formulario completo - SelectHealth Advantage

Transcrição

2014
FORMULARIO COMPLETO
Lista de Medicamentos Cubiertos
Este formulario fue actualizado el 1 de noviembre de 2014. 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 2014
(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.
H1994_2395R_FINAL_C_SP_v24 Aceptado
HPMS Aprobado Número de Identificación del Sumisión de Archivo 14000 Versión 24
i
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 2014. 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 2015.
¿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 2014 que se cubría al inicio del año, no
vamos a descontinuar ni reducir la cobertura del medicamento durante la cobertura del año 2014 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 2014. Para obtener un formulario más actual,
ii
por favor contacte con nosotros. Nuestra información de contacto, junto con la fecha que en que última
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 1. 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 p 1. 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 97. 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 Diovan. 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
iii
Advantage puede no cubrir el Medicamento B salvo que primero pruebe el Medicamento A. Si el
Medicamento A no funciona en usted, SelectHealth Advantage no cubrirá el Medicamento B.
Para averiguar si su medicamento tiene algún requisito o límite adicional, busque en el formulario que comienza
en la página 1. 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 que en que
última 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 iv 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, 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
iv
médico que emite la receta. Puede solicitar una excepción urgente (rápida) si usted o su médico consideran que su
salud podría verse gravemente afectada si espera una decisión hasta 72 horas. Si se otorga su solicitud de
excepción urgente, debemos comunicarle una decisión antes de las 24 horas tras la recepción de la declaración de
respaldo de quien emite la receta o el médico.
¿Qué debo hacer antes de hablar con mi médico acerca de cambiar mis medicamentos
o solicitar una excepción?
Como miembro nuevo o permanente de nuestro plan puede que esté tomando medicamentos que no formen
parte de nuestro formulario. O bien, puede 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 que en que última 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/TDD
deben llamar al 1-877-486-2048. O, visite www.medicare.gov.
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Formulario de SelectHealth Advantage
El formulario que comienza en la proxima página proporciona información de cobertura acerca de algunos de los
medicamentos que cubre SelectHealth Advantage. Si tiene problemas para encontrar su medicamento en la lista,
vaya al Índice que comienza en la página 97.
En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca están en
mayúscula (por ejemplo, CELEBREX) 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
Servicio del Área de Wasatch – incluye los condados de Utah: Davis, Morgan, Salt Lake, Utah, y Weber
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
$9.00
Nivel 3: Marca Preferida
$45.00
Nivel 4: Marca No Preferida
$95.00
Nivel 5: Especialidad
33% coseguro
All Other Service Areas – includes the Utah counties of Iron and Washington, and Idaho counties of Ada,
Boise, Canyon, Cassia, Jerome, Minidoka, and Twin Falls
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
$7.00
Nivel 3: Marca Preferida
$45.00
Nivel 4: Marca No Preferida
$95.00
Nivel 5: Especialidad
33% coseguro
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La información en la columna Requisitos/Límites le indica si SelectHealth Advantage tiene algún requisito
parcial de cobertura de 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 (llamada
gratuita). Los usuarios de TTY deben llamar al 711.
NM– Este medicamento no está disponible a través de nuestra farmacia de pedido por correo.
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Esta página dejada en blanco intencionadamente
viii
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
AGENTES ANTIINFECTIVOS
ANTIHELMÍNTICOS
ALBENZA TABLET 200MG
3
BILTRICIDE TABLET
4
600MG
STROMECTOL TABLET
4
3MG
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
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
pyrazinamide tablet 500mg
2
SIRTURO TABLET 100MG
4
LC 188 cada 30 dia(s)
TRECATOR TABLET
4
250MG
ANTIONGO (SISTÉMICA)
AMBISOME FOR
4
SUSPENSION 50MG
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
LC; AP; NM
NM
AP; NM
/Límites
amphotericin b for solution
50mg
CANCIDAS FOR
SOLUTION 50MG
CANCIDAS FOR
SOLUTION 70MG
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
ketoconazole tablet 200mg
LAMISIL PACKET 125MG
LAMISIL PACKET 187.5MG
NOXAFIL SUSPENSION 200
MG/5 ML (40 MG/ML)
NOXAFIL TABLET DR
100MG
2
AP; NM
5
AP; NM
5
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
2
4
4
NM
NM
NM
4
NM
4
LC; NM
AP – Autorización Previa
LC – Límites de Cantidad
TE – Terapia en Etapas
AL – Acceso Limitado
NM – No-mantenimiento
1
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
FLAGYL ER TABLET ER
24HR 750MG
hydroxychloroquine sulfate
tablet 200mg
metronidazole capsule 375mg
metronidazole tablet 250mg
metronidazole tablet 500mg
NEBUPENT FOR
SOLUTION 300MG
primaquine tablet 26.3mg
quinidine sulfate tablet 200mg
quinidine sulfate tablet 300mg
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
4
NM
2
NM
2
2
2
NM
NM
NM
4
AP; NM
2
2
2
NM
NM
NM
/Límites
quinidine sulfate tablet er
2
300mg
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
acyclovir suspension 200 mg/5
2
ml
acyclovir tablet 400mg
2
acyclovir tablet 800mg
2
adefovir dipivoxil tablet 10mg
2
amantadine capsule 100mg
2
amantadine syrup 50 mg/5 ml
2
amantadine tablet 100mg
2
APTIVUS CAPSULE 250MG
3
APTIVUS SOLUTION 100
3
MG/ML
ATRIPLA TABLET 600-2003
300MG
BARACLUDE SOLUTION
4
0.05 MG/ML
BARACLUDE TABLET
4
0.5MG
BARACLUDE TABLET
4
1MG
cidofovir solution 75 mg/ml
2
COMPLERA TABLET 2003
25-300MG
CRIXIVAN CAPSULE
3
200MG
NM
NM
NM
NM
NM
NM
NM
AP; NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
NM
AP; NM
NM
NM
2
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
CRIXIVAN CAPSULE
400MG
didanosine capsule dr 125mg
EDURANT TABLET 25MG
EMTRIVA CAPSULE
200MG
EMTRIVA SOLUTION 10
MG/ML
EPIVIR HBV SOLUTION 25
MG/5 ML (5 MG/ML)
EPIVIR SOLUTION 10
MG/ML
EPZICOM TABLET 600300MG
famciclovir tablet 125mg
FUZEON FOR SOLUTION
90MG
ganciclovir sodium for
solution 500mg
INCIVEK TABLET 375MG
INTELENCE TABLET
100MG
INTELENCE TABLET
200MG
INTELENCE TABLET 25MG
INTRON A FOR SOLUTION
10 MILLION UNIT (1 ML)
INTRON A SOLUTION 6
MILLION UNIT/ML
INVIRASE CAPSULE
200MG
3
NM
2
2
2
2
3
NM
NM
NM
NM
NM
3
NM
3
NM
3
NM
3
NM
3
NM
2
2
2
NM
NM
NM
5
LC; NM
2
AP; NM
5
AP; NM
3
NM
3
NM
3
NM
5
NM
5
NM
3
NM
/Límites
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 hbv tablet 100mg
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
PEGASYS PROCLICK
SOLUTION 135 MCG/0.5
ML
LC 4 mililitro(s) cada 30 dia(s)
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
2
3
NM
NM
3
NM
3
NM
5
LC; AP; NM
5
LC; AP; NM
3
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
PEGASYS SOLUTION 180
MCG/0.5 ML
PEGASYS SOLUTION 180
MCG/ML
PREZISTA SUSPENSION
100 MG/ML
PREZISTA TABLET 150MG
REBETOL SOLUTION 40
MG/ML
RELENZA AERO POW BR
ACT 5MG
RESCRIPTOR TABLET
100MG
RESCRIPTOR TABLET
200MG
RETROVIR SOLUTION 10
MG/ML
REYATAZ CAPSULE
100MG
REYATAZ CAPSULE
150MG
REYATAZ CAPSULE
200MG
REYATAZ CAPSULE
300MG
ribasphere capsule 200mg
ribasphere tablet 200mg
ribavirin capsule 200mg
ribavirin tablet 200mg
SELZENTRY TABLET
150MG
SELZENTRY TABLET
300MG
5
LC; AP; NM
5
LC; AP; NM
3
NM
3
3
3
3
NM
NM
NM
NM
4
NM
4
LC; NM
3
NM
3
NM
3
NM
3
NM
3
NM
3
NM
3
NM
2
LC; NM
2
NM
2
LC; NM
2
NM
3
NM
3
NM
/Límites
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)
TIVICAY TABLET 50MG
TRUVADA TABLET 200300MG
TYZEKA TABLET 600MG
valacyclovir tablet 1,000mg
valacyclovir tablet 500mg
VALCYTE FOR SOLUTION
50 MG/ML
VALCYTE TABLET 450MG
VICTRELIS CAPSULE
200MG
5
LC; AP; NM
2
2
2
2
2
NM
NM
NM
NM
NM
5
NM
3
3
3
NM
NM
NM
4
LC; NM
4
LC; NM
4
LC; NM
4
LC; NM
3
LC; NM
3
NM
4
NM
2
LC; NM
2
LC; NM
4
NM
4
NM
5
LC; AP; NM
4
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
VIDEX FOR SOLUTION 10
MG/ML (FINAL
CONCENTRATION)
VIRACEPT TABLET 250MG
VIRACEPT TABLET 625MG
VIRAMUNE XR TABLET
ER 24HR 100MG
VIREAD POWDER 40
MG/SCOOP (40 MG/GRAM)
VIREAD TABLET 150MG
VIREAD TABLET 200MG
VIREAD TABLET 250MG
VIREAD TABLET 300MG
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
3
NM
3
3
NM
NM
3
NM
3
NM
3
LC; NM
3
LC; NM
3
LC; NM
3
NM
3
NM
2
2
2
NM
NM
NM
2
AP; NM
2
NM
2
NM
2
NM
2
NM
/Límites
tablet 250-125mg
tablet 500-125mg
tablet 875-125mg
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
2
NM
2
NM
2
NM
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
5
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ampicillin trihydrate capsule
500mg
ampicillin trihydrate for
suspension 125 mg/5 ml
ampicillin trihydrate for
ampicillin-sulbactam for
solution 15 gram
ampicillin-sulbactam for
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
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
600,000 UNIT/ML
CEDAX CAPSULE 400MG
2
NM
2
NM
2
NM
2
AP; NM
2
AP; NM
2
AP; NM
2
NM
2
NM
2
2
2
2
2
NM
NM
NM
NM
NM
4
NM
4
NM
4
NM
4
NM
4
NM
4
NM
/Límites
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
cefotaxime sodium for solution
1 gram
10 gram
2 gram
500mg
cefpodoxime proxetil for
cefpodoxime proxetil for
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
AP; NM
2
AP; NM
2
NM
2
NM
6
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
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
2
NM
2
NM
2
NM
2
NM
2
2
NM
NM
2
NM
2
NM
4
4
NM
2
AP; NM
2
AP; NM
2
2
2
AP; NM
AP; NM
AP; NM
2
AP; NM
2
AP; NM
2
AP; NM
2
2
2
NM
NM
NM
/Límites
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
CIPRO FOR SUSPENSION
250 MG/5 ML
CIPRO FOR SUSPENSION
500 MG/5 ML
ciprofloxacin er tablet er 24hr
1,000mg
ciprofloxacin er tablet er 24hr
500mg
ciprofloxacin for suspension
250 mg/5 ml
ciprofloxacin for suspension
500 mg/5 ml
ciprofloxacin hcl tablet 100mg
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
2
NM
2
NM
2
NM
2
2
NM
NM
2
AP; NM
4
NM
4
NM
2
NM
2
NM
2
NM
2
NM
2
2
2
2
NM
NM
NM
NM
2
AP; NM
2
AP; NM
2
NM
2
NM
7
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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 sodium for
solution 150mg
DARAPRIM TABLET 25MG
dicloxacillin sodium capsule
250mg
dicloxacillin sodium capsule
500mg
DIFICID TABLET 200MG
doxycycline hyclate capsule
100mg
doxycycline hyclate capsule
50mg
doxycycline hyclate for
solution 100mg
doxycycline hyclate tablet
100mg
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
4
NM
2
NM
2
NM
4
LC; AP; NM
2
NM
2
NM
2
AP; NM
2
NM
/Límites
doxycycline hyclate tablet
20mg
doxycycline hyclate tablet dr
100mg
150mg
75mg
doxycycline monohydrate
capsule 75mg
doxycycline monohydrate for
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
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
8
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
gentamicin sulfate in ns
gentamicin sulfate solution 40
mg/ml
gentamicin sulfate solution 80
mg/8 ml
INVANZ FOR SOLUTION 1
GRAM
KETEK TABLET 300MG
KETEK TABLET 400MG
lansoprazol-amoxicil-clarithro
misc 30-500-500mg
levofloxacin solution 25 mg/ml
levofloxacin tablet 250mg
levofloxacin-d5w solution 500
mg/100 ml
meropenem for solution
500mg
metronidazole solution 500
mg/100 ml
minocycline hcl capsule
100mg
minocycline hcl capsule 50mg
minocycline hcl capsule 75mg
minocycline hcl tablet 100mg
2
AP; NM
2
AP; NM
2
NM
2
AP; NM
2
NM
2
NM
2
AP; NM
2
AP; NM
4
NM
4
4
NM
NM
2
NM
2
2
2
2
AP; NM
NM
NM
NM
2
AP; NM
2
NM
2
AP; NM
2
NM
2
2
2
NM
NM
NM
/Límites
minocycline hcl tablet er 24hr
135mg
45mg
90mg
moxifloxacin hcl tablet 400mg
nafcillin sodium for solution 1
gram
nafcillin sodium for solution
10 gram
NAFCILLIN SOLUTION 1
GRAM/50 ML
NOROXIN TABLET 400MG
ofloxacin tablet 200mg
ORACEA CAPSULE DR
40MG
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
penicillin g sodium for
solution 5 million unit
penicillin gk-iso-osm dextrose
solution 2 million unit/50 ml
2
2
NM
NM
2
LC; NM
2
LC; NM
2
LC; NM
2
NM
2
AP; NM
2
AP; NM
2
AP; NM
4
2
2
2
NM
NM
NM
NM
4
NM
2
NM
4
4
NM
2
AP; NM
2
AP; NM
2
AP; NM
2
AP; NM
9
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
PRIFTIN TABLET 150MG
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)
SOLODYN TABLET ER
24HR 105MG
SOLODYN TABLET ER
24HR 115MG
2
AP; NM
2
NM
2
NM
2
NM
2
NM
4
AP; NM
2
AP; NM
2
AP; NM
4
NM
4
NM
2
2
2
2
NM
NM
NM
NM
4
NM
4
LC; AP; NM
4
LC; AP; NM
4
4
LC; AP; NM
LC; AP; NM
/Límites
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
sulfasalazine tablet 500mg
sulfazine ec tablet dr 500mg
SUPRAX CAPSULE 400MG
SUPRAX FOR SUSPENSION
100 MG/5 ML
200 MG/5 ML
500 MG/5 ML
SUPRAX TABLET 400MG
SUPRAX TABLET
CHEWABLE 100MG
SUPRAX TABLET
CHEWABLE 200MG
TOBI PODHALER
CAPSULE 28MG
tobramycin nebulized soln 300
mg/5 ml
tobramycin sulfate in ns
2
AP; NM
2
NM
2
AP; NM
2
NM
2
NM
2
NM
2
2
NM
NM
4
LC; NM
4
NM
4
NM
4
NM
4
LC; NM
4
LC; NM
4
LC; NM
5
AP; NM
5
AP; NM
2
AP; NM
10
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
tobramycin sulfate solution 10
2 AP; NM
mg/ml
tobramycin sulfate solution 40
2 AP; NM
mg/ml
vancomycin hcl capsule 125mg
2 LC; NM
vancomycin hcl capsule 250mg
2 LC; NM
vancomycin hcl for solution 1
2 AP; NM
gram
vancomycin hcl for solution 10
2 AP; NM
gram
vancomycin hcl for solution
2 AP; NM
500mg
XIFAXAN TABLET 200MG
4 LC; AP; NM
XIFAXAN TABLET 550MG
4 LC; AP; NM
ZMAX FOR SUSPENSION 2
4 NM
GRAM/60 ML
ZOSYN SOLUTION 2.25
4 AP; NM
GRAM/50 ML
ZOSYN SOLUTION 3.375
4 AP; NM
GRAM/50 ML
ZYVOX FOR SUSPENSION
4 NM
100 MG/5 ML
ZYVOX SOLUTION 600
4 AP; NM
MG/300 ML
ZYVOX TABLET 600MG
4 NM
AGENTES ANTINEOPLASTICOS
AGENTES ANTINEOPLASTICOS
AFINITOR DISPERZ
TABLET SOLUBLE 2MG
5 LC; AP
AFINITOR DISPERZ
TABLET SOLUBLE 3MG
5 LC; AP
/Límites
AFINITOR DISPERZ
TABLET SOLUBLE 5MG
AFINITOR TABLET 10MG
AFINITOR TABLET 2.5MG
AFINITOR TABLET 5MG
AFINITOR TABLET 7.5MG
ALIMTA FOR SOLUTION
500MG
anastrozole tablet 1mg
ARRANON SOLUTION 250
MG/50 ML
ARZERRA CONCENTRATE
100 MG/5 ML
AVASTIN SOLUTION 25
MG/ML
azacitidine for suspension
100mg
BELEODAQ FOR
SOLUTION 500MG
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
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
2
LC
5
AP
5
AP
5
AP
5
AP
5
LC; AP
2
4
AP
2
AP
5
5
AP
AP
5
AP
4
LC; AP
11
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
cyclophosphamide tablet 25mg
cyclophosphamide tablet 50mg
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
4
LC; AP
2
2
AP
AP
5
AP
5
AP
5
AP
5
AP
5
AP
2
2
2
2
2
AP
2
AP
2
AP
5
AP
5
AP
5
AP
2
AP
4
4
/Límites
ELIGARD KIT 22.5MG
ELIGARD KIT 30MG
ELIGARD KIT 7.5MG
EMCYT CAPSULE 140MG
epirubicin hcl solution 50
mg/25 ml
ERBITUX SOLUTION 100
MG/50 ML
ERIVEDGE CAPSULE
150MG
ERWINAZE FOR
SOLUTION 10,000 UNIT
etoposide solution 20 mg/ml
exemestane tablet 25mg
FARESTON TABLET 60MG
FASLODEX SOLUTION 250
MG/5 ML
FIRMAGON FOR
SOLUTION 120MG
FIRMAGON FOR
SOLUTION 80MG
fludarabine phosphate for
solution 50mg
fluorouracil solution 2 %
fluorouracil solution 2.5
gram/50 ml
fluorouracil solution 5 %
flutamide capsule 125mg
FOLOTYN SOLUTION 40
MG/2 ML (20 MG/ML)
GILOTRIF TABLET 20MG
4
4
4
4
3
AP
AP
AP
2
AP
5
AP
5
LC; AP
5
AP
2
AP
2
LC
4
5
AP
5
AP
4
AP
2
AP
2
2
AP
2
2
5
AP
5
LC; AP
5
LC; AP
12
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
GLEEVEC TABLET 100MG
GLEEVEC TABLET 400MG
HALAVEN SOLUTION 1
MG/2 ML (0.5 MG/ML)
HERCEPTIN FOR
SOLUTION 440MG
HEXALEN CAPSULE 50MG
hydroxyurea capsule 500mg
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 (FINAL
CONCENTRATION)
5
LC; AP
3
LC
3
LC
5
AP
5
AP
3
2
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
/Límites
KADCYLA FOR SOLUTION
100MG
letrozole tablet 2.5mg
LEUKERAN TABLET 2MG
leuprolide acetate kit 1 mg/0.2
ml
lomustine capsule 100mg
LUPRON DEPOT KIT
22.5MG
LUPRON DEPOT KIT
3.75MG
LUPRON DEPOT KIT 30MG
LUPRON DEPOT-PED KIT
7.5MG
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 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
5
AP
2
LC
3
2
2
2
2
5
AP
5
AP
5
AP
5
AP
3
3
3
2
2
2
5
LC; AP
5
LC; AP
5
AP
2
2
AP
13
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
methotrexate tablet 2.5mg
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
OTREXUP 10 MG/0.4 ML
AUTO-INJ
LC 1.6 mililitro(s) cada 28
dia(s)
AUTO-INJ
dia(s)
AUTO-INJ
dia(s)
AUTO-INJ
dia(s)
oxaliplatin solution 100 mg/20
ml (5 mg/ml)
paclitaxel concentrate 6 mg/ml
POMALYST CAPSULE 1MG
2
2
AP
2
AP
4
AP
5
LC; AP
3
5
4
4
AP
LC; AP; TE
LC; AP; TE
4
LC; AP; TE
4
LC; AP; TE
5
AP
2
AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
/Límites
PROLEUKIN FOR
SOLUTION 22 MILLION
UNIT
REVLIMID CAPSULE 10MG
REVLIMID CAPSULE
2.5MG
RHEUMATREX TABLET
2.5MG
RITUXAN CONCENTRATE
10 MG/ML
SOLTAMOX SOLUTION 10
MG/5 ML
SPRYCEL TABLET 100MG
SPRYCEL TABLET 140MG
SPRYCEL TABLET 20MG
SPRYCEL TABLET 50MG
SPRYCEL TABLET 70MG
SPRYCEL TABLET 80MG
STIVARGA TABLET 40MG
SUTENT CAPSULE 12.5MG
SUTENT CAPSULE 25MG
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
5
LC; AP
5
LC; AP
5
AP
5
LC; AP
5
LC; AP
14
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
SUTENT CAPSULE 37.5MG
SUTENT CAPSULE 50MG
SYLATRON KIT 296 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
TASIGNA CAPSULE 150MG
TASIGNA CAPSULE 200MG
toposar solution 20 mg/ml
topotecan hcl for solution 4mg
TORISEL SOLUTION 30
MG/3 ML (10 MG/ML)
(FINAL CONCENTRATION)
5
LC; AP
5
LC; AP
5
5
5
AP
AP
AP
5
AP
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
5
AP
AP
5
AP
/Límites
TREANDA FOR SOLUTION
100MG
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
VECTIBIX SOLUTION 100
MG/5 ML (20 MG/ML)
VELCADE FOR SOLUTION
3.5MG
vinblastine sulfate solution 1
mg/ml
VINCASAR SULFATE
SOLUTION 1 MG/ML
vincristine sulfate solution 1
mg/ml
vinorelbine tartrate solution
50 mg/5 ml
VOTRIENT TABLET 200MG
XALKORI CAPSULE
200MG
XALKORI CAPSULE
250MG
XTANDI CAPSULE 40MG
ZANOSAR FOR SOLUTION
1 GRAM
5
AP
5
AP
5
AP
5
AP
2
3
3
3
3
5
AP
5
LC; AP; AL
5
AP
5
AP
2
AP
4
AP
2
AP
2
AP
5
5
LC; AP
5
LC; AP
5
AP
4
AP
15
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ZELBORAF TABLET
240MG
4 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
2
cream 0.05 %
2
gel 0.05 %
2
lotion 0.05 %
2
ointment 0.05 %
betamethasone valerate cream
2
0.1 %
betamethasone valerate foam
2
0.12 %
betamethasone valerate lotion
2
0.1 %
betamethasone valerate
2
ointment 0.1 %
/Límites
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 lotion
0.05 %
clobetasol propionate ointment
0.05 %
clobetasol propionate
shampoo 0.05 %
clobetasol propionate solution
0.05 %
CLOBEX LIQUID 0.05 %
CLODERM CREAM 0.1 %
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 %
2
4
2
2
2
2
2
2
2
4
4
2
4
3
4
2
2
2
2
2
2
2
2
2
16
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
diflorasone diacetate ointment
0.05 %
fluocinolone acetonide cream
0.01 %
fluocinolone acetonide cream
0.025 %
fluocinolone acetonide oil 0.01
%
fluocinolone acetonide
ointment 0.025 %
fluocinolone acetonide
solution 0.01 %
fluocinonide cream 0.1 %
fluocinonide gel 0.05 %
fluocinonide ointment 0.05 %
fluocinonide solution 0.05 %
fluocinonide-e cream 0.05 %
fluticasone propionate cream
0.05 %
fluticasone propionate lotion
0.05 %
fluticasone propionate
ointment 0.005 %
halobetasol propionate cream
0.05 %
halobetasol propionate
ointment 0.05 %
HALOG CREAM 0.1 %
HALOG OINTMENT 0.1 %
hydrocortisone butyrate cream
0.1 %
hydrocortisone butyrate
ointment 0.1 %
hydrocortisone butyrate
solution 0.1 %
hydrocortisone cream 1 %
hydrocortisone cream 2.5 %
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
/Límites
hydrocortisone enema 100
mg/60 ml
hydrocortisone lotion 2.5 %
hydrocortisone ointment 1 %
hydrocortisone ointment 2.5 %
hydrocortisone valerate
ointment 0.2 %
KENALOG AEROSOL
SOLN 0.147 MG/GRAM
LOCOID LIPOCREAM
CREAM 0.1 %
LOCOID LOTION 0.1 %
lokara 0.05% lotion
LUXIQ FOAM 0.12 %
mometasone furoate cream 0.1
%
mometasone furoate ointment
0.1 %
mometasone furoate solution
0.1 %
OLUX FOAM 0.05 %
PANDEL CREAM 0.1 %
prednicarbate cream 0.1 %
prednicarbate ointment 0.1 %
procto-pak cream 1 %
proctocream-hc cream 2.5 %
proctozone-hc cream 2.5 %
TACLONEX SUSPENSION
0.005 %-0.064 %
triamcinolone acetonide cream
0.025 %
0.1 %
0.5 %
2
2
2
2
2
4
4
4
2
4
2
2
2
4
4
2
2
2
2
2
4
2
2
2
17
Medicamento
Nivel Requisitos
/Límites
triamcinolone acetonide lotion
2
0.025 %
triamcinolone acetonide lotion
2
0.1 %
triamcinolone acetonide
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 %
4
adapalene cream 0.1 %
2
adapalene gel 0.1 %
2
adapalene gel 0.3 %
2
amnesteem capsule 10mg
2
2
2
AZELEX CREAM 20 %
4
calcipotriene cream 0.005 %
2
calcipotriene ointment 0.005
2
%
calcipotriene solution 0.005 %
2
calcitriol ointment 3 mcg/gram 2
CARAC CREAM 0.5 %
4
claravis capsule 10mg
2
Medicamento
Nivel Requisitos
/Límites
2
2
2
CONDYLOX GEL 0.5 %
4
diclofenac sodium gel 3 %
2
DIFFERIN LOTION 0.1 %
4
ELIDEL CREAM 1 %
3 TE
EPIDUO GEL 0.1 %-2.5 %
4
FINACEA GEL 15 %
4
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
PROTOPIC OINTMENT 0.03
3 TE
%
PROTOPIC OINTMENT 0.1
3 TE
%
SANTYL OINTMENT 250
4
UNIT/GRAM
TARGRETIN GEL 1 %
3
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
LC 15 gram(s) cada 30 dia(s)
ZYCLARA CREAM 3.75 %
4 LC
ANTIINFECTIVAS (LA PIEL Y MEMBRANAS
MUCOSAS)
ACANYA GEL 1.2 %-2.5 %
4
acyclovir ointment 5 %
2
18
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
AKNE-MYCIN OINTMENT
2%
ALTABAX OINTMENT 1 %
chlorhexidine gluconate
solution 0.12 %
ciclopirox cream 0.77 %
ciclopirox gel 0.77 %
ciclopirox shampoo 1 %
ciclopirox suspension 0.77 %
CLEOCIN SUPPOSITORY
100MG
CLEOCIN T GEL 1 %
CLINDACIN PAC KIT 1 %
CLINDAGEL GEL 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 %
4
4
2
2
2
2
2
3
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
/Límites
CORTISPORIN CREAM 3.5
MG/GRAM-10,000
UNIT/GRAM-0.5 %
CORTISPORIN OINTMENT
3.5 MG-400 UNIT-5,000
UNIT-10 MG/GRAM
DENAVIR CREAM 1 %
econazole nitrate cream 1 %
ery pad 2 %
erythromycin gel 2 %
erythromycin solution 2 %
erythromycin-benzoyl peroxide
gel 3 %-5 %
EURAX CREAM 10 %
EURAX LOTION 10 %
EXELDERM CREAM 1 %
EXELDERM SOLUTION 1
%
gentamicin sulfate cream 0.1
%
gentamicin sulfate ointment
0.1 %
ketoconazole cream 2 %
ketoconazole foam 2 %
ketoconazole shampoo 2 %
lindane lotion 1 %
lindane shampoo 1 %
mafenide acetate packet 50
gram
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 %
NAFTIN CREAM 1 %
NAFTIN CREAM 2 %
4
4
4
2
2
2
2
2
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
4
2
2
4
4
19
Medicamento
Nivel Requisitos
/Límites
NAFTIN GEL 1 %
4
NAFTIN GEL 2 %
4
neomycin-polymyxin b solution
2
40 mg-200,000 unit/ml
nystatin cream 100,000
2
unit/gram
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 %
OXISTAT CREAM 1 %
4
OXISTAT LOTION 1 %
4
permethrin cream 5 %
2
PHISOHEX LIQUID 3 %
4
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
ULESFIA LOTION 5 %
4
vandazole gel 0.75 %
2
zazole 0.4% vaginal cream
2
zazole 0.8% vaginal cream
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
Medicamento
Nivel Requisitos
/Límites
lidocaine patch 5 % (700
2
mg/patch)
lidocaine-prilocaine cream 2.5
2
%-2.5 %
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 GEL 0.04
4
%
RETIN-A MICRO GEL 0.1 %
4
RETIN-A MICRO PUMP
4
GEL 0.08 %
TRETIN-X 0.05% COMBO
4
PACK
TRETIN-X KIT 0.025 %
4
TRETIN-X KIT 0.1 %
4
tretinoin cream 0.025 %
2
2
2
tretinoin gel 0.01 %
2
tretinoin gel 0.025 %
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
20
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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)
BECONASE AQ
SUSPENSION 42 MCG
budesonide suspension 0.25
mg/2 ml
budesonide suspension 0.5
mg/2 ml
budesonide suspension 32 mcg
cromolyn sodium nebulized
soln 20 mg/2 ml
cromolyn sodium solution 4 %
DYMISTA SUSPENSION
137 MCG-50 MCG/SPRAY
FLOVENT DISKUS AERO
POW BR ACT 100 MCG
FLOVENT DISKUS AERO
POW BR ACT 250 MCG
FLOVENT DISKUS AERO
POW BR ACT 50 MCG
FLOVENT HFA AEROSOL
110 MCG/ACTUATION
3
LC
3
LC
3
LC
3
LC
4
2
AP
2
AP
2
2
AP
2
4
3
LC
LC
3
LC
3
LC
3
LC
/Límites
FLOVENT HFA AEROSOL
220 MCG
FLOVENT HFA AEROSOL
44 MCG
flunisolide solution 25 mcg
(0.025 %)
fluticasone propionate
suspension 50 mcg
montelukast sodium packet
4mg
montelukast sodium tablet
10mg
chewable 4mg
chewable 5mg
NASONEX SUSPENSION 50
MCG
OMNARIS SUSPENSION 50
MCG
PULMICORT FLEXHALER
AERO POW BR ACT 180
MCG/ACTUATION (160
MCG DELIVERED)
LC 2 cada 30 dia(s)
PULMICORT FLEXHALER
AERO POW BR ACT 90
MCG/ACTUATION (80 MCG
DELIVERED)
LC 2 cada 30 dia(s)
3
LC
3
LC
2
2
2
LC
2
LC
2
LC
2
LC
3
4
3
LC
3
LC
21
Medicamento
Nivel Requisitos
/Límites
PULMICORT SUSPENSION
3 AP
1 MG/2 ML
QNASL AEROSOL SOLN 80
MCG/ACTUATION
4 LC
QVAR AEROSOL SOLN 40
MCG
3 LC
QVAR AEROSOL SOLN 80
MCG
3 LC
2
inhaler 55 mcg
VERAMYST SUSPENSION
4
27.5 MCG/ACTUATION
zafirlukast tablet 10mg
2 LC
zafirlukast tablet 20mg
2 LC
ZETONNA AEROSOL SOLN
37 MCG/ACTUATION
4 LC
ZYFLO CR TABLET ER
12HR 600MG
4 LC
AGENTES DEL TRACTO RESPIRATORIO,
MISCELÁNEOS
ARALAST NP FOR
5 AP
SOLUTION 500MG
GLASSIA SOLUTION 1
5 AP
GRAM/50 ML (2 %)
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
Medicamento
Nivel Requisitos
/Límites
BRONCODILATADORES
LUFYLLIN TABLET 200MG 4
LUFYLLIN TABLET 400MG 4
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 tablet
2
300mg
lithium carbonate tablet er
2
300mg
lithium carbonate tablet er
2
450mg
lithium solution 8 meq/5 ml
2
AGENTES ANTIMIGRAÑOSOS
AXERT TABLET 12.5MG
4 LC
LC 9 cada 30 dia(s)
AXERT TABLET 6.25MG
4 LC
LC 9 cada 30 dia(s)
divalproex sodium cap
2
sprinkle 125mg
divalproex sodium er tablet er
2
24hr 250mg
divalproex sodium er tablet er
2
24hr 500mg
divalproex sodium tablet dr
2
250mg
22
Medicamento
Nivel Requisitos
/Límites
FROVA TABLET 2.5MG
naratriptan hcl tablet 1mg
LC 9 cada 30 dia(s)
naratriptan hcl tablet 2.5mg
LC 9 cada 30 dia(s)
rizatriptan tablet 10mg
rizatriptan tablet 5mg
rizatriptan tablet disperse
10mg
rizatriptan tablet disperse 5mg
sumatriptan solution 20mg
sumatriptan solution 5mg
sumatriptan succinate solution
6 mg/0.5 ml
sumatriptan succinate tablet
100mg
25mg
50mg
valproic acid syrup 250 mg/5
ml
zolmitriptan odt tablet
disperse 2.5mg
LC 9 cada 30 dia(s)
zolmitriptan odt tablet
disperse 5mg
LC 9 cada 30 dia(s)
4
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
2
2
2
2
LC
2
LC
Medicamento
Nivel Requisitos
/Límites
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
100mg
250mg
carbidopa-levodopa tablet
2
disperse 10-100mg
2
disperse 25-100mg
2
disperse 25-250mg
carbidopa-levodopaentacapone tablet 12.5-502
200mg
23
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
carbidopa-levodopaentacapone tablet 18.75-75200mg
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 0.75MG
24HR 1.5MG
24HR 2.25MG
24HR 3.75MG
24HR 3MG
24HR 4.5MG
NEUPRO PATCH 24HR 1
MG/24 HOUR
2
2
2
2
2
4
LC
2
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
/Límites
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
ropinirole hcl tablet 0.25mg
ropinirole hcl tablet 0.5mg
ropinirole hcl tablet 1mg
ropinirole hcl tablet er 24hr
12mg
2mg
4mg
4
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
LC
2
LC
2
LC
4
24
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
6mg
2 LC
8mg
2 LC
TASMAR TABLET 100MG
4
AGENTES DE LA FIBROMIALGIA
SAVELLA MISC 12.5 MG
(5)-25 MG (8)-50 MG (42)
3 LC
SAVELLA TABLET 100MG
3 LC
SAVELLA TABLET 12.5MG
3 LC
SAVELLA TABLET 25MG
3 LC
SAVELLA TABLET 50MG
3 LC
AGENTES DEL SISTEMA NERVIOSO
CENTRAL, MISC.
acamprosate calcium tablet dr
2
333mg
carbidopa tablet 25mg
2
NAMENDA SOLUTION 10
3
MG/5 ML
NAMENDA TABLET 10MG
3
NAMENDA TABLET 5 MG
3
(28)-10 MG (21)
NAMENDA TABLET 5MG
3
NAMENDA XR CAPSULE
ER 24HR 14MG
3 LC
NAMENDA XR CAPSULE
ER 24HR 21MG
3 LC
/Límites
NAMENDA XR CAPSULE
ER 24HR 28MG
NAMENDA XR CAPSULE
ER 24HR 7 MG (7)-14 MG
(7)-21 MG (7)-28 MG (7)
NAMENDA XR CAPSULE
ER 24HR 7MG
NUEDEXTA CAPSULE 2010MG
riluzole tablet 50mg
STRATTERA CAPSULE
100MG
STRATTERA CAPSULE
10MG
STRATTERA CAPSULE
18MG
STRATTERA CAPSULE
25MG
STRATTERA CAPSULE
40MG
STRATTERA CAPSULE
60MG
STRATTERA CAPSULE
80MG
XENAZINE TABLET
12.5MG
3
LC
3
LC
3
LC
4
2
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
5
LC; AP
25
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
XENAZINE TABLET 25MG
5 LC; AP
XYREM SOLUTION 500
MG/ML
5 LC; AP; AL
dia(s)
AGENTES PSICOTERAPÉUTICOS
ABILIFY DISCMELT
TABLET DISPERSE 10MG
4 LC; TE
ABILIFY DISCMELT
TABLET DISPERSE 15MG
4 LC; TE
ABILIFY MAINTENA FOR
SUSPENSION 300MG
5 LC
LC 2 cada 28 dia(s)
ABILIFY SOLUTION 1
MG/ML
4 LC
dia(s)
ABILIFY SOLUTION 9.75
4
MG/1.3 ML
ABILIFY TABLET 10MG
4 LC; TE
ABILIFY TABLET 15MG
4 LC; TE
ABILIFY TABLET 20MG
4 LC; TE
ABILIFY TABLET 2MG
4 LC; TE
ABILIFY TABLET 30MG
4 LC; TE
ABILIFY TABLET 5MG
4 LC; TE
amitriptyline hcl tablet 100mg
2
2
/Límites
amoxapine tablet 100mg
APLENZIN TABLET ER
24HR 174MG
APLENZIN TABLET ER
24HR 348MG
APLENZIN TABLET ER
24HR 522MG
BRINTELLIX TABLET
10MG
BRINTELLIX TABLET
20MG
BRINTELLIX TABLET 5MG
budeprion sr tablet er 12hr
150mg
buproban tablet er 12hr
150mg
bupropion hcl sr tablet er 12hr
100mg
150mg
200mg
bupropion hcl tablet 100mg
2
2
2
2
2
2
2
2
4
LC; TE
4
LC; TE
4
LC; TE
4
TE
4
TE
4
TE
2
2
2
2
2
2
26
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
bupropion hcl tablet 75mg
bupropion xl tablet er 24hr
150mg
bupropion xl tablet er 24hr
300mg
chlordiazepoxide-amitriptyline
tablet 12.5-5mg
chlordiazepoxide-amitriptyline
tablet 25-10mg
chlorpromazine hcl solution 25
mg/ml
chlorpromazine hcl tablet
100mg
10mg
200mg
25mg
50mg
citalopram hbr solution 10
mg/5 ml
citalopram hbr tablet 10mg
clomipramine hcl capsule
25mg
50mg
75mg
2
2
LC
2
LC
2
AP
2
AP
2
AP
2
2
2
2
2
2
2
LC
2
LC
2
LC
2
2
2
/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
EMSAM PATCH 24HR 6
MG/24 HOUR
2
LC
2
LC
2
LC
2
LC
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
27
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
FAZACLO TABLET
DISPERSE 100MG
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
4
LC
/Límites
FAZACLO TABLET
DISPERSE 12.5MG
FAZACLO TABLET
DISPERSE 150MG
FAZACLO TABLET
DISPERSE 200 MG
FAZACLO TABLET
DISPERSE 25MG
FETZIMA 20-40 MG
TITRATION PAK
FETZIMA CAPSULE ER
24HR 120MG
FETZIMA CAPSULE ER
24HR 20MG
FETZIMA CAPSULE ER
24HR 40MG
FETZIMA CAPSULE ER
24HR 80MG
fluoxetine dr capsule dr 90mg
LC 4 cada 28 dia(s)
fluoxetine hcl capsule 10mg
fluoxetine hcl solution 20 mg/5
ml
4
LC
4
LC
4
LC
4
LC
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
2
LC
2
LC
2
LC
2
LC
2
28
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
fluoxetine hcl tablet 10mg
fluphenazine decanoate
solution 25 mg/ml
fluphenazine hcl elixir 2.5
mg/5 ml
fluphenazine hcl solution 2.5
mg/ml
fluphenazine hcl tablet 10mg
fluphenazine hcl tablet 2.5mg
fluvoxamine maleate capsule
er 24hr 100mg
fluvoxamine maleate capsule
er 24hr 150mg
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
2
LC
2
LC
2
LC
2
AP
2
2
AP
2
2
2
2
2
TE
2
TE
2
2
2
4
4
2
2
TE
/Límites
haloperidol lactate
concentrate 2 mg/ml
haloperidol lactate solution 5
mg/ml
haloperidol tablet 0.5mg
haloperidol tablet 10mg
imipramine hcl tablet 10mg
imipramine pamoate capsule
100mg
125mg
150mg
75mg
INVEGA SUSTENNA
SUSPENSION 117 MG/0.75
ML
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
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
LC; TE
4
LC; TE
29
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
6MG
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
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
/Límites
mirtazapine tablet disperse
15mg
30mg
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
2
LC
2
LC
2
LC
2
2
2
2
2
2
2
2
2
2
2
AP
2
LC
2
LC
2
LC
2
LC
30
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
olanzapine tablet 10mg
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
OLEPTRO ER TABLET ER
24HR 150MG
OLEPTRO ER TABLET ER
24HR 300MG
paroxetine hcl tablet 10mg
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
2
2
2
2
4
LC; TE
4
LC; TE
2
LC
2
LC
2
LC
2
LC
/Límites
paroxetine hcl tablet er 24hr
12.5mg
25mg
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 TABLET ER 24HR
100MG
PRISTIQ TABLET ER 24HR
50MG
2
LC
2
LC
2
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
31
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
prochlorperazine edisylate
solution 10 mg/2 ml (5 mg/ml)
prochlorperazine maleate
suppository 25mg
tablet 10mg
tablet 5mg
protriptyline hcl tablet 10mg
protriptyline hcl tablet 5mg
quetiapine fumarate tablet
100mg
200mg
25mg
300mg
400mg
50mg
RISPERDAL CONSTA FOR
2
2
2
2
2
2
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
4
4
/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
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
32
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
SAPHRIS TAB
SUBLINGUAL 10MG
SAPHRIS TAB
SUBLINGUAL 5MG
selegiline hcl capsule 5mg
SEROQUEL XR TABLET ER
24HR 150MG
24HR 200MG
24HR 300MG
24HR 400MG
24HR 50MG
sertraline hcl concentrate 20
mg/ml
dia(s)
sertraline hcl tablet 100mg
SILENOR TABLET 3MG
SILENOR TABLET 6MG
thioridazine hcl tablet 100mg
4
LC; TE
4
LC; TE
2
3
LC
3
LC
3
LC
3
LC
3
LC
2
LC
2
LC
2
LC
2
LC
4
LC; TE
4
LC; TE
2
AP
/Límites
thiothixene capsule 10mg
tranylcypromine sulfate tablet
10mg
trazodone hcl tablet 100mg
trifluoperazine hcl tablet 10mg
trimipramine maleate capsule
100mg
25mg
50mg
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
AP
AP
AP
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
33
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
2
2
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
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
/Límites
ABSTRAL TAB
SUBLINGUAL 600 MCG
ABSTRAL TAB
SUBLINGUAL 800 MCG
acetaminophen-butalbital
tablet 50-325mg
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-caff-acetaminophcodein capsule 50-325-4030mg
4
LC; AP; NM
4
LC; AP; NM
2
LC; 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
LC; NM
34
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
butalbital-acetaminophencaffe capsule 50-325-40mg
butalbital-acetaminophencaffe tablet 50-325-40mg
butalbital-aspirin-caffeine
capsule 50-325-40mg
butalbital-aspirin-caffeine
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)
CAMBIA PACKET 50MG
CAPITAL W-CODEINE
SUSPENSION 120 MG-12
MG/5 ML
CELEBREX CAPSULE
100MG
CELEBREX CAPSULE
200MG
2
LC; NM
2
LC; NM
2
LC
2
LC
2
LC; NM
4
LC; NM
4
LC; NM
4
LC; NM
4
LC; NM
4
4
NM
3
LC; TE
3
LC; TE
/Límites
CELEBREX CAPSULE
400MG
CELEBREX CAPSULE
50MG
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
endocet tablet 7.5-325mg
endodan tablet 4.8355-325mg
3
LC; TE
3
LC; TE
2
2
2
NM
NM
NM
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
LC; NM
35
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
etodolac capsule 200mg
etodolac capsule 300mg
etodolac er tablet er 24hr
400mg
500mg
600mg
etodolac tablet 400mg
etodolac tablet 500mg
EXALGO ER 32 MG
TABLET
fenoprofen calcium tablet
600mg
fentanyl citrate lollipop 1,200
mcg
fentanyl citrate lollipop 1,600
mcg
fentanyl citrate lollipop 200
mcg
mcg
mcg
mcg
fentanyl patch 72hr 100
mcg/hour
2
2
2
2
2
2
2
4
LC; TE; NM
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
/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
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
2
2
2
LC
2
LC
2
LC
36
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
gabapentin solution 250 mg/5
ml
gabapentin tablet 600mg
gabapentin tablet 800mg
GRALISE MISC 300 MG (9)600 MG (69)
GRALISE TABLET 300MG
GRALISE TABLET 600MG
HORIZANT TABLET ER
24HR 300MG
HORIZANT TABLET ER
24HR 600MG
hydrocodone bit-ibuprofen
tablet 7.5-200mg
hydrocodone-acetaminophen
tablet 10-325mg
tablet 2.5-325mg
tablet 5-325mg
tablet 7.5-325mg
hydromorphone hcl er 12 mg
tab
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
2
LC; TE
/Límites
tab
tab
hydromorphone hcl tablet 2mg
ibuprofen tablet 400mg
KADIAN CAPSULE ER
24HR 200MG
KADIAN CAPSULE ER
24HR 40MG
ketoprofen capsule 50mg
ketoprofen capsule 75mg
ketoprofen capsule er 24hr
200mg
LAZANDA SOLUTION 100
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
2
LC; TE
2
LC; TE
2
LC; NM
2
LC; NM
2
LC; NM
2
2
2
4
LC; TE; NM
4
LC; TE; NM
2
2
2
5
LC; AP; NM
2
NM
2
2
2
2
37
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
meloxicam tablet 15mg
meloxicam tablet 7.5mg
methadone hcl solution 10
mg/5 ml
methadone hcl solution 5 mg/5
ml
methadone hcl tablet 10mg
methadone hcl tablet 5mg
morphine sulfate er capsule er
24hr 100mg
24hr 10mg
24hr 120mg
24hr 20mg
24hr 30mg
24hr 30mg
24hr 45mg
24hr 50mg
24hr 60mg
2
2
2
NM
2
NM
2
2
NM
NM
2
LC; NM
2
LC; NM
2
LC; TE; NM
2
LC; NM
2
LC; NM
2
LC; TE; NM
2
LC; TE; NM
2
LC; NM
2
LC; NM
/Límites
24hr 60mg
24hr 75mg
24hr 80mg
24hr 90mg
morphine sulfate er tablet er
100mg
15mg
200mg
30mg
60mg
morphine sulfate solution 10
mg/5 ml
mg/5 ml (20 mg/ml)
mg/5 ml
morphine sulfate tablet 15mg
morphine sulfate tablet 30mg
nabumetone tablet 500mg
2
LC; TE; NM
2
LC; TE; NM
2
LC; NM
2
LC; TE; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
LC; NM
2
NM
2
NM
2
NM
2
LC; NM
2
LC; NM
2
38
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
nabumetone tablet 750mg
NALFON CAPSULE 400MG
NAPRELAN TABLET ER
24HR 375MG
NAPRELAN TABLET ER
24HR 500MG
NAPRELAN TABLET ER
24HR 750MG
naproxen sodium tablet 275mg
naproxen sodium tablet 550mg
naproxen suspension 125 mg/5
ml
naproxen tablet 250mg
naproxen tablet dr 375mg
naproxen tablet dr 500mg
NUCYNTA ER TABLET ER
12HR 100MG
12HR 150MG
12HR 200MG
12HR 250MG
12HR 50MG
NUCYNTA TABLET 100MG
NUCYNTA TABLET 50MG
2
4
4
4
4
2
2
2
2
2
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
/Límites
NUCYNTA TABLET 75MG
oxaprozin tablet 600mg
OXECTA 5 MG TABLET
OXECTA 7.5 MG TABLET
oxycodone hcl capsule 5mg
oxycodone hcl concentrate 20
mg/ml
oxycodone hcl solution 5 mg/5
ml
oxycodone hcl tablet 10mg
oxycodone hcl-acetaminophen
tablet 10-325mg
oxycodone hcl-aspirin tablet
4.8355-325mg
oxycodone hcl-ibuprofen tablet
400-5mg
oxycodone-acetaminophen
tablet 2.5-325mg
tablet 5-325mg
4
LC; TE; NM
2
4
LC; NM
4
LC; NM
2
LC; NM
2
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
39
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
tablet 7.5-325mg
OXYCONTIN 10 MG
TABLET
OXYCONTIN 15 MG
TABLET
OXYCONTIN 20 MG
TABLET
OXYCONTIN 30 MG
TABLET
OXYCONTIN 40 MG
TABLET
OXYCONTIN 60 MG
TABLET
OXYCONTIN 80 MG
TABLET
oxymorphone hcl er tablet er
12hr 10mg
12hr 15mg
12hr 20mg
12hr 30mg
2
LC; NM
4
LC; TE; NM
4
LC; TE; NM
4
LC; TE; NM
4
LC; TE; NM
4
LC; TE; NM
4
LC; TE; NM
4
LC; TE; NM
2
LC; TE; NM
2
LC; TE; NM
2
LC; TE; NM
2
LC; TE; NM
/Límites
12hr 40mg
12hr 5mg
12hr 7.5mg
oxymorphone hcl tablet 10mg
oxymorphone hcl tablet 5mg
PENNSAID SOLUTION 20
MG/GRAM PER
ACTUATION (2 %)
piroxicam capsule 10mg
piroxicam capsule 20mg
REPREXAIN TABLET 10200MG
REPREXAIN TABLET 2.5200MG
ROXICET SOLUTION 5
MG-325 MG/5 ML
dia(s)
SUBOXONE FILM 12-3MG
SUBOXONE FILM 2-0.5MG
SUBOXONE FILM 4-1MG
SUBOXONE FILM 8-2MG
sulindac tablet 150mg
sulindac tablet 200mg
2
LC; TE; NM
2
LC; TE; NM
2
LC; TE; 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
4
LC; NM
2
2
40
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
SYNALGOS-DC CAPSULE
4 NM
16-356.4-30MG
tolmetin sodium capsule
2
400mg
tolmetin sodium tablet 200mg
2
tolmetin sodium tablet 600mg
2
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
zamicet solution 10 mg-325
mg/15 ml
4 LC; NM
dia(s)
ZUBSOLV TAB
SUBLINGUAL 1.4-0.36MG
4 LC; NM
ZUBSOLV TAB
SUBLINGUAL 5.7-1.4MG
4 LC; NM
ANOREXIGENICSRESPIR., ESTIMULANTE
CEREBRAL
/Límites
amphetamine salt combo tablet
10mg
12.5mg
15mg
20mg
30mg
5mg
7.5mg
DAYTRANA PATCH 10
MG/9 HOUR
DAYTRANA PATCH 15
MG/9 HOUR
DAYTRANA PATCH 20
MG/9 HOUR
DAYTRANA PATCH 30
MG/9 HOUR
dexmethylphenidate hcl er
capsule er 24hr 15mg
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP
2
LC; AP
2
LC; AP
41
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
dextroamphetamine sulfate er
capsule er 24hr 5mg
dextroamphetamine-amphet er
capsule er 24hr 5mg
FOCALIN XR CAPSULE ER
24HR 10MG
24HR 20MG
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
4
LC; AP
4
LC; AP
/Límites
24HR 25MG
24HR 35MG
24HR 5MG
METHYLIN TABLET
CHEWABLE 10MG
METHYLIN TABLET
CHEWABLE 2.5MG
METHYLIN TABLET
CHEWABLE 5MG
methylphenidate er tablet er
18mg
20mg
27mg
36mg
54mg
methylphenidate hcl cd
capsule er 10mg
capsule er 50mg
4
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
42
Medicamento
Nivel Requisitos
/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
methylphenidate la capsule er
24hr 20mg
24hr 30mg
24hr 40mg
modafinil tablet 100mg
modafinil tablet 200mg
NUVIGIL TABLET 150MG
NUVIGIL TABLET 250MG
NUVIGIL TABLET 50MG
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
2
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP
Medicamento
Nivel Requisitos
/Límites
VYVANSE CAPSULE 20MG
4 LC; AP
4 LC; AP
4 LC; AP
4 LC; AP
4 LC; AP
4 LC; AP
ANSIOLÍTICOS, SEDANTES E HIPNÓTICOS
buspirone hcl tablet 10mg
2
2
2
2
buspirone hcl tablet 7.5mg
2
EDLUAR TAB
SUBLINGUAL 10MG
4 LC; TE
EDLUAR TAB
SUBLINGUAL 5MG
4 LC; TE
eszopiclone tablet 1mg
2 LC; TE
2 LC; TE
2 LC; TE
HETLIOZ CAPSULE 20MG
5 LC; AP
hydroxyzine hcl solution 10
2 AP
mg/5 ml
2 AP
mg/ml
43
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
mg/ml
hydroxyzine hcl tablet 10mg
hydroxyzine pamoate capsule
100mg
25mg
50mg
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 0.4 MG AUTOINJECTOR
dia(s)
naloxone hcl solution 1 mg/ml
naltrexone hcl tablet 50mg
2
AP
2
2
2
AP
AP
AP
2
AP
2
AP
2
AP
3
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
4
4
2
2
LC; TE
LC; AP
AP
/Límites
ANTICONVULSANTES
APTIOM TABLET 200MG
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
DILANTIN CAPSULE
100MG
DILANTIN CAPSULE 30MG
DILANTIN TABLET
CHEWABLE 50MG
DILANTIN-125
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
4
4
2
2
2
2
2
2
2
2
4
3
3
3
3
44
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
125mg
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
FYCOMPA TABLET 4MG
FYCOMPA TABLET 6MG
FYCOMPA TABLET 8MG
GABITRIL TABLET 12MG
GABITRIL TABLET 16MG
LAMICTAL (BLUE) KIT 25
MG (35 TABS)
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
/Límites
LAMICTAL (GREEN) KIT
25 MG (84)-100 MG (14)
LAMICTAL (ORANGE) KIT
25 MG (42)-100 MG (7)
LAMICTAL ODT TABLET
DISPERSE 100MG
LAMICTAL ODT TABLET
DISPERSE 200MG
LAMICTAL ODT TABLET
DISPERSE 25MG
LAMICTAL ODT TABLET
DISPERSE 50MG
LAMICTAL XR (BLUE) KIT
25 MG (21)-50 MG (7)
LAMICTAL XR (GREEN)
KIT 50 MG (14)-100 MG
(14)-200 MG (7)
LAMICTAL XR (ORANGE)
KIT 25 MG (14)-50 MG (14)100 MG (7)
lamotrigine er tablet er 24hr
100mg
200mg
250mg
25mg
4
4
4
LC
4
LC
4
LC
4
LC
4
4
4
2
LC
2
LC
2
LC
2
LC
45
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
300mg
50mg
lamotrigine tablet 100mg
lamotrigine tablet chewable
25mg
lamotrigine tablet chewable
5mg
levetiracetam er tablet er 24hr
500mg
levetiracetam er tablet er 24hr
750mg
levetiracetam solution 100
mg/ml
levetiracetam solution 500
mg/5 ml
levetiracetam tablet 1,000mg
levetiracetam tablet 250mg
LYRICA CAPSULE 100MG
2
LC
2
LC
2
LC
2
LC
2
LC
2
LC
2
2
2
LC
2
LC
2
2
AP
2
LC
2
LC
2
LC
2
LC
4
/Límites
LYRICA CAPSULE 25MG
LYRICA CAPSULE 50MG
LYRICA CAPSULE 75MG
LYRICA SOLUTION 20
MG/ML
oxcarbazepine suspension 300
mg/5 ml
oxcarbazepine tablet 150mg
OXTELLAR XR TABLET
ER 24HR 150MG
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 300mg
4
LC
4
LC
4
LC
4
4
LC
4
4
4
2
2
LC
2
LC
2
LC
4
LC
4
LC
4
LC
4
3
3
2
46
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
phenytoin suspension 125
mg/5 ml
phenytoin tablet chewable
50mg
POTIGA TABLET 200MG
POTIGA TABLET 300MG
POTIGA TABLET 400MG
POTIGA TABLET 50MG
QUDEXY XR 100 MG
CAPSULE
QUDEXY XR 150 MG
CAPSULE
QUDEXY XR 200 MG
CAPSULE
QUDEXY XR 25 MG
CAPSULE
QUDEXY XR 50 MG
CAPSULE
SABRIL PACKET 500MG
SABRIL TABLET 500MG
STAVZOR CAPSULE DR
125MG
STAVZOR CAPSULE DR
250MG
STAVZOR CAPSULE DR
500MG
2
2
4
LC
4
LC
4
LC
4
LC
4
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP
4
LC; AP; AL
3
3
3
/Límites
TEGRETOL XR TABLET ER
12HR 100MG
tiagabine hcl tablet 2mg
tiagabine hcl tablet 4mg
topiramate cap sprinkle 15mg
topiramate cap sprinkle 25mg
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
VIMPAT SOLUTION 10
MG/ML
VIMPAT SOLUTION 200
MG/20 ML
VIMPAT TABLET 100MG
3
2
LC
2
LC
2
2
2
LC
2
LC
2
LC
2
LC
3
LC; AP
3
LC; AP
3
LC; AP
3
LC; AP
2
2
3
3
3
LC
47
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
VIMPAT TABLET 150MG
VIMPAT TABLET 200MG
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
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
/Límites
1mg
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
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
AP
2
2
2
2
2
2
AP
AP
AP
48
Medicamento
Nivel Requisitos
/Límites
diazepam tablet 5mg
2 AP
LORAZEPAM INTENSOL
2
CONCENTRATE 2 MG/ML
lorazepam tablet 0.5mg
2
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
COLCRYS TABLET 0.6MG
3 LC
ULORIC TABLET 40MG
3 LC; TE
ULORIC TABLET 80MG
3 LC; TE
AGENTES ANTIRREUMÁTICOS
MODIFICADORES DE LA ENFERMEDAD
ENBREL KIT 25 MG (1 ML)
5 LC
LC 8 cada 30 dia(s)
ENBREL SOLUTION 25
MG/0.5 ML (0.51 ML)
5 LC
ENBREL SOLUTION 50
MG/ML (0.98 ML)
5 LC
Medicamento
Nivel Requisitos
/Límites
HUMIRA KIT 20 MG/0.4 ML
5 LC
LC 2 cada 30 dia(s)
HUMIRA KIT 40 MG/0.8 ML
5 LC
LC 6 cada 30 dia(s)
leflunomide tablet 10mg
2
leflunomide tablet 20mg
2
OTEZLA STARTER PACK
5 LC; AP
OTEZLA TABLET 30MG
5 LC; AP
REMICADE FOR
5 AP
SOLUTION 100MG
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
CELLCEPT FOR
3 AP
SUSPENSION 200 MG/ML
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
49
Medicamento
Nivel Requisitos
/Límites
cyclosporine solution 250
mg/5 ml
gengraf capsule 100mg
gengraf capsule 25mg
gengraf solution 100 mg/ml
mycophenolate mofetil capsule
250mg
mycophenolate mofetil tablet
500mg
mycophenolic acid tablet dr
180mg
mycophenolic acid tablet dr
360mg
RAPAMUNE SOLUTION 1
MG/ML
RAPAMUNE TABLET 1MG
RAPAMUNE TABLET 2MG
SANDIMMUNE SOLUTION
100 MG/ML
sirolimus tablet 0.5mg
tacrolimus capsule 0.5mg
tacrolimus capsule 1mg
tacrolimus capsule 5mg
ZORTRESS TABLET
0.25MG
ZORTRESS TABLET 0.5MG
ZORTRESS TABLET
0.75MG
AGENTES PROTECTORES
amifostine for solution 500mg
MESNEX TABLET 400MG
ANTÍDOTOS
2
AP
2
2
2
AP
AP
AP
2
AP
2
AP
2
AP
2
AP
3
AP
3
3
AP
AP
3
AP
2
2
2
2
AP
AP
AP
AP
4
LC; AP
4
LC; AP
4
LC; AP
5
3
AP
Medicamento
Nivel Requisitos
/Límites
acetylcysteine solution 100
2 AP
mg/ml (10 %)
acetylcysteine solution 200
2 AP
mg/ml (20 %)
leucovorin calcium for
2 AP
solution 100mg
leucovorin calcium for
2 AP
solution 350mg
leucovorin calcium tablet
2
10mg
2
15mg
2
25mg
leucovorin calcium tablet 5mg
2
INHIBIDORES DE LA 5-ALFA REDUCTASA
AVODART CAPSULE
4
0.5MG
finasteride tablet 5mg
2
INHIBIDORES DE LA REABSORCIÓN DE
HUESO
ACTONEL TABLET 30MG
4 LC; TE
ACTONEL TABLET 35MG
4 LC; TE
LC 4 cada 28 dia(s)
ACTONEL TABLET 5MG
4 LC; TE
alendronate sodium tablet
10mg
1 LC
35mg
1 LC
LC 4 cada 28 dia(s)
40mg
1 LC
alendronate sodium tablet 5mg
1 LC
50
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
70mg
1 LC
LC 4 cada 28 dia(s)
ATELVIA TABLET DR
35MG
4 LC; TE
etidronate disodium tablet
2
200mg
etidronate disodium tablet
2
400mg
ibandronate sodium solution 3
2 AP
mg/3 ml
ibandronate sodium tablet
150mg
2 LC
LC 1 cada 28 dia(s)
pamidronate disodium solution
4 AP
30 mg/10 ml (3 mg/ml)
4 AP
60 mg/10 ml (6 mg/ml)
4 AP
90 mg/10 ml (9 mg/ml)
risedronate sodium tablet
150mg
2 LC; TE
LC 1 cada 28 dia(s)
XGEVA SOLUTION 120
5 AP
MG/1.7 ML (70 MG/ML)
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
MODIFICADORES DE RESPUESTA
BIOLÓGICA
ACTIMMUNE SOLUTION
100 MCG (2 MILLION
5 AP
UNIT)/0.5 ML
/Límites
AVONEX
ADMINISTRATION PACK
KIT 30 MCG (1 ML)
LC 4 cada 30 dia(s)
AVONEX KIT 30 MCG/0.5
ML
LC 4 cada 30 dia(s)
COPAXONE 40 MG/ML
SYRINGE
dia(s)
COPAXONE KIT 20 MG/ML
EXTAVIA KIT 0.3MG
GILENYA CAPSULE 0.5MG
REBIF SOLUTION 22
MCG/0.5 ML
dia(s)
REBIF SOLUTION 44
MCG/0.5 ML
dia(s)
REBIF SOLUTION 8.8
MCG/0.2 ML (6) - 22
MCG/0.5 ML (6)
dia(s)
TECFIDERA CAPSULE DR
120MG
TECFIDERA CAPSULE DR
240MG
TECFIDERA MISC 120 MG
(14)-240 MG (46)
THALOMID CAPSULE
100MG
5
LC
5
LC
5
LC
5
LC
5
LC
5
LC; AP
5
LC
5
LC
5
LC
5
LC; AP
5
LC; AP
5
LC; AP
3
LC
51
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
THALOMID CAPSULE
150MG
3 LC
THALOMID CAPSULE
200MG
3 LC
THALOMID CAPSULE
50MG
3 LC
TYSABRI CONCENTRATE
300 MG/15 ML
5 LC; AP
dia(s)
OTROS AGENTES TERAPÉUTICOS
MISCELÁNEOS
AMPYRA TABLET ER 12HR
10MG
5 LC; AP
ARCALYST FOR
5 AP
SOLUTION 220MG
CYSTADANE POWDER 1
4
GRAM/1.7 ML
CYSTAGON CAPSULE
4
150MG
CYSTAGON CAPSULE
4
50MG
CYSTARAN SOLUTION
0.44 %
4 LC; AP
dia(s)
DEMSER CAPSULE 250MG
4
ELMIRON CAPSULE
3
100MG
GLUCAGEN FOR
3
SOLUTION 1MG
GLUCAGON EMERGENCY
3
KIT KIT 1MG
guanidine hcl tablet 125mg
2
H.P. ACTHAR GEL 80
5 AP
UNIT/ML
KUVAN TABLET SOLUBLE
5
100MG
/Límites
MYALEPT FOR SOLUTION
5 MG/ML (FINAL
CONCENTRATION)
LC 67.8 cada 30 dia(s)
octreotide acetate solution
1,000 mcg/ml
octreotide acetate solution 100
mcg/ml
mcg/ml
mcg/ml
mcg/ml
ORFADIN CAPSULE 10MG
ORFADIN CAPSULE 2MG
ORFADIN CAPSULE 5MG
RAVICTI LIQUID 1.1
GRAM/ML
dia(s)
SENSIPAR TABLET 30MG
SIGNIFOR SOLUTION 0.3
MG/ML (1 ML)
dia(s)
MG/ML (1 ML)
dia(s)
MG/ML (1 ML)
dia(s)
SOMATULINE DEPOT
SOLUTION 120 MG/0.5 ML
SOMATULINE DEPOT
SOMATULINE DEPOT
5
LC; AP
5
AP
2
AP
2
AP
2
AP
5
AP
5
5
5
AP
AP
AP
4
LC; AP
3
3
3
5
LC; AP
5
LC; AP
5
LC; AP
5
AP
5
AP
5
AP
52
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
SYPRINE CAPSULE 250MG
4
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 167
2 AP
meq/l
sodium lactate solution 5
2 AP
meq/ml
AGENTES CALÓRICOS
AMINOSYN II SOLUTION
3 AP
10 %
/Límites
AMINOSYN II SOLUTION 7
%
aminosyn ii solution 8.5 %
AMINOSYN II SOLUTION
8.5 %
AMINOSYN M SOLUTION
3.5 %
aminosyn solution 8.5 %
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 %
dextrose in water solution 10
%
dextrose in water solution 5 %
dextrose with sodium chloride
solution 10 %-0.45 %
3
AP
2
AP
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
2
AP
AP
2
AP
2
AP
2
AP
2
AP
53
Medicamento
Nivel Requisitos
/Límites
2 AP
solution 2.5 %-0.45 %
2 AP
solution 5 %-0.2 %
2 AP
solution 5 %-0.3 %
2 AP
solution 5 %-0.45 %
2 AP
solution 5 %-0.9 %
FREAMINE HBC
3 AP
SOLUTION 6.9 %
hepatamine solution 8 %
2 AP
intralipid emulsion 20 %
2 AP
NEPHRAMINE SOLUTION
3 AP
5.4 %
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
calcium acetate capsule
2
667mg
FOSRENOL TABLET
4
CHEWABLE 1,000MG
FOSRENOL TABLET
4
CHEWABLE 500MG
FOSRENOL TABLET
4
CHEWABLE 750MG
kionex powder
2
RENAGEL TABLET 400MG
4
Medicamento
Nivel Requisitos
/Límites
RENAGEL TABLET 800MG
4
RENVELA TABLET 800MG
3
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
BUPHENYL TABLET
4
500MG
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
54
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
40 meq/l
dextrose 5%-ns-kcl solution 20
meq/l
dextrose 5%-ns-kcl solution 40
meq/l
dextrose 5%-potassium
chloride solution 20 meq/l
dextrose in lactated ringers
solution 5 %
IONOSOL B WITH
DEXTROSE 5% SOLUTION
5%
IONOSOL MB-DEXTROSE
5% SOLUTION 5 %
ISOLYTE P WITH
DEXTROSE SOLUTION 5 %
ISOLYTE S SOLUTION
klor-con 8 tablet er 8 meq
klor-con m10 tablet er 10 meq
KLOR-CON M15 TABLET
ER 15 MEQ
klor-con m20 tablet er 20 meq
lactated ringers solution
magnesium sulfate solution 4
meq/ml (50 %)
normosol-m and dextrose
solution 5 %
NORMOSOL-R AND
NORMOSOL-R PH 7.4
SOLUTION
PLASMA-LYTE 148
SOLUTION
PLASMA-LYTE 56 IN
2
AP
2
AP
2
AP
2
AP
2
AP
3
AP
3
AP
3
AP
3
2
2
AP
4
2
2
AP
2
AP
2
AP
3
AP
3
AP
3
AP
3
AP
/Límites
PLASMA-LYTE A PH 7.4
SOLUTION
potassium chl-normal saline
solution 20 meq/l
potassium chl-normal saline
solution 40 meq/l
potassium chloride capsule er
10 meq
potassium chloride capsule er
8 meq
potassium chloride in d5lr
solution 20 meq/l
potassium chloride solution 10
meq/100 ml
meq/ml
meq/100 ml
meq/100 ml
meq/100 ml
potassium chloride tablet er 10
meq
potassium chloride tablet er 20
meq
potassium chloride-nacl
solution 20 meq/l
ringers injection solution
sodium chloride solution 0.45
%
%
meq/ml
sodium chloride solution 3 %
3
AP
2
AP
2
AP
2
2
2
AP
2
AP
2
AP
2
AP
2
AP
2
AP
2
2
2
AP
2
AP
2
AP
2
AP
2
AP
2
AP
55
Medicamento
Nivel Requisitos
/Límites
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
CEREZYME FOR
5
SOLUTION 200 UNIT
ELAPRASE SOLUTION 6
5
MG/3 ML
ELITEK FOR SOLUTION
5
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
MG/ML
SUCRAID SOLUTION 8,500
4
UNIT/ML
AP
AP
AP
AP
AP
AP
AP
AL
Medicamento
Nivel Requisitos
/Límites
VPRIV FOR SOLUTION 400
5
UNIT
FORMACIÓN DE LA SANGRE, COAGULACIÓN
Y TROMBOSIS
AGENTES ANTIHEMORRÁGICOS
desmopressin acetate solution
10 mcg/spray (0.1 ml)
2 LC
dia(s)
desmopressin acetate tablet
2
0.1mg
desmopressin acetate tablet
2
0.2mg
STIMATE SOLUTION 150
4
MCG/SPRAY (0.1 ML)
AGENTES ANTITROMBOTICOS
AGGRENOX CAPSULE ER
3
12HR 25-200MG
anagrelide hcl capsule 0.5mg
2
anagrelide hcl capsule 1mg
2
BRILINTA TABLET 90MG
3 LC
cilostazol tablet 100mg
2
cilostazol tablet 50mg
2
clopidogrel tablet 300mg
2 LC
LC 2 cada 30 dia(s)
clopidogrel tablet 75mg
2 LC
COUMADIN FOR
4 AP
SOLUTION 5MG
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
56
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
COUMADIN TABLET
7.5MG
EFFIENT TABLET 10MG
EFFIENT TABLET 5MG
ELIQUIS TABLET 2.5MG
ELIQUIS TABLET 5MG
enoxaparin sodium solution
100 mg/ml
120 mg/0.8 ml
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
4
3
LC
3
LC
3
LC
3
LC
2
2
2
2
2
2
2
2
2
2
2
2
2
2
/Límites
heparin sodium solution
20,000 unit/ml
heparin sodium solution 5,000
unit/ml
jantoven tablet 10mg
jantoven tablet 1mg
jantoven tablet 2.5mg
jantoven tablet 2mg
jantoven tablet 3mg
jantoven tablet 4mg
jantoven tablet 5mg
jantoven tablet 6mg
jantoven tablet 7.5mg
PRADAXA CAPSULE
150MG
PRADAXA CAPSULE 75MG
ticlopidine hcl tablet 250mg
warfarin sodium tablet 10mg
warfarin sodium tablet 2.5mg
warfarin sodium tablet 7.5mg
XARELTO TABLET 10MG
XARELTO TABLET 15MG
XARELTO TABLET 20MG
ZONTIVITY TABLET
2.08MG
2
2
2
2
2
2
2
2
2
2
2
4
LC
4
LC
2
2
2
2
2
2
2
2
2
2
3
LC
3
LC
3
LC
4
LC
57
Medicamento
Nivel Requisitos
/Límites
AGENTES HEMATOPOYÉTICOS
ARANESP SOLUTION 100
5 AP
MCG/0.5 ML
5 AP
MCG/ML
5 AP
MCG/0.3 ML
5 AP
MCG/0.4 ML
5 AP
MCG/ML
ARANESP SOLUTION 25
3 AP
MCG/0.42 ML
ARANESP SOLUTION 25
3 AP
MCG/ML
5 AP
MCG/0.6 ML
5 AP
MCG/ML
ARANESP SOLUTION 40
3 AP
MCG/0.4 ML
ARANESP SOLUTION 40
3 AP
MCG/ML
5 AP
MCG/ML
ARANESP SOLUTION 60
3 AP
MCG/0.3 ML
ARANESP SOLUTION 60
3 AP
MCG/ML
EPOGEN SOLUTION 2,000
4 AP
UNIT/ML
4 AP
UNIT/2 ML
4 AP
UNIT/ML
4 AP
UNIT/ML
Medicamento
Nivel Requisitos
/Límites
4 AP
UNIT/ML
GRANIX 300 MCG/0.5 ML
5 AP
SYRINGE
5 AP
SYRINGE
LEUKINE FOR SOLUTION
5 AP
250 MCG
MOZOBIL SOLUTION 24
5
MG/1.2 ML (20 MG/ML)
NEULASTA SOLUTION 6
5 AP
MG/0.6 ML
NEUMEGA FOR SOLUTION
5 AP
5MG
NEUPOGEN SOLUTION 300
5 AP
MCG/0.5 ML
5 AP
MCG/0.8 ML
5 AP
MCG/1.6 ML
PROMACTA TABLET
12.5MG
5 LC; AP
PROMACTA TABLET 25MG
5 LC; AP
5 LC; AP
5 LC; AP
AGENTES HEMORREOLÓGICOS
pentoxifylline tablet er 400mg
2
HORMONAS Y SUSTITUTOS SINTÉTICOS
ADRENALES
budesonide ec capsule er 24hr
2
3mg
58
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
methylprednisolone tablet
16mg
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
2
/Límites
methylprednisolone tablet
2
32mg
methylprednisolone tablet 4mg 2
methylprednisolone tablet 8mg 2
ORAPRED ODT TABLET
3
DISPERSE 15MG
ORAPRED ODT TABLET
3
DISPERSE 30MG
prednisolone sodium
2
phosphate solution 15 mg/5 ml
prednisolone sodium
phosphate solution 25 mg/5 ml
2
(5 mg/ml)
prednisolone sodium
phosphate solution 5 mg
2
base/5 ml (6.7 mg/5 ml)
PREDNISONE INTENSOL
2
CONCENTRATE 5 MG/ML
prednisone solution 5 mg/5 ml
2
prednisone tablet 10mg
2
2
prednisone tablet 2.5mg
2
2
2
2
VERIPRED 20 SOLUTION
4
20 MG/5 ML
AGENTES ANTIDIABÉTICOS
acarbose tablet 100mg
2
2
2
ACTOPLUS MET XR
TABLET ER 24HR 154
1,000MG
LC
59
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
ACTOPLUS MET XR
TABLET ER 24HR 301,000MG
AVANDAMET TABLET 21,000MG
AVANDAMET TABLET 2500MG
AVANDAMET TABLET 41,000MG
AVANDAMET TABLET 4500MG
AVANDARYL TABLET 41MG
AVANDIA TABLET 2MG
AVANDIA TABLET 4MG
AVANDIA TABLET 8MG
BYDUREON FOR
SUSPENSION 2MG
LC 4 cada 28 dia(s)
BYETTA 10 MCG DOSE
PEN INJ
dia(s)
BYETTA 5 MCG DOSE PEN
INJ
dia(s)
4
LC
4
LC; AL
4
LC; AL
4
LC; AL
4
LC; AL
4
AL
4
AL
4
AL
4
AL
4
AL
4
4
4
AL
AL
AL
3
LC; TE
3
LC; TE
3
LC; TE
/Límites
FARXIGA TABLET 10MG
FARXIGA TABLET 5MG
glimepiride tablet 1mg
glipizide er tablet er 24hr
10mg
glipizide er tablet er 24hr
2.5mg
glipizide er tablet er 24hr 5mg
glipizide tablet 10mg
glipizide tablet 5mg
glipizide-metformin tablet 2.5250mg
glipizide-metformin tablet 2.5500mg
glipizide-metformin tablet 5500mg
GLUMETZA TABLET ER
24HR 500MG
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
4
LC; TE
4
LC; TE
1
1
1
1
1
1
1
1
1
1
1
4
1
1
1
1
1
1
1
1
60
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
5-500mg
GLYSET TABLET 100MG
GLYSET TABLET 25MG
GLYSET TABLET 50MG
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
24HR 50-500MG
JANUVIA TABLET 100MG
JANUVIA TABLET 25MG
JANUVIA TABLET 50MG
JENTADUETO TABLET 2.51,000MG
JENTADUETO TABLET 2.5500MG
1
4
4
4
4
LC; TE
4
LC; TE
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
4
LC
3
LC
3
LC
/Límites
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
ER 24HR 5-500MG
LANTUS SOLOSTAR 100
UNITS/ML
LANTUS SOLUTION 100
UNIT/ML
LEVEMIR FLEXPEN 100
UNITS/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
3
LC
3
LC
3
LC
4
LC
4
LC
4
LC
4
4
3
3
2
2
2
1
1
1
1
1
61
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
NOVOLOG FLEXPEN
SYRINGE
NOVOLOG MIX 70-30
FLEXPEN SYRN
NOVOLOG MIX 70-30
SUSPENSION 100 UNIT/ML
(70-30)
NOVOLOG SOLUTION 100
UNIT/ML
ONGLYZA TABLET 2.5MG
ONGLYZA TABLET 5MG
OSENI TABLET 12.5-15MG
OSENI TABLET 25-15MG
3
LC
3
LC
3
LC
3
3
3
3
3
3
3
4
LC
4
LC
3
LC
3
LC
3
LC
3
LC
/Límites
pioglitazone hcl tablet 15mg
pioglitazone-glimepiride tablet
30-2mg
pioglitazone-glimepiride tablet
30-4mg
pioglitazone-metformin tablet
15-500mg
pioglitazone-metformin tablet
15-850mg
PRANDIMET TABLET 1500MG
PRANDIMET TABLET 2500MG
repaglinide tablet 0.5mg
repaglinide tablet 1mg
repaglinide tablet 2mg
RIOMET SOLUTION 500
MG/5 ML
SYMLINPEN 120 PEN
INJECTOR
dia(s)
SYMLINPEN 60 PEN
INJECTOR
dia(s)
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
62
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
TANZEUM 30 MG PEN
INJECT
4 LC; TE
LC 4 cada 28 dia(s)
TANZEUM 50 MG PEN
INJECT
4 LC; TE
LC 4 cada 28 dia(s)
tolazamide tablet 250mg
1
tolazamide tablet 500mg
1
tolbutamide tablet 500mg
1
TRADJENTA TABLET 5MG
3 LC
VICTOZA 3-PAK 18 MG/3
3 TE
ML PEN
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
2
300 mcg
2
mcg
2
mcg
/Límites
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
MCG
MCG
MCG
SYNTHROID TABLET 25
MCG
2
4
4
4
4
4
4
4
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
63
Medicamento
Nivel Requisitos
/Límites
MCG
SYNTHROID TABLET 50
MCG
SYNTHROID TABLET 75
MCG
SYNTHROID TABLET 88
MCG
unithroid tablet 100 mcg
ANDRÓGENOS
ANDROGEL GEL 20.25
MG/1.25 GRAM PER
ACTUATION (1.62 %)
ANDROGEL GEL 50 MG/5
GRAM (1 %)
ANDROID CAPSULE 10MG
ANDROXY TABLET 10MG
AXIRON SOLUTION 30
MG/1.5 ML PER
ACTUATION
dia(s)
danazol capsule 100mg
2
2
2
2
4
4
4
4
4
4
4
4
4
4
4
3
3
LC
4
4
AP
4
LC; AP
2
2
2
Medicamento
Nivel Requisitos
/Límites
FORTESTA GEL 10 MG/0.5
GRAM PER ACTUATION (2
4 LC; AP
%)
METHITEST TABLET 10MG 4 AP
oxandrolone tablet 10mg
2
oxandrolone tablet 2.5mg
2
TESTIM GEL 50 MG/5
GRAM (1 %)
4 LC; AP
testosterone cypionate oil 100
2
mg/ml
testosterone cypionate oil 200
2
mg/ml
testosterone enanthate oil 200
2
mg/ml
TESTRED CAPSULE 10MG
4 AP
VOGELXO GEL 1.25 GRAM
PER ACTUATION (1 %)
4 LC; AP
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)
SOMAVERT FOR
5 AP
SOLUTION 10MG
SOMAVERT FOR
5 AP
SOLUTION 15MG
SOMAVERT FOR
5 AP
SOLUTION 20MG
TEV-TROPIN FOR
5 AP
SOLUTION 5MG
ANTICONCEPTIVOS
amethia tablet 0.15 mg-30 mcg
2
(84)/10 mcg (7)
64
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
AMETHYST TABLET 90
MCG-20 MCG
apri tablet 0.15-0.03mg
aranelle tablet 0.5 mg-35 mcg
(7)/1 mg-35 mcg (9)/0.5 mg-35
mcg (5)
aviane tablet 0.1 mg-20 mcg
balziva tablet 0.4 mg-35 mcg
BEYAZ TABLET 3 MG-0.02
MG-0.451 MG (24)/0.451 MG
(4)
briellyn tablet 0.4 mg-35 mcg
camila tablet 0.35mg
cryselle tablet 0.3 mg-30 mcg
cyclafem tablet 0.5 mg-35 mcg
(7)/0.75 mg-35 mcg (7)/1 mg35 mcg (7)
cyclafem tablet 1 mg-35 mcg
drospirenone-ethinyl estradiol
tablet 0.03-3mg
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
gianvi tablet 0.02 mg-3 mg
(24)
introvale tablet 0.15 mg-30
mcg
jolivette tablet 0.35mg
junel fe tablet 1 mg-20 mcg
(21)/75 mg (7)
2
2
2
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
/Límites
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
leena tablet 0.5 mg-35 mcg
(7)/1 mg-35 mcg (9)/0.5 mg-35
mcg (5)
lessina tablet 0.1 mg-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 24 FE TABLET 1
MG-20 MCG (24)/75 MG (4)
low-ogestrel tablet 0.3 mg-30
mcg
lutera tablet 0.1 mg-20 mcg
marlissa tablet 0.15 mg-30
mcg
mononessa tablet 0.25 mg-35
mcg
necon tablet 0.5 mg-35 mcg
NECON TABLET 0.5 MG-35
MCG (10)/1 MG-35 MCG
(11)
necon tablet 0.5 mg-35 mcg
(7)/0.75 mg-35 mcg (7)/1 mg35 mcg (7)
necon tablet 1 mg-35 mcg
nora-be tablet 0.35mg
nortrel tablet 0.5 mg-35 mcg
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
4
2
2
2
2
65
Medicamento
Nivel Requisitos
/Límites
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
SAFYRAL TABLET 3 MG0.03 MG-0.451 MG (21)/0.451
MG (7)
sprintec tablet 0.25 mg-35 mcg
sronyx tablet 0.1 mg-20 mcg
tri-legest fe tablet 1 mg-20
mcg (5)/1 mg-30 mcg (7)/1
mg-35 mcg (9)/75 mg (7)
tri-previfem tablet 0.18 mg-35
mcg (7)/0.215 mg-35 mcg
(7)/0.25 mg-35 mcg(7)(28)
tri-sprintec tablet 0.18 mg-35
mcg (7)/0.215 mg-35 mcg
(7)/0.25 mg-35 mcg(7)(28)
2
2
4
4
2
4
2
2
2
2
4
2
2
2
2
2
LC
Medicamento
Nivel Requisitos
/Límites
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 mcg35 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 BIWEEKLY
4
0.025 MG/24 HOUR
4
0.05 MG/24 HOUR
4
0.075 MG/24 HOUR
4
0.1 MG/24 HOUR
ANGELIQ TABLET 0.254
0.5MG
ANGELIQ TABLET 0.5-1MG 4
CENESTIN TABLET 0.3MG
4 AP
CENESTIN TABLET
4 AP
0.45MG
CENESTIN TABLET
4 AP
0.625MG
CENESTIN TABLET 0.9MG
4 AP
CENESTIN TABLET
4 AP
1.25MG
66
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
CLIMARA PRO PATCH
WEEKLY 0.045 MG-0.015
MG/24 HOUR
COMBIPATCH PATCH
BIWEEKLY 0.05 MG-0.14
MG/24 HOUR
COMBIPATCH PATCH
BIWEEKLY 0.05 MG-0.25
MG/24 HOUR
DEPO-ESTRADIOL OIL 5
MG/ML
DIVIGEL GEL 1 MG (0.1 %)
DUAVEE TABLET 0.4520MG
ELESTRIN GEL 0.87
GRAM/ACTUATION (0.06
%)
ENJUVIA TABLET 0.3MG
ESTRACE CREAM 0.01 %
estradiol patch weekly 0.025
mg/24 hour
mg/24 hour
mg/24 hour
mg/24 hour
mg/24 hour
mg/24 hour
3
4
4
4
3
4
LC; AP
4
4
4
4
4
4
3
2
2
2
2
2
2
AP
AP
AP
AP
AP
/Límites
estradiol tablet 0.5mg
estradiol tablet 1mg
estradiol tablet 2mg
estradiol-norethindrone acetat
tablet 1-0.5mg
estropipate tablet 0.75mg
estropipate tablet 1.5mg
estropipate tablet 3mg
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
JINTELI TABLET 1 MG-5
MCG
levonest tablet 50 mcg-30 mcg
(6)/75 mcg-40 mcg (5)/125
mcg-30 mcg (10)
levonorgestrel-eth estradiol
tablet 0.15 mg-30 mcg
loryna tablet 0.02 mg-3 mg
(24)
MENEST TABLET 0.3MG
MENEST TABLET 0.625MG
MENEST TABLET 1.25MG
MENEST TABLET 2.5MG
MENOSTAR PATCH
WEEKLY 14 MCG/24 HOUR
MINIVELLE PATCH
BIWEEKLY 0.0375 MG/24
HOUR
LC 8 cada 28 dia(s)
2
2
2
2
2
2
2
AP
AP
AP
3
4
LC
4
LC
2
2
2
2
2
4
4
4
4
AP
AP
AP
AP
3
4
LC
67
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
MINIVELLE PATCH
BIWEEKLY 0.05 MG/24
HOUR
LC 8 cada 28 dia(s)
MINIVELLE PATCH
HOUR
LC 8 cada 28 dia(s)
MINIVELLE PATCH
BIWEEKLY 0.1 MG/24
HOUR
LC 8 cada 28 dia(s)
norethindrone tablet 0.35mg
PREFEST TABLET 1 MG
(3)-1 MG-0.09 MG (3)
PREMARIN CREAM 0.625
MG/GRAM
PREMARIN TABLET 0.3MG
PREMARIN TABLET
0.45MG
PREMARIN TABLET
0.625MG
PREMARIN TABLET 0.9MG
PREMARIN TABLET
1.25MG
PREMPHASE TABLET 0.625
MG (14)/0.625 MG-5 MG
(14)
PREMPRO TABLET 0.31.5MG
PREMPRO TABLET 0.6255MG
raloxifene hcl tablet 60mg
VAGIFEM TABLET 10 MCG
4
4
4
LC
LC
LC
2
4
3
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
3
AP
2
LC
3
/Límites
VIVELLE-DOT PATCH
HOUR
VIVELLE-DOT PATCH
HOUR
VIVELLE-DOT PATCH
BIWEEKLY 0.05 MG/24
HOUR
VIVELLE-DOT PATCH
HOUR
VIVELLE-DOT PATCH
BIWEEKLY 0.1 MG/24
HOUR
zenchent fe tablet chewable 0.4
mg-35 mcg (21)/75 mg (~24.7
mg iron)(7)
GONADOTROPINAS
chorionic gonadotropin for
solution 10,000 unit
SYNAREL SOLUTION 2
MG/ML
PARATIROIDES
calcitonin-salmon solution 200
unit/spray
FORTEO SOLUTION 20
MCG/DOSE (600 MCG/2.4
ML)
dia(s)
FORTICAL SOLUTION 200
UNIT/SPRAY
PROGESTINAS
CRINONE GEL 4 %
CRINONE GEL 8 %
DEPO-SUBQ PROVERA 104
ML
3
3
3
3
3
2
2
AP
4
2
5
LC; AP
4
4
4
4
LC
68
Medicamento
Nivel Requisitos
/Límites
medroxyprogesterone acetate
suspension 150 mg/ml
2 LC
2
tablet 10mg
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
cyproheptadine hcl syrup 2
2 AP
mg/5 ml
cyproheptadine hcl tablet 4mg
2 AP
meclizine hcl tablet 12.5mg
2
meclizine hcl tablet 25mg
2
ANTIHISTAMÍNICOS de la 2a GENERACIÓN
CLARINEX SYRUP 2.5
4
MG/5 ML (0.5 MG/ML)
CLARINEX-D 12 HOUR
TABLET ER 12HR 2.54
120MG
desloratadine tablet 5mg
2
desloratadine tablet disperse
2
2.5mg
desloratadine tablet disperse
2
5mg
levocetirizine dihydrochloride
2
solution 2.5 mg/5 ml
levocetirizine dihydrochloride
2
tablet 5mg
Medicamento
Nivel Requisitos
/Límites
SEMPREX-D CAPSULE 603
8MG
MEDICAMENTOS AUTONÓMICOS
AGENTES ANTICOLINÉRGICOS
ANORO ELLIPTA AERO
POW BR ACT 62.5 MCG-25
4 LC; TE
MCG/ACTUATION
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 AP
dicyclomine hcl solution 10
2 AP
mg/5 ml
dicyclomine hcl tablet 20mg
2 AP
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
69
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
SPIRIVA CAPSULE 18 MCG
3 LC
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)
ADVAIR DISKUS AERO
POW BR ACT 100 MCG-50
3
MCG/DOSE
ADVAIR DISKUS AERO
3
MCG/DOSE
ADVAIR DISKUS AERO
3
MCG/DOSE
ADVAIR HFA AEROSOL
115 MCG-21
3
MCG/ACTUATION
ADVAIR HFA AEROSOL
230 MCG-21
3
MCG/ACTUATION
ADVAIR HFA AEROSOL 45
3
MCG-21 MCG/ACTUATION
albuterol sulfate nebulized
2 AP
soln 0.63 mg/3 ml
2 AP
soln 1.25 mg/3 ml
2 AP
soln 2.5 mg/3 ml (0.083 %)
/Límites
soln 5 mg/ml
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
ARCAPTA NEOHALER
CAPSULE 75 MCG
BREO ELLIPTA AERO POW
BR ACT 100 MCG-25
MCG/DOSE
BROVANA NEBULIZED
SOLN 15 MCG/2 ML
dia(s)
DULERA AEROSOL 100
MCG-5 MCG/ACTUATION
DULERA AEROSOL 200
MCG-5 MCG/ACTUATION
EPIPEN 2-PAK 0.3 MG
AUTO-INJCT
EPIPEN JR 2-PAK 0.15 MG
INJCTR
FORADIL CAPSULE 12
MCG
levalbuterol concentrate
nebulized soln 1.25 mg/0.5 ml
levalbuterol hcl nebulized soln
0.31 mg/3 ml
levalbuterol hcl nebulized soln
0.63 mg/3 ml
metaproterenol sulfate syrup
10 mg/5 ml
2
AP
2
2
2
2
2
3
4
LC
4
LC; AP
3
3
3
3
4
2
AP
2
AP
2
AP
2
70
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
/Límites
metaproterenol sulfate tablet
2
10mg
metaproterenol sulfate tablet
2
20mg
methyldopa tablet 250mg
2
methyldopa tablet 500mg
2
methyldopahydrochlorothiazide tablet
2
250-15mg
methyldopahydrochlorothiazide tablet
2
250-25mg
midodrine hcl tablet 10mg
2
midodrine hcl tablet 2.5mg
2
midodrine hcl tablet 5mg
2
PERFOROMIST
NEBULIZED SOLN 20
4 AP
MCG/2 ML
PROAIR HFA AEROSOL
3
SOLN 90 MCG
SEREVENT DISKUS AERO
3
POW BR ACT 50 MCG
SYMBICORT AEROSOL 160
3
MCG-4.5 MCG/ACTUATION
SYMBICORT AEROSOL 803
4.5MCG
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
2
50mg
2
5mg
cevimeline hcl capsule 30mg
2
donepezil hcl odt tablet
2
disperse 10mg
donepezil hcl odt tablet
2
disperse 5mg
donepezil hcl tablet 10mg
2
2
2
EXELON PATCH 24HR 13.3
4
MG/24 HOUR
4
MG/24 HOUR
4
MG/24 HOUR
galantamine hbr capsule er
2
24hr 16mg
2
24hr 24mg
2
24hr 8mg
71
Medicamento
Nivel Requisitos
/Límites
galantamine hbr tablet 12mg
2
2
2
galantamine hydrobromide
2
solution 4 mg/ml
MESTINON SYRUP 60
4
MG/5 ML
MESTINON TABLET ER
3
180MG
pilocarpine hcl tablet 5mg
2
pilocarpine hcl tablet 7.5mg
2
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
carisoprodol compound tablet
200-325mg
2 LC; AP
carisoprodol compound2 AP
codeine tablet 16-200-325mg
carisoprodol tablet 350mg
2 LC; AP
chlorzoxazone tablet 500mg
2 AP
cyclobenzaprine hcl tablet
2 AP
10mg
cyclobenzaprine hcl tablet 5mg 2 AP
cyclobenzaprine hcl tablet
2 AP
7.5mg
dantrolene sodium capsule
2
100mg
Medicamento
Nivel Requisitos
/Límites
2
25mg
2
50mg
metaxalone tablet 800mg
2 AP
methocarbamol tablet 500mg
2 AP
methocarbamol tablet 750mg
2 AP
orphenadrine citrate tablet er
2 AP
12hr 100mg
SOMA TABLET 250MG
4 LC; AP; TE
tizanidine hcl capsule 2mg
2 LC
2 LC
2 LC
tizanidine hcl tablet 2mg
2
tizanidine hcl tablet 4mg
2
SIMPATICOLÍTICO AGENTES BLOQUEANTES
ADRENÉRGICOS
acebutolol hcl capsule 200mg
2
acebutolol hcl capsule 400mg
2
alfuzosin hcl er tablet er 24hr
2
10mg
atenolol tablet 100mg
2
2
2
atenolol-chlorthalidone tablet
2
100-25mg
atenolol-chlorthalidone tablet
2
50-25mg
betaxolol hcl tablet 20mg
2
bisoprolol fumarate tablet
2
10mg
bisoprolol fumarate tablet 5mg 2
bisoprolol-hydrochlorothiazide
2
tablet 10-6.25mg
72
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
COREG CR CAPSULE ER
24HR 10MG
COREG CR CAPSULE ER
24HR 20MG
COREG CR CAPSULE ER
24HR 40MG
COREG CR CAPSULE ER
24HR 80MG
DIBENZYLINE CAPSULE
10MG
dihydroergotamine mesylate
solution 1 mg/ml
doxazosin mesylate tablet 1mg
2
2
3
LC
3
LC
3
LC
3
LC
4
4
2
2
2
2
4
4
4
4
4
2
2
2
AP
/Límites
ergoloid mesylates tablet 1mg
INNOPRAN XL CAPSULE
ER 24HR 120MG
INNOPRAN XL CAPSULE
ER 24HR 80MG
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
25mg
50mg
metoprololhydrochlorothiazide tablet
100-25mg
metoprololhydrochlorothiazide tablet
100-50mg
metoprololhydrochlorothiazide tablet 5025mg
MIGRANAL SOLUTION 0.5
MG/PUMP ACTUATION (4
MG/ML)
2
2
2
AP
3
3
4
2
2
2
2
2
2
2
2
2
2
2
2
2
4
73
Medicamento
Nivel Requisitos
/Límites
nadolol tablet 20mg
nadolol tablet 40mg
nadolol tablet 80mg
nadolol-bendroflumethiazide
tablet 40-5mg
nadolol-bendroflumethiazide
tablet 80-5mg
pindolol tablet 10mg
pindolol tablet 5mg
prazosin hcl capsule 1mg
propranolol hcl er capsule er
24hr 120mg
24hr 160mg
24hr 60mg
24hr 80mg
propranolol hcl solution 20
mg/5 ml
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
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
Medicamento
Nivel Requisitos
/Límites
sorine tablet 240mg
2
sorine tablet 80mg
2
sotalol af tablet 120mg
2
sotalol tablet 160mg
2
sotalol tablet 240mg
2
sotalol tablet 80mg
2
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
74
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
10-20mg
10-40mg
10-80mg
2.5-10mg
2.5-20mg
2.5-40mg
5-10mg
5-20mg
5-40mg
5-80mg
atorvastatin calcium tablet
10mg
20mg
40mg
80mg
cholestyramine light packet 4
gram
colestipol hcl granules 5 gram
colestipol hcl tablet 1 gram
CRESTOR TABLET 10MG
CRESTOR TABLET 20MG
CRESTOR TABLET 40MG
CRESTOR TABLET 5MG
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
2
TE
1
1
1
1
2
2
2
3
3
3
3
/Límites
fenofibrate capsule 130mg
fenofibrate tablet 145mg
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
KYNAMRO SOLUTION 200
MG/ML
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
2
LC
2
LC
2
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
75
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
20mg
40mg
80mg
prevalite powder 4 gram
4
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
LC
4
LC
4
LC
1
1
1
2
2
2
2
1
1
1
1
2
/Límites
SIMCOR TABLET ER 24HR
1,000-20MG
1,000-40MG
500-20MG
500-40MG
750-20MG
simvastatin tablet 10mg
VASCEPA CAPSULE 1
GRAM
VYTORIN TABLET 1010MG
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
3
LC; TE
3
LC
3
LC
76
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/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
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
AMTURNIDE TABLET 1505-12.5MG
3
LC
4
4
3
2
2
2
2
4
2
2
2
2
2
2
2
2
2
2
2
4
LC; TE
/Límites
AMTURNIDE TABLET 30010-25MG
AMTURNIDE TABLET 3005-25MG
AZOR TABLET 10-20MG
AZOR TABLET 10-40MG
AZOR TABLET 5-20MG
AZOR TABLET 5-40MG
benazepril hcl tablet 10mg
benazeprilhydrochlorothiazide tablet 1012.5mg
benazeprilhydrochlorothiazide tablet 2025mg
BENICAR HCT TABLET 2012.5MG
BENICAR HCT TABLET 4012.5MG
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
4
4
4
1
1
1
1
1
1
1
1
4
LC
4
LC
77
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
8mg
candesartanhydrochlorothiazide tablet 1612.5mg
candesartanhydrochlorothiazide tablet 3212.5mg
candesartanhydrochlorothiazide tablet 3225mg
captopril tablet 100mg
captopril tablet 12.5mg
4
LC
4
LC
4
LC
4
LC
2
2
2
2
2
LC
2
LC
2
LC
2
LC
2
LC
2
2
1
1
1
LC
LC
/Límites
captopril-hydrochlorothiazide
tablet 25-15mg
tablet 25-25mg
tablet 50-15mg
tablet 50-25mg
cartia xt capsule er 24hr
120mg
300mg
chlorothiazide tablet 250mg
chlorothiazide tablet 500mg
chlorthalidone tablet 25mg
chlorthalidone tablet 50mg
clonidine hcl er tablet er 12hr
0.1mg
clonidine hcl tablet 0.1mg
clonidine patch weekly 0.1
mg/24 hour
mg/24 hour
mg/24 hour
CLORPRES TABLET 0.115MG
DIOVAN TABLET 160MG
1
1
1
1
1
2
2
2
2
2
2
2
LC
2
2
2
2
2
2
3
3
3
3
LC
78
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
DIOVAN TABLET 320MG
DIOVAN TABLET 40MG
DIOVAN TABLET 80MG
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
enalapril-hydrochlorothiazide
tablet 5-12.5mg
eplerenone tablet 25mg
eplerenone tablet 50mg
eprosartan mesylate tablet
600mg
3
LC
3
LC
3
LC
3
3
3
4
4
4
4
4
4
1
1
1
1
1
1
2
2
TE
TE
2
LC
/Límites
EXFORGE HCT TABLET
10-160-12.5MG
EXFORGE HCT TABLET
10-160-25MG
EXFORGE HCT TABLET
10-320-25MG
EXFORGE HCT TABLET 5160-12.5MG
EXFORGE HCT TABLET 5160-25MG
EXFORGE TABLET 10160MG
felodipine er tablet er 24hr
10mg
2.5mg
5mg
fosinopril sodium tablet 10mg
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
3
LC
2
2
2
1
1
79
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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 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
INTUNIV TABLET ER 24HR
1MG
2MG
3MG
1
1
1
2
2
AP
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
LC
4
LC
4
LC
/Límites
4MG
irbesartan tablet 150mg
irbesartanhydrochlorothiazide tablet
150-12.5mg
irbesartanhydrochlorothiazide tablet
300-12.5mg
isradipine capsule 2.5mg
isradipine capsule 5mg
lisinopril tablet 10mg
lisinopril tablet 2.5mg
lisinopril-hydrochlorothiazide
tablet 10-12.5mg
tablet 20-12.5mg
tablet 20-25mg
losartan potassium tablet
100mg
25mg
4
LC
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
80
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
50mg
losartan-hydrochlorothiazide
tablet 100-12.5mg
tablet 100-25mg
tablet 50-12.5mg
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
nifedipine er tablet er 24hr
30mg
60mg
90mg
nimodipine capsule 30mg
nisoldipine tablet er 24hr
17mg
1
1
1
1
2
2
2
2
2
2
1
1
1
1
1
2
2
2
2
2
2
2
2
LC
/Límites
20mg
25.5mg
30mg
34mg
40mg
8.5mg
perindopril erbumine tablet
2mg
4mg
8mg
PROGLYCEM SUSPENSION
50 MG/ML
quinapril hcl tablet 10mg
quinapril-hydrochlorothiazide
tablet 10-12.5mg
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
1
1
1
4
1
1
1
1
1
1
1
1
1
1
1
2
2
2
81
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
spironolactone-hctz tablet 2525mg
TARKA TABLET ER 1240MG
TEKAMLO TABLET 15010MG
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
2
2
2
4
4
4
4
4
LC; TE
4
LC; TE
4
LC; TE
4
LC; TE
4
TE
4
TE
4
TE
4
TE
4
LC; TE
4
LC; TE
/Límites
telmisartan tablet 20mg
telmisartan-amlodipine tablet
40-10mg
40-5mg
80-10mg
80-5mg
telmisartanhydrochlorothiazide tablet 4012.5mg
telmisartanhydrochlorothiazide tablet 8012.5mg
telmisartanhydrochlorothiazide tablet 8025mg
TEVETEN HCT TABLET
600-12.5MG
TEVETEN HCT TABLET
600-25MG
TEVETEN TABLET 400MG
torsemide solution 20 mg/2 ml
(10 mg/ml)
torsemide tablet 100mg
2
LC
2
LC
2
LC
2
2
2
2
2
LC
2
LC
2
LC
4
LC
4
LC
4
LC
2
2
2
2
2
82
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
trandolapril tablet 1mg
triamterenehydrochlorothiazide capsule
37.5-25mg
triamterenehydrochlorothiazide capsule
50-25mg
triamterenehydrochlorothiazide tablet
37.5-25mg
triamterenehydrochlorothiazide tablet 7550mg
TRIBENZOR TABLET 20-512.5MG
TRIBENZOR TABLET 4010-25MG
TRIBENZOR TABLET 40-525MG
valsartan tablet 160mg
valsartan-hydrochlorothiazide
tablet 160-12.5mg
1
1
1
2
2
2
2
4
LC
4
LC
4
LC
4
LC
4
LC
2
LC
2
LC
2
LC
2
LC
2
LC
/Límites
tablet 160-25mg
tablet 320-12.5mg
tablet 320-25mg
tablet 80-12.5mg
AGENTES VASODILANTES
ADCIRCA TABLET 20MG
ADEMPAS TABLET 0.5MG
ADEMPAS TABLET 1MG
ADEMPAS TABLET 2MG
afeditab cr tablet er 24hr
60mg
dipyridamole tablet 25mg
ISORDIL TABLET 40MG
isosorbide dinitrate tab
sublingual 2.5mg
isosorbide dinitrate tablet
10mg
20mg
2
LC
2
LC
2
LC
2
LC
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
5
LC; AP
2
2
2
2
4
AP
AP
AP
2
2
2
83
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
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
nifedical xl tablet er 24hr
60mg
NITRO-BID OINTMENT 2 %
nitroglycerin patch patch 24hr
0.1 mg/hour
0.2 mg/hour
2
2
2
2
2
2
2
2
3
LC; AP; AL
3
LC; AP; AL
2
2
2
2
2
4
2
2
/Límites
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
REMODULIN SOLUTION
2.5 MG/ML
MG/ML
sildenafil tablet 20mg
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
5
AP
5
AP
2
LC; AP
84
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
TRACLEER TABLET
3
125MG
TRACLEER TABLET
3
62.5MG
VENTAVIS SOLUTION 10
5
MCG/ML
VENTAVIS SOLUTION 20
5
MCG/ML
MEDICAMENTOS CARDÍACOS
amiodarone hcl tablet 200mg
2
amiodarone hcl tablet 400mg
2
2
180mg
2
240mg
digoxin solution 50 mcg/ml
2
digoxin tablet 125 mcg
2
digoxin tablet 250 mcg
2
DILATRATE-SR CAPSULE
4
ER 40MG
dilt-cd capsule er 24hr 300mg
2
dilt-xr capsule er 24hr 120mg
2
2
2
diltiazem 24hr cd capsule er
2
24hr 300mg
diltiazem 24hr er capsule er
2
24hr 120mg
diltiazem 24hr er capsule er
2
24hr 240mg
diltiazem er capsule er 12hr
2
120mg
2
60mg
AP; AL
AP; AL
AP
AP
/Límites
90mg
180mg
360mg
420mg
diltiazem hcl tablet 120mg
disopyramide phosphate
capsule 100mg
disopyramide phosphate
capsule 150mg
flecainide acetate tablet
100mg
flecainide acetate tablet
150mg
flecainide acetate tablet 50mg
matzim la tablet er 24hr
180mg
240mg
300mg
360mg
420mg
mexiletine hcl capsule 150mg
MULTAQ TABLET 400MG
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
85
Medicamento
Nivel Requisitos
/Límites
NORPACE CR CAPSULE ER
12HR 100MG
NORPACE CR CAPSULE ER
12HR 150MG
pacerone tablet 100mg
pacerone tablet 200mg
capsule 100mg
capsule 200mg
propafenone hcl capsule er
12hr 225mg
12hr 325mg
12hr 425mg
propafenone hcl tablet 150mg
RANEXA TABLET ER 12HR
1,000MG
RANEXA TABLET ER 12HR
500MG
taztia xt capsule er 24hr
120mg
180mg
240mg
300mg
360mg
TIKOSYN CAPSULE 125
MCG
4
4
4
2
2
2
2
2
2
2
2
2
3
LC; TE
3
LC; TE
2
2
2
2
2
3
Medicamento
Nivel Requisitos
/Límites
TIKOSYN CAPSULE 250
3
MCG
TIKOSYN CAPSULE 500
3
MCG
verapamil er capsule er 24hr
2
120mg
2
180mg
2
240mg
verapamil er pm capsule er
2
24hr 100mg
2
24hr 200mg
2
24hr 300mg
verapamil er tablet er 120mg
2
2
2
verapamil hcl capsule er 24hr
2
360mg
verapamil hcl tablet 120mg
2
2
2
MEDICAMENTOS GASTROINTESTINALES(GI
AGENTES ANTIDIARREICOS
diphenoxylate-atropine tablet
2 AP
2.5-0.025mg
loperamide capsule 2mg
2
MOTOFEN TABLET 14
0.025MG
AGENTES ANTIINFLAMATORIOS
(MEDICAMENTOS GI)
APRISO CAPSULE ER 24HR
3
0.375 GRAM
ASACOL HD TABLET DR
4
800MG
86
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
balsalazide disodium capsule
2
750mg
CANASA SUPPOSITORY
3
1,000MG
DELZICOL CAPSULE DR
4
400MG
DIPENTUM CAPSULE
3
250MG
LIALDA TABLET DR 1.2
GRAM
4 LC
LOTRONEX TABLET
0.5MG
4 LC
LOTRONEX TABLET 1MG
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
AGENTES ANTIULCEROSOS Y SUPRESORES
DEL ÁCIDO
CARAFATE SUSPENSION 1
4
GRAM/10 ML
cimetidine solution 300 mg/5
2
ml
cimetidine tablet 200mg
2
2
2
2
DEXILANT CAPSULE DR
30MG
3 LC; TE
DEXILANT CAPSULE DR
60MG
3 LC; TE
/Límites
esomeprazole strontium
capsule dr 49.3mg
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 CAPSULE DR
20MG
NEXIUM PACKET 10MG
NEXIUM PACKET 2.5MG
NEXIUM PACKET 20MG
NEXIUM PACKET 40MG
NEXIUM PACKET 5MG
nizatidine capsule 150mg
nizatidine capsule 300mg
nizatidine solution 150 mg/10
ml
omeprazole capsule dr 10mg
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
4
LC; TE
2
2
2
2
LC
2
LC
2
LC
87
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
pantoprazole sodium for
2 AP
solution 40mg
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
4 LC
ursodiol capsule 300mg
2
ursodiol tablet 250mg
2
ursodiol tablet 500mg
2
AGENTES PROCINÉTICOS
/Límites
metoclopramide hcl solution 5
mg/5 ml
metoclopramide hcl tablet
10mg
metoclopramide hcl tablet 5mg
METOZOLV ODT TABLET
DISPERSE 10MG
METOZOLV ODT TABLET
DISPERSE 5MG
ANTIEMÉTICOS
ANZEMET TABLET 100MG
ANZEMET TABLET 50MG
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)
granisetron hcl tablet 1mg
ondansetron hcl solution 4
mg/2 ml
ondansetron hcl solution 4
mg/5 ml
ondansetron hcl tablet 24mg
2
2
2
4
4
4
4
4
AP
AP
2
LC
2
LC
2
LC
4
LC
4
LC
4
LC
4
LC
2
AP
2
AP
2
AP
2
AP
88
Medicamento
Nivel Requisitos
/Límites
ondansetron odt tablet
disperse 4mg
ondansetron odt tablet
disperse 8mg
promethazine hcl solution 25
mg/ml
promethazine hcl solution 50
mg/ml
promethazine hcl suppository
12.5mg
promethazine hcl suppository
25mg
promethazine hcl syrup 6.25
mg/5 ml
promethazine hcl tablet
12.5mg
promethazine hcl tablet 25mg
promethazine hcl tablet 50mg
promethegan suppository
25mg
SANCUSO PATCH 3.1
MG/24 HOUR
CATÁRTICOS Y LAXANTES
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
2
AP
AP
2
AP
2
AP
2
AP
2
AP
2
2
2
AP
2
AP
2
2
AP
AP
2
4
AP
3
LC
3
LC
2
2
2
Medicamento
Nivel Requisitos
/Límites
GOLYTELY FOR
SOLUTION 227.1 GRAM4
21.5 GRAM-6.36 GRAM-5.53
GRAM-2.82 GRAM
HALFLYTELYBISACODYL KIT 54
210GRAMMG
LINZESS CAPSULE 145
MCG
4 LC
LINZESS CAPSULE 290
MCG
4 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 KIT 12 MG/0.6
4 AP
ML
SUPREP SOLUTION 17.5
GRAM-3.13 GRAM-1.6
4
GRAM
trilyte with flavor packets for
2
solution 420 gram
MEDICAMENTOS de la DIGESTIÓN
CREON CAPSULE DR
PART 12,000 UNIT-38,000
3
UNIT-60,000 UNIT
CREON CAPSULE DR
PART 24,000 UNIT-76,000
3
UNIT-120,000 UNIT
CREON CAPSULE DR
PART 3,000 UNIT-9,500
3
UNIT-15,000 UNIT
89
Medicamento
Nivel Requisitos
/Límites
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
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
3
3
3
3
3
3
3
3
4
4
4
4
Medicamento
Nivel Requisitos
/Límites
VIOKACE TABLET 20,880
UNIT-78,300 UNIT-78,300
4
UNIT
ZENPEP CAPSULE DR
PART 10,000 UNIT-34,000
3
UNIT-55,000 UNIT
ZENPEP CAPSULE DR
PART 15,000 UNIT-51,000
3
UNIT-82,000 UNIT
ZENPEP CAPSULE DR
PART 20,000 UNIT-68,000
3
UNIT-109,000 UNIT
ZENPEP CAPSULE DR
PART 25,000 UNIT-85,000
3
UNIT-136,000 UNIT
ZENPEP CAPSULE DR
PART 3,000 UNIT-10,000
3
UNIT-16,000 UNIT
ZENPEP CAPSULE DR
PART 5,000 UNIT-17,000
3
UNIT-27,000 UNIT
OXYTOCICOS
OXYTOCICOS
methylergonovine maleate
2
tablet 0.2mg
PREPARACIONES PARA EL OJO, OÍDO,
NARIZ, Y GARGANTA (en inglés EENT)
AGENTES ANTIALÉRGICOS
ALOMIDE SOLUTION 0.1 % 4
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
90
Medicamento
Nivel Requisitos
/Límites
EMADINE SOLUTION 0.05
4
%
LASTACAFT SOLUTION
4
0.25 %
PATADAY SOLUTION 0.2
4
%
PATANASE SOLUTION 0.6
4
%
PATANOL SOLUTION 0.1 % 4
AGENTES ANTIGLAUCOMA
ALPHAGAN P SOLUTION
3
0.1 %
AZOPT SUSPENSION 1 %
4
betaxolol hcl solution 0.5 %
2
BETIMOL SOLUTION 0.25
4
%
BETIMOL SOLUTION 0.5 %
4
BETOPTIC S SUSPENSION
3
0.25 %
brimonidine tartrate solution
2
0.15 %
brimonidine tartrate solution
2
0.2 %
COMBIGAN SOLUTION 0.2
%-0.5 %
3
dia(s)
dorzolamide hcl solution 2 %
2
dorzolamide-timolol solution 2
2
%-0.5 %
ISTALOL SOLUTION 0.5 %
4
latanoprost solution 0.005 %
2
levobunolol hcl solution 0.5 %
2
LC
Medicamento
Nivel Requisitos
/Límites
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
%
ALREX SUSPENSION 0.2 %
4
BROMDAY SOLUTION 0.09
4
%
bromfenac sodium solution
2
0.09 %
2
phosphate solution 0.1 %
diclofenac sodium solution 0.1
2
%
DUREZOL EMULSION 0.05
4
%
91
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
FLAREX SUSPENSION 0.1
4
%
fluocinolone acetonide oil oil
2
0.01 %
fluorometholone suspension
2
0.1 %
flurbiprofen sodium solution
2
0.03 %
FML FORTE SUSPENSION
4
0.25 %
FML SUSPENSION 0.1 %
4
ILEVRO SUSPENSION 0.3
4
%
ketorolac tromethamine
2
solution 0.4 %
ketorolac tromethamine
2
solution 0.5 %
LOTEMAX GEL 0.5 %
4
LOTEMAX OINTMENT 0.5
4
%
LOTEMAX SUSPENSION
4
0.5 %
MAXIDEX SUSPENSION
4
0.1 %
NEVANAC SUSPENSION
4
0.1 %
PRED MILD SUSPENSION
4
0.12 %
prednisolone acetate
2
suspension 1 %
prednisolone sodium
2
phosphate solution 1 %
RESTASIS EMULSION 0.05
4
%
VEXOL SUSPENSION 1 %
4
ANESTÉSICOS LOCALES (EENT)
lidocaine hcl gel 2 %
2
/Límites
lidocaine hcl solution 40
mg/ml
lidocaine hcl viscous solution
2%
proparacaine hcl solution 0.5
%
ANTIINFECTIVOS (EENT)
acetasol hc solution 2 %-1 %
acetic acid solution 2 %
AZASITE SOLUTION 1 %
bacitracin-polymyxin ointment
500 unit-10,000 unit/gram
BACTROBAN NASAL
OINTMENT 2 %
BESIVANCE SUSPENSION
0.6 %
BLEPHAMIDE S.O.P.
OINTMENT 10 %-0.2 %
BLEPHAMIDE
SUSPENSION 10 %-0.2 %
CILOXAN OINTMENT 0.3
%
CIPRO HC SUSPENSION 0.2
%-1 %
CIPRODEX SUSPENSION
0.3 %-0.1 %
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 %)
2
2
2
2
2
4
2
4
4
4
4
4
3
3
2
4
4
2
92
Medicamento
Nivel Requisitos
/Límites
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 %
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 %
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
2
Medicamento
Nivel Requisitos
/Límites
polymyxin b sul-trimethoprim
2
solution 10,000 unit-1 mg/ml
PRED-G OINTMENT 0.3 %4
0.6 %
PRED-G SUSPENSION 0.3
4
%-1 %
sulfacetamide sodium ointment
2
10 %
sulfacetamide sodium solution
2
10 %
sulfacetamide-prednisolone
2
solution 10 %-0.23 % (0.25 %)
TOBRADEX OINTMENT 0.3
3
%-0.1 %
TOBRADEX ST
4
SUSPENSION 0.3 %-0.05 %
tobramycin solution 0.3 %
2
tobramycin-dexamethasone
2
suspension 0.3 %-0.1 %
TOBREX OINTMENT 0.3 %
4
trifluridine solution 1 %
2
VIGAMOX SOLUTION 0.5
4
%
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
93
Medicamento
Nivel Requisitos
/Límites
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)
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
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
BIWEEKLY 3.9 MG/24
4
HOUR
tolterodine tartrate er capsule
2
er 24hr 2mg
Medicamento
Nivel Requisitos
/Límites
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 solution 250
2 AP
mg/10 ml
theophylline anhydrous tablet
2
er 12hr 100mg
2
er 12hr 200mg
2
er 12hr 300mg
2
er 12hr 450mg
theophylline solution 80 mg/15
2
ml
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
94
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
GAMASTAN S-D
INJECTABLE 15 %-18 %
RANGE
GAMMAGARD LIQUID
SOLUTION 10 %
GAMMAPLEX SOLUTION 5
%
GAMUNEX-C SOLUTION 1
GRAM/10 ML (10 %)
PRIVIGEN SOLUTION 10 %
TOXOIDES
ADACEL TDAP
SUSPENSION 2 LF UNIT(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
INFANRIX DTAP
SUSPENSION 25 LF UNIT58 MCG-10 LF/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
CERVARIX SUSPENSION
20 MCG-20 MCG/0.5 ML
COMVAX SUSPENSION 5
MCG-7.5 MCG-125 MCG/0.5
ML
3
AP
5
AP
5
AP
4
AP
5
AP
3
3
3
3
2
3
3
3
4
/Límites
ENGERIX-B ADULT
SUSPENSION 20 MCG/ML
ENGERIX-B PEDIATRICADOLESCENT
SUSPENSION 10 MCG/0.5
ML
GARDASIL SUSPENSION
20 MCG-40 MCG-40 MCG20 MCG/0.5 ML
GARDASIL SUSPENSION
20 MCG-40 MCG-40 MCG20 MCG/0.5 ML
dia(s)
HAVRIX SUSPENSION
1,440 ELISA UNIT/ML
HAVRIX SUSPENSION 720
ELISA UNIT/0.5 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 SOLUTION
7.5 MCG/0.5 ML
3
AP
3
AP
3
3
LC
3
3
3
3
3
3
3
3
3
3
95
Medicamento
Nivel Requisitos
Medicamento
Nivel Requisitos
/Límites
PROQUAD INJECTABLE
10EXP3-10EXP4.3-10EXP310EXP3.99 TCID50/0.5 ML
RABAVERT FOR
SUSPENSION 2.5 UNIT
RECOMBIVAX HB
RECOMBIVAX HB
RECOMBIVAX HB
SUSPENSION 5 MCG/0.5
ML
ROTATEQ SOLUTION 2 ML
tetanus toxoid adsorbed
solution 5 lf unit/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
ZOSTAVAX FOR
SOLUTION 19,400
UNIT/0.65 ML
SUMINISTROS
SUMINISTROS
alcohol swabs pad
gauze pads pad 2" x 2"
3
3
3
AP
3
AP
3
AP
3
3
3
AP
3
3
3
3
3
/Límites
INSULIN SYRINGE MISC
29 GAUGE
29 GAUGE X 7/16"
30 GAUGE
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
paricalcitol capsule 1 mcg
VITAMINAS PRENATALES
PRENATAL VITAMINS
2
LC
2
LC
2
LC
2
LC
2
2
2
2
2
2
2
2
2
3
LC
3
2
2
LC
96
Índice
8-MOP ...................................... 18
abacavir ...................................... 2
abacavir-lamivudine-zidovudine 2
ABILIFY .................................. 26
ABILIFY DISCMELT ............. 26
ABILIFY MAINTENA............ 26
ABSTRAL ............................... 34
acamprosate calcium ................ 25
ACANYA................................. 18
acarbose .................................... 59
acebutolol hcl ........................... 72
acetaminophen-butalbital ......... 34
acetaminophen-codeine ............ 34
acetasol hc ................................ 92
acetazolamide ........................... 77
acetic acid ................................. 92
acetylcysteine ........................... 50
acitretin ..................................... 18
ACTHIB ................................... 95
ACTIMMUNE ......................... 51
ACTONEL ............................... 50
ACTOPLUS MET XR ........ 59,60
ACUVAIL ................................ 91
acyclovir ................................ 2,18
acyclovir sodium ........................ 2
ACZONE ................................. 18
ADACEL TDAP ...................... 95
ADAGEN ................................. 56
adapalene .................................. 18
ADCIRCA ................................ 83
adefovir dipivoxil ....................... 2
ADEMPAS............................... 83
ADRENALIN .......................... 70
ADVAIR DISKUS ................... 70
ADVAIR HFA ......................... 70
ADVICOR ............................... 74
afeditab cr ............................ 77,83
AFINITOR ............................... 11
AFINITOR DISPERZ .............. 11
AGGRENOX ............................ 56
AKNE-MYCIN......................... 19
ALBENZA .................................. 1
albuterol sulfate ........................ 70
alclometasone dipropionate ...... 16
alcohol swabs ............................ 96
ALDACTAZIDE ...................... 77
ALDURAZYME ...................... 56
alendronate sodium .............. 50,51
alfuzosin hcl er .......................... 72
ALIMTA ................................... 11
ALINIA....................................... 2
allopurinol ................................. 49
ALOCRIL ................................. 20
ALOMIDE ................................ 90
ALORA..................................... 66
ALPHAGAN P ......................... 91
alprazolam................................. 48
alprazolam er ............................ 48
ALPRAZOLAM INTENSOL .. 48
alprazolam odt .......................... 48
ALREX ..................................... 91
ALTABAX ............................... 19
ALTOPREV ............................. 74
ALVESCO ................................ 20
amantadine .................................. 2
AMBISOME ............................... 1
amcinonide ................................ 16
amethia ...................................... 64
AMETHYST............................. 65
amifostine ................................. 50
amikacin sulfate .......................... 5
amiloride hcl ............................. 77
amiloride-hydrochlorothiazide . 77
aminophylline ........................... 94
aminosyn ................................... 53
aminosyn ii................................ 53
AMINOSYN II ......................... 53
AMINOSYN M ........................ 53
AMINOSYN WITH
ELECTROLYTES ....................53
AMINOSYN-HBC ...................53
AMINOSYN-PF .......................53
AMINOSYN-RF .......................53
amiodarone hcl ..........................85
AMITIZA..................................89
amitriptyline hcl ........................26
amlodipine besylate ..................77
amlodipine besylate-benazepril 77
amlodipine-atorvastatin .......74,75
amnesteem ................................18
amox tr-potassium clavulanate ...5
amoxapine .................................26
amoxicillin ..................................5
amoxicillin-clavulanate er...........5
amphetamine salt combo ..........41
amphotericin b ............................1
ampicillin sodium .......................5
ampicillin trihydrate .................5,6
ampicillin-sulbactam ...................6
AMPYRA .................................52
AMTURNIDE ..........................77
anagrelide hcl ............................56
anastrozole ................................11
ANDROGEL ............................64
ANDROID ................................64
ANDROXY ..............................64
ANGELIQ .................................66
ANORO ELLIPTA ...................69
ANZEMET ...............................88
APLENZIN ...............................26
APOKYN ..................................23
apraclonidine hcl .......................93
apri ............................................65
APRISO ....................................86
APTIOM ...................................44
APTIVUS....................................2
ARALAST NP ..........................22
aranelle ......................................65
ARANESP ............................... 58
ARCALYST............................. 52
ARCAPTA NEOHALER ........ 70
ARRANON .............................. 11
ARZERRA ............................... 11
ASACOL HD ........................... 86
ascomp with codeine ................ 34
ASMANEX .............................. 21
ASTAGRAF XL ...................... 49
ATELVIA ................................ 51
atenolol ..................................... 72
atenolol-chlorthalidone ............ 72
ATGAM ................................... 49
atorvastatin calcium ................. 75
atovaquone ................................. 2
ATRALIN ................................ 20
ATRIPLA ................................... 2
ATROVENT HFA ................... 69
AVANDAMET ........................ 60
AVANDARYL ........................ 60
AVANDIA ............................... 60
AVASTIN ................................ 11
AVELOX ABC PACK .............. 1
aviane ....................................... 65
avita .......................................... 20
AVODART .............................. 50
AVONEX ................................. 51
AVONEX ADMINISTRATION
PACK ....................................... 51
AXERT .................................... 22
AXIRON .................................. 64
azacitidine ................................ 11
AZASAN ................................. 49
AZASITE ................................. 92
azathioprine .............................. 49
azelastine hcl ............................ 90
AZELEX .................................. 18
AZILECT ................................. 23
azithromycin............................... 6
AZOPT ..................................... 91
AZOR ....................................... 77
aztreonam ................................... 6
bacitracin-polymyxin................ 92
baclofen .................................... 72
BACTROBAN NASAL ........... 92
balsalazide disodium ................ 87
balziva ...................................... 65
BANZEL .................................. 44
BARACLUDE............................ 2
bcg vaccine (tice strain) ............ 95
BECONASE AQ ...................... 21
BELEODAQ ............................ 11
benazepril hcl ........................... 77
benazepril-hydrochlorothiazide 77
BENICAR ................................ 78
BENICAR HCT .................. 77,78
benztropine mesylate ................ 69
BEPREVE ................................ 90
BESIVANCE............................ 92
betamethasone dipropionate ..... 16
betamethasone valerate............. 16
betaxolol hcl ................... 72,78,91
bethanechol chloride................. 71
BETIMOL ................................ 91
BETOPTIC S ............................ 91
BEYAZ..................................... 65
bicalutamide ............................. 11
BICILLIN C-R ........................... 6
BICILLIN L-A ........................... 6
BICNU...................................... 11
BILTRICIDE .............................. 1
bisoprolol fumarate................... 72
bisoprolol-hydrochlorothiazide72,7
BIVIGAM ................................ 94
bleomycin sulfate ..................... 11
BLEPHAMIDE ........................ 92
BLEPHAMIDE S.O.P. ............. 92
BOOSTRIX TDAP................... 95
BOSULIF ................................. 11
BREO ELLIPTA ...................... 70
briellyn ...................................... 65
BRILINTA................................ 56
brimonidine tartrate .................. 91
BRINTELLIX ........................... 26
BROMDAY .............................. 91
bromfenac sodium .................... 91
bromocriptine mesylate ............ 23
BROVANA .............................. 70
budeprion sr .............................. 26
budesonide ................................ 21
budesonide ec ........................... 58
bumetanide................................ 78
BUPHENYL ............................. 54
buprenorphine hcl ..................... 34
buprenorphine-naloxone ........... 34
buproban ................................... 26
bupropion hcl ....................... 26,27
bupropion hcl sr ........................ 26
bupropion xl .............................. 27
buspirone hcl............................. 43
BUSULFEX.............................. 11
butalb-caff-acetaminoph-codein34
butalbital-acetaminophen-caffe 35
butalbital-aspirin-caffeine ......... 35
butorphanol tartrate................... 35
BUTRANS................................ 35
BYDUREON ............................ 60
INJ ............................................ 60
INJ ............................................ 60
BYSTOLIC ............................... 73
cabergoline................................ 23
calcipotriene.............................. 18
calcipotriene-betamethasone dp 16
calcitonin-salmon...................... 68
calcitriol ............................... 18,96
calcium acetate ......................... 54
CAMBIA .................................. 35
camila........................................ 65
CANASA ................................. 87
CANCIDAS ............................... 1
candesartan cilexetil ................. 78
candesartan-hydrochlorothiazide
.................................................. 78
CANTIL ................................... 69
CAPEX SHAMPOO ................ 16
CAPITAL W-CODEINE ......... 35
CAPRELSA ........................ 11,12
captopril.................................... 78
captopril-hydrochlorothiazide .. 78
CARAC .................................... 18
CARAFATE............................. 87
carbamazepine .......................... 44
carbamazepine xr ..................... 44
carbidopa .................................. 25
carbidopa-levodopa .................. 23
carbidopa-levodopa er .............. 23
carbidopa-levodopa-entacapone
............................................. 23,24
carboplatin ................................ 12
CARDURA XL ........................ 73
CARIMUNE NF
NANOFILTERED ................... 94
carisoprodol .............................. 72
carisoprodol compound ............ 72
carisoprodol compound-codeine
.................................................. 72
carteolol hcl .............................. 93
cartia xt ................................ 78,85
carvedilol .................................. 73
CEDAX ...................................... 6
cefaclor ....................................... 6
cefaclor er ................................... 6
cefadroxil.................................... 6
cefazolin sodium ........................ 6
cefdinir ....................................... 6
cefepime hcl ............................... 6
cefotaxime sodium ..................... 6
cefpodoxime proxetil .............. 6,7
cefprozil...................................... 7
ceftazidime ................................. 7
CEFTIN ...................................... 7
ceftriaxone.................................. 7
cefuroxime ................................. 7
cefuroxime sodium..................... 7
CELEBREX ............................. 35
CELLCEPT .............................. 49
CELONTIN.............................. 44
CENESTIN .............................. 66
cephalexin .................................. 7
CEREZYME ............................ 56
CERVARIX ............................. 95
CESAMET ............................... 88
cevimeline hcl .......................... 71
CHANTIX................................ 71
CHEMET ................................. 53
CHENODAL............................ 88
chloramphenicol sod succinate .. 7
chlordiazepoxide-amitriptyline 27
chlorhexidine gluconate ........... 19
chlorothiazide ........................... 78
chlorpromazine hcl................... 27
chlorthalidone .......................... 78
chlorzoxazone .......................... 72
cholestyramine light ................. 75
chorionic gonadotropin ............ 68
ciclopirox ................................. 19
cidofovir ..................................... 2
cilostazol .................................. 56
CILOXAN................................ 92
cimetidine ................................. 87
CIPRO ........................................ 7
CIPRO HC ............................... 92
CIPRODEX.............................. 92
ciprofloxacin .............................. 7
ciprofloxacin er .......................... 7
ciprofloxacin hcl ................... 7,92
ciprofloxacin-d5w ...................... 7
cisplatin .................................... 12
citalopram hbr .......................... 27
cladribine.................................. 12
claravis...................................... 18
CLARINEX .............................. 69
CLARINEX-D 12 HOUR ........ 69
clarithromycin ......................... 7,8
clarithromycin er ........................ 7
CLEOCIN ................................. 19
CLEOCIN T ............................. 19
CLIMARA PRO ....................... 67
CLINDACIN PAC ................... 19
CLINDAGEL ........................... 19
clindamycin hcl .......................... 8
clindamycin pediatric ................. 8
clindamycin phosphate .......... 8,19
clindamycin phosphate-d5w ....... 8
clindamycin-benzoyl peroxide . 19
CLINIMIX................................ 53
CLINIMIX E ............................ 53
clinisol ...................................... 53
clobetasol emollient .................. 16
clobetasol propionate ................ 16
CLOBEX .................................. 16
CLODERM .............................. 16
CLOLAR .................................. 12
clomipramine hcl ...................... 27
clonazepam ............................... 48
clonidine ................................... 78
clonidine hcl ............................. 78
clonidine hcl er ......................... 78
clopidogrel ................................ 56
clorazepate dipotassium ........... 48
CLORPRES .............................. 78
clotrimazole .............................. 19
clotrimazole-betamethasone ..... 19
clozapine................................... 27
codeine sulfate .......................... 35
COLCRYS................................ 49
colestipol hcl............................. 75
colistimethate sodium ................. 8
colocort ..................................... 16
COLY-MYCIN S ..................... 92
COMBIGAN ............................ 91
COMBIPATCH ....................... 67
COMBIVENT RESPIMAT ..... 69
COMETRIQ ............................. 12
COMPLERA .............................. 2
compro...................................... 27
COMVAX ................................ 95
CONDYLOX ........................... 18
constulose ................................. 54
COPAXONE ............................ 51
COPAXONE 40 MG/ML
SYRINGE ................................ 51
CORDRAN .............................. 16
COREG CR .............................. 73
CORTIFOAM .......................... 16
cortisone acetate ....................... 59
CORTISPORIN ....................... 19
CORTISPORIN-TC ................. 92
COUMADIN ....................... 56,57
CREON ............................... 89,90
CRESTOR ................................ 75
CRINONE ................................ 68
CRIXIVAN ............................. 2,3
cromolyn sodium ...................... 21
cryselle ..................................... 65
cyclafem ................................... 65
cyclobenzaprine hcl .................. 72
cyclophosphamide .................... 12
CYCLOSET ............................. 24
cyclosporine ........................ 49,50
cyclosporine modified .............. 49
cyproheptadine hcl ................... 69
CYSTADANE ......................... 52
CYSTAGON ............................ 52
CYSTARAN ............................ 52
cytarabine ................................. 12
DALIRESP............................... 22
danazol ..................................... 64
dantrolene sodium .................... 72
dapsone ...................................... 1
DAPTACEL DTAP ................. 95
DARAPRIM .............................. 8
daunorubicin hcl ....................... 12
DAYTRANA ........................... 41
decitabine ................................. 12
DELZICOL .............................. 87
DEMSER ................................. 52
DENAVIR ................................ 19
DEPEN ..................................... 53
DEPO-ESTRADIOL................ 67
DEPO-SUBQ PROVERA 104 68
desipramine hcl ........................ 27
desloratadine ............................ 69
desmopressin acetate ................ 56
DESONATE ............................ 16
desonide ................................... 16
desoximetasone ........................ 16
dexamethasone ......................... 59
DEXAMETHASONE
INTENSOL .............................. 59
dexamethasone sodium phosphate5
DEXILANT ............................. 87
dexmethylphenidate hcl er .. 41,42
DEXPAK ................................. 59
dextroamphetamine sulfate er .. 42
dextroamphetamine-amphet er. 42
dextrose 10%-0.2% nacl .......... 53
dextrose 5%-0.2% nacl-kcl ...... 54
dextrose 5%-0.225% nacl-kcl .. 54
dextrose 5%-0.33% nacl-kcl .... 54
dextrose 5%-0.45% nacl-kcl .... 54
dextrose 5%-1/2ns-kcl ........ 54,55
dextrose 5%-ns-kcl ................... 55
dextrose 5%-potassium chloride55
dextrose in lactated ringers ...... 55
dextrose in water ...................... 53
dextrose with sodium chloride53,54
diazepam ............................. 48,49
DIAZEPAM ............................. 48
DIBENZYLINE ....................... 73
diclofenac potassium ................ 35
diclofenac sodium .......... 18,35,91
diclofenac sodium er ................ 35
diclofenac sodium-misoprostol 35
dicloxacillin sodium ................... 8
dicyclomine hcl ........................ 69
didanosine................................... 3
DIFFERIN ................................ 18
DIFICID ..................................... 8
diflorasone diacetate ............ 16,17
diflunisal ................................... 35
digoxin ...................................... 85
dihydroergotamine mesylate .... 73
DILANTIN ............................... 44
DILANTIN-125 ....................... 44
DILATRATE-SR ..................... 85
dilt-cd ....................................... 85
diltiazem 24hr cd ...................... 85
diltiazem 24hr er....................... 85
diltiazem er ............................... 85
diltiazem hcl ............................. 85
dilt-xr ........................................ 85
DIOVAN ............................. 78,79
DIPENTUM ............................. 87
diphenoxylate-atropine ............. 86
dipyridamole............................. 83
disopyramide phosphate ........... 85
DIURIL .................................... 79
divalproex sodium ............... 22,45
divalproex sodium er ................ 22
DIVIGEL .................................. 67
docetaxel................................... 12
donepezil hcl ............................ 71
donepezil hcl odt ...................... 71
dorzolamide hcl ........................ 91
dorzolamide-timolol ................. 91
doxazosin mesylate .................. 73
doxepin hcl ............................... 27
doxercalciferol.......................... 96
doxorubicin hcl......................... 12
doxycycline hyclate.................... 8
doxycycline monohydrate .......... 8
dronabinol ................................ 88
drospirenone-ethinyl estradiol.. 65
DROXIA .................................. 12
DUAVEE ................................. 67
DUEXIS ................................... 35
DULERA ................................. 70
duloxetine hcl ........................... 27
duramorph ................................ 35
DUREZOL ............................... 91
DYMISTA ............................... 21
DYRENIUM ............................ 79
E.E.S. 200................................... 8
econazole nitrate....................... 19
EDARBI ................................... 79
EDARBYCLOR ....................... 79
EDECRIN ................................ 79
EDLUAR ................................. 43
EDURANT................................. 3
EFFIENT .................................. 57
ELAPRASE ............................. 56
ELESTRIN ............................... 67
ELIDEL .................................... 18
ELIGARD ................................ 12
ELIQUIS .................................. 57
ELITEK .................................... 56
ELIXOPHYLLIN ..................... 79
ELMIRON ............................... 52
EMADINE ............................... 91
EMCYT .................................... 12
EMEND ................................... 88
emoquette ................................. 65
EMSAM .............................. 27,28
EMTRIVA ................................. 3
ENABLEX ............................... 94
enalapril maleate ...................... 79
enalapril-hydrochlorothiazide ... 79
ENBREL ................................... 49
endocet ...................................... 35
endodan ..................................... 35
ENGERIX-B ADULT .............. 95
ENGERIX-B PEDIATRICADOLESCENT ........................ 95
ENJUVIA ................................. 67
enoxaparin sodium .................... 57
enpresse..................................... 65
entacapone ................................ 24
enulose ...................................... 54
EPIDUO .................................... 18
EPIPEN 2-PAK 0.3 MG AUTOINJCT ....................................... 70
EPIPEN JR 2-PAK 0.15 MG
INJCTR ..................................... 70
epirubicin hcl ............................ 12
epitol ......................................... 45
EPIVIR ....................................... 3
EPIVIR HBV .............................. 3
eplerenone ................................. 79
EPOGEN................................... 58
eprosartan mesylate .................. 79
EPZICOM ................................... 3
EQUETRO ................................ 45
ERBITUX ................................. 12
ergoloid mesylates .................... 73
ERIVEDGE .............................. 12
errin ........................................... 65
ERWINAZE ............................. 12
ery ............................................. 19
ERYPED 200 .............................. 8
ERYPED 400 .............................. 8
ERY-TAB ................................... 8
ERYTHROCIN LACTOBIONATE
.................................................... 8
ERYTHROCIN STEARATE ..... 8
erythromycin ..................... 8,19,92
erythromycin-benzoyl peroxide 19
escitalopram oxalate ................. 28
esomeprazole strontium ............ 87
ESTRACE................................. 67
estradiol..................................... 67
estradiol-norethindrone acetat65,67
estropipate ................................. 67
eszopiclone ............................... 43
ethambutol hcl ............................ 1
ethosuximide ............................. 45
etidronate disodium .................. 51
etodolac ..................................... 36
etodolac er ................................. 36
etoposide ................................... 12
EURAX..................................... 19
EVAMIST................................. 67
EVZIO 0.4 MG AUTOINJECTOR ............................... 44
EXALGO ER 32 MG TABLET36
EXELDERM............................. 19
EXELON .................................. 71
exemestane ................................ 12
EXFORGE ................................ 79
EXFORGE HCT ....................... 79
EXJADE ................................... 53
EXTAVIA................................. 51
FABRAZYME .......................... 56
famciclovir .................................. 3
famotidine ................................. 87
FANAPT ................................... 28
FARESTON .............................. 12
FARXIGA................................. 60
FASLODEX ............................. 12
FAZACLO ................................ 28
felbamate................................... 45
felodipine er .............................. 79
FEMRING ................................ 67
fenofibrate ................................. 75
fenofibric acid ........................... 75
FENOGLIDE ............................ 75
fenoprofen calcium ................... 36
fentanyl ..................................... 36
fentanyl citrate .......................... 36
FENTORA ................................ 36
FERRIPROX ............................ 53
FETZIMA ................................ 28
FETZIMA 20-40 MG
TITRATION PAK ................... 28
FIBRICOR ............................... 75
FINACEA ................................ 18
finasteride ................................. 50
FIRMAGON ............................ 12
FLAGYL ER .............................. 2
FLAREX .................................. 92
flavoxate hcl ............................. 94
flecainide acetate ...................... 85
FLECTOR ................................ 36
FLO-PRED............................... 59
FLOVENT DISKUS ................ 21
FLOVENT HFA ...................... 21
fluconazole ................................. 1
fluconazole in dextrose .............. 1
flucytosine .................................. 1
fludarabine phosphate .............. 12
fludrocortisone acetate ............. 59
flunisolide................................. 21
fluocinolone acetonide ............. 17
fluocinolone acetonide oil ........ 92
fluocinonide.............................. 17
fluocinonide-e .......................... 17
fluorometholone ....................... 92
fluorouracil ............................... 12
fluoxetine dr ............................. 28
fluoxetine hcl....................... 28,29
fluphenazine decanoate ............ 29
fluphenazine hcl ....................... 29
flurbiprofen .............................. 36
flurbiprofen sodium .................. 92
flutamide .................................. 12
fluticasone propionate ......... 17,21
fluvastatin sodium .................... 75
fluvoxamine maleate ................ 29
FML ......................................... 92
FML FORTE ............................ 92
FOCALIN XR .......................... 42
FOLOTYN ............................... 12
fondaparinux sodium ................ 57
FORADIL................................. 70
FORFIVO XL .......................... 29
FORTEO .................................. 68
FORTESTA .............................. 64
FORTICAL .............................. 68
fosinopril sodium................. 79,80
fosinopril-hydrochlorothiazide . 80
FOSRENOL ............................. 54
FREAMINE HBC .................... 54
FROVA .................................... 23
furosemide ................................ 80
FUZEON .................................... 3
FYCOMPA............................... 45
gabapentin ........................... 36,37
GABITRIL ............................... 45
galantamine hbr ................... 71,72
galantamine hydrobromide ....... 72
GAMASTAN S-D .................... 95
GAMMAGARD LIQUID ........ 95
GAMMAPLEX ........................ 95
GAMUNEX-C ......................... 95
ganciclovir sodium ..................... 3
GARDASIL .............................. 95
gatifloxacin ............................... 93
gauze pads ................................ 96
gavilyte-c .................................. 89
gavilyte-g .................................. 89
gavilyte-n .................................. 89
GELNIQUE .............................. 94
gemfibrozil ............................... 75
generlac .................................... 54
gengraf ...................................... 50
gentamicin sulfate ............ 9,19,93
gentamicin sulfate in ns .............. 9
GEODON ................................. 29
gianvi ........................................ 65
gildagia ..................................... 67
GILENYA ................................ 51
GILOTRIF ........................... 12,13
GLASSIA ................................. 22
GLEEVEC ................................ 13
glimepiride ................................ 60
glipizide .................................... 60
glipizide er ................................ 60
glipizide-metformin .................. 60
GLUCAGEN ............................ 52
GLUCAGON EMERGENCY
KIT............................................ 52
GLUMETZA ............................ 60
glyburide ................................... 60
glyburide micronized ................ 60
glyburide-metformin hcl ...... 60,61
glycopyrrolate ........................... 69
GLYSET ................................... 61
GOLYTELY ............................. 89
GRALISE ................................. 37
granisetron hcl .......................... 88
SYRINGE ................................. 58
SYRINGE ................................. 58
griseofulvin ................................. 1
griseofulvin ultramicrosize ......... 1
GRIS-PEG .................................. 1
guanfacine hcl ........................... 80
guanidine hcl............................. 52
H.P. ACTHAR .......................... 52
HALAVEN ............................... 13
HALFLYTELY-BISACODYL 89
halobetasol propionate .............. 17
HALOG .................................... 17
haloperidol ................................ 29
haloperidol decanoate ............... 29
haloperidol lactate..................... 29
HAVRIX ................................... 95
heparin sodium ......................... 57
hepatamine ................................ 54
HERCEPTIN ............................ 13
HETLIOZ ................................. 43
HEXALEN ............................... 13
HORIZANT ............................. 37
HUMIRA ................................. 49
hydralazine hcl ......................... 80
hydrochlorothiazide.................. 80
hydrocodone bit-ibuprofen ....... 37
hydrocodone-acetaminophen ... 37
hydrocortisone ..................... 17,59
hydrocortisone butyrate............ 17
hydrocortisone valerate ............ 17
hydrocortisone-acetic acid ....... 93
hydromorphone hcl .................. 37
hydromorphone hcl er 12 mg tab37
hydromorphone hcl er 16 mg tab37
hydromorphone hcl er 8 mg tab 37
hydroxychloroquine sulfate........ 2
hydroxyurea.............................. 13
hydroxyzine hcl ................... 43,44
hydroxyzine pamoate ............... 44
ibandronate sodium .................. 51
ibuprofen .................................. 37
idarubicin hcl ............................ 13
ifosfamide................................. 13
ILEVRO ................................... 92
IMBRUVICA ........................... 13
imipramine hcl ......................... 29
imipramine pamoate ................. 29
imiquimod ................................ 18
IMOVAX RABIES VACCINE 95
INCIVEK ................................... 3
INCRELEX .............................. 64
indapamide ............................... 80
INFANRIX DTAP ................... 95
INLYTA ................................... 13
INNOPRAN XL ....................... 73
INSULIN SYRINGE ............... 96
INTELENCE .............................. 3
intralipid ................................... 54
INTRON A ................................. 3
introvale .................................... 65
INTUNIV ................................. 80
INVANZ..................................... 9
INVEGA.............................. 29,30
INVEGA SUSTENNA ............. 29
INVIRASE ................................. 3
INVOKANA ............................ 61
IONOSOL B WITH DEXTROSE
5%............................................. 55
IONOSOL MB-DEXTROSE 5%
.................................................. 55
IOPIDINE................................. 93
IPOL ......................................... 95
ipratropium bromide ............ 69,93
ipratropium-albuterol ............... 69
irbesartan .................................. 80
irbesartan-hydrochlorothiazide. 80
irinotecan hcl ............................ 13
ISENTRESS ............................... 3
ISOLYTE P WITH DEXTROSE
.................................................. 55
ISOLYTE S .............................. 55
isoniazid ..................................... 1
ISORDIL .................................. 83
isosorbide dinitrate .............. 83,84
isosorbide mononitrate ............. 84
isosorbide mononitrate er ......... 84
isradipine .................................. 80
ISTALOL ................................. 91
ISTODAX ................................ 13
itraconazole ................................ 1
IXEMPRA ................................ 13
IXIARO .................................... 95
JAKAFI .................................... 13
JALYN ..................................... 73
jantoven .................................... 57
JANUMET ............................... 61
JANUMET XR ......................... 61
JANUVIA................................. 61
JENTADUETO ........................ 61
JEVTANA ................................ 13
JINTELI ....................................67
jolivette .....................................65
junel ..........................................65
junel fe ......................................65
JUXTAPID ...............................75
KADCYLA ...............................13
KADIAN ...................................37
KALETRA ..................................3
KALYDECO ............................22
kariva ........................................65
KAZANO..................................61
kelnor 1-35 ................................65
KENALOG ...............................17
KEPIVANCE ............................20
KETEK .......................................9
ketoconazole ..........................1,19
ketoprofen .................................37
ketorolac tromethamine ............92
KHEDEZLA .............................30
kionex........................................54
klor-con 8 ..................................55
klor-con m10 .............................55
KLOR-CON M15 .....................55
klor-con m20 .............................55
KOMBIGLYZE XR .................61
KUVAN ....................................52
KYNAMRO ..............................75
labetalol hcl ...............................73
lactated ringers ..........................55
lactulose ....................................54
LAMICTAL (BLUE) ................45
LAMICTAL (GREEN) .............45
LAMICTAL (ORANGE) .........45
LAMICTAL ODT.....................45
LAMICTAL XR (BLUE) .........45
LAMICTAL XR (GREEN) ......45
LAMICTAL XR (ORANGE) ...45
LAMISIL ....................................1
lamivudine ..................................3
lamivudine hbv ........................... 3
lamivudine-zidovudine............... 3
lamotrigine ............................... 46
lamotrigine er ...................... 45,46
lansoprazol-amoxicil-clarithro ... 9
lansoprazole.............................. 87
LANTUS .................................. 61
LANTUS SOLOSTAR 100
UNITS/ML ............................... 61
LASTACAFT........................... 91
latanoprost ................................ 91
LATUDA ................................. 30
LAZANDA .............................. 37
leena ......................................... 65
leflunomide .............................. 49
LESCOL XL ............................ 76
lessina ....................................... 65
LETAIRIS ................................ 84
letrozole .................................... 13
leucovorin calcium ................... 50
LEUKERAN ............................ 13
LEUKINE ................................ 58
leuprolide acetate ..................... 13
levalbuterol concentrate ........... 70
levalbuterol hcl ......................... 70
LEVEMIR ................................ 61
LEVEMIR FLEXPEN 100
UNITS/ML ............................... 61
levetiracetam ............................ 46
levetiracetam er ........................ 46
levobunolol hcl ......................... 91
levocetirizine dihydrochloride . 69
levofloxacin ........................... 9,93
levofloxacin-d5w........................ 9
levonest .................................... 67
levonorgestrel-eth estradiol ...... 67
levora-28 .................................. 65
levorphanol tartrate .................. 37
levothyroxine sodium ............... 63
levoxyl ...................................... 63
LEXIVA ..................................... 3
LIALDA ................................... 87
lidocaine ................................... 20
lidocaine hcl......................... 20,92
lidocaine hcl viscous................. 92
lidocaine-prilocaine .................. 20
lindane ...................................... 19
LINZESS .................................. 89
liothyronine sodium .................. 63
LIPTRUZET ............................. 76
lisinopril .................................... 80
lisinopril-hydrochlorothiazide .. 80
lithium....................................... 22
lithium carbonate ...................... 22
LIVALO ................................... 76
LO LOESTRIN FE ................... 65
LOCOID ................................... 17
LOCOID LIPOCREAM ........... 17
LOESTRIN 24 FE .................... 65
lokara 0.05% lotion .................. 17
lomustine .................................. 13
loperamide ................................ 86
lorazepam ................................. 49
LORAZEPAM INTENSOL ..... 49
loryna ........................................ 67
losartan potassium ............... 80,81
losartan-hydrochlorothiazide .... 81
LOTEMAX............................... 92
LOTRONEX............................. 87
lovastatin................................... 76
low-ogestrel .............................. 65
loxapine .................................... 30
LUFYLLIN............................... 22
LUMIGAN ............................... 91
LUMIZYME............................. 56
LUPRON DEPOT .................... 13
LUPRON DEPOT-PED ........... 13
lutera ......................................... 65
LUXIQ ...................................... 17
LYRICA ................................... 46
LYSODREN............................. 13
mafenide acetate ....................... 19
magnesium sulfate .................... 55
maprotiline hcl.......................... 30
marlissa..................................... 65
MARPLAN .............................. 30
MATULANE ........................... 13
matzim la .................................. 85
MAXIDEX ............................... 92
meclizine hcl ............................ 69
meclofenamate sodium ............. 37
medroxyprogesterone acetate ... 69
mefenamic acid ........................ 37
MEGACE ES ........................... 13
megestrol acetate ...................... 13
MEKINIST ............................... 13
meloxicam ........................... 37,38
melphalan hcl ........................... 13
MENACTRA ........................... 95
MENEST .................................. 67
MENOMUNE-A-C-Y-W-135 . 95
MENOSTAR ............................ 67
MENVEO A-C-Y-W-135-DIP 95
mercaptopurine ......................... 13
meropenem ................................. 9
mesalamine ............................... 87
MESNEX ................................. 50
MESTINON ............................. 72
metaproterenol sulfate ......... 70,71
metaxalone ............................... 72
metformin hcl ........................... 61
metformin hcl er ....................... 61
methadone hcl .......................... 38
methazolamide ......................... 91
methenamine hippurate .............. 1
methimazole ............................. 63
METHITEST ............................ 64
methocarbamol ......................... 72
methotrexate ............................. 14
methotrexate sodium ................ 13
methoxsalen.............................. 18
methscopolamine bromide ....... 69
methyclothiazide ...................... 81
methyldopa ............................... 71
methyldopa-hydrochlorothiazide71
methylergonovine maleate ....... 90
METHYLIN ............................. 42
methylphenidate er ................... 42
methylphenidate hcl ................. 43
methylphenidate hcl cd ....... 42,43
methylphenidate la ................... 43
methylprednisolone .................. 59
methylprednisolone acetate ...... 59
methylprednisolone sod succ ... 59
metipranolol ............................. 91
metoclopramide hcl .................. 88
metolazone ............................... 81
metoprolol succinate ................ 73
metoprolol tartrate .................... 73
metoprolol-hydrochlorothiazide73
METOZOLV ODT................... 88
metronidazole ..................... 2,9,19
mexiletine hcl ........................... 85
MICONAZOLE 3 .................... 19
midodrine hcl ........................... 71
MIGRANAL ............................ 73
minitran .................................... 84
MINIVELLE ....................... 67,68
minocycline hcl .......................... 9
minoxidil .................................. 81
MIRAPEX ER .......................... 24
mirtazapine ............................... 30
misoprostol ............................... 87
mitomycin ................................ 14
mitoxantrone hcl....................... 14
M-M-R II VACCINE ............... 95
modafinil .................................. 43
moexipril hcl ............................ 81
moexipril-hydrochlorothiazide . 81
mometasone furoate .................. 17
mononessa................................. 65
montelukast sodium .................. 21
MONUROL ................................ 1
morphine sulfate ....................... 38
morphine sulfate er ................... 38
MOTOFEN ............................... 86
MOVIPREP .............................. 89
MOXEZA ................................. 93
moxifloxacin hcl ......................... 9
MOZOBIL ................................ 58
MULTAQ ................................. 85
mupirocin .................................. 19
MUSTARGEN.......................... 14
MYALEPT................................ 52
mycophenolate mofetil ............. 50
mycophenolic acid .................... 50
MYOZYME .............................. 56
MYRBETRIQ ........................... 94
nabumetone .......................... 38,39
nadolol ...................................... 74
nadolol-bendroflumethiazide .... 74
NAFCILLIN ............................... 9
nafcillin sodium .......................... 9
NAFTIN ............................... 19,20
NAGLAZYME ......................... 56
NALFON .................................. 39
naloxone hcl .............................. 44
naltrexone hcl ............................ 44
NAMENDA .............................. 25
NAMENDA XR ....................... 25
naphazoline hcl ......................... 94
NAPRELAN ............................. 39
naproxen.................................... 39
naproxen sodium ....................... 39
naratriptan hcl ........................... 23
NASONEX ............................... 21
NATACYN ............................... 93
nateglinide ................................ 61
NEBUPENT ............................... 2
necon......................................... 65
NECON .................................... 65
nefazodone hcl .......................... 30
neomycin-bacitracin-poly-hc .... 93
neomycin-bacitracin-polymyxin93
neomycin-polymyxin b ............. 20
neomycin-polymyxin-dexameth93
neomycin-polymyxin-gramicidin
.................................................. 93
neomycin-polymyxin-hc........... 93
neomycin-polymyxin-hydrocort93
NEPHRAMINE ........................ 54
NESINA ................................... 62
NEULASTA ............................. 58
NEUMEGA .............................. 58
NEUPOGEN............................. 58
NEUPRO .................................. 24
NEVANAC............................... 92
nevirapine ................................... 3
nevirapine er ............................... 3
NEXAVAR............................... 14
NEXIUM .................................. 87
niacin er .................................... 76
nicardipine hcl .......................... 81
NICOTROL .............................. 71
NICOTROL NS ........................ 71
nifedical xl ........................... 81,84
nifedipine er .............................. 81
NILANDRON .......................... 14
nimodipine ................................ 81
nisoldipine ................................ 81
NITRO-BID .............................. 84
nitrofurantoin .............................. 1
nitrofurantoin mono-macro ........ 1
nitroglycerin ............................. 84
nitroglycerin patch .................... 84
NITROMIST ............................ 84
NITROSTAT ............................ 84
nizatidine .................................. 87
nora-be...................................... 65
norethindrone ........................... 68
norethindrone acetate ............... 69
normosol-m and dextrose ......... 55
NORMOSOL-R AND
DEXTROSE ............................. 55
NORMOSOL-R PH 7.4 ........... 55
NOROXIN ................................. 9
NORPACE CR ......................... 86
nortrel .................................. 65,66
nortriptyline hcl ........................ 30
NORVIR .................................... 3
NOVOLIN 70-30 ..................... 62
NOVOLIN N............................ 62
NOVOLIN R ............................ 62
NOVOLOG .............................. 62
NOVOLOG FLEXPEN
SYRINGE ................................ 62
NOVOLOG MIX 70-30 ........... 62
NOVOLOG MIX 70-30
FLEXPEN SYRN .................... 62
NOXAFIL .................................. 1
NUCYNTA .............................. 39
NUCYNTA ER ........................ 39
NUEDEXTA ............................ 25
NUVARING ............................ 66
NUVIGIL ................................. 43
nystatin .................................. 2,20
nystatin-triamcinolone.............. 20
octreotide acetate ...................... 52
ofloxacin................................ 9,93
OGESTREL ............................. 66
olanzapine ........................... 30,31
olanzapine odt .......................... 30
olanzapine-fluoxetine hcl ......... 31
OLEPTRO ER .......................... 31
OLUX....................................... 17
OLYSIO ..................................... 3
omega-3 acid ethyl esters ......... 76
omeprazole ............................... 87
OMNARIS ............................... 21
ONCASPAR ............................. 14
ondansetron hcl .................... 88,89
ondansetron odt ......................... 89
ONFI ......................................... 49
ONGLYZA ............................... 62
OPSUMIT ................................. 84
ORACEA .................................... 9
ORAPRED ODT ...................... 59
ORENITRAM ER .................... 84
ORFADIN................................. 52
orphenadrine citrate .................. 72
orsythia ..................................... 66
ORTHO TRI-CYCLEN LO ..... 66
OSENI....................................... 62
OSMOPREP ............................. 89
OTEZLA ................................... 49
OTEZLA STARTER PACK .... 49
AUTO-INJ ................................ 14
AUTO-INJ ................................ 14
AUTO-INJ ................................ 14
AUTO-INJ ................................ 14
oxaliplatin ................................. 14
oxandrolone .............................. 64
oxaprozin .................................. 39
oxcarbazepine ........................... 46
OXECTA 5 MG TABLET ....... 39
OXECTA 7.5 MG TABLET .... 39
OXISTAT ................................. 20
OXSORALEN .......................... 18
OXTELLAR XR ....................... 46
oxybutynin chloride .................. 94
oxybutynin chloride er .............. 94
oxycodone hcl ........................... 39
oxycodone hcl-acetaminophen . 39
oxycodone hcl-aspirin ............... 39
oxycodone hcl-ibuprofen .......... 39
oxycodone-acetaminophen .. 39,40
OXYCONTIN 10 MG TABLET
.................................................. 40
OXYCONTIN 15 MG TABLET
.................................................. 40
OXYCONTIN 20 MG TABLET40
oxymorphone hcl ...................... 40
oxymorphone hcl er .................. 40
OXYTROL ............................... 94
pacerone.................................... 86
paclitaxel .................................. 14
pamidronate disodium .............. 51
PANCREAZE .......................... 90
PANDEL .................................. 17
PANRETIN .............................. 18
pantoprazole sodium................. 88
paricalcitol ................................ 96
paromomycin sulfate .................. 9
paroxetine hcl ........................... 31
PATADAY ............................... 91
PATANASE ............................. 91
PATANOL ............................... 91
PAXIL ...................................... 31
PCE............................................. 9
PEDVAXHIB ........................... 95
PEGANONE ............................ 46
PEGASYS .................................. 4
PEGASYS PROCLICK ............. 3
PEN NEEDLES 12MM 29G .... 96
penicillin g potassium ................. 9
penicillin g procaine ................... 9
penicillin g sodium ..................... 9
penicillin gk-iso-osm dextrose9,10
penicillin v potassium ............... 10
PENNSAID .............................. 40
PENTAM 300........................... 10
PENTASA ................................ 87
pentoxifylline............................ 58
PERFOROMIST ...................... 71
perindopril erbumine ................ 81
permethrin ................................ 20
perphenazine ............................ 31
perphenazine-amitriptyline ...... 31
PERTZYE ................................ 90
PEXEVA .................................. 31
phenelzine sulfate ..................... 31
phenobarbital ............................ 48
PHENYTEK............................. 46
phenytoin .................................. 47
phenytoin sodium extended. 46,86
PHISOHEX .............................. 20
PHOSPHOLINE IODIDE........ 91
physiolyte ................................. 56
physiosol .................................. 56
PICATO ................................... 18
pilocarpine hcl .......................... 72
pindolol .................................... 74
pioglitazone hcl ........................ 62
pioglitazone-glimepiride .......... 62
pioglitazone-metformin ............ 62
piperacillin-tazobactam ............ 10
piroxicam.................................. 40
PLASMA-LYTE 148 ............... 55
PLASMA-LYTE 56 IN
DEXTROSE ............................. 55
PLASMA-LYTE A PH 7.4 ...... 55
podofilox .................................. 18
polyethylene glycol 3350 ......... 89
polymyxin b sul-trimethoprim . 93
POMALYST ............................ 14
portia ........................................ 66
potassium chl-normal saline..... 55
potassium chloride ................... 55
potassium chloride in d5lr ........ 55
potassium chloride-nacl ........... 55
potassium citrate er .................. 53
POTIGA ................................... 47
PRADAXA .............................. 57
pramipexole dihydrochloride ... 24
PRANDIMET .......................... 62
pravastatin sodium.................... 76
prazosin hcl .............................. 74
PRED MILD ............................ 92
PRED-G ................................... 93
prednicarbate ............................ 17
prednisolone acetate ................. 92
prednisolone sodium phosphate59,9
prednisone ................................ 59
PREDNISONE INTENSOL .... 59
PREFEST ................................. 68
PREMARIN ............................. 68
premasol ................................... 54
PREMASOL............................. 54
PREMPHASE .......................... 68
PREMPRO ............................... 68
PRENATAL VITAMINS ........ 96
PREVACID .............................. 88
prevalite .................................... 76
previfem ................................... 66
PREZISTA ................................. 4
PRIFTIN ................................... 10
primaquine .................................. 2
primidone ................................. 48
PRIMSOL................................... 1
PRISTIQ ................................... 31
PRIVIGEN ............................... 95
PROAIR HFA .......................... 71
probenecid ................................ 54
probenecid-colchicine .............. 54
PROCALAMINE ..................... 54
prochlorperazine edisylate........ 32
prochlorperazine maleate ......... 32
proctocream-hc ......................... 17
procto-pak ................................. 17
proctozone-hc ........................... 17
progesterone ............................. 69
PROGLYCEM ......................... 81
PROLASTIN C ........................ 22
PROLEUKIN ........................... 14
PROMACTA ............................ 58
promethazine hcl ...................... 89
promethegan ............................. 89
propafenone hcl ........................ 86
proparacaine hcl ....................... 92
propranolol hcl ......................... 74
propranolol hcl er ..................... 74
propranolol-hydrochlorothiazide
.................................................. 74
propylthiouracil ........................ 63
PROQUAD............................... 96
PROSOL................................... 54
PROTONIX .............................. 88
PROTOPIC ............................... 18
protriptyline hcl ........................ 32
PROVENTIL HFA ................... 22
PRUDOXIN ............................. 20
PULMICORT ........................... 22
PULMICORT FLEXHALER... 21
PULMOZYME ......................... 56
PYLERA .................................. 10
pyrazinamide .............................. 1
pyridostigmine bromide ........... 72
QNASL..................................... 22
quasense.................................... 66
QUDEXY XR 100 MG
CAPSULE ................................ 47
QUDEXY XR 150 MG
CAPSULE ................................ 47
QUDEXY XR 200 MG
CAPSULE ................................ 47
QUDEXY XR 25 MG CAPSULE
.................................................. 47
QUDEXY XR 50 MG CAPSULE
.................................................. 47
quetiapine fumarate .................. 32
quinapril hcl .............................. 81
quinapril-hydrochlorothiazide .. 81
quinidine sulfate ......................... 2
quinine sulfate ............................ 2
QVAR ....................................... 22
RABAVERT ............................ 96
rabeprazole sodium................... 88
raloxifene hcl ............................ 68
ramipril ..................................... 81
RANEXA ................................. 86
ranitidine hcl............................. 88
RAPAFLO ............................... 74
RAPAMUNE ........................... 50
RAVICTI ................................. 52
REBETOL .................................. 4
REBIF ...................................... 51
reclipsen ................................... 66
RECOMBIVAX HB ................ 96
RELENZA ................................. 4
RELISTOR ............................... 89
REMICADE ............................. 49
REMODULIN .......................... 84
RENAGEL ............................... 54
RENVELA ............................... 54
repaglinide ................................ 62
REPREXAIN ........................... 40
RESCRIPTOR ........................... 4
reserpine ................................... 81
RESTASIS ............................... 92
RETIN-A MICRO.................... 20
RETIN-A MICRO PUMP ........ 20
RETROVIR ................................ 4
REVLIMID .............................. 14
REYATAZ ................................. 4
RHEUMATREX ...................... 14
ribasphere ................................... 4
ribavirin ...................................... 4
RIDAURA ............................... 53
rifabutin .................................... 10
rifampin .................................... 10
RIFATER ................................. 10
riluzole...................................... 25
ringers injection ........................ 55
RIOMET .................................. 62
risedronate sodium ................... 51
RISPERDAL CONSTA ........... 32
risperidone ................................ 32
risperidone odt .......................... 32
RITUXAN ................................ 14
rivastigmine .............................. 72
rizatriptan.................................. 23
ropinirole hcl ....................... 24,25
ROTATEQ ............................... 96
ROXICET ................................. 40
ROZEREM ............................... 44
SABRIL .................................... 47
SAFYRAL ................................ 66
SAIZEN .................................... 64
SAMSCA.................................. 53
SANCUSO ............................... 89
SANDIMMUNE ...................... 50
SANTYL .................................. 18
SAPHRIS.................................. 33
SAVELLA ................................ 25
selegiline hcl ............................. 33
SELZENTRY ............................. 4
SEMPREX-D ........................... 69
SENSIPAR ............................... 52
SEREVENT DISKUS .............. 71
SEROQUEL XR....................... 33
sertraline hcl ............................. 33
SFROWASA ............................ 87
SIGNIFOR................................ 52
sildenafil ................................... 84
SILENOR ................................. 33
silver sulfadiazine ..................... 20
SIMBRINZA ............................ 91
SIMCOR ................................... 76
simvastatin ................................ 76
sirolimus ................................... 50
SIRTURO ................................... 1
SIVEXTRO .............................. 10
sodium chloride ................... 55,56
sodium lactate ........................... 53
sodium phenylbutyrate ............. 54
sodium polystyrene sulfonate ... 54
SOLODYN ............................... 10
SOLTAMOX ............................ 14
SOMA....................................... 72
SOMATULINE DEPOT .......... 52
SOMAVERT ............................ 64
sorine ........................................ 74
sotalol ....................................... 74
sotalol af ................................... 74
SOVALDI................................... 4
SPIRIVA................................... 70
spironolactone...................... 81,82
spironolactone-hctz................... 82
SPORANOX............................... 2
sprintec ..................................... 66
SPRYCEL................................. 14
sronyx ....................................... 66
ssd ............................................. 20
stavudine ..................................... 4
STAVZOR ................................ 47
STIMATE ................................. 56
STIVARGA .............................. 14
STRATTERA ........................... 25
streptomycin sulfate.................. 10
STRIBILD .................................. 4
STROMECTOL ......................... 1
SUBOXONE ............................ 40
SUCRAID................................. 56
sucralfate................................... 88
sulfacetamide sodium .......... 20,93
sulfacetamide-prednisolone ...... 93
sulfadiazine ............................... 10
sulfamethoxazole-trimethoprim 10
sulfasalazine ............................. 10
sulfazine ec ............................... 10
sulindac ..................................... 40
sumatriptan ............................... 23
sumatriptan succinate ............... 23
SUPRAX .................................. 10
SUPREP ................................... 89
SUSTIVA ................................... 4
SUTENT ............................. 14,15
SYLATRON ............................ 15
SYMBICORT .......................... 71
SYMLINPEN ........................... 62
SYNALGOS-DC ..................... 41
SYNAREL ............................... 68
SYNERA .................................. 20
SYNRIBO ................................ 15
SYNTHROID...................... 63,64
SYPRINE ................................. 53
TABLOID ................................ 15
TACLONEX ............................ 17
tacrolimus ................................. 50
TAFINLAR .............................. 15
TAMIFLU .................................. 4
tamoxifen citrate....................... 15
tamsulosin hcl .......................... 74
TANZEUM 30 MG PEN INJECT
.................................................. 63
TANZEUM 50 MG PEN INJECT
.................................................. 63
TARCEVA ............................... 15
TARGRETIN ...................... 15,18
TARKA .................................... 82
TASIGNA ................................ 15
TASMAR ................................. 25
TAZORAC ............................... 18
taztia xt ..................................... 86
TECFIDERA ............................ 51
TEGRETOL XR ...................... 47
TEKAMLO .............................. 82
TEKTURNA ............................ 82
TEKTURNA HCT ................... 82
telmisartan ................................ 82
telmisartan-amlodipine............. 82
telmisartan-hydrochlorothiazide
.................................................. 82
temazepam................................ 49
terazosin hcl ............................. 74
terbinafine hcl............................. 2
terbutaline sulfate ..................... 71
terconazole ............................... 20
TESTIM ................................... 64
testosterone cypionate .............. 64
testosterone enanthate .............. 64
TESTRED ................................ 64
tetanus diphtheria toxoids ........ 95
tetanus toxoid adsorbed............ 96
TEVETEN................................ 82
TEVETEN HCT....................... 82
TEV-TROPIN .......................... 64
THALOMID ....................... 51,52
theophylline.............................. 94
theophylline anhydrous ............ 94
thioridazine hcl......................... 33
thiothixene................................ 33
tiagabine hcl ............................. 47
ticlopidine hcl........................... 57
TIKOSYN ................................ 86
timolol maleate.................... 74,91
TIMOPTIC OCUDOSE ........... 91
tinidazole .................................... 2
TIVICAY ................................... 4
tizanidine hcl ............................ 72
TOBI PODHALER .................. 10
TOBRADEX ............................ 93
TOBRADEX ST ...................... 93
tobramycin .......................... 10,93
tobramycin sulfate .................... 11
tobramycin sulfate in ns ........... 10
tobramycin-dexamethasone ..... 93
TOBREX.................................. 93
tolazamide ................................ 63
tolbutamide .............................. 63
tolmetin sodium ....................... 41
tolterodine tartrate .................... 94
tolterodine tartrate er ................ 94
topiramate ................................ 47
toposar ...................................... 15
topotecan hcl ............................ 15
TORISEL ................................. 15
torsemide .................................. 82
TOVIAZ ................................... 94
tpn electrolytes ......................... 56
TRACLEER ............................. 85
TRADJENTA ........................... 63
tramadol hcl .............................. 41
tramadol hcl er .......................... 41
tramadol hcl-acetaminophen .... 41
trandolapril ............................... 83
tranexamic acid ........................ 94
tranylcypromine sulfate ............ 33
TRAVASOL............................. 54
travoprost .................................. 91
trazodone hcl ............................ 33
TREANDA ............................... 15
TRECATOR ............................... 1
TRELSTAR .............................. 15
tretinoin ............................... 15,20
TRETIN-X ............................... 20
TRETIN-X 0.05% COMBO
PACK ....................................... 20
TREXALL................................ 15
triamcinolone acetonide . 17,18,22
triamterene-hydrochlorothiazide
.................................................. 83
triazolam ................................... 49
TRIBENZOR ........................... 83
trifluoperazine hcl .................... 33
trifluridine................................. 93
trihexyphenidyl hcl ................... 70
tri-legest fe................................ 66
trilyte with flavor packets ......... 89
trimethoprim ............................... 1
trimipramine maleate................ 33
trinessa...................................... 66
tri-previfem............................... 66
TRISENOX .............................. 15
tri-sprintec ................................ 66
trivora-28 .................................. 66
TROKENDI XR ....................... 47
TROPHAMINE........................ 54
trospium chloride ..................... 94
trospium chloride er ................. 94
TRUVADA ................................ 4
TUDORZA PRESSAIR ........... 70
TWINRIX ................................ 96
TYKERB .................................. 15
TYPHIM VI ............................. 96
TYSABRI................................. 52
TYZEKA .................................... 4
TYZINE ................................... 94
ULESFIA ................................. 20
ULORIC ................................... 49
ULTRESA ................................ 90
unithroid ................................... 64
ursodiol..................................... 88
VAGIFEM ............................... 68
valacyclovir ................................ 4
VALCYTE ................................. 4
valproate sodium ...................... 47
valproic acid ........................ 23,47
valsartan ................................... 83
valsartan-hydrochlorothiazide .. 83
vancomycin hcl ........................ 11
vandazole.................................. 20
VAQTA .................................... 96
VARIVAX VACCINE ............ 96
VASCEPA ............................... 76
VECTIBIX ............................... 15
VELCADE ............................... 15
velivet ....................................... 66
VELPHORO ............................ 54
VELTIN ................................... 20
venlafaxine hcl .................... 33,34
venlafaxine hcl er ..................... 33
VENTAVIS .............................. 85
VENTOLIN HFA .................... 71
VERAMYST ............................ 22
verapamil er.............................. 86
verapamil er pm........................ 86
verapamil hcl ............................ 86
VERIPRED 20 .......................... 59
VERSACLOZ........................... 34
VESICARE ............................... 94
VEXOL..................................... 92
VICTOZA 3-PAK 18 MG/3 ML
PEN........................................... 63
VICTRELIS ................................ 4
VIDEX ........................................ 5
VIGAMOX ............................... 93
VIIBRYD.................................. 34
VIMOVO .................................. 41
VIMPAT .............................. 47,48
vinblastine sulfate ..................... 15
VINCASAR SULFATE ........... 15
vincristine sulfate ...................... 15
vinorelbine tartrate .................... 15
VIOKACE ................................ 90
VIRACEPT ................................. 5
VIRAMUNE XR ........................ 5
VIREAD ..................................... 5
VIVELLE-DOT ........................ 68
VOGELXO ............................... 64
VOLTAREN ............................. 41
voriconazole................................ 2
VOTRIENT .............................. 15
VPRIV ...................................... 56
VYTORIN ........................... 76,77
VYVANSE ............................... 43
warfarin sodium ........................ 57
WELCHOL............................... 77
XALKORI ................................ 15
XARELTO................................ 57
XENAZINE ......................... 25,26
XGEVA .................................... 51
XIFAXAN ................................ 11
XOLAIR ................................... 22
XOPENEX HFA....................... 71
XTANDI ................................... 15
xulane........................................ 66
XYREM ....................................26
YF-VAX ...................................96
zafirlukast ..................................22
zaleplon .....................................44
zamicet ......................................41
ZANOSAR ................................15
ZAVESCA ................................53
zazole 0.4% vaginal cream .......20
zazole 0.8% vaginal cream .......20
ZEGERID .................................88
ZELAPAR.................................34
ZELBORAF ..............................16
ZEMAIRA ................................22
zenchent fe ................................68
ZENPEP ....................................90
ZETIA .......................................77
ZETONNA ................................22
ZIAGEN ......................................5
ZIANA ......................................20
zidovudine ...................................5
ziprasidone hcl ..........................34
ZIRGAN ...................................93
ZMAX .......................................11
zoledronic acid ..........................51
ZOLINZA .................................16
zolmitriptan ...............................23
zolmitriptan odt .........................23
zolpidem tartrate .......................44
zolpidem tartrate er ...................44
ZOLPIMIST ..............................44
ZOMETA ..................................51
ZOMIG .....................................23
ZONALON ...............................20
zonisamide ................................48
ZONTIVITY .............................57
ZORTRESS...............................50
ZOSTAVAX .............................96
ZOSYN .....................................11
zovia 1-35e ................................66
ZOVIA 1-50E........................... 66
ZOVIRAX ................................ 20
ZUBSOLV ............................... 41
ZYCLARA ............................... 18
ZYDELIG ................................ 16
ZYFLO CR .............................. 22
ZYKADIA ............................... 16
ZYLET ..................................... 93
ZYTIGA ................................... 16
ZYVOX .................................... 11
Este formulario fue actualizado el 1 de noviembre de 2014. Para la
información más reciente u otras preguntas, póngase en contacto con
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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