©2008 Express Scripts, Inc. 2
(10/15/2007)
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
SELZENTRY
|
maraviroc
|
3
|
|
SUSTIVA
|
efavirenz
|
2
|
|
TRIZIVIR
|
zidovudine/lamivudine/abacavir
|
3
|
|
TRUVADA
|
emtricitabine/tenofovir
|
3
|
|
VIDEX
|
didanosine
|
2
|
|
VIDEX EC cap sa 125 mg
|
didanosine
|
2
|
|
VIRACEPT
|
nelfinavir mesylate
|
3
|
|
VIRAMUNE
|
nevirapine
|
2
|
|
VIREAD
|
tenofovir disproxil fumarate
|
2
|
|
ZERIT
|
stavudine
|
2
|
|
ZIAGEN
|
abacavir sulfate
|
2
|
|
zidovudine
|
|
1
|
|
|
MEDICAMENTOS ANTITUBERCULOSOS
|
ethambutol hcl
|
|
1
|
|
isonarif
|
|
1
|
|
isoniazid
|
|
1
|
|
MYCOBUTIN
|
rifabutin
|
2
|
|
PRIFTIN
|
rifapentine
|
2
|
|
pyrazinamide
|
|
1
|
|
rifampin
|
|
3
|
|
|
CEFALOSPORINAS
|
cefaclor, er
|
|
1
|
|
cefadroxil
|
|
1
|
|
cefazolin sodium [INJ]
|
|
1
|
|
cefdinir
|
|
1
|
|
cefepime hcl [INJ]
|
|
3
|
|
cefotaxime sodium [INJ]
|
|
1
|
|
cefoxitin [INJ]
|
|
1
|
|
cefpodoxime proxetil
|
|
1
|
|
cefprozil
|
|
1
|
|
ceftazidime [INJ]
|
|
3
|
|
CEFTIN susp
|
cefuroxime axetil
|
2
|
|
ceftriaxone [INJ]
|
|
1
|
|
cefuroxime
|
|
1
|
|
cefuroxime sodium [INJ]
|
|
1
|
|
cephalexin
|
|
1
|
|
MAXIPIME [G][INJ]
|
cefepime
|
3
|
|
|
CLORAMFENICOLES
|
chloramphenicol sod succinate [INJ]
|
|
1
|
|
|
©2008 Express Scripts, Inc. (10/15/2007)
3
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
CLINDAMICINAS
|
CLEOCIN PALMITATE
|
clindamycin palmitate
2
|
|
|
clindamycin hcl, phosphate
|
|
1
|
|
|
ERITROMICINAS
|
ERY-TAB
|
erythromycin base
|
2
|
|
ERYTHROCIN LACTOBIONATE [INJ]
|
erythromycin lactobionate
|
2
|
|
erythrocin stearate
|
|
1
|
|
erythromycin, ethylsuccinate
|
|
1
|
|
|
MEDICAMENTOS ANTIFÚNGICOS ORALES
|
ANCOBON
|
flucytosine
|
3
|
|
clotrimazole
|
|
1
|
|
fluconazole
|
|
1
|
[PAR][QLL]
|
GRIFULVIN V tab
|
griseofulvin microsize
|
2
|
|
GRIS-PEG
|
griseofulvin ultramicrosize
|
2
|
|
griseofulvin
|
|
1
|
|
itraconazole
|
|
1
|
[PAR][QLL]
|
ketoconazole
|
|
1
|
|
NOXAFIL
|
posaconazole
|
3
|
|
nystatin oral susp, polvo (50 mmu, 150 mmu,500 mmu), tabletas
|
|
1
|
|
terbinafine hcl
|
|
1
|
|
VFEND
|
voriconazole
|
3
|
[PAR]
|
|
OTROS MEDICAMENTOS ANTIINFECCIOSOS
|
ALINIA
|
nitazoxanide
|
2
|
|
baciim [INJ]
|
|
1
|
|
bacitracin [INJ]
|
|
1
|
|
colistimethate sodium [INJ]
|
|
3
|
|
CUBICIN [INJ]
|
daptomycin
|
3
|
|
INVANZ [INJ]
|
ertapenem sodium
|
2
|
|
MEPRON
|
atovaquone
|
3
|
|
MERREM [INJ]
|
meropenem
|
3
|
|
pentamidine isethionate [INJ]
|
|
1
|
|
POLYMYXIN B SULFATE 100mm
|
polymyxin b
|
2
|
|
polymyxin b sulfate inj [INJ]
|
|
1
|
|
PRIMAXIN, I.M. [INJ]
|
imipenem/cilastatin sodium
|
3
|
|
SYNERCID [INJ]
|
quinupristin/dalfopristin
|
3
|
|
TYGACIL [INJ]
|
tigecycline
|
3
|
|
VANCOCIN HCL cap
|
vancomycin
|
3
|
|
vancomycin hcl inj 500 mg, 1,000 mg, 5,000 mg, 10,000 mg [INJ]
|
|
1
|
|
ZYVOX
|
linezolid
|
3
|
[PAR]
|
©2008 Express Scripts, Inc. (10/15/2007)
4
    Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
OTROS MEDICAMENTOS ANTIVIRALES
|
acyclovir
|
|
1
|
|
acyclovir sodium [INJ]
|
|
1
|
|
amantadine
|
|
1
|
|
BARACLUDE
|
entecavir
|
3
|
|
CYTOVENE [INJ]
|
ganciclovir
|
2
|
|
DENAVIR
|
penciclovir
|
2
|
|
EPIVIR HBV
|
lamivudine
|
2
|
|
famciclovir
|
|
1
|
|
foscarnet sodium [INJ]
|
|
1
|
|
FOSCAVIR [INJ][G]
|
foscarnet
|
2
|
|
ganciclovir
|
|
3
|
|
HEPSERA
|
adefovir dipivoxil
|
3
|
|
ribapak
|
|
3
|
|
ribasphere
|
|
3
|
|
ribavirin
|
|
3
|
|
rimantadine hcl
|
|
1
|
|
TAMIFLU
|
oseltamivir phosphate
|
2
|
[QLL]
|
TYZEKA
|
telbivudine
|
2
|
|
VALCYTE
|
valganciclovir
|
3
|
|
VIRAZOLE [INJ]
|
ribavirin
|
2
|
|
ZOVIRAX crema, ungüento
|
acyclovir
|
2
|
|
|
OTROS MACRÓLIDOS
|
azithromycin
|
|
1
|
[QLL]
|
clarithromycin, er
|
|
1
|
|
|
OTROS ANTIFÚNGICOS TÓPICOS
|
ciclopirox
|
|
1
|
|
clotrimazole
|
|
1
|
|
econazole nitrate
|
|
1
|
|
ketoconazole
|
|
1
|
|
nyamyc
|
|
1
|
|
nystatin crema, ungüento, polvo (100,000 u/1g)
|
|
1
|
|
nystop
|
|
1
|
|
pedi-dri
|
|
1
|
|
|
ANTIFÚNGICOS PARENTERALES
|
ABELCET [INJ]
|
amphotericin b lipid complex
|
3
|
|
AMBISOME [INJ]
|
amphotericin b liposome
|
3
|
|
AMPHOTEC [INJ]
|
ampho b c-s
|
2
|
|
amphotericin b [INJ]
|
|
1
|
|
CANCIDAS [INJ]
|
caspofungin acetate
|
3
|
|
fluconazole in dextrose, in saline [INJ]
|
|
1
|
|
©2008 Express Scripts, Inc. (10/15/2007)
5
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
MYCAMINE [INJ]
|
micafungin sodium
|
3
|
|
VFEND IV [INJ]
|
voriconazole
|
3
|
|
|
PENICILINAS
|
amoclan
|
|
1
|
|
amox tr-potassium clavulanate
|
|
1
|
|
amoxicillin
|
|
1
|
|
AMOXIL [G]
|
amoxicillin
|
2
|
|
ampicillin sodium [INJ]
|
|
1
|
|
ampicillin trihydrate
|
|
1
|
|
ampicillin/sulbactam [INJ]
|
|
1
|
|
AUGMENTIN tabletas masticables, susp (125 mg/5ml, 250 mg/5ml)
|
amoxicillin clavulanate
|
2
|
|
dicloxacillin sodium
|
|
1
|
|
GEOCILLIN
|
carbenicillin
|
2
|
|
nafcillin [INJ]
|
|
3
|
|
nafcillin sodium [INJ]
|
|
3
|
|
oxacillin, sodium [INJ]
|
|
3
|
|
penicillin g potassium, g sodium [INJ]
|
|
1
|
|
penicillin v potassium
|
|
1
|
|
piperacillin [INJ]
|
|
1
|
|
PIPRACIL IN DEXTROSE [INJ]
|
piperacillin
|
2
|
|
ZOSYN [INJ]
|
piperacillin/tazobactam sodium
|
2
|
|
|
PLASMODICIDAS
|
chloroquine phosphate
|
|
1
|
|
DARAPRIM
|
pyrimethamine
|
2
|
|
FANSIDAR
|
pyrimethamine/sulfadoxine
|
2
|
|
HALFAN
|
halofantrine
|
2
|
|
hydroxychloroquine sulfate
|
|
1
|
|
MALARONE
|
atovaquone/proguanil hcl
|
2
|
|
mefloquine hcl
|
|
1
|
|
PRIMAQUINE
|
primaquine
|
2
|
|
QUALAQUIN
|
quinine sulfate
|
2
|
|
|
QUINOLONAS
|
AVELOX IV [INJ]
|
moxifloxacin
|
2
|
|
AVELOX, ABC PACK
|
moxifloxacin
|
2
|
|
CIPRO I.V. inj 200 mg/ml, 400 mg/ml [INJ]
|
ciprofloxacin
|
2
|
|
ciprofoxacin er, hcl
|
|
1
|
|
ofloxacin
|
|
1
|
|
|
SULFONAMIDAS
|
erythromycin/sulfisoxazole
|
|
1
|
|
©2008 Express Scripts, Inc. 6
(10/15/2007)
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
GANTRISIN
|
sulfisoxazole acetyl
|
2
|
|
sulfadiazine
|
|
1
|
|
sulfamethoxazole/trimethoprim
|
|
1
|
|
sulfatrim
|
|
1
|
|
|
TETRACICLINAS
|
demeclocycline hcl
|
|
3
|
|
doxycycline, hyclate, monohydrate
|
|
1
|
|
minocycline hcl
|
|
1
|
|
myrac
|
|
1
|
|
tetracycline hcl
|
|
1
|
|
|
MEDICAMENTOS ANTIBACTERIANOS TÓPICOS
|
BACTROBAN crema
|
mupirocin calcium
|
2
|
|
CHLORHEXIDINE GLUCONATE soln, top
|
chlorhexidine
|
2
|
|
gentamicin sulfate
|
|
1
|
|
mupirocin
|
|
1
|
|
silver sulfadiazine
|
|
1
|
|
ssd, af
|
|
1
|
|
SULFAMYLON
|
mafenide acetate
|
2
|
|
thermazene
|
|
1
|
|
COMBINACIONES ANTIFÚNGICAS-CORTICOSTEROIDES TÓPICAS
clotrimazole/betamethasone
|
|
1
|
|
nystatin/triamcinolone
|
|
1
|
|
|
ANTIINFECCIOSOS URINARIOS
|
FURADANTIN [CARE]
|
nitrofurantoin
|
2
|
|
methenamine hippurate, mandelate
|
|
1
|
|
nitrofurantoin, macrocrystal, monohyd macro [CARE]
|
|
1
|
|
PRIMSOL
|
trimethoprim
|
2
|
|
trimethoprim
|
|
1
|
|
uretron d/s [CARE]
|
|
1
|
|
urimar-t tab [CARE]
|
|
1
|
|
urogesic-blue [CARE]
|
|
1
|
|
utira, -c [CARE]
|
|
1
|
|
utrona [CARE]
|
|
1
|
|
visqid a/a
|
|
1
|
|
|
ANTIFÚNGICOS VAGINALES
|
miconazole 3
|
|
1
|
[QLL]
|
nystatin (productos vaginales)
|
|
1
|
|
terconazole
|
|
1
|
[QLL]
| |
