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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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
amoxicillin-pot clavulanate oral tablet 250-125 mg
amoxicillin-pot clavulanate oral tablet 500-125 mg
Augmentin
amoxicillin-pot clavulanate oral tablet 875-125 mg
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
carbamazepine oral tablet extended release 12 hr
Tegretol XR DO; QL
carbamazepine oral tablet,chewable DO; QL
clonazepam oral tablet Klonopin QL
clonazepam oral tablet,disintegrating 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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
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
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
Nombre del medicamento Referencia Notas
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
dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg
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
Nombre del medicamento Referencia Notas
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
dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg
Adderall XR DO; AL; QL
dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR
PA; DO; QL
POSTHERPETIC NEURALGIA AGENTS
LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
hydrocodone-acetaminophen oral tablet 10-325 mg
Lorcet HD PA; QL
hydrocodone-acetaminophen oral tablet 2.5-325 mg
Verdrocet QL
hydrocodone-acetaminophen oral tablet 5-300 mg
Vicodin PA; QL
40
Nombre del medicamento Referencia Notas
hydrocodone-acetaminophen oral tablet 5-325 mg
Lorcet (hydrocodone) PA; QL
hydrocodone-acetaminophen oral tablet 7.5-300 mg
Vicodin ES PA; QL
hydrocodone-acetaminophen oral tablet 7.5-325 mg
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
Nombre del medicamento Referencia Notas
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
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
42
Nombre del medicamento Referencia Notas
HUMIRA SUBCUTANEOUS SYRINGE KIT
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
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
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM
QL
WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM
QL
WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM
QL
WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM
QL
56
Nombre del medicamento Referencia Notas
WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM
QL
WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM
WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM
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
Nombre del medicamento Referencia Notas
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
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM
WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM
QL
WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM
QL
WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM
QL
WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM
QL
WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM
QL
WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM
WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM
58
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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 m15 oral tablet,er particles/crystals
klor-con m20 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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
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
Nombre del medicamento Referencia Notas
TERAPIA PARA TRASTORNOS DE LA ALIMENTACIÓN
AGENTES ESTIMULANTES DEL APETITO
megestrol oral suspension PA
72
73