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New York (HARP) Medicaid New York Health and Recovery Plan (HARP) Lista de medicamentos preferidos aprobada por Medicaid En vigencia desde el 1 de febrero de 2020 Leyenda En cada categoría, los medicamentos se listan en orden alfabético por marca o nombre genérico. Medicamento de marca: letra mayúscula en negrita Medicamento genérico: letra minúscula en texto sin formato AL: restricción de límite de edad DO: programa de optimización de dosis GR: restricción de género OTC: medicamento de venta libre disponible con receta. (Los recetadores deben incluir la sigla OTC en la receta). PA: requiere autorización previa. La autorización previa es el proceso mediante el cual se obtiene la aprobación de los beneficios antes de que se puedan abastecer ciertas recetas. QL: límites de cantidad. Ciertos medicamentos recetados tienen límites de cantidad específicos, por receta o por mes. SP: farmacia de medicamentos especiales ST: requiere terapia escalonada. Es posible que necesite utilizar un medicamento antes de que los beneficios para el uso de otro medicamento puedan autorizarse. Nombre del medicamento Referencia Notas ADYUVANTES FARMACÉUTICOS cvs petroleum jelly external gel CareAll Petroleum Jelly OTC RA Tugaboos Petroleum gnp petroleum jelly gel OTC Jelly RA Tugaboos Petroleum hm petroleum jelly gel OTC Jelly ORA-PLUS ORAL LIQUID OTC petroleum jelly external gel CareAll Petroleum Jelly OTC petroleum jelly external ointment OTC RA Tugaboos Petroleum petroleum jelly gel OTC Jelly RA Tugaboos Petroleum ra petroleum jelly gel OTC Jelly RA TUGABOOS PETROLEUM JELLY GEL OTC RESOURCE THICKENUP ORAL PACKET OTC RESOURCE THICKENUP ORAL POWDER OTC SIMPLYTHICK EASY MIX ORAL GEL OTC SIMPLYTHICK ORAL GEL OTC RA Tugaboos Petroleum sm petroleum jelly gel OTC Jelly sterile water for injection injection solution sterile water for injection intravenous solution SUSPENDOL-S LIQUID OTC SYRSPEND SF ORAL LIQUID OTC THICK NOW ORAL POWDER OTC THICK-IT #2 ORAL POWDER OTC THICK-IT ORAL POWDER OTC THIK & CLEAR ORAL POWDER OTC white petrolatum external ointment GRX White Petrolatum OTC white petroleum jelly external gel CareAll Petroleum Jelly OTC AGENTES ANORRECTALES COLOCORT RECTAL ENEMA cvs hemorrhoidal rectal ointment Major-Prep Hemorrhoidal OTC eq hemorrhoidal rectal suppository OTC gnp hemorrhoidal rectal suppository Medicone OTC hemorrhoidal rectal ointment Major-Prep Hemorrhoidal OTC hydrocortisone rectal cream Proctosol HC QL 2 Nombre del medicamento Referencia Notas hydrocortisone rectal enema Colocort MEDICONE RECTAL SUPPOSITORY OTC PROCTOSOL HC RECTAL CREAM QL PROCTOZONE-HC RECTAL CREAM QL px hemorrhoidal rectal ointment OTC px hemorrhoidal rectal suppository OTC qc hemorrhoidal rectal ointment Major-Prep Hemorrhoidal OTC qc hemorrhoidal rectal suppository Preparation H OTC ra hemorrhoid relief rectal suppository OTC ra hemorrhoidal rectal ointment OTC rectacaine rectal suppository Medicone OTC sb hemorrhoid rectal ointment OTC sm hemorrhoidal rectal suppository Medicone OTC tgt hemorrhoidal rectal suppository OTC TRONOLANE RECTAL SUPPOSITORY OTC AGENTES ANSIOLÍTICOS ALPRAZOLAM INTENSOL ORAL CONCENTRATE alprazolam oral tablet Xanax alprazolam oral tablet dispersible buspirone hcl oral tablet chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet DIAZEPAM INTENSOL ORAL CONCENTRATE diazepam oral concentrate Diazepam Intensol diazepam oral solution diazepam oral tablet Valium hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule lorazepam oral tablet Ativan oxazepam oral capsule AGENTES ANTIANGINOSOS isosorbide dinitrate oral tablet isosorbide mononitrate er oral tablet extended release 24 hour isosorbide mononitrate oral tablet 3 Nombre del medicamento Referencia Notas NITRO-BID TRANSDERMAL OINTMENT NITRO-DUR TRANSDERMAL PATCH 24 HOUR nitroglycerin sublingual tablet sublingual Nitrostat nitroglycerin transdermal patch 24 hour Nitro-Dur AGENTES ANTIASMÁTICOS Y AGENTES BRONCODILATADORES albuterol sulfate er oral tablet extended release 12 hour albuterol sulfate hfa inhalation aerosol ProAir HFA QL solution albuterol sulfate inhalation nebulization QL solution albuterol sulfate oral syrup albuterol sulfate oral tablet ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH QL ACTIVATED ATROVENT HFA INHALATION AEROSOL QL SOLUTION BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 QL MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-25 PA; QL MCG/INH budesonide inhalation suspension Pulmicort PA; AL; QL COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION cromolyn sodium inhalation nebulization solution FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH QL ACTIVATED FLOVENT HFA INHALATION AEROSOL QL fluticasone-salmeterol inhalation aerosol Wixela Inhub QL powder breath activated ipratropium bromide inhalation solution QL ipratropium-albuterol inhalation solution 4 Nombre del medicamento Referencia Notas metaproterenol sulfate oral syrup montelukast sodium oral packet Singulair QL montelukast sodium oral tablet Singulair montelukast sodium oral tablet chewable Singulair SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH QL ACTIVATED SPIRIVA RESPIMAT INHALATION QL AEROSOL SOLUTION STIOLTO RESPIMAT INHALATION QL AEROSOL SOLUTION terbutaline sulfate oral tablet THEO-24 ORAL CAPSULE EXTENDED QL RELEASE 24 HOUR theophylline er oral tablet extended release 12 hour theophylline er oral tablet extended release 24 hour theophylline oral solution WIXELA INHUB INHALATION AEROSOL QL POWDER BREATH ACTIVATED XOLAIR SUBCUTANEOUS SOLUTION PA; SP PREFILLED SYRINGE XOLAIR SUBCUTANEOUS SOLUTION PA; SP RECONSTITUTED zafirlukast oral tablet Accolate QL AGENTES ANTIINFECCIOSOS VARIOS clindamycin hcl oral capsule Cleocin clindamycin palmitate hcl oral solution Cleocin reconstituted dapsone oral tablet linezolid oral suspension reconstituted Zyvox PA; QL linezolid oral tablet Zyvox PA; QL metronidazole oral capsule Flagyl metronidazole oral tablet Flagyl sulfamethoxazole-trimethoprim oral Sulfatrim Pediatric suspension sulfamethoxazole-trimethoprim oral tablet Bactrim 5 Nombre del medicamento Referencia Notas SULFATRIM PEDIATRIC ORAL SUSPENSION tinidazole oral tablet QL trimethoprim oral tablet AGENTES ANTIMIASTÉNICOS/COLINÉRGICOS pyridostigmine bromide er oral tablet Mestinon extended release pyridostigmine bromide oral solution Mestinon pyridostigmine bromide oral tablet Mestinon AGENTES ANTIMIASTÉNICOS pyridostigmine bromide er oral tablet Mestinon extended release pyridostigmine bromide oral solution Mestinon pyridostigmine bromide oral tablet Mestinon AGENTES ANTIMICOBACTERIALES ethambutol hcl oral tablet Myambutol isoniazid oral syrup isoniazid oral tablet PRIFTIN ORAL TABLET pyrazinamide oral tablet rifabutin oral capsule Mycobutin rifampin oral capsule Rifadin RIFATER ORAL TABLET AGENTES ANTIPSICÓTICOS/ANTIMANÍACOS ABILIFY MAINTENA INTRAMUSCULAR PA; AL PREFILLED SYRINGE ABILIFY MAINTENA INTRAMUSCULAR PA; AL; QL SUSPENSION RECONSTITUTED ER aripiprazole oral tablet Abilify AL; QL ARISTADA INTRAMUSCULAR PA; AL PREFILLED SYRINGE chlorpromazine hcl oral tablet AL clozapine oral tablet Clozaril AL; QL CLOZARIL ORAL TABLET PA; AL; QL COMPRO RECTAL SUPPOSITORY fluphenazine decanoate injection solution AL fluphenazine hcl injection solution AL 6 Nombre del medicamento Referencia Notas fluphenazine hcl oral concentrate AL fluphenazine hcl oral elixir AL fluphenazine hcl oral tablet AL haloperidol decanoate intramuscular solution Haldol Decanoate AL; QL 100 mg/ml haloperidol decanoate intramuscular solution Haldol Decanoate AL 50 mg/ml haloperidol lactate injection solution Haldol AL haloperidol lactate oral concentrate AL haloperidol oral tablet AL INVEGA SUSTENNA INTRAMUSCULAR PA; AL; QL SUSPENSION PREFILLED SYRINGE INVEGA TRINZA INTRAMUSCULAR PA; AL; QL SUSPENSION PREFILLED SYRINGE lithium carbonate er oral tablet extended Lithobid release lithium carbonate oral capsule lithium carbonate oral tablet lithium oral solution AL loxapine succinate oral capsule AL olanzapine intramuscular solution ZyPREXA AL reconstituted olanzapine oral tablet ZyPREXA AL; QL paliperidone er oral tablet extended release Invega AL 24 hour perphenazine oral tablet AL prochlorperazine edisylate injection solution prochlorperazine maleate oral tablet prochlorperazine rectal suppository Compro quetiapine fumarate oral tablet SEROquel AL; QL RISPERDAL CONSTA INTRAMUSCULAR PA; AL; QL SUSPENSION RECONSTITUTED ER risperidone oral solution RisperDAL AL; QL risperidone oral tablet RisperDAL AL; QL thioridazine hcl oral tablet thiothixene oral capsule AL trifluoperazine hcl oral tablet AL ziprasidone hcl oral capsule Geodon AL; QL 7 Nombre del medicamento Referencia Notas ZYPREXA RELPREVV INTRAMUSCULAR PA; AL SUSPENSION RECONSTITUTED AGENTES CARDIOVASCULARES VARIOS ALYQ ORAL TABLET PA; SP; QL ambrisentan oral tablet Letairis PA; SP; QL sildenafil citrate oral tablet Revatio PA; SP; QL tadalafil (pah) oral tablet Alyq PA; SP; QL AGENTES DE INMUNIZACIÓN PASIVA GAMUNEX-C INJECTION SOLUTION PA; SP OCTAGAM INTRAVENOUS SOLUTION PA; SP SYNAGIS INTRAMUSCULAR SOLUTION PA; SP AGENTES DERMATOLÓGICOS acne foaming wash external liquid PanOxyl Foaming Wash OTC Clean & Clear Persa-Gel acne medication 10 external gel OTC; QL Max St acne medication 10 external lotion OTC; QL acne medication 5 external gel OTC acne medication 5 external lotion OTC; QL acne treatment external bar OTC Clean & Clear Persa-Gel acne treatment external gel OTC; QL Max St ACTICOAT 7 EXTERNAL PAD ACTICOAT 7 EXTERNAL SHEET ACTICOAT ABSORBENT EXTERNAL PAD ACTICOAT
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