Lista de medicamentos preferidos aprobada por Medicaid · Insurance Companies, Inc. Los nombres y...

HealthKeepers, Inc. es un licenciatario independiente de Blue Cross and Blue Shield Association. ANTHEM es una marca comercial registrada de Anthem Insurance Companies, Inc. Los nombres y símbolos de Blue Cross and Blue Shield son marcas registradas de Blue Cross and Blue Shield Association. WEBPAVA-0250-17 0910 VAW2081 2/1/2018

Lista de medicamentos preferidos aprobada por Medicaid En vigencia desde el 1 de octubre de 2018

Introducción Anthem HealthKeepers Plus es el programa de cuidado administrado ofrecido a las personas elegibles de Virginia Medicaid y FAMIS por medio de la HMO afiliada a Anthem, HealthKeepers, Inc. La Lista de medicamentos preferidos (PDL) de Anthem HealthKeepers Plus incluye los medicamentos disponibles en el beneficio de farmacia. Estos medicamentos preferidos son medicamentos recetados elegidos por su calidad y efectividad. Algunos medicamentos pueden requerir autorización previa. La PDL de Anthem HealthKeepers Plus se actualiza cada tres meses y está sujeta a cambios. Los miembros y sus proveedores recetantes serán informados si un medicamento ya no está en la PDL. Para consultar las actualizaciones regulares a la PDL, visite nuestro sitio web en www.anthem.com/vamedicaid. De forma alternativa, puede ponerse en contacto con la línea gratuita de Servicios al Miembro al 1-800-901-0020 (TTY 711).

Medicamentos de marca vs. genéricos Un medicamento de marca es uno desarrollado, patentado y comercializado por el fabricante del medicamento original. Hasta que expire la patente, ninguna otra compañía puede producir ese mismo medicamento de marca. Un medicamento genérico tiene los mismos ingredientes activos que su contraparte de marca. Un medicamento genérico puede ser fabricado por varias compañías farmacéuticas después de que la patente original expire. Un medicamento genérico es idéntico al medicamento de marca en forma de dosificación, concentración, ruta de administración, calidad y usos pretendidos. Los genéricos pueden diferir de su equivalente de marca en color y/o forma. Ambos medicamentos de marca y genéricos deben cumplir los mismos estándares estrictos de seguridad, pureza y rendimiento regulados por la Food and Drug Administration (FDA).

Límite de cantidad de suministro El límite de cantidad de suministro es la cantidad máxima de un medicamento que una farmacia puede despachar en un momento determinado. La PDL de Anthem HealthKeepers Plus cumple con las directrices de dosificación aprobadas por la FDA. Si un proveedor recetante siente que se necesita por motivos médicos una cantidad de suministro mayor a la máxima definida, entonces guiamos al recetante para que envíe una solicitud de autorización previa detallando la necesidad de exceder la cantidad recomendada.

Autorización previa El programa de autorización previa está diseñado para fomentar el uso adecuado de medicamentos. Los medicamentos que requieren autorización previa generalmente son aquellos que son parte de un régimen de terapia escalonada, tienen un alto potencial de efectos secundarios, deben reservarse para indicaciones específicas de la FDA, tienen un alto uso indebido o potencial abuso, o tienen alternativas de menor costo. Los medicamentos de marca con equivalentes genéricos disponibles requieren autorización previa para fomentar la utilización de las alternativas genéricas apropiadas como terapias de primera línea. Antes de recetar algún medicamento de marca, se les recomienda a los médicos que consideren el uso de su alternativa genérica preferida. Algunos medicamentos de la PDL pueden requerir autorización previa. Si un medicamento requiere autorización previa, debe completarse un Formulario de autorización previa por parte del recetante para ser enviado a HealthKeepers, Inc. Para obtener un formulario de autorización previa y una lista de medicamentos que requieren autorización previa, vaya al sitio web, www.anthem.com/vamedicaid. De forma alternativa, puede ponerse en contacto con la línea gratuita de Servicios al Miembro al 1-800-901-0020 (TTY 711) para obtener más información. Cómo usar esta guía La PDL de Anthem HealthKeepers Plus lista el nombre de marca o nombre común de un medicamento determinado. Si un medicamento no aparece en esta PDL, el medicamento requerirá autorización previa para ser cubierto bajo el beneficio de farmacia. El recetante debe completar un formulario de autorización previa y enviarlo a HealthKeepers, Inc. antes de que se pueda abastecer la receta. Para obtener un formulario de autorización previa, vaya al sitio web, www.anthem.com/vamedicaid. De forma alternativa, puede ponerse en contacto con la línea gratuita de Servicios al Miembro al 1-800-901-0020 (TTY 711) para obtener más información.

Información de contacto Si tiene preguntas acerca de la PDL de Anthem HealthKeepers Plus, póngase en contacto con Servicios al Miembro al 1-800-901-0020 (TTY 711) para obtener más información. El horario de atención es de lunes a viernes de 8:30 a.m. a 6 p.m. hora del Este. Además, hay disponibles actualizaciones regulares a la PDL visitando www.anthem.com/vamedicaid.

Leyenda

En cada categoría, los medicamentos se listan en orden alfabético por marca o nombre genérico.

Medicamento de marca = Letra mayúscula en negrita

Medicamento genérico = Letra minúscula en texto sin formato

OTC = Medicamento de venta libre disponible sin receta. (Los recetadores deben incluir la sigla OTC en la

receta).

PA = REQUIERE AUTORIZACIÓN PREVIA. La autorización previa es el proceso mediante el cual se obtiene la

aprobación de los beneficios antes de que se puedan abastecer ciertas recetas.

QL = LÍMITES DE CANTIDAD. Ciertos medicamentos recetados tienen límites de cantidad específicos, por

receta o por mes.

SP = Farmacia de medicamentos especiales ST = REQUIERE TERAPIA ESCALONADA. Es posible que necesite utilizar un medicamento antes de que los

beneficios para el uso de otro medicamento puedan autorizarse

Nombre del medicamento Referencia Notas

ADJUVANTES QUÍMICOS O FARMACÉUTICOS

ADJUVANTE FARMACÉUTICO (INHALADORES)

nebusal inhalation solution for nebulization

pulmosal inhalation solution for nebulization

sodium chloride inhalation solution for nebulization

AGENTES ANORRECTALES

AGENTES ANORRECTALES

hydrocortisone topical cream with perineal applicator

Anusol-HC QL

proctosol hc topical cream with perineal applicator

QL

proctozone-hc topical cream with perineal applicator

QL

AGENTES ANTI-INFECCIOSOS

AGENTES ANTIBACTERIALES, OTROS

nitrofurantoin macrocrystal oral capsule Macrodantin

nitrofurantoin monohyd/m-cryst oral capsule

Macrobid

AGENTES ANTIBACTERIANOS ANTIPROTOZOARIOS

metronidazole oral capsule Flagyl

metronidazole oral tablet Flagyl

tinidazole oral tablet QL

AGENTES ANTILEPROSOS, DAPSONA

dapsone oral tablet

AGENTES ANTIMICOBACTERIANOS

ethambutol oral tablet Myambutol

isoniazid oral solution

isoniazid oral tablet

PRIFTIN ORAL TABLET

pyrazinamide oral tablet

4


rifabutin oral capsule Mycobutin

rifampin oral capsule Rifadin

RIFATER ORAL TABLET

AGENTES ANTINFECCIOSOS, OTROS

methenamine hippurate oral tablet Hiprex

methenamine mandelate oral tablet

AGENTES PARA EL TRATAMIENTO DE HEPATITIS B

adefovir oral tablet Hepsera PA

BARACLUDE ORAL SOLUTION PA

entecavir oral tablet Baraclude PA

EPIVIR HBV ORAL SOLUTION PA; QL

lamivudine oral tablet Epivir HBV PA; QL

AGENTES PARA EL TRATAMIENTO DE HEPATITIS C

MAVYRET ORAL TABLET PA; QL

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

QL

PEGASYS SUBCUTANEOUS SOLUTION

QL

PEGASYS SUBCUTANEOUS SYRINGE QL

PEGINTRON SUBCUTANEOUS KIT

ribavirin oral capsule Ribasphere QL

ribavirin oral tablet Moderiba QL

AMIBICIDAS

paromomycin oral capsule

AMINOGLICÓSIDOS

neomycin oral tablet

AMINOPENICILINAS

amoxicillin oral capsule

amoxicillin oral suspension for reconstitution

QL

amoxicillin oral tablet

amoxicillin oral tablet,chewable

amoxicillin-pot clavulanate oral suspension for reconstitution

5


amoxicillin-pot clavulanate oral tablet 250-125 mg


Augmentin


Augmentin QL

amoxicillin-pot clavulanate oral tablet extended release 12 hr

Augmentin XR QL

amoxicillin-pot clavulanate oral tablet,chewable

QL

ampicillin oral capsule

ANTHELMINTIC AGENTS - MACROCYCLIC LACTONES

ivermectin oral tablet Stromectol

ANTIBIÓTICO SULFONAMIDA

sulfadiazine oral tablet

ANTIBIÓTICOS ANTIMICÓTICOS

fluconazole oral suspension for reconstitution

Diflucan

fluconazole oral tablet Diflucan

flucytosine oral capsule Ancobon PA

griseofulvin microsize oral suspension

griseofulvin ultramicrosize oral tablet

itraconazole oral capsule Sporanox PA

ketoconazole oral tablet

nystatin oral powder

nystatin oral tablet

terbinafine hcl oral tablet

voriconazole intravenous solution Vfend IV PA

voriconazole oral suspension for reconstitution

Vfend PA

voriconazole oral tablet Vfend PA

ANTIHELMÍNTICOS

ALBENZA ORAL TABLET PA; QL

ivermectin oral tablet Stromectol

praziquantel oral tablet Biltricide

6


ANTIRETROVIRAL - ANTI-CD4 DOMAIN 2 MONOCLONAL ANTIBODY

TROGARZO INTRAVENOUS SOLUTION PA

ANTIRETROVIRAL COMBINATIONS - INTEGRASE INHIBITOR AND NNRTI

JULUCA ORAL TABLET

ANTIVIRALES, ESPECÍFICOS DE VIH

abacavir oral solution Ziagen

abacavir oral tablet Ziagen

abacavir-lamivudine oral tablet Epzicom

abacavir-lamivudine-zidovudine oral tablet Trizivir

APTIVUS ORAL CAPSULE

APTIVUS ORAL SOLUTION

atazanavir oral capsule Reyataz

BIKTARVY ORAL TABLET

CIMDUO ORAL TABLET

CRIXIVAN ORAL CAPSULE

DESCOVY ORAL TABLET

didanosine oral capsule,delayed release(dr/ec)

Videx EC

EDURANT ORAL TABLET

EMTRIVA ORAL CAPSULE

EMTRIVA ORAL SOLUTION

EVOTAZ ORAL TABLET

FUZEON SUBCUTANEOUS RECON SOLN

PA

GENVOYA ORAL TABLET

INTELENCE ORAL TABLET

ISENTRESS HD ORAL TABLET

ISENTRESS ORAL POWDER IN PACKET

ISENTRESS ORAL TABLET

ISENTRESS ORAL TABLET,CHEWABLE

KALETRA ORAL TABLET

lamivudine oral solution Epivir

7


lamivudine oral tablet Epivir

lamivudine-zidovudine oral tablet Combivir

lopinavir-ritonavir oral solution Kaletra

nevirapine oral suspension Viramune

nevirapine oral tablet Viramune

nevirapine oral tablet extended release 24 hr

Viramune XR

NORVIR ORAL CAPSULE

NORVIR ORAL SOLUTION

PREZCOBIX ORAL TABLET

PREZISTA ORAL SUSPENSION

PREZISTA ORAL TABLET

RESCRIPTOR ORAL TABLET

RESCRIPTOR ORAL TABLET, DISPERSIBLE

RETROVIR INTRAVENOUS SOLUTION

REYATAZ ORAL POWDER IN PACKET

ritonavir oral tablet Norvir

SELZENTRY ORAL SOLUTION

SELZENTRY ORAL TABLET

stavudine oral capsule Zerit

STRIBILD ORAL TABLET

tenofovir disoproxil fumarate oral tablet Viread PA; QL

TIVICAY ORAL TABLET

TRIUMEQ ORAL TABLET

TRUVADA ORAL TABLET

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN

VIRACEPT ORAL TABLET

VIREAD ORAL POWDER PA; QL

VIREAD ORAL TABLET PA; QL

zidovudine oral capsule Retrovir

zidovudine oral syrup Retrovir

zidovudine oral tablet

ANTIVIRALES, GENERALES

acyclovir oral capsule Zovirax

8


acyclovir oral suspension Zovirax

acyclovir oral tablet Zovirax

famciclovir oral tablet QL

oseltamivir oral capsule Tamiflu QL

oseltamivir oral suspension for reconstitution

Tamiflu QL

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

QL

rimantadine oral tablet Flumadine

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

QL

valacyclovir oral tablet 1 gram Valtrex

valacyclovir oral tablet 500 mg Valtrex QL

valganciclovir oral recon soln Valcyte

valganciclovir oral tablet Valcyte

CEFALOSPORINA, ANTIBIÓTICOS

cefaclor oral capsule

cefaclor oral suspension for reconstitution

cefaclor oral tablet extended release 12 hr

cefadroxil oral capsule

cefadroxil oral suspension for reconstitution

cefadroxil oral tablet

cefdinir oral capsule QL

cefdinir oral suspension for reconstitution QL

cefpodoxime oral suspension for reconstitution

cefpodoxime oral tablet

cefprozil oral suspension for reconstitution

cefprozil oral tablet

ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg

QL

ceftriaxone injection recon soln 10 gram

cefuroxime axetil oral suspension for reconstitution

cefuroxime axetil oral tablet 250 mg

cefuroxime axetil oral tablet 500 mg QL

cephalexin oral capsule Keflex

9


cephalexin oral suspension for reconstitution

cephalexin oral tablet

COMBINACIONES DE PLASMOCIDAS

atovaquone-proguanil oral tablet Malarone Pediatric

LINCOSAMIDAS

clindamycin hcl oral capsule Cleocin HCl

clindamycin palmitate hcl oral recon soln Cleocin Pediatric

clindamycin pediatric oral recon soln

MACRÓLIDOS

azithromycin oral packet Zithromax QL

azithromycin oral suspension for reconstitution

Zithromax QL

azithromycin oral tablet Zithromax QL

clarithromycin oral suspension for reconstitution

clarithromycin oral tablet

clarithromycin oral tablet extended release 24 hr

e.e.s. 400 oral tablet

ery-tab oral tablet,delayed release (dr/ec)

erythrocin (as stearate) oral tablet

erythromycin ethylsuccinate oral tablet E.E.S. 400

erythromycin oral capsule,delayed release(dr/ec)

erythromycin oral tablet

erythromycin stearate oral tablet Erythrocin (as stearate)

PENICILINAS

dicloxacillin oral capsule

penicillin v potassium oral recon soln

penicillin v potassium oral tablet

PLASMOCIDAS

chloroquine phosphate oral tablet

hydroxychloroquine oral tablet Plaquenil

mefloquine oral tablet QL

PRIMAQUINE ORAL TABLET

10


QUINOLONES

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

Cipro XR QL

ciprofloxacin hcl oral tablet Cipro QL

levofloxacin oral solution QL

levofloxacin oral tablet QL

ofloxacin oral tablet QL

SULFONAMIDAS ABSORBIBLES

sulfamethoxazole-trimethoprim oral suspension

Sulfatrim

sulfamethoxazole-trimethoprim oral tablet Bactrim DS

sulfatrim oral suspension

trimethoprim oral tablet

TETRACICLINA

demeclocycline oral tablet

doxycycline monohydrate oral capsule

doxycycline monohydrate oral suspension for reconstitution

Vibramycin

minocycline oral capsule Minocin

minocycline oral tablet

tetracycline oral capsule

VANCOMICINA Y DERIVADOS

linezolid oral suspension for reconstitution Zyvox PA; QL

linezolid oral tablet Zyvox PA; QL

vancomycin oral capsule Vancocin PA

AGENTES DE DIAGNÓSTICO

AGENTES DE DIAGNÓSTICO: COMPLEMENTO RADIOLÓGICO GASTROINTESTINAL

GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

QL

AGENTES DE TERAPIA CARDIOVASCULAR

AGENTES BLOQUEADORES ALFA ADRENÉRGICOS

doxazosin oral tablet Cardura QL

prazosin oral capsule Minipress

terazosin oral capsule QL

11


AGENTES BLOQUEADORES ALFA/BETA ADRENÉRGICOS

carvedilol oral tablet Coreg QL

labetalol oral tablet

AGENTES BLOQUEADORES BETA ADRENÉRGICOS

acebutolol oral capsule

atenolol oral tablet Tenormin

betaxolol oral tablet

bisoprolol fumarate oral tablet

metoprolol succinate oral tablet extended release 24 hr

Toprol XL

metoprolol tartrate oral tablet 100 mg, 50 mg

Lopressor QL

metoprolol tartrate oral tablet 25 mg, 37.5 mg, 75 mg

nadolol oral tablet Corgard

pindolol oral tablet

propranolol oral capsule,extended release 24 hr

Inderal LA

propranolol oral solution

propranolol oral tablet

sorine oral tablet

sotalol af oral tablet

sotalol oral tablet Betapace

timolol maleate oral tablet

AGENTES BLOQUEADORES DEL CANAL DE CALCIO

afeditab cr oral tablet extended release 30 mg

DO; QL

afeditab cr oral tablet extended release 60 mg

QL

amlodipine oral tablet 10 mg Norvasc QL

amlodipine oral tablet 2.5 mg, 5 mg Norvasc DO; QL

cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg

DO; QL

cartia xt oral capsule,extended release 24hr 300 mg

QL

12


diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg

DILT-XR DO; QL

diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg

DILT-XR QL

diltiazem hcl oral capsule,extended release 12 hr

QL

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg

Taztia XT DO; QL

diltiazem hcl oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg

Taztia XT QL

diltiazem hcl oral capsule,extended release 24 hr 420 mg

Tiazac QL

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg

Cardizem CD DO; QL

diltiazem hcl oral capsule,extended release 24hr 300 mg, 360 mg

Cardizem CD QL

diltiazem hcl oral tablet Cardizem QL

diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg

Cardizem LA DO; QL

diltiazem hcl oral tablet extended release 24 hr 300 mg, 360 mg, 420 mg

Cardizem LA QL

dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg

DO; QL

dilt-xr oral capsule,ext.rel 24h degradable 240 mg

QL

felodipine oral tablet extended release 24 hr 10 mg

QL

felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg

DO; QL

isradipine oral capsule QL

matzim la oral tablet extended release 24 hr 180 mg, 240 mg

DO; QL

matzim la oral tablet extended release 24 hr 300 mg, 360 mg, 420 mg

QL

nicardipine oral capsule QL

nifedipine oral capsule Procardia QL

nifedipine oral tablet extended release 24hr 30 mg

Procardia XL DO; QL

nifedipine oral tablet extended release 24hr 60 mg, 90 mg

Procardia XL QL

nifedipine oral tablet extended release 30 mg

Adalat CC DO; QL

13


nifedipine oral tablet extended release 60 mg, 90 mg

Adalat CC QL

taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg

DO; QL

taztia xt oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg

QL

verapamil oral capsule, 24 hr er pellet ct Verelan PM DO; QL

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg

Verelan DO; QL

verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg

Verelan QL

verapamil oral tablet Calan QL

verapamil oral tablet extended release Calan SR QL

AGENTES DE TERAPIA ANAFILAXIA

epinephrine injection auto-injector Auvi-Q QL

epinephrine injection solution Adrenalin

AGENTES DIURÉTICOS, OTROS

acetazolamide oral capsule, extended release

acetazolamide oral tablet

methazolamide oral tablet

spironolactone oral tablet Aldactone

ANTAGONISTAS DEL RECEPTOR DE LA ALDOSTERONA

spironolactone oral tablet Aldactone

ANTIARRÍTMICOS

amiodarone oral tablet 200 mg Pacerone QL

amiodarone oral tablet 400 mg Pacerone

disopyramide phosphate oral capsule Norpace

flecainide oral tablet QL

mexiletine oral capsule

pacerone oral tablet 200 mg QL

pacerone oral tablet 400 mg

propafenone oral capsule,extended release 12 hr

Rythmol SR

propafenone oral tablet

quinidine gluconate oral tablet extended release

14


quinidine sulfate oral tablet

sorine oral tablet

sotalol af oral tablet

sotalol oral tablet Betapace

DIURÉTICOS AHORRADORES DE POTASIO

amiloride oral tablet

amiloride-hydrochlorothiazide oral tablet

spironolacton-hydrochlorothiaz oral tablet Aldactazide

triamterene-hydrochlorothiazid oral capsule

Dyazide

triamterene-hydrochlorothiazid oral tablet Maxzide

DIURÉTICOS DE ASA

bumetanide oral tablet

furosemide oral solution

furosemide oral tablet Lasix

torsemide oral tablet Demadex

GLUCÓSIDOS DIGITÁLICOS

digitek oral tablet

digox oral tablet

digoxin oral solution

digoxin oral tablet Digitek

HIPERTENSIÓN ARTERIAL PULMONAR

LETAIRIS ORAL TABLET PA; QL

sildenafil (antihypertensive) oral tablet Revatio PA; QL

tadalafil (antihypertensive) oral tablet Adcirca PA; QL

HIPOTENSIVOS, ANTAGONISTA DE LOS RECEPTORES DE LA ANGIOTENSINA

candesartan oral tablet Atacand QL

candesartan-hydrochlorothiazid oral tablet Atacand HCT QL

irbesartan oral tablet 150 mg, 75 mg Avapro DO; QL

irbesartan oral tablet 300 mg Avapro QL

irbesartan-hydrochlorothiazide oral tablet Avalide QL

losartan oral tablet Cozaar QL

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

Hyzaar QL

15


losartan-hydrochlorothiazide oral tablet 50-12.5 mg

Hyzaar DO; QL

valsartan oral tablet Diovan QL

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg

Diovan HCT DO; QL

valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg

Diovan HCT QL

HIPOTENSIVOS, INHIBIDORES DE LA ECA, COMBINACIONES

benazepril oral tablet QL

benazepril-hydrochlorothiazide oral tablet QL

captopril oral tablet QL

captopril-hydrochlorothiazide oral tablet QL

enalapril maleate oral tablet Vasotec QL

enalapril-hydrochlorothiazide oral tablet QL

fosinopril oral tablet QL

fosinopril-hydrochlorothiazide oral tablet QL

lisinopril oral tablet 10 mg, 20 mg, 5 mg Prinivil DO; QL

lisinopril oral tablet 2.5 mg Zestril DO; QL

lisinopril oral tablet 30 mg, 40 mg Zestril QL

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg

Zestoretic DO; QL

lisinopril-hydrochlorothiazide oral tablet 20-12.5 mg, 20-25 mg

Zestoretic QL

moexipril oral tablet

moexipril-hydrochlorothiazide oral tablet

perindopril erbumine oral tablet QL

quinapril oral tablet Accupril QL

quinapril-hydrochlorothiazide oral tablet Accuretic QL

ramipril oral capsule Altace QL

trandolapril oral tablet

HIPOTENSIVOS, SIMPATOLÍTICOS

clonidine hcl oral tablet Catapres DO; QL

guanfacine oral tablet DO; QL

methyldopa oral tablet

HIPOTENSIVOS, VARIOS

atenolol-chlorthalidone oral tablet Tenoretic 50

bisoprolol-hydrochlorothiazide oral tablet Ziac

16


methyldopa-hydrochlorothiazide oral tablet

metoprolol ta-hydrochlorothiaz oral tablet Lopressor HCT QL

nadolol-bendroflumethiazide oral tablet Corzide

propranolol-hydrochlorothiazid oral tablet

HIPOTENSIVOS, VASODILATADORES

hydralazine oral tablet

minoxidil oral tablet

INHIBIDOR DE LA ECA/COMBINACIÓN DEL BLOQUEADOR DEL CANAL DE CALCIO

amlodipine-benazepril oral capsule QL

INHIBIDORES DE LA PCSK-9

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR

PA; QL

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR

PA; QL

REPATHA SYRINGE SUBCUTANEOUS SYRINGE

PA; QL

LIPOTRÓPICOS

atorvastatin oral tablet 10 mg, 20 mg, 40 mg

Lipitor DO; QL

atorvastatin oral tablet 80 mg Lipitor QL

cholestyramine (with sugar) oral powder Questran

cholestyramine (with sugar) oral powder in packet

Questran

cholestyramine light oral powder

cholestyramine light oral powder in packet

colestipol oral granules Colestid

colestipol oral packet Colestid

colestipol oral tablet Colestid

fenofibrate micronized oral capsule QL

fenofibrate nanocrystallized oral tablet Tricor QL

fenofibrate oral tablet QL

fenofibric acid (choline) oral capsule,delayed release(dr/ec)

Trilipix QL

17


fenofibric acid oral tablet Fibricor QL

gemfibrozil oral tablet Lopid

lovastatin oral tablet 10 mg, 20 mg DO; QL

lovastatin oral tablet 40 mg QL

pravastatin oral tablet 10 mg DO; QL

pravastatin oral tablet 20 mg, 40 mg Pravachol DO; QL

pravastatin oral tablet 80 mg Pravachol QL

prevalite oral powder

prevalite oral powder in packet

simvastatin oral tablet 10 mg, 20 mg, 40 mg

Zocor DO; QL

simvastatin oral tablet 5 mg DO; QL

simvastatin oral tablet 80 mg Zocor PA; QL

TIAZIDA Y DIURÉTICOS RELACIONADOS

chlorothiazide oral tablet

chlorthalidone oral tablet

hydrochlorothiazide oral capsule Microzide QL

hydrochlorothiazide oral tablet 12.5 mg QL

hydrochlorothiazide oral tablet 25 mg, 50 mg

indapamide oral tablet

metolazone oral tablet

VASODILATADORES, CORONARIA

isosorbide dinitrate oral tablet Isordil Titradose

isosorbide dinitrate oral tablet extended release

ISOCHRON

isosorbide mononitrate oral tablet

isosorbide mononitrate oral tablet extended release 24 hr

nitro-bid transdermal ointment

NITRO-DUR TRANSDERMAL PATCH 24 HOUR

nitroglycerin oral capsule, extended release

Nitro-Time

nitroglycerin sublingual tablet Nitrostat

nitroglycerin transdermal patch 24 hour Minitran

nitro-time oral capsule, extended release

18


VASOPRESOR ADRENÉRGICO

midodrine oral tablet

AGENTES DE TERAPIA GASTROINTESTINAL

AGENTES ANTIEMÉTICOS/ANTIVÉRTIGOS

compro rectal suppository

ondansetron oral tablet,disintegrating Zofran ODT PA; QL

phenadoz rectal suppository AL

prochlorperazine edisylate injection solution

prochlorperazine maleate oral tablet Compazine

prochlorperazine rectal suppository Compazine

promethazine oral syrup AL

promethazine oral tablet 12.5 mg, 50 mg

promethazine oral tablet 25 mg QL

promethazine rectal suppository Phenadoz AL

promethegan rectal suppository 12.5 mg, 25 mg

promethegan rectal suppository 50 mg AL

trimethobenzamide oral capsule Tigan

AGENTES PARA LA ENFERMEDAD INFLAMATORIA INTESTINAL

budesonide oral capsule,delayed,extend.release

Entocort EC QL

colocort rectal enema

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

PA; QL

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT

PA; QL

HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT

PA; QL

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT

PA; QL

HUMIRA SUBCUTANEOUS SYRINGE KIT

PA; QL

hydrocortisone rectal enema Colocort

ANTIDIARREICOS

diphenoxylate-atropine oral liquid

19


diphenoxylate-atropine oral tablet Lomotil

ANTIESPASMÓDICOS

dicyclomine oral capsule

dicyclomine oral solution

dicyclomine oral tablet

glycopyrrolate oral tablet Robinul

hyoscyamine sulfate oral drops Hyosyne

hyoscyamine sulfate oral elixir Hyosyne

hyoscyamine sulfate oral tablet Levsin

hyoscyamine sulfate oral tablet extended release 12 hr

Levbid

hyoscyamine sulfate oral tablet,disintegrating

Anaspaz

hyoscyamine sulfate sublingual tablet Levsin/SL

hyosyne oral drops

hyosyne oral elixir

oscimin oral tablet

oscimin oral tablet,disintegrating

oscimin sl sublingual tablet

oscimin sr oral tablet extended release 12 hr

propantheline oral tablet

symax fastabs oral tablet,disintegrating

symax-sr oral tablet extended release 12 hr

ENZIMAS PANCREÁTICAS

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC)

ESTIMULANTES DE MOTILIDAD INTESTINAL

metoclopramide hcl oral solution

metoclopramide hcl oral tablet Reglan

INFLAMACIÓN CRÓNICA, ENFERMEDAD DE COLON, 5 AMINOSALICILATOS

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

QL

balsalazide oral capsule Colazal QL

mesalamine rectal enema Rowasa QL

20


mesalamine with cleansing wipe rectal enema kit

Rowasa QL

sulfasalazine oral tablet Azulfidine QL

sulfasalazine oral tablet,delayed release (dr/ec)

Azulfidine EN-tabs QL

LAXANTES Y CATÁRTICOS

constulose oral solution QL

enulose oral solution

gavilyte-c oral recon soln QL

gavilyte-g oral recon soln QL

gavilyte-n oral recon soln QL

generlac oral solution

lactulose oral solution 10 gram/15 ml Constulose QL

lactulose oral solution 10 gram/15 ml (15 ml)

QL

lactulose oral solution 20 gram/30 ml

peg 3350-electrolytes oral recon soln Colyte with Flavor Packs QL

peg-3350 with flavor packs oral recon soln QL

peg-electrolyte soln oral recon soln GaviLyte-N QL

trilyte with flavor packets oral recon soln QL

REDUCTORES DE SECRECIÓN ÁCIDA GÁSTRICA

CARAFATE ORAL SUSPENSION

famotidine (pf) intravenous solution

famotidine oral suspension Pepcid PA

famotidine oral tablet Pepcid

misoprostol oral tablet Cytotec

nizatidine oral capsule

nizatidine oral solution PA

omeprazole oral capsule,delayed release(dr/ec)

PA; Preferred for Members less than 6 years of age. PA required for members greater than 6.; QL

ranitidine hcl oral capsule

ranitidine hcl oral syrup

ranitidine hcl oral tablet Zantac

sucralfate oral suspension Carafate

sucralfate oral tablet Carafate

21


SALES BILIARES

ursodiol oral capsule Actigall

ursodiol oral tablet URSO 250

AGENTES DE TERAPIA RESPIRATORIA

AGENTES ALFA/BETA ADRENÉRGICOS

epinephrine injection solution Adrenalin

epinephrine injection syringe

AGENTES BETA ADRENÉRGICOS

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %)

QL

albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml

albuterol sulfate oral syrup

albuterol sulfate oral tablet

albuterol sulfate oral tablet extended release 12 hr

metaproterenol oral syrup

metaproterenol oral tablet

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

QL

terbutaline oral tablet

VENTOLIN HFA INHALATION HFA AEROSOL INHALER

QL

AGENTES BRONCODILATADORES GENERALES

ATROVENT HFA INHALATION HFA AEROSOL INHALER

QL

ipratropium bromide inhalation solution QL

SPIRIVA RESPIMAT INHALATION MIST QL

AGENTES PARA EL TRATAMIENTO DE LA FIBROSIS QUÍSTICA

tobramycin in 0.225 % nacl inhalation solution for nebulization

Tobi

AGENTES PARA EL TRATAMIENTO DEL ASMA

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE

QL

22


budesonide inhalation suspension for nebulization

Pulmicort PA; AL; QL

cromolyn inhalation solution for nebulization

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER

QL

montelukast oral granules in packet Singulair QL

montelukast oral tablet Singulair QL

montelukast oral tablet,chewable Singulair QL

zafirlukast oral tablet Accolate

ANTIBIÓTICOS NASALES

BACTROBAN NASAL NASAL OINTMENT

ANTICOLINÉRGICOS NASALES

ipratropium bromide nasal spray,non-aerosol

QL

ANTICUERPOS DE INMUNOGLOBULINA

XOLAIR SUBCUTANEOUS RECON SOLN

PA

ANTIHISTAMÍNICOS NASALES

azelastine nasal aerosol,spray QL

azelastine nasal spray,non-aerosol Astepro QL

ANTIHISTAMÍNICOS

carbinoxamine maleate oral liquid AL

carbinoxamine maleate oral tablet AL

clemastine oral tablet

cyproheptadine oral tablet

phenadoz rectal suppository AL

promethazine oral syrup AL

promethazine oral tablet 12.5 mg, 50 mg

promethazine oral tablet 25 mg QL

promethazine rectal suppository Phenadoz AL

promethegan rectal suppository 12.5 mg, 25 mg

promethegan rectal suppository 50 mg AL

23


COMBINACIÓN DE AGENTES BETA ADRENÉRGICOS

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

QL

COMBIVENT RESPIMAT INHALATION MIST

ipratropium-albuterol inhalation solution for nebulization

STIOLTO RESPIMAT INHALATION MIST

QL

COMBINACIONES ANTITUSIVAS NO NARCÓTICAS

benzonatate oral capsule Tessalon Perles

promethazine-dm oral syrup AL

COMBINACIONES DE ANTIHISTAMÍNICOS Y DESCONGESTIVOS

promethazine vc oral syrup AL

promethazine-phenylephrine oral syrup Promethazine VC

COMBINACIONES DE ANTITUSIVOS NARCÓTICOS

hydrocodone compound oral syrup

hydrocodone-homatropine oral syrup Hydrocodone Compound AL

hydrocodone-homatropine oral tablet Tussigon AL

hydromet oral syrup AL

promethazine vc-codeine oral syrup AL

promethazine-codeine oral syrup AL

promethazine-phenyleph-codeine oral syrup

Promethazine VC-Codeine

COMBINACIONES DE GLUCOCORTICOIDES Y BETA-ADRENÉRGICOS

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

PA; QL

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED

AirDuo RespiClick PA; QL

MUCOLÍTICOS

acetylcysteine solution

PULMOZYME INHALATION SOLUTION PA; QL

24


XANTINAS

theochron oral tablet extended release 12 hr

theophylline oral elixir Elixophyllin

theophylline oral solution

theophylline oral tablet extended release 12 hr

Theochron

theophylline oral tablet extended release 24 hr

AGENTES DEL SISTEMA NERVIOSO CENTRAL

AGENTES PARA LA FIBROMIALGIA

LYRICA ORAL CAPSULE PA; QL

LYRICA ORAL SOLUTION PA; QL

ANSIOLÍTICOS

alprazolam intensol oral concentrate DO; QL

alprazolam oral tablet Xanax QL

alprazolam oral tablet,disintegrating DO; QL

buspirone oral tablet DO; QL

chlordiazepoxide hcl oral capsule DO; QL

clonazepam oral tablet Klonopin QL

clonazepam oral tablet,disintegrating QL

clorazepate dipotassium oral tablet DO; QL

diazepam intensol oral concentrate DO; QL

diazepam oral concentrate Diazepam Intensol DO; QL

diazepam oral solution QL

diazepam oral tablet Valium DO; QL

hydroxyzine hcl oral solution QL

hydroxyzine hcl oral tablet DO; QL

hydroxyzine pamoate oral capsule Vistaril DO; QL

lorazepam oral tablet Ativan QL

oxazepam oral capsule QL

ANTICONVULSIVOS

carbamazepine oral capsule, er multiphase 12 hr

Carbatrol QL

carbamazepine oral suspension Tegretol DO; QL

carbamazepine oral tablet Epitol DO; QL

25


carbamazepine oral tablet extended release 12 hr

Tegretol XR DO; QL

carbamazepine oral tablet,chewable DO; QL



diazepam rectal kit Diastat QL

divalproex oral capsule, delayed rel sprinkle

Depakote Sprinkles DO; QL

divalproex oral tablet extended release 24 hr

Depakote ER DO; QL

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg

Depakote DO; QL

divalproex oral tablet,delayed release (dr/ec) 500 mg

Depakote

epitol oral tablet DO; QL

ethosuximide oral capsule Zarontin

ethosuximide oral solution Zarontin

felbamate oral suspension Felbatol

felbamate oral tablet Felbatol

gabapentin oral capsule Neurontin QL

gabapentin oral solution Neurontin QL

gabapentin oral tablet Neurontin QL

lamotrigine oral tablet Lamictal QL

lamotrigine oral tablet disintegrating, dose pk

Lamictal ODT Starter (Blue)

lamotrigine oral tablet extended release 24hr

Lamictal XR QL

lamotrigine oral tablet, chewable dispersible

Lamictal QL

lamotrigine oral tablet,disintegrating Lamictal ODT QL

lamotrigine oral tablets,dose pack Lamictal Starter (Blue) Kit

levetiracetam oral solution Keppra

levetiracetam oral tablet Keppra

levetiracetam oral tablet extended release 24 hr

Keppra XR QL

LYRICA ORAL CAPSULE PA; QL

LYRICA ORAL SOLUTION PA; QL

oxcarbazepine oral suspension Trileptal DO; QL

oxcarbazepine oral tablet 150 mg, 300 mg Trileptal QL

26


oxcarbazepine oral tablet 600 mg Trileptal DO; QL

phenobarbital oral elixir QL

phenobarbital oral tablet 100 mg, 15 mg, 60 mg

phenobarbital oral tablet 16.2 mg, 30 mg, 32.4 mg, 64.8 mg, 97.2 mg

QL

phenytoin oral suspension Dilantin-125

phenytoin oral tablet,chewable Dilantin Infatabs

phenytoin sodium extended oral capsule Dilantin Extended

primidone oral tablet Mysoline

ROWEEPRA ORAL TABLET

roweepra xr oral tablet extended release 24 hr

QL

tiagabine oral tablet Gabitril

topiramate oral capsule, sprinkle Topamax QL

topiramate oral tablet Topamax QL

valproic acid (as sodium salt) oral solution Depakene

valproic acid oral capsule Depakene DO; QL

zonisamide oral capsule 100 mg Zonegran QL

zonisamide oral capsule 25 mg Zonegran

zonisamide oral capsule 50 mg

ANTIDEPRESIVOS ANTAGONISTAS DE RECEPTORES ALFA-2

mirtazapine oral tablet Remeron DO; QL

mirtazapine oral tablet,disintegrating Remeron SolTab DO; QL

ANTIDEPRESIVOS TRICÍCLICOS E INHIBIDORES DE RECAPTACIÓN NO SELECCIONADOS RELACIONADOS

amitriptyline oral tablet DO; QL

amoxapine oral tablet

clomipramine oral capsule Anafranil DO; QL

desipramine oral tablet Norpramin DO; QL

doxepin oral capsule DO; QL

doxepin oral concentrate DO; QL

imipramine hcl oral tablet Tofranil DO; QL

imipramine pamoate oral capsule DO; QL

maprotiline oral tablet DO; QL

27


nortriptyline oral capsule Pamelor DO; QL

nortriptyline oral solution DO; QL

protriptyline oral tablet DO; QL

trimipramine oral capsule Surmontil DO; QL

ANTIDEPRESIVOS, OTROS

perphenazine-amitriptyline oral tablet

ANTIPSICÓTICOS, DOPAMINA ATÍPICA Y ANTAGONISTAS DE SEROTONINA

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

PA; AL

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

PA; AL

aripiprazole oral tablet 10 mg, 2 mg, 5 mg Abilify DO; AL; QL

aripiprazole oral tablet 15 mg, 20 mg, 30 mg

Abilify AL; QL

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

PA; AL

clozapine oral tablet 100 mg, 25 mg Clozaril DO; AL; QL

clozapine oral tablet 200 mg AL; QL

clozapine oral tablet 50 mg DO; AL; QL

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

PA; AL; QL

INVEGA TRINZA INTRAMUSCULAR SYRINGE

PA; AL; QL

olanzapine intramuscular recon soln Zyprexa PA; AL

olanzapine oral tablet 10 mg, 15 mg, 20 mg

Zyprexa AL; QL

olanzapine oral tablet 2.5 mg, 5 mg, 7.5 mg

Zyprexa DO; AL; QL

paliperidone oral tablet extended release 24hr 1.5 mg

Invega AL

paliperidone oral tablet extended release 24hr 3 mg

Invega DO; AL; QL

paliperidone oral tablet extended release 24hr 6 mg, 9 mg

Invega AL; QL

quetiapine oral tablet 100 mg, 25 mg, 50 mg

Seroquel PA; DO; AL; QL

quetiapine oral tablet 200 mg, 300 mg, 400 mg

Seroquel PA; AL; QL

28


RISPERDAL CONSTA INTRAMUSCULAR SYRINGE

PA; AL; QL

risperidone oral solution Risperdal AL

risperidone oral tablet 0.25 mg, 2 mg Risperdal PA; DO; AL; QL

risperidone oral tablet 0.5 mg, 1 mg Risperdal DO; AL; QL

risperidone oral tablet 3 mg, 4 mg Risperdal PA; AL; QL

ziprasidone hcl oral capsule 20 mg, 40 mg Geodon DO; AL; QL

ziprasidone hcl oral capsule 60 mg, 80 mg Geodon AL; QL

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

PA; AL

ANTIPSICÓTICOS, TÍPICOS

chlorpromazine oral tablet 10 mg, 25 mg, 50 mg

DO; AL; QL

chlorpromazine oral tablet 100 mg, 200 mg

AL; QL

fluphenazine decanoate injection solution AL

fluphenazine hcl injection solution PA

fluphenazine hcl oral concentrate AL

fluphenazine hcl oral elixir AL

fluphenazine hcl oral tablet 1 mg, 2.5 mg DO; AL; QL

fluphenazine hcl oral tablet 10 mg, 5 mg AL; QL

haloperidol decanoate intramuscular solution 100 mg/ml

Haldol Decanoate AL; QL

haloperidol decanoate intramuscular solution 50 mg/ml

Haldol Decanoate AL

haloperidol lactate injection solution Haldol AL

haloperidol lactate intramuscular syringe PA

haloperidol lactate oral concentrate AL

haloperidol oral tablet 0.5 mg, 1 mg, 2 mg DO; AL; QL

haloperidol oral tablet 10 mg, 20 mg, 5 mg AL; QL

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg

DO; AL; QL

loxapine succinate oral capsule 50 mg AL; QL

perphenazine oral tablet 16 mg, 4 mg, 8 mg

AL; QL

perphenazine oral tablet 2 mg DO; AL; QL

pimozide oral tablet Orap PA; DO; QL

prochlorperazine maleate oral tablet Compazine

29


thioridazine oral tablet 10 mg, 25 mg DO; QL

thioridazine oral tablet 100 mg, 50 mg QL

thiothixene oral capsule 1 mg, 2 mg, 5 mg DO; AL; QL

thiothixene oral capsule 10 mg AL; QL

trifluoperazine oral tablet 1 mg, 2 mg DO; AL; QL

trifluoperazine oral tablet 10 mg, 5 mg AL; QL

BENZODIACEPINAS

alprazolam intensol oral concentrate DO; QL

alprazolam oral tablet Xanax QL

alprazolam oral tablet,disintegrating DO; QL

amitriptyline-chlordiazepoxide oral tablet

chlordiazepoxide hcl oral capsule DO; QL



clorazepate dipotassium oral tablet DO; QL

diazepam intensol oral concentrate DO; QL

diazepam oral concentrate Diazepam Intensol DO; QL

diazepam oral solution QL

diazepam oral tablet Valium DO; QL

diazepam rectal kit Diastat QL

estazolam oral tablet DO; QL

flurazepam oral capsule DO; QL

lorazepam oral tablet Ativan QL

oxazepam oral capsule QL

temazepam oral capsule Restoril DO; QL

triazolam oral tablet Halcion DO; QL

COMBINACIONES DE BENZODIACEPINA/ANTIDEPRESIVOS TRICÍCLICOS

amitriptyline-chlordiazepoxide oral tablet

DÉFICIT DE ATENCIÓN, HIPERACTIVIDAD (TDAH)/NARCOLEPSIA

atomoxetine oral capsule Strattera DO; AL; QL

caffeine citrate intravenous solution Cafcit

caffeine citrate oral solution

clonidine hcl oral tablet extended release 12 hr

Kapvay AL

30


dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 5 mg

Focalin XR DO; AL; QL

dexmethylphenidate oral capsule,er biphasic 50-50 25 mg, 30 mg, 35 mg, 40 mg

Focalin XR AL; QL

dexmethylphenidate oral tablet 10 mg Focalin AL; QL

dexmethylphenidate oral tablet 2.5 mg Focalin DO; AL; QL

dexmethylphenidate oral tablet 5 mg Focalin PA; DO; QL

dextroamphetamine oral capsule, extended release 10 mg, 15 mg

Dexedrine Spansule AL; QL

dextroamphetamine oral capsule, extended release 5 mg

Dexedrine Spansule DO; AL; QL

dextroamphetamine oral tablet 10 mg Zenzedi AL; QL

dextroamphetamine oral tablet 5 mg Zenzedi DO; AL; QL

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg

Adderall XR DO; AL; QL


Adderall XR AL; QL

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg

Adderall DO; AL; QL

dextroamphetamine-amphetamine oral tablet 20 mg, 30 mg

Adderall AL; QL

metadate er oral tablet extended release AL; QL

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg

DO; AL; QL

methylphenidate hcl oral capsule, er biphasic 30-70 40 mg, 50 mg, 60 mg

AL; QL

methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 30 mg, 40 mg

Ritalin LA AL; QL

methylphenidate hcl oral capsule,er biphasic 50-50 20 mg

Ritalin LA DO; AL; QL

methylphenidate hcl oral capsule,er biphasic 50-50 60 mg

AL; QL

methylphenidate hcl oral solution Methylin AL; QL

methylphenidate hcl oral tablet 10 mg, 5 mg

Ritalin DO; AL; QL

methylphenidate hcl oral tablet 20 mg Ritalin AL; QL

31


methylphenidate hcl oral tablet extended release 10 mg

DO; AL; QL

methylphenidate hcl oral tablet extended release 20 mg

Metadate ER AL; QL

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg

Concerta DO; AL; QL

methylphenidate hcl oral tablet extended release 24hr 36 mg, 54 mg

Concerta AL; QL

DIABETIC PERIPHERAL NEUROPATHY AGENTS

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR

PA; DO; QL

ESTIMULANTES DEL SNC

dextroamphetamine oral capsule, extended release 10 mg, 15 mg

Dexedrine Spansule AL; QL

dextroamphetamine oral capsule, extended release 5 mg

Dexedrine Spansule DO; AL; QL

dextroamphetamine oral tablet 10 mg Zenzedi AL; QL

dextroamphetamine oral tablet 5 mg Zenzedi DO; AL; QL


Adderall XR DO; AL; QL


Adderall XR AL; QL

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg

Adderall DO; AL; QL

dextroamphetamine-amphetamine oral tablet 20 mg, 30 mg

Adderall AL; QL

INHIBIDOR SELECTIVO DE RECAPTACIÓN DE SEROTONINA (ISRS)

citalopram oral solution QL

citalopram oral tablet 10 mg, 20 mg Celexa DO; QL

citalopram oral tablet 40 mg Celexa QL

escitalopram oxalate oral solution QL

escitalopram oxalate oral tablet 10 mg, 5 mg

Lexapro DO; QL

escitalopram oxalate oral tablet 20 mg Lexapro QL

fluoxetine oral capsule 10 mg, 20 mg Prozac DO; QL

32


fluoxetine oral capsule 40 mg Prozac QL

fluoxetine oral capsule,delayed release(dr/ec)

QL

fluoxetine oral solution QL

fluoxetine oral tablet Sarafem DO; QL

fluvoxamine oral tablet 100 mg QL

fluvoxamine oral tablet 25 mg, 50 mg DO; QL

paroxetine hcl oral tablet 10 mg, 20 mg Paxil DO; QL

paroxetine hcl oral tablet 30 mg, 40 mg Paxil QL

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

Paxil CR DO; QL

paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg

Paxil CR QL

sertraline oral concentrate Zoloft QL

sertraline oral tablet 100 mg Zoloft QL

sertraline oral tablet 25 mg, 50 mg Zoloft DO; QL

INHIBIDORES DE RECAPTACIÓN DE ANTAGONISTAS DE SEROTONINA-2 (SARIS)

nefazodone oral tablet DO; QL

trazodone oral tablet DO; QL

INHIBIDORES DE RECAPTACIÓN DE DOPAMINA Y NOREPINEFRINA (IRND)

bupropion hcl oral tablet 100 mg QL

bupropion hcl oral tablet 75 mg DO; QL

bupropion hcl oral tablet extended release 24 hr 150 mg

Wellbutrin XL DO; QL

bupropion hcl oral tablet extended release 24 hr 300 mg

Wellbutrin XL QL

bupropion hcl oral tablet sustained-release 12 hr 100 mg

Wellbutrin SR DO; QL

bupropion hcl oral tablet sustained-release 12 hr 150 mg, 200 mg

Wellbutrin SR QL

INHIBIDORES DE RECAPTACIÓN DE SEROTONINA-NOREPINEFRINA (IRSN)

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg

Cymbalta PA; QL

33


duloxetine oral capsule,delayed release(dr/ec) 30 mg

Cymbalta PA; DO; QL

duloxetine oral capsule,delayed release(dr/ec) 40 mg

PA; DO; QL

venlafaxine oral capsule,extended release 24hr 150 mg

Effexor XR QL

venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg

Effexor XR DO; QL

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg

QL

venlafaxine oral tablet 75 mg DO; QL

venlafaxine oral tablet extended release 24hr 150 mg, 225 mg

QL

venlafaxine oral tablet extended release 24hr 37.5 mg, 75 mg

DO; QL

INHIBIDORES MAO

phenelzine oral tablet Nardil DO; QL

tranylcypromine oral tablet Parnate DO; QL

MEDICAMENTOS ANTIMANÍACOS

lithium carbonate oral capsule DO; QL

lithium carbonate oral tablet DO; QL

lithium carbonate oral tablet extended release

DO; QL

lithium citrate oral solution

MEDICAMENTOS PARA EL PARKINSON, ANTICOLINÉRGICO

benztropine oral tablet

trihexyphenidyl oral elixir

trihexyphenidyl oral tablet

MEDICAMENTOS PARA EL PARKINSON, OTROS

amantadine hcl oral capsule

amantadine hcl oral solution

amantadine hcl oral tablet

bromocriptine oral capsule Parlodel

bromocriptine oral tablet Parlodel

carbidopa-levodopa oral tablet Sinemet

carbidopa-levodopa oral tablet extended release

Sinemet CR

34


carbidopa-levodopa oral tablet,disintegrating

carbidopa-levodopa-entacapone oral tablet

Stalevo 50

entacapone oral tablet Comtan

pramipexole oral tablet Mirapex

ropinirole oral tablet Requip

selegiline hcl oral capsule

selegiline hcl oral tablet

NEUROPATHIC PAIN THERAPY


PA; DO; QL

POSTHERPETIC NEURALGIA AGENTS


PA; DO; QL

PREPARADOS PARA LA MIGRAÑA

divalproex oral tablet extended release 24 hr

Depakote ER DO; QL

ergotamine-caffeine oral tablet Cafergot

isometh-dichloral-acetaminophn oral capsule

migergot rectal suppository

naratriptan oral tablet Amerge QL

sumatriptan nasal spray,non-aerosol Imitrex PA; QL

sumatriptan succinate oral tablet Imitrex QL

sumatriptan succinate subcutaneous cartridge

Imitrex STATdose Kit Refill PA; QL

sumatriptan succinate subcutaneous pen injector

Imitrex STATdose Pen PA; QL

sumatriptan succinate subcutaneous solution

Imitrex PA; QL

SEDANTE HIPNÓTICO, BARBITÚRICOS

phenobarbital oral elixir QL

phenobarbital oral tablet 100 mg, 15 mg, 60 mg

phenobarbital oral tablet 16.2 mg, 30 mg, 32.4 mg, 64.8 mg, 97.2 mg

QL

35


SEDANTE HIPNÓTICO, NO BARBITÚRICOS

estazolam oral tablet DO; QL

flurazepam oral capsule DO; QL

temazepam oral capsule Restoril DO; QL

triazolam oral tablet DO; QL

zaleplon oral capsule Sonata DO; QL

zolpidem oral tablet Ambien DO; QL

AGENTES HEMATOLÓGICOS

AGENTES ANTIFIBRINOLÍTICOS

tranexamic acid oral tablet Lysteda QL

AGENTES HEMORREOLÓGICOS

pentoxifylline oral tablet extended release

AGENTES PARA LA ANEMIA FALCIFORME

DROXIA ORAL CAPSULE

ANTICOAGULANTES ORALES

ELIQUIS ORAL TABLET

ELIQUIS ORAL TABLETS,DOSE PACK QL

jantoven oral tablet

warfarin oral tablet Coumadin

HEMATÍNICOS, OTRO

ARANESP (IN POLYSORBATE) INJECTION SOLUTION

PA

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

PA

EPOGEN INJECTION SOLUTION PA

PROCRIT INJECTION SOLUTION PA

HEPARINA Y PREPARADOS RELACIONADOS

enoxaparin subcutaneous solution Lovenox QL

enoxaparin subcutaneous syringe Lovenox QL

heparin (porcine) injection cartridge

heparin (porcine) injection solution

heparin (porcine) injection syringe

heparin, porcine (pf) injection solution

heparin, porcine (pf) injection syringe

36


INHIBIDORES DE AGREGACIÓN PLAQUETARIA

anagrelide oral capsule

cilostazol oral tablet

clopidogrel oral tablet 300 mg Plavix

clopidogrel oral tablet 75 mg Plavix QL

dipyridamole oral tablet

AGENTES INMUNOSUPRESORES

INMUNOSUPRESORES

azathioprine oral tablet Imuran

cyclosporine modified oral capsule Gengraf

cyclosporine modified oral solution Gengraf

cyclosporine oral capsule Sandimmune

gengraf oral capsule

gengraf oral solution

mycophenolate mofetil oral capsule CellCept

mycophenolate mofetil oral suspension for reconstitution

CellCept

mycophenolate mofetil oral tablet CellCept

mycophenolate sodium oral tablet,delayed release (dr/ec)

Myfortic

RAPAMUNE ORAL SOLUTION

SANDIMMUNE ORAL SOLUTION

sirolimus oral tablet Rapamune

tacrolimus oral capsule Prograf

AGENTES OFTÁLMICOS

AGENTES ANTINFLAMATORIOS OFTÁLMICOS

dexamethasone sodium phosphate ophthalmic (eye) drops

diclofenac sodium ophthalmic (eye) drops

fluorometholone ophthalmic (eye) drops,suspension

FML Liquifilm

flurbiprofen sodium ophthalmic (eye) drops

prednisolone acetate ophthalmic (eye) drops,suspension

Omnipred

prednisolone sodium phosphate ophthalmic (eye) drops

37


XIIDRA OPHTHALMIC (EYE) DROPPERETTE

PA; QL

ANTIBIÓTICO OFTÁLMICO, COMBINACIONES DE CORTICOESTEROIDES

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment

Neo-Polycin HC

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension

Maxitrol

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment

Maxitrol

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension

neo-polycin hc ophthalmic (eye) ointment

sulfacetamide-prednisolone ophthalmic (eye) drops

QL

tobramycin-dexamethasone ophthalmic (eye) drops,suspension

TobraDex QL

ANTIBIÓTICOS OFTÁLMICOS

ak-poly-bac ophthalmic (eye) ointment

bacitracin ophthalmic (eye) ointment QL

bacitracin-polymyxin b ophthalmic (eye) ointment

AK-Poly-Bac

ciprofloxacin hcl ophthalmic (eye) drops Ciloxan

erythromycin ophthalmic (eye) ointment

gatifloxacin ophthalmic (eye) drops Zymaxid

gentak ophthalmic (eye) ointment QL

gentamicin ophthalmic (eye) drops QL

gentamicin ophthalmic (eye) ointment Gentak QL

levofloxacin ophthalmic (eye) drops

moxifloxacin ophthalmic (eye) drops Vigamox

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment

Neo-Polycin QL

neomycin-polymyxin-gramicidin ophthalmic (eye) drops

QL

neo-polycin ophthalmic (eye) ointment QL

ofloxacin ophthalmic (eye) drops Ocuflox QL

polycin ophthalmic (eye) ointment

polymyxin b sulf-trimethoprim ophthalmic (eye) drops

Polytrim QL

38


sulfacetamide sodium ophthalmic (eye) drops

Bleph-10 QL

sulfacetamide sodium ophthalmic (eye) ointment

QL

tobramycin ophthalmic (eye) drops Tobrex QL

ANTIHISTAMÍNICOS OFTÁLMICOS

azelastine ophthalmic (eye) drops QL

epinastine ophthalmic (eye) drops Elestat QL

ANTIVIRALES OFTÁLMICOS

trifluridine ophthalmic (eye) drops Viroptic QL

DESCONGESTIVOS OFTÁLMICOS

phenylephrine hcl ophthalmic (eye) drops

ESTABILIZADORES DE MASTOCITOS OFTÁLMICOS

cromolyn ophthalmic (eye) drops QL

MIDRIÁTRICOS

atropine ophthalmic (eye) drops Isopto Atropine QL

atropine ophthalmic (eye) ointment QL

MIÓTICOS/OTROS REDUCTORES DE PRESIÓN INTRAOCULAR

apraclonidine ophthalmic (eye) drops Iopidine

betaxolol ophthalmic (eye) drops

brimonidine ophthalmic (eye) drops QL

carteolol ophthalmic (eye) drops

dorzolamide ophthalmic (eye) drops Trusopt QL

dorzolamide-timolol ophthalmic (eye) drops

Cosopt QL

latanoprost ophthalmic (eye) drops Xalatan

levobunolol ophthalmic (eye) drops

metipranolol ophthalmic (eye) drops

pilocarpine hcl ophthalmic (eye) drops Isopto Carpine

timolol maleate ophthalmic (eye) drops Timoptic QL

timolol maleate ophthalmic (eye) gel forming solution

Timoptic-XE QL

39


ANALGÉSICO, ANTINFLAMATORIO O ANTIPIRÉTICO

ANALGÉSICO/ANTIPIRÉTICOS, SALICILATOS

butalbital-aspirin-caffeine oral capsule Fiorinal QL

choline,magnesium salicylate oral liquid

diflunisal oral tablet

salsalate oral tablet Disalcid

ANALGÉSICOS, NARCÓTICOS

acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml

QL

acetaminophen-codeine oral solution 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml

acetaminophen-codeine oral tablet PA; QL

ascomp with codeine oral capsule PA; QL

BELBUCA BUCCAL FILM PA; QL

butalbital compound w/codeine oral capsule

PA; QL

butalbital compound-codeine oral capsule PA; QL

butalbital-acetaminop-caf-cod oral capsule PA; QL

butorphanol tartrate nasal spray,non-aerosol

PA; QL

codeine sulfate oral tablet PA; QL

codeine-butalbital-asa-caff oral capsule Ascomp with Codeine PA; QL

diskets oral tablet,soluble PA; QL

endocet oral tablet PA; QL

fentanyl citrate buccal lozenge on a handle

Actiq PA; QL

fentanyl transdermal patch 72 hour Duragesic PA; QL

hydrocodone-acetaminophen oral solution Hycet PA; QL

hydrocodone-acetaminophen oral tablet 10-300 mg

Vicodin HP PA; QL


Lorcet HD PA; QL

hydrocodone-acetaminophen oral tablet 2.5-325 mg

Verdrocet QL


Vicodin PA; QL

40



Lorcet (hydrocodone) PA; QL


Vicodin ES PA; QL


Lorcet Plus QL

hydrocodone-ibuprofen oral tablet PA; QL

hydromorphone oral liquid Dilaudid PA; QL

hydromorphone oral tablet Dilaudid PA; QL

hydromorphone rectal suppository PA; QL

meperidine oral solution PA; QL

meperidine oral tablet PA; QL

methadone intensol oral concentrate PA; QL

methadone oral concentrate Methadone Intensol PA; QL

methadone oral solution PA; QL

methadone oral tablet Dolophine PA; QL

methadone oral tablet,soluble Diskets PA; QL

methadose oral concentrate PA; QL

methadose oral tablet,soluble PA; QL

morphine concentrate oral solution PA; QL

morphine oral solution PA; QL

morphine oral tablet PA; QL

morphine oral tablet extended release MS Contin PA; QL

morphine rectal suppository QL

oxycodone oral capsule PA; QL

oxycodone oral concentrate PA; QL

oxycodone oral solution PA; QL

oxycodone oral tablet Roxicodone PA; QL

oxycodone-acetaminophen oral tablet Endocet PA; QL

oxycodone-aspirin oral tablet PA; QL

pentazocine-naloxone oral tablet PA; QL

tramadol oral tablet Ultram PA; QL

tramadol-acetaminophen oral tablet Ultracet PA; QL

vicodin es oral tablet PA; QL

vicodin hp oral tablet PA; QL

vicodin oral tablet PA; QL

41


ANALGÉSICOS, NO NARCÓTICOS

BUTALBITAL-ACETAMINOPHEN ORAL CAPSULE

QL

butalbital-acetaminophen oral tablet Tencon QL

butalbital-acetaminophen-caff oral capsule Fioricet QL

butalbital-acetaminophen-caff oral tablet Esgic QL

capacet oral capsule QL

tencon oral tablet QL

ANTINFLAMATORIO, INHIBIDOR DE LA SÍNTESIS DE PIRIMIDINA

leflunomide oral tablet Arava

RIDAURA ORAL CAPSULE

FÁRMACOS ANTIRREUMÁTICOS MODIFICADORES DE LA ENFERMEDAD (FARME)

DEPEN TITRATABS ORAL TABLET PA

hydroxychloroquine oral tablet Plaquenil

minocycline oral capsule Minocin

minocycline oral tablet

sulfasalazine oral tablet Azulfidine QL

sulfasalazine oral tablet,delayed release (dr/ec)

Azulfidine EN-tabs QL

INHIBIDOR DEL FACTOR DE LA NECROSIS TUMORAL ANTINFLAMATORIA

ENBREL MINI SUBCUTANEOUS CARTRIDGE

PA; QL

ENBREL SUBCUTANEOUS RECON SOLN

PA; QL

ENBREL SUBCUTANEOUS SYRINGE PA; QL

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

PA; QL


PA; QL


PA; QL


PA; QL


PA; QL

42



PA; QL

INHIBIDOR DEL FACTOR DE NECROSIS TUMORAL ANTINFLAMATORIO

ENBREL MINI SUBCUTANEOUS CARTRIDGE

PA; QL

ENBREL SUBCUTANEOUS RECON SOLN

PA; QL

ENBREL SUBCUTANEOUS SYRINGE PA; QL

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

PA; QL


PA; QL


PA; QL


PA; QL


PA; QL


PA; QL

INMUNOSUPRESORES

azathioprine oral tablet Imuran

cyclosporine modified oral capsule

cyclosporine modified oral solution Gengraf

cyclosporine oral capsule Sandimmune

gengraf oral capsule

gengraf oral solution

mycophenolate mofetil oral capsule CellCept

mycophenolate mofetil oral suspension for reconstitution

CellCept

mycophenolate mofetil oral tablet CellCept

SANDIMMUNE ORAL SOLUTION

NSAIDS

celecoxib oral capsule Celebrex PA; QL

diclofenac potassium oral tablet

diclofenac sodium oral tablet extended release 24 hr

Voltaren-XR

43


diclofenac sodium oral tablet,delayed release (dr/ec)

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic

Arthrotec 50 PA

etodolac oral capsule

etodolac oral tablet Lodine

etodolac oral tablet extended release 24 hr

fenoprofen oral tablet ProFeno

flurbiprofen oral tablet

ibu oral tablet

ibuprofen oral tablet IBU

indomethacin oral capsule

indomethacin oral capsule, extended release

ketoprofen oral capsule

ketoprofen oral capsule,ext rel. pellets 24 hr

ketorolac oral tablet QL

meclofenamate oral capsule

mefenamic acid oral capsule PA

meloxicam oral suspension QL

meloxicam oral tablet Mobic QL

nabumetone oral tablet

naproxen oral suspension Naprosyn

naproxen oral tablet

naproxen oral tablet,delayed release (dr/ec)

EC-Naprosyn PA

naproxen sodium oral tablet

naproxen sodium oral tablet, er multiphase 24 hr

Naprelan CR PA

oxaprozin oral tablet Daypro

piroxicam oral capsule Feldene

sulindac oral tablet

tolmetin oral capsule

tolmetin oral tablet

ANESTÉSICOS

ANESTÉSICOS LOCALES

lidocaine hcl laryngotracheal solution LTA Pre-Attached QL

44


lidocaine topical ointment QL

ANTICONCEPTIVOS

ANTICONCEPTIVOS DE EMERGENCIA

ELLA ORAL TABLET QL

ANTICONCEPTIVOS

altavera (28) oral tablet AL

alyacen 1/35 (28) oral tablet AL

alyacen 7/7/7 (28) oral tablet AL

amethia lo oral tablets,dose pack,3 month AL; QL

amethia oral tablets,dose pack,3 month AL; QL

amethyst oral tablet AL; QL

apri oral tablet AL; QL

aranelle (28) oral tablet AL

ashlyna oral tablets,dose pack,3 month AL; QL

aubra oral tablet AL

aviane oral tablet AL

azurette (28) oral tablet AL; QL

balziva (28) oral tablet AL

bekyree (28) oral tablet AL; QL

blisovi 24 fe oral tablet AL; QL

blisovi fe 1.5/30 (28) oral tablet AL; QL

blisovi fe 1/20 (28) oral tablet AL; QL

briellyn oral tablet AL

camila oral tablet AL

camrese lo oral tablets,dose pack,3 month AL; QL

camrese oral tablets,dose pack,3 month AL; QL

caziant (28) oral tablet AL

chateal oral tablet AL

cryselle (28) oral tablet AL

cyclafem 1/35 (28) oral tablet AL

cyclafem 7/7/7 (28) oral tablet AL

cyred oral tablet AL; QL

dasetta 1/35 (28) oral tablet AL

dasetta 7/7/7 (28) oral tablet AL

daysee oral tablets,dose pack,3 month AL; QL

deblitane oral tablet AL

45


delyla (28) oral tablet AL

desog-e.estradiol/e.estradiol oral tablet Azurette (28) AL; QL

desogestrel-ethinyl estradiol oral tablet Apri AL; QL

drospirenone-e.estradiol-lm.fa oral tablet Beyaz AL

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg

Gianvi (28) AL; QL

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

Ocella AL

elinest oral tablet AL

emoquette oral tablet AL; QL

enpresse oral tablet AL

enskyce oral tablet AL; QL

errin oral tablet AL

estarylla oral tablet AL

ethynodiol diac-eth estradiol oral tablet Kelnor 1-50 AL

falmina (28) oral tablet AL

fayosim oral tablets,dose pack,3 month AL; QL

femynor oral tablet AL

gianvi (28) oral tablet AL; QL

heather oral tablet AL

introvale oral tablets,dose pack,3 month AL; QL

isibloom oral tablet AL; QL

jencycla oral tablet AL

jolessa oral tablets,dose pack,3 month AL; QL

jolivette oral tablet AL

juleber oral tablet AL; QL

junel 1.5/30 (21) oral tablet AL

junel 1/20 (21) oral tablet AL

junel fe 1.5/30 (28) oral tablet AL; QL

junel fe 1/20 (28) oral tablet AL; QL

junel fe 24 oral tablet AL; QL

kaitlib fe oral tablet,chewable AL; QL

kariva (28) oral tablet AL; QL

kelnor 1/35 (28) oral tablet AL

kelnor 1-50 oral tablet

kurvelo oral tablet AL

KYLEENA INTRAUTERINE INTRAUTERINE DEVICE

46


l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month

Amethia AL; QL

larin 1.5/30 (21) oral tablet AL

larin 1/20 (21) oral tablet AL

larin 24 fe oral tablet AL; QL

larin fe 1.5/30 (28) oral tablet AL; QL

larin fe 1/20 (28) oral tablet AL; QL

larissia oral tablet AL

layolis fe oral tablet,chewable AL; QL

leena 28 oral tablet AL

lessina oral tablet AL

levonest (28) oral tablet AL

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg

Aubra AL

levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg

Altavera (28) AL

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

Amethyst AL; QL

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

Introvale AL; QL

levonorg-eth estrad triphasic oral tablet Enpresse AL

levora 0.15/30 (28) oral tablet AL

levora-28 oral tablet AL

LILETTA INTRAUTERINE INTRAUTERINE DEVICE

lillow oral tablet AL

loryna (28) oral tablet AL; QL

low-ogestrel (28) oral tablet AL

lutera (28) oral tablet AL

lyza oral tablet AL

marlissa oral tablet AL

medroxyprogesterone intramuscular suspension

Depo-Provera AL

medroxyprogesterone intramuscular syringe

Depo-Provera AL

melodetta 24 fe oral tablet,chewable AL

mibelas 24 fe oral tablet,chewable AL

microgestin 1.5/30 (21) oral tablet AL

microgestin 1/20 (21) oral tablet AL

47


microgestin fe 1.5/30 (28) oral tablet AL; QL

microgestin fe 1/20 (28) oral tablet AL; QL

MIRENA INTRAUTERINE INTRAUTERINE DEVICE

mono-linyah oral tablet AL

mononessa (28) oral tablet AL

myzilra oral tablet AL

necon 0.5/35 (28) oral tablet AL

NEXPLANON SUBDERMAL IMPLANT

nikki (28) oral tablet AL; QL

nora-be oral tablet AL

noreth-ethinyl estradiol-iron oral tablet,chewable

Generess Fe AL; QL

norethindrone (contraceptive) oral tablet Camila AL

norethindrone ac-eth estradiol oral tablet Junel 1/20 (21) AL

norethindrone-e.estradiol-iron oral tablet Blisovi Fe 1/20 (28) AL; QL

norethindrone-e.estradiol-iron oral tablet,chewable

Melodetta 24 Fe AL

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg

Ortho Tri-Cyclen LO (28) AL; QL

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28)

Ortho Tri-Cyclen (28) AL

norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg

Estarylla AL

norgestrel-ethinyl estradiol oral tablet Ogestrel (28) AL

norlyda oral tablet AL

norlyroc oral tablet AL

nortrel 0.5/35 (28) oral tablet AL

nortrel 1/35 (21) oral tablet AL

nortrel 1/35 (28) oral tablet AL

nortrel 7/7/7 (28) oral tablet AL

NUVARING VAGINAL RING AL

ocella oral tablet AL

ogestrel (28) oral tablet AL

orsythia oral tablet AL

PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE

philith oral tablet AL

pimtrea (28) oral tablet AL; QL

48


pirmella oral tablet AL

portia oral tablet AL

previfem oral tablet AL

quasense oral tablets,dose pack,3 month AL; QL

rajani oral tablet AL

reclipsen (28) oral tablet AL; QL

RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH

AL; QL

setlakin oral tablets,dose pack,3 month AL; QL

sharobel oral tablet AL

SKYLA INTRAUTERINE INTRAUTERINE DEVICE

sprintec (28) oral tablet AL

sronyx oral tablet AL

syeda oral tablet AL

tarina fe 1/20 (28) oral tablet AL; QL

tilia fe oral tablet AL; QL

tri femynor oral tablet AL

tri-estarylla oral tablet AL

tri-legest fe oral tablet AL; QL

tri-linyah oral tablet AL

tri-lo-estarylla oral tablet AL; QL

tri-lo-marzia oral tablet AL; QL

tri-lo-sprintec oral tablet AL; QL

trinessa (28) oral tablet AL

trinessa lo oral tablet AL; QL

tri-previfem (28) oral tablet AL

tri-sprintec (28) oral tablet AL

trivora (28) oral tablet AL

tri-vylibra oral tablet AL

tydemy oral tablet AL

velivet triphasic regimen (28) oral tablet AL

vienva oral tablet AL

viorele (28) oral tablet AL; QL

vyfemla (28) oral tablet AL

vylibra oral tablet AL

wera (28) oral tablet AL

49


wymzya fe oral tablet,chewable AL; QL

xulane transdermal patch weekly AL; QL

zarah oral tablet AL

zenchent (28) oral tablet AL

zovia 1/35e (28) oral tablet AL

ANTÍDOTOS Y OTROS AGENTES DE REVERSIÓN

AGENTES QUELANTES

deferoxamine injection recon soln Desferal

DEPEN TITRATABS ORAL TABLET PA

trientine oral capsule Syprine PA; QL

ANTAGONISTAS DE NARCÓTICOS

naloxone injection solution QL

naloxone injection syringe QL

naltrexone oral tablet

NARCAN NASAL SPRAY,NON-AEROSOL

QL

ANTÍDOTOS

acetylcysteine solution

ANTINEOPLÁSICOS

MEDICAMENTOS ANTINEOPLÁSICOS/INMUNOSUPRESORES

anastrozole oral tablet Arimidex QL

bicalutamide oral tablet Casodex

EMCYT ORAL CAPSULE PA

exemestane oral tablet Aromasin QL

flutamide oral capsule

HEXALEN ORAL CAPSULE PA

hydroxyurea oral capsule Hydrea

imatinib oral tablet Gleevec PA; QL

IRESSA ORAL TABLET PA; QL

letrozole oral tablet Femara QL

leucovorin calcium oral tablet

megestrol oral tablet PA

melphalan oral tablet Alkeran

MESNEX ORAL TABLET PA

50


MYLERAN ORAL TABLET

tamoxifen oral tablet

tretinoin (chemotherapy) oral capsule

BIOLÓGICOS

INMUNOGLOBULINAS

GAMUNEX-C INJECTION SOLUTION PA

OCTAGAM INTRAVENOUS SOLUTION PA

VACUNAS INMUNOLÓGICAS

AFLURIA 2018-2019 (PF) INTRAMUSCULAR SYRINGE

QL

AFLURIA 2018-2019 INTRAMUSCULAR SUSPENSION

QL

AFLURIA QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

QL

AFLURIA QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

QL

FLUAD 2018-2019 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE

QL

FLUARIX QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

QL

FLUBLOK QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

QL

FLUCELVAX QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

FLUCELVAX QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

FLULAVAL QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

QL

FLULAVAL QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

QL

FLUMIST QUAD 2018-2019 NASAL NASAL SPRAY SYRINGE

FLUZONE HIGH-DOSE 2018-19 (PF) INTRAMUSCULAR SYRINGE

QL

FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SUSPENSION

QL

FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

QL

FLUZONE QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

QL

51


FLUZONE QUAD PEDI 2018-19 (PF) INTRAMUSCULAR SYRINGE

QL

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

AL; QL

SYNAGIS INTRAMUSCULAR SOLUTION

PA

TWINRIX (PF) INTRAMUSCULAR SYRINGE

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

AL; QL

DEPENDENCIA QUÍMICA, AGENTES PARA TRATAMIENTO

AGENTES PARA DEJAR DE FUMAR

bupropion hcl (smoking deter) oral tablet extended release 12 hr

Zyban PA; QL

bupropion hcl oral tablet sustained-release 12 hr

Wellbutrin SR QL

ANTAGONISTA DEL ALCOHOL

acamprosate oral tablet,delayed release (dr/ec)

QL

disulfiram oral tablet Antabuse

ANTAGONISTAS DE NARCÓTICOS

buprenorphine hcl sublingual tablet PA; QL

buprenorphine-naloxone sublingual tablet PA; QL

SUBOXONE SUBLINGUAL FILM PA; QL

DERMATOLÓGICO

AGENTES ANTIACNÉ, TÓPICOS

clindamycin phosphate topical gel Cleocin T

clindamycin phosphate topical solution Cleocin T

clindamycin phosphate topical swab Cleocin T

clindamycin-benzoyl peroxide topical gel Duac

ery pads topical swab

erythromycin with ethanol topical solution

erythromycin with ethanol topical swab Ery Pads

metronidazole topical cream MetroCream QL

52


metronidazole topical lotion MetroLotion

rosadan topical cream QL

AGENTES ANTINFLAMATORIOS ESTEROIDES TÓPICOS

amcinonide topical lotion

amcinonide topical ointment QL

betamethasone dipropionate topical lotion QL

betamethasone valerate topical cream QL

betamethasone valerate topical ointment QL

betamethasone, augmented topical cream

clobetasol scalp solution Cormax QL

clobetasol topical cream Temovate QL

clobetasol topical gel

clobetasol topical ointment Temovate QL

clobetasol-emollient topical cream QL

cormax scalp solution QL

diflorasone topical cream Psorcon QL

fluocinonide-e topical cream

fluocinonide-emollient topical cream Fluocinonide-E

fluticasone topical cream Cutivate QL

fluticasone topical ointment QL

halobetasol propionate topical cream Ultravate QL

halobetasol propionate topical ointment Ultravate QL

hydrocortisone topical cream Ala-Cort QL

hydrocortisone topical cream with perineal applicator

Anusol-HC QL

hydrocortisone topical ointment QL

hydrocortisone-pramoxine topical cream Pramosone

mometasone topical cream Elocon QL

mometasone topical ointment Elocon QL

mometasone topical solution QL

prednicarbate topical ointment Dermatop PA; QL

proctosol hc topical cream with perineal applicator

QL

proctozone-hc topical cream with perineal applicator

QL

TEXACORT TOPICAL SOLUTION

triamcinolone acetonide topical cream Triderm QL

53


triamcinolone acetonide topical ointment 0.025 %, 0.1 %

QL

triamcinolone acetonide topical ointment 0.5 %

trianex topical ointment QL

triderm topical cream QL

AGENTES ANTIPSORIÁSICOS

calcipotriene scalp solution

calcipotriene topical cream Dovonex PA

calcipotriene topical ointment Calcitrene

calcitrene topical ointment

AGENTES PARA ROSÁCEA, TÓPICOS

metronidazole topical gel 0.75 % Rosadan

metronidazole topical gel 1 % Metrogel QL

metronidazole topical gel with pump Metrogel

rosadan topical gel

AGENTES SISTÉMICOS CONTRA EL ACNÉ

amnesteem oral capsule PA

claravis oral capsule PA

isotretinoin oral capsule Absorica PA

MYORISAN ORAL CAPSULE 10 MG, 30 MG

PA

myorisan oral capsule 20 mg, 40 mg PA

zenatane oral capsule PA

AGENTES TÓPICOS, VARIOS

diclofenac sodium topical drops PA; QL

diclofenac sodium topical gel Voltaren PA; QL

lidocaine hcl mucous membrane jelly

lidocaine topical adhesive patch,medicated

Lidoderm PA; QL

lidocaine topical ointment QL

nivatopic plus topical cream

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP

PA; QL

podofilox topical solution PA

prumyx topical cream

54


salicylic acid topical cream Salimez

salicylic acid topical cream,extended release

salicylic acid topical film forming liquid w/appl

Virasal

salicylic acid topical foam Salvax

salicylic acid topical gel Keralyt Rx

salicylic acid topical liquid

salicylic acid topical lotion

salicylic acid topical lotion,extended release

salicylic acid topical shampoo Salex

salvax topical foam

selenium sulfide topical lotion

selenium sulfide topical shampoo

silver sulfadiazine topical cream Silvadene

ssd topical cream

urea topical cream

urea topical gel CEM-Urea

urea topical lotion Uramaxin

ANESTÉSICOS TÓPICOS

hydrocortisone-pramoxine topical cream Pramosone

lidocaine-prilocaine topical cream QL

ANTIBIÓTICOS TÓPICOS

gentamicin topical cream

gentamicin topical ointment

mupirocin topical ointment Centany QL

sss 10-5 topical cream

sulfacetamide sodium-sulfur topical cream Avar-E

ANTIMICÓTICOS TÓPICOS

ciclopirox topical cream Ciclodan

ciclopirox topical solution Ciclodan PA

ciclopirox topical suspension Loprox (as olamine)

clotrimazole-betamethasone topical cream Lotrisone QL

clotrimazole-betamethasone topical lotion QL

ketoconazole topical cream QL

ketoconazole topical shampoo Nizoral QL

nyamyc topical powder QL

55


nystatin topical cream QL

nystatin topical ointment QL

nystatin topical powder Nyamyc QL

nystop topical powder QL

ANTIVIRALES TÓPICOS

acyclovir topical ointment Zovirax PA; QL

DERIVADOS DE LA VITAMINA A

tretinoin (emollient) topical cream Refissa PA; AL

tretinoin microspheres topical gel Retin-A Micro PA

tretinoin topical cream Avita PA

tretinoin topical gel Avita PA

ESCABICIDAS Y PEDICULICIDAS

permethrin topical cream Elimite QL

spinosad topical suspension Natroba

INMUNOMODULADORES TÓPICOS

imiquimod topical cream in packet Aldara PA; QL

tacrolimus topical ointment Protopic PA; AL; QL

TÓPICO ANTINEOPLÁSICO Y PREMALIGNO

fluorouracil topical cream Efudex QL

fluorouracil topical solution QL

DISPOSITIVOS CON Y SIN AGUJAS, JERINGAS Y ACCESORIOS

AGUJAS, DISPOSITIVOS SIN AGUJAS, JERINGAS Y ACCESORIOS

BD INSULIN SYRINGE U-500 SYRINGE

DIAFRAGMAS/CAPUCHÓN CERVICAL

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM


QL


QL


QL


QL

56



QL



DISPOSITIVOS CON Y SIN AGUJAS, JERINGAS Y ACCESORIOS

ACE AEROSOL CLOUD ENHANCER SPACER

QL

AEROTRACH PLUS SPACER QL

AEROVENT PLUS SPACER QL

BD INSULIN SYRINGE U-500 SYRINGE

BREATHERITE MDI SPACER SPACER QL

BREATHERITE SPACER-MASK, NEO. SPACER

QL

BREATHERITE SPACER-MASK,ADULT SPACER

QL

BREATHERITE SPACER-MASK,CHILD SPACER

QL

BREATHERITE SPACER-MASK,INFANT SPACER

QL

BREATHERITE SPACER-MASK,S.CHLD SPACER

QL

BREATHERITE VALVED MDI CHAMBER SPACER

QL

BREATHERITE VALVED MDI SPACER SPACER

QL

COMPACT SPACE CHAMBER SPACER QL

COMPACT SPACE CHAMBER-LRG MASK SPACER

QL

COMPACT SPACE CHAMBER-MED MASK SPACER

QL

COMPACT SPACE CHAMBER-SM MASK SPACER

QL

LITEAIRE MDI CHAMBER SPACER QL

MICROCHAMBER SPACER QL

MICROSPACER SPACER QL

MINI WRIGHT PEAK FLOW METER DEVICE

QL

57


OPTICHAMBER ADULT MASK-LARGE DEVICE

QL

OPTICHAMBER DIAMOND LG MASK SPACER

QL

OPTICHAMBER DIAMOND VHC SPACER

QL

OPTICHAMBER DIAMOND-MED MSK SPACER

QL

OPTICHAMBER DIAMOND-SML MASK SPACER

QL

POCKET CHAMBER SPACER QL

PRIMEAIRE SPACER QL

PROCHAMBER SPACER QL

RITEFLO AEROCHAMBER SPACER QL

TRUZONE PEAK FLOW METER DEVICE

QL

VORTEX HOLDING CHAMBER CHILD SPACER

QL

VORTEX HOLDING CHAMBER SPACER

QL

VORTEX HOLDING CHAMBER TODDLER SPACER

QL

VORTEX VHC FROG MASK-CHILD SPACER

QL

VORTEX VHC LADYBUG MASK-TODDLR SPACER

QL



QL


QL


QL


QL


QL



58


EQUIPOS, DISPOSITIVOS, ESPACIADORES Y AUXILIARES RESPIRATORIOS

ACE AEROSOL CLOUD ENHANCER SPACER

QL

AEROTRACH PLUS SPACER QL

AEROVENT PLUS SPACER QL

BREATHERITE MDI SPACER SPACER QL

BREATHERITE SPACER-MASK, NEO. SPACER

QL

BREATHERITE SPACER-MASK,ADULT SPACER

QL

BREATHERITE SPACER-MASK,CHILD SPACER

QL

BREATHERITE SPACER-MASK,INFANT SPACER

QL

BREATHERITE SPACER-MASK,S.CHLD SPACER

QL

BREATHERITE VALVED MDI CHAMBER SPACER

QL

BREATHERITE VALVED MDI SPACER SPACER

QL

COMPACT SPACE CHAMBER SPACER QL

COMPACT SPACE CHAMBER-LRG MASK SPACER

QL

COMPACT SPACE CHAMBER-MED MASK SPACER

QL

COMPACT SPACE CHAMBER-SM MASK SPACER

QL

LITEAIRE MDI CHAMBER SPACER QL

MICROCHAMBER SPACER QL

MICROSPACER SPACER QL

OPTICHAMBER ADULT MASK-LARGE DEVICE

QL

OPTICHAMBER DIAMOND LG MASK SPACER

QL

OPTICHAMBER DIAMOND VHC SPACER

QL

OPTICHAMBER DIAMOND-MED MSK SPACER

QL

59


OPTICHAMBER DIAMOND-SML MASK SPACER

QL

POCKET CHAMBER SPACER QL

PRIMEAIRE SPACER QL

PROCHAMBER SPACER QL

RITEFLO AEROCHAMBER SPACER QL

VORTEX HOLDING CHAMBER CHILD SPACER

QL

VORTEX HOLDING CHAMBER SPACER

QL

VORTEX HOLDING CHAMBER TODDLER SPACER

QL

VORTEX VHC FROG MASK-CHILD SPACER

QL

VORTEX VHC LADYBUG MASK-TODDLR SPACER

QL

SUMINISTROS MÉDICOS Y DME: ESPIRÓMETRO

MINI WRIGHT PEAK FLOW METER DEVICE

QL

TRUZONE PEAK FLOW METER DEVICE

QL

ENDOCRINO

AGENTES ANDRÓGENOS

testosterone cypionate intramuscular oil Depo-Testosterone PA

testosterone enanthate intramuscular oil PA

testosterone transdermal gel Testim PA; QL

testosterone transdermal gel in metered-dose pump

Vogelxo PA; QL

testosterone transdermal gel in packet AndroGel PA; QL

AGENTES DE PROGESTERONA PARA LA FERTILIDAD: PREVENCIÓN DE NACIMIENTOS PREMATUROS

hydroxyprogest(pf)(preg presv) intramuscular oil

Makena PA; QL

hydroxyprogesterone cap(ppres) intramuscular oil

Makena PA; QL

MAKENA (PF) SUBCUTANEOUS AUTO-INJECTOR

PA; QL

60


MAKENA INTRAMUSCULAR OIL PA; QL

AGENTES ESTROGÉNICOS

amabelz oral tablet

estradiol oral tablet Estrace

estradiol transdermal patch transdermal patch weekly

QL

estradiol transdermal patch weekly Climara QL

estradiol-norethindrone acet oral tablet Activella

estropipate oral tablet

fyavolv oral tablet

jevantique lo oral tablet

jinteli oral tablet

lopreeza oral tablet

mimvey lo oral tablet

mimvey oral tablet

norethindrone ac-eth estradiol oral tablet Femhrt Low Dose

PREMPHASE ORAL TABLET

PREMPRO ORAL TABLET

AGENTES PROGESTACIONALES

hydroxyprogest(pf)(preg presv) intramuscular oil

Makena PA; QL

hydroxyprogesterone cap(ppres) intramuscular oil

Makena PA; QL

hydroxyprogesterone caproate intramuscular oil

PA; QL

MAKENA (PF) SUBCUTANEOUS AUTO-INJECTOR

PA; QL

MAKENA INTRAMUSCULAR OIL PA; QL

medroxyprogesterone oral tablet Provera QL

norethindrone acetate oral tablet Aygestin

progesterone micronized oral capsule Prometrium QL

AGENTES SUPRESORES HIPOFISARIOS

cabergoline oral tablet QL

ANTIHIPERGLICÉMICO, MIMÉTICO DE INCRETINA (AGONISTA DEL RECEPTOR GLP-1)

OZEMPIC SUBCUTANEOUS PEN INJECTOR

PA; QL

61


VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR

PA; QL

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR

PA; QL

ANTIHIPERGLUCÉMICOS, TIPO ANÁLOGO DE AMILINA

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

PA

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

PA

CALCITONINAS

calcitonin (salmon) nasal spray,non-aerosol

QL

GLUCOCORTICOIDES

cortisone oral tablet

dexamethasone intensol oral drops

dexamethasone oral elixir Decadron

dexamethasone oral solution

dexamethasone oral tablet Decadron

hydrocortisone oral tablet Cortef

methylprednisolone oral tablet Medrol

methylprednisolone oral tablets,dose pack Medrol (Pak)

prednisolone oral solution

prednisolone sodium phosphate oral solution

prednisone intensol oral concentrate

prednisone oral solution

prednisone oral tablet

prednisone oral tablets,dose pack

HIPERGLUCEMIA

GLUCAGEN HYPOKIT INJECTION RECON SOLN

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

HIPOGLUCEMIA, INSULINA, INTENSIFICADOR DE RESPUESTA

pioglitazone oral tablet Actos PA; QL

pioglitazone-glimepiride oral tablet DUETACT PA; QL

pioglitazone-metformin oral tablet Actoplus MET PA; QL

62


HIPOGLUCEMIA, INSULINA, TIPO ESTIMULANTE LIBERADOR

glimepiride oral tablet Amaryl

glipizide oral tablet Glucotrol

glipizide oral tablet extended release 24hr Glucotrol XL

glipizide-metformin oral tablet

glyburide micronized oral tablet Glynase

glyburide oral tablet

glyburide-metformin oral tablet

nateglinide oral tablet Starlix PA

repaglinide oral tablet PA

HIPOGLUCEMIA, TIPO BIGUANIDA

metformin oral tablet Glucophage

metformin oral tablet extended release 24 hr

Glucophage XR

HIPOGLUCEMIA, TIPO INHIBIDOR DE LA ALFA GLUCOSIDASA

acarbose oral tablet 100 mg Precose

acarbose oral tablet 25 mg, 50 mg Precose QL

HORMONAS ANTIDIURÉTICAS Y VASOPRESORAS

desmopressin nasal spray with pump DDAVP

desmopressin nasal spray,non-aerosol

desmopressin oral tablet DDAVP QL

HORMONAS DEL CRECIMIENTO

ZOMACTON SUBCUTANEOUS RECON SOLN

PA; QL

HORMONAS TIROIDEAS

levothyroxine oral tablet Levo-T

levoxyl oral tablet

liothyronine oral tablet Cytomel

nature-throid oral tablet

np thyroid oral tablet

thyroid (pork) oral tablet Armour Thyroid

unithroid oral tablet

westhroid oral tablet

63


INHIBIDOR DE LA DIPEPTIDIL PEPTIDASA IV Y COMBINACIONES

JANUMET ORAL TABLET PA; QL

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

PA; QL

JANUVIA ORAL TABLET PA; QL

INHIBIDORES DE RESORCIÓN ÓSEA

alendronate oral solution

alendronate oral tablet QL

raloxifene oral tablet Evista

INHIBIDORES DE SODIO-GLUCOSA (SGLT2)

JARDIANCE ORAL TABLET PA; QL

SYNJARDY ORAL TABLET PA; QL

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR

PA; QL

INSULINAS

ADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

QL

ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS SOLUTION

QL

BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN

QL

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION

QL

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

QL

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

QL

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION

QL

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION

PA; QL

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

PA; QL

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION

QL

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN

QL

64


MINERALOCORTICOIDES

fludrocortisone oral tablet

OXITÓCICOS

METHYLERGONOVINE INJECTION SOLUTION

methylergonovine oral tablet Methergine

PREPARADOS ANTITIROIDEOS

methimazole oral tablet Tapazole

propylthiouracil oral tablet

EQUILIBRIO ELECTROLÍTICO, PRODUCTOS NUTRICIONALES

MULTIVITAMÍNICOS

m.v.i. adult intravenous solution

PREPARADOS DE VITAMINA B

b complex 100 injection solution

cyanocobalamin (vitamin b-12) injection solution

Vitamin B-12

hydroxocobalamin intramuscular solution

pyridoxine (vitamin b6) injection solution

thiamine hcl (vitamin b1) injection solution

vitamin b-12 injection solution

PREPARADOS DE VITAMINA C

ascorbic acid (vitamin c) injection solution

PREPARADOS DE VITAMINA D

calcitriol oral capsule Rocaltrol PA

calcitriol oral solution Rocaltrol PA

ergocalciferol (vitamin d2) oral capsule Drisdol

vitamin d2 oral capsule

PREPARADOS DE VITAMINA K

phytonadione (vitamin k1) oral tablet Mephyton

vitamin k injection solution

vitamin k1 injection solution

RESINAS LIBERADORAS DE POTASIO

sodium polystyrene (sorb free) oral suspension

sodium polystyrene sulfonate oral suspension

sodium polystyrene (sorb free)

65


sodium polystyrene sulfonate rectal enema

sps (with sorbitol) oral suspension

sps (with sorbitol) rectal enema

SOLUCIONES DE IRRIGACIÓN

sodium chloride irrigation solution Aqua Care Sodium Chloride

SUSTITUTO DEL CALCIO

calcium acetate oral tablet Calphron QL

tl g-fol os oral tablet

SUSTITUTO DEL HIERRO

infed injection solution

sodium ferric gluconat-sucrose intravenous solution

Ferrlecit

SUSTITUTO DEL POTASIO

effer-k oral tablet, effervescent

k-effervescent oral tablet, effervescent

klor-con 10 oral tablet extended release

klor-con 8 oral tablet extended release

klor-con m10 oral tablet,er particles/crystals



klor-con oral packet

klor-con/ef oral tablet, effervescent

k-tab oral tablet extended release

potassium bicarb and chloride oral tablet, effervescent

potassium bicarb-citric acid oral tablet, effervescent

Effer-K

potassium chloride oral capsule, extended release

Klor-Con Sprinkle

potassium chloride oral liquid

potassium chloride oral packet Klor-Con

potassium chloride oral tablet extended release

K-Tab

potassium chloride oral tablet,er particles/crystals

Klor-Con M10

66


VITAMINAS

folic acid injection solution

ESCLEROSIS MÚLTIPLE

MEDICAMENTOS PARA TRATAR LA ESCLEROSIS MÚLTIPLE

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT

PA

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

PA

AVONEX INTRAMUSCULAR SYRINGE KIT

PA

BETASERON SUBCUTANEOUS KIT PA

EXTAVIA SUBCUTANEOUS KIT PA

EXTAVIA SUBCUTANEOUS RECON SOLN

PA

GILENYA ORAL CAPSULE PA; QL

glatiramer subcutaneous syringe Copaxone PA

glatopa subcutaneous syringe PA

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

PA

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

PA

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

PA

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

PA; QL

INSUMOS Y PREPARADOS DENTALES

AGENTES PARA LA BOCA Y GARGANTA

clotrimazole mucous membrane troche QL

lidocaine hcl mucous membrane jelly

lidocaine hcl mucous membrane solution QL

lidocaine viscous mucous membrane solution

QL

nystatin oral suspension

oralone dental paste

pilocarpine hcl oral tablet Salagen (pilocarpine) QL

triamcinolone acetonide dental paste Oralone

67


ANTISÉPTICOS, OTROS

chlorhexidine gluconate mucous membrane mouthwash

Paroex Oral Rinse QL

paroex oral rinse mucous membrane mouthwash

QL

periogard mucous membrane mouthwash QL

PREPARACIONES DE FLUORUROS

dentagel dental gel

sf dental gel

MODIFICADORES METABÓLICOS

AGENTES DE DEFICIENCIA METABÓLICA

calcitriol oral capsule Rocaltrol PA

calcitriol oral solution Rocaltrol PA

sodium phenylbutyrate oral powder Buphenyl PA; QL

sodium phenylbutyrate oral tablet Buphenyl PA; QL

PHARMACOENHANCER - INHIBIDORES DEL CITOCROMO P450

TYBOST ORAL TABLET

ÓTICO

PREPARADOS ÓTICOS, MISCELÁNEOS, ANTINFECCIOSOS

acetic acid otic (ear) solution

ciprofloxacin hcl otic (ear) dropperette Cetraxal QL

neomycin-polymyxin-hc otic (ear) drops,suspension

neomycin-polymyxin-hc otic (ear) solution

ofloxacin otic (ear) drops QL

PRODUCTOS VAGINALES

ANTIBIÓTICOS VAGINALES

CLEOCIN VAGINAL SUPPOSITORY

clindamycin phosphate vaginal cream Cleocin

metronidazole vaginal gel Metrogel Vaginal

vandazole vaginal gel

ANTIMICÓTICOS VAGINALES

miconazole-3 vaginal suppository PA

terconazole vaginal cream

68


terconazole vaginal suppository

PREPARADOS DE ESTRÓGENO VAGINALES

estradiol vaginal tablet Vagifem

yuvafem vaginal tablet

SISTEMA LOCOMOTOR

AGENTES PARA EL TRATAMIENTO DE TRASTORNOS MUSCULOESQUELÉTICOS

EUFLEXXA INTRA-ARTICULAR SYRINGE

PA; QL

GELSYN-3 INTRA-ARTICULAR SYRINGE

PA; QL

SUPARTZ FX INTRA-ARTICULAR SYRINGE

PA; QL

OTROS MEDICAMENTOS AUTÓNOMOS/DEL SNC

MESTINON ORAL SYRUP

pyridostigmine bromide oral tablet Mestinon

pyridostigmine bromide oral tablet extended release

Mestinon Timespan

RELAJANTES DEL MÚSCULO ESQUELÉTICO

baclofen oral tablet

carisoprodol oral tablet Soma QL

carisoprodol-asa-codeine oral tablet

carisoprodol-aspirin oral tablet

chlorzoxazone oral tablet

cyclobenzaprine oral tablet 10 mg QL

cyclobenzaprine oral tablet 5 mg

dantrolene oral capsule Dantrium

methocarbamol oral tablet Robaxin-750 QL

orphenadrine citrate oral tablet extended release

QL

riluzole oral tablet Rilutek PA

tizanidine oral tablet QL

69


TERAPIA DE LA GOTA Y LA HIPERURICEMIA

AGENTES URICOSÚRICOS

probenecid oral tablet

COMBINADOS DE COLQUICINA

probenecid-colchicine oral tablet

TERAPIA PARA HIPERURICEMIA, INHIBIDORES DE PURINA

allopurinol oral tablet Zyloprim

TERAPIA DEL TRASTORNO COGNITIVO

INHIBIDORES DE LA COLINESTERASA

donepezil oral tablet 10 mg, 5 mg Aricept DO; QL

donepezil oral tablet 23 mg Aricept PA; QL

donepezil oral tablet,disintegrating DO; QL

galantamine oral capsule,ext rel. pellets 24 hr

Razadyne ER DO; QL

galantamine oral solution DO; QL

galantamine oral tablet Razadyne DO; QL

memantine oral solution DO; QL

memantine oral tablet Namenda DO; QL

memantine oral tablets,dose pack Namenda Titration Pak DO; QL

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

DO; QL

rivastigmine tartrate oral capsule DO; QL

TERAPIA GENITOURINARIA

AGENTE PARA LA INCONTINENCIA/ANTIESPASMÓDICO PARA TRACTO URINARIO

darifenacin oral tablet extended release 24 hr

Enablex

flavoxate oral tablet

oxybutynin chloride oral syrup

oxybutynin chloride oral tablet

oxybutynin chloride oral tablet extended release 24hr

Ditropan XL

tolterodine oral capsule,extended release 24hr

Detrol LA

70


tolterodine oral tablet Detrol

trospium oral capsule,extended release 24hr

trospium oral tablet

AGENTES ANALGÉSICOS/ANESTÉSICOS PARA TRACTO URINARIO

phenazopyridine oral tablet Pyridium

AGENTES ANTIBACTERIANOS URINARIOS

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

Cipro XR QL

methenamine hippurate oral tablet Hiprex

methenamine mandelate oral tablet

nitrofurantoin macrocrystal oral capsule Macrodantin

nitrofurantoin monohyd/m-cryst oral capsule

Macrobid

AGENTES PARASIMPÁTICOS

bethanechol chloride oral tablet Urecholine

DESINTOXICANTES DE SANGRE

calcium acetate oral capsule QL

calcium acetate oral tablet Calphron QL

eliphos oral tablet QL

lanthanum oral tablet,chewable Fosrenol QL

sevelamer carbonate oral powder in packet

Renvela QL

sevelamer carbonate oral tablet Renvela QL

HIPERTROFIA PROSTÁTICA BENIGNA/AGENTES MICCIONALES

alfuzosin oral tablet extended release 24 hr

Uroxatral QL

finasteride oral tablet Proscar QL

tamsulosin oral capsule Flomax QL

MODIFICADORES DEL PH URINARIO

cytra k crystals oral packet

potassium citrate oral tablet extended release

Urocit-K 5

71


TERAPIA PARA TRASTORNOS DE LA ALIMENTACIÓN

AGENTES ESTIMULANTES DEL APETITO

megestrol oral suspension PA

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Lista de medicamentos preferidos aprobada por Medicaid · Insurance Companies, Inc. Los nombres y...

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