©2008 Express Scripts, Inc. (10/15/2007)
7
  Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
MEDICAMENTOS ANTINEOPLÁSICOS/INMUNODEPRESORES
|
ABRAXANE [INJ]
|
paclitaxel
|
3
|
|
adriamycin [INJ]
|
|
1
|
|
adrucil [INJ]
|
|
1
|
|
ALIMTA [INJ]
|
pemetrexed disodium
|
3
|
|
AMEVIVE [INJ]
|
alefacept
|
3
|
[PAR]
|
anagrelide hcl
|
|
3
|
|
ARIMIDEX
|
anastrozole
|
2
|
|
AROMASIN
|
exemestane
|
2
|
|
ARRANON [INJ]
|
nelarabine
|
3
|
|
AVASTIN [INJ]
|
bevacizumab
|
3
|
|
AZASAN
|
azathioprine
|
2
|
[PAR]
|
azathioprine
|
|
1
|
[PAR]
|
BEXXAR [INJ]
|
tositumomab iodine-131
|
3
|
|
BICNU [INJ]
|
carmustine
|
3
|
|
bleomycin sulfate [INJ]
|
|
3
|
|
BUSULFEX [INJ]
|
busulfan
|
3
|
|
CAMPATH [INJ]
|
alemtuzumab
|
3
|
|
CAMPTOSAR [INJ]
|
irinotecan
|
3
|
|
carboplatin [INJ]
|
|
1
|
|
CASODEX
|
bicalutamide
|
2
|
|
CEENU
|
lomustine
|
2
|
|
CELLCEPT
|
mycophenolate mofetil
|
3
|
[PAR]
|
cisplatin [INJ]
|
|
1
|
|
cladribine [INJ]
|
|
3
|
|
CLOLAR [INJ]
|
clofarabine
|
2
|
|
COSMEGEN [INJ]
|
dactinomycin
|
3
|
|
cyclophosphamide
|
|
1
|
[PAR]
|
cyclosporine
|
|
3
|
[PAR]
|
cytarabine [INJ]
|
|
1
|
|
dacarbazine [INJ]
|
|
1
|
|
DACOGEN [INJ]
|
decitabine
|
3
|
|
daunorubicin hcl [INJ]
|
|
3
|
|
DAUNOXOME [INJ]
|
daunorubicin liposome
|
3
|
|
DEPO-PROVERA inj 400 mg/ml [INJ]
|
medroxyprogesterone
|
2
|
|
DEPOCYT [INJ]
|
cytarabine liposome
|
2
|
|
dexrazoxane [INJ]
|
|
3
|
|
DOXIL [INJ]
|
doxorubicin hcl liposome
|
3
|
|
doxorubicin hcl [INJ]
|
|
1
|
|
DROXIA
|
hydroxyurea
|
2
|
|
ELIGARD [INJ]
|
leuprolide
|
2
|
[PAR]
|
ELITEK [INJ]
|
rasburicase
|
3
|
|
ELLENCE [INJ]
|
epirubicin hcl
|
3
|
|
ELOXATIN [INJ]
|
oxaliplatin
|
3
|
|
©2008 Express Scripts, Inc. (10/15/2007)
8
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
ELSPAR [INJ]
|
asparaginase
|
3
|
|
EMCYT
|
estramustine phosphate sodium
|
2
|
|
ENBREL [INJ]
|
etanercept
|
3
|
[PAR][QLL]
|
EPIRUBICIN HCL [INJ]
|
epirubicin hcl
|
3
|
|
ERBITUX [INJ]
|
cetuximab
|
3
|
|
ETHYOL [INJ]
|
amifostine
|
3
|
|
ETOPOPHOS [INJ]
|
etoposide phosphate
|
3
|
|
etoposide inj [INJ]
|
|
1
|
|
FARESTON
|
toremifene
|
2
|
|
FASLODEX [INJ]
|
fulvestrant
|
3
|
|
FEMARA
|
letrozole
|
2
|
|
floxuridine [INJ]
|
|
1
|
|
FLUDARABINE PHOSPHATE [INJ]
|
fludarabine phosphate
|
3
|
|
fluorouracil [INJ]
|
|
1
|
|
flutamide
|
|
1
|
|
fudr [INJ]
|
|
1
|
|
GEMZAR [INJ]
|
gemcitabine
|
3
|
|
gengraf
|
|
1
|
[PAR]
|
GLEEVEC
|
imatinib mesylate
|
3
|
|
HERCEPTIN [INJ]
|
trastuzumab
|
3
|
|
HEXALEN
|
altretamine
|
3
|
|
HUMIRA [INJ]
|
adalimumab
|
3
|
[PAR][QLL]
|
HYCAMTIN [INJ]
|
topotecan
|
3
|
|
hydroxyurea
|
|
1
|
|
idarubicin hcl [INJ]
|
|
3
|
|
ifosfamide [INJ]
|
|
3
|
|
ifosfamide/mesna [INJ]
|
|
3
|
|
IRESSA
|
gefitinib
|
3
|
|
leflunomide
|
|
1
|
|
leucovorin calcium
|
|
1
|
|
LEUKERAN
|
chlorambucil
|
2
|
|
LYSODREN
|
mitotane
|
3
|
|
MATULANE
|
procarbazine
|
3
|
|
MEGACE ES
|
megestrol
|
2
|
|
megestrol acetate
|
|
1
|
|
mercaptopurine
|
|
1
|
|
MESNA [INJ]
|
mesna
|
2
|
|
MESNEX
|
mesna
|
3
|
|
methotrexate
|
|
1
|
[PAR]
|
methotrexate sodium [INJ]
|
|
1
|
|
mitomycin [INJ]
|
|
1
|
|
mitoxantrone hcl [INJ]
|
|
3
|
[PAR]
|
MUSTARGEN [INJ]
|
mechlorethamine
|
2
|
|
MYFORTIC
|
mycophenolate sodium
|
2
|
[PAR]
|
©2008 Express Scripts, Inc. (10/15/2007)
9
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
MYLOTARG [INJ]
|
gemtuzumab ozogamicin
|
3
|
|
NEXAVAR
|
sorafenib tosylate
|
3
|
|
NILANDRON
|
nilutamide
|
2
|
|
NIPENT [INJ][G]
|
pentostatin
|
3
|
|
octreotide acetate [INJ]
|
|
3
|
|
ONCASPAR [INJ]
|
pegaspargase
|
3
|
|
ONTAK [INJ]
|
denileukin diftitox
|
3
|
|
onxol [INJ]
|
|
3
|
|
ORENCIA [INJ]
|
abatacept/maltose
|
3
|
[PAR]
|
ORTHOCLONE OKT-3 [INJ]
|
muronab-cd3
|
3
|
|
paclitaxel 6 mg/ml [INJ]
|
|
3
|
|
pentostatin [INJ]
|
|
3
|
|
PHOTOFRIN [INJ]
|
porfimer sodium
|
3
|
|
PROGRAF
|
tacrolimus
|
3
|
[PAR]
|
RAPAMUNE
|
sirolimus
|
2
|
[PAR]
|
RAPTIVA [INJ]
|
efalizumab
|
3
|
[PAR]
|
REMICADE [INJ]
|
infliximab
|
3
|
[PAR]
|
REVLIMID
|
lenalidomide
|
3
|
|
RITUXAN [INJ]
|
rituximab
|
3
|
[PAR]
|
SANDOSTATIN LAR [INJ]
|
octreotide
|
3
|
|
SIMULECT [INJ]
|
basiliximab
|
3
|
|
SOLTAMOX
|
tamoxifen
|
2
|
|
SPRYCEL
|
dasatinib
|
3
|
|
SUTENT
|
sunitinib malate
|
3
|
|
tamoxifen citrate
|
|
1
|
|
TARCEVA
|
erlotinib hcl
|
3
|
|
TARGRETIN
|
bexarotene
|
3
|
|
TAXOTERE [INJ]
|
docetaxel
|
3
|
|
TESLAC
|
testolactone
|
2
|
|
THERACYS [INJ]
|
vacuna bcg
|
2
|
|
THIOGUANINE
|
thioguanine
|
2
|
|
thiotepa [INJ]
|
|
3
|
|
toposar [INJ]
|
|
1
|
|
TORISEL [INJ]
|
temsirolimus
|
3
|
|
TRELSTAR DEPOT, LA [INJ]
|
triptorelin pamoate
|
2
|
|
tretinoin cap
|
|
3
|
|
TRISENOX [INJ]
|
arsenic trioxide
|
3
|
|
TYKERB
|
lapatinib ditosylate
|
3
|
|
TYSABRI [INJ]
|
natalizumab
|
3
|
[PAR]
|
VANTAS [INJ]
|
histrelin ac
|
2
|
|
VECTIBIX [INJ]
|
panitumumab
|
3
|
|
VELCADE [INJ]
|
bortezomib
|
3
|
|
VIADUR
|
leuprolide/lidocaine hcl
|
2
|
|
VIDAZA [INJ]
|
azacitidine
|
3
|
| |
