©2008 Express Scripts, Inc. (10/15/2007)
37
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
VITAMINAS, MINERALES Y PRODUCTOS RELACIONADOS
|
INTRALIPID [INJ]
|
emulsiones grasas
|
2
|
|
LIPOSYN II [INJ]
|
emulsiones grasas
|
2
|
|
LIPOSYN III inj 10 %, 20 % [INJ]
|
emulsiones grasas
|
2
|
|
liposyn iii inj 30 % [INJ]
|
|
1
|
|
multi-vit w/fluoride & iron
|
|
1
|
|
multi-vit/iron & fluoride
|
|
1
|
|
multi-vita bets w/fluoride, bets/fluoride/iron
|
|
1
|
|
multi-vitamin w/fluoride
|
|
1
|
|
multivita bets w/fluoride/iron
|
|
1
|
|
multivitamins w/fluoride
|
|
1
|
|
poly-vitamin w/fluoride, w/iron & fluoride
|
|
1
|
|
poly-vitamins w/fluoride
|
|
1
|
|
polyvitamins w/fluoride
|
|
1
|
|
tri-a-vite w/fluoride
|
|
1
|
|
tri-vit w/fluoride & iron
|
|
1
|
|
tri-vita bets w/fluoride
|
|
1
|
|
tri-vitamin w/fuoride, w/iron & fuoride
|
|
1
|
|
tri-vitamins with fluoride
|
|
1
|
|
|
MEDICAMENTOS GINECOLÓGICOS Y OBSTÉTRICOS
|
MEDICAMENTOS ABORTIVOS
|
HEMABATE [INJ] carboprost tromethamine
|
2
|
PROSTIN E2 VAGINAL SUPPOSITORY dinoprostone
|
2
|
|
MEDICAMENTOS ANDRÓGENOS
|
ANADROL-50
|
oxymetholone
|
3
|
[PAR]
|
ANDROXY
|
fluoxymesterone
|
2
|
|
danazol
|
|
1
|
|
METHITEST [CARE]
|
methyltestosterone
|
2
|
|
oxandrolone
|
|
3
|
[PAR]
|
TESTIM
|
testosterone
|
2
|
|
TESTOPEL [INJ]
|
testosterone
|
2
|
|
testosterone cypionate, enanthate [INJ]
|
|
1
|
|
|
ANTICONCEPTIVOS
|
apri
|
|
1
|
|
aranelle
|
|
1
|
|
aviane
|
|
1
|
|
balziva
|
|
1
|
|
cesia
|
|
1
|
|
cryselle
|
|
1
|
|
enpresse
|
|
1
|
|
jolessa
|
|
1
|
|
©2008 Express Scripts, Inc. (10/15/2007)
38
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
junel, fe
|
|
1
|
|
kariva
|
|
1
|
|
kelnor 1/35
|
|
1
|
|
leena
|
|
1
|
|
lessina
|
|
1
|
|
levora-28
|
|
1
|
|
low-ogestrel
|
|
1
|
|
lutera
|
|
1
|
|
microgestin, fe
|
|
1
|
|
mononessa
|
|
1
|
|
necon
|
|
1
|
|
nortrel
|
|
1
|
|
ogestrel
|
|
1
|
|
portia
|
|
1
|
|
previfem
|
|
1
|
|
quasense
|
|
1
|
|
reclipsen
|
|
1
|
|
solia
|
|
1
|
|
sprintec
|
|
1
|
|
sronyx
|
|
1
|
|
tri-previfem
|
|
1
|
|
tri-sprintec
|
|
1
|
|
trinessa
|
|
1
|
|
trivora-28
|
|
1
|
|
velivet
|
|
1
|
|
YAZ
|
eth estradiol/drospirenone
|
2
|
|
zenchent
|
|
1
|
|
zovia 1/35e, 1/50e
|
|
1
|
|
MEDICAMENTOS CON ESTRÓGENOS
ESTRACE crema vaginal
|
estradiol
|
2
|
|
estradiol
|
|
1
|
[QLL]
|
estropipate
|
|
1
|
|
MENEST
|
estrogens, esterified
|
2
|
|
PREMARIN crema vaginal
|
estrogens, conjugated
|
2
|
|
VAGIFEM
|
estradiol
|
2
|
|
|
COMBINACIONES DE ESTRÓGENO Y PROGESTINA
|
ACTIVELLA
|
estradiol/noreth ac
|
2
|
|
PREMPHASE
|
estrogen/medroxyprogesterone
|
2
|
|
PREMPRO
|
estrogen/medroxyprogesterone
|
2
|
|
|
ANTIINFECCIOSOS TÓPICOS OBSTÉTRICOS/GINECOLÓGICOS
|
amino acid cervical
|
|
1
|
|
©2008 Express Scripts, Inc. 39
(10/15/2007)
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
CLEOCIN 100 mg (óvulo vaginal)
|
clindamycin phosphate
|
2
|
|
clindamycin phosphate
|
|
1
|
|
fem ph
|
|
1
|
|
metronidazole, vaginal
|
|
1
|
|
vandazole
|
|
1
|
|
|
OXITÓCICOS
|
METHERGINE
|
methylergonovine
|
2
|
|
oxytocin [INJ]
|
|
1
|
|
|
VITAMINAS PRENATALES
|
advanced natalcare
|
|
1
|
|
advanced-rf natalcare
|
|
1
|
|
aminate w/90mg iron
|
|
1
|
|
cal-nate
|
|
1
|
|
carenatal dha
|
|
1
|
|
CITRACAL PRENATAL 90+DHA
|
prenatal vit (= or > 1mg fa)
|
2
|
|
co-natal fa
|
|
1
|
|
inatal advance, gt, ultra
|
|
1
|
|
maternity
|
|
1
|
|
mynatal, advance, plus, -z
|
|
1
|
|
mynate 90 plus
|
|
1
|
|
natacaps
|
|
1
|
|
natalcare pic, forte
|
|
1
|
|
natalcare, plus, three
|
|
1
|
|
natatab, cfe, fa
|
|
1
|
|
nutrinate
|
|
1
|
|
nutrispire
|
|
1
|
|
poly iron pn
|
|
1
|
|
prenafirst
|
|
1
|
|
prenatabs cbf, fa, obn, rx
|
|
1
|
|
prenatal 1/1, 19, ad, formula, low iron, mr 90 fe, plus, z
|
|
1
|
|
prenatal rx, 1
|
|
1
|
|
prenatal-h
|
|
1
|
|
prenatal-u
|
|
1
|
|
re dualvit ob
|
|
1
|
|
trinate
|
|
1
|
|
ultra natalcare
|
|
1
|
|
ultra-natal
|
|
1
|
|
vinatal forte
|
|
1
|
|
vinate az, gt, ii, ultra
|
|
1
|
|
vinate-m
|
|
1
|
|
vitafol-ob
|
|
1
|
| |
