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).
NIVEL 1 $
NIVEL 2 $$ NIVEL 3 $$$ AGENTES HORMONALES (cont.)
NIVEL 1 $ NIVEL 3 $$$ CONDICIONES GASTROINTESTINALES/PIROSIS (cont.) dicyclomine capsule, solution, tablet esomeprazole capsule, packet (QL) famotidine suspension, 20 mg, 40 mg tablet NIVEL 2 $$
estradiol (once weekly) estradiol (twice weekly) (QL) euthyrox levo-t levothyroxine tablet levoxyl liothyronine tablet lyllana (QL) methyl- prednisolone dosepack, tablet np thyroid prednisone prednisone intensol progesterone capsule testosterone (PA, QL) testosterone mg/10 ml, 2,000 mg/10 ml, 6,000 mg/30 ml yuvafem (QL) acyclovir capsule, suspension, tablet amoxicillin amoxicillin- clavulanate amoxicillin- clavulanate er azithromycin packet, suspension, tablet cefdinir cephalexin EMVERM erythromycin fluconazole suspension, tablet hydroxy- chloroquine cypionate 200 mg/ml, 1,000
ESTROGEL MYFEMBREE (PA, QL) ORIAHNN (PA, QL) ORILISSA (PA, QL) PREMARIN PREMPHASE PREMPRO
CYTOMEL DEPO- TESTOSTERONE EVAMIST INTRAROSA (QL) MEDROL MENOSTAR (QL) OSPHENA (QL) RAYALDEE unithroid XYOSTED (PA, QL)
CLENPIQ+ LINZESS LITHOSTAT NEXIUM DR 2.5 MG, 5 MG PACKET (QL) PANCREAZE SUFLAVE+ SUTAB+ TRULANCE VIBERZI
BONJESTA CARAFATE CUVPOSA DICLEGIS MOTOFEN MOVANTIK (PA) PROTONIX SUSPENSION, TABLET (QL, ST) RECTIV RELISTOR (PA) RELISTOR (PA) SANCUSO (PA, QL) SFROWASA SYMPROIC (PA) VARUBI (PA, QL) VIOKACE
gavilyte-c+ gavilyte-g+ gavilyte-n+ lubiprostone mesalamine
mesalamine dr mesalamine er metoclopramide omeprazole capsule (QL) ondansetron ondansetron ondansetron odt pantoprazole packet, tablet (QL) pantoprazole (QL) peg 3350-electrolyte+ peg-3350 and electrolytes+ peg3350-sodium sulfate-sodium chloride- potassium chloride sodium ascorbate- ascorbic acid+ peg-prep+ sodium sulfate- potassium sulfate- magnesium sulfate+
INFECCIONES
e.e.s. 400 LAGEVRIO (EUA) (QL) PAXLOVID (QL) PAXLOVID (EUA) (QL) XIFAXAN (QL)
AEMCOLO (QL) BAXDELA 450 MG TABLET (PA) BEYFORTUS+ BILTRICIDE
DIFICID (QL) ERYPED 200 MACROBID
MACRODANTIN PLAQUENIL (PA) SIVEXTRO 200 MG TABLET (PA) sulfatrim TAMIFLU (QL) VALTREX VIVJOA (PA) XENLETA TABLET (PA, QL)
AGENTES HORMONALES
desmopressin solution, spray, tablet dotti (QL) estradiol (QL)
ANDRODERM (PA, QL) COMBIPATCH DUAVEE ESTRING (QL)
ACTIVELLA ANDROGEL (PA, QL) ANGELIQ BIJUVA CRINONE (PA)
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