©2008 Express Scripts, Inc. (10/15/2007)
40
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
vitafol-pn
|
|
1
|
|
vynatal-fa
|
|
1
|
|
|
MEDICAMENTOS CON PROGESTINA
|
camila
|
|
1
|
|
errin
|
|
1
|
|
FIRST-PROGESTERONE VGS 100, VGS 200, VGS 25, VGS 50
|
progesterone
|
2
|
|
jolivette
|
|
1
|
|
medroxyprogesterone acetate
|
|
1
|
|
nora-be
|
|
1
|
|
norethindrone acetate
|
|
1
|
|
progesterone, in oil [INJ]
|
|
1
|
|
PROMETRIUM
|
progesterone
|
2
|
|
|
MODULADORES SELECTIVOS DEL RECEPTOR DE ESTRÓGENO
|
EVISTA
|
raloxifene
|
2
|
|
|
MEDICAMENTOS OBSTÉTRICOS/GINECOLÓGICOS ESPECIALIZADOS
|
leuprolide acetate [INJ]
|
|
3
|
|
LUPRON DEPOT, -PED [INJ]
|
leuprolide
|
3
|
[PAR]
|
SYNAREL
|
nafarelin
|
3
|
|
|
MEDICAMENTOS OFTÁLMICOS
|
MEDICAMENTOS ANTIGLAUCOMA
|
acetazolamide
|
|
1
|
|
ALPHAGAN P
|
brimonidine tartrate
|
2
|
|
betaxolol hcl
|
|
1
|
|
brimonidine tartrate
|
|
1
|
|
carteolol hcl
|
|
1
|
|
dipivefrin hcl
|
|
1
|
|
levobunolol hcl
|
|
1
|
|
LUMIGAN
|
bimatoprost
|
2
|
|
methazolamide
|
|
1
|
|
metipranolol
|
|
1
|
|
PHOSPHOLINE IODIDE
|
echothiophate iodide
|
2
|
|
pilocarpine hcl
|
|
1
|
|
timolol maleate
|
|
1
|
|
TRUSOPT
|
dorzolamide
|
2
|
|
XALATAN
|
latanoprost
|
2
|
|
|
ANTIINFECCIOSOS/CORTICOSTEROIDES OFTÁLMICOS
|
methadex
|
|
1
|
|
neomycin/bacitracin/poly/hc
|
|
1
|
|
©2008 Express Scripts, Inc. 41
(10/15/2007)
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
neomycin/polymyxin/dexameth
|
|
1
|
|
neomycin/polymyxin/hc
|
|
1
|
|
poly-dex
|
|
1
|
|
sulfacetamide/prednisolone
|
|
1
|
|
ZYLET
|
tobramycin/lotepred etab
|
2
|
|
|
CORTICOSTEROIDES OFTÁLMICOS
|
dexamethasone sodium phosphate
|
|
1
|
|
dexasol
|
|
1
|
|
fluorometholone
|
|
1
|
|
FML S.O.P.
|
fluorometholone
|
2
|
|
PRED MILD
|
prednisolone acetate
|
2
|
|
prednisol
|
|
1
|
|
prednisolone acetate, sodium phosphate
|
|
1
|
|
|
MEDICAMENTOS ANTIBACTERIANOS OFTÁLMICOS TÓPICOS
|
ak-poly-bac
|
|
1
|
|
aktob
|
|
1
|
|
bacitracin, -polymyxin
|
|
1
|
|
ciprofoxacin hcl
|
|
1
|
|
erythromycin
|
|
1
|
|
gentak
|
|
1
|
|
gentamicin sulfate
|
|
1
|
|
gentasol
|
|
1
|
|
neocidin
|
|
1
|
|
neomycin/bacitracin/polymyxin
|
|
1
|
|
neomycin/polymyxin/gramicidin
|
|
1
|
|
ofloxacin
|
|
1
|
|
polycin-b
|
|
1
|
|
polymyxin b sul-trimethoprim
|
|
1
|
|
romycin
|
|
1
|
|
sulfac
|
|
1
|
|
sulfacetamide sodium
|
|
1
|
|
sulfamide
|
|
1
|
|
tobramycin sulfate
|
|
1
|
|
tobrasol
|
|
1
|
|
ZYMAR
|
gatifloxacin
|
2
|
|
|
MEDICAMENTOS ANTIVIRALES OFTÁLMICOS TÓPICOS
|
trifluridine
|
1
|
|
|
OTROS MEDICAMENTOS OFTÁLMICOS
|
ak-con
|
|
1
|
|
ak-dilate
|
|
1
|
| |
