Lista de Medicamentos Cubiertos/media/Pharmacy/Formulary/2017-Formularies/... · 2 IEHP Medi-Cal...

Lista de Medicamentos Cubiertos

Medi-Cal

2017

1

IEHP Medi-Cal LISTA DE MEDICAMENTOS CUBIERTOS DE 2017

ÍNDICE

Analgésicos .......................................................................................................................................................... 2 Anestésicos ........................................................................................................................................................... 3 Antiartríticos ........................................................................................................................................................ 4 Antiasmáticos ....................................................................................................................................................... 4 Antibióticos .......................................................................................................................................................... 6 Anticoagulantes .................................................................................................................................................. 10 Antifúngicos ....................................................................................................................................................... 11 Antihistamínico y Combinación de Descongestionante ..................................................................................... 12 Antihistamínicos................................................................................................................................................. 12 Antihiperglucémicos .......................................................................................................................................... 13 Antiinfecciosos/Varios ....................................................................................................................................... 15 Antineoplásicos .................................................................................................................................................. 15 Medicamentos Antiparkinsonianos .................................................................................................................... 17 Medicamentos Antiplaquetarios ......................................................................................................................... 17 Antivirales .......................................................................................................................................................... 17 Medicamentos Autonómicos .............................................................................................................................. 17 Biológicos .......................................................................................................................................................... 18 Sangre ................................................................................................................................................................. 22 Medicamentos Cardíacos ................................................................................................................................... 22 Cardiovasculares ................................................................................................................................................ 23 Medicamentos del Sistema Nervioso Central (CNS) ......................................................................................... 25 Factores Estimulantes de Colonias ..................................................................................................................... 27 Anticonceptivos .................................................................................................................................................. 27 Tos/Resfriado ..................................................................................................................................................... 29 Diagnóstico......................................................................................................................................................... 30 Diuréticos ........................................................................................................................................................... 30 Ojos, Oídos, Nariz y Garganta (EENT) ............................................................................................................. 31 Electrolitos/Calórico/H2O .................................................................................................................................. 33 Gastrointestinal................................................................................................................................................... 34 Hormonas ........................................................................................................................................................... 38 Inmunosupresores .............................................................................................................................................. 39 Suministros Médicos Diversos, Dispositivos, No Farmacológicos ................................................................... 39 Relajantes Musculares ........................................................................................................................................ 39 Vitaminas Prenatales .......................................................................................................................................... 39 Medicamentos Psicoterapéuticos ....................................................................................................................... 40 Sedantes/Hipnóticos ........................................................................................................................................... 41 Piel ...................................................................................................................................................................... 42 Elementos Disuasivos para Dejar de Fumar ...................................................................................................... 44 Tiroides............................................................................................................................................................... 45 Medicamentos Sin Clasificación ........................................................................................................................ 45 Vitaminas ........................................................................................................................................................... 46 Índice .................................................................................................................................................................. 49

2

IEHP Medi-Cal LISTA DE MEDICAMENTOS CUBIERTOS DE 2017

Lista de Medicamentos Cubiertos

VIGENTE A PARTIR DEL 1 DE OCTUBRE DE 2017

minúsculas cursivas = Medicamentos genéricos MAYÚSCULAS NEGRITAS = Medicamentos de marca

Nivel de Marca (Nivel Genérico) C1= Código1 F= Lista de Medicamento Cubiertos NC= No Cubiertos

Requisitos/Límites PA= Autorización Previa QL= Límite de Cantidad SPO= Farmacia Especializada Solamente ST= Terapia Escalonada

Nombre del Medicamento

Nivel de Marca

Requisitos/Límites

Analgésicos

acetaminophen oral drops, suspension 80 mg/0.8 ml F QL

acetaminophen oral elixir 160 mg/5 ml F QL

acetaminophen oral liquid 160 mg/5 ml F QL

acetaminophen oral solution 160 mg/5 ml (5 ml) F QL

acetaminophen oral suspension 160 mg/5 ml F QL

acetaminophen oral tablet 325 mg F

acetaminophen oral tablet 500 mg F QL

acetaminophen rectal suppository 120 mg F QL

acetaminophen-codeine oral solution 120-12 mg/5 ml F

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg F QL

aspirin oral tablet 325 mg F QL

aspirin oral tablet,delayed release (dr/ec) 325 mg F QL

butalbital-acetaminophen-caff oral capsule 50-325-40 mg F QL

butalbital-acetaminophen-caff oral tablet 50-325-40 mg F QL

butalbital-aspirin-caffeine oral capsule 50-325-40 mg F QL

CAPITAL WITH CODEINE ORAL SUSPENSION 120-12 MG/5 ML F QL

CHILDREN'S NON-ASPIRIN ORAL TABLET,CHEWABLE 80 MG F QL

choline,magnesium salicylate oral liquid 500 mg/5 ml F

diclofenac potassium oral tablet 50 mg F

3


Nivel de Marca

Requisitos/Límites

dihydroergotamine injection solution 1 mg/ml F

ELMIRON ORAL CAPSULE 100 MG F

ergotamine-caffeine oral tablet 1-100 mg F

fentanyl transdermal patch 72 hour 100 mcg/hr, 75 mcg/hr F

fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr F QL

FEVERALL RECTAL SUPPOSITORY 325 MG, 80 MG F QL

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml F

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg F QL

infant's non-aspirin oral drops 100 mg/ml F QL

isometh-dichloral-acetaminophn oral capsule 65-100-325 mg F

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG F QL

ketorolac oral tablet 10 mg F QL

MIGERGOT RECTAL SUPPOSITORY 2-100 MG F QL

MIGRAINE FORMULA ORAL TABLET 250-250-65 MG F QL

morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) F QL

morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg

F QL

morphine oral capsule,extend.release pellets 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

F QL

morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml) F

morphine oral tablet 15 mg, 30 mg F QL

morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg F QL

morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg F

non-aspirin jr strength oral tablet,chewable 160 mg F QL

nortemp oral drops 80 mg/0.8 ml F QL

oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg F QL

oxycodone-aspirin oral tablet 4.8355-325 mg F

rizatriptan oral tablet 10 mg, 5 mg F QL

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg F QL

tramadol oral tablet 50 mg F QL

Anestésicos

BUCALSEP MUCOUS MEMBRANE SOLUTION F

4


Nivel de Marca

Requisitos/Límites

lidocaine topical adhesive patch,medicated 5 % F QL

LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 % F

lidocaine-prilocaine topical cream 2.5-2.5 % F QL

phenazopyridine oral tablet 100 mg, 200 mg F

Antiartríticos

allopurinol oral tablet 100 mg, 300 mg F

colchicine oral capsule 0.6 mg F

colchicine oral tablet 0.6 mg F

diclofenac sodium oral tablet extended release 24 hr 100 mg F

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg F

etodolac oral capsule 200 mg, 300 mg F

etodolac oral tablet 400 mg, 500 mg F

ibuprofen oral capsule 200 mg F QL

ibuprofen oral suspension 100 mg/5 ml F QL

ibuprofen oral tablet 200 mg F QL

ibuprofen oral tablet 400 mg, 600 mg, 800 mg F

indomethacin oral capsule 25 mg, 50 mg F

leflunomide oral tablet 10 mg, 20 mg F

meloxicam oral tablet 15 mg, 7.5 mg F

nabumetone oral tablet 500 mg, 750 mg F

naproxen oral suspension 125 mg/5 ml F

naproxen oral tablet 250 mg, 375 mg, 500 mg F

naproxen sodium oral tablet 220 mg, 275 mg, 550 mg F

piroxicam oral capsule 10 mg, 20 mg F

probenecid oral tablet 500 mg F

probenecid-colchicine oral tablet 500-0.5 mg F

RIDAURA ORAL CAPSULE 3 MG F

salsalate oral tablet 500 mg, 750 mg F

sulindac oral tablet 150 mg, 200 mg F

Antiasmáticos

acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) F

5


Nivel de Marca

Requisitos/Límites

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

F

albuterol sulfate oral syrup 2 mg/5 ml F

albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg F

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

F

ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION

F

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

F QL

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION

F QL

cromolyn nasal spray,non-aerosol 5.2 mg/spray (4 %) F

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION

F QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION

F QL

fluticasone-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

F ST; QL

INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION

F QL

ipratropium bromide inhalation solution 0.02 % F

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

F

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml

F

metaproterenol oral syrup 10 mg/5 ml F

metaproterenol oral tablet 10 mg, 20 mg F

montelukast oral tablet 10 mg F QL

montelukast oral tablet,chewable 4 mg, 5 mg F QL

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION

F QL

QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION

F

6


Nivel de Marca

Requisitos/Límites

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE

F

STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION F QL

terbutaline oral tablet 2.5 mg, 5 mg F

THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 300 MG, 400 MG

F QL

theophylline oral solution 80 mg/15 ml F

theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg

F QL

theophylline oral tablet extended release 24 hr 400 mg F QL

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION

F QL

VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION

F QL

Antibióticos

amoxicillin oral capsule 250 mg, 500 mg F

amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

F

amoxicillin oral tablet 500 mg, 875 mg F

amoxicillin oral tablet,chewable 125 mg, 250 mg F

amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

F

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg F

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg F

amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg F

ampicillin oral capsule 250 mg, 500 mg F

ampicillin-sulbactam injection recon soln 3 gram C1

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML

F

azithromycin oral packet 1 gram F

azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml F

azithromycin oral tablet 250 mg, 500 mg, 600 mg F

bacitracin ophthalmic (eye) ointment 500 unit/gram F

bacitracin topical ointment 500 unit/gram F

7


Nivel de Marca

Requisitos/Límites

bacitracin zinc topical ointment 500 unit/gram F

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram F

bacitracin-polymyxin b topical ointment 500-10,000 unit/gram F QL

bacitracin-polymyxin b topical packet 500-10,000 unit/gram F

bactroban nasal nasal ointment 2 % F QL

BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 10-0.2 % F

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 % F

cefaclor oral capsule 250 mg, 500 mg F

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

F

cefaclor oral tablet extended release 12 hr 500 mg F

cefazolin injection recon soln 1 gram, 10 gram C1

cefdinir oral capsule 300 mg C1

cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml C1

cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml C1

ceftazidime injection recon soln 1 gram, 2 gram, 6 gram C1

ceftibuten oral capsule 400 mg C1

ceftibuten oral suspension for reconstitution 180 mg/5 ml C1

ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg C1

cephalexin oral capsule 250 mg, 500 mg F

cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml F

CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % F

CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 % F QL

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 % F QL

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg F

ciprofloxacin hcl ophthalmic (eye) drops 0.3 % F

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg F

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml F

clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml F

clarithromycin oral tablet 250 mg, 500 mg F

clarithromycin oral tablet extended release 24 hr 500 mg F

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg F

8


Nivel de Marca

Requisitos/Límites

clindamycin palmitate hcl oral recon soln 75 mg/5 ml F

clindamycin phosphate topical gel 1 % F

clindamycin phosphate topical lotion 1 % F

clindamycin phosphate topical solution 1 % F

clindamycin phosphate vaginal cream 2 % F

CORTISPORIN TOPICAL OINTMENT 1 % F

cycloserine oral capsule 250 mg F

dapsone oral tablet 100 mg, 25 mg F

dicloxacillin oral capsule 250 mg, 500 mg F

double antibiotic (b.tracn zn) topical ointment 500-10,000 unit/gram F

doxycycline hyclate oral capsule 100 mg, 50 mg F QL

doxycycline hyclate oral tablet 100 mg F QL

doxycycline monohydrate oral capsule 100 mg, 50 mg F QL

doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg F QL

E.E.S. 400 ORAL TABLET 400 MG F

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 MG/5 ML

F

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG

F

ery-tab oral tablet,delayed release (dr/ec) 500 mg F

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml F

erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) F QL

erythromycin oral capsule,delayed release(dr/ec) 250 mg F

erythromycin oral tablet 250 mg, 500 mg F

erythromycin stearate oral tablet 250 mg F

erythromycin with ethanol topical gel 2 % F

erythromycin with ethanol topical solution 2 % F

erythromycin-benzoyl peroxide topical gel 3-5 % F

ethambutol oral tablet 100 mg, 400 mg F

GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) F

gentamicin injection solution 40 mg/ml C1

gentamicin ophthalmic (eye) drops 0.3 % F

9


Nivel de Marca

Requisitos/Límites

gentamicin topical cream 0.1 % F

isoniazid oral solution 50 mg/5 ml F

isoniazid oral tablet 100 mg, 300 mg F

levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml C1

levofloxacin ophthalmic (eye) drops 0.5 % F QL

levofloxacin oral tablet 250 mg, 500 mg, 750 mg F

methenamine mandelate oral tablet 0.5 g, 1 gram F QL

metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml C1

metronidazole oral tablet 250 mg, 500 mg F

metronidazole vaginal gel 0.75 % F QL

minocycline oral capsule 100 mg, 50 mg, 75 mg F

minocycline oral tablet 100 mg F

mupirocin calcium topical cream 2 % F

mupirocin topical ointment 2 % F

neomycin oral tablet 500 mg F

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

F

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %

F

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

F

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml

F

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 mg-unit-mg/ml

F

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

F

neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-% F

nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg F

nitrofurantoin monohyd/m-cryst oral capsule 100 mg F

nitrofurantoin oral suspension 25 mg/5 ml F QL

ofloxacin ophthalmic (eye) drops 0.3 % F

ofloxacin otic (ear) drops 0.3 % F QL

PCE ORAL TABLET, PARTICLES/CRYSTALS 333 MG, 500 MG F

10


Nivel de Marca

Requisitos/Límites

penicillin g potassium injection recon soln 5 million unit C1

penicillin g sodium injection recon soln 5 million unit C1

penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml F

penicillin v potassium oral tablet 250 mg, 500 mg F

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml F

PRIMSOL ORAL SOLUTION 50 MG/5 ML F

pyrazinamide oral tablet 500 mg F

rifabutin oral capsule 150 mg C1

RIFAMATE ORAL CAPSULE 300-150 MG F

rifampin oral capsule 150 mg, 300 mg F

silver sulfadiazine topical cream 1 % F

sulfacetamide sodium ophthalmic (eye) drops 10 % F

sulfacetamide sodium ophthalmic (eye) ointment 10 % F

sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) F

sulfadiazine oral tablet 500 mg F

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml F

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg F

tetracycline oral capsule 250 mg, 500 mg F

TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 % F

tobramycin ophthalmic (eye) drops 0.3 % F

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 % F

TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % F

trimethoprim oral tablet 100 mg F

TRIPLE ANTIBIOTIC (PRAM) EXTRA TOPICAL OINTMENT 3.5-500-10,000 MG-UNIT-UNIT/G

F

TRIPLE ANTIBIOTIC TOPICAL OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM

F

VIGAMOX OPHTHALMIC (EYE) DROPS 0.5 % F

Anticoagulantes

COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

F

ELIQUIS ORAL TABLET 2.5 MG, 5 MG C1

11


Nivel de Marca

Requisitos/Límites

enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

F QL

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg F

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG C1

XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) C1

Antifúngicos

3 DAY VAGINAL VAGINAL CREAM 200 MG/5 GRAM (4 %) F QL

antifungal (tolnaftate) topical cream 1 % F

ATHLETE'S FOOT (TERBINAFINE) TOPICAL CREAM 1 % F

clotrimazole mucous membrane troche 10 mg F

clotrimazole topical cream 1 % F QL

clotrimazole topical solution 1 % F QL

clotrimazole vaginal cream 1 % F QL

clotrimazole-betamethasone topical cream 1-0.05 % F QL

clotrimazole-betamethasone topical lotion 1-0.05 % F QL

econazole topical cream 1 % F

fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml F

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg F QL

flucytosine oral capsule 250 mg, 500 mg F

griseofulvin microsize oral suspension 125 mg/5 ml F QL

griseofulvin microsize oral tablet 500 mg F QL

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg F QL

ketoconazole oral tablet 200 mg F

ketoconazole topical cream 2 % F

ketoconazole topical shampoo 2 % F

MEDI-FIRST ANTI-FUNGAL TOPICAL PACKET 1 % F

miconazole nitrate topical cream 2 % F QL

miconazole nitrate vaginal comb pack,prefill appl, cream 4 % (200 mg)- 2 % (9 gram)

F QL

miconazole nitrate vaginal cream 2 % F QL

miconazole nitrate vaginal suppository 100 mg F QL

MICONAZOLE-3 VAGINAL KIT 200 MG- 2 % (9 GRAM) F QL

12


Nivel de Marca

Requisitos/Límites

MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG F QL

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % F

nystatin oral powder 150 million unit F

nystatin oral suspension 100,000 unit/ml F

nystatin oral tablet 500,000 unit F

nystatin topical cream 100,000 unit/gram F

nystatin topical ointment 100,000 unit/gram F

nystatin-triamcinolone topical cream 100,000-0.1 unit/g-% F

nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-% F

NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM F

terbinafine hcl oral tablet 250 mg F QL

terconazole vaginal cream 0.4 %, 0.8 % F QL

terconazole vaginal suppository 80 mg F QL

tolnaftate topical solution 1 % F

Antihistamínico y Combinación de Descongestionante

ALAVERT D-12 ALLERGY-SINUS ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG

F

cetirizine-pseudoephedrine oral tablet extended release 12 hr 5-120 mg F

DIMETAPP COLD-ALLERGY (PE) ORAL SOLUTION 1-2.5 MG/5 ML F

LOHIST - D ORAL LIQUID 2-30 MG/5 ML F

LORATADINE-D ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG

F

PROMETHAZINE VC ORAL SYRUP 6.25-5 MG/5 ML F

RITIFED ORAL SYRUP 1.25-30 MG/5 ML F

RYNEX PSE ORAL LIQUID 1-15 MG/5 ML F QL

WAL-ACT D COLD AND ALLERGY ORAL TABLET 2.5-60 MG F

WAL-PHED ORAL TABLET 4-60 MG F QL

Antihistamínicos

BENADRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML F QL

cetirizine oral solution 1 mg/ml F

cetirizine oral tablet 10 mg, 5 mg F

cetirizine oral tablet,chewable 10 mg, 5 mg F QL

13


Nivel de Marca

Requisitos/Límites

CHILDREN'S CLARITIN ORAL TABLET,CHEWABLE 5 MG F QL

CHILDREN'S WAL-DRYL ALLERGY ORAL PREFILLED SPOON 12.5 MG/5 ML

F QL

chlorpheniramine maleate oral tablet 4 mg F

chlorpheniramine maleate oral tablet extended release 12 mg F

cyproheptadine oral syrup 2 mg/5 ml F

cyproheptadine oral tablet 4 mg F

diphenhydramine hcl oral capsule 25 mg, 50 mg F QL

diphenhydramine hcl oral elixir 12.5 mg/5 ml F QL

diphenhydramine hcl oral syrup 12.5 mg/5 ml F QL

diphenhydramine hcl oral tablet 25 mg F QL

ed chlorped jr oral syrup 2 mg/5 ml F

hydroxyzine hcl oral solution 10 mg/5 ml F

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg F

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg F

loratadine oral solution 5 mg/5 ml F

loratadine oral tablet 10 mg F

loratadine oral tablet,disintegrating 10 mg F QL

olopatadine ophthalmic (eye) drops 0.1 % C1

promethazine oral syrup 6.25 mg/5 ml F

promethazine oral tablet 12.5 mg, 25 mg, 50 mg F

ZADITOR OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %) F

Antihiperglucémicos

acarbose oral tablet 100 mg, 25 mg, 50 mg F

alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg F ST; QL

alogliptin-metformin oral tablet 12.5-1,000 mg, 12.5-500 mg F ST; QL

APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML F

APIDRA SUBCUTANEOUS SOLUTION 100 UNIT/ML F

BASAGLAR KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

F

glimepiride oral tablet 1 mg, 2 mg, 4 mg F

glipizide oral tablet 10 mg, 5 mg F

14


Nivel de Marca

Requisitos/Límites

glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg F

glipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg F QL

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg F

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg F

HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML F

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50)

F

HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50)

F

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25)

F

HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25)

F

HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML F

HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML F

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

F

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) F

HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

F

HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML F

HUMULIN R U-100 INJECTION SOLUTION 100 UNIT/ML F

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML

F

INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG

F ST; QL

INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG

F ST; QL

INVOKANA ORAL TABLET 100 MG, 300 MG F ST; QL

JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG F ST; QL

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG

F ST; QL

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG F ST; QL

LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

F

15


Nivel de Marca

Requisitos/Límites

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML F

metformin oral tablet 1,000 mg, 500 mg, 850 mg F

metformin oral tablet extended release 24 hr 500 mg, 750 mg F

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) F

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML F

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML F

NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML F

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

F

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30)

F

NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 100 UNIT/ML F

NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML F

pioglitazone oral tablet 15 mg, 30 mg, 45 mg F

Antiinfecciosos/Varios

atovaquone oral suspension 750 mg/5 ml F

chloroquine phosphate oral tablet 250 mg, 500 mg F

hydroxychloroquine oral tablet 200 mg F

NEBUPENT INHALATION RECON SOLN 300 MG F

paromomycin oral capsule 250 mg C1

primaquine oral tablet 26.3 mg F

REESE'S PINWORM MEDICINE ORAL SUSPENSION 50 MG/ML F

Antineoplásicos

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG F PA; SPO

anastrozole oral tablet 1 mg F SPO

AVASTIN INTRAVENOUS SOLUTION 25 MG/ML F PA

bexarotene oral capsule 75 mg F SPO

COTELLIC ORAL TABLET 20 MG F PA; SPO

CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML F PA

DARZALEX INTRAVENOUS SOLUTION 20 MG/ML F PA

doxorubicin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml

F

EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG F PA

16


Nivel de Marca

Requisitos/Límites

etoposide oral capsule 50 mg F SPO

FARYDAK ORAL CAPSULE 10 MG, 20 MG F PA

farydak oral capsule 15 mg F PA

FLUOROPLEX TOPICAL CREAM 1 % F

fluorouracil topical cream 5 % F

flutamide oral capsule 125 mg F

HALAVEN INTRAVENOUS SOLUTION 1 MG/2 ML (0.5 MG/ML) F PA

HERCEPTIN INTRAVENOUS RECON SOLN 440 MG F PA

hydroxyurea oral capsule 500 mg F

ifosfamide intravenous solution 3 gram/60 ml F

IRESSA ORAL TABLET 250 MG F PA

irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml, 500 mg/25 ml F

KADCYLA INTRAVENOUS RECON SOLN 100 MG F PA

LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML F PA

LEUKERAN ORAL TABLET 2 MG F SPO

MATULANE ORAL CAPSULE 50 MG F

megestrol oral tablet 20 mg, 40 mg F QL

mercaptopurine oral tablet 50 mg F

methotrexate sodium (pf) injection solution 25 mg/ml F

methotrexate sodium injection solution 25 mg/ml F

methotrexate sodium oral tablet 2.5 mg F

MYLERAN ORAL TABLET 2 MG F SPO

ODOMZO ORAL CAPSULE 200 MG F PA; SPO

OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML F PA

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG F PA

TABLOID ORAL TABLET 40 MG F SPO

tamoxifen oral tablet 10 mg, 20 mg F

tretinoin (chemotherapy) oral capsule 10 mg F

VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG F PA

vinblastine intravenous solution 1 mg/ml F

YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML)

F PA

17


Nivel de Marca

Requisitos/Límites

ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML)

F PA

Medicamentos Antiparkinsonianos

bromocriptine oral capsule 5 mg C1

bromocriptine oral tablet 2.5 mg C1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg F

carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg F

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

F

entacapone oral tablet 200 mg F

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg F

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg F

selegiline hcl oral capsule 5 mg F QL

selegiline hcl oral tablet 5 mg F QL

Medicamentos Antiplaquetarios

anagrelide oral capsule 0.5 mg, 1 mg F

aspirin oral tablet,chewable 81 mg F QL

aspirin oral tablet,delayed release (dr/ec) 81 mg F QL

cilostazol oral tablet 100 mg, 50 mg F

CLOPIDOGREL ORAL TABLET 300 MG F

clopidogrel oral tablet 75 mg F

Antivirales

ABREVA TOPICAL CREAM 10 % F QL

acyclovir oral capsule 200 mg F

acyclovir oral suspension 200 mg/5 ml F

acyclovir oral tablet 400 mg, 800 mg F

famciclovir oral tablet 125 mg, 250 mg, 500 mg F QL

oseltamivir oral capsule 30 mg, 45 mg, 75 mg F QL

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML F QL

trifluridine ophthalmic (eye) drops 1 % F

valacyclovir oral tablet 1 gram, 500 mg F

Medicamentos Autonómicos

18


Nivel de Marca

Requisitos/Límites

ADRENALIN INJECTION SOLUTION 1 MG/ML (1 ML) F

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg F

dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg F QL

dextroamphetamine oral tablet 10 mg, 5 mg F QL

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

F QL

dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

F QL

donepezil oral tablet 10 mg, 5 mg F QL

donepezil oral tablet,disintegrating 10 mg, 5 mg F QL

epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml

F QL

epinephrine injection solution 1 mg/ml (1 ml) F

epinephrine injection syringe 0.1 mg/ml F

galantamine oral tablet 12 mg, 4 mg, 8 mg F QL

MESTINON ORAL SYRUP 60 MG/5 ML F

MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG

F

midodrine oral tablet 10 mg, 2.5 mg, 5 mg F

pyridostigmine bromide oral tablet 60 mg F

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg F

Biológicos

ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML F

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

F QL

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

F QL

AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

F QL

AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML

F QL

AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG/0.5 ML

F QL

AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG/0.5 ML

F QL

19


Nivel de Marca

Requisitos/Límites

BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG

F QL

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML F QL

BIOTHRAX INTRAMUSCULAR SUSPENSION 0.5 ML/DOSE F QL

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML

F QL

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML

F QL

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML

F

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML F QL

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML F QL

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML

F

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML

F

FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

F QL

FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION 135 MCG (45 MCG X 3)/0.5 ML

F QL

FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 180 MCG (45 MCG X 4)/0.5 ML

F QL

FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

F QL

FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

F QL

FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

F QL

FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

F QL

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

F QL

FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML

F QL

FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE 180 MCG/0.5 ML

F QL

20


Nivel de Marca

Requisitos/Límites

FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE 36 MCG/0.1 ML

F QL

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

F QL

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

F QL

FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML

F QL

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML F QL

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML F QL

HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

F QL

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML

F QL

HEPAGAM B INJECTION SOLUTION >312 UNIT/ML, GREATR THAN 312 UNIT/ML (5 ML)

F

HYPERHEP B S/D INTRAMUSCULAR SOLUTION 220 UNIT/ML, 220 UNIT/ML (5 ML)

F

HYPERHEP B S/D INTRAMUSCULAR SYRINGE 220 UNIT/ML F

HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE 110 UNIT/0.5 ML

F

HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML F

HYPERTET S/D (PF) INTRAMUSCULAR SYRINGE 250 UNIT F

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT

F QL

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML

F

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF/0.5ML

F

IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML F QL

IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML F QL

KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML

F

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML

F

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML F QL

21


Nivel de Marca

Requisitos/Límites

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN 5-2.5 MCG/0.5 ML

F

MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG

F QL

MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN 50 MCG F QL

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML

F QL

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML

F QL

NABI-HB INTRAMUSCULAR SOLUTION GREATER THAN 1,560 UNIT/5 ML, GREATR THAN 312 UNIT/ML

F

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML

F

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML F

PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML

F

PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML

F

PNEUMOVAX 23 INJECTION SOLUTION 25 MCG/0.5 ML F QL

PNEUMOVAX 23 INJECTION SYRINGE 25 MCG/0.5 ML F QL

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 0.5 ML F QL

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5

F

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT

F QL

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML

F QL

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML

F

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML F QL

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML F

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML

F

ROTATEQ VACCINE ORAL SOLUTION 2 ML F

STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,000 UNIT/0.5 ML

F

22


Nivel de Marca

Requisitos/Límites

TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML

F QL

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML F QL

tetanus,diphtheria tox ped(pf) intramuscular suspension 5-25 lf unit/0.5 ml F

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML

F QL

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML F QL

TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML

F QL

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML F QL

TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML F QL

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML

F QL

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML

F QL

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML

F QL

VARIZIG INTRAMUSCULAR RECON SOLN 125 UNIT F

VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2 BILLION UNIT

F QL

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML

F QL

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML

F QL

Sangre

pentoxifylline oral tablet extended release 400 mg F QL

Medicamentos Cardíacos

amiodarone oral tablet 200 mg F

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg F

digoxin oral solution 50 mcg/ml F

digoxin oral tablet 125 mcg, 250 mcg F

DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 40 MG F QL

diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg F

diltiazem hcl oral capsule,extended release 24 hr 360 mg, 420 mg F QL

23


Nivel de Marca

Requisitos/Límites

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

F QL

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg F

DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE 120 MG, 180 MG, 240 MG

F QL

felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg F

ISORDIL ORAL TABLET 40 MG F QL

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg F

isosorbide dinitrate oral tablet extended release 40 mg F

isosorbide mononitrate oral tablet 10 mg, 20 mg F

isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg F

LANOXIN ORAL TABLET 125 MCG, 250 MCG F

mexiletine oral capsule 150 mg, 200 mg, 250 mg F

nifedipine oral capsule 10 mg, 20 mg F

nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg F QL

nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg F QL

NITRO-BID TRANSDERMAL OINTMENT 2 % F

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg F

propafenone oral capsule,extended release 12 hr 225 mg F QL

propafenone oral capsule,extended release 12 hr 325 mg, 425 mg F

propafenone oral tablet 150 mg, 225 mg, 300 mg F

quinidine gluconate oral tablet extended release 324 mg F

TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG

F QL

verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg F

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg F

verapamil oral tablet 120 mg, 40 mg, 80 mg F

verapamil oral tablet extended release 120 mg, 180 mg, 240 mg F

Cardiovasculares

amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

F

atenolol oral tablet 100 mg, 25 mg, 50 mg F

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg F

24


Nivel de Marca

Requisitos/Límites

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg F

benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg F

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

F

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg F

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg F

cholestyramine (with sugar) oral powder 4 gram F

cholestyramine (with sugar) oral powder in packet 4 gram F

CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM F

CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM F

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg F

clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr F QL

doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg F

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg F

fenofibrate micronized oral capsule 134 mg, 67 mg F

fenofibrate micronized oral capsule 200 mg F QL

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg F

fenofibrate oral tablet 160 mg, 54 mg F

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg F

gemfibrozil oral tablet 600 mg F

guanfacine oral tablet 1 mg, 2 mg F

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg F

irbesartan oral tablet 150 mg, 300 mg, 75 mg F QL

labetalol intravenous solution 5 mg/ml F

labetalol oral tablet 100 mg, 200 mg, 300 mg F

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg F

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg F

losartan oral tablet 100 mg, 25 mg, 50 mg F

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg F

lovastatin oral tablet 10 mg, 20 mg, 40 mg F

methyldopa oral tablet 250 mg, 500 mg F

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg F

25


Nivel de Marca

Requisitos/Límites

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

F

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg F

minoxidil oral tablet 10 mg, 2.5 mg F

niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg F

NIACOR ORAL TABLET 500 MG F

pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg F

prazosin oral capsule 1 mg, 2 mg, 5 mg F

propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg F

propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) F

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg F

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg F

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg F QL

terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg F

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg F QL

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

F QL

Medicamentos del Sistema Nervioso Central (CNS)

carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg F

carbamazepine oral suspension 100 mg/5 ml F

carbamazepine oral tablet 200 mg F

carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg F

carbamazepine oral tablet,chewable 100 mg F

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG

F

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg F QL

DEPAKENE ORAL CAPSULE 250 MG F

DEPAKENE ORAL SOLUTION 250 MG/5 ML F

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR 250 MG, 500 MG

F

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 125 MG, 250 MG, 500 MG

F

DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 125 MG

F

26


Nivel de Marca

Requisitos/Límites

diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg F QL

DILANTIN EXTENDED ORAL CAPSULE 100 MG F

DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG F

DILANTIN ORAL CAPSULE 30 MG F

DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML F

divalproex oral capsule, delayed rel sprinkle 125 mg F

divalproex oral tablet extended release 24 hr 250 mg, 500 mg F

divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg F

ethosuximide oral capsule 250 mg F

ethosuximide oral solution 250 mg/5 ml F

gabapentin oral capsule 100 mg, 300 mg, 400 mg F

gabapentin oral tablet 600 mg, 800 mg F

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg F

lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg F

levetiracetam oral solution 100 mg/ml F

levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg F

memantine oral tablet 10 mg, 5 mg F

memantine oral tablets,dose pack 5-10 mg F

oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) F

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg F

phenytoin oral suspension 125 mg/5 ml F

phenytoin oral tablet,chewable 50 mg F

phenytoin sodium extended oral capsule 100 mg F

primidone oral tablet 250 mg, 50 mg F

riluzole oral tablet 50 mg F

TEGRETOL ORAL SUSPENSION 100 MG/5 ML F

TEGRETOL ORAL TABLET 200 MG F

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 400 MG

F

topiramate oral capsule, sprinkle 15 mg, 25 mg F

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg F

valproic acid (as sodium salt) oral solution 250 mg/5 ml F

27


Nivel de Marca

Requisitos/Límites

valproic acid oral capsule 250 mg F

zonisamide oral capsule 100 mg, 25 mg, 50 mg F

Factores Estimulantes de Colonias

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

C1

GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

C1 QL

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML C1 QL

Anticonceptivos

AZURETTE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 F

BALZIVA (28) ORAL TABLET 0.4-35 MG-MCG F

CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)

F

CAYA CONTOURED VAGINAL DIAPHRAGM 60-85 MM F QL

CAZIANT (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG F

CONCEPTROL VAGINAL GEL 4 % F

CONDOMS-PREM LUBRICATED DEVICE F QL

drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-0.451 mg (24) (4) F

ELLA ORAL TABLET 30 MG F QL

emoquette oral tablet 0.15-0.03 mg F

fc2 female condom F QL

GIANVI (28) ORAL TABLET 3-0.02 MG F

GYNOL II VAGINAL GEL 3 % F

JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) F

JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) F

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)

F

LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG F

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg F

LEVORA-28 ORAL TABLET 0.15-0.03 MG F

LOW-OGESTREL (28) ORAL TABLET 0.3-30 MG-MCG F

medroxyprogesterone intramuscular suspension 150 mg/ml F

medroxyprogesterone intramuscular syringe 150 mg/ml F

28


Nivel de Marca

Requisitos/Límites

MICROGESTIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG F

MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG F

MONONESSA (28) ORAL TABLET 0.25-35 MG-MCG F

my way oral tablet 1.5 mg F QL

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG F

NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG F

NECON 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG F

noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

F

norethindrone (contraceptive) oral tablet 0.35 mg F

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) F

norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

F

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

nortrel 1/35 (28) oral tablet 1-35 mg-mcg F

NUVARING VAGINAL RING 0.12-0.015 MG/24 HR F

OCELLA ORAL TABLET 3-0.03 MG F

OGESTREL (28) ORAL TABLET 0.5-50 MG-MCG F

QUASENSE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG

F

rivelsa oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg F

SRONYX ORAL TABLET 0.1-20 MG-MCG F

TILIA FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) F

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) F

TRIVORA (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) F

VAGINAL CONTRACEPTIVE FILM VAGINAL FILM 28 % F

VAGINAL CONTRACEPTIVE FOAM VAGINAL FOAM 12.5 % F

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM F QL






29


Nivel de Marca

Requisitos/Límites



xulane transdermal patch weekly 150-35 mcg/24 hr F

ZENCHENT FE ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7)

F

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG F

ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG F

Tos/Resfriado

ADULT ROBITUSSIN PEAK COLD M-S ORAL LIQUID 5-10-100 MG/5 ML

F QL

allergy relief(chlorphen-acet) oral tablet 2-5-325 mg F QL

benzonatate oral capsule 100 mg, 200 mg F QL

BIO-S-PRES DX ORAL DROPS 2.5-5-50 MG/ML F QL

BROMFED DM ORAL SYRUP 2-30-10 MG/5 ML F

BROTAPP DM ORAL ELIXIR 1-15-5 MG/5 ML F

CHILD MUCINEX STUFFY NOSE-COLD ORAL LIQUID 2.5-100 MG/5 ML

F

DIABETIC TUSSIN DM ORAL LIQUID 10-200 MG/5 ML F QL

DIMETAPP DM COLD-COUGH (PE) ORAL SOLUTION 1-2.5-5 MG/5 ML

F

EXPECTORANT ORAL LIQUID 100 MG/5 ML F QL

GUAIFENESIN AC ORAL LIQUID 10-100 MG/5 ML F QL

guaifenesin oral tablet extended release 12hr 600 mg F

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml F QL

MUCINEX COUGH MINI-MELTS ORAL GRANULES IN PACKET 5-100 MG

F

MUCINEX D MAXIMUM STRENGTH ORAL TABLET EXTENDED RELEASE 12 HR 120-1,200 MG

F QL

MUCINEX D ORAL TABLET EXTENDED RELEASE 12 HR 60-600 MG F QL

MUCINEX ORAL TABLET EXTENDED RELEASE 12HR 1,200 MG F

mucus dm oral tablet extended release 12 hr 30-600 mg F

mucus relief cough oral liquid 5-100 mg/5 ml F QL

NEO-TUSS ORAL LIQUID 30-200 MG/5 ML F QL

nohist-dm oral liquid 4-10-15 mg/5 ml F

30


Nivel de Marca

Requisitos/Límites

PEDIA RELIEF COUGH-COLD ORAL LIQUID 1-15-5 MG/5 ML F

PROMETHAZINE VC-CODEINE ORAL SYRUP 6.25-5-10 MG/5 ML F QL

promethazine-codeine oral syrup 6.25-10 mg/5 ml F QL

promethazine-dm oral syrup 6.25-15 mg/5 ml F

pseudoephedrine hcl oral tablet 30 mg, 60 mg F QL

pseudoephedrine hcl oral tablet extended release 120 mg F QL

ROBITUSSIN PEDIATRIC ORAL SYRUP 7.5 MG/5 ML F

SCOT-TUSSIN DM ORAL LIQUID 2-15 MG/5 ML F

SCOT-TUSSIN SENIOR ORAL LIQUID 15-200 MG/5 ML F QL

SUPHEDRIN ORAL LIQUID 15 MG/5 ML F QL

TUSSIN DM ORAL LIQUID 10-100 MG/5 ML F QL

TUSSIN DM ORAL SYRUP 10-100 MG/5 ML F QL

Diagnóstico

CHEMSTRIP K STRIP F

DIASTIX STRIP F

GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MG/ML F QL

KETO-DIASTIX STRIP F

MULTISTIX 10 SG STRIP F

ONETOUCH VERIO STRIP F SPO

Diuréticos

acetazolamide oral capsule, extended release 500 mg F

acetazolamide oral tablet 125 mg, 250 mg F

ALDACTAZIDE ORAL TABLET 50-50 MG F

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg F

chlorothiazide oral tablet 250 mg, 500 mg F

chlorthalidone oral tablet 25 mg, 50 mg F

DIURIL ORAL SUSPENSION 250 MG/5 ML F

DYRENIUM ORAL CAPSULE 50 MG F

ethacrynic acid oral tablet 25 mg F

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) F

furosemide oral tablet 20 mg, 40 mg, 80 mg F

hydrochlorothiazide oral capsule 12.5 mg F

31


Nivel de Marca

Requisitos/Límites

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg F

indapamide oral tablet 1.25 mg, 2.5 mg F

spironolactone oral tablet 100 mg, 25 mg, 50 mg F

spironolacton-hydrochlorothiaz oral tablet 25-25 mg F

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg F

triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg F

Ojos, Oídos, Nariz y Garganta (EENT)

acetic acid otic (ear) solution 2 % F

allergy eye (naphazoline-phen) ophthalmic (eye) drops 0.025-0.3 % F

ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % F

ARTIFICIAL TEARS(DEXT70-HYPRO) OPHTHALMIC (EYE) DROPS F

ARTIFICIAL TEARS(PVALCH-POVID) OPHTHALMIC (EYE) DROPS 0.5-0.6 %

F

atropine ophthalmic (eye) drops 1 % F

atropine ophthalmic (eye) ointment 1 % F

AYR SALINE NASAL DROPS 0.65 % F

azelastine nasal aerosol,spray 137 mcg (0.1 %) F

betaxolol ophthalmic (eye) drops 0.5 % F

BETIMOL OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 % F

brimonidine ophthalmic (eye) drops 0.2 % F

carbamoxide ear drops otic (ear) drops 6.5 % F QL

cromolyn ophthalmic (eye) drops 4 % F

CYCLOGYL OPHTHALMIC (EYE) DROPS 0.5 % F

cyclopentolate ophthalmic (eye) drops 1 %, 2 % F

dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % F

diclofenac sodium ophthalmic (eye) drops 0.1 % F

dorzolamide ophthalmic (eye) drops 2 % F

dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml F

EYE ALLERGY RELIEF OPHTHALMIC (EYE) DROPS 0.02675-0.315 %

F

FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % F

fluorometholone ophthalmic (eye) drops,suspension 0.1 % F

32


Nivel de Marca

Requisitos/Límites

fluticasone nasal spray,suspension 50 mcg/actuation F QL

FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % F

for sty relief ophthalmic (eye) ointment F

GENTEAL MILD OPHTHALMIC (EYE) DROPS 0.2 % F

HOMATROPAIRE OPHTHALMIC (EYE) DROPS 5 % F

ISOPTO TEARS OPHTHALMIC (EYE) DROPS 0.5 % F

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % F

latanoprost ophthalmic (eye) drops 0.005 % F

levobunolol ophthalmic (eye) drops 0.5 % F

lubricant eye drops (glyc-pg) ophthalmic (eye) drops 1-0.3 % F

lubricant eye drops ophthalmic (eye) drops 0.5 % F

LUBRICANT EYE OPHTHALMIC (EYE) OINTMENT 56.8-41.5 % F

lubricant eye ophthalmic (eye) ointment 83-15 % F

MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % F

metipranolol ophthalmic (eye) drops 0.3 % F

MURO 128 OPHTHALMIC (EYE) DROPS 2 % F

NASACORT NASAL AEROSOL,SPRAY 55 MCG F

NASAL SPRAY EXTRA MOISTURIZING NASAL SPRAY,NON-AEROSOL 0.05 %

F

PHENYLEPHRINE HCL OPHTHALMIC (EYE) DROPS 2.5 % F

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % F

polyvinyl alcohol ophthalmic (eye) drops 1.4 % F

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 % F

prednisolone acetate ophthalmic (eye) drops,suspension 1 % F

prednisolone sodium phosphate ophthalmic (eye) drops 1 % F

proparacaine ophthalmic (eye) drops 0.5 % F

PURE AND GENTLE EYE OPHTHALMIC (EYE) DROPS 0.3 % F

REFRESH LACRI-LUBE OPHTHALMIC (EYE) OINTMENT 56.8-42.5 %

F

REFRESH P.M. OPHTHALMIC (EYE) OINTMENT 57.3-42.5 % F

saline nasal nasal aerosol,spray 0.65 % F

sodium chloride ophthalmic (eye) drops 5 % F

33


Nivel de Marca

Requisitos/Límites

sodium chloride ophthalmic (eye) ointment 5 % F

SYSTANE NIGHTTIME OPHTHALMIC (EYE) OINTMENT 94-3 % F

tears again ophthalmic (eye) ointment 80-20 % F

TEARS NATURALE FORTE OPHTHALMIC (EYE) DROPS 0.1-0.3-0.2 %

F

timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % F

timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % F

tropicamide ophthalmic (eye) drops 0.5 %, 1 % F

Electrolitos/Calórico/H2O

amino acids 15 % intravenous parenteral solution 15 % C1

CALCIUM 600 ORAL TABLET 600 MG CALCIUM (1,500 MG) F

calcium acetate oral capsule 667 mg F

calcium acetate oral tablet 667 mg F

calcium carbonate oral tablet 500 mg calcium (1,250 mg), 650 mg calcium (1,625 mg)

F

calcium gluconate oral tablet 45 mg (500 mg), 60 mg (650 mg) F

calcium lactate oral tablet 84 mg (648 mg) F

CHELATED ZINC ORAL TABLET 50 MG F

dextrose 5 % in water (d5w) intravenous parenteral solution F

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ, 25 MEQ

F

ferrous sulfate oral drops 15 mg iron (75 mg)/ml F QL

ferrous sulfate oral elixir 220 mg (44 mg iron)/5 ml F QL

ferrous sulfate oral liquid 300 mg (60 mg iron)/5 ml F QL

ferrous sulfate oral solution 220 mg (44 mg iron)/5 ml F QL

ferrous sulfate oral tablet,delayed release (dr/ec) 324 mg (65 mg iron), 325 mg (65 mg iron)

F QL

FERROUSUL ORAL TABLET 325 MG (65 MG IRON) F QL

FLUOR-A-DAY ORAL DROPS 2.5 MG (5.56 MG SOD.FLUORID)/ML F

fluoride (sodium) oral drops 0.5 mg (1.1 mg sod.fluorid)/ml F

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

F

FLUORITAB ORAL TABLET,CHEWABLE 1 MG (2.2 MG SOD. FLUORIDE)

F

34


Nivel de Marca

Requisitos/Límites

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG F QL

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG F QL

glucose oral tablet,chewable 4 gram F

kionex (with sorbitol) oral suspension 15-19.3 gram/60 ml F

lactated ringers intravenous parenteral solution F

magnesium oxide oral tablet 250 mg, 400 mg, 420 mg, 500 mg F QL

PEDIATRIC ELECTROLYTE ORAL SOLUTION F QL

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l C1

potassium chloride oral capsule, extended release 10 meq, 8 meq F

potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml F

potassium chloride oral tablet extended release 10 meq, 8 meq F

potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq F

RENAGEL ORAL TABLET 400 MG, 800 MG F

sevelamer carbonate oral tablet 800 mg F

sf 5000 plus dental cream 1.1 % F QL

sodium chloride 0.9 % intravenous parenteral solution 0.9 % F

sodium citrate-citric acid oral solution 500-334 mg/5 ml F

sodium polystyrene sulfonate oral powder F

sodium polystyrene sulfonate oral suspension 15 gram/60 ml F

SSKI ORAL SOLUTION 1 GRAM/ML F

zinc gluconate oral tablet 50 mg F

Gastrointestinal

ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION 200-200-20 MG/5 ML

F

ANTACID MAXIMUM STRENGTH ORAL SUSPENSION 400-400-40 MG/5 ML

F

ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML F

aprepitant oral capsule 125 mg, 40 mg, 80 mg C1

aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) C1

balsalazide oral capsule 750 mg F QL

bisacodyl oral tablet,delayed release (dr/ec) 5 mg F QL

BISMUTH MAXIMUM STRENGTH ORAL SUSPENSION 525 MG/15 ML

F

35


Nivel de Marca

Requisitos/Límites

calcium carbonate oral tablet 260 mg calcium (648 mg) F

CARAFATE ORAL SUSPENSION 100 MG/ML F

cimetidine hcl oral solution 300 mg/5 ml F

cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg F

CITRUCEL ORAL TABLET 500 MG F

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

F

DICLEGIS ORAL TABLET,DELAYED RELEASE (DR/EC) 10-10 MG F PA; QL

dicyclomine oral capsule 10 mg F QL

dicyclomine oral solution 10 mg/5 ml F QL

dicyclomine oral tablet 20 mg F QL

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml F

diphenoxylate-atropine oral tablet 2.5-0.025 mg F

docusate sodium oral capsule 100 mg, 250 mg F QL

docusate sodium oral liquid 50 mg/5 ml F QL

docusate sodium oral syrup 60 mg/15 ml F QL

docusate sodium oral tablet 100 mg F QL

DONNATAL ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML F

enema rectal enema 19-7 gram/118 ml F

ENULOSE ORAL SOLUTION 10 GRAM/15 ML F

famotidine oral suspension 40 mg/5 ml (8 mg/ml) F

famotidine oral tablet 10 mg, 20 mg, 40 mg F

fiber (calcium polycarbophil) oral tablet 625 mg F

fiber (psyllium husk/sugar) oral powder 3.4 gram/12 gram F

FIBER (PSYLLIUM HUSK/SUGAR) ORAL POWDER 3.4 GRAM/7 GRAM

F

foaming antacid oral tablet,chewable 80-20 mg F

GAVILYTE-G ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM F QL

GAVISCON ORAL TABLET,CHEWABLE 80-14.2 MG F

glycerin (adult) rectal suppository F

glycerin (child) rectal suppository F

hydrocortisone acetate rectal suppository 25 mg, 30 mg F

36


Nivel de Marca

Requisitos/Límites

konsyl (sugar) oral powder in packet 3.4 gram F

lactulose oral solution 10 gram/15 ml F

lansoprazole oral capsule,delayed release(dr/ec) 15 mg F QL

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

LAXATIVE (BISACODYL) ORAL TABLET 5 MG F QL

loperamide oral capsule 2 mg F

LOPERAMIDE ORAL TABLET 2 MG F

magnesium citrate oral solution F

meclizine oral tablet 12.5 mg, 25 mg F QL

meclizine oral tablet,chewable 25 mg F QL

METAMUCIL ORAL CAPSULE 0.52 GRAM F

metoclopramide hcl oral solution 5 mg/5 ml F

metoclopramide hcl oral tablet 10 mg, 5 mg F

MILK OF MAGNESIA CONCENTRATED ORAL SUSPENSION 2,400 MG/10 ML

F

MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5 ML F

MINTOX PLUS ORAL TABLET,CHEWABLE 200-200-25 MG F

misoprostol oral tablet 100 mcg, 200 mcg C1

NATURAL FIBER LAXATIVE THERAPY ORAL POWDER F

natural psyllium fiber oral powder 3.4 gram/5.8 gram F

NEXIUM 24HR ORAL CAPSULE,DELAYED RELEASE(DR/EC) 22.3 MG

F QL

NUTRILIPID INTRAVENOUS EMULSION 20 % C1

NUTRISOURCE FIBER ORAL POWDER F

omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg F

omeprazole oral capsule,delayed release(dr/ec) 40 mg F QL

omeprazole oral tablet,delayed release (dr/ec) 20 mg F QL

ondansetron hcl oral tablet 4 mg, 8 mg F QL

ondansetron oral tablet,disintegrating 4 mg, 8 mg F QL

pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg F QL

PEDIA-LAX STOOL SOFTENER ORAL SYRUP 50 MG/15 ML F

PEDIATRIC ENEMA RECTAL ENEMA 9.5-3.5 GRAM/59 ML F

37


Nivel de Marca

Requisitos/Límites

peg 3350-electrolytes oral recon soln 240-22.72-6.72 -5.84 gram F QL

phenohytro oral tablet 16.2-0.1037 -0.0194 mg F

pink bismuth oral suspension 262 mg/15 ml F

PINK BISMUTH ORAL TABLET 262 MG F

PINK BISMUTH ORAL TABLET,CHEWABLE 262 MG F

polyethylene glycol 3350 oral powder 17 gram/dose F QL

PREVACID 24HR ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15 MG

F QL

PRILOSEC OTC ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG F

prochlorperazine edisylate injection solution 5 mg/ml C1

prochlorperazine maleate oral tablet 10 mg, 5 mg F

prochlorperazine rectal suppository 25 mg F

PROCTOFOAM HC RECTAL FOAM 1-1 % F

promethazine rectal suppository 12.5 mg, 25 mg F

PROMETHEGAN RECTAL SUPPOSITORY 50 MG F

rabeprazole oral tablet,delayed release (dr/ec) 20 mg F

ranitidine hcl oral syrup 15 mg/ml F

ranitidine hcl oral tablet 150 mg, 300 mg, 75 mg F

scopolamine base transdermal patch 3 day 1 mg over 3 days F QL

SENNA LAX ORAL TABLET 8.6 MG F

SENNA ORAL SYRUP 8.8 MG/5 ML F

SENNA PLUS ORAL TABLET 8.6-50 MG F QL

SIMETHICONE ORAL DROPS,SUSPENSION 40 MG/0.6 ML F QL

simethicone oral tablet,chewable 80 mg F QL

sodium bicarbonate oral tablet 325 mg, 650 mg F

stool softener oral capsule 50 mg F QL

sucralfate oral tablet 1 gram F

sulfasalazine oral tablet 500 mg F

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

TRILYTE WITH FLAVOR PACKETS ORAL RECON SOLN 420 GRAM F QL

trimethobenzamide oral capsule 300 mg F

ursodiol oral capsule 300 mg F

38


Nivel de Marca

Requisitos/Límites

ursodiol oral tablet 250 mg F

Hormonas

calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation F

CORTIFOAM RECTAL FOAM 10 % (80 MG) F

DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML F

desmopressin oral tablet 0.1 mg, 0.2 mg C1

DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML F

dexamethasone oral elixir 0.5 mg/5 ml F

dexamethasone oral solution 0.5 mg/5 ml F

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg F

ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) F

estradiol oral tablet 0.5 mg, 1 mg, 2 mg F

estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

F QL

estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr

F QL

estrogens-methyltestosterone oral tablet 0.625-1.25 mg, 1.25-2.5 mg F

fludrocortisone oral tablet 0.1 mg F

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg F

hydrocortisone rectal enema 100 mg/60 ml F

JINTELI ORAL TABLET 1-5 MG-MCG F

medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg F

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG F

methergine oral tablet 0.2 mg F

methylprednisolone oral tablet 4 mg F

methylprednisolone oral tablets,dose pack 4 mg F

MILLIPRED DP ORAL TABLETS,DOSE PACK 5 MG (21 TABS) F

MILLIPRED ORAL TABLET 5 MG F

prednisolone oral solution 15 mg/5 ml F

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

F

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML F

prednisone oral solution 5 mg/5 ml F

39


Nivel de Marca

Requisitos/Límites

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg F

prednisone oral tablets,dose pack 10 mg, 5 mg F

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

F

PREMARIN VAGINAL CREAM 0.625 MG/GRAM F

PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14) F

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

F QL

testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml C1

Inmunosupresores

azathioprine oral tablet 50 mg F

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg F

mycophenolate mofetil oral capsule 250 mg F

mycophenolate mofetil oral tablet 500 mg F

Suministros Médicos Diversos, Dispositivos, No Farmacológicos

AEROCHAMBER PLUS FLOW-VU SPACER F QL

bd insulin pen needle uf orig needle 29 gauge x 1/2" F

bd insulin pen needle uf short needle 31 gauge x 5/16" F

bd sharps collector F QL

ONETOUCH VERIO MID CONTROL SOLUTION F SPO

peak air peak flow meter device F QL

Relajantes Musculares

baclofen oral tablet 10 mg, 20 mg F QL

cyclobenzaprine oral tablet 10 mg F

cyclobenzaprine oral tablet 5 mg F QL

methocarbamol oral tablet 500 mg, 750 mg F QL

tizanidine oral tablet 2 mg, 4 mg F QL

Vitaminas Prenatales

O-CAL FA ORAL TABLET 66 MG IRON- 1 MG F

pnv 29-1 oral tablet 29 mg iron- 1 mg F

pnv cmb#95-ferrous fumarate-fa oral tablet 28 mg iron- 800 mcg F

prenatal complete oral tablet 14 mg iron- 400 mcg F

40


Nivel de Marca

Requisitos/Límites

PRENATAL LOW IRON ORAL TABLET 27 MG IRON- 1 MG F

PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 27 MG IRON- 1 MG

F

prenatal plus oral tablet 29 mg iron- 1 mg F

PRENATAL VITAMIN ORAL TABLET , 27 MG IRON- 0.8 MG F

PRENATAL VITAMIN WITH MINERALS ORAL TABLET 28 MG IRON- 800 MCG

F

prenatal vits96-iron fum-folic oral tablet 27 mg iron- 800 mcg F

PRETAB ORAL TABLET 29-1 MG F

vinate m oral tablet 27-1 mg F

Medicamentos Psicoterapéuticos

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg F QL

alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg F QL

amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg F

atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg F

bupropion hcl oral tablet 100 mg, 75 mg F QL

bupropion hcl oral tablet extended release 12 hr 100 mg, 150 mg, 200 mg F QL

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg F

buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg F

citalopram oral solution 10 mg/5 ml F

citalopram oral tablet 10 mg, 20 mg, 40 mg F

clonidine hcl oral tablet extended release 12 hr 0.1 mg F QL

desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg F QL

dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

F QL

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg F QL

diazepam oral solution 5 mg/5 ml (1 mg/ml) F QL

diazepam oral tablet 10 mg, 2 mg, 5 mg F QL

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 75 mg F QL

doxepin oral capsule 50 mg F

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg F QL

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg F

fluoxetine oral capsule 10 mg, 20 mg, 40 mg F

41


Nivel de Marca

Requisitos/Límites

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) F

fluoxetine oral tablet 10 mg, 20 mg F

guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg F QL

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg F

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg F QL

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

F QL

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg F QL

methylphenidate hcl oral tablet extended release 10 mg, 20 mg F QL

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

F QL

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg F

mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg F

nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg F

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg F

nortriptyline oral solution 10 mg/5 ml F

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg F

sertraline oral concentrate 20 mg/ml F

sertraline oral tablet 100 mg, 25 mg, 50 mg F

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg F

venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg F QL

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg F

Sedantes/Hipnóticos

NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET 25 MG F QL

phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) F

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

F

temazepam oral capsule 15 mg, 7.5 mg F QL

temazepam oral capsule 22.5 mg, 30 mg F

triazolam oral tablet 0.125 mg F QL

triazolam oral tablet 0.25 mg F

zolpidem oral tablet 10 mg F

zolpidem oral tablet 5 mg F QL

42


Nivel de Marca

Requisitos/Límites

Piel

acne medication topical lotion 10 % F

ACNE MEDICATION TOPICAL LOTION 5 % F

ALCOHOL PREP PADS TOPICAL PADS, MEDICATED F

AMLACTIN TOPICAL CREAM F

ammonium lactate topical lotion 12 % F

anti-dandruff with menthol topical shampoo 1 % F

aqua care topical lotion 10 % F

benzoyl peroxide topical cleanser 10 %, 5 % F

benzoyl peroxide topical gel 10 %, 2.5 %, 5 % F

BETA-HC TOPICAL LOTION 1 % F QL

betamethasone dipropionate topical cream 0.05 % F

betamethasone dipropionate topical lotion 0.05 % F

betamethasone dipropionate topical ointment 0.05 % F

betamethasone valerate topical cream 0.1 % F

betamethasone valerate topical ointment 0.1 % F

betamethasone, augmented topical cream 0.05 % F

betamethasone, augmented topical ointment 0.05 % F

calamine topical lotion F

calamine-zinc oxide topical lotion 8-8 % F

clearasil daily clear(benzoyl) topical cream 10 % F

clobetasol scalp solution 0.05 % F QL

clobetasol topical cream 0.05 % F

clobetasol topical foam 0.05 % F QL

clobetasol topical gel 0.05 % F QL

clobetasol topical ointment 0.05 % F QL

clobetasol-emollient topical cream 0.05 % F

CONDYLOX TOPICAL GEL 0.5 % F

DESITIN TOPICAL CREAM 13 % F

desonide topical cream 0.05 % F QL

desonide topical lotion 0.05 % F QL

desonide topical ointment 0.05 % F QL

43


Nivel de Marca

Requisitos/Límites

diclofenac sodium topical gel 1 % F QL

DRITHOCREME HP TOPICAL CREAM 1 % F

EURAX TOPICAL CREAM 10 % F

EURAX TOPICAL LOTION 10 % F

FLANDERS BUTTOCKS TOPICAL OINTMENT F

fluocinolone topical cream 0.01 %, 0.025 % F

fluocinolone topical ointment 0.025 % F

fluocinolone topical solution 0.01 % F

fluocinonide topical cream 0.05 % F

fluocinonide topical gel 0.05 % F

fluocinonide topical ointment 0.05 % F

fluocinonide topical solution 0.05 % F

FLUOCINONIDE-E TOPICAL CREAM 0.05 % F

fluticasone topical cream 0.05 % F

fluticasone topical ointment 0.005 % F

GERI-HYDROLAC TOPICAL LOTION 12 % F

HIBICLENS TOPICAL LIQUID 4 % F

hydrocortisone acetate topical cream 0.5 % F QL

HYDROCORTISONE ACETATE TOPICAL CREAM 1 % F QL

hydrocortisone acetate topical ointment 1 % F QL

HYDROCORTISONE PLUS TOPICAL CREAM 1 % F

hydrocortisone topical cream 0.5 % F QL

HYDROCORTISONE TOPICAL CREAM 1 % F QL

hydrocortisone topical cream 2.5 % F

hydrocortisone topical cream with perineal applicator 2.5 % F

hydrocortisone topical lotion 2.5 % F

hydrocortisone topical ointment 0.5 %, 1 % F QL

hydrocortisone topical ointment 2.5 % F

imiquimod topical cream in packet 5 % F QL

LICE KILLING TOPICAL SHAMPOO 0.33-4 % F QL

malathion topical lotion 0.5 % F QL

metronidazole topical cream 0.75 % F

44


Nivel de Marca

Requisitos/Límites

metronidazole topical gel 0.75 % F

metronidazole topical lotion 0.75 % F

mometasone topical cream 0.1 % F

mometasone topical ointment 0.1 % F

mometasone topical solution 0.1 % F

neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml F

permethrin topical cream 5 % F

permethrin topical liquid 1 % F QL

podofilox topical solution 0.5 % F

povidone-iodine topical solution 10 % F

povidone-iodine topical swab 10 % F

prednicarbate topical cream 0.1 % F

prednicarbate topical ointment 0.1 % F

PROCTO-PAK TOPICAL CREAM WITH PERINEAL APPLICATOR 1 %

F

RID COMPLETE LICE ELIM KIT TOPICAL KIT 4-0.33-0.5 % F QL

SCALPICIN ANTI-ITCH TOPICAL SOLUTION 1 % F QL

selenium sulfide topical lotion 2.5 % F

SELSUN BLUE TOPICAL SHAMPOO 1 % F

STERILE SALINE IRRIGATION SOLUTION 0.9 % F

tretinoin topical cream 0.025 %, 0.05 %, 0.1 % C1

tretinoin topical gel 0.01 %, 0.025 % C1

triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 % F

triamcinolone acetonide topical lotion 0.025 %, 0.1 % F

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % F

trianex topical ointment 0.05 % F

ULESFIA TOPICAL LOTION 5 % F QL

wart remover topical gel 17 % F

WART REMOVER TOPICAL LIQUID 17 % F

zinc oxide topical ointment , 20 %, 40 % F

zinc oxide topical paste 25 % F

Elementos Disuasivos para Dejar de Fumar

45


Nivel de Marca

Requisitos/Límites

bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg F QL

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG F QL

CHANTIX ORAL TABLET 0.5 MG F QL

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

F QL

nicotine (polacrilex) buccal gum 2 mg, 4 mg F QL

nicotine (polacrilex) buccal lozenge 2 mg, 4 mg F QL

nicotine (polacrilex) buccal mini lozenge 2 mg, 4 mg F QL

nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr F QL

nicotine transdermal patch, td daily, sequential 21-14-7 mg/24 hr F QL

NICOTROL INHALATION CARTRIDGE 10 MG F QL

NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML F QL

Tiroides

ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

F

CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG F

LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

F

levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

F

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

F

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg F

methimazole oral tablet 10 mg, 5 mg F

np thyroid oral tablet 15 mg, 30 mg, 60 mg, 90 mg F

propylthiouracil oral tablet 50 mg F

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

F

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

F

Medicamentos Sin Clasificación

alendronate oral tablet 10 mg, 35 mg, 70 mg F

46


Nivel de Marca

Requisitos/Límites

alendronate oral tablet 40 mg F QL

CARNITOR (SUGAR-FREE) ORAL SOLUTION 100 MG/ML F

CHEMET ORAL CAPSULE 100 MG F

chlorhexidine gluconate mucous membrane mouthwash 0.12 % F

disulfiram oral tablet 250 mg, 500 mg F

finasteride oral tablet 5 mg F

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg F

levocarnitine oral tablet 330 mg F

megestrol oral suspension 400 mg/10 ml (40 mg/ml) F QL

ORALONE DENTAL PASTE 0.1 % F

oxybutynin chloride oral tablet 5 mg F

oxybutynin chloride oral tablet extended release 24hr 10 mg, 5 mg F QL

oxybutynin chloride oral tablet extended release 24hr 15 mg F

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG F

SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42)

F

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG F

sodium chloride inhalation solution for nebulization 0.9 %, 10 %, 3 % F

tamsulosin oral capsule,extended release 24hr 0.4 mg F

tolterodine oral capsule,extended release 24hr 2 mg F QL

tolterodine oral capsule,extended release 24hr 4 mg F

tolterodine oral tablet 1 mg F QL

tolterodine oral tablet 2 mg F

Vitaminas

calcitriol oral capsule 0.25 mcg, 0.5 mcg F

chewable-vite oral tablet,chewable F

children's chewable oral tablet,chewable F

child's vitamin with iron oral tablet,chewable F

cholecalciferol (vitamin d3) oral capsule 10,000 unit, 5,000 unit, 50,000 unit F

cholecalciferol (vitamin d3) oral drops 400 unit/ml F

cholecalciferol (vitamin d3) oral tablet 2,000 unit F

cholecalciferol (vitamin d3) oral tablet,chewable 400 unit F

47


Nivel de Marca

Requisitos/Límites

COMPLETE MULTIVITAMIN ORAL TABLET F

complete senior oral tablet F

cyanocobalamin (vitamin b-12) injection solution 1,000 mcg/ml F

cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg F

DAILY VITAMIN WITH IRON AND CA ORAL TABLET F

ergocalciferol (vitamin d2) oral capsule 50,000 unit F

ergocalciferol (vitamin d2) oral tablet 400 unit F

folic acid oral tablet 1 mg, 400 mcg F

full spectrum b-vitamin c oral tablet 0.8 mg F QL

MEPHYTON ORAL TABLET 5 MG F

multi-day plus minerals oral tablet 18 mg iron-400 mcg-25 mcg F

multi-vit with fluoride-iron oral drops 0.25mg fluoride -10 mg iron/ml F

multi-vitamin with fluoride oral drops 0.25 mg/ml, 0.5 mg/ml F

MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 1 MG

F

MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG

F

multivitamin with iron oral tablet F

multivitamin with minerals oral tablet F

MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG

F

MULTI-VITAMINS WITH IRON ORAL TABLET,CHEWABLE F

NIACIN FLUSH FREE ORAL CAPSULE 400 MG NIACIN (500 MG) F

niacin oral capsule, extended release 250 mg, 500 mg F

niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg F

niacin oral tablet extended release 500 mg F

poly-vi-sol oral drops 750-35-400 unit-mg-unit/ml F

pyridoxine (vitamin b6) injection solution 100 mg/ml F

rena-vite rx oral tablet 1-60-300 mg-mg-mcg F QL

super multiple oral tablet F

THERA M PLUS (FERROUS FUMARAT) ORAL TABLET 9 MG IRON-400 MCG

F

THERA ORAL TABLET F

48


Nivel de Marca

Requisitos/Límites

THERAPEUTIC-M VITAMIN/MINERALS ORAL TABLET 27-0.4 MG F

THEREMS-M ORAL TABLET 27-0.4 MG F

thiamine mononitrate (vit b1) oral tablet 100 mg F

TRI-VIT WITH FLUORIDE AND IRON ORAL DROPS 0.25-10 MG/ML F

TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

F

VITAMIN B-1 ORAL TABLET 100 MG, 250 MG, 50 MG F

vitamin b-12 oral tablet 1,000 mcg F

VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG F

VITAMIN D3 ORAL CAPSULE 1,000 UNIT, 2,000 UNIT, 4,000 UNIT, 400 UNIT

F

VITAMIN D3 ORAL TABLET 1,000 UNIT, 400 UNIT, 5,000 UNIT F

VITAMINS AND MINERALS ORAL TABLET F

WOMEN'S DAILY FORMULA ORAL TABLET 27-0.4 MG F

49

Índice

3 3 DAY VAGINAL ............... 11 A ABREVA ............................. 17 acarbose ................................ 13 acetaminophen ........................ 2 acetaminophen-codeine .......... 2 acetazolamide ....................... 30 acetic acid ............................. 31 acetylcysteine ......................... 4 acne medication .................... 42 ACNE MEDICATION ......... 42 ACTHIB (PF) ....................... 18 acyclovir ............................... 17 ADACEL(TDAP

ADOLESN/ADULT)(PF) 18 ADRENALIN....................... 18 ADULT ROBITUSSIN PEAK

COLD M-S ....................... 29 ADVANCED ANTACID-

ANTIGAS ........................ 34 AEROCHAMBER PLUS

FLOW-VU ....................... 39 AFINITOR ........................... 15 AFLURIA 2017-2018 .......... 18 AFLURIA 2017-2018 (PF) .. 18 AFLURIA QUAD 2017-2018

.......................................... 18 AFLURIA QUAD 2017-2018

(PF) ................................... 18 ALAVERT D-12 ALLERGY-

SINUS .............................. 12 albuterol sulfate ...................... 5 ALCOHOL PREP PADS ..... 42 ALDACTAZIDE .................. 30 alendronate ..................... 45, 46 allergy eye (naphazoline-phen)

.......................................... 31 allergy relief(chlorphen-acet)

.......................................... 29 allopurinol .............................. 4 alogliptin .............................. 13 alogliptin-metformin ............ 13 ALOMIDE ........................... 31 alprazolam ............................ 40 amino acids 15 % ................. 33 amiodarone ........................... 22

amitriptyline ......................... 40 AMLACTIN ......................... 42 amlodipine ............................ 22 amlodipine-benazepril .......... 23 ammonium lactate ................ 42 amoxicillin .............................. 6 amoxicillin-pot clavulanate .... 6 ampicillin ................................ 6 ampicillin-sulbactam .............. 6 anagrelide ............................. 17 anastrozole ............................ 15 ANTACID MAXIMUM

STRENGTH ..................... 34 anti-dandruff with menthol ... 42 ANTI-DIARRHEAL

(LOPERAMIDE) .............. 34 antifungal (tolnaftate) ........... 11 APIDRA ............................... 13 APIDRA SOLOSTAR ......... 13 aprepitant .............................. 34 aqua care ............................... 42 ARMOUR THYROID ......... 45 ARTIFICIAL

TEARS(DEXT70-HYPRO) .......................................... 31

ARTIFICIAL TEARS(PVALCH-POVID) .......................................... 31

ASMANEX TWISTHALER .. 5 aspirin ............................... 2, 17 atenolol ................................. 23 atenolol-chlorthalidone ......... 23 ATHLETE'S FOOT

(TERBINAFINE) ............. 11 atomoxetine .......................... 40 atorvastatin ........................... 24 atovaquone ............................ 15 atropine ................................. 31 ATROVENT HFA ................. 5 AUGMENTIN ........................ 6 AVASTIN ............................ 15 AYR SALINE ...................... 31 azathioprine .......................... 39 azelastine .............................. 31 azithromycin ........................... 6 AZURETTE (28) .................. 27

B bacitracin ................................ 6 bacitracin zinc ......................... 7 bacitracin-polymyxin b ........... 7 baclofen ................................ 39 bactroban nasal ....................... 7 balsalazide ............................ 34 BALZIVA (28) ..................... 27 BASAGLAR KWIKPEN ..... 13 BCG VACCINE, LIVE (PF) 19 bd insulin pen needle uf orig 39 bd insulin pen needle uf short

.......................................... 39 bd sharps collector ................ 39 BENADRYL ALLERGY ..... 12 benazepril ............................. 24 benazepril-hydrochlorothiazide

.......................................... 24 benzonatate ........................... 29 benzoyl peroxide .................. 42 BETA-HC ............................. 42 betamethasone dipropionate . 42 betamethasone valerate ......... 42 betamethasone, augmented ... 42 betaxolol ............................... 31 bethanechol chloride ............. 18 BETIMOL ............................ 31 bexarotene ............................. 15 BEXSERO ............................ 19 BIO-S-PRES DX .................. 29 BIOTHRAX ......................... 19 bisacodyl ............................... 34 BISMUTH MAXIMUM

STRENGTH ..................... 34 BLEPHAMIDE ...................... 7 BLEPHAMIDE S.O.P. ........... 7 BOOSTRIX TDAP ............... 19 brimonidine ........................... 31 BROMFED DM ................... 29 bromocriptine ....................... 17 BROTAPP DM ..................... 29 BUCALSEP ............................ 3 budesonide .............................. 5 bumetanide ........................... 30 bupropion hcl ........................ 40 bupropion hcl (smoking deter)

.......................................... 45

50

buspirone .............................. 40 butalbital-acetaminophen-caff 2 butalbital-aspirin-caffeine ...... 2 C calamine ............................... 42 calamine-zinc oxide.............. 42 calcitonin (salmon) ............... 38 calcitriol ................................ 46 CALCIUM 600 .................... 33 calcium acetate ..................... 33 calcium carbonate ........... 33, 35 calcium gluconate ................. 33 calcium lactate ...................... 33 CAMRESE ........................... 27 CAPITAL WITH CODEINE . 2 captopril ................................ 24 CARAFATE ......................... 35 carbamazepine ...................... 25 carbamoxide ear drops ......... 31 CARBATROL ...................... 25 carbidopa-levodopa .............. 17 carbidopa-levodopa-

entacapone ........................ 17 CARNITOR (SUGAR-FREE)

.......................................... 46 carvedilol .............................. 24 CAYA CONTOURED ......... 27 CAZIANT (28) ..................... 27 cefaclor ................................... 7 cefazolin ................................. 7 cefdinir ................................... 7 cefixime .................................. 7 ceftazidime ............................. 7 ceftibuten ................................ 7 ceftriaxone .............................. 7 cephalexin............................... 7 cetirizine ............................... 12 cetirizine-pseudoephedrine ... 12 CHANTIX ............................ 45 CHANTIX CONTINUING

MONTH BOX .................. 45 CHANTIX STARTING

MONTH BOX .................. 45 CHELATED ZINC .............. 33 CHEMET ............................. 46 CHEMSTRIP K ................... 30 chewable-vite ....................... 46 CHILD MUCINEX STUFFY

NOSE-COLD ................... 29

children's chewable .............. 46 CHILDREN'S CLARITIN ... 13 CHILDREN'S NON-ASPIRIN

............................................ 2 CHILDREN'S WAL-DRYL

ALLERGY ....................... 13 child's vitamin with iron ....... 46 chlorhexidine gluconate ....... 46 chloroquine phosphate .......... 15 chlorothiazide ....................... 30 chlorpheniramine maleate .... 13 chlorthalidone ....................... 30 cholecalciferol (vitamin d3) . 46 cholestyramine (with sugar) . 24 CHOLESTYRAMINE LIGHT

.......................................... 24 choline,magnesium salicylate . 2 cilostazol ............................... 17 CILOXAN .............................. 7 cimetidine ............................. 35 cimetidine hcl ....................... 35 CIPRO HC .............................. 7 CIPRODEX ............................ 7 ciprofloxacin ........................... 7 ciprofloxacin (mixture) ........... 7 ciprofloxacin hcl ..................... 7 citalopram ............................. 40 CITRUCEL .......................... 35 clarithromycin ........................ 7 clearasil daily clear(benzoyl) 42 clindamycin hcl ...................... 7 clindamycin palmitate hcl ...... 8 clindamycin phosphate ........... 8 clobetasol .............................. 42 clobetasol-emollient ............. 42 clonazepam ........................... 25 clonidine ............................... 24 clonidine hcl ................... 24, 40 clopidogrel ............................ 17 CLOPIDOGREL .................. 17 clotrimazole .......................... 11 clotrimazole-betamethasone . 11 colchicine ................................ 4 COMBIVENT RESPIMAT ... 5 COMPLETE

MULTIVITAMIN ............ 47 complete senior ..................... 47 CONCEPTROL .................... 27

CONDOMS-PREM LUBRICATED ................. 27

CONDYLOX ........................ 42 CORTIFOAM ....................... 38 CORTISPORIN ...................... 8 COTELLIC ........................... 15 COUMADIN ........................ 10 CREON ................................. 35 cromolyn ........................... 5, 31 cyanocobalamin (vitamin b-12)

.......................................... 47 cyclobenzaprine .................... 39 CYCLOGYL ........................ 31 cyclopentolate ....................... 31 cycloserine .............................. 8 cyclosporine modified .......... 39 cyproheptadine ..................... 13 CYRAMZA .......................... 15 CYTOMEL ........................... 45 D DAILY VITAMIN WITH

IRON AND CA ................ 47 dapsone ................................... 8 DAPTACEL (DTAP

PEDIATRIC) (PF) ............ 19 DARZALEX ......................... 15 DEPAKENE ......................... 25 DEPAKOTE ......................... 25 DEPAKOTE ER ................... 25 DEPAKOTE SPRINKLES ... 25 DEPO-PROVERA ................ 38 desipramine ........................... 40 DESITIN ............................... 42 desmopressin ........................ 38 desonide ................................ 42 dexamethasone ..................... 38 DEXAMETHASONE

INTENSOL ....................... 38 dexamethasone sodium

phosphate .......................... 31 dexmethylphenidate .............. 40 dextroamphetamine .............. 18 dextroamphetamine-

amphetamine ..................... 18 dextrose 5 % in water (d5w) . 33 DIABETIC TUSSIN DM ..... 29 diazepam ............................... 26 DIASTIX .............................. 30 diazepam ............................... 40

51

DICLEGIS ............................ 35 diclofenac potassium .............. 2 diclofenac sodium ...... 4, 31, 43 dicloxacillin ............................ 8 dicyclomine .......................... 35 digoxin .................................. 22 dihydroergotamine ................. 3 DILANTIN ........................... 26 DILANTIN EXTENDED .... 26 DILANTIN INFATABS ...... 26 DILANTIN-125 ................... 26 DILATRATE-SR ................. 22 diltiazem hcl ................... 22, 23 DILT-XR .............................. 23 DIMETAPP COLD-

ALLERGY (PE) ............... 12 DIMETAPP DM COLD-

COUGH (PE) ................... 29 diphenhydramine hcl ............ 13 diphenoxylate-atropine ......... 35 disulfiram ............................. 46 DIURIL ................................ 30 divalproex ............................. 26 docusate sodium ................... 35 donepezil .............................. 18 DONNATAL ........................ 35 dorzolamide .......................... 31 dorzolamide-timolol ............. 31 double antibiotic (b.tracn zn) . 8 doxazosin .............................. 24 doxepin ................................. 40 doxorubicin........................... 15 doxycycline hyclate ................ 8 doxycycline monohydrate ...... 8 DRITHOCREME HP ........... 43 drospirenone-e.estradiol-lm.fa

.......................................... 27 duloxetine ............................. 40 DYRENIUM ........................ 30 E E.E.S. 400 ............................... 8 econazole .............................. 11 ed chlorped jr ........................ 13 EFFER-K .............................. 33 ELIQUIS .............................. 10 ELLA .................................... 27 ELMIRON .............................. 3 emoquette ............................. 27 EMPLICITI .......................... 15

enalapril maleate ................... 24 enema .................................... 35 ENGERIX-B (PF) ................ 19 ENGERIX-B PEDIATRIC

(PF) ................................... 19 enoxaparin ............................ 11 entacapone ............................ 17 ENULOSE ............................ 35 epinephrine ........................... 18 EPOGEN .............................. 27 ergocalciferol (vitamin d2) ... 47 ergotamine-caffeine ................ 3 ERYPED 400 ......................... 8 ery-tab ..................................... 8 ERY-TAB ............................... 8 erythromycin .......................... 8 erythromycin ethylsuccinate ... 8 erythromycin stearate ............. 8 erythromycin with ethanol ...... 8 erythromycin-benzoyl peroxide

............................................ 8 escitalopram oxalate ............. 40 ESTRACE ............................ 38 estradiol ................................ 38 estrogens-methyltestosterone 38 ethacrynic acid ...................... 30 ethambutol .............................. 8 ethosuximide ........................ 26 etodolac .................................. 4 etoposide ............................... 16 EURAX ................................ 43 EXPECTORANT ................. 29 EYE ALLERGY RELIEF .... 31 F famciclovir ............................ 17 famotidine ............................. 35 farydak .................................. 16 FARYDAK ........................... 16 fc2 female condom ............... 27 felodipine .............................. 23 fenofibrate ............................ 24 fenofibrate micronized ......... 24 fenofibrate nanocrystallized . 24 fenofibric acid (choline) ....... 24 fentanyl ................................... 3 ferrous sulfate ....................... 33 FERROUSUL ....................... 33 FEVERALL ............................ 3

fiber (calcium polycarbophil) .......................................... 35

fiber (psyllium husk/sugar) ... 35 FIBER (PSYLLIUM

HUSK/SUGAR) ............... 35 finasteride ............................. 46 FLANDERS BUTTOCKS ... 43 FLAREX ............................... 31 FLOVENT DISKUS .............. 5 FLOVENT HFA ..................... 5 FLUAD 2017-2018 (65 YR

UP)(PF) ............................. 19 FLUBLOK 2017-2018 (PF) . 19 FLUBLOK QUAD 2017-2018

(PF) ................................... 19 FLUCELVAX QUAD 2017-

2018 .................................. 19 FLUCELVAX QUAD 2017-

2018 (PF) .......................... 19 fluconazole ........................... 11 flucytosine ............................ 11 fludrocortisone ...................... 38 FLULAVAL QUAD 2017-

2018 .................................. 19 FLULAVAL QUAD 2017-

2018 (PF) .......................... 19 fluocinolone .......................... 43 fluocinonide .......................... 43 FLUOCINONIDE-E ............. 43 FLUOR-A-DAY ................... 33 fluoride (sodium) .................. 33 FLUORITAB ........................ 33 fluorometholone ................... 31 FLUOROPLEX .................... 16 fluorouracil ........................... 16 fluoxetine ........................ 40, 41 flutamide ............................... 16 fluticasone ....................... 32, 43 fluticasone-salmeterol ............. 5 FLUVIRIN 2017-2018 ......... 19 FLUVIRIN 2017-2018 (PF) . 19 FLUZONE HIGH-DOSE

2017-18 (PF) ..................... 19 FLUZONE INTRADERM

QUAD 2017-18 ................ 20 FLUZONE QUAD 2017-2018

(PF) ................................... 20 FLUZONE QUAD PEDI

2017-18 (PF) ..................... 20

52

FML FORTE ........................ 32 foaming antacid .................... 35 folic acid ............................... 47 for sty relief .......................... 32 full spectrum b-vitamin c ..... 47 furosemide ............................ 30 G gabapentin ............................ 26 galantamine .......................... 18 GARDASIL 9 (PF) .............. 20 GAVILYTE-G ..................... 35 GAVISCON ......................... 35 gemfibrozil ........................... 24 GENTAK ............................... 8 gentamicin .......................... 8, 9 GENTEAL MILD ................ 32 GERI-HYDROLAC ............. 43 GIANVI (28) ........................ 27 glimepiride ........................... 13 glipizide .......................... 13, 14 glipizide-metformin .............. 14 GLUCAGEN DIAGNOSTIC

KIT ................................... 30 GLUCAGEN HYPOKIT ..... 34 GLUCAGON EMERGENCY

KIT (HUMAN) ................ 34 glucose .................................. 34 glyburide............................... 14 glyburide-metformin ............ 14 glycerin (adult) ..................... 35 glycerin (child) ..................... 35 GRANIX .............................. 27 griseofulvin microsize .......... 11 griseofulvin ultramicrosize ... 11 guaifenesin ........................... 29 GUAIFENESIN AC ............. 29 guanfacine ...................... 24, 41 GYNOL II ............................ 27 H HALAVEN........................... 16 HAVRIX (PF) ...................... 20 HEPAGAM B ...................... 20 HERCEPTIN ........................ 16 HIBICLENS ......................... 43 HOMATROPAIRE .............. 32 HUMALOG ......................... 14 HUMALOG KWIKPEN ...... 14 HUMALOG MIX 50-50 ...... 14

HUMALOG MIX 50-50 KWIKPEN ........................ 14

HUMALOG MIX 75-25 ...... 14 HUMALOG MIX 75-25

KWIKPEN ........................ 14 HUMULIN 70/30 ................. 14 HUMULIN 70/30 KWIKPEN

.......................................... 14 HUMULIN N ....................... 14 HUMULIN N KWIKPEN .... 14 HUMULIN R U-100 ............ 14 HUMULIN R U-500

(CONCENTRATED) ....... 14 hydralazine ........................... 24 hydrochlorothiazide ........ 30, 31 hydrocodone-acetaminophen .. 3 hydrocodone-homatropine .... 29 hydrocortisone ................ 38, 43 HYDROCORTISONE ......... 43 hydrocortisone acetate .... 35, 43 HYDROCORTISONE

ACETATE ........................ 43 HYDROCORTISONE PLUS

.......................................... 43 hydroxychloroquine .............. 15 hydroxyurea .......................... 16 hydroxyzine hcl .................... 13 hydroxyzine pamoate ........... 13 HYPERHEP B S/D .............. 20 HYPERHEP B S-D

NEONATAL .................... 20 HYPERRAB S/D (PF) ......... 20 HYPERTET S/D (PF) .......... 20 I ibuprofen ................................ 4 ifosfamide ............................. 16 imipramine hcl ...................... 41 imiquimod ............................ 43 IMOVAX RABIES VACCINE

(PF) ................................... 20 INCRUSE ELLIPTA .............. 5 indapamide ........................... 31 indomethacin .......................... 4 INFANRIX (DTAP) (PF) ..... 20 infant's non-aspirin ................. 3 INVOKAMET ...................... 14 INVOKAMET XR ............... 14 INVOKANA ........................ 14 IPOL ..................................... 20

ipratropium bromide ............... 5 ipratropium-albuterol .............. 5 irbesartan .............................. 24 IRESSA ................................ 16 irinotecan .............................. 16 isometh-dichloral-

acetaminophn ...................... 3 isoniazid .................................. 9 ISOPTO TEARS .................. 32 ISORDIL .............................. 23 isosorbide dinitrate ............... 23 isosorbide mononitrate ......... 23 IXIARO (PF) ........................ 20 J JANUMET ........................... 14 JANUMET XR ..................... 14 JANUVIA ............................. 14 JINTELI ................................ 38 JUNEL FE 1.5/30 (28) ......... 27 JUNEL FE 1/20 (28) ............ 27 K KADCYLA ........................... 16 KADIAN ................................ 3 ketoconazole ......................... 11 KETO-DIASTIX .................. 30 ketorolac ........................... 3, 32 KINRIX (PF) ........................ 20 kionex (with sorbitol) ........... 34 konsyl (sugar) ....................... 36 L l norgest/e.estradiol-e.estrad . 27 labetalol ................................ 24 lactated ringers ...................... 34 lactulose ................................ 36 lamotrigine ............................ 26 LANOXIN ............................ 23 lansoprazole .......................... 36 LANTUS .............................. 15 LANTUS SOLOSTAR ......... 14 LARTRUVO ........................ 16 latanoprost ............................ 32 LAXATIVE (BISACODYL)36 LEENA 28 ............................ 27 leflunomide ............................. 4 leucovorin calcium ............... 46 LEUKERAN ......................... 16 levalbuterol hcl ....................... 5 levetiracetam ......................... 26 levobunolol ........................... 32

53

levocarnitine ......................... 46 levofloxacin ............................ 9 levofloxacin in d5w ................ 9 levonorgestrel-ethinyl estrad 27 LEVORA-28 ........................ 27 LEVO-T ............................... 45 levothyroxine ........................ 45 LEVOXYL ........................... 45 LICE KILLING .................... 43 lidocaine ................................. 4 LIDOCAINE VISCOUS ........ 4 lidocaine-prilocaine ................ 4 liothyronine .......................... 45 lisinopril ............................... 24 lisinopril-hydrochlorothiazide

.......................................... 24 LOHIST - D ......................... 12 loperamide ............................ 36 LOPERAMIDE .................... 36 loratadine .............................. 13 LORATADINE-D ................ 12 lorazepam ............................. 41 losartan ................................. 24 losartan-hydrochlorothiazide 24 lovastatin .............................. 24 LOW-OGESTREL (28) ....... 27 lubricant eye ......................... 32 LUBRICANT EYE .............. 32 lubricant eye drops ............... 32 lubricant eye drops (glyc-pg) 32 M magnesium citrate ................ 36 magnesium oxide.................. 34 malathion .............................. 43 MATULANE ....................... 16 MAXIDEX ........................... 32 meclizine .............................. 36 MEDI-FIRST ANTI-FUNGAL

.......................................... 11 medroxyprogesterone ..... 27, 38 megestrol ........................ 16, 46 meloxicam .............................. 4 memantine ............................ 26 MENACTRA (PF) ............... 20 MENEST .............................. 38 MENHIBRIX (PF) ............... 21 MENOMUNE - A/C/Y/W-135

.......................................... 21

MENOMUNE - A/C/Y/W-135 (PF) ................................... 21

MENVEO A-C-Y-W-135-DIP (PF) ................................... 21

MEPHYTON ........................ 47 mercaptopurine ..................... 16 MESTINON ......................... 18 MESTINON TIMESPAN .... 18 METAMUCIL ...................... 36 metaproterenol ........................ 5 metformin ............................. 15 methenamine mandelate ......... 9 methergine ............................ 38 methimazole ......................... 45 methocarbamol ..................... 39 methotrexate sodium ............ 16 methotrexate sodium (pf) ..... 16 methyldopa ........................... 24 methyldopa-

hydrochlorothiazide .......... 24 methylphenidate hcl ............. 41 methylprednisolone .............. 38 metipranolol .......................... 32 metoclopramide hcl .............. 36 metoprolol succinate ............. 25 metoprolol tartrate ................ 25 metronidazole ............. 9, 43, 44 metronidazole in nacl (iso-os) 9 mexiletine ............................. 23 miconazole nitrate ................ 11 MICONAZOLE-3 .......... 11, 12 MICROGESTIN 1.5/30 (21) 28 MICROGESTIN 1/20 (21) ... 28 midodrine .............................. 18 MIGERGOT ........................... 3 MIGRAINE FORMULA ....... 3 MILK OF MAGNESIA ........ 36 MILK OF MAGNESIA

CONCENTRATED .......... 36 MILLIPRED ......................... 38 MILLIPRED DP ................... 38 minocycline ............................ 9 minoxidil .............................. 25 MINTOX PLUS ................... 36 mirtazapine ........................... 41 misoprostol ........................... 36 M-M-R II (PF) ...................... 21 mometasone .......................... 44 MONONESSA (28) ............. 28

montelukast ............................. 5 morphine ................................. 3 morphine concentrate ............. 3 MUCINEX ........................... 29 MUCINEX COUGH MINI-

MELTS ............................. 29 MUCINEX D ........................ 29 MUCINEX D MAXIMUM

STRENGTH ..................... 29 mucus dm .............................. 29 mucus relief cough ............... 29 multi-day plus minerals ........ 47 MULTISTIX 10 SG ............. 30 multi-vit with fluoride-iron ... 47 multi-vitamin with fluoride .. 47 MULTIVITAMIN WITH

FLUORIDE ...................... 47 MULTI-VITAMIN WITH

FLUORIDE ...................... 47 multivitamin with iron .......... 47 multivitamin with minerals ... 47 MULTIVITAMINS WITH

FLUORIDE ...................... 47 MULTI-VITAMINS WITH

IRON ................................ 47 mupirocin ................................ 9 mupirocin calcium .................. 9 MURO 128 ........................... 32 my way ................................. 28 mycophenolate mofetil ......... 39 MYLERAN .......................... 16 N NABI-HB ............................. 21 nabumetone ............................. 4 naproxen ................................. 4 naproxen sodium .................... 4 NASACORT ......................... 32 NASAL SPRAY EXTRA

MOISTURIZING ............. 32 NATACYN ........................... 12 NATURAL FIBER

LAXATIVE THERAPY .. 36 natural psyllium fiber ........... 36 NEBUPENT ......................... 15 NECON 0.5/35 (28) .............. 28 NECON 1/50 (28) ................. 28 NECON 7/7/7 (28) ............... 28 nefazodone ............................ 41 neomycin ................................ 9

54

neomycin-bacitracin-polymyxin .......................... 9

neomycin-polymyxin b gu ... 44 neomycin-polymyxin b-

dexameth ............................ 9 neomycin-polymyxin-

gramicidin........................... 9 neomycin-polymyxin-hc ........ 9 NEO-TUSS .......................... 29 NEXIUM 24HR ................... 36 niacin .............................. 25, 47 NIACIN FLUSH FREE ....... 47 NIACOR .............................. 25 nicotine ................................. 45 nicotine (polacrilex) ............. 45 NICOTROL .......................... 45 NICOTROL NS ................... 45 nifedipine .............................. 23 NIGHTTIME SLEEP AID

(DIPHEN)......................... 41 NITRO-BID ......................... 23 nitrofurantoin .......................... 9 nitrofurantoin macrocrystal .... 9 nitrofurantoin monohyd/m-

cryst .................................... 9 nitroglycerin ......................... 23 nohist-dm .............................. 29 non-aspirin jr strength ............ 3 noreth-ethinyl estradiol-iron . 28 norethindrone (contraceptive)

.......................................... 28 norethindrone-e.estradiol-iron

.......................................... 28 norgestimate-ethinyl estradiol

.......................................... 28 nortemp................................... 3 nortrel 1/35 (28) ................... 28 nortriptyline .......................... 41 NOVOLIN 70/30 ................. 15 NOVOLIN N ........................ 15 NOVOLIN R ........................ 15 NOVOLOG .......................... 15 NOVOLOG FLEXPEN ....... 15 NOVOLOG MIX 70-30 ....... 15 NOVOLOG MIX 70-30

FLEXPEN ........................ 15 NOVOLOG PENFILL ......... 15 np thyroid ............................. 45 NUTRILIPID ....................... 36

NUTRISOURCE FIBER ...... 36 NUVARING ......................... 28 nystatin ................................. 12 nystatin-triamcinolone .......... 12 NYSTOP .............................. 12 O O-CAL FA ............................ 39 OCELLA .............................. 28 ODOMZO ............................ 16 ofloxacin ................................. 9 OGESTREL (28) .................. 28 olopatadine ........................... 13 omeprazole ........................... 36 ondansetron .......................... 36 ondansetron hcl ..................... 36 ONETOUCH VERIO ........... 30 ONETOUCH VERIO MID

CONTROL ....................... 39 OPDIVO ............................... 16 ORALONE ........................... 46 oseltamivir ............................ 17 oxcarbazepine ....................... 26 oxybutynin chloride .............. 46 oxycodone-acetaminophen ..... 3 oxycodone-aspirin .................. 3 P pantoprazole ......................... 36 paromomycin ........................ 15 paroxetine hcl ....................... 41 PCE ......................................... 9 peak air peak flow meter ...... 39 PEDIA RELIEF COUGH-

COLD ............................... 30 PEDIA-LAX STOOL

SOFTENER ...................... 36 PEDIARIX (PF) ................... 21 PEDIATRIC ELECTROLYTE

.......................................... 34 PEDIATRIC ENEMA .......... 36 PEDVAX HIB (PF) .............. 21 peg 3350-electrolytes ........... 37 penicillin g potassium ........... 10 penicillin g sodium ............... 10 penicillin v potassium ........... 10 PENTACEL (PF) ................. 21 PENTACEL DTAP-IPV

COMPNT (PF) ................. 21 pentoxifylline ........................ 22 permethrin ............................ 44

phenazopyridine ..................... 4 phenobarbital ........................ 41 phenohytro ............................ 37 PHENYLEPHRINE HCL .... 32 phenytoin .............................. 26 phenytoin sodium extended .. 26 pilocarpine hcl ...................... 32 pink bismuth ......................... 37 PINK BISMUTH .................. 37 pioglitazone .......................... 15 piroxicam ................................ 4 PNEUMOVAX 23 ................ 21 pnv 29-1 ................................ 39 pnv cmb#95-ferrous fumarate-

fa ....................................... 39 podofilox ............................... 44 polyethylene glycol 3350 ..... 37 polymyxin b sulf-trimethoprim

.......................................... 10 polyvinyl alcohol .................. 32 poly-vi-sol ............................. 47 potassium chlorid-d5-

0.45%nacl ......................... 34 potassium chloride ................ 34 povidone-iodine .................... 44 pramipexole .......................... 17 pravastatin ............................. 25 prazosin ................................. 25 PRED MILD ......................... 32 prednicarbate ........................ 44 prednisolone ......................... 38 prednisolone acetate ............. 32 prednisolone sodium phosphate

.................................... 32, 38 prednisone ....................... 38, 39 PREDNISONE INTENSOL . 38 PREMARIN ......................... 39 PREMPHASE ....................... 39 PREMPRO ........................... 39 prenatal complete .................. 39 PRENATAL LOW IRON .... 40 prenatal plus .......................... 40 PRENATAL PLUS

(CALCIUM CARB) ......... 40 PRENATAL VITAMIN ....... 40 PRENATAL VITAMIN WITH

MINERALS ...................... 40 prenatal vits96-iron fum-folic

.......................................... 40

55

PRETAB .............................. 40 PREVACID 24HR ............... 37 PREVNAR 13 (PF) .............. 21 PRILOSEC OTC .................. 37 primaquine ............................ 15 primidone ............................. 26 PRIMSOL ............................ 10 probenecid .............................. 4 probenecid-colchicine ............ 4 prochlorperazine ................... 37 prochlorperazine edisylate.... 37 prochlorperazine maleate ..... 37 PROCTOFOAM HC ............ 37 PROCTO-PAK ..................... 44 promethazine .................. 13, 37 PROMETHAZINE VC ........ 12 PROMETHAZINE VC-

CODEINE ........................ 30 promethazine-codeine .......... 30 promethazine-dm .................. 30 PROMETHEGAN ................ 37 propafenone .......................... 23 proparacaine ......................... 32 propranolol ........................... 25 propylthiouracil .................... 45 PROQUAD (PF) .................. 21 pseudoephedrine hcl ............. 30 PULMICORT FLEXHALER 5 PURE AND GENTLE EYE . 32 pyrazinamide ........................ 10 pyridostigmine bromide ....... 18 pyridoxine (vitamin b6) ........ 47 Q QUASENSE ......................... 28 quinidine gluconate .............. 23 QVAR .................................... 5 R RABAVERT (PF) ................ 21 rabeprazole ........................... 37 ranitidine hcl ......................... 37 RECOMBIVAX HB (PF) .... 21 REESE'S PINWORM

MEDICINE ...................... 15 REFRESH LACRI-LUBE ... 32 REFRESH P.M. ................... 32 RENAGEL ........................... 34 rena-vite rx ........................... 47 RID COMPLETE LICE ELIM

KIT ................................... 44

RIDAURA .............................. 4 rifabutin ................................ 10 RIFAMATE .......................... 10 rifampin ................................ 10 riluzole .................................. 26 RITIFED ............................... 12 rivastigmine tartrate .............. 18 rivelsa ................................... 28 rizatriptan ................................ 3 ROBITUSSIN PEDIATRIC . 30 ropinirole .............................. 17 ROTARIX ............................ 21 ROTATEQ VACCINE ......... 21 RYNEX PSE ........................ 12 S saline nasal ........................... 32 salsalate .................................. 4 SAVELLA ............................ 46 SCALPICIN ANTI-ITCH .... 44 scopolamine base .................. 37 SCOT-TUSSIN DM ............. 30 SCOT-TUSSIN SENIOR ..... 30 selegiline hcl ......................... 17 selenium sulfide .................... 44 SELSUN BLUE ................... 44 SENNA ................................. 37 SENNA LAX ....................... 37 SENNA PLUS ...................... 37 SENSIPAR ........................... 46 SEREVENT DISKUS ............ 6 sertraline ............................... 41 sevelamer carbonate ............. 34 sf 5000 plus .......................... 34 silver sulfadiazine ................. 10 simethicone ........................... 37 SIMETHICONE ................... 37 simvastatin ............................ 25 sodium bicarbonate ............... 37 sodium chloride ........ 32, 33, 46 sodium chloride 0.9 % .......... 34 sodium citrate-citric acid ...... 34 sodium polystyrene sulfonate

.......................................... 34 sotalol ................................... 25 spironolactone ...................... 31 spironolacton-hydrochlorothiaz

.......................................... 31 SRONYX .............................. 28 SSKI ..................................... 34

STAMARIL (PF) .................. 21 STERILE SALINE ............... 44 STIOLTO RESPIMAT ........... 6 stool softener ........................ 37 sucralfate ............................... 37 sulfacetamide sodium ........... 10 sulfacetamide-prednisolone .. 10 sulfadiazine ........................... 10 sulfamethoxazole-trimethoprim

.......................................... 10 sulfasalazine ......................... 37 sulindac ................................... 4 sumatriptan succinate ............. 3 super multiple ....................... 47 SUPHEDRIN ........................ 30 SYLATRON ......................... 16 SYNTHROID ....................... 45 SYSTANE NIGHTTIME ..... 33 T TABLOID ............................. 16 TAMIFLU ............................ 17 tamoxifen .............................. 16 tamsulosin ............................. 46 TAZTIA XT ......................... 23 tears again ............................. 33 TEARS NATURALE FORTE

.......................................... 33 TEGRETOL ......................... 26 TEGRETOL XR ................... 26 temazepam ............................ 41 TENIVAC (PF) .................... 22 terazosin ................................ 25 terbinafine hcl ....................... 12 terbutaline ............................... 6 terconazole ............................ 12 testosterone cypionate .......... 39 tetanus,diphtheria tox ped(pf)

.......................................... 22 TETANUS-DIPHTHERIA

TOXOIDS-TD .................. 22 tetracycline ........................... 10 THEO-24 ................................ 6 theophylline ............................ 6 THERA ................................. 47 THERA M PLUS (FERROUS

FUMARAT) ..................... 47 THERAPEUTIC-M

VITAMIN/MINERALS ... 48 THEREMS-M ....................... 48

56

thiamine mononitrate (vit b1) .......................................... 48

TILIA FE .............................. 28 timolol maleate ..................... 33 tizanidine .............................. 39 TOBRADEX ........................ 10 tobramycin ............................ 10 tobramycin-dexamethasone .. 10 TOBREX .............................. 10 tolnaftate ............................... 12 tolterodine............................. 46 topiramate ............................. 26 tramadol .................................. 3 trazodone .............................. 41 tretinoin ................................ 44 tretinoin (chemotherapy) ...... 16 triamcinolone acetonide ....... 44 triamterene-hydrochlorothiazid

.......................................... 31 trianex ................................... 44 triazolam ............................... 41 trifluridine............................. 17 TRILYTE WITH FLAVOR

PACKETS ........................ 37 trimethobenzamide ............... 37 trimethoprim ......................... 10 TRINESSA (28) ................... 28 TRIPLE ANTIBIOTIC ........ 10 TRIPLE ANTIBIOTIC

(PRAM) EXTRA ............. 10 TRI-VIT WITH FLUORIDE

AND IRON ...................... 48 TRI-VITAMIN WITH

FLUORIDE ...................... 48 TRIVORA (28) .................... 28 tropicamide ........................... 33 TRUMENBA ....................... 22 TUDORZA PRESSAIR ......... 6 TUSSIN DM ........................ 30 TWINRIX (PF) .................... 22

TYPHIM VI ......................... 22 U ULESFIA .............................. 44 UNITHROID ........................ 45 ursodiol ........................... 37, 38 V VAGINAL

CONTRACEPTIVE FILM .......................................... 28

VAGINAL CONTRACEPTIVE FOAM .......................................... 28

valacyclovir .......................... 17 valproic acid ......................... 27 valproic acid (as sodium salt)

.......................................... 26 valsartan ................................ 25 valsartan-hydrochlorothiazide

.......................................... 25 VAQTA (PF) ........................ 22 VARIVAX (PF) ................... 22 VARIZIG .............................. 22 VENCLEXTA ...................... 16 venlafaxine ........................... 41 VENTOLIN HFA ................... 6 verapamil .............................. 23 VIGAMOX ........................... 10 vinate m ................................ 40 vinblastine ............................ 16 VITAMIN B-1 ...................... 48 vitamin b-12 ......................... 48 VITAMIN B-6 ...................... 48 VITAMIN D3 ....................... 48 VITAMINS AND MINERALS

.......................................... 48 VIVOTIF BERNA VACCINE

.......................................... 22 W WAL-ACT D COLD AND

ALLERGY ....................... 12

WAL-PHED ......................... 12 warfarin ................................. 11 wart remover ......................... 44 WART REMOVER .............. 44 WIDE-SEAL DIAPHRAGM

60 ...................................... 28 WIDE-SEAL DIAPHRAGM







95 ...................................... 29 WOMEN'S DAILY

FORMULA ....................... 48 X XARELTO ........................... 11 xulane ................................... 29 Y YERVOY ............................. 16 YF-VAX (PF) ....................... 22 Z ZADITOR ............................. 13 ZALTRAP ............................ 17 ZARXIO ............................... 27 ZENCHENT FE ................... 29 zinc gluconate ....................... 34 zinc oxide .............................. 44 zolpidem ............................... 41 zonisamide ............................ 27 ZOSTAVAX (PF) ................ 22 ZOVIA 1/35E (28) ............... 29 ZOVIA 1/50E (28) ............... 29

Lista de Medicamentos Cubiertos/media/Pharmacy/Formulary/2017-Formularies/... · 2 IEHP Medi-Cal...

Documents

Transcript of Lista de Medicamentos Cubiertos/media/Pharmacy/Formulary/2017-Formularies/... · 2 IEHP Medi-Cal...