTES DE LA FIBROMIALGIA
SAVELLA TABLET 100MG
3 LC
SAVELLA TABLET 12.5MG
3 LC
SAVELLA TABLET 25MG
3 LC
SAVELLA TABLET 50MG
3 LC
1
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
Nivel Requisitos
36
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
SAVELLA TITRATION
PACK
3 LC
AGENTES DEL SISTEMA NERVIOSO
CENTRAL, MISC.
acamprosate calcium tablet dr
2
333mg
carbidopa tablet 25mg
2
disulfiram tablet 250mg
2 LC
memantine hcl solution 2
2
mg/ml
memantine hcl tablet 10mg
2 LC
memantine hcl tablet 5 mg
(28)-10 mg (21)
2 LC
memantine hcl tablet 5mg
2 LC
NAMENDA SOLUTION 2
3
MG/ML
NAMENDA TABLET 10MG
3 LC
NAMENDA TABLET 5 MG
(28)-10 MG (21)
3 LC
NAMENDA TABLET 5MG
3 LC
NAMENDA XR CAPSULE
ER 24HR 14MG
3 LC
NAMENDA XR CAPSULE
ER 24HR 21MG
3 LC
NAMENDA XR CAPSULE
ER 24HR 28MG
NAMENDA XR CAPSULE
ER 24HR 7 MG (7)-14 MG
(7)-21 MG (7)-28 MG (7)
NAMENDA XR CAPSULE
ER 24HR 7MG
NUEDEXTA CAPSULE 2010MG
riluzole tablet 50mg
STRATTERA CAPSULE
100MG
STRATTERA CAPSULE
10MG
STRATTERA CAPSULE
18MG
STRATTERA CAPSULE
25MG
STRATTERA CAPSULE
40MG
STRATTERA CAPSULE
60MG
STRATTERA CAPSULE
80MG
3
LC
3
LC
3
LC
4
LC; AP
2
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
37
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
tetrabenazine tablet 12.5mg
5 LC; AP
tetrabenazine tablet 25mg
5 LC; AP
XYREM SOLUTION 500
MG/ML
5 LC; AP; AL
dia(s)
AGENTES PSICOTERAPÉUTICOS
ABILIFY MAINTENA FOR
SUSPENSION 300MG
5 LC
LC 2 cada 28 dia(s)
ABILIFY MAINTENA FOR
SUSPENSION 400MG
5 LC
LC 2 cada 28 dia(s)
amitriptyline hcl tablet 100mg
2
2
2
2
2
2
amoxapine tablet 100mg
2
2
2
2
APLENZIN TABLET ER
24HR 174MG
4 LC; TE
APLENZIN TABLET ER
24HR 348MG
4 LC; TE
APLENZIN TABLET ER
24HR 522MG
4 LC; TE
aripiprazole odt tablet
disperse 10mg
aripiprazole odt tablet
disperse 15mg
aripiprazole tablet 10mg
ARISTADA PREFILLED
SYR 441 MG/1.6 ML
dia(s)
ARISTADA PREFILLED
SYR 662 MG/2.4 ML
dia(s)
ARISTADA PREFILLED
SYR 882 MG/3.2 ML
dia(s)
ASENAPINE MALEATE SL
TAB 10 MG (BASE EQUIV)
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
5
LC; TE
5
LC; TE
5
LC; TE
4
LC; TE
38
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
buproban tablet er 12hr
150mg
bupropion hcl sr tablet er
12hr 100mg
12hr 150mg
12hr 200mg
bupropion hcl tablet 100mg
bupropion hcl tablet 75mg
bupropion xl tablet er 24hr
150mg
bupropion xl tablet er 24hr
300mg
chlorpromazine hcl solution
25 mg/ml
chlorpromazine hcl tablet
100mg
10mg
200mg
25mg
50mg
citalopram hbr solution 10
mg/5 ml
citalopram hbr tablet 10mg
clomipramine hcl capsule
25mg
/Límites
50mg
75mg
clozapine odt tablet disperse
12.5mg
clozapine odt tablet disperse
150mg
clozapine orally disintegrating
tab 100 mg
tab 200 mg
tab 25 mg
clozapine tablet 100mg
compro suppository 25mg
desipramine hcl tablet 100mg
doxepin hcl capsule 100mg
2
1
1
1
1
2
2
LC
2
LC
2
BvsD
2
2
2
2
2
2
1
LC
1
LC
1
LC
2
2
2
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
2
2
2
2
2
2
2
2
2
39
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
doxepin hcl concentrate 10
mg/ml
duloxetine hcl capsule dr part
20mg
30mg
60mg
EMSAM PATCH 24HR 12
MG/24 HOUR
EMSAM PATCH 24HR 6
MG/24 HOUR
EMSAM PATCH 24HR 9
MG/24 HOUR
escitalopram oxalate solution
5 mg/5 ml
escitalopram oxalate tablet
10mg
20mg
5mg
/Límites
2
2
2
FANAPT TABLET 1 MG (2)2 MG (2)-4 MG (2)-6 MG (2)
LC 8 cada 30 dia(s)
FANAPT TABLET 10MG
FANAPT TABLET 12MG
FANAPT TABLET 1MG
FANAPT TABLET 2MG
FANAPT TABLET 4MG
FANAPT TABLET 6MG
FANAPT TABLET 8MG
FETZIMA CAPSULE ER
24HR 120MG
FETZIMA CAPSULE ER
24HR 20MG
FETZIMA CAPSULE ER
24HR 40MG
FETZIMA CAPSULE ER
24HR 80MG
FETZIMA CP24 THER
PACK 20 MG (2)-40 MG (26)
2
2
LC
2
LC
2
LC
4
LC; TE
4
LC; TE
4
LC; TE
2
1
1
1
LC
LC
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
LC
40
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
fluoxetine dr capsule dr 90mg
LC 4 cada 28 dia(s)
fluoxetine hcl capsule 10mg
fluoxetine hcl solution 20
mg/5 ml (4 mg/ml)
fluoxetine hcl tablet 10mg
fluphenazine decanoate
solution 25 mg/ml
fluphenazine hcl elixir 2.5
mg/5 ml
fluphenazine hcl solution 2.5
mg/ml
fluphenazine hcl tablet 10mg
fluphenazine hcl tablet 2.5mg
fluvoxamine maleate er
capsule er 24hr 100mg
fluvoxamine maleate er
fluvoxamine maleate tablet
100mg
25mg
2
LC
1
LC
1
LC
1
LC
/Límites
50mg
FORFIVO XL TABLET ER
24HR 450MG
GEODON FOR SOLUTION
20 MG/ML (FINAL
CONCENTRATION)
haloperidol decanoate solution
100 mg/ml
haloperidol decanoate solution
50 mg/ml
haloperidol lactate
concentrate 2 mg/ml
haloperidol lactate solution 5
mg/ml
haloperidol tablet 0.5mg
haloperidol tablet 10mg
imipramine hcl tablet 10mg
imipramine pamoate capsule
100mg
125mg
150mg
75mg
INVEGA SUSTENNA
SUSPENSION 117 MG/0.75
ML
2
1
1
LC
LC
1
LC
2
BvsD
2
2
BvsD
2
2
2
2
2
2
2
2
2
4
TE
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
41
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
INVEGA SUSTENNA
SUSPENSION 156 MG/ML
INVEGA SUSTENNA
ML
INVEGA SUSTENNA
ML
INVEGA SUSTENNA
ML
INVEGA TRINZA
ML
dia(s)
INVEGA TRINZA
ML
dia(s)
INVEGA TRINZA
ML
dia(s)
INVEGA TRINZA
ML
dia(s)
KHEDEZLA TABLET ER
24HR 100MG
KHEDEZLA TABLET ER
24HR 50MG
LATUDA TABLET 120MG
LATUDA TABLET 20MG
/Límites
LATUDA TABLET 40MG
LATUDA TABLET 60MG
LATUDA TABLET 80MG
loxapine capsule 10mg
maprotiline hcl tablet 25mg
MARPLAN TABLET 10MG
mirtazapine tablet 15mg
mirtazapine tablet 7.5mg
mirtazapine tablet disperse
15mg
30mg
45mg
molindone hcl tablet 10mg
4
4
4
4
4
4
4
4
LC; BvsD
LC; BvsD
LC; BvsD
LC; BvsD
4
TE
4
TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
2
2
2
2
2
2
2
4
1
LC
1
LC
1
LC
1
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
42
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
nefazodone hcl tablet 100mg
nortriptyline hcl capsule 10mg
nortriptyline hcl solution 10
mg/5 ml
olanzapine for solution 10mg
olanzapine odt tablet disperse
10mg
15mg
20mg
5mg
olanzapine tablet 10mg
olanzapine tablet 2.5mg
/Límites
2
2
2
2
2
1
1
1
1
olanzapine tablet 7.5mg
olanzapine-fluoxetine hcl
capsule 12-25mg
capsule 12-50mg
capsule 3-25mg
capsule 6-25mg
capsule 6-50mg
paliperidone er tablet er 24hr
1.5mg
3mg
6mg
9mg
paroxetine cr tablet er 24hr
12.5mg
paroxetine cr tablet er 24hr
25mg
paroxetine er tablet er 24hr
37.5mg
paroxetine hcl tablet 10mg
2
2
BvsD
2
LC
2
LC
2
LC
2
LC
1
LC
1
LC
1
LC
1
LC
1
LC
1
LC
2
2
2
2
2
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
2
LC
2
LC
2
LC
1
LC
43
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
PAXIL SUSPENSION 10
MG/5 ML
perphenazine tablet 16mg
PEXEVA TABLET 10MG
PEXEVA TABLET 20MG
PEXEVA TABLET 30MG
PEXEVA TABLET 40MG
phenelzine sulfate tablet 15mg
pimozide tablet 1mg
pimozide tablet 2mg
PRISTIQ ER TABLET ER
24HR 100MG
24HR 25MG
24HR 50MG
protriptyline hcl tablet 10mg
protriptyline hcl tablet 5mg
quetiapine fumarate tablet
100mg
1
LC
1
LC
1
LC
/Límites
200mg
25mg
300mg
400mg
50mg
REXULTI TABLET 0.25MG
REXULTI TABLET 0.5MG
REXULTI TABLET 1MG
REXULTI TABLET 2MG
REXULTI TABLET 3MG
REXULTI TABLET 4MG
RISPERDAL CONSTA FOR
ML
4
2
2
2
2
4
4
4
4
2
TE
TE
TE
TE
2
LC
2
LC
4
LC; TE
4
LC; TE
4
LC; TE
2
2
1
1
LC
1
LC
1
LC
1
LC
1
LC
5
LC; TE
5
LC; TE
5
LC; TE
5
LC; TE
5
LC; TE
5
LC; TE
4
4
LC
44
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ML
risperidone odt tablet disperse
0.25mg
0.5mg
1mg
2mg
3mg
4mg
risperidone solution 1 mg/ml
dia(s)
risperidone tablet 0.25mg
risperidone tablet 0.5mg
risperidone tablet 1mg
/Límites
SAPHRIS TAB
SUBLINGUAL 2.5MG
SAPHRIS TAB
SUBLINGUAL 5MG
selegiline hcl capsule 5mg
selegiline hcl tablet 5mg
SEROQUEL XR TABLET
ER 24HR 150MG
SEROQUEL XR TABLET
ER 24HR 200MG
SEROQUEL XR TABLET
ER 24HR 300MG
SEROQUEL XR TABLET
ER 24HR 400MG
SEROQUEL XR TABLET
ER 24HR 50MG
sertraline hcl concentrate 20
mg/ml
dia(s)
sertraline hcl tablet 100mg
4
4
2
LC
2
LC
2
2
2
2
2
LC
LC
LC
LC
LC
1
LC
1
LC
1
LC
1
LC
1
LC
1
LC
4
LC; TE
4
LC; TE
2
2
3
LC
3
LC
3
LC
3
LC
3
LC
2
LC
1
LC
45
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
thioridazine hcl tablet 100mg
thiothixene capsule 10mg
tranylcypromine sulfate tablet
10mg
trazodone hcl tablet 100mg
trifluoperazine hcl tablet
10mg
trifluoperazine hcl tablet 1mg
trimipramine maleate capsule
100mg
25mg
50mg
TRINTELLIX TABLET
10MG
TRINTELLIX TABLET
20MG
TRINTELLIX TABLET 5MG
1
LC
1
LC
2
2
2
2
2
2
2
2
AP
AP
AP
AP
/Límites
venlafaxine hcl er capsule er
24hr 150mg
24hr 37.5mg
24hr 75mg
venlafaxine hcl tablet 100mg
venlafaxine hcl tablet 37.5mg
VERSACLOZ SUSPENSION
50 MG/ML
dia(s)
VIIBRYD KIT 10 MG (7)-20
MG (23)
VIIBRYD TABLET 10MG
VIIBRYD TABLET 20MG
VIIBRYD TABLET 40MG
VRAYLAR CAP THER
PACK 1.5 MG (1)-3 MG (6)
VRAYLAR CAPSULE
1.5MG
VRAYLAR CAPSULE 3MG
VRAYLAR CAPSULE
4.5MG
VRAYLAR CAPSULE 6MG
2
1
1
1
1
2
2
2
2
2
2
2
4
TE
4
TE
4
TE
2
2
2
2
2
2
2
2
5
LC; AP
4
LC; TE
4
4
4
TE
TE
TE
4
LC; TE
5
LC; TE
5
LC; TE
5
LC; TE
5
LC; TE
46
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
ZELAPAR TABLET
4
DISPERSE 1.25MG
ziprasidone hcl capsule 20mg
2 LC
2 LC
2 LC
2 LC
ZYPREXA RELPREVV FOR
5 BvsD
SUSPENSION 210MG
ANALGÉSICOS Y ANTIPIRÉTICOS
ABSTRAL TAB
SUBLINGUAL 100 MCG
4 LC; AP; NM
ABSTRAL TAB
SUBLINGUAL 200 MCG
4 LC; AP; NM
ABSTRAL TAB
SUBLINGUAL 300 MCG
4 LC; AP; NM
ABSTRAL TAB
SUBLINGUAL 400 MCG
4 LC; AP; NM
ABSTRAL TAB
SUBLINGUAL 600 MCG
4 LC; AP; NM
ABSTRAL TAB
SUBLINGUAL 800 MCG
4 LC; AP; NM
acetaminophen-codeine tablet
300-15mg
2 LC; NM
300-30mg
300-60mg
ascomp with codeine capsule
30-50-325-40mg
buprenorphine hcl solution 0.3
mg/ml
buprenorphine hcl tab
sublingual 2mg
buprenorphine hcl tab
sublingual 8mg
buprenorphine-naloxone tab
sublingual 2-0.5mg
buprenorphine-naloxone tab
sublingual 8-2mg
butalb-acetaminoph-caffcodein capsule 50-300-4030mg
butalb-caff-acetaminophcodein capsule 50-325-4030mg
butalbital compound-codeine
capsule 30-50-325-40mg
butalbital-acetaminophencaffe capsule 50-300-40mg
2
LC; NM
2
LC; NM
2
LC; NM
2
BvsD; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
47
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
butalbital-acetaminophencaffe capsule 50-325-40mg
butalbital-acetaminophencaffe tablet 50-325-40mg
butalbital-aspirin-caffeine
capsule 50-325-40mg
butorphanol tartrate solution
10 mg/ml
dia(s)
CAMBIA PACKET 50MG
CAPITAL W-CODEINE
SUSPENSION 120 MG-12
MG/5 ML
celecoxib capsule 100mg
codeine sulfate tablet 15mg
diclofenac potassium tablet
50mg
diclofenac sodium er tablet er
24hr 100mg
diclofenac sodium gel 1 %
diclofenac sodium solution 1.5
%
2
diclofenac sodium tablet dr
25mg
50mg
75mg
diclofenac sodium-misoprostol
tablet dr 50 mg-200 mcg
diclofenac sodium-misoprostol
tablet dr 75 mg-200 mcg
diflunisal tablet 500mg
DUEXIS TABLET 80026.6MG
duramorph solution 0.5 mg/ml
duramorph solution 1 mg/ml
endocet tablet 10-325mg
endocet tablet 5-325mg
endocet tablet 7.5-325mg
etodolac capsule 200mg
etodolac capsule 300mg
etodolac er tablet er 24hr
400mg
500mg
600mg
etodolac tablet 400mg
etodolac tablet 500mg
fenoprofen calcium capsule
400mg
LC; NM
2
LC; NM
2
LC; NM
2
/Límites
LC; NM
4
4
NM
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
2
2
2
NM
NM
NM
2
2
2
2
2
2
2
2
2
4
2
2
BvsD; NM
BvsD; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
2
2
2
2
2
2
2
2
48
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
fenoprofen calcium tablet
600mg
fentanyl citrate loz on a
handle 1,200 mcg
handle 1,600 mcg
handle 200 mcg
handle 400 mcg
handle 600 mcg
handle 800 mcg
fentanyl patch 72hr 100
mcg/hour
mcg/hour
mcg/hour
mcg/hour
mcg/hour
/Límites
FENTORA TABLET 100
MCG
FENTORA TABLET 200
MCG
FENTORA TABLET 400
MCG
FENTORA TABLET 600
MCG
FENTORA TABLET 800
MCG
FLECTOR PATCH 1.3 %
flurbiprofen tablet 100mg
flurbiprofen tablet 50mg
gabapentin capsule 100mg
gabapentin solution 250 mg/5
ml
gabapentin tablet 600mg
gabapentin tablet 800mg
GRALISE 30-DAY
STARTER PACK
2
2
2
2
2
2
2
LC; AP; NM
LC; AP; NM
LC; AP; NM
LC; AP; NM
LC; AP; NM
LC; AP; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
4
LC; AP; NM
4
LC; AP; NM
4
LC; AP; NM
4
LC; AP; NM
4
LC; AP; NM
4
LC; AP
2
2
1
LC
1
LC
1
LC
2
1
LC
1
LC
4
TE
49
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
GRALISE TABLET 300MG
GRALISE TABLET 600MG
HORIZANT TABLET ER
300MG
HORIZANT TABLET ER
600MG
hydrocodone-acetaminophen
tablet 10-325mg
tablet 2.5-325mg
tablet 5-325mg
tablet 7.5-325mg
hydrocodone-ibuprofen tablet
7.5-200mg
hydromorphone er tab 24hr
deter 12mg
deter 16mg
deter 32mg
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
1
LC; NM
2
LC; NM
1
LC; NM
1
LC; NM
2
LC; NM
2
LC; NM
2
LC; TE; NM
2
/Límites
deter 8mg
hydromorphone hcl solution
10 mg/ml
hydromorphone hcl tablet 2mg
ibuprofen tablet 400mg
KADIAN CAPSULE ER
24HR 200MG
ketoprofen capsule 50mg
ketoprofen capsule 75mg
ketoprofen capsule er 24hr
200mg
LAZANDA SOLUTION 100
MCG/SPRAY
MCG/SPRAY
MCG/SPRAY
levorphanol tartrate tablet
2mg
meclofenamate sodium
capsule 100mg
LC; TE; NM
2
LC; TE; NM
2
BvsD
2
LC; NM
2
LC; NM
2
LC; NM
1
1
1
4
LC; TE; NM
2
2
2
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
2
NM
2
50
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
meclofenamate sodium
capsule 50mg
mefenamic acid capsule
250mg
meloxicam suspension 7.5
mg/5 ml
meloxicam tablet 15mg
meloxicam tablet 7.5mg
methadone hcl solution 10
mg/5 ml
methadone hcl solution 5 mg/5
ml
methadone hcl tablet 10mg
methadone hcl tablet 5mg
morphine sulfate er capsule er
24hr 100mg
24hr 10mg
24hr 120mg
24hr 20mg
24hr 30mg
24hr 30mg
24hr 45mg
/Límites
24hr 50mg
24hr 60mg
24hr 60mg
24hr 75mg
24hr 80mg
24hr 90mg
morphine sulfate er tablet er
100mg
15mg
200mg
30mg
60mg
morphine sulfate solution 10
mg/5 ml
2
2
2
1
1
2
NM
2
NM
2
2
NM
NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
NM
51
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
mg/ml
mg/5 ml (20 mg/ml)
mg/ml
mg/5 ml (4 mg/ml)
mg/ml
mg/ml
morphine sulfate tablet 15mg
morphine sulfate tablet 30mg
nabumetone tablet 500mg
nabumetone tablet 750mg
NAPRELAN TABLET ER
24HR 750MG
naproxen sodium cr tablet er
24hr 375mg
naproxen sodium cr tablet er
24hr 500mg
naproxen sodium tablet
275mg
naproxen sodium tablet
550mg
naproxen suspension 125
mg/5 ml
naproxen tablet 250mg
naproxen tablet dr 375mg
naproxen tablet dr 500mg
oxaprozin tablet 600mg
2
BvsD; NM
2
NM
2
BvsD; NM
2
NM
2
BvsD; NM
2
BvsD; NM
2
LC; NM
2
LC; NM
/Límites
oxycodone hcl capsule 5mg
oxycodone hcl concentrate 20
mg/ml
oxycodone hcl er tab 12hr
deter 10mg
deter 15mg
deter 20mg
deter 30mg
deter 40mg
deter 60mg
deter 80mg
oxycodone hcl solution 5 mg/5
ml
oxycodone hcl tablet 10mg
2
2
4
2
2
1
1
2
1
1
1
2
2
2
2
LC; NM
2
NM
2
LC; TE; NM
2
LC; TE; NM
2
LC; TE; NM
2
LC; TE; NM
2
LC; TE; NM
2
LC; TE; NM
2
LC; TE; NM
2
NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
52
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
oxycodone hcl-aspirin tablet
4.8355-325mg
oxycodone hcl-ibuprofen
tablet 400-5mg
oxycodone-acetaminophen
solution 5 mg-325 mg/5 ml
dia(s)
tablet 10-325mg
tablet 2.5-325mg
tablet 5-325mg
tablet 7.5-325mg
oxymorphone hcl er tablet er
12hr 10mg
12hr 15mg
12hr 20mg
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
12hr 30mg
12hr 40mg
12hr 5mg
12hr 7.5mg
oxymorphone hcl tablet 10mg
oxymorphone hcl tablet 5mg
PENNSAID SOLUTION 20
MG/GRAM PER
ACTUATION (2 %)
piroxicam capsule 10mg
piroxicam capsule 20mg
reprexain tablet 10-200mg
SUBOXONE FILM 12-3MG
SUBOXONE FILM 2-0.5MG
SUBOXONE FILM 4-1MG
SUBOXONE FILM 8-2MG
sulindac tablet 150mg
sulindac tablet 200mg
SYNALGOS-DC CAPSULE
16-356.4-30MG
LC; NM
2
2
/Límites
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; TE; NM
2
LC; TE; NM
4
2
2
4
LC; NM
4
LC; NM
4
LC; NM
4
LC; NM
4
LC; NM
2
2
4
NM
53
Medicamento
Nivel Requisitos
Medicamento
/Límites
tolmetin sodium capsule
400mg
tolmetin sodium tablet 600mg
tramadol hcl er capsule er
24hr 100mg
24hr 200mg
24hr 300mg
tramadol hcl er tablet er 24hr
100mg
200mg
300mg
tramadol hcl tablet 50mg
tramadol hcl-acetaminophen
tablet 37.5-325mg
VIMOVO TABLET DR 37520MG
VIMOVO TABLET DR 50020MG
ZOHYDRO ER CAP 12HR
DETER 10MG
/Límites
ZOHYDRO ER CAP 12HR
DETER 15MG
4 LC; TE; NM
ZOHYDRO ER CAP 12HR
DETER 20MG
4 LC; TE; NM
ZOHYDRO ER CAP 12HR
DETER 30MG
4 LC; TE; NM
ZOHYDRO ER CAP 12HR
DETER 40MG
4 LC; TE; NM
ZOHYDRO ER CAP 12HR
DETER 50MG
4 LC; TE; NM
ZUBSOLV TAB
SUBLINGUAL 1.4-0.36MG
4 LC; NM
ZUBSOLV TAB
4 LC; NM
ZUBSOLV TAB
4 LC; NM
ZUBSOLV TAB
4 LC; NM
ZUBSOLV TAB
4 LC; NM
ANOREXIGENICSRESPIR., ESTIMULANTE
CEREBRAL
armodafinil tablet 150mg
2 LC; AP
2
2
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
4
LC; TE
4
LC; TE
4
LC; TE; NM
Nivel Requisitos
54
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
DAYTRANA PATCH 10
MG/9 HOUR
DAYTRANA PATCH 15
MG/9 HOUR
DAYTRANA PATCH 20
MG/9 HOUR
DAYTRANA PATCH 30
MG/9 HOUR
dexmethylphenidate hcl er
2
LC; AP
2
LC; AP
2
LC; AP
4
LC
4
LC
4
LC
4
LC
2
LC
2
LC
2
LC
2
LC
2
LC
/Límites
capsule er 24hr 5mg
dextroamphetamine sulfate er
capsule er 24hr 5mg
dextroamphetamine-amphet er
capsule er 24hr 5mg
dextroamphetamineamphetamine tablet 10mg
dextroamphetamineamphetamine tablet 12.5mg
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
55
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
dextroamphetamineamphetamine tablet 7.5mg
EVEKEO TABLET 10MG
EVEKEO TABLET 5MG
FOCALIN XR CAPSULE ER
24HR 10MG
24HR 25MG
24HR 35MG
METHYLIN TABLET
CHEWABLE 10MG
METHYLIN TABLET
CHEWABLE 2.5MG
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
4
/Límites
METHYLIN TABLET
CHEWABLE 5MG
methylphenidate er capsule er
24hr 40mg
methylphenidate er tablet er
10mg
20mg
24hr 18mg
24hr 27mg
24hr 36mg
24hr 54mg
methylphenidate hcl cd
capsule er 10mg
capsule er 30mg
capsule er 50mg
capsule er 60mg
LC
4
LC
4
LC
4
LC
4
LC
4
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
56
Medicamento
Nivel Requisitos
Medicamento
/Límites
methylphenidate hcl solution
10 mg/5 ml
dia(s)
methylphenidate hcl solution 5
mg/5 ml
dia(s)
methylphenidate hcl tablet
10mg
20mg
5mg
chewable 10mg
chewable 2.5mg
chewable 5mg
methylphenidate la capsule er
24hr 20mg
modafinil tablet 100mg
modafinil tablet 200mg
NUVIGIL TABLET 150MG
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC; AP
2
LC; AP
4
LC; AP
Nivel Requisitos
/Límites
4 LC; AP
4 LC; AP
NUVIGIL TABLET 50MG
4 LC; AP
VYVANSE CAPSULE 10MG
4 LC
4 LC
4 LC
4 LC
4 LC
4 LC
4 LC
ANSIOLÍTICOS, SEDANTES E HIPNÓTICOS
buspirone hcl tablet 10mg
1
1
1
1
buspirone hcl tablet 7.5mg
1
eszopiclone tablet 1mg
2 LC; TE
2 LC; TE
2 LC; TE
HETLIOZ CAPSULE 20MG
5 LC; AP
57
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
hydroxyzine hcl tablet 10mg
2
2
2
ROZEREM TABLET 8MG
3
zaleplon capsule 10mg
2
zaleplon capsule 5mg
2
zolpidem tartrate tablet 10mg
2
zolpidem tartrate tablet 5mg
2
ANTAGONISTAS OPIÁCEOS
EVZIO SOLN AUTO-INJ 0.4
MG/0.4 ML
4
dia(s)
naloxone hcl solution 0.4
2
mg/ml
naloxone hcl solution 1 mg/ml
2
naltrexone hcl tablet 50mg
2
NARCAN LIQUID 4
MG/ACTUATION
4
LC 0.4 cada 365 dia(s)
ANTICONVULSANTES
APTIOM TABLET 200MG
4
APTIOM TABLET 400MG
4
APTIOM TABLET 600MG
4
APTIOM TABLET 800MG
4
/Límites
BANZEL SUSPENSION 40
MG/ML
BANZEL TABLET 200MG
BANZEL TABLET 400MG
carbamazepine er capsule er
12hr 100mg
12hr 200mg
12hr 300mg
carbamazepine er tablet er
12hr 100mg
12hr 200mg
12hr 400mg
carbamazepine suspension
100 mg/5 ml
carbamazepine tablet 200mg
carbamazepine tablet
chewable 100mg
CELONTIN CAPSULE
300MG
CEREBYX SOLUTION 500
MG PE/10 ML
dia(s)
DILANTIN CAPSULE
100MG
DILANTIN CAPSULE 30MG
DILANTIN TABLET
CHEWABLE 50MG
DILANTIN-125
LC
LC
LC
LC
LC
LC; AP
BvsD
BvsD
LC
LC; TE
LC; TE
LC; TE
LC; TE
4
4
4
2
2
2
2
2
2
2
1
1
4
4
LC; BvsD
3
3
3
3
58
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
divalproex sodium 125 mg cap
divalproex sodium er tablet er
24hr 250mg
divalproex sodium er tablet er
24hr 500mg
divalproex sodium tablet dr
125mg
250mg
500mg
epitol tablet 200mg
EQUETRO CAPSULE ER
12HR 100MG
EQUETRO CAPSULE ER
12HR 200MG
EQUETRO CAPSULE ER
12HR 300MG
ethosuximide capsule 250mg
ethosuximide solution 250
mg/5 ml
felbamate suspension 600
mg/5 ml
felbamate tablet 400mg
felbamate tablet 600mg
FYCOMPA SUSPENSION
0.5 MG/ML
dia(s)
FYCOMPA TABLET 10MG
FYCOMPA TABLET 12MG
FYCOMPA TABLET 2MG
/Límites
2
FYCOMPA TABLET 4MG
FYCOMPA TABLET 6MG
FYCOMPA TABLET 8MG
GABITRIL TABLET 12MG
GABITRIL TABLET 16MG
LAMICTAL (BLUE) KIT 25
MG (35 TABS)
LAMICTAL (GREEN) KIT
25 MG (84)-100 MG (14)
LAMICTAL (ORANGE) KIT
25 MG (42)-100 MG (7)
LAMICTAL ODT TABLET
DISPERSE 100MG
LAMICTAL ODT TABLET
DISPERSE 200MG
LAMICTAL ODT TABLET
DISPERSE 25MG
LAMICTAL ODT TABLET
DISPERSE 50MG
LAMICTAL XR (BLUE) KIT
25 MG (21)-50 MG (7)
2
2
2
2
2
1
4
4
4
2
2
2
2
2
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
4
4
4
4
LC
4
LC
4
LC
4
LC
4
59
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
LAMICTAL XR (GREEN)
KIT 50 MG (14)-100 MG
(14)-200 MG (7)
LAMICTAL XR (ORANGE)
KIT 25 MG (14)-50 MG (14)100 MG (7)
lamotrigine er tablet er 24hr
100mg
200mg
250mg
25mg
300mg
50mg
lamotrigine odt tablet disperse
100mg
200mg
25mg
/Límites
50mg
lamotrigine tablet 100mg
lamotrigine tablet chewable
25mg
lamotrigine tablet chewable
5mg
levetiracetam er tablet er 24hr
500mg
levetiracetam er tablet er 24hr
750mg
levetiracetam solution 100
mg/ml
levetiracetam solution 500
mg/5 ml
levetiracetam tablet 1,000mg
levetiracetam tablet 250mg
levetiracetam-nacl solution
1,000 mg/100 ml
4
4
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
1
LC
1
LC
1
LC
1
LC
2
2
2
LC
2
LC
2
2
BvsD
2
LC
2
LC
2
LC
2
LC
2
BvsD
60
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
1,500 mg/100 ml
500 mg/100 ml
LYRICA CAPSULE 100MG
LYRICA CAPSULE 25MG
LYRICA CAPSULE 50MG
LYRICA CAPSULE 75MG
LYRICA SOLUTION 20
MG/ML
oxcarbazepine suspension 300
mg/5 ml
oxcarbazepine tablet 150mg
OXTELLAR XR TABLET
ER 24HR 150MG
2
BvsD
2
BvsD
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
/Límites
OXTELLAR XR TABLET
ER 24HR 300MG
OXTELLAR XR TABLET
ER 24HR 600MG
PEGANONE TABLET
250MG
PHENYTEK CAPSULE
200MG
PHENYTEK CAPSULE
300MG
phenytoin sodium extended
capsule 100mg
capsule 200mg
capsule 300mg
phenytoin suspension 125
mg/5 ml
phenytoin tablet chewable
50mg
POTIGA TABLET 200MG
POTIGA TABLET 300MG
POTIGA TABLET 400MG
POTIGA TABLET 50MG
SABRIL PACKET 500MG
SABRIL TABLET 500MG
SPRITAM 1,000 MG
TABLET
4
2
2
LC
2
LC
2
LC
4
LC
4
LC
4
LC
4
3
3
2
2
2
2
2
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; AP
4
LC; AP; AL
4
LC; TE
61
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
SPRITAM 250 MG TABLET
tiagabine hcl tablet 2mg
tiagabine hcl tablet 4mg
topiramate cap sprinkle 15mg
topiramate cap sprinkle 25mg
topiramate er cp24 sprinkle
100mg
150mg
200mg
25mg
50mg
topiramate tablet 100mg
4
LC; TE
4
LC; TE
4
LC; TE
2
LC
2
LC
/Límites
TROKENDI XR CAPSULE
ER 24HR 100MG
TROKENDI XR CAPSULE
ER 24HR 200MG
TROKENDI XR CAPSULE
ER 24HR 25MG
TROKENDI XR CAPSULE
ER 24HR 50MG
valproate sodium solution 500
mg/5 ml (100 mg/ml)
valproic acid capsule 250mg
valproic acid syrup 250 mg/5
ml
VIMPAT SOLUTION 10
MG/ML
VIMPAT SOLUTION 200
MG/20 ML
VIMPAT TABLET 100MG
VIMPAT TABLET 150MG
VIMPAT TABLET 200MG
VIMPAT TABLET 50MG
zonisamide capsule 100mg
2
2
2
2
LC; AP
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
1
LC
1
LC
1
LC
1
LC
3
LC; AP
3
LC; AP
3
LC; AP
3
LC; AP
2
BvsD
2
2
3
3
BvsD
3
LC
3
LC
3
LC
3
LC
2
62
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
BARBITUATES
phenobarbital elixir 20 mg/5
ml (4 mg/ml)
phenobarbital tablet 100mg
phenobarbital tablet 16.2mg
primidone tablet 250mg
primidone tablet 50mg
BENZODIAZEPINAS
alprazolam er tablet er 24hr
1mg
2mg
3mg
ALPRAZOLAM INTENSOL
CONCENTRATE 1 MG/ML
alprazolam odt tablet disperse
0.25mg
0.5mg
1mg
2mg
alprazolam tablet 0.25mg
alprazolam tablet 0.5mg
alprazolam tablet 1mg
/Límites
2
2
alprazolam tablet 2mg
alprazolam xr tablet er 24hr
0.5mg
clonazepam tablet 0.5mg
clonazepam tablet 1mg
clonazepam tablet 2mg
clonazepam tablet disperse
0.125mg
0.25mg
0.5mg
1mg
2mg
clorazepate dipotassium tablet
15mg
3.75mg
7.5mg
diazepam concentrate 5 mg/ml
diazepam gel 12.5-15-17.520mg
diazepam gel 2.5mg
diazepam gel 5-7.5-10mg
diazepam solution 5 mg/5 ml
(1 mg/ml)
diazepam tablet 10mg
diazepam tablet 2mg
diazepam tablet 5mg
lorazepam intensol
concentrate 2 mg/ml
lorazepam tablet 0.5mg
lorazepam tablet 1mg
2
2
2
2
2
2
2
2
2
1
1
2
2
2
2
2
2
2
2
1
1
1
1
2
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
2
1
1
63
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
lorazepam tablet 2mg
1
ONFI SUSPENSION 2.5
4
MG/ML
ONFI TABLET 10MG
4
ONFI TABLET 20MG
4
temazepam capsule 15mg
1 LC
temazepam capsule 22.5mg
1 LC
temazepam capsule 30mg
1 LC
temazepam capsule 7.5mg
1 LC
triazolam tablet 0.125mg
2
triazolam tablet 0.25mg
2
AGENTES TERAPÉUTICOS MISCELÁNEOS
AGENTES ANTIGOTA (ÁCIDO ÚRICO)
allopurinol tablet 100mg
1
allopurinol tablet 300mg
1
colchicine capsule 0.6mg
2 LC
colchicine tablet 0.6mg
2 LC
ULORIC TABLET 40MG
3 LC; TE
ULORIC TABLET 80MG
3 LC; TE
AGENTES ANTIRREUMÁTICOS
MODIFICADORES DE LA ENFERMEDAD
ACTEMRA SOLN PREF
SYR 162 MG/0.9 ML
5 LC; AP
dia(s)
ACTEMRA SOLUTION 200
MG/10 ML (20 MG/ML)
dia(s)
ACTEMRA SOLUTION 400
MG/20 ML (20 MG/ML)
dia(s)
ACTEMRA SOLUTION 80
MG/4 ML (20 MG/ML)
dia(s)
CIMZIA KIT 400 MG (200
MG X 2)
LC 6 cada 28 dia(s)
CIMZIA KIT 400 MG/2 ML
(200 MG/ML X 2)
LC 6 cada 28 dia(s)
ENBREL FOR SOLUTION
25 MG (1 ML)
LC 8 cada 28 dia(s)
ENBREL SOLN AUTO-INJ
50 MG/ML (0.98 ML)
dia(s)
ENBREL SOLN PREF SYR
25 MG/0.5 ML (0.51 ML)
dia(s)
ENBREL SOLN PREF SYR
50 MG/ML (0.98 ML)
dia(s)
HUMIRA PEDIATRIC
CROHN'S PREFILL SYR
KIT 40 MG/0.8 ML
LC 3 cada 28 dia(s)
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
64
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
HUMIRA PEDIATRIC
CROHN'S PREFILL SYR
KIT 40 MG/0.8 ML
LC 6 cada 28 dia(s)
HUMIRA PEN CROHN'SUC-HS PEN-INJ KIT 40
MG/0.8 ML
LC 6 cada 28 dia(s)
HUMIRA PEN PEN-INJ KIT
40 MG/0.8 ML
LC 2 cada 28 dia(s)
HUMIRA PREFILL SYR KIT
10 MG/0.2 ML
LC 2 cada 28 dia(s)
20 MG/0.4 ML
LC 2 cada 28 dia(s)
40 MG/0.8 ML
LC 6 cada 28 dia(s)
KINERET SOLN PREF SYR
100 MG/0.67 ML
dia(s)
leflunomide tablet 10mg
leflunomide tablet 20mg
ORENCIA FOR SOLUTION
250MG
ORENCIA SOLN PREF SYR
125 MG/ML
dia(s)
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
/Límites
OTEZLA TAB THER PACK
10 MG (4)-20 MG (4)-30 MG
(47)
OTEZLA TABLET 30MG
REMICADE FOR
SOLUTION 100MG
SIMPONI ARIA SOLUTION
50 MG/4 ML (12.5 MG/ML)
dia(s)
SIMPONI SOLN AUTO-INJ
100 MG/ML
dia(s)
SIMPONI SOLN AUTO-INJ
50 MG/0.5 ML
dia(s)
SIMPONI SOLN PREF SYR
100 MG/ML
dia(s)
SIMPONI SOLN PREF SYR
50 MG/0.5 ML
dia(s)
TALTZ AUTOINJECTOR
SOLN AUTO-INJ 80 MG/ML
dia(s)
TALTZ SYRINGE SOLN
PREF SYR 80 MG/ML
dia(s)
2
2
5
5
LC; AP
LC; AP
5
LC; AP
5
LC; AP
5
AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
65
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
XELJANZ TABLET 5MG
5 LC; AP
XELJANZ XR TABLET ER
24HR 11MG
5 LC; AP
AGENTES INMUNOSUPRESORES
ASTAGRAF XL CAPSULE
4 BvsD
ER 24HR 0.5MG
ASTAGRAF XL CAPSULE
4 BvsD
ER 24HR 1MG
ASTAGRAF XL CAPSULE
4 BvsD
ER 24HR 5MG
ATGAM INJECTABLE 50
5 BvsD
MG/ML
AZASAN TABLET 100MG
3 BvsD
AZASAN TABLET 75MG
3 BvsD
azathioprine tablet 50mg
2 BvsD
BENLYSTA FOR
5 AP
SOLUTION 120MG
BENLYSTA FOR
5 AP
SOLUTION 400MG
cyclosporine capsule 100mg
2 BvsD
cyclosporine capsule 25mg
2 BvsD
cyclosporine modified capsule
2 BvsD
100mg
2 BvsD
25mg
2 BvsD
50mg
cyclosporine solution 100
2 BvsD
mg/ml
cyclosporine solution 250
2 BvsD
mg/5 ml
gengraf capsule 100mg
2 BvsD
gengraf capsule 25mg
2 BvsD
gengraf solution 100 mg/ml
mycophenolate mofetil capsule
250mg
mycophenolate mofetil for
suspension 200 mg/ml
mycophenolate mofetil tablet
500mg
mycophenolic acid tablet dr
180mg
mycophenolic acid tablet dr
360mg
NULOJIX FOR SOLUTION
250MG
RAPAMUNE SOLUTION 1
MG/ML
SANDIMMUNE SOLUTION
100 MG/ML
sirolimus tablet 0.5mg
sirolimus tablet 1mg
sirolimus tablet 2mg
tacrolimus capsule 0.5mg
tacrolimus capsule 1mg
tacrolimus capsule 5mg
ZORTRESS TABLET
0.25MG
ZORTRESS TABLET 0.5MG
ZORTRESS TABLET
0.75MG
AGENTES PROTECTORES
amifostine for solution 500mg
MESNEX TABLET 400MG
ANTÍDOTOS
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
BvsD
5
AP
3
BvsD
3
BvsD
2
2
2
2
2
2
BvsD
BvsD
BvsD
BvsD
BvsD
BvsD
4
LC; BvsD
4
LC; BvsD
4
LC; BvsD
5
3
AP
66
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
acetylcysteine solution 100
2 BvsD
mg/ml (10 %)
acetylcysteine solution 200
2 BvsD
mg/ml (20 %)
leucovorin calcium for
2 BvsD
solution 100mg
leucovorin calcium for
2 BvsD
solution 350mg
leucovorin calcium tablet
2
10mg
2
15mg
2
25mg
leucovorin calcium tablet 5mg
2
DISUASIVOS DE ALCOHOL
disulfiram tablet 500mg
2 LC
INHIBIDORES DE LA 5-ALFA REDUCTASA
dutasteride capsule 0.5mg
2
finasteride tablet 5mg
2
INHIBIDORES DE LA REABSORCIÓN DE
HUESO
alendronate sodium tablet
10mg
1 LC
35mg
1 LC
LC 4 cada 28 dia(s)
40mg
1 LC
5mg
1 LC
70mg
1 LC
LC 4 cada 28 dia(s)
etidronate disodium tablet
200mg
etidronate disodium tablet
400mg
ibandronate sodium solution 3
mg/3 ml
ibandronate sodium tablet
150mg
LC 1 cada 28 dia(s)
pamidronate disodium
solution 30 mg/10 ml (3
mg/ml)
mg/ml)
mg/ml)
PROLIA SOLUTION 60
MG/ML
dia(s)
risedronate sodium dr tablet
dr 35mg
risedronate sodium tablet
150mg
LC 1 cada 28 dia(s)
30mg
35mg
35mg
LC 4 cada 28 dia(s)
risedronate sodium tablet 5mg
2
2
2
BvsD
2
LC
4
BvsD
4
BvsD
4
BvsD
4
LC; AP
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
67
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
XGEVA SOLUTION 120
5 AP
MG/1.7 ML (70 MG/ML)
zoledronic acid concentrate 4
2 BvsD
mg/5 ml
zoledronic acid solution 5
2 BvsD
mg/100 ml
ZOMETA SOLUTION 4
5 BvsD
MG/100 ML
INHIBIDORES DEL COMPLEMENTO
CINRYZE FOR SOLUTION
500 UNIT (5 ML)
5 LC; AP
FIRAZYR SOLUTION 30
MG/3 ML
5 LC; AP
dia(s)
MODIFICADORES DE RESPUESTA
BIOLÓGICA
ACTIMMUNE SOLUTION
100 MCG (2 MILLION
5 AP
UNIT)/0.5 ML
AUBAGIO TABLET 14MG
5 LC; AP
AUBAGIO TABLET 7MG
5 LC; AP
AVONEX KIT 30 MCG (1
ML)
5 LC
LC 4 cada 30 dia(s)
AVONEX PEN AUTO-INJ
KIT 30 MCG/0.5 ML
5 LC
LC 4 cada 30 dia(s)
AVONEX PREFILL SYR
KIT 30 MCG/0.5 ML
5 LC
LC 4 cada 30 dia(s)
BETASERON KIT 0.3MG
COPAXONE SOLN PREF
SYR 20 MG/ML
dia(s)
COPAXONE SOLN PREF
SYR 40 MG/ML
dia(s)
EXTAVIA KIT 0.3MG
GILENYA CAPSULE 0.5MG
PLEGRIDY PEN SOLN
PEN-INJ 125 MCG/0.5 ML
dia(s)
PLEGRIDY PEN SOLN
PEN-INJ 63 MCG/0.5 ML
(1)-94 MCG/0.5 ML (1)
dia(s)
PLEGRIDY SOLN PREF
SYR 125 MCG/0.5 ML
dia(s)
PLEGRIDY SOLN PREF
SYR 63 MCG/0.5 ML (1)-94
MCG/0.5 ML (1)
dia(s)
REBIF REBIDOSE SOLN
AUTO-INJ 22 MCG/0.5 ML
dia(s)
5
LC; AP
5
LC
5
LC
5
LC
5
LC
5
LC
5
LC
5
LC
5
LC
5
LC; AP
68
Medicamento
Nivel Requisitos
Medicamento
/Límites
REBIF REBIDOSE SOLN
AUTO-INJ 44 MCG/0.5 ML
dia(s)
REBIF REBIDOSE SOLN
AUTO-INJ 8.8 MCG/0.2 ML
(6) - 22 MCG/0.5 ML (6)
dia(s)
REBIF SOLN PREF SYR 22
MCG/0.5 ML
dia(s)
REBIF SOLN PREF SYR 44
MCG/0.5 ML
dia(s)
REBIF SOLN PREF SYR 8.8
MCG/0.2 ML (6) - 22
MCG/0.5 ML (6)
dia(s)
TECFIDERA CAPSULE DR
120MG
TECFIDERA CAPSULE DR
240MG
TECFIDERA STARTER
PACK
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC
5
LC
5
LC
Nivel Requisitos
/Límites
THALOMID CAPSULE
100MG
3 LC
THALOMID CAPSULE
150MG
3 LC
THALOMID CAPSULE
200MG
3 LC
THALOMID CAPSULE
50MG
3 LC
TYSABRI CONCENTRATE
300 MG/15 ML
5 LC; AP
dia(s)
OTROS AGENTES TERAPÉUTICOS
MISCELÁNEOS
AMPYRA TABLET ER
12HR 10MG
5 LC; AP
ARCALYST FOR
5 AP
SOLUTION 220MG
CYSTADANE POWDER 1
4
GRAM/1.7 ML
CYSTAGON CAPSULE
4
150MG
CYSTAGON CAPSULE
4
50MG
CYSTARAN SOLUTION
0.44 %
4 LC; AP
dia(s)
DEMSER CAPSULE 250MG
4
desmopressin acetate solution
0.1 mg/ml
2 LC
dia(s)
69
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
10 mcg/spray (0.1 ml)
dia(s)
4 mcg/ml
desmopressin acetate tablet
0.1mg
desmopressin acetate tablet
0.2mg
ELMIRON CAPSULE
100MG
GLUCAGEN FOR
SOLUTION 1MG
GLUCAGON EMERGENCY
KIT KIT 1MG
GRASTEK TAB
SUBLINGUAL 2,800
BIOEQUIVALENT
ALLERGY UNIT
guanidine hcl tablet 125mg
H.P. ACTHAR GEL 80
UNIT/ML
ILARIS FOR SOLUTION 180
MG/1.2 ML (150 MG/ML)
LC 2 cada 28 dia(s)
KORLYM TABLET 300MG
KUVAN PACKET 100MG
KUVAN PACKET 500MG
KUVAN TABLET
SOLUBLE 100MG
2
LC
2
BvsD
/Límites
MYALEPT FOR SOLUTION
5 MG/ML (FINAL
CONCENTRATION)
LC 67.8 cada 30 dia(s)
octreotide acetate solution
1,000 mcg/ml
octreotide acetate solution 100
mcg/ml
mcg/ml
mcg/ml
mcg/ml
ORALAIR TAB
SUBLINGUAL 300 INDEX
OF REACTIVITY
ORFADIN CAPSULE 10MG
ORFADIN CAPSULE 2MG
ORFADIN CAPSULE 5MG
ORFADIN SUSPENSION 4
MG/ML
ORKAMBI TABLET 200125MG
RAGWITEK TAB
SUBLINGUAL 12 AMB A 1
UNIT
RAVICTI LIQUID 1.1
GRAM/ML
dia(s)
SENSIPAR TABLET 30MG
2
2
3
3
3
4
LC; AP
2
5
AP
5
LC; AP
5
LC; AP
5
5
5
5
LC; AP
5
AP
2
AP
2
AP
2
AP
5
AP
4
LC; AP
5
5
5
AP
AP
AP
5
AP
5
LC; AP
4
LC; AP
4
LC; AP
3
3
70
Medicamento
Nivel Requisitos
Medicamento
/Límites
SIGNIFOR LAR FOR
SUSPENSION 20MG
LC 2 cada 28 dia(s)
SIGNIFOR LAR FOR
SUSPENSION 40MG
LC 2 cada 28 dia(s)
SIGNIFOR LAR FOR
SUSPENSION 60MG
LC 2 cada 28 dia(s)
SIGNIFOR SOLUTION 0.3
MG/ML (1 ML)
dia(s)
MG/ML (1 ML)
dia(s)
MG/ML (1 ML)
dia(s)
SOMATULINE DEPOT
SOLUTION 120 MG/0.5 ML
SOMATULINE DEPOT
SOMATULINE DEPOT
STIMATE SOLUTION 150
MCG/SPRAY (0.1 ML)
STRENSIQ SOLUTION 40
MG/ML
dia(s)
/Límites
3
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
5
AP
5
AP
STRENSIQ SOLUTION 80
MG/0.8 ML
5 LC; AP; AL
dia(s)
ZAVESCA CAPSULE
100MG
5 LC; AP
ANTAGONISTAS DE METAL PESADO
ANTAGONISTAS DE METAL PESADO
CHEMET CAPSULE 100MG
4
DEPEN TABLET 250MG
4 AP
EXJADE TABLET
4 AL
SOLUBLE 125MG
EXJADE TABLET
4 AL
SOLUBLE 250MG
EXJADE TABLET
4 AL
SOLUBLE 500MG
FERRIPROX SOLUTION
4
100 MG/ML
FERRIPROX TABLET
4
500MG
JADENU TABLET 180MG
5 LC
JADENU TABLET 360MG
5 LC
JADENU TABLET 90MG
5 LC
SYPRINE CAPSULE 250MG 4 AP
BLOOD FORMATION,COAGULATION AND
THROMBOSIS
ANTITHROMBOTIC AGENTS
anagrelide hcl capsule 0.5mg
2
anagrelide hcl capsule 1mg
2
4
5
Nivel Requisitos
LC; AP; AL
71
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
aspirin-dipyridamole er
capsule er 12hr 25-200mg
BRILINTA TABLET 60MG
BRILINTA TABLET 90MG
cilostazol tablet 100mg
cilostazol tablet 50mg
clopidogrel tablet 300mg
LC 2 cada 30 dia(s)
clopidogrel tablet 75mg
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
EFFIENT TABLET 10MG
EFFIENT TABLET 5MG
ELIQUIS TABLET 2.5MG
ELIQUIS TABLET 5MG
enoxaparin sodium solution
100 mg/ml
120 mg/0.8 ml
/Límites
150 mg/ml
30 mg/0.3 ml
300 mg/3 ml
40 mg/0.4 ml
60 mg/0.6 ml
80 mg/0.8 ml
fondaparinux sodium solution
10 mg/0.8 ml
2.5 mg/0.5 ml
5 mg/0.4 ml
7.5 mg/0.6 ml
heparin sodium solution 1,000
unit/ml
heparin sodium solution
10,000 unit/ml
heparin sodium solution
20,000 unit/ml
heparin sodium solution 5,000
unit/ml
jantoven tablet 10mg
jantoven tablet 1mg
jantoven tablet 2.5mg
jantoven tablet 2mg
jantoven tablet 3mg
2
3
LC
3
LC
2
2
2
LC
1
LC
4
4
4
4
4
4
4
4
4
3
LC
3
LC
3
LC
3
LC
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
72
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
jantoven tablet 4mg
jantoven tablet 5mg
jantoven tablet 6mg
jantoven tablet 7.5mg
PRADAXA CAPSULE
110MG
PRADAXA CAPSULE
150MG
PRADAXA CAPSULE 75MG
SAVAYSA TABLET 15MG
SAVAYSA TABLET 30MG
SAVAYSA TABLET 60MG
warfarin sodium tablet 10mg
warfarin sodium tablet 2.5mg
warfarin sodium tablet 7.5mg
XARELTO TAB THER
PACK 15 MG (42)- 20 MG
(9)
XARELTO TABLET 10MG
XARELTO TABLET 15MG
/Límites
2
2
2
2
4
XARELTO TABLET 20MG
ZONTIVITY TABLET
2.08MG
HEMATOPOIETIC AGENTS
ARANESP SOLN PREF SYR
100 MCG/0.5 ML
150 MCG/0.3 ML
200 MCG/0.4 ML
25 MCG/0.42 ML
300 MCG/0.6 ML
40 MCG/0.4 ML
500 MCG/ML
60 MCG/0.3 ML
ARANESP SOLUTION 10
MCG/0.4 ML
ARANESP SOLUTION 100
MCG/ML
MCG/ML
ARANESP SOLUTION 25
MCG/ML
MCG/ML
ARANESP SOLUTION 40
MCG/ML
LC
4
LC
4
LC
4
LC
4
LC
4
LC
1
1
1
1
1
1
1
1
1
3
LC
3
LC
3
LC
3
LC
4
LC
5
BvsD
5
BvsD
5
BvsD
3
BvsD
5
BvsD
3
BvsD
5
BvsD
3
BvsD
3
BvsD
5
BvsD
5
BvsD
3
BvsD
5
BvsD
3
BvsD
73
Medicamento
Nivel Requisitos
Medicamento
/Límites
ARANESP SOLUTION 60
MCG/ML
EPOGEN SOLUTION 2,000
UNIT/ML
UNIT/2 ML
UNIT/ML
UNIT/ML
UNIT/ML
GRANIX SOLN PREF SYR
300 MCG/0.5 ML
GRANIX SOLN PREF SYR
480 MCG/0.8 ML
LEUKINE FOR SOLUTION
250 MCG
MIRCERA SOLN PREF SYR
100 MCG/0.3 ML
200 MCG/0.3 ML
50 MCG/0.3 ML
75 MCG/0.3 ML
MOZOBIL SOLUTION 24
MG/1.2 ML (20 MG/ML)
NEULASTA SOLN PREF
SYR 6 MG/0.6 ML
NEUPOGEN SOLN PREF
SYR 300 MCG/0.5 ML
NEUPOGEN SOLN PREF
SYR 480 MCG/0.8 ML
3
BvsD
4
BvsD
4
BvsD
5
BvsD
4
BvsD
4
BvsD
5
BvsD
5
BvsD
5
BvsD
4
BvsD
5
BvsD
4
BvsD
4
BvsD
/Límites
NEUPOGEN SOLUTION 300
5 BvsD
MCG/ML
NEUPOGEN SOLUTION 480
5 BvsD
MCG/1.6 ML
PROMACTA TABLET
12.5MG
5 LC; AP
PROMACTA TABLET
25MG
5 LC; AP
PROMACTA TABLET
50MG
5 LC; AP
ZARXIO SOLN PREF SYR
5 BvsD
300 MCG/0.5 ML
ZARXIO SOLN PREF SYR
5 BvsD
480 MCG/0.8 ML
HEMORRHEOLOGIC AGENTS
pentoxifylline tablet er 400mg
2
COMPUESTOS DE ORO
COMPUESTOS DE ORO
RIDAURA CAPSULE 3MG
4
DIURÉTICOS
ANTAGONISTAS DE LA VASOPRESINA
SAMSCA TABLET 15MG
4
SAMSCA TABLET 30MG
4
ELECTROLÍTICO, EQUILIBRIO CALÓRICO Y
EL AGUA
AGENTES ALCALINIZANTES
potassium citrate er tablet er
2
10 meq (1,080 mg)
potassium citrate er tablet er
2
15 meq (1,620 mg)
potassium citrate er tablet er 5
2
meq (540 mg)
sodium lactate solution 5
2 BvsD
meq/ml
5
5
BvsD
5
BvsD
5
BvsD
Nivel Requisitos
74
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
AGENTES CALÓRICOS
*amino acid electrolyte
infusion 8.5%***
*AMINO ACID INFUSION
8.5%***
amino acids solution 15 %
AMINOSYN II SOLUTION
10 %
AMINOSYN II SOLUTION 7
%
aminosyn ii with electrolytes
solution 8.5 %
AMINOSYN M SOLUTION
3.5 %
AMINOSYN WITH
ELECTROLYTES
SOLUTION 7 %
AMINOSYN-HBC
SOLUTION 7 %
AMINOSYN-PF SOLUTION
10 %
AMINOSYN-PF SOLUTION
7%
AMINOSYN-RF SOLUTION
5.2 %
CLINIMIX E SOLUTION
2.75 %
CLINIMIX E SOLUTION
4.25 %
CLINIMIX E SOLUTION 5
%
CLINIMIX SOLUTION 2.75
%
CLINIMIX SOLUTION 4.25
%
2
/Límites
CLINIMIX SOLUTION 5 %
clinisol solution 15 %
dextrose 10%-0.2% nacl
solution 10 %-0.2 %
solution 10 %-0.45 %
dextrose 2.5%-0.45% nacl
solution 2.5 %-0.45 %
solution 5 %-0.2 %
solution 5 %-0.2 %
solution 5 %-0.3 %
solution 5 %-0.45 %
solution 5 %-0.9 %
dextrose in water solution 10
%
dextrose in water solution 5 %
FREAMINE HBC
SOLUTION 6.9 %
HEPATAMINE SOLUTION
8%
NEPHRAMINE SOLUTION
5.4 %
nutrilipid emulsion 20 %
nutrilipid emulsion 20 %
PREMASOL SOLUTION 10
%
PREMASOL SOLUTION 6
%
BvsD
3
BvsD
2
BvsD
3
BvsD
3
BvsD
2
BvsD
3
BvsD
3
BvsD
3
BvsD
3
BvsD
3
BvsD
3
BvsD
3
BvsD
3
BvsD
3
BvsD
3
BvsD
3
BvsD
3
2
BvsD
BvsD
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
BvsD
3
BvsD
2
BvsD
3
BvsD
2
3
BvsD
BvsD
3
BvsD
2
BvsD
75
Medicamento
Nivel Requisitos
Medicamento
/Límites
Nivel Requisitos
/Límites
PROCALAMINE
3 BvsD
SOLUTION 3 %
PROSOL SOLUTION 20 %
3 BvsD
TRAVASOL SOLUTION 10
3 BvsD
%
TROPHAMINE SOLUTION
3 BvsD
10 %
AGENTES DE ELIMINACIÓN DE IONES
AURYXIA TABLET
210IRONMG
4 LC; TE
calcium acetate capsule
2
667mg
FOSRENOL PACKET
4
1,000MG
FOSRENOL PACKET
4
750MG
FOSRENOL TABLET
4
CHEWABLE 1,000MG
FOSRENOL TABLET
4
CHEWABLE 500MG
FOSRENOL TABLET
4
CHEWABLE 750MG
kionex powder
2
RENAGEL TABLET 400MG
4
RENAGEL TABLET 800MG
4
RENVELA TABLET 800MG
4
sodium polystyrene sulfonate
2
suspension 15 gram/60 ml
VELPHORO TABLET
CHEWABLE 500IRONMG
4 LC; TE
VELTASSA PACKET 16.8
GRAM
4 LC; TE
VELTASSA PACKET 25.2
GRAM
4 LC; TE
VELTASSA PACKET 8.4
GRAM
4 LC; TE
AGENTES URICOSÚRICOS
probenecid tablet 500mg
2
probenecid-colchicine tablet
2
0.5-500mg
DETOXICANTS DE AMONÍACO
CARBAGLU TABLET
5 AP
200MG
constulose solution 10
2
gram/15 ml
enulose solution 10 gram/15
2
ml
generlac solution 10 gram/15
2
ml
lactulose solution 10 gram/15
1
ml
sodium phenylbutyrate powder
2
0.94 gram/gram
PREPARATIVOS DE REEMPLAZO
dextrose 5%-0.2% nacl-kcl
2 BvsD
solution 20 meq/l
2 BvsD
solution 20 meq/l
2 BvsD
solution 20 meq/l
2 BvsD
solution 20 meq/l
dextrose 5%-1/2ns-kcl
2 BvsD
solution 10 meq/l
2 BvsD
solution 30 meq/l
76
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
solution 40 meq/l
dextrose 5%-ns-kcl solution
20 meq/l
dextrose 5%-ns-kcl solution
40 meq/l
dextrose 5%-potassium
chloride solution 20 meq/l
dextrose in lactated ringers
solution 5 %
IONOSOL B WITH
DEXTROSE 5% SOLUTION
5%
IONOSOL MB-DEXTROSE
5% SOLUTION 5 %
ISOLYTE P WITH
DEXTROSE SOLUTION 5 %
ISOLYTE S SOLUTION
klor-con 10 tablet er 10 meq
KLOR-CON M15 TABLET
ER 15 MEQ
klor-con m20 tablet er 20 meq
lactated ringers solution
magnesium sulfate solution 4
meq/ml (50 %)
NORMOSOL-M AND
NORMOSOL-R AND
NORMOSOL-R PH 7.4
SOLUTION
PLASMA-LYTE 148
SOLUTION
PLASMA-LYTE 56 IN
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
BvsD
3
BvsD
3
BvsD
3
BvsD
3
2
BvsD
/Límites
PLASMA-LYTE A PH 7.4
SOLUTION
potassium chl-normal saline
solution 20 meq/l
potassium chl-normal saline
solution 40 meq/l
potassium chloride capsule er
10 meq
potassium chloride capsule er
8 meq
potassium chloride in d5lr
solution 20 meq/l
potassium chloride solution 10
meq/100 ml
meq/ml
meq/100 ml
meq/15 ml
meq/100 ml
meq/15 ml
potassium chloride tablet er
10 meq
potassium chloride tablet er
20 meq
potassium chloride tablet er 8
meq
potassium chloride-nacl
solution 20 meq/l
ringers injection solution
sodium chloride solution 0.45
%
4
2
2
BvsD
2
BvsD
2
3
3
BvsD
BvsD
BvsD
3
BvsD
3
BvsD
3
BvsD
2
BvsD
2
BvsD
1
1
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
2
BvsD
2
1
1
1
2
BvsD
2
BvsD
2
BvsD
77
Medicamento
Nivel Requisitos
Medicamento
/Límites
2
%
2
meq/ml
sodium chloride solution 3 %
2
sodium chloride solution 5 %
2
tpn electrolytes solution 35
meq-20 meq-5 meq-4.5 meq2
35 meq-29.5 meq/20 ml
SOLUCIONES DE IRRIGACIÓN
physiolyte solution 140 meq-5
meq-3 meq-98 meq-27 meq-23 2
meq/l
physiosol solution 140 meq-5
meq-3 meq-98 meq-27 meq-23 2
meq/l
2
%
ENZYMES
ENZYMES
ADAGEN SOLUTION 250
4
UNIT/ML
ALDURAZYME SOLUTION
5
2.9 MG/5 ML
CERDELGA CAPSULE
84MG
5
CEREZYME FOR
5
SOLUTION 400 UNIT
ELAPRASE SOLUTION 6
5
MG/3 ML
ELELYSO FOR SOLUTION
5
200 UNIT
ELITEK FOR SOLUTION
5
1.5MG
ELITEK FOR SOLUTION
5
7.5MG
Nivel Requisitos
/Límites
FABRAZYME FOR
5 AP
SOLUTION 35MG
KANUMA SOLUTION 20
MG/10 ML (2 MG/ML)
5 LC; AP
dia(s)
LUMIZYME FOR
5 AP
SOLUTION 50MG
NAGLAZYME SOLUTION 5
5 AP
MG/5 ML
PULMOZYME SOLUTION 1
5 BvsD
MG/ML
SUCRAID SOLUTION 8,500
4 AL
UNIT/ML
VPRIV FOR SOLUTION 400
5 AP
UNIT
HORMONAS Y SUSTITUTOS SINTÉTICOS
ADRENALES
budesonide ec capsule dr part
2
3mg
cortisone acetate tablet 25mg
2
dexamethasone elixir 0.5 mg/5
2
ml
DEXAMETHASONE
INTENSOL CONCENTRATE 4
1 MG/ML
dexamethasone sodium
2 BvsD
phosphate solution 10 mg/ml
2 BvsD
phosphate solution 4 mg/ml
dexamethasone tablet 0.5mg
2
2
2
dexamethasone tablet 1mg
2
BvsD
BvsD
BvsD
BvsD
BvsD
BvsD
BvsD
BvsD
AP
LC; AP
AP
AP
AP
BvsD
BvsD
78
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
DEXPAK TAB THER PACK
1.5 MG (51 TABS)
fludrocortisone acetate tablet
0.1mg
hydrocortisone tablet 10mg
methylprednisolone acetate
suspension 40 mg/ml
methylprednisolone acetate
suspension 80 mg/ml
methylprednisolone sod succ
for solution 125mg
methylprednisolone sod succ
for solution 40mg
methylprednisolone tab ther
pack 4mg
methylprednisolone tablet
16mg
methylprednisolone tablet
32mg
methylprednisolone tablet 4mg
methylprednisolone tablet 8mg
prednisolone acetate
suspension 1 %
prednisolone sodium phos odt
tablet disperse 10mg
prednisolone sodium
phosphate solution 15 mg/5 ml
/Límites
2
2
2
prednisolone sodium
phosphate solution 25 mg/5 ml 2
(5 mg/ml)
prednisolone sodium
phosphate solution 5 mg
2
base/5 ml (6.7 mg/5 ml)
PREDNISONE INTENSOL
2
CONCENTRATE 5 MG/ML
prednisone solution 5 mg/5 ml
2
prednisone tablet 10mg
1
1
prednisone tablet 2.5mg
1
1
1
1
VERIPRED 20 SOLUTION
4
20 MG/5 ML (4 MG/ML)
AGENTES ANTIDIABÉTICOS
acarbose tablet 100mg
2
2
2
ACTOPLUS MET XR
TABLET ER 24HR 154
1,000MG
ACTOPLUS MET XR
TABLET ER 24HR 304
1,000MG
alogliptin tablet 12.5mg
2
alogliptin tablet 25mg
2
alogliptin tablet 6.25mg
2
alogliptin-metformin tablet
12.5-1,000mg
2
4
2
2
2
2
2
BvsD
2
BvsD
2
BvsD
2
BvsD
2
2
2
2
2
2
2
2
2
2
LC
LC
LC
LC
LC
LC
79
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
alogliptin-metformin tablet
12.5-500mg
alogliptin-pioglitazone tablet
12.5-15mg
12.5-30mg
12.5-45mg
25-15mg
25-30mg
25-45mg
AVANDIA TABLET 2MG
AVANDIA TABLET 4MG
BYDUREON FOR SUSP ER
2MG
LC 4 cada 28 dia(s)
BYDUREON PEN PENINJECTOR 2 MG/0.65 ML
LC 4 cada 28 dia(s)
BYETTA SOLN PEN-INJ 10
MCG/0.04 ML PER DOSE
(250 MCG/ML) 2.4 ML
dia(s)
2
2
2
/Límites
BYETTA SOLN PEN-INJ 5
MCG/0.02 ML PER DOSE
(250 MCG/ML) 1.2 ML
dia(s)
FARXIGA TABLET 10MG
FARXIGA TABLET 5MG
glimepiride tablet 1mg
glipizide er tablet er 24hr
10mg
glipizide er tablet er 24hr
2.5mg
glipizide er tablet er 24hr 5mg
glipizide tablet 10mg
glipizide tablet 5mg
glipizide-metformin tablet 2.5250mg
glipizide-metformin tablet 2.5500mg
glipizide-metformin tablet 5500mg
GLUMETZA TABLET ER
24HR 500MG
GLYSET TABLET 100MG
GLYSET TABLET 25MG
GLYSET TABLET 50MG
GLYXAMBI TABLET 105MG
LC
LC
LC
2
LC
2
LC
2
LC
2
LC
4
4
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
1
1
1
1
1
1
1
1
1
1
1
4
4
4
4
3
LC; TE
80
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
GLYXAMBI TABLET 255MG
INVOKAMET TABLET 1501,000MG
INVOKAMET TABLET 150500MG
INVOKAMET TABLET 501,000MG
INVOKAMET TABLET 50500MG
INVOKANA TABLET
100MG
INVOKANA TABLET
300MG
JANUMET TABLET 501,000MG
JANUMET TABLET 50500MG
JANUMET XR TABLET ER
24HR 100-1,000MG
24HR 50-1,000MG
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
/Límites
24HR 50-500MG
JANUVIA TABLET 100MG
JANUVIA TABLET 25MG
JANUVIA TABLET 50MG
JARDIANCE TABLET
10MG
JARDIANCE TABLET
25MG
JENTADUETO TABLET 2.51,000MG
JENTADUETO TABLET 2.5500MG
JENTADUETO TABLET 2.5850MG
KAZANO TABLET 12.51,000MG
KAZANO TABLET 12.5500MG
KOMBIGLYZE XR TABLET
ER 24HR 2.5-1,000MG
ER 24HR 5-1,000MG
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
3
LC; TE
3
LC; TE
3
LC
3
LC
3
LC
4
LC
4
LC
4
LC; TE
4
LC; TE
81
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ER 24HR 5-500MG
LANTUS SOLOSTAR SOLN
PEN-INJ 100 UNIT/ML (3
ML)
LANTUS SOLUTION 100
UNIT/ML
LEVEMIR FLEXTOUCH
SOLN PEN-INJ 100
UNIT/ML (3 ML)
LEVEMIR SOLUTION 100
UNIT/ML
metformin hcl er tablet er
24hr 1,000mg
24hr 500mg
24hr 750mg
metformin hcl tablet 1,000mg
metformin hcl tablet 500mg
metformin hcl tablet 850mg
miglitol tablet 100mg
nateglinide tablet 120mg
nateglinide tablet 60mg
NESINA TABLET 12.5MG
NESINA TABLET 25MG
NESINA TABLET 6.25MG
4
/Límites
NOVOLIN 70-30
SUSPENSION 100 UNIT/ML
(70-30)
NOVOLIN N SUSPENSION
100 UNIT/ML
NOVOLIN R SOLUTION
100 UNIT/ML
NOVOLOG FLEXPEN
SOLN PEN-INJ 100
UNIT/ML
NOVOLOG MIX 70-30
FLEXPEN SUSP-PEN-INJ
100 UNIT/ML (70-30)
NOVOLOG MIX 70-30
SUSPENSION 100 UNIT/ML
(70-30)
NOVOLOG SOLN
CARTRIDGE 100 UNIT/ML
NOVOLOG SOLUTION 100
UNIT/ML
ONGLYZA TABLET 2.5MG
ONGLYZA TABLET 5MG
OSENI TABLET 12.5-15MG
OSENI TABLET 25-15MG
LC; TE
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
4
LC
4
LC
4
LC
3
3
3
3
3
3
3
3
4
LC; TE
4
LC; TE
4
LC
4
LC
4
LC
4
LC
4
LC
82
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
pioglitazone hcl tablet 15mg
pioglitazone-glimepiride
tablet 30-2mg
pioglitazone-glimepiride
tablet 30-4mg
pioglitazone-metformin tablet
15-500mg
pioglitazone-metformin tablet
15-850mg
repaglinide tablet 0.5mg
repaglinide tablet 1mg
repaglinide tablet 2mg
repaglinide-metformin hcl
tablet 1-500mg
repaglinide-metformin hcl
tablet 2-500mg
RIOMET SOLUTION 500
MG/5 ML
SYMLINPEN 120 SOLN
PEN-INJ 2,700 MCG/2.7 ML
dia(s)
4
LC
1
LC
1
LC
2
2
2
SYMLINPEN 60 SOLN PENINJ 1,500 MCG/1.5 ML
dia(s)
SYNJARDY TABLET 12.51,000MG
SYNJARDY TABLET 12.5500MG
SYNJARDY TABLET 51,000MG
SYNJARDY TABLET 5500MG
TANZEUM PEN-INJECTOR
30 MG/0.5 ML
LC 4 cada 28 dia(s)
TANZEUM PEN-INJECTOR
50 MG/0.5 ML
LC 4 cada 28 dia(s)
tolazamide tablet 250mg
tolazamide tablet 500mg
tolbutamide tablet 500mg
TOUJEO SOLOSTAR SOLN
PEN-INJ 300 UNIT/ML (1.5
ML)
TRADJENTA TABLET 5MG
TRULICITY SOLN PEN-INJ
0.75 MG/0.5 ML
dia(s)
LC
1
2
/Límites
LC
LC
LC
LC
1
1
1
2
2
4
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
4
LC; TE
4
LC; TE
1
1
1
3
3
LC
3
LC; TE
83
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
TRULICITY SOLN PEN-INJ
1.5 MG/0.5 ML
3 LC; TE
dia(s)
VICTOZA 3-PAK SOLN
PEN-INJ 0.6 MG/0.1 ML (18
3 TE
MG/3 ML)
AGENTES DE TIROIDES Y ANTITIROIDES
levothyroxine sodium tablet
1
100 mcg
1
112 mcg
1
125 mcg
1
137 mcg
1
150 mcg
1
175 mcg
1
200 mcg
levothyroxine sodium tablet 25
1
mcg
1
300 mcg
1
mcg
1
mcg
1
mcg
levoxyl tablet 100 mcg
4
4
liothyronine sodium tablet 25
mcg
mcg
mcg
methimazole tablet 10mg
methimazole tablet 5mg
propylthiouracil tablet 50mg
SYNTHROID TABLET 100
MCG
MCG
MCG
MCG
MCG
MCG
MCG
SYNTHROID TABLET 25
MCG
4
4
4
4
4
4
4
4
4
2
2
2
2
2
2
3
3
3
3
3
3
3
3
84
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
MCG
SYNTHROID TABLET 50
MCG
SYNTHROID TABLET 75
MCG
SYNTHROID TABLET 88
MCG
unithroid tablet 100 mcg
ANDRÓGENOS
ANDRODERM PATCH
24HR 2 MG/24 HOUR
ANDRODERM PATCH
24HR 4 MG/24 HOUR
ANDROGEL GEL 20.25
MG/1.25 GRAM (1.62 %)
dia(s)
ANDROGEL GEL 20.25
MG/1.25 GRAM PER
ACTUATION (1.62 %)
/Límites
ANDROGEL GEL 40.5
MG/2.5 GRAM (1.62 %)
ANDROGEL GEL 50 MG/5
GRAM (1 %)
AXIRON SOLUTION 30
MG/1.5 ML PER
ACTUATION
dia(s)
danazol capsule 100mg
oxandrolone tablet 10mg
oxandrolone tablet 2.5mg
testosterone cypionate
solution 100 mg/ml
testosterone cypionate
solution 200 mg/ml
testosterone enanthate
solution 200 mg/ml
testosterone gel 1.25 gram per
actuation (1 % - 12.5 mg/1.25
gram)
testosterone gel 10 mg/0.5
gram per actuation (2 %)
testosterone gel 25 mg/2.5
gram (1 %)
testosterone gel 50 mg/5 gram
(1 %)
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
LC; AP
4
LC; AP
3
3
LC
LC
3
LC
3
LC
4
LC; AP
2
2
2
2
2
2
2
2
2
LC
2
LC; AP
2
LC
2
LC
85
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
cyclafem tablet 0.5 mg-35 mcg
(7)/0.75 mg-35 mcg (7)/1 mg35 mcg (7)
cyclafem tablet 1 mg-35 mcg
desogestr-eth estrad eth estra
tablet 0.15 mg-0.02 mg
(21)/0.01 mg (5)
drospirenone-ethinyl estradiol
tablet 0.03-3mg
emoquette tablet 0.15-0.03mg
errin tablet 0.35mg
introvale tablet 0.15 mg-30
mcg
jolivette tablet 0.35mg
junel fe 24 tablet 1 mg-20 mcg
(24)/75 mg (4)
junel fe tablet 1 mg-20 mcg
(21)/75 mg (7)
junel fe tablet 1.5 mg-30 mcg
(21)/75 mg (7)
junel tablet 1 mg-20 mcg
junel tablet 1.5 mg-30 mcg
kariva tablet 0.15 mg-0.02 mg
(21)/0.01 mg (5)
kelnor 1-35 tablet 1 mg-35
mcg
lessina tablet 0.1 mg-20 mcg
levonorg-eth estrad eth estrad
tablet 0.15 mg-30 mcg (84)/10
mcg (7)
levonorgestrel-eth estradiol
tablet 50 mcg-30 mcg (6)/75
mcg-40 mcg (5)/125 mcg-30
mcg (10)
levonorgestrel-eth estradiol
tablet 90 mcg-20 mcg
ANTAGONISTAS Y AGONISTAS DE
SOMATOTROPINA
INCRELEX SOLUTION 10
5 AP
MG/ML
SAIZEN FOR SOLUTION
5 AP
5MG
SAIZEN FOR SOLUTION 8.8
MG/1.5 ML (FINAL
5 AP
CONCENTRATION)
SAIZEN FOR SOLUTION
5 AP
8.8MG
SOMAVERT FOR
5 AP
SOLUTION 10MG
SOMAVERT FOR
5 AP
SOLUTION 15MG
SOMAVERT FOR
5 AP
SOLUTION 20MG
ANTICONCEPTIVOS
amethia tablet 0.15 mg-30 mcg
2
(84)/10 mcg (7)
amethyst tablet 90 mcg-20 mcg 2
apri tablet 0.15-0.03mg
2
aranelle tablet 0.5 mg-35 mcg
(7)/1 mg-35 mcg (9)/0.5 mg-35 2
mcg (5)
aviane tablet 0.1 mg-20 mcg
2
balziva tablet 0.4 mg-35 mcg
2
BEYAZ TABLET 3 MG-0.02
MG-0.451 MG (24)/0.451 MG 4
(4)
blisovi fe tablet 1.5 mg-30 mcg
2
(21)/75 mg (7)
briellyn tablet 0.4 mg-35 mcg
2
camila tablet 0.35mg
2
cryselle tablet 0.3 mg-30 mcg
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
86
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
levora-28 tablet 0.15 mg-30
mcg
LO LOESTRIN FE TABLET
1 MG-10 MCG (24)/10 MCG
(2)/75 MG (2)
LOESTRIN FE TABLET 1
MG-20 MCG (21)/75 MG (7)
LOESTRIN FE TABLET 1.5
MG-30 MCG (21)/75 MG (7)
LOESTRIN TABLET 1 MG20 MCG
LOESTRIN TABLET 1.5
MG-30 MCG
lutera tablet 0.1 mg-20 mcg
marlissa tablet 0.15 mg-30
mcg
microgestin fe tablet 1 mg-20
mcg (21)/75 mg (7)
microgestin fe tablet 1.5 mg30 mcg (21)/75 mg (7)
microgestin tablet 1 mg-20
mcg
microgestin tablet 1.5 mg-30
mcg
mononessa tablet 0.25 mg-35
mcg
necon tablet 0.5 mg-35 mcg
(10)/1 mg-35 mcg (11)
(7)/0.75 mg-35 mcg (7)/1 mg35 mcg (7)
necon tablet 1 mg-35 mcg
norethin-eth estra-ferrous fum
tablet 1 mg-20 mcg (24)/75
mg (4)
/Límites
norgestimate-ethinyl estradiol
tablet 0.18 mg-25 mcg
(7)/0.215 mg-25 mcg (7)/0.25
mg-25 mcg (7)
nortrel tablet 0.5 mg-35 mcg
nortrel tablet 0.5 mg-35 mcg
(7)/0.75 mg-35 mcg (7)/1 mg35 mcg (7)
nortrel tablet 1 mg-35 mcg
NUVARING RING 0.12 MG
-0.015 MG/24 HR
LC 1 cada 28 dia(s)
OGESTREL TABLET 0.5
MG-50 MCG
orsythia tablet 0.1 mg-20 mcg
portia tablet 0.15 mg-30 mcg
previfem tablet 0.25 mg-35
mcg
quasense tablet 0.15 mg-30
mcg
reclipsen tablet 0.15-0.03mg
SAFYRAL TABLET 3 MG0.03 MG-0.451 MG
(21)/0.451 MG (7)
sprintec tablet 0.25 mg-35
mcg
sronyx tablet 0.1 mg-20 mcg
tri-legest fe tablet 1 mg-20
mcg (5)/1 mg-30 mcg (7)/1
mg-35 mcg (9)/75 mg (7)
tri-lo-estarylla tablet 0.18 mg25 mcg (7)/0.215 mg-25 mcg
(7)/0.25 mg-25 mcg (7)
tri-lo-sprintec tablet 0.18 mg25 mcg (7)/0.215 mg-25 mcg
(7)/0.25 mg-25 mcg (7)
2
4
4
4
4
4
2
2
2
2
2
2
2
2
4
2
2
2
2
2
2
2
4
LC
4
2
2
2
2
2
4
2
2
2
2
2
87
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
tri-previfem tablet 0.18 mg-35
mcg (7)/0.215 mg-35 mcg
2
(7)/0.25 mg-35 mcg(7)(28)
tri-sprintec tablet 0.18 mg-35
mcg (7)/0.215 mg-35 mcg
2
(7)/0.25 mg-35 mcg(7)(28)
trinessa tablet 0.18 mg-35
mcg (7)/0.215 mg-35 mcg
2
(7)/0.25 mg-35 mcg(7)(28)
trivora-28 tablet 50 mcg-30
mcg (6)/75 mcg-40 mcg
2
(5)/125 mcg-30 mcg (10)
velivet tablet 0.1 mg-25 mcg
(7)/0.125 mg-25 mcg (7)/0.15
2
mg-25 mcg (7)
vienva tablet 0.1 mg-20 mcg
2
XULANE PATCH WEEKLY
150 MCG-35 MCG/24 HOUR 2 LC
LC 4 cada 28 dia(s)
zovia 1-35e tablet 1 mg-35
2
mcg
ZOVIA 1-50E TABLET 1
2
MG-50 MCG
ESTRÓGENOS Y ANTIESTRÓGENOS
DEPO-ESTRADIOL OIL 5
4
MG/ML
ESTRACE CREAM 0.01 %
3
estradiol patch tw 0.025
2
mg/24 hour
2
mg/24 hour
estradiol patch tw 0.05 mg/24
2
hour
2
mg/24 hour
estradiol patch tw 0.1 mg/24
hour
estradiol patch weekly 0.025
mg/24 hour
mg/24 hour
mg/24 hour
mg/24 hour
mg/24 hour
mg/24 hour
estradiol tablet 0.5mg
estradiol tablet 1mg
estradiol tablet 2mg
FEMRING RING 0.05 MG/24
HOUR
LC 1 cada 90 dia(s)
FEMRING RING 0.1 MG/24
HOUR
LC 1 cada 90 dia(s)
gildagia tablet 0.4 mg-35 mcg
levonest tablet 50 mcg-30 mcg
(6)/75 mcg-40 mcg (5)/125
mcg-30 mcg (10)
loryna tablet 0.02 mg-3 mg
(24)
norethindrone tablet 0.35mg
PREFEST TABLET 1 MG
(3)-1 MG-0.09 MG (3)
2
2
2
2
2
2
2
2
2
2
4
LC
4
LC
2
2
2
2
4
LC; AP
88
Medicamento
Nivel Requisitos
Medicamento
/Límites
PREMARIN CREAM 0.625
MG/GRAM
raloxifene hcl tablet 60mg
VAGIFEM TABLET 10
MCG
zenchent fe tablet chewable
0.4 mg-35 mcg (21)/75 mg
(~24.7 mg iron)(7)
GONADOTROPINAS
chorionic gonadotropin for
solution 10,000 unit
SYNAREL SOLUTION 2
MG/ML
PARATIROIDES
calcitonin-salmon solution
200 unit/spray
FORTEO SOLUTION 20
MCG/DOSE (600 MCG/2.4
ML)
dia(s)
FORTICAL SOLUTION 200
UNIT/SPRAY
MIACALCIN SOLUTION
200 UNIT/ML
dia(s)
NATPARA CARTRIDGE
100 MCG/DOSE (1.61
MG/1.13 ML)
LC 2 cada 28 dia(s)
/Límites
NATPARA CARTRIDGE 25
MCG/DOSE (0.4 MG/1.13
5 LC; AP
ML)
LC 2 cada 28 dia(s)
5 LC; AP
ML)
LC 2 cada 28 dia(s)
5 LC; AP
ML)
LC 2 cada 28 dia(s)
PROGESTINAS
DEPO-SUBQ PROVERA 104
4 LC
ML
LC 1 mililitro(s) cada 90 dia(s)
medroxyprogesterone acetate
suspension 150 mg/ml
2 LC
LC 1 mililitro(s) cada 90 dia(s)
1
tablet 10mg
1
tablet 2.5mg
1
tablet 5mg
norethindrone acetate tablet
2
5mg
progesterone capsule 100mg
2
progesterone capsule 200mg
2
MEDICAMENTOS ANTIHISTAMÍNICOS
ANTIHISTAMÍNICOS de la 1a GENERACIÓN
meclizine hcl tablet 12.5mg
1
3
2
LC
3
2
2
AP
4
2
5
LC; AP
4
4
LC; BvsD
5
LC; AP
Nivel Requisitos
89
Medicamento
Nivel Requisitos
Medicamento
/Límites
Nivel Requisitos
/Límites
meclizine hcl tablet 25mg
1
prochlorperazine edisylate
2
solution 10 mg/2 ml (5 mg/ml)
prochlorperazine maleate
2
tablet 10mg
prochlorperazine maleate
2
tablet 5mg
prochlorperazine suppository
2
25mg
promethazine hcl solution 25
2 BvsD
mg/ml
promethazine hcl solution 50
2 BvsD
mg/ml
promethazine hcl tablet
2
12.5mg
promethazine hcl tablet 25mg
2
promethazine hcl tablet 50mg
2
ANTIHISTAMÍNICOS de la 2a GENERACIÓN
cetirizine hcl syrup 1 mg/ml
2 LC
dia(s)
CLARINEX SYRUP 2.5
4
MG/5 ML (0.5 MG/ML)
CLARINEX-D 12 HOUR
TABLET ER 12HR 2.54
120MG
desloratadine tablet 5mg
2
desloratadine tablet disperse
2
2.5mg
desloratadine tablet disperse
2
5mg
levocetirizine dihydrochloride
2
solution 2.5 mg/5 ml
levocetirizine dihydrochloride
2
tablet 5mg
SEMPREX-D CAPSULE 603
8MG
MEDICAMENTOS AUTONÓMICOS
AGENTES ANTICOLINÉRGICOS
ATROVENT HFA
AEROSOL SOLN 17
4
MCG/ACTUATION
COMBIVENT RESPIMAT
AEROSOL SOLN 20 MCG3
100 MCG/ACTUATION
dicyclomine hcl capsule 10mg
1 LC
dicyclomine hcl solution 10
mg/5 ml
2 LC
dia(s)
dicyclomine hcl tablet 20mg
1 LC
glycopyrrolate tablet 1mg
2
glycopyrrolate tablet 2mg
2
ipratropium bromide solution
2 BvsD
0.2 mg/ml (0.02 %)
ipratropium-albuterol solution
0.5 mg-3 mg (2.5 mg base)/3
2 BvsD
ml
methscopolamine bromide
2
tablet 2.5mg
methscopolamine bromide
2
tablet 5mg
SEEBRI NEOHALER
CAPSULE 15.6 MCG
4 LC; TE
SPIRIVA CAPSULE 18 MCG
3 LC
90
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
SPIRIVA RESPIMAT
AEROSOL SOLN 1.25
3 LC
MCG/ACTUATION
SPIRIVA RESPIMAT
AEROSOL SOLN 2.5
3 LC
MCG/ACTUATION
STIOLTO RESPIMAT
AEROSOL SOLN 2.5 MCG3 LC
2.5 MCG/ACTUATION
TRANSDERM-SCOP
PATCH 72HR 1.5 MG
(DELIVERS 1 MG OVER 3
4 LC
DAYS)
TUDORZA PRESSAIR
AERO POW BR ACT 400
3
MCG/ACTUATION
UTIBRON NEOHALER
CAPSULE 27.5 MCG-15.6
4 LC; TE
MCG
AGENTES SIMPATICOMIMÉTICA
(ADRENÉRGICOS)
ADRENALIN SOLUTION 1
2 BvsD
MG/ML (1 ML)
ADVAIR DISKUS AERO
POW BR ACT 100 MCG-50
4 TE
MCG/DOSE
ADVAIR DISKUS AERO
4 TE
MCG/DOSE
ADVAIR DISKUS AERO
MCG/DOSE
ADVAIR HFA AEROSOL
115 MCG-21
MCG/ACTUATION
ADVAIR HFA AEROSOL
230 MCG-21
MCG/ACTUATION
ADVAIR HFA AEROSOL 45
MCG-21 MCG/ACTUATION
albuterol 5 mg/ml solution
albuterol sul 0.63 mg/3 ml sol
albuterol sul 1.25 mg/3 ml sol
albuterol sul 2.5 mg/3 ml soln
albuterol sulfate syrup 2 mg/5
ml
albuterol sulfate tablet 2mg
albuterol sulfate tablet 4mg
albuterol sulfate tablet er 12hr
4mg
albuterol sulfate tablet er 12hr
8mg
ANORO ELLIPTA AERO
POW BR ACT 62.5 MCG-25
MCG/ACTUATION
ARCAPTA NEOHALER
CAPSULE 75 MCG
ARNUITY ELLIPTA AERO
POW BR ACT 100 MCG
ARNUITY ELLIPTA AERO
POW BR ACT 200 MCG
4
TE
4
TE
4
TE
4
TE
2
2
2
2
BvsD
BvsD
BvsD
BvsD
2
2
2
2
2
4
LC; TE
4
3
LC
3
LC
91
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
BREO ELLIPTA AERO POW
BR ACT 100 MCG-25
MCG/DOSE
BREO ELLIPTA AERO POW
BR ACT 200 MCG-25
MCG/DOSE
BROVANA 15 MCG/2 ML
SOLUTION
dia(s)
DULERA AEROSOL 100
MCG-5 MCG/ACTUATION
DULERA AEROSOL 200
MCG-5 MCG/ACTUATION
epinephrine soln auto-inj 0.3
mg/0.3 ml
EPIPEN 2-PAK SOLN
AUTO-INJ 0.3 MG/0.3 ML
EPIPEN JR 2-PAK SOLN
AUTO-INJ 0.15 MG/0.3 ML
FORADIL CAPSULE 12
MCG
INCRUSE ELLIPTA AERO
POW BR ACT 62.5
MCG/ACTUATION
levalbuterol 0.31 mg/3 ml sol
levalbuterol 0.63 mg/3 ml sol
levalbuterol conc 1.25 mg/0.5
metaproterenol sulfate syrup
10 mg/5 ml
4
4
4
/Límites
metaproterenol sulfate tablet
10mg
metaproterenol sulfate tablet
20mg
midodrine hcl tablet 10mg
midodrine hcl tablet 2.5mg
midodrine hcl tablet 5mg
NORTHERA CAPSULE
100MG
NORTHERA CAPSULE
200MG
NORTHERA CAPSULE
300MG
PERFOROMIST 20 MCG/2
ML SOLN
PROAIR HFA AEROSOL
SOLN 90 MCG
PROAIR RESPICLICK
AERO POW BR ACT 90
MCG
PROVENTIL HFA
AEROSOL SOLN 90 MCG
SEREVENT DISKUS AERO
POW BR ACT 50 MCG
STRIVERDI RESPIMAT
AEROSOL SOLN 2.5
MCG/ACTUATION
SYMBICORT AEROSOL 160
MCG-4.5
MCG/ACTUATION
SYMBICORT AEROSOL 80
MCG-4.5
MCG/ACTUATION
LC; TE
LC; TE
LC; BvsD
3
3
2
3
3
3
4
LC; TE
2
2
2
BvsD
BvsD
BvsD
2
2
2
2
2
2
5
LC; AP
5
LC; AP
5
LC; AP
4
BvsD
3
3
4
3
3
3
3
92
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
terbutaline sulfate tablet
2
2.5mg
terbutaline sulfate tablet 5mg
2
VENTOLIN HFA AEROSOL
3
SOLN 90 MCG
XOPENEX HFA AEROSOL
4
45 MCG/ACTUATION
MEDICAMENTOS AUTONOMICOS, MISC.
CHANTIX TABLET 0.5 MG
(11)-1 MG (42)
3 LC
CHANTIX TABLET 0.5MG
3 LC
CHANTIX TABLET 1MG
3 LC
NICOTROL INHALER
10MG
4 LC
NICOTROL NS SOLUTION
10 MG/ML
4 LC
dia(s)
PARASIMPATICOMIMÉTICO (AGENTES
COLINÉRGICOS)
bethanechol chloride tablet
2
10mg
2
25mg
2
50mg
2
5mg
cevimeline hcl capsule 30mg
2
donepezil hcl odt tablet
2
disperse 10mg
donepezil hcl odt tablet
disperse 5mg
donepezil hcl tablet 10mg
galantamine hbr capsule er
24hr 16mg
24hr 24mg
24hr 8mg
galantamine hbr tablet 12mg
galantamine hydrobromide
solution 4 mg/ml
MESTINON SYRUP 60
MG/5 ML
pilocarpine hcl tablet 5mg
pilocarpine hcl tablet 7.5mg
pyridostigmine bromide er
tablet er 180mg
pyridostigmine bromide tablet
60mg
rivastigmine capsule 1.5mg
rivastigmine capsule 3mg
rivastigmine capsule 4.5mg
rivastigmine capsule 6mg
rivastigmine patch 24hr 13.3
mg/24 hour
mg/24 hour
mg/24 hour
2
1
2
1
2
2
2
2
2
2
2
4
2
2
2
2
2
2
2
2
2
2
2
93
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
bisoprolol fumarate tablet
10mg
bisoprolol fumarate tablet
5mg
bisoprololhydrochlorothiazide tablet 106.25mg
bisoprololhydrochlorothiazide tablet
2.5-6.25mg
bisoprololhydrochlorothiazide tablet 56.25mg
BYSTOLIC TABLET 10MG
BYSTOLIC TABLET 2.5MG
BYSTOLIC TABLET 20MG
BYSTOLIC TABLET 5MG
CARDURA XL TABLET ER
24HR 4MG
CARDURA XL TABLET ER
24HR 8MG
carvedilol tablet 12.5mg
carvedilol tablet 25mg
COREG CR CAPSULE ER
24HR 10MG
COREG CR CAPSULE ER
24HR 20MG
COREG CR CAPSULE ER
24HR 40MG
COREG CR CAPSULE ER
24HR 80MG
RELAJANTES DE MÚSCULO ESQUELÉTICO
baclofen tablet 10mg
1
baclofen tablet 20mg
1
cyclobenzaprine hcl tablet
2
10mg
2
5mg
2
7.5mg
dantrolene sodium capsule
2
100mg
2
25mg
2
50mg
tizanidine hcl capsule 2mg
2 LC
2 LC
2 LC
tizanidine hcl tablet 2mg
2
tizanidine hcl tablet 4mg
2
SIMPATICOLÍTICO AGENTES
BLOQUEANTES ADRENÉRGICOS
acebutolol hcl capsule 200mg
2
acebutolol hcl capsule 400mg
2
alfuzosin hcl er tablet er 24hr
2
10mg
atenolol tablet 100mg
2
2
2
atenolol-chlorthalidone tablet
2
100-25mg
atenolol-chlorthalidone tablet
2
50-25mg
betaxolol hcl tablet 20mg
2
1
1
2
2
2
3
LC
3
LC
3
LC
3
LC
4
4
1
1
1
1
4
4
4
4
94
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
CORLANOR TABLET 5MG
CORLANOR TABLET
7.5MG
dihydroergotamine mesylate
solution 0.5 mg/pump
actuation (4 mg/ml)
dihydroergotamine mesylate
solution 1 mg/ml
diphenhydramine hcl solution
50 mg/ml
doxazosin mesylate tablet 1mg
dutasteride-tamsulosin
capsule 0.5-0.4mg
ergoloid mesylates tablet 1mg
labetalol hcl tablet 100mg
metoprolol succinate tablet er
24hr 100mg
24hr 200mg
24hr 25mg
24hr 50mg
metoprolol tartrate tablet
100mg
25mg
3
LC; TE
3
LC; TE
/Límites
50mg
metoprololhydrochlorothiazide tablet
100-25mg
metoprololhydrochlorothiazide tablet
100-50mg
metoprololhydrochlorothiazide tablet 5025mg
nadolol tablet 20mg
nadolol tablet 40mg
nadolol tablet 80mg
nadolol-bendroflumethiazide
tablet 40-5mg
nadolol-bendroflumethiazide
tablet 80-5mg
pindolol tablet 10mg
pindolol tablet 5mg
prazosin hcl capsule 1mg
propranolol hcl er capsule er
24hr 120mg
24hr 160mg
24hr 60mg
24hr 80mg
propranolol hcl solution 20
mg/5 ml (4 mg/ml)
propranolol hcl solution 40
mg/5 ml (8 mg/ml)
propranolol hcl tablet 10mg
2
2
BvsD
2
2
2
2
2
2
2
LC
2
2
2
2
2
2
2
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
2
2
1
95
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
1
1
1
1
propranololhydrochlorothiazide tablet 40
2
mg-25mg
propranololhydrochlorothiazide tablet 80
2
mg-25mg
RAPAFLO CAPSULE 4MG
4
RAPAFLO CAPSULE 8MG
4
sorine tablet 120mg
2
sorine tablet 160mg
2
sorine tablet 240mg
2
sorine tablet 80mg
2
sotalol af tablet 120mg
1
sotalol tablet 160mg
1
sotalol tablet 240mg
1
sotalol tablet 80mg
1
tamsulosin hcl capsule 0.4mg
1
terazosin hcl capsule 10mg
1
1
1
1
timolol maleate tablet 10mg
2
2
2
MEDICAMENTOS CARDIOVASCULARES
AGENTES ANTILIPÉMICOS
ALTOPREV TABLET ER
4
24HR 20MG
ALTOPREV TABLET ER
4
24HR 40MG
ALTOPREV TABLET ER
4
24HR 60MG
amlodipine-atorvastatin tablet
10-10mg
10-20mg
10-40mg
10-80mg
2.5-10mg
2.5-20mg
2.5-40mg
5-10mg
5-20mg
5-40mg
5-80mg
atorvastatin calcium tablet
10mg
20mg
40mg
80mg
cholestyramine light packet 4
gram
colestipol hcl granules 5 gram
colestipol hcl tablet 1 gram
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
1
1
1
1
2
2
2
96
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
CRESTOR TABLET 10MG
CRESTOR TABLET 20MG
CRESTOR TABLET 40MG
CRESTOR TABLET 5MG
fenofibrate capsule 130mg
fenofibrate tablet 120mg
fenofibric acid capsule dr
135mg
fenofibric acid capsule dr
45mg
fenofibric acid tablet 105mg
fenofibric acid tablet 35mg
fluvastatin er tablet er 24hr
80mg
fluvastatin sodium capsule
20mg
fluvastatin sodium capsule
40mg
gemfibrozil tablet 600mg
JUXTAPID CAPSULE 10MG
/Límites
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
KYNAMRO SOLN PREF
SYR 200 MG/ML
dia(s)
LIVALO TABLET 1MG
LIVALO TABLET 2MG
LIVALO TABLET 4MG
lovastatin tablet 10mg
niacin er tablet er 1,000mg
niacin er tablet er 500mg
niacin er tablet er 750mg
omega-3 acid ethyl esters
capsule 1 gram
pravastatin sodium tablet
10mg
2
2
2
2
2
1
LC
1
LC
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
4
LC; TE
4
LC; TE
4
LC; TE
1
1
1
2
2
2
2
1
2
5
LC; AP
97
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
20mg
40mg
80mg
prevalite powder 4 gram
REPATHA SURECLICK
SOLN AUTO-INJ 140
MG/ML
dia(s)
REPATHA SYRINGE SOLN
PREF SYR 140 MG/ML
dia(s)
rosuvastatin calcium tablet
10mg
20mg
40mg
5mg
simvastatin tablet 10mg
VASCEPA CAPSULE 1
GRAM
/Límites
WELCHOL PACKET 3.75
GRAM
WELCHOL TABLET 625MG
ZETIA TABLET 10MG
AGENTES HYPOTENSORES
acetazolamide capsule er 12hr
500mg
acetazolamide tablet 125mg
acetazolamide tablet 250mg
afeditab cr tablet er 24hr
30mg
afeditab cr tablet er 24hr
60mg
ALDACTAZIDE TABLET
50-50MG
amiloride hcl tablet 5mg
amiloride-hydrochlorothiazide
tablet 5-50mg
amlodipine besylate tablet
10mg
2.5mg
5mg
amlodipine besylatebenazepril capsule 10-20mg
amlodipine besylatebenazepril capsule 2.5-10mg
1
1
1
2
5
5
LC; AP
LC; AP
2
2
2
2
1
LC
1
LC
1
LC
1
LC
1
LC
4
LC
4
4
4
2
2
2
2
2
4
2
2
1
1
1
2
2
2
2
2
2
98
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
amlodipine-valsartan tablet
10-160mg
amlodipine-valsartan tablet
10-320mg
amlodipine-valsartan tablet 5160mg
amlodipine-valsartan tablet 5320mg
amlodipine-valsartan-hctz
tablet 10-160-12.5mg
tablet 10-160-25mg
tablet 10-320-25mg
tablet 5-160-12.5mg
tablet 5-160-25mg
AZOR TABLET 10-20MG
AZOR TABLET 10-40MG
AZOR TABLET 5-20MG
AZOR TABLET 5-40MG
benazepril hcl tablet 10mg
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
/Límites
benazeprilhydrochlorothiazide tablet 1012.5mg
benazeprilhydrochlorothiazide tablet 2025mg
BENICAR HCT TABLET 2012.5MG
BENICAR HCT TABLET 4012.5MG
BENICAR HCT TABLET 4025MG
BENICAR TABLET 20MG
BENICAR TABLET 40MG
BENICAR TABLET 5MG
betaxolol hcl tablet 10mg
bumetanide tablet 0.5mg
bumetanide tablet 1mg
bumetanide tablet 2mg
candesartan cilexetil tablet
16mg
32mg
LC
4
4
4
4
1
1
1
1
1
1
1
1
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
2
1
1
1
1
LC
1
LC
99
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
4mg
8mg
candesartanhydrochlorothiazid tablet 1612.5mg
candesartanhydrochlorothiazid tablet 3212.5mg
candesartanhydrochlorothiazid tablet 3225mg
captopril tablet 100mg
captopril tablet 12.5mg
captopril-hydrochlorothiazide
tablet 25-15mg
tablet 25-25mg
tablet 50-15mg
tablet 50-25mg
cartia xt capsule er 24hr
120mg
180mg
240mg
300mg
1
LC
1
LC
1
LC
1
LC
1
1
1
1
1
1
1
1
1
2
2
LC
/Límites
chlorothiazide tablet 250mg
chlorothiazide tablet 500mg
chlorthalidone tablet 25mg
chlorthalidone tablet 50mg
clonidine hcl er tablet er 12hr
0.1mg
clonidine hcl tablet 0.1mg
clonidine patch weekly 0.1
mg/24 hour
mg/24 hour
mg/24 hour
CLORPRES TABLET 0.115MG
dilt-xr capsule er 24hr 120mg
diltiazem 12hr er capsule er
12hr 120mg
12hr 60mg
12hr 90mg
diltiazem 24hr cd capsule er
24hr 240mg
2
2
2
2
2
LC
1
1
1
2
2
2
3
3
3
2
2
2
2
2
2
2
2
2
100
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
24hr 120mg
24hr 300mg
diltiazem er capsule er 24hr
180mg
360mg
420mg
diltiazem hcl tablet 120mg
DIURIL SUSPENSION 250
MG/5 ML
EDARBI TABLET 40MG
EDARBI TABLET 80MG
EDARBYCLOR TABLET 4012.5MG
EDARBYCLOR TABLET 4025MG
EDECRIN TABLET 25MG
ELIXOPHYLLIN ELIXIR 80
MG/15 ML
enalapril maleate tablet 10mg
enalapril maleate tablet 2.5mg
enalapril-hydrochlorothiazide
tablet 10-25mg
enalapril-hydrochlorothiazide
tablet 5-12.5mg
eplerenone tablet 25mg
eplerenone tablet 50mg
eprosartan mesylate tablet
600mg
felodipine er tablet er 24hr
10mg
2.5mg
5mg
fosinopril sodium tablet 10mg
fosinopril-hydrochlorothiazide
tablet 10-12.5mg
fosinopril-hydrochlorothiazide
tablet 20-12.5mg
furosemide solution 10 mg/ml
furosemide solution 10 mg/ml
furosemide solution 40 mg/5
ml (8 mg/ml)
furosemide tablet 20mg
hydralazine hcl tablet 100mg
hydrochlorothiazide capsule
12.5mg
hydrochlorothiazide tablet
12.5mg
25mg
2
2
2
2
2
2
2
2
2
3
4
4
4
4
4
4
1
1
1
1
1
1
2
2
/Límites
2
LC
2
2
2
1
1
1
1
1
2
2
BvsD
2
1
1
1
1
1
1
1
1
1
1
TE
TE
101
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
50mg
indapamide tablet 1.25mg
indapamide tablet 2.5mg
irbesartan tablet 150mg
irbesartanhydrochlorothiazide tablet
150-12.5mg
irbesartanhydrochlorothiazide tablet
300-12.5mg
isradipine capsule 2.5mg
isradipine capsule 5mg
lisinopril tablet 10mg
lisinopril tablet 2.5mg
lisinopril-hydrochlorothiazide
tablet 10-12.5mg
tablet 20-12.5mg
tablet 20-25mg
losartan potassium tablet
100mg
25mg
1
1
1
1
1
1
1
1
LC
LC
LC
LC
LC
2
2
1
1
1
1
1
1
1
1
1
1
LC
1
LC
/Límites
50mg
losartan-hydrochlorothiazide
tablet 100-12.5mg
tablet 100-25mg
tablet 50-12.5mg
matzim la tablet er 24hr
180mg
240mg
300mg
360mg
420mg
methyclothiazide tablet 5mg
metolazone tablet 10mg
metolazone tablet 2.5mg
metolazone tablet 5mg
minoxidil tablet 10mg
minoxidil tablet 2.5mg
moexipril hcl tablet 15mg
moexipril hcl tablet 7.5mg
moexipril-hydrochlorothiazide
tablet 15-12.5mg
tablet 15-25mg
tablet 7.5-12.5mg
nicardipine hcl capsule 20mg
nicardipine hcl capsule 30mg
nifedical xl tablet er 24hr
30mg
nifedical xl tablet er 24hr
60mg
1
LC
1
1
1
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
2
2
2
2
102
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
nifedipine er tablet er 24hr
30mg
60mg
90mg
nimodipine capsule 30mg
nisoldipine tablet er 24hr
17mg
20mg
25.5mg
30mg
34mg
40mg
8.5mg
perindopril erbumine tablet
2mg
4mg
8mg
PROGLYCEM
SUSPENSION 50 MG/ML
quinapril hcl tablet 10mg
quinapril-hydrochlorothiazide
tablet 10-12.5mg
2
2
2
2
2
2
2
2
2
2
2
1
1
1
4
1
1
1
1
/Límites
tablet 20-12.5mg
tablet 20-25mg
ramipril capsule 1.25mg
ramipril capsule 10mg
ramipril capsule 2.5mg
ramipril capsule 5mg
reserpine tablet 0.1mg
reserpine tablet 0.25mg
spironolactone tablet 100mg
spironolactone-hctz tablet 2525mg
taztia xt capsule er 24hr
120mg
180mg
240mg
300mg
360mg
TEKTURNA HCT TABLET
150-12.5MG
TEKTURNA HCT TABLET
150-25MG
TEKTURNA HCT TABLET
300-12.5MG
TEKTURNA HCT TABLET
300-25MG
1
1
1
1
1
1
2
2
1
1
1
2
2
2
2
2
2
4
TE
4
TE
4
TE
4
TE
1
103
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
TEKTURNA TABLET
150MG
TEKTURNA TABLET
300MG
telmisartan tablet 20mg
telmisartan-amlodipine tablet
40-10mg
40-5mg
80-10mg
80-5mg
telmisartanhydrochlorothiazid tablet 4012.5mg
telmisartanhydrochlorothiazid tablet 8012.5mg
telmisartanhydrochlorothiazid tablet 8025mg
torsemide tablet 100mg
trandolapril tablet 1mg
4
LC; TE
4
LC; TE
1
LC
1
LC
1
LC
2
2
2
2
1
LC
1
LC
1
1
1
1
1
1
1
LC
/Límites
trandolapril-verapamil er
tablet er 1-240mg
tablet er 2-180mg
tablet er 2-240mg
tablet er 4-240mg
triamterenehydrochlorothiazid capsule
37.5-25mg
triamterenehydrochlorothiazid capsule
50-25mg
triamterenehydrochlorothiazid tablet
37.5-25mg
triamterenehydrochlorothiazid tablet 7550mg
TRIBENZOR TABLET 20-512.5MG
TRIBENZOR TABLET 4010-25MG
TRIBENZOR TABLET 40-525MG
valsartan tablet 160mg
1
2
2
2
2
1
1
1
1
4
LC
4
LC
4
LC
4
LC
4
LC
1
LC
104
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
valsartan-hydrochlorothiazide
tablet 160-12.5mg
tablet 160-25mg
tablet 320-12.5mg
tablet 320-25mg
tablet 80-12.5mg
verapamil er capsule er 24hr
120mg
180mg
240mg
verapamil er pm capsule er
24hr 100mg
24hr 200mg
24hr 300mg
verapamil er tablet er 120mg
1
LC
1
LC
1
LC
1
LC
1
LC
1
1
1
2
2
2
2
2
2
2
2
LC
LC
LC
/Límites
verapamil hcl capsule er 24hr
360mg
verapamil hcl tablet 120mg
AGENTES VASODILANTES
ADCIRCA TABLET 20MG
ADEMPAS TABLET 0.5MG
ADEMPAS TABLET 1MG
ADEMPAS TABLET 2MG
ISORDIL TABLET 40MG
isosorbide dinitrate tablet
10mg
20mg
30mg
isosorbide dinitrate tablet 5mg
isosorbide dinitrate tablet er
40mg
isosorbide mononitrate er
tablet er 24hr 120mg
tablet er 24hr 30mg
2
2
1
1
1
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
4
1
1
1
1
2
2
2
105
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
tablet er 24hr 60mg
isosorbide mononitrate tablet
10mg
isosorbide mononitrate tablet
20mg
LETAIRIS TABLET 10MG
LETAIRIS TABLET 5MG
minitran patch 24hr 0.1
mg/hour
mg/hour
mg/hour
mg/hour
NITRO-BID OINTMENT 2
%
nitroglycerin patch patch 24hr
0.1 mg/hour
0.2 mg/hour
0.4 mg/hour
0.6 mg/hour
nitroglycerin solution 400
mcg/spray
NITROMIST AEROSOL
SOLN 400 MCG/SPRAY
NITROSTAT TAB
SUBLINGUAL 0.3MG
2
1
1
5
LC; AP; AL
5
LC; AP; AL
2
2
2
2
4
2
2
2
2
2
4
3
/Límites
NITROSTAT TAB
SUBLINGUAL 0.4MG
NITROSTAT TAB
SUBLINGUAL 0.6MG
OPSUMIT TABLET 10MG
ORENITRAM ER TABLET
ER 0.125MG
ORENITRAM ER TABLET
ER 0.25MG
ORENITRAM ER TABLET
ER 1MG
ORENITRAM ER TABLET
ER 2.5MG
REMODULIN SOLUTION 1
MG/ML
REMODULIN SOLUTION
10 MG/ML
REMODULIN SOLUTION
2.5 MG/ML
REMODULIN SOLUTION 5
MG/ML
REVATIO FOR
SUSPENSION 10 MG/ML
dia(s)
sildenafil tablet 20mg
TRACLEER TABLET
125MG
3
3
5
LC; AP; AL
4
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
5
AP
5
AP
5
AP
5
LC; AP
2
LC; AP
5
AP; AL
106
Medicamento
Nivel Requisitos
Medicamento
/Límites
TRACLEER TABLET
62.5MG
TYVASO SOLUTION 1.74
MG/2.9 ML (0.6 MG/ML)
UPTRAVI TAB THER PACK
200 MCG (140)-800 MCG
(60)
UPTRAVI TABLET 1,000
MCG
MCG
MCG
MCG
UPTRAVI TABLET 200
MCG
UPTRAVI TABLET 400
MCG
UPTRAVI TABLET 600
MCG
UPTRAVI TABLET 800
MCG
VENTAVIS SOLUTION 10
MCG/ML
5
AP; AL
5
AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
Nivel Requisitos
/Límites
VENTAVIS SOLUTION 20
5 AP
MCG/ML
MEDICAMENTOS CARDÍACOS
amiodarone hcl tablet 200mg
1
amiodarone hcl tablet 400mg
1
digoxin solution 50 mcg/ml
2
digoxin tablet 125 mcg
2
digoxin tablet 250 mcg
2
dofetilide capsule 125 mcg
2
2
2
flecainide acetate tablet
2
100mg
flecainide acetate tablet
2
150mg
flecainide acetate tablet 50mg
2
mexiletine hcl capsule 150mg
2
2
2
MULTAQ TABLET 400MG
3
NORPACE CR CAPSULE
4
ER 12HR 100MG
NORPACE CR CAPSULE
4
ER 12HR 150MG
pacerone tablet 100mg
4
pacerone tablet 200mg
2
propafenone hcl er capsule er
2
12hr 225mg
2
12hr 325mg
2
12hr 425mg
propafenone hcl tablet 150mg
2
107
Medicamento
Nivel Requisitos
Medicamento
/Límites
Nivel Requisitos
/Límites
2
2
RANEXA TABLET ER
12HR 1,000MG
3 LC; TE
RANEXA TABLET ER
12HR 500MG
3 LC; TE
TIKOSYN CAPSULE 125
3
MCG
TIKOSYN CAPSULE 250
3
MCG
TIKOSYN CAPSULE 500
3
MCG
MEDICAMENTOS GASTROINTESTINALES(GI
AGENTES ANTIINFLAMATORIOS
(MEDICAMENTOS GI)
APRISO CAPSULE ER
3
24HR 0.375 GRAM
ASACOL HD TABLET DR
4 TE
800MG
balsalazide disodium capsule
2
750mg
CANASA SUPPOSITORY
4
1,000MG
DELZICOL CAPSULE DR
4 TE
400MG
DIPENTUM CAPSULE
3
250MG
LIALDA TABLET DR 1.2
GRAM
4 LC
mesalamine kit 4 gram/60 ml
2
PENTASA CAPSULE ER
4
250MG
PENTASA CAPSULE ER
4
500MG
SFROWASA ENEMA 4
4
GRAM/60 ML
sulfasalazine dr tablet dr
2 NM
500mg
sulfasalazine tablet 500mg
2 NM
UCERIS FOAM 2
MG/ACTUATION
4 LC; TE
dia(s)
UCERIS TABLET ER 24HR
9MG
4 LC; TE
AGENTES ANTIULCEROSOS Y SUPRESORES
DEL ÁCIDO
CARAFATE SUSPENSION 1
4
GRAM/10 ML
cimetidine solution 300 mg/5
2
ml
cimetidine tablet 200mg
2
2
2
2
DEXILANT CAPSULE DR
30MG
3 LC; TE
DEXILANT CAPSULE DR
60MG
3 LC; TE
esomeprazole magnesium
capsule dr 20mg
2 LC; TE
108
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
esomeprazole magnesium
capsule dr 40mg
esomeprazole sodium for
solution 40mg
famotidine for suspension 40
mg/5 ml (8 mg/ml)
famotidine solution 20 mg/2
ml
famotidine solution 20 mg/50
ml
famotidine tablet 20mg
famotidine tablet 40mg
lansoprazole capsule dr 15mg
lansoprazole capsule dr 30mg
misoprostol tablet 100 mcg
misoprostol tablet 200 mcg
NEXIUM CAPSULE DR
20MG
NEXIUM PACKET 10MG
NEXIUM PACKET 2.5MG
NEXIUM PACKET 20MG
NEXIUM PACKET 40MG
NEXIUM PACKET 5MG
nizatidine capsule 150mg
nizatidine capsule 300mg
nizatidine solution 150 mg/10
ml
2
2
LC; TE
BvsD
2
2
BvsD
2
BvsD
1
1
2
LC
2
LC
2
2
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
2
2
/Límites
omeprazole capsule dr 10mg
pantoprazole sodium tablet dr
20mg
pantoprazole sodium tablet dr
40mg
PREVACID TABLET
DISPERSE 15MG
PREVACID TABLET
DISPERSE 30MG
PROTONIX PACKET 40MG
rabeprazole sodium tablet dr
20mg
ranitidine hcl capsule 150mg
ranitidine hcl capsule 300mg
ranitidine hcl solution 25
mg/ml
ranitidine hcl syrup 15 mg/ml
ranitidine hcl tablet 150mg
ranitidine hcl tablet 300mg
sucralfate tablet 1 gram
ZEGERID PACKET 201,680MG
1
LC
1
LC
1
LC
1
LC
1
LC
4
LC; TE
4
LC; TE
4
LC
2
LC
1
1
2
BvsD
1
1
1
2
4
TE
2
109
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ZEGERID PACKET 404
1,680MG
AGENTES CHOLELITHOLYTICOS
CHENODAL TABLET
250MG
4 LC
ursodiol capsule 300mg
2
ursodiol tablet 250mg
2
ursodiol tablet 500mg
2
AGENTES PROCINÉTICOS
diphenoxylate-atropine liquid
2
2.5 mg-0.025 mg/5 ml
diphenoxylate-atropine tablet
2
2.5-0.025mg
loperamide capsule 2mg
2
metoclopramide hcl odt tablet
2
disperse 10mg
metoclopramide hcl odt tablet
2
disperse 5mg
metoclopramide hcl solution 5
2
mg/5 ml
metoclopramide hcl solution 5
2 BvsD
mg/ml
metoclopramide hcl tablet
1
10mg
metoclopramide hcl tablet
1
5mg
ANTIEMÉTICOS
AKYNZEO CAPSULE 3000.5MG
4 LC; BvsD
LC 2 cada 28 dia(s)
CESAMET CAPSULE 1MG
4
dronabinol capsule 10mg
2 LC
dronabinol capsule 2.5mg
2 LC
/Límites
dronabinol capsule 5mg
EMEND CAPSULE 125 MG
(1)-80 MG (1)-80 MG (1)
LC 9 cada 30 dia(s)
EMEND CAPSULE 125MG
LC 3 cada 30 dia(s)
EMEND CAPSULE 40MG
LC 1 cada 30 dia(s)
EMEND CAPSULE 80MG
LC 3 cada 30 dia(s)
EMEND FOR SOLUTION
150MG
granisetron hcl tablet 1mg
ondansetron hcl solution 4
mg/2 ml
ondansetron hcl solution 4
mg/5 ml
ondansetron hcl tablet 24mg
ondansetron odt tablet
disperse 4mg
ondansetron odt tablet
disperse 8mg
promethegan suppository
25mg
VARUBI TABLET 90MG
LC 2 cada 21 dia(s)
CATÁRTICOS Y LAXANTES
alosetron hcl tablet 0.5mg
alosetron hcl tablet 1mg
2
LC
4
LC; BvsD
4
LC; BvsD
4
LC; BvsD
4
LC; BvsD
4
BvsD
2
BvsD
2
BvsD
2
BvsD
2
2
2
BvsD
BvsD
BvsD
2
BvsD
2
BvsD
2
4
LC; BvsD
2
LC
2
LC
110
Medicamento
Nivel Requisitos
Medicamento
/Límites
AMITIZA CAPSULE 24
MCG
AMITIZA CAPSULE 8 MCG
GATTEX KIT 5MG
gavilyte-c for solution 240
gram-22.72 gram-6.72 gram5.84 gram-2.98 gram
gavilyte-g for solution 236
gram-22.74 gram-6.74 gram5.86 gram-2.97 gram
gavilyte-h and bisacodyl kit 5210grammg
gavilyte-n for solution 420
gram
GOLYTELY FOR
SOLUTION 227.1 GRAM21.5 GRAM-6.36 GRAM5.53 GRAM-2.82 GRAM
LINZESS CAPSULE 145
MCG
LINZESS CAPSULE 290
MCG
MOVANTIK TABLET
12.5MG
MOVANTIK TABLET 25MG
MOVIPREP FOR
SOLUTION 100 GRAM-7.5
GRAM-2.691 GRAM-1.015
GRAM-5.9 GRAM-4.7
GRAM
4
LC; TE
4
LC; TE
5
AP
2
2
2
2
4
3
LC
3
LC
3
LC
3
LC
4
Nivel Requisitos
/Límites
OSMOPREP TABLET 1.5
4
GRAM
peg 3350-electrolyte for
2
solution 420 gram
polyethylene glycol 3350
2
powder 17 gram/dose
RELISTOR SOLUTION 12
5 AP
MG/0.6 ML
RELISTOR SOLUTION 8
5 AP
MG/0.4 ML
SUPREP SOLUTION 17.5
GRAM-3.13 GRAM-1.6
4
GRAM
trilyte with flavor packets for
2
solution 420 gram
MEDICAMENTOS de la DIGESTIÓN
CREON CAPSULE DR
PART 12,000 UNIT-38,000
3
UNIT-60,000 UNIT
CREON CAPSULE DR
PART 24,000 UNIT-76,000
3
UNIT-120,000 UNIT
CREON CAPSULE DR
PART 3,000 UNIT-9,500
3
UNIT-15,000 UNIT
CREON CAPSULE DR
PART 36,000 UNIT-114,000
3
UNIT-180,000 UNIT
CREON CAPSULE DR
PART 6,000 UNIT-19,000
3
UNIT-30,000 UNIT
PANCREAZE CAPSULE DR
PART 10,500 UNIT-25,000
3
UNIT-43,750 UNIT
111
Medicamento
Nivel Requisitos
Medicamento
/Límites
PART 16,800 UNIT-40,000
UNIT-70,000 UNIT
PART 21,000 UNIT-37,000
UNIT-61,000 UNIT
PART 4,200 UNIT-10,000
UNIT-17,500 UNIT
PERTZYE CAPSULE DR
PART 16,000 UNIT-57,500
UNIT-60,500 UNIT
PERTZYE CAPSULE DR
PART 8,000 UNIT-28,750
UNIT-30,250 UNIT
VIOKACE TABLET 10,440
UNIT-39,150 UNIT-39,150
UNIT
VIOKACE TABLET 20,880
UNIT-78,300 UNIT-78,300
UNIT
ZENPEP CAPSULE DR
PART 10,000 UNIT-34,000
UNIT-55,000 UNIT
ZENPEP CAPSULE DR
PART 15,000 UNIT-51,000
UNIT-82,000 UNIT
ZENPEP CAPSULE DR
PART 20,000 UNIT-68,000
UNIT-109,000 UNIT
ZENPEP CAPSULE DR
PART 25,000 UNIT-85,000
UNIT-136,000 UNIT
3
3
3
3
3
4
4
3
3
3
3
Nivel Requisitos
/Límites
ZENPEP CAPSULE DR
PART 3,000 UNIT-10,000
3
UNIT-16,000 UNIT
ZENPEP CAPSULE DR
PART 40,000 UNIT-136,000
3
UNIT-218,000 UNIT
ZENPEP CAPSULE DR
PART 5,000 UNIT-17,000
3
UNIT-27,000 UNIT
OXYTOCICOS
OXYTOCICOS
methylergonovine maleate
2
tablet 0.2mg
PREPARACIONES PARA EL OJO, OÍDO,
NARIZ, Y GARGANTA (en inglés EENT)
AGENTES ANTIALÉRGICOS
ALOMIDE SOLUTION 0.1
%
4 LC
dia(s)
azelastine hcl solution 0.05 %
2
azelastine hcl solution 137
2
mcg (0.1 %)
azelastine hcl solution 205.5
2
mcg (0.15 %)
BEPREVE SOLUTION 1.5 %
4 LC
dia(s)
EMADINE SOLUTION 0.05
4
%
LASTACAFT SOLUTION
0.25 %
4 LC
dia(s)
112
Medicamento
Nivel Requisitos
Medicamento
/Límites
olopatadine hcl solution 0.1 %
2
dia(s)
olopatadine hcl solution 0.6 % 2
PATADAY SOLUTION 0.2
%
4
dia(s)
PAZEO SOLUTION 0.7 %
4
dia(s)
AGENTES ANTIGLAUCOMA
ALPHAGAN P SOLUTION
0.1 %
3
dia(s)
AZOPT SUSPENSION 1 %
4
dia(s)
betaxolol hcl solution 0.5 %
2
BETOPTIC S SUSPENSION
3
0.25 %
bimatoprost solution 0.03 %
2
dia(s)
brimonidine tartrate solution
1
0.15 %
brimonidine tartrate solution
1
0.2 %
COMBIGAN SOLUTION 0.2
%-0.5 %
3
dia(s)
dorzolamide hcl solution 2 %
2
LC
LC
LC
LC
LC
LC
LC
Nivel Requisitos
/Límites
dorzolamide-timolol solution
2
22.3 mg-6.8 mg/ml
ISTALOL SOLUTION 0.5 %
4
latanoprost solution 0.005 %
2
levobunolol hcl solution 0.5 % 2
LUMIGAN SOLUTION 0.01
%
3 LC
dia(s)
methazolamide tablet 25mg
2
methazolamide tablet 50mg
2
metipranolol solution 0.3 %
2
PHOSPHOLINE IODIDE
4
FOR SOLUTION 0.125 %
SIMBRINZA SUSPENSION
1 %-0.2 %
4 LC
dia(s)
timolol maleate gel form soln
1
0.25 %
timolol maleate gel form soln
1
0.5 %
timolol maleate solution 0.25
1
%
timolol maleate solution 0.5 % 1
TIMOPTIC OCUDOSE
4
SOLUTION 0.25 %
TIMOPTIC OCUDOSE
4
SOLUTION 0.5 %
travoprost solution 0.004 %
2
AGENTES ANTIINFLAMITORIOS (EENT)
ACUVAIL SOLUTION 0.45
%
4 LC
113
Medicamento
Nivel Requisitos
Medicamento
/Límites
ALREX SUSPENSION 0.2 %
dia(s)
bromfenac sodium solution
0.09 %
phosphate solution 0.1 %
diclofenac sodium solution 0.1
%
DUREZOL EMULSION 0.05
%
dia(s)
FLAREX SUSPENSION 0.1
%
fluocinolone acetonide oil oil
0.01 %
fluorometholone suspension
0.1 %
flurbiprofen sodium solution
0.03 %
FML FORTE SUSPENSION
0.25 %
ILEVRO SUSPENSION 0.3
%
dia(s)
ketorolac tromethamine
solution 0.4 %
ketorolac tromethamine
solution 0.5 %
LOTEMAX GEL 0.5 %
4
LC
2
2
2
4
LC
4
2
2
2
4
4
LC
2
2
4
LC
Nivel Requisitos
/Límites
LOTEMAX OINTMENT 0.5
%
4 LC
LOTEMAX SUSPENSION
0.5 %
4 LC
dia(s)
MAXIDEX SUSPENSION
4
0.1 %
NEVANAC SUSPENSION
0.1 %
4 LC
dia(s)
PRED MILD SUSPENSION
0.12 %
4 LC
dia(s)
prednisolone sodium
2
phosphate solution 1 %
RESTASIS EMULSION 0.05
4
%
VEXOL SUSPENSION 1 %
4
ANESTÉSICOS LOCALES (EENT)
lidocaine hcl gel 2 %
2
lidocaine hcl solution 40
2
mg/ml
lidocaine hcl viscous solution
2
2%
proparacaine hcl solution 0.5
2
%
ANTIINFECTIVOS (EENT)
acetasol hc solution 2 %-1 %
2
acetic acid solution 2 %
2
AZASITE SOLUTION 1 %
4 LC
dia(s)
114
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
bacitracin-polymyxin ointment
500 unit-10,000 unit/gram
BACTROBAN NASAL
OINTMENT 2 %
BESIVANCE SUSPENSION
0.6 %
dia(s)
BLEPHAMIDE S.O.P.
OINTMENT 10 %-0.2 %
BLEPHAMIDE
SUSPENSION 10 %-0.2 %
CILOXAN OINTMENT 0.3
%
dia(s)
CIPRO HC SUSPENSION 0.2
%-1 %
CIPRODEX SUSPENSION
0.3 %-0.1 %
ciprofloxacin hcl solution 0.3
%
erythromycin ointment 5
mg/gram (0.5 %)
gatifloxacin solution 0.5 %
gentamicin sulfate ointment
0.3 %
gentamicin sulfate solution 0.3
%
hydrocortisone-acetic acid
solution 2 %-1 %
levofloxacin solution 0.5 %
MOXEZA SOLUTION 0.5 %
dia(s)
2
4
4
LC
4
4
4
LC
3
3
2
2
2
1
2
2
2
4
LC
/Límites
NATACYN SUSPENSION 5
%
neomycin-bacitracin-poly-hc
ointment 3.5 mg-400 unit10,000 unit/gram-1 %
neomycin-bacitracinpolymyxin ointment 3.5 mg400 unit-10,000 unit/gram
neomycin-polymyxindexameth ointment 3.5
mg/gram-10,000 unit/gram0.1 %
neomycin-polymyxindexameth suspension 3.5
mg/ml-10,000 unit/ml-0.1 %
neomycin-polymyxingramicidin solution 1.75 mg10,000 unit-0.025 mg/ml
neomycin-polymyxin-hc
suspension 3.5 mg-10,000
unit-10 mg/ml
neomycin-polymyxin-hc
suspension 3.5 mg/ml-10,000
unit/ml-1 %
neomycin-polymyxinhydrocort solution 3.5 mg/ml10,000 unit/ml-1 %
ofloxacin solution 0.3 %
polymyxin b sul-trimethoprim
solution 10,000 unit-1 mg/ml
PRED-G OINTMENT 0.3 %0.6 %
PRED-G SUSPENSION 0.3
%-1 %
sulfacetamide sodium
ointment 10 %
4
2
2
1
1
2
2
2
2
2
1
4
4
2
115
Medicamento
Nivel Requisitos
Medicamento
/Límites
sulfacetamide sodium solution
2
10 %
sulfacetamide-prednisolone
2
solution 10 %-0.23 % (0.25 %)
TOBRADEX OINTMENT 0.3
3
%-0.1 %
TOBRADEX ST
4
SUSPENSION 0.3 %-0.05 %
tobramycin solution 0.3 %
1
tobramycin-dexamethasone
2
suspension 0.3 %-0.1 %
TOBREX OINTMENT 0.3 %
4
trifluridine solution 1 %
2
VIGAMOX SOLUTION 0.5
%
4 LC
dia(s)
ZIRGAN GEL 0.15 %
4
ZYLET SUSPENSION 0.3 %4
0.5 %
EENT MEDICAMENTOS, MISCELÁNEO
apraclonidine hcl solution 0.5
2
%
carteolol hcl solution 1 %
2
IOPIDINE SOLUTION 1 %
4
2
21 mcg (0.03 %)
2
42 mcg (0.06 %)
VASOCONSTRICTORES
naphazoline hcl solution 0.1 %
4
TETRAHYDROZOLINE
4
HCL NASAL SOLN 0.05%
Nivel Requisitos
/Límites
PRODUCTOS DE LA SANGRE/
MODIFICADORES/EXPANSORES DE
VOLUMEN
COAGULANTES
tranexamic acid solution
2 BvsD
1,000 mg/10 ml (100 mg/ml)
tranexamic acid tablet 650mg
2
RELAJANTES DEL MÚSCULO LISO
RELAJANTES DE MÚSCULO LISO
GENITOURINARIO
darifenacin er tablet er 24hr
2
15mg
darifenacin er tablet er 24hr
2
7.5mg
flavoxate hcl tablet 100mg
2
GELNIQUE GEL 10 % (100
4
MG/GRAM)
MYRBETRIQ TABLET ER
4
24HR 25MG
MYRBETRIQ TABLET ER
4
24HR 50MG
oxybutynin chloride er tablet
2
er 24hr 10mg
2
er 24hr 15mg
2
er 24hr 5mg
oxybutynin chloride syrup 5
2
mg/5 ml
oxybutynin chloride tablet
2
5mg
tolterodine tartrate er capsule
2
er 24hr 2mg
tolterodine tartrate er capsule
2
er 24hr 4mg
116
Medicamento
Nivel Requisitos
Medicamento
/Límites
Nivel Requisitos
/Límites
tolterodine tartrate tablet 1mg
2
tolterodine tartrate tablet 2mg
2
TOVIAZ TABLET ER 24HR
3
4MG
TOVIAZ TABLET ER 24HR
3
8MG
trospium chloride er capsule
2
er 24hr 60mg
trospium chloride tablet 20mg
2
VESICARE TABLET 10MG
4
VESICARE TABLET 5MG
4
RELAJANTES DE MÚSCULO LISO
RESPIRATORIO
aminophylline inj 25 mg/ml
2 BvsD
theophylline anhydrous tablet
2
er 12hr 100mg
2
er 12hr 200mg
2
er 12hr 300mg
2
er 12hr 450mg
theophylline tablet er 24hr
2
400mg
theophylline tablet er 24hr
2
600mg
RENIN-ANGIOTENSIN-ALDOSTERONE
SYSTEM INHIBITORS, MISC
ANGIOTENSIN II RECEPTOR ANTAGONISTS
ENTRESTO TABLET 2426MG
3 LC; AP
3 LC; AP
3 LC; AP
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN AND MUCOUS
MEMBRANE)
ACANYA GEL 1.2 %-2.5 %
4
acyclovir ointment 5 %
2
ALTABAX OINTMENT 1 %
4
chlorhexidine gluconate
2
solution 0.12 %
ciclopirox cream 0.77 %
2
ciclopirox gel 0.77 %
2
ciclopirox shampoo 1 %
2
ciclopirox solution 8 %
2 NM
ciclopirox suspension 0.77 %
2
CLEOCIN SUPPOSITORY
3
100MG
CLEOCIN T GEL 1 %
4
CLINDACIN PAC KIT 1 %
4
clindamycin phosphate cream
2
2%
clindamycin phosphate foam 1
2
%
clindamycin phosphate gel 1
2
%
clindamycin phosphate lotion
2
1%
clindamycin phosphate
2
solution 1 %
117
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
clindamycin phosphate swab 1
%
clindamycin-benzoyl peroxide
gel 1 %-5 %
clotrimazole cream 1 %
clotrimazole solution 1 %
clotrimazole troche 10mg
clotrimazole-betamethasone
cream 1 %-0.05 %
clotrimazole-betamethasone
lotion 1 %-0.05 %
CORTISPORIN CREAM 3.5
MG/GRAM-10,000
UNIT/GRAM-0.5 %
CORTISPORIN OINTMENT
3.5 MG-400 UNIT-5,000
UNIT-10 MG/GRAM
DENAVIR CREAM 1 %
econazole nitrate cream 1 %
ery pad 2 %
erythromycin gel 2 %
erythromycin solution 2 %
erythromycin-benzoyl
peroxide gel 3 %-5 %
EURAX CREAM 10 %
EURAX LOTION 10 %
EXELDERM CREAM 1 %
EXELDERM SOLUTION 1
%
gentamicin sulfate cream 0.1
%
gentamicin sulfate ointment
0.1 %
ketoconazole cream 2 %
ketoconazole shampoo 2 %
lindane shampoo 1 %
metronidazole cream 0.75 %
2
2
2
2
2
2
2
4
4
4
2
2
2
2
2
4
4
4
4
2
2
2
2
2
2
/Límites
metronidazole gel 0.75 %
metronidazole gel 1 %
metronidazole lotion 0.75 %
MICONAZOLE 3
SUPPOSITORY 200MG
mupirocin cream 2 %
mupirocin ointment 2 %
naftifine hcl cream 2 %
NAFTIN GEL 1 %
NAFTIN GEL 2 %
neomycin-polymyxin b
solution 40 mg-200,000
unit/ml
nystatin cream 100,000
unit/gram
nystatin ointment 100,000
unit/gram
nystatin powder 100,000
unit/gram
nystatin-triamcinolone cream
100,000 unit/gram-0.1 %
nystatin-triamcinolone
ointment 100,000 unit/gram0.1 %
nystop powder 100,000
unit/gram
oxiconazole nitrate cream 1 %
OXISTAT LOTION 1 %
permethrin cream 5 %
silver sulfadiazine cream 1 %
ssd cream 1 %
sulfacetamide sodium
suspension 10 %
terconazole cream 0.4 %
terconazole cream 0.8 %
2
2
2
4
2
2
2
4
4
2
1
2
2
2
2
2
2
4
2
2
2
2
2
2
118
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
terconazole suppository 80mg
2
terconazole vaginal cream
2
0.8%
vandazole gel 0.75 %
2
ZIANA GEL 1.2 %-0.025 %
4
ZOVIRAX CREAM 5 %
4
SUEROS, TOXOIDES Y VACUNAS
SUEROS
BIVIGAM SOLUTION 10 %
5 AP
CARIMUNE NF
NANOFILTERED FOR
4 AP
SOLUTION 6 GRAM
FLEBOGAMMA DIF
5 AP
SOLUTION 10 %
GAMASTAN S-D
INJECTABLE 15 %-18 %
3 AP
RANGE
GAMMAGARD LIQUID
5 AP
SOLUTION 10 %
GAMMAKED SOLUTION 1
5 AP
GRAM/10 ML (10 %)
GAMMAPLEX SOLUTION
5 AP
5%
GAMUNEX-C SOLUTION 1
4 AP
GRAM/10 ML (10 %)
OCTAGAM SOLUTION 10
5 AP
%
OCTAGAM SOLUTION 5 %
5 AP
PRIVIGEN SOLUTION 10 % 5 AP
TOXOIDES
ADACEL TDAP
SUSPENSION 2 LF UNIT3
(2.5-5-3-5 MCG)-5 LF
UNIT/0.5 ML
/Límites
BOOSTRIX TDAP
SUSPENSION 2.5 LF UNIT(2.5 MCG-8 MCG-8 MCG)-5
LF UNIT/0.5 ML
DAPTACEL DTAP
SUSPENSION 15 LF UNIT10 MCG-5 LF UNIT/0.5 ML
diphtheria-tetanus toxoids-ped
suspension 5 lf unit-25 lf
unit/0.5 ml
INFANRIX DTAP
SUSPENSION 25 LF UNIT58 MCG-10 LF/0.5 ML
TENIVAC INJECTABLE 5
LF UNIT-2 LF UNIT/0.5 ML
tetanus diphtheria toxoids
suspension 2 lf unit-2 lf
unit/0.5 ml
VACUNAS
ACTHIB FOR SOLUTION
10 MCG/0.5 ML
bcg vaccine (tice strain)
injectable 50mg
BEXSERO SUSP PREF SYR
50 MCG-50 MCG-50 MCG25 MCG/0.5 ML
CERVARIX SUSPENSION
20 MCG-20 MCG/0.5 ML
ENGERIX-B ADULT
SUSPENSION 20 MCG/ML
ENGERIX-B PEDIATRICADOLESCENT
SUSPENSION 10 MCG/0.5
ML
3
3
2
3
3
2
3
3
3
3
3
BvsD
3
BvsD
119
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
GARDASIL 9 SUSP PREF
SYR 0.5 ML
GARDASIL 9 SUSPENSION
0.5 ML
GARDASIL SUSPENSION
20 MCG-40 MCG-40 MCG20 MCG/0.5 ML
HAVRIX SUSPENSION
1,440 ELISA UNIT/ML
HAVRIX SUSPENSION 720
ELISA UNIT/0.5 ML
HIBERIX FOR SOLUTION
10 MCG/0.5 ML
HYPERRAB S-D
INJECTABLE 150 UNIT/ML
IMOVAX RABIES
VACCINE INJECTABLE 2.5
UNIT
IPOL INJECTABLE 40
UNIT-8 UNIT-32 UNIT/0.5
ML
IXIARO SUSPENSION 6
MCG/0.5 ML
M-M-R II VACCINE
INJECTABLE 1,000-12,5001,000 TCID50/0.5 ML
MENACTRA INJECTABLE
4 MCG/0.5 ML
MENHIBRIX FOR
SOLUTION 5 MCG-2.5
MCG/0.5 ML
MENOMUNE-A-C-Y-W-135
INJECTABLE 50 MCG
MENVEO A-C-Y-W-135-DIP
FOR SOLUTION 10 MCG-5
MCG/0.5 ML
3
3
3
3
3
3
3
3
3
3
3
3
3
3
/Límites
PEDVAXHIB SUSPENSION
7.5 MCG/0.5 ML
PROQUAD INJECTABLE
10EXP3-10EXP4.3-10EXP310EXP3.99 TCID50/0.5 ML
QUADRACEL DTAP-IPV
SUSPENSION 15 LF UNIT(20-20-5-3 MCG)-5 LF
UNIT-(40-8-32 UNIT)/0.5
ML
RABAVERT FOR
SUSPENSION 2.5 UNIT
RECOMBIVAX HB
RECOMBIVAX HB
RECOMBIVAX HB
SUSPENSION 5 MCG/0.5
ML
ROTARIX FOR
SUSPENSION 10EXP6
CCID50/ML
ROTATEQ SOLUTION 2
ML
TRUMENBA SUSP PREF
SYR 120 MCG/0.5 ML
TWINRIX SUSPENSION 720
ELISA UNIT-20 MCG/ML
TYPHIM VI SOLUTION 25
MCG/0.5 ML
VAQTA SUSPENSION 25
UNIT/0.5 ML
VAQTA SUSPENSION 50
UNIT/ML
3
3
3
3
3
BvsD
3
BvsD
3
BvsD
3
3
3
3
BvsD
3
3
3
3
120
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
VARIVAX VACCINE
INJECTABLE 1,350
UNIT/0.5 ML
YF-VAX INJECTABLE 10
EXP4.74 UNIT/0.5 ML
ZOSTAVAX FOR
SOLUTION 19,400
UNIT/0.65 ML
SUMINISTROS
SUMINISTROS
*alcohol swabs***
gauze pads pad 2" x 2"
insulin 1 ml syringe
insulin 1/2 ml syringe
INSULIN SYRINGE 0.3 ML
PEN NEEDLES 12MM 29G
VITAMINAS
VITAMINA D
calcitriol capsule 0.25 mcg
calcitriol capsule 0.5 mcg
calcitriol solution 1 mcg/ml
doxercalciferol capsule 0.5
mcg
doxercalciferol capsule 1 mcg
doxercalciferol capsule 2.5
mcg
doxercalciferol solution 4
mcg/2 ml
paricalcitol capsule 1 mcg
/Límites
paricalcitol solution 2 mcg/ml
paricalcitol solution 5 mcg/ml
VITAMINAS
PRENATAL VITAMINS
sodium fluoride tab 1 mg f
(from 2.2 mg naf)
3
3
3
2
2
2
BvsD
BvsD
3
2
2
2
LC
2
LC
2
LC
2
LC
2
LC
2
2
2
2
2
2
2
BvsD
2
2
121
Índice
*alcohol swabs*** ................ 121
*amino acid electrolyte infusion
8.5%*** ................................... 75
*AMINO ACID INFUSION
8.5%*** ................................... 75
8-MOP ..................................... 30
abacavir ..................................... 9
abacavir-lamivudinezidovudine ................................. 9
ABILIFY MAINTENA ........... 38
ABRAXANE ........................... 20
ABSTRAL ............................... 47
acamprosate calcium ............... 37
ACANYA .............................. 117
acarbose ................................... 79
acebutolol hcl .......................... 94
acetaminophen-codeine ........... 47
acetasol hc ............................. 114
acetazolamide .......................... 98
acetic acid .............................. 114
acetylcysteine .......................... 67
acitretin .................................... 30
ACTEMRA ............................. 64
ACTHIB ................................ 119
ACTIMMUNE ........................ 68
ACTOPLUS MET XR ............ 79
ACUVAIL ............................. 113
acyclovir ............................. 9,117
acyclovir sodium ....................... 9
ACZONE ................................. 30
ADACEL TDAP ................... 119
ADAGEN ................................ 78
adapalene ................................. 30
ADCIRCA ............................. 105
adefovir dipivoxil ...................... 9
ADEMPAS ............................ 105
ADRENALIN .......................... 91
ADVAIR DISKUS .................. 91
ADVAIR HFA ........................ 91
afeditab cr ................................ 98
AFINITOR .............................. 20
AFINITOR DISPERZ ............. 20
AKYNZEO ........................... 110
ALBENZA ............................... 7
albuterol 5 mg/ml solution...... 91
albuterol sul 0.63 mg/3 ml sol 91
albuterol sul 1.25 mg/3 ml sol 91
albuterol sul 2.5 mg/3 ml soln 91
albuterol sulfate ...................... 91
alclometasone dipropionate .... 28
ALDACTAZIDE .................... 98
ALDURAZYME .................... 78
ALECENSA ........................... 20
alendronate sodium ................. 67
alfuzosin hcl er........................ 94
ALIMTA................................. 20
ALINIA .................................... 8
allopurinol............................... 64
ALOCRIL ............................... 31
alogliptin ................................. 79
alogliptin-metformin .......... 79,80
alogliptin-pioglitazone ............ 80
ALOMIDE ............................ 112
alosetron hcl .......................... 110
ALPHAGAN P ..................... 113
alprazolam .............................. 63
alprazolam er .......................... 63
ALPRAZOLAM INTENSOL 63
alprazolam odt ........................ 63
alprazolam xr .......................... 63
ALREX ................................. 114
ALTABAX ........................... 117
ALTOPREV ........................... 96
ALVESCO .............................. 31
amantadine ................................ 9
AMBISOME............................. 7
amcinonide ............................. 28
amethia ................................... 86
amethyst .................................. 86
amifostine ............................... 66
amikacin sulfate ...................... 13
122
amiloride hcl............................. 98
amiloride-hydrochlorothiazide . 98
amino acids............................... 75
aminophylline inj 25 mg/ml ... 117
AMINOSYN II ........................ 75
aminosyn ii with electrolytes ... 75
AMINOSYN M ........................ 75
AMINOSYN WITH
ELECTROLYTES ................... 75
AMINOSYN-HBC ................... 75
AMINOSYN-PF ...................... 75
AMINOSYN-RF ...................... 75
amiodarone hcl ....................... 107
AMITIZA ............................... 111
amitriptyline hcl ....................... 38
amlodipine besylate.................. 98
amlodipine besylate-benazepril 98
amlodipine-atorvastatin ............ 96
amlodipine-valsartan ................ 99
amlodipine-valsartan-hctz ........ 99
amoxapine ................................ 38
amoxicillin ............................... 13
amoxicillin-clavulanate pot er .. 13
............................................. 13,14
amphotericin b ............................ 7
ampicillin sodium ..................... 14
ampicillin trihydrate ................. 14
ampicillin-sulbactam ................ 14
AMPYRA................................. 69
anagrelide hcl ........................... 71
anastrozole................................ 20
ANDRODERM ........................ 85
ANDROGEL ............................ 85
ANORO ELLIPTA .................. 91
APLENZIN .............................. 38
APOKYN ................................. 34
apraclonidine hcl .................... 116
apri............................................ 86
APRISO ................................. 108
APTIOM .................................. 58
APTIVUS ................................... 9
ARALAST NP ......................... 33
aranelle ..................................... 86
ARANESP ........................... 73,74
ARCALYST ............................. 69
ARCAPTA NEOHALER ......... 91
aripiprazole ............................... 38
aripiprazole odt ......................... 38
ARISTADA .............................. 38
armodafinil .......................... 54,55
ARNUITY ELLIPTA ............... 91
ARRANON .............................. 20
ASACOL HD ......................... 108
ascomp with codeine ................ 47
ASENAPINE MALEATE SL
TAB 10 MG (BASE EQUIV) .. 38
ASMANEX ......................... 31,32
ASMANEX HFA ..................... 32
aspirin-dipyridamole er ............ 72
ASTAGRAF XL....................... 66
atenolol ..................................... 94
atenolol-chlorthalidone ............. 94
ATGAM ................................... 66
atorvastatin calcium .................. 96
atovaquone.................................. 8
atovaquone-proguanil hcl ........... 8
ATRIPLA ................................... 9
ATROVENT HFA ................... 90
AUBAGIO................................ 68
AURYXIA................................ 76
AVANDIA ............................... 80
AVASTIN ................................ 21
AVELOX ABC PACK ............... 7
aviane........................................ 86
avita .......................................... 31
AVONEX ................................. 68
AVONEX PEN......................... 68
AXIRON .................................. 85
azacitidine ................................. 21
AZASAN .................................. 66
AZASITE ............................... 114
azathioprine.............................. 66
azelastine hcl .......................... 112
AZELEX .................................. 30
AZILECT ................................. 34
azithromycin ............................ 14
AZOPT .................................. 113
AZOR ...................................... 99
aztreonam ................................. 14
bacitracin-polymyxin ............. 115
baclofen .................................... 94
BACTROBAN NASAL ........ 115
balsalazide disodium .............. 108
balziva ...................................... 86
BANZEL.................................. 58
BARACLUDE ........................... 9
bcg vaccine (tice strain) ......... 119
BECONASE AQ ..................... 32
BELEODAQ ............................ 21
benazepril hcl ........................... 99
benazepril-hydrochlorothiazide 99
BENICAR ................................ 99
BENICAR HCT ....................... 99
BENLYSTA ............................ 66
benztropine mesylate .......... 34,35
BEPREVE.............................. 112
BESIVANCE ......................... 115
betamethasone dipropionate .... 28
betamethasone valerate ............ 28
BETASERON .......................... 68
betaxolol hcl................. 94,99,113
bethanechol chloride ................ 93
BETHKIS 300 MG/4 ML
AMPULE ................................. 14
BETOPTIC S ......................... 113
bexarotene ................................ 21
BEXSERO ............................. 119
BEYAZ .................................... 86
bicalutamide ............................. 21
BICILLIN C-R......................... 14
123
BICILLIN L-A ........................ 14
BICNU .................................... 21
BILTRICIDE ............................ 7
bimatoprost............................ 113
bisoprolol fumarate ................. 94
bisoprololhydrochlorothiazide................. 94
BIVIGAM ............................. 119
bleomycin sulfate .................... 21
BLEPHAMIDE ..................... 115
BLEPHAMIDE S.O.P. .......... 115
blisovi fe .................................. 86
BOOSTRIX TDAP ............... 119
BOSULIF ................................ 21
BREO ELLIPTA ..................... 92
briellyn .................................... 86
BRILINTA .............................. 72
brimonidine tartrate ............... 113
bromfenac sodium ................. 114
bromocriptine mesylate ........... 35
BROVANA 15 MCG/2 ML
SOLUTION ............................. 92
budesonide .............................. 32
budesonide ec .......................... 78
bumetanide .............................. 99
buprenorphine hcl.................... 47
buprenorphine-naloxone ......... 47
buproban .................................. 39
bupropion hcl .......................... 39
bupropion hcl sr ...................... 39
bupropion xl ............................ 39
buspirone hcl ........................... 57
BUSULFEX ............................ 21
butalb-acetaminoph-caffcodein ...................................... 47
butalb-caff-acetaminophcodein ...................................... 47
butalbital compound-codeine .. 47
butalbital-acetaminophencaffe .................................... 47,48
butalbital-aspirin-caffeine ....... 48
butorphanol tartrate ................. 48
BYDUREON .......................... 80
BYDUREON PEN .................. 80
BYETTA .................................. 80
BYSTOLIC .............................. 94
cabergoline ............................... 35
CABOMETYX ......................... 21
calcipotriene ............................. 30
calcipotriene-betamethasone dp 28
calcitonin-salmon ..................... 89
calcitriol ............................. 30,121
calcium acetate ......................... 76
CAMBIA .................................. 48
camila ....................................... 86
CANASA................................ 108
CANCIDAS................................ 7
candesartan cilexetil .......... 99,100
candesartan-hydrochlorothiazid
................................................ 100
CAPASTAT SULFATE ............. 7
CAPEX SHAMPOO ................ 28
CAPITAL W-CODEINE ......... 48
CAPRELSA.............................. 21
captopril .................................. 100
captopril-hydrochlorothiazide 100
CARAFATE ........................... 108
CARBAGLU ............................ 76
carbamazepine .......................... 58
carbamazepine er ...................... 58
carbidopa .................................. 37
carbidopa-levodopa .................. 35
carbidopa-levodopa er .............. 35
carbidopa-levodopa-entacapone35
carboplatin ................................ 21
CARDURA XL ........................ 94
CARIMUNE NF
NANOFILTERED.................. 119
carteolol hcl ............................ 116
cartia xt ................................... 100
carvedilol .................................. 94
CAYSTON ............................... 14
CEDAX .................................... 14
cefaclor ................................ 14,15
cefaclor er ................................. 15
cefadroxil ................................. 15
cefazolin sodium ...................... 15
cefdinir ..................................... 15
cefepime hcl ............................. 15
cefepime-dextrose .................... 15
cefixime ................................... 15
cefotaxime sodium ................... 15
cefoxitin ................................... 15
cefoxitin sodium ...................... 15
cefpodoxime proxetil ............... 15
cefprozil ................................... 15
ceftazidime ............................... 15
CEFTIN ................................... 15
ceftriaxone .......................... 15,16
cefuroxime ............................... 16
cefuroxime sodium .................. 16
celecoxib .................................. 48
CELONTIN ............................. 58
cephalexin ................................ 16
CERDELGA ............................ 78
CEREBYX ............................... 58
CEREZYME ............................ 78
CERVARIX ........................... 119
CESAMET ............................. 110
cetirizine hcl ............................. 90
cevimeline hcl .......................... 93
CHANTIX ............................... 93
CHEMET ................................. 71
CHENODAL ......................... 110
chloramphenicol sod succinate 16
chlorhexidine gluconate ......... 117
chloroquine phosphate ............... 8
chlorothiazide......................... 100
chlorpromazine hcl .................. 39
chlorthalidone ........................ 100
cholestyramine light ................. 96
chorionic gonadotropin ............ 89
ciclopirox ............................... 117
cidofovir ..................................... 9
124
cilostazol................................... 72
CILOXAN .............................. 115
cimetidine ............................... 108
CIMZIA .................................... 64
CINRYZE ................................. 68
CIPRO HC .............................. 115
CIPRODEX ............................ 115
ciprofloxacin ............................. 16
ciprofloxacin er......................... 16
ciprofloxacin hcl ................ 16,115
ciprofloxacin-d5w .................... 16
cisplatin .................................... 21
citalopram hbr........................... 39
cladribine .................................. 21
claravis...................................... 30
CLARINEX .............................. 90
CLARINEX-D 12 HOUR ........ 90
clarithromycin .......................... 16
clarithromycin er ...................... 16
CLEOCIN ............................... 117
CLEOCIN T ........................... 117
CLINDACIN PAC ................. 117
clindamycin hcl ........................ 16
clindamycin pediatric ............... 16
clindamycin
phosphate .................... 16,117,118
clindamycin phosphate-d5w ..... 16
clindamycin-benzoyl peroxide 118
CLINIMIX................................ 75
CLINIMIX E ............................ 75
clinisol ...................................... 75
clobetasol emollient .................. 28
clobetasol propionate ................ 28
CLODERM .............................. 28
CLOLAR .................................. 21
clomipramine hcl ...................... 39
clonazepam ............................... 63
clonidine ................................. 100
clonidine hcl ........................... 100
clonidine hcl er ....................... 100
clopidogrel ................................ 72
clorazepate dipotassium ........... 63
CLORPRES ............................ 100
clotrimazole ............................ 118
clotrimazole-betamethasone ... 118
clozapine ................................... 39
clozapine odt............................. 39
clozapine orally disintegrating tab
100 mg ...................................... 39
200 mg ...................................... 39
25 mg ........................................ 39
COARTEM ................................ 8
codeine sulfate .......................... 48
colchicine.................................. 64
colestipol hcl............................. 96
colistimethate............................ 16
colocort ..................................... 28
COMBIGAN .......................... 113
COMBIVENT RESPIMAT ..... 90
COMETRIQ ............................. 21
COMPLERA .............................. 9
compro ...................................... 39
CONDYLOX............................ 30
constulose ................................. 76
COPAXONE ............................ 68
CORDRAN .............................. 28
COREG CR .............................. 94
CORLANOR ............................ 95
cortisone acetate ....................... 78
CORTISPORIN ...................... 118
COSENTYX PEN .................... 30
COSENTYX SYRINGE .......... 30
COTELLIC ............................... 21
COUMADIN ............................ 72
CREON .................................. 111
CRESEMBA .............................. 7
CRESTOR ................................ 97
CRIXIVAN ................................ 9
cromolyn 20 mg/2 ml neb soln . 32
cromolyn sodium ...................... 32
cryselle ......................................86
CUBICIN ..................................16
cyclafem ....................................86
cyclobenzaprine hcl ..................94
cyclophosphamide.....................21
CYCLOSET ..............................35
cyclosporine ..............................66
cyclosporine modified ...............66
CYRAMZA...............................21
CYSTADANE ..........................69
CYSTAGON .............................69
CYSTARAN .............................69
cytarabine ..................................21
DAKLINZA ................................9
DALIRESP ...............................33
DALVANCE.............................16
danazol ......................................85
dantrolene sodium .....................94
dapsone .......................................7
DAPTACEL DTAP ................119
DARAPRIM .............................17
darifenacin er ..........................116
DARZALEX .............................21
daunorubicin hcl........................21
DAYTRANA ............................55
decitabine ..................................21
DELZICOL .............................108
DEMSER ..................................69
DENAVIR...............................118
DEPEN......................................71
DEPO-ESTRADIOL.................88
DEPO-SUBQ PROVERA 104 .89
DESCOVY..................................9
desipramine hcl .........................39
desloratadine .............................90
desmopressin acetate ............69,70
desogestr-eth estrad eth estra ....86
DESONATE .............................28
desonide ....................................28
125
desonide lotion 0.05% ............. 28
desoximetasone................... 28,29
dexamethasone ................... 78,79
DEXAMETHASONE
INTENSOL.............................. 78
phosphate .......................... 78,114
DEXILANT ........................... 108
dexmethylphenidate hcl er ....... 55
DEXPAK ................................. 79
dextroamphetamine sulfate er.. 55
dextroamphetamine-amphet er 55
dextroamphetamineamphetamine....................... 55,56
dextrose 10%-0.2% nacl .......... 75
dextrose 10%-0.45% nacl ........ 75
dextrose 2.5%-0.45% nacl ....... 75
dextrose 5%-0.2% nacl ............ 75
dextrose 5%-0.2% nacl-kcl ...... 76
dextrose 5%-0.225% nacl ........ 75
dextrose 5%-0.225% nacl-kcl .. 76
dextrose 5%-0.33% nacl .......... 75
dextrose 5%-0.33% nacl-kcl .... 76
dextrose 5%-0.45% nacl .......... 75
dextrose 5%-0.45% nacl-kcl .... 76
dextrose 5%-0.9% nacl ............ 75
dextrose 5%-1/2ns-kcl ........ 76,77
dextrose 5%-ns-kcl .................. 77
dextrose 5%-potassium
chloride .................................... 77
dextrose in lactated ringers ...... 77
dextrose in water...................... 75
diazepam .................................. 63
diclofenac potassium ............... 48
diclofenac sodium ........ 30,48,114
diclofenac sodium er................ 48
diclofenac sodium-misoprostol 48
dicloxacillin sodium ................ 17
dicyclomine hcl ....................... 90
didanosine .................................. 9
DIFFERIN ............................... 30
DIFICID .................................. 17
diflorasone diacetate ................ 29
diflunisal .................................. 48
digoxin ................................... 107
dihydroergotamine mesylate ... 95
DILANTIN .............................. 58
DILANTIN-125....................... 58
diltiazem 12hr er .................... 100
diltiazem 24hr cd ................... 100
diltiazem 24hr er .................... 101
diltiazem er ............................ 101
diltiazem hcl .......................... 101
dilt-xr ..................................... 100
DIPENTUM .......................... 108
diphenhydramine hcl ............... 95
diphenoxylate-atropine .......... 110
diphtheria-tetanus toxoidsped ......................................... 119
disulfiram............................ 37,67
DIURIL ................................. 101
divalproex sodium ................... 59
divalproex sodium 125 mg cap 59
divalproex sodium er ............... 59
docetaxel .................................. 21
dofetilide ................................ 107
donepezil hcl............................ 93
donepezil hcl odt ..................... 93
dorzolamide hcl ..................... 113
dorzolamide-timolol .............. 113
doxazosin mesylate.................. 95
doxepin hcl .................... 31,39,40
doxercalciferol ....................... 121
doxorubicin hcl ........................ 22
doxorubicin hcl liposome ........ 21
doxycycline hyclate ................. 17
doxycycline monohydrate ....... 17
dronabinol .............................. 110
drospirenone-ethinyl estradiol . 86
DROXIA ................................. 22
DUEXIS .................................. 48
DULERA ................................. 92
duloxetine hcl .......................... 40
duramorph .............................. 48
DUREZOL ........................... 114
dutasteride .............................. 67
dutasteride-tamsulosin ........... 95
DYMISTA ............................. 32
E.E.S. 200............................... 17
econazole nitrate .................. 118
EDARBI ............................... 101
EDARBYCLOR................... 101
EDECRIN ............................ 101
EDURANT............................... 9
EFFIENT ................................ 72
ELAPRASE ........................... 78
ELELYSO .............................. 78
ELIDEL.................................. 30
ELIGARD .............................. 22
ELIQUIS ................................ 72
ELITEK .................................. 78
ELIXOPHYLLIN................. 101
ELMIRON ............................. 70
EMADINE ........................... 112
EMCYT.................................. 22
EMEND ............................... 110
emoquette ............................... 86
EMPLICITI ............................ 22
EMSAM ................................. 40
EMTRIVA ............................... 9
enalapril maleate .................. 101
enalaprilhydrochlorothiazide ............. 101
ENBREL ................................ 64
endocet ................................... 48
ENGERIX-B ADULT.......... 119
ENGERIX-B PEDIATRICADOLESCENT ................... 119
enoxaparin sodium ................. 72
entacapone .............................. 35
entecavir ................................... 9
ENTRESTO ......................... 117
enulose ................................... 76
EPIDUO ................................. 30
126
EPIDUO FORTE ..................... 30
epinephrine ............................... 92
EPIPEN 2-PAK ........................ 92
EPIPEN JR 2-PAK................... 92
epirubicin hcl ............................ 22
epitol ......................................... 59
EPIVIR HBV ............................. 9
eplerenone .............................. 101
EPOGEN .................................. 74
eprosartan mesylate ................ 101
EPZICOM .................................. 9
EQUETRO ............................... 59
ERBITUX ................................ 22
ergoloid mesylates .................... 95
ERIVEDGE .............................. 22
errin .......................................... 86
ERWINAZE ............................. 22
ery........................................... 118
ERYPED 200 ........................... 17
ERYPED 400 ........................... 17
ERY-TAB ................................ 17
ERYTHROCIN LACTOBIONATE
.................................................. 17
ERYTHROCIN STEARATE... 17
erythromycin .............. 17,115,118
erythromycin-benzoyl peroxide118
ESBRIET.................................. 33
escitalopram oxalate ................. 40
esomeprazole magnesium 108,109
esomeprazole sodium ............. 109
ESTRACE ................................ 88
estradiol .................................... 88
eszopiclone ............................... 57
ethambutol hcl ............................ 7
ethosuximide ............................ 59
etidronate disodium .................. 67
etodolac .................................... 48
etodolac er ................................ 48
etoposide .................................. 22
EURAX .................................. 118
EVEKEO .................................. 56
EVOTAZ .................................... 9
EVZIO ...................................... 58
EXELDERM .......................... 118
exemestane ............................... 22
EXJADE ................................... 71
EXTAVIA ................................ 68
FABRAZYME ......................... 78
famciclovir.................................. 9
famotidine ............................... 109
FANAPT .................................. 40
FARESTON ............................. 22
FARXIGA ................................ 80
FARYDAK ............................... 22
FASLODEX ............................. 22
felbamate .................................. 59
felodipine er ............................ 101
FEMRING ................................ 88
fenofibrate ................................ 97
fenofibric acid........................... 97
fenoprofen calcium .............. 48,49
fentanyl ..................................... 49
fentanyl citrate .......................... 49
FENTORA................................ 49
FERRIPROX ............................ 71
FETZIMA ................................. 40
FINACEA ................................. 30
finasteride ................................. 67
FIRAZYR ................................. 68
FIRMAGON ............................. 22
FLAREX ................................ 114
flavoxate hcl ........................... 116
FLEBOGAMMA DIF ............ 119
flecainide acetate .................... 107
FLECTOR ................................ 49
FLOVENT DISKUS ................ 32
FLOVENT HFA ....................... 32
fluconazole ................................. 7
fluconazole in dextrose ............... 7
fluconazole-nacl ........................ 7
flucytosine................................. 7
fludarabine phosphate ............. 22
fludrocortisone acetate ............ 79
flunisolide ............................... 32
fluocinolone acetonide ............ 29
fluocinolone acetonide oil..... 114
fluocinonide ............................ 29
fluocinonide-e ......................... 29
fluorometholone .................... 114
fluorouracil ........................ 22,30
fluoxetine dr ............................ 41
fluoxetine hcl .......................... 41
fluphenazine decanoate ........... 41
fluphenazine hcl ...................... 41
flurbiprofen ............................. 49
flurbiprofen sodium .............. 114
flutamide ................................. 22
fluticasone propionate ........ 29,32
fluvastatin er ........................... 97
fluvastatin sodium ................... 97
fluvoxamine maleate ............... 41
fluvoxamine maleate er........... 41
FML FORTE ........................ 114
FOCALIN XR ........................ 56
FOLOTYN .............................. 22
fondaparinux sodium .............. 72
FORADIL ............................... 92
FORFIVO XL ......................... 41
FORTEO ................................. 89
FORTICAL ............................. 89
fosinopril sodium .................. 101
fosinoprilhydrochlorothiazide .............. 101
FOSRENOL ............................ 76
FREAMINE HBC ................... 75
furosemide ............................ 101
FUZEON................................... 9
FYCOMPA ............................. 59
gabapentin ............................... 49
127
GABITRIL ............................... 59
galantamine hbr ........................ 93
galantamine hydrobromide ...... 93
GAMASTAN S-D.................. 119
GAMMAGARD LIQUID ...... 119
GAMMAKED ........................ 119
GAMMAPLEX ...................... 119
GAMUNEX-C ....................... 119
ganciclovir sodium ..................... 9
GARDASIL ........................... 120
GARDASIL 9 ........................ 120
gatifloxacin............................. 115
GATTEX ................................ 111
gauze pads .............................. 121
gavilyte-c ................................ 111
gavilyte-g ............................... 111
gavilyte-h and bisacodyl ........ 111
gavilyte-n ............................... 111
GELNIQUE ........................... 116
gemfibrozil ............................... 97
generlac .................................... 76
gengraf ..................................... 66
gentamicin sulfate ...... 18,115,118
gentamicin sulfate in ns....... 17,18
gentamicin sulfate iv soln 10
mg/ml ....................................... 18
GENVOYA ................................ 9
GEODON ................................. 41
gildagia ..................................... 88
GILENYA ................................ 68
GILOTRIF ............................... 22
GLASSIA ................................. 33
GLEEVEC ............................... 22
GLEOSTINE ............................ 22
glimepiride ............................... 80
glipizide.................................... 80
glipizide er................................ 80
glipizide-metformin ................. 80
GLUCAGEN ............................ 70
GLUCAGON EMERGENCY
KIT ........................................... 70
GLUMETZA ...........................80
glycopyrrolate ..........................90
GLYSET ..................................80
GLYXAMBI ......................80,81
GOLYTELY ..........................111
GRALISE ................................50
GRALISE 30-DAY STARTER
PACK ......................................49
granisetron hcl .......................110
GRANIX .................................74
GRASTEK...............................70
griseofulvin ................................8
griseofulvin ultramicrosize ........8
GRIS-PEG ..............................7,8
guanidine hcl ...........................70
H.P. ACTHAR ........................70
HALAVEN ..............................23
halobetasol propionate .............29
HALOG ...................................29
haloperidol ...............................41
haloperidol decanoate ..............41
haloperidol lactate ...................41
HARVONI...............................10
HAVRIX ...............................120
heparin sodium ........................72
HEPATAMINE .......................75
HERCEPTIN ...........................23
HETLIOZ ................................57
HEXALEN ..............................23
HIBERIX ...............................120
HORIZANT.............................50
HUMIRA .................................65
HUMIRA PEDIATRIC
CROHN'S ...........................64,65
HUMIRA PEN ........................65
HUMIRA PEN CROHN'S-UCHS ............................................65
hydralazine hcl ......................101
hydrochlorothiazide ........101,102
hydrocodone-acetaminophen...50
hydrocodone-ibuprofen ...........50
hydrocortisone ....................29,79
hydrocortisone butyrate ........... 29
hydrocortisone valerate ............ 29
hydrocortisone-acetic acid ..... 115
hydromorphone er .................... 50
hydromorphone hcl .................. 50
hydroxychloroquine sulfate ....... 8
hydroxyurea ............................. 23
hydroxyzine hcl ........................ 58
HYPERRAB S-D ................... 120
ibandronate sodium .................. 67
IBRANCE ................................ 23
ibuprofen .................................. 50
ICLUSIG .................................. 23
idarubicin hcl ........................... 23
ifosfamide ................................ 23
ILARIS ..................................... 70
ILEVRO ................................. 114
IMBRUVICA ........................... 23
imipenem-cilastatin sodium ..... 18
imipramine hcl ......................... 41
imipramine pamoate................. 41
imiquimod ................................ 30
IMOVAX RABIES
VACCINE .............................. 120
INCRELEX .............................. 86
INCRUSE ELLIPTA ............... 92
indapamide ............................. 102
INFANRIX DTAP ................. 119
INLYTA ................................... 23
insulin 1 ml syringe ................ 121
insulin 1/2 ml syringe............. 121
INSULIN SYRINGE 0.3 ML 121
INTELENCE............................ 10
INTRON A............................... 10
introvale ................................... 86
INVANZ .................................. 18
INVEGA SUSTENNA ....... 41,42
INVEGA TRINZA................... 42
INVIRASE ............................... 10
INVOKAMET ......................... 81
128
INVOKANA ............................. 81
IONOSOL B WITH DEXTROSE
5% ............................................. 77
IONOSOL MB-DEXTROSE 5%77
IOPIDINE ............................... 116
IPOL ....................................... 120
ipratropium bromide .......... 90,116
ipratropium-albuterol ................ 90
irbesartan................................. 102
irbesartan-hydrochlorothiazide102
IRESSA..................................... 23
irinotecan hcl ............................ 23
ISENTRESS ............................. 10
ISOLYTE P WITH DEXTROSE77
ISOLYTE S .............................. 77
isoniazid ...................................... 7
ISORDIL................................. 105
isosorbide dinitrate.................. 105
isosorbide mononitrate............ 106
isosorbide mononitrate er 105,106
isradipine................................. 102
ISTALOL................................ 113
ISTODAX ................................. 23
itraconazole ................................. 8
ivermectin ................................... 7
IXEMPRA ................................ 23
IXIARO .................................. 120
JADENU ................................... 71
JAKAFI..................................... 23
jantoven................................ 72,73
JANUMET................................ 81
JANUMET XR ......................... 81
JANUVIA ................................. 81
JARDIANCE ............................ 81
JENTADUETO......................... 81
JEVTANA ................................ 23
jolivette ..................................... 86
junel .......................................... 86
junel fe ...................................... 86
junel fe 24 ................................. 86
JUXTAPID ............................... 97
KADCYLA .............................. 23
KADIAN .................................. 50
KALETRA ............................... 10
KALYDECO ............................ 33
KANUMA ................................ 78
kariva ........................................ 86
KAZANO ................................. 81
kelnor 1-35 ............................... 86
KENALOG ............................... 29
KEPIVANCE ........................... 31
KETEK ..................................... 18
ketoconazole ........................ 8,118
ketoprofen ................................. 50
ketorolac tromethamine .......... 114
KEYTRUDA ............................ 23
KHEDEZLA ............................. 42
KINERET ................................. 65
kionex ....................................... 76
klor-con 10 ............................... 77
KLOR-CON M15 ..................... 77
klor-con m20 ............................ 77
KOMBIGLYZE XR ............ 81,82
KORLYM ................................. 70
KUVAN.................................... 70
KYNAMRO ............................. 97
labetalol hcl .............................. 95
lactated ringers ......................... 77
lactulose .................................... 76
LAMICTAL (BLUE) ............... 59
LAMICTAL (GREEN) ............ 59
LAMICTAL (ORANGE) ......... 59
LAMICTAL ODT .................... 59
LAMICTAL XR (BLUE) ......... 59
LAMICTAL XR (GREEN) ...... 60
LAMICTAL XR (ORANGE) .. 60
LAMISIL .................................... 8
lamivudine ................................ 10
lamivudine hbv ......................... 10
lamivudine-zidovudine ............ 10
lamotrigine............................... 60
lamotrigine er .......................... 60
lamotrigine odt ........................ 60
lansoprazol-amoxicil-clarithro 18
lansoprazole ........................... 109
LANTUS ................................. 82
LANTUS SOLOSTAR............ 82
LASTACAFT ........................ 112
latanoprost ............................. 113
LATUDA................................. 42
LAZANDA .............................. 50
leflunomide .............................. 65
LENVIMA.......................... 23,24
lessina ...................................... 86
LETAIRIS ............................. 106
letrozole ................................... 24
leucovorin calcium .................. 67
LEUKERAN ........................... 24
LEUKINE ................................ 74
leuprolide acetate ..................... 24
levalbuterol 0.31 mg/3 ml sol .. 92
levalbuterol 0.63 mg/3 ml sol .. 92
levalbuterol conc 1.25 mg/0.5 . 92
LEVEMIR ............................... 82
LEVEMIR FLEXTOUCH ...... 82
levetiracetam ........................... 60
levetiracetam er ....................... 60
levetiracetam-nacl............... 60,61
levobunolol hcl ...................... 113
levocetirizine dihydrochloride . 90
levofloxacin ...................... 18,115
levofloxacin-d5w ..................... 18
levoleucovorin calcium ........... 24
levonest .................................... 88
levonorgestrel-eth estradiol ..... 86
levonorg-eth estrad eth estrad .. 86
levora-28 .................................. 87
levorphanol tartrate.................. 50
129
levothyroxine sodium ............... 84
levoxyl ...................................... 84
LEXIVA ................................... 10
LIALDA ................................. 108
lidocaine ................................... 31
lidocaine hcl ...................... 31,114
lidocaine hcl viscous .............. 114
lidocaine-prilocaine .................. 31
lindane .................................... 118
linezolid.................................... 18
linezolid tab 600 mg................. 18
LINZESS ................................ 111
liothyronine sodium ................. 84
lisinopril ................................. 102
lisinopril-hydrochlorothiazide 102
lithium ...................................... 34
lithium carbonate................. 33,34
lithium carbonate er ............ 33,34
LIVALO ................................... 97
LO LOESTRIN FE .................. 87
LOESTRIN .............................. 87
LOESTRIN FE ......................... 87
LONSURF ............................... 24
loperamide .............................. 110
lorazepam ............................ 63,64
lorazepam intensol ................... 63
loryna ....................................... 88
losartan potassium .................. 102
losartan-hydrochlorothiazide . 102
LOTEMAX ............................ 114
lovastatin .................................. 97
loxapine .................................... 42
LUMIGAN ............................. 113
LUMIZYME ............................ 78
LUPRON DEPOT .................... 24
LUPRON DEPOT-PED ........... 24
lutera......................................... 87
LYNPARZA ............................ 24
LYRICA ................................... 61
LYSODREN ............................. 24
magnesium sulfate .................... 77
maprotiline hcl .......................... 42
marlissa ..................................... 87
MARPLAN .............................. 42
MATULANE............................ 24
matzim la ................................ 102
MAXIDEX ............................. 114
meclizine hcl........................ 89,90
meclofenamate sodium ........ 50,51
medroxyprogesterone acetate ... 89
mefenamic acid......................... 51
mefloquine hcl ............................ 8
megestrol acetate ...................... 24
MEKINIST ............................... 24
meloxicam ................................ 51
melphalan hcl ........................... 24
memantine hcl .......................... 37
MENACTRA.......................... 120
MENHIBRIX ......................... 120
MENOMUNE-A-C-Y-W-135 120
MENVEO A-C-Y-W-135DIP .......................................... 120
mercaptopurine ......................... 24
meropenem ............................... 18
mesalamine ............................. 108
MESNEX.................................. 67
MESTINON ............................. 93
metaproterenol sulfate .............. 92
metformin hcl ........................... 82
metformin hcl er ....................... 82
methadone hcl ........................... 51
methazolamide........................ 113
methenamine hippurate .............. 7
methimazole ............................. 84
methotrexate ............................. 24
methotrexate sodium ................ 24
methoxsalen .............................. 30
methscopolamine bromide........ 90
methyclothiazide .................... 102
methylergonovine maleate ......112
METHYLIN..............................56
methylphenidate er ....................56
methylphenidate hcl ..................57
methylphenidate hcl cd .............56
methylphenidate la ....................57
methylprednisolone ...................79
methylprednisolone acetate.......79
methylprednisolone sod succ ....79
metipranolol ............................113
metoclopramide hcl.................110
metoclopramide hcl odt ..........110
metolazone ..............................102
metoprolol succinate .................95
metoprolol tartrate.....................95
metoprolol-hydrochlorothiazide
..................................................95
metronidazole..................8,18,118
mexiletine hcl ..........................107
MIACALCIN ............................89
MICONAZOLE 3 ...................118
microgestin................................87
microgestin fe ...........................87
midodrine hcl ............................92
miglitol ......................................82
minitran ...................................106
minocycline hcl .........................18
minocycline hcl er .....................18
minoxidil .................................102
MIRAPEX ER ..........................35
MIRCERA ................................74
mirtazapine................................42
misoprostol..............................109
mitomycin .................................24
mitoxantrone hcl .......................24
M-M-R II VACCINE..............120
modafinil ...................................57
moexipril hcl ...........................102
................................................102
molindone hcl ...........................42
130
mometasone furoate .............29,32
mononessa .................................87
montelukast sodium ..................32
MONUROL ................................7
morphine sulfate ..................51,52
morphine sulfate er ...................51
MOVANTIK ...........................111
MOVIPREP ............................111
MOXEZA ...............................115
moxifloxacin hcl .......................18
MOZOBIL ................................74
MULTAQ ...............................107
mupirocin ................................118
MUSTARGEN..........................24
MYALEPT................................70
mycophenolate mofetil .............66
mycophenolic acid ....................66
MYRBETRIQ .........................116
nabumetone ...............................52
nadolol ......................................95
nadolol-bendroflumethiazide ....95
nafcillin .....................................18
nafcillin sodium ........................18
naftifine hcl .............................118
NAFTIN ..................................118
NAGLAZYME .........................78
naloxone hcl ..............................58
naltrexone hcl ............................58
NAMENDA ..............................37
NAMENDA XR .......................37
naphazoline hcl .......................116
NAPRELAN .............................52
naproxen....................................52
naproxen sodium .......................52
naproxen sodium cr ...................52
naratriptan hcl ...........................34
NARCAN..................................58
NATACYN .............................115
nateglinide .................................82
NATPARA ............................... 89
NEBUPENT ............................... 8
necon ........................................ 87
nefazodone hcl .......................... 43
neomycin sulfate....................... 18
neomycin-bacitracin-poly-hc.. 115
neomycin-bacitracin-polymyxin
................................................ 115
neomycin-polymyxin b ........... 118
neomycin-polymyxin-dexameth
................................................ 115
neomycin-polymyxin-gramicidin
................................................ 115
neomycin-polymyxin-hc ........ 115
neomycin-polymyxin-hydrocort
................................................ 115
NEPHRAMINE ........................ 75
NESINA ................................... 82
NEULASTA ............................. 74
NEUPOGEN ............................ 74
NEUPRO .................................. 35
NEVANAC ............................ 114
nevirapine ................................. 10
nevirapine er ............................. 10
NEXAVAR .............................. 24
NEXIUM ................................ 109
niacin er .................................... 97
nicardipine hcl ........................ 102
NICOTROL .............................. 93
NICOTROL NS ........................ 93
nifedical xl .............................. 102
nifedipine er ............................ 103
NILANDRON .......................... 24
nimodipine .............................. 103
NINLARO ........................... 24,25
nisoldipine .............................. 103
NITRO-BID............................ 106
nitrofurantoin .............................. 7
nitrofurantoin mono-macro ........ 7
nitroglycerin ........................... 106
nitroglycerin patch .................. 106
NITROMIST .......................... 106
NITROSTAT .......................... 106
nizatidine ................................ 109
norethindrone ........................... 88
norethindrone acetate ............... 89
norethin-eth estra-ferrous fum .. 87
norgestimate-ethinyl estradiol .. 87
NORMOSOL-M AND
DEXTROSE ............................. 77
NORMOSOL-R AND
DEXTROSE ............................. 77
NORMOSOL-R PH 7.4 ........... 77
NORPACE CR ....................... 107
NORTHERA ............................ 92
nortrel ....................................... 87
nortriptyline hcl ........................ 43
NORVIR ................................... 10
NOVOLIN 70-30 ..................... 82
NOVOLIN N ............................ 82
NOVOLIN R ............................ 82
NOVOLOG .............................. 82
NOVOLOG FLEXPEN............ 82
NOVOLOG MIX 70-30 ........... 82
NOVOLOG MIX 70-30
FLEXPEN ................................ 82
NOXAFIL .................................. 8
NUEDEXTA ............................ 37
NULOJIX ................................. 66
nutrilipid ................................... 75
NUVARING............................. 87
NUVIGIL ................................. 57
nystatin ................................ 8,118
nystatin-triamcinolone ............ 118
nystop ..................................... 118
OCTAGAM ............................ 119
octreotide acetate ...................... 70
ODEFSEY ................................ 10
ODOMZO ................................ 25
OFEV ....................................... 33
ofloxacin ............................ 18,115
OGESTREL ............................. 87
olanzapine................................. 43
olanzapine odt .......................... 43
olanzapine-fluoxetine hcl ......... 43
131
olopatadine hcl ........................ 113
OLUX ....................................... 29
OLYSIO .................................... 10
omega-3 acid ethyl esters.......... 97
omeprazole .............................. 109
OMNARIS ................................ 32
ONCASPAR ............................. 25
ondansetron hcl ....................... 110
ondansetron odt ....................... 110
ONFI ......................................... 64
ONGLYZA ............................... 82
OPDIVO ................................... 25
OPSUMIT ............................... 106
ORACEA .................................. 18
ORALAIR................................. 70
ORBACTIV .............................. 18
ORENCIA................................. 65
ORENITRAM ER .................. 106
ORFADIN................................. 70
ORKAMBI ............................... 70
orsythia ..................................... 87
OSENI.................................. 82,83
OSMOPREP ........................... 111
OTEZLA ................................... 65
oxaliplatin ................................. 25
oxandrolone .............................. 85
oxaprozin .................................. 52
oxcarbazepine ........................... 61
oxiconazole nitrate .................. 118
OXISTAT ............................... 118
OXTELLAR XR ....................... 61
oxybutynin chloride ................ 116
oxybutynin chloride er ............ 116
oxycodone hcl ...................... 52,53
oxycodone hcl er ....................... 52
oxycodone hcl-aspirin ............... 53
oxycodone hcl-ibuprofen .......... 53
oxycodone-acetaminophen ....... 53
oxymorphone hcl ...................... 53
oxymorphone hcl er .................. 53
pacerone.................................. 107
paclitaxel .................................. 25
paliperidone er .......................... 43
pamidronate disodium .............. 67
PANCREAZE ................. 111,112
PANDEL .................................. 29
PANRETIN .............................. 30
pantoprazole sodium............... 109
paricalcitol .............................. 121
paromomycin sulfate ................ 18
paroxetine cr ............................. 43
paroxetine er ............................. 43
paroxetine hcl ...................... 43,44
PASER........................................ 7
PATADAY ............................. 113
PAXIL ...................................... 44
PAZEO ................................... 113
PCE ........................................... 18
PEDVAXHIB ......................... 120
peg 3350-electrolyte ............... 111
PEGANONE ............................ 61
PEGASYS ................................ 11
PEGASYS PROCLICK ........... 10
PEGINTRON ........................... 11
PEGINTRON REDIPEN ......... 11
PEN NEEDLES 12MM 29G .. 121
penicillin g potassium ............... 18
penicillin g procaine ................. 19
penicillin g sodium ................... 19
penicillin gk-iso-osm dextrose . 19
penicillin v potassium ............... 19
PENNSAID .............................. 53
PENTAM 300........................... 19
PENTASA .............................. 108
pentoxifylline............................ 74
PERFOROMIST 20 MCG/2 ML
SOLN........................................ 92
perindopril erbumine .............. 103
permethrin .............................. 118
perphenazine ............................. 44
PERTZYE ............................... 112
PEXEVA .................................. 44
phenelzine sulfate ..................... 44
phenobarbital ............................ 63
PHENYTEK ............................. 61
phenytoin .................................. 61
phenytoin sodium extended ...... 61
PHOSPHOLINE IODIDE ...... 113
physiolyte.................................. 78
physiosol ................................... 78
PICATO .................................... 30
pilocarpine hcl .......................... 93
pimozide ................................... 44
pindolol ..................................... 95
pioglitazone hcl......................... 83
pioglitazone-glimepiride ........... 83
pioglitazone-metformin ............ 83
piperacillin-tazobactam ............ 19
piroxicam .................................. 53
PLASMA-LYTE 148 ............... 77
PLASMA-LYTE 56 IN
DEXTROSE ............................. 77
PLASMA-LYTE A PH 7.4 ...... 77
PLEGRIDY .............................. 68
PLEGRIDY PEN ...................... 68
podofilox................................... 30
polyethylene glycol 3350........ 111
polymyxin b sul-trimethoprim 115
POMALYST ............................. 25
portia ......................................... 87
potassium chl-normal saline ..... 77
potassium chloride .................... 77
potassium chloride in d5lr ........ 77
potassium chloride-nacl ............ 77
potassium citrate er ................... 74
POTIGA.................................... 61
PRADAXA ............................... 73
pramipexole dihydrochloride35,36
pramipexole er .......................... 36
132
pravastatin sodium ............ 97,98
prazosin hcl ............................ 95
PRED MILD ........................ 114
PRED-G ............................... 115
prednicarbate .......................... 29
prednisolone acetate ............... 79
prednisolone sodium phos odt 79
prednisolone sodium
phosphate ........................ 79,114
prednisone .............................. 79
PREDNISONE INTENSOL .. 79
PREFEST ............................... 88
PREMARIN ........................... 89
PREMASOL .......................... 75
PRENATAL VITAMINS .... 121
PREVACID.......................... 109
prevalite.................................. 98
previfem ................................. 87
PREZCOBIX ......................... 11
PREZISTA ............................. 11
primaquine ............................... 8
primidone ............................... 63
PRISTIQ ER .......................... 44
PRIVIGEN ........................... 119
PROAIR HFA ........................ 92
PROAIR RESPICLICK ......... 92
probenecid .............................. 76
probenecid-colchicine ............ 76
PROCALAMINE ................... 76
prochlorperazine..................... 90
prochlorperazine edisylate ..... 90
prochlorperazine maleate ....... 90
procto-pak .............................. 29
proctozone-hc ......................... 29
progesterone ........................... 89
PROGLYCEM ..................... 103
PROLASTIN C ...................... 33
PROLEUKIN ......................... 25
PROLIA ................................. 67
PROMACTA ......................... 74
promethazine hcl ...................... 90
promethegan ........................... 110
propafenone hcl ............... 107,108
propafenone hcl er .................. 107
proparacaine hcl ..................... 114
propranolol hcl .................... 95,96
propranolol hcl er ..................... 95
propranolol-hydrochlorothiazide
.................................................. 96
propylthiouracil ........................ 84
PROQUAD ............................. 120
PROSOL ................................... 76
PROTONIX ............................ 109
protriptyline hcl ........................ 44
PROVENTIL HFA ................... 92
PRUDOXIN ............................. 31
PULMICORT FLEXHALER ... 32
PULMOZYME ......................... 78
PURIXAN ................................ 11
PYLERA .................................. 19
pyrazinamide .............................. 7
pyridostigmine bromide ........... 93
pyridostigmine bromide er ....... 93
QNASL ..................................... 33
QNASL CHILDREN ............... 33
QUADRACEL DTAP-IPV .... 120
quasense.................................... 87
quetiapine fumarate .................. 44
quinapril hcl ............................ 103
quinapril-hydrochlorothiazide 103
quinidine sulfate ......................... 8
quinine sulfate ............................ 8
QVAR ....................................... 33
RABAVERT .......................... 120
rabeprazole sodium................. 109
RAGWITEK ............................. 70
raloxifene hcl ............................ 89
ramipril ................................... 103
RANEXA ............................... 108
ranitidine hcl ........................... 109
RAPAFLO ................................96
RAPAMUNE ............................66
RASUVO ..................................25
RAVICTI ..................................70
REBETOL ................................11
REBIF .......................................69
REBIF REBIDOSE..............68,69
reclipsen ....................................87
RECOMBIVAX HB ...............120
RELENZA ................................11
RELISTOR .............................111
REMICADE..............................65
REMODULIN ........................106
RENAGEL ................................76
RENVELA ................................76
repaglinide ................................83
repaglinide-metformin hcl ........83
REPATHA SURECLICK .........98
REPATHA SYRINGE ..............98
reprexain ...................................53
RESCRIPTOR ..........................11
reserpine ..................................103
RESTASIS ..............................114
RETIN-A MICRO PUMP ........31
RETROVIR ..............................11
REVATIO ...............................106
REVLIMID ..........................25,26
REXULTI .................................44
REYATAZ ...........................11,12
RHEUMATREX .......................26
ribasphere ..................................12
ribavirin .....................................12
RIDAURA ................................74
rifabutin .....................................19
rifampin .....................................19
RIFATER ..................................19
riluzole ......................................37
ringers injection ........................77
RIOMET ...................................83
133
risedronate sodium .................. 67
risedronate sodium dr .............. 67
RISPERDAL CONSTA ..... 44,45
risperidone ............................... 45
risperidone odt ......................... 45
RITUXAN ............................... 26
rivastigmine ............................. 93
rizatriptan ................................ 34
ropinirole er ............................. 36
ropinirole hcl ........................... 36
rosuvastatin calcium ................ 98
ROTARIX ............................. 120
ROTATEQ ............................ 120
ROZEREM .............................. 58
RYTARY ................................ 36
SABRIL................................... 61
SAFYRAL............................... 87
SAIZEN ................................... 86
SAMSCA ................................ 74
SANDIMMUNE ..................... 66
SANTYL ................................. 30
SAPHRIS ................................ 45
SAVAYSA .............................. 73
SAVELLA ............................... 36
SAVELLA TITRATION
PACK ...................................... 37
SEEBRI NEOHALER............. 90
selegiline hcl ............................ 45
SELZENTRY .......................... 12
SEMPREX-D .......................... 90
SENSIPAR ......................... 70,71
SEREVENT DISKUS ............. 92
SEROQUEL XR ..................... 45
sertraline hcl ....................... 45,46
SFROWASA ......................... 108
SIGNIFOR .............................. 71
SIGNIFOR LAR ..................... 71
sildenafil ................................ 106
silver sulfadiazine .................. 118
SIMBRINZA ......................... 113
SIMPONI.................................. 65
SIMPONI ARIA ....................... 65
simvastatin ................................ 98
sirolimus ................................... 66
SIRTURO ................................... 7
SIVEXTRO .............................. 19
sodium chloride ................... 77,78
sodium fluoride tab 1 mg f (from
2.2 mg naf) ............................. 121
sodium lactate ........................... 74
sodium phenylbutyrate ............. 76
sodium polystyrene sulfonate ... 76
SOLODYN ............................... 19
SOLTAMOX ............................ 26
SOMATULINE DEPOT .......... 71
SOMAVERT ............................ 86
sorine ........................................ 96
sotalol ....................................... 96
sotalol af ................................... 96
SOVALDI ................................ 12
SPIRIVA .................................. 90
SPIRIVA RESPIMAT .............. 91
spironolactone ........................ 103
spironolactone-hctz ................ 103
SPORANOX .............................. 8
sprintec ..................................... 87
SPRITAM 1,000 MG TABLET61
SPRITAM 250 MG TABLET .. 62
SPRYCEL ................................ 26
sronyx ....................................... 87
ssd ........................................... 118
stavudine ................................... 12
STELARA ........................... 30,31
STIMATE ................................. 71
STIOLTO RESPIMAT............. 91
STIVARGA .............................. 26
STRATTERA ........................... 37
STRENSIQ ............................... 71
streptomycin sulfate ................19
STRIBILD ...............................12
STRIVERDI RESPIMAT .......92
SUBOXONE ...........................53
SUCRAID ...............................78
sucralfate ...............................109
sulfacetamide
sodium .....................115,116,118
sulfacetamide-prednisolone ..116
sulfadiazine .............................19
sulfamethoxazoletrimethoprim............................19
sulfasalazine ..........................108
sulfasalazine dr ......................108
sulindac ...................................53
sumatriptan ..............................34
sumatriptan succinate ..............34
SUPRAX .................................19
SUPREP ................................111
SUSTIVA ................................12
SUTENT .................................26
SYLATRON ...........................26
SYMBICORT .........................92
SYMLINPEN 120 ...................83
SYMLINPEN 60 .....................83
SYNAGIS ...............................19
SYNALGOS-DC ....................53
SYNAREL ..............................89
SYNERCID .............................20
SYNJARDY ............................83
SYNRIBO ...............................26
SYNTHROID.....................84,85
SYPRINE ................................71
TABLOID ...............................26
TACLONEX ...........................29
tacrolimus ...........................31,66
TAFINLAR .............................26
TAFINLAR 75 MG
CAPSULE ...............................26
TAGRISSO .............................26
TALTZ AUTOINJECTOR .....65
TALTZ SYRINGE ..................65
134
TAMIFLU ............................... 12
tamoxifen citrate ..................... 26
tamsulosin hcl ......................... 96
TANZEUM ............................. 83
TARCEVA.............................. 26
TARGRETIN .......................... 31
TASIGNA .......................... 26,27
TAZORAC .............................. 31
taztia xt .................................. 103
TECFIDERA........................... 69
TECFIDERA STARTER
PACK ...................................... 69
TECHNIVIE ........................... 12
TEFLARO............................... 20
TEKTURNA ......................... 104
TEKTURNA HCT ................ 103
telmisartan ............................. 104
telmisartan-amlodipine ......... 104
telmisartanhydrochlorothiazid ................ 104
temazepam .............................. 64
TENIVAC ............................. 119
terazosin hcl ............................ 96
terbinafine hcl ........................... 8
terbutaline sulfate .................... 93
terconazole ..................... 118,119
terconazole vaginal cream
0.8% ...................................... 119
testosterone ............................. 85
testosterone cypionate ............. 85
testosterone enanthate ............. 85
tetanus diphtheria toxoids ..... 119
tetrabenazine ........................... 38
TETRAHYDROZOLINE HCL
NASAL SOLN 0.05% .......... 116
THALOMID ........................... 69
theophylline........................... 117
theophylline anhydrous ......... 117
thioridazine hcl........................ 46
thiotepa.................................... 27
thiothixene............................... 46
tiagabine hcl ............................ 62
TIKOSYN ............................. 108
timolol maleate .................. 96,113
TIMOPTIC OCUDOSE ......... 113
tinidazole ................................. 8,9
TIVICAY.................................. 12
tizanidine hcl ............................ 94
TOBI PODHALER .................. 20
TOBRADEX .......................... 116
TOBRADEX ST..................... 116
tobramycin .............................. 116
tobramycin 300 mg/5 ml
ampule ...................................... 20
tobramycin sulfate .................... 20
tobramycin-dexamethasone .... 116
TOBREX ................................ 116
TOLAK .................................... 31
tolazamide ................................ 83
tolbutamide ............................... 83
tolcapone .................................. 36
tolmetin sodium ........................ 54
tolterodine tartrate .................. 117
tolterodine tartrate er .............. 116
topiramate ................................. 62
topiramate er ............................. 62
toposar ...................................... 27
topotecan hcl ............................. 27
TORISEL.................................. 27
torsemide ................................ 104
TOUJEO SOLOSTAR ............. 83
TOVIAZ ................................. 117
tpn electrolytes ......................... 78
TRACLEER .................... 106,107
TRADJENTA ........................... 83
tramadol hcl .............................. 54
tramadol hcl er .......................... 54
tramadol hcl-acetaminophen .... 54
trandolapril ............................. 104
trandolapril-verapamil er ........ 104
tranexamic acid....................... 116
TRANSDERM-SCOP .............. 91
tranylcypromine sulfate ............ 46
TRAVASOL .............................76
travoprost ................................113
trazodone hcl.............................46
TREANDA ...............................27
TRECATOR ...............................7
TRELSTAR ..............................27
tretinoin................................27,31
tretinoin microsphere ................31
TREXALL ................................27
triamcinolone acetonide.......29,30
triamterenehydrochlorothiazid ..................104
triazolam ...................................64
TRIBENZOR ..........................104
trifluoperazine hcl .....................46
trifluridine ...............................116
trihexyphenidyl hcl ...................36
tri-legest fe ................................87
tri-lo-estarylla ...........................87
tri-lo-sprintec ............................87
trilyte with flavor packets .......111
trimethoprim ...............................7
trimipramine maleate ................46
trinessa ......................................88
TRINTELLIX ...........................46
tri-previfem ...............................88
TRIPTORELIN PAMOATE
FOR IM SUSP 22.5 MG ..........27
TRISENOX ..............................27
tri-sprintec.................................88
TRIUMEQ ................................12
trivora-28 ..................................88
TROKENDI XR .......................62
TROPHAMINE ........................76
trospium chloride ....................117
trospium chloride er ................117
TRULICITY ........................83,84
TRUMENBA ..........................120
TRUVADA...............................12
TUDORZA PRESSAIR ...........91
TWINRIX ...............................120
135
TYBOST ...................................12
TYGACIL .................................20
TYKERB...................................27
TYPHIM VI ............................120
TYSABRI .................................69
TYVASO ................................107
TYZEKA...................................12
UCERIS ..................................108
ULORIC ....................................64
unithroid ....................................85
UPTRAVI ...............................107
ursodiol ...................................110
UTIBRON NEOHALER ..........91
VAGIFEM ................................89
valacyclovir ...............................12
VALCHLOR .............................12
VALCYTE ................................13
valganciclovir hcl ......................13
valproate sodium .......................62
valproic acid ..............................62
valsartan ...........................104,105
valsartan-hydrochlorothiazide.105
vancomycin hcl .........................20
vandazole ................................119
VAQTA...................................120
VARIVAX VACCINE ...........121
VARUBI .................................110
VASCEPA ................................98
VECTIBIX ................................27
VELCADE ................................27
velivet ........................................88
VELPHORO .............................76
VELTASSA ..............................76
VELTIN ....................................31
VENCLEXTA...........................27
VENCLEXTA STARTING
PACK ........................................27
venlafaxine hcl ..........................46
venlafaxine hcl er ......................46
VENTAVIS.............................107
VENTOLIN HFA ..................... 93
VERAMYST ............................ 33
verapamil er ............................ 105
verapamil er pm ...................... 105
verapamil hcl .......................... 105
VERIPRED 20 ......................... 79
VERSACLOZ .......................... 46
VESICARE ............................ 117
VEXOL .................................. 114
VICTOZA 3-PAK .................... 84
VIDEX...................................... 13
VIEKIRA PAK......................... 13
vienva ....................................... 88
VIGAMOX ............................. 116
VIIBRYD ................................. 46
VIMOVO.................................. 54
VIMPAT ................................... 62
vinblastine sulfate ..................... 27
vincasar pfs ............................... 27
vincristine sulfate ..................... 27
vinorelbine tartrate ................... 27
VIOKACE .............................. 112
VIRACEPT .............................. 13
VIRAZOLE .............................. 13
VIREAD ................................... 13
VITEKTA ................................. 13
voriconazole ............................... 8
VOTRIENT .............................. 27
VPRIV ...................................... 78
VRAYLAR ............................... 46
VYVANSE ............................... 57
warfarin sodium ........................ 73
WELCHOL .............................. 98
XALKORI ................................ 27
XARELTO ............................... 73
XELJANZ ................................ 66
XELJANZ XR .......................... 66
XGEVA .................................... 67
XIFAXAN ................................ 20
XOLAIR ...................................33
XOPENEX HFA .......................93
XTANDI ...................................27
XULANE ..................................88
XYREM ....................................38
YERVOY ..................................27
YF-VAX .................................121
zafirlukast..................................33
zaleplon .....................................58
ZANOSAR................................27
ZARXIO ...................................74
ZAVESCA ................................71
ZEGERID ........................109,110
ZELAPAR ................................47
ZELBORAF ..............................27
ZEMAIRA ................................33
zenchent fe ................................89
ZENPEP ..................................112
ZEPATIER................................13
ZETIA .......................................98
ZETONNA................................33
ZIAGEN....................................13
ZIANA ....................................119
zidovudine.................................13
ziprasidone hcl ..........................47
ZIRGAN .................................116
ZMAX .......................................20
ZOHYDRO ER .........................54
zoledronic acid ..........................68
ZOLINZA .................................27
zolmitriptan ...............................34
zolmitriptan odt .........................34
zolpidem tartrate .......................58
ZOMETA ..................................68
ZOMIG .....................................34
zonisamide ...........................62,63
ZONTIVITY .............................73
ZORTRESS ..............................66
ZOSTAVAX ...........................121
136
ZOSYN .................................... 20
zovia 1-35e............................... 88
ZOVIA 1-50E .......................... 88
ZOVIRAX ............................. 119
ZUBSOLV ............................... 54
ZYCLARA............................... 31
ZYDELIG ................................ 28
ZYFLO CR .............................. 33
ZYKADIA ............................... 28
ZYLET ................................... 116
ZYPREXA RELPREVV ......... 47
ZYTIGA................................... 28
Este formulario fue actualizado el 01 de septiembre de 2016. Para la
información más reciente u otras preguntas, póngase en contacto con
SelectHealth Servicios para Miembros al número gratuito,
855-442-9900 o, para los usuarios de TTY, 711, durante las siguientes
fechas y horarios:
• El 1 de octubre al 14 de febrero: lunes a viernes 7:00 a.m. a 8:00
p.m., el sábado y el domingo de 8:00 a.m. a 8:00 p.m.
• El 15 de febrero al 30 de septiembre: lunes a viernes 7:00 a.m. a
8:00 p.m, el sábado 9:00 a.m. a 3:00 p.m., cerrado el domingo.
Fuera de estas horas de operación, por favor deje un mensaje.
Su llamada será devuelta dentro de un día hábil, o visite
selecthealthadvantage.org.
P.O. Box 30196
Salt Lake City, UT 84130-0196
855-442-9900 (línea gratuita)
Usuarios de TTY: 711
selecthealthadvantage.org

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