Odb Cdi

Ontario Drug Benefit Formulary/ Comparative Drug Index No.
41
Effective June 27, 2008
Additional copies of this publication are available for purchase from: Internet In Person ServiceOntario Publications www.serviceontario.ca/publications Downtown Service Ontario Centre 777 Bay Street, Market Level Toronto ON ServiceOntario Publications 50 Grosvenor Street Toronto ON M7A 1N8 Telephone: Toll Free: FAX: TDD / TTY Toll Free: (416) 326-5300 1-800-668-9938 (613) 545-4223 1-800-268-7095
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MasterCard and Visa are accepted. Cheques and money orders should be payable to the Minister of Finance. This formulary is also available at the Ministry of Health and Long-Term Care website:
http://www.health.gov.on.ca/english/providers/program/drugs/odbf_mn.html
Queens Printer for Ontario, 1996 2008 39M/04/07 ISSN 0835-2437 Ontario Drug Benefit Formulary/Comparative Drug Index (Print) ISSN 1916-2278 Ontario Drug Benefit Formulary/Comparative Drug Index (Online)
Ministry of Health
ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX EDITION NO. 41
RECORD OF UPDATES
UPDATE NO. A DATE April 15, 1999 NEW/REVISED PAGES Cover pages 1-3, III. All pages, IV. All pages, VI. All pages, VIII. All pages, IX. 5-6, X. 1-4, XI. All pages, XII. 9-56 NOTED BY
September 15, 1999
Cover page 1, Cover page 3, I. 5-6, I. 9-12, III. All pages, IV. All pages, VI. All pages, IX. 3-6, X. All pages, XI. 17-18, XII. All pages
ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX NO. 41
TABLE OF CONTENTS
Part I Part II Part III Part lV Part V Part VI Part VII Part VIII Part IX Part X Part XI Part XII Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Formulary Listings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I .1 II .1 III .1
Part III-A: Ontario Drug Benefit Formulary (ODB) / Comparative Drug Index (CDI) III-A .1 Part III-B: Off-Formulary Interchangeable Drugs (OFI) . . . . . . . . . . . . . . . . . . . . . . . III-B .1 Consolidated Alphabetical Index of Drug Products Listed in Part III-A and Part III-B . . Index of Pharmacological-Therapeutic Classification . . . . . . . . . . . . . . . . . . . . . . . . . . Facilitated Access Drug Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV .1 V .1 VI .1
Part VI-A: Facilitated Access to HIV/AIDS Drug Products . . . . . . . . . . . . . . . . . . . . VI-A .1 Part VI-B: Facilitated Access to Palliative Care Drug Products . . . . . . . . . . . . . . . . . VI-B .1 Trillium Drug Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII .1
Exceptional Access Program (EAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VIII .1 Additional Benefits Nutrition Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diabetic Testing Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abbreviations, Tables and Sample Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . This section is currently not in use Limited Use Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XII .1 IX .1 IX .6 X .1
PART I
INTRODUCTION
A. BACKGROUND
The Ontario Drug Benefit Formulary/Comparative Drug Index (Formulary/CDI) was first introduced in 1976 in order to define the benefits provided for eligible Ontario Drug Benefit (ODB) recipients. The Formulary/CDI was developed in consultation with the Ministry of Health and Long-Term Cares (the ministry) expert drug advisory committee, the Committee to Evaluate Drugs (CED) [formerly known as the Drug Quality and Therapeutics Committee]. For many years, the Formulary/CDI has set the provincial standard for quality, therapeutic value and interchangeability of drug products. The ministry has liaised with the Ontario Medical Association, the Ontario Pharmacists Association, the Ontario College of Pharmacists, pharmaceutical manufacturers, and other professional and consumer groups as required on the content and policies embodied in this publication. Further information, including a searchable electronic Formulary, is available under the Health Care Provider Section of the ministrys website at: www.health.gov.on.ca.
1.
Purpose
The Formulary/CDI serves as a: guide to practitioners and pharmacists regarding drug products which are eligible for coverage under the ODB program. guide for pharmacists regarding conditions for payment. uide to professional committees in hospitals and institutions in the selection of drug products g uide to drug product interchangeability in respect of drug products which have been designated as g interchangeable under Ontario legislation informal source for the reimbursement price for drug products The ODB program covers over 3,200 quality-assured drug products. While the list of benefits is extensive, it does not include every drug a practitioner might prescribe.
2.
Recipient Eligibility
The ODB program provides drug benefits to residents of Ontario who are eligible for coverage under the Ontario Health Insurance Plan (OHIP) under the Health Insurance Act and who: are 65 years of age or older are receiving professional services under the Home Care Program are residents of long-term care homes or Homes for Special Care have high drug costs in relation to their income and who meet the eligibility requirements under the Trillium Drug Program, or are receiving benefits under Ontario Works or the Ontario Disability Support Program All residents of Ontario who are covered under OHIP will qualify for drug benefits under the ODB program on the first day of the month following their 65th birthday. For example, if a resident's 65th birthday is April 15th, he/she will become eligible for the ODB program on May 1st. People who do not initially meet the residency requirements for OHIP coverage but who later become eligible after the specified waiting period (e.g., new or returning permanent residents, landed immigrants) will qualify for ODB program coverage provided that they fall into one of the categories listed above. To help make the ODB program sustainable and affordable for the future and to allow government to continue to add new drugs as benefits, a co-payment scheme was introduced in July 1996. All ODB recipients are required to pay a small portion of their prescriptions. For more details about co-payments, please refer to Section C.4 of Part I, entitled Cost-Sharing.
3.
Interchangeable Products
The Drug Interchangeability and Dispensing Fee Act (DIDFA) gives the Executive Officer of Ontario Public Drug Programs (the Executive Officer) the authority to designate a product as interchangeable with one or more other products where the Executive Officer considers it advisable in the public interest
ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX JUNE 27, 2008 I.1
to do so and certain requirements and conditions set out in the DIDFA are met. The DIDFA defines an interchangeable product as a drug or combination of drugs in a particular dosage form and strength identified by a specific product name or manufacturer and designated as interchangeable with one or more other such products. The onus is on the manufacturer to provide evidence of interchangeability. Off-Formulary Interchangeability: Off-Formulary Interchangeability (OFI) is the application of interchangeable designations to drug products where the original products are not listed as ODB benefits in the Formulary/CDI. OFI became effective April 1, 2007 when changes to Regulation 935 under the DIDFA came into force. Off-formulary interchangeable drug products are reviewed by the CED or by the Ministry, and upon approval of the Executive Officer, are determined to be interchangeable with the brand non-benefit products. Notice to Dispensers: There are occasions when a drug product that is the subject of an ongoing patent dispute in the courts is designated as interchangeable in the Formulary/CDI. The designation of such a drug product is not meant to be, and does not act as, a certification that the drug product is non-infringing under federal patent laws. Dispensers should seek their own advice in that regard. If a court finds a drug product to be patent-infringing, the Executive Officer may, depending on the relief ordered, reconsider the listing status of the drug product.
4.
The Committee to Evaluate Drugs (CED)
The CED [formerly the Drug Quality and Therapeutics Committee (DQTC)] was established in 1968 as an expert advisory group to provide independent, specialized advice to the government on drug-related matters. The CED is established by Order-in-Council under the authority of section 9 of the Ministry of Health and Long-Term Care Act. The Committee provides an essential advisory service to the ministry through its rigorous, evidence-based review of drug products, resulting in recommendations regarding the listing of these products on the Formulary/CDI. The CED is composed of a Chair and 16 members appointed by Orders in Council. Two of the 16 CED members are patient representatives. The remaining CED members are all practicing physicians and pharmacists who have expertise in a wide range of specialties, including geriatrics, infectious disease, family medicine, pharmacology, health economics, epidemiology and other disciplines. Additional information on the CED membership and its terms of reference can be accessed at the following website: www.pas.gov.on.ca For drug products to be eligible for listing in the Formulary/CDI, a drug manufacturer must provide a complete submission in accordance with the prescribed conditions set out in section 12 of Ontario Regulation 201/96 made under the Ontario Drug Benefit Act, or section 6 of Ontario Regulation 935 made under the Drug Interchangeability and Dispensing Fee Act, and the requirement set out in the Ontario Guidelines for Drug Submission & Evaluation. Each complete submission undergoes a thorough review by the CED. In conducting its review, the CED considers a number of criteria, including therapeutic efficacy and safety in the population groups served by the ODB program (e.g. seniors), cost-effectiveness of a drug in comparison to alternatives already listed in the Formulary, and impact on other health services. Following its review, the CED makes recommendations to the Executive Officer as to whether a drug product should be listed as a Formulary/CDI benefit or whether a drug product should be designated as an interchangeable drug product. The Executive Officer makes the final decision regarding the reimbursement of the product. Listing proposals contained in a drug submission are reviewed by the ministry based on the CEDs recommendation. For further information on the submission review and approval process, please refer to the Ontario Guidelines for Drug Submission and Evaluation available on the ministrys website (www.health.gov.on.ca). A comprehensive roster of expert consultants has been established to assist the CED in the review of drug submissions and other drug-related issues. These experts are retained where necessary to complement the expertise available on the CED.
5.
Pharmacy Council
The ministry established the Pharmacy Council in November 2006 to provide a forum for pharmacists and the ministry to discuss drug-related policy. The 12-member Council provides expert advice on pharmaceutical and health policy as it relates to the practice of pharmacy in Ontario.
I.2 ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX JUNE 27, 2008
Members of the Pharmacy Council are appointed by the Minister of Health and Long-Term Care, including two Co-chairs, one of which is from the ministry and the other is from the Ontario Pharmacists' Association; and with representation from various stakeholder groups and regulatory bodies including: Ontario Pharmacists Association Community pharmacy Hospital pharmacy Ontario College of Pharmacists Faculty of Pharmacy at an Ontario university Ontario Medical Association Patient representative The Council will make recommendations to the Executive Officer and the Minister to: a) b) c) d) build and sustain a strong positive working relationship between the Government of Ontario and the pharmacy profession; identify opportunities for pharmacists to provide professional services and to consider a compensation model for the provision of those services; promote adherence to the Code of Conduct; advise on the appropriate role of pharmacists within the health care system, including in primary care models, and to advise on ways to enhance the quality and effectiveness of pharmacy services provided to Ontarians; consider any other matter referred to it jointly by the Ontario Pharmacists Association and the ministry.
e)
Further information on the Council, including Terms of Reference monthly meeting summaries and membership, is available under the Ontario Public Drug Programs' section of the ministrys website at http://www.health.gov.on.ca. One of the Pharmacy Council's major achievements in 2007 was the creation of MedsCheck, a medication review program that supports the appropriate use of medications. MedsCheck was launched on April 1, 2007 with the collaboration of the Council, the Ministry of Health and Long-Term Care, and the Ontario Pharmacists' Association. For more information on the MedsCheck program, please refer to the MedsCheck Guidebook at www.medscheck.ca
B. How to Use the Formulary

The objective of the Formulary/CDI is to provide a tool for practitioners and pharmacists that encourages appropriate and cost-effective utilization of drug therapies. The Formulary/CDI is a compilation of pharmaceutical products arranged in comparative categories and groupings according to the nature, strength and dosage form of the active therapeutic ingredients. This publication requires knowledgeable interpretation and is not intended for general distribution. Therefore, circulation is generally restricted to practitioners, pharmacies, hospitals and organizations associated with the manufacturing, distribution and use of pharmaceutical products. The loose-leaf format of this publication allows for easier incorporation of the changes or updates that occur as part of the continuous Formulary/CDI review process. Future supplements may include only those pages affected by changes, or a summary list of changes.
Part III-A
Classification
Ontario Drug Benefit Formulary/Comparative Drug Index
Drugs are listed by pharmacologic-therapeutic classification based on the classification system of the American Hospital Formulary Service of the American Society of Health-System Pharmacists. Permission to use this classification system has been granted by the Society, which is not responsible for the accuracy of any reproduced content.
Drugs are listed alphabetically by the generic/chemical name within each pharmacologic-therapeutic classification. The generic/chemical name of each drug that is a benefit under the ODB program is followed by the brand names that are deemed interchangeable for that dosage form and strength. The pharmacologic-therapeutic classification under which any drug is listed may be found by consulting the index in Part V of the Formulary/CDI. Drugs with multiple indications are listed under only one of the common uses. Interchangeable Categories Where there is more than one drug product listed in a specific category, the products have been designated as interchangeable under the Drug Interchangeability and Dispensing Fee Act, unless otherwise noted. The Drug Benefit Price (DBP) is listed for each drug product as well as the lowest DBP price for the interchangeable category. The ODB program will reimburse dispensing physicians and pharmacies for the product in their inventory with the lowest DBP price within an interchangeable category. Drug Identification Number (DIN) For each drug product, the Formulary/CDI lists the eight-digit drug identification number (DIN) assigned by the Therapeutics Products Directorate of Health Canada*. The DIN uniquely identifies each drug product as to its manufacturer, active ingredients, strength of active ingredients, route of administration and pharmaceutical dosage form. Please note that only products with DINs that are listed as benefits in the Formulary/CDI are eligible for reimbursement under the ODB program. * A small number of drug products, including nutrition products and diabetic test strips, have been assigned a product identification number (PIN) with leading digits 98 for the purposes of ODB claims. These PINs may differ from those shown on the manufacturers label but must be used when submitting claims to the ODB program. Daily Cost/Prescribing Notes The Formulary/CDI includes the daily cost for selected anti-infective and anti-hypertensive agents and more extensive prescribing notes. The daily cost shown is that for the most common dose prescribed (see section titled Drug Cost for more information). The Formulary/CDI also includes prescribing notes that are intended to draw the health care providers attention to important considerations related to the particular drug (e.g. adverse effects, comparative cost-effectiveness or toxicity). Limited Use Products Limited Use (LU) products are listed in the Formulary/CDI with specific clinical criteria/conditions for use and will be reimbursed under the ODB program only when those criteria/conditions have been met. LU products, together with their clinical criteria for use, are listed in Part III-A of the Formulary/ CDI based on their pharmacologic-therapeutic classification. In order to provide convenient access to a complete listing of all LU products, they are also listed alphabetically by generic name in Part XII of the Formulary/CDI. LU products will be reimbursed under the ODB program only when prescribed for an ODB-eligible recipient in accordance with the applicable LU criteria and the prescriber has provided the Reason for Use Code, either verbally, electronically or in written format with the prescription. For more details about the LU reimbursement process, please refer to Section C.8 of Part I, entitled Limited Use Products as well as to Part XII of the Formulary/CDI. The ministry is continuing to review the LU products and will be transitioning products to general benefit or conditional listing. Listings Agreements Listing agreements may be in place to support a general benefit listing or coverage under the Exceptional Access Program (EAP) and are intended to provide access to new and existing drugs under certain conditions, based on the recommendations of the CED. This process may be referred to as a conditional listing. Listing Agreements are established through negotiated agreements between manufacturers and the Executive Officer, and my include: commitment to promote appropriate use; requirement to collect outcomes data; requirement to gather further evidence related to clinical or economic information for future consideration by CED; and expenditure contracts.
Therapeutic notes are published in the Formulary as guidance and it is the responsibility of the prescriber to prescribe the drug to ODB recipients in accordance with the listed therapeutic notes. These listings will allow ODB recipients to access new drugs on a conditional basis while the information which might support continued listing is in the process of being collected and reviewed. These listings will also ease the administrative burden on prescribers as no forms or Limited Use codes are required. Through open channels of communication with manufacturers, the CED will review their ODB reimbursement recommendations when new information becomes available and the ministry will continue to assess opportunities to enter into conditional listing agreements with manufacturers.
Part III-B
Off-Formulary Interchangeable Drugs (OFI)
Off-Formulary Interchangeable drug products are listed by a pharmacologic-therapeutic classification based on the same classification system as applied under Part III-A of the Formulary/CDI. Drugs are listed alphabetically by the generic/chemical name within each pharmacologic-therapeutic classification. All drug products listed in Part III-B of the Formulary/CDI are NOT benefits. Drug product prices, as reported by the respective manufacturers to the ministry, have been listed for each product for information purposes only. In accordance with section 8(1)(7) of R.R.0 1990, Regulation 935 of the Drug Interchangeability and Dispensing Fee Act, manufacturers of these drug products shall give the Executive Officer notice of every change in the manufacturers list price for their drug products.
Part IV
Consolidated Alphabetical Index of Drug Products Listed in Part III of the Formulary/CDI
This is a consolidated alphabetical index, by both generic and brand names, for all drugs listed in the Formulary/CDI. Generic/chemical names are indicated by bold print.
Part V
Index of Pharmacologic-Therapeutic Classification
An index of the pharmacologic-therapeutic classification is provided in this section in ascending order.
Part VI
Facilitated Access Drug Products
This part lists specific products that are reimbursed through the Facilitated Access mechanism under the ODB program used to treat ODB recipients with HIV/AIDS or patients undergoing palliative (endof-life) care. Part VI has been divided into Part VI-A (HIV/AIDs) and Part VI-B (Palliative Care) to distinguish the differing categories of drug products available under this mechanism.
Part VII
Trillium Drug Benefit Program
The ministry provides benefits to recipients under the Trillium Drug Program to help individuals and families who have high drug expenses in relation to their incomes. Part VII explains how the Trillium Drug Benefit Program works and provides a list of allowable expenses.
Part VIII
Exceptional Access Program (EAP)
The ministry may consider requests for coverage of drug products not listed in the Formulary/CDI for ODB-eligible persons. Part VIII explains how the Exceptional Access Program (EAP) works.
Part IX
Additional Benefits
Nutrition Products This list includes a maximum allowable reimbursement mechanism for Nutrition Products (NP) covered under the ODB program. Practitioners must complete a Nutrition Products Form and forward a copy with the prescription to the pharmacy for each NP prescribed. Claims for NPs are reimbursed only for patients who are eligible for ODB coverage and who also meet the patient eligibility criteria described
in Part IX. ODB does not provide coverage for NPs for residents of long-term care homes. Long-term care homes are responsible for providing NPs to their residents when required. Diabetic Testing Agents Blood glucose test strips covered by the ODB program are listed in Part IX. These products are available to ODB-eligible recipients when prescribed by a practitioner . Blood glucose test strips are listed with a maximum price that will be reimbursed by the Executive Officer under the ODB program.
Part X
Abbreviations, Tables and Sample Forms
This part contains an alphabetical index of abbreviations for the names of manufacturers whose products are listed in the Formulary/CDI and the following five tables: Table 1: Table 2: Table 3: Table 4: Table 5: Abbreviations for Dosage Forms Medicinal Preparations That Can be Fatal to a 10kg Toddler Upon Ingestion of 1-2 Tablets, Capsules or Teaspoonfuls Selected List of Drugs and Their Fatality Potential in Toddlers of 10kg Approximate Relative Potencies of Listed Topical Steroid Preparations Approximate Conversion Tables from the Avoirdupois to the Metric System
Sample Forms This section contains samples of forms used in connection with the ODB program. The Health Canada - Canada Vigilance Reporting Form must accompany medically necessary No Substitution claims. Nutrition Products Form must be completed for Nutrition Product claims. These forms must be fully completed before submitting an ODB claim and will be requested during routine ODB pharmacy audits for post-payment verification. EAP Standard Template may be used to request coverage of drug products not listed in the Formulary/CDI for ODB eligible persons.
Part XI Part XII
This Section is Currently Not in Use Alphabetical List of Limited Use Products
This section contains a complete alphabetical list of all Limited Use (LU) drug products and the specific LU clinical criteria that are listed in the Formulary/CDI. It also contains a guide for prescribers and pharmacists on how to complete a LU prescription.
C. Dispensary Reimbursement/Procedure
1. Health Network System
The Health Network System (HNS) links all Ontario dispensaries to the ministry computer system and allows on-line claims processing and adjudication in real-time. Benefits of the HNS include timely reconciliation of claims and real-time adjudication of claims that previously required special claims procedures (e.g. extemporaneous mixtures). The HNS identifies who is eligible for ODB benefits, and informs pharmacists of program and policy changes on-line through an email system. The collection, use and disclosure of personal information on the HNS is governed by section 13 of the Ontario Drug Benefit Act and the Personal Health Information and Protection Act, 2004.
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JUNE 27, 2008
2.
Drug Utilization Review (DUR)
The HNS assists pharmacists in providing quality health care through a drug utilization review (DUR) mechanism. The DUR program, part of the HNS, provides an analysis of both previous prescription information/claims data and current prescription data to identify potential problems. Its primary function is to enhance the current principles of good pharmacy practice with additional information sources. The HNSs prospective DUR currently monitors for: potential drug interactions potential double doctoring duplicate prescriptions potential multiple pharmacy use refill too soon/too late. Retrospective claims analysis will also provide insights into drug trends and issues. It can help identify patterns that could form the basis for further study and the development of strategies leading to more rational drug use.
3.
Drug Cost
The drug cost set out opposite the listed drug product in Part III-A of the Formulary/CDI is the Drug Benefit Price (DBP) as defined in the Ontario Drug Benefit Act and the Drug Interchangeability and Dispensing Fee Act (for the Comparative Drug Index). The DBP for a drug in a particular dosage form and strength reflects the amount, calculated per gram, millilitre, tablet, capsule or other appropriate unit, for which a listed drug product in that dosage form and strength will be reimbursed by the ministry. For drug products listed in package (Pk) sizes (for example, pressurized inhalers), the DBP is for the package size listed. For ointments, creams, powders and liquids the cost is per gram or per millilitre. For tablets, capsules and suppositories, other than those designated Pk, the cost is per unit dosage form. A daily cost is shown for selected therapeutic categories. This information is provided as a point of reference for practitioners to show the relative cost of different therapeutic alternatives. It is not a limit on the amount that the ODB program will pay for an individual patient for a particular benefit. The daily cost is calculated for the most commonly prescribed dosage of the product; for example Cloxacillin 250mg Cap (generic): most commonly prescribed dose is 1 capsule QID; daily cost = 4 x $0.0993 = $0.40. The daily cost is based on the DBP for a particular benefit and does not include the mark-up (see Part II, Preamble) or the dispensing fee. Drug products listed in Part III-A are reimbursed under the ODB program at the listed DBP (or lowest DBP for an interchangeable category) plus a mark-up plus the lesser of a pharmacys posted usual and customary fee or the ODB dispensing fee, minus the applicable co-payment amount for every ODB prescription filled.
4.
Cost Sharing
People whose prescription drugs or additional benefits are paid for by the ODB program are required to contribute a small amount for each prescription. There are two categories of co-payment: 1) ODB recipients pay up to $2 per prescription if they are: a senior single person with an annual net income of less than $16,018 a senior couple with a combined annual net income of less than $24,175 r eceiving benefits under the Ontario Works Act, 1997 or the Ontario Disability Support Program Act, 1997 receiving professional services under the Home Care Program
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a resident of a home under the Homes for the Aged and Rest Homes Act, Nursing Homes Act, Charitable Institutions Act or Homes for Special Care Act. eligible for benefits under the Trillium Drug Program
2) Single seniors with annual net income equal to or greater than $16,018 or a senior couple with a combined annual income equal to or greater than $24,175 each pay their first $100 (i.e. deductible) in prescription costs each year. After that, they pay up to $6.11 (i.e. co-payment) toward the ODB dispensing fee on each prescription. The ODB deductible for newly eligible seniors in the higher co-payment category is prorated based on the number of months they are eligible for ODB in their first year of eligibility. The HNS will automatically track and notify pharmacists of an individuals deductible based on the month when they become eligible in their first year of ODB coverage. Only allowable drug expenses will count towards the $100 deductible, namely, prescriptions for drug products listed in Part III-A of the Formulary/CDI, prescriptions for nutrition products and diabetic testing agents approved as benefits under the ODB program, as well as extemporaneous products that are designated pharmaceutical products under the ODBA. The ODB deductible and co-payment are tracked through the HNS according to the ODB benefit year. The ODB benefit year begins August 1 and ends on July 31 of the subsequent year.
5.
Drug Quantity
The normal quantity dispensed shall be the entire quantity of the drug as prescribed by the practitioner. For most ODB eligible recipients the maximum quantity that may be charged under the ODB program must not exceed that required for a 100-day course of treatment. The quantity dispensed is subject to the ODBA, DIDFA, and to the details of the prescription as directed by the practitioner. For recipients covered under the Ontario Works Act, 1997, the maximum quantity of medication claimed under the ODB program must not exceed that required for a 35-day course of treatment. Additional quantity restrictions are also enforced by the HNS for some Trillium recipients receiving prescriptions in the third and fourth quarter of the benefit year. Please refer to Part VII for additional drug quantity restrictions related to the Trillium Drug Program. The HNS provides pharmacists with a refill too soon warning for claims where additional supplies are submitted more than ten days prior to the end of a previous supply. Pharmacists should use their professional judgment in consultation with the practitioner and patient when dispensing the second prescription. The ministry recognizes that there are circumstances where recipients have a valid and appropriate reason for obtaining an early refill of a medication (e.g. dose change). In these cases, the reason for the early refill must be documented on the hard copy of the prescription. The ministry will monitor claims to ensure that pharmacies comply with the HNS warnings and recoveries will be made where claims are submitted inappropriately. Effective March 1, 1999, ODB recipients traveling outside the province for between 100 and 200 days, may obtain an early refill (up to a 100-day supply) of medication before leaving the province. In order to obtain an early refill for a vacation supply, ODB recipients must provide the pharmacist with a letter or a copy of their travel insurance, confirming that they are leaving the province for between 100 and 200 days. The letter or copy of travel insurance must be maintained by the pharmacist for a period of 24 months, in a readily retrievable location for audit purposes. It is suggested that these documents be maintained in a separate file, instead of attaching to the prescription hardcopy. Pharmacists must have the letter or copy of their travel insurance confirming travel outside of Ontario before submitting claims for a vacation supply and overriding any rejections generated by the HNS (use intervention code MV to override the duplicate claim rejection if two claims for 100-day supply of medication are submitted for the recipient on the same day). Please refer to Part VII for Trillium vacation supply information.
6.
Conditions on Payment of Dispensing Fees for Ontario Drug Benefit (ODB) Claims
Changes have been made to O. Reg. 201/96 under the Ontario Drug Benefit Act (the ODBA Regulation) to establish conditions for the payment of dispensing fees under the Ontario Drug Benefit (ODB) Program. Effective August 1, 2008, to receive payment of a dispensing fee under the ODB Program, the dispenser must supply at one time the lesser of:
(a) (b)
the entire quantity of the listed drug product that is specified on the prescription to be dispensed at one time; or the maximum quantity permitted under section 18 of the ODBA Regulation (Maximum Quantity).
In other words, the dispenser is required to dispense at one time the Maximum Quantity unless the prescriber has directed that a smaller quantity be dispensed. In cases where the prescriber has directed the dispensing of a reduced quantity (i.e. less than the Maximum Quantity), the ministry will provide payment for a maximum of two (2) dispensing fees per medication per recipient per calendar month. Pharmacists may also dispense less than the Maximum Quantity in cases where the pharmacist has determined, in his or her professional opinion, that the ODB patient is incapable of managing his/ her medication regimen as a result of physical, cognitive or sensory impairment. In cases where the pharmacist has determined that reduced quantity dispensing is warranted due to patient impairment, the pharmacist must maintain a written record of the reasons for this opinion, as well as a record of the authorization received from the ODB patient (or person presenting the prescription) for dispensing in reduced quantities. Under these circumstances, pharmacists would receive payment under the ODB Program for no more than two (2) dispensing fees per medication per recipient per calendar month. Although claims submitted for dispensing fees in excess of the monthly 2-fee limit are not eligible for payment under the ODB Program, pharmacists would still receive payment for the drug benefit price plus any applicable markup. Pharmacists are encouraged to work with prescribers to facilitate the dispensing of the Maximum Quantity provided for under the ODBA Regulation. The above conditions do not apply if: (i) the ODB recipient is a resident of a long-term care home, or Home for Special Care (ii) the medication being dispensed is one which has been designated by the Executive Officer for an exemption. These exempted medications are generally those that are normally prescribed for periods of short duration (e.g. antibiotics) or products where there is risk of abuse or diversion (e.g. narcotics and controlled drugs). The list of exempted medications is available at the following link: http://www.health.gov.on.ca/english/providers/program/drugs/odbf/dispensing_fees_drug.pdf
7.
Cost-to-Operator Claims
Effective March 1, 2007, in accordance with section 14(3)(b) of O.Reg 201/96 made under the ODBA, the allowable use of the MI (Cost-to-Operator or CTO) intervention code is restricted to cases where a pharmacy is unable to acquire the lowest DBP product and must dispense the original product or a higher priced drug product. Supporting documentation (manufacturers or wholesalers invoice), which clearly indicates that the generic product had been ordered and was unavailable during the appropriate time period, must be retained on file for 24 months for post-payment verification. Overpayments due to inappropriate submission of MI intervention codes are subject to recovery through post-payment verification audit.
8.
Medically Necessary No Substitution Claims
The ministry will provide reimbursement of a higher cost interchangeable product in medically necessary circumstances where a patient has experienced a significant adverse reaction with a lower-cost interchangeable drug product. When a practitioner identifies a patient for which it is medically necessary that a higher cost interchangeable product be provided, the practitioner must: complete, sign and forward to the pharmacist a Health Canada - Canada Vigilance Reporting Form; and handwrite on the prescription No Substitution or No Sub. The practitioner should keep a copy of the completed form in the patients record for future use and reference.
JUNE 27, 2008
I.9
When the pharmacist receives a prescription with the handwritten notation No Substitution, reimbursement will be provided for the higher cost interchangeable product only if the prescription is accompanied by a completed Health Canada - Canada Vigilance Reporting Form. This form must be completely filled out noting the details of the adverse reaction and signed by the practitioner. Upon receipt, the pharmacist must: clearly note on the Health Canada - Canada Vigilance Reporting Form ODB NO SUBSTITUTION fax or mail the completed and signed form to Health Canadas Canada Vigilance Program retain his or her copy of the completed and signed Canada Vigilance Reporting Form. The Canada Vigilance Reporting Form will not have to be renewed but must be retained on file. The practitioner must hand-write No Substitution or No Sub on renewal or subsequent new prescriptions. The dispenser will be reimbursed the DBP plus a mark-up and the lesser of the posted usual and customary fee or the ODB dispensing fee minus the applicable ODB co-payment amount. Where a completed, signed Canada Vigilance Reporting Form is not available at the pharmacy during an audit, the difference between the cost of the higher-cost product and the lowest DBP listed for the interchangeable category will be recovered. The pharmacist must mail or fax the completed form to: Canada Vigilance Regional Office 2301 Midland Avenue Toronto ON M1P 4R7 E-mail: CanadaVigilance_ON@hc-sc.gc.ca Telephone: 1-866-234-2345 Fax: 1-866-678-6789 Blank forms can be obtained by calling the above numbers, or on-line at: http://www.hc-sc.gc.ca/dhp-mps/alt_formats/hpfb-dgpsa/pdf/medeff/ar-ei_form-eng.pdf
9.
Limited Use Products
Designating Listed Drugs as Limited Use Benefits Drug products reimbursed under the ODB program are evaluated and recommended for listing by the ministrys expert drug advisory committee, the Committee to Evaluate Drugs (CED). Limited Use (LU) drugs are those drugs recommended by the CED as having value in specific circumstances, but are not appropriate for general listing in the Formulary/CDI. LU drugs may: have the potential for widespread use outside the indications for which benefit and costeffectiveness have been demonstrated; be clinically useful, but are associated with predictable severe adverse effects and a less toxic alternative is available as a general benefit; be very costly and a lower-cost alternative is available as a general benefit. As a result, the CED may recommend that a drug product be reimbursed only when specific clinical criteria/conditions have been met. Presently, LU products, together with their specific clinical criteria, are listed in Part III-A of the Formulary/CDI based on their pharmacologic-therapeutic classification. For easy reference, all LU drug products are also listed alphabetically by generic name in Part XII. The CED and ministry will continue to review existing LU products to determine if there are opportunities to transition a given product to a conditional or general benefit listing.
I.10
JUNE 27, 2008
Limited Use Reimbursement Process Patients may take the LU prescription to the pharmacy, or practitioners may fax it directly to the pharmacy. The Reason for Use Code (RFU), may be communicated in writing, electronically or verbally. The Authorization periods for an LU prescription are noted with the drug listing in the Formulary and are based on the initial date that the first LU prescription is dispensed. See Part XII for more detailed information about the LU claims process, including instructions for practitioners and pharmacists related to LU prescriptions. In instances where an ODB-eligible patient does not meet the listed LU criteria, physicians may make a written request for special consideration for coverage under the ODB programs Exceptional Access Program (see Part VIII of the Formulary/CDI for further details). ODB Audit of Limited Use Claims The Inspection Unit of Ontario Public Drug Programs routinely conducts on-site audits of all pharmacies for post-payment verification of claims reimbursed under the ODB program. In addition, the ministry may request copies of LU prescriptions from pharmacies by mail for purposes of carrying out office audits relating to ODB claims for LU products. The ministry will recover monies paid for LU product claims where: the Limited Use (Reason for Use) code indicated on the prescription does not meet the listed LU clinical criteria the Limited Use (Reason for Use) code is not provided with the prescription. the prescription is incomplete (e.g. the date, drug, patient name or the correct CPSO number or college registration number is missing or the practitioner has not signed the prescription) the LU authorization period is expired a prescription with valid LU documentation was not obtained/retained in the pharmacy for 24 months. Pharmacists are reminded that copies of prescriptions with LU documentation must be retained by the pharmacy for 24 months as required by the regulations under the Ontario Drug Benefit Act.
10. Extemporaneous Preparations

An extemporaneous preparation is defined in section 1(1) of O.Reg 201/96 made under the Ontario Drug Benefit Act as a drug or combination of drugs prepared or compounded in a pharmacy according to a prescription. Section 17 of the Ontario Drug Benefit Act gives the Executive Officer of Ontario Public Drug Programs ("the Executive Officer") the authority to: (a) determine the conditions which must be met before an extemporaneous preparation is designated as a designated pharmaceutical product (DPP) and therefore deemed eligible for reimbursement under the ODB program; and (b) determine the drug benefit price of a DPP including a formula by which the drug benefit price may be calculated. Effective October 1, 2006, an extemporaneous preparation that is not equivalent to a manufactured drug product will be deemed by the Executive Officer to be a DPP and therefore eligible for reimbursement under the ODB program, if: a) b) the preparation is for internal consumption and contains a solid oral dosage form of a listed drug product and no other active substance; the preparation is for injection and is prepared by or under the direct supervision of a pharmacist (i.e. a person holding a certificate of registration from the Ontario College of Pharmacists in accordance with the Pharmacy Act, 1991 and the Regulated Health Professions Act, 1991) (see restrictions below); the preparation is for dermatological use and contains a listed drug product used for dermatological purposes and no other active substances other than one or more of the
JUNE 27, 2008 I.11
c)
following: camphor, compound benzoin tincture, hydrocortisone powder, liquor carbonis detergens, menthol, salicylic acid, sulfur or tar distillate; d) e) the preparation is for a topical nitrogen mustard preparation; the preparation is for a topical preparation consisting of liquor carbonis detergens, salicylic acid, sulfur or tar distillate, but no other active substances, compounded in petrolatum jelly or lanolin; the preparation is for an ophthalmic solution containing amikacin, cefazolin or vancomycin, or the preparation is for an ophthalmic solution containing gentamicin or tobramycin in a concentration greater than three milligrams per millilitre.
f) g)
Restrictions Regarding Extemporaneous Injectables: 1) Compounded injectable products which contain one or more of the drug products noted below are not eligible for reimbursement as DPPs under the ODB program unless approved by the Executive Officer under the Exceptional Access Program (EAP).
alprostadil amphotericin b lipid complex ancestim azithromycin baclofen botulinum toxin (type A) calcitriol cefotaxime cephalothin clodronate daclizumab danaparoid darbepoietin deferoxamine desmopressin dolasetron doxorubicin HCl epoetin alfa epoprostenol estradiol dienanthate/estradiol benzoate/testosterone enanthate benzilic acid hydrazone etanercept filgrastim fludarabine fondaparinux gemcitabine glatiramer acetate hepatitis a vaccine hepatitis b vaccine infliximab insulin glargine interferon alfa-2b/ribavirin interferon beta 1-a interferon beta 1-b iron dextran iron sucrose ketorolac levofloxacin mycophenolate mofetil nandrolone decanoate octreotide pamidronate disodium peginterferon alfa 2-b porcine insulin rituximab
somatrem somatropin sumatriptan tinzaparin topotecan verteporfin zoledronic acid 2) Any injectable drug product which received a Notice of Compliance from Health Canada on or after September 4, 2003 is ineligible for reimbursement as a DPP under the ODB program unless approved by the Executive Officer under the EAP. Any injectable drug product that is listed in Part III-A of the Formulary as a Limited Use benefit is ineligible for reimbursement as a DPP under the ODB program unless the patient meets the clinical criteria outlined in Part III-A of the Formulary. Claims for these products in respect of patients who do not meet the defined Limited Use criteria may be considered by the Executive Officer for reimbursement under the EAP.
3)
Please refer to Section 6.1 of the Ontario Drug Programs Reference Manual for requirements regarding claims for extemporaneous preparations. Pharmacists are reminded that claims reimbursed under the Ontario Drug Benefit Act are subject to post-payment verification. For more information regarding extemporaneous preparations that are eligible for reimbursement, please refer to the information contained on the ministrys website. In the event that there are any discrepancies or inconsistencies between the foregoing list and the list posted on the ministrys website, the website will be considered authoritative. Questions can be directed to the ministrys ODB Health Network System (HNS) Help Desk at 1-800-668-6641.
11. Professional Pharmacy Services

Effective April 1, 2007, the ministry began compensating pharmacists for providing professional pharmacy services in its MedsCheck Annual medication management reviewprograms through a framework developed collaboratively with the Pharmacy Council. In November, 2007 the MedsCheck program was expanded to include the MedsCheck Follow-Up medication review which is an additional program for those patients who may benefit from a second MedsCheck during the annual time-frame due to situations such as a hospital discharge, a planned hospital admission, a physician or RN(EC) referral or a pharmacists documented decision due to: i) significant changes made to an existing medication profile or the addition of new medications, ii) documented evidence of a patients non-compliance iii) a patient has changed both their place of residence and their pharmacy thus necessitating further review of their medications by the pharmacist The MedsCheck medication reviews compare what the physician has prescribed (e.g. drug name, drug strength and drug dosage etc.), to what the patient is actually taking. The goals of the MedsCheck program are to: create and maintain an accurate record of what medication(s) the patient is taking. The record is intended to be a complete list of the patients prescription, over-the-counter, and natural/ homeopathic medications. investigate and correct the discrepancies between physician orders and what the patient is taking. minimize potential adverse events and medication errors Professional service claims are adjudicated online through the ministrys Health Network System and claims are subject to audit by the ministry. For MedsCheck Annual reviews, as well as for MedsCheck Follow-Up reviews, pharmacists are required to keep a copy of the current medication list, signed and dated by both the pharmacist and the patient, as well as any written referrals, and notes documenting the interaction with the patient. In addition, for MedsCheck Follow-Up reviews, if the pharmacy did not
conduct the MedsCheck Annual review, pharmacists are required to obtain a copy of the Annual review medication list from the pharmacy where it was conducted, or from the patient. If a copy of the Annual review cannot be obtained, this must be noted as part of the required documentation. All required MedsCheck documentation including medication lists must be kept on file at the pharmacy for a period of not less than 2 years, for audit purposes. For more information on the Meds Check program including the Medscheck guidebook 2nd Edition, please access the website: www.medscheck.ca Professional services provide further opportunities for pharmacists to use their clinical expertise to provide patient care. Through the Pharmacy Council, the ministry will continue to explore opportunities to expand the scope of professional services.
D. 1.
Information and Assistance The Personal Health and Information Protection Act, 2004 and the Freedom of Information and Protection of Privacy Act
The information collected on ODB claims, including those on paper and electronic media, is collected for the purpose of payment under the Ontario Drug Benefit Act and for drug utilization review. It is collected under the authority of s.13 of the Ontario Drug Benefit Act, s.6(2) of the Ministry of Health and Long-Term Care Act and s.36 of the Personal Health Information Protection Act, 2004. For further information please contact: Director Drug Program Services Ontario Public Drug Programs Hepburn Block, 9th Floor 80 Grosvenor Street , Queens Park Toronto ON M7A 1R3 Tel.: 416-212-4724 Fax.: 416-325-6647 Website: www.health.gov.on.ca
2.
Inquiries and Assistance
The following information is provided to assist practitioners, pharmacists and manufacturers in obtaining details on the Ontario Drug Benefit program, claims submission and payments. Payments Claims Submissions Health Insurance and Related Payments Ministry of Health Supply and Financial Services Branch ODB Claims Processing P.O. Box 48 P.O. Box 58 Kingston ON K7L 5J3 Kingston ON K7L 5J1 For inquiries about payments or claims submissions, please call the ministrys ODB Health Network System (HNS) Help Desk at 1-800-668-6641. For more information and assistance for dispensary connections to the ministrys HNS, please contact: Ontario Public Drug Programs Registration Unit P.O. Box 3800, Station Main Kingston, ON K7L 5R6 Tel.: (613) 545-4330 NOTE: Dispensary operators are requested to notify the Registration Unit three weeks in advance of a change in status for: openings, closures or transfer of ownership. Trillium Drug Program For inquiries regarding the Trillium Drug Program, please contact: Toronto (416) 642-3038 Toll-free: 1-800-575-5386
Seniors' Co-payment Inquiries For inquiries about co-payment, please contact: Toronto: (416) 503-4586 Toll-free: 1-888-405-0405 EAP/ICR Requests Please fax any written requests to: Toronto: (416) 327-7526 Toll-free: 1-866-811-9908 Except as indicated above, inquiries and correspondence on this publication should be directed to: Director, Drug Program Services Ontario Public Drug Programs Hepburn Block, 9th Floor 80 Grosvenor Street, Queens Park Toronto ON M7A 1R3 Tel: 416-212-4724 Fax: 416-325-6647 Website: www.health.gov.on.ca
JUNE 27, 2008
I.15
FORMULARY/CDI LEGEND
ALPHABETICAL REFERENCE
A. B. C. D. E. F. Non-proprietary or generic name of the drug followed by the strength and dosage form. DIN/PIN code uniquely identifies the drug product as to its manufacturer, name and strength of active ingredients, route of administration and pharmaceutical dosage form. Brand name(s) of the drug product(s). Three-letter identification code assigned to each manufacturer. See abbreviations in Part X for manufacturers names. Drug Benefit Price of the drug product. Usual daily cost. See section entitled Drug Cost for more information.
NUMERICAL REFERENCE
1. 2. 3. 4. 5. Pharmacologic-therapeutic classification. Pharmacologic-therapeutic sub-classification. For Formulary listed benefits with Limited-Use criteria, the Reason for Use Code for each approved Clinical Criteria are provided in the shaded area. For combination drug products, the active ingredients and their concentrations are listed. Most items usually dispensed in non-divisible packages are identified by the designation Pk, which appears immediately after the package description. One package of an item described Pk is billed as 0001. The Drug Benefit Price is the listed price for that particular drug product, strength and dosage form. Designated pharmaceutical products are identified by the letters dpp. Not a Benefit indicates a product that is NOT a benefit under the ODB program, but which has retained its interchangeability designation. Claims for the product will not be reimbursed under the ODB program.
6. 7. 8.
SYMBOLS
* A single asterisk denotes a type of drug product that is provided to residents of long-term care homes and Homes for Special Care by the Government Pharmacy. Such drugs are not eligible for reimbursement when supplied to these residents by a dispensary unless an emergency authorization has previously been obtained from the ministry. + The plus sign indicates a drug product or brand of a drug that is listed for the first time in this edition of the Formulary/CDI. # The number symbol indicates a drug product that is being discontinued as a benefit, but that will be retained in the payment system until further notice to allow utilization of remaining stock.
I.16
JUNE 27, 2008
E F
ITEM NO.
DRUG NAME, STRENGTH AND DOSAGE FORM DIN
BRAND NAME
MANUFACTURER DBP
DAILY COST
1 2
08:00 ANTI-INFECTIVE AGENTS

08:08:00 ANTIHELMINTICS NIMODIPINE
540
ED ION D MIT SE TAT IRE LI EN QU U UM RE OC D

Reason for Use code 42 Clinical criteria LU Authorization Period: 1 year. 43 As prophylaxis of ischemia if surgery is delayed. LU Authorization Period: 1 year.
30mg SG Cap 02155923
Nimotop
BAH
5.9209 5.9209
As adjunctive therapy to improve the neurologic outcome following subarachnoid haemorrhage during the acute management period (within 4 days of haemorrhage).
BRIMONIDINE TARTRATE & TIMOLOL MALEATE

0.2% & 0.5% Oph Sol-5mL Pk 02248347 Combigan ALL 19.7000
19.7000
POLYETHYLENE GLYCOLE & ELECTROLYTES

Pd-1 Kit
5.0141 RIV PMS 16.1700 5.0141
5 6
Sol-1L Pk
02147793 00777846
Klean-Prep PegLyte
ALFACALCIDOL
0.25mcg Cap dpp
0.4090 0.4090 00474517 One-Alpha LEO
7
*DIPHENHYDRAMIN E
25mg Cap
00022756 00370517
Benadryl (Not a Benefit) Allerdryl (Not a Benefit)
PDA ICN
JUNE 27, 2008
I.17
PART II
PREAMBLE ONTARIO DRUG BENEFIT FORMULARY
The percentage of the Drug Benefit Price (the mark-up) that is prescribed for the purpose of paragraph 3 of subsection 6(1) of the Ontario Drug Benefit Act is 8 percent.
PART III
FORMULARY LISTINGS
PART III-A
ONTARIO DRUG BENEFIT FORMULARY (ODB) / COMPARATIVE DRUG INDEX (CDI)
ITEM NO.
DRUG NAME, STRENGTH, DOSAGE FORM DIN
BRAND NAME
MANUFACTURER
DBP
DAILY COST
04:00 ANTIHISTAMINICS
DIPHENHYDRAMINE HCL
1 * 25mg Cap 00022756 00370517 * 50mg Cap 00022764 00271411 Benadryl (Not a Benefit) Allerdryl (Not a Benefit) Benadryl (Not a Benefit) Allerdryl (Not a Benefit) PDA VAL PDA VAL
PROMETHAZINE HCL
3 2mg/mL O/L 01937693 00583979 Phenergan (Not a Benefit) RPR PMS-Promethazine (Not a Benefit) PMS
+ = NEW LISTING # = BEING DISCONTINUED AS BENEFIT IN FUTURE DBP = DRUG BENEFIT PRICE DAILY COST - SEE DRUG COST PAGE IN PART I FOR METHOD OF CALCULATION * = SUPPLIED BY GOVERNMENT PHARMACY TO RESIDENTS OF LONG-TERM CARE FACILITIES
JUNE 27, 2008
IIIA.1
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:08:00 ANTHELMINTICS
MEBENDAZOLE
4 100mg Tab 00556734 Vermox JNO 3.3383 3.3383
PIPERAZINE ADIPATE
5 Gran 2g Pk 02100215 Entacyl SHI .7230 .7230
08:12:04 ANTIBIOTICS ANTIFUNGALS

AMPHOTERICIN B
6 Inj Pd-50mg Pk 00029149 Fungizone BQU 66.6720 66.6720
JUNE 27, 2008
IIIA.3
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLUCONAZOLE
7 10mg/mL O/L 02024152 Reason for Use Code 274 Diflucan P.O.S. Clinical criteria PFI 1.0109 1.0109
ED IT E N IM S IO L U TAT EN D M U RE OC QUI D RE
For the treatment of oral/esophageal candidiasis in immunocompromised patients (e.g. patients with malignancies and transplant patients) who have failed to respond to nystatin or imidazoles and when oral tablets of fluconazole cannot be tolerated. LU Authorization Period: 1 year 275 For the treatment of patients with disseminated candidiasis when oral tablets of fluconazole cannot be tolerated. NETWORK NOTE: For disseminated candidiasis, network will limit supply to 6 weeks. LU Authorization Period: 1 year 276 For the treatment of patients with cryptococcal meningitis when oral tablets of fluconazole cannot be tolerated. LU Authorization Period: 1 year 277 For the treatment of patients with vulvovaginal candidiasis when oral tablets of fluconazole cannot be tolerated. LU Authorization Period: 1 year
NETWORK NOTE: For oral candidiasis, network will limit supply to 2 weeks. For esophageal candidiasis, network will limit supply to 6 weeks.
NETWORK NOTE: For cryptococcal meningitis (initial treatment), network will limit supply to 12 weeks.
NETWORK NOTE: For vulvovaginal candidiasis, network will limit supply to one dose 150mg (Repeats no more than every 25 days).
IIIA.4
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLUCONAZOLE
8 50mg Tab 00891800 02236978 02237370 02245292 02245643 02249294 02281260 100mg Tab 00891819 02236979 02237371 02245293 02245644 02249308 02281279 Reason for Use Code 202 2.4814 Diflucan (Not a Benefit) Novo-Fluconazole Apo-Fluconazole Gen-Fluconazole PMS-Fluconazole Taro-Fluconazole Co Fluconazole Diflucan (Not a Benefit) Novo-Fluconazole Apo-Fluconazole Gen-Fluconazole PMS-Fluconazole Taro-Fluconazole Co Fluconazole PFI NOP APX GEN PMS TAR COB PFI NOP APX GEN PMS TAR COB 2.4814 2.4814 2.4814 2.4814 2.4814 2.4814 4.96 4.96 4.96 4.96 4.96 4.96 4.96
ED IT E N IM S IO L U TAT EN D M U RE C O QUI D RE
4.4020 4.40 4.40 4.40 4.40 4.40 4.40 4.40 4.4020 4.4020 4.4020 4.4020 4.4020 4.4020 Clinical criteria For the treatment of thrush in immunocompromised patients (i.e. patients with malignancies and transplant recipients) who are unresponsive to nystatin or imidazole preparations; LU Authorization Period: 1 year 203 For the treatment of oroesophageal candidiasis in immunocompromised patients (i.e. patients with malignancies and transplant recipients); LU Authorization Period: 1 year 204 For patients with disseminated candidiasis; LU Authorization Period: 1 year 205 For the treatment of acute cryptococcal meningitis. LU Authorization Period: 1 year
JUNE 27, 2008
IIIA.5
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

KETOCONAZOLE
10 200mg Tab 00633836 02231061 02237235 Nizoral Novo-Ketoconazole Apo-Ketoconazole JAN NOP APX .9393 1.8786 .9393 .9393 .94 1.88 .94 .94
Note: A low pH is necessary for absorption. Antacids, anticholinergics/antispasmodics, H2-blockers, and omeprazole may decrease absorption. Ketoconazole is a potent inhibitor of hepatic oxidation of drugs and may cause significant elevation of blood levels of astemizole, cisapride, cyclosporine, terfenadine, theophylline and warfarin. Potentially fatal arrhythmias (torsade de pointes) can occur with the combination of ketoconazole and astemizole, cisapride or terfenadine. Insulin requirements may be reduced. Hepatotoxicity occurs in approximately 1 in 1500 patients treated with ketoconazole for onychomycosis; female gender, pre-existing disease, alcoholism and greater than 2 weeks of therapy are pre-disposing factors.
NYSTATIN
11 100000U/mL O/L 00248169 02194201 500000U Tab 00029416 02194198 .0592 Mycostatin (Not a Benefit) Ratio-Nystatin Mycostatin (Not a Benefit) Ratio-Nystatin BQU RPH BQU RPH .0592 .1680 .1680 .24 .24 .50 .50
12
IIIA.6
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

VORICONAZOLE
13 14 50mg Tab 02256460 200mg Tab 02256479 Reason for Use Code 399 11.8800 11.8800 47.5000 47.5000
ED ON IT E TI IM S L TA IRED U EN U UM REQ OC D
Vfend PFI Clinical criteria Note: Limited to 3 months of reimbursement. LU Authorization Period: 1 year.
Vfend
PFI
Outpatient continuation of treatment for documented invasive aspergillosis in patients who have demonstrated a clinical response to either oral or parenteral voriconazole. * The first prescription must be written by a physician based at the hospital where the patient was hospitalized.
08:12:12 ANTIBIOTICS ERYTHROMYCINS

Note: Erythromycin alone is not adequate for the treatment of H. influenzae infections. It lacks consistently reliable activity against this organism. Erythromycin is a potent inhibitor of hepatic oxidation of some drugs and may cause significant elevation of blood levels of astemizole, carbamazepine, cyclosporine, digoxin, dihydropyridines, terfenadine, theophylline and warfarin. Potentially fatal arrhythmias (torsade de pointes) can occur with the combination of erythromycin and astemizole or terfenadine.
AZITHROMYCIN
15 100mg/5mL O/L 02223716 02274388 200mg/5mL O/L 02223724 02274396 Zithromax PMS-Azithromycin Zithromax PMS-Azithromycin PFI PMS PFI PMS .7467 1.1093 .7467 1.0578 1.5713 1.0578
16
JUNE 27, 2008
IIIA.7
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

AZITHROMYCIN
17 250mg Tab 02212021 02247423 02255340 02261634 02265826 02267845 02275287 02278359 Zithromax Apo-Azithromycin Co-Azithromycin PMS-Azithromycin Sandoz Azithromycin Novo-Azithromycin Ratio-Azithromycin Gen-Azithromycin PFI APX COB PMS SDZ NOP RPH GEN 2.4667 5.1307 2.4667 2.4667 2.4667 2.4667 2.4667 2.4667 2.4667
CLARITHROMYCIN
18 19 20 21 500mg ER Tab 02244756 Biaxin XL ABB ABB ABB ABB PMS RPH GEN APX 2.5144 2.5144 .2785 .2785 .5545 .5545 .7861 1.5988 .7861 .7861 .7861 .7861 1.57 3.20 1.57 1.57 1.57 1.57 2.79 2.79
125mg/5mL Ped Gran 02146908 Biaxin 250mg/5mL Susp 02244641 250mg Tab 01984853 02247573 02247818 02248856 02274744 Biaxin Biaxin PMS-Clarithromycin Ratio-Clarithromycin Gen-Clarithromycin Apo-Clarithromycin
ERYTHROMYCIN BASE
22 250mg Ent Pel Cap 00607142 ERYC 00726672 Apo-Erythro E-C (Not a Benefit) 250mg Tab 00244635 00682020 Erythromid (Not a Benefit) Apo-Erythro PFI APX ABB APX .2205 .2205 .1786 .1786 .88 .88 .71 .71
23
IIIA.8
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ERYTHROMYCIN ESTOLATE
24 25mg/mL O/L 00015474 00021172 50mg/mL O/L 00210641 00262595 .0368 Ilosone (Not a Benefit) Novo-Rythro Estolate Ilosone (Not a Benefit) Novo-Rythro Estolate LIL NOP LIL NOP .0368 .0713 .0713 .74 .74 1.43 1.43
25
ERYTHROMYCIN ETHYLSUCCINATE
26 40mg/mL O/L 00000299 00605859 80mg/mL O/L 00453617 00652318 600mg Tab 00583782 00637416 .0669 EES-200 (Not a Benefit) Novo-Rythro Ethyl Succinate EES-400 (Not a Benefit) Novo-Rythro Ethyl Succinate EES-600 (Not a Benefit) Apo-Erythro-ES ABB NOP ABB NOP ABB APX .0669 .1013 .1013 .3248 .3248 1.00 1.00 1.52 1.52 .97 .97
27
28
ERYTHROMYCIN ETHYLSUCCINATE & SULFISOXAZOLE ACETYL

29 40mg & 120mg/mL O/L 00583405 # Pediazole ABB .1258 .1258 1.89 1.89
ERYTHROMYCIN STEARATE
30 250mg Tab 00000434 00545678 500mg Tab 00266515 00688568 .2069 Erythrocin (Not a Benefit) Apo-Erythro-S Erythrocin Apo-Erythro-S ABB APX ABB APX .2069 .5300 .5390 .5300 .83 .83 1.06 1.08 1.06
31
JUNE 27, 2008
IIIA.9
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PARTICLE COATED ERYTHROMYCIN

32 333mg Tab 00769991 # PCE Dispertab ABB .5200 .5200 1.56 1.56
08:12:16 ANTIBIOTICS PENICILLINS

AMOXICILLIN
Note: The activity of amoxicillin is essentially identical to ampicillin. However, amoxicillin is more completely absorbed and causes diarrhea less frequently than ampicillin. The only situation where amoxicillin should not be used to replace oral ampicillin is Shigellosis. 33 250mg Cap 02041294 00406724 00628115 00865567 02230243 02238171 500mg Cap 02041308 00406716 00628123 00865575 02230244 02238172 25mg/mL O/L 02041316 00452149 00628131 00865540 01934171 02230245 .1750 Amoxil (Not a Benefit) Novamoxin Apo-Amoxi (Not a Benefit) Nu-Amoxi (Not a Benefit) PMS-Amoxicillin (Not a Benefit) Gen-Amoxicillin (Not a Benefit) Amoxil (Not a Benefit) Novamoxin Apo-Amoxi (Not a Benefit) Nu-Amoxi (Not a Benefit) PMS-Amoxicillin (Not a Benefit) Gen-Amoxicillin (Not a Benefit) Amoxil (Not a Benefit) Novamoxin Apo-Amoxi (Not a Benefit) Nu-Amoxi (Not a Benefit) Novamoxin (Sugar Reduced) (Not a Benefit) PMS-Amoxicillin (Not a Benefit) WAY NOP APX NXP PMS GEN WAY NOP APX NXP PMS GEN WAY NOP APX NXP NOP PMS .1750 .53 .53
34
.3417 .3417
1.03 1.03
35
.0353 .0353
.53 .53
IIIA.10
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

AMOXICILLIN
Note: The activity of amoxicillin is essentially identical to ampicillin. However, amoxicillin is more completely absorbed and causes diarrhea less frequently than ampicillin. The only situation where amoxicillin should not be used to replace oral ampicillin is Shigellosis. 36 50mg/mL O/L 02042592 00452130 00628158 00865559 01934163 02230246 .0540 Amoxil (Not a Benefit) Novamoxin Apo-Amoxi (Not a Benefit) Nu-Amoxi (Not a Benefit) Novamoxin (Sugar Reduced) (Not a Benefit) PMS-Amoxicillin (Not a Benefit) WAY NOP APX NXP NOP PMS .0540 .81 .81
AMOXICILLIN & CLAVULANIC ACID

Note: Amoxicillin/clavulanic acid is not recommended as first line treatment for acute otitis media and sinusitis. Antibiotic resistance (H. influenzae, M. catarrhalis) due to B-lactamase production has caused only a minority of treatment failures with amoxicillin. Amoxicillin/clavulanic acid is first line treatment for infected bites of cat, dog or human. 37 25mg & 6.25mg/mL 01916882 02243986 02244646 50mg & 12.5mg/mL 01916874 02243987 02244647 O/L Clavulin Apo-Amoxi Clav Ratio-Aclavulanate 125F O/L Clavulin Apo-Amoxi Clav Ratio-Aclavulanate 250F GSK APX RPH GSK APX RPH GSK GSK APX .0517 .1170 .0517 .0517 .0869 .1964 .0869 .0869 .1440 .1440 .2690 .2690 .78 1.76 .78 .78 1.30 2.95 1.30 1.30
38
39 40
200mg & 28.5mg/5mL Susp 02238831 Clavulin (BID) 400mg & 57mg/5mL Susp 02238830 Clavulin (BID) 02288559 Apo-Amoxi Clav (Not a Benefit)
JUNE 27, 2008
IIIA.11
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

AMOXICILLIN & CLAVULANIC ACID
Note: Amoxicillin/clavulanic acid is not recommended as first line treatment for acute otitis media and sinusitis. Antibiotic resistance (H. influenzae, M. catarrhalis) due to B-lactamase production has caused only a minority of treatment failures with amoxicillin. Amoxicillin/clavulanic acid is first line treatment for infected bites of cat, dog or human. 41 250mg & 125mg Tab 01916866 # Clavulin 02243350 Apo-Amoxi Clav 02243770 Ratio-Aclavulanate 500mg & 125mg Tab 01916858 Clavulin 02243351 Apo-Amoxi Clav 02243771 Ratio-Aclavulanate 875mg & 125mg Tab 02238829 Clavulin (BID) 02245623 Apo-Amoxi Clav 02247021 Ratio-Aclavulanate 02248138 Novo-Clavamoxin 875 GSK APX RPH GSK APX RPH GSK APX RPH NOP .4365 .9868 .4365 .4366 .6673 1.4802 .6673 .6673 1.0009 2.2203 1.0009 1.0009 1.0009 1.31 2.96 1.31 1.31 2.00 4.44 2.00 2.00
42
43
AMPICILLIN
Note: Use with caution in urinary tract infections as even E. coli is resistant in approximately 20% of cases. 44 250mg Cap 00002003 00020877 500mg Cap 00002011 00020885 .3071 Penbritin (Not a Benefit) Novo-Ampicillin Penbritin (Not a Benefit) Novo-Ampicillin AYE NOP AYE NOP .3071 .5955 .5955 1.23 1.23 2.38 2.38
45
IIIA.12
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CLOXACILLIN
46 250mg Cap 00002046 00337765 00618292 00717584 500mg Cap 00002054 00337773 00618284 00717592 25mg/mL O/L 02042975 00337757 00644633 00717630 .1850 Orbenin (Not a Benefit) Novo-Cloxin Apo-Cloxi (Not a Benefit) Nu-Cloxi (Not a Benefit) Orbenin (Not a Benefit) Novo-Cloxin Apo-Cloxi (Not a Benefit) Nu-Cloxi (Not a Benefit) Orbenin (Not a Benefit) Novo-Cloxin Apo-Cloxi (Not a Benefit) Nu-Cloxi (Not a Benefit) AYE NOP APX NXP AYE NOP APX NXP WAY NOP APX NXP .1850 .74 .74
47
.3498 .3498
1.40 1.40
48
.0450 .0450
1.80 1.80
PENICILLIN V (POTASSIUM)
49 25mg/mL O/L 00018635 00642223 60mg/mL O/L 00331945 00391603 00642231 300mg Tab 00248843 00021202 00642215 00717568 .0535 Nadopen-V (Not a Benefit) Apo-Pen V-K VC-K 500 (Not a Benefit) Novo-Pen-VK-500 Apo-Pen V-K (Not a Benefit) PVF-K 500 (Not a Benefit) Novo-Pen-VK-500 Apo-Pen V-K (Not a Benefit) Nu-Pen VK (Not a Benefit) NDA APX LIL NOP APX FRS NOP APX NXP .0535 .0472 .0472 .0710 .0710 1.07 1.07 .71 .71 .28 .28
50
51
JUNE 27, 2008
IIIA.13
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PIVAMPICILLIN
Note: Although pivampicillin is administered every 12 hours rather than every 8 hours for amoxicillin, pivampicillin is more expensive than amoxicillin. 52 500mg Tab 00582247 Pondocillin LEO .6588 .6588 1.32 1.32
08:12:24 ANTIBIOTICS TETRACYCLINES

TETRACYCLINE
Note: Tetracycline use during tooth development (last half of pregnancy and up to age 8) may cause permanent tooth discoloration or enamel hypoplasia. These reactions are more common during long-term use. Tetracyclines should not be used in these groups unless other antibiotics are unlikely to be effective or are contraindicated. 53 250mg Cap 00024422 00580929 .0530 Tetracyn (Not a Benefit) Apo-Tetra PFI APX .0530 .21 .21
08:12:28 OTHER ANTIBIOTICS

CEFACLOR
54 250mg Cap 00465186 02185830 02230263 02231432 02231691 500mg Cap 00465194 02185849 02230264 02231433 02231693 Ceclor PMS-Cefaclor (Not a Benefit) Apo-Cefaclor Nu-Cefaclor (Not a Benefit) Novo-Cefaclor (Not a Benefit) Ceclor PMS-Cefaclor (Not a Benefit) Apo-Cefaclor Nu-Cefaclor (Not a Benefit) Novo-Cefaclor (Not a Benefit) PHE PMS APX NXP NOP PHE PMS APX NXP NOP PHE PMS APX .9697 1.0207 .9697 2.91 3.06 2.91
55
1.9300 2.0040 1.9300
5.79 6.01 5.79
56
25mg/mL Oral Susp 00465208 Ceclor 02185857 PMS-Cefaclor (Not a Benefit) 02237500 Apo-Cefaclor
.1037 .1089 .1037
1.56 1.63 1.56
IIIA.14
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CEFACLOR
57 50mg/mL Oral Susp 00465216 Ceclor 02185865 PMS-Cefaclor (Not a Benefit) 02237501 Apo-Cefaclor 375mg/5mL Oral Susp 00832804 Ceclor 02185873 PMS-Cefaclor (Not a Benefit) 02237502 Apo-Cefaclor (Not a Benefit) PHE PMS APX PHE PMS APX .1895 .1993 .1895 .2872 .2872 2.84 2.99 2.84
58
CEFADROXIL
59 500mg Cap 00507245 02235134 02240774 Duricef Novo-Cefadroxil Apo-Cefadroxil BQU NOP APX .8421 .8421 .8421 .8421 1.68 1.68 1.68 1.68
CEFIXIME
60 61 20mg/mL Oral Susp 00868965 Suprax 400mg Tab 00868981 Suprax SAV SAV .3799 .3799 3.5030 3.5030 3.50 3.50
CEFPROZIL
62 125mg/5mL Oral Susp 02163675 Cefzil 02293943 Apo-Cefprozil 250mg/5mL Oral Susp 02163683 Cefzil 02293579 Ran-Cefprozil 02293951 Apo-Cefprozil 250mg Tab 02163659 02292998 02293528 02302179 Cefzil Apo-Cefprozil Ran-Cefprozil Sandoz Cefprozil BQU APX BQU RAN APX BQU APX RAN SDZ .0791 .1644 .0791 .1581 .3286 .1581 .1581 .8092 1.6822 .8092 .8092 .8092
63
64
JUNE 27, 2008
IIIA.15
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CEFPROZIL
65 500mg Tab 02163667 02293005 02293536 02302187 Cefzil Apo-Cefprozil Ran-Cefprozil Sandoz Cefprozil BQU APX RAN SDZ 1.5867 3.2984 1.5867 1.5867 1.5867
CEFTRIAXONE DISODIUM
66 0.25g/Vial Inj Pd-1 Vial Pk 00657387 Rocephin 02250276 Ceftriaxone Sodium for Injection, BP 1g/Vial Inj Pd-1 Vial Pk 00657417 Rocephin 02250292 Ceftriaxone Sodium for Injection, BP 02287633 Ceftriaxone Sodium for Injection 02292270 Ceftriaxone 02292874 Ceftriaxone for Injection USP 2g/Vial Inj Pd-1 Vial Pk 00657409 Rocephin 02250306 Ceftriaxone Sodium for Injection, BP 02292289 Ceftriaxone 02292882 Ceftriaxone for Injection USP HLR MAY HLR MAY NOP SDZ ORC HLR MAY SDZ ORC 5.3750 11.0650 5.3750 17.0000 35.0000 17.0000 17.0000 17.5000 17.0000 33.5000 68.9700 33.5000 34.4850 33.5000
67
68
CEFUROXIME AXETIL
69 70 125mg/5mL Susp 02212307 250mg Tab 02212277 02242656 02244393 500mg Tab 02212285 02242657 02244394 Ceftin Ceftin Ratio-Cefuroxime Apo-Cefuroxime Ceftin Ratio-Cefuroxime Apo-Cefuroxime GSK GSK RPH APX GSK RPH APX .1747 .1747 .7237 1.5813 .7237 .7237 1.4337 3.1327 1.4337 1.4337 1.45 3.16 1.45 1.45 2.87 6.27 2.87 2.87
71
IIIA.16
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CEPHALEXIN MONOHYDRATE
72 250mg Cap 00253154 00342084 500mg Cap 00253146 00342114 .2250 Ceporex (Not a Benefit) Novo-Lexin Ceporex (Not a Benefit) Novo-Lexin GLA NOP GLA NOP PHE NOP PMS PHE NOP PMS PHE NOP APX NXP PMS PHE NOP APX NXP PMS .2250 .2370 .2250 .90 .95 .90 .0948 .0948 .0948 1.90 1.90 1.90 .2250 .4500 .4500 .0457 .0457 .0457 .90 .90 1.80 1.80 .91 .91 .91
73
74
25mg/mL Pd for Oral Susp 00015547 Keflex 00342106 Novo-Lexin 02177811 PMS-Cephalexin 125 (Not a Benefit) 50mg/mL Pd for Oral Susp 00035645 Keflex 00342092 Novo-Lexin 02177838 PMS-Cephalexin 250 (Not a Benefit) 250mg Tab 00403628 00583413 00768723 00865877 02177781 500mg Tab 00244392 00583421 00768715 00865885 02177803 Keflex Novo-Lexin (Not a Benefit) Apo-Cephalex Nu-Cephalex (Not a Benefit) PMS-Cephalexin (Not a Benefit) Keflex Novo-Lexin (Not a Benefit) Apo-Cephalex Nu-Cephalex (Not a Benefit) PMS-Cephalexin (Not a Benefit)
75
76
77
.4500 .4740 .4500
1.80 1.90 1.80
CLINDAMYCIN HCL
78 150mg Cap 00030570 02130033 02241709 02245232 02258331 02294826 Dalacin C Ratio-Clindamycin Novo-Clindamycin Apo-Clindamycin Gen-Clindamycin PMS-Clindamycin PFI RPH NOP APX GEN PMS .3881 .8073 .3881 .3881 .3881 .3881 .3881 3.10 6.46 3.10 3.10 3.10 3.10 3.10
JUNE 27, 2008
IIIA.17
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CLINDAMYCIN HCL
79 300mg Cap 02182866 02192659 02241710 02245233 02258358 02294834 Dalacin C Ratio-Clindamycin Novo-Clindamycin Apo-Clindamycin Gen-Clindamycin PMS-Clindamycin PFI RPH NOP APX GEN PMS .7762 1.7054 .7762 .7762 .7762 .7762 .7762
CLINDAMYCIN PALMITATE
80 15mg/mL Pd for Oral Susp 00225851 Dalacin C Flavoured Granules PFI .1147 .1147
CLINDAMYCIN PHOSPHATE
81 300mg/2mL Inj Sol-2mL Pk 00260436 Dalacin C PFI 02230540 Clindamycin Phosphate Injection USP SDZ 4.5740 7.4920 4.5740
Note: Clindamycin is well absorbed by the oral route, therefore stepdown therapy from IV to oral is possible.
IIIA.18
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SODIUM FUSIDATE
82 250mg Tab 01934252 Reason for Use Code Fucidin Leo LEO 1.1250 1.1250
I N D Dpart of combination therapy, forO treatment of serious 342 ITE As the TATto be IRE by a strain of S. on M infections coagulase-negative staphylococci likely susceptible SE confirmed NcultureQUcaused LI U UME E aureus or to fusidic acid where standard anti-staphylococcal agents are R precluded because of allergy, resistance or treatment failure. OC D LU Authorization Period: 1 year.
Clinical criteria NOV 50.6250 50.6250
TOBRAMYCIN
83 300mg/5mL Inh Sol-5mL Pk 02239630 TOBI
TOBRAMYCIN SULFATE
84 80mg/2mL Inj Sol-2mL Pk 00325449 Nebcin (Not a Benefit) 02241210 Tobramycin 4.3380 LIL SDZ 4.3380
JUNE 27, 2008
IIIA.19
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:16:00 ANTITUBERCULAR AGENTS
ETHAMBUTOL HCL
85 100mg Tab 00127957 00247960 400mg Tab 00247979 02170078 .0973 Myambutol (Not a Benefit) Etibi Etibi Myambutol (Not a Benefit) LED VAL VAL WAY .0973 .2711 .2711
86
ISONIAZID
87 300mg Tab 00272655 Isotamine VAL .0640 .0640
PYRAZINAMIDE
88 500mg Tab 00283991 Tebrazid VAL .4980 .4980
RIFABUTIN
89 150mg Cap 02063786 Reason for Use Code
D ON TI D TE MI SE TA RE I L U MEN UI U REQ OC D
Clinical criteria 103 LU Authorization Period: 1 year. 104 LU Authorization Period: 1 year.
Mycobutin
PFI
3.9000 3.9000
For the prevention of Mycobacterium Avium Intracellular (MAI) in:
Patients with a CD4+ cell count less than 200/mm3 with an AIDSdefining diagnosis.
Patients with a CD4 cell count less than 100/mm3 without an AIDSdefining diagnosis.
IIIA.20
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:16:00 ANTITUBERCULAR AGENTS
RIFAMPIN
Note: Except when used for prophylaxis in contacts of H. influenzae or N. meningitidis, rifampin should not be used as monotherapy, as bacterial resistance will develop quickly. 90 150mg Cap 00393444 02091887 300mg Cap 00343617 02092808 Rofact Rifadin Rofact Rifadin VAL SAV VAL SAV .6038 .6038 .7340 .9503 .9503 1.1551
91
08:18:00 ANTIVIRALS
ABACAVIR & LAMIVUDINE & ZIDOVUDINE
92 300mg/150mg/300mg Tab 02244757 Trizivir GSK 16.9111 16.9111
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism.
ABACAVIR SULFATE
93 20mg/mL O/L 02240358 Ziagen GSK .4474 .4474
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 94 300mg Tab 02240357 Ziagen GSK 6.7109 6.7109
ABACAVIR SULFATE & LAMIVUDINE

95 600mg/300mg Tab 02269341 Kivexa GSK 22.2692 22.2692
JUNE 27, 2008
IIIA.21
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:18:00 ANTIVIRALS
ACYCLOVIR
96 800mg Tab 01911635 02078651 02197421 02207656 02242464 02285975 Reason for Use Code Zovirax Ratio-Acyclovir Nu-Acyclovir Apo-Acyclovir Gen-Acyclovir Novo-Acyclovir GSK RPH NXP APX GEN NOP 2.2664 4.9523 2.2664 2.2664 2.2664 2.2664 2.2664
D TE I IM SE TION L U TA EN D M E U C IR DO EQU R
Clinical criteria 95 96 97 314
In contrast to bacterial infections, viral replication precedes clinical signs and symptoms. Since antiviral agents are only active against replicating viruses, clinical benefit in reducing severity of symptoms and duration of illness is only marginal, at best. Therefore, treatment initiated beyond the stated time frames below is of no value, and treatment of mild cases should be carefully considered, in light of the minimal benefit which will be achieved. In addition, the balance of evidence indicates that the use of acyclovir in normal hosts in an attempt to prevent post-herpetic neuralgia is of no value. Where specified, treatment must begin within the time frames indicated for the product to be reimbursed. There is no benefit from the therapy begun after these time frames. Acyclovir tablets will be reimbursed when prescribed for: Herpes zoster in immunocompetent patients 50 years of age or older, up to 72 hours after appearance of lesions. Dose: 800mg 5 times/day for 7 days. LU Authorization Period: 1 year. Herpes zoster ophthalmicus regardless of age, up to 72 hours after appearance of lesions. Dose: 800mg 5 times/day for 7 days. LU Authorization Period: 1 year. Herpes zoster in immunocompromised patients regardless of age and time elapsed from onset. Dose: 800mg 5 times/day for 7 days. LU Authorization Period: 1 year. Varicella zoster in immunocompetent patients greater than or equal to 12 years of age, up to 24 hours after appearance of lesions. Dose: 20mg/kg/dose (max. 800mg) 4 times/day for 5 days. NETWORK NOTE: Network will limit supply up to 7 days and up to 35 tablets. LU Authorization Period: 1 year.
IIIA.22
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:18:00 ANTIVIRALS
AMPRENAVIR
97 50mg Cap 02243541 Agenerase GSK .6691 .6691
Note: For the treatment of protease inhibitor (PI) experienced HIV-infected patients 12 years of age or older, recommended for use with other PIs e.g., ritonavir. Prescriber must be approved for the Facilitated Access mechanism. 98 150mg Cap 02243542 Agenerase GSK 2.0074 2.0074
Note: For the treatment of protease inhibitor (PI) experienced HIV-infected patients 12 years of age or older, recommended for use with other PIs e.g., ritonavir. Prescriber must be approved for the Facilitated Access mechanism. 99 15mg/mL O/L 02243543 Agenerase GSK .2007 .2007
Note: For the treatment of protease inhibitor (PI) experienced HIV-infected patients 12 years of age or older, recommended for use with other PIs e.g., ritonavir. Prescriber must be approved for the Facilitated Access mechanism.
ATAZANAVIR SULFATE
100 150mg Cap 02248610 Reyataz BQU 10.1623 10.1623
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 101 200mg Cap 02248611 Reyataz BQU 10.1970 10.1970
DARUNAVIR
102 300mg Tab 02284057 Prezista JNO 6.9600 6.9600
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. In combination with ritonavir, as part of a HIV treatment regimen for treatment-experienced adult patients who have demonstrated failure to at least 2 Protease Inhibitors.
JUNE 27, 2008
IIIA.23
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:18:00 ANTIVIRALS
DELAVIRDINE MESYLATE
103 100mg Tab 02238348 Rescriptor PFI .7178 .7178
DIDANOSINE
104 125mg Enteric Coated Cap 02244596 Videx EC BQU 3.2793 3.2793
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 105 200mg Enteric Coated Cap 02244597 Videx EC BQU 5.2467 5.2467
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 106 250mg Enteric Coated Cap 02244598 Videx EC BQU 6.5583 6.5583
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 107 400mg Enteric-Coated Cap 02244599 Videx EC BQU 10.5147 10.5147
EFAVIRENZ
108 50mg Cap 02239886 Sustiva BQU 1.1717 1.1717
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 109 100mg Cap 02239887 # Sustiva BQU 2.3430 2.3430
IIIA.24
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:18:00 ANTIVIRALS
EFAVIRENZ
110 200mg Cap 02239888 Sustiva BQU 4.6861 4.6861
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 111 600mg Tab 02246045 Sustiva BQU 14.0583 14.0583
EMTRICITABINE & TENOFOVIR DISOPROXIL FUMARATE

112 200mg & 300mg Tab 02274906 Truvada GIL 25.0500 25.0500
FAMCICLOVIR
113 500mg Tab 02177102 02278111 02278650 02292068 Reason for Use Code 147
ED IT E ION LIM US NTAT RED E UI UM REQ OC D

Clinical criteria LU Authorization Period: 1 year. Telzir GSK
Famvir PMS-Famciclovir Sandoz Famciclovir Apo-Famciclovir
NOV PMS SDZ APX
3.2026 6.7624 3.2026 3.2026 3.2026
Herpes zoster in patients 50 years of age or older, up to 72 hours* after appearance of lesions. Dose: 500mg 3 times/day for 7 days. *The patient must begin treatment within the time frame specified for the product to be reimbursed. There is no benefit from the therapy begun after this time frame. NETWORK NOTE: Network will limit supply to 7 days and 21 tablets.
FOSAMPRENAVIR CALCIUM
114 700mg Tab 02261545 8.1180 8.1180
JUNE 27, 2008
IIIA.25
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:18:00 ANTIVIRALS
GANCICLOVIR SODIUM
115 500mg/Vial Pd Inj-10mL Pk 02162695 Cytovene Reason for Use Code 41.2140 41.2140
ION D D TAT IRE TE ForSE N I 12 U the treatment ECMV retinitis U M of syndromes. secondary to AIDS and other LIM immunosuppressive EQ CU Period:Ryear. LU Authorization 1 DO
Clinical criteria Crixivan MFC 1.3467 1.3467
HLR
INDINAVIR
116 200mg Cap 02229161
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 117 400mg Cap 02229196 Crixivan MFC 2.6933 2.6933
LAMIVUDINE
118 10mg/mL O/L 02192691 3TC GSK .3067 .3067
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. Reimbursement will not be provided for the treatment of hepatitis. 119 150mg Tab 02192683 3TC GSK 4.7243 4.7243
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. Reimbursement will not be provided for the treatment of hepatitis. 120 300mg Tab 02247825 3TC GSK 9.4485 9.4485
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. Reimbursement will not be provided for the treatment of hepatitis.
IIIA.26
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:18:00 ANTIVIRALS
LAMIVUDINE & ZIDOVUDINE
121 150mg & 300mg Tab 02239213 Combivir GSK 10.2004 10.2004
LOPINAVIR & RITONAVIR

122 133.3mg/33.3mg Cap 02243643 Kaletra ABB 3.4954 3.4954
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 123 80mg/mL & 20mg/mL O/L 02243644 Kaletra ABB 2.0973 2.0973
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 124 200mg & 50mg Tab 02285533 Kaletra ABB 5.2431 5.2431
NELFINAVIR MESYLATE
125 250mg Tab 02238617 Viracept PFI 1.8200 1.8200
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 126 625mg Tab 02248761 Viracept PFI 4.5500 4.5500
NEVIRAPINE
127 200mg Tab 02238748 Viramune BOE 4.9383 4.9383
JUNE 27, 2008
IIIA.27
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:18:00 ANTIVIRALS
OSELTAMIVIR PHOSPHATE
128 75mg Cap 02241472 Reason for Use Code 371 Tamiflu Clinical criteria HLR 3.9000 3.9000
ED IT E ON TI IM L US NTA ED ME UIR CU REQ DO

LU Authorization Period: 1 year. 372 *The outbreak must be confirmed by Public Health. LU Authorization Period: 1 year. Norvir SEC ABB
For the prophylaxis (max: 75mg daily) of institutionalized individuals during confirmed* outbreaks of Influenza A or Influenza B. Note: Network will limit supply to 6 weeks.
For the treatment (max: 75mg bid) of institutionalized individuals during confirmed* outbreaks due to: Influenza B or, Influenza A (as an alternative to amantadine) or, Influenza A where new cases have developed despite amantadine prophylaxis. Note: Network will limit supply to 5 days.
RITONAVIR
129 100mg Cap 02241480 1.4353 1.4353
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 130 80mg/mL O/L 02229145 Norvir ABB 1.1446 1.1446
IIIA.28
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:18:00 ANTIVIRALS
SAQUINAVIR MESYLATE
131 200mg Cap 02216965 Invirase HLR 1.8200 1.8200
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 132 200mg Cap 02239083 Fortovase HLR 1.0557 1.0557
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 133 500mg Tab 02279320 Invirase HLR 4.2000 4.2000
STAVUDINE
134 15mg Cap 02216086 Zerit BQU 3.9985 3.9985
Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 135 20mg Cap 02216094 Zerit BQU 4.1572 4.1572
JUNE 27, 2008
IIIA.29
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:18:00 ANTIVIRALS
TENOFOVIR DISOPROXIL
138 300mg Tab 02247128 Viread GIL 16.7376 16.7376
VALACYCLOVIR
139 500mg Tab 02219492 Reason for Use Code 159
D ON TI D ITE E TA RE IM S L U MEN UI U REQ OC D

Clinical criteria LU Authorization Period: 1 year. Reason for Use Code
Valtrex
GSK
3.3924 3.3924
Herpes zoster in patients 50 years of age or older, up to 72 hours* after appearance of lesions. Dose: 1 gram 3 times/day for 7 days. *The patient must begin treatment within the time frame specified for the product to be reimbursed. There is no benefit from the therapy begun after this time frame. NETWORK NOTE: Network will limit supply to 7 days and 42 capsules.
VALGANCICLOVIR
140 450mg Tab 02245777
N TIO ED A D ITE USE MENT QUIR IM For the treatment of CMV retinitis in patients with AIDS. L374 U RE OC LUD Authorization Period: 1 year.
Clinical criteria
Valcyte
HLR
22.4100 22.4100
IIIA.30
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:20:00 PLASMODICIDES (ANTIMALARIALS)
CHLOROQUINE PHOSPHATE
141 250mg Tab 02017539 00021261 .3208 Aralen (Not a Benefit) Novo-Chloroquine SAO NOP .3208
HYDROXYCHLOROQUINE SULFATE
142 200mg Tab 02017709 02246691 02252600 Plaquenil Apo-Hydroxyquine Gen-Hydroxychloroquine SAV APX GEN .2620 .5893 .2620 .2620
08:24:00 SULFONAMIDES
SULFASALAZINE
143 500mg Ent Tab 02064472 00598488 500mg Tab 02064480 00598461 Salazopyrin PMS-Sulfasalazine-E.C. Salazopyrin PMS-Sulfasalazine PFI PMS PFI PMS .2816 .3313 .2816 .1804 .2122 .1804
144
08:32:00 TRICHOMONACIDES
METRONIDAZOLE
145 500mg Cap 01926853 00783137 02248562 250mg Tab 01926896 00545066 Flagyl PMS-Metronidazole Apo-Metronidazole Flagyl (Not a Benefit) Apo-Metronidazole SAV PMS APX RPP APX .4250 .8925 .4250 .4250 .0575 .0575 1.28 2.68 1.28 1.28 .17 .17
146
JUNE 27, 2008
IIIA.31
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:36:00 URINARY ANTI-INFECTIVES
NITROFURANTOIN
Note: Nitrofurantoin macrocrystals may be better tolerated. Avoid use of nitrofurantoin during the last 6 weeks of pregnancy. Use with caution in patients with renal impairment. 147 50mg Cap 01997637 02231015 100mg Cap 01997645 02231016 50mg Tab 00017086 00319511 100mg Tab 00017094 00312738 .3187 Macrodantin (Not a Benefit) Novo-Furantoin Macrodantin (Not a Benefit) Novo-Furantoin Nifuran (Not a Benefit) Apo-Nitrofurantoin Nifuran (Not a Benefit) Apo-Nitrofurantoin PGP NOP PGP NOP MAN APX MAN APX .3187 .6110 .6110 .1440 .1440 .1920 .1920 1.27 1.27 2.44 2.44 .58 .58 .77 .77
148
149
150
NITROFURANTOIN MONO/MICRO CRYSTALS

151 100mg Cap 02063662 MacroBID PGP .6702 .6702
IIIA.32
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

08:40:00 MISCELLANEOUS ANTI-INFECTIVES
CIPROFLOXACIN
Note: Ciprofloxacin is not intended for the treatment of asymptomatic bacteriuria in the absence of risk factors. Avoid use in pregnancy and children < 18 years of age. Ciprofloxacin inhibits theophylline clearance and also affects phenytoin kinetics. Theophylline doses should be decreased and blood levels of phenytoin or theophylline monitored when either of these drugs is used concomitantly with ciprofloxacin. 152 153 10g/100mL Oral Susp 02237514 Cipro 250mg Tab 02155958 02161737 02229521 02245647 02246825 02247339 02248437 02248756 02266962 02267934 02303728 500mg Tab 02155966 02161745 02229522 02245648 02246826 02247340 02248438 02248757 02266970 02267942 02303736 750mg Tab 02155974 02161753 02229523 02245649 02246827 02247341 02248439 02248758 02267950 02303744 Cipro Novo-Ciprofloxacin Apo-Ciproflox Gen-Ciprofloxacin Ratio-Ciprofloxacin Co-Ciprofloxacin PMS-Ciprofloxacin Sandoz Ciprofloxacin Taro-Ciprofloxacin Ran-Ciprofloxacin Ran-Ciproflox Cipro Novo-Ciprofloxacin Apo-Ciproflox Gen-Ciprofloxacin Ratio-Ciprofloxacin Co-Ciprofloxacin PMS-Ciprofloxacin Sandoz Ciprofloxacin Taro-Ciprofloxacin Ran-Ciprofloxacin Ran-Ciproflox Cipro Novo-Ciprofloxacin Apo-Ciproflox Gen-Ciprofloxacin Ratio-Ciprofloxacin Co-Ciprofloxacin PMS-Ciprofloxacin Sandoz Ciprofloxacin Ran-Ciprofloxacin Ran-Ciproflox BAY BAY NOP APX GEN RPH COB PMS SDZ TAR RAN RAN BAY NOP APX GEN RPH COB PMS SDZ TAR RAN RAN BAY NOP APX GEN RPH COB PMS SDZ RAN RAN .5582 .5582 1.1105 2.4742 1.1105 1.1105 1.1105 1.1105 1.1105 1.1105 1.1105 1.1105 1.1105 1.1105 1.2529 2.7915 1.2529 1.2529 1.2529 1.2529 1.2529 1.2529 1.2529 1.2529 1.2529 1.2529 2.3631 5.1118 2.3631 2.3631 2.3631 2.3631 2.3631 2.3631 2.3631 2.3631 2.3632 5.58 5.58 2.22 4.95 2.22 2.22 2.22 2.22 2.22 2.22 2.22 2.22 2.22 2.22 2.51 5.58 2.51 2.51 2.51 2.51 2.51 2.51 2.51 2.51 2.51 2.51
154
155
ED IT E N IM S IO L U TAT EN D UM IRE C DO EQU R

4.73 10.22 4.73 4.73 4.73 4.73 4.73 4.73 4.73 4.73 4.73 Continued on next page...
JUNE 27, 2008
IIIA.33
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CIPROFLOXACIN (Contd)
Note: Ciprofloxacin is not intended for the treatment of asymptomatic bacteriuria in the absence of risk factors. Avoid use in pregnancy and children < 18 years of age. Ciprofloxacin inhibits theophylline clearance and also affects phenytoin kinetics. Theophylline doses should be decreased and blood levels of phenytoin or theophylline monitored when either of these drugs is used concomitantly with ciprofloxacin. Reason for Use Code 332 Clinical criteria For the treatment of patients with: SST/BJ (Gram negative bacteria): Skin/soft tissue and bone/joint infection due to gram negative bacteria; severe diabetic foot infection; severe otitis externa; decubitus ulcers. LU Authorization Period: 1 year. GU Tract: Urinary tract infection/prostatitis/epididymitis caused by (suspected or documented) Pseudomonas; sexually transmitted diseases. LU Authorization Period: 1 year. COPD with risk: Acute bacterial exacerbation of chronic obstructive pulmonary disease (COPD) with risk factors1; bronchiectasis; pneumonic illness with cystic fibrosis. 1Risk factors include: poor pulmonary lung function (FEV below 1 50% predicted level), age over 65 years, co-morbid medical illness (congestive heart failure, diabetes, chronic renal failure, chronic liver disease), chronic corticosteroid use, malnutrition, prolonged duration of disease or 4 or more exacerbations per year. LU Authorization Period: 1 year. Step-Down: Step-down therapy after parenteral therapy or hospital/emergency department discharge; febrile neutropenia. LU Authorization Period: 1 year. GI: Travellers diarrhea; enteric fever syndromes; Crohns disease. LU Authorization Period: 1 year. For the prophylaxis or treatment of B. anthracis exposure. LU Authorization Period: 1 year. Exceptional cases of allergy or intolerance to all other appropriate therapies. LU Authorization Period: 1 year.
ED IT E N IM S IO L U TAT N E M ED U C IR O QU D E R
333 334 336 350 353 977
IIIA.34
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CIPROFLOXACIN HCL & CIPROFLOXACIN BASE
Note: Ciprofloxacin is not intended for the treatment of asymptomatic bacteriuria in the absence of risk factors. Avoid use in pregnancy and children < 18 years of age. Ciprofloxacin inhibits theophylline clearance and also affects phenytoin kinetics. Theophylline doses should be decreased and blood levels of phenytoin or theophylline monitored when either of these drugs is used concomitantly with ciprofloxacin. 156 500mg ER Tab 02247916 Reason for Use Code
ION D T D TE ForSE with ENTA urinary tract infections (acute I IRE 394 patients uncomplicated U cystitis) U who M failure, intoleranceare hypersensitivity to all LIM EQ Uhave alternatives that or listed as General Benefits. formulary antibiotic R C LUO Authorization Period: 1 year. D
Clinical criteria Cipro XL BAY 2.9068 2.9068
Cipro XL
BAY
2.9068 2.9068
157
1000mg ER Tab 02251787 Reason for Use Code
ION D DClinical criteria ITE ForE withNTAT urinary E infections or acute 395 patients complicated IR tract uncomplicated pyelonephritisU have failure, intolerance or who LIM US MEto all formulary antibiotic alternatives that are hypersensitivity UGeneral Benefits.Q RE C listed as DOAuthorization Period: 1 year. LU
JUNE 27, 2008
IIIA.35
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LEVOFLOXACIN
158 159 250mg Tab 02236841 500mg Tab 02236842 Reason for Use Code Levaquin Levaquin JNO JNO 4.7332 4.7332 5.3410 5.3410
ED IT E N IM S IO L U TAT N E M ED CU UIR O Q D E R
Clinical criteria For the treatment of patients with: 337 CAP with co-morbidity: Community acquired pneumonia with co-morbid illnesses or failure to first-line therapy. LU Authorization Period: 1 year. 338 COPD with risk: Acute bacterial exacerbation of chronic obstructive pulmonary disease (COPD) with risk factors1; bronchiectasis.
1Risk factors include: poor pulmonary lung function (FEV below 1 50% predicted level), age over 65 years, co-morbid medical illness (congestive heart failure, diabetes, chronic renal failure, chronic liver disease), chronic corticosteroid use, malnutrition, prolonged duration of disease, or 4 or more exacerbations per year.
LU Authorization Period: 1 year.
339
Step-Down: Step-down therapy after parenteral therapy or hospital / emergency department discharge. LU Authorization Period: 1 year.
977
Exceptional cases of allergy or intolerance to all other appropriate therapies. LU Authorization Period: 1 year.
IIIA.36
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LINEZOLID
160 600mg Tab 02243684 Reason for Use Code 362 70.6390 70.6390
ED T E ON I TI M S LI U TA EN ED UM UIR OC EQ D R
Clinical criteria For the treatment of patients with: LU Authorization Period: 1 year. 363 LU Authorization Period: 1 year. 364 LU Authorization Period: 1 year.
Zyvoxam
PFI
Methicillin-resistant Staphylococcus species (MRSA, MRSE) infections* in patients who are intolerant or have failed vancomycin therapy, or have contraindications to venous access.
Vancomycin resistant Enterococcus species (VRE) infections* in patients switching from IV linezolid.
Step-down therapy for the treatment of methicillin-resistant Staphylococcus species or vancomycin resistant Enterococcus species (VRE) infections* after parenteral therapy or hospital/ emergency department discharge. * Infections must be documented and culture proven. Not approved for colonization (e.g. nares, urine, etc). Maximum 28 days supply.
JUNE 27, 2008
IIIA.37
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MOXIFLOXACIN HYDROCHLORIDE
161 400mg Tab 02242965 Reason for Use Code 337 Avelox Clinical criteria BAY 5.5840 5.5840
D TE I IM SE TION L U TA EN ED UM IR C O EQU D R
For the treatment of patients with: CAP with co-morbidity: Community acquired pneumonia with co-morbid illnesses or failure to first-line therapy. LU Authorization Period: 1 year. 338 COPD with risk: Acute bacterial exacerbation of chronic obstructive pulmonary disease (COPD) with risk factors1; bronchiectasis.
339
977
NORFLOXACIN
162 400mg Tab 00643025 02229524 02237682 02246596 02269627 1.0898 Noroxin (Not a Benefit) Apo-Norflox Novo-Norfloxacin PMS-Norfloxacin Co Norfloxacin MSD APX NOP PMS COB 1.0898 1.0898 1.0898 1.0898 2.18 2.18 2.18 2.18 2.18
IIIA.38
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

OFLOXACIN
163 200mg Tab 01968424 02231529 02243474 300mg Tab 01968416 02231531 02243475 400mg Tab 01968408 02231532 02243476 Reason for Use Code 340 1.3041 Floxin (Not a Benefit) Apo-Oflox Novo-Ofloxacin Floxin (Not a Benefit) Apo-Oflox Novo-Ofloxacin JNO APX NOP JNO APX NOP JNO APX NOP 1.3041 1.3041 1.2161 1.2161 1.2161 1.2161 1.2161 1.2161 2.61 2.61 2.61 2.43 2.43 2.43 2.43 2.43 2.43
164
165
D TE I IM SE TION L U TA EN D M U IRE C U DO EQ R
Floxin (Not a Benefit) Apo-Oflox Novo-Ofloxacin Clinical criteria 341 338 335 339 977
For the treatment of patients with: SST/BJ (Gram negative bacteria): Skin/soft tissue and bone/joint infection due to gram negative bacteria; severe diabetic foot infection. LU Authorization Period: 1 year. GU Tract: Urinary tract infection / prostatitis / epididymitis; sexually transmitted disease. LU Authorization Period: 1 year. COPD with risk: Acute bacterial exacerbation of chronic obstructive pulmonary disease (COPD) with risk factors1; bronchiectasis. 1Risk factors include: poor pulmonary lung function (FEV below 1 50% predicted level), age over 65 years, co-morbid medical illness (congestive heart failure, diabetes, chronic renal failure, chronic liver disease), chronic corticosteroid use, malnutrition, prolonged duration of disease, or 4 or more exacerbations per year. LU Authorization Period: 1 year. GI: Travellers diarrhea; enteric fever syndromes. LU Authorization Period: 1 year. Step-Down: Step-down therapy after parenteral therapy or hospital / emergency department discharge. LU Authorization Period: 1 year. Exceptional cases of allergy or intolerance to all other appropriate therapies. LU Authorization Period: 1 year.
JUNE 27, 2008
IIIA.39
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SULFAMETHOXAZOLE & TRIMETHOPRIM
Note: Avoid using sulfamethoxazole/trimethoprim during the last 6 weeks of pregnancy. 166 40mg & 8mg/mL O/L 00270644 Septra (Not a Benefit) 00272485 Bactrim Sugar Free (Not a Benefit) 00726540 Novo-Trimel 00865753 Nu-Cotrimox 400mg & 80mg Tab 00270636 Septra (Not a Benefit) 00272469 Bactrim (Not a Benefit) 00445274 Apo-Sulfatrim 00510637 Novo-Trimel 00865710 Nu-Cotrimox 800mg & 160mg Tab 00368040 Septra DS (Not a Benefit) 00371823 Bactrim-DS (Not a Benefit) 00445282 Apo-Sulfatrim-DS 00510645 Novo-Trimel DS 00865729 Nu-Cotrimox .0198 BWE HLR NOP NXP BWE HLR APX NOP NXP BWE HLR APX NOP NXP .0198 .0198 .0482 .0482 .0482 .0482 .1221 .1221 .1221 .1221 .20 .20 .20 .19 .19 .19 .19 .24 .24 .24 .24
167
168
TRIMETHOPRIM
169 100mg Tab 00675229 02243116 200mg Tab 00677590 02243117 .1891 Proloprim (Not a Benefit) Apo-Trimethoprim Proloprim (Not a Benefit) Apo-Trimethoprim BWE APX BWE APX .1891 .3885 .3885 .38 .38 .39 .39
170
IIIA.40
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
10:00 ANTINEOPLASTIC AGENTS

ALTRETAMINE
171 50mg Cap 02126230 Hexalen LIL 3.3600 3.3600
ANASTROZOLE
172
D ION D ITE E AT IRE IM US ENT U L UM REQ OC D

Arimidex AZC Reason for Use Code 365 Clinical criteria LU Authorization Period: Indefinite. 396 LU Authorization Period: Indefinite.
1mg Tab 02224135
4.9500 4.9500
For the treatment of metastatic breast cancer in hormone receptor positive post-menopausal women.
As an alternative to tamoxifen for the adjuvant treatment of postmenopausal women with hormone receptor positive breast cancer.
BICALUTAMIDE
173 50mg Tab 02184478 02270226 02274337 02275589 02276089 02277700 02296063 02302403 Casodex Novo-Bicalutamide Co Bicalutamide PMS-Bicalutamide Sandoz Bicalutamide Ratio-Bicalutamide Apo-Bicalutamide Gen-Bicalutamide AZC NOP COB PMS SDZ RPH APX GEN 3.2200 6.4400 3.2200 3.2200 3.2200 3.2200 3.2200 3.2200 3.2200
JUNE 27, 2008
IIIA.41
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

BUSERELIN ACETATE
174 175 176 177 6.3mg Implant Kit 02228955 Suprefact Depot SAV SAV SAV SAV 703.5000 703.5000 1039.5000 1039.5000 56.9800 56.9800 72.7000 72.7000
9.45mg Implant Kit 02240749 Suprefact Depot 1mg/mL Inj Sol-5.5mL Pk 02225166 Suprefact 1mg/mL Nas Sp-10mL Pk 02225158 Suprefact
BUSULFAN
178 2mg Tab 00004618 Myleran GSK 1.4043 1.4043
CAPECITABINE
179 180 150mg Tab 02238453 500mg Tab 02238454 Reason for Use Code 346 Xeloda Xeloda HLR HLR 1.8300 1.8300 6.1000 6.1000
ED IT E N M S IO LI U AT NT D E E UM IR OC QU D RE
Clinical criteria 360 406
For the first-line treatment of patients with metastatic colorectal cancer in whom combination chemotherapy is not recommended. NOTE: Not to be used in patients who have failed 5-flurouracil. LU Authorization Period: Indefinite. For the treatment of metastatic breast cancer in combination with docetaxel in women who experience disease progression on or after an anthracycline. LU Authorization Period: Indefinite. For adjuvant treatment of stage 3 or high risk stage 2* colon cancer in patients who have completed surgery (within three months), who would normally be candidates for adjuvant chemotherapy with 5FU/LV. * high risk stage 2 colon cancer is defined as one of the following: - obstruction, - perforation, - poorly differentiated adenocarcinoma, - inadequate lymph node sampling, - T4 tumour. LU Authorization Period: 6 months.
IIIA.42
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CHLORAMBUCIL
181 2mg Tab 00004626 Leukeran GSK 1.3236 1.3236
CLADRIBINE
182 1mg/mL Inj 02022117 Reason for Use Code
N TIO ED A D ITE USE MENT QUIR 99 For hairy cell leukemia, as a single 7-day treatment course. LIM U RE OC Period: 1 year. LU Authorization D
Leustatin JNO Clinical criteria BAX BAX BQU BAX BQU BAX 5.7630 5.7630 13.4436 13.4436 .3520 .3794 .3520 .4740 .5109 .4740
53.5650 53.5650
CYCLOPHOSPHAMIDE
183 184 185 200mg Inj Pd-Vial Pk 02241797 Procytox 1000mg Inj Pd-Vial Pk 02241799 Procytox 25mg Tab 00344877 02241795 50mg Tab 00344885 02241796 Cytoxan Procytox Cytoxan Procytox
186
CYPROTERONE ACETATE
187 50mg Tab 00704431 02229723 02232872 02245898 Androcur Gen-Cyproterone # Novo-Cyproterone Apo-Cyproterone BAY GEN NOP APX 1.4085 1.4085 1.4085 1.4085 1.4085
JUNE 27, 2008
IIIA.43
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CYTARABINE
188 100mg Inj Pd-Vial Pk 00386715 Cytosar PFI 9.4780 9.4780
DAUNORUBICIN
189 Inj Pd-20mg Pk 01926683 Cerubidine ERF 85.0000 85.0000
ESTRAMUSTINE PHOSPHATE DISODIUM

190 140mg Cap 02063794 Emcyt PFI 3.0070 3.0070
ETOPOSIDE
191 50mg Cap 00616192 Vepesid BQU 33.5365 33.5365
EXEMESTANE
ED ON IT E TI D LIM US ENTA IRE M EQU CU R DO

Clinical criteria LU Authorization Period: Indefinite. 407
Aromasin
PFI
4.9500 4.9500
For the hormonal treatment of metastatic breast cancer in hormone receptor positive post-menopausal women who have disease progression following tamoxifen therapy.
For the sequential treatment of postmenopausal women with estrogen receptor-positive early breast cancer who have received 2-3 years of initial adjuvant tamoxifen therapy. LU Authorization Period: Treatment period required to complete a total of 5 years of adjuvant therapy.
IIIA.44
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLUDARABINE PHOSPHATE
193 10mg Tab 02246226 Reason for Use Code
ION D TAT IRE ED second line therapy of patients with chronic lymphocytic E 379 T For S U (CLL) MEN failedQU intolerant to chlorambucil. IMI leukemia L CU who haveRE or are LU Authorization Period: Indefinite. DO
Fludara BAY Clinical criteria Euflex Novo-Flutamide PMS-Flutamide Apo-Flutamide SCH NOP PMS APX 1.3530 1.3530 1.3530 1.3530 1.3530
37.4475 37.4475
FLUTAMIDE
194 250mg Tab 00637726 02230089 02230104 02238560
GOSERELIN ACETATE
195 196 3.6mg Depot Inj 02049325 10.8mg Depot Inj 02225905 Zoladex Zoladex LA AZC AZC 381.7500 381.7500 1087.9800 1087.9800
HYDROXYUREA
197 500mg Cap 00465283 02242920 02247937 Hydrea Gen-Hydroxyurea Apo-Hydroxyurea BQU GEN APX 1.0203 1.0203 1.0203 1.0203
JUNE 27, 2008
IIIA.45
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

IMATINIB MESYLATE
198 199 100mg Tab 02253275 400mg Tab 02253283 1) Gleevec Gleevec NOV NOV 26.4838 26.4838 105.9353 105.9353
Note: These products must be prescribed based on the following criteria: For the treatment of Philadelphia chromosome-positive chronic myeloid leukemia (CML) in chronic phase. The initial dose is 400mg/day. The dose may be increased up to a maximum of 800mg/day in patients who do not have an adequate hematologic response at 3 months or cytogenetic response at 1 year; or if there has been loss of a previously achieved hematologic and/or cytogenetic response. 2) For the treatment of Philadelphia chromosone-positive chronic myeloid leukemia (CML) in blast crisis or accelerated phase. The initial dose is 600mg/day. The dose may be increased to a maximum of 800mg/day in patients who do not have an adequate hematologic response at 3 months or cytogenetic response at 1 year; or loss of a previously achieved hematologic and/or cytogenetic response.
INTERFERON ALFA-2B
200 201 202 15mu/mL 18mu MD Pen Kit 02240693 Intron A 25mu/mL 30mu MD Pen Kit 02240694 Intron A 50mu/mL 60mu MD Pen Kit 02240695 Intron A Reason for Use Code 28
ED ION IT E AT ED IM S L NT IR U ME EQU CU R DO
SCH SCH 339.9000 339.9000 679.8000 679.8000 Clinical criteria For hairy cell leukemia. LU Authorization Period: Indefinite. 29 For Kaposis Sarcoma. LU Authorization Period: Indefinite.
SCH
203.9400 203.9400
IIIA.46
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LETROZOLE
203 2.5mg Tab 02231384 Reason for Use Code 365 Femara NOV 5.5120 5.5120
ED IT ON IM SE TI L TA ED U EN UIR UM EQ OC R D
Clinical criteria LU Authorization Period: Indefinite. 403 LU Authorization Period: 5 years. 408 LU Authorization Period: 5 years.
For the treatment of metastatic breast cancer in hormone receptor positive post-menopausal women. For the treatment of hormone receptor positive early breast cancer in postmenopausal women who have received 5 years of adjuvant tamoxifen therapy. As an alternative to tamoxifen for the adjuvant treatment of postmenopausal women with hormone receptor positive early breast cancer for a maximum of five years.
LEUPROLIDE ACETATE
204 205 206 207 208 209 210 211 212 3.75mg Inj-Kit 00884502 7.5mg Inj-Kit 00836273 11.25mg Inj-Kit 02239834 22.5mg Inj-Kit 02230248 30mg Inj-Kit 02239833 Lupron Depot PDS Lupron Depot PDS Lupron Depot PDS Lupron Depot PDS Lupron Depot PDS ABB ABB ABB ABB ABB SAV SAV SAV SAV 329.7800 329.7800 387.9700 387.9700 989.3700 989.3700 1071.0000 1071.0000 1428.0000 1428.0000 343.5800 343.5800 891.0000 891.0000 1285.2000 1285.2000 1782.0000 1782.0000
7.5mg Pd Susp Inj-Pref Syr Kit 02248239 Eligard 22.5mg Pd Susp Inj-Pref Syr Kit 02248240 Eligard 30mg Pd Susp Inj-Pref Syr Kit 02248999 Eligard 45mg Pd Susp Inj-Pref Syr Kit 02268892 Eligard
JUNE 27, 2008
IIIA.47
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LOMUSTINE (CCNU)
213 214 215 10mg Cap 00360430 40mg Cap 00360422 100mg Cap 00360414 CeeNU CeeNU CeeNU BQU BQU BQU 5.9675 5.9675 10.2725 10.2725 16.9595 16.9595
MEGESTROL ACETATE
216 40mg Tab 00386391 02195917 160mg Tab 00731323 02185423 02195925 .9054 Megace (Not a Benefit) Apo-Megestrol Megace Nu-Megestrol Apo-Megestrol BQU APX BQU NXP APX .9054 2.6867 5.6840 2.6867 2.6867
217
MELPHALAN
218 2mg Tab 00004715 Alkeran GSK 1.5310 1.5310
MERCAPTOPURINE
219 50mg Tab 00004723 Purinethol NOP 3.6680 3.6680
Note: Decrease dose of mercaptopurine to 25-33% of initial dose if allopurinol used concomitantly.
METHOTREXATE
220 221 20mg/2mL Inj Sol-2mL Pk 02182947 Methotrexate Sodium 50mg/2mL Inj Sol-2mL Pk 02170671 Methotrexate (Not a Benefit) 02182777 Methotrexate MAY WAY MAY 12.5000 12.5000 12.4800 12.4800
IIIA.48
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

METHOTREXATE
222 2.5mg Tab 02170698 02182963 02244798 Methotrexate Apo-Methotrexate Ratio-Methotrexate Sodium WAY APX RPH .6325 .6325 .6325 .6325
NILUTAMIDE
223 50mg Tab 02221861 Anandron SAV 1.9679 1.9679
PROCARBAZINE HCL
224 50mg Cap 00012750 Matulane SIG .4079 .4079
Note: Procarbazine inhibits monoamine oxidase. Avoid alcohol and foods with high tyramine content (e.g. aged cheese, red wine, yogurt, etc.)
STREPTOZOCIN
225 Inj Pd-1g Pk 00622141 Zanosar PFI 37.6600 37.6600
TAMOXIFEN CITRATE
226 10mg Tab 02048477 00812404 00851965 01926624 02088428 20mg Tab 02048485 00812390 00851973 01926632 02089858 .1750 Nolvadex (Not a Benefit) Apo-Tamox Novo-Tamoxifen Tamofen Gen-Tamoxifen Nolvadex D Apo-Tamox Novo-Tamoxifen Tamofen Gen-Tamoxifen AZC APX NOP SAV GEN AZC APX NOP SAV GEN .1750 .1750 .1838 .1750 .3500 .3600 .3500 .3500 .3675 .3500
227
JUNE 27, 2008
IIIA.49
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TEMOZOLOMIDE
228 229 230 231 5mg Cap 02241093 20mg Cap 02241094 100mg Cap 02241095 250mg Cap 02241096 Reason for Use Code 320 Temodal Temodal Temodal Temodal SCH SCH SCH SCH 7.1300 7.1300
ED T ION MI SE AT ED I L NT IR U ME EQU CU R DO
Clinical criteria LU Authorization Period: Indefinite.
28.5200 28.5200
142.6000 142.6000 356.4900 356.4900
For patients with recurrent or progressive glioblastoma multiforme or anaplastic astrocytoma.
THIOGUANINE
232 40mg Tab 00282081 Lanvis GSK 4.0921 4.0921
TRIPTORELIN PAMOATE
233 234 235 236 3.75mg/Vial Inj Pd with Sterile Water-Vial Pk 09857199 Trelstar (1 Month) 11.25mg/Vial Inj Pd with Sterile Water-Vial Pk 09857200 Trelstar LA (3 Month) 3.75mg/Vial Inj Pd-Vial Pk 02240000 Trelstar (1 Month) 11.25mg/Vial Inj Pd-Vial Pk 02243856 Trelstar LA (3 Month) PAL PAL PAL PAL 291.0000 291.0000 891.0000 891.0000 291.0000 291.0000 891.0000 891.0000
VINCRISTINE SULFATE
237 1mg/mL Inj Sol 00611182 02143305 7.1300 Oncovin (Not a Benefit) Vincristine Sulfate LIL NOP 7.1300
IIIA.50
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
12:00 AUTONOMIC AGENTS

12:04:00 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
BETHANECHOL CHLORIDE
238 239 240 10mg Tab 01947958 25mg Tab 01947931 50mg Tab 01947923 Duvoid Duvoid Duvoid SQI SQI SQI .2552 .2552 .4135 .4135 .5446 .5446
CARBACHOL
241 2mg Tab 00885568 Carbachol GLA .3727 .3727
DONEPEZIL HCL
242 243 5mg Tab 02232043 10mg Tab 02232044 Reason for Use Code 347 Aricept Aricept PFI PFI 4.7771 4.7771 4.7771 4.7771
ED T E ON TI MI S LI U TA D EN IRE UM QU OC RE D
Clinical criteria NETWORK NOTE: Maximum duration 3 months. LU Authorization Period: 1 year. 348 LU Authorization Period: 1 year.
Initial Trial: For patients with mild to moderate Alzheimers Disease (Mini-Mental State Exam [MMSE] 10-26). Patients will be reimbursed for a period of up to 3 months after which continued treatment must be reassessed.
Continuation: Further reimbursement will be made available to those patients whose disease has not progressed/deteriorated while on this drug. Patients must continue to have a MMSE score of 10-26.
JUNE 27, 2008
IIIA.51
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

GALANTAMINE HYDROBROMIDE
244 245 246 8mg ER Cap 02266717 4.7277 4.7277 4.7277 4.7277 4.7277 4.7277
N ED T E I IO IM US AT L NT ED E IR M U CU EQ DO R
16mg ER Cap 02266725 24mg ER Cap 02266733 Reason for Use Code 347 Reminyl ER Reminyl ER JNO JNO Clinical criteria NETWORK NOTE: Maximum duration 3 months. LU Authorization Period: 1 year. 348 LU Authorization Period: 1 year.
Reminyl ER
JNO
NEOSTIGMINE BROMIDE
247 15mg Tab 00869945 Prostigmin VAL .4370 .4370
PYRIDOSTIGMINE BROMIDE
248 249 180mg LA Tab 00869953 60mg Tab 00869961 Mestinon Mestinon VAL VAL .9397 .9397 .4295 .4295
IIIA.52
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

RIVASTIGMINE
250 251 252 253 1.5mg Cap 02242115 3mg Cap 02242116 4.5mg Cap 02242117 6mg Cap 02242118 Reason for Use Code 347 2.5300 2.5300 2.5300 2.5300 2.5300 2.5300 2.5300 2.5300
ED T E ON I TI M S LI U TA EN ED UM IR OC QU D E R
Exelon Exelon Exelon NOV NOV NOV Clinical criteria Network note: Maximum duration 3 months. LU Authorization Period: 1 year. 348 LU Authorization Period: 1 year.
Exelon
NOV
JUNE 27, 2008
IIIA.53
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

12:08:00 PARASYMPATHOLYTIC (CHOLINERGIC BLOCKING) AGENTS
Note: Anticholinergic agents should be used with extreme caution in the elderly due to agerelated central nervous system adverse effects (e.g., confusion, paranoia, hallucinations). Avoid in patients with dementia as drug-induced memory impairment is common. (This does not apply to ipratropium bromide).
BENZTROPINE MESYLATE
254 2mg Tab 00016357 00426857 .0450 Cogentin (Not a Benefit) Apo-Benztropine MSD APX .0450
ETHOPROPAZINE HCL
255 50mg Tab 01927744 Parsitan ERF .2000 .2000
FLAVOXATE HCL
256 200mg Tab 00728179 02244842 02245480 Urispas (Not a Benefit) Apo-Flavoxate (Not a Benefit) PMS-Flavoxate (Not a Benefit) PAL APX PMS
IIIA.54
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

IPRATROPIUM BROMIDE
257 250mcg/mL Inh Sol-20mL Pk 00731439 Atrovent (Not a Benefit) 02097141 Ratio-Ipratropium 02126222 Apo-Ipravent Inhalation Solution 02210479 Novo-Ipramide 02231136 PMS-Ipratropium 02239131 Gen-Ipratropium Reason for Use Code Clinical criteria 8.7850 BOE RPH APX NOP PMS GEN 8.7850 8.7850 8.7850 8.7850 8.7850
ED IT E N IM S IO L U TAT N ED E UM UIR C O EQ D R
256 Patients who have a tracheostomy; LU Authorization Period: Indefinite. 257 Patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. 258 Patients with severe mental or physical disabilities; LU Authorization Period: Indefinite. 259 Patients who have previously used nebulizer therapy within the last 12 month period. LU Authorization Period: Indefinite.
For the vast majority of patients, a metered dose inhaler is the preferred therapy. Nebulizer therapy will be reimbursed for patients who are unable to use a metered dose inhaler, including an inhaler with a spacer attachment, or a turbuhaler.
JUNE 27, 2008
IIIA.55
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

IPRATROPIUM BROMIDE
258 125mcg/mL Inh Sol-2mL UDV Pk 02026759 Atrovent UDV (Not a Benefit) 02097176 Ratio-Ipratropium UDV 02231135 PMS-Ipratropium 250mcg/mL Inh Sol-2mL UDV Pk 01950681 Atrovent UDV (Not a Benefit) 02097168 Ratio-Ipratropium UDV 02216221 Gen-Ipratropium 02231245 PMS-Ipratropium Reason for Use Code Clinical criteria .6590 BOE RPH PMS BOE RPH GEN PMS .6590 .6590
259
ED IT E N IM S IO L U TAT N E D M U RE C O QUI D RE
1.3180 1.3180 1.3180 1.3180 265 Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have a tracheostomy; LU Authorization Period: Indefinite. 266 Individuals must have a known hypersensitivity to the preservative in the bulk solution, and be patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. 267 Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have severe mental or physical disabilities; LU Authorization Period: Indefinite. 268 Patients who have previously used nebulizer therapy within the last 12 month period. LU Authorization Period: Indefinite.
IIIA.56
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

IPRATROPIUM BROMIDE
260 20mcg/Metered Dose Inh-200 Dose Pk 02247686 Atrovent HFA BOE 18.3400 18.3400
IPRATROPIUM BROMIDE/SALBUTAMOL
261 262 20mcg/100mcg/md Aero Inh 02163721 # Combivent 500mcg/2.5mg/2.5mL Inh Sol-2.5mL Pk 02231675 Combivent UDV 02243789 Ratio-IPRA SAL UDV 02266393 Apo-Salvent Ipravent Sterules 02272695 Gen-Combo Sterinebs Reason for Use Code Clinical criteria BOE BOE RPH APX GEN 21.2400 21.2400 .7340 1.5075 .7340 .7340 .7340
N ED T E I IO IM US AT L T EN ED UM IR C O QU D RE
256 Patients who have a tracheostomy; LU Authorization Period: Indefinite. 257 Patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. 258 Patients with severe mental or physical disabilities; LU Authorization Period: Indefinite. 259 LU Authorization Period: Indefinite.
Patients who have previously used nebulizer therapy within the last 12 month period.
JUNE 27, 2008
IIIA.57
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

OXYBUTYNIN CHLORIDE
263 1mg/mL O/L 01924753 02223376 5mg Tab 01924761 02158590 02163543 02220059 02230394 02230800 02240550 .0444 Ditropan (Not a Benefit) PMS-Oxybutynin Ditropan (Not a Benefit) Nu-Oxybutyn Apo-Oxybutynin # Oxybutyn Novo-Oxybutynin Gen-Oxybutynin PMS-Oxybutynin JNO PMS PGP NXP APX VAL NOP GEN PMS .0444 .1973 .1973 .1973 .2485 .1973 .1973 .1973
264
PROCYCLIDINE HCL
265 266 267 0.5mg/mL O/L 00004405 2.5mg Tab 00649392 5mg Tab 00004758 00587354 Kemadrin PMS-Procyclidine Kemadrin (Not a Benefit) PMS-Procyclidine BWE PMS BWE PMS .0307 .0307 .0555 .0555 .0255 .0255
TIOTROPIUM BROMIDE MONOHYDRATE

268 18mcg Cap 02246793 Spiriva BOE 2.1000 2.1000
IIIA.58
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TRIHEXYPHENIDYL HCL
269 2mg Tab 00015040 00545058 5mg Tab 00015059 00545074 .0248 Artane (Not a Benefit) Apo-Trihex Artane (Not a Benefit) Apo-Trihex LED APX LED APX .0248 .0449 .0449
270
12:12:00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS

Note: Solutions for use in nebulizers are more expensive than metered dose inhalers (MDI) and turbuhalers, and for most patients, there is no significant benefit. The only indication for this mode of administration is for selected patient groups, such as those noted in the Limited Use clinical criteria for solutions for use in nebulizers, who are unable to use other formulations. Even children who are unable to coordinate actuation of a MDI and inhalation can usually use a spacer or turbuhaler. Special fittings are available for patients with severe arthritis who have difficulty using a standard MDI.
BUDESONIDE & FORMOTEROL FUMARATE DIHYDRATE

271 272 100mcg/6mcg Pd Inh-120 Dose Pk 02245385 Symbicort 100 Turbuhaler 200mcg/6mcg Pd Inh-120 Dose Pk 02245386 Symbicort 200 Turbuhaler AZC 60.0000 60.0000
N AZC 78.0000 78.0000 D E Clinical criteria TIO D Reason forT A IMI SE Use Code NT UIRE L U For theME of asthma in patients who are using 330 U treatment EQ optimum anti-inflammatory treatment and are still experiencing R OC breakthrough symptoms. D
LU Authorization Period: Indefinite.
JUNE 27, 2008
IIIA.59
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

EPINEPHRINE HCL
273 30mg/30mL Inj Sol-30mL Pk 00155357 Adrenalin ERF 16.1000 16.1000
FORMOTEROL FUMARATE
274 12mcg/Cap Inh Pd-Device Pk 02230898 Foradil Reason for Use Code Clinical criteria D ION D I E For the treatment ofTAT in patients who are using 132T IM USE anti-inflammatory treatmentE are still experiencing N asthma UIR and optimum L breakthrough symptoms. Q ME E U NOTE: not OC This drug isR for relief of acute symptoms. D LU Authorization Period: Indefinite. NOV 46.9500 46.9500
FORMOTEROL FUMARATE DIHYDRATE

275 276 6mcg/Metered Dose Pd Inh-60 Dose Pk 02237225 Oxeze Turbuhaler AZC AZC 32.7000 32.7000 43.5500 43.5500
12mcg/Metered Dose Pd Inh-60 Dose Pk 02237224 Oxeze Turbuhaler Reason for Use Code 132 Clinical criteria
D ION D ITE E AT RE NT UI LIM US ME EQ CU R O D

NOTE: This drug is not for relief of acute symptoms. LU Authorization Period: Indefinite.
For the treatment of asthma in patients who are using optimum anti-inflammatory treatment and are still experiencing breakthrough symptoms.
IIIA.60
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ISOPROTERENOL HCL
277
N ED IT E IO IM US AT L NT D E E UM IR OC QU D RE
Reason for Use Code Clinical criteria 260 Children aged 6 years or less; LU Authorization Period: Indefinite. 261 Patients who have a tracheostomy; LU Authorization Period: Indefinite. 262 Patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. 263 Patients with severe mental or physical disabilities; LU Authorization Period: Indefinite. 264 LU Authorization Period: Indefinite.
0.5% Inh Sol-10mL Pk 02017652 Isuprel
SAO
8.4700 8.4700
JUNE 27, 2008
IIIA.61
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ORCIPRENALINE SULFATE
278 2mg/mL O/L 00249920 02192675 02236783 .0302 Alupent (Not a Benefit) Tanta Orciprenaline Apo-Orciprenaline BOE TAN APX .0302 .0302
PSEUDOEPHEDRINE HCL
279 6mg/mL O/L 00004561 00425516 60mg Tab 00004766 00342726 Sudafed (Not a Benefit) Robidrine (Not a Benefit) Sudafed (Not a Benefit) Robidrine (Not a Benefit) BWE WHB BWE WHB
280
IIIA.62
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SALBUTAMOL
281 1mg/mL Inh Sol-2.5mL Pk 02213419 Ventolin Nebules P.F. 01926934 Gen-Salbutamol Sterinebs P.F. 01986864 Ratio-Salbutamol Respirator Sol P.F. 02208229 PMS-Salbutamol 02231488 # Apo-Salvent Sterule Reason for Use Code Clinical criteria GSK GEN .4828 1.0094 .4828 .4828 .4828 .4828
RPH PMS APX 265 Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have a tracheostomy; LU Authorization Period: Indefinite. 266 Individuals must have a known hypersensitivity to the preservative in the bulk solution, and be patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. 267 Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have severe mental or physical disabilities; LU Authorization Period: Indefinite. 268 Patients who have previously used nebulizer therapy within the last 12 month period. LU Authorization Period: Indefinite.
ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX JUNE 27, 2008
IIIA.63
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SALBUTAMOL
282 2mg/mL Inh Sol-2.5mL Pk 02213427 Ventolin Nebules P.F. 02173360 Gen-Salbutamol 02208237 PMS-Salbutamol 02231678 # Apo-Salvent Sterule 02239366 Ratio-Salbutamol Reason for Use Code Clinical criteria GSK GEN PMS APX RPH .9173 1.9180 .9173 .9173 .9173 .9173
265 LU Authorization Period: Indefinite. 266 LU Authorization Period: Indefinite. 267 LU Authorization Period: Indefinite. 268 Patients who have previously used nebulizer therapy within the last 12 month period. LU Authorization Period: Indefinite.
IIIA.64 ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX
Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have a tracheostomy;
Individuals must have a known hypersensitivity to the preservative in the bulk solution, and be patients with cystic fibrosis in whom nebulizer therapy is indicated;
Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have severe mental or physical disabilities;
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SALBUTAMOL
283 5mg/mL Inh Sol-10mL Pk 02213486 Ventolin 00860808 Ratio-Salbutamol Respirator Sol 02069571 PMS-Salbutamol Respirator Solution 02154412 Sandoz Salbutamol 02232987 Gen-Salbutamol Reason for Use Code Clinical criteria GSK RPH PMS SDZ GEN 4.6850 9.7963 4.6850 4.6850 4.6850 4.6850
ED IT E N IM S IO L U TAT N D E M IRE CU QU O D RE
256 Patients who have a tracheostomy; LU Authorization Period: Indefinite. 257 Patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. 258 Patients with severe mental or physical disabilities; LU Authorization Period: Indefinite. 259 Patients who have previously used nebulizer therapy within the last 12 month period. LU Authorization Period: Indefinite.
JUNE 27, 2008
IIIA.65
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SALBUTAMOL
284 100mcg/Metered Dose Inh-200 Dose Pk 02213478 Ventolin (Not a Benefit) 00790419 Apo-Salvent (Not a Benefit) 00851841 Ratio-Salbutamol Inhaler (Not a Benefit) 00874086 Novo-Salmol (Not a Benefit) 02232570 Airomir HFA (Not a Benefit) 02244914 Ratio-Salbutamol HFA 02245669 Apo-Salvent CFC Free 0.4mg/mL O/L 02212390 02091186 2mg Tab 01961039 02146843 4mg Tab 01932691 02146851 Ventolin PMS-Salbutamol Ventolin (Not a Benefit) Apo-Salvent Ventolin (Not a Benefit) Apo-Salvent 7.7300 GLW APX RPH NOP MMH RPH APX GSK PMS GLA APX GLA APX
7.7300 7.7300 .0476 .0711 .0476 .0990 .0990 .1655 .1655
285
286
287
IIIA.66
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SALMETEROL XINAFOATE
288 289 50mcg/Blister Diskhaler-60 Disk Pk 02214261 SereVent Diskhaler Disks 50mcg Pd Inh-60 Dose Pk 02231129 SereVent Diskus Reason for Use Code 132 Clinical criteria GSK GSK 54.8051 54.8051 54.8051 54.8051
ED ON IT E TI M S LI U TA ED EN IR UM QU OC RE D
NOTE: This drug is not for relief of acute symptoms. LU Authorization Period: Indefinite. 391 LU Authorization Period: Indefinite.
For patients with moderate to severe COPD with persistent respiratory symptoms despite an adequate trial of, or an intolerance to, a regularly scheduled short-acting bronchodilator AND a long-acting anticholinergic.
JUNE 27, 2008
IIIA.67
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SALMETEROL XINAFOATE & FLUTICASONE PROPIONATE

290 291 292 293 294 25/125mcg/Metered Dose Inh-120 Dose Pk 02245126 Advair 125 25/250mcg/Metered Dose Inh-120 Dose Pk 02245127 Advair 250 50/100mcg Inh-60 Dose Pk 02240835 Advair Diskus 50/250mcg Inh-60 Dose Pk 02240836 Advair Diskus 50/500mcg Inh-60 Dose Pk 02240837 Advair Diskus Reason for Use Code 330 GSK GSK GSK GSK GSK 93.7814 93.7814
Clinical criteria LU Authorization Period: Indefinite. AZC
133.1235 133.1235 78.3393 78.3393 93.7814 93.7814
133.1235 133.1235
TERBUTALINE SULFATE
295 0.5mg/Dose Inh-200 Dose Pk 00786616 Bricanyl Turbuhaler 14.7000 14.7000
IIIA.68
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

12:16:00 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS
Note: Ergotamine is the drug of choice in the treatment of acute attacks of migraine. It may also alleviate or prevent acute attacks of cluster headache in some patients. The addition of caffeine or pentobarbital have not been proven to result in greater efficacy.
ERGOTAMINE TARTRATE & CAFFEINE

296 1mg & 100mg Tab 00176095 Cafergot NOV .7526 .7526
METHYSERGIDE BIMALEATE
297 2mg Tab 00027499 Sansert NOV .9616 .9616
Note: Fibrosis (retroperitoneal and pleuropulmonary) occurs rarely with prolonged therapy. Daily dose should not exceed 8mg, and duration of therapy should not exceed six months in a single course of therapy. It should be reserved for migraine headache prophylaxis not responsive to other prophylactic agents (e.g., beta blockers).
PIZOTYLINE
298 299 0.5mg Tab 00329320 1mg Tab 00511552 Sandomigran Sandomigran DS SQI SQI .3581 .3581 .5946 .5946
12:20:00 SKELETAL MUSCLE RELAXANTS

Note: Muscle relaxants, other than baclofen and dantrolene sodium, are not indicated for spasticity due to cerebral palsy, multiple sclerosis, spinal cord injury, etc.
BACLOFEN
300 10mg Tab 00455881 02063735 02088398 02136090 02139332 02236507 Lioresal PMS-Baclofen Gen-Baclofen Nu-Baclo Apo-Baclofen Ratio-Baclofen NOV PMS GEN NXP APX RPH .2311 .6075 .2311 .2311 .2311 .2311 .2311
JUNE 27, 2008
IIIA.69
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

Note: Muscle relaxants, other than baclofen and dantrolene sodium, are not indicated for spasticity due to cerebral palsy, multiple sclerosis, spinal cord injury, etc.
BACLOFEN
301 20mg Tab 00636576 02063743 02088401 02136104 02139391 02236508 Lioresal DS PMS-Baclofen Gen-Baclofen Nu-Baclo Apo-Baclofen Ratio-Baclofen NOV PMS GEN NXP APX RPH .4498 1.1824 .4498 .4498 .4498 .4498 .4498
CYCLOBENZAPRINE HCL
302 10mg Tab 00782742 02080052 02171848 02177145 02212048 02231353 02236506 Flexeril (Not a Benefit) Novo-Cycloprine (Not a Benefit) Nu-Cyclobenzaprine (Not a Benefit) Apo-Cyclobenzaprine (Not a Benefit) PMS-Cyclobenzaprine (Not a Benefit) Gen-Cycloprine (Not a Benefit) Ratio-Flexitec (Not a Benefit) FRS NOP NXP APX PMS GEN RPH
DANTROLENE SODIUM
303 304 25mg Cap 01997602 100mg Cap 01997653 Dantrium Dantrium PGP PGP .3780 .3780 .7684 .7684
ORPHENADRINE CITRATE
305 60mg/2mL Inj Sol-2mL Pk 01966162 Norflex (Not a Benefit) 02229731 Orphenadrine (Not a Benefit) MMH CYI
IIIA.70
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
20:00 BLOOD FORMATION AND COAGULATION

20:04:00 ANTIANEMIA DRUGS
FERROUS FUMARATE
306 300mg Cap 01923420 02237556 60mg/mL O/L 01923439 Palafer Euro-Fer Palafer GSK EUR GSK .1234 .1996 .1234 .0849 .0849
307
FERROUS GLUCONATE
308 * 300mg Tab 00031097 00021458 00545031 .0212 Ferrous Gluconate (Not a Benefit) RPR Novo-Ferrogluc NOP Apo-Ferrous Gluconate APX .0212 .0212
FERROUS SULFATE
309 75mg/mL O/L 00762954 Fer-In-Sol MJS .2436 .2436
JUNE 27, 2008
IIIA.71
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

20:12:00 COAGULANTS AND ANTI-COAGULANTS
DALTEPARIN SODIUM
310 311 312 313 314 315 316 317 2500IU/0.2mL Inj Pref Syr 02132621 Fragmin 5000IU/0.2mL Inj Pref Syr 02132648 Fragmin 10000IU/0.4mL Inj Pref Syr 09853790 Fragmin 12500IU/0.5mL Inj Pref Syr 09853820 Fragmin 15000IU/0.6mL Inj Pref Syr 09853880 Fragmin 18000IU/0.72mL Inj Pref Syr 09853910 Fragmin 10000IU/mL Inj Sol-1mL Pk 02132664 Fragmin PFI PFI PFI PFI PFI PFI PFI PFI 4.9400 4.9400 9.8280 9.8280
D TE I IM SE ION L U AT NT E M ED U C IR O QU D E R
19.7600 19.7600 24.7000 24.7000 29.6400 29.6400 35.5680 35.5680 15.6000 15.6000 25000IU/mL Multidose 3.8mL Pk 02231171 Fragmin Reason for Use Code 186 148.2000 148.2000 Clinical criteria For acute treatment of deep venous thrombosis (DVT), for a maximum of three weeks; LU Authorization Period: 1 year. 187 For DVT in pregnant or lactating females; LU Authorization Period: 1 year. 188 For DVT in patients whom treatment with warfarin is not tolerated, or contraindicated; LU Authorization Period: 1 year. 189 For DVT in patients who have failed treatment with warfarin. LU Authorization Period: 1 year.
IIIA.72
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ENOXAPARIN
318 319 320 321 322 323 324 325 100mg/mL Inj Sol-3mL Vial Pk 02236564 Lovenox 30mg/0.3mL Pref Syr-0.3mL Pk 02012472 Lovenox 40mg/0.4mL Pref Syr-0.4mL Pk 02236883 Lovenox 60mg/0.6mL Pref Syr-0.6mL Pk 09852468 Lovenox 80mg/0.8mL Pref Syr-0.8mL Pk 09852476 Lovenox SAV SAV SAV SAV SAV SAV SAV SAV 61.5000 61.5000 6.1900 6.1900 8.2000 8.2000
ED IT IM SE ION L U T TA EN D M E U C IR DO EQU R
12.3000 12.3000 16.4000 16.4000 24.6000 24.6000 20.5000 20.5000 30.7500 30.7500 120mg/0.8mL Pref Syr-0.8mL Pk 09857137 Lovenox HP 100mg/mL Pref Syr-1mL Pk 09852484 Lovenox 150mg/mL Pref Syr-1mL Pk 02242692 Lovenox HP Reason for Use Code 186 Clinical criteria For acute treatment of deep venous thrombosis (DVT), for a maximum of three weeks; LU Authorization Period: 1 year. 187 For DVT in pregnant or lactating females; LU Authorization Period: 1 year. 188 For DVT in patients whom treatment with warfarin is not tolerated, or contraindicated; LU Authorization Period: 1 year. 189 For DVT in patients who have failed treatment with warfarin. LU Authorization Period: 1 year. 323 For the acute treatment of pulmonary embolism, maximum of three weeks. LU Authorization Period: 1 year.
JUNE 27, 2008
IIIA.73
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FONDAPARINUX SODIUM
326 2.5mg Inj-0.5mL Pk 02245531 Arixtra Reason for Use Code GSK 15.0761 15.0761
Clinical criteria D ION D ITE For the post-operativeAT IRE thromboembolic 378 E IM NT prophylaxis of venous events in patients undergoing orthopedic surgery of the lower L U E US UMas hip fracture, hip replacement or knee surgery. limbs such EQ NOTE: 9 days OC Limited to R of reimbursement. D LU Authorization Period: 1 year.
HEPARIN SODIUM
327 328 10000USP U/10mL Inj Sol-10mL Pk 00740519 Hepalean 50000USP U/5mL Inj Sol-5mL Pk 00740497 Hepalean ORG ORG 3.5000 3.5000 5.8900 5.8900
IIIA.74
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

NADROPARIN CALCIUM
329 330 331 332 333 334 335 336 9500IU/mL Pref Syr-0.3mL Pk 09853936 Fraxiparine 9500IU/mL Pref Syr-0.4mL Pk 09853944 Fraxiparine 9500IU/mL Pref Syr-0.6mL Pk 09853952 Fraxiparine GSK GSK GSK GSK GSK GSK GSK GSK 9.3572 9.3572 9.3572 9.3572 9.3572 9.3572
D TE I IM SE ION L U AT T N E M ED U C IR O QU D E R
19000IU/mL Pref Syr-0.6mL Pk 02240114 Fraxiparine Forte 9500IU/mL Pref Syr-0.8mL Pk 09853979 Fraxiparine 18.7145 18.7145 9.3572 9.3572 19000IU/mL Pref Syr-0.8mL Pk 09854100 Fraxiparine Forte 9500IU/mL Pref Syr-1.0mL Pk 09853987 Fraxiparine 18.7145 18.7145 9.3572 9.3572 19000IU/mL Pref Syr-1.0mL Pk 09854118 Fraxiparine Forte Reason for Use Code 186 Clinical criteria 18.7145 18.7145 For acute treatment of deep venous thrombosis (DVT), for a maximum of three weeks; LU Authorization Period: 1 year. 187 For DVT in pregnant or lactating females; LU Authorization Period: 1 year. 188 For DVT in patients whom treatment with warfarin is not tolerated, or contraindicated; LU Authorization Period: 1 year. 189 For DVT in patients who have failed treatment with warfarin. LU Authorization Period: 1 year.
JUNE 27, 2008
IIIA.75
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TINZAPARIN SODIUM
337 338 339 340 341 342 343 10000IU/mL Inj-2mL Pk 02167840 Innohep 20000IU/mL Inj-2mL Pk 02229515 Innohep 3500IU/0.35mL Inj Pref Syr 02229755 Innohep 4500IU/0.45mL Inj Pref Syr 09853898 Innohep 10000IU/0.5mL Inj Pref Syr 02231478 Innohep 14000IU/0.7mL Inj Pref Syr 09853901 Innohep 18000IU/0.9mL Inj Pref Syr 09853928 Innohep Reason for Use Code 186 LEO LEO LEO LEO LEO LEO LEO 32.0000 32.0000 64.0000 64.0000 5.6450 5.6450 7.2580 7.2580
16.0000 16.0000 22.4000 22.4000 28.8000 28.8000 Clinical criteria For acute treatment of deep venous thrombosis (DVT), for a maximum of three weeks; LU Authorization Period: 1 year. LU Authorization Period: 1 year. For DVT in pregnant or lactating females; 187 188 For DVT in patients whom treatment with warfarin is not tolerated, or contraindicated; LU Authorization Period: 1 year. LU Authorization Period: 1 year. 323 For the acute treatment of pulmonary embolism, maximum of three weeks. LU Authorization Period: 1 year. For DVT in patients who have failed treatment with warfarin. 189
IIIA.76
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

WARFARIN
Note: The use of International Normalized Ratio (INR) instead of Prothrombin Time results to control warfarin dosing is strongly recommended. Prothrombin Time results can vary three-fold depending on the reagent used; INR corrects for this and substantially improves safety and efficacy of warfarin therapy. 344 1mg Tab 01918311 02242680 02242924 02244462 02265273 2mg Tab 01918338 02242681 02242925 02244463 02265281 2.5mg Tab 01918346 02242682 02242926 02244464 02265303 3mg Tab 02240205 02242683 02245618 02265311 02287498 4mg Tab 02007959 02242684 02242927 02244465 02265338 Coumadin Taro-Warfarin Apo-Warfarin Gen-Warfarin Novo-Warfarin Coumadin Taro-Warfarin Apo-Warfarin Gen-Warfarin Novo-Warfarin Coumadin Taro-Warfarin Apo-Warfarin Gen-Warfarin Novo-Warfarin Coumadin Taro-Warfarin Apo-Warfarin Novo-Warfarin Gen-Warfarin Coumadin Taro-Warfarin Apo-Warfarin Gen-Warfarin Novo-Warfarin BQU TAR APX GEN NOP BQU TAR APX GEN NOP BQU TAR APX GEN NOP BQU TAR APX NOP GEN BQU TAR APX GEN NOP .1415 .3029 .1415 .1415 .1415 .1415 .1496 .3203 .1496 .1496 .1496 .1496 .1198 .2564 .1198 .1198 .1198 .1198 .1855 .3971 .1855 .1855 .1855 .1910 .1855 .3971 .1855 .1855 .1855 .1855
345
346
347
348
JUNE 27, 2008
IIIA.77
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

WARFARIN
Note: The use of International Normalized Ratio (INR) instead of Prothrombin Time results to control warfarin dosing is strongly recommended. Prothrombin Time results can vary three-fold depending on the reagent used; INR corrects for this and substantially improves safety and efficacy of warfarin therapy. 349 5mg Tab 01918354 02242685 02242928 02244466 02265346 10mg Tab 01918362 02242687 02242929 02244467 Coumadin Taro-Warfarin Apo-Warfarin Gen-Warfarin Novo-Warfarin Coumadin Taro-Warfarin Apo-Warfarin Gen-Warfarin BQU TAR APX GEN NOP BQU TAR APX GEN .1200 .2569 .1200 .1200 .1200 .1200 .2153 .4610 .2153 .2153 .2153
350
IIIA.78
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

20:16:00 HEMATOPOIETIC AGENTS
DARBEPOETIN ALFA
351 352 353 354 150mcg/0.3mL Pref Syr-0.3mL Pk 02246360 Aranesp 200mcg/0.4mL Pref Syr-0.4mL Pk 09857185 Aranesp 300mcg/0.6mL Pref Syr-0.6mL Pk 09857186 Aranesp 500mcg/1.0mL Pref Syr-1.0mL Pk 09857187 Aranesp AMG AMG AMG AMG 402.0000 402.0000 536.0000 536.0000 828.0000 828.0000 1,380.0000 1,380.0000
NOTE: These products must be prescribed based on the following criteria: For the treatment of chemotherapy-induced anemia in patients with malignant cancer undergoing myelosuppressive chemotherapy with a hemoglobin count of less than 100g/L and MCV level between 75fL and 120fL. NOTE: Darbepoietin therapy should be re-assessed after 3 months of therapy and should not be continued for those patients who do not respond to therapy (i.e. Hgb level has not improved by at least 15g/L or transfusions were required after first 2 weeks of therapy) or who are no longer anemic. The following dosage regimens for Aranesp are recommended by the Committee to Evaluate Drugs: I. 200mcg q2weekly x 6 weeks, then increase to 300mcg q2weekly if inadequate response; OR II. 500mcg q3weekly x maximum duration of 3 cycles, then decrease to 300mcg q3weekly for maintenance; OR III. 150mcg qweekly.
JUNE 27, 2008
IIIA.79
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

20:16:00 HEMATOPOIETIC AGENTS
RECOMBINANT HUMAN ERYTHROPOIETIN (R-HUEPO)
355 356 357 20,000IU/mL Inj Sol-1mL Vial Pk 02206072 Eprex 10,000IU/mL Pref Syr-1mL Pk 02231587 Eprex 40,000IU/mL Pref Syr-1mL Pk 02240722 Eprex JNO JNO JNO 267.9000 267.9000 142.5000 142.5000 401.8500 401.8500
NOTE: These products must be prescribed based on the following criteria: For the treatment of chemotherapy-induced anemia in patients with malignant cancer undergoing myelosuppressive chemotherapy with a hemoglobin count of less than 100g/L and MCV level between 75fL and 120fL. NOTE: Erythropoietin therapy should be re-assessed after 3 months of therapy and should not be continued for those patients who do not respond to therapy (i.e. Hgb level has not improved by at least 15g/L or transfusions were required after first 2 weeks of therapy or who are no longer anemic. The following dosage regimens for Eprex are recommended by the Committee to Evaluate Drugs: I. II. 150 IU/kg subcutaneously 3 times a week for 4 weeks. If no response, the dose may be increased to 300 IU/kg subcutaneously 3 times a week; OR 40,000 IU once weekly. If no response after 4 weeks, the dose may be increased to 60,000 IU once weekly for 4 weeks.
IIIA.80
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

20:24:00 HEMORRHEOLOGIC AGENTS
PENTOXIFYLLINE
358 400mg SR Tab 02221977 01968432 02230090 02230401 Reason for Use Code 76 .3046 .7424 .3046 .3046 .3046
ON ED TI D IT E IM S TA RE L U MEN UI CU REQ DO
Trental Ratio-Pentoxifylline Apo-Pentoxifylline Nu-Pentoxifylline
SAV RPH APX NXP
For the treatment of patients with critical limb ischemia (with arterial ulcers, gangrene and/or rest pain) and documented arterial vascular disease. NOTE: Limited Use form must specify if arterial ulcers, gangrene and/or rest pain are present.
JUNE 27, 2008
IIIA.81
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
24:00 CARDIOVASCULAR DRUGS

24:04:00 CARDIAC DRUGS
ACEBUTOLOL HCL
359 100mg Tab 01910140 01926543 02036290 02147602 02165546 02204517 02237721 02237885 02257599 200mg Tab 01910159 01926551 02036436 02147610 02165554 02204525 02237722 02237886 02257602 400mg Tab 01910167 01926578 02036444 02147629 02165562 02204533 02237723 02237887 02257610 Rhotral Sectral Monitan (Not a Benefit) Apo-Acebutolol Nu-Acebutolol Novo-Acebutolol Gen-Acebutolol Gen-Acebutolol (Type S) Sandoz Acebutolol Rhotral Sectral Monitan (Not a Benefit) Apo-Acebutolol Nu-Acebutolol Novo-Acebutolol Gen-Acebutolol Gen-Acebutolol (Type S) Sandoz Acebutolol Rhotral Sectral Monitan (Not a Benefit) Apo-Acebutolol Nu-Acebutolol Novo-Acebutolol Gen-Acebutolol Gen-Acebutolol (Type S) Sandoz Acebutolol SAV SAV WAY APX NXP NOP GEN GEN SDZ SAV SAV WAY APX NXP NOP GEN GEN SDZ SAV SAV WAY APX NXP NOP GEN GEN SDZ .1294 .1294 .2996 .1294 .1294 .1294 .1294 .1294 .1294 .1936 .1936 .4484 .1936 .1936 .1936 .1936 .1936 .1936 .3847 .3847 .9392 .3847 .3847 .3847 .3847 .3847 .3847 .26 .26 .60 .26 .26 .26 .26 .26 .26 .39 .39 .90 .39 .39 .39 .39 .39 .39 .77 .77 1.88 .77 .77 .77 .77 .77 .77
360
361
JUNE 27, 2008
IIIA.83
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

AMIODARONE HCL
362 200mg Tab 02036282 02239835 02240071 02240604 02242472 02243836 02246194 Cordarone Novo-Amiodarone Ratio-Amiodarone Gen-Amiodarone PMS-Amiodarone Sandoz Amiodarone Apo-Amiodarone WAY NOP RPH GEN PMS SDZ APX 1.0295 2.0589 1.0295 1.0295 1.0295 1.0295 1.0295 1.0295
Note: The manufacturer recommends that treatment with amiodarone be initiated in hospital and continued in a monitored environment under the care of a cardiologist, or internist with equivalent experience in such care.
AMLODIPINE
363 364 5mg Tab 00878928 10mg Tab 00878936 Norvasc Norvasc PFI PFI 1.3312 1.3312 1.9760 1.9760 1.33 1.33 1.98 1.98
ATENOLOL
365 50mg Tab 02039532 00773689 00886114 01912062 02146894 02171791 02231731 02237600 02255545 02267985 Tenormin Apo-Atenol Nu-Atenol Novo-Atenol Gen-Atenolol Ratio-Atenolol Sandoz Atenolol PMS-Atenolol Co-Atenolol Ran-Atenolol AZC APX NXP NOP GEN RPH SDZ PMS COB RAN .2790 .5746 .2790 .2790 .2790 .2790 .2790 .2790 .2790 .2790 .2790 .28 .57 .28 .28 .28 .28 .28 .28 .28 .28 .28
IIIA.84
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ATENOLOL
366 100mg Tab 02039540 00773697 00886122 01912054 02147432 02171805 02231733 02237601 02255553 02267993 Tenormin Apo-Atenol Nu-Atenol Novo-Atenol Gen-Atenolol Ratio-Atenolol Sandoz Atenolol PMS-Atenolol Co-Atenolol Ran-Atenolol AZC APX NXP NOP GEN RPH SDZ PMS COB RAN .4586 .9446 .4586 .4586 .4586 .4586 .4586 .4586 .4586 .4586 .4586 .46 .94 .46 .46 .46 .46 .46 .46 .46 .46 .46
BISOPROLOL FUMARATE
367 5mg Tab 02241148 02247439 02256134 02267470 02302632 10mg Tab 02241149 02247440 02256177 02267489 02302640 Monocor Sandoz Bisoprolol Apo-Bisoprolol Novo-Bisoprolol PMS-Bisoprolol Monocor Sandoz Bisoprolol Apo-Bisoprolol Novo-Bisoprolol PMS-Bisoprolol BIO SDZ APX NOP PMS CRY SDZ APX NOP PMS .1750 .3974 .1750 .1750 .1750 .1750 .2900 .5800 .2900 .2900 .2900 .2900
368
JUNE 27, 2008
IIIA.85
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CARVEDILOL
369 3.125mg Tab 02229650 02245914 02247933 02252309 02268027 6.25mg Tab 02229651 02245915 02247934 02252317 02268035 12.5mg Tab 02229652 02245916 02247935 02252325 02268043 25mg Tab 02229653 02245917 02247936 02252333 02268051 Reason for Use Code .6350 Coreg (Not a Benefit) PMS-Carvedilol Apo-Carvedilol Ratio-Carvedilol Ran-Carvedilol Coreg (Not a Benefit) PMS-Carvedilol Apo-Carvedilol Ratio-Carvedilol Ran-Carvedilol Coreg (Not a Benefit) PMS-Carvedilol Apo-Carvedilol Ratio-Carvedilol Ran-Carvedilol Coreg (Not a Benefit) PMS-Carvedilol Apo-Carvedilol Ratio-Carvedilol Ran-Carvedilol GSK PMS APX RPH RAN GSK PMS APX RPH RAN GSK PMS APX RPH RAN GSK PMS APX RPH RAN .6350 .6350 .6350 .6350 1.27 1.27 1.27 1.27 1.27
370
371
372
D TE I IM SE ION L U AT T EN D M U RE C O QUI D RE
.6350 1.27 1.27 1.27 1.27 1.27 .6350 .6350 .6350 .6350 .6350 1.27 1.27 1.27 1.27 1.27 .6350 .6350 .6350 .6350 .6350 1.27 1.27 1.27 1.27 1.27 .6350 .6350 .6350 .6350 Clinical criteria For patients with: 183 LU Authorization Period: Indefinite.
a) NYHA Class II or III Congestive Heart Failure (CHF); and b) Currently being treated with an angiotension converting enzyme (ACE) inhibitor, diuretics with or without digoxin, or previously treated, and failed these agents; and c) An ejection fraction less than or equal to 35%; and d) At least one episode of symptomatic CHF within a 12 month period while receiving optimal management.
IIIA.86
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DIGOXIN
Note: Digoxin toxicity is common and serious: digoxin levels should be monitored in the elderly, after adding drugs that affect urea clearance including diuretics, particularly spironolactone; verapamil and quinidine also interact significantly with digoxin. Dose should be reduced in renal impairment and in elderly patients. Chronic therapy should be re-evaluated. 373 374 0.05mg/mL O/L 02242320 0.0625mg Tab 02242321 02245426 02281236 0.125mg Tab 02242322 02245427 02281228 0.25mg Tab 02242323 02245428 02281201 Lanoxin Lanoxin PMS-Digoxin Apo-Digoxin Lanoxin PMS-Digoxin Apo-Digoxin Lanoxin PMS-Digoxin Apo-Digoxin VRO VRO PMS APX VRO PMS APX VRO PMS APX .3561 .3561 .1089 .2177 .1089 .1089 .1030 .2060 .1030 .1030 .1030 .2060 .1030 .1030
375
376
DILTIAZEM HCL
377 378 379 380 381 382 120mg ER Tab 02256738 180mg ER Tab 02256746 240mg ER Tab 02256754 300mg ER Tab 02256762 360mg ER Tab 02256770 120mg LA Cap 02097249 02229781 02230997 02242538 02243338 02254808 Tiazac XC Tiazac XC Tiazac XC Tiazac XC Tiazac XC Cardizem CD Ratio-Diltiazem CD Apo-Diltiaz CD Novo-Diltazem CD Sandoz Diltiazem CD Gen-Diltiazem CD BIO BIO BIO BIO BIO BIO RPH APX NOP SDZ GEN .7681 .7681 1.0195 1.0195 1.3523 1.3523 1.3523 1.3523 1.3523 1.3523 .6366 1.3703 .6366 .6366 .6366 .6366 .6366 .64 1.37 .64 .64 .64 .64 .64
JUNE 27, 2008
IIIA.87
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DILTIAZEM HCL
383 180mg LA Cap 02097257 02229782 02230998 02242539 02243339 02254816 240mg LA Cap 02097265 02229783 02230999 02242540 02243340 02254824 300mg LA Cap 02097273 02229526 02229784 02242541 02243341 02254832 60mg LA Cap 02097214 02222957 90mg LA Cap 02097222 02222965 120mg LA Cap 02097230 02222973 120mg SR Cap 02231150 02245918 02271605 Cardizem CD Ratio-Diltiazem CD Apo-Diltiaz CD Novo-Diltazem CD Sandoz Diltiazem CD Gen-Diltiazem CD Cardizem CD Ratio-Diltiazem CD Apo-Diltiaz CD Novo-Diltazem CD Sandoz Diltiazem CD Gen-Diltiazem CD Cardizem CD Apo-Diltiaz CD Ratio-Diltiazem CD Novo-Diltazem CD Sandoz Diltiazem CD Gen-Diltiazem CD Cardizem-SR (Not a Benefit) Apo-Diltiaz SR Cardizem-SR (Not a Benefit) Apo-Diltiaz SR Cardizem-SR (Not a Benefit) Apo-Diltiaz SR Tiazac Sandoz Diltiazem T Novo-Diltiazem HCL ER BIO RPH APX NOP SDZ GEN BIO RPH APX NOP SDZ GEN BIO APX RPH NOP SDZ GEN CRY APX CRY APX CRY APX BIO SDZ NOP .8450 1.8190 .8450 .8450 .8450 .8450 .8450 1.1208 2.4127 1.1208 1.1208 1.1208 1.1208 1.1208 1.4010 3.0159 1.4010 1.4010 1.4010 1.4010 1.4010 .3635 .3635 .5455 .5455 .7270 .7270 .4043 .8533 .4043 .4043 .85 1.82 .85 .85 .85 .85 .85 1.12 2.41 1.12 1.12 1.12 1.12 1.12 1.40 3.02 1.40 1.40 1.40 1.40 1.40 .36 .36 .55 .55 .73 .73 .40 .85 .40 .40
384
385
386
387
388
389
IIIA.88
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DILTIAZEM HCL
390 180mg SR Cap 02231151 02245919 02271613 240mg SR Cap 02231152 02245920 02271621 300mg SR Cap 02231154 02245921 02271648 360mg SR Cap 02231155 02245922 02271656 30mg Tab 02097370 00771376 00862924 00886068 02146916 60mg Tab 02097389 00771384 00862932 00886076 02146924 Tiazac Sandoz Diltiazem T Novo-Diltiazem HCL ER Tiazac Sandoz Diltiazem T Novo-Diltiazem HCL ER Tiazac Sandoz Diltiazem T Novo-Diltiazem HCL ER Tiazac Sandoz Diltiazem T Novo-Diltiazem HCL ER Cardizem Apo-Diltiaz Novo-Diltazem Nu-Diltiaz # Gen-Diltiazem Cardizem Apo-Diltiaz Novo-Diltazem Nu-Diltiaz # Gen-Diltiazem BIO SDZ NOP BIO SDZ NOP BIO SDZ NOP BIO SDZ NOP BIO APX NOP NXP GEN BIO APX NOP NXP GEN .5366 1.1386 .5366 .5366 .7118 1.5102 .7118 .7118 .8897 1.8878 .8897 .8897 1.0732 2.2771 1.0732 1.0732 .1866 .3715 .1866 .1866 .1866 .1866 .3273 .6516 .3273 .3273 .3273 .3273 .54 1.14 .54 .54 .71 1.51 .71 .71 .89 1.89 .89 .89 1.07 2.28 1.07 1.07
391
392
393
394
395
DISOPYRAMIDE
396 100mg Cap 02030799 02224801 150mg Cap 02030802 02224828 .2545 Norpace (Not a Benefit) Rythmodan Norpace (Not a Benefit) Rythmodan RBT SAV RBT SAV .2545 .3598 .3598
397
JUNE 27, 2008
IIIA.89
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLECAINIDE ACETATE
398 50mg Tab 01966197 02275538 100mg Tab 01966200 02275546 Tambocor Apo-Flecainide Tambocor Apo-Flecainide GRA APX GRA APX .3620 .5274 .3620 .7239 1.0549 .7239
399
METOPROLOL TARTRATE
400 100mg LA Tab 00658855 02285169 02303396 200mg LA Tab 00534560 02285177 02303418 50mg Tab 00397423 00402605 00618632 00648035 00749354 00842648 00865605 02174545 02230803 02247875 100mg Tab 00397431 00402540 00618640 00648043 00751170 00842656 00865613 02174553 02230804 02247876 Lopresor SR Apo-Metoprolol SR + Sandoz Metoprolol SR Lopresor SR Apo-Metoprolol SR + Sandoz Metoprolol SR Lopresor Betaloc Apo-Metoprolol Novo-Metoprol Apo-Metoprolol (Type L) Novo-Metoprol (Uncoated) Nu-Metop Gen-Metoprolol (Type L) PMS-Metoprolol-L Sandoz Metoprolol (Type L) Lopresor Betaloc Apo-Metoprolol Novo-Metoprol Apo-Metoprolol (Type L) Novo-Metoprol (Uncoated) Nu-Metop Gen-Metoprolol (Type L) PMS-Metoprolol-L Sandoz Metoprolol (Type L) NOV APX SDZ NOV APX SDZ NOV AZC APX NOP APX NOP NXP GEN PMS SDZ NOV AZC APX NOP APX NOP NXP GEN PMS SDZ .1415 .2830 .2021 .1415 .2568 .5135 .3668 .2568 .0968 .2376 .2315 .0968 .0968 .0968 .1080 .1080 .0968 .0968 .0968 .1747 .4291 .3965 .1747 .1747 .1747 .1830 .1830 .1747 .1747 .1747 .19 .48 .46 .19 .19 .19 .22 .22 .19 .19 .19 .35 .86 .79 .35 .35 .35 .37 .37 .35 .35 .35
401
402
403
IIIA.90
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MEXILETINE HCL
404 100mg Cap 00599956 02230359 200mg Cap 00599964 02230360 .8162 Mexitil (Not a Benefit) Novo-Mexiletine Mexitil (Not a Benefit) Novo-Mexiletine BOE NOP BOE NOP .8162 1.0930 1.0930
405
NADOLOL
406 40mg Tab 00607126 00782505 02126753 80mg Tab 00463256 00782467 02126761 160mg Tab 00523372 00782475 .2465 Corgard (Not a Benefit) Apo-Nadol Novo-Nadolol Corgard (Not a Benefit) Apo-Nadol Novo-Nadolol Corgard (Not a Benefit) Apo-Nadol BQU APX NOP BQU APX NOP BQU APX .2465 .2465 .3515 .3515 .3515 .6595 .6595 .25 .25 .25 .70 .70 .70 .66 .66
407
408
NIFEDIPINE
409 5mg Cap 02155869 00725110 10mg Cap 02155877 00755907 00865591 .2440 Adalat (Not a Benefit) Apo-Nifed Adalat (Not a Benefit) Apo-Nifed Nu-Nifed BAH APX BAH APX NXP .2440 .1858 .1858 .1858
410
Note: Rapid absorption of liquid nifedipine from pulvules can cause severe hypotension and aggravation of myocardial or cerebral ischemia.
JUNE 27, 2008
IIIA.91
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PROCAINAMIDE HCL
411 412 413 250mg LA Tab 00638692 500mg LA Tab 00638676 750mg LA Tab 00638684 Procan SR Procan SR Procan SR ERF ERF ERF .3500 .3500 .4500 .4500 .7000 .7000
PROPAFENONE HCL
414 150mg Tab 00603708 02243324 02243727 02245372 02294559 300mg Tab 00603716 02243325 02243728 02245373 02294575 Rythmol Apo-Propafenone # PMS-Propafenone Gen-Propafenone PMS-Propafenone Rythmol Apo-Propafenone # PMS-Propafenone Gen-Propafenone PMS-Propafenone ABB APX PMS GEN PMS ABB APX PMS GEN PMS .3395 1.0759 .3395 .3395 .3395 .3395 .5985 1.8964 .5985 .5985 .5985 .5985
415
PROPRANOLOL
416 10mg Tab 02042177 00402788 00496480 00582255 .0192 Inderal (Not a Benefit) Apo-Propranolol Novo-Pranol PMS-Propranolol WAY APX NOP PMS .0192 .0192 .0192
IIIA.92
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PROPRANOLOL
417 20mg Tab 02042193 00663719 00740675 40mg Tab 02042207 00402753 00496499 00582263 80mg Tab 02042215 00402761 00496502 00582271 120mg Tab 02042223 00504335 .0346 Inderal (Not a Benefit) Apo-Propranolol Novo-Pranol Inderal-40 (Not a Benefit) Apo-Propranolol Novo-Pranol PMS-Propranolol Inderal (Not a Benefit) Apo-Propranolol Novo-Pranol PMS-Propranolol Inderal (Not a Benefit) Apo-Propranolol WAY APX NOP AYE APX NOP PMS WAY APX NOP PMS WAY APX .0346 .0346 .0348 .0348 .0348 .0348 .0585 .0585 .0585 .0585 .1059 .1059 .07 .07 .07 .07 .12 .12 .12 .12 .21 .21
418
419
420
JUNE 27, 2008
IIIA.93
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SOTALOL HCL
421 160mg Tab 00483923 02084236 02163772 02167794 02229779 02231182 02234013 02238327 02257858 02270633 .6492 Sotacor (Not a Benefit) Ratio-Sotalol Nu-Sotalol Apo-Sotalol Gen-Sotalol Novo-Sotalol Rhoxal-Sotalol PMS-Sotalol Sandoz Sotalol Co Sotalol BQU RPH NXP APX GEN NOP SDZ PMS SDZ COB .6492 .6492 .6492 .6492 .6492 .6492 .6492 .6492 .6492
TIMOLOL MALEATE
422 5mg Tab 00353914 00755842 01947796 02044609 10mg Tab 00353922 00755850 01947818 02044617 20mg Tab 00495611 00755869 01947826 02044625 .1649 Blocadren (Not a Benefit) Apo-Timol Novo-Timol Nu-Timolol Blocadren (Not a Benefit) Apo-Timol Novo-Timol Nu-Timolol Blocadren (Not a Benefit) Apo-Timol Novo-Timol Nu-Timolol FRS APX NOP NXP FRS APX NOP NXP FRS APX NOP NXP .1649 .1649 .1649 .2572 .2572 .2572 .2572 .5005 .5005 .5005 .5005 .33 .33 .33 .33 .51 .51 .51 .51 1.00 1.00 1.00 1.00
423
424
VERAPAMIL HCL
425 80mg Tab 00554316 00782483 00886033 02237921 .2735 Isoptin (Not a Benefit) Apo-Verap Nu-Verap Gen-Verapamil ABB APX NXP GEN .2735 .2735 .2735 .82 .82 .82 .82
IIIA.94
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

VERAPAMIL HCL
426 120mg Tab 00554324 00782491 00886041 02237922 .4250 Isoptin (Not a Benefit) Apo-Verap Nu-Verap Gen-Verapamil ABB APX NXP GEN .4250 .4250 .4250 1.28 1.28 1.28 1.28
24:06:00 ANTILIPEMIC DRUGS

Note: Nicotinic acid is the most cost-effective therapy for hyperlipidemia and is tolerated in approximately 80% of patients with adequate warning about expected flushing which disappears after five days in most cases; regular ASA will substantially reduce flushing. Bile acid sequestrants are more costly than fibrates or HMG-CoA reductase inhibitors.
AMLODIPINE BESYLATE / ATORVASTATIN CALCIUM

427 428 429 430 431 432 433 434 5mg/10mg Tab 02273233 5mg/20mg Tab 02273241 5mg/40mg Tab 02273268 5mg/80mg Tab 02273276 10mg/10mg Tab 02273284 10mg/20mg Tab 02273292 10mg/40mg Tab 02273306 10mg/80mg Tab 02273314 Caduet Caduet Caduet Caduet Caduet Caduet Caduet Caduet PFI PFI PFI PFI PFI PFI PFI PFI 2.4500 2.4500 3.2000 3.2000 3.2000 3.2000 3.2000 3.2000 2.4500 2.4500 3.2000 3.2000 3.2000 3.2000 3.2000 3.2000
Note: Patients should be stabilized on a statin or a calcium channel blocker before being initiated on Caduet.
JUNE 27, 2008
IIIA.95
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ATORVASTATIN CALCIUM
435 436 437 438 10mg Tab 02230711 20mg Tab 02230713 40mg Tab 02230714 80mg Tab 02243097 Lipitor Lipitor Lipitor Lipitor PFI PFI PFI PFI 1.6640 1.6640 2.0800 2.0800 2.2360 2.2360 2.2360 2.2360
BEZAFIBRATE
439 440 400mg SR Tab 02083523 200mg Tab 02084082 02240331 Bezalip Bezalip (Not a Benefit) PMS-Bezafibrate HLR HLR PMS 1.6000 1.6000 .8833 .8833
CHOLESTYRAMINE RESIN
441 Oral Pd-42 Dose Pk 00634093 Questran (Not a Benefit) BQU 02141795 # PMS-Cholestyramine (Sugar Free) PMS 02207745 # PMS-Cholestyramine PMS Oral Pd-Pouch Pk 00464880 00890960 01918486 02210320 Questran 9g Pk (Not a Benefit) PMS-Cholestyramine Sugar Free 5g Pk Questran Light 4g Pk (Not a Benefit) PMS-Cholestyramine 9g Pk BQU PMS BQU PMS 1.3167 1.3167 19.9200 19.9200 19.9200 1.3167
442
IIIA.96
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CLOFIBRATE
443 500mg Cap 00002038 00337382 Atromid-S (Not a Benefit) Novo-Fibrate (Not a Benefit) AYE NOP
COLESTIPOL HCL
Note: Combining psyllium with Colestid therapy improves the efficacy, and decreases costs, of antilipemic treatment. 444 445 Gran-5g Pk 00642975 Gran-7.5g Pk 02132699 Colestid Regular Colestid Orange PFI PFI .8510 .8510 .8510 .8510
EZETIMIBE

Clinical criteria LU Authorization Period: Indefinite. 381 LU Authorization Period: Indefinite.
Ezetrol
MFS
1.6800 1.6800
For use in combination with a HMG-CoA reductase inhibitor (statin) in patients with hypercholesterolemia who have not reached target LDL levels despite the use of maximally tolerated doses. For use as monotherapy in the management of hypercholesterolemia in patients who are intolerant to HMG-CoA reductase inhibitors or where HMG-CoA reductase inhibitors are contraindicated.
JUNE 27, 2008
IIIA.97
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FENOFIBRATE
447 100mg Cap 00885827 02223600 02225980 200mg Cap 02146959 02239864 02240210 02243552 02250039 02273551 160mg Tab 02241602 02246860 02288052 02289091 48mg Tab 02269074 145mg Tab 02269082 .4325 Lipidil (Not a Benefit) Nu-Fenofibrate Apo-Fenofibrate Lipidil Micro Apo-Feno-Micro Gen-Fenofibrate Micro Novo-Fenofibrate Micronized Ratio-Fenofibrate MC PMS-Fenofibrate Micro Lipidil Supra Apo-Feno-Super Sandoz Fenofibrate S Novo-Fenofibrate-S Lipidil EZ Lipidil EZ JOU NXP APX SPH APX GEN NOP RPH PMS SPH APX SDZ NOP FOU FOU .4325 .4325 1.0890 1.0890 1.0890 1.0890 1.0890 1.0890 1.0890 .6231 1.2463 .6231 .6231 .6231 .4100 .4100 1.0500 1.0500
448
449
450 451
FLUVASTATIN SODIUM
452 453 454 20mg Cap 02061562 40mg Cap 02061570 80mg ER Tab 02250527 Lescol Lescol Lescol XL NOV NOV NOV .8426 .8426 1.1831 1.1831 1.4271 1.4271
IIIA.98
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

GEMFIBROZIL
455 300mg Cap 00599026 01979574 02185407 02239951 02241704 Lopid Apo-Gemfibrozil Gen-Gemfibrozil PMS-Gemfibrozil Novo-Gemfibrozil PFI APX GEN PMS NOP .2352 .4892 .2352 .2352 .2352 .2352
LOVASTATIN
456 20mg Tab 00795860 02220172 02243127 02245822 02246013 02246542 02247056 02248572 02267969 40mg Tab 00795852 02220180 02243129 02245823 02246014 02246543 02247057 02248573 02267977 Mevacor Apo-Lovastatin Gen-Lovastatin Ratio-Lovastatin PMS-Lovastatin Novo-Lovastatin Sandoz Lovastatin Co-Lovastatin Ran-Lovastatin Mevacor Apo-Lovastatin Gen-Lovastatin Ratio-Lovastatin PMS-Lovastatin Novo-Lovastatin Sandoz Lovastatin Co-Lovastatin Ran-Lovastatin MFC APX GEN RPH PMS NOP SDZ COB RAN MFC APX GEN RPH PMS NOP SDZ COB RAN .8657 1.9103 .8657 .8657 .8657 .8657 .8657 .8657 .8657 .8657 1.5968 3.5232 1.5968 1.5968 1.5968 1.5968 1.5968 1.5968 1.5968 1.5968
457
JUNE 27, 2008
IIIA.99
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PRAVASTATIN SODIUM
458 10mg Tab 00893749 02243506 02244350 02246930 02247008 02247655 02247856 02248182 02257092 02284421 20mg Tab 00893757 02243507 02244351 02246931 02247009 02247656 02247857 02248183 02257106 02284448 40mg Tab 02222051 02243508 02244352 02246932 02247010 02247657 02247858 02248184 02257114 02284456 Pravachol Apo-Pravastatin Nu-Pravastatin Ratio-Pravastatin Novo-Pravastatin PMS-Pravastatin Sandoz Pravastatin Co Pravastatin Gen-Pravastatin Ran-Pravastatin Pravachol Apo-Pravastatin Nu-Pravastatin Ratio-Pravastatin Novo-Pravastatin PMS-Pravastatin Sandoz Pravastatin Co Pravastatin Gen-Pravastatin Ran-Pravastatin Pravachol Apo-Pravastatin Nu-Pravastatin Ratio-Pravastatin Novo-Pravastatin PMS-Pravastatin Sandoz Pravastatin Co Pravastatin Gen-Pravastatin Ran-Pravastatin BQU APX NXP RPH NOP PMS SDZ COB GEN RAN BQU APX NXP RPH NOP PMS SDZ COB GEN RAN BQU APX NXP RPH NOP PMS SDZ COB GEN RAN .7567 1.6200 .7567 .7567 .7567 .7567 .7567 .7567 .7567 .7567 .7567 .8925 1.9111 .8925 .8925 .8925 .8925 .8925 .8925 .8925 .8925 .8925 1.0750 2.3019 1.0750 1.0750 1.0750 1.0750 1.0750 1.0750 1.0750 1.0750 1.0750
459
460
IIIA.100
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ROSUVASTATIN CALCIUM
461 462 463 464 5mg Tab 02265540 10mg Tab 02247162 20mg Tab 02247163 40mg Tab 02247164 Crestor Crestor Crestor Crestor AZC AZC AZC AZC 1.2900 1.2900 1.3600 1.3600 1.7000 1.7000 1.9900 1.9900
SIMVASTATIN
465 5mg Tab 00884324 02246582 02247011 02247067 02248103 02250144 02269252 10mg Tab 00884332 02246583 02247012 02247068 02247828 02248104 02250152 02265885 02269260 Zocor Gen-Simvastatin Apo-Simvastatin Ratio-Simvastatin Co-Simvastatin Novo-Simvastatin PMS-Simvastatin Zocor Gen-Simvastatin Apo-Simvastatin Ratio-Simvastatin Sandoz Simvastatin Co-Simvastatin Novo-Simvastatin Taro-Simvastatin PMS-Simvastatin MFC GEN APX RPH COB NOP PMS MFC GEN APX RPH SDZ COB NOP TAR PMS .4500 .9929 .4500 .4500 .4500 .4500 .4500 .4500 .8900 1.9643 .8900 .8900 .8900 .8900 .8900 .8900 .8900 .8900
466
JUNE 27, 2008
IIIA.101
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SIMVASTATIN
467 20mg Tab 00884340 02246737 02247013 02247069 02247830 02248105 02250160 02265893 02269279 40mg Tab 00884359 02246584 02247014 02247070 02247831 02248106 02250179 02265907 02269287 80mg Tab 02240332 02246585 02247015 02247071 02247833 02248107 02250187 02269295 Zocor Gen-Simvastatin Apo-Simvastatin Ratio-Simvastatin Sandoz Simvastatin Co-Simvastatin Novo-Simvastatin Taro-Simvastatin PMS-Simvastatin Zocor Gen-Simvastatin Apo-Simvastatin Ratio-Simvastatin Sandoz Simvastatin Co-Simvastatin Novo-Simvastatin Taro-Simvastatin PMS-Simvastatin Zocor Gen-Simvastatin Apo-Simvastatin Ratio-Simvastatin Sandoz Simvastatin Co-Simvastatin Novo-Simvastatin PMS-Simvastatin MFC GEN APX RPH SDZ COB NOP TAR PMS MFC GEN APX RPH SDZ COB NOP TAR PMS MFC GEN APX RPH SDZ COB NOP PMS 1.1000 2.4275 1.1000 1.1000 1.1000 1.1000 1.1000 1.1000 1.1000 1.1000 1.1000 2.4275 1.1000 1.1000 1.1000 1.1000 1.1000 1.1000 1.1000 1.1000 1.1000 2.4275 1.1000 1.1000 1.1000 1.1000 1.1000 1.1000 1.1000
468
469
IIIA.102
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

24:08:00 HYPOTENSIVE DRUGS (FOR DIURETICS SEE 40:28)
ATENOLOL & CHLORTHALIDONE
470 50 & 25mg Tab 02049961 02248763 02302918 100 & 25mg Tab 02049988 02248764 02302926 Tenoretic 50/25 Apo-Atenidone Novo-Atenolthalidone Tenoretic 100/25 Apo-Atenidone Novo-Atenolthalidone AZC APX NOP AZC APX NOP .3195 .6389 .4343 .3195 .5236 1.0471 .7118 .5236
471
BENAZEPRIL
472 5mg Tab 00885835 02290332 10mg Tab 00885843 02290340 20mg Tab 00885851 02273918 Lotensin Apo-Benazepril Lotensin Apo-Benazepril Lotensin Apo-Benazepril NOV APX NOV APX NOV APX .4722 .7082 .4722 .5583 .8375 .5583 .5460 .9607 .5460 .47 .71 .47 .56 .84 .56 .55 .96 .55
473
474
CANDESARTAN CILEXETIL
475 476 477 4mg Tab 02239090 8mg Tab 02239091 16mg Tab 02239092 Atacand Atacand Atacand AZC AZC AZC .6800 .6800 1.1400 1.1400 1.1400 1.1400
CANDESARTAN CILEXETIL & HYDROCHLOROTHIAZIDE

478 16mg/12.5mg Tab 02244021 Atacand Plus AZC 1.1400 1.1400
JUNE 27, 2008
IIIA.103
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CAPTOPRIL
479 12.5mg Tab 00695661 00893595 01913824 01942964 02163551 02230203 02242788 25mg Tab 00546283 00893609 01913832 01942972 02163578 02230204 02242789 50mg Tab 00546291 00893617 01913840 01942980 02163586 02230205 02242790 100mg Tab 00546305 00893625 01913859 01942999 02163594 02230206 02242791 Capoten Apo-Capto Nu-Capto Novo-Captopril Gen-Captopril PMS-Captopril Captopril Capoten Apo-Capto Nu-Capto Novo-Captopril Gen-Captopril PMS-Captopril Captopril Capoten Apo-Capto Nu-Capto Novo-Captopril Gen-Captopril PMS-Captopril Captopril # Capoten Apo-Capto Nu-Capto Novo-Captopril Gen-Captopril PMS-Captopril Captopril BQU APX NXP NOP GEN PMS ZYN BQU APX NXP NOP GEN PMS ZYN BQU APX NXP NOP GEN PMS ZYN BQU APX NXP NOP GEN PMS ZYN .2120 .2120 .2120 .2120 .2120 .2120 .2120 .2120 .3000 .3000 .3000 .3000 .3000 .3000 .3000 .3000 .5590 .5590 .5590 .5590 .5590 .5590 .5590 .5590 1.0395 1.0395 1.0395 1.0395 1.0395 1.0395 1.0395 1.0395 .64 .64 .64 .64 .64 .64 .64 .64 .90 .90 .90 .90 .90 .90 .90 .90 1.68 1.68 1.68 1.68 1.68 1.68 1.68 1.68
480
481
482
CILAZAPRIL
483 1mg Tab 01911465 02266350 02280442 02283778 02291134 Inhibace Novo-Cilazapril PMS-Cilazapril Gen-Cilazapril Apo-Cilazapril HLR NOP PMS GEN APX .2950 .6107 .2950 .2950 .2950 .2950
IIIA.104
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CILAZAPRIL
484 2.5mg Tab 01911473 02266369 02280450 02283786 02285215 02291142 5mg Tab 01911481 02266377 02280469 02283794 02285223 02291150 Inhibace Novo-Cilazapril PMS-Cilazapril Gen-Cilazapril Co Cilazapril Apo-Cilazapril Inhibace Novo-Cilazapril PMS-Cilazapril Gen-Cilazapril Co Cilazapril Apo-Cilazapril HLR NOP PMS GEN COB APX HLR NOP PMS GEN COB APX .3400 .7038 .3400 .3400 .3400 .3400 .3400 .3950 .8177 .3950 .3950 .3950 .3950 .3950 .34 .70 .34 .34 .34 .34 .34 .40 .82 .40 .40 .40 .40 .40
485
CILAZAPRIL & HYDROCHLOROTHIAZIDE

486 5mg/12.5mg Tab 02181479 02284987 Inhibace Plus Apo-Cilazapril/HCTZ HLR APX .5530 .8175 .5530
CLONIDINE HCL
Note: Significant rebound hypertension can occur after missing even one or two doses; this drug should be avoided in patients with cardiovascular fragility or suspected problems with compliance. 487 0.1mg Tab 00259527 00868949 01913786 02046121 0.2mg Tab 00291889 00868957 01913220 02046148 Catapres Apo-Clonidine Nu-Clonidine Novo-Clonidine Catapres Apo-Clonidine Nu-Clonidine Novo-Clonidine BOE APX NXP NOP BOE APX NXP NOP .1358 .1853 .1358 .1358 .1358 .2424 .3306 .2424 .2424 .2424 .54 .74 .54 .54 .54 .97 1.32 .97 .97 .97
488
JUNE 27, 2008
IIIA.105
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DOXAZOSIN MESYLATE
489 1mg Tab 01958100 02240498 02240588 02242728 02244527 2mg Tab 01958097 02240499 02240589 02242729 02244528 4mg Tab 01958119 02240500 02240590 02242730 02244529 Cardura-1 Gen-Doxazosin Apo-Doxazosin Novo-Doxazosin PMS-Doxazosin Cardura-2 Gen-Doxazosin Apo-Doxazosin Novo-Doxazosin PMS-Doxazosin Cardura-4 Gen-Doxazosin Apo-Doxazosin Novo-Doxazosin PMS-Doxazosin AZC GEN APX NOP PMS AZC GEN APX NOP PMS AZC GEN APX NOP PMS .2750 .5665 .2750 .2750 .2750 .2750 .3300 .6795 .3300 .3300 .3300 .3300 .4290 .8835 .4290 .4290 .4290 .4290 .28 .57 .28 .28 .28 .28 .33 .68 .33 .33 .33 .33 .43 .88 .43 .43 .43 .43
490
491
ENALAPRIL MALEATE
492 2.5mg Tab 00851795 02020025 02291878 02299933 02299984 02300036 02300079 02300117 02300680 ** Vasotec Apo-Enalapril ** Co Enalapril ** Sandoz Enalapril ** Ratio-Enalapril ** Gen-Enalapril ** PMS-Enalapril ** Taro-Enalapril ** Novo-Enalapril MFC APX COB SDZ RPH GEN PMS TAR NOP .3617 .7450 .3617 .3617 .3617 .3617 .3617 .3617 .3617 .3617 .36 .75 .36 .36 .36 .36 .36 .36 .36 .36
Note: ** Each tablet is made with 2.5mg of enalapril maleate that is equivalent to 2mg of enalapril sodium, in the finished tablets.
IIIA.106
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ENALAPRIL MALEATE
493 5mg Tab 00708879 02019884 02233005 02291886 02299941 02299992 02300044 02300087 02300125 ** Vasotec Apo-Enalapril ** Novo-Enalapril ** Co Enalapril ** Sandoz Enalapril ** Ratio-Enalapril ** Gen-Enalapril ** PMS-Enalapril ** Taro-Enalapril MFC APX NOP COB SDZ RPH GEN PMS TAR .4279 .8813 .4279 .4279 .4279 .4279 .4279 .4279 .4279 .4279 .43 .88 .43 .43 .43 .43 .43 .43 .43 .43
Note: ** Each tablet is made with 5mg of enalapril maleate that is equivalent to 4mg of enalapril sodium, in the finished tablets. 494 10mg Tab 00670901 02019892 02233006 02291894 02299968 02300001 02300052 02300095 02300133 ** Vasotec Apo-Enalapril ** Novo-Enalapril ** Co Enalapril ** Sandoz Enalapril ** Ratio-Enalapril ** Gen-Enalapril ** PMS-Enalapril ** Taro-Enalapril MFC APX NOP COB SDZ RPH GEN PMS TAR .5142 1.0589 .5142 .5142 .5142 .5142 .5142 .5142 .5142 .5142 .51 1.06 .51 .51 .51 .51 .51 .51 .51 .51
Note: ** Each tablet is made with 10mg of enalapril maleate that is equivalent to 8mg of enalapril sodium, in the finished tablets. 495 20mg Tab 00670928 02019906 02233007 02291908 02299976 02300028 02300060 02300109 02300141 ** Vasotec Apo-Enalapril ** Novo-Enalapril ** Co Enalapril ** Sandoz Enalapril ** Ratio-Enalapril ** Gen-Enalapril ** PMS-Enalapril ** Taro-Enalapril MFC APX NOP COB SDZ RPH GEN PMS TAR .6204 1.2779 .6204 .6204 .6204 .6204 .6204 .6204 .6204 .6204 .62 1.28 .62 .62 .62 .62 .62 .62 .62 .62
Note: ** Each tablet is made with 20mg of enalapril maleate that is equivalent to 16mg of enalapril sodium, in the finished tablets.
JUNE 27, 2008
IIIA.107
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

EPROSARTAN MESYLATE
496 497 400mg Tab 02240432 600mg Tab 02243942 Teveten Teveten SPH SPH .6868 .6868 1.0304 1.0304
EPROSARTAN MESYLATE & HYDROCHLOROTHIAZIDE

498 600mg & 12.5mg Tab 02253631 Teveten Plus SPH 1.0304 1.0304
FELODIPINE
Note: Grapefruit juice or erythromycin triple the blood levels of felodipine and markedly increase both efficacy and adverse effects. Other dihydropyridines are affected to differing degrees by grapefruit juice. 499 500 2.5mg ER Tab 02057778 5mg ER Tab 00851779 02280264 10mg ER Tab 00851787 02280272 2.5mg SR Tab 02221985 5mg SR Tab 02221993 09857203 10mg SR Tab 02222000 09857204 Plendil Plendil Sandoz Felodipine Plendil Sandoz Felodipine Renedil Renedil Sandoz Felodipine Renedil Sandoz Felodipine AZC AZC SDZ AZC SDZ SAV SAV SDZ SAV SDZ .5087 .5087 .4620 .6797 .4620 .6925 1.0197 .6925 .5301 .5301 .4620 .7086 .4620 .6925 1.0622 .6925 .46 .71 .46 .69 1.06 .69 .46 .68 .46 .69 1.02 .69
501
502 503
504
IIIA.108
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FOSINOPRIL SODIUM
505 10mg Tab 01907107 02242733 02247802 02255944 02262401 02266008 02275252 20mg Tab 01907115 02242734 02247803 02255952 02262428 02266016 02275260 Monopril Lin-Fosinopril Novo-Fosinopril PMS-Fosinopril Gen-Fosinopril Apo-Fosinopril Ratio-Fosinopril Monopril Lin-Fosinopril Novo-Fosinopril PMS-Fosinopril Gen-Fosinopril Apo-Fosinopril Ratio-Fosinopril BQU LON NOP PMS GEN APX RPH BQU LON NOP PMS GEN APX RPH .3950 .8457 .3950 .3950 .3950 .3950 .3950 .3950 .4750 1.0170 .4750 .4750 .4750 .4750 .4750 .4750 .40 .85 .40 .40 .40 .40 .40 .40 .48 1.02 .48 .48 .48 .48 .48 .48
506
HYDRALAZINE HCL
507 508 20mg/mL Inj Sol-1mL Pk 00723754 Apresoline 10mg Tab 00005525 00441619 25mg Tab 00005533 00441627 00759473 50mg Tab 00005541 00441635 00759481 Apresoline (Not a Benefit) Apo-Hydralazine Apresoline (Not a Benefit) Apo-Hydralazine Novo-Hylazin Apresoline (Not a Benefit) Apo-Hydralazine Novo-Hylazin STE NOV APX STE APX NOP NOV APX NOP 11.6500 11.6500 .1026 .1026 .1644 .1644 .1644 .2527 .2527 .2527 .41 .41 .66 .66 .66 1.01 1.01 1.01
509
510
JUNE 27, 2008
IIIA.109
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

IRBESARTAN
511 512 513 75mg Tab 02237923 150mg Tab 02237924 300mg Tab 02237925 Avapro Avapro Avapro SAV SAV SAV 1.1874 1.1874 1.1874 1.1874 1.1874 1.1874
IRBESARTAN & HYDROCHLOROTHIAZIDE

514 515 516 150 & 12.5mg Tab 02241818 300 & 12.5mg Tab 02241819 300 & 25mg Tab 02280213 Avalide Avalide Avalide SAV SAV SAV 1.1874 1.1874 1.1874 1.1874 1.1641 1.1641
LABETALOL HCL
517 100mg Tab 02106272 02243538 200mg Tab 02106280 02243539 Trandate Apo-Labetalol Trandate Apo-Labetalol SQI APX SQI APX .1977 .2474 .1977 .3358 .4374 .3358
518
LISINOPRIL
519 5mg Tab 00839388 02256797 02285061 09853685 09857272 10mg Tab 00839396 02256800 02285088 09853960 09857286 Prinivil Ratio-Lisinopril P Novo-Lisinopril (Type P) Apo-Lisinopril Sandoz Lisinopril Prinivil Ratio-Lisinopril P Novo-Lisinopril (Type P) Apo-Lisinopril Sandoz Lisinopril MFC RPH NOP APX SDZ MFC RPH NOP APX SDZ .2694 .5547 .2694 .2694 .2694 .2694 .3237 .6664 .3237 .3237 .3237 .3237 .27 .55 .27 .27 .27 .27 .32 .67 .32 .32 .32 .32
520
IIIA.110
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LISINOPRIL
521 20mg Tab 00839418 02256819 02285096 09854010 09857287 5mg Tab 02049333 02217481 02271443 02274833 02285118 02289199 02292203 02294230 02299879 10mg Tab 02049376 02217503 02271451 02274841 02285126 02289202 02292211 02294249 02299887 20mg Tab 02049384 02217511 02271478 02274868 02285134 02289229 02292238 02294257 02299895 Prinivil Ratio-Lisinopril P Novo-Lisinopril (Type P) Apo-Lisinopril Sandoz Lisinopril Zestril Apo-Lisinopril Co Lisinopril Gen-Lisinopril Novo-Lisinopril (Type Z) Sandoz Lisinopril PMS-Lisinopril Ran-Lisinopril Ratio-Lisinopril Z Zestril Apo-Lisinopril Co Lisinopril Gen-Lisinopril Novo-Lisinopril (Type Z) Sandoz Lisinopril PMS-Lisinopril Ran-Lisinopril Ratio-Lisinopril Z Zestril Apo-Lisinopril Co Lisinopril Gen-Lisinopril Novo-Lisinopril (Type Z) Sandoz Lisinopril PMS-Lisinopril Ran-Lisinopril Ratio-Lisinopril Z MFC RPH NOP APX SDZ AZC APX COB GEN NOP SDZ PMS RAN RPH AZC APX COB GEN NOP SDZ PMS RAN RPH AZC APX COB GEN NOP SDZ PMS RAN RPH .3890 .8012 .3890 .3890 .3890 .3890 .2694 .5388 .2694 .2694 .2694 .2694 .2694 .2694 .2694 .2694 .3237 .6474 .3237 .3237 .3237 .3237 .3237 .3237 .3237 .3237 .3890 .7779 .3890 .3890 .3890 .3890 .3890 .3890 .3890 .3890 .39 .80 .39 .39 .39 .39 .27 .54 .27 .27 .27 .27 .27 .27 .27 .27 .32 .65 .32 .32 .32 .32 .32 .32 .32 .32 .39 .78 .39 .39 .39 .39 .39 .39 .39 .39
522
523
524
JUNE 27, 2008
IIIA.111
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LISINOPRIL & HYDROCHLOROTHIAZIDE
525 10mg & 12.5mg Tab 02103729 Zestoretic 02261979 Apo-Lisinopril-HCTZ 02297736 Gen-Lisinopril HCTZ 02301768 Novo-Lisinopril/HCTZ (Type Z) 02302365 Sandoz Lisinopril HCT 10mg & 12.5mg Tab 02108194 Prinzide 02302136 Novo-Lisinopril/HCTZ (Type P) 20mg & 12.5mg Tab 00884413 Prinzide 02302144 Novo-Lisinopril/HCTZ (Type P) 20mg & 12.5mg Tab 02045737 Zestoretic 02261987 Apo-Lisinopril/HCTZ 02297744 Gen-Lisinopril HCTZ 02301776 Novo-Lisinopril/HCTZ (Type Z) 02302373 Sandoz Lisinopril HCT AZC APX GEN NOP SDZ MFC NOP MFC NOP AZC APX GEN NOP SDZ .4168 .8335 .4168 .4168 .4168 .4168 .3334 .6868 .3334 .4006 .8252 .4006 .5008 1.0016 .5008 .5008 .5008 .5008
526
527
528
LOSARTAN POTASSIUM
529 530 531 25mg Tab 02182815 50mg Tab 02182874 100mg Tab 02182882 Cozaar Cozaar Cozaar MFC MFC MFC 1.2136 1.2136 1.2136 1.2136 1.2136 1.2136
LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE

532 533 50mg/12.5mg Tab 02230047 100mg/25mg Tab 02241007 Hyzaar Hyzaar DS MFC MFC 1.2136 1.2136 1.2136 1.2136
IIIA.112
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

METHYLDOPA
534 125mg Tab 00016551 00360252 250mg Tab 00016578 00360260 500mg Tab 00016586 00426830 .0966 Aldomet (Not a Benefit) Apo-Methyldopa Aldomet (Not a Benefit) Apo-Methyldopa Aldomet (Not a Benefit) Apo-Methyldopa MSD APX MSD APX MSD APX .0966 .1400 .1400 .2479 .2479 .39 .39 .56 .56 .50 .50
535
536
MINOXIDIL
537 538 2.5mg Tab 00514497 10mg Tab 00514500 Loniten Loniten PFI PFI .3288 .3288 .7250 .7250
NIFEDIPINE
539 540 541 542 20mg ER Tab 02237618 30mg ER Tab 02155907 60mg ER Tab 02155990 10mg LA Tab 02155885 02197448 20mg LA Tab 02155893 02181525 Adalat XL Adalat XL Adalat XL Adalat PA 10 (Not a Benefit) Apo-Nifed PA Adalat PA 20 (Not a Benefit) Apo-Nifed PA BAY BAY BAY BAH APX BAH APX 1.1336 1.1336 1.1336 1.1336 1.7874 1.7874 .2245 .2245 .3900 .3900 1.13 1.13 1.79 1.79 .45 .45 .78 .78
543
JUNE 27, 2008
IIIA.113
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

OXPRENOLOL HCL
544 40mg Tab 00402575 # Trasicor NOV .2907 .2907
PERINDOPRIL ERBUMINE
545 546 547 2mg Tab 02123274 4mg Tab 02123282 8mg Tab 02246624 02289296 Coversyl Coversyl Coversyl Apo-Perindopril (Not a Benefit) SEV SEV SEV APX .6000 .6000 .7500 .7500 1.0500 1.0500
PERINDOPRIL ERBUMINE & INDAPAMIDE

548 549 2mg & 0.625mg Tab 02246568 Preterax 4mg & 1.25mg Tab 02246569 Coversyl Plus SEV SEV .7900 .7900 .9400 .9400
PINDOLOL
550 5mg Tab 00417270 00755877 00869007 00886149 02057808 02231536 02261782 10mg Tab 00443174 00755885 00869015 00886009 02057816 02231537 02261790 Visken Apo-Pindol Novo-Pindol Nu-Pindol Gen-Pindolol PMS-Pindolol Sandoz Pindolol Visken Apo-Pindol Novo-Pindol Nu-Pindol Gen-Pindolol PMS-Pindolol Sandoz Pindolol NOV APX NOP NXP GEN PMS SDZ NOV APX NOP NXP GEN PMS SDZ .2023 .5183 .2023 .2023 .2023 .2023 .2023 .2023 .3490 .8850 .3490 .3490 .3490 .3490 .3490 .3490 .40 1.04 .40 .40 .40 .40 .40 .40 .70 1.77 .70 .70 .70 .70 .70 .70
551
IIIA.114
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PINDOLOL
552 15mg Tab 00417289 00755893 00869023 00886130 02057824 02231539 02261804 Visken Apo-Pindol Novo-Pindol Nu-Pindol Gen-Pindolol PMS-Pindolol Sandoz Pindolol NOV APX NOP NXP GEN PMS SDZ .5128 1.2839 .5128 .5128 .5128 .5128 .5128 .5128 1.03 2.57 1.03 1.03 1.03 1.03 1.03 1.03
PINDOLOL & HYDROCHLOROTHIAZIDE

553 554 10mg & 25mg Tab 00568627 10mg & 50mg Tab 00568635 Viskazide 10/25 Viskazide 10/50 NOV NOV .7944 .7944 .7944 .7944
PRAZOSIN HCL
555 1mg Tab 00560952 00882801 01913794 01934198 2mg Tab 00560960 00882828 01913808 01934201 5mg Tab 00560979 00882836 01913816 01934228 Minipress Apo-Prazo Nu-Prazo Novo-Prazin Minipress Apo-Prazo Nu-Prazo Novo-Prazin Minipress Apo-Prazo Nu-Prazo Novo-Prazin PFI APX NXP NOP PFI APX NXP NOP PFI APX NXP NOP .1371 .2743 .1371 .1371 .1371 .1862 .3725 .1862 .1862 .1862 .2560 .5121 .2560 .2560 .2560 .27 .55 .27 .27 .27 .37 .75 .37 .37 .37 .51 1.02 .51 .51 .51
556
557
JUNE 27, 2008
IIIA.115
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

QUINAPRIL HCL
558 559 560 561 5mg Tab 01947664 10mg Tab 01947672 20mg Tab 01947680 40mg Tab 01947699 Accupril Accupril Accupril Accupril PFI PFI PFI PFI .8543 .8543 .8543 .8543 .8543 .8543 .8543 .8543 .85 .85 .85 .85 .85 .85 .85 .85
QUINAPRIL HCL & HYDROCHLOROTHIAZIDE

562 563 564 10mg & 12.5mg Tab 02237367 Accuretic 20mg & 12.5mg Tab 02237368 Accuretic 20mg & 25mg Tab 02237369 Accuretic PFI PFI PFI .8543 .8543 .8543 .8543 .8214 .8214
RAMIPRIL
565 1.25mg 02221829 02251515 02287692 02291398 02295482 2.5mg 02221837 02247945 02251531 02287706 02291401 02295490 Altace Cap Apo-Ramipril Cap Ratio-Ramipril Cap Sandoz Ramipril Tab Co Ramipril Cap Altace Cap Novo-Ramipril Cap Apo-Ramipril Cap Ratio-Ramipril Cap Sandoz Ramipril Tab Co Ramipril Cap SAV APX RPH SDZ COB SAV NOP APX RPH SDZ COB .3250 .6797 .3250 .3250 .3250 .3250 .3750 .7842 .3750 .3750 .3750 .3750 .3750
566
IIIA.116
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

RAMIPRIL
567 5mg 02221845 02247946 02251574 02287714 02291428 02295504 10mg 02221853 02247947 02251582 02287722 02291436 02295512 Altace Cap Novo-Ramipril Cap Apo-Ramipril Cap Ratio-Ramipril Cap + Sandoz Ramipril Tab Co Ramipril Cap Altace Cap Novo-Ramipril Cap Apo-Ramipril Cap Ratio-Ramipril Cap Sandoz Ramipril Tab Co Ramipril Cap SAV NOP APX RPH SDZ COB SAV NOP APX RPH SDZ COB .3750 .7842 .3750 .3750 .3750 .3750 .3750 .4750 .9738 .4750 .4750 .4750 .4750 .4750
568
RAMIPRIL & HYDROCHLOROTHIAZIDE

569 570 571 572 573 2.5mg & 12.5mg Tab 02283131 Altace HCT 5mg & 12.5mg Tab 02283158 5mg & 25mg Tab 02283174 Altace HCT Altace HCT SAV SAV SAV SAV SAV .7500 .7500 .7500 .7500 .7500 .7500 .9500 .9500 .9500 .9500
10mg & 12.5mg Tab 02283166 Altace HCT 10mg & 25mg Tab 02283182 Altace HCT
TELMISARTAN
574 575 40mg Tab 02240769 80mg Tab 02240770 Micardis Micardis BOE BOE 1.1296 1.1296 1.1296 1.1296
TELMISARTAN & HYDROCHLOROTHIAZIDE

576 80mg/12.5mg Tab 02244344 Micardis Plus BOE 1.1296 1.1296
JUNE 27, 2008
IIIA.117
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TERAZOSIN HCL
577 1mg Tab 00818658 02218941 02230805 02233047 02234502 02243518 2mg Tab 00818682 02218968 02230806 02233048 02234503 02243519 5mg Tab 00818666 02218976 02230807 02233049 02234504 02243520 10mg Tab 00818674 02218984 02230808 02233050 02234505 02243521 Hytrin Ratio-Terazosin Novo-Terazosin Nu-Terazosin Apo-Terazosin PMS-Terazosin Hytrin Ratio-Terazosin Novo-Terazosin Nu-Terazosin Apo-Terazosin PMS-Terazosin Hytrin Ratio-Terazosin Novo-Terazosin Nu-Terazosin Apo-Terazosin PMS-Terazosin Hytrin Ratio-Terazosin Novo-Terazosin Nu-Terazosin Apo-Terazosin PMS-Terazosin ABB RPH NOP NXP APX PMS ABB RPH NOP NXP APX PMS ABB RPH NOP NXP APX PMS ABB RPH NOP NXP APX PMS .2770 .6658 .2770 .2770 .2770 .2770 .2770 .3521 .8464 .3521 .3521 .3521 .3521 .3521 .4782 1.1494 .4782 .4782 .4782 .4782 .4782 .7000 1.6825 .7000 .7000 .7000 .7000 .7000 .28 .67 .28 .28 .28 .28 .28 .35 .85 .35 .35 .35 .35 .35 .48 1.15 .48 .48 .48 .48 .48 .70 1.68 .70 .70 .70 .70 .70
578
579
580
TRANDOLAPRIL
581 582 583 1mg Cap 02231459 2mg Cap 02231460 4mg Cap 02239267 Mavik Mavik Mavik ABB ABB ABB .6901 .6901 .7931 .7931 .9785 .9785
IIIA.118
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

VALSARTAN
584 585 586 80mg Tab 02244781 160mg Tab 02244782 320mg Tab 02289504 Diovan Diovan Diovan NOV NOV NOV 1.1636 1.1636 1.1636 1.1636 1.1371 1.1371
VALSARTAN & HYDROCHLOROTHIAZIDE

587 588 589 80mg/12.5mg Tab 02241900 160mg/12.5mg Tab 02241901 160mg/25mg Tab 02246955 Diovan-HCT Diovan-HCT Diovan-HCT NOV NOV NOV 1.1636 1.1636 1.1636 1.1636 1.1636 1.1636
VERAPAMIL HCL
590 180mg LA Tab 01934317 02210355 02246894 240mg LA Tab 00742554 02210363 02211920 02237791 02246895 180mg SR Tab 02231676 Isoptin SR Gen-Verapamil SR Apo-Verap SR Isoptin SR Gen-Verapamil SR Novo-Veramil SR PMS-Verapamil SR Apo-Verap SR Covera-HS ABB GEN APX ABB GEN NOP PMS APX PFI .5204 1.3807 .5204 .5204 .6940 1.8412 .6940 .6940 .6940 .6940 .8112 .8112 .52 1.38 .52 .52 .69 1.84 .69 .69 .69 .69 .81 .81
591
592
Note: Covera-HS (verapamil HCL) is a dosage form designed to deliver peak verapamil levels in the morning. Accordingly, Covera-HS should be administered once daily at bedtime. 593 240mg SR Tab 02231677 Covera-HS PFI .9069 .9069 .91 .91
Note: Covera-HS (verapamil HCL) is a dosage form designed to deliver peak verapamil levels in the morning. Accordingly, Covera-HS should be administered once daily at bedtime.
JUNE 27, 2008
IIIA.119
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

24:12:00 VASODILATING DRUGS
Note: Pharmacologic tolerance (tachyphylaxis) may lead to loss of efficacy with chronic multiple (qid) daily dosing of nitrates. Continued relief of angina may require adjustment of dosage interval (e.g., tid).
DIPYRIDAMOLE & ACETYLSALICYLIC ACID

594 200mg/25mg Cap 02242119 Reason for Use Code
N TIO ED A D ITE ForUSE MENT QUIR 349 the secondary prevention of stroke. LIM U RE OC LU Authorization Period: Indefinite. D
Aggrenox Clinical criteria Coradur-SR (Not a Benefit) Cedocard SR (Not a Benefit) Isordil (Not a Benefit) Apo-ISDN Isordil (Not a Benefit) Apo-ISDN Isordil (Not a Benefit) Apo-ISDN
BOE
.8230 .8230
ISOSORBIDE DINITRATE
595 20mg LA Tab 00786683 00740721 5mg SL Tab 02042606 00670944 10mg Tab 02042622 00441686 30mg Tab 02042614 00441694 GLA PMS .0600 WAY APX WAY APX WAY APX .0600 .0357 .0357 .0837 .0837
596
597
598
IIIA.120
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

NIMODIPINE
599
D ON D TI E ITE E A IM S NT UIR L U ME EQ R CU O D
Nimotop BAY Reason for Use Code 42 Clinical criteria LU Authorization Period: 1 year. 43 As prophylaxis of ischemia if surgery is delayed. LU Authorization Period: 1 year.
30mg SG Cap 02155923
6.2465 6.2465
As adjunctive therapy to improve the neurologic outcome following subarachnoid haemorrhage during the acute management period (within 4 days of haemorrhage).
NITROGLYCERIN
600 601 602 603 604 605 606 2% Oint 01926454 Nitrol SQI NOV SCH NOV SCH GRA NOV .5905 .5905 .6790 .6790 .6400 .6400 .6790 .6790 .6400 .6400 .6593 .6593 .6400 .6400
0.4mg/Hr/20 Sq Cm Patch 00852384 Transderm-Nitro 0.4mg/Hr/20 Sq Cm Patch 01911902 Nitro-Dur 0.6mg/Hr/30 Sq Cm Patch 02046156 Transderm-Nitro 0.6mg/Hr/30 Sq Cm Patch 01911929 Nitro-Dur 0.4mg/Hr/13.3 Sq Cm Patch 02163527 Minitran 0.4mg/Hr/14 Sq Cm Patch 02230733 Trinipatch
JUNE 27, 2008
IIIA.121
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

NITROGLYCERIN
607 608 609 610 611 0.6mg/Hr/20 Sq Cm Patch 02163535 Minitran 0.6mg/Hr/21 Sq Cm Patch 02230734 Trinipatch 0.3mg SL Tab 00037613 * 0.6mg SL Tab 00037621 Nitrostat Nitrostat GRA NOV PFI PFI AVE GEN SAV .6597 .6597 .6400 .6400 .0278 .0278 .0289 .0289 8.4600 8.4600 13.3200 13.3200
0.4mg/Metered Dose Spray-200 Dose Pk 01926721 Nitrolingual (Not a Benefit) 02243588 Gen-Nitro SL 0.4mg/Metered Dose Spray-200 Dose Pk 02231441 Nitrolingual Pump Spray
612
IIIA.122
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
28:00 CENTRAL NERVOUS SYSTEM DRUGS

28:08:04 ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
Note: NSAIDs have a high rate of serious adverse effects in the elderly. When prescribing NSAIDs, the minimal effective dose for the shortest period of time should be used. In nonspecific pain and/or osteoarthritis, in the absence of joint inflammation (swelling), acetaminophen is a better first choice for analgesia. The most effective treatment to prevent NSAID-gastritis is misoprostol; although H-2 antagonists, such as ranitidine or cimetidine, are commonly used, they are not as effective. NSAIDs can significantly aggravate hypertension and congestive heart failure; ASA in doses below 1 gram per day is a better choice than other NSAID options if anti-inflammatory effects are required in patients with these conditions. Low dose ASA has additional benefits for anti-platelet indications that are not provided by other NSAIDs, and should be given in preference or in addition to other NSAIDs for patients with vascular indications.
ACETYLSALICYLIC ACID
613 * 325mg Ent Tab 00010332 00216666 * 650mg Ent Tab 00010340 00229296 * 325mg Tab 00036145 00040851 Entrophen Novasen (Not a Benefit) Entrophen Novasen (Not a Benefit) ASA (Not a Benefit) PMS-ASA PEN NOP PEN NOP RPR PMS .0280 .0280 .0862 .0862 .0585 .0585
614
615
JUNE 27, 2008
IIIA.123
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CELECOXIB
616 617 100mg Cap 02239941 200mg Cap 02239942 Reason for Use Code 316 Celebrex Celebrex PFI PFI .6500 .6500 1.3000 1.3000
ED N IT E IO IM US L AT NT D ME IRE CU QU DO RE
Clinical criteria NOTE: The maximum daily dose of celecoxib which will be reimbursed for the treatment of osteoarthritis is 200mg. LU Authorization Period: 1 year. 317 Rheumatoid arthritis For patients who have had: NOTE: The maximum daily dose of celecoxib which will be reimbursed for the treatment of rheumatoid arthritis is 400mg. LU Authorization Period: 1 year.
Osteoarthritis For patients who have failed an adequate trial of acetaminophen (e.g. acetaminophen 1g QID for several weeks) and have had: History of a documented, clinically significant ulcer or GI bleed; or Failure or intolerance to at least three listed NSAIDS.
History of a documented, clinically significant ulcer or GI bleed; or Failure or intolerance to at least three listed NSAIDS.
IIIA.124
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DICLOFENAC SODIUM
618 25mg Ent Tab 00514004 00808539 00839175 00886017 02231502 50mg Ent Tab 00514012 00808547 00839183 00886025 02231503 75mg LA Tab 00782459 02158582 02162814 02228203 02231504 02261901 .1902 Voltaren (Not a Benefit) Novo-Difenac Apo-Diclo Nu-Diclo PMS-Diclofenac Voltaren Novo-Difenac Apo-Diclo Nu-Diclo PMS-Diclofenac Voltaren SR (Not a Benefit) Novo-Difenac SR Apo-Diclo SR Nu-Diclo-SR PMS-Diclofenac-SR Sandoz Diclofenac SR (Not a Benefit) GEI NOP APX NXP PMS NOV NOP APX NXP PMS NOV NOP APX NXP PMS SDZ .1902 .1902 .1902 .1902 .3125 .7863 .3125 .3125 .3125 .3125 .5706 .5706 .5706 .5706 .5706
619
620
JUNE 27, 2008
IIIA.125
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DICLOFENAC SODIUM
621 100mg LA Tab 00590827 02048698 02091194 02228211 02231505 02261944 50mg Sup 00632724 02231506 02241224 100mg Sup 00632732 02231508 02241225 .7874 Voltaren SR (Not a Benefit) Novo-Difenac SR Apo-Diclo SR Nu-Diclo-SR PMS-Diclofenac-SR Sandoz Diclofenac SR (Not a Benefit) Voltaren PMS-Diclofenac Sab-Diclofenac Voltaren PMS-Diclofenac Sab-Diclofenac NOV NOP APX NXP PMS SDZ NOV PMS SDZ NOV PMS SDZ .4950 1.1807 .4950 .4950 .6665 1.5893 .6665 .6665 .7874 .7874 .7874 .7874
622
623
DICLOFENAC SODIUM & MISOPROSTOL

624 625 50mg & 200mcg Tab 01917056 Arthrotec 50 75mg & 200mcg Tab 02229837 Arthrotec 75 PFI PFI .5762 .5762 .7842 .7842
IIIA.126
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DIFLUNISAL
626 250mg Tab 00587699 02039486 02048493 500mg Tab 00576131 02039494 .2824 Dolobid (Not a Benefit) Apo-Diflunisal Novo-Diflunisal Dolobid (Not a Benefit) Apo-Diflunisal FRS APX NOP FRS APX .2824 .2824 .5180 .5180
627
FLOCTAFENINE
628 200mg Tab 02017628 02244680 400mg Tab 02017636 02244681 .4032 Idarac (Not a Benefit) Apo-Floctafenine Idarac (Not a Benefit) Apo-Floctafenine SAO APX SAO APX .4032 .7845 .7845
629
JUNE 27, 2008
IIIA.127
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLURBIPROFEN
630 631 50mg Tab 02223066 50mg Tab 00647942 01912046 02020661 02100509 100mg Tab 00600792 01912038 02020688 02100517 # Froben Ansaid Apo-Flurbiprofen Nu-Flurbiprofen Novo-Flurprofen Ansaid Apo-Flurbiprofen Nu-Flurbiprofen Novo-Flurprofen ABB PFI APX NXP NOP PFI APX NXP NOP .3710 .3710 .2221 .5124 .2221 .2221 .2221 .3039 .6708 .3039 .3039 .3039
632
IBUPROFEN
633 200mg Tab 00252409 00441643 00629324 .0243 Motrin (Not a Benefit) Apo-Ibuprofen Novo-Profen UPJ APX NOP .0243 .0243
IIIA.128
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

IBUPROFEN
634 300mg Tab 00327794 00441651 400mg Tab 00364142 00506052 00629340 600mg Tab 00484911 00585114 00629359 .0284 Motrin (Not a Benefit) Apo-Ibuprofen Motrin Apo-Ibuprofen Novo-Profen Motrin (Not a Benefit) Apo-Ibuprofen Novo-Profen UPJ APX UPJ APX NOP UPJ APX NOP .0284 .0372 .1871 .0372 .0372 .0465 .0465 .0465
635
636
INDOMETHACIN
637 25mg Cap 00016039 00337420 00611158 00865850 .0871 Indocid (Not a Benefit) Novo-Methacin Apo-Indomethacin Nu-Indo MSD NOP APX NXP .0871 .0871 .0871
JUNE 27, 2008
IIIA.129
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

INDOMETHACIN
638 50mg Cap 00016047 00337439 00611166 00865869 50mg Sup 00594466 02231799 100mg Sup 00016233 01934139 02231800 .1511 Indocid (Not a Benefit) Novo-Methacin Apo-Indomethacin Nu-Indo Indocid (Not a Benefit) Sab-Indomethacin Indocid (Not a Benefit) Ratio-Indomethacin Sab-Indomethacin MSD NOP APX NXP MSD SDZ MSD RPH SDZ .1511 .1511 .1511 .8020 .8020 .8919 .8919 .8919
639
640
KETOPROFEN
641 50mg Cap 01926403 00790427 50mg Ent Tab 01926381 00790435 02150816 .1662 Orudis (Not a Benefit) Apo-Keto Orudis E-50 (Not a Benefit) Apo-Keto-E # PMS-Ketoprofen E-50 RPP APX RPP APX PMS .1662 .1662 .1662 .1662
642
IIIA.130
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

KETOPROFEN
643 100mg Ent Tab 01926365 00761680 00842664 200mg LA Tab 01926373 02172577 100mg Sup 01926411 02015951 .3078 Orudis E-100 (Not a Benefit) # Rhodis-EC Apo-Keto-E Orudis SR-200 (Not a Benefit) Apo-Keto SR Orudis (Not a Benefit) PMS-Ketoprofen RPP SAV APX RPP APX AVE PMS .3078 .3078 .6156 .6156 .9930 .9930
644
645
MEFENAMIC ACID
646 250mg Cap 00155225 02229452 02229569 02231208 .2626 Ponstan (Not a Benefit) Apo-Mefenamic Nu-Mefenamic PMS-Mefenamic Acid PFI APX NXP PMS .2626 .2626 .2626
JUNE 27, 2008
IIIA.131
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MELOXICAM
647 7.5mg Tab 02242785 02247889 02248267 02248973 02250012 02255987 02258315 15mg Tab 02242786 02248031 02248268 02248974 02250020 02255995 02258323 Mobicox Ratio-Meloxicam PMS-Meloxicam Apo-Meloxicam Co-Meloxicam Gen-Meloxicam Novo-Meloxicam Mobicox Ratio-Meloxicam PMS-Meloxicam Apo-Meloxicam Co-Meloxicam Gen-Meloxicam Novo-Meloxicam BOE RPH PMS APX COB GEN NOP BOE RPH PMS APX COB GEN NOP .3900 .8011 .3900 .3900 .3900 .3900 .3900 .3900 .4500 .9243 .4500 .4500 .4500 .4500 .4500 .4500
648
NAPROXEN
649 650 25mg/mL O/L 02162431 750mg SR Tab 02162466 02177072 Naprosyn Naprosyn SR (Not a Benefit) Apo-Naproxen SR HLR HLR APX .0601 .0601 .7604 .7604
IIIA.132
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

NAPROXEN
651 500mg Sup 02162458 02017237 02230477 125mg Tab 00299413 00522678 250mg Tab 02162474 00522651 00565350 00865648 375mg Tab 02162482 00600806 00627097 00865656 500mg Tab 02162490 00589861 00592277 00865664 .4775 Naprosyn (Not a Benefit) PMS-Naproxen Naproxen Naprosyn (Not a Benefit) Apo-Naproxen Naprosyn (Not a Benefit) Apo-Naproxen Novo-Naprox Nu-Naprox Naprosyn (Not a Benefit) Apo-Naproxen Novo-Naprox Nu-Naprox Naprosyn (Not a Benefit) Novo-Naprox Apo-Naproxen Nu-Naprox HLR PMS SDZ SYN APX HLR APX NOP NXP HLR APX NOP NXP HLR NOP APX NXP .4775 .4775 .0763 .0763 .1068 .1068 .1068 .1068 .1458 .1458 .1458 .1458 .2110 .2110 .2110 .2110
652
653
654
655
JUNE 27, 2008
IIIA.133
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PIROXICAM
656 10mg Cap 00525596 00642886 00695718 00865761 02171813 20mg Cap 00525618 00642894 00695696 00865788 02171821 20mg Sup 00632716 02154463 .4147 Feldene (Not a Benefit) Apo-Piroxicam Novo-Pirocam Nu-Pirox Gen-Piroxicam Feldene (Not a Benefit) Apo-Piroxicam Novo-Pirocam Nu-Pirox Gen-Piroxicam Feldene (Not a Benefit) PMS-Piroxicam PFI APX NOP NXP GEN PFI APX NOP NXP GEN PFI PMS .4147 .4147 .4147 .4147 .7158 .7158 .7158 .7158 .7158 1.6460 1.6460
657
658
IIIA.134
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SULINDAC
659 150mg Tab 00456888 00745588 00778354 02042576 200mg Tab 00432369 00745596 00778362 02042584 .3824 Clinoril (Not a Benefit) Novo-Sundac Apo-Sulin Nu-Sulindac Clinoril (Not a Benefit) Novo-Sundac Apo-Sulin Nu-Sulindac FRS NOP APX NXP FRS NOP APX NXP .3824 .3824 .3824 .4840 .4840 .4840 .4840
660
TIAPROFENIC ACID
661 200mg Tab 01989782 02136112 02179679 300mg Tab 02221950 02136120 02179687 02230828 .3437 Surgam (Not a Benefit) Apo-Tiaprofenic Novo-Tiaprofenic Surgam Apo-Tiaprofenic Novo-Tiaprofenic PMS-Tiaprofenic HRU APX NOP SAV APX NOP PMS .3437 .3437 .3258 .7542 .3258 .3258 .3258
662
JUNE 27, 2008
IIIA.135
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

28:08:08 ANALGESICS OPIATE AGONISTS
Note: Narcotic analgesics can produce dependence and may be abused. Physical dependence, psychological dependence and tolerance may develop. Prescribers are cautioned about ordering these drugs for patients with a history of either emotional disturbances or drug abuse, including alcohol.
ACETAMINOPHEN & CODEINE PHOSPHATE

663 160mg & 8mg/5mL O/L 02163942 Tylenol With Codeine (Not a Benefit) 00816027 PMS-Acetaminophen With Codeine 300mg & 30mg Tab 00666130 Empracet-30 (Not a Benefit) 00608882 Ratio-Emtec 300mg & 60mg Tab 02163918 Tylenol No.4 00621463 Ratio-Lenoltec No.4 00666149 Empracet-60 (Not a Benefit) .0586 JNO PMS BWE RPH JNO RPH BWE .0586 .1300 .1300 .1384 .1384 .1384
664
665
ACETAMINOPHEN COMPOUND WITH CODEINE

666 15mg Tab 02163934 00293504 00653241 30mg Tab 02163926 00293512 00653276 Tylenol No.2 Atasol-15 (Not a Benefit) Ratio-Lenoltec No.2 Tylenol No.3 Atasol-30 (Not a Benefit) Ratio-Lenoltec No.3 JNO HOR RPH JNO HOR RPH .0476 .0476 .0476 .0524 .0524 .0524
667
ACETYLSALICYLIC ACID COMPOUND WITH CODEINE

668 30mg Tab 02238645 292 PEN .1020 .1020
IIIA.136
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CODEINE PHOSPHATE
669 670 5mg/mL O/L 00779474 15mg Tab 00779458 00593435 30mg Tab 00593451 Ratio-Codeine Codeine Ratio-Codeine Ratio-Codeine RPH ROG RPH RPH .0196 .0196 .0542 .0542 .0542 .0773 .0773
671
CODEINE SULFATE TRIHYDRATE & MONOHYDRATE

672 673 674 675
ED ON T TI D MI SE TA IRE LI U EN U UM REQ OC D
100mg CR Tab 02163748 150mg CR Tab 02163780 200mg CR Tab 02163799 Reason for Use Code 201 Codeine Contin Codeine Contin Codeine Contin PFP PFP PFP Clinical criteria LU Authorization Period: 1 year.
50mg CR Tab 02230302
Codeine Contin
PFP
.2990 .2990 .5980 .5980 .9038 .9038
1.1962 1.1962
For the treatment of chronic pain in patients who cannot tolerate, or have failed treatment with a listed long-acting opioid.
JUNE 27, 2008
IIIA.137
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FENTANYL TRANSDERMAL SYSTEM

676
677
678
679
N ED T E I IO IM US AT L NT D E M IRE CU QU DO RE
50mcg/hr Trans Patch 01937391 Duragesic 50 02249413 Ran-Fentanyl 02282968 Ratio-Fentanyl 75mcg/hr Trans Patch 01937405 Duragesic 75 02249421 Ran-Fentanyl 02282976 Ratio-Fentanyl 100mcg/hr Trans Patch 01937413 Duragesic 100 02249448 Ran-Fentanyl 02282984 Ratio-Fentanyl Reason for Use Code 201 JNO RAN RPH JNO RAN RPH JNO RAN RPH 8.0000 18.7320 8.0000 8.0000 11.2500 26.3440 11.2500 11.2500 14.0000 32.7920 14.0000 14.0000 Clinical criteria LU Authorization Period: 1 year.
25mcg/hr Trans Patch 01937383 Duragesic 25 02249391 Ran-Fentanyl 02282941 Ratio-Fentanyl
JNO RAN RPH
4.2500 9.9540 4.2500 4.2500
For the treament of chronic pain in patients who cannot tolerate, or have failed treatment with a listed long-acting opioid.
HYDROMORPHONE HCL
680 681 682 3mg CR Cap 02125323 6mg CR Cap 02125331 12mg CR Cap 02125366 Hydromorph Contin Hydromorph Contin Hydromorph Contin PFP PFP PFP .6380 .6380 .9570 .9570 1.6588 1.6588
IIIA.138
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

HYDROMORPHONE HCL
683 684 685 686 18mg CR Cap 02243562 24mg CR Cap 02125382 30mg CR Cap 02125390 20mg/mL Inj 02146118 02145936 Hydromorph Contin Hydromorph Contin Hydromorph Contin Dilaudid-HP-Plus Hydromorphone HP-20 PFP PFP PFP ABB SDZ ABB SDZ ABB SDZ ABB SDZ ABB PMS ABB ABB ABB PMS 2.3924 2.3924 3.0624 3.0624 3.6684 3.6684 3.6680 3.6680 3.6680 .9450 .9500 .9450 2.3380 2.3380 2.3380 9.7335 9.7335 9.7335 .0652 .0931 .0652 67.5750 67.5750 2.6000 2.6000 .0959 .0959 .0959
687
2mg/mL Inj Sol-1mL Pk 00627100 Dilaudid 02145901 Hydromorphone 10mg/mL Inj Sol-1mL Pk 00622133 Dilaudid-HP 02145928 Hydromorphone HP-10 50mg/mL Inj-1mL Pk 02145863 Dilaudid-XP 02146126 Hydromorphone HP-50 1mg/mL Oral Sol 00786535 01916386 250mg Pd Vial Pk 02085895 3mg Sup 00125105 1mg Tab 00705438 00885444 Dilaudid PMS-Hydromorphone Dilaudid Sterile Powder Dilaudid Dilaudid PMS-Hydromorphone
688
689
690
691 692 693
JUNE 27, 2008
IIIA.139
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

HYDROMORPHONE HCL
694 2mg Tab 00125083 00885436 4mg Tab 00125121 00885401 8mg Tab 00786543 00885428 Dilaudid PMS-Hydromorphone Dilaudid PMS-Hydromorphone Dilaudid PMS-Hydromorphone ABB PMS ABB PMS ABB PMS .1417 .1417 .1417 .2240 .2240 .2240 .3528 .3528 .3528
695
696
MEPERIDINE HCL
697 50mg Tab 02138018 SAV ION D Reason for Clinical criteria AT D E Use Code TE NT UIRE US 2 ME E for IMI Limited toUweeks supplyQ acute pain. L270 R OC LU Authorization Period: 1 year. D Demerol .1197 .1197
MORPHINE HCL
698 1mg/mL O/L 00486582 00607762 5mg/mL O/L 00514217 00607770 10mg/mL O/L 00632503 00690783 .0200 M.O.S. (Not a Benefit) Ratio-Morphine M.O.S. Ratio-Morphine M.O.S. Ratio-Morphine VAL RPH VAL RPH VAL RPH .0200 .0842 .0842 .0842 .1838 .1838 .1838
699
700
IIIA.140
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MORPHINE HCL
701 20mg/mL O/L 00632481 00690791 50mg/mL O/L 00690236 10mg Tab 00690198 20mg Tab 00690201 40mg Tab 00690228 60mg Tab 00690244 M.O.S. Ratio-Morphine M.O.S. Conc 50 M.O.S.-10 M.O.S.-20 M.O.S.-40 M.O.S.-60 VAL RPH VAL VAL VAL VAL VAL .5240 .5240 .5241 1.2426 1.2426 .1700 .1700 .3243 .3243 .4214 .4214 .5851 .5851
702 703 704 705 706
MORPHINE SULFATE
707 708 709 710 711 712 10mg ER Cap 02019930 15mg ER Cap 02177749 30mg ER Cap 02019949 60mg ER Cap 02019957 100mg ER Cap 02019965 200mg ER Cap 02177757 M-Eslon M-Eslon M-Eslon M-Eslon M-Eslon M-Eslon ETH ETH ETH ETH ETH ETH .2900 .2900 .3350 .3350 .5000 .5000 .8875 .8875 1.9100 1.9100 3.8198 3.8198
JUNE 27, 2008
IIIA.141
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MORPHINE SULFATE
713 15mg/mL Inj Sol Amp 00850330 Morphine Sulfate Injection USP (Not a Benefit) 00392561 Morphine Sulfate 50mg/mL Inj Sol-1mL Pk 00617288 Morphine HP-50 1mg/mL O/L 00591467 5mg/mL O/L 00591475 Statex Statex .9000 ABB SDZ SDZ PMS PMS PMS ABB ABB ABB ABB PFP RPH PMS PFP RPH PMS .9000 3.1400 3.1400 .0200 .0200 .0803 .0803 .3857 .3857 .3502 .3502 .7004 .7004 1.2875 1.2875 2.2454 2.2454 .2977 .6490 .2977 .2977 .4495 .9798 .4495 .4495
714 715 716 717 718 719 720 721 722
20mg/mL Oral Drops 00621935 Statex 10mg SR Cap 02242163 20mg SR Cap 02184435 50mg SR Cap 02184443 100mg SR Cap 02184451 15mg SR Tab 02015439 02244790 02245284 30mg SR Tab 02014297 02244791 02245285 Kadian Kadian Kadian Kadian MS Contin Ratio-Morphine SR PMS-Morphine Sulfate MS Contin Ratio-Morphine SR PMS-Morphine Sulfate
723
IIIA.142
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MORPHINE SULFATE
724 60mg SR Tab 02014300 02244792 02245286 02302780 100mg SR Tab 02014319 02245287 02302799 200mg SR Tab 02014327 02245288 02302802 20mg Tab 02014238 30mg Tab 02014254 5mg Tab 00594652 10mg Tab 00594644 25mg Tab 00594636 50mg Tab 00675962 MS Contin Ratio-Morphine SR PMS-Morphine Sulfate Novo-Morphine SR MS Contin + PMS-Morphine Sulfate SR Novo-Morphine SR MS Contin + PMS-Morphine Sulfate SR Novo-Morphine SR MS-IR MS-IR Statex Statex Statex Statex PFP RPH PMS NOP PFP PMS NOP PFP PMS NOP PFP PFP PMS PMS PMS PMS .7924 1.7272 .7924 .7924 .7924 1.2909 2.6334 1.2909 1.2909 2.3999 4.8958 2.3999 2.3999 .3290 .3290 .4224 .4224 .1100 .1100 .1700 .1700 .2250 .2250 .3450 .3450
725
726
727 728 729 730 731 732
JUNE 27, 2008
IIIA.143
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

OXYCODONE HCL
733 734 735 736

20mg SR Tab 02202468 40mg SR Tab 02202476 80mg SR Tab 02202484 Reason for Use Code 201 Oxycontin Oxycontin Oxycontin PFP PFP PFP Clinical criteria LU Authorization Period: 1 year.
10mg SR Tab 02202441
Oxycontin
PFP
.8506 .8506
1.2758 1.2758 2.2116 2.2116 4.0828 4.0828
For the treatment of chronic pain in patients who cannot tolerate, or have failed treatment with a listed long-acting opioid.
OXYCODONE HCL & ACETAMINOPHEN

737 5mg & 325mg Tab 00580201 00608165 01916548 .1285 Percocet (Not a Benefit) Ratio-Oxycocet Endocet BQU RPH BQU .1285 .1285
IIIA.144
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

OXYCODONE HCL & ACETYLSALICYLIC ACID

738 5mg & 325mg Tab 00580236 00608157 .2576 Percodan (Not a Benefit) Ratio-Oxycodan BQU RPH .2576
28:08:92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS

ACETAMINOPHEN
739 80mg/mL O/L 00631353 00642401 02027801 120mg Sup 01919385 02230434 325mg Sup 01919393 02230436 650mg Sup 01919407 02230437 * 325mg Tab 00293482 00389218 00544981 00589241 01928260 .1197 Atasol (Not a Benefit) Tempra (Not a Benefit) Pediatrix Abenol (Not a Benefit) ACET 120 Abenol (Not a Benefit) ACET 325 Abenol (Not a Benefit) ACET 650 Atasol (Not a Benefit) Novo-Gesic Apo-Acetaminophen Acetaminophen Panadol HOR MJS RPH PEN PMS PEN PMS PEN PMS HOR NOP APX DPC STH .1197 .5367 .5367 .6625 .6625 .7608 .7608 .0114 .0114 .0114 .0114 .0344
740
741
742
743
JUNE 27, 2008
IIIA.145
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

28:08:92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS
ACETAMINOPHEN
744 * 500mg Tab 00013668 00482323 00545007 00589233 .0149 Atasol Forte (Not a Benefit) Novo-Gesic Forte Apo-Acetaminophen Acetaminophen Extra Strength HOR NOP APX DPC .0149 .0149 .0149
28:12:00 ANTICONVULSANTS
CARBAMAZEPINE
745 100mg Chew Tab 00369810 02231542 02244403 02261855 200mg Chew Tab 00665088 02231540 02244404 02261863 Tegretol PMS-Carbamazepine Taro-Carbamazepine Sandoz Carbamazepine Chewtabs Tegretol PMS-Carbamazepine Taro-Carbamazepine Sandoz Carbamazepine Chewtabs NOV PMS TAR SDZ NOV PMS TAR SDZ .0612 .1446 .0612 .0612 .0612 .1207 .2852 .1207 .1207 .1207
746
IIIA.146
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CARBAMAZEPINE
747 200mg LA Tab 00773611 02231543 02241882 02242908 02261839 400mg LA Tab 00755583 02231544 02241883 02242909 02261847 Reason for Use Code 67 Tegretol CR PMS-Carbamazepine CR Gen-Carbamazepine CR Apo-Carbamazepine CR Sandoz Carbamazepine CR Tegretol CR PMS-Carbamazepine CR Gen-Carbamazepine CR Apo-Carbamazepine CR Sandoz Carbamazepine CR NOV PMS GEN APX SDZ NOV PMS GEN APX SDZ .1498 .3541 .1498 .1498 .1887 .1498 .2996 .7081 .2996 .2996 .3774 .2996
748
Clinical criteria LU Authorization Period: Indefinite. NOV NOV APX NOP NXP Tegretol (Not a Benefit) Apo-Carbamazepine Novo-Carbamaz Nu-Carbamazepine
For patients who have been tried on conventional carbamazepine with unsatisfactory results due to adverse effects or poor control of symptoms. .0683 .0683 .0795 .0795 .0795 .0795
749 750
100mg/5mL Oral Susp 02194333 Tegretol 200mg Tab 00010405 00402699 00782718 02042568
JUNE 27, 2008
IIIA.147
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CLOBAZAM
751 10mg Tab 02221799 02238334 02238797 02244474 02244638 Reason for Use Code 23 .1709 .4393 .1709 .1709 .1709 .1709
ED ON IT E TI D TA IRE LIM US EN U UM REQ OC D

Frisium Novo-Clobazam Ratio-Clobazam PMS-Clobazam Apo-Clobazam
OVA NOP RPH PMS APX
As adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory. NOTE: Because a large number of patients will become refractory to the anticonvulsant effects of the drug over a period of time, the effectiveness of this drug must be re-evaluated after a period of six months.
CLONAZEPAM
752 0.5mg Tab 00382825 02048701 02103656 02173344 02177889 02207818 02230950 02233960 02239024 02270641 2mg Tab 00382841 02048736 02103737 02173352 02177897 02230951 02233985 02239025 02270676 Rivotril PMS-Clonazepam Ratio-Clonazepam Nu-Clonazepam Apo-Clonazepam PMS-Clonazepam-R Gen-Clonazepam Sandoz Clonazepam Novo-Clonazepam Co Clonazepam Rivotril PMS-Clonazepam Ratio-Clonazepam Nu-Clonazepam Apo-Clonazepam Gen-Clonazepam Sandoz Clonazepam Novo-Clonazepam Co Clonazepam HLR PMS RPH NXP APX PMS GEN SDZ NOP COB HLR PMS RPH NXP APX GEN SDZ NOP COB .0925 .1943 .0925 .0925 .0925 .0925 .0925 .0925 .0925 .0925 .0925 .1595 .3350 .1595 .1595 .1595 .1595 .1595 .1595 .1595 .1595
753
IIIA.148
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DIVALPROEX SODIUM
754 125mg Ent Tab 00596418 02239517 02239698 02239701 02244138 02265133 250mg Ent Tab 00596426 02239518 02239699 02239702 02244139 02265141 500mg Ent Tab 00596434 02239519 02239700 02239703 02244140 02265168 Epival Nu-Divalproex Apo-Divalproex Novo-Divalproex PMS-Divalproex Gen-Divalproex Epival Nu-Divalproex Apo-Divalproex Novo-Divalproex PMS-Divalproex Gen-Divalproex Epival Nu-Divalproex Apo-Divalproex Novo-Divalproex PMS-Divalproex Gen-Divalproex ABB NXP APX NOP PMS GEN ABB NXP APX NOP PMS GEN ABB NXP APX NOP PMS GEN .1093 .2627 .1093 .1093 .1093 .1093 .1093 .1964 .4721 .1964 .1964 .1964 .1964 .1964 .3931 .9447 .3931 .3931 .3931 .3931 .3931
755
756
ETHOSUXIMIDE
757 758 250mg Cap 00022799 50mg/mL O/L 00023485 Zarontin Zarontin ERF ERF .3100 .3100 .0620 .0620
JUNE 27, 2008
IIIA.149
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

GABAPENTIN
759 100mg Cap 02084260 02243446 02244304 02244513 02248259 02256142 02260883 300mg Cap 02084279 02243447 02244305 02244514 02248260 02256150 02260891 400mg Cap 02084287 02243448 02244306 02244515 02248261 02256169 02260905 Reason for Use Code 136 Neurontin PMS-Gabapentin Apo-Gabapentin Novo-Gabapentin Gen-Gabapentin Co-Gabapentin Ratio-Gabapentin Neurontin PMS-Gabapentin Apo-Gabapentin Novo-Gabapentin Gen-Gabapentin Co-Gabapentin Ratio-Gabapentin Neurontin PMS-Gabapentin Apo-Gabapentin Novo-Gabapentin Gen-Gabapentin Co-Gabapentin Ratio-Gabapentin PFI PMS APX NOP GEN COB RPH PFI PMS APX NOP GEN COB RPH PFI PMS APX NOP GEN COB RPH .2000 .4160 .2000 .2000 .2000 .2000 .2000 .2000
760
761
ED IT E N IM S IO L U TAT EN D M U IRE C U DO EQ R
.4865 1.0119 .4865 .4865 .4865 .4865 .4865 .4865 .5798 1.2059 .5798 .5798 .5798 .5798 .5798 .5798 Clinical criteria As adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory. NOTE: Because a large number of patients may become refractory to the anticonvulsant effects of the drug over a period of time, the effectiveness of this drug must be re-evaluated after a period of six months. LU Authorization Period: Indefinite.
IIIA.150
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LAMOTRIGINE
762 25mg Tab 02142082 02243352 02245208 02246897 02248232 02265494 100mg Tab 02142104 02243353 02245209 02246898 02248233 02265508 150mg Tab 02142112 02245210 02246899 02246963 02248234 02265516 Reason for Use Code 136 Lamictal Ratio-Lamotrigine Apo-Lamotrigine PMS-Lamotrigine Novo-Lamotrigine Gen-Lamotrigine Lamictal Ratio-Lamotrigine Apo-Lamotrigine PMS-Lamotrigine Novo-Lamotrigine Gen-Lamotrigine Lamictal Apo-Lamotrigine PMS-Lamotrigine Ratio-Lamotrigine Novo-Lamotrigine Gen-Lamotrigine GSK RPH APX PMS NOP GEN GSK RPH APX PMS NOP GEN GSK APX PMS RPH NOP GEN .1658 .3656 .1658 .1658 .1658 .1658 .1658
763
764
.6630 1.4595 .6630 .6630 .6630 .6630 .6630 .9945 2.2018 .9945 .9945 .9945 .9945 .9945 Clinical criteria As adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory. LU Authorization Period: Indefinite.
NOTE: Because a large number of patients may become refractory to the anticonvulsant effects of the drug over a period of time, the effectiveness of this drug must be re-evaluated after a period of six months.
METHSUXIMIDE
765 300mg Cap 00022802 Celontin ERF .3800 .3800
JUNE 27, 2008
IIIA.151
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PHENYTOIN (DIPHENYLHYDANTOIN)
766 767 6mg/mL O/L 00023442 25mg/mL O/L 00023450 02250896 50mg Tab 00023698 Dilantin Dilantin Taro-Phenytoin Dilantin PFI PFI TAR PFI .0390 .0390 .0323 .0462 .0323 .0709 .0709
768
PHENYTOIN (DIPHENYLHYDANTOIN) SODIUM

769 770 30mg Cap 00022772 100mg Cap 00022780 Dilantin Dilantin PFI PFI .0517 .0517 .0646 .0646
PRIMIDONE
771 125mg Tab 02042363 00399310 250mg Tab 02042355 00396761 .0435 Mysoline (Not a Benefit) Apo-Primidone Mysoline (Not a Benefit) Apo-Primidone WAY APX WAY APX .0435 .0685 .0685
772
TOPIRAMATE
773 774 15mg Sprinkle Cap 02239907 Topamax Sprinkle 25mg Sprinkle Cap 02239908 Topamax Sprinkle Reason for Use Code 321 Clinical criteria JNO JNO 1.1087 1.1087 1.1640 1.1640
ION D ED TAT IRE MIT SE LI EN QU U M RE CU DO

In children age 16 and under, as adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory.
IIIA.152
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TOPIRAMATE
775 25mg Tab 02230893 02248860 02256827 02260050 02262991 02263351 02279614 02287765 100mg Tab 02230894 02248861 02256835 02260069 02263009 02263378 02279630 02287773 200mg Tab 02230896 02248862 02256843 02263017 02263386 02267837 02279649 02287781 Reason for Use Code 223 Topamax Novo-Topiramate Ratio-Topiramate Sandoz Topiramate PMS-Topiramate Gen-Topiramate Apo-Topiramate Co Topiramate Topamax Novo-Topiramate Ratio-Topiramate Sandoz Topiramate PMS-Topiramate Gen-Topiramate Apo-Topiramate Co Topiramate Topamax Novo-Topiramate Ratio-Topiramate PMS-Topiramate Gen-Topiramate Sandoz Topiramate Apo-Topiramate Co Topiramate JNO NOP RPH SDZ PMS GEN APX COB JNO NOP RPH SDZ PMS GEN APX COB JNO NOP RPH PMS GEN SDZ APX COB .5250 1.2339 .5250 .5250 .5250 .5250 .5250 .5250 .5250 .9950 2.3388 .9950 .9950 .9950 .9950 .9950 .9950 .9950
776
777
ED IT E N IM S IO L U TAT EN D M U RE C I DO EQU R
1.5750 3.4923 1.5750 1.5750 1.5750 1.5750 1.5750 1.5750 1.5750 Clinical criteria As adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory. NOTE: Because a large number of patients may become refractory to the anticonvulsant effects of the drug over a period of time, the effectiveness of this drug must be re-evaluated after a period of six months. LU Authorization Period: Indefinite.
JUNE 27, 2008
IIIA.153
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

VALPROATE SODIUM
778 50mg/mL O/L 00443832 02140063 02236807 02238370 Depakene Ratio-Valproic PMS-Valproic Acid Apo-Valproic ABB RPH PMS APX .0458 .1033 .0458 .0458 .0458
VALPROIC ACID
779 250mg Cap 00443840 02100630 02140047 02184648 02230768 02237830 02238048 02239714 500mg Ent Cap 00507989 02140055 02229628 02239713 Depakene Novo-Valproic Ratio-Valproic Gen-Valproic PMS-Valproic Acid Nu-Valproic Apo-Valproic Sandoz Valproic Depakene (Not a Benefit) Ratio-Valproic EC PMS-Valproic Acid Sandoz Valproic ABB NOP RPH GEN PMS NXP APX SDZ ABB RPH PMS SDZ .2062 .4957 .2062 .2062 .2062 .2062 .2062 .2062 .2062 .4125 .4125 .4125 .4125
780
VIGABATRIN
781 500mg Tab 02065819 Reason for Use Code 136 Sabril Clinical criteria OVA .9110 .9110
ION D ED MIT SE TAT IRE LI EN QU U M RE CU DO

As adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory. NOTE: Because a large number of patients may become refractory to the anticonvulsant effects of the drug over a period of time, the effectiveness of this drug must be re-evaluated after a period of six months.
IIIA.154
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

28:16:04 PSYCHOTHERAPEUTIC AGENTS ANTIDEPRESSANTS
AMITRIPTYLINE
782 10mg Tab 00016322 00335053 25mg Tab 00016330 00335061 50mg Tab 00016349 00335088 .0435 Elavil (Not a Benefit) Apo-Amitriptyline Elavil (Not a Benefit) Apo-Amitriptyline Elavil (Not a Benefit) Apo-Amitriptyline MSD APX MSD APX MSD APX .0435 .0829 .0829 .1540 .1540
783
784
BUPROPION HCL
785 100mg Tab 02237824 02275074 02285657 150mg Tab 02237825 02260239 02275082 02285665 150mg Tab 02275090 300mg Tab 02275104 Reason for Use Code 315 Wellbutrin SR Sandoz Bupropion SR Ratio-Bupropion SR Wellbutrin SR Novo-Bupropion SR Sandoz Bupropion SR Ratio-Bupropion SR Wellbutrin XL Wellbutrin XL BIO SDZ RPH .2667 .6008 .2667 .2667 .4000 .8925 .4000 .4000 .4000 .5190 .5190
786
787 788
ED IT E ON IM TI L US NTA D ME UIRE CU EQ DO R
BIO NOP SDZ RPH BIO BIO Clinical criteria For the treatment of depression. LU Authorization Period: Indefinite.
1.0380 1.0380
JUNE 27, 2008
IIIA.155
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CITALOPRAM HYDROBROMIDE
789 20mg Tab 02239607 02246056 02246594 02248010 02248050 02248170 02251558 02252112 02285622 02293218 40mg Tab 02239608 02246057 02246595 02248011 02248051 02248171 02251566 02252120 02285630 02293226 Celexa Apo-Citalopram Gen-Citalopram PMS-Citalopram Co-Citalopram Sandoz Citalopram # Novo-Citalopram Ratio-Citalopram Ran-Citalo Novo-Citalopram Celexa Apo-Citalopram Gen-Citalopram PMS-Citalopram Co-Citalopram Sandoz Citalopram # Novo-Citalopram Ratio-Citalopram Ran-Citalo Novo-Citalopram VLH APX GEN PMS COB SDZ NOP RPH RAN NOP VLH APX GEN PMS COB SDZ NOP RPH RAN NOP .6250 1.3055 .6250 .6250 .6250 .6250 .6250 .6250 .6250 .6250 .6250 .6250 1.3057 .6250 .6250 .6250 .6250 .6250 .6250 .6250 .6250 .6250
790
CLOMIPRAMINE HCL
791 10mg Tab 00330566 02040786 02139340 02244816 25mg Tab 00324019 02040778 02139359 02244817 50mg Tab 00402591 02040751 02139367 02244818 Anafranil Apo-Clomipramine # Gen-Clomipramine Co-Clomipramine Anafranil Apo-Clomipramine # Gen-Clomipramine Co-Clomipramine Anafranil Apo-Clomipramine # Gen-Clomipramine Co-Clomipramine ORY APX GEN COB ORY APX GEN COB ORY APX GEN COB .1290 .2581 .1290 .1290 .1290 .1758 .3516 .1758 .1758 .1758 .3237 .6474 .3237 .3237 .3237
792
793
IIIA.156
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DESIPRAMINE
794 25mg Tab 02099128 00010448 01946269 01948784 02211947 02216256 50mg Tab 02099136 01946277 01948792 02211955 02216264 75mg Tab 02099144 01946242 02211963 02216272 # Norpramin Pertofrane (Not a Benefit) PMS-Desipramine Ratio-Desipramine Nu-Desipramine Apo-Desipramine # Norpramin PMS-Desipramine Ratio-Desipramine Nu-Desipramine Apo-Desipramine Norpramin (Not a Benefit) PMS-Desipramine Nu-Desipramine Apo-Desipramine SAV GEI PMS RPH NXP APX SAV PMS RPH NXP APX HMR PMS NXP APX .1729 .4004 .1885 .1729 .1885 .1729 .3048 .7057 .3048 .3048 .3048 .3048 .4696 .4696 .4696 .4696
795
796
DOXEPIN HCL
797 10mg Cap 00024325 02049996 25mg Cap 00024333 02050005 50mg Cap 00024341 02050013 75mg Cap 00400750 01913441 02050021 100mg Cap 00326925 01913468 02050048 Sinequan Apo-Doxepin Sinequan Apo-Doxepin Sinequan Apo-Doxepin Sinequan Novo-Doxepin Apo-Doxepin Sinequan Novo-Doxepin Apo-Doxepin ERF APX ERF APX ERF APX ERF NOP APX ERF NOP APX .1745 .2493 .1745 .2140 .3058 .2140 .3971 .5673 .3971 .3916 .8146 .3916 .3916 .5160 1.0733 .5160 .5160
798
799
800
801
JUNE 27, 2008
IIIA.157
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DOXEPIN HCL
802 150mg Cap 00584274 01913476 .7109 Sinequan (Not a Benefit) Novo-Doxepin PFI NOP .7109
FLUOXETINE HCL
Note: Because of the long half-life of the fluoxetine metabolite, steady-state concentrations occur only after 4-6 weeks. Use with caution in anorexic patients. Fluoxetine therapy should be discontinued for 5 weeks before starting irreversible monoamine oxidase inhibitors (MAOI). Similarly irreversible MAOI should be discontinued for 2 weeks before starting fluoxetine. 803 20mg Cap 00636622 02177587 02192764 02216361 02216590 02237814 02241374 02242178 02243487 Prozac PMS-Fluoxetine Nu-Fluoxetine Apo-Fluoxetine Novo-Fluoxetine Gen-Fluoxetine Ratio-Fluoxetine Co-Fluoxetine Sandoz Fluoxetine LIL PMS NXP APX NOP GEN RPH COB SDZ .8025 1.8038 .8025 .8025 .8025 .8025 .8025 .8025 .8025 .8025
FLUVOXAMINE MALEATE
Note: Fluvoxamine therapy should be discontinued for 2 weeks before starting irreversible monoamine oxidase inhibitors (MAOI). Similarly irreversible MAOI should be discontinued for 2 weeks before starting fluvoxamine. 804 50mg Tab 01919342 02218453 02231192 02231329 02239953 02240682 02247054 02255529 Luvox Ratio-Fluvoxamine Nu-Fluvoxamine Apo-Fluvoxamine Novo-Fluvoxamine PMS-Fluvoxamine Sandoz Fluvoxamine Co-Fluvoxamine SPH RPH NXP APX NOP PMS SDZ COB .3930 .8253 .3930 .3930 .3930 .3930 .3930 .3930 .3930
IIIA.158
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLUVOXAMINE MALEATE
Note: Fluvoxamine therapy should be discontinued for 2 weeks before starting irreversible monoamine oxidase inhibitors (MAOI). Similarly irreversible MAOI should be discontinued for 2 weeks before starting fluvoxamine. 805 100mg Tab 01919369 02218461 02231193 02231330 02239954 02240683 02247055 02255537 Luvox Ratio-Fluvoxamine Nu-Fluvoxamine Apo-Fluvoxamine Novo-Fluvoxamine PMS-Fluvoxamine Sandoz Fluvoxamine Co-Fluvoxamine SPH RPH NXP APX NOP PMS SDZ COB .7065 1.4837 .7065 .7065 .7065 .7065 .7065 .7065 .7065
IMIPRAMINE
806 10mg Tab 00010464 00360201 25mg Tab 00010472 00312797 50mg Tab 00010480 00326852 .0865 Tofranil (Not a Benefit) Apo-Imipramine # Tofranil Apo-Imipramine Tofranil Apo-Imipramine NOV APX NOV APX NOV APX .0865 .1374 .2601 .1374 .2554 .5076 .2554
807
808
MAPROTILINE HCL
809 25mg Tab 00360481 02158612 50mg Tab 00360503 02158620 75mg Tab 00360511 02158639 .5493 Ludiomil (Not a Benefit) Novo-Maprotiline Ludiomil (Not a Benefit) Novo-Maprotiline Ludiomil (Not a Benefit) Novo-Maprotiline CIB NOP NOV NOP NOV NOP .5493 1.0401 1.0401 1.4204 1.4204
810
811
JUNE 27, 2008
IIIA.159
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MIRTAZAPINE
812 15mg Orally Disintegrating Tab 02248542 Remeron RD 02279894 Novo-Mirtazapine OD 30mg Orally Disintegrating Tab 02248543 Remeron RD 02279908 Novo-Mirtazapine OD 45mg Orally Disintegrating Tab 02248544 Remeron RD 02279916 Novo-Mirtazapine OD 30mg Tab 02243910 02248762 02250608 02256118 02259354 02267292 02270927 02274361 02286629 Remeron PMS-Mirtazapine Sandoz Mirtazapine Gen-Mirtazapine Novo-Mirtazapine Sandoz Mirtazapine FC Ratio-Mirtazapine Co Mirtazapine Apo-Mirtazapine ORG NOP ORG NOP ORG NOP ORG PMS SDZ GEN NOP SDZ RPH COB APX .1950 .3900 .1950 .3900 .7800 .3900 .5850 1.1700 .5850 .6200 1.2400 .6200 .6200 .6200 .6200 .6200 .6200 .6200 .6200
813
814
815
MOCLOBEMIDE
816 100mg Tab 00899348 02232148 02239746 150mg Tab 00899356 02232150 02239747 02243218 300mg Tab 02166747 02239748 02240456 02243219 .2520 Manerix (Not a Benefit) Apo-Moclobemide Novo-Moclobemide Manerix Apo-Moclobemide Novo-Moclobemide PMS-Moclobemide Manerix Novo-Moclobemide Apo-Moclobemide PMS-Moclobemide HLR APX NOP HLR APX NOP PMS HLR NOP APX PMS .2520 .2520 .2900 .5939 .2900 .2900 .2900 .5695 1.1663 .5695 .5695 .5695
817
818
IIIA.160
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

NORTRIPTYLINE
819 10mg Cap 00015229 02177692 02223139 02223511 02231686 02231781 02240789 25mg Cap 00015237 02177706 02223147 02223538 02231687 02231782 02240790 Aventyl PMS-Nortriptyline Nu-Nortriptyline Apo-Nortriptyline Gen-Nortriptyline Novo-Nortriptyline Ratio-Nortriptyline Aventyl PMS-Nortriptyline Nu-Nortriptyline Apo-Nortriptyline Gen-Nortriptyline Novo-Nortriptyline Ratio-Nortriptyline PHE PMS NXP APX GEN NOP RPH PHE PMS NXP APX GEN NOP RPH .1000 .2000 .1000 .1000 .1000 .1000 .1000 .1000 .2022 .4043 .2022 .2022 .2022 .2022 .2022 .2022
820
PAROXETINE HCL
821 20mg Tab 01940481 02240908 02247751 02247811 02248013 02248557 02254751 02262754 30mg Tab 01940473 02240909 02247752 02247812 02248014 02248558 02254778 02262762 Paxil Apo-Paroxetine PMS-Paroxetine Ratio-Paroxetine Gen-Paroxetine Novo-Paroxetine Sandoz Paroxetine Co-Paroxetine Paxil Apo-Paroxetine PMS-Paroxetine Ratio-Paroxetine Gen-Paroxetine Novo-Paroxetine Sandoz Paroxetine Co-Paroxetine GSK APX PMS RPH GEN NOP SDZ COB GSK APX PMS RPH GEN NOP SDZ COB .7950 1.7640 .7950 .7950 .7950 .7950 .7950 .7950 .7950 .8450 1.8742 .8450 .8450 .8450 .8450 .8450 .8450 .8450
822
JUNE 27, 2008
IIIA.161
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PHENELZINE SULFATE
823 15mg Tab 00476552 Nardil ERF .3482 .3482
Note: Consult the scientific literature regarding cautions and contraindications prior to prescribing and/or dispensing irreversible monoamine oxidase inhibitors.
SERTRALINE HCL
Note: Sertraline therapy should be discontinued for 2 weeks before starting irreversible monoamine oxidase inhibitors (MAOI). Similarly irreversible MAOI should be discontinued for 2 weeks before starting sertraline. 824 25mg Cap 02132702 02238280 02240485 02242519 02244838 02245159 02245787 02287390 50mg Cap 01962817 02238281 02240484 02242520 02244839 02245160 02245788 02287404 100mg Cap 01962779 02238282 02240481 02242521 02244840 02245161 02245789 02287412 Zoloft Apo-Sertraline Novo-Sertraline Gen-Sertraline PMS-Sertraline Sandoz Sertraline Ratio-Sertraline Co Sertraline Zoloft Apo-Sertraline Novo-Sertraline Gen-Sertraline PMS-Sertraline Sandoz Sertraline Ratio-Sertraline Co Sertraline Zoloft Apo-Sertraline Novo-Sertraline Gen-Sertraline PMS-Sertraline Sandoz Sertraline Ratio-Sertraline Co Sertraline PFI APX NOP GEN PMS SDZ RPH COB PFI APX NOP GEN PMS SDZ RPH COB PFI APX NOP GEN PMS SDZ RPH COB .4000 .8000 .4000 .4000 .4000 .4000 .4000 .4000 .4000 .8000 1.6000 .8000 .8000 .8000 .8000 .8000 .8000 .8000 .8750 1.7500 .8750 .8750 .8750 .8750 .8750 .8750 .8750
825
826
IIIA.162
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TRANYLCYPROMINE SULFATE
827 10mg Tab 01919598 Parnate GSK .3598 .3598
Note: Consult the scientific literature regarding cautions and contraindications prior to prescribing and/or dispensing irreversible monoamine oxidase inhibitors.
TRAZODONE HYDROCHLORIDE
828 50mg Tab 00579351 01937227 02144263 02147637 02231683 02277344 100mg Tab 00579378 01937235 02144271 02147645 02231684 02277352 150mg Tab 00702277 02144298 02147653 02277360 Desyrel PMS-Trazodone Novo-Trazodone Apo-Trazodone Gen-Trazodone Ratio-Trazodone Desyrel PMS-Trazodone Novo-Trazodone Apo-Trazodone Gen-Trazodone Ratio-Trazodone Desyrel Dividose Novo-Trazodone Apo-Trazodone D Ratio-Trazodone BQU PMS NOP APX GEN RPH BQU PMS NOP APX GEN RPH BQU NOP APX RPH .2214 .2214 .2214 .2214 .2214 .2214 .2214 .3956 .3956 .3956 .3956 .3956 .3956 .3956 .5812 .5812 .5812 .5812 .5812
829
830
TRIMIPRAMINE
831 75mg Cap 00761656 01926349 02070987 12.5mg Tab 01926357 00740799 25mg Tab 01926322 00740802 02020602 # Rhotrimine Surmontil (Not a Benefit) Apo-Trimip Surmontil (Not a Benefit) Apo-Trimip Surmontil (Not a Benefit) Apo-Trimip Nu-Trimipramine SAV RPP APX RPP APX RPP APX NXP .5197 .5197 .5197 .0820 .0820 .1040 .1040 .1040
832
833
JUNE 27, 2008
IIIA.163
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TRIMIPRAMINE
834 50mg Tab 01926330 00740810 02020610 100mg Tab 01926284 00740829 00761648 02020629 .1999 Surmontil (Not a Benefit) Apo-Trimip Nu-Trimipramine Surmontil (Not a Benefit) Apo-Trimip # Rhotrimine Nu-Trimipramine RPP APX NXP RPP APX SAV NXP .1999 .1999 .3418 .3418 .3418 .3418
835
VENLAFAXINE HCL
836 37.5mg ER Cap 02237279 02273969 02275023 02278545 02304317 75mg ER Cap 02237280 02273977 02275031 02278553 02304325 150mg ER Cap 02237282 02273985 02275058 02278561 02304333 Effexor XR Ratio-Venlafaxine XR Novo-Venlafaxine XR PMS-Venlafaxine XR Co Venlafaxine XR Effexor XR Ratio-Venlafaxine XR Novo-Venlafaxine XR PMS-Venlafaxine XR Co Venlafaxine XR Effexor XR Ratio-Venlafaxine XR Novo-Venlafaxine XR PMS-Venlafaxine XR Co Venlafaxine XR WAY RPH NOP PMS COB WAY RPH NOP PMS COB WAY RPH NOP PMS COB .4200 .8567 .4200 .4200 .4200 .4200 .8399 1.7133 .8399 .8399 .8399 .8399 .8868 1.8090 .8868 .8868 .8868 .8868
837
838
28:16:08 PSYCHOTHERAPEUTIC AGENTS TRANQUILIZERS

ALPRAZOLAM
839 0.25mg Tab 00548359 00865397 01913239 01913484 02137534 Xanax Apo-Alpraz Nu-Alpraz Novo-Alprazol Gen-Alprazolam PFI APX NXP NOP GEN .0760 .2291 .0760 .0760 .0760 .0760
IIIA.164
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ALPRAZOLAM
840 0.5mg Tab 00548367 00865400 01913247 01913492 02137542 Xanax Apo-Alpraz Nu-Alpraz Novo-Alprazol Gen-Alprazolam PFI APX NXP NOP GEN .0920 .2745 .0920 .0920 .0920 .0920
BROMAZEPAM
841 1.5mg Tab 00682314 02171856 02177153 02192705 3mg Tab 00518123 02171864 02177161 02192713 02230584 6mg Tab 00518131 02171872 02177188 02192721 02230585 Lectopam Nu-Bromazepam Apo-Bromazepam Gen-Bromazepam Lectopam Nu-Bromazepam Apo-Bromazepam Gen-Bromazepam Novo-Bromazepam Lectopam Nu-Bromazepam Apo-Bromazepam Gen-Bromazepam Novo-Bromazepam HLR NXP APX GEN HLR NXP APX GEN NOP HLR NXP APX GEN NOP .0515 .1082 .0515 .0515 .0515 .0700 .1470 .0700 .0700 .0700 .0700 .1022 .2147 .1022 .1022 .1022 .1022
842
843
CHLORDIAZEPOXIDE
844 5mg Cap 00012629 00522724 10mg Cap 00012637 00522988 25mg Cap 00012645 00522996 .0663 Librium (Not a Benefit) Apo-Chlordiazepoxide Librium (Not a Benefit) Apo-Chlordiazepoxide Librium (Not a Benefit) Apo-Chlordiazepoxide HLR APX HLR APX HLR APX .0663 .1045 .1045 .1620 .1620
845
846
JUNE 27, 2008
IIIA.165
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CHLORPROMAZINE
847 25mg Tab 01929917 00232823 50mg Tab 01929925 00232807 100mg Tab 01929933 00232831 .1365 Largactil (Not a Benefit) Novo-Chlorpromazine Largactil (Not a Benefit) Novo-Chlorpromazine Largactil (Not a Benefit) Novo-Chlorpromazine RPP NOP RPP NOP RPP NOP .1365 .1565 .1565 .3200 .3200
848
849
CLORAZEPATE DIPOTASSIUM
850 3.75mg Cap 00264938 00628190 00860689 7.5mg Cap 00264946 00628204 00860700 15mg Cap 00264911 00628212 00860697 .0694 Tranxene (Not a Benefit) # Novo-Clopate Apo-Clorazepate Tranxene # Novo-Clopate Apo-Clorazepate Tranxene # Novo-Clopate Apo-Clorazepate ABB NOP APX ABB NOP APX ABB NOP APX .0694 .0694 .0953 .1905 .0953 .0953 .1715 .3430 .1715 .1715
851
852
IIIA.166
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DIAZEPAM
853 854 855 856 5mg/mL Rect Gel-2x5mg Pk 02238162 Diastat 5mg/mL Rect Gel-2x10mg Pk 09853340 Diastat 5mg/mL Rect Gel-2x15mg Pk 09853430 Diastat 2mg Tab 00013277 00405329 5mg Tab 00013285 00362158 10mg Tab 00013293 00405337 Valium (Not a Benefit) Apo-Diazepam Valium (Not a Benefit) Apo-Diazepam Valium (Not a Benefit) Apo-Diazepam VAL VAL VAL HLR APX HLR APX HLR APX 134.5000 134.5000 134.5000 134.5000 134.5000 134.5000 .0508 .0508 .0650 .0650 .0867 .0867
857
858
FLUPENTHIXOL DECANOATE
859 860 200mg/2mL Inj Sol-2mL Pk 02156040 Fluanxol Depot 200mg/10mL Inj Sol-10mL Pk 02156032 Fluanxol Depot VLH VLH 70.4500 70.4500 70.4500 70.4500
FLUPENTHIXOL DIHYDROCHLORIDE
861 862 0.5mg Tab 02156008 3mg Tab 02156016 Fluanxol Fluanxol VLH VLH .2434 .2434 .5257 .5257
JUNE 27, 2008
IIIA.167
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLUPHENAZINE DECANOATE
863 864 100mg/mL Inj Sol-1mL Pk 00755575 Modecate Concentrate 125mg/5mL Inj Susp-5mL Pk 00349917 Modecate (Not a Benefit) 02091275 PMS-Fluphenazine Decanoate BQU BQU PMS 29.7800 29.7800 23.1600 23.1600
FLUPHENAZINE HCL
865 1mg Tab 00029378 00405345 2mg Tab 00029386 00410632 5mg Tab 00029408 00405361 .1680 Moditen HCL (Not a Benefit) Apo-Fluphenazine Moditen HCL (Not a Benefit) Apo-Fluphenazine Moditen HCL (Not a Benefit) Apo-Fluphenazine BQU APX BQU APX BQU APX .1680 .2040 .2040 .1720 .1720
866
867
HALOPERIDOL
868 5mg/mL Inj Sol-1mL Pk 00017574 Haldol (Not a Benefit) 00808652 Haloperidol 0.5mg Tab 00017655 00363685 00396796 Haldol (Not a Benefit) Novo-Peridol Apo-Haloperidol 3.8620 OMC SDZ OMC NOP APX 3.8620 .0360 .0360 .0360
869
IIIA.168
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

HALOPERIDOL
870 1mg Tab 00017663 00363677 00396818 2mg Tab 00017671 00363669 00396826 5mg Tab 00017698 00363650 00396834 10mg Tab 00381772 00463698 00713449 20mg Tab 00499579 00768820 .0614 Haldol (Not a Benefit) Novo-Peridol Apo-Haloperidol Haldol (Not a Benefit) Novo-Peridol Apo-Haloperidol Haldol (Not a Benefit) Novo-Peridol Apo-Haloperidol Haldol (Not a Benefit) Apo-Haloperidol Novo-Peridol Haldol (Not a Benefit) Novo-Peridol OMC NOP APX OMC NOP APX OMC NOP APX OMC APX NOP OMC NOP .0614 .0614 .1050 .1050 .1050 .1487 .1487 .1487 .1330 .1330 .1330 .6304 .6304
871
872
873
874
HALOPERIDOL DECANOATE
875 100mg/mL Oily Inj Sol-1mL Pk 00599093 Haldol-LA (Not a Benefit) 02130300 Haloperidol LA 50mg/mL Oily Inj Sol-5mL Pk 00599085 Haldol-LA (Not a Benefit) 02130297 Haloperidol LA 100mg/mL Oily Inj Sol-5mL Pk 00980803 Haldol-LA (Not a Benefit) 09853758 Haloperidol LA 11.6648 OMC SDZ OMC SDZ OMC SDZ 11.6648 29.5190 29.5190 58.3240 58.3240
876
877
JUNE 27, 2008
IIIA.169
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

HYDROXYZINE HCL
878 10mg Cap 00024376 00646059 00738824 01927876 25mg Cap 00024384 00646024 00738832 01938835 50mg Cap 00024392 00646016 00738840 01927884 Atarax (Not a Benefit) Apo-Hydroxyzine (Not a Benefit) Novo-Hydroxyzin (Not a Benefit) Multipax (Not a Benefit) Atarax (Not a Benefit) Apo-Hydroxyzine (Not a Benefit) Novo-Hydroxyzin (Not a Benefit) Multipax (Not a Benefit) Atarax (Not a Benefit) Apo-Hydroxyzine (Not a Benefit) Novo-Hydroxyzin (Not a Benefit) Multipax (Not a Benefit) PFI APX NOP RPP PFI APX NOP RPP PFI APX NOP RPP
879
880
LORAZEPAM
881 0.5mg Tab 02041413 00655740 00711101 00728187 00865672 1mg Tab 02041421 00637742 00655759 00728195 00865680 2mg Tab 02041448 00637750 00655767 00728209 00865699 Ativan Apo-Lorazepam Novo-Lorazem PMS-Lorazepam Nu-Loraz Ativan Novo-Lorazem Apo-Lorazepam PMS-Lorazepam Nu-Loraz Ativan Novo-Lorazem Apo-Lorazepam PMS-Lorazepam Nu-Loraz WAY APX NOP PMS NXP WAY NOP APX PMS NXP WAY NOP APX PMS NXP .0359 .0359 .0359 .0359 .0359 .0359 .0447 .0447 .0447 .0447 .0447 .0447 .0699 .0699 .0699 .0699 .0699 .0699
882
883
IIIA.170
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

OLANZAPINE
884 885 886 887 5mg Rapid Dissolve Tab 02243086 Zyprexa Zydis 10mg Rapid Dissolve Tab 02243087 Zyprexa Zydis 15mg Rapid Dissolve Tab 02243088 Zyprexa Zydis 2.5mg Tab 02229250 02276712 5mg Tab 02229269 02276720 7.5mg Tab 02229277 02276739 10mg Tab 02229285 02276747 15mg Tab 02238850 02276755 Zyprexa Novo-Olanzapine Zyprexa Novo-Olanzapine Zyprexa Novo-Olanzapine Zyprexa Novo-Olanzapine Zyprexa Novo-Olanzapine LIL LIL LIL LIL NOP LIL NOP LIL NOP LIL NOP LIL NOP 3.4764 3.4764 6.9525 6.9525 10.4289 10.4289 1.2656 1.7972 1.2656 2.5313 3.5944 2.5313 3.7969 5.3916 3.7969 5.0625 7.1888 5.0625 7.5938 10.7831 7.5938
888
889
890
891
OXAZEPAM
892 10mg Tab 02043653 00402680 15mg Tab 02043661 00402745 30mg Tab 02043688 00402737 .0350 Serax (Not a Benefit) Apo-Oxazepam Serax (Not a Benefit) Apo-Oxazepam Serax (Not a Benefit) Apo-Oxazepam WAY APX WAY APX WAY APX .0350 .0550 .0550 .0750 .0750
893
894
JUNE 27, 2008
IIIA.171
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PERICYAZINE
895 896 897 5mg Cap 01926780 10mg Cap 01926772 10mg/mL O/L 01926756 Neuleptil Neuleptil Neuleptil ERF ERF ERF .1825 .1825 .2930 .2930 .3600 .3600
PERPHENAZINE
898 2mg Tab 00028290 00335134 4mg Tab 00028304 00335126 8mg Tab 00028312 00335118 16mg Tab 00028320 00335096 .0612 Trilafon (Not a Benefit) Apo-Perphenazine Trilafon (Not a Benefit) Apo-Perphenazine Trilafon (Not a Benefit) Apo-Perphenazine Trilafon (Not a Benefit) Apo-Perphenazine SCH APX SCH APX SCH APX SCH APX .0612 .0741 .0741 .0813 .0813 .1245 .1245
899
900
901
PIMOZIDE
902 2mg Tab 00313815 02245432 4mg Tab 00313823 02245433 Orap Apo-Pimozide Orap Apo-Pimozide PHE APX PHE APX .2279 .2279 .2279 .4136 .4136 .4136
903
IIIA.172
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PIPOTIAZINE PALMITATE
904 905 906 25mg/mL Inj Sol-1mL Pk 01926667 Piportil L4 50mg/mL Inj Sol-1mL Pk 00990507 Piportil L4 100mg/2mL Inj Sol-2mL Pk 01926675 Piportil L4 SAV SAV SAV 14.7600 14.7600 25.0200 25.0200 47.5300 47.5300
PROCHLORPERAZINE
907 10mg/2mL Inj Sol-2mL Pk 01927779 Stemetil (Not a Benefit) 00789747 Prochlorperazine Mesylate 5mg Tab 01927752 00886440 01964399 10mg Tab 01927760 00886432 01964402 Stemetil (Not a Benefit) Apo-Prochlorazine Nu-Prochlor Stemetil (Not a Benefit) Apo-Prochlorazine Nu-Prochlor 1.3380 SAV SDZ AVE APX NXP AVE APX NXP 1.3380 .1055 .1055 .1055 .1290 .1290 .1290
908
909
QUETIAPINE
910 911 912 913 914 915 916 917 25mg Tab 02236951 100mg Tab 02236952 200mg Tab 02236953 300mg Tab 02244107 50mg ER Tab 02300184 200mg ER Tab 02300192 300mg ER Tab 02300206 400mg ER Tab 02300214 Seroquel Seroquel Seroquel Seroquel + Seroquel XR + Seroquel XR + Seroquel XR + Seroquel XR AZC AZC AZC AZC AZC AZC AZC AZC .4940 .4940 1.3180 1.3180 2.6467 2.6467 3.8625 3.8625 .9800 .9800 2.6200 2.6200 3.8600 3.8600 5.2400 5.2400
JUNE 27, 2008
IIIA.173
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

RISPERIDONE
918 1mg/mL O/L 02236950 02279266 02280396 Risperdal PMS-Risperidone Apo-Risperidone JNO PMS APX JNO JNO JNO JNO JNO JNO PMS RPH RAN APX GEN COB NOP SDZ JNO PMS NOP RPH SDZ RAN APX GEN COB .5520 1.3320 .5520 .5520 .7157 .7157 .9889 .9889 1.9739 1.9739 2.9614 2.9614 3.9482 3.9482 .2075 .5007 .2075 .2075 .2075 .2075 .2075 .2075 .2075 .2075 .3475 .8387 .3475 .3475 .3475 .3475 .3475 .3475 .3475 .3475
919 920 921 922 923 924
0.5mg Orally Disintegrating Tab 02247704 Risperdal M-Tab 1mg Orally Disintegrating Tab 02247705 Risperdal M-Tab 2mg Orally Disintegrating Tab 02247706 Risperdal M-Tab 3mg Orally Disintegrating Tab 02268086 Risperdal M-Tab 4mg Orally Disintegrating Tab 02268094 Risperdal M-Tab 0.25mg Tab 02240551 02252007 02264757 02280906 02282119 02282240 02282585 02282690 02292807 0.5mg Tab 02240552 02252015 02264188 02264765 02279495 02280914 02282127 02282259 02282593 Risperdal PMS-Risperidone Ratio-Risperidone Ran-Risperidone Apo-Risperidone Gen-Risperidone Co Risperidone Novo-Risperidone Sandoz Risperidone Risperdal PMS-Risperidone Novo-Risperidone Ratio-Risperidone Sandoz Risperidone Ran-Risperidone Apo-Risperidone Gen-Risperidone Co Risperidone
925
IIIA.174
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

RISPERIDONE
926 1mg Tab 02025280 02252023 02264196 02264773 02279800 02280922 02282135 02282267 02282607 2mg Tab 02025299 02252031 02264218 02264781 02279819 02280930 02282143 02282275 02282615 3mg Tab 02025302 02252058 02264226 02264803 02279827 02280949 02282151 02282283 02282623 4mg Tab 02025310 02252066 02264234 02264811 02279835 02280957 02282178 02282291 02282631 Risperdal PMS-Risperidone Novo-Risperidone Ratio-Risperidone Sandoz Risperidone Ran-Risperidone Apo-Risperidone Gen-Risperidone Co Risperidone Risperdal PMS-Risperidone Novo-Risperidone Ratio-Risperidone Sandoz Risperidone Ran-Risperidone Apo-Risperidone Gen-Risperidone Co Risperidone Risperdal PMS-Risperidone Novo-Risperidone Ratio-Risperidone Sandoz Risperidone Ran-Risperidone Apo-Risperidone Gen-Risperidone Co Risperidone Risperdal PMS-Risperidone Novo-Risperidone Ratio-Risperidone Sandoz Risperidone Ran-Risperidone Apo-Risperidone Gen-Risperidone Co Risperidone JNO PMS NOP RPH SDZ RAN APX GEN COB JNO PMS NOP RPH SDZ RAN APX GEN COB JNO PMS NOP RPH SDZ RAN APX GEN COB JNO PMS NOP RPH SDZ RAN APX GEN COB .4800 1.1585 .4800 .4800 .4800 .4800 .4800 .4800 .4800 .4800 .9583 2.3127 .9583 .9583 .9583 .9583 .9583 .9583 .9583 .9583 1.4375 3.4695 1.4375 1.4375 1.4375 1.4375 1.4375 1.4375 1.4375 1.4375 1.9167 4.6260 1.9167 1.9167 1.9167 1.9167 1.9167 1.9167 1.9167 1.9167
927
928
929
JUNE 27, 2008
IIIA.175
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

THIOTHIXENE
930 931 932 2mg Cap 00024430 5mg Cap 00024449 10mg Cap 00024457 Navane Navane Navane ERF ERF ERF .3000 .3000 .3321 .3321 .4275 .4275
TRIFLUOPERAZINE
933 1mg Tab 01918206 00345539 2mg Tab 01918214 00312754 5mg Tab 01918222 00312746 10mg Tab 01918230 00326836 .1015 Stelazine (Not a Benefit) Apo-Trifluoperazine Stelazine (Not a Benefit) Apo-Trifluoperazine Stelazine (Not a Benefit) Apo-Trifluoperazine Stelazine (Not a Benefit) Apo-Trifluoperazine SMJ APX SMJ APX SMJ APX SMJ APX .1015 .1110 .1110 .1470 .1470 .1762 .1762
934
935
936
28:16:12 PSYCHOTHERAPEUTIC AGENTS OTHER PSYCHOTROPICS

LITHIUM CARBONATE
937 150mg Cap 00461733 02216132 02242837 150mg Cap 02013231 09857532 Carbolith PMS-Lithium Carbonate Apo-Lithium Carbonate Lithane Apo-Lithium Carbonate VAL PMS APX ERF APX .0422 .0844 .0422 .0422 .0413 .0995 .0413
938
IIIA.176
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LITHIUM CARBONATE
939 300mg Cap 00236683 02216140 02242838 300mg Cap 00406775 09857540 Carbolith PMS-Lithium Carbonate Apo-Lithium Carbonate Lithane Apo-Lithium Carbonate VAL PMS APX ERF APX .0443 .0886 .0443 .0443 .0471 .0991 .0471
940
LOXAPINE HCL
941 25mg/mL O/L 02170000 02239101 .5232 Loxapac (Not a Benefit) # PMS-Loxapine WAY PMS .5232
LOXAPINE SUCCINATE
942 5mg Tab 02170019 02230837 02237534 02237651 10mg Tab 02170027 02230838 02237535 02237652 25mg Tab 02170132 02230839 02237536 02237653 50mg Tab 02170035 02230840 02237537 02237654 .1500 Loxapac (Not a Benefit) PMS-Loxapine Nu-Loxapine Apo-Loxapine Loxapac (Not a Benefit) PMS-Loxapine Nu-Loxapine Apo-Loxapine Loxapac (Not a Benefit) PMS-Loxapine Nu-Loxapine Apo-Loxapine Loxapac (Not a Benefit) PMS-Loxapine Nu-Loxapine Apo-Loxapine WAY PMS NXP APX WAY PMS NXP APX WAY PMS NXP APX WAY PMS NXP APX .1500 .1500 .1500 .2498 .2498 .2498 .2498 .3872 .3872 .3872 .3872 .5162 .5162 .5162 .5162
943
944
945
JUNE 27, 2008
IIIA.177
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

28:20:00 C.N.S. STIMULANTS
Note: Stimulant medication should only be used when diagnostic criteria for narcolepsy or attention deficit disorder have been met and when stimulant medication has been demonstrated to produce clinical benefits. The use of conventional-release medication should almost always precede the use of extended-release preparations.
DEXAMPHETAMINE SULFATE
946 5mg Tab 01924516 Dexedrine GSK .5345 .5345
METHYLPHENIDATE HCL
947 20mg LA Tab 00632775 02266687 10mg Tab 00005606 00584991 02249324 Ritalin SR Apo-Methylphenidate SR Ritalin PMS-Methylphenidate Apo-Methylphenidate NOV APX NOV PMS APX .3364 .5639 .3364 .1262 .3109 .1262 .1262
948
28:24:00 SEDATIVES AND HYPNOTICS

Note: Sedatives and hypnotics are indicated for short-term therapy only.
AMOBARBITAL SODIUM
949 950 60mg Cap 00015148 200mg Cap 00015156 Amytal Sodium Amytal Sodium LIL LIL .0960 .0960 .2114 .2114
FLURAZEPAM
951 15mg Cap 00012696 00521698 30mg Cap 00012718 00521701 .0810 Dalmane (Not a Benefit) Apo-Flurazepam Dalmane (Not a Benefit) Apo-Flurazepam VAL APX VAL APX .0810 .0930 .0930
952
IIIA.178
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

METHOTRIMEPRAZINE
953 954 25mg/mL Inj Sol-1mL Pk 01927698 Nozinan 2mg Tab 01927647 02238403 5mg Tab 01927655 02232903 02238404 25mg Tab 01927663 02232904 02238405 50mg Tab 01927671 02232905 02238406 Nozinan (Not a Benefit) Apo-Methoprazine # Nozinan PMS-Methotrimeprazine Apo-Methoprazine # Nozinan PMS-Methotrimeprazine Apo-Methoprazine # Nozinan PMS-Methotrimeprazine Apo-Methoprazine SAV AVE APX SAV PMS APX SAV PMS APX SAV PMS APX 2.3710 2.3710 .0505 .0505 .0528 .0528 .0528 .0528 .1131 .1131 .1131 .1131 .1541 .1541 .1541 .1541
955
956
957
NITRAZEPAM
958 5mg Tab 00511528 02229654 02234003 02245230 10mg Tab 00511536 02229655 02234007 02245231 Mogadon Nitrazadon Sandoz Nitrazepam Apo-Nitrazepam Mogadon Nitrazadon Sandoz Nitrazepam Apo-Nitrazepam VAL VAL SDZ APX VAL VAL SDZ APX .0680 .1428 .0680 .0680 .0680 .1017 .2137 .1017 .1017 .1017
959
JUNE 27, 2008
IIIA.179
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PENTOBARBITAL SODIUM
960 100mg Cap 00000086 Nembutal ABB .2038 .2038
SECOBARBITAL SODIUM
961 100mg Cap 00015288 Seconal LIL .1069 .1069
TEMAZEPAM
962 15mg Cap 00604453 02223570 02225964 02229455 02230095 02231615 02243023 02244814 02273039 30mg Cap 00604461 02223589 02225972 02229456 02230102 02231616 02243024 02244815 02273047 Restoril Nu-Temazepam Apo-Temazepam # PMS-Temazepam Novo-Temazepam Gen-Temazepam Ratio-Temazepam Co-Temazepam PMS-Temazepam Restoril Nu-Temazepam Apo-Temazepam # PMS-Temazepam Novo-Temazepam Gen-Temazepam Ratio-Temazepam Co-Temazepam PMS-Temazepam ORY NXP APX PMS NOP GEN RPH COB PMS ORY NXP APX PMS NOP GEN RPH COB PMS .0875 .1750 .0875 .0875 .0875 .0875 .0875 .0875 .0875 .0875 .1053 .2105 .1053 .1053 .1053 .1053 .1053 .1053 .1053 .1053
963
TRIAZOLAM
964 0.125mg Tab 00512559 00808563 01995227 .1181 Halcion (Not a Benefit) Apo-Triazo Gen-Triazolam UPJ APX GEN .1181 .1181
IIIA.180
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TRIAZOLAM
965 0.25mg Tab 00443158 00808571 01913506 .2086 Halcion (Not a Benefit) Apo-Triazo Gen-Triazolam PFI APX GEN .2090 .2086
28:92:00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS

ENTACAPONE
966 200mg Tab 02243763 Reason for Use Code 1.5648 1.5648
ION D D E TAT Parkinsons disease with 25% of TE ForSE I 367 the treatment ofN patients with IR U waking day inE off stateQU maximally tolerated doses the LIM UM the RE despite of levodopa. C LUO Authorization Period: Indefinite. D
Comtan NOV Clinical criteria
PRAMIPEXOLE DIHYDROCHLORIDE MONOHYDRATE

Note: Mirapex is indicated for both the symptomatic treatment of idiopathic Parkinsons Disease and moderate to severe idiopathic Restless Legs Syndrome under the manufacturers Drug Indentification Number (DIN). Mirapex has also been assigned a Product Indentification Number (PIN) for the indication of Parkinsons Disease specifically. Apo-Pramipexole, NovoPramipexole and PMS-Pramipexole products are interchangeable with Mirapex for the treatment of Parkinsons Disease. 967 968 0.25mg Tab 02237145 0.25mg Tab 09857268 02269309 02290111 02292378 Mirapex Mirapex Novo-Pramipexole PMS-Pramipexole Apo-Pramipexole BOE BOE NOP PMS APX 1.0513 1.0513 .4950 1.0513 .4950 .4950 .4950
JUNE 27, 2008
IIIA.181
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

Note: Mirapex is indicated for both the symptomatic treatment of idiopathic Parkinsons Disease and moderate to severe idiopathic Restless Legs Syndrome under the manufacturers Drug Indentification Number (DIN). Mirapex has also been assigned a Product Indentification Number (PIN) for the indication of Parkinsons Disease specifically. Apo-Pramipexole, NovoPramipexole and PMS-Pramipexole products are interchangeable with Mirapex for the treatment of Parkinsons Disease. 969 970 1mg Tab 02237146 1mg Tab 09857269 02269325 02290146 02292394 1.5mg Tab 02237147 1.5mg Tab 09857270 02269333 02290154 02292408 Mirapex Mirapex Novo-Pramipexole PMS-Pramipexole Apo-Pramipexole Mirapex Mirapex Novo-Pramipexole PMS-Pramipexole Apo-Pramipexole BOE BOE NOP PMS APX BOE BOE NOP PMS APX 2.1028 2.1028 .9900 2.1028 .9900 .9900 .9900 2.1028 2.1028 .9900 2.1028 .9900 .9900 .9900
971 972
IIIA.182
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
36:00 DIAGNOSTIC AGENTS

36:04:00 ADRENAL INSUFFICIENCY
COSYNTROPIN ZINC HYDROXIDE
973 1mg/mL Inj Susp-1mL Pk 00253952 Synacthen Depot NOV 29.3200 29.3200
JUNE 27, 2008
IIIA.183
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
40:00 ELECTROLYTIC, CALORIC AND WATER BALANCE

40:12:00 REPLACEMENT AGENTS
CALCIUM CARBONATE
974 Eq To 250mg Elemental Calcium Tab 02042983 Os-Cal 250 (Not a Benefit) 00645958 Calcium-250 (Not a Benefit) 00682047 Apo-Cal 250 (Not a Benefit) Eq To 500mg Elemental Calcium Tab 02042991 Os-Cal 500 (Not a Benefit) 00645923 Calcium-500 (Not a Benefit) 00682039 Apo-Cal 500 (Not a Benefit) WAY NOP APX WAY NOP APX
975
CALCIUM GLUCONATE
976 Eq To 60mg Elemental Calcium Tab 00179698 Calcium Gluconate (Not a Benefit) SDR 00241717 Calcium Gluconate (Not a Benefit) RPR 00441473 Calcium Gluconate (Not a Benefit) NOP
CALCIUM LACTATE
977 Eq To 84mg Elemental Calcium Tab 00021253 Calcium Lactate (Not a Benefit) 00179671 Calcium Lactate (Not a Benefit) NOP SDR
ELECTROLYTE & DEXTROSE

978 O/L 00630365 00981095 Pedialyte Regular Pedialyte Flavored ABB ABB .0074 .0074 .0074
JUNE 27, 2008
IIIA.185
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

40:12:00 REPLACEMENT AGENTS
ELECTROLYTE & DEXTROSE
979 Oral Pd-1 Sach Pk 01931563 Gastrolyte SAV .7950 .7950
PEG-ELECTROLYTES
980 Pd-4L Pk 00677442 00777838 16.4500 Colyte (Not a Benefit) PegLyte ZYN PMS 16.4500
POLYETHYLENE GLYCOL & ELECTROLYTES

981 982 Pd-1 Kit 02147793 Sol-1L Pk 00777846 Klean-Prep # PegLyte RIV PMS 16.1700 16.1700 5.0141 5.0141
POTASSIUM CHLORIDE
983 * 1.33mEq/mL O/L 01918303 02063859 02166372 02238604 K-10 Kaochlor-10 (Not a Benefit) Roychlor (Not a Benefit) PMS-Potassium Chloride GSK PMJ WAB PMS ABB WEL .0102 .0150 .0102 .2917 .2917 .4783 .4783
984 985
20mEq/Pouch Oral Pd-3g Pk 00481211 # K-Lor 25mEq/Pouch Oral Pd-7.8g Pk 02089580 K-Lyte/Cl
IIIA.186
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

40:18:00 POTASSIUM-REMOVING RESINS
POLYSTYRENE SODIUM SULFONATE
986 1mEq/g Oral Pd-454g Pk 02026961 Kayexalate SAV 75.9675 75.9675
40:28:00 DIURETICS
Note: The Canadian Hypertension Society Consensus Conference recommends lower doses of diuretics for treatment of hypertension, particularly in the elderly, to avoid dose-related adverse effects. Hydrochlorothiazide, 25 to 50mg daily, or other diuretics in equivalent amounts are recommended.
AMILORIDE HCL
987 5mg Tab 00487805 02249510 .2002 Midamor (Not a Benefit) Apo-Amiloride MSD APX .2002
AMILORIDE HCL & HYDROCHLOROTHIAZIDE

988 5mg & 50mg Tab 00487813 00784400 00886106 01937219 02257378 .1917 Moduret (Not a Benefit) Apo-Amilzide Nu-Amilzide Novamilor Gen-Amilazide PRE APX NXP NOP GEN .1917 .1917 .1917 .1917 .10 .10 .10 .10 .10
JUNE 27, 2008
IIIA.187
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

40:28:00 DIURETICS
CHLORTHALIDONE
989 50mg Tab 00010413 00360279 100mg Tab 00010421 00360287 .0785 Hygroton (Not a Benefit) Apo-Chlorthalidone Hygroton (Not a Benefit) Apo-Chlorthalidone GEI APX GEI APX .0785 .0397 .0397 .08 .08
990
FUROSEMIDE
991 992 10mg/mL O/L 02224720 20mg Tab 02224690 00337730 00396788 40mg Tab 02224704 00337749 00362166 Lasix Lasix Novo-Semide Apo-Furosemide Lasix Novo-Semide Apo-Furosemide SAV SAV NOP APX SAV NOP APX .2513 .2513 .0373 .0798 .0373 .0373 .0558 .1167 .0558 .0558
993
IIIA.188
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

40:28:00 DIURETICS
FUROSEMIDE
994 500mg Tab 02224755 Reason for Use Code
N TIO ED D A ITE For patients with severely impaired IR function refractory to SE MENT QU renal 33 U LIM U conventional dosages ofRE the drug. OC Period: Indefinite. D LU Authorization
Clinical criteria .0313 HydroDIURIL (Not a Benefit) Novo-Hydrazide Apo-Hydro 25 PMS-Hydrochlorothiazide HydroDIURIL (Not a Benefit) Novo-Hydrazide Apo-Hydro 50 PMS-Hydrochlorothiazide MSD NOP APX PMS MSD NOP APX PMS .0313 .0313 .0313 .0434 .0434 .0434 .0434 .03 .03 .03 .03
Lasix Special
SAV
2.7494 2.7494
HYDROCHLOROTHIAZIDE
995 25mg Tab 00016500 00021474 00326844 02247386 50mg Tab 00016519 00021482 00312800 02247387
996
HYDROCHLOROTHIAZIDE & SPIRONOLACTONE

997 25mg & 25mg Tab 00180408 00613231 50mg & 50mg Tab 00594377 00657182 Aldactazide-25 Novo-Spirozine-25 Aldactazide-50 Novo-Spirozine-50 PFI NOP PFI NOP .0859 .0893 .0859 .2236 .2325 .2236 .04 .04 .04
998
JUNE 27, 2008
IIIA.189
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

40:28:00 DIURETICS
HYDROCHLOROTHIAZIDE & TRIAMTERENE

999 25mg & 50mg Tab 01919547 00441775 00532657 00865532 .0608 Dyazide (Not a Benefit) Apo-Triazide Novo-Triamzide Nu-Triazide (Not a Benefit) SMJ APX NOP NXP .0608 .0608 .06 .06 .06
INDAPAMIDE
1000 1.25mg Tab 02179709 02227339 02239619 02240067 02245246 2.5mg Tab 00564966 02049341 02153483 02223597 02223678 02231184 02239620 Lozide Indapamide Hemihydrate PMS-Indapamide Gen-Indapamide Apo-Indapamide Lozide Indapamide Gen-Indapamide Nu-Indapamide Apo-Indapamide Novo-Indapamide PMS-Indapamide SEV SEV PMS GEN APX SEV SEV GEN NXP APX NOP PMS .1490 .2979 .1877 .1490 .1490 .1490 .2364 .4727 .2977 .2364 .2364 .2364 .2364 .2364 .24 .47 .30 .24 .24 .24 .24 .24
1001
METOLAZONE
1002 2.5mg Tab 00888400 Zaroxolyn SAV .1776 .1776
IIIA.190
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

40:28:00 DIURETICS
MIDODRINE HCL
1003
1004
ED ON T TI D MI SE TA RE LI U EN UI UM REQ OC D
5mg Tab 01934406 02278685 Reason for Use Code 01 Amatine Apo-Midodrine SHI APX Clinical criteria LU Authorization Period: Indefinite.
2.5mg Tab 01934392 02278677
Amatine Apo-Midodrine
SHI APX
.2999 .4504 .2999 .4998 .7507 .4998
For the treatment of patients disabled by moderate to severe neurogenic orthostatic hypotension (i.e. drop in systolic BP less than or equal to 20mm Hg from supine to standing position), in whom conventional nonpharmacologic and pharmacologic (i.e. fludrocortisone) therapies have proven ineffective or are poorly tolerated.
SPIRONOLACTONE
Note: Spironolactone can double digoxin blood levels within two weeks, and commonly causes mastalgia and gynaecomastia in men. 1005 25mg Tab 00028606 00613215 100mg Tab 00285455 00613223 Aldactone Novo-Spiroton Aldactone Novo-Spiroton PFI NOP PFI NOP .0692 .0720 .0692 .2120 .2205 .2120
1006
JUNE 27, 2008
IIIA.191
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

40:40:00 URICOSURIC DRUGS
PROBENECID
1007 500mg Tab 00016616 00294926 .1884 Benemid (Not a Benefit) Benuryl MSD VAL .1884
SULFINPYRAZONE
1008 200mg Tab 00010529 00441767 .1980 Anturan (Not a Benefit) Apo-Sulfinpyrazone GEI APX .1980
IIIA.192
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
48:00 COUGH PREPARATIONS

48:04:00 ANTITUSSIVES
DEXTROMETHORPHAN HBR
1009 * 3mg/mL O/L 00391069 01928783 .0088 DM-Syrup (Not a Benefit) Koffex DM PDA ROG .0088
HYDROCODONE BITARTRATE
1010 1mg/mL O/L 01916580 Hycodan BQU .1053 .1053
48:08:00 EXPECTORANTS
GUAIFENESIN
1011 * 20mg/mL O/L 00026468 00026794 00990930 Robitussin (Not a Benefit) Guaifenesin (Not a Benefit) Guaifenesin Sugar Free (Not a Benefit) WHB ROG ROG
JUNE 27, 2008
IIIA.193
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
52:00 EYE, EAR, NOSE AND THROAT PREPARATIONS

52:04:04 ANTI-INFECTIVES ANTIBIOTICS
CHLORAMPHENICOL
1012 0.25% Oph Sol 01980556 Pentamycetin SDZ .5100 .5100
FRAMYCETIN SULFATE
1013 1014 0.5% Oph Oint-5g Pk 02224895 Soframycin 0.5% Oph Sol 02224887 Soframycin ERF ERF 15.0000 15.0000 1.0250 1.0250
FRAMYCETIN SULFATE & GRAMICIDIN & DEXAMETHASONE

1015 5mg & 50mcg & 0.5mg/mL Oph/Ot Sol 02224623 Sofracort 02247920 Sandoz Opticort SAV SDZ .9800 1.7023 .9800
Note: The risk of ototoxicity with topical aminoglycoside may increase with prolonged therapy. Topical use of antibiotics increases the likelihood of development of bacterial resistance, especially with prolonged use, sometimes rendering the systemic use of this antibiotic class useless in these patients.
GENTAMICIN & BETAMETHASONE SODIUM PHOSPHATE

1016 3mg & 1mg/mL Oph/Ot Drops 00682217 Garasone 02244999 Sandoz Pentasone SCH SDZ 1.1965 1.2813 1.1965
Note: The risk of ototoxicity with topical aminoglycoside may increase with prolonged therapy. Topical use of antibiotics increases the likelihood of development of bacterial resistance, especially with prolonged use, sometimes rendering the systemic use of this antibiotic class useless in these patients.
JUNE 27, 2008
IIIA.195
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

GENTAMICIN SULFATE
1017 1018 0.3% Oph Oint-3.5g Pk 00028339 Garamycin 0.3% Oph Sol 00436771 00512192 0.3% Ot Sol 00512184 02229441 Alcomicin Garamycin Garamycin Sandoz Gentamicin SCH ALC SCH SCH SDZ 4.0000 4.0000 .4060 .5300 .4060 1.0320 1.0320 1.0320
1019
POLYMYXIN B SULFATE & BACITRACIN (ZINC)

1020 10000U & 500U/g Oph Oint 3.5g Pk 02239157 Polysporin PFI 5.5400 5.5400
POLYMYXIN B SULFATE & GRAMICIDIN

1021 10000U & 0.025mg/mL Oph/Ot Sol 02239156 Polysporin PFI .6920 .6920
POLYMYXIN B SULFATE & NEOMYCIN SULFATE & HYDROCORTISONE

1022 10000U & 5mg & 10mg/mL Ot Sol 01912828 Cortisporin GSK 1.2515 1.2515
IIIA.196
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TOBRAMYCIN
1023 1024 0.3% Oph Oint 00614254 0.3% Oph Sol 00513962 02239577 02241755 Tobrex Tobrex PMS-Tobramycin Sandoz Tobramycin ALC ALC PMS SDZ 2.3629 2.3629 .8333 1.6660 .8333 .8333
TOBRAMYCIN & DEXAMETHASONE

1025 1026 0.3% & 0.1% Oph Oint 00778915 TobraDex 0.3% & 0.1% Oph Susp 00778907 TobraDex ALC ALC 2.9143 2.9143 1.9680 1.9680
52:04:08 ANTI-INFECTIVES SULFONAMIDES

SULFACETAMIDE (SODIUM)
1027 10% Oph Oint-3.5g Pk 00252522 Cetamide ALC 3.3400 3.3400
JUNE 27, 2008
IIIA.197
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

52:04:12 OTHER ANTI-INFECTIVES
OFLOXACIN
1028 0.3% Oph Sol 02143291 02248398 02252570 Reason for Use Code 170 Ocuflox Apo-Ofloxacin PMS-Ofloxacin ALL APX PMS .7080 2.4460 .7080 .7080
ED ION D AT IRE MIT SE T LI EN QU U UM RE OC D

Clinical criteria LU Authorization Period: 1 year. Viroptic THE
For the treatment of conjunctivitis caused by susceptible strain(s) of Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae and Hemophilus influenzae which is/ are resistant or unresponsive to listed alternative agents.
TRIFLURIDINE
1029 1% Oph Sol 00687456 3.0387 3.0387
Note: Administration of trifluridine for periods exceeding 21 days should be avoided because of potential ocular toxicity.
52:08:00 ANTI-INFLAMMATORY AGENTS

Note: Topical corticosteroid can reactivate pre-existing viral keratitis. These agents should be used with caution in patients with a history of previous corneal ulceration. In some patients, prolonged use of these agents can result in significant problems such as increased intraocular pressure.
BECLOMETHASONE DIPROPIONATE
1030 50mcg Nas Sp-200 Dose Pk 02213702 Beconase Aqueous (Not a Benefit) GLW 00872318 Ratio-Beclomethasone AQ RPH 02172712 Gen-Beclo AQ GEN 12.2600 12.2600 12.2600
IIIA.198
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

BUDESONIDE
1031 1032 1033 100mcg/Metered Dose Nas Aero-200 Dose 02035324 Rhinocort Turbuhaler 64mcg/Metered Dose Nas Sp-120 Dose Pk 02231923 Rhinocort Aqua 100mcg/Metered Dose Nas Sp-165 Dose Pk 01974432 Rhinocort Aqua (Not a Benefit) 02230648 Gen-Budesonide AQ AZC AZC AST GEN 22.7000 22.7000 10.2000 10.2000 12.7400 12.7400
DEXAMETHASONE
1034 1035 0.1% Oph Oint-3.5g Pk 00042579 Maxidex 0.1% Oph Susp 00042560 Maxidex ALC ALC 8.3500 8.3500 1.5400 1.5400
FLUMETHASONE PIVALATE & IODOCHLORHYDROXYQUIN

1036 0.02% & 1% Ot Sol 00074454 Locacorten-Vioform SQI 1.3670 1.3670
FLUNISOLIDE
1037 0.025% Nas Sp-25mL Pk 02162687 Rhinalar 00878790 Ratio-Flunisolide Nasal Mist 02239288 Apo-Flunisolide IVA RPH APX 9.9000 19.8000 9.9000 9.9000
JUNE 27, 2008
IIIA.199
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLUOROMETHOLONE
1038 0.1% Oph Susp 00247855 FML ALL 2.5480 2.5480
FLUOROMETHOLONE ACETATE
1039 0.1% Oph Susp 00756784 Flarex ALC 1.7400 1.7400
KETOROLAC TROMETHAMINE
1040 0.5% Oph Sol 01968300 02245821 02247461 Acular Apo-Ketorolac Ratio-Ketorolac ALL APX RPH 1.6000 3.3600 1.6000 1.6000
LODOXAMIDE TROMETHAMINE
1041 0.1% Oph Sol 00893560 Alomide ALC 1.0250 1.0250
PREDNISOLONE ACETATE
1042 1043 0.12% Oph Susp 00299405 1% Oph Susp 00301175 00700401 02023768 Pred Mild Pred Forte (Not a Benefit) Ratio-Prednisolone Diopred (Not a Benefit) ALL ALL RPH SDZ 1.7960 1.7960 2.4400 2.4400
IIIA.200
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

52:16:00 LOCAL ANESTHETICS
BENZYDAMINE HCL
1044 0.15% Oral Rinse 01966065 02229777 02229799 02230170 02239044 Reason for Use Code 240 .0290 .1325 .0290 .0290 .0290 .0290
ION D ED TAT IRE MIT SE LI EN QU U UM RE OC D

Clinical criteria LU Authorization Period: 1 year. Xylocaine Viscous AZC
Tantum PMS-Benzydamine Novo-Benzydamine Ratio-Benzydamine Apo-Benzydamine
GRA PMS NOP RPH APX
For the symptomatic relief of treatment induced mucositis in cancer patients.
LIDOCAINE HCL
1045 2% O/L 00001686 .0875 .0875
52:20:00 MIOTICS
CARBACHOL
1046 1047 1.5% Oph Sol 00000655 3% Oph Sol 00000663 Isopto Carbachol Isopto Carbachol ALC ALC .6733 .6733 .8100 .8100
JUNE 27, 2008
IIIA.201
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

52:20:00 MIOTICS
PILOCARPINE HCL
1048 1049 4% Oph Gel 00575240 1% Oph Sol 00000841 02023725 2% Oph Sol 00000868 02023741 4% Oph Sol 00000884 6% Oph Sol 00000892 Pilopine HS Isopto Carpine Diocarpine (Not a Benefit) Isopto Carpine Diocarpine (Not a Benefit) Isopto Carpine Isopto Carpine ALC ALC DKT ALC DKT ALC ALC 2.4980 2.4980 .2047 .2047 .2360 .2360 .2667 .2667 .4580 .4580
1050
1051 1052
IIIA.202
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

52:24:00 MYDRIATICS
ATROPINE SULFATE
1053 1054 1% Oph Oint-3.5g Pk 00252484 Atropine Sulfate 1% Oph Sol 00035017 01948598 Isopto Atropine Atropine (Not a Benefit) ALC ALC NOV 5.0500 5.0500 .6000 .6000
52:32:00 VASOCONSTRICTORS
NAPHAZOLINE HCL
1055 0.1% Oph Sol 00759880 00001147 00390283 00750786 Vasocon (Not a Benefit) Albalon (Not a Benefit) Naphcon Forte (Not a Benefit) Opcon (Not a Benefit) IOB ALL ALC BSH
52:36:00 OTHER EYE, EAR, NOSE AND THROAT AGENTS

ACETAZOLAMIDE
1056 250mg Tab 02238072 00545015 .0780 Diamox (Not a Benefit) Apo-Acetazolamide WAY APX .0780
JUNE 27, 2008
IIIA.203
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

BETAXOLOL HCL
1057 0.25% Oph Susp 01908448 Betoptic S ALC 2.2280 2.2280
BIMATOPROST
1058
ED N T IO MI SE AT D LI U NT E E IR UM QU OC RE D
Reason for Use Code 171 Clinical criteria LU Authorization Period: Indefinite. 172 LU Authorization Period: Indefinite. 387 LU Authorization Period: Indefinite.
0.03% Oph Sol 02245860
Lumigan
ALL
10.8100 10.8100
As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated;
As a second line monotherapy or combination therapy in patients who do not have an adequate intraocular pressure lowering response to ophthalmic beta-blocking agents.
For use as adjunctive therapy with an ophthalmic beta-blocking agent in an urgent situation (e.g. patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective.
IIIA.204
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

BRIMONIDINE
1059 1060 0.15% Oph Sol 02248151 0.2% Oph Sol 02236876 02243026 02246284 02260077 Reason for Use Code 171 2.3100 2.3100 1.6500 3.3000 1.6500 1.6500 1.6500
N ED T E I IO IM US AT L NT D ME RE CU UI DO EQ R
Alphagan Ratio-Brimonidine PMS-Brimonidine Apo-Brimonidine ALL RPH PMS APX Clinical criteria LU Authorization Period: Indefinite. 172 LU Authorization Period: Indefinite. 387 LU Authorization Period: Indefinite.
Alphagan P
ALL
JUNE 27, 2008
IIIA.205
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

BRIMONIDINE TARTRATE & TIMOLOL MALEATE
1061 0.2% & 0.5% Oph-Sol 5mL Pk 02248347 Combigan Reason for Use Code 310 20.0600 20.0600
ON ED TI ED IT E IM S TA IR L U MEN U U REQ OC D
Clinical criteria LU Authorization Period: Indefinite. 393 LU Authorization Period: Indefinite. Azopt ALC Reason for Use Code 171 Clinical criteria
ALL
As second-line therapy for patients who do not have an adequate intraocular pressure lowering response to monotherapy with ophthalmic beta-blocking agents.
For use as initial therapy in an urgent situation (e.g. patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective.
BRINZOLAMIDE
1062
ED ON IT E TI IM S L TA D U EN RE M UI CU EQ DO R
LU Authorization Period: Indefinite. 172 LU Authorization Period: Indefinite. 387 LU Authorization Period: Indefinite.
1% Oph Susp 02238873
3.2200 3.2200
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DEXTRAN 70 & HYDROXYPROPYL METHYLCELLULOSE
1063 0.1%/0.3% Oph-Sol 00390291 Tears Naturale Reason for Use Code 49
ION D ED E TAT IRE MIT US MEN EQU LI U R OC D

ALC Clinical criteria LU Authorization Period: Indefinite.
.2800 .2800
For patients with objective evidence of keratoconjunctivitis sicca as confirmed by filamentary keratopathy on slit lamp examination or biopsy.
DEXTRAN 70 & HYDROXYPROPYL METHYLCELLULOSE & POLYQUAD

1064 0.1%/0.3%/0.001% Oph-Sol 00743445 Tears Naturale II Reason for Use Code 49 Clinical criteria
ION D ED E TAT IRE MIT US MEN EQU LI U R OC D

ALC LU Authorization Period: Indefinite. Voltaren Ophtha NOV
.2880 .2880
DICLOFENAC SODIUM
1065 0.1% Oph Sol 01940414 3.1600 3.1600
JUNE 27, 2008
IIIA.207
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DORZOLAMIDE HCL
1066 2% Oph Sol 02216205 Reason for Use Code 171 3.6400 3.6400
ED N T IO MI SE AT D LI U NT E E IR UM QU OC RE D
Clinical criteria LU Authorization Period: Indefinite. 172 LU Authorization Period: Indefinite. 387 LU Authorization Period: Indefinite.
Trusopt
MFC
DORZOLAMIDE HCL & TIMOLOL MALEATE

1067 2% & 0.5% Oph Sol 02240113 Cosopt Reason for Use Code 310 MFC 5.5170 5.5170
ON ED TI ED IT E IM S TA IR L U MEN U U REQ OC D
IIIA.208
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

IPRATROPIUM BROMIDE
1068 0.03% Nasal Spray 02163705 Atrovent 02239627 PMS-Ipratropium 02246083 Apo-Ipravent Reason for Use Code 03 Clinical criteria
ION D T D TE SE ENTA UIRE IMI U L UM REQ OC D

BOE PMS APX LU Authorization Period: 1 year. PFI Clinical criteria
.4640 .9930 .4640 .4640
For the treatment of non-allergic vasomotor rhinitis
LATANOPROST
1069
ED N T I IO LIM USE NTAT D E IRE UM QU C E DO R

Reason for Use Code 171 LU Authorization Period: Indefinite. 172 LU Authorization Period: Indefinite. 387 LU Authorization Period: Indefinite.
0.005% Oph Sol-2.5mL Pk 02231493 Xalatan
27.0400 27.0400
JUNE 27, 2008
IIIA.209
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LATANOPROST & TIMOLOL MALEATE
1070 50mcg/mL & 5mg/mL Oph Sol-2.5mL Pk 02246619 Xalacom Reason for Use Code 310 Clinical criteria 30.6000 30.6000
ON ED TI D IT E TA RE IM S L U MEN UI CU REQ DO
LU Authorization Period: Indefinite. 393 LU Authorization Period: Indefinite. Ratio-Levobunolol Sandoz Levobunolol Betagan Ratio-Levobunolol PMS-Levobunolol Apo-Levobunolol Sandoz Levobunolol RPH SDZ ALL RPH PMS APX SDZ .9334 .9334 .9334 1.2345 3.2900 1.2345 1.2345 1.2345 1.2345
PFI
LEVOBUNOLOL HCL
1071 0.25% Oph Sol 02031159 02241715 0.5% Oph Sol 00637661 02031167 02237991 02241574 02241716
1072
IIIA.210
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

METHAZOLAMIDE
1073 50mg Tab 02238071 02245882 .4706 Neptazane (Not a Benefit) Apo-Methazolamide WAY APX .4706
METHYLCELLULOSE
1074 * 0.5% Oph-Sol 00000809 1075 * 1% Oph-Sol 00000817 Reason for Use Code 49
D ION D ITE E TAT IRE M LI US UMEN EQU R OC D

Isopto Tears ALC Clinical criteria LU Authorization Period: Indefinite.
Isopto Tears
ALC
.3407 .3407 .4220 .4220
PETROLATUM/MINERAL OIL
1076 1077 55%/42.5% Oph Oint-3.5g Pk 00210889 Lacri-Lube 80%/20% Oph Oint-3.5g Pk 02125706 Duolube Reason for Use Code 49 ALL 6.9800 6.9800 4.5800 4.5800
D ION D ITE E TAT IRE M LI EN QU US UM RE OC D

BSH Clinical criteria LU Authorization Period: Indefinite.
JUNE 27, 2008
IIIA.211
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

POLYVINYL ALCOHOL
1078 1079 1% Oph-Sol 02133253 .3720 .3720 .6373 .6373
1.4% Oph-Sol 00045616 Reason for Use Code 49
ED ION D T TAT IRE IMI SE L EN QU U UM RE OC D

Liquifilm Tears ALL Clinical criteria LU Authorization Period: Indefinite. Tears Plus ALL Reason for Use Code
Hypotears
NOV
POLYVINYL ALCOHOL & POLYVINYLPYRROLIDONE

1080 Oph-Sol 00579408
N Clinical criteria D TIO ED ITE For patients withENTA UIRkeratoconjunctivitis sicca E 49 objective evidence of IM as confirmed by US UM filamentary Q L Ekeratopathy on slit lamp examination or biopsy. R OC LU Authorization Period: Indefinite. D
.3553 .3553
IIIA.212
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

RANIBIZUMAB
1081 10mg/mL Inj Sol-0.3mL Vial Pk 02296810 Lucentis NOV 1575.0000 1575.0000
Note: For the treatment of patients with new onset (< 3 months) neovascular (wet) agerelated macular degeneration (AMD) in a verteporfin PDT (Visudyne)-nave eye. Initial diagnosis should be confirmed by an appropriate diagnostic procedure and administration should be done by a qualified ophthalmologist experienced in Intravitreal injections. Patients receiving concurrent administration of verteporfin PDT (Visudyne) are not eligible for reimbursement. Treatment should be initiated with a loading phase of one injection per month for three consecutive months, followed by a maintenance phase. During the maintence phase, patients should be monitored for best corrected visual acuity or continued disease activity. If there is clinical or diagnostic evidence of disease activity such as a loss of greater than 5 letters in visual acuity (Early Treatment Diabetic Retinopathy Score (ETDRS) chart or one Snellen line equivalent), Lucentis may be administered. The interval between two doses should not be shorter than one month.
SODIUM CROMOGLYCATE
1082 2% Nas Sol-26mL Pk 00605255 Rynacrom (Not a Benefit) 01950541 Cromolyn 02231390 Apo-Cromolyn 2% Oph Sol 02230621 02009277 Opticrom Cromolyn 13.7600 FIS PMS APX ALL PMS 13.7600 13.7600 .9500 .9980 .9500
1083
TIMOLOL MALEATE
1084 0.25% Oph Gellan Sol 02171880 Timoptic-XE 02242275 Timolol Maleate-EX MFC ALC 1.9560 3.5960 1.9560
Note: Timolol maleate can potentiate bronchospasm in asthmatic patients and should not be used in patients with a history of asthma. 1085 0.5% Oph Gellan Sol 02171899 Timoptic-XE 02242276 Timolol Maleate-EX MFC ALC 2.3400 4.3040 2.3400
Note: Timolol maleate can potentiate bronchospasm in asthmatic patients and should not be used in patients with a history of asthma.
JUNE 27, 2008
IIIA.213
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TIMOLOL MALEATE
1086 0.25% Oph Sol 00451193 00755826 00893773 02083353 02166712 Timoptic Apo-Timop Gen-Timolol PMS-Timolol Sandoz Timolol MFC APX GEN PMS SDZ 1.2780 2.7650 1.2780 1.2780 1.2780 1.2780
Note: Timolol maleate can potentiate bronchospasm in asthmatic patients and should not be used in patients with a history of asthma. 1087 0.5% Oph Sol 00451207 00755834 00893781 02083345 02166720 Timoptic Apo-Timop Gen-Timolol PMS-Timolol Sandoz Timolol MFC APX GEN PMS SDZ 1.5125 3.3690 1.5125 1.5125 1.5125 1.5125
Note: Timolol maleate can potentiate bronchospasm in asthmatic patients and should not be used in patients with a history of asthma.
TRAVOPROST
1088 0.004% Oph Sol 02244896 Reason for Use Code 171 Travatan Clinical criteria ALC 10.8160 10.8160
ED T E ON TI MI S LI U TA ED EN IR UM QU OC RE D
As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated; As a second line monotherapy or combination therapy in patients who do not have an adequate intraocular pressure lowering response to ophthalmic beta-blocking agents. For use as adjunctive therapy with an ophthalmic beta-blocking agent in an urgent situation (e.g. patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective.
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
56:00 GASTROINTESTINAL DRUGS

56:04:00 ANTACIDS AND ADSORBENTS
ALUMINUM HYDROXIDE & MAGNESIUM HYDROXIDE
1089 * 40mg & 40mg/mL O/L dpp 02163136 Maalox (Not a Benefit) 00261173 Neutralca-S (Not a Benefit) 1090 120mg & 60mg/mL O/L dpp 00491217 Diovol EX (Not a Benefit) 02162369 Maalox TC (Not a Benefit) 400mg & 400mg Tab dpp 00483605 Gelusil Extra Strength (Not a Benefit) 02208253 Maalox (Not a Benefit) NOV DES HOR NOV
1091
PDA NOV
JUNE 27, 2008
IIIA.215
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:08:00 ANTIDIARRHEA AGENTS
DIPHENOXYLATE HYDROCHLORIDE & ATROPINE SULFATE
1092 2.5mg & 0.025mg Tab 00036323 Lomotil Reason for Use Code Clinical criteria PFI .4358 .4358
D TE I IM SE TION L U TA EN ED M IR U U C Q DO RE
For the treatment of diarrhea associated with: 110 An ileostomy or a colostomy; LU Authorization Period: 1 year. 111 Bowel resection, including short bowel syndrome; LU Authorization Period: 1 year. 112 Inflammatory Bowel Diseases, i.e. Crohns Disease and Ulcerative Colitis; LU Authorization Period: 1 year. 113 Cancer, including chemotherapy or radiation therapy; LU Authorization Period: 1 year. 114 HIV/AIDS; LU Authorization Period: 1 year. 115 Acute diarrhea in patients in congregated housing, i.e. Long Term Care Facilities (LTCF), or for patients receiving Home Care; LU Authorization Period: 1 year. 224 Fecal incontinence. LU Authorization Period: 1 year.
IIIA.216
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:08:00 ANTIDIARRHEA AGENTS
LOPERAMIDE HCL
1093 2mg Caplet 00860743 02132591 02212005 02228351 02229552 02257564 Reason for Use Code Imodium Novo-Loperamide Apo-Loperamide PMS-Loperamide Diarr-eze (Not a Benefit) Sandoz Loperamide JAN NOP APX PMS PMS SDZ .1903 .3806 .1903 .1903 .1903 .1903
Clinical criteria For the treatment of diarrhea associated with: 110 An ileostomy or a colostomy; LU Authorization Period: 1 year. 111 Bowel resection, including short bowel syndrome; LU Authorization Period: 1 year. 112 Inflammatory Bowel Diseases, i.e. Crohns Disease and Ulcerative Colitis; LU Authorization Period: 1 year. 113 Cancer, including chemotherapy or radiation therapy; LU Authorization Period: 1 year. 114 HIV/AIDS; LU Authorization Period: 1 year. 115 Acute diarrhea in patients in congregated housing, i.e. Long Term Care Facilities (LTCF), or for patients receiving Home Care; LU Authorization Period: 1 year. 224 Fecal incontinence. LU Authorization Period: 1 year.
JUNE 27, 2008
IIIA.217
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:12:00 CATHARTICS
Note: Cathartics (laxatives) should only be used after failure of simpler measures. A high fibre diet, adequate hydration and a review of potentially constipating drugs is often effective in relieving constipation.
BISACODYL
1094 * 5mg Ent Tab 00254142 00545023 1095 5mg Sup 00003867 Dulcolax Apo-Bisacodyl Dulcolax Dulcolax Ratio-Bisacodyl BOE APX BOE BOE RPH .0450 .1860 .0450 1.0933 1.0933 .4681 1.1000 .4681
1096 * 10mg Sup 00003875 00404802
DOCUSATE CALCIUM (DIOCTYL CALCIUM SULFOSUCCINATE)

1097 240mg Cap 02224666 00664553 .1287 Surfak (Not a Benefit) PMS-Docusate Calcium HMR PMS .1287
DOCUSATE SODIUM (DIOCTYL SODIUM SULFOSUCCINATE)

1098 * 100mg Cap 02106256 00716731 01994344 1099 4mg/mL O/L 02086018 02006758 10mg/mL O/L 02090163 Colace Docusate Sodium Soflax Colace Soflax Syrup Colace WEL TAR PMS WEL PMS WEL .0383 .1310 .0383 .0383 .0232 .0232 .0232 .1770 .1770
1100
GRAIN & CITRUS FIBRE

1101 * Tab 00779768 00595829 Fibyrax (Not a Benefit) Novo-Fibre LED NOP .0565 .0565
IIIA.218
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:12:00 CATHARTICS
LACTULOSE
1102 1103 40% Jelly-Unidose Pk 00739561 GEL-OSE 667mg/mL O/L 00703486 PMS-Lactulose JOU PMS .4534 .4534 .0147 .0147
MAGNESIUM OXIDE, CITRIC ACID, SODIUM PICOSULFATE

1104 3.5g/12g/10mg Pd for Sol-2X12g Sachet Pk 02254794 Pico-Salax FEI 12.0000 12.0000
MINERAL OIL
1105 Enema 00107875 Fleet MFC .0326 .0326
PSYLLIUM MUCILLOID
1106 * Oral Pd 02174812 00599875 01912879 .0175 Metamucil Fibre TherapyOriginal Texture Mucillium Metamucil Sugar Free (Not a Benefit) PGI PMS PGI .0246 .0175
JUNE 27, 2008
IIIA.219
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:12:00 CATHARTICS
SENNOSIDES A & B
1107 1.7mg/mL Syrup 00367729 Senokot Senokot Glysennid (Not a Benefit) Glysennid PFP PFP NOV NOV .0318 .0318 .0595 .0595 .0745 .0745
1108 * 8.6mg Tab 00026158 00604402 1109 * 12mg Tab 00027502
SODIUM BIPHOSPHATE & SODIUM PHOSPHATE

1110 160mg & 60mg/mL Ped Rect Sol 00108065 Fleet MFC MFC DPC .0440 .0440 .0205 .0236 .0205
1111 * 160mg & 60mg/mL Rect Sol 00009911 Fleet 02096900 Enemol
SODIUM CITRATE & SODIUM LAURYL SULFOACETATE

1112 Micro Enema-5mL Pk 02063905 Microlax PFI .9152 .9152
STERCULIA GUM
1113 62% W/W Gran 1 Sach Pk 02147831 Normacol RIV .2750 .2750
IIIA.220
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:16:00 DIGESTANTS
PANCRELIPASE EQUIVALENT TO LIPASE & AMYLASE & PROTEASE
1114 1115 1116 1117 8000 & 30000 & 30000 USP Units Cap 00263818 Cotazym 4000 & 11000 & 11000 USP Units Ent Microsph Cap 02181215 Cotazym ECS 4 8000 & 30000 & 30000 USP Units Ent Microsph Cap 00502790 Cotazym ECS 8 ORG ORG ORG ORG .1828 .1828 .1795 .1795 .3299 .3299 .8648 .8648
20000 & 55000 & 55000 USP Units Ent Microsph Cap 00821373 Cotazym ECS 20 Reason for Use Code 124 Clinical criteria
ED IT E ON IM US TI L TA EN ED M R CU UI DO EQ R
LU Authorization Period: Indefinite. 125 LU Authorization Period: Indefinite. 126 LU Authorization Period: Indefinite. 225 Replacement therapy for pancreatic insufficiency due to cystic fibrosis. LU Authorization Period: Indefinite.
Replacement therapy for pancreatic insufficiency secondary to pancreatic surgery (resection);
Replacement therapy for pancreatic insufficiency due to chronic pancreatitis;
Replacement therapy for pancreatic insufficiency due to carcinoma of the pancreas;
JUNE 27, 2008
IIIA.221
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:16:00 DIGESTANTS
1118 4000 & 12000 & 12000 USP Units Ent Microsph Cap 00789445 Pancrease MT4 Reason for Use Code 124 Clinical criteria .3945 .3945
ED IT E ION IM S AT ED L U ENT IR UM REQU OC D

JNO
Replacement therapy for pancreatic insufficiency due to carcinoma of the pancreas.
IIIA.222
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:16:00 DIGESTANTS
1119 1120 1121 1122 5000 & 16600 & 18750 USP Units Ent Minimicrosph Cap 02239007 Creon 5 SPH 10000 & 33200 & 37500 USP Units Ent Minimicrosph Cap 02200104 Creon 10 SPH 20000 & 66400 & 75000 USP Units Ent Minimicrosph Cap 02239008 Creon 20 SPH 25000 & 74000 & 62500 USP Units Ent Minimicrosph Cap 01985205 Creon 25 SPH Reason for Use Code 124 Clinical criteria .1670 .1670 .2670 .2670 .7923 .7923 .8340 .8340
ED IT E ON IM US TI L TA EN ED M R CU UI DO EQ R
LU Authorization Period: Indefinite. 125 LU Authorization Period: Indefinite. 126 LU Authorization Period: Indefinite. 225 Replacement therapy for pancreatic insufficiency due to cystic fibrosis. LU Authorization Period: Indefinite.
Replacement therapy for pancreatic insufficiency due to carcinoma of the pancreas;
JUNE 27, 2008
IIIA.223
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:16:00 DIGESTANTS
1123 1124 1125 1126 16800 & 70000 & 70000 USP U/0.7g Pd-114g Pk 02230020 Viokase 4500 & 20000 & 25000 USP Units SR Cap 02242374 # Pancrease 8000 & 30000 & 30000 USP Units Tab 02230019 Viokase 16mg Tab 02241933 Reason for Use Code 124 Viokase 16 BFI JNO BFI BFI 31.9800 31.9800 .3751 .3751 .1599 .1599 .3198 .3198
ED IT E ON IM US TI L TA D EN RE M I CU QU DO RE
IIIA.224
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:22:00 ANTIEMETICS AND ANTINAUSEANTS
DELTA-9-TETRAHYDROCANNABINOL
1127 1128 2.5mg Cap 00611190 5mg Cap 00611204 Reason for Use Code 40 Marinol Marinol SPH SPH 1.9332 1.9332 3.8662 3.8662
ED IT E ON IM US TI L TA D EN RE M UI CU EQ DO R
Clinical criteria LU Authorization Period: 1 year. 345 LU Authorization Period: 1 year. 00586331 Gravol Filmkote (Not a Benefit) Novo-Dimenate (Not a Benefit) Apo-Dimenhydrinate (Not a Benefit) PMS-Dimenhydrinate (Not a Benefit) HOR NOP APX PMS
For the treatment of emesis associated with cancer chemotherapy in patients who are unresponsive to conventional antiemetic therapy: Initial dose -5mg/m.sq. given 1 to 3 hours before administration of chemotherapy; Repeat doses -5mg/m.sq. every 2 to 4 hours after chemotherapy as needed, usually for 1 to 2 days: no more than 4 to 6 doses should be given in a single day.
For the treatment of AIDS-related anorexia associated with weight loss and prescription is from a prescriber approved for the Facilitated Access mechanism (see Part VI of the Formulary/CDI binder).
DIMENHYDRINATE
1129 * 50mg Tab 00013803 00021423 00363766
JUNE 27, 2008
IIIA.225
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DOLASETRON MESYLATE
1130 1131 50mg Tab 02231378 100mg Tab 02231379 Reason for Use Code 229 Anzemet Anzemet SAV SAV 13.9992 13.9992 27.9983 27.9983
ED ON IT E TI M S LI U TA D EN RE UM UI OC REQ D
Clinical criteria LU Authorization Period: 1 year. 230 LU Authorization Period: 1 year. 231 LU Authorization Period: 1 year. DUI
For the treatment of emesis in cancer patients receiving highly emetogenic chemotherapy.
For patients receiving intravenous chemotherapy who have not experienced adequate control with other available anti-emetics.
For patients receiving intravenous chemotherapy who experience intolerable side effects with other anti-emetics. NOTE: The therapeutic value of Anzemet more than 24 hours after the last dose of chemotherapy is unproven.
DOXYLAMINE SUCCINATE AND PYRIDOXINE HCL

1132 10mg & 10mg SR Tab 00609129 Diclectin 1.2000 1.2000
IIIA.226
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

GRANISETRON HCL
1133 1mg Tab 02185881 Reason for Use Code 91 Kytril Clinical criteria HLR 18.0000 18.0000
ED N IT E IO IM US L AT T EN ED UM UIR C Q DO RE
LU Authorization Period: 1 year. 92 For patients receiving intravenous chemotherapy or radiation therapy who have not experienced adequate control with other available anti-emetics. LU Authorization Period: 1 year. 93 LU Authorization Period: 1 year. 326 LU Authorization Period: 1 year.
For patients receiving intravenous chemotherapy or radiation therapy who experience intolerable side effects with other antiemetics.
For the treatment of emesis in patients receiving radiation therapy which consists of single fraction treatment to the abdominal cavity, hemi-body irradiation and total body irradiation. NOTE: The therapeutic value of Kytril more than 24 hours after the last dose of chemotherapy is unproven.
MECLIZINE HCL
1134 25mg Tab 00220442 Bonamine PFI .2919 .2919
NABILONE
1135 1136 0.5mg Cap 02256193 1mg Cap 00548375 Cesamet Cesamet VAL VAL 3.1026 3.1026 6.2050 6.2050
JUNE 27, 2008
IIIA.227
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ONDANSETRON HYDROCHLORIDE
1137 1138 4mg/5mL O/L 02229639 4mg Tab 02213567 02258188 02264056 02274310 02278529 02288184 02297868 4mg Tab 02239372 8mg Tab 02213575 02258196 02264064 02274329 02278537 02288192 02297876 8mg Tab 02239373 Reason for Use Code 215 Zofran Zofran PMS-Ondansetron Novo-Ondansetron Sandoz Ondansetron Ratio-Ondansetron Apo-Ondansetron Gen-Ondansetron Zofran ODT GSK GSK PMS NOP SDZ RPH APX GEN GSK GSK PMS NOP SDZ RPH APX GEN GSK 1.9971 1.9971 5.9884 13.0886 5.9884 5.9884 5.9884 5.9884 5.9884 5.9884
1139 1140
1141
ED IT E N IM S IO L U TAT EN D M U RE C O QUI D RE
13.0886 13.0886 9.1402 19.9722 9.1402 9.1402 9.1402 9.1402 9.1402 9.1402 Zofran PMS-Ondansetron Novo-Ondansetron Sandoz Ondansetron Ratio-Ondansetron Apo-Ondansetron Gen-Ondansetron Zofran ODT 19.9722 19.9722 Clinical criteria 216 217 218
For the treatment of emesis in cancer patients receiving highly emetogenic chemotherapy. LU Authorization Period: 1 year. For patients receiving intravenous chemotherapy or radiation therapy who have not experienced adequate control with other available anti-emetics. LU Authorization Period: 1 year. For patients receiving intravenous chemotherapy or radiation therapy who experience intolerable side effects with other antiemetics. LU Authorization Period: 1 year. For the treatment of emesis in patients receiving radiation therapy which consists of single fraction treatment to the abdominal cavity, hemi-body irradiation and total body irradiation. NOTE: The therapeutic value of Zofran more than 24 hours after the last dose of chemotherapy is unproven. LU Authorization Period: 1 year.
IIIA.228
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

56:40:00 MISCELLANEOUS G.I. DRUGS
5-AMINOSALICYLIC ACID
1142 1143 1144 1145 1146 1147 1148 1149 1150 1151 1152 500mg Del-Release Tab 02099683 Pentasa 1g/100mL Enema 02153521 4g/100mL Enema 02153556 500mg Ent Tab 02112787 500mg Ent Tab 01914030 4g Rect Susp-Pk 02112809 500mg Sup 02112760 1000mg Sup 02242146 1g Sup 02153564 400mg Tab 01997580 800mg Tab 02267217 Pentasa Pentasa Salofalk Mesasal Salofalk Salofalk Salofalk Pentasa Asacol Asacol FEI FEI FEI BFI GSK BFI BFI BFI FEI PGP PGP .5569 .5569 3.7000 3.7000 4.4600 4.4600 .4840 .4840 .6003 .6003 5.9600 5.9600 1.0893 1.0893 1.6000 1.6000 1.6300 1.6300 .5098 .5098 .9900 .9900
BETAMETHASONE DISODIUM PHOSPHATE

1153 5mg/100mL Enema-100mL Pk 02060884 Betnesol SQI 8.7914 8.7914
JUNE 27, 2008
IIIA.229
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CIMETIDINE
Note: Cimetidine is less expensive than alternatives, and is effective and well tolerated in most patients. Adequate acid suppression can be achieved by giving cimetidine as opposed to using other longer acting H2-antagonists. Long-term use of these drugs for prevention of recurrent peptic ulcers should be reviewed; specific cure of Helicobacter pylori infection with antibiotics is a more effective and less costly approach. 1154 200mg Tab 01916793 00582409 00584215 00865796 300mg Tab 01916815 00487872 00582417 00865818 02227444 400mg Tab 01916785 00600059 00603678 00865826 02227452 .0737 Tagamet (Not a Benefit) Novo-Cimetine Apo-Cimetidine Nu-Cimet Tagamet (Not a Benefit) Apo-Cimetidine Novo-Cimetine Nu-Cimet Gen-Cimetidine Tagamet (Not a Benefit) Apo-Cimetidine Novo-Cimetine Nu-Cimet Gen-Cimetidine SMJ NOP APX NXP SMJ APX NOP NXP GEN SMJ APX NOP NXP GEN .0737 .0737 .0737 .0860 .0860 .0860 .0860 .0860 .1350 .1350 .1350 .1350 .1350
1155
1156
IIIA.230
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CIMETIDINE
Note: Cimetidine is less expensive than alternatives, and is effective and well tolerated in most patients. Adequate acid suppression can be achieved by giving cimetidine as opposed to using other longer acting H2-antagonists. Long-term use of these drugs for prevention of recurrent peptic ulcers should be reviewed; specific cure of Helicobacter pylori infection with antibiotics is a more effective and less costly approach. 1157 600mg Tab 01916777 00600067 00603686 00865834 02227460 800mg Tab 01916769 00663727 00749494 .1720 Tagamet (Not a Benefit) Apo-Cimetidine Novo-Cimetine Nu-Cimet Gen-Cimetidine Tagamet (Not a Benefit) Novo-Cimetine Apo-Cimetidine SMJ APX NOP NXP GEN SMJ NOP APX .1720 .1720 .1720 .1720 .2530 .2530 .2530
1158
DOMPERIDONE MALEATE
1159 10mg Tab 00855820 01912070 02103613 02157195 02231477 02236466 02268078 02278669 .1496 Motilium (Not a Benefit) Ratio-Domperidone Apo-Domperidone Novo-Domperidone Nu-Domperidone PMS-Domperidone Ran-Domperidone Gen-Domperidone (Not a Benefit) JAN RPH APX NOP NXP PMS RAN GEN .1496 .1496 .1496 .1496 .1496 .1496
JUNE 27, 2008
IIIA.231
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FAMOTIDINE
Note: Cimetidine is less expensive than alternatives, and is effective and well tolerated in most patients. Adequate acid suppression can be achieved by giving cimetidine as opposed to using other longer acting H2-antagonists. Long-term use of these drugs for prevention of recurrent peptic ulcers should be reviewed; specific cure of Helicobacter pylori infection with antibiotics is a more effective and less costly approach. 1160 20mg Tab 00710121 01953842 02022133 02024195 02196018 40mg Tab 00710113 01953834 02022141 02024209 02196026 Pepcid Apo-Famotidine Novo-Famotidine Nu-Famotidine Gen-Famotidine Pepcid Apo-Famotidine Novo-Famotidine Nu-Famotidine Gen-Famotidine MFC APX NOP NXP GEN MFC APX NOP NXP GEN .4679 1.0323 .4679 .4679 .4679 .4679 .8423 1.8770 .8423 .8423 .8423 .8423
1161
HYDROCORTISONE
1162 100mg/60mL Enema-60mL Pk 00230316 Hycort 02112736 Cortenema VAL BFI 5.1429 5.1429 6.0500
HYDROCORTISONE ACETATE
1163 10% Rect Aero-15g Pk 00579335 Cortifoam SQI 77.0600 77.0600
LACTULOSE
1164 666.7mg/mL O/L 02091925 00854409 02242814 .0145 Cephulac (Not a Benefit) Ratio-Lactulose Apo-Lactulose Solution MRR RPH APX .0145 .0145
IIIA.232
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LANSOPRAZOLE
1165 1166 15mg DR Cap 02165503 30mg DR Cap 02165511 Prevacid Prevacid ABB ABB 2.0000 2.0000 2.0000 2.0000
Reason for Use Code
ED IT E IM S ON L TI U TA N E D M U RE C O QUI D RE
Clinical criteria 293 Gastroesophageal Reflux Disease (GERD) For the treatment of erosive GERD or upper GI malignancy; OR Patients with GERD should be reassessed within 6 months after initial treatment with a PPI. The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or stepdown therapy to H2-receptor antagonist therapy. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year 295 H. pylori-positive Peptic Ulcers For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a one-week course in combination with antimicrobial therapy. Retreatment of H. pyloripositive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy. Maximum duration: 7 days (for retreatment, a four-week period must elapse since the end of the previous treatment). LU Authorization Period: 1 Year
For the treatment of non-erosive GERD after failure of H2-receptor antagonist therapy.
Continued on next page...
JUNE 27, 2008
IIIA.233
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LANSOPRAZOLE (contd)
Reason for Use Code 297 Clinical criteria Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis: For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year
D TE I IM SE TION L U TA EN D UM IRE C O QU D E R
401 Other Gastrointestinal Disorders For the treatment of gastroduodenal Crohns disease, short-gut syndrome, scleroderma, or pancreatitis. Note: There is a lack of published evidence to support double-dose PPI therapy in these settings. LU Authorization Period: 1 Year 402 Severe Conditions: For the treatment of severe esophagitis, Zollinger-Ellison syndrome, esophageal stricture, persistent symptoms of GERD or persistent erosive esophagitis, or upon hospital discharge following a gastrointestinal bleed. For patients receiving double-dose therapy, the need to continue treatment at higher doses should be reassessed after eight weeks. For re-treatment at higher doses, a four-week period should have elapsed from the end of the previous treatment. Reassessment could include a procedural assessment of the condition or step-down therapy to lower-dose proton pump inhibitor (PPI) therapy. LU Authorization Period: 1 Year
IIIA.234
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LANSOPRAZOLE & CLARITHROMYCIN & AMOXICILLIN
1167 30mg & 500mg & 500mg Tab/Cap Pk 02238525 Hp-PAC Clinical criteria ABB 80.2000 80.2000
Reason for Use Code
ED IT E ON IM US TI L TA D EN RE M I CU QU O E D R
306 a) For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, breath test or endoscopy, for a one-week course. Maximum duration: 7 days LU Authorization Period: 1 Year 307 LU Authorization Period: 1 Year .0556 Maxeran (Not a Benefit) Apo-Metoclop Nu-Metoclopramide PMS-Metoclopramide Maxeran (Not a Benefit) Apo-Metoclop Nu-Metoclopramide PMS-Metoclopramide HMR APX NXP PMS HMR APX NXP PMS .0556 .0556 .0556 .0583 .0583 .0583 .0583
b) For the retreatment of H. pylori-positive peptic ulcers where H. pylori recurrence or persistence is documented, by breath test or endoscopy, for a one-week course. Maximum duration: 7 days (after a four-week period has elapsed since the end of the previous treatment)
Retreatment decisions should be based upon positive symptoms and positive endoscopy or positive urea breath test. Retreatment should not be based on a positive serology test, as serology tests may remain positive indefinitely. An alternative antibiotic regimen is recommended when initial therapy fails due to concerns of antimicrobial resistance. Network Note: Network will limit supply to 7 days. Network will verify that retreatments are reimbursed only after a four-week period has elapsed since the end of the previous treatment.
METOCLOPRAMIDE HCL
1168 5mg Tab 02099195 00842826 02143275 02230431 10mg Tab 02099209 00842834 02143283 02230432
1169
JUNE 27, 2008
IIIA.235
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MISOPROSTOL
1170 100mcg Tab 00813966 02240754 02244022 200mcg Tab 00632600 02244023 .1360 Cytotec (Not a Benefit) # Novo-Misoprostol Apo-Misoprostol Cytotec (Not a Benefit) Apo-Misoprostol SEA NOP APX SEA APX .1360 .1360 .2265 .2265
1171
NIZATIDINE
Note: Cimetidine is less expensive than alternatives, and is effective and well tolerated in most patients. Adequate acid suppression can be achieved by giving cimetidine as opposed to using other longer acting H2-antagonists. Long-term use of these drugs for prevention of recurrent peptic ulcers should be reviewed; specific cure of Helicobacter pylori infection with antibiotics is a more effective and less costly approach. 1172 150mg Cap 00778338 02177714 02220156 02240457 02246046 300mg Cap 00778346 02177722 02220164 02240458 02246047 Axid PMS-Nizatidine Apo-Nizatidine Novo-Nizatidine Gen-Nizatidine Axid PMS-Nizatidine Apo-Nizatidine Novo-Nizatidine Gen-Nizatidine PHE PMS APX NOP GEN PHE PMS APX NOP GEN .4196 .8392 .4196 .4196 .4196 .4196 .7603 1.5206 .7603 .7603 .7603 .7603
1173
OLSALAZINE SODIUM
1174 250mg Cap 00875848 Dipentum VLH .4961 .4961
IIIA.236
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

OMEPRAZOLE
1175 20mg 02190915 02245058 02260867 20mg Cap 00846503 02296446 09857285 Losec DR Tab Apo-Omeprazole Cap Ratio-Omeprazole DR Tab Losec (Not a Benefit) Sandoz Omeprazole Apo-Omeprazole AZC APX RPH AST SDZ APX 1.1000 2.2000 1.1000 1.1000 1.1000
1176
Reason for Use Code
ED IT E N M S IO LI U TAT N E D M U RE C O QUI D RE
1.1000 1.1000 Clinical criteria 293 Gastroesophageal Reflux Disease (GERD) For the treatment of erosive GERD or upper GI malignancy; OR For the treatment of non-erosive GERD after failure of H2-receptor antagonist therapy. Patients with GERD should be reassessed within 6 months after initial treatment with a PPI. The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or stepdown therapy to H2-receptor antagonist therapy. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year 297 Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis: For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year Continued on next page...
JUNE 27, 2008
IIIA.237
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

OMEPRAZOLE (contd)
Reason for Use Code 401 Clinical criteria Other Gastrointestinal Disorders For the treatment of gastroduodenal Crohns disease, short-gut syndrome, scleroderma, or pancreatitis. Note: There is a lack of published evidence to support double-dose PPI therapy in these settings. LU Authorization Period: 1 Year
ED IT E ON IM US TI L TA ED EN IR M U CU EQ R DO
402 LU Authorization Period: 1 Year
Severe Conditions: For the treatment of severe esophagitis, Zollinger-Ellison syndrome, esophageal stricture, persistent symptoms of GERD or persistent erosive esophagitis, or upon hospital discharge following a gastrointestinal bleed. For patients receiving double-dose therapy, the need to continue treatment at higher doses should be reassessed after eight weeks. For re-treatment at higher doses, a four-week period should have elapsed from the end of the previous treatment. Reassessment could include a procedural assessment of the condition or step-down therapy to lower-dose proton pump inhibitor (PPI) therapy.
IIIA.238
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

OMEPRAZOLE MAGNESIUM
1177 20mg DR Tab 09857195 09857267 Losec Ratio-Omeprazole AZC RPH 1.1000 2.2000 1.1000
Reason for Use Code
ED ON IT E TI D IM S TA E L U MEN IR U EQU OC R D
Clinical criteria 295 LU Authorization Period: 1 Year
H. pylori-positive Peptic Ulcers For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a one-week course in combination with antimicrobial therapy. Retreatment of H. pyloripositive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy. Maximum duration: 7 days (for retreatment, a four-week period must elapse since the end of the previous treatment).
JUNE 27, 2008
IIIA.239
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PANTOPRAZOLE SODIUM
1178 40mg Ent Tab 02229453 02285487 02292920 02305046 Pantoloc + Novo-Pantoprazole Apo-Pantoprazole Ran-Pantoprazole NYC NOP APX RAN .9785 1.9570 .9785 .9785 .9785
Reason for Use Code
Clinical criteria 293 Patients with GERD should be reassessed within 6 months after initial treatment with a PPI. The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or stepdown therapy to H2-receptor antagonist therapy. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year 295 H. pylori-positive Peptic Ulcers For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a one-week course in combination with antimicrobial therapy. Retreatment of H. pyloripositive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy. Maximum duration: 7 days (for retreatment, a four-week period must elapse since the end of the previous treatment). LU Authorization Period: 1 Year 297 Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis: For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year
Gastroesophageal Reflux Disease (GERD) For the treatment of erosive GERD or upper GI malignancy; OR For the treatment of non-erosive GERD after failure of H2-receptor antagonist therapy.
IIIA.240
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PANTOPRAZOLE SODIUM (contd)
Reason for Use Code 401 Clinical criteria Other Gastrointestinal Disorders For the treatment of gastroduodenal Crohns disease, short-gut syndrome, scleroderma, or pancreatitis. Note: There is a lack of published evidence to support double-dose PPI therapy in these settings. LU Authorization Period: 1 Year
ED IT E ON IM US TI L TA ED EN IR M U CU EQ R DO
402 LU Authorization Period: 1 Year
JUNE 27, 2008
IIIA.241
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

RABEPRAZOLE SODIUM
1179 10mg Tab 02243796 02296632 02298074 20mg Tab 02243797 02296640 02298082 Pariet Novo-Rabeprazole EC Ran-Rabeprazole Pariet Novo-Rabeprazole EC Ran-Rabeprazole JNO NOP RAN JNO NOP RAN .3250 .6500 .3250 .3250 .6500 1.3000 .6500 .6500
1180
RANITIDINE HCL
Note: Cimetidine is less expensive than alternatives, and is effective and well tolerated in most patients. Adequate acid suppression can be achieved by giving cimetidine as opposed to using other longer acting H2-antagonists. Long-term use of these drugs for prevention of recurrent peptic ulcers should be reviewed; specific cure of Helicobacter pylori infection with antibiotics is a more effective and less costly approach. 1181 1182 50mg/2mL Inj Sol-2mL Pk 02212366 Zantac 15mg/mL Oral Sol 02212374 02242940 02280833 150mg Tab 02212331 00733059 00828564 00828823 00865737 02207761 02242453 02243229 02248570 Zantac Novo-Ranidine Apo-Ranitidine Zantac Apo-Ranitidine Novo-Ranidine Ratio-Ranitidine Nu-Ranit Gen-Ranitidine PMS-Ranitidine Sandoz Ranitidine Co-Ranitidine GSK GSK NOP APX GSK APX NOP RPH NXP GEN PMS SDZ COB 2.7988 2.7988 .0932 .2037 .0932 .0932 .4042 1.1967 .4042 .4042 .4042 .4042 .4042 .4042 .4042 .4042
1183
IIIA.242
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

RANITIDINE HCL
Note: Cimetidine is less expensive than alternatives, and is effective and well tolerated in most patients. Adequate acid suppression can be achieved by giving cimetidine as opposed to using other longer acting H2-antagonists. Long-term use of these drugs for prevention of recurrent peptic ulcers should be reviewed; specific cure of Helicobacter pylori infection with antibiotics is a more effective and less costly approach. 1184 300mg Tab 02212358 00733067 00828556 00828688 00865745 02207788 02242454 02243230 02248571 Zantac Apo-Ranitidine Novo-Ranidine Ratio-Ranitidine Nu-Ranit Gen-Ranitidine PMS-Ranitidine Sandoz Ranitidine Co-Ranitidine GSK APX NOP RPH NXP GEN PMS SDZ COB .7787 2.2527 .7787 .7787 .7787 .7787 .7787 .7787 .7787 .7787
SUCRALFATE
1185 1186 1g/5mL Oral Susp 02103567 1g Tab 02100622 02045702 02125250 02134829 02238209 Sulcrate Suspension Plus Sulcrate Novo-Sucralate Apo-Sucralfate Nu-Sucralfate PMS-Sucralfate BFI BFI NOP APX NXP PMS .0934 .0934 .2335 .5141 .2335 .2335 .2335 .2335
JUNE 27, 2008
IIIA.243
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
60:00 GOLD COMPOUNDS

AURANOFIN
1187 3mg Cap 01916823 Ridaura SQI 1.9463 1.9463
SODIUM AUROTHIOMALATE
1188 10mg/mL Inj Sol-1mL Pk 01927620 Myochrysine 02245456 Sodium Aurothiomalate 25mg/mL Inj Sol-1mL Pk 01927612 Myochrysine 02245457 Sodium Aurothiomalate 50mg/mL Inj Sol-1mL Pk 01927604 Myochrysine 02245458 Sodium Aurothiomalate SAV SDZ SAV SDZ SAV SDZ 6.3100 10.9600 6.3100 7.6567 13.2900 7.6567 11.8900 20.6500 11.8900
1189
1190
JUNE 27, 2008
IIIA.245
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
64:00 HEAVY METAL ANTAGONISTS

PENICILLAMINE
1191 250mg Cap 00016055 Cuprimine ATO 3.2965 3.2965
JUNE 27, 2008
IIIA.247
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
68:00 HORMONES AND SUBSTITUTES

68:04:00 CORTICOSTEROIDS
Note: The general direction of the therapy of asthma has been toward the use of antiinflammatory agents, especially inhaled steroids, which are not associated with systemic side effects to the same degree as oral steroids. The proper technique of inhalation or use of a spacer is very important to the efficacy of these agents. Physicians and pharmacists should ensure that patients are appropriately instructed in the use of these devices.
1192 1193 50mcg/Metered Dose Aero Inh-200 Dose Pk 02242029 QVAR 100mcg/Metered Dose Aero Inh-200 Dose Pk 02242030 QVAR GRA GRA 29.2000 29.2000 58.4000 58.4000
JUNE 27, 2008
IIIA.249
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

BUDESONIDE
1194 1195 1196 0.125mg/mL Inh Susp 02229099 Pulmicort Nebuamp 0.25mg/mL Inh Susp 01978918 Pulmicort Nebuamp 0.5mg/mL Inh Susp 01978926 Pulmicort Nebuamp Reason for Use Code Clinical criteria AZC AZC AZC .2063 .2063 .4125 .4125 .8250 .8250
D TE I IM SE TION L U TA EN D M U RE C I DO EQU R
260 Children aged 6 years or less; LU Authorization Period: Indefinite. 261 Patients who have a tracheostomy; LU Authorization Period: Indefinite. 262 Patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. 263 Patients with severe mental or physical disabilities; LU Authorization Period: Indefinite. 264 Patients who have previously used nebulizer therapy within the last 12 month period. LU Authorization Period: Indefinite.
IIIA.250
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

BUDESONIDE
1197 1198 1199 100mcg/Metered Dose Pd Inh-200 Dose Pk 00852074 Pulmicort Turbuhaler 200mcg/Metered Dose Pd Inh-200 Dose Pk 00851752 Pulmicort Turbuhaler 400mcg/Metered Dose Pd Inh-200 Dose Pk 00851760 Pulmicort Turbuhaler AZC AZC AZC 30.4000 30.4000 60.8500 60.8500 109.5000 109.5000
CICLESONIDE
1200 1201 100mcg/Actuation Inh-120 Dose Pk 02285606 Alvesco 200mcg/Actuation Inh-120 Dose Pk 02285614 Alvesco NYC NYC 41.4000 41.4000 68.4000 68.4000
DEXAMETHASONE
1202 0.5mg Tab 00016462 01964976 02240684 02261081 4mg Tab 00354309 01964070 02240687 02250055 .1564 Decadron (Not a Benefit) PMS-Dexamethasone Ratio-Dexamethasone Apo-Dexamethasone Decadron (Not a Benefit) PMS-Dexamethasone Ratio-Dexamethasone Apo-Dexamethasone MSD PMS RPH APX MSD PMS RPH APX .1564 .1564 .1564 .6092 .6092 .6092 .6092
1203
DEXAMETHASONE 21-PHOSPHATE
1204 4mg/mL Inj Sol 00213624 00664227 01977547 1.6900 Decadron (Not a Benefit) Dexamethasone Sodium Dexamethasone Sodium MSD SDZ CYI 1.6900 1.6900
JUNE 27, 2008
IIIA.251
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLUDROCORTISONE ACETATE
1205 0.1mg Tab 02086026 Florinef SQI .2281 .2281
FLUTICASONE PROPIONATE
1206 1207 1208 1209 1210 50mcg/Metered Dose Inh-120 Dose Pk 02244291 Flovent HFA 125mcg/Metered Dose Inh-120 Dose Pk 02244292 Flovent HFA 250mcg/Metered Dose Inh-120 Dose Pk 02244293 Flovent HFA 250mcg/Blister Pd Inh-60 Dose Pk 02237246 Flovent Diskus 500mcg/Blister Pd Inh-60 Dose Pk 02237247 Flovent Diskus GSK GSK GSK GSK GSK 24.5274 24.5274 40.3249 40.3249 80.6394 80.6394 40.3249 40.3249 80.6394 80.6394
HYDROCORTISONE
1211 1212 10mg Tab 00030910 20mg Tab 00030929 Cortef Cortef PFI PFI .1496 .1496 .2543 .2543
METHYLPREDNISOLONE
1213 4mg Tab 00030988 Medrol PFI .3252 .3252
IIIA.252
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

METHYLPREDNISOLONE ACETATE
1214 1215 1216 40mg/mL Inj Susp-1mL Pk 00030759 Depo-Medrol 80mg/mL Inj Susp-1mL Pk 00030767 Depo-Medrol 100mg/5mL Inj Susp-5mL Pk 01934325 Depo-Medrol PFI PFI PFI 4.6920 4.6920 9.0000 9.0000 10.5100 10.5100
PREDNISOLONE SODIUM PHOSPHATE

1217 6.7mg/5mL O/L 02230619 02245532 Pediapred Oral Liquid PMS-Prednisolone SAV PMS .0671 .1165 .0671
PREDNISONE
1218 1mg Tab 00271373 00598194 5mg Tab 00210188 00021695 00312770 50mg Tab 00252417 00232378 00550957 Winpred Apo-Prednisone Deltasone (Not a Benefit) Novo-Prednisone Apo-Prednisone Deltasone (Not a Benefit) Novo-Prednisone Apo-Prednisone VAL APX UPJ NOP APX UPJ NOP APX .1035 .1035 .1035 .0220 .0220 .0220 .0913 .0913 .0913
1219
1220
JUNE 27, 2008
IIIA.253
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TRIAMCINOLONE ACETONIDE
1221 40mg/mL Inj Susp-1mL Pk 00990876 Kenalog-40 02229550 Triamcinolone Acetonide 50mg/5mL Inj Susp-5mL Pk 01999761 Kenalog-10 02229540 Triamcinolone Acetonide 200mg/5mL Inj Susp-5mL Pk 01999869 Kenalog-40 09857128 Triamcinolone Acetonide BQU SDZ BQU SDZ BQU SDZ 4.7700 6.8200 4.7700 10.2800 14.6900 10.2800 16.7100 23.8700 16.7100
1222
1223
68:08:00 ANDROGENS
DANAZOL
1224 1225 1226 50mg Cap 02018144 100mg Cap 02018152 200mg Cap 02018160 Cyclomen Cyclomen Cyclomen SAV SAV SAV .8250 .8250 1.2242 1.2242 1.9563 1.9563
IIIA.254
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:08:00 ANDROGENS
TESTOSTERONE
1227 1228 1229 1% 2.5g Foil Packet 02245345 Androgel 1% 5.0g Foil Packet 02245346 Androgel SPH SPH PAL 3.7600 3.7600 3.7600 3.7600 1.9333 1.9333
12.2mg Transdermal Patch 02239653 Androderm Reason for Use Code 397
ED ON IT E TI IM US TA ED L EN IR UM EQU C R DO
Clinical criteria LU Authorization Period: 1 year.
For male patients with confirmed low morning serum testosterone levels associated with documented, symptomatic hypothalamic, pituitary or testicular disease, or in HIV-infected patients. NOTE: Older males with nonspecific symptoms of fatigue, malaise, depression who have a low normal random testosterone level do not satisfy these criteria.
JUNE 27, 2008
IIIA.255
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:08:00 ANDROGENS
TESTOSTERONE CYPIONATE
1230 100mg/mL Oily Inj Sol-10mL Pk 00030783 Depo-Testosterone Reason for Use Code 397 Clinical criteria 24.1400 24.1400
D ON TI ED TE IMI SE ENTA UIR L U UM EQ R OC D

PFI
TESTOSTERONE ENANTHATE
1231 1000mg/5mL Oily Inj Sol-5mL Pk 00029246 Delatestryl Reason for Use Code 397
D ION D ITE E AT E IM S NT UIR L U UME Q C RE DO

THE Clinical criteria LU Authorization Period: 1 year.
24.4200 24.4200
IIIA.256
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:08:00 ANDROGENS
TESTOSTERONE UNDECANOATE
1232 40mg Cap 00782327 Reason for Use Code 397 .9400 .9400
D ON TI ED TE IMI SE ENTA UIR L U UM EQ R OC D

Clinical criteria LU Authorization Period: 1 year. WAY WAY 7.1400 7.1400 7.1400 7.1400
Andriol
ORG
68:16:00 ESTROGENS
CONJUGATED EQUINE ESTROGEN & MEDROXYPROGESTERONE ACETATE
1233 1234 0.625mg/2.5mg Tab-28 Day Pk 02242878 Premplus 0.625mg/5mg Tab-28 Day Pk 02242879 Premplus Reason for Use Code 398
ED ON T MI SE TATI ED LI U EN UIR UM REQ OC D

Clinical criteria LU Authorization Period: 1 year.
For short-term use in women who are experiencing symptoms of menopause. NOTE: Recent evidence has demonstrated that use of hormone replacement therapy (HRT) increases the rate of coronary events, breast cancer, dementia, stroke, venous thromboembolism and referrals for abnormal vaginal bleeding. These risks should be discussed with patients and reviewed periodically.
JUNE 27, 2008
IIIA.257
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:16:00 ESTROGENS
CONJUGATED ESTROGENS
1235 1236 0.3mg Tab 02043394 0.625mg Tab 00265470 02043408 1.25mg Tab 00265489 02043424 Reason for Use Code 398 Premarin C.E.S. Premarin C.E.S. Premarin WAY VAL WAY VAL WAY .1239 .1239 .0774 .0774 .1239 .1293 .1293 .2206
1237
ED IT E ON IM S TI L TA ED U EN IR UM QU C O RE D
Clinical criteria LU Authorization Period: 1 year. Premarin WAY .5914 .5914 Estring PFI 60.0000 60.0000
1238
0.625mg/g Vag Cr 02043440
ESTRADIOL
1239 2mg Vag Ring 02168898
ESTRADIOL 17-B
1240 25mcg Vag Tab 02241332 Vagifem NOO 2.6440 2.6440
IIIA.258
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:16:00 ESTROGENS
ESTROPIPATE (CALCULATED AS SODIUM ESTRONE SULFATE 1.25MG)
1241 1.5mg Tab 02089769 Reason for Use Code 398 .2804 .2804
ON ED TI ED IT E TA IR IM S L U MEN QU CU RE DO
Clinical criteria LU Authorization Period: 1 year. Ogen 2.5 PFI .4434 .4434 Reason for Use Code 398 Clinical criteria
Ogen 1.25
PFI
ESTROPIPATE (CALCULATED AS SODIUM ESTRONE SULFATE 2.5MG)

1242 3mg Tab 02089777
D ON TI ED ITE E TA IR IM S L U MEN QU CU RE DO
JUNE 27, 2008
IIIA.259
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:20:02 ANTI-DIABETIC AGENTS ORAL ANTI-DIABETIC AGENTS
Note: An adequate trial of diet and exercise therapy alone is essential before any hypoglycaemic agent is prescribed in non-insulin dependent diabetes mellitus. When indicated (i.e., fasting plasma glucose remains > 10mmol/L), drug therapy should be considered as a supplement to continuing caloric restriction and exercise.
ACARBOSE
1243 1244 50mg Tab 02190885 100mg Tab 02190893 Reason for Use Code Glucobay Glucobay BAY BAY .2518 .2518 .3487 .3487
Clinical criteria 175 LU Authorization Period: Indefinite. 176 LU Authorization Period: Indefinite.
For the treatment of non-insulin-dependent diabetes mellitus (NIDDM):
In patients who cannot tolerate or have failed treatment with other oral hypoglycemic agents or in whom other oral hypoglycemic agents are contraindicated;
In patients who require combination therapy with more than one oral hypoglycemic agent to control their serum glucose concentrations.
IIIA.260
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

GLICLAZIDE
1245 1246 30mg SR Tab 02242987 80mg Tab 00765996 02229519 02238103 02245247 02294400 Diamicron MR Diamicron Gen-Gliclazide Novo-Gliclazide Apo-Gliclazide + PMS-Gliclazide SEV SEV GEN NOP APX PMS .3725 .3725 .1863 .3725 .1863 .1863 .1863 .1863
Note: These products must be prescribed based on the following criteria for the treatment of type 2 diabetes in a patient with: a. b. c. d. e. f. Inadequate glycemic control (HbA1c > 7%) using maximal doses of glyburide (10mg/day) AND metformin (2000mg/day); OR Inadequate glycemic control and demonstrated intolerance or contraindication to metformin and are on maximal doses of glyburide; OR Inadequate glycemic control and demonstrated intolerance or contraindication to glyburide and are on maximal doses of metformin; OR Demonstrated intolerance or contraindication to both glyburide AND metformin; OR Adequate glycemic control (HbA1c <= 7%) who develops intolerance or contraindication to glyburide or metformin; OR HbA1c <= 7% and greater than 50% of fasting blood glucose (FBG > 7mmol/L) or postprandial plasma glucose (PPG > 10mmol/L) levels are not within target range and using maximally tolerated doses of glyburide and metformin.
JUNE 27, 2008
IIIA.261
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

GLYBURIDE
1247 2.5mg Tab 02224550 00720933 00808733 01900927 01913654 01913670 02020734 02236733 02248008 5mg Tab 02224569 00720941 00808741 01900935 01913662 01913689 02020742 02236734 02248009 Diabeta Euglucon Gen-Glybe Ratio-Glyburide Apo-Glyburide Novo-Glyburide Nu-Glyburide PMS-Glyburide Sandoz Glyburide Diabeta Euglucon Gen-Glybe Ratio-Glyburide Apo-Glyburide Novo-Glyburide Nu-Glyburide PMS-Glyburide Sandoz Glyburide SAV PMS GEN RPH APX NOP NXP PMS SDZ SAV PMS GEN RPH APX NOP NXP PMS SDZ .0393 .1222 .0450 .0393 .0393 .0393 .0393 .0393 .0393 .0393 .0683 .2188 .0725 .0683 .0683 .0683 .0683 .0683 .0683 .0683
1248
METFORMIN HCL
1249 500mg Tab 02099233 02045710 02148765 02162822 02167786 02223562 02233999 02242794 02242974 02246820 02257726 02269031 Glucophage Novo-Metformin Gen-Metformin Nu-Metformin Apo-Metformin PMS-Metformin Rhoxal-Metformin Metformin Ratio-Metformin Sandoz Metformin FC Co-Metformin Ran-Metformin SAV NOP GEN NXP APX PMS SDZ ZYN RPH SDZ COB RAN .0965 .2234 .0965 .0965 .0965 .0965 .0965 .0965 .1216 .0965 .0965 .0965 .0965
IIIA.262
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PIOGLITAZONE HCL
1250 15mg Tab 02242572 02274914 02297906 02298279 02301423 02302861 02302942 02303124 30mg Tab 02242573 02274922 02297914 02298287 02301431 02302888 02302950 02303132 45mg Tab 02242574 02274930 02297922 02298295 02301458 02302896 02302977 02303140 Actos Novo-Pioglitazone Sandoz Pioglitazone Gen-Pioglitazone Ratio-Pioglitazone Co Pioglitazone Apo-Pioglitazone PMS-Pioglitazone Actos Novo-Pioglitazone Sandoz Pioglitazone Gen-Pioglitazone Ratio-Pioglitazone Co Pioglitazone Apo-Pioglitazone PMS-Pioglitazone Actos Novo-Pioglitazone Sandoz Pioglitazone Gen-Pioglitazone Ratio-Pioglitazone Co Pioglitazone Apo-Pioglitazone PMS-Pioglitazone LIL NOP SDZ GEN RPH COB APX PMS LIL NOP SDZ GEN RPH COB APX PMS LIL NOP SDZ GEN RPH COB APX PMS 1.1225 2.2451 1.1226 1.1226 1.1226 1.1226 1.1225 1.1225 1.1226 1.5726 3.1453 1.5727 1.5727 1.5727 1.5727 1.5726 1.5726 1.5727 2.3646 4.7293 2.3647 2.3647 2.3647 2.3647 2.3646 2.3646 2.3647
1251
1252
Note: These products must be prescribed based on the following criteria for the treatment of type 2 diabetes in a patient with: a. b. Inadequate glycemic control (HbA1c > 7%) using maximal doses of glyburide (10mg/day) AND metformin (2000mg/day); OR Inadequate glycemic control and demonstrated intolerance or contraindication to metformin and are on maximal doses of glyburide; OR Continued on next page...
JUNE 27, 2008
IIIA.263
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

PIOGLITAZONE HCL
Note: Continued... c. d. e. f. Inadequate glycemic control and demonstrated intolerance or contraindication to glyburide and are on maximal doses of metformin; OR Demonstrated intolerance or contraindication to both glyburide AND metformin; OR Adequate glycemic control (HbA1c <= 7%) who develops intolerance or contraindication to glyburide or metformin; OR HbA1c <= 7% and greater than 50% of fasting blood glucose (FBG > 7mmol/L) or postprandial plasma glucose (PPG > 10mmol/L) levels are not within target range and using maximally tolerated doses of glyburide and metformin.
ROSIGLITAZONE
1253 1254 1255 2mg Tab 02241112 4mg Tab 02241113 8mg Tab 02241114 Avandia Avandia Avandia GSK GSK GSK 1.2853 1.2853 2.0169 2.0169 2.8842 2.8842
Note: These products must be prescribed based on the following criteria for the treatment of type 2 diabetes in a patient with: a. b. c. d. e. f. Inadequate glycemic control (HbA1c > 7%) using maximal doses of glyburide (10mg/day) AND metformin (2000mg/day); OR Inadequate glycemic control and demonstrated intolerance or contraindication to metformin and are on maximal doses of glyburide; OR Inadequate glycemic control and demonstrated intolerance or contraindication to glyburide and are on maximal doses of metformin; OR Demonstrated intolerance or contraindication to both glyburide AND metformin; OR Adequate glycemic control (HbA1c <= 7%) who develops intolerance or contraindication to glyburide or metformin; OR HbA1c <= 7% and greater than 50% of fasting blood glucose (FBG > 7mmol/L) or postprandial plasma glucose (PPG > 10mmol/L) levels are not within target range and using maximally tolerated doses of glyburide and metformin.
IIIA.264
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:20:10 ANTI-DIABETIC AGENTS INSULINS (RAPID ACTING)
INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)
1256 1257 1000U/10mL Inj Sol-10mL Pk 00586714 Humulin Regular 100U/mL Inj Sol-5X3mL Pk 09853766 Humulin R LIL LIL 18.8600 18.8600 37.9700 37.9700
INSULIN ASPART
1258 1259 100U/mL Inj Sol-10mL Pk 02245397 NovoRapid 100U/mL Inj Sol-5x3mL Pk 02244353 NovoRapid Penfill Reason for Use Code 388 Clinical criteria NOO NOO 26.0700 26.0700 52.1800 52.1800
ED T E ON TI MI S LI U TA D EN IRE UM QU OC RE D
For the treatment of patients with Type 1 diabetes mellitus.
For the treatment of patients with Type 2 diabetes mellitus using insulin in an intensive regimen with 3 or more injections per day or an insulin pump.
For the treatment of patients with Type 2 diabetes mellitus who are either experiencing recurrent hypoglycemia OR are unable to achieve adequate post-prandial glucose control while on a less intensive regimen of regular insulin (1-2 injections per day).
JUNE 27, 2008
IIIA.265
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:20:10 ANTI-DIABETIC AGENTS INSULINS (RAPID ACTING)
INSULIN HUMAN BIOSYNTHETIC
1260 1261 1000U/10mL Inj Sol-10mL Pk 02024233 Novolin ge Toronto 100U/mL Inj Sol-5X3mL Pk 09853774 Novolin ge Toronto Penfill NOO NOO 18.8600 18.8600 37.0100 37.0100
INSULIN LISPRO
1262 1263 100U/mL Inj Sol-10mL Pk 02229704 Humalog 100U/mL Inj Sol-5x3mL Pk 09853715 Humalog Reason for Use Code 388 LIL LIL 25.7900 25.7900 51.5900 51.5900
ED T E ON TI MI S LI U TA D EN RE UM QUI OC RE D
For the treatment of patients with Type 1 diabetes mellitus.
For the treatment of patients with Type 2 diabetes mellitus using insulin in an intensive regimen with 3 or more injections per day or an insulin pump.
For the treatment of patients with Type 2 diabetes mellitus who are either experiencing recurrent hypoglycemia OR are unable to achieve adequate post-prandial glucose control while on a less intensive regimen of regular insulin (1-2 injections per day).
IIIA.266
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:20:12 ANTI-DIABETIC AGENTS INSULINS (INTERMEDIATE ACTING)
INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC
1264 1265 1000U/10mL Inj Susp-10mL Pk 02024225 Novolin ge NPH 100U/mL Inj Susp-5X3mL Pk 09853782 Novolin ge NPH Penfill NOO NOO 18.8600 18.8600 36.8700 36.8700
INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC (RDNA ORIGIN)

1266 1267 1000U/10mL Inj Susp-10mL Pk 00587737 Humulin NPH 100U/mL Inj Susp-5X3mL Pk 09853804 Humulin N LIL LIL 18.8600 18.8600 36.8700 36.8700
68:20:16 ANTI-DIABETIC AGENTS INSULINS (PRE-MIXED)

INSULIN (10% NEUTRAL & 90% ISOPHANE) HUMAN BIOSYNTHETIC
1268 100U/mL Inj Susp-5X3mL Pk 02024292 Novolin ge 10/90 Penfill NOO 37.7300 37.7300


1270 1271 1000U/10mL Inj Susp-10mL Pk 02024217 Novolin ge 30/70 100U/mL Inj Susp-5X3mL Pk 09853812 Novolin ge 30/70 Penfill NOO NOO 18.8600 18.8600 37.0100 37.0100
JUNE 27, 2008
IIIA.267
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:20:16 ANTI-DIABETIC AGENTS INSULINS (PRE-MIXED)

INSULIN ASPART
1274 100U/mL Inj Susp-5x3mL Pk 02265435 NovoMix 30 Penfill NOO 48.8000 48.8000
INSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70%

1275 1276 1000U/10mL Inj Susp-10mL Pk 00795879 Humulin 30/70 100U/mL Inj Susp-5X3mL Pk 09853855 Humulin 30/70 LIL LIL 18.8600 18.8600 37.9700 37.9700
INSULIN LISPRO & INSULIN LISPRO PROTAMINE

1277 25% & 75% Inj Susp-5X3mL Pk 02240294 Humalog Mix25 Reason for Use Code Clinical criteria ION D D I E ForE requiringTAT patients E are either experiencing 226T insulin diabetic R who recurrent hypoglycemia OR are unable to achieve adequate postEcontrol while using LIM US glucose N EQUI 2 or more doses of mixed prandial M R insulin per day. CU OAuthorization Period: Indefinite. DLU LIL 51.5900 51.5900
IIIA.268
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:24:00 PARATHYROID AGENTS
CALCITONIN (SALMON SYNTHETIC)
1278 1279 100IU/mL Inj Sol-1mL Pk 02007134 Caltine 100 400IU/2mL Inj Sol-2mL Pk 01926691 Calcimar FEI SAV 7.8200 7.8200 50.6500 50.6500
68:28:00 PITUITARY AGENTS

DESMOPRESSIN ACETATE
1280 1281 1282 0.1mg/mL Nas Sol-2.5mL Pk 00402516 DDAVP 1.5mg/mL Nas Sp-2.5mL Pk 02237860 Octostim 10mcg/Metered Dose Nas Sp-2.5mL Pk 00836362 DDAVP 02242465 Apo-Desmopressin 60mcg Orally Disintegrating Tab 02284995 DDAVP Melt 120mcg Orally Disintegrating Tab 02285002 DDAVP Melt 0.1mg Tab 00824305 02284030 02287730 0.2mg Tab 00824143 02284049 02287749 DDAVP Apo-Desmopressin Novo-Desmopressin DDAVP Apo-Desmopressin Novo-Desmopressin FEI FEI FEI APX FEI FEI FEI APX NOP FEI APX NOP 47.2000 47.2000 386.0000 386.0000 33.0400 47.2000 33.0400 .9913 .9913 1.9826 1.9826 .6609 1.3217 .6609 .6609 1.3217 2.6434 1.3217 1.3217
1283 1284 1285
1286
JUNE 27, 2008
IIIA.269
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:28:00 PITUITARY AGENTS
THYROTROPIN ALFA
1287 0.9mg/mL Inj Pd-2x1.1mg Vial Pk 02246016 Thyrogen Reason for Use Code 1,324.0000 1,324.0000
N TIO ED A D NT with IR ITEFor use inSEmonitoring of patientsQUwell-differentiated E 368 U the LIM thyroid cancer. UM RE C LU Authorization Period: Indefinite. DO
GZM Clinical criteria 12.2500 12.2500 13.1900 13.1900 12.2500 12.2500 14.5092 14.5092
68:32:00 PROGESTOGENS AND ORAL CONTRACEPTIVES

DESOGESTREL & ETHINYL ESTRADIOL
1288 1289 1290 1291 0.15mg & 0.03mg Tab-21 Pk 02042487 Marvelon 21 0.15mg & 0.03mg Tab-21 Pk 02042541 # Ortho-Cept 0.15mg & 0.03mg Tab-28 Pk 02042479 Marvelon 28 0.15mg & 0.03mg Tab-28Pk 02042533 Ortho-Cept ORG JNO ORG JNO
DROSPIRENONE & ETHINYL ESTRADIOL

1292 1293 3.0mg & 0.03mg Tab-21 Pk 02261723 Yasmin 21 3.0mg & 0.03mg Tab-28 Pk 02261731 Yasmin 28 BAH BAH 11.6000 11.6000 11.6000 11.6000
ETHINYL ESTRADIOL & ETHYNODIOL DIACETATE

1294 1295 0.03mg & 2mg Tab-21 Pk 00469327 Demulen 30 0.03mg & 2mg Tab-28 Pk 00471526 Demulen 30 PFI PFI 12.1300 12.1300 12.9800 12.9800
IIIA.270
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ETHINYL ESTRADIOL & LEVONORGESTREL
1296 20mcg & 100mcg Tab-21 Pk 02236974 Alesse 02298538 Aviane 21 0.03mg & 0.15mg Tab-21 Pk 02042320 Min-Ovral 02295946 Portia 21 3 Phase Tab-21 Pk 00707600 Triquilar 21 WAY BAR WAY BAR BAY WAY BAR WAY BAR BAY 9.7400 13.2400 9.7400 9.7400 13.2400 9.7400 13.4900 13.4900 9.7400 13.2400 9.7400 9.7400 13.2400 9.7400 13.4900 13.4900
1297
1298 1299
20mcg & 100mcg Tab-28 Pk 02236975 Alesse 02298546 Aviane 28 0.03mg & 0.15mg Tab-28 Pk 02042339 Min-Ovral 02295954 Portia 28 3 Phase Tab-28 Pk 00707503 Triquilar 28
1300
1301
ETHINYL ESTRADIOL & NORETHINDRONE

1302 1303 1304 1305 1306 0.035mg & 0.5mg Tab-21 Pk 00317047 Ortho 0.5/35 0.035mg & 1mg Tab-21 Pk 00372846 Ortho 1/35 3 Phase Tab-21 Pk 00602957 Ortho 7/7/7 JNO JNO JNO PFI PFI 14.5092 14.5092 14.5092 14.5092 14.5092 14.5092 11.1200 11.1200 11.1200 11.1200
0.035mg & 0.5mg Tab-21 Pk 02187086 Brevicon 0.035mg & 1mg Tab-21 Pk 02189054 Brevicon 1/35
JUNE 27, 2008
IIIA.271
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ETHINYL ESTRADIOL & NORETHINDRONE
1307 1308 1309 1310 1311 1312 1313 3 Phase Tab-21 Pk 02187108 Synphasic PFI JNO JNO JNO PFI PFI PFI 10.2200 10.2200 14.5092 14.5092 14.5092 14.5092 14.5092 14.5092 11.1200 11.1200 11.1200 11.1200 10.2200 10.2200
0.035mg & 0.5mg Tab-28 Pk 00340731 Ortho 0.5/35 0.035mg & 1mg Tab-28 Pk 00372838 Ortho 1/35 3 Phase Tab-28 Pk 00602965 Ortho 7/7/7
0.035mg & 0.5mg Tab-28 Pk 02187094 Brevicon 0.035mg & 1mg Tab-28 Pk 02189062 Brevicon 1/35 3 Phase Tab-28 Pk 02187116 Synphasic
ETHINYL ESTRADIOL & NORETHINDRONE ACETATE

1314 1315 1316 1317 0.02mg & 1mg Tab-21 Pk 00315966 Minestrin 1/20 0.03mg & 1.5mg Tab-21 Pk 00297143 Loestrin 1.5/30 0.02mg & 1mg Tab-28 Pk 00343838 Minestrin 1/20 0.03mg & 1.5mg Tab-28 Pk 00353027 Loestrin 1.5/30 SQI SQI SQI SQI 12.0400 12.0400 12.0400 12.0400 12.0400 12.0400 12.0400 12.0400
ETHINYL ESTRADIOL & NORGESTREL

1318 0.05mg & 0.25mg Tab-21 Pk 02043033 Ovral WAY 13.2400 13.2400
LEVONORGESTREL
1319 1320 52mg Insert 02243005 Mirena BAY PAI 314.0400 314.0400 16.4400 16.4400
0.75mg Tab-2 Tabs Pk 02241674 Plan B
IIIA.272
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MEDROXYPROGESTERONE ACETATE
1321 1322 1323 150mg/mL Inj 00585092 Depo-Provera PFI PFI PFI RPH NOP GEN APX PMS PFI RPH NOP GEN APX PMS PFI RPH NOP GEN PMS APX PFI PFI APX 25.9500 25.9500 24.1900 24.1900 .0630 .1599 .0630 .0630 .0630 .0630 .0630 .1246 .3164 .1246 .1246 .1246 .1246 .1246 .2515 .6388 .2516 .2516 .2516 .2516 .2515 .6392 .6392 .8543 1.2204 .8543
50mg/mL Inj Sol-5mL Pk 00030848 Depo-Provera 2.5mg Tab 00708917 02148552 02221284 02229838 02244726 02246627 5mg Tab 00030937 02148560 02221292 02229839 02244727 02246628 10mg Tab 00729973 02148579 02221306 02229840 02246629 02277298 10mg Tab 02010933 100mg Tab 00030945 02267640 Provera Ratio-MPA Novo-Medrone Gen-Medroxy Apo-Medroxy PMS-Medroxyprogesterone Provera Ratio-MPA Novo-Medrone Gen-Medroxy Apo-Medroxy PMS-Medroxyprogesterone Provera Ratio-MPA Novo-Medrone Gen-Medroxy PMS-Medroxyprogesterone Apo-Medroxy Provera-Pak Provera Apo-Medroxy
1324
1325
1326 1327
NORETHINDRONE
1328 0.35mg Tab-28 Pk 00037605 Micronor JNO 14.5092 14.5092
JUNE 27, 2008
IIIA.273
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

NORGESTIMATE & ETHINYL ESTRADIOL
1329 1330 1331 1332 1333 1334 3 Phase Tab-21 Pk 02028700 3 Phase Tab-21 Pk 02258560 Tri-Cyclen Tri-Cyclen Lo JNO JNO JNO JNO JNO JNO 14.5092 14.5092 11.8450 11.8450 14.5092 14.5092 14.5092 14.5092 11.8450 11.8450 14.5092 14.5092
0.25mg & 0.035mg Tab-21 Pk 01968440 Cyclen 3 Phase Tab-28 Pk 02029421 3 Phase Tab-28 Pk 02258587 Tri-Cyclen Tri-Cyclen Lo
0.25mg & 0.035mg Tab-28 Pk 01992872 Cyclen
68:36:00 THYROIDS
LEVOTHYROXINE (SODIUM)
1335 1336 0.025mg Tab 02172062 0.05mg Tab 02172070 02213192 0.075mg Tab 02172089 0.088mg Tab 02172097 0.1mg Tab 02172100 02213206 0.112mg Tab 02171228 0.125mg Tab 02172119 Synthroid Synthroid Eltroxin Synthroid Synthroid Synthroid Eltroxin Synthroid Synthroid ABB ABB GSK ABB ABB ABB GSK ABB ABB .0790 .0790 .0274 .0515 .0274 .0854 .0854 .0854 .0854 .0336 .0637 .0336 .0902 .0902 .0916 .0916
1337 1338 1339
1340 1341
IIIA.274
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

68:36:00 THYROIDS
LEVOTHYROXINE (SODIUM)
1342 0.15mg Tab 02172127 02213214 0.175mg Tab 02172135 0.2mg Tab 02172143 02213222 0.3mg Tab 02172151 02213230 Synthroid Eltroxin Synthroid Synthroid Eltroxin Synthroid Eltroxin (Not a Benefit) ABB GSK ABB ABB GSK ABB GLW .0373 .0684 .0373 .0979 .0979 .0394 .0729 .0394 .0994 .0994
1343 1344
1345
THYROID
1346 1347 1348 30mg Tab 00023949 60mg Tab 00023957 125mg Tab 00023965 Thyroid Thyroid Thyroid ERF ERF ERF .0440 .0440 .0518 .0518 .0800 .0800
68:38:00 ANTI-THYROIDS
PROPYLTHIOURACIL
1349 1350 50mg Tab 00010200 100mg Tab 00010219 Propyl-Thyracil Propyl-Thyracil SQI SQI .2056 .2056 .3217 .3217
JUNE 27, 2008
IIIA.275
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
84:00 SKIN AND MUCOUS MEMBRANE PREPARATIONS

CLINDAMYCIN PHOSPHATE & BENZOYL PEROXIDE
1351 1352 1% & 5% Gel 02243158 1% & 5% Top Gel 02248472 Clindoxyl BenzaClin STI SAV .8620 .8620 .8540 .8540
FUSIDIC ACID
1353 2% Cr 00586668 Fucidin LEO .5618 .5618
MUPIROCIN
1354 1355 2% Cr 02239757 2% Oint 01916947 02279983 Bactroban Bactroban Taro-Mupirocin GSK GSK TAR .5182 .5182 .3556 .5182 .3556
SODIUM FUSIDATE
1356 2% Oint 00586676 Fucidin LEO .5618 .5618
JUNE 27, 2008
IIIA.277
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

84:04:08 ANTI-INFECTIVES FUNGICIDES
Note: Due to its efficacy and significantly lower cost, clotrimazole should be the first line of treatment for Tinea corporis and cruris. In Tinea pedis, topical terbinafine should be considered the first line of treatment due to its efficacy and lower rate of relapse.
CLOTRIMAZOLE
1357 10mg/g Cr 02150867 00812382 Canesten 1% Topical Cream Clotrimaderm BAY TAR .0884 .0999 .0884 12.0800 12.0800 .1750 .2212 .1750 .3500 .4424 .3500
1358 1359
500mg & 1% Tab & Cr 02264102 Canesten 1 Comfortab Combi-Pak BAY 10mg/g Vag Cr-App 02150891 Canesten 6 Cream 00812366 Clotrimaderm Vaginal Cream 20mg/g Vag Cr-App 02150905 Canesten 3 Cream 00812374 Clotrimaderm Vaginal Cream BAY TAR BAY TAR
1360
ECONAZOLE NITRATE
1361 1362 1% Cr 02011948 150mg Vag Sup 02010267 Ecostatin Ecostatin BQU BQU .4407 .4407 5.9167 5.9167
IIIA.278
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLUCONAZOLE
1363
ED ION D IT E IM S AT IRE L U ENT U UM REQ OC D

Diflucan-150 Apo-Fluconazole-150 Novo-Fluconazole-150 Gen-Fluconazole PMS-Fluconazole PFI APX NOP GEN PMS Reason for Use Code 235 Clinical criteria LU Authorization Period: 1 year.
150mg Cap 02141442 02241895 02243645 02245697 02282348
7.2900 15.1630 7.2900 7.2900 7.2900 7.2900
For the treatment of vaginal candidiasis. Dose: 150mg orally once daily for 1 day. NOTE: Repeats within a 25 day period will not be reimbursed.
KETOCONAZOLE
1364 2% Cr 00703974 02245662 Nizoral Ketoderm JAN TAR .3167 .4530 .3167
MICONAZOLE NITRATE
1365 2% Cr 00497797 02085852 Monistat Derm Micatin OMC MCL MCL MCL MCL MCL .2970 .2970 .2970 9.7800 9.7800 3.2600 3.2600 11.2200 11.2200 9.7800 9.7800
1366 1367 1368 1369
2% Vag Cr-App 35g Pk 02084309 Monistat 7 400mg Vag Sup 02126605 Monistat 3
2% Cr-9g & 400mg Vag Sup-3 Pk 02126249 Monistat 3 Dual Pak 100mg Vag Sup-7 Pk 02084295 Monistat 7
JUNE 27, 2008
IIIA.279
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

NYSTATIN
1370 100000U/g Cr 00029092 00716871 02194236 .0700 Mycostatin (Not a Benefit) Nyaderm Ratio-Nystatin BQU TAR RPH .0700 .0700
Note: Nystatin is not effective in the treatment of Dermatophyte infections or Tinea versicolor. 1371 100000U/g Oint 00029556 02194228 .0903 Mycostatin (Not a Benefit) Ratio-Nystatin BQU RPH .0903
Note: Nystatin is not effective in the treatment of Dermatophyte infections or Tinea versicolor. 1372 25000U/g Vag Cr 00295973 00716901 100000U/g Vag Cr 02194163 .0492 Mycostatin (Not a Benefit) Nyaderm Ratio-Nystatin BQU TAR RPH .0492 .2553 .2553
1373
TERBINAFINE HCL
1374 1% Cr 02031094 Lamisil NOV .4943 .4943
IIIA.280
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TERCONAZOLE
1375 0.4% Cr 00894729 02247651 80mg Vag Ovule 00894710 Terazol 7 Taro-Terconazole Terazol 3 JNO TAR JNO .2726 .4251 .2726 6.3767 6.3767
1376
84:04:12 ANTI-INFECTIVES PARASITICIDES

Note: All close contacts of patients with scabies should be treated regardless of symptoms to avoid reinfestation and unnecessary repeated treatments. The scabicide should be applied to all the skin from the neck down. Young children, the elderly and immunosuppressed patients may also require treatment of the head and scalp.
ISOPROPYL MYRISTATE
1377 1378 50% Top Sol-120mL Pk 09857292 Resultz 50% Top Sol-240mL Pk 02279592 Resultz NYC NYC 12.2500 12.2500 22.4200 22.4200
LINDANE (GAMMA BENZENE HEXACHLORIDE)

1379 1% Shampoo 00026220 00703605 Kwellada (Not a Benefit) PMS-Lindane (Not a Benefit) RCA PMS
JUNE 27, 2008
IIIA.281
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

84:04:12 ANTI-INFECTIVES PARASITICIDES
Note: All close contacts of patients with scabies should be treated regardless of symptoms to avoid reinfestation and unnecessary repeated treatments. The scabicide should be applied to all the skin from the neck down. Young children, the elderly and immunosuppressed patients may also require treatment of the head and scalp.
PERMETHRIN
1380 5% Cr 02219905 Reason for Use Code
ION D D TAT I TE For SE Npatients whoRE failed on a less costly listed I E 311 U the treatment of EQU have LIM UM R alternative. C DO LU Authorization Period: 1 year.
Clinical criteria Nix # Kwellada-P # Kwellada-P BWE GSK GSK .0955 .0955 .1140 .1140 .2485 .2485
# Nix Dermal Cream
GSK
.4600 .4600
1381 1382 1383
1% Cr Rinse 00771368 1% Cr Rinse 02231480 5% Lot 02231348
PYRETHRINS PIPERONYL BUTOXIDE & PETROLEUM DISTILLATE

1384 0.3% & 3% & 1.2% Top Sol 02125447 # R & C Shampoo/Conditioner GSK .0796 .0796
IIIA.282
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

METRONIDAZOLE
1385 1386 1387 1388 1389 1390 0.75% Cr 02226839 1% Cr 02242919 1% Top Cr 02156091 0.75% Top Gel 02092832 0.75% Top Lot 02248206 10% Vag Cr-App 01926861 MetroCream Rosasol Noritate Metrogel MetroLotion Flagyl GAC STI SAV GAC GAC SAV .4933 .4933 .4937 .4937 .4933 .4933 .6000 .6000 .4933 .4933 .2118 .2118
METRONIDAZOLE & NYSTATIN

1391 1392 500mg & 100000U/g Vag Cr-App 01926845 Flagystatin 500mg & 100000U Vag Sup 01926829 Flagystatin SAV SAV .5180 .5180 2.8490 2.8490
JUNE 27, 2008
IIIA.283
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

POVIDONE - IODINE
1393 * 10% Top Sol 00158348 00172944 1394 10% Vag Gel 00026034 00026611 10% Vag Sol 00026093 00252824 Betadine (Not a Benefit) Proviodine (Not a Benefit) Betadine (Not a Benefit) Proviodine (Not a Benefit) Betadine (Not a Benefit) Proviodine (Not a Benefit) PFP ROG PFP ROG PFP ROG
1395
SILVER SULFADIAZINE
1396 1397 1% Cr 00323098 1% Cr-50g Pk 09854037 Flamazine Flamazine SNE SNE .1320 .1320 10.9600 10.9600
84:06:00 ANTI-INFLAMMATORY
AMCINONIDE
1398 0.1% Cr 02192284 02246714 02247098 0.1% Lot 02192276 02247097 0.1% Oint 02192268 02247096 Cyclocort Taro-Amcinonide Ratio-Amcinonide Cyclocort Ratio-Amcinonide Cyclocort Ratio-Amcinonide STI TAR RPH STI RPH STI RPH .1955 .4027 .1955 .1955 .2270 .3343 .2270 .2740 .4027 .2740
1399
1400
IIIA.284
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

1401 1402 0.025% Cr 02089602 0.025% Oint 01927957 Propaderm Propaderm SQI GLA .4244 .4244 .4038 .4038
BETAMETHASONE DIPROPIONATE
1403 0.05% Cr 00323071 01925350 0.05% Lot 00417246 00809187 0.05% Oint 00344923 00805009 Diprosone Taro-Sone Diprosone Ratio-Topisone Diprosone Ratio-Topisone SCH TAR SCH RPH SCH RPH .2048 .2048 .2048 .1980 .1980 .1980 .2152 .2152 .2152
1404
1405
BETAMETHASONE DIPROPIONATE IN A BASE CONTAINING PROPYLENE GLYCOL

1406 0.05% Oint 00629367 00849669 Diprolene Ratio-Topilene SCH RPH .5186 .5186 .5186
Note: No more than 50 grams per week of ultrapotent steroids for a maximum of 2 weeks is recommended.
JUNE 27, 2008
IIIA.285
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

BETAMETHASONE DIPROPIONATE IN PROPYLENE GLYCOL BASE
1407 0.05% Cr 00688622 00849650 Diprolene Glycol Ratio-Topilene SCH RPH .5186 .5186 .5186
Note: No more than 50 grams per week of ultrapotent steroids for a maximum of 2 weeks is recommended.
BETAMETHASONE VALERATE
1408 0.05% Cr 00011916 00027898 00535427 00716618 0.1% Cr 00011924 00027901 00535435 00716626 0.05% Lot 02100185 00653209 0.1% Lot 02100193 00750050 0.05% Oint 00012378 00028355 00716642 0.1% Oint 00012386 00028363 00716650 0.1% Scalp Lot 00027944 00653217 00716634 .0611 Betnovate-1/2 (Not a Benefit) Celestoderm-V/2 (Not a Benefit) Ratio-Ectosone Mild Betaderm (Not a Benefit) Betnovate (Not a Benefit) Celestoderm-V (Not a Benefit) Ratio-Ectosone Regular Betaderm (Not a Benefit) Betnovate-1/2 (Not a Benefit) Ratio-Ectosone Mild Betnovate (Not a Benefit) Ratio-Ectosone Regular Betnovate-1/2 (Not a Benefit) Celestoderm-V/2 (Not a Benefit) Betaderm Betnovate (Not a Benefit) Celestoderm-V (Not a Benefit) Betaderm Valisone Ratio-Ectosone Betaderm GLA SCH RPH TAR GLA SCH RPH TAR RBT RPH SHI RPH GLA SCH TAR GLA SCH TAR SCH RPH TAR .0611 .0911 .0911 .1900 .1900 .2500 .2500 .0606 .0606 .0903 .0903 .0853 .0853 .0853 .0853
1409
1410
1411
1412
1413
1414
IIIA.286
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CALCIPOTRIOL & BETAMETHASONE DIPROPIONATE
1415 50mcg/g & 0.5mg/g Oint 02244126 Dovobet LEO 1.6000 1.6000
Note: For use in patients with psoriasis who have failed 1st line topical steroids and Dovonex (calcipotriol) therapy.
CLOBETASOL PROPIONATE
Note: No more than 50 grams per week of ultrapotent steroids for a maximum of 2 weeks is recommended. 1416 0.05% Cr 02213265 01910272 02024187 02093162 02232191 02245523 0.05% Oint 02213273 01910280 02026767 02126192 02232193 02245524 0.05% Scalp Lot 02213281 01910299 02216213 02232195 02245522 Dermovate Ratio-Clobetasol Gen-Clobetasol Novo-Clobetasol PMS-Clobetasol Taro-Clobetasol Cream USP Dermovate Ratio-Clobetasol Gen-Clobetasol Novo-Clobetasol PMS-Clobetasol Taro-Clobetasol Ointment USP Dermovate Ratio-Clobetasol Gen-Clobetasol PMS-Clobetasol Taro-Clobetasol Topical Solution USP TPH RPH GEN NOP PMS TAR TPH RPH GEN NOP PMS TAR TPH RPH GEN PMS TAR .3256 .6512 .3256 .3256 .3256 .3256 .3256 .3256 .6512 .3256 .3256 .3256 .3256 .3256 .2843 .5685 .2843 .2843 .2843 .2843
1417
1418
JUNE 27, 2008
IIIA.287
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CLOBETASONE BUTYRATE
1419 0.05% Cr 02214415 Eumovate GSK .3893 .3893
DESONIDE
1420 0.05% Cr 02048639 02154862 02229315 0.05% Lot 02115514 0.05% Oint 02115522 02154870 02229323 Desocort Tridesilon (Not a Benefit) PMS-Desonide Desocort Desocort Tridesilon (Not a Benefit) PMS-Desonide GAC CPL PMS GAC GAC CPL PMS .2610 .2900 .2610 .1450 .1450 .2610 .2900 .2610
1421 1422
DIFLUCORTOLONE VALERATE
1423 1424 1425 0.1% Cr 00587826 0.1% Oily Cr 00587818 0.1% Oint 00587834 Nerisone Nerisone Nerisone STI STI STI .3743 .3743 .3742 .3742 .3743 .3743
FLUOCINOLONE ACETONIDE
1426 0.01% Cr 00030414 Synalar Mild SYN .2387 .2387
IIIA.288
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLUOCINONIDE
1427 0.05% Cr 00716863 02161923 0.05% Emol Cr 00598933 02163152 0.05% Gel 02161974 02236997 0.05% Oint 02161966 02236996 Lyderm Lidex (Not a Benefit) Tiamol Lidemol (Not a Benefit) Topsyn (Not a Benefit) Lyderm Lidex (Not a Benefit) Lyderm TAR MEC TAR MEC MEC TAR MEC TAR .2617 .2617 .2433 .2433 .3418 .3418 .3373 .3373
1428
1429
1430
FLUOCINONIDE & PROCINONIDE & CIPROCINONIDE

1431 Emol Cr 00781371 Trisyn BAK .3256 .3256
HALCINONIDE
1432 1433 0.1% Cr 02011921 0.1% Oint 02010283 # Halog # Halog BQU BQU .5407 .5407 .5407 .5407
HYDROCORTISONE
1434 1435 0.5% Cr 00513288 1% Cr 00192597 00502200 Cortate Emo-Cort Cortate (Not a Benefit) SCH STI SCH .1333 .1333 .1629 .1629
JUNE 27, 2008
IIIA.289
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

HYDROCORTISONE
1436 1437 1438 1439 2.5% Cr 00595799 1% Lot 00192600 2.5% Lot 00595802 0.5% Oint 00513261 00716685 1% Oint 00502197 00716693 Emo-Cort Emo-Cort Emo-Cort Cortate Cortoderm Cortate (Not a Benefit) Cortoderm STI STI STI SCH TAR SCH TAR .1893 .1893 .1505 .1505 .1992 .1992 .1333 .1333 .1400 .0390 .0390
1440
HYDROCORTISONE ACETATE
1441 1% Cr 00477699 00716839 .0364 Corticreme (Not a Benefit) Hyderm ROG TAR .0364
HYDROCORTISONE ACETATE & UREA

1442 1443 1% & 10% Cr 00503134 1% & 10% Lot 00560022 Uremol-HC Uremol-HC STI STI .1580 .1580 .0921 .0921
HYDROCORTISONE VALERATE
1444 0.2% Cr 01910124 02242984 0.2% Oint 01910132 02242985 Westcort Hydroval # Westcort Hydroval BQU TPH BQU TPH .1212 .1212 .1212 .1212 .1212 .1212
1445
IIIA.290
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MOMETASONE FUROATE
1446 1447 1448 0.1% Cr 00851744 0.1% Lot 00871095 0.1% Oint 00851736 02248130 02264749 02270862 Elocom Elocom Elocom Ratio-Mometasone Taro-Mometasone PMS-Mometasone SCH SCH SCH RPH TAR PMS .6190 .6190 .4463 .4463 .2771 .5985 .2771 .2771 .2771
TRIAMCINOLONE ACETONIDE
1449 0.1% Cr 00029114 00716960 02194058 0.1% Oint 01999796 02194031 .0533 Kenalog (Not a Benefit) Triaderm Aristocort R Kenalog (Not a Benefit) Aristocort R WSQ TAR VAE WSQ VAE .0533 .0533 .1300 .1300
1450
TRIAMCINOLONE ACETONIDE 0.1% IN ORABASE

1451 Oral Top Oint 01964054 01999788 Oracort Kenalog-Orabase TAR BQU .9110 .9110 1.2960
JUNE 27, 2008
IIIA.291
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

84:28:00 KERATOLYTIC AGENTS
ANTHRALIN
1452 1453 1454 1455 1456 0.1% Cr 00537594 0.2% Cr 00537608 0.4% Cr 00537616 1% Oint 00566756 2% Oint 00566748 Anthranol Anthranol Anthranol Anthraforte 1 Anthraforte 2 MEI MEI MEI MEI MEI .2246 .2246 .2368 .2368 .2476 .2476 .3058 .3058 .3226 .3226
BENZOYL PEROXIDE
1457 1458 1459 5% Lot 00236063 10% Lot 00370568 20% Lot 00187585 00374318 Benoxyl Benoxyl Benoxyl Oxyderm STI STI STI VAL .1295 .1295 .1760 .1760 .1898 .1955 .1898
BENZOYL PEROXIDE IN ACETONE-CONTAINING GEL

1460 1461 5% Gel 00406821 10% Gel 00406848 AcetOxyl AcetOxyl STI STI .1158 .1158 .1375 .1375
IIIA.292
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

BENZOYL PEROXIDE IN ALCOHOL-CONTAINING GEL
1462 5% Gel 00263702 02162113 10% Gel 00263699 15% Gel 00403571 20% Gel 00373036 Panoxyl 5-Benzagel Panoxyl # Panoxyl Panoxyl STI NOV STI STI STI .1058 .1208 .1058 .1417 .1417 .1663 .1663 .1845 .1845
1463 1464 1465
BENZOYL PEROXIDE IN WATER-BASED GEL

1466 5% Gel 01908863 01925180 02214849 10% Gel 01908871 02223856 .1208 Desquam-X5 (Not a Benefit) Benzac W5 Panoxyl Aquagel # Desquam-X10 Panoxyl Aquagel (Not a Benefit) WSQ GAC STI BQU STI .1250 .1208 .1545 .1545
1467
JUNE 27, 2008
IIIA.293
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TRETINOIN
1468 1469 1470 0.01% Cr 00657204 0.025% Cr 00578576 0.05% Cr 00518182 01926519 0.01% Gel 01926462 0.025% Gel 00587966 0.05% Gel 01926489 0.025% Sol 00578568 Reason for Use Code 269 .2840 .2840 .2840 .2840 .2840 .2840 .2840 .2840 .2840 .2840 .2840 .2840 .2840 .1780 .1780
1471 1472 1473 1474
ED N T E IO MI S AT LI U T EN ED UM UIR C Q DO RE
Stieva-A STI Stieva-A Vitamin A Acid Vitamin A Acid Stieva-A STI SAV SAV STI Vitamin A Acid Stieva-A SAV STI Clinical criteria For the treatment of acne vulgaris. LU Authorization Period: 1 year.
Stieva-A
STI
TRETINOIN & ERYTHROMYCIN

1475 0.025% & 4% Top Gel 01905112 Stievamycin Gel STI .5200 .5200
IIIA.294
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

84:36:00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS
ACITRETIN
Note: This drug should be used with extreme caution in females of childbearing potential due to its teratogenicity. Effective contraception must be practised for at least 2 years following discontinuation. 1476 1477 10mg Cap 02070847 25mg Cap 02070863 Soriatane Soriatane HLR HLR 1.6240 1.6240 2.8527 2.8527
CALCIPOTRIOL
1478 1479 50mcg/g Cr 02150956
50mcg/g Oint 01976133 Reason for Use Code 191
D ION D ITE E TAT IRE LIM US U EN M EQ R CU O D

Dovonex LEO Clinical criteria LU Authorization Period: Indefinite. Efudex VAL
Dovonex
LEO
.7150 .7150 .7150 .7150
For the treatment of psoriasis in patients who have failed topical corticosteroids alone, or are intolerant to topical corticosteroids.
FLUOROURACIL
1480 5% Cr 00330582 .8000 .8000
JUNE 27, 2008
IIIA.295
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ISOTRETINOIN
Note: Isotretinoin is indicated for the treatment of severe nodular and/or inflammatory acne, acne conglobata and recalcitrant acne that are unresponsive to conventional therapy including systemic antibiotics. Females of childbearing potential should have a negative pregnancy test within 2 weeks prior to starting treatment. Isotretinoin should be started the second or third day of the next normal menstrual period. Effective contraception should be used for at least 1 month prior to starting isotretinoin, during treatment and for at least 1 month following discontinuation of treatment. 1481 10mg Cap 00582344 02257955 40mg Cap 00582352 02257963 Accutane Clarus Accutane Clarus HLR PRE HLR PRE .9313 .9313 .9313 1.9003 1.9003 1.9003
1482
METHOXSALEN
1483 1484 10mg Cap 01946374 10mg SG Cap 00646237 Oxsoralen UltraMOP VAL CDX .5436 .5436 .4755 .4755
PIMECROLIMUS
1485 1% Cr 02247238 Reason for Use Code 383
ION D ED IT TAT IRE LIM USE MEN U EQ R CU O D

Clinical criteria Therapy should be reassessed at 6 months. LU Authorization Period: 1 year.
Elidel
NOV
2.1277 2.1277
For use in combination with moisturizers or oral antihistamines in patients with atopic dermatitis who have failed or are intolerant to an 8 week trial of an intermediate potency topical steroid.
IIIA.296
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ZINC SULFATE
1486 * 0.5% Oint 01945939 00621447 1487 * 10mg Sup 00621439 Anusol Sandoz Anuzinc Anuzinc PFI SDZ SDZ .1033 .1320 .1033 .3542 .3542
JUNE 27, 2008
IIIA.297
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
86:00 SPASMOLYTICS
AMINOPHYLLINE
1488 1489 225mg SR Tab 02014270 350mg SR Tab 02014289 Phyllocontin Phyllocontin-350 PFP PFP .2168 .2168 .2762 .2762
OXTRIPHYLLINE
1490 10mg/mL O/L 00476390 00792934 20mg/mL O/L 00476366 00792942 .0110 Choledyl (Not a Benefit) # PMS-Oxtriphylline Choledyl PMS-Oxtriphylline PDA PMS ERF PMS .0110 .0229 .0347 .0229
1491
THEOPHYLLINE ANHYDROUS
1492 300mg LA Tab 00461008 02230087 5.3mg/mL O/L 01966219 00575151 400mg SR Tab 02014165 600mg SR Tab 02014181 .1400 Theo-Dur (Not a Benefit) Novo-Theophyl SR AZC NOP .1400 .0028 .0229 .0028 .4980 .4980 .6032 .6032
1493
Theolair Alcohol Free Oral Liquid GRA # PMS-Theophylline PMS Uniphyl Uniphyl PFP PFP
1494 1495
JUNE 27, 2008
IIIA.299
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
88:00 VITAMINS
88:08:00 VITAMIN B
CYANOCOBALAMIN
1496 * 1mg/mL Inj Sol-10mL Pk 00029165 Rubramin (Not a Benefit) 00521515 Vitamin B12-1000mcg/mL 01987003 Cyanocobalamin 3.1000 BQU SDZ CYI 3.1000 3.1000
FOLIC ACID
1497 5mg Tab 00014966 00426849 .0259 Folvite (Not a Benefit) Apo-Folic LED APX .0259
LEUCOVORIN CALCIUM
1498 5mg Tab 02170493 Leucovorin Calcium WAY 5.5294 5.5294
NICOTINIC ACID
Note: Nicotinic acid is the most cost-effective therapy for hyperlipidemia and is tolerated in approximately 80% of patients with adequate warning about expected flushing which disappears after 5 days in most cases, and is significantly reduced with regular use of ASA. 1499 50mg Tab dpp 00268593 00274496 100mg Tab dpp 00268585 Niacin-ICN (Not a Benefit) Novo-Niacin (Not a Benefit) Niacin-ICN VAL NOP VAL .0295 .0295
1500
PYRIDOXINE HCL
1501 25mg Tab dpp 00232475 00268607 00416185 Vitamin B6 Vitamin B6-ICN Vitamin B6 (Not a Benefit) PMS VAL RPR .0188 .0188 .0188
THIAMINE HCL
1502 50mg Tab dpp 00268631 00610267 Vitamin B1-ICN (Not a Benefit) Vitamin B1 (Not a Benefit) VAL LEA
IIIA.300
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
88:00 VITAMINS
88:12:00 VITAMIN C
ASCORBIC ACID
1503 * 100mg Tab 00021970 00466646 1504 * 250mg Tab 00021237 00036161 00466638 1505 * 500mg Tab 00021997 00036188 00466611 1506 1000mg Tab 00256862 00466603 00535907 Novo-C (Not a Benefit) Apo-C (Not a Benefit) Novo-C (Not a Benefit) Vitamin C (Not a Benefit) Apo-C (Not a Benefit) Novo-C (Not a Benefit) Vitamin C (Not a Benefit) Apo-C (Not a Benefit) Vitamin C (Not a Benefit) Apo-C (Not a Benefit) Novo-C (Not a Benefit) NOP APX NOP RPR APX NOP RPR APX RPR APX NOP
88:16:00 VITAMIN D
ALFACALCIDOL
1507 1508 0.25mcg Cap dpp 00474517 1mcg Cap dpp 00474525 One-Alpha One-Alpha LEO LEO .4090 .4090 1.2243 1.2243
CALCITRIOL
1509 1510 0.25mcg Cap dpp 00481823 0.5mcg Cap dpp 00481815 Rocaltrol Rocaltrol HLR HLR .9098 .9098 1.4469 1.4469
ERGOCALCIFEROL
1511 8288IU/mL O/L 02017598 Drisdol SAV .4268 .4268
JUNE 27, 2008
IIIA.301
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
88:00 VITAMINS
88:16:00 VITAMIN D
VITAMIN D
1512 50000IU Cap 00009830 # Ostoforte MFC .2169 .2169
88:28:00 MULTIVITAMINS
HEXAVITAMINS USP
1513 * Tab 00269034 00701130 Hexavitamins (Not a Benefit) Apo-Hexa (Not a Benefit) NOP APX
IIIA.302
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST
92:00 UNCLASSIFIED THERAPEUTIC AGENTS

ALENDRONATE
1514 10mg Tab 02201011 02247373 02248728 02270129 02288087 70mg Tab 02245329 02248730 02258110 02261715 02273179 02275279 02284006 02286335 02288109 Fosamax Novo-Alendronate Apo-Alendronate Gen-Alendronate Sandoz Alendronate Fosamax Apo-Alendronate Co-Alendronate Novo-Alendronate PMS-Alendronate Ratio-Alendronate PMS-Alendronate-FC Gen-Alendronate Sandoz Alendronate MFC NOP APX GEN SDZ MFC APX COB NOP PMS RPH PMS GEN SDZ .8775 1.9364 .8775 .8775 .8775 .8775 4.4250 9.7650 4.4250 4.4250 4.4250 4.4250 4.4250 4.4250 4.4250 4.4250
1515
ALENDRONATE/CHOLECALCIFEROL
1516 70mg/70mcg Tab 02276429 Fosavance MFC 9.7650 9.7650
ALFUZOSIN HYDROCHLORIDE
1517 10mg Prolong-Rel Tab 02245565 Xatral Reason for Use Code 351
D ON TI ED TE MI SE ENTA IR LI U M EQU CU R DO
SAV
.9933 .9933
For the management of benign prostatic hyperplasia where six weeks of treatment with other formulary alpha blockers (e.g., doxazosin, terazosin) have been ineffective. For the management of benign prostatic hyperplasia where other formulary alpha blockers have produced intolerable side effects.
JUNE 27, 2008
IIIA.303
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ALLOPURINOL
Note: Reduce dose of mercaptopurine or azathioprine if used concomitantly. Adjust dose of allopurinol in patients with renal impairment. Allopurinol should not be used to treat patients with hyperuricemia when decreased uricosuria is the cause. 1518 100mg Tab 00004588 00364282 00402818 200mg Tab 00506370 00479799 00565342 300mg Tab 00294322 00363693 00402796 .0780 Zyloprim (Not a Benefit) Novo-Purol Apo-Allopurinol Zyloprim (Not a Benefit) Apo-Allopurinol Novo-Purol Zyloprim (Not a Benefit) Novo-Purol Apo-Allopurinol BWE NOP APX BWE APX NOP BWE NOP APX .0780 .0780 .1300 .1300 .1300 .2125 .2125 .2125
1519
1520
AMANTADINE HCL
Note: Amantadine increases central and peripheral effects of anticholinergic drugs. 1521 100mg Cap 01914006 01990403 02034468 02139200 10mg/mL O/L 01913999 02022826 .5179 Symmetrel (Not a Benefit) PMS-Amantadine HCL Endantadine Gen-Amantadine Symmetrel PMS-Amantadine BQU PMS BQU GEN BQU PMS .5179 .5179 .5179 .0810 .0810 .0810
1522
ANAGRELIDE HCL
1523 0.5mg Cap 02260107 Reason for Use Code
N TIO ED D A NT ITE For SE Eof essentialUIR 400 U the treatment Q thrombocytosis in patients who are M LIM intolerant Uor who have failed hydroxyurea therapy. of RE C DO LU Authorization Period: 5 years.
Clinical criteria
Sandoz Anagrelide
SDZ
3.3491 3.3491
IIIA.304
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

AZATHIOPRINE
1524 50mg Tab 00004596 02231491 02236819 02242907 Imuran Gen-Azathioprine Novo-Azathioprine Apo-Azathioprine GSK GEN NOP APX .4300 .9396 .4300 .4300 .4300
Note: Decrease dose of azathioprine to 25 -33% of initial dose if allopurinol used concomitantly.
BOTULINUM TOXIN TYPE A

1525 100U/Vial Pd Inj-100U Vial Pk 01981501 Botox Reason for Use Code 10
D ION ITE E AT ED IM S NT IR L U UME QU RE OC D

Clinical criteria LU Authorization Period: 1 year. 130 LU Authorization Period: 1 year. .7708 Parlodel (Not a Benefit) Apo-Bromocriptine PMS-Bromocriptine # Parlodel Apo-Bromocriptine PMS-Bromocriptine NOV APX PMS NOV APX PMS .7708 .7708 .4328 1.0297 .4328 .4328
ALL
368.0000 368.0000
For the treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorders in patients 12 years of age or older.
To reduce the subjective symptoms and objective signs of cervical dystonia (spasmodic torticollis) in adults.
BROMOCRIPTINE
1526 5mg Cap 00568643 02230454 02236949 2.5mg Tab 00371033 02087324 02231702
1527
JUNE 27, 2008
IIIA.305
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CLODRONATE DISODIUM
1528 400mg Cap 01927078 02245828 Reason for Use Code 280 Ostac Clasteon HLR ORY 1.2083 1.8137 1.2083
ED T ON MI SE TATI ED LI U EN UIR UM REQ OC D

Clinical criteria LU Authorization Period: Indefinite. 358 LU Authorization Period: Indefinite. 359 LU Authorization Period: Indefinite. Bonefos BAY Reason for Use Code 280 Clinical criteria
For the control and prophylaxis of hypercalcemia of malignancy.
For the treatment of bony metastases in patients with breast cancer.
For the prevention and treatment of osteolytic lesions in patients with multiple myeloma.
CLODRONATE DISODIUM TETRAHYDRATE

1529 400mg Cap 01984845

1.7500 1.7500
IIIA.306
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CLOPIDOGREL BISULFATE
1530 75mg Tab 02238682 Reason for Use Code 375 Plavix Clinical criteria SAV 2.5193 2.5193
ED IT E ON IM US TI L TA EN ED UM UIR OC EQ D R
LU Authorization Period: 1 year. 376 For patients immediately pre- or post- percutaneous coronary intervention (PCI)*** Note: approval for 12 months **ACS, as defined by the CURE study, includes hospitalized patients with unstable angina or non-ST segment elevation myocardial infraction. ***Therapy may be initiated up to 10 days prior to PCI. LU Authorization Period: 1 year.
For patients immediately post-hospitalization* for non-ST segment elevation acute coronary syndrome (ACS)**; Note: approval for 12 months
*The first prescription must be written by a physician based at the hospital where the patient was hospitalized.
Network note: The Special Authorization Number (SAN) that corresponds to the hospital where the patient was hospitalized must be submitted with the first Limited Use claim.
JUNE 27, 2008
IIIA.307
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

CYCLOSPORINE
1531 1532 10mg Cap 02237671 25mg Cap 02150689 02247073 50mg Cap 02150662 02247074 100mg Cap 02150670 02242821 Neoral Neoral Sandoz Cyclosporine Neoral Sandoz Cyclosporine Neoral Sandoz Cyclosporine Neoral NOV NOV SDZ NOV SDZ NOV SDZ NOV .6238 .6238 .9952 1.4500 .9952
1533
1534
1535
100mg/mL O/L 02150697 Reason for Use Code 177
ED N IT E IO IM US L AT NT D ME RE CU UI DO EQ R
1.9400 2.8270 1.9400 3.8815 5.6560 3.8815 5.0276 5.0276 Clinical criteria LU Authorization Period: Indefinite. 178 For the treatment of rheumatoid arthritis in patients who have failed, or are intolerant to, other systemic therapies, including Disease-Modifying Antirheumatic Drugs (DMARDs). LU Authorization Period: Indefinite.
For the treatment of psoriasis in patients who have failed, or are intolerant to, other systemic therapies, including methotrexate, acitretin or PUVA;
IIIA.308
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

DUTASTERIDE
1536 0.5mg Cap 02247813 Reason for Use Code 384 Avodart Clinical criteria GSK 1.6188 1.6188
ED N IT E IO IM US L AT T D EN RE M UI CU EQ DO R
LU Authorization Period: Indefinite. 385 LU Authorization Period: Indefinite. Didronel Gen-Etidronate Co-Etidronate PGP GEN COB .6554 1.4275 .6554 .6554 Clinical criteria
For use in combination with an alpha blocker for the treatment of men with symptomatic* Benign Prostate Hyperplasia.
For monotherapy, as a second line agent in patients with symptomatic* Benign Prostatic Hyperplasia following treatment failure or intolerance to an alpha blocker. *Symptomatic is defined as having moderate (about half the time) to severe (almost always) symptoms related to the prostate in at least 4 of the following domains: 1. feeling of incomplete emptying of the bladder after voiding 2. needing to urinate again less than 2 hours after previous void 3. stopping and starting urine several times while voiding 4. difficulty postponing urination 5. weak urinary stream 6. pushing or straining to begin voiding 7. the need to get up to void at least 3 times in night.
ETIDRONATE DISODIUM
1537
D ON D TI E ITE E A IM S NT UIR L U ME EQ R CU O D
Reason for Use Code 236 For the treatment of Pagets disease; LU Authorization Period: Indefinite. 237 For the management of hypercalcemia of malignancy. LU Authorization Period: Indefinite.
200mg Tab 01997629 02245330 02248686
JUNE 27, 2008
IIIA.309
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

ETIDRONATE DISODIUM/CALCIUM CARBONATE
1538 400mg/500mg Tab-90 Tablets Kit 02176017 Didrocal 02247323 + Gen-Eti Cal Carepac 02263866 + Co Etidrocal PGP GEN COB 19.9900 39.9800 19.9900 19.9900
FINASTERIDE
1539 5mg Tab 02010909 Reason for Use Code 384 Proscar Clinical criteria MFC 1.7989 1.7989
ED N IT E IO IM US L AT T D EN IRE UM QU OC RE D
LU Authorization Period: Indefinite. 385 LU Authorization Period: Indefinite.
For use in combination with an alpha blocker for the treatment of men with symptomatic* Benign Prostatic Hyperplasia.
For monotherapy, as a second line agent in patients with symptomatic* Benign Prostatic Hyperplasia following treatment failure or intolerance to an alpha blocker. * Symptomatic is defined as having moderate (about half the time) to severe (almost always) symptoms related to the prostate in at least 4 of the following domains: 1. feeling of incomplete emptying of the bladder after voiding 2. needing to urinate again less than 2 hours after previous void 3. stopping and starting urine several times while voiding 4. difficulty postponing urination 5. weak urinary stream 6. pushing or straining to begin voiding 7. the need to get up to void at least 3 times in the night.
IIIA.310
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

FLUNARIZINE HCL
1540 5mg Cap 00846341 02246082 Reason for Use Code 60 Sibelium Apo-Flunarizine PMS APX .5308 .5308 .5308
N ED T E I TIO LIM US NTA ED E IR M U EQU C R DO

Clinical criteria LU Authorization Period: 1 year. 61 LU Authorization Period: 1 year. 62 For patients in whom propranolol is contraindicated. LU Authorization Period: 1 year. LIL 84.6600 84.6600
For patients with migraine headaches who have not responded to propranolol.
For patients who have tried propranolol and experienced significant adverse effects.
CAUTIONS: Contraindicated in patients with clinical depression and in patients with extrapyramidal disorders.
GLUCAGON RDNA ORIGIN

1541 1mg/Vial Inj Pd-Vial Pk 02243297 Glucagon
JUNE 27, 2008
IIIA.311
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LEFLUNOMIDE
1542 10mg Tab 02241888 02256495 02261251 02283964 02288265 20mg Tab 02241889 02256509 02261278 02283972 02288273 Reason for Use Code 331 Arava Apo-Leflunomide Novo-Leflunomide Sandoz Leflunomide PMS-Leflunomide Arava Apo-Leflunomide Novo-Leflunomide Sandoz Leflunomide PMS-Leflunomide SAV APX NOP SDZ PMS SAV APX NOP SDZ PMS 4.7950 10.5730 4.7950 4.7950 4.7950 4.7950 4.7950 10.5730 4.7950 4.7950 4.7950 4.7950
1543
ED IT E ON TI IM S L U ENTA ED UM QUIR OC RE D
For the treatment of rheumatoid arthritis in patients who have failed, or are intolerant to, one or more of the listed DiseaseModifying Anti-Rheumatic Drugs (DMARDs).
LEVODOPA & BENSERAZIDE

1544 1545 1546 50mg & 12.5mg Cap 00522597 Prolopa 50-12.5 100mg & 25mg Cap 00386464 Prolopa 100-25 200mg & 50mg Cap 00386472 Prolopa 200-50 HLR HLR HLR .2678 .2678 .4410 .4410 .7403 .7403
LEVODOPA & CARBIDOPA

1547 100mg & 10mg Tab 00355658 Sinemet 02182831 Nu-Levocarb 02195933 Apo-Levocarb 02244494 Novo-Levocarbidopa MFC NXP APX NOP .1877 .4221 .1877 .1877 .1877
IIIA.312
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

LEVODOPA & CARBIDOPA
1548 100mg & 25mg Tab 00513997 Sinemet 02182823 Nu-Levocarb 02195941 Apo-Levocarb 02244495 Novo-Levocarbidopa 100mg & 25mg Tab 02028786 Sinemet CR 200mg & 50mg Tab 00870935 Sinemet CR 02245211 Apo-Levocarb CR Reason for Use Code 64 Clinical criteria MFC NXP APX NOP MFC MFC APX .2803 .6303 .2803 .2803 .2803 .6835 .6835 .7385 1.2609 .7385
1549 1550
ED ON IT E TI LIM US ENTA ED M QUIR CU RE DO

LU Authorization Period: Indefinite. 65 LU Authorization Period: Indefinite. MFC NXP APX NOP .3129 .7036 .3129 .3129 .3129
For patients with Parkinsons disease who have been treated with conventional therapy (Prolopa or conventional Sinemet), and experienced adverse effects related to drug level fluctuations, such as ON/OFF or wearing off phenomena.
For patients presently requiring anti-parkinsonian drug administration (levodopa/carbidopa) more than three times daily.
1551
250mg & 25mg Tab 00328219 Sinemet 02182858 Nu-Levocarb 02195968 Apo-Levocarb 02244496 Novo-Levocarbidopa
MONTELUKAST SODIUM
1552 4mg Chew Tab 02243602 Reason for Use Code
N TIO ED D TA ITE For the SE of asthma in patientsIaged 2-5 years old. UR EN Utreatment M M Q 382 LI RE CUPeriod: 1 year. LU Authorization DO
Singulair MFC Clinical criteria
1.3989 1.3989
JUNE 27, 2008
IIIA.313
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

MYCOPHENOLATE MOFETIL
1553 1554 1555 200mg/mL Pd for Oral Susp-175mL Pk 02242145 CellCept 250mg SG Cap 02192748 500mg Tab 02237484 Reason for Use Code 190 CellCept CellCept HLR HLR HLR 288.6800 288.6800 2.0620 2.0620 4.1240 4.1240
ED ION IT E AT M I T ED L US MEN UIR EQ CU R DO

Clinical criteria For the prophylaxis of organ rejection in patients receiving allogeneic renal, cardiac or hepatic transplants. LU Authorization Period: Indefinite.
MYCOPHENOLATE SODIUM
1556 1557 180mg Ent Coated Tab 02264560 Myfortic 360mg Ent Coated Tab 02264579 Myfortic NOV NOV 1.9585 1.9585 3.9170 3.9170
OCTREOTIDE
1558 1559 1560 1561 10mg Inj Kit Pk 02239323 20mg Inj Kit Pk 02239324 30mg Inj Kit Pk 02239325 Sandostatin LAR Sandostatin LAR Sandostatin LAR NOV NOV NOV NOV OMG NOV OMG 1218.8100 1218.8100 1629.7600 1629.7600 2039.9700 2039.9700 2.4950 4.9900 2.4950 4.7100 9.4200 4.7100
50mcg/mL Inj Sol-1mL Amp Pk 00839191 Sandostatin 02248639 Octreotide Acetate Omega 100mcg/mL Inj Sol-1mL Amp Pk 00839205 Sandostatin 02248640 Octreotide Acetate Omega
1562
IIIA.314
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

OCTREOTIDE
1563 500mcg/mL Inj Sol-1mL Amp Pk 00839213 Sandostatin 02248641 Octreotide Acetate Omega 200mcg/mL Inj Sol-5mL Vial Pk 02049392 Sandostatin 02248642 Octreotide Acetate Omega NOV OMG NOV OMG 22.1350 44.2700 22.1350 45.3000 90.6000 45.3000
1564
PHENAZOPYRIDINE HCL
Note: There is no evidence that continuing treatment with phenazopyridine beyond the first 48 hours in urinary tract infections is beneficial. 1565 100mg Tab 00271489 00476714 200mg Tab 00454583 00476722 Phenazo Pyridium (Not a Benefit) Phenazo Pyridium (Not a Benefit) VAL PDA VAL PDA .1180 .1180 .1636 .1636
1566
QUINAGOLIDE HCL
1567 1568 0.075mg Tab 02223767 0.15mg Tab 02223775 Reason for Use Code 405

Norprolac FEI 1.6300 1.6300 Clinical criteria LU Authorization Period: 5 years.
Norprolac
FEI
1.0900 1.0900
For the treatment of hyperprolactinemia in patients who have: ailed to respond to a greater than or equal to 3 month trial of F bromocriptine; or ailed to tolerate bromocriptine; or F ailed to shrink a prolactinoma by greater than 1 cm after 12 F months of bromocriptine therapy..
JUNE 27, 2008
IIIA.315
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

RALOXIFENE HCL
1569 60mg Tab 02239028 Reason for Use Code Evista LIL 1.7853 1.7853
D ON TI D ITE E TA RE IM S L EN UI U UM EQ R OC D
Clinical criteria 373 Failed or, experienced intractable side effects, or have a contraindication to, alendronate OR risedronate. LU Authorization Period: Indefinite.
For the treatment of osteoporosis in postmenopausal women who have:
Failure is defined as: continued loss of bone mineral density (loss of more than 3%) after two years of therapy; or a new osteoporosis related fracture after one year of therapy.
RISEDRONATE SODIUM
1570 1571 5mg Tab 02242518 30mg Tab 02239146 35mg Tab 02246896 Actonel Actonel PGP PGP 1.7550 1.7550 11.3700 11.3700 9.3600 9.3600
1572
Actonel
PGP
ROPINIROLE
1573 1574 1575 1576 0.25mg Tab 02232565 1mg Tab 02232567 2mg Tab 02232568 5mg Tab 02232569 ReQuip ReQuip ReQuip ReQuip GSK GSK GSK GSK .2773 .2773 1.1092 1.1092 1.2201 1.2201 3.4384 3.4384
IIIA.316
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SELEGILINE HCL
1577 5mg Tab 02123312 02068087 02230641 02230717 02231036 02238102 Eldepryl Novo-Selegiline Apo-Selegiline Nu-Selegiline Gen-Selegiline PMS-Selegiline BJH NOP APX NXP GEN PMS 1.0043 2.0085 1.0043 1.0043 1.0043 1.0043 1.0043
SIROLIMUS
1578 1579 1mg/mL O/L 02243237 1mg Tab 02247111 Reason for Use Code 392
ION D ED IT TAT IRE E LIM US UMEN EQU R OC D

Rapamune WAY Clinical criteria LU Authorization Period: Indefinite. Intal (Not a Benefit) PMS-Sodium Cromoglycate Apo-Cromolyn Nu-Cromolyn AVE PMS APX NXP
Rapamune
WAY
7.1547 7.1547 7.1546 7.1546
For the prophylaxis of organ rejection in patients receiving allogeneic renal transplants.
SODIUM CROMOGLYCATE
1580 1% Inh Sol-2mL Pk 00534609 02046113 02231431 02231671 .4846 .4846 .4846 .4846
JUNE 27, 2008
IIIA.317
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

SODIUM FLUORIDE
1581 20mg Tab 02099225 Reason for Use Code 20 Fluotic SAV .3756 .3756
D ION D ITE E TAT IRE LIM US UMEN EQU R OC D

Clinical criteria For the treatment of otosclerosis. LU Authorization Period: Indefinite. 21 For the treatment of otospongiosis. LU Authorization Period: Indefinite. Prograf Prograf Prograf FUJ FUJ FUJ
TACROLIMUS
1582 1583 1584
ED ON D I IT AT RE LIM USE NT UI ME EQ CU R O D
1mg Cap 02175991 5mg Cap 02175983 Reason for Use Code 173 2.5200 2.5200 12.6200 12.6200 Clinical criteria For solid organ transplant and bone marrow transplant. LU Authorization Period: Indefinite.
5mg/mL Amp 02176009
124.5000 124.5000
TACROLIMUS
1585 1586 0.03% Oint 02244149 0.1% Oint 02244148 Reason for Use Code 383
D ON TI ED ITE E TA IR IM S L EN QU U UM RE OC D
Protopic FUJ 2.3000 2.3000 Clinical criteria Therapy should be reassessed at 6 months. LU Authorization Period: 1 year.
Protopic
FUJ
2.1500 2.1500
IIIA.318
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TAMSULOSIN HCL
1587 0.4mg Cap 02238123 02281392 02294265 02294885 02295121 02298570 0.4mg Tab 02270102 .4750 Flomax (Not a Benefit) Novo-Tamsulosin SR Ratio-Tamsulosin Ran-Tamsulosin Sandoz Tamsulosin Gen-Tamsulosin Flomax CR BOE NOP RPH RAN SDZ GEN BOE .4750 .4750 .4750 .4750 .4750
1588
ED T E ON I TI IM US L TA EN ED UM UIR OC EQ D R
.6000 .6000 Reason for Use Code 351 Clinical criteria LU Authorization Period: Indefinite. 352 LU Authorization Period: Indefinite.
Note: Randomized controlled trials have shown no significant differences in efficacy between daily doses of 0.4mg and 0.8mg of tamsulosin. Therefore, the daily tamsulosin dose should not exceed 0.4mg.
For the management of benign prostatic hyperplasia where six weeks of treatment with other formulary alpha blockers (e.g., doxazosin, terazosin) have been ineffective.
For the management of benign prostatic hyperplasia where other formulary alpha blockers have produced intolerable side effects.
JUNE 27, 2008
IIIA.319
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TICLOPIDINE HCL
1589 250mg Tab 02162776 02236848 02237560 02237701 02239744 02243587 Reason for Use Code Ticlid Novo-Ticlopidine Nu-Ticlopidine Apo-Ticlopidine Gen-Ticlopidine Sandoz Ticlopidine HLR NOP NXP APX GEN SDZ .5464 1.2564 .5464 .5464 .5464 .5464 .5464
Clinical criteria Ticlopidine is restricted to patients with transient cerebral ischemia. Ticlopidine may be somewhat more effective than ASA in preventing fatal and non-fatal strokes. However, it is associated with neutropenia in 0.8-2.4% of patients, a serious side-effect which may be fatal. Patients on ticlopidine require blood tests every two weeks for the first three months of therapy. There have been more than 60 cases of ticlopidine associated thrombotic thrombocytopenic purpura (TTP) with 33% mortality rate. As well, there are other side-effects such as diarrhea that occurs in 12.5% of patients. Ticlopidine should be used only after careful consideration. The appropriate use of ticlopidine in the management of patients with cerebral ischemic events (TIA or stroke) is based on the following: (b) If investigation demonstrates that the events are caused by emboli from the heart, the patient should be treated with anticoagulants, such as warfarin. (c) If the events are due to artery-to-artery emboli from the carotid bifurcation with a severe stenosis, the patient should probably be treated with ASA and offered carotid endarterectomy if medically suitable (70% to 99% stenosis). (d) ASA should be the first line of defense for patients with TIA and threatened stroke, and after an initial stroke of any severity.
(a) Determining that the symptoms are due to focal cerebral ischemia, and differentiating the symptoms of dizziness due to vestibular dysfunction, lightheadedness, or syncope from antihypertensive drugs or cardiac dysfunction, and from symptoms due to migraine, epilepsy, hypoglycemia, or other causes, such as tumor.
(Continued on next page...)
IIIA.320
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

TICLOPIDINE HCL
(e) The only drugs other than ASA that are available as platelet inhibitors and which have been shown to be of value for such patients are ticlopidine and clopidogrel. (f) Before abandoning ASA in favour of ticlopidine, efforts should be made to improve the tolerability of ASA by reducing the dose, taking it with food, and using enteric coated ASA. Ticlopidine will be reimbursed for patients: LU Authorization Period: Indefinite. LU Authorization Period: Indefinite.

219 220 221 Who are known to be, or become, intolerant of ASA; Where ASA is contraindicated; LU Authorization Period: Indefinite.
Who continue to have TIA or stroke symptoms while being treated with ASA.
TOLTERODINE L-TARTRATE
1590 1591 1592 1593 2mg SR Cap 02244612 4mg SR Cap 02244613 1mg Tab 02239064 2mg Tab 02239065 Reason for Use Code 290 Detrol LA Detrol LA Detrol Detrol PFI PFI PFI PFI 1.8200 1.8200 1.8200 1.8200 .9100 .9100 .9100 .9100
ED ON IT E TI M S LI U TA EN ED UM UIR OC EQ D R
For patients with urinary frequency, urgency or urge incontinence who have: Failed to respond to behavioural techniques AND An adequate trial of oxybutynin with gradual dose escalation has shown to be either ineffective or resulted in unacceptable side effects. Note: If after a trial of 2 weeks patients continue to experience similar side effects and no greater efficacy than oxybutynin, continued therapy with this more costly agent should be reassessed.
JUNE 27, 2008
IIIA.321
ITEM NO.
BRAND NAME
MANUFACTURER
DBP
DAILY COST

URSODIOL
1594 250mg Tab 02238984 02273497 Urso PMS-Ursodiol C BFI PMS .8635 1.2336 .8635
N TIO ED Reason for D Clinical criteria A IR Use Code T NT I E USE IM QU ME primary biliary cirrhosis. L 273 For the treatment of RE CU O LU D Authorization Period: Indefinite.
Urso DS PMS-Ursodiol C BFI PMS
1595
500mg Tab 02245894 02273500 Reason for Use Code 273
ION D ED TAT IRE MIT SE LI EN U QU M RE CU DO

Clinical criteria For the treatment of primary biliary cirrhosis. LU Authorization Period: Indefinite. 386 For the treatment of primary sclerosing cholangitis. LU Authorization Period: Indefinite. Reason for Use Code
1.6380 2.3400 1.6380
ZOLEDRONIC ACID
1596 5mg/100mL Inj Sol-100mL Pk 02269198 Aclasta
N TIO D A D IRE NT ITE SE E U QU 319 For the treatment MPagets disease. LIM Uof RE C LU Authorization Period: Indefinite. DO
Clinical criteria
NOV
645.0000 645.0000
IIIA.322
JUNE 27, 2008
PART III-B
OFF-FORMULARY INTERCHANGEABLE DRUGS (OFI)
Off-Formulary Interchangeability
Off-Formulary Interchangeability (OFI) is the application of interchangeable designations to drug products where the original products are not listed as ODB benefits in the Formulary/CDI. OFI became effective April 1, 2007 when changes to Regulation 935 under the DIDFA came into force. Listed offformulary interchangeable drug products are reviewed by the CED or by the Ministry, and upon approval of the Executive Officer, are determined to be interchangeable with the brand non-benefit products.
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST
04:00 ANTIHISTAMINICS
CETIRIZINE HYDROCHLORIDE
1 10mg Tab 02223554 02231603 Reactine Apo-Cetirizine MCL APX
0.5000
LORATADINE
2 10mg Tab 00782696 02243880 Claritin Apo-Loratadine SCP APX
0.6500
+ = NEW LISTING
# = BEING DISCONTINUED IN FUTURE
JUNE 27, 2008
IIIB.1
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

TERBINAFINE HCL
3 250mg Tab 02031116 02239893 02240346 02240807 02242503 02254727 02262177 Lamisil Apo-Terbinafine Novo-Terbinafine PMS-Terbinafine Gen-Terbinafine Co Terbinafine Sandoz Terbinafine NOV APX NOP PMS GEN COB SDZ
2.5243 2.5243 2.5245 2.5243 2.5243 2.5243

AZITHROMYCIN
4 600mg Tab 02231143 02256088 Zithromax Co Azithromycin PFI COB
7.6250
CLARITHROMYCIN
5 500mg Tab 02126710 02247574 02247819 02248857 02274752 Biaxin PMS-Clarithromycin Ratio-Clarithromycin Gen-Clarithromycin Apo-Clarithromycin ABB PMS RPH GEN APX
2.2009 2.2009 2.2009 2.2009

MINOCYCLINE HCL
6 50mg Cap 02173514 01914138 02084090 02230735 02237313 02294419 Minocin Ratio-Minocycline Apo-Minocycline Gen-Minocycline Sandoz Minocycline PMS-Minocycline STI RPH APX GEN SDZ PMS
0.5350 0.5350 0.5350 0.5350 0.5350
+ = NEW LISTING
IIIB.2
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

MINOCYCLINE HCL
7 100mg Cap 02173506 01914146 02084104 02230736 02237314 02294427 Minocin Ratio-Minocycline Apo-Minocycline Gen-Minocycline Sandoz Minocycline PMS-Minocycline STI RPH APX GEN SDZ PMS
1.0332 1.0332 1.0332 1.0332 1.0332

CEFOXITIN SODIUM
8 1g/Vial Inj Pd-1 Vial Pk 00663697 Mefoxin 02291711 Cefoxitin for Injection 2g/Vial Inj Pd-1 Vial Pk 00663700 Mefoxin 02291738 Cefoxitin for Injection MSD ORC MSD ORC
10.6000
21.2500
+ = NEW LISTING
JUNE 27, 2008
IIIB.3
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

08:18:00 ANTIVIRALS
ACYCLOVIR
10 200mg Tab 00634506 02078627 02207621 02242784 02285959 400mg Tab 01911627 02078635 02207648 02242463 02285967 Zovirax Ratio-Acyclovir Apo-Acyclovir Gen-Acyclovir Novo-Acyclovir Zovirax Ratio-Acyclovir Apo-Acyclovir Gen-Acyclovir Novo-Acyclovir GSK RPH APX GEN NOP GSK RPH APX GEN NOP
0.8783 0.8783 0.8783 0.8783
11
1.7288 1.7288 1.7288 1.7288
FAMCICLOVIR
12 125mg Tab 02229110 02278081 02278634 02292025 250mg Tab 02229129 02278103 02278642 02292041 Famvir PMS-Famciclovir Sandoz Famciclovir Apo-Famciclovir Famvir PMS-Famciclovir Sandoz Famciclovir Apo-Famciclovir NOV PMS SDZ APX NOV PMS SDZ APX
2.0240 2.0240 2.0240
13
2.7200 2.7200 2.7200

MEFLOQUINE HCL
14 250mg Tab 02018055 02244366 Lariam Apo-Mefloquine HLR APX
3.5688
+ = NEW LISTING
IIIB.4
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

TRIMEBUTINE MALEATE
15 100mg Tab 00587869 02245663 200mg Tab 00803499 02245664 Modulon Apo-Trimebutine Modulon Apo-Trimebutine AXC APX AXC APX
0.2598
16
0.5056

TIZANIDINE HCL
17 4mg Tab 02239170 02259893 02272059 Zanaflex Apo-Tizanidine Gen-Tizanidine ELA APX GEN
0.5106 0.5106
+ = NEW LISTING
JUNE 27, 2008
IIIB.5
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

WARFARIN
18 6mg Tab 02240206 02287501 Coumadin Gen-Warfarin BQU GEN
0.2805
+ = NEW LISTING
IIIB.6
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

SOTALOL HCL
19 80mg Tab 00897272 02084228 02210428 02229778 02231181 02238326 02257831 02270625 Sotacor Ratio-Sotalol Apo-Sotalol Gen-Sotalol Novo-Sotalol PMS-Sotalol Sandoz Sotalol Co Sotalol BQU RPH APX GEN NOP PMS SDZ COB
0.5932 0.5932 0.5932 0.5932 0.5932 0.5932 0.5932

FENOFIBRATE
20 67mg Cap 02230283 02243180 Lipidil Micro Apo-Feno-Micro FOU APX
0.4325
GEMFIBROZIL
21 600mg Tab 00659606 01979582 02142074 02230183 02230476 Lopid Apo-Gemfibrozil Novo-Gemfibrozil PMS-Gemfibrozil Gen-Gemfibrozil PFI APX NOP PMS GEN
0.7520 0.7520 0.7520 0.7520
24:08:00 HYPOTENSIVE DRUGS

CLONIDINE HCL
22 0.025mg Tab 00519251 02248732 02304163 Dixarit Apo-Clonidine Novo-Clonidine BOE APX NOP
0.1817 0.1817
+ = NEW LISTING
JUNE 27, 2008
IIIB.7
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

24:08:00 HYPOTENSIVE DRUGS
VERAPAMIL HCL
23 120mg LA Tab 01907123 02210347 02246893 Isoptin SR Gen-Verapamil SR Apo-Verap SR ABB GEN APX
0.6900 0.6900

BETAHISTINE DIHYDROCHLORIDE
24 16mg Tab 02243878 02280191 24mg Tab 02247998 02280205 Serc Novo-Betahistine Serc Novo-Betahistine SPH NOP SPH NOP
0.2940
25
0.4410
ISOSORBIDE-5-MONONITRATE
26 60mg ER Tab 02126559 02272830 Imdur Apo-ISMN AZC APX
0.4950
+ = NEW LISTING
IIIB.8
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

28:08:04 ANALGESICS NONSTERODIAL ANTI-INFLAMMATORY AGENTS
DICLOFENAC POTASSIUM
27 50mg Tab 00881635 02239355 02239753 02243433 02261774 Voltaren Rapide Novo-Difenac-K PMS-Diclofenac K Apo-Diclo Rapide Sandoz Diclofenac Rapide NOV NOP PMS APX SDZ
0.3937 0.3937 0.3937 0.3937
ETODOLAC
28 200mg Cap 02142023 02232317 300mg Cap 02142031 02232318 Ultradol Apo-Etodolac Ultradol Apo-Etodolac PGP APX PGP APX
0.6000
29
0.6000
NABUMETONE
30 500mg Tab 02083531 02238639 02240867 02242912 02244563 750mg Tab 02083558 02240868 Relafen Apo-Nabumetone Novo-Nabumetone Sandoz Nabumetone Gen-Nabumetone Relafen Novo-Nabumetone GSK APX NOP SDZ GEN GSK NOP
0.5025 0.5025 0.5025 0.5025
31
0.6825
+ = NEW LISTING
JUNE 27, 2008
IIIB.9
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

28:08:04 ANALGESICS NONSTERODIAL ANTI-INFLAMMATORY AGENTS
NAPROXEN
32 250mg Ent Tab 02162792 02243431 02246699 375mg Ent Tab 02162415 02243432 02246700 02294702 500mg Ent Tab 02162423 02241024 02246701 02294710 Naprosyn E Gen-Naproxen EC Apo-Naproxen EC Naprosyn E Gen-Naproxen EC Apo-Naproxen EC PMS-Naproxen EC Naprosyn E Gen-Naproxen EC Apo-Naproxen EC PMS-Naproxen EC HLR GEN APX HLR GEN APX PMS HLR GEN APX PMS
0.2835 0.2835
33
0.3675 0.3675 0.3675
34
0.6894 0.6894 0.6894
NAPROXEN SODIUM
35 275mg Tab 02162725 00784354 550mg Tab 02162717 01940309 Anaprox Apo-Napro-Na Anaprox DS Apo-Napro-Na DS HLR APX HLR APX
0.3422
36
0.6667
OXAPROZIN
37 600mg Tab 02027860 02243661 Daypro Apo-Oxaprozin HLR APX
0.4875
+ = NEW LISTING
IIIB.10
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

GABAPENTIN
38 600mg Tab 02239717 02248457 02255898 02260913 800mg Tab 02239718 02247346 02255901 02260921 Neurontin Novo-Gabapentin PMS-Gabapentin Ratio-Gabapentin Neurontin Novo-Gabapentin PMS-Gabapentin Ratio-Gabapentin PFI NOP PMS RPH PFI NOP PMS RPH
1.3045 1.3045 1.3045
39
1.7393 1.7393 1.7393
LEVETIRACETAM
40 250mg Tab 02247027 02274183 02285924 02296101 500mg Tab 02247028 02274191 02285932 02296128 750mg Tab 02247029 02274205 02285940 02296136 Keppra Co Levetiracetam Apo-Levetiracetam PMS-Levetiracetam Keppra Co Levetiracetam Apo-Levetiracetam PMS-Levetiracetam Keppra Co Levetiracetam Apo-Levetiracetam PMS-Levetiracetam VLH COB APX PMS VLH COB APX PMS VLH COB APX PMS
1.1175 1.1175 1.1175
41
1.3650 1.3650 1.3650
42
1.9425 1.9425 1.9425
+ = NEW LISTING
JUNE 27, 2008
IIIB.11
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

OXCARBAZEPINE
43 150mg Tab 02242067 02284294 300mg Tab 02242068 02284308 600mg Tab 02242069 02284316 Trileptal Apo-Oxcarbazepine Trileptal Apo-Oxcarbazepine Trileptal Apo-Oxcarbazepine NOV APX NOV APX NOV APX
0.5625
44
1.1250
45
2.2500
+ = NEW LISTING
IIIB.12
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

FLUOXETINE HCL
46 10mg Cap 02018985 02177579 02216353 02216582 02237813 02241371 02243486 Prozac PMS-Fluoxetine Apo-Fluoxetine Novo-Fluoxetine Gen-Fluoxetine Ratio-Fluoxetine Sandoz Fluoxetine LIL PMS APX NOP GEN RPH SDZ
1.1773 1.1773 1.1773 1.1773 1.1773 1.1773
PAROXETINE HCL
47 10mg Tab 02027887 02240907 02247750 02247810 02248012 02248556 02262746 Paxil Apo-Paroxetine PMS-Paroxetine Ratio-Paroxetine Gen-Paroxetine Novo-Paroxetine Co Paroxetine SMJ APX PMS RPH GEN NOP COB
1.0430 1.0430 1.0430 1.0430 1.0430 1.0430

ALPRAZOLAM
48 1mg Tab 00723770 02229813 02243611 2mg Tab 00813958 02229814 02243612 Xanax Gen-Alprazolam Apo-Alpraz Xanax TS Gen-Alprazolam Apo-Alpraz TS PFI GEN APX PFI GEN APX
0.3099 0.3099
49
0.5508 0.5508
+ = NEW LISTING
JUNE 27, 2008
IIIB.13
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

CLOZAPINE
50 25mg Tab 00894737 02247243 02248034 100mg Tab 00894745 02247244 02248035 Clozaril Gen-Clozapine Apo-Clozapine Clozaril Gen-Clozapine Apo-Clozapine NOV GEN APX NOV GEN APX
0.6594 0.6594
51
2.6446 2.6446

LITHIUM CARBONATE
52 300mg ER Tab 00590665 02266695 Duralith Apo-Lithium Carbonate SR JNO APX
0.1334
TRYPTOPHAN
53 500mg Cap 00718149 02248540 500mg Tab 02029456 02248538 1g Tab 00654531 02248539 Tryptan Apo-Tryptophan Tryptan Apo-Tryptophan Tryptan Apo-Tryptophan VAL APX VAL APX VAL APX
0.4987
54
0.4987
55
0.8978
+ = NEW LISTING
IIIB.14
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

28:20:00 C.N.S. STIMULANTS
METHYLPHENIDATE HCL
56 20mg Tab 00005614 00585009 02249332 Ritalin PMS-Methylphenidate Apo-Methylphenidate NOV PMS APX
0.3536 0.3536
MODAFINIL
57 100mg Tab 02239665 02285398 Alertec Apo-Modafinil BJH APX
0.9293

BUSPIRONE HYDROCHLORIDE
58 10mg Tab 00603821 02211076 02230874 02230942 02231492 02237858 Buspar Apo-Buspirone Gen-Buspirone PMS-Buspirone Novo-Buspirone Ratio-Buspirone BQU APX GEN PMS NOP RPH
0.6521 0.6521 0.6521 0.6521 0.6521
ZOPICLONE
59 5mg Tab 02216167 02243426 02245077 02246534 02251450 02257572 02267918 02271931 02296616 Imovane PMS-Zopiclone Apo-Zopiclone Ratio-Zopiclone Novo-Zopiclone Sandoz Zopiclone Ran-Zopiclone Co Zopiclone Gen-Zopiclone SAV PMS APX RPH NOP SDZ RAN COB GEN
0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 0.2231
+ = NEW LISTING
JUNE 27, 2008
IIIB.15
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

ZOPICLONE
60 7.5mg Tab 01926799 02008203 02218313 02238596 02240606 02242481 02251469 02257580 02267926 02271958 Imovane Rhovane Apo-Zopiclone Gen-Zopiclone PMS-Zopiclone Ratio-Zopiclone Novo-Zopiclone Sandoz Zopiclone Ran-Zopiclone Co Zopiclone SAV SAV APX GEN PMS RPH NOP SDZ RAN COB
0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685

61 0.5mg Tab 02241594 02269317 02290138 02292386 Mirapex Novo-Pramipexole PMS-Pramipexole Apo-Pramipexole BOE NOP PMS APX
1.3860 1.3860 1.3860
+ = NEW LISTING
IIIB.16
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

SUMATRIPTAN SUCCINATE
62 25mg Tab 02256428 02257882 02268906 63 25mg Tab 02239738 02286815 50mg Tab 02163764 02256436 02257890 02263025 02268388 02268914 02271583 50mg Tab 02212153 02286823 100mg Tab 01950614 02256444 02257904 02263033 02268396 02268922 02271591 100mg Tab 02212161 02286831 Imitrex PMS-Sumatriptan Co Sumatriptan Gen-Sumatriptan Imitrex DF Novo-Sumatriptan DF Imitrex PMS-Sumatriptan Co Sumatriptan Sandoz Sumatriptan Apo-Sumatriptan Gen-Sumatriptan Ratio-Sumatriptan Imitrex DF Novo-Sumatriptan DF Imitrex PMS-Sumatriptan Co Sumatriptan Sandoz Sumatriptan Apo-Sumatriptan Gen-Sumatriptan Ratio-Sumatriptan Imitrex DF Novo-Sumatriptan DF GSK PMS COB GEN GSK NOP GSK PMS COB SDZ APX GEN RPH GSK NOP GSK PMS COB SDZ APX GEN RPH GSK NOP 8.9900 8.9900 8.9900
8.9900
64
9.0650 9.0650 9.0650 9.0650 9.0650 9.0650
65
9.0650
66
9.9867 9.9867 9.9867 9.9867 9.9867 9.9867
67
9.9866
+ = NEW LISTING
JUNE 27, 2008
IIIB.17
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

FLUTICASONE PROPIONATE
68 50mcg/Actuation Nas Sp-120 Dose Pk 02213672 Flonase 02294745 Apo-Fluticasone 02296071 Ratio-Fluticasone GSK APX RPH
21.9700 21.9700
+ = NEW LISTING
IIIB.18
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

PANTOPRAZOLE SODIUM
69 20mg Ent Tab 02241804 02292912 Pantoloc Apo-Pantoprazole NYC APX
1.2750
+ = NEW LISTING
JUNE 27, 2008
IIIB.19
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST
64:00 HEAVY METAL ANTAGONISTS

DEFEROXAMINE MESYLATE
70 2g/Vial Inj Pd-2g Vial Pk 01981250 Desferal 02243450 PMS-Deferoxamine 500mg/Vial Inj Pd-500mg Vial Pk 01981242 Desferal 02242055 PMS-Deferoxamine NOV PMS NOV PMS
42.0000
71
8.1750
+ = NEW LISTING
IIIB.20
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

GLIMEPIRIDE
72 1mg Tab 02245272 02269589 02273101 02273756 02274248 02279061 02295377 2mg Tab 02245273 02269597 02273128 02273764 02274256 02279088 02295385 4mg Tab 02245274 02269619 02273136 02273772 02274272 02279126 02295393 Amaryl Sandoz Glimepiride Ratio-Glimepiride Novo-Glimepiride Co Glimepiride Gen-Glimepiride Apo-Glimepiride Amaryl Sandoz Glimepiride Ratio-Glimepiride Novo-Glimepiride Co Glimepiride Gen-Glimepiride Apo-Glimepiride Amaryl Sandoz Glimepiride Ratio-Glimepiride Novo-Glimepiride Co Glimepiride Gen-Glimepiride Apo-Glimepiride SAV SDZ RPH NOP COB GEN APX SAV SDZ RPH NOP COB GEN APX SAV SDZ RPH NOP COB GEN APX
0.4900 0.4900 0.4900 0.4900 0.4900 0.4900
73
0.4900 0.4900 0.4900 0.4900 0.4900 0.4900
74
0.4900 0.4900 0.4900 0.4900 0.4900 0.4900
METFORMIN HCL
75 850mg Tab 02162849 02229656 02242589 02242931 02246821 02257734 02269058 Glucophage Gen-Metformin PMS-Metformin Ratio-Metformin Sandoz Metformin FC Co Metformin Ran-Metformin SAV GEN PMS RPH SDZ COB RAN
0.2090 0.2090 0.2090 0.2090 0.2090 0.2090
+ = NEW LISTING
JUNE 27, 2008
IIIB.21
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

68:24:00 PARATHYROID AGENTS
CALCITONIN (SALMON SYNTHETIC)
76 200U/Metered Dose Nas Sp-2x14 Dose Pk 02240775 Miacalcin 02261766 Sandoz Calcitonin NS NOV SDZ
48.3112

CYPROTERONE ACETATE & ETHINYL ESTRADIOL
77 2mg & 0.035mg Tab-21 Pk 02233542 Diane-35 02290308 Cyestra-35 BAY PMS
23.3394
+ = NEW LISTING
IIIB.22
JUNE 27, 2008
ITEM NO.
BRAND NAME
MANUFACTURER
UNIT COST

ALENDRONATE
78 5mg Tab 02233055 02248251 02248727 02270110 02288079 40mg Tab 02201038 02258102 Fosamax Novo-Alendronate Apo-Alendronate Gen-Alendronate Sandoz Alendronate Fosamax Co Alendronate MFC NOP APX GEN SDZ MFC COB
1.0370 1.0370 1.0370 1.0370
79
2.6097
CABERGOLINE
80 0.5mg Tab 02242471 02301407 Dostinex Co Cabergoline PMJ COB
8.8550
PAMIDRONATE DISODIUM
81 3mg/mL Inj Sol-10mL Vial 02059762 Aredia 02245998 PMS-Pamidronate 02264951 Pamidronate Disodium 6mg/mL Inj Sol-10mL Vial 02059770 Aredia 02264978 Pamidronate Disodium 9mg/mL Inj Sol-10mL Vial 02059789 Aredia 02245999 PMS-Pamidronate 02264986 Pamidronate Disodium NOV PMS SDZ NOV SDZ NOV PMS SDZ
88.3500 88.3500
82
176.7000
83
279.0000 265.0500
+ = NEW LISTING
JUNE 27, 2008
IIIB.23
PART IV
CONSOLIDATED ALPHABETICAL INDEX OF DRUG PRODUCTS LISTED IN PART III-A AND PART III-B
PRODUCT NAME, STRENGTH & DOSAGE FORM
DIN/PIN
MFR
PART
PAGE
292 30mg Tab 3TC 10mg/mL O/L 3TC 150mg Tab 3TC 300mg Tab 5-AMINOSALICYLIC ACID 5-Benzagel 5% Gel ABACAVIR & LAMIVUDINE & ZIDOVUDINE ABACAVIR SULFATE ABACAVIR SULFATE & LAMIVUDINE Abenol 120mg Sup (Not a Benefit) Abenol 325mg Sup (Not a Benefit) Abenol 650mg Sup (Not a Benefit) ACARBOSE Accupril 5mg Tab Accupril 10mg Tab Accupril 20mg Tab Accupril 40mg Tab Accuretic 10mg & 12.5mg Tab Accuretic 20mg & 12.5mg Tab Accuretic 20mg & 25mg Tab Accutane 10mg Cap Accutane 40mg Cap ACEBUTOLOL HCL ACET 120 120mg Sup ACET 325 325mg Sup ACET 650 650mg Sup ACETAMINOPHEN Acetaminophen 325mg Tab ACETAMINOPHEN & CODEINE PHOSPHATE ACETAMINOPHEN COMPOUND WITH CODEINE Acetaminophen Extra Strength 500mg Tab ACETAZOLAMIDE AcetOxyl 5% Gel AcetOxyl 10% Gel ACETYLSALICYLIC ACID ACETYLSALICYLIC ACID COMPOUND WITH CODEINE ACITRETIN Aclasta 5mg/100mL Inj Sol-100mL Pk Actonel 5mg Tab Actonel 30mg Tab Actonel 35mg Tab Actos 15mg Tab Actos 30mg Tab Actos 45mg Tab
02238645 02192691 02192683 02247825 02162113
PEN GSK GSK GSK NOV
01919385 01919393 01919407 01947664 01947672 01947680 01947699 02237367 02237368 02237369 00582344 00582352 02230434 02230436 02230437 00589241
PEN PEN PEN PFI PFI PFI PFI PFI PFI PFI HLR HLR PMS PMS PMS DPC
00589233 00406821 00406848
DPC STI STI
02269198 02242518 02239146 02246896 02242572 02242573 02242574
NOV PGP PGP PGP LIL LIL LIL
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
136 26 26 26 229 293 21 21 21 145 145 145 260 116 116 116 116 116 116 116 296 296 83 145 145 145 145 145 136 136 146 203 292 292 123 136 295 322 316 316 316 263 263 263
IV.1
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Acular 0.5% Oph Sol ACYCLOVIR Adalat 5mg Cap (Not a Benefit) Adalat 10mg Cap (Not a Benefit) Adalat PA 10 10mg LA Tab (Not a Benefit) Adalat PA 20 20mg LA Tab (Not a Benefit) Adalat XL 20mg ER Tab Adalat XL 30mg ER Tab Adalat XL 60mg ER Tab Adrenalin 30mg/30mL Inj Sol-30mL Pk Advair 125 25/125mcg/Metered Dose Inh-120 Dose Pk Advair 250 25/250mcg/Metered Dose Inh-120 Dose Pk Advair Diskus 50/100mcg Inh-60 Dose Pk Advair Diskus 50/250mcg Inh-60 Dose Pk Advair Diskus 50/500mcg Inh-60 Dose Pk Agenerase 50mg Cap Agenerase 150mg Cap Agenerase 15mg/mL O/L Aggrenox 200mg/25mg Cap Airomir HFA 100mcg/Metered Dose Inh-200 Dose Pk (Not a Benefit) Albalon 0.1% Oph Sol (Not a Benefit) Alcomicin 0.3% Oph Sol Aldactazide-25 25mg & 25mg Tab Aldactazide-50 50mg & 50mg Tab Aldactone 25mg Tab Aldactone 100mg Tab Aldomet 125mg Tab (Not a Benefit) Aldomet 250mg Tab (Not a Benefit) Aldomet 500mg Tab (Not a Benefit) ALENDRONATE ALENDRONATE/CHOLECALCIFEROL Alertec 100mg Tab (Not a Benefit) Alesse 20mcg & 100mcg Tab-21 Pk Alesse 20mcg & 100mcg Tab-28 Pk ALFACALCIDOL ALFUZOSIN HYDROCHLORIDE Alkeran 2mg Tab Allerdryl 25mg Cap (Not a Benefit) Allerdryl 50mg Cap (Not a Benefit) ALLOPURINOL Alomide 0.1% Oph Sol
IV.2
01968300
ALL
02155869 02155877 02155885 02155893 02237618 02155907 02155990 00155357 02245126 02245127 02240835 02240836 02240837 02243541 02243542 02243543 02242119 02232570 00001147 00436771 00180408 00594377 00028606 00285455 00016551 00016578 00016586
BAH BAH BAH BAH BAY BAY BAY ERF GSK GSK GSK GSK GSK GSK GSK GSK BOE MMH ALL ALC PFI PFI PFI PFI MSD MSD MSD
IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
200 22 4 91 91 113 113 113 113 113 60 68 68 68 68 68 23 23 23 120 66 203 196 189 189 191 191 113 113 113 303 23 303 15 271 271 301 303 48 1 1 304 200
02239665 02236974 02236975
BJH WAY WAY
00004715 00370517 00271411 00893560
GSK VAL VAL ALC
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Alphagan 0.2% Oph Sol Alphagan P 0.15% Oph Sol ALPRAZOLAM Altace Cap 1.25mg Altace Cap 2.5mg Altace Cap 5mg Altace Cap 10mg Altace HCT 2.5mg & 12.5mg Tab Altace HCT 5mg & 12.5mg Tab Altace HCT 5mg & 25mg Tab Altace HCT 10mg & 12.5mg Tab Altace HCT 10mg & 25mg Tab ALTRETAMINE ALUMINUM HYDROXIDE & MAGNESIUM HYDROXIDE Alupent 2mg/mL O/L (Not a Benefit) Alvesco 100mcg/Actuation Inh-120 Dose Pk Alvesco 200mcg/Actuation Inh-120 Dose Pk AMANTADINE HCL Amaryl 1mg Tab (Not a Benefit) Amaryl 2mg Tab (Not a Benefit) Amaryl 4mg Tab (Not a Benefit) Amatine 2.5mg Tab Amatine 5mg Tab AMCINONIDE AMILORIDE HCL AMILORIDE HCL & HYDROCHLOROTHIAZIDE AMINOPHYLLINE AMIODARONE HCL AMITRIPTYLINE AMLODIPINE AMLODIPINE BESYLATE / ATORVASTATIN CALCIUM AMOBARBITAL SODIUM AMOXICILLIN AMOXICILLIN & CLAVULANIC ACID Amoxil 250mg Cap (Not a Benefit) Amoxil 500mg Cap (Not a Benefit) Amoxil 25mg/mL O/L (Not a Benefit) Amoxil 50mg/mL O/L (Not a Benefit) AMPHOTERICIN B AMPICILLIN AMPRENAVIR Amytal Sodium 60mg Cap Amytal Sodium 200mg Cap
02236876 02248151
ALL ALL
02221829 02221837 02221845 02221853 02283131 02283158 02283174 02283166 02283182
SAV SAV SAV SAV SAV SAV SAV SAV SAV
00249920 02285606 02285614 02245272 02245273 02245274 01934392 01934406
BOE NYC NYC SAV SAV SAV SHI SHI
02041294 02041308 02041316 02042592
WAY WAY WAY WAY
00015148 00015156
LIL LIL
IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
205 205 164 13 116 116 117 117 117 117 117 117 117 41 215 62 251 251 304 21 21 21 191 191 284 187 187 299 84 155 84 95 178 10 11 10 10 10 11 3 12 23 178 178
IV.3
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Anafranil 10mg Tab Anafranil 25mg Tab Anafranil 50mg Tab ANAGRELIDE HCL Anandron 50mg Tab Anaprox 275mg Tab (Not a Benefit) Anaprox DS 550mg Tab (Not a Benefit) ANASTROZOLE Andriol 40mg Cap Androcur 50mg Tab Androderm 12.2mg Transdermal Patch Androgel 1% 2.5g Foil Packet Androgel 1% 5.0g Foil Packet Ansaid 50mg Tab Ansaid 100mg Tab Anthraforte 1 1% Oint Anthraforte 2 2% Oint ANTHRALIN Anthranol 0.1% Cr Anthranol 0.2% Cr Anthranol 0.4% Cr Anturan 200mg Tab (Not a Benefit) Anusol 0.5% Oint Anuzinc 10mg Sup Anzemet 50mg Tab Anzemet 100mg Tab Apo-Acebutolol 100mg Tab Apo-Acebutolol 200mg Tab Apo-Acebutolol 400mg Tab Apo-Acetaminophen 325mg Tab Apo-Acetaminophen 500mg Tab Apo-Acetazolamide 250mg Tab Apo-Acyclovir 200mg Tab (Not a Benefit) Apo-Acyclovir 400mg Tab (Not a Benefit) Apo-Acyclovir 800mg Tab Apo-Alendronate 5mg Tab (Not a Benefit) Apo-Alendronate 10mg Tab Apo-Alendronate 70mg Tab Apo-Allopurinol 100mg Tab Apo-Allopurinol 200mg Tab Apo-Allopurinol 300mg Tab Apo-Alpraz 0.25mg Tab Apo-Alpraz 0.5mg Tab Apo-Alpraz 1mg Tab (Not a Benefit)
IV.4
00330566 00324019 00402591 02221861 02162725 02162717 00782327 00704431 02239653 02245345 02245346 00647942 00600792 00566756 00566748 00537594 00537608 00537616 00010529 01945939 00621439 02231378 02231379 02147602 02147610 02147629 00544981 00545007 00545015 02207621 02207648 02207656 02248727 02248728 02248730 00402818 00479799 00402796 00865397 00865400 02243611
ORY ORY ORY SAV HLR HLR ORG BAY PAL SPH SPH PFI PFI MEI MEI MEI MEI MEI GEI PFI SDZ SAV SAV APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX
IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB
156 156 156 304 49 10 10 41 257 43 255 255 255 128 128 292 292 292 292 292 292 192 297 297 226 226 83 83 83 145 146 203 4 4 22 23 303 303 304 304 304 164 165 13
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Alpraz TS 2mg Tab (Not a Benefit) Apo-Amiloride 5mg Tab Apo-Amilzide 5mg & 50mg Tab Apo-Amiodarone 200mg Tab Apo-Amitriptyline 10mg Tab Apo-Amitriptyline 25mg Tab Apo-Amitriptyline 50mg Tab Apo-Amoxi 250mg Cap (Not a Benefit) Apo-Amoxi 500mg Cap (Not a Benefit) Apo-Amoxi 25mg/mL O/L (Not a Benefit) Apo-Amoxi 50mg/mL O/L (Not a Benefit) Apo-Amoxi Clav 25mg & 6.25mg/mL O/L Apo-Amoxi Clav 50mg & 12.5mg/mL O/L Apo-Amoxi Clav 400mg & 57mg/5mL Susp (Not a Benefit) Apo-Amoxi Clav 250mg & 125mg Tab Apo-Amoxi Clav 500mg & 125mg Tab Apo-Amoxi Clav 875mg & 125mg Tab Apo-Atenidone 50 & 25mg Tab Apo-Atenidone 100 & 25mg Tab Apo-Atenol 50mg Tab Apo-Atenol 100mg Tab Apo-Azathioprine 50mg Tab Apo-Azithromycin 250mg Tab Apo-Baclofen 10mg Tab Apo-Baclofen 20mg Tab Apo-Benazepril 5mg Tab Apo-Benazepril 10mg Tab Apo-Benazepril 20mg Tab Apo-Benztropine 2mg Tab Apo-Benzydamine 0.15% Oral Rinse Apo-Bicalutamide 50mg Tab Apo-Bisacodyl 5mg Ent Tab Apo-Bisoprolol 5mg Tab Apo-Bisoprolol 10mg Tab Apo-Brimonidine 0.2% Oph Sol Apo-Bromazepam 1.5mg Tab Apo-Bromazepam 3mg Tab Apo-Bromazepam 6mg Tab Apo-Bromocriptine 5mg Cap Apo-Bromocriptine 2.5mg Tab Apo-Buspirone 10mg Tab (Not a Benefit) Apo-C 100mg Tab (Not a Benefit) Apo-C 250mg Tab (Not a Benefit) Apo-C 500mg Tab (Not a Benefit)
02243612 02249510 00784400 02246194 00335053 00335061 00335088 00628115 00628123 00628131 00628158 02243986 02243987 02288559 02243350 02243351 02245623 02248763 02248764 00773689 00773697 02242907 02247423 02139332 02139391 02290332 02290340 02273918 00426857 02239044 02296063 00545023 02256134 02256177 02260077 02177153 02177161 02177188 02230454 02087324 02211076 00466646 00466638 00466611
APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX
IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA
13 187 187 84 155 155 155 10 10 10 11 11 11 11 12 12 12 103 103 84 85 305 8 69 70 103 103 103 54 201 41 218 85 85 205 165 165 165 305 305 15 301 301 301
IV.5
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-C 1000mg Tab (Not a Benefit) Apo-Cal 250 Eq To 250mg Elemental Calcium Tab (Not a Benefit) Apo-Cal 500 Eq To 500mg Elemental Calcium Tab (Not a Benefit) Apo-Capto 12.5mg Tab Apo-Capto 25mg Tab Apo-Capto 50mg Tab Apo-Capto 100mg Tab Apo-Carbamazepine 200mg Tab Apo-Carbamazepine CR 200mg LA Tab Apo-Carbamazepine CR 400mg LA Tab Apo-Carvedilol 3.125mg Tab Apo-Carvedilol 6.25mg Tab Apo-Carvedilol 12.5mg Tab Apo-Carvedilol 25mg Tab Apo-Cefaclor 250mg Cap Apo-Cefaclor 500mg Cap Apo-Cefaclor 25mg/mL Oral Susp Apo-Cefaclor 50mg/mL Oral Susp Apo-Cefaclor 375mg/5mL Oral Susp (Not a Benefit) Apo-Cefadroxil 500mg Cap Apo-Cefprozil 125mg/5mL Oral Susp Apo-Cefprozil 250mg/5mL Oral Susp Apo-Cefprozil 250mg Tab Apo-Cefprozil 500mg Tab Apo-Cefuroxime 250mg Tab Apo-Cefuroxime 500mg Tab Apo-Cephalex 250mg Tab Apo-Cephalex 500mg Tab Apo-Cetirizine 10mg Tab (Not a Benefit) Apo-Chlordiazepoxide 5mg Cap Apo-Chlordiazepoxide 10mg Cap Apo-Chlordiazepoxide 25mg Cap Apo-Chlorthalidone 50mg Tab Apo-Chlorthalidone 100mg Tab Apo-Cilazapril 1mg Tab Apo-Cilazapril 2.5mg Tab Apo-Cilazapril 5mg Tab Apo-Cilazapril/HCTZ 5mg/12.5mg Tab Apo-Cimetidine 200mg Tab Apo-Cimetidine 300mg Tab Apo-Cimetidine 400mg Tab Apo-Cimetidine 600mg Tab Apo-Cimetidine 800mg Tab Apo-Ciproflox 250mg Tab
IV.6
00466603 00682047 00682039 00893595 00893609 00893617 00893625 00402699 02242908 02242909 02247933 02247934 02247935 02247936 02230263 02230264 02237500 02237501 02237502 02240774 02293943 02293951 02292998 02293005 02244393 02244394 00768723 00768715 02231603 00522724 00522988 00522996 00360279 00360287 02291134 02291142 02291150 02284987 00584215 00487872 00600059 00600067 00749494 02229521
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
301 185 185 104 104 104 104 147 147 147 86 86 86 86 14 14 14 15 15 15 15 15 15 16 16 16 17 17 1 165 165 165 188 188 104 105 105 105 230 230 230 231 231 33
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Ciproflox 500mg Tab Apo-Ciproflox 750mg Tab Apo-Citalopram 20mg Tab Apo-Citalopram 40mg Tab Apo-Clarithromycin 250mg Tab Apo-Clarithromycin 500mg Tab (Not a Benefit) Apo-Clindamycin 150mg Cap Apo-Clindamycin 300mg Cap Apo-Clobazam 10mg Tab Apo-Clomipramine 10mg Tab Apo-Clomipramine 25mg Tab Apo-Clomipramine 50mg Tab Apo-Clonazepam 0.5mg Tab Apo-Clonazepam 2mg Tab Apo-Clonidine 0.025mg Tab (Not a Benefit) Apo-Clonidine 0.1mg Tab Apo-Clonidine 0.2mg Tab Apo-Clorazepate 3.75mg Cap Apo-Clorazepate 7.5mg Cap Apo-Clorazepate 15mg Cap Apo-Cloxi 250mg Cap (Not a Benefit) Apo-Cloxi 500mg Cap (Not a Benefit) Apo-Cloxi 25mg/mL O/L (Not a Benefit) Apo-Clozapine 25mg Tab (Not a Benefit) Apo-Clozapine 100mg Tab (Not a Benefit) Apo-Cromolyn 1% Inh Sol-2mL Pk Apo-Cromolyn 2% Nas Sol-26mL Pk Apo-Cyclobenzaprine 10mg Tab (Not a Benefit) Apo-Cyproterone 50mg Tab Apo-Desipramine 25mg Tab Apo-Desipramine 50mg Tab Apo-Desipramine 75mg Tab Apo-Desmopressin 10mcg/Metered Dose Nas Sp-2.5mL Pk Apo-Desmopressin 0.1mg Tab Apo-Desmopressin 0.2mg Tab Apo-Dexamethasone 0.5mg Tab Apo-Dexamethasone 4mg Tab Apo-Diazepam 2mg Tab Apo-Diazepam 5mg Tab Apo-Diazepam 10mg Tab Apo-Diclo 25mg Ent Tab Apo-Diclo 50mg Ent Tab Apo-Diclo Rapide 50mg Tab (Not a Benefit) Apo-Diclo SR 75mg LA Tab
02229522 02229523 02246056 02246057 02274744 02274752 02245232 02245233 02244638 02040786 02040778 02040751 02177889 02177897 02248732 00868949 00868957 00860689 00860700 00860697 00618292 00618284 00644633 02248034 02248035 02231431 02231390 02177145 02245898 02216256 02216264 02216272 02242465 02284030 02284049 02261081 02250055 00405329 00362158 00405337 00839175 00839183 02243433 02162814
IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA
33 33 156 156 8 2 17 18 148 156 156 156 148 148 7 105 105 166 166 166 13 13 13 14 14 317 213 70 43 157 157 157 269 269 269 251 251 167 167 167 125 125 9 125
IV.7
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Diclo SR 100mg LA Tab Apo-Diflunisal 250mg Tab Apo-Diflunisal 500mg Tab Apo-Digoxin 0.0625mg Tab Apo-Digoxin 0.125mg Tab Apo-Digoxin 0.25mg Tab Apo-Diltiaz 30mg Tab Apo-Diltiaz 60mg Tab Apo-Diltiaz CD 120mg LA Cap Apo-Diltiaz CD 180mg LA Cap Apo-Diltiaz CD 240mg LA Cap Apo-Diltiaz CD 300mg LA Cap Apo-Diltiaz SR 60mg LA Cap Apo-Diltiaz SR 90mg LA Cap Apo-Diltiaz SR 120mg LA Cap Apo-Dimenhydrinate 50mg Tab (Not a Benefit) Apo-Divalproex 125mg Ent Tab Apo-Divalproex 250mg Ent Tab Apo-Divalproex 500mg Ent Tab Apo-Domperidone 10mg Tab Apo-Doxazosin 1mg Tab Apo-Doxazosin 2mg Tab Apo-Doxazosin 4mg Tab Apo-Doxepin 10mg Cap Apo-Doxepin 25mg Cap Apo-Doxepin 50mg Cap Apo-Doxepin 75mg Cap Apo-Doxepin 100mg Cap Apo-Enalapril 2.5mg Tab Apo-Enalapril 5mg Tab Apo-Enalapril 10mg Tab Apo-Enalapril 20mg Tab Apo-Erythro 250mg Tab Apo-Erythro E-C 250mg Ent Pel Cap (Not a Benefit) Apo-Erythro-ES 600mg Tab Apo-Erythro-S 250mg Tab Apo-Erythro-S 500mg Tab Apo-Etodolac 200mg Cap (Not a Benefit) Apo-Etodolac 300mg Cap (Not a Benefit) Apo-Famciclovir 125mg Tab (Not a Benefit) Apo-Famciclovir 250mg Tab (Not a Benefit) Apo-Famciclovir 500mg Tab Apo-Famotidine 20mg Tab Apo-Famotidine 40mg Tab
IV.8
02091194 02039486 02039494 02281236 02281228 02281201 00771376 00771384 02230997 02230998 02230999 02229526 02222957 02222965 02222973 00363766 02239698 02239699 02239700 02103613 02240588 02240589 02240590 02049996 02050005 02050013 02050021 02050048 02020025 02019884 02019892 02019906 00682020 00726672 00637416 00545678 00688568 02232317 02232318 02292025 02292041 02292068 01953842 01953834
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIB IIIA IIIA IIIA
126 127 127 87 87 87 89 89 87 88 88 88 88 88 88 225 149 149 149 231 106 106 106 157 157 157 157 157 106 107 107 107 8 8 9 9 9 9 9 4 4 25 232 232
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Feno-Micro 67mg Cap (Not a Benefit) Apo-Feno-Micro 200mg Cap Apo-Feno-Super 160mg Tab Apo-Fenofibrate 100mg Cap Apo-Ferrous Gluconate 300mg Tab Apo-Flavoxate 200mg Tab (Not a Benefit) Apo-Flecainide 50mg Tab Apo-Flecainide 100mg Tab Apo-Floctafenine 200mg Tab Apo-Floctafenine 400mg Tab Apo-Fluconazole 50mg Tab Apo-Fluconazole 100mg Tab Apo-Fluconazole-150 150mg Cap Apo-Flunarizine 5mg Cap Apo-Flunisolide 0.025% Nas Sp-25mL Pk Apo-Fluoxetine 10mg Cap (Not a Benefit) Apo-Fluoxetine 20mg Cap Apo-Fluphenazine 1mg Tab Apo-Fluphenazine 2mg Tab Apo-Fluphenazine 5mg Tab Apo-Flurazepam 15mg Cap Apo-Flurazepam 30mg Cap Apo-Flurbiprofen 50mg Tab Apo-Flurbiprofen 100mg Tab Apo-Flutamide 250mg Tab Apo-Fluticasone 50mcg/Actuation Nas Sp-120 Dose Pk (Not a Benefit) Apo-Fluvoxamine 50mg Tab Apo-Fluvoxamine 100mg Tab Apo-Folic 5mg Tab Apo-Fosinopril 10mg Tab Apo-Fosinopril 20mg Tab Apo-Furosemide 20mg Tab Apo-Furosemide 40mg Tab Apo-Gabapentin 100mg Cap Apo-Gabapentin 300mg Cap Apo-Gabapentin 400mg Cap Apo-Gemfibrozil 300mg Cap Apo-Gemfibrozil 600mg Tab (Not a Benefit) Apo-Gliclazide 80mg Tab Apo-Glimepiride 1mg Tab (Not a Benefit) Apo-Glimepiride 2mg Tab (Not a Benefit) Apo-Glimepiride 4mg Tab (Not a Benefit) Apo-Glyburide 2.5mg Tab
02243180 02239864 02246860 02225980 00545031 02244842 02275538 02275546 02244680 02244681 02237370 02237371 02241895 02246082 02239288 02216353 02216361 00405345 00410632 00405361 00521698 00521701 01912046 01912038 02238560 02294745 02231329 02231330 00426849 02266008 02266016 00396788 00362166 02244304 02244305 02244306 01979574 01979582 02245247 02295377 02295385 02295393 01913654
APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX
IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIB IIIB IIIA
7 98 98 98 71 54 90 90 127 127 5 5 279 311 199 13 158 168 168 168 178 178 128 128 45 18 158 159 300 109 109 188 188 150 150 150 99 7 261 21 21 21 262
IV.9
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Glyburide 5mg Tab Apo-Haloperidol 0.5mg Tab Apo-Haloperidol 1mg Tab Apo-Haloperidol 2mg Tab Apo-Haloperidol 5mg Tab Apo-Haloperidol 10mg Tab Apo-Hexa Tab (Not a Benefit) Apo-Hydralazine 10mg Tab Apo-Hydralazine 25mg Tab Apo-Hydralazine 50mg Tab Apo-Hydro 25 25mg Tab Apo-Hydro 50 50mg Tab Apo-Hydroxyquine 200mg Tab Apo-Hydroxyurea 500mg Cap Apo-Hydroxyzine 10mg Cap (Not a Benefit) Apo-Hydroxyzine 25mg Cap (Not a Benefit) Apo-Hydroxyzine 50mg Cap (Not a Benefit) Apo-Ibuprofen 200mg Tab Apo-Ibuprofen 300mg Tab Apo-Ibuprofen 400mg Tab Apo-Ibuprofen 600mg Tab Apo-Imipramine 10mg Tab Apo-Imipramine 25mg Tab Apo-Imipramine 50mg Tab Apo-Indapamide 1.25mg Tab Apo-Indapamide 2.5mg Tab Apo-Indomethacin 25mg Cap Apo-Indomethacin 50mg Cap Apo-Ipravent 0.03% Nasal Spray Apo-Ipravent Inhalation Solution 250mcg/mL Inh Sol-20mL Pk Apo-ISDN 5mg SL Tab Apo-ISDN 10mg Tab Apo-ISDN 30mg Tab Apo-ISMN 60mg ER Tab (Not a Benefit) Apo-Keto 50mg Cap Apo-Keto-E 50mg Ent Tab Apo-Keto-E 100mg Ent Tab Apo-Keto SR 200mg LA Tab Apo-Ketoconazole 200mg Tab Apo-Ketorolac 0.5% Oph Sol Apo-Labetalol 100mg Tab Apo-Labetalol 200mg Tab Apo-Lactulose Solution 666.7mg/mL O/L Apo-Lamotrigine 25mg Tab
IV.10
01913662 00396796 00396818 00396826 00396834 00463698 00701130 00441619 00441627 00441635 00326844 00312800 02246691 02247937 00646059 00646024 00646016 00441643 00441651 00506052 00585114 00360201 00312797 00326852 02245246 02223678 00611158 00611166 02246083 02126222 00670944 00441686 00441694 02272830 00790427 00790435 00842664 02172577 02237235 02245821 02243538 02243539 02242814 02245208
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
262 168 169 169 169 169 302 109 109 109 189 189 31 45 170 170 170 128 129 129 129 159 159 159 190 190 129 130 209 55 120 120 120 8 130 130 131 131 6 200 110 110 232 151
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Lamotrigine 100mg Tab Apo-Lamotrigine 150mg Tab Apo-Leflunomide 10mg Tab Apo-Leflunomide 20mg Tab Apo-Levetiracetam 250mg Tab (Not a Benefit) Apo-Levetiracetam 500mg Tab (Not a Benefit) Apo-Levetiracetam 750mg Tab (Not a Benefit) Apo-Levobunolol 0.5% Oph Sol Apo-Levocarb 100mg & 10mg Tab Apo-Levocarb 100mg & 25mg Tab Apo-Levocarb 250mg & 25mg Tab Apo-Levocarb CR 200mg & 50mg Tab Apo-Lisinopril 5mg Tab Apo-Lisinopril 5mg Tab Apo-Lisinopril 10mg Tab Apo-Lisinopril 10mg Tab Apo-Lisinopril 20mg Tab Apo-Lisinopril 20mg Tab Apo-Lisinopril-HCTZ 10mg & 12.5mg Tab Apo-Lisinopril/HCTZ 20mg & 12.5mg Tab Apo-Lithium Carbonate 150mg Cap Apo-Lithium Carbonate 150mg Cap Apo-Lithium Carbonate 300mg Cap Apo-Lithium Carbonate 300mg Cap Apo-Lithium Carbonate SR 300mg ER Tab (Not a Benefit) Apo-Loperamide 2mg Caplet Apo-Loratadine 10mg Tab (Not a Benefit) Apo-Lorazepam 0.5mg Tab Apo-Lorazepam 1mg Tab Apo-Lorazepam 2mg Tab Apo-Lovastatin 20mg Tab Apo-Lovastatin 40mg Tab Apo-Loxapine 5mg Tab Apo-Loxapine 10mg Tab Apo-Loxapine 25mg Tab Apo-Loxapine 50mg Tab Apo-Medroxy 2.5mg Tab Apo-Medroxy 5mg Tab Apo-Medroxy 10mg Tab Apo-Medroxy 100mg Tab Apo-Mefenamic 250mg Cap Apo-Mefloquine 250mg Tab (Not a Benefit) Apo-Megestrol 40mg Tab Apo-Megestrol 160mg Tab
02245209 02245210 02256495 02256509 02285924 02285932 02285940 02241574 02195933 02195941 02195968 02245211 02217481 09853685 02217503 09853960 02217511 09854010 02261979 02261987 02242837 09857532 02242838 09857540 02266695 02212005 02243880 00655740 00655759 00655767 02220172 02220180 02237651 02237652 02237653 02237654 02244726 02244727 02277298 02267640 02229452 02244366 02195917 02195925
IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA
151 151 312 312 11 11 11 210 312 313 313 313 111 110 111 110 111 111 112 112 176 176 177 177 14 217 1 170 170 170 99 99 177 177 177 177 273 273 273 273 131 4 48 48
IV.11
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Meloxicam 7.5mg Tab Apo-Meloxicam 15mg Tab Apo-Metformin 500mg Tab Apo-Methazolamide 50mg Tab Apo-Methoprazine 2mg Tab Apo-Methoprazine 5mg Tab Apo-Methoprazine 25mg Tab Apo-Methoprazine 50mg Tab Apo-Methotrexate 2.5mg Tab Apo-Methyldopa 125mg Tab Apo-Methyldopa 250mg Tab Apo-Methyldopa 500mg Tab Apo-Methylphenidate 10mg Tab Apo-Methylphenidate 20mg Tab (Not a Benefit) Apo-Methylphenidate SR 20mg LA Tab Apo-Metoclop 5mg Tab Apo-Metoclop 10mg Tab Apo-Metoprolol 50mg Tab Apo-Metoprolol 100mg Tab Apo-Metoprolol (Type L) 50mg Tab Apo-Metoprolol (Type L) 100mg Tab Apo-Metoprolol SR 100mg LA Tab Apo-Metoprolol SR 200mg LA Tab Apo-Metronidazole 500mg Cap Apo-Metronidazole 250mg Tab Apo-Midodrine 2.5mg Tab Apo-Midodrine 5mg Tab Apo-Minocycline 50mg Cap (Not a Benefit) Apo-Minocycline 100mg Cap (Not a Benefit) Apo-Mirtazapine 30mg Tab Apo-Misoprostol 100mcg Tab Apo-Misoprostol 200mcg Tab Apo-Moclobemide 100mg Tab Apo-Moclobemide 150mg Tab Apo-Moclobemide 300mg Tab Apo-Modafinil 100mg Tab (Not a Benefit) Apo-Nabumetone 500mg Tab (Not a Benefit) Apo-Nadol 40mg Tab Apo-Nadol 80mg Tab Apo-Nadol 160mg Tab Apo-Napro-Na 275mg Tab (Not a Benefit) Apo-Napro-Na DS 550mg Tab (Not a Benefit) Apo-Naproxen 125mg Tab Apo-Naproxen 250mg Tab
IV.12
02248973 02248974 02167786 02245882 02238403 02238404 02238405 02238406 02182963 00360252 00360260 00426830 02249324 02249332 02266687 00842826 00842834 00618632 00618640 00749354 00751170 02285169 02285177 02248562 00545066 02278677 02278685 02084090 02084104 02286629 02244022 02244023 02232148 02232150 02240456 02285398 02238639 00782505 00782467 00782475 00784354 01940309 00522678 00522651
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIB IIIB IIIA IIIA
132 132 262 211 179 179 179 179 49 113 113 113 178 15 178 235 235 90 90 90 90 90 90 31 31 191 191 2 3 160 236 236 160 160 160 15 9 91 91 91 10 10 133 133
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Naproxen 375mg Tab Apo-Naproxen 500mg Tab Apo-Naproxen EC 250mg Ent Tab (Not a Benefit) Apo-Naproxen EC 375mg Ent Tab (Not a Benefit) Apo-Naproxen EC 500mg Ent Tab (Not a Benefit) Apo-Naproxen SR 750mg SR Tab Apo-Nifed 5mg Cap Apo-Nifed 10mg Cap Apo-Nifed PA 10mg LA Tab Apo-Nifed PA 20mg LA Tab Apo-Nitrazepam 5mg Tab Apo-Nitrazepam 10mg Tab Apo-Nitrofurantoin 50mg Tab Apo-Nitrofurantoin 100mg Tab Apo-Nizatidine 150mg Cap Apo-Nizatidine 300mg Cap Apo-Norflox 400mg Tab Apo-Nortriptyline 10mg Cap Apo-Nortriptyline 25mg Cap Apo-Oflox 200mg Tab Apo-Oflox 300mg Tab Apo-Oflox 400mg Tab Apo-Ofloxacin 0.3% Oph Sol Apo-Omeprazole 20mg Cap Apo-Omeprazole Cap 20mg Apo-Ondansetron 4mg Tab Apo-Ondansetron 8mg Tab Apo-Orciprenaline 2mg/mL O/L Apo-Oxaprozin 600mg Tab (Not a Benefit) Apo-Oxazepam 10mg Tab Apo-Oxazepam 15mg Tab Apo-Oxazepam 30mg Tab Apo-Oxcarbazepine 150mg Tab (Not a Benefit) Apo-Oxcarbazepine 300mg Tab (Not a Benefit) Apo-Oxcarbazepine 600mg Tab (Not a Benefit) Apo-Oxybutynin 5mg Tab Apo-Pantoprazole 20mg Ent Tab (Not a Benefit) Apo-Pantoprazole 40mg Ent Tab Apo-Paroxetine 10mg Tab (Not a Benefit) Apo-Paroxetine 20mg Tab Apo-Paroxetine 30mg Tab Apo-Pen V-K 25mg/mL O/L Apo-Pen V-K 60mg/mL O/L (Not a Benefit) Apo-Pen V-K 300mg Tab (Not a Benefit)
00600806 00592277 02246699 02246700 02246701 02177072 00725110 00755907 02197448 02181525 02245230 02245231 00319511 00312738 02220156 02220164 02229524 02223511 02223538 02231529 02231531 02231532 02248398 09857285 02245058 02288184 02288192 02236783 02243661 00402680 00402745 00402737 02284294 02284308 02284316 02163543 02292912 02292920 02240907 02240908 02240909 00642223 00642231 00642215
IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA
133 133 10 10 10 132 91 91 113 113 179 179 32 32 236 236 38 161 161 39 39 39 198 237 237 228 228 62 10 171 171 171 12 12 12 58 19 240 13 161 161 13 13 13
IV.13
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Pentoxifylline 400mg SR Tab Apo-Perindopril 8mg Tab (Not a Benefit) Apo-Perphenazine 2mg Tab Apo-Perphenazine 4mg Tab Apo-Perphenazine 8mg Tab Apo-Perphenazine 16mg Tab Apo-Pimozide 2mg Tab Apo-Pimozide 4mg Tab Apo-Pindol 5mg Tab Apo-Pindol 10mg Tab Apo-Pindol 15mg Tab Apo-Pioglitazone 15mg Tab Apo-Pioglitazone 30mg Tab Apo-Pioglitazone 45mg Tab Apo-Piroxicam 10mg Cap Apo-Piroxicam 20mg Cap Apo-Pramipexole 0.5mg Tab (Not a Benefit) Apo-Pramipexole 0.25mg Tab Apo-Pramipexole 1mg Tab Apo-Pramipexole 1.5mg Tab Apo-Pravastatin 10mg Tab Apo-Pravastatin 20mg Tab Apo-Pravastatin 40mg Tab Apo-Prazo 1mg Tab Apo-Prazo 2mg Tab Apo-Prazo 5mg Tab Apo-Prednisone 1mg Tab Apo-Prednisone 5mg Tab Apo-Prednisone 50mg Tab Apo-Primidone 125mg Tab Apo-Primidone 250mg Tab Apo-Prochlorazine 5mg Tab Apo-Prochlorazine 10mg Tab Apo-Propafenone 150mg Tab Apo-Propafenone 300mg Tab Apo-Propranolol 10mg Tab Apo-Propranolol 20mg Tab Apo-Propranolol 40mg Tab Apo-Propranolol 80mg Tab Apo-Propranolol 120mg Tab Apo-Ramipril Cap 1.25mg Apo-Ramipril Cap 2.5mg Apo-Ramipril Cap 5mg Apo-Ramipril Cap 10mg
IV.14
02230090 02289296 00335134 00335126 00335118 00335096 02245432 02245433 00755877 00755885 00755893 02302942 02302950 02302977 00642886 00642894 02292386 02292378 02292394 02292408 02243506 02243507 02243508 00882801 00882828 00882836 00598194 00312770 00550957 00399310 00396761 00886440 00886432 02243324 02243325 00402788 00663719 00402753 00402761 00504335 02251515 02251531 02251574 02251582
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
81 114 172 172 172 172 172 172 114 114 115 263 263 263 134 134 16 181 182 182 100 100 100 115 115 115 253 253 253 152 152 173 173 92 92 92 93 93 93 93 116 116 117 117
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Ranitidine 15mg/mL Oral Sol Apo-Ranitidine 150mg Tab Apo-Ranitidine 300mg Tab Apo-Risperidone 1mg/mL O/L Apo-Risperidone 0.25mg Tab Apo-Risperidone 0.5mg Tab Apo-Risperidone 1mg Tab Apo-Risperidone 2mg Tab Apo-Risperidone 3mg Tab Apo-Risperidone 4mg Tab Apo-Salvent 100mcg/Metered Dose Inh-200 Dose Pk (Not a Benefit) Apo-Salvent 2mg Tab Apo-Salvent 4mg Tab Apo-Salvent CFC Free 100mcg/Metered Dose Inh-200 Dose Pk Apo-Salvent Ipravent Sterules 500mcg/2.5mg/2.5mL Inh Sol-2.5mL Pk Apo-Salvent Sterule 1mg/mL Inh Sol-2.5mL Pk Apo-Salvent Sterule 2mg/mL Inh Sol-2.5mL Pk Apo-Selegiline 5mg Tab Apo-Sertraline 25mg Cap Apo-Sertraline 50mg Cap Apo-Sertraline 100mg Cap Apo-Simvastatin 5mg Tab Apo-Simvastatin 10mg Tab Apo-Simvastatin 20mg Tab Apo-Simvastatin 40mg Tab Apo-Simvastatin 80mg Tab Apo-Sotalol 80mg Tab (Not a Benefit) Apo-Sotalol 160mg Tab Apo-Sucralfate 1g Tab Apo-Sulfatrim 400mg & 80mg Tab Apo-Sulfatrim-DS 800mg & 160mg Tab Apo-Sulfinpyrazone 200mg Tab Apo-Sulin 150mg Tab Apo-Sulin 200mg Tab Apo-Sumatriptan 50mg Tab (Not a Benefit) Apo-Sumatriptan 100mg Tab (Not a Benefit) Apo-Tamox 10mg Tab Apo-Tamox 20mg Tab Apo-Temazepam 15mg Cap Apo-Temazepam 30mg Cap Apo-Terazosin 1mg Tab Apo-Terazosin 2mg Tab Apo-Terazosin 5mg Tab
02280833 00733059 00733067 02280396 02282119 02282127 02282135 02282143 02282151 02282178 00790419 02146843 02146851 02245669 02266393 02231488 02231678 02230641 02238280 02238281 02238282 02247011 02247012 02247013 02247014 02247015 02210428 02167794 02125250 00445274 00445282 00441767 00778354 00778362 02268388 02268396 00812404 00812390 02225964 02225972 02234502 02234503 02234504
APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA
242 242 243 174 174 174 175 175 175 175 66 66 66 66 57 63 64 317 162 162 162 101 101 102 102 102 7 94 243 40 40 192 135 135 17 17 49 49 180 180 118 118 118
IV.15
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Terazosin 10mg Tab Apo-Terbinafine 250mg Tab (Not a Benefit) Apo-Tetra 250mg Cap Apo-Tiaprofenic 200mg Tab Apo-Tiaprofenic 300mg Tab Apo-Ticlopidine 250mg Tab Apo-Timol 5mg Tab Apo-Timol 10mg Tab Apo-Timol 20mg Tab Apo-Timop 0.25% Oph Sol Apo-Timop 0.5% Oph Sol Apo-Tizanidine 4mg Tab (Not a Benefit) Apo-Topiramate 25mg Tab Apo-Topiramate 100mg Tab Apo-Topiramate 200mg Tab Apo-Trazodone 50mg Tab Apo-Trazodone 100mg Tab Apo-Trazodone D 150mg Tab Apo-Triazide 25mg & 50mg Tab Apo-Triazo 0.125mg Tab Apo-Triazo 0.25mg Tab Apo-Trifluoperazine 1mg Tab Apo-Trifluoperazine 2mg Tab Apo-Trifluoperazine 5mg Tab Apo-Trifluoperazine 10mg Tab Apo-Trihex 2mg Tab Apo-Trihex 5mg Tab Apo-Trimebutine 100mg Tab (Not a Benefit) Apo-Trimebutine 200mg Tab (Not a Benefit) Apo-Trimethoprim 100mg Tab Apo-Trimethoprim 200mg Tab Apo-Trimip 75mg Cap Apo-Trimip 12.5mg Tab Apo-Trimip 25mg Tab Apo-Trimip 50mg Tab Apo-Trimip 100mg Tab Apo-Tryptophan 500mg Cap (Not a Benefit) Apo-Tryptophan 500mg Tab (Not a Benefit) Apo-Tryptophan 1g Tab (Not a Benefit) Apo-Valproic 250mg Cap Apo-Valproic 50mg/mL O/L Apo-Verap 80mg Tab Apo-Verap 120mg Tab Apo-Verap SR 120mg LA Tab (Not a Benefit)
IV.16
02234505 02239893 00580929 02136112 02136120 02237701 00755842 00755850 00755869 00755826 00755834 02259893 02279614 02279630 02279649 02147637 02147645 02147653 00441775 00808563 00808571 00345539 00312754 00312746 00326836 00545058 00545074 02245663 02245664 02243116 02243117 02070987 00740799 00740802 00740810 00740829 02248540 02248538 02248539 02238048 02238370 00782483 00782491 02246893
IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIB
118 2 14 135 135 320 94 94 94 214 214 5 153 153 153 163 163 163 190 180 181 176 176 176 176 59 59 5 5 40 40 163 163 163 164 164 14 14 14 154 154 94 95 8
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Apo-Verap SR 180mg LA Tab Apo-Verap SR 240mg LA Tab Apo-Warfarin 1mg Tab Apo-Warfarin 2mg Tab Apo-Warfarin 2.5mg Tab Apo-Warfarin 3mg Tab Apo-Warfarin 4mg Tab Apo-Warfarin 5mg Tab Apo-Warfarin 10mg Tab Apo-Zopiclone 5mg Tab (Not a Benefit) Apo-Zopiclone 7.5mg Tab (Not a Benefit) Apresoline 20mg/mL Inj Sol-1mL Pk Apresoline 10mg Tab (Not a Benefit) Apresoline 25mg Tab (Not a Benefit) Apresoline 50mg Tab (Not a Benefit) Aralen 250mg Tab (Not a Benefit) Aranesp 150mcg/0.3mL Pref Syr-0.3mL Pk Aranesp 200mcg/0.4mL Pref Syr-0.4mL Pk Aranesp 300mcg/0.6mL Pref Syr-0.6mL Pk Aranesp 500mcg/1.0mL Pref Syr-1.0mL Pk Arava 10mg Tab Arava 20mg Tab Aredia 3mg/mL Inj Sol-10mL Vial (Not a Benefit) Aredia 6mg/mL Inj Sol-10mL Vial (Not a Benefit) Aredia 9mg/mL Inj Sol-10mL Vial (Not a Benefit) Aricept 5mg Tab Aricept 10mg Tab Arimidex 1mg Tab Aristocort R 0.1% Cr Aristocort R 0.1% Oint Arixtra 2.5mg Inj-0.5mL Pk Aromasin 25mg Tab Artane 2mg Tab (Not a Benefit) Artane 5mg Tab (Not a Benefit) Arthrotec 50 50mg & 200mcg Tab Arthrotec 75 75mg & 200mcg Tab ASA 325mg Tab (Not a Benefit) Asacol 400mg Tab Asacol 800mg Tab ASCORBIC ACID Atacand 4mg Tab Atacand 8mg Tab Atacand 16mg Tab Atacand Plus 16mg/12.5mg Tab
02246894 02246895 02242924 02242925 02242926 02245618 02242927 02242928 02242929 02245077 02218313 00723754 00005525 00005533 00005541 02017539 02246360 09857185 09857186 09857187 02241888 02241889 02059762 02059770 02059789 02232043 02232044 02224135 02194058 02194031 02245531 02242705 00015040 00015059 01917056 02229837 00036145 01997580 02267217 02239090 02239091 02239092 02244021
APX APX APX APX APX APX APX APX APX APX APX STE NOV STE NOV SAO AMG AMG AMG AMG SAV SAV NOV NOV NOV PFI PFI AZC VAE VAE GSK PFI LED LED PFI PFI RPR PGP PGP AZC AZC AZC AZC
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
119 119 77 77 77 77 77 78 78 15 16 109 109 109 109 31 79 79 79 79 312 312 23 23 23 51 51 41 291 291 74 44 59 59 126 126 123 229 229 301 103 103 103 103
IV.17
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Atarax 10mg Cap (Not a Benefit) Atarax 25mg Cap (Not a Benefit) Atarax 50mg Cap (Not a Benefit) Atasol 80mg/mL O/L (Not a Benefit) Atasol 325mg Tab (Not a Benefit) Atasol Forte 500mg Tab (Not a Benefit) Atasol-15 15mg Tab (Not a Benefit) Atasol-30 30mg Tab (Not a Benefit) ATAZANAVIR SULFATE ATENOLOL ATENOLOL & CHLORTHALIDONE Ativan 0.5mg Tab Ativan 1mg Tab Ativan 2mg Tab ATORVASTATIN CALCIUM Atromid-S 500mg Cap (Not a Benefit) Atropine 1% Oph Sol (Not a Benefit) ATROPINE SULFATE Atropine Sulfate 1% Oph Oint-3.5g Pk Atrovent 250mcg/mL Inh Sol-20mL Pk (Not a Benefit) Atrovent 0.03% Nasal Spray Atrovent HFA 20mcg/Metered Dose Inh-200 Dose Pk Atrovent UDV 125mcg/mL Inh Sol-2mL UDV Pk (Not a Benefit) Atrovent UDV 250mcg/mL Inh Sol-2mL UDV Pk (Not a Benefit) AURANOFIN Avalide 150 & 12.5mg Tab Avalide 300 & 12.5mg Tab Avalide 300 & 25mg Tab Avandia 2mg Tab Avandia 4mg Tab Avandia 8mg Tab Avapro 75mg Tab Avapro 150mg Tab Avapro 300mg Tab Avelox 400mg Tab Aventyl 10mg Cap Aventyl 25mg Cap Aviane 21 20mcg & 100mcg Tab-21 Pk Aviane 28 20mcg & 100mcg Tab-28 Pk Avodart 0.5mg Cap Axid 150mg Cap Axid 300mg Cap AZATHIOPRINE AZITHROMYCIN
IV.18
00024376 00024384 00024392 00631353 00293482 00013668 00293504 00293512
PFI PFI PFI HOR HOR HOR HOR HOR
02041413 02041421 02041448 00002038 01948598 00252484 00731439 02163705 02247686 02026759 01950681 02241818 02241819 02280213 02241112 02241113 02241114 02237923 02237924 02237925 02242965 00015229 00015237 02298538 02298546 02247813 00778338 00778346
WAY WAY WAY AYE NOV ALC BOE BOE BOE BOE BOE SAV SAV SAV GSK GSK GSK SAV SAV SAV BAY PHE PHE BAR BAR GSK PHE PHE
170 170 170 145 145 146 136 136 23 84 103 170 170 170 96 97 203 203 203 55 209 57 56 56 245 110 110 110 264 264 264 110 110 110 38 161 161 271 271 309 236 236 305 7
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
IIIB IIIA IIIA 00272469 HLR IIIA 00272485 HLR IIIA 00371823 HLR IIIA 02239757 GSK IIIA 01916947 GSK IIIA IIIA IIIA IIIA Beconase Aqueous 50mcg Nas Sp-200 Dose Pk (Not a Benefit) 02213702 GLW IIIA Benadryl 25mg Cap (Not a Benefit) 00022756 PDA IIIA Benadryl 50mg Cap (Not a Benefit) 00022764 PDA IIIA BENAZEPRIL IIIA Benemid 500mg Tab (Not a Benefit) 00016616 MSD IIIA Benoxyl 5% Lot 00236063 STI IIIA Benoxyl 10% Lot 00370568 STI IIIA Benoxyl 20% Lot 00187585 STI IIIA Benuryl 500mg Tab 00294926 VAL IIIA Benzac W5 5% Gel 01925180 GAC IIIA BenzaClin 1% & 5% Top Gel 02248472 SAV IIIA BENZOYL PEROXIDE IIIA BENZOYL PEROXIDE IN ACETONE-CONTAINING GEL IIIA BENZOYL PEROXIDE IN ALCOHOL-CONTAINING GEL IIIA BENZOYL PEROXIDE IN WATER-BASED GEL IIIA BENZTROPINE MESYLATE IIIA BENZYDAMINE HCL IIIA Betaderm 0.05% Cr (Not a Benefit) 00716618 TAR IIIA Betaderm 0.1% Cr (Not a Benefit) 00716626 TAR IIIA Betaderm 0.05% Oint 00716642 TAR IIIA Betaderm 0.1% Oint 00716650 TAR IIIA Betaderm 0.1% Scalp Lot 00716634 TAR IIIA Betadine 10% Top Sol (Not a Benefit) 00158348 PFP IIIA Betadine 10% Vag Gel (Not a Benefit) 00026034 PFP IIIA Betadine 10% Vag Sol (Not a Benefit) 00026093 PFP IIIA Betagan 0.5% Oph Sol 00637661 ALL IIIA BETAHISTINE DIHYDROCHLORIDE IIIB Betaloc 50mg Tab 00402605 AZC IIIA Betaloc 100mg Tab 00402540 AZC IIIA BETAMETHASONE DIPROPIONATE IIIA BETAMETHASONE DIPROPIONATE IN A BASE CONTAINING PROPYLENE GLYCOL IIIA BETAMETHASONE DIPROPIONATE IN PROPYLENE GLYCOL BASE IIIA BETAMETHASONE DISODIUM PHOSPHATE IIIA BETAMETHASONE VALERATE IIIA Azopt 1% Oph Susp BACLOFEN Bactrim 400mg & 80mg Tab (Not a Benefit) Bactrim Sugar Free 40mg & 8mg/mL O/L (Not a Benefit) Bactrim-DS 800mg & 160mg Tab (Not a Benefit) Bactroban 2% Cr Bactroban 2% Oint BECLOMETHASONE DIPROPIONATE 02238873 ALC
2 206 69 40 40 40 277 277 198 249 285 198 1 1 103 192 292 292 292 192 293 277 292 292 293 293 54 201 286 286 286 286 286 284 284 284 210 8 90 90 285 285 286 229 286
IV.19
DIN/PIN
MFR
PART
PAGE
BETAXOLOL HCL BETHANECHOL CHLORIDE Betnesol 5mg/100mL Enema-100mL Pk Betnovate 0.1% Cr (Not a Benefit) Betnovate 0.1% Lot (Not a Benefit) Betnovate 0.1% Oint (Not a Benefit) Betnovate-1/2 0.05% Cr (Not a Benefit) Betnovate-1/2 0.05% Lot (Not a Benefit) Betnovate-1/2 0.05% Oint (Not a Benefit) Betoptic S 0.25% Oph Susp BEZAFIBRATE Bezalip 400mg SR Tab Bezalip 200mg Tab (Not a Benefit) Biaxin 125mg/5mL Ped Gran Biaxin 250mg/5mL Susp Biaxin 250mg Tab Biaxin 500mg Tab (Not a Benefit) Biaxin XL 500mg ER Tab BICALUTAMIDE BIMATOPROST BISACODYL BISOPROLOL FUMARATE Blocadren 5mg Tab (Not a Benefit) Blocadren 10mg Tab (Not a Benefit) Blocadren 20mg Tab (Not a Benefit) Bonamine 25mg Tab Bonefos 400mg Cap Botox 100U/Vial Pd Inj-100U Vial Pk BOTULINUM TOXIN TYPE A Brevicon 0.035mg & 0.5mg Tab-21 Pk Brevicon 0.035mg & 0.5mg Tab-28 Pk Brevicon 1/35 0.035mg & 1mg Tab-21 Pk Brevicon 1/35 0.035mg & 1mg Tab-28 Pk Bricanyl Turbuhaler 0.5mg/Dose Inh-200 Dose Pk BRIMONIDINE BRIMONIDINE TARTRATE & TIMOLOL MALEATE BRINZOLAMIDE BROMAZEPAM BROMOCRIPTINE BUDESONIDE BUDESONIDE & FORMOTEROL FUMARATE DIHYDRATE BUPROPION HCL BUSERELIN ACETATE
IV.20
02060884 00011924 02100193 00012386 00011916 02100185 00012378 01908448 02083523 02084082 02146908 02244641 01984853 02126710 02244756
SQI GLA SHI GLA GLA RBT GLA ALC HLR HLR ABB ABB ABB ABB ABB
00353914 00353922 00495611 00220442 01984845 01981501 02187086 02187094 02189054 02189062 00786616
FRS FRS FRS PFI BAY ALL PFI PFI PFI PFI AZC
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
204 51 229 286 286 286 286 286 286 204 96 96 96 8 8 8 2 8 41 204 218 85 94 94 94 227 306 305 305 271 272 271 272 68 205 206 206 165 305 199 250 59 155 42
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Buspar 10mg Tab (Not a Benefit) BUSPIRONE HYDROCHLORIDE BUSULFAN C.E.S. 0.625mg Tab C.E.S. 1.25mg Tab CABERGOLINE Caduet 5mg/10mg Tab Caduet 5mg/20mg Tab Caduet 5mg/40mg Tab Caduet 5mg/80mg Tab Caduet 10mg/10mg Tab Caduet 10mg/20mg Tab Caduet 10mg/40mg Tab Caduet 10mg/80mg Tab Cafergot 1mg & 100mg Tab Calcimar 400IU/2mL Inj Sol-2mL Pk CALCIPOTRIOL CALCIPOTRIOL & BETAMETHASONE DIPROPIONATE CALCITONIN (SALMON SYNTHETIC) CALCITRIOL CALCIUM CARBONATE CALCIUM GLUCONATE Calcium Gluconate Eq To 60mg Elemental Calcium Tab (Not a Benefit) Calcium Gluconate Eq To 60mg Elemental Calcium Tab (Not a Benefit) Calcium Gluconate Eq To 60mg Elemental Calcium Tab (Not a Benefit) CALCIUM LACTATE Calcium Lactate Eq To 84mg Elemental Calcium Tab (Not a Benefit) Calcium Lactate Eq To 84mg Elemental Calcium Tab (Not a Benefit) Calcium-250 Eq To 250mg Elemental Calcium Tab (Not a Benefit) Calcium-500 Eq To 500mg Elemental Calcium Tab (Not a Benefit) Caltine 100 100IU/mL Inj Sol-1mL Pk CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL & HYDROCHLOROTHIAZIDE Canesten 1 Comfortab Combi-Pak 500mg & 1% Tab & Cr Canesten 1% Topical Cream 10mg/g Cr Canesten 3 Cream 20mg/g Vag Cr-App Canesten 6 Cream 10mg/g Vag Cr-App CAPECITABINE Capoten 12.5mg Tab
00603821
BQU
00265470 00265489 02273233 02273241 02273268 02273276 02273284 02273292 02273306 02273314 00176095 01926691
VAL VAL PFI PFI PFI PFI PFI PFI PFI PFI NOV SAV
IIIB IIIB IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
15 15 42 258 258 23 95 95 95 95 95 95 95 95 69 269 295 287 269 22 301 185 185 185 185 185 185 185 185 185 185 269 103 103 278 278 278 278 42 104
IV.21
00179698 00241717 00441473
SDR RPR NOP
00021253 00179671 00645958 00645923 02007134
NOP SDR NOP NOP FEI
02264102 02150867 02150905 02150891 00695661
BAY BAY BAY BAY BQU
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Capoten 25mg Tab Capoten 50mg Tab Capoten 100mg Tab CAPTOPRIL Captopril 12.5mg Tab Captopril 25mg Tab Captopril 50mg Tab Captopril 100mg Tab CARBACHOL Carbachol 2mg Tab CARBAMAZEPINE Carbolith 150mg Cap Carbolith 300mg Cap Cardizem 30mg Tab Cardizem 60mg Tab Cardizem CD 120mg LA Cap Cardizem CD 180mg LA Cap Cardizem CD 240mg LA Cap Cardizem CD 300mg LA Cap Cardizem-SR 60mg LA Cap (Not a Benefit) Cardizem-SR 90mg LA Cap (Not a Benefit) Cardizem-SR 120mg LA Cap (Not a Benefit) Cardura-1 1mg Tab Cardura-2 2mg Tab Cardura-4 4mg Tab CARVEDILOL Casodex 50mg Tab Catapres 0.1mg Tab Catapres 0.2mg Tab Ceclor 250mg Cap Ceclor 500mg Cap Ceclor 25mg/mL Oral Susp Ceclor 50mg/mL Oral Susp Ceclor 375mg/5mL Oral Susp Cedocard SR 20mg LA Tab (Not a Benefit) CeeNU 10mg Cap CeeNU 40mg Cap CeeNU 100mg Cap CEFACLOR CEFADROXIL CEFIXIME Cefoxitin for Injection 1g/Vial Inj Pd-1 Vial Pk (Not a Benefit) Cefoxitin for Injection 2g/Vial Inj Pd-1 Vial Pk (Not a Benefit)
IV.22
00546283 00546291 00546305 02242788 02242789 02242790 02242791
BQU BQU BQU ZYN ZYN ZYN ZYN
00885568 00461733 00236683 02097370 02097389 02097249 02097257 02097265 02097273 02097214 02097222 02097230 01958100 01958097 01958119 02184478 00259527 00291889 00465186 00465194 00465208 00465216 00832804 00740721 00360430 00360422 00360414
GLA VAL VAL BIO BIO BIO BIO BIO BIO CRY CRY CRY AZC AZC AZC AZC BOE BOE PHE PHE PHE PHE PHE PMS BQU BQU BQU
02291711 02291738
ORC ORC
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB
104 104 104 104 104 104 104 104 51 201 51 146 176 177 89 89 87 88 88 88 88 88 88 106 106 106 86 41 105 105 14 14 14 15 15 120 48 48 48 14 15 15 3 3
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
CEFOXITIN SODIUM CEFPROZIL Ceftin 125mg/5mL Susp Ceftin 250mg Tab Ceftin 500mg Tab Ceftriaxone 1g/Vial Inj Pd-1 Vial Pk Ceftriaxone 2g/Vial Inj Pd-1 Vial Pk CEFTRIAXONE DISODIUM Ceftriaxone for Injection USP 1g/Vial Inj Pd-1 Vial Pk Ceftriaxone for Injection USP 2g/Vial Inj Pd-1 Vial Pk Ceftriaxone Sodium for Injection 1g/Vial Inj Pd-1 Vial Pk Ceftriaxone Sodium for Injection, BP 0.25g/Vial Inj Pd-1 Vial Pk Ceftriaxone Sodium for Injection, BP 1g/Vial Inj Pd-1 Vial Pk Ceftriaxone Sodium for Injection, BP 2g/Vial Inj Pd-1 Vial Pk CEFUROXIME AXETIL Cefzil 125mg/5mL Oral Susp Cefzil 250mg/5mL Oral Susp Cefzil 250mg Tab Cefzil 500mg Tab Celebrex 100mg Cap Celebrex 200mg Cap CELECOXIB Celestoderm-V 0.1% Cr (Not a Benefit) Celestoderm-V 0.1% Oint (Not a Benefit) Celestoderm-V/2 0.05% Cr (Not a Benefit) Celestoderm-V/2 0.05% Oint (Not a Benefit) Celexa 20mg Tab Celexa 40mg Tab CellCept 200mg/mL Pd for Oral Susp-175mL Pk CellCept 250mg SG Cap CellCept 500mg Tab Celontin 300mg Cap CEPHALEXIN MONOHYDRATE Cephulac 666.7mg/mL O/L (Not a Benefit) Ceporex 250mg Cap (Not a Benefit) Ceporex 500mg Cap (Not a Benefit) Cerubidine Inj Pd-20mg Pk Cesamet 0.5mg Cap Cesamet 1mg Cap Cetamide 10% Oph Oint-3.5g Pk CETIRIZINE HYDROCHLORIDE CHLORAMBUCIL CHLORAMPHENICOL CHLORDIAZEPOXIDE
02212307 02212277 02212285 02292270 02292289 02292874 02292882 02287633 02250276 02250292 02250306 02163675 02163683 02163659 02163667 02239941 02239942 00027901 00028363 00027898 00028355 02239607 02239608 02242145 02192748 02237484 00022802 02091925 00253154 00253146 01926683 02256193 00548375 00252522
GSK GSK GSK SDZ SDZ ORC ORC NOP MAY MAY MAY BQU BQU BQU BQU PFI PFI SCH SCH SCH SCH VLH VLH HLR HLR HLR ERF MRR GLA GLA ERF VAL VAL ALC
IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA
3 15 16 16 16 16 16 16 16 16 16 16 16 16 16 15 15 15 16 124 124 124 286 286 286 286 156 156 314 314 314 151 17 232 17 17 44 227 227 197 1 43 195 165
IV.23
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
CHLOROQUINE PHOSPHATE CHLORPROMAZINE CHLORTHALIDONE Choledyl 10mg/mL O/L (Not a Benefit) Choledyl 20mg/mL O/L CHOLESTYRAMINE RESIN CICLESONIDE CILAZAPRIL CILAZAPRIL & HYDROCHLOROTHIAZIDE CIMETIDINE Cipro 10g/100mL Oral Susp Cipro 250mg Tab Cipro 500mg Tab Cipro 750mg Tab Cipro XL 500mg ER Tab Cipro XL 1000mg ER Tab CIPROFLOXACIN CIPROFLOXACIN HCL & CIPROFLOXACIN BASE CITALOPRAM HYDROBROMIDE CLADRIBINE CLARITHROMYCIN
00476390 00476366
PDA ERF
02237514 02155958 02155966 02155974 02247916 02251787
BAY BAY BAY BAY BAY BAY
Claritin 10mg Tab (Not a Benefit) 00782696 Clarus 10mg Cap 02257955 Clarus 40mg Cap 02257963 Clasteon 400mg Cap 02245828 Clavulin 25mg & 6.25mg/mL O/L 01916882 Clavulin 50mg & 12.5mg/mL O/L 01916874 Clavulin 250mg & 125mg Tab 01916866 Clavulin 500mg & 125mg Tab 01916858 Clavulin (BID) 200mg & 28.5mg/5mL Susp 02238831 Clavulin (BID) 400mg & 57mg/5mL Susp 02238830 Clavulin (BID) 875mg & 125mg Tab 02238829 CLINDAMYCIN HCL CLINDAMYCIN PALMITATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE & BENZOYL PEROXIDE Clindamycin Phosphate Injection USP 300mg/2mL Inj Sol-2mL Pk 02230540 Clindoxyl 1% & 5% Gel 02243158 Clinoril 150mg Tab (Not a Benefit) 00456888 Clinoril 200mg Tab (Not a Benefit) 00432369 CLOBAZAM CLOBETASOL PROPIONATE CLOBETASONE BUTYRATE
IV.24 ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX
SCP PRE PRE ORY GSK GSK GSK GSK GSK GSK GSK
SDZ STI FRS FRS
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
31 166 188 299 299 96 251 104 105 230 33 33 33 33 35 35 33 35 156 43 8 2 1 296 296 306 11 11 12 12 11 11 12 17 18 18 277 18 277 135 135 148 287 288
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
CLODRONATE DISODIUM CLODRONATE DISODIUM TETRAHYDRATE CLOFIBRATE CLOMIPRAMINE HCL CLONAZEPAM CLONIDINE HCL CLOPIDOGREL BISULFATE CLORAZEPATE DIPOTASSIUM Clotrimaderm 10mg/g Cr Clotrimaderm Vaginal Cream 10mg/g Vag Cr-App Clotrimaderm Vaginal Cream 20mg/g Vag Cr-App CLOTRIMAZOLE CLOXACILLIN CLOZAPINE Clozaril 25mg Tab (Not a Benefit) Clozaril 100mg Tab (Not a Benefit) Co Alendronate 40mg Tab (Not a Benefit) Co-Alendronate 70mg Tab Co-Atenolol 50mg Tab Co-Atenolol 100mg Tab Co-Azithromycin 250mg Tab Co Azithromycin 600mg Tab (Not a Benefit) Co Bicalutamide 50mg Tab Co Cabergoline 0.5mg Tab (Not a Benefit) Co Cilazapril 2.5mg Tab Co Cilazapril 5mg Tab Co-Ciprofloxacin 250mg Tab Co-Ciprofloxacin 500mg Tab Co-Ciprofloxacin 750mg Tab Co-Citalopram 20mg Tab Co-Citalopram 40mg Tab Co-Clomipramine 10mg Tab Co-Clomipramine 25mg Tab Co-Clomipramine 50mg Tab Co Clonazepam 0.5mg Tab Co Clonazepam 2mg Tab Co Enalapril 2.5mg Tab Co Enalapril 5mg Tab Co Enalapril 10mg Tab Co Enalapril 20mg Tab Co Etidrocal 400mg/500mg Tab-90 Tablets Kit Co-Etidronate 200mg Tab Co Fluconazole 50mg Tab
00812382 00812366 00812374
TAR TAR TAR
00894737 00894745 02248102 02258110 02255545 02255553 02255340 02256088 02274337 02301407 02285215 02285223 02247339 02247340 02247341 02248050 02248051 02244816 02244817 02244818 02270641 02270676 02291878 02291886 02291894 02291908 02263866 02248686 02281260
NOV NOV COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB
IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
306 306 97 156 148 105 7 307 166 278 278 278 278 13 14 14 14 23 303 84 85 8 2 41 23 105 105 33 33 33 156 156 156 156 156 148 148 106 107 107 107 310 309 5
IV.25
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Co Fluconazole 100mg Tab Co-Fluoxetine 20mg Cap Co-Fluvoxamine 50mg Tab Co-Fluvoxamine 100mg Tab Co-Gabapentin 100mg Cap Co-Gabapentin 300mg Cap Co-Gabapentin 400mg Cap Co Glimepiride 1mg Tab (Not a Benefit) Co Glimepiride 2mg Tab (Not a Benefit) Co Glimepiride 4mg Tab (Not a Benefit) Co Levetiracetam 250mg Tab (Not a Benefit) Co Levetiracetam 500mg Tab (Not a Benefit) Co Levetiracetam 750mg Tab (Not a Benefit) Co Lisinopril 5mg Tab Co Lisinopril 10mg Tab Co Lisinopril 20mg Tab Co-Lovastatin 20mg Tab Co-Lovastatin 40mg Tab Co-Meloxicam 7.5mg Tab Co-Meloxicam 15mg Tab Co-Metformin 500mg Tab Co Metformin 850mg Tab (Not a Benefit) Co Mirtazapine 30mg Tab Co Norfloxacin 400mg Tab Co Paroxetine 10mg Tab (Not a Benefit) Co-Paroxetine 20mg Tab Co-Paroxetine 30mg Tab Co Pioglitazone 15mg Tab Co Pioglitazone 30mg Tab Co Pioglitazone 45mg Tab Co Pravastatin 10mg Tab Co Pravastatin 20mg Tab Co Pravastatin 40mg Tab Co Ramipril Cap 1.25mg Co Ramipril Cap 2.5mg Cap Co Ramipril Cap 5mg Cap Co Ramipril Cap 10mg Cap Co-Ranitidine 150mg Tab Co-Ranitidine 300mg Tab Co Risperidone 0.25mg Tab Co Risperidone 0.5mg Tab Co Risperidone 1mg Tab Co Risperidone 2mg Tab Co Risperidone 3mg Tab
IV.26
02281279 02242178 02255529 02255537 02256142 02256150 02256169 02274248 02274256 02274272 02274183 02274191 02274205 02271443 02271451 02271478 02248572 02248573 02250012 02250020 02257726 02257734 02274361 02269627 02262746 02262754 02262762 02302861 02302888 02302896 02248182 02248183 02248184 02295482 02295490 02295504 02295512 02248570 02248571 02282585 02282593 02282607 02282615 02282623
COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
5 158 158 159 150 150 150 21 21 21 11 11 11 111 111 111 99 99 132 132 262 21 160 38 13 161 161 263 263 263 100 100 100 116 116 117 117 242 243 174 174 175 175 175
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Co Risperidone 4mg Tab Co Sertraline 25mg Cap Co Sertraline 50mg Cap Co Sertraline 100mg Cap Co-Simvastatin 5mg Tab Co-Simvastatin 10mg Tab Co-Simvastatin 20mg Tab Co-Simvastatin 40mg Tab Co-Simvastatin 80mg Tab Co Sotalol 80mg Tab (Not a Benefit) Co Sotalol 160mg Tab Co Sumatriptan 25mg Tab (Not a Benefit) Co Sumatriptan 50mg Tab (Not a Benefit) Co Sumatriptan 100mg Tab (Not a Benefit) Co-Temazepam 15mg Cap Co-Temazepam 30mg Cap Co Terbinafine 250mg Tab (Not a Benefit) Co Topiramate 25mg Tab Co Topiramate 100mg Tab Co Topiramate 200mg Tab Co Venlafaxine XR 37.5mg ER Cap Co Venlafaxine XR 75mg ER Cap Co Venlafaxine XR 150mg ER Cap Co Zopiclone 5mg Tab (Not a Benefit) Co Zopiclone 7.5mg Tab (Not a Benefit) Codeine 15mg Tab Codeine Contin 50mg CR Tab Codeine Contin 100mg CR Tab Codeine Contin 150mg CR Tab Codeine Contin 200mg CR Tab CODEINE PHOSPHATE CODEINE SULFATE TRIHYDRATE & MONOHYDRATE Cogentin 2mg Tab (Not a Benefit) Colace 100mg Cap Colace 4mg/mL O/L Colace 10mg/mL O/L Colestid Orange Gran-7.5g Pk Colestid Regular Gran-5g Pk COLESTIPOL HCL Colyte Pd-4L Pk (Not a Benefit) Combigan 0.2% & 0.5% Oph-Sol 5mL Pk Combivent 20mcg/100mcg/md Aero Inh Combivent UDV 500mcg/2.5mg/2.5mL Inh Sol-2.5mL Pk Combivir 150mg & 300mg Tab
02282631 02287390 02287404 02287412 02248103 02248104 02248105 02248106 02248107 02270625 02270633 02257882 02257890 02257904 02244814 02244815 02254727 02287765 02287773 02287781 02304317 02304325 02304333 02271931 02271958 00779458 02230302 02163748 02163780 02163799
COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB COB ROG PFP PFP PFP PFP
00016357 02106256 02086018 02090163 02132699 00642975 00677442 02248347 02163721 02231675 02239213
MSD WEL WEL WEL PFI PFI ZYN ALL BOE BOE GSK
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIB IIIB IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
175 162 162 162 101 101 102 102 102 7 94 17 17 17 180 180 2 153 153 153 164 164 164 15 16 137 137 137 137 137 137 137 54 218 218 218 97 97 97 186 206 57 57 27
IV.27
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Comtan 200mg Tab 02243763 NOV CONJUGATED EQUINE ESTROGEN & MEDROXYPROGESTERONE ACETATE CONJUGATED ESTROGENS Coradur-SR 20mg LA Tab (Not a Benefit) 00786683 GLA Cordarone 200mg Tab 02036282 WAY Coreg 3.125mg Tab (Not a Benefit) 02229650 GSK Coreg 6.25mg Tab (Not a Benefit) 02229651 GSK Coreg 12.5mg Tab (Not a Benefit) 02229652 GSK Coreg 25mg Tab (Not a Benefit) 02229653 GSK Corgard 40mg Tab (Not a Benefit) 00607126 BQU Corgard 80mg Tab (Not a Benefit) 00463256 BQU Corgard 160mg Tab (Not a Benefit) 00523372 BQU Cortate 0.5% Cr 00513288 SCH Cortate 1% Cr (Not a Benefit) 00502200 SCH Cortate 0.5% Oint 00513261 SCH Cortate 1% Oint (Not a Benefit) 00502197 SCH Cortef 10mg Tab 00030910 PFI Cortef 20mg Tab 00030929 PFI Cortenema 100mg/60mL Enema-60mL Pk 02112736 BFI Corticreme 1% Cr (Not a Benefit) 00477699 ROG Cortifoam 10% Rect Aero-15g Pk 00579335 SQI Cortisporin 10000U & 5mg & 10mg/mL Ot Sol 01912828 GSK Cortoderm 0.5% Oint 00716685 TAR Cortoderm 1% Oint 00716693 TAR Cosopt 2% & 0.5% Oph Sol 02240113 MFC COSYNTROPIN ZINC HYDROXIDE Cotazym 8000 & 30000 & 30000 USP Units Cap 00263818 ORG Cotazym ECS 4 4000 & 11000 & 11000 USP Units Ent Microsph Cap 02181215 ORG Cotazym ECS 8 8000 & 30000 & 30000 USP Units Ent Microsph Cap 00502790 ORG Cotazym ECS 20 20000 & 55000 & 55000 USP Units Ent Microsph Cap 00821373 ORG Coumadin 1mg Tab 01918311 BQU Coumadin 2mg Tab 01918338 BQU Coumadin 2.5mg Tab 01918346 BQU Coumadin 3mg Tab 02240205 BQU Coumadin 4mg Tab 02007959 BQU Coumadin 5mg Tab 01918354 BQU Coumadin 6mg Tab (Not a Benefit) 02240206 BQU Coumadin 10mg Tab 01918362 BQU Covera-HS 180mg SR Tab 02231676 PFI Covera-HS 240mg SR Tab 02231677 PFI Coversyl 2mg Tab 02123274 SEV Coversyl 4mg Tab 02123282 SEV
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA
181 257 258 120 84 86 86 86 86 91 91 91 289 289 290 290 252 252 232 290 232 196 290 290 208 183 221 221 221 221 77 77 77 77 77 78 6 78 119 119 114 114
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Coversyl 8mg Tab Coversyl Plus 4mg & 1.25mg Tab Cozaar 25mg Tab Cozaar 50mg Tab Cozaar 100mg Tab Creon 5 5000 & 16600 & 18750 USP Units Ent Minimicrosph Cap Creon 10 10000 & 33200 & 37500 USP Units Ent Minimicrosph Cap Creon 20 20000 & 66400 & 75000 USP Units Ent Minimicrosph Cap Creon 25 25000 & 74000 & 62500 USP Units Ent Minimicrosph Cap Crestor 5mg Tab Crestor 10mg Tab Crestor 20mg Tab Crestor 40mg Tab Crixivan 200mg Cap Crixivan 400mg Cap Cromolyn 2% Nas Sol-26mL Pk Cromolyn 2% Oph Sol Cuprimine 250mg Cap CYANOCOBALAMIN Cyanocobalamin 1mg/mL Inj Sol-10mL Pk Cyclen 0.25mg & 0.035mg Tab-21 Pk Cyclen 0.25mg & 0.035mg Tab-28 Pk CYCLOBENZAPRINE HCL Cyclocort 0.1% Cr Cyclocort 0.1% Lot Cyclocort 0.1% Oint Cyclomen 50mg Cap Cyclomen 100mg Cap Cyclomen 200mg Cap CYCLOPHOSPHAMIDE CYCLOSPORINE Cyestra-35 2mg & 0.035mg Tab-21 Pk (Not a Benefit) CYPROTERONE ACETATE CYPROTERONE ACETATE & ETHINYL ESTRADIOL CYTARABINE Cytosar 100mg Inj Pd-Vial Pk Cytotec 100mcg Tab (Not a Benefit) Cytotec 200mcg Tab (Not a Benefit) Cytovene 500mg/Vial Pd Inj-10mL Pk Cytoxan 25mg Tab Cytoxan 50mg Tab
02246624 02246569 02182815 02182874 02182882 02239007 02200104 02239008 01985205 02265540 02247162 02247163 02247164 02229161 02229196 01950541 02009277 00016055 01987003 01968440 01992872 02192284 02192276 02192268 02018144 02018152 02018160
SEV SEV MFC MFC MFC SPH SPH SPH SPH AZC AZC AZC AZC MFC MFC PMS PMS ATO CYI JNO JNO STI STI STI SAV SAV SAV
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA
114 114 112 112 112 223 223 223 223 101 101 101 101 26 26 213 213 247 300 300 274 274 70 284 284 284 254 254 254 43 308 22 43 22 44 44 236 236 26 43 43
IV.29
02290308
PMS
00386715 00813966 00632600 02162695 00344877 00344885
PFI SEA SEA HLR BQU BQU
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Dalacin C 150mg Cap Dalacin C 300mg Cap Dalacin C 300mg/2mL Inj Sol-2mL Pk Dalacin C Flavoured Granules 15mg/mL Pd for Oral Susp Dalmane 15mg Cap (Not a Benefit) Dalmane 30mg Cap (Not a Benefit) DALTEPARIN SODIUM DANAZOL Dantrium 25mg Cap Dantrium 100mg Cap DANTROLENE SODIUM DARBEPOETIN ALFA DARUNAVIR DAUNORUBICIN Daypro 600mg Tab (Not a Benefit) DDAVP 0.1mg/mL Nas Sol-2.5mL Pk DDAVP 10mcg/Metered Dose Nas Sp-2.5mL Pk DDAVP 0.1mg Tab DDAVP 0.2mg Tab DDAVP Melt 60mcg Orally Disintegrating Tab DDAVP Melt 120mcg Orally Disintegrating Tab Decadron 4mg/mL Inj Sol (Not a Benefit) Decadron 0.5mg Tab (Not a Benefit) Decadron 4mg Tab (Not a Benefit) DEFEROXAMINE MESYLATE Delatestryl 1000mg/5mL Oily Inj Sol-5mL Pk DELAVIRDINE MESYLATE DELTA-9-TETRAHYDROCANNABINOL Deltasone 5mg Tab (Not a Benefit) Deltasone 50mg Tab (Not a Benefit) Demerol 50mg Tab Demulen 30 0.03mg & 2mg Tab-21 Pk Demulen 30 0.03mg & 2mg Tab-28 Pk Depakene 250mg Cap Depakene 500mg Ent Cap (Not a Benefit) Depakene 50mg/mL O/L Depo-Medrol 40mg/mL Inj Susp-1mL Pk Depo-Medrol 80mg/mL Inj Susp-1mL Pk Depo-Medrol 100mg/5mL Inj Susp-5mL Pk Depo-Provera 150mg/mL Inj Depo-Provera 50mg/mL Inj Sol-5mL Pk Depo-Testosterone 100mg/mL Oily Inj Sol-10mL Pk Dermovate 0.05% Cr Dermovate 0.05% Oint
IV.30
00030570 02182866 00260436 00225851 00012696 00012718
PFI PFI PFI PFI VAL VAL
01997602 01997653
PGP PGP
02027860 00402516 00836362 00824305 00824143 02284995 02285002 00213624 00016462 00354309 00029246
HLR FEI FEI FEI FEI FEI FEI MSD MSD MSD THE
00210188 00252417 02138018 00469327 00471526 00443840 00507989 00443832 00030759 00030767 01934325 00585092 00030848 00030783 02213265 02213273
UPJ UPJ SAV PFI PFI ABB ABB ABB PFI PFI PFI PFI PFI PFI TPH TPH
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
17 18 18 18 178 178 72 254 70 70 70 79 23 44 10 269 269 269 269 269 269 251 251 251 20 256 24 225 253 253 140 270 270 154 154 154 253 253 253 273 273 256 287 287
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Dermovate 0.05% Scalp Lot Desferal 2g/Vial Inj Pd-2g Vial Pk (Not a Benefit) Desferal 500mg/Vial Inj Pd-500mg Vial Pk (Not a Benefit) DESIPRAMINE DESMOPRESSIN ACETATE Desocort 0.05% Cr Desocort 0.05% Lot Desocort 0.05% Oint DESOGESTREL & ETHINYL ESTRADIOL DESONIDE Desquam-X5 5% Gel (Not a Benefit) Desquam-X10 10% Gel Desyrel 50mg Tab Desyrel 100mg Tab Desyrel Dividose 150mg Tab Detrol 1mg Tab Detrol 2mg Tab Detrol LA 2mg SR Cap Detrol LA 4mg SR Cap DEXAMETHASONE
02213281 01981250 01981242
TPH NOV NOV
02048639 02115514 02115522
GAC GAC GAC
01908863 01908871 00579351 00579378 00702277 02239064 02239065 02244612 02244613
WSQ BQU BQU BQU BQU PFI PFI PFI PFI
DEXAMETHASONE 21-PHOSPHATE Dexamethasone Sodium 4mg/mL Inj Sol 00664227 Dexamethasone Sodium 4mg/mL Inj Sol 01977547 DEXAMPHETAMINE SULFATE Dexedrine 5mg Tab 01924516 DEXTRAN 70 & HYDROXYPROPYL METHYLCELLULOSE DEXTRAN 70 & HYDROXYPROPYL METHYLCELLULOSE & POLYQUAD DEXTROMETHORPHAN HBR Diabeta 2.5mg Tab 02224550 Diabeta 5mg Tab 02224569 Diamicron 80mg Tab 00765996 Diamicron MR 30mg SR Tab 02242987 Diamox 250mg Tab (Not a Benefit) 02238072 Diane-35 2mg & 0.035mg Tab-21 Pk (Not a Benefit) 02233542 Diarr-eze 2mg Caplet (Not a Benefit) 02229552 Diastat 5mg/mL Rect Gel-2x5mg Pk 02238162 Diastat 5mg/mL Rect Gel-2x10mg Pk 09853340 Diastat 5mg/mL Rect Gel-2x15mg Pk 09853430 DIAZEPAM Diclectin 10mg & 10mg SR Tab 00609129 DICLOFENAC POTASSIUM DICLOFENAC SODIUM DICLOFENAC SODIUM & MISOPROSTOL
SDZ CYI GSK
SAV SAV SEV SEV WAY BAY PMS VAL VAL VAL DUI
IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA
287 20 20 157 269 288 288 288 270 288 293 293 163 163 163 321 321 321 321 199 251 251 251 251 178 178 207 207 193 262 262 261 261 203 22 217 167 167 167 167 226 9 125 207 126
IV.31
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
DIDANOSINE Didrocal 400mg/500mg Tab-90 Tablets Kit Didronel 200mg Tab Diflucan 50mg Tab (Not a Benefit) Diflucan 100mg Tab (Not a Benefit) Diflucan P.O.S. 10mg/mL O/L Diflucan-150 150mg Cap DIFLUCORTOLONE VALERATE DIFLUNISAL DIGOXIN Dilantin 30mg Cap Dilantin 100mg Cap Dilantin 6mg/mL O/L Dilantin 25mg/mL O/L Dilantin 50mg Tab Dilaudid 2mg/mL Inj Sol-1mL Pk Dilaudid 1mg/mL Oral Sol Dilaudid 3mg Sup Dilaudid 1mg Tab Dilaudid 2mg Tab Dilaudid 4mg Tab Dilaudid 8mg Tab Dilaudid Sterile Powder 250mg Pd Vial Pk Dilaudid-HP 10mg/mL Inj Sol-1mL Pk Dilaudid-HP-Plus 20mg/mL Inj Dilaudid-XP 50mg/mL Inj-1mL Pk DILTIAZEM HCL DIMENHYDRINATE Diocarpine 1% Oph Sol (Not a Benefit) Diocarpine 2% Oph Sol (Not a Benefit) Diopred 1% Oph Susp (Not a Benefit) Diovan 80mg Tab Diovan 160mg Tab Diovan 320mg Tab Diovan-HCT 80mg/12.5mg Tab Diovan-HCT 160mg/12.5mg Tab Diovan-HCT 160mg/25mg Tab Diovol EX 120mg & 60mg/mL O/L dpp (Not a Benefit) Dipentum 250mg Cap DIPHENHYDRAMINE HCL DIPHENOXYLATE HYDROCHLORIDE & ATROPINE SULFATE Diprolene 0.05% Oint Diprolene Glycol 0.05% Cr Diprosone 0.05% Cr
IV.32
02176017 01997629 00891800 00891819 02024152 02141442
PGP PGP PFI PFI PFI PFI
00022772 00022780 00023442 00023450 00023698 00627100 00786535 00125105 00705438 00125083 00125121 00786543 02085895 00622133 02146118 02145863
PFI PFI PFI PFI PFI ABB ABB ABB ABB ABB ABB ABB ABB ABB ABB ABB
02023725 02023741 02023768 02244781 02244782 02289504 02241900 02241901 02246955 00491217 00875848
DKT DKT SDZ NOV NOV NOV NOV NOV NOV HOR VLH
00629367 00688622 00323071
SCH SCH SCH
24 310 309 5 5 4 279 288 127 87 152 152 152 152 152 139 139 139 139 140 140 140 139 139 139 139 87 225 202 202 200 119 119 119 119 119 119 215 236 1 216 285 286 285
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Diprosone 0.05% Lot 00417246 Diprosone 0.05% Oint 00344923 DIPYRIDAMOLE & ACETYLSALICYLIC ACID DISOPYRAMIDE Ditropan 1mg/mL O/L (Not a Benefit) 01924753 Ditropan 5mg Tab (Not a Benefit) 01924761 DIVALPROEX SODIUM Dixarit 0.025mg Tab (Not a Benefit) 00519251 DM-Syrup 3mg/mL O/L (Not a Benefit) 00391069 DOCUSATE CALCIUM (DIOCTYL CALCIUM SULFOSUCCINATE) Docusate Sodium 100mg Cap 00716731 DOCUSATE SODIUM (DIOCTYL SODIUM SULFOSUCCINATE) DOLASETRON MESYLATE Dolobid 250mg Tab (Not a Benefit) 00587699 Dolobid 500mg Tab (Not a Benefit) 00576131 DOMPERIDONE MALEATE DONEPEZIL HCL DORZOLAMIDE HCL DORZOLAMIDE HCL & TIMOLOL MALEATE Dostinex 0.5mg Tab (Not a Benefit) 02242471 Dovobet 50mcg/g & 0.5mg/g Oint 02244126 Dovonex 50mcg/g Cr 02150956 Dovonex 50mcg/g Oint 01976133 DOXAZOSIN MESYLATE DOXEPIN HCL DOXYLAMINE SUCCINATE AND PYRIDOXINE HCL Drisdol 8288IU/mL O/L 02017598 DROSPIRENONE & ETHINYL ESTRADIOL Dulcolax 5mg Ent Tab 00254142 Dulcolax 5mg Sup 00003867 Dulcolax 10mg Sup 00003875 Duolube 80%/20% Oph Oint-3.5g Pk 02125706 Duragesic 25 25mcg/hr Trans Patch 01937383 Duragesic 50 50mcg/hr Trans Patch 01937391 Duragesic 75 75mcg/hr Trans Patch 01937405 Duragesic 100 100mcg/hr Trans Patch 01937413 Duralith 300mg ER Tab (Not a Benefit) 00590665 Duricef 500mg Cap 00507245 DUTASTERIDE Duvoid 10mg Tab 01947958 Duvoid 25mg Tab 01947931 Duvoid 50mg Tab 01947923 Dyazide 25mg & 50mg Tab (Not a Benefit) 01919547 ECONAZOLE NITRATE
SCH SCH
JNO PGP BOE PDA TAR
FRS FRS
PMJ LEO LEO LEO
SAV BOE BOE BOE BSH JNO JNO JNO JNO JNO BQU SQI SQI SQI SMJ
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA
285 285 120 89 58 58 149 7 193 218 218 218 226 127 127 231 51 208 208 23 287 295 295 106 157 226 301 270 218 218 218 211 138 138 138 138 14 15 309 51 51 51 190 278
IV.33
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Ecostatin 1% Cr Ecostatin 150mg Vag Sup EES-200 40mg/mL O/L (Not a Benefit) EES-400 80mg/mL O/L (Not a Benefit) EES-600 600mg/mL O/L (Not a Benefit) EFAVIRENZ Effexor XR 37.5mg ER Cap Effexor XR 75mg ER Cap Effexor XR 150mg ER Cap Efudex 5% Cr Elavil 10mg Tab (Not a Benefit) Elavil 25mg Tab (Not a Benefit) Elavil 50mg Tab (Not a Benefit) Eldepryl 5mg Tab ELECTROLYTE & DEXTROSE Elidel 1% Cr Eligard 7.5mg Pd Susp Inj-Pref Syr Kit Eligard 22.5mg Pd Susp Inj-Pref Syr Kit Eligard 30mg Pd Susp Inj-Pref Syr Kit Eligard 45mg Pd Susp Inj-Pref Syr Kit Elocom 0.1% Cr Elocom 0.1% Lot Elocom 0.1% Oint Eltroxin 0.05mg Tab Eltroxin 0.1mg Tab Eltroxin 0.15mg Tab Eltroxin 0.2mg Tab Eltroxin 0.3mg Tab (Not a Benefit) Emcyt 140mg Cap Emo-Cort 1% Cr Emo-Cort 2.5% Cr Emo-Cort 1% Lot Emo-Cort 2.5% Lot Empracet-30 300mg & 30mg Tab (Not a Benefit) Empracet-60 300mg & 60mg Tab (Not a Benefit) EMTRICITABINE & TENOFOVIR DISOPROXIL FUMARATE ENALAPRIL MALEATE Endantadine 100mg Cap Endocet 5mg & 325mg Tab Enemol 160mg & 60mg/mL Rect Sol ENOXAPARIN ENTACAPONE Entacyl Gran 2g Pk Entrophen 325mg Ent Tab
IV.34
02011948 02010267 00000299 00453617 00583782 02237279 02237280 02237282 00330582 00016322 00016330 00016349 02123312 02247238 02248239 02248240 02248999 02268892 00851744 00871095 00851736 02213192 02213206 02213214 02213222 02213230 02063794 00192597 00595799 00192600 00595802 00666130 00666149
BQU BQU ABB ABB ABB WAY WAY WAY VAL MSD MSD MSD BJH NOV SAV SAV SAV SAV SCH SCH SCH GSK GSK GSK GSK GLW PFI STI STI STI STI BWE BWE
02034468 01916548 02096900
BQU BQU DPC
02100215 00010332
SHI PEN
278 278 9 9 9 24 164 164 164 295 155 155 155 317 185 296 47 47 47 47 291 291 291 274 274 275 275 275 44 289 290 290 290 136 136 25 106 304 144 220 73 181 3 123
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Entrophen 650mg Ent Tab 00010340 EPINEPHRINE HCL Epival 125mg Ent Tab 00596418 Epival 250mg Ent Tab 00596426 Epival 500mg Ent Tab 00596434 Eprex 20,000IU/mL Inj Sol-1mL Vial Pk 02206072 Eprex 10,000IU/mL Pref Syr-1mL Pk 02231587 Eprex 40,000IU/mL Pref Syr-1mL Pk 02240722 EPROSARTAN MESYLATE EPROSARTAN MESYLATE & HYDROCHLOROTHIAZIDE ERGOCALCIFEROL ERGOTAMINE TARTRATE & CAFFEINE ERYC 250mg Ent Pel Cap 00607142 Erythrocin 250mg Tab (Not a Benefit) 00000434 Erythrocin 500mg Tab 00266515 Erythromid 250mg Tab (Not a Benefit) 00244635 ERYTHROMYCIN BASE ERYTHROMYCIN ESTOLATE ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE & SULFISOXAZOLE ACETYL ERYTHROMYCIN STEARATE ESTRADIOL ESTRADIOL 17-B ESTRAMUSTINE PHOSPHATE DISODIUM Estring 2mg Vag Ring 02168898 ESTROPIPATE (CALCULATED AS SODIUM ESTRONE SULFATE 1.25MG) ESTROPIPATE (CALCULATED AS SODIUM ESTRONE SULFATE 2.5MG) ETHAMBUTOL HCL ETHINYL ESTRADIOL & ETHYNODIOL DIACETATE ETHINYL ESTRADIOL & LEVONORGESTREL ETHINYL ESTRADIOL & NORETHINDRONE ETHINYL ESTRADIOL & NORETHINDRONE ACETATE ETHINYL ESTRADIOL & NORGESTREL ETHOPROPAZINE HCL ETHOSUXIMIDE Etibi 100mg Tab 00247960 Etibi 400mg Tab 00247979 ETIDRONATE DISODIUM ETIDRONATE DISODIUM/CALCIUM CARBONATE ETODOLAC ETOPOSIDE Euflex 250mg Tab 00637726 Euglucon 2.5mg Tab 00720933 Euglucon 5mg Tab 00720941
PEN ABB ABB ABB JNO JNO JNO
PFI ABB ABB ABB
PFI
VAL VAL
SCH PMS PMS
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA
123 60 149 149 149 80 80 80 108 108 301 69 8 9 9 8 8 9 9 9 9 258 258 44 258 259 259 20 270 271 271 272 272 54 149 20 20 309 310 9 44 45 262 262
IV.35
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Eumovate 0.05% Cr Euro-Fer 300mg Cap Evista 60mg Tab Exelon 1.5mg Cap Exelon 3mg Cap Exelon 4.5mg Cap Exelon 6mg Cap EXEMESTANE EZETIMIBE Ezetrol 10mg Tab FAMCICLOVIR FAMOTIDINE Famvir 125mg Tab (Not a Benefit) Famvir 250mg Tab (Not a Benefit) Famvir 500mg Tab Feldene 10mg Cap (Not a Benefit) Feldene 20mg Cap (Not a Benefit) Feldene 20mg Sup (Not a Benefit) FELODIPINE Femara 2.5mg Tab FENOFIBRATE FENTANYL TRANSDERMAL SYSTEM Fer-In-Sol 75mg/mL O/L FERROUS FUMARATE FERROUS GLUCONATE Ferrous Gluconate 300mg Tab (Not a Benefit) FERROUS SULFATE Fibyrax Tab (Not a Benefit) FINASTERIDE Flagyl 500mg Cap Flagyl 250mg Tab (Not a Benefit) Flagyl 10% Vag Cr-App Flagystatin 500mg & 100000U/g Vag Cr-App Flagystatin 500mg & 100000U Vag Sup Flamazine 1% Cr Flamazine 1% Cr-50g Pk Flarex 0.1% Oph Susp FLAVOXATE HCL FLECAINIDE ACETATE Fleet Enema Fleet 160mg & 60mg/mL Ped Rect Sol Fleet 160mg & 60mg/mL Rect Sol
IV.36
02214415 02237556 02239028 02242115 02242116 02242117 02242118
GSK EUR LIL NOV NOV NOV NOV
02247521
MFS
02229110 02229129 02177102 00525596 00525618 00632716 02231384
NOV NOV NOV PFI PFI PFI NOV
00762954
MJS
00031097 00779768 01926853 01926896 01926861 01926845 01926829 00323098 09854037 00756784
RPR LED SAV RPP SAV SAV SAV SNE SNE ALC
00107875 00108065 00009911
MFC MFC MFC
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
288 71 316 53 53 53 53 44 97 97 25 4 232 4 4 25 134 134 134 108 47 98 7 138 71 71 71 71 71 218 310 31 31 283 283 283 284 284 200 54 90 219 220 220
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Flexeril 10mg Tab (Not a Benefit) FLOCTAFENINE Flomax 0.4mg Cap (Not a Benefit) Flomax CR 0.4mg Tab Flonase 50mcg/Actuation Nas Sp-120 Dose Pk (Not a Benefit) Florinef 0.1mg Tab Flovent Diskus 250mcg/Blister Pd Inh-60 Dose Pk Flovent Diskus 500mcg/Blister Pd Inh-60 Dose Pk Flovent HFA 50mcg/Metered Dose Inh-120 Dose Pk Flovent HFA 125mcg/Metered Dose Inh-120 Dose Pk Flovent HFA 250mcg/Metered Dose Inh-120 Dose Pk Floxin 200mg Tab (Not a Benefit) Floxin 300mg Tab (Not a Benefit) Floxin 400mg Tab (Not a Benefit) Fluanxol 0.5mg Tab Fluanxol 3mg Tab Fluanxol Depot 200mg/2mL Inj Sol-2mL Pk Fluanxol Depot 200mg/10mL Inj Sol-10mL Pk FLUCONAZOLE Fludara 10mg Tab FLUDARABINE PHOSPHATE FLUDROCORTISONE ACETATE FLUMETHASONE PIVALATE & IODOCHLORHYDROXYQUIN FLUNARIZINE HCL FLUNISOLIDE FLUOCINOLONE ACETONIDE FLUOCINONIDE FLUOCINONIDE & PROCINONIDE & CIPROCINONIDE FLUOROMETHOLONE FLUOROMETHOLONE ACETATE FLUOROURACIL Fluotic 20mg Tab FLUOXETINE HCL FLUPENTHIXOL DECANOATE FLUPENTHIXOL DIHYDROCHLORIDE FLUPHENAZINE DECANOATE FLUPHENAZINE HCL FLURAZEPAM FLURBIPROFEN FLUTAMIDE FLUTICASONE PROPIONATE
00782742 02238123 02270102 02213672 02086026 02237246 02237247 02244291 02244292 02244293 01968424 01968416 01968408 02156008 02156016 02156040 02156032
FRS BOE BOE GSK SQI GSK GSK GSK GSK GSK JNO JNO JNO VLH VLH VLH VLH
02246226
BAY
02099225
SAV
IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB
70 127 319 319 18 252 252 252 252 252 252 39 39 39 167 167 167 167 4 279 45 45 252 199 311 199 288 289 289 200 200 295 318 158 13 167 167 168 168 178 128 45 252 18
IV.37
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
FLUVASTATIN SODIUM FLUVOXAMINE MALEATE FML 0.1% Oph Susp 00247855 FOLIC ACID Folvite 5mg Tab (Not a Benefit) 00014966 FONDAPARINUX SODIUM Foradil 12mcg/Cap Inh Pd-Device Pk 02230898 FORMOTEROL FUMARATE FORMOTEROL FUMARATE DIHYDRATE Fortovase 200mg Cap 02239083 Fosamax 5mg Tab (Not a Benefit) 02233055 Fosamax 10mg Tab 02201011 Fosamax 40mg Tab (Not a Benefit) 02201038 Fosamax 70mg Tab 02245329 FOSAMPRENAVIR CALCIUM Fosavance 70mg/70mcg Tab 02276429 FOSINOPRIL SODIUM Fragmin 2500IU/0.2mL Inj Pref Syr 02132621 Fragmin 5000IU/0.2mL Inj Pref Syr 02132648 Fragmin 10000IU/0.4mL Inj Pref Syr 09853790 Fragmin 12500IU/0.5mL Inj Pref Syr 09853820 Fragmin 15000IU/0.6mL Inj Pref Syr 09853880 Fragmin 18000IU/0.72mL Inj Pref Syr 09853910 Fragmin 10000IU/mL Inj Sol-1mL Pk 02132664 Fragmin 25000IU/mL Multidose 3.8mL Pk 02231171 FRAMYCETIN SULFATE FRAMYCETIN SULFATE & GRAMICIDIN & DEXAMETHASONE Fraxiparine 9500IU/mL Pref Syr-0.3mL Pk 09853936 Fraxiparine 9500IU/mL Pref Syr-0.4mL Pk 09853944 Fraxiparine 9500IU/mL Pref Syr-0.6mL Pk 09853952 Fraxiparine 9500IU/mL Pref Syr-0.8mL Pk 09853979 Fraxiparine 9500IU/mL Pref Syr-1.0mL Pk 09853987 Fraxiparine Forte 19000IU/mL Pref Syr-0.6mL Pk 02240114 Fraxiparine Forte 19000IU/mL Pref Syr-0.8mL Pk 09854100 Fraxiparine Forte 19000IU/mL Pref Syr-1.0mL Pk 09854118 Frisium 10mg Tab 02221799 Froben 50mg Tab 02223066 Fucidin 2% Cr 00586668 Fucidin 2% Oint 00586676 Fucidin Leo 250mg Tab 01934252 Fungizone Inj Pd-50mg Pk 00029149 FUROSEMIDE FUSIDIC ACID GABAPENTIN
ALL LED NOV
HLR MFC MFC MFC MFC MFC PFI PFI PFI PFI PFI PFI PFI PFI
GSK GSK GSK GSK GSK GSK GSK GSK OVA ABB LEO LEO LEO BQU
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
98 158 200 300 300 74 60 60 60 29 23 303 23 303 25 303 109 72 72 72 72 72 72 72 72 195 195 75 75 75 75 75 75 75 75 148 128 277 277 19 3 188 277 150
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
GALANTAMINE HYDROBROMIDE GANCICLOVIR SODIUM Garamycin 0.3% Oph Oint-3.5g Pk Garamycin 0.3% Oph Sol Garamycin 0.3% Ot Sol Garasone 3mg & 1mg/mL Oph/Ot Drops Gastrolyte Oral Pd-1 Sach Pk GEL-OSE 40% Jelly-Unidose Pk Gelusil Extra Strength 400mg & 400mg Tab dpp (Not a Benefit) GEMFIBROZIL Gen-Acebutolol 100mg Tab Gen-Acebutolol 200mg Tab Gen-Acebutolol 400mg Tab Gen-Acebutolol (Type S) 100mg Tab Gen-Acebutolol (Type S) 200mg Tab Gen-Acebutolol (Type S) 400mg Tab Gen-Acyclovir 200mg Tab (Not a Benefit) Gen-Acyclovir 400mg Tab (Not a Benefit) Gen-Acyclovir 800mg Tab Gen-Alendronate 5mg Tab (Not a Benefit) Gen-Alendronate 10mg Tab Gen-Alendronate 70mg Tab Gen-Alprazolam 0.25mg Tab Gen-Alprazolam 0.5mg Tab Gen-Alprazolam 1mg Tab (Not a Benefit) Gen-Alprazolam 2mg Tab (Not a Benefit) Gen-Amantadine 100mg Cap Gen-Amilazide 5mg & 50mg Tab Gen-Amiodarone 200mg Tab Gen-Amoxicillin 250mg Cap (Not a Benefit) Gen-Amoxicillin 500mg Cap (Not a Benefit) Gen-Atenolol 50mg Tab Gen-Atenolol 100mg Tab Gen-Azathioprine 50mg Tab Gen-Azithromycin 250mg Tab Gen-Baclofen 10mg Tab Gen-Baclofen 20mg Tab Gen-Beclo AQ 50mcg Nas Sp-200 Dose Pk Gen-Bicalutamide 50mg Tab Gen-Bromazepam 1.5mg Tab Gen-Bromazepam 3mg Tab Gen-Bromazepam 6mg Tab
00028339 00512192 00512184 00682217 01931563 00739561 00483605
SCH SCH SCH SCH SAV JOU PDA
02237721 02237722 02237723 02237885 02237886 02237887 02242784 02242463 02242464 02270110 02270129 02286335 02137534 02137542 02229813 02229814 02139200 02257378 02240604 02238171 02238172 02146894 02147432 02231491 02278359 02088398 02088401 02172712 02302403 02192705 02192713 02192721
GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN
IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
11 52 26 196 196 196 195 186 219 215 99 7 83 83 83 83 83 83 4 4 22 23 303 303 164 165 13 13 304 187 84 10 10 84 85 305 8 69 70 198 41 165 165 165
IV.39
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Gen-Budesonide AQ 100mcg/Metered Dose Nas Sp-165 Dose Pk Gen-Buspirone 10mg Tab (Not a Benefit) Gen-Captopril 12.5mg Tab Gen-Captopril 25mg Tab Gen-Captopril 50mg Tab Gen-Captopril 100mg Tab Gen-Carbamazepine CR 200mg LA Tab Gen-Carbamazepine CR 400mg LA Tab Gen-Cilazapril 1mg Tab Gen-Cilazapril 2.5mg Tab Gen-Cilazapril 5mg Tab Gen-Cimetidine 300mg Tab Gen-Cimetidine 400mg Tab Gen-Cimetidine 600mg Tab Gen-Ciprofloxacin 250mg Tab Gen-Ciprofloxacin 500mg Tab Gen-Ciprofloxacin 750mg Tab Gen-Citalopram 20mg Tab Gen-Citalopram 40mg Tab Gen-Clarithromycin 250mg Tab Gen-Clarithromycin 500mg Tab (Not a Benefit) Gen-Clindamycin 150mg Cap Gen-Clindamycin 300mg Cap Gen-Clobetasol 0.05% Cr Gen-Clobetasol 0.05% Oint Gen-Clobetasol 0.05% Scalp Lot Gen-Clomipramine 10mg Tab Gen-Clomipramine 25mg Tab Gen-Clomipramine 50mg Tab Gen-Clonazepam 0.5mg Tab Gen-Clonazepam 2mg Tab Gen-Clozapine 25mg Tab (Not a Benefit) Gen-Clozapine 100mg Tab (Not a Benefit) Gen-Combo Sterinebs 500mcg/2.5mg/2.5mL Inh Sol-2.5mL Pk Gen-Cycloprine 10mg Tab (Not a Benefit) Gen-Cyproterone 50mg Tab Gen-Diltiazem 30mg Tab Gen-Diltiazem 60mg Tab Gen-Diltiazem CD 120mg LA Cap Gen-Diltiazem CD 180mg LA Cap Gen-Diltiazem CD 240mg LA Cap Gen-Diltiazem CD 300mg LA Cap Gen-Divalproex 125mg Ent Tab
IV.40
02230648 02230874 02163551 02163578 02163586 02163594 02241882 02241883 02283778 02283786 02283794 02227444 02227452 02227460 02245647 02245648 02245649 02246594 02246595 02248856 02248857 02258331 02258358 02024187 02026767 02216213 02139340 02139359 02139367 02230950 02230951 02247243 02247244 02272695 02231353 02229723 02146916 02146924 02254808 02254816 02254824 02254832 02265133
GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN
IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
199 15 104 104 104 104 147 147 104 105 105 230 230 231 33 33 33 156 156 8 2 17 18 287 287 287 156 156 156 148 148 14 14 57 70 43 89 89 87 88 88 88 149
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Gen-Divalproex 250mg Ent Tab Gen-Divalproex 500mg Ent Tab Gen-Domperidone 10mg Tab (Not a Benefit) Gen-Doxazosin 1mg Tab Gen-Doxazosin 2mg Tab Gen-Doxazosin 4mg Tab Gen-Enalapril 2.5mg Tab Gen-Enalapril 5mg Tab Gen-Enalapril 10mg Tab Gen-Enalapril 20mg Tab Gen-Eti Cal Carepac 400mg/500mg Tab-90 Tablets Kit Gen-Etidronate 200mg Tab Gen-Famotidine 20mg Tab Gen-Famotidine 40mg Tab Gen-Fenofibrate Micro 200mg Cap Gen-Fluconazole 150mg Cap Gen-Fluconazole 50mg Tab Gen-Fluconazole 100mg Tab Gen-Fluoxetine 10mg Cap (Not a Benefit) Gen-Fluoxetine 20mg Cap Gen-Fosinopril 10mg Tab Gen-Fosinopril 20mg Tab Gen-Gabapentin 100mg Cap Gen-Gabapentin 300mg Cap Gen-Gabapentin 400mg Cap Gen-Gemfibrozil 300mg Cap Gen-Gemfibrozil 600mg Tab (Not a Benefit) Gen-Gliclazide 80mg Tab Gen-Glimepiride 1mg Tab (Not a Benefit) Gen-Glimepiride 2mg Tab (Not a Benefit) Gen-Glimepiride 4mg Tab (Not a Benefit) Gen-Glybe 2.5mg Tab Gen-Glybe 5mg Tab Gen-Hydroxychloroquine 200mg Tab Gen-Hydroxyurea 500mg Cap Gen-Indapamide 1.25mg Tab Gen-Indapamide 2.5mg Tab Gen-Ipratropium 250mcg/mL Inh Sol-2mL UDV Pk Gen-Ipratropium 250mcg/mL Inh Sol-20mL Pk Gen-Lamotrigine 25mg Tab Gen-Lamotrigine 100mg Tab Gen-Lamotrigine 150mg Tab Gen-Lisinopril 5mg Tab Gen-Lisinopril 10mg Tab
02265141 02265168 02278669 02240498 02240499 02240500 02300036 02300044 02300052 02300060 02247323 02245330 02196018 02196026 02240210 02245697 02245292 02245293 02237813 02237814 02262401 02262428 02248259 02248260 02248261 02185407 02230476 02229519 02279061 02279088 02279126 00808733 00808741 02252600 02242920 02240067 02153483 02216221 02239131 02265494 02265508 02265516 02274833 02274841
GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN GEN
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
149 149 231 106 106 106 106 107 107 107 310 309 232 232 98 279 5 5 13 158 109 109 150 150 150 99 7 261 21 21 21 262 262 31 45 190 190 56 55 151 151 151 111 111
IV.41
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Gen-Lisinopril 20mg Tab Gen-Lisinopril HCTZ 10mg & 12.5mg Tab Gen-Lisinopril HCTZ 20mg & 12.5mg Tab Gen-Lovastatin 20mg Tab Gen-Lovastatin 40mg Tab Gen-Medroxy 2.5mg Tab Gen-Medroxy 5mg Tab Gen-Medroxy 10mg Tab Gen-Meloxicam 7.5mg Tab Gen-Meloxicam 15mg Tab Gen-Metformin 500mg Tab Gen-Metformin 850mg Tab (Not a Benefit) Gen-Metoprolol (Type L) 50mg Tab Gen-Metoprolol (Type L) 100mg Tab Gen-Minocycline 50mg Cap (Not a Benefit) Gen-Minocycline 100mg Cap (Not a Benefit) Gen-Mirtazapine 30mg Tab Gen-Nabumetone 500mg Tab (Not a Benefit) Gen-Naproxen EC 250mg Ent Tab (Not a Benefit) Gen-Naproxen EC 375mg Ent Tab (Not a Benefit) Gen-Naproxen EC 500mg Ent Tab (Not a Benefit) Gen-Nitro SL 0.4mg/Metered Dose Spray-200 Dose Pk Gen-Nizatidine 150mg Cap Gen-Nizatidine 300mg Cap Gen-Nortriptyline 10mg Cap Gen-Nortriptyline 25mg Cap Gen-Ondansetron 4mg Tab Gen-Ondansetron 8mg Tab Gen-Oxybutynin 5mg Tab Gen-Paroxetine 10mg Tab (Not a Benefit) Gen-Paroxetine 20mg Tab Gen-Paroxetine 30mg Tab Gen-Pindolol 5mg Tab Gen-Pindolol 10mg Tab Gen-Pindolol 15mg Tab Gen-Pioglitazone 15mg Tab Gen-Pioglitazone 30mg Tab Gen-Pioglitazone 45mg Tab Gen-Piroxicam 10mg Cap Gen-Piroxicam 20mg Cap Gen-Pravastatin 10mg Tab Gen-Pravastatin 20mg Tab Gen-Pravastatin 40mg Tab Gen-Propafenone 150mg Tab
IV.42
02274868 02297736 02297744 02243127 02243129 02229838 02229839 02229840 02255987 02255995 02148765 02229656 02174545 02174553 02230735 02230736 02256118 02244563 02243431 02243432 02241024 02243588 02246046 02246047 02231686 02231687 02297868 02297876 02230800 02248012 02248013 02248014 02057808 02057816 02057824 02298279 02298287 02298295 02171813 02171821 02257092 02257106 02257114 02245372
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIB IIIB IIIA IIIB IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
111 112 112 99 99 273 273 273 132 132 262 21 90 90 2 3 160 9 10 10 10 122 236 236 161 161 228 228 58 13 161 161 114 114 115 263 263 263 134 134 100 100 100 92
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Gen-Propafenone 300mg Tab Gen-Ranitidine 150mg Tab Gen-Ranitidine 300mg Tab Gen-Risperidone 0.25mg Tab Gen-Risperidone 0.5mg Tab Gen-Risperidone 1mg Tab Gen-Risperidone 2mg Tab Gen-Risperidone 3mg Tab Gen-Risperidone 4mg Tab Gen-Salbutamol 2mg/mL Inh Sol-2.5mL Pk Gen-Salbutamol 5mg/mL Inh Sol-10mL Pk Gen-Salbutamol Sterinebs P.F. 1mg/mL Inh Sol-2.5mL Pk Gen-Selegiline 5mg Tab Gen-Sertraline 25mg Cap Gen-Sertraline 50mg Cap Gen-Sertraline 100mg Cap Gen-Simvastatin 5mg Tab Gen-Simvastatin 10mg Tab Gen-Simvastatin 20mg Tab Gen-Simvastatin 40mg Tab Gen-Simvastatin 80mg Tab Gen-Sotalol 80mg Tab (Not a Benefit) Gen-Sotalol 160mg Tab Gen-Sumatriptan 25mg Tab (Not a Benefit) Gen-Sumatriptan 50mg Tab (Not a Benefit) Gen-Sumatriptan 100mg Tab (Not a Benefit) Gen-Tamoxifen 10mg Tab Gen-Tamoxifen 20mg Tab Gen-Tamsulosin 0.4mg Cap Gen-Temazepam 15mg Cap Gen-Temazepam 30mg Cap Gen-Terbinafine 250mg Tab (Not a Benefit) Gen-Ticlopidine 250mg Tab Gen-Timolol 0.25% Oph Sol Gen-Timolol 0.5% Oph Sol Gen-Tizanidine 4mg Tab (Not a Benefit) Gen-Topiramate 25mg Tab Gen-Topiramate 100mg Tab Gen-Topiramate 200mg Tab Gen-Trazodone 50mg Tab Gen-Trazodone 100mg Tab Gen-Triazolam 0.125mg Tab Gen-Triazolam 0.25mg Tab Gen-Valproic 250mg Cap
02245373 02207761 02207788 02282240 02282259 02282267 02282275 02282283 02282291 02173360 02232987 01926934 02231036 02242519 02242520 02242521 02246582 02246583 02246737 02246584 02246585 02229778 02229779 02268906 02268914 02268922 02088428 02089858 02298570 02231615 02231616 02242503 02239744 00893773 00893781 02272059 02263351 02263378 02263386 02231683 02231684 01995227 01913506 02184648
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
92 242 243 174 174 175 175 175 175 64 65 63 317 162 162 162 101 101 102 102 102 7 94 17 17 17 49 49 319 180 180 2 320 214 214 5 153 153 153 163 163 180 181 154
IV.43
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Gen-Verapamil 80mg Tab Gen-Verapamil 120mg Tab Gen-Verapamil SR 120mg LA Tab (Not a Benefit) Gen-Verapamil SR 180mg LA Tab Gen-Verapamil SR 240mg LA Tab Gen-Warfarin 1mg Tab Gen-Warfarin 2mg Tab Gen-Warfarin 2.5mg Tab Gen-Warfarin 3mg Tab Gen-Warfarin 4mg Tab Gen-Warfarin 5mg Tab Gen-Warfarin 6mg Tab (Not a Benefit) Gen-Warfarin 10mg Tab Gen-Zopiclone 5mg Tab (Not a Benefit) Gen-Zopiclone 7.5mg Tab (Not a Benefit) GENTAMICIN & BETAMETHASONE SODIUM PHOSPHATE GENTAMICIN SULFATE Gleevec 100mg Tab Gleevec 400mg Tab GLICLAZIDE GLIMEPIRIDE Glucagon 1mg/Vial Inj Pd-Vial Pk GLUCAGON RDNA ORIGIN Glucobay 50mg Tab Glucobay 100mg Tab Glucophage 500mg Tab Glucophage 850mg Tab (Not a Benefit) GLYBURIDE Glysennid 8.6mg Tab (Not a Benefit) Glysennid 12mg Tab GOSERELIN ACETATE GRAIN & CITRUS FIBRE GRANISETRON HCL Gravol Filmkote 50mg Tab (Not a Benefit) GUAIFENESIN Guaifenesin 20mg/mL O/L (Not a Benefit) Guaifenesin Sugar Free 20mg/mL O/L (Not a Benefit) HALCINONIDE Halcion 0.125mg Tab (Not a Benefit) Halcion 0.25mg Tab (Not a Benefit) Haldol 5mg/mL Inj Sol-1mL Pk (Not a Benefit) Haldol 0.5mg Tab (Not a Benefit) Haldol 1mg Tab (Not a Benefit) Haldol 2mg Tab (Not a Benefit)
IV.44
02237921 02237922 02210347 02210355 02210363 02244462 02244463 02244464 02287498 02244465 02244466 02287501 02244467 02296616 02238596
GEN GEN GEN GEN GEN GEN GEN GEN8 GEN GEN GEN GEN GEN GEN GEN
02253275 02253283
NOV NOV
02243297 02190885 02190893 02099233 02162849 00604402 00027502
LIL BAY BAY SAV SAV NOV NOV
00013803 00026794 00990930 00512559 00443158 00017574 00017655 00017663 00017671
HOR ROG ROG UPJ PFI OMC OMC OMC OMC
IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
94 95 8 119 119 77 77 77 77 77 78 6 78 15 16 195 196 46 46 261 21 311 311 260 260 262 21 262 220 220 45 218 227 225 193 193 193 289 180 181 168 168 169 169
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Haldol 5mg Tab (Not a Benefit) Haldol 10mg Tab (Not a Benefit) Haldol 20mg Tab (Not a Benefit) Haldol-LA 100mg/mL Oily Inj Sol-1mL Pk (Not a Benefit) Haldol-LA 50mg/mL Oily Inj Sol-5mL Pk (Not a Benefit) Haldol-LA 100mg/mL Oily Inj Sol-5mL Pk (Not a Benefit) Halog 0.1% Cr Halog 0.1% Oint HALOPERIDOL Haloperidol 5mg/mL Inj Sol-1mL Pk HALOPERIDOL DECANOATE Haloperidol LA 100mg/mL Oily Inj Sol-1mL Pk Haloperidol LA 50mg/mL Oily Inj Sol-5mL Pk Haloperidol LA 100mg/mL Oily Inj Sol-5mL Pk Hepalean 50000USP U/5mL Inj Sol-5mL Pk Hepalean 10000USP U/10mL Inj Sol-10mL Pk HEPARIN SODIUM Hexalen 50mg Cap Hexavitamins Tab (Not a Benefit) HEXAVITAMINS USP Hp-PAC 30mg & 500mg & 500mg Tab/Cap Pk Humalog 100U/mL Inj Sol-5x3mL Pk Humalog 100U/mL Inj Sol-10mL Pk Humalog Mix25 25% & 75% Inj Susp-5X3mL Pk Humulin 30/70 100U/mL Inj Susp-5X3mL Pk Humulin 30/70 1000U/10mL Inj Susp-10mL Pk Humulin N 100U/mL Inj Susp-5X3mL Pk Humulin NPH 1000U/10mL Inj Susp-10mL Pk Humulin R 100U/mL Inj Sol-5X3mL Pk Humulin Regular 1000U/10mL Inj Sol-10mL Pk Hycodan 1mg/mL O/L Hycort 100mg/60mL Enema-60mL Pk Hyderm 1% Cr HYDRALAZINE HCL Hydrea 500mg Cap HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE & SPIRONOLACTONE HYDROCHLOROTHIAZIDE & TRIAMTERENE HYDROCODONE BITARTRATE HYDROCORTISONE
00017698 00381772 00499579 00599093 00599085 00980803 02011921 02010283 00808652 02130300 02130297 09853758 00740497 00740519 02126230 00269034 02238525 09853715 02229704 02240294 09853855 00795879 09853804 00587737 09853766 00586714 01916580 00230316 00716839 00465283
OMC OMC OMC OMC OMC OMC BQU BQU SDZ SDZ SDZ SDZ ORG ORG LIL NOP ABB LIL LIL LIL LIL LIL LIL LIL LIL LIL BQU VAL TAR BQU
HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE & UREA

IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
169 169 169 169 169 169 289 289 168 168 169 169 169 169 74 74 74 41 302 302 235 266 266 268 268 268 267 267 265 265 193 232 290 109 45 189 189 190 193 232 252 289 232 290 290
IV.45
DIN/PIN
MFR
PART
PAGE
HYDROCORTISONE VALERATE HydroDIURIL 25mg Tab (Not a Benefit) HydroDIURIL 50mg Tab (Not a Benefit) Hydromorph Contin 3mg CR Cap Hydromorph Contin 6mg CR Cap Hydromorph Contin 12mg CR Cap Hydromorph Contin 18mg CR Cap Hydromorph Contin 24mg CR Cap Hydromorph Contin 30mg CR Cap Hydromorphone 2mg/mL Inj Sol-1mL Pk HYDROMORPHONE HCL Hydromorphone HP-10 10mg/mL Inj Sol-1mL Pk Hydromorphone HP-20 20mg/mL Inj Hydromorphone HP-50 50mg/mL Inj-1mL Pk Hydroval 0.2% Cr Hydroval 0.2% Oint HYDROXYCHLOROQUINE SULFATE HYDROXYUREA HYDROXYZINE HCL Hygroton 50mg Tab (Not a Benefit) Hygroton 100mg Tab (Not a Benefit) Hypotears 1% Oph-Sol Hytrin 1mg Tab Hytrin 2mg Tab Hytrin 5mg Tab Hytrin 10mg Tab Hyzaar 50mg/12.5mg Tab Hyzaar DS 100mg/25mg Tab IBUPROFEN Idarac 200mg Tab (Not a Benefit) Idarac 400mg Tab (Not a Benefit) Ilosone 25mg/mL O/L (Not a Benefit) Ilosone 50mg/mL O/L (Not a Benefit) IMATINIB MESYLATE Imdur 60mg ER Tab (Not a Benefit) IMIPRAMINE Imitrex 25mg Tab (Not a Benefit) Imitrex 50mg Tab (Not a Benefit) Imitrex 100mg Tab (Not a Benefit) Imitrex DF 25mg Tab (Not a Benefit) Imitrex DF 50mg Tab (Not a Benefit) Imitrex DF 100mg Tab (Not a Benefit) Imodium 2mg Caplet Imovane 5mg Tab (Not a Benefit)
IV.46
00016500 00016519 02125323 02125331 02125366 02243562 02125382 02125390 02145901 02145928 02145936 02146126 02242984 02242985
MSD MSD PFP PFP PFP PFP PFP PFP SDZ SDZ SDZ SDZ TPH TPH
00010413 00010421 02133253 00818658 00818682 00818666 00818674 02230047 02241007 02017628 02017636 00015474 00210641 02126559
GEI GEI NOV ABB ABB ABB ABB MFC MFC SAO SAO LIL LIL AZC GSK GSK GSK GSK GSK GSK JAN SAV
02163764 01950614 02239738 02212153 02212161 00860743 02216167
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIB IIIB IIIB IIIB IIIB IIIA IIIB
290 189 189 138 138 138 139 139 139 139 138 139 139 139 290 290 31 45 170 188 188 212 118 118 118 118 112 112 128 127 127 9 9 46 8 159 17 17 17 17 17 17 217 15
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Imovane 7.5mg Tab (Not a Benefit) 01926799 Imuran 50mg Tab 00004596 INDAPAMIDE Indapamide 2.5mg Tab 02049341 Indapamide Hemihydrate 1.25mg Tab 02227339 Inderal 10mg Tab (Not a Benefit) 02042177 Inderal 20mg Tab (Not a Benefit) 02042193 Inderal 80mg Tab (Not a Benefit) 02042215 Inderal 120mg Tab (Not a Benefit) 02042223 Inderal-40 40mg Tab (Not a Benefit) 02042207 INDINAVIR Indocid 25mg Cap (Not a Benefit) 00016039 Indocid 50mg Cap (Not a Benefit) 00016047 Indocid 50mg Sup (Not a Benefit) 00594466 Indocid 100mg Sup (Not a Benefit) 00016233 INDOMETHACIN Inhibace 1mg Tab 01911465 Inhibace 2.5mg Tab 01911473 Inhibace 5mg Tab 01911481 Inhibace Plus 5mg/12.5mg Tab 02181479 Innohep 3500IU/0.35mL Inj Pref Syr 02229755 Innohep 4500IU/0.45mL Inj Pref Syr 09853898 Innohep 10000IU/0.5mL Inj Pref Syr 02231478 Innohep 14000IU/0.7mL Inj Pref Syr 09853901 Innohep 18000IU/0.9mL Inj Pref Syr 09853928 Innohep 10000IU/mL Inj-2mL Pk 02167840 Innohep 20000IU/mL Inj-2mL Pk 02229515 INSULIN (10% NEUTRAL & 90% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (20% NEUTRAL & 80% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (30% NEUTRAL & 70% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (40% NEUTRAL & 60% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (50% NEUTRAL & 50% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC (RDNA ORIGIN) INSULIN (ZINC CRYSTALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN) INSULIN ASPART INSULIN HUMAN BIOSYNTHETIC INSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70% INSULIN LISPRO INSULIN LISPRO & INSULIN LISPRO PROTAMINE Intal 1% Inh Sol-2mL Pk (Not a Benefit) INTERFERON ALFA-2B Intron A 15mu/mL 18mu MD Pen Kit
SAV GSK SEV SEV WAY WAY WAY WAY AYE MSD MSD MSD MSD HLR HLR HLR HLR LEO LEO LEO LEO LEO LEO LEO
00534609 02240693
AVE SCH
IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
16 305 190 190 190 92 93 93 93 93 26 129 130 130 130 129 104 105 105 105 76 76 76 76 76 76 76 267 267 267 268 268 267 267 265 265 268 266 268 266 268 317 46 46
IV.47
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Intron A 25mu/mL 30mu MD Pen Kit Intron A 50mu/mL 60mu MD Pen Kit Invirase 200mg Cap Invirase 500mg Tab IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE/SALBUTAMOL IRBESARTAN IRBESARTAN & HYDROCHLOROTHIAZIDE ISONIAZID ISOPROPYL MYRISTATE ISOPROTERENOL HCL Isoptin 80mg Tab (Not a Benefit) Isoptin 120mg Tab (Not a Benefit) Isoptin SR 120mg LA Tab (Not a Benefit) Isoptin SR 180mg LA Tab Isoptin SR 240mg LA Tab Isopto Atropine 1% Oph Sol Isopto Carbachol 1.5% Oph Sol Isopto Carbachol 3% Oph Sol Isopto Carpine 1% Oph Sol Isopto Carpine 2% Oph Sol Isopto Carpine 4% Oph Sol Isopto Carpine 6% Oph Sol Isopto Tears 0.5% Oph-Sol Isopto Tears 1% Oph-Sol Isordil 5mg SL Tab (Not a Benefit) Isordil 10mg Tab (Not a Benefit) Isordil 30mg Tab (Not a Benefit) ISOSORBIDE DINITRATE ISOSORBIDE-5-MONONITRATE Isotamine 300mg Tab ISOTRETINOIN Isuprel 0.5% Inh Sol-10mL Pk K-10 1.33mEq/mL O/L K-Lor 20mEq/Pouch Oral Pd-3g Pk K-Lyte/Cl 25mEq/Pouch Oral Pd-7.8g Pk Kadian 10mg SR Cap Kadian 20mg SR Cap Kadian 50mg SR Cap Kadian 100mg SR Cap Kaletra 133.3mg/33.3mg Cap Kaletra 80mg/mL & 20mg/mL O/L Kaletra 200mg & 50mg Tab
IV.48
02240694 02240695 02216965 02279320
SCH SCH HLR HLR
00554316 00554324 01907123 01934317 00742554 00035017 00000655 00000663 00000841 00000868 00000884 00000892 00000809 00000817 02042606 02042622 02042614
ABB ABB ABB ABB ABB ALC ALC ALC ALC ALC ALC ALC ALC ALC WAY WAY WAY
00272655 02017652 01918303 00481211 02089580 02242163 02184435 02184443 02184451 02243643 02243644 02285533
VAL SAO GSK ABB WEL ABB ABB ABB ABB ABB ABB ABB
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
46 46 29 29 55 209 57 110 110 20 281 61 94 95 8 119 119 203 201 201 202 202 202 202 211 211 120 120 120 120 8 20 296 61 186 186 186 142 142 142 142 27 27 27
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Kaochlor-10 1.33mEq/mL O/L (Not a Benefit) Kayexalate 1mEq/g Oral Pd-454g Pk Keflex 25mg/mL Pd for Oral Susp Keflex 50mg/mL Pd for Oral Susp Keflex 250mg Tab Keflex 500mg Tab Kemadrin 0.5mg/mL O/L Kemadrin 5mg Tab (Not a Benefit) Kenalog 0.1% Cr (Not a Benefit) Kenalog 0.1% Oint (Not a Benefit) Kenalog-10 50mg/5mL Inj Susp-5mL Pk Kenalog-40 40mg/mL Inj Susp-1mL Pk Kenalog-40 200mg/5mL Inj Susp-5mL Pk Kenalog-Orabase Oral Top Oint Keppra 250mg Tab (Not a Benefit) Keppra 500mg Tab (Not a Benefit) Keppra 750mg Tab (Not a Benefit) KETOCONAZOLE Ketoderm 2% Cr KETOPROFEN KETOROLAC TROMETHAMINE Kivexa 600mg/300mg Tab Klean-Prep Pd-1 Kit Koffex DM 3mg/mL O/L Kwellada 1% Shampoo (Not a Benefit) Kwellada-P 1% Cr Rinse Kwellada-P 5% Lot Kytril 1mg Tab LABETALOL HCL Lacri-Lube 55%/42.5% Oph Oint-3.5g Pk LACTULOSE Lamictal 25mg Tab Lamictal 100mg Tab Lamictal 150mg Tab Lamisil 1% Cr Lamisil 250mg Tab (Not a Benefit) LAMIVUDINE LAMIVUDINE & ZIDOVUDINE LAMOTRIGINE Lanoxin 0.05mg/mL O/L Lanoxin 0.0625mg Tab Lanoxin 0.125mg Tab Lanoxin 0.25mg Tab
02063859 02026961 00015547 00035645 00403628 00244392 00004405 00004758 00029114 01999796 01999761 00990876 01999869 01999788 02247027 02247028 02247029
PMJ SAV PHE PHE PHE PHE BWE BWE WSQ WSQ BQU BQU BQU BQU VLH VLH VLH
02245662
TAR
02269341 02147793 01928783 00026220 02231480 02231348 02185881 00210889
GSK RIV ROG RCA GSK GSK HLR ALL
02142082 02142104 02142112 02031094 02031116
GSK GSK GSK NOV NOV
02242320 02242321 02242322 02242323
VRO VRO VRO VRO
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA
186 187 17 17 17 17 58 58 291 291 254 254 254 291 11 11 11 6 279 279 130 200 21 186 193 281 282 282 227 110 211 219 232 151 151 151 280 2 26 27 151 87 87 87 87
IV.49
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
LANSOPRAZOLE LANSOPRAZOLE & CLARITHROMYCIN & AMOXICILLIN Lanvis 40mg Tab Largactil 25mg Tab (Not a Benefit) Largactil 50mg Tab (Not a Benefit) Largactil 100mg Tab (Not a Benefit) Lariam 250mg Tab (Not a Benefit) Lasix 10mg/mL O/L Lasix 20mg Tab Lasix 40mg Tab Lasix Special 500mg Tab LATANOPROST LATANOPROST & TIMOLOL MALEATE Lectopam 1.5mg Tab Lectopam 3mg Tab Lectopam 6mg Tab LEFLUNOMIDE Lescol 20mg Cap Lescol 40mg Cap Lescol XL 80mg ER Tab LETROZOLE LEUCOVORIN CALCIUM Leucovorin Calcium 5mg Tab Leukeran 2mg Tab LEUPROLIDE ACETATE Leustatin 1mg/mL Inj Levaquin 250mg Tab Levaquin 500mg Tab LEVETIRACETAM LEVOBUNOLOL HCL LEVODOPA & BENSERAZIDE LEVODOPA & CARBIDOPA LEVOFLOXACIN LEVONORGESTREL LEVOTHYROXINE (SODIUM) Librium 5mg Cap (Not a Benefit) Librium 10mg Cap (Not a Benefit) Librium 25mg Cap (Not a Benefit) Lidemol 0.05% Emol Cr (Not a Benefit) Lidex 0.05% Cr (Not a Benefit) Lidex 0.05% Oint (Not a Benefit) LIDOCAINE HCL Lin-Fosinopril 10mg Tab Lin-Fosinopril 20mg Tab
IV.50
00282081 01929917 01929925 01929933 02018055 02224720 02224690 02224704 02224755
GSK RPP RPP RPP HLR SAV SAV SAV SAV
00682314 00518123 00518131 02061562 02061570 02250527
HLR HLR HLR NOV NOV NOV
02170493 00004626 02022117 02236841 02236842
WAY GSK JNO JNO JNO
00012629 00012637 00012645 02163152 02161923 02161966 02242733 02242734
HLR HLR HLR MEC MEC MEC LON LON
IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
233 235 50 166 166 166 4 188 188 188 189 209 210 165 165 165 312 98 98 98 47 300 300 43 47 43 36 36 11 210 312 312 36 272 274 165 165 165 289 289 289 201 109 109
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
LINDANE (GAMMA BENZENE HEXACHLORIDE) LINEZOLID Lioresal 10mg Tab Lioresal DS 20mg Tab Lipidil 100mg Cap (Not a Benefit) Lipidil EZ 48mg Tab Lipidil EZ 145mg Tab Lipidil Micro 67mg Cap (Not a Benefit) Lipidil Micro 200mg Cap Lipidil Supra 160mg Tab Lipitor 10mg Tab Lipitor 20mg Tab Lipitor 40mg Tab Lipitor 80mg Tab Liquifilm Tears 1.4% Oph-Sol LISINOPRIL LISINOPRIL & HYDROCHLOROTHIAZIDE Lithane 150mg Cap Lithane 300mg Cap LITHIUM CARBONATE Locacorten-Vioform 0.02% & 1% Ot Sol LODOXAMIDE TROMETHAMINE Loestrin 1.5/30 0.03mg & 1.5mg Tab-21 Pk Loestrin 1.5/30 0.03mg & 1.5mg Tab-28 Pk Lomotil 2.5mg & 0.025mg Tab LOMUSTINE (CCNU) Loniten 2.5mg Tab Loniten 10mg Tab LOPERAMIDE HCL Lopid 300mg Cap Lopid 600mg Tab (Not a Benefit) LOPINAVIR & RITONAVIR Lopresor 50mg Tab Lopresor 100mg Tab Lopresor SR 100mg LA Tab Lopresor SR 200mg LA Tab LORATADINE LORAZEPAM LOSARTAN POTASSIUM LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE Losec 20mg Cap (Not a Benefit) Losec 20mg DR Tab Losec DR Tab 20mg
00455881 00636576 00885827 02269074 02269082 02230283 02146959 02241602 02230711 02230713 02230714 02243097 00045616
NOV NOV JOU FOU FOU FOU SPH SPH PFI PFI PFI PFI ALL
02013231 00406775
ERF ERF
00074454 00297143 00353027 00036323 00514497 00514500 00599026 00659606 00397423 00397431 00658855 00534560
SQI SQI SQI PFI PFI PFI PFI PFI NOV NOV NOV NOV
00846503 09857195 02190915
AST AZC AZC
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA
281 37 69 70 98 98 98 7 98 98 96 96 96 96 212 110 112 176 177 176 14 199 200 272 272 216 48 113 113 217 99 7 27 90 90 90 90 1 170 112 112 237 239 237
IV.51
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Lotensin 5mg Tab Lotensin 10mg Tab Lotensin 20mg Tab LOVASTATIN Lovenox 100mg/mL Inj Sol-3mL Vial Pk Lovenox 30mg/0.3mL Pref Syr-0.3mL Pk Lovenox 40mg/0.4mL Pref Syr-0.4mL Pk Lovenox 60mg/0.6mL Pref Syr-0.6mL Pk Lovenox 80mg/0.8mL Pref Syr-0.8mL Pk Lovenox 100mg/mL Pref Syr-1mL Pk Lovenox HP 120mg/0.8mL Pref Syr-0.8mL Pk Lovenox HP 150mg/mL Pref Syr-1mL Pk Loxapac 25mg/mL O/L (Not a Benefit) Loxapac 5mg Tab (Not a Benefit) Loxapac 10mg Tab (Not a Benefit) Loxapac 25mg Tab (Not a Benefit) Loxapac 50mg Tab (Not a Benefit) LOXAPINE HCL LOXAPINE SUCCINATE Lozide 1.25mg Tab Lozide 2.5mg Tab Lucentis 10mg/mL Inj Sol-0.3mL Vial Pk Ludiomil 25mg Tab (Not a Benefit) Ludiomil 50mg Tab (Not a Benefit) Ludiomil 75mg Tab (Not a Benefit) Lumigan 0.03% Oph Sol Lupron Depot PDS 3.75mg Inj-Kit Lupron Depot PDS 7.5mg Inj-Kit Lupron Depot PDS 11.25mg Inj-Kit Lupron Depot PDS 22.5mg Inj-Kit Lupron Depot PDS 30mg Inj-Kit Luvox 50mg Tab Luvox 100mg Tab Lyderm 0.05% Cr Lyderm 0.05% Gel Lyderm 0.05% Oint M-Eslon 10mg ER Cap M-Eslon 15mg ER Cap M-Eslon 30mg ER Cap M-Eslon 60mg ER Cap M-Eslon 100mg ER Cap M-Eslon 200mg ER Cap M.O.S. 1mg/mL O/L (Not a Benefit) M.O.S. 5mg/mL O/L
IV.52
00885835 00885843 00885851 02236564 02012472 02236883 09852468 09852476 09852484 09857137 02242692 02170000 02170019 02170027 02170132 02170035
NOV NOV NOV SAV SAV SAV SAV SAV SAV SAV SAV WAY WAY WAY WAY WAY
02179709 00564966 02296810 00360481 00360503 00360511 02245860 00884502 00836273 02239834 02230248 02239833 01919342 01919369 00716863 02236997 02236996 02019930 02177749 02019949 02019957 02019965 02177757 00486582 00514217
SEV SEV NOV CIB NOV NOV ALL ABB ABB ABB ABB ABB SPH SPH TAR TAR TAR ETH ETH ETH ETH ETH ETH VAL VAL
103 103 103 99 73 73 73 73 73 73 73 73 177 177 177 177 177 177 177 190 190 213 159 159 159 204 47 47 47 47 47 158 159 289 289 289 141 141 141 141 141 141 140 140
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
M.O.S. 10mg/mL O/L M.O.S. 20mg/mL O/L M.O.S. Conc 50 50mg/mL O/L M.O.S.-10 10mg Tab M.O.S.-20 20mg Tab M.O.S.-40 40mg Tab M.O.S.-60 60mg Tab Maalox 40mg & 40mg/mL O/L dpp (Not a Benefit) Maalox 400mg & 400mg Tab dpp (Not a Benefit) Maalox TC 120mg & 60mg/mL O/L dpp (Not a Benefit) MacroBID 100mg Cap Macrodantin 50mg Cap (Not a Benefit) Macrodantin 100mg Cap (Not a Benefit) MAGNESIUM OXIDE, CITRIC ACID, SODIUM PICOSULFATE Manerix 100mg Tab (Not a Benefit) Manerix 150mg Tab Manerix 300mg Tab MAPROTILINE HCL Marinol 2.5mg Cap Marinol 5mg Cap Marvelon 21 0.15mg & 0.03mg Tab-21 Pk Marvelon 28 0.15mg & 0.03mg Tab-28 Pk Matulane 50mg Cap Mavik 1mg Cap Mavik 2mg Cap Mavik 4mg Cap Maxeran 5mg Tab (Not a Benefit) Maxeran 10mg Tab (Not a Benefit) Maxidex 0.1% Oph Oint-3.5g Pk Maxidex 0.1% Oph Susp MEBENDAZOLE MECLIZINE HCL Medrol 4mg Tab MEDROXYPROGESTERONE ACETATE MEFENAMIC ACID MEFLOQUINE HCL Mefoxin 1g/Vial Inj Pd-1 Vial Pk (Not a Benefit) Mefoxin 2g/Vial Inj Pd-1 Vial Pk (Not a Benefit) Megace 40mg Tab (Not a Benefit) Megace 160mg Tab MEGESTROL ACETATE MELOXICAM MELPHALAN MEPERIDINE HCL
00632503 00632481 00690236 00690198 00690201 00690228 00690244 02163136 02208253 02162369 02063662 01997637 01997645 00899348 00899356 02166747 00611190 00611204 02042487 02042479 00012750 02231459 02231460 02239267 02099195 02099209 00042579 00042560
VAL VAL VAL VAL VAL VAL VAL NOV NOV NOV PGP PGP PGP HLR HLR HLR SPH SPH ORG ORG SIG ABB ABB ABB HMR HMR ALC ALC
00030988
PFI
00663697 00663700 00386391 00731323
MSD MSD BQU BQU
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA
140 141 141 141 141 141 141 215 215 215 32 32 32 219 160 160 160 159 225 225 270 270 49 118 118 118 235 235 199 199 3 227 252 273 131 4 3 3 48 48 48 132 48 140
IV.53
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
MERCAPTOPURINE Mesasal 500mg Ent Tab Mestinon 180mg LA Tab Mestinon 60mg Tab Metamucil Fibre Therapy-Original Texture Oral Pd Metamucil Sugar Free Oral Pd (Not a Benefit) Metformin 500mg Tab METFORMIN HCL METHAZOLAMIDE METHOTREXATE Methotrexate 50mg/2mL Inj Sol-2mL Pk Methotrexate 50mg/2mL Inj Sol-2mL Pk (Not a Benefit) Methotrexate 2.5mg Tab Methotrexate Sodium 20mg/2mL Inj Sol-2mL Pk METHOTRIMEPRAZINE METHOXSALEN METHSUXIMIDE METHYLCELLULOSE METHYLDOPA METHYLPHENIDATE HCL METHYLPREDNISOLONE METHYLPREDNISOLONE ACETATE METHYSERGIDE BIMALEATE METOCLOPRAMIDE HCL METOLAZONE METOPROLOL TARTRATE MetroCream 0.75% Cr Metrogel 0.75% Top Gel MetroLotion 0.75% Top Lot METRONIDAZOLE METRONIDAZOLE & NYSTATIN Mevacor 20mg Tab Mevacor 40mg Tab MEXILETINE HCL Mexitil 100mg Cap (Not a Benefit) Mexitil 200mg Cap (Not a Benefit) Miacalcin 200U/Metered Dose Nas Sp-2x14 Dose Pk (Not a Benefit) Micardis 40mg Tab Micardis 80mg Tab Micardis Plus 80mg/12.5mg Tab Micatin 2% Cr
IV.54
01914030 00869953 00869961 02174812 01912879 02242794
GSK VAL VAL PGI PGI ZYN
02182777 02170671 02170698 02182947
MAY WAY WAY MAY
02226839 02092832 02248206
GAC GAC GAC
00795860 00795852 00599956 00599964 02240775 02240769 02240770 02244344 02085852
MFC MFC BOE BOE NOV BOE BOE BOE MCL
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA
48 229 52 52 219 219 262 262 21 211 48 48 48 49 48 179 296 151 211 113 178 15 252 253 69 235 190 90 283 283 283 31 283 283 99 99 91 91 91 22 117 117 117 279
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
MICONAZOLE NITRATE Microlax Micro Enema-5mL Pk Micronor 0.35mg Tab-28 Pk Midamor 5mg Tab (Not a Benefit) MIDODRINE HCL Min-Ovral 0.03mg & 0.15mg Tab-21 Pk Min-Ovral 0.03mg & 0.15mg Tab-28 Pk MINERAL OIL Minestrin 1/20 0.02mg & 1mg Tab-21 Pk Minestrin 1/20 0.02mg & 1mg Tab-28 Pk Minipress 1mg Tab Minipress 2mg Tab Minipress 5mg Tab Minitran 0.4mg/Hr/13.3 Sq Cm Patch Minitran 0.6mg/Hr/20 Sq Cm Patch Minocin 50mg Cap (Not a Benefit) Minocin 100mg Cap (Not a Benefit) MINOCYCLINE HCL MINOXIDIL Mirapex 0.25mg Tab Mirapex 0.25mg Tab Mirapex 0.5mg Tab (Not a Benefit) Mirapex 1mg Tab Mirapex 1mg Tab Mirapex 1.5mg Tab Mirapex 1.5mg Tab Mirena 52mg Insert MIRTAZAPINE MISOPROSTOL Mobicox 7.5mg Tab Mobicox 15mg Tab MOCLOBEMIDE MODAFINIL Modecate 125mg/5mL Inj Susp-5mL Pk (Not a Benefit) Modecate Concentrate 100mg/mL Inj Sol-1mL Pk Moditen HCL 1mg Tab (Not a Benefit) Moditen HCL 2mg Tab (Not a Benefit) Moditen HCL 5mg Tab (Not a Benefit) Modulon 100mg Tab (Not a Benefit) Modulon 200mg Tab (Not a Benefit) Moduret 5mg & 50mg Tab (Not a Benefit) Mogadon 5mg Tab Mogadon 10mg Tab MOMETASONE FUROATE
02063905 00037605 00487805 02042320 02042339 00315966 00343838 00560952 00560960 00560979 02163527 02163535 02173514 02173506
PFI JNO MSD WAY WAY SQI SQI PFI PFI PFI GRA GRA STI STI
02237145 09857268 02241594 02237146 09857269 02237147 09857270 02243005
BOE BOE BOE BOE BOE BOE BOE BAY
02242785 02242786
BOE BOE
00349917 00755575 00029378 00029386 00029408 00587869 00803499 00487813 00511528 00511536
BQU BQU BQU BQU BQU AXC AXC PRE VAL VAL
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA
279 220 273 187 191 271 271 219 272 272 115 115 115 121 122 2 3 2 113 181 181 16 182 182 182 182 272 160 236 132 132 160 15 168 168 168 168 168 5 5 187 179 179 291
IV.55
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Monistat 3 400mg Vag Sup Monistat 3 Dual Pak 2% Cr-9g & 400mg Vag Sup-3 Pk Monistat 7 2% Vag Cr-App 35g Pk Monistat 7 100mg Vag Sup-7 Pk Monistat Derm 2% Cr Monitan 100mg Tab (Not a Benefit) Monitan 200mg Tab (Not a Benefit) Monitan 400mg Tab (Not a Benefit) Monocor 5mg Tab Monocor 10mg Tab Monopril 10mg Tab Monopril 20mg Tab MONTELUKAST SODIUM MORPHINE HCL Morphine HP-50 50mg/mL Inj Sol-1mL Pk MORPHINE SULFATE Morphine Sulfate 15mg/mL Inj Sol Amp Morphine Sulfate Injection USP 15mg/mL Inj Sol Amp (Not a Benefit) Motilium 10mg Tab (Not a Benefit) Motrin 200mg Tab (Not a Benefit) Motrin 300mg Tab (Not a Benefit) Motrin 400mg Tab Motrin 600mg Tab (Not a Benefit) MOXIFLOXACIN HYDROCHLORIDE MS Contin 15mg SR Tab MS Contin 30mg SR Tab MS Contin 60mg SR Tab MS Contin 100mg SR Tab MS Contin 200mg SR Tab MS-IR 20mg Tab MS-IR 30mg Tab Mucillium Oral Pd Multipax 10mg Cap (Not a Benefit) Multipax 25mg Cap (Not a Benefit) Multipax 50mg Cap (Not a Benefit) MUPIROCIN Myambutol 100mg Tab (Not a Benefit) Myambutol 400mg Tab (Not a Benefit) Mycobutin 150mg Cap MYCOPHENOLATE MOFETIL MYCOPHENOLATE SODIUM Mycostatin 100000U/g Cr (Not a Benefit) Mycostatin 100000U/mL O/L (Not a Benefit)
IV.56
02126605 02126249 02084309 02084295 00497797 02036290 02036436 02036444 02241148 02241149 01907107 01907115
MCL MCL MCL MCL OMC WAY WAY WAY BIO CRY BQU BQU
00617288 00392561 00850330 00855820 00252409 00327794 00364142 00484911 02015439 02014297 02014300 02014319 02014327 02014238 02014254 00599875 01927876 01938835 01927884 00127957 02170078 02063786
SDZ SDZ ABB JAN UPJ UPJ UPJ UPJ PFP PFP PFP PFP PFP PFP PFP PMS RPP RPP RPP LED WAY PFI
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
279 279 279 279 279 83 83 83 85 85 109 109 313 140 142 141 142 142 231 128 129 129 129 38 142 142 143 143 143 143 143 219 170 170 170 277 20 20 20 314 314 280 6
00029092 00248169
BQU BQU
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Mycostatin 100000U/g Oint (Not a Benefit) Mycostatin 500000U Tab (Not a Benefit) Mycostatin 25000U/g Vag Cr (Not a Benefit) Myfortic 180mg Ent Coated Tab Myfortic 360mg Ent Coated Tab Myleran 2mg Tab Myochrysine 10mg/mL Inj Sol-1mL Pk Myochrysine 25mg/mL Inj Sol-1mL Pk Myochrysine 50mg/mL Inj Sol-1mL Pk Mysoline 125mg Tab (Not a Benefit) Mysoline 250mg Tab (Not a Benefit) NABILONE NABUMETONE NADOLOL Nadopen-V 25mg/mL O/L (Not a Benefit) NADROPARIN CALCIUM NAPHAZOLINE HCL Naphcon Forte 0.1% Oph Sol (Not a Benefit) Naprosyn 25mg/mL O/L Naprosyn 500mg Sup (Not a Benefit) Naprosyn 125mg Tab (Not a Benefit) Naprosyn 250mg Tab (Not a Benefit) Naprosyn 375mg Tab (Not a Benefit) Naprosyn 500mg Tab (Not a Benefit) Naprosyn E 250mg Ent Tab (Not a Benefit) Naprosyn E 375mg Ent Tab (Not a Benefit) Naprosyn E 500mg Ent Tab (Not a Benefit) Naprosyn SR 750mg SR Tab (Not a Benefit) NAPROXEN Naproxen 500mg Sup NAPROXEN SODIUM Nardil 15mg Tab Navane 2mg Cap Navane 5mg Cap Navane 10mg Cap Nebcin 80mg/2mL Inj Sol-2mL Pk (Not a Benefit) NELFINAVIR MESYLATE Nembutal 100mg Cap Neoral 10mg Cap Neoral 25mg Cap Neoral 50mg Cap Neoral 100mg Cap Neoral 100mg/mL O/L
00029556 00029416 00295973 02264560 02264579 00004618 01927620 01927612 01927604 02042363 02042355
BQU BQU BQU NOV NOV GSK SAV SAV SAV WAY WAY
00018635
NDA
00390283 02162431 02162458 00299413 02162474 02162482 02162490 02162792 02162415 02162423 02162466
ALC HLR HLR SYN HLR HLR HLR HLR HLR HLR HLR
02230477 00476552 00024430 00024449 00024457 00325449 00000086 02237671 02150689 02150662 02150670 02150697
SDZ ERF ERF ERF ERF LIL ABB NOV NOV NOV NOV NOV
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
280 6 280 314 314 42 245 245 245 152 152 227 9 91 13 75 203 203 132 133 133 133 133 133 10 10 10 132 132 10 133 10 162 176 176 176 19 27 180 308 308 308 308 308
IV.57
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
NEOSTIGMINE BROMIDE Neptazane 50mg Tab (Not a Benefit) Nerisone 0.1% Cr Nerisone 0.1% Oily Cr Nerisone 0.1% Oint Neuleptil 5mg Cap Neuleptil 10mg Cap Neuleptil 10mg/mL O/L Neurontin 100mg Cap Neurontin 300mg Cap Neurontin 400mg Cap Neurontin 600mg Tab (Not a Benefit) Neurontin 800mg Tab (Not a Benefit) Neutralca-S 40mg & 40mg/mL O/L dpp (Not a Benefit) NEVIRAPINE Niacin-ICN 50mg Tab dpp (Not a Benefit) Niacin-ICN 100mg Tab dpp NICOTINIC ACID NIFEDIPINE Nifuran 50mg Tab (Not a Benefit) Nifuran 100mg Tab (Not a Benefit) NILUTAMIDE NIMODIPINE Nimotop 30mg SG Cap Nitrazadon 5mg Tab Nitrazadon 10mg Tab NITRAZEPAM Nitro-Dur 0.4mg/Hr/20 Sq Cm Patch Nitro-Dur 0.6mg/Hr/30 Sq Cm Patch NITROFURANTOIN NITROFURANTOIN MONO/MICRO CRYSTALS NITROGLYCERIN Nitrol 2% Oint Nitrolingual 0.4mg/Metered Dose Spray-200 Dose Pk (Not a Benefit) Nitrolingual Pump Spray 0.4mg/Metered Dose Spray-200 Dose Pk Nitrostat 0.3mg SL Tab Nitrostat 0.6mg SL Tab Nix 1% Cr Rinse Nix Dermal Cream 5% Cr NIZATIDINE Nizoral 2% Cr Nizoral 200mg Tab
IV.58
02238071 00587826 00587818 00587834 01926780 01926772 01926756 02084260 02084279 02084287 02239717 02239718 00261173 00268593 00268585
WAY STI STI STI ERF ERF ERF PFI PFI PFI PFI PFI DES VAL VAL
00017086 00017094
MAN MAN
02155923 02229654 02229655 01911902 01911929
BAY VAL VAL SCH SCH
01926454 01926721 02231441 00037613 00037621 00771368 02219905 00703974 00633836
SQI AVE SAV PFI PFI BWE GSK JAN JAN
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
52 211 288 288 288 172 172 172 150 150 150 11 11 215 27 300 300 300 91 113 32 32 49 121 121 179 179 179 121 121 32 32 121 121 122 122 122 122 282 282 236 279 6
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Nolvadex 10mg Tab (Not a Benefit) Nolvadex D 20mg Tab NORETHINDRONE Norflex 60mg/2mL Inj Sol-2mL Pk (Not a Benefit) NORFLOXACIN NORGESTIMATE & ETHINYL ESTRADIOL Noritate 1% Top Cr Normacol 62% W/W Gran 1 Sach Pk Noroxin 400mg Tab (Not a Benefit) Norpace 100mg Cap (Not a Benefit) Norpace 150mg Cap (Not a Benefit) Norpramin 25mg Tab Norpramin 50mg Tab Norpramin 75mg Tab (Not a Benefit) Norprolac 0.075mg Tab Norprolac 0.15mg Tab NORTRIPTYLINE Norvasc 5mg Tab Norvasc 10mg Tab Norvir 80mg/mL O/L Norvir SEC 100mg Cap Novamilor 5mg & 50mg Tab Novamoxin 250mg Cap Novamoxin 500mg Cap Novamoxin 25mg/mL O/L Novamoxin 50mg/mL O/L Novamoxin (Sugar Reduced) 25mg/mL O/L (Not a Benefit) Novamoxin (Sugar Reduced) 50mg/mL O/L (Not a Benefit) Novasen 325mg Ent Tab (Not a Benefit) Novasen 650mg Ent Tab (Not a Benefit) Novo-Acebutolol 100mg Tab Novo-Acebutolol 200mg Tab Novo-Acebutolol 400mg Tab Novo-Acyclovir 200mg Tab (Not a Benefit) Novo-Acyclovir 400mg Tab (Not a Benefit) Novo-Acyclovir 800mg Tab Novo-Alendronate 5mg Tab (Not a Benefit) Novo-Alendronate 10mg Tab Novo-Alendronate 70mg Tab Novo-Alprazol 0.25mg Tab Novo-Alprazol 0.5mg Tab Novo-Amiodarone 200mg Tab Novo-Ampicillin 250mg Cap Novo-Ampicillin 500mg Cap
02048477 02048485 01966162
AZC AZC MMH
02156091 02147831 00643025 02030799 02030802 02099128 02099136 02099144 02223767 02223775 00878928 00878936 02229145 02241480 01937219 00406724 00406716 00452149 00452130 01934171 01934163 00216666 00229296 02204517 02204525 02204533 02285959 02285967 02285975 02248251 02247373 02261715 01913484 01913492 02239835 00020877 00020885
SAV RIV MSD RBT RBT SAV SAV HMR FEI FEI PFI PFI ABB ABB NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA
49 49 273 70 38 274 283 220 38 89 89 157 157 157 315 315 161 84 84 28 28 187 10 10 10 11 10 11 123 123 83 83 83 4 4 22 23 303 303 164 165 84 12 12
IV.59
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Novo-Atenol 50mg Tab Novo-Atenol 100mg Tab Novo-Atenolthalidone 50 & 25mg Tab Novo-Atenolthalidone 100 & 25mg Tab Novo-Azathioprine 50mg Tab Novo-Azithromycin 250mg Tab Novo-Benzydamine 0.15% Oral Rinse Novo-Betahistine 16mg Tab (Not a Benefit) Novo-Betahistine 24mg Tab (Not a Benefit) Novo-Bicalutamide 50mg Tab Novo-Bisoprolol 5mg Tab Novo-Bisoprolol 10mg Tab Novo-Bromazepam 3mg Tab Novo-Bromazepam 6mg Tab Novo-Bupropion SR 150mg Tab Novo-Buspirone 10mg Tab (Not a Benefit) Novo-C 100mg Tab (Not a Benefit) Novo-C 250mg Tab (Not a Benefit) Novo-C 500mg Tab (Not a Benefit) Novo-C 1000mg Tab (Not a Benefit) Novo-Captopril 12.5mg Tab Novo-Captopril 25mg Tab Novo-Captopril 50mg Tab Novo-Captopril 100mg Tab Novo-Carbamaz 200mg Tab Novo-Cefaclor 250mg Cap (Not a Benefit) Novo-Cefaclor 500mg Cap (Not a Benefit) Novo-Cefadroxil 500mg Cap Novo-Chloroquine 250mg Tab Novo-Chlorpromazine 25mg Tab Novo-Chlorpromazine 50mg Tab Novo-Chlorpromazine 100mg Tab Novo-Cilazapril 1mg Tab Novo-Cilazapril 2.5mg Tab Novo-Cilazapril 5mg Tab Novo-Cimetine 200mg Tab Novo-Cimetine 300mg Tab Novo-Cimetine 400mg Tab Novo-Cimetine 600mg Tab Novo-Cimetine 800mg Tab Novo-Ciprofloxacin 250mg Tab Novo-Ciprofloxacin 500mg Tab Novo-Ciprofloxacin 750mg Tab Novo-Citalopram 20mg Tab
IV.60
01912062 01912054 02302918 02302926 02236819 02267845 02229799 02280191 02280205 02270226 02267470 02267489 02230584 02230585 02260239 02231492 00021970 00021237 00021997 00535907 01942964 01942972 01942980 01942999 00782718 02231691 02231693 02235134 00021261 00232823 00232807 00232831 02266350 02266369 02266377 00582409 00582417 00603678 00603686 00663727 02161737 02161745 02161753 02251558
NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
84 85 103 103 305 8 201 8 8 41 85 85 165 165 155 15 301 301 301 301 104 104 104 104 147 14 14 15 31 166 166 166 104 105 105 230 230 230 231 231 33 33 33 156
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Novo-Citalopram 20mg Tab Novo-Citalopram 40mg Tab Novo-Citalopram 40mg Tab Novo-Clavamoxin 875 875mg & 125mg Tab Novo-Clindamycin 150mg Cap Novo-Clindamycin 300mg Cap Novo-Clobazam 10mg Tab Novo-Clobetasol 0.05% Cr Novo-Clobetasol 0.05% Oint Novo-Clonazepam 0.5mg Tab Novo-Clonazepam 2mg Tab Novo-Clonidine 0.025mg Tab (Not a Benefit) Novo-Clonidine 0.1mg Tab Novo-Clonidine 0.2mg Tab Novo-Clopate 3.75mg Cap Novo-Clopate 7.5mg Cap Novo-Clopate 15mg Cap Novo-Cloxin 250mg Cap Novo-Cloxin 500mg Cap Novo-Cloxin 25mg/mL O/L Novo-Cycloprine 10mg Tab (Not a Benefit) Novo-Cyproterone 50mg Tab Novo-Desmopressin 0.1mg Tab Novo-Desmopressin 0.2mg Tab Novo-Difenac 25mg Ent Tab Novo-Difenac 50mg Ent Tab Novo-Difenac SR 75mg LA Tab Novo-Difenac SR 100mg LA Tab Novo-Difenac-K 50mg Tab (Not a Benefit) Novo-Diflunisal 250mg Tab Novo-Diltazem 30mg Tab Novo-Diltazem 60mg Tab Novo-Diltazem CD 120mg LA Cap Novo-Diltazem CD 180mg LA Cap Novo-Diltazem CD 240mg LA Cap Novo-Diltazem CD 300mg LA Cap Novo-Diltiazem HCL ER 120mg SR Cap Novo-Diltiazem HCL ER 180mg SR Cap Novo-Diltiazem HCL ER 240mg SR Cap Novo-Diltiazem HCL ER 300mg SR Cap Novo-Diltiazem HCL ER 360mg SR Cap Novo-Dimenate 50mg Tab (Not a Benefit) Novo-Divalproex 125mg Ent Tab Novo-Divalproex 250mg Ent Tab
02293218 02251566 02293226 02248138 02241709 02241710 02238334 02093162 02126192 02239024 02239025 02304163 02046121 02046148 00628190 00628204 00628212 00337765 00337773 00337757 02080052 02232872 02287730 02287749 00808539 00808547 02158582 02048698 02239355 02048493 00862924 00862932 02242538 02242539 02242540 02242541 02271605 02271613 02271621 02271648 02271656 00021423 02239701 02239702
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
156 156 156 12 17 18 148 287 287 148 148 7 105 105 166 166 166 13 13 13 70 43 269 269 125 125 125 126 9 127 89 89 87 88 88 88 88 89 89 89 89 225 149 149
IV.61
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Novo-Divalproex 500mg Ent Tab Novo-Domperidone 10mg Tab Novo-Doxazosin 1mg Tab Novo-Doxazosin 2mg Tab Novo-Doxazosin 4mg Tab Novo-Doxepin 75mg Cap Novo-Doxepin 100mg Cap Novo-Doxepin 150mg Cap Novo-Enalapril 2.5mg Tab Novo-Enalapril 5mg Tab Novo-Enalapril 10mg Tab Novo-Enalapril 20mg Tab Novo-Famotidine 20mg Tab Novo-Famotidine 40mg Tab Novo-Fenofibrate Micronized 200mg Cap Novo-Fenofibrate-S 160mg Tab Novo-Ferrogluc 300mg Tab Novo-Fibrate 500mg Cap (Not a Benefit) Novo-Fibre Tab Novo-Fluconazole 50mg Tab Novo-Fluconazole 100mg Tab Novo-Fluconazole-150 150mg Cap Novo-Fluoxetine 10mg Cap (Not a Benefit) Novo-Fluoxetine 20mg Cap Novo-Flurprofen 50mg Tab Novo-Flurprofen 100mg Tab Novo-Flutamide 250mg Tab Novo-Fluvoxamine 50mg Tab Novo-Fluvoxamine 100mg Tab Novo-Fosinopril 10mg Tab Novo-Fosinopril 20mg Tab Novo-Furantoin 50mg Cap Novo-Furantoin 100mg Cap Novo-Gabapentin 100mg Cap Novo-Gabapentin 300mg Cap Novo-Gabapentin 400mg Cap Novo-Gabapentin 600mg Tab (Not a Benefit) Novo-Gabapentin 800mg Tab (Not a Benefit) Novo-Gemfibrozil 300mg Cap Novo-Gemfibrozil 600mg Tab (Not a Benefit) Novo-Gesic 325mg Tab Novo-Gesic Forte 500mg Tab Novo-Gliclazide 80mg Tab Novo-Glimepiride 1mg Tab (Not a Benefit)
IV.62
02239703 02157195 02242728 02242729 02242730 01913441 01913468 01913476 02300680 02233005 02233006 02233007 02022133 02022141 02243552 02289091 00021458 00337382 00595829 02236978 02236979 02243645 02216582 02216590 02100509 02100517 02230089 02239953 02239954 02247802 02247803 02231015 02231016 02244513 02244514 02244515 02248457 02247346 02241704 02142074 00389218 00482323 02238103 02273756
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIB IIIA IIIA IIIA IIIB
149 231 106 106 106 157 157 158 106 107 107 107 232 232 98 98 71 97 218 5 5 279 13 158 128 128 45 158 159 109 109 32 32 150 150 150 11 11 99 7 145 146 261 21
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Novo-Glimepiride 2mg Tab (Not a Benefit) Novo-Glimepiride 4mg Tab (Not a Benefit) Novo-Glyburide 2.5mg Tab Novo-Glyburide 5mg Tab Novo-Hydrazide 25mg Tab Novo-Hydrazide 50mg Tab Novo-Hydroxyzin 10mg Cap (Not a Benefit) Novo-Hydroxyzin 25mg Cap (Not a Benefit) Novo-Hydroxyzin 50mg Cap (Not a Benefit) Novo-Hylazin 25mg Tab Novo-Hylazin 50mg Tab Novo-Indapamide 2.5mg Tab Novo-Ipramide 250mcg/mL Inh Sol-20mL Pk Novo-Ketoconazole 200mg Tab Novo-Lamotrigine 25mg Tab Novo-Lamotrigine 100mg Tab Novo-Lamotrigine 150mg Tab Novo-Leflunomide 10mg Tab Novo-Leflunomide 20mg Tab Novo-Levocarbidopa 100mg & 10mg Tab Novo-Levocarbidopa 100mg & 25mg Tab Novo-Levocarbidopa 250mg & 25mg Tab Novo-Lexin 250mg Cap Novo-Lexin 500mg Cap Novo-Lexin 25mg/mL Pd for Oral Susp Novo-Lexin 50mg/mL Pd for Oral Susp Novo-Lexin 250mg Tab (Not a Benefit) Novo-Lexin 500mg Tab (Not a Benefit) Novo-Lisinopril (Type P) 5mg Tab Novo-Lisinopril (Type P) 10mg Tab Novo-Lisinopril (Type P) 20mg Tab Novo-Lisinopril (Type Z) 5mg Tab Novo-Lisinopril (Type Z) 10mg Tab Novo-Lisinopril (Type Z) 20mg Tab Novo-Lisinopril/HCTZ (Type P) 10mg & 12.5mg Tab Novo-Lisinopril/HCTZ (Type P) 20mg & 12.5mg Tab Novo-Lisinopril/HCTZ (Type Z) 10mg & 12.5mg Tab Novo-Lisinopril/HCTZ (Type Z) 20mg & 12.5mg Tab Novo-Loperamide 2mg Caplet Novo-Lorazem 0.5mg Tab Novo-Lorazem 1mg Tab Novo-Lorazem 2mg Tab Novo-Lovastatin 20mg Tab Novo-Lovastatin 40mg Tab
02273764 02273772 01913670 01913689 00021474 00021482 00738824 00738832 00738840 00759473 00759481 02231184 02210479 02231061 02248232 02248233 02248234 02261251 02261278 02244494 02244495 02244496 00342084 00342114 00342106 00342092 00583413 00583421 02285061 02285088 02285096 02285118 02285126 02285134 02302136 02302144 02301768 02301776 02132591 00711101 00637742 00637750 02246542 02246543
IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
21 21 262 262 189 189 170 170 170 109 109 190 55 6 151 151 151 312 312 312 313 313 17 17 17 17 17 17 110 110 111 111 111 111 112 112 112 112 217 170 170 170 99 99
IV.63
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Novo-Maprotiline 25mg Tab Novo-Maprotiline 50mg Tab Novo-Maprotiline 75mg Tab Novo-Medrone 2.5mg Tab Novo-Medrone 5mg Tab Novo-Medrone 10mg Tab Novo-Meloxicam 7.5mg Tab Novo-Meloxicam 15mg Tab Novo-Metformin 500mg Tab Novo-Methacin 25mg Cap Novo-Methacin 50mg Cap Novo-Metoprol 50mg Tab Novo-Metoprol 100mg Tab Novo-Metoprol (Uncoated) 50mg Tab Novo-Metoprol (Uncoated) 100mg Tab Novo-Mexiletine 100mg Cap Novo-Mexiletine 200mg Cap Novo-Mirtazapine 30mg Tab Novo-Mirtazapine OD 15mg Orally Disintegrating Tab Novo-Mirtazapine OD 30mg Orally Disintegrating Tab Novo-Mirtazapine OD 45mg Orally Disintegrating Tab Novo-Misoprostol 100mcg Tab Novo-Moclobemide 100mg Tab Novo-Moclobemide 150mg Tab Novo-Moclobemide 300mg Tab Novo-Morphine SR 60mg SR Tab Novo-Morphine SR 100mg SR Tab Novo-Morphine SR 200mg SR Tab Novo-Nabumetone 500mg Tab (Not a Benefit) Novo-Nabumetone 750mg Tab (Not a Benefit) Novo-Nadolol 40mg Tab Novo-Nadolol 80mg Tab Novo-Naprox 250mg Tab Novo-Naprox 375mg Tab Novo-Naprox 500mg Tab Novo-Niacin 50mg Tab dpp (Not a Benefit) Novo-Nizatidine 150mg Cap Novo-Nizatidine 300mg Cap Novo-Norfloxacin 400mg Tab Novo-Nortriptyline 10mg Cap Novo-Nortriptyline 25mg Cap Novo-Ofloxacin 200mg Tab Novo-Ofloxacin 300mg Tab Novo-Ofloxacin 400mg Tab
IV.64
02158612 02158620 02158639 02221284 02221292 02221306 02258315 02258323 02045710 00337420 00337439 00648035 00648043 00842648 00842656 02230359 02230360 02259354 02279894 02279908 02279916 02240754 02239746 02239747 02239748 02302780 02302799 02302802 02240867 02240868 02126753 02126761 00565350 00627097 00589861 00274496 02240457 02240458 02237682 02231781 02231782 02243474 02243475 02243476
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
159 159 159 273 273 273 132 132 262 129 130 90 90 90 90 91 91 160 160 160 160 236 160 160 160 143 143 143 9 9 91 91 133 133 133 300 236 236 38 161 161 39 39 39
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Novo-Olanzapine 2.5mg Tab Novo-Olanzapine 5mg Tab Novo-Olanzapine 7.5mg Tab Novo-Olanzapine 10mg Tab Novo-Olanzapine 15mg Tab Novo-Ondansetron 4mg Tab Novo-Ondansetron 8mg Tab Novo-Oxybutynin 5mg Tab Novo-Pantoprazole 40mg Ent Tab Novo-Paroxetine 10mg Tab (Not a Benefit) Novo-Paroxetine 20mg Tab Novo-Paroxetine 30mg Tab Novo-Pen-VK-500 60mg/mL O/L Novo-Pen-VK-500 300mg Tab Novo-Peridol 0.5mg Tab Novo-Peridol 1mg Tab Novo-Peridol 2mg Tab Novo-Peridol 5mg Tab Novo-Peridol 10mg Tab Novo-Peridol 20mg Tab Novo-Pindol 5mg Tab Novo-Pindol 10mg Tab Novo-Pindol 15mg Tab Novo-Pioglitazone 15mg Tab Novo-Pioglitazone 30mg Tab Novo-Pioglitazone 45mg Tab Novo-Pirocam 10mg Cap Novo-Pirocam 20mg Cap Novo-Pramipexole 0.25mg Tab Novo-Pramipexole 0.5mg Tab (Not a Benefit) Novo-Pramipexole 1mg Tab Novo-Pramipexole 1.5mg Tab Novo-Pranol 10mg Tab Novo-Pranol 20mg Tab Novo-Pranol 40mg Tab Novo-Pranol 80mg Tab Novo-Pravastatin 10mg Tab Novo-Pravastatin 20mg Tab Novo-Pravastatin 40mg Tab Novo-Prazin 1mg Tab Novo-Prazin 2mg Tab Novo-Prazin 5mg Tab Novo-Prednisone 5mg Tab Novo-Prednisone 50mg Tab
02276712 02276720 02276739 02276747 02276755 02264056 02264064 02230394 02285487 02248556 02248557 02248558 00391603 00021202 00363685 00363677 00363669 00363650 00713449 00768820 00869007 00869015 00869023 02274914 02274922 02274930 00695718 00695696 02269309 02269317 02269325 02269333 00496480 00740675 00496499 00496502 02247008 02247009 02247010 01934198 01934201 01934228 00021695 00232378
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
171 171 171 171 171 228 228 58 240 13 161 161 13 13 168 169 169 169 169 169 114 114 115 263 263 263 134 134 181 16 182 182 92 93 93 93 100 100 100 115 115 115 253 253
IV.65
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Novo-Profen 200mg Tab Novo-Profen 400mg Tab Novo-Profen 600mg Tab Novo-Purol 100mg Tab Novo-Purol 200mg Tab Novo-Purol 300mg Tab Novo-Rabeprazole EC 10mg Tab Novo-Rabeprazole EC 20mg Tab Novo-Ramipril Cap 2.5mg Novo-Ramipril Cap 5mg Novo-Ramipril Cap 10mg Novo-Ranidine 15mg/mL Oral Sol Novo-Ranidine 150mg Tab Novo-Ranidine 300mg Tab Novo-Risperidone 0.25mg Tab Novo-Risperidone 0.5mg Tab Novo-Risperidone 1mg Tab Novo-Risperidone 2mg Tab Novo-Risperidone 3mg Tab Novo-Risperidone 4mg Tab Novo-Rythro Estolate 25mg/mL O/L Novo-Rythro Estolate 50mg/mL O/L Novo-Rythro Ethyl Succinate 40mg/mL O/L Novo-Rythro Ethyl Succinate 80mg/mL O/L Novo-Salmol 100mcg/Metered Dose Inh-200 Dose Pk (Not a Benefit) Novo-Selegiline 5mg Tab Novo-Semide 20mg Tab Novo-Semide 40mg Tab Novo-Sertraline 25mg Cap Novo-Sertraline 50mg Cap Novo-Sertraline 100mg Cap Novo-Simvastatin 5mg Tab Novo-Simvastatin 10mg Tab Novo-Simvastatin 20mg Tab Novo-Simvastatin 40mg Tab Novo-Simvastatin 80mg Tab Novo-Sotalol 80mg Tab (Not a Benefit) Novo-Sotalol 160mg Tab Novo-Spiroton 25mg Tab Novo-Spiroton 100mg Tab Novo-Spirozine-25 25mg & 25mg Tab Novo-Spirozine-50 50mg & 50mg Tab Novo-Sucralate 1g Tab
IV.66
00629324 00629340 00629359 00364282 00565342 00363693 02296632 02296640 02247945 02247946 02247947 02242940 00828564 00828556 02282690 02264188 02264196 02264218 02264226 02264234 00021172 00262595 00605859 00652318 00874086 02068087 00337730 00337749 02240485 02240484 02240481 02250144 02250152 02250160 02250179 02250187 02231181 02231182 00613215 00613223 00613231 00657182 02045702
NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP NOP
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA
128 129 129 304 304 304 242 242 116 117 117 242 242 243 174 174 175 175 175 175 9 9 9 9 66 317 188 188 162 162 162 101 101 102 102 102 7 94 191 191 189 189 243
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Novo-Sumatriptan DF 25mg Tab (Not a Benefit) Novo-Sumatriptan DF 50mg Tab (Not a Benefit) Novo-Sumatriptan DF 100mg Tab (Not a Benefit) Novo-Sundac 150mg Tab Novo-Sundac 200mg Tab Novo-Tamoxifen 10mg Tab Novo-Tamoxifen 20mg Tab Novo-Tamsulosin SR 0.4mg Cap Novo-Temazepam 15mg Cap Novo-Temazepam 30mg Cap Novo-Terazosin 1mg Tab Novo-Terazosin 2mg Tab Novo-Terazosin 5mg Tab Novo-Terazosin 10mg Tab Novo-Terbinafine 250mg Tab (Not a Benefit) Novo-Theophyl SR 300mg LA Tab Novo-Tiaprofenic 200mg Tab Novo-Tiaprofenic 300mg Tab Novo-Ticlopidine 250mg Tab Novo-Timol 5mg Tab Novo-Timol 10mg Tab Novo-Timol 20mg Tab Novo-Topiramate 25mg Tab Novo-Topiramate 100mg Tab Novo-Topiramate 200mg Tab Novo-Trazodone 50mg Tab Novo-Trazodone 100mg Tab Novo-Trazodone 150mg Tab Novo-Triamzide 25mg & 50mg Tab Novo-Trimel 40mg & 8mg/mL O/L Novo-Trimel 400mg & 80mg Tab Novo-Trimel DS 800mg & 160mg Tab Novo-Valproic 250mg Cap Novo-Venlafaxine XR 37.5mg ER Cap Novo-Venlafaxine XR 75mg ER Cap Novo-Venlafaxine XR 150mg ER Cap Novo-Veramil SR 240mg LA Tab Novo-Warfarin 1mg Tab Novo-Warfarin 2mg Tab Novo-Warfarin 2.5mg Tab Novo-Warfarin 3mg Tab Novo-Warfarin 4mg Tab Novo-Warfarin 5mg Tab Novo-Zopiclone 5mg Tab (Not a Benefit)
02286815 02286823 02286831 00745588 00745596 00851965 00851973 02281392 02230095 02230102 02230805 02230806 02230807 02230808 02240346 02230087 02179679 02179687 02236848 01947796 01947818 01947826 02248860 02248861 02248862 02144263 02144271 02144298 00532657 00726540 00510637 00510645 02100630 02275023 02275031 02275058 02211920 02265273 02265281 02265303 02265311 02265338 02265346 02251450
IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB
17 17 17 135 135 49 49 319 180 180 118 118 118 118 2 299 135 135 320 94 94 94 153 153 153 163 163 163 190 40 40 40 154 164 164 164 119 77 77 77 77 77 78 15
IV.67
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Novo-Zopiclone 7.5mg Tab (Not a Benefit) Novolin ge 10/90 Penfill 100U/mL Inj Susp-5X3mL Pk Novolin ge 20/80 Penfill 100U/mL Inj Susp-5X3mL Pk Novolin ge 30/70 1000U/10mL Inj Susp-10mL Pk Novolin ge 30/70 Penfill 100U/mL Inj Susp-5X3mL Pk Novolin ge 40/60 Penfill 100U/mL Inj Susp-5X3mL Pk Novolin ge 50/50 Penfill 100U/mL Inj Susp-5X3mL Pk Novolin ge NPH 1000U/10mL Inj Susp-10mL Pk Novolin ge NPH Penfill 100U/mL Inj Susp-5X3mL Pk Novolin ge Toronto 1000U/10mL Inj Sol-10mL Pk Novolin ge Toronto Penfill 100U/mL Inj Sol-5X3mL Pk NovoMix 30 Penfill 100U/mL Inj Susp-5x3mL Pk NovoRapid 100U/mL Inj Sol-10mL Pk NovoRapid Penfill 100U/mL Inj Sol-5x3mL Pk Nozinan 25mg/mL Inj Sol-1mL Pk Nozinan 2mg Tab (Not a Benefit) Nozinan 5mg Tab Nozinan 25mg Tab Nozinan 50mg Tab Nu-Acebutolol 100mg Tab Nu-Acebutolol 200mg Tab Nu-Acebutolol 400mg Tab Nu-Acyclovir 800mg Tab Nu-Alpraz 0.25mg Tab Nu-Alpraz 0.5mg Tab Nu-Amilzide 5mg & 50mg Tab Nu-Amoxi 250mg Cap (Not a Benefit) Nu-Amoxi 500mg Cap (Not a Benefit) Nu-Amoxi 25mg/mL O/L (Not a Benefit) Nu-Amoxi 50mg/mL O/L (Not a Benefit) Nu-Atenol 50mg Tab Nu-Atenol 100mg Tab Nu-Baclo 10mg Tab Nu-Baclo 20mg Tab Nu-Bromazepam 1.5mg Tab Nu-Bromazepam 3mg Tab Nu-Bromazepam 6mg Tab Nu-Capto 12.5mg Tab Nu-Capto 25mg Tab Nu-Capto 50mg Tab Nu-Capto 100mg Tab Nu-Carbamazepine 200mg Tab Nu-Cefaclor 250mg Cap (Not a Benefit) Nu-Cefaclor 500mg Cap (Not a Benefit)
IV.68
02251469 02024292 02024306 02024217 09853812 02024314 02024322 02024225 09853782 02024233 09853774 02265435 02245397 02244353 01927698 01927647 01927655 01927663 01927671 02165546 02165554 02165562 02197421 01913239 01913247 00886106 00865567 00865575 00865540 00865559 00886114 00886122 02136090 02136104 02171856 02171864 02171872 01913824 01913832 01913840 01913859 02042568 02231432 02231433
NOP NOO NOO NOO NOO NOO NOO NOO NOO NOO NOO NOO NOO NOO SAV AVE SAV SAV SAV NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP
IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
16 267 267 267 267 268 268 267 267 266 266 268 265 265 179 179 179 179 179 83 83 83 22 164 165 187 10 10 10 11 84 85 69 70 165 165 165 104 104 104 104 147 14 14
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Nu-Cephalex 250mg Tab (Not a Benefit) Nu-Cephalex 500mg Tab (Not a Benefit) Nu-Cimet 200mg Tab Nu-Cimet 300mg Tab Nu-Cimet 400mg Tab Nu-Cimet 600mg Tab Nu-Clonazepam 0.5mg Tab Nu-Clonazepam 2mg Tab Nu-Clonidine 0.1mg Tab Nu-Clonidine 0.2mg Tab Nu-Cloxi 250mg Cap (Not a Benefit) Nu-Cloxi 500mg Cap (Not a Benefit) Nu-Cloxi 25mg/mL O/L (Not a Benefit) Nu-Cotrimox 40mg & 8mg/mL O/L Nu-Cotrimox 400mg & 80mg Tab Nu-Cotrimox 800mg & 160mg Tab Nu-Cromolyn 1% Inh Sol-2mL Pk Nu-Cyclobenzaprine 10mg Tab (Not a Benefit) Nu-Desipramine 25mg Tab Nu-Desipramine 50mg Tab Nu-Desipramine 75mg Tab Nu-Diclo 25mg Ent Tab Nu-Diclo 50mg Ent Tab Nu-Diclo-SR 75mg LA Tab Nu-Diclo-SR 100mg LA Tab Nu-Diltiaz 30mg Tab Nu-Diltiaz 60mg Tab Nu-Divalproex 125mg Ent Tab Nu-Divalproex 250mg Ent Tab Nu-Divalproex 500mg Ent Tab Nu-Domperidone 10mg Tab Nu-Famotidine 20mg Tab Nu-Famotidine 40mg Tab Nu-Fenofibrate 100mg Cap Nu-Fluoxetine 20mg Cap Nu-Flurbiprofen 50mg Tab Nu-Flurbiprofen 100mg Tab Nu-Fluvoxamine 50mg Tab Nu-Fluvoxamine 100mg Tab Nu-Glyburide 2.5mg Tab Nu-Glyburide 5mg Tab Nu-Indapamide 2.5mg Tab Nu-Indo 25mg Cap Nu-Indo 50mg Cap
00865877 00865885 00865796 00865818 00865826 00865834 02173344 02173352 01913786 01913220 00717584 00717592 00717630 00865753 00865710 00865729 02231671 02171848 02211947 02211955 02211963 00886017 00886025 02228203 02228211 00886068 00886076 02239517 02239518 02239519 02231477 02024195 02024209 02223600 02192764 02020661 02020688 02231192 02231193 02020734 02020742 02223597 00865850 00865869
NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP
17 17 230 230 230 231 148 148 105 105 13 13 13 40 40 40 317 70 157 157 157 125 125 125 126 89 89 149 149 149 231 232 232 98 158 128 128 158 159 262 262 190 129 130
IV.69
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Nu-Levocarb 100mg & 10mg Tab Nu-Levocarb 100mg & 25mg Tab Nu-Levocarb 250mg & 25mg Tab Nu-Loraz 0.5mg Tab Nu-Loraz 1mg Tab Nu-Loraz 2mg Tab Nu-Loxapine 5mg Tab Nu-Loxapine 10mg Tab Nu-Loxapine 25mg Tab Nu-Loxapine 50mg Tab Nu-Mefenamic 250mg Cap Nu-Megestrol 160mg Tab Nu-Metformin 500mg Tab Nu-Metoclopramide 5mg Tab Nu-Metoclopramide 10mg Tab Nu-Metop 50mg Tab Nu-Metop 100mg Tab Nu-Naprox 250mg Tab Nu-Naprox 375mg Tab Nu-Naprox 500mg Tab Nu-Nifed 10mg Cap Nu-Nortriptyline 10mg Cap Nu-Nortriptyline 25mg Cap Nu-Oxybutyn 5mg Tab Nu-Pen VK 300mg Tab (Not a Benefit) Nu-Pentoxifylline 400mg SR Tab Nu-Pindol 5mg Tab Nu-Pindol 10mg Tab Nu-Pindol 15mg Tab Nu-Pirox 10mg Cap Nu-Pirox 20mg Cap Nu-Pravastatin 10mg Tab Nu-Pravastatin 20mg Tab Nu-Pravastatin 40mg Tab Nu-Prazo 1mg Tab Nu-Prazo 2mg Tab Nu-Prazo 5mg Tab Nu-Prochlor 5mg Tab Nu-Prochlor 10mg Tab Nu-Ranit 150mg Tab Nu-Ranit 300mg Tab Nu-Selegiline 5mg Tab Nu-Sotalol 160mg Tab Nu-Sucralfate 1g Tab
IV.70
02182831 02182823 02182858 00865672 00865680 00865699 02237534 02237535 02237536 02237537 02229569 02185423 02162822 02143275 02143283 00865605 00865613 00865648 00865656 00865664 00865591 02223139 02223147 02158590 00717568 02230401 00886149 00886009 00886130 00865761 00865788 02244350 02244351 02244352 01913794 01913808 01913816 01964399 01964402 00865737 00865745 02230717 02163772 02134829
NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP
312 313 313 170 170 170 177 177 177 177 131 48 262 235 235 90 90 133 133 133 91 161 161 58 13 81 114 114 115 134 134 100 100 100 115 115 115 173 173 242 243 317 94 243
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Nu-Sulindac 150mg Tab Nu-Sulindac 200mg Tab Nu-Temazepam 15mg Cap Nu-Temazepam 30mg Cap Nu-Terazosin 1mg Tab Nu-Terazosin 2mg Tab Nu-Terazosin 5mg Tab Nu-Terazosin 10mg Tab Nu-Ticlopidine 250mg Tab Nu-Timolol 5mg Tab Nu-Timolol 10mg Tab Nu-Timolol 20mg Tab Nu-Triazide 25mg & 50mg Tab (Not a Benefit) Nu-Trimipramine 25mg Tab Nu-Trimipramine 50mg Tab Nu-Trimipramine 100mg Tab Nu-Valproic 250mg Cap Nu-Verap 80mg Tab Nu-Verap 120mg Tab Nyaderm 100000U/g Cr Nyaderm 25000U/g Vag Cr NYSTATIN Octostim 1.5mg/mL Nas Sp-2.5mL Pk OCTREOTIDE Octreotide Acetate Omega 50mcg/mL Inj Sol-1mL Amp Pk Octreotide Acetate Omega 100mcg/mL Inj Sol-1mL Amp Pk Octreotide Acetate Omega 500mcg/mL Inj Sol-1mL Amp Pk Octreotide Acetate Omega 200mcg/mL Inj Sol-5mL Vial Pk Ocuflox 0.3% Oph Sol OFLOXACIN Ogen 1.25 1.5mg Tab Ogen 2.5 3mg Tab OLANZAPINE OLSALAZINE SODIUM OMEPRAZOLE OMEPRAZOLE MAGNESIUM Oncovin 1mg/mL Inj Sol (Not a Benefit) ONDANSETRON HYDROCHLORIDE One-Alpha 0.25mcg Cap dpp One-Alpha 1mcg Cap dpp Opcon 0.1% Oph Sol (Not a Benefit) Opticrom 2% Oph Sol Oracort Oral Top Oint
02042576 02042584 02223570 02223589 02233047 02233048 02233049 02233050 02237560 02044609 02044617 02044625 00865532 02020602 02020610 02020629 02237830 00886033 00886041 00716871 00716901
NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP NXP TAR TAR
02237860 02248639 02248640 02248641 02248642 02143291
FEI OMG OMG OMG OMG ALL
02089769 02089777
PFI PFI
00611182 00474517 00474525 00750786 02230621 01964054
LIL LEO LEO BSH ALL TAR
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
135 135 180 180 118 118 118 118 320 94 94 94 190 163 164 164 154 94 95 280 280 6 280 269 314 314 314 315 315 198 39 198 259 259 171 236 237 239 50 228 301 301 203 213 291
IV.71
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Orap 2mg Tab Orap 4mg Tab Orbenin 250mg Cap (Not a Benefit) Orbenin 500mg Cap (Not a Benefit) Orbenin 25mg/mL O/L (Not a Benefit) ORCIPRENALINE SULFATE Orphenadrine 60mg/2mL Inj Sol-2mL Pk (Not a Benefit) ORPHENADRINE CITRATE Ortho 0.5/35 0.035mg & 0.5mg Tab-21 Pk Ortho 0.5/35 0.035mg & 0.5mg Tab-28 Pk Ortho 1/35 0.035mg & 1mg Tab-21 Pk Ortho 1/35 0.035mg & 1mg Tab-28 Pk Ortho 7/7/7 3 Phase Tab-21 Pk Ortho 7/7/7 3 Phase Tab-28 Pk Ortho-Cept 0.15mg & 0.03mg Tab-21 Pk Ortho-Cept 0.15mg & 0.03mg Tab-28Pk Orudis 50mg Cap (Not a Benefit) Orudis 100mg Sup (Not a Benefit) Orudis E-50 50mg Ent Tab (Not a Benefit) Orudis E-100 100mg Ent Tab (Not a Benefit) Orudis SR-200 200mg LA Tab (Not a Benefit) Os-Cal 250 Eq To 250mg Elemental Calcium Tab (Not a Benefit) Os-Cal 500 Eq To 500mg Elemental Calcium Tab (Not a Benefit) OSELTAMIVIR PHOSPHATE Ostac 400mg Cap Ostoforte 50000IU Cap Ovral 0.05mg & 0.25mg Tab-21 Pk OXAPROZIN OXAZEPAM OXCARBAZEPINE Oxeze Turbuhaler 6mcg/Metered Dose Pd Inh-60 Dose Pk Oxeze Turbuhaler 12mcg/Metered Dose Pd Inh-60 Dose Pk OXPRENOLOL HCL Oxsoralen 10mg Cap OXTRIPHYLLINE Oxybutyn 5mg Tab OXYBUTYNIN CHLORIDE OXYCODONE HCL OXYCODONE HCL & ACETAMINOPHEN OXYCODONE HCL & ACETYLSALICYLIC ACID Oxycontin 10mg SR Tab Oxycontin 20mg SR Tab Oxycontin 40mg SR Tab Oxycontin 80mg SR Tab
IV.72
00313815 00313823 00002046 00002054 02042975 02229731 00317047 00340731 00372846 00372838 00602957 00602965 02042541 02042533 01926403 01926411 01926381 01926365 01926373 02042983 02042991 01927078 00009830 02043033
PHE PHE AYE AYE WAY CYI JNO JNO JNO JNO JNO JNO JNO JNO RPP AVE RPP RPP RPP WAY WAY HLR MFC WAY
02237225 02237224 01946374 02220059
AZC AZC VAL VAL
02202441 02202468 02202476 02202484
PFP PFP PFP PFP
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
172 172 13 13 13 62 70 70 271 272 271 272 271 272 270 270 130 131 130 131 131 185 185 28 306 302 272 10 171 12 60 60 114 296 299 58 58 144 144 145 144 144 144 144
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Oxyderm 20% Lot 00374318 Palafer 300mg Cap 01923420 Palafer 60mg/mL O/L 01923439 PAMIDRONATE DISODIUM Pamidronate Disodium 3mg/mL Inj Sol-10mL Vial (Not a Benefit) 02264951 Pamidronate Disodium 6mg/mL Inj Sol-10mL Vial (Not a Benefit) 02264978 Pamidronate Disodium 9mg/mL Inj Sol-10mL Vial (Not a Benefit) 02264986 Panadol 325mg Tab 01928260 Pancrease 4500 & 20000 & 25000 USP Units SR Cap 02242374 Pancrease MT4 4000 & 12000 & 12000 USP Units Ent Microsph Cap 00789445 PANCRELIPASE EQUIVALENT TO LIPASE & AMYLASE & PROTEASE Panoxyl 5% Gel 00263702 Panoxyl 10% Gel 00263699 Panoxyl 15% Gel 00403571 Panoxyl 20% Gel 00373036 Panoxyl Aquagel 5% Gel 02214849 Panoxyl Aquagel 10% Gel (Not a Benefit) 02223856 Pantoloc 20mg Ent Tab (Not a Benefit) 02241804 Pantoloc 40mg Ent Tab 02229453 PANTOPRAZOLE SODIUM Pariet 10mg Tab Pariet 20mg Tab Parlodel 5mg Cap (Not a Benefit) Parlodel 2.5mg Tab Parnate 10mg Tab PAROXETINE HCL Parsitan 50mg Tab PARTICLE COATED ERYTHROMYCIN Paxil 10mg Tab (Not a Benefit) Paxil 20mg Tab Paxil 30mg Tab PCE Dispertab 333mg Tab Pedialyte Flavored O/L Pedialyte Regular O/L Pediapred Oral Liquid 6.7mg/5mL O/L Pediatrix 80mg/mL O/L Pediazole 40mg & 120mg/mL O/L PEG-ELECTROLYTES PegLyte Pd-4L Pk PegLyte Sol-1L Pk Penbritin 250mg Cap (Not a Benefit)
VAL GSK GSK SDZ SDZ SDZ STH JNO JNO STI STI STI STI STI STI NYC NYC
IIIA IIIA IIIA IIIB IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
292 71 71 23 23 23 23 145 224 222 221 293 293 293 293 293 293 19 240 240 19 242 242 305 305 163 161 13 54 10 13 161 161 10 185 185 253 145 9 186 186 186 12
IV.73
02243796 02243797 00568643 00371033 01919598
JNO JNO NOV NOV GSK
01927744 02027887 01940481 01940473 00769991 00981095 00630365 02230619 02027801 00583405 00777838 00777846 00002003
ERF SMJ GSK GSK ABB ABB ABB SAV RPH ABB PMS PMS AYE
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Penbritin 500mg Cap (Not a Benefit) PENICILLAMINE PENICILLIN V (POTASSIUM) Pentamycetin 0.25% Oph Sol Pentasa 500mg Del-Release Tab Pentasa 1g/100mL Enema Pentasa 4g/100mL Enema Pentasa 1g Sup PENTOBARBITAL SODIUM PENTOXIFYLLINE Pepcid 20mg Tab Pepcid 40mg Tab Percocet 5mg & 325mg Tab (Not a Benefit) Percodan 5mg & 325mg Tab (Not a Benefit) PERICYAZINE PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE & INDAPAMIDE PERMETHRIN PERPHENAZINE Pertofrane 25mg Tab (Not a Benefit) PETROLATUM/MINERAL OIL Phenazo 100mg Tab Phenazo 200mg Tab PHENAZOPYRIDINE HCL PHENELZINE SULFATE Phenergan 2mg/mL O/L (Not a Benefit) PHENYTOIN (DIPHENYLHYDANTOIN) PHENYTOIN (DIPHENYLHYDANTOIN) SODIUM Phyllocontin 225mg SR Tab Phyllocontin-350 350mg SR Tab Pico-Salax 3.5g/12g/10mg Pd for Sol-2X12g Sachet Pk PILOCARPINE HCL Pilopine HS 4% Oph Gel PIMECROLIMUS PIMOZIDE PINDOLOL PINDOLOL & HYDROCHLOROTHIAZIDE PIOGLITAZONE HCL PIPERAZINE ADIPATE Piportil L4 25mg/mL Inj Sol-1mL Pk Piportil L4 50mg/mL Inj Sol-1mL Pk Piportil L4 100mg/2mL Inj Sol-2mL Pk PIPOTIAZINE PALMITATE PIROXICAM
IV.74
00002011
AYE
01980556 02099683 02153521 02153556 02153564
SDZ FEI FEI FEI FEI
00710121 00710113 00580201 00580236
MFC MFC BQU BQU
00010448 00271489 00454583
GEI VAL VAL
01937693
RPR
02014270 02014289 02254794 00575240
PFP PFP FEI ALC
01926667 00990507 01926675
SAV SAV SAV
12 247 13 195 229 229 229 229 180 81 232 232 144 145 172 114 114 282 172 157 211 315 315 315 162 1 152 152 299 299 219 202 202 296 172 114 115 263 3 173 173 173 173 134
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
PIVAMPICILLIN PIZOTYLINE Plan B 0.75mg Tab-2 Tabs Pk Plaquenil 200mg Tab Plavix 75mg Tab Plendil 2.5mg ER Tab Plendil 5mg ER Tab Plendil 10mg ER Tab PMS-Acetaminophen With Codeine 160mg & 8mg/5mL O/L PMS-Alendronate 70mg Tab PMS-Alendronate-FC 70mg Tab PMS-Amantadine 10mg/mL O/L PMS-Amantadine HCL 100mg Cap PMS-Amiodarone 200mg Tab PMS-Amoxicillin 250mg Cap (Not a Benefit) PMS-Amoxicillin 500mg Cap (Not a Benefit) PMS-Amoxicillin 25mg/mL O/L (Not a Benefit) PMS-Amoxicillin 50mg/mL O/L (Not a Benefit) PMS-ASA 325mg Tab PMS-Atenolol 50mg Tab PMS-Atenolol 100mg Tab PMS-Azithromycin 100mg/5mL O/L PMS-Azithromycin 200mg/5mL O/L PMS-Azithromycin 250mg Tab PMS-Baclofen 10mg Tab PMS-Baclofen 20mg Tab PMS-Benzydamine 0.15% Oral Rinse PMS-Bezafibrate 200mg Tab PMS-Bicalutamide 50mg Tab PMS-Bisoprolol 5mg Tab PMS-Bisoprolol 10mg Tab PMS-Brimonidine 0.2% Oph Sol PMS-Bromocriptine 5mg Cap PMS-Bromocriptine 2.5mg Tab PMS-Buspirone 10mg Tab (Not a Benefit) PMS-Captopril 12.5mg Tab PMS-Captopril 25mg Tab PMS-Captopril 50mg Tab PMS-Captopril 100mg Tab PMS-Carbamazepine 100mg Chew Tab PMS-Carbamazepine 200mg Chew Tab PMS-Carbamazepine CR 200mg LA Tab PMS-Carbamazepine CR 400mg LA Tab PMS-Carvedilol 3.125mg Tab
02241674 02017709 02238682 02057778 00851779 00851787 00816027 02273179 02284006 02022826 01990403 02242472 02230243 02230244 02230245 02230246 00040851 02237600 02237601 02274388 02274396 02261634 02063735 02063743 02229777 02240331 02275589 02302632 02302640 02246284 02236949 02231702 02230942 02230203 02230204 02230205 02230206 02231542 02231540 02231543 02231544 02245914
PAL SAV SAV AZC AZC AZC PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
14 69 272 31 307 108 108 108 136 303 303 304 304 84 10 10 10 11 123 84 85 7 7 8 69 70 201 96 41 85 85 205 305 305 15 104 104 104 104 146 146 147 147 86
IV.75
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
PMS-Carvedilol 6.25mg Tab PMS-Carvedilol 12.5mg Tab PMS-Carvedilol 25mg Tab PMS-Cefaclor 250mg Cap (Not a Benefit) PMS-Cefaclor 500mg Cap (Not a Benefit) PMS-Cefaclor 25mg/mL Oral Susp (Not a Benefit) PMS-Cefaclor 50mg/mL Oral Susp (Not a Benefit) PMS-Cefaclor 375mg/5mL Oral Susp (Not a Benefit) PMS-Cephalexin 250mg Tab (Not a Benefit) PMS-Cephalexin 500mg Tab (Not a Benefit) PMS-Cephalexin 125 25mg/mL Pd for Oral Susp (Not a Benefit) PMS-Cephalexin 250 50mg/mL Pd for Oral Susp (Not a Benefit) PMS-Cholestyramine Oral Pd-42 Dose Pk PMS-Cholestyramine 9g Pk Oral Pd-Pouch Pk PMS-Cholestyramine (Sugar Free) Oral Pd-42 Dose Pk PMS-Cholestyramine Sugar Free 5g Pk Oral Pd-Pouch Pk PMS-Cilazapril 1mg Tab PMS-Cilazapril 2.5mg Tab PMS-Cilazapril 5mg Tab PMS-Ciprofloxacin 250mg Tab PMS-Ciprofloxacin 500mg Tab PMS-Ciprofloxacin 750mg Tab PMS-Citalopram 20mg Tab PMS-Citalopram 40mg Tab PMS-Clarithromycin 250mg Tab PMS-Clarithromycin 500mg Tab (Not a Benefit) PMS-Clindamycin 150mg Cap PMS-Clindamycin 300mg Cap PMS-Clobazam 10mg Tab PMS-Clobetasol 0.05% Cr PMS-Clobetasol 0.05% Oint PMS-Clobetasol 0.05% Scalp Lot PMS-Clonazepam 0.5mg Tab PMS-Clonazepam 2mg Tab PMS-Clonazepam-R 0.5mg Tab PMS-Cyclobenzaprine 10mg Tab (Not a Benefit) PMS-Deferoxamine 2g/Vial Inj Pd-2g Vial Pk (Not a Benefit) PMS-Deferoxamine 500mg/Vial Inj Pd-500mg Vial Pk (Not a Benefit) PMS-Desipramine 25mg Tab PMS-Desipramine 50mg Tab PMS-Desipramine 75mg Tab PMS-Desonide 0.05% Cr PMS-Desonide 0.05% Oint
IV.76
02245915 02245916 02245917 02185830 02185849 02185857 02185865 02185873 02177781 02177803 02177811 02177838 02207745 02210320 02141795 00890960 02280442 02280450 02280469 02248437 02248438 02248439 02248010 02248011 02247573 02247574 02294826 02294834 02244474 02232191 02232193 02232195 02048701 02048736 02207818 02212048 02243450 02242055 01946269 01946277 01946242 02229315 02229323
PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA
86 86 86 14 14 14 15 15 17 17 17 17 96 96 96 96 104 105 105 33 33 33 156 156 8 2 17 18 148 287 287 287 148 148 148 70 20 20 157 157 157 288 288
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
PMS-Dexamethasone 0.5mg Tab PMS-Dexamethasone 4mg Tab PMS-Diclofenac 25mg Ent Tab PMS-Diclofenac 50mg Ent Tab PMS-Diclofenac 50mg Sup PMS-Diclofenac 100mg Sup PMS-Diclofenac K 50mg Tab (Not a Benefit) PMS-Diclofenac-SR 75mg LA Tab PMS-Diclofenac-SR 100mg LA Tab PMS-Digoxin 0.0625mg Tab PMS-Digoxin 0.125mg Tab PMS-Digoxin 0.25mg Tab PMS-Dimenhydrinate 50mg Tab (Not a Benefit) PMS-Divalproex 125mg Ent Tab PMS-Divalproex 250mg Ent Tab PMS-Divalproex 500mg Ent Tab PMS-Docusate Calcium 240mg Cap PMS-Domperidone 10mg Tab PMS-Doxazosin 1mg Tab PMS-Doxazosin 2mg Tab PMS-Doxazosin 4mg Tab PMS-Enalapril 2.5mg Tab PMS-Enalapril 5mg Tab PMS-Enalapril 10mg Tab PMS-Enalapril 20mg Tab PMS-Famciclovir 125mg Tab (Not a Benefit) PMS-Famciclovir 250mg Tab (Not a Benefit) PMS-Famciclovir 500mg Tab PMS-Fenofibrate Micro 200mg Cap PMS-Flavoxate 200mg Tab (Not a Benefit) PMS-Fluconazole 150mg Cap PMS-Fluconazole 50mg Tab PMS-Fluconazole 100mg Tab PMS-Fluoxetine 10mg Cap (Not a Benefit) PMS-Fluoxetine 20mg Cap PMS-Fluphenazine Decanoate 125mg/5mL Inj Susp-5mL Pk PMS-Flutamide 250mg Tab PMS-Fluvoxamine 50mg Tab PMS-Fluvoxamine 100mg Tab PMS-Fosinopril 10mg Tab PMS-Fosinopril 20mg Tab PMS-Gabapentin 100mg Cap PMS-Gabapentin 300mg Cap PMS-Gabapentin 400mg Cap
01964976 01964070 02231502 02231503 02231506 02231508 02239753 02231504 02231505 02245426 02245427 02245428 00586331 02244138 02244139 02244140 00664553 02236466 02244527 02244528 02244529 02300079 02300087 02300095 02300109 02278081 02278103 02278111 02273551 02245480 02282348 02245643 02245644 02177579 02177587 02091275 02230104 02240682 02240683 02255944 02255952 02243446 02243447 02243448
PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS
IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
251 251 125 125 126 126 9 125 126 87 87 87 225 149 149 149 218 231 106 106 106 106 107 107 107 4 4 25 98 54 279 5 5 13 158 168 45 158 159 109 109 150 150 150
IV.77
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
PMS-Gabapentin 600mg Tab (Not a Benefit) PMS-Gabapentin 800mg Tab (Not a Benefit) PMS-Gemfibrozil 300mg Cap PMS-Gemfibrozil 600mg Tab (Not a Benefit) PMS-Gliclazide 80mg Tab PMS-Glyburide 2.5mg Tab PMS-Glyburide 5mg Tab PMS-Hydrochlorothiazide 25mg Tab PMS-Hydrochlorothiazide 50mg Tab PMS-Hydromorphone 1mg/mL Oral Sol PMS-Hydromorphone 1mg Tab PMS-Hydromorphone 2mg Tab PMS-Hydromorphone 4mg Tab PMS-Hydromorphone 8mg Tab PMS-Indapamide 1.25mg Tab PMS-Indapamide 2.5mg Tab PMS-Ipratropium 125mcg/mL Inh Sol-2mL UDV Pk PMS-Ipratropium 250mcg/mL Inh Sol-2mL UDV Pk PMS-Ipratropium 250mcg/mL Inh Sol-20mL Pk PMS-Ipratropium 0.03% Nasal Spray PMS-Ketoprofen 100mg Sup PMS-Ketoprofen E-50 50mg Ent Tab PMS-Lactulose 667mg/mL O/L PMS-Lamotrigine 25mg Tab PMS-Lamotrigine 100mg Tab PMS-Lamotrigine 150mg Tab PMS-Leflunomide 10mg Tab PMS-Leflunomide 20mg Tab PMS-Levetiracetam 250mg Tab (Not a Benefit) PMS-Levetiracetam 500mg Tab (Not a Benefit) PMS-Levetiracetam 750mg Tab (Not a Benefit) PMS-Levobunolol 0.5% Oph Sol PMS-Lindane 1% Shampoo (Not a Benefit) PMS-Lisinopril 5mg Tab PMS-Lisinopril 10mg Tab PMS-Lisinopril 20mg Tab PMS-Lithium Carbonate 150mg Cap PMS-Lithium Carbonate 300mg Cap PMS-Loperamide 2mg Caplet PMS-Lorazepam 0.5mg Tab PMS-Lorazepam 1mg Tab PMS-Lorazepam 2mg Tab PMS-Lovastatin 20mg Tab PMS-Lovastatin 40mg Tab
IV.78
02255898 02255901 02239951 02230183 02294400 02236733 02236734 02247386 02247387 01916386 00885444 00885436 00885401 00885428 02239619 02239620 02231135 02231245 02231136 02239627 02015951 02150816 00703486 02246897 02246898 02246899 02288265 02288273 02296101 02296128 02296136 02237991 00703605 02292203 02292211 02292238 02216132 02216140 02228351 00728187 00728195 00728209 02246013 02246014
IIIB IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
11 11 99 7 261 262 262 189 189 139 139 140 140 140 190 190 56 56 55 209 131 130 219 151 151 151 312 312 11 11 11 210 281 111 111 111 176 177 217 170 170 170 99 99
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
PMS-Loxapine 25mg/mL O/L PMS-Loxapine 5mg Tab PMS-Loxapine 10mg Tab PMS-Loxapine 25mg Tab PMS-Loxapine 50mg Tab PMS-Medroxyprogesterone 2.5mg Tab PMS-Medroxyprogesterone 5mg Tab PMS-Medroxyprogesterone 10mg Tab PMS-Mefenamic Acid 250mg Cap PMS-Meloxicam 7.5mg Tab PMS-Meloxicam 15mg Tab PMS-Metformin 500mg Tab PMS-Metformin 850mg Tab (Not a Benefit) PMS-Methotrimeprazine 5mg Tab PMS-Methotrimeprazine 25mg Tab PMS-Methotrimeprazine 50mg Tab PMS-Methylphenidate 10mg Tab PMS-Methylphenidate 20mg Tab (Not a Benefit) PMS-Metoclopramide 5mg Tab PMS-Metoclopramide 10mg Tab PMS-Metoprolol-L 50mg Tab PMS-Metoprolol-L 100mg Tab PMS-Metronidazole 500mg Cap PMS-Minocycline 50mg Cap (Not a Benefit) PMS-Minocycline 100mg Cap (Not a Benefit) PMS-Mirtazapine 30mg Tab PMS-Moclobemide 150mg Tab PMS-Moclobemide 300mg Tab PMS-Mometasone 0.1% Oint PMS-Morphine Sulfate 15mg SR Tab PMS-Morphine Sulfate 30mg SR Tab PMS-Morphine Sulfate 60mg SR Tab PMS-Morphine Sulfate SR 100mg SR Tab PMS-Morphine Sulfate SR 200mg SR Tab PMS-Naproxen 500mg Sup PMS-Naproxen EC 375mg Ent Tab (Not a Benefit) PMS-Naproxen EC 500mg Ent Tab (Not a Benefit) PMS-Nizatidine 150mg Cap PMS-Nizatidine 300mg Cap PMS-Norfloxacin 400mg Tab PMS-Nortriptyline 10mg Cap PMS-Nortriptyline 25mg Cap PMS-Ofloxacin 0.3% Oph Sol PMS-Ondansetron 4mg Tab
02239101 02230837 02230838 02230839 02230840 02246627 02246628 02246629 02231208 02248267 02248268 02223562 02242589 02232903 02232904 02232905 00584991 00585009 02230431 02230432 02230803 02230804 00783137 02294419 02294427 02248762 02243218 02243219 02270862 02245284 02245285 02245286 02245287 02245288 02017237 02294702 02294710 02177714 02177722 02246596 02177692 02177706 02252570 02258188
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA
177 177 177 177 177 273 273 273 131 132 132 262 21 179 179 179 178 15 235 235 90 90 31 2 3 160 160 160 291 142 142 143 143 143 133 10 10 236 236 38 161 161 198 228
IV.79
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
PMS-Ondansetron 8mg Tab PMS-Oxtriphylline 10mg/mL O/L PMS-Oxtriphylline 20mg/mL O/L PMS-Oxybutynin 1mg/mL O/L PMS-Oxybutynin 5mg Tab PMS-Pamidronate 3mg/mL Inj Sol-10mL Vial (Not a Benefit) PMS-Pamidronate 9mg/mL Inj Sol-10mL Vial (Not a Benefit) PMS-Paroxetine 10mg Tab (Not a Benefit) PMS-Paroxetine 20mg Tab PMS-Paroxetine 30mg Tab PMS-Pindolol 5mg Tab PMS-Pindolol 10mg Tab PMS-Pindolol 15mg Tab PMS-Pioglitazone 15mg Tab PMS-Pioglitazone 30mg Tab PMS-Pioglitazone 45mg Tab PMS-Piroxicam 20mg Sup PMS-Potassium Chloride 1.33mEq/mL O/L PMS-Pramipexole 0.25mg Tab PMS-Pramipexole 0.5mg Tab (Not a Benefit) PMS-Pramipexole 1mg Tab PMS-Pramipexole 1.5mg Tab PMS-Pravastatin 10mg Tab PMS-Pravastatin 20mg Tab PMS-Pravastatin 40mg Tab PMS-Prednisolone 6.7mg/5mL O/L PMS-Procyclidine 2.5mg Tab PMS-Procyclidine 5mg Tab PMS-Promethazine 2mg/mL O/L (Not a Benefit) PMS-Propafenone 150mg Tab PMS-Propafenone 150mg Tab PMS-Propafenone 300mg Tab PMS-Propafenone 300mg Tab PMS-Propranolol 10mg Tab PMS-Propranolol 40mg Tab PMS-Propranolol 80mg Tab PMS-Ranitidine 150mg Tab PMS-Ranitidine 300mg Tab PMS-Risperidone 1mg/mL O/L PMS-Risperidone 0.25mg Tab PMS-Risperidone 0.5mg Tab PMS-Risperidone 1mg Tab PMS-Risperidone 2mg Tab PMS-Risperidone 3mg Tab
IV.80
02258196 00792934 00792942 02223376 02240550 02245998 02245999 02247750 02247751 02247752 02231536 02231537 02231539 02303124 02303132 02303140 02154463 02238604 02290111 02290138 02290146 02290154 02247655 02247656 02247657 02245532 00649392 00587354 00583979 02243727 02294559 02243728 02294575 00582255 00582263 00582271 02242453 02242454 02279266 02252007 02252015 02252023 02252031 02252058
IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
228 299 299 58 58 23 23 13 161 161 114 114 115 263 263 263 134 186 181 16 182 182 100 100 100 253 58 58 1 92 92 92 92 92 93 93 242 243 174 174 174 175 175 175
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
PMS-Risperidone 4mg Tab PMS-Salbutamol 1mg/mL Inh Sol-2.5mL Pk PMS-Salbutamol 2mg/mL Inh Sol-2.5mL Pk PMS-Salbutamol 0.4mg/mL O/L PMS-Salbutamol Respirator Solution 5mg/mL Inh Sol-10mL Pk PMS-Selegiline 5mg Tab PMS-Sertraline 25mg Cap PMS-Sertraline 50mg Cap PMS-Sertraline 100mg Cap PMS-Simvastatin 5mg Tab PMS-Simvastatin 10mg Tab PMS-Simvastatin 20mg Tab PMS-Simvastatin 40mg Tab PMS-Simvastatin 80mg Tab PMS-Sodium Cromoglycate 1% Inh Sol-2mL Pk PMS-Sotalol 80mg Tab (Not a Benefit) PMS-Sotalol 160mg Tab PMS-Sucralfate 1g Tab PMS-Sulfasalazine 500mg Tab PMS-Sulfasalazine-E.C. 500mg Ent Tab PMS-Sumatriptan 25mg Tab (Not a Benefit) PMS-Sumatriptan 50mg Tab (Not a Benefit) PMS-Sumatriptan 100mg Tab (Not a Benefit) PMS-Temazepam 15mg Cap PMS-Temazepam 15mg Cap PMS-Temazepam 30mg Cap PMS-Temazepam 30mg Cap PMS-Terazosin 1mg Tab PMS-Terazosin 2mg Tab PMS-Terazosin 5mg Tab PMS-Terazosin 10mg Tab PMS-Terbinafine 250mg Tab (Not a Benefit) PMS-Theophylline 5.3mg/mL O/L PMS-Tiaprofenic 300mg Tab PMS-Timolol 0.25% Oph Sol PMS-Timolol 0.5% Oph Sol PMS-Tobramycin 0.3% Oph Sol PMS-Topiramate 25mg Tab PMS-Topiramate 100mg Tab PMS-Topiramate 200mg Tab PMS-Trazodone 50mg Tab PMS-Trazodone 100mg Tab PMS-Ursodiol C 250mg Tab PMS-Ursodiol C 500mg Tab
02252066 02208229 02208237 02091186 02069571 02238102 02244838 02244839 02244840 02269252 02269260 02269279 02269287 02269295 02046113 02238326 02238327 02238209 00598461 00598488 02256428 02256436 02256444 02229455 02273039 02229456 02273047 02243518 02243519 02243520 02243521 02240807 00575151 02230828 02083353 02083345 02239577 02262991 02263009 02263017 01937227 01937235 02273497 02273500
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
175 63 64 66 65 317 162 162 162 101 101 102 102 102 317 7 94 243 31 31 17 17 17 180 180 180 180 118 118 118 118 2 299 135 214 214 197 153 153 153 163 163 322 322
IV.81
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
PMS-Valproic Acid 250mg Cap 02230768 PMS-Valproic Acid 500mg Ent Cap 02229628 PMS-Valproic Acid 50mg/mL O/L 02236807 PMS-Venlafaxine XR 37.5mg ER Cap 02278545 PMS-Venlafaxine XR 75mg ER Cap 02278553 PMS-Venlafaxine XR 150mg ER Cap 02278561 PMS-Verapamil SR 240mg LA Tab 02237791 PMS-Zopiclone 5mg Tab (Not a Benefit) 02243426 PMS-Zopiclone 7.5mg Tab (Not a Benefit) 02240606 POLYETHYLENE GLYCOL & ELECTROLYTES POLYMYXIN B SULFATE & BACITRACIN (ZINC) POLYMYXIN B SULFATE & GRAMICIDIN POLYMYXIN B SULFATE & NEOMYCIN SULFATE & HYDROCORTISONE Polysporin 10000U & 500U/g Oph Oint 3.5g Pk 02239157 Polysporin 10000U & 0.025mg/mL Oph/Ot Sol 02239156 POLYSTYRENE SODIUM SULFONATE POLYVINYL ALCOHOL POLYVINYL ALCOHOL & POLYVINYLPYRROLIDONE Pondocillin 500mg Tab 00582247 Ponstan 250mg Cap (Not a Benefit) 00155225 Portia 21 0.03mg & 0.15mg Tab-21 Pk 02295946 Portia 28 0.03mg & 0.15mg Tab-28 Pk 02295954 POTASSIUM CHLORIDE POVIDONE - IODINE PRAMIPEXOLE DIHYDROCHLORIDE MONOHYDRATE Pravachol 10mg Tab Pravachol 20mg Tab Pravachol 40mg Tab PRAVASTATIN SODIUM PRAZOSIN HCL Pred Forte 1% Oph Susp (Not a Benefit) Pred Mild 0.12% Oph Susp PREDNISOLONE ACETATE PREDNISOLONE SODIUM PHOSPHATE PREDNISONE Premarin 0.3mg Tab Premarin 0.625mg Tab Premarin 1.25mg Tab Premarin 0.625mg/g Vag Cr Premplus 0.625mg/2.5mg Tab-28 Day Pk Premplus 0.625mg/5mg Tab-28 Day Pk Preterax 2mg & 0.625mg Tab Prevacid 15mg DR Cap
IV.82
PMS PMS PMS PMS PMS PMS PMS PMS PMS
PFI PFI
LEO PFI BAR BAR
00893749 00893757 02222051
BQU BQU BQU
00301175 00299405
ALL ALL
02043394 02043408 02043424 02043440 02242878 02242879 02246568 02165503
WAY WAY WAY WAY WAY WAY SEV ABB
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
154 154 154 164 164 164 119 15 16 186 196 196 196 196 196 187 212 212 14 131 271 271 186 284 181 16 100 100 100 100 115 200 200 200 253 253 258 258 258 258 257 257 114 233
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Prevacid 30mg DR Cap Prezista 300mg Tab PRIMIDONE Prinivil 5mg Tab Prinivil 10mg Tab Prinivil 20mg Tab Prinzide 10mg & 12.5mg Tab Prinzide 20mg & 12.5mg Tab PROBENECID PROCAINAMIDE HCL Procan SR 250mg LA Tab Procan SR 500mg LA Tab Procan SR 750mg LA Tab PROCARBAZINE HCL PROCHLORPERAZINE Prochlorperazine Mesylate 10mg/2mL Inj Sol-2mL Pk PROCYCLIDINE HCL Procytox 200mg Inj Pd-Vial Pk Procytox 1000mg Inj Pd-Vial Pk Procytox 25mg Tab Procytox 50mg Tab Prograf 5mg/mL Amp Prograf 1mg Cap Prograf 5mg Cap Prolopa 50-12.5 50mg & 12.5mg Cap Prolopa 100-25 100mg & 25mg Cap Prolopa 200-50 200mg & 50mg Cap Proloprim 100mg Tab (Not a Benefit) Proloprim 200mg Tab (Not a Benefit) PROMETHAZINE HCL Propaderm 0.025% Cr Propaderm 0.025% Oint PROPAFENONE HCL PROPRANOLOL Propyl-Thyracil 50mg Tab Propyl-Thyracil 100mg Tab PROPYLTHIOURACIL Proscar 5mg Tab Prostigmin 15mg Tab Protopic 0.03% Oint Protopic 0.1% Oint Provera 2.5mg Tab Provera 5mg Tab Provera 10mg Tab
02165511 02284057 00839388 00839396 00839418 02108194 00884413
ABB JNO MFC MFC MFC MFC MFC
00638692 00638676 00638684
ERF ERF ERF
00789747 02241797 02241799 02241795 02241796 02176009 02175991 02175983 00522597 00386464 00386472 00675229 00677590 02089602 01927957
SDZ BAX BAX BAX BAX FUJ FUJ FUJ HLR HLR HLR BWE BWE SQI GLA
00010200 00010219 02010909 00869945 02244149 02244148 00708917 00030937 00729973
SQI SQI MFC VAL FUJ FUJ PFI PFI PFI
233 23 152 110 110 111 112 112 192 92 92 92 92 49 173 173 58 43 43 43 43 318 318 318 312 312 312 40 40 1 285 285 92 92 275 275 275 310 52 318 318 273 273 273
IV.83
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Provera 100mg Tab 00030945 Provera-Pak 10mg Tab 02010933 Proviodine 10% Top Sol (Not a Benefit) 00172944 Proviodine 10% Vag Gel (Not a Benefit) 00026611 Proviodine 10% Vag Sol (Not a Benefit) 00252824 Prozac 10mg Cap (Not a Benefit) 02018985 Prozac 20mg Cap 00636622 PSEUDOEPHEDRINE HCL PSYLLIUM MUCILLOID Pulmicort Nebuamp 0.125mg/mL Inh Susp 02229099 Pulmicort Nebuamp 0.25mg/mL Inh Susp 01978918 Pulmicort Nebuamp 0.5mg/mL Inh Susp 01978926 Pulmicort Turbuhaler 100mcg/Metered Dose Pd Inh-200 Dose Pk 00852074 Pulmicort Turbuhaler 200mcg/Metered Dose Pd Inh-200 Dose Pk 00851752 Pulmicort Turbuhaler 400mcg/Metered Dose Pd Inh-200 Dose Pk 00851760 Purinethol 50mg Tab 00004723 PVF-K 500 300mg Tab (Not a Benefit) 00248843 PYRAZINAMIDE PYRETHRINS PIPERONYL BUTOXIDE & PETROLEUM DISTILLATE Pyridium 100mg Tab (Not a Benefit) 00476714 Pyridium 200mg Tab (Not a Benefit) 00476722 PYRIDOSTIGMINE BROMIDE PYRIDOXINE HCL Questran Oral Pd-42 Dose Pk (Not a Benefit) 00634093 Questran 9g Pk Oral Pd-Pouch Pk (Not a Benefit) 00464880 Questran Light 4g Pk Oral Pd-Pouch Pk (Not a Benefit) 01918486 QUETIAPINE QUINAGOLIDE HCL QUINAPRIL HCL QUINAPRIL HCL & HYDROCHLOROTHIAZIDE QVAR 50mcg/Metered Dose Aero Inh-200 Dose Pk 02242029 QVAR 100mcg/Metered Dose Aero Inh-200 Dose Pk 02242030 R & C Shampoo/Conditioner 0.3% & 3% & 1.2% Top Sol 02125447 RABEPRAZOLE SODIUM RALOXIFENE HCL RAMIPRIL RAMIPRIL & HYDROCHLOROTHIAZIDE Ran-Atenolol 50mg Tab 02267985 Ran-Atenolol 100mg Tab 02267993 Ran-Carvedilol 3.125mg Tab 02268027 Ran-Carvedilol 6.25mg Tab 02268035 Ran-Carvedilol 12.5mg Tab 02268043 Ran-Carvedilol 25mg Tab 02268051 Ran-Cefprozil 250mg/5mL Oral Susp 02293579
PFI PFI ROG ROG ROG LIL LIL
AZC AZC AZC AZC AZC AZC NOP FRS
PDA PDA
BQU BQU BQU
GRA GRA GSK
RAN RAN RAN RAN RAN RAN RAN
IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
273 273 284 284 284 13 158 62 219 250 250 250 251 251 251 48 13 20 282 315 315 52 300 96 96 96 173 315 116 116 249 249 282 242 316 116 117 84 85 86 86 86 86 15
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Ran-Cefprozil 250mg Tab Ran-Cefprozil 500mg Tab Ran-Ciproflox 250mg Tab Ran-Ciproflox 500mg Tab Ran-Ciproflox 750mg Tab Ran-Ciprofloxacin 250mg Tab Ran-Ciprofloxacin 500mg Tab Ran-Ciprofloxacin 750mg Tab Ran-Citalo 20mg Tab Ran-Citalo 40mg Tab Ran-Domperidone 10mg Tab Ran-Fentanyl 25mcg/hr Trans Patch Ran-Fentanyl 50mcg/hr Trans Patch Ran-Fentanyl 75mcg/hr Trans Patch Ran-Fentanyl 100mcg/hr Trans Patch Ran-Lisinopril 5mg Tab Ran-Lisinopril 10mg Tab Ran-Lisinopril 20mg Tab Ran-Lovastatin 20mg Tab Ran-Lovastatin 40mg Tab Ran-Metformin 500mg Tab Ran-Metformin 850mg Tab (Not a Benefit) Ran-Pantoprazole 40mg Ent Tab Ran-Pravastatin 10mg Tab Ran-Pravastatin 20mg Tab Ran-Pravastatin 40mg Tab Ran-Rabeprazole 10mg Tab Ran-Rabeprazole 20mg Tab Ran-Risperidone 0.25mg Tab Ran-Risperidone 0.5mg Tab Ran-Risperidone 1mg Tab Ran-Risperidone 2mg Tab Ran-Risperidone 3mg Tab Ran-Risperidone 4mg Tab Ran-Tamsulosin 0.4mg Cap Ran-Zopiclone 5mg Tab (Not a Benefit) Ran-Zopiclone 7.5mg Tab (Not a Benefit) RANIBIZUMAB RANITIDINE HCL Rapamune 1mg/mL O/L Rapamune 1mg Tab Ratio-Aclavulanate 250mg & 125mg Tab Ratio-Aclavulanate 500mg & 125mg Tab Ratio-Aclavulanate 875mg & 125mg Tab
02293528 02293536 02303728 02303736 02303744 02267934 02267942 02267950 02285622 02285630 02268078 02249391 02249413 02249421 02249448 02294230 02294249 02294257 02267969 02267977 02269031 02269058 02305046 02284421 02284448 02284456 02298074 02298082 02280906 02280914 02280922 02280930 02280949 02280957 02294885 02267918 02267926
RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN
02243237 02247111 02243770 02243771 02247021
WAY WAY RPH RPH RPH
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA
15 16 33 33 33 33 33 33 156 156 231 138 138 138 138 111 111 111 99 99 262 21 240 100 100 100 242 242 174 174 175 175 175 175 319 15 16 213 242 317 317 12 12 12
IV.85
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Ratio-Aclavulanate 125F 25mg & 6.25mg/mL O/L Ratio-Aclavulanate 250F 50mg & 12.5mg/mL O/L Ratio-Acyclovir 200mg Tab (Not a Benefit) Ratio-Acyclovir 400mg Tab (Not a Benefit) Ratio-Acyclovir 800mg Tab Ratio-Alendronate 70mg Tab Ratio-Amcinonide 0.1% Cr Ratio-Amcinonide 0.1% Lot Ratio-Amcinonide 0.1% Oint Ratio-Amiodarone 200mg Tab Ratio-Atenolol 50mg Tab Ratio-Atenolol 100mg Tab Ratio-Azithromycin 250mg Tab Ratio-Baclofen 10mg Tab Ratio-Baclofen 20mg Tab Ratio-Beclomethasone AQ 50mcg Nas Sp-200 Dose Pk Ratio-Benzydamine 0.15% Oral Rinse Ratio-Bicalutamide 50mg Tab Ratio-Bisacodyl 10mg Sup Ratio-Brimonidine 0.2% Oph Sol Ratio-Bupropion SR 100mg Tab Ratio-Bupropion SR 150mg Tab Ratio-Buspirone 10mg Tab (Not a Benefit) Ratio-Carvedilol 3.125mg Tab Ratio-Carvedilol 6.25mg Tab Ratio-Carvedilol 12.5mg Tab Ratio-Carvedilol 25mg Tab Ratio-Cefuroxime 250mg Tab Ratio-Cefuroxime 500mg Tab Ratio-Ciprofloxacin 250mg Tab Ratio-Ciprofloxacin 500mg Tab Ratio-Ciprofloxacin 750mg Tab Ratio-Citalopram 20mg Tab Ratio-Citalopram 40mg Tab Ratio-Clarithromycin 250mg Tab Ratio-Clarithromycin 500mg Tab (Not a Benefit) Ratio-Clindamycin 150mg Cap Ratio-Clindamycin 300mg Cap Ratio-Clobazam 10mg Tab Ratio-Clobetasol 0.05% Cr Ratio-Clobetasol 0.05% Oint Ratio-Clobetasol 0.05% Scalp Lot Ratio-Clonazepam 0.5mg Tab Ratio-Clonazepam 2mg Tab
IV.86
02244646 02244647 02078627 02078635 02078651 02275279 02247098 02247097 02247096 02240071 02171791 02171805 02275287 02236507 02236508 00872318 02230170 02277700 00404802 02243026 02285657 02285665 02237858 02252309 02252317 02252325 02252333 02242656 02242657 02246825 02246826 02246827 02252112 02252120 02247818 02247819 02130033 02192659 02238797 01910272 01910280 01910299 02103656 02103737
RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH
IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
11 11 4 4 22 303 284 284 284 84 84 85 8 69 70 198 201 41 218 205 155 155 15 86 86 86 86 16 16 33 33 33 156 156 8 2 17 18 148 287 287 287 148 148
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Ratio-Codeine 5mg/mL O/L Ratio-Codeine 15mg Tab Ratio-Codeine 30mg Tab Ratio-Desipramine 25mg Tab Ratio-Desipramine 50mg Tab Ratio-Dexamethasone 0.5mg Tab Ratio-Dexamethasone 4mg Tab Ratio-Diltiazem CD 120mg LA Cap Ratio-Diltiazem CD 180mg LA Cap Ratio-Diltiazem CD 240mg LA Cap Ratio-Diltiazem CD 300mg LA Cap Ratio-Domperidone 10mg Tab Ratio-Ectosone 0.1% Scalp Lot Ratio-Ectosone Mild 0.05% Cr Ratio-Ectosone Mild 0.05% Lot Ratio-Ectosone Regular 0.1% Cr Ratio-Ectosone Regular 0.1% Lot Ratio-Emtec 300mg & 30mg Tab Ratio-Enalapril 2.5mg Tab Ratio-Enalapril 5mg Tab Ratio-Enalapril 10mg Tab Ratio-Enalapril 20mg Tab Ratio-Fenofibrate MC 200mg Cap Ratio-Fentanyl 25mcg/hr Trans Patch Ratio-Fentanyl 50mcg/hr Trans Patch Ratio-Fentanyl 75mcg/hr Trans Patch Ratio-Fentanyl 100mcg/hr Trans Patch Ratio-Flexitec 10mg Tab (Not a Benefit) Ratio-Flunisolide Nasal Mist 0.025% Nas Sp-25mL Pk Ratio-Fluoxetine 10mg Cap (Not a Benefit) Ratio-Fluoxetine 20mg Cap Ratio-Fluticasone 50mcg/Actuation Nas Sp-120 Dose Pk (Not a Benefit) Ratio-Fluvoxamine 50mg Tab Ratio-Fluvoxamine 100mg Tab Ratio-Fosinopril 10mg Tab Ratio-Fosinopril 20mg Tab Ratio-Gabapentin 100mg Cap Ratio-Gabapentin 300mg Cap Ratio-Gabapentin 400mg Cap Ratio-Gabapentin 600mg Tab (Not a Benefit) Ratio-Gabapentin 800mg Tab (Not a Benefit) Ratio-Glimepiride 1mg Tab (Not a Benefit) Ratio-Glimepiride 2mg Tab (Not a Benefit)
00779474 00593435 00593451 01948784 01948792 02240684 02240687 02229781 02229782 02229783 02229784 01912070 00653217 00535427 00653209 00535435 00750050 00608882 02299984 02299992 02300001 02300028 02250039 02282941 02282968 02282976 02282984 02236506 00878790 02241371 02241374 02296071 02218453 02218461 02275252 02275260 02260883 02260891 02260905 02260913 02260921 02273101 02273128
RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIB
137 137 137 157 157 251 251 87 88 88 88 231 286 286 286 286 286 136 106 107 107 107 98 138 138 138 138 70 199 13 158 18 158 159 109 109 150 150 150 11 11 21 21
IV.87
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Ratio-Glimepiride 4mg Tab (Not a Benefit) Ratio-Glyburide 2.5mg Tab Ratio-Glyburide 5mg Tab Ratio-Indomethacin 100mg Sup Ratio-IPRA SAL UDV 500mcg/2.5mg/2.5mL Inh Sol-2.5mL Pk Ratio-Ipratropium 250mcg/mL Inh Sol-20mL Pk Ratio-Ipratropium UDV 125mcg/mL Inh Sol-2mL UDV Pk Ratio-Ipratropium UDV 250mcg/mL Inh Sol-2mL UDV Pk Ratio-Ketorolac 0.5% Oph Sol Ratio-Lactulose 666.7mg/mL O/L Ratio-Lamotrigine 25mg Tab Ratio-Lamotrigine 100mg Tab Ratio-Lamotrigine 150mg Tab Ratio-Lenoltec No.2 15mg Tab Ratio-Lenoltec No.3 30mg Tab Ratio-Lenoltec No.4 300mg & 60mg Tab Ratio-Levobunolol 0.25% Oph Sol Ratio-Levobunolol 0.5% Oph Sol Ratio-Lisinopril P 5mg Tab Ratio-Lisinopril P 10mg Tab Ratio-Lisinopril P 20mg Tab Ratio-Lisinopril Z 5mg Tab Ratio-Lisinopril Z 10mg Tab Ratio-Lisinopril Z 20mg Tab Ratio-Lovastatin 20mg Tab Ratio-Lovastatin 40mg Tab Ratio-Meloxicam 7.5mg Tab Ratio-Meloxicam 15mg Tab Ratio-Metformin 500mg Tab Ratio-Metformin 850mg Tab (Not a Benefit) Ratio-Methotrexate Sodium 2.5mg Tab Ratio-Minocycline 50mg Cap (Not a Benefit) Ratio-Minocycline 100mg Cap (Not a Benefit) Ratio-Mirtazapine 30mg Tab Ratio-Mometasone 0.1% Oint Ratio-Morphine 1mg/mL O/L Ratio-Morphine 5mg/mL O/L Ratio-Morphine 10mg/mL O/L Ratio-Morphine 20mg/mL O/L Ratio-Morphine SR 15mg SR Tab Ratio-Morphine SR 30mg SR Tab Ratio-Morphine SR 60mg SR Tab Ratio-MPA 2.5mg Tab Ratio-MPA 5mg Tab
IV.88
02273136 01900927 01900935 01934139 02243789 02097141 02097176 02097168 02247461 00854409 02243352 02243353 02246963 00653241 00653276 00621463 02031159 02031167 02256797 02256800 02256819 02299879 02299887 02299895 02245822 02245823 02247889 02248031 02242974 02242931 02244798 01914138 01914146 02270927 02248130 00607762 00607770 00690783 00690791 02244790 02244791 02244792 02148552 02148560
RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH
IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
21 262 262 130 57 55 56 56 200 232 151 151 151 136 136 136 210 210 110 110 111 111 111 111 99 99 132 132 262 21 49 2 3 160 291 140 140 140 141 142 142 143 273 273
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Ratio-MPA 10mg Tab 02148579 Ratio-Nortriptyline 10mg Cap 02240789 Ratio-Nortriptyline 25mg Cap 02240790 Ratio-Nystatin 100000U/g Cr 02194236 Ratio-Nystatin 100000U/mL O/L 02194201 Ratio-Nystatin 100000U/g Oint 02194228 Ratio-Nystatin 500000U Tab 02194198 Ratio-Nystatin 100000U/g Vag Cr 02194163 Ratio-Omeprazole 20mg DR Tab 09857267 Ratio-Omeprazole DR Tab 20mg 02260867 Ratio-Ondansetron 4mg Tab 02278529 Ratio-Ondansetron 8mg Tab 02278537 Ratio-Oxycocet 5mg & 325mg Tab 00608165 Ratio-Oxycodan 5mg & 325mg Tab 00608157 Ratio-Paroxetine 10mg Tab (Not a Benefit) 02247810 Ratio-Paroxetine 20mg Tab 02247811 Ratio-Paroxetine 30mg Tab 02247812 Ratio-Pentoxifylline 400mg SR Tab 01968432 Ratio-Pioglitazone 15mg Tab 02301423 Ratio-Pioglitazone 30mg Tab 02301431 Ratio-Pioglitazone 45mg Tab 02301458 Ratio-Pravastatin 10mg Tab 02246930 Ratio-Pravastatin 20mg Tab 02246931 Ratio-Pravastatin 40mg Tab 02246932 Ratio-Prednisolone 1% Oph Susp 00700401 Ratio-Ramipril Cap 1.25mg 02287692 Ratio-Ramipril Cap 2.5mg 02287706 Ratio-Ramipril Cap 5mg 02287714 Ratio-Ramipril Cap 10mg 02287722 Ratio-Ranitidine 150mg Tab 00828823 Ratio-Ranitidine 300mg Tab 00828688 Ratio-Risperidone 0.25mg Tab 02264757 Ratio-Risperidone 0.5mg Tab 02264765 Ratio-Risperidone 1mg Tab 02264773 Ratio-Risperidone 2mg Tab 02264781 Ratio-Risperidone 3mg Tab 02264803 Ratio-Risperidone 4mg Tab 02264811 Ratio-Salbutamol 2mg/mL Inh Sol-2.5mL Pk 02239366 Ratio-Salbutamol HFA 100mcg/Metered Dose Inh-200 Dose Pk 02244914 Ratio-Salbutamol Inhaler 100mcg/Metered Dose Inh-200 Dose Pk (Not a Benefit) 00851841 Ratio-Salbutamol Respirator Sol 5mg/mL Inh Sol-10mL Pk 00860808 Ratio-Salbutamol Respirator Sol P.F. 1mg/mL Inh Sol-2.5mL Pk 01986864 Ratio-Sertraline 25mg Cap 02245787
RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
273 161 161 280 6 280 6 280 239 237 228 228 144 145 13 161 161 81 263 263 263 100 100 100 200 116 116 117 117 242 243 174 174 175 175 175 175 64 66 66 65 63 162
IV.89
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Ratio-Sertraline 50mg Cap Ratio-Sertraline 100mg Cap Ratio-Simvastatin 5mg Tab Ratio-Simvastatin 10mg Tab Ratio-Simvastatin 20mg Tab Ratio-Simvastatin 40mg Tab Ratio-Simvastatin 80mg Tab Ratio-Sotalol 80mg Tab (Not a Benefit) Ratio-Sotalol 160mg Tab Ratio-Sumatriptan 50mg Tab (Not a Benefit) Ratio-Sumatriptan 100mg Tab (Not a Benefit) Ratio-Tamsulosin 0.4mg Cap Ratio-Temazepam 15mg Cap Ratio-Temazepam 30mg Cap Ratio-Terazosin 1mg Tab Ratio-Terazosin 2mg Tab Ratio-Terazosin 5mg Tab Ratio-Terazosin 10mg Tab Ratio-Topilene 0.05% Cr Ratio-Topilene 0.05% Oint Ratio-Topiramate 25mg Tab Ratio-Topiramate 100mg Tab Ratio-Topiramate 200mg Tab Ratio-Topisone 0.05% Lot Ratio-Topisone 0.05% Oint Ratio-Trazodone 50mg Tab Ratio-Trazodone 100mg Tab Ratio-Trazodone 150mg Tab Ratio-Valproic 250mg Cap Ratio-Valproic 50mg/mL O/L Ratio-Valproic EC 500mg Ent Cap Ratio-Venlafaxine XR 37.5mg ER Cap Ratio-Venlafaxine XR 75mg ER Cap Ratio-Venlafaxine XR 150mg ER Cap Ratio-Zopiclone 5mg Tab (Not a Benefit) Ratio-Zopiclone 7.5mg Tab (Not a Benefit) Reactine 10mg Tab (Not a Benefit) RECOMBINANT HUMAN ERYTHROPOIETIN (R-HUEPO) Relafen 500mg Tab (Not a Benefit) Relafen 750mg Tab (Not a Benefit) Remeron 30mg Tab Remeron RD 15mg Orally Disintegrating Tab Remeron RD 30mg Orally Disintegrating Tab Remeron RD 45mg Orally Disintegrating Tab
IV.90
02245788 02245789 02247067 02247068 02247069 02247070 02247071 02084228 02084236 02271583 02271591 02294265 02243023 02243024 02218941 02218968 02218976 02218984 00849650 00849669 02256827 02256835 02256843 00809187 00805009 02277344 02277352 02277360 02140047 02140063 02140055 02273969 02273977 02273985 02246534 02242481 02223554 02083531 02083558 02243910 02248542 02248543 02248544
RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH MCL GSK GSK ORG ORG ORG ORG
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIB IIIB IIIA IIIA IIIA IIIA
162 162 101 101 102 102 102 7 94 17 17 319 180 180 118 118 118 118 286 285 153 153 153 285 285 163 163 163 154 154 154 164 164 164 15 16 1 80 9 9 160 160 160 160
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Reminyl ER 8mg ER Cap Reminyl ER 16mg ER Cap Reminyl ER 24mg ER Cap Renedil 2.5mg SR Tab Renedil 5mg SR Tab Renedil 10mg SR Tab ReQuip 0.25mg Tab ReQuip 1mg Tab ReQuip 2mg Tab ReQuip 5mg Tab Rescriptor 100mg Tab Restoril 15mg Cap Restoril 30mg Cap Resultz 50% Top Sol-120mL Pk Resultz 50% Top Sol-240mL Pk Reyataz 150mg Cap Reyataz 200mg Cap Rhinalar 0.025% Nas Sp-25mL Pk Rhinocort Aqua 64mcg/Metered Dose Nas Sp-120 Dose Pk Rhinocort Aqua 100mcg/Metered Dose Nas Sp-165 Dose Pk (Not a Benefit) Rhinocort Turbuhaler 100mcg/Metered Dose Nas Aero-200 Dose Rhodis-EC 100mg Ent Tab Rhotral 100mg Tab Rhotral 200mg Tab Rhotral 400mg Tab Rhotrimine 75mg Cap Rhotrimine 100mg Tab Rhovane 7.5mg Tab (Not a Benefit) Rhoxal-Metformin 500mg Tab Rhoxal-Sotalol 160mg Tab Ridaura 3mg Cap RIFABUTIN Rifadin 150mg Cap Rifadin 300mg Cap RIFAMPIN RISEDRONATE SODIUM Risperdal 1mg/mL O/L Risperdal 0.25mg Tab Risperdal 0.5mg Tab Risperdal 1mg Tab Risperdal 2mg Tab Risperdal 3mg Tab Risperdal 4mg Tab
02266717 02266725 02266733 02221985 02221993 02222000 02232565 02232567 02232568 02232569 02238348 00604453 00604461 09857292 02279592 02248610 02248611 02162687 02231923 01974432 02035324 00761680 01910140 01910159 01910167 00761656 00761648 02008203 02233999 02234013 01916823 02091887 02092808
JNO JNO JNO SAV SAV SAV GSK GSK GSK GSK PFI ORY ORY NYC NYC BQU BQU IVA AZC AST AZC SAV SAV SAV SAV SAV SAV SAV SDZ SDZ SQI SAV SAV
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
52 52 52 108 108 108 316 316 316 316 24 180 180 281 281 23 23 199 199 199 199 131 83 83 83 163 164 16 262 94 245 20 21 21 21 316 174 174 174 175 175 175 175
IV.91
02236950 02240551 02240552 02025280 02025299 02025302 02025310
JNO JNO JNO JNO JNO JNO JNO
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Risperdal M-Tab 0.5mg Orally Disintegrating Tab Risperdal M-Tab 1mg Orally Disintegrating Tab Risperdal M-Tab 2mg Orally Disintegrating Tab Risperdal M-Tab 3mg Orally Disintegrating Tab Risperdal M-Tab 4mg Orally Disintegrating Tab RISPERIDONE Ritalin 10mg Tab Ritalin 20mg Tab (Not a Benefit) Ritalin SR 20mg LA Tab RITONAVIR RIVASTIGMINE Rivotril 0.5mg Tab Rivotril 2mg Tab Robidrine 6mg/mL O/L (Not a Benefit) Robidrine 60mg Tab (Not a Benefit) Robitussin 20mg/mL O/L (Not a Benefit) Rocaltrol 0.25mcg Cap dpp Rocaltrol 0.5mcg Cap dpp Rocephin 0.25g/Vial Inj Pd-1 Vial Pk Rocephin 1g/Vial Inj Pd-1 Vial Pk Rocephin 2g/Vial Inj Pd-1 Vial Pk Rofact 150mg Cap Rofact 300mg Cap ROPINIROLE Rosasol 1% Cr ROSIGLITAZONE ROSUVASTATIN CALCIUM Roychlor 1.33mEq/mL O/L (Not a Benefit) Rubramin 1mg/mL Inj Sol-10mL Pk (Not a Benefit) Rynacrom 2% Nas Sol-26mL Pk (Not a Benefit) Rythmodan 100mg Cap Rythmodan 150mg Cap Rythmol 150mg Tab Rythmol 300mg Tab Sab-Diclofenac 50mg Sup Sab-Diclofenac 100mg Sup Sab-Indomethacin 50mg Sup Sab-Indomethacin 100mg Sup Sabril 500mg Tab Salazopyrin 500mg Ent Tab Salazopyrin 500mg Tab SALBUTAMOL SALMETEROL XINAFOATE SALMETEROL XINAFOATE & FLUTICASONE PROPIONATE
IV.92
02247704 02247705 02247706 02268086 02268094 00005606 00005614 00632775
JNO JNO JNO JNO JNO NOV NOV NOV
00382825 00382841 00425516 00342726 00026468 00481823 00481815 00657387 00657417 00657409 00393444 00343617 02242919
HLR HLR WHB WHB WHB HLR HLR HLR HLR HLR VAL VAL STI
02166372 00029165 00605255 02224801 02224828 00603708 00603716 02241224 02241225 02231799 02231800 02065819 02064472 02064480
WAB BQU FIS SAV SAV ABB ABB SDZ SDZ SDZ SDZ OVA PFI PFI
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
174 174 174 174 174 174 178 15 178 28 53 148 148 62 62 193 301 301 16 16 16 21 21 316 283 264 101 186 300 213 89 89 92 92 126 126 130 130 154 31 31 63 67 68
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Salofalk 500mg Ent Tab 02112787 Salofalk 4g Rect Susp-Pk 02112809 Salofalk 500mg Sup 02112760 Salofalk 1000mg Sup 02242146 Sandomigran 0.5mg Tab 00329320 Sandomigran DS 1mg Tab 00511552 Sandostatin 50mcg/mL Inj Sol-1mL Amp Pk 00839191 Sandostatin 100mcg/mL Inj Sol-1mL Amp Pk 00839205 Sandostatin 500mcg/mL Inj Sol-1mL Amp Pk 00839213 Sandostatin 200mcg/mL Inj Sol-5mL Vial Pk 02049392 Sandostatin LAR 10mg Inj Kit Pk 02239323 Sandostatin LAR 20mg Inj Kit Pk 02239324 Sandostatin LAR 30mg Inj Kit Pk 02239325 Sandoz Acebutolol 100mg Tab 02257599 Sandoz Acebutolol 200mg Tab 02257602 Sandoz Acebutolol 400mg Tab 02257610 Sandoz Alendronate 5mg Tab (Not a Benefit) 02288079 Sandoz Alendronate 10mg Tab 02288087 Sandoz Alendronate 70mg Tab 02288109 Sandoz Amiodarone 200mg Tab 02243836 Sandoz Anagrelide 0.5mg Cap 02260107 Sandoz Anuzinc 0.5% Oint 00621447 Sandoz Atenolol 50mg Tab 02231731 Sandoz Atenolol 100mg Tab 02231733 Sandoz Azithromycin 250mg Tab 02265826 Sandoz Bicalutamide 50mg Tab 02276089 Sandoz Bisoprolol 5mg Tab 02247439 Sandoz Bisoprolol 10mg Tab 02247440 Sandoz Bupropion SR 100mg Tab 02275074 Sandoz Bupropion SR 150mg Tab 02275082 Sandoz Calcitonin NS 200U/Metered Dose Nas Sp-2x14 Dose Pk (Not a Benefit) 02261766 Sandoz Carbamazepine Chewtabs 100mg Chew Tab 02261855 Sandoz Carbamazepine Chewtabs 200mg Chew Tab 02261863 Sandoz Carbamazepine CR 200mg LA Tab 02261839 Sandoz Carbamazepine CR 400mg LA Tab 02261847 Sandoz Cefprozil 250mg Tab 02302179 Sandoz Cefprozil 500mg Tab 02302187 Sandoz Ciprofloxacin 250mg Tab 02248756 Sandoz Ciprofloxacin 500mg Tab 02248757 Sandoz Ciprofloxacin 750mg Tab 02248758 Sandoz Citalopram 20mg Tab 02248170 Sandoz Citalopram 40mg Tab 02248171 Sandoz Clonazepam 0.5mg Tab 02233960
BFI BFI BFI BFI SQI SQI NOV NOV NOV NOV NOV NOV NOV SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
229 229 229 229 69 69 314 314 315 315 314 314 314 83 83 83 23 303 303 84 304 297 84 85 8 41 85 85 155 155 22 146 146 147 147 15 16 33 33 33 156 156 148
IV.93
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Sandoz Clonazepam 2mg Tab Sandoz Cyclosporine 25mg Cap Sandoz Cyclosporine 50mg Cap Sandoz Cyclosporine 100mg Cap Sandoz Diclofenac Rapide 50mg Tab (Not a Benefit) Sandoz Diclofenac SR 75mg LA Tab (Not a Benefit) Sandoz Diclofenac SR 100mg LA Tab (Not a Benefit) Sandoz Diltiazem CD 120mg LA Cap Sandoz Diltiazem CD 180mg LA Cap Sandoz Diltiazem CD 240mg LA Cap Sandoz Diltiazem CD 300mg LA Cap Sandoz Diltiazem T 120mg SR Cap Sandoz Diltiazem T 180mg SR Cap Sandoz Diltiazem T 240mg SR Cap Sandoz Diltiazem T 300mg SR Cap Sandoz Diltiazem T 360mg SR Cap Sandoz Enalapril 2.5mg Tab Sandoz Enalapril 5mg Tab Sandoz Enalapril 10mg Tab Sandoz Enalapril 20mg Tab Sandoz Famciclovir 125mg Tab (Not a Benefit) Sandoz Famciclovir 250mg Tab (Not a Benefit) Sandoz Famciclovir 500mg Tab Sandoz Felodipine 5mg ER Tab Sandoz Felodipine 10mg ER Tab Sandoz Felodipine 5mg SR Tab Sandoz Felodipine 10mg SR Tab Sandoz Fenofibrate S 160mg Tab Sandoz Fluoxetine 10mg Cap (Not a Benefit) Sandoz Fluoxetine 20mg Cap Sandoz Fluvoxamine 50mg Tab Sandoz Fluvoxamine 100mg Tab Sandoz Gentamicin 0.3% Ot Sol Sandoz Glimepiride 1mg Tab (Not a Benefit) Sandoz Glimepiride 2mg Tab (Not a Benefit) Sandoz Glimepiride 4mg Tab (Not a Benefit) Sandoz Glyburide 2.5mg Tab Sandoz Glyburide 5mg Tab Sandoz Leflunomide 10mg Tab Sandoz Leflunomide 20mg Tab Sandoz Levobunolol 0.25% Oph Sol Sandoz Levobunolol 0.5% Oph Sol Sandoz Lisinopril 5mg Tab Sandoz Lisinopril 5mg Tab
IV.94
02233985 02247073 02247074 02242821 02261774 02261901 02261944 02243338 02243339 02243340 02243341 02245918 02245919 02245920 02245921 02245922 02299933 02299941 02299968 02299976 02278634 02278642 02278650 02280264 02280272 09857203 09857204 02288052 02243486 02243487 02247054 02247055 02229441 02269589 02269597 02269619 02248008 02248009 02283964 02283972 02241715 02241716 02289199 09857272
SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ
IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
148 308 308 308 9 125 126 87 88 88 88 88 89 89 89 89 106 107 107 107 4 4 25 108 108 108 108 98 13 158 158 159 196 21 21 21 262 262 312 312 210 210 111 110
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Sandoz Lisinopril 10mg Tab Sandoz Lisinopril 10mg Tab Sandoz Lisinopril 20mg Tab Sandoz Lisinopril 20mg Tab Sandoz Lisinopril HCT 10mg & 12.5mg Tab Sandoz Lisinopril HCT 20mg & 12.5mg Tab Sandoz Loperamide 2mg Caplet Sandoz Lovastatin 20mg Tab Sandoz Lovastatin 40mg Tab Sandoz Metformin FC 500mg Tab Sandoz Metformin FC 850mg Tab (Not a Benefit) Sandoz Metoprolol (Type L) 50mg Tab Sandoz Metoprolol (Type L) 100mg Tab Sandoz Metoprolol SR 100mg LA Tab Sandoz Metoprolol SR 200mg LA Tab Sandoz Minocycline 50mg Cap (Not a Benefit) Sandoz Minocycline 100mg Cap (Not a Benefit) Sandoz Mirtazapine 30mg Tab Sandoz Mirtazapine FC 30mg Tab Sandoz Nabumetone 500mg Tab (Not a Benefit) Sandoz Nitrazepam 5mg Tab Sandoz Nitrazepam 10mg Tab Sandoz Omeprazole 20mg Cap Sandoz Ondansetron 4mg Tab Sandoz Ondansetron 8mg Tab Sandoz Opticort 5mg & 50mcg & 0.5mg/mL Oph/Ot Sol Sandoz Paroxetine 20mg Tab Sandoz Paroxetine 30mg Tab Sandoz Pentasone 3mg & 1mg/mL Oph/Ot Drops Sandoz Pindolol 5mg Tab Sandoz Pindolol 10mg Tab Sandoz Pindolol 15mg Tab Sandoz Pioglitazone 15mg Tab Sandoz Pioglitazone 30mg Tab Sandoz Pioglitazone 45mg Tab Sandoz Pravastatin 10mg Tab Sandoz Pravastatin 20mg Tab Sandoz Pravastatin 40mg Tab Sandoz Ramipril Tab 1.25mg Sandoz Ramipril Tab 2.5mg Sandoz Ramipril Tab 5mg Sandoz Ramipril Tab 10mg Sandoz Ranitidine 150mg Tab Sandoz Ranitidine 300mg Tab
02289202 09857286 02289229 09857287 02302365 02302373 02257564 02247056 02247057 02246820 02246821 02247875 02247876 02303396 02303418 02237313 02237314 02250608 02267292 02242912 02234003 02234007 02296446 02274310 02274329 02247920 02254751 02254778 02244999 02261782 02261790 02261804 02297906 02297914 02297922 02247856 02247857 02247858 02291398 02291401 02291428 02291436 02243229 02243230
SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
111 110 111 111 112 112 217 99 99 262 21 90 90 90 90 2 3 160 160 9 179 179 237 228 228 195 161 161 195 114 114 115 263 263 263 100 100 100 116 116 117 117 242 243
IV.95
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Sandoz Risperidone 0.25mg Tab Sandoz Risperidone 0.5mg Tab Sandoz Risperidone 1mg Tab Sandoz Risperidone 2mg Tab Sandoz Risperidone 3mg Tab Sandoz Risperidone 4mg Tab Sandoz Salbutamol 5mg/mL Inh Sol-10mL Pk Sandoz Sertraline 25mg Cap Sandoz Sertraline 50mg Cap Sandoz Sertraline 100mg Cap Sandoz Simvastatin 10mg Tab Sandoz Simvastatin 20mg Tab Sandoz Simvastatin 40mg Tab Sandoz Simvastatin 80mg Tab Sandoz Sotalol 80mg Tab (Not a Benefit) Sandoz Sotalol 160mg Tab Sandoz Sumatriptan 50mg Tab (Not a Benefit) Sandoz Sumatriptan 100mg Tab (Not a Benefit) Sandoz Tamsulosin 0.4mg Cap Sandoz Terbinafine 250mg Tab (Not a Benefit) Sandoz Ticlopidine 250mg Tab Sandoz Timolol 0.25% Oph Sol Sandoz Timolol 0.5% Oph Sol Sandoz Tobramycin 0.3% Oph Sol Sandoz Topiramate 25mg Tab Sandoz Topiramate 100mg Tab Sandoz Topiramate 200mg Tab Sandoz Valproic 250mg Cap Sandoz Valproic 500mg Ent Cap Sandoz Zopiclone 5mg Tab (Not a Benefit) Sandoz Zopiclone 7.5mg Tab (Not a Benefit) Sansert 2mg Tab SAQUINAVIR MESYLATE SECOBARBITAL SODIUM Seconal 100mg Cap Sectral 100mg Tab Sectral 200mg Tab Sectral 400mg Tab SELEGILINE HCL SENNOSIDES A & B Senokot 1.7mg/mL Syrup Senokot 8.6mg Tab Septra 40mg & 8mg/mL O/L (Not a Benefit) Septra 400mg & 80mg Tab (Not a Benefit)
IV.96
02292807 02279495 02279800 02279819 02279827 02279835 02154412 02245159 02245160 02245161 02247828 02247830 02247831 02247833 02257831 02257858 02263025 02263033 02295121 02262177 02243587 02166712 02166720 02241755 02260050 02260069 02267837 02239714 02239713 02257572 02257580 00027499
SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ NOV
00015288 01926543 01926551 01926578
LIL SAV SAV SAV
00367729 00026158 00270644 00270636
PFP PFP BWE BWE
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIB IIIB IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
174 174 175 175 175 175 65 162 162 162 101 102 102 102 7 94 17 17 319 2 320 214 214 197 153 153 153 154 154 15 16 69 29 180 180 83 83 83 317 220 220 220 40 40
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Septra DS 800mg & 160mg Tab (Not a Benefit) Serax 10mg Tab (Not a Benefit) Serax 15mg Tab (Not a Benefit) Serax 30mg Tab (Not a Benefit) Serc 16mg Tab (Not a Benefit) Serc 24mg Tab (Not a Benefit) SereVent Diskhaler Disks 50mcg/Blister Diskhaler-60 Disk Pk SereVent Diskus 50mcg Pd Inh-60 Dose Pk Seroquel 25mg Tab Seroquel 100mg Tab Seroquel 200mg Tab Seroquel 300mg Tab Seroquel XR 50mg ER Tab Seroquel XR 200mg ER Tab Seroquel XR 300mg ER Tab Seroquel XR 400mg ER Tab SERTRALINE HCL Sibelium 5mg Cap SILVER SULFADIAZINE SIMVASTATIN Sinemet 100mg & 10mg Tab Sinemet 100mg & 25mg Tab Sinemet 250mg & 25mg Tab Sinemet CR 100mg & 25mg Tab Sinemet CR 200mg & 50mg Tab Sinequan 10mg Cap Sinequan 25mg Cap Sinequan 50mg Cap Sinequan 75mg Cap Sinequan 100mg Cap Sinequan 150mg Cap (Not a Benefit) Singulair 4mg Chew Tab SIROLIMUS SODIUM AUROTHIOMALATE Sodium Aurothiomalate 10mg/mL Inj Sol-1mL Pk Sodium Aurothiomalate 25mg/mL Inj Sol-1mL Pk Sodium Aurothiomalate 50mg/mL Inj Sol-1mL Pk SODIUM BIPHOSPHATE & SODIUM PHOSPHATE SODIUM CITRATE & SODIUM LAURYL SULFOACETATE SODIUM CROMOGLYCATE SODIUM FLUORIDE SODIUM FUSIDATE Soflax 100mg Cap
00368040 02043653 02043661 02043688 02243878 02247998 02214261 02231129 02236951 02236952 02236953 02244107 02300184 02300192 02300206 02300214 00846341
BWE WAY WAY WAY SPH SPH GSK GSK AZC AZC AZC AZC AZC AZC AZC AZC PMS
00355658 00513997 00328219 02028786 00870935 00024325 00024333 00024341 00400750 00326925 00584274 02243602
MFC MFC MFC MFC MFC ERF ERF ERF ERF ERF PFI MFC
02245456 02245457 02245458
SDZ SDZ SDZ
01994344
PMS
IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
40 171 171 171 8 8 67 67 173 173 173 173 173 173 173 173 162 311 284 101 312 313 313 313 313 157 157 157 157 157 158 313 317 245 245 245 245 220 220 213 317 318 19 277 218
IV.97
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Soflax Syrup 4mg/mL O/L Sofracort 5mg & 50mcg & 0.5mg/mL Oph/Ot Sol Soframycin 0.5% Oph Oint-5g Pk Soframycin 0.5% Oph Sol Soriatane 10mg Cap Soriatane 25mg Cap Sotacor 80mg Tab (Not a Benefit) Sotacor 160mg Tab (Not a Benefit) SOTALOL HCL Spiriva 18mcg Cap SPIRONOLACTONE Statex 1mg/mL O/L Statex 5mg/mL O/L Statex 20mg/mL Oral Drops Statex 5mg Tab Statex 10mg Tab Statex 25mg Tab Statex 50mg Tab STAVUDINE Stelazine 1mg Tab (Not a Benefit) Stelazine 2mg Tab (Not a Benefit) Stelazine 5mg Tab (Not a Benefit) Stelazine 10mg Tab (Not a Benefit) Stemetil 10mg/2mL Inj Sol-2mL Pk (Not a Benefit) Stemetil 5mg Tab (Not a Benefit) Stemetil 10mg Tab (Not a Benefit) STERCULIA GUM Stieva-A 0.01% Cr Stieva-A 0.025% Cr Stieva-A 0.05% Cr Stieva-A 0.025% Gel Stieva-A 0.025% Sol Stievamycin Gel 0.025% & 4% Top Gel STREPTOZOCIN SUCRALFATE Sudafed 6mg/mL O/L (Not a Benefit) Sudafed 60mg Tab (Not a Benefit) Sulcrate 1g Tab Sulcrate Suspension Plus 1g/5mL Oral Susp SULFACETAMIDE (SODIUM) SULFAMETHOXAZOLE & TRIMETHOPRIM SULFASALAZINE SULFINPYRAZONE
IV.98
02006758 02224623 02224895 02224887 02070847 02070863 00897272 00483923
PMS SAV ERF ERF HLR HLR BQU BQU
02246793 00591467 00591475 00621935 00594652 00594644 00594636 00675962 01918206 01918214 01918222 01918230 01927779 01927752 01927760 00657204 00578576 00518182 00587966 00578568 01905112
BOE PMS PMS PMS PMS PMS PMS PMS SMJ SMJ SMJ SMJ SAV AVE AVE STI STI STI STI STI STI
00004561 00004766 02100622 02103567
BWE BWE BFI BFI
IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
218 195 195 195 295 295 7 94 94 7 58 191 142 142 142 143 143 143 143 29 176 176 176 176 173 173 173 220 294 294 294 294 294 294 49 243 62 62 243 243 197 40 31 192
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
SULINDAC SUMATRIPTAN SUCCINATE Suprax 20mg/mL Oral Susp Suprax 400mg Tab Suprefact 1mg/mL Inj Sol-5.5mL Pk Suprefact 1mg/mL Nas Sp-10mL Pk Suprefact Depot 6.3mg Implant Kit Suprefact Depot 9.45mg Implant Kit Surfak 240mg Cap (Not a Benefit) Surgam 200mg Tab (Not a Benefit) Surgam 300mg Tab Surmontil 75mg Cap (Not a Benefit) Surmontil 12.5mg Tab (Not a Benefit) Surmontil 25mg Tab (Not a Benefit) Surmontil 50mg Tab (Not a Benefit) Surmontil 100mg Tab (Not a Benefit) Sustiva 50mg Cap Sustiva 100mg Cap Sustiva 200mg Cap Sustiva 600mg Tab Symbicort 100 Turbuhaler 100mcg/6mcg Pd Inh-120 Dose Pk Symbicort 200 Turbuhaler 200mcg/6mcg Pd Inh-120 Dose Pk Symmetrel 100mg Cap (Not a Benefit) Symmetrel 10mg/mL O/L Synacthen Depot 1mg/mL Inj Susp-1mL Pk Synalar Mild 0.01% Cr Synphasic 3 Phase Tab-21 Pk Synphasic 3 Phase Tab-28 Pk Synthroid 0.025mg Tab Synthroid 0.05mg Tab Synthroid 0.075mg Tab Synthroid 0.088mg Tab Synthroid 0.1mg Tab Synthroid 0.112mg Tab Synthroid 0.125mg Tab Synthroid 0.15mg Tab Synthroid 0.175mg Tab Synthroid 0.2mg Tab Synthroid 0.3mg Tab TACROLIMUS Tagamet 200mg Tab (Not a Benefit) Tagamet 300mg Tab (Not a Benefit) Tagamet 400mg Tab (Not a Benefit) Tagamet 600mg Tab (Not a Benefit)
00868965 00868981 02225166 02225158 02228955 02240749 02224666 01989782 02221950 01926349 01926357 01926322 01926330 01926284 02239886 02239887 02239888 02246045 02245385 02245386 01914006 01913999 00253952 00030414 02187108 02187116 02172062 02172070 02172089 02172097 02172100 02171228 02172119 02172127 02172135 02172143 02172151 01916793 01916815 01916785 01916777
SAV SAV SAV SAV SAV SAV HMR HRU SAV RPP RPP RPP RPP RPP BQU BQU BQU BQU AZC AZC BQU BQU NOV SYN PFI PFI ABB ABB ABB ABB ABB ABB ABB ABB ABB ABB ABB SMJ SMJ SMJ SMJ
IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
135 17 15 15 42 42 42 42 218 135 135 163 163 163 164 164 24 24 25 25 59 59 304 304 183 288 272 272 274 274 274 274 274 274 274 275 275 275 275 318 230 230 230 231
IV.99
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Tagamet 800mg Tab (Not a Benefit) Tambocor 50mg Tab Tambocor 100mg Tab Tamiflu 75mg Cap Tamofen 10mg Tab Tamofen 20mg Tab TAMOXIFEN CITRATE TAMSULOSIN HCL Tanta Orciprenaline 2mg/mL O/L Tantum 0.15% Oral Rinse Taro-Amcinonide 0.1% Cr Taro-Carbamazepine 100mg Chew Tab Taro-Carbamazepine 200mg Chew Tab Taro-Ciprofloxacin 250mg Tab Taro-Ciprofloxacin 500mg Tab Taro-Clobetasol Cream USP 0.05% Cr Taro-Clobetasol Ointment USP 0.05% Oint Taro-Clobetasol Topical Solution USP 0.05% Scalp Lot Taro-Enalapril 2.5mg Tab Taro-Enalapril 5mg Tab Taro-Enalapril 10mg Tab Taro-Enalapril 20mg Tab Taro-Fluconazole 50mg Tab Taro-Fluconazole 100mg Tab Taro-Mometasone 0.1% Oint Taro-Mupirocin 2% Oint Taro-Phenytoin 25mg/mL O/L Taro-Simvastatin 10mg Tab Taro-Simvastatin 20mg Tab Taro-Simvastatin 40mg Tab Taro-Sone 0.05% Cr Taro-Terconazole 0.4% Cr Taro-Warfarin 1mg Tab Taro-Warfarin 2mg Tab Taro-Warfarin 2.5mg Tab Taro-Warfarin 3mg Tab Taro-Warfarin 4mg Tab Taro-Warfarin 5mg Tab Taro-Warfarin 10mg Tab Tears Naturale 0.1%/0.3% Oph-Sol Tears Naturale II 0.1%/0.3%/0.001% Oph-Sol Tears Plus Oph-Sol Tebrazid 500mg Tab Tegretol 100mg Chew Tab
IV.100
01916769 01966197 01966200 02241472 01926624 01926632
SMJ GRA GRA HLR SAV SAV
02192675 01966065 02246714 02244403 02244404 02266962 02266970 02245523 02245524 02245522 02300117 02300125 02300133 02300141 02249294 02249308 02264749 02279983 02250896 02265885 02265893 02265907 01925350 02247651 02242680 02242681 02242682 02242683 02242684 02242685 02242687 00390291 00743445 00579408 00283991 00369810
TAN GRA TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR TAR ALC ALC ALL VAL NOV
231 90 90 28 49 49 49 319 62 201 284 146 146 33 33 287 287 287 106 107 107 107 5 5 291 277 152 101 102 102 285 281 77 77 77 77 77 78 78 207 207 212 20 146
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Tegretol 200mg Chew Tab Tegretol 100mg/5mL Oral Susp Tegretol 200mg Tab (Not a Benefit) Tegretol CR 200mg LA Tab Tegretol CR 400mg LA Tab TELMISARTAN TELMISARTAN & HYDROCHLOROTHIAZIDE Telzir 700mg Tab TEMAZEPAM Temodal 5mg Cap Temodal 20mg Cap Temodal 100mg Cap Temodal 250mg Cap TEMOZOLOMIDE Tempra 80mg/mL O/L (Not a Benefit) TENOFOVIR DISOPROXIL Tenoretic 50/25 50 & 25mg Tab Tenoretic 100/25 100 & 25mg Tab Tenormin 50mg Tab Tenormin 100mg Tab Terazol 3 80mg Vag Ovule Terazol 7 0.4% Cr TERAZOSIN HCL TERBINAFINE HCL TERBUTALINE SULFATE TERCONAZOLE TESTOSTERONE TESTOSTERONE CYPIONATE TESTOSTERONE ENANTHATE TESTOSTERONE UNDECANOATE TETRACYCLINE Tetracyn 250mg Cap (Not a Benefit) Teveten 400mg Tab Teveten 600mg Tab Teveten Plus 600mg & 12.5mg Tab Theo-Dur 300mg LA Tab (Not a Benefit) Theolair Alcohol Free Oral Liquid 5.3mg/mL O/L THEOPHYLLINE ANHYDROUS THIAMINE HCL THIOGUANINE THIOTHIXENE Thyrogen 0.9mg/mL Inj Pd-2x1.1mg Vial Pk THYROID
00665088 02194333 00010405 00773611 00755583
NOV NOV NOV NOV NOV
02261545 02241093 02241094 02241095 02241096 00642401 02049961 02049988 02039532 02039540 00894710 00894729
GSK SCH SCH SCH SCH MJS AZC AZC AZC AZC JNO JNO
00024422 02240432 02243942 02253631 00461008 01966219
PFI SPH SPH SPH AZC GRA
02246016
GZM
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
146 147 147 147 147 117 117 25 180 50 50 50 50 50 145 30 103 103 84 85 281 281 118 280 2 68 281 255 256 256 257 14 14 108 108 108 299 299 299 300 50 176 270 275
IV.101
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Thyroid 30mg Tab Thyroid 60mg Tab Thyroid 125mg Tab THYROTROPIN ALFA Tiamol 0.05% Emol Cr TIAPROFENIC ACID Tiazac 120mg SR Cap Tiazac 180mg SR Cap Tiazac 240mg SR Cap Tiazac 300mg SR Cap Tiazac 360mg SR Cap Tiazac XC 120mg ER Tab Tiazac XC 180mg ER Tab Tiazac XC 240mg ER Tab Tiazac XC 300mg ER Tab Tiazac XC 360mg ER Tab Ticlid 250mg Tab TICLOPIDINE HCL TIMOLOL MALEATE Timolol Maleate-EX 0.25% Oph Gellan Sol Timolol Maleate-EX 0.5% Oph Gellan Sol Timoptic 0.25% Oph Sol Timoptic 0.5% Oph Sol Timoptic-XE 0.25% Oph Gellan Sol Timoptic-XE 0.5% Oph Gellan Sol TINZAPARIN SODIUM TIOTROPIUM BROMIDE MONOHYDRATE TIZANIDINE HCL TOBI 300mg/5mL Inh Sol-5mL Pk TobraDex 0.3% & 0.1% Oph Oint TobraDex 0.3% & 0.1% Oph Susp TOBRAMYCIN Tobramycin 80mg/2mL Inj Sol-2mL Pk TOBRAMYCIN & DEXAMETHASONE TOBRAMYCIN SULFATE Tobrex 0.3% Oph Oint Tobrex 0.3% Oph Sol Tofranil 10mg Tab (Not a Benefit) Tofranil 25mg Tab Tofranil 50mg Tab TOLTERODINE L-TARTRATE Topamax 25mg Tab Topamax 100mg Tab
IV.102
00023949 00023957 00023965 00598933 02231150 02231151 02231152 02231154 02231155 02256738 02256746 02256754 02256762 02256770 02162776
ERF ERF ERF TAR BIO BIO BIO BIO BIO BIO BIO BIO BIO BIO HLR
02242275 02242276 00451193 00451207 02171880 02171899
ALC ALC MFC MFC MFC MFC
02239630 00778915 00778907
NOV ALC ALC
02241210
SDZ
00614254 00513962 00010464 00010472 00010480 02230893 02230894
ALC ALC NOV NOV NOV JNO JNO
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
275 275 275 270 289 135 88 89 89 89 89 87 87 87 87 87 320 320 94 213 213 213 214 214 213 213 76 58 5 19 197 197 19 197 19 197 19 197 197 159 159 159 321 153 153
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Topamax 200mg Tab Topamax Sprinkle 15mg Sprinkle Cap Topamax Sprinkle 25mg Sprinkle Cap TOPIRAMATE Topsyn 0.05% Gel (Not a Benefit) Trandate 100mg Tab Trandate 200mg Tab TRANDOLAPRIL Transderm-Nitro 0.4mg/Hr/20 Sq Cm Patch Transderm-Nitro 0.6mg/Hr/30 Sq Cm Patch Tranxene 3.75mg Cap (Not a Benefit) Tranxene 7.5mg Cap Tranxene 15mg Cap TRANYLCYPROMINE SULFATE Trasicor 40mg Tab Travatan 0.004% Oph Sol TRAVOPROST TRAZODONE HYDROCHLORIDE Trelstar (1 Month) 3.75mg/Vial Inj Pd with Sterile Water-Vial Pk Trelstar (1 Month) 3.75mg/Vial Inj Pd-Vial Pk Trelstar LA (3 Month) 11.25mg/Vial Inj Pd with Sterile Water-Vial Pk Trelstar LA (3 Month) 11.25mg/Vial Inj Pd-Vial Pk Trental 400mg SR Tab TRETINOIN TRETINOIN & ERYTHROMYCIN Tri-Cyclen 3 Phase Tab-21 Pk Tri-Cyclen 3 Phase Tab-28 Pk Tri-Cyclen Lo 3 Phase Tab-21 Pk Tri-Cyclen Lo 3 Phase Tab-28 Pk Triaderm 0.1% Cr TRIAMCINOLONE ACETONIDE Triamcinolone Acetonide 40mg/mL Inj Susp-1mL Pk Triamcinolone Acetonide 50mg/5mL Inj Susp-5mL Pk Triamcinolone Acetonide 200mg/5mL Inj Susp-5mL Pk TRIAMCINOLONE ACETONIDE 0.1% IN ORABASE TRIAZOLAM Tridesilon 0.05% Cr (Not a Benefit) Tridesilon 0.05% Oint (Not a Benefit) TRIFLUOPERAZINE TRIFLURIDINE TRIHEXYPHENIDYL HCL Trilafon 2mg Tab (Not a Benefit) Trilafon 4mg Tab (Not a Benefit)
02230896 02239907 02239908 02161974 02106272 02106280 00852384 02046156 00264938 00264946 00264911 00402575 02244896
JNO JNO JNO MEC SQI SQI NOV NOV ABB ABB ABB NOV ALC
09857199 02240000 09857200 02243856 02221977
PAL PAL PAL PAL SAV
153 152 152 152 289 110 110 118 121 121 166 166 166 163 114 214 214 163 50 50 50 50 81 294 294 274 274 274 274 291 254 291 254 254 254 291 180 288 288 176 198 59 172 172
IV.103
02028700 02029421 02258560 02258587 00716960
JNO JNO JNO JNO TAR
02229550 02229540 09857128
SDZ SDZ SDZ
02154862 02154870
CPL CPL
00028290 00028304
SCH SCH
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Trilafon 8mg Tab (Not a Benefit) Trilafon 16mg Tab (Not a Benefit) Trileptal 150mg Tab (Not a Benefit) Trileptal 300mg Tab (Not a Benefit) Trileptal 600mg Tab (Not a Benefit) TRIMEBUTINE MALEATE TRIMETHOPRIM TRIMIPRAMINE Trinipatch 0.4mg/Hr/14 Sq Cm Patch Trinipatch 0.6mg/Hr/21 Sq Cm Patch TRIPTORELIN PAMOATE Triquilar 21 3 Phase Tab-21 Pk Triquilar 28 3 Phase Tab-28 Pk Trisyn Emol Cr Trizivir 300mg/150mg/300mg Tab Trusopt 2% Oph Sol Truvada 200mg & 300mg Tab Tryptan 500mg Cap (Not a Benefit) Tryptan 500mg Tab (Not a Benefit) Tryptan 1g Tab (Not a Benefit) TRYPTOPHAN Tylenol No.2 15mg Tab Tylenol No.3 30mg Tab Tylenol No.4 300mg & 60mg Tab Tylenol With Codeine 160mg & 8mg/5mL O/L (Not a Benefit) Ultradol 200mg Cap (Not a Benefit) Ultradol 300mg Cap (Not a Benefit) UltraMOP 10mg SG Cap Uniphyl 400mg SR Tab Uniphyl 600mg SR Tab Uremol-HC 1% & 10% Cr Uremol-HC 1% & 10% Lot Urispas 200mg Tab (Not a Benefit) Urso 250mg Tab Urso DS 500mg Tab URSODIOL Vagifem 25mcg Vag Tab VALACYCLOVIR Valcyte 450mg Tab VALGANCICLOVIR Valisone 0.1% Scalp Lot Valium 2mg Tab (Not a Benefit) Valium 5mg Tab (Not a Benefit) Valium 10mg Tab (Not a Benefit)
IV.104
00028312 00028320 02242067 02242068 02242069
SCH SCH NOV NOV NOV
02230733 02230734 00707600 00707503 00781371 02244757 02216205 02274906 00718149 02029456 00654531 02163934 02163926 02163918 02163942 02142023 02142031 00646237 02014165 02014181 00503134 00560022 00728179 02238984 02245894 02241332 02245777 00027944 00013277 00013285 00013293
NOV NOV BAY BAY BAK GSK MFC GIL VAL VAL VAL JNO JNO JNO JNO PGP PGP CDX PFP PFP STI STI PAL BFI BFI NOO HLR SCH HLR HLR HLR
IIIA IIIA IIIB IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIB IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
172 172 12 12 12 5 40 163 121 122 50 271 271 289 21 208 25 14 14 14 14 136 136 136 136 9 9 296 299 299 290 290 54 322 322 322 258 30 30 30 286 167 167 167
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
VALPROATE SODIUM VALPROIC ACID VALSARTAN VALSARTAN & HYDROCHLOROTHIAZIDE Valtrex 500mg Tab Vasocon 0.1% Oph Sol (Not a Benefit) Vasotec 2.5mg Tab Vasotec 5mg Tab Vasotec 10mg Tab Vasotec 20mg Tab VC-K 500 60mg/mL O/L (Not a Benefit) VENLAFAXINE HCL Ventolin 5mg/mL Inh Sol-10mL Pk Ventolin 100mcg/Metered Dose Inh-200 Dose Pk (Not a Benefit) Ventolin 0.4mg/mL O/L Ventolin 2mg Tab (Not a Benefit) Ventolin 4mg Tab (Not a Benefit) Ventolin Nebules P.F. 1mg/mL Inh Sol-2.5mL Pk Ventolin Nebules P.F. 2mg/mL Inh Sol-2.5mL Pk Vepesid 50mg Cap VERAPAMIL HCL
02219492 00759880 00851795 00708879 00670901 00670928 00331945 02213486 02213478 02212390 01961039 01932691 02213419 02213427 00616192
GSK IOB MFC MFC MFC MFC LIL GSK GLW GSK GLA GLA GSK GSK BQU
Vermox 100mg Tab Vfend 50mg Tab Vfend 200mg Tab Videx EC 125mg Enteric Coated Cap Videx EC 200mg Enteric Coated Cap Videx EC 250mg Enteric Coated Cap Videx EC 400mg Enteric-Coated Cap VIGABATRIN VINCRISTINE SULFATE Vincristine Sulfate 1mg/mL Inj Sol Viokase 16800 & 70000 & 70000 USP U/0.7g Pd-114g Pk Viokase 8000 & 30000 & 30000 USP Units Tab Viokase 16 16mg Tab Viracept 250mg Tab Viracept 625mg Tab Viramune 200mg Tab Viread 300mg Tab Viroptic 1% Oph Sol Viskazide 10/25 10mg & 25mg Tab Viskazide 10/50 10mg & 50mg Tab Visken 5mg Tab
00556734 02256460 02256479 02244596 02244597 02244598 02244599
JNO PFI PFI BQU BQU BQU BQU
02143305 02230020 02230019 02241933 02238617 02248761 02238748 02247128 00687456 00568627 00568635 00417270
NOP BFI BFI BFI PFI PFI BOE GIL THE NOV NOV NOV
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
154 154 119 119 30 203 106 107 107 107 13 164 65 66 66 66 66 63 64 44 94 119 8 3 7 7 24 24 24 24 154 50 50 224 224 224 27 27 27 30 198 115 115 114
IV.105
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Visken 10mg Tab Visken 15mg Tab Vitamin A Acid 0.05% Cr Vitamin A Acid 0.01% Gel Vitamin A Acid 0.05% Gel Vitamin B1 50mg Tab dpp (Not a Benefit) Vitamin B1-ICN 50mg Tab dpp (Not a Benefit) Vitamin B6 25mg Tab dpp Vitamin B6 25mg Tab dpp (Not a Benefit) Vitamin B6-ICN 25mg Tab dpp Vitamin B12-1000mcg/mL 1mg/mL Inj Sol-10mL Pk Vitamin C 250mg Tab (Not a Benefit) Vitamin C 500mg Tab (Not a Benefit) Vitamin C 1000mg Tab (Not a Benefit) VITAMIN D Voltaren 25mg Ent Tab (Not a Benefit) Voltaren 50mg Ent Tab Voltaren 50mg Sup Voltaren 100mg Sup Voltaren Ophtha 0.1% Oph Sol Voltaren Rapide 50mg Tab (Not a Benefit) Voltaren SR 75mg LA Tab (Not a Benefit) Voltaren SR 100mg LA Tab (Not a Benefit) VORICONAZOLE WARFARIN Wellbutrin SR 100mg Tab Wellbutrin SR 150mg Tab Wellbutrin XL 150mg Tab Wellbutrin XL 300mg Tab Westcort 0.2% Cr Westcort 0.2% Oint Winpred 1mg Tab Xalacom 50mcg/mL & 5mg/mL Oph Sol-2.5mL Pk Xalatan 0.005% Oph Sol-2.5mL Pk Xanax 0.25mg Tab Xanax 0.5mg Tab Xanax 1mg Tab (Not a Benefit) Xanax TS 2mg Tab (Not a Benefit) Xatral 10mg Prolong-Rel Tab Xeloda 150mg Tab Xeloda 500mg Tab Xylocaine Viscous 2% O/L Yasmin 21 3.0mg & 0.03mg Tab-21 Pk
IV.106
00443174 00417289 01926519 01926462 01926489 00610267 00268631 00232475 00416185 00268607 00521515 00036161 00036188 00256862 00514004 00514012 00632724 00632732 01940414 00881635 00782459 00590827
NOV NOV SAV SAV SAV LEA VAL PMS RPR VAL SDZ RPR RPR RPR GEI NOV NOV NOV NOV NOV NOV NOV
02237824 02237825 02275090 02275104 01910124 01910132 00271373 02246619 02231493 00548359 00548367 00723770 00813958 02245565 02238453 02238454 00001686 02261723
BIO BIO BIO BIO BQU BQU VAL PFI PFI PFI PFI PFI PFI SAV HLR HLR AZC BAH
IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB IIIA IIIA IIIA IIIA IIIA
114 115 294 294 294 300 300 300 300 300 300 301 301 301 302 125 125 126 126 207 9 125 126 7 77 6 155 155 155 155 290 290 253 210 209 164 165 13 13 303 42 42 201 270
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Yasmin 28 3.0mg & 0.03mg Tab-28 Pk Zanaflex 4mg Tab (Not a Benefit) Zanosar Inj Pd-1g Pk Zantac 50mg/2mL Inj Sol-2mL Pk Zantac 15mg/mL Oral Sol Zantac 150mg Tab Zantac 300mg Tab Zarontin 250mg Cap Zarontin 50mg/mL O/L Zaroxolyn 2.5mg Tab Zerit 15mg Cap Zerit 20mg Cap Zerit 30mg Cap Zerit 40mg Cap Zestoretic 10mg & 12.5mg Tab Zestoretic 20mg & 12.5mg Tab Zestril 5mg Tab Zestril 10mg Tab Zestril 20mg Tab Ziagen 20mg/mL O/L Ziagen 300mg Tab ZINC SULFATE Zithromax 100mg/5mL O/L Zithromax 200mg/5mL O/L Zithromax 250mg Tab Zithromax 600mg Tab (Not a Benefit) Zocor 5mg Tab Zocor 10mg Tab Zocor 20mg Tab Zocor 40mg Tab Zocor 80mg Tab Zofran 4mg/5mL O/L Zofran 4mg Tab Zofran 8mg Tab Zofran ODT 4mg Tab Zofran ODT 8mg Tab Zoladex 3.6mg Depot Inj Zoladex LA 10.8mg Depot Inj ZOLEDRONIC ACID Zoloft 25mg Cap Zoloft 50mg Cap Zoloft 100mg Cap ZOPICLONE Zovirax 200mg Tab (Not a Benefit)
02261731 02239170 00622141 02212366 02212374 02212331 02212358 00022799 00023485 00888400 02216086 02216094 02216108 02216116 02103729 02045737 02049333 02049376 02049384 02240358 02240357 02223716 02223724 02212021 02231143 00884324 00884332 00884340 00884359 02240332 02229639 02213567 02213575 02239372 02239373 02049325 02225905 02132702 01962817 01962779 00634506
BAH ELA PFI GSK GSK GSK GSK ERF ERF SAV BQU BQU BQU BQU AZC AZC AZC AZC AZC GSK GSK PFI PFI PFI PFI MFC MFC MFC MFC MFC GSK GSK GSK GSK GSK AZC AZC PFI PFI PFI GSK
IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIB IIIB
270 5 49 242 242 242 243 149 149 190 29 29 29 29 112 112 111 111 111 21 21 297 7 7 8 2 101 101 102 102 102 228 228 228 228 228 45 45 322 162 162 162 15 4
IV.107
JUNE 27, 2008
DIN/PIN
MFR
PART
PAGE
Zovirax 400mg Tab (Not a Benefit) Zovirax 800mg Tab Zyloprim 100mg Tab (Not a Benefit) Zyloprim 200mg Tab (Not a Benefit) Zyloprim 300mg Tab (Not a Benefit) Zyprexa 2.5mg Tab Zyprexa 5mg Tab Zyprexa 7.5mg Tab Zyprexa 10mg Tab Zyprexa 15mg Tab Zyprexa Zydis 5mg Rapid Dissolve Tab Zyprexa Zydis 10mg Rapid Dissolve Tab Zyprexa Zydis 15mg Rapid Dissolve Tab Zyvoxam 600mg Tab
01911627 01911635 00004588 00506370 00294322 02229250 02229269 02229277 02229285 02238850 02243086 02243087 02243088 02243684
GSK GSK BWE BWE BWE LIL LIL LIL LIL LIL LIL LIL LIL PFI
IIIB IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA IIIA
4 22 304 304 304 171 171 171 171 171 171 171 171 37
IV.108
JUNE 27, 2008
PART V
INDEX OF PHARMACOLOGICAL-THERAPEUTIC CLASSIFICATION
INDEX OF DRUGS BY THERAPEUTIC CLASSIFICATION

4:00 8:00 8:08 8:12 8:12:04 8:12:12 8:12:16 8:12:24 8:12:28 8:16 8:18 8:20 8:24 8:32 8:36 8:40 10:00 12:00 12:04 12:08 12:12 12:16 12:20 20:00 20:04 20:12 20:16 20:24 24:00 24:04 24:06 24:08 24:12 28:00 28:08 28:08:04 28:08:08 28:08:92 28:12 28:16 28:16:04 ANTIHISTAMINES ANTI-INFECTIVE AGENTS Anthelmintics Antibiotics Antifungals Erythromycins Penicillins Tetracyclines Other Antibiotics Antitubercular Agents Antivirals Plasmodicides (Antimalarials) Sulfonamides Trichomonacides Urinary Anti-Infectives Miscellaneous Anti-Infectives ANTINEOPLASTIC AGENTS AUTONOMIC AGENTS Parasympathomimetic (Cholinergic) Agents Parasympatholytic (Cholinergic Blocking)Agents Sympathomimetic (Adrenergic) Agents Sympatholytic (Adrenergic Blocking) Agents Skeletal Muscle Relaxants BLOOD FORMATION AND COAGULATION Antianemia Drugs Coagulants and Anti-Coagulants Hematopoietic Agents Hemorrheologic Agents CARDIOVASCULAR DRUGS Cardiac Drugs Antilipemic Drugs Hypotensive Drugs(For Diuretics see 40:28) Vasodilating Drugs CENTRAL NERVOUS SYSTEM DRUGS Analgesics Nonsteroidal Anti-inflammatory Agents Opiate Agonists Miscellaneous Analgesics and Antipyretics Anticonvulsants Psychotherapeutic Agents Antidepressants
JUNE 27, 2008
V.1
28:16:08 28:16:12 28:20 28:24 28:92 36:00 36:04 40:00 40:12 40:18 40:28 40:40 48:00 48:04 48:08 52:00 52:04 52:04:04 52:04:08 52:04:12 52:08 52:16 52:20 52:24 52:32 52:36 56:00 56:04 56:08 56:12 56:16 56:22 56:40 60:00 64:00 68:00 68:04 68:08 68:16 68:20 68:20:02 68:20:10 68:20:12
Tranquilizers Other Psychotropics C.N.S. Stimulants Sedatives and Hypnotics Miscellaneous Central Nervous System Drugs DIAGNOSTIC AGENTS Adrenal Insufficiency ELECTROLYTIC, CALORIC AND WATER BALANCE Replacement Agents Potassium-Removing Resins Diuretics Uricosuric Drugs COUGH PREPARATIONS Antitussives Expectorants EYE, EAR, NOSE AND THROAT PREPARATIONS Anti-Infectives Antibiotics Sulfonamides Other Anti-Infectives Anti-Inflammatory Local Anesthetics Miotics Mydriatics Vasoconstrictors Other Eye, Ear Nose and Throat Agents GASTROINTESTINAL DRUGS Antacids and Adsorbents Antidiarrhea Agents Cathartics Digestants Antiemetics and Antinauseants Miscellaneous G.I. Drugs GOLD COMPOUNDS HEAVY METAL ANTAGONISTS HORMONES AND SUBSTITUTES Corticosteroids Androgens Estrogens Anti-Diabetic Agents Oral Anti-Diabetic Agents Insulins (Rapid Acting) Insulins (Intermediate Acting)
V.2
JUNE 27, 2008
68:20:16 68:24 68:28 68:32 68:36 68:38 84:00 84:04 84:04:04 84:04:08 84:04:12 84:04:16 84:06 84:28 84:36 86:00 88:00 88:08 88:12 88:16 88:28 92:00
Insulins (Pre-mixed) Parathyroid Agents Pituitary Agents Progestogens and Oral Contraceptives Thyroids Anti-Thyroids SKIN AND MUCOUS MEMBRANE PREPARATIONS Anti-Infectives Antibiotics Fungicides Parasiticides Other Anti-Infectives Anti-Inflammatory Agents Keratolytic Agents Miscellaneous Skin and Mucous Membrane Agents SPASMOLYTICS VITAMINS Vitamin B Vitamin C Vitamin D Multivitamins UNCLASSIFIED THERAPEUTIC AGENTS
JUNE 27, 2008
V.3
PART VI
FACILITATED ACCESS DRUG PRODUCTS
PART VI-A
FACILITATED ACCESS TO HIV/AIDS DRUG PRODUCTS
Facilitated Access to HIV/AIDS Drugs

Specific products used to treat ODB-eligible people with HIV/AIDS are reimbursed through the Facilitated Access process under the Exceptional Access Program (EAP). Under this process, approved physicians are exempt from the usual paperwork associated with the provision of these products [i.e., exempt from obtaining special approval under the EAP], provided that the physicians College of Physicians and Surgeons of Ontario registration number also appears on the prescription for purposes of verification. For drugs which are reimbursed as Limited Use (LU) products and the indication for use is for one of the approved LU criteria, a Limited Use prescription must be completed in order for the product to be reimbursed. For more details about the LU reimbursement process, please refer to Section C.8 of Part I, entitled Limited Use Products as well as to Part XII of the Formulary/CDI. For indications that do not meet the Limited Use criteria, the claim can be processed through the Facilitated Access mechanism. The following drug products are available through the Facilitated Access process. Please note that the interchangeability of different brands of drugs available through this mechanism has not been evaluated by the ministry, unless they are designated in the Formulary/CDI as interchangeable or listed in Part III-B as Off-Formulary Interchangeable. Where interchangeability has not been designated by the ministry, it will be necessary to specify the generic drug name or the particular brand in order for it to be reimbursed by the ministry under this mechanism. Should a difficulty be encountered by pharmacies attempting to adjudicate claims for these medications, the ODB Health Network System (HNS) Help Desk should be contacted for assistance at 1-800-668-6641. PHARMACISTS ARE REMINDED THAT THIS PHYSICIAN LIST IS STRICTLY CONFIDENTIAL AND SHOULD NOT BE SHARED WITH NON-PHARMACY STAFF. THE MINISTRY EXPECTS PHARMACISTS TO TAKE RESPONSIBILITY FOR ENSURING THIS INFORMATION IS TREATED ACCORDINGLY.
JUNE 27, 2008
VI A.1
BRAND NAME
MANUFACTURER
ACYCLOVIR 200mg/5ml Susp 00886157 200mg Tab 02197405 200mg Tab 00634506 02078627 02207621 02242784 02285959 400mg Tab 02197413 400mg Tab 01911627 02078635 02207648 02242463 02285967 800mg Tab 01911635 02078651 02197421 02207656 02242464 02285975 ATOVAQUONE 750mg/5mL O/L 02217422 AZITHROMYCIN 600mg Tab 02231143 02256088 DOXYCYCLINE 100mg Cap 00740713 100mg Cap 00024368 100mg Cap 00725250 100mg Tab 00578452
Zovirax Nu-Acyclovir Zovirax Ratio-Acyclovir Apo-Acyclovir Gen-Acyclovir Novo-Acyclovir Nu-Acyclovir Zovirax Ratio-Acyclovir Apo-Acyclovir Gen-Acyclovir Novo-Acyclovir Zovirax Ratio-Acyclovir Nu-Acyclovir Apo-Acyclovir Gen-Acyclovir Novo-Acyclovir
GLW NXP GSK RPH APX GEN NOP NXP GSK RPH APX GEN NOP GSK RPH NXP APX GEN NOP
Mepron
GLW
Zithromax Co Azithromycin
PFI COB
Apo-Doxy Vibramycin Novo-Doxylin Vibra
APX PFI NOP PFI
VI A.2
JUNE 27, 2008
BRAND NAME
MANUFACTURER
FLUCONAZOLE
Note: Recommended for the treatment of oral/esophageal candidiasis in patients who have failed to respond with nystatin or imidazoles and when oral tablets of fluconazole cannot be tolerated.
10mg/mL O/L 02024152 50mg Tab 02236978 02237370 02245292 02245643 02249294 02281260 100mg Tab 02236979 02237371 02245293 02245644 02249308 02281279 GANCICLOVIR SODIUM 500mg/Vial Pd Inj - 10mL Pk 02162695 ITRACONAZOLE
Note:
Diflucan P.O.S. Novo-Fluconazole Apo-Fluconazole Gen-Fluconazole PMS-Fluconazole Taro-Fluconazole Co Fluconazole Novo-Fluconazole Apo-Fluconazole Gen-Fluconazole PMS-Fluconazole Taro-Fluconazole Co Fluconazole
PFI NOP APX GEN PMS TAR COB NOP APX GEN PMS TAR COB
Cytovene
HLR
Recommended for the treatment of oral/esophageal candidiasis unresponsive to less expensive alternatives.
100mg Cap 02047454 10mg/mL Oral Sol 02231347 NUTRITION PRODUCTS

Note:
Sporanox Sporanox
JNO JNO
Only those products on the current list of approved NPs for patients who satisfy the functional impairment criteria.
PAROMOMYCIN
Note: Recommended for the treatment of cryptosporidium. Therapy should be discontinued if no benefits are observed after a three week trial.
250mg Cap 02078759 PNEUMOCOCCAL VACCINE Inj - 1 Dose Pk 00431648
Humatin
PDA
Pneumovax 23
MSD
JUNE 27, 2008
VI A.3
BRAND NAME
MANUFACTURER
POTASSIUM SUPPLEMENTS 8meq LA Cap 02042304 8meq LA Tab 00602884 8meq LA Tab 00074225 10meq LA Tab 00471496 20meq SR Tab 00713376 PYRIMETHAMINE 25mg Tab 00004774
Micro-K Extencaps Apo-K Slow-K Kalium Durules K-Dur
WAY APX NOV AST KEY
Daraprim
GLW
VI A.4
JUNE 27, 2008
PART VI-B
FAcIlITATed Access To PAllIATIVe cARe dRug PRoducTs
Facilitated Access to Palliative care drugs

Specific products used to treat ODB-eligible patients undergoing palliative (end-of-life) care are reimbursed through the Facilitated Access (FA) process under the Exceptional Access Program (EAP). Under this process, a select group of participating physicians are exempt from the usual paperwork associated with the provision of these products [i.e. exempt from obtaining approval under the EAP on a case by case basis), provided that the physicians College of Physicians and Surgeons of Ontario registration number also appears on the prescription for purposes of verification. Palliative Care (PC) medication claims to be reimbursed by the Ontario Drug Benefit (ODB) program must be prescribed in accordance with the following patient eligibility criteria: This patient has a terminal illness and has chosen outpatient palliative treatment. Life expectancy is less than six months and the medications are being requested for symptom control for a maximum period of six months. To facilitate the reimbursement process at the pharmacy, the prescriber is asked to indicate either, Palliative or P.C.F.A., on the prescription to signify that the patient meets the above-noted eligibility criteria. This would be an indication to the pharmacist that these medications may be reimbursed under this mechanism. Physicians wishing to participate in this program are asked to note that the Ontario Medical Association (OMA) is responsible for determining eligibility to participate, and that the following criteria may be considered by OMA in order to determine eligibility: Physicians who do more than 20 palliative care consults in a year; Physicians who do more than 50 palliative care visits in a year; Physicians who have been identified as a leader in palliative care by a regional director for CCO; Physicians who have been identified as a leader in palliative care by the executive of the section of palliative medicine at the OMA; Physicians who have been identified as a leader in palliative care by an End of Life Network or Community Care Access Center; Physicians who have become members of a Palliative AFP. Physicians wishing to obtain further information regarding the current list of physicians and/or criteria for physicians to be included on the list should contact Dr. Howard Burke, c/o Ina Nesbitt, Ontario Medical Association at (416) 340-2234 or via email at Ina Nesbitt@oma.org. The following drug products are available through the FA process. Please note that the interchangeability of different brands of drugs available through this mechanism has not been evaluated by the ministry, unless they are designated in the Formulary/CDI as interchangeable or listed in Part III-B as Off-Formulary Interchangeable. Where interchangeability has not been designated by the ministry, it will be necessary to specify the generic drug name or the particular brand name in order for it to be reimbursed by the ministry under this mechanism. These medications will no longer require application via the EAP on a case by case basis for coverage for the initial six-month course of therapy. It should be noted that consideration of coverage beyond this six-month initial period and requests for drugs that are not on the list will need to be submitted to the EAP Unit as usual. Physicians are encouraged to submit renewal requests at least 4 to 6 weeks prior to the expiration date. In addition, requests for the use of these medications in other clinical settings will continue to require the physician to apply via the EAP. Pharmacies should note that adjudication for these medications via the Health Network System (HNS) will be allowed with the proviso that the PIN specifically assigned to each drug product is used for billing. Attempts to adjudicate these medications with the DIN may result in rejection of the claim. Should a difficulty be encountered by pharmacies attempting to adjudicate claims for these medications, the ODB HNS Help Desk should be contacted for assistance at 1-800-668-6641. PHARMAcIsTs ARe ReMINded THAT THIs PHYsIcIAN lIsT Is sTRIcTlY coNFIdeNTIAl ANd sHould NoT Be sHARed WITH NoN-PHARMAcY sTAFF. THe MINIsTRY eXPecTs PHARMAcIsTs To TAKe ResPoNsIBIlITY FoR eNsuRINg THIs INFoRMATIoN Is TReATed AccoRdINglY.
JUNE 27, 2008
VI B.1
PAllIATIVe cARe dRugs

DRUG NAME, STRENGTH AND DOSAGE FORM PIN BRAND NAME MANUFACTURER
dIAzePAM 5mg/mL Inj 2mL Pk 09857240 dIMeNHYdRINATe 50mg/mL Inj-5mL Pk 09857207 FuRoseMIde 10mg/mL Inj Sol-2mL Pk 09857208 gABAPeNTIN 100mg Cap 09857244 09857209 09857245 09857246 09857247 09857248 09857250 300mg Cap 09857251 09857210 09857252 09857253 09857254 09857255 09857256 400mg Cap 09857259 09857211 09857260 09857261 09857262 09857263 09857264 glYcoPYRRolATe 0.2mg/mL Inj-1mL Amp 09857212 HYoscINe BuTYlBRoMIde 20mg/mL Inj Sol 09857213 10mg Tab 09857215
Sandoz Diazepam
SDZ
Sandoz Dimenhydrinate
SDZ
Sandoz Furosemide
SDZ
Neurontin PMS-Gabapentin Apo-Gabapentin Novo-Gabapentin Gen-Gabapentin Co-Gabapentin Ratio-Gabapentin Neurontin PMS-Gabapentin Apo-Gabapentin Novo-Gabapentin Gen-Gabapentin Co-Gabapentin Ratio-Gabapentin Neurontin PMS-Gabapentin Apo-Gabapentin Novo-Gabapentin Gen-Gabapentin Co-Gabapentin Ratio-Gabapentin
PFI PMS APX NOP GEN COB RPH PFI PMS APX NOP GEN COB RPH PFI PMS APX NOP GEN COB RPH
Sandoz Glycopyrrolate
SDZ
Buscopan Buscopan
BOE BOE
loRAzePAM 4mg/mL Inj-1mL Pk 09857216
Sandoz Lorazepam
SDZ
JUNE 27, 2008
VI B.3
DRUG NAME, STRENGTH AND DOSAGE FORM PIN
BRAND NAME
MANUFACTURER
MeTHAdoNe Hcl 1mg/mL O/L 09857221 10mg/mL O/L 09857223 1mg Tab 5mg Tab 10mg Tab 25mg Tab 09857217 09857218 09857219 09857220
Metadol Metadol Metadol Metadol Metadol Metadol
PMS PMS PMS PMS PMS PMS
MeTocloPRAMIde Hcl 10mg/2mL Inj-2mL Pk 09857224 MIdAzolAM Hcl 5mg/mL Inj-1mL Pk 09857225 MoRPHINe sulFATe 2mg/mL Inj Sol Amp 09857226 10mg/mL Inj Sol Amp 09857227 oXYcodoNe Hcl 5mg 09857232 5mg 10mg 10mg 20mg 20mg 09857243 09857233 09857241 09857242 09857234
Sandoz Metoclopramide
SDZ
Sandoz Midazolam
SDZ
Sandoz Morphine Sandoz Morhpine
SDZ SDZ
Supeudol Oxy-IR Supeudol Oxy-IR Oxy-IR Supeudol
SIL PFP SIL PFP PFP SIL
PHeNoBARBITAl 120mg/mL Inj Sol-1mL Pk 09857296
Phenobarbital
SDZ
VI B.4
JUNE 27, 2008
DRUG NAME, STRENGTH AND DOSAGE FORM PIN
BRAND NAME
MANUFACTURER
PHeNYToIN (dIPHeNYlHYdANToIN) 50mg/mL Inj-2mL Pk 09857235 scoPolAMINe HYdRoBRoMIde 0.4mg/mL Inj Sol 09857236 0.6mg/mL Inj-1mL Pk 09857237
Sandoz Phenytoin
SDZ
Hospira-Scopolamine Hospira-Scopolamine
HOS HOS
PHARMAcIsTs ARe ReMINded THAT THIs PHYsIcIAN lIsT Is sTRIcTlY coNFIdeNTIAl ANd sHould NoT Be sHARed WITH NoN-PHARMAcY sTAFF. THe MINIsTRY eXPecTs PHARMAcIsTs To TAKe ResPoNsIBIlITY FoR eNsuRINg THIs INFoRMATIoN Is TReATed AccoRdINglY.
JUNE 27, 2008
VI B.5
PART VII
TRILLIUM DRUG PROGRAM
Trillium Drug Program

The Trillium Drug Program (TDP) was established on April 1, 1995, to help people who have high drug costs in relation to their incomes. This is an annual provincial government program and each year starting August 1, drug costs must be paid up to the deductible level before eligibility for coverage begins. The TDP deductible is based on income and family size. The program runs from August 1 of one year to July 31 of the following year. Effective August 1, 1999, the annual deductible is paid in four installments over the Trillium benefit year. For example, a family with an annual deductible of $500, will pay $125 for prescriptions purchased at the start of each quarter on August 1, November 1, February 1, and May 1. After the deductible is paid in each quarter, the family will receive benefits for that quarter and may be asked to pay up to $2 per prescription for a covered drug product. Any unpaid deductible in a quarter will be added to the next quarters deductible. New applicants to Trillium can choose the date within the program year on which they wish to be enrolled. The deductible is prorated based on the number of days left in the program year. The prorated deductible applies only for the first year of enrollment into the program. People may qualify for the TDP if they: have a valid Ontario Health Card, and are not currently eligible to receive drug benefits under the ODB program, and do not have prescription drug costs fully covered by a private insurance plan, and are paying a large part of their income for prescription drugs. Effective December 1, 1996, the following are considered to be allowable prescription drug expenses that can be counted toward the Trillium deductible: products listed as ODB benefits products on the Facilitated Access list (Part VI of the Formulary binder) allergenic extracts any drug product which has been approved by the Executive Officer on an individual basis, under section 16 of the Ontario Drug Benefit Act or in accordance with the regulations under the Ontario Drug Benefit Act [O.Reg. 201/96 sec. 3(4) iv, 3(5)] products on the Nutrition Products List and the list of Diabetic Testing Agents (Part IX of the Formulary binder) an extemporaneous product that is a designated pharmaceutical product under the regulations made under the Ontario Drug Benefit Act a product listed in Schedule 2 (insulin, adrenocorticotrophic hormones, nitrate vasodilators) For Trillium-eligible recipients, the ministry will pay for the lesser of a 100 days supply or a quantity sufficient to extend up to 30 days after the end of the Trillium eligibility period (e.g., in July, a quantity sufficient to last until August 30 will be covered). In addition, to ensure proper application of the Trillium program for households that have not met their annual deductibles as of the third quarter, the days supply for claims submitted during this period cannot exceed more than 30 days beyond the end of the third quarter (i.e. beyond May 30th of each benefit year). The Health Network System automatically calculates the days' supply in these circumstances and will not reimburse any exceeded amounts. During the first and second quarters of the Trillium benefit year (August 1 - January 31 of the following calendar year), a vacation supply claim of up to 100 days may be allowed (in addition to the regular 100 maximum days' supply) for Trillium recipients travelling outside the province for between 101 and 200 days, before they leave Ontario. In order to obtain a refill for a vacation supply of up to 100 days of ODB medication, provided that the prescription allows for the additional supply, recipients must provide the pharmacist with: a letter they have written themselves confirming that they are leaving the province for more than 100 days, OR
ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX JUNE 27, 2008 VII.1
a copy of their travel documentation, confirming that they are leaving the province for more than 100 days. Vacation supply claims must not be submitted through the Health Network System for Trillium recipients during the third and fourth quarters of the Trillium benefit year (February 1- July 31). Trillium recipients must pay for their vacation supply for the third and fourth quarters of the benefit year. Trillium recipients should be advised by pharmacists to submit their third and fourth quarters receipt(s) to the Ministry for consideration to be applied towards the deductible and/or for reimbursement. Each program year, Trillium recipients enrolled in the previous program year will automatically be renewed unless: Household members have declined to give consent for the Ministry to access household income information directly from Canada Revenue Agency (CRA), or consent is missing; Any household member is turning 16 years of age prior to August 1; Household member(s) are paying private insurance premiums. The household has not utilized the TDP for the previous two benefit years. A confirmation letter is mailed to households starting June of each year confirming TDP details for the program year. It is required that households inform the program of any changes or incorrect information. A supply of Trillium applications can be obtained through the Health INFOline at 1-800-268-1153 or at your local pharmacy.
VII.2
JUNE 27, 2008
PART VIII
ExcEPTIonAl AccEss PRogRAm (EAP)
Exceptional Access Program (EAP)

The Executive Officer (EO) considers requests for coverage of drug products approved for market by Health Canada but not listed in the Ontario Drug Benefit (ODB) Formulary/Comparative Drug Index (Formulary/CDI) for ODB eligible persons. The EO is guided by recommendations and guidelines developed by the Committee to Evaluate Drugs (CED), as well as supported by an extensive roster of expert medical advisers involved in the review of individual requests for coverage of drug products. Note that patients must be eligible for the ontario Drug Benefit (oDB) Program in order to receive coverage for the requested product. Patients not currently ODB-eligible may become eligible through the Trillium Drug Program (TDP). For more information on the TDP, call 1-800-575-5386. The Exceptional Access Program (EAP) is reserved for clinical situations where there are no Formulary/CDI alternatives to treat conditions or diseases that would otherwise cause severe debilitating effects and the drug is not covered under another government program. The types of drug products often requested through the EAP include: More expensive drugs introduced to the market where sufficient Formulary alternatives are available at a lower cost (thus reserving more expensive products for specific clinical situations); Drugs that do not have a traditional evidence base regarding efficacy, safety and/or costeffectiveness; but meets a specific clinical need, High cost drugs that are associated with risks of usage outside approved indications. The EAP mechanism is not intended to be used to request reimbursement for drugs to treat selflimiting conditions/symptoms, drugs promoted for patient convenience, nutritional products, diabetic test strips, drugs that do not require a prescription for sale (i.e. over-the-counter) or to provide therapy that is either part of a clinical trial or a continuation of a therapy in patients previously enrolled in a clinical trial or a continuation of a therapy in patients previously enrolled in a clinical trial once the drug is approved for marketing. Manufacturers are required to make a submission to the ODB program for their drug products to be considered under the EAP. The drug products undergo the normal ODB Formulary review process whereby the CED would conduct a rigorous review and make a funding recommendations to the EO of the Ontario Public Drug Programs who in turn makes the final decision as to the coverage status of drugs under this program. Reimbursement decision-making processes within the EAP utilize the same principles as the CED to make recommendations to the EO regarding listing of products on the ODB Formulary. The EO makes the final decision on funding. The EAP is a core component of a comprehensive approach to supporting patient access to needed medications while at the same time ensuring that the ministry reimburses on the basis of appropriate prescribing as determined by evidence of efficacy, safety, and cost-effectiveness, considering other therapeutic alternatives.
APPlIcATIon PRocEss
To apply for special coverage, physicians must send a written request to the Individual Eligibility Review Branch (IERB). Ministry staff coordinates the review process, which includes implementing a recommendation from the CED and/or external medical expert reviewers. Full clinical details of an individuals case are required in order to make an objective assessment of the rationale for the requested drug, and a recommendation to the ministry regarding whether the product should be reimbursed. Providing the information requirements listed below will ensure a complete and timely review. Requests that contain insufficient information will be returned to the physician, with a request to provide additional information to ensure a comprehensive assessment.
JUNE 27, 2008
VIII.1
Requests should be sent to the attention of: Exceptional Access Program (EAP) Unit Individual Eligibility Review Branch 3rd Floor, 5700 Yonge Street Toronto ON M2M 4K5 Facsimile: (416) 327-7526 Toll free Facsimile: 1-866-811-9908 (Faxed requests are preferred DO NOT mail in a previously faxed request) Questions from physicians related to a specific request should be directed to the EAP/ICR unit by calling the general Branch telephone number: 416-327-8109 or toll-free at 1-866-811-9893. Pharmacists with questions regarding the status of an individuals coverage for a specific drug should call the ministrys ODB Health Network System (HNS) Help Desk at 1-800-668-6641. In order to ensure a timely review, legibility is key and each request should include a concise clinical description and therapeutic plan which must include at a minimum: Physicians name, CPSO number, street address, fax number, telephone number, signature (mandatory); Patients name, gender, date of birth, Health Number (HN) / ODB eligibility number; trade or generic name, strength and dosage form of the requested drug product; specific diagnosis for which the drug is requested or reason for use; if the patient has been taking the product, provide duration of therapy and objective evidence of its efficacy; details of both drug and non-drug alternatives that have been tried to treat the condition including dosages (for drugs), length of therapy and response to therapy; where alternatives are not appropriate, outline the reasons; concomitant drug therapy to treat other conditions, and relevant details of these comorbid conditions; other relevant information e.g., culture and sensitivity reports, serum drug levels, laboratory results, bone mineral density reports, consultation reports. NOTE: To facilitate EAP requests, IERB has developed a standard template form as well as specific forms and guidelines for various drugs. A hard copy of the standard template form is included in the Formulary (Part X) for your information, and is also available on the MOHLTC website along with other forms at: http://www.health.gov.on.ca/english/public/forms/form_menus/odb_fm.html. While use of these forms is not mandatory, it is encouraged as a means of ensuring that as much relevant information as possible is submitted, thus facilitating timely review of the request and response to the physician.
REImBURsEmEnT
The Executive Officers (EO) decision on reimbursement of the proposed therapy in a particular patients case will be communicated by letter to the physician making the request. If coverage is approved, the physician may provide a copy of the approval notice for the patient to take to their pharmacy. Pharmacists are not required to keep a copy of the authorization letter on file. (Note: The ministry is aware of its obligations under the Personal Health Information Act (PHIPA) to ensure the confidentiality of all personal patient information which it holds on file as provided by requesting physicians. Physicians are requested to ensure continuation of this vigilance as it relates to patient privacy issues, particularly when transmitting EAP approval information to other parties.) Products are approved for reimbursement under the EAP for a specific timeframe (i.e., days, weeks, one or more years), depending on the drug product and medical condition in question. The ministry
VIII.2
JUNE 27, 2008
has implemented extended expiry dates for some chronic medications that are frequently requested through the EAP unit, with approvals extending for up to five (5) years. This is intended to minimize the administrative burden for physicians and to ensure continuity of treatment for patients with chronic conditions. Approvals are not retroactive, but begin from the specified coverage date and are valid until the expiration date noted on the authorization letter. The Health Network System adjudicates EAP claims on-line. As EAP authorizations are DIN specific (i.e., specific to the drug strength, dosage form, etc.), in cases where the dose of the prescription changes, requiring the use of a different strength or dosage form of the drug (i.e. requiring a different DIN), in most cases a new EAP request is required. Pharmacists should forward any questions regarding authorization of a specific EAP claim, including requests to change the DIN of a drug product, to the ministrys ODB Health Network System (HNS) Help Desk at 1-800-668-6641. For drugs approved under the EAP, the ministry will reimburse pharmacists an amount equal to the Drug Benefit Price, as outlined in Part III-A of the Formulary/CDI or as noted below, plus a mark-up and the lesser of a pharmacys posted usual and customary fee or the ODB dispensing fee minus the applicable co-payment amount. For products not listed in the Formulary/CDI, the ministry will pay dispensers the acquisition cost plus a mark-up and the lesser of a pharmacys posted usual and customary fee or the ODB dispensing fee minus the applicable co-payment amount. However, pursuant to section 15 of O.Reg. 201/96 made under the ODBA, the EO has entered into agreements with manufacturers to establish drug benefit prices (DPBs) for products reimbursed under the Exceptional Access Program (EAP). In such cases, drug products reimbursed under the EAP, the Health Network System (HNS) will adjudicate claims at the established DBP. For further details, please refer to the following link: http://www.health.gov.on.ca/english/providers/program/drugs/odbf/odbf_except_access. html
ExTEnsIon oF coVERAgE
If it is anticipated that a patient will continue to require the product beyond the approval period, the physician is required to request an extension of coverage. It is recommended that the request for continued reimbursement and all supporting documentation (including details of current dose and clinical status) be submitted to the ministry at least four (4) to six (6) weeks prior to the expiration of the current approval. It should be noted that coverage will not be continued automatically between expiration and re-issuance of approval. Requests for extension should include a summary of the patients progress on the drug product, any changes in drug therapy, the rationale for the continued need for the product and a list of all concomitant drug therapies. Sufficient information is needed to ensure a timely response to requests. Physicians are encouraged to use EAP forms (drug specific and non-drug specific) noted above to facilitate this process. Forms are available on-line at: http://www.health.gov.on.ca/english/ public/forms/form_menus/odb_fm.html.
JUNE 27, 2008
VIII.3
PART IX
ADDITIONAL BENEFITS: NUTRITION PRODUCTS/ DIABETIC TESTING AGENTS
NUTRITION PRODUCTS
Nutrition Products are not formulary benefits but are covered as additional benefits for Ontario Drug Benefit (ODB) eligible persons in defined circumstances. Nutrition Products are eligible for coverage under the ODB program only when prescribed by a practitioner as the patients sole source of nutrition. Patients tolerating some solid foods and requiring only supplementation in addition to food are not eligible for coverage. Eligibility criteria:
Nutritional products will be reimbursed for ODB eligible persons when prescribed by a practitioner as the patients sole source of nutrition and when one of the following criteria is met:
oropharyngeal or gastrointestinal disorders resulting in esophageal dysfunction or dysphagia; e.g., head and neck surgery, neuromuscular disorder, or cerebral vascular disease where dysphagia prevents eating; maldigestion or malabsorption disorder and/or significant gut failure where food is not tolerated; e.g., pancreatic insufficiency, biliary obstruction, short bowel syndrome; for patients requiring the use of a chemically defined diet as a primary treatment of a disease where the therapeutic benefit has been demonstrated; i.e. Crohns disease
Each claim for reimbursement must be supported by a valid, fully completed Nutrition Products form. A Nutrition Products form is valid for one year following the date completed by the prescriber. This form is available on-line at the following address: http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/AttachDocsPublish/014-3057-87~2/$File/3057-87_.pdf
Practitioners can order Nutrition Product forms by calling 1-888-310-9008 Pharmacists are required to retain a copy of the Nutrition Products form on file for a period of two years. Exclusion criteria: A Nutrition Product will not be reimbursed under the ODB program if it is intended for one of the following uses: prescribed weight loss in the treatment of obesity food allergies body building voluntary meal replacement nutritional supplement convenience used as a replacement for breast feeding for infants with normal gastrointestinal absorptive function
After conducting a patient assessment, the practitioner or dietician may select any Nutrition Product from the approved list, however, only the practitioner can complete the Nutrition Products form. Depending on which Nutrition Product is prescribed, the ODB-eligible person may have to pay the pharmacy the difference between the cost the ministry will reimburse the pharmacy and the current listed price for that Nutrition Product. In many cases, the maximum paid by the ministry covers the entire cost (see attached Maximum Allowable Reimbursement Schedule for the list and price of the approved Nutrition Products under the Ontario Drug Benefit program).
JUNE 27, 2008
IX.1
Maximum Allowable Reimbursement Mechanism and Pricing Schedule Nutrition Products

Administration
A valid prescription from a practitioner is required for pharmacists to dispense approved Nutrition Products under the ODB program to eligible recipients. Pharmacists and practitioners are reminded that the nutritional requirements for persons residing in Long-Term Care homes and Homes for Special Care are met by the facility responsible for the care of these patients. Claims for Nutrition Products for these residents are not reimbursed under the ODB program.
Claims
Dispensaries should note the maximum amount the ministry will reimburse pharmacies for each approved Nutrition Product. Cost-to-operator claims will not be accepted. Nutrition Products are not eligible for a mark-up.
Reimbursement Process
The maximum allowable reimbursement process provides ODB-eligible recipients with coverage for the cost of Nutrition Products in a given category, up to a maximum price established for that category, minus the co-payment. The ministry will reimburse pharmacies the amount identified in the column Amount MOHLTC Pays plus the lesser of the posted usual and customary fee or the ODB dispensing fee, minus the co-payment portion. No amount more than that shown in the column Amount Patient Pays plus the co-payment portion can be charged to recipients. The following maximum allowable reimbursement schedule lists those Nutrition Products that are approved for coverage and identifies a maximum price for specific categories. Please note that the following legend defines symbols used in the maximum pricing reimbursement schedule: A new package size B new price + new product
IX.2
JUNE 27, 2008
Maximum Allowable Reimbursement Schedule For Nutrition Products

PIN Brand Strength, Dosage Form, Package Size Mfr Cost ($) Per 1000Kcal Cost ($) Per Pkg Amt ($) MOHLTC Pays Amt ($) Patient Pays
A. COMPLETE POLYMERIC
1. LACTOSE FREE
09854258 09853170 97982610 97982580 97904333 09853529 09853537 97984671 97984698 97984701 09854380 09853723 09853731 NovaSource Renal Resource 2.0 Boost 1.5 Plus Calories Boost 1.0 Standard Ensure Plus NuBasic NuBasic Plus Nutren 1.0 Nutren 1.5 Nutren 2.0 TwoCal HN Nepro Suplena
Maximum = 5.04
Liq-237mL Pk Liq-237mL Pk 1.5kcal/mL Liq-237mL Pk 1.06kcal/mL Liq-237mL Pk Liq-235mL Pk Liq-250mL Pk Liq-250mL Pk 1kcal/mL Liq-250mL Pk 1.5kcal/mL Liq-250mL Pk 2kcal/mL Liq-250mL Pk 2kcal/mL Liq-235mL Pk Liq-235mL Pk Liq-235mL Pk NON NON NON NON ABB NES NES NES NES NES ROS ABB ABB 4.32 4.32 4.37 4.92 5.04 5.04 5.04 5.04 5.04 5.04 5.04 5.09 5.09 2.05 2.05 1.55 1.23 1.79 1.26 1.89 1.26 1.89 2.52 2.37 2.39 2.39 2.05 2.05 1.55 1.23 1.79 1.26 1.89 1.26 1.89 2.52 2.37 2.37 2.37 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.02 0.02
2.
LACTOSE CONTAINING
09853570 Nutrisure Pudding 113g Pk
Maximum = 7.14
ABB 7.14 1.21 1.21 0.00
3.
FIBRE CONTAINING
09854363 09857427 09854231 09857109 09857117 97983330 09854392 09854393 97984060 09854460 09854479 09857516 09857524 97904317 09854096 97984728 IsoSource HN with Fibre Resource Diabetic Compleat Modified Jevity 1.2 Cal Jevity 1.2 Cal Compleat Modified Glucerna Tube Feeding Glucerna Tube Feeding Jevity 1 Cal Jevity 1 Cal Jevity 1 Cal Nutren VHP Fibre Nutren VHP Fibre Ensure with Fibre Jevity 1.2 Cal Nutren Fibre
Maximum = 7.68
Liq-250mL Pk 1.06kcal/mL Liq-250mL Pk Liq-1000mL Pk 1.2kcal/mL Liq-1000mL Pk 1.2kcal/mL Liq-1500mL Pk Liq-250mL Pk Liq-235mL Pk Liq-1000mL Pk 1.06kcal/mL Liq-235mL Pk 1.06kcal/mL Liq-1000mL Pk 1.06kcal/mL Liq-1500mL Pk 1kcal/mL Liq-250mL Pk 1kcal/mL Liq-1500mL Pk Liq-235mL Pk 1.2kcal/mL Liq-235mL Pk 1kcal/mL Liq-250mL Pk NON NON NON ABB ABB NON ABB ABB ABB ABB ABB NES NES ABB ABB NES 6.10 6.57 7.45 7.61 7.61 7.66 7.68 7.68 7.68 7.68 7.68 7.69 7.69 7.69 7.70 7.88 1.83 1.74 7.97 9.13 13.70 2.03 1.80 7.68 1.92 8.14 12.22 1.92 11.53 2.00 2.17 1.97 1.83 1.74 7.97 9.13 13.70 2.03 1.80 7.68 1.92 8.14 12.22 1.92 11.53 2.00 2.17 1.92 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.05
JUNE 27, 2008
IX.3
PIN
Brand
Strength, Dosage Form, Package Size
Mfr
Cost ($) Per 1000Kcal
Cost ($) Per Pkg
Amt ($) MOHLTC Pays
Amt ($) Patient Pays
4.
HIGH NITROGEN
97984663 09854266 09854444 09854452 09854487 09857095 97973165 09854169 09857608 09853553 09853561 IsoSource HN IsoSource 1.5 Cal Osmolite 1 Cal Osmolite 1 Cal Osmolite 1.2 Cal Osmolite 1.2 Cal Osmolite HN Osmolite HN Plus Nutren VHP IsoSource VHN NuBasic VHP
Maximum = 5.11
Liq-250mL Pk Liq-250mL Pk 1.06kcal/mL Liq-1000mL Pk 1.06kcal/mL Liq-1500mL Pk 1.2kcal/mL Liq-1000mL Pk 1.2kcal/mL Liq-1500mL Pk Liq-235mL Pk Liq-235mL Pk 1kcal/mL Liq-1500mL Pk Liq-250mL Pk Liq-250mL Pk NON NON ABB ABB ABB ABB ABB ABB NES NON NES 4.03 4.99 5.04 5.04 5.04 5.04 5.07 5.11 5.14 8.51 8.64 1.20 1.87 5.34 8.01 6.05 9.07 1.26 1.44 7.71 2.12 2.16 1.20 1.87 5.34 8.01 6.05 9.07 1.26 1.44 7.66 1.27 1.28 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.05 0.85 0.88
B. INCOMPLETE POLYMERIC
09853154 Boost Fruit Flavoured Beverage Liq-235mL Pk
Maximum = 8.50
NON 8.61 1.55 1.53 0.02
C. MODULAR
1. PROTEIN
97984795 09854193 Promod HMS 90 Pd-275g Pk Pd-10g Pouch
Maximum = 15.90
ABB IMM 15.90 49.50 16.40 1.98 16.40 0.64 0.00 1.34
2.
CARBOHYDRATE
97980390 97983250 97972592 Caloreen Caloreen Polycose Pd-5Kg Pk Pd-1Kg Pk Pd-350g Pk
Maximum = 4.71
NES NES ABB 4.09 4.71 6.87 81.85 18.83 9.14 81.85 18.83 6.27 0.00 0.00 2.87
3.
FAT
97904473 MCT Oil 7.7kcal/mL Liq-946mL Pk NON 34.49 34.49 0.00
D. CHEMICALLY DEFINED FORMULA

09854390 09854391 09854401 97982750 09853618 97982830 09853200 09857133 09857125 97983500 09853090 09857126 09854274 97984779 Perative Perative Portagen Tolerex Vivonex T.E.N. Vivonex Plus Peptinex Peptinex DT Peptinex DT Vital HN Peptamen 1.5 Peptamen 1.5 Optimental Peptamen
Maximum = 35.26
ROS ROS MJN NON NON NON NON NON NON ABB NES NES ABB NES 8.83 8.83 10.40 13.90 23.44 23.70 25.65 25.68 25.68 25.87 27.36 27.36 30.80 30.84 2.72 11.48 22.23 4.17 7.03 7.03 6.08 6.42 38.52 7.77 10.26 41.04 7.30 7.71 2.72 11.48 22.23 4.17 7.03 7.03 6.08 6.42 38.52 7.77 10.26 41.04 7.30 7.71 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Liq-237mL Pk Liq-1000mL Pk 1.02kcal/mL Pd-454g Pk Pd-80g Pk Pd-80.4g Pk Pd-79.5g Pk 1kcal/mL Liq-237mL Pk 1kcal/mL Liq-250mL Pk 1kcal/mL Liq-1500mL Pk Pd-79g Pk 1.5kcal/mL Liq-250mL Pk 1.5kcal/mL Liq-1000mL Pk Liq-237mL Pk Liq-250mL Pk
IX.4
JUNE 27, 2008
PIN
Brand
Strength, Dosage Form, Package Size
Mfr
Cost ($) Per 1000Kcal
Cost ($) Per Pkg
Amt ($) MOHLTC Pays
Amt ($) Patient Pays
D. CHEMICALLY DEFINED FORMULA (Contd)

09857101 09857102 Peptamen with Prebio Peptamen with Prebio 1kcal/mL Liq-250mL Pk 1kcal/mL Liq-1500mL Pk
Maximum = 35.26
NES NES 30.84 30.84 7.71 46.26 7.71 46.26 0.00 0.00
E. PEDIATRIC FORMULA, COMPLETE POLYMERIC

1. LACTOSE FREE
09853669 09854215 97984370 Resource Just For Kids Nutren Junior PediaSure Liq-235mL Pk 1kcal/mL Liq-250mL Pk Liq-235mL Pk
Maximum = 10.51
NON NES ABB 6.60 9.00 10.51 1.55 2.25 2.47 1.55 2.25 2.47 0.00 0.00 0.00
2.
FIBRE CONTAINING
09857609 09857142 09857419 09854223 09857173 09854371 Resource Just for Kids with Fibre Resource Just for Kids 1.5 Cal Pediasure Plus with Fibre Nutren Junior Fibre Compleat Pediatric Pediasure with Fibre 1kcal/mL Liq-237mL Pk
Maximum = 10.51
NON NON ROS NES NON ROS 6.54 6.55 7.76 9.00 10.37 10.51 1.55 2.33 2.74 2.25 2.59 2.47 1.55 2.33 2.74 2.25 2.59 2.47 0.00 0.00 0.00 0.00 0.00 0.00
1.5kcal/mL Liq-237mL Pk 1.5kcal/mL Liq-235mL Pk 1kcal/mL Liq-250mL Pk 1kcal/mL Liq-250mL Pk 1kcal/mL Liq-235mL Pk
F. PEDIATRIC FORMULA, INCOMPLETE POLYMERIC

97973084 RCF Liq-384mL Pk ABB 20.16
Maximum = 20.16
6.27 6.27 0.00
G. PEDIATRIC FORMULA, CHEMICALLY DEFINED

1. OLIGOMERIC (SEMI-ELEMENTAL)
97972630 97984558 97982440 97983900 Nutramigen Alimentum Pregestimil Nutramigen 4.94kcal/g Pd-400g Pk Liq-4x237mL Pk Pd-454g Pk Liq-945mL Pk
Maximum = 13.13
MJN ABB MJN MJN 8.21 8.79 8.86 13.13 16.04 5.65 18.38 8.31 16.04 5.65 18.38 8.31 0.00 0.00 0.00 0.00
2.
MONOMERIC (ELEMENTAL)
09854207 09853510 09853308 Neocate Junior Neocate Vivonex Pediatric 1kcal/mL Pd-400g Pk Pd-400g Pk Pd-48.7g Pk
Maximum = 35.15
SHS SHS NON 20.38 20.78 35.15 37.50 35.00 7.03 37.50 35.00 7.03 0.00 0.00 0.00
H. PEDIATRIC FORMULA, OTHERS

09857124 09857172 09854398 09857100 09853588 Similac Advance NeoSure 5.15kcal/g Pd-363g Pk Enfamil EnfaCare A+ 22kcal/30mL Pd for Liq-363g Pk KetoCal 7.2kcal/g Pd-300g Pk Pediatric Peptinex DT 1kcal/mL Liq-250mL Pk Peptamen Junior Liq-250mL Pk
Maximum = N/A
ABB MJS SHS NON NES 8.02 8.51 13.89 25.68 30.84 14.99 15.29 30.00 6.42 7.71 14.99 15.29 30.00 6.42 7.71 0.00 0.00 0.00 0.00 0.00
JUNE 27, 2008
IX.5
Diabetic Testing Agents

Diabetic Testing Agents that are listed substances are covered as additional benefits for Ontario Drug Benefit (ODB) eligible persons in defined circumstances.
Maximum Allowable Reimbursement Mechanism and Pricing Schedule: Diabetic Testing Agents
Administration
A valid prescription from a practitioner is required for pharmacists to dispense approved Diabetic Testing Agents under the ODB program to eligible recipients.
Claims
Pharmacists should note the maximum amount the ministry will reimburse pharmacies for each approved test strip. Cost-to-operator claims will not be accepted. Test strips are not eligible for a markup. Please note: Only one Product Identification Number (PIN) for each brand of test strips can be used for billing. Package size should not be used since reimbursement is based on the number of unit strips of each product dispensed..
Reimbursement
Blood Glucose Test Strips The maximum allowable reimbursement process provides ODB-eligible recipients with coverage for the cost of Blood Glucose Test Strips, up to a maximum price that will be reimbursed, minus the co-payment. The ministry will reimburse pharmacies the amount identified in the column Amount MOHLTC Pays plus the lesser of the posted usual and customary fee or the ODB dispensing fee, minus the co-payment portion. No amount more than that shown in the column Amount Patient Pays plus the co-payment portion can be charged to recipients. The following maximum allowable reimbursement schedule lists those blood glucose test strips approved for coverage and the maximum price, up to which they will be reimbursed. Please note that the following legend defines symbols used in the maximum pricing reimbursement schedule: A new package size B new price + new product
IX.6
JUNE 27, 2008
Maximum Allowable Reimbursement Schedule For Diabetic Testing Agents

PIN Product Name Mfr Cost/Unit Amount MOHLTC Pays/Unit Amount Patient Pays/Unit
BLOOD GLUCOSE STRIPS 09857283 09853480 09853677 09853189 09857293 09853693 09857127 09854088 09853103 09854029 09853243 09854290 09853634 09853219 09853626 09853081 09857178 09854282 09854002 09857508 09854070 09854304 09853146 09857141 09857132 09853162 True Track Smart System Novo-Glucose Prestige Smart System Chemstrip bG Ascensia Breeze 2 Ascensia Autodisc Ascensia Contour Ascensia Elite Encore FastTake One Touch One Touch Ultra SureStep Exactech Accu-Chek Advantage Accu-Chek Easy Accu-Chek Aviva Accu-Chek Compact Advantage Comfort Precision Easy Precision Xtra Sof-Tact Precision Plus Freestyle BD Accutrend HOM NOP THR ROD BAH BAY BAY BAY BAY LIF LIF LIF LIF MED ROD ROD ROD ROD ROD ABB ABB ABB MED TER BED ROD
Maximum = 0.7290 0.4000 0.5222 0.6067 0.7193 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7301 0.7404 0.7404 0.7404 0.7441 0.7441 0.7441 0.7441 0.7452 0.7655 0.7679 0.4000 0.5222 0.6067 0.7193 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.7290 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0011 0.0114 0.0114 0.0114 0.0151 0.0151 0.0151 0.0151 0.0162 0.0365 0.0389
JUNE 27, 2008
IX.7
PART X
ABBREVIATIONS, TABLES AND SAMPLE FORMS
Abbreviations of Manufacturers Names

ABB ALC ALL AMG APX AST ATO AVE AXC AYE AZC BAH BAK BAR BAX BAY BED BFI BIO BJH BOE BQU BSH BWE CDX CIB COB CPL CRY CYI DES DKT DPC DUI ELA ERF ETH EUR FEI FIS FOU FRS FUJ GAC GEI GEN GIL Abbott Laboratories Limited Alcon Canada Inc. Allergan Inc. Amgen Canada Inc. Apotex Inc. Astra Pharma Inc. Aton Pharma Inc. Aventis Pharma Axcan Pharma Inc. Ayerst Laboratories AstraZeneca Bayer Inc., Healthcare Division Baker Cummins Inc. Barr Laboratories Inc. Baxter Corporation Bayer Inc., Consumer Care Division BD Consumer Healthcare Axcan Pharma Inc. Biovail Pharmaceuticals Canada Draxis Health Inc. Boehringer Ingelheim (Canada) Ltd. Bristol Myers Squibb Canada Inc. Bausch & Lomb Canada Inc. Burroughs Wellcome Inc. Canderm Pharmacal Ltd. Ciba Pharmaceuticals, Division of Ciba-Geigy Canada Ltd. Cobalt Pharmaceuticals Inc. Clay-Park Labs Inc. Crystaal Corp. Cytex Pharmaceutical Co. Desbergers Limited Dioptic Laboratories, Division of Akorn Pharmaceuticals Canada Inc. Dominion Pharmacal Duchesnay Inc. Elan Pharmaceuticals Inc. Erfa Canada Inc. Ethypharm Inc. Euro-Pharm International Canada Ferring Inc. Fisons Corporation Limited Fournier Pharma Inc. Merck Frosst Canada Ltd. Astellas Pharma Canada Inc. Galderma Canada Inc. Geigy Pharmaceuticals, Division of Ciba-Geigy Canada Ltd. Genpharm Inc. Gilead Sciences Inc.
JUNE 27, 2008 X.1
GLA GLW GRA GSK GZM HLR HMR HOM HOR HOS HRU IMM IOB IVA JAN JNO JOU LEA LED LEO LIF LIL LON MAN MAY MCL MEC MED MEI MFC MFS MJN MJS MMH MRR MSD NDA NES NON NOO NOP NOV NXP NYC OMC OMG ORC ORG ORY
X.2
Glaxo Canada Inc. Glaxo Wellcome Inc. Graceway Pharmaceuticals GlaxoSmithKline Inc. Genzyme Canada Inc. Hoffman-LaRoche Ltd. Hoechst Marion Roussel Canada Inc. Home Diagnostics Inc. Frank W. Horner Inc. Hospira Healthcare Corporation Hoechst-Roussel Canada Inc. Immunotech Research Ltd. Iolab Canada Inc. Ivax Laboratories Incorporated Janssen Pharmaceutica Inc. Janssen-Ortho Inc. Jouveinal Canada Inc. Lee-Adams Laboratories Lederle Cyanamid Canada Inc. Leo Pharma Inc. Lifescan Canada Inc. Eli Lilly Canada Inc. Linson Pharma Inc. Paul Maney Labs., Division of Canapharm Ind. Inc. Mayne Pharma (Canada) Inc. McNeil Consumer Products Co. Medicis Canada Ltd. Medisense Canada Ltd. Medican Pharma Inc. Merck Frosst Canada Ltd. Merck Frosst/Schering Pharma GP Mead Johnson Nutritionals Mead Johnson Canada 3M Pharmaceuticals, Division 3M Canada Inc. Marion Merrell Dow Canada Merck Sharp & Dohme, Canada, Division of Merck Frosst Canada Nadeau Laboratory Ltd. Nestle Clinical Nutrition Novartis Nutrition Corporation Novo Nordisk Canada Inc. Novopharm Ltd. Novartis Pharmaceuticals Canada Inc. Nu-Pharm Inc. Nycomed Canada Inc. Ortho McNeil Inc. Omega Laboratories Ltd. Orchid Healthcare Organon Canada Ltd. Oryx Pharmaceuticals Inc.
OVA PAL PDA PEN PFI PFP PGI PGP PHE PMJ PMS PRE RAN RBT RCA RIV ROD ROG ROS RPH RPP RPR SAO SAV SCH SCP SDR SDZ SEA SEV SHI SHS SIG SIL SKB SMJ SNE SPH SQI STE STH STI SYN TAN TAR TER THE THR TPH
Ovation Pharmaceuticals Inc. Paladin Labs Inc. Parke-Davis, Division Warner-Lambert Canada Inc. Pendopharm Inc. Pfizer Canada Inc. Purdue Pharma Proctor & Gamble Inc. Proctor & Gamble Pharmaceuticals Canada, Inc. Pharmel Pharmacia & Upjohn Pharmascience Inc. Prempharm Inc. Ranbaxy Pharmaceuticals Canada Inc. Roberts Pharmaceutical of Canada Inc. Reed & Carnrick, Division of Block Drug Company (Canada) Ltd. Rivex Pharma Inc. Roche Diagnostics, a division of Hoffman-LaRoche Ltd. Rougier Pharma, Division of Ratiopharm Inc. Ross Laboratories-Abbott (Nutritional Products) Ratiopharm Inc. Rhone-Poulenc Rorer - Ethical Division Rhone-Poulenc Rorer Consumer Inc. Sanofi Canada Inc. Sanofi Aventis Pharma Schering Canada Inc. Schering-Plough Canada Inc. Stanley Pharmaceuticals Ltd. Sandoz Canada Inc. Searle Canada Inc. Servier Canada Inc. Shire Canada Inc. SHS North America Sigma-Tau Pharmaceutical Inc. Sabex 2002 Inc. SmithKline Beecham Consumer Healthcare SmithKline Beecham Pharma Inc. Smith & Nephew Inc. Solvay Pharma Inc. Squire Pharmaceuticals Inc. Sterimax Inc. Sterling Health Stiefel Canada Inc. Syntex Inc. Tanta Pharmaceutical Co. Taro Pharmaceuticals Inc. Therasense Canada Inc. Theramed Corporation Thermor Ltd. TaroPharma, a Division of Taro Pharmaceuticals Inc.
JUNE 27, 2008 X.3
UPJ VAE VAL VLH VRO WAB WAY WEL WHB WSQ ZYN
The Upjohn Company of Canada Valeo Pharma Inc. Valeant Canada Ltd. Lundbeck Canada Inc. Virco Pharmaceutical (Canada) Inc. Waymar Pharmaceuticals Inc. Wyeth Pharmaceuticals WellSpring Pharmaceutical Canada Corp. Whitehall-Robins Inc. Westwood Squibb Pharmaceuticals Zymcan Pharmaceuticals Inc.
X.4
JUNE 27, 2008
Table 1:
Abbreviations of Dosage Forms
Abbreviation Aero App Cap Cart Chew Cl Lot CR Cr Eff Emol Emuls Ent Ent Microsph Cap
Dosage Form Aerosol with Applicator Capsule Cartridge Chewable Cleansing Lotion Controlled Release Cream Effervescent Emollient Emulsion Enteric Enteric Coated Microspheres in Capsules Extended Release Granule for Inhalation Injectable Long Acting Lotion Lozenge Multi Dose Vial Nasal in Oil Ointment Oral Liquids Ophthalmic Oral Powder
Abbreviation Oral Rinse Ot Pd Pd Inh Pel Ped Pk Pref Syr Prolong-Rel Rect Rect Aero SDV SG Cap SL Sol Sp Sprinkle Cap SR Sup Susp Tab Tamp 3 Phase Top Transderm Syst Vag
Dosage Form Oral Rinse Otic Powder Powder for Inhalation Pellet Pediatric Package Prefilled Syringe Prolonged-Release Rectal Rectal Aerosol Foam Single Dose Vial Soft Gelatin Cap Sublingual Solution Spray Sprinkle Capsule Sustained Release Suppository Suspension Tablet Tampon Three Phase Topical Transdermal Therapeutic System Vaginal
ER Gran Inh Inj LA Lot Loz MDV Nas Oily Oint O/L Oph Oral Pd
JUNE 27, 2008
X.5
Table 2:
Medicinal Preparations That Can be Fatal to a 10kg. Toddler upon Ingestion of 1-2 Tablets, Capsules or Teaspoonfuls
Drug Minimum potential fatal dose (per Kg wt) 100mg/kg 20mg/kg 20mg/kg 15mg/kg 15mg/kg 200mg/kg 8.4mg/kg 25mg/kg Maximal unitdose available 1g/5mL 250mg 200mg 75mg 100mg 1.4g/mL 600mg 200mg Amount that may cause fatality 1 tsp 2 tabs 1 tab 2 tabs 2 tabs < 1 tsp 1 tab 1-2 tabs
Camphor Chloroquine Hydroxychloroquine Imipramine Desipramine Methyl Salicylate Theophylline Chlorpromazine
Table 3:
Selected List of Drugs and Their Fatality Potential in Toddlers of 10kg

Drug Minimum potential fatal dose (per Kg wt) 25mg/kg 1.2mg/kg 15mg/kg 45mg/kg 25mg/kg 25mg/kg 25mg/kg 80mg/kg Maximal unitdose available 15mg 2.5mg 60mg 50mg 75mg 50mg 50mg 300mg Amount that may cause fatality 15 tabs 5 tabs 3 tabs 9 tabs 4 tabs 5 caps 5 caps 2-4 caps
Irreversible monoamine oxidase inhibitors Diphenoxylate Codeine Pentazocine Dimenhydrinate Diphenhydramine Orphenadrine Quinine
Adapted with permission of Dr. Koren from tables in: Koren, G. (1993). Medications which can kill a toddler with one tablet or teaspoonful. Clinical Pharmacology 31(3):407- 413.
X.6
JUNE 27, 2008
Table 4:
Approximate Relative Potencies of Listed Topical Steroid Preparations
Low Potency Desonide 0.05% (Tridesilon) Hydrocortisone 0.5%, 1% (Cortate, Cortoderm, Emo-Cort, Hyderm) Methylprednisolone 0.025% (Medrol) Medium Potency Beclomethasone Dipropionate 0.025% (Propaderm) etamethasone Valerate 0.05%, 0.1% (Betaderm, Ectosone, Valisone) B Clobetasone Butyrate 0.05% (Eumovate) Diflucortolone Valerate 0.1% (Nerisone) Flumethasone Pivalate 0.03% (Locacorten Vioform) Fluocinolone Acetonide 0.01%, 0.025% (Fluoderm, Synalar, Synamol) Hydrocortisone Valerate 0.2% (Westcort) Mometasone Furoate 0.1% (Elocom) Triamcinolone Acetonide 0.025%, 0.1% (Aristocort, Kenalog, Triaderm) High Potency Amcinonide 0.1% (Cyclocort) Betamethasone Dipropionate 0.05% (Diprosone, TARO-SONE,Topisone) Fluocinonide 0.05% (Lidemol, Lidex, Lyderm, Tiamol) Halcinonide 0.1% (Halog) Ultra High Potency Betamethasone Dipropionate in base containing Propylene Glycol 0.05% (Diprolene, Topilene) Clobetasol Propionate 0.05% (Dermasone, Dermovate, Gen-Clobetasol)
Table 5:
Approximate Conversion Tables from the Avoirdupois to the Metric System

Weight Liquid Measures 1/8 oz. 1/4 oz. 1/2 oz. 1 oz. 2 oz. 4 oz. 8 oz. 16 oz. 32 oz. 64 oz = = = = = = = = = = 4g 8g 15 g 30 g 60 g 115 g 230 g 455 g 910 g 1820 g 1/4 oz. 1/2 oz. 1 oz. 2 oz. 3 oz. 4 oz. 5 oz. 6 oz. 8 oz. = = = = = = = = = 8 mL 15 mL 30 mL 60 mL 85 mL 115 mL 145 mL 170 mL 230 mL 10 oz. 12 oz. 16 oz. 20 oz. 32 oz. 40 oz. 80 oz. = = = = = = = 285 mL 345 mL 455 mL 570 mL 910 mL 1135 mL 2270 mL
1/6 gr. 1/4 gr. 1/2 gr. 3/4 gr. 1 gr. 1 1/2 gr. 3 gr. 5 gr. 7 1/2 gr. 10 gr.
= = = = = = = = = =
10 mg 15 mg 30 mg 50 mg 60 mg 100 mg 200 mg 300 mg 500 mg 600 mg
JUNE 27, 2008
X.7
X.8
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X.9
X.10
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X.11
X.12
JUNE 27, 2008
PART XI
This section is currently not in use
PART XII
LIMITED USE DRUG PRODUCTS
PART XII
LIMITED USE DRUG PRODUCTS
Introduction Part XII of the Formulary/CDI provides convenient access to a complete alphabetical listing of Limited Use (LU) drug products and their specific clinical criteria for use. Limited Use products and their clinical criteria are also listed in Part III of the Formulary/CDI according to their pharmacologic-therapeutic classification. For information about the designation of Limited Use benefits, see Part I. Finding a LU Drug Product and its Designated Clinical Criteria LU drug products are listed in the Formulary/CDI with specific clinical criteria/conditions for use. These LU criteria identify the clinical conditions for which these drugs will be reimbursed by the Ontario Drug Benefit (ODB) program. Each LU criteria has a corresponding Reason for Use (RFU) code. LU drugs are eligible for coverage only in situations where the clinical criteria have been met. Any other indication can be considered through the Exceptional Access Program (EAP) described in Part VIII of the Formulary/CDI. Part XII has been designed to provide convenient access to a complete listing of all LU products, arranged alphabetically by generic name and their designated clinical criteria. This list can be found after the Table of Contents. LU drugs are listed alphabetically by brand name in the Limited Use Products Table of Contents. The Limited Use Products Table of Contents identifies the page number for the full LU drug listing and their clinical criteria. Limited Use Reimbursement Process Completing a LU Prescription Claims for LU drugs will be reimbursed under the ODB program only when prescribed for an ODB eligible recipient in accordance with the criteria outlined for each product and accompanied by a valid, fully completed prescription with the appropriate LU documentation (RFU code). The pharmacist should review the prescription and process the claim only if all the required information is provided. The LU authorization is valid for the duration indicated by the listed LU criteria. As of September 27, 2005, some Limited Use (LU) drugs used in chronic conditions have been granted extended authorization periods beyond one year. A number of drugs have an indefinite authorization period. For these drugs, it is only necessary for the practitioner to confirm that the patient meets the LU clinical criteria by completing an LU prescription once. For other drugs with a defined LU authorization period, a new LU prescription must be completed according to the authorization period provided in the LU criteria (usually on an annual basis). An exception to this policy may occur in situations where LU criteria have changed. In situations where LU criteria have changed, practitioners must consider whether recipients meet the new criteria. If so, a new LU prescription must be completed within three months of the change in LU criteria. Also, as of September 27, 2005, the requirement for the use of the ministry-issued LU prescription form was discontinued. Documentation that the patient meets the LU criteria may be written on a regular prescription form as long as the basic instructions for completing the LU prescription as listed on the following pages are followed. Failure to have the RFU code appropriately provided on the prescription may result in: prescription not being filled by the pharmacist recoveries of monies paid to pharmacies by the ODB patient being required to pay for the LU drug prescription All LU prescriptions require a Reason for Use (RFU) code to be completed by the practitioner. The RFU code verifies that the patient meets the LU criteria. Effective May 16, 2008, the RFU code may now be communicated:
JUNE 27, 2008
XII.1
By handwriting on an LU prescription; or Electronically on an electronically generated LU prescription; or Verbally during a verbal order of an LU prescription by a practitioner; or Verbally during a LU prescription transfer between pharmacies. LU prescriptions preprinted by manufacturers or generated by a dispensarys computer software, are neither valid nor acceptable by the ministry.. Faxed copies of LU prescriptions are acceptable (pharmacies should copy thermal paper faxes onto regular paper for record-keeping purposes). Pharmacies are required to retain LU documentation on file in the pharmacy for 24 months from the date received for the purposes of post-payment verification. Monitoring and Accountability Framework Reimbursement for Limited Use claims is made under the authority of section 23 of the Ontario Drug Benefit Act (ODBA) and can only be made if the LU clinical criteria set out in the Formulary/CDI have been met. By writing the Reason for Use (RFU) code on a prescription for an LU drug product, the practitioner affirms that the prescription conforms with these clinical criteria. For the purposes of claims review under the ODBA, it may be necessary on occasion for practitioners to provide supporting documents on request. Pursuant to section 46(1) of the Personal Health Information and Protection Act, 2004, S.O. 2004, c.3 Sched. A., a health information custodian may be required to disclose personal health information about an individual to the Minister of Health and LongTerm Care for the purpose of monitoring or verifying claims for payment for health care funded wholly or in part by the ministry. LU prescriptions may therefore be monitored by the ministry to ensure that the RFU code indicated is in accordance with the LU criteria listed in the Formulary/CDI.
XII.2
JUNE 27, 2008
A GUIDE TO COMPLETING LIMITED USE PRESCRIPTION FOR THE PRACTITIONER

In order to ensure the LU prescription is fully completed, fill in the prescription form as you normally would. In addition it is necessary to: provide the appropriate Reason for Use (RFU) code (e.g., RFU# 123) sign and date the prescription fill in your CPSO number (for practitioners other than physicians, fill in your college registration number) The initial LU prescription with the RFU code must be fully complete before patients take the prescription to the pharmacy, or practitioners fax it directly to the pharmacy. All LU prescriptions require a Reason for Use (RFU) code to be completed by the practitioner. The RFU code verifies that the patient meets the LU criteria. The methods for practitioners to communicate the RFU for LU prescriptions to the pharmacist have been expanded. Effective May 16, 2008, the RFU code may now be communicated: By handwriting on an LU prescription; or Electronically on an electronically generated LU prescription; or Verbally during a verbal order of an LU prescription by a practitioner; The LU authorization will be valid for the duration indicated by the listed LU criteria. During this period, any repeat prescription may be given verbally to a pharmacist. For drugs with extended or indefinite authorization periods, a new prescription may be required after a certain period of time to allow the drug to be dispensed in accordance with the regulations of the Ontario College of Pharmacists. If a patient has met the LU criteria before being eligible for ODB coverage, and supporting documentation is available (e.g., the diagnostic test was done prior to the person turning 65), that information can still be used to verify the LU claim. For instance, a patient who had step-up therapy in the past will not have to have step-up therapy again to prove eligibility to receive a LU drug as long as supporting documentation is available. Reimbursement for Limited Use claims is made under the authority of section 23 of the Ontario Drug Benefit Act (ODBA) and can only be made if the authorized LU criteria have been met. Practitioners should not complete a LU prescription if the patients clinical condition does not meet one of the listed LU criteria. A written request for special consideration for coverage can be made under the ODB programs Exceptional Access Program (EAP) (See Part VIII). The Pharmacist must have a fully completed prescription with the appropriate RFU code before submitting an ODB claim.
JUNE 27, 2008
XII.3
A GUIDE TO LIMITED USE PRESCRIPTIONS FOR THE PHARMACIST

All drug products, including LU drugs, are to be dispensed in accordance with the regulations of the Ontario College of Pharmacists. Pharmacists must ensure that the following information has been provided by the practitioner: the appropriate Reason for Use (RFU) code the date and practitioners signature the physicians CPSO number (for practitioners other than physicians, the practitioners college registration number is required) Only the practitioner may fill in this information. If the CPSO or college registration number is missing, pharmacists may enter it only if they are certain it is the correct number. Claims for LU products must contain a valid CPSO or college registration number (i.e. 99999 is not acceptable). Incomplete LU documentation (e.g., prescriptions that do not include the appropriate RFU code, date, practitioners signature, CPSO number or college registration number) will be subject to recoveries. Pharmacists should ensure the LU criteria have been applied appropriately. Where a pharmacist has concerns about whether the clinical criteria have been met, the pharmacist should discuss it with the practitioner and record the outcome of the discussion on the prescription according to standard pharmacy practice. The initial LU prescription with the RFU code must be fully complete before dispensing. All LU prescriptions require a Reason for Use (RFU) code to be completed by the practitioner. The RFU code verifies that the patient meets the LU criteria. The methods for practitioners to communicate the RFU for LU prescriptions to the pharmacist have been expanded. The RFU code may now be communicated: By handwriting on an LU prescription; or Electronically on an electronically generated LU prescription; or Verbally during a verbal order of an LU prescription by a practitioner; Pharmacists may also communicate the RFU code verbally during a LU prescription transfer between pharmacies. The LU authorization will be valid for the duration indicated by the listed LU criteria. During this period any repeat prescription may be given verbally by a practitioner to a pharmacist. For drugs with extended or indefinite authorization periods, a new prescription may be required after a certain period of time to allow the drug to be dispensed in accordance with the regulations of the Ontario College of Pharmacists. If a patient has met the LU criteria before being eligible for Ontario drug benefits, and supporting documentation is available (e.g., the diagnostic test was done prior to the person turning 65), that information can still be used to verify the LU claim. For instance, a patient who had step-up therapy in the past will not have to have step-up therapy again to prove eligibility to receive an LU drug as long as supporting documentation is available. Reimbursement for LU claims is made under the authority of the Ontario Drug Benefit Act (ODBA) and can only be made if the authorized LU criteria have been met. Prescriptions with LU documentation must be kept on file at the pharmacy for two years and be available for auditing purposes. The Pharmacist must have a fully completed prescription with the appropriate RFU code before submitting an ODB claim.
XII.4 ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX JUNE 27, 2008
JUNE 27, 2008
XII.5
XII.6
JUNE 27, 2008
LIMITED USE PRODUCTS TABLE OF CONTENTS

(In alphabetical order of product brand names)
PRODUCT PAGE
Aclasta 5mg/100mL Inj Sol-100mL Pk .............................................................................................. Advair 125 25/125mcg/Metered Dose Inh-120 Dose Pk .................................................................. Advair 250 25/250mcg/Metered Dose Inh-120 Dose Pk .................................................................. Advair Diskus 50/100mcg Inh-60 Dose Pk ........................................................................................ Advair Diskus 50/250mcg Inh-60 Dose Pk ........................................................................................ Advair Diskus 50/500mcg Inh-60 Dose Pk ........................................................................................ Aggrenox 200mg/25mg Cap .............................................................................................................. Alphagan 0.2% Oph Sol .................................................................................................................... Alphagan P 0.15% Oph Sol ............................................................................................................... Amatine 2.5mg Tab ............................................................................................................................ Amatine 5mg Tab ............................................................................................................................... Andriol 40mg Cap .............................................................................................................................. Androderm 12.2mg Transdermal Patch ............................................................................................. Androgel 1% 2.5g Foil Packet............................................................................................................ Androgel 1% 5.0g Foil Packet............................................................................................................ Anzemet 50mg Tab ............................................................................................................................ Anzemet 100mg Tab .......................................................................................................................... Apo-Acyclovir 800mg Tab .................................................................................................................. Apo-Benzydamine 0.15% Oral Rinse ................................................................................................ Apo-Brimonidine 0.2% Oph-Sol......................................................................................................... Apo-Carbamazepine CR 200mg LA Tab ........................................................................................... Apo-Carbamazepine CR 400mg LA Tab ........................................................................................... Apo-Carvedilol 3.125mg Tab ............................................................................................................. Apo-Carvedilol 6.25mg Tab ............................................................................................................... Apo-Carvedilol 12.5mg Tab ............................................................................................................... Apo-Carvedilol 25mg Tab .................................................................................................................. Apo-Ciproflox 250mg Tab .................................................................................................................. Apo-Ciproflox 500mg Tab .................................................................................................................. Apo-Ciproflox 750mg Tab .................................................................................................................. Apo-Clobazam 10mg Tab .................................................................................................................. Apo-Famciclovir 500mg Tab .............................................................................................................. Apo-Fluconazole 50mg Tab ............................................................................................................... Apo-Fluconazole 100mg Tab ............................................................................................................. Apo-Fluconazole-150 150mg Cap ..................................................................................................... Apo-Flunarizine 5mg Cap .................................................................................................................. Apo-Gabapentin 100mg Cap ............................................................................................................. Apo-Gabapentin 300mg Cap ............................................................................................................. Apo-Gabapentin 400mg cap.............................................................................................................. Apo-Ipravent 0.03% Nasal Spray ...................................................................................................... Apo-Ipravent Inhalation Solution 250mcg/mL Inh Sol-20mL Pk ........................................................ Apo-Lamotrigine 25mg Tab................................................................................................................ Apo-Lamotrigine 100mg Tab.............................................................................................................. Apo-Lamotrigine 150mg Tab.............................................................................................................. Apo-Leflunomide 10mg Tab ............................................................................................................... Apo-Leflunomide 20mg Tab ............................................................................................................... Apo-Levocarb CR 200mg & 50mg Tab .............................................................................................. Apo-Loperamide 2mg Caplet.............................................................................................................
92 83 83 83 83 83 35 21 21 64 64 86 85 85 85 36 36 18 20 21 25 25 26 26 26 26 27 27 27 29 42 46 46 44 47 49 49 49 54 53 56 56 56 60 60 61 63
XII.7
PRODUCT
PAGE
Apo-Midodrine 2.5mg Tab.................................................................................................................. Apo-Midodrine 5mg Tab..................................................................................................................... Apo-Oflox 200mg Tab ........................................................................................................................ Apo-Oflox 300mg Tab ........................................................................................................................ Apo-Oflox 400mg Tab ........................................................................................................................ Apo-Ofloxacin 0.3% Oph Sol ............................................................................................................. Apo-Omeprazole Cap 20mg .............................................................................................................. Apo-Omeprazole 20mg Cap .............................................................................................................. Apo-Ondansetron 4mg Tab................................................................................................................ Apo-Ondansetron 8mg Tab................................................................................................................ Apo-Pantoprazole 40mg Ent Tab ....................................................................................................... Apo-Pentoxifylline 400mg SR Tab ..................................................................................................... Apo-Salvent Ipravent Sterules 500mcg/2.5mg/2.5mL Inh Sol-2.5mL Pk........................................... Apo-Salvent Sterule 1mg/mL Inh Sol-2.5mL Pk ................................................................................ Apo-Salvent Sterule 2mg/mL Inh Sol-2.5mL Pk ................................................................................ Apo-Ticlopidine 250mg Tab ............................................................................................................... Apo-Topiramate 25mg Tab................................................................................................................. Apo-Topiramate 100mg Tab............................................................................................................... Apo-Topiramate 200mg Tab............................................................................................................... Arava 10mg Tab ................................................................................................................................. Arava 20mg Tab ................................................................................................................................. Aricept 5mg Tab ................................................................................................................................. Aricept 10mg Tab ............................................................................................................................... Arimidex 1mg Tab .............................................................................................................................. Arixtra 2.5mg Inj-0.5mL Pk ................................................................................................................ Aromasin 25mg Tab ........................................................................................................................... Atrovent 0.03% Nasal Spray.............................................................................................................. Avelox 400mg Tab.............................................................................................................................. Avodart 0.5mg Cap............................................................................................................................ Azopt 1% Oph Susp .......................................................................................................................... Bonefos 400mg Cap .......................................................................................................................... Botox 100U/Vial Pd Inj-100U Vial Pk ................................................................................................. C.E.S. 0.625mg Tab ........................................................................................................................... C.E.S. 1.25mg Tab ............................................................................................................................. Celebrex 100mg Cap ......................................................................................................................... Celebrex 200mg Cap ......................................................................................................................... CellCept 200mg/mL Pd for Oral Susp-175mL Pk .............................................................................. CellCept 250mg SG Cap ................................................................................................................... CellCept 500mg Tab .......................................................................................................................... Cipro 10g/100mL Oral Susp .............................................................................................................. Cipro 250mg Tab ............................................................................................................................... Cipro 500mg Tab ............................................................................................................................... Cipro 750mg Tab ............................................................................................................................... Cipro XL 500mg ER Tab .................................................................................................................... Cipro XL 1000mg ER Tab .................................................................................................................. Clasteon 400mg Cap ......................................................................................................................... Co-Ciprofloxacin 250mg Tab ............................................................................................................. Co-Ciprofloxacin 500mg Tab ............................................................................................................. Co-Ciprofloxacin 750mg Tab ............................................................................................................. Co-Etidronate 200mg Tab .................................................................................................................. Co Fluconazole 50mg Tab ................................................................................................................. Co Fluconazole 100mg Tab ............................................................................................................... Co-Gabapentin 100mg Cap............................................................................................................... Co-Gabapentin 300mg Cap............................................................................................................... Co-Gabapentin 400mg Cap............................................................................................................... Co Topiramate 25mg Tab ...................................................................................................................
XII.8 ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX
64 64 68 68 68 67 69 69 71 71 76 77 55 81 81 87 89 89 89 60 60 36 36 19 47 41 54 65 38 22 30 21 32 32 27 27 65 65 65 27 27 27 27 29 29 30 27 27 27 41 46 46 49 49 49 89
JUNE 27, 2008
PRODUCT
PAGE
Co Topiramate 100mg Tab ................................................................................................................. Co Topiramate 200mg Tab ................................................................................................................. Codeine Contin 50mg CR Tab ........................................................................................................... Codeine Contin 100mg CR Tab ......................................................................................................... Codeine Contin 150mg CR Tab ......................................................................................................... Codeine Contin 200mg CR Tab ......................................................................................................... Combigan 0.2% & 0.5% Oph Sol-5mL Pk ......................................................................................... Combivent UDV 500mcg/2.5mg/2.5mL Inh Sol-2.5mL Pk ................................................................. Comtan 200mg Tab ........................................................................................................................... Cosopt 2% & 0.5% Oph Sol .............................................................................................................. Cotazym 8000 & 30000 & 30000 USP Units Cap ............................................................................. Cotazym ECS 4 4000 & 11000 & 11000 USP Units Ent Microsph Cap ............................................ Cotazym ECS 8 8000 & 30000 & 30000 USP Units Ent Microsph Cap ............................................ Cotazym ECS 20 20000 & 55000 & 55000 USP Units Ent Microsph Cap ........................................ Creon 5 5000 & 16600 & 18750 USP Units Ent Minimicrosph Cap .................................................. Creon 10 10000 & 33200 & 37500 USP Units Ent Minimicrosph Cap .............................................. Creon 20 20000 & 66400 & 75000 USP Units Ent Minimicrosph Cap .............................................. Creon 25 25000 & 74000 & 62500 USP Units Ent Minimicrosph Cap .............................................. Cytovene 500mg/Vial Pd Inj-10mL Pk ............................................................................................... Delatestryl 1000mg/5mL Oily Inj Sol-5mL Pk .................................................................................... Demerol 50mg Tab ............................................................................................................................ Depo-Testosterone 100mg/mL Oily Inj Sol-10mL Pk......................................................................... Detrol 1mg Tab .................................................................................................................................. Detrol 2mg Tab .................................................................................................................................. Detrol LA 2mg SR Cap ...................................................................................................................... Detrol LA 4mg SR Cap ...................................................................................................................... Didronel 200mg Tab........................................................................................................................... Diflucan P.O.S. 10mg/mL O/L ............................................................................................................ Diflucan-150 150mg Cap ................................................................................................................... Dovonex 50mcg/g Cr ......................................................................................................................... Dovonex 50mcg/g Oint ...................................................................................................................... Duolube 80%/20% Oph Oint-3.5g Pk ................................................................................................ Duragesic 25 25mcg/hr Trans Patch .................................................................................................. Duragesic 50 50mcg/hr Trans Patch .................................................................................................. Duragesic 75 75mcg/hr Trans Patch .................................................................................................. Duragesic 100 100mcg/hr Trans Patch .............................................................................................. Elidel 1% Cr ....................................................................................................................................... Evista 60mg Tab ................................................................................................................................ Exelon 1.5mg Cap ............................................................................................................................. Exelon 3mg Cap ................................................................................................................................ Exelon 4.5mg Cap ............................................................................................................................. Exelon 6mg Cap ................................................................................................................................ Ezetrol 10mg Tab ............................................................................................................................... Famvir 500mg Tab ............................................................................................................................. Femara 2.5mg Tab ............................................................................................................................. Flomax CR 0.4mg Tab ....................................................................................................................... Fludara 10mg Tab .............................................................................................................................. Fluotic 20mg Tab ............................................................................................................................... Foradil 12mcg/Cap Inh Pd-Device Pk................................................................................................ Fragmin 2500IU/0.2mL Inj Pref Syr ................................................................................................... Fragmin 5000IU/0.2mL Inj Pref Syr ................................................................................................... Fragmin 10000IU/0.4mL Inj Pref Syr ................................................................................................. Fragmin 12500IU/0.5mL Inj Pref Syr ................................................................................................. Fragmin 15000IU/0.6mL Inj Pref Syr ................................................................................................. Fragmin 18000IU/0.72mL Inj Pref Syr ............................................................................................... Fragmin 10000IU/mL Inj Sol-1mL Pk.................................................................................................
89 89 31 31 31 31 22 55 39 37 73 73 73 73 74 74 74 74 50 86 64 85 88 88 88 88 41 45 44 24 24 77 43 43 43 43 78 79 80 80 80 80 42 42 60 84 46 83 47 33 33 33 33 33 33 33
XII.9
PRODUCT
PAGE
Fragmin 25000IU/mL Multidose 3.8mL Pk ........................................................................................ Fraxiparine 9500IU/mL Pref Syr-0.3mL Pk ........................................................................................ Fraxiparine 9500IU/mL Pref Syr-0.4mL Pk ........................................................................................ Fraxiparine 9500IU/mL Pref Syr-0.6mL Pk ........................................................................................ Fraxiparine 9500IU/mL Pref Syr-0.8mL Pk ........................................................................................ Fraxiparine 9500IU/mL Pref Syr-1.0mL Pk ........................................................................................ Fraxiparine Forte 19000IU/mL Pref Syr-0.6mL Pk ............................................................................ Fraxiparine Forte 19000IU/mL Pref Syr-0.8mL Pk ............................................................................ Fraxiparine Forte 19000IU/mL Pref Syr-1.0mL Pk ............................................................................ Frisium 10mg Tab .............................................................................................................................. Fucidin Leo 250mg Tab ..................................................................................................................... Gen-Acyclovir 800mg Tab.................................................................................................................. Gen-Carbamazepine CR 200mg LA Tab ........................................................................................... Gen-Carbamazepine CR 400mg LA Tab ........................................................................................... Gen-Ciprofloxacin 250mg Tab ........................................................................................................... Gen-Ciprofloxacin 500mg Tab ........................................................................................................... Gen-Ciprofloxacin 750mg Tab ........................................................................................................... Gen-Combo Sterinebs 500mcg/2.5mg/2.5mL Inh Sol-2.5mL Pk ...................................................... Gen-Etidronate 200mg Tab................................................................................................................ Gen-Fluconazole 150mg Cap............................................................................................................ Gen-Fluconazole 50mg Tab............................................................................................................... Gen-Fluconazole 100mg Tab............................................................................................................. Gen-Gabapentin 100mg Cap ............................................................................................................ Gen-Gabapentin 300mg Cap ............................................................................................................ Gen-Gabapentin 400mg Cap ............................................................................................................ Gen-Ipratropium 250mcg/mL Inh Sol-20mL Pk ................................................................................. Gen-Ipratropium 250mcg/mL Inh Sol-2mL UDV Pk ........................................................................... Gen-Lamotrigine 25mg Tab ............................................................................................................... Gen-Lamotrigine 100mg Tab ............................................................................................................. Gen-Lamotrigine 150mg Tab ............................................................................................................. Gen-Ondansetron 4mg Tab ............................................................................................................... Gen-Ondansetron 8mg Tab ............................................................................................................... Gen-Salbutamol 2mg/mL Inh Sol-2.5mL Pk ...................................................................................... Gen-Salbutamol 5mg/mL Inh Sol-10mL Pk ....................................................................................... Gen-Salbutamol Sterinebs P.F. 1mg/mL Inh Sol-2.5mL Pk................................................................ Gen-Tamsulosin 0.4mg Cap .............................................................................................................. Gen-Ticlopidine 250mg Tab ............................................................................................................... Gen-Topiramate 25mg Tab ................................................................................................................ Gen-Topiramate 100mg Tab .............................................................................................................. Gen-Topiramate 200mg Tab .............................................................................................................. Glucobay 50mg Tab ........................................................................................................................... Glucobay 100mg Tab ......................................................................................................................... Hp-PAC 30mg & 500mg & 500mg Tab/Cap Pk .................................................................................. Humalog 100U/mL Inj Sol-10mL Pk .................................................................................................. Humalog 100U/mL Inj Sol-5x3mL Pk ................................................................................................ Humalog Mix25 25% & 75% Inj Susp-5x3mL Pk............................................................................... Hypotears 1% Oph-Sol ...................................................................................................................... Imodium 2mg Caplet ......................................................................................................................... Innohep 10000IU/mL Inj-2mL Pk ....................................................................................................... Innohep 20000IU/mL Inj-2mL Pk ....................................................................................................... Innohep 3500IU/0.35mL Inj Pref Syr ................................................................................................. Innohep 4500IU/0.45mL Inj Pref Syr ................................................................................................. Innohep 10000IU/0.5mL Inj Pref Syr ................................................................................................. Innohep 14000IU/0.7mL Inj Pref Syr ................................................................................................. Innohep 18000IU/0.9mL Inj Pref Syr ................................................................................................. Intron A 15mu/mL 18mu MD Pen Kit .................................................................................................
33 66 66 66 66 66 66 66 66 29 83 18 25 25 27 27 27 55 41 44 46 46 49 49 49 53 54 56 56 56 71 71 81 82 81 84 87 89 89 89 17 17 58 52 52 52 78 63 88 88 88 88 88 88 88 53
JUNE 27, 2008
PRODUCT
PAGE
Intron A 25mu/mL 30mu MD Pen Kit ................................................................................................. Intron A 50mu/mL 60mu MD Pen Kit ................................................................................................. Isopto Tears 0.5% Oph-Sol ................................................................................................................ Isopto Tears 1% Oph-Sol ................................................................................................................... Isuprel 0.5% Inh Sol-10mL Pk ........................................................................................................... Kytril 1mg Tab .................................................................................................................................... Lacri-Lube 55%/42.5% Oph Oint-3.5g Pk ......................................................................................... Lamictal 25mg Tab............................................................................................................................. Lamictal 100mg Tab........................................................................................................................... Lamictal 150mg Tab........................................................................................................................... Lasix Special 500mg Tab ................................................................................................................... Leustatin 1mg/mL Inj ......................................................................................................................... Levaquin 250mg Tab.......................................................................................................................... Levaquin 500mg Tab.......................................................................................................................... Liquifilm Tears 1.4% Oph-Sol ............................................................................................................ Lomotil 2.5mg & 0.025mg Tab ........................................................................................................... Losec DR Tab 20mg .......................................................................................................................... Losec 20mg DR Tab ......................................................................................................................... Lovenox 100mg/mL Inj Sol-3mL Vial Pk ............................................................................................ Lovenox 30mg/0.3mL Pref Syr-0.3mL Pk .......................................................................................... Lovenox 40mg/0.4mL Pref Syr-0.4mL Pk .......................................................................................... Lovenox 60mg/0.6mL Pref Syr-0.6mL Pk .......................................................................................... Lovenox 80mg/0.8mL Pref Syr-0.8mL Pk .......................................................................................... Lovenox 100mg/mL Pref Syr-1mL Pk ................................................................................................ Lovenox HP 120mg/0.8mL Pref Syr-0.8mL Pk .................................................................................. Lovenox HP 150mg/mL Pref Syr-1mL Pk .......................................................................................... Lumigan 0.03% Oph Sol.................................................................................................................... Marinol 2.5mg Cap ............................................................................................................................ Marinol 5mg Cap ............................................................................................................................... Mycobutin 150mg Cap....................................................................................................................... Neoral 10mg Cap .............................................................................................................................. Neoral 25mg Cap .............................................................................................................................. Neoral 50mg Cap .............................................................................................................................. Neoral 100mg Cap ............................................................................................................................ Neoral 100mg/mL O/L ....................................................................................................................... Neurontin 100mg Cap ....................................................................................................................... Neurontin 300mg Cap ....................................................................................................................... Neurontin 400mg Cap ....................................................................................................................... Nimotop 30mg SG Cap ..................................................................................................................... Nix Dermal Cream 5% Cr .................................................................................................................. Norprolac 0.075mg Tab ..................................................................................................................... Norprolac 0.15mg Tab ....................................................................................................................... Novo-Acyclovir 800mg Tab ................................................................................................................ Novo-Benzydamine 0.15% Oral Rinse .............................................................................................. Novo-Bupropion SR 150mg Tab ........................................................................................................ Novo-Ciprofloxacin 250mg Tab .......................................................................................................... Novo-Ciprofloxacin 500mg Tab .......................................................................................................... Novo-Ciprofloxacin 750mg Tab .......................................................................................................... Novo-Clobazam 10mg Tab ................................................................................................................ Novo-Fluconazole 50mg Tab ............................................................................................................. Novo-Fluconazole 100mg Tab ........................................................................................................... Novo-Fluconazole-150 150mg Cap ................................................................................................... Novo-Gabapentin 100mg Cap ........................................................................................................... Novo-Gabapentin 300mg Cap ........................................................................................................... Novo-Gabapentin 400mg Cap ........................................................................................................... Novo-Ipramide 250mcg/mL Inh Sol-20mL Pk ....................................................................................
53 53 64 64 55 51 77 56 56 56 48 29 61 61 78 35 69 70 39 39 39 39 39 39 39 39 20 34 34 79 33 33 33 33 33 49 49 49 67 77 78 78 18 20 24 27 27 27 29 46 46 44 49 49 49 53
XII.11
PRODUCT
PAGE
Novo-Lamotrigine 25mg Tab .............................................................................................................. Novo-Lamotrigine 100mg Tab ............................................................................................................ Novo-Lamotrigine 150mg Tab ............................................................................................................ Novo-Leflunomide 10mg Tab ............................................................................................................. Novo-Leflunomide 20mg Tab ............................................................................................................. Novo-Loperamide 2mg Caplet ........................................................................................................... Novo-Ofloxacin 200mg Tab................................................................................................................ Novo-Ofloxacin 300mg Tab................................................................................................................ Novo-Ofloxacin 400mg Tab................................................................................................................ Novo-Ondansetron 4mg Tab .............................................................................................................. Novo-Ondansetron 8mg Tab .............................................................................................................. Novo-Pantoprazole 40mg Ent Tab ..................................................................................................... Novo-Tamsulosin SR 0.4mg Cap....................................................................................................... Novo-Ticlopidine 250mg Tab ............................................................................................................. Novo-Topiramate 25mg Tab ............................................................................................................... Novo-Topiramate 100mg Tab ............................................................................................................. Novo-Topiramate 200mg Tab ............................................................................................................. NovoRapid 100U/mL Inj Sol-10mL Pk ............................................................................................... NovoRapid Penfill 100U/mL Inj Sol-5x3mL Pk .................................................................................. Nu-Acyclovir 800mg Tab .................................................................................................................... Nu-Pentoxifylline 400mg SR Tab ....................................................................................................... Nu-Ticlopidine 250mg Tab ................................................................................................................. Ocuflox 0.3% Oph Sol ....................................................................................................................... Ogen 1.25 1.5mg Tab ........................................................................................................................ Ogen 2.5 3mg Tab ............................................................................................................................. Ostac 400mg Cap.............................................................................................................................. Oxeze Turbuhaler 6mcg/Metered Dose Pd Inh-60 Dose Pk .............................................................. Oxeze Turbuhaler 12mcg/Metered Dose Pd Inh-60 Dose Pk ............................................................ Oxycontin 10mg SR Tab .................................................................................................................... Oxycontin 20mg SR Tab .................................................................................................................... Oxycontin 40mg SR Tab .................................................................................................................... Oxycontin 80mg SR Tab .................................................................................................................... Pancrease 4500 & 20000 & 25000 USP Units SR Cap..................................................................... Pancrease MT4 4000 & 12000 & 12000 USP Units Ent Microsph Cap ............................................ Pantoloc 40mg Ent Tab ...................................................................................................................... Plavix 75mg Tab ................................................................................................................................ PMS-Benzydamine 0.15% Oral Rinse............................................................................................... PMS-Brimonidine 0.2% Oph Sol ....................................................................................................... PMS-Carbamazepine CR 200mg LA Tab .......................................................................................... PMS-Carbamazepine CR 400mg LA Tab .......................................................................................... PMS-Carvedilol 3.125mg Tab ............................................................................................................ PMS-Carvedilol 6.25mg Tab .............................................................................................................. PMS-Carvedilol 12.5mg Tab .............................................................................................................. PMS-Carvedilol 25mg Tab ................................................................................................................. PMS-Ciprofloxacin 250mg Tab .......................................................................................................... PMS-Ciprofloxacin 500mg Tab .......................................................................................................... PMS-Ciprofloxacin 750mg Tab .......................................................................................................... PMS-Clobazam 10mg Tab ................................................................................................................. PMS-Famciclovir 500mg Tab ............................................................................................................. PMS-Fluconazole 150mg Cap........................................................................................................... PMS-Fluconazole 50mg Tab.............................................................................................................. PMS-Fluconazole 100mg Tab............................................................................................................ PMS-Gabapentin 100mg Cap ........................................................................................................... PMS-Gabapentin 300mg Cap ........................................................................................................... PMS-Gabapentin 400mg Cap ........................................................................................................... PMS-Ipratropium 250mcg/mL Inh Sol-20mL Pk ................................................................................
56 56 56 60 60 63 68 68 68 71 71 76 84 87 89 89 89 51 51 18 77 87 67 40 40 30 48 48 73 73 73 73 75 74 76 31 20 21 25 25 26 26 26 26 27 27 27 29 42 44 46 46 49 49 49 53
JUNE 27, 2008
PRODUCT
PAGE
PMS-Ipratropium 125mcg/mL Inh Sol-2mL UDV Pk .......................................................................... PMS-Ipratropium 250mcg/mL Inh Sol-2mL UDV Pk .......................................................................... PMS-Ipratropium 0.03% Nasal Spray ................................................................................................ PMS-Lamotrigine 25mg Tab .............................................................................................................. PMS-Lamotrigine 100mg Tab ............................................................................................................ PMS-Lamotrigine 150mg Tab ............................................................................................................ PMS-Leflunomide 10mg Tab ............................................................................................................. PMS-Leflunomide 20mg Tab ............................................................................................................. PMS-Loperamide 2mg Caplet ........................................................................................................... PMS-Ofloxacin 0.3% Oph Sol ........................................................................................................... PMS-Ondansetron 4mg Tab .............................................................................................................. PMS-Ondansetron 8mg Tab .............................................................................................................. PMS-Salbutamol 1mg/mL Inh Sol-2.5mL Pk ..................................................................................... PMS-Salbutamol 2mg/mL Inh Sol-2.5mL Pk ..................................................................................... PMS-Salbutamol Respirator Solution 5mg/mL Inh Sol-10mL Pk ...................................................... PMS-Topiramate 25mg Tab ............................................................................................................... PMS-Topiramate 100mg Tab ............................................................................................................. PMS-Topiramate 200mg Tab ............................................................................................................. PMS-Ursodiol C 250mg Tab .............................................................................................................. PMS-Ursodiol C 500mg Tab .............................................................................................................. Premarin 0.3mg Tab .......................................................................................................................... Premarin 0.625mg Tab ...................................................................................................................... Premarin 1.25mg Tab ........................................................................................................................ Premplus 0.625mg/2.5mg Tab-28 Day Pk ......................................................................................... Premplus 0.625mg/5mg Tab-28 Day Pk ............................................................................................ Prevacid 15mg DR Cap ..................................................................................................................... Prevacid 30mg DR Cap ..................................................................................................................... Prograf 5mg/mL Amp ........................................................................................................................ Prograf 1mg Cap ............................................................................................................................... Prograf 5mg Cap ............................................................................................................................... Proscar 5mg Tab................................................................................................................................ Protopic 0.03% Oint........................................................................................................................... Protopic 0.1% Oint............................................................................................................................. Pulmicort Nebuamp 0.125mg/mL Inh Susp ....................................................................................... Pulmicort Nebuamp 0.25mg/mL Inh Susp ......................................................................................... Pulmicort Nebuamp 0.5mg/mL Inh Susp ........................................................................................... Ran-Carvedilol 3.125mg Tab ............................................................................................................. Ran-Carvedilol 6.25mg Tab ............................................................................................................... Ran-Carvedilol 12.5mg Tab ............................................................................................................... Ran-Carvedilol 25mg Tab .................................................................................................................. Ran-Ciproflox 250mg Tab .................................................................................................................. Ran-Ciproflox 500mg Tab .................................................................................................................. Ran-Ciproflox 750mg Tab .................................................................................................................. Ran-Ciprofloxacin 250mg Tab ........................................................................................................... Ran-Ciprofloxacin 500mg Tab ........................................................................................................... Ran-Ciprofloxacin 750mg Tab ........................................................................................................... Ran-Fentanyl 25mcg/hr Trans Patch.................................................................................................. Ran-Fentanyl 50mcg/hr Trans Patch.................................................................................................. Ran-Fentanyl 75mcg/hr Trans Patch.................................................................................................. Ran-Fentanyl 100mcg/hr Trans Patch................................................................................................ Ran-Pantoprazole 40mg Ent Tab ....................................................................................................... Ran-Tamsulosin 0.4mg Cap .............................................................................................................. Rapamune 1mg/mL O/L .................................................................................................................... Rapamune 1mg Tab .......................................................................................................................... Ratio-Acyclovir 800mg Tab ................................................................................................................ Ratio-Benzydamine 0.15% Oral Rinse ..............................................................................................
54 54 54 56 56 56 60 60 63 67 71 71 81 81 82 89 89 89 91 91 32 32 32 32 32 57 57 84 84 84 44 84 84 23 23 23 26 26 26 26 27 27 27 27 27 27 43 43 43 43 76 84 83 83 18 20
XII.13
PRODUCT
PAGE
Ratio-Brimonidine 0.2% Oph Sol ....................................................................................................... Ratio-Bupropion SR 100mg Tab ........................................................................................................ Ratio-Bupropion SR 150mg Tab ........................................................................................................ Ratio-Carvedilol 3.125mg Tab ........................................................................................................... Ratio-Carvedilol 6.25mg Tab ............................................................................................................. Ratio-Carvedilol 12.5mg Tab ............................................................................................................. Ratio-Carvedilol 25mg Tab ................................................................................................................ Ratio-Ciprofloxacin 250mg Tab .......................................................................................................... Ratio-Ciprofloxacin 500mg Tab .......................................................................................................... Ratio-Ciprofloxacin 750mg Tab .......................................................................................................... Ratio-Clobazam 10mg Tab ................................................................................................................ Ratio-Fentanyl 25mcg/hr Trans Patch ................................................................................................ Ratio-Fentanyl 50mcg/hr Trans Patch ................................................................................................ Ratio-Fentanyl 75mcg/hr Trans Patch ................................................................................................ Ratio-Fentanyl 100mcg/hr Trans Patch .............................................................................................. Ratio-Gabapentin 100mg Cap ........................................................................................................... Ratio-Gabapentin 300mg Cap ........................................................................................................... Ratio-Gabapentin 400mg Cap ........................................................................................................... Ratio-IPRA SAL UDV 500mcg/2.5mg/2.5mL Inh Sol-2.5mL Pk ........................................................ Ratio-Ipratropium 250mcg/mL Inh Sol-20mL Pk ............................................................................... Ratio-Ipratropium UDV 125mcg/mL Inh Sol-2mL UDV Pk ................................................................. Ratio-Ipratropium UDV 250mcg/mL Inh Sol-2mL UDV Pk ................................................................. Ratio-Lamotrigine 25mg Tab.............................................................................................................. Ratio-Lamotrigine 100mg Tab............................................................................................................ Ratio-Lamotrigine 150mg Tab............................................................................................................ Ratio-Omeprazole 20mg DR Tab ....................................................................................................... Ratio-Omeprazole DR Tab 20mg ....................................................................................................... Ratio-Ondansetron 4mg Tab.............................................................................................................. Ratio-Ondansetron 8mg Tab.............................................................................................................. Ratio-Pentoxifylline 400mg SR Tab ................................................................................................... Ratio-Salbutamol 2mg/mL Inh Sol-2.5mL Pk .................................................................................... Ratio-Salbutamol Respirator Sol P.F. 1mg/mL Inh Sol-2.5mL Pk ...................................................... Ratio-Salbutamol Respirator Solution 5mg/mL Inh Sol-10mL Pk ...................................................... Ratio-Tamsulosin 0.4mg Cap ............................................................................................................ Ratio-Topiramate 25mg Tab............................................................................................................... Ratio-Topiramate 100mg Tab............................................................................................................. Ratio-Topiramate 200mg Tab............................................................................................................. Reminyl ER 8mg ER Cap .................................................................................................................. Reminyl ER 16mg ER Cap ................................................................................................................ Reminyl ER 24mg ER Cap ................................................................................................................ Sabril 500mg Tab ............................................................................................................................... Sandoz Anagrelide 0.5mg Cap.......................................................................................................... Sandoz Bupropion SR 100mg Tab .................................................................................................... Sandoz Bupropion SR 150mg Tab .................................................................................................... Sandoz Carbamazepine CR 200mg LA Tab ...................................................................................... Sandoz Carbamazepine CR 400mg LA Tab ...................................................................................... Sandoz Ciprofloxacin 250mg Tab ...................................................................................................... Sandoz Ciprofloxacin 500mg Tab ...................................................................................................... Sandoz Ciprofloxacin 750mg Tab ...................................................................................................... Sandoz Cyclosporine 25mg Cap ....................................................................................................... Sandoz Cyclosporine 50mg Cap ....................................................................................................... Sandoz Cyclosporine 100mg Cap ..................................................................................................... Sandoz Famciclovir 500mg Tab ......................................................................................................... Sandoz Leflunomide 10mg Tab ......................................................................................................... Sandoz Leflunomide 20mg Tab ......................................................................................................... Sandoz Loperamide 2mg Caplet .......................................................................................................
21 24 24 26 26 26 26 27 27 27 29 43 43 43 43 49 49 49 55 53 54 54 56 56 56 70 69 71 71 77 81 81 82 84 89 89 89 50 50 50 92 19 24 24 25 25 27 27 27 33 33 33 42 60 60 63
JUNE 27, 2008
PRODUCT
PAGE
Sandoz Omeprazole 20mg Cap ........................................................................................................ Sandoz Ondansetron 4mg Tab .......................................................................................................... Sandoz Ondansetron 8mg Tab .......................................................................................................... Sandoz Salbutamol 5mg/mL Inh Sol-10mL Pk .................................................................................. Sandoz Tamsulosin 0.4mg Cap ......................................................................................................... Sandoz Ticlopidine 250mg Tab .......................................................................................................... Sandoz Topiramate 25mg Tab ........................................................................................................... Sandoz Topiramate 100mg Tab ......................................................................................................... Sandoz Topiramate 200mg Tab ......................................................................................................... SereVent Diskhaler Disks 50mcg/Blister Diskhaler-60 Disk Pk ......................................................... SereVent Diskus 50mcg Pd Inh-60 Dose Pk ..................................................................................... Sibelium 5mg Cap ............................................................................................................................. Sinemet CR 100mg & 25mg Tab ....................................................................................................... Sinemet CR 200mg & 50mg Tab ....................................................................................................... Singulair 4mg Chew Tab .................................................................................................................... Stieva-A 0.01% Cr ............................................................................................................................. Stieva-A 0.025% Cr ........................................................................................................................... Stieva-A 0.05% Cr ............................................................................................................................. Stieva-A 0.025% Gel ......................................................................................................................... Stieva-A 0.025% Sol .......................................................................................................................... Symbicort 100 Turbuhaler 100mcg/6mcg Pd Inh-120 Dose Pk ........................................................ Symbicort 200 Turbuhaler 200mcg/6mcg Pd Inh-120 Dose Pk ........................................................ Tamiflu 75mg Cap.............................................................................................................................. Tantum 0.15% Oral Rinse.................................................................................................................. Taro-Ciprofloxacin 250mg Tab ........................................................................................................... Taro-Ciprofloxacin 500mg Tab ........................................................................................................... Taro-Fluconazole 50mg Tab .............................................................................................................. Taro-Fluconazole 100mg Tab ............................................................................................................ Tears Naturale 0.1%/0.3% Oph-Sol................................................................................................... Tears Naturale II 0.1%/0.3%/0.001% Oph-Sol .................................................................................. Tears Plus Oph-Sol............................................................................................................................ Tegretol CR 200mg LA Tab................................................................................................................ Tegretol CR 400mg LA Tab................................................................................................................ Temodal 5mg Cap ............................................................................................................................. Temodal 20mg Cap ........................................................................................................................... Temodal 100mg Cap ......................................................................................................................... Temodal 250mg Cap ......................................................................................................................... Thyrogen 0.9mg/mL Inj Pd-2x1.1mg Vial Pk ..................................................................................... Ticlid 250mg Tab................................................................................................................................ Topamax 25mg Tab ........................................................................................................................... Topamax 100mg Tab ......................................................................................................................... Topamax 200mg Tab ......................................................................................................................... Topamax Sprinkle 15mg Sprinkle Cap .............................................................................................. Topamax Sprinkle 25mg Sprinkle Cap .............................................................................................. Travatan 0.004% Oph Sol .................................................................................................................. Trental 400mg SR Tab ....................................................................................................................... Trusopt 2% Oph Sol........................................................................................................................... Urso 250mg Tab ................................................................................................................................ Urso DS 500mg Tab .......................................................................................................................... Valcyte 450mg Tab ............................................................................................................................ Valtrex 500mg Tab ............................................................................................................................. Ventolin 5mg/mL Inh Sol-10mL Pk .................................................................................................... Ventolin Nebules P.F. 1mg/mL Inh Sol-2.5mL Pk ............................................................................... Ventolin Nebules P.F. 2mg/mL Inh Sol-2.5mL Pk ............................................................................... Vfend 50mg Tab ................................................................................................................................. Vfend 200mg Tab ...............................................................................................................................
69 71 71 82 84 87 89 89 89 82 82 47 61 61 64 90 90 90 90 90 23 23 72 20 27 27 46 46 34 34 78 25 25 85 85 85 85 86 87 89 89 89 89 89 90 77 37 91 91 91 91 82 81 81 92 92
XII.15
PRODUCT
PAGE
Viokase 16800 & 70000 & 70000 USP U/0.7g Pd-114g Pk .............................................................. Viokase 8000 & 30000 & 30000 USP Units Tab ................................................................................ Viokase 16 16mg Tab ........................................................................................................................ Vitamin A Acid 0.05% Cr ................................................................................................................... Vitamin A Acid 0.01% Gel ................................................................................................................. Vitamin A Acid 0.05% Gel ................................................................................................................. Wellbutrin SR 100mg Tab .................................................................................................................. Wellbutrin SR 150mg Tab .................................................................................................................. Wellbutrin XL 150mg Tab ................................................................................................................... Wellbutrin XL 300mg Tab ................................................................................................................... Xalacom 50mcg/mL & 5mg/mL Oph Sol-2.5mL Pk ........................................................................... Xalatan 0.005% Oph Sol-2.5mL Pk ................................................................................................... Xatral 10mg Prolong-Rel Tab............................................................................................................. Xeloda 150mg Tab ............................................................................................................................. Xeloda 500mg Tab ............................................................................................................................. Zofran 4mg/5mL O/L ......................................................................................................................... Zofran 4mg Tab.................................................................................................................................. Zofran 8mg Tab.................................................................................................................................. Zofran ODT 4mg Tab ......................................................................................................................... Zofran ODT 8mg Tab ......................................................................................................................... Zovirax 800mg Tab ............................................................................................................................ Zyvoxam 600mg Tab..........................................................................................................................
75 75 75 90 90 90 24 24 24 24 59 59 19 25 25 71 71 71 71 71 18 62
XII.16
JUNE 27, 2008
LIMITED USE PRODUCTS COMPLETE LISTING

(In alphabetical order by generic names)
GENERIC NAME \ STRENGTH DOSAGE FORM DIN BRAND NAME
ACARBOSE 50mg 100mg Reason for Use code
Tab Tab Clinical criteria
02190885 Glucobay 02190893 Glucobay
ED ION IT E AT ED M S NT IR LI U ME EQU CU R DO
175 LU Authorization Period: Indefinite. 176 LU Authorization Period: Indefinite.
For the treatment of non-insulin-dependent diabetes mellitus (NIDDM):
In patients who cannot tolerate or have failed treatment with other oral hypoglycemic agents or in whom other oral hypoglycemic agents are contraindicated;
In patients who require combination therapy with more than one oral hypoglycemic agent to control their serum glucose concentrations.
JUNE 27, 2008
XII.17
GENERIC NAME \ STRENGTH
DOSAGE FORM
DIN
BRAND NAME
ACYCLOVIR 800mg
Tab
01911635 02078651 02197421 02207656 02242464 02285975
Zovirax Ratio-Acyclovir Nu-Acyclovir Apo-Acyclovir Gen-Acyclovir Novo-Acyclovir
Reason for Use code
Clinical criteria In contrast to bacterial infections, viral replication precedes clinical signs and symptoms. Since antiviral agents are only active against replicating viruses, clinical benefit in reducing severity of symptoms and duration of illness is only marginal, at best. Therefore, treatment initiated beyond the stated time frames below is of no value, and treatment of mild cases should be carefully considered, in light of the minimal benefit which will be achieved. In addition, the balance of evidence indicates that the use of acyclovir in normal hosts in an attempt to prevent post-herpetic neuralgia is of no value.
ED IT E N IM S IO L U TAT EN D M U RE OC QUI D RE
Acyclovir tablets will be reimbursed when prescribed for: 95 Herpes zoster in immunocompetent patients 50 years of age or older, up to 72 hours after appearance of lesions. Dose: 800mg 5 times/day for 7 days. LU Authorization Period: 1 year. 96 LU Authorization Period: 1 year. 97 Herpes zoster in immunocompromised patients regardless of age and time elapsed from onset. Dose: 800mg 5 times/day for 7 days. LU Authorization Period: 1 year. 314 NETWORK NOTE: Network will limit supply up to 7 days and up to 35 tablets. LU Authorization Period: 1 year.
Where specified, treatment must begin within the time frames indicated for the product to be reimbursed. There is no benefit from the therapy begun after these time frames.
Herpes zoster ophthalmicus regardless of age, up to 72 hours after appearance of lesions. Dose: 800mg 5 times/day for 7 days.
Varicella zoster in immunocompetent patients greater than or equal to 12 years of age, up to 24 hours after appearance of lesions. Dose: 20mg/kg/dose (max. 800mg) 4 times/day for 5 days.
XII.18
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
ALFUZOSIN HYDROCHLORIDE 10mg Prolong-Rel Tab Reason for Use Code 351 Clinical criteria
02245565 Xatral
ION D D T ITE E TAIndefinite. E LU E Period: QUIR LIM US AuthorizationN of benign prostatic hyperplasia where other M 352 For the management E R CU alpha blockers have produced intolerable side effects. formulary O D
For the management of benign prostatic hyperplasia where six weeks of treatment with other formulary alpha blockers (e.g. doxazosin, terazosin) have been ineffective. LU Authorization Period: Indefinite. Cap Clinical criteria 02260107 Sandoz Anagrelide
ANAGRELIDE HCL 0.5mg Reason for Use Code 400
ION of essential D DFor the treatmentTAT IREthrombocytosis in patients who are E ITE intolerant ofMEwho have failed hydroxyurea therapy. US U or N EQU LIM R C LU Authorization Period: 5 years. DO
Tab Clinical criteria 02224135 Arimidex
ANASTROZOLE 1mg Reason for Use code 365
For the treatment of metastatic breast cancer in hormone receptor N Dpositive post-menopausal women. D E LU Authorization Period:TIO E T A I IMI USE alternative toT Indefinite. adjuvant treatment of N tamoxifen forR L 396 As an ME women QU the receptor positive breast postmenopausal REwith hormone CU cancer. DO LU Authorization Period: Indefinite.
JUNE 27, 2008
XII.19
DOSAGE FORM
DIN
BRAND NAME
BENZYDAMINE HCL 0.15%
Oral Rinse
01966065 02229777 02229799 02230170 02239044
Tantum PMS-Benzydamine Novo-Benzydamine Ratio-Benzydamine Apo-Benzydamine
Reason for Use code 240
Clinical criteria
ION A reliefIofED D theE For symptomaticT T E R treatment induced mucositis in US UMEN EQU MIT cancer patients. LI R C LU Authorization Period: 1 year. DO
Oph Sol Clinical criteria As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated; LU Authorization Period: Indefinite. 02245860 Lumigan
BIMATOPROST 0.03% Reason for Use code 171

XII.20
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
BOTULINUM TOXIN TYPE A 100U/Vial Reason for Use code 10
Pd Inj-100U Vial Pk
01981501 Botox
Clinical criteria
For the treatment of strabismus and blepharospasm associated N Dwith dystonia, including benignyears of age or older. or VII IOessential blepharospasm in ITE nerve disordersNpatients 12 IRED TATyear. LU Authorization 1 LIM USE ME Period: QU 130 To reduce the subjective symptoms and objective signs of cervical RE CU dystonia (spasmodic torticollis) in adults. DO LU Authorization Period: 1 year.
BRIMONIDINE 0.15% 0.2%
Oph Sol Oph Sol
02248151 02236876 02243026 02246284 02260077
Alphagan P Alphagan Ratio-Brimonidine PMS-Brimonidine Apo-Brimonidine
Clinical criteria As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated; LU Authorization Period: Indefinite.
ED ON IT E TI IM US TA ED L EN IR UM EQU OC R D
JUNE 27, 2008
XII.21
DOSAGE FORM
DIN
BRAND NAME
BRIMONIDINE TARTRATE & TIMOLOL MALEATE 0.2% & 0.5% Oph Sol-5mL Pk Reason for Use code 310 Clinical criteria
02248347 Combigan
ION D D TAT IRE ITE SE LIM U UMEN EQU R OC D

LU Authorization Period: Indefinite. 393 LU Authorization Period: Indefinite. Oph Susp Clinical criteria 02238873 Azopt
BRINZOLAMIDE 1% Reason for Use code 171

XII.22
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
BUDESONIDE 0.125mg/mL 0.25mg/mL 0.5mg/mL Reason for Use code
Inh Susp Inh Susp Inh Susp Clinical criteria
02229099 Pulmicort Nebuamp 01978918 Pulmicort Nebuamp 01978926 Pulmicort Nebuamp
ED N IT E IO IM US L AT T D EN IRE UM QU OC RE D
260 Children aged 6 years or less; LU Authorization Period: Indefinite. 261 Patients who have a tracheostomy; LU Authorization Period: Indefinite. 262 Patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. 263 Patients with severe mental or physical disabilities; LU Authorization Period: Indefinite. 264 LU Authorization Period: Indefinite. Reason for Use Code 330
BUDESONIDE & FORMOTEROL FUMARATE DIHYDRATE 100mcg/6mcg Pd Inh-120 Dose Pk 02245385 Symbicort 100 Turbuhaler 200mcg/6mcg Pd Inh-120 Dose Pk 02245386 Symbicort 200 Turbuhaler
N TIO ED A D ITE USE MENT QUIR LIM U RE OC Period: Indefinite. LU Authorization D
Clinical criteria
JUNE 27, 2008
XII.23
DOSAGE FORM
DIN
BRAND NAME
BUPROPION HCL 100mg 150mg
Tab Tab
150mg 300mg Reason for Use code 315
02237824 02275074 02285657 02237825 02260239 02275082 02285665 02275090 02275104
Wellbutrin SR Sandoz Bupropion SR Ratio-Bupropion SR Wellbutrin SR Novo-Bupropion SR Sandoz Bupropion SR Ratio-Bupropion SR Wellbutrin XL Wellbutrin XL
ION TAT IRED IT For theSE MEN depression. U treatment of EQU LIM R CU LU Authorization Period: Indefinite. DO ED
Cr Oint Clinical criteria 02150956 Dovonex 01976133 Dovonex
CALCIPOTRIOL 50mcg/g 50mcg/g Reason for Use code
ION D the treatment of TAT Iin ED who have failed topical 191 N psoriasis R patients TE For USE QU IMI corticosteroids alone, or are intolerant to topical corticosteroids. ME L RE CU Period: Indefinite. LU Authorization DO
XII.24
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
CAPECITABINE 150mg 500mg Reason for Use code 346
02238453 Xeloda 02238454 Xeloda
ED ON IT E TI M S LI U TA EN ED UM IR OC EQU D R
LU Authorization Period: Indefinite. 360 LU Authorization Period: Indefinite. 406 LU Authorization Period: 6 months. LA Tab 00773611 02231543 02241882 02242908 02261839 00755583 02231544 02241883 02242909 02261847
For the first-line treatment of patients with metastatic colorectal cancer in whom combination chemotherapy is not recommended. NOTE: Not to be used in patients who have failed 5-flurouracil.
For the treatment of metastatic breast cancer in combination with docetaxel in women who experience disease progression on or after an anthracycline. For adjuvant treatment of stage 3 or high risk stage 2* colon cancer in patients who have completed surgery (within three months), who would normally be candidates for adjuvant chemotherapy with 5FU/LV. *high risk stage 2 colon cancer is defined as one of the following: obstruction, perforation, poorly differentiated adenocarcinoma, inadequate lymph node sampling, T4 tumour.
CARBAMAZEPINE 200mg
400mg
LA Tab
Tegretol CR PMS-Carbamazepine CR Gen-Carbamazepine CR Apo-Carbamazepine CR Sandoz Carbamazepine CR Tegretol CR PMS-Carbamazepine CR Gen-Carbamazepine CR Apo-Carbamazepine CR Sandoz Carbamazepine CR
ION been tried E conventional carbamazepine DFor patients who have AT dueItoon D effects or poor control unsatisfactory results ITE with SE MENT QU Radverse IM of U symptoms. L RE CU LU DO Authorization Period: Indefinite.
Clinical criteria
JUNE 27, 2008
XII.25
DOSAGE FORM
DIN
BRAND NAME
CARVEDILOL 3.125mg
Tab
6.25mg
Tab
12.5mg
Tab
25mg
Tab
02245914 02247933 02252309 02268027 02245915 02247934 02252317 02268035 02245916 02247935 02252325 02268043 02245917 02247936 02252333 02268051
PMS-Carvedilol Apo-Carvedilol Ratio-Carvedilol Ran-Carvedilol PMS-Carvedilol Apo-Carvedilol Ratio-Carvedilol Ran-Carvedilol PMS-Carvedilol Apo-Carvedilol Ratio-Carvedilol Ran-Carvedilol PMS-Carvedilol Apo-Carvedilol Ratio-Carvedilol Ran-Carvedilol
D ION D AT RE ITE E IM S NT UI L U UME EQ R OC D

For patients with: 183 LU Authorization Period: Indefinite.
Reason for Use code
Clinical criteria
a) NYHA Class II or III Congestive Heart Failure (CHF); and b) Currently being treated with an angiotension converting enzyme (ACE) inhibitor, diuretics with or without digoxin, or previously treated, and failed these agents; and c) An ejection fraction less than or equal to 35%; and d) At least one episode of symptomatic CHF within a 12 month period while receiving optimal management.
XII.26
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
CELECOXIB 100mg 200mg Reason for Use code 316
Cap Cap Clinical criteria
02239941 Celebrex 02239942 Celebrex
317 CIPROFLOXACIN 10g/100mL 250mg Oral Susp Tab 02237514 02155958 02161737 02229521 02245647 02246825 02247339 02248437 02248756 02266962 02267934 02303728 02155966 02161745 02229522 02245648 02246826 02247340 02248438 02248757 02266970 02267942 02303736 02155974 02161753 02229523 02245649 02246827 02247341 02248439 02248758 02267950 02303744
Osteoarthritis For patients who have failed an adequate trial of acetaminophen (e.g. acetaminophen 1g QID for several weeks) and have had: History of a documented, clinically significant ulcer or GI bleed; or Failure or intolerance to at least three listed NSAIDs. NOTE: The maximum daily dose of celecoxib which will be reimbursed for the treatment of osteoarthritis is 200mg. LU Authorization Period: 1 year. Rheumatoid arthritis For patients who have had: History of a documented, clinically significant ulcer or GI bleed; or Failure or intolerance to at least three listed NSAIDs. NOTE: The maximum daily dose of celecoxib which will be reimbursed for the treatment of rheumatoid arthritis is 400mg. LU Authorization Period: 1 year. Cipro Cipro Novo-Ciprofloxacin Apo-Ciproflox Gen-Ciprofloxacin Ratio-Ciprofloxacin Co-Ciprofloxacin PMS-Ciprofloxacin Sandoz Ciprofloxacin Taro-Ciprofloxacin Ran-Ciprofloxacin Ran-Ciproflox Cipro Novo-Ciprofloxacin Apo-Ciproflox Gen-Ciprofloxacin Ratio-Ciprofloxacin Co-Ciprofloxacin PMS-Ciprofloxacin Sandoz Ciprofloxacin Taro-Ciprofloxacin Ran-Ciprofloxacin Ran-Ciproflox Cipro Novo-Ciprofloxacin Apo-Ciproflox Gen-Ciprofloxacin Ratio-Ciprofloxacin Co-Ciprofloxacin PMS-Ciprofloxacin Sandoz Ciprofloxacin Ran-Ciprofloxacin Ran-Ciproflox Continued on next page...
JUNE 27, 2008 XII.27
500mg
Tab
750mg
Tab
DOSAGE FORM
DIN
BRAND NAME
Reason for Use Code 332
Clinical criteria For the treatment of patients with:
D TE I IM SE TION L U TA EN D UM IRE C O QU D E R
SST/BJ (Gram negative bacteria): Skin/soft tissue and bone/joint infection due to gram negative bacteria; severe diabetic foot infection; severe otitis externa; decubitus ulcers. LU Authorization Period: 1 year. 333 GU Tract: Urinary tract infection/prostatitis/epididymitis caused by (suspected or documented) Pseudomonas; sexually transmitted diseases. LU Authorization Period: 1 year. 334 COPD with risk: Acute bacterial exacerbation of chronic obstructive pulmonary disease (COPD) with risk factors1; bronchiectasis; pneumonic illness with cystic fibrosis. 1Risk factors include: poor pulmonary lung function (FEV below 1 50% predicted level), age over 65 years, co-morbid medical illness (congestive heart failure, diabetes, chronic renal failure, chronic liver disease), chronic corticosteroid use, malnutrition, prolonged duration of disease or 4 or more exacerbations per year. LU Authorization Period: 1 year. 336 Step-Down: Step-down therapy after parenteral therapy or hospital/emergency department discharge; febrile neutropenia. LU Authorization Period: 1 year. GI: Travellers diarrhea; enteric fever syndromes; Crohns disease. LU Authorization Period: 1 year. 353 977 For the prophylaxis or treatment of B. anthracis exposure. LU Authorization Period: 1 year. Exceptional cases of allergy or intolerance to all other appropriate therapies. LU Authorization Period: 1 year. 350
XII.28
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
CIPROFLOXACIN HCL & CIPROFLOXACIN BASE 500mg ER Tab Reason for Use code 394 Clinical criteria
02247916 Cipro XL
ION AT IRED D ITE USE MENT QU LIM U RE OC LU Authorization Period: 1 year. D

ER Tab Clinical criteria
For patients with uncomplicated urinary tract infections (acute cystitis) who have failure, intolerance or hypersensitivity to all formulary antibiotic alternatives that are listed as General Benefits.
1000mg Reason for Use code 395
02251787 Cipro XL
N TIO ED A D ITE USE MENT QUIR LIM U RE OC D LU Authorization Period: 1 year.

Inj Clinical criteria
For patients with complicated urinary tract infections or acute uncomplicated pyelonephritis who have failure, intolerance or hypersensitivity to all formulary antibiotic alternatives that are listed as General Benefits.
CLADRIBINE 1mg/mL Reason for Use code
02022117 Leustatin
ION D TAT a RED EFor hairy cell leukemia, asUIsingle 7-day treatment course. E 99 N IT US Q ME LIM RE CU Period: 1 year. LU Authorization DO
Tab 02221799 02238334 02238797 02244474 02244638 Frisium Novo-Clobazam Ratio-Clobazam PMS-Clobazam Apo-Clobazam
CLOBAZAM 10mg
Clinical criteria
As adjunctive therapy in the treatment of seizure disorders where ION has been Dcontrol by other listed anticonvulsants ED unsatisfactory. T Because a large number of R become ITE NOTE:anticonvulsant TA of theIpatients willperiod ofrefractory M Uto the effects drug over a time, the SE MENdrug mustU re-evaluated after a period of six LI Q be effectiveness of this months.U RE C O DLU Authorization Period: Indefinite.
JUNE 27, 2008
XII.29
DOSAGE FORM
DIN
BRAND NAME
CLODRONATE DISODIUM 400mg Reason for Use code 280 358
Cap
01927078 Ostac 02245828 Clasteon
Clinical criteria For the control and prophylaxis of hypercalcemia of malignancy. LU Authorization Period: Indefinite. For the treatment of bony metastases in patients with breast cancer. LU Authorization Period: Indefinite. For the prevention and treatment of osteolytic lesions in patients with multiple myeloma. LU Authorization Period: Indefinite.
D ION D ITE E AT IRE NT U LIM US ME EQ R CU O D

359 CLODRONATE DISODIUM TETRAHYDRATE 400mg Cap Reason for Use code 280 Clinical criteria 01984845 Bonefos
ED ION D MIT SE NTAT IRE LI U ME QU RE CU DO

XII.30
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
CLOPIDOGREL BISULFATE 75mg Reason for Use Code 375
Tab
02238682 Plavix
Clinical criteria For patients immediately post-hospitalization* for non-ST segment elevation acute coronary syndrome (ACS)**; Note: approval for 12 months LU Authorization Period: 1 year.
ED T E ON I TI M S LI U TA EN ED M IR CU QU O E D R
376 For patients immediately pre- or post- percutaneous coronary intervention (PCI)*** Note: approval for 12 months **ACS, as defined by the CURE study, includes hospitalized patients with unstable angina or non-ST segment elevation myocardial infraction. ***Therapy may be initiated up to 10 days prior to PCI. LU Authorization Period: 1 year. CODEINE SULFATE TRIHYDRATE & MONOHYDRATE 50mg CR Tab 02230302 100mg CR Tab 02163748 150mg CR Tab 02163780 200mg CR Tab 02163799 Reason for Use code 201 Clinical criteria Codeine Contin Codeine Contin Codeine Contin Codeine Contin
*The first prescription must be written by a physician based at the hospital where the patient was hospitalized.
NETWORK NOTE: The Special Authorization Number (SAN) that corresponds to the hospital where the patient was hospitalized must be submitted with the first Limited Use claim.
ION Tpain in ED who cannot tolerate, For the treatment of chronic TA ED E IRpatients EN or failed a listed MIT haveUS treatment withQU long-acting opioid. LI UM RE OC LU Authorization Period: 1 year. D
JUNE 27, 2008
XII.31
DOSAGE FORM
DIN
BRAND NAME
CONJUGATED EQUINE ESTROGEN/MEDROXYPROGESTERONE ACETATE 0.625mg/2.5mg Tab-28 Day Pk 02242878 Premplus 0.625mg/5mg Tab-28 Day Pk 02242879 Premplus
D ION D ITE E TAT IRE LIM US MEN QU RE CU DO

398 LU Authorization Period: 1 year. CONJUGATED ESTROGENS 0.3mg 0.625mg 1.25mg Reason for Use code 398 Tab Tab Tab Clinical criteria 02043394 00265470 02043408 00265489 02043424 Premarin C.E.S. Premarin C.E.S. Premarin
Reason for Use code
Clinical criteria For short-term use in women who are experiencing symptoms of menopause. Note: Recent evidence has demonstrated that use of hormone replacement therapy (HRT) increases the rate of coronary events, breast cancer, dementia, stroke, venous thromboembolism and referrals for abnormal vaginal bleeding. These risks should be discussed with patients and reviewed periodically.

For short-term use in women who are experiencing symptoms of menopause. Note: Recent evidence has demonstrated that use of hormone replacement therapy (HRT) increases the rate of coronary events, breast cancer, dementia, stroke, venous thromboembolism and referrals for abnormal vaginal bleeding. These risks should be discussed with patients and reviewed periodically.
XII.32
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
CYCLOSPORINE 10mg 25mg 50mg 100mg 100mg/mL Reason for Use code 177
Cap Cap Cap Cap O/L Clinical criteria
02237671 02150689 02247073 02150662 02247074 02150670 02242821 02150697
Neoral Neoral Sandoz Cyclosporine Neoral Sandoz Cyclosporine Neoral Sandoz Cyclosporine Neoral

LU Authorization Period: Indefinite. 178 LU Authorization Period: Indefinite. DALTEPARIN SODIUM 2500IU/0.2mL 5000IU/0.2mL 10000IU/0.4mL 12500IU/0.5mL 15000IU/0.6mL 18000IU/0.72mL 10000IU/mL 25000IU/mL Reason for Use code 186 Inj Pref Syr Inj Pref Syr Inj Pref Syr Inj Pref Syr Inj Pref Syr Inj Pref Syr Inj Sol-1mL Pk Multidose 3.8mL Pk Clinical criteria 02132621 02132648 09853790 09853820 09853880 09853910 02132664 02231171 Fragmin Fragmin Fragmin Fragmin Fragmin Fragmin Fragmin Fragmin
For the treatment of psoriasis in patients who have failed, or are intolerant to, other systemic therapies, including methotrexate, acitretin or PUVA;
For the treatment of rheumatoid arthritis in patients who have failed, or are intolerant to, other systemic therapies, including Disease-Modifying Antirheumatic Drugs (DMARDs).
ED ON T TI D MI SE TA RE LI U EN UI UM REQ OC D
LU Authorization Period: 1 year. 187 For DVT in pregnant or lactating females; LU Authorization Period: 1 year. 188 LU Authorization Period: 1 year. 189 LU Authorization Period: 1 year.
For acute treatment of deep venous thrombosis (DVT), for a maximum of three weeks;
For DVT in patients whom treatment with warfarin is not tolerated, or contraindicated;
For DVT in patients who have failed treatment with warfarin.
XII.33
DOSAGE FORM
DIN
BRAND NAME
DELTA-9-TETRAHYDROCANNABINOL 2.5mg Cap 5mg Cap Reason for Use code 40 Clinical criteria
00611190 Marinol 00611204 Marinol
ED T E ON TI MI S LI U TA ED EN IR UM EQU OC R D
LU Authorization Period: 1 year. 345 LU Authorization Period: 1 year. DEXTRAN 70 & HYDROXYPROPYL METHYLCELLULOSE 0.1%/0.3% Oph-Sol 00390291 Tears Naturale Reason for Use code 49
For the treatment of emesis associated with cancer chemotherapy in patients who are unresponsive to conventional antiemetic therapy: Initial dose -5mg/m.sq. given 1 to 3 hours before administration of chemotherapy; Repeat doses -5mg/m.sq. every 2 to 4 hours after chemotherapy as needed, usually for 1 to 2 days: no more than 4 to 6 doses should be given in a single day.
For the treatment of AIDS-related anorexia associated with weight loss and prescription is from a prescriber approved for the Facilitated Access mechanism (see Part VI of the Formulary/CDI binder)
ION AT IRED D ITE USE MENT QU LIM U RE OC LU Authorization Period: Indefinite. D

Clinical criteria
Clinical criteria
DEXTRAN 70 & HYDROXYPROPYL METHYLCELLULOSE & POLYQUAD 0.1%/0.3%/0.001% Oph-Sol 00743445 Tears Naturale II Reason for Use code 49
N TIO ED A D ITE USE MENT QUIR LIM U RE OC Period: Indefinite. LU Authorization D
XII.34
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
DIPHENOXYLATE HYDROCHLORIDE & ATROPINE SULFATE 2.5mg & 0.025mg Tab 00036323 Lomotil
ED T E ON I TI M S LI U TA EN ED M R CU UI O EQ D R
For the treatment of diarrhea associated with: 110 An ileostomy or a colostomy; LU Authorization Period: 1 year. 111 Bowel resection, including short bowel syndrome; LU Authorization Period: 1 year. 112 LU Authorization Period: 1 year. 113 Cancer, including chemotherapy or radiation therapy; LU Authorization Period: 1 year. 114 HIV/AIDS; LU Authorization Period: 1 year. 115 LU Authorization Period: 1 year. 224 Fecal incontinence. LU Authorization Period: 1 year. DIPYRIDAMOLE & ACETYLSALICYLIC ACID 200mg/25mg Cap Reason for Use code Clinical criteria 02242119 Aggrenox
Reason for Use code
Clinical criteria
Inflammatory Bowel Diseases, i.e. Crohns Disease and Ulcerative Colitis;
Acute diarrhea in patients in congregated housing, i.e. Long Term Care Facilities (LTCF), or for patients receiving Home Care;
ION AT ED 349 secondaryNT IT For the SE UI of E preventionR stroke. U Q LIM UM RE OC LU Authorization Period: Indefinite. D ED
JUNE 27, 2008
XII.35
DOSAGE FORM
DIN
BRAND NAME
DOLASETRON MESYLATE 50mg 100mg Reason for Use code 229
Tab Tab
02231378 Anzemet 02231379 Anzemet
Clinical criteria For the treatment of emesis in cancer patients receiving highly emetogenic chemotherapy. LU Authorization Period: 1 year.
ED ON T TI D MI SE LI U TA IRE EN U UM REQ OC D
230 LU Authorization Period: 1 year. 231 LU Authorization Period: 1 year. DONEPEZIL HCL 5mg 10mg Reason for Use code 347 Tab Tab Clinical criteria 02232043 Aricept 02232044 Aricept
For patients receiving intravenous chemotherapy who have not experienced adequate control with other available anti-emetics.
For patients receiving intravenous chemotherapy who experience intolerable side effects with other anti-emetics. NOTE: The therapeutic value of Anzemet more than 24 hours after the last dose of chemotherapy is unproven.
ED ION IT E AT ED IM S L NT IR U ME EQU CU R DO
NETWORK NOTE: Maximum duration 3 months. LU Authorization Period: 1 year. 348 LU Authorization Period: 1 year.
XII.36
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
DORZOLAMIDE HCL 2% Reason for Use code 171
Oph Sol Clinical criteria
02216205 Trusopt
ED IT E ON TI D IM S L U ENTA IRE UM EQU R OC D

LU Authorization Period: Indefinite. 172 LU Authorization Period: Indefinite. 387 LU Authorization Period: Indefinite. DORZOLAMIDE HCL & TIMOLOL MALEATE 2% & 0.5% Oph Sol Reason for Use code 310 Clinical criteria 02240113 Cosopt

JUNE 27, 2008
XII.37
DOSAGE FORM
DIN
BRAND NAME
DUTASTERIDE 0.5mg Reason for Use Code 384
Cap Clinical criteria
02247813 Avodart
ED T E ON TI MI S I U L TA D EN RE UM QUI C E DO R
For use in combination with an alpha blocker for the treatment of men with symptomatic* Benign Prostatic Hyperplasia.
For monotherapy, as a second line agent in patients with symptomatic* Benign Prostatic Hyperplasia following treatment failure or intolerance to an alpha blocker. * Symptomatic is defined as having moderate (about half the time) to severe (almost always) symptoms related to the prostate in at least 4 of the following domains: 1. feeling of incomplete emptying of the bladder after voiding 2. needing to urinate again less than 2 hours after previous void 3. stopping and starting urine several times while voiding 4. difficulty postponing urination 5. weak urinary stream 6. pushing or straining to begin voiding 7. the need to get up to void at least 3 times in the night.
XII.38
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
ENOXAPARIN 100mg/mL 30mg/0.3mL 40mg/0.4mL 60mg/0.6mL 80mg/0.8mL 120mg/0.8mL 100mg/mL 150mg/mL Reason for Use Code 186
Inj Sol-3mL Vial Pk Pref Syr-0.3mL Pk Pref Syr-0.4mL Pk Pref Syr-0.6mL Pk Pref Syr-0.8mL Pk Pref Syr-0.8mL Pk Pref Syr-1mL Pk Pref Syr-1mL Pk Clinical criteria
02236564 02012472 02236883 09852468 09852476 09857137 09852484 02242692
Lovenox Lovenox Lovenox Lovenox Lovenox Lovenox HP Lovenox Lovenox HP
ED T E ON TI MI S LI U TA ED EN IR UM QU OC RE D
LU Authorization Period: 1 year. 187 For DVT in pregnant or lactating females; LU Authorization Period: 1 year. 188 LU Authorization Period: 1 year. 189 LU Authorization Period: 1 year. 323 LU Authorization Period: 1 year. ENTACAPONE 200mg Reason for Use Code 367 Tab Clinical criteria 02243763 Comtan
For DVT in patients whom treatment with warfarin is not tolerated, or contraindicated;
For DVT in patients who have failed treatment with warfarin.
For the acute treatment of pulmonary embolism, maximum of three weeks.
N TIO ED A D ITE USE MENT QUIR LIM U RE OC LU Authorization Period: Indefinite. D
For the treatment of patients with Parkinsons disease with 25% of the waking day in the off state despite maximally tolerated doses of levodopa.
JUNE 27, 2008
XII.39
DOSAGE FORM
DIN
BRAND NAME
ESTROPIPATE (CALCULATED AS SODIUM ESTRONE SULFATE 1.25MG) 1.5mg Tab 02089769 Ogen 1.25
D ION D AT IRE ITE E NT U IM US L ME EQ R CU O D

398 LU Authorization Period: 1 year. ESTROPIPATE (CALCULATED AS SODIUM ESTRONE SULFATE 2.5MG) 3mg Tab 02089777 Ogen 2.5 Reason for Use code 398 Clinical criteria
Reason for Use code
Clinical criteria For short-term use in women who are experiencing symptoms of menopause. Note: Recent evidence has demonstrated that use of hormone replacement therapy (HRT) increases the rate of coronary events, breast cancer, dementia, stroke, venous thromboembolism and referrals for abnormal vaginal bleeding. These risks should be discussed with patients and reviewed periodically.

For short-term use in women who are experiencing symptoms of menopause. Note: Recent evidence has demonstrated that use of hormone replacement therapy (HRT) increases the rate of coronary events, breast cancer, dementia, stroke, venous thromboembolism and referrals for abnormal vaginal bleeding. These risks should be discussed with patients and reviewed periodically.
XII.40
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
ETIDRONATE DISODIUM 200mg
Tab
01997629 Didronel 02245330 Gen-Etidronate 02248686 Co-Etidronate
Clinical criteria For the treatment of Pagets disease;
N TIO ED A D Authorization Period: Indefinite. ITE LU SE MENT QUIR U M LI237 U For the management of hypercalcemia of malignancy. RE OC D LU Authorization Period: Indefinite.
Tab Clinical criteria For the hormonal treatment of metastatic breast cancer in hormone receptor positive post-menopausal women who have disease progression following tamoxifen therapy. LU Authorization Period: Indefinite. For the sequential treatment of postmenopausal women with estrogen receptor-positive early breast cancer who have received 2-3 years of initial adjuvant tamoxifen therapy. LU Authorization Period: Treatment period required to complete a total of 5 years of adjuvant therapy. 02242705 Aromasin
EXEMESTANE 25mg Reason for Use Code 180
D ON D I ITE E AT IRE NT U LIM US ME EQ R CU O D

407
JUNE 27, 2008
XII.41
DOSAGE FORM
DIN
BRAND NAME
EZETIMIBE 10mg Reason for Use Code 380
Tab Clinical criteria
02247521 Ezetrol
ED ON D IT E TI E LIM US ENTA UIR UM REQ OC D

LU Authorization Period: Indefinite. 381 LU Authorization Period: Indefinite. FAMCICLOVIR 500mg Tab 02177102 02278111 02278650 02292068
For use in combination with a HMG-CoA reductase inhibitor (statin) in patients with hypercholesterolemia who have not reached target LDL levels despite the use of maximally tolerated doses. For use as monotherapy in the management of hypercholesterolemia in patients who are intolerant to HMG-CoA reductase inhibitors or where HMG-CoA reductase inhibitors are contraindicated.
Famvir PMS-Famciclovir Sandoz Famciclovir Apo-Famciclovir
ON D D I TE E AT IRE NT U IMI US L ME EQ R CU O D
147 LU Authorization Period: 1 year.
Reason for Use code
Clinical criteria Herpes zoster in patients 50 years of age or older, up to 72 hours* after appearance of lesions. Dose: 500mg 3 times/day for 7 days. *The patient must begin treatment within the time frame specified for the product to be reimbursed. There is no benefit from the therapy begun after this time frame. NETWORK NOTE: Network will limit supply to 7 days and 21 tablets.
XII.42
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
FENTANYL TRANSDERMAL SYSTEM 25mcg/hr Trans Patch 50mcg/hr 75mcg/hr 100mcg/hr Trans Patch Trans Patch Trans Patch
01937383 02249391 02282941 01937391 02249413 02282968 01937405 02249421 02282976 01937413 02249448 02282984
Duragesic 25 Ran-Fentanyl Ratio-Fentanyl Duragesic 50 Ran-Fentanyl Ratio-Fentanyl Duragesic 75 Ran-Fentanyl Ratio-Fentanyl Duragesic 100 Ran-Fentanyl Ratio-Fentanyl
Reason for Use code
N TIO in ED who cannot tolerate, A 201 For treatment of chronic pain R patients ED theSE I NT treatment a listed U MIT or have failedUME withQU long-acting opioid. I L RE C LU Authorization Period: 1 year. DO
Clinical criteria
JUNE 27, 2008
XII.43
DOSAGE FORM
DIN
BRAND NAME
FINASTERIDE 5mg Reason for Use Code 384
02010909 Proscar
ED N T E TIO MI S LI U TA D EN IRE UM QU C E DO R
LU Authorization Period: Indefinite. 385 LU Authorization Period: Indefinite. FLUCONAZOLE 150mg Cap 02141442 02241895 02243645 02245697 02282348
For use in combination with an alpha blocker for the treatment of men with symptomatic* Benign Prostatic Hyperplasia. For monotherapy, as a second line agent in patients with symptomatic* Benign Prostatic Hyperplasia following treatment failure or intolerance to an alpha blocker. * Symptomatic is defined as having moderate (about half the time) to severe (almost always) symptoms related to the prostate in at least 4 of the following domains: 1. feeling of incomplete emptying of the bladder after voiding 2. needing to urinate again less than 2 hours after previous void 3. stopping and starting urine several times while voiding 4. difficulty postponing urination 5. weak urinary stream 6. pushing or straining to begin voiding 7. the need to get up to void at least 3 times in the night.
Diflucan-150 Apo-Fluconazole-150 Novo-Fluconazole-150 Gen-Fluconazole PMS-Fluconazole
Clinical criteria For the treatment of vaginal candidiasis. Dose: 150mg orally once daily for 1 day.
ION AT IRED D ITE USE MENT QU NOTE: Repeats within a 25 day period will not be reimbursed. LIM U RE OC LU D Authorization Period: 1 year.
XII.44
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
FLUCONAZOLE 10mg/mL Reason for Use code 274
O/L Clinical criteria
02024152 Diflucan P.O.S.
ED IT E N IM S IO L U TAT N E M ED U C IR O QU D E R
LU Authorization Period: 1 year. 275 For the treatment of patients with disseminated candidiasis when oral tablets of fluconazole cannot be tolerated. NETWORK NOTE: For disseminated candidiasis, network will limit supply to 6 weeks. LU Authorization Period: 1 year. 276 For the treatment of patients with cryptococcal meningitis when oral tablets of fluconazole cannot be tolerated. LU Authorization Period: 1 year. 277 For the treatment of patients with vulvovaginal candidiasis when oral tablets of fluconazole cannot be tolerated. LU Authorization Period: 1 year.
For the treatment of oral/esophageal candidiasis in immunocompromised patients (e.g. patients with malignancies and transplant patients) who have failed to respond to nystatin or imidazoles and when oral tablets of fluconazole cannot be tolerated.
NETWORK NOTE: For oral candidiasis, network will limit supply to 2 weeks. For esophageal candidiasis, network will limit supply to 6 weeks.
NETWORK NOTE: For cryptococcal meningitis (initial treatment), network will limit supply to 12 weeks.
NETWORK NOTE: For vulvovaginal candidiasis, network will limit supply to one dose 150mg (Repeats no more than every 25 days).
JUNE 27, 2008
XII.45
DOSAGE FORM
DIN
BRAND NAME
FLUCONAZOLE 50mg
Tab
100mg
Tab
02236978 02237370 02245292 02245643 02249294 02281260 02236979 02237371 02245293 02245644 02249308 02281279
Novo-Fluconazole Apo-Fluconazole Gen-Fluconazole PMS-Fluconazole Taro-Fluconazole Co Fluconazole Novo-Fluconazole Apo-Fluconazole Gen-Fluconazole PMS-Fluconazole Taro-Fluconazole Co Fluconazole
Clinical criteria For the treatment of thrush in immunocompromised patients (i.e. patients with malignancies and transplant recipients) who are unresponsive to nystatin or imidazole preparations; LU Authorization Period: 1 year. For the treatment of oroesophageal candidiasis in immunocompromised patients (i.e. patients with malignancies and transplant recipients); LU Authorization Period: 1 year. LU Authorization Period: 1 year. LU Authorization Period: 1 year. For patients with disseminated candidiasis;
203 204 205 For the treatment of acute cryptococcal meningitis. FLUDARABINE PHOSPHATE 10mg Reason for Use code Tab 02246226 Fludara Clinical criteria
ION D D second line therapy AT E 379 For of patients with chronic lymphocytic ITE leukemiaE who NT failedUIR intolerant to chlorambucil. S (CLL) ME have Q or are U LIM U RE LU Authorization Period: Indefinite. OC D
XII.46
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
FLUNARIZINE HCL 5mg Reason for Use code 60
Cap Clinical criteria
00846341 Sibelium 02246082 Apo-Flunarizine
ED ON IT E TI D IM S TA RE L U MEN UI CU REQ DO
LU Authorization Period: 1 year. 61 For patients who have tried propranolol and experienced significant adverse effects. LU Authorization Period: 1 year. For patients in whom propranolol is contraindicated. 62 LU Authorization Period: 1 year. FONDAPARINUX SODIUM 2.5mg Reason for Use code 378 Inj-0.5mL Pk 02245531 Arixtra Clinical criteria
For patients with migraine headaches who have not responded to propranolol.
CAUTION: Contraindicated in patients with clinical depression and in patients with extrapyramidal disorders.
N TIO ED D TA ITE USE EN QUIR M LIM E NOTE: Limited to R 9 days of reimbursement. CU O D LU Authorization Period: 1 year.
Inh Pd-Device Pk
For the post-operative prophylaxis of venous thromboembolic events in patients undergoing orthopedic surgery of the lower limbs such as hip fracture, hip replacement or knee surgery.
FORMOTEROL FUMARATE 12mcg/Cap Reason for Use code 132
02230898 Foradil
Clinical criteria
LIM
IT
ED
N TIO ED A SE MENT QUIR U U RE NOTE: This drug is not for relief of acute symptoms. OC D LU Authorization Period: Indefinite.
JUNE 27, 2008
XII.47
DOSAGE FORM
DIN
BRAND NAME
FORMOTEROL FUMARATE DIHYDRATE 6mcg/Metered Dose Pd Inh-60 Dose Pk 12mcg/Metered Dose Pd Inh-60 Dose Pk Reason for Use code 132 Clinical criteria
02237225 Oxeze Turbuhaler 02237224 Oxeze Turbuhaler
N TIO ED D TA ITE USE EN QUIR M LIM RE CU NOTE: This drug is not for relief of acute symptoms. O D LU Authorization Period: Indefinite.
FUROSEMIDE 500mg Reason for Use code 33
02224755 Lasix Special
ION D E For TAT ED patients with severely Iimpaired renal function refractory to E IT conventional dosages QU R drug. US UMEN E of the LIM R C DO LU Authorization Period: Indefinite.
XII.48
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
GABAPENTIN 100mg
Cap
300mg
Cap
400mg
Cap
02084260 02243446 02244304 02244513 02248259 02256142 02260883 02084279 02243447 02244305 02244514 02248260 02256150 02260891 02084287 02243448 02244306 02244515 02248261 02256169 02260905
Neurontin PMS-Gabapentin Apo-Gabapentin Novo-Gabapentin Gen-Gabapentin Co-Gabapentin Ratio-Gabapentin Neurontin PMS-Gabapentin Apo-Gabapentin Novo-Gabapentin Gen-Gabapentin Co-Gabapentin Ratio-Gabapentin Neurontin PMS-Gabapentin Apo-Gabapentin Novo-Gabapentin Gen-Gabapentin Co-Gabapentin Ratio-Gabapentin
Clinical criteria
As adjunctive therapy in the treatment of seizure disorders where ION D Dcontrol by other listed anticonvulsants has been unsatisfactory. ITE Note: Because a large number of IRE may become refractory TAT patients E N to U Ethis effects of be drug over a after a period the LIM USthe anticonvulsantdrug must there-evaluated period of time,of six M effectiveness of EQ U R months. OC D LU Authorization Period: Indefinite.
JUNE 27, 2008
XII.49
DOSAGE FORM
DIN
BRAND NAME
GALANTAMINE HYDROBROMIDE 8mg ER Cap 16mg ER Cap 24mg ER Cap Reason for Use code 347 Clinical criteria
02266717 Reminyl ER 02266725 Reminyl ER 02266733 Reminyl ER
ED ON IT E TI D IM S TA RE L U MEN UI CU REQ DO
NETWORK NOTE: Maximum duration 3 months. LU Authorization Period: 1 year. 348 LU Authorization Period: 1 year. GANCICLOVIR SODIUM 500mg/Vial Reason for Use code 12 Pd Inj-10mL Pk Clinical criteria 02162695 Cytovene
N TIO ED D theE For treatment TACMV retinitis secondary to AIDS and other of IR ITE immunosuppressive syndromes. US UMEN EQU LIM R C LU Authorization Period: 1 year. DO
XII.50
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
GRANISETRON HCL 1mg Reason for Use code 91
02185881 Kytril
ED T E ON TI MI S I U L TA EN ED UM UIR C Q DO RE
LU Authorization Period: 1 year. 92 LU Authorization Period: 1 year. 93 LU Authorization Period: 1 year. 326 LU Authorization Period: 1 year. INSULIN ASPART 100U/mL 100U/mL Reason for Use Code 388 389 Inj Sol-10mL Pk Inj Sol-5x3mL Pk Clinical criteria
For the treatment of emesis in cancer patients receiving highly emetogenic chemotherapy. For patients receiving intravenous chemotherapy or radiation therapy who have not experienced adequate control with other available anti-emetics. For patients receiving intravenous chemotherapy or radiation therapy who experience intolerable side effects with other antiemetics. For the treatment of emesis in patients receiving radiation therapy which consists of single fraction treatment to the abdominal cavity, hemi-body irradiation and total body irradiation. NOTE: The therapeutic value of Kytril more than 24 hours after the last dose of chemotherapy is unproven.
02245397 NovoRapid 02244353 NovoRapid Penfill

LU Authorization Period: Indefinite. LU Authorization Period: Indefinite. 390 LU Authorization Period: Indefinite.
For the treatment of patients with Type 1 diabetes mellitus. For the treatment of patients with Type 2 diabetes mellitus using insulin in an intensive regimen with 3 or more injections per day or an insulin pump. For the treatment of patients with Type 2 diabetes mellitus who are either experiencing recurrent hypoglycemia OR are unable to achieve adequate post-prandial glucose control while on a less intensive regimen of regular insulin (1-2 injections per day).
XII.51
DOSAGE FORM
DIN
BRAND NAME
INSULIN LISPRO 100U/mL 100U/mL Reason for Use code 388 389
Inj Sol-10mL Pk Inj Sol-5x3mL Pk Clinical criteria
02229704 Humalog 09853715 Humalog

LU Authorization Period: Indefinite. LU Authorization Period: Indefinite. 390 LU Authorization Period: Indefinite. Reason for Use code 226 Clinical criteria
For the treatment of patients with Type 1 diabetes mellitus. For the treatment of patients with Type 2 diabetes mellitus using insulin in an intensive regimen with 3 or more injections per day or an insulin pump. For the treatment of patients with Type 2 diabetes mellitus who are either experiencing recurrent hypoglycemia OR are unable to achieve adequate post-prandial glucose control while on a less intensive regimen of regular insulin (1-2 injections per day).
INSULIN LISPRO & INSULIN LISPRO PROTAMINE 25% & 75% Inj Susp-5x3mL Pk 02240294 Humalog Mix25
N TIO ED A D ITE USE MENT QUIR LIM U RE OC D LU Authorization Period: Indefinite.
For insulin requiring diabetic patients who are either experiencing recurrent hypoglycemia OR are unable to achieve adequate postprandial glucose control while using 2 or more doses of mixed insulin per day.
XII.52
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
INTERFERON ALFA-2B 15mu/mL 25mu/mL 50mu/mL Reason for Use code 28
18mu MD Pen Kit 30mu MD Pen Kit 60mu MD Pen Kit Clinical criteria For hairy cell leukemia.
02240693 Intron A 02240694 Intron A 02240695 Intron A
N TIO ED A D Authorization Period: Indefinite. ITE LUSE MENT QUIR U LIM U 29 For Kaposis Sarcoma. RE OC D LU Authorization Period: Indefinite.
Inh Sol-20mL Pk 02097141 Ratio-Ipratropium 02126222 Apo-Ipravent Inhalation Solution 02210479 Novo-Ipramide 02231136 PMS-Ipratropium 02239131 Gen-Ipratropium
IPRATROPIUM BROMIDE 250mcg/mL
ED IT E ON TI IM S L TA ED U EN IR UM QU C O RE D
256 Patients who have a tracheostomy; LU Authorization Period: Indefinite. 257 Patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. 258 Patients with severe mental or physical disabilities; LU Authorization Period: Indefinite. 259 LU Authorization Period: Indefinite.
Reason for Use code
Clinical criteria For the vast majority of patients, a metered dose inhaler is the preferred therapy. Nebulizer therapy will be reimbursed for patients who are unable to use a metered dose inhaler, including an inhaler with a spacer attachment, or a turbuhaler.
JUNE 27, 2008
XII.53
DOSAGE FORM
DIN
BRAND NAME
IPRATROPIUM BROMIDE 125mcg/mL 250mcg/mL
Inh Sol-2mL UDV Pk Inh Sol-2mL UDV Pk
02097176 Ratio-Ipratropium UDV 02231135 PMS-Ipratropium 02097168 Ratio-Ipratropium UDV 02216221 Gen-Ipratropium 02231245 PMS-Ipratropium
Reason for Use code
ED IT E ON IM US TI L TA D EN RE M UI CU EQ DO R
265 LU Authorization Period: Indefinite. 266 LU Authorization Period: Indefinite. 267 LU Authorization Period: Indefinite. 268 LU Authorization Period: Indefinite. IPRATROPIUM BROMIDE 0.03% Nasal Spray 02163705 Atrovent 02239627 PMS-Ipratropium 02246083 Apo-Ipravent Reason for Use code 03
Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have a tracheostomy; Individuals must have a known hypersensitivity to the preservative in the bulk solution, and be patients with cystic fibrosis in whom nebulizer therapy is indicated; Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have severe mental or physical disabilities; Patients who have previously used nebulizer therapy within the last 12 month period.
ION AT IRED IT For theSE MENT QU U treatment of non-allergic vasomotor rhinitis LIM RE CU LU Authorization Period: 1 year. DO ED
Clinical criteria
XII.54
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
IPRATROPIUM BROMIDE/SALBUTAMOL 500mcg/2.5mg/2.5mL Inh Sol-2.5mL Pk
02231675 Combivent UDV 02243789 Ratio-IPRA SAL UDV 02266393 Apo-Salvent Ipravent Sterules 02272695 Gen-Combo Sterinebs
Reason for Use code
Clinical criteria For the vast majority of patients, a metered dose inhaler is the preferred therapy. Nebulizer therapy will be reimbursed for patients who are unable to use a metered dose inhaler, including an inhaler with a spacer attachment, or a turbuhaler. LU Authorization Period: Indefinite.
N ED IO IT E IM US NTAT D L E IRE UM QU OC RE D
256 257 Patients who have a tracheostomy; Patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. LU Authorization Period: Indefinite. Patients with severe mental or physical disabilities; 258 259 Patients who have previously used nebulizer therapy within the last 12 month period. LU Authorization Period: Indefinite. ISOPROTERENOL HCL 0.5% Reason for Use code Inh Sol-10mL Pk Clinical criteria 02017652 Isuprel
ED N T E I IO IM US TAT L EN IRED UM QU C E DO R
260 261 262 Children aged 6 years or less; LU Authorization Period: Indefinite. LU Authorization Period: Indefinite. Patients who have a tracheostomy; Patients with cystic fibrosis in whom nebulizer therapy is indicated; LU Authorization Period: Indefinite. LU Authorization Period: Indefinite. Patients with severe mental or physical disabilities; 263 264 LU Authorization Period: Indefinite.
JUNE 27, 2008
XII.55
DOSAGE FORM
DIN
BRAND NAME
LAMOTRIGINE 25mg
Tab
100mg
Tab
150mg
Tab
02142082 02243352 02245208 02246897 02248232 02265494 02142104 02243353 02245209 02246898 02248233 02265508 02142112 02245210 02246899 02246963 02248234 02265516
Lamictal Ratio-Lamotrigine Apo-Lamotrigine PMS-Lamotrigine Novo-Lamotrigine Gen-Lamotrigine Lamictal Ratio-Lamotrigine Apo-Lamotrigine PMS-Lamotrigine Novo-Lamotrigine Gen-Lamotrigine Lamictal Apo-Lamotrigine PMS-Lamotrigine Ratio-Lamotrigine Novo-Lamotrigine Gen-Lamotrigine
Clinical criteria
ION seizure disorders where DAs adjunctive therapy in the treatment of D unsatisfactory. control by other listed anticonvulsants has been T ITE Note: Because a large number of IRE may become refractory patients E anticonvulsantTA of the drug over a period of time, the to EN effects U LIM USthe Mof this drug must be re-evaluated after a period of six Q effectiveness U RE C months. DOAuthorization Period: Indefinite. LU
XII.56
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
LANSOPRAZOLE 15mg 30mg

Reason for Use code
DR Cap DR Cap
02165503 Prevacid 02165511 Prevacid
Clinical criteria
ED IT E N IM S IO L U TAT EN D UM IRE C DO EQU R

293 Patients with GERD should be reassessed within 6 months after initial treatment with a PPI. The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or stepdown therapy to H2-receptor antagonist therapy. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year. 295 H. pylori-positive Peptic Ulcers For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a one-week course in combination with antimicrobial therapy. Retreatment of H. pyloripositive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy. Maximum duration: 7 days (for retreatment, a four-week period must elapse since the end of the previous treatment). LU Authorization Period: 1 Year. 297 Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis: For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year. 401 Other Gastrointestinal Disorders For the treatment of gastroduodenal Crohns disease, short-gut syndrome, scleroderma, or pancreatitis. Note: There is a lack of published evidence to support double-dose PPI therapy in these settings. LU Authorization Period: 1 Year.
JUNE 27, 2008
XII.57
DOSAGE FORM
DIN
BRAND NAME
LANSOPRAZOLE (contd)
Reason for Use code Clinical criteria
ED T ION D IMI SE AT IRE L NT U U ME EQ R CU O D

402 LU Authorization Period: 1 Year. LANSOPRAZOLE & CLARITHROMYCIN & AMOXICILLIN 30mg & 500mg & 500mg Tab/Cap Pk 02238525 Hp-PAC Reason for Use code 306 Clinical criteria
ED ON IT E TI M S LI U TA EN ED UM UIR OC EQ D R
LU Authorization Period: 1 Year. 307 LU Authorization Period: 1 Year.
a) For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, breath test or endoscopy, for a one-week course. Maximum duration: 7 days b) For the retreatment of H. pylori-positive peptic ulcers where H. pylori recurrence or persistence is documented, by breath test or endoscopy, for a one-week course. Maximum duration: 7 days (after a four-week period has elapsed since the end of the previous treatment)
Retreatment decisions should be based upon positive symptoms and positive endoscopy or positive urea breath test. Retreatment should not be based on a positive serology test, as serology tests may remain positive indefinitely. An alternative antibiotic regimen is recommended when initial therapy fails due to concerns of antimicrobial resistance. Network Note: Network will limit supply to 7 days. Network will verify that retreatments are reimbursed only after a four-week period has elapsed since the end of the previous treatment.
XII.58
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
LATANOPROST 0.005% Reason for Use code 171
Oph Sol-2.5mL Pk Clinical criteria
02231493 Xalatan
ED IT E ON TI D IM S L U ENTA IRE UM EQU OC R D

LU Authorization Period: Indefinite. 172 LU Authorization Period: Indefinite. 387 LU Authorization Period: Indefinite. LATANOPROST & TIMOLOL MALEATE 50mcg/mL & 5mg/mL Oph Sol-2.5mL Pk Reason for Use code 310 Clinical criteria
02246619 Xalacom

JUNE 27, 2008
XII.59
DOSAGE FORM
DIN
BRAND NAME
LEFLUNOMIDE 10mg
Tab
20mg
Tab
02241888 02256495 02261251 02283964 02288265 02241889 02256509 02261278 02283972 02288273
Arava Apo-Leflunomide Novo-Leflunomide Sandoz Leflunomide PMS-Leflunomide Arava Apo-Leflunomide Novo-Leflunomide Sandoz Leflunomide PMS-Leflunomide

Clinical criteria
For the treatment of rheumatoid arthritis in patients who have failed, or are intolerant to, one or more of the listed DiseaseModifying Anti-Rheumatic Drugs (DMARDs).
LETROZOLE 2.5mg Reason for Use code 365
02231384 Femara
ED ON IT E TI D IM US NTA E L E UIR UM EQ R OC D
LU Authorization Period: Indefinite. 403 LU Authorization Period: 5 years. 408 LU Authorization Period: 5 years.
For the treatment of metastatic breast cancer in hormone receptor positive post-menopausal women.
For the treatment of hormone receptor positive early breast cancer in postmenopausal women who have received 5 years of adjuvant tamoxifen therapy.
As an alternative to tamoxifen for the adjuvant treatment of postmenopausal women with hormone receptor positive early breast cancer for a maximum of five years.
XII.60
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
LEVODOPA & CARBIDOPA 100mg & 25mg 200mg & 50mg Reason for Use code 64
Tab Tab
02028786 Sinemet CR 00870935 Sinemet CR 02245211 Apo-Levocarb CR
Clinical criteria For patients with Parkinsons disease who have been treated with conventional therapy (Prolopa or conventional Sinemet), and experienced adverse effects related to drug level fluctuations, such as ON/OFF or wearing off phenomena. LU Authorization Period: Indefinite.
D ION D AT IRE ITE E T LIM US MEN QU RE CU DO

65 LU Authorization Period: Indefinite. LEVOFLOXACIN 250mg 500mg Reason for Use code Tab Tab Clinical criteria For the treatment of patients with: 02236841 Levaquin 02236842 Levaquin
For patients presently requiring anti-parkinsonian drug administration (levodopa/carbidopa) more than three times daily.
ED IT E ON IM US TI L TA EN ED UM IR OC QU D RE
337 CAP with co-morbidity: Community acquired pneumonia with co-morbid illnesses or failure to first-line therapy. LU Authorization Period: 1 year. 338 LU Authorization Period: 1 year. 339 LU Authorization Period: 1 year. 977 LU Authorization Period: 1 year.
COPD with risk: Acute bacterial exacerbation of chronic obstructive pulmonary disease (COPD) with risk factors*; bronchiectasis. *Risk factors include: poor pulmonary lung function (FEV1 below 50% predicted level), age over 65 years, co-morbid medical illness (congestive heart failure, diabetes, chronic renal failure, chronic liver disease), chronic corticosteroid use, malnutrition, prolonged duration of disease, or 4 or more exacerbations per year.
Step-Down: Step-down therapy after parenteral therapy or hospital / emergency department discharge.
Exceptional cases of allergy or intolerance to all other appropriate therapies.
XII.61
DOSAGE FORM
DIN
BRAND NAME
LINEZOLID 600mg Reason for Use code
02243684 Zyvoxam
ED N T E TIO MI S LI U TA D EN IRE UM QU C E DO R
For the treatment of patients with: 362 LU Authorization Period: 1 year. 363 LU Authorization Period: 1 year. 364 LU Authorization Period: 1 year.
Methicillin-resistant Staphylococcus species (MRSA, MRSE) infections* in patients who are intolerant or have failed vancomycin therapy, or have contraindications to venous access.
Vancomycin resistant Enterococcus species (VRE) infections* in patients switching from IV linezolid.
Step-down therapy for the treatment of methicillin-resistant Staphylococcus species or vancomycin resistant Enterococcus species (VRE) infections* after parenteral therapy or hospital/ emergency department discharge. * Infections must be documented and culture proven. Not approved for colonization (e.g. nares, urine, etc). Maximum 28 days supply.
XII.62
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
LOPERAMIDE HCL 2mg
Caplet
00860743 02132591 02212005 02228351 02257564
Imodium Novo-Loperamide Apo-Loperamide PMS-Loperamide Sandoz Loperamide
Reason for Use code
Clinical criteria For the treatment of diarrhea associated with:
ED IT E ON IM US TI L TA EN ED UM IR OC QU D RE
110 An ileostomy or a colostomy; LU Authorization Period: 1 year. 111 Bowel resection, including short bowel syndrome; LU Authorization Period: 1 year. 112 LU Authorization Period: 1 year. 113 Cancer, including chemotherapy or radiation therapy; LU Authorization Period: 1 year. 114 HIV/AIDS; LU Authorization Period: 1 year. 115 LU Authorization Period: 1 year. 224 Fecal incontinence. LU Authorization Period: 1 year.
Inflammatory Bowel Diseases, i.e. Crohns Disease and Ulcerative Colitis;
Acute diarrhea in patients in congregated housing, i.e. Long Term Care Facilities (LTCF), or for patients receiving Home Care;
JUNE 27, 2008
XII.63
DOSAGE FORM
DIN
BRAND NAME
MEPERIDINE HCL 50mg Reason for Use code
02138018 Demerol
ION D TAT ED E 2 weeks supply forRE pain. I 270 T LimitedS U to UMEN EQU acute IMI L R C LU Authorization Period: 1 year. DO
Oph-Sol Oph-Sol Clinical criteria 00000809 Isopto Tears 00000817 Isopto Tears
METHYLCELLULOSE 0.5% 1% Reason for Use code
ION D Tevidence of keratoconjunctivitis sicca 49 For A D patients with objective IRE ITE as confirmed by filamentary keratopathy on slit lamp examination SE MENT QU U or biopsy. U LIM RE OC LU Authorization Period: Indefinite. D
Tab Tab Clinical criteria 01934392 02278677 01934406 02278685 Amatine Apo-Midodrine Amatine Apo-Midodrine
MIDODRINE HCL 2.5mg 5mg Reason for Use code 01
For the treatment of patients disabled by moderate to severe I N drop in systolic BP hypotension Dneurogenic orthostatic Hg fromO (i.e.Estanding position),less or equal to 20mm A in T T supine andD ITE thanEconventional nonpharmacologicto pharmacologic (i.e. S IM Uwhom MEN haveUIR ineffective or are poorly L fludrocortisone) therapies Q proven tolerated. RE CU O DLU Authorization Period: Indefinite. Chew Tab 02243602 Singulair
MONTELUKAST SODIUM 4mg Reason for Use code
ION ED TAT ED the SE 382 UIR EN MIT For U treatment of asthma in patients aged 2-5 years old. Q M LI RE CU LU Authorization Period: 1 year. DO
Clinical criteria
XII.64
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
MOXIFLOXACIN HYDROCHLORIDE 400mg Tab Reason for Use code Clinical criteria
02242965 Avelox
ED IT E N IM S IO L U TAT N ED E UM UIR C O EQ D R
337 CAP with co-morbidity: Community acquired pneumonia with co-morbid illnesses or failure to first-line therapy. LU Authorization Period: 1 year. 338 COPD with risk: Acute bacterial exacerbation of chronic obstructive pulmonary disease (COPD) with risk factors1; bronchiectasis.
1Risk
For the treatment of patients with:
factors include: poor pulmonary lung function (FEV1 below 50% predicted level), age over 65 years, co-morbid medical illness (congestive heart failure, diabetes, chronic renal failure, chronic liver disease), chronic corticosteroid use, malnutrition, prolonged duration of disease, or 4 or more exacerbations per year. LU Authorization Period: 1 year.
339
977
MYCOPHENOLATE MOFETIL 200mg/mL Pd for Oral Susp-175mL Pk 250mg SG Cap 500mg Tab Reason for Use code Clinical criteria
02242145 CellCept 02192748 CellCept 02237484 CellCept
ION Aof IR rejection in patients receiving DFor the prophylaxis T organED 190 T E ITE allogeneic renal, cardiacU hepatic transplants. US UMEN EQ or LIM R C DO LU Authorization Period: Indefinite.
JUNE 27, 2008
XII.65
DOSAGE FORM
DIN
BRAND NAME
NADROPARIN CALCIUM 9500IU/mL 9500IU/mL 9500IU/mL 19000IU/mL 9500IU/mL 19000IU/mL 9500IU/mL 19000IU/mL Reason for Use code 186
Pref Syr-0.3mL Pk Pref Syr-0.4mL Pk Pref Syr-0.6mL Pk Pref Syr-0.6mL Pk Pref Syr-0.8mL Pk Pref Syr-0.8mL Pk Pref Syr-1.0mL Pk Pref Syr-1.0mL Pk Clinical criteria
09853936 09853944 09853952 02240114 09853979 09854100 09853987 09854118
Fraxiparine Fraxiparine Fraxiparine Fraxiparine Forte Fraxiparine Fraxiparine Forte Fraxiparine Fraxiparine Forte

LU Authorization Period: 1 year. LU Authorization Period: 1 year. 187 188 For DVT in pregnant or lactating females; LU Authorization Period: 1 year. LU Authorization Period: 1 year. 189
For DVT in patients whom treatment with warfarin is not tolerated, or contraindicated; For DVT in patients who have failed treatment with warfarin.
XII.66
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
NIMODIPINE 30mg Reason for Use code 42
SG Cap Clinical criteria
02155923 Nimotop
N As adjunctive therapy to improve the neurologic outcome following during Dsubarachnoid haemorrhage TIOthe acute management period D haemorrhage). ITE (within 4 days ofENTA UIRE E LU Authorization US UM Period: 1 year. LIM Q 43 As prophylaxis of ischemia if surgery is delayed. RE C LU Authorization Period: 1 year. DO
Oph Sol 02143291 Ocuflox 02248398 Apo-Ofloxacin 02252570 PMS-Ofloxacin
OFLOXACIN 0.3%
Clinical criteria For the treatment of conjunctivitis caused by susceptible strain(s) of Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae and Hemophilus influenzae which is/ are resistant or unresponsive to listed alternative agents.
N TIO ED A D ITE USE MENT QUIR LIM U RE OC D LU Authorization Period: 1 year.
JUNE 27, 2008
XII.67
DOSAGE FORM
DIN
BRAND NAME
OFLOXACIN 200mg 300mg 400mg Reason for Use code
Tab Tab Tab Clinical criteria
02231529 02243474 02231531 02243475 02231532 02243476
Apo-Oflox Novo-Ofloxacin Apo-Oflox Novo-Ofloxacin Apo-Oflox Novo-Ofloxacin
ED IT E N IM S IO L U TAT EN D M E U C IR DO EQU R
340 SST/BJ (Gram negative bacteria): Skin/soft tissue and bone/joint infection due to gram negative bacteria; severe diabetic foot infection. LU Authorization Period: 1 year. 341 GU Tract: Urinary tract infection / prostatitis / epididymitis; sexually transmitted disease. LU Authorization Period: 1 year. 338 COPD with risk: Acute bacterial exacerbation of chronic obstructive pulmonary disease (COPD) with risk factors1; bronchiectasis.
For the treatment of patients with:
335
GI: Travellers diarrhea; enteric fever syndromes. LU Authorization Period: 1 year.
339
977
XII.68
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
OMEPRAZOLE 20mg 20mg

Cap
02190915 02245058 02260867 02296446 09857285
Losec DR Tab Apo-Omeprazole Cap Ratio-Omeprazole DR Tab Sandoz Omeprazole Apo Omeprazole
293 Patients with GERD should be reassessed within 6 months after initial treatment with a PPI. The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or stepdown therapy to H2-receptor antagonist therapy. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year. 297 Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis: For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year. 401 Other Gastrointestinal Disorders For the treatment of gastroduodenal Crohns disease, short-gut syndrome, scleroderma, or pancreatitis. Note: There is a lack of published evidence to support double-dose PPI therapy in these settings. LU Authorization Period: 1 Year. 402 Severe Conditions: For the treatment of severe esophagitis, Zollinger-Ellison syndrome, esophageal stricture, persistent symptoms of GERD or persistent erosive esophagitis, or upon hospital discharge following a gastrointestinal bleed. For patients receiving double-dose therapy, the need to continue treatment at higher doses should be reassessed after eight weeks. For re-treatment at higher doses, a four-week period should have elapsed from the end of the previous treatment. Reassessment could include a procedural assessment of the condition or step-down therapy to lower-dose proton pump inhibitor (PPI) therapy. LU Authorization Period: 1 Year.
JUNE 27, 2008
XII.69
DOSAGE FORM
DIN
BRAND NAME
OMEPRAZOLE MAGNESIUM 20mg

DR Tab
09857195 Losec 09857267 Ratio-Omeprazole
D ION D TE IMI SE TAT IRE L U MEN QU Maximum duration: 7 days (for retreatment, a four-week period must elapse R treatment). CU the previousE O since the end of D
295 LU Authorization Period: 1 Year.
H. pylori-positive Peptic Ulcers For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a one-week course in combination with antimicrobial therapy. Retreatment of H. pyloripositive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy.
XII.70
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
ONDANSETRON HYDROCHLORIDE 4mg/5mL O/L 4mg Tab
4mg 8mg
Tab Tab
8mg Reason for Use code 215
02229639 02213567 02258188 02264056 02274310 02278529 02288184 02297868 02239372 02213575 02258196 02264064 02274329 02278537 02288192 02297876 02239373
Zofran Zofran PMS-Ondansetron Novo-Ondansetron Sandoz Ondansetron Ratio-Ondansetron Apo-Ondansetron Gen-Ondansetron Zofran ODT Zofran PMS-Ondansetron Novo-Ondansetron Sandoz Ondansetron Ratio-Ondansetron Apo-Ondansetron Gen-Ondansetron Zofran ODT
ED T E ON I TI M S LI U TA EN ED UM UIR OC EQ D R
LU Authorization Period: 1 Year. 216 LU Authorization Period: 1 Year. 217 LU Authorization Period: 1 Year. 218 LU Authorization Period: 1 Year.
For patients receiving intravenous chemotherapy or radiation therapy who have not experienced adequate control with other available anti-emetics.
For patients receiving intravenous chemotherapy or radiation therapy who experience intolerable side effects with other antiemetics.
For the treatment of emesis in patients receiving radiation therapy which consists of single fraction treatment to the abdominal cavity, hemi-body irradiation and total body irradiation. NOTE: The therapeutic value of Zofran more than 24 hours after the last dose of chemotherapy is unproven.
JUNE 27, 2008
XII.71
DOSAGE FORM
DIN
BRAND NAME
OSELTAMIVIR PHOSPHATE 75mg Reason for Use Code 371
Cap
02241472 Tamiflu
ED IT E ON TI ED IM S L U ENTA IR M EQU CU R DO
LU Authorization Period: 1 Year. 372 LU Authorization Period: 1 Year.
Clinical criteria
For the prophylaxis (max: 75mg daily) of institutionalized individuals during confirmed* outbreaks of Influenza A or Influenza B. Note: Network will limit supply to 6 weeks.
For the treatment (max: 75mg bid) of institutionalized individuals during confirmed* outbreaks due to: Influenza B or, Influenza A (as an alternative to amantadine) or, Influenza A where new cases have developed despite amantadine prophylaxis. Note: Network will limit supply to 5 days. *The outbreak must be confirmed by Public Health.
XII.72
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
OXYCODONE HCL 10mg 20mg 40mg 80mg Reason for Use code 201
SR Tab SR Tab SR Tab SR Tab Clinical criteria
02202441 02202468 02202476 02202484
Oxycontin Oxycontin Oxycontin Oxycontin
N TIO pain D of EDFor the treatmentTAchronic E in patients who cannot tolerate, E IR IT or have failed EN US UM treatment U a listed long-acting opioid. Q with LIM RE OC D LU Authorization Period: 1 Year.
TO LIPASE & AMYLASE & PROTEASE Cap Ent Microsph Cap Ent Microsph Cap Ent Microsph Cap 00263818 Cotazym 02181215 Cotazym ECS 4 00502790 Cotazym ECS 8 00821373 Cotazym ECS 20
PANCRELIPASE EQUIVALENT 8000 & 30000 & 30000 USP Units 4000 & 11000 & 11000 USP Units 8000 & 30000 & 30000 USP Units 20000 & 55000 & 55000 USP Units Reason for Use code 124
Clinical criteria Replacement therapy for pancreatic insufficiency secondary to pancreatic surgery (resection); LU Authorization Period: Indefinite.
ED ON IT E TI IM US NTA D L E RE M UI CU REQ DO
125 LU Authorization Period: Indefinite. 126 LU Authorization Period: Indefinite. 225 LU Authorization Period: Indefinite.
Replacement therapy for pancreatic insufficiency due to cystic fibrosis.
JUNE 27, 2008
XII.73
DOSAGE FORM
DIN
BRAND NAME
PANCRELIPASE EQUIVALENT TO LIPASE & AMYLASE & PROTEASE 4000 & 12000 & 12000 USP Units Ent Microsph Cap 00789445 Pancrease MT4
D ON TI D ITE E TA RE IM S L EN UI U UM EQ R OC D
124 LU Authorization Period: Indefinite. 125 LU Authorization Period: Indefinite. 126 LU Authorization Period: Indefinite. PANCRELIPASE EQUIVALENT 5000 & 16600 & 18750 USP Units 10000 & 33200 & 37500 USP Units 20000 & 66400 & 75000 USP Units 25000 & 74000 & 62500 USP Units Reason for Use code 124 TO LIPASE & AMYLASE & PROTEASE Ent Minimicrosph Cap 02239007 Creon 5 Ent Minimicrosph Cap 02200104 Creon 10 Ent Minimicrosph Cap 02239008 Creon 20 Ent Minimicrosph Cap 01985205 Creon 25
Reason for Use code
Clinical criteria Replacement therapy for pancreatic insufficiency secondary to pancreatic surgery (resection);
125 LU Authorization Period: Indefinite. 126 LU Authorization Period: Indefinite. 225 LU Authorization Period: Indefinite.
Replacement therapy for pancreatic insufficiency due to cystic fibrosis.
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
PANCRELIPASE EQUIVALENT 16800 & 70000 & 70000 USP U/0.7g 4500 & 20000 & 25000 USP Units 8000 & 30000 & 30000 USP Units 16mg Reason for Use code 124
TO LIPASE & AMYLASE & PROTEASE Pd-114g Pk SR Cap Tab Tab 02230020 Viokase 02242374 Pancrease 02230019 Viokase 02241933 Viokase 16
D ION D TE E MI S AT IRE I L NT U U ME EQ R CU O D
JUNE 27, 2008
XII.75
DOSAGE FORM
DIN
BRAND NAME
PANTOPRAZOLE SODIUM 40mg
Ent Tab
02229453 02285487 02292920 02305046
Pantoloc Novo-Pantoprazole Apo-Pantoprazole Ran-Pantoprazole
Reason for Use code
Clinical criteria
D TE I IM SE TION L U TA EN D UM IRE C DO EQU R

293 Patients with GERD should be reassessed within 6 months after initial treatment with a PPI. The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or stepdown therapy to H2-receptor antagonist therapy. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year. 295 H. pylori-positive Peptic Ulcers For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a one-week course in combination with antimicrobial therapy. Retreatment of H. pyloripositive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy. Maximum duration: 7 days (for retreatment, a four-week period must elapse since the end of the previous treatment). LU Authorization Period: 1 Year. 297 Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis: For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 Year. 401 Other Gastrointestinal Disorders For the treatment of gastroduodenal Crohns disease, short-gut syndrome, scleroderma, or pancreatitis. Note: There is a lack of published evidence to support double-dose PPI therapy in these settings. LU Authorization Period: 1 Year.
XII.76
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
PANTOPRAZOLE SODIUM (contd)

ED T ION D IMI SE NTAT IRE L U ME EQU R CU O D

402 LU Authorization Period: 1 Year. PENTOXIFYLLINE 400mg SR Tab 01968432 02221977 02230090 02230401
Ratio-Pentoxifylline Trental Apo-Pentoxifylline Nu-Pentoxifylline
N TIO ED D A I TE SE I NT specifyRarterial ulcers, gangrene NOTE: Limited use form mustQ U restUMEpresent. U if LIM and/or C pain are RE LU Authorization Period: Indefinite. DO
Cr Clinical criteria 02219905 Nix Dermal Cream
Clinical criteria
For the treatment of patients with critical limb ischemia (with arterial ulcers, gangrene and/or rest pain) and documented arterial vascular disease.
PERMETHRIN 5% Reason for Use code
ION DFor the treatmentTAT IRED have failed on a less costly listed 311 E ITE alternative. MEN of patients who US U QU LIM RE C LU Authorization Period: 1 Year. DO
Oph Oint-3.5g Pk Oph Oint-3.5g Pk 00210889 Lacri-Lube 02125706 Duolube
PETROLATUM/MINERAL OIL 55%/42.5% 80%/20% Reason for Use code
N TIO ED 49 For A D patients with objective evidence of keratoconjunctivitis sicca ITE as confirmed by filamentary keratopathy on slit lamp examination SE MENT QUIR U or biopsy. U LIM RE OC LU Authorization Period: Indefinite. D
JUNE 27, 2008 XII.77
Clinical criteria
DOSAGE FORM
DIN
BRAND NAME
PIMECROLIMUS 1% Reason for Use code 383
Cr Clinical criteria
02247238 Elidel
ION D ED SE TAT IRE T U shouldMEN Eat 6U IMI Therapy be reassessed Q months. L R CU Period: 1 Year. LU Authorization O D
Oph-Sol Oph-Sol Clinical criteria
POLYVINYL ALCOHOL 1% 1.4% Reason for Use code 49
02133253 Hypotears 00045616 Liquifilm Tears

Clinical criteria
POLYVINYL ALCOHOL & POLYVINYLPYRROLIDONE Oph-Sol 00579408 Tears Plus Reason for Use code 49

QUINAGOLIDE HCL 0.075mg 0.15mg Reason for Use code 405
02223767 Norprolac 02223775 Norprolac
For the treatment of hyperprolactinemia in patients who have: ION D D Failed to respond to a greater than or equal to 3 month trial of bromocriptine; or TAT ITE Failed to tolerate bromocriptine; orIRE E N LIM UFS UME EQU ailed to shrink a prolactinoma by greater than 1 cm after 12 months of bromocriptine therapy. R OC LU D Authorization Period: 5 years.
XII.78
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
RALOXIFENE HCL 60mg Reason for Use code
02239028 Evista
D ION D AT IRE ITE E NT U IM US L ME EQ R CU O D

373 LU Authorization Period: Indefinite. RIFABUTIN 150mg Reason for Use code 103 Cap Clinical criteria 02063786 Mycobutin
For the treatment of osteoporosis in postmenopausal women who have:
Failed or, experienced intractable side effects, or have a contraindication to, alendronate OR risedronate. Failure is defined as: continued loss of bone mineral density (loss of more than 3%) after two years of therapy; or a new osteoporosis related fracture after one year of therapy.
N DPatients with a CD4+ cellTIOless than 200/mm3 with an AIDScount ITE defining diagnosis.TA IRED LU Authorization Period: 1 Year. LIM USE MEN QU 104 Patients with a CD4+ cell count less than 100/mm3 without an RE CU AIDS-defining diagnosis. DO
LU Authorization Period: 1 Year.
For the prevention of Mycobacterium Avium Intracellular (MAI) in:
JUNE 27, 2008
XII.79
DOSAGE FORM
DIN
BRAND NAME
RIVASTIGMINE 1.5mg 3mg 4.5mg 6mg Reason for Use Code 347
Cap Cap Cap Cap Clinical criteria
02242115 02242116 02242117 02242118
Exelon Exelon Exelon Exelon

Network note: Maximum duration 3 months. LU Authorization Period: 1 Year. 348 LU Authorization Period: 1 Year.
XII.80
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
SALBUTAMOL 1mg/mL
Inh Sol-2.5mL Pk
01926934 Gen-Salbutamol Sterinebs P.F. 01986864 Ratio-Salbutamol Respirator Sol P.F. 02208229 PMS-Salbutamol 02213419 Ventolin Nebules P.F. 02231488 Apo-Salvent Sterule 02173360 02208237 02213427 02231678 02239366 Gen-Salbutamol PMS-Salbutamol Ventolin Nebules P.F. Apo-Salvent Sterule Ratio-Salbutamol
2mg/mL
Inh Sol-2.5mL Pk
N ED T E I IO IM US AT L T EN ED UM IR C O EQU D R
265 LU Authorization Period: Indefinite. 266 LU Authorization Period: Indefinite. 267 LU Authorization Period: Indefinite. 268 LU Authorization Period: Indefinite.
Reason for Use code
Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have a tracheostomy;
Individuals must have a known hypersensitivity to the preservative in the bulk solution, and be patients with cystic fibrosis in whom nebulizer therapy is indicated;
Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have severe mental or physical disabilities;
JUNE 27, 2008
XII.81
DOSAGE FORM
DIN
BRAND NAME
SALBUTAMOL 5mg/mL
Inh Sol-10mL Pk
00860808 Ratio-Salbutamol Respirator Solution 02069571 PMS-Salbutamol Respirator Solution 02154412 Sandoz Salbutamol 02213486 Ventolin 02232987 Gen-Salbutamol
Reason for Use code
N ED T E TIO MI S LI U TA D EN IRE UM QU C E DO R
256 Patients who have a tracheostomy; LU Authorization Period: Indefinite. 257 LU Authorization Period: Indefinite. 258 Patients with severe mental or physical disabilities; LU Authorization Period: Indefinite. 259 LU Authorization Period: Indefinite. SALMETEROL XINAFOATE 50mcg/Blister 50mcg Reason for Use code 132 Diskhaler-60 Disk Pk Pd Inh-60 Dose Pk Clinical criteria
Patients with cystic fibrosis in whom nebulizer therapy is indicated;
02214261 SereVent Diskhaler Disks 02231129 SereVent Diskus
D ON TI D ITE E TA RE IM S L U MEN UI CU REQ DO

NOTE: This drug is not for relief of acute symptoms. LU Authorization Period: Indefinite. 391 LU Authorization Period: Indefinite.
For patients with moderate to severe COPD with persistent respiratory symptoms despite an adequate trial of, or an intolerance to, a regularly scheduled short-acting bronchodilator AND a long-acting anticholinergic.
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
SALMETEROL XINAFOATE & 25/125mcg/Metered Dose 25/250mcg/Metered Dose 50/100mcg 50/250mcg 50/500mcg Reason for Use code 330
FLUTICASONE PROPIONATE Inh-120 Dose Pk 02245126 Inh-120 Dose Pk 02245127 Inh-60 Dose Pk 02240835 Inh-60 Dose Pk 02240836 Inh-60 Dose Pk 02240837
Advair 125 Advair 250 Advair Diskus Advair Diskus Advair Diskus

O/L Tab Clinical criteria
Clinical criteria
SIROLIMUS 1mg/mL 1mg Reason for Use code 392
02243237 Rapamune 02247111 Rapamune
ION D the prophylaxisAT organ ED For E of IR rejection in patients receiving TE allogeneic renalNT US UME transplants. QU IMI L RE C LU Authorization Period: Indefinite. DO
Tab Clinical criteria For the treatment of otosclerosis. 02099225 Fluotic
SODIUM FLUORIDE 20mg Reason for Use code 20
N TIO ED A D Authorization Period: Indefinite. ITE LU SE MENT QUIR U 21 For the treatment of otospongiosis. LIM U RE OC D LU Authorization Period: Indefinite.
Tab Clinical criteria As part of combination therapy, for the treatment of serious infections confirmed on culture to be caused by a strain of S. aureus or coagulase-negative staphylococci likely susceptible to fusidic acid where standard anti-staphylococcal agents are precluded because of allergy, resistance or treatment failure. 01934252 Fucidin Leo
SODIUM FUSIDATE 250mg Reason for Use code 342
ION D D E TAT IRE TE US UMEN EQU IMI L R C LU Authorization Period: 1 Year. DO
JUNE 27, 2008
XII.83
DOSAGE FORM
DIN
BRAND NAME
TACROLIMUS 5mg/mL 1mg 5mg Reason for Use code 173
Amp Cap Cap Clinical criteria
02176009 Prograf 02175991 Prograf 02175983 Prograf
ION D TAT D solid SE transplant andRE marrow transplant. I E ITFor Uorgan MEN EQU bone R LIM LU Authorization Period: Indefinite. CU DO
Oint Oint Clinical criteria For use in combination with moisturizers or oral antihistamines in patients with atopic dermatitis who have failed or are intolerant to an 8 week trial of an intermediate potency topical steroid. 02244149 Protopic 02244148 Protopic
TACROLIMUS 0.03% 0.1% Reason for Use code 383
N TIO ED D A TE I SE MENT QUIR U LIM Therapy should be reassessed at 6 months. E U OC Period: R LU Authorization 1 year. D
Cap 02281392 02294265 02294885 02295121 02298570 02270102
TAMSULOSIN HCL 0.4mg
0.4mg
Tab
Novo-Tamsulosin SR Ratio-Tamsulosin Ran-Tamsulosin Sandoz Tamsulosin Gen-Tamsulosin Flomax CR
NOTE: Randomized controlled trials have shown no significant differences in efficacy between daily doses of 0.4mg and 0.8mg of tamsulosin. Therefore, the daily tamsulosin dose should not exceed 0.4mg. Reason for Use code 351 Clinical criteria
For the management of benign prostatic hyperplasia where six other formulary alpha Dweeks of treatment withTIbeenN D blockers (e.g., O ineffective. have ITE doxazosin, terazosin)A IRE T E LIM USLU Authorization Period:QU EN Indefinite. M 352 For the management Ebenign prostatic hyperplasia where other Rof CU alpha blockers have produced intolerable side effects. formulary DO LU Authorization Period: Indefinite.
XII.84
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
TEMOZOLOMIDE 5mg 20mg 100mg 250mg Reason for Use code 320
Cap Cap Cap Cap Clinical criteria
02241093 02241094 02241095 02241096
Temodal Temodal Temodal Temodal
ION A or IRED D patients with recurrentT progressive glioblastoma multiforme For T E TE US UMEN IMI or anaplastic astrocytoma. EQU L R C LU Authorization Period: Indefinite. DO
Foil Packet Foil Packet Transdermal Patch Clinical criteria 02245345 Androgel 02245346 Androgel 02239653 Androderm
TESTOSTERONE 1% 2.5g 1% 5.0g 12.2mg Reason for Use code 397
For male patients with confirmed N morning serum testosterone low documented, symptomatic hypothalamic, I or Dlevels associated withdisease,Oin HIV-infected patients. ITE pituitary or testicularTAT IRED NOTE: LIM USE Older EN with nonspecificnormal randomfatigue, M males EQU symptoms of testosterone malaise, depression who have a low level do not satisfy R criteria. these CU DO Authorization Period: 1 year. LU
TESTOSTERONE CYPIONATE 100mg/mL Oily Inj Sol-10mL Pk Reason for Use Code 397 Clinical criteria
00030783 Depo-Testosterone
For male patients with confirmed N morning serum testosterone low documented, symptomatic hypothalamic, I or Dlevels associated withdisease,Oin HIV-infected patients. ITE pituitary or testicularTAT IRED NOTE: LIM USE Older EN with nonspecificnormal randomfatigue, M males EQU symptoms of testosterone malaise, depression who have a low level do not satisfy R criteria. these CU DO Authorization Period: 1 year. LU
JUNE 27, 2008
XII.85
DOSAGE FORM
DIN
BRAND NAME
TESTOSTERONE ENANTHATE 1000mg/5mL Oily Inj Sol-5mL Pk Reason for Use Code 397 Clinical criteria
00029246 Delatestryl
For male patients with confirmed N morning serum testosterone low documented, symptomatic hypothalamic, I or Dlevels associated withdisease,Oin HIV-infected patients. ITE pituitary or testicularTAT IRED NOTE: LIM USE Older EN with nonspecificnormal randomfatigue, M males EQU symptoms of testosterone malaise, depression who have a low U level do these OC not satisfy R 1criteria. D LU Authorization Period: year.
TESTOSTERONE UNDECANOATE 40mg Cap Reason for Use Code 397 Clinical criteria
00782327 Andriol
For male patients with confirmed N morning serum testosterone low documented, symptomatic hypothalamic, I or Dlevels associated withdisease,Oin HIV-infected patients. ITE pituitary or testicularTAT IRED NOTE: LIM USE Older EN with nonspecificnormal randomfatigue, M males EQU symptoms of testosterone malaise, depression who have a low U level do these OC not satisfy R 1criteria. D LU Authorization Period: year.
THYROTROPIN ALFA 0.9mg/mL Reason for Use Code 368
Inj Pd-2x1.1mg Vial Pk Clinical criteria
02246016 Thyrogen
ION DFor use in the monitoring IRED TAT of patients with well-differentiated E ITE thyroid cancer. N US UME QU LIM RE C DO LU Authorization Period: Indefinite.
XII.86
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
TICLOPIDINE HCL 250mg
Tab
02162776 02236848 02237560 02237701 02239744 02243587
Ticlid Novo-Ticlopidine Nu-Ticlopidine Apo-Ticlopidine Gen-Ticlopidine Sandoz Ticlopidine
Reason for Use code
Clinical criteria Ticlopidine is restricted to patients with transient cerebral ischemia. Ticlopidine may be somewhat more effective than ASA in preventing fatal and non-fatal strokes. However, it is associated with neutropenia in 0.8-2.4% of patients, a serious side-effect which may be fatal. Patients on ticlopidine require blood tests every two weeks for the first three months of therapy. There have been more than 60 cases of ticlopidine associated thrombotic thrombocytopenic purpura (TTP) with 33% mortality rate. As well, there are other side-effects such as diarrhea that occurs in 12.5% of patients. Ticlopidine should be used only after careful consideration. The appropriate use of ticlopidine in the management of patients with cerebral ischemic events (TIA or stroke) is based on the following: (a) Determining that the symptoms are due to focal cerebral ischemia, and differentiating the symptoms of dizziness due to vestibular dysfunction, lightheadedness, or syncope from antihypertensive drugs or cardiac dysfunction, and from symptoms due to migraine, epilepsy, hypoglycemia, or other causes, such as tumor. (b) If investigation demonstrates that the events are caused by emboli from the heart, the patient should be treated with anticoagulants, such as warfarin. (c) If the events are due to artery-to-artery emboli from the carotid bifurcation with a severe stenosis, the patient should probably be treated with ASA and offered carotid endarterectomy if medically suitable (70% to 99% stenosis). (d) ASA should be the first line of defense for patients with TIA and threatened stroke, and after an initial stroke of any severity. (e) The only drugs other than ASA that are available as platelet inhibitors and which have been shown to be of value for such patients are ticlopidine and clopidogrel. (f) Before abandoning ASA in favour of ticlopidine, efforts should be made to improve the tolerability of ASA by reducing the dose, taking it with food, and using enteric coated ASA. Ticlopidine will be reimbursed for patients: LU Authorization Period: Indefinite.
219 220 221 Who are known to be, or become, intolerant of ASA; Where ASA is contraindicated; LU Authorization Period: Indefinite. Who continue to have TIA or stroke symptoms while being treated with ASA. LU Authorization Period: Indefinite.
XII.87
DOSAGE FORM
DIN
BRAND NAME
TINZAPARIN SODIUM 10000IU/mL 20000IU/mL 3500IU/0.35mL 4500IU/0.45mL 10000IU/0.5mL 14000IU/0.7mL 18000IU/0.9mL Reason for Use code 186
Inj-2mL Pk Inj-2mL Pk Inj Pref Syr Inj Pref Syr Inj Pref Syr Inj Pref Syr Inj Pref Syr Clinical criteria
02167840 02229515 02229755 09853898 02231478 09853901 09853928
Innohep Innohep Innohep Innohep Innohep Innohep Innohep
ED T E ON I TI M S LI U TA ED EN IR UM EQU OC R D
LU Authorization Period: 1 Year. LU Authorization Period: 1 Year. 187 188 For DVT in pregnant or lactating females; LU Authorization Period: 1 Year. LU Authorization Period: 1 Year. 189 323 LU Authorization Period: 1 Year. SR Cap SR Cap Tab Tab TOLTERODINE L-TARTRATE 2mg 4mg 1mg 2mg Reason for Use code 290 02244612 02244613 02239064 02239065 Detrol LA Detrol LA Detrol Detrol Clinical criteria
For DVT in patients whom treatment with warfarin is not tolerated, or contraindicated; For DVT in patients who have failed treatment with warfarin. For the acute treatment of pulmonary embolism, maximum of three weeks.
ON ED TI D IT E TA RE IM S L U MEN UI CU REQ DO
For patients with urinary frequency, urgency or urge incontinence who have: Failed to respond to behavioural techniques AND An adequate trial of oxybutynin with gradual dose escalation has shown to be either ineffective or resulted in unacceptable side effects. Note: If after a trial of 2 weeks patients continue to experience similar side effects and no greater efficacy than oxybutynin, continued therapy with this more costly agent should be reassessed.
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
TOPIRAMATE 15mg 25mg Reason for Use code
Sprinkle Cap Sprinkle Cap Clinical criteria
02239907 Topamax Sprinkle 02239908 Topamax Sprinkle
N TIO adjunctive therapy in the treatment 321 In age 16 and under, as ED ED childrendisordersNTA control by other listed anticonvulsants E of seizure where UIR IT S ME hasU been unsatisfactory. EQ LIM R CU Period: Indefinite. LU Authorization DO
Tab 02230893 02248860 02256827 02260050 02262991 02263351 02279614 02287765 02230894 02248861 02256835 02260069 02263009 02263378 02279630 02287773 02230896 02248862 02256843 02263017 02263386 02267837 02279649 02287781 Topamax Novo-Topiramate Ratio-Topiramate Sandoz Topiramate PMS-Topiramate Gen-Topiramate Apo-Topiramate Co Topiramate Topamax Novo-Topiramate Ratio-Topiramate Sandoz Topiramate PMS-Topiramate Gen-Topiramate Apo-Topiramate Co Topiramate Topamax Novo-Topiramate Ratio-Topiramate PMS-Topiramate Gen-Topiramate Sandoz Topiramate Apo-Topiramate Co Topiramate
TOPIRAMATE 25mg
100mg
Tab
200mg
Tab
Clinical criteria
As adjunctive therapy in the treatment of seizure disorders where ION has been Dcontrol by other listed anticonvulsants ED unsatisfactory. T large number of R ITE NOTE:anticonvulsant TA of theIpatients mayperiod of time, the E Because aN effects U drug over a become refractory S LIM Uto the UMofE drug must be re-evaluated after a period of six Q effectiveness this months. RE OC DLU Authorization Period: Indefinite.
JUNE 27, 2008
XII.89
DOSAGE FORM
DIN
BRAND NAME
TRAVOPROST 0.004% Reason for Use Code 171
Oph Sol Clinical criteria
02244896 Travatan
ED IT E ION IM S AT ED L U ENT R M QUI CU RE DO

LU Authorization Period: Indefinite. 172 LU Authorization Period: Indefinite. 387 LU Authorization Period: Indefinite. TRETINOIN 0.01% 0.025% 0.05% 0.01% 0.025% 0.05% 0.025% Reason for Use code 269 Cr Cr Cr Gel Gel Gel Sol Clinical criteria 00657204 Stieva-A 00578576 Stieva-A
00518182 Stieva-A 01926519 Vitamin A Acid 01926462 Vitamin A Acid 00587966 Stieva-A 01926489 Vitamin A Acid 00578568 Stieva-A
ION D D the treatment ofTAT vulgaris. E E IRE For US UMEN acne U MIT Q LI RE LU Authorization Period: 1 year. OC D
XII.90
JUNE 27, 2008
DOSAGE FORM
DIN
BRAND NAME
URSODIOL 250mg Reason for Use code 273
02238984 Urso 02273497 PMS-Ursodiol C
ION D D the treatment ofTAT Ibiliary cirrhosis. E E E For primary R US UMEN EQU MIT LI R C LU Authorization Period: Indefinite. DO
Tab Clinical criteria For the treatment of primary biliary cirrhosis. 02245894 Urso DS 02273500 PMS-Ursodiol C
URSODIOL 500mg Reason for Use code 273
N TIO ED D LU Authorization Period: Indefinite. TA ITE USE EN QUIR LIM UM RE 386 For the treatment of primary sclerosing cholangitis. OC D LU Authorization Period: Indefinite.
Tab Clinical criteria Herpes zoster in patients 50 years of age or older, up to 72 hours* after appearance of lesions. Dose: 1 gram 3 times/day for 7 days. *The patient must begin treatment within the time frame specified for the product to be reimbursed. There is no benefit from the therapy begun after this time frame. NETWORK NOTE: Network will limit supply to 7 days and 42 capsules. LU Authorization Period: 1 year. 02219492 Valtrex
VALACYCLOVIR 500mg Reason for Use code 159

VALGANCICLOVIR 450mg Reason for Use Code 374 Tab Clinical criteria 02245777 Valcyte
ION D D the treatment ofTAT retinitis in patients with AIDS. E For N CMV UIR TE USE Q IMI ME L RE CU LU Authorization Period: 1 year. DO
JUNE 27, 2008
XII.91
DOSAGE FORM
DIN
BRAND NAME
VIGABATRIN 500mg Reason for Use code 136
02065819 Sabril
As adjunctive therapy in the treatment of seizure disorders where ION D Dcontrol by other listed anticonvulsants has been unsatisfactory. ITE Note: Because a large number of patients may become refractory TATof theREover a period of time, the E N to LIM USthe anticonvulsantdrug mustUIre-evaluated after a period of six Q ME effects be drug effectiveness of this RE months. CU DOAuthorization Period: Indefinite. LU Tab Tab Clinical criteria 02256460 Vfend 02256479 Vfend
VORICONAZOLE 50mg 200mg Reason for Use code 399
Outpatient continuation of treatment for documented invasive in patients who have Daspergillosiseither oral orTIONdemonstrated a clinical voriconazole. ITE response to NTA parenteral ED R M E first prescription must be written by a physician based at the I * LI E USThe Uwhere the patient was hospitalized. QU hospital M RE C Note: Limited to 3 months of reimbursement DO LU Authorization Period: 1 year.
ZOLEDRONIC ACID 5mg/100mL Reason for Use code 319
Inj Sol-100mL Pk Clinical criteria
02269198 Aclasta
ION D D the treatment ofTAT Idisease. E For TE USE EN Pagets R QU IMI M L RE CU LU Authorization Period: Indefinite. DO
XII.92
JUNE 27, 2008

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Ontario Drug Benefit Formulary/ Comparative Drug Index No.

Effective June 27, 2008

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX EDITION NO. 41

September 15, 1999

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX NO. 41

The Committee to Evaluate Drugs (CED)

B. How to Use the Formulary

Ontario Drug Benefit Formulary/Comparative Drug Index

Off-Formulary Interchangeable Drugs (OFI)

Index of Pharmacologic-Therapeutic Classification

An index of the pharmacologic-therapeutic classification is provided in this section in ascending order.

Facilitated Access Drug Products

Trillium Drug Benefit Program

Exceptional Access Program (EAP)

Abbreviations, Tables and Sample Forms

Part XI Part XII

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008

Drug Utilization Review (DUR)

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008

Medically Necessary No Substitution Claims

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008

Limited Use Products

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008

10. Extemporaneous Preparations

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

11. Professional Pharmacy Services

Inquiries and Assistance

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008

DRUG NAME, STRENGTH AND DOSAGE FORM DIN

08:00 ANTI-INFECTIVE AGENTS

ED ION D MIT SE TAT IRE LI EN QU U UM RE OC D

30mg SG Cap 02155923

BRIMONIDINE TARTRATE & TIMOLOL MALEATE

POLYETHYLENE GLYCOLE & ELECTROLYTES

5.0141 RIV PMS 16.1700 5.0141

0.4090 0.4090 00474517 One-Alpha LEO

Benadryl (Not a Benefit) Allerdryl (Not a Benefit)

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008

DRUG NAME, STRENGTH, DOSAGE FORM DIN

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008

DRUG NAME, STRENGTH, DOSAGE FORM DIN

08:00 ANTI-INFECTIVE AGENTS

08:12:04 ANTIBIOTICS ANTIFUNGALS

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008

DRUG NAME, STRENGTH, DOSAGE FORM DIN

08:00 ANTI-INFECTIVE AGENTS

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008

DRUG NAME, STRENGTH, DOSAGE FORM DIN

08:00 ANTI-INFECTIVE AGENTS

ONTARIO DRUG BENEFIT FORMULARY/COMPARATIVE DRUG INDEX

JUNE 27, 2008