Programa de Farmacia de Triple-S Salud, Inc. TRIPLE-S SALUD, INC. Pharmacy Program from Triple-S Salud, Inc. TRIPLE-S SALUD, INC.
Lista de Medicamentos o Formulario Comercial 2018 Drug List or Formulary Commercial 2018
Rev. Agosto / August 2017 TSS-PROD-0436-2017-A/ TSS-PROD-0436-2017-B
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TABLA DE CONTENIDO / TABLE OF CONTENTS INTRODUCCIÓN / INTRODUCTION ...................................................................................... 15 PARTE I - DISEÑO DE LA LISTA DE MEDICAMENTOS / PART I- DRUG LIST DESIGN ... 17 ¿Cómo usar esta lista de medicamentos? / How do I use the drug list? ........................................... 17 ¿Cuánto pagas por los medicamentos cubiertos? / How much will you pay for covered drugs? ....... 17 ¿Qué son medicamentos genéricos preferidos (nivel 1)? / What are preferred generic drugs (level 1)? .......................................................................................................................................... 17 ¿Qué son medicamentos genéricos no preferidos (nivel 2)? / What are non-preferred generic drugs (level 2)? .......................................................................................................................................... 18 ¿Qué son medicamentos de marca preferidos (nivel 3)? / What are preferred brand drugs (level 3)? ......................................................................................................................................................... 18 ¿Qué son medicamentos de marca no preferidos (nivel 4)? / What are non-preferred brand drugs (level 4)? .......................................................................................................................................... 18 ¿Qué son productos especializados preferidos (nivel 5)? / What are preferred specialty products (level 5)? .......................................................................................................................................... 19 ¿Qué son productos especializados no preferidos (nivel 6)? / What are non-preferred specialty products (level 6)? ............................................................................................................................ 19 Guías de Referencia / Reference Guidelines.................................................................................... 19 Éditos de análisis de utilización (DUR) / Drug utilization review (DUR)............................................. 21 Leyenda para Símbolos y Abreviaturas / Legend for Symbols and Abbreviations ............................ 23 Derechos Reservados / Reserved Rights ......................................................................................... 24
PARTE II – MEDICAMENTOS POR CLASE TERAPEUTICA – SALUD FÍSICA / PART II DRUGS BY THERAPEUTIC CLASSIFICATION – PHYSICAL HEALTH ............................... 25 SALUD FISICA / PHYSICAL HEALTH ................................................................................... 25 Analgesics (Analgésicos) ..................................................................................................... 25 Nonsteroidal Anti-Inflammatory Drugs (Anti-Inflamatorios No Esteroidales) ..................................... 25 Opioid Analgesics, Long-Acting (Analgésicos Opiodes, Larga Duración) ......................................... 26 Opioid Analgesics, Short-Acting (Analgésicos Opiodes, Corta Duración) ......................................... 26 Others (Otros) .................................................................................................................................. 28
Anesthetics (Anestésicos) .................................................................................................... 28 Local Anesthetics (Anestésico Local) ............................................................................................... 28
Anti-Addiction/Substance Abuse Treatment Agents (Tratamiento de Abuso de Sustancias/Contra la Addición) ............................................................................................ 28
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Opioid Reversal Agents (Antagonista de Opioides) .......................................................................... 28 Smoke Deterrentes (Agentes para Cesación de Fumar) .................................................................. 28
Antibacterials (Antibacterianos) .......................................................................................... 29 Aminoglycosides (Aminoglicósidos) ................................................................................................. 29 Antibacterials, Other (Antibacterianos, Otros)................................................................................... 29 Beta-Lactam, Cephalosporins (Cefalosporinas, Beta-Lactámicas) ................................................... 30 Beta-Lactam, Other (Beta-Lactámicos, Otros) .................................................................................. 31 Beta-Lactam, Penicillins (Penicilinas, Beta-Lactámicas)................................................................... 31 Macrolides (Macrólidos) ................................................................................................................... 32 Quinolones (Quinolonas) .................................................................................................................. 33 Sulfonamides (Sulfonamidas) ........................................................................................................... 34 Tetracyclines (Tetraciclinas) ............................................................................................................. 34
Anticonvulsants (Anticonvulsivantes)................................................................................. 34 Anticonvulsants, Other (Anticonvulsivantes, Otros) .......................................................................... 34 Calcium Channel Modifying Agents (Modificadores de Canales de Calcio) ...................................... 34 Gamma-Aminobutyric Acid (GABA) Augmenting Agents (Agentes Amplificadores del Acido GamaAminobutirato) .................................................................................................................................. 35 Glutamate Reducing Agents (Reductores de Glutamato) ................................................................. 36 Sodium Channel Agents (Canales de Sodio) ................................................................................... 36
Antidementia Agents (Antidemencia) .................................................................................. 37 Antidementia Agents, Other (Antidemencia, Otros) .......................................................................... 37 Cholinesterase Inhibitors (Inhibidores de Colinesterasa) .................................................................. 37 Combinations, Other (Combinación, Otros) ...................................................................................... 37 N-Methyl-D-Aspartate (NMDA) Receptor Antagonist (Antagonista del Receptor NMDA) .................. 37
Antidepressants (Antidepresivos) ....................................................................................... 38 Antidepressants, Other (Antidepresivos, Otros)................................................................................ 38 Monoamine Oxidase B (MAO-B) Inhibitors (Inhibidores de Monoamina Oxidasa B) ......................... 38 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) (Inhibidores de la Recaptación de Serotonina/ Norepinefrina (SSRIs/SNRIs)) ................. 38 Tricyclics (Tricíclicos) ....................................................................................................................... 39
Antiemetics (Antieméticos) .................................................................................................. 39 Antiemetics, Other (Antieméticos, Otros).......................................................................................... 39 Emetogenic Therapy Adjuncts (Adjuvantes Para Terapia Emetogénica) .......................................... 40
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Antifungals (Antifungales) .................................................................................................... 40 Antifungals (Antifungales) ................................................................................................................ 40
Antigout Agents (Antigota) ................................................................................................... 41 Antigout Agents (Antigota) ............................................................................................................... 41
Anti-Inflammatory Agents (Anti-Inflamatorios) ................................................................... 41 Glucocorticoids (Glucocorticoides) ................................................................................................... 41
Antimigraine Agents (Antimigraña) ..................................................................................... 42 Ergot Alkaloids (Alcaloides de Ergotamina) ...................................................................................... 42 Serotonin (5-HT) 1B/1D Receptor Agonists (Agonistas del Receptor de Serotonina) ....................... 42
Antimyasthenic Agents (Antimiasténicos) .......................................................................... 43 Parasympathomimetics (Parasimpatomiméticos) ............................................................................. 43
Antimycobacterials (Antimicobacterianos) ......................................................................... 43 Antimycobacterials, Other (Antimicobacterianos, Otros) ................................................................... 43 Antituberculars (Antituberculosos) .................................................................................................... 43
Antineoplastics (Antineoplásicos) ....................................................................................... 43 Alkylating Agents (Agentes Alquilantes) ........................................................................................... 43 Antiandrogens (Antiandrógenos) ...................................................................................................... 44 Antiangiogenic Agents (Antiangiogénicos) ....................................................................................... 44 Antiestrogens/Modifiers (Antiestrógenos/Modificadores) .................................................................. 44 Antimetabolites (Antimetabolitos) ..................................................................................................... 44 Antineoplastics, Others (Antineoplásicos, Otros) .............................................................................. 44 Aromatase Inhibitors, 3rd Generation (Inhibidores de Aromatasa, 3ra Generación) ......................... 45 Enzyme Inhibitors (Inhibidores Enzimáticos) .................................................................................... 45 Molecular Target Inhibitors (Inhibidores del Objetivo Molecular) ...................................................... 45 Monoclonal Antibodies (Anticuerpos Monoclonales)......................................................................... 46 Retinoids (Retinoides) ...................................................................................................................... 46
Antiparasitics (Antiparasitarios) .......................................................................................... 46 Anthelmintics (Antihelmínticos) ........................................................................................................ 46 Antiprotozoals (Antiprotozoarios)...................................................................................................... 47 Pediculicides/Scabicides (Pediculicidas/Escabicidas) ...................................................................... 47
Antiparkinson Agents (Antiparkinson) ................................................................................ 48 Anticholinergics (Anticolinérgicos) .................................................................................................... 48 Antiparkinson Agents, Others (Antiparkinson, Otros)........................................................................ 48
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Dopamine Agonist (Agonistas de Dopamina) ................................................................................... 48 Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors (Precursores de Dopamina/Inhibidores de la L-Aminoácido Decarboxilasa) .................................................................................................. 48 Monoamine Oxidase B (MAO-B) Inhibitors (Inhibidores De Monoamina Oxidasa B) ........................ 49
Antipsychotics (Antipsicóticos) ........................................................................................... 49 1st Generation/Typical (1ra Generación/Típicos) ............................................................................. 49
Antispasticity (Antiespasticidad) ......................................................................................... 49 Antispasticity (Antiespasticidad) ....................................................................................................... 49
Antivirals (Antivirales)........................................................................................................... 49 Anti-Cytomegalovirus (CMV) (Anti-Citomegalovirus) ........................................................................ 49 Antihepatitis Agents (Antihepatitis) ................................................................................................... 50 Antihepatitis B (HBV) Agents (Anti-Hepatitis B (HBV)) ..................................................................... 50 Antihepatitis C (HCV) Agents (Anti-Hepatitis C (HCV)) ..................................................................... 50 Antiherpetic Agents (Antiherpéticos) ................................................................................................ 50 Anti-HIV Adjuvants (Anti-VIH, Adjuvantes) ....................................................................................... 50 Anti-HIV Agents, Integrase Inhibitors (INSTI) (Anti-VIH, Inhibidores de la Integrasa (INSTI)) ........... 50 Anti-HIV Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Anti-VIH, Inhibidores No Nucleósidos de la Transciptasa Reversa) ........................................................................................ 51 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (Anti-VIH, Inhibidores Nucleósidos y Nucleótidos de la Transcriptasa Reversa) ................................................................. 51 Anti-HIV Agents, Others (Anti-VIH, Otros) ........................................................................................ 52 Anti-HIV Agents, Protease Inhibitors (Anti-VIH, Inhibidores de la Proteasa) ..................................... 52 Anti-Influenza Agents (Anti-Influenza) .............................................................................................. 53 Antiretroviral Combinations (Combinaciones Antiretrovirales) .......................................................... 53
Anxiolytics (Ansiolíticos) ...................................................................................................... 54 Anxiolytics, Other (Ansiolíticos, Otros) ............................................................................................. 54 Benzodiazepines (Benzodiazepinas) ................................................................................................ 54
Bipolar Agents (Bipolaridad) ................................................................................................ 54 Mood Stabilizers (Estabilizadores Del Ánimo) .................................................................................. 54
Blood Glucose Regulators (Reguladores de Glucosa en Sangre) .................................... 54 Antidiabetic Agents (Antidiabéticos) ................................................................................................. 54 Glycemic Agents (Glicémicos) .......................................................................................................... 56 Insulins (Insulinas) ........................................................................................................................... 56
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Blood Products/Modifiers/Volume Expanders (Productos para la Sangre/Modificadores/Expansores de Volumen) ............................................................... 57 Anticoagulants (Anticoagulantes) ..................................................................................................... 57 Antihemophilics (Antihemofílicos) ..................................................................................................... 57 Blood Formation Modifiers (Modificadores de la Formación de Sangre) ........................................... 60 Coagulants (Coagulantes) ................................................................................................................ 61 Platelet Modifying Agents (Modificadores de Plaquetas) .................................................................. 61
Cardiovascular Agents (Cardiovasculares) ........................................................................ 61 Alpha-Adrenergic Agonists (Agonistas Alfa Adrenérgicos) ............................................................... 61 Alpha-Adrenergic Blocking Agents (Bloqueadores Alfa Adrenérgicos) ............................................. 61 Angiotensin II Receptor Antagonists (Antagonistas del Receptor Angiotensina II) ............................ 61 Angiotensin-Converting Enzyme (ACE) Inhibitors (Inhibidores de la Enzima Convertidora de Angiotensina) ................................................................................................................................... 62 Antiarrhythmics (Antiarrítmicos) ....................................................................................................... 63 Beta-Adrenergic Blocking Agents (Bloqueadores Beta Adrenérgicos) .............................................. 63 Calcium Channel Blocking Agents (Bloqueadores de Canales de Calcio) ........................................ 64 Cardiovascular Agents, Other (Cardiovasculares, Otros) ................................................................. 65 Combinations, Other (Combinación, Otros) ...................................................................................... 65 Diuretics, Carbonic Anhydrase Inhibitors (Diuréticos Inhibidores de Anhidrasa Carbónica) .............. 65 Diuretics, Loop (Diuréticos del Asa) ................................................................................................. 65 Diuretics, Potassium-Sparing (Diuréticos Conservadores de Potasio) .............................................. 66 Diuretics, Thiazide (Diuréticos Tiazidas)........................................................................................... 66 Dyslipidemics, Fibric Acid Derivatives (Dislipidémicos, Derivados de Ácido Fíbrico) ........................ 66 Dyslipidemics, HMG-CoA Reductase Inhibitors (Dislipidémicos, Inhibidores de la Reductasa de HMG-CoA) ....................................................................................................................................... 67 Dyslipidemics, Other (Dislipidémicos, Otros) .................................................................................... 67 Vasodilators, Direct-Acting Arterial (Vasodilatadores, Arteriales)...................................................... 67 Vasodilators, Direct-Acting Arterial/Venous (Vasodilatadores, Arteriales/Venosos) .......................... 68
Central Nervous System Agents (Sistema Nervioso Central) ........................................... 68 Attention Deficit Hyperactivity Disorder Agents, Amphetamines (Anfetaminas, ADHD) .................... 68 Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines (No-Anfetaminas, ADHD) ....... 68 Central Nervous System Agents, Others (Sistema Nervioso Central, Otros) .................................... 69 Multiple Sclerosis Agents (Esclerosis Múltiple) ................................................................................. 69
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Dental and Oral Agents (Dentales y Orales) ........................................................................ 70 Dental and Oral Agents (Dentales y Orales) ..................................................................................... 70
Dermatological Agents (Dermatológicos) ........................................................................... 70 Acne Agents (Acné) ......................................................................................................................... 71 Antibacterials (Antibacterianos) ........................................................................................................ 71 Antifungals (Antifungales) ................................................................................................................ 71 Caustic Agents (Caústicos) .............................................................................................................. 72 Dermatological Calcineurin Inhibitor Immunosuppresants (Inhibidores de Calcineurina) .................. 72 Dermatological Emollients (Emolientes) ........................................................................................... 72 Mitotic Inhibitors (Inhibidores de la Mitosis) ...................................................................................... 72 Non-Melanoma Skin Cancer Agents (Cáncer de la Piel No-Meloma) ............................................... 72 Photochemotherapy Agents (Fotoquimioterapia).............................................................................. 72 Psoriasis Agents (Psoriasis) ............................................................................................................. 72 Wart Agents (Verrugas) .................................................................................................................... 73 Wound-Care Agents (Cuidado de Heridas) ...................................................................................... 73
Enzyme Replacements/Modifiers (Reemplazo de Enzimas/Modificadores) ..................... 73 Anti-Cystine Agents (Anti-Cistina) .................................................................................................... 73 Fabry Disease (Enfermedad de Fabry)............................................................................................. 73 Gaucher's Disease Treatment (Enfermedad de Gaucher) ................................................................ 73 Glucosylceramide Synthase Inhibitors (Inhibidores de la Sintetasa de Glucosilceramida) ................ 73 Homocystinuria Treatment (Homocistinuria) ..................................................................................... 73 Hunter Syndrome Treatment (Síndrome de Hunter) ......................................................................... 73 Mucopolysaccharidosis Disease Treatment (Mucopolisacaridosis) .................................................. 74 Phenylketonuria Treatment (Fenilcetonuria) ..................................................................................... 74 Severe Combined Immunodeficiency Disease (SCID) Treatment (Inmunodeficiencia Combinada Severa) ............................................................................................................................................ 74 Tyrosinemia Treatment (Tirosinemia) ............................................................................................... 74 Urea Cycle Disorder Treatment (Desorden del Ciclo de Urea) ......................................................... 74
Gastrointestinal Agents (Gastrointestinales) ...................................................................... 74 Antispasmodics, Gastrointestinal (Antiespasmódicos, Gastrointestinales) ....................................... 74 Enzyme Replacement (Remplazo Enzimático) ................................................................................. 74 Gastrointestinal Agents, Others (Gastrointestinales, Otros).............................................................. 75 Histamine2 (H2) Receptor Antagonists (Antagonistas del Receptor de Histamina2 (H2)) ................ 75
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Irritable Bowel Syndrome Agents (Síndrome de Colon Irritado) ........................................................ 75 Laxatives (Laxantes) ........................................................................................................................ 76 Miscellaneous (Misceláneos) ........................................................................................................... 76 Protectants (Protectores) ................................................................................................................. 76 Proton Pump Inhibitors (Inhibidores de la Bomba de Protones) ....................................................... 76
Genitourinary Agents (Genitourinarios) .............................................................................. 77 Antispasmodics, Urinary (Antiespasmódicos, Urinarios) ................................................................... 77 Benign Prostatic Hypertrophy Agents (Hipertrofia Prostática Benigna) ............................................. 77 Genitourinary Agents, Others (Genitourinarios, Otros) ..................................................................... 77 Phosphate Binders (Enlazadores de Fosfato) .................................................................................. 78
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) (Hormonales, Estimulante/Reemplazo/Modificador (Adrenal)) ................................................................. 78 Glucocorticoids / Mineralocorticoids (Glucocorticoides/Mineralocorticoides) .................................... 78
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) (Hormonales, Estimulante/Reemplazo/Modificador (Pituitaria)) ............................................................... 80 Vasopressin Analogs (Análogos de Vasopresina) ............................................................................ 80
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) (Hormonales, Estimulante/Reemplazo/Modificador (Hormonas Sexuales/Modificadores)) ................................................................................................................................................ 81 Anabolic Steroid (Esteroide Anabólico) ............................................................................................ 81 Androgens (Andrógenos) ................................................................................................................. 81 Estrogens (Estrógenos) .................................................................................................................... 81 Progestins (Progestinas) .................................................................................................................. 82 Selective Estrogen Receptor Modifying Agents (Modificadores Selectivos del Receptor de Estrógeno) ....................................................................................................................................... 82
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) (Hormonales, Estimulante/Reemplazo/Modificador (Tiroide)) ................................................................... 82 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) (Hormonales, Estimulante/Reemplazo/Modificador (Tiroide)) ................................................................................. 82
Hormonal Agents, Suppressant (Adrenal) (Hormonales, Supresores (Adrenal)) ............ 82 Hormonal Agents, Suppressant (Adrenal) (Hormonales, Supresores (Adrenal)) .............................. 82
Hormonal Agents, Suppressant (Parathyroid) (Hormonales, Supresores (Paratiroide)) 83 Hormonal Agents, Suppressant (Parathyroid) (Hormonales, Supresores (Paratiroide)) .................... 83
Hormonal Agents, Suppressant (Pituitary) (Hormonales, Supresores (Pituitaria)) ......... 83 Hormonal Agents, Suppressant (Pituitary) (Hormonales, Supresores (Pituitaria)) ............................ 83
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Hormonal Agents, Suppressant (Thyroid) (Hormonales, Supresores (Tiroide)) .............. 83 Antithyroid Agents (Antitiroide) ......................................................................................................... 83
Immunological Agents (Inmunológicos) ............................................................................. 83 Angioedema Agents (Agentes para el Tratamiento de Angioedema) ............................................... 83 Immune Suppressants (Supresores Inmunológicos) ........................................................................ 84 Immunomodulators (Inmunomoduladores) ....................................................................................... 85
Inflammatory Bowel Disease Agents (Enfermedad Inflamatoria Intestinal) ..................... 85 Aminosalicylates (Aminosalicilatos) .................................................................................................. 85 Glucocorticoids (Glucocorticoides) ................................................................................................... 86 Sulfonamides (Sulfonamidas) ........................................................................................................... 86
Metabolic Bone Disease Agents (Enfermedad del Metabolismo del Hueso) ................... 86 Metabolic Bone Disease Agents (Enfermedad del Metabolismo del Hueso) ..................................... 86
Ophthalmic Agents (Oftálmicos) .......................................................................................... 86 Anti-Allergy Agents (Antialérgicos) ................................................................................................... 87 Antibacterials (Antibacterianos) ........................................................................................................ 87 Antiglaucoma Agents (Antiglaucoma) ............................................................................................... 88 Anti-Inflammatories (Anti-Inflamatorios)............................................................................................ 88 Ophthalmic Agents, Others (Oftálmicos, Otros) ................................................................................ 89 Prostaglandins and Prostamides (Prostaglandinas y Prostamidas) .................................................. 89
Otic Agents (Oticos) .............................................................................................................. 89 Anti-Inflammatories (Anti-Inflamatorios)............................................................................................ 89 Antibacterials (Antibacterianos) ........................................................................................................ 89 Otic, Miscellaneous (Óticos, Misceláneos) ....................................................................................... 90
Respiratory Tract/Pulmonary Agents (Tracto Respiratorio) .............................................. 90 Antihistamines (Antihistamínicos) ..................................................................................................... 90 Anti-Inflammatories, Inhaled Corticosteroids (Anti-Inflamatorios, Corticosteroides Inhalados) .......... 91 Antileukotrienes (Antileukotrienos) ................................................................................................... 92 Antitussives (Antitusivos) ................................................................................................................. 93 Bronchodilators, Anticholinergic (Broncodilatadores, Anticolinérgicos) ............................................. 93 Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) (Broncodilatadores, Inhibidores de la Fosfodiesterasa (Xantinas)) ............................................................................................................. 93 Bronchodilators, Sympathomimetic (Broncodilatadores, Simpatomiméticos) .................................... 93 Cystic Fibrosis Agents (Agentes Para Fibrosis Quistica) .................................................................. 94
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Mast Cell Stabilizers (Estabilizadores De Mastocitos) ...................................................................... 94 Phosphodiesterase Inhibitors, Airways Disease (Inhibidores De Fosfodiesterasa) ........................... 94 Pulmonary Antihypertensives (Anti-Hipertensivos Pulmonales) ........................................................ 95 Respiratory Tract Agents, Others (Tracto Respiratorio, Otros) ......................................................... 95
Skeletal Muscle Relaxants (Relajantes Musculoesqueletales) .......................................... 95 Skeletal Muscle Relaxants (Relajantes Musculoesqueletales) ......................................................... 95
Sleep Disorder Agents (Desordenes del Sueño) ................................................................ 95 GABA Receptor Modulators (Moduladores del Receptor de GABA) ................................................. 96 Sleep Disorder, Other (Desórdenes del Sueño, Otros) ..................................................................... 96
Therapeutic Nutrients/Minerals/Electrolytes (Nutrientes Terapéuticos/Minerales/Electrolitos) ................................................................................... 96 Antidotes (Antídotos) ........................................................................................................................ 96 Electrolyte/Mineral Replacement (Remplazo de Electrolitos/Minerales) ........................................... 96 Electrolytes/Minerals Modifiers (Modificadores de Electrolitos/Minerales) ........................................ 98 Prenatal Vitamins (Vitaminas Prenatales) ........................................................................................ 99
PARTE III – MEDICAMENTOS POR CLASE TERAPEUTICA – EMERGENCIA / PART III DRUGS BY THERAPEUTIC CLASSIFICATION – EMERGENCY ....................................... 104 EMERGENCIA / EMERGENCY ............................................................................................ 104 Analgesics (Analgésicos) ................................................................................................... 104 Nonsteroidal Anti-Inflammatory Drugs (Anti-Inflamatorios No Esteroidales) ................................... 104 Opioid Analgesics, Long-Acting (Analgésicos Opiodes, Larga Duración) ....................................... 104 Opioid Analgesics, Short-Acting (Analgésicos Opiodes, Corta Duración) ....................................... 104 Others (Otros) ................................................................................................................................ 104
Anesthetics (Anestésicos) .................................................................................................. 105 Local Anesthetics (Anestésico Local) ............................................................................................. 105
Antibacterials (Antibacterianos) ........................................................................................ 105 Antibacterials, Other (Antibacterianos, Otros)................................................................................. 105 Beta-Lactam, Cephalosporins (Cefalosporinas, Beta-Lactámicas) ................................................. 105 Beta-Lactam, Penicillins (Penicilinas, Beta-Lactámicas)................................................................. 106 Macrolides (Macrólidos) ................................................................................................................. 106 Quinolones (Quinolonas) ................................................................................................................ 107 Sulfonamides (Sulfonamidas) ......................................................................................................... 107 Tetracyclines (Tetraciclinas) ........................................................................................................... 107
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Anticonvulsants (Anticonvulsivantes)............................................................................... 108 Gamma-Aminobutyric Acid (GABA) Augmenting Agents (Agentes Amplificadores del Acido GamaAminobutirato) ................................................................................................................................ 108 Sodium Channel Agents (Canales de Sodio) ................................................................................. 108
Antiemetics (Antieméticos) ................................................................................................ 108 Antiemetics, Other (Antieméticos, Otros)........................................................................................ 108
Antifungals (Antifungales) .................................................................................................. 108 Antifungals (Antifungales) .............................................................................................................. 108
Antigout Agents (Antigota) ................................................................................................. 109 Antigout Agents (Antigota) ............................................................................................................. 109
Anti-Inflammatory Agents (Anti-Inflamatorios) ................................................................. 109 Glucocorticoids (Glucocorticoides) ................................................................................................. 109
Antimycobacterials (Antimicobacterianos) ....................................................................... 109 Antimycobacterials, Other (Antimicobacterianos, Otros) ................................................................. 109
Antiparasitics (Antiparasitarios) ........................................................................................ 109 Antiprotozoals (Antiprotozoarios).................................................................................................... 109
Antipsychotics (Antipsicóticos) ......................................................................................... 109 1st Generation/Typical (1ra Generación/Típicos) ........................................................................... 109
Antivirals (Antivirales)......................................................................................................... 110 Antiherpetic Agents (Antiherpéticos) .............................................................................................. 110 Anti-Influenza Agents (Anti-Influenza) ............................................................................................ 110
Anxiolytics (Ansiolíticos) .................................................................................................... 110 Anxiolytics, Other (Ansiolíticos, Otros) ........................................................................................... 110
Blood Glucose Regulators (Reguladores de Glucosa en Sangre) .................................. 110 Antidiabetic Agents (Antidiabéticos) ............................................................................................... 110 Insulins (Insulinas) ......................................................................................................................... 110
Blood Products/Modifiers/Volume Expanders (Productos para la Sangre/Modificadores/Expansores de Volumen) ............................................................. 110 Anticoagulants (Anticoagulantes) ................................................................................................... 110 Platelet Modifying Agents (Modificadores de Plaquetas) ................................................................ 111
Cardiovascular Agents (Cardiovasculares) ...................................................................... 111 Alpha-Adrenergic Agonists (Agonistas Alfa Adrenérgicos) ............................................................. 111 Angiotensin II Receptor Antagonists (Antagonistas del Receptor Angiotensina II) .......................... 111
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Angiotensin-Converting Enzyme (ACE) Inhibitors (Inhibidores de la Enzima Convertidora de Angiotensina) ................................................................................................................................. 111 Beta-Adrenergic Blocking Agents (Bloqueadores Beta Adrenérgicos) ............................................ 111 Calcium Channel Blocking Agents (Bloqueadores de Canales de Calcio) ...................................... 111 Diuretics, Loop (Diuréticos del Asa) ............................................................................................... 111 Diuretics, Thiazide (Diuréticos Tiazidas)......................................................................................... 112 Vasodilators, Direct-Acting Arterial/Venous (Vasodilatadores, Arteriales/Venosos) ........................ 112
Dermatological Agents (Dermatológicos) ......................................................................... 112 Antibacterials (Antibacterianos) ...................................................................................................... 112
Gastrointestinal Agents (Gastrointestinales) .................................................................... 112 Gastrointestinal Agents, Others (Gastrointestinales, Otros)............................................................ 112 Histamine2 (H2) Receptor Antagonists (Antagonistas del Receptor de Histamina2 (H2)) .............. 112 Proton Pump Inhibitors (Inhibidores de la Bomba de Protones) ..................................................... 112
Genitourinary Agents (Genitourinarios) ............................................................................ 112 Genitourinary Agents, Others (Genitourinarios, Otros) ................................................................... 112
Ophthalmic Agents (Oftálmicos) ........................................................................................ 113 Antibacterials (Antibacterianos) ...................................................................................................... 113
Otic Agents (Óticos) ............................................................................................................ 113 Anti-Inflammatories (Anti-Inflamatorios).......................................................................................... 113 Otic, Miscellaneous (Óticos, Misceláneos) ..................................................................................... 113
Respiratory Tract/Pulmonary Agents (Tracto Respiratorio) ............................................ 113 Antihistamines (Antihistamínicos) ................................................................................................... 113 Antitussives (Antitusivos) ............................................................................................................... 113 Bronchodilators, Anticholinergic (Broncodilatadores, Anticolinérgicos) ........................................... 113 Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) (Broncodilatadores, Inhibidores de la Fosfodiesterasa (Xantinas)) ........................................................................................................... 114 Bronchodilators, Sympathomimetic (Broncodilatadores, Simpatomiméticos) .................................. 114
Skeletal Muscle Relaxants (Relajantes Musculoesqueletales) ........................................ 114 Skeletal Muscle Relaxants (Relajantes Musculoesqueletales) ....................................................... 114
PARTE IV – MEDICAMENTOS POR CLASE TERAPEUTICA – SALUD MENTAL / PART IV - DRUGS BY THERAPEUTIC CLASSIFICATION – MENTAL HEALTH ......................... 115 SALUD MENTAL / MENTAL HEALTH ................................................................................. 115 Anti-Addiction/Substance Abuse Treatment Agents (Tratamiento de Abuso de Sustancias/Contra la Addición) .......................................................................................... 115
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Alcohol Deterrents/Anti-Craving (Disuasivos de Alcohol/Anti-Ansiedad)......................................... 115 Opioid Dependence Treatments (Tratamiento Dependiente de Opiode) ........................................ 115
Anticonvulsants (Anticonvulsivantes)............................................................................... 115 Gamma-Aminobutyric Acid (GABA) Augmenting Agents (Agentes Amplificadores del Acido GamaAminobutirato) ................................................................................................................................ 115 Glutamate Reducing Agents (Reductores de Glutamato) ............................................................... 116 Sodium Channel Agents (Canales de Sodio) ................................................................................. 116
Antidepressants (Antidepresivos) ..................................................................................... 116 Antidepressants, Other (Antidepresivos, Otros).............................................................................. 116 Monoamine Oxidase B (MAO-B) Inhibitors (Inhibidores de Monoamina Oxidasa B) ....................... 117 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) (Inhibidores de la Recaptación de Serotonina/ Norepinefrina (SSRIs/SNRIs)) ............... 117 Tricyclics (Tricíclicos) ..................................................................................................................... 118
Antipsychotics (Antipsicóticos) ......................................................................................... 118 1st Generation/Typical (1ra Generación/Típicos) ........................................................................... 118 2nd Generation/Atypical (2da Generación/Atípicos) ....................................................................... 119 Treatment-Resistant (Resistentes a Tratamiento) .......................................................................... 121
Anxiolytics (Ansiolíticos) .................................................................................................... 121 Anxiolytics, Other (Ansiolíticos, Otros) ........................................................................................... 121 Benzodiazepines (Benzodiazepinas) .............................................................................................. 121
Bipolar Agents (Bipolaridad) .............................................................................................. 121 Mood Stabilizers (Estabilizadores del Ánimo) ................................................................................. 121
Sleep Disorder Agents (Desordenes del Sueño) .............................................................. 122 GABA Receptor Modulators (Moduladores del Receptor de GABA) ............................................... 122
PARTE V – MEDICAMENTOS POR CLASE TERAPEUTICA – DENTAL / PART V - DRUGS BY THERAPEUTIC CLASSIFICATION – DENTAL .............................................................. 123 DENTAL ................................................................................................................................ 123 Analgesics (Analgésicos) ................................................................................................... 123 Nonsteroidal Anti-Inflammatory Drugs (Anti-Inflamatorios No Esteroidales) ................................... 123 Opioid Analgesics, Short-Acting (Analgésicos Opiodes, Corta Duración) ....................................... 123
Antibacterials (Antibacterianos) ........................................................................................ 124 Aminoglycosides (Aminoglicósidos) ............................................................................................... 124 Antibacterials, Other (Antibacterianos, Otros)................................................................................. 124 Beta-Lactam, Cephalosporins (Cefalosporinas, Beta-Lactámicas) ................................................. 124
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Beta-Lactam, Penicillins (Penicilinas, Beta-Lactámicas)................................................................. 125 Macrolides (Macrólidos) ................................................................................................................. 126 Quinolones (Quinolonas) ................................................................................................................ 126 Sulfonamides (Sulfonamidas) ......................................................................................................... 126 Tetracyclines (Tetraciclinas) ........................................................................................................... 126
PARTE VI – APÉNDICES / PART VI – APPENDIXES ......................................................... 127 Apéndice I - Quimioterapias Orales / Appendix I – Oral Chemotherapies ....................................... 127 Apéndice II – Límites de Especialidad (LE) / Appendix II- Specialty Limits (SL) ............................. 131 Apéndice III – Terapias Escalonadas (TE) / Appendix III - Step Therapies (ST) ............................. 134 Apéndice IV – Lista de Contraceptivos / Appendix IV - Contraceptives .......................................... 136 Apéndice V – Solicitud de Excepción Médica / Appendix V - Medical Exception Application .......... 138
PARTE VII – ÍNDICE / PART VII – INDEX ............................................................................ 139
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INTRODUCCIÓN / INTRODUCTION Tú cubierta de farmacia utiliza una lista de medicamentos o formulario que te ofrece una selección amplia de opciones de tratamiento. Your pharmacy coverage uses a Drug List or Formulary that offers you a wide selection of treatment options. Los medicamentos en esta lista de medicamentos o formulario han sido seleccionados por su seguridad, efectividad en el tratamiento de condiciones de salud y su costo. Dicha lista consiste de medicamentos con leyenda aprobados por la Administración de Drogas y Alimentos (FDA, por sus siglas en inglés) que están disponibles en el mercado y algunos medicamentos sin leyenda federal (OTC, por sus siglas en inglés), para las clasificaciones que se incluyen. The medications in this drug list or formulary have been selected based on their safety, cost, and effectiveness to treat health conditions. This list features prescription drugs that have been approved by the Food and Drug Administration (FDA) and are available in the market, as well as certain over-the-counter drugs (OTC) under the included categories. En las páginas a continuación presentamos toda la información requerida para facilitarte la lectura e interpretación. The following pages include all the information you will need to help you read and interpret the List. Te exhortamos a que evalúes con tu médico los medicamentos disponibles para tratar tu condición. Nuestra lista tiene una diversidad de medicamentos por condición, los cuales incluyen genéricos y de marca preferidos. Si utilizas estos medicamentos contribuyes a mantener los costos del beneficio de farmacia en un nivel razonable y tus copagos serán menores. We urge you to talk with your doctor and evaluate the medications available to treat your condition. Our List contains a variety of medications classified by condition, including generic and preferred brand drugs. If you use these drugs, you will be helping keep the pharmacy benefit costs at a reasonable level, and your co-payments will also be lower. Este documento presenta la forma en que se diseñó la lista de medicamentos, así como una descripción de los éditos para verificar dosis y terapias duplicadas. Se muestran los medicamentos por clasificación terapéutica, los de salud mental, dentales, los apéndices y una lista por orden alfabético (Índice) de los medicamentos disponibles en esta lista. This document shows how the Drug List was designed, as well as a description of the edits to review dosages and duplicate therapies. The drugs are listed by categories: therapeutic, mental health, dental, etc. This document also includes appendixes and an alphabetical list (index) of the drugs available in the List.
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La inclusión de un medicamento a la lista no quiere decir que está cubierto. La cubierta de farmacia es la que establece si está cubierto o no en la póliza. Por ejemplo, los agentes para la disfunción eréctil, las hormonas de crecimiento y los medicamentos sin leyenda federal (OTC) usualmente están excluidos de la cubierta de farmacia. If we feature a drug in the Drug List, it does not mean that the drug is covered. The prescription drug coverage decides whether the drug will be covered by the plan. For example, drugs to treat erectile dysfunction, growth hormones, and over-the-counter drugs (OTC) are not normally covered by the drug plans. Para una copia de la lista de medicamentos, preguntas o ayuda, llama a nuestro Centro de Llamadas al (787) 774-6060 o libre de cargos al 1-800-981-3241. Los usuarios del sistema TTY/TDD deben llamar al (787) 792-1370 o libre de cargos al 1-866-215-1999. El horario de servicio es de lunes a viernes, de 7:30 a.m. a 8:00 p.m., sábados de 9:00 a.m. a 6:00 p.m. y domingos de 11:00 a.m. a 5:00 p.m. (AST, Tiempo Estándar del Atlántico). If you need a copy of the Prescription Drug List, have questions, or need help, contact our Call Center at (787) 774-6060, or toll free at 1-800-981-3241. TTY/TDD users should call (787) 792-1370, or toll free at 1-866-215-1999. Our business hours are: Monday through Friday, from 7:30 a.m. to 8:00 p.m., Saturdays from 9:00 a.m. to 6:00 p.m., and Sundays from 11:00 a.m. to 5:00 p.m. (AST, Atlantic Standard Time).
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PARTE I - DISEÑO DE LA LISTA DE MEDICAMENTOS / PART I- DRUG LIST DESIGN ¿Cómo usar esta lista de medicamentos? / How do I use the drug list? La forma más fácil para conseguir los medicamentos es buscando en el índice. El índice provee una lista por orden alfabético de todos los medicamentos que se presentan en este documento, tanto los de marca como los genéricos. Al lado del medicamento está el número de la página donde encontrarás cómo está cubierto. Voltea a la página indicada en el índice y encuentra el nombre del medicamento en las columnas. The easiest way to find the drugs is through the Index. The Index gives you an alphabetical list of all the drugs in this document, both brand name and generic drugs. Next to the drug, you will see the page number where you can find the coverage information. Turn to the page listed in the Index to find the name of the drug listed in the columns.
¿Cuánto pagas por los medicamentos cubiertos? / How much will you pay for covered drugs? Los medicamentos se clasifican por niveles. Los niveles a continuación identifican los distintos niveles de costo compartido, o sea, lo que pagas por los medicamentos en la receta. • • • • • •
Nivel 1 –medicamentos genéricos preferidos Nivel 2 –medicamentos genéricos no preferidos Nivel 3 –medicamentos de marca preferidos Nivel 4 –medicamentos de marca no preferidos Nivel 5 –productos especializados preferidos Nivel 6 –productos especializados no preferidos
The Drug List is arranged by levels. These levels, listed below, point out the cost-sharing levels, which is what you pay for prescribed drugs. • • • • • •
Level 1 – preferred generic drugs Level 2 – non-preferred generic drugs Level 3 – preferred brand drugs Level 4 – non-preferred brand drugs Level 5 – preferred specialty products Level 6 – non-preferred specialty products
¿Qué son medicamentos genéricos preferidos (nivel 1)? / What are preferred generic drugs (level 1)? Un medicamento genérico tiene el mismo ingrediente activo en la fórmula que el de marca. Usualmente cuestan menos que los de marca y están aprobados por la Administración Federal de Drogas y Alimentos (FDA, por sus siglas en inglés). A generic drug has the same ingredient in identical amount as the brand name drug. They cost less than brand name drugs and are approved by the Food and Drug Administration (FDA).
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Este nivel incluye genéricos que han sido seleccionados por el Comité de Farmacia y Terapéutica como agentes preferidos luego de su evaluación de seguridad, eficacia y costo. This level includes generic drugs selected by the Pharmacy and Therapeutics Committee as preferred agents, after evaluating their safety, efficiency, and cost. Éstos están escritos en letras negrillas minúsculas (ejemplo, nabumetone). Generic drugs are listed in lowercase bold (e.g., nabumetone) in the Drug List.
¿Qué son medicamentos genéricos no preferidos (nivel 2)? / What are non-preferred generic drugs (level 2)? Este nivel incluye medicamentos genéricos de mayor costo que los del nivel 1. Están clasificados como no preferidos porque existen alternativas en el nivel anterior con menos efectos secundarios o que son más costoefectivos. Estos están escritos en letras negrillas minúsculas. This level includes generic drugs at higher costs than those in level 1. They are classified as non-preferred because the previous level includes alternatives that have fewer side effects or are more cost-effective. These are written out in bold, lowercase font.
¿Qué son medicamentos de marca preferidos (nivel 3)? / What are preferred brand drugs (level 3)? Este nivel incluye medicamentos de marca que han sido seleccionados por el Comité de Farmacia y Terapéutica como agentes preferidos luego de su evaluación de seguridad, eficacia y costo. Los mismos están identificados a la derecha como nivel 3. En aquellas clases terapéuticas donde no hay genéricos, te exhortamos a que uses como primera alternativa aquellos identificados como preferidos. This tier has brand name drugs that have been classified by the Pharmacy and Therapeutics Committee as preferred agents, after an in-depth review in terms of safety, efficiency, and cost. These are identified as level 3 next to the name of the drug. For therapeutic classes where there are no generic drugs, we suggest you use the preferred drugs as your first choice.
¿Qué son medicamentos de marca no preferidos (nivel 4)? / What are non-preferred brand drugs (level 4)? Un medicamento es clasificado como marca no preferido porque existen alternativas en los niveles anteriores con menos efectos secundarios o son más costo-efectivos. Si el asegurado obtiene un medicamento de marca del nivel 4, tiene que pagar un costo mayor. A brand name drug is classified as non-preferred when there are other choices in other drug levels that have fewer side effects and/or are more cost effective. If you obtain a level 4 drug, you will have to pay more for that drug.
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¿Qué son productos especializados preferidos (nivel 5)? / What are preferred specialty products (level 5)? Los medicamentos especializados requieren una administración o manejo especial, por su composición compleja. Estos se usan para tratar condiciones crónicas y de alto riesgo que requieren un manejo especial de la condición. Specialty Drugs need special administration and/or management due to their complex composition. These are used to treat high-risk and chronic health conditions that need special management. El nivel 5 presenta los medicamentos o productos en la lista que se ofrecen bajo el Programa de Medicamentos para Condiciones Especiales. Dichos medicamentos o productos incluyen genéricos, biosimilares (genéricos de productos biológicos) y de marca a un costo menor que el nivel 6 y un arreglo especial para su despacho. Level 5 features the drugs or products in the Drug List that are offered under the Special Conditions Drugs Program. This tier has generic, biosimilar (generic biologics), and brand name drugs at a lower cost than those in level 6, and it grants special provisions for its supply.
¿Qué son productos especializados no preferidos (nivel 6)? / What are non-preferred specialty products (level 6)? Los medicamentos en este nivel 6 también tienen un arreglo especial para su despacho, pero tienen un costo mayor que los del nivel 5. Éstos se usan para el tratamiento de condiciones crónicas y de alto riesgo que requieren una administración y manejo especial. The drugs in level 6 also require special handling for supply, but have higher copay when compared to level 5 drugs. These are used to treat chronic and high-risk health conditions that need special handling and administration.
Guías de Referencia / Reference Guidelines Medicamentos que requieren preautorización (PA) / Medications that require preauthorization (PA) En un esfuerzo por garantizar la seguridad y el uso apropiado de los medicamentos, algunos necesitan una preautorización para ser adquiridos. Los mismos se han identificado a la derecha con PA (requiere preautorización), en cuyo caso, la farmacia gestiona la preautorización previo al despacho del medicamento. To guarantee the safe and effective use of drugs, there are certain drugs that need a preauthorization (PA) before dispensing it. A PA is placed next to the name of the drug to identify them, and the pharmacy will process the preauthorization before dispensing it. Los medicamentos que requieren preautorización usualmente son candidatos al uso inapropiado o están
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relacionados con un costo elevado por lo que requieren que el asegurado cumpla con unos criterios antes de ser despachados. Aquellos medicamentos que han sido identificados que requieren preautorización deben satisfacer los criterios clínicos establecidos según lo haya determinado el Comité de Farmacia y Terapéutica. Estos criterios clínicos se han desarrollado de acuerdo a la literatura médica actual. The drugs that need preauthorization are those for which you need to meet certain criteria before using them, are likely to be used inadequately, or have a higher cost. Drugs identified as needing preauthorization should fulfill the clinical criteria, as determined by the Pharmacy and Therapeutics Committee. The criteria have been developed as stated by current medical literature. También, tienen requisito de PA aquellos medicamentos cuyos costos excedan $500.00 (verifica tu certificado de beneficio ya que esta cantidad puede ser diferente). La farmacia enviará copia de la receta y se encargarán del proceso. Drugs whose cost goes beyond $500.00 will require a preauthorization (check your health plan benefits, as this amount could be different). The pharmacy will send a copy of the prescription to the health plan and will take care of the process.
Programa de Terapia Escalonada (ST) / Step Therapy Program (ST) En algunos casos, requerimos que utilices primero un medicamento como terapia para tu condición antes de que cubramos otro para esa condición (Terapia Escalonada, ST por sus siglas en inglés). Por ejemplo, si el Medicamento A y el Medicamento B se usan ambos para tratar tu condición médica, nosotros requerimos que utilices primero el Medicamento A. Si el Medicamento A no te funciona, entonces cubrimos el Medicamento B. (Refiérete al Apéndice III) In some cases, you need to try one drug first to treat your health condition before we cover other drugs for the same condition (Step Therapy). For example, if Drug A and Drug B both treat your health condition, you may need to use Drug A first. If Drug A does not work for you, then we will cover Drug B. (Refer to Appendix III.)
Límites de cantidad (QL) / Limits on the amount to be dispensed (QL) Ciertos medicamentos tienen un límite en la cantidad a despacharse. Estas cantidades se establecen de acuerdo a lo sugerido por el manufacturero como la cantidad máxima adecuada que no está asociada a efectos adversos y la cual es efectiva para el tratamiento de una condición. En el área de Instrucciones de la lista de medicamentos se identificaron los límites en la cantidad a despacharse, en aquellos que aplique. Certain drugs have a limit on the amount to be dispensed. These amounts are established according to the manufacturer’s recommendation for adequate amounts to avoid adverse effects and effectively treat a health condition. The Instruction column in the Drug List points out the quantity limits for applicable drugs.
Límites de especialidad médica (SL) / Medical specialty limits (SL) Algunos medicamentos tienen un límite en la especialidad médica. Estos límites de especialidad se establecen de
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acuerdo a la literatura médica actual. El Apéndice II contiene la lista de los medicamentos que tienen límite de especialidad médica. Some drugs have medical specialty limits. These limits are established in line with current medical literature. Appendix II features the list of drugs that have a specialty limit.
Límites de edad (AL) / Age limits (AL) Algunos medicamentos tienen un límite de edad. Some drugs have an age limit.
Éditos de análisis de utilización (DUR) / Drug utilization review (DUR) A través del Programa de Beneficio de Farmacia de Triple-S Salud, Inc. se han implantado los siguientes éditos de análisis de utilización (DUR, por sus siglas en inglés) con el propósito de evitar complicaciones a los asegurados, ofreciendo un mejor cuidado. Through the Pharmacy Benefit Management Program, Triple-S Salud has implemented the following drug utilization reviews (DUR) to avoid patient complications while offering a better care.
• Édito de Validación de Dosis -coteja para dosis máximas diarias usando como referencia las dosis ®
pediátricas, de adultos y geriátricas de acuerdo a la información suministrada por Medi-Span . En la mayoría de los casos, la dosis máxima es aquella aprobada por la FDA. / Dose Validation - Verifies maximum daily doses, using pediatric, adult and geriatric Medi-Span®-approved doses as reference. In most of the cases, the maximum dosage is the one approved by the FDA. • Édito de Terapia Duplicada -verifica tu historial de medicamentos para recetas duplicadas, de dos formas:/ Duplicate Therapy – Verifies the Drug history of each insured patient for duplicate prescriptions to determine if:
1. Si recibes el mismo medicamento (Ej. mismo ingrediente activo) con dos recetas distintas (Ej. número de receta distinto, puede ser la misma farmacia o farmacias diferentes). / You’re getting the same drug (i.e. same active ingredient) through two different prescriptions (e.g. different prescription numbers, be it through the same pharmacy or different ones). 2. Si recibes dos medicamentos de la misma clase terapéutica, por ejemplo, dos antidepresivos o dos analgésicos, entre otros. / You’re getting two drugs from the same therapeutic class, such as two antidepressants, or two analgesics. Hay ciertas excepciones a estos éditos. Para evitar que el sistema rechace el servicio, nosotros les solicitamos a
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los médicos y dentistas que incluyan la siguiente información en la receta: / There are exceptions to these evaluations. To prevent the system from denying service, we suggest that doctors include the following information in the patient’s prescription: •
Cambio en dosis / Change in dose Si aumentó la dosis y necesitas más medicamentos antes de tiempo, en este caso se necesita una carta de justificación de parte del médico indicando el cambio en dosis. La farmacia requerirá una preautorización a MC-21 Corporation, luego de que se reciba la información necesaria en la receta. / If the dose is increased and you need the drug right away, a letter from the doctor to justify the change in dose will be needed. The pharmacy will need a pre-authorization from MC-21 Corporation after receiving the necessary information for that prescription.
•
Si la dosis se determina por tu peso, el médico debe indicar tu peso y estatura en la receta. / If the dose is determined by your weight, the doctor must include your weight and height in the prescription.
•
Cuando la dosis se ajuste de acuerdo a los niveles en tu sangre, el médico debe indicarlo así en la receta (Ej. Ajuste de niveles para tiroides, teofilina, anticonvulsivos, warfarina). / If the dose is changed according to your blood levels, the doctor must indicate this in the prescription (e.g.: changes in drugs treating thyroid conditions, theophylline, anticonvulsants, or warfarin).
•
Cuando para la dosis indicada en la receta no existe su presentación farmacéutica. Por ejemplo, la tableta viene de 25 mg y 50 mg, pero necesitas 75 mg (dosis indicada y aceptada). La farmacia requerirá una preautorización a MC-21 Corporation, luego de que se reciba la información necesaria en la receta (se requiere copia de la receta y hoja de preautorizaciones de MC-21). / If the dose shown in the prescription does not exist in the pharmaceutical dosage form of the drug—for example, the tablet exists in 25 mg and 50 mg, but the patient needs a 75-mg dose (dose needed and accepted)—, the pharmacy will require a preauthorization from MC-21 Corporation after receiving the necessary information for the prescription (a copy of the prescription and a copy of MC-21 Corporation’s pre-authorization form will be required).
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Leyenda para Símbolos y Abreviaturas / Legend for Symbols and Abbreviations Símbolo / Abreviatura (Symbol / Abbreviation) AL CR, ER, SR Negrilla (Bold)
Descripción Medicamentos para los cuales existe algún límite de edad. Acción prolongada, acción sostenida, acción controlada Medicamento tiene un genérico disponible en todas las presentaciones
Description
Medications associated to an age limit Controlled release, extended release, sustained release Medication has a generic available in all its dosage forms
Nivel 1
Medicamentos genéricos preferidos
Preferred generic drugs
Nivel 2
Medicamentos genéricos no preferidos
Non-preffered generic drugs
Nivel 3
Medicamentos de marca preferidos
Preferred brand drugs
Nivel 4
Medicamentos de marca no-preferidos
Non-preferred brand drugs
Nivel 5
Productos especializados preferidos
Preferred specialty products
Nivel 6
Productos especializados no-preferidos
Non-preferred specialty products
Medicamentos fuera de recetario
Over the Counter drugs
OTC
Preautorización PA
QL
SL ST
La farmacia es responsable de solicitar y obtener una preautorización con MC-21 Corporation o Triple-S Salud, Inc., antes de despachar el medicamento Medicamentos para los cuales existe algún límite en la cantidad que la farmacia puede despachar Medicamentos para los cuales existe algún límite en la especialidad médica que debe manejar la terapia con estos productos Terapia Escalonada
Preauthorization The pharmacy is responsible of requesting and obtaining a prior authorization from MC21 Corporation or Triple-S Salud, Inc., before dispensing the prescription drug.
Medications associated to a quantity limit Medications associated to a limit in the medical specialty that must manage the therapy with these products. Step Therapy
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Derechos Reservados / Reserved Rights La lista de medicamentos o formulario es una propiedad literaria. MC-21 Corporation y Triple-S Salud, Inc. son los propietarios de los derechos de autor. Bajo ninguna circunstancia se puede copiar o distribuir la lista de medicamentos ni cualquier porción de ésta sin el consentimiento escrito de MC-21 Corporation y Triple-S Salud, Inc. The Drug List is a literary property. MC-21 Corporation and Triple-S Salud, Inc. are the owners of the author rights. Under no circumstances may this material be copied or distributed in whole or any part without written consent from MC-21 Corporation and Triple-S Salud, Inc.
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PARTE II – MEDICAMENTOS POR CLASE TERAPEUTICA – SALUD FÍSICA / PART II - DRUGS BY THERAPEUTIC CLASSIFICATION – PHYSICAL HEALTH Medicamentos genéricos = letras minúsculas en negrillas / Generic Drugs = lowercase bold Medicamentos originales = letras mayúsculas / Brand name drugs = UPPERCASE
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Analgesics (Analgésicos) Nonsteroidal Anti-Inflammatory Drugs (Anti-Inflamatorios No Esteroidales) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg
2
ST
diclofenac potassium oral tablet 50 mg
1
diclofenac sodium er oral tablet extended release 24 hour 100 mg
1
diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg
1
etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg
2
etodolac oral capsule 200 mg, 300 mg
1
etodolac oral tablet 400 mg, 500 mg
1
flurbiprofen oral tablet 100 mg, 50 mg
1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
1
indomethacin oral capsule 25 mg, 50 mg
1
ketorolac tromethamine injection solution 15 mg/ml
1
QL (40 ML per 5 days)
ketorolac tromethamine injection solution 30 mg/ml
1
QL (20 ML per 5 days)
ketorolac tromethamine injection solution 60 mg/2ml
1
QL (20 ML per 5 days)
ketorolac tromethamine intramuscular solution 60 mg/2ml
1
QL (20 ML per 5 days)
meloxicam oral tablet 15 mg, 7.5 mg
1
nabumetone oral tablet 500 mg, 750 mg
1
naproxen oral suspension 125 mg/5ml
1
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
naproxen oral tablet 250 mg, 375 mg, 500 mg
1
naproxen sodium oral tablet 275 mg, 550 mg
1
salsalate oral tablet 500 mg, 750 mg
1
sulindac oral tablet 150 mg, 200 mg
1
Instrucciones (Instructions)
Opioid Analgesics, Long-Acting (Analgésicos Opiodes, Larga Duración) BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR
4
ST; QL (4 PATCH per 28 days)
buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr
2
ST; QL (4 PATCH per 28 days)
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
1
ST; QL (10 PATCH per 30 days)
morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg
2
QL (2 TAB per 1 day)
oxycodone hcl er oral tablet er 12-hour abusedeterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg
2
QL (2 TAB per 1 day)
Opioid Analgesics, Short-Acting (Analgésicos Opiodes, Corta Duración) acetaminophen-codeine #2 oral tablet 300-15 mg
1
QL (12 TAB per 1 day)
acetaminophen-codeine #3 oral tablet 300-30 mg
1
QL (12 TAB per 1 day)
acetaminophen-codeine #4 oral tablet 300-60 mg
1
QL (6 TAB per 1 day)
acetaminophen-codeine oral solution 120-12 mg/5ml
1
QL (90 ML per 1 day)
butalbital-apap-caff-cod oral capsule 50-30040-30 mg, 50-325-40-30 mg
1
QL (6 CAP per 1 day)
butalbital-asa-caff-codeine oral capsule 50-32540-30 mg
1
QL (6 CAP per 1 day)
BUTISOL SODIUM ORAL TABLET 30 MG
4
DEMEROL INJECTION SOLUTION 100 MG/2ML, 25 MG/0.5ML
4
27
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg
2
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 7.5-300 mg, 7.5-325 mg
1
QL (6 TAB per 1 day)
hydrocodone-acetaminophen oral tablet 2.5-325 mg
1
QL (12 TAB per 1 day)
hydrocodone-acetaminophen oral tablet 5-300 mg, 5-325 mg
1
QL (8 TAB per 1 day)
hydrocodone-ibuprofen oral tablet 10-200 mg, 7.5-200 mg
2
QL (5 TAB per 1 day)
hydrocodone-ibuprofen oral tablet 5-200 mg
1
QL (5 TAB per 1 day)
meperidine hcl injection solution 10 mg/ml, 25 mg/ml
2
meperidine hcl injection solution 100 mg/ml, 50 mg/ml
1
morphine sulfate (concentrate) oral solution 100 mg/5ml
1
morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml
1
morphine sulfate oral solution 10 mg/5ml
1
QL (60 ML per 1 day)
morphine sulfate oral solution 20 mg/5ml
1
QL (30 ML per 1 day)
morphine sulfate oral tablet 15 mg
1
QL (4 TAB per 1 day)
morphine sulfate oral tablet 30 mg
1
QL (2 TAB per 1 day)
oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg
1
QL (6 TAB per 1 day)
oxycodone hcl oral tablet 5 mg
1
QL (12 TAB per 1 day)
oxycodone-acetaminophen oral tablet 10-325 mg
1
QL (6 TAB per 1 day)
oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg
1
QL (12 TAB per 1 day)
oxycodone-acetaminophen oral tablet 7.5-325 mg
1
QL (8 TAB per 1 day)
tramadol hcl oral tablet 50 mg
1
QL (12 TAB per 1 day)
QL (6 ML per 1 day)
28
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
tramadol-acetaminophen oral tablet 37.5-325 mg
1
Instrucciones (Instructions) QL (8 TAB per 1 day)
Others (Otros) butalbital-apap-caffeine oral capsule 50-325-40 mg
1
butalbital-apap-caffeine oral tablet 50-325-40 mg
1
Anesthetics (Anestésicos) Local Anesthetics (Anestésico Local) lidocaine external ointment 5 %
1
QL (50 GM per 15 days)
lidocaine external patch 5 %
2
PA; QL (3 EA per 1 day)
lidocaine hcl (pf) injection solution 0.5 %, 1 %, 2%
1
lidocaine hcl external gel 2 %
1
QL (85 ML per 15 days)
lidocaine hcl external solution 4 %
1
QL (100 ML per 15 days)
lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %
1
lidocaine hcl injection solution 2 %
2
lidocaine viscous mouth/throat solution 2 %
1
QL (100 ML per 15 days)
Anti-Addiction/Substance Abuse Treatment Agents (Tratamiento de Abuso de Sustancias/Contra la Addición) Opioid Reversal Agents (Antagonista de Opioides) naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml
2
naloxone hcl injection solution cartridge 0.4 mg/ml
2
naloxone hcl injection solution prefilled syringe 2 mg/2ml
2
naltrexone hcl oral tablet 50 mg
2
Smoke Deterrentes (Agentes para Cesación de Fumar) bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg
1
QL (up to 2 fills of 90 days supply in one year)
29
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs) NICOTROL INHALATION INHALER 10 MG
Nivel (Level) 4
Instrucciones (Instructions) QL (up to 2 fills of 90 days supply in one year)
Antibacterials (Antibacterianos) Aminoglycosides (Aminoglicósidos) amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml
2
gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml
1
gentamicin sulfate intravenous solution 10 mg/ml
1
neomycin sulfate oral tablet 500 mg
1
paromomycin sulfate oral capsule 250 mg
2
tobramycin sulfate injection solution 1.2 gm/30ml, 10 mg/ml, 2 gm/50ml, 80 mg/2ml
1
Antibacterials, Other (Antibacterianos, Otros) CLEOCIN PHOSPHATE INTRAVENOUS SOLUTION 600 MG/4ML
4
clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg
1
clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml, 9000 mg/60ml
1
clindamycin phosphate intravenous solution 150 mg/ml, 900 mg/6ml
1
clindamycin phosphate vaginal cream 2 %
1
colistimethate sodium injection solution reconstituted 150 mg
2
daptomycin intravenous solution reconstituted 500 mg
2
lincomycin hcl injection solution 300 mg/ml
2
methenamine hippurate oral tablet 1 gm
1
metronidazole oral capsule 375 mg
1
metronidazole oral tablet 250 mg, 500 mg
1
QL (40 GM per 15 days)
30
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
metronidazole vaginal gel 0.75 %
1
nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg
2
nitrofurantoin macrocrystal oral capsule 50 mg
1
nitrofurantoin monohyd macro oral capsule 100 mg
2
SIVEXTRO ORAL TABLET 200 MG
4
tigecycline intravenous solution reconstituted 50 mg
2
trimethoprim oral tablet 100 mg
1
vancomycin hcl intravenous solution reconstituted 1000 mg, 500 mg, 750 mg
2
vancomycin hcl oral capsule 125 mg, 250 mg
2
Instrucciones (Instructions) QL (70 GM per 15 days)
PA
Beta-Lactam, Cephalosporins (Cefalosporinas, Beta-Lactámicas) cefaclor oral capsule 250 mg, 500 mg
1
cefadroxil oral capsule 500 mg
1
cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml
1
cefadroxil oral tablet 1 gm
1
cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 100 gm, 20 gm, 300 gm, 500 mg
2
cefazolin sodium intravenous solution reconstituted 1 gm
2
cefdinir oral capsule 300 mg
1
cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
cefepime hcl injection solution reconstituted 1 gm, 2 gm
2
cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml
1
cefpodoxime proxetil oral tablet 100 mg, 200 mg
1
31
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
cefprozil oral tablet 250 mg, 500 mg
1
ceftazidime injection solution reconstituted 1 gm, 2 gm
2
ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg
2
cefuroxime axetil oral tablet 250 mg, 500 mg
1
cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg
2
cephalexin oral capsule 250 mg, 500 mg, 750 mg
1
cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
FORTAZ INJECTION SOLUTION RECONSTITUTED 500 MG
4
ZINACEF INTRAVENOUS SOLUTION RECONSTITUTED 750 MG
4
Beta-Lactam, Other (Beta-Lactámicos, Otros) imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg
2
INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM
4
Beta-Lactam, Penicillins (Penicilinas, Beta-Lactámicas) amoxicillin oral capsule 250 mg, 500 mg
1
amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml
1
amoxicillin oral tablet 500 mg, 875 mg
1
amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1000-62.5 mg
1
amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml
1
Instrucciones (Instructions)
32
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg
1
amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg
1
ampicillin oral capsule 250 mg, 500 mg
1
ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
2
ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg
2
AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML
4
BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION 900000-300000 UNIT/2ML
4
BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML
4
BICILLIN L-A INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML
4
dicloxacillin sodium oral capsule 250 mg, 500 mg
1
oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm
1
penicillin g procaine intramuscular suspension 600000 unit/ml
2
penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml
1
penicillin v potassium oral tablet 250 mg, 500 mg
1
piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (30.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm
2
Macrolides (Macrólidos) azithromycin oral packet 1 gm
2
Instrucciones (Instructions)
33
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml
1
azithromycin oral tablet 250 mg, 500 mg, 600 mg
1
clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
clarithromycin oral tablet 250 mg, 500 mg
1
ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML
4
ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG
4
ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG
4
ERYTHROCIN STEARATE ORAL TABLET 250 MG
4
erythromycin base oral capsule delayed release particles 250 mg
1
erythromycin base oral tablet 250 mg, 500 mg
2
erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml
2
erythromycin ethylsuccinate oral tablet 400 mg
2
Instrucciones (Instructions)
Quinolones (Quinolonas) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg
1
ciprofloxacin intravenous solution 200 mg/20ml
2
ciprofloxacin intravenous solution 400 mg/40ml
1
ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)
2
ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg
2
QL (14 TAB per 30 days)
ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 500 mg
2
QL (3 TAB per 30 days)
levofloxacin oral tablet 250 mg, 500 mg, 750 mg
1
34
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
moxifloxacin hcl oral tablet 400 mg
Instrucciones (Instructions)
2
Sulfonamides (Sulfonamidas) sulfadiazine oral tablet 500 mg
2
sulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5ml
1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml
1
sulfamethoxazole-trimethoprim oral tablet 40080 mg, 800-160 mg
1
Tetracyclines (Tetraciclinas) demeclocycline hcl oral tablet 150 mg, 300 mg
2
doxycycline hyclate oral capsule 100 mg, 50 mg
2
doxycycline hyclate oral tablet 100 mg
2
doxycycline hyclate oral tablet 20 mg
1
doxycycline monohydrate oral suspension reconstituted 25 mg/5ml
2
minocycline hcl oral capsule 100 mg, 50 mg, 75 mg
1
tetracycline hcl oral capsule 250 mg, 500 mg
2
VIBRAMYCIN ORAL SYRUP 50 MG/5ML
4
Anticonvulsants (Anticonvulsivantes) Anticonvulsants, Other (Anticonvulsivantes, Otros) levetiracetam intravenous solution 500 mg/5ml
2
levetiracetam oral solution 100 mg/ml
1
levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg
1
Calcium Channel Modifying Agents (Modificadores de Canales de Calcio) CELONTIN ORAL CAPSULE 300 MG
4
ethosuximide oral capsule 250 mg
1
ethosuximide oral solution 250 mg/5ml
1
35
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG
4
ST
LYRICA ORAL SOLUTION 20 MG/ML
4
ST
Gamma-Aminobutyric Acid (GABA) Augmenting Agents (Agentes Amplificadores del Acido Gama-Aminobutirato) clonazepam oral tablet 0.5 mg, 1 mg, 2 mg
1
divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg
2
divalproex sodium oral capsule delayed release sprinkle 125 mg
1
divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg
1
felbamate oral suspension 600 mg/5ml
1
felbamate oral tablet 400 mg, 600 mg
1
gabapentin oral capsule 100 mg, 300 mg, 400 mg
1
gabapentin oral solution 300 mg/6ml
1
gabapentin oral tablet 600 mg, 800 mg
1
GABITRIL ORAL TABLET 12 MG, 16 MG
4
ONFI ORAL TABLET 10 MG, 20 MG
4
phenobarbital oral solution 20 mg/5ml
1
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
1
POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG
4
primidone oral tablet 250 mg, 50 mg
1
tiagabine hcl oral tablet 2 mg, 4 mg
1
valproate sodium intravenous solution 500 mg/5ml
1
valproate sodium oral solution 250 mg/5ml
1
valproic acid oral capsule 250 mg
1
AL (greater than 18 years)
SL
36
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Glutamate Reducing Agents (Reductores de Glutamato) BANZEL ORAL SUSPENSION 40 MG/ML
4
PA
BANZEL ORAL TABLET 200 MG, 400 MG
4
PA
lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg
1
lamotrigine oral tablet chewable 25 mg, 5 mg
1
topiramate oral capsule sprinkle 15 mg, 25 mg
1
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg
1
Sodium Channel Agents (Canales de Sodio) carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg
2
carbamazepine oral suspension 100 mg/5ml
1
carbamazepine oral tablet 200 mg
1
carbamazepine oral tablet chewable 100 mg
1
DILANTIN ORAL CAPSULE 30 MG
4
oxcarbazepine oral suspension 300 mg/5ml
1
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg
1
PEGANONE ORAL TABLET 250 MG
4
phenytoin oral suspension 125 mg/5ml
1
phenytoin oral tablet chewable 50 mg
1
phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg
1
phenytoin sodium injection solution 50 mg/ml
1
VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML
4
SL; AL (greater than or equal to 17 years)
VIMPAT ORAL SOLUTION 10 MG/ML
4
SL; AL (greater than or equal to 17 years)
VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG
4
SL; AL (greater than or equal to 17 years)
zonisamide oral capsule 100 mg, 25 mg, 50 mg
1
37
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Antidementia Agents (Antidemencia) Antidementia Agents, Other (Antidemencia, Otros) ergoloid mesylates oral tablet 1 mg
2
Cholinesterase Inhibitors (Inhibidores de Colinesterasa) donepezil hcl oral tablet 10 mg, 5 mg
1
donepezil hcl oral tablet dispersible 10 mg, 5 mg
1
galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg
1
galantamine hydrobromide oral solution 4 mg/ml
1
galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg
1
rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg
1
rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr
2
QL (1 PATCH per 1 day)
Combinations, Other (Combinación, Otros) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 14 & 21 &28 -10 MG
3
NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 2810 MG, 7-10 MG
3
N-Methyl-D-Aspartate (NMDA) Receptor Antagonist (Antagonista del Receptor NMDA) memantine hcl oral solution 2 mg/ml
2
memantine hcl oral tablet 10 mg, 5 (28)-10 (21) mg, 5 mg
2
NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG
3
ST
NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG
3
ST
38
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Antidepressants (Antidepresivos) Antidepressants, Other (Antidepresivos, Otros) bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg
1
bupropion hcl oral tablet 100 mg, 75 mg
1
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg
1
mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg
1
Monoamine Oxidase B (MAO-B) Inhibitors (Inhibidores de Monoamina Oxidasa B) EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR
4
MARPLAN ORAL TABLET 10 MG
4
phenelzine sulfate oral tablet 15 mg
1
tranylcypromine sulfate oral tablet 10 mg
2
PA
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) (Inhibidores de la Recaptación de Serotonina/ Norepinefrina (SSRIs/SNRIs)) citalopram hydrobromide oral solution 10 mg/5ml
1
citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg
1
duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg
1
escitalopram oxalate oral solution 5 mg/5ml
1
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg
1
fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg
1
fluoxetine hcl oral solution 20 mg/5ml
1
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg
1
maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg
2
QL (2 CAP per 1 day)
39
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg
2
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
1
PAXIL ORAL SUSPENSION 10 MG/5ML
4
sertraline hcl oral concentrate 20 mg/ml
1
sertraline hcl oral tablet 100 mg, 25 mg, 50 mg
1
trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg
1
venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg
1
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg
1
Tricyclics (Tricíclicos) amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
1
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg
2
clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg
2
desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
1
doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
1
doxepin hcl oral concentrate 10 mg/ml
1
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg
1
nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg
1
trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg
2
Antiemetics (Antieméticos) Antiemetics, Other (Antieméticos, Otros)
Instrucciones (Instructions)
40
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
diphenhydramine hcl injection solution 50 mg/ml
2
meclizine hcl oral tablet 12.5 mg, 25 mg
1
metoclopramide hcl oral solution 5 mg/5ml
1
metoclopramide hcl oral tablet 10 mg, 5 mg
1
promethazine hcl injection solution 25 mg/ml, 50 mg/ml
1
promethazine hcl oral solution 6.25 mg/5ml
1
promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg
1
promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg
2
trimethobenzamide hcl oral capsule 300 mg
1
Instrucciones (Instructions)
Emetogenic Therapy Adjuncts (Adjuvantes Para Terapia Emetogénica) AKYNZEO ORAL CAPSULE 300-0.5 MG
4
PA; QL (1 CAP per 7 days)
aprepitant oral capsule 125 mg
2
PA; QL (1 CAP per 7 days)
aprepitant oral capsule 80 & 125 mg
2
PA; QL (3 PACK per 7 days)
aprepitant oral capsule 80 mg
2
PA; QL (2 CAP per 7 days)
dronabinol oral capsule 10 mg, 2.5 mg, 5 mg
1
ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml
5
ondansetron hcl oral tablet 4 mg, 8 mg
1
ondansetron oral tablet dispersible 4 mg, 8 mg
1
Antifungals (Antifungales) Antifungals (Antifungales) CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG
6
SL
clotrimazole mouth/throat lozenge 10 mg
1
CRESEMBA ORAL CAPSULE 186 MG
4
SL
ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG
6
SL
41
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml
1
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg
1
flucytosine oral capsule 250 mg, 500 mg
2
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg
2
itraconazole oral capsule 100 mg
2
ketoconazole oral tablet 200 mg
1
MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG
6
nystatin mouth/throat suspension 100000 unit/ml
1
nystatin oral tablet 500000 unit
1
terbinafine hcl oral tablet 250 mg
1
QL (84 TAB per 365 days)
terconazole vaginal cream 0.4 %
1
QL (45 GM per 15 days)
terconazole vaginal cream 0.8 %
1
QL (20 GM per 15 days)
terconazole vaginal suppository 80 mg
2
QL (3 EA per 15 days)
voriconazole oral tablet 200 mg, 50 mg
2
SL
SL
Antigout Agents (Antigota) Antigout Agents (Antigota) allopurinol oral tablet 100 mg, 300 mg
1
colchicine oral tablet 0.6 mg
2
colchicine-probenecid oral tablet 0.5-500 mg
1
probenecid oral tablet 500 mg
1
ULORIC ORAL TABLET 40 MG, 80 MG
4
Anti-Inflammatory Agents (Anti-Inflamatorios) Glucocorticoids (Glucocorticoides) cortisone acetate oral tablet 25 mg
2
DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML
4
PA; QL (1 TAB per 1 day)
42
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML
4
dexamethasone oral elixir 0.5 mg/5ml
1
dexamethasone oral solution 0.5 mg/5ml
2
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg
1
dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml, 4 mg/ml
1
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg
1
MEDROL ORAL TABLET 2 MG
4
methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml
2
methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg
1
methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg
2
MILLIPRED ORAL TABLET 5 MG
4
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg
1
SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG, 250 MG, 500 MG
4
SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 2 GM, 500 MG
4
Instrucciones (Instructions)
Antimigraine Agents (Antimigraña) Ergot Alkaloids (Alcaloides de Ergotamina) dihydroergotamine mesylate nasal solution 4 mg/ml
2
ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG
4
Serotonin (5-HT) 1B/1D Receptor Agonists (Agonistas del Receptor de Serotonina) eletriptan oral tablet 20 mg, 40 mg
2
ST; QL (6 TAB per 30 days)
43
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
sumatriptan succinate oral tablet 100 mg
1
QL (9 TAB per 30 days)
sumatriptan succinate oral tablet 25 mg, 50 mg
1
QL (18 TAB per 30 days)
sumatriptan succinate subcutaneous solution 6 mg/0.5ml
2
QL (5 ML per 30 days)
Antimyasthenic Agents (Antimiasténicos) Parasympathomimetics (Parasimpatomiméticos) MESTINON ORAL SYRUP 60 MG/5ML
4
pyridostigmine bromide er oral tablet extended release 180 mg
2
pyridostigmine bromide oral tablet 60 mg
1
Antimycobacterials (Antimicobacterianos) Antimycobacterials, Other (Antimicobacterianos, Otros) dapsone oral tablet 100 mg, 25 mg
2
rifabutin oral capsule 150 mg
2
Antituberculars (Antituberculosos) CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM
4
cycloserine oral capsule 250 mg
2
ethambutol hcl oral tablet 100 mg, 400 mg
1
isoniazid oral syrup 50 mg/5ml
2
isoniazid oral tablet 100 mg, 300 mg
1
PASER ORAL PACKET 4 GM
4
PRIFTIN ORAL TABLET 150 MG
4
rifampin intravenous solution reconstituted 600 mg
2
rifampin oral capsule 150 mg, 300 mg
1
RIFATER ORAL TABLET 50-120-300 MG
4
TRECATOR ORAL TABLET 250 MG
4
Antineoplastics (Antineoplásicos) Alkylating Agents (Agentes Alquilantes)
44
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG
5
HEXALEN ORAL CAPSULE 50 MG
6
LEUKERAN ORAL TABLET 2 MG
6
MATULANE ORAL CAPSULE 50 MG
6
Instrucciones (Instructions)
Antiandrogens (Antiandrógenos) bicalutamide oral tablet 50 mg
1
flutamide oral capsule 125 mg
1
nilutamide oral tablet 150 mg
6
PA
XTANDI ORAL CAPSULE 40 MG
6
PA
ZYTIGA ORAL TABLET 250 MG, 500 MG
6
PA
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
6
PA
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG
6
PA
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG
6
PA
Antiangiogenic Agents (Antiangiogénicos)
Antiestrogens/Modifiers (Antiestrógenos/Modificadores) EMCYT ORAL CAPSULE 140 MG
4
FARESTON ORAL TABLET 60 MG
4
tamoxifen citrate oral tablet 10 mg, 20 mg
1
PA
Antimetabolites (Antimetabolitos) hydroxyurea oral capsule 500 mg
1
mercaptopurine oral tablet 50 mg
1
Antineoplastics, Others (Antineoplásicos, Otros) ERIVEDGE ORAL CAPSULE 150 MG
6
leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg
1
LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG
6
PA
PA
45
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
MESNEX ORAL TABLET 400 MG
6
NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG
6
TABLOID ORAL TABLET 40 MG
6
ZOLINZA ORAL CAPSULE 100 MG
6
Instrucciones (Instructions) PA
PA
Aromatase Inhibitors, 3rd Generation (Inhibidores de Aromatasa, 3ra Generación) anastrozole oral tablet 1 mg
1
exemestane oral tablet 25 mg
1
letrozole oral tablet 2.5 mg
1
Enzyme Inhibitors (Inhibidores Enzimáticos) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG
6
PA
ZYDELIG ORAL TABLET 100 MG, 150 MG
6
PA
Molecular Target Inhibitors (Inhibidores del Objetivo Molecular) AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG
6
PA
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG
6
PA
ALECENSA ORAL CAPSULE 150 MG
6
PA
BOSULIF ORAL TABLET 100 MG, 500 MG
6
PA
CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG
6
PA
CAPRELSA ORAL TABLET 100 MG, 300 MG
6
PA
COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG
6
PA
COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG
6
PA
COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG
6
PA
ICLUSIG ORAL TABLET 15 MG, 45 MG
6
PA
imatinib mesylate oral tablet 100 mg, 400 mg
6
PA
46
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
INLYTA ORAL TABLET 1 MG, 5 MG
6
PA
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG
6
PA
LYNPARZA ORAL CAPSULE 50 MG
6
PA
NEXAVAR ORAL TABLET 200 MG
6
PA
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG
5
PA
STIVARGA ORAL TABLET 40 MG
6
PA
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG
5
PA
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
5
PA
TASIGNA ORAL CAPSULE 150 MG, 200 MG
5
PA
TYKERB ORAL TABLET 250 MG
6
PA
VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG
6
PA
VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG
6
PA
VOTRIENT ORAL TABLET 200 MG
6
PA
XALKORI ORAL CAPSULE 200 MG, 250 MG
6
PA
ZELBORAF ORAL TABLET 240 MG
6
PA
6
PA
Monoclonal Antibodies (Anticuerpos Monoclonales) RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML
Retinoids (Retinoides) bexarotene oral capsule 75 mg
5
PANRETIN EXTERNAL GEL 0.1 %
6
QL (60 GM per 15 days)
TARGRETIN EXTERNAL GEL 1 %
6
QL (60 GM per 15 days)
tretinoin oral capsule 10 mg
5
Antiparasitics (Antiparasitarios) Anthelmintics (Antihelmínticos)
47
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
ALBENZA ORAL TABLET 200 MG
4
BILTRICIDE ORAL TABLET 600 MG
4
EMVERM ORAL TABLET CHEWABLE 100 MG
4
ivermectin oral tablet 3 mg
2
Instrucciones (Instructions)
QL (18 TAB per 365 days)
Antiprotozoals (Antiprotozoarios) ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML
4
QL (60 ML per 30 days)
ALINIA ORAL TABLET 500 MG
4
QL (6 TAB per 30 days)
atovaquone oral suspension 750 mg/5ml
2
atovaquone-proguanil hcl oral tablet 250-100 mg
2
QL (12 TAB per 365 days)
atovaquone-proguanil hcl oral tablet 62.5-25 mg
2
QL (48 TAB per 365 days)
chloroquine phosphate oral tablet 250 mg, 500 mg
1
COARTEM ORAL TABLET 20-120 MG
4
QL (24 TAB per 365 days)
DARAPRIM ORAL TABLET 25 MG
6
PA
hydroxychloroquine sulfate oral tablet 200 mg
1
mefloquine hcl oral tablet 250 mg
2
NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG
4
PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG
4
primaquine phosphate oral tablet 26.3 mg
2
quinine sulfate oral capsule 324 mg
2
QL (42 CAP per 365 days)
EURAX EXTERNAL CREAM 10 %
4
QL (60 GM per 30 days)
EURAX EXTERNAL LOTION 10 %
4
QL (60 ML per 30 days)
lindane external shampoo 1 %
2
QL (60 ML per 30 days)
permethrin external cream 5 %
1
QL (60 GM per 30 days)
Pediculicides/Scabicides (Pediculicidas/Escabicidas)
48
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Antiparkinson Agents (Antiparkinson) Anticholinergics (Anticolinérgicos) benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg
1
trihexyphenidyl hcl oral elixir 0.4 mg/ml
1
trihexyphenidyl hcl oral tablet 2 mg, 5 mg
1
Antiparkinson Agents, Others (Antiparkinson, Otros) amantadine hcl oral capsule 100 mg
1
bromocriptine mesylate oral capsule 5 mg
2
bromocriptine mesylate oral tablet 2.5 mg
1
entacapone oral tablet 200 mg
2
tolcapone oral tablet 100 mg
2
Dopamine Agonist (Agonistas de Dopamina) APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML
6
NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR
4
pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
1
ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg
1
ST
Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors (Precursores de Dopamina/Inhibidores de la L-Aminoácido Decarboxilasa) carbidopa oral tablet 25 mg
2
carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg
1
carbidopa-levodopa oral tablet 10-100 mg, 25100 mg, 25-250 mg
1
49
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
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, 50-200200 mg
1
Instrucciones (Instructions)
Monoamine Oxidase B (MAO-B) Inhibitors (Inhibidores De Monoamina Oxidasa B) rasagiline mesylate oral tablet 0.5 mg, 1 mg
2
selegiline hcl oral capsule 5 mg
1
Antipsychotics (Antipsicóticos) 1st Generation/Typical (1ra Generación/Típicos) chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml
2
chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg
1
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg
1
prochlorperazine edisylate injection solution 5 mg/ml
1
prochlorperazine maleate oral tablet 10 mg, 5 mg
1
prochlorperazine rectal suppository 25 mg
1
Antispasticity (Antiespasticidad) Antispasticity (Antiespasticidad) baclofen oral tablet 10 mg, 20 mg
1
dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg
1
tizanidine hcl oral tablet 2 mg, 4 mg
1
Antivirals (Antivirales) Anti-Cytomegalovirus (CMV) (Anti-Citomegalovirus) ganciclovir sodium intravenous solution reconstituted 500 mg
6
valganciclovir hcl oral tablet 450 mg
6
ST
50
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Antihepatitis Agents (Antihepatitis) ribavirin oral capsule 200 mg
5
PA
ribavirin oral tablet 200 mg
5
PA
Antihepatitis B (HBV) Agents (Anti-Hepatitis B (HBV)) BARACLUDE ORAL SOLUTION 0.05 MG/ML
5
PA
entecavir oral tablet 0.5 mg, 1 mg
5
PA
INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML
6
PA
INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT
6
PA
VEMLIDY ORAL TABLET 25 MG
5
PA
Antihepatitis C (HCV) Agents (Anti-Hepatitis C (HCV)) EPCLUSA ORAL TABLET 400-100 MG
5
PA
HARVONI ORAL TABLET 90-400 MG
5
PA
SOVALDI ORAL TABLET 400 MG
5
PA
ZEPATIER ORAL TABLET 50-100 MG
5
PA
Antiherpetic Agents (Antiherpéticos) acyclovir oral capsule 200 mg
1
acyclovir oral suspension 200 mg/5ml
1
acyclovir oral tablet 400 mg, 800 mg
1
acyclovir sodium intravenous solution reconstituted 500 mg
2
famciclovir oral tablet 125 mg, 500 mg
1
QL (21 TAB per 7 days)
famciclovir oral tablet 250 mg
1
QL (2 TAB per 1 day)
valacyclovir hcl oral tablet 1 gm, 500 mg
1
Anti-HIV Adjuvants (Anti-VIH, Adjuvantes) TYBOST ORAL TABLET 150 MG
4
Anti-HIV Agents, Integrase Inhibitors (INSTI) (Anti-VIH, Inhibidores de la Integrasa (INSTI))
51
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
ISENTRESS ORAL TABLET 400 MG
4
ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG
4
VITEKTA ORAL TABLET 150 MG, 85 MG
4
Instrucciones (Instructions)
Anti-HIV Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Anti-VIH, Inhibidores No Nucleósidos de la Transciptasa Reversa) EDURANT ORAL TABLET 25 MG
4
INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG
4
nevirapine er oral tablet extended release 24 hour 100 mg, 400 mg
2
nevirapine oral suspension 50 mg/5ml
2
nevirapine oral tablet 200 mg
2
RESCRIPTOR ORAL TABLET 100 MG, 200 MG
4
SUSTIVA ORAL CAPSULE 200 MG, 50 MG
4
SUSTIVA ORAL TABLET 600 MG
4
PA
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (Anti-VIH, Inhibidores Nucleósidos y Nucleótidos de la Transcriptasa Reversa) abacavir sulfate oral tablet 300 mg
2
didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg
1
EMTRIVA ORAL CAPSULE 200 MG
4
EMTRIVA ORAL SOLUTION 10 MG/ML
4
lamivudine oral solution 10 mg/ml
2
lamivudine oral tablet 150 mg, 300 mg
1
RETROVIR INTRAVENOUS SOLUTION 10 MG/ML
4
stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg
1
stavudine oral solution reconstituted 1 mg/ml 1
1
52
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM
4
VIREAD ORAL POWDER 40 MG/GM
4
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
4
VIREAD ORAL TABLET 300 MG
4
ZIAGEN ORAL SOLUTION 20 MG/ML
4
zidovudine oral capsule 100 mg
1
zidovudine oral syrup 50 mg/5ml
1
zidovudine oral tablet 300 mg
1
Instrucciones (Instructions)
PA
Anti-HIV Agents, Others (Anti-VIH, Otros) FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG
6
PA
SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG
4
PA
SELZENTRY ORAL SOLUTION 20 MG/ML
4
PA
Anti-HIV Agents, Protease Inhibitors (Anti-VIH, Inhibidores de la Proteasa) APTIVUS ORAL CAPSULE 250 MG
4
PA
APTIVUS ORAL SOLUTION 100 MG/ML
4
PA
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
4
INVIRASE ORAL CAPSULE 200 MG
4
INVIRASE ORAL TABLET 500 MG
4
LEXIVA ORAL SUSPENSION 50 MG/ML
4
LEXIVA ORAL TABLET 700 MG
4
NORVIR ORAL CAPSULE 100 MG
4
NORVIR ORAL SOLUTION 80 MG/ML
4
NORVIR ORAL TABLET 100 MG
4
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
4
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
4
53
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs) VIRACEPT ORAL TABLET 250 MG, 625 MG
Nivel (Level) 4
Anti-Influenza Agents (Anti-Influenza) oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg
2
RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER
4
rimantadine hcl oral tablet 100 mg
1
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML
4
Antiretroviral Combinations (Combinaciones Antiretrovirales) abacavir sulfate-lamivudine oral tablet 600-300 mg
2
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
2
ATRIPLA ORAL TABLET 600-200-300 MG
4
COMPLERA ORAL TABLET 200-25-300 MG
4
DESCOVY ORAL TABLET 200-25 MG
4
EVOTAZ ORAL TABLET 300-150 MG
4
GENVOYA ORAL TABLET 150-150-200-10 MG
4
KALETRA ORAL TABLET 100-25 MG, 200-50 MG
4
lamivudine-zidovudine oral tablet 150-300 mg
2
lopinavir-ritonavir oral solution 400-100 mg/5ml
2
ODEFSEY ORAL TABLET 200-25-25 MG
4
PREZCOBIX ORAL TABLET 800-150 MG
4
STRIBILD ORAL TABLET 150-150-200-300 MG
4
TRIUMEQ ORAL TABLET 600-50-300 MG
4
Instrucciones (Instructions)
54
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs) TRUVADA ORAL TABLET 100-150 MG, 133200 MG, 167-250 MG, 200-300 MG
Nivel (Level)
Instrucciones (Instructions)
4
Anxiolytics (Ansiolíticos) Anxiolytics, Other (Ansiolíticos, Otros) buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg
1
hydroxyzine pamoate oral capsule 100 mg
2
hydroxyzine pamoate oral capsule 25 mg, 50 mg
1
Benzodiazepines (Benzodiazepinas) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg
1
AL (greater than 18 years)
clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg
1
AL (greater than 9 years)
diazepam oral tablet 10 mg, 2 mg, 5 mg
1
AL (greater than 18 years)
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
1
AL (greater than 12 years)
oxazepam oral capsule 10 mg, 15 mg, 30 mg
1
AL (greater than 12 years)
Bipolar Agents (Bipolaridad) Mood Stabilizers (Estabilizadores Del Ánimo) lithium carbonate er oral tablet extended release 300 mg, 450 mg
1
lithium carbonate oral capsule 150 mg, 300 mg, 600 mg
1
lithium oral solution 8 meq/5ml
1
Blood Glucose Regulators (Reguladores de Glucosa en Sangre) Antidiabetic Agents (Antidiabéticos) acarbose oral tablet 100 mg, 25 mg, 50 mg
1
BYDUREON SUBCUTANEOUS PENINJECTOR 2 MG
3
ST; QL (4 ML per 30 days)
BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG
3
ST; QL (4 ML per 30 days)
BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MCG/0.04ML
3
ST; QL (2.4 ML per 30 days)
55
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML
3
ST; QL (1.2 ML per 30 days)
glimepiride oral tablet 1 mg, 2 mg, 4 mg
1
glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg
1
glipizide oral tablet 10 mg, 5 mg
1
glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg
1
glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg
1
glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg
1
glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg
1
GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG
4
ST
INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG
3
ST
INVOKANA ORAL TABLET 100 MG, 300 MG
3
ST
JANUMET ORAL TABLET 50-1000 MG, 50-500 MG
3
ST
JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG
3
ST
JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG
3
ST
JARDIANCE ORAL TABLET 10 MG, 25 MG
3
ST
JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG
4
ST
JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG
4
ST
metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg
1
56
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
metformin hcl oral tablet 1000 mg, 500 mg, 850 mg
1
miglitol oral tablet 100 mg, 25 mg, 50 mg
2
nateglinide oral tablet 120 mg, 60 mg
1
pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg
1
ST
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg
2
ST
SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML
4
PA; QL (13.5 ML per 30 days)
SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML
4
PA; QL (13.5 ML per 30 days)
SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5-1000 MG, 5-500 MG
3
ST
SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG
3
ST
TRADJENTA ORAL TABLET 5 MG
4
ST
TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML
4
ST; QL (2 ML per 30 days)
VICTOZA SUBCUTANEOUS SOLUTION PENINJECTOR 18 MG/3ML
3
ST; QL (9 ML per 30 days)
ST
Glycemic Agents (Glicémicos) GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG
4
PROGLYCEM ORAL SUSPENSION 50 MG/ML
4
Insulins (Insulinas) APIDRA INJECTION SOLUTION 100 UNIT/ML
4
QL (40 ML per 30 days)
HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML
3
QL (40 ML per 30 days)
HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML
3
QL (40 ML per 30 days)
HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML
3
QL (40 ML per 30 days)
57
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
HUMULIN 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS
3
QL (40 ML per 30 days)
HUMULIN N SUSPENSION 100 UNIT/ML SUBCUTANEOUS
3
QL (40 ML per 30 days)
HUMULIN R SOLUTION 100 UNIT/ML INJECTION
3
QL (40 ML per 30 days)
LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML
3
QL (40 ML per 30 days)
Blood Products/Modifiers/Volume Expanders (Productos para la Sangre/Modificadores/Expansores de Volumen) Anticoagulants (Anticoagulantes) enoxaparin sodium injection solution 300 mg/3ml
2
enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml
2
fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml
2
heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml
1
PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG
4
warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
1
XARELTO ORAL TABLET 10 MG
3
XARELTO ORAL TABLET 15 MG, 20 MG
3
PA
XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG
3
PA
Antihemophilics (Antihemofílicos)
PA
58
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT
5
PA
ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT, 750 UNIT
6
PA
AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 2500 UNIT 250 UNIT, 3000 UNIT, 500 UNIT
6
PA
ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT
6
PA
ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1500 UNIT, 500 UNIT
6
PA
ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT
6
PA
BEBULIN INTRAVENOUS SOLUTION RECONSTITUTED 200-1200 UNIT
6
PA
BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT
6
PA
COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT
6
PA
ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT
6
PA
FEIBA INTRAVENOUS SOLUTION RECONSTITUTED
5
PA
FEIBA NF RECONSTITUTED INTRAVENOUS
6
PA
HELIXATE FS INTRAVENOUS KIT 2000 UNIT, 3000 UNIT, 500 UNIT
6
PA
59
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT
5
PA
HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT
6
PA
IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT
6
PA
IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT UNIT, 500 UNIT
6
PA
KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT
6
PA
KOGENATE FS BIO-SET INTRAVENOUS KIT 1000 UNIT
6
PA
KOGENATE FS INTRAVENOUS KIT 250 UNIT
6
PA
KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT
6
PA
MONOCLATE-P INTRAVENOUS KIT 1000 UNIT, 1500 UNIT
6
PA
MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT
6
PA
NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT
6
PA
NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG
6
PA
NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT
6
PA
NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT
6
PA
60
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT
6
PA
PROFILNINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT
6
PA
RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT
5
PA
RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT, 2000 UNIT, 3000 UNIT
5
PA
VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 1300 UNIT, 650 UNIT
6
PA
WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 UNIT
6
PA
XYNTHA INTRAVENOUS KIT 250 UNIT
6
PA
XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT
6
PA
Blood Formation Modifiers (Modificadores de la Formación de Sangre) LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG
6
SL
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML
6
SL
NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML
6
SL
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
5
PA
PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG
6
PA
ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML
6
SL
61
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Coagulants (Coagulantes) tranexamic acid intravenous solution 1000 mg/10ml
6
QL (1600 ML per 8 days)
Platelet Modifying Agents (Modificadores de Plaquetas) anagrelide hcl oral capsule 0.5 mg, 1 mg
1
aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg
2
BRILINTA ORAL TABLET 60 MG, 90 MG
4
cilostazol oral tablet 100 mg, 50 mg
1
clopidogrel bisulfate oral tablet 75 mg
1
EFFIENT ORAL TABLET 10 MG, 5 MG
4
PA
PA
Cardiovascular Agents (Cardiovasculares) Alpha-Adrenergic Agonists (Agonistas Alfa Adrenérgicos) clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg
1
clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr
2
guanfacine hcl oral tablet 1 mg, 2 mg
1
methyldopa oral tablet 250 mg, 500 mg
1
midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg
1
Alpha-Adrenergic Blocking Agents (Bloqueadores Alfa Adrenérgicos) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg
1
prazosin hcl oral capsule 1 mg, 2 mg, 5 mg
1
terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg
1
Angiotensin II Receptor Antagonists (Antagonistas del Receptor Angiotensina II) irbesartan oral tablet 150 mg, 300 mg, 75 mg
1
irbesartan-hydrochlorothiazide oral tablet 15012.5 mg, 300-12.5 mg
1
losartan potassium oral tablet 100 mg, 25 mg, 50 mg
1
62
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg
1
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg
1
valsartan-hydrochlorothiazide oral tablet 16012.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg
1
Instrucciones (Instructions)
Angiotensin-Converting Enzyme (ACE) Inhibitors (Inhibidores de la Enzima Convertidora de Angiotensina) benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
benazepril-hydrochlorothiazide oral tablet 1012.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg
2
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg
1
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
1
enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg
1
fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg
1
fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg
1
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg
1
lisinopril-hydrochlorothiazide oral tablet 1012.5 mg, 20-12.5 mg, 20-25 mg
1
moexipril hcl oral tablet 15 mg, 7.5 mg
1
moexipril-hydrochlorothiazide oral tablet 1512.5 mg, 15-25 mg, 7.5-12.5 mg
2
perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg
1
63
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
quinapril-hydrochlorothiazide oral tablet 1012.5 mg, 20-12.5 mg, 20-25 mg
2
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg
1
trandolapril oral tablet 1 mg, 2 mg, 4 mg
1
Instrucciones (Instructions)
Antiarrhythmics (Antiarrítmicos) amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg
2
disopyramide phosphate oral capsule 100 mg, 150 mg
1
dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg
2
flecainide acetate oral tablet 100 mg, 150 mg, 50 mg
1
mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg
1
NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG
4
propafenone hcl oral tablet 150 mg, 225 mg, 300 mg
1
quinidine gluconate er oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg, 300 mg
1
sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg
1
sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg
1
Beta-Adrenergic Blocking Agents (Bloqueadores Beta Adrenérgicos) acebutolol hcl oral capsule 200 mg, 400 mg
1
atenolol oral tablet 100 mg, 25 mg, 50 mg
1
64
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg
1
betaxolol hcl oral tablet 10 mg, 20 mg
1
bisoprolol fumarate oral tablet 10 mg, 5 mg
1
bisoprolol-hydrochlorothiazide oral tablet 106.25 mg, 2.5-6.25 mg, 5-6.25 mg
1
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg
1
labetalol hcl oral tablet 100 mg, 200 mg, 300 mg
1
metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg
1
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
1
metoprolol-hydrochlorothiazide oral tablet 10025 mg, 100-50 mg, 50-25 mg
1
nadolol oral tablet 20 mg, 40 mg, 80 mg
1
nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg
2
pindolol oral tablet 10 mg, 5 mg
1
propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg
1
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
1
propranolol-hctz oral tablet 40-25 mg, 80-25 mg
2
timolol maleate oral tablet 10 mg, 20 mg, 5 mg
2
Instrucciones (Instructions)
Calcium Channel Blocking Agents (Bloqueadores de Canales de Calcio) amlodipine besy-benazepril hcl oral capsule 1020 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg
1
amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg
1
diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
1
65
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg
1
diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg
2
diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg
1
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg
1
nicardipine hcl oral capsule 20 mg, 30 mg
1
nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg
1
nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg
1
nimodipine oral capsule 30 mg
2
verapamil hcl er oral tablet extended release 120 mg, 240 mg
1
verapamil hcl oral tablet 120 mg, 40 mg, 80 mg
1
Instrucciones (Instructions)
Cardiovascular Agents, Other (Cardiovasculares, Otros) digoxin oral tablet 125 mcg, 250 mcg
1
pentoxifylline er oral tablet extended release 400 mg
1
phenoxybenzamine hcl oral capsule 10 mg
2
RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG
4
PA
3
PA
Combinations, Other (Combinación, Otros) ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG
Diuretics, Carbonic Anhydrase Inhibitors (Diuréticos Inhibidores de Anhidrasa Carbónica) acetazolamide oral tablet 125 mg, 250 mg
1
methazolamide oral tablet 25 mg, 50 mg
1
Diuretics, Loop (Diuréticos del Asa)
66
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
bumetanide injection solution 0.25 mg/ml
1
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg
1
furosemide injection solution 10 mg/ml
1
furosemide oral solution 10 mg/ml, 8 mg/ml
1
furosemide oral tablet 20 mg, 40 mg, 80 mg
1
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg
1
Instrucciones (Instructions)
Diuretics, Potassium-Sparing (Diuréticos Conservadores de Potasio) ALDACTAZIDE ORAL TABLET 50-50 MG
4
amiloride hcl oral tablet 5 mg
1
amiloride-hydrochlorothiazide oral tablet 5-50 mg
1
eplerenone oral tablet 25 mg, 50 mg
2
spironolactone oral tablet 100 mg, 25 mg, 50 mg
1
spironolactone-hctz oral tablet 25-25 mg
1
triamterene-hctz oral capsule 37.5-25 mg, 50-25 mg
1
triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg
1
ST
ST
Diuretics, Thiazide (Diuréticos Tiazidas) chlorothiazide oral tablet 250 mg, 500 mg
1
chlorthalidone oral tablet 25 mg, 50 mg, 100 mg
1
hydrochlorothiazide oral capsule 12.5 mg
1
hydrochlorothiazide oral tablet 25 mg, 50 mg
1
indapamide oral tablet 1.25 mg, 2.5 mg
1
metolazone oral tablet 10 mg, 2.5 mg, 5 mg
1
Dyslipidemics, Fibric Acid Derivatives (Dislipidémicos, Derivados de Ácido Fíbrico) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg
1
fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg
1
67
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
fenofibric acid oral capsule delayed release 135 mg, 45 mg
1
gemfibrozil oral tablet 600 mg
1
Instrucciones (Instructions)
Dyslipidemics, HMG-CoA Reductase Inhibitors (Dislipidémicos, Inhibidores de la Reductasa de HMG-CoA) atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg
1
ezetimibe-simvastatin oral tablet 10-10 mg, 1020 mg, 10-40 mg, 10-80 mg
2
pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg
1
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
simvastatin oral tablet 80 mg
1
ST
ST
Dyslipidemics, Other (Dislipidémicos, Otros) cholestyramine light oral packet 4 gm
2
cholestyramine light oral powder 4 gm/dose
1
cholestyramine oral packet 4 gm
2
cholestyramine oral powder 4 gm/dose
1
colestipol hcl oral granules 5 gm
1
colestipol hcl oral tablet 1 gm
1
ezetimibe oral tablet 10 mg
1
niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg
2
omega-3-acid ethyl esters oral capsule 1 gm
2
WELCHOL ORAL PACKET 3.75 GM
4
WELCHOL ORAL TABLET 625 MG
4
ST
Vasodilators, Direct-Acting Arterial (Vasodilatadores, Arteriales) hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg
1
minoxidil oral tablet 10 mg, 2.5 mg
1
68
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Vasodilators, Direct-Acting Arterial/Venous (Vasodilatadores, Arteriales/Venosos) ISORDIL TITRADOSE ORAL TABLET 40 MG
4
isosorbide dinitrate er oral tablet extended release 40 mg
1
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg
1
isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg
1
isosorbide mononitrate oral tablet 10 mg, 20 mg
1
nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg
2
nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
1
Central Nervous System Agents (Sistema Nervioso Central) Attention Deficit Hyperactivity Disorder Agents, Amphetamines (Anfetaminas, ADHD) amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
1
PA; SL; AL (less than or equal to 18 years); QL (3 TAB per 1 day)
amphetamine-dextroamphetamine oral tablet 30 mg
1
PA; SL; AL (less than or equal to 18 years); QL (1 TAB per 1 day)
dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg
1
PA; ST; SL; AL (less than or equal to 18 years); QL (4 CAP per 1 day)
dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg
1
PA; ST; SL; AL (less than or equal to 18 years); QL (3 CAP per 1 day)
dextroamphetamine sulfate oral tablet 5 mg
1
PA; SL; AL (less than or equal to 18 years); QL (3 TAB per 1 day)
Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines (No-Anfetaminas, ADHD) clonidine hcl er oral tablet extended release 12 hour 0.1 mg
2
PA; ST; SL; AL (less than or equal to 18 years); QL (4 TAB per 1 day)
methylphenidate hcl er oral tablet extended release 10 mg, 20 mg
2
PA; SL; AL (less than or equal to 18 years); QL (1 TAB per 1 day)
methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg
1
PA; SL; AL (less than or equal to 18 years); QL (3 TAB per 1 day)
69
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG
3
PA; SL; AL (less than or equal to 18 years); QL (3 TAB per 1 day)
QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 30 MG
3
PA; SL; AL (less than or equal to 18 years); QL (2 TAB per 1 day)
QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 40 MG
3
PA; SL; AL (less than or equal to 18 years); QL (1 TAB per 1 day)
atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg
2
PA; ST; SL; AL (less than or equal to 18 years); QL (3 CAP per 1 day)
atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg
2
PA; ST; SL; AL (less than or equal to 18 years); QL (1 CAP per 1 day)
Central Nervous System Agents, Others (Sistema Nervioso Central, Otros) BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT
6
PA
DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 300 UNIT, 500 UNIT
6
PA
MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT/2ML, 2500 UNIT/0.5ML, 5000 UNIT/ML
6
PA
riluzole oral tablet 50 mg
5
PA
tetrabenazine oral tablet 12.5 mg, 25 mg
6
XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 50 UNIT
6
PA
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG
6
PA
AVONEX INTRAMUSCULAR KIT 30 MCG
5
AVONEX PEN INTRAMUSCULAR AUTOINJECTOR KIT 30 MCG/0.5ML
5
AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML
5
COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML
5
EXTAVIA SUBCUTANEOUS KIT 0.3 MG
5
Multiple Sclerosis Agents (Esclerosis Múltiple)
70
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
GILENYA ORAL CAPSULE 0.5 MG
6
LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2ML
6
PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML
5
PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML
5
PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 125 MCG/0.5ML
5
PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML
5
REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML
6
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTOINJECTOR 6X8.8 & 6X22 MCG
6
REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML
6
REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG
6
TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML
5
PA
chlorhexidine gluconate mouth/throat solution 0.12 %
1
QL (473 ML per 15 days)
pilocarpine hcl oral tablet 5 mg, 7.5 mg
1
triamcinolone acetonide mouth/throat paste 0.1 %
2
PA
Dental and Oral Agents (Dentales y Orales) Dental and Oral Agents (Dentales y Orales)
Dermatological Agents (Dermatológicos)
QL (5 GM per 15 days)
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Acne Agents (Acné) ABSORICA ORAL CAPSULE 25 MG, 35 MG
4
claravis oral capsule 10 mg, 20 mg, 40 mg
2
claravis oral capsule 30 mg
1
tazarotene external cream 0.1 %
2
PA; QL (60 GM per 15 days)
TAZORAC EXTERNAL CREAM 0.05 %
4
PA; QL (60 GM per 15 days)
TAZORAC EXTERNAL GEL 0.05 %, 0.1 %
4
PA; QL (100 GM per 15 days)
tretinoin external cream 0.025 %, 0.05 %, 0.1 %
2
SL; AL (less than or equal to 23 years); QL (45 GM per 15 days)
tretinoin external gel 0.01 %, 0.025 %
2
SL; AL (less than or equal to 23 years); QL (45 GM per 15 days)
clindamycin phosphate external solution 1 %
1
QL (60 ML per 15 days)
erythromycin external gel 2 %
1
QL (60 GM per 15 days)
erythromycin external solution 2 %
1
QL (60 ML per 15 days)
gentamicin sulfate external cream 0.1 %
2
QL (30 GM per 15 days)
gentamicin sulfate external ointment 0.1 %
2
QL (30 GM per 15 days)
metronidazole external cream 0.75 %
2
QL (45 GM per 15 days)
metronidazole external gel 0.75 %
2
QL (45 GM per 15 days)
metronidazole external lotion 0.75 %
2
QL (59 ML per 15 days)
MIRVASO EXTERNAL GEL 0.33 %
4
QL (30 GM per 15 days)
mupirocin external ointment 2 %
1
QL (30 GM per 15 days)
silver sulfadiazine external cream 1 %
1
QL (400 GM per 15 days)
ciclopirox external solution 8 %
2
QL (6.6 ML per 90 days)
clotrimazole external cream 1 %
1
QL (45 GM per 15 days)
clotrimazole external solution 1 %
1
QL (30 ML per 15 days)
clotrimazole-betamethasone external cream 10.05 %
2
AL (greater than or equal to 18 years); QL (45 GM per 15 days)
Antibacterials (Antibacterianos)
Antifungals (Antifungales)
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
clotrimazole-betamethasone external lotion 10.05 %
2
AL (greater than or equal to 18 years); QL (30 ML per 15 days)
econazole nitrate external cream 1 %
1
QL (85 GM per 15 days)
ketoconazole external cream 2 %
1
QL (60 GM per 15 days)
ketoconazole external shampoo 2 %
1
QL (120 ML per 15 days)
nystatin external cream 100000 unit/gm
1
QL (30 GM per 15 days)
nystatin external ointment 100000 unit/gm
1
QL (30 GM per 15 days)
nystatin-triamcinolone external cream 1000000.1 unit/gm-%
2
QL (60 GM per 15 days)
nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%
2
QL (60 GM per 15 days)
CONDYLOX EXTERNAL GEL 0.5 %
4
QL (3.5 GM per 15 days)
podofilox external solution 0.5 %
2
QL (3.5 ML per 15 days)
Caustic Agents (Caústicos)
Dermatological Calcineurin Inhibitor Immunosuppresants (Inhibidores de Calcineurina) ELIDEL EXTERNAL CREAM 1 %
4
ST; QL (100 GM per 15 days)
tacrolimus external ointment 0.03 %, 0.1 %
2
ST; QL (100 GM per 15 days)
ammonium lactate external cream 12 %
1
QL (385 GM per 15 days)
ammonium lactate external lotion 12 %
1
QL (420 GM per 15 days)
1
QL (120 ML per 15 days)
Dermatological Emollients (Emolientes)
Mitotic Inhibitors (Inhibidores de la Mitosis) selenium sulfide external lotion 2.5 %
Non-Melanoma Skin Cancer Agents (Cáncer de la Piel No-Meloma) diclofenac sodium transdermal gel 3 %
2
QL (100 GM per 15 days)
fluorouracil external cream 0.5 %
2
QL (30 GM per 15 days)
fluorouracil external cream 5 %
1
QL (40 GM per 15 days)
Photochemotherapy Agents (Fotoquimioterapia) methoxsalen rapid oral capsule 10 mg
Psoriasis Agents (Psoriasis)
2
73
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
acitretin oral capsule 10 mg, 17.5 mg, 25 mg
2
calcipotriene external cream 0.005 %
2
QL (120 GM per 15 days)
calcipotriene external solution 0.005 %
2
QL (60 ML per 15 days)
calcitriol external ointment 3 mcg/gm
2
QL (100 GM per 15 days)
SOOLANTRA EXTERNAL CREAM 1 %
3
QL (30 GM per 30 days)
2
QL (24 EA per 15 days)
REGRANEX EXTERNAL GEL 0.01 %
6
PA; QL (15 GM per 15 days)
SANTYL EXTERNAL OINTMENT 250 UNIT/GM
4
QL (30 GM per 15 days)
Wart Agents (Verrugas) imiquimod external cream 5 %
Wound-Care Agents (Cuidado de Heridas)
Enzyme Replacements/Modifiers (Reemplazo de Enzimas/Modificadores) Anti-Cystine Agents (Anti-Cistina) CYSTAGON ORAL CAPSULE 150 MG, 50 MG
6
PA
6
PA
Fabry Disease (Enfermedad de Fabry) FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG, 5 MG
Gaucher's Disease Treatment (Enfermedad de Gaucher) CERDELGA ORAL CAPSULE 84 MG
6
PA
CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT
6
PA
ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED 200 UNIT
6
PA
VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT
6
PA
Glucosylceramide Synthase Inhibitors (Inhibidores de la Sintetasa de Glucosilceramida) ZAVESCA ORAL CAPSULE 100 MG
6
PA
6
PA
Homocystinuria Treatment (Homocistinuria) CYSTADANE ORAL POWDER
Hunter Syndrome Treatment (Síndrome de Hunter)
74
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs) ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML
Nivel (Level) 6
Instrucciones (Instructions) PA
Mucopolysaccharidosis Disease Treatment (Mucopolisacaridosis) ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML
6
PA
NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML
6
PA
VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML
6
PA
6
PA
Phenylketonuria Treatment (Fenilcetonuria) KUVAN ORAL TABLET SOLUBLE 100 MG
Severe Combined Immunodeficiency Disease (SCID) Treatment (Inmunodeficiencia Combinada Severa) ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML
6
PA
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG
6
PA
ORFADIN ORAL SUSPENSION 4 MG/ML
6
PA
Tyrosinemia Treatment (Tirosinemia)
Urea Cycle Disorder Treatment (Desorden del Ciclo de Urea) BUPHENYL ORAL TABLET 500 MG
6
PA
sodium phenylbutyrate oral powder 3 gm/tsp
5
PA
Gastrointestinal Agents (Gastrointestinales) Antispasmodics, Gastrointestinal (Antiespasmódicos, Gastrointestinales) dicyclomine hcl oral capsule 10 mg
1
dicyclomine hcl oral tablet 20 mg
1
glycopyrrolate oral tablet 1 mg, 2 mg
1
methscopolamine bromide oral tablet 2.5 mg, 5 mg
1
Enzyme Replacement (Remplazo Enzimático)
75
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT
Nivel (Level)
Instrucciones (Instructions)
4
Gastrointestinal Agents, Others (Gastrointestinales, Otros) cromolyn sodium oral concentrate 100 mg/5ml
1
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml
2
diphenoxylate-atropine oral tablet 2.5-0.025 mg
1
hydrocortisone rectal cream 2.5 %
1
hydrocortisone rectal enema 100 mg/60ml
1
loperamide hcl oral capsule 2 mg
1
MYTESI ORAL TABLET DELAYED RELEASE 125 MG
6
ursodiol oral capsule 300 mg
1
ursodiol oral tablet 250 mg, 500 mg
1
XIFAXAN ORAL TABLET 200 MG, 550 MG
4
QL (30 GM per 15 days)
PA; QL (2 TAB per 1 day)
PA
Histamine2 (H2) Receptor Antagonists (Antagonistas del Receptor de Histamina2 (H2)) cimetidine hcl oral solution 300 mg/5ml
1
cimetidine oral tablet 300 mg, 400 mg, 800 mg
1
famotidine intravenous solution 20 mg/2ml
1
famotidine oral tablet 20 mg, 40 mg
1
ranitidine hcl injection solution 150 mg/6ml, 50 mg/2ml
1
ranitidine hcl oral syrup 15 mg/ml
1
ranitidine hcl oral tablet 150 mg, 300 mg
1
ZANTAC INJECTION SOLUTION 1000 MG/40ML
4
Irritable Bowel Syndrome Agents (Síndrome de Colon Irritado) alosetron hcl oral tablet 0.5 mg, 1 mg
2
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG
4
SL; QL (2 CAP per 1 day)
RELISTOR ORAL TABLET 150 MG
4
PA; QL (3 TAB per 1 day)
76
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Laxatives (Laxantes) lactulose encephalopathy oral solution 10 gm/15ml
1
lactulose oral solution 10 gm/15ml
1
peg 3350/electrolytes oral solution reconstituted 240 gm
2
QL (4000 ML per 15 days)
peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm
1
QL (4000 ML per 15 days)
peg-3350/electrolytes oral solution reconstituted 236 gm
1
QL (4000 ML per 15 days)
6
PA
Miscellaneous (Misceláneos) CHOLBAM ORAL CAPSULE 250 MG, 50 MG
Protectants (Protectores) CARAFATE ORAL SUSPENSION 1 GM/10ML
4
misoprostol oral tablet 100 mcg, 200 mcg
2
sucralfate oral tablet 1 gm
1
Proton Pump Inhibitors (Inhibidores de la Bomba de Protones) esomeprazole magnesium cap delayed release 20 mg
OTC
lansoprazole oral capsule delayed release 15 mg
1
lansoprazole oral capsule delayed release 15 mg
OTC
lansoprazole oral capsule delayed release 30 mg
1
NEXIUM 24HR CAPSULE DELAYED RELEASE 20 MG ORAL omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg
ST
OTC 1
omeprazole delayed release tab 20 mg
OTC
omeprazole magnesium delayed release tab 20 mg (base equiv)
OTC
omeprazole-sodium bicarbonate oral capsule 20-1100 mg
1
ST
77
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs) omeprazole-sodium bicarbonate cap 20-1100 mg
Nivel (Level)
Instrucciones (Instructions)
OTC
pantoprazole sodium intravenous solution reconstituted 40 mg
2
pantoprazole sodium oral tablet delayed release 20 mg, 40 mg
1
PREVACID 24HR CAPSULE DELAYED RELEASE 15 MG ORAL
OTC
PRILOSEC OTC TABLET DELAYED RELEASE 20 MG ORAL
OTC
ZEGERID OTC CAPSULE 20-1100 MG ORAL
OTC
Genitourinary Agents (Genitourinarios) Antispasmodics, Urinary (Antiespasmódicos, Urinarios) bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg
1
darifenacin hydrobromide er oral tablet extended release 24 hour 15 mg, 7.5 mg
2
flavoxate hcl oral tablet 100 mg
2
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG
4
oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg
1
oxybutynin chloride oral tablet 5 mg
1
tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg
2
tolterodine tartrate oral tablet 1 mg, 2 mg
2
ST
Benign Prostatic Hypertrophy Agents (Hipertrofia Prostática Benigna) finasteride oral tablet 5 mg
1
tamsulosin hcl oral capsule 0.4 mg
1
Genitourinary Agents, Others (Genitourinarios, Otros) DEPEN TITRATABS ORAL TABLET 250 MG
4
ELMIRON ORAL CAPSULE 100 MG
4
78
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
phenazopyridine hcl oral tablet 100 mg, 200 mg
1
Instrucciones (Instructions)
Phosphate Binders (Enlazadores de Fosfato) calcium acetate (phos binder) oral capsule 667 mg
1
RENAGEL ORAL TABLET 400 MG, 800 MG
4
PA
sevelamer oral packet 0.8 gm, 2.4 gm
2
PA
sevelamer oral tablet 800 mg
2
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) (Hormonales, Estimulante/Reemplazo/Modificador (Adrenal)) Glucocorticoids / Mineralocorticoids (Glucocorticoides/Mineralocorticoides) alclometasone dipropionate external cream 0.05 %
1
QL (60 GM per 15 days)
alclometasone dipropionate external ointment 0.05 %
1
QL (60 GM per 15 days)
betamethasone dipropionate aug external cream 0.05 %
2
AL (greater than or equal to 12 years); QL (50 GM per 15 days)
betamethasone dipropionate aug external lotion 0.05 %
2
AL (greater than or equal to 12 years); QL (60 ML per 15 days)
betamethasone dipropionate aug external ointment 0.05 %
2
AL (greater than or equal to 12 years); QL (50 GM per 15 days)
betamethasone dipropionate external cream 0.05 %
1
AL (greater than or equal to 12 years); QL (45 GM per 15 days)
betamethasone dipropionate external lotion 0.05 %
1
AL (greater than or equal to 12 years); QL (60 ML per 15 days)
betamethasone dipropionate external ointment 0.05 %
1
AL (greater than or equal to 12 years); QL (45 GM per 15 days)
betamethasone valerate external cream 0.1 %
1
QL (45 GM per 15 days)
betamethasone valerate external lotion 0.1 %
1
QL (60 ML per 15 days)
betamethasone valerate external ointment 0.1 %
1
AL (greater than or equal to 12 years); QL (45 GM per 15 days)
clobetasol propionate e external cream 0.05 %
1
AL (greater than or equal to 12 years); QL (60 GM per 15 days)
79
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
clobetasol propionate external gel 0.05 %
1
AL (greater than or equal to 12 years); QL (60 GM per 15 days)
clobetasol propionate external ointment 0.05 %
1
AL (greater than or equal to 12 years); QL (60 GM per 15 days)
clobetasol propionate external solution 0.05 %
1
AL (greater than or equal to 12 years); QL (50 GM per 15 days)
desonide external cream 0.05 %
2
QL (60 GM per 15 days)
desonide external lotion 0.05 %
2
QL (118 ML per 15 days)
desonide external ointment 0.05 %
2
QL (60 GM per 15 days)
fludrocortisone acetate oral tablet 0.1 mg
1
fluocinolone acetonide body external oil 0.01 %
1
QL (118.28 ML per 15 days)
fluocinolone acetonide external cream 0.01 %
1
QL (60 GM per 15 days)
fluocinolone acetonide external cream 0.025 %
1
AL (greater than or equal to 12 years); QL (60 GM per 15 days)
fluocinolone acetonide external ointment 0.025 %
1
AL (greater than or equal to 12 years); QL (60 GM per 15 days)
fluocinolone acetonide external solution 0.01 %
2
QL (60 ML per 15 days)
fluocinonide external gel 0.05 %
1
AL (greater than or equal to 12 years); QL (60 GM per 15 days)
fluocinonide external ointment 0.05 %
1
AL (greater than or equal to 12 years); QL (60 GM per 15 days)
fluocinonide external solution 0.05 %
1
AL (greater than or equal to 12 years); QL (60 ML per 15 days)
fluocinonide-e external cream 0.05 %
1
AL (greater than or equal to 12 years); QL (60 GM per 15 days)
fluticasone propionate external cream 0.05 %
1
QL (60 GM per 15 days)
fluticasone propionate external ointment 0.005 %
1
QL (60 GM per 15 days)
halobetasol propionate external cream 0.05 %
2
AL (greater than or equal to 12 years); QL (50 GM per 15 days)
halobetasol propionate external ointment 0.05 %
2
AL (greater than or equal to 12 years); QL (50 GM per 15 days)
hydrocortisone external cream 1 %
1
QL (30 GM per 15 days)
80
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
hydrocortisone external cream 2.5 %
1
QL (60 GM per 15 days)
hydrocortisone external lotion 2.5 %
1
QL (118 ML per 15 days)
hydrocortisone external ointment 1 %
1
QL (30 GM per 15 days)
hydrocortisone external ointment 2.5 %
1
QL (60 GM per 15 days)
hydrocortisone valerate external cream 0.2 %
2
QL (60 GM per 15 days)
hydrocortisone valerate external ointment 0.2 %
1
QL (60 GM per 15 days)
mometasone furoate external cream 0.1 %
1
QL (45 GM per 15 days)
mometasone furoate external ointment 0.1 %
1
QL (45 GM per 15 days)
mometasone furoate external solution 0.1 %
1
QL (60 ML per 15 days)
scalacort external lotion 2 %
1
QL (30 ML per 15 days)
triamcinolone acetonide external cream 0.025 %
1
QL (454 GM per 15 days)
triamcinolone acetonide external cream 0.1 %
1
QL (80 GM per 15 days)
triamcinolone acetonide external cream 0.5 %
1
AL (greater than or equal to 12 years); QL (15 GM per 15 days)
triamcinolone acetonide external lotion 0.025 %, 0.1 %
1
QL (60 GM per 15 days)
triamcinolone acetonide external ointment 0.025 %, 0.1 %
1
QL (80 GM per 15 days)
triamcinolone acetonide external ointment 0.5 %
2
AL (greater than or equal to 12 years); QL (15 GM per 15 days)
TRIANEX EXTERNAL OINTMENT 0.05 %
4
QL (80 GM per 15 days)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) (Hormonales, Estimulante/Reemplazo/Modificador (Pituitaria)) Vasopressin Analogs (Análogos de Vasopresina) desmopressin ace spray refrig nasal solution 0.01 %
2
desmopressin acetate injection solution 4 mcg/ml
2
desmopressin acetate oral tablet 0.1 mg, 0.2 mg
1
81
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
desmopressin acetate spray nasal solution 0.01 %
2
STIMATE NASAL SOLUTION 1.5 MG/ML
6
Instrucciones (Instructions)
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) (Hormonales, Estimulante/Reemplazo/Modificador (Hormonas Sexuales/Modificadores)) Anabolic Steroid (Esteroide Anabólico) oxandrolone oral tablet 10 mg, 2.5 mg
2
Androgens (Andrógenos) ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%)
4
QL (75 GM per 30 days)
ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%)
4
QL (37.5 GM per 30 days)
ANDROGEL TRANSDERMAL GEL 40.5 MG/2.5GM (1.62%)
4
QL (75 GM per 30 days)
danazol oral capsule 100 mg, 200 mg, 50 mg
2
testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml
2
testosterone enanthate intramuscular solution 200 mg/ml
2
testosterone transdermal gel 10 mg/act (2%)
2
QL (2 GM per 1 day)
testosterone transdermal gel 12.5 mg/act (1%)
2
QL (150 GM per 30 days)
testosterone transdermal gel 25 mg/2.5gm (1%)
2
QL (2.5 GM per 1 day)
testosterone transdermal gel 50 mg/5gm (1%)
2
QL (5 GM per 1 day)
Estrogens (Estrógenos) CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/DAY
4
ESTRACE VAGINAL CREAM 0.1 MG/GM
4
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
1
estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr
2
estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg
1
QL (42.5 GM per 30 days)
82
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG
4
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
3
PREMARIN VAGINAL CREAM 0.625 MG/GM
4
PREMPHASE ORAL TABLET 0.625-5 MG
3
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG
3
estradiol vaginal tablet 10 mcg
1
Instrucciones (Instructions)
QL (30 GM per 30 days)
Progestins (Progestinas) medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg
1
norethindrone acetate oral tablet 5 mg
2
progesterone micronized oral capsule 100 mg, 200 mg
2
Selective Estrogen Receptor Modifying Agents (Modificadores Selectivos del Receptor de Estrógeno) raloxifene hcl oral tablet 60 mg
1
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) (Hormonales, Estimulante/Reemplazo/Modificador (Tiroide)) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) (Hormonales, Estimulante/Reemplazo/Modificador (Tiroide)) levothyroxine sodium 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
1
liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg
1
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
3
Hormonal Agents, Suppressant (Adrenal) (Hormonales, Supresores (Adrenal)) Hormonal Agents, Suppressant (Adrenal) (Hormonales, Supresores (Adrenal))
83
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs) LYSODREN ORAL TABLET 500 MG
Nivel (Level)
Instrucciones (Instructions)
6
Hormonal Agents, Suppressant (Parathyroid) (Hormonales, Supresores (Paratiroide)) Hormonal Agents, Suppressant (Parathyroid) (Hormonales, Supresores (Paratiroide)) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG
4
PA
Hormonal Agents, Suppressant (Pituitary) (Hormonales, Supresores (Pituitaria)) Hormonal Agents, Suppressant (Pituitary) (Hormonales, Supresores (Pituitaria)) cabergoline oral tablet 0.5 mg
2
chorionic gonadotropin intramuscular solution reconstituted 10000 unit
6
PA
LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG
4
PA
LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED), 30 MG (PED)
4
PA
octreotide acetate injection solution 100 mcg/ml 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml
5
PA
SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG
6
PA
SYNAREL NASAL SOLUTION 2 MG/ML
6
PA
Hormonal Agents, Suppressant (Thyroid) (Hormonales, Supresores (Tiroide)) Antithyroid Agents (Antitiroide) methimazole oral tablet 10 mg, 5 mg
1
propylthiouracil oral tablet 50 mg
1
Immunological Agents (Inmunológicos) Angioedema Agents (Agentes para el Tratamiento de Angioedema) CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT
6
PA
84
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML
Instrucciones (Instructions)
6
PA; AL (greater than or equal to 18 years)
azathioprine oral tablet 50 mg
1
SL
COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTOINJECTOR 150 MG/ML
6
PA
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML
5
PA
ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG
5
PA
ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML
5
PA
HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML
5
PA
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML
5
PA
methotrexate oral tablet 2.5 mg
1
mycophenolate mofetil oral capsule 250 mg
1
SL
mycophenolate mofetil oral suspension reconstituted 200 mg/ml
2
SL
mycophenolate mofetil oral tablet 500 mg
1
SL
ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML
6
PA
ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG
6
PA
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML, 87.5 MG/ML , 125 MG/ML
6
PA
REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG
6
PA
Immune Suppressants (Supresores Inmunológicos)
85
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
STELARA INTRAVENOUS SOLUTION 130 MG/26ML
6
PA
STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML
6
PA
STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML
6
PA
ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML, 400 MG/20ML, 80 MG/4ML
6
PA
ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML
6
PA
ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG
6
PA
leflunomide oral tablet 10 mg, 20 mg
1
PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML
6
PA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML
6
PA
PEG-INTRON REDIPEN SUBCUTANEOUS KIT 150 MCG/0.5ML, 50 MCG/0.5ML
6
PA
PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 80 MCG/0.5ML
6
PA
RIDAURA ORAL CAPSULE 3 MG
4
Immunomodulators (Inmunomoduladores)
Inflammatory Bowel Disease Agents (Enfermedad Inflamatoria Intestinal) Aminosalicylates (Aminosalicilatos) APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM
4
balsalazide disodium oral capsule 750 mg
2
CANASA RECTAL SUPPOSITORY 1000 MG
3
DIPENTUM ORAL CAPSULE 250 MG
4
mesalamine oral tablet delayed release 800 mg
2
mesalamine rectal enema 4 gm
2
86
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
mesalamine-cleanser rectal kit 4 gm
2
PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG
3
Instrucciones (Instructions)
Glucocorticoids (Glucocorticoides) budesonide oral capsule delayed release particles 3 mg
2
PA
Sulfonamides (Sulfonamidas) sulfasalazine oral tablet 500 mg
1
sulfasalazine oral tablet delayed release 500 mg
1
Metabolic Bone Disease Agents (Enfermedad del Metabolismo del Hueso) Metabolic Bone Disease Agents (Enfermedad del Metabolismo del Hueso) alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg
1
calcitonin (salmon) nasal solution 200 unit/act
2
calcitriol oral capsule 0.25 mcg, 0.5 mcg
1
calcitriol oral solution 1 mcg/ml
1
etidronate disodium oral tablet 200 mg, 400 mg
2
FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML
5
PA; QL (2.4 ML per 30 days)
ibandronate sodium intravenous solution 3 mg/3ml
5
PA
MIACALCIN INJECTION SOLUTION 200 UNIT/ML
4
paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml
2
PA
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg
2
PA
PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML
6
PA; QL (1 ML per 180 days)
zoledronic acid intravenous solution 5 mg/100ml
5
PA; QL (100 ML per 365 days)
Ophthalmic Agents (Oftálmicos)
QL (3.7 ML per 30 days)
87
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Anti-Allergy Agents (Antialérgicos) cromolyn sodium ophthalmic solution 4 % ketotifen fumarate ophth soln 0.025% olopatadine hcl ophthalmic solution 0.1 % ZADITOR SOLUTION 0.025 % OPHTHALMIC
1
QL (10 ML per 15 days)
OTC 1
QL (5 ML per 15 days)
OTC
Antibacterials (Antibacterianos) bacitracin ophthalmic ointment 500 unit/gm
2
QL (3.5 GM per 15 days)
bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm
2
QL (3.5 GM per 15 days)
BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %
4
QL (10 ML per 15 days)
BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %
4
QL (3.5 GM per 15 days)
ciprofloxacin hcl ophthalmic solution 0.3 %
1
QL (10 ML per 15 days)
erythromycin ophthalmic ointment 5 mg/gm
1
QL (3.5 GM per 15 days)
gentamicin sulfate ophthalmic ointment 0.3 %
1
QL (3.5 GM per 15 days)
gentamicin sulfate ophthalmic solution 0.3 %
1
QL (15 ML per 15 days)
MOXEZA OPHTHALMIC SOLUTION 0.5 %
3
QL (3 ML per 15 days)
moxifloxacin ophthalmic solution 0.5 %
2
QL (3 ML per 15 days)
neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000
2
QL (3.5 GM per 15 days)
neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1
1
QL (3.5 GM per 15 days)
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
1
QL (5 ML per 15 days)
neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025
2
QL (10 ML per 15 days)
neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1
2
QL (7.5 ML per 15 days)
ofloxacin ophthalmic solution 0.3 %
1
QL (10 ML per 15 days)
polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%
1
QL (10 ML per 15 days)
88
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
sulfacetamide-prednisolone ophthalmic solution 10-0.23 %
1
QL (10 ML per 15 days)
tobramycin ophthalmic solution 0.3 %
1
QL (5 ML per 15 days)
tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %
2
QL (10 ML per 15 days)
TOBREX OPHTHALMIC OINTMENT 0.3 %
4
QL (3.5 GM per 15 days)
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %
3
QL (15 ML per 30 days)
AZOPT OPHTHALMIC SUSPENSION 1 %
3
ST; QL (15 ML per 30 days)
betaxolol hcl ophthalmic solution 0.5 %
2
QL (15 ML per 30 days)
brimonidine tartrate ophthalmic solution 0.15 %
2
QL (15 ML per 30 days)
brimonidine tartrate ophthalmic solution 0.2 %
1
QL (15 ML per 30 days)
carteolol hcl ophthalmic solution 1 %
2
QL (15 ML per 30 days)
COSOPT PF OPHTHALMIC SOLUTION 22.36.8 MG/ML
4
QL (60 ML per 30 days)
dorzolamide hcl ophthalmic solution 2 %
1
QL (10 ML per 30 days)
dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml
1
QL (10 ML per 30 days)
levobunolol hcl ophthalmic solution 0.5 %
1
QL (15 ML per 30 days)
metipranolol ophthalmic solution 0.3 %
2
QL (10 ML per 30 days)
PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %
4
QL (5 ML per 30 days)
timolol maleate ophthalmic solution 0.25 %, 0.5 %
1
QL (15 ML per 30 days)
ACUVAIL OPHTHALMIC SOLUTION 0.45 %
4
QL (30 ML per 15 days)
dexamethasone sodium phosphate ophthalmic solution 0.1 %
1
QL (5 ML per 15 days)
diclofenac sodium ophthalmic solution 0.1 %
1
QL (5 ML per 15 days)
Antiglaucoma Agents (Antiglaucoma)
Anti-Inflammatories (Anti-Inflamatorios)
89
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
flurbiprofen sodium ophthalmic solution 0.03 %
1
QL (2.5 ML per 15 days)
ketorolac tromethamine ophthalmic solution 0.4 %
1
QL (5 ML per 15 days)
ketorolac tromethamine ophthalmic solution 0.5 %
1
QL (10 ML per 15 days)
prednisolone acetate ophthalmic suspension 1 %
2
QL (15 ML per 15 days)
NATACYN OPHTHALMIC SUSPENSION 5 %
4
QL (15 ML per 15 days)
RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %
4
PA; QL (30 EA per 15 days)
trifluridine ophthalmic solution 1 %
2
QL (7.5 ML per 15 days)
XIIDRA OPHTHALMIC SOLUTION 5 %
4
PA; QL (60 ML per 15 days)
Ophthalmic Agents, Others (Oftálmicos, Otros)
Prostaglandins and Prostamides (Prostaglandinas y Prostamidas) latanoprost ophthalmic solution 0.005 %
1
QL (2.5 ML per 30 days)
LUMIGAN OPHTHALMIC SOLUTION 0.01 %
3
QL (7.5 ML per 30 days)
TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %
3
QL (5 ML per 30 days)
ZIOPTAN OPHTHALMIC SOLUTION 0.0015 %
4
QL (30 ML per 30 days)
fluocinolone acetonide otic oil 0.01 %
2
QL (20 ML per 15 days)
hydrocortisone-acetic acid otic solution 1-2 %
2
QL (10 ML per 15 days)
CIPRO HC OTIC SUSPENSION 0.2-1 %
4
QL (10 ML per 15 days)
CIPRODEX OTIC SUSPENSION 0.3-0.1 %
3
QL (7.5 ML per 15 days)
neomycin-polymyxin-hc otic solution 3.5-100001
1
QL (10 ML per 15 days)
neomycin-polymyxin-hc otic suspension 3.510000-1
1
QL (10 ML per 15 days)
Otic Agents (Oticos) Anti-Inflammatories (Anti-Inflamatorios)
Antibacterials (Antibacterianos)
90
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
1
QL (20 ML per 15 days)
acetic acid otic solution 2 %
2
QL (15 ML per 15 days)
acetic acid-aluminum acetate otic solution 2 %
2
QL (60 ML per 15 days)
ofloxacin otic solution 0.3 %
Otic, Miscellaneous (Óticos, Misceláneos)
Respiratory Tract/Pulmonary Agents (Tracto Respiratorio) Antihistamines (Antihistamínicos) ALLEGRA ORAL TAB 180 MG, 60 MG; ORAL SUSP 30 MG/5ML
OTC
ALLEGRA-D ORAL TAB SR 12HR 180-240 MG, 60-120 MG
OTC
azelastine hcl nasal solution 0.1 %
1
QL (30 ML per 30 days)
azelastine hcl nasal solution 0.15 %
2
QL (30 ML per 30 days)
cetirizine hcl oral cap 10 mg; oral tab 10 mg, 5 mg; oral chew tab 10 mg, 5mg; oral syrup 1 mg/ml; oral soln 1 mg/ml
OTC
cetirizine-pseudoephedrine oral tab sr 12hr 5120 mg
OTC
CLARITIN ORAL CAP 10 MG; ORAL TAB 10 MG; ORAL CHEW TAB 5 MG; ORAL SYRUP 5 MG/5ML; ORALLY DISINTEGRATING TAB 5 MG; RAPIDLY DISINTEGRATING TAB 10 MG
OTC
CLARITIN-D ORAL TAB SR 12HR 10-240 MG, 5-120 MG
OTC
diphenhydramine hcl oral capsule 50 mg
1
fexofenadine oral tab 180 mg, 60 mg; oral susp 30 mg/5ml
OTC
fexofenadine-pseudoephedrine oral tab sr 12hr 180-240 mg, 60-120 mg
OTC
levocetirizine dihydrochloride oral tablet 5 mg
1
loratadine oral cap 10 mg; oral tab 10 mg; oral chew tab 5 mg; oral syrup 5 mg/5ml; orally disintegrating tab 5 mg; rapidly disintegrating tab 10 mg
OTC
ST
91
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs) loratadine-pseudoephedrine oral tab sr 12hr 10-240 mg, 5-120 mg olopatadine hcl nasal solution 0.6 %
Nivel (Level)
Instrucciones (Instructions)
OTC 2
ZYRTEC ORAL CAP 10 MG; ORAL TAB 10 MG, 5 MG; ORAL CHEW TAB 10 MG, 5MG; ORAL SYRUP 1 MG/ML; ORAL SOLN 1 MG/ML; ORALLY DISINTEGRATING TAB 10 MG
OTC
ZYRTEC-D ORAL TAB SR 12HR 5-120 MG
OTC
QL (30.5 GM per 30 days)
Anti-Inflammatories, Inhaled Corticosteroids (Anti-Inflamatorios, Corticosteroides Inhalados) ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE
3
QL (60 EA per 30 days)
ADVAIR HFA INHALATION AEROSOL 11521 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT
3
QL (12 GM per 30 days)
AEROSPAN INHALATION AEROSOL SOLUTION 80 MCG/ACT
4
ST; QL (8.9 GM per 30 days)
ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT
3
QL (30 EA per 30 days)
ASMANEX INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH
4
ST; QL (1 EA per 30 days)
budesonide inhalation suspension 0.25 mg/2ml
2
QL (120 ML per 30 days)
budesonide inhalation suspension 0.5 mg/2ml
2
QL (60 ML per 30 days)
budesonide inhalation suspension 1 mg/2ml
2
QL (30 ML per 30 days)
DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT
4
QL (17.6 GM per 30 days)
FLONASE SENSIMIST SUSPENSION 27.5 MCG/SPRAY NASAL
OTC
FLONASE ALLERGY RELIEF SUSPENSION 50 MCG/ACT NASAL
OTC
92
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST
3
QL (60 EA per 30 days)
FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT
3
QL (24 GM per 30 days)
FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT
3
QL (21.2 GM per 30 days)
flunisolide nasal solution 25 mcg/act (0.025%)
1
QL (25 ML per 30 days)
fluticasone propionate nasal suspension 50 mcg/act
1
QL (16 ML per 30 days)
fluticasone propionate nasal suspension 50 mcg/act
OTC
NASACORT ALLERGY 24HR AEROSOL 55 MCG/ACT NASAL
OTC
QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 MCG/ACT
4
ST; QL (4.9 GM per 30 days)
QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT
4
ST; QL (8.7 GM per 30 days)
QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT
3
QL (17.4 GM per 30 days)
QVAR INHALATION AEROSOL SOLUTION 80 MCG/ACT
3
QL (8.7 GM per 30 days)
SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT
3
QL (10.2 GM per 30 days)
triamcinolone acetonide nasal aerosol 55 mcg/act
1
ST; QL (16.5 GM per 30 days)
triamcinolone acetonide nasal aerosol 55 mcg/act
OTC
VERAMYST SUSPENSION 27.5 MCG/SPRAY NASAL
4
Antileukotrienes (Antileukotrienos) montelukast sodium oral packet 4 mg
2
montelukast sodium oral tablet 10 mg
1
ST; QL (10 GM per 30 days)
93
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
montelukast sodium oral tablet chewable 4 mg, 5 mg
1
zafirlukast oral tablet 10 mg, 20 mg
2
Instrucciones (Instructions)
Antitussives (Antitusivos) CAPITAL/CODEINE SUSPENSION 120-12 MG/5ML ORAL
4
guaifenesin-codeine solution 100-10 mg/5ml oral
1
QL (90 ML per 1 day)
Bronchodilators, Anticholinergic (Broncodilatadores, Anticolinérgicos) ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT
4
QL (25.8 GM per 30 days)
BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 MCG/ACT
3
QL (10.7 GM per 30 days)
COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT
4
QL (4 GM per 30 days)
ipratropium bromide inhalation solution 0.02 %
1
QL (300 ML per 30 days)
ipratropium bromide nasal solution 0.03 %
1
QL (60 ML per 30 days)
ipratropium bromide nasal solution 0.06 %
1
QL (30 ML per 30 days)
SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG
3
QL (1 CAP per 1 day)
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT
3
QL (4 GM per 30 days)
STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT
3
QL (4 GM per 30 days)
TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT
3
QL (1 EA per 30 days)
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) (Broncodilatadores, Inhibidores de la Fosfodiesterasa (Xantinas)) terbutaline sulfate oral tablet 2.5 mg, 5 mg
1
Bronchodilators, Sympathomimetic (Broncodilatadores, Simpatomiméticos)
94
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%
1
QL (540 ML per 30 days)
albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%
1
QL (40 ML per 30 days)
albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml
1
QL (360 ML per 30 days)
albuterol sulfate oral syrup 2 mg/5ml
1
albuterol sulfate oral tablet 2 mg, 4 mg
2
epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml
2
QL (2 PEN per 365 days)
levalbuterol tartrate inhalation aerosol 45 mcg/act
2
QL (30 GM per 30 days)
PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT
3
QL (17 GM per 30 days)
PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT
3
QL (2 EA per 30 days)
PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT
3
QL (13.4 GM per 30 days)
SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE
4
QL (60 EA per 30 days)
STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT
3
QL (4 GM per 30 days)
Cystic Fibrosis Agents (Agentes Para Fibrosis Quistica) tobramycin inhalation nebulization solution 300 mg/5ml
5
PA
Mast Cell Stabilizers (Estabilizadores De Mastocitos) cromolyn sodium inhalation nebulization solution 20 mg/2ml
1
QL (240 ML per 30 days)
Phosphodiesterase Inhibitors, Airways Disease (Inhibidores De Fosfodiesterasa) aminophylline intravenous solution 25 mg/ml
1
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML
4
95
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg, 450 mg
1
theophylline er oral tablet extended release 24 hour 400 mg, 600 mg
1
Instrucciones (Instructions)
Pulmonary Antihypertensives (Anti-Hipertensivos Pulmonales) LETAIRIS ORAL TABLET 10 MG, 5 MG
5
PA
sildenafil citrate oral tablet 20 mg
5
PA
TRACLEER ORAL TABLET 125 MG, 62.5 MG
6
PA
VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML
6
PA
Respiratory Tract Agents, Others (Tracto Respiratorio, Otros) acetylcysteine inhalation solution 10 %
1
QL (1200 ML per 15 days)
acetylcysteine inhalation solution 20 %
1
QL (600 ML per 15 days)
ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG
6
PA
ESBRIET ORAL CAPSULE 267 MG
6
PA
ESBRIET ORAL TABLET 267 MG, 801 MG
6
PA
GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML
6
PA
OFEV ORAL CAPSULE 100 MG, 150 MG
6
PA
PULMOZYME INHALATION SOLUTION 1 MG/ML
6
PA
TYZINE SOLUTION 0.05 % NASAL
4
QL (15 ML per 15 days)
XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG
6
PA
Skeletal Muscle Relaxants (Relajantes Musculoesqueletales) Skeletal Muscle Relaxants (Relajantes Musculoesqueletales) chlorzoxazone oral tablet 500 mg
1
cyclobenzaprine hcl oral tablet 10 mg
1
methocarbamol oral tablet 500 mg, 750 mg
1
Sleep Disorder Agents (Desordenes del Sueño)
96
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
GABA Receptor Modulators (Moduladores del Receptor de GABA) estazolam oral tablet 1 mg, 2 mg
1
AL (greater than 18 years); QL (1 TAB per 1 day)
temazepam oral capsule 15 mg, 30 mg
2
AL (greater than 18 years); QL (1 CAP per 1 day)
zaleplon oral capsule 10 mg
1
QL (2 CAP per 1 day)
zaleplon oral capsule 5 mg
1
QL (1 CAP per 1 day)
zolpidem tartrate oral tablet 10 mg, 5 mg
1
QL (1 TAB per 1 day)
2
PA; SL
Sleep Disorder, Other (Desórdenes del Sueño, Otros) modafinil oral tablet 100 mg, 200 mg
Therapeutic Nutrients/Minerals/Electrolytes (Nutrientes Terapéuticos/Minerales/Electrolitos) Antidotes (Antídotos) sodium polystyrene sulfonate oral powder
1
sodium polystyrene sulfonate oral suspension 15 gm/60ml
1
Electrolyte/Mineral Replacement (Remplazo de Electrolitos/Minerales) AMINOSYN II INTRAVENOUS SOLUTION 10 %, 8.5 %
4
AMINOSYN M INTRAVENOUS SOLUTION 3.5 %
4
aminosyn/electrolytes intravenous solution 8.5 %
1
AMINOSYN-PF INTRAVENOUS SOLUTION 7 %
4
CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS SOLUTION 2.75 %
4
CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 %
4
CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 %
4
CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 %
4
97
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 %
4
CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 %
4
CLINIMIX E/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 %
4
CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 %
4
CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION 4.25 %
4
CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS SOLUTION 4.25 %
4
CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 %
4
CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 %
4
CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 %
4
CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 %
4
CLINIMIX/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 %
4
clinisol sf intravenous solution 15 %
1
dextrose in lactated ringers intravenous solution 5 %
1
dextrose intravenous solution 10 %, 5 %
1
dextrose-nacl intravenous solution 10-0.2 %, 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 50.33 %
1
dextrose-nacl intravenous solution 5-0.45 %, 50.9 %
2
HEPATAMINE INTRAVENOUS SOLUTION 8 %
4
intralipid intravenous emulsion 20 %
1
Instrucciones (Instructions)
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
INTRALIPID INTRAVENOUS EMULSION 30 %
4
ISOLYTE-S INTRAVENOUS SOLUTION
4
lactated ringers intravenous solution
1
levocarnitine oral solution 1 gm/10ml
1
levocarnitine oral tablet 330 mg
1
NEPHRAMINE INTRAVENOUS SOLUTION 5.4 %
4
potassium chloride crys er oral tablet extended release 10 meq, 20 meq
1
potassium chloride er oral capsule extended release 10 meq, 8 meq
1
potassium chloride er oral tablet extended release 10 meq, 8 meq
1
potassium chloride intravenous solution 10 meq/100ml, 2 meq/ml, 20 meq/100ml, 20 meq/50ml, 40 meq/100ml
1
potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg)
2
premasol intravenous solution 6 %
1
PROCALAMINE INTRAVENOUS SOLUTION 3%
4
ringers intravenous solution
1
sodium chloride injection solution 2.5 meq/ml
1
sodium chloride intravenous solution 0.45 %, 0.9 %
1
sodium chloride irrigation solution 0.9 %
1
Instrucciones (Instructions)
Electrolytes/Minerals Modifiers (Modificadores de Electrolitos/Minerales) EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG
6
PA
FERRIPROX ORAL SOLUTION 100 MG/ML
6
PA
FERRIPROX ORAL TABLET 500 MG
6
PA
99
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
JADENU ORAL TABLET 180 MG, 360 MG, 90 MG
6
Prenatal Vitamins (Vitaminas Prenatales) ATABEX EC ORAL TABLET DELAYED RELEASE 29-1 MG
4
BAL-CARE DHA ORAL 27-1 & 430 MG
4
BP FOLINATAL PLUS B ORAL TABLET 1 MG
4
BP MULTINATAL PLUS ORAL TABLET 30-1 MG
4
CALCIUM PNV ORAL CAPSULE 28-1-250 MG
4
CITRANATAL 90 DHA ORAL 90-1 & 300 MG
4
CITRANATAL ASSURE ORAL 35-1 & 300 MG
4
CITRANATAL B-CALM ORAL 20-1 & 25 (2) MG
4
CITRANATAL HARMONY ORAL CAPSULE 27-1-260 MG
4
CITRANATAL RX ORAL TABLET 27-1 MG
4
COMPLETE NATAL DHA ORAL 29-1-200 & 250 MG
4
CONCEPT OB ORAL CAPSULE 130-92.4-1 MG
4
DUET DHA 400 ORAL 25-1 & 400 MG
4
DUET DHA BALANCED ORAL 25-1 & 267 MG
4
ELITE-OB ORAL TABLET 50-1.25 MG
4
EXTRA-VIRT PLUS DHA ORAL CAPSULE 291.25-350 MG
4
FOLCAPS OMEGA 3 ORAL CAPSULE 27-1 MG
4
FOLET DHA ORAL THERAPY PACK 38-1 & 350 MG
4
HEMENATAL OB ORAL TABLET 28-6-1 MG
4
INATAL GT ORAL TABLET
4
Instrucciones (Instructions) PA
100
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
INFANATE BALANCE ORAL CAPSULE 29-1265 MG
4
LEVOMEFOLATE DHA ORAL CAPSULE 271.13-0.4 MG
4
MACNATAL CN DHA ORAL CAPSULE 28-1250 MG
4
MARNATAL-F ORAL CAPSULE 60-1 MG
4
MYNATAL ORAL CAPSULE
4
MYNATE 90 PLUS ORAL TABLET EXTENDED RELEASE
4
NATACHEW ORAL TABLET CHEWABLE 281 MG
4
NATALVIT ORAL TABLET
4
NEEVO DHA ORAL CAPSULE 27-1.13 MG
4
NESTABS ABC ORAL 32-1-200 MG
4
NEWGEN ORAL TABLET 32-1 MG
4
OB COMPLETE ONE ORAL CAPSULE 50-1476 MG
4
OB COMPLETE PETITE ORAL CAPSULE 355-1-200 MG
4
OB COMPLETE PREMIER ORAL TABLET 3020-1 MG
4
OB COMPLETE/DHA ORAL CAPSULE 30-101-200 MG
4
OBSTETRIX DHA ORAL 29-1 & 387 MG
4
OBSTETRIX EC ORAL TABLET 29-1 MG
4
OBSTETRIX ONE ORAL CAPSULE 38-1-225 MG
4
O-CAL PRENATAL ORAL TABLET
4
PNV OB+DHA ORAL 27-1 & 250 MG
4
PNV TABS 29-1 ORAL TABLET 29-1 MG
4
PNV-DHA ORAL CAPSULE 27-0.6-0.4-300 MG
4
Instrucciones (Instructions)
101
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
PNV-SELECT ORAL TABLET 27-0.6-0.4 MG
4
PNV-TOTAL ORAL CAPSULE 35-5-1.2 MG
4
PR NATAL 400 EC ORAL 29-1-200 & 400 MG (DR)
4
PR NATAL 400 ORAL 29-1-200 & 400 MG
4
PR NATAL 430 EC ORAL 29-1-200 & 430 MG (DR)
4
PR NATAL 430 ORAL 29-1-200 & 430 MG
4
PREFERAOB ONE ORAL CAPSULE 22-6-1-200 MG
4
PRENAISSANCE HARMONY DHA ORAL 27-1 & 380 MG
4
PRENAISSANCE NEXT ORAL TABLET 1.2 MG
4
PRENAISSANCE NEXT-B ORAL TABLET 1.22 MG
4
PRENATA ORAL TABLET CHEWABLE 29-1 MG
4
PRENATAL 19 ORAL TABLET CHEWABLE 29-1 MG
4
PRENATAL-U ORAL CAPSULE 106.5-1 MG
4
PRENATE AM ORAL TABLET 1 MG
4
PRENATE DHA ORAL CAPSULE 28-0.6-0.4300 MG
4
PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG, 26-0.6-0.4 MG
4
PRENATE ENHANCE ORAL CAPSULE 28-0.60.4-400 MG
4
PRENATE ESSENTIAL ORAL CAPSULE 180.6-0.4-300 MG, 29-0.6-0.4-340 MG
4
PRENATE MINI ORAL CAPSULE 29-0.6-0.4350 MG
4
PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG
4
Instrucciones (Instructions)
102
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4200 MG
4
PRENATE RESTORE ORAL CAPSULE 27-0.60.4-400 MG
4
PRENATE STAR ORAL TABLET 20-1 MG
4
PREPLUS ORAL TABLET 27-1 MG
4
PRETAB ORAL TABLET 29-1 MG
4
PROVIDA OB ORAL CAPSULE 20-20-1.25 MG
4
PUREFE OB PLUS ORAL CAPSULE 162-115.21 MG
4
R-NATAL OB ORAL CAPSULE 20-1-320 MG
4
SELECT-OB ORAL TABLET CHEWABLE 290.6-0.4 MG, 29-1 MG
4
SELECT-OB+DHA ORAL 29-1 & 250 MG
4
SE-NATAL 19 ORAL TABLET 29-1 MG
4
TARON-BC ORAL 20-1 & 25 (2) MG
4
TARON-PREX ORAL CAPSULE 30-1.2-265 MG
4
TL FOLATE ORAL TABLET 27-0.5-0.5 MG
4
TL-SELECT ORAL CAPSULE 29-1.25-325 MG
4
TRICARE PRENATAL COMPLEAT ORAL 27-1 MG
4
TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG
4
TRINATAL RX 1 ORAL TABLET 60-1 MG
4
TRINATE ORAL TABLET
4
TRI-TABS DHA ORAL 32-1 MG
4
ULTIMATECARE ONE NF ORAL CAPSULE 20-7-1 MG
4
VEMAVITE-PRX 2 ORAL CAPSULE 27-1.25300 MG
4
VINATE II ORAL TABLET 29-1 MG
4
Instrucciones (Instructions)
103
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SALUD FISICA / PHYSICAL HEALTH Medicamentos (Drugs)
Nivel (Level)
VINATE M ORAL TABLET 27-1 MG
4
VIRT-C DHA ORAL CAPSULE 53.5-38-1 MG
4
VIRT-PN PLUS ORAL CAPSULE 28-0.6-0.4340 MG
4
VIRTPREX ORAL CAPSULE 26-1.2-300 MG
4
VITAFOL ULTRA ORAL CAPSULE 29-0.6-0.4200 MG
4
VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG
4
VITAFOL-OB ORAL TABLET
4
VITAFOL-OB+DHA ORAL 65-1 & 250 MG
4
VITAFOL-ONE ORAL CAPSULE 29-1-200 MG
4
VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE 30-0.6-0.4-200 MG
4
VITAMEDMD REDICHEW RX ORAL TABLET CHEWABLE 1.4 MG
4
VITAPEARL ORAL CAPSULE EXTENDED RELEASE 30-1.4-200 MG
4
VITA-PREN ORAL TABLET
4
VIVA DHA ORAL CAPSULE 28-1-200 MG
4
VP-CH-PNV ORAL CAPSULE 30-1-260 MG
4
VP-HEME OB + DHA ORAL 28-6-1 & 203 MG
4
VP-PNV-DHA ORAL CAPSULE 28-1-215.8 MG
4
ZATEAN-CH ORAL CAPSULE 27-1-250 MG
4
Instrucciones (Instructions)
104
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PARTE III – MEDICAMENTOS POR CLASE TERAPEUTICA – EMERGENCIA / PART III - DRUGS BY THERAPEUTIC CLASSIFICATION – EMERGENCY Medicamentos genéricos = letras minúsculas en negrillas / Generic Drugs = lowercase bold Medicamentos originales = letras mayúsculas / Brand name drugs = UPPERCASE
EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Analgesics (Analgésicos) Nonsteroidal Anti-Inflammatory Drugs (Anti-Inflamatorios No Esteroidales) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg
2
etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg
2
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
1
indomethacin oral capsule 25 mg, 50 mg
1
nabumetone oral tablet 500 mg, 750 mg
1
naproxen oral tablet 250 mg, 375 mg, 500 mg
1
naproxen sodium oral tablet 275 mg, 550 mg
1
salsalate oral tablet 500 mg, 750 mg
1
ST
Opioid Analgesics, Long-Acting (Analgésicos Opiodes, Larga Duración) oxycodone hcl er oral tablet er 12-hour abusedeterrent 10 mg, 20 mg, 40 mg, 80 mg
2
QL (2 TAB per 1 day)
Opioid Analgesics, Short-Acting (Analgésicos Opiodes, Corta Duración) acetaminophen-codeine #2 oral tablet 300-15 mg
1
QL (12 TAB per 1 day)
acetaminophen-codeine #3 oral tablet 300-30 mg
1
QL (12 TAB per 1 day)
acetaminophen-codeine #4 oral tablet 300-60 mg
1
QL (6 TAB per 1 day)
acetaminophen-codeine oral solution 120-12 mg/5ml
1
QL (90 ML per 1 day)
tramadol hcl oral tablet 50 mg
1
QL (12 TAB per 1 day)
Others (Otros)
105
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
butalbital-apap-caffeine oral capsule 50-325-40 mg
1
butalbital-apap-caffeine oral tablet 50-325-40 mg
1
Instrucciones (Instructions)
Anesthetics (Anestésicos) Local Anesthetics (Anestésico Local) lidocaine viscous mouth/throat solution 2 %
1
QL (100 ML per 15 days)
Antibacterials (Antibacterianos) Antibacterials, Other (Antibacterianos, Otros) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg
1
metronidazole oral tablet 250 mg, 500 mg
1
nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg
2
nitrofurantoin macrocrystal oral capsule 50 mg
1
nitrofurantoin monohyd macro oral capsule 100 mg
2
SIVEXTRO ORAL TABLET 200 MG
4
vancomycin hcl oral capsule 125 mg, 250 mg
2
PA
Beta-Lactam, Cephalosporins (Cefalosporinas, Beta-Lactámicas) cefaclor oral capsule 250 mg, 500 mg
1
cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml
1
cefdinir oral capsule 300 mg
1
cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
cefprozil oral tablet 250 mg, 500 mg
1
ceftriaxone sodium injection solution reconstituted 250 mg, 500 mg
2
106
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
cephalexin oral capsule 250 mg, 500 mg
1
cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
Beta-Lactam, Penicillins (Penicilinas, Beta-Lactámicas) amoxicillin oral capsule 250 mg, 500 mg
1
amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml
1
amoxicillin oral tablet 500 mg, 875 mg
1
amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg
1
amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg
1
ampicillin oral capsule 250 mg, 500 mg
1
ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
2
AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML
4
BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION 900000-300000 UNIT/2ML
4
BICILLIN L-A INTRAMUSCULAR SUSPENSION 600000 UNIT/ML
4
penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml
1
penicillin v potassium oral tablet 250 mg, 500 mg
1
Macrolides (Macrólidos) azithromycin oral packet 1 gm
2
azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml
1
Instrucciones (Instructions)
107
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
azithromycin oral tablet 250 mg, 500 mg, 600 mg
1
clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
clarithromycin oral tablet 250 mg, 500 mg
1
ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML
4
ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG
4
ERYTHROCIN STEARATE ORAL TABLET 250 MG
4
erythromycin base oral tablet 250 mg, 500 mg
2
erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml
2
erythromycin ethylsuccinate oral tablet 400 mg
2
Instrucciones (Instructions)
Quinolones (Quinolonas) ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg
1
ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)
2
ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg
2
QL (14 TAB per 30 days)
ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 500 mg
2
QL (3 TAB per 30 days)
levofloxacin oral tablet 250 mg, 500 mg, 750 mg
1
Sulfonamides (Sulfonamidas) sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml
1
sulfamethoxazole-trimethoprim oral tablet 40080 mg, 800-160 mg
1
Tetracyclines (Tetraciclinas) demeclocycline hcl oral tablet 150 mg, 300 mg
2
doxycycline hyclate oral capsule 100 mg, 50 mg
2
108
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
doxycycline hyclate oral tablet 100 mg
2
doxycycline hyclate oral tablet 20 mg
1
tetracycline hcl oral capsule 250 mg, 500 mg
2
VIBRAMYCIN ORAL SYRUP 50 MG/5ML
4
Instrucciones (Instructions)
Anticonvulsants (Anticonvulsivantes) Gamma-Aminobutyric Acid (GABA) Augmenting Agents (Agentes Amplificadores del Acido Gama-Aminobutirato) phenobarbital oral solution 20 mg/5ml
1
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
1
Sodium Channel Agents (Canales de Sodio) DILANTIN ORAL CAPSULE 30 MG
4
phenytoin oral suspension 125 mg/5ml
1
phenytoin oral tablet chewable 50 mg
1
phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg
1
phenytoin sodium injection solution 50 mg/ml
1
Antiemetics (Antieméticos) Antiemetics, Other (Antieméticos, Otros) metoclopramide hcl oral solution 5 mg/5ml
1
metoclopramide hcl oral tablet 10 mg, 5 mg
1
promethazine hcl oral solution 6.25 mg/5ml
1
promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg
1
promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg
2
trimethobenzamide hcl oral capsule 300 mg
1
Antifungals (Antifungales) Antifungals (Antifungales) clotrimazole mouth/throat lozenge 10 mg
1
109
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
nystatin mouth/throat suspension 100000 unit/ml
1
Antigout Agents (Antigota) Antigout Agents (Antigota) colchicine oral tablet 0.6 mg
2
Anti-Inflammatory Agents (Anti-Inflamatorios) Glucocorticoids (Glucocorticoides) INTENSOL ORAL CONCENTRATE 1 MG/ML
4
dexamethasone oral elixir 0.5 mg/5ml
1
dexamethasone oral solution 0.5 mg/5ml
2
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg
1
methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg
1
MILLIPRED ORAL TABLET 5 MG
4
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg
1
Antimycobacterials (Antimicobacterianos) Antimycobacterials, Other (Antimicobacterianos, Otros) dapsone oral tablet 100 mg, 25 mg
2
Antiparasitics (Antiparasitarios) Antiprotozoals (Antiprotozoarios) atovaquone oral suspension 750 mg/5ml
2
NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG
4
Antipsychotics (Antipsicóticos) 1st Generation/Typical (1ra Generación/Típicos) prochlorperazine maleate oral tablet 10 mg, 5 mg
1
prochlorperazine rectal suppository 25 mg
1
Instrucciones (Instructions)
110
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Antivirals (Antivirales) Antiherpetic Agents (Antiherpéticos) acyclovir oral capsule 200 mg
1
acyclovir oral suspension 200 mg/5ml
1
acyclovir oral tablet 400 mg, 800 mg
1
Anti-Influenza Agents (Anti-Influenza) oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg
2
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML
4
Anxiolytics (Ansiolíticos) Anxiolytics, Other (Ansiolíticos, Otros) hydroxyzine pamoate oral capsule 100 mg
2
hydroxyzine pamoate oral capsule 25 mg, 50 mg
1
Blood Glucose Regulators (Reguladores de Glucosa en Sangre) Antidiabetic Agents (Antidiabéticos) glimepiride oral tablet 1 mg, 2 mg, 4 mg
1
glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg
1
glipizide oral tablet 10 mg, 5 mg
1
metformin hcl oral tablet 1000 mg, 500 mg, 850 mg
1
Insulins (Insulinas) HUMULIN R SOLUTION 100 UNIT/ML INJECTION
3
QL (10 ML per 7 days)
Blood Products/Modifiers/Volume Expanders (Productos para la Sangre/Modificadores/Expansores de Volumen) Anticoagulants (Anticoagulantes) warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
1
111
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Platelet Modifying Agents (Modificadores de Plaquetas) clopidogrel bisulfate oral tablet 75 mg
1
Cardiovascular Agents (Cardiovasculares) Alpha-Adrenergic Agonists (Agonistas Alfa Adrenérgicos) clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg
1
Angiotensin II Receptor Antagonists (Antagonistas del Receptor Angiotensina II) losartan potassium oral tablet 100 mg, 25 mg, 50 mg
1
losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg
1
Angiotensin-Converting Enzyme (ACE) Inhibitors (Inhibidores de la Enzima Convertidora de Angiotensina) captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg
1
captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg
1
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
1
enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg
1
Beta-Adrenergic Blocking Agents (Bloqueadores Beta Adrenérgicos) atenolol oral tablet 100 mg, 25 mg, 50 mg
1
atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg
1
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
1
metoprolol-hydrochlorothiazide oral tablet 10025 mg, 100-50 mg, 50-25 mg
1
Calcium Channel Blocking Agents (Bloqueadores de Canales de Calcio) verapamil hcl oral tablet 120 mg, 40 mg, 80 mg
Diuretics, Loop (Diuréticos del Asa)
1
112
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
furosemide oral solution 10 mg/ml, 8 mg/ml
1
furosemide oral tablet 20 mg, 40 mg, 80 mg
1
Instrucciones (Instructions)
Diuretics, Thiazide (Diuréticos Tiazidas) hydrochlorothiazide oral tablet 25 mg, 50 mg
1
Vasodilators, Direct-Acting Arterial/Venous (Vasodilatadores, Arteriales/Venosos) nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg
2
Dermatological Agents (Dermatológicos) Antibacterials (Antibacterianos) gentamicin sulfate external cream 0.1 %
2
QL (30 GM per 15 days)
gentamicin sulfate external ointment 0.1 %
2
QL (30 GM per 15 days)
mupirocin external ointment 2 %
1
QL (30 GM per 15 days)
silver sulfadiazine external cream 1 %
1
QL (400 GM per 15 days)
Gastrointestinal Agents (Gastrointestinales) Gastrointestinal Agents, Others (Gastrointestinales, Otros) diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml
2
diphenoxylate-atropine oral tablet 2.5-0.025 mg
1
Histamine2 (H2) Receptor Antagonists (Antagonistas del Receptor de Histamina2 (H2)) cimetidine hcl oral solution 300 mg/5ml
1
cimetidine oral tablet 300 mg, 400 mg, 800 mg
1
ranitidine hcl oral syrup 15 mg/ml
1
ranitidine hcl oral tablet 300 mg
1
Proton Pump Inhibitors (Inhibidores de la Bomba de Protones) omeprazole oral capsule delayed release 10 mg, 20 mg
1
Genitourinary Agents (Genitourinarios) Genitourinary Agents, Others (Genitourinarios, Otros) phenazopyridine hcl oral tablet 100 mg, 200 mg
1
113
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Ophthalmic Agents (Oftálmicos) Antibacterials (Antibacterianos) gentamicin sulfate ophthalmic ointment 0.3 %
1
QL (3.5 GM per 15 days)
gentamicin sulfate ophthalmic solution 0.3 %
1
QL (15 ML per 15 days)
tobramycin ophthalmic solution 0.3 %
1
QL (5 ML per 15 days)
TOBREX OPHTHALMIC OINTMENT 0.3 %
4
QL (3.5 GM per 15 days)
CIPRO HC OTIC SUSPENSION 0.2-1 %
4
QL (10 ML per 15 days)
neomycin-polymyxin-hc otic solution 3.5-100001
1
QL (10 ML per 15 days)
neomycin-polymyxin-hc otic suspension 3.510000-1
1
QL (10 ML per 15 days)
ofloxacin otic solution 0.3 %
1
QL (20 ML per 15 days)
2
QL (10 ML per 15 days)
2
QL (15 ML per 15 days)
Otic Agents (Óticos)
Anti-Inflammatories (Anti-Inflamatorios) hydrocortisone-acetic acid otic solution 1-2 %
Otic, Miscellaneous (Óticos, Misceláneos) acetic acid otic solution 2 %
Respiratory Tract/Pulmonary Agents (Tracto Respiratorio) Antihistamines (Antihistamínicos) diphenhydramine hcl oral capsule 50 mg
1
Antitussives (Antitusivos) CAPITAL/CODEINE SUSPENSION 120-12 MG/5ML ORAL
4
guaifenesin-codeine solution 100-10 mg/5ml oral
1
QL (90 ML per 1 day)
Bronchodilators, Anticholinergic (Broncodilatadores, Anticolinérgicos) ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT
4
QL (12.9 GM per 15 days)
ipratropium bromide inhalation solution 0.02 %
1
QL (70 ML per 7 days)
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EMERGENCIA / EMERGENCY Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) (Broncodilatadores, Inhibidores de la Fosfodiesterasa (Xantinas)) terbutaline sulfate oral tablet 2.5 mg, 5 mg
1
Bronchodilators, Sympathomimetic (Broncodilatadores, Simpatomiméticos) albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%
1
QL (126 ML per 7 days)
albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%
1
QL (20 ML per 15 days)
albuterol sulfate inhalation nebulization solution 1.25 mg/3ml
1
QL (84 ML per 7 days)
albuterol sulfate oral syrup 2 mg/5ml
1
albuterol sulfate oral tablet 2 mg, 4 mg
2
levalbuterol tartrate inhalation aerosol 45 mcg/act
2
QL (15 GM per 15 days)
PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT
3
QL (8.5 GM per 15 days)
PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT
3
QL (1 EA per 15 days)
PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT
3
QL (6.7 GM per 15 days)
Skeletal Muscle Relaxants (Relajantes Musculoesqueletales) Skeletal Muscle Relaxants (Relajantes Musculoesqueletales) cyclobenzaprine hcl oral tablet 10 mg
1
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PARTE IV – MEDICAMENTOS POR CLASE TERAPEUTICA – SALUD MENTAL / PART IV - DRUGS BY THERAPEUTIC CLASSIFICATION – MENTAL HEALTH Medicamentos genéricos = letras minúsculas en negrillas / Generic Drugs = lowercase bold Medicamentos originales = letras mayúsculas / Brand name drugs = UPPERCASE
SALUD MENTAL / MENTAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Anti-Addiction/Substance Abuse Treatment Agents (Tratamiento de Abuso de Sustancias/Contra la Addición) Alcohol Deterrents/Anti-Craving (Disuasivos de Alcohol/Anti-Ansiedad) acamprosate calcium oral tablet delayed release 333 mg
2
SL
disulfiram oral tablet 250 mg, 500 mg
2
SL
Opioid Dependence Treatments (Tratamiento Dependiente de Opiode) buprenorphine hcl sublingual tablet sublingual 2 mg
2
PA; SL; QL (2 TAB per 1 day)
buprenorphine hcl sublingual tablet sublingual 8 mg
2
PA; SL; QL (8 TAB per 1 day)
buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg
2
PA; SL; QL (12 TAB per 1 day)
buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg
2
PA; SL; QL (3 TAB per 1 day)
SUBOXONE SUBLINGUAL FILM 12-3 MG
4
PA; SL; QL (2 FILM per 1 day)
SUBOXONE SUBLINGUAL FILM 2-0.5 MG
4
PA; SL; QL (12 FILM per 1 day)
SUBOXONE SUBLINGUAL FILM 4-1 MG
4
PA; SL; QL (6 FILM per 1 day)
SUBOXONE SUBLINGUAL FILM 8-2 MG
4
PA; SL; QL (3 FILM per 1 day)
Anticonvulsants (Anticonvulsivantes) Gamma-Aminobutyric Acid (GABA) Augmenting Agents (Agentes Amplificadores del Acido Gama-Aminobutirato) clonazepam oral tablet 0.5 mg, 1 mg, 2 mg
1
AL (greater than 18 years)
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SALUD MENTAL / MENTAL HEALTH Medicamentos (Drugs)
Nivel (Level)
divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg
2
divalproex sodium oral capsule delayed release sprinkle 125 mg
1
divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg
1
valproate sodium oral solution 250 mg/5ml
1
valproic acid oral capsule 250 mg
1
Glutamate Reducing Agents (Reductores de Glutamato) lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg
1
lamotrigine oral tablet chewable 25 mg, 5 mg
1
Sodium Channel Agents (Canales de Sodio) carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg
2
carbamazepine oral suspension 100 mg/5ml
1
carbamazepine oral tablet 200 mg
1
carbamazepine oral tablet chewable 100 mg
1
Antidepressants (Antidepresivos) Antidepressants, Other (Antidepresivos, Otros) bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg
1
bupropion hcl oral tablet 100 mg, 75 mg
1
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg
1
mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg
1
Instrucciones (Instructions)
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SALUD MENTAL / MENTAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Monoamine Oxidase B (MAO-B) Inhibitors (Inhibidores de Monoamina Oxidasa B) EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR
4
MARPLAN ORAL TABLET 10 MG
4
phenelzine sulfate oral tablet 15 mg
1
tranylcypromine sulfate oral tablet 10 mg
2
PA
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) (Inhibidores de la Recaptación de Serotonina/ Norepinefrina (SSRIs/SNRIs)) citalopram hydrobromide oral solution 10 mg/5ml
1
citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg
1
duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg
1
escitalopram oxalate oral solution 5 mg/5ml
1
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg
1
fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg
1
fluoxetine hcl oral solution 20 mg/5ml
1
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg
1
maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg
2
paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg
2
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
1
PAXIL ORAL SUSPENSION 10 MG/5ML
4
sertraline hcl oral concentrate 20 mg/ml
1
sertraline hcl oral tablet 100 mg, 25 mg, 50 mg
1
QL (2 CAP per 1 day)
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SALUD MENTAL / MENTAL HEALTH Medicamentos (Drugs)
Nivel (Level)
trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg
1
venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg
1
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg
1
Instrucciones (Instructions)
Tricyclics (Tricíclicos) amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
1
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg
2
clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg
2
desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
1
doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
1
doxepin hcl oral concentrate 10 mg/ml
1
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg
1
nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg
1
trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg
2
Antipsychotics (Antipsicóticos) 1st Generation/Typical (1ra Generación/Típicos) chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml
2
chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg
1
fluphenazine hcl injection solution 2.5 mg/ml
1
PA
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SALUD MENTAL / MENTAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
fluphenazine decanoate injection solution 25 mg/ml
2
PA
fluphenazine hcl oral concentrate 5 mg/ml
2
fluphenazine hcl oral elixir 2.5 mg/5ml
2
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg
1
haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml
2
PA
haloperidol lactate injection solution 5 mg/ml
2
PA
haloperidol lactate oral concentrate 2 mg/ml
1
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg
1
loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg
1
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg
1
pimozide oral tablet 1 mg, 2 mg
2
prochlorperazine edisylate injection solution 5 mg/ml
1
prochlorperazine maleate oral tablet 10 mg, 5 mg
1
thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg
1
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg
1
trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg
1
2nd Generation/Atypical (2da Generación/Atípicos) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg
2
PA; QL (1 TAB per 1 day)
INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML
5
PA; QL (0.75 ML per 30 days)
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SALUD MENTAL / MENTAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 156 MG/ML
5
PA; QL (1 ML per 30 days)
INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 234 MG/1.5ML
5
PA; QL (1.5 ML per 30 days)
INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML
5
PA; QL (0.25 ML per 30 days)
INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 78 MG/0.5ML
5
PA; QL (0.5 ML per 30 days)
INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML
5
ST; QL (0.88 ML per 90 days)
INVEGA TRINZA INTRAMUSCULAR SUSPENSION 410 MG/1.315ML
5
ST; QL (1.31 ML per 90 days)
INVEGA TRINZA INTRAMUSCULAR SUSPENSION 546 MG/1.75ML
5
ST; QL (1.75 ML per 90 days)
INVEGA TRINZA INTRAMUSCULAR SUSPENSION 819 MG/2.625ML
5
ST; QL (2.63 ML per 90 days)
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg
1
QL (1 TAB per 1 day)
paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 9 mg
2
PA; QL (1 TAB per 1 day)
paliperidone er oral tablet extended release 24 hour 6 mg
2
PA; QL (2 TAB per 1 day)
quetiapine fumarate oral tablet 100 mg, 200 mg, 300 mg
1
QL (3 TAB per 1 day)
quetiapine fumarate oral tablet 25 mg, 50 mg
1
PA; QL (3 TAB per 1 day)
quetiapine fumarate oral tablet 400 mg
1
QL (2 TAB per 1 day)
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG
5
PA
risperidone oral solution 1 mg/ml
2
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
1
QL (2 TAB per 1 day)
risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
2
PA; QL (2 TAB per 1 day)
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SALUD MENTAL / MENTAL HEALTH Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
1
QL (2 CAP per 1 day)
clozapine oral tablet 100 mg, 25 mg
2
PA; QL (9 TAB per 1 day)
clozapine oral tablet 200 mg
2
PA; QL (4 TAB per 1 day)
clozapine oral tablet 50 mg
2
PA; QL (6 TAB per 1 day)
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg
Treatment-Resistant (Resistentes a Tratamiento)
Anxiolytics (Ansiolíticos) Anxiolytics, Other (Ansiolíticos, Otros) buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg
1
hydroxyzine pamoate oral capsule 100 mg
2
hydroxyzine pamoate oral capsule 25 mg, 50 mg
1
Benzodiazepines (Benzodiazepinas) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg
1
AL (greater than 18 years)
clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg
1
AL (greater than 9 years)
diazepam oral tablet 10 mg, 2 mg, 5 mg
1
AL (greater than 18 years)
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
1
AL (greater than 12 years)
oxazepam oral capsule 10 mg, 15 mg, 30 mg
1
AL (greater than 12 years)
Bipolar Agents (Bipolaridad) Mood Stabilizers (Estabilizadores del Ánimo) lithium carbonate er oral tablet extended release 300 mg, 450 mg
1
lithium carbonate oral capsule 150 mg, 300 mg, 600 mg
1
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SALUD MENTAL / MENTAL HEALTH Medicamentos (Drugs) lithium oral solution 8 meq/5ml
Nivel (Level)
Instrucciones (Instructions)
1
Sleep Disorder Agents (Desordenes del Sueño) GABA Receptor Modulators (Moduladores del Receptor de GABA) estazolam oral tablet 1 mg, 2 mg
1
AL (greater than 18 years); QL (1 TAB per 1 day)
temazepam oral capsule 15 mg, 30 mg
2
AL (greater than 18 years); QL (1 CAP per 1 day)
zaleplon oral capsule 10 mg
1
QL (2 CAP per 1 day)
zaleplon oral capsule 5 mg
1
QL (1 CAP per 1 day)
zolpidem tartrate oral tablet 10 mg, 5 mg
1
QL (1 TAB per 1 day)
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PARTE V – MEDICAMENTOS POR CLASE TERAPEUTICA – DENTAL / PART V DRUGS BY THERAPEUTIC CLASSIFICATION – DENTAL Medicamentos genéricos = letras minúsculas en negrillas / Generic Drugs = lowercase bold Medicamentos originales = letras mayúsculas / Brand name drugs = UPPERCASE
DENTAL Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
Analgesics (Analgésicos) Nonsteroidal Anti-Inflammatory Drugs (Anti-Inflamatorios No Esteroidales) diclofenac potassium oral tablet 50 mg
1
diclofenac sodium oral tablet delayed release 50 mg, 75 mg
1
etodolac oral capsule 200 mg, 300 mg
1
etodolac oral tablet 400 mg, 500 mg
1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
1
indomethacin oral capsule 25 mg, 50 mg
1
ketorolac tromethamine injection solution 15 mg/ml
1
QL (40 ML per 5 days)
ketorolac tromethamine injection solution 30 mg/ml
1
QL (20 ML per 5 days)
ketorolac tromethamine injection solution 60 mg/2ml
1
QL (20 ML per 5 days)
ketorolac tromethamine intramuscular solution 60 mg/2ml
1
QL (20 ML per 5 days)
nabumetone oral tablet 500 mg, 750 mg
1
naproxen oral suspension 125 mg/5ml
1
naproxen oral tablet 250 mg, 375 mg, 500 mg
1
naproxen sodium oral tablet 275 mg, 550 mg
1
sulindac oral tablet 150 mg, 200 mg
1
Opioid Analgesics, Short-Acting (Analgésicos Opiodes, Corta Duración) acetaminophen-codeine #2 oral tablet 300-15 mg
1
QL (12 TAB per 1 day)
acetaminophen-codeine #3 oral tablet 300-30 mg
1
QL (12 TAB per 1 day)
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DENTAL Medicamentos (Drugs)
Nivel (Level)
Instrucciones (Instructions)
acetaminophen-codeine #4 oral tablet 300-60 mg
1
QL (6 TAB per 1 day)
acetaminophen-codeine oral solution 120-12 mg/5ml
1
QL (90 ML per 1 day)
hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg
1
QL (6 TAB per 1 day)
hydrocodone-acetaminophen oral tablet 5-325 mg
1
QL (8 TAB per 1 day)
hydrocodone-ibuprofen oral tablet 7.5-200 mg
2
QL (5 TAB per 1 day)
meperidine hcl injection solution 100 mg/ml, 50 mg/ml
1
oxycodone hcl oral tablet 15 mg, 30 mg
1
QL (6 TAB per 1 day)
oxycodone hcl oral tablet 5 mg
1
QL (12 TAB per 1 day)
oxycodone-acetaminophen oral tablet 10-325 mg
1
QL (6 TAB per 1 day)
oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg
1
QL (12 TAB per 1 day)
oxycodone-acetaminophen oral tablet 7.5-325 mg
1
QL (8 TAB per 1 day)
tramadol hcl oral tablet 50 mg
1
QL (12 TAB per 1 day)
tramadol-acetaminophen oral tablet 37.5-325 mg
1
QL (8 TAB per 1 day)
Antibacterials (Antibacterianos) Aminoglycosides (Aminoglicósidos) neomycin sulfate oral tablet 500 mg
1
Antibacterials, Other (Antibacterianos, Otros) clindamycin hcl oral capsule 150 mg, 300 mg
1
metronidazole oral capsule 375 mg
1
metronidazole oral tablet 250 mg, 500 mg
1
nitrofurantoin macrocrystal oral capsule 50 mg
1
trimethoprim oral tablet 100 mg
1
Beta-Lactam, Cephalosporins (Cefalosporinas, Beta-Lactámicas)
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DENTAL Medicamentos (Drugs)
Nivel (Level)
cefaclor oral capsule 250 mg, 500 mg
1
cefadroxil oral capsule 500 mg
1
cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml
1
cefadroxil oral tablet 1 gm
1
cefdinir oral capsule 300 mg
1
cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml
1
cefpodoxime proxetil oral tablet 100 mg, 200 mg
1
cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
cefprozil oral tablet 250 mg, 500 mg
1
cefuroxime axetil oral tablet 250 mg, 500 mg
1
cephalexin oral capsule 250 mg, 500 mg
1
cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
Beta-Lactam, Penicillins (Penicilinas, Beta-Lactámicas) amoxicillin oral capsule 250 mg, 500 mg
1
amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml
1
amoxicillin oral tablet 875 mg
1
amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1000-62.5 mg
1
amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg
1
ampicillin oral capsule 250 mg, 500 mg
1
Instrucciones (Instructions)
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DENTAL Medicamentos (Drugs)
Nivel (Level)
dicloxacillin sodium oral capsule 250 mg, 500 mg
1
penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml
1
penicillin v potassium oral tablet 250 mg, 500 mg
1
Macrolides (Macrólidos) azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml
1
azithromycin oral tablet 250 mg, 500 mg, 600 mg
1
clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
1
clarithromycin oral tablet 250 mg, 500 mg
1
Quinolones (Quinolonas) ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg
1
Sulfonamides (Sulfonamidas) sulfadiazine oral tablet 500 mg
2
sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml
1
sulfamethoxazole-trimethoprim oral tablet 40080 mg, 800-160 mg
1
Tetracyclines (Tetraciclinas) minocycline hcl oral capsule 100 mg, 50 mg, 75 mg
1
Instrucciones (Instructions)
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PARTE VI – APÉNDICES / PART VI – APPENDIXES Apéndice I - Quimioterapias Orales / Appendix I – Oral Chemotherapies Hay medicamentos de quimioterapia oral incluidos en el formulario. Triple-S cubrirá estos medicamentos con un co-aseguro. La siguiente tabla contiene una lista de cuáles son estos productos. / The formulary includes oral chemotherapies. Triple S will cover those medications with a copay.
MEDICAMENTOS (DRUGS)
EJEMPLOS DE NOMBRE COMERCIAL (EXAMPLES OF BRAND NAME)
Afinitor Disperz TABLET SOLUBLE 2 MG Oral, 3 MG Oral, 5 MG Oral Afinitor TABLET 10 MG Oral, 2.5 MG Oral, 5 MG Oral, 7.5 MG Oral Alecensa CAPSULE 150 MG Oral Anastrozole TABLET 1 MG Oral
Arimidex
Bexarotene CAPSULE 75 MG Oral
Targretin
Bicalutamide TABLET 50 MG Oral
Casodex
Bosulif TABLET 100 MG Oral, 500 MG Oral Cabometyx TABLET 20 MG Oral, 40 MG Oral, 60 MG Oral Caprelsa TABLET 100 MG Oral, 300 MG Oral Cometriq (100 mg Daily Dose) KIT 1 X 80 & 1 X 20 MG Oral, (140 mg Daily Dose) KIT 1 X 80 & 3 X 20 MG Oral, (60 mg Daily Dose) KIT 20 MG Oral Emcyt CAPSULE 140 MG Oral Erivedge CAPSULE 150 MG Oral
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MEDICAMENTOS (DRUGS)
Exemestane TABLET 25 MG Oral
EJEMPLOS DE NOMBRE COMERCIAL (EXAMPLES OF BRAND NAME)
Aromasin
Fareston TABLET 60 MG Oral Flutamide CAPSULE 125 MG Oral
Eulexin
Gleostine CAPSULE 10 MG Oral, 100 MG Oral, 40 MG Oral, 5 MG Oral Hexalen CAPSULE 50 MG Oral Hydroxyurea CAPSULE 500 MG Oral Ibrance CAPSULE 100 MG Oral, 125 MG Oral, 75 MG Oral Iclusig TABLET 15 MG Oral, 45 MG Oral Imatinib Mesylate TABLET 100 MG Oral, 400 MG Oral
Gleevec
Inlyta TABLET 1 MG Oral, 5 MG Oral Jakafi TABLET 10 MG Oral, 15 MG Oral, 20 MG Oral, 25 MG Oral, 5 MG Oral Letrozole TABLET 2.5 MG Oral Leucovorin Calcium TABLET 10 MG Oral, 15 MG Oral, 25 MG Oral, 5 MG Oral Leukeran TABLET 2 MG Oral Lonsurf TABLET 15-6.14 MG Oral, 20-8319 MG Oral Lynparza CAPSULE 50 MG Oral
Femara
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MEDICAMENTOS (DRUGS)
EJEMPLOS DE NOMBRE COMERCIAL (EXAMPLES OF BRAND NAME)
Lysodren TABLET 500 MG Oral Matulane CAPSULE 50 MG Oral Mercaptopurine TABLET 50 MG Oral
Purinethol
Mesnex TABLET 400 MG Oral Methotrexate TABLET 2.5 MG Oral NexAVAR TABLET 200 MG Oral Nilutamide TABLET 150 MG Oral
Nilandron
Ninlaro CAPSULE 2.3 MG Oral, 3 MG Oral, 4 MG Oral Pomalyst CAPSULE 1 MG Oral, 2 MG Oral, 3 MG Oral, 4 MG Oral Revlimid CAPSULE 10 MG Oral, 15 MG Oral, 2.5 MG Oral, 20 MG Oral, 25 MG Ora, 5 MG Oral Sprycel TABLET 100 MG Oral, 140 MG Oral, 20 MG Oral, 50 MG Oral, 70 MG Oral, 80 MG Oral Stivarga TABLET 40 MG Oral Sutent CAPSULE 12.5 MG Oral, 25 MG Oral, 37.5 MG Oral, 50 MG Oral Tabloid TABLET 40 MG Oral Tamoxifen Citrate TABLET 10 MG Oral, 20 MG Oral Tarceva TABLET 100 MG Oral, 150 MG Oral, 25 MG Oral
Nolvadex
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Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
MEDICAMENTOS (DRUGS)
EJEMPLOS DE NOMBRE COMERCIAL (EXAMPLES OF BRAND NAME)
Tasigna CAPSULE 150 MG Oral, 200 MG Oral Thalomid CAPSULE 100 MG Oral, 150 MG Oral, 200 MG Oral, 50 MG Oral Tretinoin CAPSULE 10 MG Oral Tykerb TABLET 250 MG Oral Venclexta Starting Pack Tablet Therapy Pack 10 & 50 & 100 MG Oral Venclexta TABLET 10 MG Oral, 100 MG Oral, 50 MG Oral Votrient TABLET 200 MG Oral Xalkori CAPSULE 200 MG Oral, 250 MG Oral Xtandi CAPSULE 40 MG Oral Zelboraf TABLET 240 MG Oral Zolinza CAPSULE 100 MG Oral Zydelig TABLET 100 MG Oral, 150 MG Oral Zytiga TABLET 250 MG Oral, 500 MG Oral
Vesanoid
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Apéndice II – Límites de Especialidad (LE) / Appendix II- Specialty Limits (SL) En el formulario encontrarán medicamentos asociados a las iniciales LE. LE significa que estos medicamentos requieren que un especialista evalúe el paciente y los recete. La siguiente tabla contiene los nombres de estos productos e indica el especialista que debe recetarlos. / The formulary includes drugs associated to the SL initials. SL means that those medications require that a specialist evaluates the patient and prescribe it. The following table shows which are those products and indicates the specialist that must prescribe them. PRODUCTO (PRODUCT)
ESPECIALISTA (SPECIALIST)
ACAMPROSATE CALCIUM
Psiquiatra, Psiquiatra Pediátrico / Pediatric Psychiatrist, Psychiatrist
ADAPALENE
Dermatólogo, Pedriatra / Dermatologist, Pediatrician
AMINOBENZOATE POTASSIUM
Dermatólogo, Urólogo, Reumatólogo, Dermatólogo Pediátrico, Reumatólogo Pediátrico, Urólogo Pediátrico / Dermatologist, Urologist, Rheumatologist, Pediatric Dermatologist, Pediatric Rheumatology, Pediatric Urologist
AMITIZA
Gastroenterólogo, Medicina Interna / Gastroenterologist, Internal Medicine
AMPHETAMINEDEXTROAMPHETAMINE ATOMOXETINE
AZATHIOPRINE
BUPRENORPHINE HCL
BUPRENORPHINE HCLNALOXONE HCL
CANCIDAS CLONIDINE HCL ER
Neurólogo, Neurólogo Pediátrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist Neurólogo, Neurólogo Pediátrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist Dermatólogo, Gastroenterólogo, Nefrologo, Neumlogo, Reumatólogo / Dermatologist, Gastroenterologist, Nephrologist, Pneumologist, Pulmonologist, Rheumatologist Médico cumple requisitos, notifica a HHS de su intención de prescribir buprenorfina o buprenorfina/naloxone y está en el listado de médicos SAMSHA / Meets Qualifying Requirements, Has Notified the HHS of their intent to prescribe Buprenorphine or Buprenorphine/Naloxone and is Listed on the Physician Locator at SAMSHA Médico cumple requisitos, notifica a HHS de su intención de prescribir buprenorfina o buprenorfina/naloxone y está en el listado de médicos SAMSHA / Meets Qualifying Requirements, Has Notified the HHS of their intent to prescribe Buprenorphine or Buprenorphine/Naloxone and is Listed on the Physician Locator at SAMSHA Infectólogo, Hematólogo, Oncólogo /Infectologist, Hematologist, Oncologist Neurólogo, Neurólogo Pediátrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
PRODUCTO (PRODUCT) CRESEMBA DESIPRAMINE HCL DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE ER
ESPECIALISTA (SPECIALIST) Infectólogo, Hematólogo, Oncólogo /Infectologist, Hematologist, Oncologist Neurólogo, Neurólogo Pediátrico, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatric Psychiatrist, Psychiatrist Neurólogo, Neurólogo Pediátrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist Neurólogo, Neurólogo Pediátrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist
DISULFIRAM
Psiquiatra, Psiquiatra Pediátrico / Pediatric Psychiatrist, Psychiatrist
EPIDUO
Dermatólogo, Pedriatra / Dermatologist, Pediatrician
EPIDUO FORTE
Dermatólogo, Pedriatra / Dermatologist, Pediatrician
ERAXIS
Infectólogo, Hematólogo, Oncólogo /Infectologist, Hematologist, Oncologist
GRANIX
Hematólogo-Oncólogo / Hematologist-Oncologist
LEUKINE
Hematólogo-Oncólogo / Hematologist-Oncologist
METHOTREXATE SODIUM
Gastroenterólogo, Reumatólogo / Gastroenterologist, Rheumatologist
METHYLPHENIDATE HCL METHYLPHENIDATE HCL ER MODAFINIL MYCAMINE
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Neurólogo, Neurólogo Pediátrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist Neurólogo, Neurólogo Pediátrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist Neurólogo, Neurólogo Pediátrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist Infectólogo, Hematólogo, Oncólogo /Infectologist, Hematologist, Oncologist
MYCOPHENOLATE MOFETIL
Reumatólogo / Rheumatologist
NEULASTA
Hematólogo-Oncólogo / Hematologist-Oncologist
NEULASTA ONPRO
Hematólogo-Oncólogo / Hematologist-Oncologist
NEUPOGEN
Hematólogo-Oncólogo / Hematologist-Oncologist
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
PRODUCTO (PRODUCT) NOXAFIL
POTABA
POTIGA QUILLICHEW ER
SUBOXONE
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ESPECIALISTA (SPECIALIST) Infectólogo, Hematólogo, Oncólogo /Infectologist, Hematologist, Oncologist Dermatólogo, Urólogo, Reumatólogo, Dermatólogo Pediátrico, Reumatólogo Pediátrico, Urólogo Pediátrico / Dermatologist, Urologist, Rheumatologist, Pediatric Dermatologist, Pediatric Rheumatology, Pediatric Urologist Neurólogo, Neurólogo Pediátrico / Neurologist, Pediatric Neurologist Neurólogo, Neurólogo Pediátrico, Pediatra, Psiquiatra, Psiquiatra Pediátrico / Neurologist, Pedriatric Neurologist, Pediatrician, Pediatric Psychiatrist, Psychiatrist Médico cumple requisitos, notifica a HHS de su intención de prescribir buprenorfina o buprenorfina/naloxone y está en el listado de médicos SAMSHA / Meets Qualifying Requirements, Has Notified the HHS of their intent to prescribe Buprenorphine or Buprenorphine/Naloxone and is Listed on the Physician Locator at SAMSHA
TRETINOIN
Dermatólogo, Pedriatra / Dermatologist, Pediatrician
VIMPAT
Neurólogo, Neurólogo Pediátrico / Neurologist, Pediatric Neurologist
VORICONAZOLE
Infectólogo, Hematólogo, Oncólogo /Infectologist, Hematologist, Oncologist
ZARXIO
Hematólogo-Oncólogo / Hematologist-Oncologist
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Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
Apéndice III – Terapias Escalonadas (TE) / Appendix III - Step Therapies (ST) En este formulario hay medicamentos asociados a las iniciales TE. TE significa terapia escalonada. La siguiente tabla muestra cuáles son estos productos. / The formulary includes drugs associated to the ST initials. ST means step therapy. The following table shows which are those products. TERAPIA ESCALONADA (STEP THERAPY GROUP)
ADHD – Non-Stimulant
SISTEMA BUSCARÁ USO DE… (SYSTEM WILL SEARCH…)
Use stimulants 1st
MEDICAMENTO DE SEGUNDO PASO (SECOND STEP DRUG)
Strattera CloNIDine HCl ER / Kapvay
Use dextroamphet-SR, amphetDextroamphetamine Sulfate ER / dextroamphet-SR, methylphen (CD, Dexedrine CR, OMS, LA) 1st Brinzolamide Use dorzolamide 1st Azopt Celecoxib Use NSAIDs 1st Celecoxib / CeleBREX Janumet Janumet XR Januvia Use biguanides, sulfonylureas or DPP-4 glitazones 1st Jentadueto Jentadueto XR Tradjenta DPP-4 & SGLT-2 Use DPP-4 or SGLT-2 1st Glyxambi Aldactazide Eplerenone Use spironolactone or spironolactone & hctz generic 1st Eplerenone / Inspra Ezetimibe Use statins 1st Ezetimibe / Zetia Use QVAR, Flovent or Arnuity Flunisolide HFA Inhalation Aerospan Ellipta 1st Glitazones Use biguanides or sulfonylureas 1st Pioglitazone HCl / Actos ADHD - Stimulants Extended Release
GLP-1
Use biguanides, sulfonylureas or glitazones 1st
Long Acting Opiods
Use short acting opiods 1st
Memantine SR
Use memantiene IR 1st
Miglitol Mirabegron
Use acarbose 1st Use oxybutynin or tolterodine 1st
Bydureon Byetta Trulicity Victoza Butrans FentaNYL / Duragesic Namenda XR Namenda XR Titration Pack Miglitol / Glyset Myrbetriq
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Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
TERAPIA ESCALONADA (STEP THERAPY GROUP)
SISTEMA BUSCARÁ USO DE… (SYSTEM WILL SEARCH…)
MEDICAMENTO DE SEGUNDO PASO (SECOND STEP DRUG)
Mometasone Furoate Inhal
Use QVAR, Flovent or Arnuity Ellipta 1st
Asmanex
Nasal Corticosteroid
Use OTC or generic fluticasone propionate or flunisolide 1st
Qnasl / Qnasl Childrens Triamcinolone Acetonide / Nasacort Veramyst
Use OTC 1st
Levocetirizine Dihydrochloride / Xyzal
Use Invega Sustenna 1st
Invega Trinza
Non-Sedating Antihistamines Paliperidone palmitate (Trinza) Pimecrolimus / Tacrolimus
PPIs
Pregabalin Rasagiline Repaglinide Rotigotine
SGLT-2 Inhibitors
Simvastatin 80 mg
Statins Triptans
Use topical corticosteroid or lactic Elidel acid 1st Tacrolimus / Protopic Lansoprazole 30 mg / Prevacid 30 mg Use OTC or lansoprazole/omeprazole/pantropra Omeprazole-Sodium Bicarbonate / zole generic 1st Zegerid Use anticonvulsants, TCA or Lyrica Duloxetine 1st Use selegiline 1st Rasagiline Mesylate / Azilect Use nateglinide 1st Repaglinide / Prandin Use pramipexole or ropinirole 1st Neupro Invokamet Invokana Use biguanides, sulfonylureas, glitazones, DDP-4 or GLP-1 Jardiance inhibitors 1st Synjardy Synjardy XR Ezetimibe-Simvastatin / Vytorin 10Restricted to pts taking this dose for 80mg at least 12 months Simvastatin / Zocor 80mg Use atorvastatin, lovastatin, rosuvastatin, pravastatin, Ezetimibe-Simvastatin / Vytorin simvastatin generic 1st Use sumatriptan 1st Eletriptan
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Apéndice IV – Lista de Contraceptivos / Appendix IV - Contraceptives Medicamentos contraceptivos específicos, a los cuales aplica $0 copago si son recetados por proveedores participantes según requiere el gobierno federal. A continuación, los medicamentos incluidos en esta ley: Cero ($0) copay will be applied to the following contraceptive drugs, if prescribed by participating providers, as required by Federal Law:
Contraceptive Methods (Métodos Anticonceptivos) Cervical Cap (Cápsula Cervical) FEMCAP CERVICAL CAP 26MM FEMCAP CERVICAL CAP 30MM PRENTIF CAVITY RIM CERVICAL CAP 22MM PRENTIF CAVITY RIM CERVICAL CAP 25MM PRENTIF CAVITY RIM CERVICAL CAP 28MM PRENTIF CAVITY-RIM CERVICAL CAP 31MM PRENTIF FITTING SET
Copper Intrauterine Device (Dispositivo Intrauterino de Cobre) PARAGARD INTRAUTERINE COPPER
Diaphragm (Diafragma) CAYA CONTOURED DIAPHRAGM OMNIFLEX DIAPHRAGM WIDE-SEAL DIAPHRAGM 60 MM WIDE-SEAL DIAPHRAGM 65 MM WIDE-SEAL DIAPHRAGM 70 MM WIDE-SEAL DIAPHRAGM 75 MM WIDE-SEAL DIAPHRAGM 80 MM WIDE-SEAL DIAPHRAGM 85 MM WIDE-SEAL DIAPHRAGM 90 MM
Emergency Contraceptive (Anticonceptivos de Emergencia) levonorgestrel tablet 1.5 mg
Female Condom (Condón Femenino) FC FEMALE CONDOM
Injection (Inyección) medroxyprogesterone acetate intramuscular suspension 150 mg/ml medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml
Intrauterine Device with Progestin (Dispositivo Intrauterino con Progestina) MIRENA INTRAUTERINE DEVICE 20MCG/24HR
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
Contraceptive Methods (Métodos Anticonceptivos) Oral Contraceptive (Combined Pill) (Anticonceptivos Orales (Píldora Combinada)) desogestrel - ethinyl estradiol tablet 0.15 mg -30 mcg drospirenone - ethinyl estradiol tablet 3-0.03 mg drospirenone-ethinyl estradiol-levomefolate tablet 3-0.02-0.451 mg levonorgestrel - ethinyl estradiol tablet 0.1 mg -20 mcg levonorgestrel - ethinyl estradiol tablet 0.15 mg -30 mcg levonorgestrel - ethinyl estradiol tablet 0.05-30/0.075-40/0.125-30 mg-mcg LO LOESTRIN FE TABLET 0.02MG-1MG-75MG NATAZIA TABLET 3/2-2/2-3/1 MG norethindrone - ethinyl estradiol tablet 0.5 mg - 35 mcg norgestimate - ethinyl estradiol tablet 0.25 mg -35 mcg norgestrel - ethinyl estradiol tablet 0.3 mg -30 mcg
Oral Contraceptive (Extended/Continuous Use) (Anticonceptivos Orales (Píldora Combinada de Uso Extendido/Continuo)) levonorgestrel - ethinyl estradiol (91-day) tablet 0.15-0.03 mg
Oral Contraceptive (Progestin Only) (Anticonceptivos Orales (Minipildora Sólo Progestina)) norethindrone tablet 0.35 mg
Patch (Parche) XULANE TRANSDERMAL PATCH 0.53MG-4.86 MG
Spermicide (Espermicida) ENCARE VAGINAL SUPPOSITORY 100MG nonoxynol-9 gel 4% OPTIONS GYNOL II CONTRACEPTIVE GEL SHUR-SEAL CONTRACEPTIVE GEL 2% VCF VAGINAL CONTRACEPTIVE FILM 28% VCF VAGINAL CONTRACEPTIVE FOAM 12.5%
Sponge with Spermicide (Esponja con Espermicida) TODAY SPONGE VAGINAL SPONGE 1000MG
Subdermal Implant (Implante Subdermal) NEXPLANON SUBDERMAL IMPLANT 68MG
Ulipristal Acetate (Acetato de Ulipristal) ELLA TABLET 30MG
Vaginal Ring (Anillo Vaginal) NUVARING VAGINAL RING 0.12-0.015 MG/24 HR
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Apéndice V – Solicitud de Excepción Médica / Appendix V - Medical Exception Application Nombre del Paciente y Representante Personal (si aplica): __________________________________ Núm. Contrato ______________________
Núm. de Grupo: ____________________
Se solicita la aprobación de: Medicamento no está incluido en el formulario Cubierta continuada para medicamento que se descontinuar Excepción a un procedimiento de manejo de medicamento (ei, terapia escalonada) Excepción a un procedimiento de limitación de dosis Razones para la solicitud de excepción médica: En el formulario no figura un medicamento clínicamente aceptable para tratar la condición del paciente. El medicamento que procede conforme a la terapia escalonada es ineficaz para la condición o el paciente, es probable que cause daño al paciente o y ya el paciente se encontraba en un nivel más avanzado bajo otro plan médico. La dosis disponible para medicamento probablemente es ineficaz para la condición o el paciente. Historial breve del paciente:
Diagnóstico primario relacionado con el medicamento de receta objeto de la solicitud (incluya código y descripción):
Descripción de la necesidad médica de medicamento para el cual se solicita la excepción: (Incluya hoja adicional de ser necesario)
Nombre de la Persona que expide la receta
# de Proveedor (NPI)
Firma
Fecha
Forma: CSS-AS-04-002
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PARTE VII – ÍNDICE / PART VII – INDEX abacavir sulfate ........................... 51 abacavir sulfate-lamivudine ......... 53 abacavir-lamivudine-zidovudine .. 53 ABSORICA.................................. 71 acamprosate calcium ................ 115 Acamprosate Calcium ............... 131 acarbose ..................................... 54 acebutolol hcl .............................. 63 acetaminophen-codeine ..... 26, 104, 124 acetaminophen-codeine #2 26, 104, 123 acetaminophen-codeine #3 26, 104, 123 acetaminophen-codeine #4 26, 104, 124 acetazolamide ............................. 65 acetic acid ........................... 90, 113 acetic acid-aluminum acetate ...... 90 acetylcysteine.............................. 95 acitretin........................................ 73 ACTEMRA................................... 85 Actos ......................................... 134 ACUVAIL ..................................... 88 acyclovir .............................. 50, 110 acyclovir sodium.......................... 50 ADAGEN ..................................... 74 Adapalene ................................. 131 ADVAIR DISKUS ........................ 91 ADVAIR HFA ............................... 91 ADVATE ...................................... 58 ADYNOVATE .............................. 58 Aerospan ................................... 134 AEROSPAN ................................ 91 Afinitor ....................................... 127 AFINITOR ................................... 45 AFINITOR DISPERZ ................... 45 AFSTYLA .................................... 58 AKYNZEO ................................... 40 ALBENZA .................................... 47 albuterol sulfate ................... 94, 114 alclometasone dipropionate ........ 78 Aldactazide................................ 134 ALDACTAZIDE ........................... 66 ALDURAZYME ............................ 74 Alecensa ................................... 127 ALECENSA ................................. 45 alendronate sodium..................... 86
ALINIA ........................................ 47 ALLEGRA ................................... 90 ALLEGRA-D ............................... 90 allopurinol ................................... 41 alosetron hcl ............................... 75 ALPHAGAN P ............................. 88 ALPHANATE/VWF COMPLEX/HUMAN ............... 58 ALPHANINE SD ......................... 58 alprazolam .......................... 54, 121 ALPROLIX .................................. 58 amantadine hcl ........................... 48 amikacin sulfate .......................... 29 amiloride hcl................................ 66 amiloride-hydrochlorothiazide ..... 66 Aminobenzoate Potassium ....... 131 aminophylline .............................. 94 AMINOSYN II.............................. 96 AMINOSYN M............................. 96 AMINOSYN/ELECTROLYTES ... 96 AMINOSYN-PF ........................... 96 amiodarone hcl ........................... 63 Amitiza ...................................... 131 AMITIZA...................................... 75 amitriptyline hcl ................... 39, 118 amlodipine besy-benazepril hcl... 64 amlodipine besylate .................... 64 ammonium lactate ...................... 72 amoxapine .......................... 39, 118 amoxicillin ................... 31, 106, 125 amoxicillin-pot clavulanate ... 31, 32, 106, 125 amoxicillin-pot clavulanate er ..... 31, 125 Amphetamine............................ 131 amphetamine-dextroamphetamine ............................................... 68 ampicillin ..................... 32, 106, 125 ampicillin sodium ........................ 32 AMPYRA..................................... 69 anagrelide hcl ............................. 61 anastrozole ................................. 45 Anastrozole ............................... 127 ANDROGEL................................ 81 ANDROGEL PUMP .................... 81 APIDRA ...................................... 56 APOKYN ..................................... 48 aprepitant .................................... 40
APRISO ....................................... 85 APTIVUS ..................................... 52 ARALAST NP .............................. 95 ARCALYST ................................. 85 Arimidex .................................... 127 aripiprazole ................................ 119 ARNUITY ELLIPTA ..................... 91 Aromasin ................................... 128 Asmanex ................................... 135 ASMANEX 30 METERED DOSES ............................................... 91 aspirin-dipyridamole er ................ 61 ATABEX EC ................................ 99 atenolol ................................ 63, 111 atenolol-chlorthalidone ........ 64, 111 ATOMOXETINE ........................ 131 atomoxetine hcl ........................... 69 atorvastatin calcium..................... 67 atovaquone.......................... 47, 109 atovaquone-proguanil hcl ............ 47 ATRIPLA ..................................... 53 ATROVENT HFA................. 93, 113 AUGMENTIN ....................... 32, 106 AVONEX ..................................... 69 AVONEX PEN ............................. 69 AVONEX PREFILLED ................. 69 azathioprine ................................. 84 AzaTHIOprine............................ 131 azelastine hcl............................... 90 Azilect ........................................ 135 azithromycin .. 32, 33, 106, 107, 126 Azopt ......................................... 134 AZOPT ........................................ 88 bacitracin ..................................... 87 bacitracin-polymyxin b ................. 87 baclofen ....................................... 49 BAL-CARE DHA .......................... 99 balsalazide disodium ................... 85 BANZEL ...................................... 36 BARACLUDE .............................. 50 BEBULIN ..................................... 58 benazepril hcl .............................. 62 benazepril-hydrochlorothiazide ... 62 BENEFIX ..................................... 58 benztropine mesylate .................. 48 betamethasone dipropionate ....... 78 betamethasone dipropionate aug 78 betamethasone valerate .............. 78
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
betaxolol hcl .......................... 64, 88 bethanechol chloride ................... 77 BEVESPI AEROSPHERE ........... 93 bexarotene .................................. 46 Bexarotene ................................ 127 bicalutamide ................................ 44 Bicalutamide.............................. 127 BICILLIN C-R .............................. 32 BICILLIN C-R 900/300 ........ 32, 106 BICILLIN L-A ....................... 32, 106 BILTRICIDE ................................ 47 bisoprolol fumarate ...................... 64 bisoprolol-hydrochlorothiazide..... 64 BLEPHAMIDE ............................. 87 BLEPHAMIDE S.O.P. ................. 87 Bosulif ....................................... 127 BOSULIF ..................................... 45 BOTOX........................................ 69 bp folinatal plus b ........................ 99 bp multinatal plus ........................ 99 BRILINTA .................................... 61 brimonidine tartrate ..................... 88 bromocriptine mesylate ............... 48 budesonide............................ 86, 91 bumetanide ................................. 66 BUPHENYL ................................. 74 buprenorphine ............................. 26 Buprenorphine........................... 131 buprenorphine hcl ..................... 115 Buprenorphine HCl-Naloxone ... 131 buprenorphine hcl-naloxone hcl 115 Buprenorphine/Naloxone .......... 131 bupropion hcl....................... 38, 116 bupropion hcl er (smoking det) .... 28 bupropion hcl er (sr) ............ 38, 116 buspirone hcl ....................... 54, 121 butalbital-apap-caff-cod............... 26 butalbital-apap-caffeine ....... 28, 105 butalbital-asa-caff-codeine .......... 26 BUTISOL SODIUM ..................... 26 Butrans ...................................... 134 BUTRANS ................................... 26 Bydureon ................................... 134 BYDUREON ................................ 54 Byetta ........................................ 134 BYETTA 10 MCG PEN ............... 54 BYETTA 5 MCG PEN ................. 55 cabergoline.................................. 83 Cabometyx ................................ 127 CABOMETYX.............................. 45 calcipotriene ................................ 73
calcitonin (salmon) ...................... 86 calcitriol ................................. 73, 86 calcium acetate (phos binder) ..... 78 calcium pnv ................................. 99 CANASA ..................................... 85 Cancidas ................................... 131 CANCIDAS ................................. 40 CAPASTAT SULFATE ................ 43 CAPITAL/CODEINE ........... 93, 113 Caprelsa ................................... 127 CAPRELSA................................. 45 captopril .............................. 62, 111 captopril-hydrochlorothiazide ..... 62, 111 CARAFATE................................. 76 carbamazepine ................... 36, 116 carbamazepine er ............... 36, 116 carbidopa .................................... 48 carbidopa-levodopa .................... 48 carbidopa-levodopa er ................ 48 carbidopa-levodopa-entacapone 49 carteolol hcl................................. 88 carvedilol..................................... 64 Casodex.................................... 127 CAYA CONTOURED DIAPHRAGM ............................................. 136 cefaclor ....................... 30, 105, 125 cefadroxil .................... 30, 105, 125 cefazolin sodium ......................... 30 cefdinir ........................ 30, 105, 125 cefepime hcl................................ 30 cefpodoxime proxetil ........... 30, 125 cefprozil ...................... 31, 105, 125 ceftazidime.................................. 31 ceftriaxone sodium.............. 31, 105 cefuroxime axetil ................. 31, 125 cefuroxime sodium...................... 31 CeleBREX................................. 134 celecoxib ............................. 25, 104 Celecoxib .................................. 134 CELONTIN.................................. 34 cephalexin................... 31, 106, 125 CERDELGA ................................ 73 CEREZYME ................................ 73 cetirizine...................................... 90 cetirizine-pseudoephedrine......... 90 chlorhexidine gluconate .............. 70 chloroquine phosphate ............... 47 chlorothiazide.............................. 66 chlorpromazine hcl.............. 49, 118 chlorthalidone ............................. 66
140 chlorzoxazone ............................. 95 CHOLBAM................................... 76 cholestyramine ............................ 67 cholestyramine light..................... 67 chorionic gonadotropin ................ 83 ciclopirox ..................................... 71 cilostazol...................................... 61 cimetidine ............................ 75, 112 cimetidine hcl....................... 75, 112 CINRYZE..................................... 83 CIPRO HC ........................... 89, 113 CIPRODEX.................................. 89 ciprofloxacin ........................ 33, 107 ciprofloxacin hcl ..... 33, 87, 107, 126 ciprofloxacin-ciproflox hcl er 33, 107 citalopram hydrobromide ..... 38, 117 CITRANATAL 90 DHA ................ 99 CITRANATAL ASSURE .............. 99 CITRANATAL B-CALM ............... 99 CITRANATAL HARMONY ........... 99 CITRANATAL RX ........................ 99 CLARAVIS................................... 71 clarithromycin .............. 33, 107, 126 CLARITIN .................................... 90 CLARITIN-D ................................ 90 CLEOCIN PHOSPHATE ............. 29 CLIMARA PRO............................ 81 clindamycin hcl ............ 29, 105, 124 clindamycin phosphate .......... 29, 71 CLINIMIX E/DEXTROSE (2.75/10) ............................................... 96 CLINIMIX E/DEXTROSE (2.75/5)96 CLINIMIX E/DEXTROSE (4.25/25) ............................................... 96 CLINIMIX E/DEXTROSE (4.25/5)96 CLINIMIX E/DEXTROSE (5/15) .. 97 CLINIMIX E/DEXTROSE (5/20) .. 97 CLINIMIX E/DEXTROSE (5/25) .. 97 CLINIMIX/DEXTROSE (2.75/5) ... 97 CLINIMIX/DEXTROSE (4.25/10) . 97 CLINIMIX/DEXTROSE (4.25/20) . 97 CLINIMIX/DEXTROSE (4.25/25) . 97 CLINIMIX/DEXTROSE (4.25/5) ... 97 CLINIMIX/DEXTROSE (5/15) ...... 97 CLINIMIX/DEXTROSE (5/20) ...... 97 CLINIMIX/DEXTROSE (5/25) ...... 97 CLINISOL SF .............................. 97 clobetasol propionate .................. 79 clobetasol propionate e ............... 78 clomipramine hcl ................. 39, 118 clonazepam ......................... 35, 115
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
CloNIDine .................................. 134 clonidine hcl ........................ 61, 111 clonidine hcl er ............................ 68 CloNIDine HCl ER ..................... 131 clopidogrel bisulfate ............ 61, 111 clorazepate dipotassium ..... 54, 121 clotrimazole ................... 40, 71, 108 clotrimazole-betamethasone . 71, 72 clozapine ................................... 121 COAGADEX ................................ 58 COARTEM .................................. 47 colchicine ............................ 41, 109 colchicine-probenecid ................. 41 colestipol hcl................................ 67 colistimethate sodium .................. 29 COMBIVENT RESPIMAT............ 93 Cometriq.................................... 127 COMETRIQ (100 MG DAILY DOSE) .................................... 45 COMETRIQ (140 MG DAILY DOSE) .................................... 45 COMETRIQ (60 MG DAILY DOSE) ............................................... 45 COMPLERA ................................ 53 complete natal dha ...................... 99 CONCEPT OB ............................ 99 CONDYLOX ................................ 72 COPAXONE ................................ 69 cortisone acetate ......................... 41 COSENTYX SENSOREADY 300 DOSE ..................................... 84 COSOPT PF ............................... 88 Cresemba.................................. 132 CRESEMBA ................................ 40 CRIXIVAN ................................... 52 cromolyn sodium ............. 75, 87, 94 cyclobenzaprine hcl ............. 95, 114 cycloserine .................................. 43 CYSTADANE .............................. 73 CYSTAGON ................................ 73 danazol........................................ 81 dantrolene sodium....................... 49 dapsone .............................. 43, 109 daptomycin .................................. 29 DARAPRIM ................................. 47 darifenacin hydrobromide er........ 77 demeclocycline hcl .............. 34, 107 DEMEROL .................................. 26 DEPEN TITRATABS ................... 77 DEPO-MEDROL ......................... 41 DESCOVY................................... 53
Desipramine.............................. 132 desipramine hcl................... 39, 118 desmopressin ace spray refrig .... 80 desmopressin acetate................. 80 desmopressin acetate spray ....... 81 desogestrel - ethinyl estradiol tablet 0.15 mg -30 mcg .................. 137 desonide ..................................... 79 dexamethasone .................. 42, 109 DEXAMETHASONE INTENSOL 42, 109 dexamethasone sodium phosphate ......................................... 42, 88 Dexedrine ................................. 134 Dextroamphetamine ......... 132, 134 dextroamphetamine sulfate ........ 68 dextroamphetamine sulfate er .... 68 dextrose ...................................... 97 dextrose in lactated ringers ......... 97 dextrose-nacl .............................. 97 diazepam ............................ 54, 121 diclofenac potassium .......... 25, 123 diclofenac sodium ... 25, 72, 88, 123 diclofenac sodium er ................... 25 dicloxacillin sodium ............. 32, 126 dicyclomine hcl ........................... 74 didanosine .................................. 51 digoxin ........................................ 65 dihydroergotamine mesylate ....... 42 DILANTIN ........................... 36, 108 diltiazem hcl ................................ 65 diltiazem hcl er ............................ 65 diltiazem hcl er beads ................. 64 diltiazem hcl er coated beads ..... 65 DIPENTUM ................................. 85 diphenhydramine hcl..... 40, 90, 113 diphenoxylate-atropine ....... 75, 112 disopyramide phosphate ............. 63 disulfiram .................................. 115 Disulfiram .................................. 132 divalproex sodium ............... 35, 116 divalproex sodium er........... 35, 116 dofetilide ..................................... 63 donepezil hcl ............................... 37 dorzolamide hcl........................... 88 dorzolamide hcl-timolol mal ........ 88 doxazosin mesylate .................... 61 doxepin hcl.......................... 39, 118 doxycycline hyclate ..... 34, 107, 108 doxycycline monohydrate ........... 34 dronabinol ................................... 40
141 drospirenone - ethinyl estradiol tablet 3-0.03 mg.................... 137 drospirenone-ethinyl estradiollevomefolate tablet 3-0.02-0.451 mg......................................... 137 DUET DHA 400 ........................... 99 DUET DHA BALANCED .............. 99 DULERA ...................................... 91 duloxetine hcl ...................... 38, 117 Duragesic .................................. 134 DYSPORT ................................... 69 econazole nitrate ......................... 72 EDURANT ................................... 51 EFFIENT ..................................... 61 ELAPRASE ................................. 74 ELELYSO .................................... 73 eletriptan...................................... 42 Eletriptan ................................... 135 Elidel ......................................... 135 ELIDEL ........................................ 72 ELITE-OB .................................... 99 ELIXOPHYLLIN ........................... 94 ELLA TABLET 30MG ................ 137 ELMIRON .................................... 77 ELOCTATE ................................. 58 Emcyt ........................................ 127 EMCYT ........................................ 44 EMSAM ............................... 38, 117 EMTRIVA .................................... 51 EMVERM..................................... 47 enalapril maleate ................. 62, 111 enalapril-hydrochlorothiazide ..... 62, 111 ENBREL ...................................... 84 ENBREL SURECLICK ................ 84 ENCARE VAGINAL SUPPOSITORY 100MG ....... 137 enoxaparin sodium ...................... 57 entacapone.................................. 48 entecavir ...................................... 50 ENTRESTO ................................. 65 EPCLUSA.................................... 50 Epiduo ....................................... 132 Epiduo Forte .............................. 132 epinephrine.................................. 94 eplerenone .................................. 66 Eplerenone ................................ 134 Eraxis ........................................ 132 ERAXIS ....................................... 40 ergoloid mesylates ...................... 37 ERGOMAR .................................. 42
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
Erivedge .................................... 127 ERIVEDGE.................................. 44 ERYPED 400 ...................... 33, 107 ERY-TAB............................. 33, 107 ERYTHROCIN LACTOBIONATE 33 ERYTHROCIN STEARATE. 33, 107 erythromycin.......................... 71, 87 erythromycin base ............... 33, 107 erythromycin ethylsuccinate 33, 107 ESBRIET ..................................... 95 escitalopram oxalate ........... 38, 117 esomeprazole.............................. 76 estazolam ............................ 96, 122 ESTRACE ................................... 81 estradiol....................................... 81 estradiol vaginal .......................... 82 estropipate .................................. 81 ethambutol hcl ............................. 43 ethosuximide ............................... 34 etidronate disodium ..................... 86 etodolac............................... 25, 123 etodolac er .......................... 25, 104 Eulexin ...................................... 128 EURAX ........................................ 47 EVOTAZ ...................................... 53 exemestane................................. 45 Exemestane .............................. 128 EXJADE ...................................... 98 EXTAVIA ..................................... 69 extra-virt plus dha........................ 99 ezetimibe ..................................... 67 Ezetimibe .................................. 134 ezetimibe-simvastatin.................. 67 Ezetimibe-Simvastatin............... 135 FABRAZYME .............................. 73 famciclovir ................................... 50 famotidine.................................... 75 Fareston .................................... 128 FARESTON................................. 44 FC FEMALE CONDOM ............. 136 FEIBA .......................................... 58 felbamate .................................... 35 Femara ...................................... 128 FEMCAP CERVICAL CAP 26MM ............................................. 136 FEMCAP CERVICAL CAP 30MM ............................................. 136 fenofibrate ................................... 66 fenofibrate micronized ................. 66 fenofibric acid .............................. 67 fentanyl........................................ 26
FentaNYL.................................. 134 fentanyl citrate ............................ 27 FERRIPROX ............................... 98 fexofenadine ............................... 90 fexofenadine-pseudoephedrine .. 90 finasteride ................................... 77 FIRAZYR .................................... 84 flavoxate hcl ................................ 77 flecainide acetate ........................ 63 FLONASE ................................... 91 FLOVENT DISKUS ..................... 92 FLOVENT HFA ........................... 92 fluconazole.................................. 41 flucytosine ................................... 41 fludrocortisone acetate ............... 79 flunisolide .................................... 92 fluocinolone acetonide .......... 79, 89 fluocinolone acetonide body ....... 79 fluocinonide................................. 79 fluocinonide-e ............................. 79 fluorouracil .................................. 72 fluoxetine hcl ....................... 38, 117 fluphenazine decanoate............ 119 fluphenazine hcl ................ 118, 119 flurbiprofen .................................. 25 flurbiprofen sodium ..................... 89 flutamide ..................................... 44 Flutamide .................................. 128 fluticasone propionate........... 79, 92 fluvoxamine maleate ........... 38, 117 FOLCAPS OMEGA 3.................. 99 FOLET DHA................................ 99 fondaparinux sodium .................. 57 FORTAZ ..................................... 31 FORTEO ..................................... 86 fosinopril sodium ......................... 62 fosinopril sodium-hctz ................. 62 furosemide .......................... 66, 112 FUZEON ..................................... 52 gabapentin .................................. 35 GABITRIL ................................... 35 galantamine hydrobromide ......... 37 galantamine hydrobromide er ..... 37 ganciclovir sodium ...................... 49 gemfibrozil .................................. 67 gentamicin sulfate .. 29, 71, 87, 112, 113 GENVOYA .................................. 53 GILENYA .................................... 70 GLASSIA .................................... 95 Gleevec..................................... 128
142 Gleostine ................................... 128 GLEOSTINE ................................ 44 glimepiride ........................... 55, 110 glipizide ............................... 55, 110 glipizide er ........................... 55, 110 glipizide-metformin hcl................. 55 GLUCAGEN HYPOKIT ............... 56 glyburide ...................................... 55 glyburide micronized ................... 55 glyburide-metformin..................... 55 glycopyrrolate .............................. 74 Glyset ........................................ 134 Glyxambi ................................... 134 GLYXAMBI .................................. 55 Granix ........................................ 132 griseofulvin ultramicrosize ........... 41 guaifenesin-codeine ............ 93, 113 guanfacine hcl ............................. 61 halobetasol propionate ................ 79 haloperidol ................................. 119 haloperidol decanoate ............... 119 haloperidol lactate ..................... 119 HARVONI .................................... 50 HELIXATE FS ............................. 58 hemenatal ob............................... 99 HEMOFIL M ................................ 59 heparin sodium (porcine)............. 57 HEPATAMINE ............................. 97 Hexalen ..................................... 128 HEXALEN.................................... 44 HUMALOG .................................. 56 HUMALOG MIX 50/50 ................. 56 HUMALOG MIX 75/25 ................. 56 HUMATE-P.................................. 59 HUMIRA ...................................... 84 HUMIRA PEN-PSORIASIS STARTER ............................... 84 HUMULIN .................................... 57 hydralazine hcl ............................ 67 hydrochlorothiazide ............. 66, 112 hydrocodone-acetaminophen ..... 27, 124 hydrocodone-ibuprofen ....... 27, 124 hydrocortisone ........... 42, 75, 79, 80 hydrocortisone valerate ............... 80 hydrocortisone-acetic acid... 89, 113 hydroxychloroquine sulfate .......... 47 hydroxyurea................................. 44 Hydroxyurea .............................. 128 hydroxyzine pamoate .. 54, 110, 121 ibandronate sodium ..................... 86
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
Ibrance ...................................... 128 IBRANCE .................................... 45 ibuprofen ..................... 25, 104, 123 Iclusig ........................................ 128 ICLUSIG ...................................... 45 IDELVION ................................... 59 Imatinib...................................... 128 imatinib mesylate ........................ 45 imipenem-cilastatin ..................... 31 imipramine hcl ..................... 39, 118 imiquimod .................................... 73 INATAL GT.................................. 99 indapamide.................................. 66 indomethacin ............... 25, 104, 123 infanate balance ........................ 100 Inlyta.......................................... 128 INLYTA........................................ 46 Inspra ........................................ 134 INTELENCE ................................ 51 INTRALIPID .......................... 97, 98 INTRON A ................................... 50 INVANZ ....................................... 31 INVEGA SUSTENNA ........ 119, 120 Invega Trinza ............................ 135 INVEGA TRINZA ....................... 120 INVIRASE ................................... 52 Invokamet.................................. 135 INVOKAMET ............................... 55 Invokana.................................... 135 INVOKANA.................................. 55 ipratropium bromide ............ 93, 113 irbesartan .................................... 61 irbesartan-hydrochlorothiazide .... 61 ISENTRESS ................................ 51 ISOLYTE-S ................................. 98 isoniazid ...................................... 43 ISORDIL TITRADOSE ................ 68 isosorbide dinitrate ...................... 68 isosorbide dinitrate er .................. 68 isosorbide mononitrate ................ 68 isosorbide mononitrate er ............ 68 itraconazole ................................. 41 ivermectin .................................... 47 IXINITY........................................ 59 JADENU ...................................... 99 Jakafi ......................................... 128 JAKAFI ........................................ 46 Janumet .................................... 134 JANUMET ................................... 55 Janumet XR .............................. 134 JANUMET XR ............................. 55
Januvia ..................................... 134 JANUVIA..................................... 55 Jardiance .................................. 135 JARDIANCE ............................... 55 Jentadueto ................................ 134 JENTADUETO ............................ 55 Jentadueto XR .......................... 134 JENTADUETO XR ...................... 55 KALETRA ................................... 53 Kapvay ...................................... 134 ketoconazole......................... 41, 72 ketorolac tromethamine 25, 89, 123 ketotifen ...................................... 87 KOATE-DVI ................................ 59 KOGENATE FS .......................... 59 KOGENATE FS BIO-SET ........... 59 KOVALTRY................................. 59 KUVAN ....................................... 74 labetalol hcl ................................. 64 lactated ringers ........................... 98 lactulose...................................... 76 lactulose encephalopathy ........... 76 lamivudine................................... 51 lamivudine-zidovudine ................ 53 lamotrigine .......................... 36, 116 lansoprazole ............................... 76 Lansoprazole ............................ 135 LANTUS...................................... 57 latanoprost .................................. 89 leflunomide ................................. 85 LEMTRADA ................................ 70 LETAIRIS .................................... 95 letrozole ...................................... 45 Letrozole ................................... 128 Leucovorin ................................ 128 leucovorin calcium ...................... 44 Leukeran ................................... 128 LEUKERAN ................................ 44 Leukine ..................................... 132 LEUKINE .................................... 60 levalbuterol tartrate ............. 94, 114 levetiracetam .............................. 34 levobunolol hcl ............................ 88 levocarnitine................................ 98 Levocetirizine ............................ 135 levocetirizine dihydrochloride ...... 90 levofloxacin ......................... 33, 107 levomefolate dha ...................... 100 levonorgestrel - ethinyl estradiol (91-day) tablet 0.15-0.03 mg 137
143 levonorgestrel - ethinyl estradiol tablet 0.05-30/0.075-40/0.125-30 mg-mcg................................. 137 levonorgestrel - ethinyl estradiol tablet 0.1 mg -20 mcg ........... 137 levonorgestrel - ethinyl estradiol tablet 0.15 mg -30 mcg ......... 137 levonorgestrel tablet 1.5 mg ...... 136 levothyroxine sodium................... 82 LEXIVA ........................................ 52 lidocaine ...................................... 28 lidocaine hcl................................. 28 lidocaine hcl (pf) .......................... 28 lidocaine viscous ................. 28, 105 lincomycin hcl .............................. 29 lindane ......................................... 47 liothyronine sodium ..................... 82 lisinopril ....................................... 62 lisinopril-hydrochlorothiazide ....... 62 lithium .................................. 54, 122 lithium carbonate ................. 54, 121 lithium carbonate er ............. 54, 121 LO LOESTRIN FE TABLET 0.02MG-1MG-75MG ............. 137 Lonsurf ...................................... 128 LONSURF ................................... 44 loperamide hcl ............................. 75 lopinavir-ritonavir ......................... 53 loratadine..................................... 90 loratadine-pseudoephedrine........ 91 lorazepam............................ 54, 121 losartan potassium .............. 61, 111 losartan potassium-hctz ...... 62, 111 loxapine succinate ..................... 119 LUMIGAN .................................... 89 LUPRON DEPOT-PED (1-MONTH) ............................................... 83 LUPRON DEPOT-PED (3-MONTH) ............................................... 83 Lynparza.................................... 128 LYNPARZA ................................. 46 Lyrica......................................... 135 LYRICA ....................................... 35 Lysodren.................................... 129 LYSODREN................................. 83 MACNATAL CN DHA ................ 100 maprotiline hcl ..................... 38, 117 MARNATAL-F ........................... 100 MARPLAN ........................... 38, 117 Matulane.................................... 129 MATULANE ................................. 44
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
meclizine hcl................................ 40 MEDROL ..................................... 42 medroxyprogesterone acetate..... 82 medroxyprogesterone acetate intramuscular suspension 150 mg/ml.................................... 136 medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml... 136 mefloquine hcl ............................. 47 meloxicam ................................... 25 memantine hcl ............................. 37 MENEST ..................................... 82 meperidine hcl ..................... 27, 124 mercaptopurine ........................... 44 Mercaptopurine ......................... 129 mesalamine ................................. 85 mesalamine-cleanser .................. 86 Mesnex...................................... 129 MESNEX ..................................... 45 MESTINON ................................. 43 metformin hcl....................... 56, 110 metformin hcl er .......................... 55 methazolamide ............................ 65 methenamine hippurate .............. 29 methimazole ................................ 83 methocarbamol ........................... 95 methotrexate ............................... 84 Methotrexate ..................... 129, 132 methoxsalen rapid ....................... 72 methscopolamine bromide .......... 74 methyldopa.................................. 61 Methylphenidate ........................ 132 methylphenidate hcl .................... 68 methylphenidate hcl er ................ 68 methylprednisolone ............. 42, 109 methylprednisolone acetate ........ 42 methylprednisolone sodium succ 42 metipranolol................................. 88 metoclopramide hcl ............. 40, 108 metolazone.................................. 66 metoprolol succinate er ............... 64 metoprolol tartrate ............... 64, 111 metoprolol-hydrochlorothiazide .. 64, 111 metronidazole.. 29, 30, 71, 105, 124 mexiletine hcl .............................. 63 MIACALCIN................................. 86 midodrine hcl ............................... 61 miglitol ......................................... 56 Miglitol ....................................... 134
MILLIPRED ......................... 42, 109 minocycline hcl ................... 34, 126 minoxidil ...................................... 67 MIRENA INTRAUTERINE DEVICE 20MCG/24HR ...................... 136 mirtazapine ......................... 38, 116 MIRVASO ................................... 71 misoprostol ................................. 76 modafinil ..................................... 96 Modafinil ................................... 132 moexipril hcl ................................ 62 moexipril-hydrochlorothiazide ..... 62 mometasone furoate ................... 80 MONOCLATE-P ......................... 59 MONONINE ................................ 59 montelukast sodium .............. 92, 93 morphine sulfate ......................... 27 morphine sulfate (concentrate) ... 27 morphine sulfate (pf) ................... 27 morphine sulfate er ..................... 26 MOXEZA..................................... 87 moxifloxacin ................................ 87 moxifloxacin hcl .......................... 34 mupirocin ............................ 71, 112 Mycamine ................................. 132 MYCAMINE ................................ 41 Mycophenolate ......................... 132 mycophenolate mofetil ................ 84 MYNATAL ................................. 100 mynate 90 plus ......................... 100 MYOBLOC .................................. 69 Myrbetriq ................................... 134 MYRBETRIQ .............................. 77 MYTESI ...................................... 75 nabumetone ................ 25, 104, 123 nadolol ........................................ 64 nadolol-bendroflumethiazide ....... 64 NAGLAZYME.............................. 74 naloxone hcl................................ 28 naltrexone hcl ............................. 28 Namenda XR ............................ 134 NAMENDA XR ............................ 37 NAMENDA XR TITRATION PACK ............................................... 37 NAMZARIC ................................. 37 naproxen ............... 25, 26, 104, 123 naproxen sodium ........ 26, 104, 123 Nasacort ................................... 135 NASACORT ................................ 92 NATACHEW ............................. 100 NATACYN................................... 89
144 NATALVIT ................................. 100 NATAZIA TABLET 3/2-2/2-3/1 MG ............................................. 137 nateglinide ................................... 56 NEBUPENT ......................... 47, 109 NEEVO DHA ............................. 100 neomycin sulfate ................. 29, 124 neomycin-bacitracin zn-polymyx . 87 neomycin-polymyxin-dexameth ... 87 neomycin-polymyxin-gramicidin .. 87 neomycin-polymyxin-hc . 87, 89, 113 NEPHRAMINE ............................ 98 NESTABS ABC ......................... 100 Neulasta .................................... 132 Neulasta Onpro ......................... 132 Neupogen .................................. 132 NEUPOGEN ................................ 60 Neupro ...................................... 135 NEUPRO ..................................... 48 nevirapine .................................... 51 nevirapine er................................ 51 NEWGEN .................................. 100 NexAVAR .................................. 129 NEXAVAR ................................... 46 NEXIUM ...................................... 76 NEXPLANON SUBDERMAL IMPLANT 68MG ................... 137 niacin er (antihyperlipidemic) ....... 67 nicardipine hcl ............................. 65 NICOTROL .................................. 29 nifedipine er ................................. 65 nifedipine er osmotic release ....... 65 Nilandron ................................... 129 nilutamide .................................... 44 Nilutamide ................................. 129 nimodipine ................................... 65 Ninlaro ....................................... 129 NINLARO .................................... 45 nitrofurantoin macrocrystal . 30, 105, 124 nitrofurantoin monohyd macro.... 30, 105 nitroglycerin ......................... 68, 112 Nolvadex ................................... 129 nonoxynol-9 gel 4% ................... 137 norethindrone - ethinyl estradiol tablet 0.5 mg - 35 mcg .......... 137 norethindrone acetate ................. 82 norethindrone tablet 0.35 mg .... 137 norgestimate - ethinyl estradiol tablet 0.25 mg -35 mcg ......... 137
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
norgestrel - ethinyl estradiol tablet 0.3 mg -30 mcg .................... 137 NORPACE CR ............................ 63 nortriptyline hcl .................... 39, 118 NORVIR ...................................... 52 NOVOEIGHT............................... 59 NOVOSEVEN RT ........................ 59 Noxafil ....................................... 133 NUVARING VAGINAL RING 0.120.015 MG/24 HR .................. 137 NUWIQ ........................................ 59 nystatin .......................... 41, 72, 109 nystatin-triamcinolone ................. 72 OB COMPLETE ONE ............... 100 OB COMPLETE PETITE ........... 100 OB COMPLETE PREMIER ....... 100 OB COMPLETE/DHA ................ 100 OBIZUR....................................... 60 OBSTETRIX DHA ..................... 100 OBSTETRIX EC ........................ 100 OBSTETRIX ONE ..................... 100 O-CAL PRENATAL ................... 100 octreotide acetate........................ 83 ODEFSEY ................................... 53 OFEV .......................................... 95 ofloxacin ........................ 87, 90, 113 olanzapine ................................. 120 olopatadine hcl ...................... 87, 91 omega-3-acid ethyl esters ........... 67 omeprazole ......................... 76, 112 omeprazole-sodium bicarbonate 76, 77 Omeprazole-Sodium Bicarbonate ............................................. 135 OMNIFLEX DIAPHRAGM ......... 136 ondansetron ................................ 40 ondansetron hcl........................... 40 ONFI............................................ 35 OPTIONS GYNOL II CONTRACEPTIVE GEL ....... 137 ORENCIA .................................... 84 ORENCIA CLICKJECT ............... 84 ORFADIN .................................... 74 oseltamivir phosphate ......... 53, 110 oxacillin sodium ........................... 32 oxandrolone ................................ 81 oxazepam............................ 54, 121 oxcarbazepine ............................. 36 oxybutynin chloride ..................... 77 oxybutynin chloride er ................. 77 oxycodone hcl ..................... 27, 124
oxycodone hcl er................. 26, 104 oxycodone-acetaminophen. 27, 124 paliperidone er .......................... 120 PANCREAZE .............................. 75 PANRETIN.................................. 46 pantoprazole sodium .................. 77 PARAGARD INTRAUTERINE COPPER .............................. 136 paricalcitol ................................... 86 paromomycin sulfate................... 29 paroxetine hcl ..................... 39, 117 paroxetine hcl er ................. 39, 117 PASER........................................ 43 PAXIL.................................. 39, 117 peg 3350/electrolytes.................. 76 peg 3350-kcl-na bicarb-nacl ....... 76 peg-3350/electrolytes ................. 76 PEGANONE ............................... 36 PEGASYS................................... 85 PEGASYS PROCLICK ............... 85 PEGINTRON .............................. 85 PEG-INTRON REDIPEN ............ 85 penicillin g procaine .................... 32 penicillin v potassium .. 32, 106, 126 PENTAM ..................................... 47 PENTASA ................................... 86 pentoxifylline er ........................... 65 perindopril erbumine ................... 62 permethrin................................... 47 perphenazine ...................... 49, 119 phenazopyridine hcl ............ 78, 112 phenelzine sulfate ............... 38, 117 phenobarbital ...................... 35, 108 phenoxybenzamine hcl ............... 65 phenytoin ............................ 36, 108 phenytoin sodium................ 36, 108 phenytoin sodium extended 36, 108 PHOSPHOLINE IODIDE ............ 88 pilocarpine hcl ............................. 70 pimozide ................................... 119 pindolol ....................................... 64 Pioglitazone .............................. 134 pioglitazone hcl ........................... 56 piperacillin sod-tazobactam so.... 32 PLEGRIDY.................................. 70 PLEGRIDY STARTER PACK ..... 70 pnv ob+dha ............................... 100 pnv tabs 29-1 ............................ 100 pnv-dha ..................................... 100 pnv-select ................................. 101 pnv-total .................................... 101
145 podofilox ...................................... 72 polymyxin b-trimethoprim ............ 87 Pomalyst.................................... 129 POMALYST ................................. 44 Potaba ....................................... 133 potassium chloride ...................... 98 potassium chloride crys er ........... 98 potassium chloride er .................. 98 potassium citrate er ..................... 98 Potiga ........................................ 133 POTIGA ....................................... 35 PR NATAL 400 .......................... 101 PR NATAL 400 EC .................... 101 PR NATAL 430 .......................... 101 PR NATAL 430 EC .................... 101 PRADAXA ................................... 57 pramipexole dihydrochloride ....... 48 Prandin ...................................... 135 pravastatin sodium ...................... 67 prazosin hcl ................................. 61 prednisolone acetate ................... 89 prednisone........................... 42, 109 PREFERAOB ONE ................... 101 PREMARIN ................................. 82 PREMASOL ................................ 98 PREMPHASE .............................. 82 PREMPRO .................................. 82 prenaissance harmony dha ....... 101 prenaissance next ..................... 101 prenaissance next-b .................. 101 PRENATA ................................. 101 prenatal 19 ................................ 101 PRENATAL-U............................ 101 PRENATE ................................. 101 PRENATE AM ........................... 101 PRENATE DHA ......................... 101 PRENATE ELITE ...................... 101 PRENATE ENHANCE ............... 101 PRENATE ESSENTIAL ............. 101 PRENATE MINI ......................... 101 PRENATE PIXIE ....................... 102 PRENATE RESTORE ............... 102 PRENATE STAR ....................... 102 PRENTIF CAVITY RIM CERVICAL CAP 22MM ........................... 136 PRENTIF CAVITY RIM CERVICAL CAP 25MM ........................... 136 PRENTIF CAVITY RIM CERVICAL CAP 28MM ........................... 136 PRENTIF CAVITY-RIM CERVICAL CAP 31MM ........................... 136
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
PRENTIF FITTING SET ............ 136 preplus ...................................... 102 pretab ........................................ 102 Prevacid .................................... 135 PREVACID .................................. 77 PREZCOBIX ............................... 53 PREZISTA................................... 52 PRIFTIN ...................................... 43 PRILOSEC .................................. 77 primaquine phosphate................. 47 primidone .................................... 35 PROAIR HFA ...................... 94, 114 PROAIR RESPICLICK ........ 94, 114 probenecid .................................. 41 PROCALAMINE .......................... 98 prochlorperazine ................. 49, 109 prochlorperazine edisylate .. 49, 119 prochlorperazine maleate ... 49, 109, 119 PROCRIT .................................... 60 PROFILNINE SD ......................... 60 progesterone micronized ............. 82 PROGLYCEM ............................. 56 PROLIA ....................................... 86 PROMACTA ................................ 60 promethazine hcl ................. 40, 108 propafenone hcl .......................... 63 propranolol hcl............................. 64 propranolol hcl er ........................ 64 propranolol-hctz .......................... 64 propylthiouracil ............................ 83 Protopic ..................................... 135 PROVENTIL HFA ................ 94, 114 PROVIDA OB ............................ 102 PULMOZYME ............................. 95 purefe ob plus ........................... 102 Purinethol .................................. 129 pyridostigmine bromide ............... 43 pyridostigmine bromide er ........... 43 Qnasl ......................................... 135 QNASL ........................................ 92 QNASL CHILDRENS .................. 92 quetiapine fumarate .................. 120 QuilliChew ER ........................... 133 QUILLICHEW ER ........................ 69 quinapril hcl ................................. 63 quinapril-hydrochlorothiazide ...... 63 quinidine gluconate er ................. 63 quinidine sulfate .......................... 63 quinine sulfate ............................. 47 QVAR .......................................... 92
raloxifene hcl............................... 82 ramipril ........................................ 63 RANEXA ..................................... 65 ranitidine hcl........................ 75, 112 Rasagiline ................................. 135 rasagiline mesylate ..................... 49 REBIF ......................................... 70 REBIF REBIDOSE ...................... 70 REBIF REBIDOSE TITRATION PACK ..................................... 70 REBIF TITRATION PACK .......... 70 RECOMBINATE ......................... 60 REGRANEX................................ 73 RELENZA DISKHALER .............. 53 RELISTOR .................................. 75 REMICADE ................................. 84 RENAGEL................................... 78 repaglinide .................................. 56 Repaglinide ............................... 135 RESCRIPTOR ............................ 51 RESTASIS MULTIDOSE ............ 89 RETROVIR ................................. 51 Revlimid .................................... 129 REVLIMID ................................... 44 REYATAZ ................................... 52 ribavirin ....................................... 50 RIDAURA.................................... 85 rifabutin ....................................... 43 rifampin ....................................... 43 RIFATER .................................... 43 riluzole ........................................ 69 rimantadine hcl ........................... 53 ringers ......................................... 98 RISPERDAL CONSTA ............. 120 risperidone ................................ 120 RITUXAN .................................... 46 rivastigmine................................. 37 rivastigmine tartrate .................... 37 RIXUBIS ..................................... 60 R-NATAL OB ............................ 102 ropinirole hcl ............................... 48 salsalate.............................. 26, 104 SANTYL ...................................... 73 scalacort ..................................... 80 SELECT-OB ............................. 102 SELECT-OB+DHA .................... 102 selegiline hcl ............................... 49 selenium sulfide .......................... 72 SELZENTRY............................... 52 se-natal 19 ................................ 102 SENSIPAR.................................. 83
146 SEREVENT DISKUS ................... 94 sertraline hcl ........................ 39, 117 sevelamer .................................... 78 SHUR-SEAL CONTRACEPTIVE GEL 2% ................................ 137 sildenafil citrate............................ 95 silver sulfadiazine ................ 71, 112 simvastatin .................................. 67 Simvastatin ................................ 135 SIVEXTRO .......................... 30, 105 sodium chloride ........................... 98 sodium phenylbutyrate ................ 74 sodium polystyrene sulfonate ...... 96 SOLU-CORTEF........................... 42 SOLU-MEDROL .......................... 42 SOMAVERT ................................ 83 SOOLANTRA .............................. 73 sotalol hcl .................................... 63 sotalol hcl (af) .............................. 63 SOVALDI ..................................... 50 SPIRIVA HANDIHALER .............. 93 SPIRIVA RESPIMAT ................... 93 spironolactone ............................. 66 spironolactone-hctz ..................... 66 Sprycel ...................................... 129 SPRYCEL.................................... 46 stavudine ..................................... 51 STELARA .................................... 85 STIMATE ..................................... 81 STIOLTO RESPIMAT.................. 93 Stivarga ..................................... 129 STIVARGA .................................. 46 Strattera..................................... 134 STRIBILD .................................... 53 STRIVERDI RESPIMAT .............. 94 Suboxone .................................. 133 SUBOXONE .............................. 115 sucralfate ..................................... 76 sulfacetamide-prednisolone ........ 88 sulfadiazine ......................... 34, 126 sulfamethoxazole-trimethoprim .. 34, 107, 126 sulfasalazine................................ 86 sulindac ............................... 26, 123 sumatriptan succinate ................. 43 SUSTIVA ..................................... 51 Sutent ........................................ 129 SUTENT ...................................... 46 SYMBICORT ............................... 92 SYMLINPEN 120......................... 56 SYMLINPEN 60........................... 56
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
SYNAREL ................................... 83 Synjardy .................................... 135 SYNJARDY ................................. 56 Synjardy XR .............................. 135 SYNJARDY XR ........................... 56 SYNTHROID ............................... 82 Tabloid ...................................... 129 TABLOID ..................................... 45 tacrolimus .................................... 72 Tacrolimus................................. 135 TAMIFLU ............................. 53, 110 Tamoxifen ................................. 129 tamoxifen citrate .......................... 44 tamsulosin hcl ............................. 77 Tarceva ..................................... 129 TARCEVA ................................... 46 Targretin .................................... 127 TARGRETIN ............................... 46 TARON-BC ............................... 102 TARON-PREX........................... 102 Tasigna ..................................... 130 TASIGNA .................................... 46 tazarotene ................................... 71 TAZORAC ................................... 71 temazepam ......................... 96, 122 terazosin hcl ................................ 61 terbinafine hcl .............................. 41 terbutaline sulfate ................ 93, 114 terconazole.................................. 41 testosterone ................................ 81 testosterone cypionate ................ 81 testosterone enanthate ............... 81 tetrabenazine .............................. 69 tetracycline hcl .................... 34, 108 Thalomid ................................... 130 THALOMID.................................. 44 theophylline er ............................. 95 thioridazine hcl .......................... 119 thiothixene ................................. 119 tiagabine hcl ................................ 35 tigecycline ................................... 30 timolol maleate ...................... 64, 88 tizanidine hcl ............................... 49 tl folate....................................... 102 tl-select ...................................... 102 tobramycin..................... 88, 94, 113 tobramycin sulfate ....................... 29 tobramycin-dexamethasone ........ 88 TOBREX ............................. 88, 113 TODAY SPONGE VAGINAL SPONGE 1000MG ............... 137
tolcapone .................................... 48 tolterodine tartrate....................... 77 tolterodine tartrate er .................. 77 topiramate ................................... 36 torsemide .................................... 66 TRACLEER................................. 95 Tradjenta................................... 134 TRADJENTA............................... 56 tramadol hcl ................ 27, 104, 124 tramadol-acetaminophen .... 28, 124 trandolapril .................................. 63 tranexamic acid........................... 61 tranylcypromine sulfate ....... 38, 117 TRAVATAN Z ............................. 89 trazodone hcl ...................... 39, 118 TRECATOR ................................ 43 tretinoin ................................. 46, 71 Tretinoin ............................ 130, 133 Triamcinolone ........................... 135 triamcinolone acetonide .. 70, 80, 92 triamterene-hctz .......................... 66 TRIANEX .................................... 80 TRICARE PRENATAL COMPLEAT ............................................. 102 TRICARE PRENATAL DHA ONE ............................................. 102 trifluoperazine hcl...................... 119 trifluridine .................................... 89 trihexyphenidyl hcl ...................... 48 trimethobenzamide hcl........ 40, 108 trimethoprim ........................ 30, 124 trimipramine maleate .......... 39, 118 trinatal rx 1 ................................ 102 TRINATE .................................. 102 tri-tabs dha ................................ 102 TRIUMEQ ................................... 53 Trulicity ..................................... 134 TRULICITY ................................. 56 TRUVADA................................... 54 TUDORZA PRESSAIR ............... 93 TYBOST ..................................... 50 Tykerb ....................................... 130 TYKERB ..................................... 46 TYSABRI .................................... 70 TYZINE ....................................... 95 ULORIC ...................................... 41 ultimatecare one nf ................... 102 ursodiol ....................................... 75 valacyclovir hcl............................ 50 valganciclovir hcl......................... 49 valproate sodium ................ 35, 116
147 valproic acid ........................ 35, 116 valsartan ...................................... 62 valsartan-hydrochlorothiazide ..... 62 vancomycin hcl .................... 30, 105 VCF VAGINAL CONTRACEPTIVE FILM 28% ............................. 137 VCF VAGINAL CONTRACEPTIVE FOAM 12.5% ........................ 137 VEMAVITE-PRX 2..................... 102 VEMLIDY..................................... 50 Venclexta................................... 130 VENCLEXTA ............................... 46 VENCLEXTA STARTING PACK . 46 venlafaxine hcl..................... 39, 118 venlafaxine hcl er ................ 39, 118 VENTAVIS................................... 95 VERAMYST................................. 92 verapamil hcl ....................... 65, 111 verapamil hcl er ........................... 65 Vesanoid ................................... 130 VIBRAMYCIN ...................... 34, 108 Victoza ...................................... 134 VICTOZA ..................................... 56 VIDEX ......................................... 52 VIMIZIM ....................................... 74 Vimpat ....................................... 133 VIMPAT ....................................... 36 VINATE II .................................. 102 VINATE M ................................. 103 VIRACEPT .................................. 53 VIREAD ....................................... 52 virt-c dha.................................... 103 virt-pn plus ................................. 103 virtprex....................................... 103 VITAFOL ULTRA....................... 103 VITAFOL-NANO ........................ 103 VITAFOL-OB ............................. 103 VITAFOL-OB+DHA ................... 103 VITAFOL-ONE .......................... 103 VITAMEDMD ONE RX/QUATREFOLIC .............. 103 VITAMEDMD REDICHEW RX .. 103 VITAPEARL............................... 103 VITA-PREN ............................... 103 VITEKTA ..................................... 51 VIVA DHA.................................. 103 VONVENDI.................................. 60 voriconazole ................................ 41 Voriconazole.............................. 133 Votrient ...................................... 130 VOTRIENT .................................. 46
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
vp-ch-pnv .................................. 103 vp-heme ob + dha ..................... 103 vp-pnv-dha ................................ 103 VPRIV ......................................... 73 Vytorin ....................................... 135 warfarin sodium ................... 57, 110 WELCHOL .................................. 67 WIDE-SEAL DIAPHRAGM 60 MM ............................................. 136 WIDE-SEAL DIAPHRAGM 65 MM ............................................. 136 WIDE-SEAL DIAPHRAGM 70 MM ............................................. 136 WIDE-SEAL DIAPHRAGM 75 MM ............................................. 136 WIDE-SEAL DIAPHRAGM 80 MM ............................................. 136 WIDE-SEAL DIAPHRAGM 85 MM ............................................. 136 WIDE-SEAL DIAPHRAGM 90 MM ............................................. 136 WILATE ....................................... 60 Xalkori ....................................... 130
XALKORI .................................... 46 XARELTO ................................... 57 XARELTO STARTER PACK....... 57 XEOMIN...................................... 69 XIFAXAN .................................... 75 XIIDRA ........................................ 89 XOLAIR....................................... 95 Xtandi........................................ 130 XTANDI....................................... 44 XULANE TRANSDERMAL PATCH 0.53MG-4.86 MG ................. 137 XYNTHA ..................................... 60 XYNTHA SOLOFUSE ................. 60 Xyzal ......................................... 135 ZADITOR .................................... 87 zafirlukast.................................... 93 zaleplon .............................. 96, 122 ZANTAC ..................................... 75 Zarxio ........................................ 133 ZARXIO ...................................... 60 ZATEAN-CH ............................. 103 ZAVESCA ................................... 73 Zegerid...................................... 135
148 ZEGERID .................................... 77 Zelboraf ..................................... 130 ZELBORAF ................................. 46 ZEPATIER ................................... 50 Zetia .......................................... 134 ZIAGEN ....................................... 52 zidovudine ................................... 52 ZINACEF ..................................... 31 ZIOPTAN ..................................... 89 ziprasidone hcl .......................... 121 Zocor ......................................... 135 zoledronic acid ............................ 86 Zolinza ....................................... 130 ZOLINZA ..................................... 45 zolpidem tartrate.................. 96, 122 zonisamide .................................. 36 Zydelig ....................................... 130 ZYDELIG ..................................... 45 ZYRTEC ...................................... 91 ZYRTEC-D .................................. 91 Zytiga ........................................ 130 ZYTIGA ....................................... 44
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Aviso: Informando a los Individuos sobre los requisitos de no discrimen y acceso y la declaración de no discrimen: El Discrimen Esta En Contra De La Ley Triple S Salud, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina, no excluye a las personas ni las trata de forma diferente por motivos de raza, color, origen nacional, edad, sexo o incapacidad. Triple S Salud, Inc. • Proporciona mecanismos auxiliares y servicios gratuitos a las personas con incapacidades para comunicarse efectivamente con nosotros, tales como: o Intérpretes en lenguaje de señas certificados, o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, entre otros). • Proporciona servicios de traducción gratuitos a personas cuyo primer idioma no es el español, tales como: o Intérpretes certificados, o Información escrita en otros idiomas. Si necesita recibir estos servicios, contacte a un Representante de Servicio. Si considera que Triple S Salud, Inc. no le ha provisto estos servicios o han discriminado de cualquier otra manera por motivos de raza, origen nacional, color, edad, sexo o incapacidad, comuníquese con: Oficina de Cumplimiento y Privacidad P.O. Box 11320, San Juan, PR 00922-9905 Teléfono: (787) 620-1919 ext. 4183 Fax: (787) 993-3260 Correo electrónico:
[email protected] Puede presentar su querella en persona, por correo, fax o correo electrónico. Si necesita ayuda para presentar su querella, un Representante de Servicio está disponible para ayudarle. Usted puede presentar su querella por violación a los derechos civiles con el Departamento de Salud y de Recursos Humanos de Estados Unidos, Oficina de Derechos Civiles de forma electrónica a través de su portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, por correo, o por teléfono al: 200 Independence Ave, SW Room 509F, HHH Bldg Washington, D.C. 20201 Teléfono: 1-800-368-1019, TDD: 1-800-537-7697 _______________________________________________________________ Call the customer service number on your ID card for assistance. 請撥打您 ID 卡上的客服號碼以尋求中文協助。 Gọi số dịch vụ khách hàng trên thẻ ID của quý vị để được hỗ trợ bằng Tiếng Việt. 한국어로 도움을 받고 싶으시면 ID 카드에 있는 고객 서비스 전화번호로 문의해 주십시오. Para sa tulong sa Tagalog, tumawag sa numero ng serbisyo sa customer na nasa inyong ID card. Обратитесь по номеру телефона обслуживания клиентов, указанному на Вашей идентификационной карточке, для помощи на русском языке. العربية باللغة المساعدة على للحصول هُويتك بطاقة على الموجود العمالء خدمة برقم اتصل. Rele nimewo sèvis kliyantèl ki nan kat ID ou pou jwenn èd nan Kreyòl Ayisyen. Pour une assistance en français du Canada, composez le numéro de téléphone du service à la clientèle figurant sur votre carte d’identification. Ligue para o número de telefone de atendimento ao cliente exibido no seu cartão de identificação para obter ajuda em português. Aby uzyskać pomoc w języku polskim, należy zadzwonić do działu obsługi klienta pod numer podany na identyfikatorze.
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
日本語でのサポートは、IDカードに記載のカスタマーサービス番号までお電話でお問い合わせください。 Per assistenza in italiano chiamate il numero del servizio clienti riportato nella vostra scheda identificativa. Rufen Sie den Kundendienst unter der Nummer auf Ihrer ID-Karte an, um Hilfestellung in deutscher Sprache zu erhalten. با شماره خدمات مشتری که بر روی کارت شناسايی شما درج شده است تماس بگيريد، برای دريافت راهنمايی به زبان فارسی.
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Notice: Informing individuals about nondiscrimination and accessibility requirements and nondiscrimination statement: Discrimination is Against the Law Triple S Salud, Inc. complies with applicable federal civil rights laws and does not discriminate, exclude people or treat individuals differently because of race, color, national origin, age, disability, or sex. Triple S Salud, Inc. •
Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters, o Written information in other formats (large print, audio, accessible electronic formats, other formats).
•
Provides free language services to people whose primary language is not English, such as: o Qualified interpreters, o Information written in other languages.
If you need these services, contact a Customer Service Representative. If you believe that Triple S Salud, Inc. has failed to provide these services or has discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Compliance and Privacy Office P. O. Box 11320, San Juan, PR 00922-9905 Telephone: (787) 620-1919 ext. 4183 Fax: (787) 993-3260 E-mail:
[email protected] You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Service Representative is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically, through the Office of Civil Rights Portal available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Telephone: 1-800-368-1019, TDD: 1-800-537-7697 _______________________________________________________________ Para obtener asistencia en español, llame al servicio de atención al cliente al número que aparece en su tarjeta de identificación. 請撥打您 ID 卡上的客服號碼以尋求中文協助。 Gọi số dịch vụ khách hàng trên thẻ ID của quý vị để được hỗ trợ bằng Tiếng Việt. 한국어로 도움을 받고 싶으시면 ID 카드에 있는 고객 서비스 전화번호로 문의해 주십시오. Para sa tulong sa Tagalog, tumawag sa numero ng serbisyo sa customer na nasa inyong ID card. Обратитесь по номеру телефона обслуживания клиентов, указанному на Вашей идентификационной карточке, для помощи на русском языке. العربية باللغة المساعدة على للحصول هُويتك بطاقة على الموجود العمالء خدمة برقم اتصل. Rele nimewo sèvis kliyantèl ki nan kat ID ou pou jwenn èd nan Kreyòl Ayisyen. Pour une assistance en français du Canada, composez le numéro de téléphone du service à la clientèle figurant sur votre carte d’identification. Ligue para o número de telefone de atendimento ao cliente exibido no seu cartão de identificação para obter ajuda em português. Aby uzyskać pomoc w języku polskim, należy zadzwonić do działu obsługi klienta pod numer podany na identyfikatorze. 日本語でのサポートは、IDカードに記載のカスタマーサービス番号までお電話でお問い合わせください。 Per assistenza in italiano chiamate il numero del servizio clienti riportato nella vostra scheda identificativa.
Lista de Medicamentos Comercial 2018 / Drug List Commercial 2018 Rev. Agosto 2017 / August 2017
Rufen Sie den Kundendienst unter der Nummer auf Ihrer ID-Karte an, um Hilfestellung in deutscher Sprache zu erhalten. با شماره خدمات مشتری که بر روی کارت شناسايی شما درج شده است تماس بگيريد، برای دريافت راهنمايی به زبان فارسی.
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