©2008 Express Scripts, Inc. (10/15/2007)
42
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
ak-pentolate
|
|
1
|
|
akorn balanced salt
|
|
1
|
|
allersol
|
|
1
|
|
altafrin
|
|
1
|
|
atropine care, sulfate
|
|
1
|
|
balanced salt
|
|
1
|
|
BOTOX [INJ]
|
botulinum toxin a
|
3
|
[PAR]
|
cromolyn sodium (gotas oftálmicas)
|
|
1
|
|
cyclopentolate hcl
|
|
1
|
|
cylate
|
|
1
|
|
diclofenac sodium
|
|
1
|
|
flurbiprofen sodium
|
|
1
|
|
flurox
|
|
1
|
|
homatropaire
|
|
1
|
|
ketotifen fumarate
|
|
1
|
|
mydral
|
|
1
|
|
naphazoline hcl
|
|
1
|
|
NATACYN
|
natamycin
|
2
|
|
neofrin
|
|
1
|
|
parcaine
|
|
1
|
|
phenylephrine hcl
|
|
1
|
|
proparacaine hcl
|
|
1
|
|
RESTASIS
|
cyclosporine
|
2
|
[QLL]
|
tropicacyl
|
|
1
|
|
tropicamide
|
|
1
|
|
VISUDYNE [INJ]
|
verteporfin
|
2
|
|
VOLTAREN (gotas oftálmicas)
|
diclofenac sodium
|
2
|
|
|
MEDICAMENTOS PARA EL SISTEMA RESPIRATORIO
|
ANTIHISTAMÍNICOS
|
b-vex
|
|
1
|
|
ben-tann [CARE]
|
|
1
|
|
bidhist
|
|
1
|
|
bpm
|
|
1
|
|
brompheniramine tannate
|
|
1
|
|
carbinoxamine maleate
|
|
1
|
|
chlorpheniramine maleate [CARE]
|
|
1
|
|
chlortan [CARE]
|
|
1
|
|
clemastine fumarate
|
|
1
|
|
complete allergy medicine [CARE]
|
|
1
|
|
cpm 12 [CARE]
|
|
1
|
|
cyproheptadine hcl [CARE]
|
|
1
|
|
dexchlorpheniramine maleate [CARE]
|
|
1
|
|
diphenhydramine hcl [CARE]
|
|
1
|
|
©2008 Express Scripts, Inc. (10/15/2007)
43
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
diphenhydramine min-i-jet [INJ][CARE]
|
|
1
|
|
diphenmax [CARE]
|
|
1
|
|
ed chlorped [CARE]
|
|
1
|
|
ed-chlor-tan [CARE]
|
|
1
|
|
fexofenadine hcl
|
|
1
|
[QLL]
|
lohist 12hr
|
|
1
|
|
p-tann [CARE]
|
|
1
|
|
palgic soln
|
|
1
|
|
PALGIC tab [G]
|
carbinoxamine maleate
|
2
|
|
pediaphyl [CARE]
|
|
1
|
|
promethazine, hcl [CARE]
|
|
1
|
|
tanacof xr
|
|
1
|
|
|
MEDICAMENTOS ADRENÉRGICOS BETA-2
|
albuterol inh
|
|
1
|
[QLL]
|
albuterol sulfate syrup, tab, tab sa
|
|
1
|
|
ephedrine sulfate [INJ]
|
|
1
|
|
FORADIL
|
formoterol fumarate
|
2
|
[QLL]
|
metaproterenol sulfate syrup,tab
|
|
1
|
|
PROAIR HFA
|
albuterol
|
2
|
[QLL]
|
PROVENTIL HFA
|
albuterol
|
2
|
[QLL]
|
terbutaline sulfate
|
|
3
|
|
|
MODIFICADORES DE LEUCOTRIENOS
|
SINGULAIR
|
montelukast sodium
|
2
|
[ST]
|
ZYFLO
|
zileuton
|
2
|
[ST]
|
|
METILXANTINAS
|
aminophylline
|
|
1
|
|
caffeine citrate
|
|
1
|
|
copd
|
|
1
|
|
dy-g liquid
|
|
1
|
|
dyflex-g
|
|
1
|
|
dylix
|
|
1
|
|
dyphylline gg
|
|
1
|
|
ed-bron g
|
|
1
|
|
jay-phyl
|
|
1
|
|
panfil g
|
|
1
|
|
theochron
|
|
1
|
|
theophylline, anhydrous
|
|
1
|
|
UNIPHYL [G]
|
theophylline
|
2
|
|
|
OTROS MEDICAMENTOS PARA EL ASMA
|
ADVAIR DISKUS, HFA
|
salmeterol/fluticasone
|
2
|
[PAR][QLL]
|
©2008 Express Scripts, Inc. 44
(10/15/2007)
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
ATROVENT HFA
|
ipratropium
|
2
|
[QLL]
|
COMBIVENT
|
albuterol sulfate/ipratropium
|
2
|
[QLL]
|
epinephrine [INJ]
|
|
1
|
|
EPIPEN, JR [INJ]
|
epinephrine hcl
|
2
|
[QLL]
|
GASTROCROM
|
cromolyn
|
2
|
|
INTAL oral inh
|
cromolyn
|
2
|
[QLL]
|
PULMICORT inh
|
budesonide
|
2
|
[QLL]
|
QVAR
|
beclomethasone
|
2
|
[QLL]
|
SPIRIVA
|
tiotropium bromide
|
2
|
[QLL]
|
SYMBICORT
|
budesonide/formoterol fum
|
2
|
[PAR]
|
TILADE
|
nedocromil
|
2
|
[QLL]
|
TWINJECT [INJ]
|
epinephrine hcl
|
2
|
[QLL]
|
XOLAIR [INJ]
|
omalizumab
|
3
|
[PAR]
| |
