©2008 Express Scripts, Inc. 24
(10/15/2007)
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
auroguard
|
|
1
|
|
borofair
|
|
1
|
|
chloroxylenol/pramoxine hcl
|
|
1
|
|
CIPRODEX
|
ciprofloxacin/dexameth
|
2
|
|
cortomycin
|
|
1
|
|
DERMOTIC
|
fluocinolone acetonide
|
2
|
|
dolotic
|
|
1
|
|
ear-gesic
|
|
1
|
|
FLOXIN
|
ofloxacin
|
2
|
|
neomycin/polymyxin/hc
|
|
1
|
|
omedia otic
|
|
1
|
|
oticaine
|
|
1
|
|
|
MEDICAMENTOS PARA LA NARIZ
|
ASTELIN
|
azelastine hcl
|
2
|
[QLL]
|
flunisolide
|
|
1
|
[QLL]
|
fluticasone propionate
|
|
1
|
[QLL]
|
ipratropium bromide (atomizador/gotas nasales)
|
|
1
|
[QLL]
|
TYZINE
|
tetrahydrozoline
|
2
|
|
|
MEDICAMENTOS PARA LA GARGANTA Y LA BOCA
|
chlorhexidine gluconate (productos dentales)
|
|
1
|
|
doxycycline hyclate
|
|
1
|
|
FIRST-MOUTHWASH BLM
|
mag hydrox/alh/smc/dpha/lido
|
2
|
|
periogard
|
|
1
|
|
perisol
|
|
1
|
|
pilocarpine hcl
|
|
1
|
|
triamcinolone acetonide
|
|
1
|
|
|
MEDICAMENTOS ENDOCRINOLÓGICOS
|
ANÁLOGOS DE AMILINA
|
SYMLIN [INJ]
|
pramlintide acetate
|
2
|
[PAR][QLL]
|
|
MEDICAMENTOS ANTITIROIDEOS
|
methimazole
|
|
1
|
|
northyx
|
|
1
|
|
propylthiouracil
|
|
1
|
|
COMBINACIONES E INHIBIDORES DE DIPEPTIDIL PEPTIDASA IV
|
JANUVIA sitagliptin phosphate
|
2
|
[QLL]
|
|
MEDICAMENTOS GLUCOCORTICOIDES
|
CORTEF tab 5 mg, 10 mg [G] hydrocortisone
|
2
|
|
cortisone
|
1
|
|
©2008 Express Scripts, Inc. 25
(10/15/2007)
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
dexamethasone, intensol, sodium phosphate
|
|
1
|
|
hydrocortisone
|
|
1
|
|
meprolone unipak
|
|
1
|
|
methylprednisolone
|
|
1
|
|
methylprednisolone acetate [INJ]
|
|
1
|
|
methylprednisolone sod succ inj 40 mg/ml, 125 mg, 1,000 mg [INJ]
|
|
1
|
|
prednisolone, sodium phosphate
|
|
1
|
|
prednisone
|
|
1
|
|
|
MEDICAMENTOS PARA ELEVAR LA GLUCOSA
|
GLUCAGEN [INJ]
|
glucagon, human recombinant
|
2
|
|
GLUCAGON EQUIPO DE EMERGENCIA [INJ]
|
glucagon, human recombinant
|
2
|
|
PROGLYCEM
|
diazoxide
|
2
|
|
|
MIMÉTICOS DE INCRETINA
|
BYETTA [INJ]
|
exenatide
|
2
|
[PAR][QLL]
|
|
INSULINA
|
LANTUS vials [INJ]
|
insulin glargine, hum.rec.anlo
|
2
|
|
LEVEMIR vials [INJ]
|
insulin detemir
|
2
|
|
NOVOLIN 70/30, INNOLET [INJ][OTC]
|
insulin human regular/nph
|
2
|
|
NOVOLIN L [INJ][OTC]
|
insulin, lente
|
2
|
|
NOVOLIN N, INNOLET [INJ][OTC]
|
insulin, nph
|
2
|
|
NOVOLIN R inj [INJ][OTC]
|
insulin, regular
|
2
|
|
NOVOLOG, MIX 70/30 [INJ]
|
insulin aspart
|
2
|
|
|
MINERALOCORTICOIDES
|
fludrocortisone acetate
|
1
|
|
HIPOGLICÉMICOS ORALES Y COMBINACIONES
ACTOS
|
pioglitazone hcl
|
2
|
[QLL]
|
AVANDAMET
|
rosiglitazone/metformin hcl
|
2
|
[QLL]
|
AVANDARYL
|
rosiglitazone maleate/glimepir
|
2
|
[QLL]
|
AVANDIA
|
rosiglitazone maleate
|
2
|
[QLL]
|
chlorpropamide [CARE]
|
|
1
|
|
glimepiride
|
|
1
|
|
glipizide, er, xl, -metformin
|
|
1
|
|
glyburide, micronized, -metformin hcl
|
|
1
|
|
metformin hcl, er
|
|
1
|
|
PRANDIN
|
repaglinide
|
2
|
|
PRECOSE
|
acarbose
|
2
|
|
tolazamide
|
|
1
|
|
tolbutamide
|
|
1
|
|
©2008 Express Scripts, Inc. (10/15/2007)
26
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
OTROS MEDICAMENTOS ENDOCRINOLÓGICOS
ALDURAZYME [INJ]
laronidase
|
laronidase
|
3
|
|
BONIVA inj
|
ibandronate
|
2
|
|
cabergoline
|
imiglucerase
|
1
|
[QLL]
|
CEREZYME [INJ]
imiimi
|
imiglucerase
|
3
|
[PAR]
|
desmopressin acetate
|
agalsidase
|
1
|
|
ELAPRASE [INJ]
|
idursulfase
|
3
|
|
etidronate disodium
|
alendronate
|
1
|
|
FABRAZYME [INJ]
|
alglucosidase
|
3
|
[PAR]
|
FORTEO [INJ]
|
teripatide
|
3
|
[PAR]
|
fortical
|
|
1
|
|
FOSAMAX, PLUS D
cinacalcet hcl
|
alendronate
|
2
|
[QLL]
|
MIACALCIN inj [INJ]
|
calcitonin
|
2
|
|
MYOZYME [INJ]
miglustat
|
alglucosidase alfa
|
3
|
|
NAGLAZYME [INJ]
|
galsufase
|
3
|
|
pamidronate disodium [INJ]
|
laronidase
|
1
|
|
SENSIPAR
|
cinacalcet hcl
|
3
|
|
SOMAVERT [INJ]
imiglucerase
|
pegvisomant
|
3
|
[PAR]
|
vasopressin [INJ]
|
idursulfase
|
1
|
|
ZAVESCA
agalsidase
|
miglustat
|
3
|
|
ZOMETA [INJ]
|
zoledronic acid
|
3
|
|
SUPLEMENTOS TIROIDEOS
levothroid
|
|
1
|
|
levothyroxine sodium
|
|
1
|
|
levoxyl
|
|
1
|
|
liothyronine sodium [INJ]
|
|
1
|
|
nature-throid [CARE]
|
|
1
|
|
thyroid [CARE]
|
|
1
|
|
THYROLAR-1
|
liotrix
|
2
|
|
THYROLAR-1/2
|
liotrix
|
2
|
|
THYROLAR-1/4
|
liotrix
|
2
|
|
THYROLAR-2
|
liotrix
|
2
|
|
THYROLAR-3
|
liotrix
|
2
|
|
unithroid
|
|
1
|
|
westhroid [CARE]
|
|
1
|
| |
