Lista de medicamentos con receta Standard de 4 niveles de Cigna Healthcare Los medicamentos de especialidad están cubiertos en el Nivel 4 (la lista está en las páginas 17-20).
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DIABETES (cont.) OMNIPOD 5 G6 PODS (GEN 5) (QL) OMNIPOD CLASSIC PDM KIT(GEN 3) (QL) OMNIPOD CLASSIC PODS (GEN 3) (QL) OMNIPOD DASH INTRO KIT (GEN 4) (QL) OMNIPOD DASH PODS (GEN 4) (QL) OMNIPOD GO PODS (QL) ONETOUCH ULTRA TEST STRIP ONETOUCH VERIO TEST STRIP OZEMPIC (PA, QL) RYBELSUS (PA, QL) SEMGLEE (YFGN) (QL) SEMGLEE (YFGN) PEN (QL) SOLIQUA 100-33 SYMLINPEN SYNJARDY (QL, ST) SYNJARDY XR (QL, ST) TRESIBA (QL) TRIJARDY XR (QL, ST) TRULICITY (PA, QL) V-GO 20, 30, 40 XIGDUO XR (QL, ST) ZEGALOGUE AUTO- INJECTOR (QL) ZEGALOGUE SYRINGE (QL)
DIABETES (cont.)
metformin 500 mg/5 ml, 850
ULTRA-FINE PEN NEEDLE VANISHPOINT INSULIN SYRINGE VEO INSULIN SYRINGE chlorthalidone eplerenone furosemide solution, tablet spironolactone triamterene-hctz
mg/8.5 ml cup metformin 500 mg/5 ml solution metformin er MICROLET 2 MICROLET NEXT LANCING DEVICE MONOJECT INSULIN SYRINGE NANO 2 GEN PEN NEEDLE PARADIGM PRO COMFORT INSULIN SYRINGE PRODIGY INSULIN SYRINGE SAFESNAP INSULIN SYRINGE SAFETYGLIDE INSULIN SYRINGE SURE COMFORT INSULIN SYRINGE SURE-JECT INSULIN SYRINGE TECHLITE INSULIN SYRINGE TERUMO INSULIN SYRINGE THINPRO INSULIN SYRINGE TOPCARE ULTRA COMFORT TRUE COMFORT INSULIN SYRINGE TRUEPLUS INSULIN SYRINGE ULTICARE INSULIN SYRINGE ULTIGUARD SAFEPACK SYRINGE ULTILET INSULIN SYRINGE ULTRA COMFORT ULTRA FLO INSULIN SYRINGE ULTRACARE INSULIN SYRINGE
DIURÉTICOS
CAROSPIR SUSPENSION (PA) KERENDIA (PA, QL)
MAXZIDE
MEDICAMENTOS PARA LOS OÍDOS
ciprofloxacin- dexamethasone neomycin- polymyxin-hc ofloxacin
CIPRO HC
CIPROFLOXACIN- FLUOCINOLONE OTOVEL
DISFUNCIÓN ERÉCTIL
sildenafil^ (QL) tadalafil^ (QL)
MUSE^ (PA age, QL)
CIALIS^ (QL, ST) STENDRA^ (QL, ST) VIAGRA^ (QL, ST)
CONDICIONES OCULARES
cyclosporine dorzolamide- timolol erythromycin latanoprost ofloxacin polymyxin b-trimethoprim tobramycin travoprost
AZASITE BESIVANCE BETOPTIC S BROMSITE CEQUA EYSUVIS (QL) FLAREX INVELTYS LOTEMAX 0.5% EYE OINTMENT LOTEMAX SM SIMBRINZA TOBRADEX EYE OINTMENT TOBRADEX ST XIIDRA ZERVIATE
ACUVAIL ALREX ILEVRO PROLENSA RHOPRESSA ROCKLATAN ZIRGAN ZYLET
PRODUCTOS FEMENINOS
GYNAZOLE 1 miconazole 3 200 mg suppository terconazole
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