formulario completo - SelectHealth Advantage

Transcrição

2015
FORMULARIO COMPLETO
Lista de Medicamentos Cubiertos
Este formulario fue actualizado el 1 de noviembre de 2015. 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
y su llamada será devuelta dentro de un día hábil, o visite
selecthealthadvantage.org.
SelectHealth Advantage (HMO-POS)
Formulario Completo de 2015
(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-POS 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 (cobro revertido), durante las fechas y horarios
indicados en la portada y contraportada de este libro. Los usuarios de TTY pueden llamar al 711.
H1994_3349_FINAL_C_SP_v25 Aceptado
HPMS Aprobado Número de Identificación del Sumisión de Archivo 15000 Versión 25
1
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-POS).
Este documento contiene una lista de medicamentos (el formulario) para nuestro plan que está
actualizado a partir del 1 de noviembre de 2015. 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 2016 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 presentar sus recetas, consulte su Evidencia de
Cobertura.
¿Puede cambiar el Formulario?
En general, si toma un medicamento de nuestro formulario del año 2015 que se cubría al
inicio del año, no vamos a descontinuar ni reducir la cobertura del medicamento durante la
cobertura del año 2015 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.
El formulario adjunto está actualizado a partir de la fecha 1 de noviembre de 2015.
Para obtener un formulario más actual, por favor contacte con nosotros. Nuestra información de
2
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 Cardiovasculares.” 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 114. 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 enfermedad. Por ejemplo, si un Medicamento A y un Medicamento
B tratan la misma enfermedad, SelectHealth Advantage puede no cubrir el Medicamento B
3
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 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
4
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.
5
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 114.
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
Farmacia de la Red de Venta por Menor
(Hasta un suministro de 30 días)
Nivel de Medicamento
Nivel 1: Genérico Preferido
$3.00
Nivel 2: Genérico No Preferido
$10.00
Nivel 3: Marca Preferida
$45.00
Nivel 4: Marca No Preferida
$95.00
Nivel 5: Especialidad
33% coseguro
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 855-442-9900 (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.
6
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 50mg
2
nitrofurantoin mono-macro
2
capsule 100mg
nitrofurantoin suspension 25
2
mg/5 ml
PRIMSOL SOLUTION 50
4
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)
TRECATOR TABLET
4
250MG
/Límites
ANTIONGO (SISTÉMICA)
AMBISOME FOR
SUSPENSION 50MG
amphotericin b for solution
50mg
CANCIDAS FOR
SOLUTION 50MG
CANCIDAS FOR
SOLUTION 70MG
ciclopirox solution 8 %
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
flucytosine capsule 250mg
flucytosine capsule 500mg
GRIS-PEG TABLET 125MG
GRIS-PEG TABLET 250MG
griseofulvin suspension 125
mg/5 ml
griseofulvin tablet 500mg
griseofulvin ultramicrosize
tablet 125mg
griseofulvin ultramicrosize
tablet 250mg
itraconazole capsule 100mg
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
AP; NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
LC; AP; NM
NM
4
AP; NM
2
AP; NM
5
AP; NM
5
AP; NM
2
NM
4
LC; AP; NM
2
NM
2
NM
2
AP; NM
2
2
2
2
2
2
3
3
NM
NM
NM
NM
NM
NM
NM
NM
2
NM
2
NM
2
NM
2
NM
2
LC; NM
AP – Autorización Previa
LC – Límites de Cantidad
TE – Terapia en Etapas
AL – Acceso Limitado
NM – No-mantenimiento
Puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significa por al ver la página 6.
7
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
JUBLIA SOLUTION 10 %
LC 4 mililitro(s) cada 30 dia(s)
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
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
4
LC; TE; NM
2
4
4
NM
NM
NM
4
NM
4
LC; NM
2
NM
2
NM
4
NM
2
LC; NM
2
AP; NM
2
LC; NM
2
LC; NM
2
LC; NM
4
NM
4
NM
2
NM
2
NM
/Límites
atovaquone-proguanil hcl
tablet 62.5 mg-25 mg
2
(pediatric)
chloroquine phosphate tablet
2
250mg
chloroquine phosphate tablet
2
500mg
COARTEM TABLET 20120MG
4
hydroxychloroquine sulfate
2
tablet 200mg
mefloquine hcl tablet 250mg
2
LC 5 cada 30 dia(s)
metronidazole capsule 375mg
2
metronidazole tablet 250mg
2
metronidazole tablet 500mg
2
NEBUPENT FOR
4
SOLUTION 300MG
primaquine tablet 26.3mg
2
quinidine sulfate tablet 200mg
2
quinidine sulfate tablet 300mg
2
quinine sulfate capsule 324mg
2
tinidazole tablet 250mg
2
tinidazole tablet 500mg
2
ANTIVIRALES (SISTÉMICAS)
abacavir tablet 300mg
2
abacavir-lamivudinezidovudine tablet 300-1502
300mg
acyclovir capsule 200mg
2
acyclovir sodium solution 50
2
mg/ml
NM
NM
NM
LC; NM
NM
LC; NM
NM
NM
NM
AP; NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
AP; NM
8
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
acyclovir suspension 200 mg/5
ml
acyclovir tablet 400mg
acyclovir tablet 800mg
adefovir dipivoxil tablet 10mg
amantadine capsule 100mg
amantadine syrup 50 mg/5 ml
amantadine tablet 100mg
APTIVUS CAPSULE 250MG
APTIVUS SOLUTION 100
MG/ML
ATRIPLA TABLET 600-200300MG
BARACLUDE SOLUTION
0.05 MG/ML
cidofovir solution 75 mg/ml
COMPLERA TABLET 20025-300MG
CRIXIVAN CAPSULE
200MG
CRIXIVAN CAPSULE
400MG
DAKLINZA TABLET 30MG
DAKLINZA TABLET 60MG
didanosine capsule dr 125mg
EDURANT TABLET 25MG
EMTRIVA CAPSULE
200MG
EMTRIVA SOLUTION 10
MG/ML
2
NM
2
2
2
2
2
2
3
NM
NM
NM
NM
NM
NM
NM
3
NM
3
NM
4
NM
2
AP; NM
3
NM
3
NM
3
NM
5
LC; AP; NM
5
LC; AP; NM
2
2
2
2
3
NM
NM
NM
NM
NM
3
NM
3
NM
/Límites
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
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
2
2
NM
NM
3
NM
3
NM
4
LC; NM
2
2
2
NM
NM
NM
5
LC; NM
2
AP; NM
5
LC; AP
3
NM
3
NM
3
NM
5
NM
5
5
5
NM
9
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
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
400mg
nevirapine suspension 50 mg/5
ml
nevirapine tablet 200mg
NORVIR CAPSULE 100MG
NORVIR SOLUTION 80
MG/ML
NORVIR TABLET 100MG
OLYSIO CAPSULE 150MG
3
NM
3
NM
3
NM
3
NM
3
NM
3
NM
3
NM
3
NM
3
NM
2
2
2
NM
NM
NM
2
NM
3
NM
3
NM
2
NM
2
NM
2
3
NM
NM
3
NM
3
NM
5
LC; AP; NM
/Límites
PEGASYS PROCLICK
SOLUTION 135 MCG/0.5
ML
PEGASYS PROCLICK
SOLUTION 180 MCG/0.5
ML
PEGASYS SOLUTION 180
MCG/0.5 ML
PEGASYS SOLUTION 180
MCG/ML
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)
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
5
LC; AP; NM
10
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
PREZCOBIX TABLET 800150MG
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
REYATAZ PACKET 50MG
ribasphere capsule 200mg
ribasphere tablet 200mg
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
/Límites
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 150-150200-300MG
SUSTIVA CAPSULE 200MG
SUSTIVA CAPSULE 50MG
SUSTIVA TABLET 600MG
TAMIFLU CAPSULE 30MG
TAMIFLU FOR
SUSPENSION 6 MG/ML
dia(s)
TECHNIVIE TABLET 12.575-50MG
TIVICAY TABLET 50MG
LC; NM
3
LC; NM
3
LC; NM
2
LC; NM
2
NM
2
LC; NM
2
NM
3
NM
3
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
11
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
TRIUMEQ TABLET 600-50300MG
TRUVADA TABLET 200300MG
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)
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
VIRAMUNE XR TABLET
ER 24HR 100MG
VIRAZOLE FOR SOLUTION
6 GRAM
VIREAD POWDER 40
MG/SCOOP (40 MG/GRAM)
VIREAD TABLET 150MG
4
/Límites
VIREAD TABLET 200MG
VIREAD TABLET 250MG
VIREAD TABLET 300MG
VITEKTA TABLET 150MG
VITEKTA TABLET 85MG
ZIAGEN SOLUTION 20
MG/ML
zidovudine capsule 100mg
zidovudine syrup 10 mg/ml
zidovudine tablet 300mg
BACTERICIDAS
amikacin sulfate solution 500
mg/2 ml
amox tr-potassium clavulanate
for suspension 200 mg-28.5
mg/5 ml
mg/5 ml
for suspension 400 mg-57
mg/5 ml
mg/5 ml
tablet 250-125mg
tablet 500-125mg
tablet 875-125mg
LC; NM
3
NM
3
LC
4
NM
2
LC; NM
2
LC; NM
5
LC; AP
4
NM
2
NM
3
NM
5
LC; AP; NM
3
3
NM
NM
3
NM
4
AP; NM
3
NM
3
LC; NM
3
LC; NM
3
LC; NM
3
LC; NM
4
LC
4
LC
3
NM
2
2
2
NM
NM
NM
2
AP; NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
NM
12
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
tablet chewable 200-28.5mg
tablet chewable 400-57mg
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 er
tablet er 12hr 1,000-62.5mg
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
2
NM
2
NM
2
2
NM
NM
2
NM
2
NM
2
NM
2
NM
2
2
NM
NM
2
NM
2
NM
2
NM
2
AP; NM
2
AP; NM
2
AP; NM
2
NM
2
NM
2
NM
/Límites
ampicillin trihydrate for
ampicillin-sulbactam for
solution 1.5 gram
solution 15 gram
solution 3 gram
azithromycin for solution
500mg
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
2.4 MILLION UNIT/4 ML
2
NM
2
AP; NM
2
AP; NM
2
AP; NM
2
AP; 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
13
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
600,000 UNIT/ML
CAYSTON FOR SOLUTION
75 MG/ML
dia(s)
CEDAX CAPSULE 400MG
CEDAX FOR SUSPENSION
90 MG/5 ML
cefaclor capsule 250mg
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
4
/Límites
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 gram
500mg
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
5
LC; AP; NM
4
NM
4
NM
2
2
NM
NM
2
NM
2
NM
2
NM
2
NM
2
NM
2
AP; NM
2
AP; NM
2
AP; NM
2
NM
2
NM
2
NM
2
AP; NM
2
AP; NM
2
AP; NM
2
AP; NM
2
NM
2
NM
2
AP; NM
2
AP; NM
2
AP; 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
AP; NM
14
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ceftriaxone for solution 10
gram
ceftriaxone for solution 2 gram
ceftriaxone for solution 250mg
ceftriaxone for solution 500mg
cefuroxime sodium for solution
1.5 gram
7.5 gram
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
2
AP; NM
2
2
2
AP; NM
AP; NM
AP; NM
2
AP; NM
2
AP; NM
2
AP; NM
2
2
2
2
NM
NM
NM
NM
2
NM
2
NM
2
2
NM
NM
2
AP; NM
2
NM
2
NM
2
NM
2
NM
/Límites
ciprofloxacin hcl tablet 100mg
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
2
2
2
2
NM
NM
NM
NM
2
AP; NM
2
AP; NM
2
NM
2
NM
2
NM
2
2
NM
NM
2
NM
2
NM
2
NM
2
NM
2
AP; NM
2
AP; NM
2
AP; NM
2
AP; NM
2
AP; NM
15
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
CUBICIN FOR SOLUTION
500MG
DALVANCE FOR
SOLUTION 500MG
LC 3 cada 30 dia(s)
DARAPRIM TABLET 25MG
dicloxacillin sodium capsule
250mg
dicloxacillin sodium capsule
500mg
DIFICID TABLET 200MG
doxycycline hyclate capsule
100mg
doxycycline hyclate capsule
50mg
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
4
/Límites
tablet 100mg
tablet 150mg
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 tablet 250mg
erythromycin tablet 500mg
gentamicin sulfate in ns
LC; AP; NM
4
LC; AP; NM
4
NM
2
NM
2
NM
4
LC; AP; 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
2
NM
2
NM
2
NM
3
NM
4
NM
4
NM
4
NM
4
NM
4
NM
2
AP; NM
3
NM
2
2
NM
NM
2
AP; NM
2
AP; NM
2
NM
2
AP; NM
16
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
linezolid solution 600 mg/300
ml
linezolid tablet 600mg
meropenem for solution
500mg
metronidazole solution 500
mg/100 ml
minocycline hcl capsule
100mg
minocycline hcl capsule 50mg
minocycline hcl capsule 75mg
2
NM
2
NM
2
AP; NM
2
AP; NM
4
AP; NM
4
AP; NM
4
NM
4
4
2
2
2
2
2
NM
NM
NM
AP; NM
NM
NM
NM
2
AP; NM
2
AP; NM
2
NM
2
NM
2
AP; NM
2
NM
2
2
NM
NM
/Límites
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
ORKAMBI TABLET 200125MG
paromomycin sulfate capsule
250mg
PCE TABLET DR 333MG
PCE TABLET DR 500MG
penicillin g potassium for
solution 5 million unit
penicillin g procaine
suspension 1.2 million unit/2
ml
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
5
LC; AP; NM
2
NM
4
4
NM
NM
2
AP; NM
2
AP; NM
17
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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 140-125125MG
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)
SIVEXTRO TABLET 200MG
LC 6 cada 30 dia(s)
2
AP; NM
2
AP; NM
2
AP; NM
2
NM
2
NM
2
NM
2
NM
4
AP; NM
2
AP; NM
2
AP; NM
4
NM
2
2
2
2
NM
NM
NM
NM
4
NM
4
4
/Límites
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 SUSPENSION
500 MG/5 ML
SUPRAX TABLET
CHEWABLE 100MG
SUPRAX TABLET
CHEWABLE 200MG
SYNAGIS SOLUTION 50
MG/0.5 ML
SYNERCID FOR SOLUTION
500MG
TEFLARO FOR SOLUTION
400MG
LC; AP; NM
LC; AP; NM
4
LC; NM
4
LC; NM
2
AP; NM
2
NM
2
AP; NM
2
NM
2
NM
2
NM
4
LC; NM
4
NM
4
LC; NM
4
LC; NM
4
AP; NM
4
LC; AP; NM
4
AP; NM
18
Medicamento
Nivel Requisitos
Medicamento
/Límites
TEFLARO FOR SOLUTION
600MG
TOBI PODHALER
CAPSULE 28MG
tobramycin 300 mg/5 ml
ampule
tobramycin sulfate in ns
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
ZOSYN SOLUTION 3.375
GRAM/50 ML
4
AP; NM
5
AP; NM
5
AP; NM
2
AP; NM
2
AP; NM
2
AP; NM
4
LC; AP; NM
2
LC; NM
2
LC; NM
2
AP; NM
2
AP; NM
2
AP; NM
4
LC; AP; NM
4
LC; AP; NM
4
NM
4
AP; NM
4
AP; NM
Nivel Requisitos
/Límites
ZYVOX FOR SUSPENSION
4 NM
100 MG/5 ML
AGENTES ANTINEOPLASTICOS
AGENTES ANTINEOPLASTICOS
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
ALIMTA FOR SOLUTION
5 AP
500MG
anastrozole tablet 1mg
2 LC
ARRANON SOLUTION 250
5 AP
MG/50 ML
ARZERRA CONCENTRATE
5 AP
100 MG/5 ML
AVASTIN SOLUTION 25
5 AP
MG/ML
azacitidine for suspension
5 AP
100mg
BELEODAQ FOR
SOLUTION 500MG
5 LC; AP
19
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
CAPRELSA TABLET
100MG
CAPRELSA TABLET
300MG
carboplatin solution 10 mg/ml
cisplatin solution 1 mg/ml
cladribine solution 10 mg/10
ml
CLOLAR SOLUTION 20
MG/20 ML
COMETRIQ KIT 100
MG/DAY (80 MG [1]-20 MG
[1]/DAY)
COMETRIQ KIT 140
MG/DAY (80 MG [1]-20 MG
[3]/DAY)
COMETRIQ KIT 60
MG/DAY (20 MG [3]/DAY)
cyclophosphamide capsule
25mg
cyclophosphamide capsule
50mg
CYRAMZA SOLUTION 100
MG/10 ML (10 MG/ML)
dia(s)
/Límites
5
2
4
AP
2
AP
5
5
AP
AP
5
AP
4
LC; AP
4
LC; AP
2
2
AP
AP
5
AP
5
AP
5
AP
5
AP
5
AP
2
AP
2
AP
5
LC; AP
CYRAMZA SOLUTION 500
MG/50 ML (10 MG/ML)
dia(s)
cytarabine solution 2 gram/20
ml (100 mg/ml)
cytarabine solution 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 solution 50
mg/25 ml
DROXIA CAPSULE 200MG
ELIGARD 30 MG SYRINGE
KIT
ELIGARD 7.5 MG SYRINGE
KIT
ELIGARD KIT 22.5 MG (3
MONTH)
EMCYT CAPSULE 140MG
epirubicin hcl solution 50
mg/25 ml
ERIVEDGE CAPSULE
150MG
ERWINAZE FOR
SOLUTION 10,000 UNIT
etoposide solution 20 mg/ml
exemestane tablet 25mg
5
LC; AP
2
AP
2
AP
2
AP
5
AP
5
AP
5
AP
2
AP
4
4
4
4
AP
4
AP
4
AP
3
2
AP
5
LC; AP
5
AP
2
AP
2
LC
20
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
FARESTON TABLET 60MG
FARYDAK CAPSULE 10MG
FASLODEX SOLUTION 250
MG/5 ML
FIRMAGON FOR
SOLUTION 120MG
FIRMAGON FOR
SOLUTION 80MG
fludarabine phosphate for
solution 50mg
fluorouracil cream 5 %
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
HALAVEN SOLUTION 1
MG/2 ML (0.5 MG/ML)
/Límites
4
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
5
AP
4
AP
2
AP
HERCEPTIN FOR
SOLUTION 440MG
HEXALEN CAPSULE 50MG
hydroxyurea capsule 500mg
IBRANCE CAPSULE 100MG
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
irinotecan hcl solution 100
mg/5 ml
ISTODAX FOR SOLUTION
10 MG/2 ML
IXEMPRA FOR SOLUTION
45MG
JAKAFI TABLET 10MG
JAKAFI TABLET 15MG
JAKAFI TABLET 20MG
JAKAFI TABLET 25MG
JAKAFI TABLET 5MG
JEVTANA SOLUTION 10
MG/ML (FIRST DILUTION)
2
2
2
AP
2
2
5
AP
5
LC; AP
5
LC; AP
5
LC; AP
3
LC
3
LC
5
AP
5
AP
3
2
5
LC; AP
5
LC; AP
5
LC; AP
5
5
AP
AP
5
AP
2
AP
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
5
AP
5
AP
4
4
4
4
4
AP
AP
AP
AP
AP
5
AP
21
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
KEYTRUDA FOR
SOLUTION 50MG
KEYTRUDA SOLUTION 100
MG/4 ML (25 MG/ML)
dia(s)
LENVIMA CAP THER
PACK 10 MG/DAY (10 MG
[1]/DAY)
LENVIMA CAP THER
[1]-4 MG [1]/DAY)
LENVIMA CAP THER
[2]/DAY)
LENVIMA CAP THER
[2]-4 MG [1]/DAY)
letrozole tablet 2.5mg
LEUKERAN TABLET 2MG
leuprolide acetate kit 1 mg/0.2
ml
lomustine capsule 100mg
LUPRON DEPOT KIT
11.25MG
LUPRON DEPOT KIT 22.5
MG (3 MONTH)
5
5
5
LC; AP
LC; AP
LC; AP
5
LC; AP
2
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
LYNPARZA CAPSULE
50MG
LYSODREN TABLET
500MG
MATULANE CAPSULE
50MG
MEGACE ES SUSPENSION
625 MG/5 ML
megestrol acetate suspension
400 mg/10 ml (40 mg/ml)
megestrol acetate suspension
625 mg/5 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
LC; AP
5
5
/Límites
LC; AP
LC
3
2
2
2
2
5
AP
5
AP
5
AP
5
AP
5
AP
5
AP
5
AP
5
AP
5
LC; AP
3
3
3
2
2
2
2
5
LC; AP
5
LC; AP
5
AP
2
2
AP
2
22
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
mitomycin for solution 20mg
mitoxantrone hcl concentrate 2
mg/ml
MUSTARGEN FOR
SOLUTION 10MG
NEXAVAR TABLET 200MG
NILANDRON TABLET
150MG
ONCASPAR SOLUTION 750
UNIT/ML
OPDIVO SOLUTION 40
MG/4 ML
dia(s)
OTREXUP SOLN AUTO-INJ
10 MG/0.4 ML
LC 1.6 mililitro(s) cada 28
dia(s)
15 MG/0.4 ML
dia(s)
20 MG/0.4 ML
dia(s)
25 MG/0.4 ML
dia(s)
7.5 MG/0.4 ML
dia(s)
oxaliplatin solution 100 mg/20
ml (5 mg/ml)
paclitaxel concentrate 6 mg/ml
2
AP
2
AP
4
AP
5
LC; AP
/Límites
POMALYST CAPSULE 1MG
PROLEUKIN FOR
SOLUTION 22 MILLION
UNIT
REVLIMID CAPSULE 10MG
REVLIMID CAPSULE
2.5MG
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
3
5
AP
5
LC; AP
4
LC; TE
4
4
4
LC; TE
LC; TE
LC; TE
4
LC; TE
5
AP
2
AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
5
LC; AP; AL
5
LC; AP; AL
5
LC; AP; AL
5
LC; AP; AL
5
LC; AP; AL
5
LC; AP; AL
4
5
AP
4
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
23
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
SPRYCEL TABLET 70MG
SPRYCEL TABLET 80MG
STIVARGA TABLET 40MG
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 CAPSULE 50MG
TAFINLAR CAPSULE 75MG
tamoxifen citrate tablet 10mg
tamoxifen citrate tablet 20mg
TARCEVA TABLET 100MG
TARCEVA TABLET 150MG
TARCEVA TABLET 25MG
TARGRETIN CAPSULE
75MG
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
/Límites
TASIGNA CAPSULE 150MG
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
TREANDA SOLUTION 45
MG/0.5 ML
TRELSTAR FOR
SUSPENSION 11.25 MG/2
ML
TRELSTAR FOR
SUSPENSION 22.5MG
TRELSTAR FOR
SUSPENSION 3.75 MG/2 ML
tretinoin capsule 10mg
TREXALL TABLET 10MG
TREXALL TABLET 15MG
TREXALL TABLET 5MG
TREXALL TABLET 7.5MG
TRISENOX SOLUTION 10
MG/10 ML
TYKERB TABLET 250MG
VELCADE FOR SOLUTION
3.5MG
vinblastine sulfate solution 1
mg/ml
vincasar pfs solution 1 mg/ml
4
5
LC; AP
5
LC; AP
2
2
5
LC; AP
5
LC; AP
5
LC; AP
5
5
LC; AP
5
LC; AP
4
4
5
AP
AP
AP
5
AP
5
AP
5
AP
5
AP
5
AP
5
AP
2
3
3
3
3
5
AP
5
LC; AP; AL
5
AP
2
AP
4
AP
24
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
vincristine sulfate solution 1
2 AP
mg/ml
vinorelbine tartrate solution
2 AP
50 mg/5 ml
VOTRIENT TABLET 200MG 5
XALKORI CAPSULE
200MG
5 LC; AP
XALKORI CAPSULE
250MG
5 LC; AP
XTANDI CAPSULE 40MG
5 AP
ZANOSAR FOR SOLUTION
4 AP
1 GRAM
ZELBORAF TABLET
240MG
5 LC; AP
ZOLINZA CAPSULE 100MG
3 LC; AP
ZYDELIG TABLET 100MG
5 LC; AP
ZYDELIG TABLET 150MG
5 LC; AP
ZYKADIA CAPSULE
150MG
5 LC; AP
ZYTIGA TABLET 250MG
3 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
cream 0.05 %
gel 0.05 %
lotion 0.05 %
ointment 0.05 %
betamethasone valerate cream
0.1 %
betamethasone valerate foam
0.12 %
betamethasone valerate lotion
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 %
2
2
2
2
2
2
2
2
2
4
2
2
2
2
2
2
2
2
4
25
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
colocort enema 100 mg/60 ml
CORDRAN TAPE 4
MCG/CM2
CORTIFOAM FOAM 10 %
DESONATE GEL 0.05 %
desonide cream 0.05 %
desonide lotion 0.05 %
desonide ointment 0.05 %
desoximetasone cream 0.05 %
desoximetasone cream 0.25 %
desoximetasone gel 0.05 %
desoximetasone ointment 0.05
%
desoximetasone ointment 0.25
%
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 %
/Límites
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 %
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 %
lokara 0.05% lotion
mometasone furoate cream 0.1
%
mometasone furoate ointment
0.1 %
mometasone furoate solution
0.1 %
OLUX FOAM 0.05 %
2
4
3
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
26
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
PANDEL CREAM 0.1 %
4
prednicarbate cream 0.1 %
2
prednicarbate ointment 0.1 %
2
procto-pak cream 1 %
2
proctozone-hc cream 2.5 %
2
TACLONEX SUSPENSION
4
0.005 %-0.064 %
triamcinolone acetonide
2
aerosol soln 0.147 mg/gram
triamcinolone acetonide cream
2
0.025 %
2
0.1 %
2
0.5 %
triamcinolone acetonide lotion
2
0.025 %
triamcinolone acetonide lotion
2
0.1 %
2
ointment 0.025 %
2
ointment 0.1 %
2
ointment 0.5 %
triamcinolone acetonide paste
2
0.1 %
AGENTES DE DESPIGMENTANTE Y
PIGMENTOGÉNICA
8-MOP CAPSULE 10MG
4
methoxsalen capsule 10mg
5
OXSORALEN LOTION 1 %
4
AGENTES DE LA PIEL Y MEMBRANAS
MUCOSAS, MISC.
acitretin capsule 10mg
2
acitretin capsule 17.5mg
2
acitretin capsule 25mg
2
ACZONE GEL 5 %
adapalene cream 0.1 %
adapalene gel 0.1 %
adapalene gel 0.3 %
amnesteem capsule 10mg
AZELEX CREAM 20 %
calcipotriene cream 0.005 %
calcipotriene ointment 0.005
%
calcipotriene solution 0.005 %
calcitriol ointment 3 mcg/gram
claravis capsule 10mg
CONDYLOX GEL 0.5 %
COSENTYX (2 SYRINGES)
SOLN PREF SYR 150
MG/ML
COSENTYX PEN SOLN
AUTO-INJ 150 MG/ML
diclofenac sodium gel 3 %
DIFFERIN LOTION 0.1 %
ELIDEL CREAM 1 %
EPIDUO FORTE 0.3-2.5%
GEL PUMP
EPIDUO GEL 0.1 %-2.5 %
FINACEA 15% FOAM
4
2
2
2
2
2
2
4
2
2
2
2
2
2
2
2
4
5
LC; AP
5
LC; AP
2
4
3
TE
4
4
4
27
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
FINACEA GEL 15 %
4
fluorouracil cream 0.5 %
2
imiquimod cream 5 %
2
PANRETIN GEL 0.1 %
4
PICATO GEL 0.015 %
4 LC
LC 3 cada 30 dia(s)
PICATO GEL 0.05 %
4 LC
LC 2 cada 30 dia(s)
podofilox solution 0.5 %
2
SANTYL OINTMENT 250
4
UNIT/GRAM
STELARA SOLN PREF SYR
45 MG/0.5 ML
5 LC; AP
STELARA SOLN PREF SYR
90 MG/ML
5 LC; AP
tacrolimus ointment 0.03 %
2 TE
tacrolimus ointment 0.1 %
2 TE
TAZORAC CREAM 0.05 %
3
TAZORAC CREAM 0.1 %
3
TAZORAC GEL 0.05 %
3
TAZORAC GEL 0.1 %
3
ZYCLARA CREAM 2.5 %
4 LC
ZYCLARA CREAM 3.75 %
4
ANTIINFECTIVAS (LA PIEL Y MEMBRANAS
MUCOSAS)
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 %
ciclopirox suspension 0.77 %
CLEOCIN SUPPOSITORY
100MG
CLEOCIN T GEL 1 %
CLINDACIN PAC KIT 1 %
clindamycin phosphate cream
2%
clindamycin phosphate foam 1
%
clindamycin phosphate gel 1
%
clindamycin phosphate lotion
1%
clindamycin phosphate
solution 1 %
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 %
2
2
3
4
4
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
2
28
Medicamento
Nivel Requisitos
Medicamento
/Límites
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 foam 2 %
ketoconazole shampoo 2 %
lindane lotion 1 %
lindane shampoo 1 %
metronidazole cream 0.75 %
metronidazole gel 0.75 %
metronidazole gel 1 %
metronidazole lotion 0.75 %
MICONAZOLE 3
SUPPOSITORY 200MG
mupirocin cream 2 %
mupirocin ointment 2 %
naftifine hcl cream 1 %
NAFTIN CREAM 2 %
NAFTIN GEL 1 %
NAFTIN GEL 2 %
neomycin-polymyxin b solution
40 mg-200,000 unit/ml
nystatin cream 100,000
unit/gram
Nivel Requisitos
/Límites
nystatin ointment 100,000
2
unit/gram
nystatin powder 100,000
2
unit/gram
nystatin-triamcinolone cream
2
100,000 unit/gram-0.1 %
nystatin-triamcinolone
ointment 100,000 unit/gram2
0.1 %
nystop powder 100,000
2
unit/gram
OXISTAT CREAM 1 %
4
OXISTAT LOTION 1 %
4
permethrin cream 5 %
2
silver sulfadiazine cream 1 %
2
ssd cream 1 %
2
sulfacetamide sodium
2
suspension 10 %
terconazole cream 0.4 %
2
terconazole cream 0.8 %
2
terconazole suppository 80mg
2
terconazole vaginal cream
2
0.4%
2
0.8%
vandazole gel 0.75 %
2
ZIANA GEL 1.2 %-0.025 %
4
ZOVIRAX CREAM 5 %
4
ANTIPRURIGINOSOS Y ANESTÉSICOS
LOCALES
lidocaine hcl gel 2 %
2
lidocaine ointment 5 %
2
lidocaine patch 5 % (700
2 AP
mg/patch)
lidocaine-prilocaine cream 2.5
2
%-2.5 %
2
2
2
2
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
4
2
2
2
4
4
4
2
2
29
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
PRUDOXIN CREAM 5 %
4
SYNERA PATCH 70-70MG
4
ZONALON CREAM 5 %
4
PROLIFERANTS Y ESTIMULANTES DE LA
CÉLULA
ATRALIN GEL 0.05 %
4
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 %
TRETIN-X KIT 0.05 %
4
tretinoin cream 0.025 %
2
2
2
tretinoin gel 0.01 %
2
tretinoin gel 0.025 %
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
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
ASMANEX AERO POW BR
ACT 110 MCG (30 DOSES)
LC 1 cada 30 dia(s)
ASMANEX AERO POW BR
LC 1 cada 30 dia(s)
ASMANEX AERO POW BR
LC 1 cada 30 dia(s)
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
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
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
4
2
AP
2
AP
2
AP
2
2
2
AP
4
LC
3
LC
30
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
FLOVENT DISKUS AERO
POW BR ACT 250 MCG
FLOVENT DISKUS AERO
POW BR ACT 50 MCG
FLOVENT HFA AEROSOL
110 MCG/ACTUATION
FLOVENT HFA AEROSOL
220 MCG
FLOVENT HFA AEROSOL
44 MCG
flunisolide solution 25 mcg
(0.025 %)
fluticasone propionate
suspension 50 mcg/actuation
montelukast sodium packet
4mg
montelukast sodium tablet
10mg
chewable 4mg
chewable 5mg
NASONEX SUSPENSION 50
MCG
OMNARIS SUSPENSION 50
MCG
3
LC
3
LC
3
LC
3
LC
3
LC
/Límites
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)
PULMICORT SUSPENSION
1 MG/2 ML
QNASL AEROSOL SOLN 80
MCG/ACTUATION
QNASL CHILDREN
AEROSOL SOLN 40
MCG/ACTUATION
QVAR AEROSOL SOLN 40
MCG/ACTUATION
QVAR AEROSOL SOLN 80
MCG
aerosol 55 mcg
VERAMYST SUSPENSION
27.5 MCG/ACTUATION
zafirlukast tablet 10mg
zafirlukast tablet 20mg
ZETONNA AEROSOL SOLN
37 MCG/ACTUATION
2
2
2
LC
2
LC
2
LC
2
LC
4
4
3
LC
3
LC
3
AP
4
LC
4
LC
3
LC
3
LC
2
4
2
LC
2
LC
4
LC
31
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
lithium carbonate tablet
2
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
cartridge 4 mg/0.5 ml
2
cartridge 6 mg/0.5 ml
2
sumatriptan succinate solution
6 mg/0.5 ml
2
sumatriptan succinate tablet
100mg
2
LC 9 cada 30 dia(s)
ZYFLO CR TABLET ER
12HR 600MG
4 LC
AGENTES DEL TRACTO RESPIRATORIO,
MISCELÁNEOS
ARALAST NP FOR
5 AP
SOLUTION 500MG
GLASSIA SOLUTION 1
5 AP
GRAM/50 ML (2 %)
KALYDECO PACKET 50MG 5 AP
KALYDECO PACKET 75MG 5 AP
KALYDECO TABLET
5 AP
150MG
PROLASTIN C FOR
5 AP
SOLUTION 1,000MG
XOLAIR FOR SOLUTION
5 AP
150MG
ZEMAIRA FOR SOLUTION
5 AP
1,000MG
BRONCODILATADORES
PROVENTIL HFA
4
AEROSOL SOLN 90 MCG
INHIBIDORES DE LA FOSFODIESTERASA
TIPO 4
DALIRESP TABLET 500
3
MCG
AGENTES DEL SISTEMA NERVIOSO
CENTRAL
AGENTES ANTIMÁNICOS
lithium carbonate capsule
2
150mg
2
300mg
2
600mg
lithium carbonate er tablet er
2
300mg
lithium carbonate er tablet er
2
450mg
LC
LC
LC
LC
LC
LC
LC
LC
LC
LC
LC
LC
LC
32
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
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
bromocriptine mesylate
2
capsule 5mg
bromocriptine mesylate tablet
2
2.5mg
cabergoline tablet 0.5mg
2
carbidopa-levodopa er tablet
2
er 25-100mg
carbidopa-levodopa er tablet
2
er 50-200mg
carbidopa-levodopa tablet 102
100mg
carbidopa-levodopa tablet 252
100mg
carbidopa-levodopa tablet 25250mg
carbidopa-levodopa tablet
disperse 10-100mg
disperse 25-100mg
disperse 25-250mg
carbidopa-levodopaentacapone tablet 12.5-50200mg
carbidopa-levodopaentacapone tablet 25-100200mg
carbidopa-levodopaentacapone tablet 50-200200mg
CYCLOSET TABLET 0.8MG
entacapone tablet 200mg
MIRAPEX ER TABLET ER
24HR 0.375MG
24HR 2.25MG
24HR 3.75MG
2
2
2
2
2
2
2
2
2
2
4
LC
2
4
LC
4
LC
4
LC
33
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
24HR 3MG
24HR 4.5MG
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
tablet 1mg
PRAMIPEXOLE ER 3 MG
TABLET
4
LC
4
LC
/Límites
PRAMIPEXOLE ER 4.5 MG
TABLET
pramipexole er tablet er 24hr
0.375mg
0.75mg
1.5mg
ropinirole er tablet er 24hr
12mg
2mg
4mg
6mg
8mg
ropinirole hcl tablet 0.25mg
ropinirole hcl tablet 0.5mg
ropinirole hcl tablet 1mg
RYTARY CAPSULE ER
23.75-95MG
4
4
4
4
4
4
2
2
2
2
2
2
2
LC
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
4
LC; TE
34
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
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
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
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 tablet 10mg
2 LC
memantine hcl tablet 5 mg
(28)-10 mg (21)
2 LC
memantine hcl tablet 5mg
2 LC
NAMENDA SOLUTION 10
MG/5 ML
NAMENDA TABLET 10MG
NAMENDA TABLET 5 MG
(28)-10 MG (21)
NAMENDA TABLET 5MG
NAMENDA XR CAPSULE
ER 24HR 14MG
NAMENDA XR CAPSULE
ER 24HR 21MG
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
3
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
4
LC; AP
2
4
LC
4
LC
35
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
STRATTERA CAPSULE
18MG
4 LC
STRATTERA CAPSULE
25MG
4 LC
STRATTERA CAPSULE
40MG
4 LC
STRATTERA CAPSULE
60MG
4 LC
STRATTERA CAPSULE
80MG
4 LC
tetrabenazine tablet 12.5mg
5 LC; AP
tetrabenazine tablet 25mg
5 LC; AP
XENAZINE TABLET
12.5MG
5 LC; AP
XENAZINE TABLET 25MG
5 LC; AP
XYREM SOLUTION 500
MG/ML
5 LC; AP; AL
dia(s)
AGENTES PSICOTERAPÉUTICOS
ABILIFY MAINTENA FOR
SUSPENSION 300MG
4 LC
LC 2 cada 28 dia(s)
SUSPENSION 300MG
5 LC
LC 2 cada 28 dia(s)
SUSPENSION 400MG
LC 2 cada 28 dia(s)
amitriptyline hcl tablet 100mg
amoxapine tablet 100mg
APLENZIN TABLET ER
24HR 174MG
APLENZIN TABLET ER
24HR 348MG
APLENZIN TABLET ER
24HR 522MG
aripiprazole tablet 10mg
4
LC
2
2
2
2
2
2
2
2
2
2
4
LC; TE
4
LC; TE
4
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
36
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ASENAPINE MALEATE SL
TAB 10 MG (BASE EQUIV)
BRINTELLIX TABLET
10MG
BRINTELLIX TABLET
20MG
BRINTELLIX TABLET 5MG
buproban tablet er 12hr
150mg
bupropion hcl sr tablet er 12hr
100mg
150mg
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
2
LC; TE
2
LC; TE
4
LC; TE
4
TE
4
TE
4
TE
/Límites
200mg
25mg
50mg
citalopram hbr solution 10
mg/5 ml
citalopram hbr tablet 10mg
clomipramine hcl capsule
25mg
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
2
2
2
2
2
2
2
LC
2
LC
2
AP
2
2
2
2
2
2
2
LC
2
LC
2
LC
2
2
2
2
LC
2
LC
2
LC
2
LC
2
LC
37
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
clozapine tablet 100mg
compro suppository 25mg
desipramine hcl tablet 100mg
doxepin hcl capsule 100mg
doxepin hcl concentrate 10
mg/ml
duloxetine hcl capsule dr part
20mg
30mg
60mg
EMSAM PATCH 24HR 12
MG/24 HOUR
2
LC
2
LC
2
LC
2
LC
/Límites
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
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
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
LC
2
LC
2
LC
4
LC; TE
4
LC; TE
4
LC; TE
2
2
LC
2
LC
2
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
38
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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)
fluoxetine dr capsule dr 90mg
LC 4 cada 28 dia(s)
fluoxetine hcl capsule 10mg
fluoxetine hcl solution 20 mg/5
ml
fluoxetine hcl tablet 10mg
fluphenazine decanoate
solution 25 mg/ml
4
/Límites
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
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
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
2
LC
2
LC
2
LC
2
LC
2
2
LC
2
LC
2
LC
2
AP
2
2
AP
2
2
2
2
2
TE
2
TE
2
2
2
4
TE
4
2
2
2
2
2
2
2
39
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
imipramine hcl tablet 10mg
imipramine pamoate capsule
100mg
125mg
150mg
75mg
INVEGA SUSTENNA
SUSPENSION 117 MG/0.75
ML
INVEGA SUSTENNA
SUSPENSION 156 MG/ML
INVEGA SUSTENNA
ML
INVEGA SUSTENNA
ML
INVEGA SUSTENNA
SUSPENSION 78 MG/0.5 ML
INVEGA TABLET ER 24HR
1.5MG
3MG
6MG
/Límites
2
2
2
2
2
2
9MG
KHEDEZLA TABLET ER
24HR 100MG
KHEDEZLA TABLET ER
24HR 50MG
LATUDA TABLET 120MG
LATUDA TABLET 20MG
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
2
2
2
2
4
4
4
4
4
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
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
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
40
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
45mg
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
2
/Límites
olanzapine tablet 2.5mg
olanzapine tablet 7.5mg
olanzapine-fluoxetine hcl
capsule 12-25mg
capsule 12-50mg
capsule 3-25mg
capsule 6-25mg
capsule 6-50mg
ORAP TABLET 1MG
ORAP TABLET 2MG
paroxetine hcl tablet 10mg
paroxetine hcl tablet er 24hr
12.5mg
25mg
LC
2
2
2
2
2
2
2
2
2
2
2
AP
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
2
2
2
2
4
LC
4
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
41
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
37.5mg
PAXIL SUSPENSION 10
MG/5 ML
perphenazine tablet 16mg
perphenazine-amitriptyline
tablet 2-10mg
tablet 2-25mg
tablet 4-10mg
tablet 4-25mg
tablet 4-50mg
PEXEVA TABLET 10MG
PEXEVA TABLET 20MG
PEXEVA TABLET 30MG
PEXEVA TABLET 40MG
phenelzine sulfate tablet 15mg
PRISTIQ ER TABLET ER
24HR 100MG
24HR 25MG
24HR 50MG
2
/Límites
protriptyline hcl tablet 10mg
protriptyline hcl tablet 5mg
quetiapine fumarate tablet
100mg
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
LC
4
2
2
2
2
2
2
2
2
2
4
4
4
4
2
TE
TE
TE
TE
4
LC; TE
4
LC; TE
4
LC; TE
2
2
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
42
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
sertraline hcl concentrate 20
mg/ml
dia(s)
sertraline hcl tablet 100mg
SILENOR TABLET 3MG
SILENOR TABLET 6MG
SURMONTIL CAPSULE
100MG
SURMONTIL CAPSULE
25MG
SURMONTIL CAPSULE
50MG
4
4
4
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
4
LC; TE
4
LC; TE
2
2
2
LC
2
LC
2
LC
2
LC
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
43
Medicamento
Nivel Requisitos
Medicamento
/Límites
thioridazine hcl tablet 100mg
thiothixene capsule 10mg
tranylcypromine sulfate tablet
10mg
trazodone hcl tablet 100mg
trifluoperazine hcl tablet 10mg
venlafaxine hcl er capsule er
24hr 150mg
24hr 37.5mg
24hr 75mg
venlafaxine hcl tablet 100mg
venlafaxine hcl tablet 37.5mg
2
2
2
2
2
2
2
2
Nivel Requisitos
/Límites
AP
AP
AP
AP
VERSACLOZ SUSPENSION
50 MG/ML
5 LC; AP
dia(s)
VIIBRYD KIT 10 MG (7)-20
MG (7)-40 MG (16)
4 LC; TE
VIIBRYD TABLET 10MG
4 TE
VIIBRYD TABLET 20MG
4 TE
VIIBRYD TABLET 40MG
4 TE
ZELAPAR TABLET
4
DISPERSE 1.25MG
ziprasidone hcl capsule 20mg
2 LC
2 LC
2 LC
2 LC
ZYPREXA RELPREVV FOR
5 AP
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
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
44
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ABSTRAL TAB
SUBLINGUAL 600 MCG
ABSTRAL TAB
SUBLINGUAL 800 MCG
acetaminophen-codeine tablet
300-15mg
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
4
LC; AP; NM
4
LC; AP; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
AP; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
/Límites
butalb-caff-acetaminophcodein capsule 50-325-4030mg
butalbital-acetaminophencaffe capsule 50-300-40mg
butalbital-acetaminophencaffe capsule 50-325-40mg
butalbital-acetaminophencaffe tablet 50-325-40mg
butorphanol tartrate solution
10 mg/ml
dia(s)
BUTRANS PATCH
WEEKLY 10 MCG/HOUR
LC 4 cada 28 dia(s)
BUTRANS PATCH
WEEKLY 15 MCG/HOUR
LC 4 cada 28 dia(s)
BUTRANS PATCH
WEEKLY 20 MCG/HOUR
LC 4 cada 28 dia(s)
BUTRANS PATCH
WEEKLY 5 MCG/HOUR
LC 4 cada 28 dia(s)
BUTRANS PATCH
WEEKLY 7.5 MCG/HOUR
LC 4 cada 28 dia(s)
CAMBIA PACKET 50MG
CAPITAL W-CODEINE
SUSPENSION 120 MG-12
MG/5 ML
celecoxib capsule 100mg
LC; NM
2
LC; NM
2
LC
2
LC; NM
2
LC; NM
2
LC; NM
4
LC; NM
4
LC; NM
4
LC; NM
4
LC; NM
4
LC; NM
4
4
NM
2
LC; TE
45
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
codeine sulfate tablet 15mg
diclofenac potassium tablet
50mg
diclofenac sodium er tablet er
24hr 100mg
diclofenac sodium solution 1.5
%
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
2
LC; TE
2
LC; TE
2
LC; TE
2
2
2
NM
NM
NM
/Límites
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
fenoprofen calcium tablet
600mg
fentanyl citrate loz on a handle
1,200 mcg
1,600 mcg
200 mcg
400 mcg
600 mcg
800 mcg
fentanyl patch 72hr 100
mcg/hour
2
2
2
2
2
2
2
2
2
4
2
2
AP; NM
AP; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
2
2
2
2
2
2
2
2
2
LC; AP; NM
2
LC; AP; NM
2
LC; AP; NM
2
LC; AP; NM
2
LC; AP; NM
2
LC; AP; NM
2
LC; NM
46
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
mcg/hour
mcg/hour
mcg/hour
mcg/hour
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
2
/Límites
gabapentin solution 250 mg/5
ml
gabapentin tablet 600mg
gabapentin tablet 800mg
GRALISE 30-DAY
STARTER PACK
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
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
2
LC
2
LC
2
LC
2
2
LC
2
LC
4
TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
47
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
hydromorphone er tab 24hr
deter 12mg
deter 16mg
deter 32mg
deter 8mg
hydromorphone hcl tablet 2mg
ibuprofen tablet 400mg
indomethacin capsule 25mg
indomethacin capsule 50mg
indomethacin capsule er 75mg
KADIAN CAPSULE ER
24HR 200MG
ketoprofen capsule 50mg
ketoprofen capsule 75mg
ketoprofen capsule er 24hr
200mg
LAZANDA SOLUTION 100
MCG/SPRAY
2
LC; TE; NM
2
LC; TE; NM
2
LC; TE; NM
2
LC; TE; NM
2
LC; NM
2
LC; NM
2
LC; NM
/Límites
LAZANDA SOLUTION 400
MCG/SPRAY
levorphanol tartrate tablet
2mg
meclofenamate sodium capsule
100mg
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
2
2
2
2
2
2
4
LC; TE; NM
2
2
2
5
LC; AP; NM
5
LC; AP; NM
2
NM
2
2
2
2
2
2
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
48
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
24hr 45mg
24hr 50mg
24hr 60mg
24hr 60mg
24hr 75mg
24hr 80mg
24hr 90mg
morphine sulfate er tablet er
100mg
15mg
200mg
30mg
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
/Límites
60mg
morphine sulfate solution 10
mg/5 ml
mg/ml
mg/5 ml (20 mg/ml)
mg/ml
mg/5 ml
mg/ml
mg/ml
morphine sulfate tablet 15mg
morphine sulfate tablet 30mg
nabumetone tablet 500mg
nabumetone tablet 750mg
NAPRELAN TABLET ER
24HR 375MG
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
LC; NM
2
LC; NM
2
NM
2
AP; NM
2
NM
2
AP; NM
2
NM
2
AP; NM
2
AP; NM
2
LC; NM
2
LC; NM
2
2
4
4
2
2
2
2
2
2
2
49
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
naproxen tablet dr 375mg
naproxen tablet dr 500mg
NUCYNTA ER TABLET ER
12HR 100MG
12HR 150MG
12HR 200MG
12HR 250MG
12HR 50MG
NUCYNTA TABLET 100MG
NUCYNTA TABLET 50MG
NUCYNTA TABLET 75MG
oxaprozin tablet 600mg
oxycodone hcl capsule 5mg
oxycodone hcl concentrate 20
mg/ml
oxycodone hcl er tab 12hr
deter 10mg
deter 20mg
/Límites
deter 40mg
deter 80mg
oxycodone hcl solution 5 mg/5
ml
oxycodone hcl tablet 10mg
oxycodone hcl-aspirin tablet
4.8355-325mg
oxycodone hcl-ibuprofen tablet
400-5mg
oxycodone-acetaminophen
tablet 10-325mg
tablet 2.5-325mg
tablet 5-325mg
tablet 7.5-325mg
2
2
2
3
LC; TE; NM
3
LC; TE; NM
3
LC; TE; NM
3
LC; TE; NM
3
LC; TE; NM
4
LC; TE; NM
4
LC; TE; NM
4
LC; TE; NM
2
2
LC; NM
2
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
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
50
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
OXYCONTIN TAB 12HR
DETER 15MG
OXYCONTIN TAB 12HR
DETER 30MG
OXYCONTIN TAB 12HR
DETER 60MG
oxymorphone hcl er tablet er
12hr 10mg
12hr 15mg
12hr 20mg
12hr 30mg
12hr 40mg
12hr 5mg
12hr 7.5mg
oxymorphone hcl tablet 10mg
oxymorphone hcl tablet 5mg
4
LC; TE; NM
4
LC; TE; NM
4
LC; TE; NM
2
/Límites
PENNSAID SOLUTION 20
MG/GRAM PER
ACTUATION (2 %)
piroxicam capsule 10mg
piroxicam capsule 20mg
REPREXAIN TABLET 10200MG
REPREXAIN TABLET 2.5200MG
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
tolmetin sodium capsule
400mg
tolmetin sodium tablet 200mg
tolmetin sodium tablet 600mg
tramadol hcl er capsule er
24hr 100mg
24hr 200mg
24hr 300mg
LC; NM
2
LC; NM
2
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
4
LC; NM
2
2
4
NM
2
2
2
2
LC
2
LC
2
LC
51
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
tramadol hcl er tablet er 24hr
100mg
2 LC
200mg
2 LC
300mg
2 LC
tramadol hcl tablet 50mg
2 LC
tramadol hcl-acetaminophen
2
tablet 37.5-325mg
VIMOVO TABLET DR 37520MG
4 LC; TE
VIMOVO TABLET DR 50020MG
4 LC; TE
VOLTAREN GEL 1 %
4
ZUBSOLV TAB
SUBLINGUAL 1.4-0.36MG
4 LC; NM
ZUBSOLV TAB
4 LC; NM
ZUBSOLV TAB
4 LC; NM
ANOREXIGENICSRESPIR., ESTIMULANTE
CEREBRAL
amphetamine salt combo
tablet 10mg
2 LC
Medicamento
amphetamine salt combo tablet
12.5mg
2
15mg
2
20mg
2
30mg
2
5mg
2
7.5mg
2
DAYTRANA PATCH 10
MG/9 HOUR
4
DAYTRANA PATCH 15
MG/9 HOUR
4
DAYTRANA PATCH 20
MG/9 HOUR
4
DAYTRANA PATCH 30
MG/9 HOUR
4
dexmethylphenidate hcl er
2
2
2
Medicamento
Nivel
Nivel Requisitos
LC
LC
LC
LC
LC
LC
LC
LC
LC
LC
LC
LC
LC
Requisitos
52
/Límites
capsule er 24hr 5mg
dextroamphetamine sulfate er
capsule er 24hr 5mg
dextroamphetamine-amphet er
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
/Límites
capsule er 24hr 5mg
EVEKEO TABLET 10MG
EVEKEO TABLET 5MG
FOCALIN XR CAPSULE ER
24HR 25MG
FOCALIN XR CAPSULE ER
24HR 35MG
methylphenidate er tablet er
10mg
20mg
24hr 18mg
24hr 27mg
24hr 36mg
24hr 54mg
methylphenidate hcl cd
capsule er 10mg
capsule er 50mg
2
LC
2
LC
2
LC
4
LC
4
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
53
Medicamento
Nivel Requisitos
Medicamento
/Límites
capsule er 60mg
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
24hr 30mg
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
Nivel Requisitos
/Límites
24hr 40mg
2 LC
modafinil tablet 100mg
2 LC; AP
modafinil tablet 200mg
2 LC; AP
NUVIGIL TABLET 150MG
4 LC; AP
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
2
2
2
2
buspirone hcl tablet 7.5mg
2
eszopiclone tablet 1mg
2 LC; TE
54
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
HETLIOZ CAPSULE 20MG
ROZEREM TABLET 8MG
zaleplon capsule 10mg
zaleplon capsule 5mg
zolpidem tartrate er tablet er
12.5mg
zolpidem tartrate er tablet er
6.25mg
zolpidem tartrate tablet 10mg
zolpidem tartrate tablet 5mg
ZOLPIMIST SOLUTION 5
MG/SPRAY (0.1 ML)
dia(s)
ANTAGONISTAS OPIÁCEOS
EVZIO SOLN AUTO-INJ 0.4
MG/0.4 ML
dia(s)
naloxone hcl solution 1 mg/ml
naltrexone hcl tablet 50mg
ANTICONVULSANTES
APTIOM TABLET 200MG
2
LC; TE
2
LC; TE
5
LC; AP
/Límites
APTIOM TABLET 400MG
APTIOM TABLET 600MG
APTIOM TABLET 800MG
BANZEL SUSPENSION 40
MG/ML
BANZEL TABLET 200MG
BANZEL TABLET 400MG
carbamazepine capsule er
12hr 100mg
12hr 200mg
12hr 300mg
carbamazepine suspension 100
mg/5 ml
carbamazepine tablet 200mg
carbamazepine tablet
chewable 100mg
carbamazepine xr tablet er
12hr 200mg
carbamazepine xr tablet er
12hr 400mg
CELONTIN CAPSULE
300MG
CEREBYX SOLUTION 500
MG PE/10 ML
dia(s)
DILANTIN CAPSULE
100MG
DILANTIN CAPSULE 30MG
DILANTIN TABLET
CHEWABLE 50MG
3
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
4
LC; TE
4
LC; AP
2
2
AP
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
4
4
2
2
2
2
2
2
2
2
4
4
LC; AP
3
3
3
55
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
DILANTIN-125
divalproex sodium cap
sprinkle 125mg
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 TABLET 10MG
FYCOMPA TABLET 12MG
FYCOMPA TABLET 2MG
/Límites
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 XR (BLUE) KIT
25 MG (21)-50 MG (7)
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
3
2
2
2
2
2
2
2
4
4
4
2
2
2
2
2
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
4
4
4
4
4
4
2
LC
2
LC
2
LC
56
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
25mg
300mg
50mg
lamotrigine odt tablet disperse
100mg
200mg
25mg
50mg
lamotrigine tablet 100mg
lamotrigine tablet chewable
25mg
lamotrigine tablet chewable
5mg
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
/Límites
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
1,500 mg/100 ml
500 mg/100 ml
LYRICA CAPSULE 100MG
LYRICA CAPSULE 25MG
LYRICA CAPSULE 50MG
2
2
2
LC
2
LC
2
2
AP
2
LC
2
LC
2
LC
2
LC
2
AP
2
AP
2
AP
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
57
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
LYRICA CAPSULE 75MG
LYRICA SOLUTION 20
MG/ML
oxcarbazepine suspension 300
mg/5 ml
oxcarbazepine tablet 150mg
OXTELLAR XR TABLET
ER 24HR 150MG
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
4
/Límites
phenytoin tablet chewable
50mg
POTIGA TABLET 200MG
POTIGA TABLET 300MG
POTIGA TABLET 400MG
POTIGA TABLET 50MG
SABRIL PACKET 500MG
SABRIL TABLET 500MG
TEGRETOL XR TABLET ER
12HR 100MG
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
LC
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
3
2
LC
2
LC
2
2
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
58
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
topiramate tablet 100mg
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
2
LC
2
LC
2
LC
2
LC
3
LC; AP
3
LC; AP
3
LC; AP
3
LC; AP
/Límites
VIMPAT TABLET 50MG
zonisamide capsule 100mg
BARBITUATES
phenobarbital elixir 20 mg/5
ml
phenobarbital tablet 100mg
phenobarbital tablet 16.2mg
primidone tablet 250mg
primidone tablet 50mg
BENZODIAZEPINAS
alprazolam er tablet er 24hr
0.5mg
1mg
2mg
3mg
ALPRAZOLAM INTENSOL
CONCENTRATE 1 MG/ML
alprazolam odt tablet disperse
0.25mg
0.5mg
1mg
2
2
2
3
3
3
LC
3
LC
3
LC
3
LC
2
2
2
2
AP
2
2
2
2
2
2
2
2
2
2
AP
AP
AP
AP
AP
AP
AP
AP
2
2
2
2
2
2
2
2
59
Medicamento
Nivel Requisitos
Medicamento
/Límites
2mg
alprazolam tablet 0.25mg
alprazolam tablet 0.5mg
alprazolam tablet 1mg
alprazolam tablet 2mg
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
diazepam tablet 10mg
diazepam tablet 2mg
diazepam tablet 5mg
lorazepam intensol
concentrate 2 mg/ml
lorazepam tablet 0.5mg
Nivel Requisitos
/Límites
lorazepam tablet 1mg
2
lorazepam tablet 2mg
2
ONFI SUSPENSION 2.5
4
MG/ML
ONFI TABLET 10MG
4
ONFI TABLET 20MG
4
temazepam capsule 15mg
2
temazepam capsule 22.5mg
2
temazepam capsule 30mg
2
temazepam capsule 7.5mg
2
triazolam tablet 0.125mg
2
triazolam tablet 0.25mg
2
AGENTES TERAPÉUTICOS MISCELÁNEOS
AGENTES ANTIGOTA (ÁCIDO ÚRICO)
allopurinol tablet 100mg
2
allopurinol tablet 300mg
2
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)
5 LC; AP
dia(s)
ACTEMRA SOLUTION 400
MG/20 ML (20 MG/ML)
5 LC; AP
dia(s)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
60
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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 KIT 25 MG (1 ML)
LC 8 cada 28 dia(s)
ENBREL SOLN AUTO-INJ
50 MG/ML (0.98 ML)
ENBREL SOLN PREF SYR
25 MG/0.5 ML (0.51 ML)
ENBREL SOLN PREF SYR
50 MG/ML (0.98 ML)
HUMIRA PEN CROHN'SUC-HS PEN-INJ KIT 40
MG/0.8 ML
LC 6 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)
5
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
OTEZLA TAB THER PACK
10 MG (4)-20 MG (4)-30 MG
(19)
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
SIMPONI SOLN AUTO-INJ
50 MG/0.5 ML
SIMPONI SOLN PREF SYR
100 MG/ML
LC; AP
5
LC; AP
5
LC; AP
5
LC
5
LC
5
LC
5
/Límites
LC
5
LC
5
LC
5
LC
5
LC
5
LC; AP
2
2
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
61
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
mycophenolate mofetil for
suspension 200 mg/ml
mycophenolate mofetil tablet
500mg
mycophenolic acid tablet dr
180mg
mycophenolic acid tablet dr
360mg
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
acetylcysteine solution 100
mg/ml (10 %)
acetylcysteine solution 200
mg/ml (20 %)
leucovorin calcium for
solution 100mg
SIMPONI SOLN PREF SYR
50 MG/0.5 ML
5 LC; AP
XELJANZ TABLET 5MG
5 LC; AP
AGENTES INMUNOSUPRESORES
ASTAGRAF XL CAPSULE
4 AP
ER 24HR 0.5MG
ASTAGRAF XL CAPSULE
4 AP
ER 24HR 1MG
ASTAGRAF XL CAPSULE
4 AP
ER 24HR 5MG
ATGAM INJECTABLE 50
5 AP
MG/ML
AZASAN TABLET 100MG
3 AP
AZASAN TABLET 75MG
3 AP
azathioprine tablet 50mg
2 AP
cyclosporine capsule 100mg
2 AP
cyclosporine capsule 25mg
2 AP
cyclosporine modified capsule
2 AP
100mg
2 AP
25mg
2 AP
50mg
cyclosporine solution 100
2 AP
mg/ml
cyclosporine solution 250
2 AP
mg/5 ml
gengraf capsule 100mg
2 AP
gengraf capsule 25mg
2 AP
gengraf solution 100 mg/ml
2 AP
mycophenolate mofetil capsule
2 AP
250mg
2
AP
2
AP
2
AP
2
AP
3
AP
3
AP
2
2
2
2
2
2
AP
AP
AP
AP
AP
AP
4
LC; AP
4
LC; AP
4
LC; AP
5
3
AP
2
AP
2
AP
2
AP
62
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
leucovorin calcium for
2 AP
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
AVODART CAPSULE
4
0.5MG
finasteride tablet 5mg
2
INHIBIDORES DE LA REABSORCIÓN DE
HUESO
alendronate sodium tablet
10mg
2 LC
35mg
2 LC
LC 4 cada 28 dia(s)
40mg
2 LC
alendronate sodium tablet 5mg
2 LC
70mg
2 LC
LC 4 cada 28 dia(s)
ATELVIA TABLET DR
35MG
4 LC; TE
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)
60 mg/10 ml (6 mg/ml)
90 mg/10 ml (9 mg/ml)
PROLIA SOLUTION 60
MG/ML
dia(s)
risedronate sodium dr tablet
dr 35mg
LC 4 cada 28 dia(s)
risedronate sodium tablet
150mg
LC 1 cada 28 dia(s)
30mg
35mg
LC 4 cada 28 dia(s)
risedronate sodium tablet 5mg
XGEVA SOLUTION 120
MG/1.7 ML (70 MG/ML)
2
2
2
AP
2
LC
4
AP
4
AP
4
AP
4
LC; AP
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
2
LC; TE
5
AP
63
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
zoledronic acid concentrate 4
2 AP
mg/5 ml
zoledronic acid solution 5
2 AP
mg/100 ml
ZOMETA SOLUTION 4
5 AP
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
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
ADMINISTRATION PACK
5 LC; AP
KIT 30 MCG (1 ML)
LC 4 cada 30 dia(s)
AVONEX PEN AUTO-INJ
KIT 30 MCG/0.5 ML
5 LC; AP
LC 4 cada 30 dia(s)
AVONEX PREFILL SYR KIT
30 MCG/0.5 ML
5 LC; AP
LC 4 cada 30 dia(s)
COPAXONE SOLN PREF
SYR 20 MG/ML
5 LC
dia(s)
COPAXONE SOLN PREF
SYR 40 MG/ML
dia(s)
EXTAVIA KIT 0.3MG
GILENYA CAPSULE 0.5MG
PLEGRIDY PEN SOLN PENINJ 125 MCG/0.5 ML
PLEGRIDY PEN SOLN PENINJ 63 MCG/0.5 ML (1)-94
MCG/0.5 ML (1)
PLEGRIDY SOLN PREF
SYR 125 MCG/0.5 ML
REBIF REBIDOSE SOLN
AUTO-INJ 22 MCG/0.5 ML
dia(s)
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)
5
LC
5
LC
5
LC
5
LC; AP
5
LC; AP
5
LC; AP
5
LC
5
LC
5
LC
5
LC
5
LC
64
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
REBIF SOLN PREF SYR 8.8
MCG/0.2 ML (6) - 22
MCG/0.5 ML (6)
5 LC
dia(s)
TECFIDERA CAPSULE DR
120MG
5 LC; AP
TECFIDERA CAPSULE DR
240MG
5 LC; AP
TECFIDERA STARTER
PACK
5 LC; AP
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
Medicamento
Nivel Requisitos
CYSTAGON CAPSULE
150MG
CYSTAGON CAPSULE
50MG
CYSTARAN SOLUTION
0.44 %
dia(s)
DEMSER CAPSULE 250MG
ELMIRON CAPSULE
100MG
ESBRIET CAPSULE 267MG
GLUCAGEN FOR
SOLUTION 1MG
GLUCAGON EMERGENCY
KIT KIT 1MG
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 500MG
KUVAN TABLET SOLUBLE
100MG
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
Medicamento
4
4
4
LC; AP
4
3
5
LC; AP
3
3
2
5
AP
5
LC; AP
5
LC; AP
5
5
5
LC; AP
5
AP
2
AP
2
AP
Nivel Requisitos
65
/Límites
2
mcg/ml
5
mcg/ml
OFEV CAPSULE 100MG
5
OFEV CAPSULE 150MG
5
ORFADIN CAPSULE 10MG
5
ORFADIN CAPSULE 2MG
5
ORFADIN CAPSULE 5MG
5
RAVICTI LIQUID 1.1
GRAM/ML
4
dia(s)
SENSIPAR TABLET 30MG
3
3
3
SIGNIFOR LAR FOR
SUSPENSION 20MG
5
LC 1 cada 28 dia(s)
SIGNIFOR LAR FOR
SUSPENSION 40MG
5
LC 1 cada 28 dia(s)
SIGNIFOR LAR FOR
SUSPENSION 60MG
5
LC 1 cada 28 dia(s)
SIGNIFOR SOLUTION 0.3
MG/ML (1 ML)
5
dia(s)
MG/ML (1 ML)
5
dia(s)
MG/ML (1 ML)
5
dia(s)
Medicamento
Nivel
/Límites
SOMATULINE DEPOT
5 AP
SOLUTION 120 MG/0.5 ML
SOMATULINE DEPOT
5 AP
SOMATULINE DEPOT
5 AP
ZAVESCA CAPSULE
4
100MG
ANTAGONISTAS DE METAL PESADO
ANTAGONISTAS DE METAL PESADO
CHEMET CAPSULE 100MG
4
DEPEN TABLET 250MG
4
EXJADE TABLET
4 AL
SOLUBLE 125MG
EXJADE TABLET
4 AL
SOLUBLE 250MG
EXJADE TABLET
4 AL
SOLUBLE 500MG
FERRIPROX TABLET
4
500MG
JADENU TABLET 180MG
5 LC
JADENU TABLET 360MG
5 LC
JADENU TABLET 90MG
5 LC
SYPRINE CAPSULE 250MG
4
BLOOD FORMATION,COAGULATION AND
THROMBOSIS
ANTIHEMORRHAGIC AGENTS
desmopressin acetate solution
10 mcg/spray (0.1 ml)
2 LC
dia(s)
2 AP
4 mcg/ml
desmopressin acetate tablet
2
0.1mg
AP
AP
LC; AP
LC; AP
AP
AP
AP
LC; AP
LC; AP
LC; AP
LC; AP
LC; AP
LC; AP
LC; AP
Requisitos
Medicamento
Nivel Requisitos
66
/Límites
desmopressin acetate tablet
2
0.2mg
STIMATE SOLUTION 150
4
MCG/SPRAY (0.1 ML)
ANTITHROMBOTIC AGENTS
AGGRENOX CAPSULE ER
3
12HR 25-200MG
anagrelide hcl capsule 0.5mg
2
anagrelide hcl capsule 1mg
2
BRILINTA TABLET 90MG
3
cilostazol tablet 100mg
2
cilostazol tablet 50mg
2
clopidogrel tablet 300mg
2
LC 2 cada 30 dia(s)
clopidogrel tablet 75mg
2
COUMADIN TABLET 10MG 4
COUMADIN TABLET 1MG
4
COUMADIN TABLET
4
2.5MG
COUMADIN TABLET 2MG
4
COUMADIN TABLET 3MG
4
COUMADIN TABLET 4MG
4
COUMADIN TABLET 5MG
4
COUMADIN TABLET 6MG
4
COUMADIN TABLET
4
7.5MG
EFFIENT TABLET 10MG
3
EFFIENT TABLET 5MG
3
ELIQUIS TABLET 2.5MG
3
ELIQUIS TABLET 5MG
3
/Límites
enoxaparin sodium solution
100 mg/ml
120 mg/0.8 ml
150 mg/ml
enoxaparin sodium solution 30
mg/0.3 ml
300 mg/3 ml
mg/0.4 ml
mg/0.6 ml
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
LC
LC
LC
LC
LC
LC
LC
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
67
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
jantoven tablet 3mg
jantoven tablet 4mg
jantoven tablet 5mg
jantoven tablet 6mg
jantoven tablet 7.5mg
PRADAXA CAPSULE
150MG
PRADAXA CAPSULE 75MG
SAVAYSA TABLET 15MG
SAVAYSA TABLET 30MG
SAVAYSA TABLET 60MG
ticlopidine hcl tablet 250mg
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
XARELTO TABLET 20MG
/Límites
2
2
2
2
2
4
LC
4
LC
4
LC
4
LC
4
LC
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 100
MCG/ML
MCG/ML
ARANESP SOLUTION 25
MCG/ML
MCG/ML
ARANESP SOLUTION 40
MCG/ML
ARANESP SOLUTION 60
MCG/ML
EPOGEN SOLUTION 2,000
UNIT/ML
UNIT/2 ML
2
2
2
2
2
2
2
2
2
2
3
LC
3
LC
3
LC
3
LC
4
LC
5
AP
5
AP
5
AP
3
AP
5
AP
3
AP
5
AP
3
AP
5
AP
5
AP
3
AP
5
AP
3
AP
3
AP
4
AP
4
AP
68
Medicamento
Nivel Requisitos
Medicamento
/Límites
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
MOZOBIL SOLUTION 24
MG/1.2 ML (20 MG/ML)
NEULASTA SOLN PREF
SYR 6 MG/0.6 ML
NEUMEGA FOR SOLUTION
5MG
NEUPOGEN SOLN PREF
SYR 300 MCG/0.5 ML
NEUPOGEN SOLN PREF
SYR 480 MCG/0.8 ML
NEUPOGEN SOLUTION 300
MCG/ML
NEUPOGEN SOLUTION 480
MCG/1.6 ML
PROMACTA TABLET
12.5MG
PROMACTA TABLET 25MG
4
AP
4
AP
4
AP
5
AP
5
AP
5
AP
/Límites
HEMORRHEOLOGIC AGENTS
pentoxifylline tablet er 400mg
2
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE
SYSTEM INHIBITORS, M
ENTRESTO TABLET 2426MG
4 LC; TE
4 LC; TE
4 LC; TE
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 AP
meq/ml
AGENTES CALÓRICOS
*amino acid electrolyte
2 AP
infusion 8.5%***
*AMINO ACID INFUSION
3 AP
8.5%***
5
5
AP
5
AP
5
AP
5
AP
5
AP
5
AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
Nivel Requisitos
69
Medicamento
Nivel Requisitos
Medicamento
/Límites
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
%
CLINIMIX SOLUTION 5 %
clinisol solution 15 %
dextrose 10%-0.2% nacl
solution 10 %-0.2 %
solution 10 %-0.45 %
3
AP
3
AP
2
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
2
AP
AP
2
AP
2
AP
Nivel Requisitos
/Límites
dextrose 2.5%-0.45% nacl
2 AP
solution 2.5 %-0.45 %
2 AP
solution 5 %-0.2 %
2 AP
solution 5 %-0.2 %
2 AP
solution 5 %-0.3 %
2 AP
solution 5 %-0.45 %
2 AP
solution 5 %-0.9 %
dextrose in water solution 10
2 AP
%
dextrose in water solution 5 %
2 AP
FREAMINE HBC
3 AP
SOLUTION 6.9 %
hepatamine solution 8 %
2 AP
NEPHRAMINE SOLUTION
3 AP
5.4 %
nutrilipid emulsion 20 %
2 AP
nutrilipid emulsion 20 %
3 AP
PREMASOL SOLUTION 10
3 AP
%
PREMASOL SOLUTION 6 % 2 AP
PROCALAMINE SOLUTION
3 AP
3%
PROSOL SOLUTION 20 %
3 AP
TRAVASOL SOLUTION 10
3 AP
%
TROPHAMINE SOLUTION
3 AP
10 %
AGENTES DE ELIMINACIÓN DE IONES
AURYXIA TABLET
210IRONMG
4 LC; TE
70
Medicamento
Nivel Requisitos
Medicamento
/Límites
Nivel Requisitos
/Límites
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
AGENTES URICOSÚRICOS
probenecid tablet 500mg
2
probenecid-colchicine tablet
2
0.5-500mg
DETOXICANTS DE AMONÍACO
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
2
ml
sodium phenylbutyrate powder
2
0.94 gram/gram
PREPARATIVOS DE REEMPLAZO
dextrose 5%-0.2% nacl-kcl
2 AP
solution 20 meq/l
2 AP
solution 20 meq/l
2 AP
solution 20 meq/l
2 AP
solution 20 meq/l
dextrose 5%-1/2ns-kcl solution
2 AP
10 meq/l
2 AP
30 meq/l
2 AP
40 meq/l
dextrose 5%-ns-kcl solution 20
2 AP
meq/l
dextrose 5%-ns-kcl solution 40
2 AP
meq/l
dextrose 5%-potassium
2 AP
chloride solution 20 meq/l
dextrose in lactated ringers
2 AP
solution 5 %
IONOSOL B WITH
DEXTROSE 5% SOLUTION
3 AP
5%
IONOSOL MB-DEXTROSE
3 AP
5% SOLUTION 5 %
ISOLYTE P WITH
3 AP
DEXTROSE SOLUTION 5 %
ISOLYTE S SOLUTION
3 AP
klor-con 10 tablet er 10 meq
2
KLOR-CON M15 TABLET
4
ER 15 MEQ
klor-con m20 tablet er 20 meq
2
71
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
lactated ringers solution
NORMOSOL-M AND
NORMOSOL-R AND
NORMOSOL-R PH 7.4
SOLUTION
PLASMA-LYTE 148
SOLUTION
PLASMA-LYTE 56 IN
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
2
AP
2
AP
3
AP
3
AP
3
AP
3
AP
3
AP
2
AP
2
AP
/Límites
potassium chloride tablet er 10
2
meq
2
meq
2
meq
potassium chloride-nacl
2
solution 20 meq/l
ringers injection solution
2
sodium chloride solution 0.45
2
%
sodium chloride solution 0.9 % 2
sodium chloride solution 2.5
2
meq/ml
sodium chloride solution 3 %
2
sodium chloride solution 5 %
2
tpn electrolytes solution 35
meq-20 meq-5 meq-4.5 meq-35 2
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
sodium chloride solution 0.9 % 2
ENZYMES
ENZYMES
ADAGEN SOLUTION 250
4
UNIT/ML
ALDURAZYME SOLUTION
5
2.9 MG/5 ML
2
2
2
AP
2
AP
2
AP
2
AP
2
2
AP
AP
AP
AP
AP
AP
AP
AP
AP
AP
AP
AP
2
72
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
CERDELGA CAPSULE
84MG
5 LC; AP
CEREZYME FOR
5
SOLUTION 400 UNIT
ELAPRASE SOLUTION 6
5
MG/3 ML
ELITEK FOR SOLUTION
5 AP
1.5MG
FABRAZYME FOR
5
SOLUTION 35MG
LUMIZYME FOR
5
SOLUTION 50MG
MYOZYME FOR
5
SOLUTION 50MG
NAGLAZYME SOLUTION 5
5
MG/5 ML
PULMOZYME SOLUTION 1
5 AP
MG/ML
SUCRAID SOLUTION 8,500
4 AL
UNIT/ML
VPRIV FOR SOLUTION 400
5
UNIT
FORMACIÓN DE LA SANGRE, COAGULACIÓN
Y TROMBOSIS
AGENTES ANTIHEMORRÁGICOS
0.1 mg/ml
2 LC
dia(s)
AGENTES HEMATOPOYÉTICOS
ARANESP SOLUTION 10
3 AP
MCG/0.4 ML
MIRCERA SOLN PREF SYR
5 AP
200 MCG/0.3 ML
HORMONAS Y SUSTITUTOS SINTÉTICOS
ADRENALES
budesonide ec capsule er 24hr
3mg
cortisone acetate tablet 25mg
dexamethasone elixir 0.5 mg/5
ml
DEXAMETHASONE
INTENSOL CONCENTRATE
1 MG/ML
dexamethasone sodium
phosphate solution 10 mg/ml
phosphate solution 4 mg/ml
dexamethasone tablet 0.5mg
dexamethasone tablet 1mg
DEXPAK TABLET 1.5 MG
(51 TABS)
FLO-PRED SUSPENSION 15
MG/5 ML
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
2
2
2
4
2
AP
2
AP
2
2
2
2
2
2
2
4
4
2
2
2
2
2
AP
2
AP
2
AP
2
AP
73
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
methylprednisolone tablet
16mg
methylprednisolone tablet
32mg
methylprednisolone tablet 4mg
methylprednisolone tablet 8mg
prednisolone acetate
suspension 1 %
prednisolone sodium
phosphate solution 15 mg/5 ml
prednisolone sodium
phosphate solution 25 mg/5 ml
(5 mg/ml)
prednisolone sodium
phosphate solution 5 mg
base/5 ml (6.7 mg/5 ml)
prednisolone sodium
phosphate tablet disperse
10mg
prednisolone sodium
15mg
prednisolone sodium
30mg
PREDNISONE INTENSOL
CONCENTRATE 5 MG/ML
prednisone solution 5 mg/5 ml
prednisone tablet 10mg
prednisone tablet 2.5mg
VERIPRED 20 SOLUTION
20 MG/5 ML
/Límites
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
AVANDAMET TABLET 21,000MG
4
AVANDIA TABLET 2MG
4
AVANDIA TABLET 4MG
4
AVANDIA TABLET 8MG
4
BYDUREON FOR
SUSPENSION 2MG
3
LC 4 cada 28 dia(s)
BYDUREON PEN PENINJECTOR 2 MG/0.65 ML
3
LC 4 cada 28 dia(s)
BYETTA SOLN PEN-INJ 10
MCG/0.04 ML PER DOSE
(250 MCG/ML) 2.4 ML
3
dia(s)
BYETTA SOLN PEN-INJ 5
MCG/0.02 ML PER DOSE
(250 MCG/ML) 1.2 ML
3
dia(s)
FARXIGA TABLET 10MG
4
FARXIGA TABLET 5MG
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
LC
LC
LC; AL
AL
AL
AL
LC; TE
LC; TE
LC; TE
LC; TE
LC; TE
LC; TE
74
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
glyburide micronized tablet
1.5mg
3mg
6mg
glyburide tablet 1.25mg
glyburide tablet 2.5mg
glyburide tablet 5mg
glyburide-metformin hcl tablet
1.25-250mg
2.5-500mg
5-500mg
GLYSET TABLET 100MG
/Límites
1
1
1
GLYSET TABLET 25MG
GLYSET TABLET 50MG
GLYXAMBI TABLET 105MG
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
1
1
1
1
1
1
1
1
4
1
1
1
1
1
1
1
1
1
4
4
4
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
3
LC; TE
4
LC
4
LC
4
LC
4
LC
75
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/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
4
LC
4
LC
4
LC
3
LC; TE
3
LC; TE
3
LC
3
LC
3
LC
3
LC
3
LC
4
LC
4
LC
/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
500mg
750mg
metformin hcl tablet 1,000mg
metformin hcl tablet 500mg
metformin hcl tablet 850mg
nateglinide tablet 120mg
nateglinide tablet 60mg
NESINA TABLET 12.5MG
NESINA TABLET 25MG
NESINA TABLET 6.25MG
NOVOLIN 70-30
SUSPENSION 100 UNIT/ML
(70-30)
NOVOLIN N SUSPENSION
100 UNIT/ML
NOVOLIN R SOLUTION 100
UNIT/ML
4
LC
4
4
3
3
2
2
2
1
1
1
1
1
3
LC
3
LC
3
LC
3
3
3
76
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
pioglitazone hcl tablet 15mg
/Límites
pioglitazone-glimepiride tablet
30-2mg
pioglitazone-glimepiride tablet
30-4mg
pioglitazone-metformin tablet
15-500mg
pioglitazone-metformin tablet
15-850mg
PRANDIMET TABLET 1500MG
PRANDIMET TABLET 2500MG
repaglinide tablet 0.5mg
repaglinide tablet 1mg
repaglinide tablet 2mg
RIOMET SOLUTION 500
MG/5 ML
SYMLINPEN 120 SOLN
PEN-INJ 2,700 MCG/2.7 ML
dia(s)
SYMLINPEN 60 SOLN PENINJ 1,500 MCG/1.5 ML
dia(s)
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)
3
3
3
3
3
4
LC
4
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
4
4
1
1
1
4
3
LC; TE
3
LC; TE
4
LC; TE
4
LC; TE
77
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
tolazamide tablet 250mg
1
tolazamide tablet 500mg
1
tolbutamide tablet 500mg
1
TOUJEO SOLOSTAR SOLN
PEN-INJ 300 UNIT/ML (1.5
4 TE
ML)
TRADJENTA TABLET 5MG
3 LC
TRULICITY SOLN PEN-INJ
0.75 MG/0.5 ML
4 LC; TE
TRULICITY SOLN PEN-INJ
1.5 MG/0.5 ML
4 LC; TE
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
2
100 mcg
2
112 mcg
2
125 mcg
2
137 mcg
2
150 mcg
2
175 mcg
2
200 mcg
levothyroxine sodium tablet 25
2
mcg
300 mcg
mcg
mcg
mcg
levoxyl tablet 100 mcg
liothyronine sodium tablet 25
mcg
mcg
mcg
methimazole tablet 10mg
methimazole tablet 5mg
propylthiouracil tablet 50mg
SYNTHROID TABLET 100
MCG
MCG
MCG
MCG
2
2
2
2
4
4
4
4
4
4
4
4
4
4
4
2
2
2
2
2
2
2
2
2
2
78
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
MCG
MCG
MCG
SYNTHROID TABLET 25
MCG
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
/Límites
ANDROGEL GEL 1.25
GRAM PER ACTUATION (1
%)
ANDROGEL GEL 20.25
MG/1.25 GRAM (1.62 %)
ANDROGEL GEL 20.25
MG/1.25 GRAM PER
ACTUATION (1.62 %)
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
200 mg/ml
testosterone enanthate solution
200 mg/ml
testosterone gel 1.25 gram per
actuation (1 %)
testosterone gel 10 mg/0.5
gram per actuation (2 %)
testosterone gel 25 mg/2.5
gram (1 %)
2
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
4
4
4
4
4
LC; AP
LC; AP
3
LC
3
LC
3
3
LC
3
LC
4
LC; AP
2
2
2
2
2
2
2
2
LC
2
LC; AP
2
LC
79
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
testosterone gel 50 mg/5 gram
(1 %)
2 LC
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
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)
briellyn tablet 0.4 mg-35 mcg
2
camila tablet 0.35mg
2
cryselle tablet 0.3 mg-30 mcg
2
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
ELLA TABLET 30MG
LC 2 cada 30 dia(s)
emoquette tablet 0.15-0.03mg
enpresse tablet 50 mcg-30 mcg
(6)/75 mcg-40 mcg (5)/125
mcg-30 mcg (10)
errin tablet 0.35mg
estradiol-norethindrone acetat
tablet 0.5-0.1mg
estradiol-norethindrone acetat
tablet 1-0.5mg
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
2
2
2
2
3
LC
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
80
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
levonorg-eth estrad eth estrad
tablet 0.15 mg-30 mcg (84)/10
mcg (7)
levonorgestrel-eth estradiol
tablet 0.15 mg-30 mcg
levonorgestrel-eth estradiol
tablet 90 mcg-20 mcg
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
low-ogestrel tablet 0.3 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
/Límites
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)
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
ORTHO TRI-CYCLEN LO
TABLET 0.18 MG-25 MCG
(7)/0.215 MG-25 MCG
(7)/0.25 MG-25 MCG (7)
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
2
2
2
2
4
4
4
4
4
2
2
2
2
2
2
2
2
2
4
2
2
2
2
2
2
4
LC
4
2
4
2
2
2
2
81
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
SAFYRAL TABLET 3 MG0.03 MG-0.451 MG (21)/0.451 4
MG (7)
sprintec tablet 0.25 mg-35 mcg 2
sronyx tablet 0.1 mg-20 mcg
2
tri-legest fe tablet 1 mg-20
mcg (5)/1 mg-30 mcg (7)/1
2
mg-35 mcg (9)/75 mg (7)
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 (7)/0.25
2
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)
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
ALORA PATCH TW 0.025
4
MG/24 HOUR
ALORA PATCH TW 0.05
MG/24 HOUR
ALORA PATCH TW 0.075
MG/24 HOUR
ALORA PATCH TW 0.1
MG/24 HOUR
ANGELIQ TABLET 0.250.5MG
ANGELIQ TABLET 0.5-1MG
CLIMARA PRO PATCH
WEEKLY 0.045 MG-0.015
MG/24 HOUR
COMBIPATCH PATCH TW
0.05 MG-0.14 MG/24 HOUR
COMBIPATCH PATCH TW
0.05 MG-0.25 MG/24 HOUR
DEPO-ESTRADIOL OIL 5
MG/ML
DIVIGEL GEL 0.5 MG (0.1
%)
DUAVEE TABLET 0.4520MG
ESTRACE CREAM 0.01 %
estradiol patch tw 0.025 mg/24
hour
estradiol patch tw 0.0375
mg/24 hour
hour
hour
4
4
4
4
4
3
4
4
4
3
4
LC; AP
3
2
2
2
2
82
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
EVAMIST SOLUTION 1.53
MG/SPRAY (1.7 %)
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)
MENOSTAR PATCH
WEEKLY 14 MCG/24 HOUR
/Límites
MINIVELLE PATCH TW
0.025 MG/24 HOUR
LC 8 cada 28 dia(s)
MINIVELLE PATCH TW
0.0375 MG/24 HOUR
LC 8 cada 28 dia(s)
MINIVELLE PATCH TW
0.05 MG/24 HOUR
LC 8 cada 28 dia(s)
MINIVELLE PATCH TW
0.075 MG/24 HOUR
LC 8 cada 28 dia(s)
MINIVELLE PATCH TW 0.1
MG/24 HOUR
LC 8 cada 28 dia(s)
norethindron-ethinyl estradiol
tablet 0.5 mg-2.5 mcg
norethindron-ethinyl estradiol
tablet 1 mg-5 mcg
norethindrone tablet 0.35mg
PREFEST TABLET 1 MG
(3)-1 MG-0.09 MG (3)
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
2
2
2
2
2
2
2
2
2
2
3
4
LC
4
LC
2
2
2
3
4
LC
4
LC
4
LC
4
LC
4
LC
2
2
2
4
3
2
LC
3
2
2
AP
4
2
83
Medicamento
Nivel Requisitos
Medicamento
/Límites
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 1 cada 28 dia(s)
ML)
LC 1 cada 28 dia(s)
ML)
LC 1 cada 28 dia(s)
ML)
LC 1 cada 28 dia(s)
PROGESTINAS
DEPO-SUBQ PROVERA 104
ML
medroxyprogesterone acetate
suspension 150 mg/ml
tablet 10mg
5
/Límites
2
tablet 2.5mg
2
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
2
meclizine hcl tablet 25mg
2
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
ANTIHISTAMÍNICOS de la 2a GENERACIÓN
carbinoxamine maleate
solution 4 mg/5 ml
2 LC
dia(s)
carbinoxamine maleate tablet
4mg
2 LC
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
LC; AP
4
4
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
4
LC
2
LC
Nivel Requisitos
2
84
Medicamento
Nivel Requisitos
Medicamento
/Límites
Nivel Requisitos
/Límites
clemastine fumarate tablet
2.68mg
2 LC
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
4
SOLN 17 MCG/ACTUATION
benztropine mesylate solution
2 AP
2 mg/2 ml
benztropine mesylate tablet
2
0.5mg
2
1mg
2
2mg
CANTIL TABLET 25MG
4
COMBIVENT RESPIMAT
AEROSOL SOLN 20 MCG3
100 MCG/ACTUATION
dicyclomine hcl capsule 10mg
2 LC
dicyclomine hcl solution 10
mg/5 ml
2 LC
dia(s)
dicyclomine hcl tablet 20mg
2 LC
glycopyrrolate tablet 1mg
2
glycopyrrolate tablet 2mg
2
ipratropium bromide solution
2 AP
0.2 mg/ml (0.02 %)
ipratropium-albuterol solution
0.5 mg-3 mg (2.5 mg base)/3
2 AP
ml
methscopolamine bromide
2
tablet 2.5mg
methscopolamine bromide
2
tablet 5mg
SPIRIVA CAPSULE 18 MCG
3 LC
SPIRIVA RESPIMAT
AEROSOL SOLN 2.5
3 LC
MCG/ACTUATION
STIOLTO RESPIMAT
AEROSOL SOLN 2.5 MCG4 LC; TE
2.5 MCG/ACTUATION
trihexyphenidyl hcl tablet 2mg
2
trihexyphenidyl hcl tablet 5mg
2
TUDORZA PRESSAIR
AERO POW BR ACT 400
3
MCG/ACTUATION
AGENTES SIMPATICOMIMÉTICA
(ADRENÉRGICOS)
ADRENALIN SOLUTION 1
2 AP
MG/ML (1 ML)
85
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ADVAIR DISKUS AERO
POW BR ACT 100 MCG-50
MCG/DOSE
ADVAIR DISKUS AERO
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
/Límites
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
AUVI-Q SOLN AUTO-INJ
0.15 MG/0.15 ML (1:1,000)
AUVI-Q SOLN AUTO-INJ
0.3 MG/0.3 ML (1:1,000)
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 (1:1,000)
EPIPEN 2-PAK SOLN
AUTO-INJ 0.3 MG/0.3 ML
(1:1,000)
3
3
3
3
3
3
2
2
2
2
AP
AP
AP
AP
2
2
2
2
2
4
LC; TE
4
3
LC
3
LC
3
3
4
LC; TE
4
LC; TE
4
LC; AP
3
3
2
3
86
Medicamento
Nivel Requisitos
Medicamento
/Límites
EPIPEN JR 2-PAK SOLN
AUTO-INJ 0.15 MG/0.3 ML
(1:2,000)
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
metaproterenol sulfate tablet
10mg
metaproterenol sulfate tablet
20mg
methyldopa tablet 250mg
methyldopa tablet 500mg
methyldopahydrochlorothiazide tablet
250-15mg
methyldopahydrochlorothiazide tablet
250-25mg
midodrine hcl tablet 10mg
midodrine hcl tablet 2.5mg
midodrine hcl tablet 5mg
PERFOROMIST 20 MCG/2
ML SOLN
PROAIR HFA AEROSOL
SOLN 90 MCG
/Límites
PROAIR RESPICLICK
AERO POW BR ACT 90
3
MCG
SEREVENT DISKUS AERO
3
POW BR ACT 50 MCG
SYMBICORT AEROSOL 160
3
MCG-4.5 MCG/ACTUATION
SYMBICORT AEROSOL 80
3
MCG-4.5 MCG/ACTUATION
terbutaline sulfate tablet 2.5mg 2
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
3 LC
NICOTROL NS SOLUTION
10 MG/ML
3 LC
dia(s)
PARASIMPATICOMIMÉTICO (AGENTES
COLINÉRGICOS)
bethanechol chloride tablet
2
10mg
2
25mg
3
3
4
LC; TE
2
2
2
AP
AP
AP
2
2
2
2
2
2
2
2
2
2
4
Nivel Requisitos
AP
3
87
Medicamento
Nivel Requisitos
Medicamento
/Límites
50mg
5mg
cevimeline hcl capsule 30mg
donepezil hcl odt tablet
disperse 10mg
donepezil hcl odt tablet
disperse 5mg
donepezil hcl tablet 10mg
EXELON PATCH 24HR 13.3
MG/24 HOUR
MG/24 HOUR
MG/24 HOUR
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
MESTINON TABLET ER
180MG
pilocarpine hcl tablet 5mg
pilocarpine hcl tablet 7.5mg
Nivel Requisitos
/Límites
pyridostigmine bromide er
2
tablet er 180mg
pyridostigmine bromide tablet
2
60mg
rivastigmine capsule 1.5mg
2
rivastigmine capsule 3mg
2
rivastigmine capsule 4.5mg
2
rivastigmine capsule 6mg
2
RELAJANTES DE MÚSCULO ESQUELÉTICO
baclofen tablet 10mg
2
baclofen tablet 20mg
2
cyclobenzaprine hcl tablet
2 AP
10mg
cyclobenzaprine hcl tablet 5mg 2 AP
cyclobenzaprine hcl tablet
2 AP
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
2
2
2
2
2
2
2
2
4
4
4
2
2
2
2
2
2
2
4
3
2
2
88
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
atenolol tablet 100mg
atenolol-chlorthalidone tablet
100-25mg
atenolol-chlorthalidone tablet
50-25mg
betaxolol hcl tablet 20mg
bisoprolol fumarate tablet
10mg
bisoprolol fumarate tablet 5mg
bisoprolol-hydrochlorothiazide
tablet 10-6.25mg
tablet 2.5-6.25mg
tablet 5-6.25mg
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
/Límites
2
2
2
COREG CR CAPSULE ER
24HR 10MG
COREG CR CAPSULE ER
24HR 20MG
COREG CR CAPSULE ER
24HR 40MG
COREG CR CAPSULE ER
24HR 80MG
CORLANOR TABLET 5MG
CORLANOR TABLET
7.5MG
DIBENZYLINE CAPSULE
10MG
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
ergoloid mesylates tablet 1mg
INNOPRAN XL CAPSULE
ER 24HR 120MG
INNOPRAN XL CAPSULE
ER 24HR 80MG
2
2
2
2
2
2
2
2
3
LC
3
LC
3
LC
3
LC
4
4
2
2
2
2
4
4
4
4
4
LC; TE
4
LC; TE
4
2
2
AP
2
AP
2
2
2
2
2
LC; AP
3
3
89
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
JALYN CAPSULE 0.5-0.4MG
labetalol hcl tablet 100mg
metoprolol succinate tablet er
24hr 100mg
24hr 200mg
24hr 25mg
24hr 50mg
metoprolol tartrate tablet
100mg
metoprolol tartrate tablet 25mg
metoprolol tartrate tablet 50mg
metoprololhydrochlorothiazide tablet 10025mg
nadolol tablet 20mg
nadolol tablet 40mg
nadolol tablet 80mg
nadolol-bendroflumethiazide
tablet 40-5mg
nadolol-bendroflumethiazide
tablet 80-5mg
PHENOXYBENZAMINE
HCL 10 MG CAP
pindolol tablet 10mg
/Límites
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
propranolol hcl solution 40
mg/5 ml
propranolol hcl tablet 10mg
propranololhydrochlorothiazide tablet 40
mg-25mg
propranololhydrochlorothiazide tablet 80
mg-25mg
RAPAFLO CAPSULE 4MG
RAPAFLO CAPSULE 8MG
sorine tablet 120mg
sorine tablet 160mg
sorine tablet 240mg
sorine tablet 80mg
sotalol af tablet 120mg
sotalol tablet 160mg
sotalol tablet 240mg
sotalol tablet 80mg
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
90
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
tamsulosin hcl capsule 0.4mg
2
terazosin hcl capsule 10mg
2
2
2
2
timolol maleate tablet 10mg
2
2
2
MEDICAMENTOS CARDIOVASCULARES
AGENTES ANTILIPÉMICOS
ADVICOR TABLET ER
24HR 1,000-20MG
4 LC; TE
ADVICOR TABLET ER
24HR 1,000-40MG
4 LC; TE
ADVICOR TABLET ER
24HR 500-20MG
4 LC; TE
ADVICOR TABLET ER
24HR 750-20MG
4 LC; TE
ALTOPREV TABLET ER
4
24HR 20MG
ALTOPREV TABLET ER
4
24HR 40MG
ALTOPREV TABLET ER
4
24HR 60MG
amlodipine-atorvastatin tablet
2 TE
10-10mg
2 TE
10-20mg
2 TE
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
CRESTOR TABLET 10MG
CRESTOR TABLET 20MG
CRESTOR TABLET 40MG
CRESTOR TABLET 5MG
fenofibrate capsule 130mg
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
1
1
1
1
2
2
2
3
3
3
3
2
2
2
91
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
fenofibrate tablet 120mg
fenofibric acid capsule dr
135mg
fenofibric acid capsule dr
45mg
FENOGLIDE TABLET
120MG
FENOGLIDE TABLET
40MG
FIBRICOR TABLET 105MG
FIBRICOR TABLET 35MG
fluvastatin sodium capsule
20mg
fluvastatin sodium capsule
40mg
gemfibrozil tablet 600mg
JUXTAPID CAPSULE 10MG
/Límites
2
2
2
2
2
2
2
2
2
KYNAMRO SOLN PREF
SYR 200 MG/ML
LESCOL XL TABLET ER
24HR 80MG
LIPTRUZET TABLET 1010MG
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
4
4
4
4
1
LC
1
LC
2
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
4
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
1
1
1
2
2
2
2
1
92
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
20mg
40mg
80mg
prevalite powder 4 gram
SIMCOR TABLET ER 24HR
1,000-20MG
1,000-40MG
500-20MG
500-40MG
750-20MG
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
amlodipine besylate tablet
2.5mg
amlodipine besylate tablet 5mg
amlodipine besylatebenazepril capsule 10-20mg
amlodipine besylatebenazepril capsule 2.5-10mg
1
1
1
2
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
1
LC
1
LC
1
LC
1
LC
1
LC
4
LC
4
4
4
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
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
benazeprilhydrochlorothiazide tablet 1012.5mg
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
2
/Límites
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
4mg
LC
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
2
2
2
1
LC
1
LC
1
LC
94
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
chlorothiazide tablet 250mg
chlorothiazide tablet 500mg
chlorthalidone tablet 25mg
1
LC
1
LC
1
LC
1
/Límites
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
24hr 120mg
LC
1
1
1
1
1
1
1
1
2
2
2
2
2
LC
2
2
2
2
2
2
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
95
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
24hr 300mg
diltiazem er capsule er 24hr
180mg
360mg
420mg
diltiazem hcl tablet 120mg
DIURIL SUSPENSION 250
MG/5 ML
DYRENIUM CAPSULE
100MG
DYRENIUM CAPSULE
50MG
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
/Límites
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
furosemide tablet 20mg
guanfacine hcl er tablet er
24hr 1mg
24hr 2mg
2
2
2
2
2
2
2
2
3
3
3
4
4
4
4
4
4
1
1
1
1
1
1
2
2
TE
TE
2
LC
2
2
2
1
1
1
1
1
2
2
AP
2
2
2
2
2
LC
2
LC
96
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
24hr 3mg
24hr 4mg
guanfacine hcl tablet 1mg
guanfacine hcl tablet 2mg
hydralazine hcl tablet 100mg
hydrochlorothiazide capsule
12.5mg
hydrochlorothiazide tablet
12.5mg
25mg
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
2
LC
2
LC
/Límites
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
50mg
losartan-hydrochlorothiazide
tablet 100-12.5mg
tablet 100-25mg
tablet 50-12.5mg
matzim la tablet er 24hr
180mg
240mg
300mg
360mg
2
2
2
2
2
2
2
2
2
2
2
2
1
LC
1
LC
1
LC
1
LC
1
LC
2
2
1
1
1
1
1
1
1
1
1
1
LC
1
LC
1
LC
1
1
1
2
2
2
2
97
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
nifedipine er tablet er 24hr
30mg
60mg
90mg
nimodipine capsule 30mg
nisoldipine tablet er 24hr
17mg
20mg
25.5mg
/Límites
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
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
2
2
2
2
2
2
2
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
4
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
98
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
TEKTURNA TABLET
150MG
TEKTURNA TABLET
300MG
telmisartan tablet 20mg
telmisartan-amlodipine tablet
40-10mg
40-5mg
80-10mg
/Límites
80-5mg
telmisartan-hydrochlorothiazid
tablet 40-12.5mg
tablet 80-12.5mg
tablet 80-25mg
torsemide tablet 100mg
trandolapril tablet 1mg
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 5025mg
triamterenehydrochlorothiazid tablet 37.525mg
triamterenehydrochlorothiazide tablet 7550mg
2
2
2
2
2
2
4
TE
4
TE
4
TE
4
TE
4
LC; TE
4
LC; TE
1
LC
1
LC
1
LC
2
2
2
2
1
LC
1
LC
1
LC
2
2
2
2
1
1
1
2
2
2
2
2
2
2
2
99
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
TRIBENZOR TABLET 20-512.5MG
TRIBENZOR TABLET 4010-25MG
TRIBENZOR TABLET 40-525MG
valsartan tablet 160mg
valsartan-hydrochlorothiazide
tablet 160-12.5mg
tablet 160-25mg
tablet 320-12.5mg
tablet 320-25mg
4
LC
4
LC
4
LC
4
LC
4
LC
1
LC
1
LC
1
LC
1
LC
1
LC
1
LC
1
LC
1
LC
/Límites
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
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
1
LC
2
2
2
2
2
2
2
2
2
2
2
2
2
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
100
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
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 %
/Límites
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
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
MG/ML
2
2
2
2
2
2
2
2
2
2
3
LC; AP; AL
3
LC; AP; AL
2
2
2
2
4
2
2
2
2
2
4
3
3
3
5
LC; AP; AL
4
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
5
AP
101
Medicamento
Nivel Requisitos
Medicamento
/Límites
REMODULIN SOLUTION
5
2.5 MG/ML
5
MG/ML
REVATIO FOR
SUSPENSION 10 MG/ML
5
dia(s)
sildenafil tablet 20mg
2
TRACLEER TABLET
3
125MG
TRACLEER TABLET
3
62.5MG
TYVASO SOLUTION 1.74
5
MG/2.9 ML (0.6 MG/ML)
VENTAVIS SOLUTION 10
5
MCG/ML
VENTAVIS SOLUTION 20
5
MCG/ML
MEDICAMENTOS CARDÍACOS
amiodarone hcl tablet 200mg
2
amiodarone hcl tablet 400mg
2
digoxin solution 50 mcg/ml
2
digoxin tablet 125 mcg
2
digoxin tablet 250 mcg
2
disopyramide phosphate
2
capsule 100mg
disopyramide phosphate
2
capsule 150mg
flecainide acetate tablet
2
100mg
flecainide acetate tablet
2
150mg
flecainide acetate tablet 50mg
2
Nivel Requisitos
/Límites
mexiletine hcl capsule 150mg
2
2
2
MULTAQ TABLET 400MG
3
NORPACE CR CAPSULE ER
4
12HR 100MG
NORPACE CR CAPSULE ER
4
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
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 24HR
3
0.375 GRAM
AP
AP
LC; AP
LC; AP
AP; AL
AP; AL
AP
AP
AP
102
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
ASACOL HD TABLET DR
4 TE
800MG
balsalazide disodium capsule
2
750mg
CANASA SUPPOSITORY
3
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
3
250MG
PENTASA CAPSULE ER
3
500MG
SFROWASA ENEMA 4
4
GRAM/60 ML
sulfasalazine tablet 500mg
2 NM
sulfazine ec tablet dr 500mg
2 NM
UCERIS FOAM 2
MG/ACTUATION
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
DEXILANT CAPSULE DR
60MG
esomeprazole magnesium
capsule dr 20mg
esomeprazole magnesium
capsule dr 40mg
famotidine for suspension 40
mg/5 ml
famotidine tablet 20mg
famotidine tablet 40mg
lansoprazole capsule dr 15mg
lansoprazole capsule dr 30mg
misoprostol tablet 100 mcg
misoprostol tablet 200 mcg
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
3
LC
3
LC
2
LC; TE
2
LC; TE
2
2
2
2
LC
2
LC
2
2
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
2
2
2
103
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
omeprazole capsule dr 10mg
2 LC
2 LC
2 LC
pantoprazole sodium tablet dr
20mg
2 LC
pantoprazole sodium tablet dr
40mg
2 LC
PREVACID TABLET
DISPERSE 15MG
4 LC; TE
PREVACID TABLET
DISPERSE 30MG
4 LC; TE
PROTONIX PACKET 40MG
4 LC
rabeprazole sodium tablet dr
20mg
2 LC
ranitidine hcl capsule 150mg
2
ranitidine hcl capsule 300mg
2
ranitidine hcl syrup 15 mg/ml
2
ranitidine hcl tablet 150mg
2
ranitidine hcl tablet 300mg
2
sucralfate tablet 1 gram
2
ZEGERID PACKET 204 TE
1,680MG
ZEGERID PACKET 404
1,680MG
AGENTES CHOLELITHOLYTICOS
CHENODAL TABLET
250MG
ursodiol capsule 300mg
ursodiol tablet 250mg
ursodiol tablet 500mg
AGENTES PROCINÉTICOS
loperamide capsule 2mg
metoclopramide hcl odt tablet
disperse 5mg
metoclopramide hcl solution 5
mg/5 ml
metoclopramide hcl tablet
10mg
metoclopramide hcl tablet 5mg
ANTIEMÉTICOS
AKYNZEO CAPSULE 3000.5MG
LC 1 cada 30 dia(s)
CESAMET CAPSULE 1MG
dronabinol capsule 10mg
dronabinol capsule 2.5mg
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)
4
LC
2
2
2
2
2
2
2
2
4
LC; AP
4
2
LC
2
LC
2
LC
4
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP
104
Medicamento
Nivel Requisitos
Medicamento
/Límites
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
promethazine hcl solution 25
mg/ml
promethazine hcl solution 50
mg/ml
promethegan suppository
25mg
CATÁRTICOS Y LAXANTES
alosetron hcl tablet 0.5mg
alosetron hcl tablet 1mg
AMITIZA CAPSULE 24
MCG
AMITIZA CAPSULE 8 MCG
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-n for solution 420
gram
2
AP
2
AP
2
AP
2
2
2
AP
AP
AP
2
AP
2
AP
2
AP
2
AP
/Límites
GOLYTELY FOR
SOLUTION 227.1 GRAM4
21.5 GRAM-6.36 GRAM-5.53
GRAM-2.82 GRAM
LINZESS CAPSULE 145
MCG
3 LC
LINZESS CAPSULE 290
MCG
3 LC
MOVANTIK TABLET
12.5MG
3 LC
MOVANTIK TABLET 25MG
3 LC
MOVIPREP FOR SOLUTION
100 GRAM-7.5 GRAM-2.691
4
GRAM-1.015 GRAM-5.9
GRAM-4.7 GRAM
OSMOPREP TABLET 1.5
4
GRAM
polyethylene glycol 3350
2
powder 17 gram/dose
RELISTOR SOLUTION 12
4 AP
MG/0.6 ML
RELISTOR SOLUTION 8
4 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
2
2
LC
2
LC
4
LC
4
LC
Nivel Requisitos
2
2
2
105
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
CREON CAPSULE DR
PART 24,000 UNIT-76,000
UNIT-120,000 UNIT
CREON CAPSULE DR
PART 3,000 UNIT-9,500
UNIT-15,000 UNIT
CREON CAPSULE DR
PART 36,000 UNIT-114,000
UNIT-180,000 UNIT
CREON CAPSULE DR
PART 6,000 UNIT-19,000
UNIT-30,000 UNIT
PANCREAZE CAPSULE DR
PART 10,500 UNIT-25,000
UNIT-43,750 UNIT
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
ULTRESA CAPSULE DR
PART 13,800 UNIT-27,600
UNIT-27,600 UNIT
/Límites
ULTRESA CAPSULE DR
PART 20,700 UNIT-41,400
UNIT-41,400 UNIT
ULTRESA CAPSULE DR
PART 23,000 UNIT-46,000
UNIT-46,000 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
ZENPEP CAPSULE DR
PART 3,000 UNIT-10,000
UNIT-16,000 UNIT
ZENPEP CAPSULE DR
PART 40,000 UNIT-136,000
UNIT-218,000 UNIT
ZENPEP CAPSULE DR
PART 5,000 UNIT-17,000
UNIT-27,000 UNIT
OXYTOCICOS
OXYTOCICOS
methylergonovine maleate
tablet 0.2mg
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
3
3
3
3
3
3
3
2
106
Medicamento
Nivel Requisitos
Medicamento
/Límites
Nivel Requisitos
/Límites
brimonidine tartrate solution
2
0.2 %
COMBIGAN SOLUTION 0.2
3
%-0.5 %
dorzolamide hcl solution 2 %
2
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
%
methazolamide tablet 25mg
2
methazolamide tablet 50mg
2
metipranolol solution 0.3 %
2
PHOSPHOLINE IODIDE
4
FOR SOLUTION 0.125 %
SIMBRINZA SUSPENSION
4
1 %-0.2 %
timolol maleate gel form soln
2
0.25 %
timolol maleate gel form soln
2
0.5 %
timolol maleate solution 0.25
2
%
timolol maleate solution 0.5 %
2
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
%
PREPARACIONES PARA EL OJO, OÍDO,
NARIZ, Y GARGANTA (en inglés EENT)
AGENTES ANTIALÉRGICOS
ALOMIDE SOLUTION 0.1 % 4
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
EMADINE SOLUTION 0.05
4
%
LASTACAFT SOLUTION
4
0.25 %
olopatadine hcl solution 0.6 %
2
PATADAY SOLUTION 0.2
4
%
PATANOL SOLUTION 0.1 % 4
PAZEO SOLUTION 0.7 %
4 LC
AGENTES ANTIGLAUCOMA
ALPHAGAN P SOLUTION
3
0.1 %
AZOPT SUSPENSION 1 %
4
betaxolol hcl solution 0.5 %
2
BETOPTIC S SUSPENSION
3
0.25 %
bimatoprost solution 0.03 %
2
brimonidine tartrate solution
2
0.15 %
107
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ALREX SUSPENSION 0.2 %
bromfenac sodium solution
0.09 %
phosphate solution 0.1 %
diclofenac sodium solution 0.1
%
DUREZOL EMULSION 0.05
%
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
%
ketorolac tromethamine
solution 0.4 %
ketorolac tromethamine
solution 0.5 %
LOTEMAX GEL 0.5 %
LOTEMAX OINTMENT 0.5
%
LOTEMAX SUSPENSION
0.5 %
MAXIDEX SUSPENSION
0.1 %
NEVANAC SUSPENSION
0.1 %
/Límites
4
PRED MILD SUSPENSION
4
0.12 %
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
bacitracin-polymyxin ointment
2
500 unit-10,000 unit/gram
BACTROBAN NASAL
4
OINTMENT 2 %
BESIVANCE SUSPENSION
4
0.6 %
BLEPHAMIDE S.O.P.
4
OINTMENT 10 %-0.2 %
BLEPHAMIDE
4
SUSPENSION 10 %-0.2 %
CILOXAN OINTMENT 0.3
4
%
CIPRO HC SUSPENSION 0.2
3
%-1 %
CIPRODEX SUSPENSION
3
0.3 %-0.1 %
2
2
2
4
4
2
2
2
4
4
2
2
4
4
4
4
4
108
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ciprofloxacin hcl solution 0.3
%
COLY-MYCIN S
SUSPENSION 3.3 MG-3 MG10 MG-0.5 MG/ML
CORTISPORIN-TC
SUSPENSION 3.3 MG-3 MG10 MG-0.5 MG/ML
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 %
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-polymyxin-dexameth
ointment 3.5 mg/gram-10,000
unit/gram-0.1 %
neomycin-polymyxin-dexameth
suspension 3.5 mg/ml-10,000
unit/ml-0.1 %
/Límites
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 %
sulfacetamide sodium solution
10 %
sulfacetamide-prednisolone
solution 10 %-0.23 % (0.25 %)
TOBRADEX OINTMENT 0.3
%-0.1 %
TOBRADEX ST
SUSPENSION 0.3 %-0.05 %
tobramycin solution 0.3 %
tobramycin-dexamethasone
suspension 0.3 %-0.1 %
TOBREX OINTMENT 0.3 %
trifluridine solution 1 %
VIGAMOX SOLUTION 0.5
%
2
4
NM
4
NM
2
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
2
2
4
4
2
2
2
3
4
2
2
4
2
4
109
Medicamento
Nivel Requisitos
Medicamento
/Límites
Nivel Requisitos
/Límites
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 5mg 2
OXYTROL PATCH TW 3.9
4
MG/24 HOUR
tolterodine tartrate er capsule
2
er 24hr 2mg
tolterodine tartrate er capsule
2
er 24hr 4mg
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 AP
theophylline anhydrous tablet
2
er 12hr 100mg
2
er 12hr 200mg
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
2
42 mcg
VASOCONSTRICTORES
naphazoline hcl solution 0.1 % 4
TYZINE SOLUTION 0.05 %
4
PRODUCTOS DE LA SANGRE/
MODIFICADORES/EXPANSORES DE
VOLUMEN
COAGULANTES
tranexamic acid solution 1,000
2 AP
mg/10 ml (100 mg/ml)
tranexamic acid tablet 650mg
2
RELAJANTES DEL MÚSCULO LISO
RELAJANTES DE MÚSCULO LISO
GENITOURINARIO
ENABLEX TABLET ER
4
24HR 15MG
ENABLEX TABLET ER
4
24HR 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
110
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
2
er 12hr 300mg
2
er 12hr 450mg
theophylline tablet er 24hr
2
400mg
theophylline tablet er 24hr
2
600mg
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
5 AP
%
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
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
dia(s)
CERVARIX SUSPENSION
20 MCG-20 MCG/0.5 ML
COMVAX SUSPENSION 5
MCG-7.5 MCG-125 MCG/0.5
ML
ENGERIX-B ADULT
SUSPENSION 20 MCG/ML
3
3
2
3
3
2
3
3
3
LC
3
4
3
AP
111
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ENGERIX-B PEDIATRICADOLESCENT
SUSPENSION 10 MCG/0.5
ML
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
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
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
PEDVAXHIB SUSPENSION
7.5 MCG/0.5 ML
3
/Límites
POLIOVIRUS VACCINE,
IPV INJECTION
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
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
VARIVAX VACCINE
INJECTABLE 1,350
UNIT/0.5 ML
YF-VAX INJECTABLE 10
EXP4.74 UNIT/0.5 ML
AP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
AP
3
AP
3
AP
3
3
3
AP
3
3
3
3
3
3
112
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
paricalcitol solution 2 mcg/ml
/Límites
paricalcitol solution 5 mcg/ml
VITAMINAS
PRENATAL VITAMINS
sodium fluoride tablet 1 mg
fluoride (2.2 mg)
3
2
2
LC
2
LC
2
LC
2
LC
2
LC
2
AP
3
2
2
2
2
2
2
2
2
AP
2
2
2
2
AP
113
Índice
*alcohol swabs*** ................. 113
*amino acid electrolyte infusion
8.5%*** ................................... 69
*AMINO ACID INFUSION
8.5%*** ................................... 69
8-MOP ...................................... 27
abacavir ...................................... 8
abacavir-lamivudinezidovudine .................................. 8
ABILIFY MAINTENA............ 36
ABSTRAL .......................... 44,45
acamprosate calcium ................ 35
ACANYA................................. 28
acarbose .................................... 74
acebutolol hcl ........................... 88
acetaminophen-codeine ............ 45
acetasol hc .............................. 108
acetazolamide ........................... 93
acetic acid ............................... 108
acetylcysteine ........................... 62
acitretin ..................................... 27
ACTEMRA ......................... 60,61
ACTHIB ................................. 111
ACTIMMUNE ......................... 64
ACTOPLUS MET XR ............. 74
ACUVAIL .............................. 107
acyclovir ............................. 8,9,28
acyclovir sodium ........................ 8
ACZONE ................................. 27
ADACEL TDAP .................... 111
ADAGEN ................................. 72
adapalene .................................. 27
ADCIRCA .............................. 100
adefovir dipivoxil ....................... 9
ADEMPAS............................. 100
ADRENALIN .......................... 85
ADVAIR DISKUS ................... 86
ADVAIR HFA ......................... 86
ADVICOR ............................... 91
afeditab cr ................................. 93
AFINITOR ............................... 19
AFINITOR DISPERZ .............. 19
AGGRENOX ............................ 67
AKYNZEO ............................. 104
ALBENZA.................................. 7
albuterol 5 mg/ml solution ........ 86
albuterol sul 0.63 mg/3 ml sol .. 86
albuterol sul 1.25 mg/3 ml sol .. 86
albuterol sul 2.5 mg/3 ml soln .. 86
albuterol sulfate ........................ 86
alclometasone dipropionate ...... 25
ALDACTAZIDE ...................... 93
ALDURAZYME ...................... 72
alendronate sodium ................... 63
alfuzosin hcl er.......................... 88
ALIMTA ................................... 19
ALINIA ...................................... 8
allopurinol ................................. 60
ALOCRIL ................................. 30
ALOMIDE .............................. 107
ALORA .................................... 82
alosetron hcl ............................ 105
ALPHAGAN P ....................... 107
alprazolam ................................ 60
alprazolam er ............................ 59
ALPRAZOLAM INTENSOL .. 59
alprazolam odt ..................... 59,60
ALREX ................................... 108
ALTABAX ............................... 28
ALTOPREV ............................. 91
ALVESCO ................................ 30
amantadine .................................. 9
AMBISOME ............................... 7
amcinonide................................ 25
amifostine ................................. 62
amikacin sulfate ........................ 12
amiloride hcl ............................. 93
amiloride-hydrochlorothiazide . 93
aminophylline inj 25 mg/ml ... 110
AMINOSYN II ......................... 70
aminosyn ii with electrolytes .... 70
114
AMINOSYN M ........................70
AMINOSYN WITH
ELECTROLYTES ....................70
AMINOSYN-HBC ...................70
AMINOSYN-PF .......................70
AMINOSYN-RF .......................70
amiodarone hcl ........................102
AMITIZA ................................105
amitriptyline hcl ........................36
amlodipine besylate ..................93
amlodipine besylatebenazepril ..................................93
amlodipine-atorvastatin.............91
amlodipine-valsartan .................94
amlodipine-valsartan-hctz .........94
amnesteem.................................27
amox tr-potassium
clavulanate ...........................12,13
amoxapine .................................36
amoxicillin ................................13
amoxicillin-clavulanate er.........13
amphetamine salt combo...........52
amphotericin b ............................7
ampicillin sodium......................13
ampicillin trihydrate ..................13
ampicillin-sulbactam .................13
AMPYRA .................................65
anagrelide hcl ............................67
anastrozole ................................19
ANDRODERM .........................79
ANDROGEL.............................79
ANGELIQ .................................82
ANORO ELLIPTA ...................86
APLENZIN ...............................36
APOKYN ..................................33
apraclonidine hcl .....................110
apri ............................................80
APRISO ..................................102
APTIOM ...................................55
APTIVUS ....................................9
ARALAST NP ..........................32
aranelle ......................................80
ARANESP .......................... 68,73
ARCALYST............................. 65
ARCAPTA NEOHALER ........ 86
aripiprazole.......................... 36,37
ARNUITY ELLIPTA............... 86
ARRANON .............................. 19
ARZERRA ............................... 19
ASACOL HD ......................... 103
ascomp with codeine ................ 45
ASENAPINE MALEATE SL
TAB 10 MG (BASE EQUIV) .. 37
ASMANEX .............................. 30
ASMANEX HFA ..................... 30
ASTAGRAF XL ...................... 62
ATELVIA ................................ 63
atenolol ..................................... 89
atenolol-chlorthalidone ............ 89
ATGAM ................................... 62
atorvastatin calcium ................. 91
atovaquone ................................. 8
atovaquone-proguanil hcl ........... 8
ATRALIN ................................ 30
ATRIPLA ................................... 9
ATROVENT HFA ................... 85
AUBAGIO ............................... 64
AURYXIA ............................... 70
AUVI-Q.................................... 86
AVANDAMET ........................ 74
AVANDIA ............................... 74
AVASTIN ................................ 19
AVELOX ABC PACK .............. 7
aviane ....................................... 80
avita .......................................... 30
AVODART .............................. 63
AVONEX ................................. 64
AVONEX ADMINISTRATION
PACK ....................................... 64
AVONEX PEN ........................ 64
AXIRON .................................. 79
azacitidine ................................ 19
AZASAN ................................. 62
AZASITE ................................108
azathioprine ...............................62
azelastine hcl ...........................107
AZELEX ...................................27
AZILECT ..................................33
azithromycin .............................13
AZOPT....................................107
AZOR ........................................94
aztreonam ..................................13
bacitracin-polymyxin ..............108
baclofen .....................................88
BACTROBAN NASAL..........108
balsalazide disodium ...............103
balziva .......................................80
BANZEL ...................................55
BARACLUDE ............................9
bcg vaccine (tice strain) ..........111
BECONASE AQ .......................30
BELEODAQ .............................19
benazepril hcl ............................94
benazeprilhydrochlorothiazide ..................94
BENICAR .................................94
BENICAR HCT ........................94
benztropine mesylate ................85
BEPREVE ...............................107
BESIVANCE ..........................108
betamethasone dipropionate......25
betamethasone valerate .............25
betaxolol hcl ..................89,94,107
bethanechol chloride ............87,88
BETHKIS 300 MG/4 ML
AMPULE ..................................13
BETOPTIC S ..........................107
bexarotene .................................20
BEXSERO ..............................111
BEYAZ .....................................80
bicalutamide ..............................20
BICILLIN C-R ..........................13
BICILLIN L-A .....................13,14
BICNU ......................................20
115
BILTRICIDE ..............................7
bimatoprost .............................107
bisoprolol fumarate ...................89
bisoprololhydrochlorothiazide ..................89
BIVIGAM ...............................111
bleomycin sulfate ......................20
BLEPHAMIDE .......................108
BLEPHAMIDE S.O.P. ...........108
BOOSTRIX TDAP .................111
BOSULIF ..................................20
BREO ELLIPTA.......................86
briellyn ......................................80
BRILINTA ................................67
brimonidine tartrate.................107
BRINTELLIX ...........................37
bromfenac sodium...................108
bromocriptine mesylate.............33
BROVANA 15 MCG/2 ML
SOLUTION ..............................86
budesonide ................................30
budesonide ec ............................73
bumetanide ................................94
buprenorphine hcl .....................45
buprenorphine-naloxone ...........45
buproban ...................................37
bupropion hcl ............................37
bupropion hcl sr ........................37
bupropion xl ..............................37
buspirone hcl .............................54
BUSULFEX ..............................20
butalb-acetaminoph-caffcodein ........................................45
butalb-caff-acetaminophcodein ........................................45
butalbital-acetaminophencaffe ..........................................45
butorphanol tartrate ...................45
BUTRANS ................................45
BYDUREON ............................74
BYDUREON PEN ....................74
BYETTA ...................................74
BYSTOLIC ...............................89
cabergoline ................................33
calcipotriene ............................. 27
calcipotrienebetamethasone dp ..................... 25
calcitonin-salmon ..................... 83
calcitriol............................. 27,113
calcium acetate ......................... 71
CAMBIA .................................. 45
camila ....................................... 80
CANASA ............................... 103
CANCIDAS ............................... 7
candesartan cilexetil ............ 94,95
candesartanhydrochlorothiazid ................... 95
CANTIL ................................... 85
CAPASTAT SULFATE ............ 7
CAPEX SHAMPOO ................ 25
CAPITAL W-CODEINE ......... 45
CAPRELSA ............................. 20
captopril.................................... 95
captopril-hydrochlorothiazide .. 95
CARAFATE........................... 103
carbamazepine .......................... 55
carbamazepine xr ..................... 55
carbidopa .................................. 35
carbidopa-levodopa .................. 33
carbidopa-levodopa er .............. 33
carbidopa-levodopaentacapone ................................ 33
carbinoxamine maleate............. 84
carboplatin ................................ 20
CARDURA XL ........................ 89
CARIMUNE NF
NANOFILTERED ................. 111
carteolol hcl ............................ 110
cartia xt ..................................... 95
carvedilol .................................. 89
CAYSTON ............................... 14
CEDAX .................................... 14
CEDAX FOR
SUSPENSION 90 MG/5 ML ... 14
cefaclor ..................................... 14
cefaclor er ................................. 14
cefadroxil.................................. 14
cefazolin sodium ...................... 14
cefdinir ..................................... 14
cefepime hcl ............................. 14
cefepime-dextrose .................... 14
cefixime .................................... 14
cefotaxime sodium ................... 14
cefpodoxime proxetil ............... 14
cefprozil ................................... 14
ceftazidime ............................... 14
CEFTIN .................................... 14
ceftriaxone ........................... 14,15
cefuroxime ............................... 15
cefuroxime sodium ................... 15
celecoxib ............................. 45,46
CELONTIN .............................. 55
cephalexin ................................ 15
CERDELGA ............................ 73
CEREBYX ............................... 55
CEREZYME ............................ 73
CERVARIX ........................... 111
CESAMET ............................. 104
cetirizine hcl ............................. 84
cevimeline hcl .......................... 88
CHANTIX ................................ 87
CHEMET ................................. 66
CHENODAL .......................... 104
chloramphenicol sod succinate 15
chlorhexidine gluconate ........... 28
chloroquine phosphate ............... 8
chlorothiazide ........................... 95
chlorpromazine hcl ................... 37
chlorthalidone........................... 95
cholestyramine light ................. 91
chorionic gonadotropin ............ 83
ciclopirox .............................. 7,28
cidofovir ..................................... 9
cilostazol .................................. 67
CILOXAN .............................. 108
cimetidine ............................... 103
CIMZIA ................................... 61
116
CINRYZE ................................ 64
CIPRO HC ............................. 108
CIPRODEX ............................ 108
ciprofloxacin ............................ 15
ciprofloxacin er ........................ 15
ciprofloxacin hcl................ 15,109
ciprofloxacin-d5w .................... 15
cisplatin .................................... 20
citalopram hbr .......................... 37
cladribine .................................. 20
claravis ..................................... 27
CLARINEX ............................. 84
CLARINEX-D 12 HOUR ........ 84
clarithromycin .......................... 15
clarithromycin er ...................... 15
clemastine fumarate ................. 85
CLEOCIN ................................ 28
CLEOCIN T ............................. 28
CLIMARA PRO ...................... 82
CLINDACIN PAC ................... 28
clindamycin hcl ........................ 15
clindamycin pediatric ............... 15
clindamycin phosphate ........ 15,28
clindamycin phosphate-d5w..... 15
clindamycin-benzoyl peroxide . 28
CLINIMIX ............................... 70
CLINIMIX E ............................ 70
clinisol ...................................... 70
clobetasol emollient ................. 25
clobetasol propionate ............... 25
CLODERM .............................. 25
CLOLAR .................................. 20
clomipramine hcl ...................... 37
clonazepam ............................... 60
clonidine ................................... 95
clonidine hcl ............................. 95
clonidine hcl er ......................... 95
clopidogrel................................ 67
clorazepate dipotassium ........... 60
CLORPRES ............................. 95
clotrimazole .............................. 28
clotrimazole-betamethasone..... 28
clozapine .................................. 38
clozapine odt ............................ 37
tab 100 mg ................................ 37
tab 200 mg ................................ 37
tab 25 mg .................................. 37
COARTEM ................................ 8
codeine sulfate.......................... 46
colchicine ................................. 60
colestipol hcl ............................ 91
colistimethate ........................... 15
colocort ..................................... 26
COLY-MYCIN S ................... 109
COMBIGAN .......................... 107
COMBIPATCH ....................... 82
COMBIVENT RESPIMAT ..... 85
COMETRIQ ............................. 20
COMPLERA .............................. 9
compro...................................... 38
COMVAX .............................. 111
CONDYLOX ........................... 27
constulose ................................. 71
COPAXONE ............................ 64
CORDRAN .............................. 26
COREG CR .............................. 89
CORLANOR ............................ 89
CORTIFOAM .......................... 26
cortisone acetate ....................... 73
CORTISPORIN ....................... 28
CORTISPORIN-TC ............... 109
COSENTYX (2 SYRINGES) .. 27
COSENTYX PEN .................... 27
COUMADIN ............................ 67
CREON ........................... 105,106
CRESEMBA .............................. 7
CRESTOR ................................ 91
CRIXIVAN ................................ 9
cromolyn 20 mg/2 ml neb soln . 30
cromolyn sodium ...................... 30
cryselle ...................................... 80
CUBICIN .................................. 16
cyclafem.................................... 80
cyclobenzaprine hcl .................. 88
cyclophosphamide .................... 20
CYCLOSET.............................. 33
cyclosporine .............................. 62
cyclosporine modified .............. 62
CYRAMZA .............................. 20
CYSTADANE .......................... 65
CYSTAGON ............................ 65
CYSTARAN ............................. 65
cytarabine.................................. 20
DAKLINZA................................ 9
DALIRESP ............................... 32
DALVANCE ............................ 16
danazol ...................................... 79
dantrolene sodium..................... 88
dapsone ....................................... 7
DAPTACEL DTAP ................ 111
DARAPRIM ............................. 16
daunorubicin hcl ....................... 20
DAYTRANA ............................ 52
decitabine .................................. 20
DELZICOL ............................. 103
DEMSER .................................. 65
DENAVIR ................................ 28
DEPEN ..................................... 66
DEPO-ESTRADIOL ................ 82
DEPO-SUBQ PROVERA 104 . 84
desipramine hcl ......................... 38
desloratadine ............................. 85
desmopressin acetate ...... 66,67,73
desogestr-eth estrad eth estra .... 80
DESONATE ............................. 26
desonide .................................... 26
desoximetasone ......................... 26
117
dexamethasone ......................... 73
DEXAMETHASONE
INTENSOL .............................. 73
phosphate ........................... 73,108
DEXILANT ............................ 103
dexmethylphenidate hcl er .. 52,53
DEXPAK .................................. 73
dextroamphetamine sulfate er .. 53
dextroamphetamine-amphet er . 53
dextrose 10%-0.2% nacl ........... 70
dextrose 10%-0.45% nacl ......... 70
dextrose 2.5%-0.45% nacl ........ 70
dextrose 5%-0.2% nacl ............. 70
dextrose 5%-0.2% nacl-kcl ...... 71
dextrose 5%-0.225% nacl ......... 70
dextrose 5%-0.225% nacl-kcl .. 71
dextrose 5%-0.33% nacl ........... 70
dextrose 5%-0.33% nacl-kcl .... 71
dextrose 5%-0.45% nacl ........... 70
dextrose 5%-0.45% nacl-kcl .... 71
dextrose 5%-0.9% nacl ............. 70
dextrose 5%-1/2ns-kcl .............. 71
dextrose 5%-ns-kcl ................... 71
dextrose 5%-potassium
chloride ..................................... 71
dextrose in lactated ringers ....... 71
dextrose in water ...................... 70
diazepam................................... 60
DIBENZYLINE ....................... 89
diclofenac potassium ................ 46
diclofenac sodium ........ 27,46,108
diclofenac sodium er ................ 46
diclofenac sodiummisoprostol ............................... 46
dicloxacillin sodium ................. 16
dicyclomine hcl ........................ 85
didanosine................................... 9
DIFFERIN ................................ 27
DIFICID ................................... 16
diflorasone diacetate ................. 26
diflunisal ................................... 46
digoxin .................................... 102
dihydroergotamine mesylate .... 89
DILANTIN ............................... 55
DILANTIN-125 ....................... 56
diltiazem 12hr er ...................... 95
diltiazem 24hr cd ...................... 95
diltiazem 24hr er ................. 95,96
diltiazem er ............................... 96
diltiazem hcl ............................. 96
dilt-xr ........................................ 95
DIPENTUM ........................... 103
diphenhydramine hcl ................ 89
diphtheria-tetanus toxoidsped .......................................... 111
disopyramide phosphate ......... 102
disulfiram ............................ 35,63
DIURIL .................................... 96
divalproex sodium .................... 56
divalproex sodium er ................ 56
DIVIGEL.................................. 82
docetaxel .................................. 20
donepezil hcl ............................ 88
donepezil hcl odt ...................... 88
dorzolamide hcl ...................... 107
dorzolamide-timolol ............... 107
doxazosin mesylate .................. 89
doxepin hcl ............................... 38
doxercalciferol........................ 113
doxorubicin hcl......................... 20
doxycycline hyclate.................. 16
doxycycline monohydrate ........ 16
dronabinol .............................. 104
drospirenone-ethinyl estradiol.. 80
DROXIA .................................. 20
DUAVEE ................................. 82
DUEXIS ................................... 46
DULERA ................................. 86
duloxetine hcl ........................... 38
duramorph ................................ 46
DUREZOL ............................. 108
DYMISTA ............................... 30
DYRENIUM ............................. 96
E.E.S. 200 ................................. 16
econazole nitrate ....................... 28
EDARBI ................................... 96
EDARBYCLOR ....................... 96
EDECRIN ................................. 96
EDURANT ................................. 9
EFFIENT .................................. 67
ELAPRASE .............................. 73
ELIDEL .................................... 27
ELIGARD ................................. 20
ELIGARD 30 MG SYRINGE
KIT ............................................ 20
ELIGARD 7.5 MG SYRINGE
KIT ............................................ 20
ELIQUIS ................................... 67
ELITEK .................................... 73
ELIXOPHYLLIN ..................... 96
ELLA ........................................ 80
ELMIRON ................................ 65
EMADINE .............................. 107
EMCYT .................................... 20
EMEND .................................. 104
emoquette .................................. 80
EMSAM .................................... 38
EMTRIVA .................................. 9
ENABLEX .............................. 110
enalapril maleate ....................... 96
enalapril-hydrochlorothiazide ... 96
ENBREL ................................... 61
endocet ...................................... 46
ENGERIX-B ADULT ............ 111
ENGERIX-B PEDIATRICADOLESCENT ...................... 112
enoxaparin sodium .................... 67
enpresse..................................... 80
entacapone ................................ 33
entecavir ...................................... 9
ENTRESTO .............................. 69
enulose ...................................... 71
EPIDUO .................................... 27
EPIDUO FORTE 0.3-2.5%
GEL PUMP ............................... 27
118
epinephrine ............................... 86
EPIPEN 2-PAK ........................ 86
EPIPEN JR 2-PAK ................... 87
epirubicin hcl ............................ 20
epitol ......................................... 56
EPIVIR HBV .............................. 9
eplerenone ................................. 96
EPOGEN ............................. 68,69
eprosartan mesylate .................. 96
EPZICOM ................................... 9
EQUETRO................................ 56
ergoloid mesylates .................... 89
ERIVEDGE .............................. 20
errin ........................................... 80
ERWINAZE ............................. 20
ery ............................................. 29
ERYPED 200 ............................ 16
ERYPED 400 ............................ 16
ERY-TAB ................................. 16
ERYTHROCIN
LACTOBIONATE ................... 16
ERYTHROCIN STEARATE ... 16
erythromycin ................. 16,29,109
erythromycin-benzoyl
peroxide .................................... 29
ESBRIET .................................. 65
escitalopram oxalate ................. 38
esomeprazole magnesium ....... 103
ESTRACE ................................ 82
estradiol ............................... 82,83
estradiol-norethindrone acetat .. 80
eszopiclone .......................... 54,55
ethambutol hcl ............................ 7
ethosuximide............................. 56
etidronate disodium .................. 63
etodolac ..................................... 46
etodolac er................................. 46
etoposide ................................... 20
EURAX .................................... 29
EVAMIST ................................ 83
EVEKEO .................................. 53
EVOTAZ .................................... 9
EVZIO ...................................... 55
EXELDERM ............................ 29
EXELON .................................. 88
exemestane ............................... 20
EXJADE................................... 66
EXTAVIA ................................ 64
FABRAZYME ......................... 73
famciclovir ................................. 9
famotidine .............................. 103
FANAPT .................................. 38
FARESTON ............................. 21
FARXIGA ................................ 74
FARYDAK .............................. 21
FASLODEX ............................. 21
felbamate .................................. 56
felodipine er ............................. 96
FEMRING ................................ 83
fenofibrate ........................... 91,92
fenofibric acid .......................... 92
FENOGLIDE ........................... 92
fenoprofen calcium................... 46
fentanyl ................................ 46,47
fentanyl citrate .......................... 46
FENTORA ............................... 47
FERRIPROX ............................ 66
FETZIMA ................................ 39
FIBRICOR ............................... 92
FINACEA ................................ 28
FINACEA 15% FOAM ........... 27
finasteride ................................. 63
FIRAZYR ................................. 64
FIRMAGON ............................ 21
FLAREX ................................ 108
flavoxate hcl ........................... 110
FLEBOGAMMA DIF ............ 111
flecainide acetate .................... 102
FLECTOR ................................ 47
FLO-PRED............................... 73
FLOVENT DISKUS ........... 30,31
FLOVENT HFA ...................... 31
fluconazole ................................. 7
fluconazole in dextrose .............. 7
flucytosine .................................. 7
fludarabine phosphate .............. 21
fludrocortisone acetate ............. 73
flunisolide................................. 31
fluocinolone acetonide ............. 26
fluocinolone acetonide oil ...... 108
fluocinonide ............................. 26
fluocinonide-e .......................... 26
fluorometholone ..................... 108
fluorouracil .......................... 21,28
fluoxetine dr ............................. 39
fluoxetine hcl............................ 39
fluphenazine decanoate ............ 39
fluphenazine hcl ....................... 39
flurbiprofen .............................. 47
flurbiprofen sodium................ 108
flutamide .................................. 21
fluticasone propionate ......... 26,31
fluvastatin sodium .................... 92
fluvoxamine maleate ................ 39
fluvoxamine maleate er ............ 39
FML FORTE .......................... 108
FOCALIN XR .......................... 53
FOLOTYN ............................... 21
fondaparinux sodium................ 67
FORADIL ................................ 87
FORFIVO XL .......................... 39
FORTEO .................................. 84
FORTICAL .............................. 84
fosinopril sodium ..................... 96
fosinopril-hydrochlorothiazide. 96
FOSRENOL ............................. 71
FREAMINE HBC .................... 70
furosemide ................................ 96
FUZEON .................................... 9
119
FYCOMPA .............................. 56
gabapentin ................................ 47
GABITRIL ............................... 56
galantamine hbr ........................ 88
galantamine hydrobromide ...... 88
GAMASTAN S-D.................. 111
GAMMAGARD LIQUID ...... 111
GAMMAKED ........................ 111
GAMMAPLEX ...................... 111
GAMUNEX-C ....................... 111
ganciclovir sodium ..................... 9
GARDASIL ........................... 112
GARDASIL 9 ........................ 112
gatifloxacin............................. 109
gauze pads .............................. 113
gavilyte-c ................................ 105
gavilyte-g ............................... 105
gavilyte-n ............................... 105
GELNIQUE ........................... 110
gemfibrozil ............................... 92
generlac .................................... 71
gengraf ..................................... 62
gentamicin sulfate ........ 17,29,109
gentamicin sulfate in ns....... 16,17
gentamicin sulfate iv soln
10 mg/ml .................................. 17
GEODON ................................. 39
gildagia ..................................... 83
GILENYA ................................ 64
GILOTRIF ............................... 21
GLASSIA ................................. 32
GLEEVEC ............................... 21
glimepiride ............................... 75
glipizide .................................... 75
glipizide er................................ 75
glipizide-metformin ................. 75
GLUCAGEN ............................ 65
GLUCAGON EMERGENCY
KIT ........................................... 65
GLUMETZA ............................ 75
glyburide .................................. 75
glyburide micronized ............... 75
glyburide-metformin hcl .......... 75
glycopyrrolate .......................... 85
GLYSET .................................. 75
GLYXAMBI ............................ 75
GOLYTELY .......................... 105
GRALISE ................................. 47
GRALISE 30-DAY STARTER
PACK ....................................... 47
granisetron hcl ........................ 105
GRANIX .................................. 69
griseofulvin ................................ 7
griseofulvin ultramicrosize ........ 7
GRIS-PEG .................................. 7
guanfacine hcl .......................... 97
guanfacine hcl er ................. 96,97
guanidine hcl ............................ 65
H.P. ACTHAR ......................... 65
HALAVEN .............................. 21
halobetasol propionate ............. 26
HALOG .................................... 26
haloperidol........................... 39,40
haloperidol decanoate............... 39
haloperidol lactate .................... 39
HARVONI ................................. 9
HAVRIX ................................ 112
heparin sodium ......................... 67
hepatamine ............................... 70
HERCEPTIN ............................ 21
HETLIOZ ................................. 55
HEXALEN ............................... 21
HORIZANT ............................. 47
HUMIRA ................................. 61
HUMIRA PEN CROHN'S-UCHS............................................. 61
hydralazine hcl ......................... 97
hydrochlorothiazide.................. 97
hydrocodone-acetaminophen ... 47
hydrocodone-ibuprofen ............ 47
hydrocortisone ..................... 26,73
hydrocortisone butyrate............ 26
hydrocortisone valerate ............ 26
hydrocortisone-acetic acid ..... 109
hydromorphone er .................... 48
hydromorphone hcl .................. 48
hydroxychloroquine sulfate........ 8
hydroxyurea.............................. 21
HYPERRAB S-D ................... 112
ibandronate sodium .................. 63
IBRANCE ................................ 21
ibuprofen .................................. 48
ICLUSIG .................................. 21
idarubicin hcl ............................ 21
ifosfamide................................. 21
ILARIS ..................................... 65
ILEVRO ................................. 108
IMBRUVICA ........................... 21
imipenem-cilastatin sodium ..... 17
imipramine hcl ......................... 40
imipramine pamoate ................. 40
imiquimod ................................ 28
IMOVAX RABIES
VACCINE .............................. 112
INCRELEX .............................. 80
INCRUSE ELLIPTA ............... 87
indapamide ............................... 97
indomethacin ............................ 48
INFANRIX DTAP ................. 111
INLYTA ................................... 21
INNOPRAN XL ....................... 89
insulin 1 ml syringe ................ 113
insulin 1/2 ml syringe ............. 113
INSULIN SYRINGE 0.3 ML 113
INTELENCE .............................. 9
INTRON A ................................. 9
introvale.................................... 80
INVANZ .................................. 17
INVEGA .................................. 40
INVEGA SUSTENNA ............ 40
INVIRASE ............................... 10
INVOKAMET ......................... 75
120
INVOKANA ............................ 75
IONOSOL B WITH
DEXTROSE 5% ....................... 71
IONOSOL MBDEXTROSE 5% ....................... 71
IOPIDINE ............................... 110
IPOL ....................................... 112
ipratropium bromide .......... 85,110
ipratropium-albuterol ................ 85
irbesartan .................................. 97
irbesartan-hydrochlorothiazide . 97
irinotecan hcl ............................ 21
ISENTRESS ............................. 10
ISOLYTE P WITH
DEXTROSE ............................. 71
ISOLYTE S .............................. 71
isoniazid...................................... 7
isosorbide dinitrate ................. 101
isosorbide mononitrate ........... 101
isosorbide mononitrate er ....... 101
isradipine .................................. 97
ISTALOL ............................... 107
ISTODAX ................................ 21
itraconazole ................................ 7
ivermectin ................................... 7
IXEMPRA ................................ 21
IXIARO .................................. 112
JADENU .................................. 66
JAKAFI .................................... 21
JALYN ..................................... 90
jantoven ............................... 67,68
JANUMET ............................... 75
JANUMET XR .................... 75,76
JANUVIA ................................. 76
JARDIANCE ............................ 76
JENTADUETO ........................ 76
JEVTANA ................................ 21
jolivette ..................................... 80
JUBLIA ...................................... 8
junel .......................................... 80
junel fe ...................................... 80
junel fe 24 ................................. 80
JUXTAPID............................... 92
KADIAN .................................. 48
KALETRA ............................... 10
KALYDECO ............................ 32
kariva ........................................ 80
KAZANO ................................. 76
kelnor 1-35 ............................... 80
KEPIVANCE ........................... 30
KETEK..................................... 17
ketoconazole.......................... 8,29
ketoprofen ................................ 48
ketorolac tromethamine.......... 108
KEYTRUDA ............................ 22
KHEDEZLA ............................ 40
KINERET................................. 61
kionex ....................................... 71
klor-con 10 ............................... 71
KLOR-CON M15 .................... 71
klor-con m20 ............................ 71
KOMBIGLYZE XR ................. 76
KORLYM ................................ 65
KUVAN ................................... 65
KYNAMRO ............................. 92
labetalol hcl .............................. 90
lactated ringers ......................... 72
lactulose.................................... 71
LAMICTAL (BLUE) ............... 56
LAMICTAL (GREEN) ............ 56
LAMICTAL (ORANGE) ......... 56
LAMICTAL XR (BLUE) ........ 56
LAMICTAL XR (GREEN) ..... 56
LAMICTAL XR (ORANGE) .. 56
LAMISIL ................................... 8
lamivudine ................................ 10
lamivudine-zidovudine............. 10
lamotrigine ............................... 57
lamotrigine er ...................... 56,57
lamotrigine odt ......................... 57
lansoprazol-amoxicil-clarithro . 17
lansoprazole ............................ 103
LANTUS................................... 76
LANTUS SOLOSTAR ............. 76
LASTACAFT ......................... 107
latanoprost............................... 107
LATUDA .................................. 40
LAZANDA ............................... 48
leflunomide ............................... 61
LENVIMA ................................ 22
LESCOL XL ............................. 92
lessina ....................................... 80
LETAIRIS............................... 101
letrozole .................................... 22
leucovorin calcium............... 62,63
LEUKERAN ............................. 22
LEUKINE ................................. 69
leuprolide acetate ...................... 22
levalbuterol 0.31 mg/3 ml sol ... 87
levalbuterol 0.63 mg/3 ml sol ... 87
levalbuterol conc 1.25 mg/0.5 .. 87
LEVEMIR................................. 76
LEVEMIR FLEXTOUCH ........ 76
levetiracetam ............................. 57
levetiracetam er ......................... 57
levetiracetam-nacl ..................... 57
levobunolol hcl ....................... 107
levocetirizine dihydrochloride .. 85
levofloxacin ....................... 17,109
levofloxacin-d5w ...................... 17
levonest ..................................... 83
levonorgestrel-eth estradiol ...... 81
levonorg-eth estrad eth estrad ... 81
levora-28 ................................... 81
levorphanol tartrate ................... 48
levothyroxine sodium ............... 78
levoxyl ...................................... 78
LEXIVA ................................... 10
LIALDA ................................. 103
lidocaine.................................... 29
121
lidocaine hcl .......................29,108
lidocaine hcl viscous ...............108
lidocaine-prilocaine ..................29
lindane.......................................29
linezolid ....................................17
linezolid tablet 600mg ..............17
LINZESS ................................105
liothyronine sodium ..................78
LIPTRUZET .............................92
lisinopril ....................................97
lisinopril-hydrochlorothiazide ..97
lithium .......................................32
lithium carbonate ......................32
lithium carbonate er ..................32
LIVALO....................................92
LO LOESTRIN FE ...................81
LOESTRIN ...............................81
LOESTRIN FE .........................81
lokara 0.05% lotion ...................26
lomustine...................................22
loperamide ..............................104
lorazepam ..................................60
lorazepam intensol ....................60
loryna ........................................83
losartan potassium.....................97
losartan-hydrochlorothiazide ....97
LOTEMAX .............................108
lovastatin ...................................92
low-ogestrel ..............................81
loxapine.....................................40
LUMIGAN..............................107
LUMIZYME .............................73
LUPRON DEPOT.....................22
LUPRON DEPOT-PED............22
lutera .........................................81
LYNPARZA .............................22
LYRICA...............................57,58
LYSODREN .............................22
maprotiline hcl ..........................40
marlissa .................................... 81
MARPLAN .............................. 40
MATULANE ........................... 22
matzim la ............................. 97,98
MAXIDEX ............................. 108
meclizine hcl ............................ 84
meclofenamate sodium............. 48
medroxyprogesterone acetate ... 84
mefenamic acid ........................ 48
mefloquine hcl ............................ 8
MEGACE ES ........................... 22
megestrol acetate ...................... 22
MEKINIST............................... 22
meloxicam ................................ 48
melphalan hcl ........................... 22
memantine hcl .......................... 35
MENACTRA ......................... 112
MENOMUNE-A-C-Y-W135 .......................................... 112
MENOSTAR ............................ 83
MENVEO A-C-Y-W-135DIP ......................................... 112
mercaptopurine......................... 22
meropenem ............................... 17
mesalamine............................. 103
MESNEX ................................. 62
MESTINON ............................. 88
metaproterenol sulfate .............. 87
metformin hcl ........................... 76
metformin hcl er ....................... 76
methadone hcl .......................... 48
methazolamide ....................... 107
methenamine hippurate .............. 7
methimazole ............................. 78
methotrexate ............................. 22
methotrexate sodium ................ 22
methoxsalen.............................. 27
methscopolamine bromide ....... 85
methyclothiazide ...................... 98
methyldopa ............................... 87
methyldopahydrochlorothiazide.................. 87
methylergonovine maleate ......106
methylphenidate er ....................53
methylphenidate hcl ..................54
methylphenidate hcl cd ........53,54
methylphenidate la ....................54
methylprednisolone ...................74
methylprednisolone acetate.......73
methylprednisolone sod succ ....73
metipranolol ............................107
metoclopramide hcl.................104
metoclopramide hcl odt ..........104
metolazone ................................98
metoprolol succinate .................90
metoprolol tartrate.....................90
metoprolol-hydrochlorothiazide90
metronidazole....................8,17,29
mexiletine hcl ..........................102
MIACALCIN ............................84
MICONAZOLE 3 .....................29
microgestin................................81
microgestin fe ...........................81
midodrine hcl ............................87
minitran ...................................101
MINIVELLE .............................83
minocycline hcl .........................17
minocycline hcl er .....................17
minoxidil ...................................98
MIRAPEX ER .....................33,34
MIRCERA ................................73
mirtazapine...........................40,41
misoprostol..............................103
mitomycin .................................23
mitoxantrone hcl .......................23
M-M-R II VACCINE..............112
modafinil ...................................54
moexipril hcl .............................98
moexipril-hydrochlorothiazide .98
mometasone furoate ..................26
mononessa .................................81
122
montelukast sodium.................. 31
MONUROL ................................ 7
morphine sulfate ....................... 49
morphine sulfate er .............. 48,49
MOVANTIK .......................... 105
MOVIPREP ............................ 105
MOXEZA ............................... 109
moxifloxacin hcl ....................... 17
MOZOBIL ................................ 69
MULTAQ ............................... 102
mupirocin ................................. 29
MUSTARGEN ......................... 23
MYALEPT ............................... 65
mycophenolate mofetil ............. 62
mycophenolic acid .................... 62
MYOZYME ............................. 73
MYRBETRIQ ........................ 110
nabumetone .............................. 49
nadolol ...................................... 90
nadolol-bendroflumethiazide ... 90
NAFCILLIN ............................. 17
nafcillin sodium ........................ 17
naftifine hcl .............................. 29
NAFTIN ................................... 29
NAGLAZYME......................... 73
naloxone hcl ............................. 55
naltrexone hcl ........................... 55
NAMENDA ............................. 35
NAMENDA XR ....................... 35
naphazoline hcl ....................... 110
NAPRELAN............................. 49
naproxen .............................. 49,50
naproxen sodium ...................... 49
naproxen sodium cr .................. 49
naratriptan hcl ........................... 32
NASONEX ............................... 31
NATACYN ............................ 109
nateglinide ................................ 76
NATPARA ............................... 84
NEBUPENT ............................... 8
necon ........................................ 81
nefazodone hcl ......................... 41
neomycin sulfate ...................... 17
neomycin-bacitracin-poly-hc . 109
neomycin-bacitracinpolymyxin .............................. 109
neomycin-polymyxin b ............ 29
neomycin-polymyxindexameth ................................ 109
neomycin-polymyxingramicidin .............................. 109
neomycin-polymyxin-hc ........ 109
neomycin-polymyxin
-hydrocort ............................... 109
NEPHRAMINE ....................... 70
NESINA ................................... 76
NEULASTA............................. 69
NEUMEGA .............................. 69
NEUPOGEN ............................ 69
NEUPRO .................................. 34
NEVANAC ............................ 108
nevirapine ................................. 10
nevirapine er ............................. 10
NEXAVAR .............................. 23
NEXIUM ................................ 103
niacin er .................................... 92
nicardipine hcl .......................... 98
NICOTROL ............................. 87
NICOTROL NS ....................... 87
nifedical xl................................ 98
nifedipine er ............................. 98
NILANDRON .......................... 23
nimodipine ............................... 98
nisoldipine ................................ 98
NITRO-BID ........................... 101
nitrofurantoin.............................. 7
nitrofurantoin mono-macro ........ 7
nitroglycerin ........................... 101
nitroglycerin patch ................. 101
NITROMIST .......................... 101
NITROSTAT ......................... 101
nizatidine ................................ 103
norethindrone ............................ 83
norethindrone acetate................ 84
norethindron-ethinyl estradiol .. 83
norethin-eth estra ferrous fum .. 81
NORMOSOL-M AND
DEXTROSE ............................. 72
NORMOSOL-R AND
DEXTROSE ............................. 72
NORMOSOL-R PH 7.4............ 72
NORPACE CR ....................... 102
nortrel ....................................... 81
nortriptyline hcl ........................ 41
NORVIR ................................... 10
NOVOLIN 70-30...................... 76
NOVOLIN N ............................ 76
NOVOLIN R ............................ 76
NOVOLOG .............................. 77
NOVOLOG FLEXPEN ............ 77
NOVOLOG MIX 70-30 ........... 77
NOVOLOG MIX 70-30
FLEXPEN................................. 77
NOXAFIL................................... 8
NUCYNTA............................... 50
NUCYNTA ER ........................ 50
NUEDEXTA ............................ 35
nutrilipid ................................... 70
NUVARING ............................. 81
NUVIGIL ................................. 54
nystatin .................................. 8,29
nystatin-triamcinolone .............. 29
nystop ....................................... 29
OCTAGAM ............................ 111
octreotide acetate ................. 65,66
OFEV ........................................ 66
ofloxacin ............................ 17,109
OGESTREL.............................. 81
olanzapine ................................. 41
olanzapine odt ........................... 41
olanzapine-fluoxetine hcl ......... 41
olopatadine hcl........................ 107
OLUX ....................................... 26
OLYSIO ................................... 10
123
omega-3 acid ethyl esters ......... 92
omeprazole ............................. 104
OMNARIS ................................ 31
ONCASPAR ............................. 23
ondansetron hcl ....................... 105
ondansetron odt ...................... 105
ONFI ......................................... 60
ONGLYZA ............................... 77
OPDIVO ................................... 23
OPSUMIT............................... 101
ORACEA .................................. 17
ORAP ....................................... 41
ORENCIA ................................ 61
ORENITRAM ER .................. 101
ORFADIN ................................ 66
ORKAMBI ............................... 17
orsythia ..................................... 81
ORTHO TRI-CYCLEN LO ..... 81
OSENI ...................................... 77
OSMOPREP ........................... 105
OTEZLA................................... 61
OTREXUP ................................ 23
oxaliplatin ................................. 23
oxandrolone .............................. 79
oxaprozin .................................. 50
oxcarbazepine ........................... 58
OXISTAT ................................. 29
OXSORALEN .......................... 27
OXTELLAR XR ...................... 58
oxybutynin chloride ................ 110
oxybutynin chloride er ............ 110
oxycodone hcl ........................... 50
oxycodone hcl er....................... 50
oxycodone hcl-aspirin .............. 50
oxycodone hcl-ibuprofen .......... 50
oxycodone-acetaminophen ....... 50
OXYCONTIN .......................... 51
oxymorphone hcl ...................... 51
oxymorphone hcl er .................. 51
OXYTROL............................. 110
pacerone ................................. 102
paclitaxel .................................. 23
pamidronate disodium .............. 63
PANCREAZE ........................ 106
PANDEL .................................. 27
PANRETIN .............................. 28
pantoprazole sodium .............. 104
paricalcitol .............................. 113
paromomycin sulfate ................ 17
paroxetine hcl ...................... 41,42
PASER ....................................... 7
PATADAY............................. 107
PATANOL ............................. 107
PAXIL ...................................... 42
PAZEO ................................... 107
PCE .......................................... 17
PEDVAXHIB ......................... 112
PEGANONE ............................ 58
PEGASYS ................................ 10
PEGASYS PROCLICK ........... 10
PEGINTRON ........................... 10
PEGINTRON REDIPEN ......... 10
PEN NEEDLES 12MM 29G . 113
penicillin g potassium .............. 17
penicillin g procaine ................. 17
penicillin g sodium ................... 18
penicillin gk-iso-osm dextrose . 18
penicillin v potassium .............. 18
PENNSAID .............................. 51
PENTAM 300 .......................... 18
PENTASA .............................. 103
pentoxifylline ........................... 69
PERFOROMIST 20 MCG/2 ML
SOLN ....................................... 87
perindopril erbumine ................ 98
permethrin ................................ 29
perphenazine ............................ 42
perphenazine-amitriptyline ...... 42
PERTZYE .............................. 106
PEXEVA ...................................42
phenelzine sulfate .....................42
phenobarbital ............................59
PHENOXYBENZAMINE HCL
10 MG CAP ..............................90
PHENYTEK .............................58
phenytoin ..................................58
phenytoin sodium extended ......58
PHOSPHOLINE IODIDE ......107
physiolyte ..................................72
physiosol ...................................72
PICATO ....................................28
pilocarpine hcl...........................88
pindolol .....................................90
pioglitazone hcl .........................77
pioglitazone-glimepiride ...........77
pioglitazone-metformin ............77
piperacillin-tazobactam .............18
piroxicam ..................................51
PLASMA-LYTE 148 ................72
PLASMA-LYTE 56 IN
DEXTROSE..............................72
PLASMA-LYTE A PH 7.4 .......72
PLEGRIDY ...............................64
PLEGRIDY PEN ......................64
podofilox ...................................28
POLIOVIRUS VACCINE,
IPV INJECTION.....................112
polyethylene glycol 3350 ........105
polymyxin b sul-trimethoprim 109
POMALYST .............................23
portia .........................................81
potassium chl-normal saline .....72
potassium chloride ....................72
potassium chloride in d5lr.........72
potassium chloride-nacl ............72
potassium citrate er ...................69
POTIGA ....................................58
PRADAXA ...............................68
pramipexole dihydrochloride ....34
pramipexole er ..........................34
PRAMIPEXOLE ER 3 MG
TABLET ...................................34
124
PRAMIPEXOLE ER
4.5 MG TABLET ......................34
PRANDIMET ...........................77
pravastatin sodium ...............92,93
prazosin hcl ...............................90
PRED MILD ...........................108
PRED-G ..................................109
prednicarbate .............................27
prednisolone acetate ..................74
prednisolone sodium
phosphate ...........................74,108
prednisone .................................74
PREDNISONE INTENSOL .....74
PREFEST ..................................83
PREMARIN ..............................83
PREMASOL .............................70
PRENATAL VITAMINS .......113
PREVACID ............................104
prevalite ....................................93
previfem ....................................81
PREZCOBIX ............................11
PREZISTA ................................11
primaquine ..................................8
primidone ..................................59
PRIMSOL ...................................7
PRISTIQ ER .............................42
PRIVIGEN ..............................111
PROAIR HFA ...........................87
PROAIR RESPICLICK ............87
probenecid .................................71
probenecid-colchicine ...............71
PROCALAMINE......................70
prochlorperazine .......................84
prochlorperazine edisylate ........84
prochlorperazine maleate ..........84
procto-pak .................................27
proctozone-hc............................27
progesterone ..............................84
PROGLYCEM ..........................98
PROLASTIN C .........................32
PROLEUKIN ............................23
PROLIA ................................... 63
PROMACTA ........................... 69
promethazine hcl .................... 105
promethegan ........................... 105
propafenone hcl ...................... 102
propafenone hcl er .................. 102
proparacaine hcl ..................... 108
propranolol hcl ......................... 90
propranolol hcl er ..................... 90
propranololhydrochlorothiazide.................. 90
propylthiouracil ........................ 78
PROQUAD ............................ 112
PROSOL .................................. 70
PROTONIX ........................... 104
protriptyline hcl ........................ 42
PROVENTIL HFA .................. 32
PRUDOXIN ............................. 30
PULMICORT........................... 31
PULMICORT FLEXHALER .. 31
PULMOZYME ........................ 73
PURIXAN ................................ 11
PYLERA .................................. 18
pyrazinamide .............................. 7
pyridostigmine bromide ........... 88
pyridostigmine bromide er ....... 88
QNASL .................................... 31
QNASL CHILDREN ............... 31
QUADRACEL DTAP-IPV .... 112
quasense ................................... 81
quetiapine fumarate .................. 42
quinapril hcl ............................. 98
quinapril-hydrochlorothiazide .. 98
quinidine sulfate ......................... 8
quinine sulfate ............................ 8
QVAR ...................................... 31
RABAVERT .......................... 112
rabeprazole sodium ................ 104
raloxifene hcl ............................ 83
ramipril ..................................... 98
RANEXA ................................ 102
ranitidine hcl ........................... 104
RAPAFLO ................................ 90
RAPAMUNE ............................ 62
RAVICTI .................................. 66
REBETOL ................................ 11
REBIF .................................. 64,65
REBIF REBIDOSE................... 64
reclipsen .................................... 81
RECOMBIVAX HB ............... 112
RELENZA ................................ 11
RELISTOR ............................. 105
REMICADE.............................. 61
REMODULIN ................. 101,102
RENAGEL ................................ 71
RENVELA ................................ 71
repaglinide ................................ 77
REPREXAIN ............................ 51
RESCRIPTOR .......................... 11
reserpine .................................... 98
RESTASIS .............................. 108
RETIN-A MICRO PUMP ........ 30
RETROVIR .............................. 11
REVATIO ............................... 102
REVLIMID ............................... 23
REXULTI ................................. 42
REYATAZ ................................ 11
RHEUMATREX....................... 23
ribasphere .................................. 11
ribavirin..................................... 11
RIDAURA ................................ 69
rifabutin..................................... 18
rifampin..................................... 18
RIFATER .................................. 18
riluzole ...................................... 35
ringers injection ........................ 72
RIOMET ................................... 77
risedronate sodium .................... 63
risedronate sodium dr................ 63
125
RISPERDAL CONSTA ...... 42,43
risperidone ................................ 43
risperidone odt .......................... 43
RITUXAN ................................ 23
rivastigmine .............................. 88
rizatriptan .................................. 32
ropinirole er .............................. 34
ropinirole hcl ............................ 34
ROTATEQ ............................. 112
ROZEREM ............................... 55
RYTARY ............................. 34,35
SABRIL .................................... 58
SAFYRAL ................................ 82
SAIZEN .................................... 80
SAMSCA.................................. 69
SANDIMMUNE....................... 62
SANTYL .................................. 28
SAPHRIS .................................. 43
SAVAYSA ............................... 68
SAVELLA ................................ 35
SAVELLA TITRATION
PACK ....................................... 35
selegiline hcl ............................. 43
SELZENTRY ........................... 11
SEMPREX-D ........................... 85
SENSIPAR ............................... 66
SEREVENT DISKUS .............. 87
sertraline hcl ............................. 43
SFROWASA .......................... 103
SIGNIFOR ................................ 66
SIGNIFOR LAR ....................... 66
sildenafil ................................. 102
SILENOR ................................. 43
silver sulfadiazine ..................... 29
SIMBRINZA .......................... 107
SIMCOR ................................... 93
SIMPONI ............................. 61,62
SIMPONI ARIA ....................... 61
simvastatin ................................ 93
sirolimus ................................... 62
SIRTURO................................... 7
SIVEXTRO .............................. 18
sodium chloride ........................ 72
sodium fluoride ...................... 113
sodium lactate........................... 69
sodium phenylbutyrate ............. 71
sodium polystyrene sulfonate... 71
SOLODYN............................... 18
SOLTAMOX ........................... 23
SOMATULINE DEPOT .......... 66
SOMAVERT ............................ 80
sorine ........................................ 90
sotalol ....................................... 90
sotalol af ................................... 90
SOVALDI ................................ 11
SPIRIVA .................................. 85
SPIRIVA RESPIMAT ............. 85
spironolactone .......................... 98
spironolactone-hctz .................. 99
SPORANOX .............................. 8
sprintec ..................................... 82
SPRYCEL ........................... 23,24
sronyx ....................................... 82
ssd............................................. 29
stavudine .................................. 11
STELARA ................................ 28
STIMATE ................................ 67
STIOLTO RESPIMAT ............ 85
STIVARGA ............................. 24
STRATTERA...................... 35,36
streptomycin sulfate ................. 18
STRIBILD ................................ 11
SUBOXONE ............................ 51
SUCRAID ................................ 73
sucralfate ................................ 104
sulfacetamide sodium ........ 29,109
sulfacetamide-prednisolone.... 109
sulfadiazine .............................. 18
sulfamethoxazoletrimethoprim............................. 18
sulfasalazine............................ 103
sulfazine ec ............................. 103
sulindac ..................................... 51
sumatriptan ............................... 32
sumatriptan succinate........... 32,33
SUPRAX .................................. 18
SUPREP.................................. 105
SURMONTIL ........................... 43
SUSTIVA ................................. 11
SUTENT ................................... 24
SYLATRON ............................. 24
SYMBICORT ........................... 87
SYMLINPEN 120 .................... 77
SYMLINPEN 60 ...................... 77
SYNAGIS ................................. 18
SYNALGOS-DC ...................... 51
SYNAREL ................................ 83
SYNERA .................................. 30
SYNERCID .............................. 18
SYNRIBO ................................. 24
SYNTHROID ...................... 78,79
SYPRINE.................................. 66
TABLOID ................................. 24
TACLONEX ............................. 27
tacrolimus ............................ 28,62
TAFINLAR............................... 24
TAMIFLU................................. 11
tamoxifen citrate ....................... 24
tamsulosin hcl ........................... 91
TANZEUM ............................... 77
TARCEVA ............................... 24
TARGRETIN............................ 24
TASIGNA ................................. 24
TAZORAC ............................... 28
taztia xt...................................... 99
TECFIDERA ............................ 65
TECFIDERA STARTER
PACK........................................ 65
TECHNIVIE ............................. 11
TEFLARO ........................... 18,19
126
TEGRETOL XR ...................... 58
TEKTURNA ............................ 99
TEKTURNA HCT ................... 99
telmisartan ................................ 99
telmisartan-amlodipine............. 99
telmisartanhydrochlorothiazid ................... 99
temazepam ............................... 60
TENIVAC .............................. 111
terazosin hcl ............................. 91
terbinafine hcl ............................ 8
terbutaline sulfate ..................... 87
terconazole ............................... 29
0.4% ......................................... 29
0.8% ......................................... 29
testosterone.......................... 79,80
testosterone cypionate .............. 79
testosterone enanthate .............. 79
tetanus diphtheria toxoids ...... 111
tetrabenazine ............................ 36
THALOMID ............................ 65
theophylline ............................ 111
theophylline anhydrous ... 110,111
thioridazine hcl ......................... 44
thiotepa ..................................... 24
thiothixene................................ 44
tiagabine hcl ............................. 58
ticlopidine hcl ........................... 68
TIKOSYN .............................. 102
timolol maleate.................. 91,107
TIMOPTIC OCUDOSE ......... 107
tinidazole .................................... 8
TIVICAY ................................. 11
tizanidine hcl ............................ 88
TOBI PODHALER .................. 19
TOBRADEX .......................... 109
TOBRADEX ST .................... 109
tobramycin ............................. 109
tobramycin 300 mg/5 ml
ampule ...................................... 19
tobramycin sulfate .................... 19
tobramycin sulfate in ns ........... 19
tobramycin-dexamethasone.... 109
TOBREX ................................ 109
tolazamide ................................ 78
tolbutamide............................... 78
tolcapone .................................. 35
tolmetin sodium........................ 51
tolterodine tartrate .................. 110
tolterodine tartrate er .............. 110
topiramate............................ 58,59
topiramate er............................. 58
toposar ...................................... 24
topotecan hcl ............................ 24
TORISEL ................................. 24
torsemide .................................. 99
TOUJEO SOLOSTAR ............. 78
TOVIAZ ................................. 110
tpn electrolytes ......................... 72
TRACLEER ........................... 102
TRADJENTA........................... 78
tramadol hcl .............................. 52
tramadol hcl er..................... 51,52
tramadol hcl-acetaminophen .... 52
trandolapril ............................... 99
trandolapril-verapamil er .......... 99
tranexamic acid ...................... 110
tranylcypromine sulfate............ 44
TRAVASOL ............................ 70
travoprost ............................... 107
trazodone hcl ............................ 44
TREANDA............................... 24
TRECATOR............................... 7
TRELSTAR ............................. 24
tretinoin ............................... 24,30
tretinoin microsphere ............... 30
TRETIN-X ............................... 30
TREXALL ............................... 24
triamcinolone acetonide ...... 27,31
triamterenehydrochlorothiazid ................... 99
triamterenehydrochlorothiazide .................. 99
triazolam ................................... 60
TRIBENZOR .......................... 100
trifluoperazine hcl ..................... 44
trifluridine ............................... 109
trihexyphenidyl hcl ................... 85
tri-legest fe ................................ 82
trilyte with flavor packets ....... 105
trimethoprim ............................... 7
trinessa ...................................... 82
tri-previfem ............................... 82
TRISENOX............................... 24
tri-sprintec ................................. 82
TRIUMEQ ................................ 12
trivora-28 .................................. 82
TROKENDI XR ....................... 59
TROPHAMINE ........................ 70
trospium chloride .................... 110
trospium chloride er ................ 110
TRULICITY ............................. 78
TRUMENBA .......................... 112
TRUVADA ............................... 12
TUDORZA PRESSAIR............ 85
TWINRIX ............................... 112
TYBOST ................................... 12
TYGACIL ................................. 19
TYKERB .................................. 24
TYPHIM VI ............................ 112
TYSABRI ................................. 65
TYVASO ................................ 102
TYZEKA .................................. 12
TYZINE .................................. 110
UCERIS .................................. 103
ULORIC ................................... 60
ULTRESA .............................. 106
unithroid .................................... 79
ursodiol ................................... 104
VAGIFEM ................................ 83
valacyclovir............................... 12
127
VALCHLOR............................. 12
VALCYTE................................ 12
valganciclovir hcl...................... 12
valproate sodium ....................... 59
valproic acid.............................. 59
valsartan .................................. 100
valsartanhydrochlorothiazide ................ 100
vancomycin hcl ......................... 19
vandazole .................................. 29
VAQTA .................................. 112
VARIVAX VACCINE ........... 112
VASCEPA ................................ 93
VELCADE................................ 24
velivet ....................................... 82
VELPHORO ............................. 71
VELTIN .................................... 30
venlafaxine hcl .......................... 44
venlafaxine hcl er ...................... 44
VENTAVIS ............................ 102
VENTOLIN HFA ..................... 87
VERAMYST ............................ 31
verapamil er ............................ 100
verapamil er pm ...................... 100
verapamil hcl .......................... 100
VERIPRED 20 .......................... 74
VERSACLOZ ........................... 44
VESICARE ............................. 110
VEXOL ................................... 108
VICTOZA 3-PAK .................... 78
VIDEX ...................................... 12
VIEKIRA PAK ......................... 12
VIGAMOX ............................. 109
VIIBRYD.................................. 44
VIMOVO .................................. 52
VIMPAT ................................... 59
vinblastine sulfate ..................... 24
vincasar pfs ............................... 24
vincristine sulfate ...................... 25
vinorelbine tartrate .................... 25
VIOKACE .............................. 106
VIRACEPT .............................. 12
VIRAMUNE XR ...................... 12
VIRAZOLE .............................. 12
VIREAD................................... 12
VITEKTA ................................ 12
VOLTAREN ............................ 52
voriconazole ............................... 8
VOTRIENT .............................. 25
VPRIV ...................................... 73
VYVANSE............................... 54
warfarin sodium ....................... 68
WELCHOL .............................. 93
XALKORI ................................ 25
XARELTO ............................... 68
XELJANZ ................................ 62
XENAZINE.............................. 36
XGEVA .................................... 63
XIFAXAN ................................ 19
XOLAIR ................................... 32
XOPENEX HFA ...................... 87
XTANDI .................................. 25
XULANE ................................. 82
XYREM ................................... 36
YF-VAX................................. 112
zafirlukast ................................. 31
zaleplon .................................... 55
ZANOSAR ............................... 25
ZAVESCA ............................... 66
ZEGERID ............................... 104
ZELAPAR ................................ 44
ZELBORAF ............................. 25
ZEMAIRA ............................... 32
zenchent fe ............................... 83
ZENPEP ................................. 106
ZETIA ...................................... 93
ZETONNA ............................... 31
ZIAGEN ................................... 12
ZIANA ..................................... 29
zidovudine ................................ 12
ziprasidone hcl .......................... 44
ZIRGAN ................................. 110
ZMAX ...................................... 19
zoledronic acid ......................... 64
ZOLINZA ................................. 25
zolmitriptan .............................. 33
zolmitriptan odt ........................ 33
zolpidem tartrate ....................... 55
zolpidem tartrate er ................... 55
ZOLPIMIST ............................. 55
ZOMETA ................................. 64
ZOMIG ..................................... 33
ZONALON ............................... 30
zonisamide ................................ 59
ZONTIVITY ............................ 68
ZORTRESS .............................. 62
ZOSTAVAX .......................... 113
ZOSYN ..................................... 19
zovia 1-35e ............................... 82
ZOVIA 1-50E ........................... 82
ZOVIRAX ................................ 29
ZUBSOLV................................ 52
ZYCLARA ............................... 28
ZYDELIG ................................. 25
ZYFLO CR ............................... 32
ZYKADIA ................................ 25
ZYLET ................................... 110
ZYPREXA RELPREVV .......... 44
ZYTIGA ................................... 25
ZYVOX .................................... 19
128
Este formulario fue actualizado el 1 de noviembre de 2015. 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
y 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 Cobro revertido
Usuarios de TTY: 711
selecthealthadvantage.org

formulario completo - SelectHealth Advantage

Transcrição

Documentos relacionados

Presidente Municipal Modificación

formulario completo - SelectHealth Advantage

formulario completo - SelectHealth Advantage

Hibridación de sondas de DNA LIVe en cortes de tejidos

Nombre del medicamento Posología Vía de administración

Nombre del medicamento Posología Vía de administración