©2008 Express Scripts, Inc. (10/15/2007)
11
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
clozapine tab 25 mg, 50 mg, 100 mg
|
|
1
|
|
FAZACLO
|
clozapine
|
2
|
|
fluphenazine decanoate [INJ]
|
|
1
|
|
fluphenazine hcl
|
|
1
|
|
GEODON
|
ziprasidone
|
2
|
[QLL]
|
haloperidol decanoate [INJ]
|
|
1
|
|
haloperidol, lactate
|
|
1
|
|
INVEGA
|
paliperidone
|
2
|
[QLL]
|
loxapine, succinate
|
|
1
|
|
MOBAN
|
molindone
|
2
|
|
ORAP
|
pimozide
|
2
|
|
perphenazine
|
|
1
|
|
RISPERDAL CONSTA [INJ]
|
risperidone
|
3
|
|
RISPERDAL, M-TAB
|
risperidone
|
2
|
[QLL]
|
SEROQUEL, XR
|
quetiapine fumarate
|
2
|
[QLL]
|
thioridazine hcl [CARE]
|
|
1
|
|
thiothixene
|
|
1
|
|
trifluoperazine hcl
|
|
1
|
|
ZYPREXA, ZYDIS
|
olanzapine
|
2
|
[QLL]
|
|
MEDICAMENTOS ANTIVÉRTIGO Y ANTIEMÉTICOS
|
ALOXI [INJ]
|
palonosetron hcl
|
3
|
|
COMPAZINE syrup
|
prochlorperazine edisylate
|
2
|
|
compro
|
|
1
|
|
dimenhydrinate [INJ]
|
|
1
|
|
EMEND
|
aprepitant
|
2
|
[PAR][QLL]
|
MARINOL
|
dronabinol
|
3
|
|
meclizine hcl
|
|
1
|
|
ondansetron hcl
|
|
1
|
[PAR][QLL]
|
ondansetron hcl in dextrose [INJ]
|
|
1
|
|
ondansetron, odt
|
|
1
|
[PAR][QLL]
|
phenadoz [CARE]
|
|
1
|
|
prochlorperazine edisylate [INJ]
|
|
1
|
|
prochlorperazine maleate
|
|
1
|
|
promethazine hcl [CARE]
|
|
1
|
|
promethegan [CARE]
|
|
1
|
|
trimethobenzamide hcl cap (300 mg), inj
|
|
1
|
|
univert
|
|
1
|
|
|
ANSIOLÍTICOS
|
buspirone hcl
|
|
1
|
|
meprobamate [CARE]
|
|
1
|
|
|
©2008 Express Scripts, Inc. (10/15/2007)
12
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
CARBAMAZEPINAS
|
carbamazepine
|
|
1
|
|
epitol
|
|
1
|
|
TEGRETOL XR
|
carbamazepine
|
2
|
|
TRILEPTAL
|
oxcarbazepine
|
2
|
|
|
NARCÓTICOS CLASE II
|
alfentanil hydrochloride [INJ]
|
|
1
|
|
belladonna & opium [CARE]
|
|
1
|
|
codeine phosphate inj [INJ]
|
|
1
|
|
codeine sulfate
|
|
1
|
|
endocet
|
|
1
|
|
endodan
|
|
1
|
|
eth-oxydose
|
|
1
|
|
fentanyl w/droperidol [INJ]
|
|
1
|
|
fentanyl, citrate
|
|
3
|
[PAR][QLL]
|
hydromorphone hcl
|
|
1
|
|
levorphanol tartrate
|
|
1
|
|
meperidine hcl [CARE]
|
|
1
|
|
meperitab [CARE]
|
|
1
|
|
methadone hcl, intensol
|
|
1
|
|
methadose
|
|
1
|
|
morphine sulfate inj, rectal, soln, tab, tab sa (excepto 10mg, 15mg, 30mg tabletas solubles)
|
|
1
|
|
morphine sulfate in dextrose [INJ]
|
|
1
|
|
oxycodone hcl, -acetaminophen
|
|
1
|
[QLL]
|
oxycodone/acetaminophen
|
|
1
|
|
oxycodone/aspirin
|
|
1
|
|
oxycodone/apap
|
|
1
|
|
OXYCONTIN [G]
|
oxycodone
|
2
|
[QLL]
|
perloxx
|
|
1
|
|
roxicet tab 5/325 mg
|
|
1
|
|
sublimaze [INJ]
|
|
1
|
|
|
NARCÓTICOS CLASE III
|
acetaminophen/codeine
|
|
1
|
|
apap/caffeine/dihydrocodeine
|
|
1
|
|
aspirin w/codeine
|
|
1
|
|
co-gesic
|
|
1
|
|
hydrocodone bit-ibuprofen
|
|
1
|
|
hydrocodone/acetaminophen
|
|
1
|
|
margesic h
|
|
1
|
|
reprexain tab 7.5/200 mg
|
|
1
|
|
stagesic
|
|
1
|
|
©2008 Express Scripts, Inc. (10/15/2007)
13
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
SUBOXONE
|
buprenorphine/naloxone
|
2
|
[QLL]
|
SUBUTEX
|
buprenorphine
|
2
|
|
|
NARCÓTICOS CLASE IV
|
pentazocine/acetaminophen [CARE]
|
|
1
|
|
pentazocine/naloxone hcl [CARE]
|
|
1
|
|
propoxyphene hcl, -apap [CARE]
|
|
1
|
|
propoxyphene napsylate/apap [CARE]
|
|
1
|
|
|
ESTIMULANTES PARA EL SISTEMA NERVIOSO CENTRAL
|
ADDERALL XR [CARE]
|
amphetamine/dextroamphetami ne
|
2
|
|
amphetamine salt combo [CARE]
|
|
1
|
|
caffeine and sodium benzoate [INJ]
|
|
1
|
|
caffeine citrate [INJ]
|
|
1
|
|
DESOXYN [CARE]
|
methamphetamine
|
2
|
|
dexmethylphenidate hcl
|
|
1
|
|
dextroamphetamine sulfate [CARE]
|
|
1
|
|
METADATE CD
|
methylphenidate
|
2
|
|
METADATE ER tab sa 10 mg [G]
|
methylphenidate
|
2
|
|
metadate er tab sa 20 mg
|
|
1
|
|
methylin tab 5 mg, 10 mg, 20 mg (excepto tabletas masticables)
|
|
1
|
|
methylin er
|
|
1
|
|
methylphenidate er, hcl
|
|
1
|
|
PROVIGIL
|
modafinil
|
2
|
[PAR]
|
|
MEDICAMENTOS PARA PREVENIR Y TRATAR EL DOLOR DE CABEZA
|
asa/butalb/caffeine/codeine
|
|
1
|
|
ascomp w/codeine
|
|
1
|
|
butalbital compound w/codeine
|
|
1
|
|
butalbital/caff/apap/codeine
|
|
1
|
|
butorphanol tartrate
|
|
1
|
[QLL]
|
dihydroergotamine mesylate [INJ]
|
|
1
|
|
ergotamine/caffeine
|
|
1
|
|
IMITREX
|
sumatriptan
|
2
|
[QLL]
|
MAXALT, MLT
|
rizatriptan benzoate
|
2
|
[QLL]
|
migergot
|
|
1
|
|
|
HIDANTOÍNAS
|
CEREBYX [INJ]
|
fosphenytoin
|
3
|
|
DILANTIN cap (30 mg), tabletas masticables
|
phenytoin sodium
|
2
|
|
PEGANONE
|
ethotoin
|
2
|
|
phenytoin
|
|
1
|
|
©2008 Express Scripts, Inc. (10/15/2007)
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
phenytoin sodium [INJ]
|
|
1
|
|
phenytoin sodium extended
|
|
1
|
|
|
INHIBIDORES MAO
|
EMSAM
|
selegiline
|
2
|
|
MARPLAN
|
isocarboxazid
|
2
|
|
NARDIL
|
phenelzine
|
2
|
|
tranylcypromine sulfate
|
|
1
|
|
|
OTROS ANTICONVULSIVOS
|
FELBATOL
|
felbamate
|
2
|
|
gabapentin
|
|
1
|
|
GABITRIL
|
tiagabine
|
2
|
|
KEPPRA
|
levetiracetam
|
2
|
|
LAMICTAL tab 25 mg, 100 mg, 150 mg,200 mg (excepto LAMICTAL disper tab)
|
lamotrigine
|
2
|
|
LAMICTAL kit de inicio
|
lamotrigine
|
2
|
|
lamotrigine
|
|
1
|
|
LYRICA
|
pregabalin
|
2
|
[ST]
|
NEURONTIN soln
|
gabapentin
|
2
|
|
primidone
|
|
1
|
|
TOPAMAX
|
topiramate
|
2
|
[PAR]
|
zonisamide
|
|
1
|
[PAR]
|
|
OTROS ANTIDEPRESIVOS
|
amitriptyline/chlordiazepoxide [CARE]
|
|
1
|
|
budeprion sr, xl
|
|
1
|
[QLL]
|
bupropion hcl sr
|
|
1
|
[QLL]
|
bupropion hcl, xl
|
|
1
|
|
CYMBALTA
|
duloxetine
|
2
|
[QLL][ST]
|
maprotiline hcl
|
|
1
|
|
mirtazapine
|
|
1
|
|
nefazodone hcl
|
|
1
|
|
perphenazine/amitriptyline [CARE]
|
|
1
|
|
trazodone hcl
|
|
1
|
|
venlafaxine hcl
|
|
1
|
|
OTROS MEDICAMENTOS PARA EL PARKINSON
APOKYN [INJ]
|
apomorphine hcl
|
3
|
|
bromocriptine mesylate
|
|
1
|
|
carbidopa/levodopa, er
|
|
1
|
|
COMTAN
|
entacapone
|
2
|
|
LODOSYN
|
carbidopa
|
2
|
|
MIRAPEX
|
pramipexole
|
2
|
|
©2008 Express Scripts, Inc. (10/15/2007)
Nombre del medicamento
|
Composición química
|
Nivel
|
Requisitos/
Límites
|
REQUIP
|
ropinirole
|
2
|
|
selegiline hcl
|
|
1
|
|
STALEVO 100,150,50
|
carbidopa/levodopa/entacap
|
2
|
|
TASMAR
|
tolcapone
|
2
|
|
|
OTROS MEDICAMENTOS PARA EL SISTEMA NERVIOSO CENTRAL Y AUTÓNOMO
|
ANTABUSE
|
disulfiram
|
2
|
|
atropine sulfate [INJ]
|
|
1
|
|
depade
|
|
1
|
|
flumazenil [INJ]
|
|
1
|
|
guanidine hcl
|
|
1
|
|
MESTINON syrup, tab sa
|
pyridostigmine
|
2
|
|
naloxone hcl [INJ]
|
|
1
|
|
naltrexone hcl
|
|
1
|
|
neostigmine methylsulfate [INJ]
|
|
1
|
|
physostigmine salicylate [INJ]
|
|
1
|
|
PROSTIGMIN tab
|
neostigmine bromide
|
2
|
|
pyridostigmine bromide
|
|
1
|
|
STRATTERA
|
atomoxetine
|
2
|
[PAR]
|
XYREM
|
sodium oxybate
|
3
|
|
|
AMINAS SECUNDARIAS
|
amoxapine
|
|
1
|
|
desipramine hcl
|
|
1
|
|
nortriptyline hcl
|
|
1
|
|
VIVACTIL
|
protriptyline
|
2
|
|
|
SEDANTES/HIPNÓTICOS
|
chloral hydrate
|
|
1
|
|
ROZEREM
|
ramelteon
|
2
|
[QLL]
|
zolpidem tartrate
|
|
1
|
[QLL]
|
|
INHIBIDORES SELECTIVOS DE LA RECAPTACIÓN DE SEROTONINA
|
citalopram, hbr
|
|
1
|
[QLL]
|
fluoxetine hcl
|
|
1
|
[QLL]
|
fluvoxamine maleate
|
|
1
|
[QLL]
|
paroxetine hcl
|
|
1
|
[QLL]
|
sertraline hcl
|
|
1
|
[QLL]
|
PRODUCTOS PARA DEJAR DE FUMAR
buproban
|
|
1
|
[QLL]
|
bupropion hcl sr
|
|
1
|
[QLL]
|
CHANTIX
|
varenicline tartrate
|
2
|
|
nicotine patch
|
|
1
|
| |
