Alpha Constellation Health (HMO SNP)
2014 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary ID/ ID Formulario: 14082 Version 13
This formulary was updated on July 2014. For more recent information or other questions, please
contact us, Constellation Health at 1-866-714-0724 or, for TTY users, 1-866-805-7777, Monday
through Sunday, from 8:00 a.m. to 8:00 p.m., or visit www.constellationhealth.com.
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Constellation Health.
When it refers to “plan” or “our plan,” it means Alpha Constellation Health (HMO C-SNP).
This document includes a list of the drugs (formulary) for our plan which is current as of July
2014. For an updated formulary, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or copayments/coinsurance may change on January
1, 2015.
What is the Constellation Health Formulary?
A formulary is a list of covered drugs selected by the plan in consultation with a team of health
care providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. The plan will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled at the plan’s network pharmacy, and
other plan rules are followed. For more information on how to fill your prescriptions, please
review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning of
the year, we will not discontinue or reduce coverage of the drug during the 2014 coverage year
except when a new, less expensive generic drug becomes available or when new adverse
information about the safety or effectiveness of a drug is released. Other types of formulary
changes, such as removing a drug from our formulary, will not affect members who are currently
taking the drug. It will remain available at the same cost-sharing for those members taking it for
Page 1 of 83
the remainder of the coverage year. We feel it is important that you have continued access for
the remainder of the coverage year to the formulary drugs that were available when you chose
our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step
therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected
members of the change at least 60 days before the change becomes effective, or at the time the
member requests a refill of the drug, at which time the member will receive a 60-day supply of
the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the
drug’s manufacturer removes the drug from the market, we will immediately remove the drug
from our formulary and provide notice to members who take the drug. The enclosed formulary
is current as of July 2014. To get updated information about the drugs covered by the plan, please
contact us. Our contact information appears on the front and back cover pages.
Most of the changes in drug coverage happen at the beginning of each year (January 1). However,
during the year, the plan might make many kinds of changes to the Drug List. We can:

Add or remove drugs from the Drug List.

Move a drug to a higher or lower cost-sharing tier.

Add or remove a restriction on coverage for a drug

Replace a brand name drug with a generic drug
In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug
List. The plan will send you a notice to tell you if there is a change in coverage for drugs you are
taking. Normally, we will let you know at least 60 days ahead of time. However, an updated
formulary will be posted at www.constellationhealth.com or you may also contact Member
Services. The contact numbers are in the front and back page of this document.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 7. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs
used to treat a heart condition are listed under the category, Cardiovascular. If you know what
your drug is used for, look for the category name in the list that begins on page 64. Then look
under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index
that begins on page 70. The Index provides an alphabetical list of all of the drugs included in
this document. Both brand name drugs and generic drugs are listed in the Index. Look in the
Index and find your drug. Next to your drug, you will see the page number where you can
find coverage information. Turn to the page listed in the Index and find the name of your
drug in the first column of the list.
Page 2 of 83
What are generic drugs?
El plan covers both brand name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the brand name drug. Generally, generic drugs
cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:

Prior Authorization: The plan requires you or your physician to get prior authorization
for certain drugs. This means that you will need to get approval from the plan before you
fill your prescriptions. If you don’t get approval, the plan may not cover the drug.

Quantity Limits: For certain drugs, the plan limits the amount of the drug that we will
cover. For example, the plan provides 30 per prescription for LYRICA. This may be in
addition to a standard one-month or three-month supply.
You can find out if your drug has any additional requirements or limits by looking in the formulary
that begins on page 7. You can also get more information about the restrictions applied to specific
covered drugs by visiting our Web site. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You can ask the plan to make an exception to these restrictions or limits or for a list of other,
similar drugs that may treat your health condition. See the section, “How do I request an exception
to the Alpha Constellation Health formulary?” on page 4 for information about how to request an
exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact
Member Services and ask if your drug is covered.
If you learn that the plan does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by the plan.
When you receive the list, show it to your doctor and ask him or her to prescribe a similar
drug that is covered by the plan.

You can ask the plan to make an exception and cover your drug. See below for information
about how to request an exception.
Page 3 of 83
How do I request an exception to the Alpha Constellation Health Formulary?
You can ask the plan to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug
will be covered at a pre-determined cost-sharing level, and you would not be able to ask
us to provide the drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not
on the specialty tier. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for
certain drugs, the plan limits the amount of the drug that we will cover. If your drug has
a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, the plan will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions
would not be as effective in treating your condition and/or would cause you to have adverse
medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or
utilization restriction exception. When you request a formulary, tiering or utilization
restriction exception you should submit a statement from your prescriber or physician
supporting your request. Generally, we must make our decision within 72 hours of getting your
prescriber’s supporting statement. You can request an expedited (fast) exception if you or your
doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision.
If your request to expedite is granted, we must give you a decision no later than 24 hours after we
get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For
example, you may need a prior authorization from us before you can fill your prescription. You
should talk to your doctor to decide if you should switch to an appropriate drug that we cover or
request a formulary exception so that we will cover the drug you take. While you talk to your
doctor to determine the right course of action for you, we may cover your drug in certain cases
during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited,
we will cover a temporary 30-day supply (unless you have a prescription written for fewer days)
when you go to a network pharmacy. After your first 30-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until
we have provided you with 91-day transition supply, consistent with dispensing increment,
Page 4 of 83
(unless you have a prescription written for fewer days). We will cover more than one refill of
these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on
our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of
membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have
a prescription for fewer days) while you pursue a formulary exception.
For more information
For more detailed information about your plan’s prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about the plan, please contact us. Our contact information, along with the
date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1877-486-2048. Or, visit www.medicare.gov.
Legend
In the Table shown on page 7 you will notice that cost sharing tiers are assigned to the drugs.
The following is a description of the 5 cost-sharing tiers:
• Tier 1 – Preferred Generics
• Tier 2 – Non-Preferred Generics
• Tier 3 – Non-Preferred Brand
• Tier 4- Non-Preferred Brand
• Tier 5 - Specialty
Also, there are special requirements/ limitations on the drugs. They are abbreviated as follow:
PA: We may require you or your doctor to request a pre-authorization from the plan for certain
prescription drugs before obtaining them.
QL: We may limit the quantity amount of the covered drug for a specific period of time.
MO: We provide coverage of this prescription drug through the mail order program. For certain
prescription drugs, you may use the mail order prescription drugs from the plan’s network. You
may order at least a 90 days’ supply.
Page 5 of 83
CY 2014
Alpha Constellation Health (HMO SNP)
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
ANALGESICS (ANALGÉSICOS)
Nonsteroidal Anti-inflammatory Drugs (Anti-inflamatorios No Esteroidales)
CELEBREX caps 100 mg, 200 mg, 400 mg, 50 mg
4
diclofenac potassium tabs 50 mg
diclofenac sodium dr tabs 25 mg, 50 mg, 75 mg
diclofenac sodium sr tabs 24h 100 mg
etodolac caps 200 mg, 300 mg, tabs 400 mg, 500 mg
etodolac sr tabs 24h 400 mg, 500 mg, 600 mg
flurbiprofen tabs 100 mg, 50 mg
ibuprofen tabs 400 mg, 600 mg, 800 mg
indomethacin caps 25 mg, 50 mg
2
2
2
2
2
2
2
2
CATAFLAM
VOLTAREN
VOLTAREN XR
LODINE
LODINE XL
ANSAID
MOTRIN
INDOCIN
indomethacin cr caps 75 mg
2
INDOCIN
ketorolac inj 15 mg/ml, 30 mg/ml
meloxicam tabs 15 mg, 7.5 mg
2
2
TORADOL
MOBIC
nabumetone tabs 500 mg, 750 mg
naproxen susp 125 mg/5ml, tabs 250 mg, 375 mg, 500 mg
naproxen ec tabs 375 mg, 500 mg
naproxen sodium tabs 275 mg, 550 mg
piroxicam caps 10 mg, 20 mg
sulindac tabs 150 mg, 200 mg
2
2
2
2
2
2
RELAFEN
NAPROSYN
NAPROSYN EC
ANAPROX
FELDENE
CLINORIL
Opioid Analgesics, Long-acting (Analgésicos Opiodes, Larga Duración)
fentanyl 72h patch 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50
2
DURAGESIC
mcg/hr, 75 mcg/hr
morphine sulfate sr tabs 12h 200 mg
2
MS CONTIN
morphine sulfate sr tabs 12h 100 mg, 15 mg, 30 mg, 60 mg
2
OXYCONTIN sr tabs 12h 80 mg
3
MS CONTIN
MO/R QL
[60/30]
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R QL
[120/30]
MO/R QL
[60/30]
MO/R
MO/R QL
[30/30]
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R QL
[15/30]
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R QL
[60/30]
Page 6 of 83
Drug (Medicamento)
OXYCONTIN sr tabs 12h 10 mg, 15 mg, 20 mg, 30 mg,
40 mg, 60 mg
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
3
Instruction
(Instrucción)
MO/R QL
[90/30]
Opioid Analgesics, Short-acting (Analgésicos Opiodes, Corta Duración)
acetaminophen & codeine soln 120-12 mg/5ml
2
TYLENOL/
CODEINE
acetaminophen & codeine tabs 300-60 mg
2
TYLENOL/
CODEINE
acetaminophen & codeine tabs 300-15 mg, 300-30 mg
2
TYLENOL/
CODEINE
acetaminophen & hydrocodone soln 325-7.5 mg/15ml
2
HYCET
acetaminophen & hydrocodone tabs 300-10 mg, 300-5 mg, 2
NORCO, XODOL
300-7.5 mg, 325-10 mg, 325-5 mg, 325-7.5 mg
acetaminophen & oxycodone tabs 325-10 mg
2
PERCOCET
acetaminophen & oxycodone tabs 325-7.5 mg
2
PERCOCET
acetaminophen & oxycodone tabs 325-2.5 mg, 325-5 mg
2
PERCOCET
acetaminophen & tramadol tabs 325-37.5 mg
2
ULTRACET
butorphanol inj 1 mg/ml, 2 mg/ml
butorphanol nasal spray 10 mg/ml
DURAMORPH inj 0.5 mg/ml, 1 mg/ml
fentanyl citrate lollipop 1200 mcg, 1600 mcg, 200 mcg,
400 mcg, 600 mcg, 800 mcg
hydromorphone inj 10 mg/ml
LAZANDA nasal spray 100 mcg/act, 400 mcg/act
meperidine inj 100 mg/ml, 25 mg/ml, 50 mg/ml
morphine sulfate soln 10 mg/5ml, 20 mg/5ml, 20 mg/ml, inj
0.5 mg/ml, 1 mg/ml
morphine sulfate tabs 15 mg, 30 mg
2
4
2
2
STADOL
STADOL
ACTIQ
2
4
2
2
DEMEROL
MORPHINE
2
DURAMORPH
oxycodone caps 5 mg, tabs 15 mg, 30 mg, 5 mg
2
tramadol tabs 50 mg
2
OXYIR,
ROXICODONE
ULTRAM
MO/R
MO/R QL
[180/30]
MO/R QL
[360/30]
MO/R
MO/R QL
[180/30]
MO/R QL
[180/30]
MO/R QL
[240/30]
MO/R QL
[360/30]
MO/R QL
[240/30]
MO/R
MO/R
MO/R
MO/R QL
[120/30] PA
MO/R
MO/R PA
MO/R PA^
MO/R
MO/R QL
[120/30]
MO/R QL
[180/30]
MO/R QL
[240/30]
Page 7 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
ANESTHETICS (ANESTÉSICOS)
Local Anesthetics (Anestésico Local)
lidocaine soln 2 %, topical gel 2 %, oint 5 %
2
lidocaine inj 0.5 %, 1 %
lidocaine patch 5%
2
2
XYLOCAINE
VISCOUS
XYLOCAINE
LIDODERM
lidocaine & prilocaine topical cream 2.5-2.5 %
2
EMLA
MO/R
MO/R PA^
MO/R QL
[90/30]
MO/R
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (TRATAMIENTO DE ABUSO DE
SUSTANCIAS/CONTRA LA ADDICIÓN)
Alcohol Deterrents/Anti-craving (Disuasivos de Alcohol/Anti-ansiedad)
acamprosate dr tabs 333 mg
2
CAMPRAL
disulfiram tabs 250 mg, 500 mg
2
ANTABUSE
MO/R
MO/R
Opioid Antagonist (Antagonista de Opioides)
buprenorphine sl tabs 2 mg, 8 mg
buprenorphine & naloxone sl tabs 2-0.5 mg, 8-2 mg
naloxone inj 1 mg/ml
naltrexone tabs 50 mg
SUBOXONE sl film 12-3 mg, 2-0.5 mg, 4-1 mg, 8-2 mg,
ZUBSOLV sl tab 1.4-0.36 mg, 5.7-1.4 mg
2
2
2
2
4
4
MO/R PA
MO/R PA
MO/R PA^
MO/R
MO/R PA
MO/R PA
Smoking Cessation Agents (Cesación de Fumar)
BUPROBAN sr tabs 12h 150 mg
bupropion sr tabs 12h 150 mg
2
2
CHANTIX pack 0.5 & 1 mg, tabs 0.5 mg, 1 mg
NICOTROL inhal 10 mg, nasal spray 10 mg/ml
4
4
SUBUTEX
SUBOXONE
NARCAN
REVIA
BUPROBAN,
ZYBAN SR
MO/R
MO/R
MO/R
MO/R
ANTI-INFLAMMATORY AGENTS (ANTI-INFLAMATORIOS)
Glucocorticoids (Glucocorticoides)
A-HYDROCORT inj 100 mg
budesonide sr caps 24h 3 mg
cortisone acetate tabs 25 mg
DEPO-MEDROL inj 20 mg/ml
2
2
2
4
ENTOCORT
CORTONE
MO/R
MO/R
MO/R
MO/R PA^
Page 8 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
dexamethasone conc 1 mg/ml
dexamethasone elixir 0.5 mg/5ml, tabs 0.5 mg, 0.75 mg,
1.5 mg, 4 mg, 6 mg
dexamethasone tabs 1 mg, 2 mg
dexamethasone sodium phosphate inj 4 mg/ml, 10 mg/ml
hydrocortisone tabs 10 mg, 20 mg, 5 mg
hydrocortisone sodium succinate inj 100 mg
2
2
DEXAMETHASONE
DEXAMETHASONE
MO/R
MO/R
4
2
2
2
MO/R
MO/R
MO/R
MO/R
methylprednisolone pack 4 mg, tabs 16 mg, 32 mg, 4 mg, 8
mg
methylprednisolone acetate inj 40 mg/ml, 80 mg/ml
methylprednisolone sodium succinate inj 125 mg, 40 mg
MILLIPRED tabs 5 mg
prednisolone tabs 5 mg
prednisolone sodium phosphate soln 15 mg/5ml, 6.7
mg/5ml (5 mg/5ml base)
prednisone tabs 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg
prednisone tabs 50 mg
SOLU-CORTEF inj 250 mg
2
DEXAMETHASONE
DEXAMETHASONE
CORTEF
A-HYDROCORT,
SOLU-CORTEF
MEDROL
DEPO-MEDROL
SOLU-MEDROL
MO/R PA^
MO/R PA^
MO/R
MO/R
MO/R
2
2
2
2
2
2
4
4
MILLIPRED
ORAPRED,
PEDIAPRED
PREDNISONE
PREDNISONE
Nonsteroidal Anti-inflammatory Drugs (Anti-inflamatorios No Esteroidales)
CELEBREX caps 100 mg, 200 mg, 400 mg, 50 mg
4
diclofenac potassium tabs 50 mg
diclofenac sodium dr tabs 25 mg, 50 mg, 75 mg
diclofenac sodium sr tabs 24h 100 mg
etodolac caps 200 mg, 300 mg, tabs 400 mg, 500 mg
etodolac sr tabs 24h 400 mg, 500 mg, 600 mg
flurbiprofen tabs 100 mg, 50 mg
ibuprofen tabs 400 mg, 600 mg, 800 mg
indomethacin caps 25 mg, 50 mg
2
2
2
2
2
2
2
2
CATAFLAM
VOLTAREN
VOLTAREN XR
LODINE
LODINE XL
ANSAID
MOTRIN
INDOCIN
indomethacin cr caps 75 mg
2
INDOCIN
ketorolac inj 15 mg/ml, 30 mg/ml
meloxicam tabs 15 mg, 7.5 mg
2
2
TORADOL
MOBIC
nabumetone tabs 500 mg, 750 mg
naproxen susp 125 mg/5ml, tabs 250 mg, 375 mg, 500 mg
naproxen ec tabs 375 mg, 500 mg
naproxen sodium tabs 275 mg, 550 mg
2
2
2
2
RELAFEN
NAPROSYN
NAPROSYN EC
ANAPROX
MO/R
MO/R
MO/R
MO/R
MO/R QL
[60/30]
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R QL
[120/30]
MO/R QL
[60/30]
MO/R
MO/R QL
[30/30]
MO/R
MO/R
MO/R
MO/R
Page 9 of 83
Drug (Medicamento)
piroxicam caps 10 mg, 20 mg
sulindac tabs 150 mg, 200 mg
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
2
2
FELDENE
CLINORIL
MO/R
MO/R
Aminoglycosides (Aminoglicósidos)
amikacin inj 250 mg/ml, 50 mg/ml
dexamethasone & tobramycin ophth susp 0.1-0.3 %
GENTAK ophth oint 0.3%
gentamicin ophth oint 0.3 %, soln 0.3 %
gentamicin topical cream 0.1 %, oint 0.1 %
gentamicin inj 10 mg/ml, 40 mg/ml
neomycin tabs 500 mg
paromomycin caps 250 mg
streptomycin inj 1 gm
tobramycin neb 300 mg/5ml
TOBI PODHALER caps 28 mg
tobramycin ophth soln 0.3 %
tobramycin inj 10 mg/ml, 40 mg/ml
2
2
2
2
2
2
2
2
4
5
5
2
2
AMIKIN
TOBRADEX
MO/R PA^
MO/R
MO/R
MO/R
MO/R
MO/R PA^
MO/R
MO/R
MO/R PA^
PA^
MO/R PA
MO/R
MO/R PA^
Antibacterials, Other (Antibacterianos, Otros)
bacitracin ophth oint 500 u/gm
bacitracin & polymixin & neomycin & hc ophth oint 1 %
chloramphenicol inj 1 gm
4
2
4
ANTIBACTERIALS (ANTIBACTERIANOS)
CLEOCIN vaginal supp 100 mg
clindamycin hcl caps 150 mg, 300 mg, 75 mg
clindamycin phosphate topical soln 1 %, vaginal cream 2
%
clindamycin phosphate inj 600 mg/4ml
colistimethate inj 150 mg
CUBICIN inj 500 mg
hydrocortisone & neomycin & polymyxin b otic soln 1 %,
susp 3.5 mg/ml-10000 unit/ml-1%
MACRODANTIN caps 25 mg
methenamine hippurate tabs 1 gm
metronidazole tabs 250 mg, 500 mg, topical cream 0.75 %,
gel 0.75 %, lot 0.75 %, vaginal gel 0.75 %
4
2
2
mupirocin topical oint 2 %
2
2
2
4
2
4
2
2
GARAMYCIN
GARAMYCIN
GARAMYCIN
MYCIFRADIN
HUMATIN
STREPTOMYCIN
TOBI
TOBREX
TOBRAMYCIN
CORTISPORIN
CHLORAMPHENIC
OL
CLEOCIN
CLEOCIN
CLEOCIN
COLY-MYCIN-M
CORTISPORIN /
PEDIOTIC
HIPREX
FLAGYL,
METROCREAM,
METROGEL,
METROLOTION
BACTROBAN
MO/R
MO/R
MO/R PA^
MO/R
MO/R
MO/R
MO/R PA^
MO/R PA^
MO/R PA^
MO/R
MO/R
MO/R
MO/R
MO/R
Page 10 of 83
Drug (Medicamento)
neomycin & bacitracin & polymyxin ophth oint 400u-5mg10000u/gm
neomycin & polymyxin & dexamethasone ophth oint 0.1 %,
susp 0.1 %
neomycin & polymyxin & hydrocortisone ophth susp
neomycin & polymyxin & gramicidin ophth soln
nitrofurantoin macrocrystalline caps 50 mg
nitrofurantoin monohydrate macrocrystals caps 100 mg
polymyxin b & trimethoprim ophth soln 10000 u/ml-0.1 %
SILVER SULFADIAZINE topical cream 1 %
trimethoprim tabs 100 mg
TYGACIL inj 50 mg
VANCOCIN caps 125 mg, 250 mg
vancomycin caps 125 mg, 250 mg
vancomycin inj 1000 mg, 500 mg
ZYVOX susp 100 mg/5ml, tabs 600 mg
ZYVOX inj 2 mg/ml
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
2
NEOSPORIN
MO/R
2
MAXITROL
MO/R
4
2
2
2
2
2
2
4
5
2
2
5
5
CORTISPORIN
NEOSPORIN
MACRODANTIN
MACROBID
POLYTRIM
SILVADENE
PROLOPRIM
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R PA^
MO/R
MO/R
MO/R PA^
MO/R PA
MO/R PA#
Beta-lactam, Cephalosporins (Cefalosporinas, Beta-lactámicas)
cefaclor caps 250 mg, 500 mg
2
cefaclor sr tabs 12h 500 mg
4
cefadroxil caps 500 mg, susp 250 mg/5ml, 500 mg/5ml,
2
tabs 1 gm
cefazolin inj 1 gm, 500 mg
2
cefdinir caps 300 mg, susp 125 mg/5ml, 250 mg/5ml
2
cefepime inj 1 gm, 2 gm
2
cefpodoxime susp 100 mg/5ml, 50 mg/5ml, tabs 100 mg,
2
200 mg
cefprozil susp 125 mg/5ml, 250 mg/5ml, tabs 250 mg, 500
2
mg
ceftazidime inj 1gm, 2gm
2
CEFTIN susp 250 mg/5ml
4
ceftriaxone inj 250 mg, 500 mg, 1gm, 2 gm
2
cefuroxime axetil tabs 250 mg, 500 mg
2
cefuroxime sodium inj 1.5 gm, 750 mg
2
cephalexin caps 250 mg, 500 mg, susp 125 mg/5ml, 250
2
mg/5ml
FORTAZ inj 2gm
4
SUPRAX susp 100 mg/5ml, 200 mg/5ml, 500 mg/5ml,
4
tabs 400 mg
VANCOCIN
VANCOMYCIN
CECLOR
CECLOR
DURICEF
MO/R
MO/R
MO/R
CEFAZOLIN
OMNICEF
MAXIPIME
VANTIN
MO/R PA^
MO/R
MO/R PA^
MO/R
CEFZIL
MO/R
FORTAZ
MO/R PA^
MO/R
MO/R PA^
MO/R
MO/R PA^
MO/R
ROCEPHIN
CEFTIN
ZINACEF
KEFLEX
MO/R PA^
MO/R
Page 11 of 83
Drug (Medicamento)
Beta-lactam, Other (Beta-lactámicos, Otros)
imipenem & cilastatin inj 250 mg, 500 mg
INVANZ inj 1 gm
meropenem inj 500 mg
Beta-lactam, Penicillins (Penicilinas, Beta-lactámicas)
amoxicillin caps 250 mg, 500 mg, chew tab 125 mg, 250
mg, susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400
mg/5ml, tabs 500 mg, 875 mg
amoxicillin & k clavulanate chew tab 200-28.5 mg, 400-57
mg, susp 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57
mg/5ml, 600-42.9 mg/5ml, tabs 250-125 mg, 500-125 mg,
875-125 mg
amoxicillin & k clavulanate sr tabs 12h 1000-65.5 mg
ampicillin caps 250 mg, 500 mg, susp 125 mg/5ml, 250
mg/5ml
ampicillin sodium inj 1 gm
ampicillin sodium inj 125 mg
BICILLIN C-R inj 1200000 u/2ml, 900000-300000 u/ml
BICILLIN L-A inj 1200000 u/2ml, 2400000 u/4ml,
600000 u/ml
dicloxacillin caps 250 mg, 500 mg
nafcillin inj 1 gm
oxacillin inj 1 gm
penicillin g procaine inj 600000 u/ml
penicillin v potassium soln 125 mg/5ml, 250 mg/5ml, tabs
250 mg, 500 mg
piperacillin & tazobactam inj 3-0.375 gm, 4-0.5 gm
TIMENTIN inj 3.1 gm
Macrolides (Macrólidos)
azithromycin susp 100 mg/5ml, 200 mg/5ml, tabs 250 mg,
500 mg, 600 mg
clarithromycin susp 125 mg/5ml, 250 mg/5ml, tabs 250
mg, 500 mg
E.E.S. susp 200 mg/5ml
ERYPED susp 200 mg/5ml, 400 mg/5ml
erythromycin ophth oint 5 mg/gm
erythromycin topical gel 2 %
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
2
4
2
PRIMAXIN
MERREM
MO/R
MO/R PA^
MO/R PA^
2
AMOXIL
MO/R
2
AUGMENTIN
MO/R
2
2
AUGMENTIN XR
PRINCIPEN
MO/R
MO/R
2
AMPICILLIN
SODIUM
OMNIPEN-N
MO/R PA^
2
2
2
4
2
DICLOXACILLIN
NAFCILLIN
OXACILLIN
MO/R
MO/R PA^
MO/R PA^
MO/R
MO/R
2
4
ZOSYN
MO/R PA^
MO/R PA^
2
ZITHROMAX
MO/R
2
BIAXIN
MO/R
ILOTYCIN
ERYGEL
MO/R
MO/R
MO/R
MO/R
2
4
4
4
4
2
1
VEETIDS
MO/R PA^
MO/R
MO/R
Page 12 of 83
Drug (Medicamento)
erythromycin topical soln 2 %
erythromycin tabs 250 mg, 500 mg
erythromycin ethylsuccinate tabs 400 mg
ERYTHROMYCIN LACTOBIONATE inj 500 mg
ERYTHROCIN tabs 250 mg
Quinolones (Quinolonas)
CIPRO susp 250 mg/5ml, 500 mg/5ml
CIPRODEX otic susp 0.3-0.1 %
ciprofloxacin tabs 250 mg, 500 mg, 750 mg, ophth soln 0.3
%
ciprofloxacin inj 1 %
ciprofloxacin sr tabs 24h 1000 mg, 500 mg
levofloxacin tabs 250 mg, 500 mg, 750 mg
levofloxacin inj 25 mg/ml
MOXEZA ophth soln 0.5 %
moxifloxacin tabs 400 mg
ofloxacin tabs 200 mg, 300 mg, 400 mg, ophth soln 0.3 %,
otic 0.3 %
VIGAMOX ophth soln 0.5 %
Level
(Nivel)
2
4
2
4
2
4
3
2
2
2
2
2
3
1
2
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
T-STAT
MO/R
MO/R
MO/R
MO/R PA^
MO/R
E.E.S
MO/R
MO/R
MO/R
CIPRO
CIPRO
CIPRO XR
LEVAQUIN
LEVAQUIN
MO/R PA^
MO/R
MO/R
MO/R PA^
MO/R
MO/R
MO/R
AVELOX
FLOXIN
3
MO/R
4
2
2
BLEPH-10
VASOCIDIN
MO/R PA^
MO/R
MO/R
4
2
BACTRIM / SEPTRA
MO/R
MO/R
4
BACTRIM / SEPTRA
MO/R PA^
Tetracyclines (Tetraciclinas)
demeclocycline tabs 150 mg, 300 mg
doxycycline hyclate caps 100 mg, 50 mg, tabs 100 mg, 20
mg
2
2
MO/R
MO/R
minocycline caps 100 mg, 50 mg, 75 mg
2
DECLOMYCIN
VIBRAMYCIN,
VIBRATAB,
PERIOSTAT
MINOCIN
Sulfonamides (Sulfonamidas)
BACTRIM / SEPTRA inj 400-80 mg/5ml
sulfacetamide sodium ophth soln 10 %
sulfacetamide sodium & prednisolone ophth soln 10-0.23
%
sulfadiazine tabs 500 mg
sulfamethoxazole & trimethoprim susp 200-40 mg/5ml,
tabs 400-80 mg, 800-160 mg
sulfamethoxazole & trimethoprim inj 400-80 mg/5ml
MO/R
Page 13 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
ANTICONVULSANTS (ANTICONVULSIVANTES)
Anticonvulsants, Other (Anticonvulsivantes, Otros)
FYCOMPA tabs 2 mg, 4 mg, 8 mg, 10 mg, 12 mg
4
FYCOMPA tabs 6 mg
4
levetiracetam soln 100 mg/ml, sr tabs 24h 500 mg, 750 mg,
tabs 1000 mg, 250 mg, 500 mg, 750 mg
levetiracetam inj 500 mg/5ml
POTIGA tabs 200 mg, 300 mg, 400 mg, 50 mg
2
KEPPRA
2
4
KEPPRA
Calcium Channel Modifying Agents (Modificadores de Canales de Calcio)
CELONTIN caps 300 mg
4
ethosuximide caps 250 mg, soln 250 mg/5ml
2
ZARONTIN
LYRICA soln 20 mg/ml
3
LYRICA caps 225 mg, 300 mg
3
LYRICA caps 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75
mg
zonisamide caps 100 mg, 25 mg, 50 mg
3
2
ZONEGRAN
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R
MO/R PA^
MO/R
MO/R
MO/R
MO/R
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R
Gamma-aminobutyric Acid (GABA) Augmenting Agents (Aumentadores del Acido Gamma-Aminobutírico)
divalproex sprinkle caps 125 mg
2
DEPAKOTE
MO/R
divalproex dr tabs 125 mg, 250 mg, 500 mg
2
DEPAKOTE EC
MO/R
divalproex sr tabs 24h 250 mg, 500 mg
2
DEPAKOTE ER
MO/R
gabapentin caps 100 mg, 300 mg, 400 mg, soln 250
2
NEURONTIN
MO/R
mg/5ml
gabapentin tabs 600 mg, 800 mg
2
NEURONTIN
MO/R QL
[120/30]
GABITRIL tabs 12 mg, 16 mg, 2 mg, 4 mg
4
MO/R
primidone tabs 250 mg, 50 mg
2
MYSOLINE
MO/R
SABRIL powder 500 mg, tabs 500 mg
4
LA
tiagabine tabs 2 mg, 4 mg
2
GABITRIL
MO/R
valproate sodium syrup 250 mg/5ml
2
DEPAKENE
MO/R
valproate sodium inj 100 mg/ml
2
DEPACON
MO/R PA^
valproic acid caps 250 mg
2
DEPAKENE
MO/R
Glutamate Reducing Agents (Reductores de Glutamato)
felbamate susp 600 mg/5ml, tabs 400 mg, 600 mg
2
FELBATOL
MO/R
Page 14 of 83
Drug (Medicamento)
lamotrigine chew tab 25 mg, 5 mg, tabs 100 mg, 150 mg,
200 mg, 25 mg
lamotrigine sr tabs 24h 100 mg, 200 mg, 25 mg, 250 mg,
300 mg, 50 mg
topiramate sprinkle caps 15 mg, 25 mg, tabs 100 mg, 200
mg, 25 mg, 50 mg
TROKENDI sr caps 24h 25 mg, 50 mg, 100 mg, 200 mg
Sodium Channel Agents (Canales de Sodio)
APTIOM tabs 200 mg, 400 mg, 800mg
APTIOM tabs 600 mg
BANZEL susp 40 mg/ml, tabs 200 mg, 400 mg
carbamazepine chew tab 100 mg, susp 100 mg/5ml, tabs
200 mg
carbamazepine sr tabs 12h 200 mg, 400 mg
DILANTIN caps 100 mg, 30 mg, chew tab 50 mg, susp
125 mg/5ml
oxcarbazepine susp 300 mg/5ml, tabs 150 mg, 300 mg, 600
mg
OXTELLAR sr tabs 24h 150 mg, 300 mg, 600mg
PEGANONE tabs 250 mg
phenytoin caps 100 mg, chew tab 50 mg, susp 125 mg/5ml
phenytoin inj 50 mg/ml
TEGRETOL-XR tabs 12h 100 mg
TRILEPTAL susp 300 mg/5ml
VIMPAT soln 10 mg/ml, tabs 100 mg, 150 mg, 200 mg, 50
mg
VIMPAT inj 10 mg/ml
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
2
LAMICTAL
MO/R
2
LAMICTAL XR
MO/R
2
TOPAMAX
MO/R
4
MO/R
4
4
4
2
MO/R [30/30]
MO/R [60/30]
MO/R
MO/R
TEGRETOL
2
3
TEGRETOL XR
MO/R
MO/R
2
TRILEPTAL
MO/R
4
4
2
2
4
4
4
DILANTIN
DILANTIN
4
MO/R
MO/R
MO/R
MO/R PA^
MO/R
MO/R
MO/R
MO/R PA^
ANTIDEMENTIA AGENTS (ANTIDEMENCIA)
Cholinesterase Inhibitors (Inhibidores de Colinesterasa)
donepezil odt 10 mg, 5 mg, tabs 10 mg, 23 mg, 5 mg
2
ARICEPT
EXELON 24h patch 13.3 mg/24hr, 4.6 mg/24hr, 9.5
mg/24hr
galantamine soln 4 mg/ml
galantamine tabs 12 mg, 4 mg, 8 mg
3
2
2
RAZADYNE
RAZADYNE
galantamine sr caps 24h 16 mg, 24 mg, 8 mg
2
RAZADYNE ER
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R
MO/R QL
[60/30]
MO/R QL
[30/30]
Page 15 of 83
Drug (Medicamento)
rivastigmine caps 1.5 mg, 3 mg, 4.5 mg, 6 mg
Level
(Nivel)
2
Reference Name
(Nombre de
Referencia)
EXELON
N-methyl-D-aspartate (NMDA) Receptor Antagonist (Antagonista del Receptor NMDA)
NAMENDA soln 2 mg/ml, pack 5 & 10 mg
3
NAMENDA tabs 10 mg, 5 mg
3
NAMENDA XR caps 24h 7 mg, 14 mg, 21 mg, 28 mg
3
NAMENDA XR pack
3
Instruction
(Instrucción)
MO/R QL
[60/30]
MO/R
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R
ANTIDEPRESSANTS (ANTIDEPRESIVOS)
Antidepressants, Other (Antidepresivos, Otros)
ABILIFY soln 1 mg/ml
ABILIFY tabs 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg
3
3
ABILIFY odt 15 mg
3
ABILIFY odt 10 mg
3
ABILIFY inj 9.75 mg/1.3ml
ABILIFY MAINTENA inj 300 mg
bupropion tabs 100 mg, 75 mg
bupropion sr tabs 24h 150 mg, 300 mg
4
5
2
2
WELLBUTRIN
WELLBUTRIN XL
bupropion sr tabs 12h 100 mg, 150 mg, 200 mg
2
WELLBUTRIN SR
maprotiline tabs 25 mg, 50 mg, 75 mg
mirtazapine odt 15 mg, 30 mg, 45 mg, tabs 15 mg, 30 mg,
45 mg, 7.5 mg
nefazodone tabs 150 mg
4
2
REMERON
4
SERZONE
nefazodone tabs 100 mg, 250 mg, 50 mg
4
SERZONE
nefazodone tabs 200 mg
4
SERZONE
quetiapine tabs 300 mg, 400 mg
2
SEROQUEL
quetiapine tabs 100 mg, 200 mg, 25 mg, 50 mg
2
SEROQUEL
MO/R
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R PA^
MO/R PA^
MO/R
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R
MO/R QL
[30/30]
MO/R QL
[120/30]
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R QL
[60/30]
MO/R QL
[90/30]
Page 16 of 83
Drug (Medicamento)
Level
(Nivel)
SEROQUEL XR tabs 24h 150 mg, 200 mg, 50 mg
3
SEROQUEL XR tabs 24h 300 mg, 400 mg
3
trazodone tabs 100 mg, 150 mg, 300 mg, 50 mg
2
Reference Name
(Nombre de
Referencia)
DESYREL
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R
NARDIL
PARNATE
MO/R QL
[30/30]
MO/R
MO/R
MO/R
Monoamine Oxidase Inhibitors (Inhibidores de Monoamina Oxidasa)
EMSAM patch 12 mg/24hr, 6 mg/24hr, 9 mg/24hr
4
MARPLAN tabs 10 mg
phenelzine sulfate tabs 15 mg
tranylcypromine tabs 10 mg
4
2
2
Instruction
(Instrucción)
Serotonin/Norepinephrine Reuptake Inhibitors (Inhibidores de la Recaptación de Serotonina/ Norepinefrina)
BRINTELLIX tabs 5 mg, 10 mg, 20 mg
4
MO/R QL
[30/30]
citalopram soln 10 mg/5ml
2
CELEXA
MO/R
citalopram tabs 10 mg, 20 mg, 40 mg
2
CELEXA
MO/R QL
[30/30]
duloxetine caps 30 mg, 60 mg
2
CYMBALTA
MO/R QL
[60/30]
duloxetine caps 20 mg
2
CYMBALTA
MO/R QL
[90/30]
escitalopram soln 5 mg/5ml
2
LEXAPRO
MO/R
escitalopram tabs 10 mg, 20 mg, 5 mg
2
LEXAPRO
MO/R QL
[30/30]
FETZIMA sr caps 24h 20 mg, 40 mg, 80 mg, 120 mg
4
MO/R QL
[30/30]
FETZIMA pack
4
MO/R
fluoxetine soln 20 mg/5ml
2
PROZAC
MO/R
fluoxetine caps 10 mg, 20 mg, 40 mg
2
PROZAC
MO/R QL
[60/30]
fluvoxamine tabs 100 mg, 25 mg, 50 mg
2
LUVOX
MO/R QL
[90/30]
paroxetine hcl tabs 10 mg, 20 mg, 40 mg
2
PAXIL
MO/R QL
[30/30]
paroxetine hcl tabs 30 mg
2
PAXIL
MO/R QL
[60/30]
paroxetine hcl sr tabs 24h 12.5 mg, 25 mg
2
PAXIL CR
MO/R QL
[30/30]
paroxetine hcl sr tabs 24h 37.5 mg
2
PAXIL CR
MO/R QL
[60/30]
Page 17 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
PAXIL susp 10 mg/5ml
PRISTIQ SR tabs 24h 100 mg, 50 mg
4
4
sertraline conc 20 mg/ml
sertraline tabs 25 mg, 50 mg
2
2
ZOLOFT
ZOLOFT
sertraline tabs 100 mg
2
ZOLOFT
venlafaxine tabs 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg
venlafaxine sr caps 24h 150 mg, 37.5 mg
2
2
EFFEXOR
EFFEXOR XR
venlafaxine sr caps 24h 75 mg
2
EFFEXOR XR
VIIBRYD tabs 10 mg, 20 mg, 40 mg
4
Tricyclics (Tricíclicos)
amitriptyline tabs 10 mg, 100 mg, 150 mg, 25 mg, 50 mg,
75 mg
amoxapine tabs 100 mg, 150 mg, 25 mg, 50 mg
clomipramine caps 25 mg, 50 mg, 75 mg
desipramine tabs 10 mg, 100 mg, 150 mg, 25 mg, 50 mg,
75 mg
doxepin caps 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75
mg, conc 10 mg/ml
imipramine hcl tabs 10 mg, 25 mg, 50 mg
nortriptyline caps 10 mg, 25 mg, 50 mg, 75 mg
nortriptyline soln 10 mg/5ml
protriptyline tabs 10 mg, 5 mg
SURMONTIL caps 100 mg, 25 mg, 50 mg
trimipramine caps 100 mg, 25 mg, 50 mg
Instruction
(Instrucción)
MO/R
MO/R QL
[30/30]
MO/R
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R
MO/R QL
[30/30]
MO/R QL
[90/30]
MO/R QL
[30/30]
2
ELAVIL
MO/R
4
2
2
ANAFRANIL
NORPRAMIN
MO/R
MO/R
MO/R
2
ADAPIN
MO/R
2
2
1
2
4
2
TOFRANIL
PAMELOR
PAMELOR
VIVACTIL
SURMONTIL
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
2
THORAZINE
MO/R
4
2
2
2
THORAZINE
BENADRYL
ANTIVERT
REGLAN
MO/R
MO/R
MO/R
MO/R
ANTIEMETICS (ANTIEMÉTICOS)
Antiemetics (Antieméticos)
chlorpromazine tabs 10 mg, 100 mg, 200 mg, 25 mg, 50
mg
chlorpromazine inj 25 mg/ml
diphenhydramine inj 50 mg/ml
meclizine tabs 12.5 mg, 25 mg
metoclopramide soln 5 mg/5ml, tabs 10 mg, 5 mg
Page 18 of 83
Drug (Medicamento)
metoclopramide inj 5 mg/ml
perphenazine tabs 16 mg, 2 mg, 4 mg, 8 mg
PHENADOZ rectal supp 25 mg
prochlorperazine tabs 10 mg, 5 mg, inj 5mg/ml, rectal supp
25 mg
promethazine syrup 6.25 mg/5ml, tabs 12.5 mg, 25 mg, 50
mg, inj 25 mg/ml, 50 mg/ml, rectal supp 12.5 mg, 25 mg,
50 mg
PROMETHEGAN rectal supp 50 mg
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
4
2
2
2
REGLAN
TRILAFON
2
PHENERGAN,
PROMETHEGAN
COMPAZINE
2
Instruction
(Instrucción)
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
Emetogenic Therapy Adjuncts (Adjuvantes para Terapia Emetogénica)
dronabinol caps 10 mg, 2.5 mg, 5 mg
2
MARINOL
EMEND caps 125 mg, 40 mg, 80 mg, pack 80&125 mg
3
ondansetron odt 4 mg, 8 mg, tabs 4 mg, 8 mg, inj 40
2
ZOFRAN
mg/20ml
MO/R
MO/R PA^
MO/R PA^
ANTIFUNGALS (ANTIFUNGALES)
Antifungals (Antifungales)
AMBISOME inj 50 mg
amphotericin b inj 50 mg
CANCIDAS inj 50 mg, 70 mg
ciclopirox topical nail lacquer 8 %
clotrimazole troche 10 mg, topical cream 1 %, soln 1 %
clotrimazole & betamethasone topical cream 1-0.05 %, lot
1-0.05 %
econazole topical cream 1 %
ERAXIS inj 100 mg
fluconazole susp 10 mg/ml, 40 mg/ml, tabs 100 mg, 150
mg, 200 mg, 50 mg
fluconazole & dextrose inj 400 mg/200ml
flucytosine caps 250 mg, 500 mg
GRIS-PEG tabs 125 mg, 250 mg
griseofulvin microsize tabs 500 mg
griseofulvin ultramicrosize tabs 125 mg, 250 mg
itraconazole caps 100 mg
ketoconazole tabs 200 mg, topical cream 2 %, shampoo 2
%
MYCAMINE inj 50 mg
MYCAMINE inj 100 mg
4
2
5
2
2
2
FUNGIZONE
PENLAC
MYCELEX,
LOTRIMIN
LOTRISONE
2
4
2
SPECTAZOLE
2
2
4
2
2
2
2
DIFLUCAN
ANCOBON
4
5
DIFLUCAN
GRIFULVIN
GRIS-PEG
SPORANOX
NIZORAL
MO/R PA^
MO/R PA^
MO/R PA^
MO/R
MO/R
MO/R
MO/R
MO/R PA^
MO/R
MO/R PA^
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R PA^
MO/R PA^
Page 19 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
NATACYN ophth susp 5 %
NOXAFIL dr tabs 100 mg, susp 40mg/ml
nystatin susp 100000 u/ml, tabs 500000 u, topical cream
100000 u/gm, oint 100000 u/gm
nystatin & triamcinolone topical cream 100000 u/gm-0.1
%, oint 100000 u/gm-0.1 %
terbinafine tabs 250 mg
terconazole vaginal cream 0.8 %
terconazole vaginal supp 80 mg
4
4
2
NYSTATIN
MO/R
MO/R
MO/R
2
MYCOLOG II
MO/R
2
2
2
LAMISIL
TERAZOL
TERAZOL
terconazole vaginal cream 0.4 %
voriconazole susp 40 mg/ml, tabs 200 mg, 50 mg
2
2
TERAZOL
VFEND
MO/R
MO/R
MO/R QL
[3/3]
MO/R
MO/R
2
2
4
2
ZYLOPRIM
COLBENEMID
2
2
2
PERIACTIN
ANTIGOUT AGENTS (ANTIGOTA)
Antigout Agents (Antigota)
allopurinol tabs 100 mg, 300 mg
colchicine & probenecid tabs 0.5-500 mg
COLCRYS tabs 0.6 mg
probenecid tabs 500 mg
BENEMID
MO/R
MO/R
MO/R
MO/R
ANTIMIGRAINE AGENTS (ANTIMIGRAÑA)
Antihistamines (Antihistamínicos)
cyproheptadine tabs 4 mg
PHENADOZ rectal supp 25 mg
promethazine syrup 6.25 mg/5ml, tabs 12.5 mg, 25 mg, 50
mg, inj 25 mg/ml, 50 mg/ml, rectal supp 12.5 mg, 25 mg,
50mg
PROMETHEGAN rectal supp 50 mg
PHENERGAN,
PROMETHEGAN
2
MO/R
MO/R
MO/R
MO/R
Ergot Alkaloids (Alcaloides de Ergotamina)
dihydroergotamine inj 1 mg/ml
ERGOMAR sl tabs 2 mg
2
4
D.H.E 45
MO/R PA^
MO/R
Prophylactic (Profilaxis)
divalproex sprinkle caps 125 mg
divalproex dr tabs 125 mg, 250 mg, 500 mg
divalproex sr tabs 24h 250 mg, 500 mg
propranolol tabs 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
propranolol sr caps 24h 120 mg, 160 mg, 60 mg, 80 mg
2
2
2
2
2
DEPAKOTE
DEPAKOTE EC
DEPAKOTE ER
INDERAL
INDERAL LA
MO/R
MO/R
MO/R
MO/R
MO/R
Page 20 of 83
Drug (Medicamento)
timolol maleate tabs 10 mg, 20 mg, 5 mg
topiramate sprinkle caps 15 mg, 25 mg, tabs 100 mg, 200
mg, 25 mg, 50 mg
Level
(Nivel)
2
2
Reference Name
(Nombre de
Referencia)
BLOCADREN
TOPAMAX
Serotonin (5-HT) 1b/1d Receptor Agonists (Agonistas del Receptor de Serotonina)
naratriptan tabs 1 mg, 2.5 mg
2
AMERGE
rizatriptan odt 10 mg, 5 mg, tabs 10 mg, 5 mg
sumatriptan tabs 25 mg, 50 mg
2
2
MAXALT
IMITREX
sumatriptan inj 6 mg/0.5ml
sumatriptan tabs 100 mg
2
2
IMITREX
IMITREX
4
4
4
2
GUANIDINE
Instruction
(Instrucción)
MO/R
MO/R
MO/R QL
[9/30]
MO/R
MO/R QL
[18/30]
MO/R
MO/R QL
[9/30]
ANTIMYASTHENIC AGENTS (ANTIMIASTÉNICOS)
Parasympathomimetics (Parasimpatomiméticos)
guanidine tabs 125 mg
MESTINON syrup 60 mg/5ml
MESTINON TIMESPAN cr tabs 180 mg
pyridostigmine tabs 60 mg
MESTINON
MO/R
MO/R
MO/R
MO/R
MYCOBUTIN
MO/R
MO/R
ANTIMYCOBACTERIALS (ANTIMICOBACTERIANOS)
Antimycobacterials, Other (Antimicobacterianos, Otros)
dapsone tabs 100 mg, 25 mg
rifabutin Error! Bookmark not defined.Error! Bookmark
not defined.caps 150 mg
Antituberculars (Antituberculosos)
CAPASTAT inj 1 gm
ethambutol tabs 100 mg, 400 mg
isoniazid tabs 100 mg, 300 mg
isoniazid syrup 50 mg/5ml
PASER pack 4 gm
PRIFTIN tabs 150 mg
pyrazinamide tabs 500 mg
rifampin caps 150 mg, 300 mg
rifampin inj 600 mg
RIFATER tabs 50-300-120 mg
SEROMYCIN caps 250 mg
3
2
4
2
2
4
4
4
2
2
2
4
4
MYAMBUTOL
ISONIAZID
ISONIAZID
PYRAZINAMIDE
RIFADIN
RIFADIN
MO/R PA^
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R PA^
MO/R
MO/R
Page 21 of 83
Drug (Medicamento)
SIRTURO tabs 100 mg
TRECATOR tabs 250 mg
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
5
4
MO/R PA
MO/R
4
4
4
3
5
MO/R
MO/R PA^
MO/R
MO/R
MO/R
ANTINEOPLASTICS (ANTINEOPLÁSICOS)
Alkylating Agents (Alquilantes)
CEENU caps 10 mg, 40 mg
cyclophosphamide tabs 25 mg, 50 mg
HEXALEN caps 50 mg
LEUKERAN tabs 2 mg
MATULANE caps 50 mg
Antiangiogenic Agents (Antiangiogénicos)
MEKINIST tabs 0.5 mg, 2 mg
POMALYST caps 1 mg, 2 mg, 3 mg, 4 mg
REVLIMID caps 10 mg, 15 mg, 2.5 mg, 20 mg, 25 mg, 5
mg
TAFINLAR caps 50 mg, 75 mg
THALOMID caps 100 mg, 150 mg, 200 mg, 50 mg
CYTOXAN
5
5
5
MO/R PA
PA LA
PA LA
5
5
MO/R PA
MO/R PA
Antiestrogens/Modifiers (Antiestrógenos/Modificadores)
EMCYT caps 140 mg
FARESTON tabs 60 mg
4
4
FASLODEX inj 250 mg/5ml
SOLTAMOX soln 10 mg/5ml
tamoxifen tabs 10 mg, 20 mg
4
4
2
MO/R
MO/R QL
[30/30]
MO/R PA^
MO/R
MO/R
Antimetabolites (Antimetabolitos)
ALIMTA inj 500 mg
azacitidine inj 100 mg
hydroxyurea caps 500 mg
mercaptopurine tabs 50 mg
methotrexate sodium inj 1 gm
TABLOID tabs 40 mg
5
2
2
2
2
4
Antineoplastics, Others (Antineoplásicos, Otros)
amifostine inj 500 mg
bleomycin inj 30 u
ELITEK inj 1.5 mg
ERIVEDGE caps 150 mg
4
2
5
5
NOLVADEX
VIDAZA
HYDREA
PURINETHOL
METHOTREXATE
ETHYOL
BLENOXANE
MO/R PA^
MO/R PA^
MO/R
MO/R
MO/R PA^
MO/R
MO/R PA^
MO/R PA^
MO/R PA^
PA LA
Page 22 of 83
Drug (Medicamento)
ERWINAZE inj 10000u
irinotecan inj 100 mg/5ml
ISTODAX inj 10 mg
leucovorin tabs 5 mg
leucovorin inj 100 mg, 350 mg
mesna inj 100 mg/ml
MESNEX tabs 400 mg
mitoxantrone inj 25 mg/12.5ml
ONCASPAR inj 750u/ml
ONTAK inj 150 mcg/ml
PROLEUKIN inj 22 mu
SYNRIBO inj 3.5 mg
topotecan inj 4 mg
TRISENOX inj 10 mg/10ml
VELCADE inj 3.5 mg
ZOLINZA caps 100 mg
ZYTIGA tabs 250 mg
Level
(Nivel)
5
2
5
2
2
2
4
2
5
5
5
5
2
4
5
5
5
Reference Name
(Nombre de
Referencia)
CAMPTOSAR
LEUCOVORIN
LEUCOVORIN
MESNEX
NOVANTRONE
HYCAMTIN
Aromatase Inhibitors, 3rd Generation (Inhibidores de Aromatasa, 3ra generación)
anastrozole tabs 1 mg
2
ARIMIDEX
exemestane tabs 25 mg
letrozole tabs 2.5 mg
2
2
AROMASIN
FEMARA
Enzyme Inhibitors (Inhibidores Enzimáticos)
ETOPOFOS inj 100 mg
etoposide inj 20 mg/ml, 1 gm/50ml
topotecan inj 4 mg
2
2
2
TOPOSAR
HYCAMTIN
Molecular Target Inhibitors (Inhibidores del Blanco Molecular)
AFINITOR oral susp tabs 2 mg, 3 mg, 5 mg, tabs 10 mg,
5
2.5 mg, 5 mg, 7.5 mg
BOSULIF tabs 100 mg, 500 mg
5
CAPRELSA tabs 100 mg, 300 mg
5
COMETRIQ caps 1 x 80 mg & 1 x 20 mg, 1 x 80 mg & 3
5
x 20 mg, 3 x 20 mg
GILOTRIF tabs 20 mg, 30 mg, 40 mg
5
GLEEVEC tabs 100 mg, 400 mg
5
IMBRUVICA caps 140 mg
5
INLYTA tabs 1 mg, 5 mg
5
Instruction
(Instrucción)
MO/R PA^
MO/R PA^
MO/R PA^
MO/R
MO/R PA^
MO/R PA^
MO/R
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA#
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA
MO/R PA
MO/R QL
[30/30]
MO/R
MO/R QL
[30/30]
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA
MO/R PA
PA LA
MO/R PA
MO/R PA
MO/R PA
MO/R PA
PA LA
Page 23 of 83
Drug (Medicamento)
JAKAFI tabs 10 mg, 15 mg, 20 mg, 25 mg, 5 mg
NEXAVAR tabs 200 mg
SPRYCEL tabs 100 mg, 140 mg, 20 mg, 50 mg, 70 mg, 80
mg
STIVARGA tabs 40 mg
SUTENT caps 12.5 mg, 25 mg, 50 mg
TARCEVA tabs 100 mg, 150 mg, 25 mg
TASIGNA caps 150 mg, 200 mg
TYKERB tabs 250 mg
VOTRIENT tabs 200 mg
XALKORI caps 200 mg, 250 mg
ZALTRAP inj 100 mg/4ml
ZELBORAF tabs 240 mg
ZYKADIA caps 150 mg
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
5
5
5
MO/R PA
PA LA
MO/R PA
5
5
5
5
5
5
5
5
5
5
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA^
MO/R PA
MO/R PA
Monoclonal Antibodies (Anticuerpos Monoclonales)
AVASTIN inj 100 mg/4ml
RITUXAN inj 10 mg/ml
YERVOY inj 50 mg/10ml (5 mg/ml)
5
5
5
MO/R PA#
MO/R PA^
MO/R PA#
Retinoids (Retinoides)
PANRETIN topical gel 0.1 %
TARGRETIN caps 75 mg, topical gel 1 %
tretinoin caps 10 mg
5
5
5
MO/R
MO/R
MO/R
VESANOID
ANTIPARASITICS (ANTIPARASITARIOS)
Anthelmintics (Antihelmínticos)
ALBENZA tabs 200 mg
BILTRICIDE tabs 600 mg
STROMECTOL tabs 3 mg
Antiprotozoals (Antiprotozoarios)
ALINIA susp 100 mg/5ml, tabs 500 mg
Error! Bookmark not defined.Error! Bookmark not
defined.atovaquone susp 750 mg/5ml
atovaquone & proguanil tabs 250-100 mg
chloroquine tabs 250 mg, 500 mg
COARTEM tabs 20-120 mg
DARAPRIM tabs 25 mg
hydroxychloroquine tabs 200 mg
4
4
3
MO/R
MO/R
MO/R
4
5
MO/R
MO/R
2
2
4
4
2
MEPRON
MALARONE
ARALEN
PLAQUENIL
MO/R
MO/R
MO/R
MO/R
MO/R
Page 24 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
MALARONE tabs 62.5-25 mg
mefloquine tabs 250 mg
NEBUPENT neb 300 mg
PENTAM inj 300 mg
PRIMAQUINE tabs 26.3 mg
quinine sulfate caps 324 mg
XIFAXAN tabs 200 mg, 550 mg
4
2
4
4
4
2
4
Pediculicides/Scabicides (Pediculicidas/Escabicidas)
lindane topical lot 1 %, shampoo 1 %
4
LINDANE
permethrin topical cream 5 %
2
ELIMITE
MO/R QL
[60/30]
MO/R
Anticholinergics (Anticolinérgicos)
benztropine tabs 0.5 mg, 1 mg, 2 mg
diphenhydramine inj 50 mg/ml
trihexyphenidyl elixir 0.4 mg/ml, tabs 2 mg, 5 mg
2
2
2
COGENTIN
BENADRYL
ARTANE
MO/R
MO/R
MO/R
Antiparkinson Agents, Others (Antiparkinson, Otros)
amantadine caps 100 mg
entacapone tabs 200 mg
2
2
SYMMETREL
COMTAN
4
MO/R
MO/R QL
[240/30]
MO/R
4
MO/R
5
2
4
PARLODEL
2
MIRAPEX
2
REQUIP
LA
MO/R
MO/R QL
[30/30]
MO/R QL
[90/30]
MO/R
LARIAM
QUALAQUIN
MO/R
MO/R
MO/R PA^
MO/R PA^
MO/R
MO/R
MO/R
ANTIPARKINSON AGENTS (ANTIPARKINSON)
STALEVO tabs 12.5-200-50 mg, 18.75-200-75 mg, 25200-100 mg, 31.25-200-125 mg, 37.5-200-150 mg, 50200-200 mg
TASMAR tabs 100 mg
Dopamine Agonist (Agonistas de Dopamine)
APOKYN inj 10 mg/ml
bromocriptine caps 5 mg, tabs 2.5 mg
NEUPRO patch 1 mg/24hr, 2 mg/24hr, 3 mg/24hr, 4
mg/24hr, 6 mg/24hr, 8 mg/24hr
pramipexole tabs 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1
mg, 1.5 mg
ropinirole tabs 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5
mg
Page 25 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors (Precursores de Dopamina/Inhibidores del LAmino Acid Decarboxylase)
carbidopa tabs 25 mg
1
LODOSYN
MO/R
carbidopa & levodopa tabs 10-100 mg, 25-100 mg, 25-250 2
SINEMET
MO/R
mg
carbidopa & levodopa cr tabs 25-100 mg, 50-200 mg
2
SINEMET CR
MO/R
STALEVO tabs 12.5-200-50 mg, 18.75-200-75 mg, 254
MO/R
200-100 mg, 31.25-200-125 mg, 37.5-200-150 mg, 50200-200 mg
Monoamine Oxidase B (MAO-B) Inhibitors (Inhibidores de MAO-B)
AZILECT tabs 0.5 mg, 1 mg
4
selegiline caps 5 mg
2
ELDEPRYL
MO/R QL
[30/30]
MO/R
2
THORAZINE
MO/R
4
2
4
THORAZINE
PROLIXIN
PROLIXIN
MO/R
MO/R
MO/R
2
2
MO/R
MO/R
ANTIPSYCHOTICS (ANTIPSICÓTICOS)
1st Generation/Typical (1ra Generación/Típicos)
chlorpromazine tabs 10 mg, 100 mg, 200 mg, 25 mg, 50
mg
chlorpromazine inj 25mg/ml
fluphenazine inj 25 gm/ml, tabs 1 mg, 10 mg, 2.5 mg, 5 mg
fluphenazine conc 5 mg/ml, elixir 2.5 mg/5ml, inj 2.5
mg/ml
haloperidol tabs 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg
haloperidol decanoate inj 100 mg/ml, 50 mg/ml
haloperidol lactate conc 2 mg/ml, inj 5 mg/ml
loxapine caps 10 mg, 25 mg, 50 mg
loxapine caps 5 mg
2
2
2
HALDOL
HALDOL
DECANOATE
HALDOL
LOXITANE
LOXITANE
ORAP tabs 1 mg, 2 mg
perphenazine tabs 16 mg, 2 mg, 4 mg, 8 mg
prochlorperazine inj 5 mg/ml, tabs 10 mg, 5 mg, rectal
supp 25 mg
thioridazine tabs 10 mg, 100 mg, 25 mg, 50 mg
thiothixene caps 1 mg, 10 mg, 2 mg, 5 mg
trifluoperazine tabs 1 mg, 10 mg, 2 mg, 5 mg
4
2
2
TRILAFON
COMPAZINE
MO/R
MO/R
MO/R QL
[120/30]
MO/R
MO/R
MO/R
2
2
2
MELLARIL
NAVANE
STELAZINE
MO/R PA
MO/R
MO/R
Page 26 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
2nd Generation/Atypical (2da Generación/Atípicos)
ABILIFY soln 1 mg/ml
ABILIFY tabs 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg
3
3
ABILIFY odt 15 mg
3
ABILIFY odt 10 mg
3
ABILIFY inj 9.75 mg/1.3ml
ABILIFY MAINTENA inj 300 mg
FANAPT tabs 1 mg, 10 mg, 12 mg, 2 mg, 4 mg, 6 mg, 8
mg
GEODON inj 20 mg
INVEGA sr tabs 24h 1.5 mg, 3 mg, 9 mg
4
5
4
INVEGA sr tabs 24h 6 mg
4
INVEGA SUSTENNA inj 39 mg/0.25ml, 78 mg/0.5ml
INVEGA SUSTENNA inj 117 mg/0.75ml, 156 mg/1ml,
234 mg/1.5ml
LATUDA tabs 120 mg, 20 mg, 40 mg, 60 mg, 80 mg
4
5
olanzapine inj 10 mg
olanzapine odt 10 mg, 15 mg, 20 mg, 5 mg, tabs 10 mg, 15
mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg
quetiapine tabs 300 mg, 400 mg
2
2
ZYPREXA
ZYPREXA ZYDIS
2
SEROQUEL
quetiapine tabs 100 mg, 200 mg, 25 mg, 50 mg
2
SEROQUEL
RISPERDAL CONSTA inj 12.5 mg, 25 mg
RISPERDAL CONSTA inj 37.5 mg, 50 mg
risperidone soln 1 mg/ml
risperidone odt 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg,
tabs 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
SAPHRIS sl tabs 10 mg, 5 mg
3
5
2
2
RISPERDAL
RISPERDAL
SEROQUEL XR tabs 24h 150 mg, 200 mg, 50 mg
3
SEROQUEL XR tabs 24h 300 mg, 400 mg
3
MO/R
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R PA^
MO/R PA^
MO/R QL
[60/30]
MO/R
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R
MO/R
4
4
4
4
Instruction
(Instrucción)
MO/R QL
[30/30]
MO/R
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R
MO/R
MO/R
MO/R QL
[60/30]
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
Page 27 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
ziprasidone caps 20 mg, 40 mg, 60 mg, 80 mg
2
GEODON
MO/R QL
[60/30]
Treatment-Resistant (Resistentes a Tratamiento)
clozapine tabs 100 mg, 200 mg, 25 mg, 50 mg
FAZACLO odt 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg
VERSACLOZ susp 50 mg/ml
2
4
5
CLOZARIL
MO/R
MO/R
MO/R
2
2
2
LIORESAL
DANTRIUM
ZANAFLEX
MO/R
MO/R
MO/R
4
2
5
FOSCAVIR
CYTOVENE
MO/R PA^
MO/R PA^
MO/R
ANTISPASTICITY (ANTIESPASTICIDAD)
Antispasticity (Antiespasticidad)
baclofen tabs 10 mg, 20 mg
dantrolene caps 100 mg, 25 mg, 50 mg
tizanidine tabs 2 mg, 4 mg
ANTIVIRALS (ANTIVIRALES)
Anti-cytomegalovirus (CMV) Agents (Anti-citomegalovirus)
foscarnet sodium inj 24 mg/ml
ganciclovir inj 500 mg
VALCYTE tabs 450 mg
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (Anti-VIH, Inhibidores No Nucleósidos de
la Transciptasa Reversa)
ATRIPLA tabs 600-200-300 mg
5
MO/R
COMPLERA tabs 200-25-300 mg
5
MO/R
EDURANT tabs 25 mg
4
MO/R
INTELENCE tabs 100 mg, 200 mg
5
MO/R
INTELENCE tabs 25 mg
4
MO/R
nevirapine tabs 200 mg
2
VIRAMUNE
MO/R
nevirapine sr tabs 24h 400 mg
2
VIRAMUNE XR
MO/R
RESCRIPTOR tabs 100 mg, 200 mg
4
MO/R
SUSTIVA caps 200 mg, 50 mg, tabs 600 mg
3
MO/R
VIRAMUNE susp 50 mg/5ml, tab sr 24hr 100 mg
4
MO/R
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (Anti-VIH, Inhibidores
Nucleósidos y Nucleótidos de la Transcriptasa Reversa)
abacavir tabs 300 mg
2
ZIAGEN
MO/R
abacavir & lamivudine & zidovudine tabs 300-150-300 mg 5
TRIZIVIR
MO/R
ATRIPLA tabs 600-200-300 mg
5
MO/R
Page 28 of 83
Drug (Medicamento)
COMPLERA tabs 200-25-300 mg
didanosine dr caps 125 mg, 200 mg, 250 mg, 400 mg
EMTRIVA caps 200 mg, soln 10 mg/ml
EPIVIR soln 10 mg/ml
EPZICOM tabs 600-300 mg
lamivudine tabs 150 mg, 300 mg
lamivudine & zidovudine tabs 150-300 mg
RETROVIR inj 10 mg/ml
stavudine caps 15 mg, 20 mg, 30 mg, 40 mg, soln 1 mg/ml
STRIBILD tabs 150-150-200-300 mg
TRUVADA tabs 200-300 mg
VIDEX soln 2 gm
VIREAD powder 40 mg/gm, tabs 150 mg, 200 mg, 250
mg, 300 mg
ZIAGEN soln 20 mg/ml
zidovudine caps 100 mg, syrup 50 mg/5ml, tabs 300 mg
Anti-HIV Agents, Others (Anti-VIH, Otros)
FUZEON inj 90 mg
ISENTRESS tabs 100 mg, 25 mg, 400 mg
SELZENTRY tabs 150 mg, 300 mg
TIVICAY tabs 50 mg
Level
(Nivel)
5
2
4
4
5
2
2
4
2
5
5
4
5
4
2
Reference Name
(Nombre de
Referencia)
VIDEX EC
EPIVIR
COMBIVIR
ZERIT
RETROVIR
5
5
5
5
Instruction
(Instrucción)
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
Anti-HIV Agents, Protease Inhibitors (Anti-VIH, Inhibidores de la Proteasa)
APTIVUS caps 250 mg, soln 100 mg/ml
5
CRIXIVAN caps 200 mg, 400 mg
4
INVIRASE caps 200 mg
4
INVIRASE tabs 500 mg
5
KALETRA tabs 100-25 mg
4
KALETRA soln 400-100 mg/5ml, tabs 200-50 mg
5
LEXIVA susp 50 mg/ml
4
LEXIVA tabs 700 mg
5
NORVIR caps 100 mg, soln 80 mg/ml, tabs 100 mg
4
PREZISTA tabs 150 mg, 75 mg
4
PREZISTA tabs 600 mg, 800 mg, susp 100 mg/ml
5
REYATAZ caps 100 mg, 150 mg, 200 mg, 300 mg
3
VIRACEPT tabs 250 mg
4
VIRACEPT tabs 625 mg
5
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
Anti-influenza Agents (Antiinfluenza)
amantadine caps 100 mg
MO/R
2
SYMMETREL
Page 29 of 83
Drug (Medicamento)
rimantadine tabs 100 mg
TAMIFLU caps 30 mg, 45 mg, 75 mg, susp 6 mg/ml
Antihepatitis Agents (Antihepatitis)
adefovir tabs 10 mg
BARACLUDE soln 0.05 mg/ml
BARACLUDE tabs 0.5 mg, 1 mg
EPIVIR HBV soln 5 mg/ml
INCIVEK tabs 375 mg
INFERGEN inj 15 mcg/0.5ml
INTRON-A inj 6 mu/ml
INTRON-A inj 10 mu
lamivudine tabs 100 mg
PEG-INTRON inj 120 mcg/0.5ml, 150 mcg/0.5ml, 50
mcg/0.5ml, 80 mcg/0.5ml
PEGASYS inj 135 mcg/0.5ml, 180 mcg/0.5ml, 180
mcg/ml
ribavirin caps 200 mg, tabs 200 mg
SYLATRON inj 296 mcg, 444 mcg, 888 mcg
TYZEKA tabs 600 mg
VICTRELIS caps 200 mg
Antiherpetic Agents (Antiherpéticos)
acyclovir caps 200 mg, susp 200 mg/5ml, tabs 400 mg, 800
mg
acyclovir sodium inj 500 mg
famciclovir tabs 125 mg, 250 mg, 500 mg
trifluridine ophth soln 1 %
valacyclovir tabs 1 gm, 500 mg
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
2
4
FLUMADINE
MO/R
MO/R
2
4
5
3
5
5
4
5
2
3
HEPSERA
MO/R PA
MO/R PA
MO/R PA
MO/R
MO/R PA
MO/R
MO/R PA
MO/R PA
MO/R
MO/R PA
EPIVIR HBV
5
MO/R PA
2
5
4
3
REBETOL
MO/R
MO/R PA
MO/R PA
MO/R PA
2
ZOVIRAX
MO/R
4
2
2
2
ZOVIRAX
FAMVIR
VIROPTIC
VALTREX
MO/R PA^
MO/R
MO/R
MO/R
2
BUSPAR,
VANSPAR
ADAPIN
MO/R
ANXIOLYTICS (ANSIOLÍTICOS)
Anxiolytics, Other (Ansiolíticos, Otros)
buspirone hcl tabs 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg
doxepin caps 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75
mg, conc 10 mg/ml
2
MO/R
SSRIs/SNRIs (Selective Serotonin /Serotonin-Norepinephrine Reuptake Inhibitors) (SSRIs/SNRIs)
duloxetine caps 30 mg, 60 mg
2
CYMBALTA
MO/R QL
[60/30]
Page 30 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
duloxetine caps 20 mg
2
CYMBALTA
escitalopram soln 5 mg/5ml
escitalopram tabs 10 mg, 20 mg, 5 mg
2
2
LEXAPRO
LEXAPRO
paroxetine hcl tabs 10 mg, 20 mg, 40 mg
2
PAXIL
paroxetine hcl tabs 30 mg
2
PAXIL
paroxetine hcl sr tabs 24h 12.5 mg, 25 mg
2
PAXIL CR
paroxetine hcl sr tabs 24h 37.5 mg
2
PAXIL CR
PAXIL susp 10 mg/5ml
sertraline conc 20 mg/ml
sertraline tabs 25 mg, 50 mg
4
2
2
ZOLOFT
ZOLOFT
sertraline tabs 100 mg
2
ZOLOFT
venlafaxine tabs 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg
venlafaxine sr caps 24h 150 mg, 37.5 mg
2
2
EFFEXOR
EFFEXOR XR
venlafaxine sr caps 24h 75 mg
2
EFFEXOR XR
Instruction
(Instrucción)
MO/R QL
[90/30]
MO/R
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R
MO/R
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R
MO/R QL
[30/30]
MO/R QL
[90/30]
BIPOLAR AGENTS (BIPOLARIDAD)
Bipolar Agents, Other (Bipolaridad, Otros)
ABILIFY soln 1 mg/ml
ABILIFY tabs 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg
3
3
ABILIFY odt 15 mg
3
ABILIFY odt 10 mg
3
ABILIFY inj 9.75 mg/1.3ml
ABILIFY MAINTENA inj 300 mg
GEODON inj 20 mg
olanzapine inj 10 mg
olanzapine odt 10 mg, 15 mg, 20 mg, 5 mg, tabs 10 mg, 15
mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg
4
5
4
2
2
ZYPREXA
ZYPREXA ZYDIS
MO/R
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R PA^
MO/R PA^
MO/R
MO/R
MO/R QL
[30/30]
Page 31 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
quetiapine tabs 300 mg, 400 mg
2
SEROQUEL
quetiapine tabs 100 mg, 200 mg, 25 mg, 50 mg
2
SEROQUEL
RISPERDAL CONSTA inj 12.5 mg, 25 mg
RISPERDAL CONSTA inj 37.5 mg, 50 mg
risperidone soln 1 mg/ml
risperidone odt 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg,
tabs 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
SAPHRIS sl tabs 10 mg, 5 mg
3
5
2
2
RISPERDAL
RISPERDAL
SEROQUEL XR tabs 24h 150 mg, 200 mg, 50 mg
3
SEROQUEL XR tabs 24h 300 mg, 400 mg
3
ziprasidone caps 20 mg, 40 mg, 60 mg, 80 mg
2
GEODON
2
TEGRETOL
MO/R
2
2
2
2
2
TEGRETOL XR
DEPAKOTE
DEPAKOTE EC
DEPAKOTE ER
LAMICTAL
MO/R
MO/R
MO/R
MO/R
MO/R
2
LAMICTAL XR
MO/R
2
LITHIUM
CARBONATE
LITHOBID
LITHIUM CITRATE
MO/R
Mood Stabilizers (Estabilizadores del Ánimo)
carbamazepine chew tab 100 mg, susp 100 mg/5ml, tabs
200 mg
carbamazepine sr tabs 12h 200 mg, 400 mg
divalproex sprinkle caps 125 mg
divalproex dr tabs 125 mg, 250 mg, 500 mg
divalproex sr tabs 24h 250 mg, 500 mg
lamotrigine chew tab 25 mg, 5 mg, tabs 100 mg, 150 mg,
200 mg, 25 mg
lamotrigine sr tabs 24h 100 mg, 200 mg, 25 mg, 250 mg,
300 mg, 50 mg
lithium carbonate caps 150 mg, 300 mg, 600 mg, tabs 300
mg
lithium carbonate cr tabs 300 mg, 450 mg
lithium citrate soln 8 meq/5ml
TEGRETOL-XR tabs 12h 100 mg
valproate sodium syrup 250 mg/5ml
valproate sodium inj 100 mg/ml
valproic acid caps 250 mg
4
2
2
4
2
2
2
DEPAKENE
DEPACON
DEPAKENE
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R
MO/R
MO/R
MO/R QL
[60/30]
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[60/30]
MO/R
MO/R
MO/R
MO/R
MO/R PA^
MO/R
Page 32 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
BLOOD GLUCOSE REGULATORS (REGULADORES DE GLUCOSA EN SANGRE)
Antidiabetic Agents (Antidiabéticos)
acarbose tabs 100 mg, 25 mg, 50 mg
1
ACTOPLUS MET XR tabs 24h 30-1000 mg
4
ACTOPLUS MET XR tabs 24h 15-1000 mg
4
BYDUREON inj 2 mg
3
BYETTA PEN inj 5 mcg/0.02ml
3
BYETTA PEN inj 10 mcg/0.04ml
3
CYCLOSET tabs 0.8 mg
glimepiride tabs 1 mg, 2 mg, 4 mg
4
1
AMARYL
glipizide tabs 10 mg
1
GLUCOTROL
glipizide tabs 5 mg
1
GLUCOTROL
glipizide & metformin tabs 5-500 mg
1
METAGLIP
glipizide & metformin tabs 2.5-250 mg, 2.5-500 mg
1
METAGLIP
glipizide sr tabs 24h 10 mg, 2.5 mg, 5 mg
1
GLUCOTROL XL
GLYSET tabs 100 mg, 25 mg, 50 mg
4
INVOKANA tabs 100 mg
4
INVOKANA tabs 300 mg
4
JANUMET tabs 50-1000 mg, 50-500 mg
3
JANUMET XR tabs 100-1000 mg, 50-1000 mg, 50-500
mg
JANUVIA tabs 100 mg, 25 mg, 50 mg
3
3
PRECOSE
MO/R QL
[90/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[4/28]
MO/R QL
[1.2/30]
MO/R QL
[2.4/30]
MO/R
MO/R QL
[60/30]
MO/R QL
[120/30]
MO/R QL
[60/30]
MO/R QL
[120/30]
MO/R QL
[60/30]
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[30/30]
Page 33 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
JENTADUETO tabs 2.5-1000 mg, 2.5-500 mg, 2.5-850
mg
KOMBIGLYZE XR tabs 24h 5-1000 mg, 5-500 mg
3
KOMBIGLYZE XR tabs 24h 2.5-1000 mg
3
metformin tabs 1000 mg, 500 mg, 850 mg
1
GLUCOPHAGE
metformin sr tabs 24h 500 mg
1
GLUCOPHAGE XR
metformin sr tabs 24h 750 mg
1
GLUCOPHAGE XR
nateglinide tabs 120 mg, 60 mg
1
STARLIX
ONGLYZA tabs 2.5 mg, 5 mg
3
pioglitazone tabs 15 mg, 30 mg, 45 mg
1
ACTOS
pioglitazone & glimepiride tabs 30-2 mg, 30-4 mg
1
DUETACT
pioglitazone & metformin tabs 15-500 mg, 15-850 mg
repaglinide tabs 0.5 mg, 1 mg
1
1
ACTOPLUS MET
PRANDIN
repaglinide tabs 2 mg
1
PRANDIN
SYMLIN inj 1500 mcg/1.5ml, 2700 mcg/2.7ml
4
TRADJENTA tabs 5 mg
3
VICTOZA PEN inj 6 mg/ml
3
Glycemic Agents (Glicémicos)
GLUCAGEN / GLUCAGON inj 1 mg
PROGLYCEM susp 50 mg/ml
3
4
MO/R
MO/R
Insulins (Insulinas)
APIDRA VIAL inj
4
HUMALOG VIAL inj
3
MO/R QL
[40/30]
MO/R QL
[40/30]
3
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R QL
[120/30]
MO/R QL
[90/30]
MO/R QL
[90/30]
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R
MO/R QL
[120/30]
MO/R QL
[240/30]
MO/R QL
[13.5/30] PA
MO/R QL
[30/30]
MO/R QL
[9/30]
Page 34 of 83
Drug (Medicamento)
Level
(Nivel)
HUMALOG PEN inj
4
HUMALOG MIX VIAL inj 50-50, 75-25
3
HUMULIN VIAL inj 70-30, N, R
3
LANTUS VIAL inj
3
LEVEMIR VIAL inj
3
NOVOLIN VIAL inj R
3
NOVOLIN VIAL inj 70-30, N
4
NOVOLOG MIX VIAL inj 70-30
3
NOVOLOG VIAL inj
3
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
MO/R QL
[40/30]
MO/R QL
[40/30]
MO/R QL
[40/30]
MO/R QL
[40/30]
MO/R QL
[40/30]
MO/R QL
[40/30]
MO/R QL
[40/30]
MO/R QL
[40/30]
MO/R QL
[40/30]
BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERS (PRODUCTOS PARA LA
SANGRE/MODIFICADORES/EXPANSORES DE VOLUMEN)
Anticoagulants (Anticoagulantes)
COUMADIN tabs 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 4
5 mg, 6 mg, 7.5 mg
ELIQUIS tabs 2.5 mg, 5 mg
3
MO/R
enoxaparin inj 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30
mg/0.3ml, 300 mg/3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80
mg/0.8ml
fondaparinux inj 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml,
7.5 mg/0.6ml
heparin sodium (porcine) inj 1000 u/ml, 10000 u/ml,
20000 u/ml, 5000 u/ml
PRADAXA caps 150 mg, 75 mg
2
LOVENOX
MO/R QL
[60/30] PA
MO/R
2
ARIXTRA
MO/R
1
HEPARIN
MO/R PA^
warfarin tabs 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5
mg, 6 mg, 7.5 mg
XARELTO tabs 10 mg
1
COUMADIN
MO/R QL
[60/30] PA
MO/R
XARELTO tabs 20 mg
3
3
3
MO/R QL
[30/30]
MO/R QL
[30/30] PA
Page 35 of 83
Drug (Medicamento)
XARELTO tabs 15 mg
Reference Name
(Nombre de
Referencia)
Level
(Nivel)
3
Instruction
(Instrucción)
MO/R QL
[60/30] PA
Blood Formation Modifiers (Modificadores de la Formación de Sangre)
ARANESP inj 100 mcg/0.5ml, 100 mcg/ml, 25
4
mcg/0.42ml, 25 mcg/ml, 40 mcg/0.4ml, 40 mcg/ml, 60
mcg/0.3ml, 60 mcg/ml
ARANESP inj 150 mcg/0.3ml, 200 mcg/0.4ml, 200
5
mcg/ml, 300 mcg/0.6ml, 300 mcg/ml, 500 mcg/ml
EPOGEN / PROCRIT inj 2000 u/ml, 3000 u/ml, 4000
3
u/ml
EPOGEN / PROCRIT inj 10000 u/ml, 20000 u/ml
4
GRANIX inj 300 mcg/0.5ml, 480 mcg/0.5ml
5
LEUKINE inj 250 mcg
5
NEULASTA inj 6 mg/0.6ml
5
NEUMEGA inj 5 mg
5
NEUPOGEN inj 300 mcg/0.5ml (600 mcg/ml), 480
5
mcg/0.8ml (600 mcg/ml), 480 mcg/1.6ml (300 mcg/ml)
PROCRIT inj 40000 u/ml
5
PROMACTA tabs 12.5 mg, 25 mg, 75 mg
5
PROMACTA tabs 50 mg
5
Coagulants (Coagulantes)
tranexamic acid inj 100 mg/ml
2
Platelet Modifying Agents (Modificadores de Plaquetas)
AGGRENOX sr caps 12h 25-200 mg
anagrelide caps 0.5 mg, 1 mg
BRILINTA tabs 90 mg
3
2
4
AGRYLIN
cilostazol tabs 100 mg, 50 mg
clopidogrel tabs 75 mg
1
1
PLETAL
PLAVIX
EFFIENT tabs 10 mg, 5 mg
3
CYKLOKAPRON
MO/R PA#
MO/R PA#
MO/R PA#
MO/R PA#
MO/R PA#
MO/R PA#
MO/R PA#
MO/R PA#
MO/R PA#
MO/R PA#
QL [30/30]
PA LA
QL [60/30]
PA LA
MO/R PA^
MO/R
MO/R
MO/R QL
[60/30] PA
MO/R
MO/R QL
[30/30]
MO/R QL
[30/30] PA
Page 36 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
CARDIOVASCULAR AGENTS (CARDIOVASCULARES)
Alpha-adrenergic Agonists (Agonistas Alfa Adrenérgicos)
clonidine tabs 0.1 mg, 0.2 mg, 0.3 mg, weekly patch 0.1
mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr
guanfacine tabs 1 mg, 2 mg
methyldopa tabs 250 mg, 500 mg
midodrine tabs 10 mg, 2.5 mg, 5 mg
2
CATAPRES
MO/R
2
2
2
TENEX
ALDOMET
PROAMATINE
MO/R
MO/R
MO/R
Alpha-adrenergic Blocking Agents (Bloqueadores Alfa Adrenérgicos)
DIBENZYLINE caps 10 mg
4
doxazosin tabs 1 mg, 2 mg, 4 mg, 8 mg
2
CARDURA
prazosin caps 1 mg, 2 mg, 5 mg
2
MINIPRESS
terazosin caps 1 mg, 10 mg, 2 mg, 5 mg
2
HYTRIN
Angiotensin II Receptor Antagonists (Antagonistas del Receptor Angiotensina II)
candesartan tabs 32 mg
1
ATACAND
candesartan tabs 16 mg, 4 mg, 8 mg
1
ATACAND
candesartan & hydrochlorothiazide tabs 16-12.5 mg, 3212.5 mg, 32-25 mg
DIOVAN tabs 320 mg
2
ATACAND HCT
DIOVAN tabs 160 mg, 40 mg, 80 mg
4
irbesartan tabs 150 mg, 300 mg, 75 mg
2
AVAPRO
irbesartan & hydroclorothiazide tabs 150-12.5 mg, 30012.5 mg
losartan tabs 100 mg
2
AVALIDE
2
COZAAR
losartan tabs 25 mg, 50 mg
2
COZAAR
losartan & hydrochlorothiazide tabs 100-12.5 mg, 100-25
mg, 50-12.5 mg
valsartan & hydrochlorothiazide tabs 160-12.5 mg, 160-25
mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg
2
HYZAAR
2
DIOVAN HCT
4
MO/R
MO/R
MO/R
MO/R
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[30/30]
Page 37 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
Angiotensin-converting Enzyme (ACE) Inhibitors (Inhibidores de la Enzima Convertidora de Angiotensin)
amlodipine & benazepril caps 10-20 mg, 10-40 mg, 2.5-10 2
LOTREL
MO/R QL
mg, 5-10 mg, 5-20 mg, 5-40 mg
[30/30]
benazepril tabs 10 mg, 20 mg, 40 mg, 5 mg
2
LOTENSIN
MO/R QL
[60/30]
benazepril & hydrochlorothiazide tabs 10-12.5 mg, 202
LOTENSIN HCT
MO/R
12.5 mg, 20-25 mg, 5-6.25 mg
captopril tabs 100 mg, 12.5 mg, 25 mg, 50 mg
1
CAPOTEN
MO/R
captopril & hydrochlorothiazide tabs 25-15 mg, 25-25 mg, 2
CAPOZIDE
MO/R
50-15 mg, 50-25 mg
enalapril tabs 10 mg, 2.5 mg, 20 mg, 5 mg
1
VASOTEC
MO/R
enalapril & hydrochlorothiazide tabs 10-25 mg, 5-12.5 mg 2
VASERETIC
MO/R
fosinopril tabs 10 mg, 20 mg, 40 mg
1
MONOPRIL
MO/R
fosinopril & hydrochlorothiazide tabs 10-12.5 mg, 20-12.5 2
MONOPRIL HCT
MO/R QL
mg
[120/30]
lisinopril tabs 10 mg, 2.5 mg, 20 mg, 30 mg, 5 mg
1
PRINIVIL / ZESTRIL MO/R QL
[30/30]
lisinopril tabs 40 mg
1
PRINIVIL / ZESTRIL MO/R QL
[60/30]
lisinopril & hydrochlorothiazide tabs 10-12.5 mg, 20-12.5 2
PRINZIDE /
MO/R
mg, 20-25 mg
ZESTORETIC
perindopril tabs 8 mg
1
ACEON
MO/R QL
[60/30]
quinapril tabs 10 mg, 20 mg, 40 mg, 5 mg
1
ACCUPRIL
MO/R QL
[60/30]
quinapril & hydrochlorothiazide tabs 20-12.5 mg
2
ACCURETIC
MO/R QL
[120/30]
quinapril & hydrochlorothiazide tabs 10-12.5 mg, 20-25
2
ACCURETIC
MO/R QL
mg
[60/30]
ramipril caps 1.25 mg, 10 mg, 2.5 mg, 5 mg
1
ALTACE
MO/R QL
[60/30]
trandolapril tabs 1 mg, 2 mg, 4 mg
1
MAVIK
MO/R QL
[60/30]
Antiarrhythmics (Antiarrítmicos)
acebutolol hcl caps 200 mg, 400 mg
amiodarone tabs 200 mg, 400 mg
CARTIA coated beads caps 24h 180 mg
diltiazem tabs 120 mg, 30 mg, 60 mg, 90 mg
diltiazem er beads caps 24h 120 mg, 180 mg, 240 mg, 300
mg, 360 mg, 420 mg
1
1
1
1
1
SECTRAL
CORDARONE
CARDIZEM
TIAZAC,
TAZTIA
MO/R
MO/R
MO/R
MO/R
MO/R
Page 38 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
diltiazem sr caps 12h 120 mg, 60 mg, 90 mg, caps 24h 180
mg, 240 mg, coated beads caps 24h 120 mg, 180 mg, 240
mg, 300 mg
disopyramide caps 100 mg, 150 mg
flecainide tabs 100 mg, 150 mg, 50 mg
mexiletine caps 150 mg, 200 mg, 250 mg
MULTAQ tabs 400 mg
NORPACE CR caps 12h 100 mg, 150 mg
PACERONE tab 100 mg
propafenone tabs 150 mg, 225 mg, 300 mg
propranolol tabs 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
propranolol sr caps 24h 120 mg, 160 mg, 60 mg, 80 mg
quinidine gluconate cr tabs 324 mg
quinidine sulfate tabs 200 mg, 300 mg
1
quinidine sulfate cr tabs 300 mg
SORINE tabs 120 mg
sotalol tabs 120 mg,160 mg, 240 mg, 80 mg
4
1
1
TAZTIA er beads caps 24h 120 mg, 180 mg, 240 mg, 300
mg
TIKOSYN caps 125 mcg, 250 mcg, 500 mcg
verapamil tabs 120 mg, 40 mg, 80 mg
verapamil cr tabs 120 mg, 180 mg, 240 mg
1
MO/R
4
1
1
MO/R
MO/R
MO/R
1
1
1
4
4
1
1
2
2
1
1
Beta-adrenergic Blocking Agents (Bloqueadores Beta Adrenérgicos)
acebutolol hcl caps 200 mg, 400 mg
1
atenolol tabs 100 mg, 25 mg, 50 mg
2
atenolol & chlorthalidone tabs 100-25 mg, 50-25 mg
2
betaxolol tabs 20 mg
2
bisoprolol tabs 5 mg
1
bisoprolol & hydrochlorothiazide tabs 10-6.25 mg, 2.52
6.25 mg, 5-6.25 mg
carvedilol tabs 12.5 mg, 25 mg, 3.125 mg, 6.25 mg
1
kerlone tabs 10 mg
2
labetalol tabs 100 mg, 200 mg, 300 mg
2
metoprolol & hydrochlorothiazide tabs 100-25 mg, 50-25
2
mg
metoprolol & hydrochlorothiazide tabs 100-50 mg
4
CARDIZEM CD,
CARDIZEM SR,
CARTIA
NORPACE
TAMBOCOR
Instruction
(Instrucción)
RYTHMOL
INDERAL
INDERAL LA
QUINAGLUTE
QUINIDINE
SULFATE
BETAPACE,
SORINE
CALAN
CALAN SR /
ISOPTIN SR
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
SECTRAL
TENORMIN
TENORETIC
KERLONE
ZEBETA
ZIAC
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
COREG
TRANDATE
LOPRESSOR HCT
MO/R
MO/R
MO/R
MO/R
LOPRESSOR HCT
MO/R
Page 39 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
metoprolol succinate sr tabs 24h 100 mg, 25 mg, 50 mg
1
TOPROL XL
metoprolol succinate sr tabs 24h 200 mg
1
TOPROL XL
metoprolol tartrate tabs 100 mg, 25 mg, 50 mg
nadolol tabs 20 mg, 40 mg, 80 mg
nadolol & bendroflumethiazide tabs 40-5 mg, 80-5 mg
pindolol tabs 10 mg, 5 mg
propranolol tabs 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
propranolol sr caps 24h 120 mg, 160 mg, 60 mg, 80 mg
propranolol & hydrochlorothiazide tabs 40-25 mg, 80-25
mg
timolol maleate tabs 10 mg, 20 mg, 5 mg
2
2
2
4
2
2
4
LOPRESSOR
CORGARD
CORZIDE
INDERAL
INDERAL LA
INDERIDE
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
2
BLOCADREN
MO/R
Calcium Channel Blocking Agents (Bloqueadores de Canales de Calcio)
amlodipine tabs 10 mg, 2.5 mg, 5 mg
2
NORVASC
amlodipine & benazepril caps 10-20 mg, 10-40 mg, 2.5-10 2
LOTREL
mg, 5-10 mg, 5-20 mg, 5-40 mg
CARTIA coated beads caps 24h 180 mg
1
diltiazem tabs 120 mg, 30 mg, 60 mg, 90 mg
1
CARDIZEM
diltiazem er beads caps 24h 120 mg, 180 mg, 240 mg, 300 1
TIAZAC,
mg, 360 mg, 420 mg
TAZTIA
diltiazem sr caps 12h 120 mg, 60 mg, 90 mg, caps 24h 180 1
CARDIZEM CD,
mg, 240 mg, coated beads caps 24h 120 mg, 180 mg, 240
CARDIZEM SR,
mg, 300 mg
CARTIA
nicardipine caps 20 mg, 30 mg
2
CARDENE
nifedipine sr tabs 24h 30 mg, 60 mg, 90 mg
2
ADALAT CC,
AFEDITAB,
NIFEDIAC,
PROCARDIA XL
TAZTIA er beads caps 24h 120 mg, 180 mg, 240 mg, 300 1
mg
nimodipine caps 30 mg
2
NIMOTOP
verapamil tabs 120 mg, 40 mg, 80 mg
1
CALAN
verapamil cr tabs 120 mg, 180 mg, 240 mg
1
CALAN SR /
ISOPTIN SR
Cardiovascular Agents, Other (Cardiovasculares, Otros)
AMTURNIDE tabs 150-5-12.5 mg, 300-10-12.5 mg, 30010-25 mg, 300-5-12.5 mg, 300-5-25 mg
digoxin tabs 0.125 mg, 0.25 mg
3
1
LANOXIN
MO/R
MO/R QL
[30/30]
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R QL
[30/30]
MO/R
Page 40 of 83
Drug (Medicamento)
Level
(Nivel)
pentoxifylline cr tabs 400 mg
RANEXA sr tabs 12h 1000 mg, 500 mg
1
4
TEKAMLO tabs 150-10 mg, 150-5 mg, 300-10 mg, 300-5
mg
TEKTURNA tabs 150 mg, 300 mg
3
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
TRENTAL
TEKTURNA HCT tabs 150-12.5 mg, 150-25 mg, 300-12.5 3
mg, 300-25 mg
MO/R
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R QL
[30/30]
Diuretics, Carbonic Anhydrase Inhibitors (Diuréticos Inhibidores de Anhidrasa Carbónica)
acetazolamide tabs 125 mg, 250 mg
2
DIAMOX
methazolamide tabs 25 mg, 50 mg
2
NEPTAZANE
MO/R
MO/R
Diuretics, Loop (Diuréticos del Asa)
bumetanide inj 0.25 mg/ml
bumetanide tabs 0.5 mg, 1 mg, 2 mg
furosemide soln 10 mg/ml, 8 mg/ml
furosemide tabs 20 mg, 40 mg, 80 mg
furosemide inj 10 mg/ml
torsemide tabs 10 mg, 100 mg, 20 mg, 5 mg
MO/R
MO/R
MO/R
MO/R
MO/R PA^
MO/R
3
1
1
1
1
1
1
Diuretics, Potassium-sparing (Diuréticos Conservadores de Potasio)
ALDACTAZIDE tabs 50-50 mg
4
amiloride tabs 5 mg
2
amiloride & hydrochlorothiazide tabs 5-50 mg
2
eplerenone tabs 25 mg, 50 mg
1
spironolactone tabs 100 mg, 25 mg, 50 mg
1
spironolactone & hydrochlorothiazide tabs 25-25 mg
1
triamterene & hydrochlorothiazide caps 37.5-25 mg, tabs 2
37.5-25 mg, 75-50 mg
Diuretics, Thiazide (Diuréticos Tiazidas)
chlorothiazide tabs 250 mg, 500 mg
chlorthalidone tabs 25 mg, 50 mg
hydrochlorothiazide caps 12.5 mg, tabs 25 mg, 50 mg
hydrochlorothiazide tabs 12.5 mg
2
2
2
4
indapamide tabs 1.25 mg, 2.5 mg
metolazone tabs 10 mg, 2.5 mg, 5 mg
2
2
BUMEX
BUMEX
LASIX
LASIX
LASIX
DEMADEX
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MIDAMOR
MODURETIC
INSPRA
ALDACTONE
ALDACTAZIDE
DYAZIDE /
MAXZIDE
DIURIL
HYGROTON
MICROZIDE
HYDROCHLOROTH
IAZIDE
LOZOL
ZAROXOLYN
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
Page 41 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Dyslipidemics, Fibric Acid Derivatives (Dislipidémicos, Derivados de Ácido Fíbrico)
fenofibrate tabs 145 mg, 160 mg, 48 mg, 54 mg
1
TRICOR
fenofibrate micronized caps 134 mg, 200 mg, 67 mg
1
LOFIBRA
gemfibrozil tabs 600 mg
1
LOPID
Instruction
(Instrucción)
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
Dyslipidemics, HMG CoA Reductase Inhibitors (Dislipidémicos, Inhibidores de la Reductasa de HMG CoA)
atorvastatin tabs 10 mg, 20 mg, 40 mg, 80 mg
1
LIPITOR
MO/R QL
[30/30]
pravastatin tabs 10 mg, 20 mg, 40 mg, 80 mg
1
PRAVACHOL
MO/R QL
[30/30]
simvastatin tabs 10 mg, 20 mg, 40 mg, 5 mg
1
ZOCOR
MO/R QL
[30/30]
simvastatin tabs 80 mg
1
ZOCOR
MO/R QL
[30/30] PA
Dyslipidemics, Other (Dislipidémicos, Otros)
cholestyramine pack 4 gm, powder 4 gm/dose
2
colestipol granules 5 gm, tabs 1 gm
LOVAZA caps 1 gm
2
4
niacin cr tabs 1000 mg, 500 mg, 750 mg
1
WELCHOL pack 3.75 gm, tabs 625 mg
ZETIA tabs 10 mg
4
3
Vasodilators, Direct-acting Arterial (Vasodilatadores, Arteriales)
hydralazine tabs 10 mg, 100 mg, 25 mg, 50 mg
1
minoxidil tabs 10 mg, 2.5 mg
2
QUESTRAN,
PREVALITE
COLESTID
NIASPAN
APRESOLINE
LONITEN
Vasodilators, Direct-acting Arterial/Venous (Vasodilatadores, Arteriales/Venosos)
ISORDIL tabs 40 mg
4
isosorbide dinitrate sl tabs 2.5 mg, tabs 10 mg, 20 mg, 30
1
ISORDIL
mg, 5 mg
isosorbide dinitrate cr tabs 40 mg
1
ISORDIL
isosorbide mononitrate tabs 10 mg, 20 mg
1
ISMO / MONOKET
MO/R
MO/R
MO/R QL
[120/30]
MO/R QL
[60/30]
MO/R
MO/R QL
[30/30]
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
Page 42 of 83
Drug (Medicamento)
isosorbide mononitrate sr tabs 24h 120 mg, 30 mg, 60 mg
NITRO-DUR 24h patch 0.8 mg/hr
nitroglycerin 24h patch 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr,
0.6 mg/hr
NITROSTAT sl tabs 0.3 mg, 0.4 mg, 0.6 mg
Level
(Nivel)
1
4
2
Reference Name
(Nombre de
Referencia)
IMDUR
NITRO-DUR
3
Instruction
(Instrucción)
MO/R
MO/R
MO/R
MO/R
CENTRAL NERVOUS SYSTEM AGENTS (SISTEMA NERVIOSO CENTRAL)
ADHD, Amphetamines (Anfetaminas, ADHD)
amphetamine & dextroamphetamine tabs 10 mg, 12.5 mg,
15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg
dextroamphetamine tabs 10 mg, 5 mg
dextroamphetamine sr caps 24h 10 mg, 15 mg, 5 mg
2
ADDERALL
2
2
DEXEDRINE
DEXEDRINE SR
ADHD, Non-amphetamines (No-Anfetaminas, ADHD)
clonidine sr tabs 12h 0.1 mg
methylphenidate tabs 10 mg, 20 mg, 5 mg
2
2
KAPVAY
RITALIN
methylphenidate cr tabs 20 mg
2
RITALIN
SR/METADATE ER
STRATTERA caps 10 mg, 100 mg, 18 mg, 25 mg, 40 mg,
60 mg, 80 mg
4
Barbiturates (Barbitúricos)
butalbital & acetaminophen & caffeine tabs 50-325-40 mg
BUTISOL tabs 30 mg, 50 mg
phenobarbital soln 20 mg/5ml
phenobarbital tabs 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4
mg, 60 mg, 64.8 mg, 97.2 mg
2
FIORICET
4
2
2
PHENOBARBITAL
PHENOBARBITAL
Benzodiazepines (Benzodiazepinas)
alprazolam tabs 0.25 mg, 0.5 mg, 1 mg, 2 mg
clonazepam odt 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg,
tabs 0.5 mg, 1 mg, 2 mg
clorazepate tabs 15 mg, 3.75 mg, 7.5 mg
2
2
2
XANAX
KLONOPIN
WAFERS
TRANXENE
DIASTAT ACUDIAL rectal gel 10 mg, 2.5 mg, 20 mg
diazepam soln 1 mg/ml, 5 mg/ml
diazepam tabs 10 mg, 2 mg, 5 mg
4
2
2
VALIUM
VALIUM
MO/R QL
[60/30]
MO/R
MO/R
MO/R
MO/R QL
[90/30]
MO/R QL
[90/30]
MO/R QL
[30/30]
MO/R QL
[40/30]
MO/R
MO/R
MO/R QL
[90/30]
MO/R
MO/R
MO/R QL
[90/30]
MO/R
MO/R
MO/R QL
[120/30]
Page 43 of 83
Drug (Medicamento)
Level
(Nivel)
lorazepam tabs 0.5 mg, 1 mg, 2 mg
2
ONFI tabs 20 mg
4
ONFI tabs 10 mg
4
Error! Bookmark not defined.Error! Bookmark not
defined.ONFI susp 2.5 mg/ml
temazepam caps 15 mg, 22.5 mg, 30 mg, 7.5 mg
4
2
Reference Name
(Nombre de
Referencia)
ATIVAN
MO/R QL
[90/30]
MO/R QL
[120/30]
MO/R QL
[60/30]
MO/R
RESTORIL
MO/R QL
[30/30]
Central Nervous System Agents, Others (Sistema Nervioso Central, Otros)
NUEDEXTA caps 20-10 mg
4
riluzole tabs 50 mg
2
RILUTEK
XENAZINE tabs 12.5 mg, 25 mg
5
Fibromyalgia Agents (Fibromialgia)
duloxetine caps 30 mg, 60 mg
2
CYMBALTA
duloxetine caps 20 mg
2
CYMBALTA
LYRICA soln 20 mg/ml
LYRICA caps 225 mg, 300 mg
3
3
LYRICA caps 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75
mg
3
Multiple Sclerosis Agents (Esclerosis Múltiple)
AMPYRA sr tabs 12h 10 mg
AUBAGIO tabs 7 mg, 14 mg
AVONEX inj 30 mcg, 30 mcg/0.5ml
BETASERON inj 0.3 mg
COPAXONE inj 20 mg/ml, 40 mg/ml
EXTAVIA inj 0.3 mg
GILENYA caps 0.5 mg
mitoxantrone inj 25 mg/12.5ml
REBIF inj 22 mcg/0.5ml, 44 mcg/0.5ml, 8.8
mcg/0.2ml&22 mcg/0.5ml
TECFIDERA dr caps 120 mg, 240 mg, pack
TYSABRI inj 300 mg/15ml
5
5
5
5
5
5
5
2
5
5
5
Instruction
(Instrucción)
NOVANTRONE
MO/R
MO/R
LA
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R
MO/R QL
[60/30]
MO/R QL
[90/30]
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA^
MO/R PA
MO/R PA
PA# LA
Page 44 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
DENTAL AND ORAL AGENTS (DENTALES Y ORALES)
Dental and Oral Agents (Dentales y Orales)
chlorhexidine gluconate soln 0.12 %
doxycycline hyclate caps 100 mg, 50 mg, tabs 100 mg, 20
mg
2
2
minocycline caps 100 mg, 50 mg, 75 mg
pilocarpine tabs 5 mg, 7.5 mg
triamcinolone paste 0.1 %
2
2
2
PERIDEX
VIBRAMYCIN,
VIBRATAB,
PERIOSTAT
MINOCIN
SALAGEN
KENALOG IN
ORABASE
MO/R
MO/R
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
DERMATOLOGICAL AGENTS (DERMATOLÓGICOS)
Dermatological Agents (Dermatológicos)
acitretin caps 10 mg, 17.5 mg
2
SORIATANE
acitretin caps 25 mg
2
SORIATANE
calcipotriene topical cream 0.005 %, soln 0.005 %
CARAC topical cream 0.5 %
CONDYLOX topical gel 0.5 %
diclofenac topical gel 3%
DOVONEX topical cream 0.005 %
doxycycline hyclate caps 100 mg, 50 mg, tabs 100 mg, 20
mg
2
4
4
2
4
2
DOVONEX
ELIDEL topical cream 1 %
fluorouracil topical cream 5 %
imiquimod topical cream 5 %
irrigation solution irrigation solution ,
isotretinoin caps 10 mg, 20 mg, 30 mg, 40 mg
3
2
4
2
2
lactated ringer's irrigation solution
lactic acid (ammonium lactate) topical cream 12 %, lot 12
%
OXSORALEN ULTRA caps 10 mg
PHYSIOSOL irrigation solution
podofilox topical soln 0.5 %
2
2
3
2
2
SOLARAZE
VIBRAMYCIN,
VIBRATAB,
PERIOSTAT
EFUDEX
ALDARA
ACCUTANE /
AMNESTEEM /
CLARAVIS
MO/R
MO/R
MO/R
MO/R
MO/R
LAC-HYDRIN
MO/R
MO/R
CONDYLOX
MO/R
MO/R
MO/R
Page 45 of 83
Drug (Medicamento)
Level
(Nivel)
PROTOPIC topical oint 0.03 %, 0.1 %
SANTYL topical oint 250 u/gm
selenium topical lot 2.5 %
sodium chloride irrigation soln 0.9 %
4
3
2
2
STELARA inj 0.45 mg/0.5ml, 90 mg /ml
TAZORAC topical cream 0.05 %, 0.1 %, gel 0.05 %, 0.1
%
tretinoin topical cream 0.025 %, 0.05 %, 0.1 %, gel 0.01
%, 0.025 %
VECTICAL oint 3 mcg/gm
5
4
2
Reference Name
(Nombre de
Referencia)
SELSUN
SODIUM
CHLORIDE
Instruction
(Instrucción)
MO/R
MO/R
MO/R
MO/R
MO/R PA#
MO/R PA
RETIN-A
4
MO/R PA
MO/R
ENZYME REPLACEMENTS/MODIFIERS (REEMPLAZO DE ENZIMAS/MODIFICADORES)
Enzyme Replacements/Modifiers (Reemplazo de Enzimas/Modificadores)
ADAGEN inj 250 u/ml
5
ALDURAZYME inj 2.9 mg/5ml
5
BUPHENYL tabs 500 mg
5
CEREZYME inj 200 u
5
CREON dr caps
3
CYSTADANE powder
4
CYSTAGON caps 150 mg, 50 mg
4
ELAPRASE inj 6 mg/3ml
5
ELELYSO inj 200 unit
5
FABRAZYME inj 35 mg
5
KORLYM tabs 300 mg
4
KUVAN tabs 100 mg
5
NAGLAZYME inj 1 mg/ml
5
ORFADIN caps 10 mg, 2 mg, 5 mg
5
PANCREAZE dr caps
3
PERTZYE dr caps
4
RAVICTI liq 1.1 gm/ml
5
sodium phenylbutyrate powder
5
BUPHENYL
ULTRESA dr caps
4
VIOKACE tabs
4
VPRIV inj 400 u
5
ZAVESCA caps 100 mg
5
ZENPEP dr caps
4
PA LA
PA# LA
MO/R PA
PA# LA
MO/R
MO/R
PA LA
MO/R PA#
MO/R PA#
PA# LA
MO/R PA
PA LA
PA# LA
PA LA
MO/R
MO/R
MO/R PA
MO/R PA
MO/R
MO/R
MO/R PA#
PA LA
MO/R
Page 46 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
GASTROINTESTINAL AGENTS (GASTROINTESTINALES)
Antispasmodics, Gastrointestinal (Antiespasmódicos, Gastrointestinales)
dicyclomine caps 10 mg, tabs 20 mg
2
BENTYL
glycopyrrolate tabs 1 mg, 2 mg
2
ROBINUL
methscopolamine tabs 2.5 mg, 5 mg
2
PAMINE
MO/R
MO/R
MO/R
Gastrointestinal Agents, Others (Gastrointestinales, Otros)
cromolyn conc 100 mg/5ml
diphenoxylate & atropine tabs 2.5-0.025mg
FULYZAQ dr tabs 125 mg
GATTEX inj 5 mg
loperamide caps 2 mg
RELISTOR inj 12 mg/0.6ml
ursodiol caps 300 mg, tabs 250 mg, 500 mg
XIFAXAN tabs 200 mg, 550 mg
MO/R
MO/R
MO/R PA
MO/R PA
MO/R
MO/R
MO/R
MO/R
2
2
4
5
2
4
2
4
GASTROCROM
LOMOTIL
IMODIUM
ACTIGALL
Histamine2 (H2) Receptor Antagonists (Antagonistas del Receptor de Histamina2 (H2))
cimetidine tabs 300 mg, 400 mg, 800 mg
2
TAGAMET
famotidine tabs 20 mg, 40 mg
2
PEPCID
famotidine inj 10 mg/ml
2
PEPCID
ranitidine syrup 15 mg/ml, tabs 150 mg, 300 mg
2
ZANTAC
ranitidine inj 150 mg/6ml
2
ZANTAC
Irritable Bowel Syndrome Agents (Sídrome de Colon Irritado)
AMITIZA caps 24 mg, 8 mg
3
LINZESS caps 145 mg, 290 mg
3
LOTRONEX tabs 0.5 mg, 1 mg
3
Laxatives (Laxantes)
ENULOSE soln 10 gm/15ml
lactulose soln 10 gm/15ml
polyethylene glycol & potassium chloride & sodium
bicarbonate & sodium chloride soln 420 gm
polyethylene glycol & potassium chloride & sodium
bicarbonate & sodium chloride soln 236 gm
2
2
2
2
MO/R
MO/R
MO/R PA^
MO/R
MO/R PA^
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
ENULOSE
NULYTELY
GAVILYTE-G,
TRILYTE
MO/R
MO/R
MO/R
MO/R
Page 47 of 83
Drug (Medicamento)
polyethylene glycol & potassium chloride & sodium
bicarbonate & sodium chloride & sodium sulfate soln 240
gm
Protectants (Protectores)
CARAFATE susp 1 gm/10ml
misoprostol tabs 200 mcg, 100 mcg
sucralfate tabs 1 gm
Level
(Nivel)
2
Reference Name
(Nombre de
Referencia)
COLYTE,
GAVILYTE-C
4
2
2
CYTOTEC
CARAFATE
Proton Pump Inhibitors (Inhibidores de la Bomba de Protones)
lansoprazole caps 15 mg, 30 mg
2
PREVACID
omeprazole dr caps 10 mg, 40 mg
2
PRILOSEC
omeprazole dr caps 20 mg
2
PRILOSEC
pantoprazole inj 40 mg
pantoprazole ec tabs 20 mg, 40 mg
2
2
PROTONIX
PROTONIX
PROTONIX inj 40mg
4
Instruction
(Instrucción)
MO/R
MO/R
MO/R
MO/R
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R PA^
MO/R QL
[30/30]
MO/R PA^
GENITOURINARY AGENTS (GENITOURINARIOS)
Antispasmodics, Urinary (Antiespasmódicos, Urinarios)
flavoxate tabs 100 mg
MYRBETRIQ tabs 24h 25 mg, 50 mg
2
4
URISPAS
oxybutynin tabs 5 mg
oxybutynin sr tabs 24h 10 mg, 15 mg, 5 mg
tolterodine tabs 1 mg, 2 mg
2
2
2
DITROPAN
DITROPAN XL
DETROL
tolterodine caps 24h 2 mg, 4 mg
2
DETROL LA
TOVIAZ sr tabs 24h 4 mg, 8 mg
3
trospium tabs 20 mg
2
SANCTURA
Benign Prostatic Hypertrophy Agents (Hipertrofia Prostática Benigna)
doxazosin tabs 1 mg, 2 mg, 4 mg, 8 mg
2
CARDURA
MO/R
MO/R QL
[30/30]
MO/R
MO/R
MO/R QL
[60/30]
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R
Page 48 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
finasteride tabs 5 mg
2
PROSCAR
MO/R QL
[30/30]
MO/R
MO/R
MO/R
prazosin caps 1 mg, 2 mg, 5 mg
tamsulosin caps 0.4 mg
terazosin caps 1 mg, 10 mg, 2 mg, 5 mg
2
2
2
MINIPRESS
FLOMAX
HYTRIN
Genitourinary Agents, Others (Genitourinarios, Otros)
bethanechol tabs 10 mg, 25 mg, 5 mg, 50 mg
DEPEN TITRATABS tabs 250 mg
ELMIRON caps 100 mg
2
4
4
URECHOLINE
MO/R
MO/R
MO/R
Phosphate Binders (Enlazadores de Fosfato)
calcium acetate caps 667 mg
FOSRENOL chew tab 1000 mg, 500 mg, 750 mg
RENAGEL tabs 400 mg, 800 mg
RENVELA pack 0.8 gm, 2.4 gm, tabs 800 mg
VELPHORO chew tabs 500 mg
2
3
3
3
5
PHOSLO
MO/R
MO/R
MO/R
MO/R
MO/R
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
(HORMONALES, ESTIMULANTE/REEMPLAZO/MODIFICADOR (ADRENAL))
Glucocorticoids / Mineralocorticoids (Glucocorticoides/Mineralocorticoides)
A-HYDROCORT inj 100 mg
2
alclometasone dipropionate topical cream 0.05 %, oint
2
ACLOVATE
0.05 %
augmented betamethasone dipropionate topical cream 0.05 2
DIPROLENE
%, gel 0.05 %, lot 0.05 %, oint 0.05 %
betamethasone dipropionate topical cream 0.05 %, lot
2
DIPROSONE
0.05 %, oint 0.05 %
betamethasone valerate topical cream 0.1 %, lot 0.1 %,
2
VALISONE
oint 0.1 %
budesonide sr caps 24h 3 mg
2
ENTOCORT
clobetasol lot 0.05 %, topical emollient cream 0.05 %, gel 2
CLOBEX
0.05 %, oint 0.05 %, soln 0.05 %
cortisone acetate tabs 25 mg
2
CORTONE
DEPO-MEDROL inj 20 mg/ml
4
desonide topical cream 0.05 %, lot 0.05 %, oint 0.05 %
2
DESOWEN
dexamethasone conc 1 mg/ml
2
DEXAMETHASONE
dexamethasone elixir 0.5 mg/5ml, tabs 0.5 mg, 0.75 mg,
2
DEXAMETHASONE
1.5 mg, 4 mg, 6 mg
dexamethasone tabs 1 mg, 2 mg
4
DEXAMETHASONE
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R PA^
MO/R
MO/R
MO/R
MO/R
Page 49 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
dexamethasone sodium phosphate inj 4 mg/ml, 10 mg/ml
fludrocortisone tabs 0.1 mg
fluocinolone acetonide topical cream 0.01 %, 0.025 %, oil
0.01 %, oint 0.025 %, soln 0.01 %
fluocinonide topical emulsified cream 0.05 %, gel 0.05 %,
oint 0.05 %, soln 0.05 %
fluticasone propionate topical cream 0.05 %, lot 0.05 %,
oint 0.005 %
halobetasol propionate topical cream 0.05 %, oint 0.05 %
hydrocortisone tabs 10 mg, 20 mg, 5 mg, rectal cream 2.5
%, enema 100 mg/60ml, topical cream 2.5 %, lot 2.5 %,
oint 2.5 %
hydrocortisone butyrate topical cream 0.1 %, oint 0.1 %,
soln 0.1 %
hydrocortisone sodium succinate inj 100 mg
2
2
2
DEXAMETHASONE
FLORINEF
SYNALAR
MO/R
MO/R
MO/R
2
LIDEX
MO/R
2
CUTIVATE
MO/R
2
2
ULTRAVATE
CORTEF,
PROCTOCREAM
MO/R
MO/R
2
LOCOID
MO/R
2
MO/R
hydrocortisone valerate topical cream 0.2 %, oint 0.2 %
methylprednisolone pack 4 mg, tabs 16 mg, 32 mg, 4 mg, 8
mg
methylprednisolone acetate inj 40 mg/ml, 80 mg/ml
methylprednisolone sodium succinate inj 125 mg, 40 mg
MILLIPRED tabs 5 mg
mometasone topical cream 0.1 %, oint 0.1 %, soln 0.1 %
prednisolone tabs 5 mg
prednisolone sodium phosphate soln 15 mg/5ml, 6.7
mg/5ml (5 mg/5ml base)
prednisone tabs 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg
prednisone tabs 50 mg
SOLU-CORTEF inj 250 mg
triamcinolone topical cream 0.025 %, 0.1 %, 0.5 %, lot
0.025 %, 0.1 %, oint 0.025 %, 0.1 %, 0.5%
2
2
A-HYDROCORT,
SOLU-CORTEF
WESTCORT
MEDROL
DEPO-MEDROL
SOLU-MEDROL
MO/R PA^
MO/R PA^
MO/R
MO/R
MO/R
MO/R
2
2
2
2
2
2
2
4
4
2
MO/R
MO/R
ELOCON
MILLIPRED
ORAPRED,
PEDIAPRED
PREDNISONE
PREDNISONE
MO/R
MO/R
MO/R
MO/R
KENALOG
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
(HORMONALES, ESTIMULANTE/REEMPLAZO/MODIFICADOR (PITUITARIA))
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) (Hormonales,
Estimulante/Reemplazo/Modificador (Pituitaria))
chorionic gonadotropin inj 10000 u
4
PREGNYL
desmopressin tabs 0.1 mg, 0.2 mg, inj 4 mcg/ml, nasal
2
DDAVP
spray 0.01 %
GENOTROPIN inj 0.2 mg
4
MO/R PA#
MO/R
MO/R PA
Page 50 of 83
Drug (Medicamento)
GENOTROPIN inj 0.4 mg, 0.6 mg, 0.8 mg, 1 mg, 1.2 mg,
1.4 mg, 1.6 mg, 1.8 mg, 13.8 mg, 2 mg, 5 mg
HUMATROPE inj 12 mg, 24 mg, 5 mg, 6 mg
INCRELEX inj 10 mg/ml
NORDITROPIN inj 10 mg/1.5ml, 15 mg/1.5ml, 5
mg/1.5ml
NORDITROPIN NORDIFLEX PEN inj 30 mg/3ml
NUTROPIN inj 10 mg/2ml, 20 mg/2ml
NUTROPIN AQ inj 5 mg/2ml
OMNITROPE inj 10 mg/1.5ml, 5 mg/1.5ml, 5.8 mg
SAIZEN inj 5 mg, 8.8 mg
SEROSTIM inj 4 mg, 5 mg, 6 mg
STIMATE nasal soln 1.5 mg/ml
ZORBTIVE inj 8.8 mg
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
5
MO/R PA
5
5
5
MO/R PA
PA LA
MO/R PA
5
5
5
4
5
5
4
5
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R
MO/R PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PROSTAGLANDINS)
(HORMONALES, ESTIMULANTE/REEMPLAZO/MODIFICADOR (PROSTAGLANDINAS))
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) (Hormonales,
Estimulante/Reemplazo/Modificador (Prostaglandinas))
misoprostol tabs 200 mcg
2
CYTOTEC
MO/R
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX
HORMONES/MODIFIERS) (HORMONALES, ESTIMULANTE/REEMPLAZO/MODIFICADOR
(HORMONAS SEXUALES/MODIFICADORES))
Anabolic Steroid (Esteroides Anabólicos)
oxandrolone tabs 10 mg, 2.5 mg
2
Androgens (Andrógenos)
ANDRODERM patch 2 mg/24h, 4 mg/24h
ANDROXY tabs 10 mg
danazol caps 100 mg, 200 mg, 50 mg
testosterone cypionate inj 100 mg/ml, 200 mg/ml
3
4
2
2
testosterone enanthate inj 200 mg/ml
2
OXANDRIN
DANOCRINE
DEPOTESTOSTERONE
DELATESTRYL
MO/R QL
[60/30]
MO/R
MO/R
MO/R
MO/R
MO/R
Page 51 of 83
Drug (Medicamento)
Estrogens (Estrógenos)
estradiol weekly td patch 0.025 mg/24hrs, 0.0375
mg/24hrs, 0.05 mg/24hrs, 0.06 mg/24hrs, 0.075 mg/24hrs,
0.1 mg/24hrs
MENEST tabs 0.3 mg, 0.625 mg, 1.25 mg, 2.5 mg
VAGIFEM vaginal tabs 10 mcg
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
2
MO/R
3
3
MO/R
MO/R
Progestins (Progestinas)
DEPO-PROVERA inj 400 mg/ml
medroxyprogesterone inj 150 mg/ml
medroxyprogesterone tabs 10 mg, 2.5 mg, 5 mg
megestrol susp 40 mg/ml, tabs 20 mg, 40 mg
norethindrone tabs 0.35 mg, 5 mg
oral contraceptives tabs
4
2
2
2
2
2
oral contraceptives continuous cycle tabs
2
oral contraceptives extended cycle tabs
2
progesterone micronized caps 100 mg, 200 mg
2
DEPO-PROVERA
PROVERA
MEGACE
ORTHO MICRONOR
ORAL
CONTRACEPTIVES
ORAL
CONTRACEPTIVES
CONTINUOUS
CYCLE
ORAL
CONTRACEPTIVES
EXTENDED CYCLE
PROMETRIUM
MO/R PA
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
Selective Estrogen Receptor Modifying Agents (Modificadores Selectivos del Receptor de Estrógeno)
2
EVISTA
MO/R QL
Error! Bookmark not defined.Error! Bookmark not
defined.raloxifene tabs 60 mg
[30/30]
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
(HORMONALES, ESTIMULANTE/REEMPLAZO/MODIFICADOR (TIROIDE))
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) (Hormonales,
Estimulante/Reemplazo/Modificador (Tiroide))
levothyroxine tabs 100 mcg, 112 mcg, 125 mcg, 137 mcg,
2
SYNTHROID
150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75
mcg, 88 mcg
liothyronine tabs 25 mcg, 5 mcg, 50 mcg
2
CYTOMEL
SYNTHROID tabs 100 mcg, 112 mcg, 125 mcg, 137 mcg, 3
150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75
mcg, 88 mcg
MO/R
MO/R
MO/R
Page 52 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
HORMONAL AGENTS, SUPPRESSANT (ADRENAL) (HORMONALES, SUPRESORES
(ADRENAL))
Hormonal Agents, Suppressant (Adrenal) (Hormonales, Supresores (Adrenal))
LYSODREN tabs 500 mg
3
MO/R
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) (HORMONALES, SUPRESORES
(PARATIROIDE))
Hormonal Agents, Suppressant (Parathyroid) (Hormonales, Supresores (Paratiroide))
SENSIPAR tabs 90 mg
3
SENSIPAR tabs 30 mg, 60 mg
3
MO/R QL
[120/30]
MO/R QL
[60/30]
HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (HORMONALES, SUPRESORES
(PITUITARIA))
Hormonal Agents, Suppressant (Pituitary) (Hormonales, Supresores (Pituitaria))
bromocriptine caps 5 mg, tabs 2.5 mg
2
PARLODEL
cabergoline tabs 0.5 mg
2
DOSTINEX
ELIGARD inj 22.5 mg, 30 mg, 45 mg, 7.5 mg
4
leuprolide inj 5 mg/ml
2
LUPRON
LUPRON inj 22.5 mg, 3.75 mg, 30 mg, 7.5 mg
5
LUPRON DEPOT inj 11.25 mg, 45 mg
5
LUPRON DEPOT-PED inj 11.25 mg, 15 mg
5
octreotide inj 0.05 mg/ml, 0.1 mg/ml, 0.2 mg/ml
4
SANDOSTATIN
octreotide inj 0.5 mg/ml, 1 mg/ml
5
SANDOSTATIN
SANDOSTATIN LAR inj 10 mg, 20 mg, 30 mg
5
SIGNIFOR 0.3 mg/ml, 0.6 mg/ml, 0.9 mg/ml
5
SOMATULINE DEPOT inj 120 mg/0.5ml, 60 mg/0.2ml,
5
90 mg/0.3ml
SOMAVERT inj 10 mg, 15 mg, 20 mg
5
SYNAREL nasal soln 2 mg/ml
5
MO/R
MO/R
MO/R PA#
MO/R PA#
MO/R PA#
MO/R PA#
MO/R PA#
MO/R PA
MO/R PA
MO/R PA
MO/R PA
MO/R PA
PA LA
MO/R
Page 53 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS) (HORMONALES,
SUPRESORES (HORMONAS SEXUALES/MODIFICADORES))
Antiandrogens (Antiandrógenos)
bicalutamide tabs 50 mg
2
CASODEX
finasteride tabs 5 mg
2
PROSCAR
flutamide caps 125 mg
NILANDRON tabs 150 mg
2
4
EULEXIN
XTANDI caps 40 mg
5
MO/R QL
[30/30]
MO/R QL
[30/30]
MO/R
MO/R QL
[60/30]
MO/R QL
[120/30] PA
HORMONAL AGENTS, SUPPRESSANT (THYROID) (HORMONALES, SUPRESORES (TIROIDE))
Antithyroid Agents (Antitiroide)
methimazole tabs 10 mg, 5 mg
propylthiouracil tabs 50 mg
2
2
TAPAZOLE
PROPYLTHIOURAC
IL
MO/R
MO/R
IMMUNOLOGICAL AGENTS (INMUNOLÓGICOS)
Immune Suppressants (Supresores Inmunológicos)
ACTEMRA inj 200 mg/10ml
Error! Bookmark not defined.Error! Bookmark not
defined.ACTEMRA SQ 162 mg/0.9ml
ASTAGRAF caps sr 24h 0.5 mg, 1 mg, 5 mg
azathioprine tabs 50 mg
BENLYSTA inj 120 mg
CELLCEPT susp 200 mg/ml
cyclosporine caps 100 mg, 25 mg, inj 50 mg/ml
cyclosporine modified caps 100 mg, 25 mg, soln 100 mg/ml
DEPEN TITRATABS tabs 250 mg
ENBREL inj 25 mg, 25 mg/0.5ml, 50 mg/ml
HUMIRA inj 20 mg/0.4ml, 40 mg/0.8ml
methotrexate tabs 2.5 mg
methotrexate inj 25 mg/ml
mycophenolate mofetil caps 250 mg, tabs 500 mg
MO/R PA#
MO/R PA
5
5
4
2
5
4
2
2
4
5
5
2
2
2
IMURAN
SANDIMMUNE
NEORAL
METHOTREXATE,
RHEUMATREX
METHOTREXATE
CELLCEPT
MO/R PA^
MO/R PA^
MO/R PA#
MO/R PA^
MO/R PA^
MO/R PA^
MO/R
MO/R PA
MO/R PA
MO/R
MO/R PA^
MO/R PA^
Page 54 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
mycophenolate sodium dr tabs 180 mg, 360 mg
NULOJIX inj 250 mg
ORENCIA inj 125 mg/ml, 250 mg
RAPAMUNE soln 1 mg/ml, tabs 1 mg, 2 mg
REMICADE inj 100 mg
RHEUMATREX tabs 2.5 mg
sirolimus tabs 0.5 mg
tacrolimus caps 0.5 mg, 1 mg, 5 mg
XELJANZ tabs 5 mg
ZORTRESS tabs 0.25 mg, 0.5 mg
ZORTRESS tabs 0.75 mg
2
5
5
4
5
2
2
2
5
4
5
Immunizing Agents, Passive (Inmunizadores Pasivos)
CARIMUNE inj 3 gm
GAMMAGARD inj 2.5 gm/25ml
GAMUNEX-C inj 1 gm/10ml
SYNAGIS inj 50 mg/ml
3
4
4
5
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA
5
5
5
5
5
2
5
MO/R PA
PA LA
MO/R PA
MO/R PA
MO/R PA
MO/R
MO/R PA
Immunomodulators (Inmunomoduladores)
ACTIMMUNE inj 2 mu/0.5ml
ARCALYST inj 220 mg
AVONEX inj 30 mcg, 30 mcg/0.5ml
BETASERON inj 0.3 mg
EXTAVIA inj 0.3 mg
leflunomide tabs 10 mg, 20 mg
REBIF inj 22 mcg/0.5ml, 44 mcg/0.5ml, 8.8
mcg/0.2ml&22 mcg/0.5ml
RIDAURA caps 3 mg
TYSABRI inj 300 mg/15ml
XOLAIR inj 150 mg
Vaccines (Vacunas)
ACTHIB inj
ADACEL inj
BOOSTRIX inj
CERVARIX inj
COMVAX inj
DAPTACEL inj
ENGERIX-B inj 10 mcg/0.5ml, 20 mcg/ml
GARDASIL inj
HAVRIX inj 1440 elu/ml, 720 elu/0.5ml
MYFORTIC
Instruction
(Instrucción)
RAPAMUNE
PROGRAF
ARAVA
MO/R PA^
MO/R PA^
MO/R PA#
MO/R PA^
MO/R PA#
MO/R
MO/R PA^
MO/R PA^
MO/R PA
MO/R PA^
MO/R PA^
4
5
5
MO/R
PA# LA
MO/R PA#
4
4
4
4
4
4
4
4
4
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R PA#
MO/R
MO/R
Page 55 of 83
Drug (Medicamento)
IMOVAX RABIES inj
INFANRIX inj
IPOL inj
IXIARO inj
M-M-R II inj
MENACTRA inj
MENOMUNE inj
MENVEO inj
PEDVAX HIB inj
PROQUAD inj
RABAVERT inj
RECOMBIVAX HB inj 10 mcg/ml, 40 mcg/ml
ROTATEQ inj
TETANUS TOXOID inj 5 lf
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED
ADULT inj
TWINRIX inj
TYPHIM VI inj
VAQTA inj
VARIVAX inj
YF-VAX inj
ZOSTAVAX inj
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
4
4
4
4
4
4
4
4
4
4
4
4
4
3
3
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R PA#
MO/R
MO/R PA^
MO/R
4
4
4
4
4
4
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
INFLAMMATORY BOWEL DISEASE AGENTS (ENFERMEDAD INFLAMATORIA INTESTINAL)
Aminosalicylates (Aminosalicilatos)
APRISO caps 24h 0.375 gm
ASACOL dr tabs 800 mg
balsalazide caps 750 mg
CANASA rectal supp 1000 mg
DELZICOL dr caps 400 mg
DIPENTUM caps 250 mg
LIALDA dr tabs 1.2 gm
mesalamine rectal enema 4 gm
PENTASA cr caps 250 mg, 500 mg
4
3
2
3
3
4
3
2
4
Glucocorticoids (Glucocorticoides)
A-HYDROCORT inj 100 mg
budesonide sr caps 24h 3 mg
cortisone acetate tabs 25 mg
DEPO-MEDROL inj 20 mg/ml
2
2
2
4
COLAZAL
ROWASA
ENTOCORT
CORTONE
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R PA^
Page 56 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
dexamethasone conc 1 mg/ml
dexamethasone elixir 0.5 mg/5ml, tabs 0.5 mg, 0.75 mg,
1.5 mg, 4 mg, 6 mg
dexamethasone tabs 1 mg, 2 mg
dexamethasone sodium phosphate inj 4 mg/ml, 10 mg/ml
hydrocortisone tabs 10 mg, 20 mg, 5 mg
hydrocortisone sodium succinate inj 100 mg
2
2
DEXAMETHASONE
DEXAMETHASONE
MO/R
MO/R
4
2
2
2
MO/R
MO/R
MO/R
MO/R
methylprednisolone pack 4 mg, tabs 16 mg, 32 mg, 4 mg, 8
mg
methylprednisolone acetate inj 40 mg/ml, 80 mg/ml
methylprednisolone sodium succinate inj 125 mg, 40 mg
MILLIPRED tabs 5 mg
prednisolone tabs 5 mg
prednisolone sodium phosphate soln 15 mg/5ml, 6.7
mg/5ml (5 mg/5ml base)
prednisone tabs 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg
prednisone tabs 50 mg
SOLU-CORTEF inj 250 mg
2
DEXAMETHASONE
DEXAMETHASONE
CORTEF
A-HYDROCORT,
SOLU-CORTEF
MEDROL
DEPO-MEDROL
SOLU-MEDROL
MO/R PA^
MO/R PA^
MO/R
MO/R
MO/R
Sulfonamides (Sulfonamidas)
sulfasalazine tabs 500 mg
sulfasalazine dr tabs 500 mg
2
2
2
2
2
2
4
4
2
2
MILLIPRED
ORAPRED,
PEDIAPRED
PREDNISONE
PREDNISONE
AZULFIDINE
AZULFIDINE EN
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
METABOLIC BONE DISEASE AGENTS (ENFERMEDAD DEL METABOLISMO DEL HUESO)
Metabolic Bone Disease Agents (Enfermedad del Metabolismo del Hueso)
alendronate tabs 10 mg, 40 mg, 5 mg
2
FOSAMAX
alendronate tabs 35 mg, 70 mg
2
FOSAMAX
calcitonin, salmon nasal soln 200 u/act
calcitriol caps 0.25 mcg, 0.5 mcg, soln 1 mcg/ml
etidronate tabs 200 mg, 400 mg
FORTEO inj 600 mcg/2.4ml
ibandronate inj 3 mg/ml
ibandronate tabs 150 mg
2
2
2
5
1
2
MIACALCIN
ROCALTROL
DIDRONEL
MIACALCIN inj 200 u/ml
paricalcitol caps 1 mcg, 2 mcg, 4 mcg
PROLIA inj 60 mg/ml
4
2
4
BONIVA
BONIVA
ZEMPLAR
MO/R QL
[30/30]
MO/R QL
[4/28]
MO/R
MO/R PA^
MO/R
MO/R PA
MO/R PA#
MO/R QL
[1/28]
MO/R PA^
MO/R PA#
MO/R PA#
Page 57 of 83
Drug (Medicamento)
XGEVA inj 120 mg/1.7ml
ZEMPLAR inj 2 mcg/ml, 5 mcg/ml
zoledronic acid inj 4 mg/5ml
zoledronic acid inj 5 mg/100ml
ZOMETA inj 4 mg/5ml, 4 mg/100ml
Level
(Nivel)
5
3
4
4
5
Reference Name
(Nombre de
Referencia)
ZOMETA
RECLAST
Instruction
(Instrucción)
MO/R PA
MO/R PA#
MO/R PA^
MO/R PA#
MO/R PA^
MISCELLANEOUS THERAPEUTIC AGENTS (AGENTES TERAPÉUTICOS MISCELÁNEOS)
Miscellaneous Therapeutic Agents (Agentes Terapéuticos Misceláneos)
4
Error! Bookmark not defined.Error! Bookmark not
defined.ALCOHOL SWAB
GAUZE PADS (2x2)
4
INSULIN PEN NEEDLE inj
4
INSULIN SAFETY SYRINGE inj
4
INSULIN SYRINGE inj
4
MO/R
MO/R
MO/R
MO/R
MO/R
OPHTHALMIC AGENTS (OFTÁLMICOS)
Ophthalmic Agents, Other (Oftálmicos, Otros)
CYSTARAN ophth soln 0.44%
naphazoline ophth soln 0.1 %
RESTASIS ophth emulsion 0.05 %
5
2
3
Ophthalmic Anti-allergy Agents (Antialérgicos Oftálmicos)
cromolyn ophth soln 4 %
PATADAY ophth soln 0.2 %
2
3
Ophthalmic Antiglaucoma Agents (Antiglaucoma Oftálmicos)
acetazolamide tabs 125 mg, 250 mg
2
ALPHAGAN P ophth soln 0.1 %
3
AZOPT ophth susp 1 %
3
betaxolol ophth soln 0.5 %
4
BETOPTIC-S ophth susp 0.25 %
4
brimonidine ophth soln 0.15 %, 0.2 %
2
carteolol ophth soln 1 %
2
COMBIGAN ophth soln 0.2-0.5 %
4
dorzolamide ophth soln 2 %
2
dorzolamide & timolol ophth soln 22.3-6.8 mg/ml
2
levobunolol ophth soln 0.5 %
2
methazolamide tabs 25 mg, 50 mg
2
NAPHCON FORTE
MO/R PA
MO/R
MO/R QL
[60/30]
CROLOM
MO/R
MO/R
DIAMOX
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
BETOPTIC
ALPHAGAN P
OCUPRESS
TRUSOPT
COSOPT
BETAGAN
NEPTAZANE
Page 58 of 83
Drug (Medicamento)
metipranolol ophth soln 0.3 %
PHOSPHOLINE IODIDE ophth soln 0.125 %
SIMBRINZA ophth susp1-0.2 %
timolol maleate ophth gel soln 0.25 %, 0.5 %, soln 0.25 %,
0.5 %
Level
(Nivel)
2
4
4
2
Ophthalmic Antiinflammatories (Antiinflamatorios Oftálmicos)
dexamethasone sodium phosphate ophth soln 0.1 %
2
diclofenac sodium ophth soln 0.1 %
2
flurbiprofen sodium ophth soln 0.03 %
2
FML ophth oint 0.1%
4
ketorolac ophth soln 0.4 %, 0.5 %
2
prednisolone acetate ophth susp 1 %
2
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
OPTIPRANOLOL
MO/R
MO/R
MO/R
MO/R
TIMOPTIC XE
DECADRON
VOLTAREN
OCUFEN
MO/R
MO/R
MO/R
MO/R
ACULAR LS
MO/R
ECONOPRED PLUS / MO/R
PRED FORTE
Ophthalmic Prostaglandins and Prostamides (Prostaglandinas y Prostamidas Oftálmicas)
latanoprost ophth soln 0.005 %
2
XALATAN
LUMIGAN ophth soln 0.01 %
3
TRAVATAN/TRAVATAN Z ophth soln 0.004 %
3
travoprost ophth soln 0.004 %
3
TRAVATAN
MO/R
MO/R
MO/R
MO/R
OTIC AGENTS (OTICOS)
Otic Agents (Oticos)
acetic acid otic soln 2 %
acetic acid & hydrocortisone otic soln 1-2 %
fluocinolone acetonide otic oil 0.01 %
2
2
2
VOSOL
VOSOL HC
DERMOTIC
MO/R
MO/R
MO/R
RESPIRATORY TRACT AGENTS (TRACTO RESPIRATORIO)
Anti-inflammatories, Inhaled Corticosteroids (Anti-inflamatorios, Corticosteroides Inhalados)
ADVAIR DISKUS inhal 100-50 mcg/dose, 250-50
3
mcg/dose, 500-50 mcg/dose
ADVAIR HFA inhal 115-21 mcg/act, 230-21 mcg/act, 45- 3
21 mcg/act
ASMANEX inhal 110 mcg/inh, 220 mcg/inh, 220
3
mcg/inh, 220 mcg/inh
BREO ELLIPTA inhal 100-25 mcg/inh
4
budesonide inhal 0.25 mg/2ml, 0.5 mg/2ml
2
PULMICORT
DULERA inhal 100-5 mcg/act, 200-5 mcg/act
3
MO/R
MO/R
MO/R
MO/R PA
MO/R PA^
MO/R
Page 59 of 83
Drug (Medicamento)
FLOVENT diskus 100 mcg/blister, 250 mcg/blister, 50
mcg/blister, inhal110 mcg/act, 220 mcg/act, 44 mcg/act
flunisolide nasal soln 0.025 %
fluticasone propionate nasal susp 50 mcg/act
PULMICORT inhal 1 mg/2ml
QVAR inhal 40 mcg/act, 80 mcg/act
SYMBICORT inhal 80-4.5 mcg/act, 160-4.5 mg/act
triamcinolone nasal inhal 55 mcg/act
Antihistamines (Antihistamínicos)
ASTEPRO nasal spray 0.15 %
cyproheptadine tabs 4 mg
diphenhydramine inj 50 mg/ml
levocetirizine tabs 5 mg
PHENADOZ rectal supp 25 mg
promethazine syrup 6.25 mg/5ml, tabs 12.5 mg, 25 mg, 50
mg, inj 25 mg/ml, 50 mg/ml, rectal supp 12.5 mg, 25 mg,
50 mg
PROMETHEGAN rectal supp 50 mg
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
4
2
2
4
3
4
2
3
2
2
2
2
2
Instruction
(Instrucción)
MO/R
NASAREL
FLONASE
NASACORT AQ
PERIACTIN
BENADRYL
XYZAL
PHENERGAN,
PROMETHEGAN
2
MO/R
MO/R
MO/R PA^
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
Antileukotrienes (Antileukotrienos)
montelukast chew tab 4 mg, 5 mg, pack 4 mg, tabs 10 mg
2
SINGULAIR
zafirlukast tabs 10 mg, 20 mg
2
ACCOLATE
Bronchodilators, Anticholinergic (Broncodilatadores, Anticolinérgicos)
ANORO ELLIPTA 62.5-25 mcg/inh
4
ATROVENT HFA inhal 17 mcg/act
3
COMBIVENT inhal 20-100 mcg/act
3
ipratropium nasal soln 0.03 %, 0.06 %
2
ATROVENT
SPIRIVA inhal caps 18 mcg
3
MO/R QL
[30/30]
MO/R QL
[60/30]
MO/R PA
MO/R
MO/R
MO/R
MO/R
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) (Broncodilatadores, Inhibidores de la
Fosfodiesterasa (Xantinas))
aminophylline inj 25 mg/ml
2
AMINOPHYLLINE
MO/R PA^
DALIRESP tabs 500 mcg
4
MO/R
ELIXOPHYLLIN elixir 80 mg/15ml
4
MO/R
LUFYLLIN tabs 200 mg, 400 mg
4
MO/R
theophylline sr tabs 12h 100 mg, 200 mg, 300 mg, 450 mg 2
THEO-DUR
MO/R
tabs 24h 400 mg, 600 mg
Page 60 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Bronchodilators, Sympathomimetic (Broncodilatadores, Simpatomiméticos)
ADVAIR DISKUS inhal 100-50 mcg/dose, 250-50
3
mcg/dose, 500-50 mcg/dose
ADVAIR HFA inhal 115-21 mcg/act, 230-21 mcg/act, 45- 3
21 mcg/act
albuterol syrup 2 mg/5ml, tabs 2 mg, 4 mg
2
PROVENTIL
albuterol neb 0.083 %, 0.5 %
2
PROVENTIL
ANORO ELLIPTA 62.5-25 mcg/inh
4
BREO ELLIPTA inhal 100-25 mcg/inh
4
COMBIVENT inhal 20-100 mcg/act
3
DULERA inhal 100-5 mcg/act, 200-5 mcg/act
3
EPIPEN inj 0.15 mg/0.3ml, 0.3 mg/0.3ml
4
FORADIL inhal caps 12 mcg
3
PROAIR HFA inhal 108 mcg/act
3
PROVENTIL HFA inhal 108 mcg/act
3
SEREVENT inhal 50 mcg/dose
4
SYMBICORT inhal 80-4.5 mcg/act, 160-4.5 mg/act
4
terbutaline tabs 2.5 mg, 5 mg
2
BRETHINE
Mast Cell Stabilizers (Estabilizadores de Mastocitos)
cromolyn neb 20 mg/2ml
2
Pulmonary Antihypertensives (Anti-hipertensivos Pulmonales)
ADCIRCA tabs 20 mg
5
ADEMPAS tabs 0.5 mg, 1 mg, 1.5 mg, 2 mg, 2.5 mg
5
LETAIRIS tabs 10 mg, 5 mg
5
OPSUMIT tabs 10 mg
5
sildenafil tabs 20 mg
2
TRACLEER tabs 125 mg, 62.5 mg
5
VENTAVIS inhal 10 mcg/ml, 20 mcg/ml
5
Respiratory Tract Agents, Others (Tracto Respiratorio, Otros)
acetylcysteine inhal soln 10 %, 20 %
2
ARALAST NP inj 400 mg
5
KALYDECO tabs 150 mg
5
PROLASTIN inj 1000 mg
PULMOZYME inj 1 mg/ml
TYZINE nasal soln 0.05 %
ZEMAIRA inj 1000 mg
5
4
4
5
INTAL
REVATIO
MUCOMYST
Instruction
(Instrucción)
MO/R
MO/R
MO/R
MO/R PA^
MO/R PA
MO/R PA
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R
MO/R PA^
MO/R PA
MO/R PA
PA LA
MO/R PA
MO/R PA
PA LA
MO/R PA
MO/R PA^
MO/R PA#
MO/R QL
[60/30] PA
PA# LA
MO/R PA#
MO/R
PA# LA
Page 61 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
Instruction
(Instrucción)
SKELETAL MUSCLE RELAXANTS (RELAJANTES MUSCULOESQUELETALES)
Skeletal Muscle Relaxants (Relajantes Musculoesqueletales)
methocarbamol tabs 500 mg, 750 mg
2
orphenadrine sr tabs 12h 100 mg
2
ROBAXIN
NORFLEX
MO/R
MO/R
GABA Receptor Modulators (Moduladores del Receptor de GABA)
zaleplon caps 10 mg, 5 mg
2
SONATA
zolpidem tabs 10 mg, 5 mg
2
AMBIEN
MO/R QL
[30/30]
MO/R QL
[30/30]
2
ADAPIN
MO/R
4
3
PROVIGIL
MO/R PA
PA LA
SLEEP DISORDER AGENTS (DESORDENES DEL SUEÑO)
Sleep Disorder, Other (Desordenes del Sueño, Otros)
doxepin caps 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75
mg, conc 10 mg/ml
modafinil tabs 100 mg, 200 mg
XYREM soln 500 mg/ml
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES (NUTRIENTES
TERAPÉUTICOS/MINERALES/ELECTROLITOS)
Electrolytes/Minerals Modifiers (Electrolitos/Modificadores de Minerales)
DEPEN TITRATABS tabs 250 mg
4
EXJADE susp tab 125 mg
4
EXJADE susp tab 250 mg, 500 mg
5
FERRIPROX tabs 500 mg
5
sodium polystyrene sulfonate powder , 15 gm/60ml
2
KAYEXALATE,
KIONEX
Electrolytes/Minerals Replacement (Remplazo de Electrolitos/Minerales)
amino acids inj 15 %, 6 %, 8 %
2
AMINOSYN
amino acids & electrolyte inj 8.5 %
2
AMINOSYN
AMINOSYN inj 8.5 %
2
AMINOSYN inj 10 %, 7 %
4
CLINIMIX inj 2.75 %, 4.25 %, 5 %
4
CLINIMIX E inj 2.75 %, 4.25 %, 5 %
4
dextrose inj 10 %, 5 %
2
DEXTROSE
MO/R
MO/R PA
MO/R PA
MO/R PA
MO/R
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
Page 62 of 83
Drug (Medicamento)
Level
(Nivel)
Reference Name
(Nombre de
Referencia)
DEXTROSE/
RINGERS
DEXTROSE/NACL
DEXTROSE/NACL
Instruction
(Instrucción)
dextrose & ringers inj 5 %
2
DEXTROSE & SODIUM CHLORIDE inj 10-0.2 %
dextrose & sodium chloride inj 2.5-0.45 %, 5-0.2 %, 50.33 %, 5-0.45 %, 5-0.9 %
DEXTROSE & SODIUM CHLORIDE inj 10-0.45 %, 50.225 %
electrolytes inj
fat emulsion inj 20 %
INTRALIPID inj 10 %, 30 %
ISOLYTE inj
levocarnitine soln 1 gm/10ml, tabs 330 mg
NEPHRAMINE inj 5.4 %
NORMOSOL inj
PLASMA-LYTE inj
potassium chloride inj 2 meq/ml
2
2
potassium chloride cr caps 10 meq, 8 meq, tabs 10 meq, 20
meq, 8 meq
POTASSIUM CITRATE CR tabs 10 meq, 5 meq
PREMASOL inj 10 %
PROCALAMINE inj 3 %
PROSOL inj 20 %
sodium chloride inj 0.45 %, 0.9 %, 2.5 meq/ml
2
SODIUM FLUORIDE chew tab 0.25 mg, 0.5 mg, 1 mg,
tab 0.5mg, 1 mg
TRAVASOL inj 10 %, 3.5 %
TROPHAMINE inj 10 %
UROCIT-K tabs 15 meq
4
MO/R
4
4
4
MO/R PA^
MO/R PA^
MO/R
4
2
2
4
4
2
4
4
4
2
2
4
4
4
2
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
ELECTROLYTES
INTRALIPID
CARNITOR
POTASSIUM
CHLORIDE
MICRO-K/SLOW-K
UROCIT-K
SODIUM
CHLORIDE
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
MO/R
MO/R
MO/R PA^
MO/R PA^
MO/R PA^
MO/R PA^
Vitamins (Vitaminas)
PRENATAL VITAMIN
4
MO/R
LA=Limited Access (Acceso Limitado)
MO/R=Mail Order/Retail (Servicio de Correo/Suplido Extendido)
PA=Prior-authorization (Precertificación)
PA^=Prior-authorization Part B vs Part D ONLY (Precertificación Parte B vs Parte D SOLAMENTE)
PA#= Prior-authorization Clinical Criteria and Part B vs Part D (Precertificación Criterio Clínico y Parte B vs
Parte D)
QL= Quantity Limit (Limite de Cantidad)
Page 63 of 83
Page 64 of 83
Supplemental Drugs
Level
(Nivel)
Drug (Medicamento)
cyanocobalam inj 1000 mcg/ml
folic acid tabs 1 mg
iron dextran inj 50 mg/ml
MEPHYTON tabs 5 mg
Error! Bookmark not defined.VIAGRA tabs
100 mg, 25 mg, 50 mg
3
3
3
3
3
Reference
Name
(Nombre de
Referencia)
Instructions
(Instrucciones)
INFED
QL [4/30]
Page 65 of 83
TABLE OF CONTENTS (TABLA DE CONTENIDO)
ANALGESICS (ANALGÉSICOS) .................................................................................. 6
Nonsteroidal Anti-inflammatory Drugs (Anti-inflamatorios No Esteroidales) .............. 6
Opioid Analgesics, Long-acting (Analgésicos Opiodes, Larga Duración)..................... 6
Opioid Analgesics, Short-acting (Analgésicos Opiodes, Corta Duración) ..................... 7
ANESTHETICS (ANESTÉSICOS) ................................................................................ 8
Local Anesthetics (Anestésico Local) ............................................................................ 8
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
(TRATAMIENTO DE ABUSO DE SUSTANCIAS/CONTRA LA ADDICIÓN) ...... 8
Alcohol Deterrents/Anti-craving (Disuasivos de Alcohol/Anti-ansiedad) ..................... 8
Opioid Antagonist (Antagonista de Opioides) ................................................................ 8
Smoking Cessation Agents (Cesación de Fumar) ........................................................... 8
ANTI-INFLAMMATORY AGENTS (ANTI-INFLAMATORIOS) ............................ 8
Glucocorticoids (Glucocorticoides) ................................................................................ 8
Nonsteroidal Anti-inflammatory Drugs (Anti-inflamatorios No Esteroidales) .............. 9
ANTIBACTERIALS (ANTIBACTERIANOS) ........................................................... 10
Aminoglycosides (Aminoglicósidos)............................................................................ 10
Antibacterials, Other (Antibacterianos, Otros) ............................................................. 10
Beta-lactam, Cephalosporins (Cefalosporinas, Beta-lactámicas) ................................. 11
Beta-lactam, Other (Beta-lactámicos, Otros) ................................................................ 12
Beta-lactam, Penicillins (Penicilinas, Beta-lactámicas)................................................ 12
Macrolides (Macrólidos) ............................................................................................... 12
Quinolones (Quinolonas) .............................................................................................. 13
Sulfonamides (Sulfonamidas) ....................................................................................... 13
Tetracyclines (Tetraciclinas) ......................................................................................... 13
ANTICONVULSANTS (ANTICONVULSIVANTES) ............................................... 14
Anticonvulsants, Other (Anticonvulsivantes, Otros) .................................................... 14
Calcium Channel Modifying Agents (Modificadores de Canales de Calcio)............... 14
Gamma-aminobutyric Acid (GABA) Augmenting Agents (Aumentadores del Acido
Gamma-Aminobutírico) ................................................................................................ 14
Glutamate Reducing Agents (Reductores de Glutamato) ............................................. 14
Sodium Channel Agents (Canales de Sodio) ................................................................ 15
ANTIDEMENTIA AGENTS (ANTIDEMENCIA) ..................................................... 15
Cholinesterase Inhibitors (Inhibidores de Colinesterasa) ............................................. 15
N-methyl-D-aspartate (NMDA) Receptor Antagonist (Antagonista del Receptor
NMDA) ......................................................................................................................... 16
ANTIDEPRESSANTS (ANTIDEPRESIVOS)............................................................. 16
Antidepressants, Other (Antidepresivos, Otros) ........................................................... 16
Monoamine Oxidase Inhibitors (Inhibidores de Monoamina Oxidasa) ....................... 17
Serotonin/Norepinephrine Reuptake Inhibitors (Inhibidores de la Recaptación de
Serotonina/ Norepinefrina) ........................................................................................... 17
Tricyclics (Tricíclicos) .................................................................................................. 18
ANTIEMETICS (ANTIEMÉTICOS) ........................................................................... 18
Antiemetics (Antieméticos) .......................................................................................... 18
Page 66 of 83
Emetogenic Therapy Adjuncts (Adjuvantes para Terapia Emetogénica) ..................... 19
ANTIFUNGALS (ANTIFUNGALES) .......................................................................... 19
Antifungals (Antifungales) ........................................................................................... 19
ANTIGOUT AGENTS (ANTIGOTA) .......................................................................... 20
Antigout Agents (Antigota) .......................................................................................... 20
ANTIMIGRAINE AGENTS (ANTIMIGRAÑA) ........................................................ 20
Antihistamines (Antihistamínicos) ............................................................................... 20
Ergot Alkaloids (Alcaloides de Ergotamina) ................................................................ 20
Prophylactic (Profilaxis) ............................................................................................... 20
Serotonin (5-HT) 1b/1d Receptor Agonists (Agonistas del Receptor de Serotonina) .. 21
ANTIMYASTHENIC AGENTS (ANTIMIASTÉNICOS) ......................................... 21
Parasympathomimetics (Parasimpatomiméticos) ......................................................... 21
ANTIMYCOBACTERIALS (ANTIMICOBACTERIANOS).................................... 21
Antimycobacterials, Other (Antimicobacterianos, Otros) ............................................ 21
Antituberculars (Antituberculosos) ............................................................................... 21
ANTINEOPLASTICS (ANTINEOPLÁSICOS) .......................................................... 22
Alkylating Agents (Alquilantes) ................................................................................... 22
Antiangiogenic Agents (Antiangiogénicos) .................................................................. 22
Antiestrogens/Modifiers (Antiestrógenos/Modificadores) ........................................... 22
Antimetabolites (Antimetabolitos)................................................................................ 22
Antineoplastics, Others (Antineoplásicos, Otros) ......................................................... 22
Aromatase Inhibitors, 3rd Generation (Inhibidores de Aromatasa, 3ra generación) .... 23
Enzyme Inhibitors (Inhibidores Enzimáticos) .............................................................. 23
Molecular Target Inhibitors (Inhibidores del Blanco Molecular)................................. 23
Monoclonal Antibodies (Anticuerpos Monoclonales) .................................................. 24
Retinoids (Retinoides) .................................................................................................. 24
ANTIPARASITICS (ANTIPARASITARIOS) ............................................................ 24
Anthelmintics (Antihelmínticos) .................................................................................. 24
Antiprotozoals (Antiprotozoarios) ................................................................................ 24
Pediculicides/Scabicides (Pediculicidas/Escabicidas) .................................................. 25
ANTIPARKINSON AGENTS (ANTIPARKINSON) ................................................. 25
Anticholinergics (Anticolinérgicos).............................................................................. 25
Antiparkinson Agents, Others (Antiparkinson, Otros) ................................................. 25
Dopamine Agonist (Agonistas de Dopamine) .............................................................. 25
Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors (Precursores de
Dopamina/Inhibidores del L-Amino Acid Decarboxylase) .......................................... 25
Monoamine Oxidase B (MAO-B) Inhibitors (Inhibidores de MAO-B) ....................... 26
ANTIPSYCHOTICS (ANTIPSICÓTICOS) ................................................................ 26
1st Generation/Typical (1ra Generación/Típicos) ........................................................ 26
2nd Generation/Atypical (2da Generación/Atípicos) ................................................... 26
Treatment-Resistant (Resistentes a Tratamiento) ......................................................... 27
ANTISPASTICITY (ANTIESPASTICIDAD) ............................................................. 28
Antispasticity (Antiespasticidad) .................................................................................. 28
ANTIVIRALS (ANTIVIRALES) .................................................................................. 28
Anti-cytomegalovirus (CMV) Agents (Anti-citomegalovirus) .................................... 28
Page 67 of 83
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (Anti-VIH,
Inhibidores No Nucleósidos de la Transciptasa Reversa)............................................. 28
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (AntiVIH, Inhibidores Nucleósidos y Nucleótidos de la Transcriptasa Reversa) ................. 28
Anti-HIV Agents, Others (Anti-VIH, Otros) ................................................................ 29
Anti-HIV Agents, Protease Inhibitors (Anti-VIH, Inhibidores de la Proteasa) ............ 29
Anti-influenza Agents (Antiinfluenza) ......................................................................... 29
Antihepatitis Agents (Antihepatitis) ............................................................................. 29
Antiherpetic Agents (Antiherpéticos) ........................................................................... 30
ANXIOLYTICS (ANSIOLÍTICOS) ............................................................................. 30
Anxiolytics, Other (Ansiolíticos, Otros) ....................................................................... 30
SSRIs/SNRIs (Selective Serotonin /Serotonin-Norepinephrine Reuptake Inhibitors)
(SSRIs/SNRIs) .............................................................................................................. 30
BIPOLAR AGENTS (BIPOLARIDAD) ....................................................................... 31
Bipolar Agents, Other (Bipolaridad, Otros) .................................................................. 31
Mood Stabilizers (Estabilizadores del Ánimo) ............................................................. 32
BLOOD GLUCOSE REGULATORS (REGULADORES DE GLUCOSA EN
SANGRE)......................................................................................................................... 32
Antidiabetic Agents (Antidiabéticos) ........................................................................... 32
Glycemic Agents (Glicémicos) ..................................................................................... 34
Insulins (Insulinas) ........................................................................................................ 34
BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERS (PRODUCTOS
PARA LA SANGRE/MODIFICADORES/EXPANSORES DE VOLUMEN) ......... 35
Anticoagulants (Anticoagulantes) ................................................................................. 35
Blood Formation Modifiers (Modificadores de la Formación de Sangre) ................... 35
Coagulants (Coagulantes) ............................................................................................. 36
Platelet Modifying Agents (Modificadores de Plaquetas) ............................................ 36
CARDIOVASCULAR AGENTS (CARDIOVASCULARES).................................... 36
Alpha-adrenergic Agonists (Agonistas Alfa Adrenérgicos) ......................................... 36
Alpha-adrenergic Blocking Agents (Bloqueadores Alfa Adrenérgicos) ...................... 37
Angiotensin II Receptor Antagonists (Antagonistas del Receptor Angiotensina II) .... 37
Angiotensin-converting Enzyme (ACE) Inhibitors (Inhibidores de la Enzima
Convertidora de Angiotensin) ....................................................................................... 37
Antiarrhythmics (Antiarrítmicos) ................................................................................. 38
Beta-adrenergic Blocking Agents (Bloqueadores Beta Adrenérgicos) ........................ 39
Calcium Channel Blocking Agents (Bloqueadores de Canales de Calcio) .................. 40
Cardiovascular Agents, Other (Cardiovasculares, Otros) ............................................. 40
Diuretics, Carbonic Anhydrase Inhibitors (Diuréticos Inhibidores de Anhidrasa
Carbónica) ..................................................................................................................... 40
Diuretics, Loop (Diuréticos del Asa) ............................................................................ 41
Diuretics, Potassium-sparing (Diuréticos Conservadores de Potasio) .......................... 41
Diuretics, Thiazide (Diuréticos Tiazidas) ..................................................................... 41
Dyslipidemics, Fibric Acid Derivatives (Dislipidémicos, Derivados de Ácido Fíbrico)
....................................................................................................................................... 41
Dyslipidemics, HMG CoA Reductase Inhibitors (Dislipidémicos, Inhibidores de la
Reductasa de HMG CoA) ............................................................................................. 41
Page 68 of 83
Dyslipidemics, Other (Dislipidémicos, Otros).............................................................. 42
Vasodilators, Direct-acting Arterial (Vasodilatadores, Arteriales)............................... 42
Vasodilators, Direct-acting Arterial/Venous (Vasodilatadores, Arteriales/Venosos) .. 42
CENTRAL NERVOUS SYSTEM AGENTS (SISTEMA NERVIOSO CENTRAL) 42
ADHD, Amphetamines (Anfetaminas, ADHD) ........................................................... 42
ADHD, Non-amphetamines (No-Anfetaminas, ADHD) .............................................. 43
Barbiturates (Barbitúricos)............................................................................................ 43
Benzodiazepines (Benzodiazepinas) ............................................................................. 43
Central Nervous System Agents, Others (Sistema Nervioso Central, Otros) ............... 43
Fibromyalgia Agents (Fibromialgia) ............................................................................ 44
Multiple Sclerosis Agents (Esclerosis Múltiple) .......................................................... 44
DENTAL AND ORAL AGENTS (DENTALES Y ORALES) .................................... 44
Dental and Oral Agents (Dentales y Orales)................................................................. 44
DERMATOLOGICAL AGENTS (DERMATOLÓGICOS) ...................................... 45
Dermatological Agents (Dermatológicos) .................................................................... 45
ENZYME REPLACEMENTS/MODIFIERS (REEMPLAZO DE
ENZIMAS/MODIFICADORES)................................................................................... 46
Enzyme Replacements/Modifiers (Reemplazo de Enzimas/Modificadores) ............... 46
GASTROINTESTINAL AGENTS (GASTROINTESTINALES) ............................. 46
Antispasmodics, Gastrointestinal (Antiespasmódicos, Gastrointestinales) .................. 46
Gastrointestinal Agents, Others (Gastrointestinales, Otros) ......................................... 46
Histamine2 (H2) Receptor Antagonists (Antagonistas del Receptor de Histamina2
(H2)) .............................................................................................................................. 47
Irritable Bowel Syndrome Agents (Sídrome de Colon Irritado) ................................... 47
Laxatives (Laxantes) ..................................................................................................... 47
Protectants (Protectores) ............................................................................................... 47
Proton Pump Inhibitors (Inhibidores de la Bomba de Protones) .................................. 47
GENITOURINARY AGENTS (GENITOURINARIOS) ............................................ 48
Antispasmodics, Urinary (Antiespasmódicos, Urinarios) ............................................ 48
Benign Prostatic Hypertrophy Agents (Hipertrofia Prostática Benigna) ...................... 48
Genitourinary Agents, Others (Genitourinarios, Otros) ............................................... 48
Phosphate Binders (Enlazadores de Fosfato) ................................................................ 48
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING
(ADRENAL) (HORMONALES, ESTIMULANTE/REEMPLAZO/MODIFICADOR
(ADRENAL)) ................................................................................................................... 49
Glucocorticoids / Mineralocorticoids (Glucocorticoides/Mineralocorticoides) ........... 49
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING
(PITUITARY) (HORMONALES,
ESTIMULANTE/REEMPLAZO/MODIFICADOR (PITUITARIA)) ...................... 50
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) (Hormonales,
Estimulante/Reemplazo/Modificador (Pituitaria))........................................................ 50
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING
(PROSTAGLANDINS) (HORMONALES,
ESTIMULANTE/REEMPLAZO/MODIFICADOR (PROSTAGLANDINAS)) ...... 51
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) (Hormonales,
Estimulante/Reemplazo/Modificador (Prostaglandinas)) ............................................. 51
Page 69 of 83
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX
HORMONES/MODIFIERS) (HORMONALES,
ESTIMULANTE/REEMPLAZO/MODIFICADOR (HORMONAS
SEXUALES/MODIFICADORES)) ............................................................................... 51
Anabolic Steroid (Esteroides Anabólicos) .................................................................... 51
Androgens (Andrógenos) .............................................................................................. 51
Estrogens (Estrógenos) ................................................................................................. 51
Progestins (Progestinas) ................................................................................................ 51
Selective Estrogen Receptor Modifying Agents (Modificadores Selectivos del
Receptor de Estrógeno) ................................................................................................. 52
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING
(THYROID) (HORMONALES, ESTIMULANTE/REEMPLAZO/MODIFICADOR
(TIROIDE)) ..................................................................................................................... 52
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) (Hormonales,
Estimulante/Reemplazo/Modificador (Tiroide)) .......................................................... 52
HORMONAL AGENTS, SUPPRESSANT (ADRENAL) (HORMONALES,
SUPRESORES (ADRENAL))........................................................................................ 52
Hormonal Agents, Suppressant (Adrenal) (Hormonales, Supresores (Adrenal)) ......... 52
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) (HORMONALES,
SUPRESORES (PARATIROIDE)) ............................................................................... 52
Hormonal Agents, Suppressant (Parathyroid) (Hormonales, Supresores (Paratiroide))
....................................................................................................................................... 52
HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (HORMONALES,
SUPRESORES (PITUITARIA)) ................................................................................... 53
Hormonal Agents, Suppressant (Pituitary) (Hormonales, Supresores (Pituitaria)) ...... 53
HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS)
(HORMONALES, SUPRESORES (HORMONAS
SEXUALES/MODIFICADORES)) ............................................................................... 53
Antiandrogens (Antiandrógenos) .................................................................................. 53
HORMONAL AGENTS, SUPPRESSANT (THYROID) (HORMONALES,
SUPRESORES (TIROIDE)) .......................................................................................... 53
Antithyroid Agents (Antitiroide) .................................................................................. 53
IMMUNOLOGICAL AGENTS (INMUNOLÓGICOS) ............................................. 54
Immune Suppressants (Supresores Inmunológicos) ..................................................... 54
Immunizing Agents, Passive (Inmunizadores Pasivos) ................................................ 54
Immunomodulators (Inmunomoduladores) .................................................................. 54
Vaccines (Vacunas) ...................................................................................................... 55
INFLAMMATORY BOWEL DISEASE AGENTS (ENFERMEDAD
INFLAMATORIA INTESTINAL) ............................................................................... 56
Aminosalicylates (Aminosalicilatos) ............................................................................ 56
Glucocorticoids (Glucocorticoides) .............................................................................. 56
Sulfonamides (Sulfonamidas) ....................................................................................... 56
METABOLIC BONE DISEASE AGENTS (ENFERMEDAD DEL
METABOLISMO DEL HUESO) .................................................................................. 57
Metabolic Bone Disease Agents (Enfermedad del Metabolismo del Hueso) ............... 57
Page 70 of 83
MISCELLANEOUS THERAPEUTIC AGENTS (AGENTES TERAPÉUTICOS
MISCELÁNEOS)............................................................................................................ 57
Miscellaneous Therapeutic Agents (Agentes Terapéuticos Misceláneos) .................... 57
OPHTHALMIC AGENTS (OFTÁLMICOS) .............................................................. 57
Ophthalmic Agents, Other (Oftálmicos, Otros) ............................................................ 57
Ophthalmic Anti-allergy Agents (Antialérgicos Oftálmicos) ....................................... 58
Ophthalmic Antiglaucoma Agents (Antiglaucoma Oftálmicos)................................... 58
Ophthalmic Antiinflammatories (Antiinflamatorios Oftálmicos) ................................ 58
Ophthalmic Prostaglandins and Prostamides (Prostaglandinas y Prostamidas
Oftálmicas) .................................................................................................................... 58
OTIC AGENTS (OTICOS)............................................................................................ 59
Otic Agents (Oticos) ..................................................................................................... 59
RESPIRATORY TRACT AGENTS (TRACTO RESPIRATORIO) ........................ 59
Anti-inflammatories, Inhaled Corticosteroids (Anti-inflamatorios, Corticosteroides
Inhalados) ...................................................................................................................... 59
Antihistamines (Antihistamínicos) ............................................................................... 59
Antileukotrienes (Antileukotrienos) ............................................................................. 60
Bronchodilators, Anticholinergic (Broncodilatadores, Anticolinérgicos) .................... 60
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) (Broncodilatadores,
Inhibidores de la Fosfodiesterasa (Xantinas))............................................................... 60
Bronchodilators, Sympathomimetic (Broncodilatadores, Simpatomiméticos) ............ 60
Mast Cell Stabilizers (Estabilizadores de Mastocitos).................................................. 61
Pulmonary Antihypertensives (Anti-hipertensivos Pulmonales) .................................. 61
Respiratory Tract Agents, Others (Tracto Respiratorio, Otros) .................................... 61
SKELETAL MUSCLE RELAXANTS (RELAJANTES
MUSCULOESQUELETALES) ..................................................................................... 61
Skeletal Muscle Relaxants (Relajantes Musculoesqueletales) ..................................... 61
SLEEP DISORDER AGENTS (DESORDENES DEL SUEÑO) ............................... 61
GABA Receptor Modulators (Moduladores del Receptor de GABA) ......................... 61
Sleep Disorder, Other (Desordenes del Sueño, Otros) ................................................. 61
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES (NUTRIENTES
TERAPÉUTICOS/MINERALES/ELECTROLITOS) ............................................... 62
Electrolytes/Minerals Modifiers (Electrolitos/Modificadores de Minerales) ............... 62
Electrolytes/Minerals Replacement (Remplazo de Electrolitos/Minerales) ................. 62
Vitamins (Vitaminas) .................................................................................................... 63
Supplemental Drugs........................................................................................................ 64
INDEX (INDICE)
A
abacavir ..................... 29
abacavir & lamivudine
& zidovudine......... 29
ABILIFY 16, 27, 28, 32,
33
acamprosate................. 8
acarbose..................... 34
ACCOLATE ............. 62
ACCUPRIL ............... 39
ACCURETIC ............ 40
ACCUTANE ............. 47
acebutolol ............ 40, 41
ACEON ..................... 39
acetaminophen ............ 7
acetazolamide ...... 42, 60
acetic ......................... 61
acetylcysteine ............ 64
Page 71 of 83
acitretin ..................... 47
ACLOVATE ............. 51
ACTEMRA ............... 56
ACTHIB .................... 57
ACTIMMUNE .......... 57
ACTIQ ........................ 7
ACTOPLUS ........ 34, 35
ACTOS ..................... 35
ACULAR .................. 61
acyclovir .................... 31
ADACEL .................. 57
ADAGEN .................. 48
ADALAT CC ............ 42
ADAPIN ....... 19, 32, 64
ADCIRCA................. 64
ADDERALL ............. 44
adefovir ..................... 31
ADEMPAS ............... 64
ADVAIR ............. 62, 63
AFEDITAB ............... 42
AFINITOR ................ 24
AGGRENOX ............ 38
AGRYLIN................. 38
A-HYDROCORT .. 8, 9,
51, 52, 59
ALBENZA ................ 25
albital-acetaminophencaffeine .................. 45
albuterol .................... 63
alclometasone ............ 51
ALDACTAZIDE ...... 43
ALDACTONE .......... 43
ALDARA .................. 47
ALDOMET ............... 38
ALDURAZYME....... 48
alendronate ................ 59
ALIMTA ................... 23
ALINIA ..................... 25
allopurinol ................. 21
ALPHAGAN....... 60, 61
alprazolam ................. 45
ALTACE ................... 40
amantadine .......... 26, 31
AMARYL ................. 34
AMBIEN ................... 64
AMBISOME ............. 20
AMERGE.................. 21
amifostine.................. 23
amikacin .................... 10
AMIKIN .................... 10
amiloride ................... 43
amino......................... 65
aminophylline ........... 63
AMINOPHYLLINE . 63
AMINOSYN ............. 65
amiodarone ................ 40
AMITIZA .................. 49
amitriptyline .............. 18
amlodipine........... 39, 41
amoxapine ................. 18
amoxicillin ................ 12
AMOXIL................... 12
amphetamine ............. 44
amphotericin ............. 20
ampicillin .................. 12
AMPICILLIN ........... 12
AMPYRA ................. 46
AMTURNIDE........... 42
ANAFRANIL ........... 18
anagrelide .................. 38
ANAPROX ........... 6, 10
anastrozole ................ 24
ANCOBON ............... 20
ANDRODERM ......... 53
ANDROXY............... 53
ANORO ELLIPTA ... 63
ANSAID ................. 6, 9
ANTABUSE ............... 8
ANTIVERT............... 19
APIDRA .................... 36
APOKYN .................. 26
APRESOLINE .......... 44
APRISO .................... 58
APTIOM ................... 15
APTIVUS .................. 30
ARALAST ................ 64
ARALEN .................. 25
ARANESP ................ 37
ARAVA .................... 57
ARCALYST ............. 57
ARICEPT .................. 16
ARIMIDEX............... 24
ARIXTRA ................. 37
AROMASIN ............. 24
ARTANE .................. 26
ASACOL................... 58
ASMANEX ............... 62
ASTAGRAF ............. 56
ASTEPRO ................. 62
ATACAND ............... 38
atenolol ...................... 41
ATIVAN ................... 45
atorvastatin ................ 43
atovaquone ................ 25
ATRIPLA .................. 29
ATROVENT ............. 63
AUBAGIO ................ 46
augmented ................. 51
AUGMENTIN .......... 12
AVALIDE ................. 39
AVAPRO .................. 39
AVASTIN ................. 25
AVELOX .................. 13
AVONEX ............ 46, 57
AYGESTIN............... 54
azacitidine ................. 23
azathioprine ............... 56
AZILECT .................. 27
azithromycin ............. 13
AZOPT ...................... 60
AZULFIDINE ........... 59
B
bacitracin ................... 10
baclofen ..................... 29
BACTRIM ................ 13
BACTRIM / SEPTRA
............................... 14
BACTROBAN .......... 11
balsalazide ................. 58
BANZEL ................... 15
BARACLUDE .......... 31
BENADRYL . 19, 26, 62
benazepril .................. 39
BENEMID ................ 21
BENLYSTA .............. 56
BENTYL ................... 48
benztropine ................ 26
Page 72 of 83
BETAGAN ............... 61
betamethasone ........... 51
BETAPACE .............. 40
BETASERON ..... 46, 57
betaxolol.............. 41, 61
bethanechol ............... 51
BETOPTIC ............... 61
BETOPTIC-S ............ 61
BIAXIN..................... 13
bicalutamide .............. 56
BICILLIN ................. 12
BILTRICIDE ............ 25
bisoprolol .................. 41
BLENOXANE .......... 23
bleomycin .................. 23
BLEPH-10................. 13
BLOCADREN .... 21, 41
BONIVA ................... 60
BOOSTRIX............... 57
BOSULIF .................. 24
BREO ELLIPTA . 62, 63
BRETHINE ............... 63
BRILINTA ................ 38
brimonidine ............... 61
BRINTELLIX ........... 17
bromocriptine ...... 26, 55
budesonide 8, 51, 59, 62
bumetanide ................ 42
BUMEX .................... 42
BUPHENYL ............. 48
buprenorphine ............. 8
BUPROBAN ............... 8
bupropion ........ 8, 16, 17
BUSPAR ................... 31
buspirone ................... 31
BUTISOL .................. 45
butorphanol ................. 7
BYDUREON ............ 34
BYETTA ................... 34
C
cabergoline ................ 55
CALAN ......... 40, 41, 42
calcipotriene .............. 47
calcitonin, .................. 59
calcitriol .................... 59
calcium ...................... 51
CAMPRAL ................. 8
CAMPTOSAR .......... 23
CANASA .................. 58
CANCIDAS .............. 20
candesartan ................ 38
CAPASTAT .............. 22
CAPOTEN ................ 39
CAPOZIDE ............... 39
CAPRELSA .............. 24
captopril .................... 39
CARAC ..................... 47
CARAFATE ............. 49
carbamazepine..... 15, 33
carbidopa ............. 26, 27
CARDENE ................ 42
CARDIZEM .. 40, 41, 42
CARDIZEM CD . 40, 42
CARDIZEM SR .. 40, 42
CARDURA ......... 38, 50
CARIMUNE ............. 57
CARNITOR .............. 65
carteolol..................... 61
CARTIA ........ 40, 41, 42
carvedilol................... 41
CASODEX................ 56
CATAFLAM........... 6, 9
CATAPRES-TTS...... 38
CECLOR ................... 11
CEENU ..................... 22
cefaclor ...................... 11
cefadroxil .................. 11
cefazolin .................... 11
CEFAZOLIN ............ 11
cefdinir ...................... 11
cefepime .................... 11
cefpodoxime.............. 11
cefprozil .................... 11
ceftazidime ................ 11
CEFTIN............... 11, 12
ceftriaxone................. 11
cefuroxime ................ 12
CEFZIL ..................... 11
CELEBREX ............ 6, 9
CELEXA ................... 17
CELLCEPT ......... 56, 57
CELONTIN............... 14
cephalexin ................. 12
CEREZYME ............. 48
CERVARIX .............. 57
CHANTIX................... 8
chloramphenicol ........ 10
CHLORAMPHENICOL
............................... 10
chlorhexidine............. 46
chloroquine ............... 25
chlorothiazide ............ 43
chlorpromazine ... 19, 27
chlorthalidone ........... 43
cholestyramine .......... 44
chorionic ................... 52
ciclopirox .................. 20
cilostazol ................... 38
CILOXAN................. 13
cimetidine .................. 49
CIPRO ....................... 13
CIPRODEX............... 13
ciprofloxacin ............. 13
citalopram ................. 17
clarithromycin ........... 13
CLEOCIN ................. 10
clindamycin ............... 10
CLINIMIX ................ 65
CLINORIL ............ 6, 10
clobetasol .................. 51
clomipramine ............ 18
clonazepam ............... 45
clonidine.............. 38, 44
clopidogrel ................ 38
clorazepate ................ 45
clotrimazole............... 20
clozapine ................... 29
CLOZAPINE ............ 29
COARTEM ............... 25
COGENTIN .............. 26
COLAZAL ................ 58
COLBENEMID ........ 21
colchicine .................. 21
COLCRYS ................ 21
COLESTID ............... 44
colestipol ................... 44
colistimethate ............ 10
Page 73 of 83
COLY-MYCIN-M .... 10
COLYTE ................... 49
COMBIGAN ............. 61
COMBIVENT ........... 63
COMBIVIR............... 30
COMETRIQ .............. 24
COMPAZINE ..... 19, 27
COMPLERA ....... 29, 30
COMTAN ................. 26
COMVAX ................. 57
CONDYLOX ............ 47
COPAXONE ............. 46
COPEGUS ................ 31
COREG ..................... 41
CORGARD ............... 41
CORTEF ............... 9, 59
cortisone .......... 9, 51, 59
CORTISPORIN .. 10, 11
CORTONE...... 9, 51, 59
CORZIDE ................. 41
COSOPT ................... 61
COUMADIN....... 36, 37
COZAAR .................. 39
CREON ..................... 48
CRIXIVAN ............... 30
CROLOM ................. 60
cromolyn ....... 48, 60, 63
CUBICIN .................. 10
CUTIVATE............... 52
cyanocobalam ........... 67
cyclophosphamide..... 22
CYCLOSET .............. 34
cyclosporine .............. 56
CYKLOKAPRON .... 38
CYMBALTA 17, 32, 46
cyproheptadine .... 21, 62
CYSTADANE .......... 48
CYSTAGON ............. 48
CYSTARAN ............. 60
CYTOMEL ............... 54
CYTOTEC .......... 49, 53
CYTOVENE ............. 29
CYTOXAN ............... 22
D
D.H.E ........................ 21
DALIRESP ............... 63
danazol ...................... 53
DANOCRINE ........... 53
DANTRIUM ............. 29
dantrolene .................. 29
dapsone ..................... 22
DAPTACEL.............. 57
DARAPRIM ............. 25
DDAVP ..................... 52
DECADRON ............ 61
DECLOMYCIN ........ 14
DELATESTRYL ...... 53
DELZICOL ............... 58
DEMADEX............... 43
demeclocycline ......... 14
DEMEROL ................. 7
DEPACON.......... 15, 34
DEPAKENE ....... 15, 34
DEPAKOTE . 14, 21, 33
DEPEN.......... 51, 56, 65
DEPO-MEDROL . 9, 51,
52, 59
DEPO-PROVERA .... 54
DEPOTESTOSTERONE 53
DERMOTIC .............. 61
desipramine ............... 19
desmopressin ............. 52
desonide .................... 51
DESOWEN ............... 51
DESYREL................. 17
DETROL ................... 50
dexamethasone 9, 10, 51,
59, 61
DEXAMETHASONE 9,
51, 59
DEXEDRINE ............ 44
dextroamphetamine ... 44
dextrose ..................... 65
DEXTROSE .............. 65
DEXTROSE/NACL.. 65
DEXTROSE/RINGERS
............................... 65
DIAMOX ............ 42, 60
DIASTAT ................. 45
diazepam ................... 45
DIBENZYLINE ........ 38
diclofenac .... 6, 9, 47, 61
dicloxacillin............... 12
DICLOXACILLIN ... 12
dicyclomine ............... 48
didanosine ................. 30
DIDRONEL .............. 60
DIFLUCAN .............. 20
digoxin ...................... 42
dihydroergotamine .... 21
DILANTIN ............... 15
diltiazem........ 40, 41, 42
DIOVAN ............. 38, 39
DIPENTUM .............. 58
diphenhydramine 19, 26,
62
diphenoxylate ............ 48
DIPROLENE ............ 51
DIPROSONE ............ 51
disopyramide ............. 40
disulfiram .................... 8
DITROPAN .............. 50
DIURIL ..................... 43
divalproex ..... 14, 21, 33
donepezil ................... 16
dorzolamide............... 61
DOSTINEX............... 55
DOVONEX ............... 47
doxazosin ............ 38, 50
doxepin.......... 19, 32, 64
doxycycline ... 14, 46, 47
dronabinol ................. 19
DUETACT ................ 35
DULERA ............ 62, 63
duloxetine...... 17, 32, 46
DURAGESIC .............. 6
DURAMORPH ........... 7
DURICEF ................. 11
E
E.E.S ......................... 13
E.E.S. ........................ 13
econazole................... 20
ECONOPRED........... 61
EDURANT ............... 29
EFFEXOR ........... 18, 32
Page 74 of 83
EFFIENT................... 38
EFUDEX ................... 47
ELAPRASE .............. 48
ELAVIL .................... 18
ELDEPRYL .............. 27
electrolytes ................ 65
ELECTROLYTES .... 65
ELELYSO ................. 48
ELIDEL..................... 47
ELIGARD ................. 55
ELIMITE................... 26
ELIQUIS ................... 36
ELITEK..................... 23
ELIXOPHYLLIN ..... 63
ELMIRON ................ 51
ELOCON .................. 52
EMCYT..................... 23
EMEND .................... 19
EMLA ......................... 8
EMSAM .................... 17
EMTRIVA ................ 30
enalapril..................... 39
ENBREL ................... 56
ENGERIX-B ............. 58
enoxaparin ................. 37
entacapone................. 26
ENTOCORT ... 8, 51, 59
ENULOSE ................ 49
EPIPEN ..................... 63
EPIVIR ................ 30, 31
eplerenone ................. 43
EPOGEN ................... 37
EPZICOM ................. 30
ERAXIS .................... 20
ERGOMAR............... 21
ERIVEDGE............... 23
ERWINAZE .............. 23
ERYGEL ................... 13
ERYPED ................... 13
ERYTHROCIN ......... 13
erythromycin ............. 13
ERYTHROMYCIN .. 13
escitalopram .. 17, 18, 32
estradiol ..................... 54
ethambutol................. 22
ethosuximide ............. 14
ETHYOL................... 23
etidronate................... 60
etodolac ................... 6, 9
ETOPOFOS .............. 24
etoposide ................... 24
EULEXIN ................. 56
EVISTA .................... 54
EXELON................... 16
exemestane ................ 24
EXJADE ................... 65
EXTAVIA ........... 46, 57
F
FABRAZYME .......... 48
famciclovir ................ 31
famotidine ................. 49
FAMVIR ................... 31
FANAPT ................... 28
FARESTON .............. 23
FASLODEX .............. 23
fat .............................. 65
FAZACLO ................ 29
felbamate ................... 15
FELBATOL .............. 15
FELDENE ............. 6, 10
FEMARA .................. 24
fenofibrate ................. 43
fentanyl ................... 6, 7
FERRIPROX............. 65
FETZIMA ................. 18
finasteride ............ 50, 56
FIORICET................. 45
FLAGYL ................... 11
flavoxate.................... 50
flecainide ................... 40
FLOMAX .................. 50
FLONASE................. 62
FLORINEF ............... 51
FLOVENT ................ 62
FLOXIN .................... 13
fluconazole ................ 20
flucytosine ................. 20
fludrocortisone .......... 51
FLUMADINE ........... 31
flunisolide ................. 62
fluocinolone ........ 52, 61
fluocinonide .............. 52
fluorouracil ................ 47
fluoxetine .................. 18
fluphenazine .............. 27
flurbiprofen ....... 6, 9, 61
flutamide ................... 56
fluticasone ........... 52, 62
fluvoxamine .............. 18
FML .......................... 61
folic ........................... 67
fondaparinux ............. 37
FORADIL ................. 63
FORTAZ ............. 11, 12
FORTEO ................... 60
FOSAMAX ............... 59
foscarnet .................... 29
FOSCAVIR ............... 29
fosinopril ................... 39
FOSRENOL .............. 51
FULYZAQ ................ 49
FUNGIZONE ............ 20
furosemide................. 42
FUZEON ................... 30
FYCOMPA ............... 14
G
gabapentin ................. 14
GABITRIL ................ 15
galantamine ............... 16
GAMMAGARD ....... 57
GAMUNEX-C .......... 57
ganciclovir................. 29
GARAMYCIN .......... 10
GARDASIL .............. 58
GASTROCROM ....... 48
GATTEX................... 49
GAUZE ..................... 60
GAVILYTE-C .......... 49
GAVILYTE-G .......... 49
gemfibrozil ................ 43
GENOTROPIN ... 52, 53
GENTAK .................. 10
gentamicin ................. 10
GEODON ............ 28, 33
GILENYA ................. 46
GILOTRIF ................ 24
Page 75 of 83
GLEEVEC ................ 24
glimepiride ................ 34
glipizide..................... 34
GLUCAGEN............. 36
GLUCAGON ............ 36
GLUCOPHAGE ....... 35
GLUCOTROL .......... 34
glycopyrrolate ........... 48
GLYSET ................... 34
GRANIX ................... 37
GRIFULVIN ............. 20
griseofulvin ............... 20
GRIS-PEG................. 20
guanfacine ................. 38
guanidine ................... 22
GUANIDINE ............ 22
H
HALDOL .................. 27
halobetasol ................ 52
haloperidol ................ 27
HAVRIX ................... 58
heparin....................... 37
HEPARIN ................. 37
HEPATAMINE......... 65
HEPSERA ................. 31
HEXALEN ................ 22
HIPREX .................... 11
HUMALOG .............. 36
HUMATIN ................ 10
HUMATROPE.......... 53
HUMIRA .................. 56
HUMULIN ................ 36
HYCAMTIN ............. 24
HYCET ....................... 7
hydralazine ................ 44
HYDREA .................. 23
hydrochlorothiazide .. 43
HYDROCHLOROTHI
AZIDE................... 43
hydrocortisone 9, 10, 52,
59
HYDRODIURIL ....... 43
hydromorphone ........... 7
hydroxychloroquine .. 25
hydroxyurea .............. 23
HYGROTON ............ 43
HYTONE .................. 52
HYTRIN ............. 38, 50
HYZAAR .................. 39
I
ibandronate ................ 60
ibuprofen ................. 6, 9
ILOTYCIN ................ 13
IMBRUVICA ............ 24
IMDUR ..................... 44
imipenem................... 12
imipramine ................ 19
imiquimod ................. 47
IMITREX ............ 21, 22
IMODIUM ................ 49
IMOVAX .................. 58
IMURAN .................. 56
INCIVEK .................. 31
INCRELEX ............... 53
indapamide ................ 43
INDERAL ..... 21, 40, 41
INDERIDE ................ 41
INDOCIN ................ 6, 9
indomethacin ........... 6, 9
INFANRIX ............... 58
INFED ....................... 67
INFERGEN ............... 31
INLYTA .................... 24
INSPRA .................... 43
INSULIN................... 60
INTAL....................... 63
INTELENCE............. 29
INTRALIPID ............ 65
INTRON-A ............... 31
INVANZ ................... 12
INVEGA ................... 28
INVIRASE ................ 30
INVOKANA ....... 34, 35
IPOL .......................... 58
ipratropium ................ 63
irbesartan ................... 39
irinotecan................... 23
iron ............................ 67
irrigation .................... 47
ISENTRESS .............. 30
ISMO......................... 44
ISOLYTE .................. 65
isoniazid .................... 22
ISONIAZID .............. 22
ISORDIL ................... 44
isosorbide .................. 44
isotretinoin ................ 47
ISTODAX ................. 23
itraconazole ............... 20
IXIARO..................... 58
J
JAKAFI ..................... 24
JANUMET ................ 35
JANUVIA ................. 35
JENTADUETO ......... 35
K
KALETRA ................ 30
KALYDECO............. 64
KAPVAY .................. 44
KAYEXALATE ....... 65
KEFLEX ................... 12
KENALOG ......... 46, 52
KEPPRA ................... 14
kerlone....................... 41
KERLONE ................ 41
ketoconazole ............. 20
ketorolac ............ 6, 9, 61
KIONEX ................... 65
KLONOPIN .............. 45
KOMBIGLYZE ........ 35
KORLYM ................. 48
KUVAN .................... 48
L
labetalol ..................... 41
LAC-HYDRIN .......... 47
lactated ...................... 47
lactic .......................... 47
lactulose .................... 49
LACTULOSE ........... 49
LAMICTAL ........ 15, 33
LAMISIL .................. 20
Page 76 of 83
lamivudine........... 30, 31
lamotrigine .......... 15, 33
LANOXIN ................ 42
lansoprazole .............. 50
LANTUS ................... 36
LARIAM ................... 25
LASIX ....................... 42
latanoprost ................. 61
LATUDA .................. 28
LAZANDA ................. 7
leflunomide ............... 57
LETAIRIS ................. 64
letrozole..................... 24
leucovorin ................. 23
LEUCOVORIN......... 23
LEUKERAN ............. 23
LEUKINE ................. 37
leuprolide .................. 55
LEVAQUIN .............. 13
LEVEMIR ................. 36
levetiracetam ............. 14
levobunolol ............... 61
levocarnitine .............. 65
levocetirizine ............. 62
levofloxacin............... 13
levothyroxine ............ 54
LEXAPRO .... 17, 18, 32
LEXIVA .................... 30
LIALDA .................... 58
LIDEX....................... 52
lidocaine ...................... 8
LIDODERM ............... 8
lindane ....................... 26
LINDANE ................. 26
LINZESS................... 49
LIORESAL ............... 29
liothyronine ............... 54
LIPITOR ................... 43
lisinopril .................... 39
lithium ................. 33, 34
LITHIUM .................. 33
lithium citrate ............ 34
LITHIUM CITRATE 34
LITHOBID ................ 34
LOCOID ................... 52
LODINE .................. 6, 9
LODOSYN ............... 26
LOFIBRA ................. 43
LOMOTIL................. 48
LONITEN ................. 44
loperamide................. 49
LOPID ....................... 43
LOPRESSOR ............ 41
lorazepam .................. 45
losartan ...................... 39
LOTENSIN ............... 39
LOTREL ............. 39, 41
LOTRIMIN ............... 20
LOTRISONE ............ 20
LOTRONEX ............. 49
LOVAZA .................. 44
LOVENOX ............... 37
loxapine ..................... 27
LOXITANE .............. 27
LOZOL ..................... 43
LUFYLLIN ............... 63
LUMIGAN ................ 61
LUPRON................... 55
LUVOX..................... 18
LYRICA .............. 14, 46
LYSODREN ............. 55
M
MACROBID ............. 11
MACRODANTIN10, 11
MALARONE ............ 25
maprotiline ................ 17
MARINOL ................ 19
MARPLAN ............... 17
MATULANE ............ 23
MAVIK ..................... 40
MAXALT ................. 21
MAXIPIME .............. 11
MAXITROL ............. 11
MAXZIDE ................ 43
meclizine ................... 19
MEDROL........ 9, 52, 59
medroxyprogesterone 54
mefloquine ................ 25
MEGACE .................. 54
megestrol ................... 54
MEKINIST ............... 23
MELLARIL .............. 27
meloxicam ............... 6, 9
MENACTRA ............ 58
MENEST................... 54
MENOMUNE ........... 58
MENVEO ................. 58
meperidine................... 7
MEPHYTON ............ 67
MEPRON .................. 25
mercaptopurine ......... 23
meropenem ................ 12
MERREM ................. 12
mesalamine ............... 58
mesna ........................ 23
MESNEX .................. 23
MESTINON .............. 22
METAGLIP .............. 34
metformin .................. 35
methazolamide .... 42, 61
methenamine ............. 11
methimazole .............. 56
methocarbamol .......... 64
methotrexate ........ 23, 56
METHOTREXATE . 23,
56
methscopolamine ...... 48
methyldopa ................ 38
methylphenidate ........ 45
methylprednisolone .... 9,
52, 59
metipranolol .............. 61
metoclopramide......... 19
metolazone ................ 43
metoprolol ................. 41
METROCREAM ...... 11
METROGEL ............. 11
METROLOTION ...... 11
metronidazole ............ 11
mexiletine.................. 40
MIACALCIN ...... 59, 60
MICRO-K/SLOW-K. 65
MIDAMOR ............... 43
midodrine .................. 38
MILLIPRED ... 9, 52, 59
MINIPRESS ........ 38, 50
MINOCIN ........... 14, 46
Page 77 of 83
minocycline ......... 14, 46
minoxidil ................... 44
MIRAPEX................. 26
mirtazapine................ 17
misoprostol.......... 49, 53
mitoxantrone ....... 24, 46
M-M-R ...................... 58
MOBIC ................... 6, 9
modafinil ................... 64
MODURETIC ........... 43
mometasone .............. 52
MONOPRIL.............. 39
montelukast ............... 62
morphine ................. 6, 7
MORPHINE ................ 7
morphine sulfate.......... 7
MOTRIN ................. 6, 9
MOXEZA ................. 13
moxifloxacin ............. 13
MS ............................... 6
MUCOMYST ........... 64
MULTAQ ................. 40
mupirocin .................. 11
MYAMBUTOL ........ 22
MYCAMINE ............ 20
MYCELEX ............... 20
MYCIFRADIN ......... 10
MYCOBUTIN .......... 22
MYCOLOG .............. 20
mycophenolate .......... 57
MYFORTIC .............. 57
MYRBETRIQ ........... 50
MYSOLINE .............. 15
N
nabumetone ........... 6, 10
nadolol....................... 41
nafcillin ..................... 12
NAFCILLIN ............. 12
NAGLAZYME ......... 48
naloxone ...................... 8
naltrexone.................... 8
NAMENDA .............. 16
NAMENDA XR........ 16
naphazoline ............... 60
NAPHCON FORTE.. 60
NAPROSYN ......... 6, 10
naproxen ................ 6, 10
naratriptan ................. 21
NARCAN.................... 8
NARDIL ................... 17
NASACORT ............. 62
NASAREL ................ 62
NATACYN ............... 20
nateglinide ................. 35
NAVANE .................. 27
NEBUPENT .............. 25
nefazodone ................ 17
neomycin ............. 10, 11
NEORAL .................. 56
NEOSPORIN ............ 11
NEPHRAMINE ........ 65
NEPTAZANE ..... 42, 61
NEULASTA ............. 37
NEUMEGA............... 37
NEUPOGEN ............. 37
NEUPRO................... 26
NEURONTIN ........... 14
nevirapine .................. 29
NEXAVAR ............... 24
niacin ......................... 44
NIASPAN ................. 44
nicardipine................. 42
NICOTROL ................ 8
NIFEDIAC ................ 42
nifedipine .................. 42
NILANDRON ........... 56
nimodipine ................ 42
NIMOTOP ................ 42
NITRO-DUR............. 44
nitrofurantoin ............ 11
nitroglycerin .............. 44
NITROSTAT ............ 44
NIZORAL ................. 20
NOLVADEX ............ 23
NORCO....................... 7
NORDITROPIN ....... 53
norethindrone ............ 54
NORFLEX ................ 64
NORMOSOL ............ 65
NORPACE ................ 40
NORPRAMIN........... 19
nortriptyline............... 19
NORVASC ............... 41
NORVIR ................... 30
NOVANTRONE . 24, 46
NOVOLIN ................ 36
NOVOLOG ............... 36
NOXAFIL ................. 20
NUEDEXTA ............. 45
NULOJIX .................. 57
NULYTELY ............. 49
NUTROPIN .............. 53
nystatin ...................... 20
NYSTATIN............... 20
O
octreotide................... 55
OCUFEN................... 61
OCUPRESS .............. 61
ofloxacin ................... 13
olanzapine ........... 28, 33
omeprazole ................ 50
OMNICEF................. 11
OMNIPEN-N ............ 12
OMNITROPE ........... 53
ONCASPAR ............. 24
ondansetron ............... 19
ONFI ......................... 45
ONGLYZA ............... 35
ONTAK..................... 24
OPSUMIT ................. 64
OPTIPRANOLOL .... 61
oral ............................ 54
ORAL........................ 54
ORAP ........................ 27
ORAPRED ...... 9, 52, 59
ORENCIA ................. 57
ORFADIN ................. 48
orphenadrine ............. 64
oxacillin..................... 12
OXACILLIN ............. 12
OXANDRIN ............. 53
oxandrolone............... 53
oxcarbazepine ........... 15
OXSORALEN .......... 47
OXTELLAR ............. 15
oxybutynin ................ 50
Page 78 of 83
oxycodone ................... 7
OXYCONTIN ............. 7
OXYIR ........................ 7
P
PACERONE ............. 40
PAMELOR ............... 19
PAMINE ................... 48
PANCREAZE ........... 48
PANRETIN ............... 25
pantoprazole .............. 50
paricalcitol................. 60
PARLODEL ........ 26, 55
PARNATE ................ 17
paromomycin ............ 10
paroxetine............ 18, 32
PASER ...................... 22
PATADAY ............... 60
PAXIL ................. 18, 32
PEDIAPRED... 9, 52, 59
PEDVAX .................. 58
PEGANONE ............. 15
PEGASYS ................. 31
PEG-INTRON........... 31
penicillin ................... 12
PENLAC ................... 20
PENTAM .................. 25
PENTASA................. 58
pentoxifylline ............ 42
PEPCID ..................... 49
PERCOCET ................ 7
PERIACTIN ........ 21, 62
PERIDEX .................. 46
perindopril ................. 39
PERIOSTAT . 14, 46, 47
permethrin ................. 26
perphenazine ....... 19, 27
PERTZYE ................. 48
PHENADOZ . 19, 21, 62
phenelzine ................. 17
PHENERGAN ... 19, 21,
62
phenobarbital............. 45
PHENOBARBITAL . 45
phenytoin................... 15
PHOSLO ................... 51
PHOSPHOLINE ....... 61
PHYSIOSOL............. 47
pilocarpine................. 46
pindolol ..................... 41
pioglitazone ............... 35
piperacillin ................ 12
piroxicam .............. 6, 10
PLAQUENIL ............ 25
PLASMA-LYTE ....... 65
PLAVIX .................... 38
PLETAL .................... 38
podofilox ................... 47
polyethylene .............. 49
polymyxin ................. 11
POLYTRIM .............. 11
POMALYST ............. 23
potassium .................. 65
POTASSIUM ...... 65, 66
POTIGA .................... 14
PRADAXA ............... 37
pramipexole............... 26
PRANDIN ................. 35
PRAVACHOL .......... 43
pravastatin ................. 43
prazosin ............... 38, 50
PRECOSE ................. 34
prednisolone ... 9, 52, 59,
61
prednisone ....... 9, 52, 59
PREDNISONE 9, 52, 59
PREGNYL ................ 52
PREMASOL ............. 66
PRENATAL.............. 66
PREVACID............... 50
PREVALITE ............. 44
PREZISTA ................ 30
PRIFTIN ................... 22
PRILOSEC ................ 50
PRIMAQUINE ......... 26
PRIMAXIN ............... 12
primidone .................. 15
PRINCIPEN .............. 12
PRINIVIL ................. 39
PRINZIDE ................ 39
PRISTIQ ................... 18
PROAIR .................... 63
PROAMATINE ........ 38
probenecid ................. 21
PROCALAMINE ...... 66
PROCARDIA ........... 42
PROCARDIA XL ..... 42
prochlorperazine . 19, 27
PROCRIT .................. 37
PROCTOCREAM..... 52
progesterone .............. 54
PROGLYCEM .......... 36
PROGRAF ................ 57
PROLASTIN............. 64
PROLEUKIN ............ 24
PROLIA .................... 60
PROLIXIN ................ 27
PROLOPRIM ............ 11
PROMACTA ............ 37
promethazine . 19, 21, 62
PROMETHEGAN ... 19,
21, 62
PROMETRIUM ........ 54
propafenone............... 40
propranolol .... 21, 40, 41
propylthiouracil ......... 56
PROPYLTHIOURACIL
............................... 56
PROQUAD ............... 58
PROSCAR .......... 50, 56
PROSOL ................... 66
PROTONIX .............. 50
PROTOPIC ............... 47
protriptyline............... 19
PROVENTIL ............ 63
PROVERA ................ 54
PROVIGIL ................ 64
PROZAC ................... 18
PULMICORT ........... 62
PULMOZYME ......... 64
PURINETHOL ......... 23
pyrazinamide ............. 22
PYRAZINAMIDE .... 22
pyridostigmine .......... 22
Q
QUALAQUIN........... 26
QUESTRAN ............. 44
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quetiapine ...... 17, 28, 33
QUINAGLUTE......... 40
quinapril .............. 39, 40
quinidine ................... 40
QUINIDINE .............. 40
quinine....................... 26
QVAR ....................... 62
R
RABAVERT ............. 58
raloxifene .................. 54
ramipril ...................... 40
RANEXA .................. 42
ranitidine ................... 49
RAPAMUNE ............ 57
RAVICTI .................. 48
RAZADYNE............. 16
REBIF ................. 46, 57
RECLAST ................. 60
RECOMBIVAX ........ 58
REGLAN .................. 19
RELAFEN............. 6, 10
RELISTOR ............... 49
REMERON ............... 17
REMICADE .............. 57
RENAGEL ................ 51
RENVELA ................ 51
repaglinide................. 35
REQUIP .................... 26
RESCRIPTOR .......... 29
RESTASIS ................ 60
RESTORIL ............... 45
RETIN-A................... 47
RETROVIR............... 30
REVATIO ................. 64
REVIA ........................ 8
REVLIMID ............... 23
REYATAZ ................ 30
RHEUMATREX . 56, 57
ribavirin ..................... 31
RIDAURA ................ 57
rifabutin ..................... 22
RIFADIN .................. 22
rifampin ..................... 22
RIFATER .................. 22
RILUTEK ................. 45
riluzole ...................... 45
rimantadine ............... 31
RISPERDAL ....... 28, 33
risperidone........... 28, 33
RITALIN................... 45
RITUXAN................. 25
rivastigmine............... 16
rizatriptan .................. 21
ROBAXIN ................ 64
ROBINUL ................. 48
ROCALTROL........... 59
ROCEPHIN............... 11
ropinirole ................... 26
ROTATEQ ................ 58
ROWASA ................. 58
ROXICODONE .......... 7
RYTHMOL ............... 40
S
SABRIL .................... 15
SAIZEN .................... 53
SALAGEN ................ 46
SANCTURA ............. 50
SANDIMMUNE ....... 56
SANDOSTATIN....... 55
SANTYL ................... 47
SAPHRIS ............ 28, 33
SECTRAL ........... 40, 41
selegiline ................... 27
selenium .................... 47
SELSUN ................... 47
SELZENTRY ............ 30
SENSIPAR ................ 55
SEREVENT .............. 63
SEROMYCIN ........... 22
SEROQUEL.. 17, 28, 33
SEROSTIM ............... 53
sertraline .............. 18, 32
SERZONE................. 17
SIGNIFOR ................ 55
sildenafil .................... 64
SILVADENE ............ 11
SILVER..................... 11
SIMBRINZA............. 61
simvastatin ................ 43
SINEMET ................. 27
SINGULAIR ............. 62
sirolimus.................... 57
SIRTURO ................. 22
sodium ..... 47, 48, 65, 66
SODIUM ............. 47, 66
SOLARAZE .............. 47
SOLTAMOX ............ 23
SOLU-CORTEF .. 9, 52,
59
SOLU-MEDROL . 9, 52,
59
SOMATULINE......... 55
SOMAVERT............. 55
SONATA .................. 64
SORIATANE ............ 47
SORINE .................... 40
sotalol ........................ 40
SPECTAZOLE ......... 20
SPIRIVA ................... 63
spironolactone ........... 43
SPORANOX ............. 20
SPRYCEL ................. 24
STADOL ..................... 7
STALEVO .......... 26, 27
STARLIX .................. 35
stavudine ................... 30
STELARA................. 47
STELAZINE ............. 27
STIMATE ................. 53
STIVARGA .............. 24
STRATTERA ........... 45
streptomycin .............. 10
STREPTOMYCIN .... 10
STRIBILD................. 30
STROMECTOL ........ 25
SUBOXONE ............... 8
SUBUTEX .................. 8
sucralfate ................... 49
sulfacetamide ............ 13
sulfadiazine ............... 13
sulfamethoxazole 13, 14
sulfasalazine .............. 59
sulindac ................. 6, 10
sumatriptan .......... 21, 22
SUPRAX ................... 12
SURMONTIL ........... 19
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SUSTIVA .................. 29
SUTENT ................... 25
SYLATRON ............. 31
SYMBICORT ..... 62, 63
SYMLIN ................... 35
SYMMETREL .... 26, 31
SYNAGIS ................. 57
SYNALAR ................ 52
SYNAREL ................ 55
SYNRIBO ................. 24
SYNTHROID ..... 54, 55
T
TABLOID ................. 23
tacrolimus .................. 57
TAFINLAR ............... 23
TAGAMET ............... 49
TAMBOCOR ............ 40
TAMIFLU ................. 31
tamoxifen .................. 23
tamsulosin ................. 50
TAPAZOLE .............. 56
TARCEVA................ 25
TARGRETIN ............ 25
TASIGNA ................. 25
TASMAR .................. 26
TAZORAC ................ 47
TAZTIA ........ 40, 41, 42
TECFIDERA............. 46
TEGRETOL ........ 15, 33
TEGRETOL-XR . 15, 34
TEKAMLO ............... 42
TEKTURNA ............. 42
temazepam ................ 45
TEMOVATE............. 51
TENEX ..................... 38
TENORETIC ............ 41
TENORMIN ............. 41
TERAZOL ................ 20
terazosin .............. 38, 50
terbinafine ................. 20
terbutaline ................. 63
terconazole ................ 20
testosterone ............... 53
TETANUS ................ 58
TETANUS/DIPHTHER
IA .......................... 58
THALOMID ............. 23
theophylline............... 63
thioridazine ............... 27
thiothixene................. 27
THORAZINE ...... 19, 27
tiagabine .................... 15
TIAZAC .............. 40, 41
TIKOSYN ................. 40
TIMENTIN ............... 12
timolol ........... 21, 41, 61
TIMOPTIC ................ 61
TIVICAY .................. 30
tizanidine ................... 29
TOBI ......................... 10
TOBRADEX ............. 10
tobramycin ................ 10
TOBRAMYCIN ........ 10
TOBREX................... 10
TOFRANIL ............... 19
tolterodine ................. 50
TOPAMAX ......... 15, 21
topiramate ........... 15, 21
TOPOSAR ................ 24
topotecan ................... 24
TOPROL ................... 41
TORADOL ............. 6, 9
torsemide ................... 43
TOVIAZ .................... 50
TRACLEER .............. 64
TRADJENTA ........... 35
tramadol ...................... 7
TRANDATE ............. 41
trandolapril ................ 40
tranexamic ................. 38
TRANXENE ............. 45
tranylcypromine ........ 17
TRAVASOL ............. 66
TRAVATAN............. 61
TRAVATAN/TRAVAT
AN ......................... 61
travoprost .................. 61
trazodone ................... 17
TRECATOR ............. 22
TRENTAL ................ 42
tretinoin ............... 25, 47
triamcinolone 46, 52, 62
triamterene ................ 43
trifluoperazine ........... 27
trifluridine ................. 31
trihexyphenidyl ......... 26
TRILAFON ......... 19, 27
TRILEPTAL ............. 15
TRILYTE .................. 49
trimethoprim ............. 11
trimipramine .............. 19
TRISENOX ............... 24
TRIZIVIR ................. 29
TROKENDI .............. 15
TROPHAMINE ........ 66
trospium .................... 50
TRUSOPT ................. 61
TRUVADA ............... 30
T-STAT ..................... 13
TWINRIX ................. 58
TYGACIL ................. 11
TYKERB................... 25
TYLENOL/CODEINE 7
TYPHIM ................... 58
TYSABRI ........... 46, 57
TYZEKA................... 31
TYZINE .................... 64
U
ULTRACET ................ 7
ULTRAM .................... 7
ULTRAVATE........... 52
ULTRESA................. 48
UNIPHYL ................. 63
URECHOLINE ......... 51
URISPAS .................. 50
UROCIT-K ............... 66
UROSO ..................... 49
ursodiol ..................... 49
V
VAGIFEM ................ 54
valacyclovir ............... 31
VALCYTE ................ 29
VALISONE............... 51
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VALIUM................... 45
valproate .............. 15, 34
valproic ............... 15, 34
valsartan .................... 39
VALTREX ................ 31
VANCOCIN ............. 11
vancomycin ............... 11
VANCOMYCIN ....... 11
VANSPAR ................ 31
VANTIN ................... 11
VAQTA..................... 58
VARIVAX ................ 58
VASERETIC............. 39
VASOCIDIN............. 13
VASOTEC ................ 39
VECTICAL ............... 48
VEETIDS .................. 12
VELCADE ................ 24
VELPHORO ............. 51
venlafaxine .......... 18, 32
VENTAVIS............... 64
verapamil....... 40, 41, 42
VERSACLOZ ........... 29
VESANOID .............. 25
VFEND ..................... 20
VIAGRA ................... 67
VIBRAMYCIN .. 14, 46,
47
VIBRATAB .. 14, 46, 47
VICTOZA ................. 35
VICTRELIS .............. 31
VIDAZA ................... 23
VIDEX ...................... 30
VIGAMOX ............... 13
VIIBRYD .................. 18
VIMPAT ................... 15
VIOKACE................. 48
VIRACEPT ............... 30
VIRAMUNE ............. 29
VIREAD ................... 30
VIROPTIC ................ 31
VIVACTIL................ 19
VOLTAREN ..... 6, 9, 61
voriconazole .............. 20
VOSOL ..................... 61
VOTRIENT............... 25
VPRIV....................... 48
W
warfarin ..................... 37
WELCHOL ............... 44
WELLBUTRIN... 16, 17
WESTCORT ............. 52
X
XALATAN ............... 61
XALKORI................. 25
XANAX .................... 45
XARELTO ................ 37
XELJANZ ................. 57
XENAZINE .............. 45
XGEVA..................... 60
XIFAXAN........... 26, 49
XODOL....................... 7
XOLAIR ................... 57
XTANDI ................... 56
XYLOCAINE ............. 8
XYREM .................... 64
XYZAL ..................... 62
Y
YERVOY .................. 25
YF-VAX ................... 58
Z
zafirlukast .................. 62
zaleplon ..................... 64
ZALTRAP................. 25
ZANAFLEX ............. 29
ZANTAC .................. 49
ZARONTIN .............. 14
ZAROXOLYN .......... 43
ZAVESCA ................ 48
ZEBETA ................... 41
ZELBORAF .............. 25
ZEMAIRA ................ 64
ZEMPLAR ................ 60
ZENPEP .................... 48
ZERIT ....................... 30
ZETIA ....................... 44
ZIAC ......................... 41
ZIAGEN .............. 29, 30
zidovudine ................. 30
ZINACEF .................. 12
ziprasidone .......... 28, 33
ZITHROMAX........... 13
ZOCOR ..................... 43
ZOFRAN................... 19
zoledronic.................. 60
ZOLINZA ................. 24
ZOLOFT ............. 18, 32
zolpidem.................... 64
ZOMETA .................. 60
ZONEGRAN............. 14
zonisamide ................ 14
ZORBTIVE ............... 53
ZORTRESS............... 57
ZOSTAVAX ............. 58
ZOSYN ..................... 12
ZOVIRAX................. 31
ZUBSOLV .................. 8
ZYBAN ....................... 8
ZYKADIA ................ 25
ZYLOPRIM .............. 21
ZYPREXA .......... 28, 33
ZYTIGA .................... 24
ZYVOX..................... 11
This formulary was updated on July 2014. For more recent information or other questions,
please contact us, Constellation Health at 1-866-714-0724 or, for TTY users, 1-866-8057777, Monday through Sunday, from 8:00 a.m. to 8:00 p.m., or visit
www.constellationhealth.com.
Page 82 of 83
Constellation Health is an HMO plan with a Medicare contract. Enrollment in Constellation
Health depends on contract renewal.
This information is available for free in other languages. Please call our customer service
number at 1-866-714-0724. TTY users should call 1-866-805-7777. Our service hours are
Monday through Sunday from 8:00am to 8:00pm. Esta información se ofrece gratis en
otros idiomas. Por favor, llame a nuestro número de servicio al cliente al 1-866-714-0724.
Usuarios de TTY pueden llamar al 1-866-805-7777. Nuestro horario de servicios es de
lunes a domingo de 8:00am a 8:00pm.
H3054_2014_E073 CMS Accepted
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