Medi-Cal / HK_FDB
Transcription
Medi-Cal / HK_FDB
2016 IEHP Medi-Cal LISTA DE MEDICAMENTOS CUBIERTOS DE 2016 Tabla de Contenido Analgésicos .......................................................................................................................................................... 3 Anestésicos ........................................................................................................................................................... 4 Antiartríticos......................................................................................................................................................... 5 Antiasmáticos ....................................................................................................................................................... 5 Antibióticos .......................................................................................................................................................... 7 Anticoagulantes .................................................................................................................................................. 11 Antifúngicos ....................................................................................................................................................... 11 Antihistamínico y Combinación de Descongestionante .................................................................................... 12 Antihistamínico .................................................................................................................................................. 13 Antihiperglucémicos .......................................................................................................................................... 14 Antiinfecciosos/Varios ....................................................................................................................................... 15 Antineoplastics ................................................................................................................................................... 15 Medicamentos Antiparkinsonianos .................................................................................................................... 16 Medicamentos Antiplaquetarios ......................................................................................................................... 16 Antivirales .......................................................................................................................................................... 16 Medicamentos Autonómicos .............................................................................................................................. 17 Sangre ................................................................................................................................................................. 17 Medicamentos Cardíacos ................................................................................................................................... 17 Cardiovascular .................................................................................................................................................... 19 Medicamentos del Sistema Nervioso Central (CNS) ......................................................................................... 20 Factores Estimulantes de Colonias..................................................................................................................... 21 Anticonceptivos .................................................................................................................................................. 21 Tos/Resfriado ..................................................................................................................................................... 23 Diagnóstico......................................................................................................................................................... 24 Diuréticos ........................................................................................................................................................... 24 Ojos, Oídos, Nariz y Garganta (EENT) ............................................................................................................. 25 Electrolitos/Calórico/H2O.................................................................................................................................. 27 Gastrointestinal................................................................................................................................................... 28 Hormonas ........................................................................................................................................................... 32 Inmunosupresor .................................................................................................................................................. 33 Suministros Médicos Diversos, Dispositivos, No Farmacológicos ................................................................... 33 Relajantes Musculares ........................................................................................................................................ 33 Vitaminas Prenatales .......................................................................................................................................... 33 1 Medicamentos Psicoterapéuticos ....................................................................................................................... 34 Sedantes/Hipnóticos ........................................................................................................................................... 35 Elementos Disuasivos para Dejar de Fumar ...................................................................................................... 38 Tiroides............................................................................................................................................................... 39 Medicamentos Sin Clasificación ........................................................................................................................ 39 Vitaminas ........................................................................................................................................................... 40 Indice .................................................................................................................................................................. 43 2 IEHP Medi-Cal LISTA DE MEDICAMENTOS CUBIERTOS DE 2016 Lista de Medicamentos Cubiertos VIGENTE A PARTIR DEL 1 DE JULIO DE 2016 minúsculas cursivas = Medicamentos genéricos MAYÚSCULAS NEGRITAS = Medicamentos de marca Nivel de Marca (Nivel Genérico) Requisitos/Límites C1= Código1 F= Lista de Medicamento Cubiertos NC= No Cubiertos PA= Autorización Previa QL= Límite de Cantidad ST= Terapia Escalonada Nombre del Medicamento Nivel de Requisitos/Límites Marca Analgésicos acetaminophen oral drops, suspension 80 mg/0.8 ml F QL acetaminophen oral elixir 160 mg/5 ml F QL acetaminophen oral liquid 160 mg/5 ml F QL acetaminophen oral solution 160 mg/5 ml (5 ml) F QL acetaminophen oral suspension 160 mg/5 ml F QL acetaminophen oral tablet 325 mg F acetaminophen oral tablet 500 mg F QL acetaminophen rectal suppository 120 mg F QL acetaminophen-codeine oral solution 120-12 mg/5 ml F acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg F QL ASPIRIN LOW-STRENGTH ORAL TABLET, CHEWABLE 81 MG F QL aspirin oral tablet 325 mg F QL aspirin oral tablet, delayed release (dr/ec) 325 mg, 81 mg F QL butalbital-acetaminophen-caff oral capsule 50-325-40 mg F QL butalbital-acetaminophen-caff oral tablet 50-325-40 mg F QL butalbital-aspirin-caffeine oral capsule 50-325-40 mg F QL CAFERGOT ORAL TABLET 1-100 MG F CAPITAL WITH CODEINE ORAL SUSPENSION 120-12 MG/5 ML F QL CHILDREN'S NON-ASPIRIN ORAL TABLET, CHEWABLE 80 MG F QL choline, magnesium salicylate oral liquid 500 mg/5 ml F diclofenac potassium oral tablet 50 mg F 3 Nombre del Medicamento Nivel de Requisitos/Límites Marca ELMIRON ORAL CAPSULE 100 MG F ENDODAN ORAL TABLET 4.8355-325 MG F fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr F FEVERALL RECTAL SUPPOSITORY 325 MG, 80 MG F hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml F hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg F QL infant's non-aspirin oral drops 100 mg/ml F QL isometh-dichloral-acetaminophn oral capsule 65-100-325 mg F QL KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG F QL ketorolac oral tablet 10 mg F QL MIGERGOT RECTAL SUPPOSITORY 2-100 MG F QL MIGRAINE FORMULA ORAL TABLET 250-250-65 MG F QL morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) F QL morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg F QL morphine oral capsule, extend. release pellets 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg F QL morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml) F morphine oral tablet 15 mg, 30 mg F QL morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg F QL morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg F non-aspirin jr strength oral tablet, chewable 160 mg F QL oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg F QL Q-PAP ORAL DROPS 80 MG/0.8 ML F QL rizatriptan oral tablet 10 mg, 5 mg F QL sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg F QL tramadol oral tablet 50 mg F QL QL Anestésicos BUCALSEP MUCOUS MEMBRANE SOLUTION F lidocaine topical adhesive patch, medicated 5 % F LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 % F phenazopyridine oral tablet 100 mg, 200 mg F 4 QL Nombre del Medicamento Nivel de Requisitos/Límites Marca Antiartríticos allopurinol oral tablet 100 mg, 300 mg F colchicine oral capsule 0.6 mg F colchicine oral tablet 0.6 mg F colchicine-probenecid oral tablet 0.5-500 mg F diclofenac sodium oral tablet extended release 24 hr 100 mg F diclofenac sodium oral tablet, delayed release (dr/ec) 25 mg, 50 mg, 75 mg F etodolac oral capsule 200 mg, 300 mg F etodolac oral tablet 400 mg, 500 mg F ibuprofen oral capsule 200 mg F QL ibuprofen oral suspension 100 mg/5 ml F QL ibuprofen oral tablet 200 mg F QL ibuprofen oral tablet 400 mg, 600 mg, 800 mg F indomethacin oral capsule 25 mg, 50 mg F leflunomide oral tablet 10 mg, 20 mg F meloxicam oral tablet 15 mg, 7.5 mg F nabumetone oral tablet 500 mg, 750 mg F naproxen oral suspension 125 mg/5 ml F naproxen oral tablet 250 mg, 375 mg, 500 mg F naproxen sodium oral tablet 220 mg, 275 mg, 550 mg F piroxicam oral capsule 10 mg, 20 mg F probenecid oral tablet 500 mg F RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 MG F RIDAURA ORAL CAPSULE 3 MG F salsalate oral tablet 500 mg, 750 mg F sulindac oral tablet 150 mg, 200 mg F QL Antiasmáticos acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) F albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml F albuterol sulfate oral syrup 2 mg/5 ml F albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg F 5 Nombre del Medicamento Nivel de Requisitos/Límites Marca ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) F ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION F QL budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml F QL COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION F QL cromolyn inhalation solution for nebulization 20 mg/2 ml F cromolyn nasal spray, non-aerosol 5.2 mg/spray (4 %) F FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION F QL FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION F QL INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION F QL ipratropium bromide inhalation solution 0.02 % F levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml F metaproterenol oral syrup 10 mg/5 ml F metaproterenol oral tablet 10 mg, 20 mg F montelukast oral tablet 10 mg F QL montelukast oral tablet, chewable 4 mg, 5 mg F QL PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION F QL QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION F SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE F terbutaline oral tablet 2.5 mg, 5 mg F THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 300 MG, 400 MG F theophylline oral solution 80 mg/15 ml F theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg F QL theophylline oral tablet extended release 400 mg F QL 6 QL QL Nombre del Medicamento Nivel de Requisitos/Límites Marca TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION F QL VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION F QL Antibióticos amoxicillin oral capsule 250 mg F amoxicillin oral capsule 500 mg F amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml F amoxicillin oral tablet 500 mg, 875 mg F amoxicillin oral tablet, chewable 125 mg, 250 mg F amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml F amoxicillin-pot clavulanate oral tablet 250-125 mg F amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg F amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg F amoxicillin-pot clavulanate oral tablet, chewable 200-28.5 mg, 400-57 mg F ampicillin oral capsule 250 mg, 500 mg F ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml F AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML F azithromycin oral packet 1 gram F azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml F azithromycin oral tablet 250 mg, 500 mg, 600 mg F bacitracin ophthalmic ointment 500 unit/gram F bacitracin topical ointment 500 unit/gram F bacitracin zinc topical ointment 500 unit/gram F bacitracin-polymyxin b ophthalmic ointment 500-10,000 unit/gram F bacitracin-polymyxin b topical ointment 500-10,000 unit/gram F bacitracin-polymyxin b topical packet 500-10,000 unit/gram F BACTROBAN NASAL NASAL OINTMENT 2 % F BENZAMYCINPAK TOPICAL GEL 3-5 % F BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSION 10-0.2 % F BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % F QL QL QL QL QL 7 Nombre del Medicamento Nivel de Requisitos/Límites Marca cefaclor oral capsule 250 mg, 500 mg F cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml F cefaclor oral tablet extended release 12 hr 500 mg F cefdinir oral capsule 300 mg C1 cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml C1 cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml C1 ceftibuten oral capsule 400 mg C1 ceftibuten oral suspension for reconstitution 180 mg/5 ml C1 cephalexin oral capsule 250 mg, 500 mg F cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml F CILOXAN OPHTHALMIC OINTMENT 0.3 % F CIPRO HC OTIC DROPS, SUSPENSION 0.2-1 % F QL CIPRODEX OTIC DROPS, SUSPENSION 0.3-0.1 % F QL ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg F ciprofloxacin hcl ophthalmic drops 0.3 % F ciprofloxacin hcl oral tablet 100 mg F ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg F ciprofloxacin oral suspension, microcapsule recon 250 mg/5 ml, 500 mg/5 ml F clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml F clarithromycin oral tablet 250 mg, 500 mg F clarithromycin oral tablet extended release 24 hr 500 mg F clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg F clindamycin palmitate hcl oral recon soln 75 mg/5 ml F clindamycin phosphate topical gel 1 % F clindamycin phosphate topical lotion 1 % F clindamycin phosphate topical solution 1 % F clindamycin phosphate vaginal cream 2 % F CORTISPORIN TOPICAL OINTMENT 1 % F cycloserine oral capsule 250 mg F dapsone oral tablet 100 mg, 25 mg F dicloxacillin oral capsule 250 mg, 500 mg F double antibiotic (b.tracn zn) topical ointment 500-10,000 unit/gram F 8 QL Nombre del Medicamento Nivel de Requisitos/Límites Marca doxycycline hyclate oral capsule 100 mg, 50 mg F QL doxycycline hyclate oral tablet 100 mg F QL doxycycline monohydrate oral capsule 100 mg, 50 mg F QL doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg F QL E.E.S. 400 ORAL TABLET 400 MG F E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML F ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 MG/5 ML F ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 250 MG, 333 MG F ery-tab oral tablet, delayed release (dr/ec) 500 mg F erythromycin ophthalmic ointment 5 mg/gram (0.5 %) F erythromycin oral capsule, delayed release(dr/ec) 250 mg F erythromycin oral tablet 250 mg, 500 mg F erythromycin stearate oral tablet 250 mg F erythromycin with ethanol topical gel 2 % F erythromycin with ethanol topical solution 2 % F erythromycin-benzoyl peroxide topical gel 3-5 % F ethambutol oral tablet 100 mg, 400 mg F GENTAK OPHTHALMIC OINTMENT 0.3 % (3 MG/GRAM) F gentamicin ophthalmic drops 0.3 % F gentamicin topical cream 0.1 % F isoniazid oral solution 50 mg/5 ml F isoniazid oral tablet 100 mg, 300 mg F levofloxacin ophthalmic drops 0.5 % F QL levofloxacin oral tablet 250 mg, 500 mg, 750 mg F QL methenamine mandelate oral tablet 0.5 g, 1 gram F QL metronidazole oral tablet 250 mg, 500 mg F metronidazole vaginal gel 0.75 % F minocycline oral capsule 100 mg, 50 mg, 75 mg F minocycline oral tablet 100 mg F mupirocin calcium topical cream 2 % F 9 Nombre del Medicamento Nivel de Requisitos/Límites Marca mupirocin topical ointment 2 % F neomycin oral tablet 500 mg F neomycin-bacitracin-polymyxin ophthalmic ointment 3.5-400-10,000 mg-unitunit/g F neomycin-polymyxin b-dexameth ophthalmic drops, suspension 3.5mg/ml-10,000 unit/ml-0.1 % F neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g-10,000 unit/g0.1 % F neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit0.025mg/ml F neomycin-polymyxin-hc ophthalmic drops, suspension 3.5-10,000-10 mg-unitmg/ml F neomycin-polymyxin-hc otic drops, suspension 3.5-10,000-1 mg/ml-unit/ml-% F neomycin-polymyxin-hc otic solution 3.5-10,000-1 mg/ml-unit/ml-% F nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg F nitrofurantoin macrocrystal oral capsule 25 mg F nitrofurantoin monohyd/m-cryst oral capsule 100 mg F QL nitrofurantoin oral suspension 25 mg/5 ml F QL ofloxacin ophthalmic drops 0.3 % F ofloxacin otic drops 0.3 % F PCE ORAL TABLET, PARTICLES/CRYSTALS 333 MG, 500 MG F penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml F penicillin v potassium oral tablet 250 mg, 500 mg F polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 mg/ml F PRIMSOL ORAL SOLUTION 50 MG/5 ML F pyrazinamide oral tablet 500 mg F rifabutin oral capsule 150 mg C1 RIFAMATE ORAL CAPSULE 300-150 MG F rifampin oral capsule 150 mg, 300 mg F silver sulfadiazine topical cream 1 % F sulfacetamide sodium ophthalmic drops 10 % F sulfacetamide sodium ophthalmic ointment 10 % F sulfacetamide-prednisolone ophthalmic drops 10 %-0.23 % (0.25 %) F sulfadiazine oral tablet 500 mg F 10 QL QL QL Nombre del Medicamento Nivel de Requisitos/Límites Marca sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml F sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg F tetracycline oral capsule 250 mg, 500 mg F TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % F tobramycin ophthalmic drops 0.3 % F tobramycin-dexamethasone ophthalmic drops, suspension 0.3-0.1 % F TOBREX OPHTHALMIC OINTMENT 0.3 % F trimethoprim oral tablet 100 mg F TRIPLE ANTIBIOTIC (PRAM) EXTRA TOPICAL OINTMENT 3.5-50010,000 MG-UNIT-UNIT/G F TRIPLE ANTIBIOTIC TOPICAL OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM F VIGAMOX OPHTHALMIC DROPS 0.5 % F Anticoagulantes ELIQUIS ORAL TABLET 2.5 MG, 5 MG C1 enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml F warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg F XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG C1 XARELTO ORAL TABLETS, DOSE PACK 15 MG (42)- 20 MG (9) C1 QL Antifúngicos 3 DAY VAGINAL VAGINAL CREAM 200 MG/5 GRAM (4 %) F QL antifungal (tolnaftate) topical cream 1 % F ATHLETE'S FOOT (TERBINAFINE) TOPICAL CREAM 1 % F clotrimazole mucous membrane troche 10 mg F clotrimazole topical cream 1 % F QL clotrimazole topical solution 1 % F QL clotrimazole vaginal cream 1 % F QL clotrimazole-betamethasone topical cream 1-0.05 % F QL clotrimazole-betamethasone topical lotion 1-0.05 % F QL econazole topical cream 1 % F fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml F fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg F QL 11 Nombre del Medicamento Nivel de Requisitos/Límites Marca flucytosine oral capsule 250 mg, 500 mg F griseofulvin microsize oral suspension 125 mg/5 ml F QL griseofulvin microsize oral tablet 500 mg F QL griseofulvin ultramicrosize oral tablet 125 mg, 250 mg F QL ketoconazole oral tablet 200 mg F ketoconazole topical cream 2 % F ketoconazole topical shampoo 2 % F MEDI-FIRST ANTI-FUNGAL TOPICAL PACKET 1 % F miconazole nitrate topical cream 2 % F miconazole nitrate vaginal comb pack, prefill appl, cream 4 % (200 mg)- 2 % (9 gram) F miconazole nitrate vaginal cream 2 % F QL miconazole nitrate vaginal suppository 100 mg F QL MICONAZOLE-3 VAGINAL KIT 200 MG- 2 % (9 GRAM) F QL MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG F NATACYN OPHTHALMIC DROPS, SUSPENSION 5 % F nystatin oral powder 150 million unit F nystatin oral suspension 100,000 unit/ml F nystatin oral tablet 500,000 unit F nystatin topical cream 100,000 unit/gram F nystatin topical ointment 100,000 unit/gram F nystatin-triamcinolone topical cream 100,000-0.1 unit/g-% F nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-% F NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM F terbinafine hcl oral tablet 250 mg F QL terconazole vaginal cream 0.4 %, 0.8 % F QL terconazole vaginal suppository 80 mg F QL tolnaftate topical solution 1 % F QL Antihistamínico y Combinación de Descongestionante ALAVERT D-12 ALLERGY-SINUS ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG F QL cetirizine-pseudoephedrine oral tablet extended release 12 hr 5-120 mg F QL DIMETAPP COLD-ALLERGY (PE) ORAL SOLUTION 1-2.5 MG/5 ML F 12 Nombre del Medicamento Nivel de Requisitos/Límites Marca LOHIST - D ORAL LIQUID 2-30 MG/5 ML F LORATADINE-D ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG F PROMETHAZINE VC ORAL SYRUP 6.25-5 MG/5 ML F RITIFED ORAL SYRUP 1.25-30 MG/5 ML F RYNEX PSE ORAL LIQUID 1-15 MG/5 ML F WAL-ACT D COLD AND ALLERGY ORAL TABLET 2.5-60 MG F WAL-PHED ORAL TABLET 4-60 MG F QL QL QL Antihistamínico ALLER-CHLOR ORAL SYRUP 2 MG/5 ML F BENADRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML F QL cetirizine oral solution 1 mg/ml F QL cetirizine oral tablet 10 mg, 5 mg F QL cetirizine oral tablet, chewable 10 mg, 5 mg F QL CHILDREN'S CLARITIN ORAL TABLET,CHEWABLE 5 MG F QL CHILDREN'S WAL-DRYL ALLERGY ORAL PREFILLED SPOON 12.5 MG/5 ML F QL chlorpheniramine maleate oral tablet 4 mg F chlorpheniramine maleate oral tablet extended release 12 mg F cyproheptadine oral syrup 2 mg/5 ml F cyproheptadine oral tablet 4 mg F diphenhydramine hcl oral capsule 25 mg, 50 mg F QL diphenhydramine hcl oral elixir 12.5 mg/5 ml F QL diphenhydramine hcl oral syrup 12.5 mg/5 ml F QL diphenhydramine hcl oral tablet 25 mg F QL hydroxyzine hcl oral solution 10 mg/5 ml F hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg F hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg F loratadine oral solution 5 mg/5 ml F loratadine oral tablet 10 mg F QL loratadine oral tablet, disintegrating 10 mg F QL olopatadine ophthalmic drops 0.1 % C1 promethazine oral syrup 6.25 mg/5 ml F 13 Nombre del Medicamento Nivel de Requisitos/Límites Marca promethazine oral tablet 12.5 mg, 25 mg, 50 mg F ZADITOR OPHTHALMIC DROPS 0.025 % (0.035 %) F Antihiperglucémicos acarbose oral tablet 100 mg, 25 mg, 50 mg F APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML F APIDRA SUBCUTANEOUS SOLUTION 100 UNIT/ML F glimepiride oral tablet 1 mg, 2 mg, 4 mg F QL glipizide oral tablet 10 mg, 5 mg F QL glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg F QL glipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg F QL glyburide oral tablet 1.25 mg, 5 mg F QL glyburide oral tablet 2.5 mg F glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg F HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML F HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) F HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) F HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) F HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) F HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML F HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML F HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) F HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) F HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) F HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML F HUMULIN R INJECTION SOLUTION 100 UNIT/ML F HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML F INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG F 14 QL ST; QL Nombre del Medicamento Nivel de Requisitos/Límites Marca INVOKANA ORAL TABLET 100 MG, 300 MG F ST; QL JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG F ST; QL JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG F ST; QL JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG F ST; QL LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) F LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML F metformin oral tablet 1,000 mg, 500 mg, 850 mg F QL metformin oral tablet extended release 24 hr 500 mg, 750 mg F QL NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) F NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML F NOVOLIN R INJECTION SOLUTION 100 UNIT/ML F NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML F NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) F NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION 100 UNIT/ML (7030) F NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 100 UNIT/ML F NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML F pioglitazone oral tablet 15 mg, 30 mg, 45 mg F Antiinfecciosos/Varios atovaquone oral suspension 750 mg/5 ml F chloroquine phosphate oral tablet 250 mg, 500 mg F hydroxychloroquine oral tablet 200 mg F NEBUPENT INHALATION RECON SOLN 300 MG F paromomycin oral capsule 250 mg C1 primaquine oral tablet 26.3 mg F REESE'S PINWORM MEDICINE ORAL SUSPENSION 50 MG/ML F Antineoplastics anastrozole oral tablet 1 mg F etoposide oral capsule 50 mg F FLUOROPLEX TOPICAL CREAM 1 % F fluorouracil topical cream 5 % F 15 Nombre del Medicamento Nivel de Requisitos/Límites Marca flutamide oral capsule 125 mg F hydroxyurea oral capsule 500 mg F ifosfamide intravenous solution 3 gram/60 ml F LEUKERAN ORAL TABLET 2 MG F MATULANE ORAL CAPSULE 50 MG F megestrol oral tablet 20 mg, 40 mg F mercaptopurine oral tablet 50 mg F methotrexate sodium (pf) injection solution 25 mg/ml F methotrexate sodium injection solution 25 mg/ml F methotrexate sodium oral tablet 2.5 mg F MYLERAN ORAL TABLET 2 MG F TABLOID ORAL TABLET 40 MG F tamoxifen oral tablet 10 mg F tamoxifen oral tablet 20 mg F tretinoin (chemotherapy) oral capsule 10 mg F QL QL Medicamentos Antiparkinsonianos bromocriptine oral capsule 5 mg C1 bromocriptine oral tablet 2.5 mg C1 carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg F carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg F entacapone oral tablet 200 mg F pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg F ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg F selegiline hcl oral capsule 5 mg F QL selegiline hcl oral tablet 5 mg F QL QL Medicamentos Antiplaquetarios anagrelide oral capsule 0.5 mg, 1 mg F aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg F cilostazol oral tablet 100 mg, 50 mg F clopidogrel oral tablet 75 mg F QL F QL QL Antivirales ABREVA TOPICAL CREAM 10 % 16 Nombre del Medicamento Nivel de Requisitos/Límites Marca acyclovir oral capsule 200 mg F acyclovir oral suspension 200 mg/5 ml F acyclovir oral tablet 400 mg, 800 mg F famciclovir oral tablet 125 mg, 250 mg, 500 mg F QL TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG F QL TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML F QL trifluridine ophthalmic drops 1 % F valacyclovir oral tablet 1 gram, 500 mg F QL Medicamentos Autonómicos ADRENALIN INJECTION SOLUTION 1 MG/ML (1 ML) F bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg F dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg F dextroamphetamine oral tablet 10 mg, 5 mg F dextroamphetamine-amphetamine oral capsule, extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg F dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg F donepezil oral tablet 10 mg, 5 mg F QL donepezil oral tablet, disintegrating 10 mg, 5 mg F QL epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml F QL epinephrine injection solution 1 mg/ml (1 ml) F epinephrine injection syringe 0.1 mg/ml F EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML F MESTINON ORAL SYRUP 60 MG/5 ML F MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG F midodrine oral tablet 10 mg, 2.5 mg, 5 mg F pyridostigmine bromide oral tablet 60 mg F rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg F QL F QL QL QL Sangre pentoxifylline oral tablet extended release 400 mg Medicamentos Cardíacos amiodarone oral tablet 200 mg F 17 Nombre del Medicamento Nivel de Requisitos/Límites Marca amlodipine oral tablet 10 mg, 2.5 mg, 5 mg F digoxin oral solution 50 mcg/ml F digoxin oral tablet 125 mcg, 250 mcg F QL DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 40 MG F QL diltiazem hcl oral capsule, extended release 360 mg, 420 mg F QL diltiazem hcl oral capsule, extended release 12 hr 120 mg F QL diltiazem hcl oral capsule, extended release 12 hr 60 mg, 90 mg F diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg F QL diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg F QL DILT-XR ORAL CAPSULE, EXT RELEASE DEGRADABLE 120 MG, 180 MG, 240 MG F QL felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg F QL ISORDIL ORAL TABLET 40 MG F QL isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg F QL isosorbide dinitrate oral tablet extended release 40 mg F QL isosorbide mononitrate oral tablet 10 mg, 20 mg F isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg F mexiletine oral capsule 150 mg, 200 mg, 250 mg F nifedipine oral capsule 10 mg, 20 mg F QL nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg F QL nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg F QL NITRO-BID TRANSDERMAL OINTMENT 2 % F NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG F propafenone oral capsule, extended release 12 hr 225 mg F propafenone oral capsule, extended release 12 hr 325 mg, 425 mg F propafenone oral tablet 150 mg, 225 mg, 300 mg F quinidine gluconate oral tablet extended release 324 mg F TAZTIA XT ORAL CAPSULE, EXTENDED RELEASE 120 MG, 180 MG, 240 MG, 300 MG F QL verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg F QL verapamil oral capsule, ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg F QL verapamil oral tablet 120 mg, 40 mg, 80 mg F QL 18 QL QL Nombre del Medicamento verapamil oral tablet extended release 120 mg, 180 mg, 240 mg Nivel de Requisitos/Límites Marca F QL amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 520 mg, 5-40 mg F QL atenolol oral tablet 100 mg, 25 mg, 50 mg F QL atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg F atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg F benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg F QL benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 56.25 mg F QL captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg F carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg F cholestyramine (with sugar) oral powder 4 gram F cholestyramine (with sugar) oral powder in packet 4 gram F CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM F CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM F clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg F clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr F QL doxazosin oral tablet 1 mg, 2 mg, 4 mg F QL doxazosin oral tablet 8 mg F enalapril maleate oral tablet 10 mg, 20 mg, 5 mg F enalapril maleate oral tablet 2.5 mg F fenofibrate micronized oral capsule 134 mg F fenofibrate micronized oral capsule 200 mg, 67 mg F fenofibrate nanocrystallized oral tablet 145 mg, 48 mg F fenofibrate oral tablet 160 mg, 54 mg F fenofibric acid (choline) oral capsule, delayed release(dr/ec) 135 mg, 45 mg F gemfibrozil oral tablet 600 mg F guanfacine oral tablet 1 mg, 2 mg F hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg F irbesartan oral tablet 150 mg, 300 mg, 75 mg F labetalol intravenous solution 5 mg/ml F labetalol oral tablet 100 mg, 200 mg, 300 mg F Cardiovascular QL QL QL QL QL QL QL 19 Nombre del Medicamento Nivel de Requisitos/Límites Marca lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg F QL lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg F QL losartan oral tablet 100 mg, 25 mg, 50 mg F QL losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg F QL lovastatin oral tablet 10 mg, 20 mg, 40 mg F QL methyldopa oral tablet 250 mg, 500 mg F methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg F metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg F metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg F minoxidil oral tablet 10 mg, 2.5 mg F niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg F NIACOR ORAL TABLET 500 MG F pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg F prazosin oral capsule 1 mg, 2 mg, 5 mg F propranolol oral capsule, extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg F propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) F propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg F simvastatin oral tablet 10 mg, 40 mg, 5 mg, 80 mg F simvastatin oral tablet 20 mg F sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg F QL terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg F QL valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg F QL valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg F QL QL QL QL QL Medicamentos del Sistema Nervioso Central (CNS) carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg F carbamazepine oral suspension 100 mg/5 ml F carbamazepine oral tablet 200 mg F carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg F carbamazepine oral tablet, chewable 100 mg F clonazepam oral tablet 0.5 mg, 1 mg, 2 mg F QL diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg F QL 20 Nombre del Medicamento Nivel de Requisitos/Límites Marca DILANTIN ORAL CAPSULE 30 MG F divalproex oral capsule, sprinkle 125 mg F divalproex oral tablet extended release 24 hr 250 mg, 500 mg F divalproex oral tablet, delayed release (dr/ec) 125 mg, 250 mg, 500 mg F ethosuximide oral capsule 250 mg F ethosuximide oral solution 250 mg/5 ml F gabapentin oral capsule 100 mg, 300 mg, 400 mg F gabapentin oral tablet 600 mg, 800 mg F lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg F lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg F levetiracetam oral solution 100 mg/ml F levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg F oxcarbazepine oral suspension 300 mg/5 ml F oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg F phenytoin oral suspension 125 mg/5 ml F phenytoin oral tablet, chewable 50 mg F phenytoin sodium extended oral capsule 100 mg F primidone oral tablet 250 mg, 50 mg F riluzole oral tablet 50 mg F TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG F topiramate oral capsule, sprinkle 15 mg, 25 mg F topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg F valproic acid (as sodium salt) oral solution 250 mg/5 ml F valproic acid oral capsule 250 mg F zonisamide oral capsule 100 mg, 25 mg, 50 mg F Factores Estimulantes de Colonias EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML F PA GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML F QL ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML F QL Anticonceptivos AZURETTE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5 F 21 Nombre del Medicamento Nivel de Requisitos/Límites Marca BALZIVA (28) ORAL TABLET 0.4-35 MG-MCG F CAMRESE ORAL TABLETS, DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) F CAZIANT (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG F CONCEPTROL VAGINAL GEL 4 % F CONDOMS-PREM LUBRICATED DEVICE F DESOGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.15-0.03 MG F ELLA ORAL TABLET 30 MG F QL FALLBACK SOLO ORAL TABLET 1.5 MG F QL fc2 female condom F QL GIANVI (28) ORAL TABLET 3-0.02 MG F GYNOL II VAGINAL GEL 3 % F JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) F JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) F l norgest/e.estradiol-e.estrad oral tablets, dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) F LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG F levonorgestrel-ethinyl estrad oral tablet 90-20 mcg F LEVORA-28 ORAL TABLET 0.15-0.03 MG F LOW-OGESTREL (28) ORAL TABLET 0.3-30 MG-MCG F medroxyprogesterone intramuscular suspension 150 mg/ml F medroxyprogesterone intramuscular syringe 150 mg/ml F MICROGESTIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG F MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG F MONONESSA (28) ORAL TABLET 0.25-35 MG-MCG F MY WAY ORAL TABLET 1.5 MG F NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG F NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG F NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG F NECON 10/11 (28) ORAL TABLET 0.5-35/1-35 MG-MCG/MG-MCG F NECON 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG F NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG F norethindrone (contraceptive) oral tablet 0.35 mg F 22 QL QL QL QL QL Nombre del Medicamento Nivel de Requisitos/Límites Marca NUVARING VAGINAL RING 0.12-0.015 MG/24 HR F OCELLA ORAL TABLET 3-0.03 MG F OGESTREL (28) ORAL TABLET 0.5-50 MG-MCG F QUASENSE ORAL TABLETS, DOSE PACK, 3 MONTH 0.15-30 MGMCG F SRONYX ORAL TABLET 0.1-20 MG-MCG F TILIA FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) F TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) F TRIVORA (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10) F VAGINAL CONTRACEPTIVE FILM VAGINAL FILM 28 % F VAGINAL CONTRACEPTIVE FOAM VAGINAL FOAM 12.5 % F xulane transdermal patch weekly 150-35 mcg/24 hr F ZENCHENT FE ORAL TABLET, CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7) F ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG F ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG F QL Tos/Resfriado ADULT ROBITUSSIN PEAK COLD M-S ORAL LIQUID 5-10-100 MG/5 ML F QL allergy relief(chlorphen-acet) oral tablet 2-5-325 mg F QL benzonatate oral capsule 100 mg, 200 mg F QL BIO-S-PRES DX ORAL DROPS 2.5-5-50 MG/ML F QL BROMFED DM ORAL SYRUP 2-30-10 MG/5 ML F BROTAPP DM ORAL ELIXIR 1-15-5 MG/5 ML F CHILD MUCINEX STUFFY NOSE-COLD ORAL LIQUID 2.5-100 MG/5 ML F DIABETIC TUSSIN DM ORAL LIQUID 10-200 MG/5 ML F DIMETAPP DM COLD-COUGH (PE) ORAL SOLUTION 1-2.5-5 MG/5 ML F EXPECTORANT ORAL LIQUID 100 MG/5 ML F GUAIFENESIN AC ORAL LIQUID 10-100 MG/5 ML F guaifenesin oral tablet extended release 12hr 600 mg F hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml F QL QL 23 Nombre del Medicamento Nivel de Requisitos/Límites Marca MUCINEX COUGH MINI-MELTS ORAL GRANULES IN PACKET 5100 MG F MUCINEX D MAXIMUM STRENGTH ORAL TABLET EXTENDED RELEASE 12 HR 120-1,200 MG F QL MUCINEX D ORAL TABLET EXTENDED RELEASE 12 HR 60-600 MG F QL MUCINEX DM ORAL TABLET, ER MULTIPHASE 12 HR 60-1,200 MG F MUCINEX ORAL TABLET EXTENDED RELEASE 12HR 1,200 MG F mucus dm oral tablet extended release 12 hr 30-600 mg F mucus relief cough oral liquid 5-100 mg/5 ml F QL NEO-TUSS ORAL LIQUID 30-200 MG/5 ML F QL nohist-dm oral liquid 4-10-15 mg/5 ml F PEDIA RELIEF COUGH-COLD ORAL LIQUID 1-15-5 MG/5 ML F phenylhistine dh oral liquid 2-30-10 mg/5 ml F PROMETHAZINE VC-CODEINE ORAL SYRUP 6.25-5-10 MG/5 ML F QL promethazine-codeine oral syrup 6.25-10 mg/5 ml F QL promethazine-dm oral syrup 6.25-15 mg/5 ml F pseudoephedrine hcl oral tablet 30 mg, 60 mg F QL pseudoephedrine hcl oral tablet extended release 120 mg F QL ROBITUSSIN PEDIATRIC ORAL SYRUP 7.5 MG/5 ML F SCOT-TUSSIN DM ORAL LIQUID 2-15 MG/5 ML F SCOT-TUSSIN SENIOR ORAL LIQUID 15-200 MG/5 ML F QL SUPHEDRIN ORAL LIQUID 15 MG/5 ML F QL TUSSIN DM ORAL LIQUID 10-100 MG/5 ML F QL TUSSIN DM ORAL SYRUP 10-100 MG/5 ML F QL Diagnóstico CHEMSTRIP K STRIP F GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MG/ML F KETO-DIASTIX STRIP F MULTISTIX 10 SG STRIP F Diuréticos acetazolamide oral capsule, extended release 500 mg F acetazolamide oral tablet 125 mg, 250 mg F ALDACTAZIDE ORAL TABLET 50-50 MG F 24 Nombre del Medicamento Nivel de Requisitos/Límites Marca bumetanide oral tablet 0.5 mg, 1 mg, 2 mg F chlorothiazide oral tablet 250 mg, 500 mg F chlorthalidone oral tablet 25 mg, 50 mg F DIURIL ORAL SUSPENSION 250 MG/5 ML F DYRENIUM ORAL CAPSULE 50 MG F EDECRIN ORAL TABLET 25 MG F furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) F furosemide oral tablet 20 mg, 40 mg, 80 mg F hydrochlorothiazide oral capsule 12.5 mg F hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg F indapamide oral tablet 1.25 mg, 2.5 mg F spironolactone oral tablet 100 mg, 25 mg, 50 mg F spironolacton-hydrochlorothiaz oral tablet 25-25 mg F triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg F triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg F Ojos, Oídos, Nariz y Garganta (EENT) acetic acid otic solution 2 % F acetic acid-aluminum acetate otic drops 2 % F allergy eye (naphazoline-phen) ophthalmic drops 0.025-0.3 % F ALOMIDE OPHTHALMIC DROPS 0.1 % F apraclonidine ophthalmic drops 0.5 % F ARTIFICIAL TEARS OPHTHALMIC DROPS, 0.5-0.6 % F atropine ophthalmic drops 1 % F atropine ophthalmic ointment 1 % F AYR SALINE NASAL DROPS 0.65 % F azelastine nasal aerosol, spray 137 mcg (0.1 %) F AZOPT OPHTHALMIC DROPS, SUSPENSION 1 % F betaxolol ophthalmic drops 0.5 % F BETIMOL OPHTHALMIC DROPS 0.25 %, 0.5 % F BETOPTIC S OPHTHALMIC DROPS, SUSPENSION 0.25 % F brimonidine ophthalmic drops 0.15 %, 0.2 % F QL carbamoxide ear drops otic drops 6.5 % F QL QL 25 Nombre del Medicamento Nivel de Requisitos/Límites Marca cromolyn ophthalmic drops 4 % F CYCLOGYL OPHTHALMIC DROPS 0.5 % F cyclopentolate ophthalmic drops 1 %, 2 % F dexamethasone sodium phosphate ophthalmic drops 0.1 % F diclofenac sodium ophthalmic drops 0.1 % F dorzolamide ophthalmic drops 2 % F QL dorzolamide-timolol ophthalmic drops 22.3-6.8 mg/ml F QL EYE ALLERGY RELIEF OPHTHALMIC DROPS 0.02675-0.315 % F FLAREX OPHTHALMIC DROPS, SUSPENSION 0.1 % F flunisolide nasal spray, non-aerosol 25 mcg (0.025 %) F fluorometholone ophthalmic drops, suspension 0.1 % F fluticasone nasal spray, suspension 50 mcg/actuation F FML FORTE OPHTHALMIC DROPS, SUSPENSION 0.25 % F for sty relief ophthalmic ointment F GENTEAL MILD OPHTHALMIC DROPS 0.2 % F HOMATROPAIRE OPHTHALMIC DROPS 5 % F ISOPTO TEARS OPHTHALMIC DROPS 0.5 % F ketorolac ophthalmic drops 0.4 %, 0.5 % F latanoprost ophthalmic drops 0.005 % F QL levobunolol ophthalmic drops 0.5 % F QL lubricant eye drops (glyc-pg) ophthalmic drops 1-0.3 % F lubricant eye drops ophthalmic drops 0.5 % F LUBRICANT EYE OPHTHALMIC OINTMENT 56.8-41.5 % F MAXIDEX OPHTHALMIC DROPS, SUSPENSION 0.1 % F metipranolol ophthalmic drops 0.3 % F MURO 128 OPHTHALMIC DROPS 2 % F naphazoline ophthalmic drops 0.1 % F NASACORT NASAL AEROSOL, SPRAY 55 MCG F NASAL SPRAY EXTRA MOISTURIZING NASAL SPRAY, NONAEROSOL 0.05 % F PHENYLEPHRINE HCL OPHTHALMIC DROPS 2.5 % F PHOSPHOLINE IODIDE OPHTHALMIC DROPS 0.125 % F pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % F 26 QL QL Nombre del Medicamento Nivel de Requisitos/Límites Marca polyvinyl alcohol ophthalmic drops 1.4 % F PRED MILD OPHTHALMIC DROPS, SUSPENSION 0.12 % F prednisolone acetate ophthalmic drops, suspension 1 % F prednisolone sodium phosphate ophthalmic drops 1 % F proparacaine ophthalmic drops 0.5 % F PURE AND GENTLE EYE OPHTHALMIC DROPS 0.3 % F REFRESH LACRI-LUBE OPHTHALMIC OINTMENT 56.8-42.5 % F REFRESH P.M. OPHTHALMIC OINTMENT 57.3-42.5 % F saline nasal nasal aerosol, spray 0.65 % F sodium chloride ophthalmic drops 5 % F sodium chloride ophthalmic ointment 5 % F SYSTANE NIGHTTIME OPHTHALMIC OINTMENT 94-3 % F TEARS NATURALE FORTE OPHTHALMIC DROPS 0.1-0.3-0.2 % F timolol maleate ophthalmic drops 0.25 %, 0.5 % F timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % F TRAVATAN Z OPHTHALMIC DROPS 0.004 % F travoprost (benzalkonium) ophthalmic drops 0.004 % F tropicamide ophthalmic drops 0.5 %, 1 % F QL QL Electrolitos/Calórico/H2O CALCIUM 600 ORAL TABLET 600 MG (1,500 MG) F calcium acetate oral capsule 667 mg F calcium acetate oral tablet 667 mg F calcium carbonate oral tablet 500 mg calcium (1,250 mg), 650 mg calcium (1,625 mg) F calcium gluconate oral tablet 45 mg (500 mg), 60 mg (650 mg) F calcium lactate oral tablet 84 mg (648 mg) F CHELATED ZINC ORAL TABLET 50 MG F EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ, 25 MEQ F ferrous sulfate oral drops 15 mg iron (75 mg)/ml F QL ferrous sulfate oral liquid 300 mg (60 mg iron)/5 ml F QL ferrous sulfate oral solution 220 mg (44 mg iron)/5 ml F QL ferrous sulfate oral tablet, delayed release (dr/ec) 324 mg (65 mg iron), 325 mg (65 mg iron) F QL 27 Nombre del Medicamento Nivel de Requisitos/Límites Marca FERROUSUL ORAL TABLET 325 MG (65 MG IRON) F QL FLUOR-A-DAY ORAL DROPS 2.5 MG FLUORIDE (5.56 MG)/ML F FLUORITAB ORAL TABLET, CHEWABLE 1 MG FLUORIDE (2.2 MG) F GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG F GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG F glucose oral tablet, chewable 4 gram F magnesium oxide oral tablet 250 mg, 400 mg, 420 mg, 500 mg F QL PEDIATRIC ELECTROLYTE ORAL SOLUTION F QL potassium chloride oral capsule, extended release 10 meq, 8 meq F potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml F potassium chloride oral tablet extended release 10 meq, 8 meq F potassium chloride oral tablet, er particles/crystals 10 meq, 20 meq F RENAGEL ORAL TABLET 400 MG, 800 MG F RENVELA ORAL TABLET 800 MG F sf 5000 plus dental cream 1.1 % F sodium chloride 0.9 % intravenous parenteral solution 0.9 % F sodium citrate-citric acid oral solution 500-334 mg/5 ml F sodium fluoride oral drops 0.5 mg fluoride (1.1 mg)/ml F sodium fluoride oral tablet, chewable 0.25 mg fluorid (0.55 mg), 0.5 mg fluoride (1.1 mg) F sodium polystyrene sulfonate oral powder F sodium polystyrene sulfonate oral suspension 15 gram/60 ml F SSKI ORAL SOLUTION 1 GRAM/ML F zinc gluconate oral tablet 50 mg F QL QL Gastrointestinal ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION 200-200-20 MG/5 ML F ANTACID MAXIMUM STRENGTH ORAL SUSPENSION 400-400-40 MG/5 ML F ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML F ANUSOL-HC RECTAL CREAM 2.5 % F balsalazide oral capsule 750 mg F QL bisacodyl oral tablet, delayed release (dr/ec) 5 mg F QL 28 Nombre del Medicamento Nivel de Requisitos/Límites Marca BISMUTH MAXIMUM STRENGTH ORAL SUSPENSION 525 MG/15 ML F calcium carbonate oral tablet 260 mg calcium (648 mg) F CARAFATE ORAL SUSPENSION 100 MG/ML F cimetidine hcl oral solution 300 mg/5 ml F cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg F CITRUCEL ORAL TABLET 500 MG F CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT F dicyclomine oral capsule 10 mg F QL dicyclomine oral solution 10 mg/5 ml F QL dicyclomine oral tablet 20 mg F QL diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml F diphenoxylate-atropine oral tablet 2.5-0.025 mg F docusate sodium oral capsule 100 mg F QL docusate sodium oral liquid 50 mg/5 ml F QL docusate sodium oral syrup 60 mg/15 ml F QL docusate sodium oral tablet 100 mg F QL DONNATAL ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML F EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG C1 EMEND ORAL CAPSULE, DOSE PACK 125 MG (1)- 80 MG (2) C1 enema rectal enema 19-7 gram/118 ml F ENULOSE ORAL SOLUTION 10 GRAM/15 ML F famotidine oral suspension 40 mg/5 ml (8 mg/ml) F famotidine oral tablet 10 mg F famotidine oral tablet 20 mg, 40 mg F fiber (calcium polycarbophil) oral tablet 625 mg F fiber (psyllium husk/sugar) oral powder 3.4 gram/12 gram F FIBER (PSYLLIUM HUSK/SUGAR) ORAL POWDER 3.4 GRAM/7 GRAM F foaming antacid oral tablet, chewable 80-20 mg F GAVILYTE-G ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM F GAVISCON ORAL TABLET, CHEWABLE 80-14.2 MG F QL QL 29 Nombre del Medicamento Nivel de Requisitos/Límites Marca glycerin (adult) rectal suppository F glycerin (child) rectal suppository F hydrocortisone acetate rectal suppository 25 mg, 30 mg F konsyl (sugar) oral powder in packet 3.4 gram F lactulose oral solution 10 gram/15 ml F lansoprazole oral capsule, delayed release(dr/ec) 15 mg F lansoprazole oral capsule, delayed release(dr/ec) 30 mg F LAXATIVE (BISACODYL) ORAL TABLET 5 MG F loperamide oral capsule 2 mg F LOPERAMIDE ORAL TABLET 2 MG F magnesium citrate oral solution F meclizine oral tablet 12.5 mg, 25 mg F QL meclizine oral tablet, chewable 25 mg F QL METAMUCIL ORAL CAPSULE 0.52 GRAM F metoclopramide hcl oral solution 5 mg/5 ml F metoclopramide hcl oral tablet 10 mg, 5 mg F MILK OF MAGNESIA CONCENTRATED ORAL SUSPENSION 2,400 MG/10 ML F MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5 ML F MINTOX PLUS ORAL TABLET, CHEWABLE 200-200-25 MG F misoprostol oral tablet 100 mcg, 200 mcg C1 NATURAL FIBER LAXATIVE THERAPY ORAL POWDER F natural psyllium fiber oral powder 3.4 gram/5.8 gram F NEXIUM 24HR ORAL CAPSULE, DELAYED RELEASE(DR/EC) 22.3 MG F NUTRISOURCE FIBER ORAL POWDER F omeprazole oral capsule, delayed release(dr/ec) 10 mg, 20 mg F omeprazole oral capsule, delayed release(dr/ec) 40 mg F QL omeprazole oral tablet, delayed release (dr/ec) 20 mg F QL ondansetron hcl oral tablet 4 mg, 8 mg F QL ondansetron oral tablet, disintegrating 4 mg, 8 mg F QL pantoprazole oral tablet, delayed release (dr/ec) 20 mg, 40 mg F QL PEDIA-LAX STOOL SOFTENER ORAL SYRUP 50 MG/15 ML F 30 QL QL QL Nombre del Medicamento Nivel de Requisitos/Límites Marca PEDIATRIC ENEMA RECTAL ENEMA 9.5-3.5 GRAM/59 ML F peg 3350-electrolytes oral recon soln 240-22.72-6.72 -5.84 gram F phenohytro oral tablet 16.2-0.1037 -0.0194 mg F pink bismuth oral suspension 262 mg/15 ml F PINK BISMUTH ORAL TABLET 262 MG F PINK BISMUTH ORAL TABLET, CHEWABLE 262 MG F polyethylene glycol 3350 oral powder 17 gram/dose F QL PREVACID 24HR ORAL CAPSULE, DELAYED RELEASE(DR/EC) 15 MG F QL PRILOSEC OTC ORAL TABLET, DELAYED RELEASE (DR/EC) 20 MG F prochlorperazine maleate oral tablet 10 mg, 5 mg F prochlorperazine rectal suppository 25 mg F PROCTOFOAM HC RECTAL FOAM 1-1 % F PROCTO-PAK RECTAL CREAM 1 % F proctosol hc rectal cream 2.5 % F promethazine rectal suppository 12.5 mg, 25 mg F PROMETHEGAN RECTAL SUPPOSITORY 50 MG F rabeprazole oral tablet, delayed release (dr/ec) 20 mg F ranitidine hcl oral syrup 15 mg/ml F ranitidine hcl oral tablet 150 mg, 300 mg F ranitidine hcl oral tablet 75 mg F SENNA LAX ORAL TABLET 8.6 MG F SENNA ORAL SYRUP 8.8 MG/5 ML F SENNA PLUS ORAL TABLET 8.6-50 MG F QL SIMETHICONE ORAL DROPS, SUSPENSION 40 MG/0.6 ML F QL simethicone oral tablet, chewable 80 mg F QL sodium bicarbonate oral tablet 325 mg, 650 mg F stool softener oral capsule 50 mg F sucralfate oral tablet 1 gram F sulfasalazine oral tablet 500 mg F sulfasalazine oral tablet, delayed release (dr/ec) 500 mg F TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1.5 MG (1 MG OVER 3 DAYS) F QL QL QL QL 31 Nombre del Medicamento Nivel de Requisitos/Límites Marca TRILYTE WITH FLAVOR PACKETS ORAL RECON SOLN 420 GRAM F trimethobenzamide oral capsule 300 mg F ursodiol oral capsule 300 mg F ursodiol oral tablet 250 mg F QL Hormonas calcitonin (salmon) nasal spray, non-aerosol 200 unit/actuation F CORTIFOAM RECTAL FOAM 10 % (80 MG) F DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML F desmopressin oral tablet 0.1 mg, 0.2 mg C1 DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML F dexamethasone oral elixir 0.5 mg/5 ml F dexamethasone oral solution 0.5 mg/5 ml F dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg F ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) F estradiol oral tablet 0.5 mg, 1 mg, 2 mg F estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr F QL estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr F QL estrogens-methyltestosterone oral tablet 0.625-1.25 mg, 1.25-2.5 mg F fludrocortisone oral tablet 0.1 mg F hydrocortisone oral tablet 10 mg, 20 mg, 5 mg F hydrocortisone rectal enema 100 mg/60 ml F JINTELI ORAL TABLET 1-5 MG-MCG F medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg F QL MENEST ORAL TABLET 0.3 MG, 0.625 MG F QL MENEST ORAL TABLET 1.25 MG, 2.5 MG F methylergonovine oral tablet 0.2 mg F methylprednisolone oral tablet 4 mg F methylprednisolone oral tablets, dose pack 4 mg F MILLIPRED DP ORAL TABLETS, DOSE PACK 5 MG (21 TABS) F MILLIPRED ORAL TABLET 5 MG F prednisolone oral solution 15 mg/5 ml F 32 Nombre del Medicamento Nivel de Requisitos/Límites Marca prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) F PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML F prednisone oral solution 5 mg/5 ml F prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg F prednisone oral tablets, dose pack 10 mg, 5 mg F PREMARIN ORAL TABLET 0.3 MG, 0.625 MG, 0.9 MG, 1.25 MG F PREMARIN ORAL TABLET 0.45 MG F PREMARIN VAGINAL CREAM 0.625 MG/GRAM F PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14) F QL PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG F QL testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml F PA QL Inmunosupresor azathioprine oral tablet 50 mg F cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg F mycophenolate mofetil oral capsule 250 mg F mycophenolate mofetil oral tablet 500 mg F Suministros Médicos Diversos, Dispositivos, No Farmacológicos AEROCHAMBER PLUS FLOW-VU SPACER F QL bd insulin pen needle uf orig needle 29 gauge x 1/2" F bd insulin pen needle uf short needle 31 gauge x 5/16" F peak air peak flow meter device F QL baclofen oral tablet 10 mg, 20 mg F QL cyclobenzaprine oral tablet 10 mg, 5 mg F QL methocarbamol oral tablet 500 mg, 750 mg F QL tizanidine oral tablet 2 mg, 4 mg F QL Relajantes Musculares Vitaminas Prenatales O-CAL FA ORAL TABLET 66-1 MG F pnv 29-1 oral tablet 29 mg iron- 1 mg F prenatal complete oral tablet 14-400 mg-mcg F PRENATAL LOW IRON ORAL TABLET 27-1 MG F 33 Nombre del Medicamento Nivel de Requisitos/Límites Marca PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 27 MG IRON- 1 MG F prenatal plus oral tablet 29 mg iron- 1 mg F prenatal vit#96-ferrous fum-fa oral tablet 27 mg iron- 800 mcg F PRENATAL VITAMIN ORAL TABLET , 27-0.8 MG F PRENATAL VITAMIN WITH MINERALS ORAL TABLET 28 MG IRON- 800 MCG F PRETAB ORAL TABLET 29-1 MG F vinate m oral tablet 27-1 mg F Medicamentos Psicoterapéuticos ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML F QL alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg F QL alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg F QL amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg F bupropion hcl oral tablet 100 mg, 75 mg F QL bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg F QL bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg F buspirone oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg F buspirone oral tablet 30 mg F citalopram oral solution 10 mg/5 ml F citalopram oral tablet 10 mg, 20 mg, 40 mg F QL clonidine hcl oral tablet extended release 12 hr 0.1 mg F QL desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg F QL dexmethylphenidate oral capsule, er biphasic 50-50 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg F QL dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg F DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML F QL diazepam oral solution 5 mg/5 ml (1 mg/ml) F QL diazepam oral tablet 10 mg, 2 mg, 5 mg F QL doxepin oral capsule 10 mg, 25 mg, 50 mg F doxepin oral capsule 100 mg, 150 mg, 75 mg F QL duloxetine oral capsule, delayed release(dr/ec) 20 mg, 30 mg, 60 mg F QL escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg F 34 QL Nombre del Medicamento Nivel de Requisitos/Límites Marca fluoxetine oral capsule 10 mg, 20 mg, 40 mg F QL fluoxetine oral solution 20 mg/5 ml (4 mg/ml) F fluoxetine oral tablet 10 mg F fluoxetine oral tablet 20 mg F FOCALIN XR ORAL CAPSULE, ER BIPHASIC 50-50 25 MG, 35 MG F QL guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg F QL imipramine hcl oral tablet 10 mg, 25 mg, 50 mg F lorazepam oral tablet 0.5 mg, 1 mg, 2 mg F QL methylphenidate oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg F QL methylphenidate oral tablet 10 mg, 20 mg, 5 mg F QL methylphenidate oral tablet extended release 10 mg F QL methylphenidate oral tablet extended release 20 mg F methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg F QL mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg F QL mirtazapine oral tablet, disintegrating 15 mg, 30 mg F QL mirtazapine oral tablet, disintegrating 45 mg F nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg F nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg F nortriptyline oral solution 10 mg/5 ml F paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg F sertraline oral concentrate 20 mg/ml F sertraline oral tablet 100 mg, 25 mg, 50 mg F STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG F trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg F venlafaxine oral capsule, extended release 24hr 150 mg, 37.5 mg, 75 mg F QL venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg F QL venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg F QL NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET 25 MG F QL phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) F QL QL QL QL Sedantes/Hipnóticos 35 Nombre del Medicamento Nivel de Requisitos/Límites Marca phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg F temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg F QL triazolam oral tablet 0.125 mg, 0.25 mg F QL zolpidem oral tablet 10 mg, 5 mg F QL Piel ACNE TREATMENT (BENZOYL PEROX) TOPICAL CREAM 10 % F ALCOHOL PREP PADS TOPICAL PADS, MEDICATED F AMLACTIN TOPICAL CREAM F ammonium lactate topical lotion 12 % F benzoyl peroxide topical cleanser 10 %, 5 % F benzoyl peroxide topical gel 10 %, 2.5 %, 5 % F benzoyl peroxide topical lotion 10 % F BETA-HC TOPICAL LOTION 1 % F betamethasone dipropionate topical cream 0.05 % F betamethasone dipropionate topical lotion 0.05 % F betamethasone dipropionate topical ointment 0.05 % F betamethasone valerate topical cream 0.1 % F betamethasone valerate topical ointment 0.1 % F betamethasone, augmented topical cream 0.05 % F betamethasone, augmented topical ointment 0.05 % F calamine topical lotion F calamine-zinc oxide topical lotion 8-8 % F clobetasol scalp solution 0.05 % F clobetasol topical cream 0.05 % F clobetasol topical foam 0.05 % F QL clobetasol topical gel 0.05 % F QL clobetasol topical ointment 0.05 % F QL clobetasol-emollient topical cream 0.05 % F CONDYLOX TOPICAL GEL 0.5 % F CORN-CALLUS REMOVER TOPICAL LIQUID F DESITIN TOPICAL CREAM 13 % F desonide topical cream 0.05 % F 36 QL QL QL Nombre del Medicamento Nivel de Requisitos/Límites Marca desonide topical lotion 0.05 % F QL desonide topical ointment 0.05 % F QL DRITHOCREME HP TOPICAL CREAM 1 % F EURAX TOPICAL CREAM 10 % F EURAX TOPICAL LOTION 10 % F FLANDERS BUTTOCKS TOPICAL OINTMENT F fluocinolone topical cream 0.01 %, 0.025 % F fluocinolone topical ointment 0.025 % F fluocinolone topical solution 0.01 % F fluocinonide topical cream 0.05 % F fluocinonide topical gel 0.05 % F fluocinonide topical ointment 0.05 % F fluocinonide topical solution 0.05 % F FLUOCINONIDE-E TOPICAL CREAM 0.05 % F fluticasone topical cream 0.05 % F fluticasone topical ointment 0.005 % F HIBICLENS TOPICAL LIQUID 4 % F hydrocortisone acetate topical cream 0.5 % F QL HYDROCORTISONE ACETATE TOPICAL CREAM 1 % F QL hydrocortisone acetate topical ointment 1 % F QL HYDROCORTISONE PLUS TOPICAL CREAM 1 % F hydrocortisone topical cream 0.5 %, 2.5 % F HYDROCORTISONE TOPICAL CREAM 1 % F hydrocortisone topical lotion 2.5 % F hydrocortisone topical ointment 0.5 %, 1 % F hydrocortisone topical ointment 2.5 % F imiquimod topical cream in packet 5 % F QL LICE KILLING TOPICAL SHAMPOO 0.33-4 % F QL malathion topical lotion 0.5 % F QL metronidazole topical cream 0.75 % F metronidazole topical gel 0.75 % F metronidazole topical lotion 0.75 % F QL QL 37 Nombre del Medicamento Nivel de Requisitos/Límites Marca mometasone topical cream 0.1 % F mometasone topical ointment 0.1 % F mometasone topical solution 0.1 % F neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml F permethrin topical cream 5 % F permethrin topical liquid 1 % F podofilox topical solution 0.5 % F povidone-iodine topical solution 10 % F povidone-iodine topical swab 10 % F prednicarbate topical cream 0.1 % F prednicarbate topical ointment 0.1 % F PYRETHRIN LICE TREATMENT M TOPICAL LIQUID 0.33-4 % F RID COMPLETE LICE ELIM KIT TOPICAL KIT 4-0.33-0.5 % F QL SCALPICIN ANTI-ITCH TOPICAL SOLUTION 1 % F QL selenium sulfide topical lotion 2.5 % F SELSUN BLUE TOPICAL SUSPENSION 1 % F SELSUN BLUE WITH MENTHOL TOPICAL SUSPENSION 1 % F STERILE SALINE IRRIGATION SOLUTION 0.9 % F tretinoin topical cream 0.025 %, 0.05 %, 0.1 % C1 tretinoin topical gel 0.01 %, 0.025 % C1 triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 % F triamcinolone acetonide topical lotion 0.025 %, 0.1 % F triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % F trianex topical ointment 0.05 % F ULESFIA TOPICAL LOTION 5 % F urea topical lotion 10 % F VOLTAREN TOPICAL GEL 1 % F wart remover topical gel 17 % F WART REMOVER TOPICAL LIQUID, 17 % F zinc oxide topical ointment , 20 %, 40 % F zinc oxide topical paste 25 % F Elementos Disuasivos para Dejar de Fumar 38 QL QL QL Nombre del Medicamento Nivel de Requisitos/Límites Marca buproban oral tablet extended release 150 mg F QL CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG F QL CHANTIX ORAL TABLET 0.5 MG F QL CHANTIX STARTING MONTH PAK ORAL TABLETS, DOSE PACK 0.5 MG (11)- 1 MG (42) F QL nicotine (polacrilex) buccal gum 2 mg, 4 mg F QL nicotine (polacrilex) buccal lozenge 2 mg, 4 mg F QL nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr F QL nicotine transdermal patch, td daily, sequential 21-14-7 mg/24 hr F QL NICOTROL INHALATION CARTRIDGE 10 MG F QL NICOTROL NS NASAL SPRAY, NON-AEROSOL 10 MG/ML F QL Tiroides ARMOUR THYROID ORAL TABLET 120 MG, 30 MG, 60 MG F ARMOUR THYROID ORAL TABLET 15 MG, 180 MG, 240 MG, 300 MG, 90 MG F levothyroxine oral tablet 100 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg F levothyroxine oral tablet 112 mcg, 137 mcg, 300 mcg, 88 mcg F liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg F methimazole oral tablet 10 mg, 5 mg F propylthiouracil oral tablet 50 mg F QL QL Medicamentos Sin Clasificación alendronate oral tablet 10 mg, 40 mg F alendronate oral tablet 35 mg, 70 mg F CARNITOR (SUGAR-FREE) ORAL SOLUTION 100 MG/ML F CHEMET ORAL CAPSULE 100 MG F chlorhexidine gluconate mucous membrane mouthwash 0.12 % F disulfiram oral tablet 250 mg, 500 mg F finasteride oral tablet 5 mg F leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg F levocarnitine oral tablet 330 mg F megestrol oral suspension 400 mg/10 ml (40 mg/ml) F ORALONE DENTAL PASTE 0.1 % F QL QL QL 39 Nombre del Medicamento Nivel de Requisitos/Límites Marca oxybutynin chloride oral tablet 5 mg F oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg F SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG F SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) F SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG F sodium chloride inhalation solution for nebulization 0.9 %, 10 %, 3 % F tamsulosin oral capsule, extended release 24hr 0.4 mg F QL tolterodine oral capsule, extended release 24hr 2 mg, 4 mg F QL tolterodine oral tablet 1 mg, 2 mg F QL QL Vitaminas calcitriol oral capsule 0.25 mcg, 0.5 mcg F CENTRAL-VITE FOR SENIORS ORAL TABLET F CENTRAL-VITE SELECT ORAL TABLET F chewable-vite oral tablet, chewable F child's vitamin with iron oral tablet, chewable F cholecalciferol (vitamin d3) oral capsule 10,000 unit, 5,000 unit, 50,000 unit F cholecalciferol (vitamin d3) oral drops 400 unit/ml F cholecalciferol (vitamin d3) oral tablet 2,000 unit F cholecalciferol (vitamin d3) oral tablet, chewable 400 unit F COMPLETE MULTIVITAMIN ORAL TABLET F cyanocobalamin (vitamin b-12) injection solution 1,000 mcg/ml F cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg F ergocalciferol (vitamin d2) oral capsule 50,000 unit F ergocalciferol (vitamin d2) oral tablet 400 unit F folic acid oral tablet 1 mg, 400 mcg F full spectrum b-vitamin c oral tablet 0.8 mg F MEPHYTON ORAL TABLET 5 MG F multi-vit with fluoride-iron oral drops 0.25mg fluoride -10 mg iron/ml F multi-vitamin with fluoride oral drops 0.25 mg/ml, 0.5 mg/ml F MULTI-VITAMIN WITH FLUORIDE ORAL TABLET, CHEWABLE 0.25 MG, 1 MG F 40 QL Nombre del Medicamento Nivel de Requisitos/Límites Marca MULTIVITAMIN WITH FLUORIDE ORAL TABLET, CHEWABLE 0.5 MG F multivitamin with iron oral tablet F multivitamin with minerals oral tablet F MULTIVITAMIN-CALCIUM AND IRON ORAL TABLET F MULTIVITAMINS WITH FLUORIDE ORAL TABLET, CHEWABLE 0.25 MG F MULTI-VITAMINS WITH IRON ORAL TABLET,CHEWABLE F NIACIN FLUSH FREE ORAL CAPSULE 400 MG NIACIN (500 MG) F niacin oral capsule, extended release 250 mg, 500 mg F niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg F niacin oral tablet extended release 500 mg F pediatric multivitamin oral tablet, chewable F poly-vi-sol oral drops 750-35-400 unit-mg-unit/ml F POLY-VITA ORAL DROPS 1,500-35-400 UNIT-MG-UNIT/ML F POLY-VITAMIN WITH IRON ORAL DROPS 1,500 UNIT-400 UNIT-10 MG/ML F pyridoxine (vitamin b6) injection solution 100 mg/ml F rena-vite rx oral tablet 1-60-300 mg-mg-mcg F THERA M PLUS (FERROUS FUMARAT) ORAL TABLET 9 MG IRON400 MCG F THERA VITAMIN ORAL TABLET F THERAPEUTIC-M VITAMIN/MINERALS ORAL TABLET 27-0.4 MG F THEREMS-M ORAL TABLET 27-0.4 MG F thiamine mononitrate (vit b1) oral tablet 100 mg F TRI-VIT WITH FLUORIDE AND IRON ORAL DROPS 0.25-10 MG/ML F TRI-VITAMIN ORAL DROPS 1,500-35-400 UNIT-MG-UNIT/ML F TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML F VITAMIN B-1 ORAL TABLET 100 MG, 250 MG, 50 MG F vitamin b-12 oral tablet 1,000 mcg F VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG F VITAMIN D3 ORAL CAPSULE 1,000 UNIT, 2,000 UNIT, 4,000 UNIT, 400 UNIT F QL 41 Nombre del Medicamento Nivel de Requisitos/Límites Marca VITAMIN D3 ORAL TABLET 1,000 UNIT, 400 UNIT, 5,000 UNIT F VITAMINS AND MINERALS ORAL TABLET F WOMEN'S DAILY FORMULA ORAL TABLET 27-0.4 MG F 42 Indice 3 3 DAY VAGINAL ............... 11 A ABREVA ............................. 16 acarbose ................................ 14 acetaminophen ........................ 3 acetaminophen-codeine .......... 3 acetazolamide ....................... 24 acetic acid ............................. 25 acetic acid-aluminum acetate25 acetylcysteine ......................... 5 ACNE TREATMENT (BENZOYL PEROX) ...... 36 acyclovir ............................... 17 ADRENALIN....................... 17 ADULT ROBITUSSIN PEAK COLD M-S ....................... 23 ADVANCED ANTACIDANTIGAS ........................ 28 AEROCHAMBER PLUS FLOW-VU ....................... 33 ALAVERT D-12 ALLERGYSINUS .............................. 12 albuterol sulfate ...................... 5 ALCOHOL PREP PADS ..... 36 ALDACTAZIDE .................. 24 alendronate ........................... 39 ALLER-CHLOR .................. 13 allergy eye (naphazoline-phen) .......................................... 25 allergy relief(chlorphen-acet) .......................................... 23 allopurinol .............................. 5 ALOMIDE ........................... 25 alprazolam ............................ 34 ALPRAZOLAM INTENSOL .......................................... 34 amiodarone ........................... 17 amitriptyline ......................... 34 AMLACTIN ......................... 36 amlodipine ............................ 18 amlodipine-benazepril .......... 19 ammonium lactate ................ 36 amoxicillin.............................. 7 amoxicillin-pot clavulanate .... 7 ampicillin................................ 7 anagrelide ............................. 16 anastrozole............................ 15 ANTACID MAXIMUM STRENGTH ..................... 28 ANTI-DIARRHEAL (LOPERAMIDE).............. 28 antifungal (tolnaftate) ........... 11 ANUSOL-HC ....................... 28 APIDRA ............................... 14 APIDRA SOLOSTAR ......... 14 apraclonidine ........................ 25 ARMOUR THYROID ......... 39 ARTIFICIAL TEARS .......... 25 ASMANEX TWISTHALER .. 6 aspirin ..................................... 3 ASPIRIN LOW-STRENGTH 3 aspirin-dipyridamole ............ 16 atenolol ................................. 19 atenolol-chlorthalidone ......... 19 ATHLETE'S FOOT (TERBINAFINE) ............. 11 atorvastatin ........................... 19 atovaquone............................ 15 atropine ................................. 25 ATROVENT HFA ................. 6 AUGMENTIN ........................ 7 AYR SALINE ...................... 25 azathioprine .......................... 33 azelastine .............................. 25 azithromycin ........................... 7 AZOPT ................................. 25 AZURETTE (28) .................. 21 B bacitracin ................................ 7 bacitracin zinc......................... 7 bacitracin-polymyxin b........... 7 baclofen ................................ 33 BACTROBAN NASAL ......... 7 balsalazide ............................ 28 BALZIVA (28) ..................... 22 bd insulin pen needle uf orig 33 bd insulin pen needle uf short .......................................... 33 BENADRYL ALLERGY..... 13 benazepril ............................. 19 benazepril-hydrochlorothiazide .......................................... 19 BENZAMYCINPAK ............. 7 benzonatate ........................... 23 benzoyl peroxide .................. 36 BETA-HC ............................. 36 betamethasone dipropionate . 36 betamethasone valerate .........36 betamethasone, augmented ...36 betaxolol ...............................25 bethanechol chloride .............17 BETIMOL ............................ 25 BETOPTIC S ........................ 25 BIO-S-PRES DX .................. 23 bisacodyl ............................... 28 BISMUTH MAXIMUM STRENGTH ..................... 29 BLEPHAMIDE ...................... 7 BLEPHAMIDE S.O.P. ........... 7 brimonidine........................... 25 BROMFED DM ................... 23 bromocriptine ....................... 16 BROTAPP DM ..................... 23 BUCALSEP ............................ 4 budesonide .............................. 6 bumetanide ........................... 25 buproban ............................... 39 bupropion hcl ........................ 34 buspirone .............................. 34 butalbital-acetaminophen-caff 3 butalbital-aspirin-caffeine....... 3 C CAFERGOT ........................... 3 calamine ................................ 36 calamine-zinc oxide .............. 36 calcitonin (salmon) ............... 32 calcitriol ................................ 40 CALCIUM 600 ..................... 27 calcium acetate ..................... 27 calcium carbonate ........... 27, 29 calcium gluconate ................. 27 calcium lactate ...................... 27 CAMRESE ........................... 22 CAPITAL WITH CODEINE . 3 captopril ................................ 19 CARAFATE ......................... 29 carbamazepine ...................... 20 carbamoxide ear drops .......... 25 carbidopa-levodopa .............. 16 CARNITOR (SUGAR-FREE) .......................................... 39 carvedilol .............................. 19 CAZIANT (28) ..................... 22 43 cefaclor ................................... 8 cefdinir ................................... 8 cefixime .................................. 8 ceftibuten ................................ 8 CENTRAL-VITE FOR SENIORS ......................... 40 CENTRAL-VITE SELECT . 40 cephalexin............................... 8 cetirizine ............................... 13 cetirizine-pseudoephedrine... 12 CHANTIX ............................ 39 CHANTIX CONTINUING MONTH PAK .................. 39 CHANTIX STARTING MONTH PAK .................. 39 CHELATED ZINC .............. 27 CHEMET ............................. 39 CHEMSTRIP K.................... 24 chewable-vite ....................... 40 CHILD MUCINEX STUFFY NOSE-COLD ................... 23 CHILDREN'S CLARITIN ... 13 CHILDREN'S NON-ASPIRIN ............................................ 3 CHILDREN'S WAL-DRYL ALLERGY ....................... 13 child's vitamin with iron ....... 40 chlorhexidine gluconate ....... 39 chloroquine phosphate.......... 15 chlorothiazide ....................... 25 chlorpheniramine maleate .... 13 chlorthalidone ....................... 25 cholecalciferol (vitamin d3) . 40 cholestyramine (with sugar) . 19 CHOLESTYRAMINE LIGHT .......................................... 19 choline,magnesium salicylate. 3 cilostazol............................... 16 CILOXAN .............................. 8 cimetidine ............................. 29 cimetidine hcl ....................... 29 CIPRO HC.............................. 8 CIPRODEX ............................ 8 ciprofloxacin........................... 8 ciprofloxacin (mixture) .......... 8 ciprofloxacin hcl ..................... 8 citalopram ............................. 34 CITRUCEL .......................... 29 clarithromycin ........................ 8 clindamycin hcl ...................... 8 44 clindamycin palmitate hcl ...... 8 clindamycin phosphate ........... 8 clobetasol .............................. 36 clobetasol-emollient ............. 36 clonazepam ........................... 20 clonidine ............................... 19 clonidine hcl ................... 19, 34 clopidogrel ............................ 16 clotrimazole .......................... 11 clotrimazole-betamethasone . 11 colchicine................................ 5 colchicine-probenecid ............ 5 COMBIVENT RESPIMAT ... 6 COMPLETE MULTIVITAMIN ............ 40 CONCEPTROL .................... 22 CONDOMS-PREM LUBRICATED ................. 22 CONDYLOX........................ 36 CORN-CALLUS REMOVER .......................................... 36 CORTIFOAM ...................... 32 CORTISPORIN ...................... 8 CREON ................................ 29 cromolyn ........................... 6, 26 cyanocobalamin (vitamin b-12) .......................................... 40 cyclobenzaprine .................... 33 CYCLOGYL ........................ 26 cyclopentolate ....................... 26 cycloserine .............................. 8 cyclosporine modified .......... 33 cyproheptadine ..................... 13 D dapsone ................................... 8 DEPO-PROVERA................ 32 desipramine .......................... 34 DESITIN .............................. 36 desmopressin ........................ 32 DESOGESTREL-ETHINYL ESTRADIOL .................... 22 desonide .......................... 36, 37 dexamethasone ..................... 32 DEXAMETHASONE INTENSOL ...................... 32 dexamethasone sodium phosphate .......................... 26 dexmethylphenidate.............. 34 dextroamphetamine .............. 17 dextroamphetamineamphetamine..................... 17 DIABETIC TUSSIN DM ..... 23 diazepam ......................... 20, 34 DIAZEPAM INTENSOL ..... 34 diclofenac potassium .............. 3 diclofenac sodium ............. 5, 26 dicloxacillin ............................ 8 dicyclomine .......................... 29 digoxin .................................. 18 DILANTIN ........................... 21 DILATRATE-SR ................. 18 diltiazem hcl ......................... 18 DILT-XR .............................. 18 DIMETAPP COLDALLERGY (PE) ............... 12 DIMETAPP DM COLDCOUGH (PE).................... 23 diphenhydramine hcl ............ 13 diphenoxylate-atropine ......... 29 disulfiram .............................. 39 DIURIL................................. 25 divalproex ............................. 21 docusate sodium ................... 29 donepezil............................... 17 DONNATAL ........................ 29 dorzolamide .......................... 26 dorzolamide-timolol ............. 26 double antibiotic (b.tracn zn) ..8 doxazosin ..............................19 doxepin .................................34 doxycycline hyclate ................9 doxycycline monohydrate ......9 DRITHOCREME HP ...........37 duloxetine .............................34 DYRENIUM.........................25 E E.E.S. 400 ...............................9 E.E.S. GRANULES ................ 9 econazole ..............................11 EDECRIN .............................25 EFFER-K ..............................27 ELIQUIS...............................11 ELLA ....................................22 ELMIRON ..............................4 EMEND ................................29 enalapril maleate ...................19 ENDODAN ............................4 enema ....................................29 enoxaparin ............................11 entacapone ............................ 16 ENULOSE............................ 29 epinephrine ........................... 17 EPIPEN JR 2-PAK ............... 17 EPOGEN .............................. 21 ergocalciferol (vitamin d2) ... 40 ERYPED 400 ......................... 9 ery-tab..................................... 9 ERY-TAB............................... 9 erythromycin .......................... 9 erythromycin stearate ............. 9 erythromycin with ethanol ..... 9 erythromycin-benzoyl peroxide ............................................ 9 escitalopram oxalate ............. 34 ESTRACE ............................ 32 estradiol ................................ 32 estrogens-methyltestosterone32 ethambutol .............................. 9 ethosuximide ........................ 21 etodolac .................................. 5 etoposide............................... 15 EURAX ................................ 37 EXPECTORANT ................. 23 EYE ALLERGY RELIEF .... 26 F FALLBACK SOLO ............. 22 famciclovir ........................... 17 famotidine............................. 29 fc2 female condom ............... 22 felodipine.............................. 18 fenofibrate ............................ 19 fenofibrate micronized ......... 19 fenofibrate nanocrystallized . 19 fenofibric acid (choline) ....... 19 fentanyl ................................... 4 ferrous sulfate ....................... 27 FERROUSUL....................... 28 FEVERALL ........................... 4 fiber (calcium polycarbophil) .......................................... 29 fiber (psyllium husk/sugar) .. 29 FIBER (PSYLLIUM HUSK/SUGAR) ............... 29 finasteride ............................. 39 FLANDERS BUTTOCKS ... 37 FLAREX .............................. 26 FLOVENT DISKUS .............. 6 FLOVENT HFA..................... 6 fluconazole ........................... 11 flucytosine ............................ 12 fludrocortisone...................... 32 flunisolide ............................. 26 fluocinolone .......................... 37 fluocinonide .......................... 37 FLUOCINONIDE-E ............ 37 FLUOR-A-DAY ................... 28 FLUORITAB........................ 28 fluorometholone ................... 26 FLUOROPLEX .................... 15 fluorouracil ........................... 15 fluoxetine .............................. 35 flutamide............................... 16 fluticasone ...................... 26, 37 FML FORTE ........................ 26 foaming antacid .................... 29 FOCALIN XR ...................... 35 folic acid ............................... 40 for sty relief .......................... 26 full spectrum b-vitamin c ..... 40 furosemide ............................ 25 G gabapentin ............................ 21 GAVILYTE-G...................... 29 GAVISCON ......................... 29 gemfibrozil ........................... 19 GENTAK................................ 9 gentamicin .............................. 9 GENTEAL MILD ................ 26 GIANVI (28) ........................ 22 glimepiride............................ 14 glipizide ................................ 14 glipizide-metformin .............. 14 GLUCAGEN DIAGNOSTIC KIT ................................... 24 GLUCAGEN HYPOKIT ..... 28 GLUCAGON EMERGENCY KIT (HUMAN)................. 28 glucose .................................. 28 glyburide ............................... 14 glyburide-metformin ............ 14 glycerin (adult) ..................... 30 glycerin (child) ..................... 30 GRANIX .............................. 21 griseofulvin microsize .......... 12 griseofulvin ultramicrosize ... 12 guaifenesin............................ 23 GUAIFENESIN AC ............. 23 guanfacine ...................... 19, 35 GYNOL II ............................ 22 H HIBICLENS .........................37 HOMATROPAIRE ..............26 HUMALOG ..........................14 HUMALOG KWIKPEN ...... 14 HUMALOG MIX 50-50....... 14 HUMALOG MIX 50-50 KWIKPEN ........................ 14 HUMALOG MIX 75-25....... 14 HUMALOG MIX 75-25 KWIKPEN ........................ 14 HUMULIN 70/30 ................. 14 HUMULIN 70/30 KWIKPEN .......................................... 14 HUMULIN N ....................... 14 HUMULIN N KWIKPEN .... 14 HUMULIN R........................ 14 HUMULIN R U-500 (CONCENTRATED) ....... 14 hydralazine ........................... 19 hydrochlorothiazide .............. 25 hydrocodone-acetaminophen .. 4 hydrocodone-homatropine .... 23 hydrocortisone ................ 32, 37 HYDROCORTISONE ......... 37 hydrocortisone acetate .... 30, 37 HYDROCORTISONE ACETATE ........................ 37 HYDROCORTISONE PLUS .......................................... 37 hydroxychloroquine ..............15 hydroxyurea ..........................16 hydroxyzine hcl .................... 13 hydroxyzine pamoate............13 I ibuprofen.................................5 ifosfamide .............................16 imipramine hcl ......................35 imiquimod.............................37 INCRUSE ELLIPTA ..............6 indapamide ...........................25 indomethacin ..........................5 infant's non-aspirin .................4 INVOKAMET ......................14 INVOKANA.........................15 ipratropium bromide ...............6 irbesartan ..............................19 isometh-dichloralacetaminophn ......................4 isoniazid ..................................9 45 ISOPTO TEARS .................. 26 ISORDIL .............................. 18 isosorbide dinitrate ............... 18 isosorbide mononitrate ......... 18 J JANUMET ........................... 15 JANUMET XR..................... 15 JANUVIA............................. 15 JINTELI ............................... 32 JUNEL FE 1.5/30 (28) ......... 22 JUNEL FE 1/20 (28) ............ 22 K KADIAN ................................ 4 ketoconazole ......................... 12 KETO-DIASTIX .................. 24 ketorolac ........................... 4, 26 konsyl (sugar) ....................... 30 L l norgest/e.estradiol-e.estrad. 22 labetalol ................................ 19 lactulose................................ 30 lamotrigine ........................... 21 lansoprazole.......................... 30 LANTUS .............................. 15 LANTUS SOLOSTAR ........ 15 latanoprost ............................ 26 LAXATIVE (BISACODYL)30 LEENA 28 ............................ 22 leflunomide............................. 5 leucovorin calcium ............... 39 LEUKERAN ........................ 16 levalbuterol hcl ....................... 6 levetiracetam ........................ 21 levobunolol ........................... 26 levocarnitine ......................... 39 levofloxacin ............................ 9 levonorgestrel-ethinyl estrad 22 LEVORA-28 ........................ 22 levothyroxine........................ 39 LICE KILLING .................... 37 lidocaine ................................. 4 LIDOCAINE VISCOUS ........ 4 liothyronine .......................... 39 lisinopril ............................... 20 lisinopril-hydrochlorothiazide .......................................... 20 LOHIST - D ......................... 13 loperamide ............................ 30 LOPERAMIDE .................... 30 loratadine .............................. 13 46 LORATADINE-D ................ 13 lorazepam ............................. 35 losartan ................................. 20 losartan-hydrochlorothiazide 20 lovastatin .............................. 20 LOW-OGESTREL (28) ....... 22 LUBRICANT EYE .............. 26 lubricant eye drops ............... 26 lubricant eye drops (glyc-pg) 26 M magnesium citrate................. 30 magnesium oxide.................. 28 malathion .............................. 37 MATULANE........................ 16 MAXIDEX ........................... 26 meclizine .............................. 30 MEDI-FIRST ANTI-FUNGAL .......................................... 12 medroxyprogesterone ..... 22, 32 megestrol ........................ 16, 39 meloxicam .............................. 5 MENEST .............................. 32 MEPHYTON ........................ 40 mercaptopurine ..................... 16 MESTINON ......................... 17 MESTINON TIMESPAN .... 17 METAMUCIL ...................... 30 metaproterenol ........................ 6 metformin ............................. 15 methenamine mandelate ......... 9 methimazole ......................... 39 methocarbamol ..................... 33 methotrexate sodium ............ 16 methotrexate sodium (pf) ..... 16 methyldopa ........................... 20 methyldopahydrochlorothiazide .......... 20 methylergonovine ................. 32 methylphenidate ................... 35 methylprednisolone .............. 32 metipranolol.......................... 26 metoclopramide hcl .............. 30 metoprolol succinate............. 20 metoprolol tartrate ................ 20 metronidazole ................... 9, 37 mexiletine ............................. 18 miconazole nitrate ................ 12 MICONAZOLE-3 ................ 12 MICROGESTIN 1.5/30 (21) 22 MICROGESTIN 1/20 (21) ... 22 midodrine .............................. 17 MIGERGOT ........................... 4 MIGRAINE FORMULA........ 4 MILK OF MAGNESIA ........30 MILK OF MAGNESIA CONCENTRATED ..........30 MILLIPRED ......................... 32 MILLIPRED DP ................... 32 minocycline ............................ 9 minoxidil............................... 20 MINTOX PLUS ................... 30 mirtazapine ........................... 35 misoprostol ........................... 30 mometasone .......................... 38 MONONESSA (28)..............22 montelukast.............................6 morphine .................................4 morphine concentrate .............4 MUCINEX ...........................24 MUCINEX COUGH MINIMELTS .............................24 MUCINEX D........................24 MUCINEX D MAXIMUM STRENGTH .....................24 MUCINEX DM ....................24 mucus dm..............................24 mucus relief cough ...............24 MULTISTIX 10 SG .............24 multi-vit with fluoride-iron...40 multi-vitamin with fluoride ..40 MULTIVITAMIN WITH FLUORIDE ......................41 MULTI-VITAMIN WITH FLUORIDE ......................40 multivitamin with iron ..........41 multivitamin with minerals...41 MULTIVITAMIN-CALCIUM AND IRON ....................... 41 MULTIVITAMINS WITH FLUORIDE ...................... 41 MULTI-VITAMINS WITH IRON ................................ 41 mupirocin .............................. 10 mupirocin calcium .................. 9 MURO 128 ........................... 26 MY WAY ............................. 22 mycophenolate mofetil ......... 33 MYLERAN .......................... 16 N nabumetone............................. 5 naphazoline........................... 26 naproxen ................................. 5 naproxen sodium .................... 5 NASACORT ........................ 26 NASAL SPRAY EXTRA MOISTURIZING ............. 26 NATACYN .......................... 12 NATURAL FIBER LAXATIVE THERAPY .. 30 natural psyllium fiber ........... 30 NEBUPENT ......................... 15 NECON 0.5/35 (28) ............. 22 NECON 1/35 (28) ................ 22 NECON 1/50 (28) ................ 22 NECON 10/11 (28) .............. 22 NECON 7/7/7 (28) ............... 22 nefazodone ........................... 35 neomycin .............................. 10 neomycin-bacitracinpolymyxin......................... 10 neomycin-polymyxin b gu ... 38 neomycin-polymyxin bdexameth .......................... 10 neomycin-polymyxingramicidin......................... 10 neomycin-polymyxin-hc ...... 10 NEO-TUSS........................... 24 NEXIUM 24HR ................... 30 NEXT CHOICE ONE DOSE .......................................... 22 niacin .............................. 20, 41 NIACIN FLUSH FREE ....... 41 NIACOR............................... 20 nicotine ................................. 39 nicotine (polacrilex) ............. 39 NICOTROL.......................... 39 NICOTROL NS.................... 39 nifedipine.............................. 18 NIGHTTIME SLEEP AID (DIPHEN)......................... 35 NITRO-BID ......................... 18 nitrofurantoin........................ 10 nitrofurantoin macrocrystal .. 10 nitrofurantoin monohyd/mcryst .................................. 10 NITROSTAT........................ 18 nohist-dm.............................. 24 non-aspirin jr strength ............ 4 norethindrone (contraceptive) .......................................... 22 nortriptyline .......................... 35 NOVOLIN 70/30 .................. 15 NOVOLIN N ........................ 15 NOVOLIN R ........................ 15 NOVOLOG .......................... 15 NOVOLOG FLEXPEN ........ 15 NOVOLOG MIX 70-30 ....... 15 NOVOLOG MIX 70-30 FLEXPEN ........................ 15 NOVOLOG PENFILL ......... 15 NUTRISOURCE FIBER ...... 30 NUVARING ......................... 23 nystatin ................................. 12 nystatin-triamcinolone .......... 12 NYSTOP .............................. 12 O O-CAL FA ............................ 33 OCELLA .............................. 23 ofloxacin ............................... 10 OGESTREL (28) .................. 23 olopatadine ........................... 13 omeprazole ........................... 30 ondansetron .......................... 30 ondansetron hcl..................... 30 ORALONE ........................... 39 oxcarbazepine ....................... 21 oxybutynin chloride .............. 40 oxycodone-acetaminophen ..... 4 P pantoprazole ......................... 30 paromomycin ........................ 15 paroxetine hcl ....................... 35 PCE....................................... 10 peak air peak flow meter ...... 33 PEDIA RELIEF COUGHCOLD ............................... 24 PEDIA-LAX STOOL SOFTENER ...................... 30 PEDIATRIC ELECTROLYTE .......................................... 28 PEDIATRIC ENEMA .......... 31 pediatric multivitamin .......... 41 peg 3350-electrolytes ........... 31 penicillin v potassium........... 10 pentoxifylline........................ 17 permethrin ............................ 38 phenazopyridine ..................... 4 phenobarbital .................. 35, 36 phenohytro ............................ 31 PHENYLEPHRINE HCL .... 26 phenylhistine dh.................... 24 phenytoin .............................. 21 phenytoin sodium extended ..21 PHOSPHOLINE IODIDE .... 26 pilocarpine hcl ...................... 26 pink bismuth ......................... 31 PINK BISMUTH .................. 31 pioglitazone .......................... 15 piroxicam ................................ 5 pnv 29-1 ................................ 33 podofilox............................... 38 polyethylene glycol 3350 ..... 31 polymyxin b sulf-trimethoprim .......................................... 10 polyvinyl alcohol .................. 27 poly-vi-sol............................. 41 POLY-VITA ......................... 41 POLY-VITAMIN WITH IRON ................................ 41 potassium chloride ................ 28 povidone-iodine .................... 38 pramipexole .......................... 16 pravastatin............................. 20 prazosin................................. 20 PRED MILD ......................... 27 prednicarbate ........................ 38 prednisolone ......................... 32 prednisolone acetate ............. 27 prednisolone sodium phosphate .................................... 27, 33 prednisone............................. 33 PREDNISONE INTENSOL. 33 PREMARIN ......................... 33 PREMPHASE....................... 33 PREMPRO ........................... 33 prenatal complete.................. 33 PRENATAL LOW IRON .... 33 prenatal plus.......................... 34 PRENATAL PLUS (CALCIUM CARB) ......... 34 prenatal vit#96-ferrous fum-fa .......................................... 34 PRENATAL VITAMIN ....... 34 PRENATAL VITAMIN WITH MINERALS ...................... 34 PRETAB ............................... 34 PREVACID 24HR................ 31 PRILOSEC OTC .................. 31 primaquine ............................ 15 primidone .............................. 21 47 PRIMSOL............................. 10 probenecid .............................. 5 prochlorperazine ................... 31 prochlorperazine maleate ..... 31 PROCTOFOAM HC ............ 31 PROCTO-PAK ..................... 31 proctosol hc .......................... 31 promethazine ............ 13, 14, 31 PROMETHAZINE VC ........ 13 PROMETHAZINE VCCODEINE ........................ 24 promethazine-codeine .......... 24 promethazine-dm .................. 24 PROMETHEGAN................ 31 propafenone .......................... 18 proparacaine ......................... 27 propranolol ........................... 20 propylthiouracil .................... 39 pseudoephedrine hcl ............. 24 PULMICORT FLEXHALER 6 PURE AND GENTLE EYE. 27 pyrazinamide ........................ 10 PYRETHRIN LICE TREATMENT M ............. 38 pyridostigmine bromide ....... 17 pyridoxine (vitamin b6)........ 41 Q Q-PAP .................................... 4 QUASENSE ......................... 23 quinidine gluconate .............. 18 QVAR..................................... 6 R rabeprazole ........................... 31 ranitidine hcl ......................... 31 REESE'S PINWORM MEDICINE ...................... 15 REFRESH LACRI-LUBE.... 27 REFRESH P.M. ................... 27 RENAGEL ........................... 28 rena-vite rx ........................... 41 RENVELA ........................... 28 RHEUMATREX .................... 5 RID COMPLETE LICE ELIM KIT ................................... 38 RIDAURA.............................. 5 rifabutin ................................ 10 RIFAMATE ......................... 10 rifampin ................................ 10 riluzole.................................. 21 RITIFED............................... 13 48 rivastigmine tartrate .............. 17 rizatriptan................................ 4 ROBITUSSIN PEDIATRIC 24 ropinirole .............................. 16 RYNEX PSE ........................ 13 S saline nasal ........................... 27 salsalate .................................. 5 SAVELLA ............................ 40 SCALPICIN ANTI-ITCH .... 38 SCOT-TUSSIN DM ............. 24 SCOT-TUSSIN SENIOR ..... 24 selegiline hcl ......................... 16 selenium sulfide.................... 38 SELSUN BLUE ................... 38 SELSUN BLUE WITH MENTHOL ...................... 38 SENNA................................. 31 SENNA LAX ....................... 31 SENNA PLUS ...................... 31 SENSIPAR ........................... 40 SEREVENT DISKUS ............ 6 sertraline ............................... 35 sf 5000 plus .......................... 28 silver sulfadiazine ................. 10 simethicone........................... 31 SIMETHICONE ................... 31 simvastatin ............................ 20 sodium bicarbonate............... 31 sodium chloride .............. 27, 40 sodium chloride 0.9 % .......... 28 sodium citrate-citric acid ...... 28 sodium fluoride..................... 28 sodium polystyrene sulfonate .......................................... 28 sotalol ................................... 20 spironolactone ...................... 25 spironolacton-hydrochlorothiaz .......................................... 25 SRONYX.............................. 23 SSKI ..................................... 28 STERILE SALINE ............... 38 stool softener ........................ 31 STRATTERA ....................... 35 sucralfate .............................. 31 sulfacetamide sodium ........... 10 sulfacetamide-prednisolone .. 10 sulfadiazine........................... 10 sulfamethoxazole-trimethoprim .......................................... 11 sulfasalazine ......................... 31 sulindac ................................... 5 sumatriptan succinate ............. 4 SUPHEDRIN ........................ 24 SYSTANE NIGHTTIME ..... 27 T TABLOID............................. 16 TAMIFLU ............................ 17 tamoxifen .............................. 16 tamsulosin ............................. 40 TAZTIA XT ......................... 18 TEARS NATURALE FORTE .......................................... 27 TEGRETOL XR ................... 21 temazepam ............................ 36 terazosin ................................ 20 terbinafine hcl ....................... 12 terbutaline ............................... 6 terconazole ............................ 12 testosterone cypionate .......... 33 tetracycline ........................... 11 THEO-24 ................................ 6 theophylline ............................ 6 THERA M PLUS (FERROUS FUMARAT) ..................... 41 THERA VITAMIN .............. 41 THERAPEUTIC-M VITAMIN/MINERALS ...41 THEREMS-M....................... 41 thiamine mononitrate (vit b1) .......................................... 41 TILIA FE .............................. 23 timolol maleate ..................... 27 tizanidine .............................. 33 TOBRADEX ........................ 11 tobramycin ............................ 11 tobramycin-dexamethasone .. 11 TOBREX .............................. 11 tolnaftate ............................... 12 tolterodine ............................. 40 topiramate ............................. 21 tramadol .................................. 4 TRANSDERM-SCOP .......... 31 TRAVATAN Z ..................... 27 travoprost (benzalkonium)....27 trazodone .............................. 35 tretinoin................................. 38 tretinoin (chemotherapy) ...... 16 triamcinolone acetonide........38 triamterene-hydrochlorothiazid .......................................... 25 trianex ................................... 38 triazolam ............................... 36 trifluridine............................. 17 TRILYTE WITH FLAVOR PACKETS ........................ 32 trimethobenzamide ............... 32 trimethoprim ......................... 11 TRINESSA (28) ................... 23 TRIPLE ANTIBIOTIC ........ 11 TRIPLE ANTIBIOTIC (PRAM) EXTRA.............. 11 TRI-VIT WITH FLUORIDE AND IRON ...................... 41 TRI-VITAMIN ..................... 41 TRI-VITAMIN WITH FLUORIDE ...................... 41 TRIVORA (28) .................... 23 tropicamide ........................... 27 TUDORZA PRESSAIR ......... 7 TUSSIN DM ........................ 24 U ULESFIA ............................. 38 urea ....................................... 38 ursodiol ................................. 32 V VAGINAL CONTRACEPTIVE FILM .......................................... 23 VAGINAL CONTRACEPTIVE FOAM .......................................... 23 valacyclovir .......................... 17 valproic acid ......................... 21 valproic acid (as sodium salt) .......................................... 21 valsartan................................ 20 valsartan-hydrochlorothiazide .......................................... 20 venlafaxine ........................... 35 VENTOLIN HFA ................... 7 verapamil ........................ 18, 19 VIGAMOX ........................... 11 vinate m ................................ 34 VITAMIN B-1 ...................... 41 vitamin b-12 ......................... 41 VITAMIN B-6 ...................... 41 VITAMIN D3 ................. 41, 42 VITAMINS AND MINERALS ..........................................42 VOLTAREN.........................38 W WAL-ACT D COLD AND ALLERGY .......................13 WAL-PHED .........................13 warfarin.................................11 wart remover .........................38 WART REMOVER ..............38 WOMEN'S DAILY FORMULA.......................42 X XARELTO ........................... 11 xulane ................................... 23 Z ZADITOR............................. 14 ZARXIO ............................... 21 ZENCHENT FE ................... 23 zinc gluconate ....................... 28 zinc oxide.............................. 38 zolpidem ............................... 36 zonisamide ............................ 21 ZOVIA 1/35E (28) ............... 23 ZOVIA 1/50E (28) ............... 23 49
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